i^ /O ^*,^A.. ^. |P^U L M O N A R Y TUBERCULOSIS AND ITS COMPLICATIONS friTH SPECIAL REFERENCE TO DIAGNOSIS AND TREATMENT FOR GENERAL PRACTITIONERS AND STUDENTS SHERMAN G. BONNEY, A.M., M.D. ICINE, MEDICAL DEPARTMENT CONSULTANT TO THE DENVER COUNTY HOSPITAL DIRECTOR OF THE NATIONAL ASSOCIATION FOR THE STUDY AND PREVENTION OF TUB MEMBER OF THE AMERICAN CLIMATOLOGICAL ASSOCIATION EX-PRESIDENT OF THE DENVER CLINICAL AND PATHOLOGICAL SOCIETY, ETC IVITH 189 ORIGINAL ILLUSTRATIONS, INCLUDING 20 IN COLORS AND 60 X-RAY PHOTOGRAPHS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1908 Copyright, 1908, by W. B. Saunders Company TO THE MEMORY OF MY FATHER Calvin ]f. Bonncvi, riD. 2). WHO FOR NEARLY HALF A CENTURY SUSTAINED THE HIGH IDEALS OF THE GENERAL PRACTITIONER IQ. H PREFACE It is quite impossible to present an exhaustive treatise upon all phases of pulmonary tuberculosis, and in submitting this volume for the criticism of reviewers, I have no apology to make for its limitations and imperfections. All physicians who have had a large experience in the management of pulmonary invalids are forced to the conclusion that there is not so comprehensive a knowledge of the disease as fully to conserve the interests of society. Despite the many excellent con- tributions upon the general subject, there is perhaps a justification for publishing the following pages, which embody largely the results of personal experience. This book is not designed for the benefit of skilled specialists in the treatment of pulmonary affections, but for the use of general practitioners whose opportunities for clinical study may have been somewhat limited. Its preparation, conducted during the course of an active practice, has consumed a vast amount of time, and the work has been delayed by many unavoidable interrup- tions. It has been my desire that the book should be devoted essentially to the clinical aspects of pulmonary tuberculosis, and an effort has, therefore, been made to emphasize practical considerations. To this end I have endeavored, through the various lights and shadows of every-day obser- vation, to portray different phases of the disease in such a manner as to ac- centuate important points without obscuring other detail. In the interests of clearness and force, brief illustrative cases are introduced in the text, but comparatively little space is devoted to the consideration of alluring theories. In presenting certain aspects of pulmonary tuberculosis it has been necessary to make use of the contributions of innumerable scientific workers. To those whose labors in the realm of experimental research, histologic study, or clinical observation have added to the sum-total of our present knowledge, I have endeavored to give due credit in the text. If suitable recognition has not been accorded in any instance, such omission is purely unintentional. In several para- graphs relative to the physiologic effects of climate, I have made free use of material contained in Huggard's "Handbook Upon Climatic Treatment," and wish to express my obligation. It is with some hesitation that I venture, in the last chapter of the book, to report my clinical observations concerning the practical application of vaccine therapy to cases of pulmonary tuberculosis. Some doubts have existed in my mind as to the propriety of introducing more than passing mention of this phase of specific medication. It is apparent that such a subject, even though of engrossing interest and probable value, must be adjudged upon the basis of continuous con- servative investigation. While it is recognized that errors inevitably occur in the interpretation of clinical findings, such a study relative to the actual efficiency of newer therapeutic measures must remain an important feature of scientific progress. The evolution of complete 24335 knowledge concerning the workings of the complex mechanism of immunity will be acquired only through the process of years. It may api>ear, therefore, somewhat presumptuous at this time to present clinical observations with reference to a feature of treatment that may be subject to considerable future modification. In view, however, of an instructive experience during the past one and one-half years with the bacterial vaccines, I am constrained to report the results thus far attained. Appreciative thanks are rendered to many private patients who have granted photographic illustrations. Grateful acknowledgment is made to Dr. William C. Mitchell, for valuable suggestions with refer- ence to features of bacteriologic interest; to Dr. J. A. Wilder, for reviewing the chapters upon Pathology; to Dr. Howell T. Pershing, for reading the text upon Miliary Tuberculosis, as well as upon the Symptoms and Course; to Dr. Charles A. Powers, Dr. F. L. Dixon, and Dr. George B. Packard, for reviewing portions of the book devoted to Surgical Complications; to Dr. Robert Levy, for reading the text upon Tuber- culosis of the Larynx and assistance rendered in securing photographs of this condition; to Dr. J. N. Foster, for reviewing the chapter upon Tuberculosis of the Ear and Nose; to Dr. H. B. Whitney, for reading the text relating to the Physical Signs; to my assistant, Dr. E. W. Enier}-, for very useful suggestions in connection with many portions of the book, and to Dr. S. B. Childs, for valuable aid in securing the x-ray pictures. I am indebted to Mr. Ira D. Cassidy for the skill displayed in the drawings and paintings, to Mr. F. O. Stanley and Mr. B. S. Hopkins for their interest and efficiency in connection with the photo- graphic illustrations, to my publishers for the excellence of the repro- ductions, and to my secretary, Miss Nellie Bryant, for aid in the prepara- tion of the manuscript. S. G. BONNEY. Denver, Colorado, July, 1908. CONTENTS PART I PAGE Etiology and Pathologic Anatomy 17-93 SECTION I General Etiologic Considerations 17-76 CHAPTER I Introduction 17-19 Historic Review. CHAPTER II The Tubercle Bacillus 19-26 Morphologic Cliaracteristics — Staining Metliods — Differentiation — Cultural Characteristics — Vitality — Composition — Various Types of Tubercle Bacilli: Tlie Human Bacillus, the Bovine Bacillus, the Avian Bacillus, and the Bacillus of Fish or other Cold-blooded Animals. CHAPTER III Relation of Human and Bovine Bacilli 27-35 Historic Survey — Koch's Doctrine — Results of E.xperiments — Clin- ical Study — Report of British C'ommission — Recent Investigations — Contradictory Evidence — Morphologic and Cultural Differences — Conclusions. CHAPTER IV The Congenital Method of Infection 36-42 Hereditary Transmi.ssion — Entrance of tlip P.iirilli Tliroudi the Medium of the Spermatic Fluid, tlie Ovum, ami iIm- PImi. ni.il (ircula- tion — Pathologic Evidence — E.xperimentatiuTi in Animals ( 'linical Investigation — Latency of Infection — Tulicn-lc iirpoMt in Inaccessi- ble Areas — Prevalence of Infection Among the Very ^ oung — Fre- quency of Tuberculosis Among Children of Consumptive Parents. CHAPTER V Invasion by Way of the Respiratory Tract 43-50 Modification of Former Views Regarding the Inhalation Method of Infection — Cornet's Theory — Fliigge's Investigation — Arguments in Favor of Inhalation Infection — The Supposed Frequency of Primary Lesions in the Lung in Comparison with the Intestinal Tract — Animal Experimentation — Researches of Calmette and his Followers — Localization of Tuberculous Lesions — Prevalence of Consumption in Prisons and Other Institutions — The Import of Tenement-house Investigation. CHAPTER VI Invasion Through the Digestive Tract 51-54 Invasion W Human and Bovine Bacilli — Frequency of Primary Intestinal Lesions — Experiments of Calmette. Guerin, and Others — Behring's Theory — Sources of Infection by Way of the Alimentary Tract — Importance of tliis Route of Invasion. Z CONTENTS CHAPTER VII PAGB Distribution of the Bacilli 55-56 Maimer of Dissemination of Human and Bovine Bacilli. CHAPTER VIII Prevalence of Tuberculosis Statistical Observations — Economic Considerati^ CHAPTER IX Influence of Race 59-64 The Negro — The American Inilian — The Irish — The Swede — The Jew — The American. CHAPTER X Influence of Geographic Position 65-66 Consumption Known to Occur in all Regions — Conclusive Evidence Regarding Relative Degree of Immunity Conferred Through the Influ- ence of Altitude, Dryness, and Sunshine. CHAPTER XI To Wh.\t Extent is Consumption Indigenous in Colorado? 66-71 Erroneous Views Formerly Entertained — Statistical Inquiry Con- cerning the Alleged Increase of Indigenous Tuberculosis in Colorado — . Statements to this Effect have been Shown to be Inspired by an Unwarranted Assumption as to Actual Facts. CHAPTER XII General Conditions Influencing Infection After Exposure to the Tubercle Bacillus 72-75 Heredity — Environment — Social Conditions — Occupation — Previous -Virulence of Bacilli. Pathologic Anatomy 76-93 CHAPTER XIII General Considerations 76-78 CHAPTER XIV Structure o Format i-ii tion \.- Hyperp lous I'n.r, -- .f E1.TM( r,.llii:,|. 1 ■ntary Tul.crfle- Do' ■1 1 . .■ •■ ..:, l; '• ■•: 1 ■;. 1 '^ ■ ■ hl.liy lllll;!liilii:ilniy 1 CHAPTER XV oinuent of Tubercle we Processes, Coagula- live Connective-tissue I'xtension of Tubercu- Gross Appearances Essential Differences in the Pathologic Lesions Despite Histologic Identity of the Various Tuberculous Processes — Miliary Tuberculosis-^ Acute Pneumonic Phthisis (Lobar) — Acute Pneumonic Phthisis (Lobular) — Chronic Caseofibroid Phthisis — Chronic Fibroid Phthisis^ Site of Primary Involvement. CONTENTS 3 PART II PAGE Symptomatology and Course, Varieties, and Termination 94-153 CHAPTER XVI Method of Onset Acute and Non-acute — Acute Onset Exhibited in Acute Pneumonic Phtliisis, Acute Bronchopneumonic Phthisis and Miliary Tubercu- losis of the Pneumonic Type — Acute Onset Characterized by Initial Pulmonary Hemorrhage, Pleurisy, Septic Manifestations, Severe Bronchitis, and Influenza — Non-acute Onset Developing as a Latent Infection, the Anemic Variety, the Dyspeptic Type, Initial Laryn- geal Symptoms, and Following Tuberculous Cervical Glands — Pleurisy, Pneumonia, Typhoid Fever, Measles, and Other Infectious CHAPTER XVII Cough and Expectoration 101-105 Varieties of Cough — Individual Idiosyncrasies — Relation of Cough to External Conditions — Differences in Quantity, Gross Appear- ance, Manner of Expulsion, and Composition of Expectoration. CHAPTER XVIII Pain, Hoarseness, and Dyspnea 106-110 Causes and Types of Pain — Alterations of Voice — Varieties of Dyspnea. CHAPTER XIX Fever 111-114 Significance of Fever — Origin and Variability — Clinical Types. CHAPTER XX Emaciation and Local Objective Symptoms 115-119 Relation of Body Weight to the Activity of the Tuberculous Process — Relation of Nutrition to Fever — Changes in Fingers and Skin. CHAPTER XXI CiRCtiL.\TORY Disturbances 120-122 Changes o tion of Ar of Lungs. Changes of Pulse — Frequent Acceleration in Early Stages — Diminu- tion of Arterial Tension — Cardiac Weakness — Endocarditis — Edema CHAPTER XXII Pulmonary Hemorrhage 123-130 Frequency — Causes and Types — Immediate and Remote Effects — Influence of Climate upon Hemoptysis. CHAPTER XXIII Symptoms Referable to the Digestive Apparatus 131-134 Stomach Disturbances — Organic Changes and Psychoneuroses— Intestinal Symptoms— Diarrhea. CHAPTER XXIV FAGE Symptoms Referable to the Mind and Nervous System 135-141 Incorrect Notions Concerning Essential Traits of Character Common to Consumptives — Impossibility of Definite Generaliza- tions — Individual Temperamental Peculiarities — Occasional Per- verted Mentality — Insomnia — Nervous Energy. CHAPTER XXV Symptoms Referable to the Genito-urinary Tract 142-144 Albuminuria — Casts — Amyloid — Acute Nephritis — Sexual Desire SECTION II Course, Varieties, and Termination 145-153 CHAPTER XXVI The Clinical Course 145-146 Differences in General Type and Duration. CHAPTER XXVII Special Varieties 147-151 Fibroid Phthisis — Pneumonokoniosis with Clironic Bronchitis — Emphysema — Fibrous Tissue Change, Disturbance of Circulation and Ultimate Tubercle Infection — Symptoms and Physical Signs of Preceding Group of Chronic Pathologic Conditions. CHAPTER XXVIII Termination 152-153 Modes of Death. PART III Physical Signs 154-233 Introduction. General Physical Signs 155-217 CHAPTER XXIX Inspection 155-173 Rules for the Practice of Inspection — Conditions Independent of the Thorax Nolcil upMn ln-|>irtion — Character of Respiration — Inspection of the i Im -t >i/r and Shape of the Thorax — rnilateral Irregularities — Fn -| ,i i 1 1 , .ly Mi ivements — Litten's Phenomenon — Cardiovascular f 'haii;;' > I liaiiges in the Precordia as a Whole — Changes in the Apex Impulse — Epigastric Pulsation — Changes in the Neck. CHAPTER XXX Palpation 174-176 Confirmation of the Results of Inspection — Vocal Fremitus — Normal Disparity at the Apices — Palpable Rhonchi and Friction- sounds. CHAPTER XXXI PAGE Percussion 177-190 Resonant and Non-resonant Sounds — Analytic Characteristics of Resonance, Intensity, Pitch, and Quality — Rules for the Practice of Percussion: Rules for the Patient, Rules for the Physician, Position of Pleximeter P'inger, Manner of Dealing the Blow — Position of Examiner— Percussion of the Normal Chest: Regional Differences, Disparity at the Apices, Percussion Boundaries, Areas of Cardiac Dulness and Flatness. Percussion in the Midst of Abnormal States: Absence of Resonance or Flatness, ("hanges in Intensity, Changes in Quality — Tympanitic, Amphoric, and Cracked-pot Resonance — Changes in Pitch — Wintrich's Change of Pitch and Gerhardt's Change of Pitch. CHAPTER XXXII Auscultation 191-217 Manner of Auscultation — The Stethoscope — Rules for the Per- formance of Auscultation: Rules for the Patient, Rules for the Examiner — Auscultation of the Normal Chest: Respiratory Sounds, Vesicular Respiration as Compared with Breath-sounds Heard over the Larynx, Regional Ditferences, Normal Disparity Between the Two Apices, Normal Voice-sounds, Vocal Resonance Over the Larynx or Trachea, Vocal Resonance Over Normal Lung, the Whispered Voice— Auscultation in the Midst of Pathologic Con- ditions: Modifications of Normal Respiratory Sounds, Changes in Intensity, Diminution of Intensity, Emphysematous Type of Breathing, Increased Intensity of Breath-sounds, Changes in Pitch and Quality, Bronchial Respiration, Bronchovesicular Respiration, Cavernous Breathing, Amphoric Respiration, Metamorphosing Respiration, Changes in Duration, Changes in Rhythm, RAles, Tracheal Rdles, Moist Bronchial RAles, Dry Bronchial Rdles, Vesic- ular Rales, Cavernous Rales, Pleural Rfiles, Succussion Sounds, Metallic Tinkling. Indeterminate Rales — Modifications of the Normal Spoken and Whispered Voice in Disease: Changes in Intensity, Changes in Pitch and Quality, Bronchophony, Egophony, Pectorilo- quy- SECTION II Physical Signs of Pulmonary Tuberculosis 218-233 CHAPTER XXXIII General Considerations 218-219 CHAPTER XXXIV Early Cases 219-222 The Especial Importance of Auscultatory Signs — The Significance of Localized Unilateral Rales — Value of Cough in the Detection of Fine Rales During the Ensuing Inspiration. CHAPTER XXXV Cases With Moderate Involvement 223-228 Visual Changes — Irregularity of Contour— Arhythmic Respiratory Movements— Evidences Obtained upon Palpation— Percussion Signs — Deviations from Normal Percussion Outlines. CHAPTER XXXVI Advanced Cases 229-233 Striking Combination of Physical Signs Noted upon Inspection, Palpation, Percussion, and Auscultation. 6 CONTENTS PART IV PAGE Diagnosis and Prognosis 234-323 SECTION I Diagnosis 234-298 CHAPTER XXXVII Preliminary Considerations 234-235 CHAPTER XXXVIII Provisional DL\t;.NiisTic Factors 236-239 Family Hi>tury — Acquired Predisposition — Opportunities for Infec- tion— Prt-viuus Di.seusos. CHAPTER XXXIX Present Condition 240-245 Existing Constitutional Disturbances — Cough — Loss of Weight — Fever — Acceleration of Pulse— Exploration of Chest— Results of Physical Examination — Sputum Examinations. CHAPTER XL Special Aids to Dl^gnosis 246-293 The Tuberculin Test — The Ophthalmotuberculin Reaction — Experi- ments upon Animals — The Rontgen Rays. CHAPTER XLI Differential Di.\gnosis 294-298 Importance of Laboratory Findings — "Miner's Phthisis " — Chronic Influenza — Pulmonary Syphilis — The Significance of Pulmonary Hemorrhage — Reports of Cases. SECTION II Prognosis 299-323 CHAPTER XLII General Considerations 299-300 CHAPTER XLIII Factors Pertaining to the Individual 300-311 Age — Sex — Race — Family History — Individual Resistance — Occu- pation — Temperament, Disposition. Intelligence, and Character — Financial Condition — Social Environment — Personal Equation — Change of Surroundings and Climate CHAPTER XLIV Considerations Pertaining to the Disease 312-323 Historj' of Present Illness — Physical Signs — Extent of Pathologic Change — Activity of Infection— Evidences of Immunity — Character of Systemic Disturbances — Possibility of Arrest Offered Even to Advanced Cases — Reports of Dlustrative Cases. CONTENTS 7 PART V PAGE Complications 324-559 Introduction. SECTION 1 Acute Miliary Tuberculosis ,. 324-346 CHAPTER XLV General Considerations 324-328 Historic Review — Etiology — Frequency — Varieties. CHAPTER XLVI The PNEtTMONic Type 329-330 Clinical Manifestations. CHAPTER XLVII The Typhoid Type 331-334 Method of Onset — Subjective Symptoms — Physical Signs — Differ- ential Diagnosis. CH.A.PTER XLVIII The Meningeal Form 335-346 Pathogenesis — Pathologic Change — Symptoms in Adults — Symp- toms in Children from Two to Six Years of Age — Symptoms in Infants — Differential Diagnosis — Reports of Cases — Treatment. SECTION II Tuberculosis of the Pleura 347-394 Introduction. CHAPTER XLIX Etiology and Pathology of Tuberculous Pleurisies 348-352 Secondary Nature of the Tuberculous Infection — Frequency — For- mer DifiicuUies of Diagnosis — Inflammatory Changes With or With- out Effusion — Character of Effusion. CHAPTER L Symptomatology of Tuberculous Pleurisies 353-357 Subjective Symptoms — Physical Signs — Outlines of Percussion Dul- CHAPTER LI Displacement of Organs 358-362 Frequency of Cardiac Displacement Among Pulmonary Invalids — Illustrative Cases. CHAPTER LII Dlagnosis and Prognosis of Pleurisies in Pulmonary Invalids .... 363-365 Importance of Detailed Physical E.xamination. CHAPTER LIII Treatment of Serous Effusion 366-372 General Measures — Absorption of Pleural Effusion — Indications and Contraindications for Aspiration — Rules for the Performance of Aspiration. CHAPTER LIV Empyema 373-382 Clinical Manifestations — Exploratory' Puncture — Methods of Treat- ment — Reports of Cases. CHAPTER LV Pneumothor.ix 383-388 Subjective Symptoms and Physical Signs — Diagnosis — Clinical Varieties — Prognosis — Treatment. CHAPTER LVI Pneumopyothorax 389-394 Physical Signs — Prognosis — Treatment. SECTION ill Tuberculosis of Pericardium and Peritoneum 395-411 CHAPTER LVir Tuberculosis of the Pericardium 395-403 Etiologic and Pathologic Data — Varieties — Symptoms of Peri- cardial Effusion — Physical Signs — Course and Prognosis — Diagnosis — Treatment of Effusion — Adherent Pericardium. CHAPTER LVIII Tuberculosis of the Peritoneum 404-411 Etiologic Relations — Symptoms — Physical Examination — Diagnosis — Prognosis — Treatment. SECTION IV Glandular Tuberculosis 412-439 CHAPTER LIX Pathogenesis of Glandular Infection 412-417 Distribution of Bacilli Through Lymphatic Channels— Drainage of Tributary .\reas — Role of the Tonsils and Adenoids in Affording Ports of I'ntry — Permeability of Intestinal Wall — Frequency of Glandular Tuberculosis in Children— Statistical Observations. CHAPTER LX Tuberculosis of the Cervical Gl.\nds 418-421 Clinical Manifestations — Diagnosis. CONTENTS 9 CHAPTER LXI PAGE Tuberculosis op Mediastinal and Mesenteric Glands 422-428 Symptoms of Tuberculous Enlargement of Tracheobronchial Glands — Physical Signs of Tracheal Compression — Physical Signs of Bron- chial Compression — Diagnosis of Glandular Enlargement — Illustra- tive Case — Tabes Mesenterica. CHAPTER LXII Treatment of Glandular Tuberculosis 429-439 General Treatment — Hygienic Measures — Change of Environ- ment — Recreative Existence in Open Air — Seashore Hospitals — Change to the Country or Mountains — Review of the Supposed Efficacy of the Kingly Touch — Medicinal Treatment — Specific Medi- cation. Local Efforts: Non-operative Measures Embracing Coun- terirritation, Massage, Electrolysis, x-Ray. Surgical Procedures: Including Aspiration, Interstitial Injections, Incision, and Drainage With or Without Curetment or Cauterization, Complete Excision. Illustrative Case. SECTION V Tuberculosis of Bones and Joints 440-461 CHAPTER LXIII Etiologic and Pathologic Considerations 440-443 Statistical Observations — Frequency of Bone and Joint Lesions in Early Childhood — Influence of Trauma. CHAPTER LXV Clinical Manifeistations of Bone and Joint Tuberculosis 444-456 Early Symptoms — General Prognostic Features — Caries of Spine: Symptoms and Diagnosis, Illustrative Case. Tuberculosis of Hip- joint: Symptoms, Diagnosis. Tuberculosis of Knee-joint: Symp- toms. CHAPTER LXIV Treatment of Tuberculosis of Bones and Joints 457-461 General Hygienic Management — Constitutional Treatment — Local Management — Non-operative Measures — Mechanical Contrivances —The Bier Treatment— Surgical Procedures. SECTION VI Tuberculosis op the Alimentary Tract 462- CHAPTER LXVI Etiologic and Anatomic Factors . Tuberculosis of the Mouth, Tongue, Gums, Tonsils, Esophagus, and Stomach. 10 CONTENTS CHAPTER LXVII PAGE Tuberculosis of the Intestine 466-470 Primary Lesions of the Intestine — Secondary Lesions — Statistical Observations — Pathogenesis — The Ulcerative Type of Intestinal Tuberculosis — The Hyperplastic Type — Surgical Procedures. CHAPTER LXVIII Tuberculosis of the Appendix 471-483 Primary Lesions — The LHcerative Tj^dc — The Hyperplastic Type — Clinical Symptoms — Principles of Management — Appendicitis Among Phthisical Patients — Personal Observations — Illustrative Cases. CHAPTER LXIX Rectal Fistul.\ 484-486 Varieties — Management. SECTION VII Tuberculosis of the Genito-urinary Tract 487-512 CHAPTER LXX General Etiologic Consider.^^tions 487-490 Primary and Secondarj- Infection — Direction of Bacillary Dis- semination — More Frequent Sites of Infection — Statistical Data. CHAPTER LXXI Tuberculosis of the Ividney 490-499 Pathology — Clinical Symptoms — Increased Frequency of Urina- tion — Change in Character of Urine — Pain and Tenderness in Region of the ICidney — The General Health — Diagnosis — Tubercle Bacilli in the Urine — Cystoscopic Examination of the Bladder — jr-Ray- ■ of the Ui' -..,.. • . Segregation of the Urine or Ureteral Catheterization — Excretory- Capacity of Each Ividney — Crj'oscopy — Treatment: Hygienic, PaUiative, Operative Measures, i. e. , Xephrotomy, Nephrectomy. CHAPTER LXX 1 1 Tuberculosis op the Bladder 499-503 Pathologic Appearance — Symptoms and Diagnosis — Treatment — Cystotomy — Hlustrative Case. CHAPTER LXXIII Tuberculosis of the Prostate and Seminal Vesicles 504-506 Frequency — Symptoms — Treatment. CHAPTER LXXIV Tuberculosis of the Epididymis .vnd Testes 506-510 Pathologic Change — Clinical Symptoms — Diagnosis — Pro^osis — Management — Indications for Operation — Character of Surgical Interference — Illustrative Cases. CHAPTER LXXV Tuberculosis of the Fallopian Tubes, Uterus, and Adjacent Struc- CONTENTS 11 SECTION VIII PAGE Tuberculosis of the Skin and Upper Respiratory Tract 513-540 CHAPTER LXXVI Tuberculosis of the Skin 513-524 Role of the Skin as a Channel for Tuberculous Infection — Experi- mental Investigation — Clinical Observations — The Usual Innocuous Character of Cutaneous Infections — Origin of Tuberculous Lesions — The Contagion of Tuberculous Meat — Tuberculous Processes Follow- ing Postmortem Examinations — Accidental Infection Incident to Close Contact with Infectious Sputum — Animal Experimentation — Statistical Observations — Differences of Histologic Structure — Clinical Varieties of Tuberculous Lesions — The Verrucous Type — The Necrogenic Wart— The Ulcerative Variety— The Scrofulous Type— Lupus Vulgaris— Differential Diagnosis from Syphilis- Prognosis and Management of Lupus. CHAPTER LXXVII Tuberculosis of the Larynx 524-535 Etiology — Occasional Primary Infection — Illustrative Case — Path- ologic Conditions — Subjective Symptoms — Local Appearances — Prognosis — General Principles of Management. CHAPTER LXXVIII Tuberculosis op the Ear and Nose 535-540 Etiologic and Anatomic Data — Clinical Manifestations — Occasional Infection of the Eye. SECTION IX Non-tuberculous Conditions 541-559 CHAPTER LXXIX Mixed Infection 541-549 Varieties of Microorganisms — Modifications of Clinical Course — Nephritic Disturbances — Constitutional Disturbances, as Fever, Chills, Sweats, General Prostration — Detection of Microorganisms — Prognosis of Mixed Infection — Management — Most Complete Inter- pretation of the Rest Treatment — The Employment of Bacterial Vaccines. CHAPTER LXXX Pregnancy 549-554 Influence upon the Clinical Course of Pulmonary Tuberculosis — Its Deleterious Effect not Invariable — Illustrative Cases — Indica- tions and Contraindications for Interference. CHAPTER LXXXI Syphilis 555-559 Frequent Coexistence of Syphilis and Tuberculosis — Influence of Syphilis upon Vulnerability of Tissues to Future Tuberculous Infection — Effect of Syphilis upon the Course of a Previously Acquired Tuberculosis— The Modifying Action of Tuberculosis upon Syphilitic Infections of Remote and Recent Origin — Possibilities of Error in Differential Diagnosis. 12 CONTENTS PART VI Prophylaxis, General Treatment, and Specific Treat- ment 560-762 SECTION 1 Prophylaxis 560-61 1 CH.\PTER LXXXII Reciprocal Relations of Consumptives and Society 560-565 General Principles Governing Systematic Prophylaxis — Funda- mental Data Pertaining to the Communicability of Consumption — An Imperative Obligation to Enforce all Rational Methods of Pre- vention — Necessity for a Far-reaching System of Education and Control — Wisdom of Conservatism in Administrative Supervision — The Curability of Consumption — Tlie Demand for Practical Aid Rendered to the Indigent Consumptive upon Economic, Human- itarian, and Prophylactic Grounds — The Need for a Concerted Cam- paign. CHAPTER LXXXIII Compulsory Notification and Registration 566-571 Effectiveness of Notification Dependent upon Completeness of Execution — Value of an Awakened Pubhc Sentiment — The Example of New York— The Attitude of England toward Compulsory Notifi- cation — Scotland, Ireland, Denmark, Australia, Roumania, Norway, Holland, Switzerland, Belgium, Germany, France — The Status of Compulsory Registration in the United States. CHAPTER LXXXIV The Supervision and Education of the Consumptive The Primary Necessity of Instructive Appeals to the Invalid— The Obligation of the Consumptive to his Fellows— Responsible Instruction Emanating from a Duly Authorized Source — Educa- tional Literature— Periodic Visits— Features of Individual Prophy- laxis — Disposal of Sputum — Hygiene of tlie Sick-room. CHAPTER LXXXV The Extension of Material Aid According to the Varying Needs AND Requirements of Differing Classes 57 The Obligation to Render Substantial Assistance to Consumptives — Practical Aid for tliose Confined to their Homes— Institutions for Indigent Consumptives — Sanatori\im Care Demanded for those who are Hopelessly 111 and Impoverished, the \'icious Refusing to Con- form to Estafelislied Rules and the Consumptive Poor Offering, with Suitable Assistance, a Reasonable Prospect of Recoverj' — The Scope of State Sanatoria— Industrial Facilities for the Inmates of tliese Institutions— The Influence of State Sanatoria upon Neighboring Communities and Surrounding Property— The Tuberculous Dis- pensary — ^The Day Resort — Social Service Bureaus. CONTENTS 13 CHAPTER LXXXVI PAGE The Dissemination, to the General Public, through the Medium of Various Channels, op Authentic Official Information Regarding THE Prevention of Consumption 586-595 Education of the General Public — Unity of Purpose and Harmony of Action Important Considerations — Tlie Scope of Local Anti- tuberculosis Societies — The Necessity of Aggressive Initiative, Tactfulness, and Enthusiastic Devotion to Duty of Executive Officers — The Work of The National Association for the Study and Prevention of Tuberculosis — Instruction Imparted to the People through tlie Medium of the School-room — Publications — The Lecture Platform — Exhibitions — The Family Physician. CHAPTER LXXXVII What the Public Should Know 595-601 The Procreation of Predisposed Infants — The Marriage of Tuber- culous Individuals — The Dangers of Postnatal Infection — The Character and Preparation of the Food — The Frequent Contamina- tion of Milk liy Various Bacteria — The Proximity to a Consumptive within the Household — Precautionary Rules — Prophylaxis in the School-room — The Importance of Proper Nutrition — Class Breathing Exercises — Employment of Child Labor — Effect of Alcohol — Social Indulgence — Abnormal Athletic Accomplishments. CHAPTER LXXXVIII Administrative Control 601-61 1 The Suppression of Promiscuous Expectoration in Public Places — The Regulation of Schools — Inspection of Food-supply — Control of Patent Medicine Evil-and Restriction of Medical Practice — The Demand for Hygienic Construction and Sanitary Supervision of Public Buildings, Conveyances, Factories, Tenement Houses, and Commercial Establisliments — Cooperation of Operatives — Financial Assistance to Employees when Incapacitated by Disease — Compul- sory Insiu-ance for \\'orkiiig Peojile. SECTION II CHAPTER LXXXIX General Considerations 612-615 The Responsible Obligation for the Employment of Rational Conservative Measures— Fanciful Theories of Past Generations— An Array of Methods and Remedies Vaunted Even in Recent Years— Necessity for a Careful Estimate of the lm])ortance Attach- ing to the Many Phases of Therapeutic Effort— Principles of Management. CHAPTER XC -Regard for Infinite Detail 615-619 A Careful Preliminary Investigation of all Phases of the Disease, Physical, Symptomatic, and Historic — Diligent Study of all Factors Pertaining to the Patient. Teinpprampnt.Tl. Fin.iiiVial, Dimipstic, Social— Necessity for Continual Stu.ly Mil. I Mel \i,Lnl-m.'.. i;,.L',-ird- ing the Special Requirement < in i;;i(li (':i-r linplirit ( )l» ,lii ni r lo Detailed Instructions— The Duly ..i il,,. i'liy-iri;iii \aryiiii; «iili the Inherent Requirements of the Individual— Tlie De.sirability of Emphatic Unequi\'ocal Instructions. 14 CONTENTS CHAPTER XCI PAGE Adjustment of Physical and Nervous Effort 619-625 Conservation of Energy the Watchword for Consumptives — Avoidance of Fatigue from any Cause, Physical, Nervous, or Mental — Open Air often Subordinate to Complete Rest — Physical Exertion Absohitely Forbidden to Advanced Consumptives — Fever Sug- gesting a Mandatory Insistence upon Absolute Rest — Forms of Exercise to be Selected with the Greatest Care — Recreation should be Combined with Exercise — Indications and Contraindications for Pulmonary Gymnastics. CHAPTER XCII Enforcement op an Open-air Existence 626-639 Fresh Air an Essential Factor — The Inhalation of Pure Air not the Sole Desideratum — The Necessity for an Appropriate Environment — Provision for Securing the Maximum Amount of Fresh Air — Arrangements for Comfort and Shelter — Clothing — Bed-clothing — Desirable Features of an Outdoor Abode — Porch Accommodations — Tent Life — Wooden Shelters — Sleeping Out-of-doors. CHAPTER XCIII Regul.\tion of Diet 639-651 The Importance of a Gain in Nutrition through Improvement of Digestion and Assimilation — The Attainment of such a Standard of Nutrition as will Produce the Greatest Powers of Resistance — Differences of Opinion as to Amount and Character of Food Neces- sary ti> Piiimote Nutrition to Best Advantage — Limitations to an 1! il. I ii -y^tem of Superalimentation — Futility of an Arbitrary ^ Mittetics — Caloric Values — Delusive Theories Regarding I ■ :i ; I'unctional Demands — Careful Inquiry as to Digestive • aj .it:'.\ lustes of the Patient — Variety and Character of Food — Maimer ot Cooking — Dietary Direction— Outline of Meals Appro- priate for Pulmonary Invalids — Extra Nourishment — Alcohol — Contraindications for Excessive Feeding — Fever — Disorders of Digestion — Organic Changes — Psychoneuroses. CHAPTER XCIV Scope of the San.^^torium as a THERAPErric Factor 651-667 A Suitable Regime an Essential Prerequisite for Successful Man- agement — Unusual Facilities for Autocratic Supervision Afforded in Institutions — X Perfected System of Regimen Permissible Outside .Sanatoria — Practical Utility of Sanatorium Control for Carefully Selected. Cases — Summary Recourse to Complete Institu- tional Rfsime Prcjiirlit-inl to the Interests of Some Invalids — Personnl Kpi ••■ - '' •' Patient and Physician— Character of Cases A liiii !is — The P.sychic Element — Environ- ment :iihl I Hidings — Economic and Educational Phases (.1 I 111 - . .1 ■. .-nient. CHAPTER XCV The Role of Climate in the Tre.vtment of Pulmonary Tuberculo- sis 667-701 The Value of Climate Recognized from the Earliest Days of Medicine and Attested by Irrefutable Clinical Observation — A Recent Tendency to Renounce the Therapeutic Efficacy of Cli- mate — Affirmative Evidence — Definition and General Considerations of Climate — ("hemic and Bacteriologic Purity of the Air — Physi- ologic Considerations — The Potentialities of Climate Referable" to the Influence of Surrounding Air Medium upon Metabolism — The Influence of Climate upon Nutrition Largely Dependent upon the Degree of Its Heat-abstracting Capabilities — Influence of Tempera- ture, Humidity, Wind Movement — Variability of Heat-dissipation — Diminished Atmospheric Pressure — Influence of Altitude upon Red Blood-corpuscles, Blood-pressure, Respiration, Nervous System — Necessity for Individualization — Clinical Testimony Regarding the Value of Climate — Inconsistency of Opponents — Cases Appropriate for Climatic Change — Four Distinct Classes — Cases Inappropriate for Climatic Change in General — Considerations Relative to Climatic Selection — Importance of a Discriminating Choice of Climate According to the Physiologic Adaptation of the Individual — Contra- indications for Residence in High Altitudes — Cases Suited to Low Temperature with Varying Degrees of Moisture — Popular Localities. CHAPTER XCVI Treatment op Special Symptoms 701-7 1 1 Cough — Extraordinary Differences of Character — Divergence of Therapeutic Indications — Local Causative Factors — General Con- stitutional Disturbances — Detailed Hygienic Measures — Subjective Control on the Part of the Individual — Digestive Disorders: Dietetic and Medicinal Management — Organic Disturbances: Functional Neuroses — Night-sweats: Hygienic Measures — Insomnia: Attention to Predisposing Causes — Cardiac Weakness. CHAPTER XCVII Treatment of Pulmonary Hemorrhage 711-723 General Considerations — Modifications of Treatment According to Intelligent Interpretation of the Significance of Clinical Manifesta- tions — Therapeutic Management — The Initial Directing Influence of the Physician — Attention to Vitally Important Details of Manage- ment and Environment — Rational Employment of Selected Drugs — Management of Aspiration Pneumonia — Application of Special Methods. CHAPTER XCVIII General Drug Therapy 723-726 Routine Administration of Drugs Productive of Very Injurious Effects— Prevailing Tendency to Decry the Value of all Medication — Protest Against this Popular Fad — The Intelligent Exhibition of a Few Remedies Constitutes a Valuable Adjuvant to More Important Measures of Treatment. SECTION III Specific Treatment. CHAPTER XCIX Theories of Immunity 726-738 Historic Review — The Employment of Tuberculin — Inoculations With Living Attenuated Tubercle Bacilli — Maragliano's Method— Metchnikoff's Doctrine of Phagocytosis — Opsonins — Bacterial Vaccines — Wright's Method. CHAPTER C Personal Observations upon the Use of Bacterial Vaccines 739-762 General Observations — Reports of Cases — Conclusions. PULMONARY TUBERCULOSIS PART I ETIOLOGY AND PATHOLOGIC ANATOMY SECTION I General Etiologic Considerations CHAPTER I INTRODUCTION In a work devoted essentially to the clinical aspects of pulmonary tuberculosis it is manifestly impossible to dwell at length upon features of a purely bacteriologic nature, although they constitute data of enor- mous interest in connection with the general subject of tuberculosis. A vast amount of scientific work has been performed by enthusiastic students during the cjuarter century since the discovery of the tubercle bacillus by Robert Koch. The results of their labors have been of tre- mendous value from the standpoint of scientific investigation, and of vital importance in the elucidation of practical problems pertaining to the etiology of this disease. Their patient toil in the realm of animal experimentation and of laboratory research has been productive of such a mass of absorbing medical literature as to preclude more than its cur- sory mention even were this book limited solely to a historic review of the progress achieved along these lines. Much less, then, is detailed reference permitted to the innumervable contributions of the many workers in the field of scientific study, the sum-total of whose observa- tions is of such infinite magnitude. A volume of enormous proportions is needed to accord justice and honor to the noble work of the earlier students. It would, indeed, be a Herculean task for one not especially trained in the technic of laboratory methods nor fully conversant with the intri- cate details and scope of previous investigation to attempt in review an elaborate exposition of the achievements of individual students during the slow evolution of our present knowledge concerning the etiology of tuberculosis. There is disclaimed any original scientific study or pro- found knowledge of the special departments relating to bacteriologic or histologic research. There will be no attempt to introduce contributions of this nature nor to advance unsustained personal opinions concerning the proper interpretation to be placed upon the reported results of exper- 18 ETIOLOGY AND PATHOLOGIC ANATOMY imental work by others. In such purely technical matters it is hoped to voice, as far as possible, the consensus judgment of those who are quali- fied by experience and equipment to form lational conclusions. Elabo- rate scientific treatises abound which present in detail the results of individual observations concerning the tubercle bacillus and the many aspects of infection. The large and comprehen.sive volume by Straus upon the bacillus alone is an example of the stupendous amount of litera- ture extant in relation to features of etiologic interest. An effort will be made in this connection merely to review the more practical and essen- tial etiologic facts without undue consideration of the various theories as yet incapable of complete verification. HISTORIC REVIEW Tuberculosis is, beyond question, the most important disease with which the human race has ever been obliged to contend. Its antiquity dates from the earliest records accessible to man. The writings of Hippocrates, 460 to 377 B. C, contain a description of the disease so correct in its essential details as to equal a work of modern excellence. From the period of Galen, 200 B. C, until the present time widely diver- gent conceptions have been entertained as to the pathology of consump- tion, but a uniform opinion has prevailed relative to its clinical character- istics. Only in comparatively recent years, however, has belief in its curability become general. Recognition of nodules or tubercles in the lung was obtained about the midclle of the seventeenth century. Upon beginning anatomic investigation and with the chscovery of cavity for- mation and pus collections numerous conjectures were offered as to the pathogenesis of the disease. The first efforts toward inoculation experi- ments were made in the early part of the nineteenth century, and were not attended with clearly definable results. Consequenth' there was much speculation concerning the possible infectiousness or transmissi- bility of tuberculosis. Laennec contributed much to the knowledge of the disease by establishing a more definite relation between tubercles and consumption, and by advocating the identity of pulmonary and glandular tuberculosis from a pathologic standpoint. :iltli(umh the spe- cific microorganism, of course, was unknown. Rokitaiisky was an expo- nent of the same doctrine, but insisted upon the significance of a certain adaptabUity or susceptibility to consumption, as evinced by a peculiar type, or "phthisical habitus." Virchow cleared the atrnosphere to some extent by expounding the pathologic and histologic structure of tubercle. Microscopic research had been undertaken previously by Lebert, who described the so-called "tubercle corpuscle" as a non- nucleated cell in the midst of tubercle formation. The first experimental evidence of the inoculation transmission of the di.sease was furnished by Klencke in 184.3. He inoculated rabbits with tuberculous material, and at autopsy, twenty-six weeks later, found cUsseminated tubercle deposit in the liver and lungs. In 1857 Buhl promulgated the doctrine of the origin of miliary tuberculosis as a result of the distribution, through the medium of the circulation, of an agent derived from an area of infec- tion within the body. Villemin in 186.5 conducted a .series of inoculation experiments of the greatest value. In addition to introducing into animals an infective material obtained from tuberculous tissues and the sputum of consumptives, he injected into a second class non-tuberculous THE TUBERCLE BACILLUS 19 pus, and in a third, the caseous matter from tuberculous cows. A tuber- culous deposit was found after the introduction of purely infective matter from any source, confirming the theory of the specific infectious nature of the cUsease. An apparent identity of human and bovine tuberculosis also was suggested by the demonstration of tuberculous changes in all instances irrespective of the derivation of the infective agent. Despite vigorous opposition and conflicting results of animal experimentation by others, belief in the correctness of Villemin's con- clusions became established upon a firm basis through the supplemental experiments of several observers. Among these, Cohnheim contrilsuted prominently to the acceptance of Villemin's teaching by his method of inoculation into the anterior chamber of the eye of a rabbit. By this means opportunity was afforded for visual inspection of the m^nhial development of pathologic change. The er- cle. Since this time a mass of evidence has been presented by numerous observers both for and against the acceptance of essential differences in the cultural characteristics, virulence, and powers of transmission of the bacillus in the several animals in which a natural habitat is found. Despite a degree of similarity of the clinical manifestations in different species, important difference.?, referable to the bacillus of various types have been noted and will be the subject of future discussion. The tuber- cle bacillus of human origin is of more essential present interest. CHAPTER II THE TUBERCLE BACILLUS In view of all that has been written of this microorganism, attention will be called merely to a few of its more important features. The tubercle bacillus is a small, immobile rod of somewhat varying size and shape. Tlie average length has been described as from one-fourth to one-half the diameter of a red blood-corpuscle. Differences in length, however, are found to e.xist in accordance with the virulence of the 20 ETIOLOGY AND PATHOLOGIC ANATOMY bacilli and the age of the culture. An evidence of attenuation is found in a greater lengthening and thinning of the microorganism, and of virulence by the presence of short, thick bacilli. A considerable vari- ation in size is recognized in bacilli taken from the sputum, which, as a rule, are of greater length than those observed from culture growth. Differences also exist in the contour or shape of the microorganisms, in their disposition with reference to one another, and in their specific staining reaction. A notched, beaded, or clubbed appearance, with a tendency toward flexion, is suggestive of an old attenuated bacillus. A fragmentary or broken-down rod also is strongly indicative of degener- ative change. On the other hand, the aggregation of bacilli in clumps, as opposed to an isolated or scattered disposition, is somewhat character- istic of active virulence. The same is true of their ability to take rapidly a deep primary stain. An essential property of the tubercle bacillus is its resistance to decolorization by acids. On account of this attribute it is easy to recognize the bacillus in the sputum after the removal of the primary stain from the cellular elements and associated bacteria. The subsequent blue contrast stain of these portions of the specimen renders the continuous red color of the bacilli especially pronounced. An impor- tant preliminary to the staining process is the selection from the midst of the tuberculous sputa of small cheesy particles often found in the more dependent portions. Tubercle bacilli are much more frequent in these caseous deposits than elsewhere in the expectoration. When the bacilli are particularly scanty, it is sometimes advisalale to dilute 100 c.c. of sputum with 200 c.c. of water to which have been added about 8 drops of a 10 per cent, solution of sodium hydroxid. A homogeneous solution is obtained by boiling, and the centrifuged sediment is examined for tubercle bacilli. A thin smear of this portion of the .sputum should be made either upon the cover-glass or the slide. Several methods of stain- ing are employed, notably the procedures of Gabbet, Ehrlich, the Weigert-Ehrlich, the Ziehl-Neelsen, and the Pappenheim. The principle employed in each instance is the production of a deep, primary red .stain with carbol-fuchsin and the subsequent decolorization of ail portions of the specimen except the tubercle bacilli, which later are made more conspicuous by the contrast stain of the cellular elements. The carbol- fuchsin solution is composed of one part of fuchsin, 100 parts of a 5 per cent, solution of phenol, and 10 parts of alisolute alcohol. The decolori- zation is scruicd ]- for six numtlis, l.ui iatcl\- Imiuer. Other observers have found the \itality tn \ar\ within wide limits under differ- ing conditions. Some report a loss of virulence after two or three months at most, and others not until after nine months. Cornet assumes that, under ordinary circumstances, the vitality is destroyed in about three months, and that a retention of pathogenic power for a period of six months is exceedingly rare and occasioned only by the existence of extraordinary conditions. It is evident that the lack of uniformity of results is attributable to essential differences in the conchtions to which the sputum is subjected, viz., the thickness of the layer, the exposure to the sun or to diffused sunlight, and the degree of moisture and wind as determined by seasonable changes. In this coiuiection it is reasonable to assume that il' di'st luction of growth and \italit\- ensues as a direct result of fundainciital atliibutes of weatlicf. iiicliiding sunshine, degree of moisture, air movement, etc., important lUffcrences inevitably must accompany the climatic conditions under which the experiments are conducted. In other words, if sunshine and dryness are essential factors to overcome the vitality of the bacilli, widely varying results should be reported during seasons when rains do not prevail and in localities where sunshine is almost continuous. To this end the experiments of Gardiner, of Colorado Springs, at an altitude of 6000 feet, are of con- siderable interest. C5ardiner exposed to the direct rays of the sun, sputum from a tuberculous patient containing bacilli of e.stablished virulence. The sputum remamed for varying periods upon sandstone and wood. It was found that a hard, superficial crust formed in the process of drying, and that it was impossible to detach even minute quantities from this surface with the blow-pipe. Actual grinding of the cru-st was required in order to produce distribution of the bacilli. After one and three-quarter hours of exposure the sputum was rubbed up with sterilized water and inoculated into guinea-pigs, with positive results in one case. It is noteworthy, ho\\c\cr, that the portion selected for inoculation was taken from a mass of omt two drams of unsmeared sputum, the upper surface of which had hardened into an impermeable crust. Ransome and Delephine had previously conducted an elaborate series of experiments which showed the preponderating influence of direct sun.shine as a destroyer of bacillary activity. Sputum exposed to light (not direct sun's rays) and air for forty-five days did not pro- duce tuberculosis after inoculation of rabbits. An exposure to air without sunlight during the same period was insufficient to destroy the power of transmitting the disease. Guinea-pigs were found to respond positively to sputum exposed to air in dark places, but neg- atively if the sputum had been subjected to diffused light as well as air 24 ETIOLOGY AND PATHOLOGIC ANATOMY for an equal length of time. It was found that an exposure to light for three days and one hour was sufficient to render the bacilli inert. The inference was gained from these observations that sunshine was the all-important factor for the destruction of the pathogenic virulence of the bacilli. To what extent moisture or dryness entered into the elucidation of the problem was not determined at that time. Migneco found that the bacilli in dried sputum were not killed until from twenty to thirty hours' exposure to sunlight in Italy. In 1899 MitcheU and Crouch, of Denver, after an elaborate investigation, found dried sputum to be quite virulent up to twenty hours' exposure in direct sunlight, after which the virulence became attenuated and was lost in about thirty-five hours' exposure. Recent observations by Twitchell have been conducted most carefully and furnish desirable information con- cerning the influence of dryness and temperature as well as sunlight. Direct sunshine was found capable of rendering bacilli inert after a few hours, which result is much in accord with that of Koch, who, in 1890, asserted that destruction ensued in from a few minutes to several hours. Straus found bouillon cultures were killed in two hours. Twitchell's technic was evolved so perfectly and the conclusions are so incontrovertible that a brief abstract of his methods and results is appended: One c.c. of virulent sputum from two patients with active tuber- culosis was deposited in sterilized, corked, and paraffined white glass bottles, 3 c.c. in diameter, with a depth of 1 c.c. One bottle was placed in a dark, moist box, and similar bottles in a dark closet, and in the diffused light of an ordinary room. In another series of experiments the bottles were exposed to like conditions, but were stoppered with cotton. Still again the .sputum was deposited in sand within the bottles, with the bottles corked and paraffined in some instances and unsealed in others. Sputum deposited in sterilized white glass bottles with and without sand, sealed and unsealed, were placed in the thermostat. Open white glass bottles of sputum were deposited in the open air during the winter months. Corked and paraffined bottles were buried in the ground. Other bottles corked and paraffined were packed in ice or frozen in blocks of ice. Sputum was deposited upon handkerchiefs, carpets, wood, and woolen blankets under ordinary room conditions. Subsequent in- oculation experiments with the sputum placed in sand and in blocks of ice were not satisfactory. The sputa placed in a dark moist box or a dark closet, under the varying conditions described, produced tuberculous le- sions in guinea-pigs after one hundred and fifty-seven days, but in no in- stance after one hundred and eighty-eight daj's. Positive results attended the inoculation of guinea-pigs with sputum contained in paraffined bottles after exposure to the diffused light of an ordinary room for one hundred and twenty-four days, but not after one hundred and seventy-five days. The sputum in open bottles placed out-of-doors in the winter months produced tuberculous lesions after one hundred and ten days, but not after one hundred and thirty-two days; the sputum from ice after one hundred and two days, but not after one hundred and fifty-three; from a handkerchief or woolen blanket after .seventy days, but not after one hundred and ten. The same was true of the sputum deposited upon wood. Tuberculous lesions were produced by the inoculation of sputum deposited upon the carpet after thirty-nine days, but not after seventy; upon the sand in a light, dry place after thirty days, but not after Fig. 1. — Tubercle bacilli from specimen of sputum— the so-called virulent type. Note the short, bright-staining rods, also presence of clumps. Note, further, broken-down appearance of cells and tissue. This is from patient having very large cavity. See radiograph, Fig. 72, p. 276. Fig. 2.— Bacilli decolorized by alcolio undoubtedly smegma — fro ; same case as preceding. ifugcd specimen of urine ; THE TUBERCLE BACILLUS 25 seventy. The sputum exposed to the direct rays of the sun was found productive of a tuberculous lesion after one hour, but not after seven hours. Culture growth of the tubercle bacillus has been known for years to be inhibited by the introduction into the media of a variety of substances in certain proportions. Chief among these are creasote and iodoform. The practical application of their action upon tubercle bacilli has been attempted by means of inhalations of the former, local injections of the latter, and internal administration of each. Although favorable results have been reported from time to time, their use in general has been disappointing and sometimes injurious. The human body, on account of innumerable complicating conditions and processes, is not to be adjudged a culture-medium upon the basis of which internal therapeusis is to be determined. The life of the bacillus external to the body is found to be destroyed by the action of numerous chemicals and by pro- longed boiling. Corrosive sublimate, so freely employed for the dis- infection of sputum, is, as a matter of fact, of little value on account of the protective coating of the bacillus by the coagulation of the albumi- nous matter. Twenty-four hours is required for the destruction of the vitality of the bacilli by a 5 per cent, solution of phenol. The presence of various bacteria in culture experiments or in decomposing sputum is inimical to the growth of tubercle bacilli. This is due to the compara- tively rapid growth and development of other microorganisms. The chemic composition of the tubercle bacillus has been the sub- ject of careful investigation, which has been reported by Hammerschlag, Behring, Hoffmann, de Schweinitz, Aronson, Ruppel, Levene, Baldwin, and Trudeau. It is evident, as a result of their research, that the fatty or waxy constituent is of considerable importance and obtains in much larger proportion than is the case with other bacteria. This has been found to be the only portion of the bacillus to retain the stain after the exhibition of the acicl, all the other component parts surrendering the color immediately. Baldwin has shown that the fat, however, is not an element of material significance in the production of toxemia, as the tuberculin reaction was present in animals previously inoculated with fat-free bacilli. While the fat may be assumed to form an average of 30 per cent, of the substance of the bacillus, a considerable variation has been found in the relative proportions by different observers. These fluctuations have been ascribed to the employment of various media and to the differences of method in estimating the amount of fat. Both Trudeau and Baldwin have reported separately the results of Levene's work in connection with the nucleoproteids. Three distinct forms of these substances were recognized, all containing phosphorus. Nucleic acid was found by Levene and Ruppel after treating the watery extract of pulverized tubercle bacilli with acetic acid and analyzing the resulting filtrate. The toxic properties of the bacillus are referable to this deriv- ative. Levene and others have demonstrated also the presence of carbohydrates. VARIOUS TYPES OF TUBERCLE BACILLI It has been shown that numerous microorganisms closely resemble the tubercle bacillus in form, size, and staining reaction, but exhibit differences in cultural characteristics, especially with reference to less- 26 ETIOLOGY AND PATHOLOGIC AXATOMY ened resistance and greater susceptibility to temperature conditions. In addition to the variations of virulence and growth among- tubercle bacilli it has been found that other differences exist according to their habitat. Theobald Smith has called attention to what he terms " the complex relationship established in time by a selective adaptation between two living organisms, of which one is the parafsite of the other." He empha- sizes the interdependence of both organisms, and ascribes a disturbed equilibrium between the two as a sufficient cause for important clumges in the bacillus as well as in the host. These differences in the cultural attributes of the bacilli, their virulence, and the character of resulting pathogenic processes are capable of explanation upon the basis of funda- mental changes in the species, in which the bacUlus is permitted to abide with a forced adaptation to the environment. Irrespective of these broadly conceived hypotheses, which are worthy of the utmost consideration, it is true that essential differences are recog- nized between several distinct types of tubercle bacilli, i. e., those of human origin, the bovine, the avian, and the bacilli of fish or other cold-liloodcil animals. The human and bovine forms are described as mammalian liarilli. which, with the avian, have certain characteristics in cent ladi-^i inctiDii to the bacilli found among fish. The latter bacillus is unable to survive at the temperature of the human body, and, therefore, is incapable of transmitting tuberculosis to man or animals. Among the three varieties of bacilli sometimes found in warm-blooded animals, the avian presents important features of dissimilarity in comparison with the human and bovine forms. Rivolta, Maffucci, Ribbert, Straus, and Koch have pursued investigations concerning the relation of this to the other types of tidaerde bacilli. The avian bacillus was found to with- stand a greater degree of heat than the human or bovine, its growth not being inhibited until after the temperature was elevated nearly two degrees higher than was required for other forms of tubercle bacilli. Birds upon inoculation with human bacilli were found to exhibit liut slight local reaction, without evidence of constitutional change. Nocard showed that mammalian bacilli grown in sacs of collodion within the peritoneal cavity of chickens could be modified to such an extent as to produce tuberculosis in fowl. On the other hand, Courmont and Dor demonstrated that when the avian bacillus was grown at lower temperatures and passed through rabbits it became endowed with jiatho- genic property for mammalia. Roemer reported that an interesting epizootic amoiiLi, ( hickciis resulted from eating the entrails of a tubercu- lous cow. Shatiixk. Scji^man, Dudgeon, and Panton. in a recent study of the relatiousiii]! Iictwecn avian and human tubercle Iiacilli, conclude that the human \ariety is but slightly pathogenic to the pigeon, and when introduced with food into the digestive canal, induces no local lesions of the intestine or abdominal viscera. They report that but slight local or glandular processes are produced by the injection of human bacilli into the muscles or subcutaneous tissues. Curiously conflicting results were obtained from inoculation of the rabbit and guinea-pig with avian bacilli, the former quickly yielding to ovncral infection and the latter exhibiting but slight susceptibility. Thi-c louli^are all the more remarkable in view of the relatively greater icsisiainf ni the rabbit than the guinea-pig to human bacilli. Flexner has called attention to the fact that, in spite of the susceptibility of the rabbit to the avian THE RELATION OF HUMAN AND BOVINE BACILLI 27 bacillus, the pathologic processes are radically different from those appearing as a result of infection with mammalian bacilli. He cites the absence of tubercles and caseation in the presence of an enlarged spleen. The avian, although occasionally present in lower animals, have never been discovered in man. CHAPTER III THE RELATION OF HUMAN AND BOVINE BACILLI The relation of human and bovine tuberculosis for several years has engaged the attention of the best observers. Koch, upon announcing the discovery of the tubercle bacillus in 1SS2, proiiiiiltiatcd the dictum that human and bovine tiibciculdsis wcic ulcniical, nml tliaf the bovine type was directly transmissible Id man. \iicli(i\\ had stated in 1863 that the two chseases were entirely distinct. This view, however, after the assertion of Koch, was not accepted by the profession in spite of the fact that Chauveau, Giinther, Harms, and Bollinger, after feeding calves, swine, and goats with human tuberculous material, had failed to produce tuberculosis, although these animals quiclNl\ succumlied if the food contained milk and pieces of lung from luliciculdiis cattle. In 1893 Baumgarten questioned the complete identit_y of tlie two diseases and cited the previous failures to effect a transmission of tuberculosis to cattle through the medium of human bacilli. He also reported work done by Gaiser under his direction to substantiate the correctness of his view. A calf inoculated with human bacilli exhibited no evidence of disease, and when killed after several months showed no trace of tuberculous change. Another subjected to iiKiciilatidu with b(i\ine liaeilli in the anterior chamber of the eye and in the Hank, ihs|ilayed a ty])ical tuber- culous process of the eye, and aller much emaciation dieil in six weeks, showing at autopsy general iniliai\ tubeicuhisis. In IN'.IN Smith, in this country, obtained negainc icsults iVcmi iln' incicnlaiKin i<\' cattle with human liacilli. Similai-e\|)eiinients were iccorded by I'mlhinnhani and Dinwiddle in the following year. Their conclusions, however, were not to the effect that human tuberculosis was incapable of trans- mission to cattle, but merely that the bovine bacillus possessed a higher pathogenic power for these animals than the l)acilli of hnman origin, to which the cattle were believed to be more or less i(si>ian(. Theol)old Smith had expressed doubt as to the absolute idenlii\ n\ the two dis- eases, but did not advance the theoiy of ini|j(issil lilii y of i lansmission. Koch, however, in 1901 openly disaAdwed his pivxidu- conclusions and maintained that human tuberculosis dillered trom hox me and coul.l not be transmitted to cattle. He also assumed that infection from the bovine bacillus rarely, if ever, took place in man. In substantiation of the first proposition he placed upon record the results of experiments conducted during the |ifei-edinu two years by Schiitz and himself. Nineteen younn cattle lice iVoin i ui.enulo-is were subjected to prolonged periods of inhalation exposure, lo lo(]il infection, and to direct inoculation by human bacilli. These animals, after six to eight months, presented no trace of tuberculous lesion at autopsy. The 28 ETIOLOGY AND PATHOLOGIC ANATOMY same attempts with bovine bacilli were attended with constitutional sj'mptoms within one week, and extensive tuberculous changes were found at autopsy two or three months later. Similar experiments with human and bovine bacilli yielded like results in swine, asses, sheep, and goats. In support of his second proposition he pointed to the large num- ber of bovine bacilli contained in butter and milk and to the alleged rarity of primary intestinal tuberculosis in infants. He cited statistical ob- servations concerning the infrequency of this condition, although little children especially were recognized to be exposed and predisposed to infection. But ten cases were observed during a periotl of five years in the Charite Hospital in Berlin. Baginsky was reported as never having observed, out of 933 cases, an instance of intestinal tuberculosis without simultaneous involvement of lungs and glands. Biedert was quoted as having seen but sixteen cases out of a total of 3104 autop- sies upon tuberculous children. Baumgarten, a few months after Koch's address, indorsed the position assumed with reference to the non-transmissibilit}' of the two diseases, and made, as he stated, an important contribution to the subject by recalling the experiments of Rokitansky. The latter, firm in the belief of the unity of human and bovine tuberculosis, had inoculated with bacilli from cattle a number of patients suffering from incurable malignant diseases. This was done in the hope of establishing an antagonism between the tubercle bacilli and the bacteria of previous infection, thus affording a cure to otherwise hopeless invalids. Large numbers of tubercle bacilli of bovine origin were injected without noticeable results other than small localized abscesses at the points of inoculation. The autopsies upon these patients were performed by Baumgarten, and in spite of critical macroscopic and microscopic examination of the tissues and glandular structures, no evidence of tuberculous infection was discovered. While thus espousing Koch's teaching on account of the failure of inoculation experiments both upon man and animals, and while denying any especial danger to man from the consumption of bovine products, Baumgarten insisted, however, upon certain strong points of resemblance between the two diseases. He referred to the histologic identity of the tuber- culous lesions in man and cattle as established by Schiippel, and pointed to the similar degenerative changes in the two conditions. He cited the production of acute miliary tuberculosis in cattle after infection with bovine tuberculosis, precisely as in man with the human bacillus. He further called attention to the same reaction in cattle as in man following the injection of tuberculin derived from human bacilli. These various facts, supplemented by a supposed morphologic and cultural identity of the two liacilli, were deemed sufficient by Baumgarten to establish a close similarity of human and bovine tuberculosis, notwith- standing the disparity shown by inoculation experiments. Virchow. in an addre.ss delivered before the Medical Society of Berlin in July, 1901, one or two days following Koch's communication in London, referred to his previous statements in 1863 regarding the non-unity of human and bovine tuberculosis. He said: "I was not surprised to hear that Professor Koch had finally convinced himself that they were two different things, even after my old thesis containing the same statement has been regarded by the Koch school for a con- siderable length of time with a certain contempt, and I have borne their judgment with patience. I certainly have never understood how any THE RELATION OF HUMAN AND BOVINE BACILLI 29 one could maintain that the two were identical." He further empha- sized the existence of true pathologic tubercle as a sine qua non for genu- ine tuberculosis, insisting that the bovine infection was an example of bacteriologic disease rather than of typical pathologic tissue change. Virchow did not refrain, however, from disparaging Koch's contention concerning the rarity of primary intestinal tuberculosis. He called attention to the existence of unusual intestinal and peritoneal lesions observed at the Charite, exhibiting growths peculiar to the so-called "perle disease" of cattle, but scarcely attributable to human bacilli. In view of these somewhat contradictory statements from many preeminent European authorities, based upon the results of careful study and experimentation, a renewed impetus was given to a study of the subject. Commis,sions were appointed in Germany and Great Britain to investigate this matter, and a vast amount of exhaustive research was conducted in the United States. The German authors, as a rule, were inclined to support Koch's views, although several dis- senting opinions were expres.sed, notably those of Behring and Dungern. Weber recently has reported observations of interest and value made by the Berlin Board of Health. The liovine bacillus was found fifteen times in the cervical glands of chDdren. He asserts that this vaiiety occurs almost exclusively in the young, and that a marked tendency toward spontaneous cure is noted. In almost all instances I'epoiled the children were under seven years of age. He has been able to dis- cover no instance of transmission of the bovine infection from one human being to another, and is constrained to believe that the tlanger of infection to man from bovine tuberculosis is in.significant as compared with that from the human variety. Raw, although recently announcing his conviction as to the dissimi- larity of human and bovine bacilli, yet attributes a large amount of tuberculo.sis in children to the introduction of the latter. He calls attention to the conspicuous differences between the clinical manifes- tations of pulmonary phthisis and other tuberculous affections, and em- phasizes an apparent antagonism between pulmonary and surgical tuber- culosis. He asserts that children who have suffered from strumous glands, spinal caries, tuberculous joints, and lupus are immune to phthisis pulmonalis. and, conversely, points to the infrequency of gro.ss tuberculous lesions in cases of pulmonary tuberculosis. Upon the basis of these clinical differences, and the fact that surgical tuberculosis is essentially a disease of chilillKiiHl, he concludes that the characteristic divergence of losioiis is ]>r('Slml|)ti^•o cxidciicc of di -iinil.-ii- bacilli. Re- lying upon clinic:!! ;iiid nuldpsy iil iscn:il idii . H.^cilici- «ith certain inferences from aiialony. he sulnnits ihr pl■ovi^io|lal o]iiiiion that the enlarged lymphatic lilaiuls of the iicc!<. I nl •(a(ai|oii-' pri'iioiiitis, tuber- culous l)ones ami joints, t uIhtcuIous mciiin^it i~. ami lupus are occa- sioned by the invest ion of bovine liacilli, while the origin of pulmonary phthisis is attiibutcil lo the introduction of the human bacillus. The British Conum-sion, appointed after the close of the Inter- national Antitut>errulous Conference in London in 1901, was composed of the renowned Sir Michael Foster, chairman, and Professors Wood- head, Martin, Boyce, and MacFadyean. Their first report, published in 1904, expressed quite clearly a disinclination to accept the teaching of Koch as to the non-intercommunicability of human and bovine tuber- culosis. Numerous experiments were undertaken by the commissioners 30 ETIOLOGY AND PATHOLOGIC ANATOMY to determine primarily whether the disease in animals and man was one and the same, and whether infection could take place from one to the other. Investigations were made by a comparison of the lesions produced in cattle upon the introduction of bacilli of human and bovine origin. Similar experiments were performed upon the anthropoid ape, an animal nearly related to man, and al.so upon guinea-pigs, rabbits, goats, dogs, cats, and rats. Bacterial cultures of bovine bacilli, as well as emulsions of tuberculous lesions from thirty cases of bovine tuberculosis, were in- jected into strong, healthy animals previously tested with tuberculin. In some cases the introduction was made subcutaneously, in many, into the veins of the udder, and in others, by means of the food. In numerous cases of subcutaneous injection it was found that the proximal lymphatic glands soon became involved, that fever developed about the twelfth day, and that death took place from the twentieth to the fiftieth day. At autopsy there was found general tuberculosis of the glands and serous membranes, the lungs, liver, and kidneys. In some cases, however, there were merely local symptoms of but temporary duration without especial pathologic change at autopsy. These cUvergent results were explained by the introduction of varying quantities of infective matter and by a possible difference in the resisting powers of the animals. It was found, also, that those having been subjected to udder injection exhibited a considerable variation in the character of the resulting changes. In some cases death supervened quickly, with postmortem evidences of extensive tuberculous disease. Others displayed but local evidences of infection, which subsided after a short time. Five calves out of six sucking from infected udders showed signs of local and general tuberculosis, as did monkeys, pigs, rabbits, guinea-pigs, and goats after inoculation or feeding with bovine bacilli. More resistance was shown by dogs, cats, and rats. Sharply de- fined differences were displayed in the virulence of tubercle bacilli taken from fourteen cases of human tuberculosis and injected into animals. In one group general tuberculous changes were produced after inoculation of cows and the other lower animals employed in pre- vious experiments with bovine bacilh. In this group there was but slight variation noticed in the virulence of the two types of bacilli. In another group, however, bacilli or tuberculous material taken from forty ca.ses of human tuberculosis produced merely a slight local inflammatory change, with swelling of the nearest lymphatic glands. In some of these cases the injection of large quantities of infective material did not produce any evidence of a general advancing tuberculosis, either in cattle, cats, or dogs, although there were several instances of slight non- progressive organic involvement. Monkeys, as a rule, were foimd to be non-resistant. The Commission attributed the divei'gent results of these experiments to differences of animal resistance and to variations in the virulence of the inoculated material. The report of the Com- mission is summed up as follows: "There can be no doubt that in a certain number of cases the tuber- culo-sis occurring in the human subject, especially in children, is the direct result of the introduction into the human bod}' of the bacillus of boxnne tuberculo.sis, and there also can be no doubt that, in the majority, at least, of these cases, the bacillus is introduced through cow's milk. Cow's milk containing tubercle bacillus is clearly the cause of tuberculo- sis. A very considerable amount of disease and loss of life, especially THE RELATION' OF HUMAN AND BOVINE BACILLI 31 among the young, must be attributed to the consumption of cow's milk containing tubercle bacilli. The presence of tubercle bacilli in cow's milk can be detected, though with some difficulty, if the proper means be adopted, and such milk ought never to be used as food. There is far le.ss difficulty in recognizing clinically that a cow is distinctly suffering from tuberculo.sis, in which case she may yield tuberculous milk. The milk coming from such a cow ought not to form a part of human food, and, indeed, ought not to be used as food at all." These conclusions are directly in accord with the opinions expressed by Drs. Schroeder and Cotton in this country. Their researches are reported in detail in " The Bulletin of the Bureau of Animal Industry of the United States Department of Agriculture,' ' recently issued. They even affirm that a tuberculous cow constitutes an element of much greater danger to the health of the community than a human consump- tive. Considerations pertaining to this subject will be later discussed at some length. In America, since the promulgation of Koch's doc- trine, much interest has been attached to an investigation of the inter- communicability of human and bovine tuberculosis. Ravenel called attention to the experiments conducted in 1901 by Chauveau, who finally succeeded in infecting cattle with bacilli of human origin. Well-markerl tiiberculous proce.sses were found in three cows following the inti-o(hicti(in f si\ li\- int loduciim tu- bercle bacilli with the food. In 1902 Kaxcncl iciMnicI llic ivs\ilts of his own investigations, dating back four years. < )f Imircahcs iimculated with human bacilli into the peritoneal ca\-ity. one exhiliitcd pidiMniuced illness during life and three showed at autopsy unmistakalilc c\idciices of tuberculous infection. An experiment of vast iin]i(iiiaiicc ccm- ducted by him was the inoculation of two calves with a cull are olj- tained from the mesenteric gland of a child whose death resulted fiom tuberculous meningitis, but who exhibited clear evidence of a primary intestinal lesion, presumably of bovine origin. The utmost virulence characterized the infection in each instance, and a c(iiirhi,-i(iii a-^ to the probable bovine type of the bacillus appeals ciniiienilx laiiunal. He later published the reports of four ca.ses (if accident.al iiifcition of the hands with bovine bacilli, reference to which will be made in con- nection with the skin as a channel of infection. S. von Ruck, in an exhaustive article upon the intercommunica- bility of human and bovine tuberculosis, takes exception to much of the inoculation evidence adduced by various observers in refutation of Koch's position. He points to possible sources of error and believes the results are subject to considerable criticism. He refers to the work of Waldenburg, Fox, Panum, Wyss, Cohnheim, Frankel, and other con- temporaries of Villemin, who severally succeeded in producing pseudo- tuberculosis after inoculation with non-infective material, or with tuber- culous matter rendered innocuous by boiling and prolonged submersion 62 ETIOLOGY AND PATHOLOGIC ANATOMY in alcohol. The substances injected consisted of metallic mercury, coal-dust, fresh blood of guinea-pigs, paper, lint, rubber, and pieces of sponge. It is probable, however, as pointed out by several observers at that time, to which reference has been made, that the opposition to Villemin resulted from imperfections of technic in the conduction of experiments, and that actual tuberculous material was introduced without the knowledge of the operator. It cannot be possible that such sources of error could obtain with experienced and skilful experi- menters at the present time, especially when one considers the attain- ments of those who have conducted recent investigations. It is no reflection, however, upon the merits of the earlier observers to ascribe their results to obvious possibilities of error in their attempts to transmit artificial human tuberculosis to cattle. Although Prudden, Hodenpyl, and others have shown that the intravenous injection of dead bacilli ma_v be followed by characteristic tuberculous lesions, this, contrary to the assumption of von Ruck, affords in itself no convincing argument preju- dicial to the reliability of recent inoculation experiments. Attention has been called to the contention of Baumgarten concerning the impro- priety of intravenous or intraperitoneal injection, and the greater ad- vantage of subcutaneous inoculation. This is alleged upon the ground that the latter offers opportunity to study the nuiri.ii'iit proof that tubercle bacilli may retain their virulence for ye;ii> ami \ it remain in the body as innocuous non-multiplying parasites without encapsulation. He evidently does not believe that their prolonged sojourn in the glandular tissues, even if true, can be considered an effective argument in favor of their intra- uterine origin. Despite his protests, there appear to be ample clinical and experimental ilata in support of a belief in latent infections of very prolonged duration. Huebner has recently reported that tubercle bacilli are agglutinated by the blood of many non-tuberculous children. This at least may be regarded as provisional evidence concerning the existence of latent foci of infection. The blood from the umbilical cord was reported never to agglutinate the bacilli. The lowest percentage of agglutination was found in children entirely devoid of clinical evidences of tuberculosis, and the highest, in those presenting suspicion of a scrofu- lous taint. A high percentage was also found in those with hypertrophied tonsils and adenoids. Salge has reported that the lilood of babies vmder one year of age without suspicion of tuberculo.^is agglutinates tubercle bacilli in 12.5 per cent, of cases. Schkarin recorils a po.sitive result of the agglutination test in 21.4 per cent, of non-tuberculous children. From these reports it must be admitted that latent foci of tuberculous infection are much more common in little children than is generally supposed. It hardly foUows, however, that this should be regarded as proof of heredi- tary transmission, although the evidence, as to an increased inherited predisposition, is quite conclusive. The frequency of the disease at an early age, however, is irrefutable and is responsible in a measure for Baumgarten's contention. Mortality statistics are extremely high, particularly after the last quarter of the first year, and increase progressively with each year of life up to the age of fifteen or sixteen. It must be rememljered that infants are remarkably susceptible to tuberculous infection, and that, as a rule, the course is excessively rapid. It would appear that but little resistance is offered to the onward progress of the bacillus. It is well known that the tis.sues are much more deUcate in structure and more easily permeable by bacilli than in adults, and that the lymphatic spaces are proportionately larger, offering less obstruction to the advance of the infection. It .seems diffi- cult to reconcile these established facts with a theory of the congenital transmis.sion of the microorganism as well as of the toxins. If the latter be conceded to restrict development and impair resistance, there could scarcely continue an indefinite period of bacillary infection without clinical evidence of the di.sease. That latent tuberculous foci do exist in many cases is beyond (Uspute, but it may be questioned properly if the sources of infection in such ca.ses are not extra-uterine rather than congenital. This hypothesis is the more reasonalile in view of the nega- tive evidence previously presented regarding the infrequency of tuber- culosis in utero. In this manner an explanation is afforded as to the existence of latent infection in children which is impossible of rational interpretation from an acceptance of the doctrine of hereditary trans- mission. Baumgarten, in his advocacy of the inheritance idea, has adduced two arguments to substantiate his position, which are evi- dently opposed to each other. He advances the theory of a wide- spread latency, and, at the same time, points to alarming statistics of infantile death from tuberculo.sis. The former is explainable only THE CONGENITAL METHOD OF INFECTION 41 upon the assumption of a perfectly established defense on the part of an organism infected prior to birth, and the latter upon the belief in a relatively diminished resistance at this time of life. Upon the other hand, the opponents of his theory can easily reconcile the existence of latent tuberculous infection in some children to their relatively increased powers of defense. The general fi-ecpiency of the disease among the very young may be explain(>(l in part by the unusual opportunities for extra- uterine infection ari.-;inii IVdiii llir almost ubiquitous distribution of the bacilli and the peculiarly iiie.spuusible habits characteristic of this age. The possible sources of infection at this time of life are almost infinite, and include the indiscriminate fondling by tuberculous individuals, the contamination of milk and other foods, the playing upon the floor or ground, and the placing of miscellaneous objects in the mouth. Con- siderations pertaining to the early infection of the very young through the alimentary and respiratory tracts will be reserved for later discussion. That these channels constitute important methods of infection in little children who are born healthy is impossible of controversion. The fact concerning which all observers agree is the lamentably high death-rate in infants from tuberculosis. Botz has reported 2576 autopsies in tuberculous children, of which 27.8 per cent, died the first year. Other statistical observations of a similar nature will be given in connection with glandular tuberculosis. Dietrich, of Berlin, from a recent analysis of the official publications of the Prussian statistical office, reports that "there are a greater number of actual deaths from tuberculosis in the first year of life than in any other age period." He further states that there has been no actual decrease in the number of deaths from tuber- culosis among infants in Prussia during the last ninety years. While the total mortality rate in that country from tuberculosis has diminished one-third during the past thirty years, there has taken place curiously a slight increase in the relative number of deaths from this disease in the first year of life, thus showing the disproportion existing between this and other age periods. Despite the active educational propaganda now being instituted in Prussia, it is evident that a pronounced further diminution of the total death-rate from tuberculosis can be secured only by effective measures to limit the infection in infancy. Granche'r. of Paris, after an examination of 4226 school-children, has recently rei"iitiMl tli;it l.'i per cent, were fduml tulici-cnldus, tiocder, of Berlin, as tlic i-csulr of systematic oxaininatinns. fdund a suiprisnmly large number of scliddl-rliildren with incipient tidicrculdsis. Chalnici-s, from an investigation of the frequency of tuberculosis among the chil- dren of Glasgow, reports that there is a direct relation between the prevalence of the disease and the increase of poverty. School-children belonging to families occupying three rooms were found tuberculous in 3.4 per cent, of all cases; if two rooms were used, in 5.9 per cent., but if a single room, in 8. -3 per cent. Upon the basis of all available evidence it is apparent that while there exists an alarming prevalence of tubercu- losis among children, it is probably attributable to external conditions rather than to intra-uterine infection. The localization of the tuberculous lesions among children in portions of the body not readilj' accessible to external infection is regarded by some as suggestive of a congenital origin. It is a matter of clinical record that at this age the tubercle bacilli display a special predilection for the invasion of glands, bones, and joints. Baumgarten assumes that 42 ETIOLOGY AND PATHOLOGIC ANATOMY such localization must be of accidental development if not occasioned by transmission in utero, but disclaims the former, both on account of its improbability and on the ground that the bacilli always produce some lesion at the point of entry. It is well known, however, that lymph-nodes are often invaded without visible lesion at the infection atrium, whether this be the tonsil or the intestinal, pharjTigeal. and bronchial mucosa. In a large number of cases the lymph-nodes are the primaiy seat of the tuberculous process, as was pointed out by Weigert twenty years ago. Harbitz offers corroborative testimony bj- referring to the general experience of pathologists to the effect that in children isolated tuberculous processes are rare without coincident or prior infection of the bronchial glands, while involvement of the latter without pulmonary disease is not infrequent. Ribbert and Petruschky assert that, in the great majority of cases, tuberculosis of the lymph- glands in children antedates infection elsewhere. Cnopp has shown that 147 children out of 298 victims of tuberculosis had bone or joint disease, with only eight of these exhibiting infection of the internal organs. Numerous statistical reports have been recorded by observers as to the relative frequency in children of tuberculous processes in various portions of the body. Some of these analyses will be presented in connection with tuberculosis of special organs. Upon the whole, it is noteworthy that the lymphatic glandular structures are infected in a very large proportion of cases, and that the evidence in many instances has pointed to their primary involvement. This, however, cannot be considered an argument in favor of congenital or hema- togenous invasion. Bacilli are known to penetrate intact mucous membranes and gain entrance to proximal glands without clinical evidence of disease. Furthermore, were the infection derived in utero, it would be supposed that the liver and abdominal viscera should represent the primary seat of the disease, but these organs are found involved in children much less frequently than other portions of the body. Perhaps the greatest factor in the evolution of the belief in heredi- tary transmission has been the oft-noted development of tuberculosis in succeeding generations. Williams records a family predisposition in 48.4 per cent, out of 1000 cases of consumption, but this report is divested of much of its significance when he adds that only 12 per cent, were parental and 1 per cent, grandparent al. the remaining 34.4 per cent, being of collateral relation. Solly reported, from an analysis of 250 cases, 28.8 per cent, with a history of parental tuberculosis. My own observations, based upon an analysis of 2070 ca.ses, show a family history of tuberculosis in 518. or 25 per cent. Of these. 398 were instances of parental tuberculosis and 94 of grandparental. In 26, tuberculosis had existed both in parents and grandparents. The influence of heredity will be further discussed in another connection. A noteworthy feature of this subject is the infrequency of tuberculo- sis in orphan asylums, in which one would naturally expect such a disease to flourish if hereditary influence could be assigned as a factor of especial etiologic importance. Congenital tuberculosis, though an admitted possibility, must be regarded as of rare occurrence. INFECTION BY WAY OF THE RESPIRATORY TRACT CHAPTER V INFECTION BY WAY OF THE RESPIRATORY TRACT The inhalation theory of tuberculous infection for many years was accorded a quite general acceptance. This method of invasion of the body by the tubercle bacillus appears upon superficial thought an eminently simple and natural explanation of localized tuberculous proc- esses within the lung. So reasonalile and apparently satisfactory a conviction concerning the origin of the disease in the overwhelming majority of cases has been rudely disturbed by the results of recent clinical, pathologic, and experimental investigation. The older articles of faith regarding this mode of infection, which hitherto have been sub- scribed to almost universally, are now the subject of an animated con- troversy. A spirited discussion has arisen involving the frequency of respiratory infection. Some, as a result of considerable research, are inclined to repudiate in toto the inhalation theory of bacillary invasion and to accept the alimentary tract as jiractically the exclusive channel of infection. Others, while n(il dciiyiim ilic siist:iiiicd logic of newer anatomic study, embrace the Ijclicf ili:ii Imt .-in occnsidual path for the bacillus is afforded by the g:isti-(i-iii(csl imil (miimI i>r the pharynx, and insist that such admission detracts nothing from the tenability of former views. They still adhere to the opinion that the respiratory tract con.stitutes the principal avenue traversed by the bacillus in entering the body. It is significant that even among the advocates of this theory some violent discussions have taken place with reference to the precise manner in which the microorganism is permitted to gain entrance into the lungs through the inspired air. Cornet was an early exponent of the doctrine that inhalation infec- tion took place solely through the conveyance of tubercle bacilli with contaminated dust to the terminal bi-onchinlc-; and ah'cdli li\' nicaii^ of the respii'atory current. The es.sential rlciiiciu of (laii'.ici attaclnir^ \n tuberculous sputum was regarded as attriliutaMc ('\chisi\(l\ in n- (//jim| h.i\c Keen discussed in previous chapters in connection with iiiiii(ii1;iiit fi^aiuios of infection. It has been pointed out that primary IcsioiLS of tlie intestine are not nearly so rare in children as has been asserted. The supposed infrequency of this condi- tion constituted a vital argument of Koch against the transmissibility 52 ETIOLOGY AND PATHOLOGIC ANATOMY of tuberculosis to children by means of the bovine bacillus. In like manner the unusual occurrence of primary intestinal tuberculosis was regarded as de facto evidence of the rarity of baciUary invasion through the cUgestive tract. It is now known, however, that tubercle bacilli pass readily through the intact intestinal mucous membrane. Atten- tion has been called to the reported observations of many clinicians and pathologists, who found at autopsy upon tuberculous children primary lesions of the intestine in from 17 per cent, to 137 per cent, of the cases. Allusion has been made to the finchngs of numerous observers who noted the enormous frequency of tuberculous infection in the mesenteric glands of children dying of tuberculosis. Wood- head reported this condition in 100 cases out of 127. Moreover, it has been emphasized that the lymphatic glands, despite entire absence of macroscopic change, have been found in many instances infective to lower animals. The valuable experiments of Calmette and Guerin in demonstrating the penetration of bacilli through the intestinal wall without visible lesion have been described. At the end of about thirty to forty-five days following the introduction of tuberculous material through the esophageal tube the mediastinal glands were shown to be infscted. The mesenteric glands, which were the first structures involved, often exhibited no macroscopic evidence of disease, although the tubercle deposit sometimes took place after a single infected meal. The inoculation of animals with these glands, as well as with appar- ently normal mesenteric glands, produced typical tuberculous lesions. After a continued introduction of tuberculous material with the food of animals, bacilli were found in the thoracic duct and pulmonary artery. In the chyle vessels the bacilli were engulfed by the leukocytes and conveyed to regional lymph-nodes and to the terminal capillaries in various organs, finally to become arrested and produce vascular lesions. Engel and Schlossman have performed similar experiments with like results. After administering tubercle bacilli in milk to young guinea- pigs they found, in the course of a few hours, these microorganisms in the lungs. There is permitted a strong a.ssumption that the mesenteric glands present no barrier to the advance of the bacilli after the manner of the defensive action of other lymphatic glandular structures. On account of the unobstructed passage through these glands of fat-droplets and other elements during digestion, it has been suggested that their function is somewhat different from that of the bronchial lymph-nodes. It appears from experimental evidence that tubercle bacilli mixed with the fat penetrate the intestinal wall, pass through the mesenteric glands, and appear in the thoracic duct with almost as little difficulty as do peptones after being subjected to processes of digestion. It has been shown that milk from tuberculous cows may contain tubercle bacilli and be capable of producing a virulent infection in children. The observations of Fibiger and Jen.sen have been quoted as illustrative of the added dangers of milk contamination from the exist- ence of local lesions upon the udder. That the bovine bacillus is respon- sible for the development of primary intestinal tuberculosis in children in a considerable proportion of such cases has been shown by their re- searches. Out of seven cases of this condition observed by them, five proved to be of bovine origin, as shown by the virulent results of inoc- ulation into calves and rabbits. They believe that infection from cow's milk is a frequent cause of primary intestinal lesions in children. Ernst INFECTION THROUGH THE DIGESTIVE TRACT 53 and Hirschberger have called attention to the fact that despite the absence of mammary glandular disease the milk may contain tubercle bacilli. The evidence as to the entrance of bovine bacilli into the alimentary tract of children is beyond dispute. It is obvious, how- ever, in view of the disproportion between the large number of infants ingesting infected cow's milk and the fewer number exhibiting local lesions, that in some cases this bacillus is responsible for the origin of tuberculous processes so common in childhood in other parts of the body. No explanation is afforded for the advance of the ba- cillus to the glandular structures, liones, joints, and meninges, save upon the hypothesis of their entrance into the vascular and lymph- channels from the intestinal tract, and such possibility has been shown to exist. The given factors, then, in the problem of infantile infection through the digestive tract are as follows: an alarming prevalence of the disease, with local manifestations in portions of the body accessible solely through the lymphatic and vascular channels, unusual exposure to infection through the digestive canal from ingestion of bovine and human bacilli, a known passage of the microorganism through the delicate structures of the intestine, and the subsequent invasion of mesen- teric and bronchial glands, and the demonstrable presence of bacilli in the lymph-vessels. There is no occasion for a more completely sustained argument regarding the alimentary tract as an important route of invasion iu children. It is recognized, of course, that infection takes place through other channels, but an analysis of clinical, pathologic, and experimental data affords positive evidence as to this port of entry. The early local- ization of tuberculous lesions in bones and joints among children, the frequency of glandular infection, the rarity of pulmonary or laryngeal involvement, are supplemented by the results of animal experimentation. Whether the human or bovine bacillus is the principal agent of infection in these cases is not definitely relevant to an inquiry devoted to the channels of invasion. It must be conceded that at an early period of life especial opportunities are afforded for the entrance of both types of bacilli. It is quite impossible to attribute all cases of tuber- culosis to a latent infection with the bovine bacillus acquired during infancy. The fallacy of this reasoning has been shown by the prev- alence of tuberculosis in countries where cow's milk is seldom em- ployed as an article of food for infants. Behring's theory as to the transcendent importance of the infant's milk as a carrier of infec- tion, while unwdrthv y tubercle bacilli in their entrance into the body, it may be assumed that admission is permitted through the respiratory tract less often than has been sup- DISTRIBUTION OF THE BACILLI 55 posed, and that ingress by means of the digestive canal is correspond- ingly more frequent. The acceptance of the respiratory and alimentary tracts as the two principal methods of bacillary invasion necessarily forces the conclusion that the selection of either route is determined by the special opportunities for infection in different instances. According to the varied conditions of exposure, the infection may take place in some cases with far greater ease by means of one method than the other. Thus children, for reasons pertaining to their food and habits, may be regarded as offering unusual facilities for the entrance of bacilli through the digestive canal, while adults, who, by reason of peculiar environment, are compelled to live in an atmosphere contaminated by tubercle Ijacilli, are greatly exposed to inhalation tuberculosis. In either event the important practical consideration must relate not so much to the manner of entrance into the body as to the prevention of the distribution of bacilli from the human and animal organism. CHAPTER VII DISTRBUTION OF THE BACILLI The living human and animal organism is not only the natural abiding-place of the tubercle bacillus, wherein are offered favorable conchtions for multiplication, but is also the all-important agent of distribution. The principal means of bovine dissemination is from the ingestion of infected milk. The eating of animal flesh is of less importance, as in most cities the carcasses are subjected to rigid inspection before the flesh is offered foi' public consumption, and the meat almost always is thoroughly cooked. Tubercle bacilli may sometimes be present in the milk of tuberculous cows, although there is no evidence of mammary infection, but the danger of such contamination is, of course, greater in the presence of udder lesions. Ravenel has demonstrated the possi- ble distribution of bovine tubercle bacilli by cows in the act of cough- ing. The sputum was collected upon a piece of soft pine wood placed in the bottom of a nose-bag. The dissemination of bacilli in this manner is of practical significance as regards the dangers of infection to those brought into constant association with cattle and to animals confined within the same inclosure. The chief means of exit of the bacillus from the human body is through the medium of the expectora- tion. Irrespective of the relative frequency of infection through in- gestion into the alimentary tract, or acquired thi'ough the inhalation of dried siuituni dust and of moist parlidc^ cxi idled in coughing, the fact rctii:iiiis that the expectoration r.ui-t iiuir- the vehicle for an almost uhi(i\iit(ius dissemination of the iincKMirgaiiism. Bacilli may also be eliminated from the body with the urine, feces, or infected pus through a discharging sinus. In a surprisingly large proportion of cases the urine of consumptives is known to contain tubercle bacilli even without clinical or pathologic evidences of genito-urinary tuberculosis. Their presence in the feces to any considerable extent is conditional 56 ETIOLOGY AND PATHOLOGIC AXATOMY upon the existence of local lesions in the gastro-intestinal tract. The actual distribution of bacilli through these excretions is greatly reduced b_v the comparatively small number of microorganisms thus discharged, by the sanitary cUsposal of the excrement, and by the destructive effect of putrefactive change. Sinus discharges containing bacilli are usually received upon suitable dressing and destroyed without opportunity for bacillary chstribution other than obtains from contami- nation of hands or clothing. The hands of careful consumptives have been found in numerous instances to be the repository of tubercle bacilli. This is undoubtedly true to a great extent among the immediate attend- ants of pulmonary invalids, especiall}- those accustomeil to hantUe tlie expectoration, soiled handkerchiefs, and articles of clothing. The linen and blankets particularly are in danger of contamination, and laun- dresses, for this reason, are subject to more or less exposure. A luxur- iant beard adorning the face of a consumptive, especially an overhanging growth upon the upper lip, represents an effective means of bacillary dis- tribution. Comment has been made upon the introduction of the bacillus into the mouths of children and the ea.se with which food maj' be infected by means of soiled hands and careless coughing, and upon the role of the house-fly as a cUstributing agent. Experiments to determine the exist- ence of tubercle bacilli in places frequented by careless consumptives must be accepted as conclusive proof of their emanation from dried sputum dust. In open places exposed to sunlight their vitality is of short dur- ation, and their presence, therefore, of slight significance. Only in densely populated communities are streets, pavements, and open public resorts likely to become contaminated to a serious extent, and then chiefly in dark alleys and courts, where frequent sprinkling or washing of streets is not permitted. The continued grinding and pulverization incident to passing vehicles, the exposure to sunlight, the moisture afforded by nature, the frequent sprinkling, flushing, and sweeping of streets, all conspire to render the actual danger from outdoor chstribution of bacilli in large centers of population more fancied than real. Experiments have shown the dust to contain tubercle bacilli only in places where consumptives congregate antl indulge in gross neglect of sanitarj' precau- tions. The dust from sidewalks and street-crossings is found infective to lower animals, particularly in resorts where municipal regulations pertaining to expectoration are not enforced. In view of the present administrative activity regarding street cleanliness it is probable that the practical danger of the dress-skirt as a carrier of infection from the sidewalk to the home is much exaggerated. There can be no possible doubt, however, as to the enormity of the exposure within dwelling-houses inhabited by ignorant or vicious consumptives. Aside from the con- tamination of clothing, beckUng, handkerchiefs, beard, hands, and food, the bacilli may be deposited upon the wails or collected upon carpets or draperies. Being heavier than the air. they gravitate to the floor and settle upon carpets or rugs and in numerous dark corners or recesses. When not exposed to direct sunlight, but confined in close rooms without frequent air renewal, their vitality is continued for almost indefinite periods. When subjected to continuous agitation by drafts, rustling of skirts, sweeping and dusting of rooms, they are given unusual oppor- tunities to acquire entrance into the human bod}'. The ignorance of many housekeepers as to the proper method of room-cleaning is respon- PREVALENCE OF TUBERCULOSIS 57 sible to some extent for the general dissemination of bacilli. The moist process of dusting and sweeping, the cleaning of rugs in the open air or by modern methods, diminishes materially the dangers arising from house infection. The investigations of Cornet, Flick, and Hance point not necessarily to the contamination of all dwellings inhabited by con- sumptives, but merely to the sources of danger resulting from the presence of those who are careless or ignorant. It may be assumed that the intelligent and conscientious pulmonary invalid is no menace to the family or immediate associates. The infectiousness of dust from hospital wards, street-cars, and public indoor places occupied by con- sumptives is usually demonstrable only when negligence of ordinarj^ precautions has been permitted. Positive results from inoculation were obtained in one-fifth of Flick's experiments, but in no case where proper attention had been given to the reception of sputum. The investigations of Hance along similar lines resulted in negative results in dust from sixteen out of seventeen Adirondack cottages, the exception being due to a careless consumptive who had indulged in expectoration upon the walls. Gardiner inoculated the dust taken from different rooms in the largest hotel in Colorado Springs, which had been occupied by consumptives for many years, and obtained negative results in each instance. CHAPTER VIII PREVALENCE OF TUBERCULOSIS Consumption is universally regarded as the mo.st dreaded scourge of the human race. One-seventh of all deaths in civilized countries are reported to result from this disease, and. in addition, an enormous proportion of individuals harbor unconsciously latent foci of infection. The every-day experience of pathologists in the recognition of healed and unsuspected lesions is sufficient to demonstrate the wide prevalence of non-active infections and the inherent powers of individual resistance. Statistical observations concerning the frequency of tuberculous lesions found during pastmortem inquiry have varied considerably, according to the thoroughness with which all parts of the body have been explored. During recent years these researches have been conducted in a more systematic manner than formerly, and reported instances of latent infection are far more numerous. Naegeli's statistics upon this subject, obtained from the critical study of 500"autopsies at Professor Ribbert's institute in Zurich, are particulaily startling. After carefully inspecting every organ of the body, including the lymphatic glands, and examining a large number of microscopic sections, he reports the finding of tuber- culous lesions in 97 per cent, of all the cases up to the fifteenth year, 96 per cent, to the eighteenth year, and nearly 100 per cent, up to the fortieth year. These results apparently accord with the popular German belief that every one possesses a slight focus of tuberculous infection, and tend to corroborate the old English idea that consumption was the cause of death of nearly all hard zealots in the field of letters, law, love, medi- cine, and religion. The discrepancy between the vast number of human 58 ETIOLOGY AXD PATHOLOGIC ANATOMY beings harboring localized lesions and those actually succumbing to the disease affords a striking commentary, as previously intimated, upon the effectiveness of self-immunization. In this connection it is only necessary to consider the many individuals who perish annually from consumption and those whose capacity as wage-earners is restricted by the disease. The number thus afflicted is truly appalling, and in nearly all countries exceed.s in economic loss and human suffering all other combined agencies which contribute to the pathos of fate. When one considers the value of the working power of labor, which constitutes one of the chief commodities of the State, it is not difficult to comprehend the tremendous depreciation of economic I'esources entailed by the ravages of such a pestilential disease. Even without regard to the magnitude and depth of human suffering, the deprivations and blighted prospects incident to prolonged illness, the dismemberment of families, and the agony of heart and mind, the fact remains that the prevalence of consumption upon the basis of State husbandry constitutes a national, racial, and social problem comparable to which none other is worthy of consideration. The statistics concerning the frequency of tuberculosis are too familiar to justify detailed recapitulation, but a few illustrative statements taken from recent literature are of much interest. It has been estimated that in the neighborhood of 1,500,000 people are annually incapacitated from work in the United States on account of this affliction. One hundred and fifty thousand is a low estimate of the number whose lives are terminated bj' tuberculosis during each year in this country. The average age at the time of death is com- puted to be thirty-five years, enforcing an annual preventable loss to the nation of many years of future industrial activity approxi- mating half of man's average existence. If the value to the State of each healthy inhabitant during the entire period of usefulness is estimated at $1000, the economic loss in one year from deaths so premature must approach .$.500 for each individual thus removed, making an annual drain of $75,000,000 upon the United States from this source alone. This is entirely exclusive of the additional ex- pense necessitated for the maintenance of charity organizations and institutions and the demands imposed by the disease upon private benevolence. These figures form a very conservative estimate of the potential loss each year to the United States from a cause admitted to be within the limits of prevention, and capable of producing unutterable misery. The computations of many students of political economy and observers of medical conditions far exceed those given above in an esti- mate of the financial loss to this countrv as a result of consumption. By some the amount is stated to vary from $200,000,000 to $400,000,000 annually. In these computations are included the deprivation of working capacity as bread-winners for the family, the expenditure of the savings of non-producers, the provision for children dying under twenty years, the care of those helplessly ill, and the maintenance of institutions. A commission recently appointed in Mas.sachusetts to investigate the prevalence of pulmonary tuberculosis in that State reports upon the score of replies received from physicians and the number of consumptives within the various public institutions, that nearly 8000 individuals at present are suffering from the disease. As 675 physicians failed to give information in response to circular letters, the number of consumptives now residing in Massachusetts may be INFLUENCE OF RACE 59 assumed to be somewhat larger. About one-third were in the inci- pient stage, and an equal number in advanced and in far-advanced phthisis. Biggs states that in New York city, during the year 1902, 16,000 cases of consumption were reported to the Health Department; in 1903, 17,000; and in 1904, 19,000 cases. In 1905 nearly 32,000 ca.ses were reported, of which over 11,000 were duplicates, and in 1906, 30,826, of which 10,741 were duplicates. He has presented much valuable data concerning tuberculosis in the city of New York from 1881 to the present time. From his statistical tables it appears that at least 10,000 people die annually from consumption in that city. It is probable that if nearly 20,000 cases of e.xisting tuberculosis are reported to the health authorities, nearly half as many more are afflicted without the cognizance of the department. About as many people die of phthisis in Illinois annually as in the city of New York. The same is practically true of the State of Ohio. In Englantl one-fourth of all deaths occurring during the period of useful activity are reported to result from consumption, while in Prussia this disease produces one-third of all deaths in infants. In Austria the tuberculin test has recently been employed upon healthy soldiers, with a positive result in 60 per cent, of those who were presum- ably well, suggesting again the remarkable distribution of latent infec- tion. An important practical question presents itself, as to whether or not (•onsunii)ti()ii is actually diminishing in prevalence as the result of intelligent systcinatic effort toward its restriction. Satisfying results are reported from New York city, where the reduction in the doath-rate from tuberculo.sis is nearly one-half in the pa^■t iwcut) \iais. The percentage of deaths per 1000 population is reportid \>y l',i;^u,s to have been 4.45 per cent, in 1884, and to have diminished gratlually to 2.49 per cent, in 1903. In London it was 3.12 per cent, in 1884 and 2.34 per cent, in 1901; in Berlin, 3.6 per cent, in 1884 and 2.39 per cent, in 1902; in Vienna, 7.2 per cent, in 1884 and 4.76 per cent, in 1900; in Philadelphia, 3.32 per cent, in 1861; in 1884, 3.1 per cent.; in 1903, 2.25 per cent. In Paris, however, the death-rate is not shown to have diminished, the percentage being 5.19 per cent, in 1SS4 anfl 5.46 per cent, in 1900. In Berlin, while the total tuberculosis mmtality has been reduced, the infantile death-rate from tubciculcjsis lias been increased somewhat during the past thirty years. Statistical observation with reference to the diminished prevalence of tuberculosis in Colorado will be given in connection with geographic differences of distribution. CHAPTER IX INFLUENCE OF RACE No phthisio-therapeutist of ample experience can deny the existence of essential differences among various races in the degree of resistance to pulmonary tuberculosis. An effort has been made by some statis- ticians to attribute the radical divergence in the mortality rate among nations to changes of environment rather than to variations of inherent susceptibility. There can be no doubt that in some instances the sur- t»U ETIOLOGY AND PATHOLOGIC ANATOMY rounclings and mode of life are responsible in large measure for the present high death-rate from consumption. This obtains particularly with reference to the negro population of the United States. It is impossible, however, to reconcile the chfferences in this country between the Irish. Swedes, Germans, English, Americans, and Polish Jews upon the basis of environment. It is not true that among these people there exists a remarkable dissimilarity in immechate surroundings and mode of life or in the nature of climatic influences unless it be that the Poles, who, of all nations, exhibit the very greatest resistance to con- sumption, suffer from the most unfavorable conchtions. In America, the home of all races, it is questionable if the negro undergoes greater privation or is subjected to more unsanitary conditions than the ignorant and poverty striken Jewish emigrants from Poland, yet these two races exhibit opposite extremes in the mortality rate from tuberculosis. While the influence of environment and methods of living are reacUly conceded to produce salient chfferences in powers of incUvidual resistance, it is none the less clear that a distinct effect is exerted by virtue of racial predisposition. The negro race in the United States is exceedingly susceptible to tuberculosis, and environment must be admitted to play an im- portant part. Consumption is reported almost to have been unknown upon the West coast of Africa, as well as in the interior, until the natives were brought in contact with imported cases. Though seldom before intUgenous, tuberculosis once established among the colored people has been found to pursue a rapid and relentless course, presumably on account of the non-acquirement of partial immunity as a result of trans- mission through earlier generations. The original transplantation of the negro to the southern part of the United States was not attended imme- diately by such disastrous consequences in the way of tuberculous infec- tion as might be expected from the radically changed surroundings and conditions. From a previous existence of barbarism, the slave, though brought for the first time into close association with the disease, neverthe- less was permitted a life in the open air. While his lot was necessarily one of hard and useful toil, he was provided with commocUous quarters and an abundance of food in a climate not sufficiently rigorous to produce suffering from exposure, nor to involve inadequate ventilation of apart- ments. Prior to the Civil \^'ar, consumption, while scarcely an unknown disease among the negroes, was still comparatively rare. Upon the acquirement of personal freedom there resulted inevitably such change of conditions as to produce a remarkable increase in the suscep- tibility of the race to the ravages of tuberculosis. This did not take place solely through the eagerness of the negro to move North and the endeavor to secure an adaptation to a more severe climate, for the disease flourished almost to the same extent among those remaining in the South and those living in Xe%v England. Of all cities in the country, however, Boston, with a colored population of 12.000, is reported to have the highest death-rate of tuberculosis among these people. The rational explanation of an increased prevalence of the disease among the negroes is referable to the very fact of their independence. Formerly they were compelled to work in the open fields, and in most instances were comfortably housed and fed. In later years they have flocked to the large cities, congregated in great numbers in unhealthful abodes, and have sought employment, if at all, under conditions less INFLUENCE OF RACE 61 favorable than in the days of slavery. It is not strange that, with the sudden enforced assumption of the responsibilities of self-maintenance, for which the negro in no way was prepared by mental equipment or previous experience, he should develop to a certain extent hal^its of idleness, intemperance, unsanitary living, and excessive sexual indul- gence, with resulting venereal taint. Syphilis, alcohol, improper food, and insufficient ventilation assuredly are potent agencies in the develop- ment of a predisposition to tuberculosis in any race. Supplementary to these detrimental influences an important causative factor is the peculiar nature of the occupation of the negro people as a class. Aside from their availability for domestic service, their illiteracy and shift- lessness limit the remaining avenues of work to drudgery in coal mines, hard labor as operatives in factories and mills, menial employment as porters in railway cars or steamships, waiters, cooks, janitors, and laundresses. All work of this nature entails a degree of confinement with unusual opportunities for infection. For the above reasons it is no wonder that the susceptibility of the negro to consumption is greater than that of all other races. Professor Jones, of the Hamp- ton Normal and Agricultural Institution, states that the mortality rate for the colored people is from two to seven times that shown by any other race except the Irish, who exhibit two-thirds the mortality rate of the negro. The colored children, particularly under fifteen years of age, are prone to succumb to tuberculous infection, the mortality being seven times that of white chUdren regardless of nation- ality. An important consideration pertaining to the problem of tuber- culosis among the colored people is the exceedingly large number of negroes in the United States. The proportion to the total population is greater than that of any other alien class of Americans. They com- prise 8,000,000 people, and constitute 11 per cent, of our total number of inhabitants. The high mortality rate from consumption among a class who form so large a porportion of our people invests the problem with far greater significance than relates to the prevalence of the disease among other races in our midst, who not only are decidedly less suscep- tible, but include a much smaller number of inhabitants. It is worthy of more than passing attention that consumption creates its greatest havoc among the very people who constitute the largest part of our alien population and who, as servants, are brought into far more intimate contact with the home life than the Irish, Germans, Scandinavians, French, Russians, or Poles. The alarming development of tuberculcsis among the American Indians pre.sents some points of .similarity to the spread of the disease among the negroes, and with equal propriety may be attributed in part to radical changes of immediate environment. To be sure, the Indians have not been forcibly imported to a new country, but they have been rudely driven from their own possessions by the encroachments of the white people, who, in conferring the questionable blessings of civiliza- tion, have been directly responsilile for the decimation of the race by disease. From the available data bearing upon the subject it is fair to assume that consumption among the Indians was of extremely rare occurrence prior to their contact with European races. Since that time the disease has gradually increased until at present it has assumed the proportions of a veritable scourge. The ravages of tuberculosis are more pronounced among the Indians of the older reservations than of 62 ETIOLOGY AND PATHOLOGIC ANATOMY the newer agencies in the Northwest, suggesting an increasing prevalence in proportion to the greater restrictions placed upon their nomaclic existence. The frecjuency of consumption among the Indians of all tribes has been noted by the physicians appointed to care for the various agencies. Some have reported 47 per cent, of all deaths to result from this cause. Others have placed the percentage at 66, and still others at 75 and even 95. The development of tuberculosis among the Indians has been frequently cited as a conspicuous instance of the dangers of infection pure and simple. While it is, of course, true that the disease could not have been transmitted save from contact with the tubercle bacillus, other equally important factors have been introduced, strongly enforcing a predisposition to infection. In fact, the spread of pulmonary tuberculosis among the tribes occupying reservations noted for favorable climatic influences is in itself prima facie evidence as to the existence of a gros.sly unhealthful environment as well as to the practice of pernicious habits calculated to lessen vital resistance. It is known that the IncUans have ever been inclined to keep singularly aloof from the white people, whom they regard with suspicion. The cUsease has spread among a class of beings who are kept more or less secluded in their reservations and are accustomed to an outdoor existence, in contradistinction to the negroes, who have sought indoor employment in large centers of population and have been expo.sed to numerous opportunities for infection. A study, however, of the present conditions ol itaining in most reservations is pecu- liarly enlightening in explanation of the development and mortality of the disease. Dr. J. R. Walker, Agency Physician at Pine Ridge, South Da- kota, has recently reported interesting data with reference to tuberculosis among the Oglala Sioux IncUans. Dr. I. E. Brewer, of Fort Huachuca, Arizona, presents a review of the development of tuberculosis among the IncUans of Arizona and New Mexico, embodying reports from the Colorado River Agency (Mojave IncUans), the White River Agency (Apache), the Hopi Reservation (Hopi and Navajo), the Navajo Reser- vation (Navajo), the Fort McDowell (Apache), Pima Agency (Maricopas, Pimas, and Papagoes), the Walapai Reiservation (Hovasupai and Walapai), the Mescalero Reservation (Apaches), the Santa F6 Agency (Puebloes), and the Zuni Reservation (Puebloes). While unanimity of opinion is found to exist with reference to the wide prevalence of consumption among all tribes, the reports are also uniform regarding the presence of concUtions strongly predisposing to the disease. During his primitive life the Indian was habituated to an almost continuous out-of-door existence. Though compelled to endure great hardship and subjected at times to severe physical exertion, undue exposure, insuffi- cient clothing, accustomed to improperly cooked food, and with extreme irregularity as to the time of eating, he nevertheless was comparatively free from tuberculosis on account of the invigorating influence of his open-air life. His career was e.ssentially nomadic in character, consisting of hunting or maraucUng expeditions and internecine warfare. Though filthy to a degree, the evil effects were minimized by the frequent moving of camps and the construction of tepees permitting ample ventilation at the top. The disposal of .slops ancl excrement, while un.sanitary in the extreme, was non-productive of practical harm on account of the short period of accumulation. With the erection, however, of permanent houses, which were small, low, and with perfectly tight roofs, all oppor- tunity for ventilation was prevented. Every facility likewise was offered INFLUENCE OF RACE 63 for the subjection of the inmates to other unhealthful conditions, includ- ing exposure to all manner of infective material. From a life in the open air the Inchans were wont to congregate in large numbers in overheateil rooms, with no ventilation whatever and without the slightest concep- tion of other principles of hygienic living. Upon one of their number becoming the victim of tuberculosis, no precautions were taken to prevent the spread of the infection. Expectoration was promiscuous and usually indoors. In view of these conchtions it is no wonder that the race has been threatened with extinction, but there is no suggestion of an inherent predisposition to tuberculosis as the sole factor in the appalling spread of the disease. In contrast with the negro, the Indian constitutes but 1 per cent, of our total population, and is brought but little in contact with the white people. The prevalence of consump- tion among the Indians upon the western and southwestern reservations strikingly illustrates the truism that to secure immunity from tuberculo- sis it is not altogether ivhere one lives, but in what manner. The Irish people, both at home and in other countries where they reside, have been notoriously susceptible to tuberculosis. In the United States the mortality rate is two-thirds that of the negro, being approxi- mately 4 to 1000 of the population. This is much in excess of other nationalities in America, the Scandinavians and Bohemians having a death-rate of but little over one-half that of the Irish. According to Jones's mortality chart, the Germans, as well as French, Scotch, and Can- adians, have a death-rate of one-half that of the Irish and one-third that of the negroes. The mortality rate of the Engli.sh, Ru.ssians, Italians, Hungarians, and Americans from tuberculosis is still less. The rate for the Poles is least of all, being 0.625 per 1000. These statistical con- clusions are closely in accord with Lillian Brandt's table of mortality of races, and conform to my own clinical observations concerning the degree of resistance shown by different nationalities in a suitable climate. A large number of patients of various races under similar conditions of climate and management were found to display remarkable differences in their ability to withstand the disease. Ten years ago I cited the disproportionate resistance shown by the Jews in compari- son with the Americans, English, Germans, and Scotch, and the slighter recuperative power of the Irish and Swedes. The Irish were reported to be predisposed to a special degree, the tuberculous process being active, as a rule, and attended with early cavity formation. There was noted a marked tendency to septic and nervous chsturbances, and the patients were found somewhat hard to control. This was explained in part by their volatile mercurial disposition, but lessened powers of resistance were also displayed by those not exhibiting an unstable nervous tem- perament and conforming implicitly to a strict disciplinary regime. The Swedes, though apparently hardy and vigorous, were found, as a rule, to succumb much more cjuickly than patients of our own country. They were excessively apprehensive, impressionable to a degree, and inclined to ea-sy discouragement, but usually obedient to instructions. The same was true to a great extent of the Bohemians, the majority of these people arriving in Colorado with extensive areas of pulmonary involvement, somewhat out of proportion to the relatively short period of illness. It has been my general experience that the Germans, English, Canadians, and even the Scotch readily adapted them- selves to an appropriate system of living, excelling in this respect our 64 ETIOLOGY AND PATHOLOGIC ANATOMY more restless Americans. There has seemed to obtain in most instances a lighter burden of business responsibilities and a more phlegmatic or philosophic disposition, with less of general restlessness or irritability. The American has often announced upon arrival that he had come to Colorado for a few proscribed months, that his recovery must take place within that period, as no further extension of time could be diverted from his business. The clinical exhibition of resistance on the part of the Jews has been something remarkable. In spite of extensive and long-standing pulmo- nary disease, the nutrition and strength have been maintained to a sur- prising degree. I have been impressed repeatedly by the disproportion between the physical signs and the general condition. Severe mixed infection, from my observation, is much less frequent than among all other races. On the other hand, the process of arrest has been, as a rule, rather slow and disappointing. It would appear that the Jew posses.ses a certain immunity to the toxemia of tuberculosis which, despite exten- sive destructive change, enables him to withstand the disease for pro- longed periods, but that the powers of resistance are often insufficient to produce healing of the tuberculous lesions. The tenacity with which these people retain their hold upon life in the presence of advanced pulmonary phthisis is sometimes cited as illustrative of the immunizing influence resulting from the transmission of the disease during the course of many generations. Be this as it may, the fact remains that there does exist an inherent resistance to the ravages of tuberculosis among the.se people. The peculiar character of the clinical manifestations among the Jews may not be justly attributed to environment alone, for in large cities the ignorant are crowded into densely populated districts and subjected to the direst poverty, the hardest of indoor work, the inhalation of vitiated atmosphere, and the habitation of apartments often noisome with filth. Attempts to explain the diminished prevalence of tuberculosis among such people upon the score of their obeyance of the Mosaic law pertaining to meat and drink is unscientific and chimerical. Even were all the meat rejected by the Rabbis assumed to come from tuberculous animals, there is no assurance that the flesh is thus infected, and even so, the process of cooking is known to destroy all germ life. This is not to be construed to the disparagement of municipal efforts toward rigid inspec- tion of meats offered for public consumption. Immunity to tuber- culosis among the Jews has been improperly attributed to their avoid- ance of pork, which is alleged to be tainted with tuberculous infection on account of the known existence of the disease among swine. It is probable that the abstinence from alcohol and the rarity of syphilis among the Jews are important factors in sustaining powers of resi-stance unavoidably weakened by overcrowding, insufficient food, and unhealth- ful surroundings. While the prevalence of consumption among these people, as with other races, is undoubtedly influenced to some extent by the conditions under which they live, it seems well established that the Jews are less responsive to unfavorable conditions that other nation- alities. A study of the development of tuberculosis among the Jewish poor of New York city has been conducted by Fishberg, and of Chicago, by Sachs. The latter believes that the disease is on the increase among the Hebrews in Chicago, and that their immunity is overestimated, but ascribes an increasing prevalence to abject poverty and unsanitary conditions. INFLUENCE OF GEOGRAPHIC POSITION CHAPTER X INFLUENCE OF GEOGRAPHIC POSITION For maziy years the effect of climate upon the development of indi- genous tuberculosis has been the subject of much professional specula- tion. At one time it was believed that a certain degree of immunity was established in warm regions, and patients suffering from tuber- culosis were sent to localities free from low tenii)eratures, regardless of other considerations. Later an equable climate was regarded as the chief desideratum, irrespective of moisture or sunshine. Dryness as opposed to humicUty for a time was accepted as of prime importance. The character of the soil was regarded as a factor of some moment in the causation of tuberculosis, and marshy or clay ground, which re- tained surface moisture, was thought to be less favorable than a sandy or rocky formation. Sunshine and purity of the air, wherever found, have been espoused by some as the chief elements in promoting individual resistance. Elevated regions were thought to grant an immunizing power to consumptives, and much statistical data have been introduced in apparent siilistantiation of this claim. Modei'ate altitudes were also found in cnnibine the maximum amnunt of .-sun- shine and dryness, though lacking equability. In addition to tlie diathermancy exhiljited in such localities, varying degiccs oT wind movement resulted in the dissemination of dust. Clinmte /k / m is believed by a few to possess no advantages whatever, the Of->eiitial con- sideration being thought to be mere change of surroundings, all consider- ations of sunshine, dryness, altitude, etc., being regarded as negligible factors. Upon the basis of this reasoning the consumptive in Colorado, as Fisk aptly remarks, may be expected to achieve signal improvement by a winter's sojourn in Boston in order to secure the benefits of real change. The efficacy, even of a new environment, is repudiated by others who in recent years have memorialized the advantages of door-steps, back yards, fire-escapes, and house-tops in crowded cities. While the benefits accruing from these primitive facilities for securing rest in the open air are beyond dispute and worthy of elaboration for those unable to avail themselves of greater change, it is .significant that the alleged advantages to be derived from home life are rarely taken advan- tage of by physicians when personally stricken with consumption. It is apparent from the contradictory opinions entertained by medical men, that no single climate grants immunity to tuberculosis, and, in fact, such is actually the case. Consumption is known to occur in all regions, whether dry or moist, high or low, warm or cold. The vital considera- tion in the development of the di.sease among people inhabiting a certain locality relates not to the climatic conditions alone, hut also to the crowding of the population and the character ol the Livneral occu- pation. The absence of tuberculosis in new countries lia\ing sparsely settled communities and with the early settlers living in the open air offers in itself no evidence of climatic influence favoring resistance to infection. For this reason reported observations as to the infre- quency of consumption in certain regions where these or similar condi- tions exist are practically valueless. Rational conclusions may be bb ETIOLOGY AND PATHOLOGIC ANATOMY derived only from reference to the climatic attributes obtaining in the populous cities of selected districts where other conditions offer a suitable basis for comparison as to the tuberculosis mortality rate. Judged by this token, the evidence is conclusive regarcUng the relative degree of immunity conferred through the influence of altitude combined with dryness and sunshine. The infrequency of tuberculosis in parts of Algiers, the Russian Steppes, Iceland, and Hebrides, all at low altitudes, is explained by the smaD number of inhabitants and the ab.sence of crowding or industrial pursuits. In like manner the slight prevalence of the disease in the elevated regions of Africa and India may be ascribed to the same cause. Observations, however, concerning the frequency of consumption in large centers of population at low elevations in the interior, and in such cities at moderate altitudes as Denver, City of Mexico, Santa Fe, Colorado Springs, Albuquerque, and Las Vegas, are properly eligible for comparison. Gardiner has written in no uncertain tone of the remarkably low mortality rate from non-imported consumption in Colorado Springs, at an altitude of 6000 feet. The development of indigenous pulmonary tuberculosis in Denver, a city of tall buildings, large mercantile establishments, department stores, and factories, with 200,000 inhabitants, many of whom represent cases of imported consumption, has been the subject of some tlifference of belief among medical observers. Some years ago the opinion was prom- ulgated by highly efficient health officers that non-imported tuber- culosis was increasing at a prodigious rate. This view was indorsed to some extent by a committee appointed by the State Medical Society in 1901 to investigate and report concerning the actual status of such development. At the invitation of the El Paso County Medical Society I conducted a systematic investigation concerning the matter, and reported the results of my endeavor in an address delivered before the Society at Colorado Springs in the latter part of 1901 . This was repeated by request before the Denver and Arapahoe County Medical Society in January of the following year. The questions involved are of such importance that in discussing the data concerning the development of indigenous tuberculosis in Colorado I find it ad\isable to utilize a portion of the material contained in my previous study of the subject . CHAPTER XI TO WHAT EXTENT IS CONSUMPTION INDIGENOUS IN COLORADO? It was formerly asserted by some that pulmonary tuberculosis con- tracted in Colorado constituted a very important factor in mortality statistics. An indigenous disease was thought to be increasing at such a rate an;^! assuming such proportions as to demand for its restriction drastic measui'es in the way of legislative and municipal supervision. Although heartily in sympathy with all rational measures of con- trol, I have been unable to accept the evidence presented to sub- stantiate the alleged increasing prevalence of such cases. It may be TO WHAT EXTENT IS CONSUMPTION INDIGENOUS IN COLORADO ? 67 admitted that consumption has been contracted in Colorado, as in other centers of popidation, and that to some extent it may be expected to originate here in the future. It is only with reference to the desiree and practical significance of its development that an unprejudiicd iiii|iiiry is solicited. Although consumption is communicable, it iu'\citli('li >■< is acquired chiefly by those rendered susceptible through en\ir(jiinient, occupation, previous conditions, and other unfavorable influences. The infection is known to be often slow and incremental in character, pro- longed exposure and in some instances repeated infection being neces- sary to overcome individual resistance sufficiently to produce clinical manifestations of the disease. It is to be expected, therefore, that consumption should occa.sionally develop in Colorado as a natural result of the massing of population, embracing all classes, from affluence to poverty, and including all degrees of predisposition. The disease should not be ascribed solely to an intimate association with imported pulmo- nary invalids, although there must inevitably develop frequent chsregard of precautionary measures. A considerable number of the people in Colorado pursue a peculiarly unfavorable occupation, to which may be attributed to some extent the occasional development of pulmonary phthisis. Miners are subjected for prolonged periods to entire absence of sunshine and to the inhalation of an atmosphere deficient in oxygen and vitiated by dampness, dust, and smoke. Exposure to such conditions day after day cannot fail to exert a deleterious influence throughout the respiratory tract and produce a soil notoriously favorable for infection. A large portion of the younger population in Colorado are born of tuber- culous parents, and in early life, when especially predisposed, subjected to continued undue exposure. As a legitimate result of these factors the origin of segregated cases of consumption is conceded, but this constitutes no argument detrimental to the value of altitude, sunshine, and dryness. The fact that the disease has not attained greater propor- tions is a remarkable tribute to the restraining influence of a beneficent climate. Present interest attaches to a consideration as to whether or not consumption developed in Colorado is increasing to any material extent from year to year. Upon the answer to this question depends in great measure the proper attitude of the local profession with reference to a problem extremely difficult of solution and capable of affonling honest differences of opinion. It is at once cxiilcnt that the sitiunion demands a calm, judicial inquiry, the evidence ])|csciiIim1 Id cdij^isl <>{ a cold analysis of statistical facts and not tlouiiKitic Dpinidus or picron- ceived ideas. During the past fifteen years public attention has been repeatedly drawn to an alleged rapid increase in the number of deaths from con- sumption contracted in Colorado. A review of the matei'ial offered as evidence to establish the large proportion of cases originating in this State to those contracted elsewhere indicates that the chief source of information is found in the former records of the Denver Health Department. In the annual report for 1896 it was stated tliat the numberof deaths duringthe previous year from tuberculosis devclopod in Colorado "is a little more than one-sixth of the total tuberculous i Icat li-rate." It was noted al.so that the percentage of deaths from tulicrculosis contracted in this State had been progress- ively increasing. In 1893 the proportion was stated to be 11.25 per cent. ; in 1894, 1.3.7 per cent. ; in 1895, 15 per cent. ; in 1896, 18.4 per cent. Later tm ETIOLOGY AND PATHOLOGIC ANATOMY reports from the Health Department showed the proportion in 1897 to be 18 per cent., and in 1898. 19.7 per cent. The source of information upon which these statistics were compiled was the returns upon the death-certificates. The percentage of deaths is by no means a fair criterion of the pro- portion in Denver of cases said to have developed in Colorado to those contracted elsewhere. The pulmonary invalid from a ili.stance, with a hopeless prognosis, is usually advised to return home. Compara- tively few such patients, fortunately, are permitted to die in Denver, removed from family and friends. The proportion, then, of one to six does not properly apply, as might be inferred, to the existing cases of tuberculosis in Colorado. It is easy to demonstrate the fallacy of an alleged rapid increase in the percentage of deaths from tuberculosis contracted here. It is apparent that a given ratio may be radically transformed by a change in either of its terms. In other words, the percentage of deaths from tuberculosis developed in Colorado may be increased from year to year by reason of an increase in the number of such deaths, f)rovided the total tuberculous death-rate remains unchanged. Upon the other hand, if the entire death-rate from tuberculosis is diminished, the proportion of indig- enous cases may be increased, although the actual number be less than in previous j-ears. While the figures of the Health Department previously cited show the percentage to have increased very rapidly, the actual number of cases originating in Colorado was but slightlj- larger for the four years, while the total number of deaths from tuberculosis was considerably less; this, of course, effecting an increase in the proportion, but possessing no further significance. Thus in 1893 the total number of deaths from tuberculosis was reported as 435, of which 49 were specified as contracted in Colorado, establishing a percentage of 11.2.5. The next year the total number was 377, a diminution of 58, while the number contracted in Colorado w'as 51, an increase of but two cases for the entire year. It is obvious at once that the increase is entirely insignificant, yet the proportion is published as being 13.7 per cent., a gain of 2.5 per cent, in the deaths originating in Colorado for the year. An analysis of the statistics for 1895 and 1896 gives practically the same results. The number of deaths in 1896 is but two more than for 1895, and but 17 more than for 1893, in spite of an increase in that time of 26,000 in the population. }'et the percentage is much increased in 1896 on account of a diminution of 60 in the total tuberculous death-rate. It is of much interest to note that the statistics for 1899, furnished by the Health Commissioner, were decidedly at variance with those previou.sly reported, and serve to some extent as an official refutation of the asserted rapid increase of pulmonary tuberculosis in Colorado. Despite a material increase in the population of Denver since 1893, the number of cases specified as having developed in 1899 was but four more than in 1893, and the percentage of such cases to the total deaths from tuberculosis was but 9.9, about one-half that reported for the three previous years, and less than any proportion which has been determined since 1893. The compilation of these statistics was based upon the same official sources of information as in the previous years. In the summer of 1901 the mortality statistics of consumption were reviewed upon the basis of the returns collected by tne State Board of TO WHAT EXTENT IS CONSUMPTION INDIGENOUS IN COLORADO? 69 Health rather than the Denver Healtli Department, during the sixteen months included between Junuarv, I'.KIO, and May, 1901. An investi- gation conducted by different otficiiils through the channels of another department and perhaps in accordance with other methods might be expected to disclose a cUfference in final results entailing a pos- sible mochfication of previous conclusions. It is interesting to learn, therefore, that the proportion of deaths from consumption developed in the State to the total tuberculous death-rate for the sixteen months during which the statistics were collaborated was stated to be 13.32 per cent. This chanced to be the same proportion as was published by the Denver Health Department for 1894, and failed to indicate on the face of the returns any increase whatever in such deaths during a period of seven years. As a matter of fact, the proportion was about one-third less than that reported for 1897 and 1898. Unfortunately, from 1901 to 1904 the Health Commissioner of the city of Denver preserved no record pertaining to cases of pulmonary tuberculosis contracted in Colorado. After diligent search it has been impossible to discover any data upon which to compile statistics of this nature during his tenure of office. According to the official annual report of the statement of deaths for the city and county of Denver by the Health Department in 1905, there were 39 cases of pulmonary tuberculosis stated to have developed within the State, as compared with a total mortality rate from tuliei-- culosis of 661, establishing a proportion of only 5.9 per cent., wliich is less than any year since the compilation of such statistics in 1893. In 1906, however, an increase was noted over the preceding year, there being 58 cases reported to have developed within the State as compared with a total death-rate from this disease of 634, making the percentage 9.1, which chances to be smaller than in 1893, or any succeeding year up to 1905. Another aspect of the subject is the significance of an annual increase in the population, which was not formerly considered in the official computation of vital statistics in the State. While possiljilities of error necessarily attend any effort to determine the rehitions of indigenous consumption, perhaps no method is as satisfactory in alTonlinti- approx- imate conclusions as the proportion of such cuscs to I lie population. Accepting the figures of thr ITcaltli Department relative to the popula- tion of Denver and the niiiiilier ot deatiis annually from primary tuber- culosis since 1893 as an eiiiiiieiiil\ fair hasis for analysis, the percentage of such deaths per 1000 inhabitants was found to vary but little from year to year, the proportion being less in 1894 than in 1893; in 1896, slightly less than in 1895, and in 1899, three per 10,000 people as com- pared with three and a fraction in 1893. Apropos of these results, attention is directed to the report of the Committee upon Tuberculosis, which stated that for the first eleven months of 1900, the only time during which statistics were compiled, the percentage of such deaths to the present population was three persons per 10,000 people. This coincided singularly with my analysis of death reports for previous years, being practically identical with results obtained for 1899 and 1893, being even less than in 1894, and presenting but trifling fluctuation in succeeding years. From this comparison it was seen that the Com- mittee's report failed to demonstrate the slightest increase of indigenous consumption from the time the agitation received its inspiration. 70 ETIOLOGY AND PATHOLOGIC ANATOMY As previously stated, there are no available statistics pertaining to this subject during 1901, 1902, 1903, and 1904. The proportion of deaths from indigenous tuberculosis in 1905, according to the official report of the Denver Health Department, is less than two" per 10,000 people; in 1906, a little over two for 10,000 people, in both years being less than any percentage previously obtained. Still another phase of the subject is the relation of infantile tuber- culosis mortality to the total deaths from consumption contracted in Colorado. An analysis of data obtained from the Denver Health Department showed that, of all persons reported to have died of tuber- culosis originating within the State during a period of seven years, up to 1900. nearly one-fourth were children under four and five years of age, of whom 85 per cent, died of tuberculous meningitis. During the follow- ing year, out of a series of 76 cases, concerning which special detailed information was obtained, 27, or over one-third of the entire number, were untler five years of age. Manifestly, in view of the special predisposition, such infantile cases, without qualifjdng explanation, should not be in- cluded as instances of death from indigenous pulmonary tuberculosis. A similar consideration deserving mention is that of occupation. It is found, by reference to the report of the Tuberculosis Committee, that out of a total of 224 cases 49, or more than one-fifth, occurred among miners. The vast importance attaching to so large a propor- tion among this class, modifying as it does any superficial conclusions, is appreciated when one considers that the tuberculous element is subordinate to other pathologic changes, and occurs as a mere final development. It is suggested that these patients scarcely ever asso- ciate with consumptives, but e.xhibit a constant disregard of general hygienic laws which involve subsequent tissue changes insuring a favor- able soil. Obviously, these cases should not be instanced as examples of the dangers of every-day infection. As bearing directly upon this line of thought, the attention of the student is directed to the location, in the State, of reported indigenous ca.ses. El Paso County, containing a greater relative proportion of consumptives than any other, and, therefore, likely to yield the largest percentage, presents the remarkably small nuniber of six cases, or about ^V of the whole. Gilpin County, with a much smaller popu- lation, among whom consumptives are exceedingly infrequent, the people being comprised largely of miners, offers a percentage nearly three times as great. A factor of no inconsiderable importance, to which attention was called by me in 1897, is the entire absence of proof that cases reported as developing in Colorado were actually contracted here. It was con- tended that the mere fact of an individual exhibiting physical signs of tuberculosis less than one year after arrival is no evidence of its having originated in Colorado. The arbitrary inclusion of such cases unavoidably implies a non- acceptance of the theory of a latent tuberculous process, and is op- po.sed to the incontrovertible testimony adduced in recent years as to the extraordinary frequency of unsuspected tuberculous infection. Many Colorado phy.sicians, from their daily experience, can testify concerning individuals apparently sound, with clear eye, bronzed cheek, and well-rounded proportions, yet victims of an incipient, if not active, infection. Is it not probable, among the large number of people coming TO WHAT EXTENT IS CONSUMPTION INDIGENOUS IN COLORADO? 71 to this State accompanying invalid relatives and friends, with indi- vidual resistance subsequently diminished through hardships undergone and privations endured, that some have developed an active process from an infection previously latent? If this be true, it may be asked, by virtue of what right should it be assumed that the development of the disease in apparently healthy people is sufficient ground to assert its origin in Colorado, without recourse to investigation and without at least a residence in the State of one or more years? I am unable to understand how a reasonable interpretation of official data justifies a conclusion as to an alarming increase of indigenous cases. If consumption contracted in Colorado is actually increasing to any extent year by year, it remains to be demonstrated by statistical obser- vations not as yet introduced. Let it be understood that no negative testimony is presented in rebuttal of the positive claims of those with whom I have been forced to differ. The position originally assumed was taken solely from the analysis of their own recorded official statistics, the authenticity of which has never been disputed. It is admitted that clinical reports from con- servative and painstaking observers furnish testimony from time to time concerning the occasional existence of indigenous cases. That a more interested attention is being devoted to the investigation and report of such cases is certainly a source of congratulation and gives promise of perhaps more definite future knowledge. From information thus far received, however, it would appear that in a large proportion of the cases reported, there had been abundant icason for the development of the disease by virtue of a marked inliciiicd taint, the presence of some recognized predisposing cause, ucciiiiation, or special exposure. This is illustrated somewhat by ni}- own experience, which comprises a list of 35 cases out of a series of 2070 cases seen in private practice during a period of sixteen years. In 9, occupation may be justly con- sidered to bear an important relation to the etiology, 3 being old miners, 3 stone-cutters, 1 a layer of carpets, 1 employed in a steam laundry, ancl 1 a cigar-maker. With 2 a very reasonal^le doubt may be entertained as to the origin of the disease in Colorado, 1 having developed it six months after arrival and the other having been in Sweden upon a long visit immediately before the disease manifested itself in this State. With 6 others there was a distinct history of great exposure to infection, such as would endanger health in any climate. Another is an instance of pulmonary tuberculosis occurring in a child whose mother died of consumption three weeks after he was born. The remaining cases are offered as examples of tuberculosis contracted in spite of a favorable climate, for which no explanation is made. One of these developeil tuberculosis complicating a long-standing diabetes, another in associ- ation with chronic interstitial nephritis, 2 in conjunction with pro- nounced habits of dissipation, and 4 following severe influenza. No mention is made of the several cases of tuberculous meningitis occurring during the first one or two years of life in infants born of tuberculous parents, as these do not appear to come within the scope of this inquiry. Although deprecating all sensationalism that tends to inspire alarm, there is advocated no abatement of the hearty support to be accorded to health authorities, nor of earnest and combined efforts along the lines of preventive medicine. Measures necessary for the restriction of con- sumption should be enforced in Colorado, as in other States. 72 ETIOLOGY AND PATHOLOGIC ANATOMY CHAPTER XII GENERAL CONDITIONS INFLUENCING INFECTION AFTER EXPOSURE TO THE TUBERCLE BACILLUS An inherited predisposition to consumption is commonly regarded as a feature of the utmost importance, although modern opinion con- cerning the etiologic significance of the family history is quite divergent. A mass of statistics has been cited by various observers to demonstrate and also to refute the influence of heredity in the development of the disease, and it almost appears that both the affirmative and the nega- tive contention may be substantiated by analytic inquiry. Statistics concerning this phase of pulmonary tuberculosis are usually collaborated with reference solely to tuberculosis in the immecUate antecedents, irrespective of such other features as the time of its development, its duration, the degree of association permitted with other members of the family, the environment, and the opportunities for infection. These factors, if investigated properly, often clothe the compiled results with far greater importance. Without elaborate inquiry along collateral lines, analytic reports concerning an inherited predisposition are devoid of special practical interest. The vital consideration relates not to the fact that one or more members of the family died of consumption, but chiefly to the time, conditions, and circumstances under which the disease existed. Chil- dren whose parents subsequently became tuberculous belong to an entirely different category from those whose progenitors were con- sumptives at the time of conception. The opportunities for post- natal infection /are frequently sufficient to prevent an assumption concerning the precise influence of an inherited predisposition. The tubercle bacillus is present to a particularly dangerous extent in houses inhabited by pulmonary invalids, and at no age is greater opportunity afforded for acquirement of the infection than during infancy. In the majority of cases the es.sential element in the prop- agation of the disease among children is not the inheritance of a tuberculous taint or predisposition from infected parents, but rather an undue vulnerability of tissues peculiar to infants and an excessive exposure to sources of acquired infection. These conclusions appear justified by the results of clinical experience in a health resort extensively frequented b}^ pulmonary invalids. In several instances I have seen children of perfectly health}- parents .succumb to tuberculous infection, explainable upon inquiry by contact with a pulmonary invalid. On the other hand, children of tuberculous parents have often been observed to thrive to a remarkable degree upon enforcement of rigid precautionary measures. I have in mind a child of two and a half years both of whose parents are tuberculous. The infant at birth weighed less than four pounds, was a typical "blue baby," and lost nearly one pound during the first two weeks of life. The evidences of physical debility were pro- nounced, malnutrition persisting for a long time. Though reared exclusively upon modified milk, the infant finally attained a surprising degree of nutrition and vigor. To minimize opportunities for postnatal infection the child has been kept under the successful management of a nur.se in an isolated portion of the house. CONDITIONS INFLUENCING INFECTION AFTER EXPOSURE 73 There is to be expected, of course, a diminished resistance in chil- dren born of parents with waning strength and vigor as a result of pulmonary tuberculosis, carcinoma, nephritis, syphilis, severe nervous disturbances, and old age. This impaired vitality, unless incident to infantile syphilis, bears no inherent relation to the specific nature of the parental constitutional condition. It does not characterize tuberculosis alone, and is due not to the cause of the parental weak- ness, but to the debility itself. The offspring displays a lessened resist- ance to disease in general, with no greater precUsposition to tuberculosis than to some other affection only in so far as its wide prevalence furnishes greater opportunities for acquired infection. It has been shown that children with lessened powers of inherent resistance to disease never- theless may thrive by virtue of especially favorable conditions. The relation of environment to infection is of considerable interest. It is somewhat doubtful to what extent an increased vulnerability of the tissues to tuberculous infection may result from external causes. It is quite impossible to state the relative importance of lowered resist- ance and direct exposure as causative factors in the development of the disease. It has been the tendency in recent years to ascribe the spread of tuberculosis more directly to the distribution of the bacillus, and preventive measures, therefore, have been directed almost exclu- sively toward its destruction. Through the influence of societies for the prevention of tuberculosis and the administrative efforts of municipal and State health authorities the attention of the profession has been called to the necessity of removing all possible sources of bacillary infection. Commendable as has been this work along the lines of preventive medicine, it is apparent that there exists to some extent an unconscious inclination to overlook the etiologic significance of conditions pertaining to the every-day life. It may be assumed that the factor of paramount importance in the production of tuberculosis is the presence of the tubercle bacillus, and that efforts toward its removal will be attended with a gratifying diminution in the prevalence of the disease. It may be asserted, however, with equal positiveness, that the possibility of bacillary invasion, its degree and result , arc urcatly modified by the receptivity of the soil. The activity of ilw tulictiii- lous infection is extremely variable in different people sul>ji( nd \u pre- cisely the same conditions. Among several members of a family siiriciing equal degrees of exposure the development of the disease ina>- Vie observed in but a single instance, or, if in more than one. with tlie \iru- lence of the infection strikiuiiiyiUssiniihir. This distin^nuisliiuu .IHTerence in incUvidual receptivily is dhseiNcd in ]iris(ins, i-elnrniaturies. I laii ;icl'CS, and even among the attendants (if r(insiinip(i\'es in sanalmia. I'm- a long time it has been recognized as a clinical truism that races and families manifest a remarkable difference in the degree of susceptibility to infection and in the power of sulisequent resistance. If such condi- tions are found beyond question to exist with reference to faniilies and nations, it is reasonable to expect corresponding indivi(hial \ariatiiins in the types of infection. Important controlling factors relate to the methods of living, the habits, occupation, and social conditions. Exceed- ing importance attaches to the existence of hygienic surroundings, adequate ventilation, sufficient food, proper clothing, the absence of excesses, and the avoidance of oppressive cares and burdensome vexations. 74 ETIOLOGY A\D PATHOLOGIC ANATOMY Consumption has been found to afflict the poor oftener than the well- to-do, the ignorant more than the educated, the vicious and intemperate rather than the refined and gentle, and those who are mentally depressed and despondent rather than the cheerful and sunny in disposition. The disease exhibits a proneness to select as victims hard students, indi- viduals accustomed to sedentary pursuits, those who follow certain unfavorable occupations, and, finally, persons subjected to arbitrary confinement in prisons and other detention institutions. The undue preponderance of consumption among these people and amid such conditions is, to say the least, strongly suggestive of a predisposing influence. The development of the disease among athletes and individ- uals apparently in the very prime of health and vigor constitutes no argument in opposition to the etiologic significance of a suitable soil. While such instances occasionally attain a conspicuous prominence, they are, upon the whole, quite exceptional. The inference is strong that in athletes accustomed to heroic feats of overexertion there may exist a certain pathologic disturbance of normal conditions materially favoring the development of tuberculosis. Certain it is, as a matter of clinical experience, that an infection once established in such cases is almost sure to pursue an unfavorable course. It has been my obser- vation that no class of patients exhibits less power of resistance to the ravages of consumption than the athlete or hard-working farmer. In like manner the prevalence of pulmonary tubercidosis among the inmates of prisons and reformatories has been frequently cited as an overwhelm- ing example of the danger of transmitting the disease from one per- son to another. It is apparent that there is a tendency to disregard the predisposing influence of confinement, lack of sunshine, fresh air, exercise, proper food, contentment, high ideals, and incentives to work. It is interesting to note, from a review of statistics, that the pi'opagation of the disease in prisons is not noticed as much among those who are allowed a portion of their liberty as among those subjected to solitary confinement or imprisoned for a part of the day within the confines of a narrow cell. It would appear that if, regardless of environment, the presence of the bacillus was the sole consideration, the greatest develop- ment of consumption, on account of the exceptional opportunities for infection through personal contact, should take place among convicts who are permitted to mingle more or less in crowded workshops. The fact that the spread of the disease in these institutions relates particu- larly to those who, through their segregation, are less exposed to the dangers of infection, adds corroborative evidence as to the predisposing influence of an unfavorable environment. Attention has been called to the fact that, prior to 1864, consumption was comparatively rare among the negroes, partly because of the few sources of infection, but more particularly because of their outdoor existence, obligatory physical exercise, abundance of suitable food, and the general contentment and peace of mind incident to life in the quarters. Upon being compelled to care for themselves, for which they were very imperfectly adapted by previous training, there was imposed a necessary assumption of oppressive responsibilities. The country air was changed in many instances to the less pure atmosphere of large cities, and was often foully contaminated by their crowding together in small apartments. In the absence of enforced work in the open air there developed unavoidably a tendency toward shiftlessness CONDITIONS INFLUENCING INFECTION AFTER EXPOSURE 75 and dissipation. As a result of insufficient food, inadequate clothing, occasional undue exposure, imperfect ventilation, and habits of alco- holic and sexual intemperance and disease, there has resulted a pro- nounced acquired disposition to tuberculosis, which, added to the vastly greater sources of infection, has operated toward the decimation of the race. It is true that consumption among the American Indians was unknown while they were permitted to roam at will throughout their natural domain. The later ravages of the disease may not be construed as resulting entirely from the numerous sources of infection incident to civilized life, but are dependent to some extent upon the complete transformation in the life, habits, and environment of the Indian him- self. As a matter of fact, consumption upon the frontier among the white people is extremely rare, and the opportunities for infection are not so numerous as at first might be supposed. Assuredly they are not sufficient to explain alone the somewhat remarkable spread of the disease among the Indian race. As with the negro, at least a partial explanation is found in the lessened outdoor existence, diminished exercise, infrequent Iniiitiii^ (li\ersions, marches, and marauding expe- ditions, the greater rest ri( t ions ujion their liberty, and the inculcation of habits of shiftlessness and dissipation. Still another instance of the influence of environment as a predis- posing factor in the development of tul:>erculosis is found in the some- what surprising development of the disease among soldiers who are subjected to rigid physical examinations before admission to the armies of the world. In a report recently issued concerning the health statis- tics of the United States army for the past calendar ye^r it is stated that, in spite of the short term of enlistment and their assumed normal con- dition upon entrance to the army, 0.68 per cent, of the soldiers suc- cumbed to tuberculosis, while 5 per cent, of all the deaths in the Philippines and 20 per cent, of the discharges were occasioned by this disease. These facts are not to be attributed entirely to the confinement incident to the barracks and the consequent opportunities for infection. An additional causal factor is found in the unpleasant environment, as evidenced by the frequent desertions, the irregularities in the quantity or quality of food and the time of its administration, and the fatigue, discomfort, and exposure resulting from camp life and strenuous marches. That occupation is an element of some importance in the causation of consumption is shown by the alarming prevalence of the disease among employes in department stores, mills, post-offices, printing-rooms, and saloons, in all of which places the ventilation is notoriously inade- quate. The influence of occupation is still further emphasized by the development of tulierculosis among millers, plasterers, stone-cutters, grinders, potters, and other persons necessarily obliged to breathe an atmosphere deficient in oxygen, contaminated by noxious vapors, or impregnated by particles of impalpable dust. The influence of age and race has been discussed in previous chapters. Cei-tain diseases are known to effect a varying degree of predisposition to tuberculosis, as measles, whooping-cough, bronchitis, influenza, and typhoid. It is probable that in most instances the tubercle deposit previously existed as a latent infection, a renewed activity being induced on account of the lessened resistance incident to the recent illness. The 76 ETIOLOGY AND PATHOLOGIC ANATOMY relation of the above diseases and of pneumonia, pleurisy, pulmonary hemorrhages, and trauma to tuberculosis are more properly suited for discussion in other portions of the book. In adcUtion to such incUvidual peculiarities as age, inheritance, occupation, envh-onment, and previous diseases, all of which are known to influence infection to some extent, the relative virulence of the bacilli and the character of the tissues are known to aid in determining the course of the disease. Variations in the virulence of tubercle bacilli are known to exist, and it is highly probable that essential differences in the clinical manifestations and in the nature of pathologic changes result from this cause. Another factor of considerable importance in influencing infection is the number of bacilli succeeding in gaining entrance into the body. In other words, the resulting clinical and pathologic change may be expected to correspond more or less to the dose of the infection, if such a term be permitted, the combined effects of many bacilli being far more difficult to overcome than a smaU num- ber. The receptivity of the soil in the particular portion of the body destined to be the accidental abode of the bacUlus is still another feature of moment in the determination of the resulting infection. Growth and distribution are favored particularly in vascular tissues rich in lymphatics and with an excess of moisture. Looseness of texture represents concUtions eminently suiteil to the development and spread of tuberculosis as opposed to dense structures poorly supplied with lymphatics. It is thus inexpedient to attribute the entire responsibility for the character of resulting infection to the individual upon the score of increased susceptibility, when manifestly the entire subsequent course of the disease may be dependent upon such accidental conditions as just described. As previously stated, it is possible that the clinical exhibition of supposed differences in vital resistance may be partly ex- plained by variations in the virulence of the invading microorganism. It is notorious that anemic, poorly nourished, and apparently enfee- bled individuals often succeed in effectually overcoming tuberculous infection, while others in seeming health and vigor, with an apparent surplus of resisting power, rapidly succumb to infection. SECTION II Pathologic Anatomy CHAPTER XTII GENERAL CONSIDERATIONS The morbid processes peculiar to tuberculosis may affect various organs of the body. In adults the lungs are the parts generally involved, while in children the lymphatic glands, bones, and joints are frequent seats of the disease. The pathologic conditions in tuberculosis of the meninges, pleura, serous membranes, lymphatic glands, bones, joints, GENERAL CONSIDERATIONS 77 intestines, and genito-urinary apparatus will be discussed in connection with tuberculosis of these special regions. Present discussion relates solely to a consideration of the various anatomic changes found in tuberculosis of the lungs. In pulmonary tuberculosis there exists a striking variety of pathologic conditions. The essential morbid processes are: (1) The development of minute nodules conforming to a fixed t3'pe of structural change, and known as the true pathologic tubercle; (2) the degenerative change peculiar to the tubercle itself, includ- ing caseation and softening; (3) the constructive processes within and around the tubercle; (4) conglomerate tuliercle formation; (5) diffuse tuberculous infiltration without the development of discrete nodules; (6) secondary inflammatory processes attended by their various exudates. These latter infections, with their lesions, not infre- quently constitute the most conspicuous gross anatomic change, the nodules appearing upon macroscopic inspection relatively incon- sequential. In some cases definite tubercles are absent altogether, fulminating pneumonic processes with speedy destructive change pre- dominating over the more characteristic tubcrclf. Again, in other cases, the secondary inflammatory condition is accoiniianicil liy exten- sive reactive processes of connective-tissue rciiaii'. the exudative and degenerative lesions being comparatively inconspicuous. In this way the natural constructive efforts are analogous to the sclerosis taking place in the peripheral region of the tubercle itself. Thus it is seen that the pathologic condition in the lungs of different individuals suffering from pulmonary tuberculosis or in various portions of the same organ conforms to no single anatomic type. According to the extent and character of the nioibid pincess in the pulmonary tissues there may result in several p;irts ol the same lung striking differences in the micro- scopic and macroscopic appearance. The only lesion which may be regarded as definitely characteristic of tuberculosis is the elementary tubercle, and even this, without the presence of liacilli, fails to serve as an absolutely distinguishing feature of the di.sease. Similar tubercle formation may be present in syphilis, and is sometimes produced by other microorganisms. It is even claimed that pseudotuberculosis may result from the irritation of certain foreign bodies. It is probable, however, that in nearly all instances the histologic clianges are pro- duced by bacteria, and that by far the most common microorganism in such formation is the tuliercle liacilliis. While in tuberculosis the true pathologic tubercle constitutes .-i cluirartcristic lesion, the presence of bacilli in the tissues foim- an e- eiiiial condition. I'uither, a genuine tubercle deposit may exist ui various poitious of the body without the affected tissues exhibiting the definite histologic siructnic of elementary tubercle, as commonly oljserved in lupus \ulga.ris. AlmIu. tin- luKercle itself not only may undergo certain evolutionary changes either degenera- tive or constructive, but even in the acme of its development may exhibit important differences in structural formation, as will be described later. Until quite recently it has been the general belief of pathologists that the mode of entrance of the bacillus into the pulmonary tissues has been chiefly by inhalation into the bronchial tract. In miliary tuberculosis a general distribution of the bacilli to the lungs through the medium of the circulation has been recognized for a long time. While conveyance of the infective agent to the pulmonary tissues by 78 ETIOLOGY AND PATHOLOGIC ANATOMY means of the lymphatic current was known to take place in occasional instances, immediate infection of the lungs from aspiration of the bacilli has been regarded as the much more common method. In the light of modern investigation, to which reference has been made in preceding chapters, it is probable that the principal method of bacillary distribution is through the lymphatic and vascular channels. It is known that bacilli may traverse the mucous membranes and enter the circulation without primary lesion at the point of entrance. Attention has been called to the rapid tuberculous involvement of met^enteric and bronchial glands following the penetration of an intact intestinal membrane. Shortly after test-meals of infective food, bacilli have been detected in the thoracic duct and even in the pulmonary artery. It cannot be denied that bacilli may enter the alveolar tissues via the respiratory tract, the blood-vessels, and the lymphatic circulation. In pulmonary tuberculosis, irrespective of the precise mode of infection, it is extremely difficult to discriminate between the ultimate morbid conchtions pre- sented in different instances. Therefore, it is obviously inexpedient to attempt a description of the pathologic findings based upon the several methods of invasion. The old belief that the bacilli are almost always inhaled directly into the alveoli to set up limited areas of tuberculous pneumonia, or to pa.ss between intact epithelial cells pro- ducing tubercle formation in the peri-alveolar and peribronchial connec- tive tissue, is entitled to less credence than formerly. The common location of elementary tubercles in the immediate vicinity of the arterial terminals makes it probable that primary localized lesions take place in the intima of the finer arterioles more frequently than has been supposed. Scattered tubercle deposit in the pulmonary tissues is often recognized in immediate proximity to preexisting glandular foci of infection, the lymphatics being the obvious carriers of the bacilli. In view of the relative infrequency at autopsy of pulmonary lesions without involve- ment of bronchial glands and the greater frequency of tuberculosis of the lymph-nodes without pulmonary infection, it is fair to assume that these constitute an important reservoir for the subsequent distribution of the bacilli. Finally, on account of the early merging of the pathologic conditions, regardless of the method of entrance, into a single lesion, i. e., the elementary tubercle with accompanying inflammatory changes, it is unnecessary to emphasize further the so-called bronchogenic, hematogenic, or lymphogenic methods of infection. CHAPTER XIV HISTOLOGY The structure of the primitive tubercle or nodule from which the disease derives its name is of special interest. Generally speaking, tuberculosis begins with the formation of a miliary tubercle, which is the result of mild inflammatory processes, in turn produced by the irritating presence of the bacillus in the tissues. This subsequently undergoes varying degrees of degenerative change. The miliary tubercle, though HISTOLOGY 79 deriving its name from its resemblance in size to the millet-seed, never- theless presents considerable variation in this respect. The size may vary from i^j to 3 millimeters in diameter, in some cases approaching the dimensions of a small pea. It is usually a compound body, composed of a numlier of smaller elementary tubercles which are sometimes termed "submiiiary." From ten to fifty or more of these smaller tubercles may unite to form a single miliary tubercle. The term "submiiiary" is often applied to large tuberculous masses formed by the coalescence of many miliary tubercles, but it would seem that the more proper descriptive adjective for such confluence of tubercles would be " conglom- erate," rather than "submiiiary." ' The true elementary tubercle is a small, non-vascular, translucent nodule, containing tubercle bacilli and usually characterized by giant- cells, epithelioid cells, and lymphoid cells contained within a reticulum of fibrous tissue. The tubercle bacillus is almost the sole irritative influence capable of producing this characteristic cellular proliferation. The series of events leading to this tubercle formation is undoubtedly more complex than is at once apparent. It is believed that when the bacilli first obtain lodgment in a favorable nidus for growth and de- velopment, they are rendered somewhat inert by a protective envel- ope which is later removed, permitting multiplication of bacilli and proliferation of cells. The latter increases in proportion to tlic niul- tifJlication and irritating effect of the bacilli. The nmltiiilication, in turn, is checked to a certain extent by the excessive cell division whicli it has succeeded in stimulating. The bacilli continue to multiply and the cells to increase up to the point of such peripheral connective-tissue formation as suffices to produce a protective and inclusive barrier, within which some of the bacilli are destroyed liy tlie phagocytic cells. The cellular proliferation may be essentially ciiilliclioidal or lymphoidal, according as the cells are derived from the connect i\e tissues or result from an infiltration of leukocytes from surrounding blood-vessels. The inflow of wandering leukocytes responds to the local irritative effect of the bacilli upon the vascular system, and as this influence predomi- nates, the cellular infiltration is proportionately lymphoidal. As a rule, however, the early reactive influence upon the tissues as a result of the local irritation, is a proliferation of the fixed connective-tissue cells and the endothelial cells of the blood- and the lymph-vessels. Both the epithelioid and lymphoid cells are, as a rule, mononuclear, in contra- chstinction to the giant-cells which later appear. The nuclei of the epithelioid cells stain but faintly, while the nuclei of the round-cells stain much more deeply and have a smaller pioiophismic body. While in some instances the epithelioid cells nia\ incdoniinate and in others the lymphoid, it commonly happens that the loiinei- cells are more within the tubercle structure and the latter in the peiiplieial |i:irts. The giant- cells form an important characteristic ol' tulieicle lormalion, and are known to occur in other conditions than tuberculosis, notably in the granulomata and in sarcoma. They are large, oval, or circular pro- toplasmic masses containing multiple nuclei. These are sometimes grouped at the two extremities of an oval cell constituting the so-called bipolar arrangement of nuclei, and are often disposed circularly within the giant-cell around its outer margin. Several theories have been off'ered in explanation of the formation of giant-cells. According to Councilman, they may result from the coalescence of several epithelioid SU ETIOLOGY AND PATHOLOGIC ANATOMY cells, or from division of nuclei without division of the protoplasm, or from proliferation around a thrombus of entlothelial cells of the blood or lymphatic vessels. Metchnikoff believes in their origin from a fusion of epithelioid cells, while Baumgarten adheres to the belief of their development from multiple division of the nucleus of a fixed tissue-cell. The giant-cells, which are considered by Metchnikoff to be active agents of defense, often vary considerably in number in inverse ratio to the ba- cilli. It is recognized that in tuberculosis of lymphatic glands, of bones and joints, and in lupus, the giant-cells are numerous, w-hereas the bacilli are few. In miliary tubercles, however, the reverse is the case. Bacilli may be present in the giant-cells as well as in the epithelioid and lym- phoid cells, or between the various cells in the periphery of the tubercle. They are often found in the center "t the tubercle which is undergoing degenerative change. It has been iidtcd i hat when present in giant-cells Fig. 1. — Drawing of miliary tuljerule ui ilir -i.lfrn. Iimjii case of miliary tuberculosis. Note central area of beginning necrosis and conru-ctiv. ti--uH i.fi. ulum. Note the two giant-cells, the one in the center showing distinctly pi.>ni)liei:il ai lan^.-imnt ..I the nuclei. Note further peripheral infiltration of the round-cells. they are apt to congregate in the center in the event of a peripheral or mural arrangement of nuclei, and in case of elongated cells with nuclei at one pole, to assemble at the opposite extremity. With advancing degeneration in the center of the tubercle the bacilli in this region dis- appear as a result of disintegration and death, the number increasing, however, in peripheral portions. An important constituent of the elementary tubercle is a reticulum of connective tissue, which is interwoven between the epithelioid and lymphoid cells, and sometimes appears to be a branching extension of the protoplasmic areas characterizing irregular giant-cells. The connective-tissue reticulum is much more abundant at the periphery of the tubercle. The reticulum is thought to be formed in part bj- the fibrination of the protoplasm of cells. HISTOLOGY 81 Degenerative change is characteristic of tubercle deposit and some- times takes place early in the evolution of the lesion. Owing to the absence of newly formed blood-vessels, no nutriment is conveyed to the tissues within the tubercle. The avascular condition is an important cause of the degenerative change. Other factors responsible for its production are the specific effect of the living tubercle bacillus and the toxins. The degenerative processes consist of hyaline change, coag- ulation necrosis, a degree of fatty degeneration, varying degrees of caseation, and calcification. The degenerative changes usually take place early in the central cells of the tubercle, sometimes affecting the giant-cells before all others. Usually the lymphoid cells are transformed somewhat before the degenerative process attacks those of the epithe- lioid variety, which apparently are more resistant than other cells. Owing to the excess of lymphoid cells the epithelioid ty|ic i,- often not recognized until the former have degenerated and ( lisapi K'arcd. Definite caseation is preceded by a sliiiht linuiula.i' chaii.ue in the protoplasm of the cells. With later degoiieratiini the n\iclci are found more or less broken down and fragmentary, with Ic^scihmI inclination to take ordinary stains. Some authors, however, June imictl a bright staining reaction of the nuclei even in the midst of in'cn ii ic il:ani;e. The contour of the cells becomes defined less sharply uniil I'r oiitHiies are lost altogether, the affected portion of the tiilici< Ic imi i; tniL^ <>( a lidnKiiiciuMius necrotic area. In this manner, as a rcM;!i "I roaiiiilat imi iiccKi.-i,-. the central portion of the tubercle is traii.-lui incd into a hrokcn-ilow n mass, con- taining, in addition to the disintegratetl cells, living antl destroyed Ijacilli. Outside of the caseous center there are present epithelioid cells ^\■ith an occasional giant-cell undergoing beginning degeneration, and at the periphery epithelioid and lymphoid cells icpi-csontinn the newer evolu- tion as a result of cellular proliln.iiion. In uiaiii-crll- the degenerative change also takes place in the icniei- of the cell, paiticiihniy when the nuclei are disposed circularly at the peripliery. Sten.^cl and is u.-uallv takes place at the op])osite ]iole. It has been previously stated that the tubercle bacilli, when lonnd in giant-cells, occur at the center in cti.se of peripheral nuclear ution and at the pole opposite to the gathering of nuclei. It would thus seem to be a reasonable conclusion that the regional degenerative change in giant-cells corresponds closely to that portion of the cell in which the bacilli are grouped. As the degenerative processes further advance the entire tubercle undergoes coagulation necrosis and the process of caseation becomes complete. Leukocytes are usually attracted in coiisiilerable numbers to the areas of degeneration, where they suft'er the same fate as the fixed cells. The exudative processes and the resulting caseation are not con- fined to the tissue within the tubercle. This phase of the subject will be con.sidered more fully in connection willi diffu.se tuberculous infiltration and the secondary inflammatoi\- h-ion^. Of .■ill the tis.-^ues in\ol\ed in the structure of tubercle, the hi iron- reticulum is the niosi l(■^i^lant to degeneration. Connective-tissue proliferation may remain active in the periphery of the tubercle, and eventually produce a surrounding fibrous barrier delimiting the tuberculous process and entirely encapsulating the tubercle itself. It will be seen, however, that the reactive connective-tissue hyper- 6 82 ETIOLOGY AND PATHOLOGIC ANATOMY plasia is not always sufficient to effect a complete encapsulation, oppor- tunity being afforded in many instances through the lymph-channels, and as a result of wandering phagocytes, for the deposit of bacilli in fresh tissue areas. Occasionally it does happen that the proliferation of connective tissue is sufficient to wall off entirely the tuberculous area and to produce decided contraction change. The fibrosis eventually may involve the central portion of the tubercle as well as the surrounding parts. As a result of such reorganization small foci of infection may be converted into dense cicatricial tissue comparativel}' devoid of blood- vessels, and producing an eventual healing of the involved area. These constructive efforts on the part of the tissues constitute the only means of securing a permanent arrest of the disease, if not obliteration of the tuberculous lesion. It is generally thought that even the formation of tubercle is a natural conservative process, although for the time being admittedly destructive in nature. To the extent that the bacilli are inclosed or imprisoned effectually within an encircling defensive wall the process of tubercle formation with associated sclerotic change may assuredly be regarded as an effort on the part of the organism toward self-protection. Although this mechanism of defense is often somewhat imperfect, it is true that the channels of escape for the bacillus are .suscep- tible of complete occlusion by active cellular proliferation with dense connective-tissue encapsulation. This reactive protective effort of the invaded tissues is usually accepted as representing an inherent defensive action on the part of the animal organism. Theobald Smith, however, believes that there is a reciprocal protective action between the l)acilli and the normal tissues, and ascribes the process of tubercle formation, with resulting connective-tissue proliferation, to an effort on the part of the parasite to obtain an abode where it may sojourn unmolested for intlefinite periods. While the bacillus undoubtedly affords the stimulus for the cellular proliferation, it would appear that the connective-tissue formation constitutes rather a mechanism of defense of the tissues against the invading parasite. It is apparent that the measure of the practical efficiency of the connective-tissue hyperplasia depends upon the rate of its formation. In the evolution of tubercle there are present tu'o well- defined opposing forces, the eventual supremcLcii of one denoting tissue repair and rrrnn-rii. thr other, progressive degeneration and bacillary distri- bution to suri-))iiiiiliii(i jiiiiis. Upon the one hand, there is a tendency for active cell-iinilifei:iti(>ii with fibrous tissue construction and encapsula- tion; upon tlie other, advancing caseation and extension of the infection to new areas beyond the limits of peripheral connective tissue. The situation resolves itself, therefore, into a race between the effort of con- struction and the tendency to destruction, the final issue being decided according to the relative rapidity of the contending processes. The same inclination to degeneration and to connective-tissue hyperplasia is observed in surrounding areas and even in diffuse tuberculous infiltra- tion, large masses of involved tissue exhibiting varying degrees of necrotic and proliferative change. An extension of the process from the initial tubercle takes place as a result of the penetration of the connective-tissue wall by the bacilli and the peripheral formation of miliary tubercles. In the same manner, from these .secondary tubercles, new centers of growth are again formed. Not infrequently nodules are produced consisting of many miliary tubercles which, as caseation advances in the center, become fused into large masses of broken-down tuberculous material, commonly called conglomerate tubercles, although by some the term "submiliary" is employed. To such masses, which sometimes attain the size of a hen's egg, the appellation " crude tubercle' ' was applied by Laennec. The same processes of degeneration and repair which take place in a single elementary tubercle also obtain in all the constituent tubercles compris- ing the entire mass. Caseation and softening with resulting excavation may develop as a result of the coalescence of the individual tubercles, or a firm network of fibrous tissue hyperplasia may supervene in others. The destructive tendency toward cavity formation not only involves structures of tuberculous formation, but often invades pneumonic areas resulting from secondary inflammatory changes. Factors of great importance in such cases are, first, the nature of the exudative process, which, though purulent, is not necessarily due to mixed infection, and, second, the invasion of these pneumonic areas with tubercle bacilli. Even in tubercle formation, without other associated inflammatory lesions, there is usually an abundant exudation which may consist either of polynuclear leukocytes or of serum. The exudation sometimes is fibrinous and may invade the caseous tissue or cover the surface of miliary tubercles. The exudate, of whatever character, though external to the tubercle itself, may be distributed extensively in the surrounding tissue, and considerably augment the size of nodules or conglomerate tubercles. Discrete tuberculous nodules are often absent altogether, and in their place there may exist a diffuse tuberculous infiltration con- taining numerous giant and epithelioiil cells, with varying degrees of caseation and fibrosis. In addition to the necrotic and sclerotic changes possible of development in individual tubercles or in a conglomerate mass, the process of calcification occasionally ensues. This takes place, however, only after the formation of considerable connective-tissue proliferation. The bacilli are much more frequent in the broken-down debris of these diffuse processes after softening has become advanced than in the strictly caseous material. The content of the softened tuberculous mass is ;i thick, creamy, yellowish material, somewhat re.sembling pus, thoimh (liffciing from it histologically. There are present much granular debris, broken-down cells, and fat-drops. In tuberculosis of the lungs, on account of the opening of tuberculous cavities into bronchi, the conditions are favorable for the entrance of numerous pyogenic bacteria. In pulmonary tissues the characteristic tubercle formation previously described is limited somewhat by the loose anatomic structure of the parts. The tissue is not sufficient in extent nor of such character as to permit the fullest elaboration of tubercle formation, although extensive hyperplasia occurs in surrounding areas. Exceptional opportunities are afforded, however, for dissemination of the tuberculous infection by the physiologic motion of the parts, the penetration of brondii, :inil tlic luxnri;nit network of lymphatic channels and blood-vessels. While the in(i\("iiieiits of ordinary respiration must be regarded to some extent as ininueal to rapid tissue repair, the deep inspiratory efforts attentling violent attacks of coughing are assuredly instrumental in further distribution of the liacilli throughout the respira- tory tract. A most important feature of tuberculous infection of the pulmonary tissues is the frequent extensive development of secondary inflammatory 84 ETIOLOGY AND PATHOLOGIC ANATOMY lesions. The most perfect example of typical tubercle formation in the lungs is found in miliary tuberculosis, although even in such cases exudation is not entirely absent. The tubercles are found in the walls of the alveoli, of the bronchi, and of the blood-vessels. Areas of tuber- culous bronchopneumonia with extensive retroactive inflammatory change are sometimes accompanied by miliary tubercles. These inflam- matory lesions, dependent largely upon exudative processes, may partake of the nature of catarrhal or fibrinous pneumonia, and in exceptional instances give rise to marked proliferation of connective tissue, inducing pronounced contraction change. The areas of pneu- monic involvement may ^■ary greatly in size, sometimes the process being confined to tiny areas, in other instances being distributed through- out a single lobe or an entire lung. Extensive areas may be affected simultaneously, or adjacent foci maj" subsequently become confluent. Caseation may super\-ene precisely as described in connection with the elementary tubercle. The degenerative change may involve wide areas of pulmonary tissue or appear in the form of cUscrete foci of necrosis. The inflammatory process sometimes involves the wall of the bronclii as well as pulmonary tissue. Caseation, either with or without the formation of genuine tubercle, may develop within the wall, resulting in its eventual penetration and communication with pulmonary cavities. The process of excavation maj' be astonishingly rapid in areas of pneu- monic consolidation, the destruction of tissue sometimes extending into and through the walls of several bronchi. The rapidity of the softening, with added increase in the size of the pulmonary excavation, is tlependent largely upon the character of the tissue comprising its encircling wall. If the wall of the cavity consists of an area of tuber- culous pneumonia, further excavation is much more likely than if the adjacent tissue consists of elementary tubercle formation or chronic tuberculous infiltration, in which event the contUtions are much more favorable for limiting cavity formation. Thus the remarkable diversity in the rapiditj- and extent of cavity formation is explained almost entirely by the character of the contiguous tissue. It is not to be understood that pulmonary excavation must necessarily be accompanied by rapid softening, copious expectoration, increase of bacilli in the sputum, temperature elevation, or general decline, although such clin- ical manifestations are common. Neither is it always true that cavity formation is a.ssociated with further dissemination of tubercle bacilli. The development of pulmonary hemorrhage is not always occasioned by a destructive tuberculous change involving the wall of the blood- \essels, although some are probably attributable to its caseation and rupture. In the event of cavity formation with removal of the support of the arterial wall, aneurysmal dilatation not infrequently results. Rupture subsequently takes place by reason of purely mechan- ical causes, without definite tubercle deposit in the wall of the artery. The small hemorrhages so frequently oliserved in all stages of tuberculo- sis, sometimes even in advance of physical signs, would seem somewhat difficult of explanation, becau.se in areas of tuberculous deposit with or without caseation and excavation the small bloofl-vessels are obliterated. It is known, however, that the surrounding blood-vessels which make up the collateral circulation are engorged to a considerable extent, and at times of temporary excitement or strain are incapable of withstanding the intra-arterial pressure. GROSS APPEARANCES CHAPTER XV GROSS APPEARANCES The macroscopic appearance of tuberculous pulmonary lesions varies remarkably according to the course, duration, type, and compli- cations of the disease. While degenerative change may be said to constitute the chief pathologic characteristic of pulmonary consumption, there are present in many cases featuies of essential importance aside from recognized areas of necrosis. These consist of miliary tubercles and of differing degrees and extent of pneumonic consolidation, catarrhal inflammation, caseation, cavity formation, calcification, fibrosis, com- pensatory emphysema, atelectasis, both from compression and from local occlusion of bronchioles, pleural inflammation with tubercle deposit, thickening, adhesions, perforation, and resulting pneumothorax. In addition to these conditions of pathologic interest incident to the inva- sion of the bacillus, there is exhibited a wide divergence in different cases in the amount of connective-tissue proliferation. This may be compar- atively slight or alispiit ;ilto,cTthcr, pnvticularly in cases of the acute pneumonic type — tlic sn-calli'd tulicrciilcius pneumonia. Upon the other hand, the coniHMti\(-iissuc liy])ciphisia is well marked in the more chronic cases of ca.>eoiiljruid pulmonary tuberculosis, and not infre- quently becomes a conspicuous anatomic feature, as in fibroid phthisis. In the same manner other pathologic conditions are subject to consider- able variation in differing groups. The degenerative change may be rapid and extensive, with speedy formation of cavities, or slow and unaccompanied by recognized destruction of tissue, the process of repair being continually maintained in minute centers of infection. Generally speaking, the caseous degeneration is more marked in acute cases, in which it sometimes appears as an early pathologic manifestation. The necrotic changes leading to cavity formation, though present both in acute and in chronic cases, are not ahrays exhibited in acute pneumonic phthisis on account of its 7'enj rapid developynent and brief duration. In this disease the early consolidation overshadows all other conditions and often imparts but the clinical aspect of either an ordinary catarrhal or fibrinous pneumonia, the victims sometimes succumbing before the development of extensive cavity formation. In miliary tuberculosis the degenerative process is present in disseminated tubercles, which are changed from almoist invisible, gray, translucent specks into opaque, yellowish spots. In such ca.ses gross areas of softening and excavation are seldom observed, on account of the rapid progress of the disease to a fatal termination. It is true that, exclusive qf genuine miliary tuberculosis, fresh miliary tubercles may be present in associa- tion with large areas of pneumonic consolidatinn oi' \\\\\\ ma.sses of caseous degeneration, but in such instance-^ the tulicrclc does not form the e.ssential or characterizing pathologic ((uidition. Though tubercles are often found along the edges of consolidated, cheesy, or necrotic tissue, the macroscopic appearance of the iuxohcd lung, as a whole, is entirely different from that exhibited in miliary tuljercuiosis. Again, pneumonic consolidation, although present in differing de- grees in almost all cases of pulmonary tuberculosis, and even to some 86 ETIOLOGY AND PATHOLOGIC ANATOMY extent in the midst of disseminated miliary tuberculosis, is not invariably a distinguishing feature. The pneumonic process may be confined to small areas in the immediate vicinity of the affected alveoli or be diffused throughout an entire lobe or lung. In acute pneumonic phthisis the exudation constitutes the predominant pathologic characteristic, whether the process appears as a distinct lobar affection or as a lobular involve- ment vvith more or less tendency toward the confluence of solidified areas. In miliary tuberculosis, however, the pneumonic condition is defined much less sharply and is usually quite subordinate to the diffusion of tubercles in the connective tissue in the vicinity of the fine arterial tenni- nals. As a rule, the consolidation is more apparent in cases conforming to the florid type of consumption than in the more chronic varieties. In chronic fibroid phthisis the pneumonic process is subject to consider- able variation in degree and distribution. The consolidation is often limited to the apex, and is sometimes present only in small areas of lobular involvement. In other cases the pneumonic process is pro- nounced, extensive regions becoming progressively consolidated. The formation of tubercles in the connective tissue may give rise to but slight secondary exudative change, and consequently to comparatively little inflammatory consolidation. In other instances there is an early and rapid development of caseous pneumonia, which, originating in the alveoli, is capable of considerable extension to contiguous tissues. In cases without gross pneumonic consolidation material ilifferences exist in the intensity of the catarrhal inflammation involving the alveoli and finer bronchi in close proximity to the tubercle deposit. As previously stated, the walls of either may be the seat of tuberculous infection. Without exhibiting definite tuberculous lesions, they may be filled with an exudation arising from the inflammatory condition incident to the neighboring tuberculous focus. There may exist a tlisproportionate catarrhal affection either of the bronchi or of the alveoli. Essential differences in the gross pathologic appearance may arise from the nature and extent of the pleural involvement. There may be distributed upon the surface miliary tubercles, with or without local inflammatory change. A simple congestion of the surface sometimes corresponds to the area of pulmonary disease. In other cases an exudative process involves both visceral and parietal layers, which subsequently become aggluti- nated and enormously thickened. As further organization of the pro- duct of inflammatory action takes place, extensive contraction changes develop, involving pulmonary tissues, adjacent organs, and the chest- wall. Pleural effusion or empyema occasionall)' results from infection of the pleural surfaces. Pneumothorax incident to perforation of the pleura produces varying degrees of pulmonary collapse and secondary infection. From the preceding considerations it is apparent that there is no absolute unity of the gross pathologic lesions in pulmonary tuberculosis, although the histologic identity of the primary tubercle has been long since beyond dispute. As will be seen in the accompanying illustrations (Plates 3-9), inspection of the pulmonary tissue in some cases may disclose but slight visual deviation from normal conditions, while in others the entire lung may be transformed into an unsightly mass exhibiting in places miliary tubercles, pneumonic consolidation, cheesy degeneration, calcification, softening and cavity formation, areas of atelectasis, obliteration and aneurysmal dilatation of the blood-vessels, emphysema, anthracosis. PLATE 3- Riglit lung, showing well-defined thickening of apical pleura. Areas of emphysema and bronchopneumonia. Disseminated patches of antlnacosis at base. Miliary tuber- cles plainly recognized on section near lateral margin Attciiiiim is called to Plate 10, representing the gross appearance of the left lung «( the same iiulividual. PLATE 4. Eight lung from case of miliary tuberculosis. Note extensive raised areas of emphy- sema involving nearly ail portions of the lung. Note anomaly of iissure. Note the well-defined interlobular septa. Upon section, the lung disclo.sed typical miliary de- posit. This lung was one-third larger than the left lung from the same individual. The left lung was small, contracted, and bound down by exceedingly fii-m adhesions. GROSS APPEARANCES 87 connective-tissue iiyperplasia, and pleural thickenings. In view of the wide range of pathologic conditions, the futility of any effort toward a classic description of gross pathologic appearances, to be regarded as typical of all cases of pulmonary tuberculosis, is apparent. Present knowledge derived from increasing experience in the observation, treat- ment, and autopsy findings of consumption has led to a conviction of striking changes in the anatomic as well as the clinical picture. In spite of extensive destructive change representing large areas of \irulent, active infection the processes of repair under proper conditions are .seen to have developed to an astonishing extent. Conversely, in the midst of excessive connective-tissue proliferation, rapid changes of a t ul lerc-iihius or purely inflammatory nature are found to have taken place witliout easily ■explained cause. Notwithstanding the niultii)li(it y of these pathologic conditions and the variability of their ocmuiiciicc, certain processes are sufficiently uniform to permit separate classification based upon their chi-onicity, gross appearances, and distribution of the lesions as follows: (1) Miliary tuberculosis; (2) acute pneumonic phthisis (lobar) ; (3) acute pneumonic phthisis (lobular); (4) chronic caseofibroid tuberculo- sis; (5) fibroid phthisis. MILIARY TUBERCULOSIS In miliary tuberculosis the essential feature is the presence of gray, translucent tubercles in the vicinity of the terminals of the pulmonary artery. These are often seen only with some difficulty until after they become yellow and opaque from degeneration. They sometimes increase in size, particularly as the condition becomes more chronic, but this is not very frequent. External to the periphery of the miliary nodule there develops a zone of catarrhal inflammation involving the neighboring alveoli and minute bronchi. The walls are infiltrated with an exudation of cells, become congested or swollen, and are bathed in a mucopurulent secretion which is sometimes partly hemorrhagic. In proportion to the distribution of the miliary nodules the lung becomes, as a whole, hyperemic, heavier than normal, somewhat solidified, but still containing some air. If the consolidation is extreme, the lung is sufficiently heavy to sink in water and is darkly congested. The tissue is rarely dry and friable, but is, as a rule, moist and solid on section. In chronic cases the degenerative change is pronounced and areas of yellowish, .softened tissue are recognized. The nodular dissemination is often more marked at the l:)ases than in the upper regions. ACUTE PNEUMONIC PHTHISIS (LOBAR) In this condition the early pathologic lesions vary but slightly, if at all, from those of ordinary croupous pneumonia. There is an early simultaneous involvement of many lobules, sometimes sufficient to include an entire lobe or the lung itself. There is noted an intense, dark-red congestion, suggestive of the pathologic appearance in orchnary croupous pneumonia. The pleura is dull, and may be covered with a thin exudate. The lung is heavy and airless. Upon section, a granular appearance may be imparted as a result of fibrinous coagulation. Dis- crete miliary tubercles may be scattered through the consolidated tissue, and particularly along the edges, but not infrequently these are impossi- 88 ETIOLOGY AND PATHOLOGIC ANATOMY ble of detection. With the onset of degeneration the lung assumes a yellowish or grayish color. Softening progresses rapidly, and cavity formation results. The excavations are sometimes large, but more frequently numerous small cavities are irregularly distributed through the infected area. The softening and excavation are not due wholly to the breaking-up of the exudate, as occurs during resolution in fibrinous pneumonia, but is chiefly the result of caseation and necrosis of the pul- monary tissues. In this type of acute tuberculous pneumonia but little opportunity is afforded for the process of repair. Connective- tissue proliferation is rarely permitted to any extent on account of the acute onset and course. ACUTE PNEUMONIC PHTHISIS (LOBULAR) The pathologic appearances in some respects are dissimilar from the preceding conthtion. The chief difference consists of the lobular distribution of the early lesions, the areas of ccmsolidation being identical with those in catarrhal pneumonia. In some cases the consolidation starts in a small portion of lung and exhibits an apparent migratory tendency. Discrete regions of involvement not infrequently become confluent, establishing a gradual conformity to the lobar form of acute pneumonic phthisis, the exudation often containing a considerable amount of fibrin. The cells are derived from the exudative process and from the desquamation and proliferation of intra-alveolar epithelial cells. Patches of pneumonic consolidation undergoing various degrees of cheesy degeneration and softening are unevenly distributed over portions of one lung or of both, often involving the bases. Tuberculous masses vary considerably in size, and are sometimes separated from one another by intervening areas of crepitant lung tissue. The infected areas are at first grayish red, but become opaque and yellowish as degen- eration advances. Miliary tubercles may or may not be present, as in the lobar type of tuberculous pneumonia. The finer bronchial tubes upon .section are shown to be filled with a purulent exudate, cheesy degeneration taking place in the surrounding tissue. The areas of caseation become larger, more moist, and softer, until iri'egular excava- tions make their appearance. CHRONIC CASEOFIBROID PHTHISIS In this form of tuberculosis there may be exhibited in various degrees all the gross pathologic lesions described in connection with other varie- ties of pulmonary consumption. There are found miliary tubercles consisting of a number of submiliary or true elementary tubercles, larger nodules of conglomerate tubercle formation, areas of diffuse tuber- culous infiltration, secondary inflammatory lesions represented by isolated or confluent patches of pneumonic con.solidation, cheesy degen- eration of the tuberculous tissue, marked exudative processes, necrotic changes leading to cavity formation, and, finally, a more or less extensive proliferation of fibrous tissue in the infected areas. Before discussing these respective anatomic lesions seriatim, it is well to call attention to the following facts: (1) On account of the insidious and localized development large areas of consolidation are rarely present in early stages, the process being usually limited to a small patch of tuberculous PLATE 5- Miliary tuberculosis of lung from infant six months old. Specimen hardened in formalin. Note tubercles studding the pleura — their irregular size and distribution. Section of lung luu'deneil in foi'malin, Note calcareous deposits. ing distribution of miliary tubercle Section ot lung hardened in formalin, showing patches of pnenmonie caseation at lower region, with cavity formation in the upper portion. Note blood-vessels traversing the upper cavity. GROSS APPEARANCES 89 infiltration in the apical region. (2) Typical tuberculous nodules often undergo characteristic degenerative and reparative changes, and are found in connection with small localized areas of pneumonic infiltration proceed- ing from centers of tuberculous infection. (3) The process of degeneration is seldom rapid, though often progressive in character, excavation taking place, as a rule, comparatively slowly. (4) Owing to the chronicity of the course, opportunity is afforded to a greater or less extent for con- nective-tissue hyperplasia, the constructive and destructive processes being maintained jointly for somewhat prolonged periods. In chronic caseofibroid phthisis there may be present small tuberculous nodules composed of a number of elementary tubercles involving the peri-alveo- lar and peribronchial tissues, and extending into the alveoli themselves. The finer bronchioles and surrounding tissues are invaded also by an exudative process. The terminal bronchioles are occluded as a result of the secondary inflammatory lesion, which subsequently undergoes degeneration jointly with the tubercle itself. On account of the exten- sion of the infection to contiguous structures through the medium of the lymphatics and by the discharge of tuberculous material into adjacent bronchi, the area of di.sease tends to increase progressively in size. As a result of the degenerative process the consolidated tissue presents an opaque, homogeneous, yellow appearance, in which the tubercle forma- tion is not, as a rule, perfectly distinct. Tubercles are often recognized, however, along the edges of the tuberculous masses before the degenera- tive change has become complete. The surrounding involved area is usually congested and at least partially consolidated. Upon cross- section the lung may pre.sent here and there a similar appearance to that described in connection with the more acute forms of pulmonary tuberculosis, particularly if the process at such points has been at all active. The bronchi may be completely occluded by cheesy or purulent tuberculous material. The lumen is not always plugged entirely with cheesy exudate, and a small orifice can sometimes be detected in the center of a tuberculous nodule undergoing caseous degeneration. If the bronchial tube is cut longitudinally, it may be found filled with broken-down tuberculous detritus. These masses of diseased tissue undergoing cheesy degeneration correspond to the so-called crude tulier- cle of Laennec, and may attain a diameter of one to two inches. The secondary inflammatory processes in the neighborhood of tuln'iculous foci are sufficient in some cases to produce extensive confluent arc:is of consolidation, as in the more acute forms of pulmonary iinohcnicnt. The infiltrative process may present the appearance of red hepatization in portions of the lung, while in other places the evidence of degenerative change is very apparent. Areas of pneumonic consolidation not under- going degeneration sometimes exhibit a granular or gelatinous aspect. Another form of pneumonic consolidation results from hemorrhage occurring in the course of chronic pulmonary tuberculosis. The blood is frequciifl\- ill^pired into the finer bronchi and alveoli, and not only diminislus t.i .-i cou.siderable extent the respiratory capacity, but also favors the ili'M'liipment and growth of secondary pathogenic micro- organisms. A diffuse non-tuberculous bronchopneumonia (.septic") often ensues, and occasionally gangrene. Pulmonary excavation constitutes a characteristic lesion of pulmo- nary tuberculosis, and exhibits marked differences in size, rapidity of development, and in the nature of the tissues constituting the encir- 90 ETIOLOGY AND PATHOLOGIC ANATOMY cling wall. As previously explained, the degenerative process leading to cavity formation may take place in the pulmonary tissues and finally extend to the wall of a bronchus, which subsequently ulcerates and permits the evacuation of the liquefied contents. At other times the excavation originates with the dilatation of a bronchial tube the walls of which yield to the nutritive and necrotic changes accompanying stagnating secretions. Other elements in the formation of the bron- chiectatic condition are intrabronchial pressure due to very violent par- oxysmal attacks of coughing, and in some instances to traction exerted upon the external wall as a result of surrounding fibroid change. The dilatation is also facilitated in many cases by necrotic changes in the surrounfling pulmonary tissue. As dilatation advances ulceration of the wall takes place, accompanied by extension of the necrosis into the contiguous pulmonary tissue, and further excavation ensues. The initial tuberculous process sometimes invades the wall of the bi-onchus, producing perforation and extension to surrounding tissues. Pulmo- nary cavities frequently become the seat of secondary infection, which further facilitate the process of destruction. Increase of size occurs as the result of a progressively extending degeneration and necrosis in the vicinity of a single cavity, or by the fusion of several smaller excavations. A series of cavities sometimes connect with one another in this manner. In almost all instances the cavity opens into a bronchus, affording opportunity for the evacuation of the contents, which consist of offen- sive purulent secretion with degenerated cells, elastic fibers, detritus, tubercle bacilli, and pathogenic microorganisms. A considerable dif- ference is noted in the character of the walls. When the degenerative process is rapid, as in acute pneumonic phthisis, the wall consists of an irregular mass of yellowish-gray ca.seous tissue. Sometimes the degree of excavation is indeed remarkable, even an entire hmg being broken down into an enormous cavity, as illustrated in plate 8. Perforation of pleura, producing an open or valvular pneumothorax, not infrequently results from the existence of cavities beneath the visceral layer. In the more chronic forms of pulmonary tuberculosis the walls of most cavities are somewhat defined by fibrous tissue proliferation. In place of an encircling area of tuberculous pneumonia undergoing degen- eration, as in the acute forms of phthisis, there may lie miliary tubercle formation, associated with considerable fibrous tissue hyperplasia. Pus is produced from the granulation tissue constituting the inner surface. This surrounding fibrous tissue is usually more or less vascular or hemor- rhagic, and is frequently spoken of as the "pyogenic membrane." The walls maybe smooth or rough, and irregular from protruding remnants of pulmonary tissue or traversed by blood-vessels with or without aneurysni;il ililatation. As previously shown, these vessels are some- times uMitciatiMl following occlu.sion of the lumen with thrombi. They often pass directly through portions of the cavity, and present varying degrees of saccular dilatation incident to the absence of external support. The cavities may exist in any portion of the lung, although found more frequently at the apex. The increase of size is slow in proportion to the amount of surrounding connective-tissue hyperplasia. When the walls consist of dense cicatricial tissue, the further progress of the exca- vation is almost entirely checked. If the cavities are small and the surrounding fibrosis extensive, there is not only an encapsulation of the diseased area, but often a resulting obliteration of the cavity itself. I Section of lung hardened in formalin, showing the two halves open. Enormous cavity formation. Note connection between the upper and lower cavities. Note the smooth inner surface of cavity, with almost entire absence of trabeculse or vessels. Areas of caseous ])neumonia in the lower poi'tion of the lung. GROSS APPEARANCES 91 have noted many times, after the lapse of several years, a complete dis- api^earance of the physical signs of pulmonary cavities the existence of which had been previously establisheti. In a few cases the skiagraph has served to demonstrate the ai)i>aiciii uMiteration of pulmonary cavities in individuals exhibiting undnuliiiil cn idence of excavation upon previous a:-ray examination. Tubercle ba,(-illi have been identified in the walls of pulmonary cavities which are undergoing rapid cheesy degeneration and necrosis. They are, as a rule, less virulent in old cheesy foci, and may be absent or at least infrequent in cavities whose walls consist of contracting cicatricial tissue. The data secured from clinical ol^ervation lead to the conclusion that cavities are exceedingly likely to develop in the upper portion of the lung from the clavicle to the third rib, anil in the back in the inter- scapular space. CHRONIC FIBROID PHTHISIS While in caseofibroid phthisis the process of repair is exhibited to a varying degree, in the condition known as fibroid phthisis the connective- tissue proliferation is particularly excessive. In early cases of chronic pulmonary tuberculosis the small tuberculous areas are surrounded by connective tissue. This fibrous hyperplasia is present to some extent in the peripheral portion of each elementary tubercle, and also con- stitutes an encircling wall involving the entire tuberculous mass. The diseased tissue may thus become circumscribed entirely by the protec- tive barrier, dense puckering of cicatricial tissue resulting from advanc- ing fibrosis and contraction. In other cases calcareous metamorphosis of the cheesy material takes place within the encapsulated area. Pulmo- nary concretions are formed in this way, and are sometimes expectorated in the act of coughing. It occasionally happens in cases of incomplete calcareous change that the capsule is perforated e\'en after many years of apparent arrest of the tuliorculous process, thus permitting fresh areas of infection. In fibrciid ]ihthisis the cdniiective-tissue ])rolif- eration extends from minute foci of infection which are sufficiently confluent to form masses of conglomerate tubercles, and are not associ- ated with diffu.se infiltrative change or pneumonic consolidation. Bands of connective tissue proceed from the great vessels and bronchi into the pulmonary structures, which eventually become interwoven by a dense fibrous organization. The tissues thus permeated by fibrous hyper- plasia become the seat of excessive contraction change, the sclerotic condition often invading all portions of the lung. It is not infrequent that extensive areas of connective-tissue proliferation are present in certain portions of a diseased lung, while a more recent active tuber- culous infection is progres.sing in other parts. Although in many cases of fibroid phthisis isolated areas of tubercle deposit alone are encapsulated and interspersed by the connective-tissue hyperplasia, the reparative process sometimes becomes so overdeveloped as to produce extensive pleuritic adhesions and contractions, diminishing materially the respiratory capacity. Pleuritic adhesions are, of course, frequent in practically all varieties of pulmonary tuberculosis, and result from the presence of a fibrinous inflammatory exudate upon the surface. The pleura may be thickened enormously, with miliary tubercles sometimes found upon the surface. The pleural cavity may become the seat of a suppurative process from the entrance of tubercle 92 ETIOLOGY AND PATHOLOGIC ANATOMY bacilli and the microorganisms of mixed infection which proceed from contiguous areas of disease. In case of perforation of the pleura with entrance of air to the pleural cavity the resulting pulmonary collapse is complete or partial, according to the presence or absence of firm pleuritic adhesions. SITE OF PRIMARY INVOLVEMENT The initial point of election in pulmonary tuberculosis has been the subject of con.siderable clinical and pathologic study in recent years. It was formerly believed that the infection orginated at the very apex of the lung, and proceeded downward as a result of the inhalation of the tuber- culous material to other portions of the respiratory tract. Special oppor- tunities for the spread of the infection were believed to be afforded by the convej-ance of the bacilli to previously uninfected areas through the inspiratory efforts incident to coughing. Localized catarrhal con- ditions of the finer bronchi were thought to be followed by tuberculous ulceration and by the penetration of bacilli into the peribronchial tissues. The predilection of the tubercle bacillus for the apical region, while universally recognized, was definitely attributed to such general causes as a weakened resistance of the tissues at this location, stagnation of the circulation, cUminished respiratory excursion, retention of bronchial secre- tions, and the efTects of prolonged maintenance of stooping postures incident to certain vocations. For a long time the opinion was enter- tained that the infection was more likely to involve the left apex than the right, on account of a cUfference in the angles of the primary bronchi with the trachea, .\pical involvement, however, was not frequent in children in whom other portions of the lungs were often primarily affected. The initial tuberculous process in cattle was found at the tip of the caudal lobe. It has not been made clear that the circulation at the apex is materially enfeebled, and it is difficult to reconcile the theory of a localized region of lessened resistance with the clinical fact that tuberculous infection of the apex is frequent!}- susceptible to com- plete arrest. 0.sler reports, out of 427 cases, the right apex was found involved in 172, the left in 1.30, and both in 11. Out of 2070 cases of my own whose records have been preserved, the clinical evidence pointed to priority of infection at the right apex in 978 cases, and at the left in 783. At the time of first examination lesions were recognized in both apices in 1096 cases, the tuberculous process being about equally advanced upon the two sides in 117. .^ufrecht's theory, which has been sub- stantiated by the experiments of Calmette. Guerin, and others, was to the effect that the bacilli gained entrance to the great veins and obtained a lodging-place in the terminals of the pulmonari' arteries at the apex. This effectually disposes of the common error that the site of the initial lesion is indicative of the point of entrance of the bacillus into the body. It may be assumed that tubercle bacilli are inhaled to an equal degree into all portions of the respiratory tract. Upon the theory, therefore, of inhalation tuberculosis, no reasonable or .satisfying explanation has been advanced relative to the frequency of apical involvement resulting from certain precUsposing mechanical conclitions at this point. Upon the basis, however, of localized infec- tion through the blood-vessels, the constancy of apical infection is possible of explanation through the influence of the lymph-streams. PLATE t). Section of lung hardened in formalin, showinj^ extensive areas of anthr not only the involvement at root, but also the disseminated areas at the fibrous puckering at apex. I GROSS APPEARANCES \)6 Cobb has called attention to the vis h fronte, or suction pull, which countercurrent arises from the great veins and lymi)hutic vessels in the angles of the neck, producing an area of lymphatic stasis in the apices of the lung. It is known that the primary lesion of tuberculosis is not at the extreme apex, but at a point somewhat below, varying, accorchng to the reports of several investigators, from one-half an inch to one and one-half inches below the summit of the lung, and usually somewhat nearer to the posterior surface. Fowler believes that the location of the initial lesion is also nearer the external border. The primary focus is reported by him to correspond to a point a little below the middle portion of the clavicle, and to extend along the anterior border of the upper lobe. Several authors corroborate this initial area of infection by the detection of early physical signs at the middle of the clavicle, or just below it, ami sometimes in the supraspinous fossa. Another point of early infer! icm. a,; imlicated by Fowler, is found below the outer third of the clavicle^ with downward extension along the outer portion of the upper lobe. Involvement of the lower lobe is described as taking place slightly below its apex in the posterior portion, on a line with the fifth dorsal spine. Some observers have gone so far as to state that the apex of the lower lobe is affected in the great major- ity of cases in which the physical signs of tuberculosis were recognized at the apex of the iipiJcr. They assert that the tuberculous process does not involve the uppnsite upjjer lobe until the apex of the lower lobe of the lung first diseased has liecnme the seat of tuberculous le- sions. While infeelimi readily extends upon the right side from the upper to the iniddle julx's, and upon the left from the upper to the lower, it is (pieslionable if, as claimed, the process has invariably in- vaded the ujiper poitidH of the lower lolie before the disease is recog- nized in the other apex. From a purely clinical stand]ii(al simis. Another cause, though perhaps less frequent, may be assuiiicil to be the oblitera- tion of the terminal branches of the pulmonary artery through early tuberculous infection, increasing the intra-arterial pressure just behind the point of obstruction. Hemorrhages from these causes are likely to be comparatively small or moderate in size. I have known, however, many serious and copious hemorrhages to take place as the very first symptom of pulmonary tuberculosis. Hemorrhages which result from genuine cavity formation and pulmonary aneurysms are especially severe and often immediately fatal, but these rarely appear as an initial symptom. An interesting consideration relates to the time of the development of other manifestations following the preliminary hemorrhage. In many cases, particularly if the bleeding is severe, a persisting cough at once makes its appearance, together with varying elevations of tem- perature, expectoration, loss of flesh and strength, and the physical evidences of tuberculous disease. In these cases, while the hemorrhage is the immediate precursor of rational symptoms and physical signs, it is by no means the cause of the infection. In many cases the early hem- 7 yS SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION orrhage is followed by an apparent complete recovery, several months or even years elapsing before the recurrence of pulmonary symptoms. In nearlj' all cases, however, the unmistakable manifestations of tuberculosis are delayed only for the time being. In 1901, in an analj'sis of 900 private cases of pulmonary tuberculosis, I found that 175 patients, or about 20 per cent., gave the history of a sudden hemorrhage as the first symptom of their intrathoracic disease. Out of a recent analysis of 2070 cases of pulmonary tuberculosis 347, or about 17 per cent., were found to have had a pulmonary hemorrhage as the initial symptom of the tuberculous infection. In addition, 25 were found to present a history of hemorrhage one year before the clinical recognition of the pulmonary affection, 13 two years before, and 32 over two years. The subject of pulmonary hemorrhage will be discussed later in more detail. Acute Pleurisy. — It has been known for many years that a large majority of the so-called idiopathic pleurisies are tuberculous in char- acter. While manj^ pleurisies, either with or without effusion, end in apparent recovery, some are followed after the lapse of months or years by the development of pulmonary tubercidosis. It is not very uncom- mon to observe patients whose cough, expectoration, fever, and phj^sical signs immechately follow the acute pleural invasion or so shortly there- after as to justify their classification as cases of acute onset character- ized by an initial pleurisy. Out of 2070 recorded cases of pulmonary tuberculosis, I have found 126 presenting the history of an idiopathic pleurisy as the first symptom referable to the disease. The presence of tubercle bacilli in the pleural effusion is a matter of comparatively little clinical moment. I have demonstrated their presence in some cases, while in others the bacilli have appeared sub- sequently in the sputum despite negative examinations of the exudate. Involvement of the pleura will be discussed at some length under Complications. Acute Septic Disturbances. — A number of patients present the history of an initial chill with a sharp rise of temperature as the first manifestations of tuberculous infection. The constitutional distur- bances may later become profound, even in the absence of any immediate suggestion of pulmonary disease. The chills may be of daily occurrence and of variable intensity, ranging from a succession of severe rigors to slight chilly sensations along the spine. The temperature is often subnormal in the morning, ascending rapicUy in the afternoon, falling abruptly in the evening or at night, and followed by more or less perspiration. There are headache, pain in the limbs, loss of appetite with digestive disorders, rapid emaciation, and marked prostration. (See chapter devoted to Mixed Infection, p. 541.) Such cases occasion- ally are regarded as malarial in origin, and sometimes are thought to l)e of a typhoid nature. Cough, expectoration, and all other symptoms of pulmonary infection may be absent at first, but after a short time searchintr ox.iiniii.itinn will disclose the physical signs. The spleen isusuall\- cnlii'^cil. and a innilcratc leukocj^tosis is present. The failure of the W'idal rcartidii and the aiisence of the malarial Plasmodium in the blood are sufficient to call attention to the possibility of tuberculous infection even before the recognition of physical signs. I have had METHOD OF ONSET 99 occasion to observe a very considerable number of patients presenting the histories of supposed malaria or typhoid fever, for which they had been treated for weeks or months. It is of interest to note, however, that many such invalids later exhibit the clinical manifestations of a general miliary tuberculosis, the early symptoms corresponding to the so-called typhoid type, with pulmonary or meningeal symptoms subsequently ii-.il cxcirisc is often pinductiM' oF a similar result. The paroxysms are also induced by going hxnn a warm r(K)m into the cooler outside air, or upon alternation of heat and cold within doors. Severe paroxysms often take place after eating a very hearty meal, upon exposure to a draft or strong wind, the inhalation of dust, indulgence in hearty laughter, grief or sudden emotion, nervous excitation oi' alroholic stimulation. The paroxysms may vary from a few nioim nts to several minutes' duration, during which time the face becomes sulfu.scd with a purplish lliisli. tlie veins nf the heel iind ueek unduly prominent, visible perspiration in(liii'e(| upon the liiou, and in Some cases involuntary micturition, \oinitiiig is a.n unfortunate accompaniment of the cough. It is particularly likely to ensue by virtue of the pharyngeal reflex if the paroxysms follow a hearty meal. This unfortunate symptom often interferes materially witli the chances for recovery, on account of the difficulty imposed in maintainin<; suffiiierit alimentation. When pos- sible, the patient should be comiielled lo jiaitake of more I' 1 siiortly after the cessation of vomit inu, it is .seldom that a similar result follows the second meal, :e the luduehial secretions are evacuated to some extent in the act of \'oniitiMi:, 1 have observed that the majority of patients who suffer from this dist icssing symptom experience their greatest difficulty after the evening iiie;il, iiaving been able to retain their morning and midday nouiislnnent with comparative ease. For such patients, as will be explained later, et)mplete rest after the ingestion of food is essential, with sometimes the addition of cracked ice or cocainization of the pharynx. EXPECTORATION Like the cough, the expectoration is a decidedly variable factor in pulmonaiy tulx'iculo- is. There are presented striking differences in quantity, gross .'ippeaiance, manner of expulsion, and composition. The quantity may \":iry from half a dram to over a pint in twenty- four hours. It is lielieved (|iiite -eiiei-ally that tiie quantity is slight in early cases, and iiu'icases in pnipoilion tfi the onward progress of the disease. In othei- wdids, the amount is supposed to correspond more or less closel.\- ion the diaphragm incident to violent paroxysmal cough, or it may exist simply as an expression of a neurotic disturbance. The pain attending acute bronchitis complicating pulmonary phthisis is usually felt in the front of the chest, extending from the manubrium downward along the sternum. It may vary from a feeling of rawness with oppression to a sensation of actual pain. In such cases it is often associated with soreness in the lateral regions of the chest, owing to the frequent distressing cough incident to the lironchial affection. Pain resulting directly from pleuritic involvement is always referred to the affected side of the chest. A pleurisy, however, may exist upon one side, devoid of any sensation of pain, while, as a result of other causes, complaint may be made with reference to the opposite side. While pleurisy is not invariably attended by physical discomfort, the pains, if present, are more or less sharp and stabbing in character. They are excited particularly upon deep inspiration and cough, and relieved by immobilization of the ribs. If the pain be at all consider- able, the respirations are interrupted in character and markedly restrained. The pain is not referred in all cases to the precise site of the pleural involvement. I have repeatedly recognized the friction rub of a dry pleurisy, and yet have been unable to obtain, either during forced respiration or cough, any admi.s.sion of pain in the vicinity of the evident pleural involvement. The pain may be absent entirely or referred to an inferior jioint in the cliest, even to the extreme lower margin of the ribs. Occasic.nully I have found the pain upon cough and respiration ascribed to the hiinl.,'ii' legion and lower abdomen. As is well known, moderately large pleuial effusions may exist without the slightest subjective evidence of their pi-esence. The pain of an initial pneumothorax resulting from perforation of the pleura is usually of a most severe and excruciating character, and attended by symptoms of profound prostration or collapse. In such cases the pain may not be referred to a single point, but may extend throughout the entire affected side. A frequent site, however, is in the region of the heart. Accompanying the pain in the side is the familiar oppression or "air-hunger." resulting from the sudden collapse of the lung before its fellow of the opposite side has been aljle to adjust itself to the radically increased respiratory demand. It should be remembered, however, that pneumothorax may occur without causing pain or aiiv other pronounced siihjective symptom. .Many times I have been impie.ssed by this striking plieiionienon, winch is contrary to the usual conception regarding llie clinical onset ol pneumothorax. It is noteworthy that many such c<,mliti..ns have developed while the patient was lying q\iictl\- in ImmI wiiliont exliil.ifing severe or distressing cough, and not havim; ex|ierience(l musculai- strain of any kind. Paroxysmal cough, resulling IVom more or less extensi\e <>avity formation, bronchiectasis, and pronounced bronchial iiiitatiuii is fre- quently responsil)le for the prodm-tiou of pain. This is usually referred to the lower lateral ))ortion of the chest, and very likely is cau.sed by the increa.sed tension at the attachment of the diaphragm. Intercostal neuralgia may exist among pulmonary invalids as in those who enjoy ordinary health. It is pre.sent chiefly in the region of the nipple and in the middle or lower zone of the thorax. Like the 108 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION pain of pleurisy, it may produce a decidedly restrained respiration for the time being, but the absence of fever and physical signs usually suffices for its accurate determination. Finally, complaint of pain is made by a type of individuals who exhibit evidences of a nervous temperament, and often with a well- marked functional derangement. The pain may not be localized definitely, and even may vary in its location during short intervals. If limited to a single region, it is often stated to exist in the lower portion of the thorax, far removed from the site of any recognizable tuberculous lesion. Frequently the pain is referred to the region of the liver. Sometimes it is said to be present near the lower angle of the scapula or in the region of the nipple, but rarely at the apex. When ill defined and vague in character, it usually occurs more as a hyperes- the.sia of the skin than as actual pain, and is said by the patient to be increased upon percussion or pressure with the stethoscope. VOICE SYMPTOMS Alterations in the voice are of considerable frequency, and vary from slight temporary changes in quality and intensit}' to marked hoarseness or complete aphonia. Hoarseness is sometimes one of the early symptoms of tuberculosis, but it may appear at any time during the course of the disease or be entirely absent. Change in the character of the voice may be so slight as to be scarcely appreciable, or so great as to effect a complete transformation of tone, rendering the sound harsh and discordant. The chief interest attaching to hoarseness as a symptom of consump- tion relates to its precise cause and duration. By far the most important factor in its production is a coexisting tuberculosis of the larynx. By virtue of the general anemic condition of the larynx, a paresis of the adductor muscles may account for the early hoarseness long before a definite suspicion is entertained of either a laryngeal or a pulmonary tuberculous involvement. Somewhat later an infiltrative process may occasion a slight tumefaction in the posterior commissure, preventing complete adduction of the vocal bands, and producing a distinct change in the quality of the voice. The tuberculous infiltration may extend to the vocal bands themselves, producing thickening and congestion, or to the muscles which control the movements within the larynx. Finally, distinct ulcerations may take place along the free margin of the vocal bands. (For further discussion of Laryngeal Tuberculosis see Com- plications.) Hoarseness is frequent in the course of pulmonary phthisis in the absence of tubercle deposit within the larynx. It may occur as the result of complicating acute, subacute, or chronic laryngeal catarrh, producing congestion and thickening of the bands, precisely as in non- tuberculous individuals. The hoar-seness may be intensified for brief periods by the pre.sence of i-etained secretions upon the vocal bands, preventing their perfect apposition. Changes in the quality of the voice, due to this cause, disappear in part after the act of coughing or clearing the throat, and particularly when the larynx has been thoroughly cleansed by a spray. Hoarseness may be e.xperienced as a result of muscul.ir fatigue from the overuse of the voice following loutl speaking or prolonged reading. PAIN, HOARSENESS, AND DYSPNEA 109 In the absence of definite visual changes recognizable within the larynx, the quality and intensity of the voice become impaired in many consumptives toward the later stages of the disease, on account of the extreme systemic debility. In such cases the hoarseness may be regarded as an expression of the general prostration, as in other severe constitutional diseases. Paralysis of the cords may result from the implication of a recur- rent laryngeal nerve in the pleuritic thickenings and adhesions at the pulmonary apex. It is almost unnecessary to state that the degree of hoarseness, whatever its cause, offers no possible criterion of the nature or extent of the pulmonary infection. As a matter of fact, a decided amelioration of the phthisical condition, as shown by the physical signs, sometimes follows the onset of laryngeal tuberculosis. As a general rule, a gain in the local condition takes place commensurately with general improve- ment. DYSPNEA Changes in the frequency of the respirations are more or less constant, though subject to marked variation in individual cases. The quickened rate may extend from a slightly accelerated breathing to true dyspnea. The latter is usually associated with cyanosis, and upon trifling exertion the auxiliary muscles of respiration are called upon to respond to the respiratory needs of the patient. Like other symptoms, dyspnea has no fixed relation to the extent of morbid change within the thorax. It is common to observe patients with an astonishing destruction of lung tissue and apparently an extensive reduction of respiratory area with but little, if any, shortness of breath. Others may display but slight physical evidence of disease and yet exhibit a marked degree of respiratory embarrassment. Some, in spite of a very rapid pulse, boast that they are as " long winded' ' as in former health, while others have but limited respiratory capacity, notwithstand- ing the fact that the pulse may be slow and of excellent quality. Neither fever nor anemia offers any reliable criterion by which to form conclusions regarding the dyspnea of consumptives. In general, however, certain conditions are found to exert an unquestioned influence in its causation. One of the most important of these is a material diminution of the re.spiratory surface. In this event the essential con- sideration is not so much the extent of the respiratory limitation as the suddenness of its development. The time in which the respiratory capac- ity is reduced constitutes the fundamental element in determining the extent of the resulting dyspnea. Thus many patients may be observed with numerous areas of impaired lung as a result of prolonged pulmo- nary tuberculosis, or with one lung rendered entirely inactive by a slowly developing pleural effusion, or, still further, with wonderfully diminished bilateral respiratory capacity as a result of chronic- interstitial pneu- monia, and yet suffering but slight inconvenience from shortness of breath. The reason is apparent from the fact that the obliteration of the respiratory surface takes place so slowly that the unaffected portion of lung is able to adapt itself to the changed conditions, and respond in a measure to the increasing needs which are imposed upon it. To illus- trate the impossibility of perfect adaptation and response when the respiratory function is embarrassed by the sudden involvement of large 110 SYMPTOMATOLOGY AND COUHSE, VARIETIES AND TERMIxNATION pulmonary areas, it is only necessary to cite the alarming dyspnea incident to pneumonia, and the air-hunger with collapse resulting from sudden pneumothorax. Therefore the dyspnea of pulmonary tuberculosis, while produced in part by the consolidation or destruction of lung tissue, yet in some cases may correspond but little to the extent of pathologic change. Pulmonary invalids often ask for an explanation of their dj'spnea, the issue involved in the mind of the patient being a determination as to whether the shortness of breath is due to the pulmonary involvement, to the heart, or to other conditions. It is sometimes cUfficult to arrive at a satisfactory conclusion as to the precise relation of the several factors jointly responsible for its production. A weak and rapid heart is unquestionably an important cause in many cases, especially if renal disturbances coexist. Fever is known to make the respirations more shallow and more frequent. Profound anemia is associated with short- ness of breath on account of the resulting deficient oxygenation. Upon this theory alone it is hard to explain the dj-spnea of tuberculosis, for the examination of the blood rarely shows a change proportionate to the pronounced outward manifestations of anemia. The shortness of breath is often more noticeable in neurotic than in phlegmatic patients, and is intensified by excitement or mental emotion. Many patients are oljserved who experience not the slightest respiratory embarrassment so long as they are at rest, but who suffer from distressing shortness of breath upon slight exertion. I do not regard this feature of itself as a contraindication for moderate altitudes, provided the pulse is satisfactory and evidences of general improvement are established, but rather as an emphatic indication for absolute rest regardless of location. The dyspnea of tuberculosis is, of course, subject to considerable variation according to the coexisting complications. In chronic bronchitis the increased frequency of respiration is induced to a large extent by the obstruction occasioned in the finer bronchioles by the thickened mucous membrane and the presence of secretion. The progress of air into the pulmonary alveoli is thus obstructetl to some extent, and its exit even more, as the normal act of expiration is essentially passive in character. The expiratory effort is exerted largely upon the bronchioles, thus throwing additional strain upon the pulmonary alveoli. This, in connection with coincident nutritional change, produces in time an unavoidable emphysema. In proportion as emphysema develops, either with or without asthma, will the severity of the dyspnea increase. This is also intensified liy the extension of small areas of bronchopneumonia, whether of tuber- culous or of inflammatory origin. Dyspnea following a pulmonary hemorrhage is attributable in some instances to the development of septic aspiration pneumonia. The dyspnea is increased moderately in pleural effusion, and usually to an extraordinary degree by the onset of pneumothorax. It has been mentioned that in acute miliary tuberculosis of pneu- monic type the dyspnea is out of all proportion to the physical evidences of the clisease. This would suggest that the shortness of breath is not to be accounted for entirely by the diminution of respiratory area, but to some extent by the irritation of the terminals of the vagus by reason of widely disseminated miliary tubercles. Pressure upon the vagus by enlarged bronchial glands may produce the same result. CHAPTER XIX FEVER Fever, by virtue of its overwlielming prognostic significance, sur- passes in importance all otlu-r syniptoius of consumption. Persisting elevation of tenqierature furnishes nmrc rclia,l)le evidence upon which to base unfavorable conclusions regartling ultimate success than any other clinical feature in the course of pulmonary tuberculosis. A con- tinuous fever is an insuperable obstacle to recovery. The development of fever is known to be entirely independent of the physical signs, the stage of the disease, or the nature and extent of pathnlogic change. Most extensive areas of active tuberculous infection may cxi>i wiihotit any appreciable elevation of temperature. A severe ((institutional disturbance, however, may accompany a slight, inactive tuberculous process. Many attempts have been made to offer a satisfactory explanation of the origin of fever, to account for its presence or absence in different cases and in the same individual under varying conditions, to classify arbitrarily its several forms, and to ascril)e to particular types a fixed correspondence with certain pathologic and bacteriologic conditions. Tims far siu'li efforts have not proved entirely convincing from a clinical stamlpoint. It is difficult to explain authori- tatively why it is present in some cases :;ii(l not in others; why the same patient may exhibit an elevation of teiiiiiei.'itnre i'or weeks, to be followed by an unexpected decline for variaMe |ieiio(ls; why in thoM' alilicted it is absent in the morning, only to rise in the al'teiiioon ; why there is no relation between its presence and the \aiious cHnical stages of the disease, and why it should exhibit so striking a, dissiniilarity in various cases, rather than conform to the characteristics of a single type. No effort will be made to explain the precise manner of its production and the diversity of its exhibition. Practical interest at this time attaches more to the clinical manifestations of fever and its prognostic and thera- peutic significance than to a detailed stvidy of the influence of the tubercle bacillus and the microorganisms of mixed infection. Suffice it to say that the fever may be traced directly to the tubercle bacillus as well as to the accompany ini:: bacteria of mixed infection. Among the latter the streptococ( us. st apli} iococcus, and pneumococcus are especially con- spicuous in its iiro(hiction. The fever attributaWe to the tubercle bacillus is often of minor importance in comparison with that occasioned by other iui( rooigaii- isms. That the tubercle bacillus may serve as at least a conti ibutory agent in its development is suggested i)y the fe\-er of pure miliary tuber- culosis and the ri.se of temperature follow iiiii injections of tuberculin. The fever of consumption may lie assumed to be due primarily to the absorption into the circulation of certain toxic products. The height of the fever would naturally suggest the approximate concen- tration of the poi.sons in the blood or body-fluids. The degree of saturation of the circulatory and tissue fluids would ordinarily be regarded as more or less commensurate with the area of the primary focus of infection, the degree of activity of the tuberculous process, the extent of degenerative change, and the capacity for absorption on the part of the individual. 112 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION While these factors in the absorption of toxic products may be accepted in their general application, there exist certain modifying conditions, capable in some instances of producing diverse results. Thus the absorption from a hirge area of infection may be much less than from a small focus, by virtue of changes in the tissue immediatel}^ contiguous to the tuberculous process, serving effectually to impede peri- pheral absorption. These changes may relate in some cases to the im- paired absorptive capacity or to an obliteration of the finer blood-vessels. At other times a barrier to absorption may be established through the concentration of the poisons in the tissues immecUately adjacent to the infected area. Again the degree of activity and the character of path- ologic change may not be correctly represented by the degree of fever. Rapidl}' advancing caseation is often unattended by fever, provided there is ample exit for the products of cUsorganization through free communication with a bronchial tube. Pulmonary cavities may be unaccompanied by fever, although the destructive change is cpiite exten- sive. This is particularly true if the excavation is surrounded by thick- ened, indurated tissue, affording scant opportunit}' for absorption. Further, the absorptive power of individuals varies according to their age, the state of the general circulation, and the degree of stasis in the immediate neighborhood of infected areas. Finally, the specific nature of the microorganisms constituting the secondary infection influences to a considerable extent the character and degree of fever. These considerations suggest a partial though superficial explanation of the vagaries of temperature in consumption, but the more complete elabora- tion of their production is left to others. Irrespective of its precise origin, which may be incapable of authorita- tive explanation, the fact remains that the fever of phthisis is a decidedly variable quantity. .It is often present in the early stages, only to disappear later in the chsease. This is attributable in part, though not entirely, to the enforced rest, which is insisted upon after the patient comes under competent observation. As a rule, an excessive elevation of temperature is observed only after the tuberculous process has become well advanced, or in the presence of inflammatory or septic complications. The afebrile state of some individuals may be inter- rupted temporarily by various causes, as an intercurring influenza, an acute chgestive disturbance, the development of bronchopneumonia, pleurisy, or pneumopyothorax, and by extension of the tuberculous process to hitherto uninfected areas. Ephemeral elevations of tem- perature are observed as a result of pereonal indiscretions relating to injudicious exercise, fatigue from any cause, and nervous excitement. In some patients a short walk or sitting up in bed, the entertainment of callers, card-playing, mental irritation, grief, anger, or an absorbing book are sufficient to produce moderate fluctuations. Fever is often present during the period of menstruation, although a normal temper- ature is exhibited at other times. Noticeable differences of temperature are noted according as the record is taken out-of-doors, after physical exercise, the swallowing of hot drinks, the ingestion of ice-cream, or the holding of bits of ice in the mouth. The temperature taken with the patient in the cold air is almost invariably lower than within doors. It also is elevated perceptibly after moderate exerci.se, but is difficult of recognition unless taken by the rectum. In mouth-breathers particularly it is almost impossible to obtain an accurate record after exercise on FEVER 113 account of the appreciable cooling of the buccal and lingual membrane incident to exposure to cold air. The mouth should be closed during the entire time that the thermometer remains in position. An interval . of at least five minutes should elapse before this is removed, else the record becomes extremely unreliable. Rest, both physical and nervous, is almost a sine qua non in the effort to effect a continued reduction of fever. The maintenance of the recumbent position in bed during the twenty-four hours of the day is often attencled with remarkable results in far-advanced cases. Without attempting too great refinement in a classification of the various types of fever observed among consumptives, it perhaps is sufficient to enumerate briefly the following varieties: The first class comprises patients whose temperature is normal in the morning and rises to the neighborhood of 100° F. or lOOf ° F. in the afternoon. Such invalids are frequently unaware of the exist- ence of fever, and often deny this possibility most emphatically until convinced by the use of the thermometer. There may be no flushing of the cheeks, no greater sense of warmth, or other evidence of dis- comfort from the increased body-heat. Others present the history of slight chilly sensations preceding the rise of temperature, followed by flushing and burning of the cheeks, dryness of the mouth and lips, lassitude, slight dyspnea, and more or less actual discomfort. A second class may be described as exhibiting an intensification of the fever of the preceding type. The temperature rises in the afternoon to 102° F. or 103° F., and recedes in the morning to the neighborhood of 100° F., or sometimes to normal. The fever is frequently preceded by chilliness, and attended by other unpleasant sensations, but not invariably. Patients are usually conscious of the elevated temperature, and sometimes experience considerable physical discomfort, as head- ache, disagreeable sense of warmth, anorexia in the afternoon, and general indisposition. These types of fever may be present during any stage of consumption. In a class of cases the fever may assume still another clinical form. In the morning it is considerably below normal, beginning its ascent more or less abruptly in the middle of the day, and rising until evening to 103° F. or 104° F. The fever of this class is more likely to be preceded by a distinct chill, or at least by pronounced chilly sensations, than that of any other variety. As a rule, the patient is exhausted in the morning, pale or somewhat cyanotic, with marked coldness of the hands and feet. The fall of fever is likely to be associated with drenching sweats, which may occur at any time during the night, but more par- ticularly in the earh' morning. This is known as the fever of absorption or mixed infection, and is described as hectic, corresponding to the so-called septic fever of surgeons. It has been tlKuuiht to be attended almost constantly by softening or rapi(ll>- :i(l\aii\ Uic ^I'licral rosistnnce, renders the patient (hsuin'tly mon. susccpiiMc to the ori-innl tuberculous invasion. The iiilrctioii once cstalilishcd, coiiiriiiiiic ^ iiliiio-l unavoid- ably to a further loss ol' weight. linally, the only ralioiKil iiiothod of securing an ultimate airest of the tuberculous process is ilie main- tenance of an iiiipio\ed nutrition. On account of tliese established relations between the weight inu\ the pulmonary condition it is easy to appreciate the overwhelming impoitaiice of judicious superalimentation. With but few exceptions does the emaiiatiiin go hand in hand with an advancing activity of the tubeiculous iiifei-fiou. It is true that some patients exhibit pliysii-ij e\iileiices of lapiilly extemling pulmonary disease without dis])la>imj: loi a time any coii-ideiable impairment of body weight. Occasioually 1 have noteil w ide-r|iieail iiixolvement of the lungs with extensive destruction of tissues iu \eiy corpulent individuals, but such instances are decidedly exn ptioii.il. Rarely are patients fni-funate enough to spctire an afi-e'-t of the I ubei-culous process without tlie .-it l ;uniueut of -ic;itly iuiprowil uutiitioii. If so, it is found, upon iin-e-li-atiou, tliat ,-^uc. ■(■-.-, a,- a lule. results i,n/ ajler an attciiijiU,! <,iili,rr to iucivase ImmI\- weight, but df.^pdt' the lack of any effort ill tius .lireriiiiu. 111 ,,iliei' words, the patient posse!3sing well- marked power- of ri.-i-i:iiiie cliaiices to secure the arrest of an inci]iipnt infection without being compelled to resort to a method which is invalu- able to the majority of cases. It m.i\- \»- adut the ends of the fingers give the appearance of being .shortened and broadened. The nails are almost invariably perfectly straight and but little cyanosed. This type of finger is found in connection with chronic or fetid bronchitis and bronchiectasis, either existing alone or complicating tuberculosis. The change which is more definitely characteristic of consumption is the long, slender, and tapering finger, devoid of any suggestion of thickening, but with pronounced incurving of the nails, which are usually somewhat cyanosed. In pulmonary tuberculosis it is not uncommon also to note long, slim, and narrow hands, with slender but non-tapering fingers, both with and without incurving nails. The skin of the tulierculous patient is usually dry, although the hands are often cold and clammy. This element of dryness is char- EMACIATION AND LOCAL OBJECTIVE SYMPTOMS actei'istic of the hair and nails, which are also brittle. As emaciation the skin becomes somewhat wrinkled; as anemia increases Kig. 2.— Draw- clubbing of the t posterior thickening. it is more sallow or even cachectic, and with advancing cardiac or respir- atory embarrassment it is more cyanosed and sometimes edematous. 118 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION Cyanosis and edema will lie alluded to under Symptoms Referable to the Circulation. The facial aspect and coinplcrion may vary more or less according to the particular type of the tuberculous disease. In those with pronounced lymphatic involvement the features are coar.se, the nose l)road, the lips thick, the ceneral contour of the face somewhat gross, ami the complexion muddy. In the distinctly phthisical type the skin is often extremely fair, with the subcutaneous veins especiallj^ prominent, and sometimes the face suffused with a hectic flush. A not infrequent condition is the browish-yellow, dry. scaling rash of pityriasis versicolor, most abundant upon the anterior ])ortion of the chest or abdomen. EMACIATION AND LOCAL OBJECTIVE SYMPTOMS 119 fonti othei of the chest tiny fihrillary ,rc sometimes ohservcd. In from the ixiiiit of iiercii.ssion to the farthest extremity of the muscle. This is regarded as a phenome- non of degeneration, and is produced Ijy the hyperirritability of the atrophied muscle. 120 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION CHAPTER XXI CIRCULATORY DISTURBANCES The symptoms attributable to the circulation observed in pulmonary- tuberculosis are acceleration of the pulse in the absence of recognized cardiac lesions, changes in the heart itself, including its dislocation, symptoms of resulting stasis, and, finally, pulmonary hemorrhage. Increased rapidity of the pulse-rate due to various causes may occur at any period during the course of the disease. It is often noted in very early stages, and when unassociated with other symptoms or physical signs is frequently regarded as indicative of a threatening tuberculous invasion. The truth is that in many such instances the patient is already the subject of tubercle deposit, the evidences of which thus far have been incapable of precise determination. The acceleration of the pulse may vary from a slightly increased frequency to the point of genuine tachycardia. In some cases the rapid pulse-rate is temporary in duration, being subject to con- siderable variation, accortling to external conditions. While gradual improvement is sometimes observed in the absence of exciting causes, it often happens that the increased rapidity persists indefinitely. This symptom, when present, con.stitutes one of the most important features of pulmonary tuberculosis. It possesses vast prognostic import, and suggests more imperatively even than fever the necessity of absolute rest. " It often occurs independent of fever or in the absence of pro- nounced physical signs. When occurring in very early stages, it rarely is associated with an acceleration of respiration. Many patients, how- ever, with considerable elevation of temperature and marked evidences of active tuberculous infection, fail to exhibit this symptom to any extent. The pulse is usually soft and easily compressible, the blood-pressure apparatus registering a low arterial tension in the majority of cases. In some, however, it is full and bounding, with associated cardiac excitability, the exaggerated heart action at once being recognized by the stethoscope. This form is more frequently observed either in connection with fever incident to inflammatory disturbance or in a few highly excitable and neurotic subjects. Not infrequently the heart appears unduly stimulated, the scmiu^ liciiiii ndticoaMy louder and the impulse intensified to such an extent n- to 1)I(m1uc(> a distinct ri.se and fall of the stethoscope with each iml;a!i nyev- come an alarming collapse aUemliug the enormous loss of blood incident to pulmonary hemonha.iie. Smh a clinical phenomenon would appear to be rather in line wiili the observations of those who report increasing general edema follo\\iii,i; the administration of salt solution in nephritis. The symptoms eon-ist of intense dyspnea, cyanosis, and cough. The expectoration is usually copious, distinctly frothy, and tinged with bright blood. There is dulness upon percussion, and frequently absence of breath-sounds, with innumerable bubbling rales, chiefly at the bases. Loud, coarse bubbling sounds referred to the trachea, commonly called the death-rattle, may attend the respiratory effort. As a remote effect of cardiac weakness there is seen general edema of the ankles, feet, hands, and even of the face. The swelling of the face, as well as of the extremities, is not, as a rule, perfectly symmetric. One foot or ankle is usually swollen considerably more than the other. This is often true of the hands as well. The swelling of the face may he recognized upon one side before the other shows any evidence of edema. Cyanosis of the face is, of course, present to a like degree upon both sides, as well as in the finger-nails. A unilateral flushing of one cheek, how- ever, due to vasomotor change, without other evidence of cardiac disturbance, is frequently witnessed. CHAPTER XXII PULMONARY HEMORRHAGE Allusion has been made to the frequent hemorrhagic onset of pul- monary tuberculosis. It has been made clear that hemoptysis may take place at any time in the course of the chsease, api)ai-eiitly without regard to the extent or nature of the morbid pulmonaiy chaiiiie. Its development is entirely independent of siil)jecli\-e syiHptoliis oi' physical signs. It ma\- occur in the absence of lexer. coii.i:li. ( inacaai ion. pul- monary excavation, and I'ccognized cai'diac or ciri'ulatoi}- disturbance. Even in the midst of seeming healtli and vigor alarming hemorrhages are not uncommonly experienced, a copious loss of blood suggesting the probability of a ruptured pulmonary aneurysm. Upon the other hand, many consumptives are permitted to linger for years without hemorrhagic experience, although the lungs are known to have undergone very extensive destructive change. Various observers have reported the proportion of pulmonary invalids suffering from hemorrhage to be from 20 to 80 per cent. In considering 124 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION such diverse statements, due allowance should be made for the widely differing conditions under which the respective groups of patients were observed. It is easy to understand why hemorrhages should be decidetUy more frequent among invalids who are not subject to disciplinary control than among those confined within closed sanatoria. The striking disparity recorded as to the frequency of hemorrhages within and without sanatoria has been asserted to be incident purely to the supervisory regime practised in such institutions. It is probable, however, that the incipient character of these cases is account- able in part for the disproportionate observation. In addition, the admirable discipline enforced in sanatoria is of undoubted benefit in greatly minimizing the tendency to hemoptysis. According to the rigidity of supervision, either within or without institutions, hemor- rhages are invariably less frequent. In the experience of those who have been privileged to observe a large number of cases outside of sanatoria it has been found that hemorrhagic patients always exhibit a remarkable improvement in this respect upon the inauguration of supervisory control. My own experience, which was reported in 1901, embodied the analysis of 457 hemorrhagic cases occurring at some time in the course of the disease, out of a total number of 900 patients, 20 per cent, of whom exhibited a distinctly hemorrhagic onset of their pul- monary affection. Three himdred and eighty-six cases, or over 82 per cent., occurred before the patients came under my observation. Of these, only 97, or one in four, suffered subsequent recurrences. Sometimes there is observed a rather striking periodicity in the development of hemorrhages. Long periods with but comparatively few and insignificant hemoptyses have been followed repeatedly by a disqiueting frequency of these manifestations among my patients, suggesting more than a mere coincidence. No bacteriologic studies thus far have sufficiently explained such periodic evolution of symptoms, although pneumococci have been demon.strated by Ravenel to be present in some hemorrhagic cases. I have noted the more frequent occurrence of these hemorrhages in Colorado during the spring months, coincident with abrupt changes in the weather. For many years I have been led to regard their greater frequency at this season, cor- responrliii- with periods of variability in temperature, increased wind movement, aii.l auitation of dust, as explainable in part by a relation of cause and etffct. At such times I have been forced earnestly to admonish patients against imdue exposure to wind and dust. The form or extent of pidmonary hemorrhage varies from a slight spitting of blood to an immediately fatal termination resulting from the perforation of a pulmonary aneurysm. As a rule, but little importance is attached by physicians to slight bloody discolorations of the sputum. A great difference is observed, however, among consumptives in the mental effect produced even by apparently insignificant hemorrhagic manifestations. The presence of but little blood in the expectoration is sufficient with some not only to induce an unfortunate mental disquietude, but even to arouse the wildest fears, sometimes to the point of utter demoralization. Others who have become more or less accustomed to occasional hemopty.ses apparently attach but trifling importance to the expulsion of several mouthfuls of blood. Many patients, priding themselves upon their PULMONARY HEMORRHAGE 125 past experiences, are inclined to view succeeding hemorrhages v.'ith manifest indifference and to disregard precautionary admonitions calculated to prevent their recurrence and minimize their severity. Either of these extreme attitudes on the part of the invalid is especially unfortunate, in view of the difficulty experienced in inculcating a correct and rational conception as to the true significance even of slight hemoptysis. In all cases where there is any considerable admixture of blood in the expectoration it has been my habit, regardless of the history of previous hemorrhages, to acquaint the patient in a reassuring but conservative manner with the possibility of approaching hemoptysis. I have learned to regard these bloody discolorations of the sputum in many instances as precursory manifestations of a severe hemorrhage, which may often be avoided upon the adoption of precautionary measures. It has been my custom to inform patients affecting a disdain for these occurrences that the early slight hemoptysis is analogous to the warning signal displayed in front of an approaching train, which may be ignored only through risk of imminent peril. The impending danger relates not to the slight hemoptysis itself, but, like the pre- cautionary signal, to its significance. Many threatening hemorrhages have been avoided by an immediate insistence upon rest, diet, and other details of management. Moderate hemorrhages may occur at any time, either following exercise, mental excitemmit, violent cough, a hearty meal, absolute quiet, or during sleep. r5y moderate hemorrhages are meant the expectoration of from four to eight ounces of bright arterial blood. While some hemorrhages of this character may result from prolonged and violent coughing, others are entirely unassociated with cough only in so far as the hemorrhage itself serves to furnish an exciting cause. Injudicious exercise and excitement must be regarded as potent factors in the production of hemoptysis, on account of the increased arterial tension often induced. Many patients present a history of hemorrhage from prolonged and rapid walking, lifting, running to catch a car, riding a bicycle, driving an automobile or a fast horse, or other forms of physical exercise and recreation. Others suffer a similar experience as a result of undue nervous excitement incident to attendance at the matinee or ball-game, card-playing, heated argument, grief, or excessive worry. Hemoptysis is induced not uncommonly by inhalation of the overheated and vitiated air of public buildings and conveyances. I have had occasion to note this occurrence in several instances at public gatherings, upon street-cars, steam conveyances, and in poorly ventilated apartments. Despite the enforcement of a disciplinary regime, numer- ous hemorrhages have taken place among my patients while sitting quietly in a reclining chair or resting in a recumbent position upon a couch. Not infrequently they have occurred in the absence of all mental or nervous disturbance, and even during profound sleep.. I recall several instances of fatal pulmonary hemorrhage developing in the midst of deep slumber. While a history of disturbing dieams is sometimes elicited, the patient in many cases is overcome by an inun- dating sanguineous flood during unconscious repose. Distinct pre- monitory symptoms of pulmonaiy lifniinili.'iiic -avc piilirely absent, as a rule. There may be a brief initial li'diiiii nt' npincssion in the chest, followed by a sensation of wanntli umlci- the stcinum, a saltish taste in the mouth, and expectoration of bright l)lood, which rises 126 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION nipidl}- in the throat and is expelled in mouthfuls. The cough is more or less choking, rattling, excitable, and sometimes even explo.sive iu character. The bleeding ma}' persist for several minutes, and disappear altogether, or. after an interval of quiet, it may be followed by one or several recurrences. From my experience in moderately high altitudes I have been led to expect, after the lapse of a few hours, at least one or two repetitions of the initial hemorrhage before the bleeding may be regarded as under satisfactoiy control. The expectoration of clots or blood-stained sputum usually persists for several days after the arterial hemorrhage has ceased. The clots, which are dark in color, heavy, and airless, gradually diminish in quantity and become lighter in color until the expectoration is free from blood. After motlerate or .severe hemorrhages the sputum does not always assume its previous gross characteristics, certain changes in the quantity and appearance being discerned. The expectoration may be diminished or increased, and its nature either more distinctl,v purulent or more frothy than prior to the hemoptysis. A notable reduction of cough and expectora- tion is not uncommon after the lapse of several weeks. The abatement of former paroxysmal cough is often conspicuous. A previous frothy expec- toration sometimes cUsappears almost entirely after a brisk hemorrhage, presumably on account of the depletion of congested pulmonary areas. Upon the other hand, purulent secretions in the respiratory tract, as a rule, are increased for protracted periods. Upon the advent of bronchopneumonia from the aspiration of blood into the finer bronchioles the expectoration ceases altogether. Upon the development, however, of pulmonary edema, the expectoration becomes copious in amount and frothy in character, with noticeable bloody discoloration. The most severe form results from the perforation of a pulmonary aneurysm or the rupture of a fair-sized artery traversing a pulmonary cavity. These hemorrhages are often immediately fatal, the patient being literally drowned in his own lalood. They occur without the slightest warning, and after a few moments of inexpressiljle anguish all may be over. If the bronchial tubes are not completely inundated by the uncontrollable torrent of blood, there still remains the imminent danger of death from complete exsanguination and collapse. In institutions accepting patients in all stages of consumption it is not uncommon that the unfortunate victim of this t\-pe of hemorrhage is found in the morning to have experienced the terrible onslaught during sleep, and to have expired without warning and without assistance. It is astonishing, however, to note what enormous quantities of blood may be lost during a single hemorrhage without causing death. In many instances I have witnessed the loss of over a quart of blood at such a time, which was followed at short intervals by recurrences of almost incredible amount. In such cases the blood is seen literally to gush from the mouth and nostrils, the choking being extreme, and the .spectacle, to say the least, terrifying and revolting. The cough is essentially explosive at such a time, large quantities of blood being precipitated in all directions. Several times I have seen the blood expelled with violence over the foot of the bed. bespattering the wall of the room and saturating the clothing of the nurse and attendants. During such a hemorrhage it is inevitable that a considerable portion of the blood finds its way into the stomach, and vomiting further intensifies the cUstressing experience. Provided the invalid does not PULMONARY HEMORRHAGE 127 succumb immediately to asphyxiation or shoclv, sufficient clotting may ensue to produce a temporary cessation of the hemorrhagic flood. In this event the patient is more or less in collapse, greatly exsanguinated, the countenance pallid, respiration sighing, pulse exceedingly weak and rapid, — if, in fact, this is at all palpable, — skin clammy, extremi- ties cold, and the face and brow covered with copious perspiration. In such cases it has been my lot to observe several times a complete disappearance of the pulse for several hours, complete unconscious- ness, and violent delirium, followed by recovery from the hemor- rhage and ultimate arrest of the underlying tuberculous process. Several individuals enjoying an active and useful existence ha\'e in years past undergone experiences similar to the above, but in the vast majority of instances hemorrhages of this character are attended by a speedy fatal termination. Profound nervous and ment.nl ilisfuib.'nices accompanying pulmonary hemorrhage are not, as a I'lilc, fninicnt, although occasionally observed. Delirium is marked onlj- after exces- sive bleeding, and then rarely. I recall but few instances of this kind. A patient has recently experienced one of these almost indescribalile hemorrliages during sleep. The delirium was immediately violent and m;iiii:i(:;l. the iinnlid fi)r five or six hours shouting at the top of his voice, ami i he siiimhis being interrupted 1)v repeated hemorrhages. The initial loss uf blood was cun.siderably in excess of one quart. The iwlse could not 1)6 felt for an liour. and 1 reilainly exiieded eveiy moment to be his last. After exees.-ive stimulation and the .•Mhuiiii- 1 1 ;iiion of a large amount of morphin comparati\e quiet was restored, and upon the following day the patient could not remember the occurrences of the preceding twenty-four hours, not even to having experienced a pulmonary hemorrhage. Another patient, a lady of forty-two years, after a copious and exceedingly alarming hemorrhage, icniaiiied mark- edly delirious for two weeks. Suicidal mania has been exliibited in several cases as a direct result of the hemorrhage. \Miile hysteria, melancholia, or functional nervous disturbances do not often occur during severe pulmonary hemorrhage, their subsequent development is not infrequent. Pulmonary hemorrhages should be considered further with reference to their uiimrdwir and n mote effects. The immediate effects consist of the essential danger to life attend- ing the occurrence of this unfortunate complication. The first danger is that of asi)liyxiatioii from inundation of the bi-onchial tubes. This is followed bj^ the possibility of sudden collapse from the shock incident to the more or less complete exsanguination. Upon survival of these early dangers there exists the problem of general exhaustion. In my own experience, by far the most imminent peril attaching to the occurrence of pulmonary heniiirrhage is the alarming frequency with which bronchopneumonia develops. This much-to-be-feared complication, which, following a hemorrhage, is almost universally fatal, may supervene entirely irrespective of the size of the hemorrhage or the previous condition of the patient. No one can foretell that the aspiration form of pneumonia wdll not terminate life after hemor- rhages which are apparently benign in type. Several times have I observed its dread onset following the expectoration of but a few ounces of blood in patients with little tuberculous infection. Others, despite a greatly reduced physical condition, have survived numerous 128 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION hemorrhages without its development. This complication may appear insidiously, or its onset may be displayed with abrupt symptoms. I have never seen it develop later than the fourth day. The fever may rise suddenly on the second day, and remain elevated in the neighbor- hood of 103° or 104° F., or the temperature may begin a gradual ascent upon the third or fourth day. After two or three days of rising temperature following the hemorrhage, the respirations become corres- pondingly rapid and the pulse greatly accelerated, weak, and easily compressible. The face at first is suffused, and later becomes cya- notic. The countenance in the beginning is animated, the expression anxious, with the temperament somewhat excitable. The tongue is furred, and the breath heavy and foul, despite free catharsis. With increasing cyanosis involving the nails and face, the mental condition often changes from a state of excitability to hebetude, although not invariably. From a large experience with such cases I can assert that I have never witnessed a recuri'ence of hemorrhage after the symptoms of pneumonia have once become defined. Neither have I found the cough to be a factor of any importance at this time. This, together with the expectoration, usually disappears entirely with the rise of temperature and continued acceleration of pulse and respiration. No pronounced morning remissions of temperature are exhibited, as a rule, and no sweats. The respirations rapicUy become more labored, the alee of the nose dilating with each respiratory act. At this time the Cheyne-Stokes type of respiration may be observed. The pul.se often rises to 160 or over, and is of exceedingly poor quality, in spite of every effort toward stimulation. Stupor, with or without delirium, makes its appearance. The patient, in the vast majority of cases, speedily succumbs, the duration of the condition seldom lasting over four or five days after the onset of pneumonia. It is quite unnecessary to demonstrate the physical signs of pul- monary consolidation in order to confirm the suspicion of broncho- pneumonia. A satisfactory examination of the patient is often impracticable, on account of the difficulty of access to the back. The subjective symptoms above described, occurring a few days following hemorrhage, are amply sufficient to justify the gravest fears and the rendering of an unfavorable prognosis. The remote effects of pulmonary hemorrhage are varied to a con- siderable extent, its influence upon ultimate prognosis, therefore, being somewhat uncertain. While unquestionably good results may occa- sionally follow severe hemorrhages, such happy effects are, upon the whole, infrequent. It has been stated by some that hemorrhagic cases, as a whole, may be expected to do better than the non-hemorrhagic. If true, this is explained in part by the fact that the onset of a brisk hemorrhage early in the disease may lead to a realization of the necessity of rational management. I have been unable personally to ascribe to hemorrhage cases as a class any distinctly favorable or unfavor- able influence upon the ultimate prognosis. Of my cases taken as a whole, irrespective of the question of hemorrhage, 68.5 per cent, have been reported as showing improvement. By this is meant a material lessening of the activity of the tuberculous process, as dis- closed b}^ the physical signs, a diminution of cough and expectoration, a reduction of pulse and temperature, with increased appetite, digestion, PULMONARY HEMORRHAGE 129 and weight. On account of the heterogeneous nature of the cases, most of them far advanced in type, it is perhaps better, for the purposes of comparison, in this connection not to confine the analysis merely to the completely arrested cases. Of the hemorrhagic cases, which constitute a little over 50 per cent, of the total number, 67.8 per cent, have been reported as improved. This comparison in itself fails to indicate any special influence of the hemorrhage upon the course of the disease. It is noteworthy that one-fifth of these hemorrhages occurred as the initial symptom of tuberculosis, and impelled the patient, apparently in good health, to adapt himself without delay to a method of living appropriate for pulmonary invalids, thus establishing a rela- tively high percentage of improvement for this particular class of hemorrhagic cases. On the other hand, numerous specific instances illustrate clearly the remote deleterious effects of hemorrhage occurring later in the course of the disease. It should be remembered that hemorrhage per se is but one of many manifestations peculiar to a dis- ease which exhibits widely differing pathologic conditions. This single symptom, associated with all manner of complicating conditions, is pos- sessed, in different individuals, of varying degrees of clinical importance. In exceptional cases the hemorrhage has been found to exert an influence for good, as shown by diminished cough and expectoration, lessened temperature, improved appetite, and increase in weight. It is some- times possible to date the beginning of definite improvement from the onset of pulmonary hemorrhage, but in general its prognostic significance in advanced phthisis is distinctly unfavorable. There inevitably results a decided loss of weight from the diminished alimentation, and a pro- nounced diminution of resistance from the more or less prolonged confinement. Digestion is usually impaired for a time by the employ- ment of opiates, which are necessitated by the frequent irritating cough. While in many instances a gradual return to previous conditions may rea.sonably be expected, the intercurrent complication, neverthe- less, has constituted an unfortunate interruption to forward progress, involving in all cases loss of time, and in some, of opportunity. THE INFLUENCE OF CLIMATE UPON PULMONARY HEMORRHAGE Allusion has been made to the relation of hemorrhage to such atmospheric conditions as wind and dust. In addition to the.se factors, which may be regarded as exciting causes, other climatic attributes have been found to exert an influence for and against the production of hemorrhage. Extreme variability of temperature is perhaps a factor of some importance. I have not been able to observe any special difference in the frequency of pulmonary hemorrhage during the winter or summer months, and am unable, therefore, to conclude that the continued inhalation of cold air is at all instrumental in its causation. The sudden changes of temperature, with an increased amounfof wind and dust, incident to the springtime in Colorado, have been associated with an increased number of pulmonary hemorrhages, giving rise to a belief in the existence of a causal relation. Perhaps the chief interest as regards the relation of hemorrhage to climate centers in the influence of altitude. In the past, the conviction has been somewhat general that altitude directly increases the frequency of its occurrence. This more or less popular notion is not based upon the substantial facts of 130 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION experience. From a physiologic standpoint it would appear that the increased depth and frequency of the respirations, together with tlie rate and vigor of the heart contractions incident to moderate altitudes, would produce an acceleration of blood-flow and an equalization of the circulation throughout the body. In adchtion to this tendencj^ towaixl the avoitlance of local stasis in the lungs in appropriate cases, recent experiments have shown conclusively that the blood-pressure is lower in high altitudes than at sea-level. The assumption, therefore, seems well founded that pulmonary hemorrhage in high altitudes should be distinctly lessened in cases judiciously selected with reference to other considerations. My own experience in Colorado is quite in keeping with this ^^ew. Onl}' one-fourth of the cases to which allusion has previousl}- been made have experienced a recurrence of their pulmonary hemorrhages subsequent to arrival in Colorado. Quoting from my analysis of hemorrhages in Colorado: " It is further of interest to know that of the 97 recurrences, .34 were in inchviduals who had experienced a hemorrhage within two weeks before arrival, and in whom it is reason- able to suppose the direct results hail not been fidly overcome. In fact, nearly half of these had their hemorrhage on the train or immetU- ately prior to leaving home. Twenty-two of the recurrent hemorrhages in Colorado were exhibited by people in whom the bleetUng not only took place shortly before arrival, but the recurrence within a verj- few days thereafter. It is obvious that such cases should not be embraced in the category of ' hemorrhages in Colorado, ' as the specific cause was put in (>ii(M:itinii liefore arrival. Should these be excluded, and rightly so, the |MTriiii:i'_:c of recurrences would be materially diminished. On the other haiiil. 47 cases were found to have bled more or less profusely within one or two weeks before arrival, yet have never suffered a return since residing in the higher altitude. Seventy-one patients experienced their first hemorrhage after coming to Colorado. Forty of these exhibited very extensive advanced infection, presenting such conchtions as would be likely to occasion hemorrhage anywhere. Of the 31 which took place in the midst of a general gain, a large proportion resulted from a distinct assignable cause." My experience during the six years subsequent to the compilation of these statistics parallels closely the analytic results previously obtained. Hemorrhages per se constitute neither an indication nor a con- trainchcation for high altitudes. The choice of climate should be made with reference to all the several phases and conditions, without special attention to hemorrhage itself. A small proportion of recurrences may be expected in moderate altitudes, and this number may be diminished still more by the institution of proper .supervisory control. Recurrences are more prone to ensue in those patients who bled from the lungs shortly before arrival, in which event tlie subsequent hemor- rhages are likel}' to take place during the first few days of residence in higher altitudes. Primary hemorrhages are comparatively rare in moderate altitudes, and, as a rule, occur in cases with active and exten- sive excavation or as a result of some palpable indiscretion. While hemorrhages are less apt to take place in higher altitudes than at sea-level, thej' are, however, decidedly more severe and associated with greater shock. Hemorrhages occurring in Colorado do not, as a rule, conform to the benign t3^pe so often observed at sea-level. SYMPTOMS REFERABLE TO THE DIGESTIVE APPARATUS CHAPTER XXIII SYMPTOMS REFERABLE TO THE DIGESTIVE APPARATUS Disturbances in the alimentary tract may relate either to the stomach or to the intestine. STOMACH SYMPTOMS Gastric disturbances are by no means common to all eases of pulmo- nary tuberculosis. A large number of patients are able to take pro- digious quantities of food and digest it with apparent ease. An excellent appetite with ability to digest food is sometimes noted to an astonishing degree, even in advanced cases, notwithstanding the presence of fever and extensive pathologic change. On the other hand, there is a large class of patients who exhibit disorders of digestion with confii'med loss of appetite in the very early stages of consumption, or long before the development of the disease. In such cases the gastric symptoms are exceedingly apt to pcrsi-^t tlndimhout the entire course. In another class of patients the st(nn:iili di-tiirbances are of temporary duration, though subject to frequent iccuiicnces by virtue of fever, nervous excite- ment, general exhaustion, and indiscretions of diet. As a matter of fact, it is worthy of comment that the functional power of the digestive organs is not impaiised more frequently and seriously by reason of these causes. This is all the more remarkable in view of the lack of exerci.se, the toxemia, malnutrition, and coexistence of psychoneuroses. The constancy and severity of the gastric symptoms are entirely independent of the extent of pulmonary lesions. Generally speaking, the indiges- tion is more apparent and obstinate in the presence of continued eleva- tions of temperature, general weakness, and functional nervous dis- turbances. In very iii:my cases, iianiriijarl}- of the neurotic type, it is known that an actual structmal chaimi^ in ihe digestive apparatus is not essential for the production (if llie \aii(ius symptoms of functional derangement. It is of further interest to note that severe dyspeptic manifestations often occur in the presence of normal gastric secretions. A predominating effect, then, may be ascribed in many patients to the depraved nutrition, the anemia, the nostalgia, and the enforced quiet. In addition to these influences, the profound psychoneurotic condition so common among pulmonary invalids is an etiologic factor of especial importance. Often this functional liei'aimcinent is responsible for a picturesque display of clinical manifesiatimis. The symptoms referable to the stomach partake essentialh' of ihe nature of sensory neuroses, neurasthenic consumptives being notoriou.sly introspective and hypo- chondriacal. Various causes may operate in individual cases toward the production of gastric disturbance. The organic changes sometimes relate to a preexisting chronic catarrh of the stomach, the mucosa being the site of passive congestion incident to coexisting cardiac or renal complication. Occasionally, the results of dilatation and enteroptosis lend additional color to the dyspeptic picture. Ulceration and tui)ercle deposit in the stomach are comparatively rare. In the absence of patho- 132 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION logic change in the abdominal viscera the disturbed digestion may be attributable in some cases to recognized abnormality of the stomach secretions. A frequent deviation from the normal, as determined by gastric analysis, is the existence of hypochlorhydria in advanced stages. Irrespective of fever, the hydrochloric acid may be reduced in amount or absent altogether at any period of the disease, although, as a rule, in early phthisis this constituent of the gastric secretion is normal in amount. In later stages there is found in many cases a pronounced diminution. Independent of the precise quantity of hydrochloric acid, hyper- aciditj- of the stomach-contents is frequently due to an excess of the organic acids. The gastric indigestion, especially if developing late in the disease, is sometimes but an expression of the general exhaustion. At such times there is a lack of muscular tone to the stomach, with resulting motor insufficiency. Acute indigestion following indiscretions of chet is often charac- terized by nau.sea, with or without vomiting, anorexia, bad taste in the mouth, furred tongue, offen.sive breath, headache, constipation, aiatl sometimes pain in the epigastric region. Slight jaundice may be an accompanying symptom. Patients suffering from chronic catarrh of the stomach experience loss of appetite, occasional loathing for food, coated tongue, occasional vomiting, tenderness upon pressure over the region of the stomach, and a constipated habit, with almost constant diminution of hydro- chloric acid. When the gastric indigestion exists as a concomitant manifestation of general exhaustion or profound neurasthenia, there is often an entire lack of desire for food of any kind, the very idea of eating producing extreme chsgust. In some of these cases actual hunger is described, until the process of ingestion is begun. Upon endeavoring to partake of a slight amount of food, such patients complain of the utter impossi- bility of the task, some describing an imaginary obstruction in the esophagus. A characteristic symptom is the abrupt onset of vomiting shortly after food is consumed, or even before the meal is finished. This is particularly true of the evening repast, and perhaps is explainable in part by the increased temperature elevation at this time. The vomiting occurs without any ostensible cause, and is not to be confounded with the retching and loss of food incident to paroxysmal cough. In the latter case the vomiting is not dependent upon a digestive disturbance, but is referable entirely to the influence of the cough itself. In both instances, however, the vomiting is of purelv reflex origin, the presence of food in the stomach, eructation of gas. or cough acting as exciting causes. The popular appellation of "stomach cough," applied to such cases, is, of course, an unfortunate misnomer, although it has been recog- nized that a hearty meal ma}- serve to excite cough. Patients sufTering from neurasthenia frequently exhibit other symptoms of ga.stric disturbance of such a character as to justify their classification under the head of "nervous dyspepsia." With such patients the process of digestion is not always retarded to any extent in spite of the presence of .symptoms suggestive of serious impair- ment of stomach function. The most conspicuous symptoms relate to pain in the epigastric region, nausea, pyrosis, and frequent loud eructations of gas. The latter usually take place when the stomach SYMPTOMS REFERABLE TO THE DIGESTIVE APPARATUS 133 is empty, and disappear for a short time following the consumption of food. The abdominal distress frequently occurs independently of the ingestion of food. There is often a decided sensation of fulness in the stomach, associated with perceptible chstention. The tongue some- times is red instead of coated, and the breath inoffensive. Anorexia may be extreme, but vomiting is not an invariable feature. Constipa- tion is usually the habit of the individual. INTESTINAL SYMPTOMS Disturbances of digestion originating in the intestine constitute an important feature of pulmonary tuberculosis. The condition of the bowels is of the utmost consequence, and not infrequently furnishes a sufficient basis for rendering an unfavorable prognosis. The intestinal derangement of chief importance is diarrhea. This may develop early or late in the disease, lie temporary in duration, exist for months, or persist throughout the cntiic course. It may occur without other symptomatic manifestaiimis. and in the presence of comparativelj' slight pathologic change in the pulnidiuiry tissue, or it may be absent in the midst of extensive tuberculous involvement. Both the character and extent of the diarrhea vary within wide limits. There may be but a few movements of the bowels, and these restricted to the earlj' morning hours, or there may be six or eight watery evacuations diiiiui; ilic day. In the former case the desire to empty the bowels imni((liaiil\ iijion awakening is imperative, although sleep, as a rule, has not liccn (hs- turbed. After one or two later operations, wliicli nsnally take phice after breakfast, the patient complains of no furthci- inconxcnirncc duiiiig the day. The dejections in such cases are attended with but little, if any, physical discomfort, are almost invariably liquid, but rarely "watery," and seldom contain mucus or blood, although often very offensive. Patients in whom the intestinal disturbance is more severe are frequently awakened during the night and at a very early hour in the morning. The discharges are uniformly described as watery in char- acter, but in reality are of a thin, soupy consistencj% and sometimes contain I)1(»mI and siireds of mucus. As a rule, the movements become less copious as the day advances. Intestinal flatulence is sometimes an annoying feature. When the diarrheal dejections exceed three or four in number during the twenty-four hours, there is frequently con- siderable griping colicky pain. Diarrhea may appear as a most distressing symptom, even in the midst of general improvement, and affords no criterion by which to judge as to the degree of activity of the pulmonary infection. It is a common erior to regard a persisting diarrhea as invariably dependent upon a, tulieicle ileposit in the intestine. Further, the demonstration of tubercle bacilli in the discharges does not always afford conclusive evidence that the conchtion is iiecessaiily hopeless. In a large pro- portion of the diarrheas of consuni])tives it is impossible to conclude definitely that the local condition is tuberculous in character. It is easy to theorize upon the possible dc\cl;ipnieiil of an intestinal infec- tion from the swallowing of sputum laden willi Inlieirle bacilli. This undoubtedly takes place in numerous instances, but i'linih>-si(al state, the separation from home, the life of indo- lence, the ali-iiKc 111 hiuli ideals, the lack of healthful occupation of the mind, the a-sniiatioii with othei's .similarly afflicted, and in some instances the interminable duration of the illness, must motlify to some extent their natural characteristics. By virtue of these causes some invalids may exhibit a certain accentuation of their inherent peculiari- ties; others may cUsplay a slight perversion of former proclivities, and a few may disclose acquired degenerative tendencies. It has been stated comparatively recently by various writers that consumptives, through the very nature of their disease, become more or less perverted nervously, cultivating habits of self-indulgence, loss of self-control or moral restraint, developing an inability to appreciate the proportionate fitness of things and exhihitinsr tlie stigmata of varying degrees of degeneration. WhUe such broad !:cueralizations are quite unwarranted, the fact remains that consuni]itives, like other individuals, are neces- sarily creatures of their environment. From my own observation, the most frequent resultant of the various component factors is the develop- ment of a remarkable adaptation of the individual to new surroundings and a philosophic acceptance of the radically changed status in life. An admirable resignation is more often exhibited than a rebellious disposition. Unwillingness to conform to the implacable necessities of phy.sical disability is, indeed, unusual. Following the shock of the initial information as to the character of the disease, the attitude of the average consumptive, despite an intelligent conception of the grave possibilities, is that of unflinching courage. Notwithstanding the doubtfulness of the issue, the immediate future is often contemplated with philosophic acceptance. In most instances there is exhibited a lingering and abiding hope, rather than actual faith, in a favorable outcome. This intention .to meet with fortitude what may be held in store should not be described as a form of optimism or of pessimism. Either of these may be present in individual cases, but such does not typify the mental condition of pulmonary invalids as a class. The optimism, which so often has been stated to characterize the attitude of the consumptive even in the last hours, is usually founded upon ignorance of the impending danger. This results either through SYMPTOMS REFERABLK TO THE MIND AND NERVOUS SYSTEM 137 misrepresentation by the physician and family, or on account of an utter inability of the patient to comprehend statements that have been made. Pessimism, when present, is not, as a rule, the result of long-con- tinued and unavailing efforts toward securing arrest in the sense that "hope deferred maketh the heart sick," but rather is an outward expres- sion of the mental makeup of the individual. After years of fruitless endeavor to promote recovery the attitude of the patient usually becomes that of stoical indifference rather than of pessimism, depression of spirits, or melancholia. These latter attributes were of earlier for- mation, and usually entered into the character of the patient previous to the disease. Temporary periods of depression from minor causes are fairly common, perhaps characterizing a larger number of pulmonary invalids than the exaltation of spirits which is sometimes attributed to them. Moderately increased irritalulity of temperament is not infrequent, and is accompanied by a tendency to worry over trifles. Often the.se are ma^nificil to such an extent as to assume undue propor- tions in comparison with ^•ital considerations to which little importance is attached. The inaljility to appreciate fully a due sense of propor- tion which is occasionally displayed in individual instances may be described as a lack of critical faculty obtaining among consumptives in general. Some become less cheerful, are especially susceptible to annoyance, and quick to take offense. There ai-e often exhibited im- pulsiveness, emotional weakness, and astonishing fickleness of mood. The changes from dcs]);iii- to cxiiliciancc of feeling and vice versa are striking and kaleidosc(i|iic. 'I'hc .-ilx-iicc of self-control is one of the more important feature.-, Ii),uclli(-r with ;i certain dependence upon others and lack of aggressive initiative, l^ochiction of will power and inability to think strongly and consecutively are sometimes oljserved. A few, as a result of their long-continued habits of idleness, with perhaps pre- vious non-existence of high incentives, become utterly devoid of ambition and degenerate into a state of gossipy incompetence. From my per- sonal observation, however, I can assert with emphasis that a large number of pulmonary invalids, as a direct result of their own suffering, both mental and physical, and intimate contact with misfortune and misery in others, are led to a life of greater sympathy and broader charity. PERVERTED MENTALITY In addition to the frequent exaggeration of previous temperamental tendencies among pulmonary invalids, the functional nervous disturb- ances may be of such a character as to constitute a distinctly perverted cerebration. These morbid psychologic states aic usually not sufficient in degree to justify their classification inidci' the heading of insanity. The evidences of a disturbed mental e<|iuliliiiuiii may consist merely of a definite suspicion of men and things. Usually this is associated with a gloomy disposition, surly manner, and a pronounced skeptical or pessimistic attitude. Such patients are quick to take offense over imaginary grievances, readily become perversely argumentative, are apt to attach an erroneous significance to the tenor of one's remarks, miscon- strue motives, develop implacable animosities, and cherish vindictive tendencies. Fixed delusions are rarely ob.served in the course of consumption. 138 SYMPTOMATOLOGY AXD COURSE. VARIETIES AND TERMINATION Monomania, when present, is almost always an expression of a previous disturbed mental condition, and is largely independent of the pulmonary disease. It may be intensified to a degree by tlie exhaustion, inanition, toxemia, and psychic conditions incident to the tuberculous infection. The paranoia may have been previously latent in some cases, and subse- quently become a prominent and discomforting feature, through the immediate influence of severe intercurring complications. I have seen delusions make their appearance shortly after the onset of a severe pul- monary hemorrhage and pneumothorax. In fact, in a few exceptional cases a complete transformation of the disposition and character of the patient has followed these two unfortunate occurrences. The delusions which are observed in connection with hemorrhage and pneumothorax do not always become apparent until after the acutely grave symptoms incident to the complication have subsided. The delayed delusions which I have observed imder such circumstances have been almost invariably of an unpleasant character. Thej' usually have been associated with the sudden adoption of a sullen, irritable, and morose disposition, with a distinct tendency to gloomy forebodings. Hallucinations may be present during short periods as a result of meningeal tuberculo.sis, extreme general debility, or marked hysteria. They also may occur after an abrupt elevation of temperature from any cause, in the midst of intense phy.sical suffering incident to pneumo- thorax or severe pulmonary hemorrhage, during the course of broncho- pneumonia, and particularly in patients who have been adchcted to undue alcoholic stimulation. Delusions, hallucinations, and even com- plete temporary insanitj' occasionally attend functional disturbances accompanied by intense pain in females. There is a lady now under my care who is subject to such disturbances at intervals. She recently exhibited, during a period of twelve hours, coincident with a severe migraine, dilatation of one pupil, inability to protrude the tongue, dif- ficulty in articulation, paralysis of one side of the face, one arm, and one leg, and entire absence of normal cerebration. Delusions and recurring hallucinations developing suddenly during the course of pulmonary tuberculosis and not occurring as terminal symptoms are often but temporary in duration. A proper environment, with painstaking detailed management, increased nutrition, and, above all, the judicious employment of opium, are usually sufficient to restore the patient to a normal mental condition. The reestablishment of the former mental state may be expected to correspond to a degree with the manifestations of general improvement. In the midst of a continued general decline initiatory mild delusions are sometimes replaced by an active delirium which persists for months. I have seen distinct maniacal symptoms with ravang delirium continue for two months in a patient who had suffered an intercurring pneumo- thorax. Insanity with suicidal mania is not uncommon as a final result of the profound depression and melancholia occasionally witnessed in pul- monary invaliils. I have observed three cases of suicide among my patients in whom the melancholia had been of comparatively short duration, even developing in the midst of general improvement. Some- what analogous is the case of a lady, thirty-five years of age. who devel- oped complete functional insanity notwithstanding an increased nutri- tion and an entire arrest of the tuberculous process. Her condition SYMPTOMS REFERABLE TO THE MIND AND NERVOUS SYSTEM 139 upon arrival in Colorado was that of an active extensive tuberculous infection of each lung. There was severe cough, with copious expec- toration, great emaciation, anorexia, daily fever, pallor, and dyspnea. After remaining in bed for many months in the open air and displaying remarkable improvement in all respects, there became manifest a loss of memory, great difficulty of speech, inability to articulate, lack of com- prehension, and failure to recognize her own family. There were well- defined delusions of fear, the jjatient several times attempting to jump from a second-story porch. Hallucinations were frequent. Although there had taken place a remarkable gain in weight, the nutrition later was maintained with much difficulty, as she exhibited a positive unwillingness to take food. She endeavored many times to swallow the contents of the sputum-cup, and indulged in other practices equally revolting. The condition was at first regarded by the consultant. Dr. Pershing, and myself as a functional psychosis incident to the general exhaustion, but it was somewhat difficult to reconcile this view with the fact that the mental disturbance developed during a pronounced general improvement. After the insanity had persisted for fully three months she was sent home to a lower altitude as hopelessly insane. Within two weeks following her return her mind apparently was com- pletely restored. After the lapse of three years there has been no return of her mental disturbance and no evidence of renewed activity of the pulmonary disease. The case is reported simply because of its anom- alous characteristics. Evidences of a disturbed mentality are observed quite frequently toward the end of the disease. There may be delusions, mild or raving delirium, stupor, and coma, in some cases independent of the existence of a terminal tuberculous meningitis. This disease presents well-defined manifestations, and will be considered at some length under the subject of Complications. Disturbances of the peripheral nervous system, consisting of hyperesthesia, paresthesia, anesthesia, neuralgia, and other phenomena common to the various forms of neuritis, though sometimes observed in consumptives, are scarcely worthy of special consideration. INSOMNIA Although many consumptives suffer from disturbed sleep, insomnia is not a constant feature of the disease, bears no fixed relation to the physical condition or other subjective manifestations, and is due only in part to the coexistent pulmonary condition. The loss of sleep can be traced in many instances to preexisting nervous disturbances or idiosyncrasies of temperament. The insomnia may precede consump- tion for many months or years, and disappear entirely after the advent of the tuberculous infection by virtue of a perfected system of manage- ment, and the psychic influence attending change of surroundings. Inability to sleep, therefore, is not immediately referable to the disease which it accompanies, save in those cases in which an associated etio- logic factor can be assigned. Many consumptives, irrespective of their physical condition, experi- ence but little difficulty in sleeping. Rest may be disturbed slightly by cough, which in some instances occurs immediatel.v upon assum- ing the recumbent posture, and then subsides for the night. Others suffer no especial exacerbation of cough upon retiring, but their 140 SYMPTOMATOLOGY AND COIRSE, VARIETIp;S AND TERMINATION subsequent sleep is frequently disturbed. Night-sweats may be a factor in the production of insomnia, the patient reposing quietly until awakeneel in the midst of a drenching perspiration. The discomfort incident to this distressing symptom is usually such as to preclude an immediate resumption of sleep. In many cases the origin of the insom- nia is traceable to nervous excitation incident to external causes. Animated conversation late in the evening, a controversial argument, exuberance of spirits through injudicious social indulgence, card-play- ing, and enlivening music often act as exciting causes. Among some pulmonaiy invalids the sleeplessness, although exhibiting variations in degree, may be more or less continuous and constitute a clinical manifes- tation of considerable importance. With other patients it is of purely temporary duration. Comparatively few consumptives suffer from insomnia as a result of woriy over their unfortunate condition. There may be sources of fleeting anxietj' and disquietude, but these distur- bances in many instances are occasioned by trifling affairs, as fancied grievances and personal slights, which are often exaggerated until they assume prodigious proportions. These mental obliquities are far more apt to cause nervous excitation and induce loss of sleep than is actual fear regarding the future. The attitude of man}' patients when unruffled by disturbing trifles is apparently that of complacent acquiescence. Among patients suffering from confirmed insomnia regartUess of excit- ing causes there are some who find it hard to fall asleep, but finally secure their rest after the lapse of several wakeful hours. Others experience no difficulty in going to sleep shortly after retiring, but invariably awaken a few hours later, to toss and turn during the remainder of the night. It is quite characteristic of a large class of patients who are troubled with insomnia to awaken unreasonably early in the morning. Many invalids possess the happy faculty of sleeping during the day as well as by night. Some of these will average from two to three hours daily without apparently detracting from their ability to enjoy peaceful repose at night. The favorable prognostic import of this gift is almost inestimable. With some patients its attainment appears an absolute impossibility. Sleep is not infrequently broken by disturbing dreams. These are more likely to be unpleasant than otherwise. In the more advanced cases of pulmonary phthisis the sleep may become a heavy stupor, the patient remaining for hours in a .state of semicoma. Taken as a whole, the insomnia of consumptives depends largely upon the tem- perament and nervous state of the invalid, and though influenced to some extent by associated disturbances, is not inherent to the tubercu- lous infection. In fact, when present, it is more a result of the environ- ment than of the physical condition, and responds to management directed to the individual rather than to the disease. The ability to sleep is sometimes affected strikingly by the influence of climate. It .should be borne in mind, however, that the result is not always to be attributed to the climate itself, but often to the psychic influ- ence and change in environment. It has been my observation that prolonged and refreshing sleep is more easy of attainment in high altitudes than at sea-level. Many patients, shortly after arrival, express .surprise and gratification at an ability to sleep to an extent previously unknown. The reverse is sometimes true, though less frequently. In some of the latter cases suggestion plays an impor- SYMPTOMS REFERABLE TO THE MIND AND NERVOUS SYSTEM 141 tant part, as the invalids are often told before leaving home that they may experience difficulty in sleeping at high altitudes. In 1898, in a paper entitled " Functional Nervous Disturbances in Pulmonary Invalids," I called attention to the very frequent association of con- sumption with the various forms of functional nervous disturbances, and from an analysis of 350 cases endeavored to study the relation existing between the two. It was found that in almost no case were the manifestations of nervous disorder displayed for the first time in Colorado. But few suffered an aggravation of the nervous symptoms after arrival, and many of these exhibited a satisfactory improvement. Some patients displayed a persisting insomnia, and in these cases the gain was slow and interrupted by periods of vexatious exacerbations. The continued loss of sleep was found to be of decidedly unfavorable influence upon prognosis, not merely from the entailed exhaustion, but, also, as an expression of the more profound nervous irritability with general susceptibility to all depressing or exciting influences. The few who displayed increased nervous excitation did so coincidently with a corresponding loss in the general condition. Some presented evidences of nervous disturbance attributable directly to external causes, which would be operative in any climate, as excessive dissipation, extreme burden of business cares, and unfortunate domestic relations. A reasonable interpretation of my analytic study at that time, which has been confirmed by subsequent observation, suggests that the influence of the climate upon the nervous condition is especially advan- tageous in a large proportion of cases by virtue of the increased nutrition and resulting general improvement. It can be assumed that the tuberculous invasion may render more pronounced all preexisting nervous disturbances, may increase individual susceptibility to such conditions in those already predisposed, and may provide a greater likelihood for their acquired development through the influence of impaired nutrition and general exhaustion. Likewise the existence of well-marked functional derangement affords additional opportunities for the extension of the tuberculous infection through the lessened resist- ance of the individual. Impaired general nutrition, while often a result, is also a most important factor in the causation, of each diseased condi- tion. It is thus evident that the nervous disturbance may be expected to diminish almost invariably in proportion to the degree of arrest of the tuberculous process and the gain in the general strength. It has often been asserted that the existence of insomnia and other nervous manifestations contraindicates recourse to moderate or high altitudes for the consumptive. This position is entirely in opposition to the logic of actual experience in such localities. Such statements predicate the assumption that improvement in the functional dis- turbance must precede gain in the general condition. This adva.nces the argument at the same time that the nervous derangement is of more immediate .significance than the tuberculous infection. It is decidedly more rational to regard the tuberculous involvement as the factor of essential importance. Insomnia and other nervous distur- bances in pulmonary invalids indicate an especial necessity for strict supervision of the details of management, the environment, and mode of life. 142 SYMPTOMATOLOGY AXD COURSE, VARIETIES AND TERMINATION NERVOUS ENERGY There is a vast difference in the degree to wliich pulnaonary invalids retain their nervous energy. This does not always vary in accordance with their physical endurance, nor with the progress of the pulmonary disease. Sonie exhibit an astonishing vitality almost to the very end, although their physical strength may be impaired very seriously. This disproportionate energ>' may often be observed, despite the existence of considerable dyspnea, loss of weight, fever, and night-sweats. It must not be assumed that the inordinate nervous vigor of such people is due to the influence of the disease itself. As a matter of fact, it exists in spite of advancing tuberculosis. Some individuals who have been endowed by nature with an excess of nervous force retain a sur- prising degree of vital energy notwithstanding the unceasing drain incident to pulmonary tuberculosis. It must be admitted that in many cases the overflow of nervous energy is simulated rather than real," as some patients, in their transparent effort to deceive themselves, manifest an undisguised pride in their show of apparent strength. Upon the other hand, many invalids early exhibit pronounced nervous debility. There is no stimulating effect upon the nervous system inherent to pulmonary tuberculosis. On the contrary, impairment of nervous energy usually results. Often this precedes loss of physical capacity, and sometimes the appearance of symptoms referable to the tubercidous invasion. Many patients complain of lassitude, indisposition, fatigue, loss of ambition, and extreme weariness for months before the appearance of cough, fever, or other manifestations distinctly suggestive of con- sumption. They usually awaken in the morning more or less tired, having secured no refreshing invigoration from their sleep. It is an effort for them to get out of bed, they do not enjoy work, their usual vocations appear distasteful, and minor obstacles are magnified to large proportions. They are often unable to think consecutively, the power of mental concentration being diminished to a considerable extent. They frequently lack decision or will power, and vacillation is sometimes quite apparent. Upon the definite clinical onset of pulmonary tuber- culosis these evidences of impaired nervous force increase with the advance of the disease. It is. not unusual to observe a very manifest disinclination to go out-of-doors, some invalids preferring to remain in the house and die comfortably rather than to make an effort to secure fresh air. CHAPTER XXV SYMPTOMS REFERABLE TO THE GENITO-URINARY TRACT Tuberculosis of the genito-urinary system will be found discussed in some detail under Complications. Non-tuberculous nephritic disturbances are considered in connection with Mixed Infection. A description of the symptoms of accompanying renal disease, as well as SYMPTOMS REFERABLE TO THE UEXITO-URIXARY TRACT ] 43 those pertaining to tuberculous infection of the genito-urinary tract, therefore, will not be detailed in this chapter. The various forms of nephritic distiu-bance are by no means uncom- mon in pulmonary tuberculosis. There often exist distinct degenera- tive changes of amyloid character, acute and chronic involvements of the parenchyma, and the chronic interstitial variety of kidney di.sea.se. There are frecjuently no symptoms of the ciironic forms of nephritis until the condition is far advanced, the cUagnosis being secured only through periodic examinations of the urine. Very often, in the course of routine examinations, I have found albumin in the urine long before the appearance of any symptom suggestive of the kidney involvement. Hyaline and granular casts have also been recognized in many cases, sometimes 1ieforo the appo:ir:!iico of albumin. Attention will be directed in anothci- ilui]ilci' in ilic lici|iicnt detection of tubciclr b;;cilli in the urine of puliiKin.ii y iii\ .ilid,. Animal experiiiicuuil ion li:is shown that inoculation with tlie urine of consumptives, in entire absence of tubercle bacilli or suggestive clinical manifestations, is followed in many instances by the death of the animal from tuberculous infection. The symptoms of renal disease vary, of coiu'se. with the n;iture nnd extent of the nephritic change. It is note\\(irtli\- Ihnt sm h UKinilcsta- tions as dyspnea, increasing pallor, dimiuishiiii; st rciii^th. sliiilit ciliina of the hands, face, or ankles, are commonly attributed to the pulniunary infection, although caused in many cases by an unrecognized involvement of the kidneys. There are often pi-esent digestive disturbances as well as changes in the pulse, which may become of high tension. While patients, as a rule, may be expci-tiMl id succuinli (•(iiii|i:ii:ili\cl>' mhui uI'Iit the development of marked itikiI discusc, shimc. incs]iccli\c dI' Ihi- nature and extent of the pathologic change, may lingci- iiL;('d period of time. I have in mind a man, thirty-four years dl .■me. a |iai lent of Dr. Hugueley, of Atlanta, Ga., who was sent Ikhiic \n .lie Ww years ago on account of advanced pulmonary phthisis complicated by chronic nephritis of nearly three years' duration. I recognized the presence of chronic Bright's disease in August, 1900, and was unable to note evidence of substantial improvement at any time during the following two years. In the fall of 1902 there was extensive active involvement of both lungs, with abundant excavation in each, and moderate cardiac hypertrophy. The urine was invariably diminished in quantity and of high specific gravity. There was an enormous amount of albumin, with numerous casts of the hyaline and small granular varieties, as well as occasional leukocytes and blood-cells. Edema, cyanosis, and dyspnea were marked. The patient shortly afterward underwent a double renal decapsulation in the hands of Dr. Edebohls, who reported the results of examination as follows: "Face, anemic; lips, livid. Large cavity and wide-spread infiltration in anterior portion of right lung, middle and lower lobes; smaller cavity with surrounding infiltration in left lung, middle of anterior portion. Rales abundant everywhere over both lungs. Heart hypertrophied, with apex-beat disjilaced to right; no murmurs. Neither kidney palpable. The urine ((iiitained 30 per cent, of albumin by bulk, and was loaded with casts. It looked like a hopeless case from any point of view, and the patient was so informed." The operation was performed under nitrous oxid and oxygen in October, 1903. The patient is still alive, and enjoying an active busine.ss career in Georgia. Not long ago I had opportunity to 144 SYMPTOMATOLOGY AND COURSE, VARIETIES AXD TERMINATION examine him while on a brief visit to Colorado. The urine is diminished in amount and contains a large quantity of albumin and innumerable casts. No essential change was noted in the pulmonaiy condition. It is difficult to realize how life has since been maintained in view of the physical condition of the lungs five years ago, and the complicating renal involvement. His ability to be about on his feet since then has been an ever-recurring source of wonder. I have learned recently of a severe uremic attack which took place at his home, but from which he is now convalescing satisfactorily. The various forms of chronic kidney disease have been observed to attend more frequently the long-standing cases of consumption exhil)iting cavity formation and excessive wasting. Often temporary albuminuria is found coincident with large pleural effusions, acute bronchopneumonia, or high fever from any cause. Acute nephritis is not especially uncommon among consumptives. I have seen it follow an influenza infection, and in several instances a comparatively mild tonsillitis. Nine years ago a gentleman with extensive double pulmonary tuberculosis developed a most severe nephritis immediately following a trifling tonsillitis. The acute symp- toms persisted during a period of nearly two months, and, contrary to all reasonable expectation, the patient finally made a complete recovery in spite of a long-continued uremic condition. In 1901 a patient of Dr. Tyson suddenly developed acute uremic symptoms almost immechately upon arrival in Colorado. She remained profoundly unconscious for tiventi /-three daj's, and finally recovered. Several other equally striking instances can be enumerated to illustrate the occasional development of severe acute nephritis following appar- ently trifling causes. With reference to the sexual organs, perhaps the most frequent clinical phenomenon in consumptives is the disturbance of menstruation. As the disease advances, this function is subject to considerable derange- ment, which becomes the source of much anxiety and apprehension to the patient. At first the menstrual discharge is noticetl to be scanty and of pale appearance. It subsequently becomes delayed, irregular, more scanty, with less color, and finally cfisappears altogether. As the condition improves with gain in strength and nutrition these symptoms reappear in an inverse order. The menstruation often becomes entirely normal even after its suppression during protracted periods. I have known its reappearance after the lapse of two years. It is a common belief that the sexual desire in consumptives is increased to a considerable extent, but this opinion is scarcely borne out by the facts. As far as the pulmonary involvement itself is concerned, it can be maintained that no such influence obtains. A partial explanation, however, is found in the essentially passive exis- tence, absence of diverting thoughts, the abundant use of raw eggs, and the daily administration of strychnin. In some cases the procreative power persists almost to the point of death, but, as a general rule, the sexual appetite is diminished correspondingly with the increasing exhaustion. The fact that a few exceptional patients retain their vigor in spite of advanced tuberculosis constitutes no argument capable of general application with reference to any stimulating influence of the disease. THE CLINICAL COURSE SECTION 11 Course, Varieties, and Termination chapter xxvi THE CLINICAL COURSE The course of pulmonary tuberculosis is subject to a degree of vari- ation unequaled by any other disease. The wide diversity of clinical manifestations among different invalids is responsible for essential dif- ferences in the general type, duration, and termination. The general symptomatology, however, is so varied in character, and the course so susceptible of change from time to time in the same individual, as to preclude an arbitrary classification into separate groups. It has been customary to recognize two chief forms of pulmonary tuberculosis — the florid galloping phthisis, or "quick consumption," and the chronic form popularly described as "old-fashioned consumption." A dis- tinction based upon pathologic changes affords further subdivision into three stages, i. e., incipient infiltration, softening, and excavation. These differences in the stage of the disease, though technically capable of pathologic definition, as a rule, are not sufficiently uniform to permit an accurate clinical differentiation. In some patients the type may be defined distinctly from beginning to end, and the various stages separated from one another by sharp lines of clinical demarcation. Other cases, far from pursuing an unvarying course, are characterized by abrupt and varied changes. In addition to the decided complexity of svdjjective and objective manifestations there is often a strikinjf divergence in the nature and extent of pathologic conditions. Areas of arrest may exist in immediate juxtaposition to active destructive processes. Within a relatively small region may be found, severally, an incipient infiltrative deposit, an area of secondary bronchopneumonia, one of caseous degeneration, one of complete fibrosis, and one of pulmonary excavation, with or without a surrounding zone of reactive inflammation. An explanation of the subtle variations in type, and the sudden trans- formation of the course, is found in the further dissemination of bacilli, differences in the absorptive capacity for toxins, and the development of wholly unexpected complications. Owing to the intricate character of the finer histologic processes and the varying changes in the gross pathology, it is easy to comprehend the wide range of possibilities in the duration and clinical course. The morbid changes produced by the distribution of tubercle bacilli to previously uninvaded areas vary according to the number and virulence of the bacilli and their association with other microorganisms. Thus the agents of secondary infection may produce sharp exacerbations of fever, with associated disturbances, and occasionally scattered areas of pneumonic consolidation. Often the effect of such pathogenic microorganisms as the micrococcus lanceolatus, the streptococcus pyogenes, the staphylococcus aureus, or the bacillus pyocyaneus is 10 146 SYMPTOMATOLOGY AND COtiRSE, VARIETIES AND TERMINATION sufficient to turn apparent success into disheartening failure. It is well known that conditions existing in the periphery of a tuberculous focus materially influence the rapidity and extent of toxic absorption. The toxins may be sufficiently irritant in character to set up a reactive inflammation, which, in turn, constitutes a barrier against further extension of the infective process. Cornet has called attention to a direct relation, conceived to exist between the degree of absorption and the amount of poisonous material in the immecUate environment of the tuberculous focus. He believes that the toxins adjacent to the area of infection, if not absorbed too rapidly, may aid, through their irritant action, in compressing the lymph-channels and partially obliterating the smaller blood-vessels. This presents certain obstacles to the extension of the bacillary infection and controls to some extent the further absorption of the poisons. If absorption is obstructed in this manner, the toxins remain in clo.se proximity to the tubercle, and at this point exert their influence upon the tissues. It would appear that a lessened absorptive capacity aids in the formation of an inflam- matory wall around the focus of infection. This barrier still further lessens the opportunities for absorption and guards against further distribution of the bacilli. The degree of absorption and the pathologic change in the periphery are, therefore, more or less interactive in their effect. According to the indestructibility and imperviousness of the barrier will absorption of toxins and egress of tubercle bacilli be pre- vented. These are factors of the utmost importance in determining the character of the clinical picture, which necessarily is modified in accord- ance with essential histologic and bacteriologic changes. Some ca.ses con- form .strictly to the acute type, the course from the initial symptoms to the end being completed in a relatively short period. Others present throughout the disease features of indefinite chronicity, to the exclusion of acute exacerbations or intercurring complications. There still remains a large class who exhibit at recurring intervals widely differing aspects of the affection. In this group of cases the impression received by the medical attendant regarding the probable prognosis may be either favorable or unfavorable, according to the particular time of observa- tion. It may be stated that, as a rule, the general character of the clinical manifestations at one period of the disease affords no reliable criterion as to the nature of the subsequent course. An abrupt develop- ment does not augur necessarily a short duration, nor does a subacute onset presage a chronic prolongation of the disease. As a result of judicious management, reinforced by individual powers of resistance, initial acute symptoms may become subject to satisfactory control, whOe ca.ses apparently destined to a prolonged period of invalidism are brought to a sudden termination by the supervention of alarming manifestations. The possibility of pulmonary hemorrhage, like the sword of Damocles, must hang over the head of the consumptive, irrespective of the previous history, the character of the clinical symp- toms, the apparent pathologic condition, or the duration of the disease. Cases characterized by an acute pneumonic onset and those of general miliary invasion are the least likely to undergo a change in the subsequent progress. Their diu'ation may be from four to ten or twelve weeks. Many such patients, after the lapse of four or five weeks, have sought to avail themselves of climatic influence and have survived but a few days after arrival in Colorado. The inference has been that the exhaustion and SPECIAL VARIETIES 147 hardship of the journey, in connection with the sudden change of alti- tude, have hastened a fatal termination. Scattered or confluent areas of bronchopneumonia ingrafted upon an existing pulmonary tuberculosis frequently render the disease of short duration. The consolidation sometimes extends with relentless rapidity to a massive involvement, and clearly points the way toward the end of the journey. Death may ensue in a week or ten days, owing to the functional incapacity of the lung and the exhaustion incident to the toxemia. In some instances the patient may not succumb until after several weeks, during which time evidences of softening and excavation are recognized. The shortening of the course through the influence of secondary infection is usually less conspicuous than from pulmonary hemorrhage or pneu- monic consolidation. It is extremely difficult to generalize concerning the duration of the cUsease. This has been variously stated bj^ observers to be from two to seven years, yet many cases are known to survive but a few months, and others to linger for fifteen or twenty years. The latter often present from time to time undoubted evidences of active tubercu- lous involvement. There has been no uniform basis for the computation of statistics, and the results must necessarily vary according to the character of the cases comj^rising the material from which various analyses are collnb.irnl.Ml. 'Vlw sdci.-il )' inciinciil i-lKiiiictcr admitted to sanatoriu, |i( riiiillcd lo iciiiain for considcralilc jicikmIs, and sulijfctf'd to f'(hic;ii i()ii;il iiifliiriiccs may be expected, in roni- parison with other pulnidiiary in\:iliils. to show but sli.iilit lesseiiiiii: of longevity. The experience of dlliei- cll)se^^•ers. many of ^\ll(lse patients conform to an advanced tyjx', is. of cdurse, entirely diffeveiit. The deduction is inevitable that the duration of jiulnionnr)- jilithisis in must cases is dependent upon the available opi)ortunities t<] seiMii'e ai-rest. Not infrequently the character of the clinical course is iai\uely a nj.itter of personal equation. A large majority of the inteinu'rinfi complications and retrogressions are occasioned either by the ignorance and super- ficiality of the physician, or by the stubbornness and frivolity of the invalid. The willingness and ability to avoid the sins of omission and commission on the part of the consumptive are most potent factors in modifying the course of the disease. CHAPTER XXVII SPECIAL VARIETIES In addition to the ordinary forms of ulcerative phthisis which have been described, other varieties ol' i)ulniciiiary infection are sometimes observed presenting such peculi.n itie,~ in the clinical course as to justify separate classification. There are three special forms which are strik- ingly different in their general a.spects from the ulcerative type. The first is fibroid phthisis, characterized by an overgrowth of fibrous tissue 148 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION originating from tuberculous invasion either of the lungs or of the pleura, and followed by extensive pathologic changes involving the pulmonary tissues, walls of the bronchi, and the circulatory apparatus. The second is pneumonokoniosis, usually owing its inception to an inhalation bronchitis which, in turn, is followed by emphysema, fibrous tissue change, disturbance of circulation, and ultimate tubercle deposit. The third is the pulmonary form of general miliary tuberculosis, in which the bacilli are distributed through the blood-stream, the resulting tubercles literally studding extensive portions of the lung. This form of pulmonary invasion will be considered in connection with General Miliary Tuberculosis. Brief mention should be made of fibroid phthisis and pneumonokoniosis coexisting with pulmonary tuberculosis. FIBROID PHTHISIS The term fibroid phthisis should be applied only to cases of extensive fibrous tissue proliferation emanating directly from a primary tubercle deposit in the lung or pleura. On account of accompanying pathologic changes in the lungs, bronchi, and vascular sy.stem, the symptom- complex rarely conforms to the clinical picture of pulmonary tubercu- losis. Tubercle bacilli may be unrecognized in the expectoration, or detected only in small numbers, although present in the pulmonary tissues. Inasmuch as a preexisting focus of infection represents the vmderlying cause of fibroid phthisis, the propriety of classifying the condition among the .several forms of pulmonary tuberculosis is at once apparent. In order to avoid confusion, the fibrous tissue change of non-tuberculous origin should be described as pure cirrhosis of the lung or chronic interstitial pneumonia. In fibroid phthisis the tubercle deposit finally becomes of secondary importance in comparison with the anatomic changes resulting from the primai'v infection. The symptoms referable to the early tuberculous invasion either disappear entirely or become subordinate to the pre- ponderating fibrous tissue formation, with its associated functional disturbance. The entire clinical course is dominated by the influence of the fibroid overgrowth permeating the pulmonary tissues. The duration is much longer than that of ordinary consumption, the invalids in many instances surviving for astonishing periods despite excessive emaciation and respiratory incapacity. Improvement, even under favorable conditions, is correspondingly slow and disappointing. There is usually but little if any fever, but the pulse is often accelerated perceptibly and of poor quality. The cough may be comparatively slight, but, as a rule, is somewhat frequent, dry, and paroxysmal. The expectoration in most instances is scanty or entirely absent, l)ut if at all coijious, is more likely to be light and frothy than purulent in character. In the presence of bronchiectatic cavities, however, the expectoration is often distinctly purulent and the cough markedly paro.xysmal. In such cases there is .sometimes imparted to the breath of the invalid and to the expectoration a particularly offensive odor. Digestive di-^lurhmicos nnd iinpnirniont of appetite are frequent. A beginning shoitucss of l.icath siradually progresses to the point of true dyspnea, and an eaily jjallor may finally merge into varying degrees of cyanosis. The terminal phalanges become clubbed in the characteristic manner previously described. SPECIAL VARIETIES 149 It is scarcely necessary to review the physical signs other than to allude to the conspicuous deformity of the chest-wall resulting from the pulmonary and pleural retraction, the diminished vocal resonance and fremitus occasioned by the pleural thickening, the lessened resonance upon percussion, and the reduced intensity of the respiratory sounds upon auscultation. There may be areas of bronchial or broncho- vesicular respiration, and over the site of large bronchiectases, typically cavernous breathing. A distinguishing auscultatory characteristic, aside from changes of quality, pitch, and rhythm, is the diminution of the breath-sounds incident to lessened respiratory excursion and excessive pleural thickening. As stated elsewhere, the heart is almost always pulled more or less toward the affected side, or dislocated upward by reason of contraction changes involving the mediastinal pleura. Occasionally it is dilated in later stages. Reference has been made to the visible pulsation from the second to the fourth interspaces in case of left-sided involvement. The exti'eme chronicity of the course, the occasional absence of the bacilli, and the infrequency of fever, together with the energy and vitality displayed in spite of excessive emaciation, serve to characterize definitely this foi-m of pulmonary tuberculosis. PNEUMONOKONIOSIS In pneumonokoniosis the pathologic changes may closely simulate those of fibroid phthisis. An essential difference relates to the etiologic relation of the tubercle bacillus to the accompanying anatomic condition. The tubercle deposit is in no sense a causal factor in the production of pneumonokoniosis, but takes place merely as a terminal infection. The primary cause consists chiefly of an inhalation bronchitis through continuous exposure to the palpable dust incident to certain occupations. It differs clinically from fibroid phthisis in that the course of the disease is of much shorter duration, and the fibrous tissue jnoliferation usually not so extreme, with less resulting deformity of tlic cliost. The ingraft- ing of the tuberculous infection upon a suitaMc soil, represented by a weakened general resistance and increased vulnerability of ti-ssues, affords opportunity for comparatively rapid progress. In miners, grinders, and stone-cutters, once the tuberculous character of the infection is clearly established, I have been unable to discover that the symptoms differ very essentially from those of ordinary pulmonary tuberculosis. I have been privileged to observe a moderate number of cases of pneumonokoniosis with accompanying tuberculous infection among the gold-miners of Colorado. In the very midst of all stages and conditions of imported pulmonary tuberculosis in Denver, there are foimd numerous ca.ses of miner's phthisis, difficult of differentiation from consumption, yet scarcely identical with it. There are certain etiologic factors pertaining to the condition which lend a more or less unique character to this class of cases. As stated in connection with Differ- ential Diagnosis, these patients may exhibit all the symptoms and signs of pulmonary tuberculosis, and in the later stages show the presence of tubercle bacilli, although the latter do not represent a factor of causative significance. This class of cases is regarded by the laity, and, unfor- tunately, to some extent by the profession, as a form of consumption, and many such patients are classified as tuberculous in official mortality 150 SYMPTOMATOLOGY AND COURSE, VARIETIES AND TERMINATION records. Instances of pneumonokoniosis are frequently cited to illus- trate the alleged development of indigenous tuberculosis in spite of favorable climatic conditions. The actual morbid processes consist of a more or less severe chronic bronchitis, emphysema, bronchiectasis, varying degrees of pneumonokoniosis, with often genuine cavity for- mation resulting from anemic necrosis, and secondary' circulatory disturbances. The tubercle deposit, if present, is often quite insignifi- cant in comparison with accompanj'ing pathologic changes. These cases are found to develop almost exclusively in .sections of the State devoted to the mining industry, i. e., in sparsely settled regions on mountain siiles where tuberculosis seldom exists. Prechsposing causes are found in the prolonged hours underground and the constant breathing of an atmosphere, not only deficient in oxj'gen. but vitiated by impuri- ties. The air, not being in motion, becomes more or less devitalized and is breathed over and over again. In addition to the partial asphyxiation and the frequent extreme dampness, exciting causes relate to exhalations from the cantUes confined within a relatively small air-space, and the smoke resulting from the blasting powder, which is difficult of complete removal despite modern efforts toward ventilation. The necessarily constrained position during the greater portion of the day, the frequent wetting of the feet, the alcoholic habits, immoderate exercise at high altitudes, and the unhygienic surrountUngs when not at work, constitute important supplemental features. The conditions are quite dissimilar to those obtaining in the production of coal-miner's consumption, stone-cutter's disease, grinder's or potter's phthisis, and the like, in that the sole essential factor is not the irritation produced by the inhalation of fine particles of dust. Chronic catarrhal processes take place in the bronchial mucous membranes, followed by emphysema which results fnnii nutritional changes in the pulmonary tissues, and from an increased intra-alveolar pressure during violent attacks of cough. Moderate fibrous tissue proliferation is superinduced in .some cases, but by no means to the extent observed among followers of other occupations responsible for the production of pneumonokoniosis. AVhile the distinguishing feature is the chronic bronchitis and emphy- sema, there frequently supervenes bronchiectasis, both of the cylindric and saccular varieties. Its development is due in part to the frequent paroxysmal cough, the weakening of the l^ronchial wall from emphysema, and the more or less continuous pressure exerted by stagnating secre- tions. The bronchiectatic cavities correspond largely to the fibrous tissue proliferation and the contraction changes external to the bronchial wall. Through the process of ulceration of the mucous membranes these bronchiectases may be transformed into genuine pulmonary cavities. These may develop also by reason of necrotic softening of the tissues, more particularly when the pneumonokoniosis is pro- nounced. In this event they are more likely to increase in size and have greater bearing on the subsequent course, especially if commimicating with a bronchial tube. Secondare to the pulmonary changes there ensue marked circulatory disturbances, manifested by venous engorge- ment and enlargement of the right heart. Symptoms referable to this group of chronic pathologic conditions are of gradual development and relate chieflj* to dyspnea, cough, and expectoration, followed by loss of weight and strength, with gradually increasing cyanosis. The cough is frequent and unattended at first SPECIAL VARIETIES 151 ■with much expectoration. Later it becomes more distressing and paroxysmal in character, particularly after the formation of bron- chiectases or pulmonary cavities. There exists no definite relation between the degree of bronchial irritation and the extent of fibroid change in the lung. The sputum is frequently quite frothy, light, and devoid of pigmentation, becoming more purulent with the increasing periodicity of cough. Under these conditions the characteristic sepa- ration into distinct layers may be noted. Little of practical value attaches to its bacteriologic examination, save that the occasional presence of tubercle bacilli denotes a final incidental complication. The dyspnea, which at first is noticeable only upon slight exertion, becomes progressively worse, until the patient is induced to seek relief at lower elevations. The cyanosis is usually, out of proportion to the physical evidences of cardiac and respiratory embarrassment. Impaired appetite and digestive disturbances result in diminished nutrition, increasing weak- ness, and night-sweats. There is rarely any elevation of temperature save during temporary acute exacerbations. Hemorrhages are not infrequent, and may vary from slight bloody discolorations of sputum to a sudden fatal loss of blood. The physical signs upon inspection may consist of the characteristic ■changes in the configuration of the thorax commonly ascribed to emphy- sema, with frequent unilateral or bilateral retraction of the apices and occasional capillary dilatation upon the chest front. There are often percussion-signs of partial consolidation at the apices, but in many cases the resonance is intensified and somewhat tympanitic throughout the entire pulmonary area. Fine and medium-sized moist rales may be heard in all portions of the lung, though more frequently at the bases and almost always on each sicle. The breath-sounds are invariably somewhat diminished in intensity, corresponding to the degree of emphysema. The dulness is occasionally unilateral, in which event there often are localized changes in pitch, quality, and rhythm, and ■bubbling rales. Signs suggestive of pulmonary cavities may be recog- nized in almost any portion of the lung, as in tuberculosis. There is no invariable predilection as to the site of the cavity formation. In comparison with simple chronic bronchitis and emphysema, or with ordinary cases of interstitial pneimionia, the course of the disease is short, rarely lasting over four or five years. This may be accounted for to some extent by the influence of altitude, the usual unwillingness and inability of patients to avail themselves of change of residence, and their greatly diminished resistance from habits of dissipation. While considerable relief is usually experienced on going to lower elevations, the unfortunate issue is delayed but temporarily, the prognosis almost always being unfavorable. 152 SYMPTOMAIOLOGY AND COURSE, VARIETIES AND TERMINATION CHAPTER XXVIII TERMINATION Strictly speaking, the ultimate termination is recovery or death, but a large number of cases cannot properly be included in either class. While not actually cured, they are none the less enabled, for indefinite periods, to pursue a life of useful endeavor within the bounds of considerable physical activity. In its technical sense com- plete recovery is relatively infrequent save in the most incipient cases, as the infected area is scarcely capable of restoration to its previous condition. The very conception of an enduring arrest carries with it the necessity of fibrous tissue proliferation and encapsulation, but it is unreasonable to deny, because of resulting anatomic change, the attainment of complete recovery. A permanent arrest of the tubercu- lous lesions is no less a cure despite a remaining indurative process than recovery from variola with resulting facial blemishes. It is entirely warrantable to regard patients as cured who, during a period of two or three years, present no physical signs of even a dormant infection, exhibit no subjective symptoms, and display an invariable ab-sence of tubercle bacilli. It is not contended that bacilli may not exist in the pulmonary tissues of such patients, but the non-development of any signs or symptoms suggestive of their presence during a prolonged period may be construed as sufficient evidence of their practical sur- render. Many patients fail to succeed in the acquirement of complete arrest, and yet possess undiminished vigor and activity. It is common in health resorts to observe a large class of inchviduals who have achieved apparent arrest of the active process. Many of these with entire dis- appearance of subjective symptoms e.xhibit renewed energj^ and industry, yet at intervals display a few apical signs, with attenuated bacilli in the expectoration. I have under my care several patients who have remained in Colorado for thirty years or more, and who present every outward and physical manifestation of perfect health, although occa- sionally submitting bacteriologic evidences of a remaining quiescent deposit. MODES OF DEATH For some unexplainable reason death from consumption has ever been thought to be particularly horrible and revolting. It is possible that the idea of a lingering illness, a so-called "dying by inches," has suggested to the popular mind an exaggerated notion of the physical distress during the final agony. There is no reason to believe that the dissolution of the consumptive is attended by a greater physical struggle or mental anguish than is experienced bj- other victims of the grim destroyer. In many cases the prolonged duration of the illness, rather than making death harder to bear, is instrumental to a degree in preparing the sufferer to bear the inevitable with fortitude and resigna- tion. With many the end is a welcome relief from the burdens and hardships incident to their illness. Patients of this class, far from approaching their demise with fear and trepidation, long for eternal rest with a courage and calmness incapable of simulation. TERMINATION 153 Many times have I been impressed most profoundly by the remark- able resignation of the consumptive, who, with unclouded intellect, has responded to the last summons. It has appeared that the very nature of the illness has tendetl to dispossess the end of its ordinary terrors, and to render the anticipation of the supreme moment but a deferred solace for botlily ills. Many, it is true, preserve a demeanor of indiffer- ence in the face of impending death, while others, with halting tread and protestation, are dragged to their doom. Fortunately, mental hebetude sometimes comes to the rescue, foUowetl by mild (lelirium and coma, and the patient sinks gently to the final sleep. The tlemise of the con- sumptive, as a general rule, is singularly quiet and peaceful, devoid in large measure of the struggle and anguish characterizing a fatal termi- nation of other disea.ses. It has been my observation that the only conspicuous deviation from tliis manner of departure occurs among pulmonary invalids overtaken by death as a result of intercurrent com- plications. This is particularly true in pulmonary hemorrhage, bron- chopneumonia, edema of the lungs, i)neumothorax, cardiac dilatation, and occasionally tuberculous meningitis. The end may be sudden and violent, as during severe pulmonary hemorrhage. At such a time the patient is drowned in his own bloocl, and may expire almost immediately from asphyxiation, the suffering being but momentary. Dissolution may take place suddenly from other causes, as cardiac weakness or bronchopneumonia. I have witnessed two instances of sudden death following light percussion of the precor- dial region in cases of cardiac dilatation. In bronchopneumonia of septic origin following pulmonary hemor- rhages the patient is at first restless, anxious, and excitable. After a few days this changes to apathy, stupor, mild delirium, and some- times coma. In some instances of death from aspiiation pneumonia the sensorium remains unimpaired to the last, and the air-hunger becomes extreme. This may happen also in pneumothorax, and almost invariably in pulmonary edema. In such cases the suffering is more intense than can be imagined or described. Dreadful paroxysms of cough sometimes suffice to expel foamy and bloody expectoration, causing the disappearance, for the time being, of the ominous tracheal rattle. In acute pneumothorax and in bronchopneumonia without edema there may be no expectoration whatever. At times there is insufficient strength to efTect the expulsion of the expectoration, which, if present at all, sticks to the lips and dorsal aspect of the tongue or adheres tenaciously to its base and to the posterior wall of the pharynx. The mouth and lips are exceedingly dry, and the masses of sputum are extracted only by means of a cloth or swab. The struggle, which is horrible to witness or contemplate, continues without abatement until merciful death claims its own. As a general rule, however, it seems to be a beneficent provision of nature that the vast majority of consump- tives, after months and years of lingering illness, are permitted to suc- cumb to the dread disease without sthenic manifestations. PART 111 PHYSICAL SIGNS INTRODUCTION Pulmonary tuberculosis produces a greater diversity of morbid conditions within the lungs, and hence exhibits a greater variety of physical signs, than any other respiratory affection. There is scarcely an objective manifestation observed in the course of the various pulmonary diseases which may not be exhibited by the consumptive as a direct result of the pathologic change incident to the tuberculous process or to associated complications. Thus an accurate recognition of the physical signs accompanying the varying degrees of tuberculous infection can be secured only from a thorough understanding of the principles of physical diagnosis as applied to all intrathoracic distur- bances. The confusion resulting from an incorrect terminology, the frequent errors of technic in conducting physical examinations, and the faulty interpretation of various combinations of physical signs are often responsible for the non-recognition of gross pathologic lesions, and suggest the expediency of introducing a preliminary section devoted to physical diagnosis in general. In view of the difficulties often encountered regarding many important features relating to the physical examination of the chest, it seems desirable to outline a course of pro- cedure emphasizing the essential principles of diagnosis pertaining to pulmonary conditions. In no other department of medicine is there demanded such a degree of skill as in the recognition of obscure pulmonary affections. In all respiratory diseases a precise conception of the condition can be obtained only through an exhaustive and systematic examination of the patient. While during student life dispensary facilities may be depended upon to furnish the means of acquiring a more or less practical famil- iarity with the making of physical examinations, these clinical oppor- tunities will scarcely suffice for a thorough understanding of the subject unless preceded and accompanied by competent instruction concerning the principles and facts of physical cUagnosis. To obtain practical proficiency it is highly important that a preparatory course of didactic or text-book instruction should be provided not only as to the physical signs themselves, but as well to the rationale of their production. Thus, in addition to the recognition of abstract physical signs, the beginner should be made to appreciate the relation of the various phenomena thus observed to the morbid conditions which they represent. Although no single physical sign may be said to characterize definitely any path- ologic state of the tissues within the thora.x, yet the grouping] of several associated signs in connection with essential facts pertaining to the history and symptoms, permits the differentiation of the various con- ditions. It is not permissible within the limited scope of this section to do other than review important features of diagnosis. 154 INSPECTION 155 Various methods are employed for the recognition of diseased con- ditions by means of external evidences. Physical signs refer to objective manifestations elicited by the physician, as contrasted with subjective symptoms described by the patient. The physician utilizes the following methods of conducting a physical examination of the chest, i. e., inspec- tion, palpation, percussion, auscultation, mensuration, and succussion. SECTION I General Physical Signs chapter xxix INSPECTION While much may be learned by inspection, the relative importance of this method of conducting physical examinations is often exaggerated, the tendency of several writers having been to overestimate its value. It is by no means impossible for one who is totally blind to be fully as skilful in physical exploration of the chest as expert examiners who are not deprived of the sense of sight. In fact, inspection may often give rise to erroneous impressions regarding physical conditions which can be removed only by careful recourse to other methods of examination. It is not infrequent for individuals to present every visual manifestation of perfect health and yet disclose important changes upon percussion or auscultation. It is equally true that others may exhibit many outward appearances of pulmonary disease, even displaying well- developed types of the so-called paralytic thorax or phthisical chest, and yet upon examination reveal no pathologic pulmonary condition. It is apparent, therefore, that inspection should be i-egarded strictly as an aid to the examiner supplementary to other means of physical exploration. It furnishes to some extent preliminary impressions or provisional information, which, in all cases, should be confirmed by the employment of other methods. RULES FOR THE PRACTICE OF INSPECTION Inspection may be employed with the patient standing, sitting, or reclining. If standing, the body should be held erect in an attitude of repose, with the weight borne equally upon each foot. The head should rest squarely upon the shoulders, which should be drawn slightly back- ward and held symmetrically. Care should be taken to avoid the slouch- ing posture frequently assumed by pulmonary invalids. Equal pre- caution should be exercised to prevent the tendency to throw the shoulders far backward and inflate the chest, either with or without retracting the abdomen. When the patient is told to stand erect, sometimes an appearance is presented suggesting a military inspection 156 PHYSICAL SIGNS during dress parade. He should be taught simply to assume a natural posture. The examiner should remain between the patient and the light. It is well for the physician at first to stand some little distance from the patient, in order to appreciate better the shape, size, and form of the chest, to note irregularities of contour or other asymmetric con- ditions, and to study carefidly changes in the frequency and character of the respiratory movements. If the patient is e.xamined while sitting, a moderately high stool or straight -backed chair should be used. In most eases a stool is pre- ferable, the back of the chair possessing no particular advantage and often being in the way. The habit of slouching is noticed more often with the patient sitting than standing, and should be avoiiled in all cases. It is good practice, however, when examining the back, to have the patient incline slightly forward with the arms folded, each hand resting upon the opposite shoulder, and the elbows kept as closely together as possible. This expands the broad wings of the scapulse, which in emaciated people are very prominent, and permits a more ready examination of the back than can be obtained in any other position. The examination of a male should be conducted with the patient stripped to the skin as far as the waist. There can be no excuse for neglect to insist upon this procedure. With females it is not always expedient, on the score of delicacy, to demand the entire removal of the clothing. A light shawl or cape may be drawn over the back when the front is being inspected, and vice versa. If the undershirt is loose, it may be separated in front and dropped over the shoulders, or it may be raised from below, while examining respectively the upper and lower regions of the chest. If the examination is made with the patient reclining, care should be taken that the body rests equally upon the hips and shoulders, with the head but moderately elevated. Inspection of the chest with the patient reclining can be but superficial at be.st, and when necessarily confined in bed, this method of examination is often comparatively unimportant. CONDITIONS INDEPENDENT OF THE THORAX NOTED ON INSPECTION It is usually taught that inspection should be employed particularly to note the configuration and movements of the thora.r proper. As a matter of fact, valualjle suggestions as to the general condition may be olitained through the sense of sight Ions; before the patient has been stripped to the waist for the examination of the chest. For example, the examiner unconsciously notes the degree of emaciation, the general carriage or demeanor, and the extent of physical weakness. Great practical importance in a general estimate of the patient's con- dition attaches to the facial appearance. The first impression conveyed to the mind of the examiner usually relates to the visil)le changes of the face, whether healthy or unhealthy, full or emaciated, pale or flushed, sallow, cachectic or cyanotic, dull or alert, pinched, drawn, or excitable, the various shades of expression being noted at a glance. The color of the face is always of clinical interest, .\nemia is often present, particularly in cases of pulmonary tuberculosis. This is more surely detected by depressing the lower eyelid and observing the color of the INSPECTION 157 mucous membrane. Congestion of the face is frequently noted in chronic bronchitis with emphysema, bronchiectasis, in the early stages of pneumonia, and in several forms of circulatory disturbance. Cyanosis is possessed of great significance. It consists of a purplish- blue flush, at first appearing upon the lips, tip of the no.se, and the ears, but later suffusing the entire face. This may be present as a result of valvular heart lesions, with or without dilatation, myocarditis, pericardial effusion, emphysema, asthma, pulmonary edema, chronic bronchitis, and occasionally in pulmonary tuberculosis with circulatory embarrassment. Edema of the face is often observed when no suggestion of patho- logic change can be obtained upon inspection of the thorax alone. Facial edema may fail of recognition in some instances, as the clinician may not be sufficiently familiar with the contour and appearance to make comparative observations. The careful examiner, however, will usually note the slight puffiness of the eyelids, even upon casual obser- vation. Critical inspection of the face and neck should precede the examination of the chest in all instances. Great importance attaches to the frequency and character of the respiration, which may be observed quite accurately before the patient is prepared for a conventional inspection. While a detailed observation of the nature of respiratory movements is not possible without the removal of the clothing, it is easy, nevertheless, to recognize the presence or absence of dyspnea. This may exist either as labored respiration or merely as quickened breathing. The former is detected long before the clothing is removed, and is accompanied by more or less cyanosis, with an increased play of the auxiliary muscles of respiration. Simple accelerated breathing without cyanosis and unaccompanied by the use of the accessory muscles of respiration may result from such causes as emotional excitement, fever, and exercise. Labored breathing or true dyspnea may be dependent upon a dimin- ished respiratory capacity of the lungs in the course of pulmonary tuberculosis, pneumonia, pleurisy with effusion, pneumothorax, and emphysema; from cardiac disturbance or from a .severe anemia. Change from the normal lireathing may also be recognized in the rhythm and sound of the respirations. In some cases the disturbed rhythm relates solely to the changed relations between inspiration and expiration, each respiratory act, however, being identical in character with all others. At other times the altered rhythm relates not so much to a disturbance of the relation between inspiration and expiration, as to radically differing characteristics of succeeding respira- tory acts. An example of the first class is the so-called asthmatic breathing, in which the inspiration is shorter and quicker than normal, while the expiration is prolonged and difficult. The most striking illustration is witnessed during an acute paroxysm of bronchial asthma, but this form of breathing is displayed to a less degree in well- marked emphysema. In the latter event the inspirations are not so short and jerky and the expirations are less prolonged and labored. In well-marked asthmatic breathing the sound is an element of some interest in that the respiration is decidedly wheezy in character. The disturbance of rhythm which takes place in succeeding respira- tions is found in the so-called Cheyne-Stokes type of breathing. This form of respiration may be desi-ribed as an alternating cycle of 158 PHYSICAL SIGNS progressively increasing, followed by gradually decreasing, dyspnea, and periods of complete apnea. In this type of breathing each act of respiration is different from the preceding or the following. The patient in the beginning of his rhythmic dyspnea breathes but little differently from normal. Each following respiration, however, becomes rapidly increased in volume and louder in intensity until the height of the dyspneic attack is reached, when the respirations diminish inversely in rapidity, volume, and intensity, to be succeeded by a com- plete pause or absence of respiration, called the apneic period. The entire cycle may last anywhere from half a minute to a full minute. In this type of breathing, as in the asthmatic, the disturbed rhythm is associated with an appreciable difference in the intensity and quality of the respiratory sounds. Another class of eases exhibits a distinctly restrained respiration, particularly during inspiration, which is short and conies to an abrupt termination appai'ently before the act of inspiration is fully completed. It is usually associated with a prolonged slow and cautious expiration. This peculiarity of respiration is found principally in cases of dry pleurisy, in the very early stages of pneumonia, and as a result of intercostal neuralgia, periostitis, or trauma. The restrained or catchy respiration should be distinguished from a type of irregular breathing sometimes described as cog-wheel in character. While this latter form is more often detected with the stethoscope, it may be occasionally noticed upon inspection alone. The essential characteristic is simply an interruption or irregularity of the inspiration. Another distinct type of respiration is witnessed in acute conditions among children. There is displayed a striking rapidity of the respira- tions, together with an audible sound upon expiration. The child breathes with a distinct gi'unt accompanying the expiratoiy act. This is highly significant of severe capillary bronchitis, penumonia, or begin- ning Pott's disease. A form of respiration known as stridulous breathing may occur in children whenever there is obstruction or marked change of contour of the glottis or interior of the larynx. The stridor accompanies inspiration, and is observed in edema or spasm of the glottis, false croup, laryngeal diphtheria, and whooping-cough. The slow stertor- ous respiration incident to profound coma has no remarkable charac- teristics aside from its snoring quality and the frequent association with cyanosis. Sighing respiration is occasionally oKserved following severe hemor- rhage from any source, although it is perhaps more common after pulmonary hemorrhage. INSPECTION OF THE CHEST It is unnecessary to describe the tyiiical appearance of a normal chest. In view of the innumerable (l(\iati(in-; in health from any conventional type, no two chests may be s.iid id he ]iiecisely alike, and the variety of visible conditions presented to physicians making many examinations is almost infinite. Only one chest in four has been found to be perfectly symmetric. Clinical inspection of the chest should chiefly include attention to the size and form of the thorax, and the frcqviency and character of INSPECTION 159 the respiratory movements. In most cases the attention of the examiner is primarily directed to the size of the chest. The Size and Shape of the Thorax. — There is a great diversity in the size of normal chests. Striking differences may result from inheri- tance, occupation, and from such previous conditions of health as the early existence of rickets and adenoids. The same peculiarities in respect to size are often noted in succeeding generations. Remarkable variations are also exhibited in the shape of the thorax, no two chests presenting precisely the same outward appearance. Despite innumerable peculiarities of form, chests may be classified as short or long, broad or narrow, and deep or hollow. Although certain types are commonly regarded as suggestive of intrathoracic disease. Fig. 5.— Paral: feature being the sternum. ■ig. 6.— Paralytic and long type of chest, normal area of cardiac dulness. The of percussion resonance at apices are no presumptive conclusions as to morb external appearances. A characteristic paralytic chest, so named because of the pulmonary tuberculosis. If the soft pMi' the peculiar effect is to some extent cimili d conditions are justified by variety is the phthisical or fro()uency of association with s arc coii^idciably emaciated, L^i/;('ll. 'i'hc thorax i.-^ more or less flattened anteroposteriorly, with sUght increase in the lateral diam- eter, irrespective of the length. The sternum is sunken appreciably ; the . sternal ends of the clavicles are apparently pulled downward; the neck appears longer, and the chin more sharply defined with respect to the neck. The entire bony framework of the chest assumes greater promi- 160 PHYSICAL SlCi-N nence, the ribs being more conspicuous and the intercostal spaces deeper and usually narrower. In the l)ack the scapuhr stand out broadly from -The short, broad the ribs, giving rise to a suggestive winged appearance. There is no material deviation from normal respiratory movements save under I vhom the phytiical well defined exertion or excitement, when they become noticeably shallow and are somewhat accelerated. (Mm -e INSPECTION It should lie iM.riir 111 mill. I th;it .'i w..ll-(l('lili.Ml l,,t in,-,,]ll|.^,llM,. NMlh pri'lcrl IumIiI,, ,-,ih1 ^,1 o t|, external appearance. The prominence of the scapula, sometimes thnu'^lit to ho charnctoriptif of pulmonary phthi'^is, mnA' he oliserved not ii,riv,mciill\' ,.v,.n aiiioiiii hcaltliv aini wll-ii.iuri-h < iiijihiis, inntiiiis cliisi ihi'iv i^ an iiicica-c tinct unilateral depression in these regions is <|uiikly ndtfd l.y tlic i'\:iniiner, and is immediately suggestive of a prei•\i^tiu^ tul'ci-iiilnii< ])i()rfss. Localized retraction is not infrequent in the lateral resion. liut is not always susceptible of satisfactory expla- nation. RESPIRATORY MOVEMENTS It has been stated that much information can be gained with refer- ence to the character of the resi^iration before stripping the patient for Fig. 25.— Hard 1, yeai-s of age. The c and right lung. (Cci inspection. It is difficult at times to foi-m correct impressions regarding the respiration witli the patient prepared for examination, on account of nervousness and the too conscious efforts in breathing. It is true, however, that a comparison of the respiratoi y movements upon the two 170 PHYSICAL SIGN'S sides is maiiifostly impossible without tlie removal of the clothing. Otherwise (inc i~ al-i, unable to determine whether the respiratory move- ments are iliaplna-iiiatic or costal in character. In male adults the respiratory iuo\ eiueiits bring into play the inferior part of the chest and diaphragm. In females the i-espiration is frequently confined to the uj)]3er part of the thorax — the so-called superior costal variety. In children the liroatiniiir is usually diaphragmatic. A costal type of respi- ratidii may be indurcd in adults l.iy any cause which interferes with the descent 111 the diaphragm or with the respiratory function of the lower portions t)f tlie lung, as a double i^leurisy with effusion, bilateral retrac- tion of the bases, or exten^ive tiliroid change. The descent of the diaphragm may be impeded by the jiresence of a large quantity of ascitic fluid, by great distention of the abdomen with gas, or by the existence of an acute peritonitis. The inferior costal or diaphragmatic respi- ratory movements may be increased by causes interfering with the expansion of the upper portions of the lung. While the movements of respiration should occur at the same time upon both sides, and be per- fectly (Miual. an increased (if a diminished imilateral expansion is not infre(|U('nt in the presence of pathdlogic conditions. Litten's Phenomenon. —This interesting sign in some cases is possessed of definite diagnostic value. The patient is placed in a reclin- ing position, with the feet toward the window. The examiner stands at the siile of the ]iatient and observes upon full inspiration a shadow- descending from the seventh to the ninth ribs, and receding upon expira- tion. This is ]ii()(iuced by the movement of the diaphragm in con- nection with tlie descent of the lung into Gerhardt's complemental space. It is not capable of recognition whenever phj-sical conditions prevent the fullest exjiansion of the lung. It cannot be detected in pneumonia of the lower lobe, moderate pleural effusions or pneumo- thorax, firm pleural adhesions, severe peritonitis, or ascites. Whenever INSPECTION 171 the descent of the diaphragm is not interfered with, the Litten phe- nomenon is of value as aiding in the differentiation of enlarged liver and pleural effusion. It is also of aid in some cases in the diagnosis of incip- ient apical involvement, as will be further discussed under Diagnosis. CARDIOVASCULAR CHANGES Any extended consideration of heart and circulatory conditions is entirely without the scope of this book. There exists, however, so inti- mate and reciprocal a relation between pulmonary diseases and cardio- \-ascular disturbances that brief reference to associated heart changes is desirable. The data to be obtained upon inspccCKin as regards the heart and circulation are always of much intcivM In -oiue instances but little of practical value is detected, even altci a scaidiing inspection. Often the facts thus deri\e(l bccdnic of imjiortance only when confirmed by the results of palpatimi ami pci-cussion. For successful ius|ic(ti(in with reference to the heart or circulation a careful technic imist be employed. The physician nuist l)e thoroughly familiar with the iMis^iMi' caidiac and va.sculai- cliaiiiics. and be iircp.ii-cd to watch for tlit-ii' appcaiance. Upon ins]>i'it ion with re,t;aid tn pul- monary conditions tlie patient is usuall}' oli-cixcd by the examiner from a distance in order to afford oppml uiiii y im' a comparison of the two sides of the chest. When noting canliac cumiilications, however, the physician must stand much neai-cr the patient, and the inspection becomes a matter of closer detail. The inspectidii sliould be made with the patient both in the upright and in the rcilinia^ posture. The exaniiiiei- slnnild take (■(iguizaiice ol' clian'je- leleialile to the precordia as u \vlii>iM ially with pidt riwioii nf t!ie sternum, the apex may be fotuid di^placrd -liiihlly upward and to the right of its normal positiiin. As a result (if a--i>iiatrii jiathdld^ic concUtions the apex may lie dislocated to the ri^ht (ir left, iipwaid or downward. The morbid chanij,C's sutficient to ]ii()dii'e these results may exist in the heart itself, in the ])eriranliiun in the Inn-s, in the pleura, arteries, and kidneys. The im]iortant chanm-^ in the heart sufficient to alter the location of till' ajicK-l ii'at arc ihieHy hypertrophy or dilatation. llvpfitin|ili\ ,,i' the right or left ventricle may displace the apex- beat to the h'it and -liirhtly downward. If associated with arteriosclero- sis, esiieiially in aged people, the downward displacement is considerably increased. In ]3ericarditis with effusion the apex is lifted and displaced slightly to the left. Changes in the lungs may suffice to obliterate the visible apex- lieat. to displace it downward or to either side. It may be obscured as a result of pronounced emphysema, the increased volume of lung inter- posing such a layer lietween the right ventricle and the chest-wall as to ]irec'hide an>- \i-ilile inipulse. Sometimes the apex is depressed in emphysema. The cardiac impulse may be displaced either to the right or to the left, bj^ virtue of fibroid contractions, the heart being pulled usually en masse, but occasionally with a con.spicuous change in the position of the apex. Pleurisy with effusion, on the other hand, pushes the heart away INSPECTION 173 from the affected side, often producing a considerable change in the location of the apex-beat. In left-sided pleurisies the apex is displaced to the right. Not infrequently in pleurisies of the right side it is forced to the left and somewhat elevated. In i)neumothorax also the heart is pushed peiveptibl\- lowai'd the uiiafrcctcd .- lie noted under certtiin conditions. Not infrequently this is obser\ed in thiii persons and in tho.se of decided nervous temperament. In such ca^es the jjiilsation is de\'oid of an\- ])athol(mic si'jnilicance. It may be present in aneurysm of the abdoniiiial aorta, a cciniparatively rare condition. The pulsation may be traiismitted throimh a >o|i(l neoplasm affecting the pyloric end of the stomach or the pancreas, and also tlii()UL;li the left lobe of the liver. It may exist on account of hy]>ert mi'liy oi the liiiht ventricle. Usually it is easy to ascertain the preta-e i auc of e]u.ua,stric pulsation through the process of exclusion. VISIBLE CHANGES IN THE NECK Throbbing of the carotids is easily recognized. It is usually a-^so- ciated with hypertrophy of the left ventricle in connection with aortic regurgitation, producinc' an exaggeratorl pubation also in the Ijrachial, railial. and tetnpdial icL'icii , Imrea-vil arterial pulsation is noted in exophllialniir -(.iter, ill -tati- \e:iml below the clavicle, and in both lateral regions cil' the chesl . pait i(uiail\ in the upper portions. It is also ]iic>iiiiimce(l in the interscapular ic^iims. whih' at the bases, over the scapula', and in the regicm - rare upon palpation, and their recognition perfectly simple upnu auscultation. Brief mention should be made ((lucerniag the importance of palpa- tion in examination of the heart. The position of the apex-beat may be detected in many instances when impossible of recognition by the sense of sight, and at the same time valuable information may be derived as to the cli.aracter of the cardiac iiii])nlse. In deteiiiiiiiiii- the -i/.e of the heart, the results of palpation are often more ilelmiie and })ositi\-e in character than those of percussion. The tympanitic icsonance of the stomach is often transmitted upward and to the left, iiiiei-fering with cardiac percussion. By feeling care- fully with the tii>s of the fingers at the left of the heart's apex to the furtliest point v\here any cardia- niox-etiient is recognized, an approxi- mate estimate can l:)e made of the left cardiac boundary. The presence or absence of a thrill is also ascertai'cd with the fingers laid against the precordial region. This sign is usually obtained at the apex and over the aortic valve, and has been described as similar to the sensation felt with the hand placed upon the throat of a purring cat. The thrill is usually presystolic at the apex, but in rare instances may be sy,stolic in time. PaljKition of the blood-vessels is also important. By this means delinite infoimaiion is 'jained respecting the visible pulsations in the neck, wlieiliei' of \eiioii (,r ai-terial origin. The ilr_:ree of ariia lo-ilcro is of the brachial arteries is appreciated arlrrv i oi cMivme N;,lne in noinn: llie rate, rlivtliin, tensi,ni, and cOlupr.-Ml.ility of tl,e pulse, and the character of the arterial wall. PERCUSSION CHAPTER XXXI PERCUSSION While inspection relates to the diagnosis of physical conditions through the sense of sight, and palpation through the touch, percussion refers to the act of tapping the chest, thus setting up vibrations which may be appreciated by the examiner through the sense of hearing. Nothing can so signally characterize the skill of the physician in phy- sical diagnosis as ability to perform percussion. Success can be obtained only by a thorough acquaintance with the normal percussion boundaries of the various organs and by the unvarying observation of a careful technic. Failure is accounted for by lack of familiarity with the anatomy of the thorax and its contents, as well as by neglect to adhere rigidly to prescribed methods. A perfect knowledge of the principles of percussion as applied to the normal chest is a necessary preliminary to any consideration of abnormal conditions. Despite familiarity with the theory of percussion, conspicuous skill can be secured only by continued practice. It is the intelligent technic, perfected by long experience, which serves to bring forth the sound vibrations, and enables the physician to recognize important analytic differences and to acquire confidence in the results of his examination. It is not so much the possession of a keen musical ear which some regard .as a sine qua non, as a well-trained sense of hearing with relation to the recognition of a few simple elements of sound. The sound elicited by percussion may be regarded as either resonant or non-resonant. Whenever the air contained within aerated bodies is set in vibration by percussion, the sound produced is always resonant in character. If percussion is 'practised upon solid bodies, the sound is at once recognized as non-resonant, and is described as flat. Flatness, therefore, should not be included as one of the varieties of resonance. Organs containing but little air may give rise to a diminished resonance which is called dulness. All resonant sounds may be classed with reference to four important characteristics — inten.sity, pitch, quality, and duration. Intensity refers to the extent or volume of the vibrations, and is ■commonly classified as loud or faint. This varies directly with the force of the blow, the thickness of the intervening soft parts, and the volume of the underlying lung. If the percussion blow is gentle, the vibratory intensity may be slight or inappreciable, while very powerful percussion tends to obscure the resonance by inducing vibrations in distant parts of the organ. A stronger blow is necessary to elicit audible resonance in some chests than in others. It must follow that the force of the percussion must be adjusted in all cases to the conditions presented at the time of the examination. It is obvious that the intensity must vary with the thickness of the soft parts overlying the aerated lung. Well-marked muscular develop- ment and thick layers of adipose tissue diminish the loudness of the tone and require somewhat harder percussion. A lessened intensity is noted over the scapulae because of the intervening bony formation 12 178 PHYSICAL SIGNS and the thick muscles of the back. Percussion, if attempted ovei" a large mammary gland, is usually unsatisfactory. On the other hand, gentle percussion upon the thin chests of emaciated incUviduals and in children is sufficient to awaken resonance of decided intensit}'. Other things being equal, the intensit}' is increased in proportion to the greater volume of lung on account of the larger amount of con- tained air. For this reason the resonance is more intense below the clavicles than above. Pitch refers to the length of the vibrations, and is described as low- when the vibrations are long, and high when they are short. This is the most important eleyncnt of sound from a diagnostic standpoint, and is often a source of great confusion to studc7its. It should be borne in mind that pitch bears no absolute relation to intensity. Sounds may be loud or faint, and )-et have precisely the same pitch. The lowness or highness of pitch is, of course, pureh'^ relative. The pitch obtained in aU pathologic states within the thorax is higher than in a normal chest. For the sake of convenience, the pitch in health should be described as relatively low. As there takes place a greater relative amount of solid to air in a given portion, the resonance becomes dull and higher in pitch. The pitch may also be elevated upon per- cussion over bodies of air, but this is accompanied by change in quality. Difficulty is usually foimd in descrilnng precisely what is meant by the qualiti/ of a sound. It refers to a peculiar character of the vibra- tions, dependent upon the precise construction of the air-containing body in or from which the sound is produced. Thus the quality of the sound produced by the flute, the piano, the violin, etc., varies according to the detailed construction of the instrument from which the sound is emitted. The quality of the sound from a piano, for instance, cannot adequately be described to a person who has never heard it, yet one who has been familiar, even to a slight degi-ee, with musical instruments can recognize instantly the sounds produced by a piano or other instrument in an adjacent room, not because of their intensity or their pitch, but wholly as a result of their peculiar incUvidual quality. The pitch may be high or low, the sound may be loud or faint, and yet no difficidty is experienced in differentiating its quality or character. As the quality of tones emitted by musical instruments is dependent entirely upon peculiarities of structure, .so the character of the sound obtained by percussion of the normal chest is incident to the anatomic con- struction of the air-containing organs. The term " vesicular resonance " naturally has been given to the vibrations emanating from the air- vesicles of the normal lung. This is to be chstinguished from the so- called " tympanitic resonance " obtained upon percussion over large bodies of air. AU resonance is either vesicular or tympanitic in quality. As the quality changes from vesicular to tympanitic, the pitch is corre- spondingly higher. In comparison with intensity, pitch, and quality, duration is of but slight importance as an element of percussion resonance, although of great value in the analysis of auscultatory sounds. Generally speaking, the duration of the vibrations increases with the intensity and dimin- ishes with the elevation of pitch. To elicit intelligent percussion resonance certain methods of pro- cedure should invariablv be followed. PERCUSSION 179 RULES FOR THE PRACTICE OF PERCUSSION RELATING TO THE PATIENT AND TO THE EXAMINER Rules for the Patient. — The patient, whether sitting or standing, slioulcl be in an attitiule of repose. The shoulders should not be thrown too far back, and the muscles of the neck or chest should not be put in a position of undue tension. It is necessary that the shoulders and arms be held symmetrically. The head should not Ije inclined to either side, and the face should be directed straight ahead. It is sometimes per- missible for the face to be turned slightly to one side while percussing at the apex, particularly if there is noticeable retraction at this point. Opportunity is thus offered for more satisfactory percussion. Care should be observed, however, to avoid turning the face or inclining the head sharphj to either side, as this gives rise to overstretching of the muscles and consequent interference with percussion resonance. It is often desirable that the patient should sit during percussion, and rest the back against a straight-backed chair. In examining the anterior axillary region the arm may be drawn slightly backward, and in percussing the posterior lateral region the arms may be held a little to the front. When the back is examined, the patient should fold the arms, placing each hand upon the opposite shoulder, with the elbows held as near together as possible in order to spread the scapulce. This is particularly important in emaciated people. The patient is then requested to lean slightly forward, rounding the shoulders and upper part of the back like a bow. If the patient is examined in bed, attention should be paid to the maintenance of a symmetric position of the shoulders and hips. Rules for the Physician. — These refer to the avoidance of percus- sion instruments, to the position of tlie pleximeter finger, the manner in which the lilow is dealt by the hammer finger, and the position of the examiner himself. Avoidance of Percussion Instruments. — It is almost unnecessary to state that the student and practitioner should dispense entirely with all mechanical devices for the purposes of percussion. None of the instruments of varied form and character has been found equal to the fingers of the examiner. It is much easier to avoid beginning the employment of pleximeters and hammers, than it is to be compelled to chspense with their use subsequently. Those who are skilled in percus- sion with the fingers rarely, if ever, need i-esort to mechanical appliances. On the other hand, those who are accustomed to these instruments are sadly handicapped when obliged to percuss with their fingers. The only possible advantage of pleximeter and hammer in any case is to increase intensity, but the actual need for this seldom exists. In many instances their use is contraindicated because of inability to apply the instruments to small localized areas. Thus, in emaciated inchviduals, with prominent ribs and sunken intercostal spaces, the pleximeter cannot be perfectly adapted to the surface of the chest. It is also impossible, by the use of these devices, to distinguish finer differences in sound when percussing; from the ribs to the intercostal spaces. In children their use often serves only to frighten the child and to render the examination more difficult. Percussion with the fingers, however, is not attended with any of the disadvantages of pleximeter and hammer, and in many cases a^rds 180 PHYSICAL SIGNS a distinct aid to the examiner. The fingers are not lost, broken, or forgotten, and can be applied to any portion of the chest, and rarely frighten even the most timid child. An opportunity is afforded to appreciate the resistance of the part percussed, which, of course, is impossible with any other form of pleximeter. The Position of the Pleximeter Finger. — Especial care should be taken, when comparing the two sides of the chest, to percuss in symmetric regions. Thus the pleximeter finger should not rest upon one side over a rib and upon the other in an interspace; if so, a difference in the resonance will at once be recognized. The percussion should be made upon the middle finger of the left hand, which should be firmli/ placed against the chest-wall. If due attention is not paid to this important feature, the resonance will be diminished appreciably in intensity, and in many cases will partake of a peculiar quality, to be later described as the " cracked-pot resonance." A slight lifting of any portion of the finger may be sufficient to produce this characteristic sound, therefore the pleximeter finger throughout its course should be firmly pressed against the thorax. The other fingers of the hand should lie slightly raised from the surface of the chest, in order to avoid interference with the sound vibrations. Nearly all authorities have directed that the particular part of the pleximeter finger upon which the blow should be dealt is the distal phalanx just back of the nail. This I have found to be decidedly less desirable than the second phalanx, for several reasons. The bone is much thicker and broader in the second phalanx, and affords a better medium for transmitting the vibrations. Other things being equal, those physicians make the best examiners who have large fingers with thick bones. The greater amount of soft tissue on the dorsal aspect of the last phalanx affords a cushion for the reception of the blow, thereby diminishing materially the intensity of the resonance. The distal phalanx just behind the nail, which is invariably recommended, is more sensitive to repeated percussion blows than the dorsal aspect of the second phalanx. My attention was first called to the disadvantage of the distal phalanx, because of the inflammation resulting from con- stant percussion upon this part, and recourse was had to the second phalanx, which was subsequently found to possess the advantages previously described. The pleximeter finger should be applied with equal and uniform force when comparing the two sides of the chest. Unless this precaution is observed, striking differences in resonance will often faO of recognition. In examining at the apices, particularly with the patient standing, it is sometimes difficult to adapt the pleximeter finger to the fossae above the clavicles in ca.se of emaciation or marked apical retraction. In such cases the pleximeter finger of the left hand sliould be applied to the left apex, with the examiner in front. In this posi- tion there is usually no difficulty in adapting the pleximeter finger to the left side, while considerable trouble is experienced in applying the finger to the right apex of the patient. Under these circum- stances, when percussing the right apex, it has been my custom to stand behind and to the right of the patient. Percussion should proceed along perfectly straight lines, as. if practised at random over the thorax, it avails nothing. In searching for the percussion boundaries of certain organs it is necessary to proceed toward the PERCUSSION 181 known anatomic border in a line at right angles with it. It is also of advantage in some cases to keep the pleximeter finger parallel to the border which it is desirea to outline. The Manner in lohich the Blow is Dealt. — Comparativelj^ little atten- tion is paid by the average practitioner to this feature of percussion, and it is largely for this reason that incorrect results are so often obtained. The principle to be observed in dealing the blow is to deliver it quickly, the fingers instantly rebounding like the hammer upon the pianoforte when the keys are struck. The blow should be repeated three or four times in quick succes.sion. The slightest lingering of the hammer finger upon the pleximeter finger is sufficient to interfere materially with sound vibrations, and thus modify the resonance. As sometimes practised, the hammer finger or fingers are allowed to remain upon the pleximeter finger while the examiner listens to ascertain the character- istics of the resonance. It is much better that the middle finger of the right hand should serve as the hammer and not permit the other fingers to be in contact with it. The blow should be dealt with the bulbous tip, this portion striking the pleximeter finger always at a right angle. It is imperative that a uniform amount of force be used in delivering the blow, as slight variations may result in failure to bring out striking differences of percussion. One of the most important considorations pertaining to percussion relates to the region from which the hammer motion is made. All writers who have mentioned this subject have 182 PHYSICAL SIGNS laid stress upon the fact that the blow should be directed entirely from the wrist-joint and never from the elbow. In so far as relates to the avoidance of any elbow movement this contention is, of course, correct. It is also true that there must necessarily be some motion, no matter how slight, from the wrist-joint, but the point is made that for successful percussion the best residts are obtained by a gentle tap emanating very largely from the carpophalangeal articulation. In Figs. 28 and 29 will be noted respectively the incorrect and the proper method of per- cussion. The relative merits of light and heavy percussion many times have been discussed. There can he no difference of opinion that, save under very exceptional circumstances, gentle percussion is far more satisfac- tory. This being so, there seems to be little occasion for dealing the blow from the wrist. This usually results in lifting the finger and hand as a single piece of mechanism farther from the chest than is necessary to bring out clear vibratory resonance. In most instances a gentle tap, raising the hammer finger not over one to two inches from the pleximeter finger, will suffice. The PositL07i of the Examiner. — Percussion should not be attempted unless the physician is perfectly comfortable, otherwise attention is almost unconsciously distracted from his work. When comparing the two sides of the chest, he should stand either directly in front of or behind the patient, in oi-der that the sound may proceed to him from equally distant points. He should not attempt to percuss while bencUng over the patient, as the resulting rush of blood to tlie head interferes to some extent with the sense of hearing. He should endeavor, as far as possible, to maintain the same relative position with reference to the patient when percussing various parts of the chest. If the patient is standing, the examiner may stand also, care being taken, however, to lower his own body when examining the bases, particularly if the patient is short. If very tall, however, the patient should sit while the physician examines the apices and upper portions of the chest. Often he may be alile to examine the lower portions of the thorax with ease if the patient is standing. If the person examined be very short, the physician should so lower the body that his hands may be applied with ease to the part examined. PERCUSSION OF THE NORMAL CHEST There is no fixed or arl)itrary type of percussion resonance for the normal chest. Each person necessarily has to furnish his own standard, and it is only by a comparison of corresponding parts of the chest that deviations from the normal can be ascertained. Regional differences are noted in intensity, pitch, and quality. The supraclavicular region exhibits less intensity of resonance than many other parts of the che-st, as there is less volume of lung beneath the part percussed. A diminution of vesicular qualit}' is often pronounced near the inner or sternal aspect of the lung, on account of proximity to the trachea, which contains a relatively large volume of air. As the vesicular quality diminishes and the tympanitic element becomes more defined, the pitch correspondingly rises. The characteristics of apex resonance are lessened intensity, slight admixture of the tympanitic with the vesicular quality, and a somewhat higher pitch. PERCUSSION 183 Similar changes are recognized upon percussion of the clavicle itself. The intensity is much weaker at its outer or acromial end, while the quality is relatively more tympanitic and the pitch higher at its sternal end. In the infraclavicular region, extending from the clavicle to the third rib, the intensity is usually greater than in any other part of the chest, the quality distinctly vesicular, and the pitch low. It is possible in some instances to recognize, however, a very slight tympanitic ele- ment, with a little elevation of the pitch, in the upper sternal region from nearness to the primary bronchi. The characteristics of normal resonance are identical upon the two sides of the chest in this region, as contrasted with the striking differences tlisplayed below the third ribs. The pre.sence of the underlying right auricle to the right of the sternum does not give rise to any differences in percussion resonance because of the overlapping lung. The right and left mammary regions must be considered separately on account of essential differences between the two sides. Upon the right, the resonance is diminished in intensity on account of the thicker pectoral muscles in the male and the presence of the mammary gland in the female. The quality is purely vesicular, and the pitch low. The intensity is further lessened from the level of the fifth rib to the base of the lung, by reason of the untlerlying liver. This organ rises to the fourth interspace, and in the mammary line is covered by lung to the sixth ril). The diminished resonance, however, does not cor- respond with its upper border, the area of hepatic dulness not extending higher than the fifth rib in the iiuiinmary line. This is explained by the fact that the volume iif lung ('(n-ering the liver from the fourth to the fifth ribs is sufficient to conceal effectually the percussion evidences of the deep-lying non-aerated organ. In the left mammary region the resonance is modified by the presence of the heart. In this locality a portion of the heart lies directly beneath the chest-wall. The apex is concealed by a thin, tongue-like projection of lung of insufficient volume to permit vesicular resonance. The upper portion of the heart upon the left sifle is covered with a layer of lung, gi\iim- lisc ti> ]iercussion resonance. Aldiig the thin edge of the overhi])piii,u luiiu the resonance presents diftciciH'cs IVom the normal in pitch, (lualit)-, and intensity, by virtue of wiiirli lieviations an area of cardial' dulness is recognized. Over the portion of heart in immediate contact with the chest-wall there is entire absence of resonance, this region being known as the area of cardiac flatness. The boundaries of the areas of cardiac dulness and flatness will be given presently. The resonance elicited upon percussion over the very upper portion of the sternum is slightly tympanitic in quality, owing to the proximity of the trachea. Much confusion exists in the minds of students and many practi- tioners as to the normal resonance over the sternum, especially from the second to the sixth ribs. This is one of the most important regions of the whole chest, and should always be the first locality explored upon percussion. Underneath the sternum, between the second and fourth ribs, the anterior borders of the pleura of the right and left sides lie immediately adjacent to each other. While the right pleura descends almost ver- tically to the attachment of the sixth rib, the left leaves the sternum 184 PHYSICAL SIGNS at the lower edge of the fourth rib and travels obliquely outward and downward across the chest. The anterior border of the left lung also recedes outwardly from the sternum opposite the fourth rib, and descends obliquely outward and downward. The anterior border of the left lung also recedes outwardly from the sternum opposite the fourth rib, and descends abruptly to a point near the anatomic apex of the heart, where it sweeps forward and downward to cover the apex, i. e., the so-called lingula pulmonalis. A portion of heart denudetl of lung and pleura lies in immediate apposition to the inner aspect of the sternum, between the fourth and sixth ribs. On the right side it is covered by the corresponding lung. The lower portion of the sternum overlaps the left lobe of the liver, and in some instances a portion of the stomach. In view of these anatomic relations it might be supposed that the resonance from the second to the fourth rib should be entirely different in character from that found over the lower portion of the sternum, and that a similar variation should exist upon percussion to the right and left of the mecUan line from the third to the sixth rib. Imaginary differences in permission resonance over the sternum have been described by different writers, but, as a matter of fact, there is only a very slight change in resonance between the second to the fourth rib and the fourth to the sixth. Generally speaking, there is absolutely no difference between the resonance to the right and left of the median line. The sternum is an excellent conductor of sound, and transmits almost equally throughout its entire surface, as low as the sixth rib, the resonance derived from the underlying lungs. For practical pur- poses the resonance over the sternum should be regarded as uniform from the .second to the sixth rib. Dulness from the fourth to the sixth rib must be construed as evidence of such underlying pathologic con- ditions as pericardial effusion, displacement, hypertrophy or dilatation of the heart, just as dulness in the upper portion is suggestive of aneurysm, a possible distention of veins from valvular chsease, and other causes. An area in the left anterior lateral region, along the lower margin of the ribs, is known as Traube's semilunar space. This is bounded above by the lower border of the lungs, below by the colon, on the left by the spleen, and on the right by the left lobe of the liver. Per- cussion in this region may show a tympanitic quality, with corresponding elevation of pitch, thought to be transmitted from a more or less dis- tended stomach or colon. In the lateral regions of the chest the percussion resonance is usually intense — more so than in any other portion save the infraclavicular. The quality is vesicular, and the pitch relatively low. In the back the percussion changes at the apex are not especially different from those in front, the variations in pitch and quality being recognized more readily near the spine. In the interscapular spaces the intensity is somewhat diminished, on account of the thickness of the deep muscles of the back; the pitch is .slightly raised, and the quality less distinctly vesicular by reason of the closeness of the trachea and large bronchi. Percussion resonance over the scapulse is relatively dull because of the thickness of the wing-like expanse of bone and soft parts. In the infrascapular region, on account of the thickness of the soft parts, there is recognized a PERCUSSION 185 diminution of intensity sometimes necessitating the use of iieavy per- cussion. In minutely comparing corresponding portions of the chest it should be borne in mind that at the apices, front and back, and in the iippir iiilrr- scapular regions, there exists a normal disparitij betiveen the tiro sides, the right being slightly higher in pitch, /f.s.s vesicular in quality, ami inlh diminished intensity. i Percussion Boundaries. — In describing the percussion outlines of the lung it must be understood that there is not always an exact correspondence between the anatomic borders and the resonant boun- daries. The upper limit of percussion resonance is about an inch and a half above the level of the clavicle, although some little variation may exist in different individuals. The practical consideration as to the height of the lung in any case relates chiefly to the amount of unilateral contraction, .suggesting an existing or a preexisting tuberculous process. The lower border of the lung upon the right side in the parasternal line is at the fifth rilj; in the mammary line, at the sixth, and in the axillary, at the seventh. The inferior border of the lung behind is at the level of the eleventh rib at the vertebral column. In these localities pulmo- nary resonance ceases, the liver flatness usually affording a sharp line of percussion demarcation between the two organs. As previously stated, however, the line of hepatic dulness begins one rib higher than the upper border of hepatic flatness. In this area the volume of lung is not large enough to produce the ordinary type of normal vesicular resonance. The change in the lower border of resonance upon inspiration and expiration is called the active vioiiUHy of the lungs. Upon expiration the lung tloes not meet the attachment of the pleura. Upon full inspiration, howe^'er, it descends to this point, completely filling the space formerly occupied by the diaphragm and costal borders. With returning oxjiii'Mtion tlio diaphragm ri.^es and the sides of the chest-wall retract, (iblitnatiui; the sd-callcd •■ comple- mental space" of Gerhardt. Oppoii unity is thus art'i>iun(is in the former are more intense, with iiccs in ]5itch and duration, makes it some- r to compare the sounds of inspiration with expedient to flisciii • ( breathing. It i> usi Klllv 1m istics of bron<'hi:il li ivallnii fact that the I'c^pii- lty the ]:iatient. In ex])irHt 1(111 the intensity is notably less than that of inspiration, and the ]iiirli i.- likewise lower. The quality does not partake of the same breezy chuructcr of inspiration, and for lack of a better terminology may be regarded as blowing in type. The duration is much shorter than the act of expiration, and is less than the time consumed in inspir- ation. Without attempting a detailed explanation of the reasons why these differences exist between inspinition and expiration, it is sufficient to impress upon the beginner the lad tliat they actually occur. Le Fevre has admirably explainetl that in nispii'atidn, which is an active function, the vibrations are conducted through the column of inspired air in the bronchial tubes to the air-vesicles, the sound being also traiisniitted by the ever-increasing tension of the bronchial and pulmonary tissues during the progress of inspiration. Expiration, on the other hand, is a passive motion, the direction of the air-current being away from the ear of the examiner, and the tension of the tissues constantly diminish- ing as expiration advances, thus minimizing the sound transmission. VESICULAR RESPIRATION Inspiration . . . Intensity. Pitch. Duration. Quality. -1- + + Vesicular. Expiration . . - - - Blowing. Some clinicians do not recognize essential differences in the quality of inspiration and expiration, and others describe the expiratory sounds as differing only in increased harshness. To my mind the quality of the expiratory sound differs somewhat from the inspiratory, but not in the way of greater harshness. The term appears to be an unfortunate one, for harshness often conveys to the mincl an idea of increased intensity. This is diminished invariably in expiration, and for this reason, if for no other, it is better not to employ the word "harsh" to describe the quality of the expiratory sound. This may properly be applied to a certain modification of normal vesicular respiration, often designated as puerile breathing, which refers to increased intensity rather than to other essential deviations from the normal. Employing a diagrammatic illustration of vesicular resj^iration the plus mark, in contrast to bron- chial breathing, will lie found to denote the intensity, pitch, and dur- ation of inspiration rather than of expiration. Regional Differences. — The most important modification of vesicular respiration is observed at the apices. Upon examination of either lung at the apex the inspiration is recognized as less intense than below the clavicle, the pitch higher, the quality less vesicular, and in .some cases the duration not quite so long. The expiratory sound in this region 202 PHYSICAL SIGNS is more intense than in the lower parts of the chest, the pitch higher, the quality a modification of the blowing and the tubular, and the dura- tion somewhat prolongeti. The change from the vesicular and the blending with the bronchial \'ariety in some cases may be so pronounced as to justify the appellation " bronchovesicular respiration." It is important to cinpluifiize the jact that there is a normal disparity between the tivo apices, the modification of the vesicular tjipe and the approach to the bronchial being more marked upon the right side than upon the left. At the right apex the inspiration is less intense than at the left, the pitch higher, and the equality less vesicular. The expi- ration is more intense, of higher pitch, antl more prolonged upon the right side. This physiologic difference in the auscultatory signs at the two apices is a matter of the utmost importance, and .should constantly be borne in mind in order to avoid possible mistakes in the diagnosis of incipient apical tuljerculosis. A slight change, as described, at the right ajiex may not be possessed of any special diagnostic significance, while a diminished intensity, elevation of pitch, and diminished vesicular cjuulity of inspiration, with a corresponding increase of intensity, still higher pitch, and prolongation of expiration upon the left side con- stitute positive evidence of a pathologic condition. Many patients have been sent to a distant clime on account of a supposed right apical tuberculosis, although upon examination there was found but an exagger- ation of the physiologic disparity between the two sides, without even subjective evidence of tuljerculous invasion. Some presenting unmis- takable evidence of constitutional impairment have been sent away from home with a diagnosis of a tuberculous lesion at the right apex, yet the signs of active infection were confined to other regions. These inaccm-acies sometimes occur for the reasons that physicians are in the habit of examining more carefully at the apices than in other places; that the normal difference between the two sides is often unappreci- ated; and that modifications of the normal breath-sounds are frequently recognized at the right apex, while in other parts adventitious sounds or rales are entirely overlooked because of neglect to utilize cough, which constitutes a \'aluable aid in auscultation. An appreciable retraction of the apex, with change in percussion resonance, is often of material aid in forming a correct conclusion. The recognition of moisture at one apex following a cough clears all tloutit as to the presence or absence of abnormal conditions. In the axillary or infra-axillary region the intensity of the inspiration is quite as loud as below the clavicle, being greater in these two places than in any other part of the chest. The pitch, if anything, is lower than in the infracla\-icular region, and the quality somewhat more vesicular. There is no difference between the two sides in this region. Over the scapulse the sounds of inspiration and expiration are less intense than in almost any other locality. Differences in pitch, quality, and duration are le.ss easily recognized in this region because of the (liniinished intensity. There is no disparity to be recognized between tlie two sides. In the interscapular spaces the intensity of the breath-sounds is nearly as great as in the infraclavicular or axillary regions. There exists a slight difference lietween the two sides, similar to the disparity noted at the apices, though less in degree. Normal Voice-sounds. — In describing the soimds of respiration. AUSCULTATION 203 attention was directed to the types of breathing heard over the trachea and the chest. In the same manner the sound produced by the spoken voice should be studied with reference to its characteristics when heard over the trachea and over the normal chest. Vocal Resonance over the Larynx or Trachea. — If the stethoscope is applied to the skin and the patient directed to say " ninety-nine, " there is conveyed to the ear of the examiner a disagreeable sensation of shock or fremitus, associated with a distinct appreciation of concentration and nearness. The sound is sometimes intense, but this is subject to some variation. These essential features are analogous to the sound obtained over the chest in certain states of disease. A fuller description of the sound of the spoken voice, to which the term "bronchophony" is ap- plied, will be reserved for subsequent pages. Vocal Resonance over Normal Lung. — With the stethoscope placed firmly against the chest during phonation, the auscultator is enabled to distinguish a vibration, although receiving no impression of shock or fremitus. There is no suggestion of concentration or nearness, the sounds appearing diffused and as if coming from a distance rather than emanating directly under the stethoscope. The vibration is found to increase directly with the loudness and harshness of the spoken voice, the le.sser thickness of the soft parts, and the firmer pressure of the instrument against the skin. Men afford much better illustrations of the vocal resonance than women. The resonance varies in different portions of the chest, it being more pronounced at the apices than elsewhere, and more upon the right side than upon the left. The Whispered Voice. — The stuilent should listen to this over the lar}mx and the normal chest, the sountls heard in the former location resembling closely those recognized in the presence of certain pathologic changes in the lung. It will be understood that, in whatever region auscultation is practised, the whispered voice can differ but little from the sound of expiration. As the only difference relates to intensity, but brief reference need be made to the characteristics of the whispered voice. Over the trachea the sound is shrill, high pitched, more or less intense, and tulnilar in quality, suggesting a current of air driven forci- bly through a tube. Occasionally, while listening in this region, it is easy to recognize the words uttered by the patient. During auscultation of the normal chest it is often impossible to distinguish the sound of the whispered voice. If recognized at all, the pitch is low and the quality blowing. At most an impression is received of a faint, low- pitched, whispered sound, without ability to recognize what is said by the patient. The same regional differences regarding the whispered voice are found to exist as obtain with the spoken voice. AUSCULTATION IN THE MIDST OF PATHOLOGIC CONDITIONS The study of auscultation in disease should be conducted with reference to the breath-sounds and those of the spoken voice, both aloud and whispered. Auscultation of the breath-sounds includes two distinct considerations — pathologic modifications of the normal respiratory sounds, and adventitious sounds, commonly described as rales, which are never present in health, save in .senile atelectasis. Modifications of Normal Respiratory Sounds. — Just as the study of the breath-sounds in health involves analytic comparisons of 204 PHYSICAL SIGNS the intensity, pitch, quality, and duration of inspiration with expira- tion, so in the midst of morbid conditions the same form of procedure should be emploj'ed in order to detect deviations from the normal. Rather than attempt to classify the various abnormal types of breath- ins by the use of descriptive names, as "emphysematous breathing," "asthmatic breathing," "cog-wheel breathing," etc., which method is often employed, I will group the various pathologic modifications with reference to changes in intensity, pitch, quality, and duration. This would seem to be the more simple and natural method, and it is lioped will appeal to students in being easily understood. Changes in Intensity. — This may be entirely absent, somewhat chminished, or perceptibly increased. It should be understood that in many instances changes of intensity bear not the slightest relation to differences in pitch, quality, or duration. The sounds, however, may be so feeble and faint as to afford no oppor- tunity for further study. Entire absence oj breath-sounds may result from the same causes which, if present to a less extent, merely suffice to produce a diminution of intensity. Complete suppression of the respiratory sounds may take place in pleurisy with effusion, closed pneumothorax, pneumopyothorax, pneumonic consolidation, entire occlusion of primaiy bronchi, either from aneurysm or mediastinal ulaiids, in pulmonary edema, or the fill- ing of air-vesicles with extia,\a-atc(l blood. Diminution of Intentuhi nj R, spiratort/ Sounds.-— The breath-sounds may be enfeebled by reason of changes acting upon the outer or inner walls of the bronchi, accumulations within the bronchi, pathologic con- ditions in the lung tissue, within the pleural cavity, or in the wall of the thorax, involvement of the nerves, and influences preventing the descent of the diaphragm. The outer walls of the bronchi may be subject to compression from mediastinal glands, aneurysms, new-growths, or greatly dilated hearts. The inner walls are affected by catarrhal conditions inducing a thickening of the mucous membrane or involving exudative processes sufficient partially to occlude the lumen. An accumulation of thick tenacious mucopus may obstruct the caliber of the tube to such an extent as to diminish the intensity of the breath- sounds. The presence of blood or serous secretions within the finer tubes may produce a like result. The most important change in the lung resulting in an enfeeblement of the respiratory sounds is the lessened elasticity of tissue taking place in long-standing emphy.sema. In early or so-called compensatory emphysema the tension of the pulmonary tissues is increased and the breath-sounds are correspondingly more intense, but as the emphysema becomes chronic, a reverse effect is noted. Through the loss of elas- ticity or retractile power the respiratory excursion is gradually dimin- ished. Reduction of inten.sity forms one of the chief characteristics of the emphysematous type of breathing. With this there are associated definite changes in the duration, the inspiratory .sound being shortened and the expiration prolonged. The shortening of in.spiration takes place at the beginning of the inspiratory act rather than at the end, as is found in bronchial breathing. There are no changes recognized as regards pitch in this form of respiration, neither is the quality affected materially, although the vesicular character is somewhat less distinct. AUSCULTATION _ 205 There is another form of breathing, similar in many respects to the emphysematous variety, occurring in the course of asthma. This develops as a result of spasm of the muscular fibers encircling the bronchial tubes. Like emphysematous breathing, the inspiration is shortened at the beginning of the inspiratory act and the expiration is prolonged, l)ut the intensity is usually greater than in the purely emphj'sematous type. There is recognized no change in pitch, and it is very diflicult to appreciate changes in C(uality, as loud adventitious sounds usually obscure other elements. The rales occur both during inspiration and expiration, are dry in character, and are called either sibilant or sonorous, respectively, according as they are high or low in pitch. Diminution of respiratory sounds may also be occasioned by consolidation, either partial or complete, as in pneumonia, pulmonary tuberculosis, compression of lung from pleural effusion, new-growths, and hemorrhagic infarcts. The changes within the pleural cavity capable of reducing the inten- sity of breath-sounds relate to the presence of liquid or air, as in pleural effusion, hydrothorax, pneumothorax, and pneumopyothorax. In pleurisy with but little effusion the liquid remains at the base of the pleural cavity, reducing slightly the intensity of the respiratory sounds in this region. As the effusion becomes more extensive it is molded around the lung, interposing between it and the chest-wall a layer of liquid through which the respiratory sounds must pass before reaching the ear of the examiner. In hydrothorax or dropsy of the pleural cavity the liquid remains at the dependent portion of the chest and obscures the breath-sounds in this locality. If air is present in the pleural cavity, the diminution of intensity is dependent to a great extent upon the existing type of pneumothorax. In the closed \;uict>' thf l)rc;ith- sounds are diminished or absent, but if there is a ficc opcniim intu a bronchial tube, varying degrees of intensity are exhiliitcl(> confirmatory evidence is afforded by study of the expiration, wliicli in bronchial breathing is still higher pitched and of tubulai- (|uality, and in the emphysematous variety of lower pitcli and \-esic\il,ii- in ([uality. Prolongation of the Expirntinn . — 'i'liis (iccairs in lour (y])es of breath- ing — the bronchial, eniplnseinatoiis, ca\iTii(Mis, .and amphoric. A recog- nition of the particular \aiiet\' ol' icspirat inn i- nliiaiiieil liy reference to pitch and quality. In lirouclnaj lavadiing the prolonged expiration is high pitched and tubular in (|uality: in the emphysematous form it is low pitched and faintly vesicular; in the cavernous type it is low pitched and blowing, while in the am|ilinric it is low pitched and mu.sical. A fairly accurate estimate of the \:iiiet\- ol lespiration in the presence of prolonged expiration can be made iVom the jiiidi and <|uality of the expiration itself, without reference to (lie inspiration, in dotibtful cases it is of vast service to note the dillerence of pitch in expiration and inspiration, the higher pitch with the iiil)iil,ir qualit\- oi ex)iiration suggesting lironchial breathing, and the relati\e lowncss of pitch with blowing quality denoting cavernous respiration. 210 PHYSICAL SIGNS Change in the Rhythm of Respiration. — In addition to changes in duration there is occasionally observed a variation of rhythm. This form of interrupted breathing is sometimes called "cog-wheel respira- tion," having a jerky, irregular inspiration. The impression is given that there is some mechanic hindrance to the free entrance of air to the alveoli, and during inspiration an effort is apparently made to overcome an obstruction to the passage of air through the finer tubes, Formerh- more importance was attached to the presence of this physical sign than at present. Interrupted breathing may be recognized as either general or local. If general, but little significance need be attached to its recognition. In such cases it is due to imperfect acts of breathing, either from pain, as in pleurisy and intercostal neuralgia, or occurs in nervous people and in those especially fatigued. It is quite frequently observed in women who are more or less nervous and embarrassed at the time of examination. When obtained over a localized area, it may be regarded as evidence of some obstruction in the finer bronchi, due, no doubt, to the thickened mucous membrane or to valve-like occlusion of the tubes from masses of secretion. This explains its not infrequent presence in cases of incipient apical tuberculosis with catarrhal bronchiolitis. Rales. — Rales are distinguished from the foregoing modifications of normal auscultatory sounds in being entirely different from those produced in health. They are much easier of detection than the modifi- cations of normal sounds, yet their presence is very frequently over- looked by reason of faulty technic. This is shown in failure to examine the entire chest and in neglect to utilize cough immedlatelii preceding a sharp inspiration. While rales are often recognized upon easy respira- tion, those which are of the utmost importance in diagnosis are elicited in many instances only by the employment of cough. This is particularly true of early apical tuberculosis before the development of extensive tissue change. In innumerable cases a sufficiently positive diagnosis of pulmonary tuberculosis can be made by the detection of unilateral rales before the appearance of other ph3'sicai .signs and prior to expectoration. There exists an unfortunate laxity of method in the classification of rales. This entails exceeding confusion antl doubt in the minds of students as to the significance of various rales and their method of origin. Some authors classify rales according to dryness or moistiu-e; others point out distinctive cUfferences in their qualitj-, pitch, or inten.sity, or make use of purely descriptive terms. The best plan seems to be a classifica- tion according to anatomic location, with qualifying descriptions with reference to moisture and dryness, and a final analysis according to size, quality, and time. I am well aware of the deficiencies and limitations of any .system of nomenclature, and can claim no special originality for the method to be presented. It is the one, however, that, in teach- ing, I have followed for many years and have found to be more satis- factory than any other on the score of simplicity. Rales may be divided according to their anatomic location as follows: the tracheal, bronchial, vesicular, cavernous, and pleural. These are .subject to further clas.sification according to moisture or dryness, size, quality, and time. Tracheal Rales. — These maj' be either moist or dry. Moist tracheal rales are produced by the presence of liquid in the trachea through which the air passes with each respiratory act. They are heard both AUSCULTATION 211 on inspiration and on expiration, and occur more frequently in the moribund state, at which time they constitute what is commonly called the death-rattle. They are also found in states? of coma in which the sensibility of the mucous membrane is so benumbed as to preclude an effort toward expulsion. Moist tracheal rales, both in children and adults, are sometimes heard even at a distance from the patient. This is particularly true in late stages of pneumonia, when the secretions accumulate in the trachea and give rise to loud bubbling sounds. It is not true that the existence of these rales necessarily presupposes the death of the individual. Prompt emesis in children very often suffices to remove the liquid in the bronchial tract to such an extent as to cause for a time the entire disappearance of tracheal rales. Recovery is not impossible even in adults, despite the ominous import of the death-rattle. In croupous pneumonia remarkable results are sometimes obtained even in the very midst of impending death through recourse to prompt and thorough venesection. It seems little short of miracu- lous to observe the wonderful improvement which immediately ensues in some cases following relief to the right heart and engorged pulmonary circulation. The Dry Tracheal Rale. — This variety is not produced like the preceding, by the passage of air through liquid, but its origin is incident to conditions closing to a variable degree the lumen of the trachea or producing some deviation of contour. Dry rales emanating from the upper respiratory passages may result from affections of the glottis, as spasm or edema, and from the presence of an exudative process, as in diphtheria. They may also be produced by large masses of tenacious secretion adhering to the wall of the tube over which the air passes, the sounds having a more or less distinctive character. The existence of a tumor encroaching upon the lumen of the trachea for the same reason cau.ses this type of rales. It is remarkable how an extremely small new- growth within the interior of the trachea may cause these adventitious sounds. The dry rale is entirely devoid of the bubbling character of the moist variety, and may be described as whistling, squeaking, wheezing, or stridulous. Moist Bronchial Rales. — These are produced by the passage of air through liquid in the bronchial tubes, and may be heard l^oth in inspira- tion and in expiration. Appreciable differences are recognized in size according as the rale originates from a large, medium-sized, or small tube. The chief distinguishing (h.-iractcristics of these rales are their bubbling character, their ine- be recognized with a lesser degree of consolidation than necessary for tlie production of bronchial breathing. Egophony. — Egophony is a modification of bronchophony, produced by the presence of liquid intervening between compressed lung and the chest-wall, as in pleural effusion. Two important characteristics of egophony are its high pitch and its concentration. The sensation of concentration is opposecl to the diffuseness of normal vocal resonance, but the nearness of bronchophony is replaced by an impression of distance. There is superadded to these features a certain tremulous- ness which has been described as analogous to the bleating of the goat, hence the derivation of the name. It is not always heard in cases of pleural effusion, but is often detected near the level of the liquid when the effusion is of but moderate size. It is sometimes present over con- solidated lung, but does not con.stitute a sign of special moment. Pectoriloquy. — This refers to the audible transmission to the examiner not only of the sound of the spoken voice, but also the words themselves. This sign may be elicited in the presence of con.solidated lung, pulmo- nary cavities, and occasionally open pneumothorax. Pectoriloquy does not involve necessary changes in intensity, pitch, or quality, but usually partakes more or less of the bronchophonic characteristics peculiar to con- solidated lung, and sometimes suggests the cavernous voice. The Cavernous Voice. — This is not an important sign, and is worthy of only the merest mention. The cavernous voice is heard chiefly when pulmonary excavation has taken place in the midst of indurated lung tissue. The sound is more or less intensified, with a certain admixture of the bronchophonic element. Wlrile it does not pos.sess the distinct high-pitched shock of bronchophony, it is materially different from the simple increase of intensity heard over cavities in the midst of normal lung tissue. The Amphoric Voice. — The essential characteristic of this physical sign consists of its musical intonation, which is dependent upon the presence of a body of air within a resonant cavity. It is heard more frequenth' in pneumothorax than in anj' other condition, although it may be recognized occasionally over large pulmonary cavities with unvielding walls. AUSCULTATION 217 The Whispered Voice. — The normal whispered voice has been ilescribed as exceedingly faint, soft, and low pitched, corresponding to the sound of expiration in vesicular respiration. It seems unnecessary to enumerate in detail the modifications of the normal whispered reso- nance which take place in disease, in view of the fact that the changes are almost identical with those described with reference to the spoken voice. It is sufficient to repeat briefly that the whispered resonance may be studied with regard to changes of intensity, pitch, and cjuality. The intensity may be diminished or absent from the same causes which produce enfeeblement of the sound of the spoken voice, although the whispered resonance may be entii'ely absent when the spoken voice is readily appreciable. Even in health it is so feeble as scarcely to be heard, save over the regions of the primary bronchi. The intensity may be increased from partial consolidation of lung or the presence of a pulmonary cavity. When due to slight pulmonary consolidation, not only is the intensity increased, but the pitch is more or less elevated and the quality slightly bronchial. The change in pitch and quality is due to the fact that the whispered voice is precisely iden- tical with the sound of expiration, save for the increased intensity. This increased transmission of the whispered voice with associated elevation of pitch and tubular quality constitutes a very valuable sign in the exami- nation of patients who are too feeble to breathe as desired, or who are afflicted with aphonia. An increased intensity of the whispered voice is often appreciable before recognition of bronchial or bronchovesicular respiration is possi- ble. When this is due to the presence of a cavity in the midst of com- paratively normal lung tissue, the intensity is noticeably increased, but the pitch remains low and the quality slightly blowing, the sound being described as the cavernous whisper. The high pitch and tubular quality of the whispered voice over thoroughly consolidated lung are sometimes described as the increased bronchial whisper, or whispering bronchophony. Over a pulmonary cavity of considerable size, surrounded by indu- rated pulmonary tissue, the whispered voice partakes to a certain extent of the characteristics of whispering bronchophony. Whispering pectoriloquy may be heard over the site of a pulmonary cavity, especially if superficially located, and also, though less often, over consolidated lung. The whispered resonance may assume a musical echo, and is spoken of as the whispered amphoric echo. Sometimes an appreciation of a distinctly musical intonation can be obtained more easily with the whi.spered resonance than with the spoken voice. 218 PHYSICAL SIGXS SECTION II Physical Signs of Pulmonary Tuberculosis chapter xxxiii general considerations There exists no conventional standard of physical signs common to all cases of pulmonary tuberculosis. The extent and character of phy- sical evidences are so varied in different incUviduals as to preclude the conception of a definite type or combination of signs. Irrespective of the subjective symptoms, the former may be so slight as scarcely to be recognizable upon rigid examination, and, on the other hand, so numer- ous and complex as to represent a remarkable variety of morbid changes. Pulmonary tuberculosis with its complications may admit of every pos- sible sign referable to intrathoracic disease in general. Some consump- tives, on the other hand, present every external appearance of health and vigor, displaying either extensive destructive change or compara- tively insignificant physical signs. The range of possibilities as to what may be observed upon inspection, palpation, percussion, and auscultation is almost infinite. It is mani- festly impracticable to attempt the description of any group of phj-sical signs, or even of a single manifestation, which may l)e accepted to be of general application in consumption. Current medical literature upon the diagnosis of pulmonary tuberculosis is replete with classic descrip- tions of the various physical signs, which too frequently are grouped without expression as to their respective frequency or importance. Obvi- ousl}-, an arbitrary classification of signs without regard to their con- stancy or significance affords no proper accentiuition of their compara- tive value. Failure to discriminate regarding their relative importance has led to much difficulty and delay among students and iir;Mtitioners in establishing an early diagnosis of the disease. Mall^ >ii:!i-^ i > >!nnionly regarded as characteristic of phthisis are singularly iiK iin~i,int (u devoid of definite interpretation, while others, actually pathognomonic in import, are elicited only upon correct methods of examination. It is essential, therefore, in portraying the physical signs of pulmonarv tuberculosis, to depict certain features with especial clearness in the foreground, in order to afford a proper perspective. Signs of frequent occurrence and conspicuous significance should be contrasted prominently with those of minor importance and uncertain interpretation. As a matter of fact, the physical evidences of early pulmonary phthi- sis do not refer essentially to slight ileviations from the normal apical boundaries upon percussion, nor to doubtful modifications of the respira- tory murmur. Several physical signs arising from a slight deposit of tuber- cle at one apex have been described by writers with infinite pains, but their practical value is often vastly subordinate to that of other objec- tive manifestations, the im])ortance of which is not always appreciated. It should be remembered that in very incipient phthisis gross patho- logic change capable of detection by means of physical examination is comparatively infrequent, the area involved being of such minute size EARLY CASES 219 and depth from the surface as to preclude recognition even by the most skilled examiners. Furthermore, the foci of infection are sometimes scattered to a considerable extent and separated from one another by- intervening lung tissue, which is either of normal character or the sub- ject of slight degree.s of compensatory emphysema, rendering still more obscure the detection of finer structural change. In applying to pulmonary tuberculosis the general principles of physical diagnosis enumerated in the preceding section, each sign will be considered separately, but an effort will be made to dwell at length only upon features of decided practical importance. It is believed that more of real interest and value will accrue to general practitioners from a review of the more common factors of supreme significance, than from the perusal of pages devoted purely to a recapitulation of the ultra- refined aspects of physical diagnosis. The latter are of exceptional occurrence, of cUfficult recognition, and sometimes of doubtful impoit. It is affirmed with cniphasis that failure to detect the evidences of pul- monary tuberculosis i^ nr imasured to a great extent by the amount of moisture in the lironcliinl tul)cs. In cases of moderate tuberculous infection the air-content in a given area is diminished by virtue of a partial consolidation of lung. As a direct result of the abnormality of tissue, cUstinctive changes are recognized in the physical signs. Upon inspection there is rarely noted in individuals conforming strictly to this class a marked degree of emaciation, pallor, dyspnea, or cyanosis. There may be slight flushing of the cheeks, according to the extent of vasomotor disturbance, and moderate loss of weight, but the more important visual appearances are referable to the thorax proper. These changes are often sharply localized, and consist of unilateral devia- tions from the normal contour of the chest and of arrhythmic respira- tory movements. Inasmuch as the tuberculous process usually elects the apex as its favorite site of invasion, the asymmetric conditions are observed more frequently in the upper portion of the chest. Conspicu- ous retraction of the supraclavicular fossa is often accompanied by flattening of the chest immediately below the clavicle. This Stands out with greater prominence than its fellow of the opposite side, and the acromial end is appreciably elevated. The upper intercostal spaces may liecome accentuated from atrophy of the thoracic muscles upon the affected side, and a characteristic drooping of the shoulders may be noted, although less frequently than among cases with advanced infec- tion. In addition to the altered configuration of the upper part of the thorax there may be observed localized impairment of respiration. In some cases this may consist of a diminished respiratory excursion, and in others of a retardation of the movement. While irregularity of con- tour is readily noted upon casual observation, a rigid comparative 224 PHYSICAL SIGNS scrutiny of the two sides is sometimes necessary to detect changes in the respiratory movement. They are recognized more easily if inspection be made with the examiner standing behind the patient and looking over the shoulders, to observe the simultaneous bilateral excursions. A dis- tinct apex retraction is indicative of a long-standing lesion, while a mere retardation of movement without retraction suggests the existence of a recent infection. Palpation may confirm the results of inspection with reference both to contour changes and to modifications of the normal respiratory act. It may be practised by laying the tips of the fingers in the supracla- vicular fossa, with the thumb upon the vertebra, the patient in the sitting position, and the physician standing behind. In this manner differences in the inspiratory expansion at the apices are noted with- out difficulty. Information may be secured not only with respect to inequalities of respiratory excursion, but also as to the degree of con- solidation, by virtue of the more ready transmission of voice-sounds through a partially solid medium. This is subject to considerable variation, as has been described in connection with vocal fremitus. The percussion signs in cases of moderate tuberculous involvement relate to differences in quality and intensity and to the changed resonant boundaries. It must be remembered that each person fur- nishes his own standard of resonance, as has been described. As there is no ideal type of percu.ssion resonance common to all individuals, deviations from the normal can be recognized only by a close comparison of the two sides. Attention is again called to the necessity of discrimi- nating closely between the dulness and elevation of pitch upon the right and left sides respectively. Owing to the physiologic variation at the two apices a slight impairment of resonance at the right apex is of much less significance than at the left. The normal disparity is such that it is sometimes impossible, in case of right-sided dulness, to distinguish, upon percussion alone, between a possible exaggeration of the dissimilarity in health and a localized tuberculous infection. Dulness at the left apex, however, is highly significant of tuberculous change. Difficulty may arise in recognizing the dulness incident to small areas of tubercle deposit, owing to tlie vicarious emphysema of adjacent pulmonary tissue. Deviations from the normal percussion outlines, while of great clinical interest in the more advanced cases, particularly if associated with extensive fibrosis, are not invariably pronounced in instances of moderate infection. In such the variations relate especially to the supraclavicular fossae. In health the lung rises above each clavicle to a distance of about an inch and a half, differences Ijetween the two sides being rarely observed. An appreciable unilateral diminution of the height of the pulmonary resonance may be ascribed to the shrinkage incident to tuberculous infiltration and fibrosis. The lateral apical boundary is of importance, as well as the height of the resonant lung. This has been described at length by Kronig, Minor, and other clinicians. In many cases of unilateral disease the diminution of the resonant area is somewhat striking. While it is impossible to state with absolute accuracy that the shrinkage is of long standing, it is undoubtedly true that in the majority of instances the tuberculous process is of fairly remote rather than of recent origin. It is more a matter of clinical interest than of actual diagnostic value, for the I'eason that a tuberculous change in the apex sufficient to produce a well-defined variation from CASES WITH MODERATE INVOLVEMENT 225 the normal percussion outline must almost invariably be attended with auscultatory signs capable of ready recognition. A pronounced disparity between the apical percussion boundaries upon the two sides may exist in the entire absence of tubercle deposit. Recently I have had occasion to note a conspicuous instance of apical shrinkage as determined upon percus.sion, which, without the aid of the a:-ray, would have led to a deplorable error of diagnosis. A man of twenty-five with an unfortunate family history of tuber- culosis accompanied to Colorado, in the latter part of 1906, a sister in advanced phthisis. The patient speedily succumbed to the disease, and the survivor presented himself for examination and opinion before venturing to return permanently to an unfavorable climate. There were no symptoms suggestive of pulmonary involvement, and the physical examination was negative, save for a well-defined dissimilarity in the apical jjercussion boundaries. The e.xtent of shrinkage at the right apex is shown in the ;icconijiunying phototjraph (Fig. 37). Upon j-ray the apical percussion outlines, suggesting a tuberci ticonfirmed Dy j-ray examination. (See radiograph, Fig. 44.) examination, however, it was found that a well-marked thickening of the right mediastinal pleura had taken place, resulting in pronounced traction upon the pulmonary tissues at the apex, without evidence of tubercle depo.sit. The skiagraph (Fig. 44) is presented upon p. 252. In this connection an interesting clinical phenomenon is shown in Fig. 38, which illustrates a very material apical shrinkage noted upon inspection. The patient, aged twenty, was sent to Colorado January 17, 1907. In spite of a loss of seventeen pounds in weight, with persisting fever anfl slight cough, the physical and bacteriologic examinations failed to disclose the slightest evidences of tuberculous infection. The apical percussion borders were perfectly normal, despite the extreme visible retraction upon the right side. Another patient, aged twenty-seven, arrived in Colorado in the latter part of 1907 with dis- tinct physical evidences of pulmonary tuberculosis. The shrinkage of apical percussion boundaries was pronounced at the right apex, 15 226 PHYSICAL SIGNS although the other physical signs pointed to an absence of tuberculous infection at this region. Signs of slight infiltration with moisture were detected, however, in the left lung, especially from the third rib to the Fig. 38.— PronouiiL-ed right apex, without tuberculous involv base. Upon .r-ray examination it wa.s found that the tuberculous process was limited solely to the left lung, without evidence of apical involve- ment upon either side. The extent of the dissimilarity of percussion out- lines at the apex is shown in Fig. 39. In Fig. 6 are shown practically Fig. 39. — Pronounced shrinkage of the outline of percussion absence of tuberculous involvement in this region. Pliysical ev perfectly detined in left lung. (Compare with radiograph, Fig. 53. uniform resonant boundaries at the two apices upon careful percussion. If anjrthing, the area of resonance was slightly smaller at the right apex. Reference, however, to the skiagraph (Fig. 45) reveals an appreciable CASES WITH MODERATE INVOLVEMENT 227 shadow at the right apex, suggesting the liiveliliood of a greater dif- ference in the percussion borders than was found to exist. A patient, aged twenty-eight, was sent to Colorado in October, 1907, for sus- pected pulmonary tuberculosis, presenting a history of pulmonary hemorrhage. Despite a well-marked shrinkage in the outline of per- cussion resonance at the left apex, physical examination of the chest was in other respects entirely negative. The bacteriologic fincUngs were also negative. After several weeks a pronounced hemoptysis took place, apparently adding to the significance attaching to an unquestioned disparity in the apical outlines. The outlines of per- cvission resonance upon the two sides are shown in Fig. 40. As illustrative of the very pronounced unilateral apical shrinkage in connection with advanced tuberculous change the following case is of some interest. A young man came under my observation in the Fig. 40. — Easily recognized change summer of 1907, presenting physical evidcuics of rather extensive tuberculous involvement of the right huii;. witli slight infiltration in the upper left. The extent of visual unilateral ictraction may be noted by reference to the accompanying photograph (Fig. 41). By comparing with Fig. 56, an explanation of the shrinkage is found in the destructive tuberculous change at the apex. In view of the experience afforded by the observation of the above and similar cases, it is apparent that the .significance of the percussioti outlines at the apices is subject to considerable variation. The auscultatory signs of moderate infection are modifications of the normal respiratory murmur, advontitiou.^ sounds or rales, changes in the vocal resonance and in the whispered voice. Modifications of the normal respiratory sounds partake of the general type of bronchovesicular respiration, which has been described. 228 PHYSICAL SIGNS True bronchial breathing is rarely observed in cases of partial con- solidation, although the bronchial element may markecUy predominate over the vesicular. The changes relating to intensitj', pitch, duration, and quality of the inspiratory and expiratory sounds have been dwelt upon at such length in the preceding chapters that further description is unnecessary. It must be remembered that the recognition of bron- chovesicular breathing at the right apex is possessed of far less signifi- cance than at the left, owing to the physiologic difference between the two apices. The adventitious sounds or rales incident to this class of cases may assume the same general characteristics as those occurring in incipient stages, being of an explosive, crackling type and recognized at the end of inspiration following a cough. More frequently, however, they are distinctl}' moist and bubbling, exhibiting variations in size and easily appreciable without cougli during expii-ation as well as inspiration. Fig. 41. — Pronounced visual retraction, right apex. (Compare witli cavity formation shown The rales may be elevated in pitch and consonating in character, denoting their origin in bronchial tubes surrounded by indurated pulmonary tissue. The physical signs pertaining to the spoken voice represent impor- tant changes in the vocal resonance over the partially solidified lung. The degree to which the voice-sounds are exaggerated in intensity and modified in pitch and quality, has lieen explained to vary materially according to the extent of con.sojidation. A very important sign is the inten.sification of the whispered voice in the presence of slightly con- solidated lung. This increased transmission, together with a slight elevation of pitch and change of quality, antedates considerably the recognition of bronchovesicular breathing. It is sometimes possible to detect an increased intensity of the normal heart-sounds on account of their conduction through solidified lung. ADVANCED CASES CHAPTER XXXVI ADVANCED CASES Patients conforming to this group usually exhibit a striking com- bination of physical signs. Exploration of the chest is important not so much as a means of diagnosis as a matter of clinical exactitude and as a feature of prognosis. Although extensive cavity formation may be present in some individuals exhibiting every external evidence of health and vigor, yet in a large number of cases the general appearance of the patient is highly suggestive of the disease. Emaciation, pallor, dyspnea, and cyanosis are often proiiduiiccd. The skin of the body may be dry, harsh, or even scaly, and \\\c liaiuls thin, cold, and clammy. The fingers may be elongated, with tapciiim cxl icmities and incurving nails, or the ends distinctly clubbed. The lucU is thin and appears n area of well-defined visual piU.sation in a patient w the left lung, with marked fibrosis. Note the slight deflection of i toward the unaffected side. (Compare with radiograph, B'ig. 79.) unduly long. The ears stand out prominently from the sides of the head, and are often waxy, bloodless, and almost transparent. The breathing is at times labored, with the action of the accessory muscles of respiration prominently displayed. The nose may be pinched, the eyes sharp and bright, the hair dry and lusterless, and the face pallid, cyanotic, or flushed. The complexion is sometimes remarkably pale and clear, exhibiting strikiiiiily a delicate plexus of superficial veins. The patient fi-e(|uen11y assumes a, piniKiuuced stonpiug posture, the general attitude being that oi iiuuked debility. In addition to the drooping of the shoulders, the pcapulse are very conspicuous and suggest the oft-noted resemblance to wings. The changes noted upon inspection, with 230 PHYSICAL SIGNS especial reference to the thorax, aside from its occasional conformity to the phthisical habitus, partake chiefly of flattenmg, retraction, and impaired mobility. These differences may affect chiefly one side or involve the entire chest. Unilateral shrinkage may be sufficient to transform completely the contour of the thorax and greatly restrict the respiratory excursion. There may be resulting curvature of the spine and dislocation of the sternum. If the contraction change is present to a marked degree upon the left side, a large portion of the heart is denuded of its pulmonary covering, and there result visual pulsations in the third or fourth interspaces. The cardiac apex impulse is also subject to considerable dislocation, being pulled toward the affected side, as has been described. The changes observed upon inspection are subject to ready con- firmation by palpation, which also serves to elicit certain points of tenderness and a notably increased fremitus. Rhonchi from the Fig. 43. — Representing visual cardiac impulse in a patient witli ver>- advanced tuberculous change in the left lung. The tuberculous process in this lung has been of long duration, and the fibroid contractile change is very pronounced. The wavy, undulatory impulse is detected through- out the larger circle, whereas the inner represents the location of a very pronounced impulse. bronchial tubes may be recognized in some cases with the hand laid against the chest- wall. Percussion may yield information of a varied and definite character, but this method of examination alone is incapable of affording an exact diagnosis of the morbid pulmonary conditions. In advanced consump- tion percussion changes may relate to the entire disappearance of pulmo- nary resonance, diminution of inten.sity, elevation of pitch, and cUffer- ences of quality. Total flatness results from an area of complete pulmonary con- solidation, but it is seldom that a single lung is solidified to the same degree throughout its entire area. Complete absence of resonance in pulmonary tuberculosis may also be due to complicating pleural effu- sions or pneumopyothorax, as well as to solid lung and thickened pleura. Diminished intensity of pulmonary resonance exists wherever the air-content is appreciably les.sened in a given portion of the chest, and is observed in connection with an elevation of pitch. Small deei)-seated areas of partial consolidation may escape detection because of the reso- nance of intervening normal lung tissue. Therefore the location and ADVANCED CASES 231 size of the involvement are factors of considerable importance as regards the resulting changes in percussion resonance. Owing to the thick muscles of the back, it is impossible to elicit dulness upon gentle per- cussion unless the area of consolidation be of considerable size. Save at the apices, it is doubtful if changes of percussion resonance can be noted over a superficial area of less than four or five centimeters in diameter, or at a depth of over four or five centimeters from the surface. The manner of percussion and the variations of resonance have already been sufficiently discussed. Differences in quality involve necessarily a diminution of the vesicu- lar element and a corresponding increase of the tympanitic. Owing to the varied physical conditions obtaining in the midst of the destruc- tive change incident to advanced consumption, the resonance may be purely tympanitic, assume the cracked-pot character, or present an amphoric intonation. Strictly speaking, the cracked-pot and the amphoric resonance constitute forms of the tympanitic, differing from it only by virtue of certain modifying attributes. In consumption the recognition of any one of these three varieties is suggestive of the pres- ence of a pulmonary cavity. As has been shown, however, percussion signs are of but little value in the determination of this condition. The purely tympanitic type may occasionally be observed in late consump- tion over large cavities, and rarely over a consolidated upper lobe, as a result of the transmission of air vibrations from the trachea and primary bronchi. The descriptive appellation " cracked-pot' ' resonance has frequently Ijecn iciianlcil as definitely pathognomonic of pulmonary excavation. While this ,si,i^u may be elicited now and then in the percussion of pul- HKjuary cavities, it represents but comparatively little value as a cavity sign per se. As previously stated, it is frequently absent over pulmonary cavities, and is often obtained when no cavity exists. The conditions responsible for the production of the peculiar musical intonation characterizing amphoric resonance have been described. In addition to elevations of pitch commonly noted over consolidated lung, certain modifications are sometimes recognized over localized areas in the later stages of consumption. The various changes of pitch elicited during percussion of pulmonary cavities have been described sufficiently under General Physical Signs. In the midst of extensive fibrosis the normal percussion boundaries are sometimes distorted to a remarkable extent, this being particularly true of the heart. The influence of intrapleural conditions in producing changes of percussion outlines will be discussed in connection with Complications. Upon auscultation in the miflst of advanced infection there may be found the greatest ]H,ssili|c drxiatiou lioni the normal respira- tory sounds and those of tlic sjiuki'ii ami wliispered voice. The inten- sity of the breath-sounds may lie diininislied in some cases through narrowing of the lumen of the bronchi from tubercle deposit, and in others through the accumulation of thick, tenacious secretions in the tubes. They are reduced at times by an associated omphysema, an accompanying pleural effusion, or extensive plemiiii' adhc-ions. In addition to the marked thickening of the pleura with coiii rui tiim changes incident to fibrous tissue proliferation, there may exist an obliteration of terminal bronchioles as a result of the cicatrizing process. The 232 PHYSICAL SIGNS breath-sounds are rarely suppressed altogether in consumption, though this may result upon one side from the temporary' occlusion of a bronchial tube. They maj- be absent also in areas of complete pneumonic consoli- dation, excessive fibroid change, pleurisy with large effusion, closed pneu- mothorax or pyopneumothorax, and severe pulmonary edema. Among consumptives an increased intensity of the respiratory sounds may be recognized in one lung when the respiratory function of the other is impaired to a great extent as the result of disease. This vicarious or supplemental type of respiration may obtain over small localized areas, not uncommonly at the apices, and is due to the compensatory activity of the non-tuberculous tissue. It is rarely recognized by clinicians over circumscribed regions, although patches of emphysema in tuberculous lungs are exceedingly numerous at autopsy. The chief distinguishing characteristics of the bi-eath-sounds in advanced phthisis relate to changes in pitch and quality, which are included under bronchial, bron- chovesicular, cavernous, amphoric, and the metamoi-phosing respiration. These types of breathing have been described at length under the Gen- eral Physical Signs. Changes in the duration of the sounds are sometimes observed, but these are of slight practical importance in comparison with the more striking respiratory changes during advanced tuberculous involvement. Interest attaches to the shortening of the in.spiration and the prolon- gation of the expiration incident to bronchial breathing, and the length- ened expiration of cavernous respiration. The rales of ad\'anced phthisis are of medium size or coarse, and bubbling or gurgling in character, in contradistinction to the finer clicks or crackles recognized in early cases. They are heard upon easy breath- ing, the cough being by no means a necessary factor for their production, save in areas of recent involvement. They are high in pitch in pro- portion to the degree of pulmonary consolidation. The adventitious sounds do not, as a rule, dcihe their origin from the finer tubes, except in freshly infected icuidn-;. The size of the rale corresponds to the size of the tubes and tlic |iiiliii()ii;ii\- cavities from which the sounds emanate. When the cavity ha^ atiaiiiiMl a fair size, the rale becomes gurgling in character and metallic tinkling is not altogether uncommon. The vocal resonance i~ usually nuich intensified in advanced phthisis. As a result of the consolidation of lung or the pre.sence of pulmonary cavi- ties, changes in the pitch and ciuality of the spoken voice are also recog- nized, characterizing bronchophon}- and pectoriloquy. While the sound heard over cavities in the midst of pulmonary consolidation may par- take of the bronchophonic character to some extent, bronchojjhony is heard chiefly over soliilified lung. In the same manner pectoriloquy may be recognized over areas of both consolidation and excavation. Attention has been called to the changes in the whispered voice as a result of tuberculous infiltration and cavity formation. Pulmonary cavities may occasion a marked increase in the intensity of the whispered voice, without necessarily invoh'ing appreciable changes in pitch and quality. Over thoroughly consolidated areas, howe\-er, the whispered resonance becomes high pitched and tubular in quality, corresponding to the sound of expiration in bronchial breathing. Whispering pecto- riloquy and the whispered amphoric echo maj' also be recognized. It may be well to recapitulate briefly the physical signs of pulmonary cavities, but it must be remembered that their recognition in many ADVANCED CASES 233 cases is not nearly so simple as would appear from text-book descrip- tion. There may be detected occasionally, upon percussion, tympanitic resonance, amphoric resonance, or cracked-pot resonance; Wintrich's change of pitch; Wintrich's interrupted change of pitch; or Gerhardt's change of pitch. Upon auscultation there may be elicited cavernous breathing, vesiculocavernous breathing, bronchocavernous breathing, amphoric breathing, gurgling cavernous rales, metallic tinkling, increased vocal resonance, with or without bronchophonic characteristics, pecto- riloquy, amphoric voice, the cavernous whisper, and whispering pecto- riloquy. Many of these signs may be recognized under conditions other than pulmonary excavation, and, on the other hand, cavities. may exist with- out the recognition of a single physical sign. They may be detected with ease at certain periods and escape recognition at other times. The very fact of the interraittency of the physical signs furnishes exceed- ingly strong evidence of pulmonary excavation. Failure to recognize the physical signs in such cases is explained either by the presence of large masses of mucopus in the tubes, completely obliterating their cali- ber, or by the filling of the cavity itself with purulent secretion. PART IV DIAGNOSIS AND PROGNOSIS SECTION I Diagnosis CITAPTER XXXVU PRELIMINARY CONSIDERATIONS Diagnosis is by far the most important consideration pertaining to the general subject of pulmonar}- tuberculosis. In no other disease is this of more surpassing moment. It is scarcely conceivable that any uncertainty should exist in the recognition of moderately advanced phthisis, for the history, subjective sj-mptoms, and physical signs present a clinical picture so typical as almost to preclude the possibility of error. Even when the constitutional symptoms are, perhaps, of doubtful import, the diagnosis is comparatively simple in the vast majority of instances through recourse to the physical signs, bacteriologic evidences, .r-ray examination, and, when necessary, the tuberculin tests. The incipient cases present the only reasonable difSculties in the way of accurate diagnosis, and it is in precisely this class that the early recognition of the disease is of the utmost consequence. Consumption has been shown to be a distinctly curable disease in the sense of its permanent arrest. It is known that a large proportion of the human race at some time in their lives imconsciously harbor tuberculous lesions, and that complete recovery frequently takes place by virtue of an inherent tendency exhiliited by the individual toward an encapsulation of the tuberculous process. The practical effectiveness of the natural constructive forces which constitute the fundamental basis of any successful effort toward arrest depends very largely upon the time of the definite recognition of the disease and the adoption of rational management, an early diagnosis usually insuring a good prog- nosis. While strikingly gratifying results may sometimes be secured even among far-advanced cases, a uniformly successful issue may be expected only in the incipient stages. Early cases of tuberculous infection are of vastly greater importance than those of the advanced type, by virtue of the more favorable ultimate prognosis and the avoid- ance of an indefinite period of invalidism. The majority of consumptives •with slight involvement may justly anticipate an arrest of the t\ibercu- lous process and a more or less complete restoration of their former health and vigor. It follows that the direction of such cases is vested 234 PREUMINARY CONSIDERATIONS 235 with the assumption of greater responsibility than attaches to the management of desperate patients, for whom the future holds but little hope of restoration to their former activity and usefulness. Thus, for humanitarian and economic reasons, early diagnosis assumes a position in the general consideration of consumption of infinitely more momentous consequence than any other phase of the tuberculous prob- lem. No further commentary is required upon the fiequency of delayed diagnosis than my repoi't, a few years ago, of an analysis of 1700 cases of pulmonary tuberculosis observed in private practice. A more heterogeneous lot of consumptives it would be impossible to imagine. A large majority of the.se were of an advanced type, and many died shortly after arrival. A vast number were in greatly impoverished circumstances. Physical signs of advanced tuberculous infection were found in each lung in 69.1 per cent, of the cases, while in 53.05 per cent, there were presented unmistakable symptoms of severe systemic dis- turbance, including the fever of mixed infection, emaciation, weak and rapid pulse. The physical signs of excavation, in addition to the above, warranted their classification as advanced cases. From a critical analysis of the history, which may be accepted as definitely accurate, it was found that twenty and one-third months was the average period of delay following the clinical onset before arrival in Colorado. It is, indeed, lamentable that thousands of lives are sacrificed annually on account of the tardy recognition of tuberculosis and the deferred institution of energetic management. It is charitable to believe that this distressing exhibition has been occasioned through inability to appreciate the significance of the rational symptoms, to recognize accurately the physical signs, and to interpret properly their import. An explanation of the surprising lack of familiarity with some of the considerations pertaining to the diagnosis of pulmonary tubercu- losis is found in a superficial knowledge of the fundamental principles of practical medicine. ]\Iention may be made of failure to elicit essential historic facts, to emphasize and group rational subjective symptoms, and to observe correct methods of physical exploration. A faulty technic in the examination of the chest may result from inadequate training or insufficient care. In the majority of cases the available data for diag- nosis have been amply sufficient to warrant its provisional establishment long before the medical attendant has awakened to a realization of his responsiliilities. This is partly explained by the fact that many cases of consumption exhiljit a slow and insidious onset, not calculated to inspire apprehension on the part of the patient. Frequently the symp- toms are not such as to awaken the suspicion of the physician, and the physical examination, if made at all, is practised in so superficial a manner as to preclude ;i(Tiirato i-csults. In many cases this is not conducted until a provision.il diuiiiiusis is apparent from the constitu- tional symptoms. At liiui-s the onset may be so acute in character as to simulate other diseases, and obscure, for a considerable period, the true nature of the affection. Perfect accuracy of diagnosis may be established by the recog- nition of the tubercle bacillus, but not always before the destruc- tive process has become advanced and the constitutional disturb- ances pronounced. The physical signs occasionally furnish indubitable evidence of a recent active infection long before bacilli appear in the sputum. In other cases the history and subjective symptoms 236 DIAGNOSIS AND PROGNOSIS afford provisional, if not conclusive, evidence of a latent concealed lesion despite the absence of bacilli and of well-defined physical signs. Early diagnosis is a matter of great simplicity when bacilli are demonstrable, but their presence in the sputum is dependent upon case- ation of the tuberculous area and upon their evacuation by way of a small bronchus. Thus it happens that there is not always a uniform relation between the bacteriologic evidences and the physical signs. It is not unusual to discover bacUli when no physical evidence of exist- ing tuberculous involvement can be obtained, even upon the most rigid examination. On the other hand, the microorganisms may be exceedingly scanty or absent altogether, when an apparent activity of the disease is shown by the physical signs and general subjective symp- toms. Later the bacilli may become decidedly more numerous, not- withstanding a pronounced improvement both in the pulmonary and in the general conihtion. I have under my care at the present time a gentleman who Olustrates such possibility. Upon arrival in Colorado without having secured improvement during six months' residence in a well-known sanatorium, he exhibited a daily temperature elevation with consitlerable dyspnea upon exertion. Examination of the chest disclosed the presence of extensive active tuberculous involvement of each lung. Upon the right side the affected area extended from the apex to the fourth rib and to the lower edge of the shoulder-blade; on the left side, from the apex to the fifth rib in front, and from the apex to the very base behind. Throughout these regions fine and medium- sized moist rales were easily recognized after a cough. The expectora- tion, amounting to about two ounces in twenty-four hours, con- tained very few Ijacilli. The patient has gained forty poimds in weight, presents no fever at any hour of the day, coughs but little, and has comparatively slight expectoration. There is marked improve- ment in the general health, and examination of the chest reveals a pro- nounced gain in the tuberculous process, yet the bacilli have increased to an amazing degree, all specimens of sputum being literally "peppered." ('H.\PTER XXXYIII PROVISIONAL DIAGNOSTIC FACTORS Attention is directed to tlie consideration of early diagnostic fea- tures, which antedate, in some cases, the appearance of bacilli or the recognition of well-defined physical signs. These factors relate to the family as well as the personal history, and include opportunities for infection and the influence of previous diseases. FAMILY HISTORY A tuberculous family history was formerly regarded to be of great diagnostic significance, but its importance is known to have been vastly exaggerated. While a degree of clinical interest attaches to a record of tuberculosis among immediate antecedents, it is extremely doubtful PROVISIONAL DIAGNOSTIC FACTOKS 237 if any reliable conclusions can be adduced as to the greater likelihood of infection by virtue of hereditary predisposition. To say the least, no authentic evidence has thus far been presented to establish an invariably increased susceptibility to the disease among the descend- ants of individuals eventually succumbing to pulmonary phthisis. Unfortunately, as a result of the misleading import of an excellent family history, many a consumptive has been compelled to pay the penalty of a grossly delayed iliagnosis with the chances for recovery greatly reduced. Others in perfect health, yet with knowledge of ante- cedent infection, have supposed themselves under an impending shadow of disease and endured unceasing apprehension. As a matter of diagnosis per se, a tuberculous family history has but slight, if any, import, though in some cases it should not be regarded as altogether valueless. A negative family history is unworthy of the slightest consideration in an effort to establish a diagnosis in the midst of obscure conditions. Per contra, a positive history, unless especially pronounced and extending to brothers and sisters, should not unduly influence a diagnosis otherwise more or less doubtful. There should be the same unequivocal interpretation of physical signs and the same diagnostic significance attached to subjective symptoms in all cases, regardless of the fancied influence of inherited predisposition. ACQUIRED PREDISPOSITION By acquired predisposition is meant an added susceptibility to the disease through the operation of certain causes w liich tliminish individual resistance. Among these are included overwork, either physical or mental, oppressive cares and responsibilities, sleepless nights, despon- dency, alcoholic or sexual dissipation, financial reverses, domestic infelicities, social excesses, and a multitude of burdens incident to our modern civilization. The influence of these several features of every- day life in preparing the soil for a non-resistant reception of tubercle bacilli is too thoroughly recognized to warrant elaboration. Further- more, the relation of these component factors to the general problem of tuberculous transmission has been discussed at some length under Conditions Influencing Infection. Their practical significance from the standpoint of diagnosis, in ca.ses admitting of reasonable doubt, should ever be borne in mind. It is apparent that a thorough investigation concerning the previous environment in connection with associated facts pertaining to the history may furnish information of decided diag- nostic value. OPPORTUNITIES FOR INFECTION A review of the personal history should include a scrupulous search for all possible sources of individual infection. This necessitates an inquiry into details which is frequently tedious, but nevertheless essential. An all-important consideration relates to the intimacy of contact, if any, with a consumptive. Upon admission of such associa- tion the investigation .should proceed concerning the time that this existed, the condition of the patient, the final termination, and the disposal of the sputum. In many instances equal significance may be attached to the presence of phthisical patients in workshops, stores, and offices, as in the family. Surprising difficulty is sometimes 23S DIAGNOSIS AND PROGNOSIS experienced in an effort to elicit information of a reliable character concerning the possibilities of infection from contact with infected invalids. An account is often given of the death of a relative from so-called "bronchitis," "asthma," "pneumonia which did not clear," "chronic pleurisy." "general debility," especially in the aged, "child- birth," etc. A careful inquiry will frequently disclose the history of a prolonged illness, characterized by pulmonary hemorrhages, fever, night-sweats, progressive emaciation with persisting cough and expec- toration, thereby revealing the true nature of the disease. The existence of tuberculosis, either in the family circle or within the immediate business environment of the incUvidual, having been demonstrated, it is desirable to ascertain regarding the intimacy of association. If affecting husband or wife, sisters or brothers, informa- tion should be secured as to whether or not the two occupied the same apartment or the same bed. Often it is found that one was engaged in nursing the other, and confined for many hours by day and night within the sick-room, which, perchance, was overheated and insufficiently ventilated. The duration of the period during which close associa- tion took place possesses considerable interest. If prolonged during several months, the suspicion of an acquired infection would be i-endered greater than if for a relatively short time. The likelihood of contract- ing the disease varies somewhat according to the condition of the patient. Some consumptives with incipient or moderate involvement and a small amount of tuberculous sputum constitute but a slight element of danger to their associates. Others with advancing exca- vation, excessive expectoration, and marked physical exhaustion inci- dent to the later stages represent a constant source of peril to those about them. By far the greatest importance relates to the information acquired concerning the disposal of the sputum. This factor alone measures to a great extent the degree of clanger attaching to the presence of a pulmonary invalid. If the receptacles for expectoration be ordinary cuspidors, handkerchiefs, rags, or newspapers, the possibilities of infec- tion are, indeed, sufficiently obvious. Many patients, however, imagine that they are scrupulously careful in this matter, although, upon inquiry, they are found guilty of gross hygienic errors. Very recently I have questioned' a lady of the utmost refinement who protested that she observed extraordinary precautions with reference to the sputum. I soon foimd that she coughed a great deal in the night, and was in the habit of spreading newspapers upon the floor at the side of the bed upon which to expectorate. The enormity of the offense was intensified by the presence, in the family, of a year-old baby. The practical consideration regarding the sputum relates not so much to its chemic disinfection as to keeping it moist, for if evaporation can be prevented, the danger of infection is reduced to a minimum. Expectoration into shallow cuspidors with small apertiu-es and broad upper surfaces is almost as bad as, if not worse than, upon new.spapers, as adherent particles of sputum are frequently allowed to remain for an entire day. The small sputum-cups at the bedside, even though con- taining water or strong disinfecting solutions, are notoriou.sly inade- quate unless covers are provided. It is almost impossible for the bed- ridden consumptive resorting to the use of these receptacles to deposit the sputum directly into the solution, as inevitably a portion will cling PROVISIONAL DIAGNOSTIC FACTORS 239 tenaciously to the sides of the cup. The drying of such sputum pro- ceeds with the utmost rapidity, and results in an element of veritable danger. In the exhaustion and sometimes the delirium incident to the last stages the possible sources of infection in the sick-room are greatly enhanced. The dangers of contamination of the bed-clothes, walls, and carpets are exceedingly great, as the patient, no matter how care- fully instructed, has lost to a degree his appreciation of individual responsibility. Thus in doubtful cases a careful investigation relative to the oppor- tunities for infection may aid in the establishment of at least provisional conclusions. PREVIOUS DISEASES A history of certain diseases prior to the development of tuber- culous manifestations is possessed of undoubted diagnostic signi- ficance, both in children and adults. A severe attack of measles, whooping-cough, typhoid fever, pneumonia, pleurisy, or influenza may represent the first signal of approaching danger. The sj-mptoms of pulmonary infection may develop shortly after the subsidence of the acute disorder, or only after prolonged intervals, when the restoration to health is apparently complete. A diagnosis of the tuberculous nature of a sthenic pneumonia may be made in some cases from the tenth to the fourteenth day, but in others not until after the lapse of several weeks. The resolution, though slow, may appear sufficiently progressive to disabuse the mind of the clinician concerning the possi- bility of tuberculosis. Sometimes there is a seeming recovery from the initial disease, save for the failure of the patient to regain a full measure .of strength and vitality. Frequently no suspicion of the onset of consumption is entertained, the pneumonia being supposed to fur- nish an ample explanation for the impaired general condition. In a similar manner a protracted convalescence from typhoid fever or malaria often represents the period of early tuberculous manifestations. In many of these cases the tuberculous infection is present from the very beginning, but the evidences of pulmonary invasion may be recog- nized only after a considerable interval. I have observed a few cases in which the possibility of a pure tuberculous infection with initial typhoidal manifestations could be completely eliminated, yet after a slow and tedious convalescence from unquestionable typhoid the subjective and objective evidences of tuberculosis were detected. The history of an idiopathic pleurisy with or without effusion is assuredly a factor of considerable importance in cases presenting symptoms and signs of doubtful interpretation. A very large propor- tion of idiopathic pleurisies are known to be tuberculous in character, irrespective of the later appearance of distinct pulmonary lesions. Sixty-seven of my cases out of a total of 2070 present the record of a previous pleurisy. The history of pleurisy without assignable cause should suggest, even in the absence of well-defined clinical manifest- ations, at least a strong possibility of existinc; i>\ilni()n;uy tuberculosis. In obscure cases the history of influenza, ritlui- iiM-ent or remote, furnishes still another landmark pointing towaid a lul.crrulous process. The relation of this infection to the subsequent ile\elopinent of tubercu- losis has been chscussed in earlier pages. It has been contended by 240 DIAGNOSIS AND PROGNOSIS some that the onset of consumption following influenza is accounted for largely by the means offered for the more extensive distribution of tubercle bacilli. This hardly appears reasonable, a simpler explana- tion being found in the increased vulnerability of the tissues through the influence of a prevailing epidemic, in connection with the frequency of latent infections. In any event the symptoms of consumption have often appeared some weeks or months after an attack of influenza in individuals formerly in perfect health. The previous occurrence of influenza, therefore, in cases admitting of considerable doubt, must be accounted a factor of some cUagno.^tic importance. The etiologic significance of jiulmonary hemorrhages has been reviewed in a prececUng section. The fact that aliout 20 per cent, of all piJmonary hemorrhages appear in the midst of apparent health as the first symptom referable to tuberculosis indicates the vast importance to be attached to this history in doubtful cases. As previousl_y asserted, a moderately severe hemorrhage maj' take place in the entire absence of subjective symptoms or of physical signs, even upon rigid physical examination. While the history of a remote pulmonar}- hemorrhage, with or without occasional recurrences, does not j-ield indisputable testimony as to the existence of a possible concealed focus of tuberculous infection, the fact remains that such admission, in association with constitutional s}-mptoms, even of a doubtful character, must be regarded as strongly in favor of pulmonary tuberculosis. In each instance of pulmonary hemorrhage of uncertain origin, however, a pronounced effort should be made to determine beyond peradventure the absence of other con- ditions capable of explaining its occurrence. A pro\-isional conclusion as to the tubercidous significance of pulmonary hemorrhage can be reached only by a careful systematic elimination of other possible etio- logic factors, as mitral disease, vicarious menstruation, purpura hemor- rhagica, etc. CHAPTER XXXIX PRESENT CONDITION The principal diagnostic features relating to the character and extent of constitutional disturbance are cough, loss of weight, fever, and accel- eration of pulse. These, in connection with the physical and bacteriologic e\itlences, usually j-ield information of an imdovdjted character. COUGH The cough, which has been descrilied at length imder General Symptomatology, is often the first subjective manifestation of pul- monary tuberculosis. It is more frequently present than any other initial symptom, and at once attracts attention to some involvement of the respiratory- tract. It often serves a useful purpose in arousing the early apprehension of patient and friends, and is of signal value in exciting the suspicion of the physician as to a possible tuberculous invasion. Upon investigation the cough may be found to be occasioned by catarrhal bronchitis or laryngitis, an elongated uvula, or a follicu- I('licii(l('iit upon conditions other lie ali-ciicc of readily explained ih 1(>^< (il weight or fever, should 1 a IiiIhtcuIoiis iiif(M-lioii, (Icspitc al M-iis. .1 iiKiiilir, ,xi>l<,r,ifinii ■r Ihr hunirn „, proo/ rcluiy upon inroln IN, III. is. indeed, a variable quantity. It \y may lie out of all proportion to nlc d(•p(>^i1. I'licrc is no I'elation ir nature oi' extenl of tlii' lubercu- iperamenlal idie-vneranes of the deieiiuiiunt;- lactoi' in the degree ■i>nsi,-t nieiel\- (if a sliuht clearing of ly (iriau' in se\'eiv paroxysms, with enll\ (.1 a di-tiiirlly nel\nus type, ■d ]i\- othel' CMdenres ul hN'Steria. -ame iiidixidual. a.-Mudin- to the laeililie- alTerded tnv mental dis- li-i- i- iiMMv likeix 1(1 (M-cin- in the he l.alanceol |iie('la\\ Hoarseness ' the afternoon, or it may precede PRESENT CONDITION 241 lar pharyngitis. Wldle frp(pie than tuherculosis. its ]>ersi,^len( cause, particidai'ly in comliinati be construed as stroiml\- imlica failure to elicit chaiacleii lie of the chrst in siirll I'llsrs ihirs iiii, the cnuiiiurr irhn ilmilils ,i tuim The couiih (if incipient tulieiv may not be presenl al all. or its Other manifest at ions of liciiinmn whatever bet ween this sNinptdn lous process. In eaily'(aecs tl patient are appaivntly an imp. andcharactei'dllhecduji. Tlii- tiic throat at intervals, or the c(ii or without expectoration. It i- in which event it maj- be accdi It is subject to much vaiiaiinn influence of external caii.cs am traction. The couuh of incipient pliili early mornim; a 11(1 KmIi appea rdiirini: t li may develop during I'.e latter jiarl of all other sympnims. and from its persistence afford a strong suspicion of an un(.leilyiiig tulierculous infection. The ap]iearance of the cords may be almost normal, or there may be tliickeiiiiiL; and reddening from an existing catarrh in a; (iciation with othei' laryn.geal clianges. In very early stages of con: r,m]ii ion the (iia.miostic value of cough or hoarseness consists almo, t entir(ly ol the siiui^cstiftn offered to the examiner of po.s.sible intrailidiacic di ca-c. If the cou.iih does no more in such cases than to emphasize the necessity of a thoi'ough chest examination, and a judicial inquiry as to the significance of accompany- ing symptoms, this surely is sufficient to establish its clinical value. LOSS OF WEIGHT Loss of weight has loni; l^een regarded as one of the cardinal mani- festations of consumption, but its diagnostic significance in incipient cases appears to have been exag-ierafed to a great extent. In very early cases the impairment of nutrition is but trilling or absent alto- gether. Sli.uhtly later in the disea-c it i an almost invariable accom- paniment of other s\'mp1omatic (ii-tiirbanci>s. and is then iiiuhly sug- gestiveof tulieivuhw'i-. .\- a -eiiei-al rule, patients exhibitim; decided emaciation h.ave heeii .alHicte(l l'oi- ,a lorn;- time, and inamlest other evidences of the t nberculous mature of the .alfectioii. Cases displaying pronounced loss ,,f weight c.aily in the disease are necessarily those of acute onset, with considerable ele\-ation if lemperat lire. In such cases the dia.gno.sis is not made upon the basis of the dimini-hed wei.uht, but rather by virtue of the accompan\inu s\inptoms .and jihysical signs. Even without cough, exjiectoiatiou. or fe\-ei-. if combined with lo.ss of strength, shortness of breath, and a(a'eleration of pulse, with failure of appetite without .satisfact(ii\- explanation, emaciation strongly empha- sizes the need of exhaustive jihysical investi,gation with .r-i-ay exami- nation and the employment, in occasional instances, of the tuberculin tests, 16 242 DIAGNOSIS AND PROGNOSIS FEVER The importance of fever is perlnips greater tlian tliat of any other subjective .symptom during the early stage of tuberculosis. While its absence constitutes no argument for the exclusion of a positive tliaanosis, its ])resence under certain conditions is assuredly a feature of cxi-ciMliui: iliauiidstic value. Statements of jjatients regarding the exisifiicc of ic\ci' '.ivr frequently unreliable. Many experience no sen- sations (if iiirrcascd warmth or flushing of the cheeks. These patients quite invariably deny the presence of fever, which is rexealcd only by the intelligent "use of the thermometer. Almost to an (M|ual extent is it unsafe to place dependence upon the reports of in\alids who. with- out competent instruction, have been taking their own temperature. Nothing is more certain regarding the fever of phthisis than its extreme variability, not only at different hours. I.)ut ujion succeeding days. It is clear that unless the t:'inii;M-aTui-c i< t:ikcn fi-i-i |iici!tly and systematic- ally, the ai-i|inri"nirin of arcuraic Liiow Iri L,' roiiccrniiiL: the fever record is well-nigh inipo<~ilil.'. It li i- I'Cfw a -oiim. n\ ( \ ci-rccin-ring surprise to learn in many individial in-iaiici'- that ]ih\ .-.irians were content to observe the temperatuiv iiui our- i da\'. and then only during the morning hours. A neuaUNc icsult oiim atti-nds several observations of the tempeiatui'c daily, d—pitc c. iii^i; leiaMc intervening elevations. To obtain approxiniaii'lN coiiimi intorniat ion tlie thermometer must be used in suspcctrd cases at inter\als of every two hours, and preferably during a period of several weeks. When practicable, the temperature should be taken by some person other than the patient, and a careful record maintainecl. I have obser\'ed many invalids who have been instructed by their m-'diral attendants to avoid the taldng of tem- peratures on account of a |Mis-il)le md'ortunata mental influence. Itisnot iineonuuon tonote. amoni; iiiT\diis jieople. a temlency to take the temper- attn-e l"re(|nentl\\ witli an exi-,-.-i\-e mental |iei-tnrliation following even sliiihl ele\alioii<. In e\e,.|,lional in^tam-es objr.et i,,n< to |l,e use'of the tlKThioniet - may l.e .ii^lauied alter till' diagnosis has,, nee lieeu estab- lished. Kilt iliiiinii thi' period .iie;iri\- observation, in doulitful cases. its use should lie in~i-ted ii|ion. iei:.ii( lle<-: of all other considerations. Employ- ment of I hi- theiiiionieier re]iiesents one of the old-fashioned principles of ilia^no-i-. the rarefiil and | laiiKt.i kinu apjilication of which, in recent yeai'^. too 1 lei |iient ly ha- been o\-,Tlooked. Notwithstanding irrecon- cilalile dilferem :•.- in the \arious makes of thermometers. rea.sonably aiTiiiate result- ni,i\- 1 le -eriired, provided the instrument is retained in 'he inoiitli fill- .1 ^illirieiit time. One-minute or two-minute ther- monieteis aie often e\ti-ein 'ly unreliable. Regardless of the particular type emploj-ed, the instrument should be held under the tongue with the lips tightly closed for not less than five minutes, any shorter reten- tion being practically valueless. As a general rule, the temperature should lie ta';eu indoors, as there is often noted in cold weather a differ- eini' of iVoni one-half a degree to a degree, according as the patient is in the open ail- or in the house. I have found, during the winter, that patients necessarily housed upon stormy days exhibit a uniform elevation of temperature. The characteristics of tlie temperature which are of more especial importance are its irregularity and atypical course, its usual but not invariable rise in the evening, and the exhibition of an average for the day slightly above normal. Occasionally, in cases PRESENT CONDITION 243 with very incijiifiu iiiffciidii, ilic tciii[)('i-;itiii(' is slightly elevated after a hearty iiic:il. iihy-iial cxrnisc. and (hiiiiiu periods of temporary excitemeiii . IVxcr in sonic cases nia}- lie cxjiccted to attentl the time of menstiiiatidn and tlic cnsuiiii; lew days. It is frequently present at noon, onl\' to sid>siilc tnward evening, or it maj' be absent during almost tlie entiic day. and rise late in the afternoon. In children the range of tein])erature is usually higher than in adults, though not always. At tlie othci' e\t renie nf life the fever is proportionately lower antl sometimes alisi^ni aliogetliei'. in sjiite of the existence of an active direct suspicion toward a tubercul.jus in\ cil\ ( nieiit . even if accompany- ing symptoms are exceedingly indefinite. ACCELERATION OF THE PULSE There is oftennocharaci en-Ill- change in the pulse during the incipient stage of consumption, it liein^ apparently normal in very many cases. Sometimes, howexcr. clian^e- nccm- diiiini: the incipiencv of the infec- tion, and cvi 11 lielore a , leiiioiisl r,-i,Me l,acillar\- sta-e. 'ilie pulse is. .lien of low ten-i.iii, weak. inilaMc, or rapid, 'facliyardia. from unkiM.wn heart and aorta are perhaps of small size in such cases, as stated bv Brehmer, <'linical veiificatioii is seldom pos.-iMe. The pulse is subject to considerable \ai'ialion as a ivsult of coliipara liwl \' trillin- conditions, as sli-lit exertion, aiun.aled c.,n v,T-ali.Mi , ,,r oilier caiis.-s ot nervous excitation. A bi.'tor of s„nie iniporl.aiire i- ihe iiTilabilitv an.l ac^-lera- tion of the ]iulse upon cliaiiiic of ] osilion. all lu.ii.i^li at rest il may appear entirely ncn-mal. This view is (lirectly o])poscd to the - of a n i< ire strict and con- iples of ph\-sical diagnosis, which are .Mienti.ui' should a-ain be called: (1 1 ^"o the d('l;i \' the developineni in in-i-tiiiL; upon of pronounced c ( Insi iVu t'l . i'l la l' 'a'n' d' ' I'.'i il'i 1 1'. .'i i a r\" i n i p.-, i r- nient; ('_>' failure efie<-lii,-,nv prev,- rot;ions often b.-i defined tubercuh forced ins])iratioi: nliii'^ an\- ;ippi'i itire .-he^l. the b: lus inleclioii: ( 1 1 in eliciting the | iiot withstanding evidences of cleai'ly ' failure to (itilize cough preceding uvsence of moisture in the finer tubes. 244 DIAGNOSIS AND PROGNOSIS The physical signs of the ^•arious stages of consumption have been described in the preceding section, but it is, perhaps, well to review briefly a few featiu-es pertaining to cases of incipient infection. The attention of the examiner should be directed to a possible retraction at the apex and to a localized retardation of respiratory movements. Upon palpation he should carefully note the existence of increased vocal fremitus, particularly at the left apex. The absence of slight per- cussion dulness must not be misconstrued, the tuberculous process often being capable of recognition upon auscultation considerably before the evidences of consolidation are apparent. Especial attention should be given to outlining the boundaries of percussion resonance at the apices in order to determine the shrinkage from infiltration or con- traction. Although the examiner must be on the alert to recognize minor changes upon auscultation, e\-en before the appearance of moisture, the presence of unilateral apical rales are of especial signifi- cance, and are almost ah\a>s i)athognomonic of consumption. Con- siderable importance attin hcs to < lianges in the spoken and whispered voice. In cases of sliuiit intiltiatinn the spoken voice may exhibit mereh' an iniTca-cd intcn-iT\- ni' xnral r.'SDiiaiir.', but with a greater degree of ciiii-MliilMiidii diMiiirt lii()iicli(i|ilii.iiy i~ obtained. An ele- ment not al\\:i>'s appri'iiati'il is an iiitaiisiticai inn of the whispered voice. This, if present at one apex, and particularly the left, suggests a diminution of the air-content of recent or remote tulierculous origin. The presence of moist rales, percussion dulness, increased fremitus, or vocal resonance, with unusual intensification of the whispered voice, are more or less easy of recognition in comparison with the finer devia- tions from normal respiratory sounds. For tire detection of the latter changes the utmost concentration of the mind, added to a somewhat extended experience, is absolutely essential. It is customary to describe the modifications of pitch, intensity, quality, and rhythm of the apical rc<]>iiation as bronchovesicular. It is difficult to conceive of aii\- dcviatidii from the normal vesicular respiration in early phthisis which iIdi's nut entail changes conforming to this type of breath- ing. In the event of very slight pathologic change involving the mucosa of the finer tubes there may he noted but slight modification of the normal respiration. The vesicular element markedly predominates over the bronchial without appreciable abnormality in the pitch, intensity, or dvu-ation of the expiratory sound. The change from the normal may relate exclusively to the inspiration, and partake merely of a roughening of the sound, produced by the thickened mucosa, which impedes the free entrance of air. This may represent one of the very first auscultatory signs of incipient phthisis, but it is hard to imagine how any considerable obstruction of the lumen can exist without likewise interfering with expiration, prolonging its sound, and raising the pitch to some extent. The inspiratory sound in some cases may be interrupted, giving rise to the appellation "cog-wheel"' respiration, but this is sometimes recognized among the non-tuberculous. As has been explained, modifications of the respiratory sounds discoverable at the left apex are possessed of much greater significance than at the right on account of the normal disparity between the two sides. If these signs are detected at the left apex, they may be regarded as pathognomonic of a tuberculous process. The presence of unilatei-al 7-dle.t at either apex is of infinitely greater importance. They may be PRESEXT CONDITION 245 present in the morning and disuiipcur in the uffernoon, only to recur u]nm the following day. Iiulisiinct and iiKldiiiite rales may assume greater prominence following tho tciuporai)' adniiiiistration of potassium iodid. Through the detailed application of the principles of palpation, auscultation, and percussion, irrespective of the neA\er and special aids to diagnosis, the nature of the tuberculous process may be recog- nized in many instances prior to positive bacteriologic evidences. SPUTUM EXAMINATIONS The discovery of tubercle l;>acilli in the sputum furnishes the most convincing ))roof as to the true nature of the jniluiduai y afTcctidn, While their presence may be regarded as c()nclusi\c (■\i(l(iicc, I heir non- recognition. sa\-e by an expert after I'epoatcd cxainiiianiiiis. does not preclude their existence in fhespntuui. 'I'Im ir deindii-^l I'aMe absem-e dance with a eareiul technic alfc.nls no abnilnte inlurinal i"ii as to the non-tubennilous charaiier of the aflection. Tlie all too pre\alent of thebacilbis isa praet ice cahailated to lelieve the plixsician of a portion evasion of lii> moral ol ilii^.-it'ioii to the ]iatient. Tlic most pi.rnicions feature of a dia^no- , , l,,un,le,l exclir climates. On account of the involved respoir-il iilit \- ami through moti\cs of per- sonal interest in the invalid and family, the chiuciaii nui} olteii hesiiile to pronounce .sentence without the coi-rob(]rali\c e\i(lence lurnished by bacilli. In cases in whicii the combined siibjeclixe symptoms and siu'us are stroni;I\- suu'^est i\'e of a luberiailous process, there can be no gre.-iler dereliction of d'utv on tli,. part ,A the ph vsiciam t lian to withhold tlie (li.-L^noM- until the appearance of bacilli. ' ( »ii tl ther hand, in tlie absence ol clearh' delilied indical ions ol tuberculous llilection, an un.|uali(ied po-utiNV decision shouhl not be rea.'lu.l thron.nh the uncertain intiu-pret .at H m of a sinde factor. e\cn thoui;h possessed of considerable cliiiii-al iiit(U'e>i- until the recognition of bacilli aiiscs iVdiii the tact that there are a cniisKlcraljle number of physicians \\li(), ilnotmh iiisiitficient training and inadequate teehnic, are unaUe to detiMt bacilli tintil the_y are present in large numbers and the tlisease ha.s (•(.irrfspdiidingly advanced. Another though less fre- quent source of error relates to the detection of supposed tubercle bacilli by superficial observers. It thus appears that the practical value of the sputum examination, no less than of the physical explora- tion, depends upmi ihc al>i!ity and training of the examiner. The selection of bancn paitii()|iir i(^ common causes of mistaken conclusions iv;:aiiliim the iircsi-nrc of bai'illi. The manner of examination ]ii-c\iously described ma\- be inoilificd by comliining the decolorization and tiie counTci^-tainini; .according, to the method of Gab- bet. After the iintial stain i^ washed with \\atei-. this consists of dry- ing the cover-gla-- tor a tew seconds in a solution eoniiiosed of "25 c.c. sulplniric .acid. 11)11 I.e. water, and _' milli;;rams methylene-blue. follow- inii which the '.ila-- i> airain washed and examined after drying. The only ad\aiiiaL:i' -allied, which is \eiy slicht. relates to the shortening of the proce--. hut the ie-iiltsare not quite so satisfactory as with the metho.l de-iiihe.l m ,iii e.i il ier chapter. If the Kaiilli are found to be absent alter -e\ei.al exaliiiliations. more conclilsi\e results may be obtained by treating the sputum with a solution of soda or potash and centrifuging. CHAPTER XL SPECIAL AIDS TO DIAGNOSIS For genera! ]3iu-poses the diagnosis can lie made witli sufficient acctirac\- and i-eleiiiy w itliimt recourse to the newer methods or special aids. Melay h,i~ been occasioned, in the vast majority of cases, not throuiih in.iliility to utilize these methods, but on account of failure to recoRiuzc the ample sulijective and objective clinical data already available. There are many difliciilties in the way of establishing an exact and early diagnosis thiouirli the agency of special methods, the necessary restrictions upon their employment placing them beyond the imineiliate reach of the general practitioner. The}' may be regarded, howe\er, as of value in very exceptional and obscure cases. The newer methods of diagnosis of special importance relate to the use of the tuberculin tests, animal experimentation, and the Rontgen-rays. SPECIAL AIDS TO DIAGNOSIS. 247 THE TUBERCULIN TEST Save under very puzzling conditions, recourse to the old tuberculin of Koch ])}• subcutaneous injection is quite unnecessary and unwar- ranted. When the diagnosis is siithcii'iitly clear by other means, the tuberculin test presents no addiiioiial feature of value, while its employment, unless in the liands n{ a caicful and experienced physician, is vested with ceiiaiii |Mis>iliilitics (if danger. Shortly after its intro- duction by Kocii II \\a> pidi lainicd by several students, as a result of considerable icscaich and tinucal observation, that the tuberculin served to renew I he .-iciiN iiy of pre\i(iusly latent fnci, and to disseminate a general tiihei-eulun- infeciidn. Kailically difleiing views were enter- tained by palli(i|ii,L;i.-ts a-, to lis possiMe inlluence, at a time when it was used in la.r.ncr doses than in i-ereiil yeais. It may be assumed at present that the tubeiculin in carefully ,iiiaduated doses in the hands of a skilled cliniciaii is entirel\- liariiiless, the only danger resulting from its indisciiniinate and (■■■ncle^s adininist lation. In like manner the possiliility of correci conchi-ions following il< u.-e de])ends entirely upon a. r\'/u\ a.dlierence lo cerlain pivi'aiilionar\' liieaMiivs, the reaction, if present. I>ein,-les. The production iiiuies the h.-isi- ol ihe ie>i. Some op]iosition to its use arises from the e.xhibition of a i)o>iti\e reaction in cases apiiareiitl\- not tuberculous, the variable degree of the reaction, and sometimes, I hough rarely, its entire al:)sence in infected individuals. It is impoitant to note, however, that when the reaction has occurred in the supposedly non-tuberculous, autopsy lindinus have often dis- closed the presence of concealeil foci of inaclixe inlection. While this partly accounts for its exhiliition ainom: ap|)arently healthy people, the very fact of latent tubercidosis a ni; a lait;e portion of the race detracts to some extent from the sii;iiilicance of the reaction among individuals suspected of early pulmonary lesions. The occasional absence of reaction among the tuberculous is ex])lained largely by failure of less practised observers to conform to a strict technic in the manner of its employment. The reaction has Ijeen founil to be more pi'onounced in recent cases, and comp:ira1i\'el\' slii^lit among the far advanced, the increased lolerance a i; lhi> l.iliei' suggesting an effort of luiture towaid the esiaMishnient of partial immunity. It is po.sse.ssed of but lilile diai:noslic siunilicance if administered in the presence of even ^li^hi ele\alions of temperature, a fever of over \)'.)° F. being sufficient in many cases to preclude accurate cUagnostic interpri'tations. Inasmuch as ihe |-eaclion nia\- be allelided by fever raimiim from one to three or four decree- alHi\e normal, it is readily a]ipa rent that a detailed record of the leinperatiire. hir several days preceding its administration, is essential. I'.efore employing the test the tem])erature should he taken at not less than two-hour intervals during a jieriod of two or three days, pivhualily a week, in order to avoid any confusion arisinu from ordinal)' lliicl uat ions. The i-eaction iisu;ill\ nccurs m the nei^hlioi hood of t he tenth hour, but may be delayed until the second day. It is s aiv often of |ii-oiiouiieed chaiarter in tuberculous involvement of the Ixuies. joints, L;hiuds, and testicle, the dclcciioii of definite change in the areas of pulmonary infection is not alw a\ s |iM^.-;ible. My experience with the ohl tulierculin for diagnos- tic |iiir|i(i,-e,- has been very limited, ha\iim used the test as a last resort in but a very few doubtful cases. Aniph' oppdrtunity has been afforded, however, to witness marked local reaction ioljowni.u tiie administra- tion of the bacilH emulsion for therapt'utic jiurpo.ses. During the past year this aucui has Keen ^i\cn .■.xti'iided emphiynient in .selected cases. Thus mean- h.i\c l>ccn acipiiivd lor ;i >t U(l>- of the hical ivai'tion in a few conspiciiou- in-i:inccs. In '■onncciicm with the not uncommon aggravation of con^ih and the added amount of e.\i>ectoialion there has been found in sonir in-i:inces upon auscultation a temporary increase of moisture in inUriid at. -as. With the bacilli enuilMon I have not lieen able to detect an .ipj ireciable modification of the former respira- toi\- soiuids, but tills is reported to have been recognized at times after injection of the old I iiberculin. In makiii'4 usi' of the dlai:nostic test the beginning dose should not exceed ,'„ of a inllll'.:rain, although some clinicians are accus- tomed to eiiiplo\- Initial dii~,~ of two or three milli2;rams. There is nothliL- part Iciihnh' tub,, l:;. mrd 1 iv adopt In- the lai-er d.ise in the be-in- mn-. which 111 in.an'v ,■;.--- iv-uli- m cMrciii.. di-v.,nnurt to the patient and pres,.|il-c,Tlai.M-l..|neiil.ul danger. 1 1 I h.. re i~ no react ion following its initial adiiniii-l rat ion, a Second dose may be iincii after tli(> lajise of several da\s. dining which time the temperature should be recorded with c.are in the saine manner as prior to the fii- rarely jnstiliable to resort to over two or three millliiiams. The only objection to the u.se of the smaller doses is the ]io~~ib!i. i-i:ili|ishmeiit of a gradual tolerance on the part of the system and the c()n-ei|iieiit failure to secure reaction. .\n intelligent use of the tiibeiciilin demaii.ls the exercise of tlie utmost c.-,ie in adjusting the size of the dose. Till- ari-i- parllv fnmi the n.^ce-Mlv of diluting the crude |iroduct. It is well to make the dilnti(.n at the time of its admin- istraiidii. as ilie product becomes inert after remaining diluted for more than inriy-iiiiht hours, although some continue its use for two weeks after ii h.i~ been prepared. The best metliod of dilution is the use of O.o |HT ceiil of phenol in ,Iistille,l water. .Ml the .appliances emploved in Its .adinini-lralion. which iiidud.' the -viw-r. lubes, pipet-. etc., .Shonhl 1.,. made .ab-,,lutelv sterile bv boiliil-, precedm.Ll each injection. The 111(1-1 ii'.:id ase]itii' precautions are iiece-:\irposes, is extremely small, and its tiehl of usefulness confined cxclu-ixcly to a few doubtful cases otherwise iiicap^iMc of i>iccisc dctciiiiinatioii, it, ni'\-(MtlK'less. is safe to conclude liiiii iis intclliiiciit ciiiiiio^iiicnt in ihis iiuinnci' is not only harmless, A recent iiiijxirtiiiil i,i,»lijirali(ui of the tuberculin tost has been introduced l.v Caiiiiette and Wolff-Kisner. known as il,e ophthalmo- lulMirului rnniinn. I'.y means of tliis nietlKul the tuberculin test rei)rescnts a most \-aluai>le aiti t(i diaiiiio^is. and it> careful employment seems to be diveste.l of all dl^a,ulveaMe ur , Imil'cious features. The diagnostic purposes is f.ni'nd m the |,,r;,l' rea.'t i..n"exlul.ited bv infect. hI individuals folliiwin- the admnust lal i.m of the tdxms of tlie tubeivie bacillus. This .sciisitivenc>> c,f tlie tisMies was n.Hed |(,n- a-o follow in- the u.se of Koch's old tuberculin. W hil,' |.m;,| |e,M(.n- were bv n.i nieaus uniform, the frecjuencv of li\-pei'emia an.l .^wi'llini^ ai the site ol' injection was iifti'U the subject' of cc.niment. .\|s,, ni animal expeiameni .a'l i..n it was noted. a> staled in oilier rliapteis. lli.al in main' iiiM.aiire- an acquired paitial imimmilv afler pnmar\ iiio.ailat ions was Me-eM,.| bv the more intense local reaeli.m .alleiidm,- t he .M'coiid injections. Uefeivncc is made in the chapter upon lmmiinit\- to the ai'tion of the toxic sub- stances in the jiresein'e of llie i nl lercuioiis foia of infeiied individuals. The development of local lemons following the subcutaneous emplo_y- ment of tubenulin siiui:ested u response of the tissue-cells as a result of the absorptixe products from the foci of iidection. Th(> (irrculin to the conjunctiva. By the use of 95 per cent, afcohol he precipitateil the tubeiculous toxins from Koch's old tuberculin. After dryini; and dilution with 1 jicr cent, sterile water or normal salt solution, one dr either'a neuativc' result was noted or efse the reaction w.as mild and of short dur.alion. The fst has been applied bv a c.Hisiderable number of observei's, who li.ave reported in the main fairlv uniform results ction whatever. Of the latter number, the family hi-tur\ , dppni i imiiii-^ for exposure, previ- ous history, and subjective sytnpidin- -iii;L:(-te(| >t idniily the possibility of a tuberculous infection despite neuatixe i(-iilt< of physical exami- nation. In many of these cases a pro\ie- who presented a positive reaction to the nphthalmntulieiculiii test, a delinite diagnosis seemed impo.s.sible upon the l.a-i- ni' th.e pli\~ical sjuns or bacteriologic evidences. Varying degree- of react inn were exhiMteil among the twenty- seven patients, responding i)()siti\'ely. In the latter cases the ^ per cent. solutinu of ]>iecipitated ttd^rculin was invariabl\ einploxed. the result- ing iuflainination being very pronounced in fi^■e in-tances and lasting for several days. The 1 per cent, solution wasuscil only uijon patients who did not react to the initial test. A drop was instilled into the other eye after an interval of two days, but in no instance was a reaction noted upon the employment of the stronger solution. An interesting feature was the delay of the reaction in a few cases. In one case the conjunc- tival inflammation did not appear imtil after the lapse of thirty-six hours, and in several the maximum intensity of the reaction appeared not until after eighteen hours. Fifteen patients submitting to the oph- SPECIAL AIDS TO DIAGNOSIS 251 thalmotuberculin test had been subjected for variable periods to small weekly injections of bacilli emulsion. Of these, ten exhibited a much slighter reaction than those not subjected to tuberculin therapy. The test was not employed upon any individuals who were presumably well. Despite the comparatively small number of patients to whom the test was applied, the results thus far have seemed to offer abundant evidence as to its value in doulitful cases. EXPERIMENTS UPON ANIMALS The introduction of suspected sputum into the pt-iitdiical cavity or tissues of aniniuls cdnstit utes a special means y the sejiaration of the sidn from the subcutaneous tissue. In either event the haii' is shaved from a small area siuroundiiiu the site of the operation, which is per- formed under sfiict antiseptii- piiMaui ions. The animal killed after six or eight weeks will show, in jMisitiM' cases, pathologic evidences of a tuberculous infeciion. The unlorlunate delay in securing definite information is said to ha\c been o\-erconic ici'enfl\- 1 1,\- inject inu suspected material inlo the nialnluai'v iilaiids of ,l:uuic:i-| m.^-^ oi' i-abluls which are suckling their \-oung. I\\perinienl.- | j- lie s.ah'Iy i'esei\cil for cases exceptin. this absence of asymmetric change may be assumed to indicate the non-existence of any gross 252 DIAGNOSIS AND PROGNOSIS tissue abnormality. On the other hand, a structural lesion sufficient to s)ww a distinct shadow change is often preceded by such sub- jective and objective signs as will warrant an unqualified diag- nos:is. The use of the fluoroscope is admittedly of some aid in afford- ira, exerting pro- f^iKns suggesting tuber- iilates aortic aneurysm. ing an opportunity to note the delaj-ed or diminished descent of the diaphragm. This" has been reported l)y several as characteristic of the very incipient stage of apical involvement. It may be present, however, in cases of long-standing pleural adhesions and certain abdomi- nal conditions interfering with the movement of the diaphragm. In SPECIAL AIDS TO DIAGNOSIS 253 such cases this sign is, of course, devoid of uiiy si)eci;il si<;nific:uice. I have observed a material retardation in the (icsccut of the iliuphragm upon one side, without tlie slightest ohtainahh' e\iilencc of tuberculous infection. Some have reported, as a result of transillumination, a distinct appreciation of the comparatively small size of the heart in spite of normal apical ndular.at root of riKlit peculiar conflguiation of ribs. consumptives. While this is of clinical interest in yielding confirmatory evidence of previously entertained impressions, such recos;nition per se IS insufReient to justify an assumption as to the existence of early tuberculosis. In the same way it may be added that while wonderfully accurate and valuable information may be secured as to the extent and 254 DIAGNOSIS AND PROGNOSIS nature of tlio strurtural diaimv^ in advanced phthisis, this constitutes no evidence a- in tlic nirarnihlr utilit\- (il tlie x-Tnv for diagnostic pur- poses in incipient ca.^es wilhdui pioniiunced lesions. One of the chief objections to the use of the Rontgen rays for intra- thoracic lUagnosis is the necessity of their exclusive employment by Fig. 46. — Posterior view. Very sliglit tliiclcening left apex. Moderate apex witli tuberculous infiltration extending to fourth rib. Note tlie peculiar curve of ribs in upper part of picture. Heart small, partially obscured, and flisplaced sliglitly to the left. experts. Only in such hands may it be possible to secure sufficient detailed definition to permit of cfurect interpretations. In an effort to obtain the necessary detail the time of exposure should be as short as possible, and the chest should lie at rest. SPECIAL AIDS TO DIAGNOSIS Fig 48. — Posterior view. Slight tuberculous infiltration each apex, with small dis.seminated tuberculou.s glands in the cervical and upper mediastinal regions. Arrow indicates isolated remnants of cervical glands. (For fuller description of this case see p. 421.) Heart small and pulled upward. 256 DIAGNOSIS AND PROGNOSIS During the past year, with the valued assistance of Dr. S. B. Childs, I have resorted to "radiography in a large number of clearly defined cases of tuberculosis, in order to compare the clinical and skiagraphic findings. This method of cUagnosis has lieen used to confirm, if possible, 5r view. Well-defined tuberculous infiltration at the : of physical siffns. in a patient exhibiting progressive 1 Heart displaced sliEhtly to the right. the results of physical examination with reference to small circum- scribed efTusions, pulmonary cavities, and suspected mediastinal glands. As a rule, the information secured has been strikingly conclusive. As a result of this intniiry. however, previous convictions as to the .slight SPECIAL AIDS TO DIAUA'OSIS Fig. 50.— Posterio . — on, right interscapular ...,.„.., ^„ 3 clicks at end of in.>ipiration following : 258 DIAGNOSIS AND PROGNOSIS practical value of the x-ray in the diagnosis of very incipient cases without well-defij^ed structural lesions, have been substantially con- firmed. Though transillumination of the chest has not been found to be of great utility for the purposes of early diagnosis, save in excep- tional cases, it has afforded in some advanced stages information of a highly important nature. Decided value has at ment corroborative of. or supplementary to. the re- examination. It is of .some interest to note that ~i \t r, but undoubted infection, upon the basis of pliysical m to exhibit no appreciable shadow variation, l^^j* the other hand, although the physical examination in some iT;?it;ane^s disclo.sed signs its employ- of physical ^os of .slight were found SPECIAL AIDS TO DIAGNOSIS 259 . Fij;. 53. .„ apical mvolvemei case is of interest 'NoteTeenliTStf H™"'^*'''^ tuberculous infection „f tl,r I,.ft |„„g witl.ouf or view, Extensi- mottling in scapul pare with Fie.W.plie^ms'""'""' ~"" DIAGNOSIS AND PROGNOSIS of an exceedingly definite character, apparently permitting conclusive interpretations, the radiograph revealed a surprising divergence from the clinical findings. The lack of correspondence between the results of the physical and z-ray examinations related particularly to the deter puln., prlerate tuberculous infiltration of both apices. Cavity size of egg Ki'iiing of mediastinal pleura extending above clavicles, with great- liiberculous gland at junction of sixth rib with vertebra, as indi- aitially obscured, and displaced upward. '\/.f and position of the lioart, the diagnosis of ,1 the .leteelioii ol l,roiM'l,ial glands. 'derate canliac ilisplaceiiieiit from the traction le iiroliferation was found in several cases, when I suggested upon physical examination. This upward displacement resulting from marked SPECIAL AIDS TO DIAGNOSIS 261 fibrosis of the mediastinal i)leiira. It is well understood that certain difficultif's ill the \\a\- nf acciiiatc physical diagnosis are incident to the anaiduiic Idcalimi ni a coii-idcralilc portion of the heart beneath and to the right of the sternum, and to its frequent denudation upon Fig. 56.— Posterii tissue contractile change. Note lieight to with left. Slight involvement of right apex circumscribed area simulating cavitv. He: Compare with Fig. 102. the left side by pulmonary shi of cardiac dulnoss in t\ilicicul(i Several times I ha\c cxpcricnci of the a--ray in dctcnniniim wit dilated or hypertrophicd oi'nan. :;-;■;'! 'iy' ob>n' I'.'ed.'and di iiS right. Th is often increases the area '^^ Id t ( liiru ,■(■|■^• mat MllfV «it il ex- it th( lent. ■ aid nil !>(■ 1\\c< I'll a (lis] liar cd ai lid a sta( ■ie s in the way of a cori'ect DIAGNOSIS AND PROGNOSIS pare with Fig. 169. \ i.w. Pronounced thickening of mediastinal pleura, with infiltration of righl ; strongly suggestive of pulmonary cavity. Second and tliird ribs on the riglit I order to permit collapse of cavity. No cavity discoverable in picture. Com- SPECIAL AIDS TO DIAGNOSIS 263 differentiation between simple ilisplaccnioni , :i and changes in size incident to udliricut pciicauli are enhanced by the morl.iid puhuuuaix- iic U rnwlU ber of inteie.-tiiiu leptdchiiticiiis ai ■e present position. the .-li: ihasl.e iiK-al and ,.ii I.Mved radid- raphv, in most UHportant isideral >\o num- to illus trate this 268 DIAGNOSIS AND PROGNOSIS It is worthy of note, however, that in a few exceptional cases the employment of the x-ray was of signal advantage as an aid to the early diagnosis when the physical findings admitted of reasonable doubt. It should be understood that, in submitting the following radio- Fig. 64. — Positerior view. Extensive tuberculous infiltration, ■ation, right apex. Well-defined media-stinal gland at root of right 3scured. and displaced to left. graphs, the plates are selected almost entirely with reference to their relation to the results of physical examination. It is designed to pre.sent the .r-ray findings of a few patients, in whom the diagnosis was more or less obscure, upon the basis of the phvsical exploration of the chest. In addition, there are exhibited radiographs of individuals SPECIAL AIDS TO DIAGNOSIS 269 displaying well-defined physical evidences of active and extensive tuberculous infection. Tlie patients comprising the series of cases, as represented by the radiographs, do not conform to any fixed type of pulmonary tuberculosis, the physical signs denoting a varying degree placed Fig. 65.— Posterior view. Tuberculous infiltration, entire left lung, with pronouncei at base. Note mottling in scapular region. Heart small, partially obscured, t infiltration, root of right lung. Cavity in left upper bacli. Slighl and character of pulmonary invuh-puiont. x-ray standpoint, the differftit ]):ithi>liioic culosis, from the veiy incipiency nf the (lis( The pathologic processes shown IS will be seen, from an ;cs in ]uiliii"iiary tulier- i the advaiiceil .s'ta.ses. IV examination consist of slight apical infiltration, moderate tuberculous consolitlation, localized 270 DIAGNOSIS AND PROGNOSIS in extent, wide-spread areas of tuberculous consolidation, sometimes involving an entire lung and parts of the other, differing degrees of pulmonary excavation, diffused tubercle deposit in miliary tuberculosis, Fig. 66.— Posterior fibrous tissue change, p by the lieart over the li distributed through thi- ef vertebral column, i : liii.c.witliwell-i iark sliadow occasione Well-marked circumscribed tuberculous patchc : of right. Xote absence of heart shadow m froc ipare with Fig. 98, well-marked thickeningof mediastinal pleura, often simulating aneurysm, tuberculous enlargement of tracheobronchial glands, contractile changes incident to fibrous tissue proliferation, resulting upward and lateral displacement of the heart, the frequent small size of this organ, the SPECIAL AIDS TO DIAGNOSIS 271 imperfect descent of the diaphragm upon one side, niarkeil unilateral pleuritic thickening simulating effusion, small an -Imwn by tlic pci-ciis tlic extcni and nature of the involvement was of considerable value. As previously stated, this related especially to the detection of slight degrees of cardiac displacement unrecognized upon physical examination. In addition to the cardiac displacement from traction exertedby virtue of fibrous tissue proliferation, the enormous thickening of medias- DIAG^OSIS AND PROGNOSIS tinal pleura has been of much interest in many cases. The lack of ])arallelism between the physical and radiographic findings, with reference to pulmonary cavities, has already been cited. The frequency of the conspicuous enlargement of tracheobronchial Fig. 74. — Posterior view. Case of localized empyema of Skiagraph taken through dressings, showing drainage-tube obscured. Compare with Fig. 106. glands, when unsuspected upon physical examination, is also worthy of note. In addition to these general considerations, to which attention has been called, it is perhaps well to analyze a few features in some detail. The radiograph discloses the existence of tuberculous infiltration in both lungs in 28 out of a total of .37 ca.ses of pronounced pulmonary infection. In 9 instances the infection of the lesser involved lung SPECIAL AIDS TO DIAGNOSIS 279 was not noted upon physifal examination, although the more extensive processes in the other were leadily detected. In these cases small areas of tuberculous infiltratinn are shown in the radiograph, either at the apex or at the root of one lung. Fig. 75. — Posterior view. Ca.se of old pneumopyothorax two vears after Schede i Cavity injected with three and one-half ounces of bismuth solution. Note retraction of and unilateral curvature of spine. Heart obscured. Compare with Figs. 107, 108, 109. Among the non-tul)erculous cases, numliorinji- 10. :•! are instances of extensive thickening of mediastinal pleura, nf which th(> radiograph in 1 case sinuilated the appearance of aneurysm to a striking de- gree. One shows clearly the characteristic letter " S " curve in pleural 280 DIAGXOSIS AND PROGXOSIS effusion, 2 are cases of circumscribed pneumothorax, 2 of pneumopyo- thorax, 1 represents the pathologic change in carcinoma of the medias- tinum and lung, and 1, in abscess of right lung following pneumonia. In the distinctly tuberculous cases the mediastinal pleura is greatly thickened in 19, the simulation of aneurysm being pronounced in 5. In the radiographs taken from cases of carcinoma of the mediastinal pleura and abscess of the lung respectively, the resemblance to aneurysm is especially marked. SPECIAL AIDS TO DIAGNOSIS Extensive unilateral thickening of the pleura is found in 18 instances. Of these, the possibility of pleural effusion is suggested by the radio- graphic findings in 8 cases. A pronounced disparity with reference to the height of the diaphragm upon the two sides is noted in 8 cases. Fig. 77. — Po.sterior view. Case of circumscribed empyema 1 ing resection of tentli rib. Small dark spot in riglit base is tlie siiadow of a the middle of tlie cicatrix. Slight infiltration, upper portion of each lunj at the right. Thickening of mediastinal pleura. Pulling of heart upward i of small size. Compare with Fig. 105. specially pronounced ■ 1 the right. Heart The heart is apparently of small size in 20 instances. It is partially or entirely obscured in 17, while in the remaining cases no deviation from the normal size is suggested. As a result of the traction incident to fibrous tissue change the heart is tlisplaced to the right in 9 cases, ^»^ DIAOXOSIS AND PROGNOSIS to the left in 10. upward in 6. upward and to the right in 5. upward and to the left in 1, making a total of 31 instances of cardiac tlisplace- meut. Slight tuberculous infiltration of right upper lung. ' i pleural thickening at right base. Compare with Fi( Pulmonary cavities are shown in 13 cases, and perceptible enlarge- ment of tracheobronchial glands in 10. SPECIAL AIDS TO DIAGNOSIS 283 Fig. 79.— Posterior vi( pleural thickening at base. Note the lateral s change.^. Moderate tuberculou.s infiltration, obscured, and displaced to the left. Compare re left lung, with marked fibrous tissue contractile Heart of small size, partially DIAGNOSIS AND PROGNOSIS Fig. 80.— Posterior view. SliEht flii tuberculous involvement. Sliclit luoltlinj infection. Well-defined pleural tliickenini placed slightly to the right. SPECIAL AIDS TO DIAGNOSIS „. -tf, ^'av w?°Bif" ?!^ ^"'J^i Moderate tuberculous infiltration, right apex.witli a small and arge cavity Slight infiltration eft apex. Thickening at roof of left lung. Heart of small size. Well- marked thickening of mediastinal pleura simulating aneurysm. CD PRtKiNOSIS Fig. 83.— Posterior view, pleura, simulating aneurysm. root of both lungs. Heart displi Gross infiltration at right apex, with thickening of mediastinal Slight tuberculous opacity at left apex, with some thickening at iced a little to the right. Partial obliteration of cavity at right apex. SPECIAL AIDS TO DIAGI> rked fibrosis of mediastinal pleura, simuliiluig aiuui>.>iii. . and below clavicle, inclosed by fibrous tissue band wliicb IS disclosed by the fluoroscope. Heart small, partially eft. A complete cervical rib on right, rudimentary on left DIAGNOSIS AND PROGNOSIS Fi^. S'). — Posterior view. Infiltration of each apex. Well-defined ttiiclceninff, mediastinal pleura, markedly simulating aneuo'sm. Large circular pulmonary' cavity in right upper region, t'harartpristic mottling from tuberculous infiltratioa on both sides. Heart small and displaced SPECIAL AIDS TO DIAGNOSIS Fig. 86.— Posterior view. Extensive < simulating aneurysm. Diffused glandular involvement in both I ment of the left breast, which was completely excised two y infiltration in the lung are corroborative of physical signs. A per pliotograph ( Fig. 25), over the upper part of the .sternum, and to the right. rs ago. Evidences of advanced ible palpable mass, recognized as leart obscured, displaced upward DIAGNOSIS AND PROGNOSIS Fii: *^7 r.>-i.-iii.r \ i.w . Skiagrapli taken after death from general miliary- tuberculosis compli- cating pulmonary phthisis. Extensive tuberculous infiltration with pleural thickening of left side. Heart small, obscured, pulled materially to left. This picture is of especial interest as showing well-defined miliary deposit in right lung, unobscured by thickened pleura. SPECIAL AIDS TO DIAGNOSIS 291 fHF Fie. 88. — Posterior view. Pronounced fibi marked displacement of heart to right. Slight ( ity. best marked between sixth and seventh rib.s. condition is more fully described in text, see p. 2£ >us tissue proliferation of right lung, produc'ng ?struction of pulmonarv tissue, as shown by cav- Moderate infiltration at root of left lung. (This 1.) Heart of small size. DIAGNOSIS AND PROGNOSIS terior view. Thickening of medias^tJiial pleura, w in right upper lung. Two well-marked glands at St by virtue of anomalous shadows upon eacli side, by x-ray appearance. Heart of small size. dislocated upward. ght bronchus. This apable of interpretation by SPECIAL AIDS TO DIAGNOSIS 293 Fig. 90.— Anteric shadow very closely .*i confirmed by autop.sy Bw. Large abscess in right lung, following pneumonia. Cir ating aneurysm, and blending with the shadow of tlie heart, jrtesy of Dr. Sewall). DIAGNOSIS AND PROGNOSIS CHAPTER XLI DIFFERENTIAL DIAGNOSIS The clinical manifestations of a few chronic non-tuberculous pul- monary conditions closely simulate those of consumption. While a provisional dia.snosis may be made from the histoi'v, occupation, clinical course, and ))liysi(Ml sii;ii>. in many iiisiaiiccs. a definite differ- entiation from piiliiiuiiary tulicrculci^i- is n-iidi'iid pd-sihle only by exhaustive sputum r\aiiiiiiaii(in>. and, in a lew ca.^os, tlirough recour.se to the newer methods of diai;nosis. Occasionally even the presence of bacilli does not alToi-d accuiate information as to the precise nature of the patlio|o'.iii- (■liaiii;c. 'I'his is particularly true of the so-called "niinci's phi hi^i^. ' dilliculf of disassociatiou from consump- tion, yet (hlTcrili'^ \\idi'l\' iii the chararlcr ol' the nioi'liid conditions. The appoaram-c ol' l.a(alli onl>' atlci' Iouli-i-oiii iiiihmI oI)sci'\ ation does not justif\- the a,~siiiii|ilioiL of tiilM'i'cii|o~i~ as a faclor nf ,■! lojo-ic importance. The tcianiiia! iiifrci 10,1 1- iii,.|f|y m^raft.'d upon a -.,ii prc\iousl>- made receptive Ijy viituc of marked patholo-ic ihaimc. Aliiici's phthisis consists of an interact i\c comliiuation of cliidiiic I ironchit is. cnipliy.sema, and pneumonokoniosis iu comicction with frccpicnt bionchiectases and circniatorv distui liariccs. Thi- sxinpioms and i;cncial course are described cNcwIiciv. In lliis connection ii is sulli(aent to state that the clinical manifol.al ions are \-ery .-uiiLiesI i\-e of tuliei-culosis, especially the cou^ili, expectoiation, ily-piiea, and the occasional hemorrhages. There is raivl\-. ho\\e\-ei'. an\ e|e\,iiion of temperature. The c_yanosis is quite di-pinpoi tionate lo the pli\--ical evidences of pulmonary involvement. The dyspnea ra]jidl\- increases \intil it is noticeable even upon the slightest exertion. The couuli i- H-iiall\' patow-mal, and the sputum frothy and light. The ])li>-ical -i'jii< which are described in ooimectjon with pneumonokoinosis do tiot ijilfer materially from those di-].|ayed l.v nianv cas.-s of pultiM.narv t ul .efculosis. "' WhUe often there aiv liilatei'ai e\ idences of cat ;i lalial liud|\-enient and emphy- sema,, ph\~ical examiiialion -(iineliine- di-dose- signs of unilateral I ciic-um-ciihed aiva- ol' ni..i-tiiic and not infrequently I's. The hi-toiy. occupaiion. alisence of fever, dis- piie.a. and c\aiiosis, the parow-m.al character of the cut ,-epaiation of the spvitiim into distinct layers, liihiteial -iLins of catarrhal dist ni l.,iiice ami the coexist- iith colli iimed negative bacteiiologic lindings, suggest -tiiberciiloiis chaiacter of the condition, despite the loiihage and the occasional unilateral involvement. little excuse for confounding pulmonary tuberculosis iiiic bronchitis, bronchiectasis, uncomplicateil emphy- iiitei-stilial pneumonia. The fact, howc\-ef. that this is in connection with varying degrees of [jneunionoko- nio-i- as fiv.piently obsi.|\ci| in miniiit: icuions, with or without cavity formation, con-iitutes .a \'ei\- iniisidei .aMe proportion of all cases of chronic uon-tuberculoiis pulmonary affections, affords ample opportunity for errors in diagnosis. This grouping of conditions is more or less frequent in parts of Colorado, and is often confused with tuberculosis. con- -oli.l.ation. \ pulr pro] COUi di, tile fre toge thei' with tl ing 1 the L^mphyseni: essential n occurrence of 1 There can be 1. with 1 actite or c seni: a, or chroii groi; ipof COlldlt DIFFERENTIAL DIAGNOSIS 295 Other non-tuberculous ailments are found to present an apparent similarity to consumption. The existence of chronic influenza is a frequent cause of mistaken diagnosis. I have seen this condition produce all the rational symptoms anil physical signs of tuberculosis. These cases usually present the histdiy of an acute onset, with moderate constitutional derangement and hronchitic disturbance. The cough is often paroxysmal, and the expcctoratidu purulent, without tubercle bacilli, or other microorgan- isms except the Pfeiffer bacillus. Apropos of the rather strong simi- larity uf the influenza infection to consumption, I will cite the report of a few cases which have come under my observation. Case 1. — A striking illustration of the possible influence of this infection was observed four years ago in a child of ton years who was placed in my care about one month after the iiiiii:il dii-et nl' her ilhu'ss. In a i he cdnsdlidatidii ^i-n.hi- ally extended downuani tc the Icurth lil.aii.l hiwer ainile of the .scapula, witii moist rales thniii-hoiit this ic-ion. 'I'here also devi^ioped an aggra- vation of the licneral svin|iloni>. with incicasinu loss of weight. The physical condition leinaNie.J stati.maiy for the ensuing two or throe months, when i^iailnal iiii|iid\ciMent i)ei;an to l;iki' |i|ace. liefore the tion, with increased weight and no reuuuiun?i exideiice of the slightest pulmonary involvement. The child has reni.iineil alisolntely well e\(>r since. .Vn interesting feature of this case is t he f.-ict that 1 he pi-omcss of the consolidation corresponded to the so-called "line of march " of down- ward extension in tuberculosis on which considerable stress has been laid by some observers. Case 2. — Another instance of the possibility of error resulting from the presence of the influenza bacillus was exhibited by a woman who has remained under my obs,.|valion ten yeais, displaying, upon arrival in Colorado, signs of vei-\- act i\c and extetisive tuberculous infection of each lung. There h,-is taken place an :ist..nishin,u ini].rovenieiit , includ- ing a gain of o\-ei' loity ptiiiliances, in the absence of tubercle bacilli. ('lis, :;. In 1896 a man from Vermont, recovering from tuberculo- sis in Colorado, was suddenly summoned home by the telegraphic announcement that his three-year-old boy was dying of acute pneumonic tuberculosis. He returned to Colorado immechately, bearing in his arms thr child, wiin had brcn alnidst coniatose the entire distance. The tenipcraturc liad rciiiaiiicd in ilic iiciulil ini'hciod of 105° F. and the pulse and ri'.-pi ration,-; were Inimd inaiLcdh' accelerated. There were mod- erate cyano.si.s. ,r. and a |Milialiv r,,nM,lidated right hmg. The chief point of interest attaihes Id tlie ilela\id icscihition, which was not completed for several xi'ais. Tlieic perM-ied lor jidli/ a year a daili/ a/tcnioon rise oj ti inp, nihir, . finiliiiinil rough, with signs of consolidation and mdist rales, irillidiit hih,i;-li Imcilli. The child is now perfectly well, after the lapse ni ele\eu \ears. physical examination of the chest being entirely negative. It is almost imjiossiMe tn cdnceive of this pneumonia as having been tuberculous, not only because of the absence of the bacilli, but also in view of the comjilete lei c>\(rv in a child so young. Any attempt to explain the absence of bacilli by an alleged miliary disturbance with pulmonary manifestations is almost entirely controverted by the fact that the child recovered. Though undoubt- edly an instance of pneuinococcic inl'ection. the peisistence of the sj'mptoms and signs strc in l;1\- MiL;'_;e^iiM| a tulxTculous jirncess. Casei. — A woman, tliirt\ --i\ Maisold. i-.m^iilnd me upon August 30, 1907, four years after the' devi'lopnieiit of puhuonaiy trouble. The onset is of peculiar interest. In the mid-t oT a laryimoscopic application at the hands of a well-known laryimoloui>i a lari;e ]j|eilm't of cotton was permitted to entei- the trachea.. This was immeiliately followed by . the patient almost expiring from asphyxia- tly confined to the bed for three months, >-t inressaiit couuIl and ]iaroxysms of chok- ed to the pie-eni lime. iIioul li cxpectoration .en place rouMderaMe lo,-.-, of weight and i|M)n -liulit exertion. While fever is not perature is freqvienth' elevated for weeks at tion (lis, loses evidences of moderate infiltra- ni( li-t 1 ali's from apex to base, front and back, lie ila\iile to the fourth rib. There is pro- ■ liiilit upper chest. Confirmation of the ob.served by reference to the skiagraph (Fig. 88). It is scarcely conceivable that the result- of pliysic:d and x-ray examination could indicate more clearly a genuine tuberculous invasion, yet repeated examinations of the sputum fail to reveal tubercle bacilli. A i.eioi oi cs-;,.niial importance is the history of an acute onset of pulmonai \ ,-ympioms I rom ob\ious cause in an individual previously enjoying good health. Another condition which may be the occasion of mistaken diagnosis is pulmonary syphilis. It cannot be doubted that this disease coex- ists with consumption oftener than is generally supposed. In some instances the clinical evidences are confounded with those of pulmo- nary phthisis. The subjective symptoms of the two are almost iden- tical, the cough, expectoration, loss of weight and strength, and even the physical signs being very suggestive of ordinary consumption. An severe paroxysms . if eou- tion. She was sii bse.p.e suffering g: reatly fi ■om all ing. The. •ough h; IS per-i is scanty. There has t. streiiuth". u-itli ,\\ •spne;, uniloimly ■I time 1 ' ll\'~ic-|| tion of the I'ii^ht lui 1-.:. Will and on tht ' lelt Md e iV.iln nounced r< eiractioi 1 ol' t physical hndings wUl i) iVrfiu-f ill t iii|i('i'alure. lie clinical manife.st Tlii.s must licit he i ations is the infrequent enarded as an invariable (■lini;n'lcnst ic, as it is kiKiwii t hat fever may occur in philLS an.l 1 . ai tul.civl, .fan-i(llliV( liat many cases of 111- iiroloiiged inti'i\a ■ liacilli in the expei rsti,i:,a.ti(in iv^anlin- c(insuni|iti(in are deviiid ■tciralidii. Thi- Mi^uests the hlM,.rv, whirl, sli.iuhl .dinissi,,.! (H- denial n! an inilial lesi.in, tlie e\r-lel,re of sh, ana liiss (if hair. Sii|ililenieii itai'x' t(i this, theresh, mid , search l..r I'le (■xternal evideln •es (if the alilecedeiU dis- 1,1 l«. ..nipl.a sized that the stiiiit est disaXdW.-il ,if :i .syjihil- DIFFERENTIAL DIAGNOSIS 297 important dillY elevation of I distin,!;uishinL pulmonary s\ of teniix'iatni by the alisem the propriety embrace the sore throat, r: be instituted ease. It shoi itic infection, coupled with the aliseiice of clinical liianhe: t at ions of the disease, con.stitutes no coiiclusi\'o evidence as to iis piv\iou- non-exist- ence. Tlie grouping of the sulijective and object i\c syin|itonis of consumption without the bacteriologic e\'ideiices is snihcieiii to awaken a suspicion of pulmonary syphilis and jnsiiiy the iminediate employment of the iodids. That the t\\(i iid'ection- ((k \i-t with con- siderable frequency no oliiierver of piilnionaiy tulieniilosis will he dis- posed to deny. This subject will he discussed more fully under (.'om- plications. The diagnostic significance of pulmonary hemorrhage is sometimes subject to erroneous inter])retation. In view of the fact that many cases of pulnional'V 1 ulierculosi^ present a. hein(i|-iha'.iic onset in the ab.sence of previous sulijecti\-e symptoius or ph>:-ical si-ns. il hillows that the occurrence of hemorrhage, excn in indi\i(!uals in ap]ia,reiit health, should immediateix' aw aken a si innu' su.-piciou of iucipi,'iit l uherculous iiifeci ion. If hemorrhage develops in. associaUon will, lo:-,-: of wemht, ..lev.aliou of temperature, and counh. e\-en without jihysh'al sii^ns, a wananlaMe basis is furnished for ;i pi'(i\-isional diauiiosis. It i.- e,--eni i.mI , liowe\-er, in cases with negatiM' ]il,\>ical e\idences of tuberculosis, to eliminate all othei' condi'ions possibly ivsponsible for lien,opi y.ds. t^.everal times I l,a.\'e olisei'\-ed i,em(i,','ha,^es a n, on ^;- pal lent s p,'esei,i ing every apparent sulijective indicaiioii of piili,,onary I ill ei'culosi,-, in the ab.sencc of definite physical signs, tlic bleediim beini;- dependent upon other causes. A citation of a few cases may ihusi i-aie the o],po; i unit \- foi- mi- lakes in diagnosis through incorrect inlerpictal ions of the sii:nif,cance of iccur- ring pulnionar\- helnoiiha'ie. The fireated|y. rpon the lia-i~ of these heiuorrhages, in connection with the loss of wciiiht and subjecii\'e symptoms, a diai;nosis of tuberculosis had been made, and chanuc of climate recommended. Upon examination, dulness was found in the left front from the apex nearly to the base, with comiilete absence of breath- and voice-sounds. A supjiosed ajjcx-beat was \isilile well within the mammai\- line, but sliuhtly ele\ated. In the posterior axilla and in the back ( uackliu- lales. ol a mcatei' intensity than can be described or imai^iued. wiuc lieaid. both on inspiration and expiration, and recognized easily with the stethoscope slightly removed from the skin. No dulness was found at the right of the sternum, and it was 298 DIAGNOSIS AND PROGNOSIS almost impossible to outline the left lioundaiy of heart dulness. The cardiac impulse, however, could be felt nearly to the anterior axillary line, and murmurs of mitral stenosis and regurgitation were audible. Sputum examination was negative. A diagnosis was made of occlusion of the left bronchus from a cUlated heart. Hemorrhages continued with considerable frequency during the ensuing six weeks. There were also periodic attacks of alarming dyspnea and cyanosis. Although a degree of dilatation still existed at the time she was sent home, there were no symptoms of cardiac embarrassment. In front there was con- sideral)ly less huig compression and all adventitious sounds had dis- appeared from the back. The next lase illustrates, in the absence of mitral disease, the pos- sibility of error in ascribing pulmonary hemorrhages to a latent or con- cealed tuberculous process even when associated with loss of weight and strength. Nearly twelve years ago a man in middle life was sent to Colorado for supposed tuberculo.sis. I found him in bed, bleetling from the hmgs and coughing moderately. The hemorrhages hiid lieen frequent for several months, and there had been considerable loss of weight and strength. There was marked pallor, weak and rapid pulse, but no fever. The examination of the chest was entirely negative. A diagnosis of purpura luemorrhagica was sub-c(|uciitl\- ('stal>lished. The next case still further illii~i raic- tin- 'lifi'n-ulties encountered in arriving at correct conclusions (■(nicciiuiii; the significance of hemoptj-sis: A woman of nervous temperament was sent to Colorado in 1899 on account of very severe reciu'ring pulmonary hemorrhages. Her husband, who was a phA-sician, had made a diagnosis of consumption. Both parents and three brothers and sisters had died of tuberculosis, she being the only survivor. There was moderate dry cough, some expectoration, witlr loss of weight and a very considerable anemia, but chest and sputum examinations were negative. Shortly after arrival she suffered a severe pulmonary hemorrhage, followed by a recurrence of like character in exactly four weeks. It then developed upon inquiry that all her previous hemorrhages had occurred at a time corresponding to the menstrual period. Tlie diagnosis of vicarious menstruation was promptly made, and the nature of the condition fully explained. Treat- ment referable to the control of the neurotic conilition and the anemia sufficed to bring about an ultimate recovery. GENERAL CONSIDERATIONS 299 SECTION II Prognosis CHAPTER XLII GENERAL CONSIDERATIONS To the medical profession as a whole the general prognosis of pulmo- nary tuberculosis has hitherto assumed a minor degree of importance in comparison with other phases of the t ulierculdsis ])i-()ijlem. Active organized effort has Ijccii i-eiiteicd hirL;<'l\- u|miii ihe adoption and execu- tion of preventive lueasures, hut ihiiuii; iciciit \cais there also has been evolved definite knowledge as to tlie curaliilily n\ the (li>ease, b\- \iitue of patient and intelligent endeavor. To the iniliiKniary iinalid pro.ij;- nosis has ever been the one feature of supreme iiiieiesl. luiinechately upon awakening to a, realization of ilie coiiihtioii. the paraniotuit ques- tion relates to the chances, il' aii\-. there aic lor rec()\'ery. The prognosis of consumption is sulije<-t to coii-ideraMe ehisticity of interpretation. This is readily appreciated in noting the iniiuiiieral«le inteiiiieihary results between complete recovery and early death. Ily ctirf in its technical sense is meant the alisolute eliniiiuiti, niHin, „l i-rst,,rnli„ii ,,/ j„n,n r ,trhritii anil iisrj,il,n.-s. The suspeiiM, ,1, ,,l all ilu iuediat el v lalal i~sue. toll.iwed l)y an iii.h'lmite ihtkhI u( iiivalidiHu. shouhl not be .•(,n^ll■l;ed as u,,illiy oi' inclusion under a, cjassilicai ion of favorable results. The proper interpretation of a so-calle(l t a \-oi able prognosis involves ,•! disapjiearance of l)acilliandof thepliysical ^i^ns denoting active iindhcmeiit . an appar- ent return of previous siicnulh and vijior. an enduiance which must not be subjected to umci-onable tests, and a icstoiat ioii o|' earmii'i power. It is evident tliat tlie de-ive of anvst and the time iiece>>ai-y to|- its The llexibilitv .if its applicat ion is emphasized bv I he wide laiiueof .•liiiical results. It is allotted to Muue to enjoy .a conspiiaious rehabilitation of health, with entile disappeaiaiice ol' subjective and objective signs. Others are destined to secure a temporary respite from imminently impeii.hiiii daiiiicr. with siibse.nient partial arrest of the tuberculous proce.ss, an indehnite quiescence of the di.sease |iermittin,u a measure of usefulness, although often in a different sphere ol actixity. The con- sumptive should be made to understand that mice the tuberculous infection has become active, no matter how >,iii-i\ nm the later im]iro\'e- ment, the general mode of existence is ik cess.n il\ ch.iimi'd in maii\- of its essentials. In most cases of arrested tul>erciilo,~i> a minimi im of sac li I ice and suffering is secured only through a contmueil confoiinity to certain principles of daily living. 300 DIAGNOSIS AND PROGNOSIS The pi'osnosis of consumption is not only susceptible of uncertain construction as to its general meaning, but is at best of doubtful defini- tion in IndiriduaJ cases. The formation of a definite prognosis is often attended wit lit he ::ii'ai est diiHriilty. by \irtiUM if the diverucut significance attaching to >\■ the adxcnt of uiiliui'sccu cdin])!!- cations. Often the unexpected is ton ud tn liappcn. Many patients apjuir- ently doomed to death by virtue of every arcepted pid^nu-iic (•(lusidcr- ation are seen to make strikingly pictureMpie iccoNciies. wliile others, almost free from the influence of the di-ea-e. (|uirkly sm-cumb to an intercurrent pulmonary hemorrhage, with superxcinn- aspiration pneu- monia. Apropos of the not infrecpieut alniipt dexcldpiiieiit of untortu- nate complications. I have in mind twoyouim men who ha\-edied recently from pulmonary hemorrhage, alihoimh ha\iim exhibited, during a period of two years, most matil\iim iinpro\eiiieiit wiih eoiiiiiU'te dis- appearance of subjective synipleiii- and inaiked sub.-ideni-i> ot physical signs. These patients I ha ( liihl under eight years has secured an ancst of pulindiiary tulx'in Iom,- while under my su])ci\ision. Not infrequently, however, have 1 lieen permitted to niite the attainment of very satisfactory results in patients from eight to fifteen years of age. Two (•(,iisi.i,'ii..us ciiscs are cited for tlie pui-posc .il' illust I'at ion. In June, l!)(i:., 1 dl-clKir-cd :,. ciivd a Nnv ,,l ,.|,.vcii v..:,i> whi, h:id remained under m\- (>lis<'i'\ ;il kmi hrcrisclx- l wd yr:\v<. Al llir tin l' arrix'a! in Cohiradn'his illness IkmI I .eeu ( ,| I,,ui niuntlis' , iui':. I i. ,n , :,.||uwnn:an ^i.'Ute onset with rapid siil ,-.e(|Uent .lerjiia . whirl, was iiKirLed l.v 1iil:1, teni|ier- atureelevati.in ami extivnie .leMlitv. .A^ the det:,il~ .,1 tlu^ .-a-e will he reported in another i-diiiieci ion, ii i- sidlicieni .-ii tin- tune to e: II :inen- tion merely to a tew es.-enli^il le:itnres. 'I'here were e\t ivine ein;iclal ion. pallor, anil indnouneeil dy~piii':i. the rhihl, .-i- the n-nlt of ph\M.-al exhau.stion. l.eiii'.: sr:ireel\- alile lo st,-ilid iip.m lil~ fe.^l. f:xaliiinat ion of the chest dise|..-e,l tl!ee\iMenceo!e\tenM\C tnliereiilous invasion of the entire left liin,-. 'rhroui^honl I his .-ire: dences of moderate consolidation, with base. It goes without saying that ; almost unqualifieilly rendered. Hy y\v\ rigid su])ei\ision. a snipiising irnpidxc arrest of t!:e tuherrlllous proress was ; fibrous tissue proliferation. 'I'he .•hild the past two years, without xisiMe retroL^i recently to examine the paiieni. I was evidences of enduring arre,-t. Some idi with resulting unilateral deformitv mav be obtained Fig. 91. In May, 1906, a boy of fourteen was placed under my care, six months after an abrupt development of pulmonary tul)errulosis. The family history was excellent. The entire life of the chihl had heen ~pent in New Mexico until the earlv fall of 1905. when the famih- removed to Los Angeles. A severe cohl di'velopcd shortly afterward, with per.sisting cough, expectoration, temperature elex'ation. and loss of W(auht. Upon arrival in Colorado tlie |iatient was anemic and much (leMlitated. On examination of the chest, moist rales were recoi:nized in the left front, from the apex to the third rib, and upon the ri-ht side, from the apex to the .'iecond interspace. The left back was clear, but u|ion the right side moisture was detected to the lower third of the interscapular space. Tubercle li.icilli were exceedingly iiunierou.s. In view of the marked coiisiituiional change and extern of i uberculous involvement the prog- nosis was at best extremely guarded, I'liiler strict disciplinary con- trol a gain of lifty-li\e pounds w.is .'ichiexcd in six months. There is now no temperature elexatioii. cou,uh. it course. It is note- worthy that, as a general rule, ojijiorluiiilns for prnnioting recovery through change of climate and pn\ii(iiiiiiciit ;iic not uttered to the female equally with the male. If eneruct ir iik^imiivs in the way of climatic change and rational management aic insiiiuicd at all for the female, they are often deferred to later St a i;rs r equipped by virtue of inherent and acquired tendencies to adapt herself to unusual conditions. She exhibits, to a marked extent. ;i diminished restlessness under imposed restraint, suffers a lesser strain incident lo the cures and responsibilities of life, and bears a lighter biiiden of lin.mcial obligations. In addition, she manifests far less tendency to acts of iin|iru(lciice and dissipation. She not only yields a more read\- accept.-ince ol the luinciples of eaily supervisory control, but her subse(|uent obedience and com])|iance with detailed instructions are more complete and implicit. Only in exceptional instances is separation from family, either in favorable climates or in sanatoria, harder for the female than for the male. In open health resorts the hu.sband, if stricken with tuberculoisis, is often accompanied by his wife, while the woman, if similarly afflicted, is usually alone. It 304 DIAGNOSIS AND PROGNOSIS will lie cxiilainoil later that in the majority of instances the prospects of a s\i((i'— ml i-cUit inoguii-is ni females relates to the ver>- fart of their precious imloor environment and the more complete siilis((|ii('iit transformation of the mode of life. Another element, ajtpliiaMi' particularly to tho.se who seek climatic change, con.sists of the relatix'ely su]HMi(ir fiiianeial ciicunisiaMces of the female invalid. Unfortiuiateiy. ycMiim men with exieu-nc tuiierculous involve- ment and sa(ll>- iiia(lci|uate resources are niieii sent to health resorts with instructions to secure immechate employment. Many, financially im])overished, are compelled to work for a mere pittance in order to supply the imperative necessities of life. Further commentary is to the effect that while females are not iiri\ileL;ed to take advantage of climatic change as frequentl\- a~ male-, as a lule. they are not hurried to health resorts without proper pri)\ i-mu heuig made for their support. RACE Race has ever been found to exercise a con.siderable influence upon the determination of final results, as has been made clear in an earlier chapter. (See p. 59.) Its prognostic import may be regarded as a clinical truth incapable of controversial ar^uineiii. although the actual scope of its effect and the precise manner in which it is exerted may be subject to considerable variation. Its jini-nn-i k- liearing is due not infrequently to national differences of siisre|itil>ility to the disease. The utter lack of resistance against the rava'.;e- . .1 1 ul lerculosis is exempli- fied particularly by the prevalence and m(Hta.lii\- erculosis is extremely rare among the colored rail', although I have seen a few notable instances of such an occurrence in Colorado. The course of the disease is usually rapid, attended with progressive excavation, and marked by a high degree of toxemia. A striking illustration of the occasional complete arrest of the tuber- culous process in the negro is found in the following case: The patient, aged forty-five, developed well-defined evidences of ptilmonary tuberculosis two years ago. The phy.sical examination disclosed a massive consolidation of the left lung, with characteristic constitutional FACTORS PERTAINING TO THE INDIVIDUAL 305 disturbances, the loss of weight and general prostration being pro- nounced. There has taken place an entire arrest of the tuberculous process, with complete absence of subjective symptoms. The extent of pathologic change is illustrated in the skiagraph recently taken (Fig. 57), and the present excellent nutrition in Fig. 93. It should be added, however, that this rather unusual result is largely explained by the fact that exceptional opportunities were afforded for securing an arrest. The prevalence of the disease and its high mortality rate among the Irish people can hardly be explained by their social conditions or methods of living. A decided lack of resistance is exhibited by the wealthy and highly educatetl, as well as by the poor and ignorant. It must be assumed that Celtic temperamental characteristics have an intrinsic bearing upon the prognosis. Though brave to a remarkable degree in the face of imminent danger, the Irish courage in the absence of a critical emergency is not attended with that unswerving tenacity of purpose so Fig. g.S.— Compl of advanced tuberculous infection in negro. necessary for the maintenance of a protracted regime. The prognosis among the Irish is less favorable than in any other Caucasian race. Their neighbors, the Scotch, although endowed with less mercurial tendencies, are often more difficult to manage on account of their prover- bial stubborn characteristics, a continuous suitable regime being fre- quently out of the question. The Swedes, from my personal observations, appear to be more sus- ceptible to consumption than the Norwegians, Danes, or Dutch. In spite of their historic endurance and hardiness, they have exhibited an unexpected lack of resistance after the infection is established. The English and Germans particularly excel in their unwavering adherence to a fixed systematic regime. I have found the prognosis among these people markedly favored by their dogged perseverance in endeavoring to secure arrest, unmindful of external distractions and allurements. 306 DIAGNOSIS AND PROGNOSIS The Americans offer a less favorable prognosis than their more stoical kindred of English descent or their phlegmatic German cousins. The spirit of unrest and endeavor incident to the strenuousness of American life characterizes to a certain extent the pulmonary invalid of our own country. All too frequently it is asserted that recovery must take place within a certain stipulated time limit, which represents the maximum period allotted for the consummation of the desired result. The American charges into the proposed struggle for arrest with an impetuosity and enthusiasm corresponcUng to the energy displayed in commercial life or professional pursuits. Upon attaining a tangible improvement, he frequently cannot refrain from resuming his former duties, despite an incomplete arrest of the tuberculous process. Of all people, the Hebrews present the most unique and picturesque exhibition of racial influence upon the prognosis of consumption. The historic condemnation of the Jews to the ravages of disease seems literally to have been fulfilled in the prevalence of tuberculosis among these sorely afflicted people. In direct accordance, however, with their wonderful survival of persecution is observed, in many instances, a remarkable immunity to the toxins of pulmonary phthisis. Though quite susceptible to infection and unable frequentlj' to overcome the tuberculous process, the}-, nevertheless, exhibit powers of resistance which are indeed marvelous, despite the existence of extensive areas of destructive change. Early in my experience with pulmonary invalids there was noted in Hebrew patients a disproportion between the physical signs and the general condition. While, as a rule, the course of the disease is prolonged indefinitely, the process of arrest is slow and dis- appointing. The Jew is usually obedient and conscientious to the last degree in following instructions. FAMILY HISTORY AND PREVIOUS HISTORY The etiologic relation of an inherited predispo.sition has been dis- cussed in a previous chapter. After the disease is acquired, the family history must be accepted as having some bearing upon the ultimate outcome, although its prognostic import is not a factor of especial importance. The absence of a tuberculous family history has but slight, if any, favorable significance, but a strong hereditarj' taint renders the outlook for eventual arrest somewhat more gloomy in the majority of cases. A negative history of tuberculosis among immediate ancestors, if accompanied by a record of several deaths among the brothers and sisters, must be construed to indicate an impaired resistance characterizing the present generation. Deaths among brothers and sisters are frequently observed to take place at about the same age, suggesting that the powers of resistance, sufficient to withstand infection up to a certain point, are finally exhausted. Such a family record is undoubtedly a factor worthy of some consideration in a determinatiop of the individual prognosis. The prognosis is influenced to a marked degree by the apparent resistance of the indrndiial . as exhibited in a review of the previous career. This should embrace the history of infancy and early life, the record of previous di.seases, their duration, severity, sequel*, and an inquiry of past and present habits. Children whose parents (either one or both) at the time of conception were exhausted by disease or dissipa- FACTORS PERTAINING TO THE INDIVIDUAL 307 tion, are likely to be puny and delicate in infancy and to present the history of many severe illnesses during later childhood, with distinct manifestations of impaired strength and vitality in adult life. This element of diminished resistance to disease is shown in prolonged and tedious convalescence from typhoid fever or other constitutional affec- tions. If to such a history as this are added the unfortunate effects of dissipation or excesses of any nature, there results an inevitable shadow upon the final prognosis. OCCUPATION Considerable importance has always been attached to the influence of certain occupations upon prognosis. The inhalation of palpable dust by stone-cutters, glass-workers, potters, millers, grinders, and either coal or metalliferous miners has been regarded as particularly unfavor- able. Conclusions entertained with reference to the unfortunate out- look for such persons are unquestionably correct, although the tuber- culous element in these cases is entirely secondary to the antecedent pathologic change. While consumption is not the essential cause of death, the fact remains that the ingrafting of a terminal bacillary infec- tion upon a combination of morbid conditions, as chronic bronchitis, emphysema, pneumonokoniosis, and circulatory disturbance, carries with it a profound impression as to a fatal issue. Generally speaking, the prognosis is bad among people whose occupation involves confinement during many hours of the day, in small, ill-ventilated, and overheated rooms, as in factories and work- shops. It is universally conceded that people engaged in indoor pur- suits with marked sedentary habits are more likely to become subjects of tuberculous infection than their more fortunate fellows who enjoy an outdoor existence. It does not follow, however, that the former class possesses inferior opportunities for subsequent recovery. The pri- mary causal factor among such individuals relates to a diminished resis- tance resulting from impaired general health. This may react to their ultimate di.sadvantage chiefly from a continuance of the same unfavor- able environment. It has been my observation that invalids previously subject to more or less confinement are afforded a much better outlook after they conform to a system of rational management than those who have pursued an active outdoor occupation. An explanation of the more favorable prognosis in the former group is found in the more radical change in mode of life and consequently a greater impression upon the general health. Farmers and athletes who not only are accustomed to living out-of- doors, but also are trained to superior muscular development, are less likely to get well after consumption has been contracted than those occu- pying clerical positions. Thus the bookkeeper, who sits for hours at his desk in a cramped anterior po.sture, though much more likely to develop tuberculosis than the team-driver, offers a much better prognosis. The change to an outdoor life is usually followed by immediate general improvement, which is denied to those already habituated to an open- air existence. Among no class of people is the disease attended with less favorable results than in those accustomed to feats of physical strength involving prolonged effort and unusual endurance. In the same way it has been my observation that the more favorable the 308 DIAGNOSIS AND PROGXOSIS climate in which the infection occurs, the less hopeful the prognosis. In Colorado, while indigenous consumption is relatively infrequent, when once acquired, the subsequent course is usually rapid. TEMPERAMENT, DISPOSITION, INTELLIGENCE, AND CHARACTER There are but few favorable factors influencing prognosis of greater import than a phlegmatic attitude, gentleness of disposition, alertness of intellect, and strength of will. Individuals endowed with a philo- sophic temperament are less subject to nervous irritation, resulting from the annoyances and worriments incident to their environment and the indefinite period of invalidism. The benefit accruing from such a tem- perament is greatly accentuated by a cheerful disposition, keen intelli- gence, and strength of character. The stoical attitude, if not thus rein- forced, may be less advantageous even than a distinctly nervous tem- perament, supplemented by mildness of cUsposition, firmness of will, and refinement of manner. I have found improvement in patients exhibiting decided nervous tendencies without pronounced neiu-oses, quite as frequently as among those devoid of all e.xcitable proclivities. This is due to the fact that such persons are more keenly alive to the importance of their condition, more amenable to advice, and more conscientious in observing specific instructions. While in general the phlegmatic temperament is assuredly more conducive to good results than the irritable or unstable, an attitude moderately nervous often affords more active cooperation and obedience on the part of the patient. Rather high degrees of irritability present serious obstacles to a successful issue, but simple restlessness and excitation of manner, under rigid and tactful management, may yield fairly satisfactory re- sults. As the neurotic disturbance increases the balance at once is thrown to tlie disadvantage of the individual. While the exhibition of nervous tendencies always imposes more exacting demands upon the energy, patience, and skill of the medical adviser, a resourceful and tactful response is frequently sufficient to minimize their unfavorable influence. Innate cheerfulness of disposition modifies prognosis to an enormous extent, as the time element in the arrest of the disease makes unceasing call upon the patience and hopefidness of the invalid. The optimism of the cheerful and sanguine, supported by an active cooperation, is far more desirable than- the pessimism of the depres.sed and melancholic, even if accompanied by passive obedience to instructions. A happy, contented disposition enables the invalid to make the most of all suc- cesses and to minimize the import of temporary discouragements. Patients displaying a despondent or surly nature, on the other hand, are unwilling to accept the true significance of any favorable aspect, and are apt at all times to misconstrue motives, exaggerate trifles, and take offense at imaginaiy slights. Discriminating intelligence is of the utmost value, as it insures in the mind of the individual a precise conception of the nature of the disease and the manner in which an arrest may be secured. It often affords a comprehensive understanding of the rationale of therapeutic methods, and tluis permits a far more ready acceptance of the enforced regime. To .such patients there is usually but little occasion for argu- ment, as a simple statement of directions is sufficient to entail implicit obedience and to establish relations of mutual sympathetic cooperation. FACTORS PERTAINING TO THE INDIVIDUAL 309 The character of the patient is of vast importance in the continuous maintenance of an enforced regime. An unyielding determination to succeed is of no less value in the effort to recover from consumption than in other departments of human endeavor. Strength of will enables the invalid to rise above temporary obstacles and discouragements to which the weak and vacillating often succumb. Patients exhibiting indomitable perseverance and tenacity of purpose may be depended upon to pursue steadfastly the course which has been outlined, regard- less of distracting influences. FINANCIAL CONDITION The financial status must be regarded as a factor of considerable importance in the ultimate prognosis. There is a measure of truth in the saying "Only the rich can afford to have consumption." Such aphorisms, however trite, fail to convey accurately and completely the logic of actual facts. Although embarrassed resources certainly represent in many cases a serious obstacle to the attainment of best results, a large number of pulmonary invalids, despite this hancUcap, are enabled to achieve final success. It is not so much the size of one's bank account which permits a comparatively easy path toward arrest, but rather the judicious adaptation of the method and environment to the available funds. It has been my experience that impecunious circumstances, unless extended to the point of abject penury, furnish no insurmountable difficulties in the way of recovery. There is likely to exist among the poor a keener appreciation of the exigency confront- ing them, and hence a lesser likelihood of retrogression through dis- sipation, frivolous excesses, or other acts of indiscretion. The desire to take advantage of every reasonable facility at their command is especially overpowering to patients with small means or those dependent upon the assistance of others. By virtue of their financial limitations there is usually observed a conscientious adherence to the principles of systematic living. The financial condition is, at the very most, but a single factor among many, each of which has its due weiglit in a deter- mination of the final issue. Even a greatly restricted incnme, if asso- ciated with other conditions of favorable moment, is more to be desired than affluence if unattended by siinil.Mi- ]iro|iitious factors. The pro- longed period of invalidism, the deinninl Im su]ieralimentation, and the requirement of a proper social ami hy^iciuc environment illu.strate the value of an ample fortune, but not its invariable necessity. In view of the sanatorium provision in many parts of the country, a meager monthly allowance is often sufficient to supply actual needs. For people with inadequate resources, however, a practical difficulty is experienced at the time of departure from sanatoria. The end of their stipulated period of regime is followed in many instances by a return to work and to an eminently unsuitable environment. A rational solution of the problem for such invalids consists of the excellent oppor- tunities at their disposal in favorable climates. A class of patients with limited means, though not absolutely impecunious, are offered assuring possibilities of improvement from climatic change, provided accurate information is obtained in advance concerning appropriate accommoda- tions at a minimum expense. Patients dependent largely upon their own efforts for support, but exhibiting only incipient infection, are often 310 DIAGNOSIS AND PROGNOSIS permitted to secure arrest through outdoor employment in favorable regions. Many who are less fortunate than their fellows in their finan- cial equipment, possess other compensatory factors of favorable prognos- tic import, and with slight assistance in the beginning, are restored to their former usefulness and activity. This course of remark is pre- sented to emphasize the fact that a moderately restricted income is not in itself an insurmountable obstacle to success. SOCIAL ENVIRONMENT Few factors pertaining to the future welfare of the patient are of more importance than a hopeful and cheerful social atmosphere. In some cases the presence of the husband or wife may be of inestimable benefit in promoting the comfort and contentment of the invalid, and in guarding against indiscretions. In other cases, no matter how well conceived the intention or devoted the service, incalculable injury is inflicted through absence of tact, perversions of judgment, and obliqui- ties of disposition. Little children may be regarded in all instances as decided incumbrances to the progress of the patient, although mothers are prone to insist upon their decided influence for good, and protest strenuously against even a temporary separation. There is imposed a demand for careful individualization under such circumstances, pre- cipitate action not always improving the immediate prospects of the invalid. In general, children, regardless of their intelligence or gentle- ness of disposition, are of necessity a source of added care and anxious responsibility and cannot fail to disturb to a marked extent the quiet regime of invalidism. Segregation of the patient insures, in the majority of cases, more satisfactory results than are otherwise attained. The ready adaptation of the consumptive to a proper social environment affords in part a favorable estimate as to the possibility of final arrest. It should be remembered that it is not the patient alone whose temper- amental peculiaiities demand thoughtful consideration, but, unfortu- nately, the accompanying relatives as well. Many invalids are com- pelled to pay the penalty for the perversity, ignorance, and delu.sions of members of their family. In such cases the prognosis varies according to the keen discernment of the physician and his insistence upon removal of imfavorable social influences through such isolation as may be reason- able and practicable. While patients are not always ready to accept at once the wisdom of such advice, if presented firmly and tactfully, the difficulties of its execution often are removed. PERSONAL EQUATION IN MEDICAL SUPERVISION From the foregoing considerations it is easy to comprehend that the welfare of the patient is influenced to a remarkable extent by an inter- ested, painstaking regard for detail on the part of the medical advaser. The best results can be obtained only through a certain inherent aptitude of the physician, a devotion to the work in which he is engaged, and a personal solicitous interest in the individual. To discharge properly the many obligations incident to the care of the consumptive, and to assume with composure and confidence the anxious, vexatious responsi- bilities imposed, the physician must possess to an unusual degree patience, determination, vigilance, sympathy, tact, and enthusiasm. FACTORS PERTAINING TO THE INDIVIDUAL 311 The extent to which such endowment is possessed determines largely the welfare of the patient and frequently is sufficient to change impend- ing failure into ultimate success. CHANGE OF SURROUNDINGS AND CLIMATE As a general rule, the chances for recovery are greatly enhanced if opportunity is afforded for suitable change of environment. Patients are much less likely to do well at home, as the difficulties in maintaining a proper regime are sufficiently great to interfere with the accomplish- ment of the best residts, and to suggest the impracticability of the attempt, when possible to avoid it. Not only are the social conditions non-conducive to an unbroken period of nervous and physical relaxation, but the incidental interruptions, by friends and relatives, unavoidably impair the good effects of a systematic regime. The situation of the dwelling with relation to other buildings often is not such as to afford a sufficient amount of fresh air and sunshine. Atmospheric contami- nations may exist by reason of smoke, dust, and other impurities. Assuming an advantageous location of the residence, there may be lacking ample porch accommodations, preventing the possibility of attaining rest and fresh air jointly. The perfect fulfilment of these cardinal features of management is likely to be achieved only when special provision is made for the reception of pulmonary invalids. Due cognizance should be taken of the value of the psychic element attending a change of environment. The novelty of radically differing surroundings is a factor of the utmost importance in inspiring the patient with a degree of hope far in excess of that evinced at home. The invalid is forcibly impressed with the fact that something definite and tangible is being done to promote recovery, and often an abiding confidence is thereby established. This is especially likely to be the case if brought in contact with others who, through the force of example, instil an ambition to pursue an appropriate routine and, through the recital of their favorable progress, infuse transcendent faith in the attainment of similar results. A consideration of no slight importance relates to the direct educational influence exerted upon the patient in properly managed local institutions. Residence in sanatoria, even without the involvement of climatic change, is a factor of unquestionable prognostic value. Change of climate in properly selected cases, with or without recourse to sanatorium control, is of far-reaching importance in the effort to secure an enduring arrest. While improvement in many incipient ca.ses assuredly may take place by virtue of intelligent systematic management in relatively unfavorable climates, the chances for such happy results are not equal to those presented in more healthful resorts under the same conditions of management. There can be no question upon the basis of actual experience that the prognosis is wonderfully improved by removal to a suitable climate. Not only are the opportunities for arrest of the tuberculous process immeasurably greater, but stranger assurances are afforded for its enduring maintenance upon the active resumption of a useful occupation. 312 DIAGNOSIS AXD PROGNOSIS CHAPTER XLIV CONSIDERATIONS PERTAINING TO THE DISEASE Much iniportiiiice attaches to the history of the present illness, the physical signs, the evidences of apparent immunity, the extent of sj-s- temic disturbance, and the development of complications. HISTORY OF PRESENT ILLNESS Rigid inquiry concerning the early history of the disease will often disclose data of vital prognostic interest. The method of onset may be suggestive of the subsequent type and termination. Many cases with an abrupt invasion after the manner of acute pneumonic phthisis or acute miliary tuberculosis may he expected to pursue an exceedingly rapid course, with a correspondingly unfavorable prognosis. When the onset is characterized by other acute manifestations, at least an inti- mation may be afforded concerning the clinical course; thus acute septic disturbances, if predominating early in the cUsease, often persist to the very end. While initial hemorrhages usually call emphatic attention to the pulmonary condition and induce a more ready adaptation of the invalid to a suitable environment, it cannot be assumed that the exist- ence of early pulmonary hemorrhage exerts any inherent influence upon prognosis. Pulmonary tuberculosis supervening immediately upon an attack of influenza is usually of serious prognostic import. The indi- vidual resistance at such a time is comparatively slight, and the disease, in the larger number of eases, advances rapidly to destructive tis- sue change and pronounced constitutional impairment. Within certain limits it is safe to assert that the more acute the onset, the less favorable the prognosis and the more insidious the invasion, the greater likelihood of effecting an arrest. Exclusive of the manner of onset, a review of the extent and nature of systemic disturbance is also of considerable value in establishing a reasonable prognosis. The history of progressive loss of weight and strength, with fever, chills, night-sweats, and increasing dyspnea, sug- gests, of course, a far less favorable prognosis than obtains in afebrile cases without constitutional impairment. The previous duration of the disease is not without some significance, although it is scarcely true that the longer the condition has persisted, the less favorable the prognosis. If the infection has been of long duration and unattended by progressive pulmonary invasion or by symptoms of severe uonstitutional derangement, it may be assumed that the invalid possesses unusual powers of resistance, and that these fighting qualities, under proper management, may be later directed to a success- ful issue. After a period of disastrous delay, liowever, there inevitably must come a time, soon for some, later for others, and finaUi/ for all, when the patient becomes utterly unable, even with strenuous efforts of management, to display anything like former combativeness against the disease. It thus follows that while a prolonged duration, in the absence of distinctly unfavorable manifestations, may be construed as a favorable prognostic consideration in some cases, yet delay in the adoption of rational management results in a decided loss of opportunity in the effort to secure arrest. CONSIDERATIONS PERTAINING TO THE DISEASE 313 PHYSICAL SIGNS The physical signs are of signal importance as indicating the area of tuberculous infection, the nature and activity of the process, the extent of destructive change, and the amount of tissue fibrosis. The morbid pulmonary changes thus disclosed, although of essential value in an approximate estimate of the final results, are sometimes of far less prognostic importance than the accompanying symptoms. In view of the striking lack of conformity between the physical signs and the subjective symptoms, it is apparent that the former alone are quite inadequate for the purposes of prognosis. Many patients exhibiting extensive acti\'e areas of involvement display wonderful powers of resistance and secure an ultimate arrest of the infection. Others with comparatively slight evidence of pathologic change in the lung never- theless decline rapidly to a fatal issue, despite the best conditions of management and environment. The physical signs are of especial prognostic value in connection with the associated evidences of con- stitutional disturbance, when their significance becomes of vital impor- tance. The area of involvement, regardless of other considerations, is not always of vital prognostic import, the size of the infected region being of much less moment than the character of the tuberculous process and its degree of activity. A diffused infiltrative tubercle deposit without definite consolidation, abundant moisture, or softening offers a far more hopeful outlook than a circumscribed area of infection associated with advancing destructive change. The extent of liacillary distribution in pulmonary tuberculosis becomes of especial piognostic interest in pro- portion to the degree of secondary inflammatory disturbance and accompanying degenerative change. Other features of prognosis being equal, it is, of course, true that the outlook is better among patients exhibiting comparatively small areas of infection. A limitation of the disease at one apex is of more favorable import than a l)ilaterul involvement. It is insisted, however, that efforts to forecast the future of the invalid strictly according to the boundaries of tuberculous infec- tion are without warrantable basis. Attempts of this kind represent a profound misconception of the nature of the various pathologic proc- esses, the influence of constitutional symptoms, and other prognostic data. Chief importance attaches to the character of the lesions, the activity of the infection, and the tendency to cavity formation. Infiltrative processes are more susceptible to complete arrest through fibrous tissue proliferation than are areas of massive consolidation, in which subse- quent softening with excavation is likely to take place. In the latter event the constitutional symptoms are often more severe, the tuber- culous extension rapid, and the course of the disease comparatively short. In some ca.ses, however, consolidation, even of an entire lobe, may continue indefinitely without resulting cavity formation or per- sisting systemic disturbance. A conspicuous example of this phe- nomenon is shown by the following case: In June, 1897, a gentleman of forty-eight, a patient of Dr. Babcock, came to Colorado, exhibiting a massive consolidation of the entire left lung with abundant moisture throughout. There were marked emacia- tion, physical exhaustion, fever, and rapid pulse. He returned to 314 DIAGNOSIS AND PROGNOSIS Indiana in May, 1903, thirty pounds heavier, without fever or other evidence of constitutional disturbance, exhibiting not the slightest physical evidence of remaining tuberculous activity, although the con- solidation was complete and the function of the lung entirely suspended. He has continued without retrogression to the present time. While successful results of this character are sometimes observed, the prognosis, as a rule, is unfavorable in cases of gross pulmonary consolidation. Scattered areas of pneumonic consolidation supervening in the course of pulmonary tuberculosis are occasionally followed by apparent resolu- tion, but softening and cavity formation are the usual sequela?. If arrest of the tuberculous process eventually takes place, there is nec- essarily an enduring loss of functional activity throughout the diseased area. In some instances the prognosis, as a result of the fimctional impairment and the physical incapacity of the invalid, relates chiefly to a prolonged period of restricted activity. Corresponding to the degree of respiratory limitation, the patient may either be permitted to enjoy a useful career, or be tloomed to a life of complete invalidism. The activity of the infection is disclosed to a great extent by the amount of moisture within the bronchial tract. Despite pronounced indications of general improvement, rather definite information con- cerning a remaining active tuberculous process is afforded by the recog- nition of fine and medium-sized moist rales. No tuberculous deposit can be regarded as arrested or even quiescent so long as these physical evidences persist. There is no invariable relation between the state of the tuberculous lesions and the amount of cough or expectoration. I almo.st daily observe patients exhibiting moist rales upon examination, yet having but slight cough without expectoration. In the presence of bubbling rales the tendency to further extension of the tuberculous process is greatly enhanced, irrespective of subjective symptoms. Waiving tem- porarily a consideration of other elements influencing prognosis, it is fair to assert that the chances for recovery are improved in proportion to the diminution of moisture in the infected area. Prior to its com- plete disappearance favorable prognostic indications consist of a reduc- tion in the size of the rales, a lessening of their distinctly bubbling character, and their non-recognition save upon the act of coughing. The extent of tissue destruction as represented by pulmonary exca- vation adds greatly to the danger of hemonhage and the likelihood of septic absorption. This, with the accdniiianying evidence of advancing infection, constitutes an important tacim in prognosis. In some cases the cavity per se, even if it be of (•oiisKlcraliJc size, may possess but little significance regarding the probable outcome. If surrounded by indu- rated lung tissue, it may gradually diminish in diameter through inter- stitial contraction to such an extent as to prevent its further recognition. The unfavorable import to be attached to cavity formation relates to the rapidity of development, the progressive increase in size, the accom- panying moisture, and the subjective symptoms. Aside from gurgling rales over the site of the excavation, an indication of the activity of the infection is found in the amount of moisture present within an adjacent zone. Coarse bubbling rales in close proximity to the cavity suggest a further extension of the destructive process. Even rapid cavity formation may not always be construed as of luifavor.ible import, CONSIDERATIONS PERTAINING TO THE DISEASE 315 though this assuredly is the general rule. The first clinical manifesta- tions of general improvement are occasionally observed only after a rapid excavation with elimination of innumerable virulent bacilli and diminution of toxic absorption. As a general rule, the prognosis im- proves in proportion to the proliferation of fibrous tissue. In excep- tional instances the fibrosis assumes such undue prominence as to occasion circulatory embarrassment through obliteration of the finer subdivisions of the pulmonary artery. With extensive fibrous tissue change there may result such disturbance of physiologic function as to incapacitate the individual for an existence beyond the limits of passive invalidism. EVIDENCE OF APPARENT IMMUNITY , The relative immunity of individuals to tuberculous invasion is of much interest from a prognostic standpoint. Two essential influences are worthy of consideration, i. e., difTerenees in the virulence of the bacillus and in the resistance of the host. The former has been demonstrated by experiments upon animals and by the results of laboratoiy investigation. Cultures of tubercle bacilli inoculated into guinea-pigs have produced death of the animals in three or four weeks, while inoculations of similar animals with bacilli from another source of infection have been followed by death only after considerably longer intervals, denoting a decided difference in the viru- lence of the cultures. Thus it may be assumed that in the human being a corresponding variation of virulence may exist, and represent a factor of some importance in the evolution of individual immunity. Some enthusiastic observers have even attempted to forecast a prognosis from the character of the clinical manifestations exhibited by the person from whom a recent infection is ostensibly derived. Thus a benign type of the disease is alleged to attend an infection acquired from con- tact with invalids exhibiting quiescent tuberculous processes. This line of thought presupposes a predominant influence of the bacillus as a factor in prognosis, to the exclusion of all considerations pertain- ing to the resistance of the host. Such conclusions are utterly at variance with the results of clinical observation. In numerous instances I have noted a rapid course and a fatal termination of pulmo- nary phthisis in the husband or wife, while the infection of the consort from whom the disease was contracted remained inactive for years or became entirely arrested. Aside from inherent differences as to the virulence of the bacilli, a pronounced influence upon their virulent action is exerted by the character of the .soil. The individual resistance may be active and aggressive, or the defense of the organism may be comparatively slight. In some people the power to withstand the bacterial infection applies to the destructive change, and in others to the accompanying toxemia. It is well kndwii that marked differences are exhibited liy invalids in their susccjitiliilit y to the tuberculous invasion, and that the prognosis improves in pidiKntidn to the apparent resistance. To what extent in the determination of the resulting immunity the influence of the host is exerted upon the bacillus and vice versa is diflicult of differentiation. The trend of modern thought does not incline to the recognition of the bacillus as the factor of greater importance. Clinical evidence 316 DIAGNOSIS AXD PROGNOSIS as to the determining influence of the soil is demonstrated in the trans- formation of virulent bacilli into microorganisms of the attenuated type, as a result of progressive general improvement. It is not uncommon in the observation of a single case of pulmonary tuberculosis that short, thin, bright-staining bacilli devoid of granulations, and characterized by an even stain, are subsequently found to become long, thin, beaded, and to stain unevenly. The fact that the attenuated variety make their appearance only in proportion to the evidences of physical and general improvement may be construed as of material significance. CHARACTER OF SYSTEMIC DISTURBANCE Among the subjective symptoms endowed with variable degrees of prognostic significance, fever is by all odds the most important. There is no single feature throughout the entire clinical course of the disease of more fateful import than a persisting high temperature elevation. As previously explained, the true influence of fever in a determination of the final result depends upon its height, cause, and duration, but its unfavorable effect is exerted chiefly by virtue of its persistency. While fever may greatly modify the clinical course, its existence is not always precursory of disaster. A stubborn temperature elevation is often susceptible of great amelioration, if not of complete control, according to the nature of therapeutic management. Therefore, high fever must not be accepted as an element of fatal import until its unyielding nature has been demonstrated by exhaustive clinical effort. An undue acceleration of the pulse independent of fever or other obvious cause must always be regarded as of unfavorable moment. At the time of examination it is often impossible to judge accurately con- cerning the character and rate of the pul.se by reason of coexisting nervous excitement. An inorchnately rapid pulse, occasioned by exer- cise, mental emotion, or excitement, is rarely an insuperable obstacle to arrest, but continuous acceleration, constituting a true tachycardia, is possessed of grave significance as regards the remote prognosis. While less optimistic opinions must be rendered with reference to this con- dition, a conscientious application of hygienic principles of management may result in ultimate recovery. The degree of nutrition has been described as a consideration of momentous importance. A progressive diminution of body weight, despite the existence of other features of favorable significance, must be construed as a factor of ill omen. However, in some instances of exten- sive fibroid change involving both lungs, with marked impairment of function, a considerable loss of weight may accompany even an entire arrest of the tuberculous infection. These cases are seldom observed, but are conspicuous on account of the disparity between the external appearance and the physical signs. The fullest significance of emacia- tion is reflected in failure to respond to superalimentation and rest. Much more frec^uently, however, is loss of weight dependent upon dimi- nution of appetite and disturbances of digestion. Comparatively slight importance is attached to the acute gastric and intestinal symptoms resulting from an injudicious interpretation of the principles of superalimentation. Digestive disturbances occasioned by continuous dietary indulgence must undoubtedly influence prognosis, but the intelligence of the patient and physician usually is sufficient to CONSIDERATIONS PERTAINING TO THE DISEASE 317 guard against too frequent repetition of such disorders. As a feature of prognosis, the practical disadvantage of digestive derangement con- sists of the confirmed loss of appetite and the inability, without this, to conform to a satisfactory system of dietetics. A poor stomach repre- sents one of the most serious obstacles to a successful issue. The prognosis is also influenced materially by the physical findings in the upper air-passages, heart, liver, and kidneys. As stated elsewhere, a passive congestion of the liver is possessed of decidedly unfavorable import. Grave significance must necessarily be attached to many foims of kidney disturbance which have been described. Decided arterioscle- rosis invariably has an unfortunate bearing upon prognosis. The influ- ence of enteroptosis and the various psychoneuroses, together with the prognosis of laryngeal tuberculosis, pleurisy with effusion, empyema, pneumothorax, and other complications, will be discussed in their appro- priate place. The cough is of but slight interest as a feature of prognosis. Exten- sive bronchial irritation may exist even in the presence of satisfying gain in the pulmonary condition, but subsidence of cough and expectora- tion at such a time adds hopeful color to the permanency of the improve- ment. The cough may be distinctly disadvantageous on account of the resulting exhaustion, disturbance of sleep, and the production of reflex vomiting. Generally speaking, however, it is idle to suggest a relation Isetween the degree of cough and the probable outcome. The number of bacilli demonstrable in the expectoration is not always endowed with especial prognostic import. A reasonable construction to be placed upon their relative frequency is to the effect that their gradual diminution constitutes a favorable indication, particularly in connection with their increasing attenuation. In view of the encouraging outlook for the pulmonary invalid of to-day, as compared with the pessimistic attitude of the profession in the past, it will be of interest to read the following from an address delivered by Dr. Oliver Wendell Holmes in 1867 before the Harvard Medical School. These words by one universally revered by the medical profession are introduced largely because of the singular beauty of expression. In his simple and inimitable style he depicts the old-fash- ioned manner of medical instruction by presenting to one's imagination a worthy physician making his round of visits accompanied by his one student. "They jogged along the bridle path on their horses until they came to a lowly dwelling. They sat a while with a delicate looking girl in whom the ingenuous youth takes a special interest. . . . and so they left the house. "What thinkest thou, Luke, of the maid we have been visiting?" "She seemeth not much ailing, Master, according to my poor judgment. For she did say she was better. And she had a red cheek and a bright eye, and she spake of being soon able to walk unto the meeting, and did seem greatly hopeful, but spare of flesh, methought, and her voice something hoarse, as of one who hath a defluxion, with some small coughing from a cold, as she did say. Speak I not truly, Master, that she will be well speedily?" "Yea, Luke, I do think she shall be well, and mayhap speedily. But it is not here with us she shall be well. For that redness of the cheek is but the sign of the fever, which after the Grecians, we do call the hectical; and that shining of the eyes is but a sickly glazing, and 318 DIAGNOSIS AND PROGNOSIS they which do every day get better and likewise thinner and weaker shall find that way leadeth to the church-yard gate. This is the malady which the ancients did call tabes, or the wasting disease, and some do name the consumption. A disease whereof most that fall ailing thereof do perish. This Margaret is not long for earth, but she knoweth it not, and still hopeth." The logic of latter-day experience affords irrefutable testimony that save under exceptional conditions, no given case of tuberculosis should be pronounced absolutely hopeless. Far-advanced cases of consumption exhibiting marked constitutional disturbances and exces- sive tissue destruction are sometimes capable of undergoing a complete and enduring arrest. Clinicians whose experience has been confined to the observation of incipient cases in sanatoria may not be inclined to accept this statement, but those who have enjoyed the varied experience rendered possible in health resorts will verify such a conclusion. A few illustrative cases are presented to show precisely what is meant by reported recoveries of cases at first considered to be hopeless. Case 1. — A woman, twenty-four years old, consulted me ilay 24, 1902, the day of arrival in Colorado, eight months after recognized symptoms of tuberculosis. There had been progressive rapid failure from the beginning, and a loss of over fifty pounds of weight. She had experienced chills daily, with severe night-sweats, the average afternoon temperature being from 102° to 103° F. The cough was excessive and the expectoration, which contained numerous bacilli, amounted to four ounces during the twenty-four hours. Dyspnea was marked, and the pulse ranged from 120 to 140. Upon examination there was found extensive infection of both lungs; in the left, signs of consolidation with fine moist rales after cough from the apex to the fourth rib in front , and to the very base behind; in the right, numerous fine clicks from the second interspace to the base in front, and from the middle of the inter- scapular space to the ba.se in the back. On account of the extensive pulmonary involvement, the great emaci- ation, the long-continued sepsis, and an irritable, nervous temperament an absolutely unfavorable prognosis was rendered. The urgency of the case was such that cardiac stimulation was employed constantly, and upon several occasions I was constrained to believe that she would not survive twenty-four hours. With a beginning diminution of fever and circulatory disturbance, at the end of six weeks there gradually developed increase of appetite, cUgestion, strength, and weight, with lessening of cough and expectoration. Following a progressive improve- ment during a period of two years the patient was discharged as an arrested case and permitted to return home, having gained forty-three pounds in weight. There was no cough or expectoration and the pulse was uniformly under 80. Physical examination at that time disclosed no evidences of existing tuberculous infection. There had resulted, however, extensive proliferation of fibrous tissue throughout the infected areas, giving rise to appreciable changes in the pitch and quality of respi- ratory sounds without rales. She has remained at home over five j'ears, and last advices show no evidence of retrogression, in spite of the fact that she has given birth to two children since she left Colorado. Case 2. — A woman, thirty-five years old. arrived in Colorado in April, 1899, nearly five years after the recognized onset of her pulmonary CONSIDERATIONS PERTAINING TO THE DISEASE 319 infection. There had been a loss of fifty-five pounds in weight; the cough was distressing and paroxysmal, with daily high fever and a pulse varying from 130 to 160 at rest. She was unalsle to sit up in bed and for weeks nourishment had been taken through a tube. Upon examination there were found signs of extensive active tuberculous infection of each lung; in the right upper front a cavit}' the size of a small orange, surrounded by consolidation which extended to the fourth rib, and in the back to the lower edge of the scapula; in the left, consoli- dation from the apex to the third rib and to the middle of the inter- scapular space. Throughout this entire region moist bubbling rales were recognized on easy respiration. A hopeless prognosis was made without qualification. The family physician who accompanied her to Colorado stated that she could survive but a week or ten days at the most. She was kept in bed in the open air for nearly six months, with licjuid nourishment and nutritive enemata for two months. She remained under my constant oliservation for two years, during which time she exhibited a slow, but remarkable, improve- ment. During the first six months in bed she gained fifty pounds in weight, with a corresponding improvement in her general and pulmo- nary conditions. At the time she was discharged there was a gain of nearly seventy pounds in weight, but with a slight persisting bronchial cough. There was no moisture recognized upon physical examination, though fibrous tissue changes were cjuite pronounced. She moved to a remote part of the State and continued to maintain her improvement until she cUed, two years ago, of acute appendicitis. Case 3. — A woman, twenty-nine years old, arrived in Colorado February, 1898, two years after developing pulmonary tuberculosis. During this period she progressively declined in all respects. Theie were great emaciation, daily elevation of temperature, weak, rapid, and irregular pulse, chstressing paroxysmal cough, and copious exijectora- tion with very numerous bacilli. Examination disclosed evidence of an active process involving a large portion of each lung. In the upper right lung in front there was a cavity the size of an orange, in the midst of an area of consolidation, with numerous bubbling rales from the apex to the fourth rib, and in the back from the apex to the very base. On the left side there was consolidation with moist rales from the apex to the third rib. Moisture was recognized in the left axilla, and in the back from the apex to the lower third of the interscapular space. On account of the exten.sive pathologic change, pronounced dyspnea, irritable pulse, hysteric temperament, poor appetite, and frequent vomiting, an ultimately hopeless prognosis was entertained without reserve, which opinion was indorsed by Dr. Babcock, who saw the patient shortly after her arrival in Denver. She has remained under my personal oljservation during a period of ten years. During the first three years very little change was noted, either in the general state or in the condition of the lungs. The cough was frequent and exhausting, expectoration copious, and bacilli numerous. During the fourth year a beginning improvement was ob.served in the genei-al condition, the physical signs remaining practically stationary. D\iring the fifth year a gain of fifty pounds was made in weight, followed by an astonishing improvement in every respect. During the past five years she has maintained an excellent nutrition and gained remarkably in strength. 320 DIAGNOSIS AND PROGNOSIS For nearly four years there have been no bacilli found in the sputum after numerous examinations. There is a persisting bronchial cough at intervals, with occasional expectoration. The examination of the chest shows no indication of an existing tuberculous process, although fibroid changes are reachly detected. Cose 4. — A young man, aged nineteen, consulted me in May, 1899, his illness having developed ten months previously as an acute pneu- monia involving the major portion of the left lung. The patient was sent originally to Las ^'egas, New Mexico, in company with a physician and trained nurse, and two months later to Arizona, Koch's tuberciJin being used dail.v for a prolonged period. Following an initial gain while in the Southwest there ensued a persistent elevation of temperature, loss of weight and strength, followed by several recurring hemorrhages. Upon arrival in Colorado there was a loss of thirty-two pounds in weight, the temperature was 104° F. in the afternoon, and the pulse rarely below 120. Numerous bacilli were found in the sputum. There were signs of massive consolidation in the left front from the apex to the fifth rib, with moist rales throughout, and semidry clicks in the left axilla. In the back, bubbling rales were heard to the very base, with an area of well-defined consolidation extending from the apex to the middle of the interscapular space. On the right side there was slight consolidation at the apex, with moist rales to the second rib, and scattered areas of infil- tration with moisture throughout the front. Fine clicks were heard in the right interscapular space. In view of the age, the active advanced process in one lung, the more recent invasion of the other, the hemorrhagic tendency, persisting faver, and rapid pulse, the prognosis could scared}' l^e other than imfavorable. There developed, however, a gradual resolution of the consolidated areas, and a lessened activity of the tuberculous process, as shown by the slighter amount of moisture, chminution of cough and expectoration, fewer bacilli, ami incipase of weight and strength. Three and a half years ago, aftei- tnc years' con.stant mechcal observation, the patient had gained nearly sixty pmmds, and there was entire absence of cough and expectoration. Examination of the chest failed to disclose any tuberculous activity whatever, there remaining only a somewhat pro- longed high-pitched expiration, tubidar in quality at the left apex, with- out moisture. During the past three years he has resided much of the time in Illinois. At present, nearly nine years after coming under my observation, the arrest is complete. Case 5. — A boy, nine years old, arrived in Colorado June 1, 1903, exactly three months after the development of acute bronchitic symp- toms. Following the initial onset he remained eight weeks in bed with a persisting fever and moderate cough. At the end of two months, accompanied by his parents and family physician, he went to New Mexico, remaining thirty da3-s. During this period there had been a progressive rapid decline. At the time I saw him he was greatly emaciated, weighing exactly fifty pounds. His average afternoon temperature was 101.5° F.; there was marked dyspnea on exertion, the appetite was exceedingly poor, pulse 124, and there was a persi.sting cough without expectoration. There were signs of con.solidation throughout the entire left lung, with moist rales upon easy respiration from the apex to base, front and back. In view of the age, the histor}- of the development of an idiopathic CONSIDERATIONS PERTAINING TO THE DISEASE 321 pleurisy, undoubtedly tuberculous, the continued fever, the great emaciation, and physical signs, an unfavorable prognosis was rendered. The exclusive care of the child was committed to a trained muse, and an unbroken regimen was maintained for a period of two years and one month. During this time the child exhibited most remarkable improve- ment in spite of the fact that at the end of four months he contracted a typhoid fever which was of eight weeks' duration, and was followed in the second year by an acute fulminating appendicitis, operated during the first twenty-four hours. He was discharged as cured in June, 1905, there being not the slightest trace of moisture recognized after repeated examinations of the chest, although fibroid tissue pro- liferation was extensive. His general condition was excellent in all respects, his weight approaching eighty pounds. He has remained well ever since. Case 6. — A man, forty-one years old, came to Colorado in September, 1904, nine months after an acute pneumonia, which was followed by severe persisting cough and continued fever with night-sweats. In the mean time he had experienced a severe hemorrhage and lost much weight and strength. The sputum had been loaded with bacilli. He had gained eighteen pounds in a well-known health resort, but exhibited persisting elevation of temperature, with occasional chills and severe sweats. Although remaining in bed during day and night for months, there was subsequent loss of weight, with increased cough and expec- toration. The condition of the patient was pronounced entirely hopeless by an eminent physician. Upon arrival in Colorado examina- tion of the chest disclosed extensive active tuberculous infection of each lung. On the right side moist rales were heard in front to the third rib, and in the back from the apex to the very base. On the left side there was well-marked consolidation in the upper portion, with but slight moisture in front, but with coarse rales in the back from the apex to the lower angle of the scapula. A further decline was exhibited during several weeks. The tem- perature was constantly elevated, chills and night-sweats were frequent, and there resulted greater loss of flesh and strength. The cough was extremely distressing, the expectoration copious, containing numerous bacilli, the temperament markedly nervous, the patient apprehen.sive and discouraged. The active, widely disseminated tuljerculous infec- tion, the unmistakable evidence of sepsis, impaired digestion with entire absence of appetite, the weak and rapid pulse, and the general prostration were sufficient to justify, almost without reserve, an unfavor- able prognosis. After several months a gradual improvement was observed which has continued without interruption. In September, 1905, one year after coming West, there was but little or no expectoration, fever had been absent several months, a gain of forty-five pounds in weight had been established, and the pulse was uniformly of good character. At the present time it is impossible to discover any physical signs attrib- utable to an existing tuberculous process, no moisture being recognized after careful exploration, although fibrous ti.ssue change is marked. The patient has engaged in an arduous legal practice in an unfavorable climate during the past two years, devoting the summer season to rest and recreation in the mountains of Colorado. At the time of his resumption of work examinations of the sputum failed to disclose the 322 DIAGNOSIS AND PROGNOSIS presence of bacilli. They have been discovered at intervals since then, but not invariably. Case 7. — A young lady, eighteen years old, consulted me in June, 1896, immediately upon coming to Colorado. Her illness was of one and one-half years' duration, during which time she had spent several months in the White Mountains and in Asheville. There were great emaciation and pallor, dyspnea upon the slightest exertion, nau.sea and daily vomiting with diarrhea, pulse 120 to 130 at rest, cough exceedingly severe, expectoration purulent and copious. Upon exami- nation the entire left lung was found to be involved. There were signs of pronounced consolidation throughout, coar.se bubbling rales on easy breathing from apex to base, front and back, with a cavity nearly the size of a fist in the front of the left upper lung. There was nothing in the history or condition to furnish a warrant- able basis for the slightest encouragement. Her age was against her, she was profoundly septic, and her powers of resistance were evident!}^ exhausted. Cavity formation had already taken place, and softening was rapidly going on in a lung partially consolidated from apex to base. She has remained under my observation during the ensuing ten and one-half years. Without entering upon a tedious recital of her detailed progress I will state that during the greater portion of this period she conformed to a strict regime. Resulting impro\ement was noted from time to time, despite the fact that her circumstances were limited and only absolute necessities permitted. Her eight years of unremitting effort and patience sufficed to bring about a complete arre.st. At that time there was but little cough, and the expectoration essentially bronchial in character. She had gained fortj'-three pounds in weight, had shown no constitutional .symptoms for one or two years, and the examination of the chest revealed no evidence of existing tuberculous activity. Examination of the sputum was entirely negative. She was married to an army officer verj' shortly afterward, and for over a year led the gay and strenuous social life incident to a military post in close proximity to a large city. At the time of her departure for the Philippines I was privileged to make a carefid physical exami- nation. In spite of her late hours of social chssipation it was found that there had developed no renewed activity of her former infection. A large cavity persisted in the upper left front without moisture. No rales could be heard in any portion of the lung, which, through the lapse of yeai's, was found to have undergone extensive fibrosis. There was occasional cough, but the sputum was subjected to examination with continued negative results. In connection with the foregoing reports there are several important facts to be borne in mind: (1) That these cases are selected merely to illustrate the possibUit;/ of arrest in far-advanced cases, and that other instances of improvement equally striking can be cited. (2) That the cases here described were considered without exception, by other physicians and by myself, as being utterly hopeless by virtue of every consideration which ordinarily influences prognosis. (3) That these patients have not simply undergone improvement with the ultimate outcome as yet uncertain, but, in the proce.ss of years, have secured a complete arrest of the tuberculous trouble, with entire absence of physical signs, sputum, and bacilli, and restoration to former useful- ness and activity. (4) That the necessity for the practice of strict economy CONSIDERATIONS PERTAINING TO THE DISEASE 323 has been no insuperable barrier to the acquirement of complete arrest in a suitable climate under a proper regime. (5) No claim is made that the results obtained were referable entirely to climatic influences. It is contended, however, that such I'esults in equally desperate cases are impossible of attainment in what may be regarded as relatively unfavorable climates, no matter how perfect the regime. (6) No special methods of treatment were employed other than those familiar to every physician of experience in the management of pulmonary tuberculosis. (7) No credit for results obtained is assumed other than that which may relate to an unremitting personal attention to detail, and an adaptation of means to ends at times somewhat radical. (8) No case is here reported that is not entirely subject to confirmation by the attending physicians, whose names are not cited in the report. As logical conclusions from such results it may be stated, fii-st, that no physician can assume with positiveness to pronounce death sentence upon any case, no matter how desperate the apparent extremity. Second, that each case strictly on its merits is entitled to a determined, painstaking, and aggressive effort to secure arrest. It follows that while the rich are abundantly able to combat the disease through such means as their medical advisers may counsel, the poor, deprived of such advantages, are justly entitled, at the hands of the State, to adequate hospital provision in an effort to preserve life, rather than to be instructed merely as to the proper method of passing their remaining days. PART V COMPLICATIONS INTRODUCTION In a book of this character it is particuhirly desirable to review the various complications observed in the course of pulmonary tubercu- losis in the light of their clinical significance. It is not designed to limit the consideration of complications to tubei'culous infections of other organs or remote parts of the bod}', but to include, as well, the intercurrent non-tuberculo\is affections which exert a modifying influ- ence upon prognosis. From a practical standpoint the coexisting tuber- culous processes in other regions are of especial importance and will be considered in some detail. Tubercle bacilli may be chstributed to various portions of the human system through the medium of the blood-stream; to the pleura, pericardium, lymphatic glands, and certain other regions through the lymph-channels; to the pharynx, stomach, and intestines through the process of ingestion; and to the larynx, in some instances, through direct contact with the expectoration. In the following consideration of coexisting tuberculous infections the grouping of the various com- plications is attempted as far as practicable in accordance with their supposed pathogenesis. Through the agency of the circulation as a route of distribution the bacilli are deposited not only in remote and widely separated regions sometimes involving an entire organ or part of an organ, but also are disseminated throughout the body. The general distribution of the bacilli by the blood-stream gives rise to the clinical recognition of what is known as acute miliary tuberculosis. SECTION I Acute Miliary Tuberculosis C'H.XPTER XLV GENERAL CONSIDERATIONS This condition is characterized by the presence, in an infected organ or in many organs, of innumerable, grayish-red tubercles, the size of a millet-seed, which are evidently of simultaneous deposit and exhibit the same degree of development. The present clear conception GENERAL CONSIDERATIONS 325 of the etiology of miliary tuberculosis has been afforded as a result of the admirable work of Buhl, Sir Astley Cooper, Weigert, Benda, Pon- fick, Simmonds, Cornet, Engel, Heller, Eichhorst, and others. Sir Astley Cooper recognized the existence of tuberculosis of the thoracic duct in 1798. Tubercles have since been found in the duct by Ponfick, Weigert, Koch, Meisels. Brasch, Hanau, Sigg, and Benda. Weigert demonstrated the existence of tuberculosis of the blood- vessels and its association with miliary tuberculo.sis. Tubercle bacilli were found in the blood by Baumgarten, Weichsel- baum, Meisels, Lustig, Kutimoyer, and Sticker. Tuberculosis of the veins was described by Miigge, Schuchardt, Bergkammer, Hau.ser, Meyer, Will, Heller, Brasch, Banti, Schmorl, Kockel, and others (Cornet). From the reports of these men it has been definitely established that miliary tuberculosis can result only from the distribution of bacilli through the circulation, and that these microorganisms always gain entrance to the blood-stream from a preexisting degenerative tuberculous focus, although the latter is sometimes almost impossible of detection. They have shown that a genuine tubercle deposit may take place in the arteries, veins, and tho- racic duct as a result of the peripheral extension of adjacent tuberculous foci. In some cases a thickening and obliteration of the finer arteries and veins accompanies the tuberculous extension, while in others, with or without perforation, the bacilli are permitted to enter the circulating fluid through degeneration of tubercles in the wall of the arteries, veins, or thoracic duct. It has been demonstrated that the bacilli do not multiph' in the blood. The primary source of infection may be found in a caseating nodule in the lungs, or in a tuberculous focus in the lymphatic glands, the genito-urinary system, bones or joints, pleura, intestines, or peritoneum. Longcope, in a reported analysis of thirty cases of generalized tuberculosis with aspecial reference to the thoracic duct as a site of localized infection, introduces interesting data pertaining to the fre- quency of such involvement in cases of the more acute type, in asso- ciation with a generally disseminated tubercle deposit in the various organs. In subacute cases the duct was rarely involved, and in chronic cases not at all. It is easy to understand that the precise distribution of bacilli to various parts of the body must correspond to their point of entrance into the circulation according to the site of vessel-wall infection. If the bacilli only penetrate comparatively small aiierial luanches, the resulting miliary deposit will he confined to the parts thus supplied. In the event of "their entrance iiitd tlie pulmonary vein, the distribution takes place throughout the sysiemic circulation from the aorta to tlie smallest arterial branches. ^\ heii the bacilli are conveyed to the lungs via the lesser circulation, these organs act more or less as a filter, and become diffusely studded with miliarj' tubercles. Manifestly, the oiJiioituinties for miliary infection should obtain especially in cases of extensive pulmonary tuberculosis, and in this disease a general tubercle deposit occasionally supervenes. In some eases the pulmonary involvement is quite insignificant, suggesting the possibility of its non-relation to the development of the miliary infection. While pulmonary tuberculosis is an important etiologic 326 COMPLICATIONS factor in the production of miliary tuberculosis, comparatively few- cases of consumption are complicated by tliis condition. That miliary involvement is not of more common occurrence in the course of pulmonary tuberculosis has been the occasion of con- siderable comment. Certain it is that the clinical manifestations of miliary tubercidosis are observed much less often than woidd be supposed in view of the unusual opportunities for general infection. This occurs more frequently in early years than in adult life. Miliary tuberculosis has been reported by some observers to follow frequently the absorption of infected lymphatic glands or the exudate of tuberciUous pleurisy or peritonitis. From the observation, however, of a large number of cases of this description I recall but few instances of sub.sequent miliary involvement. I have noted manj^ times, however, the development of miliary tuberculosis in pulmonary invalids who, though well nourished, were suffering from profound emotional disturbance. Individuals of decidedly ner\-ous tem- perament are especially prone to this condition, particularly if subjected for prolonged periods to either depressing or exciting influences. I recol- lect, in particular, a young man with arrested pulmonary infection of over a year's standing, in excellent nutrition, and presenting every physical indication of perfect health, who developed a miliary infection tnlldwnii: -cvcial nmnths of mental perturbation as a result offinaiM i.il all. I >|iiiiir~iir I iiil.anassment. My attention has been called to the snnii'wha.t miu-iial lic(iueiicy of miliary tuberculosis in alcoholic individuals, or in those previously accustomed to such overindulgence. The structural formation and development of tidjercle have been discussed in a preceding chapter. The clinical symptoms of general miliary tuberculosis are variable to an extraordinary degree. Notwith- standing the remarkable diversity of clinical manifestations common to this disease, it is possible to group the various combinations of symptoms exhibited in different cases into three fairly distinct classes. These forms of general miliary tuberculosis are designated the pneumonic type, because of the predominance of symptoms referable to the lungs ami ihc iriosfuition of definite physical signs; the typhoidal, from the ( 1(1-1 ■ -mil il It ion of typhoid fever; and the Jneningeal, by reason of clinical data iiniiituig conclusivel.v toward a cerebral involvement. It is not always possible to differentiate closely between these three varieties of miliary tuberculosis. No matter how clearly defined the early manifestations and how threctly suggestive of either the typhoidal or the pneumonic type, a meningeal tubercidosis not infrequently super- venes as a terminal condition. Many cases, however, are distinctly typhoidal. pulmonary, or meningeal from the beginning to the very end. Even among cases closely conforming to any single variety of miliary tuberculosis a very considerable latitude is observed in the combination of clinical symptoms. A purel.y typical case of, respec- tively, the pulmonary, typhoidal, or meningeal form is easily the subject of text-book de.scription, l)ut as a matter of clinical observation there are often noticed in the same general class conspicuous tlifferences in the grouping of symptoms. Cases conforming to any of the distinct varieties may be of abrupt onset or they may begin with less defined symptoms. There is also noted a striking variation in the cour.se and duration. Cases of the typhoidal t3-pe may be attended with consider- able temperature elevation or may be purely afebrile throughout. GENERAL CONSIDERATIONS 327 The various combinations of symptoms, particularly in the typhoidal and the meningeal forms, are exceedingly numerous, and yet the clinical picture in each instance may be sufficiently characteristic to permit its classification. In a series of cuscs of inoningeal tuberculosis certain manifestations or groups of syiii|iioiiis may l.)e present in some and entirely absent in others. Tliis is illust rated liy the inconstancy of rigidity of the neck, retraction of the head, vomiting, constipation, inequality of the pupils, irre.mihu- pulse, retraction of abdomen, changes in the reflexes, spasm, and jjai-alysis. In spite of the wide range in the clinical data and the incompetency of single symptoms as immutable features of diagnosis, accurate inter- pretations as to the significance of the varied manifestations are usually affortled. In meningeal tuberculosis it has been found that age exerts an especial influence in determining the nature of the clinical picture, certain comljined symptoms unusual in childhood being more or less characteristic of infancy. A single disease capable of producing so infinite a variety of subjective and objective manifestations, when unac- companied by recognizable evidences of pulmonary tuberculosis, must of necessity present added difficulties in the way of clinical different iution and interpretation of symptoms, when developing as a cniiijilii-ii/ion of an intrathoracic infection associated with more or less systemic disturli- ance. The early symptoms of general miliary tuberculosis are especially obscure when this" condition complicates a preexisting pulmonary infec- tion. Thus the significance of fever incident to a beginning miliary involvement is entirely lost in a distinctly febrile case of pulmonary phthisis. One of the chief obstacles to the early recognition of acute miliary tuberculosis relates to the predominance of general symptoms over local manifestations until late in the disease. The systemic disturbances are occasioned liy the toxic absorption which takes place a few hours after the entrance of bacilli and soluble poisons into the blood, while the local phenomena are due solely to the formation of tubercles, which are of much later development. Thus it happens that the clinician is often unable to ascribe a definite pathologic significance to preliminary symp- toms, and is compelled to approximate his early conclusions upon the basis of combined general manifestations and a review of all possilie etiologic factors. The varied combinations of clinical features in miliary tuberculosis are entirely inexplicable, save upon the score of essential differences attending the entrance of bacilli and toxins into the blood- vessels. Widely divergent symptoms in different individuals are depen- dent upon the site of the original focus of infection, the relative number of bacilli, and the amount of soluble poison introduced into the circu- lation. According to the location of the eruptive source, the bacilli may find their way directly to the left ventricle and enter the larger circulation for distribution throughout the entire body, or proceed to the terminals of the pulmonary arteries through the intervention of the lungs. In this manner there is exerted to no small degree an influence upon the character of the ensuing manifestations. The number of tubercle bacilli, together with the amount of soluble poison entering the circulation, produce a deter- mining effect upon the severity of the general symptoms and the extent of tuljcrcle formation. Their ingress into the blood-stream is subject to enormous variation according to the size and number of degenerating vascular foci. The entrance of comparatively few bacilli into the cir- 328 COMPLICATIONS dilation from a single eruptive focus may not produce a widely dis- seminated tubercle deposit, and if not followed by successive crops, may cause clinical disturbances of but temporary duration, sometimes result- ing in apparent recovery. It unfortunately happens that in the large majority of cases opportunity is afforded for a renewed discharge of tubercle contents into the circulation from the same focus, and that egress of microorganisms from similar foci often takes place in other parts of the vascular system. This permits a ready explanation of the occa- sional exacerbation of temperature and other clinical disturbances follow- ing such a quiescence of symptoms as to suggest a possible recovery. Differences in the virulence of the bacilli and toxins introduced into the circulation from an eroded tuberculous area are not without their proportionate influence in characterizing the severity of both the general and the local symptoms. Cornet has called attention to the fact that bacilli discharged from a recent focus of infection are much more active in producing general tubercle formation than the attenuated, broken- down microorganisms from a non-progressive and long-standing tuber- culous process. On the other hand, he attributes especial virulence to the soluble poisons accompanying the latter type of bacilli, and a com- paratively benign toxic effect to the former variety. Irrespective of the verity of this assertion it would appear that the age of the patient, the previous condition, the degree of emaciation, and the capac- ity for absorption must play an important part in the severity of the toxic manifestations. Certain it is that the hypothesis as to an increa.sed virulence of the toxemia produced by attenuated bacilli is not borne out by the clinical evidences in pulmonary tuberculosis. In my exper- ience the lesser amount of toxic absorption has u.sually been observed when the bacilli have shown a tendency toward degeneration andattenua- tion, and the greater toxemia coincident with the pre.sence of the so-called virulent microorganisms. If this obtains in pulmonary tuber- culosis in which the absorption of soluble poisons into the circulation is often slow, it is difficult to comprehend why the same relation should not hold true when the toxins enter the blood-stream directl}' instead of through the medium of the lymphatics. If this is not the case, gen- eral miliary tuberculosis developing in individuals harboring non-active or quiescent lesions with attenuated bacilli would be expected to exhibit a more severe toxemia than in consumptives suffering from rapidly advancing infection. This scarcely is in accord with my personal observations. I have found the general sj'mptoms more marked, as a rule, when the miliary condition complicates an active destructive change. This has been especially true in children in whom the severity of the general symptoms is characteristic, the facilities for absorption more pronounced, and the active virulent nature of the infection strik- ingly manifest. Regardless of any fixed relation between the toxic symptoms and the specific characteristics of the bacilli, it is sufficient for pre.sent pur- poses to recognize simply that marked differences exist in the viru- lence both of the bacilli and of the soluble poisons sufficient to stamp their impress upon the clinical picture. Tlii< ji.illm^pnic variation in individual cases offers perhaps a partial cxphiiKiUnii 1,1' the remarkable differences in the clinical course of miliary iul;n. u1(j.-is which otherwise would remain com])letely inexplicable. THE PXEUMOXIC TYPE 329 CHAPTER XLVI THE PNEUMONIC TYPE General miliary tuberculosis with predominating symptoms refer- able to the lungs may occur in the midst of apparent health, or it may exist as one of the complications of chronic pulmonary tuber- culosis. A preexisting focus of tuberculous infection is absolutely essential for its development. This form of miliary tuberculosis may begin somewhat abruptly, or the onset may simulate the development of catarrhal bronchitis. The rapid fulminating type with brusque initial symptoms has been described in connection with the acute onset of pulmonary tuberculosis. The first manifestations of the pulmonarj' variety of miliary tuberculosis may he moderate rigors and other evi- dences of systemic disturbance, as fever, incUsposition, and headache. Attention is early directed to the lungs by cough, dyspnea, and cyan- osis. As a rule, the cough is frequent, distressing, and unattended at first by expectoration. The sputum, if present, is of but slight amount, and noticeably thin or frothy in character. Patients sometimes succuml) to the malady before the appearance of expectoration. Rarely is it purulent, and then only in the later stages of the disease, when the clinical manifestations clearly show the desperate nature of tlie con- dition. Streaks of blood occasionally discolor the expectoration, or it may assume a distinctly rusty liue. Although tubercle bacilli are rarely found in the sputum, the clinical evidences of miliary infection are fairly conclusive. Two of the most important subjective features are the dyspnea and the ci/anosis, both of which greatly exceed the significance ordinarily attached to the physical findings. Sometimes these symptoms are found to precede the cough, the dyspnea in par- ticular often being the first to attract the attention of the patient. In most cases this increases rapidly in association with an aggravation of cough and progressive loss of strength. Some cases are devoid of special cyanosis, but this is quite unusual. The patient is often extremely nervous and apprehensive, but rarely appreciative of the extreme grav- ity of the condition. Fever is present only to a moderate extent, the temperature sel- dom being elevated above 102° or 103° F. Its course is extremely irregular, marked differences of temperature being noted on succeeding days. It is sometimes higher in the afternoon than in the morning, while in other ca.ses the inverse type of fever is displaj'ed. This lack of periodicity in the temperature elevation is often an interesting feature in connection with the disease. Iliuh lV\ci- usually yields to cold baths, but often rises again after a l)rici' iiiicr\al. The daily fall of temperature is attended, as a rule, by iiH)(lci;iicly ]irofusi Chilly sensations are frequent in the course of the day. citlic or accompanying the development of fever. The pul^c is rapid, soft, and easily compressible, the blood-pressuic aim being found materially reduced. There is ra])i(l loss of strength, with diminution of appetite and impairnunt of diiii Upon examination the physical signs are ap])areiitly comparison with the subjective evidences of systemic infection and respiratory incapacity. There is rarely dulness upon percussion, save ' sweat: ing. pn.c.M ling bly ist alw" avs flesh ; and •stion. trivial in 330 COMPLICATIONS in the exceptional development of moderately large areas of broncho- pneumonia in children. In some cases a general tympanitic resonance is elicited. Upon auscultation, as a rule, no modifieations of the nor- mal respiratory sounds are heard, though occasionally a roughening of the vesicular quality is detected. The adventitious sounds, however, are quite characteristic, the one distinguishing /eature of the physical examination consisting of innumerable very fine and moist rules. These are disseminated throughout all portions of each lung, the signs being those of a diffused catarrhal bronchiolitis. The rales may be entirely absent upon ordinary respiration, but are detected reatlily during inspiration following a short cough. Jiirgenson has called attention to occasional friction-rubs of a peculiar soft character, due to tuberculosis of the pleura, and heard both upon inspiration and expiration. Cases of the pulmonary type, beginning with less acute onset, may simulate for a time the typhoidal form of general miliar}^ tuberculosis. Although the cough may chance to be a subordinate feature, the increas- ing dyspnea and deepening cyanosis are sufficient to suggest a probable pulmonary involvement, which is suljject to confirmation by the physical signs. The course of the di.sease in most cases is short, the patient usuallj- exhibiting a rapid ami uninterrupted decline from the beginning to the end. The duration is seldom longer than a few weeks, althouiih a marked abatement of the previous rapid progress is occasionally exliilutcd. I have observed a number of cases of undoubted miliary tul)erculosis of the pneumonic variety presenting features of decided chronicity. In some cases the di.sease has assumed a chronic aspect partaking of the essential characteristics of ordinary pulmonary tuberculosis. General miliary tuberculosis, irrespective of its particular type, has formerly l^een regarded as invariably fatal. Actual recoveries from the pneumonic variety, as well as others to be described, are occasionally reported. I have had occasion to note its stay of execution in several instances, and the adoption of a protracted course, but rarely an apparent complete arrest. I have under my care at the present time a young man exhibiting characteristic evidences of the ])iilinimar\" form of general miliary tuberculosis. His attending phy~i' i:iu in a distant portion of the country, in referring the patient tor climatic change, wrote: "The bearer, Mr. has miliary tuberculosis, having had this condition for about two and one-half months." At the time he came under my observation the history, subjective symptoms, and physical signs were such as to justify an assumption of pneumonic miliary invasion. Exceedingly fine semidry rales were heard throughout both lungs. The dyspnea was entirely out of proportion to the physical evidences. Extreme pallor and physical weakness were apparent. The cough was slight and the expectoration scanty; an occasional bacillus was detected only after long searching. Marked fluctuations characterized a moderate daily temperature elevation. The pulse was very weak, irregular, rapid, and easily compressible. 63- virtue of continuous rest in the recumbent position the patient has displayed a material gain in weight, with corresponding reduction of temperature. The dyspnea is somewhat less than at the time of arrival. While the ultimate prognosis is at best uncertain, there has taken place a pronounced recession in the severity of the symptoms, suggesting at least the possibility of a further retardation in the progress of the disease. THE TYPHOID TYPE 331 In striking contrast to the above, the following case is of especial interest, illustrating, as it does, the more frequent clinical course after the advent of a miliary invasion of the pneumonic type. In 1904 a young man of about thirty years of age, a former patient of Dr. V. Y. Bowditch, was seen in consultation with Dr. C. E. Edson, one month after arrival in Colorado. At the time climatic change was advised the disease had been of comparatively short duration and the general condition was excellent. There had been but little cough and expectoration, nutrition was but little impaired, and the tempera- ture elevation was very slight. The physical signs denoted but an incipient infiltrative process at the right apex. Upon full inspiration following a cough fine clicks were occasionally heard from the apex to the second rib. The condition was, of course, such as to justify an optimistic prognosis. After three weeks' i-esidence in Colorado there developed abruptly a moderate dyspnea, which for a time was incapable of rational explanation. This increased with each succeeding day until, after an interval of a week, the shortness of breath became very pronounced. The dyspnea was accompanied by a moderate dusky discoloration of the face and finger-nails. Much physical debility was exhibited as the air-hunger became more extreme. There was but slight cough, with thin, frothy expectoration. The temperature eleva- tion at no time had exceeded 100° F. Physical examination was negative until the expiration of one week after the onset of acute manifestations. At this time numerous exceedingly fine, semidry clicks were heard throughout all portions of each lung. The rales were very fine, without partaking of a bubbling character, and at first were almost imperceptible. The expectoration gradually assumed a pinkish hue, ami later became more definitely blood-tinged. A cUagnosis of the pulmonary form of miliary tuberculosis was rendered, together with an unfavoral)le prognosis. The patient survived less than three weeks, the suffering becoming daily more intense by virtue of the inordinate hunger for air. This case is particularh^ instructive as illustrating the development of the pneumonic invasion in the midst of an apparently benign infec- tion, the remarkably rapid decline to a fatal issue, and the striking disproportion between the dyspnea and the physical signs. CHAPTER XLVII THE TYPHOID TYPE The onset of this form of miliary tuberculosis is characterized by the development of vague and indefinite symptoms. In some instances the early manifestations may be decidedlj- more acute than in others, and include moderate rigors, temperature elevation, and headache. Usually, however, there is a preliminary history of lassitude, physical weakness, and indisposition of from several days' to two weeks' duration. Frequently complaint is made of pain in the head, anorexia, and constipation, the frontal headache being a con- 332 COMPLICATIOXS spicuous feature in very many cases. Often the repugnance to the sight, smell, or even the thought of food is extreme. The patient at first is restless or excitable, but there is manifested a disinclination to physical activity. The sleep is broken by disturbing and usually unpleasant dreams. The tongue may be coated heavily, but the breath rarely assumes the offensive oclor characteristic of typhoid fever. There is moderate elevation of temperature, with frequent morning remissions and evening exacerbations, as in typhoid, but the fever, as a rule, does not attain so high a point as in the latter chsease. A factor of vital importance is its variable atypical course, even an afebrile condition being no contraindication of the possible existence of miliary tuberculo- sis. While in exceptional cases the fever is ab.sent altogether, it some- times is higher in the morning than at night, thus conforming to the inverse type. In the same individual upon different days the exacerba- tions of temperature elevation may take place either in the morning or at night. The distinguishing characteristic of the fever is its extreme irregularity. The atypical curve is strongly suggesti-\-e of miliary tuber- culosis in contrachstinction to typhoid fever, but a temperatm-e con- forming closely to that of typhoid affords no insuperable argument against the tuberculous character of the affection. The daily subsidence of fever is frequently attended by moderate perspiration, although this is observed less often than in typhoid. Also the elevated temperature is decidedly more responsive to baths or cold sponging. In nearly all cases the pulse is markecUy accelerated from the very beginning, rarely declining to under 100, and usually ranging from 1 10 to 130. It is almo.st invariably soft, easily compressible, and occasionally dicrotic. As the diseiise advances, the respirations are likely to be more rapid than in typhoid fever, although often incapable of satisfactory explanation from the results of physical examination. In later stages the character- istic Cheyne-Stokes type of breathing not uncommonly makes its appear- ance. Cough may be present in typhoid fever as an initial symptom, and develop later in the course of the disease on account of a concurrent bronchopneumonia or hypostatic congestion. This may be confused with the frequent distressing cough which sometimes constitutes a clinical feature of miliary tuberculosis. This symptom, together with dyspnea and cyanosis, is particularly characteristic of those cases in which the typhoid type of the chsease gradually merges into the pulmo- nary. Nosebleed is sometimes observed as in typhoid, though less frequently. Neither its presence nor its absence should be regarded as especially suggestive of the nature of the disturbance. The headache is subject to considerable variation in each disease. It is u.sually more severe in miliary tuberculosis, and is likely to increase in severity rather than the reverse, as in typhoid. Early in the cour.se there may exist the same restlessness and nervous excitabilit_v and subsequently mental hebetude, drowsiness, stupor, and finally delirium or coma. In mili- ary tiilHTciil(i-;is there is often exhibited at different times a striking variation .ii iIk mental condition in the same individual. The patient, upon 111 iiii; aiiii-cd from a moderate .stupor or even a heavy sleep, may regain full pos-ession of the faculties for the time being, only to lapse into a drowsy indifference when the attention is withdrawn. A mild delirium in like manner may give way to a rational coherence of tliovitrht and utterance for a brief period. These abrupt changes in the mental status no doubt are occasioned in pai't 1)V differences in the degree of toxic THE TYPHOID TYPE 333 absorption, and are somewhat suggestive of tuberculosis. Tlie mutter- ing delirium and singultus coincident with profound stupor, though present at times, are probably observed less often than in typhoid. Herpes is rarely present in typhoid, but is noted frequently in the early course of acute miliary tuberculosis. Rapid loss of flesh and strength are characteristic of the two conditions. Generally speaking, the flushed face of typhoid is contrasted with the pronounced pallor which usually accompanies miliary tuberculosis, especially during the afebrile period. Diarrhea and meteorism may be present in each disease, and the abdomen may be either retracted or distended. Rose-spots, though regarded as a distinguishing feature of typhoid, are sometimes present in miliary tuberculosis. The spleen is enlarged to a greater extent in typhoid, in which condition it is almost always palpable. Leukocytosis may be detected in miliary tuberculosis, rarely in typhoid. The diazo-reaction may be recognized in both conditions, and has, therefore, but slight diagnostic value. Albuminuria, while sometimes observed in typhoid, is more often present in miliary tuberculosis. In this condition tubercle bacilli are reported to have been demonstrated in the blood, but while their presence is undoubtedly of positive value, their absence possesses no negative significance. In like manner recog- nition of choroidal tubercle is conclusive evidence of miliary tuberculosis, but its absence on repeated examinations does not negative the existence of the disease. The Widal test is of the utmost value, and may be regarded as definitely ilecisive of typhoid. The presence of tubercle bacilli in the cerebi-ospinal fluid, as demonstrated by lumbar puncture, also offers incontrovertible evidence of a miliary invasion. It is beyond dispute that some cases do not admit of positive diagnosis until the autopsy findings are disclosed. Provisional infor- mation is furnished by the prevalence of a typhoid epidemic in the immediate neighboi-hood, the existence of tuberculosis in the same household, or the history of important predisposing causes. Thus coexisting or antedating pulmonary tuberculosis, enlarged lymph- atic glands, tuberculosis of bones and joints, icUopathic pleurisies, or in children a recent whooping-cough or measles, would suggest a general miliary tuberculosis on account of the recognized facility for general infection. Even in iloubtful cases an accompanying tuljer- culous process in other parts of the body does not offer conclusive evidence of a general bacillary invasion. Pulmonary invalids are quite as likely to contract typhoid fever as non-consumptives, but the presence of bacilli in the sputum at least strengthens to a considerable extent the theory of a general infection. It must not be understood, however, that a negative history of tuberculosis in association with other s_ymp- toms precludes the possibility of miliary tuberculo.sis. Attention to the above features of differential diagnosis suffices for the accurate determination of the conc'ition in the great majority of cases, although in some instances a definite conclusion is quite impossil)le during life. As a rule, failure to establish a correct diagnosis in cases of this type of miliary tuberculosis is not occasioned so much by reason of any lack of credible data for this purpose, as through neglect on the part of the physician to utilize properly the means which are available. A single instance from my recent experience is cited for the sake of illus- tration. 1 .saw, in consultation with a prominent and respected member of 334 LOMPLICATIOXS the profession, a man of forty-fi\e years, who was stated to have been suffering from typhoid fever for three months. In the absence of a pre- vailing epidemic the physician in charge had made the diagnosis during the first week of his illne.ss upon the basis of headache, fever, general intlisposition, and repugnance for food. Throughout the entire period of illness the physician extended assurances that defervescence must shortly be established. The medical attendant asserted that he had been privileged to observe nearl}- 1000 cases of typhoid fever, anil that the accuracy of the diagnosis was beyond question. Upon preliminary inquiry I elicited the information that there had been no nosebleed, no enlarged spleen, no rose-s]5ots, and that the Widal test had not been emploj-ed. The examination of the fever-chart disclosed an irregular, jagged line of temperature elevation. During most of the time there were morning exacerbations and evening remissions, followed by exces- sive perspiration. The tongue had not Ijeen coated at any period of the disease. At no time was the intellect clouded to the .slightest degree. It was apparent, even before seeing the patient, that the diagnosis of tj-phoid fever was almost untenable. It de\eloped that the invalid several years before, had been pronounced an arrested case of pulmonary tuberculosis. Upon examination the evidences of general miliary tuberculosis were of a very suggestive character, and a definite suspicion was entertained as to a threatening meningeal invasion. Two days later the patient developed a sudden apoplectiform attack, resulting in profound coma from which he ne\'er emerged. This case is rather a striking commentary, not upon the difRculties in the way of accurate diagnosis, but upon the ease with which vital clinical data may be overlooked. The course of this form of miliary tuberculosis is exceecUngly variable, the duration extending from ten days to several months. In the more acute cases the progress may be sufficiently rapid to produce death within one or two weeks. Such fulminating cases are not uncommon. Others, after a variable period, exhibit the .symptoms and signs of pulmo- nary involvement, i. e., the increasing rapicUty of the respirations, the cough and cyanosis, the Jiirgenson friction-rub, and the fine rales of diffuse bronchiolitis. Death may be hastenetl by the pulmonary inva- sion or by the onset of meningeal complications. Recover}' from miliary tuberculosis has always been regarded as extremelj' rare, if not alto- gether impossible, but authentic cases have occasionally been reported. From my own experience I can recall several exceptional instances of recovery from supposed miliary tuberculosis of the typhoid type. I have in mind a patient who, eleven months ago, exhibited in another State apparent evidences of miliary invasion, although the condition was at first regarded by attending physicians as typhoid fever, -\fter the lapse of two months the extreme prostration was followed by the characteristic phj-sical and bacteriologic manifestations of pulmonary involvement. The .severity of the general symptoms finally showed signs of abatement and the patient exhibited suflficient improve- ment to justify his removal to Colorado. Upon arrival there were physical evidences of a disseminated tubercle deposit involving a large portion of both lungs, very fine moist i-ales being recognized in the absence of appreciable consolidation. The pul.se and respir-ition were both rapid. Complete rest in the open air during a period of six months has been attended by a gain of fifteen pounds in excess of the normal THE MEXIXGEAL FORM 335 weight, and by a gradual reduction in the rate of the pulse and respi- ration. Complete absence of subjective symptoms and a negative physical examination constitute in this case the final result of an initial condition, which was presumably miliary in character, though not sub- ject to absolute confirmation. Not infrequently cases of pulmonary tuberculosis have been observed whose origin was referred by attending physicians to a miliary infection of the typhoid type. I have not been convinced that it has been inrariabli/ more difficult to secure improve- ment in cases presenting such history than in those of chronic ulcerative phthisis. This anomalous oxixM'ience is to be explained largely by the fact that cases of mili:iiv i uhciculosis conforming to the typhoid variety, as a rule, are not penniltcd ti. seek change of climate until the begin- ning of favorable manil'estatiuns. It , of course, cannot be contended that in general, chronic consumption originating from general miliary tuber- culosis is as hopeful as ortlinary phthisis. CHAPTER XLVIII THE MENINGEAL FORM Pathogenesis. — The meningeal variety of miliary tuberculosis con- sists essentially of an inflammation of the pia mater resulting from bacillary infection. The condition was known as acute hydrocephalus, dropsy of the brain, granular meningitis, or basilar meningitis, long before its precise origin was recognized. It may be assumed in all cases to be secondary to a preexisting tubercle deposit in other parts of the body. Although it is sometimes impossible to discover antecedent tuberculous processes at autopsy, such failure does not establish the existence of this conchtion as a primary infection. It has been suggested that the original bacillary in\asion may take place through the nostrils and the cribriform plate of the ethmoid. While it is unnecessary to attempt to controvert this possibility in very exceptional instances, it may be accepted as true that, in the vast majority of cases, the meningeal infection is secondary to a primary, though perhaps undisco^■el■abIe, focus elsewhere. It is often comparatively easy to recognize tuberculous processes of undoubted priority, in the lym]ih-giands, liones, joints, lungs, larynx, kidmns, l.hid.ln' i;cni1al or-aiis, inlcsliiirs, and middle ear. Meningeal tubciculci^i- may "(■.•ur al aliii.isl any lime of life, though rarely during tlie iirst year, and iulVc<)ucnlly in old age. As a rule, it is more difficult to ascertain upon postmortem examination the precise anatomic origin of the condition in young people than in later years. In infants or little children the condition sometimes appears to develop de novo, the autop.sy findings being entirely negative. Its derivation in early life may be ascril)ed in many cases to unsuspected tuberculous infection of the mediastinal or mesenteric glands. Among adults it occurs most frequently in connection with readily disco\'erat3le pulmonary tuberculosis. Although this disease furnishes a primary source of infection for many cases of meningeal tuberculosis, comment has been made upon the fact that the latter complication is not of more 336 COMPLKATIOXS frequent occurrence. The wonder is that, with the innumerable oppor- tunities for blood-vessel tuberculosis in pulmonary phthisis, miliary invasion does not take place far more often than is actually the case. An interesting and somewhat singular clinical phenomenon is the lack of relation between the extent or degree of activity of the pidmonary process and the probable occurrence of meningeal infection. Meningeal tuberculosis is quite as likely to result in connection with quiescent cases of pulmonary tuberculosis as with those exhibiting an active infection and extensive destructive change. I have frequently observed the development of this complication among pulmonary invalids who presented every indication sugges- tive of a favorable issue. I ha\e been compelled to witness its occurrence even among patients who had been fortunate enough to secure an apparent arrest of the pulmonary infection. A few cases of miliary infection are recalled in individiuxls who for years had exhibited upon examination every appearance of perfect health, and had pursued lives of physical activity in the open air. Upon the basis of my own observations it is impossible to establish any relation between the activit}', duration, or extent of the pulmonary process and the suscepti- bility to meningeal complications. Certain other conditions seem to possess an undoubted bearing upon the likelihootl of future meningeal involvement. Generally speaking, irritable and highly excitable indi- viduals have been found to develop meningeal tuberculosis more fre- quently than those of phlegmatic temperament. The cheerful and sunny in disposition are less prone to suffer from this complication than the pessimistic and depressed. I have observed its development in numerous cases following a protracted season of severe nervous strain or emotional chsturbance. I have in mind a man, thirty-two years of age, in whom the arrest of the pulmonary infection was apparently complete, who experienced unusual mental worry and depression of spirits from a rapid culmination of unfortunate events, including finan- cial reverses, domestic infelicities, and the death of a child. Although nutrition remained unreduced for a time and the appearance was that of remarkable vigor, tuberculous meningitis finally supervened. By a strange coincidence his wife, exhibiting a slight pulmonary involvement and a nervous, irritable temperament, also succumbed to this complica- tion after a period of profound despondency. Although it may be but one of the anomalies of my experience, the history of excessive alco- holism has frequently been associated with the subsequent development of tuberculous meningitis. This disease has been found to be more common in males than in females. Although the greater portion of my patients have been of the female sex, meningeal invasion has not been observed among them nearly so often as among the males. I have seldom witnessed its occurrence in pidmonary invalids over fifty years of age, presumably on account of the lessened opportunities for exten- sion of tuberculous processes at this time of life. I do not recollect a single instance of its development among the .Jews, the negroes, or the Swedes. It has appeared less often among the Irish than might be expected from their mercurial disposition and excitable temperament. The Scotch, Germans, and Americans among my own cases have suffered from this complication more frequently than other nationalities. The pathologic changes in the jna mater are found more often at THE MENINGEAL FORM 337 the base, though they are occasionally present at the sides and upon the cortex. The tubercle deposit may also take place in the brain substance, the convolutions, the ventricles, and the blood-vessels. The pia may be studded by the eruption of few or numerous miliary tubercles, varying in size from a pinpoint to a small seed. Not only do the granulations vary considerably in number and in size, but also with reference to their location and attenchng inflammatory disturbance. The tubercles often extend along the course of the blood-vessels, and are present particularly in the reflected interior spaces, such as the fissure of Sylvius, around the optic chiasm, and the anterior and po.sterior perforated spaces. They are sometimes found upon the lateral surface of the meninges, but rarelj' upon the conve.xity of the hemispheres. Considerable difference exists in the amount and character of the inflammatory exudate, which may be of a serous, fibrinous, purulent, or sometimes even of a hemorrhagic nature. In some cases the fluid exudate is slight, in others, compara- tively abundant. The upper surfaces of the brain may be distinctly edematous, or they may be normal in appearance. Flattening of the convolutions is sometimes observed, particularly at the bases. The lateral ventricles are often distended by variable amounts of fluid. Small nodular tubercles may occur upon the arteries of the anterior and posterior perforated spaces. Nodular tuberculous enlargements are found upon the smaller arteries (Osier). Man}' of these small tubercles in the perivascular sheaths of the smaller arteries are in varying stages of caseation (Collins). The changes in the wall of the blood-vessel may consist of an endarteritis of tuberculous origin with intramural pro- liferation as a result of the invasion by the bacilli of the blood-stream (Hektoen). Narrowing and obliteration of the finer vessels often take place. Solitarj' tubercle of the pia occasionally results from the confluence of a large number of miliary tubercles confined within a sharply circum- scribed area. In such cases the bacillary invasion takes place through a single small meningeal blood-vessel. These solitary tubercles some- times attain astonishing size, without producing symptoms suggestive of their presence. This may happen only when the tubercle chances not to encroach upon the area of the brain having jurisdiction over special functions. It is often separated from the contiguous brain sub- stance by an area of granulation tissue (Collins). The symptoms of tuberculous meningitis are extremely diverse in character, the clinical picture being decidedly complex, even among patients of the same age. It is impossible to describe any single type to which all cases may be expected to conform. It is interesting to note that some observers have described the symptoms as exceedingly uniform, while others have regarded them as varied and indefinite. Much con- fusion results from the fact that the general symptomatology varies within wide limits, accorchng to the period of life during which the disease makes its appearance. To afford greater clearness it is well to recognize essential differences in the mode of onset and course of tuberculous meningitis among adults, young children, and infants, and to avoid any attempt toward an arbitrary classification of .S3^mptoms applicable to varying ages. By cHscriminating sharply between the clinical mani- festations at different times of life, the so-called atypical cases are less frequent in actual practice. It is easy to comprehend the many diffi- culties attending any attempted exposition of a single group of symptoms to be submitted as a single type of the disease, and to appreciate the 338 CdJlPLKATIOXS innumerable opportunities for error resulting from such effort. It is desired to distinguish between the meningeal tuberculosis of adults, developing in the course of pulmonary phthisis, and the apparently primary infection of children and of infants. Symptoms in Adults. — Among phthisical patients the clinical manifestations of meningeal invasion are somewhat varied. The onset of this complication during the course of pulmonary lulx'iculdsis may be fairly abrupt in some cases, while in others the begiuiiini; :^yiii|j)()ms may be exceedingly vague and indefinite. Occasionally the uiitial manifestations may be entirely subjective in character, and develop with sufficient rapidity to surpass in importance the significance of delayed objective phenomena. At other times the local signs assume an early prominence before suspicion of a meningeal involvement has been awakened by subjective symptoms. The clinical evidences of its development may be obscured to a degree l^y the fever incident to the pulmonary condition, th>- nuiscuhir weakness and exhaustion, the irritability, digestive chstuiliancc, insomnia, and headache. In the absence of confusing sym|it(iiii^, li()\vi'\i"i-. the existence of a pulmonary lesion, rather than m.iskinu ihc dcx rl(i|iuiciit of meningeal tuberculosis, tends to emphasize ilic |H>"iliilit\ n\ it> occun-cnce. The more frequent nictlKid of diisci (■p;iriiii xinmi^t i-hk e to disturbing visions than from actual pain. Tlie jterioil ni t laiisit khi iidm these conditions to the state ol' comiilete ({nua, described in connection with the preceding class of cases, is usii:ill\' l)iief. Sometimes the uk niiiucal iiilectinn ilex-elups with obstinate vomiting or hiccough, which precedes for days all oilier niaiiilesialions indicative of the condition. I recollect one instance in wliiili the nn^d was so distinctly sudden as to suggest the apopleetiloiin metlioil of develop- ment. In this instance tlie patient fell to the floor while putting on his clothes, and mergeil from a shoi t peiiod of consciou.sness into a state of delirium, with later oeuhar ami motor symptoms, these manifestations persisting to a fatal termination in ten days. Among some consumptives an early symptom of tuberculous men- ingitis consists merely of gi-eatly increased restlessness. Such patients are especiall\- apt to sidTer from insomnia. The delirium which finally develojis in these cases is likely to be acute and maniacal. Among these patients loud screaming, both hy day and night, is not infrequent. The delusions are those of danger, and the clinical picture is not markedly dissimilar to delirium tremens. Tremor and muscular twitchings of the face and extremities are sometimes observed. Several times I have noted the first manifestations of approaching meningeal tuberculosis to be tremor and twitching of the extremities in the absence of all subjective symptoms. Other objective signs may appear long in advance of headache, fever, vomiting, or impaired intellect. Inequality and irregularity of the pupils may be the first indication of impending meningeal involve- ment. I have occasionally observed a gradually increasing paralysis of an arm and leg before the exhibition of other suljjective or objective symptoms. Ocular and motor signs, however, do not supervene, as a rule, until after the subjective manifestations have become fairly well defined. At such times there may be noticed inequality of the pupils or dilatation, strabismus, conjugate deviation, optic neuritis, and ocular palsies. Choroidal tubercle is sometimes recognized. The •stiffness of the neck becomes marked, and the head greatly reti-acted. There may be monoplegia or hemiplegia. In some cases tetanic contraction of a limb may take place. Kernig's sign is usually pi'esent, consisting of failure to extend the leg upon the thigh, which is in turn flexed upon the abdomen. The pulse may be slow, and of high tension, or rapid and irregular. The duration is varial)le, death taking ])lace within a few days, 340 COMPLICATIONS or the course may be protracted throughout a period of many weeks. There is frequently observed a relation between the manner of onset and the subsequent type of the disease, cases with initial acute symp- toms usually pursuing a violent and rapid course. It sometimes happens, however, that even cases with insidious onset later de\'elop acute symptoms and terminate abruptly. It will be seen that the general clinical picture of meningeal tuberculosis, even among adults, is subject to great variation. Symptoms in Children from Two to Six Years of Age. — At this period of life the early symptoms are always subjective rather than objective in character. The onset may be comparatively sudden, with violent manifestations, or the acute symptoms may be preceded by a prodromal period of one or two weeks' duration. In some cases they are shortly antedated by a fall or by an acute infectious disturbance, as measles, influenza, or whooping-cough. These premonitory symp- toms are more or less ill defined, and consist of impaired appetite, pallor, loss of weight, peevishness, irritability, disturbed sleep, and sometimes a perceptil)le change in disposition. Severe gastro-intestinal distur- bances often accompany the onset. There may be a slight irregular elevation of temperature in the very early stages. As a rule, there is not noted any invariable change in the character of the pulse at this time. The early attention of the parents is attracted chiefly to the restlessness and appearance of fatigue, with pallor and emaciation. Usually by the end of a week more acute symptoms are observed. Vomiting" is very common, is occasionally expulsive in character, and often has no connection with the ingestion of food. The temperature is found to be moderately elevated, and the child is seen to put the hand to the head as if in pain. Headache is the most important symp- tom concerning which complaint is made. This, with vomiting and fever, often independent of prodromal manifestations, is sufficient to awaken suspicion concerning the possible nature of the condition. The disquietude of the physician is much intensified if these symptoms are found to supervene immediately after the prodromal manifestations which have been described. In some cases the onset may be still more abrupt, the first symptoms referable to the condition consisting of convulsions, which may recur at intervals. After the lapse of several days the general symptoms become more pronounced. The rate of the pulse is not accelerated, as a rule, but is often irregular. A slow and irregular pulse in connection with other symptoms is of much importance in diagnosis. While fever is not always present, the temperature in most cases is elevated to a moderate extent, but seldom is there observed any distinct periodicity attending its rise. There is often fever at one hour of the day and a normal or subnormal temperature at other times. It is sometimes present in the morning and absent in the afternoon. In some cases the fever is continuous for several days, and is followed by a brief recession, only to rise subse- quently in the cour.se of the disease. Occasionally the respirations are irregular and even .sighing in character, but change in this respect is not a factor of especial clinical moment. The restlessness, pallor, loss of strength and weight progressively increase. The child becomes extremely irritable, and cries upon the slightest provocation and often without any assignable cause. The least change in the position of the patient is usuallj^ sufficient to provoke a scream, which appears to be THE MENINGEAL FORM 341 occasioned by pain in the head. A sudden jar in the room, as the closing of a door or window, falling of a book, moving of a chair or the bed, adjusting the clothing or even a window-shade, may disturb the child and incite a pitiful cry. The screaming, however, is often independent of external causes, and occurs, as a rule, in paroxysms, which are fol- lowed by lulls of short duration. In exceptional cases it becomes con- tinuous until the child is relieved by opiates. The cry, which is of peculiar character, is regarded as especially suggestive of tuberculous meningitis, and for many years has been described as the hydro- cephalic cry. The facial appearance of the child is often quite as charac- teristic as the cry, though extremely difficult of descrijition. The features are more or less drawn and pallid, the expression anxious and appealing. In early stages nothing remarkable may be noted in the eyes, but on account of the emaciation, they may appear to be unusually large. The pupils may be contracted, dilated, unequal, or show no change whatever. It is not uncommon to find them equally contracted at this time. Sleep is short and fitful, may be accompanied by moaning, and is often interrupted by sudden screams, the child apparently awakening in extreme terror. Twitching or jerking of the extremities is frequently observed during sleep. Physical examination early in the course of the disease is negative, objective signs not being discovered, as a rule, until the irritative stage has passed. As the disease advances the acute signs of irritation subside to a great extent, and the child becomes dull and heavy. Headache no longer is complained of, and the screams materially diminish in frequency and severity. There develops, on the other hand, a distinct apathy with indifference to surroundings. Noises cease to disturb, sleep is profound, and it is often difficult to arouse the patient. Delirium sometimes supervenes. The bowels are constipated, and the abdomen retracted in many cases. Considerable importance has been attached by some observers to the existence of the tcwhe ca-ebrale upon the skin of the abdomen, but its import has been greatly exaggerated. The vomiting is now less frequent, and may disappear altogether. The patient no longer is able to sit up in bed unless supported, and is inclined to rest quietly upon the side. The head may become noticeably retracted, and the neck stiffened to an appreciable extent. Inequality of the pupils may now be noticed, together with strabismus. Ptosis and nystagmus may exist, and the pupils may not react to light. Kernia's siirn. pre- viously described, is possessed of great diagnostic ^i'^nilic-iin-c. Hab- inski's sign is also of con.siderable importance, cdii-i^i m- ul c\ten- sion of the great toe, instead of the normal flexion ujiuii s( laU liing the sole of the foot. In the last .stages of the disease the .symptoms are not especially different from those already enumerated in connection with meningeal tuljerculosis of adults. The stupor increases to the point of coma. After this has become established, consciousness is rarely, if ever, restored, although the child may linger for many days. Moaning or muttering delirium during the comatose state is less often observed in children of this age than in adults. From my own observa- tion I am inclined to think there is less tendency toward picking of the bed-clothes or waving of the hand in front of the face. Conjugate deviation is often noted, and optic neuritis not infrequently occurs. The ghastliness of the picture is increased by the upturned eye- 342 COMPLICATIONS balls and the partially closed lids. Retraction of the head becomes more pronounced. Twitching of the facial muscles sometimes takes place, together with spasmodic contractions of the limbs of one side. Complete paralysis of certain parts may develop — frequentlj- an arm and a leg of the same side. The pulse is now extremely rapid, and dissolution appears very imminent. It is surprising, however, how long the patient may persist in an apparently moribund condition. Several times I have seen a week or ten days elapse after the develop- ment of coma before death. Symptoms in Infants. — An essential difference between the symp- toms of meningeal tuberculosis in infancy and childhood is the more sudden on.set in the former, and the greater frequency of initial convul- sions. It has been stated by certain observers that some of the important features in the differential diagnosis of meningeal tuberculosis and cerebrospinal meningitis are the more sudden development in the cerebrospinal cases, the greater violence of the sj^mptoms, and the shorter duration of the disease. This relation hardly obtains in the meningitis of infants, as the onset of meningeal tuberculosis in such patients is often extremely abrupt, and the course short and violent. On the other hand, the ilevelopment of cerebrospinal meningitis is sometimes slow and indefinite, with a subsequent protracted course. Morse has recently called attention to this interesting comparison in a class of forty cases of meningitis in infancy, equally divided between the tuberculous and the cerebrospinal forms. His diagnosis was made in each instance by autopsy or lumbar puncture. The duration of the disease in his tuberculous cases varied from one to forty-four days; in the cerebrospinal, from seven days to six months. The majority of the tuberculous cases lasted from six to fourteen days, and the cerebrospinal, from seven days to several weeks. A slow pulse is some- what less likely to be observed in infancy than in childhood, as is also a slow respiration. The so-called stage of irritation is also shorter as a general rule. Initial restlessness is less pronounced, while apathj-, stupor, and unconsciousness develop earlier. I am inclined to believe that strabis- mus is more frequent in infants than at a later time of life. The fontanel may be closed, level, or elevated in meningeal tubercidosis of infants, or may vary from time to time. Morse especially emphasizes, in his analysis of cases, the marked similarity of the symptoms in the menin- geal and cerebrospinal forms. Aside from the fact that the general condition of the patients was somewhat better in the cerelnospinal variety of meningitis, no very essential difference was noted in other symptoms. The temperature, pulse, respiration, gastro-inte.stinal lUs- turbances, pain, convulsions, condition of eyes and abdominal muscles were practically the same. \^Tiile the rigidity of the neck ami retraction of the head, as well as paralysis and siiasni of the extremi- ties, were somewhat more constant in the ccivlird^iMnal cases, no important differences sufficient to justify a difiin n' i il ri,i;;uosis were observed. Among other symptoms common tu thf tuo tUseases in infants were noted rapidity of the pulse and respiration, the relative infrequency of excessive vomiting, constipation, and manifestations of pain. Differential Diagnosis. — Koplik has completed an analysis of fifty-two ca.ses of tulierculous meningitis, the diagnosis being con- THE MENINGEAL P'ORM 343 firmed by lumbar puncture, autopsy, or animal inoculation. He emphasizes the significance of low temperature, the absence of hyper- esthesia, of herpes or petechia, the presence of optic neuritis or choroidal tubercle, and the importance of skull percussion for the detection of hydrocephalus. From the reports of most clinical observers it would appear that in tuberculous meningitis the temperature is seldom elevated to a marked degree, particularly in early stages, while cerebrospinal meningitis, especially the epidemic form, is characterized by an abrupt onset and high fever. The meningeal tuberculosis of babies, however, fails to conform to the type of symptoms in childhood, which has often been assumed to represent the standard for all cases in early life. Differential diagnosis between tuberculous and cerebrosfinal meningitis in infancy is practically im- posisible upon the basis of the clinical symptoms, and can he deter- mined with accuracy only by examination of the cerebrospinal fluid obtained by lumbar puncture. An excess of mononuclear cells is characteristic of the tuberculous form, while a predominance of poly- nuclear cells suggests the probability of the cerebrospinal variety. Tubercle bacilli and meningococci are sometimes discovered. The historj' of exposure to tuberculous infection affords provisional evidence as to the nature of the disease. There is no condition presenting greater opportunity for errors of diagnosis than meningeal tuberculosis in infants. From a considerable experience with such cases and other affections closely simulating this disease I am impelled to urge the withholding of a positive diagnosis prior to the performance of lumbar puncture. No matter how desperate the condition or how apparently conclusive the diagnosis upon the basis of the subjective and objective signs, its unreliability has been demonstrated all too frequently by an experience not altogether agreeable. It is inadvisable to withhold indefinitely from the family the nature of one's suspicions regarding the gravity of the condition, Init it is often inox])edient to render an al)so- lutely unqualified diagnosis. The nicdica] attendant may occupy but few moi-e unpleasant positions tluiii obtain when presuming to diagnose and prognosticate unfavoralily a case of supposed meningeal tuberculosis, which eventually proceeds to complete recovery. The evidence is irrefut- able either that other conditions so closely simulate meningeal tuberculosis in infants as to preclude a positive diagnosis save on the basis of lumbar puncture, or that a few cases of tuberculous meningitis unquestionably re- cover. The opportunities for error in diagnosis were much greater in foi'mer years than at the present time, when the iiic(lic;il jittcixlant is pii\il("s(M-vf'd al)out twelve years ago. The patient was an infant in arms, the iiiolhcr liciiit;- (wticniely tlelicate and the father a victim of pulmonary tulierculdsis of sc\eral years' standing. The child displayed typical symptoms of meningeal tuberculosis, there being much wasting of the tissues, pronounced pallor with repugnance to food, great irritability and peevishness, and the characteristic hydro- cephalic cry. There were retraction of the head, stiffness of the neck, and other symptoms of such a nature as to suggest almost beyond ques- tion the probability of meningeal tuberculosis. A provisional diagnosis to this effect was made by Dr. H. T. Pershing and myself, but an abso- lutely unfavorable prognosis was not rendered for reasons previously 346 COxMPLRATIOXS outlined. The child made an eventual recovery, though developing shortly afterward caries of the upper dorsal vertebra'. The other case was observed in July, 1906, the patient being a boy of four years, whose mother was exceptionalh- frail and the father tuber- culous for several years. The illness occurred at a time when the family was sojourning for the summer in the mountains of Colorailo, far removed from easy communication. The child had been delicate for months, poorly nourished, and exceptionally pale. Sleep and digestion had been disturbed, and the appetite capricious. After a prodromal period of peevishness and irritability the child developed fever, with vomiting and exceptionally .severe headache. Physical examination was entirely- negative, even to absence of .splenic enlargement. The Widal test, several times employed, was invariably negative, as was also the search for the malarial plasmochum. The early restlessness was succeeded by beginning drowsiness and stupor. The temperature remained persistentlj- elevated, constipation was marked, and the abdomen was carinated to a pronounced degree. The headache continued until stupor was well established. The loss of weight was very rapid, and the child speedily presented a much emaciated appearance. Mild delirium was present, with retraction of the head and marked stiffening of the neck. Kernig's and Babinski's signs were present, together with inequality of the pupils and conjugate deviation. Lumbar puncture was not emploved, as this was considered hardly necessary for the establishment of a diagnosis which seemed almost incontrovertible. A month of the utmo.st anxiety was passed in efforts to support the child with concentrated liquid nourishment. Upon the gradual subsidence of the fever the patient was greatly prostrated for many weeks. He was unable to sit up in laed. ami stiffness of the neck and retraction of the head persisted for several weeks. The sub.sequent convalescence w-as slow, but progressive. Kernig's and Babinski's signs disappeared completely, and the child was finally able to walk, although this was accomplished at first with the utmost difficulty, the locomotion being distinctly ataxic. There was inability to coorchnate the movements of the lower limbs, and a perceptible dragging of the toes. This gratlually improved following the employment of massage, strychnin, and potassium iodid, although to what extent these measures were of practical benefit it is impossible to state. If this was not a case of meningeal tuberculosis, it was, to say the least, a condition which I was unable to diagnose. The lesson to be learned from such an experience is to the effect that no matter how apparently hopeless the condition and how definite the diagnosis, the physician, in deference to his responsible trust, should refrain from assuming the hopelessness of despair, but should hold in reserve to the very end an abicUng faith in the possibilitii of recover}'. The treatment of all cases of miliary tuberculosis, whether of the pulmonary, typhoidal, or meningeal variety, and entirely regardless of age, must be almost entirely symptomatic in character. Authentic reports are recorded of highly gratifying results following repeated lumbar puncture in tuberculous meningitis. Prompt benefit vmdoubt- edly may occasionally he obtained upon remo\-al of the cerelirospinal fluid, which, according to some ob-servers. should be allowed to escape until the flow ceases spontaneously. Several cases of complete recovery have been reported despite the demonstrated presence of bacilli in the withdrawn fluid. This would appear to be possible, particularly when INTRODUCTION 347 bacilli of attenuated virulence are found. Piebold has reported a case of tuberculous meningitis in a girl of sixteen years, with a favorable termination, after two months' illness. Lumbar puncture was per- formed daily during the first two weeks, and twenty-four times alto- gether. A total of 574 c.c. of cerebrospinal fluid containing tubercle bacilli was removed. While I have not made personal use of lumbar puncture for other than diagnostic purposes, some evidence of its thera- peutic utility in occasional instances has been reported. SECTION II Tuberculosis of the Pleura INTRODUCTION The various forms of miliary tuberculosis have been described as resulting from the direct distribution of bacilli through the medium of the blood-stream, but infection of remote parts of the body may be of distinct hematogenous origin without accompanying evidence of acute miliary tuberculosis. Thus tuberculosis of the pleura, the peritoneum, larynx, and portions of the alimentary and genito-urinary tracts may occur as a result of conveyance of the infection by means of the circula- tion. This does not imply, however, that localized tuberculous processes may not exist in such organs and tissues by reason of some other method of bacillary invasion. Tuberculosis of certain organs may take place in some instances by reason of hematogenous invasion, but bacilli may be conveyed to the same portion of the body by means of the lym- phatics, by direct contact with infected secretions, and, finally, by extension of the tuberculous process from immediately contiguous tissue. Tuberculous processes in remote portions, occnniiiu /// (onncc- tion with acute general miliary tuberculosis, are of but iiilliim i liiiical importance, as the patient usually dies long before e-\ti-iisi\c changes are permitted to take place. In view of the foregoing considerations it scarcely seems practicable to attempt the classification of the various disseminated tuberculous processes solely according to the preci.se method of bacillary trans- mission. The complicating tuberculous conchtions in different regions, irrespective of their mode of invasion, will be considered, therefore, somewhat in the order of their relative importaiui' ami fr<iis iiit rapl^ural romlitions due to other causes, yet coexisting with the pulmomu} inlcriicii and exercising a powerful influence upon prognosis. The tlistiimiii shaip nv .stabbing in character, and intensified ujion ilccp rrs|iiiati(»ii or cough. An extreme variability is exhibited in the degree of pain experienced by different individuals. In some instances it is so slight as to occasion but little complaint ; in other cases it is very distressing. I have observed many invalids w^hose suffering was most excruciating and was relieved only by large hypodermic doses of morphin. I recall one instance of initial pleural pain in a delicate woman whose anguish was so extreme as to demand over a grain of morphin in the course of a few liours, after hot applications, fixation of the ribs with tight adhesi\e 354 COMPLICATIONS strapping, and dry cupping had not proved of the slightest avail. Seldom have I found the pain referred to the nipple, but in the majority of cases to the inferior axillary region. It is often reported to be most severe near the lower margin of the ribs, and it is occasionally felt in the abdomen and back, in this event suggesting the possibility of a diaphrag- matic involvement. In such cases the pain is enhanced by pressure over the insertion of the chaphragm in the region of the ninth and tenth ribs. Fever, if present at all, is usually moderate. It may be of but a few days' duration, or in inchvidual cases persist for many weeks. In acute pleurisy cough is usually a symptom of minor importance. Expectoration is scanty, and consists largely of viscid mucus which now and then is streaked with blood. Dj^spnea may be a conspicuous feature of cases having an acute onset. The stabbing pain in the side often imparts a characteristic restrained and interrupted type of respiration. While these initial manifestations of acute pleurisy are extremely suggestive of the condition, they are occasionally simulated by the early symptoms of pneumonia, while effusions of large size may exist without the slightest subjective disturbance. I have found with great frequency small and moderate effusions among pulmonary invalids in the absence of all rational symptoms. Recognition of the concUtion has been afforded in the course of routine physical examinations, and no suggestion conveyed by fever, dyspnea, pain, cough, nor bj'' such prodromal symptoms as malaise, loss of appetite, or emaciation. Without detailed exploration of the chest all so-called latent pleurisies must escape detection. That pleurisy with effusion is much more frequent than is generally supposed is explained almost entirely by the fact that it is overlooked in many instances. Provided an effort is made to conduct a thorough chest examination, it is difficult to con- ceive how even a moderate effusion can remain unrecognized. When such is the case, this must be regarded as due to faulty and superficial methods of physical exploration. Upon inspection there may be noted in some cases a diminished respiratory excursion upon the affected side, the degree of immobility var3^ing in accordance with the amount of pleural exudation. Oblitera- tion of the intercostal spaces sometimes takes place, and the entire side may present a round, bulging appearance. Palpation serves to confirm the results of inspection with reference to the imilateral restriction of respiratory movement, and in addition affords extremely valuable evidence by virtue of greatly diminished or absent vocal fremitus. This tactile fremitus is almost always found to be lessened, even over the site of small effusions. Recourse to mensuration is of but little avail in determining the presence of pleural effusions, as among consumptives a considerable disparity between the two sides of the chest is not infrequent. No con\ancing evidence is thus afforded as to the existence of a pleural effusion, the signs of which are usually subject to easy recognition by other means. Percussion of the entire chest is of the utmost value in a search for small and moderate pleural effusions among phthisical patients, although the results :iic sdiiictiini's obscure on account of the extensive pathologic iliaiiL;!-. iIkii 1i:i\c :ilrc.nl\- taken place in the pulmonary tissues. Among (■niisuiiipti\cs this is pniticularly true upon percussing the back, on account of the enormous pleural thickening which is sometimes present at one base. Further difficulties are experienced by reason of the SYMPTOMATOLOGY OF TUBERCULOUS PLEURISY 355 varying degrees of pulmonary infiltration or areas of partial consoli- dation. Failure to exhibit typical percussion boundaries may be occasioned by the presence of a partially consolidated and non-com- pressible lung. The difficulty of correct percussion interpretations will at once be appreciated ujjon consideration of the modifications of resonance produced by such preexisting pathologic change. It is not always easy by percussion alone to outline with precision the border-line between the flatness of a pleural efTusion and the marked contiguous dulness incident to compressed lung. In some instances but a thin stratum of fluid is molded around the lung, serving as an intervening layer between it and the chest-wall. The so-called skodaic resonance so frequently recognized in the subclavicular region among non-con- sumptives and resulting from the relaxation of pulmonary tissue is not obtainable among phthisical patients, who exhibit in this region varying Fig. 94.— Typical letter "S of consolidation or cavity formation. As a result of the numer- ous pleural adhesions and the dense fibrous bands traversing the pleural cavity and invading the lung, the former may be subdivided into several circumscribed chambers. In such event an effusion is prevented from assuming the characteristic curve so common among non-consumptives. Generally speaking, there is either complete flatness, or extreme dulness upon percu.ssion over the seat of the effusion. The resonance has often been described as of a peculiarly wooden or resistant quality. The typical letter "S" curve which marks the boundary between the lung and the effusion is not always subject to verification among pul- monary invalids, as has been stated, on account of previous morbid changes in the lung and pleura. When present, however, the lowest point of the curve is invariably near the spine, and extends upward and outward to the shoulder or upper axilla, as shown in Fig. 94. From this point the line of dulness descends obliquely in front in a perfectly straight line. This peculiar configuration of the upper per- 356 COMPLICATIONS cussion boundary is present only if the effusion is of moderate size. As this increases the cur\ed hne of dulness presents an upward con- cavity, which is often extremely difficult of recognition. In slight pleural effusions the letter "S" curve is entirely absent the line of dulness proceecUng from the spine and dropping suddenly in the axilla, as depicted in Fig. 95. It will be. noted that, as the fluid increases from a small to a moderate size, there is an abrupt and pro- nounced change in the upper boundary of percussion dulne.ss. This phenomenon, first recognized by Weil, and to which Whitnej- called attention in 1894, I have had occasion to confirm in innumerable instances. It is the small effusion that most frequently escapes detec- tion, the area of flatness being confined to the lower posterior portion of the chest, sometimes extending lateral! v but a short distance. A Fig. 95. — Out line of percussion dulness in small pleural effusion. Not striking verification of the letter " S" curve in moderate effusions will be found by reference to the radiograph (Fig. 73). Respiratory sounds and even moist rales are not uncommonly heard with distinctness through an area of dulness. Thus it is apparent how such an effusion may be overlooked even by careful and experienced examiners. It is exceedingly important to percuss to the very base of each lung in the back, and to outline the lower border of resonance in order to compare accurately the two sides. The difficulties in the way of correct conclusions in such comparison may be increased by a unilateral compensatory emphysema, which materially depresses the lower boundary of resonance. The auscultatory signs of especial importance relate to the intensity of the respiratory sovmds anil of the vocal I'esonance. In early pleurisy adventitious sounds are often heard before deviations from the normal respiratory murmur. Allusion has been made to .liirgensen's sign, which consists of a peculiar soft rubbing sound simultaneous with the respiration. This may be present in the beginning of a distinct SYMPTOMATOLOGY OF TUBERCULOUS PLEURISY 357 tuberculous pleurisy, particularly if of the miliary type; In many cases dry friction-rubs are recognized in the axillary regions. The sounds may be fine and grazing in character, or loud and creaking. As a rule, they are intensified by pressure with the stethoscope. Occa- sionally the sounds are somewhat similar to the crepitant rale previously described. They sometimes reappear after the absorption of an effusion. Pleural friction-rubs are often jerky or interrupted, and are heard both with inspiration and with expiration. In cases of pulmonary tuberculosis without consolidation of lung near the site of the pleural involvement, and without marked pleural thickening and adhesions, the normal respiratory sounds at first may not be appreciably altered. As the pleural exudation increases the breath-sounds become enfeebled and markedly distant, and in large effusions disappear altogether. Above the level of the liquid the sounds are sometimes bronchovesicular in character, with a distinct prolonga- tion of the expiration. Confusion regarding the auscultatory signs may result from a coincident tuberculous infiltration in inferior portions of the lung. Under such conditions the respiratory sounds, though some- what distant and often of diminished intensity, may partake more or less of the characteristics of bronchial or bronchovesicular respiration. Still greater confusion arises if small pleural effusions exist in connection with localized areas of lir- tuberculosis. (Compare with radiograph. Fig. 62.) extremely marked. Sub.sequently there resulted a renewed activity of the infection. The e.xtent of the displacement as determined upon percussion is verified Ijy the .r-ray pictui-e (Fig. 62). The skiagraph not onlj- illustrates the marked traction exerted upon the heart by the Fig. 103.— UhLstrat •ith pul- fibroid proliferation, but also the extensive pathologic change throughout the entire chest. In cases similar to those just cited, it is manifest that no significance can be attached to the cardiac displacements as an aid to diagnosis of pleural effusions. DIAGNOSIS AND PROGNOSIS OF PLEURAL EFFUSION CHAPTER LII DIAGNOSIS AND PROGNOSIS OF PLEURAL EFFUSION IN PULMONARY INVALIDS Great variations are observed in the course of pleurisies developing among pulmonary invalids. The fever which is often present in the beginning may not continue longer than a week or ten days, but in some cases the temperature maj^ remain elevated for prolonged periods, and be associated with other symptoms of constitutional disturbance, more or less profound, according to the bacterial nature of the effusion. As a rule, the manifestations of cardiac and respiratory embarrassment correspond approximatel}' to the size of the exudate. It is surprising, however, to note occasionally considerable dyspnea with temperature elevation and a rapid pulse in comparatively small effusions. Comment has been made upon the fact that astonishingly large pleural exudates may exist without the slightest symptoms of their presence. The effusion may remain of small or moderate size for a short period and cUsappear, or it may persist indefinitely without perceptible increase in volume. While the effusion in many cases is absorbed with varying degrees of rapicUty it sometimes is found to increase progressively in size, the volume of contained liquid being so great as to demand removal. In such cases, particularly among pulmonary iinnlids, there is con- siderable likelihood of reaccumulation, even if tlie ertusicm li(> seimis in character. I have never seen sudden death from jiulnioiiaiy cmliolisni in connection with pleural effusions, although instances of this have been reported, especially when the heart iias Iteen greatly dislocated. In one instance, however, a sudden fatal termination took place twelve hours after the withdrawal of a large effusion. From what has been stated with reference to the physical signs, it is conceivable that errors of diagnosis should occur, only in exceptional cases, provided there be condncted ;in intolliaciit chest examination. Non-recognition of pleuritic cimi|i|ic:irK)iis is dcciMdned in the majority of instances, not because of ;uiy ;il>sencc of re^idily available data for this purpose, but through failure to apply the estab- lished principles of diagnosis to the evidence presented. In this connection it may be stated that the frequent unfortunate results of treatment are sometimes due not so much to the lack of adequate therapeutic measures, as to the misconception of their rational scope in individual instances. It may be stated parenthetically that, unlike many diseases of the lungs, the primary ob.stacles to success in the management of pleural complications in pulmonary tuberculosis may not be ascribed invarialily to delayed diagnosis. It is a humiliating reproach to state thai iidt inl're<|uently the interests of the patient would be better suliseixcd if tlie cciiidition remained unrecognized. The justice of this i-eHectiou upon tlie medical and surgical manage- ment, in some cases, will be later explained. While early diagnosis must be encouraged through detailed examinations of the chest, the essential considerations relate to a correct interpretation of the prognostic significance of the effusion in individual cases, and an intelligent appreciation of the rationale of remedial measures. Let 364 COMPLICATIOXS it be emphasized that the existence of pulmonary tuberculosis very materially modifies the consiileration of those surgical methods which maj- be styled operations of cvpediency. At the same time the consumptive, no matter how hopeless his condition, is entitled, by \'irtue of everj^ instinct of humanity- to the fullest measure of surgical aid in conchtions involving so-called operations of necessiti/. My con- clusions are derived from the errors as well as the successes incident to personal experience. More of real benefit sometimes accrues from an opportunity to witness the deplorable results of mistaken judgment than from the elated observation of a successful issue following a fortu- nate choice of procedure. In support of views to be presented, a few illustrative cases will be presently introduced. The diagnosis of pleural effusion is too frequently dependent upon an employment of the aspirating neeiUe. A provisional diagnosis having been established by the physical signs, verification is commonly attempted through recourse to exploratory puncture. This procedure, though often affording positive results, does not invariably yield infor- mation of a reliable nature, owing to errors of technic in inexperienced hands. I have known numerous instances of moderate effusion, particu- larly of circumscrilsed empyema, to remain unconfirmed by aspiration. The tendency to withdraw the pleural exudate is especially strong among young practitioners. So far as the diagnosis perse is concerned, the use of the aspirating needle by trained clinicians affords a most trust- worthy and reliable aid to accuracy of conclusions. In the majority of cases, however, a rigid and painstaking examination of the entire chest is sufficient to enable a skilful clinician to arrive at an accurate diagnosis. Attention has been called, however, to the peculiar cUfficuIties sometimes involved in the physical examination of pulmonary invalids with compli- cating pleural effusions. For years it has been customary for writers to emphasize the variation in the level of percussion dulness in pleural effusions upon change in the position of the patient. While I am not prepared to deny with positiveness that some slight modification of the level of the effusion ma}' be detected in exceptional cases when the patient assumes a different position, my own experience is to the effect that such mobility of percussion outlines, as a rule, is exceedingly slight, and rarely constitutes a factor of especial diagnostic value. It appears unwise to lay stress upon a technical point which is often incapable of detection even by expert examiners, for confusion and discouragement must unavoidably result in the minds of students who attempt to recog- nize the existence of so slight and inconstant a variation of percussion boundaries. As a matter of fact, the only practical value attaching to change in the level of the effusion simultaneously with differing postures, is found in cases of pneumopyothorax, in which there is not only liquid, but air, in the pleural cavity. In these cases the change is most pronoimced and should be capable of recognition by the \-eriest amateur in physical examinations. There are other interesting features in connection with the level of the liquid in the latter affection, which will be discussed in their appropriate place. The .subjective symptoms in pleural effusions, though decidedly unreliable as diagnostic features, are nevertheless possessed in some instances of more or less clinical importance. The gradual develop- ment, the moderate fever, slight cough, and scanty, mucoid expecto- DIAGNOSIS AND PROGNOSIS OF PLEURAL EFFUSION 365 ration are distinctly suggestive of pleural effusion in contradis- tinction to the sudden onset, the chill, abrupt elevation of tempera- ture, distressing cough, and tenacious or blood-streaked expectoration characteristic of pneumonia. The dyspnea is almost always accentuated to a greater degree in pneumonia than in pleural effusion. I have been in the habit of attaching considerable diagnostic significance to the presence of herpes labialis in pneumonia. Although by no means pathognomonic of this condition, it is, at least, quite unusual in acute pleurisies. The existence of leukocytosis in doubtful cases is, of course, suggestive of pneumonia. The prognosis of pleural effusions in consumptives depends pri- marily upon the extent and degree of activity of the tuberculous process, and conforms to a great extent to the principles of prognosis enumerated with reference to the pulmonary infection. In addition to this the outlook for the patient depends largely upon the caiise and nature of the pleurisy and the character of the therapeutic management. Many effusions may remain unresolved for years, and yet not seriously affect the welfare of the invalid. Other pleurisies, by virtue of their absorp- tion, not infrequently produce a disastrous influence upon the general condition. Among pulmonary invalids I have noted that the develop- ment of moderate pleural effusions has sometimes been followed by most gratifying results, which had previously been impossible of attain- ment. The foregoing prelirninary considerations will be more fully elaborated in connection with treatment. Serous effusions are the only ones likely to IxHonio al )sorbed or not to reaccumulate after aspiration. Exudates wlii( h niaihially assume a greater cloudiness with increasing number of leukocytes often assume eventually the characteristics of a purulent effusion, and become subject to the principles of prognosis and treatment applical^le to empyema. While serous effusions are much more benign than those which are purulent, the latter variety in many phthisical patients apparently exercises no more detrimental effect than the distinctly serous exu- dates. This statement applies exclusively to sterile effusions unattended by septic absorption. The prognosis varies materially, according to the specific microorganism present in the exutlate, the degree of consti- tutional disturbance, and the nature of subsequent treatment. The observations of Courmont concerning the seroprognosis of tuber- culous pleurisies are extremely intei'esting. He has shown that the degree of agglutinating power of the blood in typhoid fever is com- paratively small in the presence of the more virulent infections, and large in proportion to the resistance of the individual. Griffon, a few years later, demonstrated that the agglutinating power of the blood in pneumonia is greatest at the time of recovery, and almost absent in hopeless cases. Courmont and Arloing have reported that the maximum agglutination of the blood is greater, as a rule, in benign cases of pulmo- nary tuberculosis, and that it is slight in the desperate forms. Courmont has devoted a vast amount of study to the agglutinating power of the blood-serum and of the serous effu.sions in tuberculous and non-tuber- culous pleurisies. He found that the non-tuberculous exudates do not agglutinate the bacillus of Koch, and that the greater part of the tuber- culous fluids agglutinate tubercle bacilli in the proportion of one to five up to one to twenty. His more recent conclusions are to the effect that the prognosis of tuberculous exudates is favorable in proportion to a 366 COMPLICATIONS high agglutinating power of the effusion, and becomes more grave with a diminution or absence of the reaction. The maximum agghitination took place as the patients proceedetl toward recovery, while a chminution was found to occur as the conchtion became more desperate. His con- clusions are as follows: " 1. The mortality is about 25 per cent, in cases the pleural effusion of which has agglutinating power, and 75 per cent., on the contrary, in those in which the fluid has no agglutinating power. "2. Among patients with an agglutinating effusion the number of recoveries is large in proportion as the agglutination is high. "3. One can observe the agglutinating power of the effusion increase in proportion as the case progresses to recovery, and, on the contrary, chminish in those patients in whom the termination is near." CHAPTER LIU TREATMENT OF SEROUS EFFUSION To avoid confusion it is well to consider separately the management of serous and purulent effusions among phthisical patients. The treat- ment of serous exudates must necessarily vary in accordance with the strength and vigor of the invalid, the chronicity of the effusion, the degree of pain, the constitutional disturbance, and the extent of respira- tory and cardiac embarrassment. There is no arbitrary system of man- agement which is rationally applicable to all individuals. Each case should be regarded as a law unto itself, the therapeutic inchcations being determined upon the merits of the patient, as well as the effusion. Irrespective of considerations pertaining to the exudate, the course of procedure must be mocUfied in accordance with the extent and activity of tuberculous change and the apparent effect of the effusion upon the general condition. The primary consideration relates to a determi- nation as to whether or not the pleural involvement is doing actual harm by virtue of the pain, chscomfort, fever, dyspnea, and cardiac embarrassment, or producing, for the time lieing, relief of cough, severe pleuritic pain, or tendency to hemorrhage. It is at once obvious that upon a correct interpretation of its influence will depend an intelligent conception of its management. In some cases it will be found best not to disturb the effusion, while in others the indications for energetic in- terference become highly imperative. The precise manner of procedure appropriate for patients who are little reduced physically is scarcely appropriate for those with a similar effusion but much prostrated from prolonged disease, and offering but vevy slight prospects for reco\'ery from the pulmonary condition. Among many individuals the size and effect of the effusion are not sufficient to demand operative interference in order to save life. Whenever the local condition is such as to demand operations of necessiti/, even an apparently hopeless general condition should in nowise preclude the effort to render surgical aid. It is needless to state that the condition of the patient necessarily modifies in some instances not only the choice of surgical procedure, but also the nature TREATMENT OF SEROUS EFFUSION 367 of the medical treatment. Active depletion, venesection, and catharsis, though of undoubted value in selected cases, nevertheless may result in incalculable injury through their indiscriminate use. Sometimes relief of pain is urgently indicated. In mUd cases this may be accomplished by counterirritation, blisters, and warm applica- tions. Hot flaxseed poultices are occasionally productive of great comfort. If but little relief is afforded by such means, I have been in the habit of resorting to dry cupping of the chest over the seat of pain, and the results, as a rule, have been highly satisfactory. Fixation of the ribs by tight strapping with adhesive plaster often gives immediate relief. It is desirable, however, that the overlapping plaster shoidd be drawn very tightly, each strap being not less than two inches wide. When the pain does not yield to such measures, recourse may be taken to the administration of one or two doses of morphin hypodermatically luitil the early suffering is in part controlled. I have observed several obstinate cases in which large hypodermatic doses of morphin repeated at short intervals have been insufficient to afford relief. In a few instances I have not hesitated to resort to free general venesection, which procedure has been followed by the imme- diate disappearance of pain. In general a brisk calomel purge should be administered early, followed by the daily use of saline cathartics, large watery evacuations tending to promote reabsorption of the exudate. The salicylates have been found to induce moderate i:>erspiration and to aid indirectly in the absorptive process. In the n(in-;iciite cases, and particularly in the absence of fever, potassium idilid is, perhaps, of some use in promoting the disappearance of the effusimi. Siiiuiltaneously with efforts to hasten absorption the patients slioiild be iiistrurtcd to ingest but small quan- tities of liquid. It is iiitcicsf in^ id note iluit among pulmonary invalids marked general impi(i\cnicnt may occasionally take place as a result of the development of small effusions. Several years before Murphy proclaimed his treatment of tuberculosis by the introduction of nitrogen gas into the pleural ca\dty, it had been observed that the compression of lung by pleural effusions sometimes produced a salutary effect upon the immediate course of pulmonary tulierculosis. There were occa- sionally manifested a diminution of fever, improvement in cough, marked lessening of the expectoration, absence of previous pleuritic pains, and a material gain in weight. The prompt removal of the effusion by aspiration was followed in several instances by an aggravation of annoy- ing symptoms, which were previously held in abeyance. Such pro- cedure was frequently the precursor of an exacerbation of temperature, increase of cough and expectoration, loss of weight, and an apparent renewed activity of the tuberculous process. This would suggest the positive benefit sometimes to be derived from the intrapleural com- pression of lung for varying periods. It should be remembered, how- ever, that a favorable influence does not always obtain, even in pleural effusions; that these benefits are usually but temporary, and that no artificial compression, either by gas or external contrivances, save in exceptional instances, and to fulfil special indications, is to be commended. In other words, it is not the treatment of the tuber- culous lung per se, nor the tuberculous effusion alone, that should represent the effort of the medical adviser, but rather the manage- ment of the tuberculous individual. Laudable as have been the 368 COIIPLICATIOXS attempts to secure a favomlilc cffcrt upon the tuberculous process by direct mechanical compressinn, ii iiuist be stated that the clinical results have not been particuLnly .liiaiihing. It is no detraction from the genius of Murphy to alkule to the frequent impracticability of his method, and to discourage its adoption for general purposes. It remains, however, for the practitioner to take cognizance of the prac- tical truth emphasized by his work, to the effect that in some cases an idiopathic compression from serous effusion may be, for the time being, of distinct value. To say the least, efforts to secure its immediate removal by absorption or aspiration are not invariably demanded among pulmonary invalids. The practical lesson relates to whether or not there exist special indications for its removal. At this juncture the advisability of exploratory puncture or as])iration must be considered. Indications and Contraindications for Aspiration. — A very decided difference of opinion exists as to the indications for and against the aspiration of pleural effusions in pulmonary phthiiis. The majority of clinicians are prone to advocate the withdrawal of the exudate as soon as the diagnosis is established. Their attitude is based upon the assumption that the longer the fluid is permitted to remain in the pleural cavity, the greater the likelihood of firm adhesive inflammation, permanent lung compression, bronchiectasis, chronic interstitial pneu- monia, and deformities of the chest. Their position is apparently justified by the self-evident truth that, (jcneralli/ speaking, no indi\-idual can be expected to derive benefit from a pleural effusion, and that there is no justifiable excuse for withholding its removal until the advent of dangerous symptoms. They assume, further, that compression of lung from any cause is not good for the patient or the lung. It must be admitted that these postulatory statements are absolutely correct as far as they apply to non-consumptives, and even to the majority of phthisical patients suffering from acute pleural effusion. From the observation of many ra-^i-s of plcui-.'i! cffusicin :unong pulmonary invalids, both with and withmil aspiiatimi. 1 haxc Uccii constrained for some years to take exceptimi \n tliis as an iiir.irliihl,' procedure. Consump- tives should scarcely i)e embraced in the same category with non-tuber- culous cases as far as pertains to the indications for aspiration. In the pleural effusions of pulmonary invalids a new element is introduced, which does not appear among the so-called idiopathic cases. The indi- cations for the removal of the effusion are subject to considerable vari- ation, according to the acuteness or chronicity of the exudate, the likeli- hood of its reaccumulation, and the general condition. Tuberculous cases should not be aspirated save in the presence of certain special indications, the mere existence of a moderate pleural effusion in a consumptive affording insufficient wariant for its immediate removal. If the effusion he sufficient in extent to occasion cardiac or respiratory embarrassment, the demand for its witlidiawal is peremptory and brooks of no delay. Even the character of the effusion constitutes no ahso- lutclii reliable guide as to the method of procedure in consimiptives. The principle of surgery that pus wherever found should be evacuated does not always hold true with icfcifiicc to ]ihniral effusions in phthisi- cal patients. In such cases tlic coiisidciation is not so much the char- acter of the effusion, as its effect. I'liis pliasc of the subject will be dis- cussed in connection with empyema. In order to afford greater clearness, it is well to review briefly the TREATMENT OF SEROUS EFFUSION 369 manner in which spontaneous absorption is supposed to take place and the arguments that have been advanced upon pathologic grounds for its early aspiration. Forchheimer has recently called attention to the methods by which serous effusions are removed by nature. Absorption by the veins is shown to be enhanced up to a certain point by the increased intra- pleural pressure occasioned by the effusion, but later to be much diminished or entirely absent on account of the compression of the veins themselves. West, as quoted by Forchheimer, takes the ground that absorption occurs much more through the lymphatics than through the veins. He likens the pleural cavity unto a lymph-space possessing a lining of endothelial cells, the interlying stomata forming the openings of lymph capillaries which finally lead into the thoracic duct. In the presence of a large effusion absorption tlii(Jiii;h the 1\ iii])liati('s is sup- posed to cease on account of the greatly iliminislicd icspiiatoiy act and the consequent inefficient "lymph-pump." Forchheimer regards the compression of the lung by the pleural effusion as an essential factor in the diminished alxsorption, because of the simultaneous compression of the stomata and the lymph-vessels, as well as the veins. He thus explains the absence of absorption in less extensive effusions because of a similar effect upon the smaller portion of lung. It would seem rather difficult to explain upon this hypothesis the rapid absorption that sometimes takes place even in large effusions following the removal of a comparatively small portion of the exudate. Irrespective of the pathologic cause, it is known, however, that the larger the effusion, the less likelihood of absorption. Doerfler's work is also referred to in con- nection with pleural exudates of tulierculous nature. It is shown that with the prompt removal of the fluid by aspiration a preexisting anemia, due to the compression, is followed by an artificial hyperemia. This hyperemia is daimetl to be more or less permanent by reason of vaso- motor paralysis, and is apparently analogous in principle to the Bier treatment of inflammations. If this be true, an increased leukocytosis is inevitable, with a resulting increased formation of connective tissue, which is supposed to inhibit to some extent the further progress and development of the tubercle. The above is the argument in favor of the performance of early aspiration in pleural effusions, and may be accepted as applicable in part to the non-f ubcrcuhius as well as the tuberculous varieties. In view of these reu,^i ms. i c luci her with the greater likelihood of permanent lung compression ami the danger of sudden death, it would seem that there could be no valid ground to dispute the wisdom of prompt aspiration in all cases of pleural effusion provided there is not coexistent such pulmonary involvement as to modify con- clusions in individual instances. In some cases the condition of the patient is of more essential importance than the existence of a moderate exudate producing no subjective symptoms. The logic of clinical facts regarding the welfare of the phthisical invalid will be found more satisfying in the treatment of pleural effusions among con- sumptives than adherence to formulated tlieories. There can be no doubt as to the wisdom of aspiration in cases of acute effusion asso- ciated with fever, dyspnea, increased cough, or with the development of symptoms dangerous to life. The majority of serous effusions among consumptives, however, are of insidious origin, exhibiting a definite chronicity in their course, a tendency to reaccumulate after aspiration 24 370 COMPLICATIONS and an inability to attain large proportions on account of antecedent pulmonary and pleuritic change. In chronic effusions it is not necessary to resort invariably to aspii-a- tion in the absence of fever and dyspnea, or of such degree of medianical compression as threatens seriously to embarrass cardiac and respiratory functions. If these conditions exist, however, removal of the liquid should be performed regardless of all other considerations. Riiles for the Performance of Aspiration. — It is unnecessary to discuss at length the modus operan
  • oiiit of tenderness which may suggest the site of the empyema. Purulent effusions, however, often exist entirely devoid of any rational symptoms suggestive of their presence. Their early recog- nition necessitates painstaking examinations of the chest, which should be repeated at short intervals. Among pulmonary invalids unilateral immobility of the chest-wall or a localized impairment of expansion is of much less significance than 374 COMPLICATIONS among the non-tuberculous, because of other pathologic changes cap- able of producing a limited respiratory movement. The attention of the examiner, however, may be directed by this means to detailed phy- sical investigation. Edema of the chest-wall is sometimes present, though not a constant accompaniment of empyema. In some cases the pus accumulation may rupture spontaneously into a bronchial tube and be discharged through the mouth in large quantities, or produce death from inundation of the bronchial tract. Rarely, the purulent exudate may point externally and be evacuated in this manner— the so-called "empyema necessitatis." Among consumptives the vocal freniitus in interlobar empyemas is vague and capable of misinterpretation, on account of the transmission of the vibrations through areas of pulmo- nary consolidation. A consideration of some importance pertaining to percussion signs in such cases is the relation of the area of dulness to the interlobar septa. Musser has been particularly successful in localizing purulent empyemas by following the lines of the septa. He reports the area of dulness well below the lobar fissures in cases in which the empyema exists deeply between the lobes. Despite the absence of breath- and voice-sounds over a given area it is not especially infrequent to distinguish in these cases an increased skodaic tympany. On account of the antecedent pathologic changes in the lung and pleura among pulmonary invalids, but little importance need be attached to the shape or location of the pleural effusion. An auscultatory feature of special interest in connection with the small empyemas of consumptives is the remarkable frequency with which moist bubbling rales are transmitted with perfect clearness through a considerable effusion. This phenomenon has frequently led to errors in diagnosis because of the inference that the presence of loud bulsbling rales is incompatible with an effusion. Exploratory Puncture. — The possible dangers attending exploratory puncture are more practical than is usually supposed. The negative results which so often attend its employment are, to say the least, mis- leading, and permit of dangerous delaj's. This line of remark with reference to the inadvisability of paracentesis for diagnostic purposes is not to be construed as opposing aspiration with a large-sized needle whenever the symptoms and physical signs suggest the expediency of such undertaking. I would sooner resort to efficient surgical explora- tion of a suspicious area, provided the subjective and objective signs were sufficiently clear, than to dismiss such interference solely on the evidence of repeated negative exploratory puncture. It is unwise, however, to acce])t the more or less radical position assumed by some in favor of siiruir;il in\csli<::iticin, unless there is clinical evidence of an undoubted Idi-ili/i'd Incus ;liiv of iinliu-iuii a, dangerous pneumothorax. I will cite luidl)' :ui inicirsi nui cxikm icucc wliich illus- trates the difficulties so fr(M|uciul\- ciuDiiiniMcd ui tlu> diagnosis and management of intrathoracic disease. The patient was a w-oman of twenty-seven years who came to Colorado from Tennessee on account of suspected pulmonary tuberculosis. Her illness had been of six months' duration, following an acute onset which was characterized by severe pleuritic pain lasting nearly six weeks. EMPYEMA 375 There had been much loss of strength and flesh, with constant fever and severe cough, the expectoration being purulent and amounting to about six ounces daily. Upon arrival she was markedly anemic, emaciated, and experienced moderate dyspnea upon slight exertion, the temperature ranging between 102° and 103° F., and the pulse from 120 to 130. There were almost daily chills. Upon examination the respiratory movements upon the right side were found somewhat limited. There was moderate dulness in the back from the spine of the scapula to the base; also in front from the fourth rib to the base, and in the axilla. Respiratoiy sounds throughout this region were cnlVcMed and markedly distant. There was complete absence of vocal ficinit us and vocal resonance. The symptoms and signs pointed to an iui lallidiacic pus-collection, probably of pleural origin. Aspiration was practised in the eighth interspace in the line of the angle of the scapula with negative result. This was repeated several times during the ensuing week, until at least seven or •eight punctures had been made. Despite failure to discover pus it was impossible to entertain any other chagnosis than that of ah abscess within the chest. It was determined to explore the lung itself, but, owing to inability to elicit tenderness at any point, or to detect a sharply circum- scribed area of flatness, it was somewhat difficult to select a site for deep exploration. The needle was inserted nearly to its full length (four inches) at a point just below and slightly within the lower angle of the scapula. Something less than an ounce of pus was withdrawn, which was found to be of streptococcic nature. One or two days subsequently rib resection was performed at this point by Dr. Charles A. Powers. Extremely firm and extensive pleural adhesions entirely obliterated the pleural cavity at the site of operation. The insertion of the needle through the deeply injected pleura into the lung resulted in the withdrawal of one-half teaspoonful to one teaspoonful of pus. A deep incision was made into the lung, and was followed by moderate finger curetage. All the lung tissue within reach of the finger was found honeycombed with very small pus-cavities. The trabecule were broken down as much as possible with the finger, and a single pulmonary cavity, the size of a small orange, was produced into which drainage-tubes were inserted. There was no elevation of temperature following the operation. The patient gained thirty-five pounds in weight, assumed a healthy appear- ance, and was sent home at the end of three and one-half months in excellent general condition, the physical signs, howe\'er, remaining practically unaltered. Advices received from her attending surgeon in Nashville, Dr. McGannon, are to the effect that her general condition remains excellent, although the abscess is discharging slightly. She has had one or two slight hemorrhages following paroxysmal cough. The site of the operation is shown in the accompanying photograph (Fig. 104), taken shortly after her return. The extent of pathologic change in the lung is seen in the skiagraph recently made. The impor- tant lesson to be learned from such an experience is to the effect that exploratory operation should lie resort id lo despite negative punc- tures, provided the symptoms and siun- point strongly toward an intra- ■ thoracic pus-collection. I know this to lie coni rar>- to the teaching of many surgeons, who decline to extend o|iirai i\ c micrference in thoracic cases unless a verification of the condition is alToidcd by the use of the needle. It is easy to appreciate that in this case pus might not have been discovered even after numerous attempts at aspiration. In siich 376 COMPLICATIONS event the patient must have inevitably proceeded to a rapidly fatal issue. Among consumptives a decision relative to the expediency of explo- ratory puncture is in many cases extremely difficult. As a general rule, routine recourse to the use of the exploring needle as a means of diagnosis is productive of less satisfactory results than are obtained by reserving aspiration for those cases exhibiting positive surgical indica- tions for its employment. Methods of Treatment. ^In former years it was the general dictum of the medical profession that the treatment of all cases of empyema should be that of surgical interference, the only difference of opinion relating to the choice of method. It may be of interest to quote brief extracts from a paper prepared by me thirteen years ago, and deter- mine to what extent one can indorse the views then entertained. "The important practical thought to be emphasized in this connec- tion is the recognition of the existence of several species of bacteria in Fig. 104. — Showing site of operation in pulmonary abscess with recover>'. (Compare with radio- the exudate, endowed with varying properties and possessing marked differences in their virulence. The most benign of these characterize the empyemas of chiklren and the metapneumonic pleurises of atlults, and thereby furnish to the physician a justification for not resorting immediately, in all instances, to the more radical and nuitilative measures of treatment. The therapeutic indications are conceded to be, first, prompt and thorough evacuation of the pus; second, prevention of reaccumulation by means of free and continuous drainage; third, the maintenance of asepsis; and, finally, the obliteration of the pus-secreting cavity through adecjuate provision for the expansion of the lung and the collapse of the chest-wall. Save in extreme cases a general tuber- culous infection never contraindicates an operation from which satisfac- tory results are frequently obtained." A single preliminarn aspiration was advocated in children and in the metapneumonic pleurisies of adults. This was not based upon any EMPYEMA 377 faith in the adequacy of aspiration to effect a cure, but rather with an aim to afford temporary relief, and at the same time to establish a definite diagnosis. The purulent nature of the effusion, particularly in adults, was thought almost invariably to demand subsequent opera- tive measures. Free opening of the pleural cavity was strongly recom- mended on account of the complete exit offered to the coagula and organic debris, and the much improved facilities for a continuous dis- charge. Save for the employment of the single preliminary aspiration in children, this method was urged as an initial procedure in the treat- ment of all cases of empyema regardless of other qualifying conditions. It was insisted that if resection of rib was more frequently employed in the early stages of empyema before opportunity was afforded for the development of unfavorable conditions, there would result far less frequently the necessity for recourse to so severe a procedure as the multiple rib resection. For several years the conclusions which were largely derived from the experience of others were conscientiously applied to appropriate cases of tuberculosis, with almost iii\ariably unfortunate results. The essential principle of tre;itni(iii w.is to perform pleurotomy, provided the general condition of the ciiiiMinijiiiNc was not materially impaired, regardleiss of such vitally iinpoii .-mt ron^iderations as fever, chills, sweats, and emaciation. If the coiiditioii of the i);iti('iit in f;ir-:iii\;iiiced phthisis was desperate, it \\;is tluiuulii iiuui' inciiilul to jicrinit liiiii to die without inflicting the added toi-tiivc of an o])crati()n. In the light of a considerable cxpciicnci' il luis become apparent that the previ- ous course was dircrHy and ladically wrong. Cases will be reported at length in order t(i illu.^tiate the great responsibility assumed in advocating a radical operation for those comparatively well, and in withholding such surgical aid from others in urgent need, though apparently beyond hope. It is well to bear in mind that rib resection is necessarily followecl by one of two conditions. There either takes place a considerable expansion of the previously compressed lung, which affords opportunity for renewed acti^'it.y of the tuberculous process and rapid cavity formation, or there de^•elops failure of the lung to expand, involving long-continued pus-formation and great danger of amyloid change. In the absence of such clinical indications as fever, sweats, and chills it seems exceedingly ill considered to precipitate the patient into the midst of such peril. In 1895 a young man, a patient of Dr. F. C. Shattuck, con- sulted me immediately upon arrival in Colorado, exhibiting moder- ate tuberculous infection of the right lung. His illness had been of fourteen months' duration, the first symiitoms relati\-e to the pulmo- nary involvement beginning October, INOl. ( dui^li and expectoration were moderate. There was slight dailx I'lcvaiion of temperature, with some acrcleration of the pulse, flxanmiatiim of the chest dis- closed moist vMi-< in the right lung from the apex to the third rib. After a peri'id <>l' scxcral weeks a pleural effusion was recognized and thirty ounces of sterile serous exudate were withdrawn. Subse- quently the fluid was removed many times .it intei'v.uls of from three to six weeks. In the light of my present cdin irtions this procedure was quite unwarranted. There had developed no increased elevation of temperatu-e, no greater rapidity of pulse, or other constitutional disturb- ance suggesting its removal. Upon the other hand, the general condition 378 COMPLICATIONS after the advent of the effusion was considerably imjDroved. Chills and sweats were absent, and there was no evidence of respiratory or cardiac embarrassment. In this case the controlling indication for the removal of liquid was believed to be the continiious presence of a large inflammatory exudate, which proved incapable of absorption. It was thought that no good could result from the presence of even a sterile fluid in the pleural cavity, and possibly considerable harm from the consequent lung compression and other pathologic changes. The position was as- sumed that a case exhibiting progressive improvement both in the physi- cal signs and general condition was endowed with an excellent prognosis, and hence was vested with greater responsibilities than would have been true of a less favorable conchtion. Accordingly, it seemed rational to prevent continuous lung compression even by a fluid thus far unpro- ductive of subjective disturbances. It was not appreciated that a measure of the improvement in the general condition and physical signs might justly be attributed to the very fact of the compression. Unfortunately, the effusion, whether or not by virtue of repeated aspirations, finally was converted from a serous into a purulent one. This change in the character of the exudate was not accompanied by the least evidence of systemic disturbance, and upon the score of the general condition the necessity of an empyema operation was not apparent. Pus, however, was known to be present in the pleural cavity, and this was believed to constitute an imperative indication for its evacuation and subsequent drainage. Single rib resection was per- formed by Dr. Powers. From the standpoint of the intrapleural pus accumulation the operation was satisfactory to a degree, drainage was perfect, and the lung expanded to a very considerable extent. Judged from the basis of the individual, however, the remote effects of tlie operation were extremel.y disastrous. With the pulmonary expansion there ensued a perceptible increa.se in the activity of the tidierculous process. The bronchial rales became coarser anfl bubbling in char- acter. Cough increased materially, and expectoration became more profuse. Fever, impairment of appetite, and emaciation were attended by rapid softening and excavation until the decline was terminated by death. The peculiarly instructive feature of this case is the fact that the improvement in the general condition was uninterrupted up to the time of the operative interference, and the subsequent retrogression rapid and relentless. After several similar experiences the conclusion has been forced that in the absence of pronounced septic infection afford- ing distinct indications for operation, the interests of the patient are better subserved for the time being by non-interference. It goes with- out saying that under circumstances similar to the case just cited, it is somewhat difficult, upon the score of actual results, for the lay mind of patient and friends to acquiesce in the rationale of the operation. Another case is that of a man, aged twenty-eight, who had resided in Colorado one and one-half years before coming under my obser- vation, November, 1899. A progressive decline had been displayed from the beginning. He had been bedridden for several months, and a speedy fatal termination was predicted by two physicians who had Ijeen in attendance. For many weeks there had occurred daily chills, succeeded Ijy sharp elevations of temperature, which in turn were followed by severe sweats. Cough was .severe and distressing, ex- pectoration purulent and copious, and the appetite had failed entirely. EMPYEMA 379 I found the patient apparently moribund. There were extreme emacia- tion and cachexia. The countenance was drawn and ashen, with pinched features, the entire face being covered with cold perspiration. The pidse was exceedingly weak, scarcely palpable, and constantly over 150, while dyspnea was marked. Upon examination extensive tuber- culous infection was recognized in the right lung, together with a mod- erate involvement of the left. A small circumscribed pleural effusion was detected at the right base, which was found by exploratory punc- ture to be purulent in character. Arrangements were made for an immediate rib resection, although it was believed that any effort in this direction would be utterly unavailing as far as the saving of life was concerned. The position was assumed that the sepsis and prostration were directly dependent upon the contained pus, and that the invalid, in spite of his extremity, was legitimately entitled to the adoption of the same energetic measures as a non-consumptive. The patient and family, who were quite conversant with the desperate nature of the con- dition, were made acquainted with the radical treatment advised. The surgeon who was summoned to perform immediate rib resection was amazed at the condition of the patient, and declined to render surgical assistance upon the ground that the invalid was a hopeless consumptive at best. In view of the fact, however, that I was committed to the oper- ation, he reluctantly consented to extend surgical assistance, although contrary, as stated, to the ethics and principles of surgery applicable to the empyemas of far-:1d^•an(■ed consumption. Nearly 20 ounces of pus were evacuatt'd, :in(l the fiiiiicr inserted through the chest-wall demon- strated the ciiiuiiisciilicil luiiiiic of the empyema. After the operation the patient renuuncd utterly piostrated for many weeks, but a slow and gradual improvement subsequently took place. The wound closed in six months after the operation. After convalescence became established the patient was kept constantly in the open air, subjected to superalimenta- tion, and gradually achieved a pronounced gain in nutrition. This was followed, after several years, by an entire arrest of the tuberculous process. During the past seven years the patient has devoted himself assiduously to indoor work, and the arrest of the pulmonary infection is apparently permanent and complete. Some idea as to the subsequent result may be obtained by reference to the accompanying photograph, recently taken (Fig. 105). It is well to report another case, of more recent occurrence, which illustrates almost equally the possibilities of confusion in diagnosis, and the justification for radical operation, notwithstanding extreme physical debility. The patient, aged thirty-six, arrived in Colorado November 24, 1906, and consulted me upon the following day. Her illness had been of one year's duration,' a progressive decline being characterized by distressing cough, moderate expectoration, extreme exhaustion, pallor, and emaciation. In a letter from her pliysician it was stated that, after a futile effort to seciu-e improvement at home, she was sent to Colorado as a last resort, though without any reason- able hope as to her improvement. Her temperatm-e was descriljed as having been continuously high throughout the period of observa- tion, and her pulse exceedingly rapid. The general appearance upon arrival was assuredly suggestive of a highly desperate condition, but some valid ground for hope was established by the recognition of a small circumscribed and irregular area of flatness in the left back, with 380 COMPLICATIONS diminution of breath-sounds and vocal resonance. Pus was obtained upon aspiration, and the patient, despite her unfavorable contUtion, committed to immetliate rib resection which was performed by Dr. F. L. Dixon. About twelve ounces of pus of staphylococcic origin were evacuated. Upon rallying from the operation there was manifested a remarkable improvement in all respects. Coincidently with the obliteration of the pus-cavity there was a complete disappearance of physical signs attributable to pulmonary involvement. After a gain of thirty pounds in weight, the former health was apparently restored and the mother of five young children was returned to her family. Fig. 105. ation for empyema Fig. 77, p. 281). The site of the circumscriljed empyema is represented by the percus- sion outlines shown in Fig. 106, which is of added interest in connec- tion with the skiagraph showing, eight weeks after operation, an entire absence of shadow change. To witness a rapidly progressive decline, with a fatal termination, in one who before operation was well nourished, devoid of fever, to out- ward appearances in good condition; to observe the astonishing recovery from an empyema in one who at first was refu.sed operation as being almost moribund, and to note a permanent restoration to health in others, is sufficient to shake one's faith in the tenability and wisdom of previously accepted principles pertaining to a course of treatment accorded pulmonary invalids. Other equally conspicuous cases could be reported, if necessary, to demonstrate the correctness of these con- clusions. My present custom in the empyema of consumptives is to let it alone unless there is some good and sufficient cause for interference along the lines previously suggested. If rcnioxa! is indicated, simple aspiration EMPYEMA 381 is employed, and repeated as frequently as demanded. The only excep- tion to this relates to thoroughly septic cases, exhibiting chills, fever, sweats, and great prostration. Under such conditions no time should be lost through temporizing measures in securing free opening and thorough drainage. Occasionally it is expedient, however, to excise the rib and drain a small well-circumscribed empyema even in the absence of septic manifestations provided the tuberculous process is very slight. It is unnecessary to describe in detail distinctly surgical procedures. It may be permissible, however, to call attention to one or two features that have repeatedly impressed me as of great importance. First, the opening should not be too low, in order that it may not be later closed by the rising diaphragm. The pus is not emptied from the thorax altogether through the force of gravity, but is pumped out to a large extent by the action of the lung in inspiration and expiration. Secondly, the opening should be maintained sufficiently patulous to permit free drainage. This does not refer alone to the opening in the chest-wall, but to the tubes as well. Many times I have seen fenestrated tubes when kept in position for a prolonged period completely occluded by a growth of granulation tissue. Third, the tube should be removed daily and cleansed, as well as shortened from time to time, in order to permit the fullest possible drainage, and to avoid the violent paroxysms of coughing produced by irritation of the approaching visceral pleura. Conspicuous relief from distressing paroxysms of cough may be afforded by frequent shortenina; of the tube. Fourth, daily, after removal of the tube, the patient should not merely be turned on the side, but should also be subjected to a short series of pulmonary gymnastics in various posi- tions. This permits the fullest possible drainage, which, as a rule, is not attained by ordinary turning of the patient. Gentle coughing is often sufficient at such a time to expel violently large masses of floccu- a»Z COMPLICATIONS lent coagula, or at least to cause them to appear at the opening and allow their subsequent removal by the forceps. Irrigation need not be employed save under quite exceptional con- ditions. It is permissible to irrigate with salt solution from time to time in order to estimate the total capacity of the pus-cavity, and obtain thereby some definite information as to the degree of pulmonary expan- sion. It is also proper to irrigate in case of a distinctly fetid odor of the pus, although fetor in itself suggests the necessity of a larger opening and of more complete drainage, rather than of irrigation. Unpleasant results have frequently been reported from the use of irrigating fluids. Such possibility may be avoided, to a large extent, provided certain pre- cautions are t^ken concerning the method of irrigation. A normal salt solution or one of boric acid is the best fluid for this purpose. The use of solutions of mercury bichlorid, phenol, and similar prepa- rations capable of undue toxic absorption is to be interdicted. Owing to the admirable drainage usually following empyema operations the liability of toxic absorption froni the use of the more powerful anti- septics is indeed slight, but disastrous results occasionally follow their use. A much more serious accident from the employment of irrigation is the occurrence of shock, which in very rare instances is fatal. At times there may suddenly develop severe nervous manifestations, resulting from irritation of the pleura. Such symptoms as syncope, convulsions, hysteria, epileptiform attacks, delirium, monoplegia and hemiplegia, and disturbances of vision, though exceedingly rare, never- theless may occur regartlless of the nature of the irrigating fluid. The avoidance of untoward manifestations accompanxdng irrigation may be secured in most cases by proper attention to the temperature of the fluid and to the manner in which it is injected. Extremes of heat or cold are to be avoided, a temperature of about 100° F. being the most desirable. The solution should be introduced into the pleural cavity in a gentle, steady flow. The correct application of the dressings after pleurotomy requires the observance of strict antiseptic precautions. The demand for the most scrupulous care in this respect remains continuously and rigidly in force until the final closure of the wound. An adherence to these principles during each subsequent dressing should prevent secondary bacterial contamination. An appropriate dre.ssing may also be of material assistance in favoring the expansion of the lung. It is very desirable that this be made to expand as quickly as possible and to the fullest extent. Should the lung become bound down by the formation of pleuritic adhesions, when in a state of only partial dilatation, its subsequent expansion is rendered extremely difficult, if not impossible. By reviewing the mechanic principles involved in the process of lung expansion it becomes apparent that one function of the dressing should be to provide for the ready passage of the air jrom the pleural cavity, and to obstruct, as far as possible, its reentrance. In order to obtain a possible valve-like action of the dressing some surgeons employ external to a thick layer of aseptic gauze a piece of oiled sUk large enough in size to project upon the skin in every direction, to which it is closely applied by the elastic pressure of the outer dress- ings. WhUe several theories have been presented to explain the expansion PNEUMOTHORAX 383 of the lung after entrance of air to the pleural cavity, their elucidation involves a consideration of the principles of dynamics, which does not fall within the scope of this book. It is sufficient to show that at least one element among the several that may combine to promote lung expansion is the application of an appropriate dressing. The use of the oiled silk or muslin, as described, commends itself highly in theory. It may be properly questioned, however, if a generous occlusive aseptic dressing does not answer quite as well. In the after-treatment systematic "lung gj-mnastics" may be of considerable service in aiding the expansion of the previously compressed lung. The use of the James method, which consists of the transfer of water from one large Wolff bottle to another by means of the expiratory effort of the patient, is undoubtedly of some service. The expansion of lung is aided to a considerable extent by a tem- porary residence in moderately high altitudes. I have had opportunity in several instances to note the excellent results obtained among cases sent to Colorado for this purpose. CHAPTER LV PNEUMOTHORAX Symptoms and Physical Signs. — The pathologic conditions, as well as the syinptoiiis :iiul })h>sieal signs, are found to differ materially in the various forms of pneumothorax. In like manner essential tiiffer- ences of treatment are indicated according to the particular type of the disease. A discussion of the symptoms, physical signs, diagnosis, and treatment of this somewhat frequent complication of consumption should include, therefore, a separate consideration of the open, closed, and valvular varieties. In pneumothorax among tuberculous cases the entrance of air into the pleural cavity is effected by perforation of the visceral pleura, as the result of an imderlying pulmonary cavity or subpleural caseous focus. Other ways in which air may enter the pleural cavity are of rare occurrence among pulmonary invalids. The symptoms and signs are directly dependent upon the changed intra- thoracic relations, which vary in degree according to the antecedent pathologic conditions. Further, the clinical manifestations and treat- ment are modified by the amount of air present in the pleural cavity, and by certain mechanic conditions influencing the degree of positive intrathoracic pressure. Thus the character and severity of the symp- toms vary according as the air passes in and out with each respiratory act, remains in a closed chamber, or, through a valvular action at the point of perforation, is pumped into the cavity with each inspiiation. In ordinary cases of complete pneumothorax occurring without previ- ous pleuritic adhesions the cardiac and respiratory embarrassment is extreme and the physical signs exceptionally well defined. Among pul- monary invalids, however, by virtue of the previous anatomic change in the pulmonary and pleural tissues, varying amounts of air may enter 384 COMPLICATIOXS the pleural ca\aty and produce essential differences in the clinical picture. In partial or circumscribed pneumothorax the non-existence of typical symptoms and signs frequently leads to grievous errors in diagno- sis. The classic symptoms of general pneumothorax are of sudden development, consisting of excruciating pain in the side, extreme dysp- nea, cyanosis, and collapse. In addition to the agonizing pain and sense of impending suffocation there is often experienced keen mental anguish, which is reflected in the facial expression, the features being pinched and drawn. The tcininrature in such cases is almost always subnormal at first, but m:i\ i i-r Mil xciuently. The pulse, though usually regarded at such time.s ;i> \ti\ itcMe. extremely rapid, and thready in character, does not always conform to this description. I have observed several invalids exhibiting extreme dyspnea, yet \\ith the pulse but slightly affected. Some 3-ears ago I saw, in consultation, at the request of Dr. Sewall, a case of complete pneumothorax in which all the symptoms save the slow and regular pulse suggested immediate dissolution. The patient, who had assumed the sitting posture in bed. was supported upon each side by an attendant and was rocking to and fro, moaning and screaming as much as his labored and frequent respirations would permit. There were pronounced cyanosis and excessive dyspnea. A provisional diagnosis of pneumothorax, which was entertained on the score of the abrupt onset and urgent symptoms, was verified upon exami- nation, and the patient relieved for the time being by aspiration. The development of pneumothorax frequently accompanies unus- ually severe spells of cough or sudden exertion. I have observed its occurrence several times in connection ^^^th the lifting of heavy objects, and in two instances as a result of rising upon the toes and stretching the arm to reach a chandelier. In contradistinction to the sudden terrifying onset with pain, mental anguish, air-hunger, and varying degrees of collapse following severe cough or other obvious cause, pneumothorax ?««// develop in pitlmmmri/ invalids and be entirely devoid of clinical symptoms and witliout visible explanation. The absence of initial symptoms does not suggest the necessity of physical exploration, and the condition often remains unsuspected until recn^iiizcil at tlie time of a subsequent examination. I have discovered instaiicis m imeumothorax several weeks after a care- ful chest examination, nu iutcnurring symptoms of note having super- vened. In a few cases it developed without symptoms or apparent cause, the patient being constantly in the recumbent position. A case in point is that of a male patient, whose chest was examined with negative result as regards pneumothorax two days before going to bed for an acute tonsillitis. One week later, before permitting him to arise, the lungs were examined, and a well-defined pneumothorax was found. A patient, shortly before a pulmonary hemorrhage, disclosed not the slightest evidence of an existing pneumothora.x, but several days after subsidence of the bleeding this condition \va.s discovered. This seems all the more remarkable in view of the fact that morphin was freely administered and a slow respiration rate maintained through- out the illness. This case was especially interesting and instructive because of the previous existence of fibrous tissue contraction pulling the heart appreciably to the left, upon which side the pneumothorax PNEUMOTHORAX 385 took place. There resulted the anomalous presence of a wfll-defined pneumothorax with heart displaced toward the affected side. An important feature in connection with the clinical manifestations of pneumothorax in some cases is the mild initial disturbance, with a continuous increase in severity, even to the point of suffocation and death, unless relieved by aspiration. This sequence of urgent symp- toms following an apparently benign onset is due to the entrance of air through a perforation of minute size, with, however, a progressive gradual accumulation. Upon inspiration but a slight amount of air is admitted through a patulous opening, while on account of its immediate closure the air is unable to escape during expiration. The symptoms may rapidly or slowly increase in severity in proportion to the amount of air enter- ing the cavity with each respiratory act. Whether this difference in the time of development of distressing symptoms is due entirely to the size of the perforation or in part to the degree of valvular competency is difficult to determine. Certain it is that, from a clinical standpoint, cases of valvular pneumothorax exhibit an extreme variation in the onset of desperate symptoms, as well as in their recurrence following aspir- ation. It has been my experience that the average patient develops a sense of urgent air-hunger in two or three hours after the immense relief afforded by aspiration. I have, however, seen invalids lapse into their previous impending suffocation before the expiration of one-half hour subsequent to removal of the air. On the other hand, two patients have recently been observed in whom the entrance of air with each inspiration was so slight that the recurring symptoms were delayed for forty-eight hours after the aspiration. The physical signs of pneumothorax in pulmonary invalids must vary within wide limits, according to the extent of the condition and the peculiar type present in individual cases. It should not be imagined that pneumothorax must invariably exhibit such typical signs as bulging of the rib-spaces, complete immobility of side, resounding tyiiipuuy, dislocation of organs, and amphoric or cavernous respiiaticui. Such a group of physical signs should be understood to apply solely to casts of complete pneumothorax. In such cases there may be impaired mobility of the affected side, which is compensated for by an exaggerated excur- sion of the other. Bulging of the rib-spaces is by no means constant, although occasionally present. The vocal fremitus, which is often described as much diminished or absent over the affected side, may even be somewhat intensified when there is a free communication with a bronchial tube. In closed or valvular forms of pneumothorax, how- ever, the vocal resonance and fremitus are diminished very considerably. The percussion-note varies materially in accordance with the form of pneumothorax and the quantity of contained air. In the open variety the resonance is usually tympanitic or amplioric. although the cracked- pot sound is .sometimes recognized, as well as Winl rich's change of pitch. In cases of clo.sed or valvular pneumothorax the tympanitic reisonance is usually pronounced, but may be muffled in charactel', and the pitch more or less elevated. An excessive hyperdistention of the pleural sac incident to the contained air may give rise to marked dulness and occa- sion an error of diagnosis. I recollect an instructive case, seen ten years ago, the patient coming under observation some two weeks following an initial pain in the side, with gradually increasing shortness of breath. There was but little cough or expectoration. The fever was moderate, 386 COMPLICATIONS and dyspnea well marked. Examination of the chest disclosed pro- nounced dulness of the entire left side, front and back, with complete absence of respiratory and voice-sounds, save in the extreme upper portion. The heart was dislocated to the right. The extreme dulness of the left side, in conjunction with other signs, suggested clearly a chagnosis of large pleural effusion, which was indorsed by two con- sultants preliminary to aspiration. The conchtion, however, proved to be one of simple valvular pneumothorax. It is important to emphasize, in this connection, the pos.^ibility of didness upon percussion on account of the extreme tension incident to intrathoracic pressure. The auscultatory signs are also subject to great variation in different cases. In open pneumothorax the respiration is usually amphoric or cavernous in character. These types of respiration cannot exist unless the air passes freely in and out of the pleural ca\it}- with each respiration. Under such conchtions the vocal resonance is intensified, as in pulmonary cavities. Rales are sometimes heard which possess a distinct musical qualit}". Metallic tinkling occurs only when liquid as well as air is present in the pleural cavity. This is also true of the succussion sign and the area of movable flatness, to which allusion has been made. In the closed or valvular forms of pneumothorax the breath-sounds may be suppressed entirely or much enfeebled, together with the vocal resonance and fremitus. The coin sign is of especial value in open pneumothorax, and consists of the intensified echo transmitted to the ear of the examiner from the tapping of one coin upon another placed upon the opposite side of the chest. The diagnosis of acute pneumothorax, simple as it would appear, is nevertheless attended with some difficulty in many cases. A complete exploration of the chest should be sufficient, as a general rule, to estab- lish an accurate chagnosis. There should be no difficulty encountered in recognizing the condition whenever liquid, as well as air, is present in the pleural cavity, as the signs of pneumopyothorax are so characteristic as to preclude confusion in their interpretation by an experienced examiner. The signs especially iiatlmundnKinic of pneumopyothorax will be considered in connection with iluit ((nidition. Cases of circumscribed i)neuniiitli(iiax are not always susceptible of eas}^ chfferentiation from pulmonary cavities, as these conditions possess many physical signs in common. Among these are the caver- nous and amphoric types of respiration, although the latter is more common in pneumothorax. The cracked-pot resonance is an inconstant sign, and is present not infrequently in other conchtions. In pneumo- thorax there is often immobility of the side, with displacement of the apex-beat. The respiratory sounds and the vocal resonance and frem- itus are diminished, both in circumscribed pneumothorax and over large pulmonary cavities, provided there is no opportunity for free entrance and exit of air. If tlierc is open communication with a bron- chial tube, however, there nia\' be ikiKhI in either conihtion cavernous or amphoric breathing, as well as gurizliug rales and pectoriloquy. Pneu- mothorax rarely occurs in the extreme upper portion of the chest, while pulmoiuuy cavities may exist in any part of the lung. The prognosis in pulmonary invalids varies according to the general condition, the antececient pathologic change, the size of the air-chamber, and the particular variety of pneumothorax. Provided there is not PXEUMOTHOKAX 387 an immediate fatal termination, the outlook for the patient must be considered upon the basis of the chronic pneumothorax. Patients surviving the first few hours, or possibly a day, often linger for several weeks and may even recover in some instances. The prognosis attend- ing a closed pneumothorax is unquestionably the most favorable of the three forms. The existence of this variety implies a previous rupture of the ]:)lciii-a. whirh sul)Sc(|ucntlv has complotolv cld.^ed. I'])Oii tlic hasis of the pliNsiral -1,-iis alone ii is soiiictiiiics diiiicult to (list iu^ui^h this from tln' \alviilaj- type, althou.^ij. as a. nilc. in the (■lo^(■(l va.ni-t>- there is less innnobility of the side ami less buluinu, while tlie symptoms are usually not urgent. The prognostic inlhience of tliis form of pneumo- thorax upon pulmonary tuberculosis is not necessarily unfavorable. The chief danger lies in the opiiortuiiity alToi('e(| for secondar}^ infection through the entrance of niiiToor^anisms betore healing of the perfora- tion. There is at times an apparent diminution in the activity of the tuberculous infection, as a result of the pulmonary compression, the expectoration and cough often being materially lessened. If the pneumo- thorax is not complete, there is but slight cardiac or respiratory embar- rassment. Gain in weight and (Iisap)i(>arance of fever sfimetimes attend moderate compression of Inni!. in man}- cases tiie aii- is absorbed gradually, after which an advain'inii exjiansion of the lun,n lalu'S place. On the other hand, the open jjneumothorax, in the majority of cases, is transformed without delay into a pneumopyothorax bj' the entrance of bacteria. The prognosis of these cases varies, as in empj^ema, accord- ing to the character of the infection and the resulting influence upon the general health. In addition to the paroxysmal cough, with copious morning and evening expectoration, symptoms of profound systemic infection may supervene. In this event the patient exliibits cliills and sharp daily exacerbations of temperature, and in many instances pro- fuse sweats. The future of these consumptives is fraught with great danger, but the condition is not necessarily fatal. Some, under prompt surgical manauement, lin.-illy achieve recovery, and others secure a pro- longed lease of lile. althoHLih succumbing eventually. The valvular torm of |incrinoth()i'ax is the least favorable of all varieties. Tlie sympionis are extremely urgent, the sufferings severe, the dyspnea intense, and ilie (la,n,!j;er imminent. The immediate outlook for the patient is largely dependent upon tlie character of therapeutic management. Stimulation. ;ilthou,i;ii clearly indic:ite(l, is of but trifling value in comparison with tlie \asi inipoitaine attached to the relief of the intrathoracic distention by removal of the contained air. Often the respite afforded by aspiration is of but a few hours' duration, and although this may be repeated at intervals, the patient is saved merely from an initial collapse. A certain number of cases, no matter how desperate the situation, finally recover through prompt and repeated aspiration accompanied by heroic stimulation. An eventual disappear- ance of the pneumothorax may take place in a few instances, as will be shown by tlie citation of an illustrative case. At best the prognosis is exceedingly grave. Treatment. — The treatment of simple pneumothorax depends almost entirely upon the urgency of the symptoms. If extreme, the early medicinal treatment con.sists of excessive stimulation and the hypodermic administration of morphin. The latter is often of the utmost value, and in many ca.ses transcends in importance all other dOO COMPLICATIONS remedial efforts. A quarter of a grain of morphin injected subeutane- ously will often mitigate to a marked extent the severity of the symp- toms. As cardiac and respiratory stimulants, str3-chnin and atropin are recommended, together with free inhalations of oxygen. The urgency of the condition in acute general pneumothorax represents one of the few occasions when oxygen is peculiarly efficacious. The indications for treatment point solely to general measures, as morphin, stimulation, and oxygen. In open cases the efforts of the physician must be con- fined to the relief of pain and general stimulation, imtil opportunity has been afforded for the adaptation of the damaged respiratory appar- atus to the functional needs of the system. The treatment of a closed pneimiothorax should relate to the avoid- ance of a renewed perforation, which would expose the patient to the dan- ger of .secondary infection. Absolute quiet should be enjoined for a con- siderable time, lest by some sudden untoward movement ruptm-e of the pleura may result. Cough must be avoided as much as possible. To this end opiates are sometimes indicated for the time being, to meet the requirements of individual cases. If the cough is especially severe, it is good practice to strap the chest with adhesive plaster in order to restrict, as much as possible, the movement of the affected side. After several weeks' delay it may be permissible to withdraw a small portion of air under verj- gentle negative pressiu-e. This procedure, however, is not to be commended in general, as even if carefully practised it may sometimes result in reopening the visceral pleura. In acute valvular cases relief, as a rule, is seciu-ed only through the performance of aspiration, and is almost instantaneous with the with- drawal of air. This is imperatively indicated as soon as the symptoms become at all lu-gent. There is no conventional point of puncture to be recommentled. The essential consideration is to enter the air- chamber, the limits of which are determined by the physical signs. The same precautionary measures should be observed as with aspiration of the fluid in pleural effu.sions. in which event no liad results attend repeated withilrawal of the air. If a considerable time elapses after aspiration before the i-eappearance of dangei-ous symptoms, the indica- tions point to its repetition rather than to more radical measures. It occasionally happens that a few judiciously interspaced aspirations are sufficient to sustain life during the period of extreme urgency. Cases exhibiting a .speedy recurrence of alarming symptoms following aspira- tion demand a free opening through the chest -wall into the pleural cavity. I do not hesitate in such cases to insert a large-sized trocar and cannula. The trocar is withdrawn and the cannula is fastened to the chest-wall by plaster, and covered lightly with an aseptic dressing, which is frequently changed. This method of treatment is attended by a pronounced egress of air from the chest with each expiration, and in man}' cases is instrumental in affording relief from most distressing symptoms. It is the treatment par excellence for desperate cases, and will occasionally enable the invalid to secure an adaptation to the radi- cally changed respiratory condition. .At this time tlie free use of oxy- gen as in initial open pneumothorax is of substantial aid. In connection with the preceding principles of treatment applicable to extreme conditions the following case is of especial interest, and also illustrates the not infrequent slowness of onset. In the summer of 1905 a young man with advanced pulmonary PNEUMOPYOTHORAX 389 tuberculosis was sojourning with his parents in the mountains of Colo- rado, at a point far removed from railroad communication. After several days of indisposition, shortness of breath was noted, together with moderate pain in the left side and conspicuous aggravation of cough. This was frequent, distressing, markedly paroxysmal, and unattended by expectoration. The transition fi-om an amiable, gentle disposition to extreme irritability was a uolicculjlr feature. Dy.spnea, pain, and the nervous disturbance pro,nr('ssi\'cly increased during the next few days. In response to an urgent sunuiious I found the patient after the lapse of nearly twelve hours in extremis by rea.son of a per- fectly defined valvular pneumothorax. The relief afforded by aspiration was almost instantaneous, but this was again required after twelve hours. Aspiration was employed at intervals of four or five hours during the ensumg two days, and afforded in each instance a great measure of relief. The patient, however, became much exhausted from the frequent recurrence of positive intrathoracic air-pressiu'e, and his sufferings were almost beyond endurance. The nervous control was entirely lost, and the condition became almost maniacal. During a period of two hours the pvilse entirely disappeared, the skin being bathed with cold perspiration. Cyanosis was intense, and death was imminent. Against the protests of the parents, who demanded that his sufferings should be permitted to cease, I resorted to an unusual degree of stimu- ulation with strychnin, atropin, and subcutaneous salt solution and made a free opening into the pleural cavity. A lai'ge trocar and can- nula were inscrtcil bclwccii the Ihinl Mid louitli lilis in the anterior axillary lino, 'i'hc tiocui' \\:is icnidved. and :i iii;li1. Idcim^ aseptic dre.s.sing applied over the cannula. The e.\it of air, which was attended by a loud hissing noise, afforded immediate relief. The cannula remained in place for three days, during which time a perceptible improvement was noted in the general condition, the respirations, and pulse. It was then removed, but replaced upon the following day, on account of the renewed development of dyspnea and cyanosis. After several days the cannula was again removed without a subsequent reappearance of urgent symp- toms. A week later a small amount of air was removed by gentle aspir- ation, care being taken to avoid too great a negative pressure within the pleural cavity. This was repeated several times at intervals of one or two weeks. The patient greatly improved in his general condition, and at the end of three months it was impossilile to detect upon rigid physical examination the .slightest evidence of pneumothorax. I have refrained from devoting space to the enumeration of the physical signs in this case, as they conformed closely to the type described as charac- teristic of such cases. CHAPTER LVI PNEUMOPYOTHORAX Physical Signs. — When, in addition to tlie air, liquid is also present in the pleural cavity, the symptoms common to simple pneumo- thorax are considerably modified. The more important differences in the clinical manifestations relate to the varying degrees of .systemic 390 COMPLICATIONS disturbance. The presence of pus in the pleural cavity often gives rise to the exhibition of chills, fever, sweats, and digestive disorders. This group of sj'mptoms, though not invariably present in pneumopyothorax, are more frequent than in the preceding concUtion. The appetite is often impaired, and gastric cUsturbance with constipation is common. Edema of the face may be noticeable, together with slight cyanosis. There is frequently imparted a slight c}-anotic cUscoIoration to the face, which in association with pallor and edema produces a rather character- istic appearance. The ends of the fingers are usually thickened, both laterally and anteroposteriorly, and present a peculiar clubbed shape. The cough is apt to be paroxysmal and associated with the periodic expectoration of large quantities of purulent sputum. This is especially noticeable in the morning and evening, as well as upon stooping over or l3'ing down during the daj*. These patients usually sleep upon the back, though sometimes upon the affected side. Turning to the oppo- site side may be accompanied by the expulsion of considerable expec- toration. When the condition is essentially a chronic process, in the absence of systemic infection there may be lacking any rational symp- toms to suggest its presence. The physical signs, however, are strikingly characteristic, although frequently unrecognized. While the presence of air is often detectetl upon examination, the liquid, if occurring only in moderate amount, is not infrequently overlooked. In pneumopyothorax the upper level of the fluid conforms strictly to a horizontal plane, and being contained at the extreme base of the thorax, may escape notice if a careful physical investigation is not made at this point. By comparing the lower boundaries of percussion resonance on the two sides there should be no difficulty in recognizing an area of flatness. The disparity between these corresponding regions upon percussion is emphasized b}- the usual development of emphysema upon the opposite side, still further lower- ing its resonant border. In contradistinction to the curved line of dulness incident to pleural effusions the upper boundary of percussion flatness in pneumopyothorax is always pcrfectlfi straight and horizontal. A striking corroborative percussion sign is the marked variation in the level of flatness, with a corresponding change in the position of the patient. The presence of air and liquid combined in the pleural cavity is the only condition permitting a pronounced change in the upper level of percussion flatness. This is a physical sign of the utmost impor- tance, and may be regarded as cUstinctly pathognomonic of pneumo- pyothorax. The auscultatory signs are not appreciably different from those of simple pneumothorax, save that the breath- and ^'oice-sounds are dimin- ished or absent below the level of the liquid. Metallic tinkling, as pre- viously described, may be recognized, antl is strongly suggestive of pneumopyothorax, although occasionally heard in the presence of large pulmonary cavities containing liquid. A feature of great import is the succussion splash elicited by shaking the body quickly with one ear in direct apposition to the chest. The treatment of pneumopyothorax among consumptives in the absence of well-defined septic manifestations consists of a rigid adher- ence to the " laissez faire' ' policy. Sometimes the indications point to the removal of the fluid by reason of its mechanic effect and the degree of septic absorption. Occasional aspiration is the most conserva- PNEUMOPYOTHORAX • 391 tive means of emptying the cavity, and in some cases this measure is all that is required. Excellent results may attend the employment of siphon drainage. A trocar with cannula is inserted between the ribs, the trocar removed, and a tightly fitting rubber tube inserted through the cannula. This is subsequently withdrawn over the tube, which is left protruding into the pleural cavity. The other end of the tube is passed through the cork of a bottle, which may be carried in the pocket and emptied at intervals during the day. The flow is controlled by clamps upon the tube. 1 have known of several cases in which this procedure has produced highly satisfactory results. If this expedient is found impracticable, or insufficient on account of the existence of urgent symptoms, recourse must be taken to an operation which, to this class of cases, is often of direful import, i. e., the permanent opening of the pleural cavity. From my observation it would almost seem that for these unfortunates the classic inscription of Dante should be changed to "Abandon hope all ye who are entei-ed here." The thoroughly collapsed and atelectatic lung is usually bound down by firm adhesions, precluding all prospect of its ever expanding without removal of the visceral pleura, and even then to a limited extent. There begins at once the period of interminable suppuration and drainage, the none too cheerful prospect of repeated rib resections, after the manner of Estlander or Schede, decortication of lung, as introduced by Delorme and Fowler, or discission of pleura, as devised and practised by Ransohoff. The shock attending these major operations, the subse- quent suitViiiLu, tlie disaiipointment incident to non-healing wounds, the iucN itaiilc exhaustion, and the frequent amyloid change jointly con- stitute rdUMilcratious of sufficient import to furnish grounds for reason- able hesitation in advising these mutilative procedures. Judging solely from a considerable experience with these cases, the conclusion is reached that the results at best are likely to be unsatisfactory, although in some instances a prolonged respite is offered to the unfortunate consumptive. Perhaps a few years of this existence is preferable to an earlier death, and affords a justification for the operation in selected cases. The dictum laid down by some authors that pyopneumothorax developing among consumptives, regardless of other considerations, con- traindicates the adoption of radical measures is unquestionably errone- ous. In the presence of sepsis, chills, fever, and sweating, the indications for immediate removal of the pus by means of a permanent opening into the pleural cavity are equally imperative as with the non-tubercu- lous. No matter how great the cxticniit y. the pulmonary invalid is entitled to the same prompt mcasuirs u( idicf as the non-consumptive. It must be admitted, however, that tlic cdutlition of the patient is a strong determining factor in a choice of the precise method of surgical interference. Even in highly desperate conditions with extreme phy- sical debility and pronounced evidence of sepsis, aspiration alone is scarcely ever sufficient. In such ca.ses thoracotomy is more efficacious as a means of prolonging life and promotmg recovery, and also is quite as easily performed even without the employment of anesthesia. The operation consists of the introduction of a large trocar and cannula into the chest- wall, followed by the removal of the trocar and the retention of either the cannula or of a short rubber tube over which the cannula is withdrawn. Care should be taken that the end of the tube is not inserted too far within the pleural cavity. Continued drain- 392 COMPLICATIONS age by this method is usually unsatisfactory, as the narrow rib-spaces prevent more than a small opening. The tube is very likely to become occluded by obstructive coagula of pus, blood, or lymph. When, therefore, the prompt removal of pus is demanded in profoundly septic cases, single rib resection should be performetl no matter how desperate the condition. This procedure conserves the interests of the patient, both as regards the immediate present and the not too remote future. All cases permitting the administration of an anesthetic should be sub- jected to single rib resection in preference to aspiration or puncture, but the inadvisability of an anesthetic should not always be con- strued as an argument against the more radical operation. This may be performed by a skilful surgeon in an exceetlingly short time without general anesthesia, as I have been permitted to observe upon repeated occasions. In desperate cases thorough preliminary cocainization of the .soft parts renders the incision down to the rib perfectlj- painless. After denudation of the periosteum the rib may be quickly resected, either without anesthetic or with the patient under the influence of somnoform. By the use of this anesthetic Dr. Powers has recently resected the rib of one of my patients who was apparently moribund. The preliminary incision was rendered painless by the use of cocain, while the entire period of somnoform anesthesia was less than half a minute. Before the discovery of somnoform I performed rib resection with cocain in a very extreme case unsuited for general anesthesia. The operation was undertaken twelve years ago, when the contlition of the patient was such as almost to demand non-interference. His sub- sequent general improvement was remarkable until the development of amyloid after several years. Multiple rib resection, decortication of lung, and discission of pleura are permissible only in selected cases, months after the preliminary opening into the pleural cavity. It is of the utmost importance that such operations be deferred until long after the initial evacuation of pus. The condition of the patient is usually such at the time of the initial rib resection as to render the case inoperable as regards the major operations. With the removal of pus and the maintenance of continuous drainage an entire disappearance of systemic infection often takes place. Opportunity is thus afforded for gain in strength and, above all, in nutrition, the value of which in such cases cannot be overestimated. After a dela.v of several months the patient is enabled to imdergo the shock of a severer operation. Radical surgical interference, which may be unworthy of consideration at the time of the initial pus evacuation, may be attended by marked benefit six months later. I recall the case of a patient with pneumopj^othorax upon whom, at my request, Dr. Powers performed a single rib resection fovu- years ago, and who almost succumbed from the effects of the preliminary operation. The capacity of the pleural cavity shortly after the opera- tion, as determined by the introduction of normal salt solution, was 64 ounces. In spite of perfect drainage and daily irrigation a persisting temperature of septic t.vpe was observed during a period of five months. The infection was distinctly staphylococcic in character, and was a.s.so- ciated with a profound purpura ha^morrhagica. Hemorrhages took place from the mouth, no.se, throat, gums, and intestines, with the for- mation of petechia under the skin. About two months following the first operation, in the midst of an exceedingly poor general condition, a large PNEUMOPYOTHORAX 393 counteropening was made in the chest-wall. Despite perfect drainage, secured by the daily passing of sterile gauze from one opening to the other, there ensued no resulting improvement. During the following three months there occurred morning remissions, with sluup evening exacerba- tions of temperature, with daily chills and sweats. Tliere was marked emaciation, with weak and extremely rapid i)ulse. At this time I decided to substitute iodoform gauze for that previously used. This was drawn from one opening to the other and the jileural cavity freely packed. The temperature receded to normal upon the .second day, and remained so for ten days. In order to avoid any misconception as to the effort of the ioflo- form, I reverted once more to the use of the sterile gauze. This was fol- lowed by an immediate elevation of temperature, whicli persisted several days and receded at once upon a return to the iodoform pack. It is, of course, recognized that a single case of this kind must not be accepted as establishing a direct relation of cause and effect, as regards the employ- ment of the iodoform pack. Improvement was progressive and rapid from this time. Nine months after the rib resection the patient, having gained thirty-five pounds in weight, a Schede operation was performed by Dr. Powers, which reduced the capacity of the pleural cavity to four ounces. The patient is now in excellent condition, the discharge being almost nil and the cavity holding but one and one-half ounces of salt solution. Figs. 107, 108. and 109 are of interest in showing the amount of deformity resulting from the multiple rib resection to effect an oliliter- ation of the pus-secreting cavity. This would have been completely out of the question as an early operation. The extent of the operation must depend largely upon the size of the cavity and the age of the patient. The operation is rarely demanded in children on account of the greater elasticity of the thorax. Among adults, however, the rigidity of the chest-wall presents an insuperable obstacle to the obliteration of the suppurating space, and in the absence of lung expansion the resection of ribs becomes the only rational pro- cedure. The removal of a large portion of the bony thorax permits the COMPLK ATIOXS apposition and cicatrization of granulating surfaces. It is scarcely pertinent to the purpose of this book to enter into a discussion of the Fig. 108.— Same pat comparative merits of the Estlander or the Schede operation, or to attempt a description of the technic. Decortication of the lung, as introduced by Delorme. consists of the removal of tho viscoi:!' |ilf'-' from the lower half of the collapsed and Fig. 109.— Photograph of atelectatic lung, which permits, to a very considerable extent, its sub- sequent expansion. This operation has been found to be much safer TUBERCULOSIS OF THE PERICARDIUM 395 and more easily performed than the attempted removal of adhesions between the costal and visceral pleura. The operation is sometimes practised in connection with Sehede's multiple rib resection, in which event the skin-flap coalesces and cicatrizes with the denuded lung. In other cases a trap-door operation is performed, which includes the lifting of a portion of the chest- wall, permitting free access to the collapsed lung and the denudation of its pleura. Subsequently the trap-door is replaced and provision made for adequate drainage. Discission of the pleura was devised and performed by Ransohoff, and has yielded fairly satisfactory result.s. This procedure consists of free incisions of the pleura carried downward to the lung proper. SECTION III Tuberculosis of the Pericardium and Peritoneum CHAPTER LVII TUBERCULOSIS OF THE PERICARDIUM Etiologic and Pathologic Data. — This condition, on account of its relative infrequency, is of much less importance than tulierculosis of the pleura or peritoneum. It is, however, considerably more common than generally supposed. The clinical evidences of tuberculous involve- ment of the pericardium are exceedingly obscure. The position and size of the heart may be outlined with reasonable accuracy during life by a skilful examiner, and the results confirmed or modified by .r-v:iy cxumination, but the only reliable data as to the fre- quency and natiii'c of the pericardial complications in pulmonary tuber- culosis are furnished by autopsy findings. To be of definite value it is obvious that the postmortem study should be conducted by a trained pathologist, and embrace a large number of autopsies upon tuberculous subjects. Only by means of such investigations are there afforded cor- rect conceptions as to the prevalence of the condition. During the first two years of the existence of the Phipps Institute for the Study of Tuberculosis there were conducted 143 autopsies, 88 of which were performed in the first year. Of the 88 autopsies, there was but 1 case of typical miliary tuberculosis with pericardial involvement. There were, however, 3 cases out of the 143 autopsies during the two years. Of the total numlaer, there were reported 3 cases of local peri- cardial adhesions, 1 instance of general pericardial adhesion, 1 of thick- ened pericardium, and 8 of total obliteration of the pericardium. Only 1 case of acute serous pericarditis was found. Evidence of peiicardial involvement of some kind was obtained in 18 cases out of 143, including both acute and chronic varieties. Actual tubercles were found in only 3 instances, and it is, therefore, more or less problematic whether or not the other cases were of actual tuberculous origin. It must remain a matter 39b COMPLICATIONS of conjecture if the cases of chronic obliterative pericarditis and those with local adhesions were directly occasioned by tuberculous infection. It is reasonable to believe, however, that nearly all low-grade chronic inflammations of the pericardium among pulmonary invalids owe their existence to tubercle deposit. If the tuberculous character of nearly all idiopathic pleurisies is admitted, even among apparently non-tubercu- lous subjects, it is safe to assume that a similar involvement of the pericardium may occasionally take place among phthisical patients. The autopsy report with study of heart lesions at the Phijips Institute was made by Drs. White and Norris. In the third annual report, recently issued, there is contained a record of 57 autopsies conducted during the past year upon phthisical patients, with practically negative pericardial findings. Thus, out of 200 autopsies reported in three years, but 3 cases of miliary involvement of the pericardium were found, and 8, or 4 per cent., of o])literative peri- carditis. During the first year White reports the latter concUtion in 3.4 per cent, of the cases recorded, and submits for comparison oblit- erative pleurisy of both sides in 4.5 per cent, of cases — the left side, 19.5 per cent., and the right in 17 per cent. Of the pericardial cases, one coexisted with obliterative pleurisy upon each side, one with right- sided pleurisy, and one with general adhesions on both sides. No histo- logic investigation was macle to determine precisely the tuberculous origin of the adhesions. Norris, in 1904, collected statistics concerning pericardial involvement in 1780 autop.sies upon tuberculous subjects, and, exclusive of doubtful cases, found pericarditis, which w^as presum- ably tuberculous, to have occau-red in 4.6 per cent. Although the pericardium occupif>^ a more or less protected position as far as opportunity for secdiulai y infection is concerned, it is not sui-- prising that tuberculous iii\(il\iMiiciit should supervene on account of the existence of tuberculous proccs.ses in adjacent structvu-es. The condition may originate from neighboring foci of infection in the pleura, lungs, mediastinal glands, and from caries of some part of the bony intrathoracic wall, notably the stermmi. ribs, and dorsal vertebra. In a large number of cases the symptoms of tuberculous pericarditis are entirely latent during life. At times there are present the usual manifestations of general miliary tuberculosis, without distinct evidence of pericardial involvement. It may exi.st clinically as the ordinary acute form of pericarditis, either of the dry variety or accompanied by effusion. Another group of cases may be expected to exhibit the symp- toms of functional incapacity a.ssociated with dilatation and hyper- trophy, which result in many instances from the existence of chronic pericardial adhesions. The two latter varieties are of especuil interest, one pertaining solely to an acute pericardial coiidition, and the other relating to adherent pericardium, with possible cliaiiiics in the size and position of the heart and accompanj'ing circulatory di.stuibance. Varieties. — Acute tuberculous pericarchtis which is likely to be overlooked clinically may exist in two forms — the dry plastic variety and the type characterized by effusion. The exudate may be serous, .serofibrinous, purulent, or hemorrhagic. The more common form is the plastic pericarditis, which may be unattended either by subjective symptoms or physical signs. The serous membrane may present but a dull, slightly roughened appearance, or a shaggy, irregular fibrinous coating. The fibrinous exudation upon the internal pericardium varies TUBERCULOSIS OF THE PERICARDIUM 397 much in thickness, and successive layers of lymph sometimes completely cover the macroscopic evidences of tubercle deposit. The thickened membrane may be infiltrated with tiny yellowish-gra}' tubercles, or granulations may exist between the layers which later become confluent. Upon gross inspection there is often no evidence of tubercle deposit, but the tuberculous character of the process may be readily demon- strable, despite a normal macroscopic appearance. Sjrmptoms. — The only subjective symptom of the acute plastic form of tuberculous pericarditis is pain, ancl this is not always present. It is rarely intense, although in exceptional instances quite distressing. The pain is usually referred either to the precordial region or to the tip of the ensiform appendix. It is sometimes sharp or stabbing, and occasionally synchronous with the cardiac pulsation. But little sig- nificance is to be attached to the presence of fever unless this develops in conjunction with pain and objective signs. Upon palpation there is sometimes recognized, synchronous with the heart contractions, an appreciable fremitus to the left of the sternum between the third and fourth ribs. The important auscultatory sign is the to-and-fro friction-sound. This may be creaking, grazing, rul)- bing, or grating in character. It is more frequently a rub, and gives the impression of coming from directly under the stethoscope. These super- ficial sounds are usually intensified by increased pressure upon the skin with the bell of the instrument. They may be heard at the base, but the more frequent site is over the right ventricle. A peculiar feature of the friction-sounds is their inconstancy, as they are often recognized at one time and not at another. They are distinguished from tlie pleuro- pericardial friction-rub by the difference in rhythm ami the influence of the respiratory movement. There is but little difficulty in differ- entiating the distinct rubbing character of the pericardial sounds from the soft blowing endocardial murmurs. This form of tuberculous peri- carditis may terminate in effusion, or the contlition may be changed into that of adherent pericardium, owing to the fusion of the serous surfaces through connective-tissue proliferation. The symptoms of tuberculous pericarditis with effusion are extremely variable, and, as a rule, are unposses,sed of special significance. In many cases they are entirely absent for prolonged periods, and the con- dition escapes recognition altogether. At other times the diagnosis is made purely through recourse to the objective signs. It is not unusual for symptoms previously latent, suddenly to assume an aggravated character. Marked dyspnea, pain, pallor, or cyanosis may quickly supervene upon a period of ill-defined malaise, slight shortness of breath, and tendency toward fatigue. Thus the development of the condition is occasionally founrl to lip decidedly insidious, without exhibition of clinical manifestations, until the effusion has attained such size as to permit pronounced |)liysicai signs. On the other hand, the onset is not infrequently arute and attended by well-defined symptoms, even before the recognition of pericardial exudation. Often complaint is made of pain, which may range from a sharp, agonizing stab to a mere sense of oppression referred to the precordia. The pain may be increased upon pressure at the lower end of the sternum. A beginning shortness of breath in acute or subacute cases rapidly changes to a marked dysp- nea, which necessitates a maintenance of the upright or semireclining posture: The patient is tlistinctly restless, and the expression anxious. 398 roMPLiCATioxs There is almost ahva.ys pallor or slight cj'anosis. The alae of the nostrils, particularly among the young, are seen to dilate with each respiration. As the restlessness increases insomnia or delirium may supervene. I have seen marked hj-steria, melancholia, and chorea develop in severe cases, and have recently observed pronounced stammering during the height of the effusion, and persisting for weeks after its removal. The pulse is always rapid and frequently irregular. Many observers have described the pulsus paradoxus, characterized by an extremely weak and feeble pulse, during in.spiration. Upon inspection there is more or less circumscribed prominence over the precordial region, with bulging of the intercostal spaces and in some cases edema of the chest-wall. Sometimes the respiratory expansion of the left chest is notably diminished. In very large effusions a promi- nence in the epigastrium may be produced by the downward displace- ment of the left lobe of the liver. The apex impulse may be feeble or entirely absent. Upon palpation the apical impulse is frequently oblit- erated completely, particularly in the event of a large effusion. Though displaced in some cases, its position in others is unaltered. The per- cussion signs are of especial importance, chiefly with reference to a gradual increase in the area of cardiac dulness. The lungs offering but little resistance to the encroachment of the pericardium are correspond- ingly compressed. There is considerable difference of opinion as to the configuration of the dull area, many writers being in the habit of describ- ing the outline as irregular or pyriform in shape, with the nari-ower por- tion pointing upward towartl the manubrium or the left sternoclavicular notch. For practical purposes, in outlining this area in pericardial effusion, it is quite justifiable to disregard any presupposed idea as to its pyramidal shape. The essential consideration as far as the percussion outline is concerned, is the mere fact of a symmetric enlargement of t!ie area of dulness in all directions. In extreme cases this may extend far to the left of the left nipple, to the right well l:)eyond the light border of the sternum, and upward as far as the clavicle. Wien the outline at the base and lower lateral regions is suggestive of a pyramidal form, the upper portion is usually somewhat truncated, the upper border rarely conforming to an apical outline. In beginning small effusions the changes in percus.sion resonance to the right relate to an increasing dulness over the sternum from the fourth to the sixth rib. As the effusion increases and the dull area encroaches more and more to the right of the sternum, the diminished resonance is noted in the neighbor- hood of the sixth rib. Much attention has been directed to the so-called Rotch sign, which consists of the obliteration of the cardiohepatic angle. This sign is not always easy of exact determination, simple as it may seem, and to the general practitioner is not of especial value. Ewart has called attention to a quadrangular patch of percussion dulness in the left infrascapular region. Bamberger's sign consists in the diminution of percussion resonance in the lower axilla, and about the angle of the left scapula, owing to pulmonary compression. While it is possible occasionally to detect an increased dulness in the left axilla, it must be conceded that Bamberger's sign and Ewart 's sign are of doubtful value in the average case. Change in the area of percussion dulness is sometimes produced by a change in the position of the patient. The most important auscultatory sign is the progressive enfeeble- TUBERCULOSIS OF THE PERICARDIUM 399 ment of the heart-sounds, which in some cases become scarcely aucUble. Preexisting endocarchal murmurs are usually found to disappear with an increasing effusion. Worthin calls attention to the frequent accen- tuation of the pulmonary second sound. Friction-rubs heard early in the case disappear with the development of the effusion, though they are sometimes aucUble at the bases. The course and prognosis depend largely upon the character of the effusion. As a rule, the progress is slow and tedious in tulicrculous pericarditis, though in serous effusions the exudation may lie al)sor1)ed with coniiiuerable rapidity. Absorption may take place to a certain extent even with purulent effusions, but the outlook is by no means good in such cases. The diagnosis of tuberculous pericardial effusion is often attended by the greatest difficulty. The observant clinician who has been per- mitted to watch the case from the beginning and to note the gradual but progressive development of physical signs, is far more likely to anive at an accurate cUagnosis, than the consultant who is called upon to differ- entiate between moderate or large-sized pericardial effusion and extreme cardiac dilatation. At such time a correct determination of the condition is frequently impossible without recourse to paracentesis. It is not infrequent that the most skilled examiners are found to be in error under these conditions. Attention li.-is hccn icpcatcdly called to the wavy character of the cardiac impul^:;■ in (lihilaiicin, and the shock or slap of the cardiac sounds. In cUlatation tlie urea of dulnoss does not extend upward as far as in effusion, and the heart-sounds arc less indisl inct or muffled. Important points are the disappearanco, in crfusidu, ul' a, ]iicviously recognized endocarihal murmur, and the chunge in the ;uf:i oi cardiac dulness upon change of posture. Osier calls attention to the fact that in dilatation the distention is rarely sufficient to comjiress the kmg and produce per- cussion changes in the axillary region. I have seen this result, however, in a notable instance of cardiac cUlatation in which there was even suffi- cient pulmonary compression to occlude entirely a primary bronchus. Extreme difficulty of diagnosis may be presented in some cases despite an intelligent review of the symptoms and physical signs. Even paracentesis does not invariably afford a positive conclusion concerning the pathologic condition, as will be illustrated by the following report of a case recently under observation: The patient was a delicate child, ten years of age, with a distinct family history of pulmonary tuberculosis, although no physical evidences of a tuberculous process had thus far been recognized. I was summoned at the end of a period of malaise and lassitude of one week's duration. The temperature was 102° F., pulse 108 and of good quality. The child was dressed and reclining upon a couch in the open air, but manifested a disinclination to sit up. The expression was dull and the face mark- edly pale. Complete physical examination was negative. The child was put to bed immediately and a liquid diet instituted. The bowels were thoroughly moved, and the salicylates with potassium citrate administered. Upon the third day a faint mitral systolic murmur was heard at the apex, coincident with a distinct to-and-fro pericardial friction-sound over the right ventricle. There was slight precordial discomfort, but complaint was made of severe pain in the left shoulder. Upon the fourth day the pain continued sharply localized in the shoulder. 400 COMPLICATIONS but was also intense over the region of the heart. The patient was restless, and the suffering difficult to control in spite of hypodermics of codein and finally of morphin. Meantime the temperature had risen to 104° F. and pulse to 130. The bowels were obstinately constipated. A beginning dyspnea was noted in connection with slight cyanosis. The pericardial friction-sound cUsappeared at the end of twenty-four hours, but the endocardial murmur persisted for several days. A diagnosis of pericarditis had been rendered, and a blister two inches square produced over the precordium. This was attended by considerable benefit for about a day and a half, during which time the child was thoroughly purged with calomel. Appeal was made to the skin and kidneys, and cartliac stimulants cautiously administered. A progressive increase in the area of cardiac dulness was noted. Impaired resonance was recognized well to the right of the sternum and to the left of the left nipple, with a continual upward rise of the area of dulness. The pain over the precordial region increased in severity and the child became hysteric and almost unmanageable. The dyspnea was pronounced, as was also the cyanosis. The respirations were nearly fifty to the minute, the alse of the nose dilating markedly. The cardiac impulse became much enfeebled, and finally disappeared altogether. The heart-sounds were distant and muffled. With the increase of effusion the endocardial murmur became more indistinct and was finally incapable of recognition. Despite active cardiac stimulation the condition became extremely desperate by the end of one week. There was orthopnea, insomnia, excruciating pain over the heart, a temperature ranging from 104° to over 105° F. at all hours of the day, with a pulse of 144 to 150, and of exceedingly poor quality. The cardiac dulness extended to the second rib, slightly over an inch to the right of the sternum, and an inch and a half to the left of the left nipple. The chagnosis appearing unquestion- able, I determined to perform immediate paracentesis of the pericardial sac. Before resorting to this proceilure I requested counsel and received a confirmation of the diagnosis and indorsement of the aspiration by Drs. Hall, Powers, and Emery. The puncture was made by Dr. Powers in the fifth interspace, an inch and a half to the left of the left margin of the sternum. The needle was inserted not over three-quarters of an inch. The aspirated fluitl presented all the appearance of pure blood, of which twelve ounces were withdrawn. Coagulation of the blood took place in the receiving bottle liefore the aspiration was completed. Des- pite our consternation at the sight of a fluid which scarcely could be described as a sanguineous exudate, but rather as blood from a ventricle, the aspiration was continued as long as the flow persisted. The natural impulse upon the first appearance of the blood to withdraw the needle was restrained, chiefly because there was no visitile movement of the needle, as might be expected in case the ventricle \\:is iMcncd. While it was conceivable that in the event of a greatly iHI.himI Ikmi-i the vas- cular contractions might impart but slight nuncuieiit U> the needle, complete absence of impulse suggested that the point remained within the pericardial sac. This conclusion was strengthened by the knowledge of its comparatively superficial insertion. The improvement in the child's appearance and respiration was immediate and pro- nounced. He also experienced decided relief from pain. Directly following the withdrawal of the needle I outlined with care the area of heart dulness, anil the result was corroborated by the other physi- TUBERCULOSIS OF THE PERICARDIUM 401 cians present. The size of the heart was found to be reduced remark- ably, as shown by Fig. 110, which is taken from a photograph illustrating the lines of cardiac flatne.ss immediately prior to and following the oper- ation. A record was taken of the boundaries of cardiac dulness and the outlines were indicated upon the chest following recovery. The tempera- ture was 104f ° F. at the time of operation, and at the end of six hours had dropped to 101° F., with corresponding improvement in the pulse and general condition. Shortly after the aspiration a returning endocar- dial murmur was recognized, together with greater chstinctness of the heart-sounds and a gradual reappearance of the impulse. The aspirated blood was found by Dr. W. C. Mitchell to be absolutely sterile upon bacteriologic examination. During the next few weeks the child improved progressively in all respects, the temperature finally recechng to normal, and the pulse remaining in the neighborhood of from 96 to 108. Pain entirely chs- appeared, as did dyspnea, cyanosis, and all other subjective symptoms. Fig. 110.— The upper and for suspected pericardial effusi of twelve ounces of blood. There persisted, however, a loud .systolic murmur at the apex, with a noticeable wavy cardiac impulse. The dull area then extended slightly to the right of the sternum and half an inch to the left of the left nipple. It would appear that were the child to be seen for the first time uiitler these later concUtions, the diagnosis of chlatation would be almost unavoidable. I was forced to assume that regardless of what the pre- vious condition might have been, the heart was now moderately dilated. Although the child was improving steadily, I decided at the end of one month following the operation, to relieve the heart as much as possible by sencUng the patient to a lower altitude, and at the same time to give him the benefit of the Nauheim treatment. He was accordingly referred to Dr. Babcock, of Chicago, under whose supervision he remained for six weeks. The child has continued to improve steadily since his return to Colorado, and at the present time, one year after his initial attack, shows no evidence of dilatation and but a scarcely perceptible endo- cardial murmur. The question arises, did the child have originally a 26 402 COMPLICATIONS pericardial effusion consisting of pure blood, which coagulated imme- diately, or was the blood withdrawn from the ventricle? Irrespective of the diagnosis there can be no doubt that life was saved by the operation, and that even ventricular aspiration is rational treatment for an extremely dilated heart. Opinions may differ as to the actual condition which existed in this case. It is certainly unusual to remove a fluid from the pericardial sac presenting all the gross appearances of blood with its nature confirmed by examination. On the other hand, it is equally difficult to reconcile certain features of this case with the presence of a dilated heart. The early symptoms and physical signs were distinctly those of an increr^idng pericardial effusion. The shape of the dull area corresponded to the expected outline of effusion. The muffling of the heart-sounds and disappearance of the murmur before the aspiration, with subsequent return, lend color to the accuracy of the diagnosis. This is further strengthened by the absence of movement imparted to the needle, the short distance of its insertion, and the immediate reduction in the size of cardiac dulness. On the other hand, it is almost indisputaljle that the heart was distinctly dilated two weeks after the aspiration and remained so for a month or six weeks. It would seem that if the orig- inal diagnosis of effusion is correct, the only rational explanation of the resulting dilatation is found in the formation of epicardial and peri- cardial adhesions, of such extent as to embarrass the cardiac movement and occasion temporary dilatation. The difficulties attending a definite diagnosis, regardless of possible tuberculous infection ami the responsi- bilities involved in the adoption of pericardial paracentesis, are better appreciated throusi'h the force of a vivid experience than by the perusal of classics pertaining to the differential diagnosis. Treatment. — Rest constitutes the es.sential feature of treatment of pericarcUal effusions, whether or not tuberculous. Medicinal measures are of doubtful efficacy. Many cases improve without other treatment than absolute rest, and others are found to go from bad to worse, irrespective of the nature of the therapeutic agencies employed. Opiates are indicated for the relief of pain and sometimes to promote sleep. I am satisfied that their application in such cases is more rational than the indiscriminate administration of hypnotics, which are likely to depress the heart to a certain extent. Although lilisters are considered inadvisable by some writers unless the signs of effusion have become very apparent, it is, nevertheless, excellent practice to resort to their use early in the disease. I can see no possible ol)jection to their employment after the diagnosis has been determined, and but little to be gained by delaying until the effusion has become of large size. It appears that their efficacy is largely dependent upon the time of their employment. It is not clear that recourse to a blister interferes mate- rially with a close study of the physical signs, and rarely with peri- cardial puncture. Active purgation is not always permissible, but is sometimes indicated in fairly robu.st patients. In early stages the application of the ice-bag over the region of the heart is of some value, and often affords considerable relief to the precordial discomfort. Salicylates are of doubtful utility, and when pushed indiscriminately, are apt to depress the heart. In such cases potassium iodic! is one of the be.st cardiac sedatives. There is a wide difference of opinion as to the site of election in TUBERCULOSIS OF THE PERICARDIUM 403 making the pericardial puncture. The left costoxiphoid angle is pre- ferred by many, who thrust the needle upward and backward from this point. This site is more satisfactory in case of extremely large effusions than under other conditions. The fourth interspace at the left sternal margin or at an inch and a cjuarter from the margin, as well as the fifth interspace an inch and a half from the edge of the sternum, are respec- tively advised. Some clinicians in the presence of large effusions ai'e in the habit of aspirating to the left of the left nipple, the effort t)eing made to insert the needle just in.side the outer left border of dulness. Personally I am not aWe to indorse aspiration other than through the small area over the ventricle where the lung does not come in immediate apposition to the die; 't- wall. In theeventof apurulent cffii: ion surgical measures should be imme- diately instituted. They cf lice incision, sometimes resection of rib, and the maintenance of rdiitiiiiiniis drainage, affording a thorough evacuation of thick pus and coaguhiljlc flocculi. ADHERENT PERICARDIUM There are two forms of adherent pericardium. In one group there is present a simple ailhesion of the pericardial and epicardial layers. In these cases the surrounding structures are frecjuently uninvolved, although there may be a considerable union of the two laycr.'^. In another group adhesions are formed between the outer laj^er of the peri- cardial sac and the chest-wall, diaphragm, and pleura, by virtue of their immediate contiguity. The parts may be fused closely together and be associated with more or less mediastinal connective-tissue formation. The symptoms incident to the presence of pericardial adhesions, irrespective of other cardiac lesions, vary according lo llicir cxlcnt and situation. In the event of simple adhesions of tlie two lasers of ihc sac there may be no symptoms whatever, although hypertrophy ocia-ionally may result. Dr. Babcock has called attention to the occasional union of the two surfaces of the pericardium tluring the time the luari i> .iiiitcly dilated, either as a result of niyo<':u(litis oi- of \alviila,i- di case, liider .such circumstances its romplete diniinuiion in si/.e i< alnio-i ini|io— iMe, and a disturbance in its function is (piife inevitable. When the adhe- sions are external to the sac and involve neighboring structures, the condition is of much more serious import, owing to the unavoidable restriction in the movements of the heart and consequent emljarrassment of its function. Hypertrophy, dilatation, and circulatory stasis are frequent. There are often palpitation, dyspnea, broiicliial i nit at ion Avith weak pulse, and digestive disturbance. The li\er is someiinies enormously enlarged from passive congestion. In some i asi's, however, the liver bcomes much reduced in size through conneiii\(Missue pro- liferation, and the condition may suggest chronic interstitial hepatitis. The physical signs upon inspection relate to the prominence of the precordium, and a more or less exten.sive dift'usion of the carchac impulse, with occasional displacement of the apex. The impulse is often undu- latory over a wide area, transgressing frequently the limits of the normal precordial region. In some cases there is ininiohility of the apex impulse, either with a change in the position of the body or during full inspiration. During .systole a tugging retraction of the chest- wall is commonly noted in the lower left epigastric region. This may be 404 COMPLICATIONS followed by a diastolic rebound of the interspaces immediately over the point of apex retraction. Broadbent's sign consists of a visible systolic retraction of the chest- wall, not only in the region of the seventh or eighth ribs in the left para- sternal line, but also between the ele\enth antl twelfth ribs on the left side behind, at the point of attachment of the lUaphragm. Friedreich's sign consists of the diastolic coUapse of the cervical veins ascribed to the sudden emptying of these vessels as a result of the expan- sion of the chest-waU. A paradoxic pulse, though less common than in acute pericarditis, is sometimes recognized upon palpation, owing to the traction of the cicatricial mediastinal tissue upon the aorta during inspiration. The percussion signs relate to an increase in the area of cardiac dul- ness, owing to hypertrophy and dilatation, which may be extreme. Irrespective of the presence of endocarihal murmurs, which are occa- sionally dependent upon the dilatation, the important auscultatory signs are the pleuropericarchal friction-sounds. These sounds may be heard both with inspiration and expiration, and, as a rule, are distinctly creaking in character. It is not infrequent to find the sound consider- ably more intensified during inspiration than expiration, and sometimes vice versa. It often disappears, howe\'er, upon holding the breath. It is heard to best advantage over the left border of the heart. The exact determination of carcUac hypertrophy or dilatation among pulmonarj- invalids is often a matter of extreme difficulty, even by most skilled examiners. From a comparison of the results of my own chnical fincUngs with the skiagraph I have become convinced, first, that the heart is displaced very much ojtener than woidd he imagined from the literature upon the subject, and, secondly, that the onlinary methods of percussion and auscultation are sometimes quite insufficient to afford an accurate determination of its position and size among this class of patients. This has been cUscussed more fully in connection with Diagnosis. CHAPTER LVIII TUBERCULOSIS OF THE PERITONEUM Tuberculosis of the peritoneum may exist as one of the local manifes- tations of acute miliary tuberculosis, or as a cUstinct peritoneal process of more or le.ss chronic character. When the condition is inciilent to a general miliary infection, the tubercles are diffu.sed over the parietal and visceral layers of peritoneum, without, as a rule, any active inflammatory change. When tuberculous peritonitis exists as a local condition purely, the inflammatory condition ma.v be accompanied by various pathologic processes. In some cases there is an extensive proliferation of connec- tive tissue with numerous adhesions between intestinal coils and adjacent viscera, with occasionally an imj)lication of the abdominal walls. In others with less tendency to adhesions there is found a pronounced thick- ening of the peritoneum, omentum, and mesentery incident to their infil- tration with degenerative tubercle deposit. This form is sometimes TUBERCULOSIS OF THE PERITONEUM 405 characterized by the presence of large ulcerative tuberculous masses. Palpable tumors simulating tuberculous growths are produced by a localized matting and drawing of the intestines, which is intensified in some instances by the traction exerted by a shrunken mesentery. In still another group of cases there is a profuse exudative process.' This may be unassociated with marked pathologic changes within the peri- toneal cavity, or it may attend the proliferative type, with multiple adhesions, or even the caseous and ulcerating forms. The exudation may be serous, seropurulent, or bloody in character, and may be general or sacculated. A simple general ascites of insidious or very acute onset mthout subjective symptoms may accompany a developing tuberculous deposit unattended by other pathologic change. In some cases the exu- dative processes are found in a.ssociation with extensive connective- tissue change. It is manifestly inijiroper to divide all cases of tuljer- culous peritonitis, aside from the niiliai y form, into two distinct classes — the proliferative and the exudati\(' kioujis as has been attempted. The etiologic relations of tiilxiculuus jieiitonitis have been the subject of much clinical study and investigation. The condition is almost always secondary to some other tuberculous focus, the primary source of infection being traced to the lungs in the large majority of cases. At least foui'-fifths of ;ill instances of tuberculous peritonitis occur in association \\ith easily i-pr( ionized pulmonary involvement. Cummins has reported a scries dl' cases ill wlmli ,S4 per cent, succeeded pulmonary tuberculosis and .'>!'. G i)er cent, intestinal involvement. The same observer has quoted Priln-am's report of the result of 165 autop- sies upon cases of tulierculous peritonitis, of which 87 were attributed to intestinal tuberculosis. 65 to glandular disease, 8 to tubal and uterine, and 5 to osseous tulierciiln-i-^. Douglass has quoted Borschke, who failed to find a primary focus in but 2 cases out of 226 of peritoneal tuberculosis. From a total of bil)3 autop.sies upon tuberculous subjects, tuberculous peritonitis was found to exist in 226 cases, or 16 per cent. Peritoneal invohcment in t\d)er(iilous invalids has been reported by other observers to vary from 10 per cent, to 20 per cent. Tuberculous peritonitis may exist at any time of life, although observed more frequently in young adults. When occurring in children, it is often in association with a general miliary involvement. Frederick C. Shattuck has recently reported some slatisiical observations upon a series of 98 cases of tuberculous peritonitis treated at the Massachusetts General Ho.spital during a period of eleMii years from 1889 to 1900. The youngest was thirteen months old, while the oldest was sixty-two years. Six occurred in children fron one to five years of age, 7 from five to ten years, 8 from ten to fifteen years, 56 cases, or 57.1 per cent. of the whole number, between the ages of fifteen and lhirt>- years. There were 13 cases between thirty and forty and but s cases over forty years of age. In view of the fact that a relatively snudl lumiber of children enter the Massachusetts General Hospital, the proportion of cases among children in the series reported by him is perhaps smaller than usual. Tuberculous peritonitis is usually conceded to exist with greater frequency among females, although some observers maintain that it is more common in the male sex. It would be reasonable to suppose that the statistics should favor the preponderance of the condition among females, on account of their special predisposition to infection through the genital tract. This conclusion seems to be borne out by the obser- 406 COMPLICATIOXS vations of surgeons, which, of course, are based upon purely operative cases. There are several ways in which the peritoneum is known to become infected. A common method of invasion is from a tuberculous involve- ment of the wall of the stomach, or of the small intestine, appendix, or colon. The extension of the tuberculous process into the peritoneum from slowly ulcerating deposits upon the intestinal wall in some cases gives rise to purely local changes. In the event of sudden perforation of the tuberculous ulcer a septic general peritonitis rapidly develops through the entrance into the free cavity of the agents of decomposition. The infected area is sometimes sharply circumscribed by the existence of firm adhesions between cUfferent coils of intestine. In some instances tliese atlhesions involve the parietal peritoneum. Another route of infection is that resulting from the caseation and subsequent perforation of mesenteric or retroperitoneal lymph-glands. In such instances the tuberculous process may become cUffused through- out the free peritoneal cavity, or it may be localized through the forma- tion of adhesions. An acute septic peritonitis is far less likely to result from this form of infection than from tuberculous intestinal ulcers. The mesenteric glands have been shown to become infected by the migration of tubercle bacilli through a healthy intestinal wall, an intact mucous membrane constituting no proof that it may not be an atrium of infection. As stated previously with reference to the tonsil, the tissue at the point of invasion may be less favorable for the growth and development of tubercle than more distal parts. It has not been demonstrated as yet that the peritoneum may become primarily infected by the passage of bacilli through a normal mucous membrane without first producing an involvement of the mesenteric and retroperitoneal glands. The fact that tuberculous peritonitis in excep- tional instances has been found to exist in the absence of a cUscoverable primary focus does not controvert a belief in the secondary nature of the infection. * Another pathway of peritoneal infection is by way of the lymphatics from the pleura through the diaphragm, from the abdominal or pelvic organs or from some distant focus. The especial frequency of peritoneal tuberculosis in adult females is explained in part by the facilities for cUrect extension from the female genital organs. The Fallopian tube is frequently a primary focus of infec- tion, from which point the bacilli may gain entrance to the peritoneum, either by cUrect extension through a free tubal opening or by means of the lymph-channels. It is the consensus of opinion of many observers that the Fallopian tubes are involved in a large proportion" of cases of tuberculous peritonitis, which i- v:iii(iusly estimated at from 2.5 to .50 per cent. There seems to lie -I'lnc iliitcrouce of belief as to whether the involvement of the tube is in m'licial the cause or the result of the peri- toneal infection. It is scarcely necessary at this time to review the controversial literature bearing upon the precise direction of the bacillary invasion, whether ascenchng from the genitals or descending from the peritoneum. It is .sufficient to state that the authentic oliscrvations of many authorities appear somewhat conflicting and cont rac lictorv. What- ever one's theories may be in this matter, it is possible to secure both corroborative and negative testimony as to their correctness. Mayo has called attention to the fact that the tuberculous process in the peritoneum TUBERCULOSIS OF THE PERITONEUM 407 is especially pronounced in the immediate neighborhood of the primary focus of infection. Certain it is that, irrespective of the source of infec- tion, removal of the tubes is followed in a large number of cases by gratifying improvement. It is also true that in many cases, despite pronounced tuberculous involvement of the tubes, the uterus is found to present an entirely normal appearance. Tuberculous peritonitis has been reported to occur along the route of the male generative tract, although this route of invasion is decidedly less direct than in females. Horowitz describes the pathway from the epididymis through the lym- phatics of the spermatic plexus and the ampulla end of the vas deferens. Osier cites seven instances in which the sac alone is involved. Cruveilhier and Haegler have reported cases of primary hernial tuber- culosis. Cotte reports 5 cases of apparently primary tuberculous pro- cesses in hernia, together with a summary of 136 recorded cases. It is, of course, easy to understand how hernia may take place in subjects afflicted with tuberculosis of the peritoneum with associated infection of the sac, or of the intestinal coils therein contained, hut it is liard to com- prehend why there should exist any inherent susce])til)ility to hernial tuberculosis independent of the peritoneum itself. Symptoms. — The symptoms of tuberculous peritonitis are somewhat variable, according to the type of peritoneal involvement. The con- dition is of acute onset in but a small proportion of cases. Shattuck reports 29 of acute onset out of a total of 98. Personally, I have seen but 3 cases of acute tuberculous peritonitis, exclusive of the localized infections coexistent with a tuberculous appendix. In the latter event the onset is often sudden, presenting rapidly fulminating symptoms. Several of my pulmonary invalids have exhibit (.'li tuberculous appendi- citis with a localized peritoneal invasion of subacute type. In the majority of instances tuberculous peritonitis is of slow, gradual development. While the course of the disease usually conforms to the chronic type, there may occur for a time acute exacerbations, periods of improvement being followed by recurriiji; iclapses. 1 ic(:ill sc\-ei-al cases of remarkably slow and insicUous ousel, wliich, aftef tlie lapse of several years, exhibited periods of severe pain with other acute mani- festations which gradually subsided, but were followed by intervals of abdominal chscomfort. Acute cases of tuberculous peritonitis are always characterized by rather extreme pain, and usually by tenderness and tympanites. The pain, however, is not always of an acute character, and in some cases is but little more than a sense of abdominal discomfort, with occasional intercurring colicky attacks. It is increased by intra-abdominal pies- sure, the tension upon the abdominal wall often being sufficient to pi'o- duce a voluntary flexion of the thighs upon the abdomen. This position is suggestive of acute general peritonitis. Nausea and vomiting are quite common in the acute type, but are rarely present in the chronic form, in which the symptoms are rather vague and ill defined. The severity of such acute symptoms as pain, distention, tenderness, nausea, and vomiting, w-ith weak and rapicl pulse, is largely dependent upon the extent of peritoneal involvement. In the event of a general peritonitis these symptoms rapidly develop, and are attended by great prostration and followed shortly by a speedy fatal termination. In circumscribed tuberculous peritonitis the symptoms are consider- 408 COMPLICATIONS ably less severe. Both the pain and tenderness are localized, while the vomiting is less frequent and sometimes of but short duration. The fever may be quite as high as in general peritonitis, but the cases run a much longer course, sometimes ending in apparent recovery after a prolonged convalescence. The physical examination, exclusive of the determination of tender- ness or rigidity, relates to the detection of fluid and the recognition of definitely circumscribed masses. In cases characterized by excessive exudation, dulness is obtained upon percussion. This is early recog- nized in the flanks, and is found to vary in location with a corresponding change in the position of the patient. As the fluid increases the dulness in some cases becomes general and fluctuation is detected. Rising of the cUaphragm, acceleration of the respiration, and alteration in the position of the cardiac apex is possible in severe cases. Circumscribed collections of fluid are recognized by palpation, chiefly in the form of rounded, fluctuating tumors. Sometimes, however, on account of the extreme ten.sion of the contained fluid they appear as resisting masses. Hard, unyielding tumors ma.y be present, which strongly simulate solid neoplasms of various organs. These masses, either solid or apparently so, maj^ occur in almost any portion of the abdominal cavity and resemble almost any conceivable new-growth. They may occur in the right or left epigastric region, in either hypo- chondrium, above the pubis, in the right or left iliac fossa, ami in the neighborhood of the umbilicus. The location of the induration and the simulation of solid growth are often sufficient to confound the most experienced examiner. It is possible at times to appreciate a distinct peritoneal friction or crepitation, which affords quite definite infor- mation as to the character of the involvement. Diagnosis. — The (Uagno.sis may be comparatively simple in many cases, but in others it is often exceechngly cUfficult. Acute perforative cases exhibiting a sudden and violent onset are seldom regarded in the beginning as instances of tuberculous peritonitis. Such cases are likely to be confused with appendicitis, strangulated hernia, and the common form of acute peritonitis, a positive tUagnosis often not being established until the abdominal (•a\ity has lieen opened. In internal hernia and acute intestinal obstruction from other cause the pain, as a rule, is localized and paroxysmal. In such cases the abdominal distention is due to gas rather than to fluid, and constipation is common. The earl_y vomiting soon becomes fecal in character. In appendicitis the onset is usually acute, but the rigidity, pain, and tenderness are localized in a definite area in the immediate region of the appendix. While tumor-like masses are often present in tuberculous peritonitis, they are exceedingly rare in the acute fulminating type, pxliiMtiuir a violent onset. In some cases of appendicitis despite the lii^t.ny <,< cliill. ia|'id puNc .■uid vomit- ing, there may be elicited by phy.sical cxaiiiiii.-iiidii imi t lie -li^h test exter- nal evidence of its presence. Per coulra lliei-c nuiy l>e luuud a sharply localized area of resistance and tenderness over the region of the appen- dix, without associated subjective symptoms. This will he considered more fully in connection ■\\ith tuberculosis of the appendix and simple appendicitis among pulmonary invalids. Difficulties of diagnosis also attend the chronic forms of general tuberculous peritonitis. In these cases the condition at times may be essentially latent, and give rise to no symptoms whatever. The cUagno- TUBERCULOSIS OF THE PERITONEUM 409 sis is often made at the time of an operation for some other condition among individuals in excellent nutrition. There may be absence of fever or of previous suspicion of tuberculous involvement. Peritoneal infection is undoubtedly present more frequently among pulmonary invalids than is commoiily supposed. Many consumptives with quies- cent pulmonary infection, display abdominal tenderness, moderate distention, and continuous slight elevations of temperature without explainalile cause other than the hypothesis of a mild peritoneal infec- tion. This group of symptoms in the presence of a known tuber- culous lesion in the lung capable of producing temperature elevation, is often attributed to disturbances of digestion. Many of these cases exhibit recurring attacks of slight colicky pain, which is more or less vague and indefinite in localization. The per.sistence of such mani- festations among consumptives is sufficient to suggest the possible existence of a chronic peritoneal tuberculosis. Especial confusion is likely to be experienced in the differentiation of the circumscribed exuda- tions and tumor-like masses from the solid neoplasms or fluctuating tumors peculiar to certain organs. It is hardly appropriate to infringe upon the domain of surgery and enter upon a necessarily detailed consideration of technical diagnostic features pertaining to the simulation of cysts of the pancreas, pyonephro- sis, empyema of the gall-bladder, hydatid cysts, ovarian tumors, pus- tubes, pelvic disease, and new-growths in the stomach or intestine. A precise diagnosis is often out of the question without an exploratory operation. A tuberculous omental tumor, however, presents somewhat fewer difficulties than the more definitely circumscribed masses, because of its characteristic elongated shape. When the omentum is the seat of tuberculous infection, it is sometimes stretched across the abdomen in a firm mass which is attached to the transverse colon a little above the region of the umbilicus. This hard, band-like mass may be similarly situated in cases of carcinoma, though less often than in tuberculous In doubtful cases the existence of tuberculosis elsewhere should afford a reasonable assumption as to the nature of a local peritoneal involvement. In the event of an undiscoverable tuberculous focus in other parts of the body a distinct family history of this disease is of undoubted significance, as is also the admission of an idiopathic pleurisy, glandular enlargements, or caries of bone. It has been shown quite conclusively that the tuberculin reaction in obscure cases is of unmistakable value. If this is absent, a reasonable doubt may be enter- tained as to the tuberculous nature of the affection, while a positive result is strong prima facie evidence of such condition. In douljtful cases recourse to the ophthalmotuberculin test is worthy of trial. As indicated previously the age is often an important determining factor. I have in mind the case of an intimate friend, thirty-five years old, of tuberculous family history. He was well nourished and unusually robust, but in the midst of apparent health experienced a severe rigor with sliarp pain in the left lower abdomen, followed by vomiting and abrupt elevation of temperature. Upon examination tenderness and resistance were at once detected. Had the physical signs existed upon the right side, instead of the left, the conclusion would have been unavoidable that the condition was acute appendicitis demanding imme- 410 COMPLICATIONS diate operative interference, and in this connection the possibUitj- of transposition of the viscera was entertained. Drs. Powers and Bagot concurred in the non-advisability of immediate exploratory laparotomy and counseled for the time being a policy of delay. After weeks of recur- ring pain and nausea, with progressive emaciation and physical debility, following the subsidence of the initial violent symptoms, an exploratory operation disclosed extensive tuberculous involvement of the perito- neum with multiple atlhesions of intestinal coils. There had previously been recognized upon examination a firm, hard, linear mass extending from the left iliac fossa upward into the flank for a distance of five to six inches. This mass was found to be due to a localized proliferative and adhesive peritonitis, the fibrous tissue growth being especially marked. The patient survived but a few days following the operation. The acute onset of abdominal symptoms took place less than two weeks following an accident while riding horseback through an almost impene- trable region in the mountains, the horse in falling ha\'ing pressed upon the abdomen with great force. The thought is, therefore, suggested that the tuberculous involvement may have lieen of traumatic origin. Prognosis. — The prognosis of tuberculous peritonitis varies in accordance with the age, the severity of the infection, the extent and character of the involvement, and the general condition of the patient. In young children, particularly if of tuberculous parentage, the outlook is less favorable than in adults. Acute cases of suppurative peritonitis following perforation are almost invariably fatal. Localized tuberculous involvement, even if acute, is not necessarily hopeless, though uniformly of grave significance. Exudati\'e cases possess a much more favorable prognostic import than the adhesive and proliferative forms. Many cases are amenable to cure, as the result of either medical or surgical management. Of Shattuck's 25 cases subjected to me(hcal treatment alone, the mortality was 68 per cent., which is accounted for in part by the fact that in all but 6 of these cases there were present other important complications. Among his 57 cases submitting to surgical operation the mortality was 47. .3 per cent. An analysis of Shattuck's report disclo.sed the fact that the most favorable results were obtained in the non-exu- dative cases, while the mortality was high in ascitic cases irrespective of the nature of the fluid. These results are at variance with the usual conception of the prognostic im]mrt attaching to the exudative type as compared with ca--c~ cxhil.ii inn well-dcliuccl masses. As a rule, the subacute or chronic cMiilatiNc iornis fiunish the host results, particularly if subjected to opi'r;iii\r inicrfei'ence. JMotlern opinion regarding the manner in which iiii|ii(i\ciiiciit is secured in such cases as a result of opening the abdomen, im lims toward an increased phagocyting power of the white blood-cells by virtue of the direct entrance of air into the abdominal cavity, or, in accordance with tiie theory of Wriglit. tlie presence of a new exudate rich in opsonins. Cameron calls attention to the hichly favorable influonre resulting from the stimulation given to the lympliaiic and vasciiluT circulations on account of the trauma and the reduccil nitia-a.b.loniiual iii-cssure. It is apparent that ojieration offers but little to patients exhibiting the fibrous obliterative type or ulcerous form. The existence of advanced tuberculous infection in other parts of the boily adds to the gravity of the prognosis. The same is true of suppurative proce.sses, persisting fever, diarrhea, and progressive loss of weight. Generally TUBERCULOSIS OF THE PERITONEUM 411 speaking, about 50 per cent, of all cases may reasonably be expected to improve, if not absolutely recover. Treatment. — There is no general method of treatment for tubercu- lous peritonitis which may be considered justly applicable to all cases. Quite a proportion are known to recover under purely medical manage- ment, while some do well after tapping the abdomen and removing as much as possible of the ascitic fluid. Others demand, on the merits of the case, an exploratory ©jxTaiiun, which determines at once the nature of the subsequent management. At .such a time many cases are chs- covered to be entirely inoperaWe. The general nicdiial treatment is chiefly that of superalimentation, with due regard for jiossible digestive disturbances, rest, hygienic sur- roundings, and attention to six'iial s\ in])toms. A suitable environment with cheerful surroundings, ^dod IucmI, and outdoor facilities is of prime importance. Symptoms shuuld he ivlicxcd, if possible, as they ari.se. It is proper to resort to occasional l,i.iii>iii,ii if demanded for the comlort of the patient. My experience with this ccmdition has been somewhat limited, but sufficient to afford satis! yini; piodF as to the efficacy of rest. improved nutrition, and absence of worr}' in the effort to establish con- valescence. I have in mind a young lady in whom the diagnosis of peritoneal tuberculosis was established at the time of operation for appencUcitis in lOOO, |)revious to which there had been no symptoms suggestive of ahdoiiiin.i! disease. For several years following the oper- ation there were nn cliuical evidences of peritoneal infection, but there developed a sliglit pulmonary involvement witli lar\-n,ncal coni|)]ica,tions which constituted the basis for her comiiii; (o ( '(ihuailn. In the midst of a most excellent nutrition, ab.sence of cou,i;li. cxpccidiatiDu. and lever, there took place, five years following her initial peritoneal involvement, a severe rigor and sharp elevation of temperature, associated with intense abdominal pain and vomiting. Examination of the abdomen was entirely negative, save for a very slight distention and general stiffening of the abdominal wall, without localized tenderness. With recurring chills and continued high elevation of temperature, increasing abdominal distention, and beginning general tenderness, the abdomen was opened by Dr. Powers, and an extensive adhesive tuberculous peritonitis was found. The serous membrane was studded throughout l)Oth its parietal and visceral layers with small tubcicle deposits, and there were multiple adhesions between the iMiisliiial coils, adjacent organs, and the abdominal wall. The case is of csiiccial iiilci-ostin view of the knowl- edge that during a period of nian\' years, despite an extensive patho- logic change involving the wall oi the pent al ia\it\ and its con- tents, she exhibited no symptoms w lia.iexcr of general oi' alidominal dis- turbance. The operation was indicated as an exploratory procedure, but was recognized to be unavailing as a therapeutic measure, on account of the character and extent of peritoneal infection. It is often difficult to determine satisfactorily when the indications point conclusively toward the expediency of operati\c inierfeicnce. An exploratory laparotomy is often justified after failure to secure improvement under fom- to si\ weeks' medical management, and earlier if the patient is rapidlx' declining-. In acute nulia.i\- tuberculosis the patient often dies before the symp- toms of peritoneal infection are apparent, but if detected, operation is clearly contraindicated in the majority of cases. All cases presenting 412 COMPLICATIONS evidence of acute intestinal obstruction should be accorded the possible benefit to be derived from abdominal section, although unusual diffi- culties for successful results are presented by the existence of the numer- ous adhesions. Surgical interference avails practically nothing in cases associated with great prostration and emaciation. The coexistence of tuberculous infection in other parts of the body does not necessarily contraindicate operation, providing the general condition is not that pf extreme pros'- tration. The nature of the operative interference must vary in indi- vidual cases. A simple incision is sometimes sufficient and often highly satisfactory. The opening of the abdominal cavity must be performed with special care, on account of the possibility of intestinal and peri- toneal adhesions immediately beneath the site of the incision. It is important to remove as much of the contained fluid as possible in order to diminish the likelihood of reaccumulation. It is rarely advisable to resort to drainage or flushing of the abdominal cavity. In general, the less meddlesome the interference, the more satisfactor}- the results. It is unwise to attempt to break up adhesions unless to relieve intestinal obstruction or to pro\'ide opportunity for the removal of the contained fluid. It is important to remove, when possible, local foci of infection. This applies particularly to the Fallopian tubes, the appendix, or large cheesj' ma.s.ses in the omentum. It is under such circumstances that drainage is at all permissible, and even then but for a short period. The danger of fecal fistula is much enhanced in those cases in which drainage is employed. A reaccumulation of fluid does not in itself contraindicate the per- formance of a second or a third operation. SECTION IV Glandular Tuberculosis CHAPTER LIX PATHOGENESIS OF GLANDULAR INFECTION The relation of the lymphatic system to the development and spread of tuberculosis is of exceeding interest. The distribution of bacilli from a primary focus of infection is effected in very many instances along the lymphatic and circulatory channels. In the light of comparatively recent investigation it is known that tulierculosis of the lymph-nodes, i. e., the cer\'ical, tracheobronchial, mesenteric, and retroperitoneal glands, often represent primary foci of infection. An initial tubercle deposit having taken place, the infection is conveyed subsequently by way of the lymphatics much more frequently than bj- the blood- vessels. When the vascular system is the sole carrier of bacilli, the PATHOGENESIS OF GLANDULAR INFECTION 413 infection of various tissues is found to occur in distal portions of the body in sharp contrast to the direct sequence of glandular involvement which ensues when the microorganisms are chstributed through the lymphatic channels. In the latter instance the proximal gland is the first enlarged, the subsequent infection throughout the immediate chain of lymphatics exhibiting a progressively diminishing centrifugal involve- ment. The smaller size of the glands in proportion to their distance from the original infective focus illustrates the method of gradual bacil- lary invasion along the lymphatic route. When the filtrative capacity of the successive glands has become completely overtaxed, the barriers are removed, which hitherto have obstructed to a degree the onward march of the invaders. The progressive advance of the infection is shown not only by the gradually , as well as with the corresponding set of the opposite side. The deeper liroup especially serves as a reser- voir for the lymphatics of the tonsils, mouth, nose, eye, and larynx. Glandular enlargement is usually noted in the re^on of the angle of the jaw before a downward extension along the neck is recognized. In like manner the tracheobronchial glands are the reservoir for the lymphatics from the lungs, pleura, and surrouncUng parts. These glands are located near the bifurcation of the trachea, and are more numerous, as a rule, upon the right than upon the left side. A chain of smaller glands lie in close proximity to the left recurrent larjTigeal nerve in its course under the aorta, and another along the right in its passage under the subclavicular artery. Glands accompany the smaller lym- phatics along the primary divisions of the bronchi, and are found, accord- ing to Quain, at the bifurcation of the branches of the pulmonary arter}-. There is some cUfference of opinion regarcUng the intercommunicabilitj'- of the lymphatics of the neck and chest. Barety is quoted by Dr. J. N. Hall as authority for a relationship between the bronchial and supracla- vicular glands, upon the basis of a connecting link esta])lished by a group of glands behind the sternoclavicular articulation. Volland ascribes the origin of many cases of pulmonary tuberculosis to an infected cervical gland. Cornet calls attention to the fact that while involvement of the cervical glands may occasionally take place by extension upward from the bronchial glands, nevertheless, in piilmonary tuberculosis of children, the glands of the neck are rarely chseased. In case of a simultaneous involvement of the cervical and bronchial glands he chooses to assume a separate focus of infection for the two groups. The mesenteric or retroperitoneal glands serve as filters for the intes- tinal tract, the peritoneum, and sometimes the genito-urinary apparatus. Less interest attaches to tuberculosis of lymphatic glands of other parts of the body on account of the comparatively slight opportunity of infec- tion through the skin. In defining certain sets of glands as the drainage basin for a given tributary area, it must not be assumed that a primary focus of tuber- culosis necessarily exists within this region. As a matter of fact, the majority of cases of glandular tuberculosis, especialh' in children, are of primary rather than secondary development, as has been clearly established through the recognition of a macroscopically intact mucous membrane. Ravenel has shown by experiments upon doi:s that the liacilli may pass through an intact intestinal wall directly t" the in.'seiiteric lym- phatic glands. Sydney Martin has also demon.-i rated that the bacilli may permeate a healthy intestinal mucosa and gain access to the mesen- teric glands. Cornet. Orth, Klebs, Baumgarten, \\'alsham, and Litterer, as well as Calmette and his followers, have concluded, as the results of their own experiments, that the tubercle bacillus often secures a port of entry through a normal mucous membrane. Benda and Hamilton PATHOGENESIS OF GLANDULAR INFECTION 415 voice the consensus of opinion that the point of invasion, by virtue of local concUtions, may be an unfavorable site for tuberculous develop- ment, and yet the bacilli be conveyed to a soil which is more receptive. It is known that tuberculous glands are found with great frequency at autopsy among children in whom there are no other discoverable lesions. Repeated investigations have demonstrated the role of the tonsils and adenoid vegetations in affording a port of entry for the tubercle bacillus, even in the absence of local inflammatory changes. The deep crypts in the tonsillar tissues constitute an infection atrium from which the further progress of the bacilli uldii.i;- tlic 1\ inpliutic channels to neigh- boring glands is practically unimpeded. ( >ii the other hand, tubercle bacilli have been shown to be iiicsini in the tonsils and in ade- noid growths despite failure to discover tul.ierculous infection in other parts of the body. The adenoids have been found tuberculous some- what more frequently than the tonsils, undoubtedly on account of the greater narrowing of the respiratory passage and the increased oppor- tunities afforded for tubercle deposit. Fifteen per cent, of all adenoids were found tuberculous by Lartigau, while Robertson reports bi.t S ].cr cent, of hypertrophied tonsils to be infected. Lermoyez, as a re.'-i'.lt ol inonihition experiments upon guinea- pigs, stated the proportion of tubcri uio^is in adenoids to be 20 per cent, and in hypertrophied tonsils I'.i per cent. Wood reports that out of a total of 1671 adenoids or tonsils examined for tuberculosis, without evidence of tuberculous involvement elsewhere, a positive result was obtained in 88, or about 5 per cent. The presence of tul icicle bucilli in the tonsils and adenoid growths of apparently healtli\- iiidi\iduals suggests the probability of their not infrequent passage to the lyniph.'itic glands, producin.'; therein a primary seat of tuberculous infection. Jacobi has held to the opinion for years that infection of the cervical nodes occurs much less frequently through the tonsils or adenoids than through the medium of the lymph-follicles in the nose and pharynx. It must be admitted that enlargement of the cervical lymph-glands follows inflammatory processes in the nose and nasopharynx more quickly and more frequently than an infection confined solely to the tonsils. It has been shown conclusively that when the lungs are also diseased, the pulmonary involvement in the vast majority of cases is secondary to tuberculosis of the bronchial glands. The precise manner in which the bronchial glands become subject to tuberculous infection remains a somewhat disputed point, although the preponderance of evidence suggests an invasion of the body by bacilli through the digestive .system. Some maintain that the essential consideration is the aspiration of the bacilli into the bronchial tract and their passage through an intact bronchial mucosa. Behring asserts that the infection takes place originally through the intestine rather than by inspired air. He believes the infant's milk to be the chief source of tuberculosis in childhood as well as in adult life. He asserts that the foci of infection thus engendered remain latent for varjdng periods of time until individual resistance is sufficiently lowered to per- mit their active development. Behring's \'iews have been cUscussed in connection with the method of infection through the alimentary canal, as have also the experimental observations of others who have demonstrated the ease with which tubercle bacilli may penetrate the 416 COMPLICATIONS intestinal wall without visible lesion and gain ready access to the glandular structures. The later researches of Calmette and Guerin, Engel and Schlossman, have shown the passage of bacilli through an intact mucous membrane to the mesenteric and bronchial glands of animals, and their early appearance in the thoracic duct and pulmonary artery. Behring"s contention that the permeability of the intestinal wall is much greater in infancy on account of the more delicate structure is of much interest. Differences in the passage of microorganisms through the wall of the intestine at varous ages were demonstrated by experiments upon animals. Tubercle bacilli were fed to guinea-pigs with the result that only the very young became tuberculous, enlarge- ment of the glands of the neck being noticed even while the general concUtion appeared entirely normal. Ravenel, on the other hand, has recently introduced tubercle bacilli with the food into the stomach of two monkeys and one cow, producing tuberculosis of the bronchial glands and lungs without mesenteric or intestinal lesions. Some inves- tigators have been unable to produce tuberculosis of the lungs or bron- chial glands after carefully conducted inhalation experiments. There can be no doubt as to the primary involvement of the bronchial lymph- atic nodes in little children. In the light of all the evidence presented it would seem that it must remain sub judice whether in individual cases the initial infection is purely respiratory or intestinal. It has been demonstrated beyond question that the infection may pursue either of these routes in cUfferent cases. Apropos of experimental investigation, it may be stated that the important consideration in this connect ion is not altogether the deter- mination of the exact pathogenesis of glandular infection, but rather the fact that, by whatever route, glandular tuberculosis occurs with great frequency in little children. Opinions differ concerning the significance of the family history. Statistics have been cited both to demonstrate and to deny the influ- ence of heredity as an etiologic factor. Lowered resistance may take place among children of healthy parents, wlrile others with more or less inherent predisposition to disease may thrive by virtue of especially favorable concUtions. A positive family history of tuberculosis while not to be regarded as a factor of great import, must, neverthele-ss, be conceded to possess some practical .significance. The reasons for a greater frequency of glandular tuberculosis in children than in adults are found in the comparative ease with wliich the delicate mucous mem- branes are traversed by bacilli, and the increased facilities with which the germs are conveyed through the open permeable lymph-spaces. In addition may be cited certain accessory features which increase the likelihood of infection and to a material extent diminish inchvidual resistance. The influence of enlarged tonsils and adenoids in encroach- ing upon the normal respiratory passages and ofTeiing a site for the depo.sit of bacteria has been mentioned. Infants being directly depen- dent upon the care of others are subjected to increaseil danger of expo- sure to tuberculous infection. The child is often upon the floor, and thus is brought in closer contact with the bacilli, which contaminate the carpets and rugs. The vitality of infants is frequently reduced by digestive chsorders and catarrhal disturbances, inferior ventilation, and improper hygienic concUtions. Irrespective of the causes, the fact remains that tuberculosis is exceedingly common in childhood and that, PATHOGENESIS OF GLANDULAR INFECTION 417 in the great majority of cases, the lymphatic glands constitute the pri- mary focus of infection. The accuracy of this statement is substantiated by the reports of numerous observers. Medical literature abounds in statistical analyses as to the frequency of tuberculosis of the lymph- nodes in childhood. For the purposes of illustration it is well to refer briefly to some of these investigations, though any attempt to quote at length would seem superfluous. \'olland, Beruti, Balmann, and Wohlgemuth, as the result of an examination of very many children, report the cervical lymphatic glands to be enlarged in the proportion of from 81 per cent, to 96 per cent., according to Pottenger. The reports of other observers as to the char- acter of the cervical enlargement in children would indicate that nearly two-thirds are tuberculous. Cornet's analysis of the autopsy records of the Berlin Pathological Institute for a period of fifteen years shows not a single case of tuberculosis out of 486 cases from birth to the end of the first month; from two to three months, 6 per cent, of the cases; from three to six months, 10.5 per cent. ; from six to nine months, 17 per cent. ; from nine to twelve months, 27.7 per cent.; from one to two years, 26.6 per cent.; from two to three years, 29.6 per cent.; from three to four years, 31.8 per cent.; from four to five years, 22.4 per cent. Several other observers, notably Miiller, Babes, Heubner, Newmann, Still, Hand, iSimonds, Schever, Bolz, Jacobi, and Holt have reiioitcd statistics not especially dissimilar to these results, the proportion raimini:. in < hildfcn up to five years, from 22 to 40 per cent. Forei,!in statistics ((inccruing the prevalence of glandular tuberculosis show higher percentages than &re obtained in this country. Nearly all observers agree that, in the majority of cases, the pathologic evidence points to involvement of the lymphatic glands as the primary foci of infection, the lungs being secondarily diseased. In autopsies upon tuberculous children the bron- chial glands are almost always found tuberculous. Cornet quotes the statistics of Steiner and Neureutter, who report tuberculosis of the lymph-glands in 299 out of 302 autopsies. The bron- chial glands were tuberculous in 286 of these cases. He also refers to the report of Rilliet and Barthez, who found the lymphatic glands tuberculous in 248 cases out of a total of 312 autopsies upon tuberculous subjects. Northrup's report of bronchial glandular involvement in every instance in a series of ]2.i aiitniipics has been widely quoted. The same results were obtained !)>• .Xoithiup in a second series of 125 cases in the New York Foundling Hosiiital. llojt reports 119 ca.ses in which the bronchial glands were tuberculous in every instance. In 115 autopsies Hand reports the bronchial glands involved in 81.7 per cent.; the lungs, in 78 per cent. Both Steffen and Bulius found the lymphatic glands infected in nearly every autopsy reported upon tuberculous patients. All observers agree that the tracheobronchial glands are involved more frequently than any others, with the cervical system next in order. Haushalter, in a report upon the results of 78 autopsies performed upon children who had died of acute miliary tuberculosis, states that tuber- culosis of the mediastinal glands was found in all but 4 cases. Enlarged bronchial glands from individuals exhibiting no evidence of tuberculosis have been found by inoculation experiments to be infective to animals. Allusion has been made to the experiments of Pizzini and others, who reported positive inoculation results in a large proportion of cases. Pizzini, after inoculating animals with the bronchial glands of 40 27 418 COMPLICATIONS patients, found 42 per cent, tuberculous. It is interesting to note that injection of the cervical glands from the same subjects was followed by tuberculosis in but 2 per cent, of the animals, while none showed evidence of infection with inoculation of the mesenteric glands. Loomis has demonstrated by inoculation experiments with bronchial glands the existence of tuberculo.sis which had previously been unrecognized. Bertalot discovered tidjercidosis of the bronchial glands in 20 out of 24 children w-ho had tiled of tuberculous meningitis. Both Reiner and Henoch report tuberculosis in nearly all cases of tubercidous meningeal infection. The symptomatic manifestations of enlarged tuberculous glands vary according to their location. The clinical picture of cervical tuber- culous adenitis is quite different from that of tabes mesenterica. Enlargement of lironchial glands often produces still another character- istic grouping of symptoms, as well as definite physical signs. It is well, therefore, to consider separately the clinical features of tuberculosis of the various lymph-nodes. CHAPTER LX TUBERCULOSIS OF THE CERVICAL GLANDS This form is very common among little children, and not infre- quently occurs in young adults. It exists occasionally in middle life. Local conditions favoring its development are hypertrophied tonsils, chronic catarrhal processes in the nose, nasopharynx, and phar3Tix, eczema of the scalp, otitis media, and disease of the gums or teeth. Tuberculous glands of the neck often accompany a beginning conva- lescence from measles, whooping-cough, and sometimes influenza. Dur- ing the past few years I have noted an increasing number of instances of enlarged glands near the angle of the jaw in children following influ- enza and simple tonsillitis. Many of these cases were at first regarded as belonging to the category of ordinary glandular fever, but their chronicity suggests the probability of a tuberculous infection. Among general conditions predisposini: to tlio development of tuber- culosis of the cervical glands may be mentioned inil>erculosis, the origin of which is undoubtedly to be traced to a small gland in the neck the size of a small walnut, of one and one-half ycais' duration. On account of the general invasion, with characteristic .■iniii- l,ii yugeal involvement, the patient has been advised to return to his Ikhiic. Fig. Ill, repro- duced from a photograph, shows not only the small .size of the gland, which is almost unnoticeable unless the head is inclined to the opposite side, but also the excellent nutrition, which thus far has been but little affected. Diagnosis. — The special feature of diagnosis, aside from the exis- tence of tuberculosis elsewhere, relates to a differentiation from the 420 COMPLICATIONS enlargement of simple inflammatory adenitis, lymphatic leukemia, and Hodgkin's disease. The persistence of the mass without acute inflammatory signs, par- ticularly in the absence of such exciting causes as the acute infectious diseases or poor teeth, sufficiently characterizes the condition to exclude a simple glandular aljscess. The absence of loiikdcytosis, \\liic!i always accompanies lymphatic leukemia, is easily ilctcriiiinccl l>y ihc ixammation of the blood. It is sometimes difficult t<> iliffercntiate aicmatcly between lymphatic tuber- culosis and the lymphadenoma of Hotlgkin's disease. In general it may be stated that in the latter condition suppuration rarely takes place, and the glands are usually firmer, harder, and less tender than in tuberculosis. Although they may attain large size, they are more often discrete and less adherent to one another and to surrounding parts. 1.'. tulluwed by le They rarely are fused into large ma.s.ses, but tend rather to preserve their individuality, and, as a rule, are somewliat movable under the skin. The condition is perhaps less frequent in children, although it may occur at any age. In Hodgkin's disease the site of the enlargement is usually in the lower part of the neck, while the reverse is true in tulierculosis. The tuberculin reaction is not always perfectly reliable, as it has been shown that the two conditions m.-xy coexi.st. Fever may be present in either case. It is probable that the ophthalmotuberculin test may be of value when the diagnosis is obscure. Several cases have been reported presenting the clinical picture of Hodgkin's disease, which were found to be tuberculous at autopsy. Sternberg and Musser are quoted by James as of the opinion that the glandular enlargement of Hodgkin's cUsease is tuberculous in character, thus explaining the irregular fever which so often is pre.sent. Dr. D. M. Reed and Dr. W. B. James, however, report negative results from inoculation experiments and careful study of the TUBERCULOSIS OF THE CERVICAL GLANDS 421 glands in a number of cases of Hodgkin's disease exhibiting temperature elevation. The difficulties of exact differential diagnosis between the two con- ditions is shown by a case which has been under my observation something over ten years. The patient was thirty years old, of negative family history, and previous good health when he consulted me with reference to a rapidly growing mass in the left neck, slightly above the clavicle. The enlargement had been of but three or four weeks' dur- ation, but was associated with much general weakness, extreme pallor, and emaciation. The glands were hard, perfectly discrete, painless, and more or less movable, presenting no resemblance to a brawny swelling. There was no redness, adhesion of the skin, or fever. The injection of tuberculin for diagnostic purposes was attended by a negative result. The glands continued to increase in size until the patient was unable to wear a collar. A second group of glands became enlarged back of the angle of the jaw, and presented the same charac- teristics. There developed a slight involvement upon the right side of the neck, in the left axilla, and in each groin. The spleen became dis- tinctly palpable. The examination of the blood was negative. The patient rapidly became ])rost rated and was forced to remain in bed. The diagnosis of Hodgkin's di.sease was made and later indor.sed unequivocally by Drs. Bergtold, Powers, Whitney, and others. The family were informed as to the hopeless nature of the condition and a comparatively speedy termination was expected. There soon developed an intense bronzing of the skin of the entire body, with progressive glandular enlargement. Almost daily vomiting prevented recourse to superalimentation. The treatment consisted simply of rest, very large doses of Fowler's solution, and bone-marrow. The downward progress of the disease gradually became arrested, but the patient remained in bed for a period of many months, followed by a life of invalidism for nearly two years. The glands became slowly and almost imper- 422 COMPUCATIONS ceptibly reduced in size, as also the Spleen. The bronzing of the integument persisted for three or four years and was accompanied by a remarkable thickening of the skin of the hands and feet, with pronounced peeling at short inter\'als. Two years after the initial onset the patient was seen by Dr. Coley, of New York, who concurred in the previous diagnosis. During the ensuing years several relapses of a milder nature have taken place. Since the introduction of the a--rays their employ- ment has been resorted to periodically in this case with considerable benefit. At the present time the patient exhibits all the external appear- ances of perfect health , and the enlarged glands of the neck have almost entirely disappeared. There remain two nodules of moderate size, recognized upon inspection, in the upper left neck, and several small palpable masses in the lower right, just above the clavicle. There is, moreover, dulness with diminished intensity of the respiratory sounds at each apex, extending nearly to the second rib. As a result of prolonged x-ray exposures a well-defined telangiectasis has appeared upon each side of the neck. Fig. 112 repre.sents the photograph of the neck just taken, which is of interest in connection with the skiagraph, Fig. 48, showing well-marketl apical involvement of the lung. In plate 11 is shown the present telangiectatic condition upon each side, and the two visible nodules upon the left. It would appear that no case could present a clearer picture of Hodgkin's disease, and yet, in the light of the improvement and the present physical signs, despite a negative tuberculin test, the conclusion is forced that the original glandular infection was of a tuberculous nature. CHAPTER LXI TUBERCULOSIS OF THE MEDIASTINAL AND MESEN- TERIC GLANDS MEDIASTINAL GLANDS The clinical manifestations of tuberculous enlargement of the tracheobronchial glaiuls are extremely varied in character, there being no direct relation between the symptoms and physical signs. It fre- quently happens that pronoimced symptoms ari.se suggesting the probability of enlarged mediastinal glands, with an entire absence of objective signs. In other cases the physical evidences of tuberculous glandular enlargement may be so definite as to permit the recognition of a distinct mass without the exhibition of symptoms. The condition is more common in little children than at any other age; typical cases in young adults are not infrequent. Both the symptoms and signs are largely dependent upon the location of the glandular enlargement, the degree of compression exerted upon contiguous parts, with consequent functional disturbance, the possible perforation through an intervening wall into adjacent structiu-es, and the extension of the infection through the l.ymphatics into neighboring il 12 |2 "si TUBERCULOSIS OF THE MEDIASTINAL AND MESENTERIC GLANDS 423 The usual location of the tuberculous glands has been stated to be in the neighborhood of the bifurcation of the trachea in the posterior por- tion of the mediastinal space. Attention has been called to their fre- quent proximity to the left recurrent laryngeal nerve. Among neighbor- ing structures apart from the trachea and bronchi are the pulmonary artery, the superior vena cava, the aorta with its branches, the pulmo- nary veins, the pneumogastric and phrenic nerves, and the esophagus. Well-defined symptoms may result from compression of any of these parts to a greater or less degree by a mass of tuberculous glands. The nature of the symptoms varies according to the particular point of compi'ession upon any of these structures. The pressure symptoms of perhaps more frequent occurrence relate to the trachea and primary bronchi. If compres.sion be exerted upon the trachea alone, alarming dyspnea may supervene. This is often associated with a violent dry paroxysmal cough, not very dissimilar to that of pertussis. In other cases the cough and respiration simulate asthma to some extent. The severity of these symptoms is not altogether dependent upon the degree of compression. 1 well remember the case of an adult who exhibited most distressing dyspnea, with almost incessant paroxysmal cough and wheezing respiration. There was found at autopsy but slight compres- sion from a glandular mass adherent to the trachea, penetrating the posterior wall and protruding within the lumen to the size of a small pea. The physical signs of tracheal compression consist primarily of a diminished respiratory excursion and an enfeebled respiratory murmur in all parts of each lung. Normal resonance is elicited upon percussion. I have never recognized the peculiar character of the respir- atory sounds described by the French as carnage, which is ascribed to the rush of air through a narrowed lumen, but have noted an inspiratory retraction of the thorax, the so-called tirage, which is often pronounced in the lower lateral region. Edema or spasm of the glottis and genuine diphtheria may be excluded by laryngoscopic examination and by the fact that the voice is unaffected in tracheal obstruction. When the compression is exerted upon a single ■primary bronchiis, there is but moderate dyspnea unless the enlargement of the gland has taken place suddenly. As a rule, the increase in the size of the affected glands is gradual and hence the pressure occlusion of the bronchus is incomplete and the dyspnea slight. In such cases there are often no symptoms incident to the pressure upon the bronchus per se. If sub- jective clinical manifostatioiis are present, they are occasioned by pres- sure upon otlier cdiiti.iiuous ]);uts. as will he explained. The physical signs of bronchial compression, however, are defined sharply and constitute a group of clinical data sufficient to characterize the condition and lead to its almost invariable recognition. Upon inspection the restricted moljility of the affected side is at once apparent. In place of the inspiratory expansion is seen a more or less pronounced retraction in the lateral region. Upon percussion there is found but slight, if any, deviation from the normal resonance. The respiratory sounds are absent altogether, or else markeiUy diminished in intensity, without perceptible difference in rhythm, pitch, or quality, save for the occasional recognition of the carnage. In exceptional instances a capil- lary bronchitis is detected by the presence of extremely fine moist rales, which are disseminated throughout the lung of the affected side. This 424 COMPLICATIONS condition is rarely incident to the compression itself, but is produced by the penetration of the gland en masse into the bronchus, with subsequent aspiration of tiny particles of infective material, to which condition atten- tion will presently be directed. The presence of a closed pneumothorax may be excluded by the failure to recognize a dislocation of the cardiac apex, together with other signs previously alluded to. The unchanged percussion resonance and diminished breath-sounds then permit an assumption as to the existence of some form of bronchial obstruction. The nature of the obstruction is determined, as a rule, by a review of such essential features as the age, history, habits, and a further study of the physical signs. The suspicion of a foreign body in the bronchus may usually be eliminated by the history. Aneurism is often excluded by the age, history, and associated conditions, together with the absence of signs especially characteristic of the condition. An .r-ray examina- tion is sometimes of undoubted value in obscure cases. The compression of other contiguous structures, though somewhat less frequent than that of the trachea or large bronchi, is attended by rather more conspicuous symptoms. Pressure upon the recurrent laryngeal nerve may produce hoarseness or aphonia, together with a paroxysmal cough, the latter often being extremely distressing. (In this connection it is interesting to note that the chronic noisj^ breathing of hor.ses, commonly termed "roaring," is occasioned by pressure upon one of the nerves controlling the move- ments of the larynx by lymphatic glands within the chest.) The cough usually persists indefinitely and is not attended, as a rule, by an inspiratory whoop. There is often no expectoration whatever, but if present, it consists almost entirely of mucus. The laryngoscopic evidences of compression of the recurrent laryngeal are numerous and varied. There may be paralysis of any single muscle, and in some cases of a pair of muscles, as all the movements of the larynx are controlled by the recurrent laryngeal nerves. Complete or partial paralysis of at least one group of muscles is almost always observed. Pressure upon the recurrent laryngeal may produce dyspnea, irre.spectiveof the presence or absence of bronchial compression. Dyspnea is also effected by com- pression of the phrenic, and often occurs in conjunction with hiccough. Painful and difficult swallowing, as in esophagismus, sometimes results from esophageal obstruction or compression. Dr. J. N. Hall has called attention to the possible development of the traction diverticula in the esophagus from contraction changes either in the gland or in the esoph- ageal wall, giving rise in part to the symptoms of obstruction. He also alludes to the possible effect of pressure upon the pulmonary arteiy in fa- cilitating the tendency to pulmonaiy tuberculosis through the lessened blood-supply. In the event of compression of the superior vena cava an impeded venous circulation is noted in the veins of the face, arms, and shoulders, and sometimes over the anterior surface of the thorax. In these cases the network of distended veins is plainly discernible upon the skin. Edema of the lungs may result from compression of the pulmo- nary veins. Vomiting or tachycarcha may be present from compression of the pneumogastric, and either dilatation or contraction of the pupil, as a result of pressure or irritation of the sympathetic. It should be borne in mind that the pressure symptoms referable to enlarged bronchial glands are occasioned not only by the contiguiti/ of important structures, but also by the immobilitii and resistance of the TUBERCULOSIS OF THE MEDIASTINAL AND MESENTERIC GLANDS 425 parts in contrast with the easily movable and yielding walls within the abdominal cavity. In the event of adhesion to immediate structures, with perforation of an intervening wall, the resulting changes are often of especial importance. The gland may penetrate the bronchus, soften, and permit the aspiration of tiny particles of infective material into the correspond- ing bronchial tract. The symptoms and physical signs of a bronchiolitis are not infrequently merged into an acute bronchopneumonia. This form of pneumonia of tuberculous origin usually induces an early fatal termination. Abscess of lung and pulmonary gangrene may possibly develop as secondary processes following the perforation of a bronchus. Many instances are on record relative to the discovery at autopsy of bronchial glands in the air-passages. In many of these cases the gland producing the obstruction was found to be of such size as to pre- vent its expulsion through the trachea and larynx. It is not altogether impossible that a sloughing gland may be expectorated. Some years ago Hall reported a case of obstruction of the left primary bronchus, which was presumably from a tuberculous gland. This was followed by bronchopneumonia of the adjacent lung, with expectoration of a large amount of pus daily, without evidence of empyema or bronchiectasis. There was an abrupt cessation of the expectoration, with speed}- com- plete recovery after the expectoration of a " fleshy mass, presumably a bronchial gland." Dr. Hall was unable to secure the supposed glandular obstruction for the purpose of examination. Cases of calcareous metamorphosis of the affected gland have been reported, with the expectoration of so-called lung stones. When perforation takes place into the trachea, sudden and alarming dyspnea invariably supervenes. Such a condition is the probable cause in many in-stances of sudden death in little children following abrupt and severe dyspnea. Several cases confirmed by autopsy have been reported. Instances of perforation of the esophagus by an ulcer- ating gland are fairly numerous, as well as rupture into the pleura and pericardium. Although glandular perforation is by no means essential for the pro- duction of tuberculous pleiuisy and pericarditis, these secondary proc- esses, together with pneumothorax and mediastinal abscess, are some- times the chrect result of a suppurating tuberculous gland. Perfor- ation of the wall of the larger blood-vessels is comparatively infre- quent, but has been found to take place in the pulmonarj' artery and the aorta. Ulceration into a vein establishes a direct communi- cation of the softening gland with the blood-current, and results in a miliary tuberculous infection. Tuberculous meningitis, as well as the other forms of general miliary tuberculosis, are known to be secondary in a large proportion of cases to involvement of the bronchial glands, both the blood- and lymph-currents constituting the avenue of infection from tlie primary focus. In view of the remarkable frequency of tulierculous involvement of the tracheo- bronchial glands it is difficult to explain the comparative rarity of general tuberculous infection. It is certain, however, that, through the medium of the lymphatics, extension of the tuberculous process takes place in neighboring organs, notably the lung. It is important to bear in mind that in children pulmonary tuber- culosis emanating from a diseased bronchial gland presents a somewhat 426 COMPLICATIONS different clinical picture than in adults as regards the localization of the area of infection. In children the apex is usually uninvolved at first, the infection spreading from the hilus in the immediate neighborhood of the primary glandidar focus to the middle and lower portions of the lung. Involvement of the lower lobe is often produced by the aspir- ation of cheesy portions of gland penetrating a larger bronchus. In the absence of an ulcerating gland within the bronchus, permitting a down- ward extension of the tuberculous process, the area of initial pulmonary infection is closely adjacent to the bronchial glands, between the second and fifth dorsal vertebrsp. An investigation of the middle or lower portion of the back in children is usually attended by positive results. In this region signs of beginning consolitlation with bronchial or bron- chovesicular respiration and fine or medium-sized moist rales are recog- nized. Enlarged tracheobronchial glands often give rise to no physical evi- dences at the immediate site of their location, but if pressure sijmptoms are exhibited, an early and con\-incing diagnosis can be matle in many- instances. In other words, the physical signs referable to the compres- sion of a bronchial gland are sufficient in character in connection with associated data, to justify a definite diagnosis as to the nature of the obstruction. The clinical detection, however, of the enlarged glands themselves is often impossible, even if of sufficient size to produce pres- sure symptoms. It is true that in some cases a considerable enlarge- ment of the bronchial glands is possible of recognition, although the mass may be so situated as to exert no pronounced compression upon import- ant structures. It is claimed by some observers that dulness upon percussion ma}' be recognized in the interscapular space in the neighborhood of the fifth dorsal vertebra, and especially just aliove this area. I have never been able to detect changes in resonance in this region in cases of suspected glandular enlargement. Many authors deny the existence of such percussion change unless the glands are of extreme size. In a very few instances I have been able to recognize percussion dulness referable to glandular enlargement just below the sternocla\icular articulation upon one side. The percussion change is rendered more pronounced if the head is held well retracted during a deep inspiration. Recognition is ea.sier in young adults than in little children on account of the tliminished size of the thymus gland. But little dependence can be placed upon any circumscribed auscul- tatory signs supposedly attributable to glandular enlargement. There may be, in some cases, enfeebled respiratory sounds and in others a distinct bronchovesicular element due to conduction through a solid gland. At best both the percussion and auscultatory signs over the site of the tuberculous gland are vague and indefinite, save in instances of very pronounced enlargement. To illustrate certain points to which attention has been directed. I will report briefly the case of a young man which is of exceeding interest in this connection. The patient, aged twenty-eight .vears, was sent to Colorado during the latter part of 1905 on account of advanced pulmonary tuberculosis, the symptoms of which immediately followed an attack of croupous pneumonia. At that time there were severe paroxysmal cough, copious expectoration, rigors, fever, night-sweats, and dyspnea. The patient was referred to me in March, 1907, by a prominent physician in TUBERCULOSIS OF THE MEDIASTINAL AND MESENTERIC GLANDS 427 another part of the State, under whose direction he had remained while in Colorado. The average afternoon temperature was 103° F. and occasionally higher. Dyspnea was pronounced, cough severe and markedly paroxysmal, the expectoration amounting to six ounces in twenty-four hours. Upon examination of the chest there was noted a slightly impaired mobility of the entire left side, with inspiratory retraction in the lateral region. The percussion resonance was normal, and there was no cardiac displacement. There was recognized a considerable diminution in the intensity of the respiratory sounds, with very fine moist rales over the entire left lung. Slight moisture was present at the right apex, without evidence of infiltration. Occlu- sion of the left primary bronchus from a tuberculous mediastinal gland was suggested, and an effort made to detect localized percussion changes. Percussion of the liack from the third to the fifth dorsal spine was entirely negative. No deviation from normal resonance was elicited in the left sternoclavicular articulation with the head held perfectly erect. When it was thrown well back, however, and particularly upon deep inspiration, there was noted upon light percussion a slight but distinct dulness, the outline of which is shown in the accompanying photograph (Fig. 113). There was thus established a positive diagnosis of obstruction to the left primary bronchus near the bifurcation of the trachea by a tuberculous bronchial gland. This was confirmed the following day by the .r-ray picture (Fig. 55), the enlarged gland being found in close apposition to the .sixth dorsal vertebra upon the left side. There was no hoarseness or aphonia, but the laryngoscopic image clearly showed a partial paralysis of the abductors, indicating that the mass was impinging to at least a slight extent upon the nerve controlling the move- ments of the larynx. Dr. Levy's report of the laryngoscopic examination follows: "No apparent change in the mobility of the vocal bands upon tranquil respir- ation. Upon forced inspiration abductor excursion of the left vocal 428 COMPLICATIONS band, limited to an extent equal to about one-half that of the right; upon phonation a small chink l)et\vcen the vocal bands, due to paresis of the internal thyro-arytenuid muscle; line of approximation was obliquely to the right, owing to exaggeration of the action of the adductor of the left vocal band over the abductor, causing an overriding of the left aryte- noid in front of the right. "Diagnosis. — Slight pressure upon the left recurrent laryngeal or left pneumogastric, involving only the abductor fibers, and these but slightly. " The fibers of the recurrent laryngeal going to the abductors of the larynx are first affected in pressure lesions of this nerve or of the pneumo- gastric, in accordance with the law laid down by Semon, which is to the effect that when pressure is made upon the recurrent laryngeal, the fibers going to the abductors are first involved, owing to a peculiar suscepti- bility of these fibers. The first manifestation of pressure upon the recurrent laryngeal, therefore, is abductor paralysis. As the pressure continues the adductors become paralyzed as well, thus giving to the vocal band neither abduction nor adduction, allowing it to remain in what is known as the cadaveric position." The subsequent progress of the case under the use of tuberculin and an autogenetic vaccine is detailed under Specific Mechcation. MESENTERIC GLANDS Tuberculosis of the mesenteric and retroperitoneal glands, commonly termed tabes mesenterica, is frequently foimd at autopsy to have been present in little children, even though unsuspected during life. Suppu- ration takes place far less often than in the glands of the cervical region. Caseation is common, and calcification sometimes occurs. The condition is found with great frequency among the neglected children of the very poor. The patient is usually quite anemic and poorly nourished. The trunk, arms, and legs are thin and wasted, while the belly is quite prom- inent. The abdominal enlargement is produced more from the coexist- ing tympanites than from the direct presence of the glamls themselves. Diarrhea is often present, and the stools are offensive, and, as a rule, the appetite and digestion are considerably impaired. The older writers however, speak of " emaciation and voracity combined' ' in such cases. There are almost always fever, peevishness, and irritability. As a rule, little is determined upon examination on account of the tympanitic condition of the bowels. The glands are rarely felt. In case of coexisting tuberculous peritonitis the abdomen may be firm, resistant, and presenting nodular enlargements. In some in.stances tuberculous involvement of glands is recognized in other regions, notably the cervical and axillary. This type of glandular tuberculosis often is observed among negroes, and is not infrequent in adults among these people. TREATMENT OF GLANDULAR TUBERCULOSIS 429 CHAPTER LXII TREATMENT OF GLANDULAR TUBERCULOSIS While in the past tuberculosis of the cervical lymph-nodes has been subjected to a variety of local remedial efforts, both non-operative and surgical, involvement of the mediastinal, mesenteric, and retroperitoneal glands has not been regarded as amenable to other than constitutional treatment. The general management of all cases of glandular tuber- culosis has consisted chiefly of tonic and supporting measures, which in cervical adenitis have been supplemented by local procedures. The present conception of the proper treatment of glandular tuberculosis affords a reasonable belief in the attainment of more satisfying results than formerly. It is now appreciated that a tuberculous gland, no matter how small, may be an active focus for further tuberculous infec- tion, and hence the necessitij of instituting without delay an intelligent systematic course of treatment even to incipient cases. While the lymphatic glands of the neck comprise a group especially suited for surgical interference, the glands of the mediastinum and abdomen, after the diagnosis has become definitely established, some- times respond to active therapeutic efforts in conformity with compara- tively new ideas of management. The modern treatment of glandular tuberculosis may be regarded as general and local . GENERAL TREATMENT This form of management embraces the hygienic treatment and the medicinal. Hygienic Treatment. — The hygienic principles of treatment relate especially to an abundance of outdoor air, exercise, chversion, change of environment, and nutritious food. In glandular infections, as in all other forms of surgical tuberculosis, attention to no single factor is suf- ficient for the accomplishment of the best results. An out-of-door existence, important though it be, is totally inadequate by itself, but should be combined with such favorable influences as accrue from judicious exercise, with opportunities for recreation and amusement. There should also be an ingestion of food sufficient in character and quantity to appease the cravings of ;ui iHiic;i.siiif; .-ii (petite. It is difficult to conceive of the inestimable benefits (Icincd by liltic children from a radical change in their immediate sunoundiugs. Kemoval from the city to the country or the seashore not only permits a greater purity of the air, but affords a natural incentive for more or less unwonted exercise, and provides a means for the enjoyment of unaccustomed sights, which awaken the interest and maintain a buoyancy of spirits in the young. The p.sychic influence of a novel environment even among the well-to-do is of undoubted value, while such a change is a veritable blessing to the poor, who, since their birth, have been deprived of sun- light, fresh air, proper food, and clothing, cheerful surroundings, and uplifting influences. In a vast number of cases of glandular tuberculosis the actual needs of the child are better subserved by attention to these hygienic features of treatment than through recourse to purely medicinal or surgical management. 430 COMPLICATIONS By an outdoor regime is meant far more than the air permitted to enter sleeping-rooms and hospital wards through open windows. It is not always an eas}- matter to persuade parents that their duty to the child consists of provision for a recreative existence in the open air as the first essential of treatment. The inconvenience of the family, the additional expenditure, and the social or business interruptions are assuredly unworthy of consideration in comparison with the boon granted by virtue of a radically changed environment. Clinical evidence is now conclusive to the effect that many cases of glandular tuberculosis are clearly susceptible of rapid and permanent cure, through the adoption of an unrestricted out-of-door existence. While this principle of open-air treatment, exclusive of surgical manage- ment, is thoroughly recognized, a considerable chfference of opinion is entertained with reference to the comparative merits of the sea, inland, or mountain air. The French and English appear to have an abiding faith in the efficacy of sea air for children afflicted with tuberculous glands or bones. In the latter part of the eighteenth centurv the Royal Sea Bathing Hospital was founded at Margate, England. Since then convalescent homes for invalids suffering from so-called surgical tuber- culosis have been established upon the seashore of England. At the present time nearly all European cotmtries maintain hospitals upon the coast for invalids similarly afflicted. Brannan, the prime mover in organizing the work of our single experi- mental station at Sea Breeze, which is supported by the New York Association for Improving the Condition of the Poor, reports 23 marine hospitals along the Italian .shores of the Mediterranean and Adriatic, containing a total of over 10.000 beds. Calot has described the hospital at Berck-sur-mer, which was founded by the city of Paris in 1860 and now contains 750 beds. In this institution remarkable improvement has been achieved by one of my former patients, who became afflicted with Pott's disease. While the child was still an infant the father, a physician of New York city, died in Colorado, in 1898, as the result of a severe pulmonary hemorrhage occurring in the course of advanced phthisis. A few years later the child was sent to Berck-sur-mer, where he remained for a period of nearly two years and secured an apparent complete recovery from the tuberculous process. The child was taken daily from the bed and placed upon a truck, which was rolled almost to the water's edge. There he was permitted to lie during the entire da}% save imder unusually se\-ere weather conditions. This is practised as a routine measure at the several institutions at Berck-sur-mer. There are several seashore hospitals in South America containing over 800 beds, largely devoted to the treatment of tuberculosis of cliilclhood. It appears that nearly all the countries of Europe and some in South America have been far more ready than the United States to make national provision for the care of little sufferers with various forms of surgical tuberculosis. Brannan calls attention to the fact that France maintains on her sea-coast fifteen sanatoria, which, with other institutions, open only during a portion of the year, contain 4000 beds. He quotes the reports presented by Armaingand and D'Espine at the International Congress of Tuberculosis in Paris in Octolier, 190.5. concerning the work done in the various seaside sanatoria of Europe. During the past twenty years TREATMENT OF GLANDULAR TUBERCULOSIS 431 60,000 children have been treated in these sanatoria in France, 84 per cent, of whom exhibited favorable results; of these, 59 per cent, were regarded as absolute cures, and 25 per cent, as instances of pronounced improvement. Of those absolutely cured, the percentage ranged from 32 in Pott's disease, to 74 in glandular tuberculosis. Nearly all European seaside institutions exclude pulmonary tuberculosis. The consensus of opinion abroad is strongly in favor of the seaside resorts as opposed to inland climates for the treatment of tubercu- losis of childhood. The results already accomplished at Sea Breeze are instructive and inspiring. There has been an almost invariable improvement in the general conilition of the children, with a corres- ponding change in the local le.sions. These results have been attained by virtue of the new surroundings in connection with non-operative therapeutic measures. Out of a total of ten cases of glandular tuber- culosis, six have been entirely cured and three very much improved. The essentials of ti-eatment at Sea Breeze are constant exposure to the sea air by night as well as day, abundant nourishment, and the establish- ment of a bright, happy child-life for the little patients. They are allowed to exercise to a remarkable extent, playing and romping in the sand in spite of their physical infirmities. Halsted, in his paper before the Clinical and Climatological Section at the first meeting of the National Association foi- the Study and Pre- vention of Tuberculosis, reports decidedl.y iiratif\iiiK results obtained l)y inland out-of-door management. His early iilisciNatimis concfrning the efficacy of the open-air treatment were conlined to the " bridge' ' of the Johns Hopkins Hospital. Unusual results in surgical tuberculosis have been obtained in the Adirondacks and other eastern inland resorts. Lowman believes that along the borders of the Great Lakes there may be accomplished results in all respects equal to those obtained at the seashore. Morse has called attention to the Convalescent Home at Wellesley, established many years before Sea Breeze, and employing practically the same methods. He asserts from the experience at Wellesley that the sea air is by no means a sine, qua non, and that children may be expected to do fully as well in the country as at the seashore. Freeman affirms, from a surgical experience of over seven years in Colorado, and of equal duration in Cincinnati, that moderately high altitudes with dryness offer far gi'eater advantages than the seashore for the treatment of glandular and bone tuberculosis. He reports remarkably fewer cases of tuberculosis of the lymphatic glands in Colo- rado than in Ohio. Powers, after ten years' resiclcnco in Colorado, fol- lowing an equal period in New York, arrives at the same coni'lusion. From an experience of sixteen years in this Stuti- 1 feel warranted in asserting that both tubei'culosis of the uhmds .■uid bones is decidedly infrequent, the vast ma,joi-it\- of siidi |iHtieiils <'oiiiiii,ij, from a distance to avail themselves of climatic advantages. It is highly significant that amidst a large invalid population with innumerable children born of tuberculous parents, exceedingly few incUgenous cases of glandular tuber- culosis are observed. Even among a moderately large negro population, who in other regions exhibit not uncommonly tuberculosis of all the glands of the body, there are observed in this State but comparatively few instances even of localized glandular infection. It is reasonable to believe that a rarefied, stimulating atmosphere, with many hours of 432 COMPLICATIONS sunshine, should be more beneficial for individuals with diminished resistance than a climate teeming with fog, frequently saturated with moisture, thus permitting less opportunity for out-of-door recreation. Wai^dng at this time any extended consideration of the value of climate in the treatment of glandular tuberculosis, great emphasis should be added to hygienic management in the open air, with ample exercise, as an indispensable therapeutic factor, whether at the seashore, in the country, at the lakeside, or in the mountains. While the doctrine of conservative open-air treatment for cases of glandular and bone tuberculosis in children is accorded a general accept- ance in modern text-books upon surgery, it would seem that the present teaching as to the efficacy of fresh air, sunlight, and exercise is consider- ;ilil\- ill advance of the actual niethods coinmonhj practised by physicians ami -umiMins in assuming to chrect the destinies of these patients. It is HI It >\ilii( lent to advise in a perfunctory way that the child should be kept out-of-doors. The obligation of the attending practitioner is not dis- charged until he has urged, in an active personal capacity, the necessity of change to the country, the seashore, or the mountains, as may appear most practicable in indi%'idual cases. Further, the so-called ambulatory treatment in the open air is not alone applicable to cases convalescing from operation, but in many instances is equally appropriate for con- ditions formerly supposed to demand immediate operative interference. The vital consideration, irrespective of age, is the greater resistance to tuberculosis accruing from an outdoor existence in favorable climates, \\ith suitable provision for cUversion, recreation, and exercise. Apropos of the present conception concerning the vast importance of the purely hygienic principles of management, it is of considerable historic interest to re^^ew the practice in vogue in the early centuries, based upon an abiding faith in the efficacy of the kingly touch in the cure of scrofula. The antiquity of the belief has been established, together with a mass of almost credible evidence as to its value. In France the practice dates back to the time of Clovis in 481 A. D. In England this method of treatment was introduced by Edward the Confessor, who reigned from 1044 to 1066. The disease was commonly regarded as "a vice in the .sj-stem," and possible of eradication only through the purification afforded by the royal touch. Scrofula, there- fore, was popularl}' called "the king's evil." During a period of seven hundred years this custom was followed by the reigning monarchs of England and consisted of the laying on of hands. Henry the Seventh originated the plan of tj'ing a ribbon around the neck, to which was attached either a silver or a gold coin. Historians cUffer as to the per- formance of the practice by Mary, William, and Ann. It was believed by many people that these rulers did not possess the hei'ecUtary gift of healing, for the ascribed reason that they did not occupy the throne by Divine right. Writers of history assert that multitudes came from great lUstances to avail themselves of the wondrous benefits to be acquired through the sovereign touch. Charles the Second is reputed to have treated in the neighborhood of 100,000 people suffering from the king's e\il during a period of twelve years. Louis XIV. of France, upon Easter Sunday. 1686, is reported to have treated over 1600 people. That a not altogether implicit faith in the efficacy of the method was entertained by the French ruler is suggested by the words, "The king has touched j'ou, ma}' God cure you." TREATMENT OF GLANDULAR TUBERCULOSIS 433 John Browne, Chirurgeon in Ordinary to his Majesty of England in 1684, has written several treatises concerning "the real art of healing strumae by the imposition of the sacred hands of our kings of England and France given them at their inaugurations." Dr. H. F. Stoll has recently called attention to the interesting fact that although Browne lived in an age of superstition and frequently assisted the king in the ceremony of royal touch, he, nevertheless, stated in his writings that the malady was "no fictitious distemper or imaginary e\Tl, but rather a proper disease." In the light of our present knowledge regarding the probable elas- ticity of the term " scrofula' ' as then applied, and also concerning the beneficial effect of travel, life in the open air, and buoyancy of spirits, it is not unlikely, as Halsted suggests, that the prolonged pilgrimages from remote points, the protracted journeyings in the open air, the invigoration incident to changed surrounding.s and renewed hope, served effectually to delude the sufferers as to the efficacy of this supernatural method of healing. Medicinal Treatment. — For many years the purely medicinal treat- ment of glandular tuberculosis has related largely to the administration of iodid of iron and cod-liver oil. With no desire to detract from the undoubted value of these remedies, in a large majority of cases it is, never- theless, true that the benefits to be derived from their use are decidedly inferior to the results afforded by general hygienic management. Medi- cinal agents of any kind are not indicated invariably in these cases, and when employed at all, should not be prescribed in accordance with a conventional or routine method. Attention to digestion is of the utmost importance. The correction of such disturbances through diet- ary precautions and medicinal aids is of much more value than the administration of cod-liver oil, arsenic, or the ferruginous tonics. The appetite is usually capricious at best, and the digestive function more or less enfeebled. In such cases the indications point more to the consumption of greater quantities of nutritious food than to enforced dosage with drugs. In the absence of distinct contraindica- tions, however, it is excellent practice to use the syrup of the iodid of iron, alternating occasionally with Fowler's solution, given well toward the limit of toleration. The various preparations of iron, manganese, cod-liver oil, or easily cUgestible fats are often of undoubted value, pro- vided that appetite and digestion are not impaired. Aids to nutrition in this, as in other forms of tuberculosis, may be expected to increase vital resistance. Specific medication of unquestionable merit, applicable to all forms of glandular and bone tuberculosis, has recently been employed. The administration of the bacilli emulsion of Koch to cases of glandular tuberculosis opens an entirely new therapeutic field and is, perhaps, destined to yield gratifying results in many cases thus far but little amenable to management. Wright's work adds confirmation to the value of this agent as applied to nearly all cases of surgical tubercu- losis. Although his reported results suggest the predominant value of the new tuberculin' in cases preisenting a localized focus of tuberculous infection, as in tuberculous bones and joints, highly satisfactory results are sometimes obtained in carefully selected cases of pulmonary tuber- culofsis. With the addition of the bacilli emulsion to the armamentarium 434 COMPLICATIONS of the physician, the future of children afflicted with enlargement of mediastinal and mesenteric glands is rendered somewhat brighter. After a provisional establishment of the diagnosis by the sidjjective and objective signs, together with the use of the x-ray, ample justification is afforded for the cautious administration of the tuberculin. LOCAL MEASURES Local efforts, limited to the cervical glands, relate to — (1) Non- operative measures, embracing counterirritation, massage, electrolysis, the J"-ray, and (2) surgical procedures, including aspiration, interstitial injections, incision, and drainage, with or without curetment or cauteriz- ation, and, finally, complete excision. Local non-operative measures should consist primarily of efforts to remove, as far as possible, all sources of infection. It is of essential importance to investigate the condition of the tonsils, pharynx, teeth, nose, ears, and scalp. Hypertrophied tonsils containing deep crypts should be removed immediately. Excellent results are sometimes obtained by painting the tonsils and posterior pharynx with solutions of iodin containing potassium iodid. There is no doubt that l)enefit is obtained by the use of chsinfecting, stimulating, and astiiugent applica- tions to these parts. Attention should be given to catarrhal comlitions of the nose and inflammations of the ears and scalp. Stark and Koerner, according to Dr. Leonard Freeman, found decayed teeth in 41 per cent, and 73.8 per cent, respectively in their cases of glandular tuberculosis. Counterirritation by ointments or stimulating solutions containing preparations of iodin, ichthyol, and resorcinol is still extensively em- ployed, although its utility is extremely doubtful and quite unsus- tained by practical results. The use of these external applications must be regarded rather in the nature of a placebo, but the necessity for such practice seldom exists. In addition to the negative effect there is usually entailed a loss of valuable time before the institution of rational measures, during which period the patient is exposed to the constant danger of further infection. Massage of the glands is unworthy of other than condemnatory men- tion. The practice of manipulating the structures is distinctly danger- ous upon the score of increasing the possibility of further dissemination. Electrolysis has been found uniformly ineffective, its employment being based upon the densest ignorance, or constituting a form of unjustifiable deception. The x-ray is of undoubted efficacy in the treatment of many cases of cervical adenitis. I have seen tuberculous glands of large size tiisappear entirely under the systematic employment of this agent, but it should be borne in mind that such method of treatment is applicable only to carefully selected cases, as there are certain limitations and restrictions even to its special emploj'ment. Its practical utilit_v is dependent largely upon the discrimination exercised concerning the character of cases to which it is applied. Its successful u.se does not depend so much upon the size of the gland, as upon the nature of the pathologic structure. It is of special value when the glands are firm, adherent, and devoid of any apparent inflammatory condition. In the presence of softening or caseation, however, the remedy is ineffective and involves an unnecessary delay before the patient is accorded the benefit of much- TREATMENT OF GLANDULAR TUBERCULOSIS 435 needed surgical interference. Under such conditions there is no pro- motion of alDsorption by the x-ray, and, therefore, no positive diminution in the size of the enlargement. Inasmuch as it is sometimes extremely difficult to determine with accuracy the pathologic state of deep-seated tuberculous glands, it follows in doubtful cases that failure to secure positive results from the x-ray after a few weeks' trial should be accepted as definitely conclusive of their inefficacy. A well-founded suspicion of softening is sufficient to contraindicate even its initial employment. The value of x-ray exposure, however, is conceded following extirpation of glands, the post-operative treatment being worthy in all cases of careful consideration. Despite a seeming thoroughness of the oper- ation, a glandular swelling not uncommonly reappears in the imme- diate region of the wound. Such possibility is somewhat more remote provided several exposures of the x-ray are permitted once or twice a week following the operation. In the event of a renewed glandular enlargement the systematic employment of the x-ray is indicated prior to an immediate repetition of the operation. It is hardly necessary to add that treatment by this method should be received only at the hands of a skilled and experienced radiographer. Care should be taken that the decision concerning the character of the treatment, whether of surgical nature or by means of the x-ray, should not be made upon the basis of the presence or absence of a resulting scar. Too often parents and physicians are prevailed upon to discountenance operation, and elect the x-ray form of management through fear that a disfiguring scar may follow complete excision. It cannot be impressed too strongly that this is an entirely subordinate consideration, and should have no place in the mind of the medical attendant in a decision as to the choice of procedure, even with reference to the female sex. As a matter of fact, unsightly appearances, especially capillary dilatations in the form of telangiectases, sometimes result when under the care of competent radiographers. The reader is referred to plate 1 1 , representing the dis- figurement occasionally observed from the use of the x-ray. Upon the whole, while the utility of the x-raj' for the treatment of a class of tuberculous glands has been fully demonstrated, its exact place from a therapeutic standpoint must still be regarded to some extent as sub judice. Surgical Procedures. — Among the purely surgical procedures should be mentioned especially incision with drainage and complete extirpation. Aspiration of the fluid contents, with or wdthout the later injection of various preparations, has been attended with almost invariable dis- appointment. Solutions of iodin, phenol, alcohol, silver nitrate, guaia- col, camphorated naphthol, balsam of Peru, cinnamic acid, iodoform, and zinc chlorid, when injected into the tissue of the gland, often produce considerable discomfort, and at times give rise to dangerous symptoms. Nearly fifteen years ago I tried in several instances the injection of iodoform dissolved in ether, and in one case suspended in olive oil, with, upon the whole, unsatisfactory results. At best this practice is regarded as unwarrantable. It is distinctly evasive of the more immediate indi- cations, and involves a continvied waste of time, which sometimes con- stitutes as well a loss of opportunity. Simple incision is indicated in cases of acute glandular tuberculosis exhibiting unmistakable evidences of softening. As soon as suppuration 4d0 COMPLICATIONS occurs and is rendered possible of detection by fluctuation, the at however small, should be opened. The incision should be of no greater length than necessary to insure complete evacuation of the pus and sub- sequent drainage. In order to render the scar but slightly conspicuous, surgeons should open superficial abscesses, when possible, by a horizontal incision, thus insuring its concealment by the collar. The horizontal in- cision is also preferable to the longitudinal, for the reason that the re- sulting scar is less likely to be reddened and hypertrophied on account of the diminished traction incident to the frequent turning of the head. If the abscess is deep, the direction of the incision, however, must be determined with reference to the position and course of the blood-vessels, surgeons prefering an olilique downward and forward incision at the upper part of the neck, but a transverse one in the lower portion. Pre- caution should be taken not to insert the knife too far into the tissues of the neck. Either a pair of blunt -pointed scissors or a grooved cUrec- tor should penetrate the fascia in a search for the suppurating cavity. After the insertion of the scissors or forceps into the abscess, the fascia should be torn and stretched by withdrawing the instrument opened, thus avoiding the danger of injury to immediate structures. Curetment is sometimes employed, especially in cases of large abscess formation, and is particularly applicable to gland sinuses with a probable mixed infection. When prolongetl anesthesia and radical surgical intervention is precluded by the general condition, it is occasion- all .y permissible to attempt the disintegration of glands by this process, the results varying according to the thoroughness with which the glandular tissue is scraped away. To remove this entirelj' without penetrating the adherent capsule is well-nigh impossible, while considerable traumatism may result, not only involving possible injury to immediate blood- vessels, but also producing a rapid extension of the tuberculous infection to other parts. Mayo recommends the application of iodoform emulsion or tincture of iodin following incision and curetment, and an immediate closure of the incision in order to avoid prolonged drainage. Sinuses are stimu- lated with phenol in order to effect as complete sterilization as possible. Gould prefers the application of a solution of zinc chlorid, 40 grains to the ounce, as an efficient germicide. In many cases it is sufficient to pack lightly the cavity wth iodoform gauze for a few days. The oper- ation is simple, necessitates but a small incision, and leaves, as a rule, no disfiguring scar. There is but little danger of penetrating the cap- sule and. injuring veins, arteries, or nerves. pro\ided a blunt spoon curet is employed. The deficiencies of the operation relate to its un- reliability and the possibility of further tulaerculous extension. Total excision of tuberculous glands is, in the majority of instances, the operation of choice. This time-honored procedure is said to have originated with Galen, and to have lieen employed by Par6. It is of some interest to note, however, that for several hundred years up to the latter part of the nineteenth century, the attempt to remove enlarged glands of the neck was quite uniformly deplored, (^ooper, in 1815, objects to the practice " becavise tlie removal of a scrofulous gland can hardly be said to do much good to a patient whose whole system is under the influence of strumous enlargement." Druit, in his "Modern Surgery," published in 1841, states that "it is sometimes expedient to extirpate one or more glands." but deprecates such effort in nearl_v all cases. Miller, in his " Principles of Surgery," published in 1853, says: TREATMENT OF GLANDULAR TUBERCULOSIS 437 "It is almost unnecessary to state that chronic enlargements of lym- phatic glands by tuberculous deposit in the neck are not to be made the subject of severe operation, discussed, they may be, or by suppuration they may be broken down and extruded, but extirpation is, in truth, but reckless and unwarrantable cruelty, injurious to the patient, sur- geon, and surgery." Erichsen and Ashhurst, in 1869, state that "exci- sion of enlarged cervical glands is seldom necessary, and advise against undertaking the operation unless the disease has been of many years' standing and the glands very large." In 1873 Hamilton, in his " Prac- tice of Surgery," says: " Excision has in all cases been followed by a speedy return. After the most thorough extirpation, new glandular enlargements have soon been presented." He urges the limiting of operation to cases "in which only one or at most only a few adjacent glands are involved, and then not until the size and relation of the tumor immediately imperils life." In 1881 Savory and Roberts, in Holmes' " System of Surgery," state: " Should the tuberculous gland be removed by operation? Hardly ever. The operation can be justified only when the glands have remained for a very long time stationary in spite of all local measures and constitutional treatment, and when it is an unsightly deformity or not connected with diseased glands more deeply situated." Such teaching in comparatively recent years, denying the rationale of complete excision of tuberculous glands, is somewhat startling in view of our present knowledge regarding the relation of lymphatic enlargements to pulmonary tuberculosis and general miliary infections. Groben, after an analysis of the statistics of several clinicians, reports that pulmonary tuberculosis developed in 75 per cent, of all non-operated cases, and in less than 15 per cent, of tho.se undergoing excision. The conclusions of other observers hardly bear witness to these results, but the evidence remains irrefutable that the proportion of cases developing other foci of tuljerculous infection is much larger in patients denied the benefit of active surgical interference. In this connection it is of much interest to read the remarkable words of John Browne, of whom mention has been previously made, apropos of healing by "royal touch,' ' as quoted by Stoll. In the seventeenth century he says: " These tumors do require extirpation and extraction. . . . to be so dexterously performed as that no part be left behind. . . . Our greatest advice in the use of the knife is to have a particular and special care to the vessels bordering upon the parts, namely, the nerves, veins, ;ni(l aileries, lest they be injured thereby. The glands are to be cxt i^i.lcd with great care and caution, so as no ve.s.sel whatsoever be injured l>y tlie operation; and if any flux of blood may happen in this operation, it is presently to be stopped with restrictives, and this method is to be prosecuted till every part of the cystus or bags thereof are perfectly and thoroughly eradicated and extracted, the which being done and the part clean, mundifie the ulcer, digest, incarn and then induce a cicatrix." It is scarcely witliin the province of this book to elaborate the technic of the operation. It is sufficient merely to call attention to several important considerations in connection with the principles of surgery as applied to glandular tuberculosis. A large proportion of cases of cervical adenitis are suited to radical operation. The existence of a moderate pulmonary infection does not in itself offer any distinct contraindication for operative interference. If the pulmonary involvement is not far advanced, the indications for oper- 438 COMPLICATIONS ation are emphasized by the very fact of its existence. Added oppor- tunities for recovery are offered by virtue of the removal of an important and often primary focus of infection. The supposed danger of anes- thesia to the consumptive has been found by actual experience to be largely a myth. I do not recall a single instance of unfortunate results of chloroform or ether anesthesia among the many phthisical patients undergoing operation for various causes. Complete extirpation of tuberculous glands is often one of the most difficult and techous operations which the surgeon is called upon to perform. It should not l)e undertaken by other than those possessing an excellent technic and thorough familiarity with the anatomic rela- tions. A most important con.sideration is the complete and thorough removal of all affected glands. To this end search must be made patiently and carefully in the midst of highly important structures for almost innumerable glands not originally detected. Much has been written about the advantages and cUsadvantages of the various forms of incision. Some surgeons recommend several small ones, either oblique or transverse; others urge large sweeping incisions, either of the letter Z or letter S shape, or conforming to a simple transverse curve across the upper portion of the neck. No conventional incision is applicable to all cases. The essential desider- atum is to have plenty of room, and this demands a large opening, extending in many cases from the mastoid to the clavicle, regardless of subsequent deforming cicatrix. To avoid injury to important parts the dissection should be made as much as possible with a blunt instru- ment. Care should be taken to remove the glands intact without rup- ture of their capsule, in order to prevent all danger of disseminating the infection through contamination of the wound. This possibility, together with the danger of injury to nerves and blood-vessels, repre- sents one of the cUsadvantages of the operation. Its thoroughness, however, more than offsets any objections incident to its severity. It is essential to remove with a wide excision all gland-l^earing fascia. A subcuticular suture will lessen the prominence of the scar. Further discussion of the surgical details is inappropriate in connec- tion with a work devoted to pulmonary tuberculosis. It is permissible to allude briefly to the danger of wounding veins, arteries, and nerves. The chief parts liable to injury are the jugular vein and the spinal accessory nerve, together mth the pneumogastric, phrenic, laryngeal, sympathetic, and the facial. A somewhat unique accident, occurring in the course of oper- ation, came under my observation seven years ago. A young man consulted me in January, 1900, with reference to a tuberculous enlarge- ment upon the right side of the neck the size of a hen's egg. He had been operated upon in 1891 by Dr. W. T. Bull, who removed a large ma.ss from the left side. I advised immediate operation for the right-sided involvement, and referred the patient to Dr. Powers. The patient, however, after some delay submitted to operation at the hands of a surgeon in another locality. I was not present at the operation, but was informed subsequently that there was profuse hemorrhage and that, by means of an aneurysm needle, the deep ves.sels were tied with heavy silk ligatures. It was found impossible to complete the operation after this on account of the collapse of the patient. Upon recovery from the anesthetic there were distre.s.sing spasmocUc cough and aphonia. The severe cough was practically constant for several days, while the loss of TREATMENT OF GLANDULAR TUBERCULOSIS 439 voice persisted for some weeks. After a gradual subsidence the cough was quickly excited at all times by gentle pressure in the region of the wound. About five weeks subsequent to the operation the patient again came under observation and the further management was directed by Dr. Powers, who reported the case at length. On ac- count of the unsatisfactory condition of the patient, it was not thought wise to attempt any surgical interference until January of the following year. Powers reports: "The scar on the right side of the neck was exceedingly irritable, even slight pressure at any point in its upper third occasioned severe spasmodic coughing. Nearly a year following the previous operation the end of a heavy silk ligature presented at the upper end of the sinus. Traction with an artery clamp occasioned intense coughing, pain, shortness of breath, and vomiting." During the operation, which followed shortly, the loop of the ligature was found surrounding a large mass of granulation tissue, in the midst of which lay the pneumogastric nerve. "The slightest interference with this portion of the wound and the slightest traction of the ligature brought on alarming coughing and cyanosis." The patient made a good recovery. Some months after the operation the tendency to cough upon pressure at the site of the wound almost disappeared. During the last few years his recovery has seemed apparently complete, until a recent appearance of glandular enlargement, for which the bacilli emulsion is bein;"; administered at the present time. The tendency to recurrence should always be borne in mind. Mayo has pointed out that the term recurrence is used improperly in that the enlargement is due to the growth of new glands, rather than to an impossible re;i.i>i)oaiaiico of glands once removed. It should be made clear to the patient and friends that the excision of enlarged glands offers no positive assurance that other glandular structures previously quiescent may not come to the front in due time, and present them- selves in the neighborhood of the former site. The percentage of recur- rences varies from about 25 to 70, as reported by several observers. Mayo reports that during the past four years there have been operated in Rochester 235 cases for primary tuberculous enlargement of the glands, and but 15 cases for secondary involvement. The return of the trouble is not always due to a lack of skill or knowl- edge on the part of the operator at the time of the initial operation, nor is it dependent necessarily upon an impaired condition of the patient. I recall the case of a young man who consulted me in 1896, imme- diately upon arrival in Colorado, on account of moderately enlarged tuberculous glands of the left side of the neck. There was no evidence of tuberculous lesion elsewhere, the general condition was unusually robust, the patient was plethoric, and nutrition was unimpaired. An operation which lasted several hours was performed very patiently and skilfully by Dr. Edmund J. A. Rogers. During the next few years four different operations were performed by the same surgeon for enlarged tuberculous glands upon each side of the neck, the general condition remaining unimpaii'ed, with no evidence of tuberculous infection in other parts of the body. Enlarged glands continued to appear, how- ever, with but little delay, following each operation, and there finally developed an acute miliary infection which terminated his suffering. It is a reasonable assumption that had this case been observed after the discovery of the x-rays, better results might possibly have been obtained from their employment as a postoperative procedure. COMPLICATIONS SECTION V Tuberculosis of Bones and Joints CHAPTER LXIII ETIOLOGIC AND PATHOLOGIC CONSIDERATIONS The etiology of tuberculosis of the bones and joints is not especially different in its essential characteristics from the conditions giving rise to involvement of other parts of the body. The pathologic condition is due primarily to the presence of the tubercle bacillus in the affected part, although the manner of its introduc- tion to the seat of the disease is not always entirely clear. A somewhat obscure conception as to the precise method of infection, arises by virtue of the supposed protection of the parts from an anatomic standpoint, the dense structure, the frequent sharp localization of the diseased area, and the failure to discover a possible neighboring focus of tuberculous infection. Further confusion results from the promulgation of the theory of a strong hereditary influence in determining the development of the disease. The acceptance of certain clinical data also affords ground for -nidely tUffering opinions regarding the etiology. It is well known that the great majority of cases of tuberculosis of bones and joints develop in early life. Billroth reports one-third of all cases to have occurred during the first ten years of life, and one-half before the twentieth year. Wliitman reports, out of a total of .5461 cases of tuberculous di.sease under treat- ment at the Hospital for Ruptured and Crippled, that seven-eighths of the patients were under fourteen years of age and that 85 per cent, of those recently treated were in the first decade of life. The fact remains, however, that it not uncommonly develops among apparently strong and healthy individuals without any evidence of preexisting tubercu- lous disease or other assignable cause. I have had occasion to note, in a rather surprising number of cases, the .so-called idiopathic devel- opment of tuberculous processes in bones and joints among adult robust farmers and others accustomed to physical acti\aty in the open air. The r61e of trauma, with or without penetrating wounds, consti- tutes another etiologic phase susceptible perhaps of varying interpreta- tions. Slight concussion without visible wountl has been followed by distinct infective processes, w'hile severe contu.seel or penetrating injuries have often occasioned no evidence of tuberculous bone lesions despite the pre.sence of apparently similar conditions. Incised wounds have been known to heal promptly with the speedy subsequent appearance of a localized tuberculous process in iniiividuals presenting every external appearance of vigorous health. On the other hand, invalids with advanced pulmonary tulierculosis rarely develop bone or joint lesions. Further, the parts most frequently affected are those least liable to external injury. Tuberculous lesions of the lower ETIOLOGIC AXD PATHOLOGIC CONSIDERATIONS 441 extremities are observed much more often tlian of the upper, although the latter are far more likely to undergo injury. Upon the basis of the above established truths it is somewhat diffi- cult to formulate a consistent theory as to the precise method of invasion of bones and joints capable of application to all cases. A studious analysis of the available data upon which to base con- clusions justifies the assumption that in the majority of instances the affection of the bones is secondary to an antecedent tuberculous focus, and that the involvement of the joints is in most cases a simple peri- pheral extension from a tuberculous osteitis. It is undoubtecUy true, however, that local tuberculous processes may sometimes originate within the joint without previous involvement of the bone. Primary tuberculosis of the synovial membrane is described by various observers, and is believed to be a not uncommon condition of the knee-joint in adults. It is reasonable to assume, however, from the observations of Nichols, that painstaking investigation would disclose the presence of foci in the osseous tissues antedating tlie joint involvement. Contrary to the opinion entertained by many that the infective material is conveyed to the part through the circulatory channels, it is held that the route chiefly traversed by the bacilli is along the lymphatics. Were the vascular system the chief medium for the distribution of the infective agent, it would be natural to expect a more general involvement. Neither failure to discover a previous tuberculous focus in the neighbor- hood of a bone or joint lesion, nor absence of a visible infection atrium in the skin affords any valid argument in favor of the primary nature of the process. That infections, metastatic in character, may take place in these parts via the lymphatics and circulatory systems is illustrated by the observation of joint disturbances in rheumatism, gonorrhea, and toxic arthritis. However, in all these affections the frequent localization of the process in a single joint strongly suggests the rather predominant in- fluence of the lymphatics as compared with the vascular channels. It is scarcely necessary to recognize definitely the site and method of inva- sion or to demonstrate the presence of antecedent tuberculous foci as points of departure of l^one and joint lesions, in order to substantiate their secondary character. It has been shown in previous chapters that glands may present every external appearance of a normal condition, and yet contain imprisoned bacilli constituting latent foci of infection. It is easy to conceive that under a quickly developing inflammation attending such acute infectious diseases as diphtheria, measles, scarlet fever, and whooping-cough, the glandular tumefactions may be suffi- cient to produce a rupture of the capsule, giving rise to further tuber- culous dissemination, and yet disclose no subsequent macroscopic evidence of involvement. Cornet has quoted the results of 67 autopsies performed by Konig- Orth. In 53 cases, or 79 per cent., there were found tuberculous lesions besides the bones and joints, but in 14 cases no other tuberculous foci were discovered. The lungs were involved in 37 instances, the glands in 21, and the genito-urinary apparatus in 9. He also cites Bollinger's and Unger's statistics with respect to the frequency of hereditary transmis- sion, the former reporting a direct inherited taint in 97 out of 2.50 cases, the latter in 11 out of 54. These proportions are much smaller than the 442 COMPLICATIONS reported experience of many observers. In Bollinger's statistics a his- tory of tuberculosis was inclusive of the four grandparents, as well as the" father and mother. The frequency of tuberculosis in the parents of children afflicted with bone or joint lesion is certainly much greater among the cases that I have been permitted to observe in Colorado. I can recall but few instances of bone or joint infection in children up to seven or eight years of age, one of whose parents was not the subject of a non-arrested pulmonary tuberculosis at the birth of the child. In almost every case in which this was not true one or both parents were victims of some other cUsorder impoverishing nutrition and gi'eatly im- pairing vitality. The theory that the influence of herecUty relates to a diminished cell resistance rather than an imparted disease is not restricted in its application to the existence of tubercido.sis. It is clear that a de- ficient vitalization with increased vulnerability of tissue may be imparted at the time of conception as a result of other debilitating conditions. During the first few years of life, at the very age when glandular tuber- culosis is most likely to develop, the combative phagocytic power of the ceils is less pronounced than after growth has been attained. The child has emerged from the successive periods of undue susceptibility occa- sioned by repeated digestive cUsturbances and acute inflammatory con- ditions of the nose and pharjmx, inclucUng hypertrophied tonsils and adenoids. Finally measles, pertussis, scarlet fever, bronchopneumonia, recurring bronchitis, and influenza produce a general enfeeblement of the system, and excite latent tuberculous foci to renewed activity. In other words, the occurrence of tuberculous bone and joint lesions during early life is the direct and demonstrable result of a preexisting focus of infec- tion, from which points of departure are jjermitted through lowered indi- vidual resistance. At this age the latency of tuberculous infections is maintained with more tlifficulty, as the natural constructive processes are less pronounced, the lymph-spaces more permeable, allowing more ready distribution of bacilli, and the vulnerability of the tissues definitely increased. The prevalence of tuberculosis in infancy and childhood, together with its excessive fatality, affords a priori a rather convincing argument as to the verity of Behring's theory regarding infection through the intestinal tract at this age, and in many cases the persistence of latent foci to adult life. The origin of local bone and joint tuberculosis in adult years is often traceable to trauma. Whitman alludes to the experience of Hildebrand, Konig, Mikulicz, and Bruns. who report, out of a total of 3398 ca.ses of osseous and joint tuberculosis, 513 properly attributable to trauma. Krause has shown that the cancellous tissue is made more vulnerable to the action of tubercle bacilli following an injury. In but exceptional cases, however, is there afforded througii this means a tUrect gateway of infection. It may be assumed as an almost univer- sal condition that a means of invasion had already been established through some other channel, and that the cellular resistance had thus far been sufficient to hold the infection in abeyance. Through the influence of slight traumatism the defensive power of the tissue-cells is diminished by virtue of the new inflammatory con- chtion. If the injuiy is severe, however, the in\aders are repelled more readily as a result of the increased resistance incident to the excessive local congestion arising from the trauma. In this event the increased phagocytosis is somewhat analogous to that attencUng the ETIOLOGIC AND PATHOLOGIC CONSIDERATIONS 443 congestion produced by the so-called Bier treatment of chronic inflam- mation of the joints. The order of frequency of tuberculous lesions of the bones and joints, established by a review of the statistical reports of various institutions, shows the vertebrae to be affected in nearly one-half of all the cases, the hip-joint, in from 30 to 35 per cent., with involvement of the knee, ankle, wrist, elbow, and shoulder decidedly less frequent. The microscopic pathology of bone and joint tuberculosis is not essentially dissimilar to that obtaining in other parts of the body, although, owing to the greater density of the histologic structures, the process is of slower development than tuberculous lesions elsewhere. Circumscribed tuberculous nodules composed of individual tubei-cles are produced. Within the tubercle deposit are found cells of various shape, the epithelioid variety usually predominating. Masses of polynucleated giant-cells are also present. Bacilli are observed both within and with- out the various cells. Round-cells are numerous within the tuberculous structure. With increasing development of the tubercle, which takes place by extension in the periphery, retrograde changes occur in the center. With the appearance of polynucleated leukocytes a degener- ative process supervenes, followed by caseation and softening. As a result of the coalescence of numerous tubercles, each undergoing in the center degenerative change and softening, aliscess formation eventually takes place. The suppurative procrss rcincsciits, therefore, the center of the entire tuberculous mass, while a new tuberculous development takes place at the outer margins. Supjiuralidn results not solely from the action of the tubercle bacilli, but often fidiii tlie added presence of some other microorganism, notably, the staiihyldciH riis. The develop- ment of secondary or mixed infection is usually attended by greater infiltration of adjacent tissues and increased suppuration. Fibrous tissue metamorphosis sometimes occurs, inducing varying periods of quiescence of the tuberculous process. This may con- tinue as a partially arrested degenerative change in the bony structure, undergo calcification, or finally remain encapsulated as a cold abscess. Through the influence of an aggi'essive phagocytosis the destructive progress of the tuberculous bone lesion is sometimes interrupted. On the other hand, the tubercle deposit may produce softening and subsequent absorption of the bony trabeculse. With in- creasing formation of granulation tissue there ensues an osseous necrosis. Caries of bone thus established is associated with the detachment of destroyed portions which takes place either in small particles or in the separation of a definite sequestrum. As a rule, the tuberculous deposit occurs primarily in the short bones or in the extremities of the long bones. When the short bones are attacked, especially the phalanges and metacarpi, the tuberculous infiltration involves the medullary tissue, giving rise to the term tuber- culous osteomijelitis. In the long bones, as the femur and tibia, the deposit of tuberculous material takes place, as a rule, in the epiphysis or immediately adjacent to it. In caries of the ribs and vertebrae the initial tuberculous involvement is directly beneath the periosteum, pro- ducing erosion and sometimes extensive destruction of the osseous tissue. Bone tuberculosis occurring as a part of an acute general miliary infec- tion has but slight, if any, clinical interest. The process originating in the epiphysis of the long bones extends 444 COMPLICATIONS peripherally in all directions, and often advances to the articular or joint surface. The entire cartilaginous attachment occasionally becomes loosened and separated en inas.sc from the bone. In the event of infec- tion of the sjaiovial membrane there results a chffused infiltration of the surface and occa.sional nodular formation. With further degenerative change there is foimd a deposit of tuberculous granulations, with erosion of the cartilage, and progressive infection of neighboring tissues as a result of the capsule perforation. After this has taken place the second- ary changes in adjacent structures partake of fibrous tissue proliferation, which results in greater or less fusing of the muscles and tendon-sheaths, thus retarding still further the mobility of the joint. In adchtion to ad- hesions produced by the organization of fibrinous deposits there often ensues the formation of bony new-growth from periosteal irritation. Fluid may accumulate in the joint in varj-ing amounts, the exudate containing broken-tlown caseous material and sometimes flocculent coagula. Attention is called to the widely varying character of the joint lesions, which, as previously stated, are sometimes apparently primary in character. Both the prognosis and treatment are largely dependent upon the extent and character of the tuberculous involvement of the articular sur- face. In proportion as the synovial membrane of the articulation is thickened and the cartilage perforated will there be increased restric- tion of motion, added cUfficulty in securing arrest, and increasing dan- ger of subsequent tuberculous cUssemination through the retention of infective general detritus. CHAPTER LXIV CLINICAL MANIFESTATIONS OF BONE AND JOINT TUBERCULOSIS Early Symptoms. — The symptoms of bone and joint tuberculosis are worthy of separate consideration. The early manifestations of osseous tuberculosis affecting the long bones are often exceedingly indefinite. A sense of vague cUscomfort in the limb is frecjuently exper- ienced as an initial symptom. An enlargement of the bone is noted which is usually unilateral. Moderate tenderness is often present, and when marked over a circumscribed region, abscess formation external to the bone may be suspected. Tuberculous enlargement of the small bones, especially the phalanges, is often capable of very early recog- nition, the shape of the fingers being exceedingly characteristic. ' The affection is seldom confined to a single finger, the phalanges are chs- tinctly spindle sluxped, conforming to the appearance commonly ob- served in hereditary sj-philis, but the latter condition, as a rule, may be excluded by the absence of associated evidences of a specific taint. There is rarely pain, and but occasional abscess formation, in this variety of bone tuberculosis. In tuberculous periostitis affecting the rib, pain is sometimes, though not always, experienced. Suppuration is almost constant, and a small CUNICAL MANIFESTATIONS OF BONE AND JOINT TUBERCULOSIS 445 localized tumor is recognized. The skin is rec'dened, and fluctuation is present. In joint tuberculosis the swelling and pain may be acute in some cases and almost entirely absent in others. The pain may even be referred to points remote from the affected joint. The symptoms are largely dependent upon the degree and nature of the pathologic change upon the articular surface. Complaint may be made at first of but mere uneasiness or discomfort of the limb, without especial localization in the joint, this being particularly true of hip disease. As the disease progresses an effusion takes place, and limitation of motion, together with actual pain, results upon movement of the joint or the imposition of weight. Swelling of the affected articulation is noted upon in- spection, together with a relative increase of heat upon palpation in comparison with the corresponding joint of the other side. In adchtion to the physical evidences of synovial effusion sometimes present a general inflammatory condition, commonly described as doughy, is Fig. 114.— Cicat recognized in the immecUate neighborhood of the joint. More or less deformity takes place, and the limb assumes a position of partial flexion. Reflex pains are now more pronounced, though local tenderness is usually present. As the morbid changes within the joint advance to perforation or increased thickening of the membrane and cartilage, abscess formation results and even ankylosis. Generally speaking, the diagnosis of tuberculous joint lesions in chil- dren is confounded principally with that of rheumatism. Unfortunately, the tendency is quite common to regard many of these cases as instances of simple rheumatism, and much valuable time is lost before the patient receives the benefit of rational management. It should be remembered that single joint inflammation in children points strongly toward a lesion of tuberculous character. The slow onset, without immediate temper- ature elevation or acceleration of pulse, together with flexion of joint and muscular rigidity, also are almost conclusive evidences of tubercu- lous joint disease. 446 ( OMPLICATIOXS The prognostic considerations relate to the danger of further dissemination of the tuberculous infection, directly endangering life, and to the character of the local changes involving deformity, impaired function, and injury to neighboring structures. The probability of ex- tension of the tuberculous infection from bone and joint lesions is con- siderably less than the likelihood of dissemination from primary foci in the lymphatic glands and lungs. The influence of tuberculous joint lesions upon the ultimate prognosis is, of course, dependent largely upon the location of the diseased area, involving a separate consideration of the affected joints. It is manifeistly impossible in a book of this character to consider at length the clinical aspects of tuberculous affections of the various parts of the body. It is sufficient to call brief attention to some of the more salient features of caries of the spine and tuberculosis of the hip- and knee-joints. Caries of the spine, consisting of tuberculous involvement of the anterior portion of the body of the vertebra in various portions of the spinal column, is not only more frequent than other varieties of bone and joint tuberculosis, but is relatively more important. This is due to the pro.ximity of the cUseased area to highly important structures. The results of the affection are not confined in all cases to the immediate neighborhood of the tuberculous process. In some instances not only the thoracic and abdominal organs are involved, but often the entire body. The extent and character of the deformity and the degree of com- pres.sion of vital organs depend to a great extent upon the precise location of the disease in the spinal column — the nearer the middJe of the spine, the greater and more unfortunate the deformity. The dorsolumbar region is the portion most frequently affected. The proportion of involvement of the various regions of the spine is in the neighborhood of 60 per cent, for the dorsal, 25 to 30 per cent, for the lumbar, and 7 to 12 per cent, for the cervical. A concise review of the symptoms and signs of early Potfs disease should be of special interest to the general practitioner. The prevention of deformity and of the resulting eompres.sion of the thoracic and abdom- inal organs, with impairment of vital functions, is almost entirely depend- ent upon the early recognition of the condition. An angular projection has ever been regarded as the chief characteristic sign of Pott's disease, and the diagnosis has often been delayed until the enforced detection, by this means, of a destructive process already considerably advanced. As a matter of fact, the earlj' symptoms of the disease are sufficiently characteristic to permit a positive conclusion as to the nature of the affection long before there is encountered irregularity in the con- tour of the spine. Occasional complaint is made of pain produced by sudden jars, and referred not to the region of the vertebrae, but to the abdomen or thighs. This is often pronounced at night as a result of involuntary muscular movement. Upon examination of the spine an impaired mobility is at once detected, and constitutes a mo.st important diagnostic feature. The stiffness is produced ]:)y reflex muscular spasm, antl in part by an almost unconscious effort on the part of the patient to so adapt the position and movements of the body, as to insure the greatest possible protection to the spine. Thus attitudes are assumed which produce a change in CLINICAL MANIFESTATIONS OF BONE AND JOINT TUBERCULOSIS 447 the habitual appearance of the patient. There is an evident disinclina- tion to walk, with pronounced indications of physical weakness. The child frequently refuses to stand without support, and if compelled to walk, does so with slight flexion of the knees, careful tiptoeing steps, and with the arms partly outstretched in front, as if in silent appeal for immediate support. Tests to determine the flexibility of the spine demonstrate, in addition to the stiffness, the peculiar awkward attitude already mentioned, and changes in the contour of the spinal curves. The abnormal outline and diminished flexibility are detected when the patient is forced to assume an anterior bending po.sition. By means of this test a limitation of motion of a particular portion of the spine is found to take the place of a sweeping regular curve. The ability to stoop in a natural way to pick something from the floor is also materially diminished. In whatever method the cliild imdertakes to seize the object upon the floor it is noticed that the spine is almost invariably held without flexion, this attitude being particularly pronounced in involvement of the lower region. In such cases the child stands in an unusually erect position, with a beginning tendency toward lumbar lordosis. A slight unilateral limp may be noted as a result of psoas contraction from beginning ab- scess formation. This condition may be suspected if unilateral exten- sion of the thigh is considerably restricted. The child is held prone upon the table, and effort made to raise the leg with the pelvis immobilized by the hand of the examiner. The search for pelvic abscess, though important, does not possess, from the standpoint of early diagnosis, the significance of the other signs already enumerated, as many months usually elapse before its presence can be detected. Caries of the dorsal region of the spine is not especially different in many of its clinical features from that of the lumbar portion, the described characteristics of tuberculosis of the lumbar vertebrae being found, in the majority of instances, to obtain with but slight modifica- tions in the dorsal portion. In the event of involvement of the upper dorsal region the body is inclined somewhat forward, the head thrown back, the shoulders elevated, and the general attitude that of marked debility. A tendency toward the so-called pigeon-breast is sometimes noted. Slight catarrhal irritation of the bronchial tubes, as evidenced by varying degrees of cough, often coexists in these cases. The respir- ation is occasionally of a grunting character, particularly if the child is fatigued. Abscess formation in the neighborhood of the diseased verte- bra may be detected by the physical signs. Tuberculosis of the cervical region is usually attended by a peculiar stiffness in the neck. The head is often inclined to one side, but may be held in the median line in some cases. An evident disinclination is noted to rotate the head from side to side. Either the eyes are turned with the head immobilized in a fixed position, or the entire body is turned. In older patients the chin is sometimes supported by the hands. Without reporting further diagnostic features inappropriate in this connection, it is sufficient to reiterate that in the majority of cases the warrantable data for the establishment of at least a provisional diagnosis are ample before the recognition of visible deformity. This is illustrated by an instructive experience with an important case some ten years ago. The child was between two and three years of age when the mother 448 COMPLICATIONS noticed a disinclination to walk or stand, which she attributed to general weakness. After some weeks the head became inclined to one side and was persistently held in that position. The shouklers became slightly elevated, the chin depressed, with absence of rotation of the head. The awkwartlness and gait of the child were characteristic. The knees were flexed, and when compelled to walk, the hands were invariably out- stretched. The parents were disinclined to accept a diagnosis of spinal caries, and a fateful period of delay was maintained for seven or eight months, during which time a most unfortunate deformity developed both in the cervical and upper dorsal regions. In striking contrast to the preceding, attention is directed to a case of caries of the spine in an individual with arrested pulmonarj- and intestinal tuberculo.sis coexistent with parenchymatous nephritis. Fol- Fig. 115.— Case of fair. patient with advanced puln vCunipare witli radlugrapli, Fig. 116 lowing a period of one year's complete arrest of all tuberculous proc- esses, as far as could be determined, there developed a degenerative change in both kidneys, followed in a few weeks by sudden severe pain in the lumbar region, more intensified upon the right side than upon the left. There were marked rigidity of the spine, slight tenderness in the neighborhood of the sacro-iliac articulation, inability to extend the leg upon the flexed thigh with the patient upon the back, and other characteristic evidences of spinal caries. Segregation of the urine showed both kidneys to be undergoing a parenchymatous change, wiih the proc- ess more advanced upon the right side. Repeated pfl'orts to discover tubercle bacilli were unavailing. The question arose as to whether or not a tuberculous proce.ss in the right kidney might |i(issili|y cnnstitiite tlie immediate primary cause of the symptoms refpraliie to the spine with a subsequent tuberculous involvement of the bodies of the vertebra. It CLINICAL MANIFESTATIONS OF BONE AND JOINT TUBERCULOSIS 449 was_finally decided by Drs. Baer, Packard, Powers, and myself that the original diasnosis of spinal caries was correct. There was no angular projection, and the skiagraph shows no deviation from normal contour of the spine. point at which sacral Fig. 115 illustrates a pronounced dofr and lumbar caries and a. discli.'i i-in- im vation in Janiuuy, l'.!()7. Ili- pi linnii years' standing, following an aU;uk of a In May, 1906, after visiting various health rnuty in a patient with sacral -, uho i;iiiii. under my obser- '> ili-i':i-i' had been of four ipciidicitis without operation, ■esorts, he experienced marked 450 COMPLICATIONS pain in the neighborhood of the left sacvo-iliac articulation, with the sub- sequent development of a fluctuating tumor which was opened at once. The lower portion of the spinal column is seen to have undergone an abrupt curvature to the left. The accompanying skiagraph (Fig. 116) shows exten.sive necrosis of the sacrum with moderate involvement of the bodies of the second and third lumbar vertebrae. The .symptoms of tuberculosis of the hip-joint are almost always of very insidious onset, although they occasionally begin more or less Fig. 117. — Tuberculou.'* infectioi diseased area is indicated b.v t!ie arr formation. This patient died about tuberculous meningitis. nf the inferior part of the third hniibar vertebra. The ■. Note dark shadow above arrow resulting from abscess le year subsequent to the time of this examination from abruptly. The condition is recognized as an involvement of a single joint, thus affording a differentiation from rheumatism and other poly- articular affections. There is no invariable relation between the symp- toms referable to the joint and the general condition, although many patients are observed to present indications of more or less physical debility. Fever is present in some instances, but possesses compara- tively little diagnostic import. The early symptoms are pain, lameness, and iniii.-iiretl mobility of the CLINICAL MANIFESTATIONS OF BONE AND JOINT TUBERCULOSIS 451 joint, due to musi be absent at Mty si, me nf il between the uniouiit cif pai ing the joint. It is soiuet process involving tlie iiead the acetabulum. If there very intense. < >ften it is to the product iciii of ni-hi during the niulit is iHdduii ation of the nui.silcs, wliicl spasm. Pi it, and may dependence uige involv- ilcsti-uctive iiiirc pi-oiKiuiiccil (luiiiii.; slccj), ;iik1 gives rise (lies, which ha,\c liccu described. The pain d by spasiiindic cent lucl ions following relax- , during wukiiig hours, have served to protect the sensitive joint. The child does not always awake, but if aroused, rarely complains of pain or bad dreams, and does not exhibit evidences Fig. 118. — Incipient ttilirr irregularity in the upper pan .if each joint. Clinical symptom- taking the skiagraph, but were in this case evidently originated and by the greater amount of a of fright. In the early p:i of local pain or sensitixci however, these syin])tiiins extent. The pain is usuall jarring or manipulating th may take place. Lameitr early symptom of hip-joii less characteristic, the pati as pos.sible upon walking, of gait, with diminution in of the affected joint. The than the heel, and is sjicc cases there is a tendencv 'idle the I wciuli '(Ul\- 1 towai the disease there is but little admission 1 pressure. As the affection advances, l)ecome pronounced to a considerable rred to the knee, and is aggravated upon ). ^'a.lying degrees of remis.sion of pain of much more importance, even as an •asc, than pain. The limp is more or •in;: cil'si I \ci| to favor the joint as much ■c is a noiiccalilc stiffness or irregularity •iii;tii !„ „! .-iiini; is proihiccl by flexiiin and abihiction with in\\a,!'d !'(ilaa!(ii!, \\]\\i\\ pn-ilioi! \n iikhv a,.l\a,!!i\,[ c-ascs is \-(iliinta- rily assiinicil upon walkiuu. This is ai-i'iil!!pa!i!,'(l b\- ai! iipwai-d tilting of the affected side. When the lii!ib is apipajcni l\- l.n-thcnetl, the fold between the thigh and -hitcal lat i-^ l.-wci^ than ii< Idlow of the opposite side, and is less piduniinccd mi a<-c(i!int ni ihc llcxion of the thigh, ^^■hpn the limb presents the appearance of shortening, the glu- teal foil! is higher and shallower than upon the unaffected side, while Fig. 12U.— I uli.i. uh.ii- in!,., lion of tlie left acetabulum, llie Ui^east- ih uiduau-a in tlie skiagrapti by ttie Imliin -li:i,|,r.\ - wljicli are seen in the upper part of tlie acetabulum. Note the atrophy that has laki n |.|:ii i in lii.- left femur. This skiagraph shows the disease a little farther advanced than in npu-cnir.l m lUrs. 118 and 119. in front the vulva is elevated and the inguinal fold is deepened and lengthened. Atrophic changes in tlio muscles of the affected limb are almost constant, and aic espei iall\- pii nn niiiced in the thigh and gluteal region. Theatn.phy takes place siirpriMiidv early. Sui>i)uration ma\- (lenir liotli wiiliin :iiid without the joint, and give rise to external exideme- nl ali~ie-- lurmalicm, pus often presenting in the anterior and latei'al ivLjimi- <>l' ilie thi'^ih. Late in the course ol liip-jdini ili-ea~e actual shortening of the limb may take place. This (•iiiiditiiui. l!(i\\('\ cr, is of loiiipaiatixcly .slight importance in diagim-i^ on .■indunt nl its delaM'd iiLaiiifestation. In Figs, lis to 124 inclnsixe are shown the .serial stages of hip- joint disease from incipiency to recovery as disclosed by the .r-ray. 454 :'OMPLICATII)NS TIio t the van. hip-(li>ca Strict h' \\ TllC s essential lesions mentioned on p. -145. Atteiiti lyrical cxaiiiiiiatinn. the inctlKMls of ascertaining MHv tliaii any uiIut till icriailmis joint lc>ion, belong nam oforthopeilic sur!j,ei-\-. tuberculosis of the knee-joint cont'onn in their the siciu'i-al (lesciiptiou of tuliercrJous joint diiecteil to local swell- s/6 c£^\i. ^ Fig. 121 almost en pus from %. 121. — Active tuberculous disease of i entirely absorbed. A drainage tube is m the joint daily at tlie time of tiie ex i left liip-joint. ing, tenderness, pain, circumscribed temperature elevations, infiltra- tion of tissues, limitation of motion and flexion. The.se changes afford a fairly accurate characterization of the symptoms of knee-joint tuberculoisis. Lameness is usually present, the limp varying with the intensity of the inflammatory and destructive proce.ss. The swelling is produced by the pathologic changes in the neighborhood of the joint, in the synovial membrane it-self, and by the presence of moderate effusion between the articular surfaces. Motion is limited, and flexion is invari- CLINICAL MANIFESTATIONS OF BONE AND JOINT TUBERCULOSIS 455 Fig. 122.— Well-marked tulx femur. The disease in this case 1 is becoming established. Note tl iphy oi" tlie left femu Fig. 123.- use of the leg. i been absorbed are well shown 456 COMPLICATIONS ably present, as well as reflex spasm of the muscles. The degree of flexion corresponds largely to the acuteness of the infection. Other deformities of a secondary character may take place. The various femur has been absorbed. Firni boii acetabulum, permitting no moveraen displacements of the tibia upon the femur with certain other deformities are late manifestations of the condition, and do not require more than mention of their occasional existence in such cases. TREATMENT OF TUBERCULOSIS OF BONES AND JOINTS 457 CHAPTKPv LXV TREATMENT OF TUBERCULOSIS OF BONES AND JOINTS It is possible to consider but briefly the principles upon which is based the management of tubei'culdus bones and joints. Obviously, no attempt can be made to dis(•ll^s .^iiccial methods of treatment, par- ticular mechanical coiit ii\ .nirc,-. m dtho' icclniical features. The treatment musists, lirsi, i>i f;encial liy.uicnic ni:mai;omont , and, secondly, local nicasiuvs, which may be non-opera.ti\c or |imcl\ >iii-ical. General Hygienic Management. — The hy;;iciiic tivai incnt of tuberculosis of Ixmcs ;uul joints is i-. whcieas in other cases such inter- vention is permitted to take place at a time when the general vitalitv and condition of the lis-nes i[\v such as to insure not onlv a more rapid he.alin,-. but t,, le,-.,.n inat.a'i.aljy the Hk.'Hliood ,;f further tilbeivulon- dis>enunatioiu bi tlie excnt ol' lno,|ei-ate lil.rous tissue pruliferalioii aliout a tubercujcjiis focus, operatixc sui'i:( ly is attended with much less danger of geneial tubeiculou- iniection than when fresh open surfaces are brouglit directly in contact with in- fective material. The process of repair in su( li ca-i - i'oii-i-t< essen- tially of the indosure or incapsulation of the i uliei ( nloi,:- locu- ky a barrier of protective connective tissue. Absoiption, a- well a- elimiiui- tion through abscess formation, at tinie< \']:i\> an iiupoitaiit pait in an arrest of the Ji^ea.se, but the foi iicil ion ot uraiiulal ion ti-sm- m the l)eii])hery (p|" tlie diseu.sed area, and n- >ul>~e'iueni oi '^auu'ai on icsulling in den.se fibrous tissue development con-thutes natin-e':- const met i\-e efforts toward the aiav-t of the tuberculous h^-i-m. It must Ik- remem- bered that tlie condition is liihnriilosis presenting the same features of pathologv as the pulnioiiaiw affection, difteren.vs in tvpe, but, neveVt helc-s, si and ahordin- similar indications in the w: The reparative pr.ic.-ses ,-,!e accelerated inci-eased gener.-il \-il;ilii\- :]iid tlu' local essential consideration, therefore, in all fortify the .general condition by a conscii application of the principles of nutrition : air, with an abundance of nutritious food : increases the reparative forces to an e> therapeutic agent. In those cases in which the articular surface of the joint is not seriously involved, although an intact cartilage may be found to con- ceal an extensive destructive process in the bone, general hygienic .xllilulillL!. It i <., dn linct ject to 111,' s; ;i nie ,ples. ', '!'■' liagi'l ion t( iient. . the sistalice of tli e tis> lies. The ises is the ]il iniar V etto It to ions and s,)!) letlll dii'al d hv-iene, 1 .ife 11 a the open 1 opportunit\ ' loi' 1 ■eciea tion, ■ut unequalet 1 by any 1 jther 458 COMPLICATIONS management alone is sometimes sufficient to briii;: altont an ultimate quiescence, if not arrest, of the tuberculous pi i »(•-■. I!\(ii in cases in which the joint is involved to such an extent as \n pircliulc the control of the disease and to necessitate active sur.iiical intcixcntion there may be afforded, through a period of rest in the open :iii-, with enforced nutrition, a heightened soil resistance and a suitaMr prciiaiaiion for the surgical ordeal. The importance of the constilutiunal treatment, therefore, can scarcely be exaggerated, and equals in many instances the efficiency of all local measures of treatment, including the various forms of apparatus. The value of the general regime, aside from the immediate en- vironment and other features of management, is dependent upon the amoimt of sunshine and the number of hours in the day that the patient is in'iniiitcil to remain in the open air. As stated in connec- tion with the h\ wienie treatment of glandular tuberculo.sis, there is a conflict of opinion in regard to the relative ad^•:lntaL'os of the sea, coun- try, or mountain air. It is apparent tlnit ihi' -ci-ioa-i sanatoria upon the shores of the Mediterranean or the .-Vdnatir aiv haiilly siiital.)le for comparison at all times of the yeai- with re.-oii,- ii]mjii ilie Ailantic coast, on account nf dilTeriiiL: \\i\-ithei' con .lit ions. If the uodd elTecis in various locations are pidiluced to aii\- extent 1 >y the aindiint (d' sunsliine and other I'liinaiic cuiiilitiuiis artnr(liii- pictli~|iii itiou on the part of a large portion of our infant populatinu. tulx iculuus hdiie and joint lesions are remarkably rare. There is, Ijeyonil i|iH-ti(iii. dpcidedly less tendency toward sup- puration and active syiii|iidiii~ iliaii is ic]idit •.[ td evi^t in other regions. Actual experience lias denidiist rated a -hditer duratidii of the disease in Colorado and, as a rule, tlie attainiiieiit of better functional results. The details of an open-air regime, either within or without sanatoria, will 1)6 reserved for the Treatment of Pulmonary Tuberculosis. General medicinal measures are of but slight avail, though tonics and nutrients are sometimes indicated by an anemic, im])overished con- dition. The administration of the bacilli emulsion of Koch is now recognized to be of undoubted value for many of the.se cases, and promises to constitute one of the exceedingly important features of treatment. The local management of tuberculous joint lesions includes non- operati\c iiirasiitvs and active surgical intervention. The choice between iIk-c two lieneral methods of procedure depends upon essential diffei-eiire- ill till' I xjie of the disease, its acuteness, the extent of destruc- ti\'e cliaiiue, Idcatidii. inipairnieiii df i'linctidii. pi'esence of suppuration, especiallx- if a-~d(ialed willi ^ecdihlaiy iiilertion, the danger to life, existence of tiiberculous foci iu other parts of the body, and the age of the patient. The decision should rest not solely upon the consideration TREATMENT OF TUBERCULOSIS OF BONES AND JOINTS 459 of a single factor, but i-ather iijion a review of all the clinical features. It is essential that a wcll-sustaiiKMl estimate he made uf their l)earing upon the life of the iinlividual and the preservation of function. It is clearly the duty of the surjicon to lie i>rcpared to eniijluy all rational mea- sures with a wise discrimmat ion aicoiding to widely varying concUtions, to the end that life may be sa\cd « iihdut unnecessary mutilation. Treat- ment along the lines of <'onsci\ai i\r siii-,i;cry iia.^ been jiroductive of liiglily gratifying results, save in those instanrcsdcnia,ndi iiL::iinnici li, -it c opci^a-tive interference upon the basis of cci'lain I'linical or pal liolo^ic daia.. In the latter event meclianical contrivances arc as nnich out of phicc as amputation would be in favorable cases. When the exigency exists, however, there should be no hesitation even in sacrificing a liml) in order to preserve life. In general, it may be stated that in children with tuberculous bones and joints the field of operative surgery is comparatively limited. At this age the lymphatic sj^aces are more permeable and thcic is neater danger of (li-,-(inination of the disease. This is partirulaily true if operations aic pcrloi mcd before opportunity is affordc.l ior abundant fibrous tissue loiniaiioii about a tuberculous area. Fibrosis lakes place luucli nioi-e .|Uiekl>' aiuou- childi-eii than adults, onaccouni of ilie rapidly ioi'nun- i;i'anulat imi li-sue in eaiix' Hfe. Thus the process of repair is often siiHieieiil in I lie \'er\ \(iunii to insure such a degree of arrest of tlie tubeicuious picjcess as would be iiii|iossible in later life. At the same time, afler urowtli lias been atlained. exrision of a tuberculous area does not in\ol\'e the loss of as w'ulc a portion of healthy bone as is ti-iie in the lirowing tissues of cliildicn. Nichols has shown that there is an undoiibled tuberculous infection of bone, at least an inrh beNond the limits of its macroscopic a]ipparance, thus suggestim: the expediency of renio\iim a considerable |ioition of ap- parently unaffectei 1 lioiii' \\lieiie\-ere\c|sion is practised. Such a procccl- ure,unfortunatel\ , lii\(>l\csa sile of operation outside the |iroleiti\e barri- ers of fibrous tissue formal ion, ■iiiddoesa\va\-at on, -e with t he ad vantages derived from this source, to winch allusion has been made. .\,uain, it is questionable if it is always ad\isab|e to atiempi the .•oniplete lemoval of infected tissues. As a matter of lad, \\u' operation is often more or less incomplete at best, thou.-h atien.led by excellent I'esults, thus sug- gesting the important i-61e of the n.-itur.il repa,rati\e forces. Therefore, operations upon children, in whom the lou-t luctiNc ilToit- toward arrest are most pronounced, are to be aMnded on aone lesion is sec lai\ to other foci in the lymphatic glands. The removal of the sec lary focus is not followed by a complete restoration of health unless tiie surgical treatment is accompanied by so complete an elaboration of the principles of hy,i!:ieinc management as to insure the incapsiilation of the primary seat of dis- ease. In adults the primary focus is more likely to be quiescent, if not entirely arrested, and the extirpation, therefore, of the local secondary lesion, even of long standing, is less apt to he followed by renewed infection than in early life. Conservative measures, then, are to be employed in children whenever not positively contraindicated. Local non-operative procedures consist of the application of such varying forms of apparatus as will enforce rest and secure a degree 460 COMPLICATIONS of fixation and extension. As far as the local treatment is con- cerned, these three conditions constitute the essential desiderata in an effort to arrest the tuberculous process. Thus protection is also afforded against further injury, and suppuration rendered less likely. The ulti- mate preservation of the function of the joint is rendered more probable as the local irritation diminishes. Fixation of the joint, with complete rest and traction, not only lessens the joint pressure, but relieves pain and muscular spasm. Goldthwait chffers from the majority of orthopedic surgeons in believing that the joint should not be absolutely confined. He favors merely a limitation of function rather than complete fixa- tion. He limits the motion of the joint only to such an extent as will control the symptoms, and permits the use of the joint up to the point of toleration, believing that by this means there results less dis- turbance of the circulation and nutrition. In other words, he regards the principles of treatment of tuberculous joint lesions as closely analo- gous to, if not identical with, those involved in the management of pul- monary tuberculosis. He takes the position that the respiratory func- tion in the latter cases should be in no way restricted, and in order still further to increase respiratory effort, he advocates considerable activity in high altitudes, combined with special exercises along the lines of pulmonary gymnastics. His conclusion as to the wisdom of retaining a limited function of affected joints is entitled to an appreciative con- sideration, for his views are based upon an experience sufficient to carry conviction as to the accuracy of his opinion. The principles of treat- ment of the pulmonary involvement, however, as regards exercise, should not he accepted as belonging to the same category with those apjilicalile to affected joints. In one case the condition is purely local, not tlirectly involving the preservation of life, and subject almost entirely to mechan- ical principles. In the other, the \atal organs affected are constantly performing the function necessary for the continuance of life. Nearly all orthopedic surgeons agree that after the acute stage has been passed, with extension in the recumbent po.sition. limited motion may be cautiously permitted, pro^ided the diseased joint is jjrotected from bearing the weight of the l)ody. It is manifestly impossilile to discuss the relative merits of the various methods of securing rest, fi.\- ation, and extension for the tuberculous joint, or to enter into a con- sideration of the numerous special appliances, all of which aim to afford as much protection as possible to the joint. The purely technical con- sideration of mcclianical contrivances is strictly within the pro\ance of the ortlni]>('ilii- -uriieon. In (iiiiiraili-tiiiction to the employment of apparatus whose action is confined as far as possible to the restriction of motion, utilization is sometimes made of passive congestion without confinement of the joint. The so-called Bier treatment of t^iberculoii^ joints consists of the establishment, through mechanical means, of a localized passive con- gestion. The venous circulation is constricted by means of a rubber bandage above the affected joint, applied in such a manner as not to interfere with the arterial supply. In order to localize the congestion the limb is bandaged from its distal portion nearly to the lower part ol the tuberculous joint. The principle of treatment is based upon the clinical fact that pulmonary tuberculosis is seldom observed in people suffering from passive congestion of the huigs incident to cardiac di.s- TREATMENT OF TUBERCULOSIS OF BONES AND JOINTS 461 turbance. The vonous coniiostion is believed to increase phagocytosis, stimulate absDipiidn. dimiiiish the activity of the disease, and acceler- ate the fonnatiiiii nl' IiImous ussuc. Relief of pain and other beneficial results occasionally attend the employment of this method. It would seem that, if it be used at ail in the treatment of joint tuberculosis, it should not be permitted to suj^plant entirely the protection afforded by rest and fixation of the juint. The piiicly siii-ijinil procedures consist of amputation, excision of joint, eia-iiiii 111 I •, and the management of tuberculous abscess. Amputalion is iiccaMiiiKilly demanded in adults on account of complete orextensi\T(lcsli'Ucli(iii (if lioiir and a, ^i-cath- iiiipaii-eil i;riici'al resistance. The sacniir,. uf the liiiil, is .-penally indi.'al.'d if. in s].ilc .,f tlic bc-t of food and surroundings, the general condition is shown to grow progies- sively worse. Excision of the joint, which consists of the complete removal of the articular surface of the diseased bones, is not uncommonly practised in adults and si)nictiriii-s in childivn. Tlic iiHli<'ati(.n for tlic (i]icration is the known exlcai-ixc dcsl met imi of the art iiaihit ilii: surfaces, i-ciider- ing the joint iiiualy hopeless and jire.senting, at the same time, a constant nienarc to tho patient on account of the possibility of further tuberculous (hssciiiiii.at ion, Erasion or the renu.ival of a localized area of bone is sometimes possible without resorting to complete excision. It (iniM-ts ol tlie extirpation of diseased l>one tissue by means of knife, gouuc. cuni, cir scissors, followed by the free use of iodin, pure phenol, or alcohol, in order to avoid the danger of secondary infections or extension of the tuberculous disease. The treatment of tul)erculous aliscesses should vary to some extent according to the e^■i(l(■U(•(■s of general infection and the inijiaii'nieiit of function. In case of cousiileraMe teni|ieratui-e elex'atioii, with or with- out chilling, togethei- with a delerioiation in the geiii'ral coiidilion, incision and dl'aill:iuc should be perh.iaiied willi as tlioroU',:li disiiileel ion of the cavity as possilile. if. I.,,wever, the pivseiie ' the al.-eess occasions niei'ely an iniei'fereiice of lniicti( temic infection, elf'oHs towaid the reiiio\al n' : tion are to be enip|o>-ed bejoic resoriing to 1 tion is prefer.aMe in sncli e;i\(t. that s\ich irritants as alcohol and tobarco have an c.^pcciul predi.sposing inlhieuce upon the development of tlir local idinliiion. The to?igweislessfnM|Ufntly imoUcd upon its upper or lower surfaces, the tip and lateral niafiiins bcini: t lie most com moii seat of the tulicrcio de- posit. The process is usually, p iti^ supeificial. cnnsi.t in- of inlilt r.ation or shallow ulceratic a IS. 'I'lie outlnie. as a fule. i,- irivuul.ai'. and the eilges are sli?htlv beveled. Small v.'llo\\ish-i:Tav spots nia\- be discei'iie. I here and there'upol. t he iv.ldisl, . -r.auulat m- sui'lac. Tlieiv is but litllesin'- roundiim- induration, altliouuli .aitei' c.uii|ileie lacal I'iz.at icai this is some- times noted. The pinii and oilier sul.jecti\c ,s\inptoins are, as a rule, comparativelv sli^lit, in contradistinction to llie ilisc.jmlori and suffer- ing e-xperience.l in the event of t ubiaviilous imol \ vnieiit of the soft palate, ton als.and ]iliaiyii.\. Seldom is there found a secondary enlarge- ment of the i'er\ical ulalids. Tuhi iriil(isi.-< <>/ tin ijiniis conforms in general to the type of lesions found upon the tmimie and hard j^alale. the infection being, as a rule, relatively l)cni,nn. \\ hile -iipei(i( i.al |e, ions |)re(|oniiiiate, deep tuber- culous uicerat ion occasionallx takes place. i,e\y lias recently shown a typical deep ulceratK.m extending tu a necrotic alveolar process, the diagnosis being confirmed by examination of the infected tissues, in which were found well-defined tuliercles and few tubercle bacilli. He has also exhibited a series of very interesting tuberculous lesions, involv- ing the hard ]).alate. soft iialate, and i(in-ils. Tuberculosis of the lips is very unconnnon. and corresponds more or less to the slow benign variety of tuberculous lesions of the skin, i. e., lupus vulgaris. Unlike tuberculous affections of the pharynx, soft palate, or tonsils, the lesions are pos.sessed of but very slight importance, as they influence almost to no extent the general j^rognosis. Tuberculosis of the .sop piiloli ii,iii\ .ire involved, a beginning pallor is usually observed, with or ^\itliout a slight edematous swelling. With the thickening of the mucous niemlnane there may be noticed the appearance of small tubercles, which are seen as tiny j-ellowish-gray (■>~arilv results lVi)m -a. Sc vri'al times I i;,,i, 1 |iliai'}-iix in 1 \ >lll!ll ' Kcccn tly there has >li-ht 1 riss of weight IdUS lllc( -ra-tion of the .n-l„.|n re imlniniuuy (■ rlu.>t (liselose.l the ■ticill Ul latlericlea by 464 COMPLICATIONS spots. Ulceration soon takes place, attended with pain, which is espe- cially severe upon deglutition. The local condition is often an accompaniment or expression of a general miliary invasion. It may (n-cur, however, in the latei stages of pulmonary tuberculosis, when the sticimih of tlie patient is well- nigh exhausted, and the retention of simtiini in the pharynx is favored by benumbed local sen-iMliiies and (hiuiuished ex]iulsive power. It must not be assume. 1, (le.-]iiie ihese unusual opportunities for local infection, that the tubercle (h pcisi the inward penetration of tin pli.n \iiueal have seen tuberculous ulceraiinu ot the s( strong and robust individual- exluliitinu b come lUlilei- m\' ol i-ei'\-.al ii in a L-elillenian wit andstren-th, i.ut exIulntuiL; w, ll-.leluie.l tubercuh po.sterior wall of the pharynx, whiih di^xehipeil |( involvement was suspected. Exaniinaumi (n ih presence of a slight quiescent iiulm(inai\ inle. expectoration. Attention has been called to the frequency of tonsillar infection in pulmonary phthisis, aufl to the occasional presence of bacilli in the tonsils III' inili\-iiluals exhiliitim;- no s\-mptiims of tubeiTuloiis disease. The rii.'xi^lenee iil |,.ra||/,.,| iniiMllar lul.en iili.-i- ni the miiLst of far- advaneeil pulnii.uar\ plillii i< r- suinelimes i lenmusl rable, but the role of the tnn-il ni inu linmim iii\ariably an open pathway of infection to the ier\iial '^laud- r- -iilijeri \n siime question, Jacobi has re- cently ca lied .atteiiiiim 111 reiiain iliniral and anatomic facts which prejudice strongly the likelilKi.iil nf lieipient sysiemir in\asi(in by way of the tonsil. He rites the (■(unparalnelx lew changes whieii take place in the cei-xical lymphaiir ^'laiul- in luuneci inn with inllani- matiou 111' llie liiii-^iN amla-umes llial a live rDiiuniimrat ii in bet ween the tun il all.! Ilie -\-teni b\ v,a\ ui llie b- m| ballr- 1- pieveliled bv a dense Jibruu- Mrunuiv ui|.'i\ruiim beluei n llie liin-illar liluigus. Von Schrotter reports two cases i>\ tulK'iculosis of the esophagus recently observed, in each instance I lie iiireitimi followiii'.; a primary involvement of the right lung, with :Mlhesiun of tlie esopliai^eal wall. The diagnosis was made by direct in.spectiou of the lesions with the Tuberculosis of the stomach is exceedingly rare, and is possessed of but slight interest or clinical importance. It has resulted occa.sionally from the extension of peritonenl tiibereulosis. The possibility of a tuberculous infection ingrafted upcui the site of an open gastric or pyloric ulcer remains a somewliat disputed question. In general the conditions within the stomach inimical to the development of local tuberculosis are the dilutiou nf the bacilli, the muscular movements, .ajid the acid reaction of the gastric juice. In addition to these factors Barchasch calls attention to the scarcity of lymphatic follicles in the stomach-walls, and believes that important causes in the develop- ment of tuberculous le.sions in the stomach relate to the increase of lymphoid follicles incident to chronic gastric catarrh. He suggests that, inasmuch as the pylorus is supplied with lymphoid tissue to a greater extent than other portions of the stomach, possibly stenosis of this region is tuberculous oftener than has been supposed. He calls attention to the tuberculous ulcer, the miliary tubercle, the solitary tubercle, and tumor-like masses in the stomach closely simulating •carcinoma. 4bb • COMPLICATIONS CHAPTER LXVII TUBERCULOSIS OF THE INTESTINE Allusion has been made in earlier pages to the results of pathologic research and experimental study, which demonstrate conclusively the importance of the digestive tract as a direct avenue for the primary invasion of the system by tubercle bacilli. Local tuberculous processes in the intestinal wall, especially in adults, are secondary in the majority of instances to involvement of other parts. They undoubtedly take place in consumptives as the re- sult of unusual local exposure to infection, with an added vulnerability of tissues induced by virtue of the original disease. Primary tubercle deposit in the intestine, though less infrequent than formerly supposed, is decidedly more rare than the secondary infection. Fiirst has collected the histories of 160 authenticated cases of primary intestinal involve- ment. Many cases are reported by such authors as Demme, Baginsky, Epstein, Orth, Kossel, Lubarsch, Eisenhardt, Hermsdorf, Ivlemperer, Wyss, Ollivier, Ganghofner, and Herterich. Orth reports that, from a recent observation of 44 tuberculous children, primary intestinal tuber- culosis was present in 10 per cent, of the cases. It has been shown that a considerable number of primary lesions of the intestine were caused by tubercle bacilli of the bovine type. Bovaird has called attention to the lack of uniformity in the results reported by various observers regarding the prevalence of primary intestinal infection in tuberculous children who have come to autopsy. Among American observers, out of 369 autopsies, but 5, or IJ per cent., disclosed a primary tuberculous deposit in the intestine. The Germans report 9 cases, or 4 per cent., out of 236 autopsies. From among 128 autopsies reported by the French there was no single instance of primary intestinal disease. The English, however, have observed 136 cases, or 18 per cent., out of 748 autopsies. After allowing for the apparent dis- crepancies in these reports, it may reasonably be inferred that primary tuberculous lesions of the intestine occur at most in but a small per- centage of cases. The significance of the preceding statistics is enhanced by consideration of the fact that little children are exposed to the dangers of infected food to a far greater extent than adults, on account of the preponderance of milk as an article of diet, and the much greater deli- cacy of the intestinal structures. On the other hand, tuberculous processes in the intestine are extremely frequent among individuals suffering from antecedent pulmo- nary involvement. In the Second Annual Report of the Henry Phipps Institute for the Study, Treatment, and Prevention of Tuberculosis White reports, out of a total of 143 autopsies upon consumptives, 45 cases exhibiting well-defined tubercle deposit in the small intestine, involving chiefly the ileum and the vicinity of the appendix. During the past year, out of 57 autopsies conducted, tulierculous ulcers were found in the jejunum in 7 cases, in the ileum in 32, and in 18 cases in which the location is not cited. These results show a smaller percentage of tuberculous processes in the intestine than are reported by other observers. According to Oornet, Eichhorst found intestinal ulcers in 21.9 per cent, of 462 au- TUBERCULOSIS OF THE INTESTINE 467 topsies upon pulmonary invalids; Heinze, 51 per cent, in 1226 cases; Honing, in 70 per cent.; Weigert and Orth, in 90 per cent.; and Herx- heimer, in 57 cases out of 58. It is noteworthy that local processes in the intestine are far more common than in any other portion of the alimentary tract. Among the various causes which may be ascribetl to explain the relative frequency of infection in this part of the digestive system are the anatomic structure of the epithelial mucosa, the increased absorptive capacity of the intes- tinal follicles, the absence of an acid medium supposed to be inhibitory to the activity of the bacilli, the lessened dilution of the microorganisms after the absorption of the assimilable contents thus permitting a closer and more continuous contact with the mucous membrane, the separation of the bacilli from the protective coating of mucus in the sputum with which it is clothed in its passage from the pharynx through the esophagus and stomach, and, finally, the opportunities afforded in certain parts of the intestine for the retention of microorganisms. A brief consideration seriatim of these factors will afford perhaps a plausi- ble explanation of the preponderance of lesions in this portion of the alimentary tract. Bacilli are enabled to penetrate the cylindric epithelium of the gut much more readily than the stratified pavement epithelium of the pharynx and esophagus or the epithelium of the stomach. Absorption takes place essentially from the follicles of the intestine, in which imme- diate situation the tubercle deposit more frequently occurs. The follicu- lar structure is more apparent in the lower portion of the ileum; the Peyer's patches are the more common seat of tuberculous involve- ment. It is well known that tubercle bacilli do not thrive in an acid medium, though their vitality is not destroyed by the hydrochloric acid of the stomach. The alkaline reaction of the intestinal contents, while perhaps not distinctly favorable for their growth, is without doubt less inimical to their activity than the secretions from the mouth or stomach. Tubercle bacilli gain entrance to the digestive tract largely as a result of contaminated food and the swallowing of infected sputum by consumptives. If bacilli be conveyed at meal time into the alimentary tract, there is afforded sufficient dilution almost to preclude infection in the stomach or upper digestive canal. With the absorjition, however, of the liquid portion of the intestinal contents, barilli w liidi do not enter the chyliferous ducts are relatively more abundant in ilic solid i-esidue, and are brought into more immediate and prolonged contact with the mucosa. In view of the comparative rarity of primary tuberculous processes in the intestine and the remarkable frequency of local lesions among con- sumptives, it is apparent that an important etiologic factor is the occa- sional introduction of tubercle bacilli into the alimentary tract with the sputum of pulmonary invalids. Upon entrance to the digestive canal there is often such an admixfurc of tciuicious mucus as to encompass effectually the opaque, semicaseous ni:tsscs of s])utum in which the micro- organisms lurk in great abundance. .\s a, n>siilt of the various digestive processes, the protective coatini^ of bronchial mucus is finally separated from that portion of the sputum containing bacilli. Prolonged contact with the intestinal' wall is thus permitted, e.specially in the region of the appendix, and the longer the stay of the microorganism at a given 4b8 COMPLICATIOXS point within the intestinal canal, the greater the likelihood of local infection. Other pockets for the lodgment of tubercle bacilli are found in the little cUverticula of the mucous membrane in the lower portion of the rectum, especially just above the anus. These are often of considerable depth, and imbedded to some extent in connective tissue. Slight trauma- tism, which not infrequently results upon a small scale from the hardened and inspissated feces, facilitates the colonization and invasion of bacilli. Further, the openings of the tiny lacunie may become contracted more or less in an analogous manner to the occlusion of the proximal end of the appenchx, giving rise to similar inflammatory changes. Thus may be explained the development of suppurati\-e processes in this region resulting in the production of anal fistula. Bacilli are frequently dem- onstrated in the discharge, but it has not been shown that over one- half the cases of rectal fistula are positively tuberculous in character. The affection is not uncommon in pidmonary invalids, but it is doubtful if a large percentage of the patients can be shown to be definitely tuber- culous. The distinct pathologic features pertaining to tuberculous lesions of the intestine, aside from their location, relate either to the ulceration of the nodules, or to the thickening of the intestinal wall as a result of fibrous tissue proliferation after the manner of the pleura and perito- neum. Two distinct ti/pes of intestinal tuberculosis, therefore, are recog- nized — the ulcerative and the hiiper plastic. Irrespective of the nature of the tuberculous change the part chieflj' involved is the cecum and its immecUate neighborhood. Either form of the cUsease, however, may extend upward into the intestinal tract, involving the jejunum and duodenum, or downward into the ascenchng, transverse, or descencUng colon, and even affect the sigmoid flexure and rectum. Fenwick and Dodwell report that out of a total of 883 cases of tuberculous involvement of the intestine observed at autopsies per- formed upon 20,000 intUviduals dying of tuberculosis in the Brompton Hospital for Consumption, ulceration of the intestine was found in 500 cases, or 56.6 per cent. The ileocecal region was the seat of the cUsease in 85 per cent, of these cases, and in nearly 10 per cent, the tuberculous infection was confined to this region. In 28 per cent, of the cases there was involvement of the jejunum, in 3.4 per cent, of the duodenum, in 51.4 per cent, of the ascending colon, in 21 per cent, of the descencUng colon, in 13.5 per cent, of the sigmoid flexure, and in 14.1 per cent, of the rectum. It is sometimes possible to demonstrate visually the existence of tuberculous ulcei-s in the rectum, from four to eight inches from the anus, by means of the proctoscope and reflected light with the patient in the knee-chest position. In one patient the ulcers in this region were treated locally for a considerable period by Dr. Jayne and myself without. howe\-er, very satisfactory results. Ulcerative Type. — The intestinal ulcerations vary in size, shape, depth, and in their disposal upon the wall of the gut. The ero.'^ion is sometimes superficial in character, extending merely to the submucous tissue, and at other times involves the entire wall of the inte.stine and even perforates into the peritoneal cavity. The size varies from a minute point of ulceration in the center of a nodule covered with epi- thelium, to a discrete, fairly circular erosion, which occasionally assumes the dimensions of a large bean or a dime. Even larger size may some- TUBERCULOSIS OF THE INTESTINE 469 times be attained by the coalescence of several individual areas of ulcer- ation, in which event the outline becomes very irregular. The shape of discrete ulcerations, as a rule, is round or oval, but not infrequently the lesion becomes elongated and is chsposed around the wall of the bowel, the long axis being transverse to that of the intestine. The borders of the ulcer may be infiltrated or exhibit overhanging edges. The floor presents a more or less characteristic grayish appearance, and is sometimes studded with small nodules, with at times slightly reddish projections. Cicatrization of tuberculous ulcers is not frequent, but takes place occasionally, instances of intestinal stenosis confirmed by autopsy being reported from this cause. The hyperplastic form of intestinal tuberculosis is characterized by extensive connective-tissue formation, producing at times an enor- mous thickening in the wall of the bowel, which is usually more or less localized. Prior to 1891 occasional instances of intestinal tuberculosis were reported, in some cases there being a definable tumor and in others a stricture of the bowel. A genuine hyperplastic type of tuber- culosis of the intestine was not recognized until Hartman and Pilliet described the condition in detail. Eight or nine years later Lartigau and Motel presented a histologic record of cases reported by various observers. Nancrede has recently published an illustrative case coming under his observation, and has reviewed at some length the literature pertaining to the sul)ject. Fairly numerous cases have been reported, exemplifying in their description the conspicuous feature of fibrous tissue hyperplasia resulting from local tuberculous infection. This form of intestinal tuberculosis is associated at times with a varying degree of stenosis of the bowel. The indurated condition may be con- fined to a circumscribed region, usually in the neighborhood of the cecum, but occasionally extensive areas of the intestinal wall are involved. A considerable dilatation of the bowel may exist above the seat of the obstruction. This may be followed liya coiuiicnsutory hyper- trophy of the wall in an effort to overcome the initial ocrjusion. As a result of localized hyperplastic change a distiucily iJaliiaMe tumor is sometimes recognized, giving rise to errors of diagnosis on account of confusion with carcinomatous and syphilitic neoplasms. I recall a single instance of this hyperplastic type of localized intestinal tuberculosis occurring in conjunction with similar processes in the peritoneum. The obstruction of the bowel was located in the region of the sigmoid flex- ure, but the precise nature of the condition was not established until the time of operation, the patient being under the observation of Drs. Bagot, Craig, Powers, and myself. Hartman calls attention to the fact that these tuberculous hyper- plastic processes resemble closely in aspect and evolution syphilitic changes in the bowel. Baum has recently reported seven cases of ileocecal tuberculosis treated by operation, and describes the pathologic condition to be a benign hyperplastic form of primary tuberculosis, the macroscopic appearance of which resembles the hypertrophic form of lupus, with tubercle bacilli relatively infrequent. It is probable, as stated pre- viously, that these apparently benign primary cases are often produced by the bovine bacillus, but it must not be assumed that all cases of hyperplastic intestinal tuberculosis are of benign character. Quite to the contrary, it is found that in the majority of instances they are 470 COMPLICATIONS possessed of the greatest ultimate significance. To be sure, the develop- ment is often slow and insidious, without appearance of definite symp- toms, but the hyperplastic growth relentlessly increases in size, and without operation eventually results in a fatal termination. The clinical onset is sometimes acute, and closely simulates the classic reac- tion exhibited in appendicitis. This was true to a marked extent in the case previously cited, and also in a conspicuous instance of hyper- plastic involvement of the appendix, to be reported presently. The practical interest regarcUng ulcerative tuberculous processes of the intestine among consumptives relates principally to the frequent digestive disturbances and the unfortunate effect upon the general condition. The chief clinical manifestations of the non-acute type of hyperplastic involvement are the S3'mptoms of gradually increasing intestinal obstruc- tion and the existence of a discoverable tumor upon palpation. Treatment. — Tuberculosis of the bowel, regardless of the particular type of the disease, is frequently amenable to surgical management. Several times it has been pointed out that in the presence of tuberculous processes involving the gut, the intestine tolerates radical surgical inter- ference to a far greater extent than in the miilst of other pathologic conditions. McArthur has called attention to the practice of excision or exclusion in these conchtions, and reports five cases of extensive tuberculous involvement which have resulted in prompt recover}' following operation. His views coincide with those of Baum as to the expediency of resection whenever the contlitions permit its perform- ance. This is more applicable, as a rule, to the hyperplastic type than to the ulcerative, on account of the more circumscribed area of the involvement and the more favorable condition of the patient. This method of surgical procedure, however, is permissible even in the ulcer- ative variety, provided too great an area is not chseased and the exhaustion with loss of nutrition not excessive. The simpler method of exclu.sion or intestinal anastomosis may be practised when the extent of the disease and the debility of the patient would preclude the major operation. Hartman reports, from a review of the literature, 229 operative cases with 46 deaths. By means of intestinal anastomosis following a fresh implantation of the unaffected portions of the bowel very extensive parts of the intes- tine may be excluded, with relief of previous distressing symptoms in individuals incapable of withstanding the shock incident to the per- formance of excision. It is remarkable, however, to what extent por- tions of the bowel may be resected successfully, even in patients exhibit- ing evidences of marked exhaustion. A case in point is that of an individual to whom I urged resection of the bowel in 1898. Despite a loss of over 60 pounds, together with much prostration, six inches of the ileum, the cecum, all of the ascending colon, two-thirds of the trans- verse colon, and most of the omentum were removed by Dr. Rogers, followed by complete recovery. TUBERCULOSIS OF THE APPENDIX 4/1 CHAPTER LXVIII TUBERCULOSIS OF THE APPENDIX Tuberculosis of the appendix has been shown by autopsy observa- tions to be a frequent condition among advanced pulmonary invalids. In a series of autopsies conducted upon consumptives at the Phipps Institute tuberculous ulcers of the appendix were found in 44 out of 143 cases, but this proportion of about one to three must not be regarded as a fair basis upon which to compute its general frequency among pul- monary invalids as a class. It must be remembered that the condition of the appendix among individuals dying of far-advanced phthisis a,ffords, for the purposes of comparison, no accurate data upon which to base conclusions relative to the frequency of similar involvement in patients exhibiting less extensive pulmonary infection. In the one instance the victim, after a more or less prolonged illness, has suc- cumbed to an advancing infection following greatly diminished indi- vidual resistance and with exceptional opportunities for invasion of intestinal tissues. In the other, the essential consideration relates to the fact that the patient is still alive and maintaining, with varying success, the struggle to promote an arrest of the activity of the tuber- culous processes, other tissues frequently becoming resistant to attack. Necropsy reports with reference to tuberculosis of the appendix, there- fore, may be regarded, from a clinical standpoint, as more or less neg- ligible quantities. Ample means are undoubtedly offered for a protracted sojourn of tubercle bacilli in the blind appendiceal pouch, even to a greater extent than in the cecum. If, in addition to the indeterminate retention of the bacilli in the appendix, one considers the various influences leading to erosions and the other inflammatory and degenerative changes, it is easy to appreciate the favorable conditions afforded for the develop- ment of tuberculous ulcers. Great practical importance attaches to the surgical findings at the time of operation and the character of previous manifestations. Tuber- culosis of the appendix, as of the intestine, has been found to exist in two distinct types — the nlcerative and the hyperplastic. The former is much more common, and usually occurs in association with tuberculous lesions of the intestine, while the latter variety is relatively infrequent and characterized by an extensive connective-tissue hypertrophy. In either type of appendicular tuberculosis the process is in many instances coexistent with ileocecal disease. It is often impossible to assert, from the surgical or pathologic data, whether or not the tuberculous developed simultaneously with the intestinal lesions. While the of the appendix is usually coeval with a corresponding affection of the cecum, it has been shown that the process may occasionally be limited to the appendix, but very rarely occurs in the cecum without appendi- cular involvement. In Fenwick and Dodwell's report regarding the site of tuberculosis of the intestine, to which allusion has been made, it is stated that the appendix was found diseased in nearly every instance of ileocecal infection, which comprised 85 per cent, of the cases. In seventeen instances the appendix was the only portion exhibiting evi- dence of tuberculous change. 472 COMPLICATIONS Primary tuberculosis of the appendix without discoverable lesion of the intestine or other parts of the body is extremely infrequent. Deaver doubts if any perfectly authenticated case has ever been reported. Kelly described six cases of primary appenchceal tuberculosis, one of which occurred under his own observation, the others being reported by Cullen, Sonnenberg, Henrotin, Crowden, McCosh, and Hawkes. He assumes the condition to be primary in character, because the clinical evidences pointed strongly in this direction, and asserts a confirma- tion of this belief by the" fact that the removal of the appendix was followed by recovery. In no instance was the tuberculous character of the appendiceal involvement suspected until the specimen was subjected to routine histologic examination. This latter fact, in connection with present knowledge concerning the latency of tuberculosis and the im- prisonment of the bacilli within tissues and organs presenting no abnor- mal macroscopic appearance, would seem to constitute in itself insuffi- cient evidence to justify positive conclusions as to the primary form of the appendicular affection. Failure to discover definite evidence of tubercle deposit in any portion of the body upon post inoi ten 1 ixa mi nation scarcely warrants the absolute exclusion of a concealcil TiilnrriiliiM- inicction, particularly in glandular tissues. If the absence of autopsy lim lings does not always justify the elimination of a possible tuberculous focus in a remote portion of the body, still greater difficulties must attend the exclusion of such infec- tion solely upon the basis of the clinical evidences during life. Further, the mere recovery of the patient after operation affords an insufficient basis for the assumption of a primary lesion of the appendix. This course of remark is not intended to reflect in the least upon the po.ssi- bility of primar\- tubciculous involvement of this region, but rather to suggest the insiiifiiicni y of the data upon which such views are neces- sarily based. As a matter of fact, the infrequency of primary infection of the appentlix appears somewhat remarkable in view of the fact that the anatomic conditions particularly favor the development of tubercu- lous processes at this point in preference to any other portion of the intes- tinal tract Assuming the introduction of bacilli into the digestive canal, the ap])eiiilix shoMJ,! afford the most natural site for infection, on account of the icteiitiou of its contents and the receptivity of soil induced by frequent mflainmatoiy and degenerative changes. That instances of supposed |iiiiiiar\ t ul ieii'ilo>is of this portion of the intestine are not more fic(|uently repoite.l is explainable by the non-appearance of macro- scopic clutnge ami tlie aii-eiicc of lii-tolo-i.' examination. In very niaii\ ca-es there i^ no di-tui'/ui-lunii characteristic of tuber- culous infection to lie ivi-o-iiized uiion \i>ual examination, the condition apparently confurniuig to the various types of inflammation. In some instances, however, the detection of the nature of the involvement is rendered easy by the presence of small tuberculous nodules upon the peritoneal covering. In the ulcerative type small caseous erosions may be found upon opening the appendix, the point of ulceration conforming to the general characteristics of tuberculous ulcers of the intestine as regards shape, contour, depth, disposal, and appearance of the floor and edges. Suppur- ation sometimes takes place as the result of a secondary infection. The pus-formation thus induced so transforms the clinical aspect of the con- dition as to overshadow the element of tuberculous infection. It is TUBERCULOSIS OF THE APPENDIX 473 reasonable to infer, from cumulative clinical experience, that the tendency to perforation is considerably greater in cases of ulceration of the appendix than in any other portion of the intestinal wall. There is but little pathologic evidence upon which to hazard an opinion as to the relative frequency in the appendix and cecum of cicatrization and healing by fibrous tissue formation. Surgical experience, however, rela- tive to the discovery at operation of old adhesions and extensive fibrous tissue change suggests a somewhat greater tendency toward cicatrization in the appendix than in the intestine. The hyperplastic form of tuberculosis of the appendix represents the same type of pathologic change as has been described in connection with the hypertrophic variety of tuberculosis of the intestine. The condition is characterized by a marked increase in the size of the appen- dix, its firm consistency, and its irregular contour. The diameter is often increased to such an extent that the cylindric shape is entirely lost. The surface is smooth, with occasional rounded protuberances. The wall is thickened by fibrous tissue proliferation, which some- times encroaches upon the lumen sufficiently to produce a genuine stenosis. A slight degenerative change may be indicated by small yellowish spots. Areas of definite caseation and softening are recog- nized upon section. The microscopic changes are similar to those described as obtaining in the intestinal hyperplasia of tuberculous origin. Anatomic tubercles and tubercle bacilli are no more numerous than in the preceding condition. The con.spicuous neoplastic feature of this form of tuberculous appendicitis, especially when associated with ileo- cecal hypertrophy, is such as to confound the condition clinically with new-growths of a malignant nature. In plate 12 is shown a tuberculous appendix of the hyperplastic type removed from a pulmonary invalid October 7, 1907. This case, which is of unusual interest, will be reported presently. Clinical Symptoms. — The symptoms referable to this form are usually more pronounced if the condition is accompanied by similar tuberculous hyperplasia of the cecum. When the fibrous tissue change is limited solely to the appendix and remains uncomplicated by mixed infection, there may be but slight, if any, clinical evidence of the condition. A connective-tissue hyperplasia of the cecum and appendix jointly is attended by pain in most instances. This is usually of a subacute type, but there are, however, occasional severe exacerbations, vomiting, and other evidences of digestive derangement. There may be indica- tions of intestinal occlusion, with the demonstration of a circumscribed ileocecal tumor. Should a purulent process supervene in the appendix, there ensue the well-known manifestations of ordinary suppurative appendicitis. The symptoms of the ulcerative type, which is of more common occurrence, do not differ essentially from those of non-tuberculous disease of the appendix. In some cases the subjective signs are quite indifferent and even devoid of suggestion of appendicular disease. At other times the evidence of acute or chronic inflammation, perforation, and peritoneal extension correspond accurately to the evolution of symptoms characteristic of non-tuberculous appenditicis. It should be emphasized that an ulcerative condition of the appendix of tuber- culous origin is often identical clinically with ordinary appendicitis. The differential diagno.sis is almost always impossible without the 474 COMPLICATIONS laboratory examination, and the two conditions are subject to the same general principles of management. It is, therefore, futile among pul- monary invalids to endeavor to discriminate clinically between an ulcerative tuberculosis of the appendix and a non-tuberculous appendi- ceal involvement. Tuberculosis of the appendix may exist in the absence of discover- able tuberculous lesions in other parts of the body. While pulmonary invalids often exhibit the classic features of simple acute appendicitis, more extended histologic examinations may reveal in the future its more frequent tuberculous origin. At present it may be assumed that this condition occurring among consumptives is not necessarily tuber- culous in character. Assuredly it does not conform to any particular type as regards the clinical manifestations and indications for treatment. Principles of Management. — Each individual case of appendicitis among consumptives, as well as among the non-tuberculous, must be . adjudged in accordance with the established principles of surgical pro- cedure to be applied according to the merits of the appendicular indica- tions. It should be remembered that the exigency relates solelij to the appendiceal disease, and not to the pulmonary involvement. Measures to avert an impending general septic peritonitis should take precedence over a chronic condition of the lungs which of itself is often self- limited. Some surgeons confess to considerable hesitation in perform- ing the operation for appendicitis upon a consumptive, and advise delay unless the condition is especially acute. The position assumed appears illogical and non-subservient to the best interests of a class entitled to every prompt consideration. It is true that, from a surgical standpoint, the responsibilities are greater, and perhaps the results less uniformly spectacular, than among individuals in previous good health. This does not alter the fundamental truth, however, that the indications demanding operation among the non-tuberculous obtain to an equal if not greater degree among consumptives. On account of the dimin- ished resistance of these invalids, delay is often more disastrous and attended by the assumption of far greater moral responsibility by the surgeon. It is not contended that the consumptive presents in all cases the same possibilities of speedy recovery as those who are not afflicted with pulmonary disease. This, however, is not the point at issue in determining the choice of procedure in such cases. The vital proposition relates to the question, whether or not the existence of pulmonary tuberculosis so complicates or modifies the problem, as to preclude upon this basis alone the rendering of surgical assistance. A negative decision regarding the operation is not justified upon the score of the anesthetic unless the pulmonary disease is obviously so far advanced as to render recovery impossible, in which event ordinary discretion, of course, discountenances operation. It has been shown, however, in a previous chapter, that it is often impossible to assert with positivcncss that a given case is beyond hop&of ultimate arrest. I am well awiir ili.ii the decision concerning operative interference, even in sini]ilc :ipi>rii, Ileitis, is often a choice of the lesser of two evils, and fraught with iiiaii\ anxious responsibilities. It is conceded that in a judicial estimate of tlie relative bearing of the many phases pertaining to an individual case, the existence of advanced phthisis may in excep- tional instances constitute the determining consideration, and justly turn the balance of argument in favor of delay. Cases of this character, TUBERCULOSIS OF THE APPENDIX 475 however, do not comprise the category, concerning which doubt as to the expediency of operation is usually expressed by surgeons. As a matter of fact, the bed-ridden consumptive rarely exhibits evidence of an appendiceal involvement. From a close observation of over 2000 cases of pulmonary tuberculosis I can recall but a single instance of appen- dicitis developing in the last stages, and in this case Dr. Powers and I quicidy agreed as to the futility of surgical intervention. It is sub- mitted, however, that when a reasonable doubt is entertained, the invalid should be accorded the benefit of the doubt, and in case of emergency receive the same prompt surgical aid as the non-tuberculous. In the presence of recognized imminent danger from fulminating appen- dicitis, the peril of the consumptive is assuredly no less than his more fortunate fellow, and hence the rational advocacy of equal opportunity for surgical relief. An increased liability to succumb from the shock of .the operation, even if true, would not militate directly against its ready performance in the face of conditions clearly indicative of its necessity under other circumstances. In this event failure to survive the surgical ordeal is not of itself condemnatory of the operation. On the other hand, when the conditions are not such as to involve a reasonable doubt concerning the propriety of the operation, no hesitation as to the choice of procedure should be permitted. In other woi'ds, a decision as to the relative advantages and disadvantages of the early and interval opera- tions in such cases should be made upon the merits of the appendicitis itself, precisely as among individuals previously well, without taking cognizance of the existing pulmonary affection. Pulmonary invalids, as a rule, undergo anesthesia without special difficulty. Important considerations in favor of operation are the possibility of an abrupt termination in the absence of surgical aid, the inevitable confinement incident to prolonged convalescence among non-operative cases, and the added difficidty in sustaining nutrition due to gastro- intestinal disturbances so often incident to chronic appendicitis and the ever-present danger of relapse. Failure to discover definite physical signs in the right iliac fossa in the presence of sudden chill, fever, nausea, vomiting, general abdominal pain, and prostration affords no assurance whatever of the non-existence of a grave appendiceal condition. The contention is made that in appendicitis there is no constant relation between the severity of the symptoms or signs and the nature of the pathologic change within the abdomen. There is no invariable rule lay which to hazard an opinion concerning the existence of gangrene, perforation, pus-accumulation, circumscribing adhesions, or localized peritoneal involvement. The pathologic condition, without opening the abdomen, is at best a mere matter of conjecture, even in the absence of unfavorable symptoms. A considerable experience with appendicitis, both among pulmonary invalids and the non-tuberculous, confirms the belief that it is impossible in a given case to describe the pathologic process in the neighborhood of the appendix or to estimate with accuracy the imminence of threatening morbid change. Some years ago I reported several cases of appendicitis among pulmonary invalids whose abdominal pain was general rather than local, witii entire absence of tenderness or resistance over the region of the appendix upon careful physical examination. In two of these cases, upon opening the abdomen, free pus was found in the general cavity, with an exceedingly long appendix dipping over and below the 476 COMPLICATIOXS brim of the pelvis, where the tip had become adherent. This position of the distal end amply explained failure to elicit tenderness or rigidity upon early palpation, in spite of advanced pathologic change. These cases demonstrate conclusively that a genuine involvement of the appendix may exist without the exhibition of palpable evidence, although the general and constitutional symptoms may be sufficiently definite to characterize the attack as a most serious abdominal condition of some kind. Such an experience estabhshes the fact that, in the presence of severe abdominal pain of violent onset, with change in pulse and temperature, even despite absence of rigidity and tenderness over the region of the appendix, an absolute exclusion of appendicitis is quite impossible without recourse to exploratory laparotomy. It may be regarded as unwarranted for an internist to formulate his own ideas, and base his conclusions as to a general course of action in appendicitis and other abdominal affections, from his comparatively restricted opportunities for observation. Irrespective, howe^■er, of the degree of familiarity with the recorded results of others, it remains for an active experience to crystallize one's views and define a general course of procedure with reference to this condition. Among pul- monary invalids as well as the non-tuberculous, appendicitis exhibits a startling prevalence, and an unnecessarily high mortality rate. So long as the dailj' press continues to record frequent deaths from a disease which at some period of its course is recognized by the medical profession to be distinctly curable, so long will there remain a justification for its most thoughtful and oft-repeated consideration. Although obviously a surgical condition, the discussion of appendicitis among phthisical patients appears particularly appropriate in a work devoted to pulmo- nary tuberculosis. The position assumed by the attending physician concerning this affection is sometimes equivocal, compromising, and most unsatis- factory. Although not directly involved in the later surgical manage- ment of the disease, he is compelled, nevertheless, to accept an obligation fraught with infinitely greater responsibility than that assumed by the surgeon. It so happens, in the majority of cases, that it is the physician, rather than the surgeon, whose professional services are sought early in the disease. This is explained not only by the abiding confidence reposed in the familj' physician, but also through failure of the patient or friends to appreciate fully the character and possi- bilities of the ailment. Thus it is that at the very time when the hour- to-hour question of management is all vital to the life of the individual, the case is rested solely with the physician, the fate of the patient often depending upon the detail and accuracy of observation, the definiteness of purpose, and the promptness of action during the first twenty-four to thirty-six hours. There can be no greater reflection on the pro- fessional attainments and acumen of a physician than failure to recognize at once the possible nature of the disease and to arrange for operation at an opportune time, rather than to summon surgical aid after a period of disastrous and delu.sory expectancy. Upon the development of acutely violent abdominal symptoms, suggesting appendicitis or per- forative peritonitis, few complicating conditions furnish legitimate contraindications for operation. In such an emergency the mere existence of pulmonary tuberculosis affords insufficient grounds for hesitation or delav. TUBERCULOSIS OF THE APPENDIX 477 A substantiation of the correctness of these views has seemed to be afforded from my experience with appendicitis among consumptives. An early operation has been performed upon 14 moderately advanced pulmonary invalids, with uniformly favorable results. In no case was there occasion to regret the operation, and in 11 instances it is fair to assert that life was saved through immediate surgical aid. In 3 cases it was impossible to conclude with positiveness that recovery might not have talven place without operation. In addition to the 14 cases of early surgical interference, 3 others died from general septic peritonitis, the free abdominal cavity in each instance being filled with pus at time of operation. None of these patients succumbed from the effects of the operation per se, as the abdominal condition was such as to preclude recovery. In all cases the anesthetic was admirably borne. Six additional consumptives, with well-defined appendicitis for whom operation was not advised, eventually recovered from the appendiceal involvement, while one, refusing operation, died after a few days. Objection has been made by some to operation among this class of patients through fear of a protracted convalescence, the formation of multiple abscess, and the possibility of fecal fistula. I have never found the surgical convalescence unduly prolonged among consumptives. Multiple abscesses have never been observed among my cases, and there has been but one case of fecal fistula. A small superficial sinus developed in two cases after operation, but subsequently healed. For the purposes of illustration I will report briefly several cases of operation among advanced consumptives. ILLUSTRATIVE CASES Case I. — A woman, thirty-one years of age, came under my observa- tion May 6, 1907, two years after the development of pulmonary tubercu- losis. Despite a sojourn in several health resorts tlie general trend of the disease had been downward. There was a loss of twenty pounds in weight, with ooiTesponding diminution of strength, a moderate tem- perature elevaliiJii, :iiiil slight cough and expectoration. The appetite was exceedingly pnor mid digestion much impaired. There were five or six loose bowel nioveuients daily, attended by considerable abdominal pain. Tubercle bacilh were found in the fecal discharges. The examination of the chest disclosed extensive tuberculous involvement of each lung, upon the right side the infected area extending from the apex to the third rib and to the lower angle of the scapula; upon the left side, from the apex to the base in front and to the middle of the interscapular space. Under rigid hygienic and dietetic measures a moderate improvement was exhibited from May until October. There was an increase of ten pounds in weight, with gain in the general strength and a continuous reduction of fever. There remained, however, con- siderable impairment of digestion, with loose bowel movements and occasional colicky attacks of pain of short duration. Upon October 4th she experienced severe pain in the right iliac region, accompanied by a slight rigor and vomiting. This was followed by moderate temperature elevation and acceleration of pulse. The abdomen was extremely tender and rigid upon the right side. A diagnosis of appendicitis was made, but on account of her general condition, a decision as to the 478 COMPLICATIONS advisability of operation was held in abeyance for a few hours. Upon the following day there was a complete remission in the severity of the symptoms, the pain disappearing entirely, the temperature returning to normal, and the pulse to 96. The condition of the abdomen, however, was unchanged. No food was administered by the mouth, and further ilelay appeared justifiable. During the evening of the second day the patient suffered another chill, with recurring pain, renewed temperature elevation, and vomiting. Immediate operation was urged, but stub- bornly refused. Despite emphatic insistence upon recourse to surgical measures, consent was not obtained unil the morning of October 7th, the temperature in the mean time having risen to 103° F., and the pulse to 136. The operation was performed by Dr. Powers, and a tuberculous appendix of the hyporplnstic type was removed. Although Fig. 125.— Drawing of miliary tuluM.!.- of ili.- ;,,,,H'iidix. (See plate 12.) Note the well- defined connective-tissue reticulum aiui tiie i;iani-c-cll in tlie center, witli circular mural dis- position* of the nuclei. Note central areas of degeneration and cellular proliferation in the per- the cecum was also found the seat of similar tuberculous involvement, the general condition of the patient precluded resection of the bowel. The patient made an uneventful recovery from the operation, although a fecal fistula persisted. An interesting feature of this case was the diagnosis before operation of the tuberculous nature of the appendiceal involvement. This is explained by the fact that ^wsa of a milligram of the new tubercuhn had been administered less than twenty-four hours prior to the develop- ment of appendiceal symptoms. The acute onset following the institution of tuberculin treatment suggested a probable relation of cause and effect in the way of a local and general reaction. The hard, irregular, and nodular mass, as it appeared immediately after removal, is shown in plate 12, figure 1. After hardening in a 2 per cent, solution of formalin for two days, the mass was incised, and showed well-marked caseation % Fig. 1. — Hyperplastic tuberculous appendix removed from pulmonary invalid. Note irregular contour with rounded protuberances. The needle is inserted partly into the lumen. Compare with following illustration representing the appendix upon section. The histologic appearance is shown in Fig. 12.5. Fig. 2. — Section of tuberculous appendix of the hyperphistic type, hardened in formalin for two days before being incised. Note in each half the characteristic tuber- culous ca-seation, with well-defined areas of softening and partial obliteration of the lumen. Compare with preceding illustration, same specimen. TUBERCULOSIS OF THE APPENDIX 479 with small areas of softening. There was an almost complete oblitera- tion of the lumen of the appenciix. The appearance of the specimen at that time is shown in plate 12, figure 2. Typical tubercle formation was recognized upon microscopic examination, as shown in the accom- panying illustration (Fig. 125). Case II. — The patient was a young woman who came under my obser- vation September 29, 1902, when twenty-one years of age. Four members of her immediate family had died of consumption. Her pulmonary involvement had been of two and one-half years' standing. She had resided in Colorado for two years, during which time progressive failure had taken place. The patient was greatly emaciated, exhibiting con- siderable temperature elevation daily, and suffering from numerous loose bowel movements. Tubercle bacilli were found in the rectal discharges. There was extensive tuberculous ulceration of the larynx. The exami- nation of the chest showed tuberculous involvement of the greater portion of right lung, without cavity formation. After the lapse of two years a remarkable improvement took place. Abdominal distention and diarrhea had ceased altogether, cough and expectoration had mark- edly diminished, the weight had increased over thirty pounds, and the tuberculous involvement of the larynx had improved to such an extent that local treatment was suspended. The examination of the chest disclosed an evident quiescence of the tuberculous process, although complete arrest had not thus far been secured. Shortly after this she married, and assumed the responsibilities of housekeeping, following which she lost in weight and exhibited renewed activity of the tubercu- lous infection. In July, 1905, she developed a typical acute appendicitis and was hurried to operation a few hours after the development of initial symptoms. The patient had not been under medical observation for , eight or ten months prior to this time, and her general condition was far from favorable. The operation was performed by Dr. Dixon, and a much enlarged and inflamed appendix removed. The patient made a prompt and uninterrupted recovery. At present there are no signs of activity of the tuberculous disease. The examination of the chest is negative, with the exception of fibrosis. There are no bacilli in the sputum, no evidences of intestinal disturbance, and a complete healing of the laryngeal involvement. Case III. — A man of forty-eight with a family history of tubercu- losis came to Colorado ten years ago on account of extensive tubercu- lous involvement of the left lung. After several years of rational living there was secured a complete arrest of the tuberculous process. In 1904 the patient experienced a beginning digestive disturbance, with constipation, intestinal flatulence, and fleeting attacks of pain referred to the region of the appendix. As a result of the digestive disturbance and impaired appetite, there took place a progressive loss of weight and strength, accompanied by a renewed activity of the tuberculous process in the lung. The weight was reduced nearly forty pounds and the vitality much enfeebled. In April, 1906, there was a sudden attack of pain in the right iliac fossa, without vomiting or temperature eleva- tion. There was absolutely no resistance or rigidity of the muscles of the right lower abdomen. The face was pinched and ashen. Upon deep palpation a small tumor was recognized well to the outer edge of the abdomen. Laparotomy was immediately performed in spite of extreme prostration, malnutrition, and active pulmonary tuberculosis. The 480 COMPLICATIONS decision to operate was based in part upon the expediency of removing a possible cause for the protracted digestive derangement. It was felt that even a disappearance of the acute stage of inflammation, with remission of the urgent symptoms, would leave the patient with but slight opportunity to secure arrest of the pulmonary infection. Operation performed by Dr^ W. A. Jayne disclosed a much elongated and thickened appendix, with beginning gangrene. The patient recovered promptly from the effects of the surgical procedure, and has since attained a complete restoration of his previous health. There has been a con- spicuous gain in weight (25 pounds) and strength, with entire absence of physical signs of the pulmonary affection. Case IV. — A boy, nine years old, was brought to Colorado June 1, 1903, after several months' progressive decline in New Mexico. There was extensive active involvement of the left lung and a moderately advanced tuberculous process in the right. There were great emacia- tion and physical debility, moderate temperature elevation daily, and an exceedingly weak and rapid pulse. No hope of securing an arrest was entertained. After three months of complete rest in bed in the open air, with active efforts toward superalimentation, a gain of fifteen pounds wasestablishr-ii. with n rresponding improvement in the general condition. The stren^ith aiiaiu was reduced by a six weeks' illness with typhoid fever, upon recovering from which a satisfactory improve- ment in the general condition was continued until January, 1905, when an appendicitis developed with moderate pain and vomiting. There was no fever, the resistance in the right iliac region was very slight, but the pulse was 1.30 and of poor quality. The question was presented as to the expediency of operating upon a ten-year-old boy with advanced phthisis and a poor general condition, in the absence of parents. There was some hesitation as to the wisdom of surgical interference on account of the lack of tenderness, temperature elevation, and rigidity, suggesting that the condition was not especially acute. After some hours' delay it was decided to assume the responsibility of operation. A gangrenous appendix was removed by Dr. Dixon, and speedy recovery ensued. Complete arrest of the pulmonary tuberculosis has since been secured. Thff child has been at home for over two years, and I am advised exhibits no evidence of icucwinI activity of the tuberculous infection. Case V. — The patient was a woman, fort3--two years old, who arrived in Colorado in June, 1906, presenting the history ofadvanced pulmonary tuberculosis of four years' duration. There was marked loss of weight, dyspnea, and rapid pul-p. Eacli lung was extensively diseased, an active infection beiui: k-i Mi^nizcd upon the right side from the apex to the third rib, and upon ilu- left from the apex to the fourth rib, with pronounced pulmonary excavation. An unfavorable prognosis was necessarily entertained. Improvement, however, was noted during a period of two months, after which she experienced sudden pain, nausea without vomiting, moderate elevation of temperature, and increased rapidity of the pulse. Very slight resistance was obtained in the right iliac region. Immediate operation was advised, although due cognizance was taken of the responsibility assumed in surgical interference upon a case of this character. It was feared that if the appendix was permitted to remain, convalescence would be unavoidably protracted, and alimentation greatly reduced. An acutely inflamed and elongated appendix was removed by Dr. Dixon. The subsequent TUBERCULOSIS OF THE APPENDIX 481 history of the case will be reported in connection with Clinical Obser- vations upon the Use of Bacterial Vaccines. The improvement in the general and pulmonary conditions has been pronounced. Case VI. — A pulmonary invalid, thirty-four years of age, while in the mountains of Colorado in the summer of 1906, suddenly experienced fairly acute abdominal pain, which was followed by chill and vomiting. After remaining in bed for several days the acuteness of the pain sub- sided somewhat, and the general condition was so improved as to permit his undertaking a twenty-five-mile ride to the nearest railway station. By the merest chance I met the patient upon the way, and was solicited to render medical aid. The patient was emaciated, extremely pale, with weak and rapid pulse, but no elevation of temperature. Examina- tion made at the time showed a generally distended abdomen. There was no especial localization of the pain or tenderness in the region of the appendix. The patient was removed to Denver, and operation decided upon in spite of a poor geheral condition, pulmonary involve- ment, and a considerable degree of uncertainty as to the precise nature of the abdominal disturbance. A circumscribed ileocecal abscess was evacuated by Dr. Powers, but efforts to discover the appendix were unavailing. The patient made a satisfactory recovery. Case VII. — A woman, thirty-two years of age, having resided in Colorado for four years on account of an extensive tuberculous involve- ment of each lung, suddenly experienced, upon November 30, 1905, severe abdominal pain in the right ileocecal region. This was attended by chill and vomiting. She had previously secured a gain of about fifty pounds in weight, and a pronounced improvement in the pulmonary condition. The face was flushed, expression anxious, temperature slightly elevated, and pulse 1.30. Careful examination of the abdomen was entirely negative. After two or three hours a beginning tenderness with slight resistance was noted in the right iliac region. Operation was decided upon, and performed without delay by Dr. Dixon. There was found a perforative gangrenous appendix with beginning general septic peritonitis. The appendix was removed and thorough drainage instituted. The patient, however, died upon the third day. This case is of interest in view of the fact that the fatal termination occurred not by virtue of the pulmonary involvement, but as the result of a perforation of the appendix which probably took place simul- taneously with the very earliest symptoms. Had there been exhibited evidence of appendiceal disease prior to the perforation, recovery would undoubtedly have taken place notwithstanding the pulmonary disease. Case VIII. — The patient, a woman, aged thirty-three, with a long- standing tuberculous process in both lungs, experienced a sudden acute pain during the night of February 13, 1901. This was followed almost immediately by a chill, and subsequently by vomiting. She was seen by me on the following morning. The temperature was but slightly elevated, the pulse was of good quality and not especially rapid. The pain in the abdomen, which was general rather than localized, had materially subsided. Careful physical examination failed to disclose the slightest tenderness or resistance over the region of the appendix. During the next twenty-four hours no especial change was noted in the condition. No nourishment was permitted by mouth. Shortly afterward the pain became more severe, and was attended by renewed vomiting and a slight chill. The next morning the physical exami- 31 482 COMPLICATIONS nation remained completely negative. The expression, however, was not so good as on the preceding day. After consultation and a con- tinued negative result of abdominal, vaginal, and rectal examination, it was determined to resort to exploratory incision. The operation, unfortunately, was delayed another twenty-four hours, during which time the temperature roseio 104° F., the pulse to 136. The abdomen had become distended, and the whole picture was that of septic peri- tonitis. The operation was performed by Dr. Horace G. Wetherill. On opening the abdomen free pus was found throughout the gen- eral cavity. The appendix was exceedingly long, with its tip dip- ping down over and below the brim of the pelvis, where it had become adherent, thus explaining the failure to elicit tenderness or rigidity on early examination. Perforation had taken place, and the appendix was gangrenous in places. The patient's condition during the operation was extremely desperate. She was taken from the operating-room in collapse, and it was not doubted that death would speedily ensue. During tlie next two or three daj's the condition remained as desperate as can be imagined. The pulse was exceedingly weak, the temperature considerably elevated, and the abdomen greatly distended. Fecal vomiting began on the third day following the operation, and the patient became practically unconscious. In spite of vigorous efforts the bowels had not moved, and there had been no passage of gas. It was evident that the stomach must he relieved of the fecal matter and the intestinal distention reduced as much as possible. While the patient was in a semicomatose condition, the stomach was washed out at very short intervals with a solution of soda. Enormous quantities of gas were removed at each washing, together with considerable fecal matter. The lavage was continued in each instance until the water returned perfectly clear. It was remarkable to note the very decided relief of the abdominal distention after each washing. The improve- ment in the mental condition soon became marked. Stimulation was vigorously continued, and the lavage was repeated at short intervals during the next three days. Renewed efforts to move the bowels were finally successful, and in the course of a week normal peristalsis was restored. The patient continued to exhibit gratifj'ing im))ro\ement for a period of nearly seven weeks, when there suddenly de\eloped symptoms of acute intestinal obstruction. Operation by Dr. Wetherill disclosed very extensive intestinal adhesions, and the patient survived but a few days. This case is cited as illustrating the statement previously made that a genuine involvement of the appemlix may exist without any early evidence of its presence being elicited upon physical examination. In this case the general and constitutional symptoms were sufficiently definite to characterize the attack as a most serious abdominal condition. Through failure to tliscover definite phj-sical evidences of appendicitis there was permitted to take place a most disastrous period of delay, which resulted eventually in the death of the patient. The lesson to be drawn from such an experience is plain to the effect that, in the presence of such an acute onset, severe abdominal pain, with change in pulse and temperature, even despite absence of rigidity and tenderness over the region of the appendix, the only safe and rational course would have been to perform an exploratory laparotomy. The dangers of opening the abdomen in such cases are comparatively slight, while the TUBERCULOSIS OF THE APPENDIX 483 unfortunate possibilities from delay are very great. When in doubt early in the course of such acute abdominal affections it must be recognized that the best interests of the patient are subserved by exposure to the relatively slight dangers of abdominal section, in order to secure, first, definiteness of diagnosis, and, secondly, opportunity to invoke life- saving surgical aid. Case IX. — The patient, aged fifty years, came to Colorado September 6, 1906, one year after the development of pulmonary tuberculosis. There were great emaciation and physical debility. Dyspnea was pronounced upon sight exertion, and the cough was frequent and paroxysmal. The expectoration, was profuse, the appetite poor, and the sleep much disturbed. Physical examination disclosed extensive active tuberculous infection of the right lung and slight involvement of the left. No appreciable improvement was noted after several months' residence in Colorado. Early in 1907 the patient developed an acute appendiceal attark. The initial ligijr was severe, and the pain in the right iliac region cxcTuciat ing. Ininicdiately after the early vomiting the pulse became exccc(li]iu,ly weak ami rapid. The patient was seen in consultation by Dr. F. L. Dixon, and much hesitation, in view of the extreme physical debility, was felt as to the expediency of operation. Despite the unfavorable general condition, however, it was decided that the invalid was entitled to the same operative procedure that would be accorded a non-tuberculous patient. An acutely inflamed and beginning gangrenous appendix embedded in a mass of inflamed and gangrenous omentum was removed, and the patient made an unevent- ful recovery. Dr. Powers has recently operated upon a tuberculous patient of Dr. J. A. Wilder presenting symptoms of acute fulminating appen- dicitis with a history of several former attacks. At the time of the previous illness it was decided to resort to an interval operation as soon as practicable. This was subsequently opposed by the jjatient and family on account of the far-advanced tuberculous cnmlitidii. He suddenly experienced severe pain, chill, and underwent iniuicdiate collapse. Under great stimulation the (i]ieraticiii was performed and the appendix found to have sloughed directl\- oxer i lie wall of the cecum, leaving a patulous opening into the intestine wliich discharged its fecal contents into the general abdominal cavity. The appendix itself was extensively gangrenous. The abdomen was freely and cniitimiously irrigated for many days with the patient in the Fowler position. Itccciv- ery took place, and the patient was permitted to resume the effort to secure arrest from the pulmonary involvement. This case offers a striking illustration of the wisdom, in general, of the interval operation upon the pulmonary invalid, when the history of previous attacks establishes the diagnosis of recurring appendicitis. 484 COMPLICATIONS CHAPTER LXIX RECTAL FISTULA This condition originates from abscesses in the connective tissue surrounding the lower portion of the rectum. It usually results from neglect in the treatment of simple anal abscess or in that of a similar pus-collection in the ischiorectal fossa. Among tuberculous patients, however, a persisting indolent fistula may develop despite thoroughlj^ ef&cient surgical treatment of the original abscess. There are several types of fistula, one of which is the open variety, with a free communication to the external skin, as well as into the intestinal canal. Another is termed the blind internal fistula, in which the sinus opens into the bowel but has no external outlet. The blind external fistula opens upon the skin, but does not perforate the rectum. Irrespective of the type of fistula, the course of the sinus in almo.st every instance is tortuous and irregular. The point of internal perfora- tion is frequentl}' but a short distance above the anus, though in some cases the sinus extends upward a considerable distance before pene- trating the bowel. The external opening may be situated in immediate proximity to the anus or at a distance of several inches. The discharge of pus or liquid feces from the sinus produces, as a rule, considerable discomfort and irritation. In most eases there is a comparative lack of pain and tenderness. The discharge varies according to the nature of the infection. When of tuberculous origin, the secretion is often scant and watery in character. In case of mixed infection it is usually more profuse, of greater density, and of a greenish-yeUow appearance. Tuberculous fistulse are apt to e.xhibit at the cutaneous orifice a reddened, irregular, and overhanging edge. The method of origin of small abscesses arising from the anal diver- ticula is closely analogous to appendicitis with pus-formation. Oppor- tunity is aflorded in both conditions for the entrance of numerous different microorganisms. Their presence, together with the indefinite retention of fecal matter and foreign substances, gives rise to varying degrees of irritation and inflammatory change. In reviewing the general etiologj^ of tuberculous lesions of the intestinal tract attention was called to the mechanic facilities offered for the lodgment of tubercle bacilli in the tiny lacunae existing in the mucous membrane above the anus. This e.xplains the distinctly tuberculous origin of many cases of rectal fistula. While in a consider- able number of cases the fistulous abscesses are in themselves tuber- culous, a non-tuberculous fistula is not infrequent among pulmonary invalids. Although nearly 15 per cent, of all fistulse occur among this class of people, the local condition is not invariably tuberculous. The relation of fistula in ano to pulmonary tuberculosis has been the subject of much uncertainty and confusion for many years. The proportion of consumptives afflicted with anal fistula varies, according to different observers, from 2 to 5 per cent. The condition has existed in slightly over 2 per cent, of the cases coming under my personal observation. It was even thought at one time that the existence of fistula produced a degree of immunity to pulmonary tuberculosis. Among non-consumptives, therefore, it was considered rational to RECTAL FISTULA 485 prevent the healing of the sinus for fear lest a tuberculous infection of the lungs would subsequently develop. If the victim of the fistula was a consumptive, the chances for recovery from the pulmonary disease were believed to be enhanced by a continuance of the fistula, and materially diminished by its closure. According to Freeman, it was at one time considered good treatment to produce artificial fistula in consumptives as a means of cure of the original disease, upon the theory that injurious humors were thus drained from the system. At present there exist considerable differences of opinion as to the true relation of these two affections, and especially as to the applica- bility of remedial measures under varying conditions. It is well to bear in mind, as stated, that tuberculous fistulse may occur in individuals presenting no other evidence of similar infection, and that non-tuber- culous fistulse may sometimes develop in the midst of pulmonary phthisis. In this respect there is maintained a further resemblance iDetween abscesses in the appendix and in the region of the anus. There is, however, in the two conditions a striking difference as to the practical construction to be placed upon these relations. In connection with appendicitis it was stated that a clinical distinction was unnecessary between tuberculous appendicitis and a simple inflammatory involve- ment among consumptives, as the indications for treatment were iden- tical. The principles of management as applied to cases of rectal fis- tulse, however, are not similarly uniform, for reasons that are perfectly obvious. Appendicitis, regardless of its origin, is recognized as a distinct menace to life, without immediate operation. Rectal fistula, however, at no time threatening the life of the individual, is embraced under an entirely different category, the results of surgical treatment being depen- dent upon the influence of the general health. It is important to distinguish between fistulse in themselves tuber- culous without evidence of infection in other parts of the body, and fistulse in consumptives irrespective of the origin. Among the latter the essential consideration is not the local condition of possible tuber- culous origin, but the existence of an infection in remote parts, causing a diminished resistance of the tissues and retarding, if not preventing, complete union after operation. In this event surgical interference may become non-effective and may even react to the disadvantage of the patient through the refusal of the wound to heal, the increased area of broken-down tissue, the occasional impaired function of the sphincter, and the not infrequent mental depression. The decision as to therapeutic management must be based upon certain prognostic considerations which relate directly to the extent of pulmonary tuberculosis and the general vitality. Tuberculous fistulse in otherwise healthy individuals are subject to the same prin- ciples of radical surgical management as simple fistulse among the same class of patients. In consumptives the special indications for the operation relate to the supposed ability of the tissues to heal promptly after thorough excision. Surgical interference among pulmonary invalids as a class has fallen into considerable disrepute because of the frequent unsatisfactory results of the operation. It must be admitted that among these patients it is notoriously unsuccessful in a large proportion of cases. It is well known that the course of the pulmonary disease is not influenced either for better or worse by the complicating fistula, save for the unfavorable results sometimes noted after ill- COMPLICATIONS considered and untimely surgical procedures. The alleged development of pulmonary tuberculosis following operation for rectal fistula is prob- ably explained by the previous latency of the pulmonary infection ami its delayed clinical recognition. On the other hand, the influence of advanced pulmonary phthisis upon the local fistulous condition is beyond question. The unfortunate results of operation upon consumptives are fre- quently traceable to the lack of proper discrimination exercised as to the selection of cases. The operation is often performed upon invalids with advanced pulmonary disease, or at a time when the infection, though of recent developnient, is associated with greatly impaired nutri- tion and lessened individual resistance. The essential consideration as to the propriety of the operation attaches not to the extent or duration of the tuberculous change in the lung, but rather to its comparatively slight activitij and the existence of an excellent nutrition as indicative of general vitality. It is my custom to deny this operation to patients until the pulmonary infection has undergone almost if not complete arrest, with the restoration of at least a normal body weight. Until such time patients are quieted with the assurance that the persisting fistula exercises no possible influence upon the disease, and that a fortunate result of operation is permitted only by an increased general resistance. A significant commentary as to the frequency of ill-advised operation is the fact, that in nearly every instance of rectal fistulse among pulmonary invalids at the time of coming under my observation an operation had previously been performed with unsatisfactory result. The surgical management, aside from ordinary drainage operations which are indicated in all cases of abscess formation in this vicinity, consists of simple incision with curetment, or of total extirpation of the fistulous tract. Incision is the less formidable and more usual method of procedure, and is sometimes attended by satisfactory results. In case of a complete open fistula a grooved director is passed from the external opening into the rectum, and the intervening tissues divided with a sharp curved bistoury. This is preceded by thorough stretching of the sphincter. If the fistula is incomplete, a connection must be established from the skin to the interior of the bowel by the director. After the entire sinus has been laid open, the infected area is forcibly scraped and sterilized with pure phenol. The wound is packed with iodoform gauze, the healing taking place by granulation. The process of excision, which is more likely to be attended by a speedy and gratifying result among tuberculous cases, consists of the dissection of the entire fistulous canal. Great care must be taken to remove, if possible, a considerable area of apparently non-infected tissue. This procedure is even advisable in chronic cases exhibiting dense fibrous tissue formation along the wall of the sinus. After cleansing and sterilization, the wound is closed with silkworm-gut sutures in an effort to secure accurate coaptation of the walls. Especial care should be taken to bring the parts in perfect apposition at the anal end of the sinus. For this purpose the ends of the sphincter muscle should be united by a suture encircling and passing through the muscle. Primary union takes place in a large proportion of cases. If asepsis is imperfect and suppuration ensues, the stitches should be immediately i-emoved and the reopened wound packed with gauze, thus permitting healing to take place by granulation. GENERAL ETIOLOGIC CONSIDERATIONS SECTION VII Tuberculosis of the Genito-urinary Tract CHAPTER LXX GENERAL ETIOLOGIC CONSIDERATIONS Tuberculous infection of either tlie genital or urinary system is almost always secondary to a preexisting focus in some other portion of the body. It is difficult, however, to deny absolutely the possible existence of primary tuberculosis in these parts. Isolated cases of such an infection are found in the literature of the subject, but the evidence is frequently insufficient to sustain the assertion that the reported condition is one of genuine primary infection of the genito- urinary system. The term ■primary is often used in connection with tuberculosis of this region, not as denoting the initial site of infection of the entire organism, but rather as indicating a priority of involve- ment in a given portion of the genito-urinary system in comparison with infection of neighboring parts. In discussing the general etiology of tuberculous infection of the genito-urinary tract, the word primari/ will be used simply in the sense of its local application, it being well understood that the infection must proceed in all cases from some antecedent, though often undiscoverable, focus. The primary origin of tuberculous lesions in these regions and the sub- sequent sequence of infection have been the subject of much investiga- tion. In the past decided differences of opinion have been entertained as a result of clinical and pathologic research. Following much experimental study in recent years, there is a greater unanimity of medical opinion as to the preponderating sites of infection and the more common direction of further dissemination. The parts most frequently involved are the kidney, Fallopian tubes, epididymis, and prostate. It is known that the tuberculous process may be primary in any of these organs. From a clinical or surgical standpoint it is fair to assume that the so-called primary origin of the disease occurs with almost equal frequency in the kidne>-, ppiili(l\iiiis, and Fallopian tubes, with the prostate gland less coiiiiii(iiil\- the seat of early infection. Research work now being conducted at tlic I'hipps Institute in connection with renal tuberculosis forces the conclusion, however, that the kidney is by far the more frequent site of infection. The urine of 60 patients with pulmonary consumption was exhaustively examined for the recognition of tubercle bacilli. After eliminating all possibility of error resulting from the possible confusion of the bacilli with other micro- organisms, it was found that the examination in 44 instances was attended by a positive result. This work was of importance in showing that tubercle bacilli were being excreted with the urine of phthisical patients to a much greater extent than had been generally supposed. The result was susceptible of a double interpretation — first, that the bacilli had been filtered from the blood through the glomeruli without COMPLICATIONS local lesion along the urinary tract, and, secondly, that genuine tuber- culous lesions existed either in the kidney or along the downward course of the urinary system. Heiberg and Morris report tuberculosis of the kidney to be found at autopsy in only 2 per cent, of the cases of pulmonary tuberculosis. Hamilton has shown that after the bacilli gain entrance to the circulation, they may be found in the glomeruli of the kidney, within the afferent arteries, in the interstitial tissue, and in the uriniferous tubules. Wal- sham, in his study of excretion tuberculosis, has demonstrated the presence of bacilli in the glomeruli without evidence of change in the surrounding tissues or in the vessels of the glomerulus. He has proved that the bacilli may become arrested at some point in the uriniferous tubes, often in the medulla of the kidney, and produce secondary foci of tuberculous infection. His views as to the epithelial spread of the infection in the kidney are indorsed by Benda, who calls attention to the presence of bacilli en masse in the midst of the epithelial constituents of the kidney in the common, straight, and convoluted tubules. He emphasizes the extension of tubercle deposit from the straight and common uriniferous tubes in explanation of the origin of renal tuber- culosis in the medullary substance, but ascribes the infrequency of dis- semination from the convoluted tubes in the cortex to the plugging incident to the tuberculous processes. Apropos of Walsham's study the further investigations at the Phipps Institute under the supervision of Walsh are of special interest. Sixty autopsies were performed upon tuberculous subjects, and the Ixidiicys in each instance were cut into very small pieces and subjcitcd t^ careful macroscopic and histologic examination. Definitely typi.-al lulici'cles were found in 35 cases. In addition, the condition in (iilin- laiscs closely resembled a tuberculous invasion of the kidney, an :i»uiii]i;i(iu as to its probable character being justified by the presence nt miliary tubercles in other organs. If the latter instances be included, a tubercle deposit was found in 63 per cent, of the cases. Out of 37 cases examined by Hein, tubercles were found in 21 instances, or about 57 per cent. In the light of such pathologic data it must be accepted that tuberculosis of the kidney exists in approximately one-half of the cases of pulmonary tuberculosis, and to a greater extent than in any other portion of the genito-urinary system. These results are in striking contrast to Senn's recent estimate that one out of every 18 consumptives exhibits a tuberculous process in some portion of the genito-urinary sj'stem. The pathologic institute at Prague has reported but 5.6 per cent, of renal tuberculosis recognized at autopsy upon adult consumptives, while Rilliet and Barthez report 15.7 per cent, among children. It is probable that the frequency of ]iriinar>- involvement of the epididymis corresponds fairly closely to that nf tlie Fallopian tubes. As a result of tuberculous infection of the epidiil) mis an extension of the process may take place to the seminal vesicles, prostate, and some- times to the bladder. From the Fallopian tubes the infection may be disseminated to the ovary, uterus, and peritoneum. Priniary tuberculosis of the bladder is exceedingly rare. Its second- ary involvement may proceed from a downward infection originating in the kidney, or from an upward distribution emanating from the prostate or male genital organs. It is doubtful if upward extension of the tuberculous infection may take place from the bladder to the GENERAL ETIOLOGIC CONSIDERATIONS 489 kidney. Giani has concluded, as a result of his own experimental research, that ascending tuberculous infection to the kidney is absolutely impossible against a normal downward current of urine. The mode and direction of tuberculous infection involving both the genital and urinary systems, with the bladtler as more or less a neutral point, were formerly a greater bone of contention than at present. Cornet believes urogenital tuberculosis to be almost always ascending in character, its origin in most cases being traceable to the genitals. He, therefore, regards tuberculosis of the urinary apparatus as generally secondary to that of the genital system, and states that "this conception is almost universally adopted." He bases his conclusions upon his clinical experience with individual cases and upon the greater relative fre- quency of genital than of urinary tuberculosis, as shown by the autopsy reports of several foreign observers. It is important to call attention to the fact that statistical reports concerning the relative frequency of tuberculous lesions in various parts of the genito-urinary system, are in themselves of little value as con- stituting a basis for conclusions concerning the primary seat of the disease and the method and direction of extension. It is even impossible to differentiate with accuracy the priority of the various tuberculous deposits by a comparison of their stages of development. It should be remembered that the age of lesions per se in any part of the body is not a determining factor in the degree of their development. Cornet explains the ascent of the bacilli to the kidneys partly by extension along the surface of the ureters, partly through the lymph- channels of the mucous membrane, and to some extent by regurgitation of infected urine. He opposes the theory of downward extension from the kidneys to the bladder upon the basis of the washing process incident to the flow of the urine. He cites numerous cases reported by observers in substantiation of his theory regarding primary involvement of the genital organs, and the subsequent ascending infection. He regards the prostate as the most important site of the primary process in the male, and the Fallopian tubes in the female. He describes at length the numerous possibilities of exogenous infection, and explains the relative infrequency of tuberculous lesions upon the external genitals by the supposedly analogous penetrability of the mucous channels by the gonococci. In support of his theories he describes with much circumstance the opportunities for the development of genital tubercu- losis either through auto-infection or otherwise. Even were other clinical and pathologic facts not distinctly antagonistic to this view, it would still appear difficult to reconcile such an opinion to the not infrequent development of genito-urinary tuberculosis among children. Numerous instances have been reported of this infection niiiDiis the \'ery young. Morse has recently cited a case of tuberculosis of I he l^i(hiey in an infant of six months, the bacilli being demonstrated in the urine microscopically, culturally, and by animal inoculations. It certainly involves a vivid stretch of the imagination to explain any considerable number of instances of genito-urinary tuberculosis among the very young upon the fancied theory of infected towels. Baumgarten has endeavored to show by experiments upon animals that the course of the tuberculous infection follows the flow of the secretions, the direction extending doivnward from the kidneys to the bladder and upward from the testicle toward the prostate. The consensus of modern opinion, 490 COMPLICATIONS however, based upon the results of exhaustive studj-, points to the principal mode of infection as emanating from the circulation. Ascending infection in some portions of the genito-urinary tract is not to be denied in occasional instances. There undoubtedly occurs an upward extension from the epididymis to the testes, and from the prostate to the bladder. The involvement of the kidney, however, may usually be regarded as primary and filtrative from the blood. Inability to demonstrate the presence of bacilli in the blood in such cases, affords no valid argument against this method of infection, as it is well known that even in acute miliary tuberculosis with abundant tubercle formation in the kidney, blood examinations have been repeat- edly negative in character. It is worthy of note that tuberculosis of the kidney in women, among whom there is no opportunity for upward extension to this organ from the genital tract, is found at autopsy nearly twice as often as in the male sex. The infection may sometimes take place through the capsule of the kidney, as a result of direct exten- sion from a neighboring tuberculous process. It may be assumed that in a few isolated cases of renal tuberculosis trauma has caused the development of active manifestations among patients in whom the condition had previousl}' been latent. CHAPTER LXXI TUBERCULOSIS OF THE KIDNEY The chief clinical interest attaching to tuberculosis of the genito- urinaiy system relates to the involvement of the kidney. Tuberculous infection of this organ is exceedingly common among pulmonary invalids, as shown by the statistical data, to which allusion has been made in the previous chapter. Autopsy iil>s, r\ jtinns indicate that the con- dition is bilateral in from 50 to (iii | ' r n m. if the cases. Bevan has referred to the report of 12,732 autMp~ii~ n Kiel. Among the cases of renal tuberculosis, 62. .3 per cent, were bilateral and 37.6 per cent, unilateral. These results are in .striking contrast to the infrequency of bilateral involvement as observed at the operating table. Upon the basis of the clinical evidence alone renal tuberculosis is Ijilateral in not over 15 per cent, of the cases. Israel found over 90 per cent, unilateral, as did Facklan. Kiimmel reported 8S per cent, unilateral and Kron- lein, 92 per cent. Rovsing reported a unilateral infection in 216 out of 350 cases. These results strongly suggest an involvement limited to a single kidney in cases of initial renal tuberculosis. The necessity of an early recognition of the condition is thus apparent, as well as the wisdom of more prompt recourse to surgical interference. It must be remembered, however, that such evidence is entireh^ of a clinical nature, and that, in fact, the condition is bilateral much oftener than is indicated by the general symptomatology or the results of clinical examination. In view of the histologic studies of Walsh as to the frequency of tubercle deposit in the kidneys of consumptives, it is apparent that the diagnostic evidences of tuberculous infection are TUBERCULOSIS OF THE KIDNEY 491 often absent. The clinical data alone might seem to establish merely a unilateral involvement. An assumption as to the non-limitation of the disease to a single kidney must not be construed, however, as an argument against the rationale of radical surgical measures directed to the seat of the recognized involvement. Pathology. — The primary pathologic condition is the deposit of numerous tubercles in the kidney. These are at first discrete, but subsequently exhibit a rapid coalescence. In acute miliary tuberculosis the tubercles are found chiefly in the cortex, and occur merely as a part of a general miliary involvement of other organs. It has been questioned if the miliary nodules of the kidney proceed to genuine caseation liefore the death of the patient. The evidence from numerous pathologists is to the effect that cascatidn t:ikos place extremely early in these cases, and that this cuiidition is IrcMnicntly observed at autopsy among patients succumbing to acute iniHary tul)erculosis. This is particularly true of the tuberculous nodules in the cortical substance of the kidney, and especially as they approach the surface, in contrast to the tubercle deposit in the medulla. The nodules of the cortex are almost uniformly of small size, comparable to that of the millet-seed, but may sometimes attain the dimensions of a large pea. Hamilton calls attention to a change in the shape of the nodules according to their locality, being wedge shaped upon the surface of the cortex, more rounded within the cortical substance, and fusiform within the medulla. He asserts that caseation takes place as soon as the nodule is sufficiently large to permit macroscopic recognition. In the non-miliary form small tuberculous nodules may arise from within a tiny blood-vessel in the cortical sub- stance, or within one of the uriniferous tubules. In the former instance the infection is clearly hematogenous in origin, and in the latter, excre- tory. In either event, whether the center of the primary focus be situated within a blood-vessel, in the cortex, or within a urinferous tube, extension and coalescence of adjacent tubercles ra])i(lly take place. Caseation and softening supervene, and the parenchyma nf I lie kidney becomes broken down into cavities filled with pus and debris. As a result of the abscess formation and necrosis, the entire kidney is some- times transformed into a single pouch of broken-down tissue, or there may be multiple discrete abscesses with well-defined septa. Nodules may appear upon the kidney surface, and produce an infection of adja- cent structures. The process may extend peripherally through the capsule of the kidney and result in the formation of perinephritic abscesses. The infection may travel downward, eausin,;; u tubeiculous involvement of the ureters and bladder. The walls of the ureter- may become thickened throughout the entire course, and ulceiatidus ilexclop upon the mucous surface. Stenosis of the ureter may be iiiciduced by the occlusive effect of the inflammatory thickeiiinp,, in conjunction with the presence of debris. This may result in the retention of urine and dilatation of the pelvis, with enlargement of the kidney. A clinical fact of considerable importance in connection with a tuberculous process in one kidney is the development of non-tuberculous irritative and degenerative changes in the kidney of the opposite side. I have recently seen this occurrence in two conspicuous cases, in both of which the second kidney was apparently non-tuberculous, but exhibited evidence of nephritic degeneration to such an extent as to contraindicate, in the minds of surgeons, a nephrectomy upon the tuberculous kidney of 492 COMPLICATIONS the other side. In general, however, the existence of an irritative or even degenerative condition in the second kidney should not preclude the prompt performance of nephrectomy upon the genuinely tuberculous organ, for the reason that excision of the tuberculous focus often removes the source of secondary infection. Sjrmptoms. — The symptoms of renal tuberculosis are usually of insidious onset, entailing in many cases an advanced tuberculous process before recognition of the condition. Extensive destructive change limited to one kidney may take place without the exhibition of any clinical symptoms whatsoever. This is more likely to be the case wlien the bladder has not become secondarily affected, and when the tuberculous process does not involve the pelvis or renal tubes. In cases unattended by bladder infection, the symptoms of the kidney involvement may be altogether absent for prolonged periods. An occasional complete obliteration of one ureter may prevent a recognition of characteristic changes in the urine. The ordinary symptoms of renal tuberculosis consist of increased frequency of urination, change in the character of the urine, pain and tenderness in the region of the kidney, with possibly attacks of renal colic, enlargement of kidney, and the coexistence of slowly progressive constitutional symptoms. Frequent jnicturition often occurs, long before the recognition of pus, blood, albumin, renal casts, or tubercle bacilli in the urine. The earliest clinical feature may consist of simple polyuria, or there may be associated symptoms of more or less bladder irritation. The desire to urinate recurs at short intervals during the night, as well as by day, and is often attended by varying degrees of pain and tenesmus. A characteristic change in the appearance of the urine is sometimes the first symptom to attract the attention of the individual. The urine may be cloudy, smok^•, or distinctly opaque, .somewhat resembling diluted milk, though in the latter ca.se the color is apt to be rather yellow. The cloudy or the smoky effect is produced by the presence of small quantities of pus or blood respectively. A mixed infection occasionally supervenes, the bacilluria often being clue to the presence of the staphylococcus or the colon bacillus. I have under observation at the present time an exceedingly interesting ca.se of colon bacillus infection which will be described in connection with the clinical appli- cation of the bacterial vaccines. Botli the pus and blood may vary greatly in amount, in some instances being recognized only by micro- scopic examination. In other cases there is iiii|iait(>d a distinct change to the gross appearance of the urine. Ilcini'iiliam-; sometimes suffice to occlude the ureter and produce intense pain, with other associated symptoms of renal colic. In some cases a sudden hematuria may be the first symptom referable to the condition. The microscopic exami- nation of the urine easily establishes the presence or absence of pyuria, hematuria, or bacilluria. Considerable difficulty is usually encountered in the microscopic search for tubercle bacilli in the urine, but exhaustive examinations with perfected technic will demonstrate their presence in a very considerable number of cases. The smegma Ijacillus may be differentiated by the use of alcohol, as explained in the opening chapter. Pain may be so slight as to attract little attention, and at other times become an exceedingly prominent symptom. The pain may con- sist merely of discomfort and uneasiness in the lumbar region, or it may TUBERCULOSIS OF THE KIDNEY 493 extend downward in the direction of Poupart's ligament. In the latter event it is usually more severe and is often accompanied by nausea and vomiting. These symptoms, in connection with intense lumbar pain radiating to the bladder, are characteristic of the passage of blood, necrotic tissue, or debris through the ureter. The pain in this locality does not always partake of an acute nature, but may appear as a dull, grinding ache or a sense of ill-defined soreness. With the development of perinephritic abscesses the pain and tenderness are confined to the region of the kidney in the costovertebral angle, and are accompanied by other manifestations suggestive of abscess formation, consisting of temperature elevations, chills, and tumor in the renal region. In coincident vesical involvement the symptoms relate to frequent micturition, tenesmus, and pain emanating from the neck of the blad- der and referred to the perineum. These are aggravated upon exer- tion, particularly walking, riding, or jarring of the body, and are more pronounced in the sitting than in the recumbent position. Several of my patients have complained that the pain is considerably more intense during the cold weather and whenever the surface of the body has become chilled to any extent. An enlargement of the kidney is sometimes recognized upon palpa- tion, but this is by no means constant. Furthermore, an increased size of one kidney, in the presence of other clinical manifestations of renal tuberculosis, does not always afford in itself positive evidence as to the organ involved, as will be explained presently. Considerable importance attaches to the condition of the general health. There is frequently a slight elevation of temperature, with loss of appetite and general indisposition, together with more or less nervous disturbance as a cumulative result of the continued bladder irritation. A certain peevishness and irritability of temperament are noted. Sleep is much disturbed, and nutrition suffers to a moderate extent. Often tuberculous lesions in other parts of the body may be recognized upon careful examination. The diagnosis of renal tuberculosis rests upon the previous history, the exhibition of symptoms just described, the results of physical exami- nation, the cUscovery of tubercle bacilli in the urine, the cystoscopic examination of the bladder, x-ray differentiation, the segregation of urine or catheterization of ureters, and an investigation of the excretory capa- city. The previous histoiy is of value in yielding possible data concerning antecedent tuberculous processes in other parts of the body. Physical examination often furnishes positive information regarding tuberculous deposits in the lungs, glands, bones, joints, serous mem- branes, epididymis, or prostate. It should be borne in mind that too much dependence should not be placed upon the symptoms per se, as other conditions, especially stone in the pelvis of the kidney, may closely simulate the clinical picture of renal tuberculosis. Again, the tuberculous character of the affection having been definitely established by urinary examination, a decision from the symptoms alone as to which kidney is diseased is not always devoid of difficulty. The likelihood of confusion relates to a possible exaggeration of the significance of pain and of enlargement. Kelly calls attention to the pos.sibility of pain upon the unaffected side, and Meyer recites a case in point coming under his observation, the correct 494 COMPLICATIONS selection of the kidney suitable for operation being made upon the basis of the cystoscopic findings, although complaint was constantly made of pain upon the opposite side. In the same way. even with urinary evi- dence of renal involvement, a non-tuberculous kidney considerably hypertrophied may become very misleading. There is no definite relation between a demonstration of tiibercle bacilli in the urine and a genuine renal involvement, as it has been shown that bacilli may be found in the urine of a considerable number of advanced pulmonaiy invalids without actual pathologic evidence of renal tuberculosis. In many cases they find their way, as pre\iou.sly stated, into the uriniferous tubules from the glomeruli without visible structural change. In some ca-ses tubercle bacilli are eliminated with the urine from an infected bladder, which is known to be a frequent seat of secondary involvement. In case of a previous ascencUng infec- tion from the prostate to the bladder, or from the epicUdymis to the prostate, the bacilli may contaminate the flow of urine despite absence of kidney disease. On the other hand, bacilli may be present in the urine as a result of actual tuberculous lesions of the renal tissues without the exhibition of clinical symptoms. Slight tuberculous processes in the kidney are occasionally subject to complete fibrous repair, and are unattended by further caseation or necrotic change. The recognition of bacilli, therefore, is insufficient to afford any accurate criterion by which to judge of the existence and degree of renal disease. The bacilli are of especial import in connection with accompanying symp- toms and other methods of clinical diagnosis. It is essential to recognize a distinction between the significance of the laboratory finthngs and the other clinical evidences of kidney tuberculosis. In other words, the acceptance of an immediate surgical aspect of the condition should not be based alone upon the presence of bacilli in the urine. Occasionally, the characteristic .'jymptoms of advanced tuberculosis of this organ may exist without an early microscopic demonstration of the bacilli. Negative examinations, however, are less frequent than formerl}-, on account of the more careful and elaborate technic employed at the present time. Failure to discover the microorganisms upon urin- ary examination in cases of renal tuberculosis may often be followed by a positive result of animal inoculations. The centrifuged sediment, if injected into the peritoneal cavity of guinea-pigs, is almost always suc- ceeded b}' the development of general miliary tuberculosis, which is found at autopsy after the lapse of from three to five weeks. The cytologic findings are not without some diagnostic significance, although a study of the morphologic character of the cells is seldom practised by the clinician. The presence of mononuclear cells, of course, suggests the greater possibility of finding tubercle bacilli. Colombino has noted certain important changes in the leukocytes, occurring exclusively in tuberculous infection of the genito-urinary passages. The outline is described as angular and irregular, and the cells are elongated and grooved. Sometimes the nuclei are entirely detached. Cystoscopic examination of the bladder is of considerable importance on account of the opportunity afforded for inspecting the ureteral orifices, for noting the presence or absence of ulceration, for comparing the size of the openings upon the two sides, and observing the flow of the urine from each kidney. Decided hyperemia in the immediate vicinity of one orifice is strongly suggestive of a descending tuberculosis of the TUBERCULOSIS OF THE KIDNEY 495 kidney of the corresponding side. Ulcerative changes at this point, with dilatation of the mouth of the ureter, are regarded as almost pathog- nomonic of the conilition. Kelly has referred, however, to an instance of erroneous selection of a kidney for removal, occasioned by the presence of ureteral dilatation upon the unaffected side. He also reports a rare case of primary bladder tuberculosis in which one orifice was much dilated and the other congested, without involvement of either kidney, as shown when first one and then the other was opened for suspected renal disease. Cystoscopy is often difficult of execution because of vesical irritability and contraction, but may sometimes be accomplished even in unfavorable cases, by the injection of :i cuc'iiu solution. The use of the x-ray is of value in facilitat Iul; ■ lin liin isis largely through the process of exclusion. By this means thr imscnce or absence of stone may be determined with approximate accuracy. In the event of enlargement, detected upon palpation, and failure to demonstrate the bacilli, together with negative a:-ray examination, Bevan assumes the probable condition to be simple hypernephroma. The segregation of urine and ureteral catheterization are of the utmost importance from a diagnostic standpoint. Their value consists in part of the means presented by either method to differentiate in many cases the healthy from the affected kidney. The urine from each side may be examined with reference to its quantity, gross appearance, presence of pus, blood, bacilli, or other microorganisms. The unilateral existence of non-tuberculous irritative or degenerative change may also be detected in this manner. By the use of the Harris segregator or by catheteriza- tion there is permitted a determiiiMtinn df the excretory capacity of each organ. Considerable importance h:is been attached to the employ- ment of elaborate methods of urinary cxaniiiuition after catheterization, in order to ascertain the functional power of each kidney. The sup- posed need of such investigation is the necessity, first, of unfailing accuracy in the selection of the diseased kidney for operation, and, secondly, of absolute certainty in the elimination of any possible involvement in the remaining organ. There can be no argument as to the force of the former, but the recognition of the diseased kidney is usually clear upon the i the ilium. Upon bringing the kidney outside of the wound the vessels uro ligated with strong catgut. Considerable difference of opinion is entertained ic^ardiim tlie advis- ability of removal of the ureter if diseasetl. This |ir(i(ciliirc is recom- mended by some on account of the frequent developnieul of fistula and lumbar abscess, with possible danger of further dissemination of the disease. It is Relieved by many that the ureter, even though partially diseased, should be retained because of the increased danger and extent of the operation. Tuberculous sinuses arising from this source sometimes cUsappear after a few months. No objection is made to the removal of a portion of a diseased ureter, and cauterization of the distal end with pure phenol when unattended by special difficulty or too great prolongation of the operation. CHAPTER LXXII TUBERCULOSIS OF THE BLADDER This condition, in the great majority of in.stances, is secondary to tuberculous change in other parts of the genito-urinary system. It may occur as a result of either ascending or descending infection. It is probable that the larger proportion of cases of bladder tuberculosis take place as an extension from a primary lesion in one kidney. Involve- ment of the bladder may occur as a result of ascending infection from portions of the genital system, in accordance with Baumgarten's law regarding the flow of the secretions. It is extremely doubtful, how- ever, if the original source of infection in any considerable numlier of cases is traceable to the external genitals. In other words, the primary infection in all portions of the genito-urinary tract is usually hemato- genous rather than exogenous in origin. Though of rare occurrence, primary tuberculosis of the bladder is sometimes observed. It must be remembered, as previously stated, that the term primary, as applied in this connection, refers simply to the genito-urinary tract, exclusive of infoc'tion in other parts of the body. Primary vesical tuberculosis is i-ather more common among females than in the opposite sex, and, according to Fournier, is occa- sionally due to infection from the female genitals. The pathologic changes relate essentially to the formation of small grayish nodules, which enlarge, caseate, assume a yellowish appearance, and eventually ulcerate. The ulcerations often exhibit an irregular contour on account of the coalescence of multiple tubercle deposits. They vary not only in their lateral distribution, but to some extent as well in depth. Though superficial, in many instances involving merely the mucosa or 500 COMPLICATIONS submucosa, in exceptional cases they penetrate the vesical wall, and produce perforations into the rectum or vagina. The ulcers are usually sui-founded by a zone of more or less intense hyperemia. In fact, before ulceration has taken place the only deviation from the normal macro- scopic appearance may consist of reddened, irregular patches of mucous meml)rane. Symptoms and Diagnosis. — The s3'mptoms are often of slow develop- ment. They may remain unrecognized for a considerable period or they may suggest merely a varying degree of vesical irritability. Complaint is rarely made of pain in the beginning of the affection, but later this becomes a prominent symptom. Early attention is usually called to the contlition by the frequency of urination. Examination of the urine at this time discloses the presence of a variable amount of pus, and some- times of blood. The latter may be recognized as an occasional red blood- cell, or in some cases as a distinct hematuria. A few drops of clear blood may make their appearance at the end of urination. Failure to explain the bladder irritation, and the presence of Ijlood and pus by the demonstration of stone in the bladder or of other recognized patho- logic condition, suggests immediately the probability of tuberculous infection. This hypothesis is substantiated by the discovery of bacilli in the urine, although their non-recognition upon microscopic search of the sediment constitutes no negative evidence as to their presence. The tliagnosis may be definitely estalilished by a positive result of animal inoculation. Cystoscopy, even at an early period, may )'^ield information of almost pathognomonic character. Irregular reddened patches of mucous membrane may be recognized, which are frequently situated in the trigonum. In case of descending infection from one kidney there is usually observed, as already described, a distinct reddening and dilatation, with or without ulceration of the ureteral orifice. It maj' be assumed that the absence of dilatation and ulceration at the mouth of both ureters, with tuberculous nodules and ulcerations in other portions of the bladder is prima facie evidence that the infection is either ascend- ing in character or primary in the bladder, ilej'er reports a single instance of contraction of the ureteral orifice in tuberculosis of the corre- sponding kidney. After the tuberculous lesions in the bladder undergo the process of ulceration, the general type of the symptoms assumes a greater degree of severity. The desire to urinate is more frequent and impera- tive. Sleep is sometimes well-nigh impossible, as the patient is awakened at brief intervals by urgent vesical discomfort. Pain is often very intense, and may be accompanied by considerable tenesmus. Though the bladder capacity often becomes much diminished, the reten- tion of a variable amount of residual urine may take place. Incon- tinence sometimes occurs if the ulcerative process involves the neck of the bladder. The rapidity of the development of symptoms varies somewhat with the location of the ulcerative changes. If the trigonum is involved, the evolution of clinical manifestations is considerably more rapid than when the process does not invade this region. After ulceration has become established, a secondary infection almost inevit- ably supervenes, and adds to the sufferings of the patient, already sorely afflicted, .\ppetite and nutrition l)ecome impaired, and nervous disturbances pronounced. TUBERCULOSIS OF THE BLADDER 501 Treatment. — The treatment of bladder tuberculosis is attended by much more gratifying results than in former years. In early states the management of the vesical affection itself, exclusive of the surgical indications relating to operation upon other portions of the genito- urinary tract, should be based upon the principles of nutrition and rest. As in other tuberculous conditions, the utmost importance attaches to the establishment of the best possible hygienic environment. Rest, as a rule, is more imperative than in any other tuberculous infection, although moderate exercise may sometimes be permitted if carefully supervised. The patient, in the event of suitable weather conditions, should be exposed to the open air for prolonged periods, but the fullest conception of the principles of outdoor living is capable of fulfilment only in regions where sunshine, blue skies, and an invigorating atmos- phere predominate. The climatic conditions appropriate to the successful management of pulmonary tuberculosis are those most likely to influence favorably the course of tuberculous processes in other parts of the body. Treatment with the bacilli emulsion, or, in case of mixed infection, with other bacterial vaccines, may occasionally be attended by favor- able results. The local treatment of vesical tuberculosis as generally employed is most unsatisfactory. The injection of various solutions into the bladder is likely to be productive of considerable pain and discomfort. In the presence of a very acid urine, the injection of mild cleansing solutions, as boric acid, sometimes exerts temporarily a soothing effect upon the inflamed mucous membrane. The injection of iodoform suspended in olive oil has been more or less employed, with varjdng reports. Agents directed to the relief of the bladder symptoms should be selected not only with reference to the acuteness of the clinical manifestations, the condition of the urine, the presence or absence of mixed infection, but primarily to the stage of the tuberculous process. Nodular tuberculosis is not attended by secondary infection, and scarcely calls for local applications of any kind. Instrumentation of the bladder at this period should be absolutely avoided, as the topical solutions do not come in actual contact with the local tuberculous process, while added oppor- tunity is afforded for the introduction of secondary microorganisms into the bladder. Unnecessary irritation is often induced, and the course of the tuberculous disease thereby hastened. Rest and attention to the general health are of especial importance at this time. Diluents should be administered, and excesses of all kinds enjoined, especially indulgence in alcohol, coffee, or highly spiced food. Urotropin is of some utility in case of an alkaline urine, especially if bacilluria is present, although this rarely precedes ulceration unless as a result of careless catheterization. If ilic mine is highly acid, alka- line diuretics are indicated, to which tiiirluir <<( liyoseyamus may be added in the event of extreme vesical irrit:il)ility. Mter the ulcerative process has become established and secondary infection has supervened, considerable benefit may be obtained from the intelligent use of various strong antiseptics. Solutions of corrosive sublimate, as originally advocated by Guyon, have been quite extensively employed. Garceau recommends the early instillation of a solution of 1 : 5000 into the blad- der in case of vesical tuberculosis in the female. With increasing tolera- tion for the drug the strength is increased up to 1 : 500. If the pain 502 COMPLICATIONS is severe an injection of cocain or eucain is advised as a preliminary procedure. He also practises the application of solid silver nitrate to the diseased surface by means of the cystoscope, with the patient in the knee-chest position. "Etherization is sometimes necessary for the initial exploration and application. Tuberculous granulations are reported to have been destroyed by this method, and the process of healing decidedly stimidated. The application of silver nitrate in solu- tion to the tuberculous bladder of males has been attended by much less favorable results. Rovsing, of Copenhagen, has obtained remark- able results by the injection of 5 per cent, solution of phenol into the bladder subsequent to cocainization. The surgical treatment of vesical tuberculosis relates to the curet- ment of tuberculous ulcers, excision of portions of the bladder, and cystotomy. Curetment is practised through a large cystoscope, and is applicable only to large active granulations covering a localized area of ulceration. If curetment is performed, it is usually necessary to cauterize the base of the ulcer with the silver nitrate. The operation is impracticable in most cases, and is attended by the disadvantage of possible further dissemination of the infection. Excision of tuberculous ulcers, or even of a considerable portion of the wall of the bladder, has been practised in occasional instances, but the proper scope of its application is very limited. An important objection to its more general use is the fact that the ulcerative process involves with great frequency the vicinit}' of the ureters, in which locality excision is rarely permissible. Cystotomy is the operation of choice on account of its comparative safety, and the immediate relief afforded to the patient, whose sufferings have been well-nigh ' intolerable. It is especially indicated in severe continuous bladder discomfort, with almost incessant efforts toward urination. The torture resulting from advanced tuberculosis of the bladder is almost instantly relieved by the opportunity provided for immediate evacuation of the urine. For women the infrapubic operation is recommended by some sur- geons, the vagina being regarded the natural route for drainage. It would appear, however, that while vaginal cystotomy has obvious advantages, a decided objection to its employment relates to the fact that operation through this channel is especially likely to invade the area of active tuberculous ulceration, and open up fresh avenues of infection. This objection does not obtain to the same extent in the suprapubic operation. In 1902 Dr. C. A. Powers reported a case of suprapubic drainage for advanced tuberculo.sis of the bladder upon a patient of Dr. S. A. Fisk, who subsequently came under my observation. As the case is somewhat unique in view of the excellent resvdt attending the operation, extracts of Dr. Powers' report are appended. The patient was a man, fifty years of age; his wife and two daughters had died of pulmonarv phthi.sis, and one son was the subject of existing tuberculous infection. "The patient is of rather spare physique, who appears to be between sixty and sixty-five years of age. Examination of the chest negative. Vesical discomfort and tenesmus are urgent. He urinates every half- hour, both day and night. He takes three-quarters of a grain of mor- phin daily. His bladder capacity at this time is about one ounce; there TUBERCULOSIS OFTHE BLADDER 503 is about one-half ounce of residual urine. The urine is pale, neutral, its specific gravity 1014. It contains bacteria, bladder epithelium, mucus, and a little pus. Tubercle bacilli are sought, but not found. Cocain examination for stone is negative; the introduction of the searcher causes slight bleeding. So far as one can judge, there is no other tuber- culous lesion in the genito-urinary tract." After the lapse of two years the patient again came under obser- vation. His condition had grown progressively worse. There was marked spasm at the neck of the bladder; urination was performed every ten minutes, day and night; hematuria was constant. Four grains of morphin were taken daily. " He was examined under chloroform December 26, 1896. Bladder capacity, about six drams. Cystoscopic examination revealed an irregu- lar ulcer, three-quarters of an inch in diameter, at the neck of the bladder posteriorly. This ulcer bled very easily. No stone was found. After prolonged search tubercle bacilli were found in the urine." Permanent suprapubic drainage was performed. The bladder was found not larger than an English walnut. The wall was greatly thick- ened, intensely congested, and studded here and there with miliary tubercles. "There was an irregular ulcer the size of a penny at the neck poste- riorly, rather more on the left side. The ulcer was gently curetted, and its base cauterized with pure phenol. It bled pretty freely. The bladder was drawn up and its edges stitched to the skin. It seemed to resemble in size and shape the finger of a glove. The orifices of the ureters were not seen. A large drainage-tube was placed in the bladder, care being taken that its end should not touch the posterior wall, and the bladder was tightly sewn about it. The outer wound was partially closed. "The patient was out of bed on the tenth day, and at the end of three weeks was wearing a permanent tube and urinary receptacle. At that time his morphin had been decreased to two grains daily. A month later he resumed his occupation, that of traveling aucUtor for a large national corporation. During the two or three months imme- diately following the operation there was occasionallj' moderate leak- age about the tube. The tube itself was a soft-rubber catheter, No. 30 of the French scale, having a velvet eye at the end. as well as at the side. It was carefully adjusted mu\ held well in place. Twice daily the ]iaticnt removed and "boiled the eii(ii-e apparatus and washed ('rcul(i,~is, altcntion is directed to the role of the skin as a chavnd fur lulu i-ciilmis infection. This is perhaps of gi-eater scientific interest than tlie local manifestations of the tuberculous condition. It is to be remembered that a localized tuberculosis of the integument affords no evidence in favor of the skin as a port of entry for the initial tuberculous invasion. Local processes, however, may be expected to attend an entrance of the infection through the skin. It has been claimed by some observers that whenever the skin constitutes the avenue of infection, the tuberculous deposit is confined to the integument, and remains a distinctly localized process. This is unsupported by clinical data, although in many instances the advance of the baciUi is arrested by the proximal lymphatic glands. The virulence of the infection following inoculation is usually slight. 514 COMPLICATIONS Its progress in the lymphatic channels is more or less obstructed, and the evolution of tuberculous lesions of the skin exceedingly slow. The difficult genesis of cutaneous tuberculosis is explained by the unfavorable character of the soil. The thickened epithelium, especially in certain localities, offers a protective barrier against tuberculous infection, even though exposure be excessive and long continued. Further, the temperature is usually insufficient for the growth of bacilli, even in the event of direct inoculation into the subcutaneous tissue. After the actual development of tuberculous skin lesions the number of bacilli are few in comparison with similar processes in the internal organs. In 1898 Baldwin demonstrated the presence of living tubercle bacilli upon the hands of pulmonary invalids. He poured over the palmar surface of the fingers from 5 to 10 c.c. of a sterilized 1 per cent, solution of NaCO^, using sterilized plain glass finger-bowls as receptacles. The washings were inoculated into guinea-pigs, with a positive result in 10 out of 15 cases. Tubercle bacilli were also found in the micro- scopic examination of the centrifuged sediment in 2 cases. Somewhat similar results had been obtained by Cornet in the previous year. In connection with these experiments it is interesting to consider the much greater exposure of the lips. Important considerations are the lessened protection arising from the relative delicacy of the tissues, the common existence of fissures upon the mucous surface, and yet the infrequency of local lesions among a class of people compelled dailj^ to expectorate enormous numbers of bacilli. Even in this location resulting lesions, if present, are almost alwaj's indolent. There are recorded numerous instances of the limitation of the tuberculous process upon the hands following contamination with infected material and accidental inoculation. Even after intrnckiction directly into the subcutaneous tissues, the infective material is usually discharged by suppuration, or the resulting tumor disappears by resolution without clinical evidences of further infection. The resis- tance to infection by the skin is also demonstrated by experiments upon the lower animals. It is well to refer to some of the cKnical and experimental data upon which is based the assumption of a definite localization of the tuberculous process, either upon the integument or at most in the proxi- mal lymphatic glands. The evidence as to the comparatively innocuous character of the infection relates — (1) To the development of lesions upon the hands of individuals after exposure by contact with tubercu- lous meat; (2) similar processes involving the skin of pathologists following postmortem examinations of human and animal subjects; (3) instances of accidental penetration of the bacilli through the skin of those thrown into clo.se association with consumptives, or accustomed to handle infectious sputum; (4) the attempted cutaneous inoculation of animals with subcutaneous or intraperitoneal injections in control animals, (5) ineffective inoculation of unfortunates suffering from malignant non-operable disease. These several considerations may be briefly discussed seriatim. The infection of the hands after exposure to contact with tuberculous meat is always a strictly localized condition. Lozzar, in 190.3, exhibited a number of such cases, in which there had taken place no extension of the tuberculous process beyond the point of infection, although the TUBERCULOSIS OF THE SKIN 515 local lesions had existed for many years. If it be assumed that general dissemination of the infection takes place from the site of inoculation in such cases, it must follow that butchers, before the days of meat inspection, would have shown a relatively high mortality rate from tuberculosis. This has not been demonstrated to be the case. Von Ruck has called attention to the observations of Heilburg, who reported an average of 618 butchers in Copenhagen with but 25 deaths from tuberculosis during a period of ten years. During recent years numerous instances have been reported of an apparently benign local infection following small abrasions of the skin, or accidental injury during autopsy upon man and animals. A conspicuous example of the non-virulent character of such local infec- tion is found in the experience of Laennec, who suffered an accidental inoculation while performing an autopsy, and survived twenty years, though finally dying of phthisis attributed by some to the original local invasion. Gerber's case is also of interest. Following an autopsy wound, and in spite of immediate disinfection, a "Leichen" tubercle the size of a cherry developed at the site of the injury, and persisted for months. Shortly after excision of the nodule the axillary glands became involved, and when extirpated were found to contain tubercle bacilli and to present characteristic tissue changes. There were no evidences of further tuberculous extension. Many isolated cases of injury during autopsy upon consumptives could be cited to support the contention, made by the advocates of a limited benign tuberculous process, that the infection is either confined to the site of inoculation or is arrested by the nearest lymphatic glands. Extension by means of the lymphatics is more frequent in case of the anatomic wart following autopsy upon the human subject, than in association with the local lesions upon the hands of those exposed to contact with tuberculous meat, viz., the verruca cutis described by Riehl and Paltauf. Accidental inoculation occasionally results from autopsies upon tuberculous cows, and cases have been reported of this occurrence without secondary extension of the infection. Ravenel has cited four cases of local tuberculous change following a skin wound upon the hands of veterinarians during postmortem examination. In no instance was there an extension of the process even to the nearest lymphatic glands, although the growth of the nodule at the seat of inoculation was very rapid in one or two cases, suggesting a decided virulence of the infection. In the first case reported the diagnosis was based upon the clinical history and the histologic lesions, bacilli not being demonstrated in the sections. In the second case the local lesion developed at the expiration of three weeks after injury. The nodule was excised two months after the initial skin abrasion, and two guinea-pigs were inoculated sub- cutaneously, with positive results. In the third case the local process developed at the expiration of nearly four weeks after the accident. The nodule was excised at the end of six weeks, and tubercle bacilli were found in the sections. In his report of the fourth case local symptoms were described as appearing in about four weeks, with a well-de\eloped nodule within six weeks. Two guinea-pigs inoculated with portions of the nodule developed generalized tuberculosis, and tubercle bacilli were found upon examination of other portions of the growth. Tscherning has reported a case of accidental injury to the hands of a 516 COMPLICATIONS veterinary surgeon occurring at autopsy. The process was essentially local, though attended by slight extension through the lymphatics. Ravenel has referred to the experience of Mueller, who describes two cases of injury to the fingers resulting during work upon tuberculous cattle. In each case the synovial sheath of a tendon was opened. After operation there was found a distinct tuberculous deposit upon the wall of the sheath, and U])cin the tendon in immediate proximity to the site of the wound, in one rase extending not over a distance of 10 centimeters, and in the other merging into the forearm. Ravenel further alludes to one case observed by de Jong, and to two reported by Joseph and Trautman, in all of which the tuberculous lesion resulted from injury received while at work upon tuberculous cows, and was confined to the point of inoculation in each instance. A similar case is reported by Braquehaye. Penetration of the sldn of individuals by tubercle bacilli of human origin is not uncommon as a result of accidental injury. Numerous cases of such inoculation have been observed among nurses, attendants, relatives, and domestics thrown into close association with pulmonary invalids and with tuberculous products. According to Cornet, cases have been reported by Tscherning, Merklen, Lesser, and Hoist, in which the wound was received through contact with a broken edge of a cuspidor or glass sputum cup, the local process being followed by involvement of the lymphatic glands. I have under observation at the present time a case which presents features of unusual interest. The patient is a woman of forty-five years who has been employed as a servant during the past ten years in a large and well-known institution for consumptives. Throughout this entire period her work has consisted of the very frequent handling of cuspidors. Some three years ago she developed an advanced tuber- culous tenosynovitis or compound ganglion at the front of the right wrist. This extended down the sheaths of the tendons of the little and index fingers nearly to the tips. A physician recently opened the swelling at the middle of the little finger, squeezing out the so-called rice- bodies. From day to daj- more or less of these were expresseil. The little finger becaiiie infected through the wound, and the infection spread up the sheath of the tendon to the general bursa at the front of the wrist and thence to the index tendon. In view of the acute septic manifestations which supervened, it was necessary to amputate the little finger, to excise its flexor tendon, and to lay open and drain the compound ganglion itself, as well as the sheath of the index flexors. Diligent attention by Dr. Powers saved the hand proper. Instances of local infection are reported by Cornet to have taken place as the result of a bite by a consumptive (\'erchere, Jeanselme, Leloir). Other cases of accidental injury of various kinds, with sub- sequent local lesions, are recorded among attendants upon consumptives and even among pulmonary invalids tlicinMlxcs. Local cutaneous tuberculosis is found occasionally amoiiu l.iiiii^li(<-es accustomed to handle the linen of consumptives. It has l)een known to result from the piercing of ears and the wearing of infected earrings. Czerny is authority for two cases resulting from skin-grafting. Ulcerative tuberculous lesions, especially of the face, are not infrequently traced to slight abrasions of the skin in consumptives or others exposed to an obvious source of infection. In occasional instances the same is true TUBERCULOSIS OF THE SKIN 517 of the external genitals. Under such circumstances lupoid changes have supervened at the site of unhealed sores, incised or punctured wounds, and almost all forms of excoriation upon the skin, including eczematous and vaccination surfaces. Animal experimentation has also been instructive in determining the role of the skin as a port of entry of general tuberculous infection. Calves, sheep, swine, goats, and guinea-pigs were made the subject of investigation by Chaveau, Giinther, Horner, and Bollinger in former years. Laboratory experiments conducted upon animals in the effort to produce a cutaneous inoculation with highly virulent human bacilli were frequently unsuccessful. In like manner negative results have followed similar attempts to infect these animals by means of subcuta- neous or intraperitoneal inoculations, with the single exception of the guinea-pig, which is the most susceptible of the entire animal species. Bollinger was unable to produce infection through the skin of the guinea-pig in a series of six experiments, but was successful in the sub- cutaneous injections of the control animals. Baumgarten, in 1901, reported work done in his institute by Gaiser in connection with experi- ments upon calves with human tubercle bacilli. It was found that after subcutaneous injections of large numbers of bacilli from pure culture, the point of inoculation remained almost without reaction, and when the animals were killed, several months later, no trace of tuberculous change existed in any part of the body. These results closely con- formed to those obtained by Koch, who inoculated young cattle with pure cultures of tubercle bacilli taken from human beings without dis- covering subsequent symjitoms of disease or the slightest evidence at autopsy of pathologic change. A somewhat doubtful result of inocula- tion experiment was reported by de Schweinitz, Dorset, and Schroeder. A heifer was inoculated with a portion of lung and intestine from a human subject dead of miliary tuberculosis. After six months an autopsy was performed and a small abscess found at the point of injec- tion. Tuberculous involvement of proximal lymphatic glands was dis- covered, and indeterminate growths upon the pleura and diaphragm. The relation of human to bovine tuberculosis necessarily involved in these and other experiments has been discussed at some length, hence further reference to this relationship will be made as brief as possible. Previous to the investigations of Koch and Baumgarten, Rokitansky had endeavored in vain to produce an infection in human beings suffering from incurable disease. Bovine tubercle bacilli were employed in these ineffective inoculations because they had been found highly virulent for rabbits, and were supposed to be identical with the type of micro- organisms derived from human tuberculosis. After a dozen trials without resulting infection the experiment was abandoned, and no attempts of a similar character, as far as I have been able to ascertain, have been repeated. The foregoing considerations comprise a portion of the evidence which, from time to time, has been regarded as sufficient to justify the belief in a cutaneous infection which is almost invariably localized and benign. Ravenel, in his contention for the intercommunicability of bovine and human tuberculosis, explains the innocuous character of the lesions produced by accidental inoculation with bovine tubercle bacilli, by assuming an equally benign local process resulting from infection with human bacilli. This again introduces the question of 518 COMPLICATIONS differences between these two varieties of bacilli, and also suggests the presentation of data to disprove a frequent limitation of the tuberculous process at the site of inoculation, irrespective of the special type of tubercle bacilli. Attention is, therefore, directed once more to the cutaneous lesions appearing upon the hands, derived from tuberculous meat and the cadavers of man and animals, or from inoculation with infected material through contact with tuberculous sputum, and also to different experiments upon animals with the human and bovine bacilli. The verrucous variety of tuberculous lesions of the skin may be accepted as the most frequent manifestation of the local infection. Admittedly this form of cutaneous tuberculosis is rarely accompanied by evidence of lymphatic involvement, although superficial extension does take place in many instances. The process, though insignificant at first, may spread rapidly upon the surface of the integument from the point of invasion until several inches are embraced within the diseased area. The necrogenic wart, the common form of autopsy lesion, though more localized in the cutaneous tissues than the verrucous type, is more often accompanied by secondary extension, and sometimes even by grave systemic infection. A case in point is the recent observation by Ransome (Walsham), concerning the development of acute symptoms following an injury to the left hand of a physician while performing an autopsy upon a child who had died of tuberculous peritonitis. Six days later the temperature rose to 103° F., and a small localized pneu- monic consolidation was detected at the base of the left lung. Shortly afterward the left axillary glands exhibited evidence of invasion. Two weeks after the injury the swelling of glands, together with the constitutional disturbance, was sufficient to demand measures for surgical relief. After incision the pus was found to contain tubercle bacilli, and was infective to guinea-pigs in three weeks. Cases of secondary involvement of glands, pulmonary infection, and finally death have been reported by Verneuil, \'erchere, Pich, and Pfeiffer (Cornet). I am personally cognizant of a similar case of autopsy infec- tion to which a former colleague succumbed. The physician, previously in robust health, suffered a slight injurj^ to the thumb from the breaking of a slide while examining tuberculous sputum. There shortly developed a sore upon the thumb, character- istic of the verrucous form of cutaneous tuberculosis. Amputation of the thumb was advised, but refused. In spite of involvement of the proximal lymphatic glands, the sore healed in from a month to six weeks. After a few months an idiopathic pleurisy developed, which sub.sequently proved to be of tuberculous nature. He died of pulmonary tuberculo-i- in t \y<< yoars from the time of the injury. It is |i .--ililr that such cases would be more numerous were it not for the piutcctidii afforded by the bleeding, and the prompt measures toward disinfection. Deneke has recorded a case of localized cutaneous tuberculosis, followed by infection of the cervical lymphatics and death in a child. The injury was occasioned from a broken jar used by a tuberculous mother. Instances of a fatal termination from accidental inoculation with bovine baciUi are also recorded. Hartzell reported the development of the verrucous type of cutaneous lesion, followed by death from pulmonary tuberculosis within one year. Pfeiffer has related the case of a veterinary surgeon, who exhibited a definitely localized TUBERCULOSIS OF THE SKIN 519 tuberculosis of the cutaneous tissues, yet who succumbed to consump- tion at the end of one and one-half years after the injury. Ravenel has cited the death of Mr. Thomas Walley, Principal of the Royal Veterinary College of Edinburgh, as a probable instance of infection received during autopsy upon a tuberculous cow. The experiments upon animals by Baumgarten and Koch, which have been described, were accompanied by similar inoculation of calves, swine, asses, sheep, and goats with the use of bovine bacilli. In the first calf infected by Baumgarten, death took place within six weeks from general miliary tuberculosis attended with great emaciation and dyspnea. The investigations of Koch with bovine bacilli yielded almost identical results. Injections of tubercle bacilli taken from the lungs of cattle with advanced pulmonary tuberculosis were made subcutaneously. After a brief period there developed high fever and progressive emacia- tion. Many died after the lapse of one or two months. At autopsy, characteristic changes were found not only at the site of inoculation, but also in the lymphatic glands, lungs, spleen, omentum, and peri- toneum. Since the report of these early experiments much investigation of a similar nature has been conducted by European and American observers. It has been pointed out, in connection with the relation of human and bovine tuberculosis, that tubercle bacilli of human origin have been found in many instances to be virulently infective to animals. It is apparent, from a review of the foregoing, that the evidence relating to cutaneous infection is more or less conflicting. It is safe to assume, however, that inoculation with tuberculous material is much more frequent than commonly suppo.sed and likely to be attended by serious consequences. It is probable that the danger of infection through the skin is greater from tubercle bacilli of human origin than from the bovine variety. The role of the skin as an avenue of tuberculous infection should not be dismissed as of trifling significance, although this was formerly believed to be the case. The relation of tuberculous lesions of the skin to the existence of infective processes in other parts of the body is of considerable impor- tance. Among my own patients I have been unable to procure suflScient data as to the comparative frequency of cutaneous tuberculosis aynong consumptives to hazard even an approximate opinion upon this subject. My experience has been confined to the observation of a class of patients outside of free dispensaries and charitable institutions and, therefore, would hardly reflect a correct estimate of the actual proportion of such cases. It is well known that the cutaneous lesions are more common among the ignorant and uncleanly, on account of the much greater opportunity for infection. Among my private cases of pulmonary tuberculosis, however, numbering in excess of two thousand, I recall but two instances of lupus, one appearing upon the forehead and one over the sternum, and a single ulcerative tuberculous process upon the female genitals. Upon the other hand, the evidence is conclusive regarding the frequency of pulmonary involvement among the victims of cutaneous tuberculosis. Bender made inquiry in 159 cases of lupus, and found existing tuberculosis elsewhere in 77 cases, and a history of previous involvement in 22 others. Fox, in a class of 96 hospital cases of his own, reported .33 instances of glandular involvement. Among 144 cases cited by Bloch, 114 exhibited other evidence of tuberculous 520 COMPLICATIONS infection. Sachs reported 115 patients, among whom only 15 failed to present a history of hereditary infection or of active tuberculous disease (Stel wagon). Of 66 cases of lupus reported by the same observer, all of whom exhibited evidence of tuberculous infection in other regions, 36 were definitely tuberculous before the development of lupus. Besnier records 8 cases of pulmonary tuberculosis among a total of 38 suffering from lupus, and Leloir, 98 out of a total of 312 (Cornet). A lessened resistance of the tissues to bacillary invasion, and added means of infec- tion either from without, as a result of accidental inoculation, or from contiguity of diseased structures, constitute ample explanation of the greater prevalence of cutaneous lesions among individuals afflicted with other forms of tuberculosis. Variations in the clinical manifestations and in the character of the pathologic change in the several forms of skin tuberculosis are believed to be due largely to essential differences in the nature of the infective agents. Besnier, Leloir, and Tavernier regard a secondary infection as the chief etiologic factor in the development of tuberculous ulcers, and the inoculation of tubercle bacilli alone as the determining feature in the production of the verrucous forms. According to Stel- wagon, they differentiate, in the various phases of lupus, between a neoplastic and a suppurative process, the former being ascribed to the irritative action of the tubercle bacillus, and the latter to the presence of the staphylococcus aureus. Wright is of the opinion that all cases of suppurative lupus are associated with a staphylococcic infection, and that especially aggravated cases of lupus exhibit invariably a streptococcic infection. The tuberculous character of the cutaneous lesions has been demon- strated by the presence of the bacilli, their growth in pure culture, the results of animal experimentation, and the tuberculin test. Such an array of testimony regarding the nature of the condition appears for clinical purposes to be quite sufficient, despite the dictum of Virchow that the presence of a true pathologic tubercle is the sole determining factor in genuine tuberculosis. He discriminated between a bacter- iologic and a pathologic tubercle, the latter being a cellular organization, developed from the tissues of the host, though stimulated originally by the irritative effect of tubercle bacilli. He emphasized the essential forma- tive or productive element of the cells, which is not inherent to the bacilli alone. Judged solely by this token, it is difficult to reconcile the structure of certain forms of bacillary skin invasion, viz., the verrucous types, lupus vulgaris, and the ulcerative lesions, with true tuberculosis. The anatomic structure of scrofuloderma, however, is closely analogous to that of tuberculosis of other organs, the subcutaneous tissue being the seat of small round-cell proliferation, with epithelioid cells and occa- sionally giant-cells. .\s degeneration progresses ulceration finally takes place through the superficial layers of epidermis. On account of the divergence in the pathologic and histologic structure of lupus from tuber- culous processes elsewhere, it has been suggested that the lesions were produced by two different types of tubercle bacilli, though possessing the same morphologic and biologic characteristics, but this view is not entertained to any extent at present. Reference has been made to the hypothesis advanced by Smith and others that the various recognized differences between the several types of tubercle bacilli may be attribut- able in part to a change in the host, and that the same organism ulti- PLATE 13. f m •^■ss ife-? all! I. ^ ii E -I I g t^' 1 lis 3-0.2 ii(ls, of course, upon the general condition and the extent nf niliiiculous processes in other parts of the body. The personal equal imi is also a most important factor, as most patients, on account of the slow and unsatisfactory progress and the frequent renewed exacerbations fol- 524 COMPLICATIONS lowing an apparent recovery, become exceedingly difficult to manage. Thus the individuality of the patient and of the physician assumes a degree of inportance in the character of ultimate results. In general, it may be stated that if the involved area is not too extensive before active medical interference is instituted, fairly satisfactory progress toward securing cicatrization may be maintained. The process of recovery is, however, tedious to a degree, and demands the exercise of great patience, perseverance, and intelligence, qualities not always attributable to this class of patients. The disease is commonly regarded as less virulent in this country than abroad. Treatment. — The rational management of lupus, as of other varieties of cutaneous tuberculosis, involves the adoption of both constitutional and local measures. The general health must be conserved and -encour- aged in all instances. Precisely as in other forms of tuberculosis, it is the individual as well as the local condition that appeals to the medical attendant for advisory and supervisory attention. The treatment of the general condition is perhaps no less important than in pulmonary tuberculosis, and includes the consideration of such therapeutic agents as climatic change, hygienic surroundings, and appropriate medication. The general management should be based upon the same principles of nutrition, sunshine, and outdoor life as have been described in connection with tuberculosis of the glands, bones, joints, and the genito-urinary system. Medicinal therapeutics comprise the administration of the various tonic and constructive remedies, aids to digestion and prepara- tions directed to the relief of special disturbances. In addition, definite benefit may sometimes be expected from the employment of the tubercle bacilli emulsion in carefully adjusted doses. In ulcerative forms due to the presence of staphylococcic infection a homologous vaccine made from a pure staphylococcic culture should offer satisfying results in occasional instances. In former years, under the use of the old tuber- culin of Koch, rapid healing was induced in many cases, but the relapses were frequent and sudden, and the method was gradually abandoned. The local management embraces the use of topical applications of a soothing or destructive nature, the x-ray or the concentrated light of Finsen, and operative measures. The number of local applications recommended by various dermatologists under the several conditions presented is almost infinite. Their enumeration, as well as the descrip- tion of the technic of the operative methods, belong strictly within the domain of dermatology or general surgery. The procedure usually adopted is that of curetment and scarification. Excellent results have been reported to attend the use of the Finsen light. The x-rays are of undoubted benefit in many cases. CHAPTER LXXVII TUBERCULOSIS OF THE LARYNX This condition is undoubtedly the most frequent complication of pulmonary tuberculosis. Statistical observations as to the proportion of cases of laryngeal involvement among consumptives are more or PLATE i;. \. Lupus vulgaris involving the anterior surface of the chest, of many yeai's' duration, in a woman sixty-five yeai-s of age. Note especially the marked protuberance over the center of the sternum, the characteristic smaller nodules, the crusts, blood-clots, and marginal healing. TUBERCULOSIS OF THE LARYNX 525 less divergent. Bosworth, from an analysis of a large number of collated cases, concludes that tuberculosis of the larynx exists in about one-third of all cases of pulmonary phthisis. He believes, however, that from a clinical standpoint, the number exhibiting subjective symptoms do not exceed 13 per cent., as previously stated by Willigk. According to Thompson, the pathologic statistics from the Brompton Consumption Hospital demonstrated an actual tuberculous involvement of the larynx in 50 per cent, of all cases of consumption coming to autopsy. Cornet has referred to the statistics of several observers, who reported as follows: Kruse, 16.6 per cent, out of 742 cases of consumption; Gaul, 25.7 per cent, out of 424 cases; Eichhorst, 28.1 per cent, out of 462 autopsies; Heinze, 30.6 per cent, out of 1236 autopsies; de Lamallerie, 44.2 per cent, out of 502 cases. In connection with these analyses it is important to call attention to the essentially different conditions obtaining in the computation of statistics based upon the autopsy findings, and those founded purely upon clinical observation. In the former the patients had succumbed to an exhausting disease of a tuberculous nature, abundant opportunity for secondary infection having been provided through overwhelming exposure and absence of tissue resistance. In the other cases the clinical evidence relates to the exhibition of subjective and objective signs among individuals in all stages of pulmonary disease, in many of whom the process is undergoing arrest. Obviously, there is afforded but little opportunity for comparison. It is manifestly improper to state that because approximately one-third of all tuberculous subjects at autopsy exhibit laryngeal disease, a similar ratio must exist among pulmonary invalids as a class. One author has assumed that inasmuch as 50 per cent, of the autopsies upon pulmonary invalids at the Bromp- ton Hospital in London showed pathologic changes in the larynx, and as 70,000 people die annually in England from con.sumption, it must follow that 35,000 sufferers from laryngeal tuberculosis succumb each year in the United Kingdom, and not less than 75,000, "upon the statistics of averages," who are at present afflicted with the disease. Others have gone so far as to indulge in the sophistry that if laryngeal tuberculosis affects nearly one-half of all consumptives, and if pulmonary tuberculosis comprises one-seventh of all deaths, then about one- fourteenth of the population must suffer from tuberculosis of the larynx. As a matter of fact, the clinical manifestations of laryngeal tuberculosis are not as frequent among pulmonary invalids as the pathologic findings at autopsy would iiidimto. Further, it should be borne in mind that the laryngeal Inrnlniiii nl iii:i\- in some cases be quite devoid of chnical significance and it'innin ;[ failure entireli/ suboi-dinalc to the pulmonary affection. In a considerable number of cases, however, the laryngeal disturbance assumes a prominence sufficient to overshadow all other considerations. Among pulmonary invalids, on account of the coexis- tence of a considerable variety of non-tuberculous laryngeal lesions, it is easy to understand how there may arise radically differing statisti- cal observations. Schrotter reported laryngeal tuberculosis in 6 and 8 per cent, of his cases of pulmonary consumption, while McKenzie recognized its existence in 33 per cent, of such cases. Chronic catarrh of the larynx, though of frequent occurrence among phthisical patients, and predisposing more or less to the development of a local tuberculous infection, is unworthy of inclusion among cases of laryngeal tuberculosis. 526 COMPLICATIONS Etiology. — Tuberculosis of the larynx may be primary or secondary, but, in the great majority of instances, its secondary character is estab- lished. Many clinicians have been led to question the existence of a primary infection, but the evidence that such occasionally takes place appears incontrovertible. There came under my observation, in the early part of 1907, a young man who arrived in Colorado three months after the recognition of a tuberculous infection. There was very pronounced hoarseness and slight cough with expectoration. A loss of twenty pounds in weight was exhibited, but there had been no temperature elevation. Upon examination there was a complete absence of the physical evi- dences of pulmonary infection, but the sputum was found to contain innumerable tubercle bacilli as well as the microorganisms of mixed infection. Examination showed the interior of the larynx to be pur- plish red with irregular, slightly nodular infiltration of both vocal bands. The subglottic infiltration was covered with hemorrhagic spots, and the arytenoids were swollen and red. The infiltration upon the left side was more marked than upon the right. It is quite unwarrantable to assume the existence of a primary infection simply upon the basis of a negative physical examination of the chest. The possibility of failure to detect the presence of a small tuberculous focus in the lungs should be fully recognized. In connection, however, with the absence of other clinical evidences of pulmonary disease, and in view of the positive conclusions derived by several pathologists with reference to the possibility of primary laryngeal tuberculosis, it is reasonable, in this case, to question a pulmonary infection prior to the detection of physical signs or the development of laryngeal lesions. In general authentic evidence of primary laryngeal tuberculosis can be obtained only through recourse to the postmortem findings. Massucci reported several cases of primary laryngeal tuberculosis without the discovery of pulmonary lesions at autopsy. Orth has recorded a single instance of similar character. Demme has described a case of larynseal tuberculosis in a child four and one-half years old. who died of tuber- culous meningitis, and in whom the pulmonary tissues were unaffected. Numerous cases have been recorded by observers illustrating the greatly delayed pulmonary involvement following an apparently primary laryngeal infection. It is not uncommon to detect eventually the characteristic signs of pulmonary infection among individuals in whom the evidences of tuberculous involvement were at first confined to the larynx. The clinical recognition, however, of tuberculous proc- esses in the lung after the lapse of many months subsequent to well- defined laryngeal tuberculosis, does not in itself refute the assumption of a primary infection of the larynx. It is true that, in general, tuiserculosis of the larynx either accom- panies or occurs as a later complication of pulmonary consumption. The infection in .some ca.ses is probably produced as a result of the passage and retention of bacilli-laden sputum. The peculiarities of anatomic construction of the interior of the larynx are such as to afford especial opportunity for the lodgment of tiny masses of sputum. The complexity of structure of the many parts of the larynx, the variety of affections, the almo.st unceasing movements in respiration, vocalization, coughing, and deglutition, the irregular disposition of the mucous membrane in intralaryngeal folds, and its intimate attachment to TUBERCULOSIS OF THE LARYNX 527 underlying tissues, all combine to favor a secondary infection in a region traversed frequently by the bacilli. Not only are unusual facilities offered for the hospitable reception of bacilli, but the local structures are subject to constant irritation by reflex excitability and trauma. Cornet has called attention to the fact that the stagnating sputum permitted to remain in various portions of the larynx is usually retained in close proximity to a joint, and in such position that with the normal movements of the larynx a massage-like motion is imparted. Infection also takes place occasionallj' through the circulation. This method of bacillary transmission to the larynx occurs largely as a local instance of a general miliary invasion. The process is usually more or less acute in type, and is attended by other manifestations suggestive of the systemic involvement. As to whether or not local infection may result through the medium of the vascular channels other than in general miliary tuberculosis, opinions differ widely. Some assert that the location of the tuberculous process in the subepithelial tissue and the scant number of bacilli toward the epithelial surface are a priori evidence that the invasion took place from within. This basis of reasoning, however, is unsupported by the accumulated evidence of many observers, who have demonstrated the passage of bacilli through an intact mucous membrane in various parts of the body. Further, irrespective of the larynx, the infiltrative process is known to be more active in the deeper tissues of the various organs. Therefore, the universal predilection of the bacilli for the subepithelial portion, even if true, would afford no argument against direct infection through the epithelial surface of the mucous membrane. Tubercle bacilli have been found, moreover, in large numbers, upon the surface of larj^ngeal ulcers. In the case of apparent primary tuberculosis of the larynx previously cited, without pulmonary signs, the sputum expelled in the act of clearing the throat was peppered with bacilli, although the process in the larynx remained essentially superficial. If the fact of hematogenous infection be denied, save in eases of general miliary tuberculosis, it is difficult to explain satisfactorily the development of laryngeal involvement prior to pulmonary infection, save upon the assumption of extension from a concealed focus through the lymphatics. Such method of development involves necessarily the previous existence of some neighboring tuberculous focus, which, if incapable of demonstration at autopsy, suggests the possibility of inhalation infection in .some cases of primary laryngeal involvement. The testimony thus far adduced as to this possibility is by no means convincing. The demonstration of tulinrlc bacilli, in the nostrils of nurses and attendants in sanatoria, as well as in the tonsillar crypts and adenoid growths of children, woukl affdnl prima facie evidence of their entrance into the larynx of mouth-breathers. In cases of primary tuberculosis of the larynx a consideration in favor of an inhalation infection is the fact, to which allusion has been made, that in laryngeal invasion occurring as a local manifestation of general miliary tubercu- losis, the process is acute, displaying a somewhat uniform, bilateral involvement, with the tissues more or less edematous. If this be true in the event of hematogenous infection attending a general systemic invasion, it may be questioned why it should not also be the case if infection occurs through the medium of the vascular channels without a general miliary tuberculosis. It so happens, however, that cases of 528 COMPLICATIONS primary laryngeal tuberculosis do not exhibit the characteristic appear- ance, nor manifest the typical course, obtaining in general miliary infection. In the former the lesions are usually unilateral at first, of slow development, and chronic course. The assumption appears tenable, therefore, that in cases of primary involvement the source of infection is not invariably attributable to the circulation. An attempt has been made by some observers to demonstrate, in cases of secondary laryngeal involvement, an especial predilection to tuberculous infection iipon the sit'e corresponding to the pulmonary disease. This has failed of sulistantiation in almost all instances, though Schrotter claims, out of 114 autopsies, to have found this rela- tion in 74. It is difficult to explain such phenomena upon the basis of any physiologic data. It would seem that a rational explanation of a unilateral disturbance of function within the larynx is offered by compression of the recurrent laryngeal nerve as a result of pleural thickening or enlarged mediastinal glands. A noteworthy instance of the latter is found in the ease reported upon page 427. It is impossible, however, to reconcile in this manner a corresponding unilateral tubercle deposit in the larynx. I have had occasion many times to observe an active laiyngeal tuberculosis confined to the side opposite the pulmonary infection. A conspicuous example has come under observation and is illustrated by the drawing, Fig. 129, which shows the initial tubercle deposit to have involved the left side of the epiglottis. In this case the early sj-mptoms referable to a tuber- culous process developed with hoarseness in 1887. For several years the patient remained under the continuous observation of expert laryngologists in this country, as well as abroad. On account of the badly ulcerated condition of the left side of the epiglottis, amputation of the left half was performed. The physical evidences of pulmonary involvement were confined entirely to the upper portion of the right lung. The pathologic condition consists of superficial ulceration, infil- tration, deeper ulceration, and tuberculous new-growths. One or all of these conditions may be present in the same larynx. In the majority of cases infiltration is the earliest manifestation of pathologic change. The most frequent site of tuberculous lesions is the region of the aryte- noids and the interarytenoiil commissure. Lake reported this portion of the larynx affected twice as often as the vocal cords, and about three times as often as the epiglottis and ventricular bands (Thompson). In striking contrast is the experience of Gaul, who reports, out of 113 cases, an involvement of the arytenoids in less than two-thirds as many cases as of the vocal cords, and in but little more than one-half the number affecting the epiglottis (Cornet). The consensus report of many laryngologists, however, indicates the preponderance of arytenoid involvement, and the comparative infrequency of epiglottidean affection. Levy in 1889 reported, out of 144 recorded cases, lesions of the epiglottis in but 41. My own observation, in a general way, concerning the loca- tion of tuberculous processes in the larynx among pulmonary invalids, points toward an apparent predilection of the infection for the region of the arj-tenoids. In Figs. 127 and 128 are shown drawings of the laryngeal conditions in two patients recently under observation. I have noticed repeatedly that cases of pronounced epiglottidean invasion were those of general miliary infection, especially if the local process TUBERCULOSIS OF THE LARYNX 529 was accompanied by more or less edema. In such cases there were often recognized small miliary tubercles scattered over the crescentic surface. Fig. 130 represents a drawing of the larynx of a patient who succumbed to general miliary infection. While infiltration usually precedes other pathologic changes, it may be associated with the formation of papillomatous a:riiwths, and finally with varying degrees of ulceration. I have been iininc^cd with the :ir ulous in6Itration, great frequency of small cauliflower excrescences within the inter- arytenoid commissure among phthisic-il |iaiicnt.s, as well as in others exhibiting no evidence of tubeiriilnus inlcction. Tubercle bacilli are sometimes found at the base of the papilloiiiata after curetment. The tuberculous process within the larynx is often roniplicated by varying degrees of mixed infection. In the case uf piinuu-y disease Fig. 129. — Scar of tuberculous ulceration, half of epiglottis, nodular "' I vocal and ventricular bands. previously cited, the secondary infection was pronounced, consisting of many varieties of microorganisms, the staphylococcus and the strep- tococcus predominating. In this connection it is of interest to consider the possibility of secondary involvement of the lung, and the develop- ment therein of local non-tuberculous processes, as a result of extension from the larynx. The downward bacillary distribution may relate to the bacteria of mixed infection, as well as to tubercle bacilli. It has 530 COMPLICATIONS become a matter of common clinical observation, as stated, that an apparent primary tuberculous deposit in the larynx is followed after a variable time by the appearance of pulmonary lesions. Apropos of a possible aspiration infection in the lung, the following case is perhaps worthy of brief report: A bo}', thirteen years of age, the patient of Dr. Robert Le\'j', Dr. Henry Sewall, and myself, was brought to Colorado in February, 1906, presenting a history of hoarseness of one year's duration. An utterly hopeless prognosis was rendered on the strength of an advanced laryn- geal infection. The larynx was found to present the ulcerative stage of tuberculous involvement, and the chest to exhibit signs of definite consolidation from the apex to the third rib of the right lung, with fine clicks at the end of inspiration following a cough. The afternoon tem- perature averaged in the neighborhood of 103° F. The amount of expectoration for twenty-four hours was from three to four ounces. Despite the tuberculous character of the laryngeal disturbance and the pronounced physical signs, the sputum was found to contain no tubercle bacilli after exhaustive examination, but pneumococci were present in large numbers. The case is of interest as illustrating the possible primary infection of the larynx, which, through the dysphagia induced, and the consequent aspiration of particles of food, became responsible for the subsequent development of a pulmonary infection of pneu- mococcic origin. The subjective symptoms of tuberculosis of the lar3-nx consist essentially of varj'ing degrees of hoarseness and dysphagia. To these may be added an increased sensitiveness, which is manifested bj' efforts to clear the throat and by an added tendency to cough. A not infre- quent symptom is pain, extending to the ears and aggravated upon swallowing. This is often noted early in the development of ulceration. While the hoarseness and dysphagia constitute the most prominent symptoms, the former being one of tlie earliest manifestations of the disease, man}^ cases exhibit considerable tuberculous change within the larynx prior to the development of any subjective symptoms whatever. .4 routine examination of the larynx should be conducted from time to time despite entire absence of suggestive symptoms. In this connection it is important to bear in mind the anatomic causes of the voice impairment and of the dysphagia. Impairment of voice takes place as a result of imperfect coaptation of the vocal cords, through involvement of the crico-arytenoid articu- lation, thus interfering with normal tension and producing deficient ab- duction and adduction. Imperfect approximation of the cords ma}' also result from the presence of papillomatous growths in the interarytenoid commissure. Irrespective of the movements of the cords, the voice may be impaired by thickening and ulceration of their free margins. Dysphagia, on the other hand, is produced by ulceration along the free edge of the epiglottis and in the aryepiglottic folds. Only in the presence of this condition is the pain upon swallowing actualh"^ acute. Difficult swallowing, with sometimes a moderate sensation of pain, is experienced in case of extensive infiltration and ulceration of the arytenoids. The onset of laryngeal dysphagia is indeed a most dis- tressing symptom, and may also occur as a result of ulceration of the epiglottis from any cause. I have under observation at present a woman, in advanced pulmonary phthisis, who suffers considerable dysphagia TUBERCULOSIS OF THE LARYXX 531 and dyspnea from the presence of a tuberculous tumor in the right half of the larynx, involving the right vocal band and the right ventric- ular band. A considerable involvement of certain parts of the larynx may exist without the production of subjective symptoms. This is par- ticularly true of moderate changes in the ventricular bands and aryte- noids. The hoarseness may begin as a slight change in the quality or timber of the voice, and extend to the point of complete aphonia. Aside from this impairment of the vocal sounds, a certain huskiness or interference with normal phonation may result from the presence of large quantities of mucus. It is especially noticeable among patients afflicted with epiglottidean swelling, and is sometimes associated with frequent efforts to expel clear mucus of a viscid and often ropy consis- tency. It is possible that the peculiar character of the voice in such cases may be partly occasioned by the encroachment of the edematous epiglottis into the normal air-chamber, thus interfering with the sound vib'-ations and modifying their quality. The dysphagia may vary from a sense of uneasiness duiing the act of swallowing to the most acute suffering. In case of advanced ulcera- tion and immobility of the epiglottis, regurgitation of liquids often takes place through the nostrils. It often happens that patients are able to swallow semisolids when liquids are rejected. Owing to the swelling of the epiglottis, the aryepiglottic folds and the arytenoids, together with the faulty muscular action from infiltration, the larynx is not sufficiently protected during the act of deglutition. Thus liquids having less cohesive property than semisolids readily find their way into the larynx at this time. In the event of severe dysphagia a degree of relief may be secured by taking food through a tube with the head lower than the shoulders. This procedure may be undertaken with the patient reclining over the edge of the bed, the head being downward. The same principle applies in such cases as obtains at the time of administration of food following the performance of intubation in laryngeal diphtheria. Patients are able to swallow more easily with the head lower than the body, because of the fact that in this position the food is not permitted to gravitate into the larynx. A detailed description of the local appearances, revealed upon laryn- goscopic examination, is scarcely appropriate in a book devoted to pulmonary tuberculosis, but the visual conditions are so characteristic, as a rule, that a brief allusion to the more important features is in order. Even before the development of infiltration or of superficial ulceration, typical changes are observed in the color of the mucous membrane, especially within the interim' n( the larynx. The lining mucous membrane is more or less pale or yrllow in appearance, in place of the normal pink. The blanching of tlie membranes may persist in some cases for almost indefinite periods without infiltration or ulceration. Usually, however, minute yellowish, opaque spots show through the superficial epithelial surface. Following a somewhat slow process of softening and disintegration, small points of ulceration are observed, which eventually coalesce and form ulcers of varying size but of shallow depth. Meanwhile localized infiltration frequently takes place in the arytenoids, which are transformed into rounded or club-shaped swellings. While one arytenoid is usually more infiltrated than its fellow, it is 532 COMPLICATIONS somewhat exceptional for the tuberculous process to be definitely unilateral as regards this particular region. The papillomatous excres- cences previously mentioned are easil.y recognized in the posterior arytenoid commissure during abduction, only to disappear from view inthe act of phonation. For a time the cords may continue to present a normal appearance, but in many cases they exhibit a thickening and congestion, with here and there a tiny ulcer upon the free edge. Inden- tations maj^ subsequently form, or the cords may become partially obliterated as the result of marginal extension of the initial ulcerative points. With the commencement of epiglottic invoh-ement authorities are wont to describe a symmetric edematous swelling, giving rise to a so-called "turban-shaped epiglottis," frequently studded with small deposits of miliary tubercle. This larj^ngoscopic image is certainly pathognomonic of 07ie variety of epiglottidean tuberculosis, which has been referred to as especialh' likely to accompany a general miliar}- involvement. There is often noted, however, a marked difference in the distinguishing characteristics of tuberculosis of this region. In the finst place, the edema or infiltrative process may be strictly unilateral. There are, moreover, many cases of tuberculosis of the epiglottis which are not associated with tumefaction and congestion, with the formation of miliar}' tubercles, or even with points of active ulceration. I refer to instances, often observed, of a pale, anemic epiglottis, the crescentic margin of which is somewhat irregular, with a peculiar localized notching, at which points the process may perhaps be described as a crumb- ling, non-inflammatory disintegration. Although considerable deformity sometimes results, the condition is usually attended by no subjective manifestations. In advanced cases of laryngeal tuberculosis, the con- tour of the interior is greatly altered, and extensive areas are involved by the ulcerative processes. It is often difficult to distinguish between the ulcerative and infiltrative regions, owing to the close similarity of their appearance. I am cognizant of the many deficiencies of the foregoing description of the visual appearances in laryngeal tuberculosis, but have endeavored in few words to present the subject from the standpoint of an internist, rather than to aspire to an elaborate exposition, from a laryngologic point of view. For this reason no attempt will he made to introduce elements of differential diagnosis between tuberculosis, syphilis, lupus, perichondritis, and malignant growths, as these considerations pertain not to the complications of pulmonary tuberculosis, but strictly to the domain of laryngology. The prognosis of laryngeal tuberculosis is a matter concerning which clinicians in health-resorts are enabled to form in general fairly definite opinions. There has been observed of late among writers a tendency to indulge in more or less generalization concerning this subject. One very prominent author, from his own experience and that of others, has recently asserted that the average duration of life following the onset of pulmonary tuberculosis is three years, and the period after the development of a complicating tul)erculosis of the larynx, one and one-half years. It must be apparent that each case of laryngeal tuberculosis, like the pulmonary infection, must necessarily be a law strictly unto itself. Each individual instance of this complica- tion, in accordance with the widely differing conditions in force, must be judged solely upon its own intrinsic merits. I have been privi- TUBERCULOSIS OF THE LARYNX 533 leged to observe very many cases entirely recover in the hands of my colleagues, to whom such patients were referred for local treatment. In other cases I have been forced to witness a speedy termination in a suprisingly short time after the development of the laryngeal condition. Furthermore, a few patients have been observed, in whom recovery took place spontaneously, the improvement in the laryngeal affection developing pari passu with the gain in the general condition. Heryng has reported fourteen cases in which the healing was spontaneous. The prognosis of tuberculosis of the larynx may be assumed to vary according to the state of the general health; the extent and degree of activity of the pulmonary infection; the tendency toward tissue repair, as shown by the previous history; the location, duration, and character of the laryngeal process; the nature of the general super- visory control; the skill and experience of the laryngologist; and the personal equation of the patient as regards temperamental peculiarities. Before rendering an opinion as to the probable outcome, all the phases of the individual case should receive thoughtful consideration. The important bearing of the general health and of the condition of the lungs upon the ultimate prognosis is too obvious to warrant explanation. The situation of the tuberculous lesion is of considerable significance as regards its amenability to arrest and the degree of resulting functional disturbance. Generally speaking, a tuberculous deposit within the larynx is possessed of much less direful import than attaches to involve- ment of the arytenoids, and particularly of the epiglottis. Even per- manent impairment of the voice, resulting from extensive destructive change involving the cords and ventricular bands, is assuredly attended by less disastrous consequences than follow the development of dysphagia. Aside, however, from the purely functional incapacity, an infection upon the exterior of the larynx is more likely to be of rapid progress than within, and is more frequently an accompaniment of a general miliary invasion. Tuberculous processes upon the ventricular bands are usually slow. Perhaps the one factor of especial prognostic moment favoring recovery is improvement in the general condition. Treatment. — The management of laryngeal tuberculosis must be primarily directed toward a restoration of the strength and powers of resistance. It is questionable if, in a very considerable number of cases, this feature of treatment should not take precedence over the employment of local applications. Any desire to reflect upon the utility of local treatment, for properly selected cases in the hands of competent laryngologists, is emphaticall> disciaiiiied. It is contended, merely, that not every case of laryngiMl f ulii'iculosis is suitable for local therapeusis. In some patients the nnlun- of the tuberculous process is not such as to demand other tli:ni lociil doanliness, which can be maintained at home under proper iiistiuctions. In others, the character and extent of the underlying puhiicniai)- affection, with the accompanying temperature elevation and exhaustion, are sufficient to preclude attention to the larynx, unless means to conduct the treatment are improvised in the home. Even among patients whose general condition is admittedly less desperate, unfortunate results often attend the effort involved in seeking throat treatment at a point necessarily remote from one's place of temporary abode. It is probable that some patients do not secure results at all commensurate with the expenditure of energy, the nervous excitement, the interruption of the outdoor 534 COMPLICATIONS regime, the frequent accession of fever, and acceleration of pulse con- sequent upon the journey to the of&ce of the larj-ngologist. There can be no doubt as to the correctness of the preceding assertion, even among invalids for whom local management is actually indicated upon the merits of the laryngologic condition. Under such circumstances it necessarily becomes a choice of the lesser of two evils, the decision as to the method of procedure demanding a wise discrimination upon the part of an experienced clinician. There can be no argument as to the propriety of local management in cases of ulcerative laryngeal involvement among individuals whose general condition does not contraindicate the effort required to secure the treatment. Nothing can be more pitiful, however, than to witness advanced and hopeless consumptives dragging themselves to a doctor's office day after day to receive a few moments of laryngologic attention, no matter how skilful or rational the treatment. It is not within the scope of this book to enter into the details of local treatment applicable to the manifold conditions present in laryngeal tuberculosis, and, therefore, but a cursory discussion of the general principles is appropriate. The determination of the particular form of local treatment to be accorded individual cases is entirely beyond the province of the internist. The conservative judgment of the experi- enced laryngologist as to methods of application is of far greater value than dexterity of manipulation. In general, alkaline cleansing solutions are indicated for any variety of tuberculous lesions. Solutions of cocain and eucain are of value in case of painful deglutition, or as a preliminary to the introduction of other preparations. Levv frequently uses preparations of menthol which are antiseptic, anesthetic, and stimulant. He descriljes their effect "in relieving the pain, diminishing the cough, and giving the patient a feeling of general well-being." Ulcerative processes are variously treated by applications of iodoform, aristol, lactic acid, nitrate of silver, and occasionally by the careful use of the curet. Cohen has cautioned against the use of lactic acid unless the mucous membrane is broken, but he believes it to be of especial value in case of superficial ulceration. It should not be used in excess of 80 per cent, strength, anil usualh' in considerably weaker solutions. Its efficac)- depends upon the thoroughness of its application, which in\olves a degree of rubbing or massage. Dr. J. M. Foster prefers a 2 to 8 per cent, aqueous solution of formaldehyd, which is to be thoroughly rubbed into the ulcers. For the technic of the several procedures, together with their special indications, the reader is referred to text- books upon laryngology. In dismissing the subject of laryngeal tuber- culosis attention is again called to the paramount importance of general management. The same principles of climatic, hygienic, and consti- tution;il treatment apply as in tuberculo.sis of glands, bones, joints, genito-urinary organs, and other regions already described. It should be noted, however, that laryngeal tuberculosis, more than all other complications, is apt to be associated with considerable pulmonary involvement and a varying degree of functional derangement, systemic infection, and exhaustion. For these reasons rest, as opposed to exer- cise, should be emphatically enjoined. Sunshine, fresh air, and super- alimentation are demanded even more, rigidly than in other forms of local tuberculosis. Favorable climatic influences are of special benefit on account of the improved nutrition afforded, the increased facilities TUBERCULOSIS OF THE EAR AND NOSE 535 for outdoor exercise, and the psychic effect of changed environment. A tendency has been observed to decrj' the advantages of climate for invahds suffering from any form of laryngeal tuberculosis. As a matter of fact, however, if the general condition and the pulmonary infection are such as to suggest the propriety of climatic change, the existence of a laryngeal tuberculous deposit only intensifies the necessity of prompt action. Any therapeutic agent known to exert a favorable influence upon the course of the pulmonary disease may be expected to exercise a corresponding effect upon the local condition. The existence, therefore, of vulnerable tissues within the larynx, in association with pulmonary tuberculosis, in the absence of special contraindications, accentuates the wisdom of early climatic change. CHAPTER LXXVIII TUBERCULOSIS OF THE EAR AND NOSE The frequency of purulent otitis media among pulmonary invalids is a matter of common clinical observation. The tuberculous nature of the affection is demonstrated by the presence of bacilli in the secretion and by the results of autopsy, the latter having disclosed tubercle deposit in the membrana tympanum, the middle ear, and even the inner ear. According to James, Wingrave found true tubercle bacilli in the purulent discharge of 17 patients with middle-ear disease out of a total of 100, and pseudotubercle bacilli in 7 cases. There appears to be no fixed relation between the activity or extent of the pulmonary process and the development of tuberculous disease in the ear. It is generally believed, however, that the otitis is more prone to occur among advanced consumptives, and to be relatively infrequent during early stages of pulmonary disease. As a matter of fact, tuberculosis of the ear is comparatively rare as a clinical manifesta- tion among rapidly progressive cases of pulmonary tuberculosis, but, upon the contrary, develops somewhat _moi-e frequently among chronic invalids in whom the pulmonary process is more or less stationary. It should not be assumed that the aural affection rarely supervenes .during periods of general or pulmonary improvement, nor that a pre- vious otitis media invariably undergoes a corresponding change for the better at such a time, after the manner of laryngeal tuberculosis. It is not uncommon, even among consumptives who have attained a mod- erate degree of improvement in the general condition, with an apparent quiescence of the tuberculous infection. I have had occasion to note its occurrence not infrequently among cases of the fibroid type, and it has appeared in some cases after a complete arrest of the pulmonary infection has been secured. Several patients have presented the history of a purulent discharge of a demonstrably tuberculous nature as the first manifestation of tubercle deposit. In view of the preceding observations, it is reasonable to question to what extent the disease of the ear is dependent upon the pulmonary infection per se. Unusual facilities are presented among consumptives 636 COMPLICATIONS for the extension of the tuberculous infection to the middle ear, the Eustachian tubes constituting the medium of bacillary transmission. The orifices of the tubes are subject to almost continuous exposure to infection, on account of the frequent passage of sputum to the pharynx, and the forced distribution of bacilli to neighboring regions by violent expulsive cough. Masses of infected sputum frequently become adherent to the posterior wall of the pharynx, and remain for prolonged periods. This is also true of the nasopharynx, particularly with the patient in the recumbent posture during sleep. Cornet has referred to the statement of Dmochowski concerning the difficult detachment of bacilh after their deposit upon the projectile lips of the Eustachian orifices, and to the opinion of Haberman that the tubes are wiiler in consumptives, by reason of the greater absorption of fat and tissues. There also exist among pulmonary invalids certain other exciting and aggravating causes of bacillary extension to the middle ear. The acts of coughing and sneezing, vomiting and retching, so common among this class of patients, provide a means of ready communication to the ear through a patulous tube. In this connection the thought is suggested that the violent paroxysmal cough, frequently observed among cases of the fibroid or bronchitic types, is at least a partial explanation of the surprising development of ear tuberculosis in patients otherwise maintaining a degree of improvement. The conveyance of tuberculous infection to the ear through the tympanum by the introduction of contaminated fingers and a multitude of miscellaneous articles, as claimed by various authors, although accepted as a most remote possibility, is of but slight practical interest. There are, however, other sources of infection of undoubted importance exclusive of the existence of pulmonary tuberculosis. Purulent otitis media is a not infrequent sequel or accompaniment of cervical adenitis in children. In the discussion of glandular tuberculosis it was pointed out that involvement of the cervical glands was often due to an infection traceable to the nose, mouth, pharynx, or tonsils. The development, therefore, of tuberculosis of the glands of the neck simultaneously with that of the middle ear, in the absence of pulmonary disease, suggests the probability of their common origin. Attention has been called to instances of tuberculous infection of the tonsils and adenoid structures, which serve both as receiving reservoirs for bacilli and as points of departure for further dissemination. The reports of various observers as to the frequency of involvement of these tissues have been cited. The faucial tonsils and the lymphoid tissues in the nasopharynx are unusually receptive to wandering bacilli, by virtue of their exposed position and the anatomic peculiarity of their construction. The evidence is apparently (•iinclusi\c (h;i( iiifcctinii of tlicso parts, even in the absence of ]niliiiMii:iry t iilici-culdsis. dccui-s (■(uisiilci-nbly (iftcner than has been supjidscd, ami tliat a ready tiaiisniissioii may be effected to the ear through the Kustachian tul)C. Jonathan Wright has repeatedly called attention to the fact that various forms of bacteria are retained upon the surface of the epithelial lining of the tonsillar crypts, while carmin granules and oily particles traverse the tissues without obstruc- tion. He regards the tonsillar crypts as pits especially suited for the lodgment and retention of tubercle bacilli. The cavities are unpro- tected by cilia, which serve to sweep away the bacteria in upper portions of the respiratory tract. It is evident that the tonsils and contiguous TUBERCULOSIS OF THE EAR AND NOSE 537 areas are regions of essential importance as regards the occasional transmission of tuberculous infection to various parts of the body. The origin of middle-ear tuberculosis is sometimes referable to a distribution of the infective microorganisms through the circulatory channels, but this is, to say the least, quite exceptional, save in cases of general miliary infection. The development of mastoid involvement -without middle-ear disease is perhaps suggestive of hematogenous infection. The extension of the tuberculous process to the mastoid follovnng middle-ear infection is fairly common, though by no means so frequent as the secondary involvement of the mastoid after non- tuberculous otitis media. Personally, I have observed but very few instances of mastoid disease complicating middle-ear tuberculosis among pulmonary invalids. Dr. W. C. Bane reports that not over 3 per cent, of all the cases of mastoiditis operated by him were of tuberculous origin. Dr. J. M. Foster, after a careful review of his cases submitting to mastoid operation during three years, reports no single instance of tuberculous infection. As the result of a wide experience, he is inclined to regard the tubercle bacillus in the production of mastoiditis requiring operation as a negligible quantity. It is hard to subscribe to a state- ment, recently made, that the common channel of tuberculous infection to the meninges of the brain is by way of the ear. The onset of otitis media among pulmonary invalids is less often abrupt or attended by acute inflammatory symptoms than among cases of a non-tuberculous nature. An early premonitory symptom is a sensation of slight fulness in one ear, and a beginning impairment of the hearing. At times complaint is made of pain, though this is rarely extreme, and is much less acute than in cases of non-tuberculous otitis media. The pain, though localized in the ear, frequently radiates from this point to the entire side of the head, and there is often present a distinct throbbing sensation. In the beginning there is usually but slight, if any, elevation of temperature, thus differing from the early fever almost invariably present in ordinary acute suppurative inflamma- tions of the middle ear. With increasing distention of the drum, these symptoms, as a rule, become correspondingly more severe, while dizzi- ness and tinnitus aurium are often distressing manifestations. After perforation has taken place a varying amount of purulent secretion is discharged. In addition to tubercle bacilli there is usually present a secondary infection consisting of streptococci, staphylococci, or pneu- mococci. The pain in most cases disappears with the appearance of the discharge, which, as a rule, is non-odorous, finally becoming scanty and of a thick, tenacious consistency. This often evinces a tendency to dry upon the edges of the perforation, which in some instances is completely covered, producing an underlying maceration of tissue. There is usually a dulling and reddening of the ear-drum as a result of the inflammatory change, and the membrane is thickened to a con- siderable extent. The perforation varies in size and shape, sometimes an extensive area of the membrane having been destroyed. Necrotic changes in the middle ear occasionally supervene, and the process continues to extend to the destruction of the inner ear, involving the labyrinth, or spreading posteriorly to the mastoid. Fever is common, as is also a fetid discharge. The involvement of the mastoid may be either chronic or acute, neither condition, however, being especially frequent in tuberculous disease of the middle ear, though possible of 538 COMPLICATIONS development as a result of exposure to cold or severe influenza. In this event the pain becomes more pronounced, but is localized more or less in the mastoid region and aggravated by pressure. As a means of prophylaxis, it is important to caution patients against violent blowing of the nose or practising unconsciously the method of Valsalva, as thereby infected material is likely to be intro- duced into the Eustachian tubes. Before the stage of pus-formation, the treatment should consist of efforts toward maintaining a free opening of the tube into the middle ear. Catheterization is indicated if cautiously performed. If fever is present, free catheterization, light diet, rest in bed, and the administration of aconite or saline fever mixtures are important, together with the employment of leeches, either in front of the tragus or over the mastoid. Irrigation with hot salt solution is often attended by considerable relief. Paracentesis of the drum is indicated if bulging is prominent. After the perforation has taken place, the chief effort should relate to keeping the ear clean and dry. Routine irrigation is not recommended, liut an occtisional instillation of a cleansing solution is indicated, followed bj' careful drying with a pledget of cotton. The latter procedure should be prac- tised by the patient from time to time. General treatment is demanded, as in all other forms of tuberculosis. Another important source of bacillary infection is found in the anterior nares. Although tuberculosis of the nasal cavity is extremely rare, the presence of baciUi in large numbers within the nares is quite common. The investigations of Straus several years ago, as to the exist- ence of bacilli in the nostrils of healthy individuals, attracted wide-spread interest among students of tuberculosis. He demonstrated virulent tubercle bacilli in the nasal cavities in nine out of twenty-nine people, who were brought into association with consumptives, br. Walter B. James has reported the experience of Dr. W. Noble Jones, who in 1900 obtained a positive result in 10.3 per cent, of cases from the inoculation of guinea-pigs with the nasal secretions of well people, who were not brought into intimate contact with pulmonary invalids. Despite the occasional presence of bacilli in the nostrils of healthy persons, and the enormous invasion of the nasopharj^nx and posterior nares among consumptives by reason of violent acts of coughing, but comparatively few instances of primary tuberculous infection of the nasal mucous membrane have been recorded. Willigk, out of 1600 autopsies, observed only a single case of tubercle deposit upon the nasal septum, although 450 of the subjects exhibited evidences of pulmo- nary disease (Walsham). Weichselbaum, however, in 146 autopsies upon consumptives, discovered two instances of nasal tuberculosis. In 1900 St. Clair Thomson recorded a case of primary tuberculosis of the nose. Fein has recently reported a probable primary tuberculosis of one turbinate in a trained nurse. Many European observers have cited similar cases, and Heryng collected from the literature a total of 90. In 1906 Onodi reported an extensive primary tuberculous lesion of the nasal septum, although there was no clinical evidence of tubercu- lous involvement in other parts of the body. It is quite possible a local tubercle tleposit might be discovered in more instances were the char- acter of the clinical manifestations such as to suggest detailed inspection. I have seen among pulmonary invalids numerous cases of erosion and TUBERCULOSIS OF THE EAR AND NOSE 539 perforation of the septum supervening upon an initial slight excoriation of the mucous membrane, and attended by crust formation, but it is, of course, impossible to assume a tuberculous involvement in such cases. It is apparent that the anatomic structure and physiologic processes within the nose jointly furnish a soil inimical to the growth and develop- ment of tubercle bacilli, although these microorganisms are arrested in large numbers with the inspired air. It would seem that the element of protection is referable more to physiologic considerations than to essential peculiarities of anatomic construction. The mucous membrane of the nose is not less permeable than that of the pharynx or larynx, and- therefore differences in the susceptibility of the tissues are not attributable solely to changes in the epithelial structures, although the cilia undoubtedly exert a certain protective influence. The impene- trability of the mucosa by the bacilli is rather to be ascribed to the reflex excitability of the nasal mucous membranes, and to the immediate outflow of defensive secretions upon the inhalation of foreign agents. For a long time the convolutions of the turbinated bones were thought to act as a filter for the bacteria contained within the inspired air. In addition to the action of the vibrissse at the entrance of the nostril, it is known that an extra amount of viscid fluid is secreted over the sur- face of the convoluted folds of mucous membrane, when irritated by inhaled dust. The bacteria are kept on the move at least for a consider- able distance through the wave-like motion of the ciliated epithelium. They are also washed away from the upper portion of the nose by the gravitating serum, thus affording protection to the region of the cribri- form plate of the ethmoid. It is seen, therefore, that in the complex processes of infection and immunity the cilia act in a mechanic way as agents of defense. Accord- ing to Wright, von Dungern has demonstrated that the ciliated epithelial cells like the circulating cells in the fluids of the organism, manufacture antibodies, so that it may be inferred that the protection against infec- tion within the nose is not entirely mechanic in nature. Cornet calls attention to the chemic action of the various secretions in inhibiting the development of bacteria, and refers, for illustrative purposes, to the failure to secure pure cultures of pneumococci in this location. It does not seem, however, that too much influence should be ascribed to the supposed chemic processes opposed to bacterial growth in the nose. If such bactericidal properties exist to any considerable extent, infec- tion with the diplococcus meningitidis, and its conveyance through the cribriform plate would be decidedly less frequent than is actually the case. It is probable that the tubercle bacilli are washed from the mucous membrane by the copious secretions, and thus discharged from time to time without opportunity for prolonged retention. It has been shown by Renshaw, Cornet, De Bono, and Frisco that bacilli may gain entrance to the lymphatics through the mucous membrane of the nose in rabbits and guinea-pigs, suggesting at least the absence of bacteri- cidal power in the nasal secretions of animals especially susceptible to general infection. Furthermore, the penetration of the membrane, and the ingress of bacilli into the lymphatic circulation of children, even in the absence of structural change of the mucosa, are suggested by the development of cervical adenitis. Several authors have advanced the possibility of meningeal involvement through the medium of the lymph- spaces emanating from the nose. Irrespective of considerations pertain- 540 COMPLICATIONS ing to the lymphatics, it is easy to conceive of the probable distribution of the bacilli from the nose and nasopharynx to the immediate region of the Eustachian orifices, with resulting disturbance of the middle ear as the first clinical manifestation of the tuberculous infection. Further discussion of a subject so purely technical is entirely inap- propriate in a book of this character. Similar con.siderations preclude more than the briefest possible allusion to the various forms and .sites of tuberculous infection of the eye. There is no portion of this organ which may not become the seat of tuberculous involvement. Tuberculosis of the choroid was shown by Cohnheim in 1867 to be in most cases a local manifestation of a general miliary infection. It is often associated with meningeal tuber- culosis, and occasionally with a similar involvement of the brain. Cornet has referred to the abundant blood-supply of the choroid and attributes to this interesting fact the coincidence of early infection in association with the circulatory distribution of bacilli in miliary tuber- culosis. The condition is always bilateral in contradistinction to a unilateral involvement in other parts of the eye, in which the infection occurs as a result of inoculation or secondary extension. Opportunity for direct infection of the eye, and especially the cornea or conjunc- tiva, would appear more or less abundant among pulmonary invalids on account of contaminated fingers, handkerchiefs, or towels. No instance, however, of such an occurrence has ever come under my observation, but such cases have been reported by others. The evidences pointing to external infection consist of the unilateral involvement, close association with phthisical invalids if the patient be not the subject of tuberculosis, history of trauma, and absence of pre- existing foci of infection in the immediate neighborhood. It is, of course, conceivable that a primary tuberculosis of the cornea or of the conjunctiva may occur from the entrance of infected dust or by the dis- semination of bacilli in the act of coughing. The greater frequency of conjunctival tuberculcsis as compared with corneal is no doubt explained by the increased facility of retention of microorganisms upon the surface of the former. The removal of foci from these parts is usually followed by complete recovery, without a subsequent return of the tuberculous process. Many instances have been reported of tuberculosis of the iris and occasionally the vitreous, the sclera, retina, and lacrimal sac. Verhoeff, in the early part of 1907, reported some observations in con- nection with tuberculosis of the sclera. He regards scleritis as almost always a tuberculous process. He observed 13 cases of this conchtion, in which the diagnosis was made in all instances by the tuberculin test. A general reaction was obtained in all cases and a local reaction in 9. He was unable to obtain evidence of systemic tuberculosis in but 3 cases. MIXED INFECTION 541 SECTION IX Non-tuberculous . Complications CHAPTER LXXIX MIXED INFECTION Attention has been called repeatedly to the essential differences observed in the postmortem findings, the symptoms, clinical course, and prognosis of pulmonary tuberculosis. The absence of any conven- tional type, as shown by the variety of pathologic conditions and the modifications in the character of the disease, is undoubtedly dependent to some extent upon the presence in the tissues of pathogenic bacteria in addition to the tubercle bacillus. While in many instances the clinical manifestations are subject to considerable alteration through the influence of pyogenic microorganisms, the evidence at hand is not sufficient to permit the assumption of a definite and invariable relation of cause and effect. It is known that many bacteria may exist within the elementary tubercle or the surrounding tissues, and be expelled with the tuberculous sputum. They are also found upon mucous or serous membranes, upon walls of pulmonary cavities, in organs of the body aside from the lungs, and sometimes in the blood. These micro- organisms may fraternize with the tubercle bacillus, forming a true symbiosis, the more common forms being the streptococcus, the staphy- lococcus albus and aureus, the pneumococcus, the influenza bacillus, the micrococcus catarrhalis, and the colon bacillus. In addition, several other species, notably the diphtheria bacillus, have been reported by observers. Among my own patients, the above-mentioned micro- organisms have been found many times in specimens of washed sputum, and in several instances the pneumococcus and streptococcus in the blood. It is believed that, as a general rule, in the terminal fevers conforming to the septic type, the pus-producing organisms are present in the pulmonary tissues, constituting a bacteremia. The streptococcus has been reported to be present in miliary tubercles before disintegra- tion. The relative gravity of the mixed infection produced by the various microorganisms has not been definileli/ established, but in view of the fact that the pneumococcus, staphylococcus, and streptococcus belong to the well-known group of pathogenic microorganisms, it is reasonable to assume a priori that they are capable of inflicting great damage in the presence of pulmonary lesions. Many times I have noted the presence of the pneumococcus in connection with gross anatomic changes in the pulmonary tissues, as evidenced upon physical examination, but have observed that, as a rule, the general systemic evidences of mixed infection, i. c.. chills, mental heljotude, excessive emaciation, and general prostration are more frequent in association with streptococcic or staphylococcic infection. Attempts to attribute the occurrence of pulmonary hemorrhage esseiitially to the action of the pneumococcus have thus far not been entirely substantiated. Both the staphylococcus 542 COMPLICATIONS and the streptococcus are capable of producing severe constitutional disturbance, the clinical condition being characterized bj' chills, fever, sweats, rapid loss of weight, physical weakness, and a tendency toward cj'anosis, with slight etlema of the face and hands. It has rather been my conclusion that the intellect is more likely to be clouded in cases of staphylococcic infection, the mentality often being unaffected if the streptococcus is the offending microorganism. This clinical feature of streptococcic infection among pulmonary invalids is somewhat surprising in view of the well-known delirium attending puerperal septicemia, erysipelas, and other streptococcic infections. The expecto- ration attending the presence of these pus-producing microorganisms is profuse, heavy, and usually of a greenish-yellow^ appearance. Though usually distinctly purulent and raised with ease, it is sometimes decid- edly ropy and tenacious. The influence of the influenza bacillus is somew-hat doubtful as far as the destruction of tissue is concerned, although areas of broncho- pneumonic consolidation frequently result. As a rule, these pneumonic processes are not of long duration, resolution taking place in from several days to a few weeks. In exceptional cases, however, I have observed a persistence of the consolidation until after the lapse of several months, when the physical evidences of the condition finally disappeared. A notable instance of this condition is reported in connection with Differential Diagnosis. A pronounced influenza infection is often accompanied by increase of fever, malaise, aching of limbs, impaired appetite, and aggravation of cough, the latter being more or less paroxys- mal in nature in some cases. I have found the colon bacillus very largely responsible for the clinical symptoms attending infection of the genito-urinary tract, and have observed remarkable improvement following the exhibition of a colon bacillus vaccine derived from the urine. Hematuria and asso- ciated symptoms suggestive of tuberculosis of the kidneys and of other portions of the genito-urinary system have entirely disappeared under treatment for the mixed infection. The reader is referred to Case No. 22 upon p. 752. The nephritic disturbances so common in cases of advanced pulmonary tuberculosis undoubtedly are produced in man}^ instances as a result of the multiple mixed infections persisting during indefinite periods. The clinical evidence is amply sufficient to substantiate the belief that a prolonged secondary infection, though slight in degree, is suffi- cient to produce desquamative and degenerative changes in the kidneys of pulmonary invalids. Several times I have noted the development of severe acute nephritis following a temporary streptococcic infection of the tonsils. The clinical symptoms in these cases were of so urgent a nature as to suggest the probabilit}' of a general septicemia. Chronic parenchymatous nephritis has frequently followed other secondary infections if long continued, even though apparently of slight severity. A large number of patients have developed well-defined nephritic disturbances, after apparent arrest of the tuberculous process, suggesting a possible relation between the gradual onset of kidney irritation and the acquired immunity from the tuberculous disease. It has almost seemed in some cases that the price paid for the subsidence of the activity of the tuberculous infection is the insidious development of nephritis. Irrespective, however, of this feature as applied to pul- MIXED INFECTION 543 monary invalids in general, it is demonstrated that kidney disturbances are much more common in those cases of pulmonary tuberculosis exhibiting varying degrees of secondary infection. Many cases are almost devoid of clinical symptoms, while others exhibit either vague or indefinite manifestations. A considerable number, however, present symptoms undoubtedly due to insufficiency of the kidneys, although often attributed to the effects of pulmonary tuberculosis. Among these are included slight edema, rapid pulse, varying degrees of dyspnea, gastro-intestinal disturbance, cyanosis, and mild chronic uremic symptoms. The more common evidences suggestive of nephritic involvement are fatigue and rapid pulse. These are often present upon slight exertion in the absence of all other clinical manifestations referable to the kidney condition. Dyspnea is frequently out of all proportion to the amount of respiratory incapacity occasioned by the pulmonary involvement. Edema of the face, hands, feet, and ankles is also common, as is diarrhea, though the latter is more frequently associated with amyloid degeneration. I have been unable, from my own observations, to ascribe as much significance to pain and aching in the lower back as have other observers. The pulse-rate, while abnormally rapid in many cases, is not invariably accompanied by an increase of arterial tension. Upon the contrary, it has been my experience that the blood-pressure is frequently under 100 in cases of nephritic involvement in the course of pulmonary tuberculosis. Cardiac murmurs have not been found unduly frequent or possessed of special significance in these cases. The examination of the urine often fails to disclose the presence of large numbers. The albumin, though usually found in amj'loid or albumin, although hyaline and granular casts may be present in very advanced parenchymatous change, is, nevertheless, absent in a sur- prising number of cases in which the casts show long-continued irritative and degenerative change. It is known that among non-tuberculous individuals, hyaline and fine granular casts are present in numerous cases, particularly during middle life or later years, without the slightest trace of albumin. They are also observed in lithemic patients, whose physical exercise has been of necessity greatly restricted as a r&sult of the tuber- culous disease. These individuals exhibit gastro-intestinal disturbances, joint manifestations, and other evidences of impaired metabolism. It is not to be supposed that the development of kidney changes among pulmonary invalids in health resorts may be referred to the influence of high altitude, as some would have us believe. Not infrequently have I observed the nephritic disturbance to improve materially, and even to disappear altogether upon change of residence to lower elevations. It is none the less true, however, that instances of similar improvement are witnessed in spite of continued sojourn in high altitudes and even upon change from sea-level to the elevated regions of Colorado. Clinical evidence is assuredly sufficient to refute statements that residence in high altitudes tends to provoke kidney irritation. It is probable that the toxemia responsible for the development of nephritis is produced, to some extent, by the microorganisms of mixed infection, as well as by the irritating products of imperfect metabolism. The precise pathologic effect of these microorganisms upon the sub- sequent course of pulmonary phthisis is not yet fully determined. That a distinct modifying influence is produced by the bacteria of secondary infection is, however, beyond question. It is well established that the 544 COMPLICATIONS accompanying bacteria play an important role in the development of the pathologic processes common to pulmonary tuberculosis, and serve to characterize clinically certain phases of the disease, but a clear and accepted differentiation of the entire part assumed by the several microorganisms in the pathogenesis of consumption has not thus far been made. Some features of mixed infection remain the subject of material differences of opinion among trained observers. Many clinicians regard all pronounced temperature elevations as referable directly to the action of secondary microorganisms, while others maintain that the tubercle bacillus alone is responsible for the fever of pulmonary tuber- culosis. A rational interpretation of the relation of mixed infection to the fever of phthisis points at least to an appreciable influence, in cases of the hectic type, for chills, sweats, and prostration, definitely charac- terize bacterial infection of other organs of the body. Upon the other hand, manifestations of a like character may apparently be produced by the presence of the tubercle bacillus alone. That absorption of the toxins of the bacillus may give rise to the exhibition of symptoms, simulating the septicemia of mixed infection, is suggested by the frequent results following an administration of the various preparations of tubercuhn. It thus follows that the so-called clinical picture of mixed infection is not always produced solely by secondary microorganisms, but that it maj- result from the action of the tubercle bacillus alone or in combination with other agents of bacterial infection. The clinical manifestations of pure tuberculous origin are not essentially different from those dependent upon mixed infection, the chilly sensations, aching of limbs, sweating, general prostration, and other constitutional disturbances being subject to considerable variation. It is probable, however, that in the majority of cases the so-called hectic fever of phthisis is associated with a definite secondary infection. It is generally believed that a disproportionate effect upon the circulatory apparatus, reflexes, and mental attitude is jjeculiarly suggestive of the action of the tubercle bacilli, while excessive emacia- tion and exhaustion, violent cough, copious expectoration in addition to high fever, indicate a probable secondary infection. This relation, though commonly observed, does not invariabh^ obtain. Changes in the mental condition and in the character of the circulation are by no means a constant accompaniment of pure tulserculous infection, and often are exhibited in association with other bacterial infections, even without excessive temperature elevation. I have repeatedly observed among consumptives extreme mental hebetude and slowness of pulse, without fever, in connection with the microorganisms of mixed infection. In other instances of secondary infection there may be noted either excitability of temperament with acceleration of pulse, or depression of spirits and melancholia. It has l^een rather my experience that dulling of the intellect, as mentioned, is particularly likely to occur in cases of infection with the staphylococcus aureus. Rapid emaciation, violent cough, and profuse expectoration, though more likely to attend instances of severe mixed infection, nevertheless may exist in the absence of such a condition. While it is true that the breaking down of tuberculous tissue is facilitated by the presence of the pus-producing organisms, yet the process of softening and excava-' tion may take place regardless of the streptococcus or staphylococcus. MIXED INFECTION 545 These latter pathogenic microorganisms unquestionably aid in the disintegration of the tubercles, and thus in the exodus of the parasite, but it is not clear that they stimulate the growth of the tubercle bacilli. Upon the contrary, despite the frequent urgency of symptoms and the progressive decline of the invalid, evidence is not lacking to support the theory that multiplication of the bacilli is sometimes repressed by the bacteria of secondary infection, much as the tubercle bacilli are annihilated and overcome by other bacteria outside the body. Several times recently I have noted a complete disappearance of the tubercle bacilli from the sputum in cases of severe mixed infection. The presence of secondary microorganisms in the sputum affords no reliable measure of the severity of the mixed infection. In fact, nearly all the bacteria said to be responsible for the clinical mani- festations of secondary infection may be found in the throats and mouths of apparently healthy people. The discovery of their existence in the sputum is, therefore, robbed of a portion of its special signifi- cance unless precautions are taken to avoid contamination of the sputum with infection from the throat and mouth. For this purpose a sterile, cleansing mouth-wash consisting of a saturated solution of boric acid may be used before the sputum is expectorated. This is washed with sterile water and a portion selected for examination from the center of the mass. Even after the careful execution of these pre- liminary precautions, the bacterial findings are not always conclusive as regards the clinical severity of the infection. The various bacteria of secondary infection may often be found in profusion in washed sputum in the absence of the slightest clinical suggestion of their presence in the tissues. A study of the mixed infection of pulmonary phthisis in connection with the employment of bacterial vaccines during the past year has demonstrated the surprising frequency of streptococcic, staphylococcic, pneumococcic, and influenza infection, as shown by the bacteriologic examination of the sputum, in the absence of temperature elevation or of other constitutional symptoms commonly associated with such conditions. It also has been of some interest to note, as intimated previously, that, in the majority of cases of mixed infection, particularly if accompanied by well-defined clinical symptoms, the tubercle bacilli have been considerably less numerous than in instances of seemingly pure tuberculous involvement. Upon the other hand, the characteristic constitutional evidences of secondary infection are often observed in spite of failure to discover the specific microorganism, in the sputum. Inability to recognize the agents of infection by a single bacteriologic examination should not be construed, however, as negative evidence. It is frequently possible to demonstrate the bacterial nature of the infection in doubtful cases only after very many examinations, both microscopic and cultural. In a considerable number of cases, however, continued efforts toward the detection of the microorganisms remain utterly futile, even in association with a perfect clinical picture of severe secondary infection. Thus it is clear that clinical manifestations suggesting the existence of this condition may be exhibited in some cases of purely tuberculous origin, an assumption apparently confirmed by clinical experience and bacteriologic investigation. The recognition of mixed infection, therefore, is attained at times ■with much difficulty, its differentiation from miliary tuberculosis in 546 COMPLICATIONS particular often being obscure and imperfect. During a comparatively short period of time the symptoms of the two conditions may appear practically identical. The recognition of the microorganisms in the sputum is not of itself sufficient to establish definitely the diagnosis of a mixed infection as the sole responsible cause for the clinical mani- festations. As already stated, these microorganisms are sometimes found in profusion despite careful technic without the advent of any clinical symptoms, and, further, the agents of bacterial infection in the sputum may coexist with the development of miliary tuberculosis. It is not always permissible in these cases to reach a positive diagnosis of miliary tuberculosis merely upon the exclusion of secondary infection as the result of negative bacteriologic examinations. Upon the whole, the diagnosis of this condition must be determined upon the basis of the principles previously enumerated in connection with miliary tuber- culosis, involving a systematic physical examination and a well-con- sidered analysis of all available clinical data. For general purposes, it is reasonably safe to assume provisionally that the condition is one of mixed infection, and to recognize only the remote possibility of a miliary involvement, provided the clinical manifestations suggestive of the former are reinforced by recognition of the microorganisms in the sputum. It is claimed that repeated observations of the opsonic index may sometimes suffice to establish a definite diagnosis in cases previously admitting of reasonable doubt. In the enthusiasm attending recent laboratory aids to diagnosis care should be exercised not to overlook important clinical features. The fever of miliary tuberculosis is not subject to the same degree of fluctuation as that of mixed infec- tion, is less often associated with chills, but is attended more frequently by headache, dyspnea, and mental symptoms. With the early develop- ment of motor disturbances, discoverable upon careful examination, all possibility of error is removed. Prognosis of Mixed Infections. — The prognosis of all mixed infec- tions characterized l)y clinical symptoms is primarily identical with the prognostic significance attaching to fever, which has been described. The outlook for the patient must be adjudged largely in accordance with the principles outlined in connection with a persisting fever. The prognosis is grave not merely from the presence of fever, but from its continuance. Many cases with long-continued mixed infection of great severity sometimes respond to appropriate treatment. The prime obligation of the medical attendant relates, as far as possible, to remedial rather than palliative measures. No practice can be more superficial than the effort to lower temperature temporarily through medicinal or hydrotherapeutic agencies, without immediate recourse to the employ- ment of other means tending to prevent its recurrence. Night-sweats, diarrhea, cough, and even hemorrhages may be treated as they arise, through methods found to be productive of temporary relief, but the fever of sepsis demands far more than the employment of measures to increase the comfort of the patient. If the policy of laissez /aire is instituted, the future contains nothing for the patient but speedy disaster. If active steps are taken to combat the sepsis of mixed infection, the condition of the invalid is in no wise made worse, even in the event of failure, and in many cases the results obtained are most gratifying. The measures which I have been in the habit of employing for many years are — (1) The most complete interpretation of the rest treatment; MIXED INFECTION 547 (2) the use of the antistreptococcic serum (now seldom used) ; (3) during the past year the administration of the bacterial vaccines derived from the sputum of the patient, as suggested by Wright. Management. — The preliminary essential factor in the control of fever is red. Its effect is often remarkable, provided the invalid is kept in bed at all times. Coincident with the reduction of temperature there is a corresponding improvement of appetite, digestion, and assimi- lation, with resulting increased nutrition and greater powers of resistance. In some cases the diminution of fever is immediate upon the adoption of the recumbent position. There are many patients, however, who exhibit at first but slight subsidence of temperature elevation, months sometimes elapsing before the fever recedes to the neighborhood of 100° F. While the prolonged indefinite period of rest constitutes a trial to one's patience and courage, the invalid is constantly laying the foundation for a possible ultimate and complete recession to'iKirnial. Any special deviation from the strict interpretation of tlio |iriiici|ilos of the rest treatment, even for a short time, is inevitalil}- drstiiicd to result in failure. This method should be adopted ;is :i pnlinnnary measure in all cases presenting the septic fever of advanced tuliciciilosis, save in the presence of such special indications as (lenKiml prcnipt recourse to more radical procedures. Whenever, from the antecedent history, it is apparent that the continuance of the rest treatment offers no reasonable assurance of success, refusal to resort to specific medica- tion, even if believed of doubtful utility, represents, nevertheless, culpable negligence on the part of the physician. In a few cases conspicuously gratifying results have been obtained bj' the administration of the antistreptococcic serum. In former years a justification for the employment of this agent, concerning which com- paratively little was known and the clinical effects of which were not invariably favorable, was found in the unfortunate prognostic import of continued high fever. While the rationale of its adniiinstintinn has been incapable of bacteriologic demonstration, practical icsiills, far beyond the limits of laboratory knowledge, were sometimes obtained. No medical growth can take place without recourse to investigation and experiment. Development should take place along clinical lines, as well as from the results of laboratory research. It is known that in streptococcic infections the toxins are not soluble in the .blood, but are inclosed within the microorganism itself, constituting an endotoxin, hence a neutralization of the toxins, as in tetanus or diphtheria, is impossible. It has been shown by Bordet, von Lingelsheim, and Denys that in animals, following the administration of an antistreptococcic serum, a previously existing negative chemotaxis is converted into a positive one. As the repellant action between the microorganism and the leukocytes is changed into an attraction, there is afforded added opportunity for resulting destruction of the streptococci by the inglobing and digesting of the microorganisms. Thus far the results obtained in animal experimentation have not been found to hold true in man. This fact, however, should not be construed as being sufficient to pre- clude altogether the administration of the sci'iim, for the clinical evidence of its value in a small number of cases a|i|ieais incontrovertible. The results of my observation alteraling the use of the antistrepto- coccic serum were reported five years ago. A considerable experience since then has emphasized my conviction as to its utility in desperate 548 COMPLICATIONS cases, failing to exhibit improvement through other means. While thoroughly cognizant of some of the disadvantages attending its employ- ment, I have seen thus far no valid reason to discountenance its tentative administration in properli/ selected cases. The particular type of cases in which there has been afforded a justification for the use of the serum must be understood to be that class exhibiting well-defined clinical evidence of streptococcic infection, substantiated by the presence of the microorganisms in the sputum or blood, and associated with such constitutional disturbances as chills, irregular elevations of temperature, sweats, and general prostration. Any physician having considerable experience in the management of tuberculosis, and constantly brought into intimate association with the disease, cannot fail to be impressed with the great significance of a pronounced streptococcic infection. There is ever impressed upon the medical attendant an appreciation of the disproportion frequently existing between the physical signs and the general condition of the patient. Many with comparatively slight activity of the tuberculous process, and with small areas of pulmonary involvement, in the presence of this infection have been forced to an irresistible decline. My conclusions, previously reported, are briefly summarized as follows: 1. About one case out of every four or five may reasonably be expected to exhibit an appreciable diminution of temperature by the end of a week or ten days. 2. The remaining cases do not show any bad results from its employ- ment, other than the occasional intolerance of the system for the serum of the horse. 3. This so-called reaction, which is independent of the specific nature of the remedy, but common to all other serum preparations, bears no relation to the ultimate results obtained. 4. Some eases show marked improvement in spite of temporary discomfort in the way of chills, fever, urticaria, and painful sweUing, with stiffness of the joints, while others exhibit no improvement, although there is entire absence of constitutional disturbance. 5. Reaction may take place within twelve hours after the use of the serum, or it may be delayed for six weeks. 6. Occasionally the improvement is indefinitely delayed until the occurrence of the reaction, following which there may be complete and enduring subsidence of the fever. 7. As a result of the serum, the temperature may either subside to normal, or be reduced several degrees, remaining, however, somewhat elevated. 8. I have not been in favor of its continued subcutaneous employ- ment, and have given, as a rule, not over four or five doses at intervals of one or two days. 9. I have occasionally practised the tentative administration of the remedy by the rectum for ten or twelve doses before resorting to its hypodermatic use, in order to avoid the discomfort which sometimes follows its injection into the tissues, but have been unable to secure satisfying results from this method. id. I have seen unquestionable good attend its u.se even when strep- tococci were not found in the sputum, and believe that under such con- ditions the clinical evidences of a persisting sepsis may sometimes afford, from a humanitarian standpoint, a warrantable basis for its use. PREGNANCY 549 Bacterial Vaccines. — The foregoing considerations pertaining to the use of the antistreptococcic serum are introduced in justification of its employment by physicians, who are unable to avail themselves of the recent advantages offered by the use of the bacterial vaccines, to which detailed reference will be made in a later chapter. The scope of their application, particularly in connection with the opsonic index, is of necessity greatly limited among general practitioners Idv the absence of laboratory equipment and training. Under such circumstances recourse to the antistreptococcic serum in cases of severe streptococcic infection is not only justified, but in some cases demanded. The principles upon which depend the elaboration of an artificial resistance to infection will be discussed under the subject of Immunity. Through the genius and indomitable labor of Sir A. E. Wright, certain valuable contributions have been made to the elucidation of the com- plex mechanism of immunity. The chief of these discoveries related to an unsuspected substance in the blood, to which he gave the term "opsonin," and which was found to act on the bacteria. It is the function of this element to prepare the bacteria for inglobing by the leukocytes. Wright found that these opsonins could be increased in the blood by the introduction of cultures of dead bacteria. Bacteria suit- ably prepared for injection were called by him "vaccines." A descrip- tion of the preparation of vaccines occurs in connection with the Theo- ries of Immunity. His elaborate technic for the precise determination of the opsonic power, with reference to the various forms of bacterial invasion, will be reviewed in detail, together with the status of our present knowledge regarding the principles of opsonic therapy. The practical application of vaccine therapy to cases of secondary infection accompanying pulmonary tuberculosis I have made the subject of considerable clinical study. My observations have been actuated largely by reason of tlie frrrpicnt iinrrUability of the antistreptococcic serum and its dtlici' cil.\-i(nis ilisinli-dntiif/rs. An effort was also made to ascertain, if pisssiMc the icsulis id he dbtained from the employment of tuberculin mcilication, in cases of jjulmonary tuberculosis uncomplicated by mixed infection. In view of the fact that the scope of my investiga- tion embraced cases of pure tuberculous involvement as well as of secondary infection, further discu.ssion of the subject will be reserved for the consideration of Specific Medication in Pulmonary Tuberculosis. CHAPTER LXXX PREGNANCY Pregnancy as a complication of pulmonary tuberculosis is almost universally believed to be distinctly detrimental to the health of the consumptive, regardless of the extent or activity of the disease. Some observers assert that the harmful effects may be expected to develop shortly after conception has taken place, and continue without interrup- tion until the termination of labor or convalescence from the puerperal period. The majority of clinicians, however, incline to the belief that 550 COMPLICATIONS the unfavorable influence of pregnancy upon the course of puhnonary phthisis is exerted chiefly after childbirth. Nearly all agree that the combined effect of pregnancy, the puerperium, and lactation constitute a tremendous tax upon the physical energies of the consumptive, and directly lower the powers of resistance. In view of the clinical observa- tion as to the frequent increased activity of the tuberculous process after childbirth, with a progressive subsequent decline, pregnancy has come to be generally regarded as a factor of grave prognostic import among such patients. Instances of actual improvement in the condition of the tuberculous lungs as a result of concurring pregnancy rarely have been recorded. It is but natural, therefore, that pulmonary invalids should have been instructed as to the inadvisability of marriage, the imperative avoidance of conception, and even the expediency of a speedy termination of pregnancy. It is true that a complete justification for such advice often obtains in special instances, when efforts toward the preservation of the tuberculous mother properly become the paramount considera- tion. It is not invariably the case, however, that such precipitate action is warranted. The existence of pregnancy per se, irrespective of important features inherent to the individual case, is not to be regarded as necessarily inimical to the welfare of the consumptive, nor as prima facie justifica- tion for the performance of abortion. Its development among pul- monary invalids as a class is assuredly to be deplored, and unfortunate results must of necessity be expected in a large number of cases, if the pregnancy is permitted to continue to full term. It is to be remembered, however, that generalizing statements concerning the influence of pregnancy upon consumption are not always correct in their individual application. As a matter of fact, each case is worthy of thoughtful, well-considered action based upon the merits of its several features. The conditions obtaining in special cases may suggest the advis- ability of prolonged, detailed observation, and in others demand recourse to prompt and energetic measures in the way of surgical relief. Unfor- tunately, the great majority of cases are adjudged in accordance with hastily formed opinions, or even preconceived notions as to routine principles of procedure. The practical lessons taught by a considerable experience among such a class of invalids are somewhat surprising in the light of generally accepted views. No denial can be made of the deleterious effect of pregnancy upon a vast number of pulmonary invalids, but such influence is by no means invariable. It is not always clear that the rapid progress of the tuberculous affection after childbirth is distinctly referable to the pregnancy or the puerperal period. It is well known that conception may take place at almost any time during the course of pulmonary tuberculosis, even in far-advanced stages of the disease. Among so desperate a class, a rapid progressive- deterioration of the physical condition, with a fatal termination, may be reasonably expected by the end of one year, with or without the added influence of pregnancy. It is thoroughly substantiated that the effect of pregnancy upon the general health, and the course of the pulmonary involvement maii be decidedl)' favorable in a few instances. I have observed several patients who presented, during the entire period of pregnancy, and particularly in the earlier months, remarkable evidences of general and pulmonary improvement. This PHEGNANCY 551 was often illustrated by increase of weight and strength, diminution of cough and expectoration, and reduction of the temperature. The nausea and vomiting commonly incident to early pregnancy are often singularly lacking among consumptives, thus precluding' a diminu- tion in the ingestion of food and the consecjuent loss of nutrition. On the contrary, the appetite is sometimes enhanced materially, and the digestion unimpaired or improved, with resulting gain in weight. It is certainly true that physiologic processes, previously dormant, are often stimulated to such a degree as to produce a change in the general nutrition of the utmost benefit. I have been privileged to observe in a few cases during pregnancy, even the complete disappearance of all the subjective and physical evidences of pulmonary tuberculosis, which previously had been persistent for several years. I have in mind two conspicuous instances of advanced tuberculous infection of several years' duration, for whom the development of pregnancy proved of undoubted benefit. In each case the pulmonary process became entirely arrested during pregnancy, and was not followed by a renewed activity of the infection after the termination of labor. For the sake of exactitude the two cases are briefly reported as follows: Case 1. — A woman, twenty-six years old, consulted me in March, 1901, two and one-half years after arrival in Colorado, and five years after the development of pulmonary tuberculosis. There had taken place a loss of twenty-five pounds in weiglit. The cough and expectora- tion were moderate, and the general condition good. There was extensive involvement of the left lung, moist rales being readily de- tected upon easy respiration from apex to base, both front and back, with considerable consolidation in the upper portion. In the right side there was slight infiltration with moist rales at the apex. Bacilli were numerous. During the first two years that she remained under my observation, in spite of a material gain in weight, there developed unmistakable evidences of an increased activity of the tuberculous process. The cough and expectoration perceptibly increased, dyspnea became much more pronounced, the pulse accelerated, and beginning physical evidences of cavity formation were recognized in the left upper front. She then became pregnant, and shortly afterward suffered to an unusual degree from nausea and vomiting, until, at the end of two months, she reluctantly consented to the evacuation of the uterus. This procedure had been advised from the beginning upon the score of the extensive active tuberculous involvement, and the interference with proper nutrition. The patient recovered rapidly from the effects of the curetment performed by Dr. W. S. Bagot. At the end of two years she again became pregnant and prompt interference was advised. There had developed a large cavity in the left upper lobe below the clavicle, and moist rales were recognized throughout the left lung, and in the right apex to the third rib. There was a loss of ten or fifteen pounds in weight from the normal, paroxysmal cough, copious expecto- ration, slight temperature elevation, and moderate dyspnea. All efforts to influence the patient to consent to the termination of the pregnancy were unavailing, nausea and vomiting being comparatively insignificant. After the second month there ensued a diminution of cough and expectoration, and the beginning of a remarkable gain in weight, which continued for months after childbirth. With improve- ment in the general condition, there took place a diminution in the 552 COMPLICATIONS activity of the tuberculous infection, as shown by the lessened amount of moisture upon examination. At the expiration of her period of pregnancy she had attained a very material gain in weight, and there was an entire disappearance of cough and expectoration. Fine clicks at each apex were barely recognized at the end of inspiration following a cough. Labor was exceedingly difficult and exhausting, the presentation being a breech, and the progress necessarilj' slow in spite of strong uterine contractions. The patient was not allowed to nurse the child, nor to share to any extent in the responsibilities involved in the care of the infant. The remarkaV)le improvement, noted for the first time during the course of the pregnancy, was continued without interruption during the following year. The patient was per- mitted to return home in 1906, exhibiting at that time, upon exami- nation, no evidence of any existing active tuberculous involvement. There was entire absence of moisture in the finer bronchi, as well as of cough and expectoration. She displayed a gain of fully fifty pounds in weight, and thus far has suffered no relapse. Upon the basis of the clinical evidence, it is reasonable to assume that the pregnancy con- stituted an important factor in restoring the patient to a life of useful- ness and comparative health. Case 2. — A woman, aged twent\--two years, consulted me imme- diately upon arrival in Colorado in February, 1903, three years after the development of pulmonary tuberculosis. There was a loss of thirty pounds in weight and an excessive cough. The expectoration amounted to eight ounces in twenty-four hours and contained numerous bacilli. There were daily temperature elevations of two or three degrees and marked dyspnea. Examination disclosed extensive active tuber- culous involvement of the left lung, with areas of consolidation, and moist rales from apex to base, front and back. A beginning tuberculous infection of the right apex was noted. During the following eighteen months there was presented a progressive improvement in all respects. A gain of forty-five pounds in weight was established, with correspond- ing improvement in the pulmonary condition. She then moved to another city in Colorado, and did not come under my observation again until late in 1905, when she was found to have lost nearly twenty pounds in weight, and was experiencing a decided increase of the cough and expectoration. Upon examination moist rales were readily detected from apex to base upon the left side. Efforts to increase nutrition and promote the general condition were unavailing until she became preg- nant in the late spring of 1906. Thereupon there developed a remark- able improvement in appetite and digestion. This was the precursor of a pronounced gain in weight, with an eventual disappearance of the cough and expectoration. She was examined in the early fall, and for the first time since coming to Colorado, exhibited an entire absence of physical signs. The gain thus established during, and presumably as a result of, the pregnancy has been maintained to the present time. Several other cases have been ob.served which illustrate the coinci- dence of an undoubted improvement in the general condition and in the physical signs during the period of pregnancy. In these cases the clinical data strongly suggested a relation of cause and effect. A fever previously persistent has been found, in exceptional instances, to disappear with the development of pregnancy. It is but fair to state that the improvement was usually quite unexpected, in some cases. PREGNANCY 553 premature delivery having been recommended and refused. It is apparent that pregnancy is not always distinctly detrimental to the interests of the consumptive, that some patients may secure a temporary gain during the period of gestation, and that a few may derive per- manent benefit through its influence. In addition to the extent, nature, and degree of activity of the tuberculous lesions, the amount of fever and loss of weight are ^•itally important considerations in the determination of a rational course of procedure. An essential feature is the recognition, during the first few months of pregnancy, of any appreciable change in the cough, expectoration, nutrition, temperature elevation, and physical signs. The present nutrition of the invalid, together with the number and history of previous pregnancies, must be regarded of great importance in estimating the probable influence to be exerted during succeeding child-bearing periods. In general it may be assumed that greatly impaired nutrition is in itself a distinct contraindication to the con- tinuance of pregnancy. It has been asserted by some clinicians that repeated gestations are uniformly productive of unfortunate results. I have not found this to be invariablj' true. Several patients have been observed, who have apparently undergone the second and third accouchement quite as well as the first. The following case is of some interest: A woman, thirty-three years of age, after three years' residence in Colorado, came under my observation in December, 1896, five years after the onset of a tuberculous infection. She was at that time four and one-half months pregnant, and had already borne six children, all living and in good health. She had done her own housework in addition to caring for the children. There was a loss of nearly twenty pounds in weight, slight cough and expectoration, and well-defined physical evidences of tuberculous lesions at each apex. The confine- ment was normal and followed by no appreciable tendency toward further decline. The patient eventually secured a complete and permanent arrest of the tul)erculous process, with disappearance of cough, expectoratiiui, and |)h>sical si^ns of active infection. It is a matter uf (•(mm ■liiiical observation that some patients, in spite of impi-nxcnu'iit duiint:: the period of pregnancy, exhibit a rapid decline following parturition. Just why this phenomenon should take place is somewhat difficult of satisfactory explanation. It cannot be that such results are referaljle to the mere process of labor, with its attending pain and exhaustion, for an unfavorable influence is not infrequently exerted even after a brief and easy parturition. It is also questionable if the mere emptying of the uterus produces so complete a change in the physiologic processes as to bring about a renewed activity of the tuberculous lesions. It is quite probable that, to some extent, the unfortunate clinical results are referable to the burdens of motherhood, the frequent lactation, the confinement to the house, and the added responsibilities incident to the care of the child. But slight, if any, unfavorable effect of the labor may be anticipated in most cases, if the confinement is tcniiiiiatcd as quickly as possible under the judicious employment of aiicst hcsia. This should be followed by immediate bandaging of the breasts and the a\(>idance of lactation, the placing of the invalid upon vigorous supporting treatment, and adherence to a rational system of living. 554 COMPLICATIONS It sometimes happens that a premature termination of labor is attended by distinctly unfavorable results, often in excess of those exhibited after normal parturition. Patients presenting definite evidences of improvement during the earlier months of pregnancy, have been observed to undergo a pronounced decline following an accidental miscarriage. This is referable in part to excessive loss of blood and the resulting exhaustion, but a general decline .sometimes follows the evacuation of the uterus by artificial means. This is much less likely to take place, however, following prompt and thorough curetment during anesthesia, than after tedious and painful methods of producing abortion. The insertion of catheters, bougies, and sounds, though sometimes thought to be indicated in cases of advanced phthisis on account of objections to the administration of an anesthetic, is, upon the whole, worthy of condemnation. As stated in connection with the discussion of surgical operations upon pulmonary invalids, the dangers and disadvantages of anesthesia to such patients are greatly overestimated. A painless and speedy evacuation of the uterus is seldom, if ever, attended by unpleasant results, while prolonged efforts to expel the fetus by means of uterine contractions, excited through the presence of a foreign body, are often productive of serious hemorrhage and profound physical exhaustion. It is chiefly in the latter class of cases that consumptives are observed to do badly following miscarriage. I recall the case of a young woman of twenty-three, who came to Colorado in 1903, three months pregnant, presenting the history of a tuberculous infection immediately following a miscarriage two years previously. There were excessive cough and copious expectoration, moderate loss of weight, slight temperature elevation, with active tuberculous infection of the left lung from apex to base, front and back. Throughout this region there were signs of slight consolidation, with moist rdles upon easy breathing. The patient exhibited a pronounced improvement during the first month in Colorado, there taking place a diminution of cough and expectoration and a materially improved nutrition. Upon induction of premature labor by the insertion of a catheter in the hands of a surgical colleague, the uterus was finally emptied after the lapse of thirty-six hours. This was followed by an immediate exacerba- tion of fever and other unfavorable sj-mptoms, re])resenting the begin- ning of a relentless decline, which was terminated by her death a few months subsequently. In this instance the influence of the pregnancy itself had not been harmful, but the induction of premature labor marked the onset of a renewed activity of the tuberculous process. It is clear that no general rule may be formulated relative to the effect of pregnancy upon pulmonary tuberculosis which can properly be applicable to all cases. The preceding course of remark is not to be construed in advocacy of an invariable continuation of pregnancy, but more as an emphasis to the fact that the effect of this condition is not always detrimental, and that unfortunate results often attend precipitate interference. CHAPTER LXXXI SYPHILIS The coexistence of sj'philis and tuberculosis is much more frecjuent than generally supposed, but the precise relation of the two infections to each other remains somewhat doubtful. The dual association of these diseases, which represent the two most frequent and dreaded scourges to which mankind is subject, is of special interest to the clinician by virtue of tlie influence exerted by one infection upon the other, and the possibilities of error in the differential diagnosis of the thoracic manifestations. The common relation of syphilis to tuberculosis consists of — (1) the influence of syphilis upon the vulnerabiUty of the tissues to future tuber- culous infection; (2) the effect of syphilis upon the course of a previously acquired tuberculosis; (.3) the inodifying action of tuberculosis upon syphilitic infections of remote and recent origin. Various widely conflicting views have been expressed by observers as to the clinical results exhibited by the combination of the two diseases. The somewhat singular divergence of opinion is perhaps explainable by the failure of clinicians to recognize the same essential differences of classification. Thus the extent and character of the influence exerted by one infection upon the other are dependent to a great degree upon their relative development in point of time. It goes without saying, moreover, that marked differences exist in the virulence of each infection. Observation of a large number of patients afflicted with both diseases will necessarily include some presenting clinical evidences of an intensely virulent syphilis, with comparatively insignificant tuberculosis, and others exhibiting an apparently benign syphilitic infection, with active advancing tuberculous processes. A progressive destructive tendency of both infections will sometimes be noted, while among other individuals the clinical manifestations incident to both diseases are subject to ready control. Another important consideration is the personal equation, which involves the question of alcoholism or other excesses, vigor of con- stitution, mode of life, occupation, financial status, and temperamental peculiarities, all vastly influencing the amenability to treatment. While an arbitrary classification of cases, therefore, is not permissible, certain liroad generalizations are in order, as evidenced by the results of clinical (ihservation. Hereditary syphilis is known to predispose toward the development of tuberculosis. It is natunil to suppose that the puny, ill-nourisheel children of syphilitic patents shduld exhibit, as a result of their impaired vitality, a pronounced diiiiiniilion of resistance to tuberculous infection. It has been shown that, as I'egards tuberculosis, the influence of heredity consists in most cases of the transmission to the infant of an enfeebleil constitution, with impaired powers of resistance to tuberculous infection. In hereditary syphilis, however, a direct specific taint is inflicted upon the child, but the enfeeblement of constitution is no less apparent than in children born of tuberculous parents. It may well be imagined that the physical debility, retardation of growth, and imperfect development exhibited as a result of infantile syphilis are accompanied by a corres- 556 COMPLICATIONS ponding weakening of tissue resistance. Clinical observation suggests that, in addition to these incontestable factors, a direct predisposing influence to tuberculosis is exerted by the inherited syphilitic taint, regardless of nutrition or apparent vigor of constitution. It cannot be truly said that tuberculosis attacks only those syphilitic children who present suggestive manifestations of an inherited taint. I have frequently noted that seemingly healthy children, whose parents have been admittedly syphilitic, after thriving for one or two years, suddenly fall victims to tuberculous infection. The suggestion derived from such an experience, as to the ultimate predisposing influence of the syphilitic virus in young children, is of some interest in comparison with the siirprisingln few instances of tuberculosis, observed among children, one or both of whose parents were tuberculous at the time of conception. During many years of observation in a health resort for pulmonary invalids, comment has been made repeatedly upon the comparatively few cases of tuberculosis in childhood, despite the exis- tence of active infection in the parents and of exceptional opportunities for acquired infection through almost wanton exposure. Upon the other hand, instances of tuberculous development in children have not been infrequent when a history of syphilis has been freely admitted by a parent, or its previous existence strongly suspected. For the foregoing reasons it may be accepted in general that the transmission of hereditary syphilis to young children greatly increases the vulnera- bility of the tissues to tuberculous infection. It is also probable that among 3'oung adults, the depressing influ- ence of acquired syphilis increases to some extent the susceptibility to tuberculosis. Instances of active tuberculous infection, following closely upon the contraction of syphilis, are not uncommon. There is borne in mind the case of a young man who recently consulted me presenting a history of pulmonary tuberculosis which developed not over two or three months after the appearance of the initial lesion. I have observed several cases in which the malnutrition incident to recent syphilis has appeared to favor predisposition to tuberculosis. In such cases, if the tendency to tuberculosis is not directly augmented by the syphilitic taint, it is at least clear that, thrt)up:h diminished resis- tance of the soil, a tuberculous infection, previously latent, is brought into renewed artivity. Tlie delotoridus effect (if sy|)hilis in its relation to tuberculous il, ninjiin, nl is iVecnieiiily a(illi in the sputum is not alwaj^s sufficient to exclude entirely the .sypliilitic origin of the pulmonary con- dition. Several times I have hatl occasion to note the remarkable paucity of tubercle bacilli, although present after long searching, in patients exhibiting characteristic subjective and objective signs of an active pulmonary tuberculosis. A disproportionately small number of bacilli contained in the copious expectoration of an intractable bron- chitis or in the presence of pulmonary excavation should awaken sus- picion as to the possible underlying syphilitic nature of the infection, upon which an incipient tuberculosis may have been ingrafted. The same is true of an absence or a pronounced scarcity of bacilli accompanying extensive fibrosis. While the evidence in these cases is by no means conclusive, the wisdom of a searching inquiry to secure either the ad- mission of !33^philis or the recognition of other manifestations is appar- ent. It should be emphasized that syphilitic dlMa-c df ilu- lung, either alone or in combination with tuberculosis, is far iii"ic Ik^iik m thanpi'ac- titioners have been prone to acknowledge. Gpiiiiall\ sjk akmg, in pure pulmonary syphilis there is less tendency to temjjerature elevation than in tuberculosis, less diarrhea, irritability, and acceleration of the pulse, night-sweats, or emaciation. In other words, syphilis, as a rule, is less SYPHILIS 559 frequently associated with mixed infection than is tuberculosis, which accounts for the diminished temperature elevation and the usual absence of septic symptoms in the former disease. It is true, however, that some cases are observed in which the temperature elevation is quite out of proportion to the degree of pulmonary involvement. The per- sistence of fever, despite a prolonged maintenance of systematic man- agement in cases exhibiting exceedingly incipient infection, is sometimes suggestive of the possibility of a syphilitic taint. The course of pulmonary syphilis is often protracted to a degree, patients sometimes exhibiting an astonishing tolerance for the infec- tion in the presence of extensive structural change. In doubtful cases recourse should be taken to the tentative employment of antisyphilitic treatment and the specific medication subsequently increased according to the therapeutic indications. The relation of pulmonary syphilis and tuberculosis is further discussed on page 296. PART VI PROPHYLAXIS, GENERAL TREATMENT, AND SPECIFIC TREATMENT SECTION I Prophylaxis chapter lxxxii reciprocal relations of consumptives and SOQETY No argument is needed to substantiate the assertion that the pre- vention of consumption has been for years the most vital sociologic and economic problem of all civilized races. The wide-spread distribution of the disease among the masses, the peculiar conditions under which it is disseminated, its high rate of mortality, its demonstrable preventa- bility and curability, all furnish convincing testimony as to the over- whelming necessity of aggressive effort toward its limitation and con- trol. The former apathetic recognition of the direful significance of con- sumption has been supplemented, during the past decade and a half, by an active educational and governmental agitation throughout the world toward its restriction. As a result of the energetic campaign already instituted, the way has been prepared for the irresistible advance of the organized forces of prevention against this common enemy of mankind. The ravages of a veritable scourge are becoming diminished, and hope may perhaps be entertained of a complete subsidence of the disease, as obtained in Europe with leprosy, a kindred affection, after the middle ages. A great deal that is highly commendable and fraught with far-reaching beneficent results has been accomplished, but there remains much to engross the attention and stimulate the activities of phthisiosociologists. The present status of the crusade against tuber- culosis is too well known to clinicians and students of economic con- ditions to warrant repetition. Recent literature has been replete with the reports of the proceedings of societies for the prevention of consump- tion, suggestions concerning the .social asjjpcts of the disease, advices as to its administrative control, recomiiiciKhitinn^ fcgarding the best manner of conducting an educational pr(i]i.iL;:iiiil:i, k pcnts of committees authorized to investigate conditions, reitciatidiis of important individual precautions, and finally personal appeals from essayists in advocacy of more or less coercive measures of prevention. RECIPROCAL RELATIONS OF CONSUMPTIVES AND SOCIETY 561 In a work devoted essentially to the clinical rather than to the social features of tuberculosis, it is idle to attempt an exhaustive consider- ation of the many aspects of general and individual proph^daxis. The academic recital of the almost infinite phases of the problem of pre- vention, even if, perchance, not entirely familiar to a portion of the readers, would scarcely fall within the scope of this book, as the tedious details of such an inquiry do not entirely harmonize with a predomi- nating endeavor toward clinical study. It is designed to present a brief exposition of the trend of recent prophylactic endeavor, to review the generally accepted preventive measures pertaining to society, as well as to the individual, and to call attention primarily to the trust imposed ujion the jnmihj phii- sician, who constitutes by far the most responsible (ujinl jar Ihr nsiiii-iiini and control of consumption. It also is desired to cnipliusizc, both upon humanitarian and economic groniuls, the obligation of the professi(jn and of society toward those (ilnvdij afflicted with the disease, no less than toward the body pulitir. Tliis phase of the subject has hitherto received but comparatively little attention. During recent years the organized work of antituberculosis associations has been devoted chiefly to the awakening of public interest and the adoption of effective prophylactic measures. Such laudable efforts, wherever systematically conducted, have resulted in a reduction of the mortality-rate and in the education of society to a more or less intelligent conception of the nature of the affection. While this inures greatly to the piotpction of future communities, to what extent the welfare of the eiiiisinnprn-r is being subserved by concerted medical interest is justly suljjcct 1 1 > iiu niii y . It is apparent that the recent Tphthisiotherapeutic thought has been directed very largely to the interests of pulmonary invalids included in the category of incipient cases, to whom alone are offered a welcome in most institutions supported by private and public benevolence. With no desire to reflect upon the great utility of such sanatoria open to very early cases, it is none the less opportune to mention the fact that patients of this character do not constitute such a menace to society as the more advanced cases, and demand far less the personal supervision of a resi- dent physician, with his retinue of subordinates. While an elaborate systematic control is often accorded to incipient cases, and incidentally unusual facilities for recovery, the same practical and sympathetic consideration is not extended to those exhibiting more pronounced infection. Advanced cases are denied admission to nearly all sanatoria and are also persona non grata to all municipal hospitals. It cannot be doubted that these unfortunates should be permitted to profit from the recent agitation concerning consumption. While they are privi- leged to be registered at headquarters and to receive instructions from some responsible medical source, they are forced to appreciate the fact that they constitute a source of immediate danger to other members of the family. These invalids, by virtue of their advanced condition, are denied those advantages which are freely bestowed upon others, who are less worth;/ upon the score of their actual needs, and con- stitute, to a subordinate extent, elements of danger to the public. In this connection let it be understood that it is the consumptive, with unmistakable evidences of advanced infection, who represents the chief source of further bacillary distribution. It is for such individuals espe- cially that disciplinary control is indicated and for whom instructions 562 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT should be provided. Proper efforts addressed to invalids of this class cannot fail to yield a satisfactory return. The practical results possible of attainment in the effort to restrict tuberculosis must depend to a great extent upon the willing, intelligent cooperation of the patient. Public protection can never be secured in jull through legislative enactment, or attempts toward municipal control, unless the invalid from whom emanate the agents of infection strives conscientioushj to perjorm his part. Faithful service in this respect, even in the absence of a suitable environment, may be obtained by instructive persuasive appeals, reinforced, when necessary, by drastic expedients for the ignorant or \-icious. Any action bearing upon the preservation of the public from tuberculosis should be attended by an effort to promote the welfare of the coiiMiinpiixc ( h; s, especially among the poor. This involves the rendering of ■^ul>.-^h'iili:irticul:uly enlighten- ing. In no other cit)- in the wdild has iliciv lakcii piaic any reduction of the death-rate fioin lulx'iculnsis at .all cnniiiara.Me to that achieved in our American nicti(i|i(ilis, in s]jite of the density of her population in tenement districts and tlir diivst poverty among a large class of people of foreign birth. The fall in tlie mortality rate during the past twenty years is estimated at about 40 per cent., inclusive of all cases of tuber- culosis. No more striking commentary can be afforded as to the benefi- 568 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT cent and practical results capable of attainment in the supervision of a disease to a large extent preventable. In England the Government, for the purposes of observation and educational review, has permitted the enforcement of compulsory notification for a limited time in a single large city (Sheffield). Scur- field. Medical Health Officer to the City of Sheffield, reports that the Compulsory Notification Act has been in operation since November 1, 1003, without any organized opposition on the part of the public or the profession. Voluntary notification had been in vogue during the preceding four years. The general attitude in England must be regarded at present as one of reserve and conservatism. This is perhaps occasioned in part by the fact that many of the most eminent medical authorities have not been in strict accord concerning the expediency of obligatory notification. Sir Richard Thorne, the Medical Adviser to the Local Government Board of Great Britain, in his lecture upon the Administrative Control of Tuberculosis one year after the adoption of compulsory notification in New York city, definitely opposed such a procedure in England, regarding it to be completely unjustifiable. In Scotland, where approximately 10,000 people die annually from some form of tuberculosis, a more determined effort toward adminis- trative control has been established. During the thirty years from 1871 to 1901, the death-rate from phthisis, according to Bramwell, has been reduced from 278 to 153 per 100,000. In the latter part of 1906, compulsory notification was unanimously adopted in Glasgow, a system of voluntary notification having been in operation during the preceding six years. In other cities a similar voluntary sj'stem is now in vogue, but through the noteworthy efforts of Bramwell, McKenzie, Phillips, and Dittman, this is being more generally regarded as an unfortunate compromise, if not a vicious makeshift. In Ireland, according to the reports of Sir John W. Moore and Edward J. McWeeney, the magnitude of the tuberculosis problem is illustrated by the fact that the death-rate has recently reached the maximum of 2.9 per 1000 of the population, representing the deaths of 12,694 per.sons during the year. Only in the years 1880, 1897, 1898, and 1900 has such a high mortality rate been previously attained. The death-rate in England is reported to have fallen, since 1864, from 3.3 per 1000 to 1.7; in Scotland, from 3.6 per 1000 to 2.1, and yet in Ireland to have risen from 2.4 per 1000 in 1864 to 2.9 in 1904. That the Irish jipople are awakening to the enormity of the danger is evidenced by the f.ict tlmt in 1906, at a meeting of the Dublin Branch of the Natioii.il A>s(iriation for the Prevention of Consumption, a resolution was u(l(i|)ted providing for the adoption of a system of compulsory notification. In Denmark, according to Vilhelm Maar, 20,000 people out of a total of 2,500,000 inhabitants are at present afflicted with tuberculosis, and approximately 8000 new cases are developing annually. In compliance with the suggestions embodied in the report of the Parliamentary Commission appointed in November, 1901, to investigate conditions and propose remedial measures, all physicians are compelled to report cases of existing tuberculosis coming under their observation as well as the deaths. In Australia, which possesses a dry sunny climate with a compara- tively small population exhibiting but little poverty, the death-rate COMPULSORY NOTIFICATION AND REGISTRATION 569 from tuberculosis is reported by Armstrong as 29 per cent, less than in England in 1904. The mortality rate has become progressively reduced since 1885. Compulsory notification has been in force in parts of Aus- tralia smce 1898. Neglect to comply with notification laws is subject to heavy penalty. Gratifying results have been secured in Adelaide, Melbourne, and Sydney. In Roumania, ilitulescu reports that the death-rate from tuberculosis in the large cities is 3.6 per 1000 people, the rate in Bucharest being particularly high. Since 1901 effective efforts have been instituted to introduce compulsory notification, work along these lines being accorded active support by the profession and public. Great interest in the campaign against tuberculosis is manifested in Norway, Holland, Switzerland, and Belgium. Compulsory notifica- tion is admitted to be a decided success in Norway, where it has been carried out since 1901, and is earnestly advocated by the leaders of the profession in other countries. Holmlxic. nf ( luistiana, reports that obligatory notification no longer meets with icsistance, that early exaggerated notions as to the fear of infecliun have subsided, and that administrative control is meeting with growing favor on account of the increasing enlightenment of the people. Dr. Carriere, of Berne, reports a progressive diminution in the mortality rate of pulmonary tuberculosis since 1883, despite an increase in the total mortality from other tubercu- lous affections. In Germany it is estimated from the official data furnished by the Imperial Health Office that from 110,000 to 120,000 people die annually of consumption. In nearly all cities the statistics show a gratifying diminution in the mortality rate of tuberculosis of approximately 40 per cent, during the past thirty years. Many municipalities have adopted regulations enforcing obligatory notification and registration. Com- pulsory notification, according to Glasenapp, President of Police, Rix- dorf , is soon to be introduced in that city for all cases of open pulmonary or laryngeal tuberculosis. The unfortunate results of the present lack of compulsory notification are greatly minimized, however, by the work of the inquiry bureaus and tuberculous dispensaries. Kayserling, Secre- tary General of the Central Committee for these oi-ganizations in Berlin and suburhs, reports that detailed notification is obligatory upon the nurses connected with the service, and that effective measures of pre- vention and supervision are immediately instituted by the inquiry stations. In France the principle of compulsory notification at first met with considerable opposition. In 1899 the Acailemy of Medicine in Paris appointed a special commission to suljmit propositions regarding the administrative control of tuberculosis. Compulsory notification was resisted strongly at that time as being uncalled for and distinctly objectionable. In recent years a vast amount of good has been accomplished by the Permanent Committee for the Prevention of Tuberculosis in France, pubhc interest having been awakened with reference to all important features of prophylaxis. While many American cities have emulated the example of New York in adopting regulations requiring reports of tuberculosis to health authorities, but comparatively few compel their actual enforcement. In Philadelphia notification was recommended by the County Medical Society in 1893, but failed of inauguration until 1905. In Boston com- 570 PROPHYLAXIS, GENERAL AND SPECIFIf TREATMENT pulsory registration has been in force since 1900. Of the 86 largest cities of the United States, according to a report made by Wm. H. Baldwin and other members of a committee appointed by the National Association for the Prevention of Consumption, 57 had enacted laws by the early part of 1906, pertaining to compulsory registration. Of these 57, nearly one-fifth passed their ordinances during 1905, as will be seen by the following table presented by the committee: _ r,.„„ T .„, Population, Forms to be City. Date of Law. jg^j Reported. New York City Jan. 18,1897 3,437,202 All Camden, N. J Dec. 27, 1897 73,935 All Cincinnati, O Aug. 19. 1898 325,902 Not stated Elizabeth, N.J March 6, 1899 52,130 Not stated Boston, Mass May 1, 1900 560,892 Pulmonary Buffalo, N.Y 1900 352,387 Not stated Rochester, N.Y 1900 162,608 Not stated Trenton, N.J Jan. 8, 1901 73,307 Pulmonary Bridgeport , Conn April 23, 1902 70,996 Pulmonary Lowell. Mass Sept. 1902 94,969 Pulmonary Worcester, Mass Oct. 6,1902 118,421 Pulmonary Louisville, Ky Oct. 1902 204,731 Not stated Atlanta, Ga Oct. 1902 89,872 Not stated Oakland, Cal 1902 66,960 Pulmonary Providence, R. I Jan. 15,1903 175,597 All Hartford, Conn March 4, 1903 79,850 All Cambridge, Mass March 11, 1903 91,886 Pulmonary Omaha, Neb June 30, 1903 102,555 Not staled San Francisco, Cal Oct. 27,1903 342,782 All Los Angeles, Cal Oct. 1903 1 02,479 Not stated Memphis, Tenn 1903 102,320 Not stated St. Paul, Minn Jan. 1904 163,065 All Minneapolis, Minn Aug. 26,1904 202,718 All Reading, Pa Sept. 1, 1904 78,961 All Somerville, Mass Oct. 6, 1904 61,643 Pulmonary *Des Moines, la Oct. 28, 1904 62,139 All Springfield, Mass Nov. 1, 1904 62,059 Not stated Cleveland, O Feb. 3,1905 381,768 Not stated Youngstown, O Feb. 6, 1905 44,885 Pulmonary Yonkers, N. Y Feb. 1905 47,931 Not stated Paterson, N. J March 3, 1905 105,171 Pulmonary *Salt Lake City, Utah March 9, 1905 53,531 Pulmonary Grand Rapids, Mich March 1905 87,565 Pulmonary St. Louis, Mo April 7, 1905 575,238 Pulmonary ♦Baltimore, Md April 8,1905 508,957 Pulmonary tPhiladelpliia, Pa April 27,1905 1,293,697 Pulmonary New Haven, Conn April 1905 108,027 Not stated ♦Milwaukee, Wis May 15, 1905 285,315 All Fall River, Mass June 13, 1905 104,863 Pulmonary Waterbury, Conn Sept. 5, 1905 45,859 All tPittsburgh, Pa Sept. 10,1905 321,616 All New Bedford, Mas.s Nov. 8, 1905 62,442 Not stated Columbus, Ohio 1905 125,560 Not stated Erie, Pa Jan. 1,1906 52,733 Not stated Chicago, 111 Jan. 1, 1906 1,698,575 All Liiwicncf, Mass Feb. 19,1906 62,559 All r. ..Ill, 111 Feb. 20,1906 56,100 Not stated U.tinii, Mich 285,704 Not stated llulyuke, .Mass 45,712 Not stated Seattle, Wash 80,671 All Wilkes Barre, Pa 51,721 Not stated Troy, N. Y 60,551 Not stated Indianapolis, Ind 169.164 Not stated *Stato law fState law; enforcement in this city begun about this time. THE SUPERVISION AND EDUCATION OF THE CONSUMPTIVE 571 The only cities of over 125,000 population which had not ordinances requiring notification were Chicago, New Orleans, Newark, Jersey City, Kansas City, and Denver. It is frequently urged by some that compulsory notification is especially indicated for Denver on account of the influx of imported cases, and the possible development of an indigenous disease seriously imperiling the future of the community. While denying that for such alleged reason an unusual necessity exists in Colorado for a tuberculosis crusade, it is admitted, nevertheless, that measures for the restriction and control of tuberculosis should be rigidly enforced in Denver as elsewhere. That such is not the case is indeed a reflection upon the profession, unextenuated by the existence of favorable climatic conditions, the absence of an overcrowded popu- lation, or the relatively insignificant amount of poverty. Irrespective of locality or other inherent etiologic factors there should be observed in all cities compulsory notification as preliminary to a campaign of edu- cation and supervision. This should embrace all ca.ses of tuberculosis, include each change of dwelling, and become obligatory upon the attend- ing physician, the nurse, the head of the family, and the owner of the house. CHAPTER LXXXIV THE SUPERVISION AND EDUCATION OF THE CONSUMPTIVE The pulmonary invalid, in the absence of certain precautions relative to daily habits, is a direct menace to the family and the public, but strict conformity to prescribed instructions entirely removes all elements of danger. Upon these premises two conclusions are obvious. First, that society has the right to demand of the consumptive the most rigid observance of sanitary rules, and, secondly, that the victim of tuberculo- sis is entitled to receive from the health authorities systematic instruc- tion with reference to the arrest as well as the control of the disease. The burden of action thus lies with the public in the education of the consumptive preparatory to any successful scheme of supervision. To this end public eff'ort toward the restriction of the disease should con- sist primarily of such assistance as will secure a hearty recognition of reciprocal obligations. The methods to be employed in undertaking the education of the invalid are various. Certain well-defined groups of consumptives are recognized to whom are indicated separate and widely differing means of imparting knowledge. In many instances the attending physician represents one of the most important channels Ijy which information may be conveyed with the greatest likelihood of enlisting active cooperation. Unfortunately, the practical effectiveness of this method may be limited in its general appli- cability by the negligence of the physician. Too often the general prac- titioner either utterly fails to appreciate his responsibility in the mat- ter, or neglects to impart detailed instruction solely on account of the time and trouble involved. In other cases the physician, although per- haps earnest and conscientious, may not be sufficiently informed to train 572 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT the patient in a proper manner. In many instances, however, according to the discretion of the health authorities, the personal instruction of the consumptive may be delegated to the phj^sician in charge, but this, under no circumstances, should prevent the supplementary distribution of educational literature, in order to insure accuracy and thoroughness of observed precautions. Among the more intelligent classes carefully prepared circular infor- mation, portraying in detail the necessary preventive measures, often suffices to impart to the invalid an adequate conception of individual responsibilities. Grateful and appreciative readers of such literature are not always found among the masses, particularly the wage-earners, who are often indifferent to their surroundings and careless in their habits. For these, educational leaflets of a more emphatic nature are demanded, and their contents should be adapted to the peculiar requirements of such a class. Such circulars of information should, above all, be clear, brief, concise, of simple phraseology, in effect more or less mandatory, without attempt at unnecessary explanation, and printed in various languages. The work of responsible instruction must develop in the main upon duly authorized and specially trained assistants, working under the sanc- tion either of the Health Department or of various charity organizations. Through the influence of personal contact and force of example, educated women serving either as visiting nurses or sanitary inspectresses, are enabled to inspire immediate confidence and secure intelligent cooper- ation. Thus the precautionary rules left for perusal are more likely to be understood and obeyed. PeriocUc visits, with systematic reports to higher authorities, result in the preservation of valuable records, through which means administrative control may become more effective and the official mind, if occasion requires, awakened to the necessity of coercive action. Other means for the education of the consumptive are afforded through the medium of tuberculosis classes, free dispensaries, sanatoria, and the various methods of enlightening the general public, to all of which consideration will be given in the proper place. Tuberculosis is essentially a house disease, however, and it is in the hojne that the vast majority of pulmonary invalids must receive their instruction and become subject to supervision. By far the most impor- tant feature of prophylaxis relates to the disposal of the sputum in the sick-room, and it is to this phase of the subject that especial attention must be directed. It is essential that scrupulous care be taken to avoid contamination of clothing, bedding, furniture, rugs, floor, hands, lips, beard, or any other portion of the body with tubercle bacilli. In the act of coughing tiny invisible droplets of infective material may lie forcefully distrili- uted in all directions. For this reason it is important that the spray be arrested by some suitable medium held before the mouth at such a time. For this purpo.se paper napkins or pieces of gauze or old cloth are usually available, and should be immediately burned or deposited in a paper bag, paraffined envelop, reticule, or similar receptacle made of oiled silk or rubber. It is undesirable to make use of the handker- chief in endeavoring to prevent a possible dissemination of bacilli, but such practice is, of course, less objectionable and filthy than the habit of utilizing it at the time of expectoration. If the patient holds the handkerchief before the mouth when coughing, this should be folded THE SUPERVISION AND EDUCATION OF THE CONSUMPTIVE 573 at once and set aside until cleansed in the manner to be described for all linen. In the absence of suitable material upon which to gather the tlroplet emanations from the mouth while coughing, the patient should be instructed to hold the hand before the lips and wash it at once. The lips should be carefully wiped with paper napkins or gauze, although in some cases preference is given to washing with a mOd disinfecting solution. In this event the advantage accrues not so much from the nature of the .solution, as from the thoroughness of cleansing. No handkerchief, gauze, or cloth should be used more than once for wiping the lips. As a rule, the consumptive should be advised to dispense with his beard, especially if at all luxuriant. Nothing is more unsightly or unclean than an overhanging growth upon the upper lip of pulmonar}'- invalids, unless it is the time-honored chin-whisker of our countrymen upon which may adhere particles of bacilli-laden sputum. If objection be made to the removal of the beard, it at least should be cropped very closely. A proper receptacle for the sputum is of the utmost importance. It is essential that the expectoration should not be permitted to dry exposed to the air of the room, nor to soil liy accident any article for which it was not intended. It should be deposited, without going astray, in earthen cups partly filled with water, in paper spit-cups, or upon pieces of gauze. Old-fashioned cuspidors upon the floor are an abomination not to be tolerated. In all instances the patient should deposit the s])utuni with the cup or other receptacle held closely to the mouth, in oi'dci' to avoid scattering the agents of infection. Earthen cups used for tliis inirpo.se should be cylindric in shape and provided with a cover. It is important that some means be taken to conceal the unsightly expectoration and prevent the entrance of flies, thus avoiding consequent distribution of bacilli to articles of food, as has been described. Under no circumstances should there be used hand cuspidors with an inclined ujjper surface terminating in a small aper- ture at the center, as it is inevitable that particles of adherent sputum will become dried upon the presenting upper portion. Caution should be exercised to ]irevent the retention of sputum in a similar manner upon the sides or edges of earthen cylindric cups. If paper spit-cups are used, they should be destroyed by fire, and if these are contained within a square tin box, the latter should be boiled daily. If pieces of cheese-cloth or gauze are emj^loyed, they should be folded immedi- ately after expectoration, and deposited temporarily in a proper recep- tacle, as has been explained, and subsequently burned. If an ordinary earthen cup is used as a receptacle for the sputum, it is important that it should have a handle and be partly filled with water. It is unneces- sary to employ disinfectants, provided proper attention is given to emptying and refilling the cup at frequent intervals. If a receptacle of this sort is used, the primary essential is that the sputum should be kept moist and covered. In cities with modern sewerage facilities the cup may be emptied into the water-closet. In other cases the sputum should either be boiled or exposed to a strong phenol solution for several hours. An elaborate method for the sterilization of tuberculous sputum has been described by Kirkland and Patterson. The sputum is poured into an iron vessel, which is provided with a movable lid and has at the bottom 574 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT two steam jets which, in operation, give a circular motion to the contents. After the aputum has been emptied into the iron receptacle and the lid screwed down, the steam is introduced through the jets at the bottom to a pressure of fifteen pounds. After the sputum has boiled for twenty minutes it is allowed to cool, and is then drained into the sewer by the opening of a valve at the bottom of the sterilizer. The sputum-cups are cleaned in a somewhat similar manner. They are first suspended by their handles upon a series of horizontal brass tubes, which form the essential feature of a cage which, in turn, is lowered into the iron tank. Into this are admitted water and steam, the boiling being permitted for twenty minutes. The advantages of this method appear to be marked economy of time, greater safety in the handling of the cups, and more thoroughness than if washed by hand. It is of the utmost importance that proper provision be made for the cleansing and sterilization of the linen. In the later stages of consumption, when the patient is completely bedridden, the danger of soiling the linen with infected sputum becomes exceedingly great on account of the physical exhaustion. In many cases the intellect is impaired more or less and the patient is totally unable to appreciate his status as a source of danger to others. The responsibilitj- for a proper hygiene of the sick-room then devolves entirely upon the atten- dant. At such a time it is better that the sputum should be deposited upon pieces of cheese-cloth or gauze, rather than in sputum-cups, as these are often upset if permitted in the hands of the patient. The paramount consideration relates to the observance of the utmost cleanliness as regards the clothing, hands of the invalid, bed-clothes, floor, and rugs. The hands of the attendant, as well as the patient, should be kept absolutely clean at all hazards. All articles of soiled linen which are not to be destroyed, should be brought into immedi- ate contact with a 5 per cent, solution of phenol or immersed for several hours in a solution of corrosive sublimate and subsequently boiled. The solution may be made by dissolving a dram each of corro- sive sublimate and ammonium muriate in a gallon of water contained within a wooden bowl or tub. This solution may also be used for washing floors, walls, or wooden furniture. In institutions sterilization plants are essential for a proper cleansing of the linen. The furniture of the sick-room should be as simple as possible. Draperies, lace curtains, velvet or plush furniture, antl all articles likely to retain dust should be excluded. It is desirable to clean the room, if possible, only when the patient is out-of-doors. Care should be taken not to dust with feather-dusters or to sweep vigorously with a dry broom. The rugs should be cleaned in the open air, and dusting should be performed only with a moist cloth. There should be no carpet in the room occupied by a consumptive. It is properly one of the prerogatives of health officials to supervise effective methods of disinfection of apartments, after the death or removal of the consumptive. Much has been written of late concerning the necessity of disinfecting such rooms and the contained furniture at public expense. The movement relative to the destruction or disinfection of all articles with which the invalid has come in contact has extended sufficiently to inspire on the part of certain students and educators an advocacy of cremation. It is well in this connection to call attention to the fact that the administrative control of tuberculosis pertains far THE SUPERVISION AND EDUCATION OF THE CONSUMPTIVE 575 more to the supervision of the consumptive, and his immediate environ- ment while he is yet alive, and disseminating innumerable agents of infection, than to the disposal of his body after the potent source of danger has ceased to exist. As a matter of fact, an insistence upon strict precautionary measures relating to personal cleanliness and the hygiene of the sick-room during life is of infinitely more importance than the disinfection of apartments and the destruction of their con- tained articles after death. It would appear, however, that both the profession and the public are educated more or less to a belief in the wisdom of rigid disinfection of apartments occupied by consumptives. Frequently, however, no particular concern is manifested as to their immediate presence in the family for prolonged periods. Disinfection of apartments by no means is to be deprecated, but the thought is suggested that in some instances the importance of this procedure is exaggerated. As suggested by Chapin, disinfection should not be regarded as an expiatory atonement for previous unsanitary sins. It is particularly to be recommended in crowded tenements exhibiting a sad deficiency of sunlight or fresh air, and occupied by the ignorant, impoverished, and sometimes the vicious. Disinfection, when done at all, should be practised in a most thorough manner, and may be performed by the burning of sulphur or foimaldehyd. Formaldehyd disinfection is the more modern, and probably the more efficient, method. The key-holes, window-cracks, fire-places, door apertures, and all other crevices should be tightly sealed. Articles of clothing or bedding should be spread or suspended in the room in order that the disinfec- tion may be as thorough as possible. The most convenient manner of formaldehyd disinfection results from the use of the generator. As commonly employed, however, the formaldehyd is sprinkled upon a sheet and suspended upon a clothes- line. There should be used one pint of formaldehyd to every 1000 cubic feet of air, and the room tightly closed for at least twelve hours in order to make fumigation as thorough as possible. Much of the clothing, bedding, and sometimes the rugs may be disinfected by placing in a steam sterilizer. If sulphur is used, it should be placed in an iron vessel, which in turn is put into a tub partly filled with water. The iron kettle should stand upon bricks placed in the bottom of the tub. About three pounds of powdered sulphur should be used for every 1000 cubic feet of air. After the sulphur has been ignited, the room should be tightly closed, and remain unopened for from ten to twelve hours. If sulphur candles are employed, there is considerable danger that the disinfection will be incomplete unless several candles are burned at the same time in a small room. The walls, window-frames, and other wooden portions of the room should be thoroughly washed with the disinfecting solution previously described. Further considerations relating to the care of the consumptive, the hygiene of the room, and the importance of detailed in.structions in the interests of the invalid will be discussed in connection with the following subdivision. 576 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT CHAPTER LXXXV THE EXTENSION OF MATERIAL AID ACCORDING TO THE VARYING NEEDS AND REQUIREMENTS OF DIFFERING CLASSES An organized effort toward the suppression of consumption, to be effective, must take cognizance of the obligation imposed upon society to render, when needed, substantial assistance to sufferers from the disease. The movement for the restriction of tuberculosis must not be permitted to assume the characteristics of a "crusade" against the indi\idual consumptive, but rather against the conditions which make possible the existence of the scourge. There must be a campaign against tuberculosis rather than the tuberculous. Both for the attain- ment of the best results in prophylaxis and for humanitarian reasons the attitude of society, as clirected largel}' by the mecUcal profession, must not partake of oppression and persecution. Arbitrary measures are demanded oiilj' by the exigencies of unusual cases. Upon the other hand, the predominating spirit actuating all attempts of adminis- trative control should be that of benignanc}-, supervisory helpfidness, and material aid. The first appeal for assistance arises from the great mass of needy consumptives who are confined to their homes. To such a class, instruc- tions as to the sanitary disposal of sputum and the hygiene of the room are of but slight value unless means are provided to permit their proper execution. In other words, practical aid to the ignorant and impover- ished constitute an essential factor in the general scheme of supervision surely no less important than the distribution of educational leaflets and the periodic visits of nurses and inspectresses. The benefits derived as a result of the visiting nurses' association and similar organizations, though manifold, can be greatly augmented by the disbursement, under their direction, of sputum-cups, gauze, di-sinfectants, or other material used for the purposes of prevention. The cost is utterly insignificant in comparison with the results to be obtained, and the same is true of the expense necessary to supply deficiencies in the way of food or clothing in individual cases. At least fresh eggs and milk should he freely furnished to the very poor. By this means not only are there afforded additional opportunities for the restoration of working power and sub- secjuent maintenance of families, but also greater assurances of compli- ance with precautionary rules. Among the destitute the proliability of faithful cooperation on the part of invalid or family is much enhanced if there are sustained relations of mutual reciprocity. The advanced consumptive who, in ignorance and poverty, is destined to succumb to prolonged illness at hotne represents by all odds the greatest source of danger as regards the transmission of the disease to others. Assuredly no investment can }-ield a more substantial return than the extension of material aid to such a class, in the hope of thereby diminishing the possibilities of contagion. Assistance to these people should also include the distribution of needful articles of clothing and such medicines as are demanded under the sanction of the visiting nurse or other official representatives. Provision should be made for the proper cleansing of rooms and cloth- EXTENSION OF MATERIAL AID ACCORDING TO VARYING NEEDS 577 ing, the cost of frequent scrubbings of the floor and washing of the linen being defrayed at public expense. Not the least important province of the nurse or inspectress in the interest of the patient is a supervision of the immediate environment. Although often a matter of techous detail, the advantages of a proper attention to the surroundings are almost incalculable. An intelligent and resourceful inspection of apartments often affords means for an ■out-of-door existence which would at first be considered as impossible of attainment. Recourse may be taken to back porches, i-oofs of tene- ment houses, tents, and improvised aeraria, by means of which simple ■contrivances the invalid is permitted to partake of the benefits of fresh air and sunshine. If the patient is unable to stay out-of-doors, the mere supervision of the sick-room is sometimes fraught with important benefits. The selection of a room containing the greatest facilities for ventilation, and with a simny exposure, falls entirely within the scope of visiting supervision, as does even the arrangement of the furniture, ■the situation of the bed near an open window, the adjustment of tem- perature, and the regulation of the amount and character of bed- covering. Attention to the foregoing considerations involves but slight ■expense, while a devotion to detail adds immeasurably to the material comfort of the sufferer and insures, as a rule, conformity to precaution- .ary instructions. An important advantage of systematic periodic vis- itation is the opportunity permitted to acquire accurate data as to the sanitary conditions and the probable dangers of infection to others. Upon this evidence may be based any action leading to the forcible removal of the patient to special institutions. INSTITUTIONS FOR CONSUMPTIVES From the aspect of prophijlaxis, institutional care and supervision are demanded by three fairly distinct classes of pulmonary invalids: (a) The hopelessly ill and impoverished. (b) The vicious, who refuse to conform to established rules. (c) The consumptive poor, who, with suitable assistance, offer a reasonable prospect of recovery. No inclusion is made of the non-inchgent incipient class, for whom ■especially sanatorium provision has been provided. Without the slightest reflection upon the usefulness of institutions open only to patients with slight infection and in comfortable circumstances, the fact remains that from the standpoint of prevention such patients do snot comprise a group constituting important elements of danger to others. The construction of sanatoria for incipient non-charity cases in the interests of prophylaxis does not represent a legitimate obligation upon society. The proper scope of such institutions will not be con- sidered at this time, but will be reserved for later discussion in con- nection with Treatment. The Hopelessly 111 and Impoverished. — For the very advanced cases, it is clearly incumbent upon society to provide segregation hos- pitals where the last comforts of life can be administered without the slightest danger to families or the community, and where death may be robbed of a portion of its horrors through judicious nursing and medical care. The destitute and dying consumptive who is not granted & welcome in municipal hospitals open to other classes of suffering 578 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT humanity, and is even denied admission to special sanatoria, is entitled, upon humanitarian grounds, to receive from the Commonwealth insti- tutional aid when needed. In turn, society has the right, at the discre- tion of the health officers, to insist upon the forcible removal of hopeless cases to such institutions when sanitary precautions are wantonly or unavoidably disregarded. All municipalities should provide adequate facilities for the housing and care of these indigent advanced cases under the supervision of the health departments. In the campaign of prevention the great usefulness of institutions of this character must be appreciated by those who have become at all familiar with the deplorable conditions existing in large cities. The number of patients properly falling within the scope of hospitals for advanced and impoverished cases is legion. But little provision has thus far been made for such unfortunates, as sanatoria possessing facilities for their care are exceed- ingly few. From an institutional standpoint these invalids are unde- sirable because of the nature of their physical infirmity, and by virtue of their ignorance, destitution, and obstinacy. It is probable that many would object strenuously to detention in special institutions, and very likely would refuse to conform to established rules, and it is pre- cisely for such consumptives that some form of sanatorium provision is demanded. It is not merely the hopeless indigent invalid who remains at home, a constant menace to the immediate family and associates, whom it is desired to remove to special hospitals, but also the great army of homeless, roving, shiftless, iiitemperate. and vnndi/ consumptives who are notoriously neiiligont regarding sanitary instructions. The Vicious Who Refuse to Conform to Established Rules. — This, of all classes, undoubteiUy represents l.iy far the greatest danger to so- ciety on account of the wide-spread distribution of bacUli resulting from reckless expectoration. The cases comprising this group of vicious, dissipated, or unmanageable consumptives are radically different from those embraced in the preceding class. The thought is, therefore, sug- gested that there may properly be displayed a corresponding difference in the character of the sanatoria prepared for these two classes of in- digent invalids. WhOe unnecessary multiplication of institutions mu.st be avoided, it is, indeed, a reflection upon modern civilization to crowd these two groups indiscriminately in poorly ventilated and sometimes loathsome poorhouses. Adequate accommodations should be provided for worthy advanced consumptives without an enforced intimate association with the vicious and dissipated. The hospital for advanced cases should, indeed, be a refuge in literal compliance with the spirit of the German institutions, i. e., "Friedensheim," or " Home of Peace." It is apparent that, in the interests of humanity, separate provision should be made for those le.ss entitled to sympathetic consideration. Neither does it appear that the common jail is quite the appropriate place even for those who infringe upon the rights of society. Although admittedly violators of the law and entitled for this reason to no more consideration than other criminals, the fact remains that they do not come under precisely the same category and, therefore, should not be given a similar penalty. It is apparent that the punishment to be allotted to offenders against criminal law, even if tuberculous, should bear no relation to their physical infirmity. It is equally true that miiui infringement of sanitary laws by consumptives cannot justify, EXTENSION OF MATERIAL AID ACCORDING TO VARYING NEEDS 579 even in the interests of prevention, the imposition of an indefinitel ij prolonged jail sentence. Experience has shown that tuberculosis is already frequent among those incarcerated for other crimes in penal institutions. It would, indeed, be a short-sighted policy to crowd jails, reformatories, and prisons with unruly consumptives. In such an event it is difficult to conceive in what manner either the purposes of justice or the cause of prevention could be effectually subserved. The vast number of such individuals would preclude their proper housing under State supervision. The responsibility for their management and control should be assumed by the local communities burdened by their presence, as pi'ovision can be made with but comparatively slight expense for their proper housing. It is not insisted that a necessity exists for the construction of special detention institutions for these patients, but it is contended that separate ■provision for their reception should be made either upon the county farms, or in special wards in existing hospitals for advanced cases. It is perfectly feasible to construct suitable accommodations upon the town farm for the care of worthy hopeless consumptives, as well as for the vicious and unmanageable. Appropriate wards or camps may be set aside to comply with the separate needs and requirements of each class. Such institutions, if conducted under the supervision of local health authorities, would aid greatly in the accomplishment of practical prophylactic results. All communities should be compelled to extend aid of this character to the hopeless impoverished consumptive and exact in return strict compliance with the law on the part of others. The Consumptive Poor Who, With Proper Assistance, Offer Reasonable Prospects of Recovery. — Many of the people included in this group, as a result of substantial assistance, can resume their former positions as wage-earners. As a rule, they are unable in their ordinary environment to observe precautionary rules, and hence become with advancing infection a distinct menace to the community. There can be no question, therefore, as to the obligation devolving upon society to care for its non-hopeless indigent consumptives. The eco- nomic feature of the problem has been considered. The responsibility devolving upon the Commonwealth can be discharged only by the erec- tion of State sanatoria or convalescent farms for those whose condition requires institutional regime, and by the construction of free tubercu- losis dispensaries in thickly settled communities for the ambulant cases. STATE SANATORIA The maintenance of State sanatoria for partly indigent incipient cases has been amply justified by the results thus far accomplished in several localities, in which the experiment has been tried, notably in Massachusetts. In emulation of the example set at Rutland, the pendulum of public opinion is swinging strongly toward the erection of such institutions. Neither the charitable features nor the economic utility of sanatoria of this kind are subject to doubt even among the most skeptical. There is room, however, for honest differences of opinion as to the jurisdiction under which they should be operated, the manner of construction, location, the extent of industrial opportunities offered, and the character of the management. From a practical stand- 580 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT point it matters little whether these institutions are supported by State aid or by local public or pri\'ate benevolence, provided the true spirit ostensibly inspiring their construction is conscientiously maintained by those in charge. This, unfortunately, is not always the case in public institutions on account of the pernicious influence of politics. The selection of the site is sometimes grossly inappropriate and unnecessarily expensive. Buildings ill adapted for the purpose are occasionally erected through the advice of partizan architects. Grossly incompetent medical superintendents may be selected as a result of political favor. There may result, therefore, a great diminution in the actual usefulness of institutions, endowed with almost infinite possi- bilities in the way of service to others. The essential considerations are that these buildings should be properly located, so designed and constructed as to afford suitable accommodations to the gi-eatest number at a nominal expense, and con- ducted in accordance with broadly humanitarian instincts as well as along scientific lines. To this end it is obvious that the best results can be secured only through the active cooperation of representative medical men. It is quite impracticable to expect from a Committee of the Legislature, rendering allegiance primarily to some political ring, the elaboration of modern well-sustained ideas concerning the construction and maintenance of sanatoria. Upon such a subject there must be brought to bear the enlightenment and experience of those especially engaged in medical and sociologic work. The responsibility for the erection and supervision of such institutions should be delegated to members of the medical profession interested in the elucidation of problems of this nature. Through the cooperation of State and county medical societies, associations for the study and prevention of tuber- culosis, the various charity organizations, and the local health authorities, the direction of these institutions may be consigned to individuals who are perfectly competent to discharge satisfactorily the imposed trust. It is probable that the practical efficiency of sanatoria designed for this purpose would be greatly increased if they were erected in various com- munities throughout the State, supported in the main by local subscrip- tions, yet receiving substantial aid from the State. Irrespective of the amount of assistance rendered by private benevolence, it is undoubtedly true that more satisfying results would accrue from the distribution of several institutions of this nature in different localities, than from the erection of a single imposing structure for indigent consumptives. It goes without saying that a single building of this description, no matter of what size, must be entirely inadequate to supply the pressing needs of the many unfortunate sufferers scattered throughout a State. It is also true, in spite of the insufficient accommodations, that but little stimulus would be given to the extension of further aid either through local pride or private philanthropy. The logical solution rests with the creation of so advanced a public sentiment as will inspire the construc- tion of numerous abodes of this character for early consumptives who have not the means of self-support. It is to be regi-etted also that buildings erected entirely through private generosity, though of beautiful architectural design and mag- nificent in proportions, are often ill suited to the needs and require- ments of the comparatively small number of indigent consumptives who chance to be admitted within their walls. Meanwhile the expense EXTENSION OF MATERIAL AID ACCORDING TO VARYING NEEDS 581 incident to these monumental structures is entirely out of proportion to the practical benefits to be secured. The question of affording industrial facilities to the inmates of State sanatoria is very properly subject to some comment. As fur- nishing a means of diversion to those not likely to be injured by such pursuits, there is undoubtedly much to recommend the performance of light out-of-door work, either in the fields or garden, and of handiwork of various kinds while at rest upon the porches. Indoor employment should be deprecated under all circumstances. Many of the arts and crafts, even if practised in sunny, well-ventilated apartments, exercise a distinctly deleterious effect on account of the confinement, physical effort, and inhalation of dust. Upon the other hand, work in the fields, garden, or at the wood-pile is often attended by unfortunate conse- quences. Compulsory employment of this kind is not likely to be received with the utmost enthusiasm even by individuals participating in the bounties of State or private philanthropy. The provision for industrial pursuits may not be expected to furnish financial assistance to public or private institutions of this character. As a source of income, pure and simple, any scheme of organized work is not to be recoinmended , as the industrial features cannot be expected to yield a financial return at all commensurate with the expenditure. Carefully selected patients may be permitted to perform such light work upon the premises for brief periods of time, as their physical condition will justify, but any organized effort toward increasing the income through the labor of patients is utter folly. Assuredly one of the important objects of such institutions wiil be defeated, unless the inmates are constantly subjected to the closest surveillance in order to forestall the possiliilitu oj orerexertion. The Influence of State Sanatoria upon Neighboring Com- munities and Surrounding Property. — It is important to call attention to these features connected with the erection of hospitals for advanced cases, concerning which there has been considerable popular misappre- hension. The impression has become somewhat prevalent that residents of smaller towns, in which have been situated sanatoria for consumptives, have been subject to more or less danger of contagion from the influx of imported cases. In the consideration of the possible danger of infection from visiting tuberculous invalids, it is well to discriminate clearly between the influ- ence of so-called closed sanatoria, and that of open resorts for consump- tives. The evidence thus far presented is quite overwhelming to the effect, that the closed institutions are everywhere responsible for a material diminution in the tuberculosis mortality rate among the neighboring inhabitants. This is explained by the pronounced educa- tional influence exerted throughout the community by lessons in hygienic living, and the precautionary measures taught through the force of actual example. The development of tuberculosis among physicians, nurses, and attendants in institutions for consumptives is known to be exceptionally rare, in spite of prolonged intimate asso- ciation with invalids in advanced stages of the disease. Upon the acceptance of these facts, it is difficult to conceive how the resident population of towns in which such institutions are located, are especially liable to infection, the exposure being practically nil and the measures of prevention being thoroughly understood. As a matter of fact, the 582 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT existence of well-conducted tuberculosis hospitals in any community must serve as an added element of protection to the public rather than as a menace. As regards the open resorts, where, on account of climatic advantages, pulmonary invalids in advanced stages of the disease flock in large numbers, there might be expected, upon purely theoretic grounds, a possible increase of the non-imported tuberculosis mortality rate. Certain towns in Europe, notably Mentone and Nice, have frequently been cited as illustrating the development of indigenous tuberculosis among the inhabitants from the importation of pulmonary invalids. The reports from these places as to the prevalence of local infection are, however, decidedly at variance. The observations of experienced clinicians in other health resorts of Europe and America are, however, singularly in accord as to the entire lack of statistical data upon which to base the assumption of an increase in the practical dangers of infection from the influx of consumptives. Communications from St. Moritz, Davos Platz, and Cairo concur in positive statements concerning the lack of evidence as to the increase of tuberculosis among the native population at any time during recent years. In 1905 an inquiry was conducted by Dr. C. F. Gardiner as to the influence, if any, of imported pulmonary invalids upon the native tuber- culosis death-rate in open resorts throughout Massachusetts, Connecticut, New York, North and South Carolina, Virginia, Georgia, Texas, New Mexico, Arizona, Utah, California, and Colorado. The result of this inquiry showed conclusive!}' that the imported tuberculous invalid was scarcely ever a source of danger to the native population, and that the practical likelihood of such infection in open resorts was grossl}- exag- gerated. It must be insisted, in spite of such reports, that the pro- tection of these communities is dependent largely upon the vigilance of the health authorities and the effectiveness of their administration. Gardiner has reported that an investigation conducted by himself and other physicians in Colorado Springs, including different liealth officers, has disclosed, out of a population of approximately 2().()()() people, but one case each year since 1889 originating among the native population, or sixteen cases in sixteen 3'ears in spite of an exceedingly large number of imported pulmonary invalids. My own observations in the city of Denver during a period of sixteen years have been reported in connection with the Geogi'aphic Distribution of Tuberculosis. No valid objection can he presented to the erection of hospitals for tuberculous patients upon the score of fancied dangers to the com- munity. Strenuous opposition may sometimes be interposed as to their erection, but this usuallj^ emanates from propertj'-owners in the imme- diate vicinity, who assume that values will be unfavorably affected by the proximity of such institutions. This element of deterioration in the value of surrounding property, which is more imaginary than real, cannot obtain when a site is chosen either in the country or in the suburbs of the larger cities. On the other hand, it has been found that the presence of these institutions has been decidedly helpful rather than unfavorable. In almost all instances surrounding property has appreciated in value through the increase of population in localities previously isolated or abandoned. With increase of visitors there necessarily takes place expansion of business of all kinds, improvement of adjacent property, with attention to the locality as a healthful EXTENSION OF MATERIAL AID ACCORDING TO VARYING NEEDS 583 and desirable place of resort. Prejudice and preconceived ideas as to the supposed undesirability of institutions of this kind, founded upon misconceptions of actual facts, should not be permitted to thwart the important interests either of the Commonwealth or of pulmonary- invalids as a class. Considerations pertaining to the location of san- atoria, hygienic conditions, immediate surroundings, water-supply, soil, drainage, accessibility, initial expenditure, and cost of maintenance will be considered in connection with the Sanatorium Treatment of Consumption. It is submitted at this time, however, that institutions designee! for indigent cases do not require an elaborate outlay for buildings, and that a suitable selection of the site, with provision for the largest possible number of inmates, is of far greater importance than the erection of imposing structures. Institutions non-charitable in character and not maintained at public expense may be, of course, as ornate and magnificent as their promoters desire. THE TUBERCULOSIS DISPENSARY One of the most important factors in a supervisory and educational campaign is the tuberculosis dispensary. While its province is more directly for ambulant cases than for others, its scope is surprisingly far reaching. Upon superficial inquiry it might appear that the necessity of special dispensaries for tuberculous patients does not exist, and that this feature could be safely delegated to the other free dis- pensaries, so common in large municipalities. This aspect of the move- ment toward the prevention and control of consumption has been regarded by some as subordinate to many other phases of the campaign. In truth, however, the ultimate influence of the tuberculosis dispensary is almost beyond estimation. Its usefulness is not confined merely to the rendering of routine gratuitous assistance to consumptives, but more to the opportunity afforded for personal contact with the pul- monary invalid in his home, the inspection and control of his environ- ment, and the imparting of responsible instructions. Among the varied functions of such an institution there should be recognized its peculiar position as the central point of all other agencies engaged in the pre- vention of the disease. In other words, it often represents the initial step in the acquirement of data regarding centers of infection. To R. W. Phillip, of Edinburgh, are students of preventive medicine indebted for the present conception of the unique province of the ' tuberculosis dispensary. Through his individual efforts there was founded, in 1887, the Victoria Dispensary for Consumption in Edinburgh, the first institution of this kind in existence. Since then similar buildings have been constructed in Belgium, France, and Germany, and a few cities of the United States. The underlying motive inspiring the founding of the \'ictoria Dispensary by private charitable enterprise was not so much the care of patients applying for treatment nor the possible amelioration or cure of the disease. It was hoped to obtain a more ready access to centers of infection in families and lodging-houses, in order that a more comprehensive supervision of infected dwellings might prevail and the general scheme of prophylaxis become more effective. In Scotland, unlike other countries, the tuberculosis dispensary ante- dated the erection of saruitoria, antl has remained not merely an isolated 584 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT feature of the tuberculosis movement, but has gradually developed into the most important integral part of the entire system of organized effort. It should be, in fact, a clearing-house for all indigent consumptives, from which, after thorough examination of the physical conditions and. environment, they may be sent, when necessary, to appropriate institu- tions. The province of the tuberculosis dispensary as a sort of general bureau of information may be subdivided for the following purposes: 1 . Invitation of indigent tuberculous patients and those presenting suspicious evidence of the disease. 2. Thorough physical examination of all comers, with bacteriologic analysis of the sputum and the preservation of a detailed record of the family history, previous history, present illness, occupation, residence, and environment. In this manner there is obtained an accurate diag- nosis of the condition, the early recognition of the disease representing one of the most important elements in the war of prevention. 3. Facilities offered for the imparting of competent instructions to patients, and for the inspection of dwellings and workshops. In addition to personal advice and exhortation to obey instructions, circular infor- mation may be distributed in \-arious languages, as previously described. 4. Opportunity for the inclusion of the case in a list of those to be observed continuously by the visiting nurses' association or similar organizations. 5. Discrimination permitted between patients who are best suited for residence in institutions for incipient cases, detention resorts, or hospitals for hopeless consumptives. The proper classification of these individ- uals and the recognition of their pecidiar needs and requirements rep- resents one of the important functions of the dispensary. 6. The extension of material aid, when necessary, in the way of gra- tuitous advice, food, clothing, medicines, sputum-cups, gauze, disin- fectants, etc., in accordance with the manner outlined for the consump- tive at home. 7. The offering of comfort, reassurance, and general guidance to immediate relatives and friends upon matters pertaining to the general subject of prevention. Under tliis heading should be included, when suggested by the visiting nurses, the examination, by some mcmlier of the dispensary medical staff, of any member of the famih' or others with whom the patient has been brought into intimate association. In general, the primary function of the tuberculosis dispensary is its position as a basis for further operations. Without this the house- to-house visitation, with supervision of the consumptive at home, is entirely impracticable in cities devoid of compulsory notification laws. Further, the proper selection of cases for the various institutions for consumption would be quite impossible without the preliminary direc- tion exercised at the dispensary. A valuable modification of the tuberculosis free dispensary is found in the so-called da;/ resort or day cure. In 1900 a plan was adopted in Berlin for the establishment of day resorts for convalescents from various hospitals, of which tuberculous patients comprised approximately one- half. Accommodations were secured in a large open place, and facilities afforded for patients to recline in the open air during pleasant weather. They were permitted to converse and play games during a portion of the day, but were compelled to rest at other times. They were also instructed with care as to the danger of transmitting the disease to EXTENSION OF MATERIAL AID ACCORDING TO VARYING NEEDS 585 Others. Food was served several times during the day. This system of " day cures" has been adopted in Germany, France, England, Belgium, and Austria, and remarkable results are being achieved. A similar estab- lishment has been started in Roxbury, Mass., known as "The Parker Hill Sanatorium." Here invalids are offered the benefit of pure air, good food, and such medicine as is needed. They are afforded an oppor- tunity to rest in reclining chairs or cots, and are comfortably clothed and housed during inclement weather. Similar facilities are offered to women in Boston at the Samaritan Hospital Day Camp. Valuable as is this modification of the free dispensary, the effective- ness of such a scheme must be very greatly curtailed unless there be instituted a system of domicUiary visitation, precisely after the manner of the tuberculosis dispensary. It is this latter feature of reaching the homes, where grossly unsanitary conditions are found to e.xist, that is productive of the best results in the effort toward prevention. The greatest degree of protection to the public must accrue from the daily personal dissemination of practical truths in the very homes and workshops of the poor, where exists the most important habitat of the disease. In view of the fact that indigent consumptives are out of all proportion to the capacity of any number of institutions, it is apparent that the tuberculosis movement should relate not alone to providing a temporary means of lodging for the known victims of disease, but to conducting a definite system of defense. Through the influence of kindly personal contact resulting from periodic domiciliary visits, the propagation of knowledge regarding the dangers of infection becomes particularly effective. It must he remembered that it is this educational influence within a community that reflects one of the chief benefits of all consumptive institutions or agencies. Those who have profited, either at home or in sanatoria, through the force of example readily become, in turn, self-constituted apostles to spread broadcast the gospel to which they have become so much indebted. With a correct appreci- ation of the proper methods of hygienic living, the consumptive is enabled in a practical way to enlighten those with whom he may come in con- tact, concerning the manner of restricting the transmission of the disease. Still another modification of the tuberculosis free dispensary, known as The Tuberculosis Class Si/stem, originating with Dr. Pratt, and per- fected by the assistance of Dr. Hawes, 2d, of Boston, has been established. It has been the effort further to elaborate the educational feature and supplement the deficiency in supervision and discipline which necessarily obtains where the dispensary methods alone prevail. This system is de- signed to reach but comparatively few people, but to extend to those the maximum attention. The patient is admonished to lead a strictly out- of-door life, avoid work, and to comply rigidly with detailed instructions. The clinical history is taken, and the lungs and sputum periodically exam- ined. Visits to the home are made by nurses or "friendly visitors," so called, definitely qualified to impart kindly words of advice and yet to exact obedience. Facilities are found, if possible, for sleeping out-of- doors, either upon a balcony or upon the roof, protected by awnings, or in tents upon the ground. Reclining chairs are provided and needed assist- ance rendered in the way of food and clothing, after the manner inaug- urated under the auspices of charity organizations and visiting nurse associations in different cities. Similar work may be accomplished in the suburbs of large cities, 586 PROPHYLAXIS, GEXERAL AND SPECIFIC TREATMENT as is practised under the supervision of the Social Service Bureau of the Massachusetts General Hospital. Suburban tuberculosis classes are formed to provide for out-of-town consumptives. While the percentage of cures has thus far been very small, the primary object, namely, the education of the patient, has been accomplished in nearly all cases. An element of some importance in the conduction of suburban classes is the greater probability of arousing a local interest among the suburban health authorities. An active initiati\-e among these officials to care for their own consumptives is a result fondly to be desired. The class system, though worthy of much commendation, appears, on account of tile elaborate detaO, to be very limited in its application. It would almost seem, in the present state of public apathy and indifference in some quarters, with the tendency toward hysteric phthisiophobia in others, that more practical results along the lines of prevention could be secured by not concentrating the energies of intelligent workers upon so comparatively few patients. It is probable, in the interests of prophylaxis alone, that the sphere of usefulness of the class system in some instances coidd be extended by dispensing with the weekh^ meet- ings after a short period, and thereby increasing the list of members or by the formation of new classes from time to time. CHAPTER LXXXM THE DISSEMINATION, TO THE GENERAL PUBLIC, THROUGH THE MEDIUM OF VARIOUS CHANNELS, OF AUTHENTIC OFFICIAL INFORMATION REGARDING THE PREVENTION OF CONSUMPTION Emphasis has been given to the prime necessity of imparting imme- diate instruction to the pulmonary invalid, and of appealing in devious ways to his sense of obligation, that the rights of others may be respected. In the effort to restrict a preventable di.sease that destroj'S annuallj' 150,000 lives in this country, especial importance also attaches to the education of the general public. The ignorance, apathy, and indiffer- ence for a long time exhibited regarding a subject worthy of the utmost concern, and the popular prejudice later entertained, jointly suggest the need of a comprehensi\-e system of education directed to all classes and conditions. Above all, there is demanded an acceptance of rational, well-sustained conceptions relative to the possil^Uities of infection, and the best means of avoidance. To divest the pulslic mind of exaggerated and distorted notions regarding certain supposed elements of danger, is no less desirable than to enliuhten the masses reuarding proper methods of defense against conditions actually inimical to health. The education of the public concerning a prol>lem of such overwhelm- ing importance can he secured only by the wide-spread inculcation of practical knowledge and the convincing demon.stration of actual facts. By whatever methods popular instruction is attempted, it is quite essen- tial that, for real effectiveness, there should be instituted a systematic propaganda of education. Lenity of purpose and harmony of action are DISSEMINATION OF INFORMATION REGARDING PREVENTION 587 important considerations, and to tiiis end it is suggested tliat all local effort should receive its general direction and impetus from some duly recognized and responsible source. The vital element of success in the educational movement relates to the establishment of the most com- plete confidence on the part of the people in the ability, sincerity, and executive capacity of those upon whom is imposed the task of official guidance. There is, perhaps, no better medium for the dissemination of authentic data concerning consumption than the formation of local antituberculosis societies, acting in full unison with municipal and State health authorities, and in cooperation with a central organization of national scope. In this manner the truths to be carried home to each individual will be in nrcmd with the most modern scientific investiga- tion, and will reflect upoii practical questions the consensus judgment of active, trained \\(iikcMs, whose lives have been devoted to the study of medical and sociologic conditions. Practical instruction emanating from such sources, and resourcefully conveyed to the general public through various channels, cannot fail to have a most enlightening influ- ence. Local organizations, either charitable in character or operating purely in conjunction with the National Association for the Study and Prevention of Tuberculosis, constitute, if efficiently officered and properly equipped, the most effective agencies under whose aus- pices may be transmitted trustworthy data for the information of the public. It should be borne in mind that the educational aim to be accomplished is attained, not wholly as a result of the organization employed for this purpose, but rather by virtue of the aggressive initi- ative, tactfulness, and enthusiastic devotion to duty ofthe executive officers. In this connection it is not inappropriate to pay a tribute to the indomitable energy of those who have so cheerfully and capably discharged their official obligations during the present national agita- tion regarding consumption. Other things being equal, the most satisfactory efforts in the way of public enlightenment may be expected to attend a plan of cam- paign formulated along the lines of a national association with subordi- nate State organizations. Such a situation prevails in the majority of the States, or^aiiizcd \\c stated parenthetically that some information has been presented which casts much doubt upon the every-day role of milk as the carrier of tuberculous infection to children. Upon the other hand, there can be no question that the health of little ones is seriously impaired by gross inattention to diet. Aside from the improper preparation of food, a menace to the young is found in the frequent contamination of milk as a result of the presence of nearly all forms of bacteria. It is true that the vitality of these germs may be destroyed by boiling or effective pasteurization, but such measures are not universally employed. Furthermore, little satisfaction may be derived from the thought of ingesting with the milk the filth products of the dairy, no matter how thorough the pasteurization. Sterilized animal feces, though perhaps less objectionable than the unsterilized, are hardly to be considered a desirable constituent of milk for commercial purposes, yet it has been found by actual analysis, that a large proportion of the milk sold in large cities contains all manner of contamination derived from uncleanly dairies. Absolute cleanliness of the stables, of the animals themselves, and of the recep- tacles for transportation is assuredly a factor of the utmost moment, concerning the importance of which the public should be appraised. Supplementary to this knowledge regarding the prime necessity of purity of milk-supply, there should be generally diffused instructions as to the proper pasteurization, in case doubt may be entertained re- garding the observance of proper antecedent precautions. Another consideration of especial importance in the effort to protect infants from tuberculous infection is the avoidance of proximiti/ to a consumptive within the household. The safest coui'se to pursue is 598 PROPHYLAXIS, GENERAL AXD SPECIFIC TREATMENT undoubtedly the complete removal of the invalid or the child from the dwelling. This seldom being practicable, recourse must be taken to measures insuring the greatest degree of isolation of the pulmonary invalid, immediate contact with the infant under no circumstances being permitted. When possible, a separate portion of the house and a private porch should be set aside for the exclusive use of the con- sumptive. The care of the child should be given to a person known to be free from infection, not even the mother, if tuberculous, being allowed to fondle or caress the infant. Kissing upon the mouth by any one should be absolutely prohibited. The child should be brought but infrequently into the room of the consumptive mother and should remain only a short time. The infant should not be placed upon the bed of the invalid, nor allowed to play upon the floor of the room wherein the patient is confined. Scrupulous care must be observed with reference to the cleanliness of the hands and person of the consumptive, as well as the clothing and bedding, which must be laundered separately from the family linen in accordance with instructions already prescribed. The precautions laid down relative to the arrest of possible droplet infection, through the use of gauze or cheese-cloth held before the face in the act of coughing, should be enforced most rigidly when young chil- dren remain in the same house. This is particularly necessary on account of the gravitation of bacilli to the carpet or rugs and the prevalent cus- tom, among nurses and attendants, of leaving the little ones to amuse themselves upon the floor. With proper precautions against the distri- bution of bacilli throughout the room, the habits of chUdi'en in putting miscellaneous articles in the mouth are attended with much less danger of infection. Despite the observance of strict hygienic measures on the part of the invalid, the instinctive practice among infants of con- veying to the mouth almost everything that their hands can touch, remains a source of possible danger, and should be prevented in very early life by the watchfulness of the nurse and in later months by ad- monitory talks. Especial pains should be taken in the modern manner of dusting and sweeping, while the ventilation and sunning of rooms should be made as complete as possible. The sputum must be disposed of in accordance with directions previously described, and. in short, all directions addressed to the invalid must be obeyed more conscientiously than if the dwelling be occupied solely by adults. Even with the strict enforcement of all precautionary rules, there must persist to a degree an element of danger in houses occupied bj^ consumptives. For this and other obvious reasons it is expedient to keep the children in the open air as much as practicable, and to send them awaj' to the country, seashore, or mountains when possible so to do. The children of the poor, to whom these luxuries are denied, should be sent to the open parks of the large cities and kept away from the squalor of noisome tenement houses and dark alleys. WTiile the poverty, ignorance, and miser)- of their parents residing in densely crowded districts, effectually preclude the acquirement of suitable hygienic conditions at home, the children, as a result of S3'stematic effort, may be drawn to the sun- shine, fresh air, and other attractions of the public parks. It is highly important that societ}^ should be educated to the point of providing country resorts for the temporary sojourn of unfortunate children, to whom fresh air, good food, and kindly treatment have previously been WHAT THE PUBLIC SHOULD KNOW 599 unknown. Provision of this character must prove not only a veritable blessing to the poor, but as well a successful feature in the campaign of prevention. As children advance to the age of school life, the problem of pro- phylaxis assumes still greater proportions. AdcUtional factors are en- countered in the housing of a large number of pupils in comparatively small apartments, often with deficient ventilation and improper heating facilities, the more or less intimate contact with tuberculous children, if not with consumptive teachers, and finally the proverbial careless- ness of school-children in regard to their personal habits, or an utter defiance of sanitary rules. The selection of suitable sites for school- buildings, the details of construction, inclusive of ventilation and heat- ing, the hygienic care of the rooms, and the general supervision of teachers and pupils will be discussed in connection with the adminis- trative control of tuberculosis in the following section. Efforts toward the protection of children should not partake simply of the distribution of printed mandatory rules which, without explana- tory interpretation, will be completely ignored in the majority of in- stances. Attention has been called to the necessity of frequent admoni- tions on the part of teachers regarding the many sanitary improprieties of school-children, and to the expediency of sending concise circular information to parents in the hope of inculcating habits of personal cleanliness and hygiene. An important phase of the educational movement to be addressed to parents and teachers for the protection of the young consists of an appeal to increased resistance through the influence of proper nutrition. It is a matter of common knowledge that the majority of school-children are underfed and poorly nourished. As a direct result they exhibit weakened powers of resistance. Although susceptibility to infection is greatly increased by the feebleness of constitution and anemia thus engendered, the demands of a growing child in the way of superali- mentation are but little appreciated by parents. Opportunity to re- ceive light nourishment between meals is not afforded to school- children, no matter how urgent the need, save in the hasty swallowing of candy, corn-balls, or other sweet preparations at recess. In some cities the one session system is in vogue, admitting merely of the in- gestion of a cold lunch at the noon hour. Whatever may be the sup- posed advantages of the single session which ends at three o'clock in the afternoon, it is difficult to understand how sufficient benefit can be derived to compensate for the loss of a hearty meal partaken at home in the middle of the day. It is high time that the attention of parents and educational authorities be directed to the actual needs of a large proportion of children for decidedly more nourishment than is provided for them at present. Even the serving of milk or sandwiches at recess, as recommended by Dr. S. A. Knopf, would be productive of excellent results — assuredly more satisfactory than the purchase of fruits and sweets. Other features in the cause of prevention among school-children concerning which the public should be instructed are the advantages of daily class breathing exercises, with other systematically conducted gymnastics, and the necessity of clothing more perfectly adapted to seasonal requirements. The distinct benefits afforded by carefully performed respiratory gymnastics are too well understood to justify 600 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT enumeration, but it is important to bear in mind that under proper conditions of weather their efficiency may be increased if conducted in the open air. Insufficiency of clothing is undoubtedly a factor of some importance in the development of conditions favoring the spread of tuberculosis among children. In fact, the inadequacy of dress among the young is such in many cases to occasion wonder that even a greater number do not become susceptible to infection. It is idle to comment upon the necessities of the very poor and the inevitable paucity of their clothing, but to supply the needs of such unfortu- nates falls within the province of charitable if not antituberculosis organizations. It is worthy of comment, however, that the children of the well-to-do are sometimes clothed as improperly as those whose parents are in less comfortable circumstances. Discretion and good judgment in the matter of children's dress do not always go hand in hand with a fortunate financial status. While any discussion bearing upon the details of needed dress reform for children, particularly girls, is hardly appropriate in connection with the prophylaxis of consumption, it is, nevertheless, opportune to call attention to the fact that among children far less consideration is given to the proper protection of the body than among adults. This is particularly true with reference to the insufficient covering of the limbs, the use of unsuitable undergar- ments, the frequent absence of rubbers, stout shoes, warm gloves, or heavy outer apparel. The correction of this treatment of young chil- dren constitutes one feature of the movement toward popular education. By all odds the most glai-ini^ ami vicious alnise of the young, which also represents a most potcni Inctin' in tlic (k'velopment of tuberculosis at an early age, is found in (he > injiIoi/iik id uj child labor. Opportunities for diversion and recreation in the open air are absolutely essential for the nurture and well being of children. The wanton restraint of natural health-giving proclivities, with denial of fresh air and sunshine through long hours of confinement in ill-ventilated workshops, results in an early acquired predisposition to tuberculosis. The public, which blindly permits criminal disregard for the laws of health, decency, and humanity through failure to enact and enforce regulations pertaining ta child labor, must be prepared to pay the penalty exacted. This relates to the creation of fresh centers of tuberculous infection, the greater distribution of other diseases, the development of alcoholism and various forms of dissipation, the tendency toward youthful degener- acy, the increased suffering of families, and an economic loss to society of no mean proportions. In the years of approaching manhood and ivomanhood young people should be urged to lend attentive ears to the lessons of hygienic science, in their relation not only to ventilation and cleanliness, but more par- ticularly to the baneful effect of alcohol, and the detrimental physical consequences of late hours, with other forms of overindulgence. Pro- longed and undisturbed sleep at this time of life is prerequisite for sound health and physical endurance. Intemperance of any kind, be it alco- holic or athletic, a reckless abandonment to social dissipation, or an undue devotion to study, must surely sap the energies of the young, and impair their u.sefulness in after-life, if not making them an earlier and easier prey to the consuming ravages of tuberculosis. In later years a similar diminution of individual resistance is found in the ner- vous and physical strain incident to overwhelming business cares and ADMINISTRATIVE CONTROL 601 responsibilities, the dabbling in speculation, with its frequent financial reverses, and the multitudinous social and domestic obligations devolv- ing upon the modem housewife even in small families. It is, therefore, of the utmost importance in the midst of the insistent demands im- posed by an active, if not strenuous, civilization, that due cognizance be taken as to the inevitable drain upon individual resistance, and the vital necessity for all possil^le conservation of energy. It should be made clear that undue alcoholic stimulation directly predisposes to tubercu- losis, and in no wise retards the advance of an infection once estab- lished. Its pernicious influence upon the physical health and the de- velopment of character should be explained in the school-room through the use of reputable text-books expounding clearly, without hysteric distortion of facts, its physiologic a.ction and toxic properties. Young men, enamored by the glitter of abnormal athletic accom- plishments, should be warned of the inherent dangers resulting from the continuous practice of arduous feats. While a sane indulgence in nearly all forms of outdoor sjDorts tending to healthy physical develop- ment and recreation should be encouraged, no means should be spared to acquaint the young with the folly of the slightest indiscretion in their ambition to excel in this respect. As stated in earlier chapters, clinical experience bears out the assertion that athletes are especially prone to tuberculosis and succumb to the disease even more readily than those unaccustomed to feats of prodigious strength. The loss of sleep and of mental rehabilitation entailed by excessive social indulgence or over- study should be emphasized to the youth as an unfailing cause of nervous strain and physical impairment. The consequences of overtaxing the resources of the individual and the increased likelihood of tuberculous infection should be made a matter of common every-day knowledge. CHAPTER LXXXVIII ADMINISTRATIVE CONTROL Considerable stress has been laid upon the necessity of organized effort for the education of the 7nasses as a fundamental factor in the successful control of tuberculosis. In spite of a vigorous educational propaganda already inaugurated by enthusiastic workers, there is still exhibited a deplorable degree of pul^lic apathy and indifference. It is apparent that such enlighteiiincut nf the people as will insure an active universal movement tow.ud incMiition can be effected only through the process of years, pendinn w liiili ii is essential that aggressive restrictive measures be instituted, when necessary, by public authorities. In order at this time to secure a beginning control of the pestilence, it becomes the duty of the Commonwealth to exercise an arlDitrary super- vision over certain features of the tuberculosis problem. 1 he necessity of compulsory notification and registration has been di-i u>mm| at some length, as well as the advantages accruing from public instil utiuual pro- vision for indigent consumptives. Other dominating considerations in the matter of administrative control relate: (1) To the suppression 602 PROPHYLAXIS, GEXERAL AXD SPECIFIC TREATMEXT of promiscuous expectoration in public places; (2) the regulation of schools; (3) the inspection of food-supply; (4) the control of patent medicines and the restriction of medical practice; (5) the demand for hygienic construction and sanitary supervision of public buildings and conveyances, factories, tenement houses, and commercial establishments. Control of Expectoration. — Indiscriminate expectoration is known to be responsible in a large measure for the transmission of consumption from one incU\-idual to another. With a suitable disposal of the spu- tum under all circumstances, tuberculosis would undoubtedly diminish to a vast extent, and it would seem, therefore, that the enforcement of stern measures looking toward the mitigation of the spitting evil should become obligatory upon all municipal authorities. It also appears that no valid objection can be interposed on the part of the public against the summary suppression of the nuisance. Society has been informed repeatedly as to the direful consequences of indiscriminate expectoration, yet this disgusting practice is indulged in daily by careless, non-ignorant individuals, who are utterly indifferent to the rights of others. Regu- lations have been enacted to abate the indecent and pernicious custom, placards of warning have been posted in street-cars and public places, but even ruthless violation of the law is seldom followed by arrest or the impo- sition of a penalty. It is evident that ordinances governing this practice must remain a dead letter until public sentiment is awakened to a real- ization of the actual danger from an unclean and inexcusable habit. When the happy state of affairs shall be reached that society will rise in its wrath, demand the rigid enforcement of the law and the exac- tion of the maximum punishment to violators, no longer will the public eye be offended by unsightly printed notices calling attention to a personal, if not national, impropriety. The necessity for such signs is indeed a reproach to the intelligence and civilization of any community in which they are exhibited. While considerable opposition may be expected in many localities from the arbitrarv^ execution of the anti- spitting ordinances and much personal humiliation unavoidably imposed, the remedy for the evil lies at present in the summary action of fearless municipal authorities. Verbal warnings to pedestrians or the handing of printed cards have thus far proved of slight avail. In some cities the practice of indiscriminate spitting has been curtailed to a great extent. It is, of course, apparent that the people must have some place in which to expectorate, and should under no circumstances swallow the sputum. To those unprovided with pocket cuspidors or gauze, opportunity should be afforded to expectorate in closed sanitary cus- pidors in public places. These should be self-flushing, with sewer con- nection. Regulation of Schools. — The regulation of schools and school life should begin with the selection of a proper site. An open elevated space should be reserved if possible for this purpose in sections removed as far as practicable from tall buildings or large chimneys. Wherever the location, it is absolutely essential that the playground be spacious and well kept. An important function of municipal government pertains to the supervision of the construction of school-buildings. Important details to be observed are the facilities for ventilation, sunshine, and heating. All rooms should be high posted and provided with numerous large windows, which should be kept open, whenever possible, without subjecting the occupants to direct drafts. ADMINISTRATIVE CONTROL 603 Forced ventilation should be employed in all buildings of this nature, the hot air being driven into the upper portion of the room and an exit provided near the floor. Experience has shown that a properly equipped ventilating and heating apparatus should provide a complete change of air within a very few minutes, and yet maintain an equable temperature within the room. For this purpose the entrance of cold air in the basement is followed by its passage over a tempering coil, by means of which the temperature is raised to the neighborhood of from sixty-five to seventy-five degrees. It then is forced by means of a fan into a mass coil chamber, from which exits are provided to different rooms, the temperature being regulated by dampers automatically adjusted by thermostats. The heated air should be driven into the rooms at a distance of about eight feet from the floor, permitting its circular distribution and diffusion to all portions of the apartment. The exit near the floor should be upon the same side of the room as the point of ingress, in order to avoid a direct draft. By a proper adjustment of all parts of the heating and ventilating plant according to the size of the room, it is estimated that from 2500 to 3000 cubic feet of fresh air may be supplied to each pupil in the course of an hour. It is desirable that the greatest degree of care should be observed in the daily cleaning of all school-rooms, this being performed strictly in accordance with modern methods, which preclude the raising of any appreciable quantity of dust. School-rooms ought not to be used for public or social gatherings in the evening, on account of the difficulty in obviating the danger of careless expectoration. If used for lecture purposes, the rooms should be thoroughly aired before the children are permitted to reenter, and the floors and desks washed with a weak solu- tion of formaldehyd. It is unwise to employ any teacher who is known to have tuberculosis, and the presentation of a certificate of health from a recognized authority ought to accompany all applications for positions. In case of doubt, the teacher should be compelled to submit to an exam- ination by competent medical men designated for this purpose. Chil- dren should be required to pass inspection from time to time by medical examiners, who should make periodic visits to the various departments and conduct a physical inquiry whenever necessary. No pupil found to be the subject of tuberculosis should be permitted to attend school, and no employe suffering from the disease should be retained in his position. All teachers found to have contracted tuberculosis while in the discharge of official duties are justly entitled to retirement upon one-half or one- third pay. It is well known that no class of people occupying equally responsible positions receive such inadequate remuneration as the teachers in our public schools. Society can well afford to donate an annual stipend to those incapacitated by disease, which was acquired while in active service. Inspection of Food-supply. — The control of animal food-supply must embrace an administrative supervision of dairies and slaughter- hou.ses, with a detailed inspection of their products. It is not sufficient to rest with the employment of the tuberculin test upon cattle at infre- quent intervals. All establishments should be subjected to rigid investigation from time to time, and facts elicited as to the conditions under which the animals are housed and kept. Cleanliness of the stables, cows, attendants, and utensils must be regarded as a sine qua non for the issuance of a license, without which no farmer should be permitted 604 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT to sell milk. It is essential that the control of these matters should include a definite limitation of the number of cows to be cared for by each attendant. It has been the dictum of some students and educators for years that all cattle respondmg to the tuberculin test should be con- demned, the loss being sustained either by the State alone or jointly with the owners. The experiment has been tried m several States and found almost impracticable, on account of the prohibitive cost even when a portion of the loss is borne by the owner. Bovine tuberculosis, however, as shown by herd inspection, has become somewhat less prevalent in these States. In the light of recent scientific research it is clear that immunization of cattle may be reduced to a practical working basis through the inoculation of attenuated living cultures of tubercle bacilli, thus minimizing the magnitude of the annual loss to owners of cattle. The inspection of all animal food offered for public consumption should be made as thorough as that practisetl by the federal government in relation to the meat offered to the export trade. In some instances the meat intended for home consumption throughout the United States is either not inspected at all, or so superficially as to rob the procedure of any practical value. The control of the milk-supply should consist of more than the detection and correction of impurities or diluents. While the maintenance of a required standard of milk should be enforced by municipal authorities, it is important that there be instituted a strict surveillance of the animals and premises where the product is obtained. No milk from tuberculous cows shoidd be offered for sale, and such animals, if not destroyed, should be segre- gated from the rest of the herd during the employment of the vaccine treatment. Competent and fearless inspection of dairies is not to be expected if appointments to the position are obtained as a mark of political preferment. Devotion to the work, attention to detail, and the strictest integrity and impartiality, combined with the courage of one's convictions, are essential qualifications for those upon whom devolve the responsibilities of food inspection. Control of Patent Medicines and Restriction of Medical Prac- tice. — The patent medicine evil is responsible for many of the ills visited upon mankind during the present generation. Through the influence and under the auspices of the American Medical Association recent attention has been called in a convincing manner to the prodigious consumption, and the detrimental effect upon the health of iniqui- tous preparations foisted upon the public under the name of proprie- tary medicines. The vast majority of these nostrums contain large per- centages of alcohol, to say nothing of other injurious .substances, the nature, dosage, and effect of which are entirely unknown to the consumer. An infinite amount of harm is produced by the swallowing of these deleterious preparations, which are offered to an unsuspecting people under the guise of harmless remedies. The proprietors, imhandicapped by scientific knowledge or conscience, usually succeed in enlisting for a consideration, the cooperation and assistance of otherwi.se reputable citizens. Flamboyant advertisements as to the virtues of these prepara- tions, guaranteed to cure all diseases of men, women, and children, are often accompanied by testimonials from clergymen and men in public life, together with their photographs. It is worthj' of more than pass- ing comment that the more glaring the deception, the more pernicious the nostrum, and the more extravagant and unreasonable the claims of ADMINISTRATIVE CONTROL 605 promoting fakirs, the more likely are quasi-intelligent citizens to become inveigled into lending their unqualified indorsement. Waiving the mani- fest impropriety in permitting their names to be attached to false and blandishing testimonials, the situation is dominated by the deplorable fact that these well-meaning people are instrumental in the production of untold misery and in abetting an evil which represents one of the greatest curses of our present civilization. It is, indeed, to be regretted that some reverend gentlemen, even though unintentionally, should assume the fearful responsibility of leading others to lives of alcoholism and habits of cocain degeneracy. Were the extent of the nuisance limited to a financial loss on the part of the people, or even to the delay thus occasioned in seeking competent medical counsel, the evil would still assume sufficient proportions to demand the enactment of vigorous legislative measures toward its suppression. Unfortunately, however, the baneful consequences of yielding to alluring advertisements of this nature are decidedly more far reaching. Recourse to quack nostrums on the part of the ill is often attended with loss of valuable time before the recognition of the disease and, worse still, loss of the opportunity to secure arrest. In view of these considerations of fact relating to the undermining of health, there is imposed upon the State an obligation to restrict the wholesale consumption of these fraudulent and vile con- coctions, and to control the character oj medical advertisements in the public press. The American people are greatly in need of protection from unscrupulous and ignorant vendors of sure cures for consumption. The loss to the unfortunate victim of these pretentious discoverers of special methods of treatment is quite beyond the power of estimation. The poor, who constitute the class more frequently deluded by their representations, are robbed at the very beginning of the savings of a lifetime. After the lapse of a few weeks or months, during which they have dragged themselves wearily to offices for the inhalation of pungent or aromatic vapors, they are wantonly left to their own resources, ill prepared, by reason of impaired finances and abandoned hope, to cope with the exigency of their present situation. While reputable physicians, impelled to seek change of residence in the various States, are subjected to much unnecessary embarrassment in order to qualify satisfactorily before State examining boards, the law in many localities refuses to take cognizance of the iniquitous practice, indulged in by unworthy and degenerate physicians, who have previously succeeded, through devious means, in securing diplomas or passing examinations. THE DEMAND FOR HYGIENIC CONSTRUCTION AND SANITARY SUPERVISION OF TENEMENT HOUSES, WORKSHOPS OR FACTO- RIES, COMMERCIAL ESTABLISHMENTS, PUBLIC BUILDINGS, AND CONVEYANCES The regulation of tenement-house construction through legal enact- ment constitutes, without doubt, an exceedingly important feature of a,dministrative control. While there can be no excuse for the faulty construction of such buildings, containing an innumerable quantity of small dark rooms and furnishing an abode for countless people, it must not be assumed that absence of sunshine, insufficient ventilation, and unsanitary plumbing are the only factors responsible for making these structures prolific breeding-spots for tuberculosis. The squalor, filth, misery, ignorance, and poverty of the occupants are assuredly not to be bOb PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT ignored as important etiologic considerations. These unfortunate con- ditions would obtain to a large extent even were such buildings con- structed in accordance with sanitary regulations. Without the observ- ance of general hygienic conditions by people dwelling in tenement houses, municipal prophylactic efforts would remain unavailing even in rooms of adequate size, with large windows permitting the entrance of sunshine and fresh air. Upon the other hand, in small, dark, ill- ventilated rooms and halls, the maintenance of perfect cleanliness is insufficient in itself to prevent the deterioration of health and the development of physical conditions favoring infection. While impure air and excessive crowding of people within a limited area, are important factors in the development of tuberculosis, these are accentuated by the filth, and utter neglect by tenement-house occupants to observe sanitary conditions. Some students of medicosociologic affairs have described in graphic terms the criminal disregard for the laws of hygiene in the building of tenement houses, to which is ascribed a large measure of the responsi- bility for the spread of tuberculosis. An abuse of this kind constitutes but a single factor in the general problem pertaining to the develop- ment of consumption among a class of people peculiarly predisposed as the result of a great variety of causes. It is true that an appalling preva- lence of tuberculosis has been observed in the tenement-house districts of many of our larger cities. Certain blocks have been designated as "lung blocks," by reason of the frightful distribution of the disease in these localities. It is also true that the ignorance and filth in these places are quite as revolting as the faults of building construction. The tenement-house evil, therefore, seems to present two important indica- tions for immediate reform, i. e., the regulation of construction by State or municipal government, and the removal of squalid unsanitary con- ditions. The preceding considerations apply with almost equal force to workshops and factories, and, in fact, to all manufacturing and commer- cial establishments. Certain occupations have long been regarded, both by the laity and the profession, as inimical to health. Attention has been called to the prevalence of the disease among cigar-makers, shoemakers, tailors, machinists, factory operatives, laun- dry workers, stone-cutters, and upholsterers. It must be admitted that a few occupations directly favor infection on account of the unusual opportunities afforded for the inhalation of fine particles of dust, which may serve not only as carriers of tubercle bacilli, but also as agents of irritation to mucous surfaces. This is particularly true of weavers, millers, machinists, stone-cutters, miners, and potters. It is probably true, as has been described, that the detrimental effects consist, in part, of the development of chronic catarrhal conditions of the mucous meml^ranes, as a remote effect of which the resistance to tuberculous infection is diminished. There are many other pursuits, however, exhibiting a frightful mortality rate from tuberculosis, in which the inhalation of dust from any source cannot be regarded as a definite etiologic factor. The disease, however, has been supposed to claim an appalling number of victims bj' virtue of some mysterious influence incident to the occu- pation. In many instances there obtain widely diverse unfavorable conditions, which are definitely responsible for the development of consumption. These are not always peculiar to the occupation and ADMINISTRATIVE CONTROL 607 the conditions under which workmen are employed, but are inherent, to some extent, to the particular class of people engaged in these pursuits, their previous methods of existence, their poverty, shiftlessness, and habits of dissipation. Thus the ignorant and underpaid employe in certain lines of work, which demand but little intelligence or training, is non-resistant to disease not merely through a direct detrimental effect of the occupation, but also from deficiency of nourishment, inadequate- ness of clothing, and the physical drain incident to previous disease. Carelessness of expectoration and other habits of personal uncleanliness in the workshop are much in vogue among employes of the foregoing description. It is precisely among such a class of people that squalor and filth abound, and it is quite as reasonable to attribute the develop- ment of consumption to the effect of the ten or fourteen hours spent in the home as to the eight or ten passed in the workshop. It is not desired to minimize the unfavorable influence of certain occupations, nor to dis- parage the vital need of better facilities for ventilation and other details of hygienic building construction. The point is raised, however, that a broad consideration of the problem of prevention demands in many indi- vidual instances the inclusion of other factors than the occupation itself. While employes of mills, factories, steam laundries, manufacturing and printing establishments are often compelled to work in over- heated and poorly ventilated apartments, operatives engaged in other industrial occupations are often prone to neglect hygienic consider- ations. There has been advanced no substantial reason why the shoemaker, from the nature of his work, should be especially liable to the development of tuberculosis, either from direct exposure or through diminution of individual resistance, yet the highly unfavorable conditions under which he has been wont to toil have been responsible for an alarming mortality rate. The shops have almost invariably been contracted, low posted, and dingy, located either in some dark recess or basement, unprovided with ventilation of any description, and often superheated to a degree of intolerance. Consumption has been found to be quite prevalent among the employes of large commercial establishments, the chief injurious factors being the indoor confinement and deficiency of ventilation. It is important in such places and in all workshops that there should be adequate provision for air-renewal. In many department stores the facilities for ventilation are crude and imperfect, and as a result of the influx of people, the clerks for hours at a time are compelled to breathe a noxious atmosphere. Details of hygienic construction should be arranged in accordance with the purposes for which such buildings are intended. The necessity of proper construction and careful supervision applies strongly to public buildings of all description. It is a regrettable fact that a large proportion of the buildings designated for the use of the public, possess exceedingly inadequate facilities for ventilation, par- ticularly post-offices, federal buildings, court-houses, and in many instances State capitols. Even the halls of such structures, where people are wont to congregate or pass to and fro, are often redolent with foul air and sometimes offensive from the aggregation of filth. Cuspidors, if provided at all, are usually of improper construction, rarely, if ever, filled with water, and, as a rule, insufficiently cleansed. The necessity for attention to details of hygienic construction and per- bU» PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT feet sanitary cleanliness appears emphasized by the indifferent habits of individuals frequenting such buildings. In all commercial establishments and factories, as well as in public buildings, rules against indiscriminate expectoration should be rigidly enforced, and sanitary cuspidors universally provided. It is insufficient to post notices in workshops warning employes of the dangers of con- sumption and calling attention to the necessity of compliance with de- tailed instructions. Cooperation of operatives must be secured in order to make any organized effort effective. To this end the employes should be privileged to receive the periodic attendance of a physician free of expense. By this means the disease may be recognized at an early stage, and the invalid excused from the workroom, or at least subjected to the closest surveillance. This advances an important feature in the control of tuberculosis, i. e., provision for the detection of consumption among employes and for their financial assistance when incapacitated by disease. This idea has been amplified to a considerable extent in Germany, where a system of compulsory insurance for working-people is in vogue. In 1881, under the influence of Kaiser Wilhelm der Grosse, workingmen's insurance was instituted to combat, as far as possible, the misery and poverty of a portion of the laboring class. The operative in Germany, who is compelled by law to join the Government Assurance Association, becomes insured against sickness, accident, invalidity, and old age. When incapacitated for these reasons he is entitled to assistance for himself and family, and a vast amount of distress is effectually prevented. The workingmen are divided into vari- ous classes in accordance with a certain wage scale. The premiums of sick insurance are paid through the employer, who contributes one-third of the entire amount, deducting the other two-thirds from the wages of the employe. In case the latter, through physical disability, becomes unable to work, he receives an allowance equal to one-half his wages for a period of many weeks and sometimes a year, and receives, in addi- tion, free medical attention. Provision of a somewhat similar nature is made for workingmen insured against accident or invalidity. Insur- ance against old age and invalidism is compulsory to every person follow- ing certain prescribed pursuits, over sixteen years of age, whose annual wage earnings do not exceed $500. Through the beneficent influence of these various forms of insurance, merging more or less into one organiza- tion, results of a highly important nature from an economic and humani- tarian .standpoint have been secured. An essential feature of the propo- sition is the governmental aid, protection, and paternalism so highly characteristic of the general social policy in Germany. Although a portion of the burden in the payment of premiums is borne by the wage- earner, there is introduced, at the same time, the element of governmental coercion, intelligently elaborated to meet the necessities of unfortunate social conditions. While it is not believed that in America a detailed interpretation of the German insurance laws for workingmen could be tolerated on account of the spirit of individual independence, the funda- mental principle of cooperation and as.sistance in its practical application to the needs of wage-earners is endowed with enormous beneficent possibilities. Certain modifications of the German system for years have been in vogue among the employes of large railway corporations and other industrial establishments. These voluntary relief associ- ations, which sometimes partake more or less of the nature of fraternal ADMINISTRATIVE CONTROL 609 organizations, have proved to be immensely effective in diminishing dis- tress at the time of sicl^ness. Especial importance attaches to the question of prison reform, as tuberculosis has ever been found prevalent in penal institutions. WhUe the disease is known to flourish among those who are permitted physical and mental occupation in the workshops, statistics indicate a partic- ularly alarming mortality rate among convicts subjected to close con- finement. Although there are certain mitigating conditions to be offered in explanation of the spread of tuberculosis in prisons and reformatories, a few facts may be adduced which even magnify the abuse of hygienic laws permitted in these institutions. Many prisoners, when admitted to State penitentiaries, have been addicted for years to dissipation, and afflicted with direst poverty. Some of these unfortunates have become tuberculous as the result of excesses practised during lives of misery and degeneracy. The law, not recognizing that tuberculosis is any excuse for crime, exacts the same penalty from the sick as from the well. Phthisical individuals are not subjected to physical examination before being sent to these institutions, and, therefore, are a decided menace to their fellow-convicts for indefi- nite periods before their true condition is recognized. Many are sent to the crowded workshops to pursue some industrial occupation, in close proximity to others. Some, though permitted employment in the open air, are compelled to perform arduous labor far beyond their physical strength. Still others, who are subjected to solitary confinement, are necessarily denied fresh air, sunshine, and nourishing food, all of which are demanded for their unsuspected tuberculous condition. The effect of these injurious factors is materially augmented by the psychic influ- ence of restraint, the absence of mental diversion, and the conflicting emotions obtaining in the majority of those convicts upon whom the solitary confinement is impo.sed. Added to these influences are careless- ness in the personal habits of the inmates, and the imperfect ventilation of cell-houses, corridors, and all rooms occupied by convicts for industrial purposes. Some criticism may justly be directed to the imperfect details of architectural construction and the lack of enforcement of necessary hygienic regulations by prison authorities. In institutions where discipline in all other respects is the supreme desideratum of oflScials, the vital element of hygienic regime should not be disregarded. Sani- tary cu.spidors should be provided for the convicts and instructions issued with reference to the proper disposal of the expectoration, violation of rules being subject to reasonable punishment. There is no reason why the cells and corridors should not be kept scrupu- lously clean, and why blankets and bedding should not be disinfected periodically. A systematic investigation from time to time regarding the physical condition of the inmates appears absolutely essential as a preliminary feature of any general effort toward prevention. Proper ventilation should be provided for the cells, cell houses, and workrooms, the entire problem of fresh air-supply being as obligatory upon the atten- dants as any other feature of prison discipline. It is desirable that the work which any inmate is designated to perform, should be adapted to his physical condition. The pulmonary invalid, if compelled to work, should at least be permitted to engage in some light occupation in the open air which may not be altogether detrimental to his physical health. 610 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT The supervision of sleeping apartments in hotels, Pullman cars, and steamboats must be regarded as an important step in any organ- ized movement toward prevention. But little has been done in any- State in the way of supervision of hotels, although in some localities circular information has been freely distributed. There should be an obligatory notification of the reception of consumptives within the hostelry or boarding-house, after which the health officers may enforce the observance of all sanitary precautions, both on the part of the invalid and the attendants. Thorough disinfection of apartments, inclusive of carpets, rugs, furniture, clothing, blankets, and linen, occupied by 'consumptives should be made fully as obligatory in hotels as in private families. Especial interest attaches to the supervision of public convey- ances, and particularly to the enforcement of radical precautionary measures in Pullman sleeping-cars. From a practical standpoint, the opportunities for infection during transportation are comparatively slight in ordinary day-coaches and electric cars. As people usually ride but short distances in these conveyances, the accumulation of filth and the scattering of oral excretion are rather inconspicuous. Upon long journeys advanced pulmonary invalids are often confined in sleeping berths for several days. The facilities for ventilation are much better in the former conveyances, as the doors are opened more frequently and greater opportunity afforded for direct draft than in the Pullman cars, with their winding passages. Therefore, in sleeping coaches the possi- bility of infection during transportation is of especial concern, and the necessity of stringent regulations a paramount consideration. In these conveyances many objectionable features are almost unavoidably en- countered, among which must he nicntidiicil primarily the presence of unfortunate consumptives, p.-u ti(iil;ul\- updu trains running to and from popular health resorts. Muiiy nf these individuals, exhausted by disease, are compelled to remain in the drawing-room or berth, while the cough is often aggravated by the maintenance of the recumbent position and the inhalation of smoke and dust. Innumerable bacilli are scattered throughout the immediate vicinity of the invalid as a result of the droplet infection incident to violent cough. The expectoration is often deposited upon handkerchiefs or in receptacles utterly inappropriate for this purpose. Masses of sputum remain adherent upon the upper surface of shallow cuspidors, and are exposed for long hours to the confined and overheated air, while blankets and linen are almost inevitably soiled by the excretions from the mouth. No opportunity is afforded en route for proper ventilation or for sweeping and dusting in accordance with modern methods. Neither is it possible to effect an immediate sterilization of blankets, which are packed away without exposure to the sun or fresh air. The cars, as a rule, are either greatly overheated or uncomfortably cold, the maintenance of an equable temperature with adequate ventilation being necessarily attended with the greatest difficulty. People obliged to travel long distances, therefore, in addition to the other discom- forts, are often subjected to direct exposure to tuberculous infection. Another factor of some importance is the attention of the porter, who becomes ubiquitous at the end of the journey, and with the ostentatious flourishing of the whisk, raises clouds of dust in the faces of passengers. It is apparent that public protection during transportation in these ADMINISTRATIVE CONTROL 611 conveyances can be secured only by the enactment of uniform regulations throughout the United States, enforcing the maintenance of sanitary conditions. Some States have already passed laws pertaining to car sanitation within their borders, while others have made no effort to secure similar legislation. Much prai.se should be accorded to the Pullman {'ompany for the hygienic efforts undertaken upon their own initiative. During recent years the interior furnishing of Pullman cars has been made more simple, thus permitting greater ease and thoroughness of cleaning. Some of the upholstery has been dispensed with and a portion of the carpeting, while rubber tilings have been placed in the lavatories and smoking-rooms. A thirtl sheet has been provided to protect the upper blanket, thus minimizing materially the danger of wholesale distribution of bacilli upon the woolen fabric. Dr. T. R. Crowder, Superintendent of Sanitation for the Pullman Company, states that immediately the car enters the yard after completing the trip, the seats, cushions, carpets, blankets, and bedding are cleaned out-of-doors by means of compressed air. If a single berth is known to have been occupied by a consumptive, the interior woodwork is cleaned with moist cloths and the entire car fumigated. For the purpose of disinfection, formalin is left to evaporate, with all the berths open, for a number of hours. Supplementary to the commendable work under- taken by the company in the interests of more perfect sanitation, it is suggested that some changes are needed in the disposal of the sputum. Undoubted dangers accompany the use of the cuspidors now in vogue, and yet manifest disadvantages, if not insuperable objections, attend the employment of sanitary floor receptacles for sputum. Cus- pidors at present in use are shallow, of small size, incapable of holding water or a disinfecting solution, and quickly become filthy by the reten- tion and drying of sputum upon their upper surface. Upon the other hand, high cylindric cuspidors containing liquid are apparently pre- cluded by the necessity for economy of space and the continual motion of the train. For these reasons it appears that .some other provision should be made for the disposal of the sputum than the use of floor cuspidors. It should be made obligatory upon pulmonary invalids traveling in these conveyances to be equipped either with sanitary pocket cuspidors or with chee.se-cloth and bags of paraffined paper, oiled silk, or rublier. The dry sweeping of cars and indiscriminate dusting either of seats or individuals should not be permitted in transit. Con- siderable difficulty is to be experienced in securing a proper degree of air-renewal on account of the objections raised by passengers. Con- ductors, brakemen, and porters, however, should be instructed to give particular attention to the maintenance of as thorough ventilation as is practicable by means of the doors, windows, and transoms. PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT SECTION 11 Treatment CHAPTER LXXXIX GENERAL CONSIDERATIONS There is demanded in the management of no disease in the entire realm of medicine the exercise of such slcill and judgment on the part of the physician as is required for the intelligent treatment of the clinical manifestations and for the resourceful control of the tuberculous indi- vidual. It is doubtful if the trained clinician, accustomed to definiteness and accuracy of opinion born of wide experience, is compelled to observe a greater regard for detail or a more sagacious adaptation of means to satisfy imperative and often conflicting indications, than in the indi- vidualized treatment of pulmonary hemorrhage. Notwithstanding the urgent claim upon the profession for a sustained support of rational conservative measures of treatment, there ever has been in evidence a lamentable diversity of therapeutic methods. Even in recent years numerous remedies and wideh' di\ergent methods have been highly vaunted for their supposed efficacj'. Without a wise, judi- cious guidance, it is almost impossible for the student in perusing the literature extant, to select the authentic reports, the substantiated facts, and the mature conclusions from the superficial observations, the erro- neous deductions, and the fanciful theories. It is not pleasant to contem- plate the many vagaries of medical opinion and the therapeutic absurd- ities practised even in recent generations. No comment is necessary concerning previous inconsistencies of treatment other than to note the facility with which men of apparently sound minds have been led to embrace unworthy therapeutic methods. It is fortunate that the tendency is growing to refuse a blind and unthinking acceptance of prevailing medical fads with reference to the management of a disease which, more than all others, demands the exercise of conservatism and stability of judgment. Even at the present time there is occasionally manifested an incli- nation toward the formation of hasty conclusions, the presentation of inaccurate data, and the promulgation to the profession and the general public of irrational opinions with reference to the relative advantages and disadvantages of certain remedial measures. The opinions expressed by some writers in the height of their exuberant enthusiasm over the results of some therapeutic procedures are bizarre in the extreme. Many of the so-called " cures' ' which are flaunted in the face of the profession and the public by men to be dcsi<;iiated merely as "optimistic" are, in reality, not subject to verification upon the basis of the physical and bacteriologic findings. While consumption is, indeed, curable, it is essential for the public to be informed that enduring success in this respect is not as beatifically simple as might be supposed from some of the current literature. It is desirable that the people should be thoroughly aroused from the lethargy and resignation prevailing in GENERAL CONSIDERATIONS 613 former years as to the fatality of consumption, but with the dawn of renewed hope, it is. highly important for them to understand that the effort to regain health is fraught with no slight degree of individual responsibility, and that success may be attained only through wisely directed personal endeavor. Consumption, though distinctly subject to arrest, is by no means cured in all instances. If recognized early, the possiliilities of arre.st are surely present, but the personal equation, both of the physician and patient, must remain a vitally decisive factor in the determination of the final outcome. The opportunities presented for a complete ultimate recovery from pulmonary tuberculosis in individual cases scarcely warrant an assumption as to the general or invariable curability of the disease. Yet such a conclusion, regardless of vitally important condi- tions, has become a war-cry of some of the " crusaders." It should be understood that the term " curability of tuberculosis" is necessarily subject to considerable flexibility in its general application and in the interpretation of its meaning. To the public, the impression has been conveyed that "cure" is synonymous with absence of sub- jective symptoms and restoration of working capacity. To the pro- fession a literal definition of "cure" represents the entire disappearance of physical and bacterial evidences of the disease. There is also implied an obliteration of the tuberculous process through fibrous tissue pro- liferation, or at least the enduring encapsulation of tubercle bacilli within the barriers, which encompass the previous foci of infection. It is, of course, obvious that a large number of cases fail to attain a technical cure even though all clinical manifestations of tuberculosis have dis- appeared. Despite an apparent restoration of health with resumption of physical activity and usefulness, the supposed recovery is not founded upon a strictly anatomic basis. By what token may it be assumed in individual cases that the connective-tissue formation is .sufficiently dense to prochicc (ililiterative focal contraction or to imprison effectually the bacilli withm ("uciirling walls? Clinical experience attests the facility with whicli, cvoii in the midst of apparent recovery, there is finally secured an avenue of escape for bacilli through a cordon of connective tissue, and their subsequent access to uninvaded pulmonary areas, or the development of metastatic foci of infection in other portions of the body. It is evident that unqualified statements addressed to the public relative to the general curability of tuberculosis should be care- fully avoided in order to forestall popular chstrust and misconception. Even in supposedly favorable cases the expression of precipitate con- clusions regarding a successful issue should be rendered with the utmost conservatism, that erroneous ideas may not be dis.seminated, and that individuals may not be doomed to eventual disappointment. Some observers have seen fit to exalt the practical utility of certain therapeutic agencies to a point far beyond their due value. Others have deigned to renounce in toto the benefits accruing from methods of undoubted efficacy. A just and well-proportioned estimate of the true importance attaching to the many phases of therapeutic effort is entertained by comparatively few physicians presuming to direct the destinies of pulmonary invalids. It is believed that the best inter- ests of the consumptive are subserved, if there l)e accorded by the medical attendant a recognition of the importance of the following general principles of management. PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT PRINCIPLES OF MANAGEMENT The existing status of medical opinion regarding the rational manage- ment of tuberculosis has been stated to be somewhat unique, on account of the considerable lack of uniformity exhibited in the way of thera- peutic effort. This appears all the more remarkable in view of the fact that the present consensus of opinion among all qualified observers relates solely to the consideration of outdoor life, rest, superalimentation, and constant supervision as the all-important elementary factors. It is difficult to understand how there can exist such witlely differing interpretations of the a]3plication of these basic principles as to permit the resulting divergent methods of practice, where harmony of thought and action might reasonalily be anticipated. It is recognized that pulmonary mvalids as a class demand, upon the merits of their condition, the fullest conception of an intelligent system of management. This may be attained only through a detailed elabor- ation of underlying principles, subject to modification according to pecu- liar individual needs. From numerous sources, however, there is ad- vanced, with perfect integrity of motive, the indorsement of several distinctive methods of treatment which appear unalterably opposed to one another. It goes without saying that a more or less partizan appreci- ation of their comparative merits is de^•eloped by the immediate en%i- ronment and .special opportunities of the olxserver. Thus is to be explained the repudiation of the advantages of climatic change for any case, or the advocacy of several totally differing localities for nearly all classes and conditions. In like manner is noticed the strenuous insistence by some upon a rigid disciplinary regime within a closed sanatorium, as applicable to all cases of consumption, regardless of many vitally important considerations, and at the same time an equally enthusiastic indorsement by others of the advantageous con- ditions rendered possible at home. Unfortunately, the picture is some- times painted in its most dismal colors by ardent opponents. The invalicl in the mournful contemplation of banishment to a distant clime, incarceration within the walls of an institution for consumptives, or seclusion upon his back porch, and, perhaps, in an unsightly yard, may often w^onder which fate can possess the least terror. It does not necessarily follow that because one of these methods is rational in certain instances that the remainder are necessarily inapplicable to other cases. Manifesth% each has much of merit, according to the individual conditions imposed, and through the exercise of an intelligent discrimination on the part of the medical adviser may be utilized for the material aid of an appropriate class. Irrespective of the particular plan pursued, it is of the utmost importance to remember that the efficacy of all therapeutic procedures is directl.y dependent upon their power to augment the inherent resisting forces of the individual. The natural constructive processes are stimu- lated only by measures leading to consrrvntion of strength. This, then, is the true fundamental princijMe underlying all general therapeutic agencies in the effort to secure arrest of the tuberculous infection. The accumu- lation of a substantial reserve in strength is known to take place through the influence of increased nutrition and a diminished expenditure of physical energy. These factors in the problem of management are utilized by an- intelligent regulation of the mode of life. Another feature REGARD FOR INFINITE DETAIL 615 of essential importance is the variation of individual adaptability, which imposes the necessity of a critical differentiation of cases. Con- ceding that each case is a law unto itself and must be adjudged solely upon the intrinsic merits of its many component factors, it appears that a preconception of fixed ideas as to the management of consump- tion must give way to a just recognition of the valid and established claims of several methods. The application of the various principles of treatment to an individual constitutes a responsible trust, the satis- factory fulfilment of which can be afforded only through a sufficient appreciation of its true character. The cardinal features to be rigidly observed in the management of all cases consist of: (1) Regard for infinite detail; (2) adjustment of physical or nervous effort; (3) enforce- ment of an open-air existence; (4) regulation of diet. CHAPTER XC REGARD FOR INFINITE DETAIL The first great requisite for rational treatment consists not only of a careful preliminary investigation of all phases of the disease, his- toric, symptomatic, and physical, but also a diligent study of all factors pertaining to the patient, i. e., temperamental, financial, domestic, and social. Only through such means may the clinician hope to arrive at definitely correct conclusions concerning the manner of applying the principles of treatment to the best possible advantage. It is not the most complete interpretation of a single feature, no matter how impor- tant, that is to accomplish the best results. Neither are these to be obtained by the most radical conception of several thoroughly accepted principles, if at the obvious expense of remaining factors, perhaps not as well recoi^uizcd, yet entirely pertinent to the invalid in question. The fullest measuK nt mk i ess in management is to be secured only by the wisest possihli (innijiiiHj of all the favorable influences pertaining to the case. This imposes an obligation for painstaking detail, and necessitates a vast amount of study regarding the special requirements in each instance. Personal effort directed to a critical analysis of all the phases of each case is absolutely essential in order to afford not only a wise pre- liminary guidance, but also to facilitate subsequently a continued adap- tation of the consumptive to a projicr ('iniinmncnt. Thoughtful study and alert vigilance must be mainlaincd ilirou^lidut the entire period of observation, in order to provide such iiioile of life and surroundings as are especially appropriate to changing conditions, and in harmony with the varying needs of the patient. Following a review of the clinical history and an exhaustive exami- nation of the chest, it is my practice to make a brief report of the con- dition, and tn oliii such reassurance as is consistent with the facts and seems advisuMe iicjiu lirst impressions, declining, however, to grant a detailed advisory statement until after the urine and sputum have been examined. This plan of procedure permits not only precise clinical infor- 616 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT mation regarding some important phases of the case, but, what is more important, affords not less than twenty-four hours' delay, during which time its many aspects may be reviewed. It is desirable, in the majority of instances, to transmit to the patient and family some intelligent idea as to the natui'e of the disease and the manner in which it is hoped to secure arrest. In plain unequivocal language, the information shoidd be conveyed as to the overwhelming importance of the condition and the necessity of implicit obedience to detailed instructions. In general a guardedly favorable prognosis should be rendered, thus offering sufficient encouragement to insure faithful, earnest cooperation. The degree of reassurance to be extended shoukl be carefully adjusted by the clinician in accordance with the tempera- mental proclivities of the patient. The attitude of the phy.sician toward the pulmonary invalid, who is, as a rule, very susceptible to suggestion, should vary materially with the requirements of the intlividual case. The vital thought ever to be borne in mind is the fact that the extent of tuberculous infection is often of less importance than the temperamental characteristics of the tuberculous patient. A perfunctory recommendation of conventional routine measiu-es of treatment is of but little avail, if uninspired by a genuine devotion to the well being of the invalid. As a general ride, the imparting of advice should be accompanied by the exercise of consummate tact in its adapta- bility and manner of presentation. Thus the personal equation of the phy- sician becomes a highly important factor, often of greater moment than skill in diagnosis, knowledge of the disease, or familiarity with motlein methods of phthisiotherapy. In view of the pronounced individual peculiarities often exhibited by pulmonar}' invalids, the value of an intelligent dircciiim iiitlncnce is almost beyond description. Alcoholic dissipation and cither i-\i(>sses should be controlled by stern admonition; foolish optimism, umluc exaltation of spirits, and frivolity, by kindly, forcible restraint; mental (Icprcssidn .'ind nervous irritability by con- stant sustaining hope and (■iicoiira^riucnt. Above all, it is important to make clear that a large portion of the credit or responsibility for ultimate results must rest directly upon the patient, the prospects of a successful termination being greatly enhanced by strict conformity to instructions. It should be emphasized that, for the time being, the invalid is engaged in a momentous undertaking of infinitely greater magnitude than the pursuit of business or indulgence in social enjoyment. Patients should be taught that the period of treat- ment is the vitally important era of their existence, and that no reason- able sacrifice is too great, provided progress toward recovery is thereby facilitated. They should be informed that the duration of the period of medical observation is necessarily prolonged and that, in the verbiage of the legal profession, " Time constitutes the essence of the proposition." It is usually well to acquaint invalids with the fact that their path may be beset wth difficulties, and that the journey to recovery is attended by trials to their patience, endurance, and fortitude, but that the hard- ships are surmountable by dint of courage, wise guidance, and indomita- ble perseverance. In the effort to impress trifling young men with the gravity of the situation I sometimes have made use of the following homely illustration: "You are engaged in an arduous conflict with a most formidable antagonist. Your opponent is worthy of your most strenuous efforts, and will be quick to take advantage of the REGARD FOR INFINITE DETAIL 617 slightest opening to inflict a serious blow. The struggle is no four- or six-round contest, but the fight is destined to continue to a finish. There can be no such thing as a draw. Either your enemy will be finally van- quished or pulmonary tuberculosis will have attained the victory over you. It is for you alone to decide whether you will enter the arena with a determination to succeed and with the exercise of eternal vigilance be prepared to withstand successfully the onslaughts of an unrelenting foe." It is often expedient to inform the invalid concerning the signal advantage possessed by virtue of the natural powers of resistance to tuberculous infection. It is usually well to make clear that there is no special method of treatment, and that the position of the medical attendant is that of counsellor, to guard against blunders and indis- cretions, and that strict compliance with instructions is a sine qua non to success. I have found it desirable in many instances to explain in a simple and conci.se way the manner in which the inherent con- structive forces of the individual are capable of producing arrest. Among intelligent invalids I have found this of practical advantage in the stimulation of renewed efforts, and in the reassurance conve.yed as to the rationale of the treatment. Words to the following effect have usually been found satisfactory for this purpose. " Any injury to the surface of the body attended by a loss of substance is followed by the formation of new connective tissue, which differs markedly in structure from the adjacent parts. The scar tissue which results is dense, tough, fibrous, and contractile. The formation of this tissue, which has no analogue in health, is nature's method of repairing damage in the various organs and soft parts of the body. Consumption is a disease produced by a certain microorganism, which, upon gaining entrance to the lungs, incites characteristic tissue change. Tiny elementary tubercles are formed, several of which become confluent and unite to produce definite nodules. One of the essential characteristics of these tubercles is the tendency toward central degeneration, caseation, and disintegration. As this takes place, the proce.ss of repair becomes established in varying degree in different individuals. The two processes continue simultane- ously, and a race is established between tissue destruction and tisstie construction. If in your fight with tuberculosis you possess sufficient vitality to manufacture new tissue more rapidly than the lung tissue is destroyed, you win. If, on the other hand, your efforts toward the making of scar tissue are enfeebled, the reverf5e is inevitable. The measure of your constructive capacity is the conservation of strength, which to a great extent is to be proportionate to your gain in weight and your rigid economy in the expenditure of bodily energy. To secure satisfactory results in your struggle with tuberculosis, it is necessary to attain a surplus of vital energy through the influence of nutrition. This is accomplished as a joint result of superalimentation and physical rest. It is not altogether what you earn through enforced feeding, but also what you save by being quiet." As a result of this personal understanding of the rationale of the methods to be advised, it is easy to conceive how much more ready is the acceptance of an enforced regime, how much greater confidence is established between patient ancl physician, and to what greater extent there may be instituted mutual sympathetic cooperation. Thus, having instituted early relations of confidence and reciprocal effort, the 618 PROPHYLAXIS, GENERAL AND SPECIFIG TREATMENT physician is usually permitted with less opposition to elaborate ideas of treatment, which might otherwise be non-acceptable to patient and friends. In maintaining a responsible direction of the patient, the clinician is repeatedly confronted by the necessity of observing a dili- gent, painstaking regard for detail. It is comparatively simple to prescribe rest, fresh air, and plenty of good food, but the obligation of the physician is not discharged until he personally provides such accommodations as wiU insure the proper continuous execution of his directions. The surroundings of the patient should be subjected to personal inspection, simple inquiry relative to the environment being utterly inadequate for the determination of its fitness. Accurate information must be secured as to the appropriate- ness of the location, the adaptability of the dwelling to the purposes and needs of the patient, the character of the food, and the nature of social or recreative features. Attention should be specifically directed to the occupation, habits, financial status, domestic relations, resources for individual entertainment or diversion, and finally to the disposition and degree of self-control. The management of consumptives is radi- cally different from that of any other class of human beings, in view of the fact that, by virtue of their illness, there are sometimes exhibited decided changes of temperament and mental attitude, as described in connection with the General Symptomatology. Pulmonary invalids constitute a class decidedly unique and peculiar to themselves, demand- ing of the medical attendant the exercise of the greatest tact, judgment, and skill that is required in all the domain of medicine. It unfortunately happens in many cases that the accompanying members of the family exhibit traits of character and disposition which add vastly to the trials and vexations of the physician. While many patients have literally committed suicide through their own folly and indiscretions, others are sacrificed through the perversity, ignorance, and delusions of their immediate relations. Petting, sympathy, con- dolence, or indulgence on the part of others constitutes a most serious hindrance to the accomplishment of best results. For these reasons conspicuous success often attends complete segregation of the patient. Several times I have insisted upon the separation of little children from their parents for over two years at a time, and have placed them under the care of trained nurses especially adapteil to the work. While this may seem chfficult of execution, I have found that, if properly presented, the family are usually quick to appreciate the wisdom of such advice and govern tlicmschi- nrcordingly. At no ;ii;r :iic ii.iiii-iits more domineering, wilful, and difficult of management ilum iu tlie neighborhood of eighteen, even if confined to the bed. I have found the care of such patients to be made conspicu- ously more simple and effective if removed from their parents. The separation of husband and wife is often expedient by reason of various widely differing considerations in individual cases. In such instances the physician must possess the courage of his convictions sufficiently to insist upon the removal of these influences through such isolation as may be reasonable and practicable. The task of enforcing a proper regime varies witliin wide limits. It is comparatively easy to secure the active cooperation of patients who are intelligent, phlegmatic in temperament, and amenable to advice, but it is the experience of those who are brought in contact with the vari- ADJUSTMENT OF PHYSICAL AND NERVOUS EFFORT 619 ous stages and conditions of pulmonary tuberculosis that all patients do not conform to this class. When to the care of the pulmonary invalid there are added the difficulties arising from the peculiarities and per- versions of judgment of members of the familj', it is easy to appreciate that successful management necessitates such a degree of patience, determination, and attention to detail as almost to constitute a form of genius. The extent to which this endowment is posse.ssed by the medical attendant is responsible in large measure for the success which may be expected to attend his efforts. CHAPTER XCI ADJUSTMENT OF PHYSICAL AND NERVOUS EFFORT The regulation of exertion constitutes a cardinal principle of treat- ment, applicable to all cases of tuberculosis. The processes of repair in general are stimulated by the enforcement of appropriate rest. For the accomplishment of best results it is imperative to minimize the demands upon the nervous forces, as well as upon the physical strength. Conservation of energy in every conceivable manner should be the watchword imparted to the patient, without which the onward progress toward recovery is interrupted by the interposition of serious, if not insurmountable, obstacles. Rest for pulmonary invalids must be accepted as a purely relative term, varying in its interpretation from absolute immobilization in the recumbent position to moderate degrees of physical exercise. The im- portant desideratum is the avoidance of fatigue from any cause, whether physical, nervous, or mental. Fatigue necessarily develops at varying times, and in vastl}' differing degree, according to the condition of indi- vidual patients. A restrained physical activity, which in some persons constitutes comparative rest, may represent in others an unwarranted excess. In the same way reading, study, conversation, card-playing, knitting, eml^roidery, or other handiwork may offer healthful diverting occupation to some, but become acutely exhausting to others, through the entailed mental effort or nervous excitement. Rest may be regarded as eminently desirable for pulmonary invalids as a class, but the paramount consideration relates to an accurate determination of the extent to which this should ajiply to individuals. The intelligent .'ind cMVciive regulation of the exciiion :ii>iii(i]iriate for a given consuiiipti\c. tliuuiih attended at times wiili ilic '_:icatest diffi- culty, perhap.s truiiscciids in importance all other lc:i,iiiivs dl treatment. Fresh air and superalimentation have long been recognized as valuable therapeutic factors, but practical experience leads to the belief that the adjustment of physical and nervous effort is even more important. While the necessil\- Im- judiciims circumspection regarding exercise obtains even among imipicm ca-c-. ilic role of rest as a therapeutic measure of the first niagiutmli' is f(M'i;dly emphasized in connection with far-advanced patients. Open air, which admittedly is indispen- sable to all stages and conditions of the disease, becomes in desperate 620 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT cases subordinate in importance to complete rest. Either one of these factors, with the sacrifice of the other, is of but slight value to such a class. No matter how manj' the hours out-of-doors, if attended by fatigue, each day must be summed up as a failure. In like manner the enforced consumption of a proper amount of food can avail but little if the nervous force required for the proper performance of digestion and assimilation is dissipated through the influence of undue exercise or excitement. Phj-sical exertion must be forbidden, even to the slightest extent, among far-advanced consumptives, not only because it produces exhaustion and further deranges digestion, but also on account of its tendency to increase temperature elevation and to excite hemorrhage. Duriii-r the active advance of the infection the digestive, circulatory, and respiratory functions become embar- rassed more or less by the presence in the blood of toxins which, formed in excessive amount, give rise to the fever and other character- istic symptoms of sepsis. It is precisel}' at such times that the addi- tional burden imposed by physical exertion upon already overtaxed functions is productive of most disastrous results. Fever, then, may be regarded in any stage of tuberculosis as an unfailing indication for a mandatory insistence upon complete rest. By absolute rest is meant the actual relaxation of the patient in bed during the entire twenty-four hours. A temperature in the neighbor- hood of 102° F. at any hour of the day suggests the wisdom of main- taining the recumbent position for an indefinite period, the patient not being permitted to rise until the fever has materially abated. An afternoon temperature of 100° F. or thereabouts, despite the absence of fever earlier in the day. demands a decided restriction of physical effort. Under such circumstances it is expedient to enjoin complete rest in bed at least during the period of temperature elevation. If the fever recedes to normal during the early e\-ening, it is sometimes well to allow the patient to sit up for a short time before retiring for the night. In general, patients exhibiting a temperature of 99f ° F. at any time of the day should be forbidden to indulge in walking as a form of exer- cise, as in such cases the fever is frequently increased even by a short, slow- walk. In this connection it is important to discriminate between a temporary elevation of temperature taken in the rectum shortly after exercise is concluded, and the fever w'hich may appear after an interval of rest. It has been ascertained that a considerable physiologic rise of temperature in health may follow prolonged or unusually severe exercise, even moderate walking for a comparatively short time may produce a slight elevation of temperature, which completely recedes after a half- hour interval of physical repose. The susceptibility of pulmonary inva- lids to temporary elevations of temperature after walking is much greater than of healthy people. The fever reaction in such cases is not only more marked, but of longer duration, the rise of temperature frequently being sustained for manj' hours in spite of complete rest. Much confusion regarding the effect of exerci.se upon the body heat may be avoided if the temperature be taken in the mouth only after a period of rest. A transitorj' fever shortly after exercise may be detected if the temperature is taken in the rectum, while no indication of its pres- ence would be afforded by the oral record. After the lapse of a short interval of rest, the physiologic elevation of temperature, as indicated in ADJUSTMENT OF PHYSICAL AND NERVOUS EFFORT 621 the rectum, is found to subside, while the fever of pathologic significance is recognized in the mouth and remains persistent for several hours. It thus appears that but slight practical importance attaches either to the oral or rectal temperature taken immediatehj after exercise, the former being fallacious and the latter ephemeral. The development of fever, as evidenced by the oral record, after rest is an undoubted indication of the immediate deleterious effect produced by physical effort. For such patients exercise should not be again permitted until the temperature has receded below 99° F. and remained practically normal for at least several days. When walking is resumed tentatively, the utmost caution should be taken to guard against overexertion. Upon the whole, fever may be regarded as the leading contraindication for physical exercise. Complete rest in bed is also demanded in the presence of severe dyspnea and cyanosis, with a weak and i-apid pulse. As a rule, circula- tory or respiratory embarrassment does not suggest as emphatically as fever the imperative necessity for absolute rest. In such cases, with- out temperature elevation, the indications point to a considerable restric- tion of active physical effort with, sometimes, under competent super- vision, the systematic employment of passive mo\ements. Rubbing, gentle massage, or resistance exercise may be utilized occasionally to promote capillary dilatation, to equalize the circulation, and to develop the heart. In less desperate cases, in which the maintenance of the recum- bent position is not warranted, much good may be accomplished in selected cases by carefully adjusted exercise. It is essential, however, that the degree of physical activity should be subject to a judicious regulation and control. Through the increase of appetite, the promotion of oxidation and elimination, the general tone of the system is materially improved and resistance correspondingly increased. It should be insisted that muscular development is not the end to be achieved, and that exercise is of value only in proportion as general resistance is pro- moted. Patients should be informed that the accumulation of a reserve in nutrition and vital energy is of vastly more importance than muscular strength or powers of endurance. In selecting a form of exercise con- sistent with the needs of a given ca.se, there is demanded of the physician far more than a consideration of the physical condition. A feature of no little significance is the psychic element, which may be taken advan- tage of through an intelligent inquiry regarding the tastes of the indi- vidual. By this means there may be afforded a wise discernment regarding the appropriateness and value of various forms of outdoor amusement. For the accomplishment of the most satisfying results in the continued maintenance of an outdoor regime, it is essential that recreation be combined with exercise. Natural and acquired proclivities of individuals should form within certain limits an important, if not a determining, factor in the character of the phy.sical cUversion permitted to pulmonary invalids. A measure of the usefulness of any outdoor pastime, provided that this is not subject to especial contraindications, and pursued in strict accordance with prescribed directions, is the degree of actual enjoyment afforded. Correctly regulated exercise, if adapted to the inclinations of the invalid, is diverting in nature and correspond- ingly healthful, while physical effort without recreation, no matter how perfectly adjusted, remains but work, and hence less advantageous. Walking in the open air is the simplest, safest, and usually most 622 PROPHYLAXIS, GEXERAL AND SPECIFIC TREATMENT acceptable form of exercise for pulmonary invalids. This appears capa- ble of an easy and accurate regulation, but such is not always the case. The paramount thought is to avoid the slightest fatigue, shortness of breath, or cardinc /kiI pildlion. -~ It is essential ihat the invalid should be permitted to resume a posi- tion of rest not alici- 1k' has experienced fatigue, hut before. He should not walk until he is tired and then attempt to return, but should arrive upon the porch before this sensation is felt. If fatigue is experienced as a result of the walk, and particularly if peisistent after a rest of ten or fifteen minutes upon the couch, definite harm has been inflicted. While it is apparent theoretically that the duration of the walk, the direction, the time of day or night, and even the company should be definitely outlined by the physician, such a degree of supervision is not always practicable. Furthermore, the utmost difficulty attends anything like a correct esti- mate of the individual capabilities at different times. Invalids exhibit a decided variance in the effect produced by a fixed amount of exer- cise even upon successive days. The extent of the walk appropriate for the consumptive can be tletermined only by a comprehensive regard for much detailed data. While it is comparatively easy to prescribe perfunctorily the exact distance, the hour, the course, and even the pace, such a refinement of treatment savors more of ignorance and imposture than of clinical exactitude. From a purely practical standpoint the conviction has been forced that while rigid supervisory guidance in the matter of exercise falls properly within the province of the physician, the detailed application of the prin- ciples of rest must be left to some extent to the intelligence, obedience, and judgment of the patient. The enforcement of a strict advisory regime should not necessarily imply that pulmonary invalids be compelled to resolve themselves into unthinking automatons whose very existence shall be controlled by autocratic dictation. After an elaboration of the principles upon which the determination of appropriate exercise is based, an appeal to the reason and understanding of the consumptive serves to establish relations of confidence and good feeling and, in addition, inspires the invalid with a sense of his personal responsibility. To intelligent inva- lids, devoted to the cause in which they are forced to enlist, the advisory direction should not partake of an arbitrary character. In view of the chfficulty attending the accurate differentiation of individual capa- bilities and requirements, it not infrequently happens that the patient, even better than the medical adviser, is enabled to appreciate the effect of prescribed exercise, and to judge approximately concerning the pro- priety of its repetition. JIany patients who have been suitably in- structed concerning the dangers of overexertion, quickly recognize its deleterious effect, and learn to exercise a judicious regard for their own welfare in the matter of physical activity. The physician should insist upon comparative rest for all ambulant cases, and admonish earnestly that general directions in this respect be scrupulously oboycd. Definite commands well within the limits of safety must I'c i--uril to the ignor- ant, headstrong, and frivolous. Consumptives who arc wilful or vicious are wont to disobey mandatory instructions, no matter liow emphatically or definitely given. It is highly essential that the beginning walk for convalescent inva- lids should be short, slow, and upon level ground. With increasing strength greater indulgence may be extended from time to time, pro- ADJUSTMENT OF PHYSICAL AND NERVOUS EFFORT 623 vided no unfavorable effects are noted. In the interests of safety it is well to inculcate in the minds of patients the conviction, that exercise does not constitute an especially important desideratum in the effort to secure arrest, but rather represents an indulgence to be gi'anted in selected cases with wise discrimination. Prolonged walks and arduous hill-climbing should be interdicted, even to patients well upon the road to recovery. In general issue is taken with the recommendation of graduated walks upon upward inclines, a practice, unfortunately, still somewhat in vogue. While this procedure in some instances produces beneficial effects in the development of the heart and impi-ovement of the respiratory function, untoward results from such strenuous exer- tion are all too frequently noted. These consist not only of general fatigue, breathlessness, and cardiac palpitation, infallible criteria of the unfavorable effect of exercise, but also of the occasional intercurrence of pulmonary hemorrhage or pneumothorax. The character of the pulse is often an important guide to the regula- tion of the walk. Marked rapidity, weakness, or imtability clearly indicate the necessity of continuous enforced rest. It is the custom of some internists to attempt a reduction in the pulse-rate through a graduated system of active methodic exercises. An experience in the higher altitudes leads to the belief that such measures, no matter how carefully conducted, are, as a rule, distinctly deleterious, and that overfrequency of the heart demands, in the majority of instances, insistence upon complete rest. Patients who are considerably exhausted by disease usually become readily amenable to control as regards the extent and character of their physical exercise. With beginning subsidenc^e of subjective symptoms a continued ready compliance with instructions is often manifested, but with returning strength, increase of vitality, and buoyancy of spirits an overconfidcnce in the physical capabilities and endurance is naturally engendered. At this time it is often exceedingly difficult to impress the patient with the fact that recovery has not yet taken place. The invalid should be made to realize that despite the complete disappear- ance of all clinical manifestations, an improved nutrition and the con- sciousness of physical strength, there still remain definite pathologic changes in the pulmonary tissues. Far from permitting the assumption that a cure has been permanently established, it is expedient to designate the condition as a quiescent tuberculous infection undergoing arrest. The further evolution of a complete enduring recovery is dependent largely upon the degree to which the patient confoi-ms to wise cdunsels regarding conservation of strength. Evni llic physician :i,1 lliis stage is likely to deceive himself by a sense of false seen lity, and, yicldin.ii (d tiie blandishments and confident assertions of the patient, may permit a lax- ity in the supervisory control, .seriously jeopardizing the interests of the apparently cured consumptive. There can be but little ultimate satis- faction to the physician in having his patient improve unless he succeeds in bringing about a final arrest of the tuberculous process. To this end no therapeutic measure is of more undoubted efficacy than a continued economi) in the expenditure of physical and nervous energy long after the disappearance of all clinical inanifestations of the disease. An interesting and somewhat remarkable difference of opinion is entertained among medical observers with reference to the practical utility of pulmonary gymnastics. Some there are who advocate deep 624 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT breathing exercises as of striking therapeutic value, while others entirely discountenance such measures as fraught with definite ele- ments of danger. Strikingly different arguments are advanced by those advocating and opposing pulmonary gymnastics for consump- tives. The former assert that an underlying principle of treatment is exercise of the tuberculous lungs, in order to promote their expansion, circulation, and nutrition, thus adding to the aeration of the blood, the elimination of carbon dioxid, and the resistance of the entire organism. It is the contention of others that a cardinal feature to be observed is the maintenance of rest for the tuberculous kmg. as well as of the tuberculous individual, in order to avoid an extension of the infection into new pulmonary areas, and to avert the development of pneumothorax or pulmonary hemorrhage through unusual activity and depth of the respiratory excursions. Clinical evidence is not lacking to sustain the claims of those entertaining views diametrically opposed to each other. The beneficial effects obtained in the higher altitudes afford a presumptive confirmation of the advantages derived from an increased activity of the respiratory function, although in such resorts other factors share in the production of favorable results. Upon the other hand, attention has been called in previous chapters to the not infrequent improvement noted during compression of lung bj' a mod- erate pleural effusion. A review of the available data discloses the fact that an active expansion of affected pulmonary areas is of undoubted value in a large proportion of cases, that compression of affected lung is useful in others, but, above all, that artificial methods of producing either vesicu- lar dilatation or compression are frequently attended by possibilities of danger. While their employment in some instances is followed by results of a gratifying nature, in others the effect is eminently injuri- ous or of doubtful utility. It is clear that the scope of pulmonary gymnastics is subject to con- siderable limitation, and that belief in their efficacy or harmfulness varies according to the environment, personal experience, and point of view of medical observers. It is apparent that if unfortunate consequences are to be avoided from the employment of deep breathing exercises, judici- ous discrimination must be exercised in their individual application. Pulmonary gymnastics are undoubtedly of decideil benefit in the pres- ence of certain non-tuberculous changes in the lung and pleura. It is important to distinguish clearly between the chronic anatomic con- ditions present in such cases and the acute pathologic processes incident to pulmonary tuberculosis. In the midst of extensive pleural thickening with marked fibroid change, incomplete expansion of lung following operation for empyema or pneumopyothorax, delayed or partial resolution following pneumonia, or pleuritic adhe.sions subsequent to an effusion, it is important to restore the respiratory function as fully as possible. The indications then point to the enforcement of vigorous breathing exercises in order to promote expansion of the already crippled lung, and incidentally to enhance the compensatory activity of the non-damaged pulmonary areas. There is no valid reason why the existence of similar conditions among tuberculous patients should not suggest the expediency of the same procedures, provided important contraindications do not exist. While routine recourse to the employ- ment of pulmonary gymnastics for consumptives should be unquali- ADJUSTMENT OF PHYSICAL AND NERVOUS EFFORT 625 fiedly condemned, carefully supervised breathing exercises have proved to be eminently beneficial in the partial restoration of the respiratory function resulting from the above-mentioned complications. The practice of forcible breathing among active advanced cases offers but little if any advantage, and much in the way of disastrous results. Among the unfortunate sequelae sometimes observed are the further extension of the tuberculous infection, the gradual production of gen- eral emphysema, the development of pneumothorax from rupture of pleura, the onset of pulmonary hemorrhage, and, rarely, an aspiration pneumonia. The practice of recommending deep breathing exercises to pulmonary invalids should be discredited whenever the subjective manifestations and physical signs portray an active or extensive tuberculous infection, especially if there exist acute inflammatory complications, pulmonary excavation, recurring hemorrhages, fever, irritable pulse, or exhaustion. The advocates of pulmonary gymnastics have adopted various methods of putting deep breathing exercises into effect, with and with- out supplemental movement of the arms, changes of posture, and exer- cises of the body. Deep forcible respirations may be practised with the patient in the erect or reclining position and during the act of walking. It does not appear to be essential that the inspiration should be taken through the nose, as some have maintained, but it is important that the breath should be held for a few moments. The expiration, while not violent, should be as complete as possible in order to minimize the amount of residual air. Some aid is secured by bringing into play the voluntary muscles of expiration. To this end the arms may be raised to the horizontal position or over the head in inspiration, to be dropped quickly at the time of expiration. It is unwise to permit more than five or six deep respiratory excursions of this nature at one time, although in suitable cases they may be repeated several times during the day. Many instructors in physical exercise insist upon the backward movement of the arms until the dorsal surfaces of the hands touch each other in the back during inspiration, the arms being brought forward in expiration. At the time of inspiration, with or without supplemental arm movements, the body may be raised slightly upon the toes and held in that position as long as the breath is retained. The use of a breathing-tube is of no practical benefit, though in some instances possessing a slight moral effect. It is important to bear in mind that the great majority of pulmo- nary invalids who are induced to seek medical counsel present sufficient evidence of active destructive lesions to contraindicate the employment of pulmonary gymnastics. In the presence of less active tuberculous infection, with partial pulmonary incapacity through subacute or chronic pathologic changes, the utility of such measures cannot be denied. Under these conditions it has been my custom to make occasional use of deep breathing exercises in Colorado, but, owing to the compulsory increase of respiratory activity at high altitudes, the practice has not been per- mitted unless very strong indications for its employment are presented. 626 PKOPHYLAXIS, GENERAL AND SPECIFIC TREATMENT CHAPTER XCII ENFORCEMENT OF AN OPEN-AIR EXISTENCE It is impossible to overestimate the importance of fresh air as an essen- tial factor in the treatment of pulmonary tuberculosis. In reality, an out- of-door existence is an indispensable feature of modern phthisiotherapy. Upon this all medical observers are of a single mind, but, unfortunately, radical differences of opinion exist as to what constitutes the desirable qualities of inspired air. Puritj' and freshness of air, attributes unani- mously conceded to be invaluable, are regarded by some as the only impor- tant considerations. The inhalation of an atmosphere cariying a proper amount of oxygen and devoid of injurious contamination is asserted by some to be productive of the fullest possibilities of improvement. Irre- spective of other qualities of atmosphere and of the environment, fresh air, in its influence upon the course of tuberculosis, is proclaimed by these oljservers to be the same wherever found. Regardless of such essential features of climate as dryness, temperature, sunshine, altitude, atmospheric pressure, and wind movement, with their known modify- ing effects upon the respiration, circulation, digestion, skin, nervous system, and the general tone of the organism, the contention is incon- ceivably made that the sole de.sideratum is the inhalation of oxj^gen- ated air. Thus it has been announced broadcast that quite as good results may be obtained in one place as in another, provided the air is pure and fresh. This fallacious doctrine has been preached with a devotion and fanaticism worth}' of a truer cau.se by many who should recognize the folly of subscribing to such an article of faith. In pur- suance of this delusion, the tUctum has gone forth that fresh air suited to the neetls of the consumptive may be secured in the large cities as well as in the country, at the seashore as well as in the moun- tains, in damp marshy regions as well as upon dry sandy soil, and in a district characterized by fog, cloud, and rain as well as in the land of almost perpetual sunshine. It is not designed at this time to encroach even briefly upon the merits of the various climatic attributes in the treatment of consumption, a subject reserved for future dis- cussion, but it is desirable en passant to tlenounce emphatically the false notions often entertained with reference to the role of fresh air, exclusive of all other modifying conditions of atmosphere and environ- ment. Even should it be assumed, however, that fresh air is but fresh air in any locality, decided issue must still be taken with the teaching that this feature constitutes the all in all of an outdoor existence. It matters greatly whether the air is obtained in the alleys and back yards, upon the house-tops and fire-escapes, and in densely populated chstricts or in properly constructed porches, shacks, or tents in the open country. Further, a factor of no little importance relates to the manner in which, through details of arrangement, fresh air is provided for the pulmonary invalid. The practical benefits to be derived from exposure to outdoor air are enhanced or lessened according to the opportunities afforded for the acquirement of an environment adapted to the individual. No principle of treatment throughout the long course of pulmonary tuber- culosis is established more conclusively, than the necessity of rendering ENFORCEMENT OF AN OPEN-AIR EXISTENCE 627 the consumptive comfortable physically, and of inspiring a cheerful mental attitude through the influence of pleasant, properly supervised sur- roundings. It is essential that phthisical patients should spend not merely a brief portion of the day out-of-doors, but should remain in the open air as many hours out of the entire twenty-four as weather con- ditions will permit. It is far from sufficient to advise the invalid to stay out-of-doors as much as possible. If left to the exercise of his own judgment and inclinations, the period of fresh-air existence is lamentably short, and usually accompanied by unfortunate indiscretions in the way of physical exertion. For consumptives to obtain fresh air at all hours, and at the same time to remain completely at rest, it follows that, in addition to definite instructions of such a nature, special provision must be made for this purpose. The i-equirements to be observed relate — (1) to devices for securing the maximum amount of fresh air with the invalid at rest within doors ; and (2) to arrangements for the comfort and shelter of the patient if in the open air. No matter how spacious the indoor ajiartments, how perfect the ventilation, how flooded with sunshine, nor how equipped for pro- tection from drafts, there can exist no compensation for lack of outdoor accommodations. In case facilities for open-air existence are entirely unavailable, and partiriilaily wliru circumstances do not permit the occupancy of lar^c miuhx , \\cll-\i'iiiil:ited rooms, several ingenious methods have licni prc-i'iiicd in pci'imi the inhalation of pure air. An arrang(Miicin kimwuas the aorarium provides for the partial outward extension nl' a cut l)ed from an open window, the head and shoulders of the pa.liciit thus being in the open air, though protected by an awning outwide the window. The sleeping-room in which reposes the body of the patient is kept measurably warm in cold weather by the interposition of a heavy curtain suspended from the lower portion of the raised lower window-sash and tucked around the body of the patient. The sides may be opened or closed at will, ventila- tion being secured through the lower and upper part of the aerarium, the roof of which is double and provided with an ojiening. Another contrivance of more doubtful utility is the conduction of air from the outside to the head of the patient in the sleeping room through a large flexible tube consisting of heavy cloth supported by a series of light but stiff rings. This arrangement, for obvious reasons, appears less practic- able than resourceful. The window-tent devised by Dr. S. A. Knopf embodies all the desir- able features of the aerarium and obviates some of the disadvantages. The window-tent is virtually an inside awning, consisting of canvas stretched upon an iron frame attached to the lower half of the window, as shown in Fig. 131. The tent is designed to rest upon a single bed, and to inclose the upper portion of the patient's body, its height, length, and degree of curvature being necessarily dependent upon the dimensions of the window. In its construction the effort is made to provide fresh outdoor air which shall not be allowed to mix with the air in the room. In case there is but a single window, a measure of venti- lation for the room is afforded by an air-space of about three inches between the top of the window-tent and the lower edge of the sash. This space may be reduced or closed entirely by lowering the window. It would appear that the access of fresh air rendered possible by this bii» PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT method is much greater than nhtains in Idwcr berths of Pullman sleeping- cars, though the conditions arc iu -nini' n-|MMts quite similar. With the upper berth made up and the curtains iii;litly ilrawn the traveler in the lower compartment occupies throughout his entire length a modified wdndow-tent. The comparatively small window opening is practically offset by the forcible entrance of air incident to the rapid motion of the car, j^et the air within this confmed space, even during hot weather, when the windows are open, often becomes noticeably foul. It is apparent that a vitally important feature of the wimlow-tent is the opportunity afforded for the egress of expired air by virtue of the proportionately large open- ing. An added factor is the small capacity of the inclosed tent, with its rounded upper surface facilitating the course of the air-current. In describing the ventilation of the window-tent Knopf states that the cold air enters at the bottom of the open space, descrilies a quarter circle, and makes its exit at the top, carrying with it the exhaled carbon Fig. 131.— Dr. S. A. Knopfs window-tent. dioxid. This I have verified by the use of a delicate instrument known as the air meter, the current being perceptibly inward at the bottom and outward at the top. In cold weather it is apparent that the outward direction of the air-current at the top is facilitated b}- the egress of heated air from the room through the aperture above the window-tent. This, of course, would not obtain during warm weather or when the window is brought down to the level of the canvas. It is also found that the degree of ventilation within the tent varies materially according to the chrection of the wind and the temperature of the surrounding atmo- sphere: in other words, it is dependent somewhat upon the temperature relation of the inspired and expired air. The cour.se and vigor of the air-current within the tent are greater in proportion as the temperature of the exhaled portion is ivanner than that of the outside atmosphere. In cold weather the warm expired air rises to the upper portion of the tent and makes its exit in that region, its place being taken by the ENFORCEMENT OF AN OPEN-AIR EXISTENCE 629 entrance of cold air at the base. This is not true to an equal extent in warm weather, at which season an additional aid to the air movement seems particularly desirable. In the summer-time the window-tent is of less practical value than in winter, as opportunities for otherwise obtaining fresh air are usually ample. Moreover, unless a north window be utilized, the tent is converted into a veritable oven, the heat of the sun becoming well-nigh unbearable. Under such circumstances an outside awning, to afford protection from the summer heat, appears desirable. At any season of the year ventilation of the tent may be facilitated by the use of a small inexpensive fan propelled by air, and possibly by the insertion into the upper third of the window-frame of a piece of wood about one foot wide, slanting downward. A substitute for the window-tent has been devised by Dr. Charles Denison. This is known as the sleeping canopy and, like the preceding, is designed to pro- vide fresh air to the consumptive who may be confined to the room. The canopy curtains are so arranged that they may descend from the upper portion of the window and encircle the exposed sides of the bed. At best, it is hard to conceive how the aerarium, window-tent, or other device for putting the patient at an open window can be productive of the very best results. While such ingenious arrangements are assuredly better than nothing, their disadvantages consist of the limited amount of fresh air capable of attainment, the obstacles in the wiiy of special care and nursing on account of the hood arrangement , and the psychic influence, which hardly can be regarded as encouraging or inspiring. Arrangements for the comfort and shelter of patients privileged to enjoy an outdoor existence are scarcely less important than the inhala- tion of pure fresh air. An essential feature in the acquirement of physi- cal comfort for the outdoor consumptive relates to the adequate protec- tion of the body despite low degrees of temperature. Coolness of air presents, as a general rule, no insuperable objection to the policy of stay- ing out-of-doors at all hours. In fact, it has been my observation that more satisfactory results are often obtained during cold weather than during the summer months, unless patients are permitted to inspire the bracing air of the mountains at this time and experience the exhilarating effects of a new environment. Even when exposed to extremely low temperature, provided proper attention be given to the maintenance of body heat, patients are found to do extremely well in the open air, on account of the stimulation of the normal functions by the cold. It is, of course, important to avoid chilling of the surface of the body, but this may be prevented through the use of suitable clothing and, when neces- sary, by the application of hot-water bottles to the feet or about the body. It is desirable during the winter months that the patient should be kept moderately warm under all circumstances, but this does not imply the necessity of bundling up in heavy wraps, chamois-skin undergarments, and chest protectors to such an extent as to interfere with the proper function of the skin. The important desideratum is that the invalid be made comfortable through the use of proper apparel. Much harm may result from the wearing of clothing ill adapted to the state of the weather, frequent colds and physical debility ensuing from the burden, perspira- tion, and subsequent chilling occasioned by too heavy apparel. Patients should be taught that the actual utility of their undergarments is more dependent upon the fabric and construction than upon the weight. , In extremely cold weather moderately heavy woolen underclothing is 630 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT almost indispensable. In rigorous climates a double suit or a woolen chest protector, with an extra pair of socks, is sometimes necessary. The wearing of chamois-skin garments or of newspapers attached to the underclothing should be intertlicted, on account of their imperviousness to air and the tendency to produce relaxation of the skin. Cotton gar- ments or those made of outing flannel should not be worn next the skin in any season or in any locality. The cotton being a good conductor of heat, serves to promote radiation of animal heat from the body in cold weather, and to convey the overheated air directly to the body in sum- mer. Its activity as a heat conductor is intensified bj' the retained moisture resulting from perspiration. In the milder climates and during less severe weather in cold regions, a light, loosely fitting woolen garment is preferable to the heavy skin-tight flannels so frequently worn. In very many instances the maximum of comfort may be obtained by the use of linen-mesh garments, which are light in weight, non-irritating, non- shrinking, and productive of no interference with the proper function of the skin. In the matter of dress for the feet an important consideration relates to the avoidance of sweating. Socks should be of wool, but not too heavy, as perspiration is induced, especially by the use of old-fashioned knit stockings. When this takes place, an immediate change of socks, with vigorous rubbing of the feet, is desirable. The practice of inclosing the feet and ankles in heavy overshoes is less commendable than the use of stout, thick-soled .shoes or felt boots. In extreme weather the feet may be kept warm by the use of a hot-water bottle and blanket. The wearing of sweaters with a heavy roll tightly incircling the neck is more or less objectionable, as local perspiration is induced and the susceptibility to colds and sore throats increased. The same disad- vantage obtains from inclosing the neck Ijy a fur collar, save in the coldest weather. For the warmth of the ears it is much better to i-esort to the use of the time-honored ear-muffs than to employ scarfs or fur collars, unless tlemanded for the protection of the face. At night, during the severity of the winter, the patient should sleep upon a double mattress, or a pair of woolen blankets should be placed next the spring, with another pair of blankets resting upon the mattress, in order to prevent the penetration of cold air from below the bed. In many instances a light woolen robe may l)e placed between the sheets, which the invalid, if desired, maj^ wrap around the body. Consumptives often prefer to .sleep in blankets with the body inclosed in woolen pajamas. In extreme wi-athcr slcc]iiii'i-lia!;s may be utilized, consisting of heavy woolen mati'iial, (HiiciiMK- lined with fur or feathers, and buttoning closely around tin- neck and boulders. It is important that the outer bed-clothing should not be too heavj', lest sleep may be disturbed to a considerable extent. Warmth is attained far more from the quality of the material used for bed-covering than from the weight. Old-fashioned quilts and comforters should be dispensed with whenever possible, and woolen blankets substituted in their place, while for the well-to-do eiderdown quilts are advantageous on account of their lightness. It is often deisirable to protect the head with a light woolen night-cap, which may be drawn over the ears, leaving the face exposed. Protection is thus afforded to all portions of the liody likely to suffer from exposure except the no.se. Occasionally patients complain bitterly of the sen- sation of cokl experienced at night at the very end of the nose. To ENFORCEMENT OF AN OPEN-AIR EXISTENCE 631 obviate this difficulty I have sometimes made use of a device sug by Dr. James A. Hart, formerly of Colorado Springs, consisting of a piece of thick flannel or felt which is placed upon the nose and securely fastened by strips of rubber adhesive plaster extending horizontally upon the cheeks. In addition to the protection of the bodfj by means of proper cloth- ing, it is important that various means of outside shelter be devised. During the summer provision should be made in all cases for protection from the intense heat of the sun and the sudden showers, and also means afforded for the avoidance of nervous irritation and loss of sleep pro- duced by the ubiquitous fly or mosquito. In winter adequate shelter must be provided from the chilling blasts and protracted storm, indicat- ing in no uncertain manner the violence of the elements at this time of year. A superimposed roof of some kind is the first essential in the way of shelter for the tuberculous invalid in the open air. It is true that in Colorado, New Mexico, Arizona, and other comparatively arid regions the consumptive is often permitted to sleep in perfect safet}" under no other canopy than the starry skies, but a similar attempt in less favored regions, even in pleasant weather, is not to be regarded as an ideal con- servative practice. Next to the roof, the most desirable feature of an outdoor abode for the invalid is the presence of at least two protecting contiguous walls. These are requiretl to give proper shelter in the event of storm or wind, at which times the bed may be moved into the sheltered corner, beyond the reach of snow and rain. A third wall is by no means indis- pensable, though sometimes of signal advantage in inclement weather. Opportunity to inclose temporarily the air-space upon the third side, and to remove subsequently the awning or screen at will is, therefore, a feature of added value. In order to afford satisfactory ventilation, it is absolutely necessary that the front or remaining side be kept entirely open. Under all circumstances the floor should be of matched wood, entirely impervious to air, and raised a considerable distance from the ground. The front exposure should be toward the sun during a portion of the day, but it is not at all essential that it face the south. Means for ready communication with a nurse or attendant in case of need is a prime necessity. Of further advantage is proximity to a commodious, well-heated apartment, into which the bed may be moved at any time. This not only permits the removal of the patient into the house during unpleasant weather, but also secures the privacy of the sleeping-room for bathing purposes, as well as gi-eatly facilitating toilet arrangements. Another advantage of no little value consists of the easy accessibility of the kitchen, refrigerator, ami pantry, enabling the invalid to receive food in appetizing form. Lighting arrangements are also greatly simpli- fied by an immediate contiguity of the dwelling and the easy extension of electric wiring. Freedom from intrusion and protection from the stare of passers-by represent important desiderata to be secured by de- tails of location and construction. Protection from the glare of the sun by means of easily adjusted screens, and from the annoyance of insects through the generous use of wire netting, is an added feature of comfort and utility. 632 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT From the foregoing considerations it is at once apparent that all the detailed advantageous conditions can be supplied only by special provision for porch accommodations. The second-story veranda as above described is undoubtedly the ideal arrangement for an open-air existence of the pulmonary invalid, but, unfortunately, this plan is not within the reach of all sufferers from consumption. Numerous methods have been devised looking toward the acquirement of fresh air at a modi- cum of expense. Several of these contrivances have been capable of application at certain seasons of the year, but have failed dismally at other times. Some have succeeded, to be sure, in offering to the con- sumptive a sufficient amount of fresh air, but at the expense of a large measure of his physical comfort and peace of mind. At other times the invalid, if rendered comparatively comfortable, is necessarily deprived, to some extent, of the very air which is so strenuously sought. Tent life, ardently advocated by some observers, is open to many unavoidable objections. It is manifestly difficult or impossible by the use of tents to supply the required conditions already described as constituting an ideal arrangement. The tent occupant is neces- sarily near the ground for a prolonged period, and save in favorable climates, is exposed to a considerable degree of dampness, which is enormously increased in wet weather. In addition to the inevitable inconvenience and deprivation, there is much difficulty in cooler weather in securing physical comfort combined with proper ventilation. No matter how modern the effort toward sufficient ventilation, tents are usually cold in winter, if not overheated at the expense of fresh air, and often extremely oppressive in summer unless open to direct drafts. It thus happens that recourse to tent life, without special supervision as to details of construction and mode of habitation, is attended by results woefully disastrous to the unsuspecting invalid, deluded with the belief that "roughing it" is a panacea for tuberculosis. Rain- proof canvas is, of course, air-proof as well, and while of little value in excluding the cold, serves effectually to keep out fresh air. In cold or boisterous weather the occupant is of necessity compelled to remain in a small, improperly heated, and poorly ventilated air-space, harassed meanwhile by the continual flapping of the canvas and the spasmodic tugging of the guy ropes. Numerous attempts have been made to remedy the glaring defects common to the ordinary tent of former j^ears. Important improve- ments have been embodied in the Gardiner, Tucker, and Fisher tents, the two former being employed somewhat extensively. The Gardiner tent, devised by Dr. C. F. Gardiner, of Colorado Springs, consists of a hexagonal wooden frame without center pole, but with vertical sides and conic top. The canvas is stretched over the framework and fastened to a I'aised board floor, thus dispensing with the necessity of stakes or guy ropes. Air is allowed to enter at the bottom and around the lower edges, exit being provided at the conic top, through which a stovepipe may emerge if desired. The sides may be turned back or kept tightly laced, according to weather conditions. The Tucker and Fisher tents also afford excellent ventilation facilities, but the expense in each instance is considerable and. upon the whole, the results attained less satisfactory than can be secured from the erection of other varieties of sleeping structures at a diminished cost. While it has been my practice, as a general rule, to oppose the occu- ENFORCEMENT OF AN OPEN-AIR EXISTENCE 633 pancy of tents by my patients, fairly gratifying results in recent sum- mers iiave attended tlae use of tents in the mountains by small colonies of invalids in straightened circumstances. The form of tent usually employed, for which no originality is claimed, but Vhich subserves all practical purposes better than any other model I have observed, is shown in the accompanying illustration (Fig. 132). The important features consist of its comparatively slight expense, its large size, the dimensions being 12 by 14 with a height of 10 feet, the tightly matched wooden floor raised considerably from the ground, the vertical wooden sides to a distance of three feet, the upper portion of the sides consisting of canvas upon adjustable frames, the extension of the top well beyond the sides of the tent, thus effectually excluding the rain without the air, the use of the double top or fly thus minimizing the heat to a percep- tible degree, the sliding shade insuring privacy at night without obstruct- ing the entrance of fresh air, and finally the canopy of large meshed Fig. 132. — Inexpensive tent adapted for tlie use of pulmonary invalids during the summer months, fly netting over the bed. It is easy to understand that during the summer months the erection of fifteen or twenty similarly constructed tents upon high, dry and sloping ground in close proximity to an estab- lishment, containing an excellent dining-room, is of vast benefit to a class of pulmonary invalids. Another form of tent appropriate for occu- pancy during the warm weather is shown in Fig. 133. Various forms of wooden shelters for consumptives have been designed from time to time, all based upon the same principle as a somewhat elevated porch. Among the desirable features embraced by these contrivances are cheapness of construction, protection from the elements by an overhanging roof and an inclosure upon three sides, abundance of fresh air, and in some instances communication with an adjoining inside room with heating and toilet facilities. A disadvantage of an enforced recourse to such improvised accommodations relates to the depressing effect upon the patients from the crudeness of con- 634 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT struction, and the frequent uninviting environment. Other drawbacks to their practical efficacy for advanced cases consist ot inaccessibility 1 housekeeping purposes. to the dwelling, remoteness ot the kitchen, and consequent difficulty in serving properly prepared food, the frequent absence of nurse or ENFORCEMENT OF AN OPEN-AIR EXISTENCE 635 attendant, especially at night, and a location, as a rule, too near the ground, which becomes wet and damp in unfavorable weather. How- ever, these wooden structures, notably Millet's sleeping shack and King's lean-to, are eminently useful devices, far superior to any form of tent in cold weather, and appropriate for a large number of patients. The c appropriate for warm weather. sleeping shack is, in effect, a porch severed from all communication with the house, thus entailing certain disadvantages, as described. It is my custom to obviate these objections during the summer months by providing in the mountains, for a class of patients, shacks 636 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT that are suitable not only for sleeping, but for hons, k< , pliifi purposes. These are inexpensive, but perfectly comfortabli" uml well adapted to small families. A view of these somewhat priniiti\e Imt none the less inviting abodes secured at a minimum of expense is shown in the accompanying photographs. The lean-to arrangement, as developed by Dr. King, of Loomis Sana- torium, is virtually a sleeping shack designed for the accommodation of from eight to sixteen people. A wide shed is erected with a projecting roof over an open front. The ends may be open or closed, according to the requirements imposed by weather conditions. The beds, which are placed in a row in the rear of the inclosure, facing the opening in front, are assured of sufficient protection from beating rain or snow. Space is afforded for reclining chairs between the foot of the bed and the front of the inclosure. Canvas curtains are suspended along the open exposure, which is thus capable of being closed at certain times. The most recent modification of the original lean-to consists of the con- struction of a well-equipped dressing-, bath-, and toilet-room, and a spacious sitting-room connecting two separate apartments for sleeping purposes. An ingenious, somewhat expensive, and rather impracticable device is the revolving shelter, so constructed that the support of the building is borne by wheels which traverse a circular iron rail aroimd the base, with a pivot at the center. The only important principle invoked by the substitution of these structures for the ordinary sleeping shack, is the means afforded for avoiding more completely the chilling effect of wind and storm, as well as for securing, if desired, the greatest possible ENFORCEMENT OF AN OPEN-AIR EXISTENCE 637 amount of sunshine. The revolving shelter may be of any size, of either cheap or substantial construction, of nearly square or circular form, and equipped with sliding windows or adjustable sides. After some opportunities for observation relative to the utility of such a contrivance erected six or seven years ago, at a cost of $500, in con- nection with the Oakes Home in Denver, evitlence has been lacking to justify its employment in favorable climates. Upon the whole, it appears that, if more or less unfavorable accom- modations are good for a class of people unable to secure anything else-, a commodious, specially arranged porch opening directly from the sleeping-room upon the second floor is infinitely better for others. So high a value is placed upon this arrangement that I frequently insist upon the construction of such porches even by patients who take houses under lease. The porches should be covered by a perma- nent roof, sheathed from the bottom a distance of three feet, with a wide sill, and inclosed with wire screening, as shown in the accom- panying illustration (Fig. 137). It has been advised by some that patients should remain directly exposed to the rays of the sun as many hours as possible, regardless of the season. To this principle I am opposed, as it may happen that a porch, comfortable in the morning, becomes almost unbearable in the afternoon, and vice versa. My rule is to permit the patient to 638 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT remain in the direct rays of the sun only during such times as actual benefit is experienced, and to remove the invalid whenever chscomfort supervenes. It is not altogether the varying degrees of heat from the sun's rays that produce beneficial results. At different times there is demanded a judicious exposure to direct sunshine or protection from the intense heat according to the state of the patient and conditions of weather. I am not in sympathy with an application of the theory of outdoor sleeping at night regardless of other considerations. This practice, when advised with proper discrimination, is capable of producing ^^">^. inestimable benefit in the way of an iniproxed appetite and (.ligestion, with an increased feeling of bien lire, but its routine adoption is followed in some instances by harmful results. It must not be forgotten that the patient at all times must be kept perfectly comfortable, as well as being supplied with fresh air. In extremes of weather comfort can be secured only by lowering the canvas curtains, and closing all outside apertures to such an extent as to preclude proper ventilation. During severe cold, patients not only are more comfortable in a bed-room with moderate heating facilities, but at the same time are afforded much better ventilation from one or two open windows, than is possible upon an outside porch \\ ith all curtains tightly closed. Further, it has been my REGULATION OF DII 639 experience, save during the summer, tliat some patients do poorlj^ wlien sleeping out-of-doors. An explanation is found in the varying degree of bronchial irritation coexisting with the tuberculous infection. In so far as the bronchial element predominates, by just so far is the cough made more distressing and the general condition thereby less favorable through exposure to the cold air at night. During the winter months the thei-;ii>cutic indication for cases of chronic bronchitis per se is not fresh air, Imi latlier protection from drafts and exposure. It appears The upper sleeping porcht consistent and wise to offer bronchitic patients suffering trom com- plicating tuberculous processes, the same judicious consideration. While in many cases there is no direct relation between the extent of the tuberculous change and the amount of bronchial irritation, the fact remains that severe bronchial disturbance reacts decidedly to the disadvantage of the invalid. This is especially exhibited in the fatigue incident to the cough, and in the I'eflex vomiting after the ingestion of food, which materially interferes with nutrition. CHAPTER XCIII REGULATION OF DIET The vast importance attaching to the diet of tuberculous invalids is demonstrated by the fact that nutrition is, to a very great extent, the measure of nature's constructive efforts toward an arrest of the disease. It is true that occasionally individuals develop tuberculosis 640 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT even when there is little if any loss of weight, and that others exhibit improvement despite a considerably impaired nutrition. For practical purposes, however, it ma}' be assumed that improvement in the general condition and in the state of the tuberculous process is fairly commen- surate with the gain in nuti'ition. Thus an increased weight within certain limits is to be regarded as a safe criterion of the tendency of the invalid toward restoration to health. The first great proposition, therefore, is to so improve digestion and assimilation as to permit a substantial increase of nutrition. Rad- ical chfferences of opinion exist, however, among phthisiotherapeutists as to the degree to which efforts should be made toward the promotion of body weight. It is, of course, apparent that the greatest success will result in individual instances from the attainment of such a standard of nutrition as corresponds most closely with health, and produces the greatest powers of resistance. It sometimes happens that the tone of the general health is not improved by excessive gain in weight, with the attendant disturbance of digestive capacity and cardiac function. The increased nutrition may be associated with impairment of metabolism and the development of functional changes characteristic of pathologic obesity. It is under such circumstances that tuberculous infection secures a foothold among the very corpulent. It is often impossible to state with accuracy just when a sufficient improvement of nutrition has taken place, as the progress of arrest ma,y become retarded as a result of indiscriminate "stuffing." While due caution should be exercised to avoid a predominating aim toward the accumulation of a disproportionate amount of fat, the comparative possibilities of producing such pathologic condition are few, and the dangers, save in exceptional instances, considerably exaggerated. Provision, therefore, for a generous and sustaining dietary becomes not only sane and rational, but indeed absolutely essential. No matter how rigid the regime in other respects, nor to what degree the strength of the invalid is conserved by judicious rest, nutrition must remain largely dependent upon the ingestion of food sufficient to supply the natural demands, and aid directly in the reparative process. Much obscurity still continues to inshroud the proper detailed application of important principles of diet for the tuberculous invalid. In the midst of the widely differing concUtions so frequently worthy of special con- sideration, even in early cases, and the ever-varving complications inci- dent to advanced stages, definite information is often lacking with refer- ence to the precise amount and character of food best adapted to the promotion of nutrition. Many conflicting notions have long been enter- tained relative to this vital consideration. It was not many years ago that consumptives were advised to imbibe generous, if not inordinate, quantities of whisky. The ingestion of an almost unlimited amount of food has been urged from time to time. By some the frequent use of lean meat has been strongly recommended and by others enjoined altogether. Conflicting ideas have been entertained as to the relative \alue of the variou:; vegetable products, leguminous articles being held in much repute by some and considered of slight utilitj', if not objectionable, by others. A high estimate is placed by a great many observers upon the value of raw eggs, milk, cream, and beef-juice; while nuts, vegetable juices, meat -powders, extracts, and similar preparations are vaunted by a few. REGULATION OF DIET 641 Until a comparatively recent period, emphatic insistence was made upon the necessity of an elaborate system of superalimentation. It followed that in the attempt to carry out the prmciples of excessive feeding, the physician frequently failed to take cognizance of import- ant modifying conditions inherent to individual cases. In numerous instances a highly injudicious stuffing process was inaugurated by physi- cians endowed with more energy and enthusiasm than with scientific instincts. Notwithstanding the existence of fever, digestive disturb- ances, and repugnance at the thought of eating, instructions were issued to pulmonary invalids to partake daily of a most extraordinary quantity of food, regardless of its capability as a producer of heat-units, or of its adaptability to the peculiar needs of special cases. Too frequently the quantity of the food, its selection as regards the nutritive value, and its appropriateness in the presence of functional disorders was left entirely to the tastes and inclinations of the patient. As opposed to the previous superficial practice of extreme engorge- ment, with its distinctly deleterious results, there is exhibited at pres- ent a tendency toward mathematic precision in conformity with a fixed standard of diet, representing, upon the whole, a somewhat imprac- ticable refinement of therapy. It is obvious that, through careful atten- tion to detail, the amount and character of the food may be so regulated that general dietary principles may be formulated, which are susceptible of modified individual application. It is clear, from a physiologic point of view, that the value of any general system of feeding to be accepted as an approximate standard of dietetics for pulmonary invalids must be dependent upon the relative caloric value of the various food-stuffs ingested. While nutrition varies directly according to the heat-producing properties of the assimilated or metabolized food, it must be borne in mind that the relative proportion of ingested fats, proteids, and carbohydrates per kilo of body weight bears no invariable relation to the nourishment of the individual. In other words, the caloric value of the food eaten by the patient is not always a, criterion of the caloric energy imparted, through the processes of digestion and assimilation. In view of the numerous functional and organic changes common to pulmonary invalids, it is apparent that the dietarj^ consideration of vital importance is not the definite quantity of the food, nor the relative proportion of the various inurcdicnts, but rather the completeness of its subsequent assimilatinu. ami the reduction of physiologic strain. Owing to the consideiuldc xaiiation of individual metabolism among consumptives and the degree of taxation imposed upon the powers of digestion and assimilation, the impracticability of an ideal standardized diet is appreciated. A definitely systematized diet, although theoretically ideal according to the principles of physiology, is utterly incapable of detailed practical application. The observations of Voit, Chittenden, Folen, Atwater, Goodbody, Bardswell, Chapman, and others have been of decided interest and value. It has been estimated by Voit that from 30 to 35 calories per kilo of body weight are required daily to maintain good health in a normal adult while at rest, and about 40 calories if more or less active, repre- senting in general 120 grams albumin, 50 grams of fat, and 500 grams of carbohydrates. These figures are more or less in accord with the statement of the late Sir Michael Foster, to the effect that the proportions 41 642 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT of food-Stuffs consumed by healthy man were as follows: 100 to 130 grams albumin, 40 to 80 grams of fats, and 450 to 550 grams carbo- hydrates. Chittenden, however, has taken issue with these figures, niaintaining that the amount of food ordinarily taken by a grown man in good health is materially less. The conclusions of Goodbody, Bardswell, and Chapman are to the effect that a diet properly adapted to a pulmonary invalid should contain 120 grams of albumin, 140 grams of fat, and 300 grams of carbohydrates. Burton Fanning has placed himself in accord with the above conclusions in indorsing the expediency of a substantial increase of fats and a corresponding diminution of carbohydrates for phthisical patients. In this country a numl)er of observers have insisted upon a slight increase of the albumin, with a great addition to the fats and a diminution of one-half of the carbo- hydrates. It is generally believed that the equivalent of about 2200 or 2.300 calories for a healthy man at rest, or of about 2700 or 2800 calories' w-hen at work, should be increased approximately to 3500 or 5000 calories for the pulmonary invalid, according to the state of digestion and the demonstrable effect of the diet upon body weight. It is known, however, that satisfactory results are sometimes attained among consumptives upon the daily ingestion of not over 25 calories per kilo of body weight, while failure to increase nutrition may result from the consumption of double this amount. Remarkable gains in weight ma}^ occasionally follow the ingestion of a phenomenal number of calories daily, sometimes approaching even 100 per kilo, but it is the opinion of Goodbody, Bardswell, and Chapman that such overfeeding, rather than increasing the powers of resistance, exerts a highly deleterious effect. The conclusions of Chittenden as to the evil consequences result- ing from an excessive consumption of alljumin have been ascribed by Fisher to obtain similarh" among pulmonary invalids. The latter observer a.ssumes, on the basis of "physiologic economy," that with proper selection of food, embodjdng a certain proportion of fat elements, 3000 calories a day is ample for the nourishment of the average con.sumptive, although this is admitted to be no more than the amount consumed by a healthy person. It is important to point out that although the principle of physiologic economy is sound for normal iiicli\'iilua.!s. it docs imt jnllou-. l)y any 'means, that the essential considd-atio,/ aiiicmii iiuliiiniia;\ iinaliils consi.sts of making the slightest possihiv ilruKimls \\\Mm tlic di-c-^tixe and eliminative apparatus, nor of giving the hast amount of food necessarn to maintain body weight. Under such circumstances the question properly resolves itself into a choice of the lesser of two evils. The decision must be made between a gratifying increase of nutrition, with corresponding enhancetnent of resisting power, even at the expense of a temporary tax upon physio- logic functions, or an economy of functional demands, with the unnec- essary sacrifice of a large portion of the means of defense against an insidi- ous and relentless di.sease. In the presence of a wasting affection, the obligation is assuredly imperative to promote the powers of resistance through prompt recourse to vigorous, though rational, superalimentation. In general it is essential that the patient should take daily all that it is possible to administer within the limits of digestion and assimilation. The word "administer" is used advisedly. It is not what the patient desires to satisfy the cravings of hunger, it is not what he is willing to REGULATION OF DIET 643 take or even what he feels pciMiiiallx- he is able to eat, but, after carejul inquiry as to the ditjc^tiri injiacihi. it is uU that the physician and nurse are able to persuade liini to mnest through their personal influence and direction. The system of superalimentation is subject to great variation, accord- ing to the individual, principles appropriate for one class being entirely inapplicable to another. The very greatest importance attaches to the enjoyment of a good appetite and digestion. Under these conditions it is quite unnecessary, for practical purposes, to institute any elaborate system pertainiu,'.: to the jtcljiistineiit of the diet;i,r>-. A aciierous mixed diet in .such casrs, without special fefei'elice to tjie ivLitix'i- Jiroportion of proteids, fal.^. ami raj'l.oh>-,lratr.s, is usually all sutlicieiit. It must not be assunieil. !io\m'\it, that lu tlu' piv^i'iur of a normal apjietite and anunimpaireil. ilu:e-ti\-e capa' ii\ . i In- aiuouin of food should be regulated entirely by the iuclHuitioiis oi the paiieui . The ])Owers of digestion are often greatly in excess of the inilii-iiliuns (ifiordiil hij the aiijietile. Therefore, under a properly direete' f;i>il\ diiicstible solid food as soon as practicable. Milk constitutes an iniiMutaut article of diet for pulmonary invalids, and is borne exceedingly well li> the majmity of patients. While admittedly productive of digestive (Icraii'^cinint- in a few exceptional cases, the vast majority of patients cmikiuu ;i disinclination to milk, are enabled, by means of firm but gentle persuasion, to overcome their natural repugnance. In intractable cases it may be peptonized or diluted with seltzer or other sparkling water. Prolonged adherence to the so-called "milk cure" is of extrenich' ddulitful utility. To supply the deficit in carbohydrates and protei. it i> dc-iial'li' tn aild cautiously to the dietary raw eggs, lieef-juice. soiii.iin-c, -. with an ultimate trial of lean meats and -luiiilcut M'm'talilrs. Swccis. starciios, and fats, together with fruit auil [la-ti-y, sliduld be deni(>d to patients with diar- rheal disturbances, or witii other evidence of gastro-intestinal indigestion. Also these should be interdicted, together with alcohol in any form, for THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 651 those with pronounced uric-acid diathesis, the nitrogenous foods usually being productive of less harmful results than the carbohydrates. The use of medicinal measures for the control or alleviation of digestive dis- turbances will be discussed in connection with the treatment of special symptoms. True progress in the art of medicine is not dependent alone upon the results of laboratory investigation, nor the acceptance of theories thus deduced, no matter how alluring or convincing. To the established facts of clinical experience there should be accorded an equal right for recognition in the endeavor to judge sanely regarding the proper diet for consumptives amid the present diversified state of opinion. From the light afforded by careful observation, it is clear that the adoption of a standard diet applicable to pulmonary invalids in general is eminently impracticable and unscientific. CHAPTER XCIV THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR Throughout the preceding pages devoted to general considerations of treatment, an effort has been made to emphasize the great importance of attention to detail, rest, outdoor living, and superalimentation as the fundamental principles of management. It is self-evident that the complete application of these cardinal features is utterly impossible without the maintenance of strict disciplinary control. In fact, the es.sential prerequisite for the successful development of any elaborated system of management is found in the rigid enforcement of a suitable regime, for which unusual facilities are afforded in special institutions for consumptives. Inspired by the excellent results attained through the influence of continuous autocratic supervision, phthisiotherapeutists have been in- strumental in establishing numerous sanatoria in various parts of the world. Regardless of climate, location, or immediate environment, the primary function of these institutions was thought by some to relate principally to the means thus secured for insistence upon disciplinary control. This was made much easier in sanatoria, partly as a result of important details of construction. In properly located, thoroughly equipped, and well-conducted institutions, rest in the open air, at all hours of the day and in nearly all states of weather, is permitted upon specially constructed verandas, solaria, and sleeping porches. In view of the opportunities thus afforded for the inauguration of a suitable method of living, the idea has become somewhat prevalent that a perfected system of regimen obtains ojily within closed sanatoria. It is not true, however, that the methods in vogue in such closed resorts for consumptives are essentially different from those frequently em- ployed among a similar class of invalids outside of institution walls. The term "sanatorium regime" should be understood to apply merely to the maintenance of a proper method of living within an institution 652 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT designed for this special purpose, rather than to define a radically distinctive method of management. Although it is much easier to exact implicit obedience within sanatoria so constructed and equipped as to furnish exceptional opportunities for systematic management, yet by dint of earnest effort on the part of a resourceful medical attendant, an equally rational supervision can be successfully instituted elsewhere. No reflection is intended upon the great practical utility of closed sanatoria, but issue is taken with the assumption of their invariable necessity in order to secure the fulfilment of a satisfactory regime. It is also insisted that the ample recognition accorded to such institutions, with reference to their large field of usefulness, does not justify a belief in the practical appropriateness of sanatorium life for all cases of con- sumption. Unfortunately, the doctrine of sanatorium control, which has been advocated so zealously during the past decade, has been literally accepted by many as the exclusive means of securing satisfactory results. In order to minimize the evils resulting from extravagant and erro- neous ideas entertained concerning the role of the closed institution for consumptives, it is important that the supporters of the sanatorium movement should assume an eminently conservative position. It seems fitting to institute an inquiry as to the precise scope of the sanatorium treatment of consumption, without bias, prejuclice, or preconceived ideas, save those founded upon the substantial facts of experience. It is not desired in the merest way to detract from the honor and glory of the early pioneers who devoted their lives to a cause so worthy, and who are destined to leave a lasting monument to their ability and per- sonal sacrifice. The movement for the treatment of tuberculosis in closed institutions originated with Bodington. of Warwickshire, Eng- land, in 1839. The theories advanced were subjected to extreme ridi- cule, and the promoter doomed to much personal disappointment and humiliation. His ideas were subsequently championed by Herman Breh- mer, of Germany, who, despite much bitter oppo.sition and contumely, succeeded in establishing a sanatorium for consumptives at Goerbers- dorf , in the Silician mountains. Following the demonstrated soundness of Brehmer's views, and stimulated by his example, several prominent physicians were encouraged to adopt similar methods. Notable among the early followers were Dettweiler and ^^'alther, Sir Herman Weber, and Trudeau. In recent years the sanatorium idea has taken deeper root than ever in the professional and public minds, until the outgrowth has assumed such proportions as to endanger its practical efficiency and benevolence. Though inspired by no spirit of iconoclastic criticism, it is believed that the time is opportune for a presentation of some negative phases of the sanatorium proposition. With no derogation of the noble work per- formed by the advocates of this method, the plea is presented that, fol- lowing their example in its essentials, and profiting by their experience, equally good results may be accomplished without the aid of special institutions. In this connection an appreciative acknowledgment should be made of the peculiarly beneficent mission of the sanatorium from the standpoint of public prophylaxis. Attention has already been called to its humanitarian scope and economic value, as well as to the pronounced educational influence, which reflects one of its chief advantages. In appreciation of the great usefulness of sanatorium management for certain carefully selected THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 653 cases, it is designed to discuss merely its medical scope for non-indigent, non-hopeless consumptives, regardless of climatic location. Paradoxic as it may appear, the propositions are advanced that residence within a closed sanatorium offers to a class of cases the best possible conditions to be obtained, and that summary recourse to complete institutional regime is distinctly prejudicial to the best interests of others. These differences pertain to such determining individual factors as the financial status, temperamental peculiarities, and domestic conditions. Other considerations which may justly obtain in certain instances are the possible accommodations to be secured other than institutional, and the character of medical counsel to be obtained either within or without the sanatorium. The sole claim of sanatorium advocates relates to the degree of success possible of attainment in establishing and maintaining a per- fected system of disciplinary regime. An unceasing medical super- vision is sometimes necessary for the well-being of certain cases, while an equal amount of surveillance is distinctly detrimental to the best interests of others. A particular regard for the minutest detail, either within or without an institution, is dependent almost entirely upon the solicitous attention of the physician. It is almost purely a question of personal equation, and demands, in addition to a masterful familiarity with tuberculosis, a certain aptitude for the peculiar require- ments of the position, a devotion to the work for its own sake, an interested regard for the slightest welfare of the patient, broad sym- pathy, infinite tact, intuitive perception, and unyielding firmness. These qualities may be utilized for the benefit of the consumptive with- out a closed institution, which in most instances is a valuable adjuvant rather than a sine qua non. It is the man, not tlio institution, influencing the degree of cooperation and hearty goo(l-lcllii\\>liiii between physician and clientele, which alone can insure a proju-r iliM'iiiliuary control. By as much as it is not the sanatorium alone, but also the attending physician determining the influence for good, by the same token must it be remem- bered that it is not the disease to be considered solely, but the invalid as well. This presupposes the consideration of other factors than purely medical or sociologic features. For the consumptive the question of success or failure frequently depends upon the aljility to adapt oneself to unusual conditions, and in this quality the invalid is often found deficient. The wisdom of an intelligent modification or adjustment of the immediate environment to satisfy peculiar individual require- ments is readily apparent. There surely is not implied an invariable necessity of confinement within sanatorium walls, although this is admit- tedly desirable for many cases otherwise difficult of management. In addition to intractable ca.ses, patients for whom sanatoria are particu- larly appropriate are those with such limited finances as to preclude the acquirement of satisfying conditions without the benevolent aid of partially endowed sanatoria. The founding of modest institutions of this character, inoxiilin^ excellent accommodations to worthy consump- tives at a mini III II III nj i xjn /i.sf, without ostentatious display or sole regard for beauty of architectural design, represents the most substantial form of true charity and practical philanthropy. It has been asserted that the special advantages sometimes accruing from a properly conducted sanatorium are not altogether inherent to the institution itself. The erection of imposing structures and the laying 654 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT out of beautiful grounds sometimes represent in themselves onlj- the taste and ambitions of the founders, rather than the practical needs of the inmates. Ample porch accommodations, with wise provision for private balconies, rooms with sunnj- exposure, proper facilities for heat- ing and ventilation, and finally a generous tempting cuisine, of vast importance though they be, are none the less to be secured in many instances outsideof closed sanatoria. The attainment of suitable sur- roundings and conditions is frequently most difficult, and imposes a seri- ous tax upon the time, energy, and perseverance of the medical atten- dant; yet in most communities this may be accomplished through the personal attention of physicians willing to recognize their obligations with reference to such details. Experience has taught that the mecUcal adviser, if he so elects, may devote sufficient supervisory attention to his patient outside an institution, and through the exercise of painstaking effort may inaugu- rate proper methods of living somewhat along the same lines as in well-regulated sanatoria. The same well-recognized principles may be enforced upon a smaller scale, and freciuently more to the actual advantage of the pulmonary invalid. If detailed autocratic super- vision, which in many cases is admittedly indispensable for the accom- plishment of the best results, was the only essential factor involved in a question relating to the lives of unfortunates, the decision would be invariably made in favor of the closed sanatorium upon some remote hilltop. The fact remains, however, that to the consumptive there .should be accorded a consistent regard for certain other fundamental considerations. In spite of his bodily infirmities he remains a human being, possessing essential peculiarities of temperament and disposi- tion of no small significance. The factors inherent to the individual are sometimes of more transcendent importance than the tuberculous infection. A problem of this character cannot always be adjusted prop- erly by a summary recourse to its medical and sociologic aspects. While life in a closed sanatorium is perhaps more strictly in accordance with the principles of modern phthisiotherapeutic thought, nevertheless, in its every-day application to special cases, its non-adaptability is not infrequently apparent. It may be questioned if the uniformly good results which have been reported, demonstrating the value of sanatorium treatment, are depen- dent entirely upon the institution. It is fair to assume that a consider- ation of vast importance relates to the incipient character of the cases admitted for. treatment. Rejection of invalids with advanced infection is in accordance with the avowed jnui^ose of nearly all sanatorium authorities, who have reported statistical observations. It is, of course, natural that, as a rule, sanatoria sluiuld pxtcud a welcome only to such cases as offer an eminently faMnal'lf ]iiii^iiosis. At some popular in.stitutions it is stated that patient- an- adiiiittedfromthelistoftho.se who have passed the necessary examination, not in the order in which they have applied, but according to their physical condition, the most favorable ca.ses being admitted first. A review of the annual medical re- ports emanating from several of the sanatoria in this country has recently shown that the condition is described as favorable in an exceedingly large proportion of the patients. Digestion was unimpaired in the majority of cases upon admission, the average maximum temperature being over 100° F. in a very few instances. Many are reported to be THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 655 without tubercle bacilli upon arrival. Nearly all cases were practically devoid of important complications. In some of the cases aclmitted to sanatoria the condition is of so doubtful a character that the patients are kept under observation in order to arrive at a definite diagnosis, yet institutions both at home and abroad are accepting but a small propor- tion of the consumptives applying for admission. It is difficult to understand how in(li\'iduals with incipiont infpftion, without temperature elevation. ili^c.-ti\c iniiKUi-mrnt . mnilici' (•(unplica- tions, and frecpiently without IniriHi. cuii r('(|uiiT upcm liic miTit - cii their condition that degree of medical attciitidii nccc-j-itai mi: icMdi'iicc within a closed sanatorium. As regarrls thd c institution . h.i i lioiiut^- a mis- cellaneous aggregation of con.sumi)ti\('-. it wmild ;i|ii>i';ir that the social conditions could not be such as to promote the happiue.s.s and content- ment of invalids. Aside from these considerations, which surely are more substantial than sentimental, may be mentioned the value of the psychic element to Fig. 141. — Summer residence used annually for a group of .selected patients. be observed from occasional judicious change of residence and immediate surroundings. This potent influence for good is not obtainable under the fullest interpretation of the so-called institutional ri'gime. As the result of some clinical study in an effort to recognize essential facts, to apply established principles, and to effect a mutual interada]itation of indi- viduals to special conditions, <-ert:iiii (•oncliision-- lia\e tivadually assumed shape. The conviction has thus Ijceii loiced thai for ni:iii\' cax's the idea of a home and genuine hv.me life is the iile.il >piiit to be lusieicd. t(JL;etlier with a judicious amount ,.f medicil i out rol. If close dail\' snpeiv i~ioii of early ca.sesisnot invari;d>l\- del nam led. the medical uchisei' may e\e rci.se sufficient personal dire/tiou over his patients, if he su elects, in private abodes, promoting in many cases the happiness and social \\elfare of the invalids. The careful selection of a residence meeting all known requirements as regards location, sunshine, porch room, and outdoor accommodations, the wisest grouping of a chosen few with 656 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT reference to coiigenialit}-, temperamental peculiarities, tastes, stage of the disease, and financial ability, the presence of a competent housekeeper and nurse, and finally the directing influence of a non-resident medical attendant, must afford a combination sufficient to produce satisfying results. In Fig. 141 is shown a summer residence peculiarly adapted to the needs of a few patients. The house, octagonal in shape, is entirely surrounded by a screened porch, which is divided into sections by inter- vening wire screening and adjustable awnings. The medical control should not be permitted to predominate offen- sively, but should continue as a non-intrusive factor in the con.stant physical guidance of the temporary household. It seems unnecessary to more than mention the improved psychic effect of such an environment, which exercises a potent influence upon many pulmonary invalids. In this manner much of the ennui and nostalgia, with resulting general depression, so frequently observed in institutions, may be effectually obviated. On the other hand, to tho.se previously unaccustomed to separation from home, sanatorium sojourn is often utterly beyond their powers of individual adaptation. In pursuance of the foregoing ideas it has been my custom for many years to provide suitable accommo- dations for my patients in residences appropriate for varying clas.ses. These abodes are selected either on the outskirts of Denver or in the mountains of Colorado, according to the season. This grouping of patients, particularly during the warmer weather, in the midst of new surroundings, has been found, as a rule, especially advantageous. As a result of the constant attendance of an efficient nurse, a suitable regime is maintained somewhat along the lines of a cottage sanatorium. Some THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 657 idea as to the jn'ivatc ;kt afforded l>\- rclcrcncr id llic :MTiiin|i;ui seekin.i; cliiiKilic ud\a.ni:i:ic,- away IV exceptioiudl\- inii'a.iiaM" ra c . Am autocratic coiiti-o| i> iu-cnil\- iiidica.i iv-ula,tc(l saiiaJoila, l.nii- I.. mid ,-ul.s, liciicccomliiciw lo lic.l rcsulls. Tlic ncccs-il V of .•aivlul mdi vi.lualiza- tiou IS thus apparent, I lie most suitalilcciiviroiiiiu.nl lor. .lie I ,ciii- (lUlte inappropriate for another. Apropos of the foregoing considerations, it is of interest to compare the ad\antages of the sanatorium with certain objectionable features patients of tliis class nuiv he pilot om-apli.. eiide.l t,. apply to invalids ..line. Iiut ,lo,.,- 11, ,t n.l,T to Ultients of liie lalter class, ic n.utiiu. dccipliiie ■ 1 - ex|ii'i'jeiiced HI maii\- m- t.iiii'e- 111 -eciiriiiu an sphere of complete i-eposi'. In a.ddllion. tlie coiitmiious piCM factors ari.se liy \'irtue of the I'oiiliici im; opimoie- -omet imes euiei bvapuront,liii^l>a,nd.or\vif|. n.-ardiim ( lie appropri.a.teiie" .if the i and bvtlie lack of insi-teiice up., II i-.n,, unmix lo piVMril.e.i m-tru The phy.-i.'i-m e^ lik.'lv t., l.e :,.nouslv liaJi.li.'app.'.l 1 . v lli.' -iuKIm and perver-ity ol a.c.'.mipau viu- relat i\-.'s. wli.ise temper.'Uiii'iil al arities ami di' p..- it i..ii m;i\' di'm.aji.l the (li-;pla\- of nioiv l.-u'l. .lis,' and finiiii..-- than tli.^ .■.mtr.il .,f tlu^ p.ali.^iit. I'liw a.iTa.ul e.l p condoleii.'c. .,r m.luluen.'e i- ic^ponMl.le 111 many iiiHa,m-cs for retardation of recovery. Provided relatives evince a cheerful ance of the instructions detailed by the physician, it frequently accept- follows 658 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT ■c*~^; ^*o., ^^^ %^ wmmmmm^^ ! -.iM.- i.iiu-c as preceding. THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 659 that, despite their cordial acquiescence, the patient is wont to refuse to near ones that implicit obedience which could otherwise be obtained. The influence of home life, e\en thrduuh no !ic,uli;;ciicc or ]ici'V(M-.sity of judgment on the part of the fuiiiily, is somctiino ii's]i(iiisililc for unfor- tunate laxity of discipline. In :uiilition to the occasioiia.l likelihood of physical or social indulLiciicc, tlic hours of rest in the open air are less apt to remain undistiirlicd. and the ingestion of food, upon the whole, less satisfactory. It is unnecessary to .state that the.se olijections do not invariably obtain, the efforts of the physician in some eases lieing vigorously reinforced by accompanying relatives. In lunleitakini!, the management of pulmonary invalids, particularly serious cases, in pri- vate houses, it is desirable to .secure the services of a forceful, quiet, and discreet nurse, through whose tact and firmness there may be secured implicit compliance with directions. Given an atmosphere of Fig. 146. — Mountain residence with .sleeping d soutliern exposu repose and contentment in a well-(iio>eii liousr, satislactiicc|ii kui of in -i ii iit lonal n'Liiii An important and sonicwiial nculccicd a-pe torium is the possil.U' role ot ,-iicli in-i ii m ion : research, but thi.s feature, whiih i- rc<'OLini/,cd a < be amplified to the fullest I'xtent onl\ in ihose by State aid. .\mple opportunii\' loi' oiiiiin.il la should obtain in san.'itoi'i.a conducted lor the liciicl tives. Upon the othi-l' li.Uid. ciuuc.-d oli.-MTWUl merit is permitted ont-ide of iiisutution- to jili^ proper equipment and ideals. An economic phase of the sanatorium mo\'ement is worthy of pass- ing mention. It appears, from a practical standpoint, that more bene- he closed sana- ers of scientific iMi-e \a.lue. may i\ iin-eMmalion Imcnt consump- i hn:li order of • possessing the 660 PKUPHVLAXIS, GENERAL AND SPECIFIC TREATMENT Fig. 148.— AiiotLer view of ^aIue house. Taking the cure in the nimintains. fioent results may be attained by the construction of a greater number of tuberculosi.s dispensaries, and by the more generous mamtenance of anti- THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 661 ;ui liy im sli avagaiit sums of i\ato sanatoria. The 111' o.stensible purpose of housing p Uk iit-- \\itli //( impairment wiici ii< iiiiou apparent Hit i ost (it -^ud licet Mill \VI lldllt CdllStitl tiiinal niiisUndhi ,i,t-oj-,l,,<,rs u ([uite sassurudlv nit ol all pro) (iition to the benevolent results. On the other hand, at a less expense, endur- ing benefits can be obtained through the establishment of modest dis- pensaries. Protest, therefore, should be made against the unreasonable 662 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT expenditure of public money for costly buildings, which, in many in- stances, are injudiciously located in damp, moist regions or in immediate proximity to large centers of population. It frequently happens that in proportion as the cost for construction is excessive, the funds for maintenance are insuffi neiit sanatoi::i, iu IJii^ that no practical a,il\:ii details of collet I'uct inn ( odations upon three sides. it. This is particularly true of several promi- d and America. It should be emphasized :rs III the consumptive accrue from elaborate illuous equipment. tage with sleeping porch. Despite ample facilities for the accommodation of tulierculous patients in England, the King's sanatorium near Midhurst has lieen recently completed at an approximate expen.se of $1,000,000. The THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 663 Fig. 154.— "Rock Rest.' outlay in many respects was not strictly demanded, yet no provision was made for the admission of cases which were not entirely charitable. The cost of the Beelitz Sanatorium near Berlin is even more prodigious. 664 PROPHYLAXIS, GENERAL AXD SPECIFIC TREATMENT Three million dollars have been expended for its construction, with pro- vision, however, for 600 beds. It is hardily necessary to present photo- graphs of the various sanatoria in thi^^ conntrv and abroad in order to illustrate the beauty of arcliitiMtui;il (k">ii:ii ami ilir general magnificence of construction. The niajcuii} nf reader.^ arc already quite familiar with the general featnresof American .-iauatoiia, the iin.).->t modern of which pos- .sess admiiii-traiidii (iffices in close proximity to the buildings devoted to the houMii- (11 patients. Private sleeping balconies communicating directly with aii inside chamber are provided almost invariably, while protection is afforded in extremes of weather from the summer heat and the winter storms. It is important that all rooms occupied by con- sumptives should be spacious, sunny, and well ventilated. These con- siderations are particularly important with respect to a common dining- room, ill \\lii(h the air during the winter sea.son is likely to become noticcaJil}^ I'liiil. I'cnlio -liduld be constructed in nearly all available phicc^. e~iie(iall\ 111 |ii(iteeteil coiTiers, in Order that shelter may be secured wlieii iieee~-ar\ Iniiii sun, wind, snow, and rain. Waiviiiu ,iii\ mint ion of climatic considerations, it is important that due a.tteiiii that -aliatiMia ■ and preferabh- The site for tlic I. II lie uiven to the matter of location. If the teaching ihe eliicacv of fresh air is correct, it is essential that ■■nr>\ lor tlic cxcliiMve ai.l "t" r.inMunptivcs sl„,„ld be ) render tlie ureale-t |Mi~-ihle liellelil. It i- nn|>ortant i.Mlld l.c located apart Inmi .Icn-ely populated .listricts, 11 mountainous regions, rather than upon the lowlands, nstittition should not be selected upon the extreme crest THE SCOPE OF THE SANATORIUM AS A THERAPEUTIC FACTOR 665 of an ele\atecl ies:ion on k i cmnt ot tin (iinicccss:i,i-\- cxixi-urc to severe winds Foi the same lei <>ii it lix itum iipmi tin- uiipinicitccl ])l;iins, paitKuliih in the hij;h( i illiludc is |i(MMili;ul\' inuppi-opriatc. no natui il shdtfi l.iin-, illoidi dtKiin xlu \w:i\ (.fthcMiu dm iii.n the suniiner months iiid liuiii tli( liiii iiiiMis wind (iccusidinilly |ii'i'\a.iliii;i a,l (itlier seasons ( ( it uu ([i- id\ int u( -- iKo u riuc frmn ]ihicini; the Imildings in deep \ ille\ s on k ( ount ot tht lessei hours of sunshine and the greater tendencj to dampness with infeuoi diainage. An ideal site for a sana- torium 01 in f^f t foi all buildings especially designed for pulmonary invalids should he upon the southern slope of a hill or near the base of a model iteh huh mountain In oidei to afford shelter from the prevailing winds th( biiildinj;s should be located, according to regional weather Fig. 156. — Six-room cottage, somewhat primitive, but quite comfortable room. conditions, cither to the east or west of a spur -extending southward. It is still ijioi'e a,dvantaffeous if the mountain rises to a considcral>le distance in the tar l.a(d<,m-,Miiid, even to a, lic.i.^hl of M.veral hundred feet, as shown in the aceoin|ia.n\iiii: illn-lralion n\ a, pri\ate re-i(l<>nce (Fig. 157). The soil dioiild I.e ,iry. poroi,-, a.nd ~andy . all hmmh a rorkv for- mation is not nndeHiaJ'le. I »ii aecoinit of tJie necessity of irrigation in dry climate . no elaKoi ale aiieinpi hoiild lie made to beautify the grounds by hiMUL; oui expan-JNc lawns, or by disposing flower-gardens in the immediate \irinit\ of the s.^natoiiuMi. a.lthoudi such (unaiiien- tation greatlv adds to the o;itw-a,rd att ract ixiaiess of the institution. Undoubted benefit arenies to the pulinonuiv in\alid from a pleasing landscape. Attracti\-e \-iews, combining lantl and sli>tiMe loi^n- of .■linical i>\|ieneii.-e. a - 'what bitter iconoclasm has lieeu exliilnted in late ye.ais ((luceiinni; the beneficial influence of climate. There has I'sen an-en a tendem y to renounce completely its value as a therapentir ia( toi. the oppdnents offering the contention that an open-air exisiem-e, icuaidless dt essen- tial meteorologic conditions, represents the sole important desideratum. An inquiry in.stituted for the purpose of determining what foundation, 66S PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT if any, exists Ici the iiiciilcatuin disucli helief. discloses an utter disregard for scientific pniM ipli- ^r i-iaMi-lKMl cluneal facts. The position of climate as a tactnr ni cxccrdiu;: \ aliio ill ihi' treatment of consumption can never be assailed by thr hkic (■x|iic.-si..ii uf opinion. No dictum is worthy of general acce]itaiirc n iii-|iircd \- adduced in Mibstantiation of such an influence, it almost appears that the liuiilen > i pnidf rests with any who may have indulged in more or le-s \ imIcih icpudiation. Thei-e are Init tim uriiinmids wnrtliy ci| ci.n.M.leialion, to be advanced by the ojijiofii Ills ni climate: liist, the kimwledne that Some cases of tuberciilnsis ultimately lecnNcr in any liic(ilit;i. as the result of a proper outdoor regime; secondly, that simie fail to secure good results although subjected to a prondunced change of cfimatic conditions. The first propo.silinii relates to the occasional arrest of a disease formerly suppnsed in \ naiinail\ In I je ex| lected from the recognition of such beneficent possil.iilitie< fur eailx ca.-es. ilinmgh the injhteiicc of a properly conducted method of livi)iy. (.'iMi.-umptinn, Imwexei-. irrespecti\t' nf climate, maj' become arrested in smne instances, ihsjiitt inili'i'iu nir .surroundings, undue exposure, ins.ifilrii nl fmiil ists of the personal supervision oi' !iv-ir!nc deiaiU, i he impon aiicr of which is not open to dispute. The oxerw helniiuLi e\ idiMice ihai con.~iuni)tion is sometimes arrested in un-mtalile reuions i~ far from predicating the assumption that climate is of no value for the enormous remaining number of pulmonary invalids. As well might it be inferred that because some patients recover from various diseases without medication, judicious recourse to drugs is in all instances of nn avail. Carefulh' directed mental suggestion has been found of therapeutic efficacy among a class of nervous invalids, but the recognition of this scientific principle affords no jiistiHcation for the de\elo]iment of a system of religious belief ,-uitaMe for i he cure of l.oilily ills. In other words, the recognition of the po~MMc henefii accruint; to individuals having complaints does not waiiaiit ihc :i"iiiiiplion that this cult is applicable to f/lVase. The analoL;\ -ui;ui-icd heiween apjiarent supernatural healing and the utter repudiation of clim.iiic intluenco for consiiinpti\-es is more real than imaginary, the principle iuxdked in either instance being the acceptance of a demonstrable trutli, but an utter misinterpretation of its signifi- CLIMATE IN THE TREATMENT OF PULMONARY TUBERCULOSIS 669 cance and applicability. The fact that imaliils (icca^^idiially recover from incipient tuberculofsis wiilmiit i-limalic cliaii.iic, is no mure to be considered as an argument against the wisdum of its intelligent applica- tion in individual cases, than is the recovery without operation of a given patient with appendicitis to be considered a reflection upon the general expeiliencv of surgical interference. The smind r'„vs„l< r- \-ictims of tub-i'ciijosi-. in lieallli ivsoits no inquire as to the und.'i'iymg causes of I he ilj-li-e— obsei'N'ed in I'limates popularly believetl to possess some (hreci inlhieiice upon pulmonary invalids. The fact is at once de\ilo|ie<| ihai ihere aic sent annually to health resorts a consitlerable numliei' ol phihi-ical patients, wdio should have been jiermitted to end ihei:' da\ s al home. It i> also afipar- ent to the experienced ol)sei\ cr, thai Iml lillle judgment is displayed in many instances in the silrdion of entl\, the ut mo-i dis- crimination and acumen must be exhibited in each ca-r in determining the cardinal prin.aples upon which t he ch.iice ol' chmai e Mionld lie l.ased. There is no mu-I,. chmate applical .I.' lo all ca-c- ,,| coi,Mim| ,t ion. The peculiarities of teni|.eranient . the e\(a'-\ ar\ mg coml , mat ions of physical signs, the ass.iciated di,-t urbaiice of (Mrculatioii, digestion, and elimination, and the financial status furni.^h a combination that must be adjudgeil /// nlnhon lo tin !.:n,>in, /ili ,/si,ili„/ir , iJVrl of lli, nirious cUinat'rs oikI Ihr llu ni p, iitir orlooi lo h, (hsnril. i ii 'main' caMS failure to attain the best results from climatic change is uiidoiibte'illy occasioned by lack of familiarity with the pred.iininating at spheric attributes in ditferent localities, and their ]il]\sio|ogic effect upon an organism modilied b\- diM'.a.^e and b\- |ire\iou> eiiMroument. Although the iiii>iiilaliility of a part iiailar climate is often a potent cause for ultimate disaster, this leature prr s, does not fully explain the deplorable results loived upon the ol .ser\ation of ph\siciaiis m health resorts. It should be borne in mind that, in a wist majority of iiist .-nices, failure takes place not because of climatic change, but /(/ s/oir of it, the essential factor in determining the limil issue being the complete non-conformity to hygienic principles of li\ing. An astonishingly laroc number of pati.'aits aiv led to a\ail fhemsehcs of the siip|io,sed advaiitag.'S of an injudiciously sel.vted clim.ate, without the sloihtcst (ippnroihon of Ihr nohirr atn'l r.rlnil of lloir p, rsouol ,> s poii^ohil liics. Some arc entindy iiniiist riicli'd or, al best, are without that degree of medical super\ ision which insures compliance with directions. Others, as the result of irrational ad\ice, are impelled to indulge in various excesses suliicieiit to desiro\- e\-eii .a renioli' possibiht}" of recovery. A very coii,,ider:ible mimlier of innor.ant. fri\-o|ous. and impatient Consumpti\-es Hoat like \-erit,aMc llot-,-im and jets.am iipmt Ihrir oum initiatiir, drifting aimles-l\ from one resort to aiiothei-. Such patients are, as a rule, but slightly aineiial)le to jiidiiaous goxcrning inlhiences, and come uniler medical obseixation onl\- at times of acaite manifesta- tions. In former years climatic change was often advised regardless of the 670 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT constitutional condition of the patient, or of the extent and activity of the disease. Localities possessing radically different climatic con- ditions were indiscriminately recommended to phthisical patients. Invahds chancing to consult a number of physicians before directing their steps toward a distant clime, might have been ordered, according to the choice of their advisers, to such widely differing regions as Colorado and the Bermudas, Florida and the Adirondacks, New Mexico and portions of North and South Carolina, California and Arizona. It is obvious that, if the climatic conditions peculiar to one of these localities are adapted to special individual needs, some of the other regions must be less favorable in their influence, if not distinctly preju- dicial. The errors of judgment, which ha\-e been displayed in the selection of climate, have served onlj' to acccentuate the unfortunate results of deferred diagnosis. Temporizing delay on the part of the jjhysician after the nature of the condition has become estabhshed is explanatory, in large measure, of the indifferent success attained after removal to favorable climates. It is also resjjonsible to a considerable extent for the reflections unjusth' cast upon the utility of climatic change. Ill-considered advice with reference to the policy of therapeutic management many times has been imparted by medical attendants, at home and in health resorts. Until recent years it has been no uncom- mon experience in favorable climates to observe patients who ha\e been admonished to avoid doctors, to climla mountains, to ride horseback, and to drink whisky. Some physicians, in sending their patients away from home, have seen fit to issue instructions as to the entire future conduct of the patient. Many invalids have been told to beware of medical advice, or at most to secure an opinion as to results obtained only upon the lapse of several months after arrival. JIany of these, as a direct result of the injudicious counsel of their home advisers with reference to exercise, work, or manner of living, are compelled to seek medical aid much sooner than anticipated. The reputation of climate has alsii bopii maile tn siiffpv for numerous errors of professional judg- ment ciiiiiiiiitrc^l li\' ic-i^lciit !'!i\ -iciaiis. It is idle to comment upon the itiiii'iaiit, iinii-ct hical till, III -'Miici lines assuming to exercise juris- dictiiui "\cr the |ihysical destinies ut tlie consumptive in health resorts. It is api'aiiMiT that medical counsel received from these sources has too often licrii 'Itlivcied without the incumbrance of knowledge or the handicap uf conscience. In but comparatively recent years, has the necessity of rational living been insisted upon by medical ob-servers. In any discussion bearing upon the relative merits of climatotherapy and the so-called home treatment, due cognizance should be taken of the fact, that the doctrine of hygienic living was early emphasized l)y meilical workers in favnralijp climates. Largely through their efforts the profession has l)cfii Uiu-hr the importanceof rational living, and advised concerning the rule 111 rliiiiatc as a valuable adjuvant to other measures of thera- peutic nuuia.iicmcnt. During the past decade an unceasing endeavor has been made by observers in healthful localities, to inculcate among general practitioners a degree of familiarity with the practical side of climatotherapy. Numerous appeals have been made for the exercise of a wise discrimination concerning the character of invalids permitted to journey to a distant land. CLIMATE IN THE TREATMENT OF PULMONARY TUBERCULOSIS 671 The non-recognition, in former years, of the importance attaching to hygienic details, is being replaced by a tendency to exalt the value of a suitable regime far above the influence of climate. An unfortunate phase of American life is the tentlency to go to extremes. Once awakened to the importance of strict hygienic methods, the medical profession has been prone to accejjt this feature as the chief therapeutic indication. No greater menace to the welfare of the consumptive now exists than the further development of the delusion regarding the futility of climatic change. It is not surprising, h()w(>vor. in view of the incon- testable merits of pro; )ril\- rrmiUitcd iiii'tlinils oi' IJMiig in any locality, and the many causes Uh- lailuic in liculili icsciits. thut an inclination is displayed to regard fresh air. witliDUt reference to modifying conditions, as the sole atmospheric desideratum. The fallacy of such reasoning is apparent upon consideration o( the affirmative aspects of climatic influence. Affirmative Evidence. — The evitlence upon which there may be returned a final verdict as to the l)eneficent role of climate is found: (1) In the known physiologic effect ])roduced by various climatic attri- butes, either separate! \- nr jciimly: ('_'' in tlic unimpeachable testimony presented as a result ol ini]KU tiul clinical (il>M'i\a,tion. Preliminanj to any re\ic\\ nl' ihc dmionst i-able influence of atmos- pheric conditions upon the luima.n oi-aiiisin, it is well to define what is meant by climate, and to cnuincratc its essential factors. Reference to the views entertained li>- luiniciuus nicicdiDlogists suggests the follow- ing definition of climate, /, c the cliara,cteii,-t ic \ve,a,tlier t inlluencc of the stun of utnio.s- pheric con.litions upon the vitality, comfort, and nitellectual - of nations to adapt themselves to weather con- ditions, markedly dissimilar to those to which they have been accus- tomed. The combined atmospheric phenomena commonly described as weather, bear reference chiefly to variations of heat and cold, moisture and dryness, the direction and velocity of the wiiui. atin(is]jlieiic pres- sure, and the amount of sunshine. These attribute- di ilmiate, which are of especial importance to students of phthisiotliciapy and clima- tologj^ are the result of such causative factors as latitude and altitude, the character of the soil, rainfall, extent of frost, and the distribution of air-currents. From the standpoint of the physician, it is unnecessary to dwell even briefly upon the uii(lcil>iiiti influences responsible for the creation of the various atnKJ-niiciir ((nulitions. Interest centers more particularly upon the .several tnustitucnt attrilnites of climate, and their effect upon ]ih\-i(iloL;ii- fumtioiis of the liody. Such inquiry is more pertinent to tlr- |imi )n- luiiclanicntal agencies involved in the production of climate. Among the climatic attributes capable of exerting a profound influ- ence upon the animal organism, a place of some importance by popular accord has been assigned to the chemic and bactcriologic 'purity of the air. Insistence upon chemic purity of the atmosphere as a sine qua non for the health of individuals, presupposes the idea that the actual com- position of the air i< siibjcit ic cniisidcralile variation in different loca- tions. This notion as in (liiicicii' r- in the relative amount of oxj'gen, nitrogen, carbonic acid and mluT ingredients has been found to be erroneous, save in rclatKni tn nnijnnil .-./) sion of gases is preveiitiil and ilic iiiHucn By virtue of the latter aucUMc- tin' c/n mi, is subject to almost Inti pi^ ■n-, ,ti'ict- till' air i- "ll-ii |i(.lliitc(i I .\- , In sucli LiralHic- a i.nl:nl la,rl,,r iin- all emailatiiiii dl' -iniil..i' iVdin larui' rhiniiii althou-ll piVM-|!l I(,a, l(--r\lcll1 ill tlu-l may iminvmiaic the air m tiic (-(111111 1>- as well as (iT the city. While the deleteridiis crirri di clicinic ai iiidsiiliciic impurities in ill-ventilated apartment-, ami nf ilust contamination or bacteriolo.cic pollution in densely iHipulaied districts is too apparent for further comment, the elementary ((imposition of the air is devoid of practical significance with reference to a consideration of climate. PHYSIOLOGIC CONSIDERATIONS The utmost interest attaches to a conception of the manner in which the system is affected by the various combinations of atmos- pheric conditions. In reviewing the physiologic action of the several climatic attributes upon the organism, brief mention will be made of the more important conclusions, which have been recorded as the result of much systematic study by scientific investigators. No deductions will be presented which have not stood the apparent test of patient research and pitiless criticism. ,lu-r<. th AimI is a n.^ it ion d e complete diffu- .Itdgetlier absent. i the atmosjiliere This li as been demon- , uiKinil le !U I'^ili articl(v- 1 ic r elated iilains, I'dihddd of popu- .1 nidiianic dust. amiiiation is the V.aeterK il.-liar-cl ilduic impurities, ly settle(_l regions. CLIMATE IN THE TREATMENT OF PULMONARY TUBERCULOSIS 673 It may be stated as a preliminary postulate that the chief beneficent action of climate consists of a profound influence upon tissue change, which transcends in importance any primary effect upon the diseased organs of respiration. The potentialities of climate relate not so much to the existence of an atmosphere supposed to be enaowiMl, on uccount of its freshness and purity, with peculiar virtues for the puipotic.'i of inspiration, but rather to its presence as a surrounding medium, possessing qualities capable of exerting a decided influence upon metabolism. Through the instrumentality of a continuous but irregular air-bath a reaction is often established sufficient to modify functional equilibrium. This influence upon the animal functions, which represents the response of the individual to climatic change, determines the measure of the result- ing effect upon nutrition, and hence is, in reality, the vital factor in the physiologic problem. Climate then should be studied with reference to changes induced in the stability of functional processes. According as the animal functions are stimulated or impaired, metabolism is influ- enced for the better or worse respectivel}^ An important factor in determining the character and extent of alteration of fimction is the demand for heat-production, which fluctu- ates proportionately with the amount of heat-abstraction. In turn the degree of heat-abstraction varies in accordance with essential differ- ences in climatic conditions. Hence a certain relation is establisheil between the heat-abstracting powers of a climate, and the attainment of maximum nutrition, the sequence of action being the effect of certain climatic attributes in abstracting the heat of the body, the consequent demand for greater production, the stimulation of the various physio- logic functions, with increased metabolism and improved nutrition. Evolutionary changes of such satisfying nature are, of course, contingent upon the ability of the individual to respond to the unusual demands for heat-production. The practical effect of climatic change varies widely according to the vigor of the oxicUzing process, this factor in a decision as to the availa- bility of certain climates being even of greater importance than the extent or character of the tuberculous infection. The personal equation thus becomes an important consideration in ascertaining the value of the physiologic change in different people exposed to the same climatic conditions. In general, the influence of climate upon nutrition is largely contingent upon the degree of its heat-abstracting capabilities, which feature is defined by Huggard, in his admirable treatise upon the physiology of climate, to be the one fundamental principle of clima- totherapy. In view of the fact that the possibilities of heat-abstraction in any climate are dependent upon temperature in connection with the modifying influence of humidity and wind movement, it is well to consider these factors in common. Despite extreme variation in the physical condition of the surround- ing air, the temperature of the body in health remains practically con- stant. The removal of heat from the organism is subject to great fluctuation Ijy virtue of diurnal, seasonal, and climatic changes, influenc- ing essentially the manner as well as the degree of its abstraction. It follows that a corresponding variation must exist at different times in the working efficiency of the heat-producing apparatus. The non-vary- ing temperature of the body is manifestly not the result alone of a fixed amount either of heat-production or of heat-dissipation, but rather 674 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT the balance obtained from a perjcctly adjusted relation of respoixse to demand. Through automatic control of the mechanism involved in heat-production, the supply is regulatetl precisely by the expenditure. Thus the processes of oxidation chiefly responsible for the development of animal heat are directly modified by external conditions affecting heat-abstraction. With increased removal of heat from the body, the peripheral contraction of blood-vessels is accompanied by hyperemia of internal organs, with greater consequent activity of the oxidizing processes engaged in heat-production. Conversely, with diminished loss of heat, liy reason of peculiar atmospheric conditions, a compensatory effort is made to favor its removal by an increased functional activity of the skin, with engorgement of the surface vessels and corresponding depletion of the circulation in the alidominal and other internal organs. With lessened heat-dissipation oxidation is retarded and functional activity diminished. If the removal of heat is facilitated, the stimu- lating effect upon digestion and a.ssimilation is pronounced in accordance with the general law of response and demand. Waiving for the time being the question of personal equation, it may be stated broatUj' that the increased expenditure of heat is followed by renewal of supply, which is attended by such functional activity as to entail promotion of metabolism and improvement of nutrition. In proportion to the degree of heat-dissipation there is also exerted within certain limits for different individuals, an influence upon the tone of the general muscular and nervous systems. Save in exceptional extremes, the stimulation or impairment of energy varies respectively with the increase or diminution of heat-dissipation. The removal of heat is not altogether commensurate with the tem- perature of the surrounding air. An important modifying influence is found in the amount of contained moisture. With respect to the degree of relative humidity, striking differences are recognized between the physical and sensible temperatures of an atmosphere, which involve corresponding variations in the extent of heat-dissipation. In moist regions common experience attests the raw. chilling effect of moderately cold weather and the relaxing, enervating influence of heat. Upon the other hand, in dry climates, the sensible appreciation of winter cold or summer heat is minimized to a perceptible degree. In cold dry weather the heat is removed chiefly by radiation, which is greatly reinforced by conduction, if the element of moisture is substituted for that of dryness. In warm dry regions the heat is dissipated by evaporation of the per- .spiration, and to some extent b}' radiation, both of which agencies are seriously retarded in their action by the presence of moisture in the air. Thus a humid atmosphere, on account of its relatively good conductive qualities, becomes unduly effective in the removal of heat in cold weather, and interferes with evaporation during the hot season, inten- sifying the uncomfortable effect of both extremes. The disadvantage of moisture is not confined to its above-mentioned unfavorable influence during excessive heat or cold. It is found, even in the presence of moderate temperatures, that the loss of heat by means of conduction is disproportionate to the actual needs of the organism. Under such conditions the heat-abstraction is often unrestricted by the protecting action of peripheral contraction, and proceeds benond the capac- ity of the heat-producing apparatus for immediate supply. The chilling effect is further accentuated by the wearing of apparel which, upon satu- CLIMATE IN THE TREATMENT OF PULMONARY TUBERCULOSIS 675 ration with moisture, possesses excellent powers of conduction. Cotton garments, which are good conductors of heat, even in the dry state, derive increased conductivity when moist. In the event that surface con- striction be sufficiently prompt to produce internal hyperemia and stimu- late the oxidizing processes to greater activity in the production of heat, the conduction becomes ineffective in reducing the surplus, while radi- ation and evaporation are inoperative by reason of the moisture. In addition to the resulting physical discomfort and sense of inertia, the functional activities are again impaired, oxidation diminished, and derangements of dige.stidii rcndcnMl pi'dhaJdc, tductlici- with rcdnclion of nutrition. Huggurd has called ul tcnl imi xcvy clcail\ In the mi|i\ \f\cv i^icatl)- eniplia- sizes the e\])e(licqi( y lit , ucli a mOve. No Ul'eatel- fdlly call lie exliiljited than the jiract ice 111 wailing for the fever to suliside. uiira.bl<' reuioiis will prdiliice an increase of the temperature elevalion. An iin]iiiita.nt factor in the reduction of fever is the niaiiitenaiice of complete rest iii the open air duriiii; as many hours as pos.ible. Ihe elabor.-ition of >iich ;i s\steni of living must be more complete in localities peinutt iiiii the inaxinuini amount of sunshine. It follows that the es.cniial consideration in such cases is the avoidance of any unnecessary dekiy in the selection of climate in accordance with the manifold plia. cs of the case. Excessive bronchial irritation also is regarded l>y some as a con- traindication for sojourn in luidi and dry climatic resorts with \aiiable temperatures. OccaMoiuill>' this aiiuoyiu.i; mauilestat ion is tempor.urily aggravated in elevated regions, but tlie ),o,-sib|e initalixe effect upon the bronchial mucous membrane is by no means a criterion of the jirecise influence of the climate. The efficiency of the la.ttei- is measuicd solely "rse of the tulierculous jirocess, cial importance. The bronchial or significance, and in nearly all lioi'ation under a proper regime. -al.ilit\- of warm, equable, and .■..iiuain(rica,ted. u|i]Micd lo jurni.sh a contraindi- s. is le^s likel\' to ensue in such rturi' from home is delaved until a brief iulerval ha,- ela|i>e,l alter the heinonlia-e lia.s ceased. This subject ha- been discussed in some detail in connection with Symptoms. In general, it may be assumed that the special contraindications for sojourn in ele\-ated regions are not so numerous and urgent as some have been led to believe. POPULAR LOCALITIES Professor Moore has stated, " Within the 1 ndad confines of the United States there are many, but not all. shades and \arieties of climates." A cUversity of climatic conditions is incN'ital )le a.~ :i result of the enormous size of the couiiti\', the e-seiitial differences in the m'iiei:il toiiography, the presence ol laiue mienor boilies of water, and the pidximitv to the Atlantic a.nd I'acilic ()cea.iis. It is well to call attention briefly to the general characteristics peculiar to a few isolated localities. The predominant features obtaining in the Adirondack Mountains with reference to the subsequent co which is the only consideration of esp irritation in sucii cases is often of mil instances is susce plil.le of decided am Onlv when tin- .-. .nditi.ui i^ass.iciated ])atiioli\c, r\('ii in this mountainous resort. The soil is sand\-, and lurcsts of |uii(' aliound. This region is known to possess man\- al ti-art n'lis lur the ptiliniinary invalid in the novelty of sur- roundiiius, licainiiul scriici y, i;ciii-ial . li\ cit iiig influences, opportunities for rcciratiuii, ami \ri\ cxcclliMit aci'( niinii " lations. Here is situated the achiHialile .Vdin.iidack (',.iiai;i> Saiiai-iiuiii, the creation of Dr. E. L. Trudeau. The cssciiiial I'limatic aM lilmtcs, however, do not vary materially in thcii' ucmaal i)li\ si..liiuic actinn from these obtaining in otliei- licalth I'psoit- scattcrci t hruufilidui the New England States, althduuli Ideal (liffiTPiii'cs ot' iiiiudr importance are recognized. This locality has for many years oiijuycd a well-deserved reputation as a place df sdidiiiii fur pulmonary invalids. The remarkable beauty of the lake- and furests and the excellent facilities for fishing, render the Adirdudai-k ici^ion a pleasurable and appropriate resort for those whose physical iiiliriiiities tlo not preclude indulgence in outdoor sports. The hi.iilily ^ai i-taetory results so frecjuently attained in the Adirondacks from >\>teinaiie medical supervision are worthy of especial mention. The same is true of the Loomis Sanatorium for Consumptives under the management of Dr. Herbert Maxon King, and situated at Liberty, Sullivan County, New York. Asheville, N. C, is situated at an elevation approximately identical with that of the Adirondacks. The adjacent country is mountainous and heavily wooded. As a a:eiieral rule, the temperature is compara- ti\ely equable, althoiioh extreme fluctuations sometimes take place. The relative humidii \ is liiiih at all times of year. The winters are cold, although much less -d tlian in the Adirondacks, while the summers are not oppressive. The sm >u . w liich remains for many weeks in the Adiron- dacks, melts speedil\' in Aslieville, leaving the ground exceedingly mudily for consideialile ixaidils. This beautiful city, situated upon an elevated plateau witli niduntains but a few miles distant, rising an additional l.-.OI) leet, ..ffers advanlai;.- Id,- ■, lai-e elas-^ df pulmonary invalids. Tliei-e ai'e many line residence-, laiinly hotels, and exception- ally well-appointed lioanlin^-liouses. Tlie W inyali Sanatorium, under the direction of Dr. Kai-1 \on Hnck, has pn,ioyed a long and useful existence. The excellent accommodations outside of sanatoria render Asheville jiarticularly inviting to tlio.se not desirous of residing within a clo-ed in-tilution. The mountain drives in almost all directions in thi' ,-ui loundin.s; country are unusually attractive, while the scenery throuiihout the entii-e district hel]is to make this resort especially delightful l)Oth during the winlei' and the summer months. Aiken, S. C, at an altitude .if neaily 600 feet, is possessed of a sandy soil, moderate dryness of the atmosi)here, and equability of temperature. There is but little wind and there are a considerable number of sunny days. The winters are warm and delightful, but the summers are exceedingly oppressive. The hotel accommodations are exceedingly good, while the Aiken Cottage Sanatorium provides excellent facilities for pulmonary invalids to pursue an open-air existence. This institu- CLIMATE IN THE TREATMENT OF PULMONARY TUBERCULOSIS 691 tion, under the supervision of Dr. C. F. McGahan, is one of the oldest sanatoria in the United States. Those portions of Florida which in former years enjoyed a remark- able prestige as a place of sojourn for pulmonary invalids during the winter months, are characterized by warmth, moisture, equability, and high atmospheric pressure. In the interior of the State the atmosphere is not particularly moist and the sunshine fairly abundant, but the summers are quite enervating: and wet. The climate of soulliciii (':ilitni-iii;i is of a somewhat tropical charac- ter, being depressinii, sunny, nmisi , and, upon the whole, equable. Con- siderable differences obtain in various portions of this I'egion, according to the proximity of the ocean, or a location in the drier mountainous sections. The climate at the seashore is essentially moist, and is quite undesirable for consumptives of any class. In Ln.s Angeles but a very few hours of the twenty -four may be regarded as rcasi mablx- dry. Along the southern coast, both in summer and winici', f he Inimiilit y is marked, and the fog noticeably dense in the earlier puitiuu of the day. A foggy spell of seventeen days' duration is recorded at iSanta Barbara in May and June of 1903. The humidity of the fogs penetrating inland from the coa.st is considerably greater than that nf Boston or New York. Marked diurnal variatiims of Iminidity are luuiid in resoits .along the coast of the Pacific. \\ hiie e(|u,iliilit,\- of temiieiatnic, sunshine, dryness of soil, with but little wiiui movement, are inipuiiant climatic features, the vast amount of moisture in the air constitutes so im- portant a characteristic as to result in frequent tendency to chilling, and to interfere seriously with a continuous out-of-door existence. A satisfactory conformity of the organism to the irreiiulaiity of demands for heat-production is sometimes quite out of (lie (|uestion. It is difficult to understand for precisely what class dt ]i\ihnonary invalids, if any, the climate along the sdiillurn niasl n< ( 'alil'i'inia is really adapted. Upon the other hand, in the luountainnus i-euions there are freedom from fog, diminished humidit\, and al'sem-e uf e.vtreme heat or cold, resulting in less general dejiression and iclaxatinn. In Dr. Pottenger's Sanatorium at Monrovia and in the ISarlmv Sanatorium near Los Angeles the general environment and character of accommodations are well suited to a class of pulmonary invaliils. The arid regions of Arizona possess climatic features of great value to the climatotherapeutist. While ceilain characteristics are common to the entire territory, a noticeable difference is observed in the altitude of various portions. Sandy deserts abuund in a (hstrict far reni(i\-ed from large bodies of water. The counti->- is bii)];eiiei,il exrellence of the climate relates to the occurrence of high wind-. Iiiilijiiii; in susjionsion enormous clouds of dust, which are some- times driNeii wuli exti-enie velocity. These winds are more prevalent durinu ilie winter .iinl spring months, and exert an undeniable effect upon the iierxnii^ .-ysteiu of ]iulmonary invalids, who, for this reason, are prone tn exiiiUil at times eniisiilei-alile irritability of temperament. The climate, especial!)- in tlie nortlieiu portion and in the more elevated regions, is deridedly in\-ii;ojatin m-eat nuiss of pul- monary invalids. In common with iiortliern \e\\ .Mi'xico. the climate is extremely dry, with prolonged sunshine and intense solar radiation, marked diathermancy, low barometric pre.ssure, variability of tem- perature, and moderate winds — in short, all the combined attributes which constitute a favorable climate for a large class of phthisical patients. Colorado, which is preeminently a land of sunshine and dryness, has been endowed by nature with a sandy, porous soil, an inspiring scenery, and all the invigorating qualities incident to moder- ately diminished atmospheric pressure. The climate cannot justly be reiiardeil as ei|iial)le. and in this, as previously stated, is concealed a desiialile feature with respect to the regularity and degree of heat- abstraction. Among the disadvantages sometimes stated to obtain from residence in this region are the extreme cold of winter and the high winds and dust, olijectioii- which, in point of fact, are more fancied than real. Despite numerous statements to the contrary by those unfamiliar with actual condii ions, Colorado is indeed a delightful resort during the entire year, on account of the remarkable difference obtaining between the physical and sensible temperatures. Generally speaking, there is an absence of extremes of heat or cold, the winters not being characterized CLIMATE IN THE TREATMENT OF PULMONARY TUBERCULOSIS 693 by very low temperatures nor the summers by excessive heat. During the cold season the weather is rarely such as to interfere with a contin- uous out-of-door existence. At this time of year rain is exceedingly uncommon and snow-storms comparatively infrequent. The winter cold is seldom, if ever, depressing, save to extremely debilitated indi- viduals. Upon the contrary, a general exhilarating effect is often noted, as a result of which appetite and digestion are stimulated to an appre- ciable extent. As oppo.sed to the enervating sense of inertia peculiar to warm regions, the invigorating effect of a Colorado winter is, in fact, a positive advantage. It must be concedfMl that at times a distinct dis- advantage relates to the ]ir('\alriicc cif wiml :iii(l dust. During a few of the spring months, antl especially in the al'li-iiKKin, there is more or less temporaiy annoNaiice fioiii those sources, but it is seldom that the invalid is mil peiiii it led to remain in the open air upon a slielterinu porch. These untax (naiili^ tactois obtain to a less degree than in Aiizona and southern portions of New Mexico, while the relaxation from heat during the summer is comparatively slight. A desirable feature of considerable importance is the avoidance of necessity for removal from one climate to another at diffeient seasons of the year. Such changes involve not only considi'ialile expense, inconvenience, and difficulty of securing appropri- ate acconiniodaiions, but, above all, the frecjuent deviations from an appropriate regime. Instances of this are all too frequent within the ex- perience of observers in health resorts in any locality. The climate of Colorado is in many respects similar to that of the Swiss Alps, though in the latter region" there are fewer hours of possilile sunshine and a severer winter, but a ilimini-lietl amount of wind and dust. Climatologii- liteialnre abounds with statistical comparisons of meterologic data., lallnm attention to essential differences of tempera- ture, relative humidiix , Min-lmie. precipilation, and wind mo\-eiuent in Colorado, and vaiiou,- <;//m , /,«,//,//,> (■njoyinii u-iH-dismal leputations as health resorts. While ]Hirlion> of Arizona anility of temperature, these qualities, though eminently desiraMe in iliemselves, are offset to some extent liy tlle );-reater tendeln'N' to wind.- and dust, the lessened stimulalmu etlect , the llec<•s^it\- of ^ea^ona I clia n;_:e. and nol in I Vei |nelltly the existence of intiTior a.cconiniod;;,! ion,- ('onipa,n-<,n,- l,et\\een the meteoroloiiic condition,- olitainiim in ('olorado k^cmIs and eastern locali- ties are too in\-idioiis and lannliar to just ily ehunieration. It is just to as.sei-i thai tliere i,- alniosi no pail of Colorado where the invalid may not deinc cliinaiic oppoit unit les tor material improve- ment. In numeroii.s coininiinitie,- t ln'onulioui I lie Sta,te a,inple provision is made for the reception of \-i,-itiii;; con.-iiinpt ncs. Two localities suit- able for residcMice diiiinn the entire year are worthy of special mention — Den\cr and ( 'ojoiado Sjirings. Slight ineiitioii need he made of the climatic attributes peculiar to Denver, which iii general are similar to those .already enumerated as obtaining in Colorado, but there are some essential feature.- i oncerning which there has been more or less popular misi-onception. Attpiition has lieen directed from time to time to alleged (li.-a.v .la\ a >ra or plain liici'/r. li\- iiiLilit a shore or mountain breeze." The iinpulatiiiu i> luiiiiici-nl laiL;rl\ ni cnn-uniptives wiio have recovered their healtii by reason of sojourn in tins locality. Contrary to the statements of some writers, the city exhibits a remarkably pleasing and imposing appearance, particularly in the residence district. The streets are unusuall^v broad, and are rendered quite attractive by the abundance of shade trees. Exceedingly good accommodations may be obtained in numerous boarding-hou.ses. as well as in the Glockner and Cragmor Sanatoria, both of which are admirably conducted. The former has been in existence for many years under the direction of the Sisters CLIMATE IN THE TREATMENT OF PULMONARY TUBERCULOSIS 699 ,/■■ of Charity and provides ac- r commod;itioiis for about 200 ' patient-s. The latter was [ founded in 1904 through the efforts of the late Dr. S. E. Solly and the senerositv of Gen. Wm. ,1. l'nlni,.r. 'it is located on the nm-kiiis of the city, afford cxccllrul :ic- commodatiou;s lur iweuty-live patients, and is under the supervision of Drs. C. F. Gardiner, W. H. Swan, and H. W. Hoagland. It is not to Denver and Colorado Springs alone that the invalid in search of health need look for suitability of climate, attractiveness of ac- commodations, and opportu- nity for recreation. Aci-ording to seasonal cha.u^os. o]ipftvtu- nity is afforded in mlii-i- parts of the State for .-inh tempo- rary sojourn as may suit the inclinations and satisfy the apparent needs of those for whom a rational diversion is indicated to break an other- wise unceasing monotony. With the advent of warm weather patients may avail themselves of the facilities presented in various resorts for the enjoyment of country life and mountain air. Ex- cellent accommodations may be obtained at Estes Park, seventy-five miles from Den- ver, at an altitude of about 7000 feet. This park, at the foot of Long's Peak, consists of a plateau a.boiit ten miles j long and six miles wide, con- I tuinin,;; imniiiieialile hills and j valleys, and smiounded by gigantic mountains witli snow- clad peaks and cia.uuy pieci- pices. Fifteen years ago the late Dr. Ilnedi. upon arrival from S\\il/;eilaiid. endeavored to select in Colorado a location suitable for comparison with Davos as to climatic characteristics, fauna, and flora. He found that "a difference 700 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT of 2000 feet between Colorado and Switzerland was required to puv invalids under the same conditions." Considerable reseml)lance was shown between Estes Park and Davos, except as to the factor of altitude. A.r u result uf close meteorologic ol)ser\-ation he wa> enabled to call attention to a diminished variation in the barometric pressure in Estes Park as compared with that of Davos, and to the far greater number of at Estes Park. hours of possible sunshine. A striking difference in the humidity was also noted, the absolute precipitation in the Swiss mountains being considerably in excess, but the prevalence of wind decidedly less marked. TREATMENT OF SPECIAL SYMPTOMS 701 Attention is sometimes called to the supposed inability of invalids to retui-n home after an arrest has been secured in high altitudes. It is hard to conceive how i-esidence at high elevations can render the in- valid more susccptililc td a renewed acti\-ity nf the tuberculoiis process upon return id ihc low l.uids. Even were tins tiiic !iowc\cr, it would not militate auuinst prompt recourse to the f;i\-or;i.l i|c inlluciicc of in• of the 1 nonchial tract. Among some invalids jiromotion of expectoration is demanded. |jut in a large proportion of ca.ses the amount of bronchial irritability is far in excess of that required to free the respiratory passages. 702 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT Preliminary to the institution of treatment, it is of prime importance to conduct a critical inquiry as to the existence of local causative factors. The pharynx should lie carefully inspected in order that a prolonged uvula may be aminitatcd if necessary, and enlarged follicles upon the posterior wall of the iiharyux destroyed. The larynx also should be examined, that areas of infiltration, ulceration, or necrosis may be sub- jected promptly to local treatment. The recognition of cardiac embar- rassment is of importance, for a venous engorgement of the pulmonary circulation often jn'odisposes to the devclojimont of bronchial irritability. In this event the cxliibltioii uf nitro^lyccnn ami utlici- iviiicdies to relieve the pulmonary ronm-iKiu is iiv(|iiei[i |y niiciidcd l.y M-iial benefit. The coexistence of ne{)hntic tlisturlianie, a rheunuilic iliathesis, gout, and chronic alcoholism should be ascertained, and treatment appropriate for the underlj-ing condition immediately inaugurated. Exposure to dust , wind, or smoke should be restricted, and loud or prolonged talk- ing enjoined. The medical advice should be governed largely by the character of cotigh, the conventional administration of syrups and sedative tablets, irrespecti\e of other considerations, being productive of no inconsider- able harm. It is hiuhly inexpoflient tn resort to the employment of any agent not a.li-iilutcly (IciiuhiiIimI. and, above all, to permit its use according to the falicilul jud-iiii-nl ni ihe patient. As a rule, ample nieaMires are availalile for the restriction of cough without recourse to opiates. In all rase,- ui dry cough with unnecessary and spasmodic efforts toward the I'xiiul-iou of expectoration, detailed utilization of various iiyuieiiir ineasnivs are of ui'ent value. These par- oxysms have been described as occimiim alter liea\ >' meals, upon change of position, as arisinu iiulie moiiuimor iciiiim: for the nii^ht. upon abrupt alternation of heat or cokl, upon exjjosure to raw, chilling winds, inha- lation of smoke or dust, indulgence in ph3-sical exercise or inordinate laughter, and during a state of mental excitability. The frequency and severity of spasmodic coui^h are al'-o aggravated to no little extent by dist\irliaii(<'s of iliuestioii and coii-1 ipat ion. It is at once apparent that the olilmatioii oi' the medical atteii.laiit relates not to the unthinking admini-tr.itioii ol (•daii\c-. Imt to the comprehensive reco<;nition of all infiueiire- re-|M,n.,l,lelorthecouL;h. u 1 let her -eueral or lor.-d . and at teu- tion to tlii'ir remo\al or routiol. The di'-ree to wlu.-h excessive bron- chial irntabilily with exhau-lim; coii-li may be relieved by carefldly supervised hygienic measures r-almoM beyond belief. Successful results are greatly facilitated by the willin.u coopeiation of the patient, which can be secured only by a detailed recital of the possible causative in- fluences. ■ In many cases complete physical rest in the recumbent or semi- reclining posture sho\dd bo secured for at least one-half hour after meals. This, of course, is particularly -lilted iinl'i to |iatients whose paroxysms of cough are not exrncd upon a-sumim: tin- |Mi-itioii. It is especially appropriate for those with tlecidedly neiMnis temperament, and with marked susceptibility to variations of external iein|iera.t>ire. It is impor- tant that meals should not be eaten at tinx's ol menial excitement or phy- sical exhaustion, as the tendency to cough and vomit is then accentu- ated to a marked degree. Inasmuch as the coughing at such a time is largely of reflex origin, it is often desirable to restrict the amount of food TREATMENT OF SPECIAL SYMPTOMS 703 ingested with the meals. Many patients are able to receive into their stomachs a moderate quantity of food without excitation of paroxysmal cough, but exhibit, upon overindulgence, distressing reflex irritability. Invalids of this class should receive their food frequently, but in com- paratively srnall amounts. Bits of ice may be held in the mouth after eating if the tendency to cough is pronounced. In extreme cases tablets containing a small amount of cocain may be slowly dissolved in the mouth, or the fauces may be sprayed with a weak solution. The influence of change in position is illustrated by the customary cough in the early morning and late evening. At such hours the need of controlling cough is less apparent than at other times, as the expulsion of the secretions is more or less imperative and the danger of reflex vomiting much diminished. During the balance of the day, particularly after taking food, the restriction of severe cough sometimes necessitates rest in the upright position, or at most reclining slightly in an invalid chair. Many patients complain liitterly of the cough which ensues immediately upon lying down at night, resulting in the loss of the evening meal from reflex vomiting. This unfortunate occurrence is far more apt to take phu-c whou imalids retire shortly after food is ingested. WhUe it is hiulily (IcsiniLIc to -ccure as many hours of sleep as possible, this in no case sIkhiM take j)rccc(lenre over efforts to control the paroxys- mal evening cough. In such cases it is my custom to instruct patients to partake somewhat sparingly of the evening meal, and to retire for the night not until after the lapse of several hours. Animated conversation, music, and playing and other forms of social indulgence are interchcted. Exposure to the cold night air is often injudicious for this class of invalids, even if at rest upon the porch. Quiet and seclusion in a well-ventilated and not overheated room are indicated until such time as the processes of digestion are well estalijishi'd. 'i"hc ('\riiiiiii may be spent in light reading, with the jiaticut in a sciiiiupri;;lit jKisture. Experience has shown that in man>' in •ta,iicc~ the later lidur of retiring is compensated for by the diminished teiideni)- to cnuiili when the recumbent position is finally assumed, by tlie lesser likelihond of reflex vomiting, and by the greater ]>r()lial)ilii>- nf secuiiim: unbroken sleep. In all cases'the frequent alleiiialKin nf luii a-nd cold air must be avoided as far as possible, and prdtection alTcnded lioni drafts, chilling winds, or atmospheric containinatidu with siudi^e or dust. Physical exercise and undue hilarity incident to extdierance of sjiirits nuist be prohibited until cough has been siilidued within reasonable bounds. The ingestion of copious drafts of hot water upon arising in the morning, with or without the atldition of sodium phosphate or other alkaline preparation, is often peculiarly efficacious in i-elieving the severity and shortening the period of morning paroxysms. Subjective control on the part of the patient is of exceeding import- ance. Invalids should be taught to repress the desire for coughing unless assured that the expectoration is easy of exjiulsion. To a very great extent the frequency of cbugh is influenced l)y halnt, which, by the exercise of firm volition, is capable of much restraint. It is par- ticularly desirable, for obvious reasons, that the tendency to cough should be overcome at meal-time, and the possibilities for repression at this time are sometimes remarkable. Counterirritation over the sternum is frequently of some value in the severity of cough during acute bronchial exacerbations. 704 PROPHYLAXIS, GENERAL AND SPtX^IFIC TREATMENT At this particular period inhalations are also of considerable benefit, but should not be emploj-ed for over a few days at a time. In acute cases the inhalation may consist of various combinations of eucalyptus, menthol, thymol, oil of puie, and phenol, and in chronic cases of crea- sote, balsam of Peru, tincture of benzoin, iodin, terebene, etc. During periods of excessive irritability considerable imi3ro\-emeiit is sometimes afforded by this means. It is essential that tlic mliulation of medicated steam be practised in great moderation, and thut i lie patient refrain from going out-of-doors until at least one-half hour has ehipscd. The spas- modic cough, characterized by absence or tenacity of expectoration, is favorably influenced in many cases by the periodic administration of the syrup of hydriodic acid. An experience of many vears with this agent has est.-tl'li-hcd the conclusion that, adminiritered thi'ee times a day for varyiim pnidds. it is often capaWe of lessening the severity of cough to a iiiatci uil i-\tfiit and promoting ease of expectoration. Ill lasc the idimli iviiiains persistent in sjijte of liygienic measures, deleti'iHius elieit - are iiicN itaM}" obserxcd in the production of reflex emesis, iiuiiairineiit oi iiutiitioii, (U turbaiice of sleep, and diminution of strength, liuler the. e ciicuin tames relief should be afforded within moderate limits by the judii'ious employment of sedative agents, among whiili coileiu aii(l heidui take the lirst place. In many cases codein may be lomliiiieil to a.il\ ania-e with terpin liydrate in doses of { and 2h grains i-e-piMindy. Iiriii: therap\ for the relief of cough .should be restricteii as iinnii as jio: , ible, and under no circumstances should be left to the jutlgment of the patient. Opium deri\'atives may be admin- istered either in tablet or liquid form, but if the latter is used, care should be taken to exclude syruixs. on account of their pernicious influence upon iligestion. Not rntil all hope of recovery has vanished, should the comfort of the jiatieiit with di tressing cough, be promoted by the free exhibition of moiplun, lieidin. or codein. DIGESTIVE DISORDERS The contraindications for excessive feeding, together with the general principles of dietetic treatment, have been described in connection with the general subject of superalimentation. The dietetic and mrdirnml iiiaiia'.:ement of the various disturbances of the gastro-intestinal tiart i~ attended by the assumption of much responsibility, for on the pre-er\ai nni of digestion rests the cliief hope of the consuinptive. In addition to the ] io- iiinrc cltcn than has been supposed. Rosenberger has found bacilli in tliu fi'tul cli^^charge of a number of individuals who were not suspected to be subjects of tuberculous infection. In a large proportion of these cases the autopsy finchngs disclosed tubercle deposit in some portion of the body. The nature of the treatment is not necessarily dependent upon a deter- mination of the fundamental character of the diarrhea, all three varieties demanding practically the observation of the same general measures. The diet should be restricted almost entirely to milk, soup, and albumi- nous foods. Lean meats, eggs, fish, and oysters may be given freely, but no vegetables, fruits, or pastry should be allowed. It is sometimes necessary to insist upon protracted confinement in bed and an exclusive diet of boiled milk. It is excellent practice to empty the bowels at inter- vals with calomel in divided amounts, or with sweeping doses of castor oil, following which there is not uncommonly secured a temporary respite from the annoying diarrhea. Among the intestinal astringents 708 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT of considerable value may be mentioned the salicylate and subgallate of bismuth, tannigen, and tannalbin. Sixty to eighty grains of salicylate of bismuth should be given daily, while the subgallate may be adminis- tered in still larger amounts. Thirtj' to forty grains of tannigen may be given each day, supplementary to either the salicylate or subgallate of bismuth. In very obstinate cases recourse may be taken to powdered opium and subacetate of lead, in doses of J grain and one grain respect- ively. Enemata of starch, with deodorized tincture of opium, may be occasionally employed, together with solutions of silver nitrate. In the event of intestinal flatulence resulting from excessive fermentation, antiseptics are of more importance than astringents. A most excellent remedy for this purpose is the beta-naphthol bismuth, given in seven- grain capsules two hours after eating. Creasote is often of undoubted efficacy in small doses, its effect being somewhat enhanced by the addi- tion of ^ grain of menthol. Mucous colitis is not especially infrequent among pulmonary invalids, particularly of the neurotic type. Paroxysmal attacks of pain and tenderness in the abdomen, with the passage of mucous shreds or strings, may be associated with periods of excessive mental worry or excitement. The treatment should be directed essentially toward the management of the general condition, with dietary precautions, although high irrigation of the colon with normal salt solution is some- times attended by satisfactory results. Only such food should be per- mitted as is easy of digestion. Meats may he given freely, but green vegetables, fats, and starches should be interdicted. The treatment of intestinal tuberculosis has been described under Complications. Instances of acute intestinal toxemia also are not infrequent among phthisical patients. The attacks are invariably of sudden onset, characterized by chill, headache, and often severe pain in the back and limbs. With the history of constipation the tongue is often heavily coated, the breath offensive, and the taste of the mouth extremely unpleasant. Without other symptoms directly refera!)le to the gastro- intestinal tract, the temperature may range as high as 103° F., but some- times does not exceed 101° F. The patient, as a rule, is completely prostrated, and the general clinical manifestations are those of a severe mixed infection of some kind. There may be tenderness in the alidomen, but this is not present in all cases. Occasionally small hard papules appear on the hands, arms, or body, and itch intensely, suggesting the gastro-intestinal tract as the seat of the trouble. The condition is differentiated from influenza by the absence of cough or catarrhal symp- toms in the upper air-passages. Tonsillitis is excluded by in.spection of the throat, and pneumonia in most instances by physical examination of the chest. The possibility of tuberculous meningitis may be elimin- ated only after careful ohservation of the case. The initial therapeutic indications consist of immediate purgation with large doses of calomel, followed by magnesium sulphate. After the bowels have been thor- ouglily evacuated, high enemata of normal salt solution should be freely administered and water given in large amounts by the mouth, with diuretin or potassium citrate to stimulate the kidneys. Food, of course, should be restricted during the acute stage, the chief efforts at treatment being directed toward evacuation of the bowels, gastro-intestinal rest, dilution and elimination of the toxins. TEKATMENT OF SPECIAL SYMPTOMS 709 NIGHT-SWEATS Attention has been called to the intimate relation between night- sweats and fever, both symptoms being characteristic manifestations of mixed infection. In such cases the perspiration accompanies the fall of temperature in the early morning hours. Night-sweats, however, may be observed without appreciable temperature elevation, and, per contra, may not accompany the fever of sepsis. Despite the inconstancy of association with fever and other subjective symptoms referable to mixed infection, it is probable that in all instances night-sweats are influenced to some extent by the effect of toxemia upon the vasomotor system. When sweating occurs as an incident of elevated temperatures, it is rational, if not obligatory, to concentrate therapeutic efforts for the time being, upon the reduction of fever in the manner elsewhere described. It is not always true, however, that disappearance of the night-sweats will follow a subsidence of the fever. Thus measures are indicated for the relief of the night-sweats, whether or not fever is present. For this purpo.se hygienic measures are of especial importance. Generally speaking, the tendency to night-sweats will diminish with the more complete elaboration of a system of outdoor life. In addition to the constant supply of fresh air and perfect rest in the recumbent posi- tion, it will be found that dietetic and hydropathic methods often suffice to cause the disappearance of night-sweats without recourse to drug therapy. The bed-covering should be light and of woolen material, to the entire exclusion of comforters, quilts, or heavy spreads. Gener- ous alimentation with regulation of the digestion is fundamentally important. If the temperature is not materially elevated in the latter part of the day, the patient should partake of a hearty evening meal, which may be followed by light nourishment at bedtime. Two or three teaspoonfuls of brandy upon retiring may be administered with advan- tage. The body should be sponged with dilute alcohol or some acidu- lated preparation, in the latter part of the afternoon, and again in the late evening. Vinegar or dilute acetic acid may be used for this pur- pose. Quinin dissolved in alcohol is sometimes employed in the pro- portion of one dram to the pint. In my own experience excellent results have attended the use of chloral hydrate dissolved in brandy and water, 2 drams being added to 4 ounces each of brandy and water. Sponging the surface of the body twice daily with these solutions, which are allowed to evaporate upon the skin, often mitigates the severity of the night-sweats, if not affording complete relief. In obstinate cases medicinal measures are indicated from time to time. Camphoric acid has frequently been successful in doses of 15 grains two or three times a day, preferably after the midday and evening meals. In my experi- ence this method of administration has been preferable to the employ- ment of a large dose at bedtime. Picrotoxin, in do.ses of ^wo to ?V oi a grain, and agaricin, -^ to y'j of a grain, are recommended. The latter should be given not less than six or eight hours before the time of the expected sweat. If all other measures are found of no avail, atropin, in doses of Ywu to eV of a grain, may be given at bedtime, though recourse to this drug should be deferred as long as possible on account of its dis- turbing action upon the digestive functions. PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT INSOMNIA Sleeplessness may result from cough, physical discomfort, digestive disturbances, night-sweats, unpleasant dreams, general restlessness, and nervous excitability. Any comprehensive sj-stem of management must be based upon an accurate recognition of the predisposing causes, attention to cough, night-sweats, and digestive disorders being suggested as essential prerequisites for undisturbed sleep. The bed should be comfortable, the clothing neither too light nor too heavy, and the general en\ironment suited to the needs of the patient. It is unwise to permit indulgence in a hearty meal shortly before retiring for the night. Mental perturbation also should be scrupulously avoided, particularly in the latter part of the day. Mental suggestion, if practised intelligently and per.sistently, may accomplish much in the control of insomnia. Hot drinks at bedtime, particularly milk or malted milk, may increase the tendency to sleep, while a small bottle of ale is of some service provided the digestion will permit. A hot mustard foot-bath in the latter part of the evening is often advan- tageous, as is cold sponging of the entire body. I have frequently found massage at bedtime to be of signal benefit in promoting sleep which, under other circumstances, seemed almost impossible of attain- ment. Hypnotics should be given only in e.xtreme cases, and then but for brief periods of time. In such ca.ses it has been my practice to administer an initial dose of from 10 to 15 grains of trional or veronal in hot milk, and, if possible, induce profound sleep for a single night. Upon the following evening not over half the dose is administered, and even less upon the third. Upon the several ensuing nights the milk is administered alone, without the knowledge of the patient. When occasion requires, small doses of the hypnotic are renewed from time to time, the object being to secure the greatest amount of sleep with a minimum use of the drug. Opiates should not be employed for this purpose under any circumstances. CARDIAC WEAKNESS It has been emphasized, in preceding pages, that rest, subject to mollification according to the requirements of the individual, is an essential feature of modern therapeutic management. AbsoltUe rest in bed is demanded for patients exhibiting manifestations of cardiac weakness. It goes without saying that tachycardia, palpitation, breath- lessness, exhaustion, edema of the extremities, and dizziness of cardiac origin, permit of no deviation from this procedure. By rest is not meant simple physical inertia, but also a complete avoidance of mental excitement. Worry, agitation, and the strain of maintaining a weari- some conversation are as much to be prohibited, as indulgence in bodily exercise. The various symptoms of heart weakness are frequently traced to the existence of pronounced neurasthenic conditions, which in themselves are influenced for good by enforced repo.se. The cardiac manifestations oltcn improve commensuratcli/ with gain in the general strength, and in the more stable equilibrium of the nervous system. Digitalis and strophanthus have been found to be of little value. In most cases strychnin is the remedy par excellence, and in appropriate conditions may be associated with nitroglycerin. Camphor has been TREATMENT OF PULMONARY HEMORRHAGE 711 used to some extent with quite successful results. Ten to twenty minims of a sterilized 10 per cent, solution in olive oil may be admin- istered for several weeks without especial inconvenience to the patient, and often with evidence of signal improvement. Aromatic spirits of ammonia, and alcohol, in the form of whisky, brandy, or champagne, are especially desirable if the heart weakness is accompanied by fall of temperature. The application of an ice-bag is sometimes of service, particularly in cases of pronounced tachycardia. Light massage with carefull}^ adjusted resistance exercises are occasionally permissible, pro- vided, of course, the nature of the cardiac difficulty is suited to the application of these measures. Obviously, the latter form of therapeusis for the heart, though eminently satisfactory to the requirements of cer- tain individuals exhibiting a coincident slight tuberculous infection, is entirely inappropriate for advanced cases. CHAPTER XCVII TREATMENT OF PULMONARY HEMORRHAGE GENERAL CONSIDERATIONS The treatment of this condition is uniquely different from that of hemorrhage occurring in other parts of the body, by virtue of the fact that management is restricted to palliative and expectant measures, to the entire exclusion of surgical procedures. In sharp contrast to the prompt exposure and ligation of bleeding points within the abdomen, loss of blood from ruptured vessels in the thorax must be controlled, if at all, through supplementary aid to the natural agencies productive of spontaneous arrest. Fortunately, the undisturbed forces of nature are much more likely to effect a cessation of hemorrhage from the lungs, than from abdominal organs, the contraction of vessels and thrombus formation often taking place before exsanguination is complete or col- lapse profound. The inherent tendency of the organism to effect a spontaneous control through reduction of volume, increased coagula- bility, and diminished rapiditi/ of blood-flow undoulitedly explains the surprising number of recoveries in the presence of divergent and some- times irrational methods of practice. The management of no other clinical manifestation calls for an equal display of judgment and acumen on the part of the physician, and demands such implicit obedience from the patient and attendants. The conception of treatment should be preeminently practical, rather than theoretic, and, in fact, may become almost intuitive. No attempt should be made to base the nature of therapeutic management in differ- ent cases upon a precise determination of the possible causes. Such differentiation is quite impracticable, and bears no actual relation to the manner of treatment. Not only is it of but slight importance to distinguish between the various anatomic conditions responsible for the production of hemorrhage, but in like manner the recognition of the extent and character of gross pathologic change fails to modify appre- 712 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT ciably the indications for rational therapeusis. It is frequently impossi- ble to secure perfect familiarity with the phj'sical condition, on account of the inexpediency of conducting a thorough examination until the likeli- hood of recurrence has subsided. While the information concerning the existence of pulmonary cavities, areas of consolidation, or of fibroid induration does not materially influence the character of therapeutic management, certain features of pathologic import are possessed of great significance, notably the presence of mixed infection, chronic nephritis, and the development of septic pneumonia. The vital con- sideration is the modification of treat incut according to an intelligent interpretation of the clinical maniji stdtions. rather than from a groping assumption as to the exact causatirt nijlmnccs. Clinical features of great moment in association with hemorrhage, are elevation of tem- perature, cyanosis, heightened blood-pressure, the acceleration or feeble- ness of the pulse, dyspnea, and collapse. It is of the utmost importance to appreciate the rarying indications for treatment which are presented by different people, and often from hour to hour by the same patient. In every case of pulmonary hemor- rhage the management should be determined to a large extent, according to the peculiar clinical manifestations exhibited by the individual. Under no other circumstances are the exercise of vigilant observation, atten- tion to detail, and a critical study of cause and effect more necessarj-. No medical practice can be productive of more harmful results than the employment of routine methods in the treatment of hemoptysis, to the exclusion of a wise discrimination regarding drug therapy and hygienic details. Numerous remedies without regard to their physiologic action, or their suitability for special cases are occasionaUy administered in a spirit of utter empiricism. In other instances, purely theoretic notions are elaborated as to the effect of certain drugs upon the general and pulmonary circulation, while erroneous conceptions are not infrequently entertained regarding the influence of external hygienic measures. Thus a disproportionate value may be attached to a few time-honored rem- edies, with neglect to utilize important features of regime. The admin- istration of medicinal preparations, with a few notable exceptions, is attended by directly harmful results, while detailed supervision of the patient and surroundings is remarkably efficacious. In disparaging the employment of general drug therapy for pulmonary hemorrhages, it is important not to include one or two remedies which exert a profound influence upon the entire system, with indirect effects upon the pulmo- nary circulation. As will be seen presently, their value in judiciously proportioned doses is exceedingly great. THERAPEUTIC MANAGEMENT The treatment of pulmoiuirv hemorrhage has been thought to be capable of division into palliative and preventive efforts. It appears quite unnecessar}', however, to make this distinction save in extreme cases, as there is no essential difference characterizing the attempt to arrest bleeding, and the endeavor to pre^•ent immediate recurrence. Hemorrhages often take place in .serial form, one following another either in comparatively quick succession or after the lapse of a few hours. Occasionally one or two days may intervene between these distressing experiences. In view of the tendency to prompt recurrence and the neces- TREATMENT OF PULMONARY HEMORRHAGE 713 sity of continuous rigid precautions, the palliative treatment naturally resolves itself into one of prevention. The physician is rarely present at the time of the initial hemorrhage, while the subsequent recurrences form but an incident in the general scheme of systematic management. In view of the many degrees of severity, the manifold phases exhibited, and the variety of therapeutic indications in different instances, it is manifestly impossible to recite in detail methods of treatment properly applicable to hypothetic cases. Broad generalizing statements, how- ever, may be made from which to formulate principles capable of indi- vidual application. Important features of treatment relate — (1) To the initial directing influence of the physician; (2) attention to vitally important details of management and environment; (3) rational employment of selected drugs; (4) application of special methods. INFLUENCE OF THE PHYSICIAN Experience has shown that in the very beginning of treatment a firm, controlling influence upon the mental attitude of the patient is of incalculable value. Nothing is more subservient of good results than the possession of a calm, hopeful frame of mind, combined with an earnest desire for obedient cooperation. Such mental status is often exceedingly difficult of inculcation, and is dependent to an enor- mous extent, upon the personal influence and demeanor of the medical attendant. Extraordinary differences are exhibited by patients in the men- tal effect estabUshed by the incidence of pulmonary hemorrhage. Many are prone to regard the occurrence as of trifling significance, and affect a seeming indifference. With apparent nonchalance they boast of the number of hemorrhages experienced, and, strangely enough, manifest pride in their previous non-conformity to instructions. To such patients, who are referring continually to their past record, it is with the utmost difficulty that there may be conveyed an adequate appreciation of the importance of the condition, and the necessity of careful supervision. Not infrequently these people, doubting either the sincerity or the soundness of their medical advice, are loath to accept the statement, that recovery from an astonishingly large number of hemorrhages affords no valid excuse for ignoring the possible gravity of recurrences. It is not uncommon in health resorts, to observe among these "old timers" great reluctance in submitting to medical super- vision. In some cases, despite the onset of pulmonary hemorrhage, an active out-of-door existence may for a time remain uninterrupted until the patient of neces.sity is compelled to yield final obedience. Occasion- ally, a portion of the responsibility for the evil results must be assumed by the medical adviser, to whose laxity and carelessness is attril:)utal)le the disastrous delay. Let it be asserted with the utmost emphasis that every case of pulmonary hemorrhage should be regarded as of grave import until its complete arrest, prevention of recurrence, and absence of .iequelse have been determined beyond peradventure. as a result of continuous observation. No matter how apparently insig- nificant the hemorrhage, loss of blood from the lungs is worthy in all instances of judicious supervision. Several times I have been forced to witness the development of septic bronchopneumonia and death, follow- 714 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT ing the initial expectoration of two or three ounces of blood by indi- viduals refusing to yield conformity to the principles of rest and hygienic management. I recall many instances of sudden death from severe hem- orrhage as a result of bicycle-riding, driving, and dancing, despite the warning signals displayed by slight initiatory hemoptyses. Small repeated hemorrhages, though not in themselves necessary elements of clanger, yet if persistently ignored, represent, like the red flag waved before the approaching train, the existence of possible sources of destruction. An appeal, therefore, is made for at least the tentative enforcement of pre- cautionary measures in all cases of hemoptysis, even if the loss of blood is quite inconsiderable. Among people of this class, in order to secure implicit obedience, the attitude of the physician should often be that of -peremptory command, indomitable patience, and co7isummate tact. The effect of hemorrhage upon another group of patients is quite the reverse of the preceding, there sometimes being produced the greatest possible amount of consternation and dismay. The fears of the invalid may be so exaggerated as to take the form of an almost hopeless and unspeakable terror. This unfortunate mental state is accentuated in many cases by the excitability of relatives. Under such circumstances prompt and emphatic reassurance not only represents a prime obligation upon the mecUcal attendant, but constitutes as well a most important feature of treatment. It is eminently good practice to calm the per- turbed feelings and restore equanimity of temperament as quickly and fully as possible. A judicious endeavor to assuage the fears of the patient is usually successful in inspiring hope, the establishment of confidence often minimizing to a degree the likelihood of recurrence. It is impossible to overestimate the beneficial effect produced by the kindly encouraging words of the physician at a time of such critical moment. Optimistic cheer should be extended no less in the midst of desperate conditions, than in the presence of smaller hemorrhages. Physicians who. upon words of encouragement, ha\-e noted the relieved countenance of the invalid in place of an overshadowing expression of fear and demoralization, will accord hearty support to the wisdom of ever-ready reassurance to patients of this class. REGARD FOR DETAIL Attention to infinite detail represents a feature of management of the very greatest importance. It should be remembered that hemorrhagic patients are extremely susceptible to nervous influences, the tendency to bleed being aggravated enormously by slight annoyances and minor physical indiscretions. Thus it is incumbent upon the physician to exercise a strict supervisory control over all that pertains to the invalid and the environment. It is essential that no person should be allowed in the sick-room besides the nur.se, as to who.se .selection considerable discrimination should be exercised. In addition to perfect familiarity with similar conditions, the nurse must display primarily a ready adaptability to the individual requirements, in order that the sensibilities of the patient be not disturbed by virtue of peculiar idiosyncrasies. Her predomi- nant characteristics should be cheerfulness but firmness of disposition, reticence but courage at times of emergency, scrupulous devotion to detail, and vigilance of observation. If the patient is consigned to the TREATMENT OF PULMONARY HEMORRHAGE 715 care of relatives, a painstaking effort should be made in the selection and instruction of the attendant, to the end that a soothing and rest- ful influence surround the invalid at all times. Conversation in the room should be strictly enjoined, the patient being addressed only when necessary and always in words of encouragement. The invalid should not be permitted to reply save in the whispered voice, assent being made whenever possible by a mere nod of the head, as loud talk- ing is often conducive to a recurrence. The room should be kept at an even, cool temperature, with an abundance of air, but without exposure of the patient to chrect drafts. The temperature should rarely exceed 60° F. in the bed-chamber, which should be isolated as much as practicable from other portions of the house. Frequent opening and closing of windows or doors should be prohibited, in order that the element of noise be eliminated to the great- est possible extent. For the same reason the jarring of tables, moving of beds, or rocking of chairs should be restricted. The patient should remain at all times in the recumbent posi- tion, upon a moderately hard mattress, with the head but slightly elevated. In exceptional instances the head and shoulders may be raised slightly, this being justified by severe dyspnea, but permittetl for no other reason. The contention is made by some clinicians that the semirecumbent position is more advantageous on account of the added facilities afforded for easy expectoration. With the invalid in the complete recumbent posture, the expectoration may be received into a towel or piece of gauze held by the nurse, with the head of the patient turned slightly to one side. Other physicians advise placing the patient upon the affected side, in order to prevent the return passage of blood into the bronchi of the sound lung, but tlu'sc conclusions appear more theoretic than practical. As a rule, invalids aic ;il jjc to remain squarely upon the back for prolonged periods, but this is not the case if resting upon either side. The act of turning, e\cu with the assistance of the nurse, is often sufficient to induce cough, jurclcraic icspiration, elevate blood-pressure, excite nervous apprehension . and pioduce hemorrhage. It is difficult to understand why regurgitation of lilood into the bronchi of the sound lung is more to be feared than into the bronchial tract of the affected side. In fact, it would seem that the tendency to broncho- pneumonia might be increased by the inspiration of blood in those bronchioles exhibiting previous pathologic change. A cardinal principle of management should be the absolute main- tenance of the patient in a fixed position. The arms should remain in a comfortable position by the side, at no time being raised to the head. The knees should not be elevated save during the use of the bed- pan. The bed-clothing should be light and consist merely of a sheet and one or two blankets, according to the season. The food should be simple, and consist entirely of cold liquids or semiliquids during the period of greater emergency. Milk, beef-juice, gelatinous ]iicp;ir:iti()ns, and ice-cream may be given, provided but small quantitii- aic ullowed at a time. No articles of diet should be permitted requiring mast icai ion. It is unwise to administer medicine by mouth, for fear of inducing vomit- ing, with the attendant strong probability of exciting recurring hemor- rhages. No remedy save an occasional cathartic is indicated that cannot be administered to greater advantage hypodermatically, by inhalation, or by the rectum. In taking nourishment the head should not be raised 716 PROPHYLAXIS, GEXKRAL AND SPECIFIC TREATMENT from the pillow, the food being given by the nurse either with a spoon or through a drinking tube or cup. Pieces of ice to be held in the mouth may be freely given. This is found to add materially to the comfort of the invalid, to relieve dryness of the buccal mucous membrane, to lessen the likelihood of recurrence, to allay cough, and control nausea. It is eminently desirable that the bowels be moved once daily, although it must be recognized that imminent danger of hemorrhage is induced by the strain incident to defecation. Save under exceptional circum- stances, particularly the development of renewed hemorrhage, failure to secure a satisfactory evacuation of the bowels once in twenty-four hours constitutes palpable neglect. Inattention to this feature, with the development of fecal impaction, has constituted the turning-point in the destinies of many an unfortunate sufferer from pulmonary hemor- rhage. The function of defecation often I'epresents one of the most important obstacles in the path of the bleeding consumptive, instances of recurrence during or immediately following the performance of this act, being common in the experience of all phthisiotherapeutists. The difficulties are intensified to a very great extent by the unavoidable administration of opiates. It is an excellent practice to produce softening of the rectal con- tent by the injection of small quantities of sweet oil. Two ounces may be given in this manner, followed in two hours by a similar amount, and again after an equal lapse of time by an enema of soap- suds and water. Comparatively little or no discomfort is experienced from these injections. If a satisfactory result is not secured by this means, a safe procedure consists of the injection of five or six ounces of the compound infusion of senna, which is also retained, as a rule, without difficulty. If repeated every hour for two or three doses, thorough evacuations are usually secured. In the e^■ent of obstinate constipation and abdominal distention high enemata are found to be particularly efficacious. These may consist of two ounces each of a saturated solution of magnesium sulphate, glycerin, and spirits of tur- pentine, diluted with six ounces of normal salt solution. With some patients recourse must be taken to the mouth for the administration of an effective laxative, the use of magnesium citrate or other alkaline preparations often being followed by satisfactory results. In obstinate cases no agent is so thoroughly and blandly efficient in producing sweep- ing movements of the bowels as a large dose of castor oil. The natural repugnance of the patient is entirely overcome by administering the oil in a small quantity of beer or slightly flavored effervescent water, but success in this respect depends entirely upon the technic of its admin- istration. One ounce of oil should be "placed in a wineglass. The beer or the effervescent liquid should be poured into a drinking-glass, and stirred, if necessary, to promote foaming, when the wineglass containing the oil, should be in^■erted over and poured into the center of the aer- ated liquid without touching the side of the glass, and the preparation swallowed without delay. Thus deprived of its disagreeable taste, the oil is rarely, if ever, productive of nausea. It is, of course, apparent that some modification of stringent detail in the management of pulmonary hemorrhage may be permitted for less urgent conditions, but, in general, a necessity exists for the obser- vance of rigid detailed precautions. For the purpose of illustration the TREATMENT OF PULMONARY HEMORRHAGE 717 following case, which has recently come uilder my observation, is of interest. The patient was found to have experienced a series of hemor- rhages during a period of three weeks, and to have become much exhausted, more or less exsanguinated, having an embarrassed respi- ration, feeble pulse, and daily elevation of temperature. Inquiry elicited the fact that despite perfectly rational medicinal management, she had been permitted to sit up in bed during the entire period, to receive callers daily, to engage in trying conversation, to indulge in hearty meals, and to reject the use of the bed-pan. No more striking commentary is needed to verify the assertion that the importance of detail in the management of pulmonary hemorrhage is not always recognized to a sufficient extent. EXHIBITION OF DRUGS The employment of drugs for pulmonary hemorrhage has been based, to a great extent, upon their supposed influence in diminishing the volume of blood in the lungs, increasing its coagulability, or in reducing arterial pressure in the pulmonary circulation. Recent experimental research has shown that views previously entertained with reference to the relation of the systemic to the pulmonary blood-pressure, have been erroneous. It has been made clear that constriction of the peripheral vessels is attended by a greater influx of blood in the pulmonary artery, with consequent increase of pressure. Thus ergot and similar remedies possessing styptic qualities through the vasomotor constriction induced, must exert a distinctly unfavorable influence by virtue of the heightened pressure in the pulmonary artery and its branches. Even were such agents known to produce identical effects upon the pulmonary and general arterial circulation, it is extremely doubtful if practical good could be accomplished in an attempt to reduce the volume of blood in the lung, for the accompanying pathologic changes are often of such a character as to prevent the contraction of the vessel at the site of the hemorrhage. All remedies, therefore, calculated to reduce volume are not only worthless, but directly harmful. Digitalis may be included in this list, although it may be seriously questioned if, in doses usually prescribed, the present commercial preparation, as adulterated, can exert any influence whatever. At all events, any effect produced by this agent, in the vast majority of hemorrhagic cases, must be delayed, cumulative, and disastrous. Wright has shown that the coagulability of the blood is increased by the exhibition of calcium lactate and diminished by sodium citrate. Clinical experiments have been conducted in the hope of utilizing the information acquired to the practical benefit of invalids suffering from pulmonary hemorrhage. My own experience with calcium lactate in 15-grain closes, and calcium chlorid in 10-grain doses, has not been such as to establish their clinical value. In some instances vomiting has promptly ensued, and in other cases mild gastric disturbances not properly attributable to other causes. Calcium chlorid given by rectum has failed to yield positive assurance of its remedial efficiency. Gelatin administered hypodermatically may be endowed with some properties tending to increase the coagulability of the blood, but its administration in this manner is exceedingly painful, and attended with the possibility of inducing tetanus. If thus employed, the greatest caution should be / Is PROPHYLAXIS, GENERAL AXD SPECIFIC TREATMENT observed in sterilizing the liquid and eliminating commercial impurities. The following method of preparation is reasonably safe: Sterilized salt solution, 4 ounces; best white gelatin, 1.2 ounces; make slightly alkaline with sodium hydroxid, 1.2 drams. Place in flask with glass stopper and sterilize one-half hour, under steam, for five sucte.s.si\ p days. If cloudy from alka- linization, it should be filtered until clear. This is to be diluted eight times to make one quart for subcutaneous use. Gelatin if given by the mouth, can do no harm and possibly some good, but this remains subject to verification. j\I\' practice, when using it in this manner, is to give not less than one-third ounce of com- mercial gelatin daily, but this large amount usually becomes repugnant to the patient within a short time. Efforts to diminish arterial pressure in the pulmonary circulation by reducing the total volume of blood are usually irrational, a consider- able general depletion having already taken place as a result of the hemorrhage itself. Occasionally, good results may be obtained by moderate venesection, especially when the initial loss of blood is slight, fever persistent, small hemorrhages frequent, and blood-pressure abnor- mally high. In general, a satisfactory reduction of arterial pressure may be secured by the cautious employment of amyl nitrite, nitro- glycerin, or sodium nitrite. These agents produce chlatation of the peripheral arteries, with also a probable reduction of pressure in the pulmonary circulation. It has been claimed by some, that their action upon the pulmonary arteries is that of \-asoconstriction, being precisely the i"everse of their effect upon the general arterial circulation. Their clinical value, however, seems to be abundantly established, regardless of theories concerning the physiologic action. Amyl nitrite is the most prompt in its salutary effect, but its influence upon the circulation is dissipated within a short time. Its employment should be restricted to the actual period that hemorrhage is taking place, when it may be given by inhalation in doses of from three to five minims. Similar con- .stitutional effects, but of longer duration, may be instituted by the use of nitroglycerin and sodium nitrite. Under the exhibition of these agents a distinct fall in general arterial pressure is usually noted upon palpation of the pulse, as well as by the use of the blood-pressure appa- ratus. While the tendency to recurrence is undoubtedly lessened under* the influence of nitroglycerin, it is often impossible to determine with accuracy the limits of safe and justifiable dosage. Administered in y^-grain doses every three or four hours for a few days according to apparent indications, it is admittedly of some value. Its place, how- ever, in the drug armamentarium of the physician is quite subordinate to that of one or two other remedies. By far the most important medicinal agent in the treatment of pulmo- naiy hemorrhage is morphin, the influence of which is directed toward the relief of cough, the calming, as a rule, of nervous cxcitnhilit)/. and the slowing of the respiratiorrs. There is also an apparent effect upon the hemorrhage itself. No other drug is endowed with such highly beneficent power, in the treatment of a condition often frightful beyond description, and always distressing to a degree. The measure of its efficacy is entirely dependent upon the intelligence and sagacity of the physician in recog- nizing clearly the indications for size and frequency of dosage. Of all things, there should not be permitted any adherence to conventionalism in its administration, at a time when the life of the patient is so greatly TREATMENT OF PULMONARY HEMORRHAGE 719 contingent upon a judicious conception of the therapeutic relation of cause and effect. It is vitally important that the patient should be kept constantly under the benign influence of the drug, the cough allayed by its soothing effect, and the nervous system subdued to a state of peaceful calm. Sleep is often profound at such times, the respirations are slow, and the likelihood of hemorrhage correspondingly diminished. The remedy should not be administered in stereotyped doses, nor at long, irregular intervals. The important indications pertaining to the adjustment of dosage consist of the degree (if restlessness, the frequency and severity of cough, the recurrence of lileeiliug, and the rate of respiration. The initial dose should vary fioni i to f of a grain, according to the age and the exigency of the condition, but in extreme cases a full grain or more may be given within a relatively short time. Among aged people and children, it should be given with greater caution, as fatal results may follow large indiscriminate doses at both extremes of life. The size and frequency of subsequent doses must be determined exclusively by the effect, thus demanding of the physician the exercise both of courage and of conservatism. Cough must be controlled, bleeding arrested, I'estlessness assuaged, and the i-espirations maintained under twenty to the minute, until alarming symptoms have gradually subsided. Nausea, which often supervenes in the event of small haphazard doses given at irregular intervals, completely disappears if the patient is continuously maintained in a condition of moderate narcosis. Upon gradual suspension of the drug no nausea is likely to be exhibited. Another remedy of exceecUng value is atropin, which is particularly advantageous in the more urgent cases. In the event of very profuse hemorrhage, it may be given in an initial dose of -,'„ grain, to be repeated only after .several hours. A suggesfiim <>!' ils ^dnd el'lect i- untod in the redness of the skin occasioned bj- peripheral (lilatatidu imideut to vaso- motor paresis, with consequent reduction of pressure in the pulmonary circulation. It is unwise, however, to combine injudicious atropin medication with correspondingly large doses of morphin. Upon the development of bronchopneumonia from the inundation of the bronchial tract with inspired blood, the atropin in small doses is of some value as a respiratory stimulant. Upon the advent of bronchopneumonia. \\\\\v\\ is a most alarming sequel of pulmonary hemorrhage, the moi)iliiii -hould be immediately suspended. At such a time the drug ])r(i(luies harmful results by blunting the cough, which is now peculiarly advantageous. Inasmuch as a cessation of bleeding always takes place with the onset of this much-dreaded complication, the necessity for its administration no longer exists. The remedial indications consist of a prompt exhibition of cardiac stimulants, occasional inhalations of various kinds, a possible vaccine or serum therapy, and sometimes venesection and salt infusion. Among the heart stimulants, strychnin and alcohol should take foremost rank in preference to digitalis, spartein, or adrenalin. Their certainty of action as general or cardiac stimulants is more pronounced, and a broader margin established between therapeutic and toxic effects. Stimulating inhalants are, as a rule, of very doiditful efficacy, though apparently beneficial effects sometimes are noted from the inhalation of turpentine, benzoin, balsam of Peru, phenol, etc. During the severe dyspnea incident to septic bronchopneumonia, inhalations of 720 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT oxygen add greatly to the comfort of the patient, though rarely instru- mental in the saving of life. Almost insuperable chfRculties are found in the way of rational vaccine therapy on account of the frequent impos- sibility of securing sputum for the mailing of a vaccine, and the rapid approach of dissolution. Venesection is permissible in the presence of a laboring or dilated right heart, highly elevated blood-pressure, pulmonary edema, cyanosis, and coma. Tlie degree of temporary improvement is often astonishing and quite beyond the imagination of those unfamiliar with the effect of this procedure in such desperate conditions. Unfortunately, a per- manent change for the better is secured in but very few instances. Vene- section should be invariably accompanied by the subcutaneous injection of hot salt solution, which is very frequently of value as a cardiac stimu- lant during the course of the pneumonia. At times of extreme urgency the salt solution may be given intravenously in order to avoid loss of time, but for no other reason, this method being eminently irrational vmless the necessity for haste is paramount. Upon three or four occa- sions I have witnessed sudden death in the midst of this final effort to save life. Upon the other hand, imminent death has been averted in several instances by prompt recourise to salt infusion, particularly during the collapse following an extraordinarily profuse hemorrhage. I have in mind an experience of several years ago with a patient suffer- ing almost complete exsanguination from a frightful hemorrhage, which took place shortly after arrival in Colorado. In the absence of palpable pulse and during complete coma, with gasping respiration, the salt solu- tion was administered as a last resort by my assistant. Dr. E. W. Emery, and repeated at very frequent intervals with cardiac stimulation and oxygen inhalations during the next few days. Despite active and exten- sive tuberculous involvement of both lungs, great emaciation, and long- continued fever, the patient, after the lapse of a year and a half, was enabled to engage in an active occupation. During the past two years cough, expectoration, and physical signs have entirely disappeared. The contention has been made by some that salt solution is con- traindicated after profuse hemorrhage, upon the ground that with renewed volume of circulation and increased pressure, the bleeding is likely to recur. A cautiously supervisetl infusion following drenching exsanguination has never been followed, in my experience, by recurring hemorrhage. It should be remembered that the bleeding often ceases long before death occurs, dissolution taking place from collapse and inability of the heart to contract upon a greatly diminished volume of blood. The deficiency may be supplied by a supplementary infusion of salt solution, while the tendency to thrombus formation, already insti- tuted by the reduction of volume, is in no wise lessened, provided an undue excess of salt solution be not administered. SPECIAL METHODS In addition to the use of salt injections, the special measures worthy of trial from time to time, are the application of cold, the employment of traction plasters to constrict the chest, and the use of ligatures upon the extremities. Cold may be conducted to the chest in several ways, i. e., by fre- quent application of cloths previously placed upon blocks of ice, or TREATMENT OF PULMONARY HEMORRHAGE 721 saturated with ice-water, by the employment of a lead coil through which ice-water slowly flows, and by the use of the ice-bag. The objec- tion to the first method consists of the almost incessant changing of the cloths, to which the nurse must devote practically her entire time. The chest of the patient is constantly exposed throughout the period during which this method is practised. While perhaps of some value at the time of copious hemorrhage, its practical utility i.s open to serious doubt at a later period. On account of the unceasing active attendance required, and the incidental manipulation of the patient, it is extremely unlikely that this practice possesses any decided superiority o\'er the use of the ice-bag. The employment of the lead coil is also attended by some dis- advantages. Its weight is sometimes quite objectionable, as is also the necessity of frequent attention to the flow of water. Upon the whole, no special advantages are secured to compensate for the added incon- venience. On the contrary, it is probable that for the average case the inferiority of this method is beyond dispute. Its efficiency has been markedly less in my own experience, than has been reported by others. Considerable difficulty is met in maintaining a close apposition of the coil to the chest wall, on account of the rigidity of the leaden tubes. Failure to secure juxtaposition of coil and soft parts is particularly notice- able among emaciated individuals with shrunken rib-spaces. Under these circumstances, the non-flexible tubes are found to rest here and there upon elevated ribs without sufficient coaptation to the skin to secure practical efficiency. Some of the cUsadvantages incident to the lead coil are obviated by using a coil of rubber tubing. All these objections are removed by the intelligent employment of the ice-bag. It is not unduly heavy, as it need not be completely filled with ice. Its use is attended by comparatively no inconvenience, and the cold is applied to the skin without the need of unremitting attention, the patient being quite undisturbed by the ice-bag. Necro- sis of the soft parts may be prevented by the intervention of protect- ing gauze between the bag and the skin. It is, of course, essential that the ice be replenished at not infrequent intervals, as the presence of a rubber bag containing water is not conducive to the best results. Further, the position of the ice-bag upon the abdomen where, owing to the carelessness of the nurse, it too often is found, is not in accord with the principles of its employment. In the same way its application over the lung, from which bleeding does not ensue, is unlikely to exert any direct influence against the recurrence of hemorrhage. Erro- neous conclusions as to the particular lung from which the loss of blood takes place are far more frequent than might be supposed. In case both lungs are involved, it is not always easy to differentiate by the physical signs, the unilateral origin of the hemorrhage, nor is it wise in general to examine the chest at this time. If one lung is but slightly diseased and the other unaffected, difficulty in determining the precise area of tuberculous infection is sometimes encountered by inexperienced examiners. I have under observation a patient recently sent to Colorado following a series of small hemorrhages, which occurred during a period of two weeks. Throughout this entire time an ice-bag was kept upon the anterior chest wall of the sound lung, the signs at the other apex having been sufficiently obscure to escape detec- tion. The application of the ice-bag over the heart is often of signal 722 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT value, particularly in case of marked arterial excitement. In some cases greater importance may be attached to the position of the ice-bag over the cardiac area, than over the supposed site of pulmonary hemor- rhage. Constriction of the chest by means of tight strapping with rubber adhesive plaster constitutes a not uncommon procedure. As usually employed, overlapping strips are drawn tightly from sternum to spine over the side corresponding to the lung from which the hemorrhage is supposed to take place. The principle invoked is the restriction of respiratory movements as far as possible upon the affected side. This curtailment of function is in part compensated for by the supplemental exaggerated function of the other lung. It is at once apparent that, in addition to the impropriety of subjecting the patient at such a time to a physical exploration of the chest, an error in differentiating the site of hemorrhage must be singularly unfortunate in that the sound lung would become crippled in efficiency, while a greater burden would be imposed upon the damaged lung of the unrestricted side. It is not entirely clear that the important underlying principle should be an effort to minimize the use of the aft'ei-tcil hiuii, but rather to reduce the depth of the respiratory excursion iipnii Imlli sides. Equally good results seem to be obtained through the const lictKin of the entire chest by a single broad strip of rubber adhesive plaster, tightly encircling the ribs below the nipple. A very considerable advantage of this simple procedure is the ease with which the constricting band is applied with- out appreciable disturbance of the patient. In sharp contrast is the difficulty experienced in applying tightly overlapping unilateral straps, as in this event the patient must be turned upon the side and the trac- tion distributed to less advantage. For the same reason, the employ- ment of ingeniously devised traction plasters designed to restrict power- fully the movements of one side, or to compress pulmonary cavities, are not always of practical value in cases of pulmonary hemorrhage, on account of the difficulties of their intelligent application without undue disturbance of the- invalid. If the indications are sufficiently urgent to point to the advisability of retarding the rpspiratory move- ments at all, the prime desideratum should be the product ion of restric- tion in the simplest possible manner. This is secured witli i^erfect ease by the use of a broad incircling strap of rubljer adhesive plaster. Ligation of the extremities has proved exceedingly effective in the control of alarming pulmonary hemorrhage. While some clinicians have been led to doubt its utility, my own experience has been strongly confirmatory of the claims presented by its early advocates. The method is not to be recommended save in the presence of rather copious hemorrhages, with tendency to frequent recurrence. The ligature should be applied around the limb not far from the trunk, and should be sufficiently tight to compress the veins but not the arterial vessels. The principle involved is the reduction of blood volume in the lung, as a result of preventing the return of the venous circulation in the extremi- ties. Coldness or cyanosis of the hands or feet must, of course, be avoided. In desperate cases it has been my custom to keep the liga- ture closely applied for much longer periods than usually advised — in some instances for an entire day — without disagreeable result. It is very important that the bandages be removed with the utmost caution, it being urged that they be gently loosened one at a time, GENERAL DRUG THERAPY 723 with intervening periods of not less than one-half hour. I recall an illustrative incident, occurring many years ago, when in attend- ance, throughout an entire night, upon a patient suffering from repeated terrifying hemorrhages during the temporary absence of the attending physician. Ligatures were placed upon all four e.xtremi- ties close to the body and the loss of blood eventually controlled through their influence. The following morning, upon the arrival of the physician in charge, all the ligatures were quickly removed, with an immediate resulting deluge of blood from the mouth of the patient, and instan- taneous death. CHAPTER XCVIII GENERAL DRUG THERAPY The routine administration of drugs to pulmonary invalids, which has been so largely in vogue for many years, has been the immediate cause of an untold amount of harm. The adoption of this pernicious practice in the treatment of all clas.ses, regardless of the character of the remedy or existence of special indications, has been responsible for two conspicuous evils — the directly injurious effect upon the disiostive functions, and the enormous loss of time and (ipjiorhiiiilii sulTcicd by consumptives in seeking hygienic, dietetic, antl cliiuuiii' :k1\ jiitaiics. No words of condemnation concerning the indiscrimiuute and i,i;ii()- rant employment of drugs can too strongly stamp the disapproval of the profession. There can be no dissenting opinion that the ,i;en(!ral practitioner should be encouraged to utilize to a far greater cxtont tlie facilities for recovery offered by superalimentation, rest, oiihlnin' li\ iiig, and climate. Furthermore, he should be urged to discard the comcn- tional exhibition of cough syrups, tonics, hypophosphites, mult jtrepara- tions, and emulsions with which the market is surfeited. Upon the other hand, there should be condemned with equal emphasis the pre- vailing tendency to decry the administration of any drug whatever, irrespective of its nature and the exigency of the demand. Some specialists in tuberculosis have denied in toto the value of medication for almost any aspect of the disease. The former tendency toward the administration of drugs to the exclusion of rational measures has given way to such a reversal of sentiment that the use of important remedies to meet urgent symptomatic indications is often met with strenuous objections. To such an extent have the susceptibilities of general practitioners and patients been played upon regarding the supposed disadvantages of all mecUcine for the consumptive, that an unreasoning prejudice against its employment has become a popular fad. Thus, unnecessary embarrassment is occasioned to the resource- ful physician, who seeks to utilize the beneficial effects of judicious medication, in order to control untoward symptoms. Without desire to condone the ignorance responsible for indis- criminate dosage, the conviction is sustained by practical experience, that an intelligent exhibition of a few remedies to meet the varying needs and requirements of tuberculous invalids is eminently proper, 724 PROPHYLAXIS, GEiNEllAL AND SPECIFIC TREATMENT and constitutes a valuable adjuvant to more important measures. It would seem that quite as much evil may be expected from allegiance to the principles of medicinal nihilism, as from persistent adherence to the old-fashioned doctrine of overmedication. Protest, therefore, is offered against the inculcation, in the popular mind, of delusions con- cerning the non-utUity of all drugs for the pulmonary invalid. To deny their occasional favorable influence in the practice of discerning, dis- criminating, and resourceful clinicians is as idle as to repudiate the known advantages of hygienic measures and climate. In the management of special symptoms, it has been insisted that the treatment should be conducted along the lines of hygienic methods, but that due recognition should be accorded to the intrinsic merit of judicious drug therapy. The suppression of hemorrhage, the restora- tion of disordered digestion, and the alleviation of various disturbed functions are often wondrously facilitated by the employment of appro- priate medication. It cannot be asserted that equally beneficial results are obtained by the employment of drugs for their general effect. In fact, the indications for general drug therapy are exceedingly few and relatively unimportant. In selected cases, however, some value may be attached to the administration of strychnin, arsenic, creasote, and preparations of emulsified fats. Strychnin is often of advantage through its influence as a general stimulant. In physiologic doses it is supposed to exert an effect upon all body functions. By virtue of its stimulation of the nervous system the activity of the vital processes of cell nutrition are correspondingly promoted. It is thought, with increased functional activity, added defense is acquired against the tuberculous infection. It has been claimed by some that the maximum benefit from the exhibition of this drug, may occur only when the do.se is progressively increased to the limit of physiologic toleration. The amounts reported to have been administered without toxic effect by enthusiastic advocates of strychnin therapy for consumptives, almost surpass understanding, in" some instances a grain of the drug having been given daily for prolonged periods without unpleasant effects. While it may be accepted as capa- ble of clinical demonstration, that the best effects follow its employ- ment in considerably larger doses than have formerly been given, its routine administration in increasing doses should not be encouraged. It is po.ssible that unusual conditions may exist suggesting the expe- diency of the maximum physiologic dosage, but the employment of the drug at other times, save to a judicious extent, should be deprecated. Generally speaking, in the absence of special contraindications, good results may be expected among pulmonarj' invalids by the adminis- tration of ^V grain three or four times daily. Under its influence the appetite and general functional activities are often advantageously stimulated. It has been my custom for many years to combine the administration of arsenic with that of strychnin, although never as a routine procedure. Through the employment of Fowler's solution, which is perhaps the best form for administration, the promotion of appetite is sometimes pronounced. On account of the narrow margin between the therapeutic and toxic doses it is es.sential that extreme care be exercised in its employ- ment. It should be given in beginning doses of one minim three times a day, which may be cautiously increased to five minims. The remedy GENERAL DRUG THERAPY 725 should not be taken in less than one-half glass of water after each meal, and should be promptly suspended upon the appearance of nausea or other disagreeable symptoms. As a rule, it is unwise to persist continuously in the use of this preparation for a longer period than two months, when there maj' be substituted to advantage agreeable prepara- tions of iron. In the event of dry, spasmodic cough the syrup of hydri- odic acid may often be administered with gratifying results. Unfortunately, creosote has been regarded for many years as of essential value by numerous practitioners. For three-quarters of a century, with varying degrees of enthusiasm, the supposed specific action of this drug has been highly vaunted. Its value at first was thought to consist of a certain inhibiting influence upon the growth of tubercle bacilli, and its greatest efficacy was thought to follow its maximum administration by way of the digestive tract. In the majority of cases it was found that in large doses, the entrance of this drug into the stomach was followed by indigestion, disagreeable eructations, repugnance for food, vomiting and diarrhea, with occasional nephritic disturbance. Routine persistence in its employment despite the manifestations of gastric rebellion, has often resulted in incalcul- able damage, the initial loss of appetite and digestive derangement apparently becoming confirmed. It must be admitted, however, that in exceptional instances, very material benefit has followed its use, notably an improvement of appetite and digestion and disinfection of the intestinal canal, in cases of flatulence and fermentative diarrhea. Other effects have occasionally been noted among patients with exces- sive, purulent, and heavy expectoration. It is apparent that in the overwhelming majority of cases, creasote must be regarded as an agent capable of producing a definite amount of harm, but among a com- paratively few presenting possibilities of some benefit if intelligently and cautiously administered. For general ii,se it cannot be condemned too emphatically, for the unfortunate results far overshadow the isolated instances of improvement. The most that can be said in its behalf is that it has a valid claim for tentative employment among a compara- tively few ca.ses. It should be administered, if at all, in small initial doses of not over one or two minims, preferably in capsules, and increased but moderately. Its use should be restricted to intractable cases of gastric and intestinal fermentation, with impaired appetite, chronic bronchitis, or bronchiectasis complicating tuberculosis, and pulmonary excavation attended by profuse purulent expectoration. Furthermore, it should be promptly discontinued as soon as it becomes apparent that the appetite and digestion are impaired by the drug. But little confidence may be reposed in its practical utility for the purposes of inhalation. The many derivatives of creasote have been found less advantageous than the crude article. Several preparations of cod-liver oil and easily digested fats must be accepted as possessing certain advantages for a class of pulmonary invalids. The only benefit represented by the administration of such agents, is reflected in the ingestion of a generous amount of easily digested fat. Much discrimination should be exercised in the employment of these preparations on account of their frequent effect in retarding diges- tion. Obviously, they should not be given to patients with fever and pronounced gastric derangement. In general, they are borne much better in the winter than during the hot summer months. Their special 726 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT utility is found in the treatment of individuals who, on account of straightened financial circumstances, are not favored by an overabun- dance of good nutritious food. Thus these preparations have been of considerable service, chiefly among dispensary patients, and other con- sumptives, but sparingly endowed with this world's goods. The neces- sity for their employment is much less when the patient is supplied with large quantities of cream, butter, and eggs. SECTION III Specific Treatment CHAPTER xrix THEORIES OF IMMUNITY The underlying principle, upon which have been based all efforts in the way of biologic therapy in tuberculosis, is the production of arti- ficial immunity by the introduction, into the body, of some bacterial agent stimulating resistance to infection. It is becoming established that effective means are available for the reinforcement of the natural but complex processes of immunity. The present recognition of the possible stimidation of the defensive resources of the organism by arti- ficial means, has been of slow development, but the overwhelming logic of experimental research and of clinical experience appears to be well- nigh irresistible. It can no longer be disputed that in many instances, through the employment of immunizing substances, results of consider- able value may be achieved. In conceding the clinical efficiency of specific medication as at present employed, a tribute of the highest honor should be paid to the numerous workers through whose inde- fatigable labors in the midst of almost insurmountable obstacles, the evolution of our present knowledge has been made possible. Before proceeding to the clinical application of the principles upon which depend the production of an artificial resistance to tuberculous infec- tion, it is well to present a brief historic sketch of the various experi- mental contributions bearing upon the relation of culture products to immunity. The first endeavor to produce an artificial immunity to tuberculosis originated with Koch, who observed essential differences following the inoculation of pure cultures of tubercle bacilli in healthy and in tubercu- lous guinea-pigs. In the former the sequence of local changes consisted of apparent healing, the formation of a hard nodule in ten to fourteen days, and a subsequent persistent ulcer until the death of the animal. In pigs already tuberculous, there was an initial attempt at healing, followed shorth' by necrosis of skin and superficial ulceration, which soon healed permanently. Dead bacilli were found to produce no general effect when injected into healthy animals, but prolonged the life of those THEORIES OF IMMUNITY 727 already infected. As a result of these experiments, tuberculous animals were assumed to acquire immunity against reinfection, but there was no evidence pointing to a successful resistance of the previous infection. It was apparent, however, that some specific influence was exerted by the products of the dead tubercle bacilli. Tuberculin, which was reported to the profession by Koch in 1890, ■was at once hailed as a specific, and widely administered. It was made by evaporating glycerin bouillon cultures of the tubercle bacillus in a water-bath to one-tenth of its volume. The dead bacilli were filtered, the tuberculin in the filtrate containing 40 to 50 per cent, of glycerin. When dilutions are made of this product, phenol is added for the pur- pose of preservation. A brief resume of the more prominent effects of this agent is of some interest, though familiar to all students of immunity. Curiou.sly, it was found in small doses to exert but little influence in well people, but to produce striking phenomena in the tuberculous. The innocuousness of its administration to healthy individuals has been ascribed, according to Flexner and others, to a combination of the active principles, from which the toxic substance is incapable of separation, save in the tuber- culous foci of infected individuals. Ingenious as is this explanation, it is difficult of reconciliation with the known fact of its profoundly poisonous influence in the non-tubcicnlous, if given in doses somewhat larger than employed for those aliciuly inlccicd. It was found to pro- duce, after a few hours, severe coiislitutidiial .'^lymptoms, consisting of chill, headache, vomiting, high fever, rapid pul.se, prostration, and sweat- ing. The convalescence, as a rule, was prompt. Among patients with even slight tuberculous involvement similar effects, known as the gen- eral reaction, followed much smaller do.ses. In circumscribed or external tuberculous processes a more or less defined local reaction was observed, consisting of pain, swelling, tenderness, and visual engorgement. In some cases of pulmonary phthisis, cough was temporarily aggravated, and complaint made of soreness or tightness of the chest, with shortness of breath. Hemorrhage sometimes ensued a few hours after the injec- tion, but this was not usiuilly attended by serial recurrences. Areas of increa.sed dulness were (Hcusionally recognized, together with added moisture in the finer lironc IikiIi's. The violence of the general reaction was often greatly disprop(ii-ti(in;iir to the local cvidcures. but the latter sometimes resulted without -yniptdin- of coiistitutional disturbance. Marked differences existed hi the .■.us(ci)tiliility of individuals and of the same person at various times. Repeated inoculations appeared to confer a striking indifference on the part of the organism to subsequent injections, but increased susceptibility to reaction returned after dis- continuance of the injections. Incalculable damage was inflicted by its reckless employment by inexperienced clinicians, and in some instances from its administration even by well-trained observers. Failure to demonstrate its practical value, together with the popular recognition of its disadvantages, speedily resulted in an era of violent condemnation. During a period of fifteen years, from 1890 to 1905, the wave of repudiation increased in volume and power until its effect appeared almost overwhelming. In the mean time, through an appreciation of its complex but subtle influence upon tuberculous processes, many students were inspired to continue investigations in the hope of discovering a modified tuberculin 728 PROPHYLAXIS, GENERAL AXD SPECIFIC TREATMENT that would j-ield satisfactory results. Numerous preparations were used in an effort to produce among animals artificial immunity to a subsequent tuberculous infection. These were also employed to a wide extent as therapeutic agents. Koch, in an endeavor to make a preparation containing the toxins of the bacillus suitable for therapeutic employment, presented the tuberculin TR. Virulent cultures of tubercle bacilli, after being dried in vacuum, were thoroughly pulverized. Upon the addition of distilled water, centrifuging was employed for three- quarters of an hour at the rate of 4000 revolutions to the minute. The white, opalescent fluid in the upper portion was designated TO, and the slimy residuum.'TR. The supernatant fluid was aspirated, the residuum mixed with more distilled water, and the centrifuging process repeated. The tuberculin TO represented the soluble components in glycerin and was similar in its effect to the old tuberculin. The TR contained the insoluble parts in a fine emulsion, representing all the immunizing sub- stances, and was capable of absorption. To this 20 per cent, glycerin was added. His more recent preparation is the l)acilli emulsion, which is a suspension of pulverized bacilli in water with an equal amount of glycerin. This was presented to the profession in 1901. A variety of agents, all of which comprise some modification of the original tubercu- lin, were advanced l^y Klebs, Maragliano, Hirschfelder, Hahn, Land- mann, von Ruck, and Behring. It was found that the injection of pul- verized living or dead bacilli produced for a time an increased resistance to tuberculous infection, but not sufficiently to withstand completely a previous bacillary invasion. In other words, the relative immunity produced was not permanent nor especially pronounced. It became quite definitely established that immunity could be con- ferred upon some animals by inoculation with living attenuated tubercle bacilli. Dixon, in 1889, in experiments upon guinea-pigs and rabbits, found that, after inoculation with cultures of slight virulence, an apparent immunity from subsequent infection was secured. In 1890 and 1891 experiments of this nature were performed by Martin, Grancher, Ledoux-Lebard, Courmont, Dor, Htricourt, and Richet, in some instances use being made of attenuated human bacilli, and in others, of the avian variety. The experiments of Trudeau in 1892 and 189.3 are of great interest and have often been quoted. Rabbits were inoculated twice with avian bacilli, three weeks intervening between the protective treatments. Some months later the anterior chamber of the eye was inoculated with virulent mammalian bacilli, it being uncertain whether the cultures were of human or bovine type. In the control animals a slowly pro- gressive degenerative change took place in the eye. resulting in its ulti- mate destruction. Among those previously- treated with a\'ian inocu- lations, the inflammatory changes were manifested much more rapidly, but were correspondingly quick to subside, disappearing altogether after a few weeks. DeSchweinitz, in 1894, inoculated guinea-pigs with an attenuated culture of human tubercle bacilli cultivated for twenty generations. This was not found virulently infective to these animals, but afforded an undoubted protection against further inoculation, as was shown when they were later subjected to the injection of virulent bovine bacilli. These remained unaffected while the control animals survived but six or seven weeks. THEORIES OF IMMUNITY 729 In 1903 Ti-udeau continued his investigations upon guinea-pigs, in an effort to determine whether his previous satisfying attempts toward the production of artificial immunity, were referable solely to the injec- tions of the living bacillus. He, therefore, in his later experiments, made use both of living attenuated human cultures, and of dead bacilli previously subjected to steam sterilization for fifteen minutes. A second inoculation was performed one month later. At this time a slight enlargement of the inguinal glands was noted in those receiving attenu- ated living bacilli, while the animals inoculated with dead bacilli were apparently unaffected. In another month all were subjected to inoculation with virulent human bacilli, together with an equal number of controls. All the latter were dead in ninety days, exhibiting upon examination extensive general infection of organs. A considerable number of the animals inoculated with dead bacilli had also succumbed, but this was not true of a single pig injected with attenuated living cultures. The pathologic changes in the control animals were very similar to those in the pigs inoculated with dead bacilli. On the other hand, the pathologic lesions in those injected wuth living bacilli were comparatively insignificant, there being no evidence of caseation. Great interest attaches to experiments performed upon cattle in an effort to produce artificial immunity. Much work has been done and results reported liy llacFadyean, Behring, Pearson, Gilliland, and others. MacFadyean, early in 1901, after intravenous inoculation of several cattle, two of which were tuberculous, with living cultures of tubercle bacilli, found that their resistance to infection was remarkably increased. Later in the same year Behring began experimental work upon a large scale, with a view to produce artificial immunization of cattle. After having secured rather indifferent, if not entirely unsuccessful, results from the use of tuberculin and its modifications, he succeeded in immun- izing these animals with attenuated cultures of living tubercle bacilli of bovine origin. A culture of human bacilli of low virulence was given to many cattle, and followed by another of increased activity after a few months. It was found that an enormous tolerance to virulent tuber- culous infection from the bovine bacillus was established. Inoculations with such infective material were usually attended by no appreciable results, while control animals unprotected by previous inoculation succumbed in a few weeks. The duration of the period of immunization has not been definitely determined. Pearson has shown conclusively, from references contained in an exhaustive and valuable article recently published, that Behring' s belief concerning the prolonged duration of the immunity has not been supported by subsequent facts in many instances. Recently experiments have been made at Melun, in the Department of Seine et Marne, by Valle. In February, 1905, Dutch cows, Limousin bulls, and Normandy cattle, all young and healthy, were treated by injections of a vaccine prepared by Valle in accordance with Behring's method. In the following June all were subjected to inoculation with virulent bovine cultures. Seven of the same age and race were inoculated subcutaneously, as were an equal number of controls. In one month all the control animals exhibited extensive tuberculous change, while only one or two of those vaccinated, exhibited even the slightest trace of infection. Six others were inoculated intravenou.sly. The vaccinated animals remained apparently unaffected, while the controls became 730 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT seriously ill, three dying within two weeks. Another set of animals were placed side by side with tuberculous cows in the same shed and inclosure. Resistance to infection was found in those protected by previous inoculations, while advanced tuberculous change was recog- nized at autopsy among the controls. It is of further interest to note that immunization of cattle through the digestive tract has been reported. Roux and Valle have very recently recorded experiments of this nature. Cultures of living tubercle bacilli were fed sparingly to young calves, and the reported resulting immunity was shown by the tuberculin test. Calmette and Guerin have reached the same con- clusion as to the production of immunity through the alimentary tract. The experimental investigations thus far reported have been suf- ficient to demonstrate beyond question the active protective influence resulting from inoculations of living attenuated cultures of tubercle bacilli. It has also been shown that injections of dead bacilli in animals do not exert more than a fleeting or partial immunity. The early researches of Koch in connection with tuberculin, and of other workers upon its various modifications, prepared the way for a recognition of the increasing tolerance established for bacterial toxins. There was suggested the possibility of securing an antituberculin or antitoxin capable of neutralizing the tuberculosis toxins. It was not altogether appreciated that the bacterial toxins of tuberculosis were but partially soluble in the blood, and that they remained more or less inwrapped within the solid substance of the parasite. It was assumed that cliffusion of the bacterial poison in the fluids of the liody took place in tuberculosis as in diphtheria and tetanus. Numerous methods were employed, and various animals utilized, in an endeavor to secure a supposed immunizing influence from the blood or the blood-serum. Maragliano found that the tuberculin reaction could be considerably^ diminished, if not prevented altogether, by the simultaneous adminis- tration of the serum of animals to whom the agent had previously been given. This and similar experiences by others with the serum from \-arious inoculated animals, were attributed to the presence of an anti- tuberculin. The so-called antitoxins were prepared in various waj's, but the claims made concerning their merits by their several advocates, have been unsustained by animal experimentation or clinical observa- tion. In the meantime Arloing and Courmont called attention to a peculiar effect produced upon tubercle bacilli contained in bacilli emulsion, by the serum of tuberculous individuals. A clumping of Iwcilli was recog- nized under these conditions, and the reaction was termed the agglutina- tion test. The clumping of bacilli is more "properly a sedimentation or precipitation, as the bacterial emulsion undoubtedly holds some of the toxins in solution, and tuberculin injections are known to increase the precipitating power of serum. Baldwin has shown that the injection of tuberculin into rabbits is followed by a high degree of precipitating power of the l)lood-serum for the tuberculin, and by an increased agglutination capacity for bacilli emulsion. For many years Jlaragliano has devoted much patient study to the subject of serum-therapy for pulmonary tuberculosis. He has made use of the .serum of animals previously injected with toxins and the bodies of dead bacilli. He has contended, since 1895, that a serum could be produced "rich both in antibodies and antitoxins." The THEORIES OF IMMUNITY 731 proportion of these substances is subject to much variation in different sera, and depends upon the manner of inoculating the producing animal. The amount of antitoxin is increased if the animal is treated with toxins, and the number of antibodies, if treated by the watery extract from the bacilli themselves. His doctrine of defense consists of the formation of antibodies and the consequent power of agglutination. He regards the agglutinating power as a measure of the antibodies. This reaction, which is regarded by Koch as the earliest indication of approaching immunization, is believed by Maragliano to corre.spond to the development of bactericidal properties of blood-serum. The latter is subject to precise determination by his method of showing an attained immunization. The animal is subject to repeated immunizing injections until the serum (which is subsequently standardized) is found to exhibit a sufficiently high power of agglutination. He asserts that new anti- toxins and new antibodies are produced by the introduction of the serum into the human organism, and that they supplement the natural resisting processes. He concedes that the general oiganism of itself is responsible in large measure for the increase of the defensive process in the blood, and hence that best results can take place only when the disease is not far advanced, general nutrition not greatly impaired, and mixed infec- tion not pronounced. Prior to the discovery of the tubercle bacillus, there existed widely prevalent ideas as to the production in man of varying degrees of immun- ity to tuberculosis from the preexistence and coexistence of certain other diseases, notably, scrofula, asthma, chronic bronchitis, and forms of heart disease associated with venous congestion of the lungs. The resistance of the body to tuberculous infection in the midst of these conditions, was not wholly ascribed to the influence of local processes rendering the soil unreceptive to a deposit of tubercle, but rather was attributed to a certain antagonism between the diseases in question. Even in scrofula, which was recognized to possess some relation to pul- monary phthisis, there w'as exhibited a certain stubbornness to general tuberculous involvement, suggesting a form of systemic resistance. Later statistical observations tended to confirm the early supposition that a natural immunity was conferred upon a number of people by the very pressence of a tuberculous affection. This was illustrated in the low mortality-rate of tuberculosis in comparison with its high morbidity. The fact that from 85 per cent, to 9.5 per cent, of the human race have been at some period of life the subject of tuberculous infection, as demon- strated by autopsy findings, and that only mic pci: (in in seven ,succuml.)s to the disease, was indicative of a local ti>-iic k i-i.-mcc, alTmdini; ])re- sumptive evidence of a general tendency- nf the c)rii:i.uisni to withstand advancing infection. Clinical experience has demonstrated from time to time an increased resistance to infection accompanying the development of localized tuberculous proces.ses, a remarkable inhibitory influence upon the progress of pulmonary phthisis sometimes being noted undci- tliese circum-stances. I recall several instances of tuberculous in\ (il\cnicnt of joints, bones, glands, kidne.ys. andepicUdymis, andparticnhuly rases of spinal caries, with the onset of which, there was exhibited an immediate and continuous retrogression in the activity of the pulmonary di.sease. This coincidence has been so frequent as to admit of no doubt concerning the increased general resistance often accompanying, if not occasioned by, the local affection. Such cHnical phenomena are strictly in accord 732 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT with Wright's doctrine, as to the stimulated machinery of self-immuniza- tion by the entrance into the circulation of a not undue amount of the toxins emanating from the site of local infection. The protective influence resulting from injecting attenuated cultures of various forms of bacteria was recognized by Pasteur in 1879, and con- stituted the first important advance toward the experimental production of biologic immunity. The well-known doctrine of phagocytosis, promul- gated by Metchnikoff in 1882. related to the conflict between the invad- ing parasites and the army of defense composed of leukocytes. The role of the latter was supposed to consist of the attack upon foreign elements, and their subsequent inglobement and digestion. It was eonceivetl 1)}" Metchnikoff that there "existed in certain sera, substances capable of enhancing the phagocytic powers of the leukocytes. To these substances the term "stimulins^' has been applied. Phagocytosis is known to vary in accordance with the existence of cellidar attraction or repulsion. This theory of chemotaxis. evolved by Pfeffer, the botanist, was extended by j\Ietchnikoff to apply to his hypothesis concerning the phagocytic power of the white cells. The presence, respectively, of a positive or negative chemotaxis as a determining factor in the production of phago- cytosis, was resourcefully accepted by Metchnikoff to be a fundamental principle of his doctrine, a positive chemotaxis being assumed as a basic condition for the formation of phagocytosis. Other theories of immunity have subsequently been advocated, and much experimental e\"idence presented to establish their correctness. Some of these appear inherently opposed to the doctrine of phagoc3'tosis, some capable of a reconcilable interpretation with this theory, and others of an entirely independent relation. It is impossible, in this connection, to cUscuss the theory of Ehrlich, the demonstrator of the mechanism of antitoxins, of Behring and Pfeiffer, the discoverers, respectively, of anti- toxin and the bacteriolytic action of immune blood-serum, nor of Gruber and Widal, the orginators of the agglutination tests. All point to the irre- sistible conclusion that the human body possesses means of defense other than obtain alone from the phagocytic action of the leukocytes. Ehrlich advanced the theory of a biologic union of the liacterial toxins and the receptor cells of the individual, as an essential condition of actual tox- emia. As a result of this union of the haptophores. the reaction takes place in the affected receptor cells, which are stimulated to make an excess of similar groups, constituting agents of defense and called anti- toxins. Unfortunately, the practical application of the principles of antitoxic immunity in pulmonary tuberculosis are unsatisfactory on account of the insolubility of the toxins in the blood. The tubercle bacilli and other pathogenic bacteria commonly present in tuberculosis retain their toxin, or more properly endotoxin, closely inwrapped within the protoplasmic body. In this connection the work of Pfeiffer, with reference to bacteriolytic action, is of considerable interest. Bacteriolysis is thought to be attended in some instances with such a liberation of the endotoxin, that the disintegration of the bacilli may not only afford no protection against the toxin, but possibly may even increase systemic intoxication. The tubercle bacillus has been found to respond to no bactericidal or bacterio- l3i;ic action of the blood, and. generally .speaking, to no antitoxic influ- ence, after the manner of diphtheria and tetanus. In the light of recent investigations, it is apparent that in tuberculosis, phagocytosis still THEORIES OF IMMUNITY 733 remains a most important element in the production of immunity. The degree of phagocytosis, however, is dependent upon conditions other than the simple presence of a positive chemotaxis. Substances are known to exist in the blood which exert a predominant influence upon the phagocytic action of the leukocytes. I'his power of defense by the organism is found to vary according to the effect of certain preparatory substances upon the bacilli, increasmg their susceptibility to the action of the white cells. According to Potter, the earliest demonstration of an increased phagocytosis referable to alterations of the microorganism, was made by Denys and Leclef in 1895. This was followetl by consider- able experimental work by Bordet, Mennes and Leishman, Wright and Douglass, Neufeld and Rimpau, Bullock, Western, Ruediger, Saw- tchenko, Dean, and Hektoen. All a.tcrecil :is to the specific effect of the serum upon the microorganism and its c.-^scutiul role in the production of phagocytosis. Potter has reccnti\- shown that the phagocyting power of corpuscles taken from a di chsimI person is considerably less than that of corpuscles from a suppn.-cdl y healthy individual. Thus, in addition to the differences in nornidl srrd, rariations are found in the phagocytic activity of leukocytes of patients subjected to bacterial infection and individuals apparently well. Potter has suggested, as a result of his observations, that during a severe infection, the phagocytic power is disproportionately lower than the opsonic index of the serum, and upon recovery the defensive activity of the leukocytes, in compari- son with the corpuscles of normal individuals, enhanced more noticeably than the opsonic power. The term " opsonin' ' has been applied by Wright to the substance preparing the microorganisms for phagocytosis. As mentioned pre- viously, there are other elements involved in the mechanism of immu- nity, i. e., the agglutinins, the bactericidal substances, the bacterio- lysins, and the antitoxins. In recognition of the action attributed to these substances, all may be grouped under the term " bacteriotro- phins." Wright, modifying the nomenclature of Ehrlich, speaks of the products of immunity generally as antitropic elements or antitropins. The source of the opsonins in the blood is unexplained, but Wright believes that they are stimulated locally, hence the expechency in tuber- culous glands and lupus, of injecting vaccines near the site of infected processes. Hektoen and Ruecliger, in 1906, showed that a lytic action without opsonic power can exist in normal serum and vice versa. They also showed that immunization may be attended by opsonic action without agglutination or bacteriolysis. It has been claimed by Wright and his school that a separate opsonin exists in the blood for each variety of microorganism. An elaborate and technical method for the precise determination of the opsonic power of chfferent individuals at varying times in relation to the several forms of bacterial invasion has been advanced by Wright. The amount of opsonins present to combat a single infec- tion may be widely at variance with the extent of opsonic action against other bacteria. Further, the quantity of opsonic substance within the blood is known to vary considerably in the same individual from time to time under differing conditions. These conditions relate not only to external factors, such as exercise, excitement, food, etc., but also to varying changes within the body. In other words, there is going on at different times a distinct effort on the part of the 734 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT organism toward self-immunization, which process is subject to remark- able fluctuation in accordance with certain pathologic and physiologic conditions. In accordance with the law of biologic immunity, when bacteria or their poisons are introduced into the system, the response of the organism consists of the elaboration of protective substances against these invaders. The mechanism of defense relates to the action of agglutinins, lysins, bactericidal substances, antitoxins, and opsonins. Under soTne. circumstances the tuberculous individual develops resources of tlefense unattained by those not thus affected, antl in other instances awaits artificial aid to immobilize a waiting army of defense. It may Ije that even an excess of poisons exists in the body to start the machinery of immunization, but is incapable of utilization by virtue of being locked up within foci of infection by heightened bacteriotrophic pressure. Thus artificial excitation of the protective processes remains to be secured by the introduction of bacterial agents. In other cases an overproduction of poisons emanating from centers of infection is attended by a dimin- ished opsonic power. It is thus apparent that the maximum amoimt of opsonins is to be acciuired neither from a paucity nor a surplus of toxins, but rather from such a tlosage at different times as will supply the deficit in the working capital of the individual, whose unaided resources of a toxic nature are insufficient for the maintenance of sat- isfactory immunization. In some chronic infections, where a lowered bacteriotrophic pressure continuoush' prevails, Wright is of the opinion that the introduction of a suitable \;iitiu(' act s as :i St inuilHut to the dormant processes of immimity. The oiisiiiiius aic oil ell sulijcct lo much variation, according to the inflow into the cirrulation of the liai-terial products, whether they are present during the course of the disease or are introduced for therapeutic pur- poses. In tuberculosis the inflow of tuberculo-opsonic substance is by no means constant. Some patients are continuously overinfecting them- selves from numerous foci, and others persistently suffering from defi- cient stimulating toxins. Wright's practice consists of an attempted regulation or adjustment of the amount of protective poisons b}' means of carefully estimated and properlj' interspersed doses of artificial \af- cines, based upon the frequent estimate of the op.sonic power. He has demonstrated a certain definite sequence of changes in the opsonic action after the injection of vaccines. Following this injection there is induced a phase in which the protective substances in the blooii. opso- nins, agglutinins, etc., are diminished — the so-called negative phase. This is followed after a longer or shorter period of time, according to the size of the injection, by a rise in the amount of protective substances — the so-called positive phase. During this time phagocytosis is markedly stimulated. This cyclic variation in the amount of protective sub- stance in the blood is termed "the law of ebb and flow and reflow, and the maintained high tide of immunity." Successful results of inoculation depend greatly upon the adaptation of the size of the dose to the needs and requirements of the general organ- ism. The excursion of the negative and positive phases is dependent not only upon the quantity of vaccine introduced, but also upon the original amount of opsonins present. Thus a small do.se in case of a relatively high opsonic power, may produce but slight, if any, negative phase, and a correspondingly insignificant positive reaction. A similar clo.se, given in the presence of a much diminished opsonic power, may be followed THEORIES OF IMMUNITY 735 by a more pronounced negative disturbance, and, up to a certain point, a proportionately greater positive phase. If, however, a large amount of toxin be injected, the negative phase may appi'oach to a condition of collapse and be attended by severe constitutional disturbance, per- sisting for a prolonged period and not followed liy any positive phase whatever. It will be seen that the very essence of the method consists of an approximately accurate estimate of the deficit in opsonic resources, and the effort to supplant the natural protective forces by carefully adjusted artificial dosage. By injudicious injections the natural forces of defense may be supplantecl altogether, thus destroying, by artificial means, the very efforts toward self-protection. With diminished resist- ance through continuous indiscreet inoculations, a large dose admin- istered during the negative phase or at the time of low opsonic power, may culminate in such depletion of protective elements as to overwhelm the individual. By the use of suitalily prepared vaccines the bacteria within the system are rendered more .•^uscei)til)le to phagocytosis. The vaccine in all cases of bacillary invasion sa\-e that of tuberculosis should be pre- pared from the particular strain of bacterial infection present in the individual to whom it is to be administered. It is probable that in tulierculous affections the best results may be attained by the use of homologous vaccines. In case of pure tuberculous infection without constitutional or bac- teriologic evidence of secondary invasion by a variety of pathogenic bacteria, the toxic agent ,ni'iii'raHy ciiiiilnycd for practical therapeutic purposes is Koch's l.iaiilli I'lnul mn. ihc new tuberculin. In the event of mixed infection in puliii(Hi;ir\- t iiliciculo.-i-. with considerable temper- ature elevation it is often inexpedient to attempt an increase of the ^M6ercM/o-opsonic power on account of the fluctuating toxic infection, which precludes any effort in the way of artificial adjustment. In such cases I have sometimes been able to secure satisfactory results by the use of homologous vaccines. Clinical observations of this nature will be later reported. The vaccine directed toward the relief of the secondary infection is i)l)t;iinc(l from the sputum of each invalid for whom the agent is to be ciiiplDX (m1. The technic of this prejKuatidu, as performed by Dr. W. C. Mitchell, according to Wright's methoil, is as follows: After sterilization of the mouth and throat with a saturated solution of boric acid, the sputum is deposited directly from the mouth into a sterilized bottle. A portion of the sputum is separated from the interior of the mass and carefully teased in a sterile Petri dish with sterile forceps or platinum loops. This rnass is rubbed upon the surface of a blood-serum culture-medium and the process continued through a series of five or six test-tubes, the loop being sterilized between each inoculation. After subjection to a temperature of .37° C. in the incubator for one or two days, the various isolated colonies of bacteria are recognized in the fourth or fifth tub^. From these tubes they may be separated into individual cultures liy transference to other tubes of culture-media and incubated. After thus securing pure cultures of the microorganism, the culture is scraped with a glass rod or a platinurn loop into a small amount of sterile salt solution, making a bacterial emulsion. This is placed m a sterile test-tube which is drawn out to a fine point and sealed. I-t is then shaken for fifteen minutes in order to break up the clumps. To dctcnniiv the slriiii;tli of the preparation one volume of blood from the finger is mixed with :iii ri|ii:il i|u,in- tity o' the above bacterial emulsion, and diluted with three voluni.- ni iinriii;il ^alt solution. After smearing, fixing, and staining the ratio of niiircii>ri.':iiii-i]i> to the red blood-cells is computed from the study of a number of fields. The examiner is enabled to determine the number of bacilli in a unit of volume by the known 736 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT number of red cells in a cubic millimeter. Thus the proportion is as follows: The number of red blood-cells in a given number of fields is to the number of bacilli in the same number of fields as 5.500,000 red blood-cells (Colorado altitude) is to X. X equals tlie number of bacilli in a cubic millimeter. From this the number of bacteria in a cubic centimeter is obtained by multiplying the number in a cubic millimeter by 1000. The test-tube containing the bacterial emulsion is again sealed and placed in the hot-water bath at 60"-02° C. for one hour. It is necessary to destroy the vitality of the microorganisms but to preserve at the same time their toxic properties. Too short a period of sterilization will fail to kill the bacteria, while if this is too prolonged the preparation will be rendered inert. After the process of sterilization is completed the bacterial emulsion is diluted with sterile salt solution, and a computation made of the number of bacteria in each cubic centi- meter. Control cultures are made in all cases to demonstrate that the vitality of the bacteria is actually destroyed. The tubercle bacilli vaccine, in contradistinction to the above, is estimated by weight rather than by enumeration, and is given in initial doses of from one ten-thousandth to one one-thousandth of a milligram. The determination of the opsonic power of an individual consists of an estimate of the relative number of bacteria ingested by washed white blood-cells under the influence of the patient's serum, in comparison with the number ingested by the same number of cells in the presence of normal blood-serum under precisely similar conditions. It follows, therefore, that as essential factors there must be blood from the patient ; blood assumed to be normal : and washed leukocytes. In addition, there must be at hand an emulsion of the sporific hartrria concerning which the opsonic action is sought. After cleansing of tin fiii;;' r tin' patient's blood is withdrawn by means of capillary attraction into the cm \ r.l cm ninity of a glass capsule, the fine capillary ends of which have been broken. The st rai' o( his met hod of attempted artificial immunization. The general consensus ul' djuuion among scien- tists and clinicians is to the effect that mcrinr medication is founded upon rational grounds and is destined tn lejuesent a great advance in the therapy of the future. The jirirlsr ni/uldlion of the dosage, based upon the determination of the opsonic index, however, is ojien to con- troversy. Adverse opinions are freely expressed iimceruiim the general impracticability of his work, on the score of the iiiaii\ opportunities for error and confusion in the detailed ajijiliratioii of the iiiiii<'ate terhnic. In addition to the dilliculiie.- aHeiiiliiii: the lecliiiic, due eounizauce should be taken of the pos-ilih> sources ol enoi' iidierelit to dijjir, nccs in the susceptibilit!/ of tlie microorgauisni.s lo agglutination in a com- paratively large volume of serum, and to the variations in the effect of the pathologic sera upon normal phagocytes. It does not follow, however, that ifor these reasons alone the method of Wright is unworthy of recourse by those qualified, through training and equipment, to take advantage of his contributions. Wright and Bullock have called attention to one of the difficulties in securing immunization in pulnioiiai\- t ul>erculosis from the em- ployment of tuberculin. They atfrilnite eousulerable importance to the histologic and pathologic struct me ot the pulmonary tubercle as offering a barrier to the antil>ariei iai forces of the organism. They believe that the toxins, otherwise simulating to the machinery of immu- nization, are locked up within these foci of infection, and, per contra, if artificial aids to the immunizing process are introduced into the cir- culation, that the bacilli remain protected to some extent behind a wall of non-vascular connective tissue. It thus appears that inoculations with bacilli emulsion are regarded as dangerous for one class of consump- 738 PROPHYLAXIS, GENERAL A.ND SPECIFIC TREATMENT lives suffering from an excess of toxins, and as non-e^cctive on account of structural conditions for those exhibiting a deficiency of these pro- tective substances. This hypothesis of the defense of the bacillus is opposed to usually accepted ideas concerning the inclosure of the bacil- lus, its possible exclusion from the organism as a result of encapsula- tion, and the protection accruing to the individual by this means. The theory of Theobald Smith as to the defensive role of the celkdar out- lying breastworks in the interests of the bacillus containetl within its tubercle abode, is somewhat in accord with that of Wright, although inspired by no acceptance of a special relation of opsonins or blood leuko- c}-tes to immunity. He regards the tissue reaction concernetl in the process of tubercle formation as an important element in the mechan- ism of defense, both for the host and the parasite. Thus a quiescent focus is secured for the indefinite and undisturbed sojourn of the bacil- lus, but opportunities at the same time are denied for its multiplica- tion or escape. He also advances the theory, as previously stateil, that the bacilli are at times pro\ided with a protective envelope, which he believes, in contradistinction to Wright's hypothesis, to remain intact when the opsonic power is low, and thus exert a protective influence upon the organism by preventing multiplication. An apparent immunitj'^ is supposed to exist at such a time, to be succeeded Iny removal of the envelope, multiplication of bacilli, and greater tuberculous activitj- in proportion as the opsonic power is elevated. It would seem, in the midst of conflicting views entertained bj' many eminent authorities, that general clinical observations should lie worthy of presentation. CHAPTER C PERSONAL OBSERVATIONS UPON THE USE OF BACTERIAL VACCINES' The published reports of Wright and his fellow-workers indicate the value of vaccine medication in localized tuberculous infections of the bones, joints, glands, and portions of the genito-urinary tract, but suggest that the results of its emploj'ment in pidmonary tuberculosis are likely to be disappointing. He recognizes elements of danger if the bacilli emulsion is administered indiscriminately to pulmonary invalids, and particularly in the presence of fever and a widel}- fluctu- ating index-curve. Under such conditions the patient is already under- going a continuous infection from an improperly adjusted and inter- spersed dosage of the toxins. At such a time the employment of the vaccine only adds to the burden of the individual, and diminishes any effort on the part of the organism toward autoimmunization. This objection to the use of the vaccine in pulmonary tuberculosis, obtains in the event of an existing surplus in the blood of toxins emanating from tuberculous foci, and as well from centers of secondary injection. The ' A portion of this chapter was written for the annual meeting of the American Climatological Association, held in Washington, May, 1907, but was not reatl, owing to unavoidable absence. A supplement arj" report is appended, embracing the results of subsequent observation. PERSONAL OBSERVATIONS UPON USE OF BACTERIAL VACCINES 739 thought naturally arises whether the existence of a severe mixed infec- tion in pulmonary tuberculosis materially alters the indications for tuberculin, or suggests the expediency of resorting to an autogenetic vaccine. It is very essential to establish somewhat definitely if vaccine medication is of clinical value in pulmonary tuberculosis, and to what extent its employment should be based upon the determination of the opsonic index. In view of the unreliability of the serum preparations sometimes em- ployed to combat the mixed infection of pulmonary tuberculosis, and the many disadvantages attending their use, 1 was actuated, in the early part of 1907, to institute a clinical inquiry concerning the results possible of attainment with the bacterial vaccines. It was also my purpose to deter- mine, if possible, the effect of the bacilli emulsion upon cases of pulmo- nary tuberculosis uncomplicated by mixed infection. It was recognized that a purely scientific investigation along these lines would involve such frequent estimates of the opsonic index as to be prohibitive of the obser- vation of more than a few cases. In view of the supposed range of variation in the indices of many pulmonary invalids, it was felt that approximately correct conclusions from an opsonic or laboratory stand- point would demand the observations of the index once daily. I did not feel, however, that the scope of my investigation should relate merely to the recording of indices, and the assumption of an increased power of resistance in a very few closely observed cases, but rather to the clinical stud[/ of a comparatively large number of patients conforming to the same general class. This has necessitated the taking of the index of each patient at quite infrequent intervals. A degree of compensation for this discrepancy has been secured by the careful selection of cases, and the fact that the patients were kept under the closest practicable supervision in order to avoid diurnal fluctuations of the index from external causes. I beg to express my obligation to Dr. W. C. Mitchell for his careful performance of the technical portion of the work, includ- ing the determination of the opsonic indices and the preparation of the bacterial vaccines. An appreciative recognition is also accorded Dr. E. W. Emery for valuable assistance rendered in the opsonic work. In all instances the index was secured prior to the first dose, and thereafter at intervals of from ten days to a few weeks. In the beginning an effort was made to take the indices more frequently, but this practice was discontinued for several reasons. The e\'ident futility of such spas- modic efforts to obtain an approxiin.-itc csiimate of the mean daily opsonic power was apparent. In \ic\v uf ihr lai'ge number of patients undergoing vaccine treatment, frequent olisiMN'ation of the indices was impossible. The increased financial burtlcu incident tn their oft-repeated determination represented a factor of cdii-ideialile importance. The clinical study was undertaken solely for practical junposes, and despite its deficiencies resulted in an instructive experience. The total number of patients undergoing vaccine therapy, in the first four months of 1907 was 67, who were divided into three widely differing groups. In work of this character a proper classification of cases constitutes a feature of the utmost importance. Group 1 comprised 42 cases of chronic pulmonary tuberculosis without symptoms referable to mixed infection. It was recognized that all patients should represent, if possible, the same general type and 740 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT stage of the disease, and conform more or less closely to a fixed regime. It seemed highly desirable that there should be eliminated all sources of confusion arising from climatic influence or change of environment. To this end patients included in this ^luup \\(>ie selected with extreme care. In view of the uncertainties .ii icn.liui; its employment, no indi- vidual was permitted to undergo the ticat incut, whose general condition and previous progress had been entirely satisfactory, or who exhibited appreciable temperature elevation. On the other hand, an effort was made in the selection of cases to include onl}- those who, in spite of a continued residence in Colorado xitidi r (ipiirdjirintc ronditions of daily life, had failed to secure an entire arro.-t ol the tuliciculcjus process. It was believed that more definite infornuuiim rouicnuuii the effect of the treatment, coidd be secured by limiting its api^lication to those whose condition had been almost stationary for prolonged periods. Of all the eases comprising this group, the average period of residence in Colorado, with practically unchanged environment, was two years and eleven months, the longest being ten and one-half years and the shortest six months. A remaining activity of the tuberculous process was present in all cases, as evidenced by physical signs, cough, expectoration, and bacilli. A new method of treatment was hailed with enthusiasm by these patients as precursory of possil^le future recover^-, thus introduc- ing a psychic element impossible of elimination. The injections were administered at regular intervals of two weeks. This periocUcity of dosage was decided upon in order to conform as far as possible to the expected expiration of the positive phase. The initial dose was usually one ten-thousandth of a milligram. Both a low and high index were considered suggestive of a small dose in the beginning. It was noted that the initial opsonic index of several patients, upon the basis of Wright's conclusions, suggested a «o?i-tuberculous concUtion. The variation in health is supposecl to range from 0.8 to 1.2. Wright has assumed that any persisting deviation from these limits is fairly indicative of a bacterial invasion, and has regarded a normal index as suggestive of its probable exclusion. As a matter of fact, in this series many patients exhibiting a normal index were individuals cUs- playing pronounced physical and subjective evidences of advanced tuberculous change. There was shown a wide range in the opsonic index, even among a group of patients especially selected with a view to securing approximate uniformity of conditions. It may be stated parenthetically that the subsequent clinical results in a few patients with high indices, indicated their favorable response to the tuberculin injections, quite as much as in others with a beginning low opsonic power. During the entire period of observation a disparitii was noted between the clinical and opsonic findings. Many patients disj^laying conspicuous improvement as a result of the tuberculin injections were found to exhibit trifling variations in the opsonic index. Upon the other hand, several whose index curve was found to undergo a satisfactory elevation, nevertheless failed to respond favorably to the specific medi- cation. The early discrepanc}' between the clinical and opsonic results suggested that the lack of parallelism, occasioned presumably by rea- son of the difficult and intricate technic was sufficient to vitiate any practical deductions based upon the observation of the index. It soon became questionable if any reliable information was furnished by the opsonic index either concerning the clinical progress or the size PERSONAL OBSERVATIONS UPON USE OF BACTERIAL VACCINES 741 and frequency of dosage. In the light of these investigations it was later decided to discontinue the study of the indices, but to pursue the inquiry along the lines of clinical observation. Although especial inter- est attaches to the individual cases, the clinical results may be gener- alized briefly. In no instance have I been able to detect permanent injury from the treatment, and in some cases conspicuous improve- ment. Although demonstrable progress has been established in many instances, it is probable that in some cases the psychic element has been a factor of con.siderable importance. It is noteworthy, however, that not infrequently depression of spirits has ensued for one or two days following the injection, several complaining of phy.sical weakness, lassi- tude, and .slight indisposition. Some have exhibited a rise of tempera- ture of one or two degrees, beginning a few hours after the injection and persisting during the next day. In a few instances there has been a slight chill, followed by fever, and in two patients a severe rigor. In one case a sharp hemorrhage took place within a few hours, but ceased abruptly and was not followed by recurrences. Two others experienced a slight hemorrhage of very short duration. A number have complained of headache, this being severe in but two cases, one of which was relieved by calcium lactate. In some instances there has been temporary exacerbation of cough and expectoration. It is apparent from these manifestations, that the agent is not always unattended by local and constitutional reaction, but the unpleasant symptoms are almost uniformly of short duration and relatively infre- quent. Upon the other hand, there has beeir several times an admission of a material diminution of cougli, and sometimes its complete cessa- tion. The sputum has been markedly lessened in many cases. In a few instances a conspicuous diminution of l)acilli has been noted several months after the inauguration of this treatment. A gain in weight has been exhibited by several patients whose previous efforts in this direction had proved unavailing. In no case has there been a loss of nutrition. A better appreciation of the character of results reasonably to be expected from time to time among cases of this character, is afforded by a brief history of a few special cases. Case 1. — An army officer, thirty-three years of age, consulted me November 20, 1905, immediately upon arrival in Colorado, eighteen months after the development of his initial tuberculous trouble. During a six months' sojourn in New Mexico, he experienced several hemor- rhages without appreciable change in the general condition. There was some temperature elevation daily, and considerable dyspnea upon exertion. There were extensive areas of active infection in each lung, moist rales being recognized upon the right side from the apex to the fourth rib, and to the lower edge of the shoulder-blade; on the left to the fifth rib, and to the very base behind. During the following year he exhibited a pronounced improvement in many rospprts. establishing a gain of nearly forty pounds in weight, with corrcs]ili\ ,-i( :il signs. During the en.^uiiiL! i\ immhiIi^ the patient gained an adcUtional fifteen pounds in \vei,i;hi. wiih rorre.sponding improvement in the general condition. There is an almost entire absence of cough and expectoration, and a complete disappearance of tubercle bacilli. The physical signs, however, do not denote an entire arrest of the tubercu- lous process. Evidences of moisture are no longer recognized in the right lung, but very fine clicks are detected after a cough in the upper portion of the left back. (See Fig. 60.) Cose 4.— A woman of thiit y-tliree couMilted nie Febniaiy 17, 1905, two years after arrival in Cdloradn. and Um- year- aiiei ilie dexelop- ment of her pulmonary tulieicuhisis, diuinii wlinh (iiiie ^lie liad \isited various health resorts. The general trentl of the case hax'ing been downward from the beginning, she was advised by her medical attendant to return home. Cough was severe, expectoration copious, the tempera- ture elevated daily, and dyspnea marked upmi sH^lii exercise. She came under my care at this time, showing extciiMvc a< ii\e tuberculous involvement of both lungs. Upon the left side iheie was extensive consolidation, with coarse bubbling rales to the fifth rib and to the mid- dle of the interscapular space, and upon the right, moist rales, without consolidation, to the third rib and to the spine of the scapula. During a period of one year and eleven months up to January, 1907, she exhibited remarkable progress, gaining forty pounds in weight, with correspond- 744 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT ing improvement in strength and in the condition of the lungs. The cough and expectoration, however, remained but little affected. Tu- bercle bacilli, though not numerous, were recognized in every micro- scopic field. Injections of bacilli emulsion were commenced on January 10th. Like the preceding case, a very perceptible gain has been noted throughout the entire period of administration. The improvement has been maintained continuously, the cough and expectoration being greatly reduced. Tubercle bacilli are absent alto- gether in some specimens, and in others found only after long search- ing. (See Fig. 83.) Case 5. — A woman, aged twenty-three, developed tuberculosis in March, 1905, and after spending nine months in Las Vegas, New Mexico, came to Colorado with active extensive tubercidous infection of each lung. There was a loss of fifteen pounds in weight, moderate fever, weak and rapid pulse, nervous temperament, paroxysmal cough, and exces.5ive expectoration. There were signs of consolidation in each upper lung, with moist rales on the left side, from the apex to the fourth rib and to the lower angle of the scapula; upon the right, from the apex to the third rib and to the middle of the scapula. During the summer and fall of 1906 a pronounced gain was established, the weight increasing twenty-five pounds. The upward progress apparently reached a standstill early in 1907, the physical signs being practically the same as upon arrival, and the cough and expectoration not espe- cially diminished. The tuberculin treatment was instituted January 24th. A material subsidence of the cough and expectoration was estab- lished after a few injections, together with a distinct improvement in the physical signs, the opsonic intlex, however, showing scarcely any variation. An examination of this patient, made January 6, 1908, showed no evidence of tuberculous trouble in one lung, and a very slight amount of moisture in the apex of the other. Several examinations of the sputum have failed to disclose the presence of bacilli during the past few months. (See Fig. 65.) Case 6. — A woman of twenty-three sought climatic change m October, 1900, exhibiting active tubercidous involvement of both lungs of six months' duration. There was pronounced loss of weight and strength. The examination of the chest revealed well-defined con- solidation at the right apex, with bubbling rales to the third rib and middle of the interscapular space. Upon the left side moisture was readily detected from the apex to the spine of the scapula. The progress of the case up to January, 1907, could not be regarded as satisfactory. The cough and expectoration showed but little abatement. There were daily elevations of temperature, decided impairment of appetite, and continued activity of the tul)erculous process, as evidenced by numerous bacilli and persisting moisture in the finer bronchi. Through- out an entire year (1906) the patient suffered almost continuously with severe pleuritic pains in the right side, with frequent .slight hemopty.ses. The tuberculin was given in January, 1907, and upon the following day there was a severe rigor, followed by a sharp elevation of temperature, which persisted for two days, with noticeable aggravation of cough. In sub.sequent doses of one four thousandth of a milligram the patient has experienced slight malaise and inchsposition for one day, without other disagreeable manifestations. A material improvement has been ex- PERSONAL OBSERVATIONS UPON USE OF BACTERIAL VACCINES 745 hibited in the general condition and physical signs, without appreciable variation in the opsonic index. At no time since beginning the adminis- tration of the vaccine, have the pleuritic pains been felt or has the slightest trace of blood appeared in the sputum. The improvement in the physical condition has been pronounced. At present the physical sip;ns in the loft lunc; arc entirely negative. Upon the right side, while the cNidciiccs uf the (vuIn cousnlidation in the upper portion still persist, but :iu cxci'i'dinjily .^li^lu uiuount of moisture can be recognized upon careful examination. Very line clicks are detected in a small circumscribed area below the clavicle, and at the very apex behind. The general condition is excellent, although the cough and expectoration have not entirely disappeared and bacilli are present in small numbers. Case 7. — A woman, twenty-four years old, arrived in Denver dur- ing the summer of 1906, after having suffered from pulmonary tuber- culosis during a period of three and one-half years. There was a loss of twenty pounds in weight, moderate cough without fever, an excellent appetite and digestion. There existed marked consolida- tion of the left upper front to the third rib and to the middle of the scapula. Moist rales were recognized to the fourth rib in front and to the base behind. Upon the right side there were moist i-ales to the second rib and to the upper angle of the scapula. Bacilli were present in large numbers. During the succeeding six months not the slightest improvement was exhibited in spite of favorable surroundings and implicit obedience to detailed instructions. There resulted a loss of seven pounds in weight, a diminution of strength, increase of cough and expectoration, without fever. In view of the absence of fever and the unmistakable evidences of progressive decline, it was determined, for experimental purposes, to administer the tuber- culin in spite of a relatively high opsonic power. The first dose was given on January 20th, and continued with regularity every two weeks. While no disagreeable symptoms resulted from its administration, no appreciable improvement was noted during the first six weeks. There developed subsequently a gratifying change for the better, as evidenced by great diminution of cough and expectoration, a gain in weight, and increase of strength, with lessened activity of the tuberculous process. The bacilli were decidedly less numerous in the sputum. During the latter part of 1907 the patient evinced a remarkable improvement in all respects. The examination of the chest revealed an entire absence of moisture, while the cough and expectoration almost disappeared. (See radiograph. Fig. 64.) Case S. — This case is somewhat similar to the preceding in many respects. A woman of forty-six came under my observation in August, 1903, after residing in Colorado two years, and exhibiting a progressive decline from the onset of her tuberculous infection. On account of emaciation and extreme prostration, with high fever daily, diarrhea, distressing cough, and advanced tuberculous change in the lungs, the patient had been advised by her physician to return home. During the following two years she gained thirty pounds in weight and exhibited definite evidence of improvement in the general condition and in the pulmonary process. After many months' confinement in bed as a re- sult of a .series of severe hemorrhages, she lost twenty pounds in weight, and exhibited during the following year but slight recuperative power. 746 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT As a probable result of the tuberculin inoculations, the cough and expectoration materially diminished and a pronounced improvement was noted in the general strength. The bacilli were considerably less numerous than before the injections were given, but the tuberculo- opsonic index remained unchanged. An examination of the patient upon January 5, 1908, shows an entire arrest of the tuberculous process in the right lung, with extensive fibrosis. But very fine semidry clicks are recognized after cough at the very apex of the left lung. The cough and expectoration are relatively slight, while the bacteriologic findings are absolutely negative. (See Fig. 61.) Case 9. — A woman of twent.v -seven considted me in July, 1904, eight months after arrival in Colorado and five jears following the develop- ment of her tuberculous infection. There was a loss of fifty pounds in weight, daily afternoon temperature of 101 ° to 102° F., marked dyspnea, and prostration. There was slight consolidation, with moist rales in the left lung from apex to base, and upon the right side to the third rib. As a result of a continuous conformity to a systematic regime, a slow but progressive improvement has taken place. In January, 1907, she had gained fifteen pounds in weight and materially in strength. The physical signs remained, however, practically unchanged. Cough was frequent and distressing, and expectoration profuse. Shortly after beginning the injections of bacilli emulsion there took place a pro- nounced improvement in all respects. The cough and expectoration have almost ceased. There is a gain in the general condition and a perceptible diminution in the number of bacilli. The patient was permitted to return home during the summer of 1907, and I am informed that no retrogression has taken place. (See Fig. 68.) Case 10. — A man, forty-one years old, came under my observation in September. 1904. nine months after the onset of pidmonary tuber- culosis. There were much emaciation and physical weakness, a daily temperature elevation of two or three degrees, and distressing cough. The tuberculous process was extensive and active in each lung. Upon the right side there was consolidation with moist rales to the third rib and to the very base behind. An appreciable consolidation was recog- nized upon the left side, in the upper front, with slight moisture, while in the back there were coarse rales from the apex to the lower angle of scapula. Up to the fall of 1906 there was exhibited a decided improve- ment in all respects, the cough and expectoration tlisappearing altogether, the weight becoming greatly increased, with no longer evidence of active involvement upon physical examination. This case was reported a year ago as an instance of an apparent total arrest of the tuberculous process, although previously adjudged to have been utterly hopeless. After returning home and engaging again in an arduous career, he returned to Colorado in the spring of 1907, exhibiting a loss of twenty pounds in weight and renewed activity of the tuberculous process with numerous bacilli in the expectoration. After three or four doses of tuberculin were given there took place a moderate le.ssening of the cough and expectoration, with a corresponding diminution in the number of tubercle bacilli. After a summer in the mountains of Colorado, during which further improvement was attained, the patient again returned to his home and resumed the duties incident to his profession. 1 am informed that a PERSONAL OBSERVATIONS UPON USE OF BACTERIAL VACCINES 747 further gain in weight has been secured, that the cough and expectora- tion are very slight, the former strength and endurance but little impaired, although a few bacilli are occasionally detected in the sputum. (See Fig. 81.) The foregoing cases have been selected as illustrative of the beneficial influence undoubtedly exerted by the bacilli emulsion. The conclusion seems unavoidable that this agent has been responsible in large measure for the improvement noted. Of the remaining 32 cases in this class, 15 may be said to have exhibited some favorable effect from the administration of the remedy. In 12 there was no appreciable influence properly attributable to the tubercidin. Five exhibited an increase of cough and expectora- tion after each injection, to such an extent that the tuberculin was suspended after three or four doses. It is noteworthy that no patient with high initial tuberculo-opsonic index, even though much in excess of normal, failed to respond favorably to the influence of the remedy. The diminution of bacilli in a number of cases is reported solely as a matter of interest, with due regard for the fact that this observation is of doubtful importance. Group 2 consists of ten patients who had resided in Colorado for varying periods of time, but whose localized tuberculous processes sug- gested the advisability of this treatment. In this class arc included three cases of tuberculous cervical glands, one of tuberculosis of the sacral and lumlDar \-ertebr8e, with discharging sinus, one of primary tuberculosis of the larynx, one of tuberculosis of the pharynx, one of tuberculous bronchitis, two cases of tuberculosis of the testes, and another of the kidneys. The case of lumbar and sacral caries with discharging sinus was complicated by severe mixed infection, and, therefore, will he described under the succeeding group. One case of glandular involvement was not under observation sufficiently long to warrant the expression of a positive opinion, as to the efficacy of the treatment, but distinct improve- ment was noted in the second instance. The third patient with gland- ular tuberculosis had suffered a return nf ihis condition after several years' disappearance of the glands. Idljowiui:, a prolonged couise of treatment with the .r-ray. On accouiil of an unsighth' and progressively enlarging nevus over the site of the glands, presumablj- occasioned by the too frequent use of the .r-ray, further recourse to this agent was impracticable upon the reapjiearance of the glandular enlargement. Two injections, therefoi-c. of tuKeiriiliii wpi-o aihiiinistei-fd. and attended in each instance by a -liar|i Icm.iI icai'tion, without other ron>tiniiional disturbance than physical weakness and iiiahiiso. The day following the second dose the glamlular mass became increased in size, reddened, and decidedly painful. The external appearance was that of acute inflammation. In view of the pain and local discomfort, further con- tinuance of the tuberculin was not deemed practicable. On account of the presence of the nevus, which occasioned considerable disfigure- ment, it was decided to resort to surgical methods for its excision and for the removal of the glandular enlargement. The case of primary tuberculosis of the larynx has lieen reported elsewhere. (See p. 526.) The patient was referred for laryngologic treatment to Dr. Levy, who rendered a guarded prognosis. The patient was kept under treat- 748 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT raent for two months, with but slight resulting improvement either in the lociil or general condition. He was then given the injections of bacilli emulsion during a period of two months, from which an improvement in the local condition was reported. No conclusion of value could be drawn from the administration of the remedy to the patient with pharyngeal tuberculosis as manifes- tations of a general miliary involvement speedily supervened. The case of tulierc'ilosis of the testes, which is of great interest, has been described under Genito-urinary Complications upon p. 509. Another case of tuberculosis of both testes has exhibited an appreci- able improvement following the tuberculin injections. The tuberculous involvement upon one side was of thirteen months' duration, and upon the other of five months, the patient being a boy of nineteen without pulmonary involvement. A perceptible diminution of the discharge from each sinus has taken place, together with a reduction in the size of the tuberculous organs. The ca.se of tuberculosis of the kidney is also instructive. The patient, a man of about thirty-five years of age, came under my obser- vation February 16, 1907, being referred to me by Dr. Leonard Free- man for opinion with reference to the advisability of nephrectomy. The patient had been under his care since November 1, 1906, consulting him at that time on account of a perinephritic abscess of the left side of ten days' duration following a cold. The urine was loaded with pus. The abscess was opened and found to contain a foul, thick, purulent secre- tion. The kidney was easily felt, and contained several small superficial abscesses, which were not incised. Subsequent examinations of the urine showed no tubercle l^acilli, but numerous colon bacilli. Inocula- tion into the peritoneal cavity of a guinea-pig was followed by innumer- able tuberculous deposit:! in the peritoneum and omentum. The urine was turbid, ropy, and .slightly alkaline, containing a large amount of albumin. Macroscopic pus was recognized upon standing. There were many large and small round-cells, occasional normal blood-cells, and a few leukocytes. A catheterized specimen of urine from the ureter of the opposite side contained a considerable amount of albumin and a number of hyaline, granular, and epithelial casts. Catheterized speci- mens three weeks later .showed an increased amount of albumin and casts. Early in March edema of the feet and ankles developed. The general condition was very poor, with much emaciation and weakness. The urine continued to contain a large amount of albumin and macro- scopic pus, with occasional normal blood-cells. The state of the general health was not such as to suggest the expediency of immediate opera- tion. Owing to the unquestionable tuberculous process involving one kidney, and an irritative, if not degenerative, condition in the other, it was thought best to administer the tuberculin temporarily and note results with reference to the local tuberculous process and the general condition. The bacilli emulsion was administered at frequent intervals during a period of four weeks, without the .slightest evidence of resulting improvement. In .spite of the desperate condition of the patient and the known serious involvement of l)Oth kidneys, I advised the performance of nephrectomy on the ground that no harm could possibly result from the removal of a large focus of tuberculous material. The operation was performed by Dr. Freeman. A fatty tumor the size of the fist was found to form a part of the kidney. The organ was disintegrated PERSONAL OBSERVATIONS UPON USE OF BACTERIAL VACCINES 749 and contained several abscesses, as well as a stone the size of the last joint of the little finger. This was soft and easily crushed. The patient did exceedingly well for some months following the removal of the kidney. He was able to walk about; the edema of the extremities largely disappeared, and the urine became much clearer, though con- taining some pus and albumin, occasional large and small round-cells, squamous epithelial cells, but no blood or casts. The improvement, however, was temporary, the patient succumbing several months after the operation. Group 3 comprises an entirely (liffci'cut cutcsioi'v of patients from the preceding class, as it embraces ci. cs cvhilMiiuu imt (>\dy advanced tuberculous change, but also profouml const it uiioii;i,l ili-.turli;uice result- ing from secondary infection. Xo jiaiii nt hn.s In , n iik-IikIkI in this ijinup C07icerning whom th<:n cimld Ikut lucn >i\ c stimulation and subcutaneous salt infusions. He eventually rullicil, ;ind was later given the first injection of staphylo- coccic vaciinc: I'ucli cubic centimeter consisted of 100,000,000 micro- organisms, the iuitiul (lose being one-tenth of a cubic centimeter. There was no chill or other evidence of general disturbance follDwiiii; iliis injec- tion, although the temperatui'e remained high for two il:iy<. \']um the third day the fever suddenly subsideil. the temperature rcinaiuinu- in the vicinity of normal for over a week. Tliis was accompanied by a remark- able improvement in the mental ((UKlii imi. the patient becoming entirely rational, the cyanotic flush dis;t])|ie:ii iiiu liom the face, and the pulse declining to the eighties. The st:i,]ili\ locdciic vaccine was subsequently administered every ten days, tniivilier with occasional injections of a vaccine prepared from the staiili^lncoccus albus. At no time there- after did the copious daily sweats recur, nor did the mental condition again become clouded. There were occasional exacerbations of tem- perature of a few days' duration, but these were comparatively infre- quent and never attained a high degree. The cciimh and expectoration were considerably lessened. It was apparent, lidwexcr. that I lie tuljer- culous infection was too far advanced to warrant any reusi)ii:il>le hope of a sustained improvement, and the patient finally succumbed to general exhaustion. Case 29. — A woman of forty-three, after a three years' illness, came to Colorado June 13, 1905, coming under my observation six months later with extensive tuberculous infection of both lungs, the left side being actively diseased throughout. There were daily fever of two or three degrees, occasional chills and night-sweats, much exhaustion, and the history of a progressive decline. She remained in the recumbent position in the open air for nearly one year without showing any satisfactory evidence of beginning improvement. In January, 1907, there had been a further decided loss of weight and strength, the temperature remaining between 102° and 103° F. daily, while the cough and expectoration were pronounced. The sputum was found to contain not only very many bacilli, but also numerous streptococci. A streptococcic vaccine was 758 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT administered Felnuary 4th and was repeated weekly without pronounced effects immediately referable to the injections, although in one or two instances there resulted moderate temperature elevation for one or two days. There developed, however, in the cour.^e of three months a con- siderable increase of strength and a gradual dhninution of fever, with lessening of cough. The temperature remained in the neighborhood of 100° F. and rarely reached 101° F. The improvement in the general condition thus noted was followed in the late summer by frequent exacerbations of fever, attended by marked prostration. Under these conditions the vaccine was chscon- tinued. The patient rapidly declined, and died in the latter part of 1907. Case 30. — A man, forty-one \-ears old, who had previously secured a complete arrest of pulmonary tuberculosis in Colorado and was in active business, experienced, early in February, 1907, a severe rigor and speetlily developed a typical croupous pneumonia. The expectoration was bloody, respiration short, jerky, and painful, and the cough most dis- tressing. It was early apparent that the condition was to be an exceed- ingly desperate one. Upon the fourth da}' it was decided to prepare a pneumococcic vaccine from the Woody expectoration, although it was hardly thought likely that the patient would survive until the vaccine could be in readiness for administration. By the time this was prepared upon the eighth day, the crisis had apparently passed, and the general outlook was quite reassuring, suggesting the inexpediency of vaccine therapj- in this case. The patient rapidly improved for fom- or five days, when there developed unexpectedly another severe rigor, and the tem- perature rose to 10.5° F., with recurrence of bloody expectoration, diffi- cult and rapid respiration, and great prostration. Examination of chest disclosed an extension of the pneumonic process to the other lung, as shown by the recognition of the crepitant rale and beginning con- solidation. The vaccine was immediately administered. Eight hours later the temperature was normal and remained so for about fourteen hours, when it again rose sharply, preceded by a distinct chilling. Upon the succeeding dav- the temperature remained constantly elevated, although the general condition was improved. A noteworthy feature at this period was the failure of the second lung to proceed to gross consolidation, as in the former instance. The temperature still remain- ing elevated upon the third day after the injection, another dose of the vaccine was administered. This, like the preceding, was followed by a speedy and pronounced decline of the fever, which subsequently recurred, however, upon the following day. The vaccine was repeated eveiy third or fourth day. Several examinations of the sputum failed to disclose the presence of tubercle bacilli. After several weeks of con- valescence the patient proceeded to complete recovery. Case 31. — A man of fifty-five years came under observation March 18, 1907, six years after arrival in Colorado. The tuberculous infection developed twenty vears before. Cough and expectoration had been particularly severe during this entire period. Nutrition, however, had been preserved to a remarkable extent. He had traveled exten- sively, visiting numerous health resorts in this country and abroad, and had been subjected for prolonged periods to a considerable variety of special treatments. Several years ago a large cavity was diagnosed in the upper portion of the right lung, and the second and third ribs were excised in the hope of producing a retraction of the chest-wall and PERSONAL OBSERVATIONS UPON USE OF BACTERIAL VACCINI 759 thus securing a partial obliteration of the cavity. The site of the incision is shown in the accompanying illustration (Fig. 169). Upon coming under my observation, the examination of the chest showed an area of consolidation in the upper portion of the right lung, with numerous fine and medium-sized moist rales from the apex to the fourth rib, with a suspicion of cavity below the clavicle. No tubercle baciUi were found in the sputum. The skiagraph disclosed an entire absence of cavity formation, but a sharply localized consolidation in the upper portion of the lung. Upon bacteriologic examination numerous colonies of micrococcus catarrhalis were found. A vaccine was pre- pared, and the remedy ailministered upon April 1st. The first dose consisted of 50,000,000 microorganisms. This has been increased until the patient received 15(J,000,000 at each injection. After six or eight injections a beginning improvement was noted in the amount of cough and expectoration. The efficacy of the vaccine in this case is quite apparent from the fact that during the remainder of li»()7 tlie i)atient has coughed but little, and has shown an iniprcn-ement in the physical signs with dis- appearance of the microorganisms in the sputum. Case 32. — ^'ery pronounced improvement has attended the adminis- tration of a staphylococcic vaccine in a case of an apparently hopeless consumptive with tuberculous laryngitis. The patient was a young woman, twenty-four years of age, who came to Colorado March, 1907, one year after the development of her pulmonary involvement. For six weeks before arrival severe rigors were experienced daily, followed by sharp elevations of temperature. There were pronounced emacia- tion and prostration. Examination of the chest disclosed active tuberculous involvement in the left lung from apex to base, front and 760 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT back, with coarse bubbling rales throughout this region; on the right side, from the apex to the third rib and to the lower angle of the scapula. There was a large cavity in the right front under the clavicle. The condition was so desperate, it did not seem that the slightest encourage- ment could be offered. The staphylococcic vaccine was prepared and administered at weekly intervals. This was commenced in the middle of March, and after a few weeks produced a perceptible diminu- tion in the maximum daily temperature. Following the first three or four injections the fever was increased, and the general prostration more marked. The patient, however, invaiiably volunteered the information four or five days after its administration that she felt better than before it was given. In the latter part of August the temperature returned to normal, and has remained so until January 1, 1908. The patient has gained twenty pounds in weight, and examination of the chest shows but very slight moisture in the lungs. Cough and expectoration are much diminished. Case 33. — A man of thirty-nine consulted me June 6, 1907, imme- diately upon arrival in Colorado, presenting the history of pulmonary tuberculosis of over one }-ear's duration. The onset was acute, and the decline progressive. There were marked loss of weight, copious purulent expectoration, and dyspnea upon the slightest exertion. The temperature was elevated daily to the neighborhood of from 103° to 104° F., with marked acceleration of pul.se. The examination of the chest disclosed the presence of active and extensive tuberculous infec- tion, the area involved upon the right side extending from the apex to the base, with moderate consolidation throughout and a small cavity below the clavicle. Upon the left side the process was less active, though fine clicks were heard over the entire lung. During a period of two months the patient was kept in bed upon a large protected porch, a rigid enforcement of hygienic and dietetic principles being secured by the attendance of a nurse. Despite these important features of regimen, no abatement of temperature or other e\idence of improvement was noted. A bacteriologic examination disclosed a pronounced streptococcic infection, and upon July 28th the bacterial vaccine was administered for the first time, the maximum temperature for that day being registered as 103° F. Upon the second day the temperature rose to 103.6° F., and on the third day was 103° F. In the course of three weeks the temperature gradually subsided to normal or there- abouts. During the ensuing five months the temperature has rarely exceeded 100° F., and has averaged in the vicinity of 99i° F. in the afternoon, the vaccine being administered at intervals of one week. The fall of temperature has been attended by corresponding evidences of constitutional improvement. During the eight months that have elapsed since the writing of the foregoing pages extended opportunities have been offered for closer observation of the effects of the bacilli emulsion and of the homologous vaccines. These agents have been employed in a considerable number of cases since the preparation of the previous report. In using the bacilli emulsion, the same principles have been applied in the selection of cases as in the first group, the administration, as a rule, being restricted to individuals who had remained for prolonged periods in Colorado without achieving entirely satisfactory results. No permanent dis- PERSONAL OBSERVATIONS UPON USE OF BACTERIAL VACCINES 761 agreeable effects have thus far been observed from its employment among an increasing number of patients, and a general upward tendency has been exhibited in many instances. The i-emedy was invariably denied to incipient cases. The skiagraph (Fig. 67) illustrates the extensive pathologic changes in an individual exhibiting frequent cough and copious expectoration, with a resulting entire disappearance of tubercle bacilli. The tubercuhn has been thought to be of value in several cases of tuberculous laryngitis. Improvement has also followed its application in a few additional cases of glandular tubercu- losis. In my own practice, with one exception, neither the bacilli emulsion nor the autogenetic vaccines have been given more frequently than once in five days. Neither have I found it advisable in many cases to resort to progressive increase of dosage. This, perhaps, explains the absence of intolerance in my later experience, as contrasted with previous occasional manifestations of local reaction with headache, fever, malaise, and loss of appetite for a few days following the injections. In but few instances has the agent been used for patients presenting a temperature of over 100° F. It is interesting to note, however, that Krause has recently reported excellent results from the administration of tuberculin to febrile patients. He reports a permanent disappear- ance of the fever in all cases, and suggests, at least, a tentative adminis- tration of the remedy among a few patients who have resisted all other measures. Recently I have had occasion to employ the tuberculin in 6 cases exhibiting persisting fever of from 102° to 10.3° F. daily, despite pro- longed rest in bed in the open air. In 3 cases no appreciable effects were noted; in one the temperature receded within a few days to normal and has remained so for four weeks; in 2 cases the temperature has gradually receded to the neighborhood of 99° and 99.5° F. Special bacterial vaccines have been prepared for twelve recent cases of severe mixed infection, making a total of twenty-seven patients to whom the homologous vaccines have been administered. In the use of both the tuberculin and the bacterial vaccines among eases observed during the past few months, the dosage has been deter- mined without reference to the opsonic index. This course has been pursued because determinations of the index sufficiently frequent to afford a basis for substantial accuracy of dosage were almost impracti- cable. It was found that even in carefully selected cases of pulmonary tuberculosis, the range of variation in the opsonic findings was so great as to suggest the impropriety of any arbitrary or conventional dosage without recourse to detailed clinical study. There was found to be no fixed relation between the opsonic variations and the character of the clinical manifestations. In view of the unavoidable sources for error in estimating the index, and the confusing interpretations as to the dosage, it was decided to permit the character of clinical manifestations to be the sole guide for tentative medication. The results obtained have demonstrated fully that, for practical purposes, approximate accuracy of judgment in this respect may be derived from a continuous vigilant study of the subjective and physical data. In the light of later experience it is questionable if, for general usage, the clinical method of dosage, influenced solely by the symptomatic course, is to be displaced by the laboratonj method, controlled by the observation of the opsonic index. The same conclusions have been reached by 762 PROPHYLAXIS, GENERAL AND SPECIFIC TREATMENT Trudeau, Baldwin, Brown, and other clinicians in various parts of the country. It is recognized that, amid the many complicating conditions inherent to the disease and its management, many difficulties obtain in establishing the value of any therapeutic agent. It is fair to assume, however, from the accumulating mass of evidence, that the use of tuberculin and bacterial vaccines is in accord with modern theories relative to the production of artificial immunity. As a result of my investigations, which were pursued largely along clinical lines, the following conclusions are suggested: 1. In general it may be stated that the administration of bacilli emulsion is of undoubted efficacy in so7ne cases of long-standing afebrile pulmonary tuberculosis. 2. That the remedy also possesses possibilities of an injurious influ- ence. 3. That the demonstration of an increase in cough and expectoration shortly after the injection is not necessarily indicative of its harmful effect. 4. That the persistence of these clinical manifestations, together with fever and greater physical weakness, despite an attempted dis- crimination regarding the dosage, may be accepted as definitel}' con- clusive of its detrimental action. 5. That, in the event of severe mixed infection with considerable temperature elevation, it is highly inexpedient, as a rule, to attempt the production of an increased tuberculo-opsonic power until after the amelioration of the secondary infection. 6. That the administration of bacterial vaccines derived from the secretions of the patient is often indicated in the presence of the consti- tutional and bacteriologic evidences of mixed infection. 7. That, in view of the numerous possiljilities of error incident to the opsonic findings, discriminating clinical shidy is absolutely essential in the determination of the size and frequency of the dosage. 8. That despite the uncertainties of action of autogenetic vaccines, a justification for their employment is found in the desperate character of the cases to which they are given, and their superiority over the various sera formei'ly used. 9. That in some cases bacterial vaccines present possibilities of benefit far bej'ond the limits of former therapeutic efforts. 10. That the role of the opsonic index in vaccine therapy still remains an experimental study, to be approached with the utmost conservatism, but in a spirit of receptive inquiry. The data thus far presented suggest that this feature should remain for the present sub judice. INDEX 5, tuberculous, in bone and joint tuberculosis, treatment, 461 Acceleration of pulse, 120 diagnostic import, 2-13 Adenoid vegetations as port of entrance for tubercle bacillus, 415 Adherent pericardium, 403 Broadbent's sign in, 404 Friedreich's sign in, 404 Administrative control, 601 Advanced cases, physical signs. 229 Age, influence, on prognosis, 301 Air, existence in, comfort and shelter in, 629 enforcement of, 629 walking in, in treatment, 621 Air-hunger, 107 Alcohol in tuberculosis, 646 Alimentary tract, infection through, 51 tuberculosis of, 462 anatomic factors, 462 etiology, 462 Altitude, influence of, on nervous system, 678 on red blood-corpuscles, 677 on respiratory rate, 678 on tissue change, 677 variations in blood-pressure at, 677 Amphoric resonance, 189 respiration, changes in pitch and quality, 208 voice, 216 Anatomic wart, 513 Anatomy, pathologic, 17, 76 Anemic onset, 100 Animals, experiments on, diagnostic import, 251 Ankles, edema, 123 Antistreptococcic serum in mixed infec- tion, 547 Apex of heart, cardiac impulse at, changes in, 172 Apex-beat, changes in location, 172 Apical rales, unilateral, diagnostic import. 244 Appendicitis, tuberculous, 471. See also Vermiform appendix, tuberculosis of. Appendix, vermiform, tuberculosis of, 471. See also Vermiform appendix, tuberculosis of. Area of cardiac dulness, 185 flatness, 186 Arsenic in phthisis, 724 Aspiration in glandular tuberculosis, 435 in serous effusion in tuberculosis of pleura, indications and contraindication.^, 308 rules, 370 Asthmatic breathing, 204 Atropin in pulmonary hemorrhage, 719 Auscultation, 191 in pathologic conditions, 203 manner, 192 of broncliial respiration, 200 of che,st, 199 of res|5iratory sounds, 199 of vesicular respiration, 199, 200 rules, 198 with stethoscope, 193 Bacillus, lepra, and tubercle bacillus, resemblance, 21 tubercle, 19. See also Tubercle bacillus. Bacterial vaccines in mixed infection, 549 in tuberculosis, 738 Bacteriolysis and immunity, 732 Bacteriotrophins, 733 Bamberger's sign in tuberculosis of pericardium, 398 Barrel chest, 163 763 764 Bier treatment of tuberculous joints,460 Bladder, cystoscopic examination, in renal tuberculosis, 494 tuberculosis of, 488, 499 curetment in, 502 cystotomy in, 502 diagnosis, 500 primary, 499 symptoms, 500 treatment, 501 Blood in sputum, 104, 124 Blood-corpuscles, red, influence of alti- tude on, 677 Blood-pressure, variations in, at dif- ferent altitudes, 677 Blood-vessels, palpation, 176 Bones, tuberculosis of, 440 clinical manifestations, 444 etiology, 440 microscopic pathology, 443 prognosis, 446 symptoms, early, 444 treatment, 457 hygienic, 457 local, 458 non-operative measures, 459 surgical, 461 tuberculous abscess in, treatment, 461 Bovine tuberculosis and human tuber- culosis, relation, 27, 517 Bowles' stethoscope, 197 Breast, funnel, 165 pigeon-, 163 Breatliing. See Respiration. Broadbent's sign in adherent pericar- dium, 403 Broncliial compression, physical signs, in tuberculosis of mediastinal glands, 423 glands, tuberculosis, 415 treatment. 429 irritation, 102, 639 onset. 99 rales, dry. 212 moist. 211 respiration, auscultation, 200 changes in pitch and quality, 206 Bronchitis, acute, comphcating phtliisis, pain in, 107 onset, 99 Bronchocavernous respiration, 208 Bronchophony, 203, 216 Bronchopneumonia after pulmonary hemorrhage, treatment, 719 Bronchopneumonic phthisis, acute, method of onset, 95 Bronchovesicular respiration, 202 changes in pitch and quality, 206 Buccal mucous membrane, tuberculous lesions of, 462 Buildings, public, hygienic construction and sanitary supervision, in pro- phylaxis, 605 Calmette and Wolff-Eisner's oph- thalmotuberculin reaction, 249 Camman's stethoscope, 194 Canopy, sleeping, 629 Cardiac dulness. area of, 185 flatness, area of, 186 impulse at apex, changes in, 172 Cardiovascular changes, 171 Caries of spine. 446 Caseofibroid phthisis, chronic, gross appearances, 88 Cases, advanced, physical signs, 229 appropriate for climatic change in general, 682 early, physical signs, 219 with moderate involvement, physical signs, 223 Catheterization, ureteral, in diagnosis of renal tuberculosis, 495 Cavernous breathing, changes in pitch and quality, 207 rales, 213 voice. 216 Cells, giant-, 79 .Cerebrospinal meningitis and meningeal tuberculosis, differentiation, 343 Cervical glands, tuberculosis, 418 and Hodgkin's disease, differen- tiation, 420 diagnosis, 419 treatment, 429 lymphatic tuberculosis, phtliisis following, 101 Character, influence of, on prognosis, 308 Chemic composition of tubercle bacillus, 25 Chest. See Thorax. Chest- wall, retraction of, 173 Cheyne-Stokes type of breathing, 157 765 Child labor in development of tubercu- losis, 600 Circulation, stasis in, 122 Circulatory disturbances, 120 Class system, tuberculosis, 5S5 Climate, affirmative evidence in favor of, 671 arguments advanced by opponents, 668 cases appropriate for change in, 682 change of, influence, on prognosis, 311 errors of judgment in selection of, 670 explanation of not infrequent failure to secure favorable results, 669 inconsistencies of precept regarding, 679 influence, on pulmonary hemorrhage, 129 in treatment, clinical testimony, 679 physiologic considerations, 672 role of, 667 popular localities, 689 selection of, consitlerations relative to, 685 Clubbed fingers, 1 16 Cog-wheel breathing, 158, 204, 210, 221 Cold applications in pulmonary hemor- rhage, 720 Colitis, mucous, treatment of, 708 Color of face, 156 Colorado, tuberculosis indigenous in, extent, 66 Commercial establisliments, hygienic construction and sanitary super- vision, in prophylaxis, 605 Complemental space, Gerhardt's, 185 Complexion, 118 Complications, 324 non-tuberculous, 541 Compulsory notification, 566 registration, 506 Congenital method of infection, 36 Congestion, pulmonary, 122 Conglomerate tubercles, 79, 83 Consonating rales, 212 Constipation, treatment, 707 Consumption. See Phthisis. Contamination of milk, danger from, 597 Contra-indications for excessive feeding, 647 Control, administrative, 601 Conveyances, public, hygienic construc- tion and sanitary supervision, in prophylaxis, 605 Cornage, 423 Corpuscle, tubercle, 18 Cough, 101 and vomiting, 103 diagnostic import, 240 paroxysmal, 107 stomach, 132 treatment, 701 Counterirritation in glandular tubercu- losis, 434 Course, 145 Cracked-pot resonance, 190, 231 Crackling vesicular niles, 212 Creosote in phthisis, 725 Crepitant rales, 212 Crude tubercle, S3 Cryoscopy in renal tuberculosis, 496 Cultural characteristics of tubercle bacil- lus, 22 Cure, 299 day, 584 from social standpoint, 563 Curetment in glandular tuberculosis, 436 in vesical tuberculosis, 502 Cyanosis in pneumonic type of miliary tuberculosis, 329 of face, 157 Cystoscopic examination of bladder in renal tuberculosis, 494 Cystotomy in vesical tuberculosis, 502 Cytology in tuberculosis of pleura, 350 Day cure, 584 resort, 584 Death, modes of, 152 Death-rate in infants, 41 Degenerative changes in tubercle deposit, 81 Delusions, 137, 138 Depression, circumscribed, of chest, 168 Detail, infinite regard for, in treatment, 615 of pulmonary hemorrhage, 714 Diagnosis, 234 acceleration of pulse, 243 acquired predisposition, 237 aids, 246 apical rales, 244 cough, 240 766 641, Diagnosis, differential, 294 examination of sputum, 245 experiments on animals, 251 exploration of chest, 243 family history, 236 fever, 242 loss of weight, 241 ophthalmotuberculin, 249 opportunities for infection, 237 present condition, 240 previous disease, 239 provisional factors. 236 Rontgen rays, 251-293 tuberculin test, 247 Diarrhea, 133 treatment, 707 Diet, physiologic considerations i 642 regulation of, in treatment, 039 Digestive apparatus, symptoms referable to, 131 disorders, treatment, 704 tract, infection through, 51 Diseases predisposing to tuberculosis, 75 pre\nous, diagnostic import, 239 Disinfection, formaldehyd, of sick-room, 575 Dispensary, 583 Displacement of heart in tuberculosis of pleura, 358 of organs in tuberculosis of pleura, 358 Disposition, influence, on prognosis, 308 Distribution of tubercle bacilli, 55 Domiciliary visitation, 585 Droplet infection, 43 Drugs, 723 in pulmonary hemorrhage, 717 Dry bronchial rales, 212 tracheal rale, 21 1 vesicular rales, 212 Dulness, 177 cardiac, area of, 185 Dyspepsia, nervous, 132, 649 treatment. 704 Dyspeptic type, 100 Dyspnea, 109 in pneumonic type of miliary tuber- culosis, 329 Ear, tuberculosis of, 535 Early cases, physical signs, 219 Edema of ankles, 123 of face, 123, 157 of feet, 123 of hands, 123 of lungs, 122 Education and supervision, 571 Educational literature, 590 distribution, 591 Effusion, serous, in tuberculosis of pleura, aspiration for, indications and contra- indications, 368 rules, 370 treatment, 366 Eggs in treatment. 646 Egophony, 216 Electrolysis in glandular tuberculosis, 434 Emaciation, 115 Emphysematous chest, 162 respiration, 204 Empyema, 373 clinical manifestations, 373 exploratory puncture in, 374 necessitatis, 374 treatment, 376 Endocarditis, 122 Energy, conservation of, in treatment, 619 nervous, 142 Environment, relation, to infection, 73 social, influence on prognosis, 310 Epididymis, tuberculosis of, 488, 506 diagnosis. 507 treatment, 508 Epigastric pulsation, 173 Epiglottis, turban-shaped, 532 Esophagus, tuberculosis of, 464 Etiology, 17 Ewart's sign in tuberculosis of pericar- dium, 398 Examination of sputum, diagnostic import, 245 Excessive feeding in treatment, 641 contraindications, 647 Excision in glandular tuberculosis, 436 Exercise in treatment. 620 Exhibitions, instruction in prophylaxis through, 592 Expectoration, 103. See also Sputum. Experiments on animals, diagnostic import, 251 Expiration, prolongation. 209 767 Exploration of chest, diagnostic import, 243 Exploratory puncture in empyema, 374 Extension of material aid according to varying needs and requirements of differing classes, 576 Extremities, ligation of, in pulmonary hemorrhage, 722 Eye, tuberculosis of, 540 Face, appearance of, 118, 156 color of, 156 cyanosis of, 157 edema of, 123, 157 Fallopian tubes, tuberculosis, 488, 511 symptoms, 512 treatment, 512 Family history, diagnostic import, 236 Fatigue, avoidance of, in treatment, 619 Feeding, excessive, in treatment, 641 contraindications, 647 Feet, edema of, 123 Fever, 111 clinical types, 113 diagnostic import, 242 hectic, 113 in pneumonic type of miliary tubercu- losis, 329 of absorption, 113 temperature during, 113 Fibroid phthisis, 148 chronic, gross appearances, 91 Financial condition, influence on prog- nosis, 309 Finger, pleximeter, position, in per- cussion, 180 Fingers, appearance of, 116 clubbed, 116 Fistula, rectal, 484 treatment of, 485 Flatness, cardiac, area of, 186 percussion, absence of, 187 Food, character of, to be substituted for human milk, 596 Food-supply, inspection of, in prophy- laxis, 603 Formaldehyd disinfection of sick-room, 575 Fowler's solution in phtliisis, 724 Fremitus, vocal, 174 diminished, 175 Fremitus, vocal, increased, 175 Friction-sounds, pericardial, 176 pleural, 176 Friedreich's sign in adherent pericar- dium, 404 Funnel breast, 165 Furniture of sick-room, 574 Galloping consumption, 95 Gastric disturbances, 131 Gastro-intestinal tract, infection through, 51 Genito-urinary symptoms, 142 tract, tuberculosis of, 487 etiology, 487 in children, 489 in female, 511 Geograpliic distribution, influence of, 65 Gerhardt's change, of pitch, 191 complemental space, 1 85 Giant-cells, 79 Glands, bronchial, tuberculosis of, 415 treatment, 429 cervical, tuberculosis of, 418 and Hodgkin's disease, differen- tiation, 420 diagnosis, 419 treatment, 429 lymphatic tuberculosis of, 412 treatment, 429 mediastinal, tuberculosis of, 422 clinical manifestations, 422 physical signs of bronchial com- pression in, 423 of tracheal compression in, 423 roaring in, 424 treatment, 429 mesenteric, tuberculosis of, 428 treatment, 429 tuberculosis of, 412. See also Glan- dular tuberculosis. Glandular tuberculosis, 412 aspiration in, 435 counterirritation in, 434 curetment in, 436 electrolysis in, 434 excision in, 436 hygienic treatment, 429 incision in, 435 massage in, 434 medicinal treatment, 433 768 Glandular tuberculosis, pathogenesis, 412 surgical treatment, 435 treatment, 429 general, 429 hygienic, 429 local, 434 non-operative, 434 medicinal, 433 surgical, 435 x-rays in, 434 Gross appearances, 85 Gums, tuberculosis of, 463 Gymnastics, pulmonary, in treatment, 623 Hallucinations, 138 Hands, edema of, 123 tubercle bacilli on, 514 Harsh respiration, 221 Heart, apex of, cardiac impulse at, changes in, 172 displacement of, in tuberculosis of pleura, 358 weakness of, 121 treatment, 710 Hectic fever, 113 Hemorrhage, pulmonarj', 123. See also Pulmonary hemorrliage. Hereditary syphilis, 555 transmission, 36 Hip-joint, tuberculosis of, symptoms, 450 Histology, 78 Historic review, 18 History, family, diagnostic import, 236 influence, of, on prognosis, 306 of present illness, influence of, on prognosis, 312 previous, influence of, on prognosis, 306 Hoarseness, 108 Hodgkin's disease and tuberculosis of cervical glands, differentiation, 420 Houses, tenement, hygienic construction and sanitary super\'ision, in propliy- laxis, 605 Hygiene, proper, in prophylaxis, 600 Hygienic treatment of glandular tuber- culosis, 429 of tuberculosis of bones and joints, 457 Hyperplastic form of tuberculosis of intestine, 469 of vermiform appendix, 471, 473 Ice-bag in pulmonarj' hemorrhage, 720 Illness, present, history of, influence, on prognosis, 312 Immunity and bacteriolysis, 732 and opsonins, 733 and tuberculin, 727 apparent, evidence of, in prognosis, 315 theories of, 726 Incision in glandular tuberculosis, 435 Indeterminate rales, 214 Indians, tuberculosis in, 61, 75 Indigestion, 131, 647 gastric, acute, treatment of, 704 chronic, treatment of, 705 Industrial pursuits in State sanatoria, 581 Infants, death-rate in, 41 protection of, from tuberculous infec- tion, 596, 597 Infection, conditions influencing, after exposure to tubercle bacillus, 72 congenital method, 36 droplet, 43 hereditarj', 36 inhalation, 43 intra-uterine, 38 latent imsuspected, 99 mixed, 113, 541 antistreptococcic serum in, 547 bacterial vaccines in, 549 prognosis of, 546 treatment of, 547 opportunities for, diagnostic import, 237 postnatal, dangers of, 596 relation of environment to, 73 role of skin as channel for, 513 through alimentary tract, 51 digestive tract, 51 gastro-intestinal tract, 51 intestinal tract, 51 respiratory tract, 43 Infectious diseases, phthisis following, 101 Infinite details, regard for, in treatment, 615 of pulmonary hemorrhage, 714 7fio Influence of age on prognosis, 301 of family history on prognosis, 306 of geographic position, 65 of race, 59 on prognosis, 304 of sex on prognosis, 303 Influenza, 99 and meningeal tuberculosis, differen- tiation, 345 Inhalation infection, 43 Inherited predisposition, 72 Insanity, 138 Insomnia, 139 treatment, 710 Inspection, 155 conditions independent of thorax noted, 156 of thorax, 158 rules for, 155 Inspiration, shortening, 209 Institutions, 577 for hopelessly ill and impoverished, 577 for poor consumptives, 579 for vicious patients, 578 Intelligence, influence of, on prognosis, 308 Intercostal neuralgia in phthisis, 107 Intestinal symptoms, 133 toxemia, acute, treatment of, 708 and meningeal tuberculosis, differ- entiation, 345 tract, infection through, 51 Intestine, tuberculosis of, 466 hyperplastic form, 469 pathologic features, 468 treatment, 470 ulcerative type, 468 Intra-uterine infection, 38 Introduction, 17 Irish, tuberculosis in, 63 Joints, tuberculosis of, 440 Bier treatment, 460 clinical manifestations, 444 microscopic pathology, 443 pathology, 440 prognosis, 446 symptoms, early, 444 treatment, 457 hygienic, 457 local, 458 non-operative measures, 459 Joints, tuberculosis of, treatment, surgi- cal, 461 tuberculous abscess in, treatment, 461 Jousset's method of diagnosing tuber- culosis of pleura, 350 Jiirgensen's sign in tuberculosis of pleura, 356 Kidney, tuberculosis of, 487, 490 cryoscopy in, 296 cystoscopic examination of bladder in, 494 diagnosis, 493 frequent micturition in, 492 nephrectomy in, 498 nephrotomy in, 498 pain in, 492 pathology, 491 phlorizin test in, 496 prognosis, 496 segregation of urine in diagnosis, 495 symptoms, 492 treatment, 496 ureteral catheterization in diagnosis, 495 urine in, 492 x-rays in diagnosis, 495 Knee-joint, tuberculosis of, symptoms, 454 Labor, cliild, in development of tuber- culosis, 600 La grippe, 99 and meningeal tuberculosis, differen- tiation, 345 Laryngeal manifestations, 100 Larynx, tuberculosis of, 524 etiology, 526 prognosis, 532 symptoms, local, 531 subjective, 530 treatment, 533 vocal resonance over, 203 Latent unsuspected infection, 99 Lectures, instruction in prophylaxis through, 592 Lepra bacillus and tubercle bacillus, resemblance, 21 Ligation of extremities in pulmonary hemorrhage, 722 770 Linen, care of, 574 Lingula pulmonalis, 172, 184 Literature, educational, 590 distribution of, 591 Litten's phenomenon, 170 Lobar phthisis, acute, gross appearances, 87 Lobular phthisis, acute, pathologic appearances, 88 Loss of weight, diagnostic import, 241 Lungs, active mobility, 185 passive mobility, 185 vocal resonance over, 203 Lupus verrucosa, 513 vulgaris, 522 Lymphatic glands, tuberculosis, 412 treatment. 429 system in development and spread of tuberculosis, 412 tuberculosis, cervical, plithisis follow- ing, 101 Macroscopic appearance of epididymis and testis, 506 of tuberculosis of appendix, hyper- plastic type, 473 of tuberculous pulmonary le-sions, 85 Marriage of tuberculous individuals. 595 Massage in glandular tuberculosis, 434 Measles, phthisis following. 101 Mediastinal glands, tuberculosis. 422 clinical manifestations. 422 physical signs of bronchial com- pression in. 423 of tracheal compression in, 423 roaring in, 424 treatment, 429 Medical practice, restriction of, in prophylaxis, 604 Medicines, patent, control of, in pro- phylaxis, 604 Membrane, pyogenic. 90 Meningeal form of miliar}' tuliorculosis. 335. See also Meningeal liiher- culosis. tuberculosis, 335 and cerebrospinal meningitis, differ- entiation, 343 and influenza, differentiation. 345 and intestinal toxemia, differentia- tion. 345 Meningeal tuberculosis and middle-ear disease, differentiation, 344 and pneumonia, differentiation, 344 and typhoid fever, differentiation, 344 diagnosis, differential, 342 patliogenesis, 335 pathologic changes, 336 symptoms, 337 in adults, 338 in children from two to six years of age, 340 in infants, 342 tache cerebrale in, 341 treatment, 346 Meningitis, cerebrospinal, and meningeal tuberculosis, differentiation. 343 Mental disturbances during pulmonary liemorrhage, 127 effect of pulmonary hemorrhage. 713 symptoms. 135 Mentality, perverted. 137 Mesenteric glands, tuberculosis, 428 treatment, 429 MetaUic rales, 214 Metamorphosing respiration. 208 changes in pitcli and quality, 208 Micturition, frequent, in renal tuber- culosis. 492 Middle-ear tlisease and meningeal tuber- culosis, differentiation, 345 Miliary tuberculosis, 324 general considerations, 324 gross appearances, 87 meningeal form, 335. See also Meningeal tuberculosis. pneumonic type, 329 cyanosis in. 329 dyspnea in. 329 fever in. 329 method of onset, 96 typhoid type. 331 differentiation from typhoid fever. 332, 333 Milk, contamination of, danger from, 597 in treatment. 650 Miner's phthisis, differential diagnosis, 294 Mixed infection, 113. 541 antistreptococcic serum in, 547 bacterial vaccines in, 549 prognosis, 546 treatment, 547 771 Mobility, active, of lungs, 185 passive, of lungs, 185 Moderate involvement, intensification of whispered voice in, 228 physical signs, 223 Moist bronchial rdles, 211 Moisture, disadvantages of, in treatment, 674 Monomania, 138 Morphin in pulmonary hemorrhage, 718 Mucous colitis, treatment, 708 membrane, buccal, tuberculous lesions of, 462 rMes, 211, 212 Neck, visible changes in, 173 Necrogenic wart, 513, 521 Negro, tuberculosis in, 60, 74 Nephrectomy in renal tuberculosis, 498 Nephritic disturbances, 143 Nephritis, 144 Nephrotomy in renal tuberculosis, 498 Nervous energy, 142 disturbances after pulmonary hemor- rhage, treatment of, 714 during pulmonary hemorrhage, 127 dyspepsia, 132, 649 effort, adjustment, in treatment, 619 individuals, pain in, 108 symptoms, 135 system, influence of altitude on, 678 Neuralgia, intercostal, in phthisis, 107 Neuroses, functional, gastric, 131 treatment of, 706 Night-sweats, treatment, 709 Non-consonating rales, 211 Non-tuberculous complications, 541 Nose, tuberculosis of, 538 Notification, compulsory, 566 Nummular sputum, 104 Nutrition, impaired, tuberculosis in infants from, 597 tuberculosis in school-children from, Objective symptoms, local, 1 16 Occupation, influence, on prognosis, 307 predisposing to tuberculosis, 75 Onset, acute, 94 septic, 98 anemic, 100 Onset, bronchial, 99 hemorrhagic, 97 method of, 94 non-acute, 94, 99 Open-air existence, comfort and shelter in, 629 enforcement of, 626 Ophthalmotuberculin reaction, 249 Opsonins and immunity, 733 Oral tuberculosis, 462 Osteomyelitis, tuberculous, 443 Otitis media, tuberculous, 535 Overfeeding in treatment, 641 contraindications, 647 Pain, 106 in acute bronchitis complicating phtliisis, 107 in chest, 106 in head in meningeal type of miliary tuberculosis, 338, 340 in typhoid type of miliary tuber- culosis, 331, 332 in nervous individuals, 108 n renal tuberculosis, 492 n tuberculosis of appendix, 473 of bladder, 500 of bones and joints. 445, 446, 450, 451 of epididymis, acute, 507 of initial pneumothorax, 107 resulting from pleuritic involvement, 107 Palate, soft, tuberculosis of, 463 Palpable rhonchi, 176 Palpation, 174 of blood-vessels, 176 Paralytic chest, 159 Paroxysmal cough, 107 Patent medicines, control of, in prophy- laxis, 604 Pathologic anatomy, 17, 76 conditions, auscultation in, 203 percussion in, 186 Pectoriloquy, 216 Percussion, 177 avoidance of instruments, 179 boundaries, 185 flatness, absence, 187 in abnormal states, 186 manner of dealing blow, 181 of chest, 182 regional differences, 182 772 Percussion, position of examiner, 1S2 of pleximeter finger, 180 resonance, 177. See also Resonance. rules for patient, 179 for physician, 179 Pericardial friction-sounds, 176 Pericardium, adherent, 403 Broadbent's sign in, 404 Friedreich's sign in, 404 tuberculosis of, 395 Bamberger's sign in, 398 course, 399 diagnosis, 399 etiologic and patliologic data, 395 Ewart's sign in, 398 prognosis, 399 Rotch's sign in, 398 symptoms, 397 treatment, 402 varieties, 396 Peritoneum, tuberculosis of, 404 diagnosis, 408 etiologic relations, 405 pliysical examination in, 408 prognosis, 410 symptoms, 407 treatment, 411 Perle disease, 29 Personal equation in medical supervision, influence of, on prognosis, 310 Perverted mentality, 137 Pharynx, tuberculosis of, 463 Phlorizin test in renal tuberculosis, 496 Phthisical chest, 161 habitus, 18 Phthisis florida, 95 Physical effort, adjustment, in treat- ment, 619 signs, 154, 218 general, 155 in advanced cases, 229 in early cases, 219 in moderate involvement, 223 in prognosis, 313 Physician, instruction in prophylaxis through, 593 Pigeon-breast, 163 Pitch, 178 changes in, 190 Gerhardt's change of, 191 Wintrich's change of, 190 Pleura, tuberculosis of, 347 cytology in, 350 Pleura, tuberculosis of, diagnosis, 363 displacement of heart in, 358 of organs in, 358 etiology, 348 Jousset's method of diagnosing, 350 Jiirgensen's sign in, 356 pathologic changes, 351 pathology, 348 prognosis, 365 serous effusion in, aspiration for, indications and contra- indications, 368 rules, 370 treatment, 368 symptoms, 353 Pleural friction-sounds, 176 rules, 213 Pleurisy, acute, 98 phthisis following, 101 Pleuritic involvement, pain resulting from, 107 Pleximeter finger, position of, in per- cussion, 180 Pneumonia and meningeal tuberculosis, differentiation, 344 phthisis following, 101 Pneumonic acute miliary tuberculosis, method of onset, 96 consolidation, 85 phthisis, acute, gross appearances, 87, method of onset, 95 lobular, gross appearances, 88 type of miliary tuberculosis, 329 cyanosis in, 329 dyspnea in, 329 fever in, 329 Pneumonokoniosis, 149 Pneumopyothorax. 389 physical signs, 389 treatment, 390 Pneumothorax, 383 initial pain of, 107, 384 percussion, 385 physical signs, 383 prognosis, 386 symptoms, 383 treatment, 387, 388 varieties, 383 Porch in treatment, 632 Postnatal infection, danger; Pott's disease, 446 Precordia, changes in, 171 Predisposition, acquired, import, 237 inherited, 72 Pregnancy, 549 Present illness, history, influence of, on prognosis, 312 Prevalence, 57 Prevention, 560. See also Prophylaxis. Previous history, influence, on prognosis, 306 Primary involvement, site of, 92 Prognosis, 299 age, 301 change of surroundings and climate, 311 character, 308 of systemic disturbance, 316 disposition, 308 evidence of apparent immunity, 315 factors pertaining to individual, 300 family lustory, 306 financial condition, 309 history of present illness, 312 intelligence, 308 occupation, 307 personal equation in medical super- vision, 310 physical signs, 313 previous history, 306 race, 304 sex, 303 social environment, 310 temperament, 308 Prophylaxis, 560 administrative control, 601 authentic official information to gen- eral public regarding, 586, 595 compulsory notification and registra- tion, 566 control of patent medicines in, 604 of sputum in, 602 education of consumption. 571 extension of material aid to differing classes, 576 hygienic con.struction and sanitary supervision of commercial establishments in, 605 of public buildings and con- veyances, '605 of tenement houses in, 605 of workshops or factories in, 605 ! Prophylaxis in infants, 596, 597 in school-cliildren, 599 1 inspection of food-supply in, 603 institutions for consumptives, 577 instruction in, through exhibitions, 592 lectures, 592 physician, 593 public schools, 589 publications, 590 proper hygiene in, 600 reciprocal relations of consumptives and society, 560 regulation of schools in, 602 restriction of medical practice in, 604 State Sanatoria, 579 supervision of consumptive and his environment, 571 what the public should know, 597 Prostate, tuberculosis of, 488, 504 symptoms, 504 treatment, 505 Provisional diagnostic factors, 236 Public buildings, hygienic construction and sanitary supervision in prophy- laxis, 605 conveyances, hygienic construction and sanitary supervision in prophy- laxis, 605 general, authentic official information to, regarding prophylaxis, 586, 595 instruction in prophylaxis to, through exhibitions, 592 lectures, 592 physician, 593 public schools, 589 publications, 590 schools, instruction in propliylaxis through, 589 Publications, instruction in prophylaxis through, 590 Puerile respiration. 205 Pulmonary congestion, 122 edema, 122 gymnastics in treatment, 623 hemorrhage, 123 atropin in. 719 bronchopneumonia after, treatment, 719 cold applications in, 720 constriction of chest in, 722 during sleep, 125 histology, 84 774 Pulmonary hemorrhage, ice-bag in, 720 immediate effects, 127 influence of climate on, 129 initial, method of onset, 97 hgation of extremities in, 722 moderate, 125 morphin in, 718 nervous and mental disturbances during and after, 127, 713, 714 remote effects, 128 severe. 126 treatment, 711 drugs in, 717 general considerations, 713 regard for detail, 714 special methods, 720 venesection and salt solution in, 720 Pulsation, epigastric, 173 Pulse, acceleration of, 120 diagnostic import, 243 irregularity of, 121 Puncture, exploratory, in empyema, 374 Pyogenic membrane, 90 Race, influence of, 59 on prognosis, 304 Rachitic chest, 163 rosary, 164 Rfiles, 210 apical, unilateral, diagnostic import, 244 bronchial, dry, 212 moist, 211 cavernous, 213 consonating, 212 crepitant, 212 in diagnosis of early cases, 220 indeterminate, 214 metallic, 214 mucous, 211, 212 non-conscnating, 211 pleural, 213 resonant, 212 subcrepitant, 212 succussion, 214 tracheal, 210 dry, 211 vesicular, 212, 213 crackling, 212 dry, 212 Receptacle for sputum, 573 Reciprocal relations of consumptives and society, 560 Recovery, 299 Recreation in treatment, 621 Rectal fistiUa, 484 treatment, 485 Red blood-corpuscles, influence of alti tude on, 676 Registration, compulsory, 566 Renal tuberculosis, 487, 490. See also Kidney, tuberculosis of. Resonance, 177 absence of, 187 amphoric, 189 changes in intensity, 188 in quality, 188 cracked-pot, 190, 231 duration of. 178 quality of. 178 tympanitic. 178, 188 vesicular. 178 vocal, changes in intensity, 215 in pitch and quality, 216 increased. 215 modifications, in disease, 215 over larynx. 203 over lung. 203 over trachea. 203 suppression or diminution, 215 Resonant nlles. 212 Resort, day, 584 Respiration, amphoric, changes in pitch and quality, 208 asthmatic, 204 bronchial, auscultation of, 200 changes in pitch and quality, 206 bronchocavernous. 208 bronchovesicular, 202 changes in pitch and quality, 206 cavernous, changes in pitch and quality, 207 Cheyne-Stokes type, 157 cog-wheel. 158, 204, 210, 221 emphysematous. 204 frequency and character, 157 harsh, 221 metamorphosing, 208 changes in pitch and quality, 208 puerile. 205 restrained. 1,58 rhythm and sound, 157 sighing, 158 stridulous, 158 775 Respiration, vesicular, auscultation of, 199, 200 regional differences, 201 vesiculocavernous, 208 Respiratory movements, 169 rate, influence of altitude on, 678 sounds, absence of, 204 auscultation of, 199 clianges in duration, 209 in intensity, 204 in pitch and quality, 206 in rhythm, 210 diminution of intensity, 204 increased intensity, 205 modification, 203 tract, infection through, 43 upper, tuberculosis of, 524 Rest in treatment, 619 Restrained respiration, 158 Reticulum of elementary tubercle, 80 Retraction of chest- wall, 173 unilateral, of chest, 167 Revolving shelter in treatment, 636 Rhonchi, palpable, 176 Roaring in tuberculosis of mediastinal glands, 424 Rontgen rays, diagnostic import, 251- 293 in diagnosis of renal tuberculosis, 495 in treatment of glandular tubercu- losis, 434, 435 Rosary, rachitic, 164 Rotch's sign in tuberculosis of pericar- dium, 398 Salt solution and venesection in pul- monary hemorrhage, 720 Sanatoria, scope of, in treatment, 651 State, 579 industrial pursuits in, 581 influence of, on neighboring com- munities and surrounding prop- erty, 581 tuberculosis in, 41 prophylaxis, 598 Schools, public, instruction in prophy- laxis through, 589 regulation of, in prophylaxis, 602 Scrofuloderma, 513, 522 Segregation of urine in diagnosis of renal tuberculosis, 495 Semilunar space, Traube's. 184 Seminal vesicles, tuberculosis of, 505 Septic disturbances, acute, 98 Serous effusion in tuberculosis of pleura, aspiration for, indications and contraindications, 368 rules, 370 treatment, 366 Serum, antistreptococcic, in mixed infec- tion, 547 Serum, Maragliano's, 730, 731 Sex, influence of, on prognosis, 303 Sexual desire, 144 organs, 144 Sick-room, formaldehyd disinfection of, 575 furniture of, 574 Sighing respiration. 158 Sign, Bamberger's, in tuberculosis of pericardium, 398 Broadbent's, in adherent pericardium, 404 E wart's, in tuberculosis of pericar- :ich's, in adherent pericardium, is of pleura, of pericar- Friedn 404 Jiirgensen's, in tuberculo 356 Rotch's, in tuberculosis dium, 398 Signs, physical, 218 in advanced cases, 229 in early cases, 219 in modern involvement, 223 in progno.sis, 313 Site of primary involvement, 92 Skin, condition of, in tuberculosis, 116 role of, as channel for tuberculous infection, 513 tuberculosis of, 513 diagnosis, 523 prognosis, 523 scrofulous type, 522 treatment, 524 ulcerative form, 521 varieties, 521 verrucous variety, 521 Sleep, disturbed. 139 pulmonary hemorrhage during, 125 Sleeping canopy. 629 Sleeplessness, 139 treatment of, 710 Social environment, influence, on prog- nosis, 310 776 Society and consumptives, reciprocal relations, 560 Soft palate, tuberculosis, 463 Soldiers, tuberculosis in, 75 Sounds, respiratory, absence of, 204 auscultation of, 199 changes in duration, 209 in intensity, 204 in pitch and quality, 206 in rhythm, 210 diminution of intensity, 204 increased intensity, 205 modification of, 203 voice-, 202 Space, Gerhardt's complemcntal, 185 Traube's semilunar, 184 Specific treatment, 720 Spine, caries of, 440 Spoken voice, modifications of, in tlis- ease, 215 Sputum, blood in, 104, 124 care of, 572 composition of, 105 control of, in prophylaxis, 602 examination of, diagnostic import, 245 gross appearances, 104 nummular, 104 quantity, 103 receptacle for, 573 sterilization of, 573 Staining tubercle bacillus, 20 Stasis in circulation, 122 State, duty of, to tuberculosis, 563 sanatoria, 579 industrial pursuits in, 581 influence of, on neighboring com- munities and surrounding proper- ties, 581 Sterilization of sputum, 573 Stethoscope, auscultation with, 193 Bowies', 197 Camman's, 194 Stomach cough, 132 symptoms, 131 tuberculosis of, 465 Stridulous breathing, 158 Strychnin in phthisis, 724 Subcrepitant rAles, 212 Submiliary tubercles, 79, 83 Succussion rales, 214 Suction pull, 93 Sunlight, effect of, on tubercle bacillus, 23 Supervision and education, 571 Surroundings, change of, influence on prognosis, 311 Sweats, night-, treatment of, 709 Swedes, tuberculosis in, 63 Symptoms, 94 cough and expectoration, 101 emaciation and local objective symp- toms, 115 fever, 111 methods of onset, 94-101 pain, hoarseness, and dyspnea, 106 referable to circulation, 120 to digestive apparatus, 131 to genito-urinary tract, 142 to mind and nervous system, 135 special, treatment of, 701 Syphilis, 555 already existing, modifying action of tuberculosis on, 557 and phthisis, differential diagnosis, 296, 558 hereditary, 555 influence of. on previously acquired tuberculosis, 556 on vulnerability of the tissues to future tuberculous infection, 556 Systemic disturbances, character, influ- ence of, on prognosis, 316 TO tuberculin, 728 TR tuberculin, 728 Tache cer^brale in meningeal tuberculo- sis, 341 Tacliycardia, 120 Temperament, influence, on prognosis, 308 Temperature, clinical types of fever, 1 13 Tenement houses, hygienic construction and sanitary supervision, in prophy- laxis, 605 Tent life in treatment, 632 window-, Knopf's, 627 Termination, 152 Test, ophthalmo-tuberculin, 249 phlorizin, in renal tuberculosis, 496 tuberculin, 247 Testes, tuberculosis of, 506 diagnosis, 507 treatment, 508 Thorax, au.'icultation of, 199 barrel, 163 777 Thorax, circumscribed depression, 168 prominences, 168 conditions independent of, noted on inspection, 156 constriction of, in pulmonary hemor- rhage, 722 emphysematous, 162 exploration of, diagnostic import, 243 inspection of, 158 pain in, 106 paralytic, 159 percussion of, 182 regional differences, 182 phthisical, 161 unilateral prominence, 167 retraction, 167 rachitic, 163 size and shape, 159 Tirage, 423 Tissues, character of, as determining course of tuberculosis, 76 Tone, William's tracheal, 189 Tongue, tuberculosis of, 463 Tonsils as port of entrance for tubercle bacillus, 415 tuberculosis of, 464 Toxemia, intestinal, acute, treatment of, 708 and meningeal tuberculosis, differ- entiation, 345 of pneumonia and meningeal tuber- culosis, differentiation, 344 Trachea, vocal resonance over, 203 Tracheal compression, physical signs, in tuberculosis of mediastinal glands, 423 rates, 210 dry, 211 tone, William's, 189 Transmission, 562 hereditary, 36 Traube's semilunar space, 184 Treatment, 612 adjustment of physical and nervous effort, 619 alcohol, 646 avoidance of fatigue, 619 climate, clinical testimony, 679 physiologic considerations. 672 role of, 667 conservation of energy, 619 diet, regulation of, 639 disadvantages of moisture, 674 Treatment, eggs, 646 excessive feeding, 643 contraindications, 647 exercise, 620 general, 560 considerations, 612 King's lean-to arrangement, 636 Knopf's window-tent, 627 milk, 650 of special symptoms, 701 open-air existence, comfort and shelter in, 629 enforcement of, 626 overfeeding, 641 contraindications, 647 porch, 631, 632 principles of, 614 pulmonary gymnastics, 623 recreation, 621 regard for infinite detail, 615 regulation of diet, 639 rest in, 619 revolving shelter, 636 role of climate, 667 clinical testimony, 679 physiologic considerations, 672 sanatorium, scope of, 651 sleeping canopy, 629 porches, 631, 632 specific, 560, 726 tent life, 632 walking in open air, 621 wooden shelters, 633 Tubercle, 79 bacillus, 19 adenoid vegetations as port of entrance, 415 and lepra bacillus, resemblance, 21 channels of entrance, 36 chemic composition, 25 conditions influencing infection after exposure to, 72 cultural characteristics, 22 distribution, 55 in body, 36 effect of sunlight on, 23 means of exit, 36 on hands, 514 relation of human and bovine, 27 staining, 20 tonsils as port of entrance, 415 various types, 25 778 Tubercle bacillus, virulence, as determin- ing course of disease, 76 vitality, 22 conglomerate, 79, 83 corpuscle, 18 crude, 83 degenerative clianges in, 81 reticulum of, SO submiliary, 79, S3 Tuberculin and immunity, 727 test, 247 T O, 728 T R, 728 Turban-shaped epiglottis, 532 Tympanitic resonance, 178, 188 Typhoid fever and meningeal tuber- culosis, differentiation, 344 phthisis following, 101 type of miliary tuberculosis, 331 Ulcerative type of cutaneous tuber- culosis, 521 of tuberculosis of intestine, 468 of vermiform appendix, 471, 472 Ureteral catheterization in diagnosis of renal tuberculosis, 495 Urine in renal tuberculosis, 492 segregation of, in diagnosis of renal tuberculosis, 495 Uterus, tuberculosis of, 511 symptoms, 512 treatment, 512 Vaccines, bacterial, in mixed infection, 549 in tuberculosis, 738 Varieties, 94, 147 Vegetations, adenoid, as port of entrance for tubercle bacillus, 415 Venesection and salt solution in pul- monary hemorrhage, 720 Vermiform appendix, tuberculosis of, 471 clinical symptoms, 473 hyperplastic form, 471, 473 illustrative cases, 477 primary, 472 principles of management, 474 ulcerative type, 471, 472 Verruca cutis, 513 necrogenica, 513 Vesical tuberculosis, 488, 499. See also Bladder, tuberciUosis of. Vesicles, seminal, tuberculosis of, 505 Vesicular rales, 212, 213 crackling, 212 dry, 212 resonance, 178 respiration, auscultation, 199, 200 regional differences, 201 Vesiculocavernous respiration, 208 Virulence of tubercle bacillus as deter- mining course of disease, 76 Visitation, domiciliary, 585 Vocal fremitus, 174 diminished, 175 increased, 175 resonance, changes in intensity, 215 in pitch and quality, 216 increased, 215 modifications, in disease, 215 over larynx, 203 over lung, 203 over trachea, 203 suppression or diminution, 215 Voice, amphoric, 216 cavernous, 216 spoken, modifications, in disease, 215 symptoms, 108 whispered, 203 intensification, in moderate involve- ment, 228 modifications, in disease, 217 Voice-sounds, normal, 202 Vomiting and cough, 103 Walking in open air in treatment, 621 Wart, anatomic, 513 necrogenic, 513, 521 Weight, loss of. 115 diagnostic import, 241 What the public should know, 595 Whispered voice, 203 intensification, in moderate involve- ment, 228 modifications, in disease, 217 William's tracheal tone, 189 Window-tent, Knopf's. 627 Wintrich's change of pitch, 190 Wooden shelters in treatment, 631, 632, 633 Workshops, hygienic construction and sanitary supervision, in prophylaxis, 605 SAUNDERS' BOOKS Practice, Pharmacy, Materia Medica, Thera- peutics, Pharmacology, and the Allied Sciences W. 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The Medical World " The methods are practical. ; and the required apparatus is simple and We commend it to every doctor as a valuable aid in cxactnes: i in diagnosis. THE PRACTICE OF MEDICINE Anders' Practice of Medicine A Text=Book of the Practice of Medicine. By James M. Anders, M. D., Ph. D., LL. D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadelphia. Hand- some octavo, 1 3 17 pages, fully illustrated. Cloth, $5.50 net; Sheep or Half Morocco, $7.00 net. THE NEW i8th) EDITION The success of this work is no doubt due to the extensive consideration given to Diagnosis and Treatment, under Differential Diagnosis the points of distinction of simulating diseases being presented in tabular form. 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JUST ISSUED-THE NEW (3d) EDITION This new edition has been carefully revised, making it still more useful than the two editions previously exhausted. The articles on milk and alcohol have been rewritten, additions made to those on tuberculosis, the salt-tree diet, and rectal feeding, and several tables added, including Winton's, showing the composition of diabetic foods. George Dock. M. D. Professor of Theory and Practice and of Clinical Medicine, Tulane University. •• It seems to me that you have prepared the most valuable work of the kind now available. I .am especially glad to see the long list of analyses of different kinds of foods." PRACTICE OF MEDICINE Rolleston on the Liver Diseases of the Liver, GalUbladder, and Bile-ducts. By H. D. Rolleston, M. D. (Cantab), F. R. C. P., Physician to St. George's Hospital, London, England. Octavo volume of 794 pages, fully illus- trated, including a number in colors. Cloth, ^6.00 net. 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ENLARGED TWO EDITIONS IN ONE YEAR Dr. Boston here presents a practical manual of the clinical and laboratory examinations which furnish a guide to correct diagnosis, giving only such methods, however, which can be carried out by the busy practitioner in his office as well as by the student in the laboratory. In this new second edition the entire work has been carefully and thoroughly revised, incorporating all the newest advances. Boston Medical and Surgical Journal " He has produced a book which may be regarded eminently as a practical and serrice. able guide. . . . The illustrations are both numerous and good." SAUNDERS' BOOKS ON AMERICAN EDITION NOTHNAGEL'S PRACTICE li.NIIER THE EDITORIAL bUPERVTSION UK ALFRED STENGEL, M.D. Professor of Clinical Medicine in the University of Pennsylvania; Visiting Physician to the Pennsylvania Hospital. ■ acknowledged that the Gern thi; suhj ns lead the world in Internal Medicine ; and igel's '■ Specielle Pathologie und Therapie " BEST IN EXISTENCE is coiUL-dcd by scholars ' of Meilicine in existence, of Internal Medicine thai original German. In vie\ be without question the best Practice So necessary is this book in the study it comes largely to this country in the 1 of these facts, Messrs. W. B. Saunders FOR THE PRACTITIONER PROMINENT SPECIALISTS Company arranged with the publishers of the German edition to ,e an authorized American edition of this great Practice of Medicine. The work has been issued in twelve volumes, and those subjects selected that are of the greatest importance to the physician engaged in general practice. In fact, these volumes contain the real essence of the entire work, so that the purchaser obtains at less than half the cost the cream of the original. This work is a Practice of Medicine for the General Practitioner. The work has been translated by men possessing thorough knowledge of both English and German, and each volume has been edited by a prominent specialist. It has thus been brought thoroughly up to date, and the American edition is more than a mere translation ; for, in addi- tion to the matter contained in the original, it represents the very latest views of the leading American and English specialists in the various departments of Internal Medicine. Moreover, as each volume has been revised to the date of its publication by the eminent editor, the objection that has heretofore existed to treatises published in a number of volumes has been obviated, since the subscriber receives the com- pletedwork while the earlier volumes are still fresh. The American publication of the entire work is under the editorial supervision of Dr. Alfred STENGEL, who has selected the subjects for the .American Edition, and has chosen the editors of the different volumes. The usual method of publishers when issuing a publication of this kind has been to require physicians to take the entire work. This seems to us in many cases to be undesirable. Therefore, in purchasing this Practice physicians are given the opportunity of subscribing for it in entirety ; but any single volume or any num- ber of volumes, each complete in itself, may be obtained by those who do not desire the com- plete series. This latter method offers to the purcha.scr many advantages which will be appreciated by those who do not care to subscribe for the entire work. Subscription. SEE NEXT TWO PAGES FOR LIST VOLUMES SOLD SEPARATELY PRACrrCE OF MEDICINE. g AMERICAN EDITION NOTHNAGEL'S PRACTICE Per volume : Cloth, 85-00 net WORK NOW COMPLETE Half Morocco. 86.00 net Typhoid and Typhus Fevers By Dr. H. Curschmann, of Leipsic. The entire volume edited, with additions, by William Osler, M. D., F. R. C. P., Regius Professor of Med- icine, Oxford University, Oxford, England. Octavo volume of 646 pages, fully illustrated. Smallpox ( including Vaccination ), Varicella, Cholera Asiatica. Cholera Nostras, Erysipelas, Erysipeloid, Pertussis, and Hay Fever By Dr. H. Immermann, of Basle ; Dr. Th. von Jurre.nsen, of Tubingen ; Dr. C. Liebermeister, of Tubingen ; Dr. H. Lenhartz, of Hamburg ; and Dr. G. Sticker, of Giessen. The entire volume edited, with additions, by Sir J. W. Moore, M.D., F. R. C. P. 1., Professor of Practice, Royal Col- lege of Surgeons, Ireland. Octavo, 682 pages, illustrated. Diphtheria, Measles, Scarlet Fever, and Rotheln By William P. Northrup, M. 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D., Hersey Professor of the Theory and Practice of Physic, Harvard University ; and Frederick A. Packard, M. D., Late Physician to the Pennsylvania and Children's Hos- pitals. Octavo of 918 pages, illustrated. Diseases of the Stomach By Dr. F. Riegel, of Giessen. Edited, with additions, by Charles G. Stockton, M. D., Professor of Medicine, liniversity of Buffalo. OcUvo of 835 pages, with 29 text-cuts and 6 full-page plates. Diseases of the Intestines and Peritoneum Second Edition By Dr. Hermann Nothnagel, of Vienna. The entire volume edited, with additions, by H. D. Rolleston, M, D., F. R. C. P.. Physician to St. George's Hospital, London. Octavo of iioo pages, finely illustrated. lo SAUNDERS' BOOK'S ON AMERICAN EDITION NOTHNAGELS PRACTICE Per volume : Cloth, S5.OO net WORK NOW COMPLETE Half Morocco. $6.00 net Tuberculosis and Acute General Miliary Tuberculosis ISy Dr. G. Cornet, of Berlin. Edited, with additions, by Walter B. James, M. D., Professor of the Practice of Medicine, ColuiBbia University, New York. Octavo of 806 pages. Diseases of the Blood ' .-tnemiti, chlorosis. Leukemia, and Pseudoleukemia) By Dr. P. Ehrlich, of Frankfort-on-the-Main ; Dr. A. Lazarus, of Char- lottenburg ; Dr. K. von Noorden, of Frankfort-on-the-Main ; and Dr. Feli.x Pinkus, of Berlin. The entire volume edited, with additions, by Alfred Stengel, M. D., Professor of Clinical Medicine, University of Pennsylvania. Octavo of 714 pages, with text-cuts and 13 full-page plates, 5 in colors. Malarial Diseases, Influenza, and Dengue By Dr. J. Mannaberg, of Vienna, and Dr. O. Leichtenstern, of Cologne. The entire volume edited, with additions, by Ronald Ross, F. R. C. S. (Eng.), F. R. S., Professor of Tropical Medicine, University of Liverpool ; J. W. W. Stephens, M. D., D. P. H., Walter Myers Lecturer on Tropical Medicine, University of Liverpool ; and Albert S. Grunbaum, F. R. C. P., Professor of Experimental Medicine, University of Liverpool. Octavo of 769 pages, illustrated. Diseases of Kidneys and Spleen, and Hemorrhagic Diatheses By Dr. H. Senator, of Berlin, and Dr. M. Litten, of Berlin. The entire volume edited, with additions, by James B. Herrick, M. D., Professor of the Practice of Medicine, Rush Medical College. Octuvo of 815 pages, illust. Diseases of the Heart By Prof. Dr. Th. von Jurgensen, of Tiibingen ; Prof. Dr. L. Krehl, of Greifswald ; and Prof. Dr. L. von SchrOtter, of Vienna. The entire volume edited, with additions, by George Dock, M. D., Professor of Theory and Practice of Medicine and Clinical Medicine, Tulane University of Louisiana. Octavo of 848 pages, fully illustrated. SOME PRESS OPINIONS London Lancet ( Typhoid volume) '■ We welcome the translation into English of this excellent practice of medicine. The first volume contains a vast amount of useful information, and the forthcoming volumes are awaited with interest." Journal American Medical Association ( Tuberculosis volume) "We know of no single treatise covering the subject so thoroughly in all its aspects as this great German work. ... It is one of the most exhaustive, practical, and satisfactory works on the subject of tuberculosis." Medical News, New York {Liver volume) " Leaves nothing to be desired in the way of completeness of information, orderly arrange- ment of the text, thoroughgoing up-to-dateness, handiness for reference, and exhaustive dis- cussion of the subjects treated." EACH VOLUME IS COMPLETE IN ITSELF AND IS SOLD SEPARATELY MA TERIA MED/CA. Stevens' Modern Therapeutics A Text-Book of Modern Materia Medica and Therapeutics. By A. A. Stevens, A. M., M. D., Lecturer on Physical Diagnosis in the University of Pennsylvania. Octavo of 670 pages. Cloth, $3.50 net. THE NEW (4th) EDITION Adapted to the New ( I905) Phairmacopeia Dr. .Stevens, by his extensive teaching experience, has acquired a clear, concise diction that adds greatly to his work's pre-eminence. In this edition new articles have been added on Scopolamin, Ethyl Chlorid, Theocin, Veronal, and Radium, besides much new matter to the section on Radiotherapy. The numerous changes in name or strength of various drugs and preparations, as called for by the new Pharmacopeia, have also been made. The work includes the following sections : Physiologic Action of Drugs ; Drugs ; Remedial Measures other than Drugs ; Applied Therapeutics ; Incompatibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of Diseases ; the treatment being eluci- dated by more than two hundred formulae. University Medical Magazine " The author has faithfully presented modern therapeutics in J comprehensive work . . . and it will be found a reliable guide and sufficiently comprehensive." Camac's Cpoch-Making Contributions Epoch-Making Contributions in Medicine and Surgery. Col- lected and arranged by C. N. B. Camac, M. D., of New York City. Octavo of 450 pages, illustrated. Artistically bound, $4.00 net. RECENTLY ISSUED Dr. Camac has collected some of the most important epochal articles in medicine and surgery — articles that record masterpieces of scie7iiific research — and has presented them in the original, together with a portrait and a brief biographic sketch of the discoverer. The articles included are : Antisepsis (Lister), Circula- tion (Harvey), Percussion (Auenbnigger), Auscultation (Laennec), Anesthesia (Morton), Puerperal Fever (Holmes), Vaccination (Jenner). SAUNDERS' BOOKS ON Amy's Principles qf Pharmacy Principles of Pharmacy. By Henry V. Arny, Ph. G., Ph. D., Professor of Pharmacy at the Cleveland School of Pharmacy. Octavo of I200 pages, with 250 original illustrations. READY IN JUNE Professor Arny divides his subject into seven parts : The first part deals with pharmaceutic processes, a striking feature being the clear discussion of the arith- metic of pharmacy ; the second part deals with galenic preparations of the Phar- macopeia and those unofficial preparations of proved value ; the third part deals with the inorganic chemicals used in pharmacy, and includes also a chapter on chemical theories and chemical arithmetic ; the fourth part discusses the organic chemicals used in pharmacy, the most modern classification being adopted ; the fifth part is devoted to chemical testing, presenting a systematic grouping of all the tests of the Pharmacopeia — a feature not found in any other book ; the si.xth part discusses the prescription from the time it is written until it is dispensed ; the seventh part is devoted to laboratory work, a feature being the e.xercises in equa- tion writing and chemical arithmetic. Hatcher and Sollmann's Materia Medica A Text-Book of Materia Medica : including Laboratory Exercises in the Histologic and Chemic Examination of Drugs. By Robert A. Hatcher, Ph. G., M. D. ; and Torald Sollmann, M. D. i2mo of 411 pages. Flexible leather, $2.00 net. Eichhorst's Practice A Text-Book of tlie Practice of Medicine. By Dr. H. Eichhor.st, University of Zurich. Fidited by A. A. Eshner, M. D. Two octavos of 600 pages each, with 150 illustrations. Per set: Cloth, $6.00 net. MA TERIA MEDICA. Sollmann's Pharmacology Including Therapeutics, Materia Medica, Pharmacy, Prescription-writing', Toxicology, etc. A Text-Book of Pharmacology, By Torald Sollmann, M. D., Professor of Pharmacology and Materia Medica, Medical Department of Western Reserve University, Cleveland, Ohio. Handsome octavo volume of 1070 pages, fully illustrated. Cloth, $400 net. THE NEW (2d) EDITION Because of the radical alterations which have been made in the new (1905) Pharmacopeia, it was found necessary to reset this book entirely. The author bases the study of therapeutics on a systematic knowledge of the nature and properties of drugs, and thus brings out forcibly the intimate relation between pharmacology and practical medicine. J. P. Poiheringham. M. D. Pyof. of Therapeutics and Theory and Practice of Prescribing Trinity Med. College, Toronto. " The work certainly occupies ground not covered in so concise, useful, and scientific a manner by any other text I have read on the subjects embraced." Butler's Materia Medica Therapeutics, and Pharmacology A Text-Book of Materia Medica, Therapeutics, and Pharmacology. By George F. Butler, Ph. G., M. D., Professor and Head of the Department of Therapeutics and Professor of Preventixe and Clinical Medicine, Chicago College of Medicine and Surgery, Medical Depart- ment Valparaiso University. Octavo of 702 pages, illustrated. Cloth, ^4.00 net ; Half Morocco, ^5.50 net. RECENTLY ISSUED— NEW (6th) EDITION For this sixth edition Dr. Butler has entirely remodeled his work, a great part having been rewritten. All obsolete matter has lieen eliminated, and special atten- tion has been given to the toxicologic and therapeutic effects of the newer com- pounds. The classification adopted is a practical one, aiding the student in grasp- ing the subject, and the practitioner in finding the information sought. Medical Record. New York " Nothing has been omitted by the author which, in his judgment, would add to the com- pleteness of the te.Kt, and the student or general reader is given the benefit of latest advices bearing upon the value of drugs and remedies considered." saujXders' books on Thornton's Dose-Book Dose-Book and Manual of Prescription-Writing. By E. Q. Thorn- ton, M. D.. Assistant Professor of Materia Medica, Jefferson Medical College, Phila. Post-octavo, 392 pages, illustrated. Flexible Leather, g2.oo net. The New (3d) Edition Dr. Thornton, in making this revision, has brought his book in accord with the new (1905) Pharmacopeia. Throughout the entire work numerous references have been introduced to the newer curative sera, organic extracts, synthetic com- pounds, and vegetable drugs. To the Appendix, chapters upon Synonyms and Poisons and their antidotes have been added, thus increasing its value as a book of reference. C. H. MUler. M. D., Professor of Pharmacology , Northwestern University Medical School, Chicago. " I will be able to make considerable use of that part of its contents relating to the correct terminology as used in prescription-writing, and it will afford me much pleasure to recommend the book to my classes, who often fail to find this information in their other text-books." Lusk on Nutrition Elements of the Science of Nutrition. By Graham Lusk, Ph.D., Professor of Physiology' in Cornell University Medical School. Octavo of 325 pages. Cloth, $2.50 net. This practical work deals with the subject of nutrition from a scientific stand- point, and will be useful to the dietitian as well as the clinical physician. There are special chapters on the metabolism of diabetes and fever, and on purin metab- olism. Lewellys T. Barker. M.D.. Professor of the Principles and Practice of Medicine, Johns Hopkins University. " I shall recommend it highly. It is a comfort to have such a discussion of the subject." Mathews' How to Succeed in Practice How to Succeed in the Practice of Medicine. By Joseph M. Mathews, M.D., LL.D., President American Medical Association, 1898-99. l2mo of 215 pages, illustrated. Cloth, $1.50 net. PRACTICE. MATERIA MEDIC A, Etc. 15 The American Pocket Medical Dictionary. just Ready The American Pocket Medical Dictionary. Edited bv W. A. Newman D.ir- LANI>, M. D., Assistant Obstetrician to the Hospital of tlie University of Pennsylvania. Containing the pronunciation and definition of the principal words used in medicine and kindred sciences, with 64 extensive tables. Flexible leather, with gold edges, jSl.oo net ; with thumb index, $1.25 net. "I can recommend it to our students without reserve."— J. H. Holland. M. D., 0/ the Jefferson Mldicat College. Philadelphia. Pusey and Caldwell on X-Rays second Edwon The Practical Application of the Kontgen Rays in Therapeutics and Diagnosis. By William Allen Pusey, A. M., M. D., Professor of Dermatology in the University of Illinois; and Eugene W. Caldwell, B. S., Director of the Edward N. Gibbs X-Ray Memorial Laboratory of the University and Bellevue Hospital Medical College, New York. Octavo of 625 p.iges, with 200 illustrations. Cloth, jtS-OO net ; Half Morocco, $6.50 net. " It is indispensable to those who use the X-rays as a therapeutic agent ; and its illustrations are so numerous . . . that it becomes valuable to every one." — Boston Medical and Su7-^cal Journal. Cohen and Eshner's Diagnosis. Second RevUed Edition Essentials of Diagnosis. By S. SoLis-Cnni \, M. 1 1,, >. uior Assistant Professor in Clinical Medicine, Jefferson Medical Coll,,--. 1 ',, 1 A. A. EsHNER, M. D., Professor of Clinical Medicine, Philadelphia I-;. 1 i ! 1 ..ctavo, 3S2 pages; 55 illustrations. Cloth, gl. 00 net. In SnuiiJen' {^.i :. /i i "jiul Series. of subject, terse in expression of fact."— Awerican Journal 0/ the Morris' Materia Medica and Therapeutics. New (7th) Edition Essentials of Materia Medica, Theraphutics, and Prescription-Writing. By Henry Morris, M. D., late Demonstrator of Therapeutics, Jefferson Medical College, Phila. Revised by W'. A. Bastedo, M. D., Instructor in Materia Medica and Pharmacology at Columbia University. I2ino, 300}>ages. Cloth, ^I.oo net. In Saunders^ Question- Compend Series. " Cannot fail to impress the mind and instinct in a lasting manner."— fi«^i/(i Medical Journal. Williams* Practice of Medicine Essentials of the Practice of Medicine. By W. R. Williams, M.D., formerly Instructor in Medicine and Lecturer on Hygiene, Cornell University ; and Tutor in Therapeutics, Columbia University, N. Y. l2mo of 456 pages, illustrated. In Saunders' Question-Compend Series. Double number, $1.75 net. Stoney's Materia Medica for Nurses New ,3rd) Edition Materia Medica for Nurses. Bv Emily A. M. Stoney, Superintendent of the Training School for Nurses at the Carney Hospital, South Boston, Mass. Handsome i2mo volume of 300 pages. Cloth, $1.50 net. "It contains about everything that a nurse ought to know in regard to A-ryi^^."— Journal 0/ the American Medical Association. Grafstrom's Mechano-therapy second Edition. Enlarged A Text-Book of Mechano-therapy (Massage and Medical Gvmnasticsl. Bv Axel V. Grafstrom, B. Sc, M. D., Attending Physician to Augustus Adolphus Orphan- age, Jamestown, N. Y. i2mo. 200 pages, illustrated. 51.25 net. Bridge on Tuberculosis Tuberculosis. By Norman Bridge, A. M., M. D., Emeritus Professor of Medicine in Rush Medical College. I2mo of 302 pages, illustrated. Cloth, ^1.50 net. SAC:\\D£/^:s- BOOKS ox PRACTICE, Etc. Jakob and Eshner's Internal Medicine and Diagnosis Atlas AND Epiiomk (jf IsrtKNAL Medicine and Ci.imcal Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited, with additions, by A. A. Eshner, M. D., Pro- fessor of Clinical Medicine, Philadelphia Polyclinic. With 182 colored figures on 68 plates, 64 text-illustrations, 259 pages of text. Cloth, $3.00 net. In Saunder^ Hami-Allas Series. lingly to the practicing physician no less than to the student."— Lockwood's Practice of Medicine. Re^dld^E^r^ged A Manual of the Practice of Medicine. By Geo. Roe Lockwood, M. D., Attending Physician to the Bellevue Hospital, New York Citv. Octavo, S47 pages, with 79 illustrations in the text and 22 full-page plates. Cloth,' S4. 00 net. Barton and Wells' Medical Thesaurus A Thesaurus of Medical Words and Phrases. By W. M. Barton, M. D., and W. A. Wells, M. D., of Georgetown University, Washington, D. C. l2mo of 535 pages. Fle.\ible leather, S2.50 net; thumb indexed, S3.00 net. Jelliffe's Pharmacognosy .■\N Introduction to Phakmacognosy. By Smith Ely Jelliffe, Ph. D., M. D., of Columbia University. Octavo, illustrated. Cloth, $2. 50 net. Stevens* Practice of Medicine New (8th) Edition .-\ Manual of the Practice of Medici.ne. By \. A. Stevens, A. M., M. D., Professor of Pathology, Woman's Medical College, Phila. .Specially intended for students preparing for graduation and hospital examinations. Post-octavo, 556 pages, illustrated. Flexible leather, S2.50 net. Paul's Materia Medica for Nurses Matfkia Medica for Nurses. By George P. Paul, M. D., Assistant Visiting Physician and .\djunct Radiographer to the Samaritan Hospital, Troy, N. V. i2mo of 240 pages. Cloth, Si. 50 net. Saunders' Pocket Formulary Recently luued— New (pth) Edition Saunders' Pocket Medical Formulary. By William M. Powell, M. D. Containing 1S31 formulas from the best-known authorities. With an .Appendix con- taining Posologic Table, Formulas and Doses for Hypodermic Medication, Poisons and their -Antidotes, Diameters of the Female Pelvis and Fetal Heail, Obstetrical Table, Diet-list, Materials and Drugs used in .Antiseptic Surgery, Treatment of .Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, etc., etc. In flexible leather, with side index, wallet, and Hap, S1.75 net. Gould and Pyle's Curiosities of Medicine .Anomalies and Curiosities of Medicine. By George M. Gould, M. D., and Walter L. Pyle, M. D. An encyclopedic collection of rare and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Sur- gery, derived from an exhaustive research of medical literature from its origin to the present day. Octavo of 968 pages, 295 engravings, and 12 lull-page plates. C'oth. S3. 00 net ; Half Morocco, $4. 50 net. Date Due Vhk'^ '^ ' ■■ "- MiN ? ft nrp'n PR.NTEOIN u.3.;> CAT NO 24 161 BS8 illllf,. 000 165 UO» WF300 B71TP 1908 Bonney, Sherman G. Pulnonary tuberciaosis MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664 Illlll iiiiiiii! 1 i p?;;!:ii!iia^^ aiiiiisiil lii iiifi! la