Recast from Lectures Delivered at Rash Medical CoIIegfe, in Affiliation with the University of Chicago NORMAN BRIDGE, A.M., M.D. Emeritus Professor of Medicine in Rush Medical College ; Member of tlie Association of American Physicians ; Member of the American Climatolcgical Association ; Corresponding Member of the Wisconsin Academy of Sciences, Arts, and Letters. Philadelphia, New YorK, London ( W. B. SAUNDERS ^ COMPANY 1903 i ?0 Copyright, 1903, by W. B. Saunders & Company. Registered at Stationers' Hall, London, England. PREFACE The substance of the lectures on Medical Tuber- culosis delivered by the author in Rush Medical Col- lege during the past three years is embodied in this book. The form of the work has been somewhat changed ; some more detail has been introduced, in statistical matter and otherwise, and some few things uttered in the necessity of lecture-room discussion have been omitted. The treatment of the subject is not, and with the size of the volume could not be, exhaustive; but a correct statement of the science of the disease has been attempted, and at the same time the practical side of the care and management of those sick with its different non-surgical forms, and for the protec- tion of the community from the spread of the dis- ease, has been emphasized. This latter phase of the subject has heretofore been neglected by many of the profession, to the ca- lamity of both the sick and the. well. The old and inadef|uate way of regarding consumi)tives and deal- ing with their diseases was due partly to habit and partly to the gloom with which such invalidism was surrounded. Rut in this day of better hope for the victims of this amazing disease, and better knowl- edge of how to prevent it. a new science and a new 3 4 Preface gospel need to be taught, to the end that both the profession and the pubhc may be aroused to their duty and opportunities. This booi< is submitted in the hope that it may help, if only in a small way, toward this consumma- tion. The author has great pleasure in expressing his indebtedness to Dr. Henry B. Stehman and Dr. Stanley P. Black for generous and critical assistance in the prei)aration of the volume. Los Angeles, California, March, 1903. CONTENTS. CHAPTER I. PAGE The Bacillus Tuberculosis 9 CHAPTER II. The Tuberculous Process 27 CHAPTER III. Forms of Tuberculosis 39 CHAPTER IV. Pathology of Tuberculosis 51 CHAPTER V. Etiology of Tuberculosis 69 CHAPTER VI. Symptoms of Tuberculosis 79 CHAPTER VII. Physical Signs ok Tuberculosis 100 CHAPTER VHI. Diagnosis of Tuberculosis 120 CHAPTER IX. Prognosis of Tuberculosis 143 CHAPTER X. Prophylaxis ok Tuberculosis 161 CHAPTER XT. Treatment, General Principles 177 6 6 Contents CHAPTER XII. PAGR Treatment, Hygienic 192 CHAPTER XIII. Management ok the Diseased Lung 214 CHAPTER XIV. Treatment, Climatic 230 CHAPTER XV. Treatment, Medicinal and Local 248 CHAPTER XVI. Treatment, Medicinal (Continued) 262 CHAPTER XVII. Special Treatments 278 CHAPTER XVIII. Sanatoria for Tuberculosis 286 Index 297 TUBERCULOSIS TUBERCULOSIS CHAPTER I THE BACILLUS TUBERCULOSIS Tuberculosis is the most frequent and destruc- tive disease of man. It attacks many organs and appears in many forms, — forms that have been re- garded as distinct diseases and known by a variety of names ; and it destroys probably at least one- ninth of all the white races. It is now known to be due to the growth in the tissues of the tubercle bacillus, discovered by Koch in 1882, and no tuber- culous lesion exists without the presence of this or- ganism or of the direct influence of its growth and development. The bacillus tuberculosis is only one of many microbes, pathogenic and non-pathogenic, invading the human body. Most of the micro-organisms are received into the body by inspired air and by food and drink, and the number acquired is enor- mous. In different atmospheres the number of or- ganisms inhaled by an adult person varies from probably half a dozen to several lumdrcd every 9 lO Tuberculosis minute of life. Tubercle bacilli are acquired some- times through direct contact with abrasions of the skin, wounds and orificial mucous membranes, as well as through the respiratory and digestive organs. Koch's bacillus is a colorless, aerobic, rod-like organism, often slightly curved, probably non-motile Fig I. — Bacillus tuberculosis in sputum, stained with carbol- fuchsin and aqueous methylene-blue. X^^oo- and unflagellate, of variable length to the limit of 3.5 or 4 mikrons, or three-quarters of the diameter of an average red lilood-corpuscle, and al^out one- tenth as broad (Fig. i). It differs in form and size somewhat, and may be branched or nodulated, The Bacillus Tuberculosis ii all depending on the circumstances under which it has grown and possibly on the bodies through which its generations have passed. The branched or nodulated forms are rarely found save as the result of experimental growth. When stained red, it looks, under the microscope, not unlike a minute cutting of attenuated red hair. Some believe that the different sizes and shapes of the bacilli differ in their infecting powers to the system ; the shorter and thicker specimens, which take the stain best, being the product of the severer cases.' If this is true, it would argue that these forms are fewer generations removed from their origin in bovine bacilli. The bacillus is peculiar in containing various oily substances, thought by some to reside in a (rather supposititious) firm surrounding wall, and giving different appearances when treated by various sub- stances, especially alcohol and ether. Cold alcohol extracts 8 per cent, of the total weight of the bacilli, and becomes very red by the change of a form of chromogen in the presence of alcohol and oxygen. From 8 to 20 per cent, or more by weight is extracted by a mixture of alcohol and ether, depending somewhat on the age of the culture. Ruppel has separated from tubercle bacilli a new ptomain w^hich he has named tuberkulosamine. He 'Dr. Henry Scwall. The Medical News, March 16, 1901. 12 Tul)erciilosis believes it to exist in the organisms in combina- tion with nucleinic acid. The tubercle bacillus stains with difficulty, re- quiring the aid of a mordant like carbolic acid, anilin, or an alkali, but when once stained, it re- tains its color more tenaciously than most other organisms, and more than the tissues of the body, when treated by decolorizing agents. This power undoubtedly resides in the fatty matters of the bacillus. Koch has found that -the fatty substances which the bacilli contain include two unsaturated fatty acids, one of which is soluble in dilute alcohol, while the other is proof against everything but boiling alcohol and ether. Therefore it must be lliat the former is removed by the staining fluid which contains alcohol, and that the latter remains after the destaining, and therefore is probal)ly the substance that fixes the stain. It is this staining proi)erty that led to the discovery of the bacillus. It was at first supposed that no other bacillus which more or less resembles it had this peculiarity, but several possess it in varying degrees, especially the lepra and smegma bacilli ; while those of butter, hay, and grass have similar tinctorial qualities. The smegma bacilli, unlike tubercle bacilli, are de- colorized by thorough treatment with absolute al- cohol.^ Several different organisms are more acid- ^Dr. George Rlumer, Bender Laboratory, Albany, N. Y. The Bacillus Tuberculosis 13 proof than the Koch bacillus. The peculiar staining property of these bacilli is due to the fat they con- tain or which surrounds them, acquired probably from the substances in which they grow. Remove the fat by alkalis and this property is gone. The bacillus grows in various artificial media, but, as compared with many other organisms, it is difficult to propagate. The temperature that most favors its growth is about 37.5^ C. (99.5° F.), but it does grow at a temperature as low as 60° F. under some circumstances; its development is retarded by any considerable variation from this point. It grows fairly well in blood-serum, acid- ulated agar agar with glycerin, bouillon with gly- cerin, and e\en on cooked potato. It has been grown on filter-paper and on common wall-paper, when moistened l)y human l)reatli or by aqueous vapor emanating from damp soil. The bacillus multi])lies by division, — whether by manifold division into spores remains to be shown, and is unlikely. Many individual bacilli, presum- ably the older ones, are seen under the microscope to have the ai)pearance of a string of beads, as though just undergoing division into spores; but it is alleged that the spaces between the red dots are vacuoles, or points in the walls or substance of the bacillus that either have not taken the stain or have relinquished, it more quickly to the de- 14 Tuberculosis staining fluid, and that the appearance is no proof of spores. This bacihus is found in the bodies of various lower animals, where it produces many of the phe- nomena seen in the human subject. Monkeys, cat- tle, sheep, goats, swine, horses, chickens, cats, dogs, rats, rabbits, and guinea pigs (even fish fed on tuberculous sputa), and doubtless many other ani- mals, are thus afflicted with tuberculosis, althougii it rarely occurs spontaneously in domestic animals except cattle. The proportion of slaughtered cattle found to be tuberculous at inspected abattoirs ranges from 4 to 25 per cent. The butter and milk of the market sometimes contain bacilli. The bovine ba- cillus tuberculosis is shorter than the human and more virulent to other animals. Rabbits inoculated with it die of the disease in from seventeen to twenty-one days, but where human sputum is used they live from six to tw^elve weeks, and may for a time thrive and get fat, and even bear young. The same effect is found when cattle are inoculated, but it is substantially impossible to produce tubercu- losis in cattle l)y human bacilli. That the bacillus develops spontaneously outside of the animal body remains to be proved, but the evidence in favor of that possibility is increasing. It was the claim of Koch that it is a pure parasite originating in the animal body, and never spon- The Bacillus Tuberculosis 15 taneously a saprophyte existing outside of it. The recurrence of tuberculosis in certain districts and houses, and the encouragement of the growth of the bacillus by organic vapors, lead to the suspicion that it can and does sometimes grow spontaneously outside the animal body. No degree of cold yet produced (that of liquid air, more than 300° below Fahrenheit zero) is capable of destroying this bacillus ; after exposure for hours to such a temperature it will grow in arti- ficial media. Heat of 82.2° C. (180° F.) promptly kills it, while an exposure of 15 or 20 minutes to a temperature of 60° C. (140° F.) destroys it in milk.' Its vitality is reduced or destroyed by pro- longed daylight and fresh air acting from five to seven days, while in confined air it retains its virulence for a long time. Sunshine kills it after a period varying from one to twenty-four hours, depending on the intensity of the rays and the direct- ness of their effect upon it ; and the intensity de- pends on the clearness of the atmosphere and its freedom from moisture, either visible or invisible. A virulent sputum exposed to twelve and one-half hours of sunshine dailv for four days has failed after forty-three days to induce tuberculosis by in- oculation in gin'nea-pigs. The bacillus is destroyed by strong acids, and even by the degree of acidity 'Theobald Smith. l6 Tuberculosis often found in the stomach during digestion, by strong alkahs, and by germicides in general. The bacillus has a tryptic faculty by which it is capable of transforming various albuminoid sub- stances into peptones and tryptophan. Its life power and its virulence differ according to the animal body in which it is developed. Under cer- tain conditions it has great tenacity of life; it is even capable of being cultivated after it has been for many months incarcerated in scars in the animal body, yet at times it is killed in lung-tissues or old cavities, the expectorated bacilli, if present, being incapable of artificial cultivation. Certain animals seem to be perfectly immune to this organism. Many are relatively immune — that is, under ordinary conditions of health they do not acquire the disease when inoculated, but do acquire it if greatly reduced in vitality. This is an experi- ence that is nearly identical with that of the human body, which, when in every part perfectly well and vigorous, rarely, if ever, takes the disease. The blood-serum is germicidal to a certain degree, as the leukocytes are, to this organism. Repeated propagation of the bacilli in laboratory media lessens their virulence to animals. Several stainiui^ fluids have been used with suc- cess for tubercle bacilli, but the most practical is the carbol-fuchsin stain, composed of i part fuch- The Bacillus Tuberculosis 17 sin, 5 parts carbolic acid, 10 parts absolute alco- hol, and 85 parts water. (The same purpose sub- stantially is accomplished by the following formula : Saturated alcoholic solution of fuchsin, i part; five per cent, watery solution of carbolic acid, 9 parts.) This solution may be kept for a number of weeks, but should be renewed the moment it shows any precipitate or fails to stain perfectly. For decolorizing, a watery solution of nitric or sulphuric acid, 10 to 20 per cent, may be used. Or 3 per cent, hydrochloric acid in a 70 per cent, solu- tion of alcohol. The specimen is immersed in one of these solutions till all red color disappears and till washing with water will not restore it to any considerable degree. Then it should be washed free of acid and mounted, when the bacilli alone will be colored red. A better solution is one that contains a contrast stain, whereby with one pro- cess the red color may be removed from all parts of a specimen excej^t the bacilli, and all the other portions stained blue. One such solution is com- posed of 2 parts or less of methylene-blue (not methyl-blue) to 100 parts of a 25 per cent, watery solution of sulphuric acid. Another solution of perhaps equal value is composed of nitric acid 2 parts, alcohol 3 parts, and water 5 parts, with llie addition of methylene-blue to saturation. The use of these solutions leaves the bacilli stained red in 2 l8 Tuberculosis a blue field, which facilitates the search for them under the microscope. When colorless acid solu- tions are used, a most excellent counter-stain is a i per cent, watery solution of malachite-green, which produces instantaneously a beautiful green field, but leaves the bacilli with their red stain undimin- ished. The demonstration of tubercle bacilli is not diffi- cult, and any student with an ordinary microscope outfit, including a 1-12 immersion objective and a light-condenser below^ the stage, can easily be- come an expert. A few tools and solutions are necessary, and when one begins right and acquires the best methods, he can mount a specimen for the microscope in from five to ten minutes. The things needed are : a spirit-lamp, two needles fixed in handles (the base of a common large sewing- needle forced into the end of a soft piece of wood will do), a Stewart cover-glass forceps, an ordin- ary dissecting forceps, thin cover-glasses, slides, a solution for staining and another for decolorizing (or a contrast stain), and a bottle of glycerin or Canada balsam. The sputum is best secured, after rinsing the mouth thoroughly, by having the patient expecto- rate into a clean dish or a bottle with a wnde mouth. Then the sputum should be spread out upon glass over a black surface, and one of the small pearly The Bacillus Tuberculosis 19 lumps or flecks of purulent matter that usually abound in the expectoration should be picked out with the needles for the examination. The bacilli are usually found in these little particles, but they are found nearly as constantly in the larger masses of pure pus. The portion selected should with needles be spread on a cover-glass, or spread out by rubbing it between two of them, which are then pulled apart. It is best not to have the film too thin or too uniform in thickness; if some par- ticles are too thick to be well stained and studied with the microscope, there will be enough other surface for study, and the thicker and darker spots will aid in focusing the microscope. It is, of course, best to examine sputum soon after it is ex- pectorated ; otherwise more or less decomposition and granular degeneration will be found in it; but this will not prevent the discovery of the bacilli, which persist in spite of the degeneration. The film on the cover-glass is to be dried care- fully in the heat at a point a few inches above the flame of a spirit-lamp, when it may be passed through the flame rather quickly two or three times, to fix it to the glass. It is then ready for staining, and is to receive from a pipette, while being held level by the cover-glass forceps (which need not let go its l)ite till all the staining process is done), enough of the carbol-fuchsin solution to cover the 20 Tuberculosis slip as deeply as possible and not have it flow off. This must now be heated slowly to nearly or quite the boiling point. As soon as this is accomplished the staining is sufficient, and the solution may be washed off with cold water, and the decolorizing solution with the methylene-blue applied immediately and in the same manner. In one minute this solution may be wash- ed off, best by holding the cover-glass edgewise or nearly so in a stream of water; then the speci- men is dried by pressure between folds of soft cloth or bibulous tissue-paper or by warmth over the flame, and mounted in water or glycerin for imme- diate inspection, or in Canada balsam if it is to be preserved. If the specimen is to be kept for any length of time, the balsam must of course be used ; and if the acid has been completely washed out, the specimen will keep indefinitely without deteri- oration ; but if any acid remains, it will sooner or later destroy all the color in the bacilli. The red stain should never be allowed to dry on the cover- glass. If a very careful search is to be made in suspected sputum containing few if any bacilli, the specimen may be centrifugated for five minutes (or sedi- mented by standing in a test-tube for a day) after its tenacity has been destroyed by caustic soda, and the sediment stained and examined in the usual The Bacillus Tuberculosis 2i way. To liquefy the sputum, water is added in amount depending on the tenacity of the sputum, and then from i to 5 per cent, of a saturated aqueous solution of soda, and the mixture boiled until perfect fluidity is produced, but no longer. The sediment secured by the centrifuge will contain elastic fibers from the walls of the air-vesicles if dissolution of lung-tissue is going on, but these will not interfere with the demonstration of bacilli. In searching for bacilli in urine the centrifuge is used with a fresh specimen, or the urine, anti- septicized with 2 to 5 drops to the ounce of carbolic acid, may be sedimented for twenty-four hours in a deep conical glass and the sediment examined in the usual way, except that a thicker layer of sedi- ment may be spread upon the cover-glass than of the sputum. The best way of all is to centrifugate the lowest dram of the sedimented specimen. To search for bacilli in milk the same method may be used, only the fat in the sediment is a hindrance, and may be removed by immersing the dried cover-glass preparation in chloroform for five minutes before staining. Suspected butter may be manipulated thoroughly with a little water, the water being then centrifugated. Any bacilli pres- ent may be discovered in the sediment. The pres- ence of salt in the mixture does not interfere with the process. 22 Tuberculosis It is difficult to find bacilli in the fluid of pleural effusion and in pus from cold abscesses, even when tuberculosis is present; but such fluids injected into the peritoneal cavity of guinea-pigs usually pro- duce tuberculosis. The discovery of bacilli in animal tissues requires a much more elaborate process. The tissue is first hardened, preferably in absolute alcohol; it is then imbedded in celloidin and cut into sections ; the sections are immersed in oil of cloves or in equal parts of alcohol and ether to remove the celloidin, and are then put in alcohol, and finally into water. They are next stained in carbol-fuchsin solution, being allowed to remain in the mixture, kept at room-temperature, for twenty-four hours, although perfect staining will take place in two hours at a temperature of 60° C. (140° F.). They are then decolorized In weak hydrochloric acid ( i or 2 per cent.) in 70 per cent, alcohol, but this process is not carried to the point of complete decolorization. Contrast-staining is done with a 2 per cent, watery solution of methylene-blue. Finally the sections are dehydrated in alcohol, cleared by oil of cloves or xylol, and mounted in balsam. A large amount of experimental work has been done with tubercle 1)acilli, in cultures under varying conditions, through artificial tuberculosis in animals, and in efforts to develop in the blood of animals a The Bacillus Tuberculosis 23 substance capable of destroying or repressing the bacilli in the human body. Certain animals convenient for the laboratory are found very susceptible to tuberculosis, when the bacilli are introduced by means of inoculation of sputum under the skin, by inoculation into the an- terior chamber of the eye, or by injection into the peritoneal or pleural cavity or into the blood-ves- sels. Among these animals the most commonly used are guinea-pigs, rabbits and field mice, named here in the order of their susceptibility. Tuber- culosis of the lungs has been produced in laboratory animals by causing them to inhale the dust of dry, powdered sputum; by feeding them on infected sputum they have acquired the disease in the intes- tinal tract; and after inoculating a part of the body with bacilli a local development of tubercu- losis can be produced in a distant part by lowering its vitality in some w'ay, as through traumatic in- jury to a joint. Cattle prove refractory to these methods to a surprising degree when human sputum is used. Where local inoculation is performed, the tuber- culous process extends from this point by means of the lymph-channels, and attacks the lymphatic glands first reached, which swell and pass through the several stages of the disease. In efforts to produce a serum for the cure of 24 Tuberculosis tuberculosis, horses and other animals have been subjected to repeated hypodermic injections of pure cultures of the tubercle bacillus, or of the products of artificial bacterial growth, the dosage being so gauged as not to imperil the animal. Gradually a tolerance of the poison is developed ; larger and larger doses can be endured without reaction, until finally the animal appears to be immune to the poison. Then the blood-serum (secured by an or- dinary phlebotomy) is separated from the other ele- ments of this fluid, is antisepticized for preserva- tion, and is prepared for therapeutic use. The fluid products of the artificial growth of the tubercle bacillus were first separated from the cul- tures by the discoverer of the bacillus, and have become known as tuberculin or Koch's lymph. The substance has come into extensive use for diagnostic purposes for cattle, and to some extent for human subjects, and to a moderate degree as a remedy for tuberculosis. It is obtained usually from a glycer- in-bouillon culture of the bacillus, which is con- centrated to one-tenth volume by rapid evaporation over a water-bath, and then forced through a por- celain filter to separate the dead bodies of the bacilli. The fluid is then preserved by the addition of some antiseptic, as half of one per cent, of carbolic acid, or an equiv^alent amount of trikresol. In the evap- oration it is, of course, the water, not the glycerin, The Bacillus Tuberculosis 25 that disappears, and so tuberculin is a rather con- centrated solution in glycerin. It is proof against rather high temperatures; boiling temperature it stands well, and even higher heat (248"^ F.). It is tolerably constant, and retains its power and prop- erties for a long time. One property of tuberculin, when administered hypodermically in even minute doses, is to produce fever in animals and patients afflicted with any form of active tuberculosis. The fever reaction comes on a few hours after a dose of i to 5 milligrams is administered, is attended with all the symptoms which usually accompany fever, and passes off with the usual discomforts a few hours afterward. Ten years ago Koch experimented extensively with tu- berculin on different forms of tuberculosis in the hope of curing the disease, but with little or no success except upon lupus. Tuberculin is used enormously in many coun- tries for the diagnosis of tuberculosis in cattle, and laws exist in most of the states of our own country requiring, under certain regulations, the examination of cattle and the destruction of those found to have the disease. Probably there are several substances combined in tuberculin — some derived from the bacilli, and some from the culture media — and it has fairly been inferred that but one insfredient of the mixture 26 Tuberculosis produces the fever. Repeated efforts have been made to ehminate this ingredient, but with only moderate success. Klebs has, as he believes, pre- cipitated it by chemicals, producing a substance which he has named aiiti-phtliisin; also another, which is this substance plus an extract from the bodies of the bacilli, and which he has named tnbcr- ciilocidin. These substances produce less fever in tuberculosis than tuberculin does. Koch has produced two new tuberculin products, which he calls respectively upper tuberculin or T O, and tuberculin residuum or T R. The T O contains the soluble products of the bacilli, and is nearly iden- tical with the original tuberculin ; the T R contains the insoluble parts of the bacilli. In its manufacture the bodies of the dried bacilli are ground into fine powder in a mortar, and centrifugated with water; and the sediment is again dried, ground, and cen- trifugated, and this process is repeated until the substance of the bacilli is rendered soluble. The fluid of the first centrifugation is T O; the final product is T R. The latter substance is suspended in a 20 per cent, solution of glycerin, and when injected hypodermically does not cause abscesses. The T R has been used to a considerable extent as a therapeutic agent. Von Ruck has produced a watery extract of tu- bercle bacilli for a therapeutic agent. CHAPTER II THE TUBERCULOUS PROCESS What happens in the human body infected with tuberculosis? While there can be no tuberculosis without bacilli, tubercles are sometimes absent in this disease. Such cases occur where there is an unusual and rapid dissemination of the tubercle bacilli throughout the body, — to such a degree that the patient dies from the overpowering effect of the poisoning before the tubercle nodules can be formed. The bacilli do not travel by their own activity, so far as we know, although there is some evidence that they have motile power; but as they develop they spread, because in their very multiplica- tion they must extend. A bacillus divides in the center; it grows, and with its growth it pushes or is pushed into a new field. Then the bacilli are sometimes moved by the leukocytes of the blood, as they migrate outward and inward from the ves- sels and among the tissues; and, finding their way into the blood-stream, the bacilli are carried far. What usually happens is the formation of trans- lucent, grayish, spherical nodules 1-25 to 1-8 of an inch in diameter, known as " tubercles," which it 27 28 Tuberculosis is a property of the bacillus to produce, or to pro- voke the tissues to produce. The nodules accumu- late in distinct masses, giving an appearance known as tubercular. We use the term tuberculous as meaning affected with tuberculosis; the w'ord tu- bercular as meaning filled with or covered with little granular nodules, whether of tuljerculosis or not. Some of the skin diseases are tubercular in their appearance, but are not tuberculous. The tubercles of this disease develop rapidly and crowd into masses of various shapes and sizes, depending on the tissue and part invaded. This endless development of the tubercles enables them very soon to fill the center of the affected region so that it is one continuous mass, and the tuber- cular appearance is lost except at the periphery. The tubercles then develop only around the out- side, and so the mass spreads. If the disease occurs in the lungs, some of this substance gets into the bronchi. Perhaps the lesion began in the lining of the bronchi, and the material is carried along to fresh regions by the movement of the air in res- piration and by gravity, and so spreads, and new foci of the disease begin. If we cut through a single tubercle and examine its contents, we find it has few morphologic ele- ments, and these substantially constant. Bacilli, of course, are always present; two kinds of cells — The Tuberculous Process 29 the epithehoid (or endotheliod ) and the lymphoid; and the appearance known as the "giant-cell." In histologic examinations the giant-cell has been usu- ally regarded as diagnostic of tubercle. It is not completely so, since it is sometimes found under other conditions ; but the presence of tubercle ba- cilli is diagnostic. There are no blood vessels in the tubercle; as the mass develops the vessels be- come plugged up and disappear. They may endure for some time among the general tuberculous ag- gregation in tissues that have not yet become com- pletely transformed, but in the center of a mass that is wholly composed of tubercles there are no blood-vessels. The giant-cell is a globular body, made up of a central mass of granular substance and around its periphery a few nuclei. These nuclei are never in the center. The center is a homogeneous sub- stance, and is probably in the beginning stage of degeneration. The nuclei are the left-over elements of the epithelioid cells, both the cells and the nu- clei that occupied the site of the center of the giant- cell having lost their outlines in the degenerative change. As we see the giant-cell under the mi- croscope it is in section or flattened out, and the nuclei appear around its circumference, but in the site of its growth thev probably encompass the cen- tral granular mass completely. 30 Tiil:)erculosis When a mass of tubercles attains anything hke the size of the end of the httle finger, it becomes degenerate in the center, and there begins the pro- cess we know as caseous degeneration, which is a| pecuhar form of necrosis. The tendency of all tuberculous nodules is toward this change in the center, and I believe the inside of a giant-cell illus- trates the beginning of the process. The caseous substance has crudely the appearance of soft cheese, hence its name. Poverty of blood in the center of the tuberculous mass and lack of nourishment for the cells contribute to the degeneration. This is one of the things that the bacilli do — they cause the development of masses of tuber- cles, and the plugging of the vessels so that the center of the mass loses its nutrition, and thereby becomes degenerate as a necessary consequence. In course of time the caseous matter undergoes a fur- ther degeneration and becomes soft and semi-liquid ; it has at first a battery consistency, then a more liquid form ; and finally chemical changes in its substance produce certain acids. These last unite with the lime-salts that are dissolved in the blood and are present in this liquid, and produce small stony particles, the calcareous degeneration of the caseous matter. Patients occasionally expectorate these little masses of the size of a small finger- nail or even larger. Tlie Tuberculous Process 31 In a cavity of a lung the bacilli often die. They also die in the center of a tuberculous mass; and if a compact pile of tubercles is examined, it will be found that the bacilli thrive most around the outside, where they can find the nourishment they require; they cannot find it in the center of the mass. We have heretofore found that acid sub- stances are inimical to tubercle bacilli. Acids are produced in the degeneration of tuberculosis, and probably kill many bacilli, wdiile more die from want of adequate nutriment. In the growth of pure cultures the organisms develop something that destroys themselves, — a thing that is illustrated by the history of most other germs. As the tuber- culous mass spreads, it often produces more or less ordinary inflammation, so we have that added to the tuberculous process. Not only is there development of tubercles in a mass, but the disease occurs on surfaces — the skin and mucous and serous membranes — where no such aggregations can be formed. In the mass, degen- eration goes on in the center; on the surfaces, ulcers are often produced instead, as in lupus and intestinal ulceration. Degenerate masses are ex- truded, and the products of the disease are cast off as they form. The products of the ulceration represent what in a parenchymatous organ is the caseous center of a degenerate mass. In surface ^2 Tuberculosis tuberculosis the disease sometimes remains quite superficial, but sometimes it burrows rather deeply. Inflammation often occurs around the tubercu- lous areas. Not only this, 1)ut that which usually happens in inflammatory processes — namely, the growth of pus microbes. Hence we have purulent discharge from the ulcers and from the cavities produced by the liquefaction of a tuberculous mass, and the patient absorbs some of the products of this suppuration ; as a consequence, more or less general infection ensues. There result chills, fever, and sweating of various degrees, which we recog- nize as belonging in some way to the disease known as septicemia or pyemia. This subject we will discuss later on. I may say, however, that most of the deaths from tuberculosis are produced by this septic poison. The poisoning and the fever wear the patient out. These cases represent what is called mixed infection — infection from pus mi- crobes and tubercle microbes and their products. There is reason to suppose that the high fever of pulmonary tuberculosis is always caused by pus products. ]Many other kinds of fever are produced in this manner. Nearly all the tissues of the body are obnoxious to tuberculosis. One of the most resistant of them is the walls of blood-vessels, and yet these become The Tuberculous Process 33 involved, grow friable, and break easily. The usual blood-pressure within ruptures them, and so we have the hemorrhages of consumption. j\Iany times the tuberculous ulcers and cavities heal. They heal with a thick mass of scar-tissue, within which great numbers of bacilli are imprisoned. The scars are weak for a long time, and it is never safe to regard a lesion as cured until the scar is a year or more old. The process that goes on to make the scar is a conservative one — nature's invention evidently for abbreviating the disease — and we call it fibrosis. When a tuberculous deposit occurs in the lungs, the fibrous tissue of the trabecular structure of the organ round about usually begins to thicken, and the process goes on in a progressive manner, increasing in lines radiating from the center, so that as we examine the lung from time to time we can demonstrate that the fibrosis has extended far beyond the area of the tuberculosis. Fibrosis is most marked directly around the mass of tuber- culous infiltration ; but it reaches out into the nor- mal tissue, shading off to the perfectly nor- mal lung-substance some distance away. It helps to limit the process of tuberculosis, and it occurs in all degrees from the slightest quantity of fibrous tissue to the most profound dissemination of it through the lungs, producing that form which we 3 34 Tuberculosis know as fibroid p/itliisis. The fibrosis probably con- tinues to increase for some time after the tubercu- losis is healed — after it has segregated the tuber- culous mass from the circulation and lymphatics, and after a tuberculous cavity has been opened into a bronchus and is regularly evacuated. In such cases the fever may cease and the patient improve, but the fibrosis continues to spread. If in a case of pulmonary tuljerculosis the fibroid change fails to take place, we know that the patient is in greater peril in consequence, that the disease is more likely to spread, and that nature has failed to throw around the lesion any barrier to prexent its spread. If we were to make a list of the tissues more commonly invaded by tuberculosis, somewhat in the order of their susceptibility, it might be roughly as follows : Lymphatic glands, bronchi, bronchi- oles, lung-tissue, pleura, joints, larynx, peritoneum, testicles, intestines, bones, cerebral meninges, urin- ary bladder, kidneys, skin, adrenals, muscles, nerve- sheaths, and blood-vessel walls. Numerous complications, apparent and real, occur in this disease. It is a question as to many of the so-called complications whether we should not con- sider them as evidences of the usual spread of the disease. For instance, at the beginning the dis- ease appears in the surface of the lining of a l)ron- chial tube; it cxtciuls to the submucous tissue and The Tuberculous Process 35 then into the king-tissue; the bacilH get into the circulation and start to grow in a kidney or an epididymis; the trachea is covered more or less with them ; they lodge there and are expectorated to a large degree; they remain for hours along the lining of the windpipe; frequently they are aspired back into a healthy bronchus, where they start a new focus of disease; sometimes by a spas- modic cough they are carried into the post-nasal region ; more or less phlegm lodges on the hands and gets into cuts and abrasions, and so starts a skin lesion. Tuberculosis of the larynx may set in, and extend up into the pharynx ; the bacilli may be swallowed; if there is sufficient acid^ in the stomach, it destroys them; if not, they pass down the digestive tube, to produce possible ulcers of the intestines. We ought hardly to say that these examples are complications; they are due rather to the natural spread of the disease in a body whose resisting power to the bacilli is lowered. The disease begins oftenest in the upper part of the right lung. That sometimes recovers with the formation of fibrous tissue; then the disease appears in or near the apex of the left lung. This we recognize as probably due to the aspiration of the bacilli-laden phlegm into the larger bronchus 1 There is reason to believe that the usual degree of acidity of the gastric contents is not sufficient to repress tubercle bacilli to any great extent. ^C) Tuberculosis of the left side. Again, the kidneys become in- volved, the epididymis, the joints, the sheaths of tendons, and we are apt to say that these are com- plications; but they really are only examples of the spread of the disease. The joints swell, often too the sheaths of tendons and the fibrous tissues about them, and the patients say they have rheumatism ; but these are the legitimate results of the disease in patients who are unable to resist, who have lost the power to destroy the microbes. There is no doubt that the bacilli permeate every part of the body sooner or later. They find in the blood, of course, substances inimical to them, and if the nu- trition and general resisting power of the patient are fairly good, they are destroyed ; but they grow and thrive if the nutrition and the resisting power are poor. The epididymis is very susceptible to this infec- tion, though the testicle proper is rarely involved. The movement of fluid from the epididymis into the vesiculae seminales. bladder, and urethra often causes an extension of the tuberculosis to these parts; and when the bladder is invaded, the dis- ease sometimes travels up into the kidneys by exten- sion, as well as through the l)lood in a manner similar to that in which it first reached the epi- didymis and the joints. One of the most common forms of the disease The Tuberculous Process 37 that we have to deal with is pleurisy. Alost pleu- risies are tuberculous. This cannot be demonstrated in the fluid very readily, but inoculation of guinea- pigs with it generally produces the disease. Serous membranes are in a way more resistant than other tissues of the body, and the pleura frequently re- covers permanently and no general infection occurs, perhaps because for anatomic reasons absorption into the general circulation is less here than from most other tissues. Many of the cases of peritonitis that formerly were known by a variety of other names are noth- ing but tuberculosis. This form recovers in a cer- tain percentage of cases, sometimes by rest and a fresh increment of resisting power, sometimes by surgical aid. There is a form of tuberculosis of the skin of recent discovery, known as anatomic tuberculosis. It produces a roughness of the skin and thickening that resembles chapping of the hands. It spreads, thickening the skin a little, and is very persistent. Men performing surgical operations, dissecting, and making post-mortem examinations occasionally ac- quire it. The tissues of disease contain but few bacilli. The rather unusual affection called In-onzed skin or Addison's disease, known for many years to be associated with lesion of the adrenals, we now 38 Tuberculosis know to be due generally to tuberculosis of these organs. The disease is characterized by great pros- tration, profound weakness (patients usually dying of it), and by bronzing of the skin if the patients live long enough. The skin becomes dark in spots, particularly those portions of the surface exposed to the light, and pigmented parts not so exposed, as the genitalia and the area about the nipples. Therefore, from a few forms of tuberculosis with which the study of the disease started, we easily discover numerous forms; and doubtless other af- fections, heretofore known by quite different names, will be found to be only variations of this wonder- ful disease. CHAPTER III FORMS OF TUBERCULOSIS Tuberculosis attacks numerous tissues of the body. It often docs this in the course of its spread from a single focus. For example, in lung tuber- culosis there is frequently a middle ear infection. The drum becomes inflamed, breaks down in ulcer- ation, and a perforation results. Sometimes the mastoid cells become involved. These complica- tions may improve and go on to recovery with more or less deafness. The mucous membranes are spe- cially prone to this disease. In a proportion of cases the larynx becomes involved — very rarely in a primary way, nearly always consecutive to the lung disease. Laryngeal tuberculosis does not im- ply that the patient has carried through the larynx an unusual amount of bacillary phlegm and so has infected it, but rather that the resisting power of the part and of the patient is low. There are two noticeable forms of laryngeal tu- berculosis. In one form there is roughening and ulceration of the vocal cords, producing aphonia, which is not dangerous and from which the i)alicnt may recover; in the other form the arytenoid regions and the posterior structures of tlic larynx become . 39 40 Tuberculosis more particularly affected. In the latter condition there are pain, swelling, and perhaps ulceration, sometimes but not always aphonia, and nearly al- ways painful deglutition. The disease may spread to the trachea, rarely to the esophagus and stomach, and to the bowels, ure- thra, prostate gland, and kidneys. Fistula in ano, which occurs in many cases of consumption, may or may not at first be tuberculous, but usually it becomes so sooner or later. It is one of the re- sults of abscess by the side of the rectum, caused by the extension of microbic growth through the mu- cous membrane from this reser\'oir. This latter event is made possible by the general reduction in bodily vigor and by the local irritation due to reten- tion of fecal matter and to filthy conditions of the parts. The serous membranes, the pleura, meninges, and peritoneum especially, are often involved. Tuber- culous cerebral meningitis is a form that is substan- tially always mortal. It occurs in children mainly, rarely in adults, save as a terminal event in con- sumption. In children it may apparently be inde- pendent of tuberculosis elsewhere, but it is probably nearly always secondary. The bacilli in some way enter the blood-vessels and reach the membranes of the brain, and through the capillaries produce meningitis. As to the peritoneum and pleura, the Forms of Tuberculosis 41 connective tissue beneath these membranes becomes involved. The dense cartilages, the skin, and even the muscles including the heart may be affected; so also may the lymphatic glands and the various secreting organs, as the kidneys, adrenals, liver, spleen, pancreas, and testicles. There are two forms of tuberculosis of the skin — lupus and anatomic tubercle. This latter occurs mostly on the hands, is probably due to direct in- fection, and has the appearance of thickened plaques and warts. Bone tuberculosis, a surgical variety not to be discussed at any length here, is often attended with necrosis. The spongy structure of the bone is most likely to be affected, as the bodies of the vertebrae, where it produces angular curvature of the spine. Osteomyelitis of the long bones is not infrequently tuberculous, and leads to various surgical incidents and deformities. The joints are involved frequently, the hip and knee especially. The hi]) disease known as morbus coxarius and white swelling of the knee are usually tuberculous. The tendon-sheaths become involved, those of the wrists most frequently, and attached to their surfaces minute rice-like bodies appear in great clusters, with swelling and some pain, espe- cially on motion. These bodies, like the structure of fibrosis, are mostly fibrous material. 42 Tuberculosis The disease of the glands of the mesentery known as tabes niesenterica is generally, if not always, tuberculous. It is infrequent, occurs mostly in children, and is usually mortal. Swelling of the glands of the'*'neck wntli abscesses, followed by pro- tracted supi:)uration and the formation of ugly scars, is a common affection, and is known by the general name of scrofula. This, too, is an affection of child- hood, and is now proven to be almost invariably tuberculous. It is probably always secondary to infection of the tonsils. It is, to my mind, a cu- riosity in pathology that lymphatic glands can be- come tuberculous, suppurate, even break open spon- taneously, discharge for a long time, recover, and the patients never afterward have tuberculosis other- wise or elsewhere. The tuberculous character of these cases would be doubtful if the proof on this point were less positive. " Miliary tuberculosis " usually is taken to mean a general sudden explosion of tuberculosis through- out many parts and tissues of the body, with high fever. But as it is referred to in text-l)ooks it is, I am sure, a misleading idea. In the descriptions of fevers and the rules for diagnosis of febrile con- ditions as set forth in the literature of medicine general miliary tuberculosis is regarded as one of the causes of suddenly occurring high fever, and we are asked to balance the evidence between this and Forms of Tuberculosis 43 typhoid fever, malarial fever, and some other in- fections, in a search for the pathology of an attack. But the affection very rarely produces high fever except as a terminal disorder or complication in a patient profoundly poisoned with tuberculosis or greatly prostrated by some other disease. It may in the lungs be chronic, and attended with little fever, and it is not at all uncommon for numerous organs to be involved within a short time, as a terminal event. With a circumscribed deposit of tuberculosis a patient may resist the disease for a long time ; but finally it spreads a little, vitality becomes lower, cachexia creeps on, when suddenly numerous organs and tissues become infected within a few days, and death ensues speedily. And this may occur with little fever, and that little very irregular. The frequency of such terminal events in this disease recalls what an eminent writer has said in a general way — that " it is rare for people to die of the diseases that have afflicted them." The lungs are the chief seat of tuberculosis as a medical disease, and I am sure that most of us have had an imperfect conception of its behavior in these organs. We may profitably classify the disease under a number of forms as it occurs in the lungs and olhcr organs, for this will hel}) to a clearer understanding of its variations. But nature makes no such sharj:) lines of classification as our 44 Tuberculosis grouping would suggest. These types merge more or less into each other; but the want of some divi- sion of this sort is to some extent responsible for the habit of assuming that all cases of lung tuber- culosis must follow about the same course — a habit that has led us into many mistakes and done much harm to the patients. Lung tuberculosis is a most variable disease in its manifestations and course. First let us consider the fibrous form, in which there is a great deal of fibrosis, where the lesion begins on the mucous surface, and the fibrosis starts beneath it. The fibrous tissue of the lung becomes thickened. The same material is deposited there as in scar-tissue, and this extends widely in all directions and far from the seat of the bacillary deposit. There is very little breaking down of the lung into masses of degeneration or into cavities. There is little of the caseous degeneration and relatively little suppuration or mixed infection. The progress of the cases is slow. The diseased lung contracts greatly, and, as there is little suppuration, there is little absorption of pus products, and rarely much fever. The cases, as a rule, are unilateral at the beginning, and often remain so. Sometimes both lungs become involved, the second one usually in a less severe way. If the disease is confined to the left lung, it presents an interesting ])icture of the uncovered heart with its pulsations seen through Forms of Tuberculosis 45 the third and fourth costal interspaces. E\en the movements of the auricle can often be plainly seen. The measurement of the chest shows marked con- traction and there is reduced motion on the affected side. The cases frequently pass into a condition that we call recovery; but it is somewhat ques- tionable whether the recovery is complete, because there is always imbedded within the fibroid tissue many bacilli that retain their vitality for some time, and if the tissue breaks down, they are liable to multiply and reinfect the patient. This form may exist for a long time with slight physical changes, although there is always some debility and short- windedness. The second form differs radically from the first in the fact that there is always a sharply circum- scribed deposit of tuberculosis. Most often it is in the apex of a single lung, and the physical signs are marked. The fibrosis, which is usually consid- erable, is within and around the location of the disease, rarely diffused widely throughout the lung. This form shows the effective and economical means that nature employs to abbreviate the disease. It throws a barrier around the affected area that seg- regates it from the rest of the lung-tissue. Cavi- ties may occur, suppuration take place, and caseous matter and even calcareous granules may be ex- pelled, and yet the sequestration of the mass may 46 Tuberculosis be so secure tbat other portions of the lungs and body escape completely. These patients frequently recover with contractures and moderate lessening of breathing capacity. The third form is the same as the second except that little or no fibrosis occurs. The lung-tissue at some point becomes profoundly involved, cavities result, there is high fever from pus absorption, and no tendency to recover. These cases consti- tute what is known as quick or galloping consump- tion. They all die : where there is no tendency to fibrosis there is no chance to recover. Such patients frequently die before the other organs are involved. They die. as a rule, of an overpowering mixed infection, and not from the extension of the disease to other organs. There is a fourth form in which the disease is slight and is confined to one lung for years, with no extension to other organs and with little effect on the general nutrition. Fibrosis is considerable; there is little or no fever, and the patients pass for healthy people. I believe that in many of these cases the disease is confined to the bronchial mucous membrane almost exclusively. The lining of a bronchus may be a culture field for bacilli for a long time. The mucous formations and other products of the disease are in small amount and rarely expectorated. There is often only moderate Forms of Tuberculosis 47 fibrosis with slight contraction of the lung, and such slight change in the tissues that the patients pass for persons in health. Their condition is, however, easily discovered if they happen to run or to make violent exertion, for they are slightly short-winded, showing that the lung-capacity is impaired to some degree. They complain of frequent colds. They cough immediately on getting below their usual physiologic standard ; this is their "cold," and on resting and recuperating the " cold " passes off. They may have with these attacks a slight rise of temperature — not enough to impair nutrition much, and so it does not lower their general health. They sometimes even gain in weight and are heavier than before they had the disease. They live for years, and sometimes recover completely. The fifth form is that in which the disease is confined to the lungs at first and then spreads to other organs — the stomach, intestines, kidneys, tes- ticles, larynx, ears, prostate — in fact becomes a general infection, and death always results. These are the cases in which there is very little natural resisting power, or where the patients are under extremely adverse physiologic and hygienic condi- tions. They may resist the disease for a little time after it attacks the lungs, when it appears to belong to the second form ; but soon there is a rapid spread of the disease to other organs. 48 Tul3erculosis The sixth form is the most decepti\-e of all. and particularly so to the young practitioner. It has a symptomatology of the lungs that leads generally to a mistaken diagnosis. It might be called the fibrous and dissolving form. Diffused moderate fibrosis occurs, disseminated dissolution of the lung- tissues and almost no rales or expectoration. The fibrosis develops in and about the tuberculous masses, and the latter have a diffused, non-solid form. They contract to the degree necessary to choke the blood-vessels that supply the septa be- tween the air-vesicles. As a result, many of the septa break down and are absorbed. Thus tw^o or more vesicles are thrown into one, the respiratory space is reduced, and in consequence the patient breathes more rapidly. There is reduced oxygen- ation and reduced vitality. These patients do not expectorate, or expectorate little, and of thick, yel- low material. There is no dulness on percussion, but great resonance everywhere; generally both lungs are more or less involved, and they are about equally resonant. If both lungs are not involved, then the unaffected one, having to do more duty, develops puerile sounds, and hence resonance on percussion over both sides is loud; auscultation re- veals puerile breathing, and so the doctor is con- fused. The patient coughs, there is loud reson- ance on percussion, no bronchial breathing any- Forms of Tuberculosis 49 where, not a rale to be heard, and the physician is likely to think that the case cannot be one of tuber- culosis. He finds that his patient is low in vitality, has a little fever and disorder of digestion and therefore he is tempted to refer the symptoms to some affection of the stomach or general nutrition. But the patient is breathless, and if the doctor lis- tens carefully, he finds with a variety of loud lung- sounds that the true vesicular murmur is greatly reduced. The disease progresses slowly but stead- ily, and if by persistent efforts the patient succeeds in bringing up a little si:)eck of yellow phlegm, it is found to be teeming with tubercle bacilli. This form is steadily progressive, and the patients all die of it, if not cut off by some intercurrent disease. There is a se^'enth class, composed of cases that begin with a tuberculous deposit in the right apex, and which recover with some consolidation and contraction, to be followed by a deposit in the upper part of the left lung. In some of these cases the left-sided infection gets well or death ensues with- out the right side breaking out again. This class is not very numerous, but sufficiently so for iden- tification. I do not remember to h^xe seen the reverse of the experience — that is, where the left apex became infected and recovered, to be followed by infection of the right apex. There is an eighth class of patients who ha\c 4 50 Tuberculosis wide and extensive deposits of tubercles scattered rather uniformly over a large part of a lung or both lungs, with almost no pus formation, little or no expectoration, and only a little fever, which may occur irregularly. There may be some dul- ness on percussion ; sometimes the dulness is mark- ed. There are a few fine and faint scattered rales, heard most on inspiration. There is always great dyspnea and a rapid heart-beat. Sometimes the condition is secondary to a rather long existing quiescent tuberculosis in a circumscriljed lung area; sometimes it appears to be primary. As there is little pus, mixed infection is rare. The patients all die eventually, but some remain at a standstill for a long time. This form of tuberculosis is often misleading to the ^iractitioner, but is very instruc- tive. It proves, as injections of Koch's lymph do, that the pure infection of tuberculosis may cause fever, the irregular fever of these cases probably being due to the intermittent discharge of the tu- berculin into the current of the circulation. A most proper name for this form of disease would be " miliary tuberculosis." CHAPTER IV THE PATHOLOGY OF TUBERCULOSIS There are a few principles that should be kept distinctly in mind as to the pathology of this disease. The tubercle bacillus, like all germs, grows with dif- ficulty except under favoring conditions. It finds a good culture field in many tissues and organs of animal bodies. Normal tissues of the human body, and especially blood, are inimical to the growth of it, and the blood that is shed appears to be most so. As long, therefore, as the blood in the body can be kept up to a strictly normal standard, a great number of bacilli may be thrown into its current and carried to distant organs without start- ing tuberculous growths in any of them. The blood will kill the bacilli if its normal state is maintained. The vigor of the constitution must be lowered where tuberculosis spreads through the blood-current. It has long been known that patients with pulmonary tuberculosis w4io have occasional slight hemorrhages are more likely to recover than others. A patient will often make a sudden slight im- provement after a moderate hemorrhage. We were at a loss to understand why this was so until it was SI 5- Tujjerculosis discovered that the blood outside of the vessels has a power more destructive to microbes than that inside. Blood - vessel walls in the course of the disease become invaded and rupture; the blood flows out and surrounds these broken vessels, fills the cavities, flows along the bronchi, and doubtless kills many of the bacilli. It is true that it also washes away some of the products of the disease and helps to get them out of the body, which is useful so far as it goes. There are different degrees of antagonism to tuberculosis in difi^erent human bodies; some have a great deal, and some have very little. Different ages, the sexes perhaps, and different races all have their variations, and there is a marked varia- tion in hereditary susceptibility. Very young per- sons or children with tuberculosis of the lungs sometimes show relatively great resisting power. A child of twelve years with tuberculosis of the lungs may go on to maturity, resisting the inroads of the disease, and recover. There seems to be something in the physiologic evolution of develop- ing tissue that increases the protecting substance in the blood. Let a person contract the disease at eighteen or twenty years of age, and it will be more likely to terminate fatally; but if the disease comes on at thirty or forty, the likelihood of re- covery will be much greater. The Patlioloe:v of Tuberculosis 'S,* It may therefore be said that the normal resist- ing power must become lowered in a part before the disease can start. It must be lowered in some way ; and there are different ways, and probably ways of which we must be long ignorant. The lining of certain bronchi is markedly susceptible. Here the resistance may be diminished by an inspired foreign body that irritates the part and destroys the cilice that cover the cell surface, or by some other unknown influence. Then tubercle bacilli are car- ried to the point by the blood-current, or more likely by the inspired air; here they start a culture and pro- duce the disease. Not one bacillus will do this. A cell or a patch of them lowered in vitality will prob- ably resist one or two bacilli ; but presumably there must be many bacilli deposited in such a spot to start a tuberculous lesion, unless the physical depreciation of the part is extreme. Once started, the process goes on for a length of time, extends to other cells, and causes numerous minute tubercle nodules long before any symptom or physical sign is produced. The lymphoid and epithelioid cells gather about this region of disease; coagulation necrosis takes place, capillaries are closed off by inflammation or thrombosis, and we ha\e the giant-cells with their degenerate centers and the other elements of the tubercle. In reference to the pathology of the giant-cell 54 Tuberculosis in tuberculosis and other lesions (for it is found in others — even in ordinary ulceration, various non - tuberculous tumors and irritated parts), the evidence is accumulating that this cell in some of its elements is conservative, and exercises some power toward the destruction of micro-organisms. It is believed by some surgeons that giant-cells in the midst of foreign bodies — in silk ligatures in a wound in the meshes of which they burrow — exer- cise a destructive influence on the foreign body, and are hence beneficial. If such a power exists, it must l)e b}' virtue of the nuclei in the periphery of the cell. That the inside of the cell is a mass of beginning degeneration is probable; and it is a question, from a pathologic standpoint, whether in tuberculosis the giant-cell is simply a morbid ele- ment produced by the irritation of the bacilli or one of nature's instruments to destroy the latter. Of course, reasoning from analogy, we should be inclined to say that all the processes of tubercu- losis are conservative — that even the tubercle itself, which develops around the bacilli, represents ail effort of nature to segregate the micro-organisms and destroy them. And while the giant-cell may be composed of nothing but a few epithelioid and other cells with their persisting nuclei and a mass of granular material in the center, these cells may have been gathered together for a conservative pur- The Pathology of Tuberculosis 55 pose, and it may be that the nuclei actually multiply in the periphery of the giant-cell for this very rea- son. In this way we reach ground where it is difficult to say whether the action of this cell is conservative or is altogether morbid. We know that the leukocytes in the blood do take up and in some degree destroy micro-organisms by the process of phagocytosis. And it is perhaps true that some- times the leukocytes travel out from the blood-ves- sels into cavities or surfaces of mucous membranes, gather substances into their mass, and carry them back into the circulation. As to the ingress of tubercle bacilli to the body, we must remember that the portals of nature for their reception are mostly the nose and the mouth. They are inspired through the nose, and lodge on the mucous membrane of its cavities; they are swallowed or find lodgement in the throat, and remain there, and sometimes produce infection of the pharynx and tonsils and the lymphatic glands in the neighborhood. From the tonsils the infec- tion may travel downward through the lymphatics and invade a lung apex. Infection takes place rarely in the nose, oftener in the larynx, occasion- ally in the trachea, and very frequently in the bronchi and lungs. Being swallowed, the bacilli produce not infrequently tuberculosis in the ali- mentary canal, particularly if acids are lacking in 56 Tuberculosis the stomach. They enter wounds and abrasions of the skin and produce direct infection. Doubtless it is true that a lung tuberculosis may be produced by the bacilli being carried in the blood-current, but this I believe is very unusual. They are generally carried to the lung by the in- spired air. A series of cases was studied very care- fully by Birch - Hirschfeld to determine the place of origin of lung tuberculosis, and he found that nine-tenths of the cases showed that the lesion be- gan on the mucous surface of the medium-sized bronchi. One case only began in the deep tissue of the mucous membrane. This question is a very difficult one to decide, since little help can possibly be derived from an advanced case of tuberculosis or from post-mortem studies of the disease. Tu- berculosis begins in the apex of the lung more often than in other portions, and in the right side rather oftener than in the left. Theories in ex- planation of these facts have been numerous, one of which is that the size and position of the main bronchus on the right side favor a deposit of bacilli in the right apex. This, of course, cannot be true, since the large bronchus of the left side is slightly nearer vertical and is more inviting to the deposit of bacilli than the right bronchus. Perhaps the right apex is more susceptible to injuries 1)ecause it is nearer the outside air and is exposed to more vicis- The Pathology of Tuberculosis 57 situdes. The air in passing into the left apex goes down at an angle of about forty-five degrees and then rises again. On the right side the process is only a little different. A study of the behavior of inspired dust in the different portions of the lung throws light on the subject. As a result of some careful researches it is found that inspired dust gets into the lower part of the lung more readily than into the upper part. This is what we should expect. Dust enters the base of the lung first, then the middle, and finally the upper portion ; it is eliminated soonest and most from the lower part, and remains longest in the apex, which is what we might not expect. Since the bacilli are a part of the dust, we see why the apex should furnish the greatest number of original foci of the disease. But we do not know why the apices fail to expel the dust as promptly as other parts of the lungs. ^ This is a common ex- perience in scientific studies : the phenomena that explain a condition themselves often need to be explained. Once the tubercle deposit occurs on a mucous or serous membrane, its products are easily carried to distant regions. I'^rom a focus in a lung, in- fecting phlegm is easily carried backward along the 1 In the bellows movement of the lunid under con- ditions of good hygiene, they will escape the dis- ease; whereas they succumb promptly when starved or under bad conditions. Many persons undergo a sort of star\-ation in numerous ways, — not always by lack of food, often by disturbances of digestion and assimilation. The result is exactly as with animals: they are rendered susceptible to the dis- ease. Sometimes the tissues are partially starved, and poisoned even when a large amount of food is The Etiology of Tuberculosis 73 taken regularly : the assimilation is poor and the depuration bad. Mental worry and discouragement lower vitality and so invite the disease. A class of people who receive ten per cent, less wages than another class doing identical work will show a larger proportion of tuberculosis, even when they have the same qual- ity and amount of food as those with the higher wages, and when the physical stamina of the two classes is substantially identical. Over-stimulation plays a part in causation. In our intense lives we can hardly avoid overstimulat- ing, in some direction, at some time. If it is not alcohol, it is coffee or tea, or some article of diet, or it is tobacco — if this is really a stimulaiit. These non-food articles are, sometimes at least, poisons to the brain, and they may disturb assimilation and balance, and so lower the vitality. Excesses in child-bearing and in the indulgence of passions are strains upon the system and lower its resistance to tuberculosis. The vitality of the system may be lowered by disease, and so tuberculosis ensue. Here, in addi- tion to the reduced vigor, we have some possible secondary effect of tlie microl)es which caused the preceding disea.se. Typhoid fever, measles, Ijron- chitis, and whooping cough are not infref|uently followed by tuberculosis. Sex seems to have little 74 Tuberculosis influence on the acquisition of the disease. Age has a good deal of influence. Children often recover from tuberculosis of the glands, and sometimes even when the lungs are involved. They are able to resist, probably because they are growing and devel- oping. In the years of adolescence the resisting power to tuberculosis seems to be less. The body has perhaps attained its growth, but the tissues and powers are still unhardened, and the system goes down rapidly under the disease. The best hope of recovery is untler twelve or over twenty-five years of age. From twenty-five to fifty-five are probably the most resisting years of life. The resistance shown by the growing body is illustrated in pregnancy. A woman with tubercu- losis of the lungs that is making rapid progress, becoming pregnant, may go through this period and the disease seem to stop; it often does stop its progress. Her resisting power has been aroused by the increased and changed physiologic movement of the body due to the new condition. These patients often go down to death speedily after confinement. The belief is current among the laity that or- dinary simple catarrh of the nasal passages and pharynx is likely t(^ lead to tuberculosis of the lungs by some process of traveling downward. But this, theory is wholly groundless. These forms of ca- tarrh not only ne\-er produce tuberculosis, but they The Etiology of Tuberculosis 75 do no harm of any sort except to the convenience of the patient. So far from causing this disease, catarrh is likely to protect the tissues from contact of the bacilli. The catarrh in certain cases is prob- ably a consequence of physical debility, which itself always invites tuberculosis; but it never travels downward to produce the disease. Nationality has some influence on susceptibility to tuberculosis. The Jewish people have very little of it ; on the other hand, Americans and Irish have it in large proportion, and the negro in America is very susceptible. Climate exercises little or no protective influence over the individual against the acquisition of tuber- culosis. Such a statement will strike many as sur- prising; but it is true. In Colorado, New IMexico, Arizona, and Southern California, places where in- valids are sent in great numbers to recover from the disease, and where they often do recover, people acquire it initially and from the same causes as in other climates. Those climates are not pro- tective per sc, although they may be slightly so by the outdoor life they make possible. Of course, the resistance is greatest where the climatic worries are least. Altitude, that has been supposed to exercise such a power over tuberculosis, has none to prevent a person from taking it. Dryness of atmosphere probably has no protecting influence, whatever its 76 Tuberculosis therapeutic power may l^e. Regions of great sun- shine and atmospheric chathermancy show a small proportion of acquired cases; but this is probably due less to any inlTuence on human susceptibihty than to tlie greater destruction of the bacilli in the air l)y the sun's rays. ' We accjuire the disease mostly through the air, but also through food and drink, as well as by direct contact. The bacilli are taken into the lungs direct; they lodge in the mouth and throat and are swal- lowed. Thence they enter the mesenteric glands and get into the blood. They also enter the tonsils and pass into the cervical glands and probably the lungs. We acf|uire the disease mostly, perliaps wholly, from human sources ; possibly sometimes we get it from animal sources, as from milk, yet the evi- dence is increasing that bovine tuberculosis must be very rarely transmitted to man. Sour milk is quite as cai)al)le of carrving the germs as sweet milk. Rarely do wc acfjuire live bacilli fn^m meat, because meat for food is nearly always cooked. It is found that one per cent, of tubercnlous cows have the disease in the udder. The milk of infected cows with n()n-tul)ercul()us udders contains bacilli in 50 per cent, of cases. So there is no lack of bovine bacilli in the milk served l)y careless or un- scrupulous dairymen. The Etiology of Tuberculosis 'jy It is almost impossible to produce tuberculosis in cattle, pigs, sheep, and goats "by inoculation, in- halation, and feeding with the products of human tuberculosis; while they are easily infected and die speedily from those of the bovine disease. Accord- ing to Koch, this argues the improbability of the transmission of the disease to man from the flesh and milk of cattle. If it could occur easily, the number of cases of the primary disease of the intes- tines among children, who sul)sist largely on cow's milk, ought to be much greater than it is. As a matter of fact, this form of the disease is extremely rare. Of 933 cases of tul^erculosis among children in hospitals in Berlin, no case of tu1)erculosis of the intestines was found except in conjunction with disease of the lungs and bronchial glands (Bagin- sky). Biedert found but 16 cases of primary intes- tinal tuberculosis in 3104 autopsies on tuberculous children, or 51-100 of one [)er cent. And Koch has seen but 2 cases of primary tuljerculosis of the intestines post-mortem. It is certain that the disease is distributed \)y the sputum becoming dry and being ground into powder, thus forming a part of the dust of the air and scattering tlic bacilli widely. We get them not only in the streets, but in the dust of our houses. Even when every effort is made to destroy the sputum of patients, a violent and explosive 78 Tuberculosis cough will frequently expel small particles which may alight on carpets, hangings, furniture, clothes, and beards, and so get into the air. Patients often expectorate into their handkerchiefs; these becoiVie dry, and when crushed and handled they likewise distribute the bacilli. Animal bacilli are more virulent than those from human beings. Old cultures that have been kept for a long time in test-tubes and propagated from time to time lose their virulence. It is said that the orio'inal stock of bacilli of Professor Koch, that o has been kept alive by repeated cultivation, has become non-virulent. On the other hand, if you take a slightly virulent culture and inoculate an animal with it, from this animal another one, and so on, the virulence will increase until the highest point of intensity is reached. CHAPTER VI THE SYMPTOMS OF TUBERCULOSIS The symptoms of tuberculosis do not appear at the beginning of the disease. That is one of the misfortunes of the study and treatment of it. The bacilh grow, spread, and burrow for a time before symptoms or signs appear. The disease begins the moment a few bacihi find a good culture-medium in the body and commence to multiply. They spread, perhaps with the aid of leukocytes that move in most unexpected ways; they burrow into the tissues by their multiplication, and around them the minute tubercles develop. This goes on pro- gressi\ely until one of two or three things oc- curs : either the appearances are changed and so signs appear, as in local or surface tuberculosis, of which lupus and anatomic tubercle are examples; or there is an organic change and functions become disturbed ; or there is lowered vitality from sys- temic poisoning — or all three together. The pa- tient does not realize it until the appearances change or the functions are altered — the functions of the part or of some other ]5art dependent upon it — or until some new function appears, such as cough, or some calamity like a hemorrhage. 79 8o Tuberculosis Therefore, in lung tuberculosis we are obliged to wait for evidence until the function of the part is disturbed, as in some impairment of the breathing, or until some effect is produced on the system that lowers its vigor or impairs other functions. And often the first symptom that appears belongs to the third category, that of infection, and consists of reduced vigor, or fever, or both. In a great num- ber of cases the first symptom the patient can tell about is lowered vitality. In some of the lung cases cough or hemorrhage, or both, occur nearly as early. Lowered vitality is expressed by loss of weight, strength, and appetite. At the same time the digestion becomes poor, and the patient may complain of gastric discomfort and diarrhea or constipation. The body is infected with the poison of the dis- ease, and perhaps with pus i)roducts, or wholly by the latter. By the time the i)us infection is at all marked, cough occurs and is often vexatious, and daily fever as well, perhaps with chills at the begin- ning and perspiration at the end. We not only have these changes of function, but we have cough, which can hardly be said to be a change of function. Rather it is one of nature's reserve functions, whose purpose is to relieve the respiratory passages of offensive materials ; and it often tries blindly to brush away irritations, which it is powerless- to affect. The Symptoms of Tuberculosis 8i Discomfort in a lung is a most unusual thing. The patient is uncomfortable because he has a cough, or possibly some pain in the chest-wall. Perhaps he expectorates phlegm, sometimes even a little blood, and that alarms him; but pain, if he has it — and he often has — is not in the lung. It is always in either the walls of the chest or the pleura, or both. He will declare that his lung is sore ; but we know that he is mistaken, and that the pain is outside that organ. The elevation of temperature will be recognized as an evidence of infection, and usually mixed infec- tion. It has wide variations in degree, and if the pus infection is considerable, the fever is liable to rise rapidly and to be announced by a chill, which occurs early in the day. At first it is not a pro- nounced chill, but a slight chilly sensation that is followed or attended by fever. The temperature is highest in the afternoon and evening, and as it falls the patient may perspire a variable amount. When this condition has been reached the vitality is often much reduced, the power of the body drops, the patient is losing weight, his digestion is impaired, and he begins to actphre tliat condition known as ca- chexia. If the temperature rises swiftly at any time, it is proof of pus infection to a consideral)le degree. If there is a rapid rise of temperature, there is likely to be relatively more profound chills. Then, too, 6 82 Tuberculosis the temperature is most likely to drop quickly and with profuse perspiration. This is the colliquative sweat of phthisis. Now these symptoms, which are the general ones of the disease, come in a thousand different ways and in as many different proportions, so that no two patients present the same clinical picture. One patient coughs more than another; one has more fibrous tissue that protects the diseased parts; one gets sick faster than another. As a consequence of personal idiosyncrasy, the irritation in the bron- chial tubes or in the trachea is most variable. Hence some victims cough violently or excessively, and others very little. Some patients with tuber- culosis have great quantities of pus in the breath channels and the most remarkable rales of all kinds, and yet hardly cough at all. Others cough on the slightest provocation ; and they cough violently to raise particles of phlegm no larger than the head of a pin ; they e\'en cough from irritation w^hen there is no phlegm to raise. In general these pa- tients resist cough by taking shallow breaths. It is a significant symptom of the disease if the patient coughs on taking a deep inspiration ; for then one may know^ that there is some phlegm in the bron- chial tubes, probably the smaller ones, and that the inspiration has drawn some of it peripherally into still more minute tubes whose mucous sur- The Symptoms of Tuberculosis 83 face is more normal, and so produced the cough. jMost of the phlegm that these patients raise is mucus even when it looks very purulent. The amount of pus is, as a rule, relatively small. Case- ous matter is seldom brought up, and still less often small particles of calcareous matter. The propor- tion of pus and mucus varies widely at different times and under different circumstances. Blood is occasionally present in the expectoration, and in varying amount, from a mere streak of color to almost pure blood in great quantities. It should not disturb the mind of any patient if the amount is small, for slight bleedings are useful. The patient nearly always coughs more or less if the tuberculosis begins proximally to the outer sur- face of the lung — that is, if the bronchi are irri- tated and if there are unoccluded air-vesicles and bronchioles situated distally to the lesion. If one lung is solely or chiefly affected, and the lesion has not reached the surface of it, the patient always coughs more when he lies on the affected side. This is for the same reason that a deep inspiration causes cough — namely, that the phlegm flows from larger and diseased tubes into smaller and healthy ones. Tills always sets up coughing. In lying on the affected side, gravity favors this phenomenon. Let a patient have tuberculosis in the most com- mon point — near the center of the apex of a lung, 84 Tuberculosis with some unaffected l)ronclii peripherally to it. Fluid will appear in the bronchi of the part, and if the patient lies on the diseased side, the fluid \y\\\ by its weight tend to flow downward into the smaller tubes ; it will pass into tubes that are healthy, set up an irritation, and produce rales and cough. Let the patient now turn on the other side, and the cough will cease, because the affected region is uppermost and the phlegm, in flowing downward, traverses enlarging tubes and finds less and less obstruction. The mucus will stick to the lining of the larger bronchi and trachea, w'ill lose by evapora- tion some of its moisture, and so, being more con- centrated, may remain for many hours. In this way a patient will often retain his phlegm for a whole night; but wdien he gets up and takes food and drink, more fluid soon appears on the lining of the tubes — oozes from the mucous membrane ; this loosens the retained expectoration, which is set in motion by the air-currents and so causes rales or rhonchi ; it flows down into smaller tubes ; then the patient begins to cough and expectorate. He may expel all the products of a night in a few minutes. A i)atient will frequently cough almost incessantly during the night if he is obliged to lie on the affected side, while if he lies on the sound side he may pass the night in quiet sleep. The Symptoms of Tuberculosis 85 This symptom^ ceases if, and when, the lesion extends to the distal portions of the lung, and all the air-spaces are filled with the products of the disease. Then there is no normal bronchial mu- cous surface to be irritated by the encroachment of morbid matter; there is no air beyond the limits of the lesion to be utilized to move phlegm, and so there is no cough from irritation in that quarter. The vitality of these patients is often lowered by their failure to get sufficient sleep, because of nagging cough in the night. And the act of cough- ing is often harmful, since it may cause fatigue, and more or less violence to the diseased tissues, thereby increasing fibrosis. The cough is to be en- couraged when it l)rings up phlegm, but it should be restricted to the gentlest efforts that will accom- plish this purpose. The cough often tires the chest- muscles, but it does not otherwise hurt the system as a whole, and it rarely injures the larynx. But when it keeps the patient awake it is a misfortune; and when the cough is racking and harassing, as when no phlegm or very little is brought up, it sometimes provokes a hemorrhage, l)ut rarely a large one, for the large ones only follow extreme invasion of the vessel walls by the tuljcrculosis ; and that 'For a fuller account of this "symptom," see a paper by the author, entitled, "Cough Induced by Posture as a Symp- tom Nearly Diagnostic f)f Phthisis," where (so far as he knows) it was first described, 'rransactions of tlie Association of American Physicians, 1894, vol. ix, p. 229. 86 Tuberculosis event produces large hemorrhages with or without cough. Indigestion of various forms and degrees is a symptom of pulmonary tul)erculosis, particularly where there is fever. As a result of the fever there is anorexia; most of the patients eat little, and they eat in a most erratic manner. They do not know how to eat ; that is, they devour the things they like best, which are usually the foods that are least nourishing and digestible. They will take fruit that is appetizing, but little nourishing, and refuse foods that make tissue; and they eat at times and in quantity as their whims move them. Left to themselves, they rarely eat more than three times a day, usually two \-ery slight meals, and one rather hearty meal which is never perfectly digested. In this way their digestion is disturbed and they have gastric discomfort, acidity, water-brash, occasional vomiting, and very often diarrhea. Sometimes this last is due to tuljerculosis of the intestine. Some- times it occurs in old and weak patients as a ter- minal complication in the pulmonary disease. Most often it is due to simple indigestion ; that is, with good diet and regimen it is usually correctable. Vomiting often occurs in pulmonary tuberculosis, and is a troublesome symptom ; but it comes mostly with cough paroxysms, and means little or nothing as to the condition of the digestive function. Some- The Symptoms of Tuberculosis 87 times it is due to overloading the stomach, and a very small meal may be too much for the condition of the patient. In such cases vomiting may be remedial, like the vomiting of excess of milk by a normal baby, or like lavage in any case of dyspepsia. In women, if the disease is contracted during menstruating life, this function usually ceases as soon as the patient becomes markedly debilitated. This is a symptom that expresses an effort of nature to save the life of the patient. It is always a mis- fortune when a tuberculous woman menstruates, for she has no surplus of blood to lose. The rate of progress of this disease varies greatly. Some people with tuljerculosis of the lungs go on with their business, and may recover while they are about it. They are able by their physiologic powers and forces to segregate the disease in a part of the lung, and to destroy any small number of its bacilli that get into the circulation. Others fail rapidly even when resting. They improve a little, then get worse, have an extension of the disease, with catarrhal pneumonia aljout the seat of it, and in a few days get up and are better again ; but each time, as a rule, the im])rovement following these backsets is not quite so great as it was the previous time; that is, it fails to bring the patient up to his previous standard. Some of them in their par- tial recoveries put on weight in a remarkable man- 88 Tuberculosis ner. A run-down patient goes away for a vacation ; fresh air in abundance and rest soon improve him; he gains what he had lost, and gains more. From being many pounds below his normal weight he may reach ten to twenty pounds above it. Most of this is made by mere fat, but sometimes it is in a meas- ure due to new muscle produced by athletic exercise. In either case it is always a misfortune. Over- development of fat or muscle is usually followed by a relapse of the tuberculosis, with reduced prospects of ultimate recovery. Pulmonary consumption is often a remarkably painless disease. Patients go through the course of it and die, suffering almost no pain at all, so that some of them say, as they have many times said to me, that it is a most comfortable disease to die of. But the majority of them do have more or less pain from time to time in the walls of the chest, in the intercostal nerves or pleura, in the abdomen from indigestion, and from some of the complica- tions late in the disease. Joint pains with swelling are not uncommon. Sometimes a patient becomes very ner\ous, although that is exceptional and is probably the result of personal idiosyncrasy. I have si)oken of the sputum and the things it contains — mucus, Ijlood, granular and calcareous matter. As the lung dissolves, particles of its tis- sue, in the shape of curved fibers especially, are The Symptoms of Tuberculosis 89 present, and may be found by the aid of the micro- scope. It practically never happens that the patient expels a mass of the lung of any considerable size, although physicians sometimes fancy this to occur when shreads of buf¥-colored fibrin are coughed up following a hemorrhage. Once in a thousand cases perhaps a small fragment of lung-tissue is, from the spread of the disease, suddenly cut off from its base of nutrition and becomes gangrenous. Then the breath of the patient emits an intense aromatic fetor, and he may expectorate a little piece of lung- tissue with darkish fluid, with or without blood. I have never seen such a piece larger than the end of my little finger. The things that we usually find in the sputum that show that the lung is dissolving are substantially nothing but the fibrous tissue of the walls of the air-vesicles, fibers curled in various shapes that w^e recognize as such under the micro- scope. But many times, in examining sputum in progressing phthisis, we fail to find anything of this kind. A few years ago we were taught, and believed, that fever per sc is extremely hazardous to life. Now we know that such is not the case, and that one may tolerate fever for a long time with only moderate harm. Therefore a little increase in temperature for some hours of every day in a phthisical patient consists with fair nutrition, and some patients actu- 90 ' Tuberculosis ally gain in weight under these conditions. I have known a patient to have fe\er every afternoon for a year and finally recover, and not lose very much in weight during the time. It is the thing that produces fever that often destroys life, and if this continues long enough and the influence is profound, of course it wears out the resisting power and death ensues. It is therefore the poisoning of the system by the tuberculosis and pus products, and not the fe\'er, that destroys life in the end. Some patients are cut off by hemorrhage and other accidents, and by various complications of the disease. In the average case, where fever oc- curs only a part of the day, the temperature at cer- tain other times is likely to be subnormal ; that is, it is likely to be subnormal if the patient is in a debilitated state — his vigor much depreciated. During the first six months of the disease a patient who has a good deal of physical vigor, but a little fe\-er e\-ery afternoon, will ha\-e a normal tempera- ture night and morning, and will not appear to fail much. Let this go on until there supervenes mark- ed debility and some cachexia, and in the morning he will probably have a subnormal temperature to the extent of one degree or more. It is instructive to observe that fever is always made worse by influences that put a strain on the powers of life. A patient with a temperature of The Symptoms of Tuberculosis 91 100° F. in the afternoon, when he is quiescent, will have it rise to 101° or 102° F. if he walks two or three blocks or holds a vexatious conversation or one involving a mental strain of any kind. It is therefore not true that fever is always induced solely by poisoning. In the study of fever as a pathologic process we have heretofore rather assumed that there is only one thing that produces it — namely, poisoning or infection. The experience with tuber- culous patients has negatived this theory to some extent, and that experience is worth a great deal. A medical friend had for some little time a slight daily fever (not from tuberculosis, but probably from a form of malaria), and he found that by play- ing a round of golf or taking other active exercise his temperature would rise higher at once. The truth must be that exercise and excitement raise the temperature when the system is being poisoned by some toxin which it is trying to get rid of, but only succeeds in keeping in abeyance, and when the exer- cise and strain would not otherwise produce any such effect. This explains how we may save the lives of some patients by keeping them still. The sweats of phthisis are a great trouble to the patients and their friends. There is a popular no- tion that night-sweats are inimical to life; and if a patient perspires a little in the night, he calls it a night-sweat and is liable to be greatly distressed 92 Tuberculosis about it and, if the sweat is profuse, to insist upon having some drug to stop it at once. Most of the sweatings of these patients are shght, occurring al)out the head, neck, and shoulders, scarcely ever being sufficient in quantity to more than moisten the night-clothing — never enough to wet the bed. They are a matter of little consequence. There are probably a dozen medical students in every class of a hundred, who, if working hard preparing for examinations, have the same condition at night and take no notice of it. This perspiration, if it means anything at all, is a useful thing. Perspiration rids the system of poisons. The perspiration of a healthy person, if injected in small quantity beneath the skin of a little animal, will generally prove harm- less; but if that of a patient with typhoid fever or some similar grave poisoning is used, the animal immediately becomes sick and may die. The colliq- uative sweats are a great annoyance to the patient. They make him feel disagreeable; they wet the bed, even to the mattress, give him a chilly sensation if he gets uncovered, and he is made unhappy from that condition, and more so because he thinks it is a very grave thing and may even mean death. I have seen patients recover after having this kind of a sweat every night for many months. Tt is unproven that the sweating does any particular harm. The patient may declare that the night- The Symptoms of Tuberculosis 93 sweats are killing him, but it is not true. The patient may be dying, but if he is, it is from the thing that causes the night-sweats. The sweat evac- uates a lot of saline water as well as effete matter, and drinking-water and table-salt can easily replace the needed elements to the blood. Every patient has more or less short-windedness, and this fact is one of the most useful hints for diagnostic purposes. It is perfectly natural that he should be short-winded, and he always is to some degree, and the annoyance from this is considerable, particularly when he exercises. Even when he passes into recovery it does not stop, but sometimes goes on progressively for a long time. It does not cease until the deposit of fibrous tissue in the lung- ceases; and the fibrosis probably always continues to increase for some time after the tuberculosis is healed. Frequently a patient is annoyed by the wheezing and rattling sounds in the chest. These are often minified or overcome by his lying on the sound side of the chest, if the disease is one-sided. Patients nearly always become cachectic to some degree, and as the disease progresses the cachexia becomes more profound. It will come to be admit- ted, I think, that the cachexia should not be known by any qualifying name. I do not know how to distinguish cancer cachexia from that of tuberculo- 94 Tuberculosis sis. The cachexia of pernicious anemia produces usually more of a lemon tint than the average patient with phthisis has, but not more than some con- sumptives have. We hear a great deal about the " glassy eye " of phthisis. Vv'e see repeated references to it in gen- eral literature, and even in books on medicine. The appearance is spoken of as though it was an actuality and of some diagnostic value, or at least character- istic. But the eyes of consumptives are no more glassy than the eyes of other people who expose an equal amount of conjunctival surface to the effect of reflected light. In any emaciation the fat be- neath the eyelids shrinks or disappears, and the eye opens a little wider than usual, and so offers a larger moist surface for reflection. This symp- tom, if such it may be called, has no diagnostic value under any circumstances; it is found in any emaciation. We must always remember that in the recovery from phthisis there remain damaged organs; that the patient is always somewhat short-winded, par- ticularly if he exercises; if he walks up stairs at the usual pace, or lifts heavy weights, it always shows. No matter how long a patient may live, the injury to the lung from the disease, the thick- ened connective tissue or scar-tissue, always changes the sounds of auscultation and percussion. Slight The Symptoms of Tuberculosis 95 dulness and some bronchial breathing can usually be perceived over the site of the lesion to the end of life. I have referred to some of the complications of tuberculosis, but from the clinical standpoint some of them ought to be considered rather as natural extensions of the disease; as, for example, the tu- berculosis of the larynx, in which the vocal cords, the epiglottis, and the arytenoids may be affected. But there may be congestion of the vocal cords and other laryngeal structures without ulceration or tuberculous deposits. In the severe cases of tuber- culosis of the larynx there is always partial or com- plete aphonia, because either the vocal cords are tuberculous or the mucous membrane of the larynx is swollen at some point near them, and presses upon one or both cords and interferes with their vibration. If the arytenoid region of the larynx is much involved, there is nearly always dysphagia, sometimes to an extreme degree. Swallowing is so painful as to make starvation welcome. Sometimes the pharynx becomes tuberculous and is studded with numerous minute whitish deposits. The diseased pharyngeal surface is always tender, and deglutition is painful. This must not be con- fused with the whitish appearance of follicular de- posits in the tonsils. With this latter condition there may be some deep discomfort in swallowing, 96 Tuberculosis but never the acute local tenderness and pain of pharyngeal tuberculosis. There will sometimes oc- cur ulceration of the ear-drums, usually late in the disease, resulting in more or less deafness, although the patient may have no discomfort; indeed, he rarely has any with this complication, and the dis- charge is rarely profuse. It may, howe\-er, be fetid. A frequent symptom is diarrhea, with more or less pain in the bowels, especially just before an evacuation. This symptom may occur both with and w^ithout tuberculosis of the intestines; more often it occurs without it and as a casual result of indigestion. This latter nearly always causes diarrhea, either by the discharge of insufficiently elaborated material from the stomach into the intes- tines, which directly provokes the diarrhea, or l)y reduced digestive power in the intestines themselves. A very common complication is some rectal trouble, as hemorrhoids and little abscesses near the anus, and resulting fistulcC. This last often gives little inconvenience or pain, but continues long; indeed, a patient rarely recovers from it while he is tuber- culous. The ci)ididymis and vas deferens are often involved; less often the testicles, bladder, kidneys, seminal vesicles, and prostate gland. And these complications are often borne for a long time with only moderate effect on the health when the lungs are but slightly diseased. The Symptoms of Tuberculosis 97 The albuminuria that comes on late in the dis- ease is a serious thing. It may be extreme in degree, may last many months, and then decrease or disappear entirely as the lung trouble improves. In only a small proportion of the cases do we find tube-casts in the urine. In these patients there is probably always amyloid degeneration of the kid- neys, which permanently impairs their functions. The li\'er sometimes swells, and may project down as low as the umbilicus or lower. The enlargement is uniform, there are no nodules, and no pain or serious discomfort results. This complication may, after enduring for a year or more, actually disap- pear, the organ returning to its normal size and lea\'ing no sign or symptom of reduced hepatic func- tion. Cold abscesses occur in the subcutaneous parts occasionally, resulting probably from some injury to the deep tissues, as by a blow or squeeze that may have been forgotten. They are a complication of some gravity, but not necessarily great gravity; they are usually tuberculous, and frequently heal. Thus their presence is not inconsistent with general recovery. ]\Ieningitis as a complication always de- stroys life, but it does not occur often in the course of pulmonary tuberculosis. Tuberculous meningi- tis occurs mostly in children who have apparently no other focus of tuberculosis, although they 7 98 Tuberculosis usually have a hidden one somewhere, perhaps in some gland. Here the symptoms are those of men- ingitis in general, with all their irregularity and simulation of typhoid and other fevers. A very common accompaniment of the pulmonary disease is pleuritis. There is some question as to whether it should be called a complication, for it is a fact that nearly ahvays a tuberculosis of the lung causes inflammation of the pleural surfaces covering the region of the disease. In post-mortem examinations we always find adhesions in cases of advanced tuberculosis, but we never knew, until the Murphy method of treating apical tuberculosis by pleural inflation was used, how^ generally pleuritis and adhesions occur in the earlier stages of the disease. Now we find that the inflation treatment cannot be employed except in an early period of the disease. After the latter has continued for a few months adhesions are so extensive usually that the pleural cavity cannot be inflated. There is sometimes no pain with pleurisy, and it rarely causes pain for long. With each extension of the disease there is generally a little pain for a few days, and there may be in a given case several extensions at variable intervals. In exceptional cases there is a condition of dry pleurisy without adhesions but with abundant friction sounds, that may continue for a long time with little or no pain. The Syniptums of Tuberculosis 99 Little further need be said about general miliary tuberculosis, save that it is rare except as a terminal event in various forms of tuberculosis where the resisting power has become greatly reduced. This profound reduction in vitality invites all sorts of complications in numerous organs, and these fre- quently occur and lead to the death of the patient. Patients often die of diseases remote in character and location from those with which the}- were first attacked. CHAPTER VII THE PHYSICAL SIGNS OF TUBERCULOSIS The physical signs of the chest in tul:)erculosis constitute a branch of the subject that might per- haps be considered entirely under the head of diag- nosis. But there are some good reasons for treat- ing it in a broader way, and many of its truths will bear repeating many times over. The physical signs are data that we discover by physical exploration, by study with unusual methods, by examining the naked chest critically and in a variety of ways. They differ very much from the symptoms, which are largely the experiences which the patient can tell about. He can tell little of his physical signs, save occasionally when they are naturally related in his mind with the symptoms, as when he hears and feels the rattling of phlegm which he is expec- torating, or when he feels his heart beating in a place he knows to be abnormal. The sul)ject of the physical signs of the chest be- comes simplified if we consider for a moment just what is meant by the terms, and what happens inside the chest in health and in disease. It is like trying to find out what is going on in the next room that we cannot see : we try to learn about it ICG The Physical Signs of Tuberculosis loi by listening to the various sounds, including the con- versation ; and perhaps by various physical tests applied to the partitions and through the cracks and keyholes. The methods must necessarily be more or less indirect, and their proper execution will recjuire judgment and carefulness always. To begin with, there are to be observed some surface changes that are of consequence. One side of the chest expends less than the other, and we know that there is something inside that impedes its free movement ; one side has fallen in a little or sunken, and we know that some disease has prob- ably happened to cause it. Again, where the light strikes the emaciated body to make rib-shadows, we see that at the lower part of the chest some organs move up and down with respiration, but on one side they move farther than on the other; that tells us that the excursion of the diaphragm is less on the one side than on the other, which argues possible adhesion of the pleura on the side of lesser motion. Then we may see or feel the heart pulsat- ing through the chest-wall — not where it is seen to beat ordinarily, but above it, between the second and third ribs to the left of the sternum. That tells us either that the heart is very large or that something that usually covers it has disappeared ; and we remember that the heart is covered by a wedge-shaped portion of the lung, and that if this I02 Tuberculosis covering were pulled away, the heart would fall against the chest-wall and he seen to beat through it. So we look for contraction of the left lung. As an indispensable aid to physical examination of these parts we must understand and keep in mind what goes on physically in a disease of a lung like tuberculosis. Such a disease thickens the lung; then it hardens and contracts it. Hardening pre- cedes contraction; the connective tissue thickens and liardens. The disease dissolves the tissue in places, hence cavities ; it may cause the partitions bet^^•een the air-vesicles to be dissolved in scattered regions, so that the air-spaces that carry on the respiration are larger than normal. There are cast into the bronchi fluid and semi-fluid substances which the moving to and fro of the air disturbs, producing various sounds called rales and rhonchi, and which substances are brought up as phlegm through the trachea by air-pressure. These changes, of course, alter the structure and function, and so the physical signs of the lung. The pleuritis is a thing outside the lung, and if efifusion takes place, it compresses the organ. So, knowing that the physical condition of the lung is changed by the disease, we resort to various devices to see if we can discover through the chest-wall what is going on inside. That is the purpose of our physical exam- ination outside the chest. The Physical Signs of Tnljerculosis 103 The lung in health is full of air and cannot be wholly emptied of it. And we take advantage of this fact, and use the lung as a sound-transmitting body. We test its power to transmit vibrations, those produced by ( i ) the inflow and outflow of air, (2) by the heart, (3) by the voice, (4) by various accidental conditions, and (5) by numerous artificial devices. We listen to the chest with vari- ous instruments or with the ear, to see if the sounds that belong to health are present or have become changed; and we have learned, by examining the chest in this way and by a study of post-mortem conditions, what changes in the lung produce certain changes in the sound. In the main, the changes in the physical signs are logical ; when we come to reason about it, they are mostly, but not altogether, what we should expect with the particular path- ologic conditions. We listen to the sounds of the heart through the lungs ; that tells, by their faintness or intensity, of the conditions of the transmitting lung-tissue. There are other vibratory changes that we listen for. Other evidence we get by placing the hand over the chest when the patient is speaking; that we call vocal fremitus. If you put your hand on the back of the chair that you are sitting in, you feel the vibrations that your voice makes. Vibratory impulses travel down through the bronchi and I04 Tuberculosis through the hings and sohd tissues of the chest into the chair. They are intensified by some thick- ening of the lung-tissue. We listen for the voice and whisper with an instrument or the naked ear over various parts of the chest-surface to see if the sounds are transmitted through any part with increased or lessened force. We listen to these sounds and make these tests in the normal body and observe them in patients, and compare the two lungs of an individual with each other. As the lungs are changed structurally, so are these signs changed. There are sounds produced by the movement of phlegm, serum, mucus, pus, and blood, by the closure and opening of channels through which air rushes. These are adventitious or unnatural sounds that we know by various names as rale and rhonchi, with many variations of de- scription, as moist or dry, crackling or sibilant, coarse or fine, and many others. Then we measure the expansion of the chest and of the sides by com- parison, and measure them at rest, and observe their motion and shape, and try to learn if an}- abnormal- ity has been produced by disease. In the practice of internal medicine we should not try to remember all the possible changes by the unaided power of memory, but should learn to apply all the tests to cases and then consider the signs and symptoms rationally, so that when certain The Physical Signs of Tuberculosis 105 sounds are heard or certain signs are perceived they shall have a logical meaning and we may perceive in imagination the physical changes that cannot be seen with the eyes. Sometimes a machine known as a spirometer is used to measure the amount of air that can be ex- pelled from the lungs after a deep inspiration, for comparison with the supposed normal amount. This apparatus is made much of by some physicians ; and if we could know as to every patient what his lung-capacity is when he is well, and then measure it when he is ill, it would prove of great value. As a matter of fact, we rarely know that, and people differ widely in the amount of air they can take in and expel. It frequently happens that a man with tuberculosis can blow more air into the spiro- meter than some vigorous men in health. We never expel all the air that is in our lungs; a variable amount of residual air is always left. There are some chest skeletons so constructed that they can compress the lungs more than others, and so expel more air, just as there are people with loose joints who can contort their bodies into various shapes that are impossible to others. It is what the patient can expel rather than what he can hold that the spirometer tells. In testing for vocal fremitus, always put the two hands on corresponding regions of the two sides io6 Tuberculosis of the chest; then let the patient phonate, perhaps say " ninety-nine " — that makes a maximum amount of tremor. After having done that, press the ulnar edge of the fists or of the extended hands against the chest similarly; then cross the hands and press them against reverse sides, to correct any errors in touch due to right or left-handedness. Then test the two sides successively with one hand. Whenever the fremitus is greater than normal, the tissue of the lung is, we argue, a little thickened, with patulous bronchi, and therefore the voice vibra- tions are transmitted more vividly; when it is less than normal, we suspect the presence of fluid in the pleural cavity, or partial or complete closure of some of the bronchi, to inhibit the vibrations. If the bronchi are filled with phlegm or obstructed, of course they cannot transmit voice vibrations and produce fremitus. It is not always safe to say that, because there appears to be reduced fremitus in a particular place, the bronchi are obstructed, since the disease may be on the other side and cause in- creased vibration there, which may be misleading. We use percussion as a means of testing, in a way, the physical condition of the lungs; really we learn by it the amount of air in particular re- gions, and to some extent the size of the air-con- taining spaces. The best means of percussion, to be used when possible, is the examiner's fingers. The Physical Signs of Tuberculosis 107 The best way is to press the fore and middle finger- ends firmly together and use them as a hammer, using the middle finger of the other hand as a pleximeter. One can strike a strong blow in that way. The middle finger alone is a good hammer when used expertly. A great number of percussion instruments have been devised, many of which are useful. The best percussors are, first, a little ball of metal over which rubber is stretched, and attached to a handle; and second, a firm handle to which is attached a metallic hammer, into a hole in the striking face of which is fixed a projecting plug of rather yielding rubber. The former makes a high-pitched tone which can be produced by the gentlest blow — one that does not cause pain to the tenderest surface, even over an inflamed peritoneum; the latter produces a low- pitched tone more like that made by the finger. Each kind of percussion hammer produces tones somewhat different from every other; so if any one of them is to be used for diagnostic purposes, some practice will be necessary to learn the signifi- cance of its tones. If you percuss lightly, you will elicit sounds showing the condition of the surface of the lungs; if you strike heavy blows, you will make sounds in which the deeper organs are more or less concerned. We make what we call auscultatory percussion by lo8 Tuberculosis listening with a stethoscope over the chest while percussing near it. This is rarely used and is not very valualjle. But students should learn early and use often the open-mouth percussion. If you direct the patient to open his mouth wide and to breathe naturally through it without noise, and then percuss over a region of lung that is more or less infiltrated, you v^ill find the abnormal sounds more pronounced and get a better idea of the changes in the lung. But you will not find one person in a hundred who can do this act perfectly the first time he tries, for it is a psychologic fact that a person can rarely do correctly on first trial any maneuver that involves more than a- single idea, as this one does. With this method percussion over a thickened lung, in front and near the clavicle especially, elicits sounds of higher pitch than wnth the ordinary method. A sound that would be called dull by the ordinary method becomes flat by this. In many cases we may produce by heavy percussion over an apex, and more vividly by this method, the cracked-pot sound — a peculiar click that is not simulated by any other sound. It is brought out better by percussing with the fingers than with any machinery. Hie click is probably due to the striking together of the sun- dered surfaces within the lung, or by the sudden pulling apart of contact surfaces by the jar of the chest produced by the blow. It consists with small The Physical Signs of Tuberculosis 109 cavities, with bronchi partially filled with phlegm and surrounded by nearly solid lung, and may some- times be produced in normal children. The per- cussion with the open-mouth breathing is one of the most useful of all methods for testing the con- ditions of the upper front part of the lungs. Sometimes the percussion tones are changed by posture. This is evidence of fluid surrounding the lung. Wherever there is such fluid there is dulness on percussion, and in a few cases the liquid in the pleural cavity is so manifest that a shaking of the patient elicits a splashing sound that may be heard some distance away. For auscultation there are but few instruments that are useful, or that are better than the ear applied to the chest. In using a stethoscope one should test the different varieties on the market, and learn to use the one that is best adapted to his ears. There are great differences among them, and what is perfectly adapted to one person may not be used with any satisfaction by another. The best instrument is that one which conveys to the ear most accurately the lung tones, increased in intensity, and with the least disturbance from adventitious noises. The monaural wood, hard rubber, or metallic stethoscope, with oval chest-piece and slightly concave ear-disk, is the best instrument for faithfulness of transmission and accuracy of no Tuberculosis tone, bul it is something of an art to use it, and one that many physicians ne\er learn. More con- venient to use about the patient, and withal a very satisfactory one, is a binaural instrument with tul)es in part flexible and in part metallic, that, by a spring, press rather large ear-tips firmly into the ears and at the proper angle for the particular individual. A hinged spring that makes the ear-tips adjustable at any angle is a great convenience, as is also a chest- piece with reversible ends of different diameters, and fixed to the Y-shaped metallic tube with a slip- joint and devoid of screw-threads.^ The phonendoscope is a useful instrument when made w^ith a firm metallic chest-box, wnth a large diaphragm of hard rubber slightly bulging in the center, and attached to metallic ear-tubes held stead- ily by a reliable spring. Thus constructed, it mag- nifies the chest-sounds beyond the power of any stethoscope, and preserves their qualities to a re- markable degree. In effect it takes the listening ear almost into the chest cavity. The soft-rul)l)er ear- tubes, with no means of firm or uniform fit to the ears, that have been much exploited and used, are unphilosophical, cannot give uniform results and ought to be discarded. Let us now consider the progressing disease in a lung and see what occurs in physical signs. The first 1 The Ingals stethoscope. The Physical Signs of Tuberculosis 1 1 1 change in the lung, as a physical medium for the transmission of vibrations, that actually occurs in most cases of tuberculosis, is a thickening of the general connective tissue of the organ, and of the bronchi with their peribronchial tissue. And it is important for us to be able to distinguish the phy- sical signs at this early period. The first sign that would naturally be searched for is a trifling dulness on percussion. But that is not the first one that will be found. The first sign consists in changed aus- cultation sounds, and these are nearl}^ always pres- ent early. Rales may and may not appear. A sud- den expiration or a cough may abolish rales by car- rying the mucus along the tubes toward larger diameters ; or a deep inspiration may cause them to disappear by expanding the bronchi. The first change is usually an expiratory sound a little louder and longer than normal. We speak of it as a trifle rude ; that word is expressive. The tendency of one's mind is to say erroneously that it is higher in pitch. It seems so. Sometimes it is higher, but often it is not, but only louder and longer. The normal sound of expiration is a little gentle puff, which, because it is short and gentle, we are wont to say is low in pitch. When the tis- sues of the lung begin to thicken, the expiratory sound is usually soon heard to be slightly prolonged and louder, and so seems higher in musical pitch 112 Tuberculosis than normal. Thus we have tubular or bron- chial expiration, louder than the inspiratory sound, and yet in many cases the inspiratory sound is louder than normal and harsh ; again, it is some- times fainter than normal, a result sometimes of damage to the air-vesicles. If the bronchi are patu- lous, the fremitus is a little increased over the thick- ening as compared with the other side. It must be remembered that for some reason there is, in health, over the right apex a longer expirator}' sound than over the left, and therefore a little sug- gestion of tubular breathing. We should be care- ful not to confound the normal disparity between the two sides with disease of the right apex. In order to be safe and accurate, we are frequently obliged to state to the patient that in the right apex a thickening of the connective tissues seems to have been produced by some inflammation that has oc- curred some time in the past ; and that whether it is a fixed exaggeration of the normal disparity between the two sides, or is pathologic, time and further evidence alone can tell. To recapitulate, we have : Prolonged slightly tu- bular expiratory sound, possibly a little elevated in pitch ; inspiratory sound possibly more rude, possi- bly suppressed to some degree; increased fremitus; no particular change in the percussion tone. These are the signs that we note in the very beginning of The Physical Signs of Tuberculosis 113 an infiltration in a lung region ; and we should expect to find them only slight in degree. Let us suppose, now, that the tuberculous process has gone on to produce more marked thickening; that it is simply an extension of the condition first described. Now the fibrosis is greater, there is more thickening of the trabecular matter in the neighborhood of the region of diseased lung. The lower line of tuberculous deposit in an apex may be at the level of the second rib. The signs that have been mentioned are now simply exaggerated over the apex where the consolidation exists. But the fibrosis extends to a slight degree down perhaps to the line of the fifth rib. You see the patient in the first two months of his sickness, and you find the few signs I have spoken of at the very apex, and possibly a few rales. At the end of another month or two, if the disease progresses, there is more thickening, indicated by more extensive tubular breathing, more adventi- tious noises, and less rather than more of the pure inspiratory vesicular murmur. You find now that the evidence of fibrosis has extended far l:)elo\v the fifth rib, and the prolonged expiration shades off at this point to the normal sounds at the bottom of the lung. Now let the process become still more extended and many of the air-vesicles filled with the l)roducts of the disease. the bronchi perhaps narrowed 114 Tuberculosis a little by the pressure of the contracting fibrosis (for the fibrous deposit always contracts as it grows oklj, and there is reduced resonance and elevation of pitch on percussion, otherwise dulness, or, if the condition is extreme, tlatness. There are few or many rales, depending on the amount of fluid discharged into the bronchi. Now, perhaps, little cavities begin to form in the apex, giving a gurgling sound as the patient breathes, and, if they get larger, the amphoric sound of true empty cavities. When there is distinct per- cussion dulness or flatness, with patulous bronchi, there is a peculiar expiratory sound that is always important to be distinguished. It is a loud, pro- longed, often rather hissing expiratory sound of high pitch, the sound appearing to be near the ear, while the inspiratory tone is shorter and fainter and devoid of the quality of true vesicular murmur. This is the true extreme bronchial breathing, and is exactly what you hear in an ordinary lobar pneu- monia over the region of consolidation; you hear it also early in pleuro-pneumonia. In such cases, sometimes l)efore you can distinguish any change by percussion, you will be able to elicit this tubular sound by auscultation. Once heard, it can never be forgotten, and its meaning is invariable that the lung is consolidated around patulous bronchial tubes. If there befalls a large cavity that is full of liquid, The Physical Signs of Tuberculosis 115 it fails to change distinctively the lung sounds by auscultation,or by percussion save to increase slightly the dulness. If it becomes empty and its walls are thick enough or the surrounding tissue firm enough to pre\xnt collapse, we may hear the am- phoric sound, like that produced by blowing across the open mouth of a bottle. Now^ suppose, as happens not infrequently, that the fibrosis does not occur uniformly over the dis- eased area, but presses sharply upon some localized part of a large bronchus; or suppose some of the lymphatic glands swell and make such pressure : we shall then hear exactly the sound that is produced when a large goiter presses against the windpipe. It is a tubular sound, very loud, and simulates some- what the sound heard when a stethoscope is placed over the normal trachea. The same kind of a tone is in rare instances found to be due to localized tu- mors of the lungs — chiefly cancer and sarcoma. As to the sounds produced by moving air in con- tact with phlegm in the lungs, the variations are almost limitless. We have numerous kinds of rales and rhonchi. Some we call dry rales, because they do not suggest fluid; if a bronchus is collapsed at some point, or a little bunch of thick phlegm ob- structs it, there results the sibilant or whistling rale. The air churns the semi-fluid material in the tubes, producing moist rales; these sounds are ii6 Tuberculosis sometimes aptly described as gurgling. Another descripti\e and very good term is crackling rales, the phlegm having become so thick and sticky that when it is moved by the breath, crackling sounds are produced. We must remember that all the sounds produced by phlegm are things that come and go, and that we may find any such sort of a rale to-day and none to-morrow. We often hear over a tuberculous lung the friction sounds of pleural rubbing. The sound produced by the slight movement upon each other of the palms pressed together firmly over your ear is a good illus- tration of these tones. Of course, when fluid is present in the pleural cavity, there can be no friction sounds, but dulness on percussion. Sometimes when the patient changes his posture the upper line of flat- ness changes if there is fluid, but often it does not change, owing to encapsulation. Over a mass of fluid or air or gas in the pleural cavity the vocal fremitus is lost, whereas over a partially consolidated lung, where the bronchi are open, the fremitus is always increased. We should avoid falling into the rather common error of thinking, simply because there is flatness with some rales in the lower part of a chest, that there is certainly consolidation of the lung-tissue instead of fluid. When much fluid is present, the lung sounds are so distant that they are hardly perceived unless the pleural cavity is The Physical Signs of Tuberculosis 117 severely distended ; then faint bronchial and even lung tones may l;e transmitted through it. The voice and whisper signs are interesting in tuberculosis. They are not especially valuable in late cases : the value of the voice signs is early. When a point is reached where pectoriloquy is ob- tained, it is simply a curiosity. At this stage of a case usually other signs have already established the diagnosis. Bronchophony is a very valuable sign, but valuable at the beginning. Whenever there is increased fremitus, the voice signs are usu- ally increased, and this is a valuable confirmatory indication. There are certain obstacles to learning these phy- sical signs that we need to study in a practical way. You will find ^'ery soon that the average patient does not know how to breathe for you to listen, and when making an examination your calling his atten- tion to this function fixes his mind on the perform- ance so that he ceases to breathe naturally. If your ears are acute to slight variations of sound, you are liable to become confused by some adventitious tones. The chief trouble is with the muscle tones. Be- cause he thinks he is breathing for you to listen, the patient may take deep breaths and not sufficiently expel the air, and use twice the muscular power necessary. A muscle in the act of contracting always produces a slight continuous humming noise ii8 Tuberculosis that can be heard with the stethoscope. It is a sound that you cannot locate, but you will recognize it as a muscle tone, and know that the patient is using some muscles about the chest, and using muscle power not necessary for respiration. Many patients, when breathing for you, will be unable to breathe normally; they will breathe vio- lently, with unusual force ; they cannot be tranquil about it. When properly auscultating a chest, it is necessary that every muscle about it not needed for respiration shall be absolutely at rest. When you enjoin this upon patients you will many times find it impossible for them to obey; the harder they try not to have the muscles tense, the more they fail to succeed. You may sometimes counter- act this tendency by diverting the attention away from the act of breathing. Have the patient lie down on his back, turn on his sides alternately, and on the abdomen while you listen over his back ; have him stand and bend his body forward. These changes of posture will sometimes cause him to for- get completely that he is breathing. Then you can hear the chest sounds most perfectly. Deep inspira- tions with shallow expirations is a frequent and troublesome fault of breathing on the part of a pa- tient who is impressed with the fact that you are listening to his chest. This trick so distends the air-spaces of all kinds as often to abolish rales and The Physical Signs of Tuberculosis 119 bronchial breathing. Then the patient should be asked to expire profoundly and to cough at the end of such an expiration. This maneuver partially collapses the air-spaces and bronchi and nearly al- ways elicits rales if anything can, and brings out the full degree of bronchial breathing. Any patient, by the fault of breathing I have described, thereby increasing above the normal his residual air, can effectually hide from the most careful aus- cultator both rales and bronchial breathing of mod- erate degree. The examiner must be watchful and detect this usually unwitting deception on the part of the patient, and correct its errors. The lung sounds heard by auscultation are liable to differ to a very considerable degree, depending on whether the patient is breathing through the mouth or the nose; and this difference is some times as marked over the back as over the front of the chest. Several times I have, while listening over the apices, heard what appeared to be a distinct bronchial tone that was wholly produced by open- mouth breathing and which disappeared the moment the patient began to breathe through the nose. CHAPTER VIII THE DIAGNOSIS OF TUBERCULOSIS For purposes of diagnosis as well as for treat- ment, it is important to make, at the first examina- tion of every case, a careful record of the local find- ings and of the general physical and symptomatic conditions, as well as the history of the case from the beginning. Then subsequent examinations, the results of which should also be recorded, will show the progress of the disease for better of for worse. No less precise method than this is to be commended. The practice followed by some physicians of trying to remember the conditions from time to time of all their chest cases is a loose and reprehensible custom. It begets unscientific habits of mind that are sure in the end to tell against the interests of patients ; and it leads to many blunders in prescrib- ing. Many methods of case-taking and recording have been devised, and various charts and blanks have been recommended. But the most useful for the painstaking physician is, I believe, a plain piece of paper with outline drawings of the human body, especially of the chest, on which, by various marks and characters, the pathologic findings may be re- I20 The Diaonosis of Tuberculosis 121 corded. So simple a scheme as this is, I am sure, far better than some of the complicated recoird charts now in use. The accompanying cut (Fig". 2) illustrates the chart used by the author, with signs to indicate the various more common changes of disease. It is not offered as anything perfect, but simply as a useful tool which any one may vary. Fig. 2. — Author's chart with illustrative markings. // Bronchial hreathing and dulness, marked. Increased voice, whisper, and vocal fremitus. — Reduced vesicular murmur. II Rales, mostly moist. \>^ Flatness on percussion, with reduced fremitus and al)- scnce of lung sounds. O Cracked-pot sound on percussion with open-mouth hreathing. Amphoric sound moderate. 00 Faint and distant amphoric sound. XX Frictions. The intensity of the signs is in proportion to the heaviness and the numhcr of strokes or marks. 122 Tuberculosis In the care of the sick there are few things of more importance than the early discovery of tuber- culosis ; for early diagnosis makes possible the most effecti\-e treatment — which is early treatment — and if made in every instance, it would lead to a great increase in the already large percentage of recover- ies from this disease. But we never can expect to make early diagnoses until we appreciate a truth that is usually overlooked — namely, that tuberculosis, especially in the lungs, always exists for a considerable time before it an- nounces itself by signs or symptoms. It is some- times present for a long time before symptoms ap- pear, and our only proper course is to be alert for the first hint of any evidence that can point to its existence. Probably it can never be known positively, but there is little reason to doubt that tuberculosis may exist in the walls of the bronchi for weeks be- fore it induces enough irritation to cause notice- able cough; and it may exist a very long time be- fore any conscious local irritation is produced. It must be rare that marked fever occurs — if it occurs at all — until some degree of mixed infection has been produced by suppuration at the point of lesion. This las't event often occurs through some broken surface, some ulceration of the bronchial mucous membrane produced by the increase of the superficial The Diagnosis of Tuberculosis 123 tubercles which are cut off from efficient blood-sup- ply. Before pus- formation the only general symptoms would be some slight depreciation of the vital powers — perhaps some lowering of the weight and some sensations of fatigue on exercise. Tuberculosis of the lungs is prolific in simula- tions of other diseases, and when the ideal signs in the chest are absent, we are frequently in great perplexit)^ The disease then sometimes resembles tuberculous meningitis and mild typhoid fever; it frequently simulates mild malarial fever; it resem- bles fevers produced by slo\v infection through some pus focus, or a leaking cyst somewhere in the body that produces no local signs. When focal signs are absent, we must hunt for evidence pointing to the correct diagnosis. Loss of weight, debility, cough, and indigestion should always lead to the suspicion of tuberculosis, and in every case of pro- longed low fever we should promptly suspect this form of infection. It is the most common of all diseases producing long-continued fever, and we should never study a case of the latter without con- sidering the possibility of tuberculosis. We some- times forget this when there are no focal signs ; and where there is a history of cough extending over a considerable time, we sometimes guess the case to be one of simple bronchitis. I wish to refer agfain to the lather valueless char- 124 Tuberculosis acter of the percussion tones early in the disease. If the disease were always unilateral, and if we could be sure that the air-vesicles had before possessed the same physical characters in the two lungs, and if we all had musical ears and could discriminate sharply as to pitch, resonance, and quality of tone, then percussion early would l)e valuable. Late in the disease it is always valuable; but early it is often misleading, and has differing significations to different examiners, as determined by their varying degree of expertness in tone. In incipient cases there is always abundant resonance, and physicians often make the mistake of assuming that there is no lung disease because there is no dulness or other change perceptible on percussion. The average ])er- son is a poor judge of minute changes in percussion pitch. Take a case where you suppose you have on one side distinct elevation in pitch or slight dul- ness ; then have a musical expert come in and listen to your percussicMi. and see him correct your reck- oning! He will probably say that your supposed higher tone has the same pitch as that of the well side, the only dift'erence being one of quality. I would give a hundredfold more for a careful study of the changed expiratory sound on auscultation, as showing the beginning of tuberculosis, than for any slight change in the percussion signs. If some of the air-vesicles near the diseased area happen to The Diagnosis of Tuberculosis 125 be dilated, the cause of duhiess that otherwise would exist is neutralized; but disease signs still appear in the auscultation, especially if it is prac- tised with various kinds and degrees of breathing. We often fail to make a critical examination of both sides of the chest. We sliould always do this for comparison, and take time to do it well. It is never enough to listen to one side where the disease is supposed to be. We should listen on the two sides alternately, traversing with the stethoscope from apex to base of both lungs, the patient mean- while breathing deeply (especially expiring fully) at our direction, and note any difference between the two sides, — note where it is, and its character and degree. If there is thickening in the apex, there is sure to be at the top a more distinct and longer expiratory tone and increased fremitus, both of which shade off to normal conditions lower down the lung. In regions where the expiratory .=ound is a little louder and longer than normal, the vesicular murmur on inspiration is also usually somew^hat lessened. These signs mean a thickening of the connective tissue of the lung where the changed breathing exists — a change due to some disease process still going on or that has existed at some previous time. In searching for slight changes, in cases where the disease is beginning, we must not only note the 126 Tnljerciilosis differences as we hear them under the usual con- ditions of respiration, but the patient must exhale forcefully and cough at the end of such an expira- tion, to show what differences can be demonstrated between different parts, and to demonstrate rales that otherwise might be hidden. Where the relative difference is greatest, whether at the top or the bottom of the lung, there is the focus of the disease, and the signs shade off toward the other parts of the organ. You listen at the bottom of both lungs and find the tones exactly alike: listen a little higher, and the tones of both inspiration and expi- ration become slightly different in the two lungs; go up toward the top, and the expiratory sound is perhaps distinctly tubular, with reduced vesicular murmur on one side while there are normal tones on the other. This positively locates the focus of disease at the top. \\q not infrequently find a slight lessening of the vesicular murmur with possible slight increase in fremitus over a whole lung and uniformly, and no other sign. For this demonstration the back is per- haps the best place to listen, although the difference can be made out on the sides ; it is less easily found in front. The changes referred to mean that some disease, perhaps at some long previous time, has involved the whole surface of the lung and left its effects as a permanent condition. Pleuritis is the The Diagnosis of Tuberculosis \2y disease that most often produces this effect. When a patient comes to you with vague chest symptoms, and you find the vesicular murmur shghtly lessened all over one lung, with slightly increased fremitus and no physical signs besides, you may say with a considerable degree of certainty that a general pleu- ritis has occurred at some previous time. The pa- tient may promptly confirm this, or perhaps at first deny it, then remember that he did have a pleurisy several years before. Pleurisy unconnected with lung disease is likely to involve the whole covering' of the lung or a large part of it. It always leaves a little thickening of the surface of the lung as well as the pleura, so that ever afterward there is a slight reduction in the vesicular murmur over the region. Now, it happens occasionally that you find tubercu- losis in the other lung — a condition of things that is very confusing ; for there are then the focal signs of a deposit on one side, and uniform reduction in vesicular murmur over the other. This makes it seem as though the tuberculosis had actually in- creased the vesicular murmur over the whole of the infected lung. It is usually easy to demonstrate in a lung the presence of a cavity of large size if it is empty and connected with a bronchus ; but small cavities often exist for months without producing any sign what- ever. Amphoric sound depends on a cavity of some 128 Tuberculosis size open to the movement of air into and out of it or across its open mouth. A cavity of moderate size might contain air, but might have its opening into the bronchus closed at the moment of ausculta- tion, and there would be no amphoric sound. And the tympanic percussion tone of a cavity is never produced by a small excavation or by one full of fluid — but flatness is more likely instead. A number of physicians think they can demon- strate cavities where, I am sure, none exist. The pure and ideal tubular breathing is sometimes mis- taken for evidence of a cavity; or it is this sound with coarse rhonchi,or the latter alone, or some other and perhaps unusual tone that is similarly far re- moved from the amphoric breathing and voice, that is seized upon as proof of cavity. On the other hand, small cavities, and many of them at once, often exist and give no evidence of their presence except, perhaps, by gurgling rales. Sometimes loud rales and rhonchi confined to one lung are transmitted through the large bronchi to the other lung, and give an impression to the aus- cultator that it also is diseased. This mistake is not infrequent, and sometimes seems almost una- voidable. But the illusion can usually be detected by first noting carefully the character of the rales in the lung known to be diseased, and then tracing them toward the other lung step by step with the The Diagnosis of Tuberculosis 129 stethoscope. If the rate and character of the rales and their relation to the acts of inspiration and ex- piration remain the same on receding from the dis- eased lung, — if the only change is merely a growing faintness of tone, — we may be sure the sounds are transmitted. If, on the other hand, the character and relation change, then the sounds originate in the other lung, and both organs are diseased. The presence of the curved fibers of the walls of the air-vesicles in the sputum is of some, but not great diagnostic importance, for it rarely reveals much evidence that cannot be found by auscultation and percussion. It does, indeed, tell of the melting away of some of the air-vesicle walls; but this may occur from any ulceration besides that of tuberculo- sis, and when it is due to this disease, considerable fibrosis nearly always is present. The examination for the fibres is not difficult to make. Boiling the sputum in a solution of caustic soda for a few min- utes makes it quite liquid ; then it may be diluted with cold water, and sedimentetl by standing in a conical glass or l:)y means of the centrifuge; then a drop of the sediment is placed under the micro- scope with a low power, and tlie fil)ers appear. It is not safe to say that a patient has tuberculo- sis of the lungs because he has any or all the chest signs so common to phthisis. For there are cases — rare, indeed, but they exist — of non-tuberculous 9 1 30 Tuberculosis phthisis that almost perfectly simulate the tubercu- lous. Therefore it is necessary to search the sputum for bacilli in every case. Once found they should never be expected to disappear so long as purulent expectoration continues, unless this comes from the inside of an old cavity. The differentiation of tuljerculosis and typhoid fever ought not to be difficult or long delayed, for in the latter condition we have almost invariably, after eight days, the positive result of the Widal blood reaction, so that the test of time and the mi- croscope very soon mark the line between these two diseases. Malarial fever can be told by finding the Plasmodia in the lilood with the microscope; and any practitioner with a good instrument can learn to make the examination. Fever states due to local disease sometimes present more difficulty, but the focus nearly always gives some other sign or symp- tom besides fever that points to it. Where a fever continues with cough and expectoration, and espe- cially if the slightest change can be detected in the lung, we should always regard tuberculosis as more than half proven. The tuberculin test for the presence of tuljercu- losis is a safe and relatively reliable procedure to be resorted to in cases of doubt. We can inject hypo- dermically from i to 5 milligrams, starting with not more than 2 (i is better), and if tuberculosis is The Diagnosis of Tuberculosis 131 present, the temperature .will rise two to three de- grees above its usual maximum, beginning in a vari- able period of four to twelve hours, and continuing from four to thirty hours. There will be some of the usual symptoms of a febrile attack, as chilliness at the onset of the fever, headache, general pain, restlessness, possibly nausea, weakness, and rapid pulse.' As the fever subsides all these symptoms will gradually disappear. If there Is no reaction after the first injection, it may be repeated once or twice at Intervals of a few days. The second dose may be double the first, and so on for three or four doses, the last being 8 or 10 milligrams. If then no febrile reaction results, we may conclude with a fair degree of certainty that tuberculosis does not exist. There may be congestion and swelling of the diseased regions as a local reaction to the tuberculin. This occurs In conjunction with the general reac- tion of fever, and may be observed readily in tuber- culous skin, glands, joints, and larynx, but is not as easily made out by auscultation and percussion In 1 Dr. C. M. Wood, formerly in charge of the Hospital for Consumptives in Ciiicago, formulates the following tests of a perfect reaction from tuberculin. 1. The rise in temperature must amount to at least two degrees. 2. It must reach its height between six and twenty-four hours after the injection, except in fibroid cases, where it may be delayed thirty-six hours. 3. It must be accompanied by at least two of the following symptoms : Chilliness, headache, nausea, and muscular pains. 1 32 Tuberculosis the affected areas of the lung'. It undoubtedly oc- curs in all internal forms of the disease. In using this test, great care should be taken to get reliable lymph. The test should not be attempt- ed on febrile cases, but only on those whose temper- ature, if at all above normal, is but slightly so, and constant for many days together. In making the test the temperature should be taken every two hours for a day before the injection and as often for a day afterward, in order to be sure of the precise effect of the procedure. A few years ago many physicians suspected that injections of tuberculin might cause an extension of the disease throughout the body. This fear no longer prevails, and no such result follows its use. The fact of the local reaction to tuberculin has encouraged the fear of the spread of the disease; but with the tentative dosage advised, and the slight local change resulting, there is probably no danger at all, even if a profound reaction were capable of doing harm. And, even assuming a marked reac- tion, it is not all certain that it could set free into the circulation swarms of bacilli without which no extension can occur. The local reaction is a con- gestive process about the fficus of the disease, and may, for all we know, l)e restrictive of the bacilli and actually prevent their dissemination. More- over, the presence of a small (|uantity of tuberculin The Diagnosis of Tuberculosis 133 in the blood (and with any fair vigor of system) must logically be expected to beget some power or thing that acts the part of an antitoxin to tubercle bacilli, rather than to encourage their growth. Syphilis occasionally gives a febrile reaction to tuberculin ; and a reaction may possibly occur from a very large dose injected into a healthy person. On the other hand, reaction sometimes fails to occur, even from a liberal dose, in an advanced case of consumjition. These drawbacks only slightly im- pair the value of the tuberculin test, for its percent- age of failures in early cases and with proper dosage is very small. And it is in the incipiency of the disease tliat the test is most useful. In making the injections, aseptic precautions should be strictly observed, as well as care for the size of the dose. Tuberculin properly prepared is of uniform strength and will keep almost indefi- nitely. For convenience in using, it may be diluted to a 10 per cent. solutifMi in distilled water contain- ing 2-5 per cent, of carbolic acid — a solution that also keeps indefinitely. At the time of administra- tion a I per cent, solution may be made by diluting the first solution to tenfold w'ith distilled water; this represents i milligram of tuberculin in lyi minims. One of the latest discoveries is that the blood- serum of tuberculous patients actually agglutinates 134 Tuberculosis the bacilli of tuberculosis. It causes them to gather together in clumps, as is the case in the Widal reac- tion of typhoid fever. Certain other diseases have the same peculiarity; that is. the blood-serum of a l)erson who has had the disease destroys pure cul- tures of the causing bacilli. Thus it has been dem- onstrated that the Bacillus dysenteria:, causing the dysentery of the West Indies and the Philippines, in pure culture is agglutinated by the blood of the patient ; so the Widal method is not restricted to typhoid fever. I should say that this agglutination by the serum in tuberculous cases is no m(~)re reliable than the tuberculin injection in any case, and is prol)ably much less reliable in the slight cases where the diagnosis is doubtful. The cases of joint, bone, gland, and skin tuber- culosis are all announced by symptoms and signs that are more or less distinctly focal. Many of these affections are surgical in their character, and I shall not discuss them at length here. I wish to say, however, that where the joints, bones, or ten- don-sheaths are involved in any lesion that pro- duces pain, tenderness, or swelling, we should al- ways suspect tuberculosis, whether it exists in the lungs or not; for this infection frequently produces such lesions. Of course, if one of these lesions occurs in the course of a lung tuljerculosis, we would more naturally think of it. Frequently we fail to The Diagnosis of Tuberculosis 135 think of it if the hmgs are not evidently diseased and if the patient is not physically debilitated. In susceptible subjects a blow or other violence is likely at any time to lower the vitality of one of these parts so that tuberculosis may supervene. Tuberculous meningitis requires special study for diagnosis, because it differs in many ^\'ays from other forms of tuberculosis. It occurs mostly in a class of young patients who are wanting in any easily discoverable evidence of infection of the lungs or of any other part of the body. It occasionally comes as a late phenomenon in lung cases, and then we have no difficulty in diagnosis. Children have tuberculous meningitis more often than adults, and with them it often appears as an apparently initial lesion. There is evidence that the bacilli, entering the blood from some previously existing focus of tuberculosis, are carried to the meninges, and at the base of the brain find their way through the capil- laries and light up the disease. It produces a set of symptoms that are the most amazing of any to be found in all the practice of medicine, because they are so irregular and so atypic. It is impossible to describe a case of tuberculous meningitis so that one's first case of the disease shall surely tally with that description. Pain is one of the first symptoms, but it does not always appear; it usually comes early, but sometimes not until late 136 Tuberculosis in the disease. It occurs usually as an irregular sharp pain in the head, but sometimes it is a pro- longed, disagreeable ache. Sometimes the head is drawn back in opisthotonos, and then the meninges of the spinal cord are invohed ; but this symptom is usually absent. Fever always occurs some time during the course of the disease; usually it 1)egins as a trifling eleva- tion of temperature, and each successive day, for a number of days, it rises exactly as in the so-called classical typhoid fever. Sometimes, however, the fever is entirely irregular; it may occur as a quick explosion, the temperature rising rapidly and re- maining for a day or two as in remittent fever or the initial fever of measles or scarlet fever; then it subsides, and for a time the ])atient seems to be con- valescent so far as the fever is concerned ; then the fever returns. The appetite is lost, the patient may vomit occa- sionally, or for a brief period he may eat voraciously and digest his food. He usually has constipation, but not always. These general symptoms are ex- tremely perplexing. There is not one of them that points very positively toward the brain, except it be the pain. That, indeed, does hai)pcn in the brain disease; Imt children frequently have pain in the head with other diseases. They have migraines like adults, and great pain in the head with various The Diagnosis of Tuberculosis 137 trifling ailments, and there is nothing surprising about it. So it happens that this disease in the early stages is very frequently taken for other af- fections. Probably it is most commonly taken for typhoid fever. This error is sometimes unavoidable during the first few days, but never after eight or ten days; and cases of tuberculous meningitis may last a week or ten days before focal symptoms ap- pear. After a case has continued for ten days, the Widal test should settle the question as to typhoid fever. The patient with tuberculous meningitis loses weight rapidly, but not more rapidly than is often the case in typhoid fever. In a few days, however, usually from four to ten, general symptoms occur that point unmistakably to the cerebrum. One of these is strabismus, convergent usually, but some- times divergent. The pupils become unequal in size. That does not prove meningitis, because sometimes people in ordinary health have one pupil larger than the other as a result of fatigue ; but with other symptoms it may be a valuable sign. In meningitis the pupils become later immobile. That always reveals brain disease. Then the ])ulse becomes irregular, showing that the regulating machinery of the heart, that manifests itself through the pneumogastric nerve, is regulat- ing the rate imperfectly; the pulse is rapid, then 138 Tuberculosis slow. It does not drop a beat occasionally, as in functional disorders of the heart, but is slow and fast alternately. Then if we draw the finger-nail over the skin of the abdomen, we find that the red line produced by it appears and disappears slowly if the case is one of tuberculous meningitis. This is what is known as cerebral or meningeal tache, and is a sign of some, but not great, diagnostic value, since it appears in other conditions. It is a result of vaso-motor paresis. The abdomen becomes flat, and then sinks late in the disease. Finally the patient ceases to be able to vomit, and refuses to take food unless forced to; he frequently emits a little whine or cry, and he is always unconscious, and therefore wholly insen- sible of suffering. Various distortions of his body may occur. One of the limbs may be drawn up in spasm, or the eyes may be drawn to one side. A valuable diagnostic pointer in this late stage of the disease is lumbar puncture — puncturing the lumbar region of the spinal canal with a tubular needle. In meningitis there is an excessive amount of spinal fluid, — really an excess of cerebro-spinal fluid, for the fluid in the subarachnoid space con- nects with that of the spinal canal. For this opera- tion all that is needed is a hypodermic syringe with a long needle, or a small detached aspirating needle. All ordinary aseptic precautions should be taken The Diagnosis of Tuberculosis 139 with instruments, hands, and field of operation. The patient should sit or lie with the body bent slightly- forward, and the needle should be held in such a way as to prevent its being plunged in too deeply. Three-quarters of an inch for a child is a sufficient depth usually; twice as much for an adult. The needle should be inserted slightly to one side of the spines of the vertebrae, and be pushed carefully up- ward and inward toward the spinal canal. The point of election is below the second or third lum- bar vertebra. If there is an excess of spinal fluid, it will be drawn into the syringe, or will drop from the needle if this is detached from the syringe. In this manner a dram or two of the fluid may be drawn in a case of meningitis. The fluid may be clear and almost colorless, or opalescent from pus or leukocytes, or it may contain particles of fibrin- ous material or blood. In tuberculous meningitis bacilli may often be found in the fluid by staining the sediment procured by the centrifuge. Of cases of tuberculous pleuritis little need be said. We cannot tell the tuberculous from the non- tuberculous. Some insist that the cases are all tu- berculous, Vk^-hich is not true, though the majority doubtless are so. The physical signs are simply those of pleurisy. Whether the deposit in the pleu- ral cavity is in the shape of firm or pasty material that makes friction, or organized material that fin- I40 Tuberculosis ally compresses the lun<4', or whether it is serum or pus, — if there is much of it, it will produce duluess on percussion, the degree depending on the amount of it. It will lessen or abolish the vesicu- lar murmur of the lung beneath it. If a chest cavity is so full of serum or pus as to put it upon the stretch, it will transmit vibratory impulses. Then distant faint Ijreath-sounds from the lung above or from the opposite side may be heard. This is a prolilic source of error on the part of students and young practitioners. They discover percussion flatness, but because they hear the lung sounds e\'en faintly, they forget about the condition of the inter- costal spaces, the situation of the heart, and the fremitus, and conclude that the case cannot be one of fluid in the pleura. When fluid is present in any considerable amount, the intercostal spaces are sure to be less sunken than normal ; they are more full, although \-ery rarely bulging. This intercostal space sign is nearly diag- nostic of the presence of fluid. A tumor may cause the dulness and lack of fremitus, and even dis- place the heart, but it is rarely of sufiicient size to spread over a surface extensive enough to produce a uniform bulging of the spaces. In case of any degree of doubt, one should always explore the chest-cavity with a large aseptic hypodermic needle, and, if possible, procure some of the contents. This The Diagnosis of Tuberculosis 141 will usually clear up the diagnosis. We should be careful that the syringe works and will make suc- tion, and that the skin is surgically clean. With relative absence of fremitus and of lung sounds (or the remoteness of them from the ear), short-wind- edness, and the displacement of the heart, in addi- tion to the intercostal sign, the diagnosis should be plain. If the effusion is on the left side, the heart is pressed to the right, and vice versa. The first sus- picion should always be that the displacement of the heart is due to pressure ; it may be due to con- traction. But the apex beat may be moved by en- largement of the heart, and with no disease of the pleura or of the heart-valves or portals. Then, of course, the urine should be examined for fibroid disease of the kidneys — a condition that is always attended with arterio-fibrosis. We should never regard as complete the examination of a patient who has flat percussion sound over the lower part of one side of the chest, until we have made the needle puncture. It cannot always be done, but its omis- sion sometimes leads to humiliating errors in diag- nosis. Under the safeguarding of surgical cleanli- ness it is a harmless procedure, and, properly done, it is substantially painless. The l)est way to do it is to press a forefinger firmly into the proper inter- costal space, the palmar surface l)eing downward 142 Tuberculosis and pressed more against the lower rib; then to plunge the needle boldly into the chest, sliding it over the finger nail as a guide. The pressure of the finger obtunds or diverts the sensibility of the part so much that the prick of the needle is often not felt at all. The X-ray is of some, but not great, value in the diagnosis of chest diseases. It reveals slight shading over regions of lung that are deeply infiltrated with tuberculosis, when seen by the fluoroscope; \X is less satisfactory w^ien studied by the radiograph. The motions of the heart can be seen by the fluoroscope, and the movements of the diaphragm. But the nec- essary apparatus is costly, and difficult to use, and it reveals little or nothing that cannot be demon- strated by the usual exploration that is within the reach and capacity of every physician. CHAPTER IX THE PROGNOSIS OF TUBERCULOSIS The prognosis of tuberculosis is of the greatest importance both to the individual and to the public. Will this patient get well? What is the prospect of recovery? These are intense questions daily asked of the physician. Years ago a patient v^ith tuberculosis of the lungs was supposed to be doomed to die. It was thought then that relatively fewer people have the disease. Now we know that at least half of all the people have it some time, and that a large proportion of them reco\'er entirely, while in a vast number the focus of disease becomes encysted and harmless. As to the morbidity of the disease, some patholo- gists hold that 70 per cent, of all people have tubercu- losis somewhere in their bodies, some time in their lives; others put it as low as 40 per cent. I think we may safely say that half the peoi)le have tuberculosis somewhere, some time. It shows strikingly the prevalence of this disease that Chicago in forty-two years lost 39,000 people from the pulmonary form. The disease kills 30 times as many people as variola and scarlet fever together, 16 times as many as ty- phoid fever, 8 times as many as diphtheria, and 143 144 Tuberculosis 4.5 times as many as all combined. In New South Wales, in twelve years, ^2 per cent, of all deaths from tuberculosis were from phthisis, and "j.y per cent, were due to tuberculous meningitis. During the same time the deaths from the six chief zymotic diseases were only 75 per cent, as many as died from tuberculosis. In Ireland, in 1895-97 inclusive, the mortality from tuberculosis was 11.5 per cent, of all deaths, which were 17.3 per thousand of population per annum. The mortality increases irregularly with age, and yet hardly any one would suppose so. The pop- ular belief is that, in proportion to their number, young people suffer more deaths from tuberculosis than older people ; yet it has been found by earlier census reports, that there are more l^etween sixty and seventy years of age. In proportion to the liv- ing, deaths from tuberculosis are more frecjuent between those years than in any other time of life — showing, pr()l)al)l}', that lowering of vitality by work, age, other diseases, and the vicissitudes of life and of seasons invites phthisis and makes re- covery from it impossil)le. These statements do not even hint at the proportion of deaths to the cases of the disease. The last census reports of the United States show that the proportion of deaths was greatest between 70 and 80 years, the mortality from phthisis [)eing The Prognosis of Tuberculosis 145 during that decade 1.91 times greater than the pro- portion of the Hving at that age; while at the age of the greatest mortality in proportion to all deaths from the disease — 20 to 30 years — the ratio was only 1.59. The following table and Chart I show the proportion of deaths from consumption at dif- ferent ages, and the proportion of the living at the same ages, in percentages of the whole population. Chart II shows how the fluctuations in the deaths from the disease at different ages compare with the proportion of the living at the same ages. This information from the census as to deaths is interesting and instructive. It is greatly to be re- gretted that we have no means of know'ing the pro- portion of people at" the different ages who acquire the disease, as well as that of those who die of it. It will be observed that at no time of life do the deaths from consumption correspond exactly with the proportion of living people of the same age. Except during the first four half-decades of life, the proportion of deaths from this disease to all the deaths from it is far above the proportion of people living at the same ages, save during the two half- decades from 45 to 54 inclusive. 10 146 Tuberculosis Tabic sJiozviiig deaths from Coiisitinplion at cer- tain ages, in percentages of tJic total deaths from t/iis disease, and tlie proportion of living persons at the ages shozcn, in percentages of the ivJwle popn- lation. Compiled from United States Census Re- ports, 1900. > •n '-i > "-a •id trcrq :? c q !="'S c q q SLtn D-5" t-h, ^ — 2 M-i ^ ,5 w crq n c::.QrQ CU CU Under 5 4.08 12.07 501054 5.01 3.87 5 to 9 1. 18 11.68 55 to 59 4.06 2.91 10 to 14 2.12 10.63 60 to 64 3.35 2.35 15 to 19 8.35 9.95 65 to 69 2.93 1.71 20 to 24 14.71 9.72 70 to 74 2.19 1. 16 25 to 29 14.51 8.65 75 to 79 1-33 -68 30 to 34 11.75 7-34 80 to 84 56 .33 35 to 39 9-'98 6.55 85 to 89 19 -n 40 to 44 7.68 5.60 90 to 95 044 -03 45 to 49 5-25 4-55 The Prosnosis of Tuljerculosis 147 CHART I. S/wzving t/ic (Icai/is from Coiistniiptioii at dif- ferent ages, ill percentages of the total deaths from this disease: also the proportion of the liz'tng at these ages, i:i percentages of the zchole population. Compiled from Reports of the United States Census of 1900. Solid line, deaths; dotted line, population. % . Cl •^ T Ci s n -f* ^ 3 CS 2 •^ g S s s 6^ A 3 s s S 5 6 :.? s 3 !2 s 3 s lo% 14'- r ■^ 13" \ 12'- 1 \ \ \ 11'- *% \ \ ^ V 10" * \ W- \ / X \ U" 1 \ I ^ I ■^ I 8" J \ \ j J \ 1 V \ j \ \ 6" j \ [ ^ \ \ L -• \ \ \ \ 4" \ ■*< N^ \ \ V s 3" \ * \ \ V, X 3" \ ; >^ \, 1" V / V. 'x \ »., ,vj ^ 1 '"^■ 148 Tuberculosis The records of post-iiiortcins in late years are sur- prising. Out of 3067 autopsies, it was found ihat 41.86 per cent, had tuberculous lung lesions, and in 11.97 P^^ cent, these lesion were healed, or 28.5 per cent, of all the tuberculous cases. Of 826 bodies where death was due to acute non-tuberculous dis- eases or to accidents, tuljerculous lesions were found post-mortem in the lungs of 20.7 per cent, of them, of which 4.2 per cent, were incipient, 3.8 per cent, were rather extensive, and 12.7 per cent, were fib- rous or healed.^ That is, 8 per cent, of these people (38.6 per cent, of the tul)erculous cases) had more or less active forms of tuberculosis. Therefore 61.4 per cent, of all the tuberculous cases in this series must ha\e become quiescent and harmless by abso- lute cure or encystment and segregation. In an- other series reported by Koehler, about 26 per cent, of dissected bodies showed vestiges of tuberculosis, and in all these cases death from tuberculosis was positively excluded. These bodies were from among the poor and unfortunate. It is an old record and an old doctrine that one- seventh of all people die of tuberculosis ; that is over 14.25 per cent, of all deaths. These figures have been quoted so often and so long that they seem like a law of nature. But they are wrong for this day, whatever authority they may have had. 1 Birch-Hirschfeld. The Prognosis of Tuberculosis 149 CHART II. Showing the fluctuations in deaths from Con- sumption at different ages (in ratio of all deaths from the disease) as compared zuith the number of the living at the same ages. The heaz'y hori:;ontal line indicates the proportion of the living; the zig- zag line shows the deaths. (Compiled from the U. S. Census Reports of 1900.) Half-df of 1 cades 11 W % f; I s 3 ?> 8 m ^ 1 i ■^ s % g s -P S s srx" 88-2/ /^i c 75 " / / ~n \ e% " /^ 7 % / if" 69^ V 1 it 1 1 — 50 " 1 "7 \ 0% ) / > \ t 37K" 1 V 39; ?.•- J >% 46; A a 25 '• 1 1 /o A% p! 12)2 ■■ V, Proport ion of liviiig 1 c or .1 l\ i!.l "i - ziy^ " 1 ^ 5 ■; 50 " 1 - 2 JR Si Z e2x " -- 'a -r .. \ J £ 87^" \ \/\"' ■ ' KM) ■• vfc^ t 1 50 Tuberculosis The mortality from all forms of tuberculosis now is not over 1 1 per cent, of all deaths, and that from the pulmonary form probably does not much, if at all, exceed 9 and loj/ per cent, in rural and urban populations respectively. Koehler puts the mortal- ity from consumption in cities at 2.25 per 1000 peo- ple per annum (with a total mortality per 1000 of 21.8), or 10.3 per cent, of all deaths. The United States census of 1900 shows 10.56 per cent, of all deaths reported in the registration sections of the country for the previous year to have been due to " consumption." The census of " gen- eral tuberculosis," being added, brought the propor- tion up to 10.68 per cent. These figures, it must be remembered, do not apply to the whole country, but to the " registration area," — mostly towns and cities where the census officials believed that fairly accurate records could be procured. The Public Health and ]\Iarine-Hospital Service of the United States has compiled the mortality sta- tistics of 1435 cities, towns, and villages in this country for the year 1901, with this result: Total deaths, 365,216; from "tuberculosis," 41,938, or 1 1.4 per cent, of all deaths. This is more than double the number of deaths from enteric and scarlet fevers, measles, and diphtheria comljined, these dis- eases having destroyed 20,787 people. It is rather surprising that the figures from the The Prognosis of Tuberculosis 151 two sources quoted should vary so much. There is no doubt of the effort at accuracy of the persons engaged in the work of registration and compila- tion ; their differing views as to classification of diseases and the diagnosis of the causes of death, together with the human tendency to error in figures and records, would make some disparity unavoid- able. The records from the two sources, moreover, do not cover exactly the same communities ; and it is to be regretted that we have no such adequate records of mortality in the rural districts as we have in the cities and towns. The farming com- munities certainly have a lower death-rate than the cities and towns. In Germany in 1895 t^"*^ mortality from consump- tion was 1 0.22 "per cent, of the total mortality. The deaths from this disease numbered 215.3 in each 100,000 of the population. The death-rate per 1000 of population was 21.06. The death-rate from tuberculosis is declining, especially in communities where repressive measures are in vogue. The United States census of 1890 showed, in the registration area, that the deaths from consumption and general tuberculosis combined were 12,146 for each 100,000 deaths from all causes, or 12.14 per cent, of all deaths; while the census of 1900 showed 10,688 to each 100,000 deaths, or 10.68 per cent, of the total mortality. In 1890 1 52 Tuberculosis there were 245.4 deaths from tuberculosis in each 100,000 of the population; while in 1900 the num- ber had fallen to 190.5. These figures show a re- duction in the ratio of deaths from tuberculosis to total deaths of nearly ly^ per cent., and an actual lessening of deaths from the disease of over 22 per cent, of the higher figure, or more than one for each week in every community of 100,000 people. This saving of life is probably to some extent more apparent than real ; it probably does not rep- resent 54.9 fewer cases of tuberculosis in the given community, but in part speaks for the better care of the cases, and so the postponement of the deaths of some of them. This argument applies to the decade just passed, which has witnessed a great improvement in the care of consumptives. It may not apply to future decades. But, allowing for this element and for possible errors in computation, there still can be no doubt that the mortality from tuber- culosis is on the decrease in this country. The mortality from consumption in Italy is de- creasing. The annual deaths per 100,000 people during 1887 to 1889 inclusive were 107.53; during the three years 1895 to 1897 inclusive the rate had fallen to 102.63. This means a reduction from the higher figure of 4.5 per cent. In Liverpool, during the decade ending with 1875, among 100,000 people there were 430 deaths from The Prognosis of Tuberculosis 153 this disease, or 4.3 per 1000; the next decade there were 309 deaths, or 3.09 per 1000; and in three recent years 256 deaths, or 2.56 per 1000. The deaths in nine cities of Europe for the decade ending 1890 were 3.82 per 1000 people; while for the same time in twenty-eight American cities it was 2. 68. In Prussia, prior to 1889, the deaths from lung tuberculosis were annually 3.14 per 1000 people. In the following eight years it was 2.18 per 1000. In New York City the mortality from tuberculosis since 1886 has dropped 35 per cent, of its previous rate (Biggs). In Prussia, in 1880-86, the deaths from consumption were 31 1.2 per 100,000 people; in 1895 the rate had fallen to 232.6. The mortality from consumption at different ages and of the two sexes, as revealed by the last census, makes a chapter of the greatest interest. The num- ber of deaths, which is low during the first three half-decades of life, mounts rapidly during the next two or three, whence it falls steadily to the seven- teenth (80th to 85th year). The mortality among females during this period is lower than that of males, except during the second to seventh half- decades inclusive (5th to 34th year), when it is con- siderably higher, especially during the years from 15 to 30. Chart III shows the facts in a graphic manner. 154 Tuberculosis CHART III. Relative deaths from Consumption in the two sexes, shown by half-decades of life, in the census " registration area," in whicli the deaths for the year, from all causes, numbered 1,039.094. The solid line indicates males; tJie dotted line, females. (Compded from the U. S. Census Reports of 1900.) Ages Judt lyr. r2 to 4 incl. to SI 14 to 19 24 29 to 34 39 40 to 44 45 to 49 00 to 'to 59 00 04 09 70 to 74 76 to 79 SO to S4 85 to «9 90 to 94 Ovc< 95 Number of Deaths 9600 9000 }' 92 8500 • >80 57 8000 1 1 1 7000 \ 7000 7104 . OSOO ; f A 10 20 GCOO 1 1 G28 ^ 5500 583( / 1 A" C80 6000 ; 514 'V \ 4500 ' \ V 047 4000 i^ \ V 3500 1 SS2 ^\ \= r 3000 / 274 ' \ 210 2500 ; / 27 o\ V ;08 2000 / C2' K, \^ KO 1500 ^ ^ 150 i 1 181 151^ ^ V 53 1000 ^ ^ / ' / IIU k" 600 H t n 19 70 ^^ S i= 00 "*2- 30 -vv^ .^ 12 J^[-- r Ijr. 1^4 incl 9 10 H Ij to 19 20 to 24 1 oO to 36 40 44 4j to 49 JO 10 54 50 00 to 04 05 to 09 70 74 1 S4 S5 911 to to S9 94 Ovtr 95 In studying this chart it should be remembered The Prognosis of Tuberculosis 155 that the sexes are, in our population, not quite equal numerically, the census of 1900 having shown that there are 51.2 per cent, of males and 48.8 per cent, of females. If 50 per cent, of all the people have tuberculosis some time, and 1 1 per cent, of all people die of the disease, that would make 22 per cent, of all tul)ercu- lous cases to die, and 78 per cent, to fail to die of the disease. Of these last, a part recover, to die of something else; and a part, failing to recover com- pletely from the tuberculosis, are still carried off by intercurrent diseases. Even on the basis of the false assumption that the deaths from all forms of tuberculosis are 14 per cent, of all deaths, or 28 per cent, of all cases of tuberculosis, (i. e., on the basis of a morbidity of the disease of 50 per cent.), then y2 per cent, of all the tuberculous patients fail to die directly of this disease. And this is a re- markable showing in recoveries from a disease that many of the people — most of them in certain quar- ters — have regarded as practically incurable. It is impossible to say what proportion of the lung cases actually recover, but it is manifestly much larger than was formerly supposed. Probably few recover so completely as to have all the bacilli de- stroyed in the body by and in the healing process. Many recover by healing and encystment of the tuberculous area and products, including the liacilli, 156 • Tuberculosis to die of other diseases. What the proportion is cannot be known exactly ; reports and estimates differ, and many of these are unreliable. It is probably safe to say that the recoveries from known lung tuberculosis amount to 33 per cent, or over. If we are to generalize from the post-mortem and dissection records already quoted, the percentage would be much above this figure; counting all the hidden and unrecognized cases, the figure would probably reach 50 per cent. Of the cases of tuberculosis of skin, bones, joints, glands, serous membranes, and encysted nodules in various parts of the body, a very large proportion recover. When the disease attacks the cerebral me- ninges, death is practically certain ; yet Hektoen has reported one post-mortem study that shov.ed a per- fect recovery over small areas of a tuberculous men- ingitis. The disease continued to spread and so the patient succumbed; but the fact that healing has been shown to occur over any part of the affected tissues in this disease gives hope that occasionally a perfect recovery may take place. The prognosis in individual cases depends on circumstances. These are — (a) hereditary influ- ences, which means inborn resisting power to the disease; (b) the actual resisting power, as shown by the history of the case, in the ability (i) to limit the lesion by the process of fibrosis; (2) to avoid The Prognosis oi Tuberculosis 157 pus infection and therefore fever — which means the abihty to keep the disease from burrowing deeply and away from channels of exit fcM- the prod- ucts of the disease process; (3) to keep up body nutrition and avoid emaciation; (4) to maintain secretions and excretions; (5) in women, to con- tinue menstruation; and (6) to avoid physical and physiologic calamities, such as overdoings, accidents, colds, fevers, complications, and pregnancies. H the show^ing in these several ways is good, so is the prognosis. If the power in these directions is low and the success poor, then the prognosis is bad. Most cases die that lack enough stamina of the kind that resists tuberculosis to recover under rest and the best hygiene. All complications and other diseases (as of heart, kidneys, digestive organs, and blood-making functions) add greatly to the gravity of any case. So do the burdens of the ordinary business of life. There are certain physiologic peculiarities that stamp people as probably deficient in normal resist- ing power to tuberculosis. Among these may be named : a fastidious appetite ; distaste for meat — especially for fat meat — and other articles of the common diet of mankind ; inability to take stimu- lants, when properly diluted, without signs of gas- tric or cerebral disturbance from small doses. The rate of progress of pulmonary tuberculosis 1 58 Tuberculosis toward either recovery or the opposite varies with the cases. No two are ahke. The disease is essen- tially a long one. A few cases of so-called " gal- loping consumption " run a rapid course and ter- minate in death in a few months; some of them seem to terminate in a few weeks, but nearly all such have had a longer duration than has been sup- posed. They ha\e perhaps been progressing in a slow way for months before the nature of the dis- ease was discovered; then this has spread rapidly and gone on to a fatal issue in a few weeks. Patients are sometimes so little disturbed in health by the disease as to go on with their ordinary voca- tions for years with hardly a symptom beyond a trifling cough occasionally for a few days at a time. When these exacerbations occur, they suppose them- selves to have taken slight colds. Even then the expectoration is sometimes slight ; but there is nearly always some degree of shortness of breath that shows on running, especially running up stairs. This last may be so slight and may have come on so gradually as to escape the notice of the patient, unless his attention is fixed sharply upon it. I have known men acti\'ely engaged in business and given to sports considerably athletic, who have carried tuberculosis in a single side for ten or fifteen years, as shown by repeated findings of bacilli, and who have passed in the community as well people The Prognosis of Tuberculosis 159 all the time. Their looks indicated normal, even superior vigor ; they had only slight inconveniences, and these consisted of a trifling cough occasionally, and perhaps some moderate annoyance from chron- ically irritated joints. I have known a woman with tuberculosis of one lung, often free expectoration of bloody muco-pus, and occasionally fever, to main- tain apparently unimpaired health for ten years, and in the mean time bear two children, each of which she nourished during a part of the nursing period. But, of course, in such cases ph3^sical examinations always reveal slowly progressive fibrosis of the af- fected lung, and some contraction of it as shown by circumference measure. During the exacerbations, too — the periods of the " colds " — there is often daily elevation of tem- perature to the extent of a quarter to half a degree; but in the intervals, which often extend to many weeks, there is normal temperature at all hours of the day. In such cases the tuberculosis is mostly confined to the bronchi and peribronchial tissues, where the irritation of the disease always provokes the formation of fibroid tissue to cause thickening and contraction. There is no tendency to the forma- tion of suppurative foci outside the bronchi, the prod- ucts of which would be unable to find exit through the tubes, but would be absorbed into the blood and produce fever. i6o Tuberculosis It is a general truth that of those forms of pul- monary tuberculosis that do not produce fe\'er, the prognosis is relatively good. Persistent high fever, with or without much pus discharge externally, means a bad prognosis. The prognosis is bad, too. where there is little fever, cough, or expectora- tion, but where there is progressive emaciation and dyspnea, with no dulness on percussion or bronchial breathing and with diminishing true respiratory murmur. Such cases are of the dissolving type, where the lung-substance slowly disappears by dis- seminated ulceration of the vesicular tissue. The cases that promise most for resistance are those where fibrosis occurs in mass around the tubercu- lous focus, and this always shows itself by bronchial breathing and some dulness on percussion. Exces- sive general fibrosis of both lungs, however, makes the prognosis ultimately bad, since it is almost sure to increase slowly until it chokes the blood-supply to the parts concerned in respiration, causing thereby dissolution of air-vesicle walls, and so finally wear- ing out the patient. CHAPTER X THE PROPHYLAXIS OF TUBERCULOSIS Prophylaxis of tuberculosis is next in impor- tance to the treatment of it. There is hardly any ground for hope that tuberculosis can ever be wholly extirpated as a disease of mankind. But there is much that can be done to reduce the number of cases; and danger to life from the disease will be lessened somewhat l)y measures that tend to decrease the cases. If it is true, as it probably is, that most of the bacilli with which human l^eings are infected come from the bodies of people, then measures to lessen the number of them at large must be potent in reducing the danger of infection. This is the direction in which we can do most good, and in this way we should make constant and strenuous war against the disease. To reduce the number of bacilli in the air is a cardinal necessity, and to reduce them in the food and drink is important. Much can be done by pa- tience and insistence in the destruction of sputum. The sputum can be easily destroyed by heat or chem- icals (carbolic or bichloride solutions), and most of it can be caught in spit-receptacles, which should always be within reach of the patient's hand, so i6i II 1 62 Tuberculosis that it may be destroyed. These are to some degree attainable measures. We can insist that tubercu- lous patients shall care for their expectoration in some way to prevent it from becoming a part of the dust of the air. It will require constant watchful- ness, often some severity, and a good deal of mis- sionary work to create a public sentiment that will demand it, but it can be done — and without actual hardship to the sick. The body- and bed-clothing used by patients ought to be disinfected from time to time by the heat of boiling water or of an oven or b}^ chemicals — as formaldehyd gas or wetting with i : 500 corrosive sublimate solution. Keeping clothes in chests or closets strong wnth formalin is a good way, or ex- posure to many hours of intense sunshine. This is a precaution that is rarely taken, but ought to be whenever a patient has a cough of an intense char- acter and rather fluid sputum, for then small par- ticles of it are sure to be ejected upon the clothing. Patients should be discouraged from wearing beards, particularly mustaches, and from the use of utensils in common with other people. This last is a means of distributing the bacilli occasionally. Init I l)elieve not often. Nor do I think that the kissing of con- sumptives is a frequent means of transmitting the disease. But there is no (lou1)t that projectile cough is a common method of disseminating the bacilli. The Prophylaxis of Tuberculosis 163 Those patients who have what is known as a hard, dry cough often project minute particles of bacilli containing phlegm three of four feet into the air, without their knowledge or suspicion. These parti- cles, when dry, are more or less ground into dust by the movements of the garments, to be perhaps inhaled by others. Patients may be urged to hold a cloth before their faces while coughing in that manner, but most of them will forget, become heed- less, or disbelieve in the need of it, or even refuse to try the measure. Most people will not, except in sanatoria, have their body-clothing disinfected from time to time, so that dried sputum contaminating it shall be de- stroyed. The average person in private life will not do this, even if you implore him to. Nor is the measure perfectly effective to protect others from the bacilli lodging on the clothing. In order to be a perfect safeguard, the clothing would need to be disinfected daily — and probably that is a de- gree of scrupulosity that we can hardly expect pa- tients and care-takers to attain. The melancholy rule in vogue is, both in [irivate practice and in hospitals, never to disinfect the outer clothing at all ; probal)ly not two per cent, of tlie patients ever have this service done for them, yet it ought to be done for every one of them, it is most needful for the patients who are housed, and for all patients 164 Tuberculosis ill cloudy weather. Those who are much in the sunshine have l)y that inlluence (jiiite an effective disinfection of all the outer garments. If clothing can receive no other disinfecting agency it may usu- ally without much troul)le be exposed to the bright sunshine, and not less than this should be done. Something can be done toward the destruction of sputum by legal steps against spitting in public places. But ordinances against spitting on side- walks are not so useful as has been supposed. If women would always wear short dresses, never gowns that sweep the ground, and if we could avoid treading upon the sputum, I am sure that, aside from esthetic reasons, it would be better to allow spitting on the sidewalks rather than in the streets, for on the sidewalks the sputum receives more direct sunshine which may destroy the bacilli, while in the streets it gets rolled in dust that impedes the sun's rays, and so the bacilli persist longer and become more readily diffused through the air. Of course, every legal restriction should be sought to prevent people from spitting in street and railway cars and in all public conveyances, and in such places as public halls and lobbies. But ordinances will not execute themselves, and if they arc ever to do the pul)lic any large amount of good, some one must assume the unpleasant duty of prosecuting offenders. This is a task that everybody shirks. The Prophylaxis of Tul^erculosis 165 Some special instruction should be early given to every patient as to the care of his sputum. If he expectorates infrequently, and can to some extent control the function, he may always find a cuspidore with water or other safe place of deposit for the sputum. But if the cough is frequent and the dis- charge uncontrollable, he should always have some spit-receptacle upon his person or within his reach, and should use it with absolute constancy for every particle of tangible sputum. The receptacle must be destroyed, or emptied, cleansed, and disinfected, every day or several times a day, with the certainty and precision of clockwork. In no case should the expectoration be swallowed — nor should a hand- kerchief be used for a receptacle; this breeds care- lessness and a spread of the bacilli, for usually the patients do not promptly and fully disinfect their handkerchiefs thus polluted. There are numerous hand and pocket spit-cups on the market for tuberculous patients, some of them simple and ingenious, others ingenious and complicated. Patients differ in the ease and skill with which they use these utensils. The test is. of course, effectiveness. No cup should be used that breeds carelessness or that fails to catch and hold com])lctely and neatly all the tangible sputum. One of the Ijest devices of all is an ordinary news- paper folded many times, and the folds cut out on 1 66 Tuberculosis all sides but one, so as to make a rude book, between the leaves of which the patient spits. He can safely carry it in his pocket, to be burned at the proper time, and can have a new one several times a day if necessary. Another proi)er scheme is to have a pocketful of pieces of soft cloth or paper to be used for the sputum and to be stuffed into a paper-bag as soon as contaminated, the bag and its contents to be dul)- burned. But the habit of putting these polluted cloths or papers into a pocket of the clothes, or the saving of the bag for continuous use — even a bag of oil silk — is unsafe or actually vicious and ought not to be countenanced. Rooms in which ])eop1e die of tuberculosis, and where it is not certain that the greatest care has been used to keep them from being contaminated, should be disinfected with sulphur or formalin. Such contaminated rooms doul)tless often spread the disease. x\nd I believe that it is best to have local health officers required as a matter of routine duty, when a case is reported of death from tuberculosis, to investigate the premises, and if they find reason to believe there has Ijeen carelessness in the care of the patient, to insist upon disinfecting the rooms. Such a procedure, discreetly carried out, would prol)- ably arouse very little anatgonism on the part of the public, while it would do a great deal of good. The Prophylaxis of Tuberculosis 167 The best way to disinfect a room is probably by the very thorough use of formaldehyd gas, dis- charged by evaporating formalin over a fire or lamp, a pint being used to a room of 100 square feet of floor space; or by some other apparatus that will discharge the pure gas into the room. The formalin is often evaporated from hanging sheets, but this is less efifecti\'e. The rooms should be closed and sealed during the process, and not be opened for twenty-four hours. Rooms may be purified nearly or quite as well by washing floors, woodwork, walls, and ceilings with a rather strong solution of cor- rosive sublimate, say i : 1000 or even i : 500. The surfaces do not need to be rubbed with the solution, but simply wetted, and they may be wiped dry in five minutes, after which the rooms are ready for use again. Another prophylactic measure that has been at- tempted in a few cities, and one that would do much good if it could be carried out, is a requirement that physicians shall report to the Health Department all cases of tuberculosis, exactly as they do cases of scarlet fever, diphtheria, small-pox, and other contagious diseases. Tuberculosis is in a way con- tagious; scarlet fe\er is, but differently, and many physicians claim that the two diseases should be dealt with in the same way. If health ofiicers knew where all the cases of tulicrculnsis arc. they might 1 68 Tuberculosis exercise some wholesome repressive influence over the distribution of the disease. lUit they cannot know of all the cases, nor half of them, and the people are probably not sufficiently advanced, or used to official supervision at present, to submit to such a rule unless very discreetly administered. Some few cities have adopted the regulation, but it has so far never been effective. Both public and profession disregard it to a large degree. Many physicians fail to report their cases frankly ; they forget, perhaps wittingly, to make a diagnosis, or call their tuberculous cases by some other name; and the people are ready to connive at such a course. This is hardly to be wondered at. A disease that at some time in their lives attacks at least half of all the people, and makes a large percentage of these its victims ; that often permits them to go about and appear to have only a simple cold or to be merely a little depressed or debilitated, and that has a range of duration from a few weeks to forty years, cannot be regulated by law as scarlet fever, small-pox, and diphtheria are. These diseases come on and termi- nate rapidly, and much is done to limit the spread of them by current methods of prompt legal iden- tification, so that the people readily acquiesce ; but tuberculosis offers in many particulars a different problem and requires different dealing. Probably the time will come when in many com- The Prophylaxis of Tuljerculosis 169 munities most of the cases of tuberculosis will be reported ; but a large measure of delicate and con- siderate discretion will need to be exercised by health officers in order to make it possible. If such a meas- ure could be thoroughly carried out, it might be of great assistance to the public in preventing the spread of the disease through the dissemination of the bacilli. This is almost the sole way in which the disease can be limited, and this benefit must for a long time to come be expected — and needs be sought — mainly through the efforts of physicians and the enlightened sense of the general public rather than by attempted official regulation. There is another direction in which we can do something toward preventing the spread of tuber- culosis. That is by discouraging the use of carpets and the sweeping of rugs in houses. Rugs should never be swept as they lie on the floor, and carpets are a hygienic abomination ; they fill the air with dust and pollution of many sorts, and undoubtedly spread tuberculosis. A housemaid will cover and iM"otect her hair while sweeping them, but will breathe the dust and filth into her lungs. We can reduce the tubercle bacilli in food. The only foods likely to cause the disease in people are meat and milk. If meat is cooked it cannot transmit the disease, for a temperature of 180° F. destroys the bacilli. We naturally object on esthetic grounds 1 70 Tuberculosis to eating the meat of tuberculous animals, but if it is well cooked, no harm can result to the health of consumers. Alany States require by law the de- struction of tuberculous cattle, as these are the only animals that can l)e to any considerable degree, if indeed they are, a menace to mankind in this direc- tion. Such laws are both good and l)ad : good because seriously sick animals should be slaughtered; bad if the execution of the laws is so literal and sweeping as to sacrifice a great amount of property that does no harm to any one. This latter has been done in certain States, causing unnecessary burdens to the taxpayers who have had to pay for the slaugh- tered animals. As a result, some of the laAvs have been repealed. Professor Russell of the I'niversity of Wisconsin has demonstrated that there is no need of destroying all tuberculous cattle. An animal slightly sick, and put under hygienic conditions, will ofter recover; its lung lesions will become encysted, as those of man often arc, and it will be well except for the scars remaining after the disease. And it is a ques- tion whether we should be squeamish about a food animal that looks well, but in which a few bacilli are found (in non-food p.arts chiefly), when the meat is cooked and eaten by people one-half of whom have bacilli somewhere in their own bodies. Calves of tuberculous cows, if prevented from taking their The Prophylaxis of Tuberculosis 171 mother's milk until it has been pasteurised, may subsist upon it without acquiring the disease. It is better and easier to take care of cattle than of people, and there is more hope of recovery for them. In the next few years the laws directed against tu- berculous cattle in this country will probably be modified so that animals that are manifestly sick will be destroyed at public expense, and the healthy looking ones, even if they do react slightly to tuber- culin, may be kept, if people will house and care for them. The laws ought to require the State to exercise some supervision over herds that are even slightly infected with tuberculosis, in order to prevent the spread of the disease. But it is more important to supervise the dairies, and to prevent the distributi(Mi of milk that is out of condition or is below standard, than to supervise the meat that goes into private houses. Here is a direction in which physicians can do a useful service. Dairies selling milk to the public should be inspected frequently, and all sick cows eliminated in some way. If they react to tuberculin in the slightest degree, their milk should never be sold to the public. But it may l)e pasteur- ized and used as food for pigs or calves without harm to any1)ody. The danger of tuberculous cows' milk carrying the disease to the intestinal canal of children is shown by recent studies by Koch to be 172 Tuberculosis greatly overrated. By his estimate, based on great numbers of careful post-mortems, the children who have primary tuberculosis of the intestines are not one per cent, of the whole numljer dying of tuber- culosis. This goes far to prove that children rarely take the disease from infected milk. Nevertheless, the selling of tuberculous milk should be made a crime l)y law. How may an individual avoid acquiring tubercu- losis? Direct infection needs only to be mentioned. One should avoid getting tul)erculous sputum or other bacilli carriers on the hands or on excoriated surfaces of the body, and avoid going into great accumulations of bacilli. One probably cannot es- cape the bacilli altogether in towns and cities any- where in the world, but he may avoid going where they are \ery numerous and where there is evidence that they are thick in the dust of the air. As al- ready said, it is less a question of who gets bacilli into his system than of who fails to resist them. Almost anyone can probably resist a few on his mucous surfaces, but scarcely anyone who takes in a swarm of them. There is no need of fearing the tuberculous pa- tient if he is well cared for — the thoughtful and considerate ])atient who knows he is tuberculous. It is, in my judgment, a great wrong both to indi- viduals and to the community to keep such patients The Prophylaxis of Tuberculosis 173 in ignorance of their true condition. With ver)' few exceptions, patients with tuberculosis should know the fact. It terrilies them less to know it than it does their friends; and if they know how they may constantly put their neighbors in peril, they will usually be careful. In many health re- sorts people refuse to take such patients to board, even if they are known to be scrupulous in the man- agement of their sputum and to follow all the pre- scribed regimen. This fear is really groundless if the patients are careful ; but to be careful is to de- stroy all sputum and even to disinfect regularly, by sunlight or otherwise, all outer clothing, so as to prevent the minute particles of sputum ejected in coughing, and lodging on the clothes, from con- taminating the air. Nurses of consumptives, if care- ful of their patients and careful of themselves, rarely take the disease unless they become reduced in health.^ To a^•oid tuberculosis one should keep himself well, even vigorous, and do those things that tend to keep his body in a normal condition. The fault of most of us is that we do not keep in a normal condition ; we work too much, have bad digestion, iThe experience of the Chicago Hospital for Consumptives under Dr. Wood is instructive. So great was the scrupulosity in the care of the sputum, that, after a continuous occupancy of the building by an average of 100 patients for over two years, it was impossible to demonstrate bacilli in the dust gathered from the wards. 174 Tuberculosis pay too little attention to ventilation, are housed too much — are too little in the great out-of-doors. Then we are, many of us, foolish enough to believe that if we exercise greatly and become athletes we shall escape the disease. It is almost as much a risk to carry the system above a normal condition of muscular vigor as it is to allow it to fall below. Excesses of all sorts predispose to tuberculosis. The kind of lives that many young people lead predisposes to the disease. I mean lives of spon- taneity. If they enjoy work, they overdo it and go without sleep; they neglect disturbances of di- gestion, neglect constipation, and they stimulate — because they like stimulants or because they are in- vited to take them. As a result, they live much of the time below tlieir proper physiologic standard. Considering these circumstances, it is no wonder that tuberculosis is as prevalent as it is among the young. Wherever careful and systematic measures have been consistently carried out toward prophylaxis, they have succeeded to a most encouraging degree. The records of many cities show this, and they will hereafter show it more. But these benefits have come mainly through the lessening of the bacilli in the air, not so much from any improvement in the habits of the public. People who are careful of their health and see to it that they keep steadily The Prophylaxis of Tuberculosis 175 in good vigor are more hkely to avoid the disease; and the people who need to learn this lesson belong to all ages of the activity of human life. The cardinal doctrines, to be emphasized at all times, are : Keep well and normally strong; always breathe the best and cleanest air; and avoid the bacilli of tubercu- losis — not by making pariahs of the sick, but by a never-ending wise campaign for the destruction of these microbes. It is easy to say what precautions may limit the spread of tuberculosis. They all have for their chief object the limitation of the bacilli, mostly in the air; but the difficulty comes in trying to have them enforced. And there are many patients, mostly among the poor and ignorant, who never will, in their own homes if they have such, or wandering from place to place, carry out any measures of caution. There is only one way to prevent them from daily spreading the contagion, and that is to segregate them from the rest of the coninmnity in sanatoria at public expense. That this will some time be done to a very large extent I have no doubt whatever. Several States are already moving in this direction, and others will follow.^ Nor will it in the end be any special burden to the State, for this precautionary step, l)y lessening the disease 1 Massachusetts already has maintained one such sana- torium for some time, to the great satisfaction of both pro- fession and public. 176 Tuberculosis in the community, is sure to prevent other losses that are vastly greater in a pecuniary way than the cost of the sanatoria. In a sanatorium it is possible to control irrespon- sible and careless people and make them mindful of their habits and the harm they are liable to bring to others. It is not possible to do these things anvwhere else. CHAPTER XI TREATMENT OF TUBERCULOSIS. GENERAL PRINCIPLES I WISH to speak first of some general considera- tions of the management of tuberculosis, and after- ward to deal in more detail with the several phases of the subject. The most natural thing to seek first is some means to destroy the bacilli of tuber- culosis in the diseased body, without serious injury to the body. Many investigators have worked on this problem and numerous experiments have been made, but all to little effective purpose. No germi- cide that fills these conditions has been found. Pos- sibly some of the so-called antitoxic animal serums, some modified products of tuberculin, and drugs that increase the leukocytes of the blood, like nu- cleinic acid and nucleins, may repress the growth and spread of bacilli a little; but if they produce this efifect, it is not known whether they do it directly or indirectly; and proof of anv great power on their part is wanting. The chief factor in tlie recovery of \ictims of non-surgical tuberculosis is the power of their own physiologic resistance. Their prospects of recovery are enhanced by an increase of this power and are always lessened by the slightest reduction of it, 177 12 1/8 Tuberculosis and no measure of treatment that lowers or neglects this power is entitled to serious consideration. All through the long course of sickness the truth is daily verified, that any depreciation in the general vigor and resisting power is followed by an increase in the e\idence of the disease, while any manifest increase of physiologic force is straightway fol- lowed by a decrease in the symptoms. To adopt any treatment that neglects or low^ers the physiologic resisting power, in the hope of producing some mys- terious destruction of the disease itself, or its bacilli, is constructive suicide, if not constructive homicide. So far as w-e know, the bacilli within the human body may be killed or imprisoned by the forces of the body, not by drugs or other things put into it. And how^ to increase that power is the paramount purpose of treatment. One of the great obstacles to the successful treat- ment of medical tuberculosis is the widespread no- tion, both in and out of the profession, that the treatment may be short and that satisfactory results may be attained quickly. The truth is that the disease is long and chronic, and that treatment must be long and sustained, and of such a character that it may endure and l)e borne for a long time. Unfortunately, most of our treatment of tubercu- lous patients heretofore has been haphazard, or based on the theory that there are only a few things that General Principles of Treatment 179 we can do for them. One of these is to send them to a climate for consumptives, and another is to keep them at home and prescribe drugs, chiefly such as cod-liver oil and guaiacol or creasote. With these patients we should least of all think that a particu- lar drug is of any great value against the disease, and that we can do our duty by prescribing it. This is the smallest part of the right management. Regarding every patient who comes to us, we should ask the question at the beginning whether the probabilities are that, under any management whatever, there is hope of recovery. Of course, as to some cases, when they first come, it is a foregone conclusion that death must be certain and rather speedy. Take a patient, for instance, in the years of adolescence, with a bad family history, who has a large lung infiltration that has come on rapidly with high fever, and therefore extreme mixed in- fection. We know that for such a patient there is no possible recovery. But many have small deposits developing slowly, and strong physiologic powers; they have little fever and good digestion, and thus a good prospect of recovery. If in any case the prospect is even fair, we should outline a campaign like one of war, for it is such a campaign ; and the fact that it is a long and not a short one should be strongly impressed upon the patient. His course sliould be mapped out in minute i8o Tuberculosis detail, and l)e put on paper if necessary. As it may often go to the length of making him uncumfoilal)le, the fact should Ije impressed upon him that its pur- pose is to save his life. He should know the char- acter of his disease, and its dangers. We may find it necessary to restrict his pleasures, to segregate him from his friends if they are harmful to him or he to them, and to prescribe many things that are unpleasant. \Yg may fairly try to enlist him in a long and perhaps arduous and self-denying cam- paign if there is a chance of saving his life, and he should know the full meaning of this last considera- tion, and feel it if he can. If there is little or no chance of improvement, we should pursue a different course — one that more concerns the present comfort, even pleasures, of the patient ; and so we can never have a routine treatment for this disease. We may, if it seems best, refrain from telling this patient the full nature of his disease and his prospects, and should never say that his case is hopeless; and we ought to manage him so that his pleasures will not be much inter- fered with, and will yet be prex-ented from harming him much. Many of these patients may be kept comfortable by our ministrations, and death may come to them so slowly and unconsciously that they will never lose hope. They may plan for their tem- poral affairs up to within a short time before or General Principles of Treatment i8i even to the hour of death. To these we do as great a service — to their hearts and minds and to their friends — as we do to those who recover, because we make their sickness as happy as possible, and almost completely painless. For those who have a fair chance of recovery we should plan our treatment logically and consistently; and there are a few cardinal facts that must always be considered in every case of this sort. The patient should, as a rule, know that he has tuberculosis, and know what the treatment means. He should know his own danger, and what danger he brings to others. The first lesson for him to learn is that it is his chief business in life to get well if he can, and that for the present he has no other vital occupation. Only the necessities of existence are an exception. You will find among such patients business men and young men planning to engage in new kinds of business, or to go on with their old ones in their wonted intensity, when there is really no need for them to work, and they are able to devote their lives to getting well. And they are sometimes eager to launch out into all sorts of social diversions and imagined duties. Every one of these schemes must^ 1)e demolished if possiljle. You must charge the patient that such devices are worse than useless ; that he must devote himself to his sole duty of re- covery if he hopes to succeed. 1 82 Tuberculosis The treatment ought to be so planned as to re- store the already lowered power of resistance, and thus lessen the lack oi balance between the vital powers of the patient and the load they are re- (juired to bear. The ])o\vers that are below^ par must be raised; none will need to be l)roug"ht down. Rest, exercise, and tonics may carry the patient up to his physiologic par; this should never be ex- ceeded, and so no athletic exercises are to be in- dulged in beyond the evident requirements of the normal standard. l"he exercises that can be used with propriety are all gentle, as some non-tiring out- door occupation like horseback riding, driving, and walking, and these never to the extent of increasing the musculature above normal. The general activi- ties of life must be reduced. Many a patient can recover and li\e long if he will be content with a more moderate speed, when he would kill himself in a year or two if he insisted on his habitual gait. The forces that have reduced the average patient must be studied and dealt with. The first is too much work, too much strain of some kind. The natural remedy for that is rest, and for the fever cases com- plete and absolute rest. Next is lack of sufficient l)erfect and clean air to breathe. This is the com- mon affliction of nearly all the people. The remedy for this is obvious, but it is one of the most difficult remedies to induce people to take. The fever pa- General Principles of Treatment 183 tient must never be permitted to exercise under any circumstances if we can prevent it, and I wish to say this with all the force possible. For those without ievev there must be a change in exercise and occupation. The effect upon the human body of a change in activities, work, and scene is remarkable. It rests the tired brain powers and the tired muscles, and puts the strain on muscles that have been little used and on mental powers and forces that ha\e been resting for long. That is to say, it shifts the load. If you carry a heavy load on one shoulder until it is tired, and can then shift it to the other shoulder, it rests you and gives a great sense of relief ; it not only rests but it strength- ens you, and enables you to conserve power. The same is true of mental and nervous experiences. We are creatures of custom as to work and rest. We rest usually one day in seven, and work per- haps eight to twelve hours out of the twenty-four; business and professional men often work fifteen hours. We eat three times a day and sleep about seven or eight hours, and are in bed a little over eight hours. These are habits grown out of experi- ence, and fit the needs of the well. We must start out with the postulate that all this ought to be changed for the average tuberculous patient. From ])eing recumbent eight hours in the twenty-four, he must recline twelve or fifteen hours; for bad cases, 184 Tuberculosis the longer the rest and the more complete it is, the better. He must, if poorly nourished, change his eating habits to four or six food doses a day, with corresponding changes in his dietary. He must un- derstand that he is not like a well person, and must have some rules of life that nullify certain of the customs of society. Ordinary house-air, and especially bed-room air, in\-ites tuberculosis, and fosters it when present. We all breathe too little good air. The house-air usually contains more or less dust and bad gases, is lacking in oxygen, and contains too much carbon dioxid. Patients should breathe air as free from dust as possible, and constantly outdoor air, or as near that as can be had; and the night-air is the best of all, since it is the cleanest. Nearly all the benefit that comes of going to a resort for consumptives is due to the fact that the patients are placed where they breathe better and purer air. A primary purpose is to be much out of doors, Ijut almost the sole benefit from that comes of the purity of the air breathed. Nor should the inspired oxygen be reduced by breathing through reducers — little mouth-tubes that impede the outflow or inflow of air, and distend the air-vesicles of the lungs. Moreover, such de\'ices probably injure the lungs, as also do repeated pro- found unimpeded inspirations, since they both tend to put the diseased lung-tissue on the stretch, which General Principles of Treatment 185 is almost sure to do harm. It is substantially im- possible that a severe physical strain of tuberculous tissue can ever do good. Many of the patients have poor nutrition, take too little food, and often of the wrong kinds, take it in the wrong way, and have bad digestion almost constantly. A study ought to be made of each case, with a view to improving these conditions. How and when shall a patient take food, that the best digestion may be attained and the best use be made of such digestive power as he has and can have? The fault usually is that the tasks put upon the di- gestive organs are too large and too few. The patient may need to have food six times a day in- stead of three, and the portions to be reduced in size. The articles of food, the methods of orepara- tion, and the ways of eating may be wrong, and need to be changed in order to avoid discomfort and other symptoms of poor function. The dose of food should be reduced to the point where it will, if possiljle, l)e well digested, and the eating-times be as frequent as possible and not interfere with diges- tion. That is, the best use should be made of the power of the organs that make blood; and, weak- ened as they are by the tuberculosis, that power is best expended on small quantities of food taken fre- quently. The patient may have a pain in the stomach or 1 86 Tuberculosis bowels, and, if the pbysician is not careful, he will find himself prescribing bismuth or some other quiet- ing drug when the better remedy might be a change in the food or the dose of it, in the method of cook- ing or the insalivation of it, or the use, perhaps, of a little of some of the pharmaceutical aids to diges- tion. Discomfort in the bowels may be due to in- digestion or to lack of drainage, and the drainage from the colon may be deficient, notwithstanding a loose stool each day. For diarrhea astringents are likely to be prescribed when perhaps all that is needed is a careful attention to the regimen. If careless, one may prescribe some physic for constipa- tion, to be followed by worse constipation, when an enema or an intestinal tonic might serve the purpose and be followed by no ill-effects. It is curious how the moral and mental condi- tions of life, the daily worries, disturb these cases. Two sets of people may work side by side, and one set recei\'e a few cents more wages a day than the others, li\-ing perhaps on the same kinds of food, and under conditions similar in every other respect. But the poorer-paid set will have more sickness than the others, and have less resisting power when they are sick. So the mental state of the patient is al- ways a leading factor in his prospects. Often a change of climate relieves the moral monotony; but in advising a change, if a physician is not careful, General Principles of Treatment 187 he will toss his patient from the frying-pan into the fire. One may advise him to go off to a good cli- mate for consumption, and, in so doing, take him away from his friends, their care and sympathy, and, no provision being made to take the place of these, his disease may not only be unimproved, but may get worse because he is homesick and unhappy. The free stimulation in which your patient has perhaps indulged, and excesses of all kinds that have lowered his vitality, must be corrected. The patient is to have no excess in his life whatever; his life must be serious and tranquil, and may be happy. If a young man, he ought to live the life of a man of forty-five. The trouble with such advice to young- people is that they are mostly incapable of the en- joyment of the life of a person of forty-five, because they lack the mental perspective and capacity for the higher pleasures. Few people will ever have any such mental joys in the time before as they will after that age. Youth has no perspective; it cannot look back and see the relation of things, and so be able to weigh them ; and it frets and fumes about a lot of questions that it tries hard to settle. At forty- five the ripening of the mind is so much advanced, and mentrd pleasures are so much greater, that one who has reached that age in serenity is to be con- gratulated. He has the power to minify the carking effects of his sickness. 1 88 Tuberculosis We are apt to declare that a person in health does not need stimulation, yet we all indulge in it more or less. W'e drink coffee and tea and use tobacco (there are some who contend that tobacco is not a stimulant), and we take various forms of alcohol and numerous condiments. But the records of armies and life companies show that normally healthy people can live longer and endure" more without than with alcoholic stimulants. Probably this is true of all stimulants. If a person with tuberculosis has been in the habit of taking stimulants excessively, he should stop the excess anyway, if not the hal)it en- tirely. But such a patient who has never had the habit will often find alcoholic stimulants beneficial, if taken regularly as a tonic and in moderation. And if taken, a stimulant should be used with the same regularity as any other drug. There are some w'ho cannot take alcoholic tonics at all ; who get light- headed and red-faced, and are generally uncomfort- able on taking the smallest quantity. These persons have, I believe, less resisting power to the disease than those who can take alcoholics with comfort and benefit. There are numerous drugs that, taken internally, do various degrees of good ; they aid the functions of the body, and so the powers of life, and they are mainly tonics. But some are corrective of faults of secretion, of digestion, and of depuration ; some are General Principles of Treatment 189 really foods. Average the cases, and it is a truth that in the past too much medicine has been given to patients with tuljerculosis. The doses have often been too large, and the drugs have been given at random and without due consideration of symptoms. Great harm has resulted from the excess of the drugs, but far greater harm has come from the fact that reliance upon them has obscured the potent resources of hygiene that must always be the main- stay in the treatment of this disease. There are measures acting locally on the diseased resfion that are in certain cases useful. One of these is immobilization of the lung by inflation of the pleural cavity with nitrogen or air, according to the method of Murphy. This is applicable in incipient one-sided cases. Another is the use of adhesive straps or other apparatus for the same purpose, and applicable to such cases in all stages of the disease. Another method is partial immobilization of the dis- eased lung by muscular control on the part of the patient himself. The lymph treatments are of some value, but only a little. Like the use of drugs, these measures are only secondary. The climate treatment is, when properly used, the best of all the measures of l)enefit ; but it should never be prescriloed unless one is sure that it can be taken in the right way and be attended 1)y all the aids that are otherwise available. Many times it is 190 Tuberculosis worse than useless. The patient in any climate must be properly fed, housed, clothed, and warmed. It is just as important that he should have contentment and mental peace. I would rather have a patient kept in the outskirts of an Eastern city (or even in the heart of the city), under good hygienic manage- ment, sleeping in tlie best air obtainable winter and summer, and with his friends and comforts about him, than to send him to some better climate to shift for himself and be lonesome and homesick. If a patient can have all the conditions for happiness in the new country, then the right change of climate is a thing of paramount consequence; but to send him away to a strange region to shift for himself, and perhaps to do a hundred foolish things, is worse than useless. He may be instructed in detail how to take care of himself, and he may strive to follow the directions implicitly; but even if he does so for thirty days, he is almost sure on the thirty-first to do something that will pull down all the good he has done himself. Explicit directions of caution can be observed to the letter in a sanatorium, and if the patient is subject to daily watchfulness or is under the care of a competent nurse; but almost never when he is left to care for himself, and sub- ject to all the conflicting and manifold advice of officious neighbors. It is never safe to regard a case of tuberculosis General Principles of Treatment 191 as permanently cured simply because the symptoms have disappeared. A long time must elapse before healed ulcers and closed-up cavities can be trusted as being beyond the danger of easily breaking open again. Scar-tissue must become hard and quiescent, and a year at least is required for this to occur — and that after all evidence of progressive disease in the tuberculous focus is gone. Nor is it always safe to rely on the appearance of recovery from this disease in the lungs, for active disease or pus drain from some other part of the body may cause a tem- porary abatement of the lung symptoms without the slightest progress toward actual recovery of the lung. Cough and expectoration may subside and rales disappear by the influence of a diarrhea or a suppurating sinus in some other part of the body, or a chronic non-tuberculous inflammation in a dis- tant organ. Even the condition of pregnancy may cause a nearly complete cessation of symptoms until parturition is over. Then the disease generally flares up and makes rapid progress, usually to a fatal termination. These general principles will be elaborated and enlarged upon in the chapters to follow. CHAPTER XII TREATMENT, HYGIENIC The hygienic treatment of tuberculosis is the most important of all. This means the putting of the patient under such health conditions as to pre- serve and conserve to the utmost his forces of life and his resisting power to the disease. In carrying this out it is important that we should give definite and detailed rules as to what the patient is to do, how he is to care for himself, the food and drink he is to take and the times for taking, the hours to be spent in bed, the hours out of doors, and the things to do and to omit, and all matters of ventila- tion, clothing, excretions, and the care of sputum. Left to himself he will not follow good hygienic lines much, and relying on verbal directions he may forget ; hence written and minute directions are often needed. They may now and then save a patient's life. At successive visits it is vastly more important that we should inquire if the patient has carried out his hygienic rules than if he has taken his medicine. When variations in the symptoms occur that are unpleasant or ominous, we can often help him better by changing some detail of his management than 192 Treatment, Hygienic 193 by changing- his drug treatment. Furthermore, if we lay special stress on the importance of these rules, the patient will probably follow them; other- wise he is likely to forget and to become careless, and do or omit things that may put him back a month in his recovery, or directly hasten his death. In sanatoria great account is taken of such details, and patients come to think of them as more vital than anything else — more even than their own physiologic forces. Wc can as truly impress these ideas on patients living in their own homes if we are in earnest and insistent, and if we are patient and persistent. In carrying out this treatment, tranquillity on the part of the patient and a great deal of rest are among the most important measures. A patient with fever must be kept horizontal for at least three- fourths of each twenty-four hours. It is often best to keep him in bed for some weeks continuously; and he must take his vertical life in two to four periods each day, so that he is never up for long at a time. Exercise, even the little involved in the erect posture for an hour at a time, increases the temperature of a fever patient. Given infection enough to produce even slight fever, and a small amount of exercise is capable of increasing it. The patient must be guarded from distress of mind as well as body. If things worry him, it is 13 T94 Tuberculosis just as bad as if he exercised physically; it will send his temi)erature up. To give him the best hope he must also be free from nostalgia, for that is as bad as exercise. He must not be worried, but cheerful ; he must l)e a philosopher about his own case, and take enforced idleness gracefully; and this last is probably the hardest lesson that he will have to learn. For a tuberculous patient with no fever, a mod- erate amount of exercise is proper; but never for the purpose of developing muscle, as that term is usually understood ; never because it is a duty ; solely because he feels like it. You get uj) in the morning and stretch 3'our muscles because it makes you feel good to do so; you take a walk because every step is a joy. Your non-febrile tuberculous patient may exercise on that l)asis with propriety, but should never carry it to the extent of the slightest fatigue that is not promptly recovered from by brief rest. Many a time the patient will not be aljle to sleep ; he will fret and fume because he cannot, which al- ways increases the wakefulness. For this symptom drugs are to be avoided if possible, unless the sleep is broken by dry and unproducti\'e cough. A potent remedy for nervous insomnia is for the patient to re- solve that he does not wish to sleep and will stay awake, and in nine cases out of ten he will drop into slumber in a few minutes. To sleep well one must be Treatment, Hygienic 195 tranquil and untroubled; and if he sincerely resolves that he prefers not to sleep, but to lie awake and perhaps read an unexciting book, that mental atti- tude makes him tranquil and invites drowsiness. A hot-water bottle or a hot foot-bath for cold feet will often induce sleep ; as will an enema for a loaded colon, or a drink of sodium bicarbonate solution for a sour stomach, or of warm milk for an empty one. The thing that a physician will find most difficult to bring about with such patients is the outdoor life. That is nearly if not quite as important as the rest of body and mind, and it is the chief factor of benefit in nearly all the climatic influences that come to these patients — the outdoor life, the breathing of fresh, pure air, and the getting of some sunshine. The sunshine is extremely valuable, but less so than the fresh air. There may be elements in the outdoor air that are valuable besides the due amount of oxygen and the freedom from contamination, but we assume that these are its chief advantages. We had thought for a century that we knew all that the atmosphere was composed of, and all the advantages of a pure air and all the disadvantages of an impure one. It was left to the last decade to discover in the air the new substance argon, of whose influence on animal I)hysiology we are completely ignorant. Other ele- ments may still be discovered that possibly will fur- 196 Tuberculosis ther explain the great influence of slight changes of the atmosphere on the human Ixxly. Patients should religiously kee^) away from indoor crowds, whether in theater, hall, or church; for there they always breathe the worst possible atmosphere. There is no doubt of the great value of outdoor life to these patients, and it must l)e mostly due to the better air they breathe. It has been found prac- tically impossible to ensure in a house or a hospital ward, wdth any attainable provision, a constant at- mosphere that does not contain at least twice as much of those contaminations harmful to man as are found in the outer air. This is a sufficient ex- planation of the great benefit that patients experience from living out of doors. It requires a great deal of preaching and persist- ency on the part of the doctor to keep some of the patients out of doors. They will hesitate, fear they will take cold, declare it will kill them ; and gen- erally fail to appreciate the vast importance of this measure. Even when one has consented to try to do it, the art of staying out of doors is one that has to be learned. Especially is this true when the weather is cool or cold. A man told to be out of doors say for ten hours a day \\\\\ sit on a porch if it is warm and agreeable ; but if it is cool he wdll think he must walk constantly or ride horseback to avoid Treatment, Hygienic 197 feeling chilly. The horseback riding is beyond most of the patients, and even that exercise, indulged in for hours, is tiring to the sick, so that most of them, left to themselves, will walk and walk to keep warm. They thus get themselves tired and worn out, and often bring on fever, to their harm. Yet these very people find it natural and comfortable to ride in an open carriage on the same cool days that they would fear to sit on a porch. It is one of the curiosities of the psychology of invalidism that it never occurs to the patient, unless he is told of it, that he can wrap himself in warm, thick clothes, put on mittens and overshoes, and put a heavy lap-robe about his legs and feet, ex- actly as he would if going driving, and sit or lie on a porch or on the ground for hours, and get all the advantages of a carriage ride safely and without its expense. The physician must go into all these details with patients, and many times over if nec- essary, to help them to the benefits of outdoor life. The delicate patients should lie on a cot or a reclin- ing chair, as their condition requires. Some of the patients are so literal that they will try to carry out their directions regardless of all variations in conditions, and often make themselves very uncomfortable in consequence. Told that sun- shine is good for them, tliey will take it in its in- tensity every hour of the day. The patient should 198 Tuberculosis lie or sit in shade or sun as his comfort requires. He must, if possil)le. be comfortable at all times. I have often seen a consumpti\e torture himself for hours jjy sitting in the hot sunshine, l)ecause he sujjposed it was his duty, and had n(>t the acumen to know that all prescriptions for the sick are to be taken with some measure of common sense. A tubercul(jus patient ought to sleep with a slight zephyr of air moving over his face. The physician may be accused of recklessness and cruelty in advis- ing such a thing, but the fact is that one can sleep out of doors with the wind blowing over his face at any time witliout taking cold, provided his body and head are warm. If these proper precautions are taken, you may defy any patient to take cold. Most patients can be educated to sleep in the open, to the point where they will feel lost without a little movement of air over their faces. Soldiers sleep under tents or trees, or out under the sky with their blankets wrapped about them, and rarely have colds. Let them go home and sleep in rooms with closed windows, and they will soon begin to sneeze and cough. If a patient sleeps in a ^■ery cold place or in the wind, he should wear a night-cap. The best kind is a knitted jersey affair that may be easily drawn over the head. If it is \-ery cold, he should sleep between woolen blankets. lie must be so wrapped Treatment, Hygienic 199 up and protected that he can sleep with the tem- perature at zero without discomfort. After he be- comes adjusted to it he will thank you for the de- lights that you have led him to. Occasionally, if an afebrile patient feels cold, he will have what he terms rheumatic pains; they are generally merely neuralgic pains, mostly in the muscles, and will rarely occur if the patient is constantly warm, unless his digestion is out of order in some way. The patient sleeping in a cold room should, if possible, have a warm place in which to dress, al- though this is not indispensable, provided he has good vigor and is able to dress rapidly. For the weakly ones with poor blood-making powers, who tire and breathe rapidly on exertion, we ought to invent clothing that requires little change on rising from bed. For this class of patients of both sexes the ordinary day clothing involves a wickedly use- less waste of time and strength and heat in being put on and taken off. /Vny nurse or patient can devise a set of garments that will considerably minify this waste, provided the patient will pocket his pride and forego his ambition to appear dressed (and in bed even) like well people. The day garments should be fewer, simpler, and looser than is fashionable; they should more resemble the bed garments ; and some of them may be identical with the latter. There is no law against wearing thick pajamas both in and 200 Tuberculosis out of bed ; and a single long, thick gown will cover and protect the body both in and out of bed. The common multiplicity of garments is, like appetite, something provided for the well ; for the sick they may be a grievous and a useless burden, as they al- ways are in the face of cold and fatigue. Clothing should be simple and loose, should, if possible, cover the body equably, and should give a sense of warmth, not one of heat. Chest-pro- tectors and alxlominal bands are not to be advised unless the patients like them. No tight clothing should be permitted ; corsets are usually a nuisance for a tuberculous woman ; and tight collars and shoes and heavy head-gear should be tabooed per- manently. There is a vast amount of useless cough at night, by some patients, due to the fact that the clothing over the neck, shoulders, chest, and arms is thinner than that worn by day. This should never be permitted ; more rather than less should be worn at night. The quantity of clothing is a great bone of con- tention with many of the younger women patients and a few of tlie younger men. They often de- clare that they are wariu and feel warm, even in cold weather, with garments so few and so thin as to terrify their mothers and sometimes their doctors. They make this declaration, too, when their hands and noses are blue with cold ; yet they protest their Treatment, Hvsfienic 201 fc) candor, and that they have no sentiment against more clothes. In connection with such cases, it is well to remem- ber a few truths of human nature as well as of human pathology. One is that we rarely take cold solely from lack of clothes, but often from debility, fatigue, indigestion, and lack of excretion from the body. These thinly-clad youths do not often appear to suffer injury solely from their cold extremities and noses, lout they do from other conditions named. Then, it has a harmful influence on the spirits of such a one to nag her perpetually about her clothes ; it conduces to spiritual rebellion and consequent failure of digestion and sleep. She might, perhaps, be better off developing the qualities of the aborig- ines as to her clothes, than have dyspepsia and insomnia. On the other hand, it is perhaps true that such lack of clothing may bring on or hasten Bright's disease in a tuberculous patient. It is better to have the skin warm and near the sweating point, for the sake of its function as an excreting organ. On the psychologic side it is true that vanity and foolishness as to appearances control many of these simple people without their consciousness of the fact. They fil) about tlicir sensations as easily and as blindly as a girl denies that her corset is tight, or a boy that his shoes bind or that his 202 Tuberculosis collar is uncomfortable. Besides this, it seems to be a normal mental trait of many sensitive unathletic women to hate physical sensations of warmth and of perspiration. It is a quality of the neurotic, is temperamental, and can hardly be argued out of a woman. But the excessive touchiness to a sensa- tion of heat produced l)y clothes is to a large degree one of unnecessary sentiment ; even neurotics get over it easily if they find the clothing is inevitable. I suppose it is an uncontrovertible truth that any severe strain on the system to maintain its body heat in cold weather may lessen its power to resist tuberculosis. So it is best to insist on a proper amount of clothing, even if it does cause some little mental anguish. It is not important that the skin clothing should always be of wool, contrary to the general impres- sion, although this is a most proper fabric. Silk, cotton, and linen will do well enough, if they are woven loosely, so as to contain many air spaces. The question of baths is a worrying one to some consumptives. Many good people seem to feel that they are guilty of a mortal sin if they do not wash their bodies all over e\'ery day, and that somehow if they are always clean they have a right to expect to be well ; also that the something called the stop- ping of " the pores of the skin " is fraught with the most dire consef|uences, which baths prevent. Treatment, Hygienic 203 Unfortunately, no such theory will stand ; for many very filthy people seem to get on quite as well as those who bathe e\'ery day. And no stop- ping of the pores of the skin by any ordinary un- cleanliness of the surface seems able to interfere with the free flow of perspiration whene\'er the conditions are otherwise favorable for that function. Yet it is probably true that a daily bath is benefi- cial to a moderate degree, provided it does not tire the patient unduly or chill his body too much. It carries away some of the superficial epithelium, and in the taking of the bath some manipulation of the surface tissues is produced which has a good effect. But the bath never can be reckoned as of much value when compared with proper food, rest of the body, and a supply of pure air and other physical comforts. Well-selected tonic medicine is worth in- comparably more than baths ; and when the bath is taken at the expense of needed physical strength, as well as when it leads to shivering of the body from cold — often lasting for an hour — it is worse than useless and ought not to be resorted to often. It is rational to suspect that, by reflex action, stim- ulation of the skin to just the necessary degree by baths containing some stimulating substance, such as mustard, capsicum, or carbon dioxid, might do good if it were to be used regularly and for a long time. But this cannot be asserted until lone' and 204 Tuberculosis careful trial has shown it to be true. Unfortu- nately, most of the experimentation with baths has been clone by specialists in hydrotherapy — a circum- stance not conducive to unbiased reports. Rubbing of the skin thoroughly with a coarse, dry towel is a measure nearly or quite as conducive to good hygiene of the surface as any bath, while it is safer for most consumptives. One of the very important things is the diet. The patient, if at all del)ilitated, must eat oftener than usual, preferably six times a day. One need not dignify all these eatings as formal meals, and the patient must be disabused of the notion that he is expected to eat a great deal each time. He may not be asked to eat a total of more than he has taken in his previous three meals, but it must be distributed over six doses. And he must l)e forbidden to take at any time a large meal, as that might provoke an indigestion from which he could not recover in weeks. He should take an early breakfast, eat again in the middle of the forenoon, at noon, mid-afternoon, at nightfall, and before going to bed. Many will declare that they have no appetite; that they cannot swallow food so often; that they will surely Ijecomc bilious, or that tliey will \-omit. But such fears are mostly groundless. If the pa- tients trv to eat six times a dav. thev usuallv succeed. Treatment, Hygienic 205 They soon find that they can do it with as much ease as they formerly ate three times, and that they take considerably more in the aggregate. Most of them even come to like this way of taking their food; it helps them to learn that the thing called appetite, which is nature's device for well people, is not necessary in order to take a small amount of food, and that they can even ignore it. Most squeamish patients eating three times a day have a poorly selected diet. They follow their whims, and so take many articles of low food value, like fruits, salads, green vegetables, and ices. At least they often do this for two meals each day, while for the other they eat inordinately of hearty foods, and in conse(|uence often get indigestion. Eating from four to six times a day removes the temptation to over-eat at any meal, and abolishes the pathetic struggle to find something to please a mor- bid appetite to which the patient instinctively thinks he must cater. He now eats as a matter of routine, and even forgets whether he has an a])pctite ; that emotion becomes a negligible element in his daily life. The articles of food are important and should be insisted on. Four common articles are about all that is necessary — bread, meat, eggs, and milk and its products. Breadstuffs or starches should consist of stale bread or crackers, toasted if pre- 2o6 Tuberculosis ferred, and, as a rule, eaten with l)Utter. There is no need of rice, potatoes, or mushes of any de- scription, although there is no necessary objection to them if they can be well insalivated. This latter is a difficult thing to do with any mush, and the bread should be eaten dr}' and stale, so as to en- courage a free How of saliva. Almost any tender meat is proper. The eggs should be soft-cooked or raw. The milk may be raw or pasteurized (r6o° F.), never sterilized (212° F.), and may be com- bined in numerous mixtures. These four articles are all that the human body needs, provided some of the milk is taken uncooked. If the milk must all be cooked, then it is better if there is a little fruit or some vegetables taken each day to ward off any tendency to scorbutus. Patients will frequently object to what they are likely to call such a restricted diet; but it is not restricted. A vast dietary may be made out of these four articles. A dozen kinds of meat are possible. Rare or raw meat is the best, and some recent ob- servers have offered evidence that raw meat is inim- ical to the growth of tubercle bacilli in the human body. Whether it shall be shown that this is always true, or whether the benefit is because the raw meat is more easily digested, there is certainly little or no objection to taking raw beef. It should be chopped fine, and it may be flavored in any way Treatment, Hygienic 207 to suit the taste — with salt and pepper, or mixed with nutmeg, allspice, cinnamon, lemon-juice, or anchovy, and spread thin between slices of dry bread in sandwiches. Patients come to enjoy it in this way. The eggs may be cooked rare in a variety of forms, the curdled egg^ being the best, or they may be taken raw. One of the best forms is an egg-nog which combines milk and sugar with a moderate dose of some alcoholic stimulant. If this is properly prepared and flavored to the taste of the patient, he will usually relish it, especially if it is cold and taken through a straw or a glass tube. The best flavor is perhaps produced by one part of rum and four parts of whiskey, a tablespoon ful be- ing used to a glass of the mixture. ]\Iilk may be prepared in many forms, and stale bread may be made to appear in many different ways for the sick. You must resort to various devices to make your patients eat. Many will declare that they cannot take milk — that it causes l)iliousness and leaves a disagreeable taste in the mouth. But the latter can be rinsed out of the mouth with a little water, perhaps flavored with something. Most patients can digest milk if it is taken in small drafts — that is, a teaspoonful at a time. lAn egg is "curdled" by being dropped (unbroken) into a small kettle of boiling water, wbicb is at that instant taken off the stove and set on the hearth. In five to eight minutes it is sufficiently cooked. 2o8 Tuberculosis A bili(Uis suljject slioukl never drink niiik in quantity, as it may form a mass of curd in the stom- ach ; he should take it broken up in the way de- scribed, or, better, with some breadstuff eaten with it or between its mouthfuls, so as to dihite it. A Httle cooked starch — a small teaspoonful to a pint, as advised by Prof. \V. S. Haines — or a cracker crushed and mixed with a pint of milk will pre\'ent its forming into hard curds in the stomach. The same purpose may be helped by a little sodium bi- carbonate taken just before eating-. The taste of milk may Ije changed by the addition of charged seltzer water; and if there is any danger that it is not in prime condition, it should be pasteurized by being heated to i6o° F., but it should never be boiled. Slightly sour or clabbered milk is some- times relished and is altogether wholesome ; but- termilk is a delightful thing to many invalids; and koumyss is another eligible form of milk. With a majority of tuberculous patients specific directions must be given about the taking of food as well as about the food itself. Then the physi- cian must not stop with prescribing the right diet and the right kind of eating, but must aid digestion, both of the proteids and the starch foods. For the former nothing is so good as pepsin with hydro- chloric acid taken soon after meals ; but for certain patients papoid and pineapple-juice are decidedly Treatment, Hygienic 209 beneficial. For the starch foods there is perhaps nothing better than taka-diastase and diazyme. For patients with too much acid in the stomach, as shown by eructations of acid fluid or otherwise, an excehent thing is a dose of 20 to 60 grains of sodium bicarbonate dissohed in half a glass of hot water, and taken preferably half an hour before a meal. It is proper, however, any time after eating, Avhen the proof of a sour stomach is present. Flot water helps many of these patients with their di- gestive troubles, a glassful being taken in sips shortly before a meal. Like the soda, it seems to aid the stomach in freeing itself from the debris of a previous meal, probably by coaxing the pylorus to relax. Lavage should be tried in all cases of persistent gastric indigestion in tuberculosis. IMany of these cases have an excess of acid, probably pyloric spasm, and consequent gastric dilatation, which this meas- use is potent to correct. I ha\e known cases to recover under the use of lavage, that seemed to be doomed to die until it was resorted to. The stomach should be washed out e\-ery day if it seems best, even oftener than once if recjuired, although once is usually sufficient. Sometimes great relief is found in a lavage every second or third day. The best time for most cases is perhaps two or three hours after the last meal of the day. 14 2IO Tuberculosis By the lavage the particles of undigested food and more or less mucus are evacuated, the stomach is collapsed, and the patient generally sleeps better for it. He gets up hungry, to eat well the next day, taking six meals and digesting them. Many of the cases grow better daily after the lavage is begun. But, of course, in some instances no benefit results even after several trials; then it should be promptly abandoned as a treatqient, for it is the rule that any benefits from this measure are experienced rather promptly. Many consumptives have trouble with their bow- els — sometimes very annoying ones (not due to tuberculosis of the intestines), that retard or prevent their recovery. It may take the form of pain, flat- ulence, constipation, or diarrhea, or these last two conditions may alternate e\ery few days. True chronic intestinal catarrh may exist, with all its attendant conditions. This trouble not infrequently is due to lack of drainage of the colon and sigmoid, hecal matter is retained in the pockets and tortuosi- ties of these parts until it provokes diarriiea, after which constipation returns. Sometimes the patient takes a dose of physic to relieve the bowel, and this produces diarrhea, to be followed by worse consti- pation than before. This state of things is, of course, inimical to good health and good digestion. It too often produces ischiorectal abscesses and re- Treatment, Hygienic 211 suiting fistulse, which rarely heal if the vitality of the body is low. The best remedy for the condition is daily rather large warm enemas of normal salt solution (a heaped teaspoonful — 130 grains — of common salt to a quart of water) to wash out the descending colon and sigmoid, if not the entire large intestine. It will frequently stop a diarrhea, proving it to have been due to some retention in the large bowel, and stop the nagging discomfort of colicky pains that so often attend this disorder. At the same time it will often improve the condition of the stomach in respect to both its sensations and its digesting power. The enemas should be used rather warmer than the body temperature — 100 "^ to 105° F. (110° does not hurt the body), and can be used without danger. It is not always possible to use them, as they occasionally disagree with the patient in some way (most often by an absurd attempt on his part to retain the Ihiid for some time against a nor- mal impulse to expel it) ; and we daily encoun- ter the popular fallacy, as senseless as it is ground- less, that there is danger of forming something that may be called " the enema-ha1)it," and that will continue through life and l)e fraught with some dire calamity. If enemas are a comfort to the patient and help his digestion, they should be used 212 Tuberculosis regularly; if they are not, they must be abandoned, but no whim of the patient, nor his esthetic squeam- ishness about taking them, must stand as an obsta- cle for an instant. The presence of tuberculosis of the intestine is no l)ar to the use of enemas, pro- vided they relieve discomfort and aid digestion. Massage is fre(|uently beneficial in tuberculosis. It takes the place of exercise, and may be comfort- ing to the patient. But the skin and muscles are often sensitive and tender ; hence manipulations must be gentle and brief. Light rubbing of the skin with alcohol, or with oil after free washing with soap or alkaline water, may comfort the ])atient and do some slight good. There was a time when we felt sure that oils rubbed into the skin Avere to a large extent absorbed and so might nourish the system ; Init the experimental work of the labora- tories seems to have proved that view to have been delusive. We now rub the skin with oil for the comfort of the patient or the good of the skin itself, and rely on the digestixe canal to carry nutriment into the general system. Light massage in one form or another may be beneficial because it di\'erts the patient's mind from his disagreeable thoughts and sensations, and takes the place of exercise which he is perhaps forbidden to have; and because it is good for the skin and is some help to nutrition. Nor should it be used upon Treatment, Hygienic 213 a part of the body that is tuberculous. Therefore all swollen joints, glands and other tissues, whether tender or not, should be avoided in such manipula- tions. Just the contrary is the tendency of nearly all who are engaged in giving massage. Many of them seem possessed of two cardinal and most erro- neous notions : one, that they are in duty bound to rub out every pain and force away every swell- ing ; and the other, that they are physicians, although they protest the contrary. CHAPTER XIII THE MANAGEMENT OF THE DISEASED LUNG The hygiene of the diseased lung itself is a sub- ject of great importance. The wise and useful practice of the profession in treating ah varieties of tuberculosis, except that of the lungs, has been to put the part at rest so far as possible. Just the opposite course has oljtained in managing the lungs. The almost uniform practice has been, as soon as these organs become tuberculous, to urge the patient to take repeated deep breaths and " expand the lungs." Various exercises have been prescribed to this end. Little tuljes have been used to breathe through, the expiration being made under pressure, so as to stretch the air-vesicles as much as possible; and both patient and doctor have been proud if the measuring tape has shown an increase in the cir- cumference of the chest. All these methods are harmful and wrong. There is no proof that the lung is an exception to the rule that tuberculous organs do best when perfectly qui- escent; and there is nnicli evidence to the contrary. A diseased lung needs to be ])ut to rest so far as it can 1)e. To this end there should be no deep breathing unless ,the affected lung can be put to 214 The Management of the Diseased Lung 215 rest and the work of respiration be done mostly or entirely by the well one. Any obstruction to the outflow of air is certainly harmful, since it does violence to the lung-tissue; and no tuberculous lung should ever be allowed to expand and grow larger. Even cough should be suppressed when- ever possible, in order to avoid the stretching and injury to the diseased tissues. One of the results of violence to an ulcer on the surface of the body is to increase the amount of scar-tissue. The smallest scar forms where clean and sterile surfaces are brought together and kept still. If you prod a sore every day you should expect to see it heal slowly and with a large amount of new connective tissue that will contract after- ward. The tuberculous lung heals, if at all, with more or less new connective tissue (l c. scars) around and in the midst of the diseased area. That is na- ture's way of cure and we call it " fibrosis." The new tissue contracts after the cure, and causes more or less narrowing of the lung. The process is pre- sumably conservative; but if too much fibrosis oc- curs, the contraction cripples the lung and may itself destroy life. The irritation of the disease starts the deposit of new tissue, and the great de- sideratum is to have as little fibrosis as possible consistent with cure; that is, to have a minimum of damage to lung-tissue after recovery. 2i6 Tuberculosis There can Ije little doubt that, other things being equal, the amount of fibrosis bears some proportion to the measure of \-iolence or motion to which the lung tissue has been subjected during the disease. If this is true, it is our duty to minify or abolish the motion of the diseased lung. The only way to abolish it \vh(j]ly is to inflate the pleural cavity with sterile air or nitrogen gas after the manner of Mur- phy. This treatment is applicable to the incipient cases of unilateral tuberculosis without adhesions. The effect of it is to collapse the lung and stop all of its motion ; then the pus that gets into the bronchi by the gentle pressure of the tissues flows out mto the trachea, to be coughed up by blasts of air from the other lung. The diseased lung thus put to rest often recovers. The treatment is attended with little pain, but the process of inflating the chest seems rather for- midable, and most patients shrink from it. The gas is gradually al)sorbed, so that after a number of weeks a fresh inflation is usually needed. Some- times three or four are required before the cure is complete. The patient experiences after the in- flation the same sort of dyspnea that comes when a pneumothorax occurs suddenl)-; 1)ut this is rarely severe enough to make it unsafe for the physician to do the operation in his oflice and allow the patient to go home after an hour's rest. If the air or gas is .The Management of the Diseased Lung 217 sterile, no infection takes place in the pleura ; but an effusion of serum is an occasional complication of the treatment. The necessary instruments are few. A rather large aspirator needle attached to a long rubber tube, to the other end of which is fixed any appara- tus for drawing air through a large tube containing sterile cotton for the purpose of filtering the air, would do. A better plan is to have a cylinder of compressed sterile nitrogen gas that is let out into a little gasometer of one or two quarts' capacity, to be thence let into the chest. By this means the exact amount of gas introduced can be measured. It should be allowed to flow into the chest without any special pressure until the pleural cavity is fully inflated. The needle should be sterile, and it as well as the tube, should l)e filled with the sterile gas ; then the needle may be plunged into the chest-wall at the common point of election for aspiration of the chest, and deeply enougli to reach just be3'ond the chest- wall. A deep inspiration usually starts the inflow of gas and begins the separation of the pleural sur- faces. The instant the gas begins to flow rather freely, the needle ought to be pushed deeper, to make sure that its point is carried fully Ijcyond the wall of the chest, so as to prevent any subcutaneous emphysema — a thing that frequently happens. It 2i8 Tuberculosis can be pre\'ented to some degree by the after dress- ing of a hard pad (a roll of bandage lying parallel with the ribs is a good one) held firmly against the chest-wall by a stout bandage around the body. If the needle at first is pushed too far, it will enter the lung, draw blood, and fail to let air into the pleura; then it must be withdrawn slightly. The results of this treatment are not all that was at first hoped for it, l^ut they are such as to stamp it as an eligible operation, and to add to the proof that effusions of serum and pus in the pleural cavity had already given us — that the putting of a tuberculous lung to rest is good treatment for it. But the inflation treatment will probably be used in only a very limited number of cases. It will liave to be restricted to (i) incipient cases of (2) one-sided disease, where there are (3) no adhesions, where (4) the patient will consent, and where (5) the doctor is prepared and w'illing to administer it. These conditions restrict the proportion of cases greatly. The vast majority of patients can never have the treatment, and these require rest of the lung as truly as any. We can put the lung to partial rest by a variety of measures, always assuming that there is one sound Iuii£j to breathe with. One of these measures is to repress cough by personal effort, especially the useless cough. This The Management of the Diseased Lung 219 can be done to a large extent by the wih of the patient. He can try to prevent the cough except when loose phlegm is present in the trachea or large bronchi, and can succeed half of the time ; the other half of the time he can prevent the intense, hard coughing efforts that are preceded by deep inspira- tions. The process is psychologic, and it will suc- ceed often. There is a vast amount of wholly unnecessary coughing done by these patients at the l)ehest of tickling sensations in the throat, which, if the cough were suppressed for a moment, would disappear. Waiting for a few minutes, the phlegm becomes so loose as to be raised by a slight effort — sometimes by the maneuver of hawking. Spraying the throat with soothing solutions, as of a one per cent, solution of carbolic acid and menthol in albo- lene, or gargling with a weak alum solution, may help the patient to suppress the cough. The neb- ulizers are better than the spray machines for the oily medicaments, the particles of the latter being rendered more minute. Another method of great value in reducing the labor of expectorating is to cough at the end of a profound expiration. Then the bronchi, and cavi- ties if there are such, are partially collapsed, and through their narrowed channels a mass of a given size can be pushed out by half the force of air- blast that is usually required. To cough at the 220 Tuberculosis end t)f a deep inspiration is to increase the force and volume of air required to move a mass of pbleom toward the exit (since the air-channels are widened), and tul)erculous patients ought to avoid it as far as they can. Any patient who will try the two methods alternately and faithfully will be con- vinced of the value of coughing- at tlie end of ex- piration, may save himself considerable discomfort, may spare his lung-tissues, and thereby favor re- covery from his disease. We ha\e many of us long advised patients to cough, and to cough forcefully, so as to expel the purulent phlegm, on the theory that its retention produces fever. I am now satisfied that this is an error, for pus in a bronchus does not to any extent cause fever. It mav be long retained in bronchiec- tatic cavities with almost no fever. The fever- causing pus products are substantially always in cavities outside the bronchi, or in some of the wall tissues of the bronchi themselves, and beneath the mucous membrane. Another useful maneux'cr is, while horizontal, to lie on the well side, so as to have the force of gravity to fa\'or the flow of the phlegm toward the trachea, and thereby minify the cough. Some- times a whole night may tlurs be spent in sleep ^^•ilhnut cougli. tlic discharge flowing liy its weight into larger and larger tubes and partially drying The JNlanagement of the Diseased Lung 221 on their waUs without irritating them. It is loos- ened Ijy the activities of the morning and the tak- ing of fluids, which cause a shght flow of serum upon the mucous membrane; then it is all easily coughed up in a few minutes. The mucous mem- brane proximal to the lung lesion becomes in a measure tolerant of the presence of this morbid material, but the parts distal to the lesion are often so sensitive as to provoke a cough the instant any of the material invades them. A general habit must Ije cultivated of breathing quietly — breathing more rapidly, if necessary, but never more deeply than usual. There must be no public speaking or singing, as these exercises always strain the lungs, and experience shows that patients who indulge in them are injuied thereby. They are even worse than using the breathing tubes, which are sufficiently harmful. The diseased lung can be forced into partial quiescence 1)y means of adhesive bandages applied about the chest to minify the motion of the riljs on the affected side, with tlie addition sometimes of a wide band around the abdomen to restrict the excursions of the diaphragm. This is a method that has often Ijeen employed to limit movement w^iere, from injur}^ or neur.nlgia or inllammation, a side has been in pain ; and for that purpose it has been effecti\'e. It ought to be employed more in 222 Tuberculosis diseases of the lung itself, where quiescence always tends toward recovery. When it can be carried out with some degree of continuity, it will, I believe, materially assist in the process of recovery by short- ening the disease, lessening the amount of fibrosis, Fig. 3. Strapping the chest to restrict the action of a lung. (Rear view.) and reducing the tendency to amyloid degeneration of important organs from prolonged suppuration. It produces in many cases marked amelioration of some of the annoying symptoms, and the benefit is often instantaneous. It stops the rales and rhon- The Management of the Diseased Lung 223 chi that keep many patients awake and annoy them into frenzy; it lessens harassing and useless cough, often to a marked degree; it relieves the sensation of fatigue in the side that many patients complain of. They feel from it a sense of support of the side that is grateful. Fig. 4. Strapping the chest to restrict the action of a lung. (Front view.) The strapping is best done with rubber adhesive plaster, two inches wide, passed about the chest below the axilla horizontally, and extending two or three inches beyond the center line on to the 224 Tuberculosis \vell side. The lirst strip is best applied at the bot- tom of the chest, and the successive ones above this slightly overlap each other, so that when the dress- ing is finished the side of the chest is almost com- pletely covered. The arm must hang vertical as the strips are applied, for if it is elevated, the upper edge of the plaster is almost sure to cut into the folds of the axilla when the arm is brought down ; and to cover the space front and back above the level of the axilla, the strips must be placed diago- nally, spread out in a fan-shaped manner, those in front beginning over the upper end of the sternum and ending below the scapula of the well side, those in the back starting over the interscapular space of the well side and terminating beyond the ensi- form cartilage. Finally, two strips should be car- ried over the shoulder and brought down front and back to the lowest edge of the applied plaster, and be pressed firmly against it. The skin of the shoulder is easily irritated by the plaster, and would better be protected by a piece of cloth beneath it, for it is not necessary to have the plaster adhere to the shoulder ; its object is to prevent motion by holding the shoulder down by its pull against the transverse plaster lielow. Everv strip of the plaster nuist be applied with the chest in profound expiration, and, except over the shoulder, each strip should touch the skin first at its center, the tw^o ends being then drawn to place The Management of the Diseased Lung 225 at the same instant and pressed firmly until their adhesive material has taken a good hold. The plaster remains in place effectively for a variable length of time, depending on the heat of the surface of the body, the amount of perspiration and oil on the skin, the condition of the skin, and probably on other and not well-known conditions as well. Usually it requires to be taken off and replaced at the end of about a week. By that time the plaster has crept a little, and its tissue may have stretched a trifle also. The imprisoned skin, too, has perhaps begun to show some irritation. .\ few pimples and spots of excoriation may have ap- peared, and the patient may have been annoyed by itching. Dr. Charles Denison has suggested ingeniously that the shoulder of the well side be made a fixed point of attachment for the narrow ends of plasters, which are made some six inches wide at the part that covers the diseased side. This ought to prevent some of the creeping of the plaster ; and experience may show that the method will l)e tolerated well by the patient. iVfter the plaster has been removed, some simjile dusting powder may be applied for a day or two if the irritation is at all severe, when fresh i^laster should be put on again, and so on for many months. The skin, after the first few applications of the plaster, may grow tough, so that the annoyance 15 226 Tuberculosis is much reduced. But if the tendency to irritation persists, an adhesive plaster containing- some oxide of zinc may be used. This seems to agree with a vulnerable skin better than the unmedicated plas- ter, although it is rather more yielding. In remov- ing the plaster the least discomfort is produced when, after cutting the shoulder strap, the whole mass is peeled off together, beginning at the front edge and pulling back along the surface of the body, and not at right angles to it. A quick, firm pull startles the patient a trifle, l^ut really causes less discomfort than taking the plaster off slowly. When abdominal breathing is extensive, the effect of any fixation of the ribs by the plaster may be almost neutralized by the vertical motion of the lung. Then a rather firm bandage for the abdomen will be necessary ; but as most patients breathe almost wholly with the thorax, this will not often be required. For the purpose any simple firm cloth will do, w'hen pinned at half a dozen points. It does not seriously embarrass the al)doniinal organs unless there is inflammation or tuberculosis w'ithin this cavity. E\en when the diaphragm is fixed or almost motionless, fixation oi the ribs of one side l)y any means whatever cannot completely put the lung at rest, since the mediastinum will move slight- ly with each movement of the other side of the chest ; Init this is only a slight drawback to the value of the method here described. If it were not The ]\lanagement of the Diseased Lung 227 for the annoyance the plasters give the skin, I feel certain that this means of lung fixation would come into general use in unilateral cases of consumption. A better fixation apparatus is a perfectly fitting, unyielding jacket or splint embracing one side of the chest. When accurately applied and well fitted to the chest, it materially reduces motion, and is so far a most useful device. It has the advantages that it does not irritate the surface and that it main- tains a uniform degree of pressure continuously. Its drawbacks are : some difficulty in having it well made and properly fitted ; the repeated tinkering often required before it will fit firmly without an- noying some part or spot ; some nervous discomfort for a few days from a sense of imprisonment on beginning to wear it ; and at first the annoyance at having to wear it at night — for it ought to be kept on constantly, or nearly so, to have the best effect. A little patience and perseverance usually remove all these obstacles in a few days. The apparatus may be made of any liglit material, as thick leather or yucca wood, supported and kept in position by stout steel bands, which may be bent to fit the body after the manner of the steel of a truss. A plaster cast of the chest is necessary over which to fit the splint ; such a cast helps, but can never enable one to make a perfect fit for the chest in life and activity. More or less adjustment will probably always be necessary after the instrument 228 Tuberculosis is made, before it is both efficient and comfortable. Once adjusted properly, it can be worn for months without change. No one but a superior Ijrace-maker is capable of fitting- successfully such an apparatus as is here described. Fig. 5. Author's jacket for reducing the motion of one side of the chest (made by the W. W. Sweeney Co., Los Angeles, Cal.). This jacket is best worn over a smooth-fitting undergarment, which should be changed frequently. Even then, perspiration will sometimes dampen the lining of the apparatus, and it is sure to have at times a musty or sour odor. This can be corrected any time by heating it to a safe degree by cautiously The Management of the Diseased Lung 229 holding it for a few minutes over a fire, or over a kerosene lamp with a large flame. Finally, a resourceful patient can develop the power and create a habit of repressing to a moderate degree the action of the muscles of one lateral half of the chest, thereby reducing the motion of that side and rendering the lung relatively quiescent. It re- quires for a time almost constant minute attention Fig. 6. Author's jacket applied. to the subject, a good deal of \y\\\ power, and a peculiar mental control of the muscles, in order to be able to form thus a new habit in breathing. No very sick person has the power of attention that is required, and perhaps no one is capable of develop- ing the habit of one-sided breathing to such a de- gree as to carry it on perfectly in sleep. Probably few patients will ever succeed in using tlic measure to any great effect ; Init the effort ought to be made, and those who accomplish it deserve to recover. CHAPTER XIV TREATMENT, CLIMATIC One of the best of all treatments for pulmonary tuberculosis is a new climate — and the best climate for the disease. The best for the particular patient is usually some other than the one in which he contracted the disease. No climate is exempt from the initial occurrence of tuberculosis. The disease originates in all the " resorts " for its cure. If any place had such exemption, it would be the refuge for all people who suppose themselves predisposed to the disease; but certain climates are better than others for patients who have acquired it, and such benefits as they possess every patient ought to have if he can. There is a good deal of confusion, both with the profession and the people, on this whole subject, not only as to what are the best climates for consumption, but as to why and by what ele- ments any climate commends itself as a residence for those who have the disease. So far as our knowledge goes, there can be but a few elements involved in the variations of climate anywhere in the world. It must be a matter almost exclusively of the atmosphere near the surface of the earth, ancl includes the elements of temperature, humidity, 230 Treatment. Climatic 231 weight (Ijarometric pressure), motion, and purity of the air. The humidity covers much of the ques- tion of fogs and storms, and so of degree of sun- shine; and weight is concerned with that of ahi- tude; while temperature explains and defines much of the changeableness of weather. It is evident that altitude, latitude, and the presence of moun- tains and large bodies of water are the chief factors that determine the qualities of any climate. These elements given, and a careful study will almost certainly enable a student of the subject to say what the climatic qualities of a particular region must be, showing that there cannot be any very mysteri- ous quality in any climate. That is, the features of all climates are rational ; and it is rational that some should Ije more and some less fit for those sick with particular diseases. This is especialy true of pulmonary tuberculosis. There can be no question that one of the good effects of any climate to which a consumptive may go is its newness to him, and his hope and belief that it is to do him good. It is a change, and a change is per se beneficial. But there are certain qualities of climate in particular regions that spe- cially commend them to these sick people and make their lot in li\-ing easier. The one of chief value is mildness — absence of any disagreeable quality that is depressing to the patient, so that he not nnlv can. 232 Tuberculosis but is by the very weather invited to, spend much of his time out of doors. Outdoor hfe is the most valuable treatment of tuberculosis extant; hence any place where the weather makes it easy for the patient to have with comfort this surpassing remedy all the time, is salutary for this disease. And 1 have no hesitation in saying that the major part of all the benefits of climate for consumptives is due to this one fact; no other influence is at all comparable to it. But there are qualities of atmosphere that are valuable independently of mildness and purity. Chief among them are the low barometric pressure of altitude, and dryness. Low relative humidity of the atmosphere has long been held to be beneficial in consumption, and probably with good reason. The patients do better, other things being equal, in such climates ; and this is the best evidence of all. In the dryer air there is less expectoration, at first proljably due mostly to reduction of the watery elements of the phlegm, not so much to any decrease in the pus. If the pus is lessened at all, it is an advantage, since the formation of it for long periods is an injury to the system. And the reduction of cough is a good thing, because it is always more or less of a strain on the diseased lung- tissue, which ought to l)e kept still : if the cough is severe, the strain is considerable, and constitutes Treatment, Climatic 233 an amount of physical exercise that tires the system and perhaps elevates tem[)erature. The fever should be expected to be higher on days of a good deal of cough. Reduction of the cough and rest of the lung and muscular system tend to recuperation of the powers of the Ijody, and so less pus is finally formed, with less danger of injury from its absorp- tion. But not all of the benefits of dry regions can be due to the absence of humidity, nor are all the disad- vantages of so-called bad or poor climates for con- sumption due to the presence of it ; for some of the latter have at times as little moisture as some of the better ones. The arid regions of the United States — namely, Colorado, New Mexico, Arizona, and Utah — are reputed of great value for tuber- culosis because they are dry. The inland regions of Southern California enjoy a similar reputation, founded somewhat on their dryness. Patients are sent from the East and Middle West to these regions constantly, esi)ecially in winter; they are also sent from San Francisco, Oregon, and Washington. The actual humidity in these dry regions in summer is considerably less than that of the Middle West, but in winter the difference is less, and \'ery little. The regions of Lake Michigan, Minnesota, and the Dakotas show as little actual moisture in the air of winter as most of the arid regions. San Fran- 234 Tuberculosis cisco has less actual humidity than Southern Cali- fornia, averaging winter and summer, and in winter as little as many places in Arizona, New Mexico, and Colorado. In the month of January, for ten years, the foot-hills region of Southern California had two grains of water to each cubic foot of air, and Little Rock, IMemphis, and Norwalk had the same; but Milwaukee, Denver, Deadwood, Santa Fe, and Las Animas had only half as much, while Des IMoines, LaCrosse, and St. Paul had even less llian half; San Francisco had the same as Los An- geles, while Boston and Portland, Me., had 40 per cent, as much. In July, however, all the arid local- ities had a marked reduction as compared with all regions east of the Missouri River; Los Angeles had 25 per cent, more than San Francisco, but 11 per cent, less than St. Paul and Chicago. These facts show that there must be some quality of the arid regions other than the actual humidity that is important for the sick. That quality is the low relative humidity, the low percentage of actual saturation of the air for a large part of the time. It fluctuates with the time of day. In the night and early morning, with low temperature, it may be 90 to 100 per cent., while during the day and evening, with higher temperature, it may be only 60 to 80 per cent, of saturation ; yet the difference in the amount of water per cubic foot of air may be Treatment, Climatic 235 only the fraction of a grain, the increase Ijeing in the evening, when the relative percentage is lowest, and being due to increased evaporation during the day. Warm air takes and holds more moisture than cold air, and in geometric ratio as the tem- perature rises. The more moisture the air takes up, the lighter it is ; the vapor of water is therefore lighter than air. The thing the sick need most is such a degree of humidity and temperature as will give most com- fort, and most assist the powers of their physiology, and relative dryness often helps in this direction. Low relative humidity seems unavoidably connected with frequent or average high temperatures; but these latter are endurable if there can be free evap- oration from the body, and low relative humidity favors this, regardless of the actual water in the air; for evaporation does not depend on how much water the air contains, but on how much more it can take and hold. Radiation of heat from the body is easy with the temperature at 50° to 70° F. — /. c. 25 to 45 degrees below body tem- perature — regardless of humidity. If the air is nearly saturated with moisture and not too warm, it seems to our sensations soft and balmy; with much less moisture it is not uncomfortable and is more invigorating. Tn air relatively dry, perspira- tion evaporates rapidly and so reduces body-heat ; 236 Tuberculosis with tlie air at 50° to 60° there needs to be Httle perspiration unless there is free exercise; but, with the temperature 90'' to 100° or over, the perspira- tion is profuse, and must be carried off rapidly in order to keep the l)ody-heat down to the plane of comfort; and if the air is near saturation point, evaporation is reduced or abolished, and great dis- comfort as well as danger to pulmonary invalids is sure to obtain. There is a good deal of fluctuation in relative humidity at different times of the twenty-four hours in dry regions, depending on the temperature; and the temperature fluctuates greatly. As the temper- ature falls the saturation point is approached, and it is often reached or exceeded for a short time in the night or morning; then the moisture becomes visible in clouds, fog, or rain. And in dry regions the air is rapidly chilled by the most remarkable radiation of heat from the surface of the earth the moment the sun disappears in cloud or night. This phenomenon results from the marked diathermancy of the air due to its dryness. Moist air is an obsta- cle to the radiation of heat as well as to the trans- mission of light; the stars are brightest in a dry atmosphere. It is fortunate that the highest relative humidity of dry countries occurs at the time of lowest tem- perature, so that there is no discomfort from heat. Treatment, Climatic 237 When the air temperature is near that of the human body or above it, the relative humidity is so low that temperatures of 5 to 10 degrees above the body- heat are hardly noticed, so rapid is evaporation from the skin. Hence it is true that the perceptible tem- perature of the air may be very different from that shown by the thermometer. In dry districts the perceptible temperature is always below the reading of the instruments on hot days ; and once the United States Weather Bureau undertook to record the range of this difference, but it has been abandoned as being perhaps difficult of scientific measurement. There is no reason to think the daily brief ap- proach to the saturation point does any particular harm to the sick, provided they clothe or otherwise protect themselves against the cold; only they can- not safely protect against it by shutting out the fresh air even if it be loaded with fog. The fog- is a bugbear to many sick people, and there is a great popular prejudice against it; but it does little, if any, harm if people will only clothe according to the temperature. Fog may be disagreeable l)y the dampness left on the clfjthes and body, that must e\aporate and cause further coolness as soon as the sun warms the earth ; as well as by obscuring the sun. But the moment the fog appears, if it occurs in a warm region, there is often, if not al- ways, actually less water present than there was 238 Tii1)erculosis before; for the very force that usually ])rocluces the fog is a mass of cold air, low in dissolved water, rushing into and mingling with a body of warmer air containing much more water, so that the result is less actual humidity. We ought to caution all lung patients in dry cli- mates to so clothe themselves at all times, especially out of the sunshine, that they will be and feel warm constantly, except when they are chilly from the rising tendency of fever. This last no amount of clothing will prevent ; it is a false sensation due to tlie pathologic process set up by some absorbed poison. The caution about clothes is most needed by the ambulating patients who have but slight sensations of cold at night and in cloudy weather. They should wear all the clothes they can, without positive discomfort, not simply what they must wear or may think they need. A large amount of sunshine is desirable. The patients enjoy it if the weather is nut too hot, and it helps to keep them out of doors, which is the great desideratum. Rainy weather is objectiona1)le if the rain continues for many hours at a time, be- cause it keeps the patients housed, and prolongs the period of atmospheric saturation point ; the for- mer is bad, and the latter may be. That the latter is not necessarily and always bad is shown abun- dantly by a large number of recoveries from pul- Treatment, Climatic 239 monary tuberculusis in mikl and enjoyal)le climates on the sea-coast, on islands of the sea, and on ship- board. Santa Barbara and San Diego, in Califor- nia, not to name many other places, have furnished sufficient examples of this sort. While the balance of proof is in favor of a dry climate for consumption, the balance is not very large, for many patients have appeared to do better in moist and mild climates like those of the coast of Southern California and the north shore of the Mediterranean Sea, as well as out to sea in mild climates. Here the patients complain less of dry- ness of the respiratory passages and have less of the annoying, dry, and useless cough; and as the mildness permits them to live much out of doors, they are able to have the greatest benefit of any climate. Altitude has long been held to be beneficial in pulmonary tuberculosis, and probably with good reason. An elevation of three to fi\'e thousand feet above sea-level often starts a process of better nu- trition in patients who come from lower levels. The change sometimes begins an improvement that goes on to recovery. The reason for the benefit is a matter of some speculation. A favorite theory long held was that the more rai)id and deeper breath- ing required by the rarefied air expanded lung vesi- cles and so helped to cure the disease. But I be- 240 Tuberculosis lie\'e this theory is untenable, because it is no benefit to tlic diseased lung- tissue, but the contrary, to have it expanded extremely. It is well established now that as one journeys from a lower to a higher alti- tude the red corpuscles of the blood increase in number, there heing perhaps a slight reduction in their diameter. In the time required to travel cjuickly to the top of a high mountain the number increases by some thousands for each cubic mille- meter of blood. But not all the increase shown l)y the usual examinations of the Ijlood is real ; some of it is due to a rapid flow of the red corpuscles from the deeper vessels to the surface of the body.^ Such rapid changes in the blood elements are a hint of further changes as vital in the other physio- logic conditions, that can explain any l)enefit to the sick far better than a supposititious influence on the mechanics of the lungs, due to rarefied air. The cases that do best at high altitudes are in- cipient ones ; more advanced cases often run a rapid course to death. Where the lung-tissue is much crippled by lesions, whether of infiltration, cavities, or fibrosis, high altitudes are apt to depress the patients, and they had better go to lower levels. But the common fear of hemorrhage from the alti- tude is, I believe, quite groundless ; bleedings are as likely to occur at sea-level as at the mountain- 1 Campbell and Hoagland : " Tlic Blood-count at High Altitudes," .Im. Jour. Med. Sci, Nov., 1901. Treatment, Climatic 241 top. That is, no relative increase of blood-pressure is likely to occur at the seat of lesion because of the altitude. When the blood-vessel walls are invaded by tuberculosis and become fragile, the normal blood-pressure will cause them to break, and hem- orrhage will occur, whatever the altitude. Then the problem is to minify the damage and danger from the bleeding; but the bleeding to some degree will be inevitable. It is claimed by some that high altitudes induce great nervousness in invalids, and are for this reason objectionable; but I am satisfied that this danger is much overrated. Doubtless such an effect does oc- cur to some patients after a time, but it must be rare, and almost solely after a residence in the altitude for several months or years. The greatest benefit is probably experienced in the early months of resi- dence at an elevation ; and this good influence can nearly always be had before any bad effects come to the nerves. In the United States there is every variety of dry climate and all degrees of altitude, and these qualities are in many cases in combination. The highlands of Colorado, New Mexico, Utah, and Ari- zona are all arid to a remarkable degree. The mountains of California are mostly less dry, but dryer than the regions east of the Missouri River; while Arizona and Southern California have some 16 242 Tuberculosis regions at or about sea-level, some above and some below it, that are as dry as any habitable place on earth. At the same time we have along our south- ern Atlantic and Pacific coasts many places where a mild sea climate can be found in perfection. There is a medium climate, less dry than the arid lands, but more so than the sea-coast, with eleva- tions approaching two thousand feet, that is grateful to a large proportion of pulmonary patients; it is beneficial to many of them as well. This is repre- sented by such spots as the Adirondacks in New York and the foot-hills of Southern California from Pasadena to Redlands. Patients often dread low temperatures of winter, even when they are in an otherwise ideal climate. But there is little reason for the dread unless they are too weak to endure the cold under the condi- tions that are necessary. It is easy for any patient of fair vigor to endure even zero weather, sitting out of doors well wrapped against the cold, or asleep in his room with his windows open. The air in such a degree of cold is always dry, freer from moisture than the air of the warm dry coun- tries, and strong in oxygen from its concentration by the cold. The only objection to the cold is that it is less agreeable and convenient than the warmer air, and requires better heat-producing powers in the body. Patients can be up and go about easier and Treatment, Climatic 243 with more pleasure in milder weather; it is doubt- ful that it is really any better for them than the cold, provided that in the latter they can be out of doors enough. In connection with this subject there is one signal danger that must not be forgotten. The tendency is always strong for the patient and his friends to regard the climate he goes to as the only thing- necessary for his recovery, and to neglect any good, sustained hygienic care of himself after he arrives there. He often goes alone, without friends, lives among strangers, is homesick, has no fit course of conduct given him to follow, and takes the advke of every lay acquaintance he makes, in the most implicit faith that they know the right way and are worthy of being followed. As a matter of fact, such lay advice is usually the worst sort of vicious nonsense that can be imagined ; as, for example, that the night air is bad to breathe ; that the patient should not be out of doors later than four o'clock in the afternoon, should not venture out till eight o'clock in the morning, and that it will not do to have his room ventilated so as to cause a draft of air about his person ; that he should take as much walking exercise as possible, and should not sit down out of doors in the cool weather unless in the sunshine. These several pieces of advice are not only wrong, unscientific, and harmful, but if 244 Tuberculosis they had been conceived in a deHberate intent to do the sick as much injury as possible under the guise of kindness, they could not be more fitly stated. Such advice is given so uniformly and by so many people that it is small wonder the patients believe it, which they generally do unless they have been put on their guard by their [)hysicians. And it is one of the curiosities of mind that among the lay people these errors should be carried so faith- fully from mouth to mouth for years. Then the sick, away from home and after climate, sometimes follow their own whims, appetites, and desires so far as possible, and are more concerned about their entertainment than for the things that will help them recover. They make their absence from home a matter of sightseeing rather than a systematic campaign against tuberculosis. As a re- sult, many a one loses half the good he might have because he fails to carry out a perfect hygienic course with his climatic treatment. He goes to a climate where he can find a better air to breathe than he had at home, and then shuts himself in a closed room and bad air for more than half the time. If then he fails to improve, he blames the climate, and loses the time and money he has spent so lav- ishly to get well. It is a most pathetic witchery of errors, of which the profession is not wholly fault- less. Treatment, Climatic 245 If patients cannot be provided against homesick- ness and be sure to take all legitimate advantage of their time and opportunities in their climate-seek- ing, they had much better remain at home, where at least they might be happy and be kept under conditions of good hygiene. With the best intentions, and acting on the best of advice, the patient often does himself injury by occasionally forgetting his rules and regulations. He will watch his regimen and daily round of care of himself for a month at a time, gaining from day to day; then he will forget and over-exercise for a single hour or over-eat at a single meal and get indigestion, thereby losing all he had gained for many weeks. The effect of good climate for consumptives ought to be added to — never take the place of — the very best measures of general management and treatment, which should continue without a break for months and years. These are the patients who, above almost all others, cannot afford to forsfet and make mistakes, even occasionally. But it is a mel- ancholy fact that they seem fated to make mistakes in their own care, both frequent and grave. There seems to be something in the mere fact of climate-seeking that tends to make people forget that climate is not the only thing necessary for the sick. As a result, these pe()])le do some \ery queer 246 Tuberculosis and illogical things. When one of them moves to a climate thought to be good for his disease, he ex- pects to experience benefit in a- few days. If he fails of this, he is not only unhappy, but he is sure in a short time to lose faith in the new influence, and perhaps will make several moves in rapid suc- cession to different localities, even of the same gen- eral climate, always blaming the one where he gets worse and praising the one where improvement be- gins. In this way different localities acquire reputations, both good and bad, which they do not deserve, and patients put themselves to vast expense and incon- venience for nothing, or worse than nothing. Such errors could easily be avoided if people would re- member these most incontrovertible truths: thnt no sudden marked benefit e\er results solely from any climate whatsoever; that all climatic advan- tages come slowly through the months; that no relapse or rapid getting worse ever comes of the legitimate effect of any climate; that vicissitudes of weather in any climate — of heat and cold and wind and storm — may any day harm an unpro- tected patient; and that there is no magic or medi- cine that is known of as inhering in any climate, but only the possibilities of clean air to breathe, and such physical influences of air as may enable the normal physiologic jiowers of the sick to have the Treatment, Climatic 247 best chance and the freest field for the cure of the body from disease. Nothing is gained by demand- ing of climate more than it can do. more than it is reasonable to expect of it. ]\Iuch is lost by for- getting the weighty things of the laws of human physiology. CHAPTER XV TREATMENT, MEDICINAL AND LOCAL The medicinal treatment most constantly de- manded in tuberculosis is that with tonics. This is the best for nearly all invalids who are below their par of general vigor, and most tuberculous patients are below it. But some of them are quite up to their usual level, even above it, when meas- ured by any known standard of physical vigor ; they are below simply and only in some unmanifest power of resistance to the disease tul:)erculosis ; they apparently resist everything else as well as anybody can. Whether for this class ordinary systemic ton- ics are as useful as for other patients cannot be said, and it is rather doubtful; but we do not know of any other medicinal treatment as useful for them. Tonics produce different and varying effects on the several functions of the l)ody. Some benefit most the digestive organs and improve the powers of blood-making, and through that the general vigor ; others appear to increase the strength of the body directly and to add to its power of resisting ad- verse influences; others appear to aft'ect more the nerve force, and to increase mental poise and the power of normal nerve-action, and the aliility to 248 Treatment, Medicinal and Local 249 sleep and be refreshed. As to the action of many of them we are very ignorant, and perhaps as to all of them. We know that they affect different people in different ways, dependent on individual idiosyn- crasies. Some tonics that agree perfectly with cer- tain persons wholly disagree with others, and pro- duce in exceptional cases the most unexpected ef- fects, both good and bad. Tonics differ in their rate of action. Some are slow, others are rapid. Cod-liver oil — if it is a tonic and not merely a food — is very slow ; alco- hol, which to certain patients is a positive tonic, is very rapid ; while iron and all the numerous bitter and other tonics come in between in varying rates of effect on the system. Probably the tonic that agrees best with the great- est number of the tuberculous is a mixture of some form of iron with bitter principles from two sources — the nux \'omica bean and Peruvian l)ark ; and the most eligi1)le preparation is a mixture of iron with quinin and strychnin. But the dosage of these med- icines as they are usually prescribed is not very well adjusted. The rjuinin rmd iron doses are apt to be too large, and the strychnin too small. (Juinin should not l)e given as a tonic, except for a few days at a time, in doses as large as two grains three times a day; one grain is. enough, and half a grain is better if it is to be given long — and it is usually 250 Tuljcrculosis best to give it long in tuberculosis. On the other hand, strychnin is usually given in doses so small that, even when long continued, the best effect is not secured; 1-30 grain is better than 1-60 for brief medication, and the latter is not too large for long continued use. Any unirritating form of iron will do; a favorite with me is the reduced iron (ferrum redactum), but the citrate and the peptonate of iron are eligible, and perhaps the last is the best. The combination may be taken for a long time with benefit, or the articles may be given separately and be changed from time to time. Arsenic in the form of arsenate of sodium is a safe medicine and a tonic for some patients, and may be continued for a long time if it agrees. Cacodylate of sodium promises to be a valuable remedy, but there are drawbacks to its use, and its value is yet to be proved. The mineral acids are often useful, the l)est being the hydrochloric or the nitrohydro- chloric. One of these with tincture of nux vomica makes a most useful aid to digestion for some patients when taken after eating, especially when preceded b}^ a moderate dose of Ijicarbonate of so- dium greatly diluted and taken before the meal. The effect of the latter is probably, by neutralizing any excess of acid in the stomach, to facilitate the exit of the debris of a previous meal into the duo- denum, preparatory to the digestion of the new one. Treatment, Medicinal and Local 251 The malt preparations have been greatly lauded for their tonic powers, but, except for their aid in the digestion of starch foods, they are not very valu- able. Nor is cod-liver oil of much use in any way. It has a certain food value, which is slight, owing to the small amount taken, and the medicinal effect is hardly proven to exist. Really the small value that it possesses is scant compensation to the patient for the months of patience he must exercise in tak- ing a disagreeable medicine. Other fats, like olive oil and butter, are more agreeable substitutes, and probably nearly or quite as useful. Various aids to digestion are often invaluable, as the pepsin and pancreatin products, the taka- diastase, diazyme, and similar preparations for the starch digestion. Salol, oil of cloves, creasote, guai- acol, and others of their kind have a certain use- fulness in prex'cnting fermentation in the intestines. It is not proven that any of them has a direct effect on or against the tuberculosis. Creasote, guaiacol derived from it, and their carbonates have been used in a routine way by a large number of practitioners, some of whom believe profoundly in the beneficial effects of these drugs. They have kept patients taking such medicines for months, even years, and sometimes in enormous doses continuously. That most of tlie patients have escaped harm from them so generally is a valuable lesson, but T am sorry I can- 252 Tuberculosis not agree that the tuberculosis is retarded by them except as just indicated. Chlorid of gold and sodium has been much used in America in the general treatment of tuberculosis, but we lack evidence that it acts in any way except as a moderate tonic. At one time it was thought to have some directly antagonistic influence to tuber- culosis, but the theory is without proof. Nuclein in various forms and nucleinic acid are worthy of trial for their possible power of increasing the resisting power to tuberculosis. It seems to be demonstrated that they increase the white corpuscles of the blood ; that they increase the forces that destroy the bacilli in equal ratio is not so well dem- onstrated. Many physicians believe they have wit- nessed clinical benefits from these drugs, but no extensive tests have been made with a large numl)er of cases, under circumstances that permit scientific comparisons with other treatments. The prepara- tions deserve a more general use. They have the advantage of not being objectionable to the patient or harmful to any of his functions. My own pref- erence is for the nucleinic acid, which may be taken in 2 grain doses between meals, and in conjunction with the ordinary tonics. For the consti])ation laxati\'e medicines are some- times needed; but they had best always be given regularly, and in doses so small as to act as intes- Treatment, Medicinal and Local 253 tinal tonics. Among these the most valuable are aloes, senna, cascara, and rhubarb. The doses sliould be adjusted to avoid a cathartic effect; and the addition to the laxative mixtures of belladonna to prevent griping, and strychnin or nux vomica on the theory of producing some good effect in con- junction with the laxative, is rather fanciful, as neither does any particular good in this way. It can- not be said,however,that they do any harm, provided the laxative is not required to be taken often enough to carry so much belladonna as to cause constitu- tional effects ; these last are always disagreeable and wholly unnecessary. The strychnin with the laxa- tive is never enough to do any harm unless the drug is being taken independently in sufficient doses. A better addition to the laxative mixture would be a small dose of capsicum or piperin. The laxatives act more or less as general systemic tonics, and there is no objection to their being continued for a long time if they agree with the patient. The saline laxatives are entirely eligible if they fit the patient. I should say, however, that they do not, as a rule, agree as well as the vegetable ones. The most useful iorm is a mixture containing the phosphate and sulphate of sodium in about equal parts with a quarter of a part of bicarbonate of sodium, a heaped teaspoonful of the mixture being taken in a large draught of hot water once a day. 254 Tuberculosis or oftener if necessary, and half an hour before a meal. Calomel does not agree with tuberculous pa- tients as well as with most other sick people, and the habit of taking it in rather full doses to " clean ofif " a coated tongue or to remove feelings of " bilious- ness," as many patients do without advice, is vicious, for it fails to do these desirable things, and it does debilitate the patient instead. For the average patient the best laxative is a large enema of warm water t)r warm normal salt solution ; it agrees with more and disagrees wnth fewer patients than any drug or combination of them. If this fails and drainage is defective, then laxatives must be given regularly, and from among the best the idiosyncrasy of the patient must deter- mine which is most adapted to his case. Anodynes are occasionally required in tuberculo- sis, especially the pulmonary form, and chiefly for two very particular conditions — namely, pain and excessive cough. A pain that cannot be quieted by warmth to the part, counter-irritation, and rest (or, if in the side, by fixation of the chest-wall by adhe- sive straps or bandages, which, if motion of the lung can be spared, should always be tried) requires some anodyne if the pain is not easily bearable. The most eligible drug for this class of patients is probably codein and its salts, although for a slight pain of evidently temporary character some of the Ireatment, Medicinal and Local 255 coal-tar preparations often act pleasantly. Opium and morphin should be avoided if possible. The pain most likely to call for an anodyne is in the intercostal nerves or the pleura; headache is not very common; joint-pain is not infrequent, but is rarely so severe as to call for an anodyne, provided the joint is kept still and warm. Rather free coun- ter-irritation with tincture of iodin, croton oil, chlo- roform liniment, ointment of biniodid of mercury, or small blisters will usually relieve the pain in the chest, back or limbs, and avoid the need of quieting drugs. The cough may require anodyne drugs if it is too violent, if it is useless as failing to bring up phlegm, if it tires the patient greatly, if it keeps him awake to his evident injury, or if it is attended with much pain. It is best to abolish all cough that does not with fair ease luring up phlegm; but drugs should not be given until warmth of the chest and neck has been tried, nor until the patient has done his utmost to stop the unnecessary cough by his own will-power. These failing, medication should be resorted to, and those agents used that will disturb digestion and nutrition least. It is no harm if they produce slight constipation — that is easily relieved by enemas ; but the integrity of gastric digeston is a sacred thing and must be con- served to the utmost. The best cough medicines are codein and heroin, neither of which is objection- 256 Tuberculosis able to the average patient on the conditions named. A quarter grain of codein (or sulphate of codein) or a third as much heroin will often produce a quiet night for a patient who might otherw^ise, through his cough, lose half his required sleep, to his great injury. Two or three doses of these drugs in a night will be allo\vable if needed. Occasionally a tickling in the throat — /. c. the larynx or trachea — produces a most vexatious cough that continues for an hour. Sometimes this may be quieted by a pungent thing in the mouth and pharynx, like a gargle of alum- water, a lozenge of capsicum, a swallow of whiskey, some highly fla- vored candy, or chewing dry and swallowing slowly a half grain tablet of acetanilid. A spray (to be described more fully later on) of carbolic acid in albolene, or nebulized fluid of this or some similar quieting substance, taken for a few minutes occa- sionally, will sometimes quiet this kind of a cough. Occasionally it is helped by applying a w^arm woolen bandage around the neck. Very often at night it is produced by lack of sufiicient clothing about the neck, arms, and shoulders while in bed ; then the remedy is obvious. The clothing about the upper part of the body in bed ought to be as thick and warm as that worn during the day — or even to exceed this; but such is not the j^ractice of most people, either sick or well. Treatment, Medicinal and Local 257 It has for generations been fashionable to give coughing patients expectorant drugs, whether they are expectorating freely or not, whether their coughs are tight or loose. Most of these drugs are of the nauseant or sedative kind, and calculated, when given freely, to produce nausea and a free flow of saliva, and of serum from the bronchi. Antimony, ipecacuanha, squill, and senega have been much used, apomorphin less so. When the cough is " dry," — /. c. without expectoration and therefore useless — their addition to small doses of anodyne drugs is not spe- cially objectionable, provided they do not interfere in the slightest degree with the taking of food or with digestion. As a matter of fact, they have in the past been used domestically, and often prescribed in the most routine manner, and used recklessly by vast numbers of patients. They have probably done in the aggregate much more harm than good as they have been employed. As a rule, they had l;etter not be prescribed, for they often do interfere with the digestive organs and probably cause coating of the tongue, and to give them when there is no use- less cough is bad ])ractice. Nor is it probable that the nauseants assist to any valuable degree the effect of anodynes that may be prescribed to quiet a cough. The opiates given alone have substantial! \- tlic same effect on the cough, and no objectionable feature of the action of any of them is counteracted by the nauseants to an extent that warrants their use. 17 258 Tiil)crculosis Local medication of the respiratory passages has some, but not great, value. Its chief good is to assuage annoying sensations in the throat and tra- chea. Various sprays and nel)ulized or atomized fluids and vapors ha\-e been used in the hope of destroying the bacilli in the lungs, but they are all entirely i)()\verless to do it without doing mortal harm to the jxitient. They may at times, and when used freely, repress to a slight degree the bacilli on the surfaces that the medicine touches, but this can never be any region of the lungs where mischief is going on. The bacilli that do harm always produce their havoc beneath a layer of mucus that no cough- ing can e\'er carry away completely, and usually beneath the surface of the mucous membrane, and no projected particles of medicament can ever reach them in these situations. This form of medication, however, may do good to the mucous membrane near the tuberculous lesions and which is irritated by the disease. Often the conscious irritation in the breath-passages is entirely confined to the non-tu])erculous congested mucous membrane in the neighl^orhood of the lesions and usually proximal to them. To these surfaces some soothing application may be a great boon ; it gives the patient comfort, and possibly retards the spread of the disease to adjacent tissues. Treatment, Medicinal and Local 259 Such medicines should be used whenever they are agreeable to the patient and as often as he likes. The best of them are composed of albolene or some similar oily substance for a base, and some fragrant and agreeable admixture that has a harmless, slightly anodyne, and possibly antiseptic effect. Of these the best are carbolic acid, creasote, menthol, oil of cloves, and oil of pine. A few drops or grains to the ounce (^ to i per cent.) are enough, and the best apparatus with which to divide the medicament is one that makes a cloud of perfectly nebulized substance. For this a pressure tank of air is useful but not indispensible; pressure can be made with an ordinary bicycle-pump, forcing air into a nebulizing jar from which the medicine is carried through a tube to the patient's mouth. An ordinary atomizer of the best pattern with an effect- ive hand bulb will do in the absence of a better machine; only, if the patient is weak, some other hand than his should work the bulb. Inhalations of such medicines, if they are to be used with efii- ciency, should be taken frequently; hence it is neces- sary that the patient should have the proper facilities himself, and not be obliged to go to the doctor's office for the treatment. Inhalation of the vapor of soothing or stimulating- drugs from cotton or a. sponge in a tu])C with open ends or from an empty bottle is sometimes both 26o Tul)crculosis agreeable and beneficial. The iodid of ethyl, crea- sote, carl)olic acid, and eucrdyptol are proper. They are best nsed dissoK'cd in alcohol or compound spirits of ether, and should not be stronger than 5 to 15 per cent. If there is nuich annoying cough, the ether preparation is the l^etter excipient. Three or four whiffs from the apparatus may be taken every hour during the day. and if found desirable, the l)ottle or tube may be left under the patient's pillow, uncorked, all night. The apparatus should, of course, jje tightly corked when not in use.^ The menthol tuljes so much used by inhalation for their supposed effect on headache and common colds will fre(|uently allay a tickling sensation in the throat if used rather freely. The inhalation of oil of peppermint with the hope of destroying the bacilli of tuberculosis in the lungs, as recommended by Carasso. has been used considerably, and with some evidence but no proof of its special value. It is not unlikely that the vapor of the oil, if carried into the lungs almost constantly from inhalers worn day and night for a long time, may destroy the bacilli on the very surfaces where it strikes, but it does not penetrate beneath the surface to produce lA good formula is: 15^ Ethyl iodid i5y> Eucalpytol f5V2 Crcasotc f3i Compound spirits of ether q. s. ad 5 1 • — M. Sig. — Drop in inhaling tube as required. Treatment, Medicinal and Local 261 any effect, and, as already said, it is there that the chief mischief is always going on in pulmonary tuberculosis; there bacilli are multiplying in vast swarms, to spread in every direction where they find resistance low enouoh. CHAPTER XVI TREATMENT, MEDICINAL— (Continued) Tuberculosis of the larynx has received varied and numerous local treatments, most of which have had little effect, while some of them have heen positively harmful to a high degree. In consider- ing these cases we should understand, to begin with, that tuberculosis of the vocal cords is a matter of little inconvenience except from the hoarseness and aphonia; it is not i)ainful, and it does not interfere with deglutitir)n or in any way immediately imperil life; moreover, it is sometimes recovered from. It sometimes interferes a little in the expulsive cough, by the difliculty in closing the glottis firmly enough to get a strong blast of air; hut probably no patient suffers any evil effects from retention of pus in his tubes in consequence. On the contrary, it may spare the lungs from some injury that might result from straining cough. It is the disease of the arytenoicl regions and the space between them, as well as the epiglottis, that is so grave a condition in laryngeal tuberculosis. This causes painful swallowing; pain often when the throat is at rest; and, after ulceration has come, sometimes violent cough, even strangling, on at- 262 Treatment, Medicinal 263 tempts to swallow. Only \-ery few people recover from this form, for it leads to such resistance to taking food as to amount to starvation in a short time, and this, with the poison of the disease, rapidly pulls the patient down. No local treatment of the larynx in any of these cases should be thought of unless it promises either to relieve discomfort or to increase the prospects of recovery. The severe treatments have so far sig- nally failed to do either. They consist of applica- tions to the ulcerous surfaces and the swollen tissues about them of strong stimulating or cauterizing drugs, the chief of which has been lactic acid in nearly or quite full strength; and the effect has almost invariably Ijeen to cause a great deal of pain of body and mind, without vStaying the course (^f the disease. These measures have in the main been one pathetic death-tragedy, often prolonged, and without a ray of solace to the patients. The indications for treatment arc to lessen dis- comfort and to keep the ulcerous surfaces as nearly aseptic as possible, so as to favor the healing by the natural forces. The former is fulfilled by sprays of local anesthetics; tlie latter is ])oorly fulfilled at best, but some l)encfit comes from the use of sprays of antiseptics. Fortunately these two indications are covered largely by the same drugs; but the list is small that can be used with safety, for nothing 264 Tuberculosis must 1)e employed that will harm the system by being" absorbed from either the throat or the stomach. All medicaments used with the spray are swallowed to a certain extent, and even those that are applied carefully by the physician are often swallowed. The most ideal application for comfort is, of course, cocain (in a 2 to 4 per cent, solution) , but when used its dose has to be increased rather rapidly, it fails to give much relief, and its injurious systemic effects become a great drawback, Eucain (A) is a more eligible agent with fewer disadvantages. It may be used in a 2 or 3 per cent, solution ; but its solutions do not keep well and must be renewed frequently. Orthoform is better still, for it pro- duces very little, if any, constitutional effect, and it has perhaps some antiseptic influence. But the orthoform must be insufflated as a powder,^ and frequently the patient tires of the annoyance of its use and complains that it has not been blown upon the right place. Tn most of these cases it is better to rely on the slight benumbing effect of menthdl, 'Orthoform 4 parts, sugar of milk or powdered acacia i part, make an eligilile mixture; hut the ortlioform is often used pure, only it is liahlc to pack in the insutTiating tuhc. 'I"he hest form of tuhc is the ordinary slightly hent one in common use for taking medicine. A half inch of its end is hent at a ri.ght angle to its straight side, in an alcohol flame, and the other end attached I0 a tuhc of ruhher one foot long. The hent end of the tuhe is dipped in tlie powder, and the hlast of air is lilown from the operator's lips or from a hulh. The hulh is hetter. as it does not carry breath-moisture into the tuhe to clog it. Treatment, Medicinal. 265 carbolic acid, or oil of cloves, any one of which may, in weak solution, be sprayed into the throat often without harm. No amount of these drugs that would ever be swallowed when used as spray can do any particular harm. The carbolic acid may be used in ^ to 5 per cent, solution in water or albolene (2 to 20 grs. to i oz.) ; the menthol in a 5 to 10 per cent, solution in albolene; and the oil of cloves in a saturated watery solution (0.75%). To give comfort, they should be used shortly before eating; and they may also be used with safety after every meal. Morphin may be added to these me- dicaments, but I think it is rather better to give it internally or hypodermically if it is necessary to use it. It should be used with great caution. There is one drug that offers some hope of healing laryngeal ulceration, and it may be used with a spray. That is the trichlorid of iodin, a strong germicide that seems to penetrate deeper into a tul)erculous ulcer than any other non-toxic agent, and to favor healing. It may be sprayed in i-io to 34 of one per cent, aqueous solution (]/> gr. to I oz.), the strength being increased if tolerance per- mits. But il is an irritant if tbe solution is strong. There is no objection to using it frequently. The drug is rapidly decomposed on toucliing tlic ulcerous surfaces, setting free iodin and cliloriii. whicb in their nascent stale are \crv dcstructixe to niicrol)es. 266 Tuberculosis The preparation so readily decomposes that it is important to have it always fresh and perfect. Frequently a patient will complain of pain in the throat, with swallowing or otherwise, when no lesion can be discovered to account for it. Then usually the trouble is in the deeper tissues, the nerves or muscles of the tlu'oat, and in pathology is probably not unlike the slightly painful joints so common in this disease. Sometimes the pain is quite evanescent, lasting but two or three days. It is sometimes called rheumatic, although probably by a wrong use of the word. No treatment is required for it. Some symptoms of tulierculosis are so trouble- some as to demand special consideration. The mo$t constant of these, if not the most portentous, is fever. It often occurs in some \)n.vt of each day for many months together; sometimes it continues a large part of each twenty-four hours. It is the one symp- t(Mu that, more than any other, ma}^ be depended on to re\eal the progress toward recovery or the reverse. If much fever is present, it shows there must l)e some mixed infection, and conditions that, if they continue long enough, must wear out the patient and destroy life. But moderate fever lasting only a part of every day can be borne for a very long time with only slight peril ; nor is it true, as was formerly supposed that moderate fever is per se Treatment, Medicinal 267 specially harmful. It is the thing that produces the fever that does the great harm by impeding the physiologic processes and bringing on cachexia and all the long train of conditions that cause death. Very high fever may cause delirium and uncon- sciousness, as in sunstroke; but such symptoms are most unusual in tuljerculosis. Occasionally the patient feels uncomfortable in the head or elsewhere during the highest temperature, and needs an anti- pyretic. Then antipyrin, phenacetin, acetanilid, or some similar drug may be used with caution. The temptation is great, especially to the young practi- tioner, to treat the fever actively. But, as a rule, the only treatment that is useful consists in sustaining the powers of life and keeping the patient still. Cer- tainly no antipyretic drug treatment for the fever has so far shown any power to stop its recurrence or shorten its period or increase the prospects of ultimate recovery. A few years ago a large number of doctors all over the country found themselves ready to confirm somebody's hypothesis that guaiacol freely rubbed into the skin would promptly " bring down the fever;" they even reported numbers of their own cases to prove that such a result followed. Now they have generally ceased to use the drug, and prob- ably regret that they reported their cases, and won- der why they ever believed the hypothesis. There 268 Tuberculosis was not, I am sure, any scientific reason why they should believe in it, for the guaiacol manifestly had no effect on the temperature. The fever fell in some cases a short time after the rul)l)ing- was done, and fell for some reason connected with the action of the fever-producing agent in the blood, and the rubbed-in drug got the credit of it. The night-sweats of phthisis are often a serious inconvenience, and, according to popular Ijelief, a danger as well. The patient is sure to think his sense of prostration of the day is due to the sweat of the night before, wholly ignorant that the high fever and profound pus-poisoning that caused the fever could have anything to do with it. Great weakness does, indeed, attend conditions where profuse sweating occurs, but there is no proof that the sweating causes it. The phenomenon is in some way connected with a phase of infection where high fever falls suddenly, and the sweat comes when the temperature drops. The perspiration carries away a good deal of poisonous matter as well as salts, and this is without doubt something of an advantage to tlie patient infected by pus and tuber- culosis. And the saline matter and water are easily replaced by the food and drink. Tt is not proven that a night-sweat is not a conservative process, to be encouraged rather than otherwise: and until the proof exists ])hysicians should be careful to avoid stnjng and function-disturbing measures to stop it. Treatment, Medicinal 269 The sweat is disagreeable by the amount of it, and patients think their night-clothes must be changed the moment they awaken and find themselves moist, for fear of taking cold; but there is no danger of catching cold so long as the body is warm, nor is there need of changing the clothing during the night except for sensations of comfort. The patient's definition of a night-sweat is often faulty. He is liable to apply the term to a trifling perspiration, mostly above the waist-line, that slightly moistens the night-clothes. These minute perspirations are usually due to trivial nervous causes, and they are hardly an inconvenience except to the mind. It is the colliquative sweats, which wet the night-clothes and the bed-clothing almost to the dripping point, and even moisten the mattress, that alone ever re- quire medical treatment for the relief of the dis- comfort they produce. I am not satisfied that the sweats require treat- ment, since they neither cause the weakness com- plained of nor harm the patient otherwise. And it is an open question whether we ought, on the solici- tation of the patient, simply for his comfort, to try to prevent the sweats, when to do so we should be obliged to give drugs that disturb the digestion or some other function that is important in maintaining the powers of life. My own view is that treatment 2/0 Tuberculosis is very rarely justified. There is no treatment that is even fairly efficient, any way; the best single remedy is perhaps atropin, and that drug is of ques- tionable value unless given to the extent of produc- ing its full physiologic effect — which latter is dis- turbing both to functions and to comfort. The aromatic sulphuric acid treatment has, I think, no effect on the sweating, although the drug is some- thing of a tonic, and is therefore unobjectionable. The local applications are all useless. When, as will occur in the absence of treatment, there happens to be a night without a sweat, the? patient and his friends are very likely, if any treatment has been resorted to, to attribute the improvement to it; and this is almost the sole basis of the reputation of drugs and applications for night-sweats. The one measure that the physician should never omit is an insistent statement to the patient that his sweats do not harm him or cause weakness, Imt are due to the cause of the weakness, which is another thing altogether. If this declaration is repeated often enough, the patient will usually believe it, and stop worrying unduly about his sweats. Many patients with tuberculosis fail to obtain the proper amount of sleep. They are kept awake by a great variety of causes, some of which were dis- cussed in the chapter on the general principles of treatment. The chief causes of insomnia are cough. Treatment, Medicinal 271 fever, sweating, pain, indigestion (sour stomach), constipation, diarrhea, and mental worry. Cough is the most potent cause, and if this can be reduced and any of the other existing causes corrected, sleep usually ensues after the fatigue of the day. Obvi- ously, all the causes named cannot always be re- moved, but efforts should be made to do this by hygienic and symptomatic treatment carried out in a careful and painstaking way. Usually it is pos- sible, except in a few very nervous patients, to secure enough sleep without soporific drugs, but occasion- ally nothing seems capable of doing this but a sleep- ing potion. The best of all are sulphonal and trional, in the usual dose of 5 to 15 grains. Trional is rather preferable of tlie two, and 10 grains is enough usually. But these drugs should never be used continuously for many weeks at a time; their proper field is as an occasional relief. Bromides sometimes act pleasantly, 10 to 15 grains of the sodium salt being used two hours before bed-time. Occasionally a stimulant, as a moderate dose of whiskey well diluted, or a glass of l)eer, will com- pose a patient f(;r tlie night. If the stomach is sour, a dose of aromatic spirits of ammonia, well diluted, sometimes does good ; or a liberal dose of bicarbon- ate of sodium may l)e taken with benefit. For ner- vousness that prevents- sleep, such nervines as vale- rian, sweet spirits of nitre, and asafetida ought to 272 Tuberculosis be used more than they are at present, and in more frequent doses than is usual. Pulmonary hemorrhage is a sym))t()m that always disturbs and often terrifies the patient and his friends, and there is usually an urgent demand for something to stop it. Small hemorrhages are useful rather than otherwise, and require no treatment beyond carefulness on the part of the patient to avoid creating an increased blood-pressure, and thereby perhaps opening larger vessels. The patient should keep still, recline with the head high, avoid excite- ment, eat sparingly, avoid constii)ation, keep the head cool and the body and extremities warm, and be as serene as possible in his mind. If he takes any drug, the preferable one should be some opiate — that is, opium or some of its preparations. Of these, morphin is the best, and had better be taken with the proper admixture of atropin. If the hem- orrhage is at all free, the hypodermic method should alone be relied upon ; it is worse than useless to depend on absorption from the stomach or the rec- tum in such cases, for a quick effect is imperative. Moreover, in a se\cre hemorrhage the patient often vomits a great quantity of nuicus and blood before the attack is over, so that the chances of any medi- cine being absorbed from the stomach are very small. A quarter grain of morjjhin with 1-150 grain of atropin is a fair dose for an adult, and Treatment, IMedicinal 273 this may be repeated with caution if occasion re- quires. But it ought not to be given at all for a trifling hemorrhage, a slight spitting of blood in occasional mouthfuls, unless the patient is demoral- ized and frightened. The opiate tranquilizes the mind and drives away fright, and this is one of the cardinal advantages of the drug. To do a large service physiologically to the part involved, the drug ought to lessen the blood-pressure in the deep regions of the body. It does not do this to any large degree, yet it is much the most useful medication that we know of. The common habit of giving ergot in cases of hemorrhage from the lungs is most reprehensible, for it increases the blood-pressure and so makes it more likely that a \'essel-wall made fragile by tuber- culous deposit will rupture. Ergot always increases the bleeding in these cases, never decreases it, yet by a sort of fatality a large proportion of even intelligent physicians continue to use it. Its use for bleeding from the lungs has been a sort of fad among certain doctors, and a foolish if not a wicked one, that started in the groundless notion that good would somehow be done by contracting the blood- vessels. But the vessels whence the blood comes cannot contract in response to this or any other drug, for their muscular fibers are powerless, and by con- traction of all the rest of the vascular system an 18 274 Tuberculosis iucrease of blood-pressure everywhere is produced, which puts the diseased, fragile vessels upon greater strain than before. There is in the whole range of professional experience hardly a more striking ex- ample than this of the frequent prescribing of a potent drug with an effect the exact opposite of the one intended. If the fad were less harmful, it would be amusing. From current reports, some promise of relief from hemorrhage seems to be offered by suprarenal ex- tract (or adrenalin) given internally. But if the purpose sought is to contract all the l^lood-vessels, then we shall probably be disappointed, for this is what ergot does — to the increase, not the decrease, of the hemorrhage. But possibly this wonderful substance has some other power over hemorrhage, and is the great coming remedy. One of the best measures, in addition to quiescence and opiates, is to tie handkerchiefs firmly around the limbs next to the body. This segregates the blood to some degree in the limbs and tends to lessen the 1)Iood-pressure in the center of the body. Another measure of easy application and great value is (if the lesion is unilateral) adhesive straps to the diseased side, to immobilize the lung, after the manner already described. The straps should be numerous, and should be drawn as tightly as pos- sible. Of even greater value is inflation of the Treatment, Medicinal ^7o pleural cavity with sterile air or nitrogen gas. This puts the diseased lung to complete rest, and does it promptly, and the hemorrhage usually stops at once. Unfortunately, it is only in the rarely excep- tional case that this measure will ever be resorted to promptly. But it can be used promptly and effi- ciently in cases without adhesions; for the simple device already referred to of an aspirator needle and tube can be employed, or a large hypodermic needle with a bit of cotton wrapped about its head. Every physician carries this instrument, and there is no more harm or pain in using it than in giving a hypodermic injection. A good way is to insert the needle at a point least likely to encounter adhe- sions — as far away from the lesion as possible — and leave it there for a few minutes, gently changing its depths in the body from time to time, till, if possible, the inspiratory movements of the patient shall begin to suck air into the pleural cavity. Then the needle should be pushed far enough to be sure that it has passed clear beyond the chest-wall and free into the pleural cavity. If the temperature is high at the time of a bleed- ing, it should be promptly brought down with anti- pyretics, and if the pulse is hard and full, aconite and veratrum may l)e justifiable for their effect on the heart's action ■ — not to lower the temperature, for they do not produce this effect. 2'](^ Tuberculosis In case of a \'ery large hemorrhage the pulse should be \vatched carefully, and if it becomes very faint, hypodermoclysis of normal salt solution ought to be resorted to promptly. The best place to intro- duce the tluid is in the subchuicular region ; and for apparatus an ordinary fountain syringe and an aspirator needle from the physician's pocket case constitute the necessities. The syringe can be cleansed, if necessary, with scalding water, and the needle may be held for a moment in a gas-flame or over a lamp-flame; the apparatus is then ready. The solution may be quickly strained through a clean cloth or a bit of sterile cotton as it passes into the bag. The solution can be made in an instant with a heaped teaspoon ful of table-salt to a quart of any drinking water, preferably that which has been boiled, although that is not indispensable. This mixture is not exactly the equivalent of the water of the blood. Imt it is near enough for all physiologic purposes. The custom is to heat the solution to loo'^ F. or over before putting it in the bag, in the expectation that it will pass through the needle at a temperature not below that of the body. But this end is very rarely attained ; the solution passes so slowly that when it enters the tissues its temperature is often only 85° or 90° F. A much better way is to pour the unheated solution into the bag, and then to im- Treatment, Medicinal 277 merse a coil of the tube (near the needle) in a dish of hot water containing at least a quart. This water should be renewed as often as it gets cool. The hypodermoclysis, while necessary at times to save life, may undoubtedly be carried so far as to increase the blood-pressure to the danger point. This we should be careful to avoid. Remember that it is desirable that the pulse should become weak and the blood-pressure low ; for in these conditions is the greatest hope of a firm and obliterating blood- clot at the bleeding point. CHAPTER XVII. SPECIAL TREATMENTS Under the name " serums " are included a num- ber of substances that have l)een used for tubercu- losis, and which have their origin either in the tuber- cle bacilli directly or in the bodies of animals in some way treated with the products of tl:e bacilli. One of these is the so-called horse scrum, which is the blood-serum of the horse after the animal has been treated by repeated hypodermic injections of tuberculin. The theory is that by this treatment there is developed in the animal's blood an anti- toxin to tuberculosis, after the manner of the diph- theria antitoxin which has been so successfully used against that disease. There is much to justify such a theory. The serum is used hypodermically, and, unlike that for diphtheria, which is rarely used beyond the second or third dose, it is given in a dose so small as not to produce fever, and repeated daily or every second day for a long time. It is usually injected into the back, deeply ])eneath the skin, in doses of lo to 15 drops. It produces some local swelling and inflammation, and in susceptible patients occasionally a small abscess. Some ])e()ple ha\'e a good tolerance for it, and take a large number 278 Special Treatments 279 of injections with little complaint or discomfort. Occasionally a disagreeable, if not dangerous, nervous shock is produced by the injections of horse serum. It occurs one or two minutes after an injection has been taken. Its symptoms are pain in the abdomen, general discomfort, flushed face, and a feeling of great fear and apprehension, all of which pass off in a few minutes. If the dose of the serum is too large, it is sure to cause fever for a few hours. The experience with this serum has not been very satisfactory. Some practitioners have reported good results, others remarkable ones, and still others bad or indifferent ones. The testimony has been so vari- ous and contradictory that it is difficult to determine just what the effect upon the sick has been. Cer- tainly no obser\'er has recorded results based on the use of the serum in a large series of cases, under control with another series of similar cases managed in an identical way with the single exception of the omission of the serum. Until such records are made we cannot be said to have any scientific data on which to base definite conclusions as to the effect of this agent. On the lower animals, especially guinea-pigs, really scientific observations have been made, show- ing that when treated with the horse serum an ani- mal's life after inoculation with human tuberculous sputum is considerably prolonged over that of the 28o Tuberculosis control animals. This seems to be the uniform result of laboratory tests. Yet the results of the use of the serum on human beings at the hands of careful observers has not been more than slightly beneficial. And the good results reported have in every instance been based on the observation of a few patients, without controls for comparison, and therefore with no means of knowing positively that they would not have done as well without the serum. I have repeatedly employed this serum, sometimes with apparent good effect, and see no objection to its cautious use in any case where it produces no special discomfort or phlegmons or other terror to the patient, and provided always that no other ele- ment of the best treatment, hygienic, sanitary, or medical, is omitted in the slightest degree. This last condition is one that is usually forgotten and for this reason the t<^tal result of the scrum treat- ment of all kinds and forms has been probably a little less than nothing of value. The belief that the serum will somehow cure the disease absolutely, and that notliing else need be thought of, is a maggot that gets into the heads of many of the patients and some of the physicians, to the great injury of the prospects of recovery. Tuberculin and sex'eral modifications of it have been used rcmedially with more or less ajjparcnt and alleged success. In doses of i milligram given Special Treatments. 281 hypodermically, it usually causes fever in a tuber- culous patient who is not in extreme cachexia and whose disease foci are not yet completely encysted. When tuberculin is used therapeutically, it is given in doses so small as not to produce fe\'er, and re- peated every few days. After a few injections a tolerance of it is developed to some degree, so that the dosage can be increased somewhat. The theory of its use is that it adds to the tuberculin in the blood and dexelops in the patient's body a resisting power to the disease greater than existed before. But the theory is unsatisfactory, as the effects of the tuberculin are neither uniform nor convincing. The lymph has been used persistently by a few practitioners who believe they have observed good results. By the majority it has been condemned as not only useless but harmful, and they have refused to even try it. They have argued that the patient is daily casting quite enough tuberculin into his blood and tissues from the cultures of his own disease, and that no good can come of increasing the amount But, on the other hand, much of the auto-developed tuberculin is absorbed in conjunction with pus- products which probably retard the antitoxic ])Ower of the tuberculin. Moreover, to increase the tuber- culin in the blood beyond the quantity made by the disease may produce and increase some antitoxin for the tuberculosis. 282 Tuberculosis Unfortunately, the use of tuberculin, except for diagnostic purposes, has been open to the same sort of objection as that to the horse serum. It has been used on a few cases only, and the results have probably not warranted either the extravagant claims for or those against it. The most thorough test yet made in America is probably that of Dr. Trudeau. His trial of it extended over a number of years, and was scientific and fair in every way. His records show that those treated with the lymph, by comparison with other similar cases treated witli- out it, did better by a small percentage. But he says that the benefit shown was " not sufficiently marked to be in any way conclusive." All the experience with this agent seems to show that under proper precautions it is devoid of danger, especially in cases with a fair degree of vigor — and it should never be used in any other cases. That being true, there is no reason why it should not be used more exten- sively. There are several conditions that should be insisted on if one is to use it therapeutically. The dose must be so small as to produce only slight local reaction in the form of moderate congestion of the diseased area, never constitutional reaction to the extent of distinct fever. This practically rules out all advanced cases with mixed infection, and restricts its use to the early and mostly non-febrile cases. It is necessary to begin with a small fraction ( r-ioo Special Treatments 283 to 1-150) of a milligram for a dose, and repeat it rather often, every two or three days, increasing the dose as tolerance is established, gradually lengthen- ing the intervals and giving always the largest dose possible short of producing febrile reaction. The injections are least likely to produce phlegmons when made deeply beneath the skin. After marked tolerance to tuberculin has been established — which never occurs until it has been used for several months — it is a good plan to stop its use for some weeks, and resume it later. But it will then be discovered that some of the tolerance has been lost, and it will be necessary to start again with smaller doses. Then, after having the treat- ment worked up to the maximum dose, it will be well to omit it again and resume it later, and so on as long as there seems to be any hope of its doing good. Koch's tuberculin T. R. may be used in the same way as the ordinary tuberculin, only in slightly smaller doses. I am not aware that it has been proven to have any therapeutic superiority over pure tuberculin, while it is distinctly more likely to produce irritation at the point of injection. Injec- tions of tul)erculin, when made deeply, very rarely cause any inflammatory action at the point of injec- tion. Several modifications of tul)crcuhn have been used 284 Tuberculosis besides the T. R. product. One is known as anti- phtliis'ui, and is said to consist substantially of tuber- culin that has been treed, by some chemical process, of a part or all of its fe\-er-pro(lucing ingredients. It is uscfl by the hypodermic method very much as other serums are, and may be useful in some such way as the tuberculin is, luit we lack as yet any definite scientific proof of its value. The fubcrciilocidiu of Klebs is the same as anti- phthisin,with the addition of some kind of an extract of the bacilli. This is more likely to be useful than the antiphthisin, but its value is based on the same sort of observation as that of the other agents. Klebs Ijelieves that this substance is absorbed as well from the rectum as from beneath the skin, so he uses it by this and the hypodermic method indif- ferently, in doses of 10 to 15 drops hypodermically, or a quarter as much more injected into the rectum. In using it in this latter way it should be diluted with 2 or 3 drams of water, and taken after the bowels have been evacuated, so as to insure the most complete absorption. Von Ruck has used extensively his zcotcry extract of tubercle bacilli. He believes it to be much more efficacious than any form of tuberculin. A few phy- sicians have used it and testify to its value. I hope it is as valuable as they think, and believe it deserves an extensive trial in comparison with pure tuber- special Treatments 285 ciiliii. But so far as I am aware, no such scientific comparison has been made with series of cases, as none has been made with it and under control of non-serum cases. Until such tests are made we cannot speak with any degree of positiveness of the value of these or any similar remedies. Any physician who will treat with a particular serum every alternate case that comes to him, record- ing the others as controls, and managing all the cases otherwise in the same way in every particular, will, when his cases reach a hundred or tw^o, have something of value to say to the waiting profession and to an army of tuberculous patients. Our mis- fortune, if not our fault, has been that we have mostly let our enthusiasm run aw^ay with our science, and been content to believe or guess that a serum w^as good, and so have used it, chiefly without con- trol or system, and on cases likely to recover by rest and good hygiene. By thus having nothing j^roven we have thrown doubt and discredit on the whole subject, and have not added anything to the knowl- edge of the world. CHAPTER XVIII SANATORIA FOR TUBERCULOSIS Sanatoria for tuberculosis have many advan- tages for the treatment of cases over any sort of home management. Tuberculosis is a type of the long continuing dis- eases. Depending on the tissue attacked and on the resisting power of the patient, the disease lasts from a few days to many years, and in hopeful cases the great desideratum is for means to combat it in a persistent campaign, for several years if need be, without a break in the perfect continuity of its strenuous tension. There must he no relaxation of watchfulness to prevent surprises ; no lessening of the resisting forces by unsanitary conditions of life that would lower the vitality of the factors of de- fence. There must be no sleeping on watch in this camp, nor dissipating of powers by unwholesome pleasures, nor engaging in industries not necessary to the perfection of the bodily forces as a power of defence. And there must be no loopholes in the lines of resistance, for the enemy is one that never sleeps nor rests wherever it can find physical con- ditions adapted to its work; it requires no intelli- 286 Sanatoria for Tuberculosis 287 geiice, but works with the precision and fate of an automaton. For such a campaign against this disease the prospects of uhimate success are best when it is conducted in a chmate best adapted for it, under residential conditions most fit, and under the care and observation of experts in this sort of a campaign, who are not likely to relax their watchfulness or lose their wisdom about it from one year's end to another. These conditions are in the average case best at- tained in sanatoria for tuberculosis. This truth is so plain as to be really self-evident. It is a truth that needs no argument that these best conditions can he found neither in the average household nor in the routine of the life of the average patient. A few pa- tients of unusual self-control and wisdom, whose families and attending nurses and friends have sense and decision, and who have the means of surround- ing themselves with all the comforts, can do as well or even Ijetter than at the best sanatoria ; but these are rare exceptions. The allurements of business and pleasure and of social dissipations; the temptations of appetite and the fashions of eating, of dress, and of social usages; the love of travel and the desire to roam from place to place — 'putatively for health, but mostly for mental diversion, — these are dangers 288 Tuberculosis that handicap most patients with chronic tubercu- losis who live at home or outside of an institution. 'J1iey follow their inclinations chiefly, and try to carry out the advice of their doctors somewhat. Too often the sole advice that is followed is confined to the taking of some drugs, and perhaps residence in a particular place. If the doctor gives minute direc- tions in all particulars necessary to accomplish the best effects, the patient usually finds that they are so radical, and so completely change all the habits and regimen of his life, as well as perhaps his occu-' pations, that he is apt to think them unnecessary and fussy, and to be ready to neglect most of them. In a sanatorium he finds it easy to follow all of them, for there it is the fashion to do this; there is no temptation to the contrary, and the new life and novel regimen furnish both occupation and amuse- ment. The sanatorium for tuberculosis is, in .\merica, a relatively new idea ; until recently it has been unfashionable, and people have even dreaded the thought of going to such an institution or having their friends go there. They have hated hospitals of all kinds, and in a blind and foolish way. For- tunately, during the past few years the value of sanatoria and of expert care for such cases has come to be better understood and appreciated. Such insti- tutions, until recent years confined to one or two Sanatoria for Tuberculosis 289 in number (that of Dr. Trudeau at Saraiiac Lake, New York, easily being the pioneer, to the great credit of its creators and management), are now springing up in many parts of the country, and meeting with the success that their enthusiastic advocates have predicted. Now that the evidence is growing that the great danger of acquiring tuberculosis is from human rather than animal patients, and that if the disease is ever destroyed as a pest of mankind, or even much circumscribed, it must be chiefly by a systematic and persistent destruction of bacilli from human expectoration, the need of such sustained care of sputum, clothing, and utensils of consumptives as sanatoria almost alone provide is l)eing more and more appreciated. But the ignorance on this sub- ject among the people is still very dense, and much enlightenment is needed even among the profession. The great goal to work for is an atmosphere charged as little as possible with bacilli of tubercu- losis. In no city of any civilized country is the street-air wholly free from them now, and with current methods in the care of tuberculous patients we cannot look for much improvement. Artificial destruction must reinforce the power of sunshine before that desirable end is accomplished, and sana- toria certainly succeed, in doing this 1)ctter than it is done anywhere else. The claim is not unfair that 19 290 Tuberculosis the atmosphere within the walls and grounds of the best of the sanatoria is more nearly germ-free than that of the streets of any city. An uninfected per- son is therefore safer within them than at his home, especially if that is in an urban community. But the regulations and methods of a sanatorium that is entitled to be classed as the best are some- thing startling in their thoroughness. They include, besides the saving for destruction of every particle of tangible sputum, such precautions against the intangible and usually overlooked but always freely scattered minute particles of sputum as the follow- ing: Uncarpeted floors, unupholstered furniture, and both (as well as walls and ceilings) regularly cleansed at short intervals ; regular and frequent ster- ilization by sunshine or heat of all clothing, beds, rugs, and every utensil used on or about the patients. They include constant watchfulness of the personal habits of the patients, and such searching precautions that no l)acilli discharged from any part of the body of a patient can long escape destruction. And all these measures are carried out year after year with- out a break. In what home of a tuberculous patient are any such thorough precautions taken? And yet it can- not be doubted that e\'ery one of them is necessary f(^r every case if the community is ever to be pro- tected. The greatest danger is, of course, from the Sanatoria for Tuberculosis 291 poor and careless patients. All people when greatly prostrated are liable to be careless in their personal habits ; they are almost certain to be. The well-to- do and those who have attentive friends can, in spite of themselves, be kept in a fairly sanitary state; but the neglected ones are a constant menace to every uninfected person for miles around them. That menace is now just coming to be partially understood by the public, and it is beginning to dawn on us that for the common protection sanatoria at public expense are needed for such cases. And if the science of tuberculosis is not wholly reversed by future discoveries, there will gradually develop such a popular understanding of the danger referred to as will lead to the creation of such institutions all over the country. The cost to the public to build and support them would, of course, be enor- mous, but the loss to the community entailed by the neglect of the cases is now vastly more; it would be economy to take care of them as a ])ublic burden. Great as is the advantage to the general jniblic in having patients live in sanatoria, the benefit to the patients themselves is vastly more. They live perforce hygienical ly, and every day, and so liave the best chance of recovery. They take the best care of themselves, for that is their occupation ; and they take their peculiar diet and carry out the various hygienic rules as a matter of course. They eat 292 Tuberculosis properly and regularly, and so far from violating the details of their regimen, they become advocates of it, and watch themsehes and each other in a loy- alty to it that is both novel and hopeful. There are no social allurements to harm ; the social functions of the institution are planned for the sick. Female l)atients hnve little temptation to dress unwhole- somely, and they easily consent to wear short skirts and loose clothes everywhere. This last is an almost indispensable condition to recovery; the conven- tional waist-clothing is an abomination to the con- sumptive woman. The nursing is done by experts who are little moved to do foolish things for the patients, either at their suggestion or out of blind love and sympathy for them. The danger of overdoing is minified by the con- stant and wise watchfulness that is the habit of the institution and by the routine lives that the patients lead — which means the highest degree of wholesome living; and this is rarely attainable in one's home unless at the hands of a trained nurse not of the patient's family. One can live well and be well cared for at a sanatorium for what such a nurse often costs, or even less. The constant sup- ply of fresh air, so hard to provide for a patient at his home, is always secured at such an institution. This is the most important remedy, the value of which cannot be overrated. Sanatoria for Tuberculosis 293 One of the greatest advantages of all is the mental tranquillity that comes to many patients through the fact of being in a small community where the chief fashions are to be quiescent and to do and endure certain things that are understood to be proper for the sick. IMuch depends on the emotional basis on which we do things. At home the basis is that of the well people, and we seek to do the things of the well, as in exercise, business, amusements, and diver- sions, and eat always on the basis of an appetite which we feel bound to cultivate and follow. In a sanatorium the basis is that of the sick ; we are glad to do the things of the sick in all these par- ticulars, and we eat as a matter of routine, without feeling compelled to pay homage to appetite. This letting go of the emotional tension that makes a sick man try to be a well one and pretend that he is, often tips the balance in favor of recovery and saves the patient from a death that otherwise would be inevitable. If every person with pulmonary tuberculosis could from the very first give up and not pretend to himself or to others that he is well, but settle down with patience and attention to the business of getting well, the proportion of recoveries would be greatly increased. The sanatorium life is conducive in a high degree to this good philosophy. It is attainable at home, but less easily; there the temptation to do all sorts 294 Tuberculosis of things often begets an attempt to hide even the existence of tuberculosis as though it were a disgrace like drunkenness or opium-taking, to be spoken of only in an undertone, and even forgotten by the patient. This nearly always leads to the doing or omission of things that are inimical to tlie prospects of recovery. Those cases of tuberculosis where the patient is perfectly informed and is himself frank about it are most of all likely to recover, for they pursue, on an average, a more wholesome course of life and treatment, and they are exposed to decidedly fewer risks of all kinds. The proper placing, the location, of a sanatorium is of great importance, although less vital than the management of the patients within it. It is essen- tial that it shall be in the country, and far away from manufactories and all other industries and things that can contaminate the air or render it in the slightest degree unpleasant to the senses. Tliere ought to be a free circulation of air, theref(M'e an elevated spot may be desirable. Still, the situation would be unfortunate if strong winds prevailed so as to make outdoor life for the patients difficult. High hills to the east should l^e avoided, as they make a late sunrise; an early sunset is less objec- tionable, but is to be avoided if possible. Trees and verandas are desirable for shade from the intense sun, but never to make it hard to hunt the Sanatoria for Tuberculosis 295 sunshine. Scenery, trees, hills, rocks, and running water are good aids and make for contentment, but are hardly to be called essential. Nearness to a town has its good and its bad influences. Nearness means conveniences, and possibility of amusements, but it often tempts patients away from the con- tentment with the sanatorium life that is so necessary to the best progress in recovery. Most patients can never go to a sanatorium, but must stay at home. Here they recover if they can, or die if they must. Many of them could carry out the true sanatorium management at home far better than they do ; most of them never even attempt it — they find it too radical and inconvenient. For these enforced stay-at-homes the modern physician has a large duty and may do incalculable good, but he can do it only by insistence and watchfulness that are sustained through the years, regardless of the heedlessness, impatience, and even censure on the part of the patients and the public, and sustained by a determination to do a duty to both tliat neither of them can know with any such force as he knows it. NDEX. Abscesses, cold, 97 Acidity of stomach, 209 sodium bicarbonate for, 209 Addison's disease, 37 Adhesive straps to chest, 221 A(h-enalin, 274 Adrenals, 37 Advice, lay, 243 Age, influence of, in tuberculosis, 74 Albuminuria in tuberculosis, 97 Aloes, 253 Altitudes, blood-count in, 240 efi"ect of, 239 in the etiology of tuberculosis, 75 Anatomic tubercle, 41 tuberculosis, 37 Animals, immunity of, to human tuberculosis, 77 Anodynes, 254 Antimony, 257 Antiphthisin, 26 Apomorphin, 257 Arid regions of the United States, 233 Arsenic, 250 Arytenoids, tuberculosis of, 262 Athletic exercise, 70 Auscultation, 109 Auscultatory percussion, 107 Bacilli, 9 animal experimentation with, 23 animals affected, 14 dangers from, 163 death of, 31 differing virulence of, 78 distribution of, by sputum, 77 through the body, means of, 66 effect of heat and cold upon, 15 extract of, 284 in milk, 21 in sputum, 18 in tissue, 22 in mine, 15 mode of entrance into body, 55 properties, 12, 13 staining methods, 16 watery extract of, 26 Bad air, 72 Baths, 202 Bladder, tuberculosis of, 36 Blood-count in altitudes, 240 Body, chart of, 12I Bone tuberculosis, 41 Breathing-tubes, 221 Bronchi, phlegm in, 82, 83 pus in, harmlessness of, 220 Bronzed skin disease, 37 297 298 Index Cachexia in phthisis, 93 pathology, 67 Cacodylate of sodium, 250 Calomel, 254 Carasso treatment, 260 Carpets and rugs, 169 Cascara, 253 Caseous degeneration, 30 Case -taking, 120 Catarrh, intestinal, 210 nasal, in tuberculosis, 74 Catarrhal pneumonia, 65 Cattle, tuberculous, laws as to, 1 70 Cavities, 114, 127 Cell, giant-, 29 pathology, 53 Chart Land III., deaths, 147, 154 Chart II., deaths from phthisis, 149 Chart of body, 121 Chest, adhesive straps to, 221 jacket for fixation of, 227 Chest protectors, 200 Child-bearing, excessive, 73 Chills, 80, 81 Climate in etiology of tuberculosis, 75 mild sea, 242 nature of, 231 Climatic treatment, 189, 230 Clothing, amount necessary, 201, 238 at night, 256 disinfection of, 162 new kinds needed, I99 Cloves, oil of, 251 Codein, 254 Cold abscesses, 97 catching, 201 Cough at end of expiration, 219 effect of posture on, 83 Cough, harmful, 85 medicines, 255 spray for, 219 useless, 200 varieties of, 82 voluntary repression of, 218 Creosote and guaiacol, 251 Cure, when complete, i8i Curved fibers in sputum, 129 Death of bacilli, 31 Chart I. and III. as showing, 147, 154 from phthisis, Chart II. as showing, 149 percentages of, 148 table of, 146 Degeneration, caseoys, 30 Denison modification of fixation plasters, 225 Diarrhea, 86 in tuberculosis, 96 Diet, 204 Disinfection, 166 Drainage from colon, lack of, 210 Drugs in treatment, 188 soporific, 271 Dry climate, effect of, 232 Dryness in etiology of tuberculosis, 75 Dust in lungs, behavior of, 57 Eating, times of, 204 Egg-nog, 207 Eggs, curdled, 207 Enema-habit, 211 Enemas, 254 for intestinal troubles, 211 Epididymis, tuberculosis of, 35 Ergot, 273 Index 299 Eucain, 264 Exercise, athletic, 70 Expectorants, 257 Extractor tubercle bacilli, 284 watery, of tubercle bacilli, 26 Eye, glassy, 94 Fever, 80, 81 effect of, per se, 89 exercise in, 194 bad effects from, 90 high, 267 treatment, 193 Fibers, curved, in sputum, 129 Fibroid phthisis, 34 Fibrosis, 33 from lung motion, 215 in different diseases, 62 pathology, 61 Fibrous form of consumption, 44 Fog, 237 Food, articles of, 205 Fremitus, vocal, 105 Friction-sounds, 116 Gangrene of lungs, 89 Giant-cell, 29 jiathology, 53 Glassy eye, 94 Gold and sodium chlorid, 252 Guaiacol and creosote, 251 external use, for fever, 267 Health officers, notification of cases to, 167 Hemorrhage, treatment, 272 Horse serum, 23, 278 Humidity, relative, 234 Hygienic treatment, 192 Hypodermoclysis, 276 Immobilization of chest-wall by splint, 227 Immobilizing chest by adhesive straps, 221 Immunity of animals to human tuberculosis, 77 Indigestion, 86 Infection, mixed, 32 Insomnia, 194 treatment, 270 Intestinal catarrh, 210 lodin trichlorid, 265 Ipecacuanha, 257 Iron, 249 Jacket for fixation of chest, 227 Joint-tuberculosis, 36, 41 Kidneys, tuberculosis of, 35 Koch's lymph, 24 Laryngeal tuberculosis, 35, 39 treatment, 262 Lavage, 209 Laws as to tuberculous cattle, 170 Laxatives, 252 saline, 253 Lay advice, 243 Life, outdoor, 195 Lumbar puncture, 138 Lung, diseased, management, 214 rest for, 214 dust in, behavior of, 57 gangrene of, 89 pain in, 81 tuberculosis, point of begin- ning, 56 Lupus, 41 Lym]ih, Koch's, 24 300 Index Massage, 212 Meningitis, tuberculous, 97, 135 Menstruation in tuberculosis, 87 Miliary tuberculosis, 42, 65, 99 Milk in biliousness, 208 Mixed infection, 32 Morbidity of tuberculosis, 143 Morpliin and opium, 255 Mortality from tuberculosis, 144 Mouth-percussion, open, 108 Mouth-tubes, 184 Murphy inflation treatment, 216 Muscle tones, 117 Muscular vigor and tni)ercuIosis, 70 Nasai. catarrh in tuberculosis, 74 Nationality in tuberculosis, 75 Night-sweats, treatment, 268 Notification of cases to health officers, 167 Nuclein, 252 Oil of cloves, 251 of pejjpermint, 260 Opium and morphin, 255 Orthoform. 264 Out-door life, 195 Over-stimulation, 73 Pain in lung, Si rheumatic, of throat, 266 Painlessness of consumption, 88 Peppermint, oil of, 260 Percussion, 106 auscultatory, 107 instruments, 107 open mouth-, 108 Peritonitis, 37 pathology, 58 Pharj'nx, tuberculosis of, 95 Phlegm in bronchi, 82, 83 Phonendoscope, iio Physical signs, lOO Pleural effusion, 140 Pleurisy, 37 Pleuritis, tuberculous, 98, 139 pathology, 58 Pneumonia, catarrhal, 65 Post-mortem records, 148 Posture as a symptom of cough, 83 Pregnancy in tuberculosis, 74 Process, tuberculous, 27 Public speaking and singing, 221 Puncture, lumbar, 138 Pus in bronchi, harmlessness of, 220 Qui N IN, 249 Rales and rhonchi, 115 demonstration of, 126 Records, post-mortem, 148 Recoveries from phthisis, 155 Red corpuscles, increase of, in high altitudes, 240 Resisting power to tuberculosis, 51 Rest for diseased lung, 214 how to take it, 197 Rheumatic pain of throat, 266 Rhubarb, 253 Rugs and carpets, 169 Saline laxatives, 253 Salol, 251 Sanatoria for poor, 175 _, for tuberculosis, 286 proper location of, 294 regulations of, 290 Scrofula, 42 Sea climate, mild, 242 Index 301 Senega, 257 Senna, 253 Serum from llie horse, 23 Serums, 278 Short-windedness, 93 Sight-seeing, 244 Signs, voice, I17 Singing and public speaking, 221 Skin disease, bronzed, 37 rubbing of, 204 Sleep in draft, 198 Sodium bicarbonate for acidity of stomach, 209 cacodylate, 250 phosphate, 253 sulphate, 233 Soporific drugs, 271 Sources of tuberculosis, 76 Speaking, public, and singing, 221 Spirometer, 105 Spray for cough, 219 for throat, 256, 258, 259, 265 Sputum, care of, 165 contents of, 88 curved fibers in, 129 destruction of, 164 Sputum-cups, 165 Squill, 257 Staining bacilli, methods, 16 properties of bacilli, 12, 13 Starvation as causing tuberculosis, 72 Stethoscopes, 109 Stimulants, 188 Stimulation, over-, 73 Stomach, acidity of, 209 sodium bicarbonate for, 209 Strapping of chest, 221 Strychnin, 249 Sunshine, amount desirable, 238 Suprarenal extract, 274 Sweats of phthisis, 82, 91 Tabes mesenterica, 42 Temperature, perceptible, 237 subnormal, 90 Test, tuberculin, 130 dangers, 132 rules for, 131 Throat, local medication of, 258 rheumatic pain of, 266 spray for, 256, 258, 259, 265 T. O., 26 Tonics, 248 T. R., 26 Tubercle, anatomic, 41 Tuberculin, 24 for diagnosis, 25 hypodermic use of, 25 residuum, 26 test, 130 dangers of, 132 rules for, 13I therapeutically, 280 T. R., 283 Tubcrculocidin, 26, 284 Tuberculosis, anatomic, 37 bone, 41 classification, 43 complications, 34, 95 diagnosis, 120 etiology, 69 fibroid, 34 forms of, 39 in utero, 7 1 miliary, 42, 65, 99 of arytenoids, 262 of bladder, 36 of epididymis, 35 302 Index Tuberculosis of joints, 36, 41 of kidneys, 35 of larynx, 35, 39 treatment, 262 of pharynx, 95 patholog)', 51 prognosis, 143 prophylaxis, 161 sources of, 76. spread of, from initial de- posit, 57 sweats of, 82, 91 symptoms, 79 rate of progress, 87 treatment, climatic, 189, 230 general principles, 177 medicinal, 238 Widal reaction in. 68, 134 Tuberculous cattle, laws as to, 170 Tuberculous meningitis, 135 pleuritis, 139 process, 27 Tubes, breathing-, 221 mouth-, 184 United States, arid regions of, 233 Vesicular murmur, 126 Vocal fremitus, 105 Voice signs, 117 Vomiting, 86 Watery extract of bacilli, 26 Weather, zero, 242 Widal reaction in tuberculosis, 68, 134 X-RAY in diagnosis, 142 SAUNDERS* BOOKS Practice, Pharmacy, Materia Medica, Thera- peutics, Pharmacology, and the Allied Sciences W. B. SAUNDERS 6 COMPANY 925 Walnut Street Philadelphia NEW YORK LONDON Fuller Building, 5th Ave. and 23d St. 9. Henrietta St.. Covent Garden SAUNDERS' SUCCESSFUL PUBLISHING AS is well-known, the lists of most publishers contain a number of books that have nc\er paid, and for which the publisher will never ^et back the mone\^ invested. Messrs. W. B. Saunders & Company would call attention to the fict that they have no such works on their list. In all the years of their business experience they have never published a book at a U)ss. This they confidently consider a most remarkable record, and submit the fact to the attention of the profession as an example of what mii^ht justly be called " Successful PublishiuL;." A Complete Catalogue of our Publications will be Sent upon Request s.u:\7>/-'a:s' book's ox Saunders' Pocket Medical Formulary Sixth Edition, Revised Saunders' Pocket Medical Formulary. By William M. Po\VKi,L, Al. 1)., author of " Essentials of Diseases of Chil- dren " ; Member of Philadelphia Pathological Society. Con- taining 1844 formulas from the best-known authorities. With an Appendix containing Posological Table, Formulas and Doses for Hypodermic Medication, Poisons and their Antidotes, Diam- eters of the Female Pelvis and Fetal Head, Obstetrical Table, Diet-lists, Materials and Drugs used in Antiseptic vSurgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, etc., etc. In flexible morocco, with side index, wallet, and flap. $2.00 net. CONTAINING 200 NEW FORMULAS In compiling this handy volume the author has introduced as many of the more important recently discovered druijs as possible. Besides the many hundreds of famous formulas collected from the works ot the most eminent physicians and surgeons of the world, it contains many valuable, and hith- erto unpublished, prescriptions from the private practice of distinguished practitioners of to-day. In this new edition the work has been thoroughly and carefully revised and corrected, and some two hun;l.-idly exchnnge a multitude fif the relatively useless works which but encumher all branches <>l medicine for one so comprehensive so exhaustive, so able, and so remarkable in its field as this." THE PRACTICE OE MEDIC EYE Anders' Practice of Medicine Fifth Revised Edition A Text=Book of the Practice of Medicine. By James M. Anders, M. 1)., Ph. I)., LL. D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadelphia. Handsome octavo, 1297 pages, fully illustrated. Cloth, $5.50 net ; Sheep or Half Morocco, $6.50 net. FIVE LARGE EDITIONS IN FOUR YEARS The success of this work as a text-book and as a practical guide for physicians has been truly phenomenal. Five large editions have been called for in less than four years. The rapid exhaustion of each edition has made it possible to keep the book absolutely abreast of the times, so that Anders' Practice has become justly celel)rated a.s the most up toclate work on practice. In this edition extensive changes have been made in connec- tion with the large group of Infectious Diseases The etiology and mode of transmission of Malaria and of Yellow Fever have V^een almost entirely rewritten. Certain affections of growing importance, as Dij)htheritic Dysen- tery and Parasitic IIemo])tysis, have been recast and more fully discussed. The new articles include Fatty Infiltration of the Heart, Streptococcus Pneu- monia, and Acute Diffuse Interstitial Nephritis. PERSONAL OPINIONS James C. Wilson, M. D., Pr/)/essiu- I'/ the Practice of Medicine and of Clinical Medicine. Jefferson Medical Collide, I'/tiladel/>hia. " It is an excellent book — concise, comprehensive, thorough, and up-to-date. It is a credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." A. C. Cowperthwait, M. D., President if ilte Illinois Homeopathic Medical Association. " I consider Dr. Anders' book not only the best late work on Medical Practice, but by- far the best that has ever been published. It is concise, systematic, thorough, and fully up-to-date in everylliiiig. I consider it a great creilit tn both tliu author and the pub- lishers, " SAUA'DERS- BOOK'S ON AMERICAN EDITION NOTHNAGEL'S PRACTICE i;ni>ek the KDiroRiAi, sui'i:r\ isiuN ok ALFRED STENGEL, M.D. Professor of Clinical Medicine in the University of I'cnnsylvania; Visiting rhysician to the Pennsylvania Hospital. BEST IN EXISTENCE FOR THE PRACTITIONER It is universally acknowledged that the Germans lead the world in Internal Medicine; and of all the German works on this subject, Nolhnagel's " Speci- elle Pathologic und Tiieraijie" is conceded by scholars to be without question the best Practice of Medicine in existence. So necessary is this l)ook in the study of Internal Medi- cine that it comes largely to this country in the orig- inal German In view of these facts, Messrs. W. B. .Saundi'rs & Company have arranged with the pub- lishers of the (ierman edition to issue at once an authorized .Vniericaii edition of this great Practice of Medicine. For the present a set of ten volumes, selected witli especial thought of the needs of the practising physician, will be published. These volumes will con- tain the real essence of the entire work, and the jiurchaser will therefore obtain, at less than lialf the cost, the cream of the original. 1 ,nter the special and more strictly scientific vohinies will be offered from time to time. The work will be translated by men possessing thorougii knowledge of both linglish and German, and each V(jhime will be edited by a prominent specialist. It will thus be brought thoroughly up to date, and tiie .American edition will be more than a mere translation ; for, in addition to the matter contained in the original, it will rcpre- -^ent the very latest views of the leading American and h'nglish specialists in the various di partnients of In- ternal Medicine. Moreover, as each volume will be revised to the date of its pnbMcation by the eminent editor, the objection that has heretofore existed to treatises published in a number of volumes will be obviated, since the subscriber will receive the comjileted work while the earlier volumes are still fresh. The .American publication of the entire work is under the ediloi ial supervision of Dr. Ai.i'Ki'.l) Stkncki,, who has selected the subjects for the American P^dition, and has chosen the editors of the different volumes. The usual method of publishers when issuing a publication of this kind has been to compel physi- cians to take the entire work. This seems to us in manv cases to be undesirable. Therefore, in pur- chasing this Practice jihysicinns will be given the opportunity of subscribing for it in entirety ; but any single vohmie or any number of volumes, each complete in itself, may be obtained by those who do not desire the complete series. This latter method offers to the purchaser many advantages which will be appreciated by those who do not care to subscribe for the entire work at one lime. SEE NEXT TWO PAGES FOR LIST PROMINENT SPECIALISTS VOLUMES SOLD SEPARATELY THE PRACTICE OF MEDICINE AMERICAN EDITION NothnageTs Practice VOLUMES NOW READY Typhoid and Typhus Fevers By Dr. H. Cukschm ann, of Leipsic. The entire volume edited, with additions, by Wm. Osi.ek, M. D. , F. R. C. P., Professor of the Principles and Practice of Medicine, Johns Hopkins University, Bait. Octavo, 646 pages, illustrated. Cloth, jg5.oo net ; Half Morocco, $6.00 net. " The monograph on typhoid fever is the best exponent of the knowledge that we have in regard to this disease that is to be had in any language. "^yy«r««/ of the A»ie>'can Mt'dical Association. Smallpox (including Vaccination), Varicella, Cholera Asiatica, Cholera Nostras, Erysipelas, Erysipe- loid, Pertussis, and Hay Fever By I)K. H. ImmI'.kmann, of Basle; I)K. 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