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A CLINICAL SYSTEM OF TUBERCULOSIS 








Pe CrINIGAl SYSTEM. OF 
TUBERCULOSIS 


DESCRIBING ALL FORMS OF THE DISEASE 


BY 


Dr. B. BANDELIER) ax» Dr. O. ROEPKE 


Medical Director to the Sanatorium Medical Director to the Sanatorium 


Schwarzwaldheim at Schomberg, for Ratlway Workers at Stadtwald 


near Wildbad in Melsungen, near Cassel 


Translated from the Second German Edition 


BY 
G. BERTRAM HUNT, M.D., B.S. 


Late Physician to the Scarborough Hospital 


THE MACMILLAN CO. OF CANADA jg bl BE 
TORONTO 


1913 





TRANSLATOR’S PREFACE. 


THERE are various distinct advantages in the method adopted 
by Drs. Bandelier and Roepke of considering all forms of tuber- 
culosis together in one volume. The distinction formerly drawn 
between ‘‘ medical’’ and ‘‘surgical’’ forms of the disease is 
steadily becoming obscured; specific treatment, various forms of 
rays, and other conservative measures are being increasingly used 
for tubercular glands, bones, and joints, while many forms of 
abdominal tuberculosis are now frequently submitted to operation, 
and active measures, designed to produce compression, are being 
taken even against phthisis. Many of the modern biological 
methods of diagnosis are the same, too, in all forms of the 
disease. Some forms of tuberculosis can be better studied in 
one organ, some in another. The action of tuberculin on tuber- 
cular tissue can be more easily and directly observed in the eye 
than in an internal organ like the lungs; just as many of the 
changes produced by inflammation were worked out in the eye, 
the results thus obtained being afterwards applied to the more 
inaccessible organs. 

This consideration of tuberculosis as a pathological entity is 
certainly logical; that it also meets the requirements of the prac- 
titioner is shown by the fact that a new edition of the German 
work was called for in a little more than a year. 

In the belief that it should be equally useful to the English- 
speaking medical public the whole work has been translated, with 
the exception of parts of certain sections dealing with German 
sanatoriums, health resorts, and colonies, and the legal regula- 
tions in connection with public health and the German Insurance 
Act; also certain directions as to the technique of animal experi- 
ments have been abbreviated. 

Wherever desirable the metric system has been converted into 
the English, and the Centigrade scale into Fahrenheit. The 
doses of tuberculin in the original were given in fractions of the 
cubic centimetre; these have been changed to the cubic millimetre, 


Vi TRANSLATOR’S PREFACE 


as being both more convenient and more in accord with several 
recent English works. 

Although in the text some references are made to English 
and French workers, it will be found that the authorities men- 
tioned at the end of the book are almost entirely German. No 
attempt has been made to alter or add to this list; as it is felt that 
this deficiency is of less importance in the English translation 
than in the original, English readers being able to supply many 
of the omissions themselves. 

Drs. Bandelier and Roepke are already known to many 
English-speaking practitioners, since a second edition of the 
English translation of their work on “ Tuberculin in Diagnosis 
and Treatment ’’ is about to appear. 

I am indebted to Dr. Morland, of Arosa, for help with the 
chapter on pulmonary tuberculosis. 

For the few foot-notes which have been added, I am solely 
responsible. 

THE TRANSLATOR. 


AUTHORS’ PREFACE TO THE SECOND EDITION. 


WHEN a medical work of the size of our ‘‘ Die Klinik der 
Tuberkulose ’’ requires a second edition after one and a halt 
years, it proves that a book treating of all forms of tuberculosis 
has become a necessity for the medical profession, and also 
shows the opinion that is held of it as a scientific work. 

The present second edition has not been altered either in 
form or in purpose. It has been our chief aim to give in due 
order, and as shortly as possible, a full and complete clinical 
description of every form of tubercular disease, so that specialists 
and hospital physicians, but, above all, general practitioners and 
students, may be able to find in one work information concerning 
tuberculosis on its anatomical, clinical, diagnostic, prognostic, 
therapeutic, and prophylactic sides. 

The alterations and additions in this present issue have been 
chiefly designed to give the latest discoveries and the most recent 
views in all the chapters of the book. Therefore no chapter has 
remained entirely unaltered; several, as those on tuberculosis of 
the upper air passages, the blood and lymphatic systems, the 
digestive organs, the skin and the nervous systems have been 
completely reconstructed, as has also that on the disease in child- 
hood; the sections on the climatic and surgical treatment of 
pulmonary tuberculosis, and those on tuberculosis of the kidney, 
the bladder, the tonsil, the throat, and the larynx have been con- 
siderably increased. New schematic charts for recording the 
condition of the lungs and new temperature charts have been 
added. Further remarks have been made on the ways and means 
of introducing a general system of treatment founded on the new 
laws of State insurance; and sections on tuberculosis of the gall- 
bladder, on Hodgkin’s disease, on the tubercular psychoses and 
mental states, &c., make their first appearance. 

We have also introduced, according to desire, plates from 
Robert Koch’s immortal work on ‘‘ The Etiology of Tubercu- 
losis,’? on the bacteriological diagnosis, and on the pathological 
anatomy of tuberculosis of the lungs and larynx. On the other 
hand, we have not considered it necessary to include pictures of 


vill AUTHORS’ PREFACE 


reclining couches, of spittoons, of instruments, Or of invalid furni- 
ture. In view of the essentially practical aim of this work we 
have purposely limited the allusions to the literature of the sub- 
ject, but we have made the index of references more convenient 
by dividing it into chapters. 

The first edition of this book has been very favourably 
received, having been praised by the responsible medical press 
both in Germany and other countries. We wish to thank all our 
critics and reviewers, especially those who have called our atten- 
tion to deficiencies, or who have expressed wishes for alterations. 
We have examined all suggestions, and have introduced them 
into this second edition, whenever they appeared to us to be 
improvements. 

By this means the second edition has been increased by more 
than 160 pages, apart from figures and plates. The publishers 
have not raised the price substantially, in spite of these additions, 
and in spite of the excellent way in which they have produced the 
work, for which we are thankful to them. 

A Spanish edition of ‘‘ Die Klinik der Tuberkulose ’’ has 
already appeared; an English one will soon follow. 

Our wish is that this book may henceforth play a part in 
stimulating interest in the clinical and practical recognition and 
treatment of tuberculosis in all its forms as a disease of the people. 
With this hope we offer our work to the public. 


THe AUTHORS. 
Melsungen and Schomberg, 
May, 1912. 


CONTENTS. 


[A TIOLOGY OF TUBERCULOSIS 


> 1.—HISTORY OF TUBERCULOSIS 
_—THE TUBERCLE BACILLUS ... 
, 3.—HISTOLOGY OF TUBERCLES 
- 4.—PATHS OF INFECTION 
5.—HEREDITY 
6.—-PREDISPOSITION 


NO 


Il.—PULMONARY TUBERCULOSIS ... 


1.—ANATOMICAL CHANGES 
- 2,—SYMPTOMS AND COURSE 
3.—DIAGNOSIS an ae Sti2 
i.—The History of the Patient 
ii.Physical Diagnosis 
iii.—Bacteriological Diagnosis 
iv._—Diagnosis by means of Tuberculin 
v.—Diagnosis by Réntgen Rays 
vi.—Other Diagnostic Methods 
vil.—Differential Diagnosis 
4.—PROGNOSIS 
5.— PREATMENT 


~ 4,—General Hygienic and Dietetic Treatment ... 


~ ij—The Specific Treatment 
— ii.—Surgical Treatment 
ee ive-— Tuo sLreatment 2. 
- y.—Inhalation Treatment 
- vi.—The Pneumatic Treatment 
~ vii.—Climatic Treatment 
A.—Mountain Climates 
B.—Climates at a Low Altitude 
C.—Sea Climates 
viil.—Watering Places 
ix.—Symptomatic Treatment 


x._Treatment in Sanatoriums, Health Resorts and 


Hospitals 
- xi.—Home Treatment 


6.—PROPHYLAXIS 


lll.—_TUBERCULOSIS OF THE PLEURA 


1.-_TUBERCULAR PLEURISY 
2._-TUBERCULAR PNEUMOTHORAX 


X CONTENTS 


PAGE 

iV. TUBERCULOSIS OF THE UPPER AIR PASSAGES 232-202 
I.— TUBERCULOSIS OF THE NOSE ... ae 7a ae dass 
2.—TUBERCULOSIS OF THE NASO-PHARYNX ... Pee ae Rae ahs: 
3.—TUBERCULOSIS OF THE LARYNX ... - Boe <1) 240 
4.—TUBERCULOSIS OF THE TRACHEA OF THE LARGER Baowe Hl 2 eee ou 

Y V.—TUBERCULOSIS OF THE DIGESTIVE ORGANS 203-303 
1.-—TUBERCULOSIS OF THE MOUTH AND TONSIL ... tee Ljs) eer 
2.—TUBERCULOSIS OF THE PHARYNX ae ise ae = 271 
3.—TUBERCULOSIS OF THE CESOPHAGUS _... Be oe o00 ee 
4.—TUBERCULOSIS OF THE STOMACH oe a Si pee? 7 (6) 
5.—TUBERCULOSIS OF THE INTESTINE ae ae ame ee 
6.—TUBERCULOSIS OF THE PANCREAS oe. ee set ><a ZOD 
7.—TUBERCULOSIS OF THE LIVER ... fe i ae 2) 9202 
8.—TUBERCULOSIS OF THE GALL-BLADDER ... — are Ss2 ed. 
9.--TURBERCULOSIS OF THE PERITONEUM _... we Pee 32 zoS 
10.—-TUBERCULOSIS OF HERNIAL SACS Ae wes feos se ix gos 


w~ VI.—TUBERCULOSIS, OF THE UROGENITAL ORGANS 304-341 


A.—UROGENITAL TUBERCULOSIS OF MEN ... - ee joe, ASO 
t.—Tuberculosis of the Urethra ne 2 hi: «36 
2.—Tuberculosis of the Prostate an : Set 4 SOF 
3.—Tuberculosis of the Vesicule Semnales + 309 
4.—Tuberculosis of the Testicle, the Epididymis, ned ee 

Vas Deferens Shr yee ae ee ieee eS 
5.—Tuberculosis of the Unatrsy Bladder ... a. vee Beye 
6.—-Tuberculosis of the Kidney and Ureter An 25 RESO 
7.—Tuberculosis of the Suprarenal Body ... vs van 22 

B.—TUBERCULOSIS OF THE FEMALE GENITAL ORGANS ... ee, 
1.—Tuberculosis of the Vagina ce at : tg 25 
2.—Tuberculosis of the Uterus 553 Pat ae an 1ges 
3.—Tuberculosis of the Tubes An = as sf Bae 
4.—Tuberculosis of the Ovaries ace Se sh jun RSBS 
5.—Tuberculosis of the Breast ve BeBe 
6.—Tuberculosis in connection with Maniacs! Preenaueed 

the Puerperium, and Abortion ... a shel soe oe ae 


la VII. TUBERCULOSIS OF THE VASCULAR AND LYMBEH- 


ATIC SYSTEMS 2 216 ; mS 342-363 
I1.—TUBERCULOSIS AND THE BLOOD at a ES = eee 
* _2,—-TUBERCULOSIS AND THE CIRCULATION ... ars a : iss 
3.—TUBERCULAR PERICARDITIS Cee ao ae act i Bas 
4.—-TUBERCULAR MYOCARDITIS re ee =f SY ese 
5.—TUBERCULAR ENDOCARDITIS Lae ; fms a3 so) SR 
6.—TUBERCULOSIS AND THE LYMPH-STREAM ae = ne Se 
7.— TUBERCULOSIS OF THE LYMPHATIC GLANDS... ie 25 SeSES 
8.—TUBERCULOSIS OF THE SALIVARY GLANDS = ae PE le te 
9.—TUBERCULOSIS OF THE THYROID GLAND Me Ba! SSO 
10..-TUBERCULOSIS OF THE SPLEEN ... ey. a ee ce BOS 


11.—HODGKIN’s DISEASE ae Lie tg fe = .y egOz 


CONTENTS XI 


SY VIUlL—TUBERCULOSIS OF THE SKIN oe ee “ce 364-380 
A.—TRUE TUBERCULAR DISEASES... oa = Ld --- 365 
1.—Tuberculosis cutis propria =e _ ays 305 
2._—Scrofuloderma = 366 
3.—Lichen Se afulosaram s Be = = .. 368 
4.—Tuberculosis cutis verrucosa = "ar ie pas 
5.—Tuberculosis cutis necrogenica .-.- ah ae ... 370 
6.—Lupus vulgaris = Be ae = < a 637 
B.—THE TUBERCULIDES = <a ss: ae =i egor 
1.—Erythema Z = 382 
2.—Acnitis and Folliclis ze 2S: sic 383 
3-—Ame cachecticorum sive scroiulosorum 384 
4.—Erythema induratum 385 
5.—Lupus pernio ... - 386 
a —tLupus erythematodes 386 


J IX._TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 390-416 


_1.—TUBERCULOSIS OF THE MUSCLES wee : = 300 
>—TUBERCULOSIS OF THE TENDON SHEATHS AND  Burs® <i ks SOE 
3.—TUBERCULOSIS OF THE BONES AND JOINTS. _.-. <a Os 
4.—TUBERCULAR RHEUMATISM 533 ee 5s So ALT 
X— TUBERCULOSIS OF THE NERVOUS SYSTEM ... 417-436 
1. TUBERCULAR NEURITIS. ..- oa = ag =. | ADT 
2—TUBERCULOSIS OF THE SPINAL Coup a esp a 4 »420 
3.—TUBERCULOSIS OF THE BRAIN ..- a nee oe La) 423 
4.—TUBERCULAR MENINGITIS ree 2 ARS 


5._-FUNCTIONAL NERVOUS- CHANGES IN TUBERCUI LAR PATIENTS 430 
6—-NEUROSIS AND PSYCHONEUROSIS IN TUBERCULAR PATIENTS 431 
7._TUBERCULAR PSYCHOSIS AND TUBERCULAR MENTAL DISEASE 434 


Xf— TUBERCULOSIS OF THE EYE =F = ae 430-451 
1 TUBERCULOSIS OF THE CONJUNCTIVA ..- = a -. 437 
> TUBERCULOSIS OF THE CORNEA = mee = ... 4390 
3.—TUBERCULOSIS OF THE SCLERA .-.. a a ... 441 
4.—TUBERCULOSIS OF THE [RIS AND Crary Bony Ae -.. 442 
5.—TUBERCULOSIS OF THE CHOROID a = wee =-- 445 
6.—OTHER TUBERCULAR EYE DISEASES a = ree --- 447 
>.—TUBERCULIN IN DISEASES OF THE EYE ae A =) Bay 
} 
| Xil_TUBERCULOSIS OF THE EAR _ = = 452-465 
1.—-TUBERCULOSIS OF THE EXTERNAL EAR = ix -.. 452 
dj > TUBERCULOSIS OF THE MIDDLE EAR ... es = .. 453 
ar 3.—TUBERCULOSIS OF THE INTERNAL EAR ay) eR... “abe 
> 
KHEL—MILIARY TUBERCULOSIS -- = == 466-472 


Pe 





BUMRMEEGRONUEA 0 ABS 


Kit 


XV.—TUBERCULOSIS IN CHILDREN 


EISiMOe AULHORTETES, 
i.—Etiology of Tuberculosis 


ji.— Tuberculosis 
iii.— Tuberculosis 
iv.—Tuberculosis 
v.—Tuberculosis 
vi.—Tuberculosis 
vii.—Tuberculosis 


Systems ... 


vili.—Tuberculosis 
ix.—Tuberculosis 
x.—Tuberculosis 
xi.— Tuberculosis 
xii.— Tuberculosis 


xiii.—Miliary Tuberculosis 


xiv.—Scrofula : 
xv.—Tuberculosis 


CONTENTS 


aichaldnoad 







PAGE 
484-510 

ad r 7 
51 1-520 


of the Lungs --.- aon oF AA 
of the Pleura aa oD 
of the Upper Air eee 
of the Digestive Organs 


of fhe Bin! : ‘ 
of the Organs of Pecomanaen 

of the Nervous System 
of the Eye 
of the Ear 


CEHIAPIE Res Ie 


Etiology of "Tuberculosis. 


1. HISTORY OF TUBERCULOSIS. 


TUBERCULOSIS, in its chronic pulmonary form, was even 
in antiquity a well-known and_ probably a_ widely-spread 
disease. To the clear picture drawn by Hippocrates (B.C. 400) 
only slight touches were added by Celsus, Aretzeus and Galen. 
We find no further progress in the knowledge of the nature 
of the disease till the seventeenth century. Sylvius was the first 
to bring out the relationship between the nodules in the lungs 
and phthisis; he considered them as enlarged lymphatic glands, 
a view rejected by Morgagni and Baillie. Bayle recognized in 
miliary tubercle, as it was afterwards called by him, the 
anatomical basis of tuberculosis as a general disease. From 
Bayle’s various forms of pulmonary tuberculosis Laennec 
separated gangrene of lung, cancer, &c., as not being tubercular 
processes, and so proclaimed the unity of the disease. The con- 
ception of tubercle as a new formation held its ground against 
the views of Broussais and Andral, who believed it to be a 
product of inflammation. Virchow separated caseous pneumonia 
from the processes characterized by tubercle formation, and so 
started the theory of duality, which was brought to an end by 
Robert Koch’s discovery of the tubercle bacillus in 1882. 

The idea of the infectious nature of phthisis took root early. 
It is of interest that the bearers of two well-known names, Val- 
salva and Morgagni, were afraid to dissect phthisical corpses. 
Laénnec considered himself infected through a wound received 
in making an autopsy on a case of phthisis. The conviction of 
the contagiousness of consumption, and the intention to prevent 
its spread, are expressed, for example, in the regulation made 
in Italy at the end of the eighteenth century, that clothes and 
bedding used by consumptives on their death must be burnt. The 
first to produce artificial tuberculosis by inoculation on a rabbit 

I 


2 A CLINICAL SYSTEM OF TUBERCULOSIS 


was Klencke. Villemin showed the infection of tuberculosis by 
further important animal experiments, using tubercles, caseous 
tubercular tissue and sputum, and also material from a tubercular 
cow. He did not obtain, however, general acceptance for his 
views. It remained for Robert Koch to show that in all tuber- 
cular tissue and material, and only in them, there was a charac- 
teristic little rod, which could be grown on artificial media in 
pure culture; the inoculation of this culture on animals producing 
typical tuberculosis, in which the same organism was to be found. 
By this discovery of the tubercle bacillus the question of the 
ztiology of tuberculosis was solved. 


2. THE TUBERCLE BACILLUS. 


The tubercle bacillus is a straight or slightly curved little rod, 
whose length on an average is about half the diameter of a red 
blood-corpuscle. It has no power of movement. In its growth 
it is unusually polymorphic, forming short or long rods, strings, 
chains, clubs and branched forms. The bacilli lie singly or in 
groups or clumps, sometimes they are arranged in plaits. Ina 
hanging drop they show strongly refractive granules. On stain- 
ing they are often seen to contain clear spaces at regular distances ; 
these were at first thought to be spores; now they are generally 
considered to be vacuoles. The bacilli have, according to the 
now generally accepted view, a fatty or waxy envelope, which 
gives them their specific staining properties, and also accounts 
for the unstained spaces. It is to this envelope also that the 
bacilli owe their powers of resistance to such external influences 
as cold, dryness, putrefaction and chemical agents. The bacillus 
dies on being heated to about 80° C. It is, however, very sensi-. 
tive to light; it is killed by exposure to direct sunlight for a few 
minutes, or to diffuse daylight for a few days. It cannot multiply 
outside the human or animal body, being thus an obligatory 
parasite. In artificial media it grows only in the presence of 
oxygen and at the temperature of the body. 

The bacilli treated with alcohol and ether are dissolved into 
free fatty acids, neutral fats and wax; further into albumens, 
carbohydrates, and mineral constituents (Asche). According to 
Deycke, it is the neutral fats which really confer the great resist- 
ing powers on the tubercle bacilli, while their special staining 
reaction is bound up in fatty acids, for the neutral fats are in 
their pure state absolutely unstainable. 

The specific staining reaction of tubercle bacilli is that the 
colour is fast to both acids and alcohol. The usual staining 


ETIOLOGY OF TUBERCULOSIS 3 
methods are those of Ziehl-Neelson and Gabbet; they leave the 
tubercle bacilli stained red on a blue ground. Recently Much 
has discovered in tubercular and lupoid tissue, as also in tuber- 
cular products, a rod-shaped, beaded organism, which he takes 
to be a growing or persisting form of tubercle bacillus: this he 
has named the Granula. They are not stained by the above- 
mentioned methods, but only by Gram’s process. 

Much, Deycke, and others have also found the granules where 
tubercle bacilli cannot be discovered; Deycke especially in bovine, 
bone and joint tuberculosis; Kriiger and Much also in lupus 
tissue. It is still undecided whether they are to be considered as a 
special growing or resting form of tubercle bacillus, or whether 
they are rather a degenerate form. Deycke and Much put forward 
the view that the granules are the primitive original form, from 
which the acid-fast tubercle bacillus has developed phylo- 
~ genetically; and that under the influence of bacteriolytic forces 
the acid-fast bacilli revert to the primitive and resisting forms 
(granula). According to Much they consist, probably, chiefly of 
nuclein. From their resistance to the action of antiformin he 
concludes that they also contain fat. As they have lost the 
Ziehl staining reaction, it is known that they do not contain fatty 
acids. According to the researches of Deycke, their power of 
resistance is only dependent on the presence of neutral fats. 

Further investigation is required into the prognostic signifi- 
cance of Much’s granules in tuberculosis. According to our 
observations up till now, cases with Much’s granules in the 
‘sputum have a favourable prognosis. As regards diagnosis, our 
examination has shown that granules can frequently be detected 
in the sputum when Zieh] staining bacilli cannot be found. We 
must, however, take care only to reckon those structures as 
granules which by their shape and arrangement can be recognized 
as bacilli in groups. 

According to the latest observations of Bittrolff and Momose 
in the Heidelberg Institute of Hygiene no other forms of the 
tubercle bacillus can be shown by Much’s method than by Ziehl’s. 


The very various material examined was obtained from the different 
forms of human tuberculosis, and from tuberculosis of cattle, swine, birds, 
rabbits, and guinea-pigs, and also from a large number of pure cultures 
of different ages, both human and bovine. In every preparation it was 
found that the tubercle bacilli, which stained with Much’s method, were 
also acid-fast when stained by Ziehl. Also, the cases negative to Ziehl’s 
method never gave a positive result to Much’s. In several cases the 
granules recognized by Much’s method with Ziehl’s appeared as short, acid- 
fast rods. If the tubercle bacilli by the action of various chemical agents 
were deprived of their property of being acid-fast, then also in the pre- 
parations by Much’s method the granules in the bacilli disappeared. Not 


4 A CLINICAL SYSTEM OF TUBERCULOSIS 


on one occasion could the disappearance of the acid-fast component of the 
tubercle bacillus with the persistence of the Gram-positive albuminous 
ground substance of Much be obtained. The authors mention the necessity 
of prolonged staining for twenty-four hours in Ziehl’s method for such 


researches. 


The human tubercle bacillus is under suitable experimental 
conditions transferable to all warm-blooded animals, and evokes a 
similar disease to human tuberculosis. But it is probable that 
each animal species has its own special producer of tuberculosis, 
all of which exhibit great biological resemblance. The bacilli of 
tuberculosis in the cold-blooded animals are also closely related 
to the other forms. In the same species may be included also the 
similar forms of pseudo tubercle bacilli found in men, animals, 
and plants, which share with the tubercle bacilli the property of 
not being decolorized by acids, and which are therefore known 
as acid-fast: such as the Timothy bacillus, grass-bacillus II, 
dung, milk, butter, leprosy, smegna and pseudo bovine tuber- 
culosis bacilli. 

It is now well established by experiment that, contrary to 
the older view, tubercle bacilli are met in varying strains with 
regard to their virulence; this fact is of importance in connection 
with the progress of infection in the human body. 

Many of the general symptoms of tuberculosis are ascribed 
to the absorption of toxic products of the tubercle bacilli. We 
are concerned here partly with the secretion products of living 
bacilli, which are true toxins but with a difference; and partly 
with the endotoxins, which are set free by the death and breaking 
up of cell bodies. 


3. HISTOLOGY OF TUBERCLES. 


The regular local tissue changes produced by living tubercle 
bacilli are on the one hand the result of the mechanical irritation 
of foreign bodies, causing a useful proliferation having a repara- 
tive character; on the other hand the products of disintegration 
and the endotoxins evoke an inflammatory exudation. The tissue 
reactions vary according to whether one or the other process pre- 
dominates. 

The entering bacilli multiply, stimulate their surroundings 
to an exuberant growth, and cause a new formation of epithelioid 
cells, chiefly produced from connective tissue cells. In these 
central epithelioid cells, thus produced, a plentiful appearance of 
karyokinetic figures can be observed after seven days. This 
proliferation affects not only the connective tissue, but also the 
epithelial and endothelial cells of the vessels, and causes by 


Bandelicr and Roepke, Clinical System of Tuberculosis. Plate II. 





Fig. 1. Section from a phthisical lung showing the advance of the tubercle-bacilli into the alveoli. 


“a 





Fig. 2. Part of the internal wall of a large cavity. On the right the free border of the cavity. On th 
left the collapsed airless alveolar tissue. 


After R. Koch, Die Atiologie der Tuberkulose. (Berlin, Springer.) 


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ZETIOLOGY OF TUBERCULOSIS 5 


repetition of the cell division a great piling-up of epithelioid cells. 
Between these are found small round cells with strongly staining 
nuclei, which-are wandering leucocytes, motile cells that play the 
chief réle in the transport of tubercle bacilli. From the great 
enlargement of single epithelioid cells and nuclear multiplication 
are formed the giant cells, well known cells that often contain 
tubercle bacilli. Between the nuclei and the bacilli there exists 
a kind of antagonism; so that if the nuclei are found at one pole, 
the bacilli will be at the other. By the production of new cells 
the stroma of the original connective tissue is pushed apart and 
opened out, and so gives rise to the reticulum of the tubercle. 
The cell proliferation exercises a pressure on the peripheral layers, 
and so causes a dense heaping-up and flattening of these cells, 
tending to an encapsulation of the tubercle. The included vessels 
are destroyed by coagulation. 

The now completed tubercle forms macroscopically a little, 
grey, transparent granule, of the size of a millet seed (miliary). 
The further ultimate fate consists in caseous or fibrous changes. 
In the centre begins a gradual death of the cells, first of the 
leucocytic elements, then of the epithelioid cells; the nuclei 
disintegrate and lose their staining properties. There is now a 
uniform mass of débris enclosing fat globules—caseation. Macro- 
scopically the tubercle takes on a yellow colour. With or without 
the co-operation of other bacteria suppuration or softening follows. 

The process of healing of tubercle comes about in the follow- 
ing manner. The epithelioid cells exhibit prolongations and 
lengthen into spindle-shaped fibroblasts. Next a network of 
fibres is built up that gradually penetrates the whole tubercle, and 
converts it into fibrous tissue. This is healing by fibrous trans- 
formation. But it may happen that the caseous contents remain 
encapsuled in the connective tissue, and will be absorbed or 
calcified. The histological changes of tubercle are largely the 
same in the tissues of different organs. 


4. PATHS OF INFECTION. 


While in most infectious diseases only certain organs are 
attacked, in tuberculosis any organ may be the seat of the disease. 
The question therefore arises which are the favourite paths of 
entry of the tubercle bacillus, and which are the most frequent 
and important sources of infection in human tuberculosis? As 
the lungs and their lymphatics are the seats of predilection for 
tubercle, they are to be chiefly considered in discussing this 
question. 


6 A CLINICAL SYSTEM OF TUBERCULOSIS 


The skin need hardly be considered as a portal for the entry 
of the tubercle bacillus; for in an intact state it is not permeable, 
and so offers no favourable ground for its development. There- 
fore an entry can only be made through the mucous membrane 
lining the interior of the body. In fact, this passage through 
the mucous membrane is met with frequently, leading to the 
lodgment of the bacilli in the individual organs. 

In childhood the lymphatic glands are extremely sensitive to 
tuberculosis in the form of scrofula. The glandular tuberculosis 
of childhood can be best explained by the entry of bacilli through 
small superticial lesions, especially of the mucous membrane of 
the nose, throat, mouth, or bronchi, probably aided by the predis- 
posing influence of a catarrh. They usually produce no changes at 
the point of entrance, but pass on to the neighbouring glands, 
where they may remain latent for some time. 

The principal gates of entry into the human body are the air 
passages and the gastro-intestinal tract; therefore the aerogenous 
and the enterogenous infections can be distinguished. 

In pulmonary tuberculosis the chief réle is 
naturally played by aerogenous infection. 
According to present views the tubercle 
bacilli can enter the lung either by the air passages or by means 
of the lymphatics and blood-vessels. The supporters of the inhala- 
tion theory rely on the special frequency of localization of the 
disease in the lungs, more especially so at its first onset, and 
indeed to a less degree in advanced stages; on the analogous 
condition of pulmonary anthracosis, which without doubt is due 
to inhalation; and on accurate inhalation experiments on animals 
by the insufflation of only a small number of bacilli, corresponding 
to the conditions obtaining in human infections. The views of 
Cornet and Fliigge are in direct opposition, whether the more 
important part is played by infection from dry, pulverized sputum, 
or by droplets sprayed out during coughing, speaking or sneez- 
ing. It would take us too far to sift the statements for and 
against both views. The comprehensive and exact labours of 
both camps have shown that both kinds of infection are possible, 

and must be reckoned with in devising prophylactic measures. 
Infection through The hematogenous origin of tuberculosis is 
many-sided; and the different explanatory 

the Blood. ; 2 

theories of pulmonary infection through the 
blood are very complicated. In this mode of infection the tubercle 
bacilli entering the body at any point (no matter whether by the 
skin or the mucous membrane of the nose, throat, mouth, digestive 
organs, or urino-generative system) are carried by the lymphatics 


Infection through 
the Air Passages. 


42TIOLOGY OF TUBERCULOSIS 7] 


and blood-vessels to the lungs, which by this theory are accorded 
a peculiar local disposition to the disease. But opinions here 
diverge as to which point of entry the bacilli choose. Ribbert 
holds that the inhaled bacilli traverse the alveolar wall without 
being changed, reach the bronchial lymphatic glands, and there 
provoke a tubercular infection. Occasionally they then break into 
the blood-stream, and reach the apex of the lung for a second time 
with the circulating blood, and infect either the smallest bron- 
chioles or the alveolar passages. It is not yet decided why they 
should not do so at first. Other observers uphold the view that 
the inspired bacilli adhering in the cavity of the nose and mouth 
are absorbed by the tonsils (Beckmann), the pharyngeal tonsil 
(Aufrecht), the mucous membrane of the mouth and the lingual 
tonsils (Westenhoeffer for children), and are transported through 
the lvmph-channels to the cervical glands, and from thence to 
the bronchial and mediastinal glands, pleura, and apices of the 
lungs, or into the arterial blood-stream. But apart from the 
rarity of primary tonsil tuberculosis it is certain that a direct 
connection between the cervical and the bronchial or mediastinal 
glands does not exist at all under normal conditions. The sup- 
porters of the infection of tuberculosis through the blood-stream 
place their reliance chiefly on the frequently found tubercular 
affection of the small arterial branches in early tuberculosis. The 
possibility of such an explanation will be by no means contested, 
but only its general applicability. According to Lubarsch the 
frequency of disease of the small arteries in advanced, and especi- 
ally in very pronounced, pulmonary tuberculosis speaks strongly 
against its primary nature. Also Orth, who first recognized the 
affection of the small vessels, did not consider that it supported 
the view of the frequency of lung infection through the blood- 
stream. On the contrary in advanced lung tuberculosis one can 
see microscopically the overlapping of the processes in the 
bronchioles and arterial walls. 
2 The teaching of v. Behring that infants’ 
Infection through See eos S rs 
milk is the chief source of lung tuberculosis 
the has again brought up the question of entero- 
Intestinal Canal. genous infection. This view of v. Behring, 
founded on the long latency of tubercle bacilli in the lymphatic 
glands, was well grounded, but, as a general explanation, has only 
received small support. This mode of infection was energetically 
advanced by Calmette and his school. Their feeding experiments, 
in which they claim to have produced anthracosis through the 
intestinal tract, cannot be confirmed if proper precautions are 
taken ; but have rather been explained as an inspiration infection 


8 A CLINICAL SYSTEM OF TUBERCULOSIS 


due to experimental errors. Infection through the digestive tract 
is not only concerned with food derived from tubercular animals, 
but also with bacilli of human origin. These acquired by inhala- 
tion or from infected food, table utensils, the fingers, &c., may 
remain in the mouth, and being swallowed with the saliva or 
food, may be carried to the digestive organs. Thus can be 
produced a primary tuberculosis of the tonsils, the lymphatic 
glands of that region, the intestines, the mesenteric glands, or 
other organs; a mode of infection which we, following B. Frankel, 
may call deglutition tuberculosis. This process, however, is 
rarely met with; a progressive tuberculosis does not begin in this 
way, and it is only seen in children. 
A change of views has taken place concern- 
ing the transmission of animal tuberculosis 
to men since Koch’s work on the differences 
between the organisms producing human and bovine tuberculosis, 
a subject on which there is still no complete agreement. From 
the labours of various commissions appointed to inquire into this 
question both in Germany and elsewhere, the following results 
have been obtained. There are two types of tubercle bacilli, one 
peculiar to men and the other to animals, which ‘are best dis- 
tinguished as the human and bovine types. It is certain that 
the human type of tubercle bacillus is not pathogenic for cattle. 
In nearly all of the large number of cases of phthisical sputum 
examined pure cultures of the human type could alone be grown. 
Those cases of human tuberculosis in which the bovine type was 
found occurred nearly always in children, and the tubercular 
changes were generally local, and only slightly progressive. The 
chief source of infection is the phthisical person who coughs and 
spits. The war against tuberculosis, therefore, must first be 
directed against human infection and the human type of bacilli. 
As the chief deductions to be drawn from these definite 
experimental results, Kossel, representing the standpoint of R. 
Koch and the Berlin Institute of Infectious Diseases, enunciated 
the following propositions at the seventh International Congress 
of Tuberculosis, held at Rome this year (1912). Human pulmon- 
ary tuberculosis is with very few exceptions to be traced to an 
infection with bacilli of the human type. The source of infection 
in consumption is almost exclusively to be sought in human 
tuberculosis. (The ingestion of tubercle bacilli of the bovine type 
with the milk or meat from tubercular animals plays a very sub- 
ordinate part in spreading tuberculosis. In the conflict against 
tuberculosis results can only be expected from measures intended 


to prevent or diminish the transference of infection from man to 
man. 


Varieties of 
Tubercle Bacilli. 


ETIOLOGY OF TUBERCULOSIS 9 


Almost at the same time Orth, in a communication to the 
Prussian Academy of Science, while acknowledging the necessity 
of combating infection from human bacilli, comes to a different 
conclusion on the importance of the bovine bacillus. In opposi- 
tion to Koch’s Institute for Infectious Disease, Orth places the 
proportion of the bovine infections in tuberculosis of children at 
IO per cent. at least. Not only does he consider the causation of 
pulmonary tuberculosis ‘by bovine bacilli to be possible, but he 
even thinks he has found evidence of it in the fact that an infection 
with bovine bacilli in childhood, that has been withstood, may 
predispose for a later outbreak of lung tuberculosis. Orth 
ascribes particular importance to the discovery of the so-called 
transitional forms of tubercle bacilli, which he calls atypical 
varieties. Those forms of bacilli which are found in the majority 
of cases of lupus, and which Eber especially has succeeded in 
cultivating, he takes as evidence against the unchangeable stability 
of both types. According to Orth the bovine bacilli play an 
important part in tuberculosis of children and in lupus, and 
“human tuberculosis can never disappear as long as fresh bovine 
bacilli are constantly being transferred from animals to mankind.”’ 


5. HEREDITY. 


Before the discovery of the tubercle bacillus it was natural 
to look for an explanation of the dissemination of tuberculosis in 
the constitutional factor of heredity. That one generation after 
another was carried off was by this means most easily explained. 
But even to-day the pre-natal transmission of the tubercle bacillus 
has celebrated supporters; not permanently, however, since 
aecording to recently developed theories we are not able to find 
a satisfactory explanation of it, though we cannot deny its possi- 
bility altogether. At their head stands v. Baumgarten: ‘‘ The 
bacillus lives not only with man and through him, and does not 
only die with him, but accompanies him in his propagation 
from generation to generation.’’ This view is built, much more 
than any other discussed theory, on the idea of a long latency 
for the tubercle bacilli, and indeed vy. Baumgarten assumes for 
the tubercle bacillus an individual state of existence, still unknown 
to us, like the spores of other bacilli, in which form it emigrates 
from the father directly into the offspring. 

As it has not been proved that the bacilli enter the spermato- 
zoon itself, v. Baumgarten considers that the germinative trans- 
ference from the father has been demonstrated by the experiments 
of Friedmann, who found in animals bacilli mixed with the sperm, 


10 A CLINICAL SYSTEM OF TUBERCULOSIS 


which was thus transferred to the foetus, and later into the different 
organs, while the mother remained free from tubercle. The 
facts discovered by the same observer of the infection of the 
ovum within the ovary from a maternal tuberculosis are possible 
but rare. There has lately been an attempt to explain by this 
theory of v. Baumgarten’s the fact that guinea-pigs can be infected 
from the organs of the foetus of other tubercular guinea-pigs, 
though in these foetal organs there are no tubercular changes, and 
no tubercular bacilli can be detected. 

On the other hand the transference of tubercle bacilli through 
the placenta to the embryo is much more common ; placental tuber- 
culosis offers a proof of this. In fact the number of discoveries of 
tubercle bacilli in placentas, which are normal to the naked eye, 
is increasing from day to day, owing to the recent introduction 
of the accurate antiformin method of Uhlenhuth making possible 
the breaking up of whole pieces of organs, whereby the discovery 
of tubercle bacilli is greatly facilitated. v. Baumgarten lays stress 
on the fact that it is just the early forms of disease of the placenta, 
which can only be recognized with difficulty, that lend themselves 
particularly to the ‘transmission of the disease; and that the less 
the organ itself suffers from the bacilli the more easily will these 
be driven on by the circulation into the body of the foetus. He 
also supports the view of the hereditary origin of the tubercle 
bacilli which are frequently found in the enlarged lymphatic 
glands of new-born infants and of children of a year old. The 
tracheo-bronchial glands are found to be especially affected, so 
they have acquired a particular significance in the production of 
tuberculosis; the disease from them infecting the body through 
the lymphatics and blood-stream. 

By these ingenious views of ante-natal infection, v. Baum- 
garten thinks to have avoided all the difficulties which are opposed 
to the incomplete demonstration of infection through the air and 
intestinal tracts as the usual, frequent, everyday modes of entry 
of tuberculosis; he considers, however, the view of inhalation 
infection as useful, and also admits intestinal infection as a partial 
explanation. 

The views of v. Baumgarten are in opposition with the results 
of the very numerous cutaneous tuberculin tests; new-born 
children give, nearly without exception, no reaction, even when 
the mother shows a positive reaction. Therefore up to now the 
view of the germinative origin of infection has been accepted by 
very few observers; and the development of an infected ovum is 
considered very unlikely. Transference through the placenta, 
which is after all rare, is really an inter-uterine infection ; and so, 


ETIOLOGY OF TUBERCULOSIS II 


properly speaking, cannot be acknowledged as hereditary trans- 
mission. What can be transmitted is only the susceptibility to 
infection, the predisposition. 


6. PREDISPOSITION. 


Careful posi-moriem examination (Nageli, | Schmorl, 
Lubarsch, &c.) has shown the great frequency of tubercular 
deposits, especially in the lungs and their lymphatic glands. As, 
in spite of this frequency, which must not, however, be taken to 
mean universality, only a part of mankind is carried off by tuber- 
culosis, there must be some circumstances in existence which 
modify the progress of the disease; the assumption of a pre- 
disposition cannot be excluded. There is a _ distinction now 
between inherited and acquired predisposition. 

There is still some obscurity about the 
question of an hereditary specific predisposi- 
tion. There are prominent observers who 
only allow it a small place in the etiology of tuberculosis, 
adducing the example of races in a state of nature (Negroes, 
Arabs) in whom tuberculosis is practically unknown, so that they 
can have no specific hereditary predisposition, yet who quickly 
succumb when exposed to the contagion in civilized countries. 
The importance given to the factor of hereditary disposition is 
also diminished by the reduction of tuberculosis which has now 
been secured, and even more by the success in averting infection 
and raising the natural resistance, which has been obtained by 
improvements in the hygienic conditions of life. The faulty 
development and the anatomical weakening in the tissues of those 
from a tubercular stock may be rather considered as results of the 
already acquired latent tuberculosis, than as causes of the predis- 
position to the disease. We are inclined to assume the existence of 
a marked manifestation of the disease in earliest life rather than 
a strong predisposition. On the other hand, it is quite possible 
to conceive that part of the bodily inferiority is a consequence of 
the damage to the germ plasma by the tubercular virus. A new 
impetus towards the better comprehension of hereditary predis- 
‘position has been given by Turban’s idea of the transmission of 
a locus minoris resistent'@, or weak spot, for tuberculosis. Turban 
could prove in more than a hundred cases that pulmonary tuber- 
culosis in members of the same family (descendants or collaterals) 
began in the same part of the lung. It may be a question here 
of the hereditary transmission of a faulty structure of part of an 
organ, a weak anatomical development, or a local tissue weakness ; 


Hereditary 
Predisposition. 


12 A CLINICAL SYSTEM OF TUBERCULOSIS 


for example, an impaired resistance of the elastic fibres (Hess). 
The striking similarity in the localization of pulmonary tubercu- 
losis in persons who are related is confirmed by Strandgaard. 

Besides tuberculosis itself the following are generally con- 
sidered as causes of hereditary predisposition: Other wasting 
diseases (cancer, diabetes), generaly bodily weakness, old age, 
inbreeding, &c. According to Brehmer, in large families it is 
especially the youngest children, and in turn their descendants, 
who are liable to tuberculosis. This hereditary tendency may be 
also seen in very weak premature children, twins and triplets. An 
innate predisposition also awaits the children of life-long bad 
eaters, a fact to which Brehmer has again drawn attention. 

In connection with the hereditary predisposition may be 
considered the question of the fertility of the tuberculous and its 
biological importance for the race. According to the interesting 
and careful observations of Weinberg tuberculosis does not occur 
with any special frequency in fertile families; the fertility also of 
tubercular people is not increased, but seems even to be con- 
siderably less than that of the non-tubercular, and the children 
of tubercular parents have a markedly higher mortality than those 
of unaffected parents. 

The reason for the inborn predisposition lies principally in 
a defective development of certain organs, especially the thorax 
and its contents, which is described by the term  phthinoid 
chest. As more or less well recognized distinguishing marks 
there have been described stenosis of the upper part of the thorax 
(Freund, Hart), smallness of the heart, and abnormal constriction 
of the large blood-vessels, aorta, and especially the pulmonary 
artery (Lebert, Benecke). 

The existence of smallness and weakness of the heart as a 
primary abnormality is, however, by no means certain. The 
affirmative opinion held by Laénnec, Louis, Bizot, Rokitansky, 
and Benecke has been developed further by estimations of the 
volume of the heart, and by recognition of the frequent constric- 
tion of the main arteries. A support for these views was found in 
Virchow’s observation of hypoplasia of the large arteries and its 
importance in chlorosis. Brehmer successfully upheld the view 
that the small heart with too large lungs is an important element 
in the predisposition to phthisis. | We can to-day take it as a 
settled fact that a number of phthisical patients, and even those 
with an asthmatic chest, have a heart below the normal size as a 
primary constitutional abnormality. On the other hand, we have 
also the recent work of Miller, and especially of Hirsch, who by 
weighing the heart have shown that the small size of the 


4ETIOLOGY OF TUBERCULOSIS 13 


phthisical heart is analogous with the general cachexia, and that 
the diminution in size of the organ runs parallel with the wasting 
of all the muscles of the body. 

Towards the production of an acquired pre- 
disposition there are a large number of local 
and general factors, which cannot, however, 
be sharply separated from each other. Among the local predis- 
posing factors the diseases of the various organs play a chief part, 
e.g., mechanical injury to the tissues, disorders of nutrition and 
circulation, and pathological changes in the tissues from other 
infections. The most important general predisposing influences 
are under-feeding, anaemia, constitutional and nutritional changes, 
bodily and mental over-fatigue, serious nervous and_ psychical 
disturbances, infectious diseases, and toxic conditions (syphilis, 
alcoholism). So far as the predisposition for tuberculosis is of 
importance for different organs it will be considered under the 
separate headings. We will only consider a little here the pre- 
disposition for lung tuberculosis, as the general predisposing 
causes for this have also more or less importance for tuberculosis 
of other organs. 

The overwhelming relative frequency of tubercular deposits 
in the lungs is escribed to the peculiar arrangement of these organs 
equally by supporters of the views of infection through the air- 
passages and the blood-stream. Just as the inspiratory air- 
currents bring the tubercle bacilli to the smallest bronchioles where 
there is the least movement, so also the whole volume of venous 
blood is brought to the lungs, with the lymph from all the lym- 
phatic channels. The slowing of the blood-stream in the pul- 
monary capillaries favours the deposition there of any bacilli in 
the circulation. The special predisposition of the lungs is also 
shown by the fact that suitable experiments, even on slightly 
susceptible animals, succeed in producing tuberculosis limited to 
the lungs, no matter by which channel the infection is produced ; 
and by the further experimental result that infection by inhalation 
of a very small number of bacilli takes place in the same way as 
infection, for example, through the intestinal canal. 

Among the local causes of predisposition 
; oa to lung tuberculosis stenosis of the upper 

Predisposition. aperture of the thorax is cf the first 
importance.- Its occurrence was first recognized by Freund, the 
causes of it have lately been investigated by Hart. The first rib on 
one or both sides is shortened, bent, or lengthened; the cartilage 
is ossified, abnormally short, or quite absent; there is thus pro- 
duced an encroachment on the upper aperture of the thorax, on 


Acquired 
Predisposition. 


Local 


14 A CLINICAL SYSTEM OF TUBERCULOSIS 


one or both sides. By the narrowing of the first thoracic ring 
the next ribs will be interfered with, leading to a flattening and 
diminished expansion of the upper part of the chest, so that the 
apices of the lungs are unfavourably affected both in form and 
function, and the phthinoid chest is thus produced. There is, in 
consequence, not only a deficient entry of air, but, what is of 
more importance, an impaired circulation, engendering a weak 
spot favourable to the lodgment and growth of tubercle bacilli. 
Pulmonary stenosis affords a classical example of the fact that 
a deficient circulation through the lung increases the disposi- 
tion to disease, for a very large proportion of these cases die of 
tuberculosis. The anomalies of the first rib, according to Hart, 
are either congenital or are developed secondary to a fixation or 
curvature of the cervical or upper thoracie vertebra (scoliosis, 
kyphosis). They are also frequently the consequence of rickets 
(rickety thorax, pigeon breast, shoemaker’s chest), and states of 
congenital or acquired debility, giving rise to a paralytic thorax, 
which is separated by Hart from the phthinoid chest. These do 
not often appear in childhood, but from puberty onwards. This 
explains why the lung apices in children are not so particularly 
liable to tuberculosis; also in them the lungs do not lie so high 
in the upper aperture of the thorax. 

These abnormal arrangements of the first rib are in agree- 
ment with the discovery of Birch-Hirschfeld, who was able to 
recognize in lungs affected by early tubercular deposits a bending 
and stunting of the ramifications of the posterior sub-apical 
bronchus; and the first onset of tuberculosis was just in the terri- 
tory of this bronchus. The encroachment on the size and 
capacity of the apex of the lung was confirmed by Schmorl, who 
frequently found the formation of a groove in lungs compressed 
by an abnormal first rib. These furrows correspond accurately 
with the distribution of the posterior sub-apical bronchus, which 
Schmorl also recognized as a site of predilection for early tuber- 
culosis. The systematic examinations of Hart have confirmed the 
connection between those abnormalities and the consequent 
mechanical predisposition of the apices to tubercular disease. 
Bacmeister has lately succeeded in producing experimentally on 
young rabbits an isolated apical tuberculosis at the point of 
pressure, by causing a gradual aperture stenosis with consequent 
pressure of the underlying lung apex, and afterwards setting up 
direct and indirect hematogenous infection. 

As further acquired predisposing influences the following are 
of weight: slight injuries to the smallest bronchial tubes from 
inhalation of particles of mineral, metallic, vegetable, or animal 


ZETIOLOGY OF TUBERCULOSIS 15 


dust. The harder, sharper, more pointed the dust particles the 
more likely are they to injure the lung tissue, to open the way to 
tubercle bacilli, and to favour their development by setting up 
chronic inflammation. Likewise some substances, as corrosive 
vapours and gases, cause chemical injuries. As anatomical 
lesions may be caused by various fine mechanical irritants, so 
gross traumatic injuries from direct or indirect violence (punc- 
tures, shots, blows, falls, and crushing) produce injury to the 
lung tissue, and favour possible infections. But much more 
frequently it will happen that a latent inactive focus, usually in 
the bronchial glands, is brought into activity by an injury, or a 
latent but active tuberculosis made evident; which, however, is 
the same thing from the legal point of view. Injurious also are 
catarrh and inflammation of the smaller air passages and of the 
lungs (bronchitis, pneumonia, measles, scarlet fever, whooping 
cough, influenza) from epithelial damage, retained secretions, and 
inflammatory products, opportunity being thus offered to the 
entrance and lodgment of tubercle bacilli. But these diseases, 
especially measles and influenza, much more frequently cause the 
manifestation of a hitherto latent tuberculosis. Lastly, we must 
recognize the predisposing influence of hampered respiratory 
movements due to pleural adhesions, which renders the expulsion 
of intruding bacilli more difficult, and facilitates their develop- 
ment; but here, too, we must remember that pleurisy is very 
often the first symptom of a hitherto quiescent tuberculosis. 

Mention will only be very briefly made of 
the more important of the general diseases 
and of other causes favouring infection: 
anemia, chlorosis, deficient air and light, unhealthy dwellings, 
long hours in close rooms during work, particularly such occupa- 
tions as involve much sitting, unfavourable climate and climatic 
changes, under-feeding, chronic stomach and intestinal disease, 
nutritional and constitutional affections, blood diseases, extreme 
debility following severe infections (typhus, rheumatic fever, 
malaria), advanced nervous disease, syphilis, chronic gonorrheea, 
alcoholism, sexual excess, dissolute life, physical and mental over- 
strain, psychical depression, grief and anxiety, numerous and too 
frequent confinements, severe labour, puerperal complications, 
over-prolonged suckling, &c. All these diseases and bad con- 
ditions, which may be met with in many combinations, induce a 
predisposition by lowering the powers of resistance of the whole 
organism or of individual organs, and increase the probability of 
infection by diminishing the natural resistance of the normal cell ; 
presuming that there is sufficient exposure to the disease. There 


General 
Predisposition. 


16 A CLINICAL SYSTEM OF TUBERCULOSIS 


is also in a certain sense a predisposition when the _ before- 
mentioned morbid influences only choose the critical moment for 
rendering the disease active, or for aggravating latent disease, 
wh:ch in an individual case is not always easy to recognize, and 
in practice comes to the same thing. 

Here it may be mentioned that to certain diseases as gout, 
nephritis, asthma, emphysema, and many forms of heart failure 
have been rightly or wrongly ascribed an immunizing tendency. 
In these conditions the onset of tuberculosis is impeded in fact 
by venous stasis. As is well known, Bier has applied the prin- 
ciple of congestion hyperzemia to the conservative treatment of 
tubercular bones and joints. The general statement of Roki- 
tansky, that there was an antagonism between all forms of val- 
vular disease and tuberculosis, has been limited by Traube and 
v. Leyden principally to mitral stenosis. It is certain that mitral 
stenosis, of all forms of heart disease, is most rarely combined 
with lung tuberculosis, and that pulmonary tuberculosis is 
relatively seldom found with all forms of mitral disease, which 
produce brown induration of the lung tissue in consequence of 
chronic venous congestion. v. Romberg, who holds the view 
that the infection in pulmonary tuberculosis occurs through the 
blood, explains the difficulty the bacilli have in finding a lodg- 
ment in these cases, by the mechanical dilatation of the smallest 
lung capillaries in consequence of the congestion. 

Age and sex likewise affect the nature, onset and course of 
the disease: the male sex is more liable, and in both sexes the 
period of development is the most favoured. The causes for this 
lie only in the individual himself. More important is the presence 
and number of the above-mentioned causes which bring on 
and maintain the disease. 

If there is a difference in the susceptibility 
of different races to tuberculosis, it is not 
yet well understood. Many observers main- 
tain the existence of racial predisposition. ‘‘ The  phthisical 
tendency is diminished for the northern race, just as the apoplectic 
tendency is for the Alpine, brachycephalic race’’ (Sofer). The 
argument of a racial predisposition is not in itself very powerful ; 
in animals quite small differences of race are of greatest import- 
ance in resisting equal infections. On the other hand, the idea 
of a racial immunity, which has been asserted on many sides, 
may really be due to small opportunity of infection, and circum- 
stances in the home-surroundings unfavourable to the growth of 
bacilli. But if tuberculosis is imported into such hitherto more 
or less unaffected countries, it shows itself in a more acute and 


Race and 
Immunity. 


ETIOLOGY OF TUBERCULOSIS 17 
severe form and has a malignant course, as Deycke has shown 
for Turkey. This brings us to the question of race immunity, 
which Reibmayr thinks to have proved for single families, who 
in the struggle for life have acquired and handed down from 
generation to generation a resistance to tuberculosis by having 
recovered from the disease. This is also affirmed by Sofer for 
the whole northern race. In support of this we have the severe 
nature of tuberculosis when imported into new countries, as 
mentioned above. There is an analogy in syphilis which becomes 
less severe when the epidemic has passed through a series of 
generations, as among the Indians. 

In connection with the development of immunity there is 
the idea that a favourable course of a case of chronic adult tuber- 
culosis is caused by a relative immunity conferred by recovery 
from a mild infection in childhood (v. Behring and Roemer). 


CHAPIE RK © Ti. 


Pulmonary Tuberculosis. 


1. ANATOMICAL CHANGES. 


BEFORE discussing the anatomical changes in the lungs, we 

may review shortly the various forms of pulmonary tuberculosis 
according to the mode of entry of the bacillus. Following the 
classification of Heller, we may distinguish: (A) Primary “ in- 
halation ’’’ pulmonary tuberculosis (1) of the alveoli, (2) of the 
bronchioles, (3) of the lymphatic follicles of the lung; and (B) 
Secondary tuberculosis of the lung (4) by inhalation, (5) through 
the blood-stream, (6) through the lymphatics, (7) and by direct 
rupture of a lymphatic gland into the air passages. The initial 
localization of pulmonary tuberculosis may therefore take place 
at various sites, and it is further influenced by the special liability 
of the apices. 
The initial tissue changes in the formation 
of tubercles and their various later modifi- 
cations have already been described in the 
section on the histology of tubercle. By an extension of these 
processes, several small tubercles at the same point caseate in 
their centre, join together and form a caseous nodule of varying 
size. These, like individual tubercles, may become encapsuled 
by connective tissue growth and undergo calcification; or the 
caseous contents may soften and break through into a bronchus. 
There is thus formed a small cavity; and the previously closed 
tuberculosis has become open, permitting the escape of secretion 
containing bacilli into the bronchial tubes and so into the outer 
world. By the emptying of its caseous contents, and the forma- 
tion of granulation tissue, a cavity may become gradually smaller, 
and by cicatricial contraction may entirely heal. 

However, if the process is not arrested, the disease spreads 
by continuity, or through the lymphatics, blood-vessels, or air- 
tubes. The further pathological changes are extraordinarily 


Tubercles and 
Caseous Nodules. 





Landelicr and Roepke, Clinical System of Tuberculosis. Plate ITf- | 


Tissue containing ail 


Commencing cavity 
formation 


3reaking-down 
caseating nodule 





Confluent caseous nodules 


Cavity with clean, smooth wall 


in deeper part 


Calcareous deposit 


Peribronchial nodules, in the 
middle the lumen of the tube 
can be seen 


—————— 


Caseous Pneumonia of the right Lung, Cavity and Tubereular Bronchitis in the Middle Lobe. 






Bronchus with its 
branches 


reaking-down caseous nodules, caused 
by aspiration from bronchus 


Typical Aspiration Tuberculosis. 


After G. Cor 


Large clean Cavity, 
contents ex pectorated, 
smooth slate- gray wall 


net, 


Thickening of pleura 








Bronchieetasis, small healed 
cavities 


Puckering of the pleurs 


Slate-colored indurat 
lung tissue 


Healed phthisis, slate-colored induration of 
apex with bronchiectasis and clean cayities. 


Die Tuberkulose. (Wien, Holder.) 


3ands containing vessels between the 
cavities (vessels obliterated) 











Caseous necrosis 


| Bandelicr and Roepke, Chnaical System of Tuberculosts. Piaieg TV 
| 


Pleuritic thickening 
Cavity 


Puckering of the pleura 


ribronchial lymphatic 
gland, pigmented 


Peribronchial tubercular 
nodules 
Vessel with 
thickened wall 


Chronic phthisis, apical cavities, bands containing vessels, 
easeous bronchitis and peribronchitis. 













Diffuse caseous nodules 


= Fz of irregular shape 
; ; SS 
4 3 e/ 
£ “ “"F 


® Calcifying cireum- 
seribed caseous 
nodule 










Miliary 
tubercle 
Especiall: 
round th 
yessels 


Caleareous deposits 


Lymphatie gland. 






Nodule of 
anthracosis 


Caseous (cretaceous) pneumonia. Miliary tuberculosis. 


After G. Cornet, Die Tuberkulose. (Wien, Hélder.) 





u 


PULMONARY TUBERCULOSIS Ig 


multiform, according to method by which the dissemination 
occurs, to the number and virulence of the bacilli, and the pre- 
dominant action of the bacilli themselves or of their toxin. The 
tissue change may be of the nature of exudation, proliferation, or 
necrosis, especially caseation. A sharp division between these 
various pathological processes is not possible; generally they 
are all found together, sometimes one is more prominent, 
sometimes another, according to the resistance of the various 
lung tissues. The following are the principal forms that can be 
distinguished. 
If the tubercular process begins in the wall 
of a small or medium bronchus, as appears 
to be most often the case, it consists of a 
sub-epithelial infiltration, spreading towards the periphery of the 
wall—tubercular bronchitis. It is important to notice that this 
newly-formed tissue near the surface ulcerates easily, and that 
this variety becomes very early an open tuberculosis. The 
tubercle bacilli soon grow into the peri-bronchial and peri-vascular 
lymphatics, and so develop a new series of nodules along the 
bronchioles and blood-vessels. 
Out of tubercular bronchitis develops the 
well-known macroscopic _ peri-bronchitis. 
But the development of one form from the 
other may be at times reversed. In the originally grey, later 
yellow, foci there can be still seen at first the open lumen of 
the bronchiole, which becomes gradually blocked by necrosis of 
the growing cells. Through wider extension and fusion of neigh- 
bouring foci there appears what is known clinically as diffuse 
tuberculous infiltration. The peri-bronchial foci may caseate 
in the centre, and the bronchial lumen be expanded 
into an irregular space, the beginning of a cavity. But 
generally these chronic processes tend to limitation and _ heal- 
ing. Round the tubercular deposits and small caseous infiltra- 
tions there is a growth of connective tissue forming a fibrous 
capsule, leading later to contraction and cicatrization. The 
isolated, encapsuled, caseous masses calcify; whether softened 
caseous material can be re-absorbed is doubtful. 
By diffuse connective tissue overgrowth 

Induration. large parts of the lung, especially at the 
apices, may become airless and quite indurated with fibrous 
infiltration. These indurations consist of firm, tough, blue-grey 
or slate-coloured fibrous tissue. In consequence of the contrac- 
tion the bronchial tubes in the neighbouring areas of the lungs 
are usually dilated; bronchiectasis is thus produced, and under 


Tubercular 
Bronchitis. 


Tubercular 
Peri-Bronchitis. 


20 A CLINICAL SYSTEM OF TUBERCULOSIS 


the strain of great contraction bronchiectatic cavities. Com- 
pensatory emphysema is often found surrounding the shrunken 
lung areas. Such indurative processes, which have a very chronic 
course and a relatively favourable termination, are included under 
the head of fibroid phthisis. 

Involvement of the alveolar tissue gives 
quite another anatomical picture, and is 
brought about by aspiration of infectious 
material into healthy lung, collapsed from bronchial obstruction. 
Exudation is a prominent feature; the alveoli are filled with a 
tenacious, albuminous, fibrinous mass, with epithelioid cells, 
leucocytes, and red blood-corpuscles; thus producing caseous 
hepatization. According to the arrangement of the lesions in 
single scattered foci of various size, which have not necessarily 
arisen at the same time, or in large patches, the disease is dis- 
tinguished as lobular or lobar caseous pneumonia. 

Caseous bronchitis may also be produced, 
the inspired infective material not reaching 
the alveoli, but only the bronchi and 
bronchioles. Varieties of this process, brought about in a similar 
way, have been distinguished as desquamative pneumonia (Buhl), 
glazed pneumonia (Virchow), and gelatinous infiltration (Laén- 
nec) ; inflammatory processes that are still capable of complete re- 
absorption. They owe their production, probably, to the in- 
spiration of material which is only slightly infective. When due 
to scanty bacilli caseous pneumonia presents a transitional form 
with small caseous islets. 

Small caseous foci can become encapsuled 
and calcified; larger caseous areas soften 
and form cavities. By degrees the cavity 
opens into one or more bronchi, and the fluid contents are ex- 
pelled. Under favourable circumstances the cavity may become 
quite clean, grow smaller and smaller from the formation of 
granulation tissue, contract up entirely, and be converted into a 
puckered cicatrix. Such a process leads to great contraction of 
the lung, with marked flattening or retraction of the chest wall. 
If the cavity is too large, or the contraction prevented by 
adhesions, the next most favourable outcome is that it may be 
healed by the formation of a firm, smooth, pyogenic membrane; 
but the cavity remains open, and for its possessor there is always 
the threatened danger of a secondary infection from without. If 
the tendency towards healing is deficient the destructive process 
extends at one or more points, neighbouring cavities may coalesce, 
and other complications may assist in the destruction of pul- 
monary tissue. 


Caseous 
Pneumonia. 


Transitional 
Forms. 


Cavity 
Formation. 


PULMONARY TUBERCULOSIS 21 


The view has up to now received general 
acceptance that secondary pus-producing 
organisms (chiefly streptococci, more rarely 
staphylococci and diplococci, &c.) may gain entrance, especially 
into cavities, but also into fibro-caseous nodules not undergoing 
destructive changes. This chronic, active, mixed infection makes 
the disease more severe and produces characteristic fever; the 
tubercle bacilli open up the way and a rapid tissue destruction 
follows. The secondary entry of highly virulent bacilli is the 
chief cause of the rapidly destructive process known as florid 
phthisis. According to the recent excellent observations of 
Kogel, the importance of chronic mixed infection in pulmonary 
tuberculosis has been considerably over-rated. As the result of 
very careful work on the hemolytic properties of the concomitant 
bacteria, he has come to the conclusion that the saprophytic 
septic organisms found in the lungs only acquire the power of 
penetrating into the tissues after the resisting powers of the 
organism have been weakened by advanced disease, and that the 
Streptococcus longus is of much less importance than the Strepto- 
coccus viridans and the non-hemolytic staphylococci. 

The very frequent occurrence of hemoptysis 
in the course of phthisis demands a few 
words on the anatomical involvement of 
the vessels. In tubercular deposits the small vessels usually be- 
come obliterated by endarteritis; larger vessels acquire a thicken- 
ing of their walls, which gives them great resisting powers to 
destructive process; a good example of which is seen in the 
strands and ridges containing vessels which are found in cavities. 
Tubercle can, however, develop in healthy vessels, an event which 
the supporters of the vascular origin of pulmonary tubercle claim 
to be a regular occurrence; at any rate, hemorrhage, from the 
breaking down of such vessel-wall tubercles, is an early symptom 
of commencing pulmonary tuberculosis. Also the rupture of a 
small over-stretched vessel in a tubercular bronchiectasis may be 
the cause of an initial hemoptysis. Severe bleedings generally 
come from a distended or aneurismal large vessel in a cavity. 

By the rupture of a tubercle on a vessel wall 


Mixed 
Infection. 


Involvement of 
the Vessels. 


Tub aad ane and entry of sufficient number of bacilli into 
: ai. ONS OMS circulation, miliary tuberculosis is 
ae: caused. In this condition the lung is 


crowded with tubercular nodules, which are either of equal size 
throughout the lung, the uniform variety, or are the largest in 
the upper parts of the lungs and smaller and more uniform in 
the lower parts, the form of uneven distribution, which by many 


22 A CLINICAL SYSTEM OF TUBERCULOSIS 


observers is called the chronic form of miliary tubercle. The 
reason of the pathological arrangement in these cases is not clear, 
and will be referred to later in the chapter on miliary tuberculosis. 
The most frequent complication of pul- 
monary tuberculosis is pleurisy, which in 
its various forms will be especially con- 
sidered under tuberculosis of the pleura. By the opening of 
superficial caseous foci or cavities into the pleural space, pneumo- 
thorax is produced, which by the entry of caseous debris may be 
converted into a pyo-pneumothorax. 
A very common complication is tuberculosis 
of the bronchial glands, which, especially 
of the in young individuals, is seldom absent. 
Brenemaly Glands: The condition of the glands is very varied. 
Often there are only small latent nodules, or single retrograding 
caseous foci; in other cases the glands are swollen and markedly 
infiltrated; out of these may be produced large masses, with 
calcified or partly softened and gritty contents. 
The anatomical changes in these structures and in the other 
organs, both in connection with chronic pulmonary tuberculosis 
and when separately affected, will be considered in later chapters. 


Pleural 
Complications. 


Tuberculosis 


2. SYMPTOMS AND COURSE. 


The usual course of pulmonary tuberculosis offers a typical 
example of a chronic disease. It may last for years; it may 
remain latent for long periods; it may heal without ever being 
recognized; after long periods of apparent arrest it may break 
out again and progress; according to the diversity of the anatomi- 
cal changes it may manifest itself in very various ways; in its 
slow progress it may gradually sap the strength of the patient, 
without causing him bodily suffering, his pleasure in life and 
power of work remaining almost to the last; or it may, through 
various complications, change for the worse at any time, rapid 
aggravation or even sudden death occurring. It must also be 
noticed that a special character may be given to the course of 
the disease, according to the powers of resistance to the various 
processes possessed by the organism; that the number and viru- 
lence of the bacilli, the predominance of the organisms themselves 
or of their toxins, or the addition of various septic microbes, may 
cause extreme variations in the form of the disease; so it is 
only to be expected that the clinical symptoms of phthisis should 
be extraordinarily multiform. So long as a closed tuberculosis 
is purely local, clinical symptoms are almost entirely absent. We 


PULMONARY TUBERCULOSIS 23 


know that even fairly extensive changes may long remain latent. 
When products of cell destruction and bacterial poisons are set 
free and absorbed, general symptoms make their appearance. It 
is the secondary tissue destruction which first points clearly to 
the presence of disease of the respiratory organs, and causes the 
distinctive lung symptoms. 

These few observations must suffice to show that in the 

description of the symptoms of phthisis given in this work it is 
only possible to give a representation of the most marked 
features. 
One of the most early symptoms is the 
cough, which is generally produced by 
secretion irritating the vagus nerve-endings in the bronchial 
mucous membrane. It varies much in different individuals and 
at different times; generally it only appears in the morning, or 
is worse then; sometimes it is most frequent during the night 
or at bed-time. It may be of any severity from the slightest 
cough to a tormenting, barking paroxysm causing vomiting. 

Generally expectoration is connected with the cough, but the 
two do not always run parallel with each other; on the contrary, 
the cough often diminishes so soon as the sputum becomes more 
abundant and therefore more easily expectorated; and it is often 
most troublesome when due to the scanty, tenacious, chemically 
irritating secretion of the early stage of the disease, which causes 
intense irritation of the bronchioles, and produces the sensation 
of a foreign body. 

The cough caused by pleuritic irritation, by large bronchial 
glands pressing on the vagus, and by other various causes of 
reflex cough, is of special symptomic signification. 
Expectoration is by no means an early 
symptom. By careful inquiry one can 
determine that it regularly appears decidedly later than the cough. 
Cases of early tuberculosis in public sanatoriums, for instance, 
have no sputum in a large proportion of cases. Of course, 
patients pay little attention to slight expectoration; they, 
especially children and females, frequently swallow it. At first 
it consists of frothy, glairy, tenacious mucus, like frogs’ spawn, 
containing scattered points of blackish pigment. Later it will 
be more turbid, on account of the proportions of formed elements, 
contains yellowish spots and streaks, and is more abundant and 
purulent. Sputum from a cavity is almost pure pus, more grey 
however than yellow, only slightly mucoid; it is nummulated, 
or in small lumps, and sinks in water as it contains but little 
air; the rounded pieces with irregular, rough surfaces reveal their 


\ Cough. 


Expectoration. 


24 A CLINICAL SYSTEM OF TUBERCULOSIS 


origin. Small calcareous particles (lung calculi) are also occa- 
sionally found. 

The quantity of expectoration is very variable. In the fibroid 
forms of phthisis, on account of the blocking of the blood-vessels 
and lymphatics, it is scanty, and may be completely absent even 
in extensive disease. With cavity formation it is at its greatest; 
it is brought up periodically, especially in the morning, in large 
quantities, generally with continuous coughing. 

Sputum has a sweetish taste and a faint odour; only after 
standing does it become unpleasant or foetid. 

Besides the tubercle bacilli, which, even in extensive disease, 
may be absent when the expectoration is scanty, there may be 
found in sputum a series of other bacilli, which may be either 
harmless saprophytes of no importance (passive mixed infection), 
or those with unfavourable influence on the course of the disease 
(active mixed infection). 

Though they may be found in any form of destruction of 
the lung tissue, the discovery of elastic fibres in the sputum is 
of great importance; they are at first to be sought for in small 
particles derived from cavities, which may be recognized by the 
naked eye. 

Coughing up of blood is a symptom of 
practical importance and of considerable 
diagnostic value. Small points and streaks of blood may be 
due to non-specific catarrhal lesions of the mucous membrane of 
the pharynx and upper air-passages; but they may also be the 
forerunners of a larger hemorrhage. An hemoptysis is not 
seldom the first symptom of a hitherto latent tuberculosis; it 
may, however, appear at any stage of the disease. All grades, 
from a tiny trace of blood, to a fulminating fatal gush, may 
be met with. Apart from small bleedings, it is a symptom of 
excavation. In rare cases it is the result of the breaking down of 
a tubercle of the vessel wall, more usually, especially in advanced 
cases, it occurs in consequence of a rupture of an aneurismal 
vessel in a cavity. The bleeding commences either quite without 
reason or in consequence of some exciting cause (over-exertion, 
traumatism, attack of coughing, sneezing, emotion, &c.). There 
is no possibility of being able to account for its onset or course 
with even approximate accuracy, for centrally situated softening 
in the lung may be quite beyond physical recognition. The more 
chronic the course of the tuberculosis and the more fibrous its 
character the less the tendency to hemorrhage. Sometimes large 
haemorrhages are ushered in by traces of blood, pain in the chest, 
or tickling in the throat. Sometimes patients, who have already 


Hzemoptysis. 


PULMONARY TUBERCULOSIS 25 


had hemorrhages, will complain of a taste of blood in the mouth 
before a fresh relapse. It is well known that climatic influences, 
changes in the atmospheric pressure, excessive moisture in the 
air, great heat, sultriness, storms, &c., favour the occurrence of 
hemorrhages; but definite knowledge on this subject is wanting. 

The quantity of the blood and the frequency of the bieeding 
vary much. Small hemorrhages are usually recovered from, un- 
less they are accompanied by other complications. More severe 
hemoptysis is generally a serious complication, both from the 
prostration of the patient, and from extension of the tubercular 
process, owing to aspiration of blood mixed with contents of the 
cavity. It may also be the immediate cause of death from loss 
of blood, suffocation, or collapse. 

The course the hamoptysis takes depends on the size of 
the aperture, on the calibre and condition of the vessel, on the 
physical opportunities of the formation of a thrombus (the size 
and situation of the cavity and its bronchus, the amount of 
secretion), on the viscosity of the blood, on the blood-pressure, 
and lastly on the conduct of the patient. It is also important, 
especially for treatment, to know whether the bleeding is arterial 
or venous; which certainly is not always easy to determine. The 
arteries of the lungs give dark venous blood, the veins light red. 
Arterial bleeding is checked with more difficulty, and returns 
more frequently. To account for the varying liability of appa- 
rently similar patients one is inclined to assume a predisposing 
disposition, which is in accord with the differences found in the 
vessel wall microscopically. Of more importance for the estima- 
tion of the effect of the hemoptysis on the course of the disease 
is the behaviour of the temperature; the absence of fever, or only 
a short and moderate fever of re-absorption, is a favourable sign ; 
the occurrence of continued fever points to an advancing disease. 
Pain is not a constant symptom of pul- 
monary tuberculosis; even advanced disease 
may progress entirely without it, while in other slighter cases it 
may be a prominent symptom. The lung tissue itself does not 
feel pain, so that rapid excavation may occur without it. The 
chief causes of the complaints of stabbing pain are affections of 
the pleura; the more rapidly they appear, the worse the pain, 
as is well seen in acute, dry pleurisy. 

The site of the pain depends chiefly on its origin. Wander- 
ing, non-localized, intermittent pains will also frequently be 
complained of ; they are brought on by respiratory efforts, cough- 
ing, laughing, pressure, percussion of the chest, &c. Pleuritic 
irritation, inflammation and adhesions, also enlarged thoracic 


Pain. 


20 A CLINICAL SYSTEM OF TUBERCULOSIS 


glands (sternal, mediastinal, bronchial) often cause these pains. 
Lastly, in the skin over the affected lung areas reflex hyper- 
zsthesia and intercostal neuralgia are occasionally in evidence. 
Breathlessness is also a very variable sym- 
ptom. It depends partly on reduction of 
the lung area, partly on nervous causes (vagus irritation). The 
production of dyspnoea by the first cause, and its severity, if 
produced, depend on the rapidity of the destructive processes. 
An acute, sudden pneumothorax produces great shortness of 
breath, while a slowly evolved phthisis with extensive destruc- 
tion causes hardly noticeable breathlessness. This is due to the 
patient becoming gradually accustomed to the conditions, and 
also to the fact that the deficiency of oxygen is obviated in slow 
disease by increased frequency of respiration. 

The dyspnoea is generally brought out by exercise, inter- 
current catarrh or fever, and may be considerable in amount. In 
other cases there may be short, rapid attacks of dyspnoea due 
to irritation of the vagus nerve-endings by tubercular deposits, 
or to pressure on the trunk of the vagus by inflamed or calcified 
endothoracic glands. In this way there may be produced con- 
siderable paroxysms of dyspnoea (Jessen) and even asthmatic 
attacks (Briigelmann, Cornet, Eichhorst). This dyspnoea is in- 
fluenced by the condition of the general nervous system, as it 
is observed chiefly in nervous, easily excitable women, girls or 
children. 


Dyspneea. 


Apart from specific tubercular disease of 
the larynx during the course of phthisis, 
changes in the voice and affections of the vocal organs may be 
met with, which have more or less importance. In many cases 
of phthisis the voice keeps its normal tone right to the end, but 
usually during the course of time the voice loses something of 
its strength and clearness, and becomes lower, thicker, hoarse 
and toneless. The causes for this are to be sought in the in- 
creasing prostration, the weakness of respiration, and changes 
in the muscles of the larynx, which in consequence of the strain of 
coughing may suffer from congestion, catarrh, paresis or fatty 
degeneration. 

Sometimes hoarseness presents itself as an early symptom, 
due to paresis of the adductor muscles with concomitant laryngeal 
catarrh. In rare cases the loss of voice is due to paresis or 
paralysis of the recurrent laryngeal nerve, as a consequence of 
pleuritic adhesions, or of pressure of enlarged bronchial or 
mediastinal glands encroaching on the supra-clavicular region. 
Pressure on the left recurrent laryngeal has also been observed 
from large pleural effusions and from pericardial exudations. 


Hoarseness. 


PULMONARY TUBERCULOSIS 27 


Ikxtreme sensitiveness of the body tempera- 
ture is characteristic of tuberculosis. Quite 
moderate exercise or emotion may cause fever; a fact of immediate 
diagnostic value. The digestive mechanism may act in the same 
way; therefore it is better to take the temperature after, rather 
than before, meals. Of special symptomatic importance is the 
pre-menstrual rise of temperature. It is not even necessary for 
the maximum temperature to reach the level of fever, unusual 
oscillations of temperature often have the importance of fever, 
or at least are suspicious. It must here ke noticed that the 
rectal temperature is only of diagnostic value if its measurement 
“is preceded by complete rest. Under those circumstances the 
rectal temperature usually runs parallel with the mouth and 
axillary readings. After physical exercise the rectal temperature 
alone may rise 2° F. and more above the normal, without the 
general blood temperature being raised to the point of fever; 
therefore this rise, which has been considered of importance by 
many authors, cannot be reckoned as an early symptom of tuber- 
culosis (Staubli). 

The cause of the fever is not yet well understood. There 
are cases, chiefly of the very chronic fibroid forms, which progress 
to a fatal end practically without fever; but they are exceptions. 
As a rule fever appears quite near the commencement, and is 
seldom absent in progressive cases. The chief cause of the fever 
is absorption of the products of the growth of the bacilli and of 
the tissue destruction they induce ;)also the substances formed by 
the breaking up of the white corpuscles doubtless raise the tem- 
perature. / Here, too, must be mentioned the rise of temperature 
due to progressive loss of weight. The next most common cause 
of fever is the entry of secondary organisms (streptococci, staphy- 
lococci, influenza bacilli, pneumo- and diplo-cocci, pyocyaneus 
and tetragenus bacilli), which in various ways take part in the 
tissue destruction and fever production, either as more passive 
accompanying organisms, or by producing the severer symptoms 
of mixed infection.) Whether tubercle bacilli and septic organisms 
themselves enter the blood—apart from miliary tuberculosis or 
during the death agony—and so assist in fever production, there 
is a difference of. opinion, and further observations are required 
on this point. (According to recent researches tubercle bacilli 
are very commonly found in the blood-stream in pulmonary 
tuberculosis, their detection being easier the more severe the 
tuberculosis.) The entry of other pathogenic organisms into the 
blood-stream in uncomplicated pulmonary and laryngeal tuber- 
culosis during life seems to be very exceptional, and ecnly to 


Fever. 





28 A CLINICAL SYSTEM OF TUBERCULOSIS 


occur in very small numbers; they are more frequently found, 
however, in tuberculosis of the intestines and urinary organs. 
Strauchs has also determined, from post-morlem blood examina- 
tion in 2,000 cases, that the presence of bacteria in the blood is 
the rule in joint and general glandular tuberculosis and also in 
advanced amyloid degeneration. 

(The height of the fever and the course it runs depend on the 
excitability of the heat centres, and with that on the nervous 
system and mental state of the patient. It is not possible to 
separate the fever into fixed types, as it is extraordinarily variable, 
according to the diversity of the causative conditions; and the 
individual differences between phthisical patients increases the 
difficulty. 

Slight, irregular rises of temperature, only appearing from 
time to time in the afternoon or evening, the condition being 
otherwise favourable, may be considered as sub-febrile. Medium 
or high temperatures, returning at some time of the day to 
normal, form the intermittent type; while remittent fever only 
drcps 2° to 4° F. High fever with daily differences of less than 
2° F. is reckoned as continuous. Particularly characteristic is 
hectic fever, which often lasts unchanged for months, and is 
distinguished by a high evening temperature and a daily morning 
fall, with a difference of 7° F. or more between the two. Exacer- 
bation of the morning temperature with evening remissions give 
the inverse type of fever. Collapse temperature (93° to 95° F.) 
is a particularly unfavourable symptom, so also is a very uneven 
or changeable temperature curve, of no regular type) or with 
many exacerbations during the day. 

Cyclical periods of fever with afebrile intervals of shorter 
or longer duration are not rare.) A general explanation of this 
condition is hardly possible, as it may depend on various causes. 
It may be due to the flaring up and softening of an old nodule, 
or the outbreak of new lobular foci around it; or a part may be 
played by the bronchial glands, by toxic absorption from retained 
sputum, by entrance of tubercle bacilli into the blood-stream, by 
recurrent attacks of catarrh due to action of secondary septic 
organisms. So that an explanation or probable diagnosis can 
only be given by careful observation of the patient combined 
with examination of the sputum and possibly of the blood. In 
chronic fever a change from one form into another is often seen 
in the same patient.) A definite pathognomonic signification can- 
not be ascribed to the various types of fever (but continued high 
fever is in every case the mark of an advancing phthisis. 

The temperature curve has thus in pulmonary phthisis a high 


US OF DISEASE. 
























252s200050ee0nne 
vera PAARL aaa 
Baar pete AAS 
ne cua ae 


Continuous moderate fever in chronic fibro-caseous phthisis. — —— 


Day OF DISEASF. 


10. 11] 2] 13.| | 5.| 16.| 77.| 18 |20| 27} 





KXemittent tever in progressive hbro-caseous phthisis. (Authors? observation.) 


DAY OF DISEASE. 


SC OCEREERERERORaogo 
_ ES e aaa eee eaeeeee 
_| SSeS Shas eea eee 
Pe IN ATM ALATA ta 
Arey ir yy vA An 
_ ESS ae Sees 


Intermittent fever in sub-acute caseating phthisis with destruction ; rapid easton 
(Authors’ observation.) 




















BOOOCOSEEOOGOG 
CT a al | 
RCA LP 
AIM ee Te 
aL 


ont eee 
glee ele eee ee 


Hectic fever a Reece abereulosis of lungs and intestines; rapid termination. 
(Authors’ observation. ) 





Day OF DISEASE. 


SCC SRRU QUOC SGRoRm 
BEER EEEEEEEE 
SiN NGSGEe ee Seeeene 
PSE TSR PSS PUSS 
(cl ee fn SES 


Inverse type of tever ccurrig betore death is severe oo with cavities, laryngeal 
and intestinal tuberculosis. (Authors’ observation.) 









(uojearasqo sIoyjNY) “voONoaJuL paxitu g199090/dIp f syeAdaquL TeINSo1a1 Je wnjnds jo JuNoWE UL osvoddUT dIpOTIag 















{LT Moat f i oF 

bes Waal CULE EULA 

OLE 
oor 

o'ae 
ovoI— 

O'Gs 
to1— 


‘ASVASI(] AO AVC 


‘asinoo siuoryo Araa jo sisiyyd payeavoxa ur rAay peotpoha 







o ALTE 
2s Pr AN TRI UY PP vi" Y, Va wa, : PV VN vy, 

PTE MAPPER EPPM AEET 
on NHNAAIOTEOHL HUNTON UUNOWRUOONNOAAAGACCNOOENNERUORONENUET 
oe eee 
: S Rae SID /AlS 19 |/9N& SIND SIS|OI Hor ialy |S /AlOOiS|'9/ S/N S/AlDM!A/9 49/3 


‘asvasIq dO AVC 
























































PULMONARY TUBERCULOSIS BI 

diagnostic and prognostic value. All the changes of the many- 
sided disease, improvements, aggravations and complications are 
reflected in the temperature chart. The continued control of the 
progress of the temperature is therefore of the greatest practical 
importance, and a careful observation of the temperature curve 
is the indispensable duty of the medical attendant. 
Connected with the fever is the common 
symptom of perspiration during the night, 
although these sweats do not run quite parallel with the height 
of the fever. There may be any degree of perspiration from 
slight moisture of the head, hands or feet to a profuse sweat 
bathing the whole body. Their appearance is subject to indi- 
vidual differences; nevertheless, they so often appear quite in an 
early stage of phthisis, that they must be reckoned as a patho- 
gnomonic early symptom. Also in acute relapses and in rapidly 
“advancing disease they are a regular symptom, and one very 
annoying to the patient. 

The perspiration during the night is partly the result of 
the fall of temperature from the evening maximum to the morning 
remission ; just as the critical temperature fall in other infectious 
diseases is accompanied by sweating. Irritation of the sweat 
centres is very probably another cause, induced on the one hand 
by the accumulation of carbonic acid, due to the respiratory dis- 
turbance, and on the other hand by the absorption of toxins of 
the tubercle bacilli and other organisms. The _ tuberculous 
perspire especially during their sleep, because the diminution of 
the respiratory surface, which then occurs, favours the accumula- 
tion of carbonic acid in the blood (Traube). 

It is quite plausible that later the absorbed products of tissue 
destruction may injure the vaso-motor control centres. This 
accounts for the sweats being associated with the fever, and in- 
deed with the fall of the latter during the second part of the 
night, when the blood-pressure and pulse-frequency diminish. 
That the toxin of the tubercle bacilli actually plays a part here 
is shown by the fact that the amount of perspiration is incom- 
parably greater in the more acute processes, and that it diminishes 
under tuberculin treatment with increased resistance to the toxin. 

Sometimes unilateral hyperhidrosis is observed, as in many 
neurotic forms of sweating. This indicates an affection of the 
nervous system. We know that the secretion of sweat may 
be induced by irritation of nerve fibres in the sympathetic and 
central nervous systems {Jessner). 

Mere overheating is often enough the cause of night sweats. 
It is a well-known fact that patients often lose them all at once 


Night Sweats. 


32 A CLINICAL SYSTEM OF TUBERCULOSIS 


on exchanging the warm, stuffy feather-beds of their homes for 
the hygienic surroundings of a sanatorium. 
Absorption of the poisons of the tubercle 
Symptoms con- bacilli causes an alteration of the blood 
nected with the and its chemical condition, setting up a 
Circulatory Organs. toxemia, such as can be produced experi- 
mentally on animals. The blood changes, 
which are very soon revealed by a general pallor of the skin and 
mucous membranes, consist usually of an early diminution of the 
haemoglobin content, and, generally only in a later stage, of a loss 
of red blood-corpuscles. In early stages the lymphocytes are 
often increased, and this lymphocytosis has therefore a certain 
amount of diagnostic vaiue. 

As the disease advances, especially if mixed infection occurs, 
leucocytosis is found, the increase in the white cells being chiefly 
due to a rise of the polynuclear neutrophyl leucocytes. Also 
these leucocytes themselves undergo a qualitative change in the 
size, shape and number of their nuclei, which, according to the 
valuable observations of Arneth, have a prognostic importance. 
The specific gravity of the blood is lowered, its alkalinity 
diminishes steadily, and the blood-pressure falls more and more, 
according to the progress of the disease. A lowering of the 
blood-pressure is considered by many authors a very early sign 
of pulmonary tuberculosis. 

Accompanying the fall in blood-pressure, and due to the 
same cause, namely, bacterial poisons, there is found acceleration 
of the pulse-rate. The toxic pulse appears very early and gives 
rise to a suspicion of tuberculosis when other more certain evid- 
ence is not to be found. Secondary causes of the acceleration 
of the pulse are the mechanical changes in the pulmonary cir- 
culation and dilatation of the peripheral vessels. The symptomatic 
importance of tachycardia from compression of the vagus by 
enlargement of the bronchial glands may be just mentioned here. 

The feeble low-tension pulse is the characteristic expression 
of heart weakness, which often appears very early and is of 
weighty import. It, too, is a consequence of bacterial toxemia 
and in its last stage is a very frequent cause of death from 
syncope. 

Emaciation, fever and deficient blood circulation tend, in 
the later stages of phthisis, to atrophy and fatty degeneration of 
the heart muscle. A soft, blowing, functional murmur over the 
arterial apertures is often a sign that the heart is exhausted and 
beginning to fail. 

In the chronic fibroid form of phthisis, in which the area 
of the pulmonary circulation is progressively diminished, hyper- 


PULMONARY TUBERCULOSIS 33 
trophy of the right ventricle succeeded by dilatation may be 
detected. Pleural adhesions, chronic bronchitis and emphysema 
play, too, a large part in its production. The pronounced con- 
dition is easy to recognize by the accentuation of the second pul- 
monary sound, the increase of cardiac dulness to the right, by 
epigastric pulsation, and by a systolic murmur over the tricuspid 
area. Under increased demands compensation fails, so that con- 
gestion of the liver, kidneys or extremities, and later phlebitis 
and venous thrombosis appear. There may be cyanosis of the 
visible mucous membranes, or asthmatical attacks on account 
of the respiratory deficiency. 

Obstinate loss of appetite is not a constant 
symptom, but appears very frequently and 
often quite early, so that even a careful 
observer may give the stomach his whole attention and overlook 
the commencing lung trouble. A bad eater is already predisposed 
to phthisis. The loss of appetite may be enhanced by an aver- 
sion to every suitable form of food, especially meat, eggs and 
milk. This early anorexia is of a toxic nature, the secretory 
and motor functions of the stomach being usually quite normal; 
many authors find a moderate percentage increase of hydro- 
chloric acid, others a deficiency of it. We have no information 
as to which of these conditions is the more frequent or important; 
and too little attention has been paid to the influence of the 
severity of the disease, or the existence of fever. 

As the disease progresses, to the anorexia there are added 
indigestion, gastric pain, sensations of fulness, nausea and irrita- 
bility of the stomach. Generally these are due to a _ merely 
nervous dyspepsia. In other cases, especially with progressive 
disease, more serious stomach disturbances with anatomical 
changes develop and accelerate the loss of strength. Among 
the prejudicial causes which play a part in their production are 
dental caries, so common in tubercular patients, unsuitable and 
too much food, and the habit of swallowing the sputum. 

A very troublesome symptom is frequent vomiting, induced 
by severe cough; it occurs at first with a full stomach, and during 
the morning emptying of the lungs. Connected with it is the 
so-called stomach-cough, which not seldom comes on during 
meal-times. Its causation is not sufficiently clear; Cornet 
ascribes it to hyperzesthesia of the mucous membrane of the 
stomach. 

The functions of the bowel are usually normal, and may 
remain so even in the last stages of the disease; not infrequently, 
however, there may be more or less obstinate constipation. 


3 


Gastro-intestinal 
Symptoms. 


34 A CLINICAL SYSTEM OF TUBERCULOSIS 


In advanced cases toxic diarrhoea often makes its appearance ; 

it usually comes on periodically and alternates with constipation. 
In rare cases this gives rise to a blood intoxication; but toxic 
absorption through the intestinal wall is usually the direct result 
of habitually swallowing abundant sputum. Even if it is only 
due to a reflex condition of augmented peristalsis, or to catarrhal 
or other superficial lesions of the mucous membrane, diarrhoea 
must always be considered as a serious complication, with ex- 
tremely debilitating effects. Danger from fresh sapping of the 
strength of the patient is equally to be feared from the specific 
and non-specific pathological changes of the intestine, which will 
be referred to later. 
Phosphaturia has been described as an im- 
portant early symptom, but its connection 
with tuberculosis is not close; it is an 
evidence of an anomaly of nutrition and is also met with in many 
other diseases. Intermittent albuminuria, in connection with 
phosphaturia and highly toxic urine, especially in young indi- 
viduals with an hereditary tendency, is considered by the French 
school as a prodromal symptom. The value of this group of 
symptoms is not yet fully determined; in spite of Maragliano, 
Teissier, and others, the existence of a specific toxin in the urine 
is not generally accepted. 

The supposed frequent occurrence of constant albuminuria 
in the initial stage of tuberculosis has also been considered as an 
early symptom; a similar claim is also made for albumosuria, 
which also is not more constantly found in tuberculosis than in 
other chronic septic and febrile diseases. On the other hand 
orthostatic albuminuria seems to be of some value as an early 
diagnostic sign, an opinion previously advanced by Poncet. 
Liidke and Sturm found albuminuria in a large percentage of 
tubercular patients with healthy kidneys after standing for one 
hour, and they consider this to be due to irritation of the kidney 
by a toxin derived from the tubercular foci. The correctness of 
their view is shown by the fact that nearly half of those patients 
who presented no albuminuria after standing gave a positive 
result on repeating the standing after a small tuberculin injection, 
not sufficient to raise the temperature. 

The presence of indican in the urine of children has equally 
small diagnostic value. 

The diazo reaction has some importance, particularly in rela- 
tion to prognosis. In early cases it may appear temporarily 
without serious meaning; in more severe cases it is often 
absent; if, however, it is constantly strongly positive it indicates, 
with few exceptions, that the disease will be steadily progressive. 


Urinary 
Organs. 


PULMONARY TUBERCULOSIS 35 
Mention has necessarily been made in the 
above brief sketches of the various implica- 
tions of different organs of tissue wasting, which in the first place 
affects the fatty tissue. In many cases a striking loss of weight 
is the first sign pointing to serious disease. The loss of weight 
varies very much as to its time of appearance and intensity ; some- 
times slow and steady, sometimes rapid, sometimes with alter- 
nating periods of loss and gain. Many causes have already been 
mentioned, loss of appetite, insufficient food, digestive troubles, 
vomiting, diarrhoea, hemorrhage, excessive expectoration, pro- 
fuse sweats, toxic absorption, and fever. 

The tissue loss is not confined to the subcutaneous fat, but 
affects also the muscles, which undergo atrophy and fatty degen- 
eration. A characteristic phenomenon, which has been incorrectly 
described as distinctive, is fibrillary muscular contraction, easily 
obtained by percussing the pectoral muscles. The muscles in 
general often show an increased excitability to direct mechanical 
stimulation, especially, according to recent observations, the 
muscles covering the affected part of the lung. Fischer has lately 
studied the condition of the thoracic muscles, and has come to 
the following conclusions: the muscles of the region over the 
tubercular foci in recent cases are paretic, as is early shown by 
the results of mechanical irritation; this increased irritability is 
dependent on a commencing degeneration of the muscles, and 
must be due to the tubercular toxin. The theory of Pottenger, 
which is described later, on muscle spasm and muscle degenera- 
tion is very similar. 

The want of nutrition is also seen in the skin, which becomes 
loose and wrinkled, and presents a faded grey colour. The 
glands degenerate, so that the skin is dry, lustreless, and rough. 
Pigment spots appear, and mycotic fungi develop easily. The 
atrophy affects the growth of the hair and nails. It is noticeable 
that the skin secretes an excessive amount of sebaceous material, 
and becomes smooth and greasy to the touch. It is supposed 
that this may be explained in these cases by a fatty degeneration 
of the liver and a fatty infiltration of the sebaceous glands 
(Jessner). 


Wasting. 


Manifold alterations of the general nervous 
system may show themselves in different 
ways. A very frequent symptom, and of 
value as appearing early, is vaso-motor changes; sudden rushes 
of blood to the head, rapid changes of colour, quick perspirations 
—the hands and even the whole upper part of the body being 
instantaneously bathed in sweat. Here also may be mentioned 


The Nervous 
System. 


20 A CLINICAL SYSTEM OF TUBERCULOSIS 


the frequent rapid perspirations in the armpits, causing the 
sweat to run down the body in large drops. 

Hypereesthesia of the skin over the affected lung areas has 
already been mentioned. | 

Sometimes there is neuralgia of the intercostal, phrenic, 
trigeminal, or sciatic nerve, either as a result of toxic infection, or 
from pressure of large lymphatic glands on the nerve trunk. Irri- 
tation of the sympathetic by involvement in contraction of the 
apex of the lung or by pressure of enlarged glands may cause 
inequality of the pupil. French authors have particularly studied 
these phenomena, and recognize them as early symptoms which 
may precede for several years the manifest symptoms of the 
disease. 

Toxic absorption may induce neuritis, degenerative changes 
in the peripheral nerves, which are the commonest cause for the 
appearance in various parts of the body of hyperzsthesia, pares- 
thesia, anesthesia, and analgesia. Frequently the tendon reflexes 
are exaggerated. In rare cases deficiency of vision, or hardness 
of hearing progressing to deafness, may be met with; of which 
similar essential degenerative nerve changes are the cause. 

The central nervous system may also be affected by anzemia, 
hyperemia, inflammation, toxic infection, or direct tubercular 
changes, as will be mentioned later; however, in general the 
mental functions remain unaltered. 

It may be mentioned that the psychology of tubercular 
patients may undergo many alterations, according to the kind or 
duration of the disease. This reaction has individual differences 
according to the age, sex, constitution, education, character and 
knowledge of life. One can recognize in phthisical patients 
in general a great changeability of mood, weakness of will 
power, frivolity, defective judgment, optimism and _ over- 
estimation of their physical powers. Cornet says with reason 
that the phthisical patient is in great part only the product 
of his circumstances and surroundings, and that the changes 
in his mental processes are brought about by the manifold and 
long-continued changes in the organs induced by chronic 
disease, which ultimately can be traced back to the absorption 
of tubercular bacterial toxins. 

The large number and extreme multiformity 
of the symptoms which have been described 
will account for the various courses taken by 
pulmonary tuberculosis. These depend chiefly on the kind and 
intensity of the primary infection, the virulence of the organisms, 
and the way in which the extension of the tubercular processes 


Progress of the 
Disease. 


PULMONARY TUBERCULOSIS Bi7f 


takes place. The wide anatomical differences in the morbid pro- 
cesses best explain the great variations in the clinical progress of 
the disease. The infection may remain local or cicatrize without 
producing manifest signs; after lasting for years in the form of 
chronic phthisis it may, in spite of transitory or repeated relapses, 
result in permanent healing; it may in the pneumonic form cause 
periods of serious iliness, lasting for a longer or shorter time and 
alternating with relatively tranquil intervals, after which healing 
of the lesion may even take place; or it may lastly in a few weeks 
or months end in rapid or even sudden death from extensive 
destructive processes. Moreover, there are numerous possibilities 
and complications which may cause the progress of the disease to 
vary in countless ways. 

As a rule pulmonary tuberculosis begins slowly and insid- 
iously, hiding at first its true character. It often reveals itself 
first not through the respiratory organs; but if respiratory sym- 
ptoms are present the suspicion of phthisis is soon roused. A 
dry cough appears, which is ascribed to a cold, but lasts longer 
than usual. It is followed by a little expectoration, which also 
at first does not attract attention. Aches, stabbing pains, and 
feelings of oppression, which may or may not be localized in a 
fixed spot, then follow; not infrequently quite early there may be 
a noticeable shortness of breath, especially on exertion. 

In other cases several of the before-mentioned toxic symptoms 
may be most prominent, or they may accompany the lung sym- 
ptoms. An obstinate loss of appetite is to be noticed, or without 
this being particularly bad an exceptional loss of weight, with 
anemia, exhaustion, tendency to fatigue, great need of sleep, 
throbbing in the head, and vaso-motor changes. The symptoms 
often resemble those of chlorosis, especially if those connected 
with the respiratory organs are absent; so much so that treatment 
may actually be directed to that complaint for some time. Or 
indigestion with loss of appetite and weight may be the prominent 
symptoms, so that the attention may be directed to the supposed 
gastric catarrh, as has been already mentioned. Often, too, 
feverish symptoms, such as shivering, flushed cheeks after meals, 
or in the evening, or irregular night sweats, may claim notice 
rather than the pulmonary condition. 

Fairly often an initial hemoptysis is the first sure sign of 
phthisis that brings the patient to the doctor. Most patients have 
had many of the above-mentioned symptoms for a longer or 
shorter time without noticing them; but it is not rare for a 
hemorrhage due to latent tuberculosis to come entirely as a 
surprise to a person in good health. 


Rie A CLINICAL SYSTEM OF TUBERCULOSIS 


The slow, gradual onset that was described 
corresponds generally to a chronic indura- 
tive process, beginning in the apex of the 
lung, of relatively favourable prognosis. Under proper treat- 
ment, a suitable mode of life, and good hygienic surroundings the 
disease is soon arrested, the symptoms disappear more or less 
quickly, the strength increases, and the general condition becomes 
normal again. The objective signs in the lung remain stationary 
or improve gradually, often only after long months of unsatisfac- 
tory examinations. The result may be complete healing with 
cicatricial contraction of the lung and drawing in of the upper 
part of the thorax. In other cases, even after many months of 
subjective well-being, the disease being apparently at a standstill, 
the tubercular process may commence to progress steadily and 
lead to a fatal issue, usually from gradual exhaustion. 

; In contradistinction to these chronic varie- 
ties we have the pneumonic form of tuber- 
culosis, with its sudden onset and rapid 
course. The disease begins acutely in the guise of pneumonia, 
for which at first it may be mistaken; or an acute aggravation 
occurs of a disease which has been recognized for a shorter or 
longer time. The site of the lobar infiltration is more often the 
lower lobe than the upper. The expected resolution of the 
supposed genuine pneumonia is deferred, the fever is not resolved 
either by crisis or lysis, the expectoration becomes more copious, 
and the patient sinks visibly; this is the rapidly fatal florid 
phthis:s. . Anatomically one finds by the side of more or less 
extensive old tubercular infiltration a caseous hepatization, with 
commencing cavity formation at one or more points. The pneu- 
monia in these c>ses is gene-ally produced by espiration of caseous 
débris, and is not infrequently observed in connection with a 
severe hemoptysis. 


Chronic Indurative 
Forms. 


Pneumonic 
Forms. 


Between these two extreme types there are 
many forms cf commencement and course of 
an intermediate character. Cases resembling 
the pneumonic form do not always have a fatal ending, but under 
some circumstances may even undergo slow re-absorption. This 
occurs in the rare cases in which there has been aspiration 
of only slightly infectious material. After a long illness 
there may be restitutio ad integrum, and the process takes 
its course through other pathological changes. Here and 
there it may happen that only a_ few bacilli develop, 
so that an isolated caseous nodule is formed, which may 
suffer the usual fate cf other caseous nodules, either connective 


Transitional 
Forms. 


PULMONARY TUBERCULOSIS 39 


tissue encapsulation, calcification, or softening, and excavation. 
This may form the starting point of infection for a secondary 
lobar diplococcal pneumonia or of a lobular influenza pneumonia. 
A frequent clinical type is that of unilateral 
contraction of the lung, which represents 
fibroid phthisis in the proper sense. Ana- 
tomically considered, there is usually a well marked, connective 
tissue, cicatricial contraction in the upper part of the lung with 
bronchiectasis; the thoracic wall is affected by the shrinking pro- 
cess, and is usually markedly drawn in. Cavities also occur. 
The process of contraction involves neighbouring organs: the 
spine presents a lateral curvature, the heart is much displaced, 
and the right ventricle hypertrophied, the diaphragm is drawn up, 
and the healthy lung becomes more or less emphysematous. These 
changes indicate a relatively favourable ending to a slowly 
developed, severe, excavated phthisis. The general health of the 
patient is but little affected, the nutrition is generally good, the 
cough and expectoration are small in amount unless otherwise 
increased, fever is absent or only occasionally slightly raised, 
shortness of breath is insignificant, usually slight cyanosis is 
present. Nevertheless, these patients are in constant danger of 
becoming worse, especially from spread of infective material 
through the bronchi from the cavities; yet frequently they may 
remain in this state for many years, if they take care of them- 
selves and if they continue free from complications. 
So very various are the atypical anatomical 
Atypical Forms. changes, such as limited fibrous tubercular 
nodules, insular or lobular caseous_ pro- 
cesses, which may be in any form of cavity formation, changes 
which may occur successively or be present side by side, or which 
again may be greatly altered by secondary inflammatory pro- 
cesses, that it is impossible to give an exhaustive clinical descrip- 
tion of the course the disease may follow. The end of most cases 
of advanced disease is death, brought about by general exhaus- 
tion, increasing suffocation, or heart failure. Complications also 
play an important part in producing a fatal issue, as is sufficiently 
described in the account of tuberculosis of the individual organs. 


Lung 
Contraction. 


3. DIAGNOSIS. 


The modern methods of diagnosing pulmonary tuberculosis 
consist of a series of component parts, corresponding with the 
various epochs in the history of medicine. The important sym- 
ptoms just described, recognized as the result of empiricism and 


40 A CLINICAL SYSTEM OF TUBERCULOSIS < 


of careful observation of the patient, serve for the making of 
an empirical diagnosis, familiar to the physicians of the classical 
ages. The discovery of percussion by Auenbrugger and of aus- 
cultation by Laénnec laid the foundations for the method of 
physical diagnosis, which by the middle of the nineteenth century 
in all essentials had already attained the same perfection as it has 
to-day. The discovery of the tubercle bacillus opened the era 
of bacteriological diagnosis, which naturally for some time com- 
pletely governed the clinical study of tuberculosis, without matur- 
ing into essential progress towards the full understanding of the 
disease. This was reserved for the discovery of the tuberculins, 
which especially inaugurated the era of early diagnosis of tuber- 
culosis, and placed on a firmer basis the problem of combating 
tuberculosis as a racial disease. Our knowledge on these subjects 
has been greatly advanced by means of the use of tuberculin for 
diagnosis. With it ranks in value the great discovery of the 
diagnosis by R6ntgen-rays in the living patient. Other methods 
of early diagnosis, which in part have only reached the impor- 
tance of interesting biological phenomena occurring in the 
tubercular organism, have lately acquired a certain value; such 
are the observations on the agglutinative property, the opsonic 
index, complemental deviation, anaphylaxis, lymphocyte sputum, 
and the neutrophil blood-count of Arneth. 

This short review of our diagnostic methods in their historical 
erder will give an idea of their number. They will now be separ- 
ately considered, regard being paid to their practical importance, 
so that but brief attention will be given to those methods whose 
value is still more or less doubtful, or which on account of the 
expense or time involved are hardly suitable for medical practice. 


I. The History of the Patient. 


Careful consideration of the previous history of the patient 
has, for the diagnosis of phthisis, an importance which must not 
be under-estimated. <A so-called positive history is not only of 
determining value in cases of doubtful diagnosis, but by affording 
an accurate idea of the mode of onset of the disease may give 
valuable information as to prognosis. 

In the pronounced forms of manifest tuberculosis the history — 
of the patient may appear superfluous, but for early diagnosis it 
is indispensable. If, for example, it is a question of very early 
disease of the apex, of mischief in an unusual site, of difficulty 
in differential diagnosis from diseases closely simulating 
pulmonary tuberculosis, or of suspicious general symptoms exist- 
ing with doubtful objective signs, then the history of the patient 


PULMONARY TUBERCULOSIS 4l 
may place the diagnosis on a surer basis, if it is elicited in a way 
suitable to the individuality and intelligence of the patient. The 
details of the history will afford an insight into all those predis- 
posing causes mentioned in the section on predisposition. From 
the history we seek to ascertain under what particular circum- 
stances and in what way the disease originated; we must follow 
the source of infection in the family, examining closely into the 
question of an hereditary tendency, and, if the infection is to be 
sought outside the family, we must endeavour to ascertain whence 
and how it occurred. If we succeed in obtaining a possibly com- 
plete explanation of the infection, and the internal and external 
conditions accompanying the development of the disease, it will 
be not only of scientific importance for adding to the knowledge 
of the etiological causes in single cases, but will also give many 
indications for prophylaxis and treatment. 

A careful consideration and critical examination of the data 
supplied by the history, taken in conjunction with the results of 
clinical examination, will also make a prognostic opinion on the 
case possible; and will make it easier to determine whether we 
have to do with a healing, stationary, or progressive disease. The 
determination whether a case of phthisis is only developing slowly 
in spite of a hard occupation, unhygienic surroundings, or other 
unfavourable influences, or whether it is showing a great tendency 
to active advance in spite of an easy life, care, and suitable treat- 
ment, whether loss of weight is absent or insignificant, occurring 
gradually, or suddenly and quickly, are very noteworthy points in 
the history of individual cases for the purpose of foretelling the 
course the disease will take. The necessity of extending the 
diagnosis on its prognostic side not only frequently affects the 
private practitioner in relation to patients of all classes of life, 
but is a constantly recurring problem in all cases of pulmonary 
tuberculosis affected by compulsory insurance. 


II. Physical Diagnosis. 


Inspection includes the consideration of the 
general appearance of the patient, for which 
at least the upper part of the body must be completely unclothed. 
Particular attention must be given to the constitution, the state 
of nutrition, the muscles, the subcutaneous fat, the skin, the 
colour, the carriage of the body, and expression. In many cases 
that general appearance can be recognized which the older writers 
well designated the phthisical aspect. Its essential characteris- 
tics are: a slender stature, slightly stooping carriage, poorly 
developed muscles, scanty adipose tissue, pale skin with venules 


Inspection. 


42 A CLINICAL SYSTEM OF TUBERCULOSIS 


showing through, red hectic flush, long hair, a lengthy, narrow, 
flat thorax, small thin hands, and a tired expression, the peculiar, 
moist, glittering eyes being very noticeable. These signs, to 
which may be added a striking irritability of the vasomotor 
system, are not always to be found in their entirety, but make up 
between them the phthisical aspect. 

Particular importance has been attached from antiquity to 
the paralytic thorax. It is a long, narrow, flat chest with narrow 
intercostal spaces, an acute epigastric angle, sloping shoulders, 
and wing-like projecting shoulder blades. With this the clavi- 
cular hollows are flattened, and the jugular vein sinks in; the 
acromial end of the clavicle is lower and comes more forward; the 
antero-posterior diameter of the thorax is shortened, and the 
circumference of the chest is deficient; the sternal angle is small, 
or the sternum may be flat or even sometimes bent inwards. 


Rothschild denotes by the sternal angle, which has been quite wrongly 
called the angulus Ludovici, the ‘‘ pyriform exostosis” of the sternal 
angle, ‘‘ which in phthisical patients indicates a premature ossification, and 
is of itself a pathognomonic sign of a predisposition to tubercular infec- 
tion.” It cannot be denied that the premature ossification of the cartilage 
between the manubrium and sternum will be injurious in the same way 
as ossification of the first rib cartilages; but it occurs relatively much too 
rarely to be considered of the importance for the predisposition to phthisis 
that Rothschild estimates it. More recent examination of this subject by 
A. Hofmann, Ebstein, and others, also supports the Jatter view. Moreover, 
it is incorrect to consider the prominence of the sternal angle as an exostosis. 


The paralytic thorax is no doubt a common concomitant of 
phthisis; it is, however, absent in the majority of cases, and is 
also often met with without the existence of phthisis. 

Of great diagnostic vaiue are local flattenings or depressions ; 
so also are partial limitation of the respiratory movement, and 
slight expansion and delayed movement of the diseased areas, 
especially over the upper part, but which from disease in 
the lower lobe or pleura may occur over the whole side. The 
flattenings or depressions may be on one or both sides, in the 
latter case usually more marked on one side; in most cases they 
accompany chronic fibroid processes, and they are especially in- 
dicative of the amount of contraction in the underlying lung. 

A unilateral drawing-in of the apex of the lung is especially 
a sign of tubercular disease. 

Mention must be made of a peculiar muscular atrophy, which 
cannot be explained as a wasting from disuse. A toxic influence 
has also been adduced as the cause, but this could not account 
for a partial atrophy in a single muscle. Jessen explains the 
limited atrophy as the result of nerve change, and leaves it 


PULMONARY TUBERCULOSIS 43 
undecided whether this is a latent neuritis or a purely functional 
change. New light has been thrown on this subject by the theory 
of Pottenger, which will be considered in the section on palpation. 

Dropping of the acromial end of the clavicle, which normally 
stands slightly higher than the sternal end, is characteristic 
(Aufrecht); so also is lagging behind of the acromion on deep 
inspiration (IKKuthy). 

While retraction is usually only met in late cases of fibroid 
phthisis, and is associated with a small expansion, the delayed 
respiratory movement usually occurs in quite an early stage, and 
is therefore of importance as an early symptom. The side that 
lags behind may reach the maximum movement of normal inspira- 
tion, but later than the other side, or may remain deficient in 
movement. With progressing lung contraction the delayed 
movement usually disappears, while the flattening remains. 

Bilateral disease causes the respiratory movement to be 
different on the two sides, and indeed markedly so, since the 
delayed movement affects the newly implicated side, while on the 
side of the old disease the expansion is limited on account of 
cicatricial contractions. These changes occur in suitable cases 
with such regularity that the diagnosis cannot infrequently be 
made from them alone. Sometimes crossed delay of movement is 
found (Turban), for example, with infiltration of one apex and 
pleurisy of the opposite side. 

These phenomena can be best observed if one sits in front of 
a standing patient or stands behind one sitting, so that the 
thoracic movements of both sides can be observed‘and compared 
more in profile. 

The degree of partial thoracic retraction, or of extensive 
thoracic shrinking, indicates the amount of contraction of the lung 
tissues; here it is especially the elasticity of the chest wall, de- 
pendent on the age of the patient, which turns the scale. The 
greatest retraction accompanies one-sided contraction of the lung 
with pleural adhesions; when there is often also displacement of 
the neighbouring organs which can be detected by inspection, 
e.g., cardiac displacement, or curvature of the spine. 

Sometimes emphysematous pads appear above the clavicle, 
which are the visible signs of a vicarious emphysema surrounding 
a central area of contraction; however they do not in any way 
exclude the existence of active processes. 

Litten’s diaphragmatic sign* is another condition helpful for 


* This consists of a visible wave 24 in. to 22 in. in amplitude, due to the 


respiratory movements of the diaphragm, the patient being placed in a 
certain position in a good light. The breathing must be of maximal depth, 
and there must not be too much fat. 


44 A CLINICAL SYSTEM ._OF TUBERCULOSIS 


diagnosis in suitable cases. It fails in the presence of extensive 
pleural adhesions and of fluid or air in the pleural cavity. 
Unilateral diminution of the diaphragmatic movement is due to 
disease of the lung or the pleura. It depends on certain parts of 
the lung being cut off from respiration, or hindered in their func- 
tion. This unilateral limitation of the diaphragmatic movement 
is important as an early symptom of slight, initial, apical disease ; 
in conditions of apical induration its presence is, according to 
Kronig, in favour of a tubercular origin. It is most commonly 
caused by adhesion of the pleural surfaces. As further causes, 
reflex action through the respiratory nerves and injury of the 
phrenic nerve by pleuritic adhesions at the lung apices, or by 
pressure of enlarged tubercular glands, have been mentioned. 

On inspection of the skin one can often recognize enlarged 
venules on the anterior wall of the chest, or enlarged stellate 
capillaries, especially at the upper aperture of the thorax before 
and behind, and more frequently still along the lower margin of 
the ribs. They are due to chronic venous engorgement of the 
internal mammary and intercostal veins on account of stasis in 
the azygous vein. They, as well as the enlarged temporal vein 
mentioned by Sirakoff, are observed in connection with phthisis, 
especially in association with enlarged lymphatic glands. 

There are often various symptoms connected with pulmonary 
tuberculosis which can also be detected by inspection: a red or 
bluish line on the gums, the frequently mentioned inequality of 
the pupils, the common occurrence of a high, angular palate, 
lowering of the nipple on the affected side in men, atrophy of the 
breasts, and diminution of the pigment in the usually small 
areole of the nipples. In cases of thoracic contraction the 
atrophy of the breast is sometimes only apparent. 

We may pass over other still more indefinite symptoms con- 

nected with the stigmata of degeneration of the tubercular pre- 
disposition. 
Palpation completes and augments the 
results of inspection. The delay of move- 
ment and the deficiency of expansion can be well estimated by 
palpation, if for any reason, as poor illumination, inspection is 
not sufficient. Goldscheider recommends that a lagging behind 
of the first rib, which can nearly always be felt, should be sought 
for. By palpation we may also detect a great resistance of the 
infiltrated parietes. 

With disease of the upper part of the lung the overlying 
muscles of the neck and thorax may be felt, best with the lightest 
palpation, to be more rigid and tense than those of the sound 


Palpation. 


— 


Se ee ee eee 


lt i i 


 -_**. 


= PULMONARY TUBERCULOSIS 45 


side. These spastic contractions, which may be also visible, are, 
according to Pottenger, a special sign of fresh active disease, and 
are caused by reflex irritation emanating from the lung or pleura, 
conveyed by the sympathetic, spinal cord and motor nerves to 
the muscles. This segmental irritation of the spinal cord prob- 
ably affects the motor nerves in the same way as Head has shown 
for the sensory nerves (Head’s zones). In chronic processes the 
muscles will lose their elasticity and undergo a pulpy change in 
consequence of secondary degeneration processes. 


Pottenger empleys the observation of the muscle changes in the neck 
and thorax for the diagnosis of disease of the lung and pleura, and lays 
special stress on the state of the muscle in forming a differential diagnosis 
between active and inactive disease. 

He ingeniously explains the delayed movement and flattening of the 
chest wall as the result of muscle spasm and degeneration of the contracted 
muscle; and sees also in the abnormalities of the upper aperture of the 
thorax, the rounded shoulders and deformities of the chest, the final results 
of muscular changes. 

His observations have taught us that muscular changes are best detected 
by light palpation. From further observations he concludes that by this 
method of touch not only can the normal organs of the chest and abdomen 
be marked out from each other, but that it is possible to diagnose certain 
diseases of these organs by changes in their consistence. 

These new methods of very light palpation have hardly yet received 
confirmation in Germany, but they resemble the methods of estimating 
resistance by touch and Ebstein’s tactile percussion, and deserve further 
trial as they tend,to the refinement of diagnostic methods. 


In this connection reference must still be made to the 
increased irritability to mechanical and electrical stimuli of the 
thoracic muscles over the diseased areas. 

Palpation is also of service for the examination of vocal 
fremitus. A distinction can be drawn between the subjective 
vocal fremitus, which can often be detected by the patient himself, 
and the objective fremitus as observed by the examining hand. 
It varies much over tubercular deposits and affections of the 
pleura according to the power of elasticity and resonance of the 
tissues. The vocal fremitus is usually increased over fibroid 
indurations, over infiltrations, over cavities lying near the surface, 
over dense well-conducting pleural thickenings, and over the 
compressed lung above a pleural exudation. It is diminished 
or quite obliterated by an effusion of serum, air, or pus into the 
pleural space, or by blocking or compression of a bronchus by 
secretion, or enlarged glands, &c. In fat and very feeble persons 
the detection of vocal fremitus is difficult. It is more easily felt 
normally on the right side, especially in the upper posterior 
region, on account of the greater size of the right bronchus. 


46 A CLINICAL SYSTEM OF TUBERCULOSIS 


By pressing or tapping over the upper part of the chest we 
can elicit not uncommonly a tenderness over the affected part of 
the lung, on account of the inflammatory irritation of the apical 
pleura; this sensibility can most often in early disease be detected 
in the supraspinous fossa. Another area which is often tender 
on pressure is the interscapular region, and the spinous processes 
of the upper thoracic vertebrze; it is associated with tuberculosis 
of the intrathoracic glands. Strong percussion will bring out 
these tender areas more easily than palpation. 

By palpation can be also observed a narrowing of the inter- 
costal spaces in contraction of the chest wall. In retraction of 
the lung there is a broadening and augmentation of the heart’s 
impulse, which can be best and earliest detected as a pulsation of 
pulmonary artery. 

Moreover by palpation we must obtain information about 
the lymphatic glands, so often the site of tubercular disease. Very 
frequently the lymphatics of the neck are infiltrated, but the 
anatomical and pathological connection between these supra- 
clavicular glands and the deeper cervical lymphatic chain is not 
yet sufficiently determined. Recently v. Lebrowski has drawn 
attention to the subcutaneous thoracic lymph glands, but they 
may be palpable in non-tubercular lung processes, and not so 
in tubercular disease. 


In about 20 per cent. of the cases of pulmonary tuberculosis the 
lymphatic glands lying in the mid-axillary line in the fourth and fifth spaces 
are enlarged. The enlargement of this lower group of lateral thoracic 
glands is in consequence of specific changes, due to passing out of bacilli 
from glands in the interior of the chest. These glands may serve to direct 
attention to lung apices, and in doubtful cases may assist the diagnosis. 
In individuals free from lung disease v. Lebrowski found these glands 
enlarged in only 2.5 per cent. of the cases. 

Since these glands are also enlarged in acute, inflammatory, non-tuber- 
cular processes (pneumonia), in doubtful cases the suggestion of Schulze to 
remove a small gland for microscopical examination or inoculation may be 
followed. 


Turban draws attention to a slight swelling of the thyroid 
gland as one of the earliest symptoms of tuberculosis, more 
seldom seen in later cases. This enlargement of the thyroid is 
especially seen in young women, and may reach such a grade 
that, in conjunction with the tachycardia frequently present in 
tuberculosis, it may lead to an erroneous diagnosis of ex- 
ophthalmic goitre in cases of early or latent phthisis. We 
must, however, not forget that many French authors, and also 
some German, consider tuberculosis as a cause of Graves’s 
disease. 


PULMONARY TUBERCULOSIS 47 


The circumference of the chest must be 

Chest :; ; 
taken with the arms horizontal in the 
respiratory pause; in men, just below the 
shoulder-blades and nipples; in women, above the breasts. It 
should, in normally-developed men, measure at least half of the 
height; if it is less the thorax is weak and predisposed to phthisis. 
Of importance for the function of the lungs is the respiratory 
expansion, the difference between the chest circumference on 
expiration and on deep inspiration, which should not be less 
than 2 in. An increase of the expansion during treatment is at 


least an objective sign of an improvement in the respiratory 
mechanism. 


Measurements. 


The combined measurements of the body-weight, height, 
chest circumference and respiratory expansion give a good idea 
of the general condition and of the development of the thorax; 
by means of calipers the length, breadth and depth of the thorax 
can be easily and quickly added. Similar measurements of both 
halves of the thorax, to estimate, for example, the amount of 
retraction of the chest after pleurisy, can be suitably made with 
a thin lead pipe or a cyrtometer. , 

v. Ziemssen utilizes the relation between 
the vital capacity of the lung and the 
height, first observed by Hutchinson, as a means of distinguish- 
ing normal and subnormal respiratory powers. In normal men 
he takes the lowest proportion to be 1 cm. of height to 20 c.c. 
vital capacity; in normal women, 1 to 17. If the proportion falls 
below this v. Ziemssen considers that there is a considerable 
disturbance of the respiratory organs; an important fact, the 
truth of which was confirmed for phthisis 1 sy Turban, and whjch 
we also can support from the examination of a large number of 
cases. Further, we can state, as the result of reliable spirometric 
measurements taken at the same time of day, that a continued 
diminution of the vital capacity indicates advancing tubercular 
disease, while an increasing capacity indicates an improvement 
in the general lung condition. This increase does not merely 
mean an augmentation of the respiratory surface from opening 
up of infiltrated areas, but also is a most important indication 
that the whole respiratory apparatus is in better order. 
Only the most important points for the 
diagnosis of pulmonary tuberculosis need 
be referred to in connection with the method and technique of 
percussion. Which method of percussion is preferred is a matter 
of practice and custom. We, like other observers, use by choice 
either the finger or the pleximeter. In both methods the feeling 


Spirometry. 


Percussion. 


45 A CLINICAL SYSTEM OF TUBERCULOSIS 


of resistance is communicated to the percussing finger in the same 
way; both methods also allow of the tactile percussion recom- 
mended by Ebstein and Turban, that is, estimation of the tactile 
sensation received on giving short percussion taps with a stiff 
wrist. The percussion note is always to be compared over the 
two lungs in corresponding places and with equally strong taps. 


Of course the comparison of symmetrical spots does not alone determine 
the existence and amount of diminution of the note or dulness. The 
comparative percussion of symmetrical spots permits the contrasting of the 
altered lung note with the normal sound which is absolutely necessary in 
order to appreciate the fine grades of difference between loss of resonance 
and absolute dulness. 

It is clear that comparative percussion in symmetrical spots does not 
produce a normal lung note of constant pitch and resonance, but that it must 
be different in every individual, since it arises from the vibrations of the 
chest wall and thoracic organs—two variable factors. The correctness of 
this interpretation has recently been further confirmed by the experiments 
of Moritz and Rohl. 


Percussion is practised from above downwards, first in front, 
then at the back. In each intercostal space the median and 
lateral parts are to be compared with each other. For the per- 
cussion of the back the arms are to be crossed over each other, 
so as to draw the shoulder-blades as far as possible apart. It 
is important that the head be kept quite in the middle line, and 
that the muscles of the thorax, especially the shoulder muscles, 
be completely relaxed; therefore the patient must assume an 
easy attitude and must not throw out the chest. Every part of 
the thorax is to be percussed, and the axillz especially, if the 
result of percussion at the apices is doubtful. Behind, the inter- 
scapular region is especially to be examined; deficient resonance 
here indicates changes in the hilus, which are much more fre- 
quently met with in tuberculosis than was previously thought. 
In estimating the lower limits of the lung one pays attention to 
their powers of expansion on deep inspiration. This is the more 
important as a unilateral deficiency of expansion with a flattening 
of the note not uncommonly points to an affection of the pleura. 

The thickness of the overlying soft parts must be considered, 
_so that percussion behind must be rather firmer than in front. 
The best results are afforded by the lightest percussion that just 
gives a perceptible sound. The pleximeter or finger must be 
carefully kept parallel to the edge of the lung, especially in mark- 
ing out its lower border. For purposes of control and in doubtful 
cases the tactile percussion of Ebstein is useful. Usually the 
patient should only breathe gently, but if the results are uncertain 
a deep inspiration will sometimes bring out the difference of note. 
If the note is only slightly changed in the upper part of both 


PULMONARY TUBERCULOSIS 49 


lungs, so that its estimation is difficult, then it is best to percuss 
upwards from the lower part of the lung with normal note to- 
wards the apex. The method of v. Striimpell can also be 
employed. 

As tubercular disease usually begins in the apex of the 
lung it is by the careful examination of this part that an early 
diagnosis is chiefly to be made. Percussion naturally fails to 
detect very slight early changes; a distinct diminution of the 
amount of air contained is required to produce a difference in 
note. From lowering of the tension the note often acquires a 
tympanitic character. In unilateral apical disease percussion of 
the clavicles will often determine the affected side. The first rib 
lies in close relationship to the lung apex, so that, according to 
Plesch, we may obtain the resonance of the whole extent of the 
apex by percussing over the manubrium sterni, a hand being laid 
on the other apex to exclude its vibrations. It is often useful 
to stand a patient against a door while percussing; it will then 
be more easy to obtain apical dulness as the background is 
resonant (Goldscheider, Wenzel). With alteration of the note 
on both sides it may be very difficult to determine which side is 
affected; auscultation here comes to our aid. In more advanced 
changes not only can the infiltration be detected, but also the 
contraction cf the lung by lowering of the apex; it is then that 
marking out the upper lung limit is cf special value. 

Very good results accrue from mapping out Kronig’s band 
of resonance. The upper limit of the lung apex is not deter- 
mined, but the lateral borders of the apical resonance are pro- 
jected as a broad, vertical band above the shoulder girdle by the 
lightest percussion passing from within outwards before and 
behind. While healthy lung apices give the same clear note 
over equally broad areas, if there is even quite slight infiltration 
and retraction an easily measurable diminution of the resonant 
area will be detected. 

Goldscheider employs another method for mapping out the 
upper limit of the lung. He rightly raises the objection that the 
real lung apices, especially their highest points, are not marked 
out at all by Kronig’s method, that his band of resonance 
is only the projection of one and the same point of the apex in 
different directions, and that the lateral limits are thoroughly 
unreliable, since not the apices, but the part of the lung under- 
lying the third and fourth ribs is percussed tangentially. To be 
able to mark out the absolute lung apices it is necessary to be 
quite clear about their topographical anatomy, as shown in Gold- 
scheider’s diagram (fig. 3). 

4 


50 A CLINICAL SYSTEM OF TUBERCULOSIS 


We see that in the supra-clavicular region there are three 
parts of the lung concerned, which are not of equal value for 









ay 


Kronig’s posterior area of 


Vertebra prominens +... _-. resonance 
oa t 
= ’ 
=> e 
Boa 
> 
! <e a 


Y) 


‘i \| 
\ 
+ Wil 
yi 
/¢ ik \ 
7 


A 
\\ 








Lower border of lung Lower border of lung 
on quiet respiration on deepest inspiration 


28. Ns : . Kronig’s anterior area of 
Kr6nig’s anterior area of : reconanee 
' 


resonance 


Relative heart dul- 
ness 


Upper limit of relative 


i tal Absolute heart dul- 
iver dulness 


ness 


Lower edge cf lung 
Lower edge of lung on Waa Zz Wy) h- on quiet respir- 
quiet respiration ~---- ' TE. abi. 4 | ation 


- -- Splenic dulness 
Lower edge of lung 
on deepest in- 
é spiration 
~ Traube’s semilunar space 


Lower edge of lung on ¥Y¥ 2 = PS , ss 
deepest inspiration S Zo F ie” eee 
Absolute liver dulness -- 


Lower margin of liver _ 
dulness : 


Fic: 72. 
Figs. 1 and 2 after Krénig, ‘‘ Deutsche Klinik,’’ Bd. 11. 


percussion : (1) The true apical portion, which projects from the 
aperture of the first rib and is largely covered by the sterno- 


PULMONARY TUBERCULOSIS St 


mastoid muscle; (2) the portion of the lung covered by the first 
rib; (3) a smaller part between the first and second rib, belonging 
to the first intercostal space. The two latter comprise the sub- 
apical part of the lung. The highest point of the apex cor- 
responds to the neck of the first rib, marked behind by the pro- 
jection of the spinous process of the first dorsal vertebra. There- 
fore, in front the apex of the lung occupies only the inner part 
of supra-clavicular fossa; and, behind, only a small median part 
of the supra-spinous fossa comes into relation with the lung. This 
is of importance as the whole of the supra-clavicular and supra- 
spinous fossz are still identified with the lung apex. The actual 
margin of the lung apex may be defined by very light sagittal 





\ y 


BiGes3. 


Topography of the apex of the lung after Goldscheider. —Upper and mesial margins 
of the lung. Outline of the first rib and clavicle. On the left side the clavicular head of 
the sternomastoid muscle is removed, so that the scalenus, anticus is seen. The upper 
limit of the lung lies a little above the inner edge of the first rib behind. 


1.—Apical part. 2 and 3.—Sub-apical part. 


percussion with the use of Goldscheider’s glass pencil or Plesch’s 
finger movement. In the latter method the finger that is struck 
on the second inter-phalangeal joint is bent at right angles at 
the first inter-phalangeal joint, while the other fingers are held 
with the palmar surface parallel to the percussed area without 
touching it. 

Goldscheider now employs a special method of percussion, 
that is, one so light that a scarcely perceptible sound is produced. 


52 A CLINICAL SYSTEM OF TUBERCULOSIS 


This method of very gentle percussion is quite on the principle 
of Weil, but was first employed by Ewald for the delineation of 
the relative heart and liver dulness, and is founded on the law 
of Fechner for the appreciation of differences of sensation. 

After the whole of the apices of the lungs have been marked 
out in front in the usual way, percussion must then be made, 
with the patient in a sitting position, between the heads of the 
sternomastoid muscle, comparing both sides from below up- 
wards, and estimating the height of the upper margin of the 
lung and its distance from the upper border of the clavicle. 
Percussion of the mesial border of the apex succeeds the best 
when the head is turned to the opposite side without putting the 
sternomastoid muscle on the stretch. Afterwards the first rib 
is percussed from its tubercle to the most internal point that can 
be reached, also the clavicle in the neighbourhood of the sterno- 
clavicular joint. It is superfluous to percuss out the external 
lateral edge of the apex. To uncover the first intercostal space 
from the clavicle the shoulder must be drawn up and back as 
far as possible. By strong upward movement of the shoulders 
percussion can be carried to the highest points of the armpits, 
and often gives the most exact results. 

Percussion of the lung apices behind with the lightest finger- 

to-finger movement, the shoulder-blades being drawn as_ far 
as possible outwards and forwards, shows that the resonance 
begins close to the vertebral column at the level of the spinous 
process of the first thoracic vertebra, exactly where Goldscheider 
localizes the highest point of the lung. The inner edges of the 
lungs converge opposite the second thoracic vertebra, and from 
there downwards lie close to the vertebral column. Goldscheider 
considers the delineation of the outer margin of the lung apex 
to be equally valueless behind as in front. 
The question whether to give the preference to Krénig’s or 
Goldscheider’s methods may be answered as follows: the estima- 
tion of the position of the lung apices and of their inner margins 
by Goldscheider’s method is doubtless very possible; but, on 
the other hand, the technique of Kronig’s method is simpler, and 
gives in practice sufficiently useful results. Both methods should 
be learnt and employed in exceptionally doubtful cases, so that 
the results of one method may be controlled by the other; this 
will also demonstrate the fact that one is very easily deceived in 
estimating very slight differences of note. 

The most frequent sources of error in percussion are in- 
equality of the osseous framework, slight scoliosis, and varying 
thickness of the shoulder muscles. Therefore most attention for 


PULMONARY TUBERCULOSIS 53 


diagnosis is paid to slight differences of note if they are not 
accompanied by obvious retraction of the affected side. It must 
further be remembered that a lower position of the apex is indica- 
tive of a contraction and therefore also of healed nodules. On 
these grounds we consider the comparative percussion of both 
apices during deep inspiration is required in bilateral alteration 
of the note; the anatomical changes hinder the entry of air on 
the affected side in spite of the deep inspiration and the difference 
in the note is therefore brought out more sharply. 

The initial shortening of the note is converted with the in- 
creasing infiltration of the lung tissue into dulness, which may 
be slight and relative, or intense and absolute. The dulness only 
indicates that the underlying tissue is more or less airless. One 
must always, according to the localization, think of the existence 
of enlarged glands, mediastinal tumours, pleural thickening, &c., 
and seek for means of differential diagnosis. 

With advancing infiltration the dulness increases in intensity 
and extent. From the nature of the disease it is obvious that 
these changes are not regularly progressive, but may be altered 
in many ways by re-absorption or destructive changes, by the 
development of specific or non-specific pneumonic patches, by 
pleural complications and by emphysema. 

In consequence of the diminished tension of the lung tissues 
the dull percussion note may become tympanitic. This tympani- 
tic note is heard especially over cavities, over incomplete pneu- 
monic infiltration and above large pleuritic effusions. 

The percussion note is affected in various characteristic ways 
by cavity formation. It is very frequently tympanitic or dull 
tympanitic, and presents different kinds of changes in the note 
of which the following are the most important. Commonest is 
Wintrichs’s sign, when the tympanitic note is higher with the 
mouth open and lower with the mouth closed. The respiratory 
change of Friedreich consists of the tympanitic note becoming 
higher with a deep inspiration, and even disappearing from the 
respiratory tension on the cavity walls. Gerhardt’s sign depends 
on the fact that alteration of the position of the fluid contents of 
the cavity changes the piich of the tympanitic note, so that the 
note usually becomes higher if the patient assumes an erect posi- 
tion. Over smooth-walled cavities of regular shape and sufficient 
size the percussion note has a metallic sound. Over cavities 
communicating with an open bronchus by a narrow opening, 
especially apical cavities, a cracked-pot or coin-clinking sound 
may be heard. 

Percussion also gives information as to the enlargement or 


54 A CLINICAL SYSTEM OF TUBERCULOSIS 


displacements of neighbouring organs, especially of the heart. 
With contraction of the lung the heart is often dragged to the 
affected side. But also with the heart in its normal position the 
absolute heart dulness may be displaced towards the affected side, 
whilst it is equally diminished on the sound side from emphyse- 
matous changes in the unaffected lung compensating for the 
shrinking (Turban). Even in moderate shrinking of the right 
apex a displacement of the absolute heart dulness to the right, 
with or without a displacement of the heart itself, is, according 
to Turbany of such regular occurrence that he considers it a 
typical leading feature of long-standing, right-sided, apical 
disease. This condition must not be considered as a broadening 
of the heart’s dulness to the right. The true outline of the heart 
can only be ascertained by the lightest percussion or by Ebstein’s 
tactile percussion. 

For the purpose of avoiding extrane- 
ous sounds, the position of the patient 
during auscultation must be the same as that mentioned 
in the section on percussion. Likewise, each spot of 
the thorax is to be examined, the axille, the anterior 
‘inner margins of the lungs and the lingula not being 
omitted; for the initial processes may develop in = an 
atypical place. Auscultation with the unaided ear is only 
suitable for the examination of gross lesions over largé surfaces ; 
for the recognition of finer signs over small deposits a stethoscope 
is required. The material and form of this is not indifferent; a 
wooden one with a large ear-piece and small chest-piece is the 
best. If the examination room is not sufficiently shut off from 
disturbing outside noises the non-ausculting ear may be closed 
in a convenient way, or one may accustom oneself to a binaural 
stethoscope in one of its forms with india-rubber connections. 
But with all such instruments one must first learn to eliminate 
extraneous sounds. 

For auscultation the patient must breathe quietly and some- 
what deeply through the nose, so that the lungs are uniformly 
expanded (Turban). In mouth breathing the expiration especially 
acquires rather an accentuated character, which must be allowed 
for if nasai obstruction compels its use; the weakened inspiration 
and prolonged expiration being then deceptive. The stethoscope 
is placed several times in each intercostal space, in front and 
behind, according to the size of the chest. Both sides are to be 
compared at corresponding places, and, of course, both sides may 
be diseased. 


On auscultation we must observe the quality and strength 


Auscultation. 


PULMONARY TUBERCULOSIS 5 


tn 


of the respiratory sounds, and the relation between the inspira- 
tory and expiratory sounds in regard to nature and duration. 
Of particular importance, as often the first symptom of com- 
mencing apical mischief, is a not clear or hoarse vesicular sound, 
which often has a vibratory character. Its production depends 
on a soft swelling of the finer air passages (Dettweiler), on small 
isolated rhonchi, not yet accompanied by secretion, in the 
bronchioles (Sahli), or on the air in consequence of the existence 
of small airless nodules entering the alveoli by fits and starts 


(Turban). 


From the pathological harsh breathing we must separate the physio- 
logical breathing accompanied with a sort of humming sound, which is often 
heard as an unbroken sound during inspiration and the greater part of 
expiration, becoming louder with inspiration and dying down with expira- 
tion. With Waller, we hold these to be muscle sounds, especially due to 
the contraction of the inspiratory muscles. It is not, however, correct to 
ascribe, like Waller, well-marked harsh breathing to the same muscular 
cause and to give it the same pathological meaning. 


Cog-wheel breathing is to be explained in the same way as 
harsh breathing, which, according to Turban’s supposition, 
is due to quite large lung areas of defective function in the 
neighbourhood of infiltrations; but it is not to be confused with 
the systolic cog-wheel breathing caused by the systole of the 
heart and which is not pathological. Cog-wheel breathing is 
usually accompanied by exaggerated vesicular breathing, and 
is in favour of tuberculosis, especially if it is limited to one apex. 
It may also, with diffuse bronchitis, be a sign of local catarrh, 
but much more often it is the result of exaggerated respiration 
near contracting processes or in the neighbourhood of small 
nodules, and easily assumes a harsh character. Weak vesicular 
breathing, like harsh breathing, is a sign of early mischief, and 
they are often met together. Weak breathing over the whole 
of one side may also be the result of extensive pleural adhesions 
or of compression or partial blocking of a main bronchus. In 
more advanced changes it disappears. 

With advancing infiltration the breathing becomes more 
bronchial. As transitional forms Dettweiler recognizes the 
vesiculo-bronchial breathing, when the vesicular character pre- 
dominates, and the broncho-vesicular when the bronchial charac- 
ter is more marked. Both forms may also be harsh or weak. 

We agree with Turban that minute sub-divisions of indefinite 
breath sounds at the most are only for the convenience of ex- 
pression and are best excluded from the nomenclature. If the 
character of the breath sounds is in fact indefinite, then it is 
interfered with or masked by other sounds. 


56 A CLINICAL SYSTEM OF TUBERCULOSIS 


The respiratory alterations which have hitherto been 
described affect both inspiration and expiration. In the early 
alterations of the inspiratory sounds expiration is frequently stl 
unchanged, but gradually it becomes affected, but it, as a rule, 
becomes markedly bronchial later than inspiration. As soon 
as the infiltration has become established in the apex it is louder, 
rougher and more bronchial in character. Prolongation of the 
expiration is characteristic, and appears with supervention of 
contraction, and particularly in the presence of emphysema. In 
tuberculosis of the upper part of the lung, if heard over the lower 
healthy portion, or over the other lung, it indicates emphysema. 

A very important practical point is that expiration may be 
louder, sharper and more prolonged over the right apex, 
especially behind, without the lung being affected. This physio- 
logical difference from the left side is found approximately in a 
third of healthy people, and is due to the larger size and straighter 
course of the right upper bronchus. 

The intensity and extent of the bronchial breathing is 
regulated by the density and size of the infiltration, but it is not 
usually so widely diffused as in a genuine pneumonia. Expira- 
tion 1s sometimes more intensely bronchial than inspiration. Also 
condensation or compression, as above a pleural effusion, may 
produce bronchial breathing. Cavities are also a most common 
cause of bronchial breathing, if they communicate with a 
bronchus. Over a cavity the bronchial breathing often takes 
an amphoric character. Amphoric breathing in conjunction with 
Wintrich’s or Gerhardt’s percussion signs is the surest indication 
of a cavity, especially if it has a metallic quality. The conditions 
for the production of this phenomenon are the same as for the 
metallic percussion sound: the cavity must be of regular shape, 
smooth-walled and comparatively large. Sudden change during 
inspiration from vesicular to bronchial character, or metamor- 
phosed breathing, also indicates a cavity. 

One cf the most important signs of lung tuberculosis is 
rales, which, not only by themselves in early cases, may make 
the diagnosis certain, but in the majority of cases give the most 
trustworthy indication of the extension of the disease. It must 
be emphasized, of course, that the affection of the lung may 
last a long time free from catarrh, solely in the form of chronic 
infiltration, which alone can be shown by alteration of the breath 
sounds and the results of percussion. Rdales depend on the pre- 
sence of secretion in the air tubes. They are the more numerous 
the thinner and more abundant the secretion; their size and loud- 
ness depend on the size of the space in which they are produced. 


on 


PULMONARY TUBERCULOSIS ov 


According to number the rales may be designated occasional, 
scanty, fairly numerous or numerous; according to size as crepita- 
tions, fine, medium, or coarse rales; according to character as 
consonant, tinkling, or metallic. A division between dry and 
moist rales is not to be recommended, but it is better to reckon as 
rhonchi, and not as true rales, those assuming a thick or dry 
character, and to speak of crackling, rattling, creaking, whistling, 
humming, or sonorous rhonchi. | Buttersack considers the dry 
crackling rales and rhonchi to be due to unequal elasticity and 
abnormal tension in consequence of morbid changes in the paren- 
chyma of the lung. 

All the morbid sounds that have been mentioned appear 
in the various stages of tuberculosis, often combined in many 
different ways. Those sounds which are distinguished by their 
position, localization and duration, are particularly valuable for 
the diagnosis of tuberculosis, especially if other manifest clinical 
symptoms are absent. Of the greatest value for diagnosis and 
prognosis is the fact that these catarrhal sounds, even in pro- 
gressive disease, are often first made perceptible by cough, while 
they cannot be heard in the least even on deep breathing. There- 
fore each portion of the lung must be examined during quiet 
respiration, and also during deeper breathing after a cough. 
Whoever omits that shows a want of care. We meet many 
cases in which even numerous rales can only be detected after 
the patient has coughed some four or six times, one after another, 
without inspiring between, like the cough of whooping cough, 
and then takes a deep breath. We like to employ this manceuvre 
in every case in which catarrh is absent, but only after percussion 
has been performed and the character of the respiratory sounds 
noticed. 

Noises which may be confused with rales can be produced 
by hairs, by very dry skin, or by insecure placing of the stetho- 
scope. Also the muscles and tendons of the head and shoulder- 
girdle give rise to sounds if the patient is in an unsuitable 
position. The shoulder noises, which are produced by friction 
between the shoulder-blade and thorax, and may be of a crackling, 
creaking, or rubbing character, are, according to Turban, re- 
moved usually by repeated rotation of the outstretched arm. 
Other extraneous sounds are produced by swallowing movements 
of the patient, for which one must be cn the look-out. Ascending 
sounds from the cesophagus, and similar noises caused by move- 
ments of the stomach and intestines, are more easily dis- 
criminated. 

A sharp distinction between pleuritic and pulmonary sounds 


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PULMONARY TUBERCULOSIS 59 


is often very difficult or quite impossible. The following are 
some points of difference: The pleural rub is audible during the 
whole of inspiration and also during expiration, it is most easily 
heard at the height of inspiration, it is not altered by cough, it 
is increased by pressure with the stethoscope, it sounds nearer 
to the ear than the finer rales; but all these aids frequently fail, 
so that a more prolonged observation is required for a correct 
decision. 

For quickly recording the results of percussion and ausculta- 
tion, so that at any time they can be recognized in a moment, 
physicians have for many years employed schematic outlines of 
the chest, on which each separate departure from the normal 
may be noted by means of special graphic signs. In the method 
of employing these signs there is, as yet, no agreement; the 
attempt to come to an international arrangement on the graphic 
recording of lung sounds will certainly not succeed. Neverthe- 
less, the proposals of Nahm and Pischinger contain the essential 
parts of many different ideas. We therefore give here the graphic 
signs, and, as an example, also a schematic representation of the 
results of percussion and auscultation. 

Auscultation will be completed by the examination of the 
whispering voice, the changes of which are chiefly associated with 
bronchial breathing. Particularly it may give information of 
small infiltrations quite in good time, when there is still doubt 
about the presence of bronchial breathing, and especially if the 
patient is breathing badly on account of pain (Sahli). Pectoriloquy 
and egophony are sometimes heard also over infiltrations. Both 
phenomena are really forms of exaggerated bronchophony. 

Lastly, mention must be made of the apparently little-noticed 
subclavian murmur, a systolic blowing sound over the subclavian 
artery, more often heard above than below the clavicle; it may 
be present during both phases of respiration or partly in in- 
spiration, partly in expiration. When it is only just audible 
it may be increased by forcible inspiration, more rarely by deep 
expiration; sometimes by this means it is first brought into 
observation at the height of one or other movement. These 
facts prove that it is a stenosis murmur. It is produced by 
an adhesion of both pleural surfaces to each other and to 
the wall of the subclavian artery. Whether it may also rarely 
occur in health, as has been asserted, is difficult to say; in any 
case, it is most frequently found with apical tuberculosis. As 
the result of our prolonged observations we consider ourselves 
justified in holding unilateral subclavian murmurs as indicative of 
tuberculosis. 


60 A CLINICAL SYSTEM OF TUBERCULOSIS 


If the results of percussion and auscultation are opposed to each other 
it may be asked which of the two fundamental methods is of more value for 
the diagnosis of early disease. We hold such a question to be idle for the 
following reasons: Percussion informs us of the density of the tissues, and 
with the necessary practice allows quite the smallest departure from normal 
to be recognized. It can also detect a nodule of disease at a time when 
auscultation still gives no information. Therefore v. Romberg gives so 
much weight to the percussion results in detecting a focal reaction after 
a diagnostic tuberculin injection, when auscultatory signs are absent. The 
difficulty only is that percussion in many cases, to put it shortly, reveals 
too much; for example, healed mischief or non-specific processes. Also 
spinal curvature, asymmetrical development of the thorax, abnormal position 
of the clavicle and the neighbouring ribs, pathological thickening of the 
overlying tissue, swollen lymphatic glands in the supra-clavicular fossa, &c., 
may affect the percussion results in a misleading way, and auscultation 
clears up the question. 

On the other hand, alterations of the breath sounds and fine catarrhal 
signs may with certainty indicate tuberculosis, while percussion leaves one 
quite in the lurch or only gives uncertain results. The conclusion, therefoie, 
is that each method must be used to complete the other to obtain the best 
possible result from physical diagnosis. 


Ill. Bacteriological Diagnosis. 


The finding of tubercle bacilli in the sputum affords the 

surest evidence of the existence of pulmonary tuberculosis. On 
the other hand, patients with undoubted phthisis may, owing to 
septic complications, expectorate large quantities of sputum, in 
which, in spite of careful examination, tubercle bacilli cannot be 
found. This means that the quantity, colour and character of 
the sputum afford no indication of the presence of tubercle 
bacilli, even if it comes from a lung which, on clinical grounds, 
is doubtless tubercular. 
The examination of the sputum may be 
simply, reliably and cleanly carried out in 
the following way: The patient must be 
instructed to expectorate some of the real 
sputum, without troublesome admixture of mucus from the throat 
or nose, into a clean glass vessel. A naked-eye examination 
must precede the microscopic search. By this means it is seen 
if it has a mucoid, purulent or bloody character; if it is thin, 
tenacious, gelatinous or ropy; the form, size and density of 
the separate masses are noticed, its smell is observed, and also 
whether it contains carbon particles, bacterial pigments, or 
blood-colouring matter, granules or tissue fragments. 

The examination should take place as soon as possible, as 
on standing long the staining properties of many of the tubercle 
bacilli suffer, and, from the destruction of the leucocytes, the 
characteristic connection between them and the bacilli is effaced. 


Technique of 
Sputum 
Examination. 


Bandelier ana ke Dre, CLINICAL SYSTEM « Lubercu TSE Flate 





Acid-fast bacteria in sputum. Pseudotubercle-bacilli in pharyngeal mucus 
(After Lichtenstein, Zeitschr. f. Tub. Bd. Il After Kayserling, Zeitschr. f. Tub. Bd. ITT.) 





Tubercle-bacilli in sputum. Lymphocytic sputum with tubercle-bacilli. 
(After Hirschkowitz, Brauer, Beitriige, Bd. II. (After W ol ff-Eisner, Friihdiagnose nnd 





Intra-cellular tubercle-bacilli in sputum. Granular form of tubercle organism. 
(After Turban-Baer, Brauer, Beitriige, Bd. X.) (After Lenhartz, Mikroskopie und Che 





PULMONARY TUBERCULOSIS OI 


The material to be examined should be taken from the thickest, 
most cellular part; the small, firm granules, which usually come 
from a cavity, should be sought for. To aid the search it is 
useful to spread the sputum on a black dish or on a glass slide 
on a black background. The chosen particles are picked up 
with sterilized platinum needles from about ten different parts 
of the sputum and spread in the thinnest and most uniform layer 
possible on a slide. 
Staini As soon as the preparation is quite dry it 
taining : i tote 3 
is passed slowly through the flame three 

Methods. times, with the sputum side upwards, in 
order to fix it, and is then stained in the following way by 
Ziehl-Neelson’s or Gabbet’s methods :— 


(1) Ziehl-Neelson.—Stain for two minutes in hot (till bubbles form), or 
better for twenty-four hours in cold, carbol-fuchsin (fuchsin 1, absolute 
alcohol 10, liquefied carbolic acid 5—dissolve, then dilute with distilled 
water 100); decolorize for five seconds in 25 per cent. sulphuric acid or 
30 per cent. nitric acid; wash in 60 per cent. alcohol until the preparation 
is colourless (if necessary, repetition of the decolorizing and washing); 
counter-stain with methylene-blue (1 part saturated alcoholic solution of 
methylene-blue, 4 parts water); wash in water. 

(2) Gabbet.—Stain in carbol-fuchsin as above, decolorize and counter- 
stain at the same time for one to two minutes in Gabbet’s solution (methy- 
lene-blue 2, 25 per cent. sulphuric acid 100). 


These two processes have kept their place till to-day as 
the customary and best methods, in spite of many new modifica- 
tions. If the results of the examination are not satisfactory, it 
must not be forgotten that staining for twenty-four hours in the 
cold gives better results than the hot method, a fact which may 
be of decisive importance in the discovery of scanty bacilli with 
bad staining properties. 

The number of the bacilli can be recorded 
most conveniently by Gaffky’s scale, which 
gives the average number found in a field. 
For practical purposes they may well enough 
be classified as scanty, fairly numerous and very numerous. If the 
bacilli are very few an examination of the sputum of two or 
three successive mornings will generally be successful. If the 
expectoration is very scanty it may be collected in a_ well- 
stoppered glass bottle containing a little carbolic lotion, the 
patient using this for several days. 
ror : In spite of these precautions, the discovery 
ntiformin arte 

of scanty bacilli in very abundant sputum, 
Eee such as is produced by a secondary septic 
infection, may be very difficult. For such cases several methods 


Estimation of 
the Number 
of Bacilli. 


62 A CLINICAL SYSTEM OF TUBERCULOSIS 


have been suggested; the sputum may be made homogeneous, 
may be rendered less copious, may be divided by sedimentation 
or centrifugalization. These methods are both complicated and 
lengthy, so that for practical purposes they hardly come into 
consideration. All the more important therefore is the antiformin 
method which Uhlenhuth has lately introduced into practice. 
It marks a great advance in the practice of sputum examination, 
and according to the observations of many, including ourselves, 
gives better and quicker results. 

Commercial antiformin, a happy combination of liq. sod. 
hypochlor. and caustic potash, has the property of dissolving 
all bacilli with the exception of the acid-fast organisms (timothy- 
grass, butter, leprosy and smegma bacilli), which owe their 
resistance to their fatty envelope. At the same time, owing to 
the addition of antiformin, even the thickest sputum is dissolved 
into a state of almost uniform fluidity in several hours (at the 
longest twenty-four) at the ordinary room temperature, and, as 
a rule, forms a sediment easily. By the addition of spirit, which 
lowers the specific gravity of the mixture, or especially by centri- 
fugalizing, the sedimentation will be naturally hastened. The 
sediment is then washed with distilled water to remove the 
strong alkalinity and to facilitate its fixation. The adhesion of 
the sputum to the slide may also be increased by the addition 
of a little fresh sputum of the same sample, or of a little white 
of egg or glycerine albumin. 

After trial of all the known modifications we have had the 
best results from the method worked out by Schulte under 
Uhlenhuth’s direction in the Imperial Health Office. 


One part of sputum and two parts of 50 per cent. antiformin are mixed 
in an Erlmeyer’s flask, shaken up and allowed to stand till the sputum is 
completely broken up (ten to thirty minutes). Three parts of rectified spirits 
are then added, and the mixture is shaken and centrifugalized for half to 
one minute. The lowest part is spread over a slide, the dried preparation 
fixed above a flame and stained by Ziehl-Neelson or Gabbet’s method. If 
the bacilli are present in the sputum at all they will be found with tolerable 
certainty. 

Lorenz finds a greater number of tubercle bacilli if the mixture of anti- 
formin and sputum is boiled to more complete homogeneity. 


Still more exact, but more complicated, is the Ellermann- 
Erlandsen’s modification of the antiformin method by incubation. 


One part of sputum is mixed in a graduated centrifuge tube with a 
half part of 0.6 per cent. sodium carbonate solution, and the mixture 
allowed to stand for twenty-four hours in an incubator at 37° C. The 
greater part of the upper fluid portion is drawn off, the bottom centri- 
fugalized, and the fluid again drawn off. Then to one part of the sediment 


PULMONARY TUBERCULOSIS 63 
is added four parts of 0.25 per cent. caustic soda, and the mixture boiled 
with careful stirring. After cooling it is again centrifugalized and the 


sediment used for the microscopical preparation. 


Loffler’s modification of the antiformin 


‘ ; 
Bee.” method requires a good centrifuge, and 

Oe ai makes possible the discovery of the bacilli 
Modification. 


in fifteen to twenty minutes. According 
to Loffler’s directions it is as follows :— 


A measured quantity of sputum (5, 10 or 20 c.c.) is mixed in a flask 
of Jena glass with the same quantity of 50 per cent. antiformin and boiled. 
A frothy and light brown solution is formed at once. To 10 c.c. of the 
solution is added 1.5 c.c. of a mixture of ten parts of chloroform and ninety 
parts of alcohol. After thorough shaking, best in a flask with a patent 
stopper, the fluid part is centrifugalized for fifteen minutes. There is then 
a layer of material centrifugalized out, and above it the chloroform. The 
fluid part is drained off, and the whole of the other material is placed on 
the slide. After removal of the superfluous liquid with a filter paper, and 
the addition of a drop of egg-albumen, preserved with 0.55 per cent. 
carbolic acid, the material is spread with a second slide. 


If a good centrifuge is not obtainable the 


iformin- oie : ; ; 
as era antiformin method can be combined with 
nein the ligroin modification of Lange and 


Modification. Nitsche. There is a great affinity between 


tubercle bacilli and hydro-carbons (ligroin), so that on careful 
shaking with some drops of hydro-carbon they are more fully 
separated and carried to the top, and found in great numbers 
at the junction of liquids. The antiformin-ligroin method, 
according to Schulte, is as follows :— 


Ten c.c. of sputum and 20 c.c. of a 20 per cent. antiformin solution 
are shaken together from time to time till they form a homogeneous 
solution. 20 c.c. of water is added and shaken, and then 2 c.c. of ligroin, 
the mixture being thoroughly shaken till a thick emulsion results. It is 
placed in a water-bath at 60° C. till there is a clean separation; 3-1 c.c. of 
methylated spirit carefully added drop by drop, and material removed to 
a slide with a platinum needle, and treated as before. 


The combined antiformin-ligroin method is considerably 
longer, but it gives, without a centrifuge, reliable results owing 
to accumulation of the bacilli at the junction of both media. 

An evident drawback of the antiformin methods is that all 
the cellular elements, and also the leucocytes and elastic fibres, 
are completely dissolved, so that if one wishes to observe these 
the antiformin method cannot be employed. 

The position of the tubercle bacilli inside 
the leucocytes of the sputum has a certain 
value, which has not yet been sufficiently 
examined. It is generally a favourable prognostic sign, and is 


Position of the 
Tubercle Bacilli. 


64 A CLINICAL SYSTEM OF TUBERCULOSIS 


especially observed in cases improving under the influence of 
tuberculin treatment. 
Eosi : According to Teichmuller the sputum con- 
osinophile Ss, 2 SMS Bae: 
tains eosinophile cells for months before the 
Cells. bacilli appear, and with the appearance of 
the bacilli the cells diminish or disappear. With a favourable 
course of the disease there is an increase of these cells, with an 
unfavourable course a diminution, in which Teichmuller sees the 
working of a defensive mechanism against the infective organ- 
isms. From our own observations we cannot endorse these 
results; we can recognize no clear connection between the eosino- 
phile cells and the prognosis of tuberculosis. 
Elasti _ Elastic fibres in the expectoration indicate 
meu with certainty the presence of destructive 
Fibres. processes in the trachea, bronchi, or sub- 
stance of the lungs; mostly they appear in consequence of 
tubercular necrosis of the parenchyma of the lungs, but are 
absent in stationary tuberculosis when no tissue destruction is 
going on. On the other hand elastic fibres may proceed from 
abscess of the lung or bronchiectasis, while in gangrene of the 
lung they are produced in quantities, but are seldom recognized 
in the sputum, as they are quickly destroyed by some substance 
still unrecognized chemically (ferment ?). Elastic fibres are thus 
in no way pathognomonic of tuberculosis. They are quite 
bright, of double contour, and often bifurcated, frequently undu- 
lating or rolled together, crooked or curled at the ends; they often 
present an alveolar arrangement. 
Elastic fibres have great powers of resistance to alkalis, a 
fact which is useful for their detection. 


A suspicious particle of sputum is treated on a slide with a small 
drop of to per cent. caustic potash. If the fibres are very scanty it is 
useful to make the sputum homogeneous and allow it to form a sediment: 
the sputum is well shaken with 10 per cent. caustic potash, perhaps also 
boiled, till the whole is homogeneous; it is then allowed to form a sediment, 
or centrifugalized, and the sediment examined. Confusion may be caused by 
particles of food, which might be mixed with the sputum, by cotton-wool 


fibres (without double outline), and by crystals of fatty acids (melted by 
heat). 


A confusion with true tubercle bacilli may 
be caused by pseudo tubercle bacilli; as the 
smegma bacilli in secretion from the throat 
and nose, or from a furred tongue or coated teeth, and from the 
follicles of the tonsils; as pseudo tubercle bacilli of milk or butter; 
or from acid-fast bacilli in gangrene of the lung and fibrinous 
bronchitis, which are occasionally expectorated. The distinction 


Pseudo 
Tubercle Bacilli. 


PULMONARY TUBERCULOSIS 6 


on 


between true and pseudo bacilli in the sputum has thus a similar 
importance for the diagnosis of phthisis as the differential diag- 
nosis between smegma and tubercle bacilli has in uro-genital 
tuberculosis. But if the bacterial diagnosis is not divorced from 
the clinical examination this distinction will not be of great 
importance. The differential diagnosis may be made as fol- 
lows :— 

The sputum is shaken up with sterile culture broth and incubated for 
some time at a temperature of 30° C. If there is a continued distinct 
development of acid-fast bacilli they are pseudo tubercle bacilli, as true 
tubercle bacilli do not multiply under these conditions. 

This method is simpler and still more trustworthy than 

- animal experiment, since pseudo tubercle bacilli in large numbers 
are also able to produce a disease with nodules resembling experi- 
mental tuberculosis. In contrast to the tubercle bacilli, however, 
they lose their peculiar staining properties in their fresh develop- 
ment, and so may further be distinguished. 
For the recognition of nearly all the other 
bacilli in the sputum a second preparation 
stained with weaker carbol fuchs in (1 to 10 
aq. dest.) for a short time in the cold is serviceable. We need 
not consider here the further differentiation of bacteria which may 
be present in tubercular sputum, such as strepto-, staphylo- and 
diplo-cocci, Micrococcus tetragenus, catarrhalis, and influenza 
bacilli. For the recognition of the most common streptococcal 
forms Gram’s method, with or without Weigert’s modification, is 
of great service. 


Much’s 
Granula. 


Other Bacteria in 
the Sputum. 


For the interpretation of the Gram-positive 
forms great caution 1s required, since it has 
been shown by Much that there is a granu- 
lar form of the tubercular organism, which can only be made 
visible by a certain modification of Gram’s method. 


The staining method (Gram II) given by Much is as follows: The 
thinnest possible film is left for 24 to 48 hours in a solution of methylene 
violet (10 c.c. saturated alcoholic solution in 100 c.c. two per cent. carbolic 
acid solution) at 37° C., or the slide, covered with the solution, may be 
heated to boiling. After washing, the slide is placed in iodine potassium 
iodide sol. two to three minutes, in five per cent. sulphuric acid one minute, 
in 3 per cent. hydrochloric acid ten seconds, and lastly, one minute in 
acetone-alcohol (equal parts), and is then washed and dried. 

This method of staining brings out the bacilli in different forms, partly 
developing, partly degenerating; having lost their free fatty acid the bacilli 
no longer stain with Ziehl-Neelson, but only with Gram. 


Observations, which we also can confirm, show that in 
sputum preparations from tubercular patients, beside the Ziehl- 
Neelson staining bacilli there are as a rule to be found Much’s 


5 


66 A CLINIGAL SYSTEM OF “TUBERCULOSIS 


granules in rod form, staining by Gram II method. The rarer 
isolated granules are to be received with greater reserve. 
They may be recognized by their rod form from the other cocci, 
nucleoli, and dirt particles. A certain alternation between the 
two forms of tubercle bacilli has been observed, in so far as, with 
the diminution of the acid-fast bacilli, the number of granules 
increase proportionally, a change which we have not been able 
to observe. On the other hand, our systematic observations have 
shown that in the sputum of clinically manifest tuberculosis in 
which even with the antiformin method Ziehl-Neelson staining 
bacilli cannot be found, Much’s granules isolated, or in rod form, 
may be observed in fewer or greater numbers. The practical 
interest lies in the great importance of employing the above- 
mentioned staining method for granules if the examination of the 
sputum is negative. Whether Much’s granules are to be con- 
sidered as a breaking-down form of the tubercle bacillus, or as its 
true resting form, or as a relatively weakened variety of the 
organism, we cannot yet decide. 

In all probability they are not any special form of tubercle bacilli, 
but the chemically-resisting constituents of the normal bacillary bodies, 
whose nature is not sufficiently known. Liebermeister considers them 
identical with the Bakes-Ernst corpuscles, which are seen in different 


bacteria; according to him they have nothing to do with Spengler’s bodies 
and are not spores, since spore-forming bacteria are found with them. 


_. French authors, especially Roger and Lévy- 
Albumin Reaction Valensi, have stated, not as a new fact, 
of the that tubercular sputum contains albumen 
Sputum. constantly, and that its presence has value 

for diagnosis even in early cases, still doubtful clinically. The 
albumin reaction is likewise positive according to many observa- 
tions, but not with the same regularity, in non-tubercular inflam- 
matory affections of the lung, as pneumonia, pleurisy, bronchi- 
ectasis, gangrene, infarct and oedema of the lung; more seldom 
in the different forms of passive congestion; never, how- 
ever, in simple and chronic bronchitis, or in emphysema. The 
value of the reaction lies in this: that a negative result in doubt- 
ful cases, with great probability, is against the existence of an 
active tuberculosis, while a positive result is only of importance 
if the above-mentioned non-tubercular diseases can be excluded. 
Biernacki, whose observations are in accord with what has been stated, 
has also systematically estimated the amount of albumin present quanti- 
tatively, and has found in active tuberculosis about two per thousand. 
Schmey also recognizes the value of the reaction, and thinks it valuable, 
especially for early diagnosis. In connection with the orthostatic albu- 
minuria of phthisis described by Liidke and Sturm, we may conclude that 


the albumin is derived from the bronchial and alveolar vessels in conse- 
quence of a toxic irritation from an active tubercular deposit. 


a 


ri 


een 


PULMONARY TUBERCULOSIS 67 


We have examined the reaction in a large series of tubercular cases, 
usually of the open variety, and have throughout found it positive; in 
several cases of acute or protracted bronchitis the result was negative, or 
there was only a very slight turbidity. We agree with Prorok that the 
amount of albumin in the tubercular sputum has no connection with the 
stage of disease or the amount of pus in the sputum. The value of the 
reaction for early diagnosis appears to us not sufficiently proved: and we 
do not esteem it highly for this purpose, as really early cases provide no 
sputum. 

The albumin reaction is obtained in this way: fresh sputum, as free as 

possible from saliva, is thoroughly mixed with an equal quantity of water, 
and several drops of acetic acid added, the mucus thus precipitated being 
filtered off; this process is repeated till no more mucus comes down. The 
clear filtrate is then examined for albumin by one of the methods employed 
im urine analysis, and for quantitative purposes Esbach’s tube may be 
employed. 
It not infrequently happens, especially in 
women, that it is necessary to stimulate the 
production of sputum, so that it may be 
examined and tubercle bacilli sought for. The simplest method is 
the application of a cotton-wool jacket at night, followed by a 
cold friction in the morning on removal of the packing; the 
stimulus may procure the expectoration of the scanty secretion 
produced under the influence of the warmth. In a similar way 
inhalation with saline solutions, the internal use of alkaline 
mineral water, or of potassium iodide may have some effect. The 
diagnostic tuberculin injection may sometimes produce, during 
the reaction, sputum containing bacilli. 

In those cases in which there is a suspicion that the sputum 

is swallowed, or when the patient has been observed to swallow 
it unconsciously, and this again occurs more often in women than 
men, the bacilli may be sought for in the expelled stomach con- 
tents or in the feces; the latter examination being much facili- 
tated by Uhlenhuth’s method. 
With regard to the prognostic value of 
bacilli in the sputum it may be said in 
general that with advancing disease not 
only is the percentage of bacilli, but also 
their total number, large. This point has no value in practice, 
since sometimes in initial tuberculosis the bacilli are found in 
large numbers, while in rare cases of advanced phthisis they may 
be altogether absent. 


Stimulating the 
Expectoration. 


Prognostic Value 
of 
Tubercle Bacilli. 


It is agreed that the discovery of tubercle 
bacilli in the sputum is the surest sign of 
the existence of pulmonary tuberculosis; 
but it gives no indication of the form, the 
progress, and the prospects of healing of the disease. For the 
early diagnosis of phthisis the bacteriological examination is of 


Diagnostic Value 
of 
Tubercle Bacilli. 


68 A CLINICAL SYSTEM OF TUBERCULOSIS 


very small value, as only about a tenth of all really first-stage 
cases produce sputum containing bacilli. It is therefore a sad 
confession of want of skill to allow the diagnosis of tuberculosis 
to depend upon the bacteriological examination, or to wait for 
the appearance of bacilli in the expectoration ; the most favourable 
time for treatment will be lost, for the successful management of 
phthisis stands or falls with early diagnosis. 

Animal experiment is the sovereign method 
of proving the existence of tuberculosis, 
when the discovery of bacilli in stained 
preparations from the sputum, exudate, blood, or urine fails- 
The most suitable method is the intraperitoneal inoculation of 
susceptible animals, especially guinea-pigs.* 

Kiralyfi found in eight to fourteen days after the infection 
the retro-jugular glands to be enlarged, caseating, and containing 
bacilli, at a time when tubercular changes could not be recog- 
nized in the other glands or in the organs. 

Bicce elond The usual intraperitoneal or subcutaneous 
inoculation has the drawback that it 
entails a delay of four to six weeks, and 
even after this time the changes may be so slight that they can 
only be shown with certainty by a microscopical examination. 
A shortening of this period may be obtained by Bloch’s method 
of crushing the glands of the groin after inoculation in the 
inguinal region. 


Animal 
Inoculations. 


Crushing Method. 


Bloch has lately improved the method by treating the material. to be 

examined with weak antiformin, the other bacilli are thus destroyed and 
the probability of sepsis diminished. After nine to eleven days the crushed 
glands are extirpated, treated by the antiformin method, and examined for 
bacilli. 
Oppenheimer practises the inoculation 
into the liver, with the idea that this organ 
offers a good developing ground for the 
bacilli, and is a place where the tubercular nodules can be recog- 
nized at an early stage of development. Up till now he has only 
employed this method for examination of the urine; every case 
of tubercular urine was positive, every control experiment with 
non-tubercular material negative. Further controls have shown 
that pseudo-tuberculosis or coccydiosis gives rise to no changes 
which can be confused with tuberculosis. 

According to our observations the intraperitoneal injection 
gives by far the most certain results, though it takes rather 


Intra-Hepatic 
Inoculation. 


* The technique of the animal experiments has been omitted, since 1m 
England they can only be performed in licensed laboratories. 


PULMONARY TUBERCULOSIS 69 


longer. At all events the older method should always be com- 
bined with Bloch’s or Oppenheimer’s methods as a control. 

Lately Jacoby and Meyer have attempted to hasten the proof 
of tuberculosis in animal experiments by means of the increased 
sensitiveness to tuberculin. They obtained in 80 per cent. of the 
cases a positive result by the following method: ‘‘ If one intro- 
duces a sufficient number of tubercle bacilli, for example in 
infected sputum, into the peritoneal cavity of a guinea-pig, and 
after about fourteen days gives the animal a subcutaneous injec- 
tion of 0.5 ¢.c. of tuberculin, it will die in several hours with an 
extremely low body temperature.’’ 

The authors employ these methods as a control combined 
with Bloch’s gland crushing, and pay special attention to 
Kiralyfi’s sign of enlarged retro-jugular glands. 


IV. Diagnosis by Means of Tuberculin. 


Tuberculin is the most exact and finest reagent for proving 

the existence of a tubercular deposit in the living organism. 
There are three methods chiefly to be considered, the cutaneous, 
the conjunctival, and the subcutaneous tuberculin tests; all three 
ean be carried out with Koch’s old tuberculin. 
The cutaneous tuberculin test of v. Pirquet 
depends on the super-sensitiveness of the 
skin of a tubercular person to a_ small 
amount of inoculated tuberculin. The tuberculin and the anti- 
bodies, which are the products of reaction against the existing 
infection of the body, combine together and produce a reaction 
at the point of inoculation after twenty-four to forty-eight hours 
in the form of an inoculation papule of a specific tubercular 
nature. If the organism is still free from tubercular infection 
there are no antibodies, and therefore the conditions of reaction 
fail, and no papule forms. 

The cutaneous test is done by placing drops of 25 per cent., 
or in adults of pure, tuberculin some four inches apart on the 
inner side of the forearm on two spots previously cleaned with 
ether. The skin underlying the drops, and also previously at a 
spot between as a control, is perforated with a v. Pirquet’s borer, 
which makes a uniform, round, superficial hole in the skin. 
After inoculation the tuberculin is left for several minutes on 
the superficial abrasion; a bandage is not necessary afterwards. 

A negative result of the cutaneous test is in general indica- 
tive of freedom from tuberculosis; if the skin does not react the 


Cutaneous 
Tuberculin Test. 


7O A CLINICAL SYSTEM OF TUBERCULOSIS 


person may be considered free from tubercle in the anatomical 
sense with the greatest probability. A positive skin reaction 
shows that the body has at some time and in some way been 
infected with tubercle bacilli; thus a reaction may be obtained 
both with manifest tubercular patients and also with people who 
clinically are not tubercular, that is with those who are apparently 
sound, but have somewhere in the body a healed and therefore 
quite unimportant tubercular nodule. This excessive delicacy of 
the cutaneous reaction is its great drawback, which almost 
entirely negatives its importance in adults, since of them go per 
cent. or more carry such obsolete tubercular deposits, which 
have no importance for the physician. The cutaneous reaction, 
however, is of great value in children, and the more so the 
younger the child is. 

Therefore in adults only the negative result has a diagnostic 
value, as it excludes the existence of tuberculosis. The cutaneous 
test is absolutely harmless and has no contra-indication. It has 
no prognostic value.* 

Of the various modifications of the cutan- 
eous test mention need only be made of 
Moro’s percutaneous test, which is done by 
rubbing in a piece of 50 per cent. tuberculin ointment of the size 
of a pea with moderate pressure for ore minute into an area of 
skin of about 10 square inches. Ina positive reaction red points, 
or confluent red spots, or even small papules appear in twenty- 
four to forty-eight hours. The percutaneous method is consider- 
ably inferior to the cutaneous in certainty. 

The conjunctival tuberculin test, also 
known as the ophthalmic reaction (Cal- 
mette) and the conjunctival reaction (Wolff- 
Eisner), is similarly a local tissue reaction, due to the fact that 
the conjunctival tissues of tubercular persons are specially sensi- 
tive to tuberculin. Just as the cutaneous reaction shows the 
supersensitiveness of the skin, so this shows the conjunctiva pos- 
sesses the same property, which it shares with all the other 
mucous membranes of the body; it cannot therefore be considered 
as an actual discovery. 

It is performed by placing in the conjunctival sac of one 
eye a drop of freshly prepared 1 per cent. tuberculin solution, 
and if the result is negative two days later a drop of 4 per cent. 


Percutaneous 
Tuberculin Test. 


Conjunctival 
Tuberculin Test. 


* Attempts have been made to overcome the excessive delicacy of the 
cutaneous reaction by using diluted tuberculin. Ellermann and Erlandsen 
have devised a method in which a series of four dilutions are used, the 
resulting papules being accurately measured; it has been fully described 
by Morland (Lancet, 4645, p. 688). 





" 
. 
: 
4 


PULMONARY TUBERCULOSIS 7 


solution in the other eye, the conjunctiva being brought well in 
contact with the fluid. It is recommended to do the test in the 
afternoon and the control on the next morning, and if there is a 
negative result that it should be again inspected after a further 
twenty-four hours. 

The positive reaction consists of a more or less well marked 
redness of the caruncle and of the semilunar fold, which may 
spread to the palpebral and scleral conjunctiva, and in a severe 
reaction cause chemosis of the whole sac with fibrinous and puru- 
lent secretion. Injurious results to the body generally are not 
met with. Subjective local signs, such as photophobia, irritation, 
lachrymation, and a feeling as of a foreign body as a rule only 
occur with strong reactions. On the other hand there are numerous 
definite published observations of serious and lasting local dis- 
turbance of the eye, even of permanent injury to the organ, almost 
entirely destroying the sight, which cannot be explained by a 
defective technique or the use of an unsuitable preparation, but 
must be laid to the charge of the conjunctival reaction itself 
solely. In consequence of these facts the use of a conjunctival 
test cannot be recommended as a routine to the careful practi- 
tioner, all the more as he has constantly hanging over his head 
a sword of Damocles in the form of legal damages. 

Absolute contra-indications are all diseases of the eye of any 
nature or any age, even quite quiescent affections; also old age, 
scrofula, and infancy. 

Not only is the conjunctival reaction distinctly dangerous, 
but it is also markedly uncertain and unreliable. The positive 
reaction generally only indicates that there is a tubercular focus 
in the body, it is silent as to its site, its activity, or its inactivity ; 
and a negative result does not prove the absence of tuberculosis. 
So that a positive reaction is given by cases not tubercular clini- 
cally, such as inactive healed cases; and further, a positive 
reaction has been observed in cases proved free from tuberculosis 
by post-moriem examination, especially in patients suffering from 
articular rheumatism, enteric fever, pneumonia, and cancer. 

For prognosis the conjunctival reaction is of practically no 
value, as Calmette himself admits; it is only regarded favourably 
in respect to the prognosis of phthisis by Wolff-Eisner, in spite 
of many adverse proofs furnished by ourselves and others. For 
this purpose the conjunctival reaction is of no more service than 
the cutaneous. Besides, a method which is not trustworthy for 
diagnosis can be of no vaiue for prognosis, since prognosis is 
only a more widely extended, finer form of diagnosis. 

In the fiasco of the tuberculin eye-drops is also involved the 


72 A CLINICAL SYSTEM OF TUBERCULOSIS 


similar modification recommended later by Wolff-Eisner of test- 
ing the conjunctiva by means of tuberculin-vaselin, which is 
attended by still greater drawbacks and dangers. 

The subcutaneous tuberculin test is the 
most practically serviceable, and most fer- 
tile in results, of the diagnostic methods. 
The doses for adults are :— 


Subcutaneous 
Tuberculin Test. 


Initial dose ... ane ey <  O22°Coinee 
First increased dose ~ ae I i 
Second increased “dose = ro ei A 
Lastedose= 3 oe oe cs EO 4 


For children half the e doses is sufficient. The dilution of 
the tuberculin is performed under antiseptic precautions with 
0.5 per cent. carbolic acid. Between the separate injections at 
least forty-eight hours must elapse. It must be most forcibly 
emphasized that the next dose is only to be increased if the 
previous dose has produced no rise of temperature. If the 
temperature is only slightly raised the next dose must not be 
increased, but the same quantity be given again, and not 
till the temperature has completely returned to normal. The in- 
creased reaction which then usually occurs is an infallible sign of 
the existence of tuberculosis. If these precautions are carefully 
observed bad results from the tuberculin will not be met with. 

There are altogether four divisions of the tuberculin 
reaction : the reaction at the site of injection, the febrile reaction, 
the general reaction, and the reaction at the seat of disease. 
These reactions may all occur together, or one or more may only 
be observed. The febrile and general reactions are most often 
met with. The reaction may be regarded as positive if the 
injection raises the temperature at least 19 F. The most trust- 
worthy is the focal reaction, which can generally be detected if 
the patient is examined at the commencement of the reaction. 
If it can be detected objectively, or only subjectively, an active 
tuberculosis may be diagnosed with certainty. 

Confusion may be caused by a pseudo-reaction, such as may 
occasionally be caused by an intercurrent febrile disease, which 
cannot be immediately recognized, as tonsillitis, alveolar abscess, 
&c. Rises of temperature from psychological causes or sugges- 
tion must be remembered. They are met with in persons of 
unstable nervous systems, hysterical, neurasthenic individuals, 
and may be induced by an injection of distilled water, which can 
with advantage be used as a control injection. 


EE OE Oe ee ne, ae ee 


PULMONARY TUBERCULOSIS 73 


Contra-indications to the employment of 
subcutaneous, diagnostic tuberculin injec- 
tions are: (1) A temperature above 99.2° F. 
in the mouth or 99.8° F. in the rectum; axillary temperatures 
are not reliable; (2) recent haemorrhage from the mouth of uncer- 
tain origin and cause; (3) heart disease; (4) kidney disease; (5) 
epilepsy, and severe cases of hysteria and neurasthenia; (6) a 
suspicion of miliary or bowel tuberculosis ; (7) severe diabetes, 
apoplectic tendency, advanced arterio-sclerosis, amyloid changes 
in the abdominal viscera; (8) convalescents and persons weakened 
by severe disease. 


Contra- 
indications. 


The indications for the subcutaneous tests 
are (1) ine tclinically “doubtiuls. cases for 
making certain the early diagnosis; (2) in cases of difficulty in 
the differential diagnosis, for deciding the line of treatment. 

A negative resuit excludes with certainty an active tuber- 
culosis. A positive result indicates with certainty the presence 
of a tubercular focus, and even assists to a certain degree in 
differentiating between active and inactive disease, and between 
recent or old deposits. Fresh and active disease usually reacts 
promptly to the smaller doses, while old changes of a more 
chronic nature only as a rule to the higher doses, and, indeed, 
frequently show a delayed reaction. A further indication is that 
a large proportion of cases show a reaction at the seat of disease, 
demonstrating the active character of the process. These focal 
reactions may be either discovered objectively, as by the augmen- 
tation of the physical signs, or may show themselves subjectively 
by oppression of the chest, pain, dyspnoea, irritative cough, &c. 
Also the early diagnosis may be made from pleural irritation as 
a result of a tuberculin reaction. 

The subcutaneous tuberculin test is, in conjunction with the 
other results of clinical examination, history of the patient, tem- 
perature, &c., the sovereign method of diagnosis for the recog- 
nition of active, early, lung tuberculosis in adults. It gives the 
most important information in all doubtful cases, but must be 
practised with due care to avoid harmful effects. We have given 
an outline here which may be filled in by reference to our book 
on “‘ Tuberculin in Diagnosis and Treatment.’’ 


Indications. 


V. Diagnosis by Rontgen Rays. 


The examination by Réntgen rays has of recent years become 
of special interest, since it has been employed more than hitherto 
for the diagnosis of tuberculosis of lungs, thanks to refinements 


714 A CLINICAL SYSTEM OF TUBERCULOSIS 


of technique. The diagnostic results are essentially improved, 
but still to-day opinions as to their value differ, according to the 
standpoint of the writer and his line of work. Whilst for 
example Rieder ascribes to the Rontgen-ray examination a most 
important value, not only for the recognition cf chronic lung 
tuberculosis itself, but also of its secondary changes and complica- 
tions, A. Frankel denies its wider value, and considers that only 
in solitary nodules, especially in tubercular peribronchitis, have 
the rays been of service in improving the diagnosis. 

We agree rather with Rieder, and will point out in the 
following short sketch what information the Rontgen rays may 
give. But we must first say that according to our results the 
rays for early diagnosis are of very small importance. One must 
clearly understand that the rays can only give a shadow picture of 
the lungs which is affected by the thickness of the media, so 
that the really initial change “5 must be missed, that further they 
can give no information as to the specific nature or activity of 
the disease, and that lastly there is a great difficulty in correct 
observation and correct interpretation of the shadows. 
According to Ziegler and Krause an 
isolated tubercular nodule must have an 
area of about 4 square millimetres, and lie 
near the plate, before it can give a shadow. Catarrhal changes 
without condensation are also not visible. It is also most difficult to 
decide whether small isolated shadows are tubercular nodules and 
glands, since the crossing of bronchi and vessels will normally give 
shadows. The intensity of the shadow given by small tubercular 
nodules is practically the same whether they are formed of caseous 
tissue, of closely packed miliary tubercles, or of connective tissue. 
Larger nodules of caseating material, of dense connective tissue, 
or of calcification give dark shadows, more or less differentiated 
and circumscribed. Cavities, of even quite small diameter, can 
be easily recognized, if they are well encapsuled, being then 
characterized by a darker ring of shadow round the periphery. 
But even larger cavities are not visible if they are surrounded by 
dense infiltration, or if they are obscured by the shadow of 
thickened pleura. The contents of the cavity seem to influence 
the clearness of the picture little or not at all. Miliary tubercu- 
losis of the lung can also be recognized by the marbled appear- 
ance. Slight pleural changes are not distinguishable; dense 
adhesions, thickenings, and exudation give intense shadows. 
Apical disease first gives a shadow when the air contained by the 
tissue is considerably diminished; isolated nodules must also 
reach a certain size before they can throw a definite shadow, if 


Changes in 
the Lungs. 





—— 


PULMONARY TUBERCULOSIS a5 


diffuse infiltration has caused a uniform darkening of the apical 
regions. 

Healed or non-tubercular processes may cause difficulty in 
the differential diagnosis by causing apical shadows; for example, 
cicatrices at the apex, pleural thickening, enlarged glands in 
supra-clavicular fossa, low position of the thyroid glands, fatty 
deposits, scleroderma, or other thickening of the skin, the sub- 
cutaneous tissue or the muscles, abnormal position of the clavicle 
and first rib or slight scoliosis of the vertebral column. According 
to P. Krause there may be slight shadows from deficient entry 
of air into the apices in persons who for some time have not 
breathed sufficiently deeply ; sometimes they will clear up during 
the examination if deep inspirations are taken. From his experi- 
ence at the Roéntgen Institute of the Vienna Poliklinik, Kreuz- 
fuchs recommends the illumination of the lung apices with the 
softest possible tube, and the weakest possible light; also to move 
the screen away from the patient to enlarge the shadows of small 
nodules. He also employs a moderate cough after deep inspira- 
tion as an aid to differential diagnosis; in persons with healthy 
lungs, especially those showing slight accidental shadows due 
to apical atelectasis, there is constantly seen a brightening of the 
apices, such as does not, or only very imperfectly, occur in 
organic disease. 

As to the meaning of the much discussed shadow tracks 
passing from the hilus to the apex there is still no agreement; 
as they may be also seen in normal cases, their interpretation 
when associated with patholegical changes is very difficult. At 
all events there is a connection between disease at the apex and 
the hilus. 

The Ro6ntgen rays have a special value for 
the diagnosis of diseases of the hilus of the 
lung, which are more or less undetected by 
the other methods of clinical diagnosis. 
By the discovery of tubercular nodules at the root of the lung, 
and of the extensions from them, an early diagnosis becomes 
possible (Rieder). The difficulty lies in rightly appreciating the 
differences between the normal shadows of the root of the lung 
and those only slightly altered; chronic enlargement of the glands 
at the hilus is no rare occurrence, and may easily simulate tuber- 
culosis of the bronchial glands. The dispute, whether the normal 
hilus shadow is due to the bronchi or to the vessels, we think 
with v. Hansemann to be useless, for doubtless both structures 
in their various planes or crossings throw shadows; as do also 
the glands lying between them, which in adults usually contain 


Disease of the 
Root 
of the Lung. 


76 A CLINICAL SYSTEM OF TUBERCULOSIS 


carbon particles. The experiments of M. Cohn and Weber show 
that the vessels play the preponderant part. 

The Rontgen photograph can also give 
valuable further information on the behavi- 
our of the heart during the course of 
phthisis; the position of the neighbouring 
organs, the large vessels, the trachea, and the cesophagus; on 
the condition of the pleura as to dry and serous pleurisy, or as 
to the existence of an interlobar, encysted exudation, and as to 
the after-effects of pleurisy; on pneumothorax and the state of 
the underlying lung; and lastly, as to the action of the 
diaphragm. Of distinct value as an early symptom is diminu- 
tion of the diaphragmatic movement of the affected side, first 
described by Williams, which consists of deficient inspiratory 
lowering of the diaphragm from its normal expiratory position. 
The most common cause is adhesion of the pleura in different 
parts. From adhesions of the diaphragmatic pleura various dis- 
placements of the diaphragm may ensue (blunt projections, 
bands of adhesions, undulating contour, flattening, darkening, 
and diminution of the complemental pleural space, &c.). Of 
late the well known abnormality of the upper aperture of 
the thorax and ossification of the first rib cartilage is being 
observed and studied during life by help of the Rontgen 
rays. 


Further Information 
Afforded 
by the Rays. 


The rays may furnish help for the differen- 
tial diagnosis, for example, by distinguish- 
ing chronic bronchitis, bronchiectasis, and 
pneumokoniosis, in which affections the alterations of the 
bronchial tubes can be more or less easily observed by the shadow 
picture. In the different forms of affections of the lungs by dust 
particles the appearance is often very characteristic and valuable 
for diagnosis. The rays also give valuable and indispensable 
service in the recognition of aneurism and tumours of the lung 
and mediastinum, as will be mentioned later. 

It is obvious from the foregoing remarks that the Rontgen 
rays can in many cases give much information as to the nature 
and extent of the pathological changes in the lung, and that in 
fact they increase our power of diagnosis. It is further clear 
that these results must not be taken by themselves, but only 
in combination with all the other methods of examination at our 
command must they be carefully and critically employed. He 
will receive the most assistance from the Réntgen rays who makes 


the best use of the general clinical and physical examination 
(M. Cohn). 


Differential 
Diagnosis. 





PULMONARY TUBERCULOSIS 


~r 
“I 


VI. Other Diagnostic Methods, 


For the sake of completeness short sketches are given of 
several other diagnostic methods, most of which have only 
recently come into use. 

The discovery of bacilli in the circulating 
: blood has a certain diagnostic importance. 
mn It succeeds the more readily the severer is 
the Blood. the form of tuberculosis; but even in clini- 
cally slight cases the bacilli are no rarity in the blood. A posi- 
tive result may under some circumstances settle all diagnostic 
doubt, especially in clinically uncertain febrile diseases, in which 
a test injection of tuberculin is inadmissible. 
Arloing and Courmont endeavoured to 
employ for tuberculosis the agglutination 
phenomenon due to the serum reaction, 
which has proved of such high value in enteric fever. They 
succeeded in obtaining by means of a special process of culture 
a homogeneous growth of tubercle bacilli, and recommended the 
agglutination test for early diagnosis as the result of 1,200 
examinations. The process of agglutination examination was 
made more useful and reliable by R. Koch’s introduction of 
an agglutinative test fluid; since then much work has been 
done on this subject in Germany. The results of these re- 
searches, including our own, may be shortly summed up in this 
way: The agglutination test is a most important guide for the 
specific treatment of tuberculosis, indicating the formation of a 
specific reactive product associated with immunity ; for diagnosis, 
especially for early diagnosis, it is useless, since the serum from 
active tubercular cases sometimes gives no agglutination, while 
on the other hand a positive reaction is often obtained with 
those who have long recovered from the infection. 
Wright has worked out a method, which 
by a numerical comparison of the results 
of mixing under stated conditions a fluid containing leucocytes 
with an emulsion of bacilli, allows the estimation of the opsonic 
power of a given serum. The proportion between the opsonic 
capacity of the patient and that of a healthy individual gives 
the opsonic index, which furnishes an objective measure of the 
amount of anti-bacterial substance in the blood. If the opsonic 
index lies above or below certain limits it is a sign that the body 
is contending with the tubercle bacillus, and is of diagnostic and 
prognostic value. According to the results hitherto obtained 
from many experiments, Wright’s opsonic method is useful for 


Tubercle Bacilli 


Agglutination 
mest. 


Opsonic Index. 


78 A CLINICAL SYSTEM OF TUBERCULOSIS 


the diagnosis of tuberculosis, but we have other methods of 
simpler technique, less wasteful of time and more certain in 
their results; the prognostic importance of the opsonic index is 
slight. 

The method of fixation of the complement, 
according to Bordet and Gengou, facilitates 
the recognition of the existence of specific 
amboceptors in the serum, and has been worked out by Wasser- 
mann for the diagnosis of syphilis with the most important 
practical results. Attempts have been made to employ a similar 
process for the early diagnosis of tuberculosis. The question 
whether this is possible under certain conditions must be 
answered in the negative. According to our experiments the 
serum of clinically non-tubercular persons can give the same 
complement fixation results as the serum of tubercular people. 
Often, too, as with the agglutination test, the results of an old 
contest between the organism and the bacillus may suffice to 
produce the reaction. 


Complement 
Fixation. 


Calmette’s method of making cobra poison 
active has the same value. It depends on 
the fact that cobra poison alone in the 
greatest dilution has no power to destroy blood-corpuscles, but 
it will do so if mixed with the inactive serum of a tubercular 
patient. In confirmation of the work of Calmette, we have the 
results of v. Szaboky and Pekanovick, which were positive up 
to complete hemolysis in 94 per cent. of phthisical patients; but 
we find that non-tubercular sera also make the cobra poison 
active in a considerable (48 per cent.) proportion of cases. Ludke 
has even observed 80 per cent. positive results in healthy persons. 
According to Nowaczynski, the activating substance for cobra 
poison is also produced in other diseases, such as all the other 
infections and nephritis, and indeed with greater frequency than 
in tuberculosis. 


Cobra-poison 
Test. 


Bauer’s discovery of the passive transfer- 
ence of super-sensitiveness to the tubercular 
poison depends on the fact that healthy guinea-pigs, who have 
received an injection of the serum from a tubercular patient, 
become passively super-sensitive, so that they give a typical 
febrile reaction to a tuberculin injection. The animal experi- 
mented on is thus in the same condition as persons who react 
to tuberculin. Unfortunately this method partakes of the un- 
certainty of the other serum tests mentioned before. It fails in 
undoubtedly tubercular cases. Also, according to our experi- 
ments, quite indifferent injections, such as milk or saline solution, 


Anaphylaxis. 


eS a 





PULMONARY TUBERCULOSIS 79 


may confer sensitiveness on guinea-pigs, so that they will react to 
tuberculin injections; therefore the test has no specific signifi- 
cance. 
W olff-Eisner has lately drawn attention to 
the great frequency of lymphocytic sputum 
in tuberculosis. The lymphocytes appear 
in strikingly large numbers in the sputum, under certain cir- 
cumstances forming up to go per cent. of all the sputum cells, 
both in early and advanced cases of phthisis, and even in those 
with mixed infection. According to Wolff-Eisner they are an 
evidence of the presence, or even of the approaching appearance, 
of tubercle bacilli. The toxins of tubercle bacilli have an attrac- 
tive power for the lymphocytes, in contra-distinction to the toxins 
of other bacilli of chronic catarrhal conditions, which have a 
chemotactic action on the polymorphic leucocytes. Also in other 
inflammatory changes, such as effusions, a preponderance of 
lymphocytes is in favour of the tubercular nature of the 
disease, aS was first shown by Wolff-Eisner, and  con- 
firmed especially by Wiidai. According to these _ obser- 
vers the discovery of lymphocytic sputum is of value 
in cases in which tubercle bacilli cannot yet be found. 
We have, up to now, not found it with that regularity which 
would be necessary for an important early sign; also the 
majority of initial cases produce no real sputum from the lung. 
The lymphocytes are well stained with Loffler’s methylene-blue ; 
the customary counter-staining with methylene-blue in the 
ordinary process of staining for tubercle bacilli is therefore suffi- 
cient for their demonstration. In looking through the preparation 
one must guard against confusing the lymphocytes with 
degenerated epithelium and swollen leucocytes. 
The value of Arneth’s observations on the 
; increase of neutrophile blood-cells and its 
Neutrophile Cells connection with tuberculosis will be dis- 
in Blood. cussed in connection with tuberculosis of 
the blood and lymphatic vessels. 


Lymphocytic 
Sputum. 


Increase of 


VII. Differential Diagnosis. 


There are a number of chronic diseases of the lungs and 
bronchial system, and also of the other intra-thoracic organs, 
which by their symptoms may simulate tuberculosis of the lungs, 
and which cannot be always clearly discriminated by physical 
examination. The chief diseases of this nature will be now 
briefly mentioned. 


SO A CLINICAL (SYSTEM OF TUBERCULOSIS 


Chronic bronchitis affects especially the 
lower posterior part of the lungs, and from 
its signs and its course cannot well be 
mistaken for tuberculosis. It may, however, cause difficulty in 
the differential diagnosis, in so far as it is a very frequent con- 
comitant of tuberculosis, especially when mixed infection is 
present. If such a complication should occur the tubercular foci 
can generally be distinguished from the diffused bronchitis by 
the limitation of their catarrhal signs to their special regions; 
where they can be distinguished by their persistence and intensity. 
Asthma and emphysema give such a 
characteristic symptom complex that they 
likewise do not cause confusion with tuber- 
culosis; at the same time they make its onset more unlikely in 
consequence of the venous congestion of the pulmonary circula- 
tion. In those rare cases in which tuberculosis supervenes on 
both these diseases, its detection is very difficult in the early 
stages before the appearance of bacilli. Scattered rales at the 
apex without percussion changes may be caused by asthma or 
emphysema; but they may also be the result of tubercular mis- 
chief, the signs of infiltration being masked by the emphyse- 
matous condition. Frequent examinations, other careful ob- 
servations, and the assistance of tuberculin will make the 
diagnosis certain quite early. 

Emphysema of the aged requires special attention; behind 
it tubercular lung changes frequently occur, usually in the form 
of very slow and afebrile, chronic, indurative processes and 
masked fibroid phthisis. The surrounding vicarious emphysema, 
producing definite emphysematous pads above the apices, 
may interfere with the percussion of even marked tissue thicken- 
ing; but auscultation gives the right diagnosis earlier. In such 
cases one should not neglect the antiformin examination of the 
sputum, which is hardly ever absent. Hoppe-Seyler rightly 
draws attention to the great danger of infection of the surround- 
ines by these old people with their supposed asthma, often 
lasting several years. 


Chronic 
Bronchitis. 


Asthma and 
Emphysema. 


Of the very greatest practical importance is 
differentiation of mnon-tubercular apical 
changes, which are occasionally produced 
by pneumonia or influenzal pneumonia. Also certain anatomical 
conditions, such as slight lateral curvature of the cervical or 
thoracic vertebra, unilateral muscular atrophy, dropping of the 
right shoulder girdle, differences in the course and branching 
of the apical bronchi, &c., may cause changes in percussion 


Non-tubercular 
Apical Changes. 





+4 


PULMONARY TUBERCULOSIS SI 


and auscultation, without any affection of the lung tissue itself. 
Lately Kilbs has notified, from the medical clinic at Berlin, 
the fact that in young people there may be very regular 
and constant rales over one apex, causing a suspicion of tuber- 
culosis, but due to a local bronchitis, accompanied by tracheitis 
and pharyngitis, and often also by emphysema. We must 
think that a localized bronchitis in such a position is usually 
of a specific nature; in such cases the diagnostic tuberculin in- 
jection will give the surest information. 

In this connection there is also Kronig’s 
collapse and induration of the right lung 
apex in cases of chronic obstruction to the 
nasal passages, a condition which gives the physical signs of a 
right-sided tuberculosis, but ztiologically has no connection with 
that disease. Kronig thinks that an important point in the dif- 
ferential diagnosis is that the respiratory excursion of the lower 
lung limit, in opposition to what occurs in active tubercular 
processes, remains unaltered. But this diminished respiratory 
movement of the diaphragm (Williams’s sign), which may be 
of much value in the Rontgen-ray examination, is only evidence 
of an accompanying pleurisy, and cannot of itself be a constant 
diagnostic sign in distinguishing between tubercular and non- 
tubercular apical induration. The collapse induration may also 
undergo secondary infection, so that it is recommended to have 
frequent recourse to the subcutaneous tuberculin test. 

The forms of pneumoconiosis produced by 
prolonged inhalation of mineral, metallic, 
animal and vegetable dust may, on the one hand, simulate a 
tubercular infiltration, and, on the other hand, very fre- 
quently undergo secondary tubercular infection and usually pro- 
gress unfavourably. An early recognition is therefore of the 
greatest importance, and for this, as long as the bacilli cannot 
be discovered in the sputum, there is no better means than the 
diagnosis by tuberculin. The position of the inner margins of 
the lung along the sternum affords some information; Baumler 
first described their retraction in pneumoconiosis. The value of 
the Roéntgen-rays has already been mentioned in the section on 
that subject. 


Collapse and 
Induration. 


Pneumoconiosis. 


There are similar diagnostic difficulties 
with chronic pneumonia, which may simu- 
late phthisis, especially when due _ to 
streptococci or influenza bacilli, but which may be complicated 
with tuberculosis; so that the discovery of streptococci or ‘in- 
fluenza bacilli does not exclude phthisis. 

6 


Chronic 
Pneumonia. 


82 A CLINICAL SYSTEM OF TUBERCULOSIS 


Bronchiectasis, abscess and gangrene of the lung may, by 
their symptoms and physical signs, cause confusion with 
phthisical cavities; in these cases the constant absence of tubercle 
bacilli does not exclude tuberculosis. 

Non-tubercular bronchiectasis is usually 
situated in the lower lobes, and especially 
in their upper parts about the level of the angle jomagge 
scapula, and is much rarer in the upper lobe; it is usually 
only unilateral. Examination into the history will show 
the commencement with a pneumonia, a severe acute bronchitis 
or a pleurisy. The cough 1s_ characteristic, occurring in 
paroxysms usually directly after change of position; the expec- 
toration comes up in mouthfuls and has a faint sweetish odour, 
‘which becomes foetid on standing; the masses of sputum stick 
together, unlike the cavity sputum of phthisis, and on standing 
form three layers. The bronchiectatic patient usually maintains 
a good state of health for years; he may be cyanotic or pale, but 
aot cachectic; fever is usually absent; club-fingers are more often 
found than in phthisis. 

For the diagnosis of abscess of the lung 
the inquiry into the history is of special 
importance; the disease usually commences 
with an embolic, genuine, catarrhal, or deglutition pneumonia, 
sometimes with an injury to the lung. The most important 
sign is the condition of the expectoration, it 1s moderate in 
amount, usually consisting of pure pus, contains many elastic 
fibres in an alveolar arrangement, tissue fragments and some- 
times also hamatoidin crystals in such abundance as to give it a 
brownish colour. 


Bronchiectasis. 


Abscess of 
Lung. 


Gangrene is more easily to be distinguished 
by the highly penetrating odour, which 
even affects the air round the unfortunate 
patient. The copious, dirty-grey sputum contains an enormous 
number of bacteria, and often large portions of lung tissue, while 
elastic fibres are scanty on account of the rapid gangrenous 
destruction; at all events they are not in the number that would 
be expected. 


Syphilis of the 
Lung. 


Gangrene of 
the Lung. 


There is often great difficulty in diagnosing 
between tuberculosis and syphilis of the 
lung. From the results of numerous post- 
mortem examinations it is very probable that syphilis of the 
lung, in the form of chronic indurative contraction of the 
lung in syphilitic patients, has been diagnosed much too fre- 
quently ; and that usually the process is tubercular. There is no 


PULMONARY TUBERCULOSIS 83 

characteristic clinical picture of lung syphilis, it generally takes 
the form of chronic interstitial pneumonia. The catarrhal signs 
often appear later than the percussion changes. Haemoptysis and 
fever are rare. If other syphilitic conditions are present at the 
same time as the lung signs, if tubercle bacilli are constantly 
absent from the sputum, and if the clinical picture differs much 
from that of pulmonary tuberculosis, then a probable diagnosis 
of syphilis of the lung may be made. This probability is much 
increased if the indurative changes are favourably influenced, 
even to a slight degree, by treatment with iodide of potassium 
or mercury. [t must be always remembered that tuberculosis 
and syphilis may be combined, so that diagnosis by tuberculin 
may not give complete information. It has been maintained that 
tuberculin may give a local and general reaction in cases of 
lung syphilis; it is more likely that they were cases of such 
mixed infection. Wassermann’s reaction of complement devia- 
tion has also now increased our means of diagnosis. 
Growths in the lung are usually metastases ; 
the most frequent are secondary carcinoma 
and sarcoma. The primary tumour in other parts of the body 
gives the diagnosis if it can be recognized; but often the primary 
tumour is latent, or quite insignificant in size in comparison with 
the lung metastasis. For the purposes of clinical diagnosis the 
primary and secondary tumours are considered together. 

The primary tumours of the lungs are very rare; of them 
cancer of the lung has clinically the greatest importance. There 
is nothing distinctive about either the subjective or the functional 
alterations. Also the history of the disease may be absolutely 
similar to that of tuberculosis. Old age is in favour of tumour, 
especially if the lung condition is not characteristic of tuberculosis. 
The symptoms sometimes resemble those of chronic pneumonia, 
especially as long as the tumour remains limited to the lung 
substance; at other times compression signs are most prominent. 
The physical signs are not constant and usually not characteris- 
tic; they consist of dulness, often very marked diminution of the 
breath-sounds, strikingly scanty catarrhal signs, and rarely of 
cavity formation. Freedom of the apices, exclusive localization 
in the root of the lung and the lower lobe, sharp percussion 
outlines, and absolute dulness are all against tuberculosis and 
in favour of tumour. With the involvement of the pleura the 
resemblance to tuberculosis is much increased; only unusually 
intense board-like dulness is the certain’ sign of a 
carcinomatous pleurisy. If there is an exudate, it may be more 
or less of an aid to diagnosis; tumour cells make the diagnosis 


Neoplasms. 


84 A CLINICAL SYSTEM OF TUBERCULOSIS 


certain, or the cytological examination may be in favour of 
tuberculosis; hemorrhagic effusions are more common. with 
tumour than with tuberculosis. But cough, expectoration, pains 
in the chest, breathlessness, fever, pleural exudation or adhesions, 
and even hemoptysis may heighten the resemblance to tuber- 
culosis. Such a case, presenting all these symptoms, we our- 
selves have lately observed. Repeated hamorrhages, not in- 
fluenced by any treatment, combined with paroxysmal attacks 
of coughing, chiefly raised the suspicion of primary carcinoma 
of the lung; the observation with Rontgen rays of rapid increase 
of the disease made the diagnosis certain, and it was afterwards 
confirmed on post-mortem examination. 

Sometimes, however, one of these symptoms may be suffi- 
ciently characteristic to furnish the probable diagnosis of a 
tumour. The cough often comes on in paroxysmal attacks and 
is accompanied with great cyanosis of the face; like the 
cough of enlarged bronchial glands it is due to compression of 
the vagus. Severe, cutting pains, radiating forwards from the 
spine, are to be explained in a similar way. Other factors for 
their production, however, are carcinomatous pleurisy and ** the 
direct involvement, displacement and erosion of nerves, 
especially in the region of the posterior mediastinum, from 
masses of tumour and cicatricial contraction ’’ (Grau). J. Schwalbe 
lays stress on the asthmatic attacks; according to Ebstein the 
dyspnoea may reach a pitch which is never observed in any other 
disease likely to cause difficulty in diagnosis. The expectora- 
tion may be of very various nature; at the commence- 
ment it is clear mucus, it becomes more or less puru- 
lent from concomitant bronchitis or from the production 
of bronchiectasis by pressure of the tumour; as destruc-- 
tive processes ensue, masses of débris and tumour particles, 
visible to the naked eye, or microscopic tumour elements, 
may be recognized; frequently the sputum is bloody. The quan- 
tity of blood and its character are very uncertain; a severe 
hemoptysis is seldom observed (A. Frankel, J. Schwalbe), more 
common are small but frequently repeated bleedings, often of 
long duration, and resisting all methods of treatment. Very 
suggestive is prolonged bleeding with clear mucoid sputum, a 
combination very rarely seen in tuberculosis. Very characteristic 
is a currant-jelly appearance of the sputum; the colour of the 
blood, which depends on greater or smaller alterations of the 
blood pigments, is of no value. The type of fever, when it is: 
present, has no clinical importance, as it is due to different 
causes, such as secondary bronchitis, broncho-pneumonia, absorp 


B. 


PULMONARY TUBERCULOSIS 85 


tion from the breaking-down tumour, mixed infection of the 
necrotic tissue, &c. But the absence of fever of one of the 
tubercular types has some diagnostic value. A distinction may 
correctly be drawn between the cachexia of primary tumours of 
the lung and that of phthisis, and also that of abdominal malig- 
nant tumours, in that the first usually appears later, especially 
with the dissemination of metastases and the necrotic changes 
in the tumour. We have seen a patient improve during treat- 
ment in an institution and gain more than 20 lb. in weight, till he 
succumbed to a sudden, fulminating hemorrhage. Metastases in 
the lymphatic glands may make the diagnosis certain, especially 
if they are multiple, grow quickly and are of hard consistency. 
Puncture of the lung has frequently revealed undoubted tumour 
elements. 

Of our diagnostic aids, the tuberculin method takes the 
first place. The result of the cutaneous reaction is not of 
decisive importance; if a test tuberculin injection is not contra- 
indicated by the existence of fever, it should return a positive or 
negative answer; but at the same time in carcinoma reactions 
have sometimes been obtained. Here the possibility of a con- 
currence of cancer and tuberculosis is to be thought of. Hart 
has described a case of bronchial cancer, in which tubercle bacilli 
led a saprophytic existence in the stagnant secretion of the com- 
pressed tube. Such very rare cases may be delusive on the one 
hand by furnishing tubercle bacilli in the sputum, and on the 
other hand by giving a tuberculin reaction without specific tissue 
changes. 

Radiography is of the greatest value for diagnosis; it seldom 
fails, and then generally only in the early stages of tumour; but 
difficulties may be caused by enlarged tubercular bronchial glands 
and extensive pleurisy. But a combination of all the other 
diagnostic methods at our command, with the important Rontgen- 
tay examination, should place the diagnosis on a sure foundation 
with few exceptions. 

Several of these points are also useful for 
the diagnosis of hydatid disease of the 
lungs. The subjective symptoms and the physical signs in the 
lungs are very similar to those of tumour. Spasmodic cough, 
ill-defined pains, sense of oppression, difficulty of breathing, loss 
of strength, blood-stained expectoration, even a large hemoptysis 
may simulate tuberculosis. Here also Rontgen rays or the tuber- 
culin diagnosis will clear up the difficulty in one direction or 
the other. Many authors warn against the puncture of the lung, 
in consequence of the danger of producing an asthmatical attack. 


Hydatid Disease. 


86 A CLINICAL SYSTEM OF TUBERCULOSIS 


The contents of an echinococcal cyst are often expectorated, and 
make the diagnosis certain. 
By the entrance of the mycelium into the 
respiratory organs an actinomycosis of the 
lung may be produced, and may simulate a slowly developing 
phthisis, on the one hand by the production of a pneumonic 
infiltration, and on the other by a destruction of the lung tissues. 
The correct interpretation of the initial symptoms is impossible ; 
but as long as fever is absent a diagnostic tuberculin injection 
will exclude the existence of tuberculosis. As the disease ad- 
vances, hectic fever, cachexia and amyloid degeneration usually 
occur. The diagnosis becomes certain if actinomycotic fungus 
is expectorated or discharged in the pus through a fistulous open- 
ing, produced by the extension of the disease from the lungs to 
the pleura and thoracic wall; for this the disease has a special 
tendency. 

Difficulty of diagnosis caused by mediastinal tumours and 
affections of the pleura will be alluded to in the later sections 
on these diseases. 


Actinomycosis. 


The existence of the various pseudo-tubercle 
bacilli in the lungs and the means of 
differentiating them from the true tubercle 
bacilli have been mentioned under the bacteriological diagnosis. 
Whether these bacilli are harmless saprophytic parasites, merely 
important on the diagnostic side, or whether they, too, play a 
vole in the pathology of the respiratory organs, there is a differ- 
ence of opinion. At all events, more attention than hitherto 
should be devoted to these questions, since the pseudo tubercle 
bacilli exhibit a likeness to the true tubercle bacilli, not only in 
their staining properties, but also in their biological relationships. 


Pseudo- 
Tubercle Bacilli. 


4. PROGNOSIS. 


To make general statements about the prognosis of pul- 
monary tuberculosis is only possible within wide limits and with 
many reservations and exceptions. We know to-day that phthisis 
is curable, and consider that this knowledge, based on a skilful, 
well-founded, therapeutic system, is the greatest medical acquisi- 
tion of the last decade of the previous century. But the course 
and termination of the disease depends on so many elusive 
factors, that the prognosis, even in an individual case, is one 
of the most difficult problems of diagnosis. It is not always 
possible in the initial stage to give a definite decision, whether 
tubercular foci will become healed, or whether the disease will 


i Aw 


PULMONARY TUBERCULOSIS 87 


end fatally after a longer or shorter time. This difficulty must 
be remembered in discussing prognosis. But, on the other hand, 
tuberculosis presents certain fixed types of disease which manifest 
themselves clinically in more or less characteristic forms, and in 
spite of their multiformity furnish valuable indications for 
prognosis. 

The differences in the course of the disease depend on two 
factors, which equally affect the prognosis. There is first the 
nature of the infecting agent, the form and intensity of the 
primary infection, the virulency of the infecting organism, and 
the manner in which the infection progresses. The second factor 
is the constitutional sensibility and reaction of the patient, that 
is, ‘he individual disposition of the infected organism in its widest 
sense. The formation of a prognosis depends on the correct 
understanding of the clinical peculiarities of individual cases. 

As in all diseases, the prognosis is better the smaller the 

amount of disease; and the prognosis becomes worse the more 
extensive the mischief is, and the more unfavourable the condi- 
tions are for healing. We are therefore under the necessity of 
drawing distinctions between the widely different cases classed to- 
gether as “ phthisis,’’ and to form them into groups according 
to the nature and severity of the disease and according to their 
different stages. Such a classification facilitates the formation 
of a prognosis. 
The practical necessity of a useful division 
of the disease into forms and stages doubt- 
less exists, and has always existed. It is natural, from the many 
forms of the disease, that the proposals which have been made 
have not always been the same, but have varied according to 
the state of the scientific knowledge of the disease. 

The usual classifications are founded on an anatomical and 
pathological basis. In the consideration of the histology of 
tubercle and the pathological changes in the lung tissue it was 
explained that the tubercle bacilli had a threefold effect on the 
tissues, cell proliferation and tubercle formation, exudative in- 
flammation and necrosis. This triad of changes can be seen in 
every stage of the disease, only sometimes one or other change 
may predominate. According to the predominance of diffuse 
formation of new tissue with extension into surrounding areas, 
or of exudative inflammation succeeded by caseation and necrosis, 
the two well-defined clinical forms of fibrous and caseous phthisis 
can be separated from each other. On these two opposing 
tendencies influencing the march of the disease, the older writers 
founded their classification, and long ago recognized clinically 


Clinical Forms. 


88 A CLINICAL SYSTEM OF TUBERCULOSIS 


the ‘‘ fibroid’’ and ‘‘ colliquative’’ forms. Brehmer subdivided 
the second group into infiltration, large or small cavity forma- 
tion, and spreading necrosis. This marks no progress; the three- 
fold changes correspond rather with the ancient classification of 
phthisis incipiens, confirmata and desperata. 

Many divisions and groups were also made from the clinical 

point of view. Thus the disease was described as active or in- 
active, as latent, larval or manifest, as progressive, stationary or 
retrogressive, or as open and closed; or it was classified according 
to the predominant symptom into catarrhal, anzemic, dyspeptic, 
pleuritic, hemorrhagic and febrile forms. The attempts at 
classification can hardly stand their ground against criticism, 
since they neglect too much the pathology of the disease. A 
practically useful classification must, as far as possible, consider 
the tendency in both directions; it must, on the one hand, be 
founded on an anatomical and pathological basis, and, on the 
other hand, it must sufficiently consider the clinical symptoms. 
To satisfy both claims the classification founded on the intensity 
of the progress of the disease will be of service: the acute form 
(miliary tuberculosis, septicaemic forms, and florid phthisis), the 
subacute and chronic forms (caseous, fibro-caseous, and fibroid 
phthisis), and the abortive form (a particularly mild variety 
usually localized in the apex), have been more especially dis- 
tinguished by Bard. A sharp division between the different 
forms naturally does not exist and cases may pass from one 
class into the other, but this classification marks out the charac- 
teristic courses the disease may take. 
Within this classification the most space is 
taken up by chronic lung tuberculosis, 
which is a mixed form of caseous and fibrous 
changes. From the excessive multiformity of this class of disease 
it is a recognized necessity to map out certain grades according to 
the changes that can be recognized by physical examination. The 
most general recognition has been accorded to Turban’s classifica- 
tion, which besides the intensity, specially considers the extent, 
of the disease. This is also the foundation of the Turban- 
Gerhardt classification, which has been adopted for the purpose 
of unification of international statistics. It recognizes three 
grades :— 

Stadium J.—Slight disease confined to a small part of 
one lobe, for example, in cases of disease of both sides not below 
the spine of the scapula, and the collar bone, in unilateral disease 
not below the second rib in front. 

Stadium II.—Slight disease more extensive than I., at the 


Division into 
Stages. 





PULMONARY TUBERCULOSIS 39g 


most the whole extent of one lobe; or in severe cases at the most 
affecting half a lobe. 

Stadium III.—AII cases above Grade II., and all cases with 
extensive cavity formation. 

Under slight disease are included disseminated nodules, 
revealed by slight dulness, harsh, weak, broncho-vesicular breath- 
ing, with fine or medium rales. 

Under severe disease are placed cases with infiltration, shown 
by more marked dulness, much weakened, broncho-vesicular or 
bronchial breathing with or without rales. 

Extensive cavities, with tympanitic note, amphoric breathing, 
with coarse metallic rales, &c., come into Grade III. 

Pleuritic dulness, if it is not more than a centimetre in extent, 
is not to be considered; if more, the pleurisy must be specially 
considered as a complication. 

The grade of the disease is taken for each side separately. 
The classification of the case as a whole depends on the grade of 
the worst side; thus right side II, left side I = Grade II. 

This simple and clear classification into grades has, in our 
opinion, in comparison with Turban’s original scheme, this draw- 
back, that it includes too much, especially under the head of 
Grade I, but also in Grade II. On the other hand it has the 
advantage of a separate heading for both sides. Cornet with 
reason objects that a classification founded solely on the extent of 
the disease and on the physical signs has only a partial importance 
for the recognition of the severity of the case and its probable out- 
come, since it takes no account of the rapidity of the progress of 
the disease. However, it is easy to indicate on Turban’s scheme 
by means of conventional symbols or signs whether high or slight 
fever, sputum containing bacilli, mixed infection or complications 
in other organs are present, so that the most important conditions 
affecting the prognosis can be easily recognized at the same time 
as the grade of disease. The chief thing is that, on the whole, 
the long desired agreement has produced at last a uniform classi- 
fication into grades. 

The prognosis of the acute form may be 
dismissed with a few words. Miliary tuber- 
culosis, the septiceemic form of pulmonary tuberculosis and florid 
phthisis progress, in the course of several weeks or months, relent- 
lessly to a fatal end. The few accounts of these conditions result- 
ing in recovery must be received with the greatest scepticism, and 
do not affect the unfavourable prognosis. 

These conditions, which often begin acutely 
and progress afterwards less acutely, are 
generally forms of caseous phthisis due to aspiration, and have 


Acute Form. 


Subacute Form. 


gO A CLINICAL SYSTEM OF TUBERCULOSIS 


a better prognosis. There are several forms to be differentiated ; 
the caseous hepatization as the result of an hamoptysis, the casea- 
tion as the result of changes in a small or large nodule, or in a 
large part of a lobe, in either case the result depending on whether 
the aspirated material is highly or less infectious. We refer here 
to the anatomical changes of caseous pneumonia, to its different 
transformations, and to its probable progress. These pneumonic 
forms are not always fatal, but may result after a severe conflict 
in excavation, connective tissue formation, and encapsulation, and 
under certain conditions even in slow reabsorption. 

This form of pulmonary tuberculosis has 
the most favourable prognosis, as it is 
usually only very slight in amount, localized to the apex, and 
frequently heals quite spontaneously. 

There is more scope for prognostic skill in 
the chronic forms of pulmonary tubercu- 
losis. The prognosis first of all depends on the grade of disease 
at the commencement of treatment; which leads us to consider a 
little more the classification into grades. It depends on the 
amount of disease and its intensity, that is, it differentiates 
between slight and severe disease. The chronic pulmonary tuber- 
culosis may be either a mixed form of slight fibroid disease, with 
cicatricial contraction and healing processes, or a severe caseous 
form with destructive tendencies. The prognosis is the more 
favourable the more the fibrous form predominates, the more 
limited the disease is to one side, and the more localized it is to 
a definite part of the lung; and it is more dubious and serious the 
more scattered the foci are, the quicker the infiltration occurs, and 
the more extensive and the more rapid are the caseating and 
necrotic changes. Processes localized in the lower parts of the 
lung have of course a worse prognosis on account of the tendency 
towards defective limitation and encapsulation. 

The close examination and mapping out of the morbid 
changes with the help of all the refinements of diagnosis is a great 
aid to prognosis. The division of chronic lung tuberculosis into 
(1) slight, (2) moderately severe, and (3) severe cases, or with 
regard to their future tendencies into (1) favourable, (2) difficult 
to check but still curable, and (3) doubtful or unfavourable (no 
healing at all or relapse more likely), also serves the same purpose. 
Owing to the nature of the disease each grade can only be 
imperfectly marked off; and the deductions drawn from the 
pathological anatomy and from the clinical course do not entirely 
coincide. So that a strict division cannot be made between the 
individual grades, as need hardly be further explained. 


Abortive Forms. 


Chronic Forms. 





PULMONARY TUBERCULOSIS GI 


The healing of an afebrile case of Grade III may take place 
more smoothly and quickly than that of a feverish case of Grade I 
with unfavourable localization of the disease. The idea that 
disease of the left lung on the whole is more unfavourable than 
that of the right we cannot confirm; on the contrary, owing to the 
favourable anatomical situation of the lower part of the anterior 
border of the left lobe, a high degree of contraction, and thus a 
favourable prognostic course, is observed much more frequently 
in the left side than the right (Turban). We will not allude 
further to the separate prognosis of the individual grades, the 
statistics on this point are of no value. 

Two weighty factors, which together affect the prognosis, 

have already been mentioned, the severity of the infection, and 
the powers of resistance of the infected organism. The consti- 
tutional or natural resistance of the individual depends both on 
the resistance of the pulmonary and connective tissues, and on 
the vital energy of the whole organism. If the disease has already 
taken root, then its further progress depends on the capacity of 
the organism to react with the necessary forces for healing. Of 
the greatest importance for this is the functional capacity of the 
chief organs. With each complication, whether tubercular or 
non-tubercular, the prognosis deteriorates, and the more so 
the more important the function of the organ secondarily affected, 
the damage to the second organ sapping some of the strength 
required for withstanding the principal disease. Particularly far 
reaching, to mention only one example, is an affection of the 
blood and the blood-producing organs, in which the protecting 
substances against tuberculosis are formed. Accordingly there is 
a whole series of factors which influence the prognosis of chronic 
lune disease, in different directions. 
An hereditary predisposition has import- 
ance for prognosis according to the general 
experience of the practitioners of the older 
school. According to Turban’s statistics cases with an hereditary 
taint lived longer than those without, and those patients both of 
whose parents were tubercular even still longer than those only 
affected on one side of the family. According to the theory of 
Reibmayr not only is the pathological tendency transmitted, but 
also the powers of resistance acquired in the contest with the 
disease, which in the course of generations is raised into an 
immunity. 


Hereditary 
Predisposition. 


The prognosis depends in a definite way on 
the constitution. Usually the course of 
phthisis is more favourable in strong patients with a well-built 


Constitution. 


Qg2 A CLINICAL SYSTEM OF TUBERCULOSIS 


thorax, than in those of weak build; also according to statistics 
the duration of life is better in the first, and becomes more 
unfavourable the more marked the phthisical aspect. Just as 
certain diseases in the parent at the time of procreation, such as 
cancer, diabetes, general bodily weakness, old age, inbreeding, 
&c., are correctly considered as causes of hereditary predisposi- 
tion, as are also the lifelong weakness and bad appetite from 
youth described by Brehmer, so these factors also play a part in 
prognosis, especially if they appear also in the individual himself. 
If the hereditary predisposition and the phthisical build, which is 
the outward sign of the inborn disposition, are both met with in 
one patient the prognosis is so much the worse. 
The phthisical thorax, as revealed by 
measurements and_ spiro-metric observa- 
tions, also furnishes points of value in form- 
ing a prognosis. Although the measurements of the circumfer- 
ence and depth of the chest and of the capacity of the lungs are 
not of much service for the finer diagnosis of the functions of the 
lungs, yet, according to our results obiained from a large number 
of patients over many years, exact uniform measurements are of 
value for prognosis. The estimation of the vital capacity is more 
reliable than the external measurements, which only vary within 
small limits. A real increase of the vital capacity indicates re- 
absorption of infiltration; and as this does not mean exclusively 
an increase of the respiratory surface, but to an even greater extent 
a strengthening of the whole respiratory apparatus, such an 
improvement in the general condition of the lungs and thorax is 
of favourable prognostic meaning. With even more certainty 
does a diminution of the vital capacity indicate an increase in the 
tubercular lung changes, an objective sign which is of the more 
value as it may indicate new deep-seated foci which cannot be 
fully detected by physical examination. 
é The state of the general health of the tuber- 
General 5 
cular patient is not to be under-estimated ; 

Health. individuals, whose strength is undermined 
by disease, excesses, alcoholism, bodily and mental overstrain, 
frequent pregnancies, difficult labours, grief, privation, and other 
factors lowering in many different ways the resistance and nutri- 
tion, have a bad prognosis. 
Particularly unfavourable are chronic affec- 
tions of the digestive and assimilative 
organs. Regular appetite, a healthy 
stomach, and an unimpaired digestion are priceless gifts for the 
consumptive; they may defer for a long time the loss of strength, 


Thoracic 
Measurements. 


Digestion and 
Assimilation. 








PULMONARY TUBERCULOSIS 93 


and are the best indications of a favourable prognosis in long- 
standing disease. On the other hand a failing appetite and 
progressive loss of weight have always a sinister meaning. The 
more important diseases of the digestive organs and their pro- 
gnostic importance will be referred to later. 
Valuable information for prognosis may be 
afforded by the condition cf the heart and 
circulation, particularly by the state of the 
pulse. The many claims on the heart during the varying course 
of chronic phthisis need a healthy muscle and intact valves. It 
may be noticed that just as defects of the mitral valve afford a 
relative defence against the onset of tuberculosis, by the induced 
congestion of the pulmonary circulation, so also, if met during 
the course of the disease, they are less serious than affections of 
arterial valves. The course of an already existing tuberculosis is 
but little influenced by accidental heart failure; on the other hand 
the effect of tuberculosis on the compensation of valvular changes 
is more unfavourable the more rapid the disease. In all con- 
siderable organic, functional, and compensatory affections of the 
heart it may fail in consequence of acute complications, and the 
summation of depressing influences such as toxins and fever. As 
the chief power of resistance to infection lies in the blood, so 
each morbid alteration in the blood affects the prognosis. The 
alteration of the white cells described by Arneth is of particulary 
importance, since the polynuclear leucocytes are the chief 
carriers of the antibodies. The quite early diminution of the 
blood-pressure is of value for prognosis, as it falls more and more 
with the progress of the disease. Acceleration of the pulse 
has a similar importance. According to Turban a very 
changeable pulse, easily increased by slight psychical and other 
influences, calls for caution in forming a prognosis, and a con- 
stantly frequent pulse, even in the early stage, is an unfavourable 
sign. A close examination and registration of the pulse curve 
is therefore of value in all doubtful cases. A marked enfeeble- 
ment of the pulse, especially conjoined with undue frequency, 
is unfavourable, and is a sign of heart weakness often occurring 
quite early in the disease. 
The sex of the patient is without special 

Sex. importance for prognosis. The duration of 
life of men patients in public sanatoriums is less than that of 
women, but that is in consequence of their harder occupations; 
the prognosis of men in better positions is in no way more 
unfavourable than that of women. On the other hand the chances 
of women are lowered by the consequences of marriage, especially 
during pregnancy, child-birth, and the puerperium. 


Circulatory 
System. 


94 A CLINICAL SYSTEM OF TUBERCULOSIS 


More important is the age of the patient. 
In infancy tuberculosis takes regularly a 
rapid, lethal course. With increasing age this lethal tuberculosis 
is proportionately rarer, and one meets unsuspected tuberculosis 
with increasing frequency, that is to say, the increasing powers of 
resistance of the organism of 7 years old and upwards dimin- 
ishes the tendency to generalization, and increases the frequency 
of chronic and healed disease. Wauth the supervention of puberty 
the tuberculosis of children approaches the adult type, the lungs 
are specially picked out. The resistance, however, is not yet so 
great as in adults, so that acute progressive phthisis is frequent 
at this age. In later years florid phthisis is-rarer, and the prog- 
nosis becomes more favourable with age. At somewhere about 
60 it gradually gets more and more serious, a_ substantial 
improvement in the lung disease will be rarely attained. 

Of greater importance for prognosis than 
the age of the patient is the age and pre- 
vous course of the disease. Herein lies 
the value of a careful history, and of a critical examination of 
the data thus obtained; it makes it easter to determine whether 
the case in question is advancing, stationary, or healing and 
retrograding. 


Age. 


Duration of 
the Disease. 


In individual cases the most important 
criterion for prognosis is the temperature. 
Complete absence of fever may be seen in progressive tubercu- 
losis and in terminal cases as a result of complete failure of the 
power of resistance, but it is nearly always a sign that the disease 
is ata standstill. The higher the fever is and the longer it lasts, 
in spite of absolute rest and suitable treatment, the less likelihood 
there is of a favourable outcome. But if the body-weight is main- 
tained, or, at all events, if it dces not fall rapidly, there is still 
ground for hoping the temperature will drop. Hectic fever, with 
high evening temperature and big morning drop, is very serious. 
The inverse and collapse temperatures are always unfavourable. 
A definite meaning cannot be given to the different types of fever ; 
however, a mixed streptococcic infection plays a most important 
part in the production of continued high fever; tetragenus also 
has a very injurious effect. 

The prognostic importance varies with the 
amount and frequency of the bleeding. 
Small hemorrhages are generally without importance, indeed the 
favourable fibroid form is particularly inclined to bleed. Also 
contracting and distinctly healing disease may give rise to 
hemorrhage. Hzemoptysis is not rarely the first sure sign of 


Temperature. 


Hzemoptysis. 





PULMONARY TUBERCULOSIS 95 


the existence of phthisis, and so is indirectly favourable by making 
the situation clear, and it may have a valuable educational influ- 
ence on careless and frivolous patients. Copious and frequent 
hemorrhages reveal a tendency of the disease towards destructive 
changes, and are serious, not only from the loss of blood, but 
more so from the great danger of caseous pneumonia due to 
inhalation of blood mixed with sputum and bacilli. Death from 
hemorrhage or suffocation is also possible. 

The examination of the sputum gives some 
definite prognostic information. The 
amount of the expectoration is not of special importance. Acute 
processes produce as a rule little or even no sputum; copious 
sputum need not necessarily be due to tuberculosis alone, but 
weakens the patient through the often considerable loss of 
albumin. Progressive diminution of the sputum is a favourable 
sign. The existence of tubercle bacilli in the sputum is of 
importance, in so far as open tuberculosis is usually of more 
advanced grade than the closed form, and therefore in general has 
a more unfavourable prognosis. Of slighter value is the number 
of the bacilli; however, a constantly high number is a bad sign, 
and progressive diminution and total disappearance of bacilli is 
an important objective mark of improvement. There is a differ- 
ence of opinion as to the meaning of the forms and staining 
properties of the bacilli, and of the presence of granules. We 
observe that cases with Much’s granules in the sputum have a 
strikingly favourable course, an observation which agrees well 
with the view that Much’s granules develop out of the tubercle 
bacilli as spores, being reduced to this change as an adaptation 
to unfavourable conditions for their life. 

Reference has been made to mixed infection when speaking 
of fever. The presence of elastic fibres is a sure sign of an 
advancing, destructive process. An intracellular position of 
the tubercle bacilli is generally observed in cases progressing 
towards healing either naturally or under the influence of tuber- 
culin. On the other hand the presence of eosinophile cells has no 
prognostic value. 


Sputum. 


Much work has been done on the prognostic 
value of the diazo-reaction. The results are 
that a transitory diazo-reaction is meaningless for prognosis, 
constant absence throughout does not speak for a good prognosis, 
on the other hand a persistently marked positive result is indica- 
tive, with few exceptions, of a progressive form of disease. But 
this is usually by then so obvious that it does not need to be shown 
by the diazo-reaction. 


Diazo-reaction. 


9G A CLINICAL SYSTEM OF TUBERCULOSIS 


The prognostic information given by the 
various tuberculin tests is still slight, but 
work is now being done on the subject. 
The conjunctival methed is of no value in this connection, and 
the cutaneous but of littke more, while a larger or smaller reaction 
to a subcutaneous injection of tuberculin permits a certain conclu- 
sion to be drawn as to the activity and intensity of the disease. In 
general it can be decided, apart from quite hopeless cases, with 
no sensibility to tuberculin, that both slight cases with marked 
tendency to healing, and also more severe stationary cases with 
markedly favourable progress of the disease, possess a raised 
power of natural resistance to tuberculin, which indicates a great 
capacity of the organism of withstanding tuberculosis. On the 
other hand newly affected cases show a very ready reaction to 
small doses of tuberculin. But whether in initial cases a high 
sensitiveness to tuberculin in the cutaneous or subcutaneous tests is 
to be considered a particularly favourable sign, and as evidence 
of a great power of reaction inherent in the individual, the results 
which have hitherto been obtained do not suffice to show. 
.4; Lhe discovery of tubercle bacilli in the 
Tubercle Bacilli : 

j circulating blood succeeds with greater 

in the Blood. — frequency the more severe the tuberculosis 
and the nearer the end of the patient. In spite of this, a positive 
result has no prognostic significance, as it is also obtained in 
early cases of not excessively severe disease. The consideration 
of this subject is deferred to the section on ‘* Tuberculosis and 
the Blood.”’ 


Tuberculin 
Tests. 


Opinions are not in agreement as to the 
value of the opsonic index for prognosis. A 
positive result, and still more an increase, of 
the agglutination phenomena give an important indication of the 
formation of specific products of reaction with immunizing 
qualities, either under the influence of general hygienic or dietetic 
treatment, or during a course of tuberculin. In individual 
cases, however, the reaction proves untrustworthy. 

Ludke and Sturm have undertaken a series of observations on 
the serum reaction before and after specific treatment which 
should supply valuable information for the formation of 
prognosis. In spite of the difficulties in the way of an exact inter- 
pretation of the results of the experiments, owing to the variable 
course of tuberculosis, and the spontaneous appearance of specific 
reaction preducts in the serum, the authors could recognize that 
an increase in the amount of complement fixation was in most 
cases a favourable prognostic point; while the cobra-venom test, 


Serum 
Prognosis. 





PULMONARY TUBERCULOSIS O7 


the agglutination test, and the precipitation experiments, on 
account of deficiencies in the method, gave no useful results. But 
the indications for prognosis founded on the results of serum 
tests of the increase of antibodies must come after the considera- 
tion of the clinical factors of prognosis. 
It would take too long to consider how the 
Complications. prognosis of tuberculosis is affected by 
every tubercular and non-tubercular compli- 
cation; but the previous chapter will furnish many points of use 
in prognosis. Particularly unfavourable complications are 
diabetes, alcoholism, and severe forms of exophthalmic goitre. 
in the chapter on therapeutics will be given information as to the 
influence of certain complications not only on the treatment but 
also on the prognosis. How tuberculosis of other organs affects 
the prognosis of phthisis may be gathered from the chapters on 
the separate organs. 
It is obvious that the prognosis of phthisis 
depends in a large measure on the means 
which can be employed for the cure of the 
patient. So that there is also a social side to the question of 
prognosis. We will explain later in various stages of the disease 
what conveniently can be done, and what necessarily must. We 
will show, too, that though the first and last part of the treatment 
of tuberculosis devolves on the family doctor, who must play an 
important part in any method of treatment, yet, for reasons to be 
mentioned, nearly all cases benefit by a removal from their homes 
in the critical period of the disease, and often enough such a 
change is absolutely necessary. Therefore it is a most important 
point in the prognosis whether this indispensable treatment away 
from the home of the patient can be commenced at the right time 
and be continued long enough. In this way the prognosis 
depends on the pecuniary position of the patient, which also very 
largely affects his conditions of life after the conclusion of the 
special treatment. But even for the less fortunate classes phthisis 
has lost its worst terrors by the organization of public institutions. 
ter of the Lastly, the DUC Ae inenlssy to a large 
i extent, on the behaviour of the patient 
Baan: himself. During the long and frequently 
changeable course of the disease there will be many calls on the 
patience, judgment, and intelligence, and often enough also on 
the self-control and resignation of the patient while undergoing 
treatment and afterwards. Weak-minded, nervous, excitable, 
Over-anxious, and frivolous patients do not possess the qualities 
necessary for a satisfactory and lasting success in dubious cases, 


J 


Social 
Conditions. 


98 A CLINICAL SYSTEM OF TUBERCULOSIS 


and their prospects of cure will often be much less than those of 
serious, intelligent, and strong-minded individuals. Therefore 
the character of the patient plays a part in the prognosis of 
phthisis, and, indeed, not the smallest part. 


5. TREATMENT. 


For the treatment of pulmonary tuberculosis, wherever it is 
carried out, there are two main factors. 

The first is essentially a constitutional treatment. We under- 
stand by the constitution of the patient the whole of the vital 
changes that are perceptible to the physician, so that the essence 
of constitutional treatment is to restore disordered functions to 
their normal state. Owing to the particular importance of the 
lungs in connection with the gaseous exchanges any disturbance 
of their functions, which are of primary vital necessity, will 
derange the working of the nervous system, the action of the 
heart, and the economy of the whole organism ; so that pulmonary 
tuberculosis interferes not only with the working of the respiratory 
apparatus but also with the functions of the whole organism, both 
bodily and mental. The treatment, therefore, must be both 
physical and psychical; physical, to restore the proper working of 
the tissues and organs; psychical, to act on the mind of the 
patient by guiding, instructing, and educating him. 

In the second place the treatment must be adapted to the 
individual patient; his bodily and mental peculiarities must be 
grasped by the doctor, and a plan of treatment founded on 
knowledge and experience devised for this one special tubercular 
person. It therefore follows that the treatment of pulmonary 
tuberculosis consists of physical and mental treatment of 
individual tubercular cases. 

Brehmer and Dettweiler performed the great service of build- 
ing up the principle of individual constitutional treatment on the 
foundation of general hygienic and dietetic therapeutics. 


I. General Hygienic and Dietetic Treatment. 


All treatment of tuberculosis is based from beginning to end 
on general hygienic and dietetic treatment; which must, there- 
fore, form a part of every method of cure. On the other hand, 
one must not overlook the fact that it is only one link in the whole 
system, and that it is always a mistake to tear one method from 
the united whole and to proclaim it the method of curing con- 
sumption. 


PULMONARY TUBERCULOSIS 99 


We begin with the psychical treatment, be- 
ing of the opinion that ‘‘ a bad psychologist 
can never be a good lung doctor ’’ (Cornet). 
This psychical treatment is more or less deduced from physiological 
conditions, and is necessary, as the patient must have his will 
power and endurance encouraged for months and often for years ; 
he must live conformably with the doctor’s orders, he must follow 
rules of moderation and must change his prejudicial habits, often 
enough deeply rooted. First of all the patient must be educated. 
The course of treatment must be written out for him in every 
detail, and the utility and reason of the orders clearly explained 
in an intelligible way, for ‘‘ every rule is better imprinted on 
the mind and enforces itself more fully on the obedience if 
supported by a reason that can be clearly understood’ (Dett- 
weiler). Rules as such are not necessarily obeyed, but if they are 
first understood they will be conscientiously carried out. Besides 
the rules of treatment, the most conscientious and cautious cleanli- 
ness in dealing with the expectoration must be impressed on the 
mind of the patient. 

Very important, even necessary, is the instruction of the 
patient as to the nature of his disease. He must, as long as he 
is not hopelessly ill, be told the truth. For never will he see 
the necessity of irksome rules and of wholesome constraint of his 
whole manner of life, if the full seriousness of his condition is 
not explained to him. The unfortunate terms ‘‘ catarrh’’ and 
‘weakness ’’ of the lungs must never be used in reference to 
pulmonary tuberculosis; they only lull the patient into a 
dangerous carelessness, for which he will later suffer. At the 
same time, it is naturally wrong to exaggerate the danger. Most 
tubercular patients are impulsive, nervous weaklings, who, on 
a warning of merely “lung weakness,’’ are not inclined to give 
up even one of their injurious habits, but who, on the hint of 
consumption, can more or less restrain themselves. Nowadays 
a verdict of tuberculosis is no longer a death warrant, and an 
exposition of the powers of therapeutics may remove many diff- 
culties. What else can be said to each individual patient must 
be left to the tact of the doctor, who will act as he thinks fit. 
In hopeless cases medical frankness must give place to merciful 
evasions, for truth would here be cruelty. On the other hand, 
even a curable patient must be informed, if not at the first con- 
sultation, then later on, that he is suffering from a serious illness, 
from which he can recover only by following the doctor’s orders, 
and co-operating with him while leading a fixed and regular 
course of life. The comprehension of the nature of his disease, 


Psychical 
Treatment. 


100 A CLINICAL SYSTEM OF TUBERCULOSIS 


the hope of recovery and the conviction of the necessity of the 
requisite treatment, are stages in the education of the consumptive. 

The education of the patient also includes the acquisition of 
faith in his doctor and in medical science, which he must retain 
through the good and bad days of his chronic malady. As a 
rule, it is not difficult to persuade the frequently impulsive, but 
usually good-natured, consumptive, what he must do, and what 
he must leave undone. A certain severity on the doctor’s part 
against frivolity, benevolence towards ignorance, and a warm but 
restrained sympathy for all, are pre-eminently helpful factors in 
the educational psychical treatment. 

Mental disturbance and unrest are harmful, and should, if 
possible, be obviated; we need only recall to our mind the rises 
of temperature and attacks of sudden hemoptysis which may 
follow emotional outbreaks. On the other hand, complete idle- 
ness and mental apathy are not the right things. We should, 
therefore, urge melancholy patients to light amusements, such 
as draughts, halma, dominoes, and chess; or to interesting books, 
music, discussions, garden parties, &c. Card games may be per- 
mitted if not played for money. Reading, at least in young 
patients, must be strictly supervised; so-called popular medical 
works are not good, as they may cause mental disturbance and 
prolonged agitation. 

In the physical treatment the two chief 
things are the management of the rest and 
exercise, which may be applied to the whole 
body or to the diseased lung itself. Under the first heading we 
have rest and exercise in the open air; under the latter we have 
breathing exercises and methodical deep breathing. In these 
matters we find great differences of opinion; while there are 
some who lay great stress on the exercise, and others who think 
more of the rest, the correct method lies in regulating the two 
for individual cases; but rest must take the chief place. 

The open-air cure includes both rest and 
exercise in the open. For it no special 
altitude or climate is necessary. The important point is the 
freshness of the air and its freedom from dust, gases and 
organisms. The purity of the atmosphere increases with its 
distance from human habitations, and its freshness with the 
amount of exposure to sun and wind. Excessive direct sunshine, 
damp thick fog, and keen east winds are not desirable for 
the open-air treatment. The patients must be sheltered from 
them, as also from rain and snow and rapid alterations of 
temperature. 


Physical 
Treatment. 


Open-air Cure. 


PULMONARY TUBERCULOSIS IOI 


This consists in lying out in the open air. 
The patient spends his day out in the air 
in convenient shelters, warmly clad, and with his muscles re- 
laxed. To spend the day in this way and the night in an airy 
bed near an open window is to fulfil the conditions of a continuous 
air-cure. Open halls, pavilions, balconies, verandahs and 
shelters protect against direct sunshine, rain and wind, and make 
the open-air cure possible on every day and at every season of 
the year. Private institutions, which receive more severe cases 
who cannot go out, should have open halls, which can be heated 
and into which the febrile patients, still in bed, can be moved; 
costiy but very necessary constructions, which we particularly 
recommend. Huts and shelters can generally be arranged with a 
little trouble in the woods and gardens for short rests. In good 
weather the treatment can be carried out under the open sky, and 
in hot weather under trees. 


Rest Cure. 


Iron couches with mattresses and movable backs are the most useful; 
fixed backs are not to be recommended, as rest in a horizontal position with 
the head only slightly raised is often desirable. - Recently Jacoby has con- 
demned the usual half-sitting position during cure, as it induces anemia ot 
the apices of the lung, which according to both ancient and modern views is 
conducive of tuberculosis of that region; this has been our opinion also for 
many years. Jacoby goes still further and altogether forbids the semi-reclining 
position; he places the thorax flat, with the pelvis raised on an adjustable 
elevator. The abdominal organs are thus pressed up against the 
diaphragm, compelling a deep costal type of breathing, and by compression 
of the lower lobes driving the blood into the upper part of the lungs, and 
producing a relative hyperemia of the apex favourable to cure. 

Hammocks and canvas folding-chairs are not suitable, as they cause 
compression of the thorax, instead of allowing free and easy breathing. As 
protection blankets may be.used, and in winter furs or sacks, some of the 
latter being sterilizable. 


The rest cure is to be strictly carried out at the appointed 
times and in the appointed way. Patients who are sitting up, 
or running to and fro, or lying on their sides reading, or drawn 
up over some work, are not carrying out the treatment; for a 
most important part of this is directed towards rendering the 
lungs hyperemic by rest in an almost horizontal position. The 
duration of the cure hours must be settled for each individual 
patient, according to the state of his lungs, his digestion and 
his heart. For afebrile patients of the first and second grades 
from six to eight hours are necessary, divided into periods of 
14 to 2 hours in the morning, afternoon and evening; with 
steady improvement half of this will be sufficient; but slightly 
febrile, or aneemic patients, also those with much cough, must 
rest the whole day. These latter cases should have systemati? 


102 A CLINICAL SYSTEM OF TUBERCULOSIS 


passive movements, or, better still, massage of the extremities and 
trunk, to overcome the sluggish circulation induced by absolute 
rest. Very sensitive or weak patients must be gradually accus- 
tomed to the open-air treatment; they should be brought into the 
house at sunset, and not be exposed to the night air till they are 
fully acclimatized. 

What are the advantages of the open-air treatment? The 
prolonged exposure to the unrestricted light and pure air in all 
weathers counteracts many of the effects of tuberculosis, especially 
the wasting, the toxic heart weakness, the catarrh and the fever. 
Further, the daylight and sunlight stimulate the cellular tissues, 
strengthen the organic functions, facilitate the excretion of car- 
bonic acid, stimulate the blood changes, and restore the impaired 
action of the skin. There is an increase of energy, and the patient 
is hardened, strengthened and tranquillized. The heart beats more 
steadily and strongly, the appetite and body-weight improve, 
night sweats disappear, the slighter grades cf fever are removed, 
the sleep is more peaceful, and the feeling of general well-being 
is augmented. Improvement in the lung condition goes hand 
in hand with this, the cough becomes less, the expectoration 
diminishes, and the breathing becomes altogether more free. 

Jacoby observed after rest with the chest horizontal and the 
pelvis raised, that in a much shorter time the breathing became 
deeper, the cough less, the expectoration loosened and then 
ceased, and especially the pains in the chest and back disappeared. 
We agree that these results are possible, but from our own experi- 
ence must make the reservation that the ‘‘ auto-transfusion ”’ 
position of Jacoby, even if the lowering of the thorax and raising 
of the pelvis are cautiously and gradually done, cannot be con- 
tinuously and systematically employed for all patients, and not 
even for the greater majority. Many patients refuse at once from 
indolence or other unreasonable considerations; but not a small 
number of those who carefully follow all the rules after rest 
in this position suffer from cerebral and general congestion, 
which more than counterbalances any useful hyperzemia of the 
lungs which may have been induced. In spite of this we hold 
with Jacoby that it is scientifically correct to try and induce some 
hyperemia of the lung during rest cure. It must be attempted 
by encouraging rest in a completely horizontal position, and 
when this is well borne the foot of the couch may be slightly 
raised; the horizontal position at least being absolutely insisted 
on. The benefits of the rest cure are frequently not sufficient by 
themselves; and outside the sanatorium they are almost entirely 
valueless. 





PULMONARY TUBERCULOSIS 103 


With increasing improvement in the lungs 
and the general condition there is an im- 
pulse on the part of the patient towards exercise, which may be 
utilized under careful supervision. It must be remembered that 
the consumptive is a weakling whose duty it is to save his 
strength. Brehmer’s old rule very truly said “‘ the healthy man 
sits when he is tired, but the consumptive must sit that he should 
not become tired.’’ We may begin by permitting two to three 
walks a day of a quarter to half an hour’s duration, on level 
ground, at an easy pace; but in every case the amount of move- 
ment must always be controlled by observation of the temperature, 
pulse, heart and general condition. One patient will require more 
rest, another more movement; as a general injunction, ‘‘ Go for a 
good walk’’ is almost more absurd than “ Lie a lot in the open 
air.’ If all signs of- reaction are absent the rest may be 
shortened, and the walks lengthened to one or two hours, still 
forbidding much hill climbing, especially for strong, quite afebrile 
patients with localized disease, and in a good state of nutrition. 

The walks must be finished in good time, so that the patient 
can still have a quarter to half an hour’s rest before meals; this 
will facilitate the digestion. After the midday dinner, rest, with 
or without sleep, is always required, unless the patient is a well- 
nourished, heavy eater, who should not put on more weight. 
In summer the early morning and late afternoon hours are to be 
preferred for long walks; in winter the later morning and early 
afternoon; they are not to be given up for unfavourable weather, 
such as wind, light rain and snow. In severe rain, tempests, 
storms and heavy snowfalls the patient must not go far from the 
house. He must always walk with an upright carriage, and take 
care to breathe evenly through the nose. In steep places he must 
walk more slowly, and must stop or turn if the breathing and 
heart action become accelerated. 

It cannot be doubted that the amount of rest ordered by 
doctors was previously excessive, and perhaps is so still. Dett- 
weiler, who introduced the rest cure, has himself spoken against 
excessive rest and in favour of more exercise. But the contrary 
opinion, that lung tuberculosis can be cured quite without rest by 
means of exercise and work, is equally unfounded. The broad, 
middle path must here be followed and the correct *‘ dose’ of 
exercise carefully prescribed, drawing distinctions between wasted 
and corpulent patients, between febrile and afebrile cases, between 
early and chronic third-grade cases, and between a tubercular 
diabetic and one with an affection of the heart. The way the 
nervous system reacts to rest and movement must also be con- 


Exercise. 


104 A CLINICAL SYSTEM OF TUBERCULOSIS 


sidered. Patients, who on the rest couch are nervous and 
neurasthenic, may have their rest hours broken up by more 
exercise, if the state of their lungs allows it. 

No general rule can be made on the question of permitting 
exercise in the form of games, sports and physical labour. When 
long walks, especially uphill, are well borne, lighter work in the 
open air cannot be harmful. We also think that it is useful to 
systematically habituate to work those who must soon return 
to arduous occupations. We lay less stress on the still un- 
determined ‘‘ auto-inoculation ’’ produced by more severe work 
than on the psychical stimulus of knowing that the power of 
work is returning. Under similar conditions croquet and skating 
may be permitted, but lawn-tennis, bowls, gymnastics, cycling, 
rowing and dancing must be forbidden if the disease is still active. 
Riding and tobogganing are on the border line, they may be 
allowed if the patient knows how to be moderate. In general 
the doctor should take the line that much care and prudent exer- 
cise is the best for his patient. 

; Recently it has been proposed to combine 

Air and Sun Pe 

air and sun baths with the rest cure. The 
Baths. sun-bath is given in many different ways, 
which cannot be described here in detail; in consequence of the 
direct action of the sunlight its effect is more marked and more 
severe than that of the air-bath. If the prejudice against the 
use of sun-baths in tuberculosis has been removed, there. still 
remains the doubt as to their action apart from the necessary 
exposure to the air, and whether their effect is due to the warmth 
of the sun only, or to the intensity of the light, and whether the 
tissue-penetrating yellow and red rays are as powerful as the 
blue and ultra-violet, which owing to absorption have only a 
quite superficial action. It is quite certain that the sun-baths 
stimulate tissue changes. Therefore they may be recommended 
for the heavy, pasty consumptive, who is corpulent or tends 
to become so. Prudence and caution are, however, required, as 
sun-baths may produce rises of temperature from 2° to 3° F. or 
more, cardiac irregularity, and increased irritability of the nervous 
system. They are contra-indicated in advanced neurasthenia and 
in cases with a tendency to fever or hemorrhages. The head 
must be protected, and the duration of the sun-bath must not 
exceed half an hour. 

Air-baths act on the skin by means of the air and light; 
they influence the heat regulation, lessen nerve irritation and 
increase the perspiration. The results are stimulation of the 
phagocytic action of the cells, increase of tissue changes and of 


‘ 


PULMONARY TUBERCULOSIS 105 


the appetite, strengthening of the heart’s action and of the 
respiration, and diminution of the expectoration. The air-baths 
also harden and strengthen the patient, and have a_ beneficial 
action on neurasthenic and anemic individuals, if commenced 
with care. Apart from the general hardening, they improve the 
constitution and remove secondary catarrhal conditions. Hzamor- 
rhages and temperature rises need not be feared, only the bath 
must not be prolonged for more than ten to fifteen minutes; also 
they must be commenced with caution at certain seasons of the 
year. At unfavourable seasons air-baths in the room, lasting 
from ten to eighteen minutes, accompanied by physical exercises, 
may be recommended, but only on the doctor’s orders. 

More necessary and important is the permanent air-bath, in 

the sense that permeable clothing and coverings should allow, 
both by day and night, a constant interchange between the air 
surrounding the body and the outer air. Without chilling the 
body this will facilitate the action of the skin, and diminish the 
perspiration. On these grounds corsets must be forbidden, and 
also thick feather-beds and heated bedrooms. 
Exercise and movement of the lungs by 
means of lung gymnastics requires adroit 
and vigilant individual management to 
avoid excess. We do not share the fears of those over-cautious 
physicians who see in every deep breath a danger of drawing 
bacilli into the deeper parts of the lungs. If this were so all 
therapeutics would be useless, since unintentional deep 
breaths are inevitable. Neither can we agree with those who 
attempt to eliminate from the body the diseased parts by means 
of injudicious exercises, on the ground that the sooner the affected 
part is removed the better for the organism. This is a dangerous 
doctrine; since early processes may become healed without loss 
of substance, and a rapid separation of the diseased part, even 
if it is successful, is not desirable. Mechanical irritation of 
recently inflamed tissue will cause an increase of exudative and 
destructive changes, augment toxic absorption and infallibly end 
in hemorrhage, fever or heart disturbance. The recovery of 
tubercular lungs and of the whole organism can only take place 
by a process of regular, slow development. Therefore it is better 
that necrotic tissue should be slowly removed, and the still un- 
affected surrounding areas strengthened, not roughly and rapidly, 
but by methodically weighing and proving each step. Only thus 
shall we avoid the bitter experience of having to attribute to the 
progressive character of the disease bad effects, which are 
really due to unsuitable and carelessly applied lung exercises. 


Lung 
Gymnastics. 


106 A CLINICAL SYSTEM OF TUBERCULOSIS 


However, in cases which have come to a standstill under 
treatment, and in which the fever, expectoration and cough have 
disappeared, it is well from time to time to vary the rest treat- 
ment with exercises. This may be done by regular, methodical, 
deep breathing, inspiration taking place slowly and _ steadily 
through the nose without over-distending the lungs. This is 
followed by a rapid, jerky expiration, which may be assisted by 
pressure of the arms on the chest. But the patient must be 
informed that movements of the arms alone, without attention to 
the method of breathing, are useless. Naturally these exercises 
require constant control. 

Simple deep breathing in the open air is sufficient : apparatus 
for respiratory gymnastics are superfluous in consumption. As 
much as we dare attempt to do, that is, to improve the nutrition 
of the still healthy tissues by the necessarily increased blood- 
flow, and to raise the blood and lymphatic flow through the 
diseased areas and their surrounding parts back to normal, we 
can achieve with exercises without apparatus. An increased flow 
of air through the lungs goes hand in hand with an increased 
flow of blood. It is obvious that lung exercises may also be 
regulated by means of walks, especially by mounting gentle 
inclines. 

Treatment by means of baths is the second 
Treatment by . A ee ae 
method of physical treatment. The treat- 
Baths. ment affects the general health, and may 
be employed to a greater or less extent, according to the local 
and general state. It mechanically purifies the body, it educates 
the patient in the value of cleanliness, it promotes the natural 
functions of the skin, and so raises the powers of resistance of 
the organism against infection. These measures of hydro- 
therapeutics are efficacious in stimulating the nerves in the 
skin, strengthening the action of the heart, diminishing the 
peripheral resistance both in the systemic and pulmonary 
systems, improving the state of the blood, deepening the respira- 
tion, facilitating the exchange of gases, regulating assimilation 
and nutrition, and improving the digestion and appetite. 

Consumption is a disease of the skin, in so far as the 
physiological skin breathing is disturbed. |For the purpose of 
restoring this function a hot bath at go° to 95° F. for five to ten 
minutes once or twice a week is useful; plenty of soap must be 
used to get rid of perspiration, grease, scurf and epidermic 
scales. After the bath a cool douche of 68° to 80° F., or a 
tepid sponging, followed by careful drying, should be used. 
Slightly febrile patients should take their bath in the morning 


PULMONARY TUBERCULOSIS 107 


as the time freest from fever, and should then go to bed. Patients 
with temperatures of 100° to 102° F. generally stand the bath well, 
if the heart is in good condition. Kohler observed, even after 
a hot bath of 105° to 108° F., a fall in the temperature, and recom- 
mends hot baths for feverish patients, if there is no contra- 
indication, every two to four days, according to the reaction, 
but not every day. We have not observed this immediate effect 
of hot baths on tubercular fever, and do not recommend them 
for very feverish and advanced cases more often than once a 
week ; and employ instead dry rubbing of the whole skin till it 
becomes red every morning. For preventing the perspirations 
we use every morning or evening partial or complete sponging 
with vinegar, alcohol, or aromatic spirits of ammonia 70 parts, 
sea-salt solution 20 parts, and eau-de-Cologne 10 parts. 

The skin of the consumptive is also affected as regards the 
power of adjusting the cutaneous vaso-motor system to the 
changes of temperature of the air. Thence comes, apart from the 
affection of the lung, the peculiar liability to catch cold, which 
is a pathognomonic sign, even in quite early stages, and lasts 
throughout the disease, especially in acute cases. The harden- 
ing of the skin by means of baths is therefore very important. 
We must, by means of a careful and lengthy employment of 
baths, bring up the thermal resistance of the whole skin of the 
consumptive to the level of that of the face (Winternitz). 

For the treatment by baths it is necessary that the details 
be adapted to the individual susceptibility of the patient. The 
patient may feel the effects of cold, with bath temperatures only a 
few degrees below the indifferent point. The bath should be 
taken when the patient is warm either naturally or after rest in 
bed, exercise, or a warm breakfast; it should be short and should 
not chill the patient, who should feel braced up and invigorated. 
One a day is generally sufficient. 

A simple form of treatment, that can be applied anywhere, 
is moist friction and partial washing in bed in the early mornings. 
The chest, back and extremities are quickly rubbed down with 
brisk movements of a bath-glove or towel soaked in spirit or 
water, and afterwards dried with a rough towel. One part after 
the other being exposed to the cold water in this method the 
total effect is mild. The patient is te remain in bed for some 
time after the rubbing down. Rubbing down with cold water 
is infinitely to be preferred to lukewarm washing, because after 
the latter there is no comfortable warm feeling, as after the 
former; also a tonic effect on skin, vaso-motor, and circulatory 
functions is hardly to be obtained with tepid water. For 


108 A CLINICAL SYSTEM OF TUBERCULOSIS 


advanced or weakened cases we order a rubbing down with spirit 
after the cold-water friction. 

As the strength increases one can employ more severe moist 
friction of the whole body. The completely naked patient lies 
outside the bed, and is rubbed down by sharp strong movements 
of a damp sheet thrown over his shoulders, either cold water or 
5 per cent. salt water being used. After this the patient is 
enveloped in a dry sheet and well rubbed. The whole process 
lasts one to two minutes. The water at first must be of a tem- 
perature of 75° to 85° F., and can gradually be reduced to 
55° to 65° F. The patient may dress immediately after this, or 
go back to bed for a quarter of an hour. The action of this 
method consists in the contraction of the peripheral vessels by 
the stimulus of the cold water and their subsequent dilatation 
after the rubbing. 

A more marked stimulation may be obtained by hot Sitz 
baths with cold douche on the upper part of the body, increasing 
in force, to be followed by dry rubbing. They must only be 
employed for fairly strong patients, whose powers of reaction 
are still good; they are contra-indicated for anzemic cases. Per- 
spirations, cold feet, headache and sleeplessness may be treated 
by hot or cold foot-baths or foot douches; for this purpose it is 
best to begin with hot water and finish with cold, so producing 
a maximum effect on the vessels. Short cold Sitz baths after 
massage to the body are often of great service against the chronic 
constipation of consumptives. Arm and hand baths will be 
found useful for perspirations, for cold hands, and for feverish 
patients. 

The most energetic form of hydro-therapeutics is the spray, 
jet or needle douche, to be followed by energetic rubbing and a 
walk. It must be decided for each individual case which douche 
to use, whether it lasts for five, ten or fifteen seconds, and 
whether it should be tepid (68° F.) or cold. It must be reserved 
for strong patients in whom prolonged observation has shown 
that the disease is stationary or healing; in winter special caution 
must be taken in ordering the length and temperature of the 
douche. With proper precautions the patient need not be afraid 
of bad effects. A good skin reaction and a subjective sense of 
well-being are signs that it has been well borne. The douche 
should be taken immediately after the night’s rest, or better still, 
after breakfast; in the former case it is better with delicate 
patients, especially women, to give a glass of warm milk before 
the douche, which will assist the skin reaction. 

Lately the hot douche has been employed in the form of a 





PULMONARY TUBERCULOSIS 10Q 


jet of water at 104° to 120° F. directed from three or four yards 
off on to the principal seat of disease. The duration of the 
douche must be short, and the temperature of the water main- 
tained throughout. It is beyond doubt that the hot douche 
removes pains in the chest, deepens the respirations, and loosens 
and diminishes the expectoration; it may therefore be indicated 
for certain cases of desquamative pneumonia, difficult expectora- 
tion, and advanced cases. But it can never take the place of the 
cold douche, which remains for stationary cases the means of 
hardening par excellence. According to our experience the hot 
douches can be dispensed with; not so, however, the cold and 
tepid shower and needle douches. The strong stimulus not only 
to the organ directly attacked, the skin, but also to the muscles 
and their vessels, causes a change in the blood distribution of 
the whole body. Also the contractions of the heart are strength- 
ened, the tissue changes stimulated, and the breathing accelerated 
and deepened. It follows from this that the douche must not 
be used for febrile patients, for those with active disease, and for 
weak, anemic persons. The colder the water, the greater the 
amount of water used, and the higher the pressure the more 
energetic, naturally, will be the skin and general reaction. It 
is not rare for strong and well nourished persons to react too 
much to the douche; it may cause dizziness, great exhaustion, 
and more or less severe headache, sufficiently severe to prevent a 
repetition of the treatment. The headache can generally be pre- 
vented by tying a wet cloth round the forehead before entering 
the douche. . 

Therapeutic measures even more valuable than those just 
mentioned are the regulated chest packs of Winternitz. They 
can be applied by a chest bandage or by several towels joined 
together. 

According to the directions of Winternitz, an 8-in. bandage about 7 or 
8 yards long is dipped in cold water and wrung out. It is carried round 
the chest, passing alternately under one armpit and over the opposite 
shoulder, the rest of the bandage being carried circularly round the lower 
part of the thorax. Over this a dry flannel bandage can be wound. If 
delicate and anaemic patients get chilled it is advisable to rub the skin well 
beforehand with alcohol and water, and also to place layers of waterproof 
stuff between the turns of the bandage, which retains the heat and is 
particularly serviceable for pains in the chest and for promoting the 


absorption of pleuritic inflammatory products. Irritation and eczema of 
the skin sometimes compel frequent removal of the packing. 


The packing is ordered for the night. By those staying in 
bed they may be used also every three hours during the day, or 
in afebrile cases every five to six hours. At every change of 
packing the skin must be dried and rubbed till it glows. 


110 A CLINICAL SYSTEM OF TUBERCULOSIS 


The followers of Winternitz give a physiological explanation 
of the action of the packing on the respiratory organs and whole 
body. In the first place the packing during the night quietens 
the movements of the chest, and therefore also of the diseased 
lungs, and in the second place it acts in a tranquillizing way on 
the whole organism, without having any drawbacks; the dis- 
tressing cough, and the irritation of the air passages will be 
lessened, pains in the chest and side alleviated, and sleep will be 
easier and deeper. As a consequence of the undisturbed sleep, 
quieter cough, and painless breathing there is the desired loosen- 
ing and facilitating of the expectoration of the accumulated secre- 
tion, especially if, after the bandage is removed, the chest and 
back are strongly rubbed with cold water. If it occurs in the 
morning directly after waking the easy expectoration is followed 
by a long salutary rest. The action can be still further increased 
in pleural affections by pouring alcohol on the damp bandages, 
which increases the hypereemia. 

The use of hot chest packs, instead of the cold bandages, 
may be desirable for patients who at the same time are suffering 
from rheumatic pains, and for those who are so anemic or badly 
nourished that they become chilled and not warmed in the cold 
pack. Simply placing damp towels on the chests of recumbent 
patients is not to be recommended, as they are easily displaced 
and may cause chills. Other partial packs may be ordered at 
any time. It is better not to employ general cold packs as they 
may raise the temperature to the point of fever, and increase the 
work of the heart. 

Dietetic The dietetic treatment consists principally 
in providing the consumptive with suitable 
nourishment. Nourishment is of the first 
importance for the progress of the patient on account of its 
direct influence on the condition of the body. Just as the 
loss of weight is one of the first clear evidences of tuberculosis, 
so from a purely empirical standpoint an increase and mainten- 
ance of the weight is distinctly a favourable sign. ‘“‘ As the 
digestive organs are one of the first lines of defence against 
tuberculosis, so also are they one of the most important factors in 
the healing of that disease ’’ (Dettweiler). It has been shown 
both physiologically and clinically that with a raised state of 
nutrition the condition of the blood improves, the blood corpuscles 
increase, the action of the heart is regulated, and the powers of 
resistance of the tissues become and remain greater. As the 
circulating blood possesses more or less powerful protective 
bodies for the lungs, and antitoxic and antibacterial elements 


Treatment. 





PULMONARY TUBERCULOSIS LEX 


which can resist the tubercular infection, so every improvement in 
the general state of nutrition will directly oppose the exciting 
causes of the disease. In this sense the increase of body-weight 
is of value as a sign of the raised resistance of the organism. The 
question of nourishment becomes the keystone of treatment, if 
tuberculosis of the lungs in its constitutional result of malnutrition 
corresponds with starvation of the tissues, as Brehmer and Dett- 
weiler have always emphasized. 

The attempts to influence favourably the tissue changes of 
consumptives have, however, nothing in common with forced 
overfeeding, the inconsiderate stuffing, which for many years 
has passed as almost the only weapon against tuberculosis. We 
know to-day, to mention only a few points, that the introduction 
of large quantities of albumen, especially of animal albumen, not 
only fails to increase the powers of resistance, but may in weakly 
constitutions produce further harm from the excessive work 
thrown on the digestion and from the formation of toxic by- 
products. It is not in accordance with sound therapeutics 
to order a consumptive with flabby heart muscles to drink 
as much milk as is possible, simply because it contains all 
the necessary foodstuffs in a comparatively digestible form; to 
supply the requisite number of calories something like seven or 
eight pints a day would be required. All excess of fluid not 
required by the body produces sensation of fulness and discom- 
fort, and in sensitive patients disturbances of respiration and of 
the heart’s action, without offering any nutritional advantage 
worth mentioning. In fact excessive nourishment of consump- 
tives up to the point of corpulency is no advantage but a dis- 
advantage, because it throws increased work on to the lungs, which 
would be better without it; and in any case the acquired fat is 
very easily lost and does not protect against relapses. Rapid 
and excessive formation of adipose tissue is particularly disad- 
vantageous when there is much diminution of the respiratory lung 
surface, as occurs with marked fibroid or destructive changes in 
the lung; the dyspnoea on exertion is increased, and fatty de- 
generation of the heart favoured. 

Therefore the dietetic treatment of the consumptive must also 
be adapted to individual cases. We must strive to obtain the opti- 
mum and not the maximum nutrition in each case, not to overload 
the body with fat and water, but to increase the capacity for work 
by improving the blood and the muscles; not to increase the 
quantity of the cells but to raise their quality and energy. This 
aim is soonest attained by a suitably varied and prepared diet, 
avoiding excesses either of animal or vegetable food, and paying 
less attention to its caloric value than to avoidance of sameness. 


1G) A CLINICAL SYSTEM OF TUBERCULOSIS 


The mixed diet must contain all categories of foodstuffs, 
albumens, fats, carbohydrates, and salts. As this gives a very 
wide range it is possible to supply the requisite number of 
calories in many different ways. 

The tubercular adult requires, in order to supply a balance 
towards a gain in weight, about 3,500 to 4,000 calories; that is 
100 grm. of albumen supplying 400 calories, 200 grm. of fat 
giving 1,800 calories, and 400 grm. of carbohydrate producing 
1,400 calories, altogether about 3,600 calories. 

According to recent researches the minimum of albumen 
should be 50 grm. a day. But there is not the least ground for 
limiting the consumptive to this amount. On the contrary, 
Rubner maintains even for the healthy ‘‘ that more than the 
margin of safety is necessary.’’ Albuminous foods include meat, 
poultry, game, fish, and eggs; meat and eggs being particularly 
valuable. 

Apart from its caloric value meat claims a large place in the 
menu, as it is richer than any other food in substances stimulating 
the palate, the heart, and the nervous system. But in our esti- 
mation of the value of meat we need not go so far as is done in 
Paris, where there are still to-day special dispensaries for zymo- 
therapy, that is, for the treatment of the tuberculous with the raw 
flesh of such animals as are not subject to tuberculosis. We 
can also do very well without the use of large quantities of fresh 
ox-blood as a food (200 grm. mixed with milk or wine). The 
use of large quantities of meat in any case requires a good diges- 
tive state. Hoppe-Seyler considers its use justifiable in the 
chronic, more fibroid varieties of phthisis. 

Eggs possess a high nutritional value, and can be placed 
before the patient in an agreeable and appetizing form, or may 
be added to other solid or liquid foods. Still the addition of 
half a dozen eggs to a meal already sufficient in itself, as is 
sometimes done, is a gross error, which the doctor must oppose. 
In cases of poor appetite it is advisable to use only the yolks, 
which contain two-thirds of the nourishment; they can be added 
to liquids and soups, or may be beaten up with a little lemon- 
juice, sugar, cognac, or wine. Three, or at most four, eggs may 
be used in cases in which the appetite is very bad. 

Fats play a special part in the nourishment of consumptives, 
especially if there is much wasting. The form in which the 
increased quantity of fat is introduced depends on the habits and 
inclinations of the patient, as well as on the climate and season 
of the year. It is now understood that the cod-liver-oil treatment, 
so popular of former years, is only possible in the winter, and 





PULMONARY TUBERCULOSIS ise 


generally only with children. Adults dislike taking the oil 
regularly, and it often does not suit them in summer. Fat bacon 
and meat, also suet, may be taken by adults in the more northern 
climates. Specially prepared dishes with much fat soon become 
repugnant, especially if the gastric secretion is deficient. The 
quantity of fats may be with more advantage supplied in the 
form of good butter, milk, and cream. 

Butter may be plentifully used in the preparation of meat, 
flour and egg dishes, and in soups; it is also always easily eaten 
with bread. Milk, as an addition to the diet, is rightly much 
valued. If only about half to three-quarters of a pint of milk is 
taken at breakfast, lunch, in the afternoon, and at bed-time there 
is no fear of producing digestive disturbance; always provided 
that it is taken by mouthfuls, and that the milk is above suspicion. 
Boiled milk is better than raw, as it is easier to digest and safer. 
The unpleasant taste that many patients find in boiled milk can 
be removed by the addition of a little salt or lime-water, or in 
exceptional cases, of brandy. Milk can also be taken with an 
equal quantity of mineral water, or with one of the prepared foods, 
or as bread-and-milk. To the well-known preparations kefir and 
koomis has been recently added yoghurt, which may be recom- 
mended as a substitute in cases of aversion to pure boiled milk. 
As cream has three times the caloric value of milk it is sufficient 
to take a quarter of a pint of cream in the day, in order to con- 
siderably increase the nutritive value of a meal without appreci- 
ably increasing its bulk. 

The importance of carbohydrates as an article of diet for 
consumptives lies in the fact that they can be served in a variety 
of ways, and prevent an exclusively, or too preponderatingly, 
albuminous diet. Further, in cases of averison to meat, they 
form with fat, especially butter and eggs, a very valuable food- 
stuff. Peas, beans and lentils may be recommended in the form 
of soup, when, however, they soon induce a feeling of repletion ; 
or better as cooked vegetables with meat. The various forms of 
breads, biscuits, soup thickenings, macaronis, vegetables, and 
puddings may be just mentioned; some of the latter are valuable 
with fruit juice if the action of the bowels is sluggish. Potatoes 
should be served in one form or another with every meat course. 

Vegetables of all sorts are of great value in cases of con- 
sumption, as in the other chronic diseases. Asparagus, spinach, 
cauliflower, and carrots may be specially mentioned, and if the 
digestion is good the various kinds of cabbage. The question of 
the dietetic use cf their mineral contents is not yet thoroughly 
understood, they seem to have no special significance in tubercu- 

8 


I14 A CLINICAL SYSTEM OF TUBERCULOSIS 


losis. A suitable quantity of vegetables supplies that amount of 
indigestible matter needed for the mechanical work of the bowels, 
and prevents them from becoming torpid. 

Salads and fresh or cooked fruits have a similar importance 
for the regulation of the bowels; one or other should never be 
lacking. 

Artificially prepared foods can never replace natural foods. 
They have their place, however, when the intake of food is 
reduced, on account of the more concentrated nourishment they 
contain. The artificial meat preparations can be quite excluded, 
as they act as stimulants rather than foods, and a similar effect 
can be obtained as well, and more cheaply, by home-made beef- 
tea. Trcopon, containing 90 per cent. of easily assimilated 
albumen, is much to be recommended. Amongst ithe casein 
preparations we may mention sanatogen, plasmon, nutrose, and 
eucaine; and of the vegetable albumen preparations, roborat. 
They are considerably cheaper than peptone, which supplies 
albumen in an already prepared form to patients with deficient 
hydrochloric acid secretion; Liebig’s and Kemmerich’s peptone 
may be recommended, also somatose. There is no need of 
artificial preparations containing fat, except cod-liver oil and 
lipanin. The carbohydrate food preparations are very valuable : 
such as prepared oatmeal and groats, malt extracts, bio-malt, 
Mellin’s food, hygiama, guajakose, biocitin, and Riedel’s 
lecithin. v. Noorden has lately recommended riba, a fish 
albumen preparation, which can also be obtained combined with 
malt as riba-malt; our patients would take the latter, but soon 
refused the first on account of its fishy taste and smell, which are 
difficult to disguise. Before prescribing any preparation of this 
kind it is as well to inquire into price. 

On the question of the use of alcohol we follow the middle 
path, and hold it to be not necessary for the consumptive, but 
also not harmful; a general prohibition is not justified. There is 
no compelling reason to make a tubercular patient a_ total 
abstainer. A glass of beer, or a glass of light table wine, should 
be allowed at the principal meals to those who eat better with it, 
for such small quantities of dilute alcohol certainly do no harm; 
they are rather favourable, as they increase the secretion of 
digestive juices. Even Forel recognizes the sense of well-being 
induced by alcohol in certain forms of weakness, and also utilizes 
its narcotic properties for inducing euthanasia; we wish to 
draw the attention of the strongly teetotal physicians to this, 
when they stigmatize the supply of alcohol to feverish and hope- 
less phthisical patients as dram poisoning. On the other hand 


PULMONARY TUBERCULOSIS 115 


alcohol must not be ordered as a tonic either with the meals or 
between them. Tubercular children and young people must not 
have alcohol in any form, even if it seems indicated. Great stress 
must be laid on the dangers of alcoholic excess. 

According to what has been said a good plain fare is 
sufficient for tubercular patients, one meat course being enough 
at the mid-day meal. If patients desire and are accustomed to 
more it may be allowed; nevertheless we should remember that 
there is no advantage in a long menu, in which certain dishes 
are liable to recur with wearying frequency. Certainly more 
variety can be obtained by limiting the number of courses, which 
should be tas‘efully and appetizingly prepared and served; but 
tastiness must not be sought by excess of spices; piquant dishes 
difficult to digest must be limited in number or entirely avoided. 

Careful mastication of the food is important. The patient 
must be allowed time to eat, so that he does not bolt his food. 
A defective set of teeth must be repaired and supplemented; till 
that is done the meals must be reduced. A fixed routine in the 
way of life and regular meal times are to be strictly adhered to. 
For it is just the habit of regularity in pane food that produces 
in most patients a feeling of hunger. ‘To give w ay at all hours 
to the whims and weaknesses of the stomach is bad ’ ’ (Dettweiler). 
The meals must be separated from each other by two or three 
hours, for the stomach requires that time for its work. 

The weight should be taken once a week, at the same hour, 
and in the same clothes. The normal weight, apart from slight 
variations due to sex, age, and calling, in adults should be as 
many kilograms es there are centimetres in the proportional 
height above a metre. 


The proportional height is twice the distance from the crown of the 
head to the middle of the symphysis pubis. If that distance is 85 cm., for 
example, the proportional height is 170 cm., and the normal body weight 
should be 7o kilos. 


The following arrangement of meals, in accord with the 
previous remarks, should be followed :— 

(1) Breakfast at 7.30 to 8 a.m. Weak coffee, tea, or cocoa, 
with plenty of milk (half-pint), or porridge, white bread and 
butter (in badly nourished cases an egg, in cases of constipation 
brown bread, honey, or jam). 

(2) Luncheon at 10 a.m. Half to three-quarters pint milk, 
cocoa, or thick soup, with dry or buttered bread, or an egg. 

(3) Mid-day dinner at 1 p.m. Soup, meat course, potatoes 
and other vegetables, stewed fruit, or salad, a milk pudding (if 
more is required a fish course or a second meat course may be 
added). With this a glass of beer or wine or mineral water. 


116 A CLINICAL SYSTEM OF TUBERCULOSIS 


(4) Tea at 4 p.m. Tea, coffee, or cocoa with plenty of milk 
(half to three-quarters pint), with bread and butter and cake. 

(5) Supper at 7 p.m. Soup, hot or cold meat or eggs, bread 
and butter and cheese; with it a glass of beer or wine, or weak 
tea or mineral water (if more is demanded both hot and cold meat 
may be given, or another course may be added). 

(6) Late supper at 9 p.m. Half-pint of milk, cocoa, or thick 
soup. 


Il. The Specific Treatment. 


The specific treatment includes the means of producing both 
active and passive immunity. While the first method incites the 
organism itself to prepare actively the specific protective bodies, 
in the second method the protective materials are formed in other 
organisms, and are supplied as serums ready made to the tuber- 
cular patient, who therefore has nothing to build up for himself. 
The tuberculins are used to produce active 
immunization. In Germany the most 
important and the most carefully studied 
and tried tuberculin preparations are the three of Robert Koch: 
the old tuberculin, the new tuberculin T.R., and the new bacillary 
emulsion tuberculin B.E.- Of these preparations the new tuber- 
culin T.R. is hardly used to-day owing to its high price and slight 
durability ; also it is by no means indispensable. _ By the side of the 
old tuberculin we have, what is according to Koch the still more 
completely albumose-free preparation, tuberculin A.F.; it is free 
from albumens, peptones, and meat extractive bodies, which the 
old tuberculin contains on account of the gelatine-broth, as it is 
prepared from cultures grown on an albumose-free fluid medium 
(asparagin). Also Koch’s bacillary emulsion, in our opinion 
the best and most effectual of all hitherto known tuberculins, has 
been rendered milder by the addition of a very valuable tubercu- 
losis serum, the new preparation being the sensitized bacillary 
emulsion (S.B.E.), the tuberculosis sero-vaccine of Hdchst. 
Besides these, there are Denys’ tuberculin, Landmann’s tuber-. 
culin, Klebs’s tuberculin, Béraneck’s tuberculin, Carl Spengler’s 
bovine (perlsucht) tuberculin, tuberculinum purum of Gabrilo- 
witsch, the iron tuberculin, and tuberculins prepared after Koch’s. 
method from tubercle bacilli of birds and fish. 

For the production of passive immunization 
there are Maraghano’s serum, Figari’s. 
hemo-antitoxin, Marmorek’s antitubercular 
serum, and various antistreptococcic serums. The preparations. 
for passive immunization have hitherto done so little in the treat- 


Active 
Immunization. 


Passive 
Immunization. 





ef 


PULMONARY TUBERCULOSIS LEAL) 


ment of pulmonary tuberculosis that their value is more than 
doubtful. In any case they come so extraordinarily far behind 
the active immunizing tuberculins in effect and importance, that 
we may pass over them here without detriment to the value of 
this chapter. We would refer our readers to our book on ‘* Tuber- 
culin in Diagnosis and Treatment,’’ which gives a_ detailed 
account of all these preparations. 

The “ passive-active ’’ treatment of tuberculosis by means of 

Carl Spengler’s immunizing body (I.K.) may be also passed 
over, since we have shown by extensive clinical tests that I.K. is 
useless for the treatment of human tuberculosis. Numerous other 
authors have obtained the same negative result. For this reason 
the latest attempts of Frau Fuchs-Wolfring to bring I.K. to the 
fore will never be successful. 
The tuberculin treatment attacks directly 
both the tubercular toxin and the tubercular 
foci in the lungs; and it is in fact these two 
points which require treatment.) Whilst the hygienic and dietetic 
treatment aims only at increasing the natural resistance of the 
affected organism,(the tuberculin treatment develops over and 
above this, by means of the production of artificial immunizing 
substances, an elective action on the morbid tissue,) and produces 
results which are beyond the capacities of the hygienic and 
dietetic treatment alone. 

The tuberculin treatment has not been irrationally added of 
recent years to the natural methods of healing; /the substance 
introduced into the system is not antagonistic to the organism, 
but stimulates it to produce reactive products (antibodies), which 
it is not ab!‘e of itself to form in sufficient quantities. By stimu- 
lating the vital functions to the formation of antibodies the tuber- 
culin treatment imitates the natural process of self-healing, which 
it in fact reinforces. Thus the tuberculin treatment is in no 
way in opposition to the usual constitutional treatment. The 
general treatment of the patient must rather be necessarily joined 
with the tuberculin treatment} the latter being of the greatest 
service when full advantage of the hygienic and dietetic régime 
under medical supervision can be taken at the same time. 

We therefore consider this combination of the two treatments 
to be at present the most efficient means of combating active 
pulmonary tuberculosis. 

When the combination of both methods of treatment is not 
possible, tuberculin by itself must be employed, wherever it can 
be done. More will certainly be achieved with it than with 
any other method of treatment used by itself. 


Tuberculin 
Treatment. 


118 A CLINICAL SYSTEM OF TUBERCULOSIS 


There is no need to enter into the details of the first tuberculin 
era, with its vague and incorrect methods of employing the 
remedy. We need only condemn the idea of producing by 
means of tuberculin ‘‘a generalization of the tuberculosis with 
mobilization of the bacilli,’’ in case that still lingers anywhere. 

Let us turn to the tuberculin therapy of to-day, and the 
present conception of it. It is peculiarly a gentle, gradual 
method, which begins with quite small doses of tuberculin and 
increases them only by very small amounts in the course of 
the treatment, so that strong reactions are avoided. 

The method of avoiding reactions, as far as possible, serves 
for all forms of disease, and for all the tuberculins. It has great 
advantages over the original method of procedure. It is founded 
on the principle of nil nocere in the widest sense; it allows of 
reactions being entirely avoided, and yet of large doses being 
reached; it makes the tuberculin treatment practicable in the 
worst forms of tuberculosis; it does not prevent any other 
approved method of cure being carried out at the same time; 
and it may be carried out as an ambulant treatment without 
hindering the patient performing his occupation. 

The two principal specific results of tuberculin are to raise 
the powers of resistance of the organism to the toxin, and to 
increase the flow of blood through the area of disease. 

By becoming gradually accustomed to the tubercular toxin, 
and ultimately tolerant of it, the system is enabled to neutralize 
the effects of the bacillary poisons absorbed from the foci of 
disease, of which general symptoms such as headache, chest 
pains, loss of appetite, palpitation, faintness, disturbed sleep, 
nervous irritability, loss of appetite, fever or night sweats are 
common examples. 

The second factor is the local hyperemia, whose therapeutic 
value is familiar to us in the method associated with the name 
of Bier. On the one hand it leads to absorption of the inflam- 
matory products round the tubercular foci, and, on the other, it 
favours a process of demarcation, with softening and expulsion 
of the irretrievably affected parts. 

The lung is the one tissue of the body which is capable of 
undergoing cicatricial contraction with obliteration of the area 
of disease, even after extensive necrotic processes, while retaining 


its function as an organ. Moreover, in tuberculosis of the lungs 


there is not much danger of the breaking-down tubercular 
masses causing fresh damage, for the lung has the power in 
the greatest degree of getting rid of the products of destruction 
by means of the natural passages, and of the ordinary method 
of expulsion. 


PULMONARY TUBERCULOSIS 119 


The principles of the modern tuberculin 


Outlin C 
e ; treatment are shortly as follows: As the 
of Tuberculin ee ‘ mh a “of : 
sensitiveness to tuberculin is different in 
Treatment. 


individual cases, the treatment must be 
strictly adapted to the individual. Therefore no universal scheme 
can be given, only a general outline founded on the fact that 
severe reactions can be avoided by small doses. To this end we 
must be guided first of all by the body temperature, the regular 
and exact measurement of which throughout the whole treatment 
is absolutely necessary. Slight reactions may take place, how- 
ever, without fever, and may be recognized by such general 
symptoms as headache, faintness, &c. For this reason all such 
conditions should be carefully inquired for. 

The observations of the body-weight and of the pulse give 
further indications whether we are proceeding rightly with the 
dose. They inform us whether we may carefully proceed to in- 
crease the dose, or must continue longer with the same. In 
some cases a distinct rise of temperature compels us to postpone 
the injection for a few days, until the fever has completely 
subsided, and then to repeat the same dose, or in the case of 
a very severe reaction to begin again with a smaller dose. 

There are thus a whole row of signposts, which should be 
sufficient to keep us in the right path during tuberculin treat- 
ment. It need not be emphasized that a careful and regular 
examination of the lung must form part of the course; and that 
the physical signs are to be regularly noted and compared. 

But in spite of all care and experience, the demand that 
all fever reactions, even the slightest, should be avoided, cannot 
be always fulfilled. This, however, is not immediately attended 
with injury to the patient; on the contrary, a small push forward, 
a so-called ictus immunisatorius, is often given thereby with good 
effect, especially to indolent, torpid cases. There only remains 
to be considered the possibility of the patient being overloaded 
with toxin, which shows itself as super-sensitiveness to the poison. 
In such cases of excessive toxemia and super-sensitiveness the 
repetition of the same, or even of a smaller, dose of tuberculin, 
is apt to cause a greater febrile reaction than the original dose. 
According to results obtained by the use of Wright’s opsonic 
index it is probable that these cases are in the negative phase, 
during which the anti-bacterial power of the blood is diminished. 
Here it is best to introduce a break of eight or even fourteen 
days, and to recommence with a considerably smaller dose, which 
must be very slowly raised with redoubled care. 

We therefore advise the beginner to lay special stress upon 


120 A CLINICAL -SYSTEM OF TUBERCULOSIS 


the avoidance of reactions in the tuberculin treatment, but not 
to be impatient and give up the treatment at once if super- 
sensitiveness should occur. 

As sites of injection the skin between the shoulder-blades 
or in the loin may be chosen, the right and left sides being used 
alternately. We recommend the morning hours as the time for 
injection, not the evening. The intervals between the doses vary, 
apart from the effect of the last injection, with the dose; with 
small doses injections may be given every second day, with larger 
doses twice a week, and with the largest every eight to fourteen 
days. Injections every day are too often. Other methods of 
giving tuberculin, besides subcutaneous injection, are both more 
troublesome and of less value. 

The gradual increase of the dose must in no way be precipi- 
tated in order to attain the highest possible dose or to be finished 
with the cure at a certain time. 

Those doses of tuberculin are always of most use to the 
patient that he can just bear without reaction, and it is not 
nearly so important to climb up to a certain dose of tuberculin as 
to employ only those doses that the patient can deal with. 

Upon this depend the questions as to how long the tuber- 
culin treatment should last, and with what final dose it should 
be brought to an end. Definite instructions cannot be given on 
these points, as the most varied circumstances must be reckoned 
with. It may, however, be generally stated that the patient, as 
soon as he notices the beneficial effect of tuberculin, will wish to 
continue the treatment till he is cured. A normal standard of 
an absolute maximum dose can be ignored, but our efforts must 
still be directed to reaching the greatest dose that the patient can 
deal with. 

In cases where healing is not attained by tuberculin it is 
advisable to give several repeated courses, on the method pro- 
posed by Petruschky. 

What cases of tuberculosis are suitable for 
treatment with tuberculin? The question 
may be answered in different ways, according to the individuality 
of the cases, according to the experience of the doctor, and 
according to the external circumstances. Complications affecting 
other organs, and the state of the constitution, also play a part. 
This much, however, we may state as a guide to practice, that 
every uncomplicated, afebrile case of pulmonary tuberculosis of 
the first and second grades can be treated by means of the 


Indications. 


gradual, reactionless method. . Also that the so-called cachectic 


consumptives, who, in spite of a bad state of general health and 


ake 


PULMONARY TUBERCULOSIS 121 


a delicate appearance, often have only slight physical signs in 
the lungs, respond very well to tuberculin treatment. 
Tuberculin treatment is chiefly contra- 
indicated in severe forms of tuberculosis, 
with high fever and mixed infection, in patients, often of a ruddy 
and plump appearance, who have diffuse mischief in both lungs, 
in very weak individuals, in hemophilics and patients with very 
frequent severe hemorrhages, in severe organic heart disease, 
and in marked cases of diabetes, cirrhosis of the liver, nephritis, 
neurasthenia and epilepsy. Further, those patients are less 
favourable who are prone to inflammation and _ subsequent 
caseation, and those febrile cases following broncho-pneumonia, 
measles or influenza, in which the disease slowly spreads over 
a whole lobe of the lung without fever. In estimating contra- 
indications, the beginner should be more exact and comprehen- 
sive than he who has had considerable practical experience with 
tuberculin. 

The foregoing are generalities characteristic of treatment with 
all the tuberculins. 


Contra-!ndications. 


The consideration of the individual specific 
preparations, their peculiarities, their 
method of. manufacture and their exact 
mode of employment would not be in place here. A common 
agreement of the whole medical profession on the subject of 
specific treatment seems to us to be both possible and of the 
most pressing necessity ; for this we consider that a fundamental 
study of the theory and practice of the specific tuberculin treat- 
ment is absolutely required. We cannot therefore undertake here 
to go into details, or to give a sketch of the employment of any 
special preparation. Whoever takes up tuberculin treatment 
must first master the general details of the use of this valuable 
remedy, and must have the desire and the ability to make him- 
self familiar with the various irregularities which may occur. 
Whoever is not prepared for this useful study would not be 
benefited by a mere sketch of the details of the method, and 
would be rather encouraged in his attitude of refusal than drawn 
in as a fellow-worker. 

From these considerations, for a theoretical study of: the 
question we refer our readers to certain chapters of our book on 
“ Tuberculin in Diagnosis and Treatment,’’ which contains what 
is absolutely necessary, leaving it open, of course, to anyone to 
obtain information elsewhere. We only warn most emphatically 
against starting injections on the instructions of a prospectus in 
favour of some special preparation. Accounts of the tuberculin 


General Remarks 
on Tuberculin. 


122 A CLINICAL SYSTEM OF TUBERCULOSIS 


treatment, according to Dr. X. or Dr. Y., are even dangerous 
on account of their unintentional bias. Without fundamental 
knowledge of the preparation and its peculiarities the doctor who 
uses it in a single case will frequently do harm instead of good. 
This holds good of all therapeutic systems, but specially so for 
the tuberculins, on account of their specific varying actions. The 
melancholy experience of the first introduction of tuberculin is 
not a warning against the use of tuberculin, but an argument in 
favour of its proper and selective employment. What formerly 
was ignorance would to-day be culpable carelessness, culpable 
because it can be avoided. 

The practical study of the specific treatment is nowadays 
possible in sanatoriums, dispensaries and most hospitals. In 
Germany post-graduate courses for the study of the use of tuber- 
culin have been organised. By combining a theoretical study 
of the action of tuberculin with practical experience in the method 
of its use, we shall arrive at that safety which makes the specific 
treatment of pulmonary tuberculosis practicable in its widest 
range and full of possibilities. 


Ili. Surgical Treatment. 


The surgical treatment of pulmonary tuberculosis is chiefly 
adapted for quite early or for far-advanced cases; also for 
moderately severe cases in the commencing stages. 

The direct attack on the affected part of the lung has not 
afforded any good results. Neither attempts to remove apparently 
localized nodules in the lung nor the opening up of tubercular 
cavities have been satisfactory, and both operations are very 
dangerous. 

Of the operations which do not attack the diseased lung 
itself, both division of the first rib cartilage and the paravertebral 
resection of the first rib are intended for cases of early tuber- 
culosis. 

The surgical treatment of early tuberculosis 
is founded on the work of Freund and his 
pupils, and of Hart, on the mechanical disabilities of the apex 
of the lung in phthisical cases. According to these authors an 
abnormal shortness and a separate ossification of the first rib 
cartilage lead to stenosis of the upper aperture of the thorax, 
and this creates, on account of deficient entry of air into the 
apex of the lung, an opportunity for the lodgment of tubercle 
bacilli; and by weakening also the natural resistance of the lung 
tissue favours the development and spread of the disease. 


Chondrotomy. 


PULMONARY TUBERCULOSIS 123 


Chondrotomy of the first rib cartilage is therefore proposed as 
a treatment designed to remove the cause by bringing about a 
widening and mobilization of the upper thoracic aperture. 

The indications for the operation were discussed in detail 
at the Twenty-ninth German Surgical Congress (1910). It was 
agreed that neither the paralytic thorax nor the senile thorax 
were suitable for this operative procedure; and Freund’s type 
of chest only when the tuberculosis of the apex has not advanced 
further than the second rib. Apart from this the indications 
depend on the form of disease. Bronchitis and asthma are not 
contra-indications. Local disturbances of the circulation must 
be, as far as possible, relieved before the operation by medical 
treatment. In suitable cases division of the first rib cartilage 
should not be delayed too long; while on the other hand it should 
not be undertaken if the same results can still be achieved by 
suitable exercises and gymnastics. It is only justified after exact 
clinical observation has been carried out for a long time; it is 
not to be employed as a prophylactic operation. 

The following arguments may be raised against chondrotomy. 
First the diagnosis of this stenosis presents great difficulties; and 
it is not certain how often, and in what degree,* pulmonary 
tuberculosis arises in consequence of stenosis of the upper thoracic 
aperture. By means of careful pathological and anatomical 
examinations it has been shown that in many cases the change 
in the first rib cartilage may occur secondarily, and it must not 
unconditionally be made responsible for the onset of tuberculosis. 
Secondly, it is not proved that chondrotomy induces improved 
respiratory mobility and healing in the portions of the lung 
damaged by stenosis; on the contrary, Tendeloo fears that the 
increased movement might have an injurious effect on the inflamed 
parts of the lung, like massage on tubercular tissue. Chondro- 
tomy, too, only does away with the fixation of the first rib 
without increasing the size of the aperture of the thorax; and 
the mobility of the first rib has no such very important influence 
on apical tuberculosis as Freund assumes. Thirdly, chondrotomy 
is not free from danger owing to the close proximity of large 
veins and the nerve plexus. 

We are not now so powerless against apical tuberculosis as 
to require an opcration, the results of which are at least doubtful, 
both theoretically and practically ; and we feel obliged to deny the 
advantage of chondrotomy for apical tuberculosis as long as the 
indications and results of the operation rest on no surer basis 
than at present. There are, up to the present, only twelve cases 
known of such operation. 


124 A CLINICAL SYSTEM OF TUBERCULOSIS 


Bacmeister’s animal experiments, consist- 


iat seep a ing of an artificial narrowing of the upper 
esection Of the thoracic aperture by wiring the costal 
First Rib. 


cartilages, showed that the greatest pressure 
of the first rib on the lung occurred at the latero-posterior portion. 
Since the relationships of the first rib are quite analogous in the 
animal and human body, from these experiments has _ been 
derived the idea of dividing the narrowed first rib ring in its 
paravertebral part, where it exerts the greatest pressure. Sauer- 
bruch and the Zurich surgical school consider that posterior 
paravertebral resection of the first rib is indicated in apical 
tuberculosis with Freund’s narrowing of the first rib segment. 
But we must deny the utility of this operation also, as it, like 
chondrotomy, only aims at mobilizing the first rib segment. 
But to what extent its fixation is concerned in the production of 
pulmonary tuberculosis, and to what extent operative division 
of this ring favours healing, is doubtful. Hypotheses and 
analogies can furnish no indication for the operative treatment 
of lung tuberculosis in its early stages, which experience has 

shown may be cured by medical means alone. 
Artificial In -severe; essentially unilateral cases of. 
pulmonary tuberculosis surgical treatment 

Pneumol = te indir collapse of the lung by means 
of artificial pneumothorax may be indicated. 

The formation of the pneumothorax may be brought about 
either by Forlanini’s method of simple puncture, or by the 
method of Murphy and Brauer of cutting down on to the surface 
of the pleura. Nitrogen gas is introduced into the pleural cavity 
under the control of a pressure gauge, to the extent of at least 
half a litre at the first sitting. The danger of injury to the 
pulmonary pleura or of producing a fatal air embolism is to be 
avoided. According to our experience this can be better done 
by the method of incision than by Forlanini’s puncture. The 
later introductions of gas, the necessary frequency of which is 
to be decided with the aid of the Rontgen rays, can be done 
with the simple puncture needle; at first at intervals of eight, 
ten to fourteen days, later of three, four to five weeks. The 
duration of time during which the lung must be kept under the 
pressure of the pneumothorax depends on the form of disease; 
on the average it is about one to two years. 

The collapse treatment of the lung by means of a pneumo- 
thorax depends on the tendency to heal by cicatricial contraction. 
It aims at producing a compression and immobilization of the 
lung, and by inducing stasis in the blood-vessels and lym- 
phatics of the collapsed lung to diminish the amount of toxic 





PULMONARY TUBERCULOSIS I25 


absorption, to the benefit of the whole organism. The diminution 
of toxic absorption also acts locally by permitting an increased 
growth of connective tissue, with demarcation of the diseased 
areas. The collapse and immobility of the lung also lessen the 
amount of secretion produced in the diseased areas and the aspira- 
tion of this secretion into other healthy parts. Lastly, full play 
is given to the contractile tendency of a tubercular lung, unhin- 
dered by the restraining influences of the chest wall. 

In fact, the anatomical changes which come about under the 
influence of an artificial pneumothorax consist of enormous con- 
nective tissue formation and contraction, even to obliteration of 
the bronchioles and alveoli, and further in dilatation of the lymph- 
atic spaces with deposition of carbon particles and invasion of the 
epithelium by connective tissue, without the formation of fresh 
centres of disease. This explains the favourable influence on 
the phthisical patient. The diminution or cessation of toxic 
absorption is followed by improvement in the general state of 
health, shown by fall of temperature, increase in the appetite and 
state of nutrition and cessation of the night sweats; while the 
progressive sclerosis of the lung leads to decrease and disappear- 
ance of the sputum and bacilli. . 

Only a few general directions can be given as to the indica- 
tions for the operation, which will be frequently helpful in form- 
ing a decision, but which occasionally lead one astray. The 
establishment of an artificial pneumothorax is necessary, that is 
to say, is to be strongly advised, if the tubercular mischief is 
unilateral, but so severe and widely spread in the affected lung 
that, according to clinical experience, healing without the opera- 
tion is improbable or impossible. Progressive, moderately severe 
cases, which are advancing on one side in spite of all treatment, 
should be subjected to the compression before they reach the 
third stage. Forlanini lays down the rule, which Wellmann 
rightly emphasizes, that it is not the extent, but rather the 
steady progress, of the disease, which gives the indication for 
the operation, and all the more so if there are still considerable 
healthy areas in the lung to be compressed. There are cases, 
examples of which we have seen lately in the Pathological 
Institute at Gottingen, in which, in spite of most severe disease 
on one side, the other is quite sound, even microscopically. 

Artificial pneumothorax is also justified and permissible if, 
with severe disease on one side, there is no active or extensive 
mischief on the other; that is if the other is practically sound, 
apart from slight and inactive changes. To-day great stress need 
not be laid on the one-sidedness of the disease, since Forlanini 
has reported cases in which he has attacked first one side and 


126 A CLINICAL SYSTEM OF TUBERCULOSIS 


then the other in stages, and has effected cure. Other authors 
operate on cases where one side is badly diseased, if not more 
than a third of the other is affected, without marked destruc- 
tive changes. Disease of the upper lobe on the Wiese 
affected side affords a better chance than even slight destructive 
disease of the lower lobe; in the latter case, i.e., severe disease 
of one lung with evidence of breaking down in the opposite 
lower lobe, the indications for the operation are more than 
doubtful. 

Whether artificial pneumothorax is practicable depends on 
the pleura; absence of adhesions makes Brauer’s operation simple ; 
slight, new, or at least not too old, adhesions on the diseased 
side cause no difficulties that cannot be overcome; if their pre- 
sence 1s ascertained by the Rontgen-ray examination they do not 
contra-indicate the attempt. On the other hand, dense 
pleural thickenings make every attempt hopeless, and extensive 
pleural adhesions prevent the formation of a sufficiently large 
pneumothorax. Holmgren has recently recommended, in cases 
of adhesions, as a preparatory measure, that sterile physiological 
salt solution at a temperature of 40° C. should be forced by an 
india-rubber syringe through a needle into the pleural cavity; 
after this the introduction of the nitrogen gas takes place without 
difficulty. Rudiger, Klemperer and others warn emphatically 
against the forcible breaking down of adhesions. We also must 
point out that the preliminary intra-pleural injection of salt 
solution is not without danger, even if it is not also useless. 

As strict contra-indications for the operation, apart from 
extensive adhesions on the side in question, we have (1) con- 
siderable destructive disease on the other side, and (2) severe 
complications in other organs, which does not include slight 
laryngeal disease, or non-tubercular diarrhoea. 

It is necessary for success that a sufficiently large pneumo- 
thorax can be formed. The dangers are remote with proper 
technique. Bad results to the other lung can be avoided by 
proper selection of cases; injurious effects on the heart and 
respiration by proper regulation of the amount of gas introduced. 
If the patient becomes worse, or if undesirable complications 
supervene, the nitrogen gas can be drawn off. A serous pleural 
effusion not infrequently occurs, but it usually runs a short and 
mild course, and does not disturb the continuation of the pneumo- 
thorax treatment. 

There have been numerous reports of favourable results, 
especially by Forlanini, Brauer, Saugmann, L. Spengler, v. 
Muralt, and others. 


PULMONARY TUBERCULOSIS 127 


L. Spengler reports the results of forty cases as: 45 per cent. very good, 
17 per cent. good, 15 per cent. satisfactory, and only 15.5 per cent. unsatis- 
factory, and 7.5 per cent. deaths; and also gives the later results in fifteen 
cases nine months at least after the production of the pneumothorax, in 
whom now neither fever, cough, nor expectoration exist, and who possess 
full capacity for work. Of these fifteen cases, twelve before the operation 
had an absolutely bad prognosis and three an unfavourable one. Of these 
patients five had ages between 11 and 20, five between 22 and 30, four 


between 31 and 35, and one of 43 years; in seven cases the pneumothorax 
was on the right side, in eight cases on the left; in nine cases a complete, 
and in six cases an ultimately almost complete, pneumothorax was obtained. 
As a complication in seven cases an effusion occurred, and in seven the 
pneumothorax remained almost dry, in one case a pre-existing effusion 
became gradually replaced by nitrogen. The time from the first filling to 
the last was in one case only 2 months, once 5, in six cases 73-10. in three 
cases 10-16, and in four cases 18-24 months. The dry pneumothorax re- 
mained after the last filling from 3-4 months on an average, those with 
effusion between 5 and 1o months. The pneumothorax came to an end in 
one case after g months, in six cases after 1-1} years, in seven cases after 
13-23 years, and in one case after 4 years. 


There is thus proof that lasting results may be obtained by 
means of artificial pneumothorax, even in desperate cases. In 
all cases the treatment makes great demands on the patience of 
the invalid and the doctor. It is also necessary that the patient 
should have the advantage of good social and hygienic conditions 
of life for some years, on account of the care that must be taken 
and the drawbacks that may be met. From our own experience 
we may summarize the present standing of the pneumothorax 
treatment by saying that it is only suitable for a comparatively 
small proportion of cases of pulmonary tuberculosis, and that 
the treatment is successful in only a certain percentage of those 
cases, and that of the successful cases there is again only a 
certain percentage of lasting results, as L. Spengler especially 
has noticed. 

But in contrast with chondrotomy and paravertebral rib 
resection in initial cases, it may be emphatically asserted that 
the pneumothorax treatment must be considered for severe cases 
with bad prognosis, that is, for cases which are beyond cure 
by constitutional and specific treatment. 

The pneumothorax treatment must be reserved for patients 
in institutions, and lies within the sphere of the physician, as 
the surgical technique is quite overshadowed by the medical judg- 
ment required in considering the indications. 

This procedure dates back to the publications 
of Quincke (1888) and Carl Spengler (1890). 
While Quincke claimed, that if the presence 
of a tendency to contraction can be proved in cases of destructive 


Extra-pleural 
Thoraco-plasty. 


128 A CLINICAL SYSTEM OF TUBERCULOSIS 


changes in the lung, such tendency to contraction and healing 
would be favoured by mobilizing the chest wall; Carl 
Spengler too recommended ‘‘ thoraco-plasty without opening the 
pleural cavity’’ in the treatment of ‘tubercular cavities with 
rigid walls.’’ The aim of the operation is to put the chest wall 
into such a condition that the diseased lung becomes collapsed 
and motionless. Rib resection, with more or less extensive re- 
moval of bone, is therefore necessary to influence the mechanical 
conditions of the chest wall and the breathing capacity and circu- 
lation of the lungs. Wihuth these objects there are two procedures 
in use: (1) The diminution of the thorax by means of resection 
of ribs as practised by Wilms, and (2) Friedrich’s thoraco-plastic 
pleuro-pneumolysis. 

Wilms recommends, in cases of unilateral disease of the 
upper lobe and in bilateral cavity formation, the removal of 
pieces of rib of 1 to 14 in. long in the neighbourhood of the 
costal angle, and if this posterior resection is not sufficient the 
removal of the rib cartilages with bone forceps. There is thus 
produced a diminution in the size of the upper part of the thorax 
and compression of the tubercular apex, while the breathing in 
the other lung is unaffected. Marked external deformities are 
avoided, and the operation can be done painlessly under local 
anesthesia. The chief necessity for the operation is that the 
tubercular mischief should not be recent, but of chronic fibroid 
or fibro-cavernous nature. The operation is contra-indicated if, 
besides the upper lobe, the lower lobe or other organs are 
affected. The results of cases of apical tuberculosis hitherto 
operated on have been surprisingly successful; increase of bodily 
strength and weight, fall of temperature, markedly rapid and 
steady decrease in the amount of sputum, diminution and cessa- 
tion of the cough; in fact, all the recognized results of lung 
collapse, have been observed. In eight cases Wilms has up to 
now had no deaths. 

From a therapeutic standpoint we consider that Wilms’s 
operation is unnecessary for chronic indurative apical tuber- 
culosis. If one proposes to operate on such forms of tuberculosis 
as are tending to heal it must be because one doubts the possi- 
bility of curing lung tuberculosis without an operation, which 
is not a justifiable position. On the other hand, the operation 
may be considered, on account of its simplicity and relative free- 
dom from danger, for those cavities of the apex which, under 
suitable treatment, show no sign of contracting or drying up, 
and which are prevented from doing so by the state of the chest 
wall. Such cavities, however, seldom oceur; if they do not 


ce 





af 
ne 


PULMONARY TUBERCULOSIS 12g 


improve under suitable treatment they are apt to assume a 
quickly progressive character without fibrosis, and that, accord- 
ing to Wilms, is a contra-indication. We therefore think that 
the conditions for Wilms’s operation are fulfilled in only ex- 
tremely few cases. At the most it can only compete with the 
artificial pneumothorax in cases of concurrence of apical tuber- 
culosis and pleural adhesions. 

The much more extensive operation of total or partial excision 
of the ribs Friedrich considers indicated in cases of ‘‘ fibro- 
cavernous’’ unilateral tuberculosis, of not very acute course, 
with or without fever, which, in spite of exhaustive general and 
climatic treatment, is still progressing unfavourably; so that the 
prospects of cure continually recede. There must, however, be 
a sufficient amount of strength, and the age must not be under 15 
years nor over 45; as below the first age the operation necessitates 
too great interference with the growth of the bony framework, 
and above the second the tissues-of the chest wall and the diseased 
lung no longer have the necessary power of contraction to pro- 
duce a cure by this method. A tendency to contraction and 
adhesion of the pleural surfaces on the diseased side is a specially 
favourable indication. Less severe and older disease in the other 
lung does not contra-indicate the operation, as do recent infiltra- 
tions, and complications in the larynx, bowels, and bones. The 
existence of bacilli is a matter of indifference. It must be 
decided for each case by a careful estimation of the patient’s power 
of resistance and capacity of his heart, the form of disease in the 
lung being also considered, whether the total removal of bone 
from the chest wall or a partial resection of the ribs is to be 
undertaken, and whether the operation is to be completed in one 
or more sittings. It is important to operate as quickly as pos- 
sible; the costal pleura must always be preserved, and also the 
periosteum, which ensures a greater firmness of the chest wall 
later. Too little bone should never be removed; neither should 
two or three ribs be resected every year, as then the lung does not 
contract sufficiently, nor does the patient survive to the final 
operation. The effects of the operation are abatement of the 
fever and sputum, and improvement in the general condition and 
body-weight, and a permanent contraction of the lung and 
obliteration of the cavities. The dangers of the operation are 
great (Syncope, aspiration of septic material into the sound lung, 
&c.). Friedrich, in spite of his great experience of the operation 
and its after-treatment, admits eight deaths in twenty-nine cases, 
and of these six had tubercular metastases in other parts of the 
body; on the other hand he obtained complete capacity for work 


9 


130 A CLINICAL SYSTEM OF TUBERCULOSIS 


in six cases. That is certainly a success considering the unfavour- 
able state of the cases operated on; but the results altogether are 
far from satisfactory. It is certain that Friedrich’s thoraco-plastic 
operation may produce severe deformity of the chest, even on 
patients above 15 years, and that there are frequent troublesome 
after-effects on the heart. It must be performed only by very 
experienced surgeons on carefully selected cases, in which the 
artificial pneumothorax is impossible on account of extensive 
adhesions. 


IV. Drug Treatment. 


The number of drugs recommended for pulmonary tubercu- 
losis reaches to hundreds, and new preparations are constantly 
being added on account of the activity which exists in this branch 
of therapeutics. It is exactly this excessive number of remedies, 
and the rapidity with which each appears and disappears, which 
indicates their very slight efficacy, and calls for caution on the 
part of the doctor. 

[t is not possible to kill the tubercle bacilli by any medicament 
taken internally, or even to weaken them. For those substances 
which kill or weaken the bacilli are, if sufficiently concentrated, 
also poisonous for the tissue cells, and would injure the whole 
organism. An antitoxic effect, that is a power of neutralizing the 
toxins of the tubercle bacilli, has not been demonstrated for any 
chemical substance. 

On the other hand it may be possible for a drug to raise 
directly the resistance of the still healthy lung parenchyma against 
the tubercular virus, perhaps by producing a leucocytosis. But it 
is much more likely that those drugs which have a favourable 
effect act by improving the general condition of the patient, rais- 
ing his appetite and state of nutrition, and thereby producing 
indirectly an increased resistance of the lung tissues. Such possi- 
bilities and probabilities make it impossible to reject on general 
grounds the treatment of pulmonary tuberculosis by drugs; in 
many of the complications of the disease, also, they can hardly be 
dispensed with. On the other hand we must always ask ourselves 
whether the drug in the customary doses is absolutely harmless, 
and whether the advantages of its use counterbalance the dis- 
advantages. If we are guided by these considerations we shall 
make but restricted use of the less tried remedies. 

Creosote has been much prescribed from 
the year 1830 to the present day. Whilst 
the earlier mineral preparation caused 
harmful effects and even poisoning, the 
vegetable variety has proved a gastric and intestinal disinfectant, 


Creosote and 
Guaiacol 
Preparations. 


PULMONARY TUBERCULOSIS West 


very effective for that purpose in the initial stage; it is not uncom- 
mon also to see the sputum diminish with creosote. 

It may be given in the form of drops (creosote 1 part, tincture of 
gentian 2 parts, 8 to 20 drops in water three times a day) or mixed 
with wine according to Penzoldt’s formula (creosote 5i, tr. gent. 
Sil, Spr. vini. rect. 31, sherry wine to 3viii; 3ss t.d.s. in water). 
The most pleasant prescription is that of 1 to 15 minims of creosote 
with cod liver oil or other oil in a gelatine capsule. Creosote pills 
are of no use, as they are mostly passed unchanged in the stools. 
The creosote preparations must never be taken before breakfast, 
or on an empty stomach. They are contra-indicated in gastric 
disturbance, hemoptysis, and kidney disease. The urine must 
be examined from time to time for albumin. Should irritation of 
the kidneys, disturbance of appetite or digestion, or even a strong 
aversion from the unpleasant taste and smell ensue, then creosote 
must be abandoned. 

Guaiacol as a substitute will not as a rule be better tolerated, 
for its principal ingredient is creosote, and it does not taste or 
smell much better. From a considerable number of trials of the 
painting of pure guaiacol on the skin to reduce fever we have 
seen no good results. The subcutaneous, rectal, and intra- 
pulmonary administration of guaiacol seems to have been rightly 
abandoned. The compounds of creosote and guaiacol with 
carbonic acid are much easier to take. |Duotal (carbonate of 
miuaiacol) is Ordered in doses of 3 to 6 gr. t.d.s. in cachets; 
¢creosotal (carbonate of creosote) in doses of 5 to 30 drops t.d.s. 
in milk or wine half an hour after food. Other guaiacol prepara- 
tions are thiocol (5 to 15 gr. t.d.s.) and for children ro per cent. 
solution of thiocol in orange syrup, and sirolin (1 to 3 tea- 
spoonfuls a day). Also eosote (creosote valerianate) and geosote 
{guaiacol valerianate) are recommended; as are pulmoform and 
pneumin, which are produced by the action of formaldehyde on 
guaiacol and creosote. The latter has not, according to the 
exact observations of Hall, very good effects on intestinal and 
pulmonary symptoms. A more favourable opinion can be passed 
on guaiacose, a solution of 8 per cent. guaiacol sulphate of cal- 
cium and fluid somatose, on account of its beneficial effect on the 
appetite, night sweats, sleep, and cough. 

According to Landerer, balsam of Peru pro- 
. : i duces round tubercular foci, a reactive 
Cinnamic Acid, inflammation leading to healing. Later 
Hetol. Landerer extended the use of balsam of 

Peru from surgical to pulmonary cases. The molecules of the 
emulsion of yolk of egg and balsam of Peru were supposed to 
be carried by the blood-stream to the tubercular foci and act 


Balsam of Peru, 


132 A CLINICAL SYSTEM OF TUBERCULOSIS 


there. Still later Landerer recommended in the place of the Peru 
balsam emulsion which is difficult to produce, cinnamic acid in 
the form of its sodium salt, hetol, for intravenous injection in 
dilute solution. Although Landerer does not claim that hetol ts 
a specific against tuberculosis, yet he considers the action of cin- 
namic acid on the tubercular processes as unique in its way, 
resembling in its chemiotactic properties the antitoxins and anti- 
bodies. Animal experiments show that under the leucocytosis 
induced by hetol tubercular nodules in the lung become shut off 
and encapsuled. Unfortunately the results of intravenous injec- 
tions of hetol on human patients neither corresponded with those 
of animal experiments, nor confirmed the very good results which 
Landerer himself obtained. Our own experience has been that 
long continued hetol injections have neither prevented the recru- 
descence or the advance of the disease, nor the formation of new 
foci, in spite of supplementary treatment in an institution. 

According to Landerer’s instructions a 1 per cent., and later 
a5 per cent., aqueous solution of hetol should be used. Before use 
it must be sterilized in a water bath and then injected intraven- 
ously at the bend of the elbow. The treatment is commenced 
with .1 c.c. of 1 per cent. sol. (= 1 mg.), increasing each second 
day by 1-20 to I-10 c.c.; after a dose of 10 mg. is reached the 
5 per cent. sol. is used, of which .1 c.c. = 5 mg. One should not 
go beyond 15 to 20 mg. If a hemorrhage occurs the injections 
should be stopped for at least fourteen days, and should then be 
very slowly increased up to a maximam of 5 mg. For further 
information we refer the reader to Landerer’s article. The 
advocates of the hetol injections are continually pressing the 
claims of the treatment, apparently without result. Blos recom- 
mends the combination of tuberculin and hetol, the latter provides 
the necessary leucocytes for the action of tuberculin. ‘* When 
combined with hetol, Koch’s lymph has become the efficacious 
and harmless agent in the contest against tuberculosis that it 
deserves to be’’ (Blos). 
Arsenic was introduced into  phthisical 
therapeutics by Buchner for the reason 
that it increases the power of resistance of 
the lung tissues. The enthusiastic statement of Kemper, that the 
effects of arsenious acid in improving the general constitution 
equalled that obtained by the most approved and expensive 
methods of cure, was not endorsed by the German Medical Con- 
gress (1884). 

Lately Burow, on the ground of experimental researches, has 
stated that guaiacol arsenate is “‘a real and active anti-tubercular 


Arsenic 
Preparations. 





PULMONARY TUBERCULOSIS 133 


remedy,’’ in which the arsenic acts as a specific against the 
tubercle bacilli, while the guaiacol is a specific against the toxic 
products. of breaking down living matter, the tox-albumins. 
Neither statement is correct according to Nirnberger’s work in 
the Erlanger Pathological Institute; guaiacol and arsenic do not 
prevent the growth of bacilli either separately or combined ; more- 
over, both substances have not the slightest effect on tubercle 
inoculations on rabbits and guinea-pigs. 

If the organic arsenic compounds are used to a certain extent 
in sanatoriums it is to stimulate the blood-forming organs. We 
prefer the subcutaneous injection of sterilized sodium cacodylate 
(.5 c.c. then 1 c.c. of a 10 per cent. aqueous solution two to 
three times a week), or arsacetin (14 to 3 gr. in watery solution 
every two or three days), which is just as effective, and three or 
four times less toxic than atoxyl, or the soluble iron-arseniate. 


Natural arsenical water, as Durkheimer, is very efficacious and 


suitable. Also nucleogen, which contains arsenic, may be used. 
In over 200 cases we have seen no advantage in the arsenical 
bacillary emulsion tuberculin, prepared from human_ tubercle 
bacilli grown on a medium containing arsenic, over the ordinary 
bacillary emulsion tuberculin of Koch. 

lodine is of value when syphilitic or para- 
syphilitic manifestations are associated with 
tuberculosis. It generally exercises. a 
favourable effect on the expectoration, for which purpose accord- 
ing to Kohler iodoglidine (Klopfer) is the best. Not uncom- 
monly, however, potassium and sodium iodide act most unfavour- 
ably on the gastric functions of tubercular patients; and iodism 
frequently interrupts the treatment. JIodoform, though useful in 
surgical tuberculosis, has no good effect in pulmonary cases, 
either when given internally, in pill form, or when injected into 
the parenchyma of the lungs. We have seen no good from 
iodipin either internally, subcutaneously, or intramuscularly ; 
once in spite of strict aseptic precautions an abscess formed in 
the gluteal region. We have no personal experience of the 
iodipin-menthol injections (menthol 10, eucalytol 20, 25 per cent. 
iodipin 50 parts; 1 c.c. daily). 

Recently the radio-active menthol iodide has been energetic- 
ally advertised under the name of dioradin (Dr. A. von Szen- 
deffy). Bernheim, of Paris, states that he has only had ten fail- 
ures in 173 cases of phthisis of the most varied nature treated with 
dioradin injections. The dioradin treatment is given in a series of 
40 injections; in initial cases 1 to 2 series are sufficient to stop 
the spread of the disease, in severe cases 4 to 6 series are neces- 


lodine 
Preparations. 


134 A .CLINICAL SYSTEM OF TUBERCULOSIS 


sary, that is from 40 to 240 injections, and as a packet for six 
injections costs nine shillings, initial cases require £3 to £4 
worth, and severe cases £12 to £18 worth of dioradin. The 
assertions that the combination of iodine, menthol, and radium 
forms ‘*‘ the most potent anti-tubercular reagent imaginable,’’ and 
that ‘‘no other therapeutic means up till now has had such striking 
results,’’ are to be received with caution. The Lancet describes 
the experimental results of Szendeffy and Bernheim as inexact, 
the clinical data as incomplete, and the chemical constitution of 
the remedy as unstable. We should like to underline the last 
objection in reference to the components producing the radium 
emanation, which, moreover, are slight in dioradin. 

Ichthyol in drops, pills, capsules, and mix- 

Other Drugs. tures has been recommended, but has no 
advantage over the creosote and guaiacol preparations. 

In administering camphor we prefer the subcutaneous use of 
oil of camphor* in cases free from fever, and have seen a favour- 
able, but not constant, effect on the heart, pulse, and respiration 
with daily injections of 1 c.c.; it is of no service as a febrifuge. 

Mercury (hydrarg. thymolo-acetate) has no good effect unless 
syphilis is present with the tuberculosis. In such eases we have 
been able to bring about an improvement in the lung condition by 
means of a prudent inunction treatment, but often it was not 
lasting. 

The carbonic acid treatment of Weber and the cantharides 
treatment of Liebreich need not be dragged from their well- 
deserved oblivion. 

The chemical treatment of tuberculosis by means of methyl- 
ene-blue, particularly iodine methylene-blue and certain copper 
compounds, introduced by Finkler, is still in the experimental 
stage. 


V. Inhalation Treatment. 


We are justified in approaching the inhalation treatment very 
sceptically. Without going into the practice of inhalation from 
the times of Hippocrates downwards, we must allow the possi- 
bility of drugs in the form of powder, fluid, or steam being 
drawn into the respiratory organs, and that those in the form of 
gas can penetrate even into the deeper parts of the lung. But we 
know as yet no medicinal substances which can be carried in such 
quantity, and such concentration, to the tubercular deposits, 
as to be able to heal or even arrest them. The cells lining the 


* Camphor 1, olive oil 9 parts. 


PULMONARY TUBERCULOSIS 135 


air passages would be first injured, and a general toxemia set up. 
Tubercular deposits are either cut off from the general air currents 
by the inflammatory swelling of the surrounding structures, or if 
tubercular cavities are open they are unaffected by inhalations 
because they have lost their power of absorption. Also we cannot 
limit the action of inhaled drugs to the diseased areas, but they 
musi also come in contact with the healthy mucous membrane. 
Owing to the sensitiveness of the lining epithelium inhalation of 
only quite dilute and feebly acting substances is permissible; and 
even these may have an irritating instead of a sedative effect, 
and produce much coughing. Inhalation therefore can hardly be 
reckoned as a method of cure of pulmonary tuberculosis. Only in 
rare cases in which the disease is localized in the larger bronchi 
has it a certain justification as an adjuvant treatment. 
On the ground that pulmonary tuberculosis 
is comparatively rare amongst the men 
working in chalk and gypsum works, in 
spite of an excessive inhalation of dust, inhalation of finely 
powdered chalk has been considered to have an immunizing 
effect and has been recommended as a form of treatment. Several 
years ago we made attempts in this direction, making the patients 
beat chalk bags and inhale the dust. The results were absolutely 
discouraging; in nearly every case an increase in the cough and 
expectoration led to the cessation of the treatment. 
: Apparatus of the most varied kinds has 
Inhalation of : ‘ ’ ; 
: been constructed for the inhalation of fluids, 

Biuids. with the intention of spraying cold medi- 
cated solutions by means of compressed air, or warm fluids by 
means of steam. For producing inhalations on a_ large 
scale there are the systems of Wassmuth, Reif, Bulling, Mack, 
Clar, and others; on a smaller scale for hospitals and sanatoriums 
the ideal steam spray of Wassmuth may be used. Without 
entering into a criticism of individual systems, we may say that 
the medicament must be scattered in the finest spray. In spite 
of this it is doubtful if it reaches the alveoli. The likelihood is 
less with nasal than mouth breathing. It is thought that the 
detention of tubercular cases in private and public inhalation 
rooms leads to diminution of the irritating cough and loosening 
of the secretion. 

A cold spray of chloride of iron solution is recommended in 
cases of hemoptysis. We must issue a most emphatic warning 
against all kinds of inhalation in cases of hemorrhage. For 
those phthisical patients who are tormented by obstinate tough 
sputum and continual cough, or who are burdened with much 


Inhalation of 
Powders. 


136 A CLINICAL SYSTEM OF TUBERCULOSIS 


catarrhal secretion from the upper air passages, a warm inhalation 
may be considered. As a simple apparatus for the use of 
individual patients we may mention Siegel’s inhaler, and also 
Jahr’s and Heyer’s apparatus, and Bulling’s thermo-variator. 
We strongly advise that the price should be ascertained before 
ordering any apparatus; in any case Siegel’s is the cheapest. 

For the purpose of loosening phlegm, salt solution or Ems 
water may be used as an inhalation for ten to twenty minutes 
two or three times a day. 

The addition of antiseptics such as carbolic acid, sublimate, 

creosote, guaiacol, boracic acid, formalin, &c., 1s often recom- 
mended, but must in all circumstances be avoided. Solutions of 
morphia and cocaine are also best kept out of the inhalations. 
On the other hand volatile oils such as menthol or eucalyptus may 
be used in cases of decomposition of sputum in cavities, as may 
also turpentine and pine oil for diminishing and deodorizing the 
secretion. 
The volatile oils penetrate still better into 
the lungs as vapours. For this purpose the 
medicament is placed on a mask, such as 
Curschmann’s or Hartmann’s, and inhaled, or is vaporized in 
a bowl over a spirit lamp and inhaled through a funnel. Of the 
forms of apparatus constructed for the purpose we may mention 
Simon’s inhalation flask, and Schreiber’s, Sanger’s, Heryng’s, 
and Rosenberg’s modifications. F. Kraus recommends Spiess’s 
vaporizing apparatus, which by means of a stream of carbonic 
acid gas delivers all the usual medicaments in such a fine spray 
that they are sure to reach the bronchial mucous membrane. We 
prefer Sanger’s apparatus and coryfin (Bayer-Elberfeld) as the 
medicament, and obtain with it immediate relief in acute or sub- 
acute laryngitis and trachitis, that is to say, alleviation of those 
attacks of coughing so prejudicial to the tubercular lungs. 

Inhalations of ligno-sulphite, a combination of volatile oils 
with sulphuric acid, have been recommended. We have noticed 
no favourable results, and enjoin caution, as the ligno-sulphite 
vapours are not without action on the healthy bronchial mucous 
membrane. 


Inhalation of 
Vapours. 


Inhalation of gases has been recommended 
at various times; but for the last few years 
has been given up. Nitrogen, carbonic 
acid gas, sulphuretted hydrogen, prussic acid, chlorine, iodine, 
and bromine inhalations have not realized the hopes with which 
they were introduced. Also inhalations of oxygen and ozone are 
founded on false assumptions, and are not to be recommended ; 
neither is the inhalation of hot air. 


Gaseous 
Inhalations. 


. 





PULMONARY TUBERCULOSIS 137 


Go 


The inhalation of the saline air at salt 
springs loosens the phlegm and allays the 
cough. It contains all the ingredients of good breathable 
air, OXygen 20.7 per cent., nitrogen 78.8 per cent., carbonic acid 
-03 to .04 per cent., water vapour .47 per cent. To this is added 
from the trickling brine small crystals of common salt, and a 
certain quantity of ozone, hydrogen, hydrogen peroxide, and 
other gaseous bodies. It is still an open question whether the 
radio-active substances contained in salt water springs have any 
effect. 

The effect of the air at the salt springs is materially assisted 
by the refreshing coolness produced by the evaporation. This 
produces a stimulation of the respiratory centre, with an increase 
of the respirations, so that the lungs absorb more oxygen and 
give out more carbonic acid, with a beneficial effect on the circu- 
lation and the blood. In this way may be explained the good 
effect of the salt springs on the mucous membranes and the general 
constitution. If, as is intended, the inhalations at the salt springs 
can be combined with an open-air treatment, then a more perman- 
ent effect may be obtained. It may, however, be asserted without 
fear of contradiction that tuberculosis cannot be cured by a short 
course lasting three to four weeks of daily walks to the salt 
springs. 

To sum up, we may say that the inhalation of powders, fluid, 
vaporized or gaseous medications have a subordinate value in 
the treatment of phthisis; and that we must therefore be more 
sparing of their use than hitherto, especially at health resorts. 


Salt Springs. 


VI. The Pneumatic Treatment. 


From what we have said before on the 


Active importance of sparing the lungs, it is only 
Pneumatic natural that we should shudder at the active 
Treatment. 


pneumatic treatment of pulmonary tubercu- 
losis by means of breathing compressed air with a Waldenburg 
or other apparatus. We need not decide here whether it is of 
prophylactic value in cases of phthisical tendency, or whether “‘ it 
is equivalent to a stay in the mountains ’’ (Waldenburg). For us 
there is not the slightest doubt that the maximal respiratory move- 
ments with the apparatus, even if quite correctly used, are fraught 
with danger for the tubercular patient. It is a fact that damage 
to the lung and hemorrhage have been observed. Also there is 
the danger of infecting the healthy parts of the lung by the deep 
breathing; and the fear of the transference of infection is not 
removed by giving each patient a separate mouthpiece. 


1338 A CLINICAL SYSTEM OF TUBERCULOSIS 


We are not much less averse’ to) the 
passive pneumatic treatment, the use of 
compressed air in pneumatic chambers. As 
a prophylactic measure it may be un- 
reservedly recommended, but in cases of pronounced disease it is 
not of curative, but only of symptomatic, value. Because of this 
the indications for its use must be carefully looked for. 

The effects of compressed air are antihypereemic and anti- 
catarrhal; at the same time the breathing becomes slower and 
deeper. For these reasons the use of the pneumatic cabinet 
seems indicated in cases of dry catarrh, accompanied by 
a swollen condition of the mucous membrane; for those forms of 
tuberculosis with a moderately pientiful and tenacious secretion ; 
and for cases with atelectasis of the lung tissue. For the last 
condition, which is often a relic of pleural effusion, the passive 
pneumatic treatment exceeds in its results the methodical breath- 
ing exercises. But great care must be taken in ordering its use; 
above all, attention must be paid to the condition of the lungs. 
Unconditional contra-indications are given by fever, cavities, 
pleural irritation, and hemorrhage, or even a tendency to it. 
The principle of the treatment with Kuhn’s 
mask is the same as that of the pneumatic 
treatment. <A celluloid mouthpiece, firmly 
fixed round the nose and mouth, permits the gradual increase of 
obstruction to inspiration, which must be performed through the 
nose, by means of adjustable ventilation holes, whilst expiration 
through the nose and mouth is unimpeded. By this means the 
pressure of air in the thorax is reduced, and as a further result an 
aspiration of blood into the pulmonary area ensues. The treat- 
ment on this account must not be combined with breathing exer- 
cises, to which, in fact, it is opposed in principle, as the hindrance 
to inspiration diminishes the expansion of the lungs, and puts the 
lungs as far as possible in a state of rest. In this way practically 
the same treatment is applied to the lungs as Bier’s aspiration 
glasses perform for other parts of the body; hyperzemia of the 
lungs is produced with an increased production of lymph. The 
physiological effect is an increase of the pulmonary circulation, 
followed by an augmentation of the blood corpuscles, improve- 
ment of the heart’s action, and deepened respiration. With the 
increased flow of blood and lymph through the lungs a greater 
amount of toxin is carried into the general circulation, so that, 
according to Kuhn, treatment with his mask leads to a process of 
auto-inoculation. 

The first effects on the diseased lung are decrease of the 


Passive 
Pneumatic 
Treatment. 


Treatment 
with Masks. 


q 

‘ 
7 
’ 
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PULMONARY TUBERCULOSIS 139 


cough, sputum, and dyspnoea, which are followed later by 
connective tissue growth round the tubercular nodules. At the 
same time, in consequence of the diminished diaphragmatic 
movement, adhesions of the cicatrizing tissue are prevented, and 
the upper part of the thorax becomes enlarged and mobilized. 
Kuhn recommends the mask particularly for slight and medium 
cases of pulmonary tuberculosis as an aid to the general treat- 
ment. Bad results have not been observed by him. Slight rises 
of temperature of .5° to 1° F. at the commencement of the mask 
treatment disappear spontaneously during the continuation of 
the treatment. 

The theoretical basis of the treatment is in accord with the 
results of animal experiments. Clinical observations show that 
there is an increase in the number of red blood corpuscles, and 
with less regularity of the amount of hemoglobin. Also increase 
of the blood-pressure and of the capacity of the lungs, though 
generally to a smaller and less lasting degree, have been observed. 
Though the symptoms usually diminish on account of the favour- 
able influence on the cough and breathing, a marked improvement 
in the physical signs, the fever and the body-weight are not 
usually obtained. 

Thus the treatment with the mask, although it produces an 
improvement of the symptoms, does not succeed in producing a 
cure. The few cases in which an improvement in the physical 
signs occur during the use of the mask do not seem to us to be 
sufficient to prove the value of the treatment. An objective 
improvement of the disease should occur with fair regularity, but 
this, according to the observations of ourselves and others, has 
certainly not been the case. We limit ourselves in the use of the 
mask to cases with clear indications; it seems to us of value for 
dry cough and for regulating the breathing of difficult or refrac- 
tory patients. 

Bad results, particularly hemorrhage, we have never seen 
from use of the mask. Patients with marked heart weakness and 
those with a tendency to fever are not suitable for the treatment. 
The mask is first applied with the apertures fully opened for half 
an hour three times a day; the duration of the application and the 
amount of obstruction to inspiration are gradually increased. 


VII. Climatic Treatment. 


The climatic treatment of consumption has long been highly 
esteemed by doctors, and still more by the laity. But even to-day 
our knowledge is very defective of the influence on tubercular 


140 A CLINICAL SYSTEM OF TUBERCULOSIS 


cases of climate, air, warmth, sunshine, damp, barometric 
pressure, winds, in short, of all the climatic factors. We do 
not even know if sunshine and good weather have any direct 
influence apart from their effects on the mind of the patient, or 
if rain, fog, or wind are directly injurious. We must therefore 
be still guided by experience. This teaches us that one patient 
may be benefited by a high altitude, another by a stay in the 
desert, a third by treatment at a low level, and a fourth by sea air; 
all of which climates may be unsuitable for other patients. It 
therefore follows that there exists no climate suitable for all cases. 
But if no single climate has specific healing power it shows that 
a patient can be cured in any climate. This does not exclude the 
possibility of one climate having an advantage over another, or 
of certain symptoms of tuberculosis being favourably influenced 
by different climates. The reaction of the consumptive to climatic 
influences must also be considered. These reactions consist of 
alterations of nutrition and assimilation which follow every 
change of place. The alteration may only affect the skin in some 
of the milder climates; others may make demands on every organ 
and system, particularly on the respiratory organs. Therefore 
the indications and contra-indications of the different climates 
must be considered for each individual person. The doctor who 
sends his tubercular patients away for treatment has the difficult 
task of individualizing the case, especially if he orders a stay 
in the mountains. He must be guided by his knowledge of the 
various climates and by the presence or absence of contra- 
indications. It might seem that a very frequent change of 
climate is desirable; but this is not so, because it is impossible 
to foresee the effects of a change of climate and because ‘‘ The 
way in which the treatment is conducted is more important than 
the, place~” (FE: Wolff). 

According to the position and the height above sea-level 
we may distinguish (1) mountainous, (2) low level, and (3) sea 
climates. 


A. Mountain Climates. 


Mountain climates include high altitudes (over 4,500 ft.); 
medium altitudes (2,500 to 4,500 ft.), and moderate altitudes 


{under 2,500 ft.). 
The most important elements in the climate 
High Altitudes. ,, high altitudes are the diminution of the 
atmospheric pressure, the warmth and intensity of the sun heat, 
the great actinic power of the sun-rays, the rapid changes of tem- 
perature, the dryness of the air, freedom from dust and germs, 





PULMONARY TUBERCULOSIS I4l 


in winter marked stillness of the air, intense light and many 
bright and clear days, and finally increased amount of ozone, 
especially in the winter. The effects on the patients are increase 
in the pulse frequency and of the capacity of the lungs, aug- 
mented flow of blood to the skin and lungs, increase in the loss 
of heat and water vapour, improvement of the appetite, alterations 
in the nutrition and a relative increase of the blood-corpuscles 
with slight augmentation of the hamoglobin. 

The mountains also have a high value in increasing the 
powers of resistance of the patient, as they intensify all the 
organic changes. But as the capacity of adjustment of a tuber- 
cular patient is inferior to that of a healthy person he will not 
always be able to stand the effects of the high altitude. There- 
‘fore we must carefully consider the indications and contra- 
indications for treatment in the high mountains, which we, 
following Egger, consider to be as follows :— 

Indications: (1) Prophylactic and hereditary tendency and 
latent tuberculosis; (2) tubercular catarrh of the lung apices; (3) 
tubercular infiltration of the apices; (4) commencing processes 
of breaking down of the lung; cavities with only slight loss of 
substance and without rapidly progressive disease or continued 
fever; (5) non-purulent pleural effusions which show only slight 
tendency to absorption. 

Contra-indications: (1) Rapidly progressive disease; (2) ex- 
tensive mischief in both lungs, even if only of a chronic nature; 
(3) advanced laryngeal mischief; (4) albuminuria or marked 
diabetes; (5) extensive emphysema; (6) heart failure and arterio- 
sclerosis ; (7) alcoholism. 

It may also happen that on trial of the treatment it is found 
that the patient is constitutionally intolerant of the high mountain 
climate, or suffers from obstinate diarrhoea or asthmatic attacks, 
the latter usually in consequence of emphysema or cardiac dilata- 
tion, since true bronchial asthma is, as a rule, very favourably 
influenced by high altitudes. 

The mountains possess no specific power of healing tuber- 
culosis, neither do they confer an absolute immunity. It may 
be said that all the essential factors of the constitutional treat- 
ment, namely, a prolonged stay in pure, dry, open air, in sun- 
shine and in light can be very suitably obtained, of course, for 
the proper patients, by a rest cure in the mountains. On the 
other hand, it may produce cardiac symptoms or acceleration of 
the disease in over-excitable, anaemic or elderly patients, also 
in those with already damaged hearts. 

Whether the mountains have a particular influence on certain 


142 A CLINICAL SYSTEM OF TUBERCULOSIS 


symptoms of pulmonary tuberculosis is not yet decided. From 
the rare occurrence of septic infection in the mountains it appears 
that they have a restraining influence upon mixed infection and 
its consequences. Fever and night sweats may perhaps be more 
quickly removed; hamorrhage is not more frequent, but on the 
other hand more rare than at low levels. It is not yet sufficiently 
proved that there is a more rapid drying up and calcification of 
caseous nodules. The differing opinions upon this may 
be due to the variability of the disease, and perhaps partly to lack 
of experience. One need not be prevented from sending a patient 
with a tendency to hemorrhage to the mountains by a_ false 
analogy between high mountains and very rarefied air, which 
latter may induce hamorrhage even with healthy persons. There 


is also, as Turban rightly remarks, a difference between the’ 


mountain health resorts 4,000 to 6,000 ft. high and balloon 
ascents to an altitude of 15,000 to 20,000 ft. 

The winter is the most advantageous time of the year for 
the mountain treatment, although Davos was first employed as 
a summer resort by Alexander Spengler. But the consumptive 
may remain the whole year in the mountains if the necessary 
precautions are taken during the transition period. The wide- 
spread idea that the spring with the melting snow gives rise to 
acute illnesses Turban has shown to be inaccurate. According 
to his opinion, not only the patients in the disciplined sana- 
toriums, but also those in the hotels, &c., at Davos, suffer much 


less in the spring-time from acute illnesses than the patients in 


the regular spring stations lower down. 


The most important places for the treatment of pulmonary tuberculosis 
are: Davos (Grisons, 5,000 ft.), Clavadel (Grisons, 5,500 ft.), Arosa 
(Grisons, 6,000 ft.), Sils Maria (Upper Engadine, 5,800 ft.), and Leysin 
(Vaud, 4,500 ft.). Summer cure resorts for slight stationary tubercular 
cases are to be found in the Upper and Lower Engadine, in the Bernese 
Oberland and in the South Tyrol. 


; The climate of the medium altitude has 
Medium Altitudes. ine same effect on tubercular patients as 
the Alpine resorts, without being so marked. in its effects. The 
resorts at this altitude produce a hardening of the patient and 
regulate the nervous system, the appetite, and the nutritional 
changes; and as they do not suffer from the same brusque changes 
in temperature as the high mountains they permit a more extended 
employment of the open-air cure. 

With regard to the indications, it need only be said that 
seriously ill, hectic consumptives, and those with severe com- 
plications, cannot be sent to the medium altitudes any more than 
to the high ones. 


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| 
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PULMONARY TUBERCULOSIS 143 


The choice of the time of year for treatment at these altitudes 
is of less importance. It can be carried out in summer and winter 
with equally good results, provided that the place is properly 
adapted for receiving visitors in the winter. 


Among the places of an altitude of 2,500 ft. or more we may name 
St. Blasien, Todtmoos, Triberg, Schweigmatt (in the Black Forest), Oberhof 
in Thuringia; Les Avants (near Montreux), Gossensass (Brenner) Glion and 
Caux (Vaud); Weissenburg (Berne); Beatenberg (Thun), Churwalden 
(Grisons), Heiden (Appenzell), Biirgenstock and Engelberg (Unterwalden) ; 
Oberstdorf (Argovie), Partenkirchen and Kainzenbad, Mittenwald, Bad 
Kreuth, Berchtesgaden, in the Bavarian Mountains. 


The lower mountain resorts make no great 
claims on the organism. Their climato- 
logical merit consists chiefly in the scarcity 
of germs in the air and in their position on a plateau, slope or 
valley. In many of these resorts the propinquity of mountain 
lakes produces a uniformity of the temperature and a certain 
moisture of the air. These lower mountain resorts are of a certain 
importance as intermediate stations between the high mountains 
and the plains. There are a large number of them in almost 
all countries. We will only mention the most important :— 


Moderate 
Altitudes. 


Suitable for the autumn are Gries and Bozen, Meran and Obermais 
(Tyrol), Vahrn (Brixen), Montreux and Vevey. There are many summer 
cure resorts on the Lakes of Lucerne, Thun and Brienz (Switzerland), 
Constance and other lakes of Bavaria and Austria, in the Black Forest, 
the Taunus and Harz Mountains; such places are Interlaken, Ischl, 
Reichenhall, Badenweiler, Bad Liebenzell, Tabarz, Salzungen. Most of 
these places are for summer cure only, the season lasting from May to 
October. 


B. Climates at a Low Altitude. 


Of the climates at a low altitude we may distinguish places 
in the temperate zone, the Italian lakes, the deserts, and the 
sea-coast. 

The lower levels of the temperate zone have 
no characteristic climatic influence, as the 
places vary greatly; sometimes the climate 
is of the continental type, sometimes the influence of the sea 
predominates. As regards warmth and moisture the climate of 
the German plains is ‘‘ cool and moderately damp.’’ Extremes 
do not exist, being modified by the neighbourhood of hiils, 
forests, or the sea. The forests especially affect the tempera- 
ture, moisture and light, and differentiate the climate from that 
of the bare plains. They also shelter from the wind, and are 
associated with that fresh, pure, dust-free air, so necessary for the 
consumptive. Wherever these conditions prevail, where the soil 


The Temperate 
Zone. 


144 A CLINICAL SYSTEM OF TUBERCULOSIS 


and water supply is good, and where the proper constitutional 
measures, especially rest in the open air, can be thoroughly 
carried out, there are all the conditions necessary for the cure 
of tuberculosis. This is shown by the success of the German 
sanatoriums in hilly, wooded, sunny positions, sheltered from 
the wind, and with pure ozone-containing air; on this subject 
we need say no more. 
‘ The low-level climate of the lakes in 
The Italian . pen 
Northern Italy and the adjoining part of 
Lakes. Switzerland is moist and warm. The great 
expanse of lakes, certainly in winter, makes the air warmer, and 
at the changes of seasons tends to maintain a fairly even warm 
temperature. The best times to visit these agreeable resorts are 
spring, autumn, and winter; summer, in spite of the cooling 
effects of the lakes, is much too warm. There are no special 
indications or contra-indications. Slightly febrile patients with 
fairly advanced disease often do better here than in the high 
mountains. 

As spring, autumn, and winter stations, may be mentioned Gardone- 
Riviera and Fasano (Lake Garda), Areo (one mile from Lake Garda, in 
winter only), Lugano (Lake of Lugano), Pallanza and Locarno (Lake 
Maggiore), Cadenabbia (Lake Como), Weggis and Vitznau (Lake of 
Lucerne). 


The climate of the desert, which is generally 
only suited for consumptives in the winter, 
is warm and dry. The most important are the health resorts 
of Egypt, the Soudan, and the Biskra oasis in Algiers. Their 
chief merits are copious sunshine and aseptic air rich in ozone; 
their disadvantages are great variation of temperature, violent 
dry winds and severe dust storms. The dry air is an advantage 
for patients with profuse secretion and a propensity to bronchial 
catarrh, also for kidney. complications; on the other hand, these 
places are not suitable for patients with dry catarrh of the upper 
air passages or tuberculosis of the larynx. Plehn_ originally 
recommended the climate of Egypt especially for persons who 
had contracted tuberculosis in the tropics, and that indication 
still holds good. Weak powers of resistance, advanced tuber- 
culosis, fever and heart affections are contra-indications. In 
recommending such a climate the long, fatiguing and costly 
journey must be considered, and arrangements must be made 
for suitable medical supervision of the patient. 


Desert Climates. 


As winter health resorts of this class we may mention Helouan (eleven 
miles from Cairo), Luxor, Assouan, and Mena House (at the pyramids), all 
in Egypt. 


{ 
{ 
‘ 
















PULMONARY TUBERCULOSIS 145 


Island and seaside resorts, with a warm, 
dry climate, and only moderate or slight 
moisture, are suitable for the winter, and 
are sedative in their action. To them may be sent patients with 
excessive catarrh of the mucous membranes, for whom the moun- 
tains are contra-indicated. On account of the dangerous dis- 
tractions that are often to be found, great caution should be 
used in selecting these places; we need only mention the gaming- 
tables of Monte Carlo, and the fast life of Nice. Also on the 
Riviera, the hygienic conditions are often defective, the dust from 
the great automobile traffic is intolerable, the air is frequently too 
dry in spite of the propinquity of the sea, and there is often 
insufficient protection against the cold of February and March; 
Dut in spite of these drawbacks it maintains its popularity. 


Dry Coast 
Climates. 


Representative examples of their climate are Corunna, Santander, San 
Sebastian, Biarritz, Arcachon, Ajaccio, Capri, Palermo, Corfu, Abazzia; 
on the Riviera di Levante, Rapallo, St. Margherita, Nervi; and on the 
Riviera di Ponenti, Cannes, Nice, Mentone, and Hyéres, in France; and 
Ospedaletti, Bordighera, San Remo, in Italy. 


C.—Sea Climates. 


Maritime climates are noted above all for the uniformity of 
the temperature, and pureness and saltness of the air; to which 
may be added high atmospheric pressure and strong atmospheric 
currents. On strong patients they produce a stimulation of the 
nutritional changes, a retardation of the pulse, and quietening of 
the nervous system; while with weak patients loss of appetite, 
diarrhoea, sleeplessness and hemorrhages are not uncommon. 
But the most important effect of the sea climate is that the 
respiratory quotient falls. 

According to the temperature and relative dryness of the 
air we may distinguish the cool, moist climate of the North Sea, 
the milder, warmer, sea-coast climates, and the real ocean climate. 
: For treatment by the climate of the North 
Climate of the : 4 

Sea patients must be carefully selected. 

North Sea. Besides altering the gaseous exchanges, 
this climate has a marked effect on the circulatory organs, which 
shows itself regularly by increase of the blood-pressure, a slowing 
of the pulse, and diminution of the albuminous contents, the last 
in consequence of increased muscular work while taking the sea- 
baths. We consider the North Sea climate specially suitable for 
prophylactic treatment and also for persons suffering from tuber- 
culosis of the bronchial glands or initial pulmonary tuberculosis 
without fever or hemorrhages. It may further be used for cases 

10 


146 A CLINICAL SYSTEM OF TUBERCULOSIS 


of chronic stationary phthisis, for early laryngeal tuberculosis, 
and for cases complicated by non-tubercular chronic catarrh of 
the upper air passages and bronchial tubes. Healthy digestive 
organs are essential. 

Unsuitable are (1) very excitable patients; (2) febrile cases; 

(3) cases of caseous pneumonia, cavities, profuse secretion and 
haemorrhages ; (4) advanced laryngeal tuberculosis ; (5) cases with 
tuberculosis of other organs, intestine, kidney, &c.; (6) cases 
complicated by marked cardiac, gastro-intestinal or nutritional 
changes, and markedly neurotic patients. The North Sea resorts 
have their greatest importance for the treatment of scrofula and 
surgical tuberculosis of children. 
Coming under the influence of the Gulf 
Stream the resorts on the south and west 
coasts of England and Ireland are warmer 
and milder than those on the North Sea, 
and therefore are more suitable for cases with severe catarrh of 
the upper air passages. As examples we may mention Ventnor, 
in the Isle of Wight, Bournemouth and Torquay. 

Still less stimulating and more sedative are the warm mari- 
time climates of more southern islands. Types of these are 
Funchal, in Madeira, and Orotava, in Teneriffe. 

The real ocean climate can be made use of 
by means of sea voyages. Although known 
in Pliny’s time, it is not yet agreed whether sea voyages should 
be ordered for consumptives, in spite of the undoubted advan- 
tages of pure air free from dust and bacteria, continual atmos- 
pheric movement, comparative rest, and ample sojourn in the open 
air. It is agreed that they have a remarkably stimulating effect 
in cases of bodily weakness and psychical disturbance. The 
changes of scene and climate divert the mind, raise the appetite 
and accelerate tissue changes. The skin, lungs, and all organs 
which react to changes to temperature are exercised and hardened. 
Also the large amount of moisture, salt and ozone in the ocean 
air is advantageous for some cases of tuberculosis. On the other 
hand, there are drawbacks, such as scarcity of space in the cabins, 
monotonous nourishment, and fear of prolonged sea-sickness. 
In long sea voyages, involving changes of climate, too sudden 
changes of temperature and excessive air currents are also to 
be feared. Moreover, the social conditions under which the 
passengers must live and the absence of expert treatment and 
medical discipline are disadvantageous. The question of the 
construction of ship sanatoriums has been discussed in different 
countries, but has had no practical result, in spite of the recom- 


Milder and 
Warmer 
Sea Climates. 


Sea Voyages. 






PULMONARY TUBERCULOSIS 147 


mendation of medica! authorities and the attempts of powerful 
marine companies. Although the idea of floating sanatoriums 
under medical supervision has much that is good, there are too 
great difficulties against its practical undertaking. Also from a 
medical standpoint, this kind of thalasso-therapy for tuberculosis 
can only be recommended within very narrow limits; the patients 
must be very carefully chosen and those with a strong disinclina- 
tion against sea voyages must in no case be over-persuaded. 
They are only suitable for strong patients free from fever, hamor- 
thages or complications, and with sound nervous and digestive 
systems. For consumptive doctors, the popular proceeding of 
taking a post as ship’s surgeon is always rather hazardous; if 
the doctor is capable of work he will do better to take a post 
as assistant in one of the many land sanatoriums. 

In the choice of the sea route one must have regard to the 
wishes of the patient as much as possible: in spring and winter 
the voyage is generally rougher, in winter also the changes of 
climate seem more brusque than in spring and summer. It is 
worthy of notice that ocean currents and the propinquity of the 
land influence the temperature of the air, and give the sea voyage 
a cool or hot character. Voyages interrupted by frequent and 
long land visits are not at all suitable for consumptives, they 
only allow an opportunity of contracting malaria or other in- 
fections. 

Mediterranean voyages are suitable for the winter, and for 
the summer trips up the Norwegian coast to the North Cape, or 
longer voyages to Australia, New Zealand, West Indies, North 
America, &c. 

The question may arise of making use of 
the Colonies and the Tropics. It may be 
known that some years ago, under the 
influence of a well-known physician, a movement was started to 
build sanatoriums in South-West Africa, and to send _ there 
German tubercular working-men at the cost of the National In- 
surance Companies. After the cure they were either to be 
brought back home or to remain in the Colony. The plan fell 
through and the committee dissolved, so we have nothing further 
to expect from either. It is the experience of the Cape Colony 
that the tubercular patients were regarded uneasily by the 
natives; it appeared that for one white tubercular patient who 
died there were six deaths among the native population, in spite 
of the very favourable climate. This was due to the small power 
of resistance to the new disease and to the bad hygienic condi-. 
tions, crowding together, indiscriminate spitting, drinking, &c.. 


Colonies and 
Tropics. 


148 A CLINICAL SYSTEM OF TUBERCULOSIS 


The conditions in Cape Colony are a warning against sending 
tubercular lung cases to German South-west Africa. Kuhn says 
that ‘‘ the Colony has nothing to fear for the health of its in- 
habitants, for the greatest prudence reigns among the tubercular 
immigrants’’; but the greatest prudence in this case is the 
keeping away of all tubercular persons. Similar conditions pre- 
vail in the other German colonies. We have every good reason 
to keep and treat our tubercular patients at home, both in the 
interests of the patients themselves, and for the political, 
economical and hygienic advantage of the colonists. We want 
healthy colonials, physically strong and energetic, but not early 
phthisical cases or persons sent out as a prophylactic measure. 


VIII. Watering Places. 


The treatment at watering-places is a combination of the 
climatic treatment with the medicinal effects of the waters. 
But the climate at these watering-places is often very unsuitable, 
either because these resorts are generally situated at a low 
altitude and are neither bracing nor sedative, or because they 
have usually developed into towns, which with their industries 
have vitiated the purity of the air. The medical treatment is 
limited to the prescription of the waters of the place, either 
internally or externally in the form of baths; or, in addition, 
whey, kéfir or grapes may be ordered. 

; Used as baths mineral water has no special 

Mineral Springs. effect on the consumptive, at any rate, no 
more than the ordinary warm baths. 

The value of the internal use of the natural mineral waters 
in the treatment of consumption is also very doubtful. Some 
lay great stress on the efficacy of drinking the waters, others 
believe that they are of no more value than an equal amount 
of tea or warm water. According to our own observations at 
one of the springs most frequented by tubercular cases, the use 
of the waters is no specific remedy against the disease. It is 
not established that the treatment with mineral waters, without 
the use of other methods simultaneously, has any healing effect. 
The fact that in healed tubercular nodules lime salts are deposited 
does not warrant the assumption that taking water containing 
lime is to be recommended, since the ordinary nourishment 
supplies enough lime salts for that purpose. On the other hand, 
one may concede the fact, that the mineral waters used for cases 
of tuberculosis may, from their composition and temperature, 





. 
c 
4 
q 


PULMONARY TUBERCULOSIS 149 


have some local or general action on the affected organism; to 
explain this the general chemical laws of osmosis and diffusion 
are sufficient, without invoking the radio-activity of the water. 

The mineral waters affect the chemical changes of the blood 
by altering the osmotic pressure of the tissue fluids, from the 
regular ingestion of considerable quantities of salts in solution. 
By this means the results of the tissue changes are more easily 
eliminated, partly by absorption, and the destruction of diseased 
cells with the formation of new ones with increased resistance 
is hastened. 

It may therefore be urged that the treatment with mineral 
waters is capable of regulating the digestion, of increasing the 
action of the kidneys and mucous membranes, and of accelerating 
tissue changes; and that it may be legitimately employed as an 
aid to the general constitutional treatment. 

Thus it is not correct to deny that the mineral waters have 
any influence whatever in combating pulmonary tuberculosis; 
but it is still more incorrect to assert that they are of essential 
importance, and that they can replace the general hygienic treat- 
ment. We agree with the opinion of Penzoldt that the treatment 
of tuberculosis by mineral waters, when accompanied by other 
general treatment, is admissible, but that it 1s also wnnecessary. 
But we see that there is no small danger in its use if doctors 
and patients, in blind confidence in the mineral water treatment, 
“neglect the important for the unimportant,’’ that is to say, 
allow a course of waters and baths lasting four to six weeks to 
replace a strict and regular hygienic treatment. 

We need not consider the individual springs and baths. It 
is sufficient to say that those resorts will be of most service where 
drinking the water can be combined with properly regulated 
constitutional treatment, always provided that the duration of the 
treatment is not too short. For it is one of the claims of those 
interested in the mineral water treatment that this method gives 
quicker, and therefore better, results than any other. 

As regards the indications for this treatment, we take the 
standpoint that persons should not be sent for reasons of pro- 
phylaxis to any resort for consumptives, on account of the possi- 
bility of infection. The recommendation of a suitable watering- 
place may come into question for cases of closed tuberculosis. 
who are suffering from non-tubercular chronic diffuse catarrh, 
or changes in the lower lobes of the lungs. The cases of open 
tuberculosis that are most suitable are those patients without 
fever, who have already been disciplined by a proper hygienic 
treatment, and who will no longer suffer institutional treatment, 


4 
“ 
‘ 
4 


150 A CLINICAL SYSTEM OF TUBERCULOSIS 



























or who have some special complication, which may be relieved 
by the use of the waters. 

Where Kerr and ERIE ES Ee prepated pe fresh 

goat’s, cow’s, or sheep’s milk by removing 

Grape Treatment. the casein and fat by the addition of rennet. 
Its nutritional value is small, and its therapeutic worth nil, 
even a minus quantity, since the whey may produce slight catarrh 
of the bowels. The resorts for treatment with whey are not fit 
places for tubercular patients. 

Keéfir, that is to say, cow-milk that is undergoing alcoholic 
fermentation from the action of the kéfir ferment, may be a 
useful aid to nutrition in cases of repugnance against ordinary 
milk, or when pure milk is not obtainable. It may be also used 
to regulate the bowels, since fresh kéfir is a laxative, while that 
three days old is constipating. It has no value as a curative 
agent. Kéfir can be prepared anywhere by the help of an arti- 
ficial ferment; we recommend the kéfir tablets for private cases. 
There is no need of a kéfir cure resort. 

The grape cure can be taken on the Rhine, in Alsace, on 
the Lake of Geneva, or in Silesia, Austria and Italy, during the 
months of September and October. One to four pounds of 
grapes must be taken daily, without skin or pips. The treatment 
may increase the appetite and power of assimilation, but it also 
causes loosening of the teeth, sore mouth, and gastric and_in- 
testinal disturbance. The grape cure and grape-cure resorts may 
be very well left on one side . 


IX. Symptomatic Treatment. 


Of all symptoms, fever is the most fre- 
quent and the most serious; it is also the 
reost difficult to fight. 

Like other persons, a consumptive may suffer from fever, 
which has no connection with tuberculosis of the lungs. Acute 
tonsillitis, appendicitis, acute intestinal affections, rheumatism 
and influenza may be mentioned; in the treatment of which the 
condition of the ling must be taken into account. 

More often\fever is due to a catarrhal infection of the upper 
air passages, bronchial tubes or alveoli; that is, (the fever is due 
to changes in the lungs, but not to the tubercular mischief) In 
these cases great care is necessary | Jest the mixed bacterial infec- 
tion should open up fresh pathways ‘for tuberculosis, and give - 
rise to fresh tubercular foci. Every such case should have rest — 
in bed on a fever diet. A radiant heat bath, and several doses 


Fever. 


PULMONARY TUBERCULOSIS 5 


of calomel (3 gr. every two hours) to produce diuresis and empty 
the bowels, will generally shorten the fever. 

The rises of temperature which precede or accompany 
menstruation in tubercular women have a definite pathognomonic 
importance; as have also the sudden rises of temperature asso- 
ciated with severe physical or mental exertion; they are known 
as menstrual, exercise or psychological fevers. The treatment 
consists in quieting the over-excitable nervous patient, and 
ordering bodily and mental rest. Preparations of valerian are 
harmful.) 

A few words may be said on the diagnosis and measurement 
of tubercular fever. The temperature curve must be based on 
measurements taken every two to three hours. If it rises to 
eo-2° Fin the mouth, or to 99.6° F. in the réctum, there is 
fever, or, taking individual differences and possible sources of 
error into consideration, at least suspicion of fever. We con- 
sider that three hourly measurements at 8 and 11 a.m. and 2, 5 and 
8 p.m., taken in the mouth, are sufficient. Useful infor- 
mation as to the temperature after eating is thus obtained. It 
may be further noted that a temperature of 99.2° F. in the morn- 
ing is fever; and that a temperature that never falls below 
98.69 F., and one which varies more than two whole degrees 
between the minimum and maximum, is not normal. 

(in patients who are nervous and excited about their tem- 


‘perature, it should be taken by a nurse with a non-registering 


thermometer in the rectum. Very feverish patients should never 
take their own temperature. 

(A knowledge of the biological significance of fever is 
important for its treatment. According to our latest knowledge 
the rise of temperature, which accompanies infectious diseases, 1s 
to be considered as a reaction against the cause of the illness, 
and as an aid to the organism for more quickly and powerfully 
freeing itself from the infection. Certainly fever influences 
favourably the vital functions of the leucocytes, and the formation 
of agglutinin, of hemo- and _ bacterio- lysins and of antitoxin} 
From this may be learnt the lesson that( in tubercular fevers tt 
is not wise to interfere with the immunizing leucocytosis and 
formation of antibodies by a “‘ routine attack on the raised tem- 
perature at any cost, the one and only indication being the 
height of the fever”? (Richter).) 

It must, on the other hand, be noted that/ pulmonary tuber- 
culosis being a chronic disease, even low fever tempera- 
tures, on account of their duration, have bad effects on the 
central nervous system, the respiratory and circulatory centres, 


152 A CLINICAL SYSTEM OF TUBERCULOSIS 


































the digestive apparatus, the kidneys, &c. High and hectic tem- 
peratures are even more injurious. Herein lies the indi- 
cation for the treatment of tubercular fevers. As it is not 
the rise of temperature that must be obviated, but rather its 
injurious results and consequences, there should be no heroic 
treatment of tubercular fever, with drastic drugs or external 
applications. 

Tubercular fever is maintained at the cost of the tissues of 
the body, and the accompanying loss of appetite prevents this 
loss being made good. Therefore it is most important to limit 
as far as possible all forms of tissue destruction; and _ the 
sovereign way of doing this is rest in bed. The supposition that 
this weakens the body is erroneous. The weakness is not a con- 
sequence of the rest in bed, but of the illness which compels it. 
Bed must be kept till the feverishness has gone; every consider- 
able movement, every premature getting up, postpones that date. 
Open-air cure can be carried out at the same time by wheeling 
the bed on to a balcony, or up to the window, kept widely open 
day and night. When the temperature has been quite normal 
for two to three days rising may be permitted, but at first only 
for one hour; if the temperature remains normal it may be 
extended to two to three hours. Still no walks are to be taken; 
the effort of dressing and undressing, and walking to the re- 
clining chair and back, is sufficient. If the temperature rises in 
the afternoon, even one-tenth degree above normal, the fever has 
not gone, and the strictest rest in bed is again necessarv. if 
may be required for weeks and months, but the strictest rest leads 
to the desired goal most surely. Only under certain conditions 
may these rules be relaxed—e.g., in hopeless cases, in patients 
whose surroundings are so unhygienic that rest in bed entails 
bad air, or in chronic fever and cavity cases, in which the long 
rest is depressing the appetite and spirits, and hindering the 
expectoration. 

The food of feverish patients should be ample, but easily 
digestible. Fever diet should not be a hunger diet; on the 
contrary, by frequent additions to the diet, and by skilful cook- 
ing, one should try to supply the requisite number of calories. 
This is not easy when the appetite is bad. Stomachics, con- 
durango, pepsin in mixture with hydrochloric acid and tablets, 
orexinum tannicum (4 gr. in powder or tablets, three times a day), 
and tonic wines, containing relatively little alcohol and much— 
meat extract, may be useful. As a beverage, milk, with or with- 
out cream, and kéfir are to be preferred. 

Alcohol is often of the greatest service. A glass of wine 


om 


PULMONARY TUBERCULOSIS ESS 


may be given at meal-times, especially at the beginning of the 
fever. A glass of hot grog or mulled wine an hour before the 
usual shivering is very useful in hectic fever; at the same time 
an ice-bag should be applied to the heart, and the patient well 
wrapped up. 

Of hydro-therapeutic measures, there are chest packs, friction 
of the skin with alcohol or damp towels, and prolonged bathing 
of the hands and arms with water not tco cold. These measures, 
besides helping to lower the temperature, will stimulate the 
organic functions. 

_ Antipyretic drugs must be very carefully ordered, lest they 
do more harm than the fever. They are only indicated if the 
subjective symptoms are severe, or the fever prolonged, other- 
wise it is better not to interfere with the defensive mechanism. 
It is best, as far as possible, to give the drug before the rise of 
temperature. At the height of the fever it must only exceptionally 
be ordered, and then only in small doses, so as to avoid producing 
profuse sweating and collapse. For the same reason antipyretics 
should never be given with a falling temperature. 

We only give a small list of the many recognized anti- 
Ppyretics. Quinine has been generally given up.- Salicylates 
have, by the addition of arsenic, been brought back to favour 
meidtesdisen..~ or., sod. salicyl. 150 gr:, ft. pil. 100, two to 
be taken three or four times a day). These pills cause a slow 
fall of temperature without after-effects, but sometimes they pro- 
duce noises in the head, and indigestion. 

More frequently used are aspirin (4 to 7 gr.), antifebrin (3 to 
4 gr.), antipyrin (7 to 15 gr.), lactophenin (7 to 15 gr.), and 
citrophen (7 to 15 gr.). 

We give the preference to phenacetin (4 to 8 gr.), salipyrin 
(15 gr.), and especially pyramidon. Salipyrin is particularly 
useful in febrile disturbances associated with menstruation, and 
in sleeplessness due to evening or nocturnal rises of temperature. 
Phenacetin acts promptly and well, and is without after-effects ; 
lt is specially serviceable if there is headache at the same time. 

Pyramidon is the antipyretic par excellence. It requires 
about two hours for its action, which takes place imperceptibly 
and gradually, and without unfavourable effects on the heart. 
In continued fever one can give repeated doses of a tablespoonful 
of 1 in 100 pyramidon solution in water. In cases of irregular 
fever 2 to 3 gr. of pyramidon may be dissolved in a glass of 
water and drunk in mouthfuls extending over half an hour, com- 
mencing about two hours before the rise is expected. If the 
fever is causing loss of appetite it is recommended to give this 


154 A. CLINICAL SYSTEM OF TUBERCULOSIS 


































drug two hours before the chief meal. Sometimes after a long 
course of pyramidon the fever does not return, sometimes it 
returns again when the drug is intermitted; if the fever is quite 
uninfluenced the prognosis is very bad. 

About maretin and phthisopyrin tablets there are both good 
and bad reports; W. Heubner expressly warns against the former, 
-which, according to his observations, is a strong blood poison. 

The chief point in the treatment of fever by drugs, no matter 
which is employed, is that small doses must be given at the 
right time to prevent the rise. But the patient whose temperature — 
is artificially kept down by drugs is by no means to be con- 
sidered as free from fever. 

Recently reports have multiplied of the good effects of treat- 
ing the cause of the fever with tuberculin, especially Koch’s 
new bacillary emulsion. But this method, although it strikes at 
the root of the fever and not merely at the symptom, cannot 
be always used. The treatment begins with the smallest doses, 
the first dose of the new bacillary emulsion being about .ooI c.mm. | 
We may refer to our book on ‘* Tuberculin in Diagnosis and 
Treatment.” 
For the treatment of most cases of night- 
sweats general hygienic and hydro-thera- 
peutic measures are sufficient ; by themselves they usually remove 
the weakness of the heat centres caused by the specific toxins, 
and raise the tone of the vessels. The open-air treatment must 
be thoroughly carried out, with very complete ventilation of the 
bedroom, which may be heated in winter to allow this. Horse- 
hair mattresses and pillows are the best. Heavy coverings must 
be replaced by lighter woollen ones, or a light eider-down quilt. 
Cornet advises that the arms should be left outside the coverings, 
and the legs kept apart by sheets. The clothing must be changed 
morning and evening, and the bedding well aired every day. 

Attention to the skin by means of regular baths, alcoholic 
or cold frictions and dry rubbing, is also important. Before going 
to sleep Brehmer’s favourite remedy of half a pint of cold milk 
with a teaspoonful to a tablespoonful of brandy may be taken; 
or if alcohol is contra-indicated, tinct. salvie (20 drops t.d.s.) 
may be ordered. 

If these measures fail in severe cases then the patient may 
be washed all over every evening with dilute brandy or vinegar; 
also 2 to 5 per cent. lysoform used morning and evening has 
given us good results in bad cases. Afterwards tannoform 
(tannoform 1 part, tale 2 parts) must be rubbed into the skin 
with the palm of the hand. There are no advantages in the 
use of formalin with alcohol or soap. 


Night-sweats. 


PULMONARY TUBERCULOSIS ry5 


Of the internal remedies atropin and agaricin are to be 
recommended. <Atropin may be given in the form of pills 
1/240 gr. in each), two at night, or two in the morning and two 
at night. If the digestion is disturbed it must be given sub- 
cutaneously (1/300 to 1/60 gr.). Toxic symptoms, such as dry- 
ness of throat and dilated pupils, must be guarded against; the 
maximum dose must not be exceeded, nor given for more than 
several days together. 

Agaricin requires about six to seven hours to act and often 
causes diarrhoea; and it may therefore be well combined with 
Dover’s powder in pill or powder form (agaricin % to § gr., 
pulv. Doveri 13 gr.). It may be given for many days together, 
but is contra-indicated from the first for patients with disordered 
digestion. 

Acidum camphoricum (15 to 30 gr. a dose) and guacamphol 
(3 to 7 gr. in the evening) have been of less service to us than 
pyramidonum bicamphoricum (Hochst), with which, in doses of 
ma tO I5 gr. several times a day, we were well pleased. If 
there is also sleeplessness, sulphonal (15 gr.), veronal or sodium 
veronal (4 to 7 gr.), or adalin (7 to 15 gr.) must be ordered for 
several evenings in succession in a warm drink. 

It must be remembered that all these remedies have only a 
symptomatic value, and that they must fail if proper hygienic 
measures are not taken. 
ge A distinction must be made between cough 

Cough and i: x octet = 

with and without expectoration, and also 
between reflex and irritative coughs. 

The dry cough of early phthisis may be suppressed with 
a little effort and discipline; it has more importance for diagnosis 
than treatment. 

The loose cough is regulated by the state of the lungs. it 
is usually most marked in the morning, because the secretions 
have accumulated during the night. 

The reflex cough that is necessary for bringing up expectora- 
tion must not be checked without a reason. The patient who 
brings up his expectoration with but littl cough during the 
morning “toilette of the lung’’ would not be helped, but rather 
injured, by suppressing the cough. It is only to be seen that 
the cough and expectoration are in the right proportion, and that 
the cough is followed by the latter. The only useful treatment 
will be that directed towards loosening the expectoration. 

In many cases there is an irritative or spasmodic cough, 
which is started perhaps by the tubercular foci in the lungs, but 
which is aggravated into attacks of continuous, convulsive, or 
explosive coughing by catarrhal complications in the mucous 


Expectoration. 





156 A CLINICAL SYSTEM OF TUBERCULOSIS 


membranes of the upper air passages and larger bronchi. This 
cough must be combated by all the means at our disposal, as it 
disturbs the night’s rest and nutrition of the patient, and prevents 
the lung from healing by stretching the tissues. Every continuous 
violent cough must be treated for several reasons. It causes 
pains in the muscles of the chest, vomiting, and possibly hamor- 
rhage or pneumothorax. It may force sputum containing bacilli 
back from the tubes into healthy alveoli, and in short injures the 
patient both bodily and mentally. 

The patient must be instructed to discipline the cough as far 
as possible. He must be told that “‘ coughing causes coughing ”’ 
(Penzoldt), and that he may by will-power overcome the first 
tickling in the throat. According to Cornet, about ten very slow 
inspirations with more forcible expirations are very effective in 
controlling the irritation. Pure air, rest to the voice, breathing 
through the nose, sips of hot or cold drinks, Ems pastilles, Ice- 
land moss, menthol, coryfin and other lozenges, dragées and pas- 
tilles are useful. 

If these measures fail we may order several days’ rest in bed, 
in a room in which the moisture is increased by steam, or by 
sprays of salt solution (one teaspoonful to two pints), or of 
sodium carbonate solution (1 to 2 per cent.), or by hanging 
up damp sheets. Complete silence, chest-packs, alkaline water 
alone or with milk, and, as a last resource, opiates, may all be 
used. 

We have had so few good results from cannabis indica, tinct. 
gelsemii, ext. hyoscyami and paraldehyde that we have given 
them up for some years. 

We have found dionin (ethyl-morphia-hydrochloride) and 
codeine phosphate to be the most useful; they act as local and 
general sedatives and favour sleep, without checking the expec- 
toration or causing constipation. In this, and the fact that they 
are less poisonous and less likely to cause a habit, lie their great 
superiority over morphia. For children they may be ordered in 
the form of a syrup (1 in 100, a teaspoonful in the evening), for 
adults as drops (3 to 4 gr. in 511i of water, or aq. laurocerasi, 10 
to 20 drops t.d.s. or at night), more rarely in the form of pills 
(4 to 4 gr.) or suppositories (4 to $ gr.). 

A new remedy of value is pantopon. Compared with mor- 
phia it is but slightly narcotic, and affects the respiration and 
heart frequency much less; but it has a strongly sedative effect 
on the cough. It is best given in small single doses, not on an 
empty stomach (for adults 10 to 30 drops of 2 per cent. solution 
three or four times a day, for children 5 to 15 drops). 


tle Be dt de hl ne tt is 





PULMONARY TUBERCULOSIS 7) 


Morphia remains as a last resource, which must not be with- 
held from hopeless cases. On account of its general sedative 
action it is particularly valuable in cases of pain, marked unrest 
and psychical disturbance. In these terminal cases the danger 
oi the morphia habit need not be considered, but unfortunately 
this is not sufficiently thought of in early cases. All the same, 
one should always try the effect of small doses, and reserve 
the larger doses and subcutaneous injections for cases of necessity. 
Vomiting, occurring at meals or soon after, requires larger doses 
of morphia to be taken half an hour before food, or, if an in- 
jection is given, shortly before the meal. 

We have already emphasized the fact that the amount of 
cough depends on the looseness of the expectoration, which 
therefore must be, as far as possible, promoted. This may 
usually be done by inhalations, by warm drinks, and by warm 
mineral waters taken fasting early in the morning, in preference 
to using the so-called expectorants. Of these we have the 
mistura solvens (ammon. chlor. and _ liquorice), ipecacuanha, 
senega, apomorphin, and particularly iodide of sodium; the last 
also may be combined with ipecacuanha and senega. Klopfer’s 
1iodoglidine, a combination of vegetable albumen with an organic 
iodine compound, acts better and is better tolerated than sodium 
iodide. Sometimes an opiate, as mentioned above, may be added 
in small doses. We have also found the new remedy for 
whooping-cough, pnigodin, a harmless expectorant. 

By far the best method of loosening the expectoration, and 
thereby diminishing the cough, is the chest-packs of Win- 
ternitz, which we can warmly recommend. We have already 
described the method of applying them (p. 10g). Other 
methods of diminishing the expectoration, and if necessary of 
deodorizing it, we have mentioned in the section on inhalations 
(p. 134). The danger of swallowing the expectoration is men- 
tioned in another place. 

The first essential for the treatment of 
hemoptysis is that patients with even very 
slight bleeding must submit to complete bodily rest at once. Also 
we must forbid excessive mental activity, devotions to Bacchus 
or Venus, hot drinks, especially strong tea and coffee, and the 
breathing of air containing dust. If the bleeding is in any 
quantity complete confinement to bed is necessary, with entire 
mental rest. Relations must be kept away by an allusion, if 
necessary, to the gravity of the condition. Severe cough must 
be treated with a suitable drug. The food must be lessened, and 
non-irritating lukewarm soup and drinks given. The action of 


Heemoptysis. 


158 A CLINICAL SYSTEM OF ‘TUBERCULOSIS 


the bowels is to be regulated with an aperient or a saline enema. 
The patient must not get up till the bleeding has ceased for 
several days. 

In very severe haemorrhage there is the possibility that 
coagulated blood may block the air passages; the patient becomes 
cyanotic and suffocated. In such a case the pharynx must be 
cleared out as low down as possible with the finger, then the 
patient - is to be. made to cough violently, and 9a. 
drink some stimulating fluid (wine or brandy). While the 
patient is undergoing complete rest in bed ice-bags may be 
applied to the chest; also Penzoldt’s sand-bags or Nieder’s 
bandages of strapping may be used. The ice-bag has at the 
same time a sedative action on the heart. The upper part of the 
body must be raised with a bed-rest, in that position the lungs are 
freed from expectoration as easily as possible. It is important 
that the clots and thrombi be not disturbed. If on the doctor’s 
arrival the haemorrhage has not ceased he must quieten the 
patient as much as possible, enjoin silence, and refrain from 
physical examination. The old home remedy of drinking a tea- 
spoonful of salt in half a glass of water is excellent; above all, it 
is always at hand. If ice can be obtained a fairly large ice-bag 
should be placed over the diseased or painful area, which com- 
bines the effect of cold with pressure and immobility. Later a 
second smaller ice-bag may be placed over the heart; while to 
alleviate the tickling in the throat pieces of pure ice of the size of 
a pea or bean may be sucked. These measures also act by 
suggestion. We have not seen gastric or intestinal disturbance 
from their use. 

Bandaging the limbs, a very old remedy, is worth consider- 
ing. It acts as a hemostatic by emptying the large veins and 
by raising the coagulability of the blood, in consequence of 
hydremia of the part of the circulation which is obstructed. The 
middle of the thighs and upper arms are bandaged one after the 
other with an elastic or ordinary bandage, in such a way that the 
unaltered pulse shows that the arterial flow is not affected while 
the venous return to the lungs is obstructed; after half to one 
hour the bandages are very slowly and gradually loosened one 
after the other. Lastly a narcotic is given to diminish the 
bodily and mental unrest of the patient, the dry irritating cough, 
and the pressure in the pulmonary circulation. The substitutes 
for morphia may be used: Dionin (} to + gr.), pantopon, codeine 
phosphate (4 to 3} gr.), and heroin hydrochloride usually act 
promptly if given subcutaneously. Dover’s powder (3 to 4 gr.) 
is also useful. If restlessness and cough do not subside, morphia 


















_s oe a 


peer 


= a oe a. oe 


PULMONARY TUBERCULOSIS 159 


is the sheet anchor. Lately a warning has been issued against 
morphine injections in these cases from the fear of stopping the 
expectoration of the blood, and of inducing morphinism, which 
in our experience is groundless. The fear that morphia will 
hinder the expulsion of the pent-up blood, and so induce disease 
in the lower lobes, is exaggerated, and the danger of morphinism 
is a theoretical one. It acts both psychically by quieting the 
patient, and physically by lowering the blood-pressure. It is 
best to begin with small doses of morphia (;'5 to } gr.), which 
allay the cough without checking the expectoration; it can be 
once repeated. If there is heart weakness digitalis may be given 
at the same time. The combination of morphia and atropine has 
no advantages; the addition of scopolamine (735 gr.) has been 
warmly recommended as avoiding the depressive action; we can- 
not support this recommendation. 

No general lines can be laid down for the treatment of pro- 
tracted haemorrhage. We can only give some hints. The food must 
be easily digestible, and must be neither hot nor quite cold. The 
amount of liquid need not be much restricted, but smaller and 
more frequent quantities are to be recommended. Hot liquids, 
strong beef tea, and concentrated alcohol are to be avoided, while 
milk, acid lemonade, puddings containing gelatine and lime, and 
food that is rich in salt, but not constipating, are to be recom- 
mended. The regular emptying of the bowels is most important. 

Of drugs, ergot and its derivatives, hydrastis, stypticin, styp- 
tol, liq. ferri perchlor., tannic acid, and lead acetate fail with such 
regularity that their use should be abandoned. If after their 
administration the heemorrhage ceases it is probably an accidental 
occurrence, or merely the effect of suggestion. The preparations 
raising the blood-pressure, adrenalin and suprarenin, and those ~ 
dilating the vessels, amyl nitrite and nitroglycerine, can be passed 
over ; the former may be even dangerous, and the latter is only to 
be used with the greatest caution. 

The coagulative action of calcium chloride (15 gr. t.d.s.) 1s 
uncertain in severe hemorrhages; Reiche recommends it in com- 
bination with morphine (§ gr.). Calcium lactate has the advantage 
of being tasteless. The use of a combination of sodium chloride 
75 gr.) and sodium bromide (30 to 60 gr.) may be recommended ; 
the salt increases the coagulability of the blood, whilst the 
bromide tranquillizes the patient (van der Velden). We give at 
intervals of one and a half hours alternately salt (75 gr.) and 
bromide (45 gr.), up to 300 to 450 er. of salt and 180 to 220 gr. 
of bromide a day. 

The use of gelatine for bleeding is very old; the Chinese 


160 A CLINICAL SYSTEM OF “TUBERCULOSIS 


employed it in the third century. Recent observations have 
shown that gelatine does not only raise the coagulability of the 
blood, but that this rise persists a long time (Grau). However, 
the indications for its use cannot be laid down as long as we are 
ignorant of the mechanism by which this increased power of 
coagulation is brought about. Our opinion of the value of the 
treatment is not so high, and the results obtained are not so certain 
and constant, that we can feel ourselves justified in submitting 
our cases with haemorrhage to an injection of gelatine, with its 
dangers of rise of temperature, severe pains, nephritis, urticaria, 
&c. The rises of temperature are to be particularly feared after 
an injection of gelatine in tubercular patients, so that its use musi 
be limited to cases completely free from fever, in which other 
measures have failed to check severe haemorrhage. Merck, of 
Darmstadt, supplies carefully sterilized gelatine in closed glass 
vessels; 40 c.c. of a 10 per cent. solution of this are heated 
to 99° F., and injected with a sterile syringe deeply into the upper 
part of the thigh, the buttock, or into the subcutaneous tissue of 
the axilla. The intravenous injection of 100 c.c. of a 2 per cent. 
solution, and the rectal administration of a saline gelatine enema 
(75 gr. of gelatine in two pints of physiological salt solution at 
104° to 120° F. several times a day) have also been recommended. 
We wish to issue a most emphatic warning against the intra- 
venous injection, the preparation for which is no longer made 
by Merck. Repeated injections of gelatine do not lead to super- 
sensitiveness. 

For serious cases we prefer intravenous injections of saline 
solution, which have been recommended lately by van der Velden 
as a styptic. They have not failed us in a series of apparently 
hopeless cases. Sometimes, indeed, the improvement is only 
fugitive, since the coagulative effect passes off. Three to 5 c.c. ofa 
IO per cent. solution are injected into the vein of an arm. The 
solution can be easily prepared and sterilized as required. Sub- 
cutaneous injections of 200 c.c. of 2 per cent. solution have also 
been recommended; their effect is rather less rapid. With these 
saline injections a rise of temperature of 2° to 3° F. can nearly 
always be observed. This fever is regular in its appearance and 
disappearance, is due to sympathetic irritation, and shows 
the importance of regulating the temperature of the fluid. 

As a last resource for cases of profuse recurring haemorrhage 
there is the formation of an artificial pneumothorax, providing 
that the site of the haemorrhage is known with certainty, and 
that the state of the other lung permits the procedure. 

We have no experience of the hzemostatic injection of the 





p 
' 


PULMONARY TUBERCULOSIS 161 


serum of another animal, which has been recommended in France. 
The possibility of the occurrence of anaphylactic symptoms 
(albuminuria, urticaria, or subcutaneous hemorrhages, &c.), 
especially if the injection of the foreign serum has to be repeated, 
makes this treatment unsuitable for tubercular hamoptysis. 
Sterile horse serum for the purpose can be obtained. Lately the 
injection of human serum has been recommended; but the time 
does not seem to us to have come for its practical employment. 

In cases of severe heart failure digitalis and similar prepara- 
tions are most useful; they have been recommended as 
hemostatics in cases in which the colour of the blood and the 
nature of the bleeding indicate its venous origin. But this 
distinction is not usually possible. Focke has lately advanced 
the view that the spontaneous hemorrhage of pulmonary tubercu- 
losis arises in the great majority of cases (somewhere about nine 
cases out of ten) from the mucous membrane of the larger bronchi, 
in consequence of circulatory obstruction causing venous and 
capillary stasis; whilst bleeding from the tearing of a large vessel 
Or an aneurism is more rare. We are far from believing that a 
tear of the vessel wall can be the cause of all pulmonary hemor- 
rhage; but pathological anatomy shows that it is so in all profuse 
bleedings. The great frequency of bleeding in the ulcerative 
forms of phthisis, no matter whether the process is in an early or 
late stage, is against the view that a circulatory congestion is a 
frequent, almost constant, cause. We consider, however, that a 
passive congestion of the deeper lung tissues may account for 
certain repeated small hemorrhages, associated with heart weak- 
ness and a falling blood-pressure. Then digitalis preparations 
may be indicated, in combination with regulation of the stools, 
careful deep breathing, and small doses of alcohol. We prefer 
digalen (15 to 20 drops t.d.s., or 15 minims subcutaneously), 
Focke’s infusion of digitalis, dialysed digitalis, and digipuratum. 

We have not dared to employ the heroic remedy of emetics 
for pulmonary hemorrhage: they have been warmly recom- 
mended by Stricker. 

Inhalations of chloride of iron and surgical interference are 
to be avoided; blisters and mustard plasters are useless. Blood- 
letting, which increases coagulation by thickening the blood, is 
only to be considered when the blood is markedly overloaded 
with carbonic acid. 

According to the severity of the bleeding, and the general 
condition, the patient must be kept in bed at least three days, and 
preferably from five to ten, after the blood has completely dis- 
appeared from the sputum. 

a 


i62 A CLINICAL SYSTEM OF TUBERCULOSIS 


For the removal of clots from the air passages expectorants 

and packs may be used after the hemorrhage has ceased for 
several days. To assist recovery from the consequent anzmia 
iron and blood preparations (lactate of iron, liq. ferri albuminati, 
ferratose, iron-somatose, iron-tropon, lecithin, &c.) may be 
ordered. 
During the course of pulmonary tubercu- 
losis breathlessness develops but slowly and 
imperceptibly. In advanced disease the demands on the lungs 
become less, so that the still sound lung areas are able to maintain 
compensation. Therefore in uncomplicated phthisis breathless- 
ness does not usually require special treatment. The rest that is 
ordered often suffices by limiting the need of oxygen. Temporary 
relief may be given by inhalation of oxygen mixed with air in a 
special mask, by small doses of alcohol, by heart tonics, and by 
oxycamphor (7 gr. t.d.s.) and oxaphor (40 minims in water t.d.s. 
before food), which are recommended by Jacobson and Cornet. 
This treatment is evidently directed towards an artificial stimula- 
tion of the heart, not to the state of the lungs; and it must be 
remembered that an overworked heart should not be treated for 
long with a whip. We hold that it is better to spare the heart, 
and, if there is great breathlessness, to use narcotics, probably 
morphia. 

If sudden and severe breathlessness comes on during the 
course of phthisis it is usually due to an extension of the disease 
(miliary tuberculosis of the lungs, or general miliary tuberculosis), 
or to some tubercular or non-tubercular complications, such as 
pleural effusion, pneumothorax, aspiration pneumonia, broncho- 
pneumonia, nervous asthma, and heart weakness. We need not 
here enter into details. The exact cause of the breathlessness 
must be discovered in each case, and the correct treatment applied. 
Sleeplessness is no rare symptom in. all 
stages of pulmonary tuberculosis. It is 
more common in women than men, in the upper classes than with 
poorer people. If it is affecting the patient bodily or mentally 
iLis important that it should be removed. For this it is necessary 
to ascertain whether it is due to certain symptoms, such as cough, 
pain, perspiration, &c., or whether it has a nervous, neurasthenic, 
or toxic origin; for on this the treatment will depend. Of first 
importance is the general treatment by diet and _ hygiene, 
especially fresh air day and night, the afternoon nap, mental rest 
in the evening, early supper, and a regulated diet. A wall may 
be taken in place of the evening rest. Lukewarm baths, carbonie 
acid baths, chest-packs, and the use of the constant current (4 to 1 


/ Breathlessness. 


Sleeplessness. 








PULMONARY TUBERCULOSIS 163 
milliampere) to the forehead and nape of the neck (Cornet) are 
useful. We have often used the carbonic acid baths, which are 
given in the morning and not in the evening, and are to be 
followed by an hour’s rest, but not sleep. 

Frequently drugs must be employed. If there are no pro- 

minent symptoms infusion of valerian may first be tried, which is 
better than the tincture; then the bromine preparations, especially 
a mixture of the sodium, potassium, and ammonium bromides, or 
an effervescing bromide mixture, bromural tablets, veronal, 
sodium veronal, or adalin. One should begin with 4 gr. of 
veronal or sodium veronal in a hot liquid, and if it loses its effect 
increase to 74 gr. ther preparations, such as dormiol (2 to 5 
capsules), sulphonal (15 gr.), trional (15 gr.), are not required. 
Dionin and pantopon are only to be used if the sleeplessness is 
due to cough; morphia only in the very last stages. We advise 
that the hypnotic should be given for at least three evenings in 
succession, even when the first dose has already acted. If they 
have to be given for some time the preparation should be changed 
at intervals. 
As tuberculosis of the abdominal organs is 
separately considered, we may limit our- 
selves here to functional disturbances of 
digestion. They are very important; according to the figures of 
Janowski and H. Strauss at least a third of early cases of pul- 
monary tuberculosis suffer from gastric and intestinal dyspepsia. 
Besides the true dyspeptics there are also those suffering from 
pseudo-dyspepsia, without anatomical or functional changes. 
The fact that some cases of phthisis belong to families of bad 
eaters 1S important. 

Dyspepsia and the feeding of the patient are so very 
important in the course of tuberculosis, that their management is 


the first, and not the least weighty, part of the treatment of 
individual cases. 


Digestive 
Disturbances. 


The loss of appetite, which often amounts to an aversion from 
food, frequently comes in early cases from unfavourable hygienic 
‘surroundings; in more serious cases it is part of the disturbance 
of all the functions caused by fever. In the latter case we are 
unfortunately often quite helpless. The appetite cannot improve 
on account of the severe disease, and this cannot improve on 
account of the insufficient nourishment. 

The loss of appetite of early cases is generally to be overcome 
by an easily digestible and mixed diet, the different dishes of 
which must be both appetizing and varied. In this way the food 
will assist the effects of the open-air cure, the exercises, and the 


1604 A CLINICAL SYSTEM OF TUBERCULOSIS 


hardening and bracing treatment. The cold meat treatment of 
Dettweiler, in which hot dishes are supplemented with cold, 
deserves consideration. Good cooking permits the combination 
of albuminous liquids and meat extracts with a slight amount of 
alcohol, and the addition of Madeira or other wine to strong meat 
broths, ox-tail soup, sauces, Wc. 

In obstinate cases a change of residence or climate may be 
considered. Hydro-therapeutic measures, such as complete and 
partial frictions, or compresses to the abdomen, may be tried; as 
may also stomachics and bitters (tinct. cinchon. co., hydrochloric 
acid, tinct. rhei, strychnine, orexin, acid pepsin in mixture or 
tablets, thiocol, and sirolin). 

In irritable states of the stomach with hyperzsthesia, feeling 
of pressure, pain, hyper-acidity, pyrosis, and vomiting, all strong 
and spiced food must be avoided, and thick soup, gruel, stewed 
meat in small quantities, and especially milk, with or without lime- 
water, which also serves to neutralize the hyper-acidity, may be 
ordered. A particularly useful drug is bismuth in not too small 
doses (5ss t.d.s. before food), or in combination with extract of 
belladonna (bismuth subnit. 15 to 30 gr., ext. bellad. } gr., ft. 
pulv., one three times a day before food in water). 

For superacidity and pyrosis sod. bicarb. or mag. carb., or 
a combination of both, may be used before food. Creosote 
preparations are often very useful, especially for heartburn. 

For distension and flatulence, besides antacids, menthol (1 gr. 
in pill) or carbonate of guaiacol may be given. 

For nervous hypereesthesia, if bismuth and sod. bicarb. alone 
do not succeed, codeine may be added, or an opium suppository 
ordered. The carbohydrates must be diminished, the clothes 
must be loosened after meals, and no corsets worn. 

If retching and vomiting are present it must be considered 
whether they are due to the cough, to hyperzsthesia of the 
pharynx, or to a general state of reflex irritability. In different 
cases dionin, codeine, or morphia, throat lozenges or bromine 
preparations may be indicated. Very useful also are orexin 
basicum (4 gr. an hour before food), chloral-hydrate, the combina- 


tion of tincture of iodine and chloroform recommended by Cornet 


(5 drops of an equal mixture of both in water during mealtimes), 
or validol (10 to 20 drops). 

In cases of very obstinate dyspepsia we may follow Penzoldt’s 
advice and wash out the stomach. It must only be done in cases 
in which the pulmonary disease is not very far advanced. 

In conditions of diminished acidity, or in cases of achlor- 
hydria, which latter are very rare, the meat food and fats must 


——— a 





PULMONARY TUBERCULOSIS 105 


be cut down. A fluid or vegetable diet should be ordered, to 
which may be added soluble albuminous powders (eukasin and 
nutrose), which are both tasteless and odourless, contain 86 to go 
per cent. of albumen, and about thirty calories in a teaspoonful. 
Also bitters, hydrochloric acid, and pepsin are to be given, either 
in a mixture or in tablets. 

The chief aim in treating all dyspeptic cases is so to alter 
the diet that in spite of the change there should be no diminution 
in the amount of nourishment taken. Whether this is always 
possible is another thing, but it must be always attempted by 
every means at our disposal. 

In cases of intestinal indigestion and diarrhoea coarse food 
of every kind must be cut off; thick soup, rice, soft liquid foods, 
and especially good butter may be given. Astringent drugs may 
be required. 

The constipation of consumptives must be treated by diet. 
Massage of the lower abdomen, followed by a short cold sitz-bath, 
enemata, and mild laxatives are all useful. 

Binberes Whilst diabetes very seldom develops. dur- 
ing the course of pulmonary tuberculosis, 
Mellitus. the latter is a very common complication of 
a previously existing diabetes. The frequency with which 
diabetes is complicated with pulmonary tuberculosis varies, 
according to the social status of the patient, from 5 to 50 per cent., 
the latter figure being obtained from statistics drawn from the 
poorer diabetes. Raw observed sixty-two cases of diabetes for 
periods up to 12 years, twenty-five cases were examined post 
mortem, and in all 37 or 59 per cent. were tubercular! This 
frequency must mean that diabetes produces a toxic predisposi- 
tion to tuberculosis. 

Pathologically the pulmonary tuberculosis of diabetes is 
characterized by having no predilection for the apex, but being 
localized in any part of the lung, not uncommonly in the lower 
lobe. There is usually extensive caseation and breaking down, 
without the least tendency towards connective tissue formation. 
The presence of sugar in the tissues affords a more favourable 
condition for the development of the tubercle bacilli and of the 
other organisms of a mixed infection. According to Raw the 
addition of diabetic blood to a culture medium encourages a 
luxuriant growth of tubercle bacilli. 

Clinically there is a remarkably quick loss of weight, and in 
cases of very rapid phthisis a diminution of the amount of sugar 
in the urine. The fever is often moderate, in spite of mixed 
infection. Sweats are absent, on account of the desiccation of 


100 A CLINICAL SYSTEM OF TUBERCULOSIS 


the tissues. The diagnosis is not difficult, but one must make it 
a duty to examine the urine in all cases of alteration of nutrition. 
The course of pulmonary tuberculosis in diabetes is always 
unfavourable, and with bad conditions of life usually very rapid. 

The treatment of tubercular diabetics is largely a question of 
diet, in arranging which the elimination of the sugar from the 
urine, under all circumstances, should not be our only object. 
Milk must not be entirely excluded from the dietary. The 
ingestion of carbo-hydrates must be kept within the limits of 
tolerance. Those articles of diet are to be considered the most 
suitable which contain the maximal amount of albumen in propor- 
tion to the carbo-hydrate. The amount necessary for nutrition 
must be made up by an increase of the easily digestible forms of 
fat, especially good butter. The duration of the rest cure must 
be restricted, but the exercise must be broken up by frequent 
short pauses for rest. Of drugs the opium preparations take the 
first place. 

The combination of pulmonary tuberculosis 

Obesity. and obesity is not so very rare, though 
generally phthisis is characterized by a disappearence of the sub- 
cutaneous fat. Tuberculosis is accompanied by obesity in 
chlorotic and alcoholic subjects. Or it may be a consequence of 
prolonged super-alimentation of the tubercular patient with large 
quantities of albumen, fat, and carbo-hydrate, which, owing to 
the diminution of the assimilative powers, produce a secondary 
obesity. Not uncommonly alimentary glycosuria or diabetes is 
present at the same time. Clinically, the combination produces 
dyspncea or exertion, sweating, increased expectoration, and 
cyanosis. The fatty infiltration of the skeletal muscles causes 
weakness and languor, the fatty degeneration of the heart cardiac 
failure. The latter will be the more prominent the greater are the 
demands made on the heart by the pulmonary disease. 

Obesity makes the prognosis worse; the lung disease usually 
follows a rapid course. Heart failure and pneumonic complica- 
tions may be fatal. 

The treatment is limited to the adiposity of stationary 
phthisical cases, since with progressive disease the fatty tissue 
disappears in any case. But even in stationary cases the rational 
cures for adiposity of Banting, Ebstein, and Orteil can only quite 
exceptionally be employed. We may, first of all, without a 
rigid diet, by diminishing the fats, carbo-hydrates, and fattening 
fluids, and by limiting the albuminous foods, attempt to bring 
about a weekly reduction of weight from two to, at the most, four 
pounds. A regular control by means of the weighing machine 


_ 
























PULMONARY TUBERCULOSIS 167 


and of urinary analysis is essential. Rest and sleep must be 
limited, and the amount of bodily exercise regulated by the 
capacity of the heart. So-called work (terrain) cures are only 
suitable for quite early cases, and must be very carefully regu- 
lated; the patient must not be allowed to sweat, which 
he does very readily, and which frequently causes chills 
on account of the bad cutaneous circulation. Massage 
and prolonged exposure to pure ozone-containing air 
increase the oxidation processes; the energetic tissue 
changes produced by high altitudes are particularly advan- 
tageous to these patients; they lose weight and gain strength. 
Vapour baths are contra-indicated, so too is usually thyroid treat- 
ment. A course of mineral water, especially at Kissingen and 
Homburg, is serviceable. The severe treatment of Moritz, which 
consists of taking fourteen pints of milk, without other solid or 
liquid, for five to seven days, makes demands on the capacity of 
the heart, which corpulent tubercular patients can rarely stand. 
On the other hand, one day of milk diet a week, on which two to 
three pints of milk is the only food taken, and as much bodily rest 
as possible is enjoined, is a useful method, free from danger, of 
diminishing the fat of tubercular people. 
According to Ebstein, gout and tuberculosis 
Gout. are not uncommonly associated ; but current 
medical opinion is in agreement with Minkowsky, who finds that 
the two diseases are seldom combined, though they do not exclude 
each other. Raw found in fifty-seven cases of gout (with eleven 
autopsies) in no single instance even a trace of tuberculosis; so 
that he considers gout to be directly antagonistic to tuberculosis. 
The recognized antithesis between the tubercular and gouty dis- 
position is considered to be the reason for this. This is correct, 
since the constitutional form of gout, in contradistinction to 
the so-called acquired form, is associated with a build and state of 
nutrition which is unfavourable for the development of tubercu- 
losis. But experimental and clinical observations do not show 
that an increase in the uric acid contents of the blood is a protec- 
tion against tuberculosis. The therapeutic feeding on raw meat, 
meat juice, or nuclein is not, therefore, to be justified on these 
grounds. The observations of Raw must be taken into account, 
however, who only obtained a scanty growth of tubercle bacilli on 
media to which blood from gouty persons had been added. 
Pathologically the tubercular processes in the lungs of 
gouty persons are marked by a great amount of connective tissue 
contraction. In advanced tubercular disease the likelihood of the 
occurrence of attacks of acute gout is diminished, on account of 


168 A CLINICAL SYSTEM OF TUBERCULOSIS 































the weakening of the whole body. From the point of view of 
diagnosis it may be noted that a hemoptysis in a gouty patient 
may be due to a non-tubercular congestion of the lung. 

The prognosis is good. The course of treatment must follow 
the middle path between the measures suitable for tuberculosis 
and for gout. Alcohol should be entirely excluded from the diet, 
meat and fats in every form may be allowed, green vegetables and 
raw fruit should be recommended, and the carbo-hydrates 
diminished. The mineral water of Vichy or Neuenahr may be 
drunk, or the warm baths of Wildbad, Wiesbaden, or Baden- 
Baden employed, according to whether tuberculosis or gout 
predominates. 

ae Syphilis plays no small part in the etiology 
Syphilis. of tuberculosis. Constitutional venereal 
disease and its specific treatment weaken the organism often to 
such a degree that phthisis may easily be contracted, or an old 
tuberculosis may be transformed into an obvious or acute form. 
Also the progress of phthisis is usually very unfavourably 
influenced by an already existing syphilitic infection, if the latter 
is still in a recent active stage. In cases in which the first 
symptoms of pulmonary tuberculosis appear soon after a 
syphilitic infection, it frequently develops into a rapid florid 
phthisis. The tubercular disease spreads over various lobes of 
both lungs, with high fever and marked blood changes. Without 
there being much dulness there are extensive catarrhal and 
destructive processes; the larynx or intestine becomes infected, 
and in spite of the diminution of the syphilitic symptoms, either 
spontaneously, or under prompt treatment, a fatal issue occurs in 
several months, or in any case extremely rapidly. One sees in 
such cases that the recent syphilitic virus has undermined all the 
natural defences of the body against tuberculosis. 

If the venereal disease is already in the third stage when the 
tubercular infection gains an entry, the course of the tuberculosis 
is not unfavourably influenced. French authors even think the 
prognosis is favourable if the syphilitic virus has exhausted itself 
(Bernheim), and the tuberculosis takes on a more fibroid character 
(Mansion). The latter is true in so far as the pathological 
changes due to the venereal disease may encapsule the tubercular 
foci, and so prevent their extension. 

The second possibility is that during the course of pulmonary 
tuberculosis syphilis may be contracted. Old chronic forms of 
tuberculosis are usually not made worse, while recent disease, 
which is inclined to progress, is generally spurred on. Also the 
syphilitic symptoms, according to Fournier, are more severe in 


PULMONARY TUBERCULOSIS 169 


the presence of tuberculosis. But there is also an idea that 
syphilis, contracted by a phthisical patient, runs a mild course in 
consequence of an antagonism between the syphilitic and tuber- 
cular poisons. Lochte limits this by saying that it is only in 
febrile phthisical patients that the syphilitic symptoms are slight 
or do not appear. 

Lastly, there is a form of double infection by syphilis and 
tuberculosis, in which both diseases occur at the same time in 
lungs or larynx, and reciprocally affect each other. Such cases 
are found at autopsies, but are rare and very difficult to recognize 
clinically ; their course is very variable. 

In the treatment of the combination of syphilis and tubercu- 
losis the general measures of hygiene and diet are indispensable. 
How much may be done, beyond the general measures of treat- 
ment directed principally against the tuberculosis, in the form of 
specific anti-syphilitic treatment, depends on the grade of the 
pulmonary disease. In regard to mercurial treatment the follow- 
ing indications are generally recognized: Far advanced, cachetic 
phthisical cases with high fever must be excluded altogether from 
mercurial treatment, which would only hasten the end. In all 
other cases it can and must be tried, the dose of mercury being 
carefully regulated. The inunction method, which with intervals 
of rest may even be used for borderland cases, serves to prepare 
the way for the subcutaneous or internal administration of mer- 
cury; the latter must not be used without preliminaries. | For 
strong, afebrile cases we have employed the usual inunction cure 
(ungt. hydrag. cin. 30 to 60 gr. a day), combined with short 
radiant baths to induce perspiration, and have thereby obtained 
an improvement also in the lung condition and in the number of 
bacilli in the sputum. When the inunction method cannot be 
continued we give mergal (Riedel) internally (two capsules three 
to four times a day). 

Iodine preparations we do not employ. Whether they can 
in large doses, such as are required for the treatment of syphilis, 
produce hemorrhages, may be left on one side. Even when 
given as sodium iodide they affect the appetite unfavourably, 
cause general perspirations and frequently have no good effect on 
the combination of syphilis and tuberculosis. Large injections of 
iodipin we cannot recommend, as we have seen abscess formation 
in the buttock with their use, in spite of the most careful asepsis. 

As there can be no more doubt that Ehrlich’s salvarsan is 
a specific means of cure for syphilis, its use seems to be indicated 
also for syphilitic phthisical cases. We are guided by the con- 
sideration that on the one hand the arsenic preparation cures 


I7O A CLINICAL SYSTEM OF TUBERCULOSIS 


syphilis surprisingly rapidly, and so prevents the bad influence 
syphilis and tuberculosis have on each other, and on the other 
hand mercurial treatment may accelerate the phthisis. In the 
Virchow Hospital, in Berlin, phthisical patients have received 
salvarsan injections, not only without bad effects, but with a 
regular alleviation of the symptoms and an improvement in the 
body-weight. Weber especially recommends salvarsan for those 
cases of syphilis which are complicated by tuberculosis. R. 
Hoffmann observed in a patient with a positive Wassermann 
reaction, who was suffering from advanced open tuberculosis, 
with extensive tubercular complications in the pharynx and 
larynx, that after an injection of salvarsan all the granulations 
and ulcerations disappeared; possibly they were of a syphilitic 
nature. Also Treupel and Levi have found in a large number 
of cases, that syphilitics, who also suffered from an open tuber- 
culosis, after a salvarsan injection had no bad lung symptoms. 
Only one patient, who had old apical dulness, developed a 
febrile pleural effusion, some three weeks after the intra-muscular 
injection, and it is quite possible that in this case a latent tuber- 
culosis was rendered active. Severe non-tubercular, purulent 
catarrh and marked heart weakness are contra-indications. As 
arsenical preparations improve the nutrition of consumptives, 
sometimes with the best results, one would expect salvarsan to 
have a favourable, rather than an unfavourable, effect on pul- 
monary tuberculosis. 
Since one author considers the regular con- 
sumption of a glass of beer or wine as 
alcoholism, while another will include under that head nothing 
short of habitual, daily drunkenness, all statistics as to the casual 
connection of alcoholism and consumption have only a relative 
value; and we have no need of such statistics. We know that 
the alcoholic person is a diseased person; that alcohol is a muscle 
and nerve poison, to which people are susceptible in a varying 
degree; and that habitual and frequent drinking, even if the 
amount of alcohol is not excessive, in every case will lead sooner 
or later to a deterioration of nearly all the tissues and organs, 
and a lowering of the resistance of the body. This may either 
increase the liability to a tubercular infection, or may give an 
impetus to a more rapid spread of an already existing disease, 
and diminish the chances of healing. We need not go into 
details; the dangers and evil consequences of alcoholism in 
favouring the development of the many complications of tuber- 
culosis are a matter of everyday observation. 

There is a question what part alcohol should play in the 


Alcoholism. 





PULMONARY TUBERCULOSIS I71 


treatment of tuberculosis. Large doses of alcohol (Mircolo 
ordered 5 pints of wine a day) have been given to consumptives, 
with the idea that such quantities favoured the growth of con- 
nective tissue and the cicatrization of the diseased areas of the 
lungs. It has also been stated that large quantities of alcohol 
increase the powers of the organism to neutralize the tubercular 
toxin, and raise the antitoxic value of the serum. We must 
refuse to accept such results founded on isolated post-mortem 
evidences. It is also certain that the assertion of the total 
abstainers is not correct, that pulmonary tuberculosis may be 
due to alcoholism alone, and that with the cessation of the 
alcoholic abuse the lung disease will disappear of itself. But 
in individual cases, in which alcohol and tuberculosis are working 
together to damage the lungs, our first care must be to cut out 
entirely the alcoholic factor. Alcoholics, and patients intolerant 
of alcohol, must be compelled to abstinence. We recommend a 
gradual reduction, since undoubted cases of delirium have 
occurred in consumptives from sudden cessation of alcohol. After 
the reduction alcohol must not be used as a drug, either internally 
or externally, and the patient must be induced to become a total 
abstainer. 

We consider it important that the alcoholic consumptive, 
when he is not amenable to the restraints of abstinence, 
should be cut off from the benefits of sanatorium treatment 
for the good of the community. Such patients receive scarcely 


any benefit from the sanatorium treatment, they lead other 


inmates astray to the public-houses, and induce in those unaccus- 
tomed to alcohol a habit which may persist after the discharge 
from the sanatorium and may considerably aggravate the disease. 
There have lately been efforts to make all inmates of public 
sanatoriums abstainers by the exclusion of all alcoholic drinks; it 
is hoped that a large number may remain abstainers after leaving 
the institution, and that the money so saved may help to improve 
their conditions of life. The pros and cons of this question, and 
the relative merits of abstinence and temperance, we may leave 
to the individual judgment. 


X. Treatment in Sanatoriums, Health Resorts, 
and Hospitals. 


We have intentionally first considered all the methods of 
cure that we have at our disposal for the treatment of pulmonary 
tuberculosis, one after another in sections complete in themselves. 
We have tried to avoid throughout taking a one-sided standpoint, 


172 A CLINICAL ‘SYSTEM OF TUBERCULOSIS 


and everything which might seem to indicate personal interest 
in any one method, or prejudice against others. We wish, fur- 
ther, to leave it to the judgment of every conscientious doctor to 
choose, out of the many weapons we possess, those which he 
considers possible, suitable and necessary for the treatment of 
each individual patient. In that consists the whole art of medi- 
cine as applied to the treatment of pulmonary tuberculosis. It 
is a matter of indifference whether the doctor is connected with 
a sanatorium, hospital or health resort, or whether he is in general 
practice. No preconceived opinion, no dictum of authority, and 
no personal interest must blind us to the paramount interests of 
the patient. 

It might be thought that these considerations might be taken 
for granted, and that the foregoing were merely superfluous 
words. But it is not so. Pulmonary tuberculosis is a ubiquitous 
disease; every doctor is brought into contact with it every day. 
There is a feeling that, according to vested interests, this or 
the other method of treatment is put forward as the best and 
only right way of dealing with tuberculosis, and that on the 
other hand private practitioners can hardly be expected to rob 
themselves of their clientele, so that it is high time to speak 
plainly. 

We will therefore put into the foreground of the following 
sections on the treatment of pulmonary tuberculosis in  sana- 
toriums, hospitals and health resorts, the general point of view. 
A section on hoine treatment, which must naturally form the 
commencement and end of the treatment of every case of phthisis, 
concludes the whole. 

Sanatorium treatment may be carried out 
in public or private institutions. The former 
have been constructed in consequence of the 
good results obtained in private sanatoriums, and from a general 
feeling that a similar treatment should be practicable for the less 
wealthy classes. The public institutions have been built perhaps 
with less regard to comfort, but not less to hygiene; they provide, 
it is true, a more simple nourishment, but one entirely adequate 
in quantity and quality. In both the treatment is founded on 
the general lines of hygiene and dietetics laid down by Brehmer 
and Dettweiler. The difference, therefore, is in no way funda- 
mental, but is purely one of expense. The private sana- 
torium does not offer more in the way of chances of cure to 
the wealthy for eight to twelve shillings a day, than the public 
one does to the less wealthy for three to four shillings. We con- 
sider the private institutions separately for the sake of con- 


Sanatorium 
Treatment. 


ee a 


——— =e rt e”mhO 



























ie i le ee, 


PULMONARY TUBERCULOSIS Iterhet 


venience, but both represent the same principle, namely, the 
treatment of pulmonary tuberculosis in an enclosed institution. 

Penzoldt considers that a well appointed and directed sana- 
torium should have the following advantages: A favourable 
position in its own grounds, in the neighbourhood of hills and 
woods, well exposed to the air, but sheltered from the winds. 
In the construction proper regard must be paid to hygiene in 
the matter of the positions of the rooms, ventilation, heating, 
&c. Proper provision must be made for lying in the open air 
by means of shelters, verandahs, balconies, &c. Absolute clean- 
liness, especially in dealing with the expectoration, good cooking 
and a good milk supply are all essential. The institution must 
be conducted by an energetic doctor, who has had a good general 
experience, but who is also a specialist in tubercular diseases ; 
he must have absolute authority over the patients; there must 
be a sufficiency of trained assistant doctors, and a good staff of 
servants. The patients must be completely cut off from their 
domestic affairs, and friendly intercourse and permissible diver- 
sions must be encouraged; ali excesses on their part must be 
impossible, and they are to be excluded as far as possible from 
the contagion of intercurrent maladies. 

We fully agree with these remarks, and, for our part, would 
refuse the name sanatorium to any institution in which the con- 
Struction or management did not comply with these requisites ; 
they should be more correctly termed boarding houses or con- 
valescent homes. 

What cases of pulmonary tuberculosis are suitable for 
Sanatorium treatment? In deciding this question it ts not 
sufficient merely to consider the grade of the disease, because this 
classification is based upon the state of the lung alone, which is 
not the only important factor. It may be said in general that 
initial pulmonary tuberculosis, as long as it is not accompanied 
by persistent fever, or by severe tubercular or non-tubercular 
affections, is suitable for institutional treatment; and that the 
last clinical stage, with more or less high fever, is unsuitable. 
There are no difficulties, or at least there should be none, in 
recognizing cases of either extreme as suitable or unsuitable for 
sanatoriums. 

Cases on the border line, which may be either still suitable 
or no longer so, cause more difficulty; the temperature in such 
cases is of the greatest importance. If the mouth temperature, 
taken regularly every two or three hours for several days in 
succession, never exceeds 99.6° F., it can be inferred that there 
is no swiftly advancing disease. It is important also to know if 


174 A CLINICAL SYSTEM OF TUBERCULOSIS 


the lung trouble is only slowly spreading in spite of unfavourable 
conditions and continual work, or if it is making rapid progress 
though the surroundings and mode of lie of the patient are 
favourable. The importance of the character, disposition, age, 
and hereditary tendencies of the patient must not be under-esti- 
mated. It is an established fact that phlegmatic consumptives 
reap a quicker benefit from sanatorium life than excitable, highly- 
strung, nervous natures; and that middle-aged or elderly people 
make a better and more lasting cure than the young. An 
inherited tendency makes the prospect worse, when it shows itself 
in defective bodily development. If the associated conditions are 
favourable, that is if the patient has a strong general constitution 
with a well-developed chest and sound heart muscle, and if the 


general bodily and mental health is not much lowered, then 


there are still good prospects from treatment in an institution, 
even though the case is on the border-line, and large areas of the 
lungs are diseased. But these cases certainly must not be com- 
plicated by tuberculosis of other organs, or by other illnesses, as 
diabetes and inflammation of the kidneys. 

The selection of patients for sanatorium treatment is neces- 
sary, not in order to obtain good statistical results, but in the 
interest both of the slight and the severe cases themselves. The 
institution is provided with a domestic staff for average cases; 
it cannot attend to now 10 per cent., now 30 per cent. of patients 
confined to bed, as such severe cases must be. If, too, hopeless 
cases are congregated in a sanatorium, so that deaths are frequent, 
it has a most depressing effect on all the other patients. Since 
sanatoriums can be of no real service to hopeless cases, and must 
consider the good of the majority, they must insist that the cases 
they receive have fair prospects of recovery, or at least of 
improvement. We may pass over other reasons. 

An important practical point is whether cases may be 
admitted into sanatoriums for prophylactic reasons. We do not 
consider that there is much danger of infection in a well-appointed 
and well-directed institution, but we answer the_ questions 
decidedly in the negative, for the principal reason that anyone 
disposed to tuberculosis should not be introduced into the com- 
pany of those already tubercular. 

For the same reason we consider the admittance of non- 
tubercular lung cases into sanatoriums for consumptives as ailto- 
gether contra-indicated. The differential diagnosis may not 
always be possible in general practice, but it is the first and most 
important duty of those in charge of institutions to verify the 
diagnosis, and to send away the non-tubercular. The exclusion 





.. 


PULMONARY TUBERCULOSIS WF) 


of both prophylactic and non-tubercular cases from institutional 
treatment is not only to be observed amongst patients sent at the 
cost of industrial insurance, clubs, unions, &c., but also for all 
cases, even in private sanatoriums. 

What results are obtained by the sanatorium treatment. of 
pulmonary tuberculosis? Whether good results are obtained by 
public sanatoriums has been disputed, while the success of 
private institutions is usually recognized. This can be accounted 
for by the fact that patients stay considerably longer in 
private institutions, and that after discharge the conditions of 
life are more conducive to their keeping in health. We must 
bear in mind that the length of stay in public sanatoriums is on 
the average ten to thirteen weeks, and that, after leaving, the 
patients, almost without exception, are obliged to return to very 
harmful surroundings, some of which they can help, some they 
cannot. The results, therefore, appear quite good, considering 
also that only one-third are admitted in the first stage of the 
disease, while one-third are in the third stage. Collection of a 
large number of statistics gives the following results: (1) The 
immediate result of sanatorium treatment was that 88 per cent. 
were capable of work; (2) the result after five years was that 42 
to 43 per cent. were still able to work; (3) the number of deaths 
during the five years was 20 per cent. These figures, like all 
others, may be objected to; they have the advantage of being 
based on large numbers. 

Further, at least 20 per cent. of the patients, who came to 
the sanatorium expectorating tubercle bacilli, lost the bacilli under 
treatment. Cornet disputes this; while the opinion of F. Kraus 
is that the extent to which bacilli disappear in sanatoriums is “‘ no 
less than surprising.”’ 

But the sharp criticisms passed by Cornet, Grotjahn, and 
others on the sanatorium results have done good. It has com- 
pelled sanatorium doctors to make more efforts to improve their 
results, especially in open cases of pulmonary tuberculosis, by 
reconstructing their system. According to our ideas this could 
only have been brought about by tuberculin treatment; and we 
were right, it has been brought about. 

We will only use statistics dealing with large numbers. 
According to Curschmann, after a three months’ combined sana- 
torium and tuberculin treatment in the Baden Insurance Institu- 
tion, 80 per cent. of the patients with open pulmonary tuberculosis 
in the first stage, 47.7 per cent. of those in the second, and even 
33-75 per cent. of those in the third, became free of bacilli. 
Lowenstein reports from the Berlin Insurance Sanatorium that out 


176 A CLINICAL SYSTEM OF TUBERCULOSIS 


of 682 patients, at the end of the tuberculin treatment, 361—52.93 
per cent. had no longer bacilli. _We ourselves have ascertained 
that of 500 cases of open tuberculosis treated for a long time ina 
sanatorium with tuberculin, 100 per cent. of cases in stage one, 
87.3 per cent. in stage two, and 44.2 per cent. in stage three lost 
both bacilli and sputum by the end of treatment. The conclusion 
to be drawn is that the combination of general hygienic treatment 
with the use of tuberculin is very effective, and far excels the- 
results of either method employed singly. We can therefore 
understand why tuberculin, which was employed in only 30 per 
cent. of the sanatoriums in 1907, was used in 75 per cent. in 1911; 
and, according to the latest inquiries of Muttray, as many as 
gi per cent. of the public sanatoriums now systematically employ 
the specific treatment in order to obtain more lasting results in a 
shorter time. The most experienced practitioners in the high 
mountain resorts also do not omit tuberculin from their armamen- 
tarium. They find that the combination of the three factors, 
sanatorium, climate, and tuberculin reduces the fever more rapidly 
and more permanently, and gives more satisfactory and lasting 
results in those moderately severe chronic cases of tuberculosis, 
which are refractory to the influences of the sanatorium, the 
climate, and the sun. 

It cannot now be said by those antagonistic to sanatoriums 
that they do nothing but create ‘‘an endless number of discon- 
tented people.’’ It appears to us that treatment in an institution 
is beneficial in three ways: (1) It ensures the exclusion of the 
harmful factors arising from the occupation and the home, and 
the persistent infection connected with the unhygienic mode of 
life in the widest sense, the removal of all which is so very 
important in dealing with many chronic diseases; (2) the general 
treatment strengthens the resisting powers of the system, increases 
the whole vital energy, and stimulates the failing powers by regu- 
lated rest and exercise; (3) it gives an opportunity at the same 
time for reaping the full benefit of any other approved treatment, 
such as the use of tuberculins. 

If the facilities for the institutional treatment could be 
increased the progress of tuberculosis as a national disease would 
be checked. 

To recapitulate, we consider that the combination of the 
tuberculin treatment with the general sanatorium treatment is to 
be strongly supported as the most successful method for all cases 
of pulmonary tuberculosis who have a chance of recovery. It is 
urged that it should be carried out for all still curable cases, which, | 
without it, threaten to become worse or incurable. 





PULMONARY TUBERCULOSIS yr 


For private patients, who pay their own 
expenses, matters are very simple. If the 
patient is prepared, in accord with medical 
advice, to undergo sanatorium treatment, it is easy to furnish 
him with a list of institutions which can be recommended. The 
choice will depend upon financial, personal, and local circum- 
stances, and the wishes of the patient. Having obtained full 
details of the institution selected, the patient, or the doctor, ascer- 
tains if admission is possible. Some private sanatoriums require 
a full and detailed medical report; the majority are satisfied to 
learn in what stage the disease is, the state of the temperature, 
and whether complications are present or absent. Many institu- 
tions are satisfied with the statement that the practitioner considers 
the patient a suitable case. The patient should not start till he 
has heard that he can be received, and must not neglect to inform 
the sanatorium authorities of the time of his arrival. The most 
important point is that the patient should be introduced into the 
sanatorium at the earliest possible stage of the disease. Although 
private sanatoriums need not be as strict as public ones as to the 
cases they receive, yet they have a right to expect that practi- 
tioners should not send them hopeless or terminal cases. Patients 
should be advised by their doctor as to the arrangements for the 
journey, stopping the night en route, &c. 

In Germany, for those who are insured by 


Private 
Sanatoriums. 


ee the State insurance scheme, and for their 
pe mnence widows—but not for their wives—the cost 
Scheme. 


of the sanatorium treatment is undertaken 
by the insurance societies, pension funds, and State-sanctioned 
societies. The insured has no legal claim on these benefits. To 
attain as far as possible a uniform procedure it is enacted that the 
sanatorium treatment is only allowable: (1) If a near approach of 
invalidity (prolonged restriction of more than two-thirds of the 
capacity to earn a living) is to be feared without such treatment ; 
(2) if there is a certainty, or a probability bordering on a certainty, 
that by means of such treatment the approach of invalidity will 
be prevented for a succession of at least two to three years. For 
instance, the mere need of strengthening the patient can never 
justify the ordering of the treatment. There must be expected to 
result from the treatment, either a definite prolongation of the 
present capacity for work, or a shaking off of the existing 
incapacity, which is to last several years. The aim of the scheme 
is to avert premature invalidity ; so that what is spent on the cure 
may be recovered from the revenue. If these suppositions cannot 
be justified the doctor may not recommend the cure at the expense 


12 


178 A CLINICAL SYSTEM OF TUBERCULOSIS 


of the insurance society. It is therefore evident how enormously 
important is the early diagnosis of pulmonary tuberculosis among 
the working classes. 
In the sections on climatic treatment and 
Health 
balneotherapy we have already stated our 
Resorts. opinion that the cure of pulmonary tuber- 
culosis is not to be expected from climate or medicinal waters 
alone. On the other hand the effects of these factors on certain 
cases of phthisis cannot be disputed, so that they may often be 
used to support other methods of treatment. Care must be taken 
that the benefits are not counterbalanced by dark and sunless 
rooms, by swallowing the sputum through fear of using thesputum 
flask, by excesses of alcohol or gambling, by love making, or by 
insufficiency of medical treatment and guidance. Also in health 
resorts precautions must be taken against the tubercular patients 
indulging in excess of sport of any kind. The doctors, of course, 
cannot keep the patients away from every harmful form of distrac- 
tion, as is possible in a sanatorium, but they must always do all 
in their power towards this. They are more likely to succeed if 
they give the patient printed directions for the treatment, and fill 
up the day with suitable divisions of exercise and rest, the latter 
in the open-air. We are glad to be able to say that this is becom- 
ing more and more possible in the resorts for lung cases. By 
adding the tuberculin treatment to the climatic, it becomes more 
potent and individualized. There is no fear that on this account 
the health resorts will lose their reputation; the one form of 
treatment does not exclude the other. We are entirely in accord 
with Wolff-Eisner, who warmly recommends, both for open and 
closed forms of tuberculosis, the climatic treatment, combined 
with tuberculin. We also hope that the doctors practising 
in the resorts for lung cases will see that by adding tuber- 
culin to their treatment they will enhance the reputation of 
their resorts. 

‘To make a correct choice of a health resort is an art” 
(Kraus). The state of the lungs must not only be taken into 
account, but also the general physical and mental constitution of 
the patient, his character, inclination, idiosyncrasy to climates, 
financial means, the time he can give to the cure, and the pres- 
ence or absence of other complications. The doctor also should 
have knowledge of the health resort to which he sends his patient, 
with its facilities for treatment, its means of housing, the outlay 
demanded, and the medical colleagues practising there. He 
is safest if he first sends his patient to a sanatorium in the health © 
resort; of which there are a considerable number. If after a 





PULMONARY TUBERCULOSIS 17G 


longer or shorter period of observation it is found that the patient 
would be better at another place or at home the change must be 
made by the sanatorium doctor. 

The indications and contra-indications for the climatic health 
resorts and watering-places have been given earlier, but there 
are still a few general directions. There are patients who have 
a violent, almost morbid, aversion to being secluded in a 
sanatorium. In such a place they become sleepless, nervous, and 
melancholy, lose all their appetite when they enter the common 
dining hall, grumble at everything, resist all treatment, see 
unjustifiable restraint in all beneficial rules, and, in fact, give 
a display of behaviour which betrays complete loss of mental 
equilibrium. For such patients treatment in a health resort, out- 
side institutions, is suitable. So also is it for slight cases, which 
have already undergone sanatorium treatment; also for chronic 
cases which have remained stationary for years, and for cured 
patients, who by means of such a yearly holiday may maintain 
their health and strength. Prophylactic cases should not be sent 
to a sanatorium, nor to frank, or veiled, resorts for consumptives, 
but for a winter visit in some other mountain place. Lastly, 
climatic treatment can only be recommended to patients of a 
serious character, and of sufficient will-power to carry out the 
general constitutional treatment to the end, without perpetual 
medical control. 

Patients who are beyond cure or hope of improvement must 
be discouraged by their doctor from making the journey. He 
must try and keep them back, must comfort them, and even 
deceive them. He will thus spare them the fatigue, and the 
inevitable disappointment; and their friends the often appai- 
ling expense which is apt to be incurred by death away from 
home. 

Fever is not an absolute contra-indication for travelling, pro- 
vided it is only moderate, not above 100.4° F. for example. More 
depends upon the general condition and strength, and the place 
to which the patient is to travel. To allow feverish patients to 
travel to a health resort without having first arranged for their 
reception is always very dangerous. -We know that the tempera- 
ture will rise still more with the journey, and that such patients 
are exposed to great risks of pneumonia, haemorrhage, &c., if 
they have to drive about in a carriage looking for rooms. We 
cannot reckon, moreover, on the quick disappearance of the fever 
with the change of climate. It is possible that it may occur, but 
not with any regularity ; high fever may not be at all diminished, 
or only after a long stay. The necessity of going to bed on his 


180 A CLINICAL SYSTEM OF SGUBERCULOSIS 


arrival with high tever, which in spite of the climatic influences 
and a prolonged rest in bed may last for weeks, has a very depres- 
sing effect on the patient; the loneliness and isolation produce 
home-sickness; the thought that the health resort was _ not 
properly chosen arises, and that the expenditure of time and 
money is all in vain. It is therefore better in cases of considerable 
fever to wait, and to allow the patient to travel only when it has 
diminished; when he may be accompanied by some _ sensible 
person to some place where they are prepared to receive him. 
Feverish patients should be sent neither to a hotel nor a boarding- 
house, but to a sanatorium. 

On the other hand we may have to insist on the journey if it 
is being constantly postponed by the patient without real cause, 
as is frequently done by married women for easily understandable 
reasons. The disease gets worse by waiting, and the curable 
case may become incurable; and then the doctor is frequently 
reproached with having recognized or disclosed the disease too 
late. 

We agree with Cornet that difficult children are better treated 
at home, and that as a rule they are better in the charge of a 
reliable stranger than a relation. We also agree that it is better 
for a healthy young husband or wife not to accompany their sick 
wife or husband as a rule; but here it is necessary to be guided 
by circumstances, which are not the same in every case. 
Whether hospitals were suitable or neces- 
sary for the treatment of pulmonary tuber- 
culosis was for a long time disputed, but 
has now been decided in the affirmative by the Federal Govern- 
ment (for Germany). In order to make use of hospitals proper 
hygienic arrangements are the first necessity. It is desirable 
that they should afford the opportunity of effective isolation for 
prolonged periods of as many cases of advanced pulmonary and 
laryngeal tuberculosis as possible. Besides serving the purpose 
of isolation, which will be further considered under the section on 
prophylaxis, they are to be used, very rightly, also for treatment. 
For investigations made in the homes of incurable patients have 
shown that only if a simultaneous curative treatment is carried 
out is voluntary isolation to be obtained in any considerable 
degree. 

It has been ordered, to attain these ends, that State hospitals 
are to be fitted with separate annexes, constructed according to 
sanatorium principles with open-air shelters, baths, douches, &c. 
In new hospitals attention must always be paid to the construction ~ 
of such annexes for tuberculosis; in old ones in large towns with 


Hospital 
Treatment. 





PULMONARY TUBERCULOSIS ISI 


unsuitable surroundings, a separate tuberculosis hospital is to be 
built in some healthy neighbourhood. 

The question arises whether the therapeutics of tuberculosis, 
especially the open-air cure, can be properly carried out in hos- 
pitals and annexes. There can be no doubt that a tuberculosis 
hospital constructed ad hoc, in a healthy wooded district outside 
the town, may offer all that is required in the way of pure air, 
protection, &c. It only remains to secure a doctor experienced 
in tuberculosis treatment for the hospital to become a sanatorium 
and home for all stages of pulmonary tuberculosis. Whether an 
annex to an already existing hospital can be suitable is more 
debatable. It largely depends if the hospital has suitable 
grounds, in which pure air, quiet, &c., can be obtained; a condi- 
tion that cannot be fulfilled in all industrial towns. 

The cases suitable for the hospital treatment are :— 

(1) Early cases, which are waiting, often for four to eight 
weeks, their turn for admission into a sanatorium. By this 
means they are at once removed from the harmful surroundings 
of their home. 

(2) Cases temporarily unsuited to sanatoriums may remain in 
the tuberculosis hospital until improvement has progressed so far 
that sanatorium treatment is possible, which sometimes occurs in 
apparently unlikely cases. 

(3) Advanced cases may remain in the hospital to the end, 
with great increase of comfort to the patient, and removal of the 
danger of infection of his home surroundings. 

(4) Chronic cases, which at times are able to work, but which at 
other times, especially in the winter and autumn, are incapacitated 
by intercurrent catarrhs and other infections, may be received for 
six weeks or so at a time, with great benefit to the patient and 
prolongation of his capacity for work. 

(5) Ambulant cases may come to the hospital as a centre for 
tuberculin treatment, after being discharged from the sanatorium 
or from the hospital itself. There can be no doubt that dis- 
charged patients at present may secure an improvement in their 
home conditions, food, and work, but that there is great difficulty 
in prolonging the tuberculin treatment. So much may be done 
in this way that this branch of the work of the tuberculosis hos- 
pital should become most important. 

For this purpose there must be systematic co-operation of 
the hospital doctor with the sanatorium physician, and the 
general practitioners, especially with those engaged in working 
the insurance scheme. 

It will thus be seen that there is a splendid programme of 


182 A CLINICAL SYSTEM OF TUBERCULOSIS 
































work for the tuberculosis hospital, worthy to be carried out by 
the very best physicians.* 


/ 


XI. Home Treatment. 


In looking through the recent literature on tuberculosis, we 
are constantly meeting the idea that it is the duty of the practi- 
tioner to diagnose pulmonary tuberculosis in its early stage, and 
then hand the patient over for institutional treatment. We hear 
but little about the co-operation of the practitioner in that treat- 
ment; and about the difficulty of attaining the ideal laid down. 

In practice weeks and months may pass 


Scope of between the recognition of the disease and 
Home the possibility of the patient being received 
Treatment. 


in a sanatorium. During this time the 
patient must be treated by the practitioner. After three months’ 
treatment in a sanatorium the patient turns up in the doctor’s con- 
sulting room cured, or not yet cured; in any case continuation of 
the treatment is generally necessary. So it may go on for years, 
with now and then a relapse and at times a spell in bed. Some- 
times another stay in the sanatorium may interrupt the attend- 
ance of the practitioner; otherwise the home treatment continues. 
Or else the patient may have come too late to the sanatorium; he 
returns home no better, and remains under his doctor’s treatment 
until death. Other patients, for whom the benefits of the sana- 
torium are not available, may remain under the care of the 
practitioner from beginning to end. 

Even if sanatoriums are provided for the poor and the rich, 
there is a great lack of provision for the middle classes; the public 
sanatoriums are continually full, and the private ones are mostly 
too expensive. On account of the expense, there is often a long 
wait to see if the first treatment of the doctor at home will be — 
successful. If this fails a visit to a sanatorium or health resort 
is decided on, but usually cannot last long enough; questions of 
the means of existence, and the claims of the business or profes- | 
sion only too often bring the stay to a premature end, and further 
home treatment is necessary. 

Even in circles where the question of expense does not enter, 
the inclination of the patient to leave home and spend several 
months in a sanatorium is not great. Many go to a winter or 
summer resort, and return home at the end of the season. The 


* From this section have been omitted a list of sanatoriums, nearly ally 
in Germany, and some of the details connected with the working of the 
German insurance regulations. 


PULMONARY TUBERCULOSIS 183 


result is that the private practitioner or specialist is again visited ; 
in either case home treatment must be resumed. 

Considering all these facts, we see that the home treatment of 
pulmonary tuberculosis must take the first and most important 
place. Statistics show this also. The 14,186 sanatorium beds in 
Germany, with an average stay of three months a patient, can 
receive about 56,700 cases of pulmonary tuberculosis a year. 
Against this there are about 500,000 to 600,000 cases requiring 
treatment; so that about half a million demand home treatment. 
Figures also show that by far the greatest number of cases die in 
their own homes; in Prussia about 50,000 a year. 

Enough has been said to show that the beginning and end 
of the treatment of phthisis must take place in the home. It is 
not altered in the least by the obligation, which rightly rests on 
the practitioner, of giving up the treatment of every case as soon 
as he has an impression that it could be carried out better else- 
where. 

We now come to the most important practical question. 
Which are the cases of pulmonary tuberculosis for whom home 
treatment does not promise to give much result ? 

In a broad sense the injurious effects of 
Difficulties of occupation can be avoided by cessation of 
Home Treatment, Wwork—but this usually means cessation of 
income also—-so that the possibility of pro- 
viding the necessary increased nourishment becomes an improba- 
bility. The open-air cure is practically impossible in a house in 
the middle of a town, perhaps in the factory quarter. In the 
summer the patient may be able to carry out the cure in woods 
around the town, but in winter it is scarcely possible. Hydro- 
therapeutic means may be employed, but the proper understanding 
of them is wanting; as is also that required for the maintenance of 
good personal hygiene, and the avoidance of harmful influences 
both to the patient and his healthy relatives. So that everything 
impels us to remove tubercular patients of the working classes 
from their unhygienic surroundings, and give them the chance of 
proper general treatment in an institution. Only when the 
patient has been instructed here, and has felt personally what is 
good for him, can the home surroundings be made the best of, 
and the system of home treatment, to be carried out to the end 
by the practitioner, be based on a sure foundation. 

Even in families in a good position there are often difficulties 
in the way of home treatment. Firstly the patient is not suffi- 
ciently cut off from the business or occupation, especially so in 
the case of married women; even if bodily or other work is given 


184 A CLINICAL SYSTEM OF TUBERCULOSIS 


up there still remain excitement, worry, responsibility, social 
duties, &c., which interfere with complete rest. Some people 
while at home consider it a sign of foolishness and lack of energy 
to impose on themselves the necessary restrictions. A patient, 
too, will frequently swallow his sputum, from esthetic considera- 
tion of others. In such cases the doctor will see that the home 
treatment had better be replaced by several months in an institu- 
tion, during which the patients ‘‘ all receive an education in self- 
treatment before they are thrown more on their own resources.”’ 
(Penzoldt). So here again the lessons learnt in a sanatorium are 
necessary preliminaries to effective home treatment. 

But what is to happen to nine-tenths of all the cases of 

phthisis, who for various reasons never enter a sanatorium? Is 
the practitioner to retain his former passive attitude to them, 
which has hardly given cheerful results ? 
In the home treatment of phthisis general 
constitutional measures again form the 
foundation on which we must build. There- 
fore in the several sections of this chapter we have never insisted 
that the various necessary measures, especially open-air treatment, 
proper nourishment and hydrotherapy, can only be carried out in 
a sanatorium, since they can all to a certain extent be practised at 
home. From what we have seen in our own practice we can say 
that general home treatment, if limited to essentials, in most cases 
may with goodwill be carried out without special difficulties. 
When in exceptional cases all means are lacking, then help must 
be obtained from the poor law, dispensaries, convalescent homes, 
soup kitchens, &c. Here it is a case of where there’s a will there’s 
a way. 

There is, spread over the whole of Germany, an organization 
for the fight against tuberculosis, which offers to necessitous 
cases the possibilities of sufficient nourishment and the benefit of 
the important factors—light, air, and water. These measures will 
have to be adapted to the home treatment of tuberculosis. This 
has already been systematically done in many places by means of 
dispensaries and polyclinics for tubercular lung cases; and alsa 
by means of country homes, which have lately been built to 
provide nightly rest under healthy conditions. 

It is particularly the dispensaries (Fir- 
sorgestellen) which do so much good work 
in the fight against tuberculosis, because they assist the general 
practitioner in detecting the tubercular lesions, and in disinfecting 
and rendering as healthy as possible infected households. The 
dispensary doctors are not, as was at first feared, the competitors 


General Home 
Treatment. 


Dispensaries. 





PULMONARY TUBERCULOSIS 185 


of the club and poor law doctors, but rather aid them in making 
the diagnosis, in furnishing the necessary reports, and devising a 
line of treatment, which the private practitioner may carry out. 
The nurses, visiting the homes and families of the patient, assist 
both in treatment and prevention. Dwellings are put into the 
best sanitary condition possible, and maintained so; patients with 
bacillary sputum are put into separate beds, and if possible into 
separate rooms; wives are urged to manage their children on 
hygienic lines, to keep them clean, and to feed them as appro- 
priately as possible; suspected relatives are examined for tuber- 
culosis, and infected children removed to suitable institutions. 
The finances of the dispensary provide not only for beds, blankets, 
rent, disinfectants, sputum flasks, thermometers, but also for 
milk, invalid food, clothing, &c. All these measures considerably 
simplify the work of the practitioner, and the home treatment of 
tubercular patients in the poorer class of society. The following 
figures will show the range of work; for instance, under Piitter in 
Berlin, the founder of German dispensaries, during a period of 
two and a half years, 34,800 persons were examined for tubercu- 
losis, 18,200 dwellings had their sanitation improved, and 1,600 
children were sent to special homes. Every year about 1,000 
patients with open pulmonary tuberculosis were isolated ! 

In every clinically suitable case of tubercu- 


Ambulant : 
, losis the tuberculin treatment may be added 
Tuberculin : rigs : : 
to the general constitutional measures, 
Treatment. S 


whether the patient be rich or poor. In our 
experience there is no great difficulty in the continuation while at 
home of tuberculin treatment begun in an institution. We have 
proofs of this which ex-cathedra statements to the contrary cannot 
shake. There will always be an urgent necessity of continuing at 
home the specific treatment of patients, whose stay in the institu- 
tion has been broken off too soon. 

But in the interests of the home treatment of these cases who 
have not been in a sanatorium we must go a step further. We 
desire that a gentle, gradual, reactionless tuberculin treatment 
should become an integral part of the home treatment of tubercu- 
losis. Robert Koch wrote in the preface of the third edition of 
our book on tuberculin, ‘‘ I should like to associate myself with 
the recommendation of the specific treatment in ambulant practice, 
for carefully selected cases only.’’ 

The difficulties of ambulant tuberculin treatment are doubtless 
still overestimated by many; in any case they are not so great 
that they cannot be overcome by any doctor, who is confronted 
every day with greater difficulties. The demand for a more active 


186 A CLINICAL SYSTEM OF TUBERCULOSIS 


home treatment is quite justified. The practitioner must be, that 
is to Say, must again become, the centre for the treatment of tuber- 
culosis in his district. This is rendered essential by the ubiquity 
of tuberculosis. 


6. PROPHYLAXIS. 


Pulmonary tuberculosis is easier to prevent than to cure. 
Therefore the doctor has a double 7éle to play ; firstly to cure those 
affected by the disease, and secondly to protect the healthy from 
falling victims. 

At the head of this chapter should be placed the words: 
wavta pet. No generally recognized prophylactic measures 
against tuberculosis can be enunciated as long as the views vary 
concerning the origin of tubercle bacilli, their modes of entrance 
and methods of propagation. The rival views, whether infection 
or predisposition plays the more important part in the production 
of tuberculosis, are also opposed. Further, the ‘‘ infectionists ”’ 
are not united among themselves. But at any rate there is 
abundant experimental, clinical, and pathological evidence that 
prophylaxis may be favoured in two ways. 

The first method aims at limiting infection and preventing 
contagion. Thanks to the timely discovery of R. Koch we can 
recognize the enemy and his dispositions, and are “‘ therefore in 
a position to stop him and attack him at his weakest point” (R. 
Koch). 

The tuberculosis frequency has diminished considerably 
during the last twenty-five years. For example, in Prussia both 
the total deaths from tuberculosis and the relative proportion of 
deaths from this cause to the total mortality are the most favour- 
able in the year 1909 since the earliest Prussian statistics (1875). 
The proportion has diminished one-half from 32.51 per cent., the 
maximum it attained in the year 1878, to 15.59 per cent.; and 
the absolute number was 60,781 in 1909, as against 88,283 in 
1886. These figures are the more remarkable since the population 
has increased from twenty-eight to forty millions. In the whole — 
German Empire the mortality from tuberculosis has constantly 
fallen, but not in such a marked degree. 

We need not here consider whether we are justified in ascrib- 
ing this decrease wholly, or only in part, to ‘‘ antibacillary pro- 
phylaxis.’’ It would also lead us too far to examine the 
almost colossal literature on the question whether Cornet’s 
dust infection, or Fligge’s drop infection, or v. Behring’s 
theory of the origin of human tuberculosis from the gastro-intes- — 
tinal tract in the earliest vears of life, is most important in relation 








PULMONARY TUBERCULOSIS 187 


to prophylaxis. But it is certain that no theory covers the whole 
ground. 

Let us not in quarrelling with others forget the possibility of 
all three sources of infection, for disunited leaders always lose the 
battle. Let us also beware of individual fads in the battle against 
the tubercle bacilli. Above all, we must not let it develop into a 
battle against the patient; for that will only lead to concealment, 
hushing up, and driving away of the phthisical cases, in whose 
hands prophylaxis really lies; and it is the majority that will have 
to suffer. The correctness of the phrase ‘* no tuberculosis without 
the tubercle bacillus’’ is the justification of all antibacillary 
prophylaxis. 

The chief dangers arise from the thoughtless spitting of 
tubercular persons, and from careless coughing with an uncovered 
mouth. Against the first there is only the general direction that 
everyone with a cough and expectoration is dangerous, and must 
be educated into being harmless. For this purpose spittoons 
filled with disinfecting fluid are useful in closed rooms; while 
patients in bed should be provided with sputum mugs, and 
patients who are getting about with pocket sputum flasks. The 
sputum thus collected must be destroyed by burning, by adequate 
boiling, or by the addition of strong disinfectants. Spitting in the 
streets must be entirely prevented, even with the help of the police. 
But light, sun, rain, and cold destroy the virulence of tubercle 
bacilli, hence the extremely low tuberculosis mortality of the 
Berlin street sweepers. 

The handkerchief will be used as a receptacle for sputum by 
people who have an insurmountable horror of the pocket flask, 
which no argument can overcome. It is certainly a lesser evil 
than indiscriminate spitting, but advice on this subject is required. 
The handkerchief that is used in this way should be changed at 
least once or twice a day, and should be carried in a separate 
pocket, which should have a lining of waterproof stuff. After 
use it should be placed directly in a disinfecting solution (2 per 
cent. raw lysoform) for twenty-four hours. Changeable pocket 
linings for coats, trousers, and ladies’ dresses should be recom- 
mended for the pocket reserved for the sputum flask or handker- 
chief. Paper hendkerchiefs of an absorbent nature, to be placed 
in watertight bags, may also be recommended; they have only to 
be completely burnt after use. 

Besides the proper disposal of the sputum a discipline of the 
cough is important. This must be attained by frequent explana- 
tions and a general diffusion of a knowledge of the laws of decency. 
The healthy must not be coughed over unnecessarily by the con- 


188 A CLINICAL SYSTEM OF TUBERCULOSIS 


sumptive ; this applies specially to intercourse in families, between 
man and wife, parents and children, servants and children, &c. 
The patient must be taught to close his mouth when coughing, 
and to hold his handkerchief, and not his hand, in front of his 
mouth. In any case it is better that the hands be very frequently 
washed, especially before meals as in sanatoriums. 

Further, the tubercular patient must be educated as to. cleanli- 
ness of the body, the beard, and the clothes. The danger of 
bringing bacillary material into the home on dresses and 
feet may be obviated by wearing dresses that clear the ground, 
and by changing the boots on entering the house. Specially strict 
rules must be observed by households where there is a case of 
chronic phthisis, who is still working. A light bedroom without 
hangings and upholstered furniture, a separate bed, and frequent 
damp cleaning are required. In more serious or bedridden cases 
the doctor must attempt isolation as far as possible. Where the 
most effective isolation in hospitals is not possible, a room separate 
from the family must be aimed at. Owing to the length of the 
illness and the scarcity of house room this is not always possible. 
Therefore in each case the imperfect isolation must be supple- 
mented by disinfection, which in cases of tuberculosis is “‘ both of 
the utmost importance for reasons of sanitation and of political 
economy ”’ (Kirchner). 

The frequent disinfection of the sick bed, which cannot be 
ordered by the sanitary officials and is not spontaneously done by 
the family itself, often does not occur to the mind of the doctor. 
And yet it is more important than all the other means of disinfec- 
tion. Infected materials must be dealt with by burning, boiling, 
or disinfectants. 

Clothes, bed-linen, towels, and especially handkerchiefs 
must be disinfected by boiling, or by soaking from twelve to 
twenty-four hours in a 2 per cent. lysoform solution. According 
to the observations of the Berlin Institute the ironing of linen only 
produces disinfection if it is done on both sides, and if the iron is 
very hot (about 250° C.). Spores are not certainly destroyed even 
at this temperature. Articles such as crockery, glasses, forks, and 
knives must be boiled, or at least cleansed with hot soda solution. 
The room, especially the walls and floor around the bed, must be 
frequently cleansed with damp clothes, and scrubbed with hot, 
strong, soft-soap solution. If the patient is removed to a hospital 
or sanatorium then the room must be thoroughly disinfected, 
together with the bed, bed-clothes, pillows, clothing, furniture, 
curtains, hangings, &c. This is best done by a formaldehyde pro- 
cess, after a preliminary mechanical cleansing with a brush and 


~ 





PULMONARY TUBERCULOSIS 159 


disinfectant. Though it is not ordered by law, yet it is the duty 
of the doctor to see that it is done in the interests of the healthy 
members of the family. The same must be done when cases of 
advanced phthisis die, or change their lodgings. Kirchner 
correctly says that *‘ when the dead man is carried out of the 
house a fatal inheritance is left behind for those who live there 
after him. Numberless healthy familics have moved into such 
houses, and after a short time been attacked by tuberculosis.”’ 
In Germany it is now provided that such disinfection should 
be carried out at the expense of the community. For this pur- 
pose the co-operation of the practitioner is required, but care 
must be taken that the patient is not injured by the communication 
of professional secrets. 

After the death of a phthisical person, besides the formalde- 
hyde disinfection, it is now a legal requirement that all unwash- 
able clothes, beds and mattresses, blankets, curtains, carpets, 
table-cloths, &c., should be removed for steam disinfection, as 
formaldehyde gas cannot be relied upon to kill all the bacilli in 
them. 

The means for this disinfection after death are sufficiently pro- 
vided by the notification of the practitioner, and the powers of the 
sanitary authorities, but what we must now press for is the estab- 
lishment of a similar method of compulsory disinfection each 
time that an advanced case of phthisis changes his abode, which 
is an indispensable weapon required in our fight against the 
disease. 

These questions are worthy of detailed considerations because 
facts have forced us more and more to the conclusion that the 
prophylaxis of tuberculosis is most important in childhood, and 
especially in the earliest years, and that it is this age that above 
all must be protected from severe, or even moderate, family infec- 
tions from phthisical relatives. In order to obtain the exclu- 
sion of infection from the household the co-operation of the 
mother is first of all needed, whose immediate duty it is to look 
after both the house and the children. For this reason it is 
desirable to educate our school-girls of every class as housewives, 
and to teach them to become efficient helpers in procuring the 
proper hygiene of the house and the child, from the point of view 
of the prophylaxis of tuberculosis. Since the law is at present 
insufficient, doctors must continue the effort to enlighten the 
public, especially by means of the education of women in anti- 
tubercular matters. And this is largely work for the general 
practitioner. 

It is idle to waste time over medical disputes whether sana- 


1gO A CLINICAL SYSTEM OF TUBERCULOSIS 


toriums or dispensaries or hospitals have the greatest prophylactic 
value. We are of the opinion that it is not a matter for compari- 
son. Hospitals isolate the most dangerous cases, but can still 
only receive too small a number. The effect of the dispensary 
in tracing cases of tuberculosis, and in improving house sanita- 
tion, is also very great, and there is room for a vast extension and 
multiplication of these agencies. The sanatoriums free one sec- 
tion of their inmates from bacilli, and so discipline the other 
section that they become harmless bacilli carriers; while all the 
patients should be, when discharged, apostles of a healthy mode of 
life. We therefore cannot do without any of these three agencies. 

The prophylactic measures against the danger of infection 
from tubercular animals and articles of food containing bacilli are 
discussed in the section on Tuberculosis of the Digestive Tract, 
and in that on Tuberculosis of Childhood. We will here indorse, 
however, the opinion of Abel that “‘hygienic regulations as applied 
to articles of food should be enforced by general laws, and not by 
local police orders; and that they must go hand in hand with the 
enlightenment of the public concerning food supply.” 

Flies, as the possible carriers of tubercle bacilli, deserve more 
attention than they have received, since there is proof that flies 
in houses containing a serious case of phthisis may be considerably 
infected with tubercle bacilli; and there are many possibilities of 
these organisms being conveyed to men. Most important is the 
probability of infection of articles of food by transference of 
material containing bacilli, or by the deposit of excretions from 
the fly on the food. Lord has shown that in 2,000 fly spots, 
deposited in three days by thirty flies fed on tubercular sputum, 
there must have been between six and ten million tubercle 
bacilli, which retain their power of infection for at least 
fifteen days. Therefore attention must be paid to the removal and 
disinfection of sputum, to the covering of sputum mugs, and the 
keeping of food in safes inaccessible to flies. 

The second method of prophylaxis aims at teaching the 
healthy how they can protect themselves from infection, and in 
raising the power of resisting the contagion of those who are 
threatened. Therefore we have not only to educate the patient so 
that he is no longer a danger to the community, but also to instruct 
the healthy how they can avoid the infection~-of tuberculosis, 
which they can do to a certain extent as soon as they are old 
enough. We consider that enough instruction of this sort has not 
been given to our growing youth in schools. We do not mean 
by this that an overw helming fear of bacilli is to be fostered. It 
should be known that intercourse with a patient who is seriously 





PULMONARY TUBERCULOSIS Ig! 


ill, but cleanly in his habits, is less dangerous than with a slightly 
affected but uncleanly person; that the use of the sputum flask by 
the patient is not a danger, but a protection, to others; that close 
contact with a tubercular person in the same house, and even in 
the same room, does not necessarily entail a danger of contagion ; 
and that not every bacillus which reaches the lungs need cause 
tuberculosis. 

Every healthy organism has a number of forces automatically 
working for protection, and which are capable of rendering harm- 
less certain infections. Nevertheless the body may succumb if 
the infection is severe or continuous, or if the organism is tem- 
porarily weakened, or is habitually predisposed to the disease. 
We are apt to consider such a transitory or permanent lowering 
of the defensive powers as an inherited or inborn disposition to 
tuberculosis. Individuals may be protected by warning them 
firstly to avoid close continuous intercourse with phthisical 
patients, especially uncleanly persons living in close, unhealthy 
rooms, secondly to maintain a good state of general bodily health, 
and thirdly to raise their resistance as much as possible. 

These prophylactic means can be employed not less often 
in everyday life than the antibacillary measures, and are applic- 
able to all classes of society, and to all ages. For example, the 
question of marriage of tubercular persons often arises. We are 
obliged to discountenance the marriage of recent cases of pul- 
monary tuberculosis of both sexes, for reasons which have already 
been given, and also that of women suffering from the more 
chronic forms of disease, in spite of favourable social conditions. 
The scientific principles of heredity are not sufficiently known 
to justify the legal prevention of marriage by consumptives on 
account of racial reasons and the transmission of the predisposi- 
tion. Another example of everyday occurrence is that we are 
often required to assist in the choice of an occupation for a weakly 
youth, burdened with a bad family history. It may be assumed 
that he will probably get stronger and remain well if he under- 
takes a light occupation chiefly in the open-air; while under the 
same conditions of infection he will fail a victim if his calling 
compels much exertion, or a sedentary life in dusty or confined 
atmosphere. The school and family doctor could do much good 
in this direction. 

Hardening the body, exercises, sport, care of the mouth and 
teeth, appropriate clothes suitable to the season increase the 
individual power of resistance against injurious influences, and 
remove already existing weakness of the organism. On the other 
hand insufficient food, alcohol, unhealthy home conditions, 


192 A CLINICAL SYSTEM OF TUBERCULOSIS 


injurious occupations, uncleanliness, tight clothes, hampering the 
breathing, &c., prepare the soil to receive the bacilli. Many of 
these points involve questions of hygiene which may be dealt 
with by the Legislature. We need only mention the housing 
difficulty, an exampie of which we find in the fact that in Berlin 
over half a million of people live in houses in which every room 
is occupied by five or more people. | According to the official 
statistics of Berlin 228 cases who died of consumption in the 
year 1903 occupied till their death the same room as two other 
persons, 169 the same as three others, 153 as four, seventy-five as 
five, forty-five as six, twelve as seven, six as eight, and six as ten 
or more other people; and that the same room served for sleeping, 
living, and eating. Altogether 8,229 persons were living in one- 
roomed dwellings with consumptives. In Schoneberg, near 
Berlin, a house inspection of 400 dwellings containing 439 con- 
sumptives produced the following results: In 103 cases the 
patient lived with his family in one room, kitchen, or corridor; 
in thirty-nine cases there were five to eight people in a single 
room ; only forty-six patients had their own bedroom separate from 
the healthy, and thirteen of these slept in the kitchen; twenty-six 
shared their couch with children or adults. 

The housing question is therefore of immense importance for 
the prophylaxis of tuberculosis, and it is one which the medical 
profession must not weary of emphasizing. The decrease of the 
tuberculosis statistics in England show that the care of the 
dwelling is one of the most important weapons in the fight against 
consumption ; the quicker and the more completely the prevailing 
conditions can be remedied, the smaller our difficulties will become 
in the future. 

Besides aiming at a wide measure of housing reform we must 
never relax our efforts towards attaining an effectual domestic 
prophylaxis against tuberculosis, the essential points of which 
have already been enumerated, and which should form part of the 
instruction given in schools. The house is not only the produc- 
tion of the architect, but also of those who live in it. When we 
remember that tubercular human beings are the source of tubercu- 
losis, then ‘‘ it becomes less important how the house is built than 
how it is kept’? (Kirchner). 

Closely connected with the housing question is that of 
alcohol. The man who comes home from a dusty workshop and 
finds no comfort is only too apt to seek company in the public- 
house, and warmth and stimulation in alcohol. The following 
data bear on the connection between alcoholic excess and the — 
tuberculosis mortality: The mortality from tuberculosis in per- 





PULMONARY TUBERCULOSIS 193 


sons over thirty 1s from two to three times as great amongst males 
as amongst females, the latter being less addicted to alcohol. 
At greater ages the excess of tuberculosis mortality among men 
as compared with women becomes greater. In other countries 
the tuberculosis figures are highest in those districts in which the 
consumption of alcohol, and especially of spirits, is greatest per 
head. There is a marked excess, too, of the mortality of tubercu- 
losis among those occupied in the spirit trade, compared with 
other occupations which also entail confinement in close rooms but 
without exposure to alcohol. In Germany the tuberculosis mor- 
tality among brewers is more than double, among publicans more 
than three times, and among barmen more than four times, that 
of the average for the German Empire. The reasons are obvious. 
Chronic alcoholism lowers the powers of resistance to infection of 
the whole body, and especially of the lungs. Then when the 
bacilli have entered, the protective forces which should oppose 
them are weakened. Also when there is a considerable part of 
the income sacrificed to alcohol the outlay on food, housing, &c., 
will fall below what is necessary. Above all, parents and educa- 
tors must be shown that alcohol does not build up but destroys 
the tissues, and that alcohol in any form or any quantity musi be 
forbidden to children and youths. If they are allowed to take 
alcohol regularly, to strengthen them or for other reasons, a race 
of candidates for consumption will be produced. So the fight 
against tuberculosis includes that against alcohol. 

A large amount of pulmonary tuberculosis is the result of 
other illness and disturbances of general nutrition (anemia, 
chlorosis, asthenia, &c.); also of non-tubercular pulmonary 
diseases (bronchial catarrh, pneumonia, whooping cough, pneumo- 
coniosis), of non-tubercular affections of other organs (diabetes 
mellitus, syphilis, measles, influenza), and, lastly, of tubercular 
affections of other organs than the lungs (pleura, glands, bones, 
and urino-genital organs). These will be considered in other 
sections, especially that on scrofula and tuberculosis of infancy. 

R. Koch shortly before his death drew attention to the spread 
of tuberculosis in country districts, and Jacob has shown the very 
defective hygiene which exists in them even to a greater 
extent than in the towns. The chief factors are unhygienic sleep- 
ing apartments, unhealthy schoolrooms and inns, insufficient 
feeding of the children, alcoholism, uncleanliness, absence of any 
care of the skin and teeth, and inadequate clothing, all leading to 
a spread of contagion, which is unhindered by any prophylactic 
measures, until actually whole villages have the disease. The 
individual doctor with the best will can do little here; far-reaching 


13 


194 A CLINICAL SYSTEM OF TUBERCULOSIS 


radical measures are required to stop what has become an 
epidemic. A network of dispensaries under energetic organiza- 
tion would deal best with the evil. 

There remains to be considered the question whether for the 
purpose of prevention most attention should be directed to infec- 
tion or to predisposition. It is certain that both factors are not of 
constant value, but vary considerably according to time and 
place. It is clear that without previous infection no tubercular 
disease is possible, but infection and disease are not always 
identical, and the one does not always follow the other, but the 
occurrence of disease depends in the main on the constitution. 
it can never be established in a single case whether infection has 
led to the disease in the absence of predisposition. On the other 
hand we are agreed from the results of post-mortem examinations, 
and the cutaneous tuberculin test, that in spite of the existence of 
infection tubercular disease is frequently absent. 

Practically the conditions in every case are such that “‘ family 
infection ’’ and “‘ family predisposition ’’ cannot be distinguished 
or separated from each other in their results. We must in the 
interests of the coming generation try and arrest family and house 
infection by all means in our power, and at the same time combat 
family predisposition just as energetically, so that the individual 
may not fall a victim to infection received outside the family. 

In prophylaxis extremes are even less justified than in treat- 
ment. We therefore exhort infectionists and predispositionists to 
work together for practical purposes; in medio tutissime ibis. 
For the development of phthisis both infection and individual pre- 
disposition are necessary ; therefore our preventive measures must 
be directed against both. 


y 





CEA PIER, 


Tuberculosis of the Pleura. 


THE anatomical and physiological connections of the pleura 
are of importance in relation to the occurrence of tuberculosis. The 
pleura is a kind of large lymph-sac with innumerable lymphatic 
apertures; it communicates with the glandular system, and is 
susceptible to tubercular infection to a slighter degree than the 
lungs. In conditions of increased infection the power of absorp- 
tion may fail and the pleura become affected, but it possesses a 
natural means of defence in the form of inflammation. Inflamma- 
tion of the pleura is thus an effort, by means of productive and 
exudative changes, to weaken and make powerless the specific 
infecting agent. 

From the arrangement of the pleura it follows that in nearly 
all cases the tubercular infection is carried to it from 
the lung. Either a tubercular focus in the lung breaks through 
into the pleural cavity, or it extends to the pulmonary pleura and 
thence to the parietal pleura by continuity. On the other hand 
the lymphatic channels between the pleura and the neighbouring 
organs may permit the entry of tubercle bacilli into the pleural 
cavity. The blood-stream is rarely the path of infection. 


1. TUBERCULAR PLEURISY. 


The anatomical changes in tuberculosis of 
the pleura are the same as in pulmonary 

Changes. tuberculosis. Only from the arrangement 
and struciure of the pleura exudation is usually more important 
and tissue formation or necrosis less so. 

If the tuberculosis of the pleura occurs without being accom- 
panied by inflammation it takes the form of a simple eruption of 
tubercles. Miliary tuberculosis of the pleura may occur as a part 
of general miliary tuberculosis, or as a localized formation of 
miliary tubercles over a chronic tubercular nodule in the lung. 
The accompanying exudation is nearly always sanguineous. 


Anatomical 


1g6 A CLINICAL SYSTEM OF TUBERCULOSIS 


The second, and on practical grounds more important 
variety is the appearance during chronic pulmonary tuberculosis 
of a tubercular pleurisy. Inflammatory changes of a productive 
or exudative character predominate, without the pleural surface 
being necessarily affected. 

Tubercular pleurisy takes many forms, from a_ localized 
fibrinous exudation to an extensive thickening and adhesion of 
the pleural surfaces; while different grades of inflammatory 
exudation into the pleural cavity may occur. These forms, like 
those of pulmonary tuberculosis itself, are extraordinarily variable 
and fluctuating. The old division of dry and exudative pleurisy 
is useful on practical grounds, though there are also many 
transitional forms. 

By dry tubercular pleurisy is meant the purely fibrous form 
in which there are slight circumscribed thickenings of the pleura, 
or a fine coating of fibrin, which with greater exudation becomes 
an extensive, thick, shaggy membrane. It usually accompanies 
slowly developing disease of the apical region, and is frequently 
found on the para-veriebral portion of the apex of the lung, and 
at the base, especially in the postero-lateral region. The fibrinous 
exudation may be either completely absorbed or become organ- 
ized with granulations and connective tissue. In the granulation 
tissue covering the pleura tubercles also appear. As a residuum 
of old fibrinous pleurisy one finds at post-mortem examinations 
fibrous nodules, circumscribed thickenings of different size, and 
adhesions in the form of strands or bands or extensive cohesions 
of both pleural surfaces. These changes are found in nearly all 
cases of phthisis, especially at the apices of the lungs. 

When extensive masses of fibrin become organized very hard 
fibrous cicatrices, often 1 or 2 cm. thick, are formed, which by 
the deposition of lime salts often become calcified. These 
changes are what is known as fibrous pleurisy, or if both pleural 
surfaces are matted together, as adhesive pleurisy. | Circum- 
scribed adhesions may become drawn out in the form of bands 
between the chest wall and the lung. If between the adhesions 
there are the remains of an effusion the term sacculated pleurisy 
is used. 

The dry pleurisy is the same ztiologically as the exudative 
form, the tubercular pleurisy with exudation. |The exudation 
may be serous, sero-fibrinous, or purulent, or each variety may 
become haemorrhagic from the mixture of blood out of the dis- 
tended capillaries. 

The purely serous exudation is not different from that found ~ 
in non-tubercular cases. As a rule there are neither tubercle 





TUBERCULOSIS OF THE PLEURA 197 


bacilli to be discovered in the exudate, nor specific changes in 
the pleural cavity. It is often due to a toxic irritation of the 
pleura proceeding from an existing tuberculosis of the lung. 

In the sero-fbrinous inflammation there is a variable mixture 
of serous exudate and fibrin. The fibrin appears as a delicate, 
fine, membranous deposit on the wall of the cavity, and as finer 
fibrinous flocculi in the exudation fluid. Tubercle bacilli can 
be discovered in the exudate. 

The quantity of serous and sero-fibrinous exudate is usually 
about half to two pints, but may reach three to five pints, and 
compress the lung severely. The compression of the lung may 
reach such a pitch that it forms an airless, atelectatic stump. 
According to the amount of exudate, displacements of the neigh- 
bouring organs, the heart, the diaphragm, the liver, the stomach, 
the colon, &c., may occur. But adhesion of the lung to a 
neighbouring organ may prevent displacement. If there is only 
an incomplete absorption of the exudation there will be more or 
less extensive organization and new formation of blood-vessels 
and connective tissue which have already been described under 
dry pleurisy. Long-continued pleurisy with exudation frequently 
leads to marked thickening. 

Purulent tubercular pleurisy or tubercular empyema may be 
due to tubercle bacilli exclusively, or to the entry of other organ- 
isms. It is not rare to find an empyema free of organisms 
in tuberculosis, which has been explained as the result of the 
chemical irritation of a bacterial toxin. 

The condition favourable for the production of a tubercular 
empyema is the occurrence of a tubercular cavity close under the 
pulmonary pleura, a situation where it may also cause a pneumo- 
thorax. 

In purulent pleurisies the cavity is covered with a pyogenic 
membrane; sometimes a fibrinous deposit permeated with liquid 
pus settles at the bottom of the pleural space. In the pus tubercle 
bacilli can generally be discovered. In these cases also there 
may be a partial organization and connective tissue formation. 
When these form septa and break up the purulent exudate, one 
speaks of a loculated empyema. 

As to the frequency of tubercular pleurisy 
there is a great difference of opinion. While 
Landouzy recognizes 98 per cent. of all so- 
called simple pieurisies as tubercular, according to Stintzing not 
more than half of them are; Jakob and Pannwitz put it at 10 per 
cent., v. Sokolowski at only 2.8 per cent. The estimation of 50 
per cent. seems to be most nearly correct, since extensive statistics 


Symptoms and 
Course. 


198 A CLINICAL SYSTEM OF TUBERCULOSIS 


show that ‘‘ idiopathic’’ pleurisies are in about half the cases 
tubercular, and indeed regularly so during the first five years of 
life. 

In any case pleurisy, in all its anatomical forms, is very 
frequently tubercular. It is nearly always secondary, usually to 
pulmonary tuberculosis, more rarely to tuberculosis of the bron- 
chial and mediastinal glands, or of the vertebra, the ribs, the 
peritoneum, or the pericardium. Or the tubercular infection 
may be transported to the pleura by means of the lymphatics from 
a more distinct source, as for example a tubercular rectal fistula. 
Pleurisy may be merely a part of a general miliary tuberculosis. 

The possibility of a primary disease is allowed; that is, the 
bacilli may reach the pleura through a penetrating wound of the 
thorax, or by way of the tonsils, bowel or lungs, without affecting 
these organs; but such an occurrence has no practical importance. 
The cases in which an apparently sound person is attacked with 
pleurisy and afterwards manifests signs of lung tuberculosis are 
to be explained by a latent lung tuberculosis, which first produces 
pleurisy and later shows itself in its true form. 

Men suffer from tubercular pleurisy much more often than 
women ; according to v. Ziemssen in the proportion of sixty-five 
to thirty-five. As predisposing causes exposure to cold and 
injury have a certain force. A meteorological influence is shown 
in the fact that there are most cases of pleurisy in January and 
fewest in the autumn months. 

Miliary tuberculosis of the pleura gives slight or no clinical 
evidence, so long as it does not lead to exudation or plastic 
inflammation. But it has a marked tendency to set up a spreading 
miliary tuberculosis. It has a fairly acute course. 

Dry tubercular pleurisy generally produces very characteristic 
symptoms. They consist of local feeling of pressure and constric- 
tion in the chest, and a dry irritating cough. Painful feelings of 
pressure, especially over the apex of the lung, are usually due to a 
localized dry pleurisy. The pains are increased with each inspira- 
tion, so that the respiratory movements are _ intentionally 
restrained ; the cough is anxiously repressed, or the pain lessened 
by fixing the diseased side. It is a characteristic sign that the — 
patient, even if the pleurisy is due to a genuine pneumonia, nearly 
always lies on the affected side. Fever is absent or slight in 
amount; existing tubercular fever is generally augmented. 

Percussion usually gives no clear evidence in dry pleurisy, — 
provided that the lung near the pleuritic nodules is normal ; some-_ 
times with lighter percussion the note seems to be shorter or 
weaker. 





war? 


TUBERCULOSIS OF THE PLEURA 199 


The breath sounds are weakened if there are adhesions or 
fibrinous layers between the pleural surfaces; in recent cases the 
inspiratory sound may be increased or it may be discontinued 
with the pulse rhythm. Inspiratory sounds intermitting with the 
pulse rhythm along the lower border of the lung are a frequent 
sign of dry pleurisy (Brecke) ; which may be explained by the fact 
that adhesions and inflammatory products in the pleura hinder 
the uniform expansion of the underlying lung. More definite is 
the friction rub heard with inspiration and expiration; it may 
frequently be also felt. Its character differs with the varying 
nature of the inflammatory roughening, which according io 
Franizel may be villous, shaggy, or areolar, or like a coating of 
hoar frost, or in thick lines, or like the marks on a sandy sea- 
shore, or like the dorsal surface of an ox-tongue. 

Dry pleurisy, with its sharp pains, is frequently in tubercu- 
losis the precursor of an exudation, more seldom of a hemoptysis, 
a pneumothorax, or of a sudden recrudescence of old, apparently 
healed nodules in the lung. Local pleuritic irritation may also 
occur over healed foci, without stirring them into activity, usually 
in the neighbourhood of cicatricial contraction, sometimes on the 
affected side, sometimes on the other; the neighbourhood of the 
heart is a favourite spot. 

Dry pleurisy may run a varying course. It may last for 
years in the same condition; or may be completely absorbed, 
leaving only a slight staining or thickening of the pleura. In 
other cases it leads to adhesions of the pleural surfaces, or it may 
develop into the exudative form. 

Tubercular pleurisy with exudation also usually begins with 
stabbing pains, increased irritative cough, and shortness of breath. 
While the pains and the cough diminish, when the increasing 
formation of fluid separates the pleural surface the shortness of 
breath increases, and in rare cases reaches the grade of ortho- 
pnoea. The amount of shortness of breath depends on the rapidity 
with which the effusion forms, and on the respiratory capacity of 
the other lung. Slowly developed effusions, even if large in 
amount, produce no marked difficulty of breathing if the other 
lung is sound or only slightly affected. It is therefore not so rare 
for patients with a tubercular effusion to perform heavy work, and 
the pleurisy may not be discovered on a superficial examination. 
Large effusions produce marked cyanosis from pressure of the 
fluid on the heart and vessels. The temperature is raised, usually 
to between 100° F. and 103° F.; both slight and high fever are 
uncommon. 

On inspection the increase of the affected side can be detected, 


200 A CLINICAL SYSTEM OF TUBERCULOSIS 


the intercostal spaces are enlarged, and in large effusions rather 
bulged; the affected side lags behind in inspiration or remains 
motionless. 

Lately Jacobeus has employed the cystoscope* used by 
Kelling for the serous cavities for the direct observation of the 
pleural changes. After removal of the exudate and the introduc- 
tion of filtered air or nitrogen, the intensity of the inflammation 
and the presence of tubercular nodules, &c., may be observed with 
the thoracoscope. 

The procedure is shortly as follows: After subcutaneous, intramuscular 
and perineural anesthesia, and after cutting through the skin, a trocar is 
introduced, preferably above the ninth rib, into the pleural cavity. The 
trocar must be large enough to admit a No. 12 Nitze’s cystoscope. After the 


fluid is removed, in fact, blown out, the cystoscope is introduced and the 
pleural cavity illuminated. 


The percussion note over the effusion is absolutely dull and 
flat, and above the area of dulness tympanitic, on account of the 
compression of the lung tissues. The limits of dulness vary with 
the position of the patient, the upper limit is horizontal in a 
patient who is getting about, and in the recumbent patient higher 
behind than in front or in the axilla. Large effusions may reach 
up to the clavicle in front and the spine of the scapula behind. 

On auscultation bronchial breathing is heard over the dulness, 
and weak bronchial breathing over the compressed lung. Vocal 
fremitus is weakened or lost. Over the tympanitic area above the 
effusion bronchophony on zgophony may be heard. The explana- 
tion is that the voice sounds are directly conducted from the 
broncho-tracheal air passages by the compressed lung tissue to 
the chest wall. 

The displacement of organs is more or less obvious according 
to the amount of exudation; the heart is drawn to the sound side, 
the diaphragm lies lower, and the liver also in right-sided effu- 
sions. The displacements are caused both by the pressure of the 
effusion, and by the loss of elasticity of the compressed lung. 

The urinary secretion is much diminished while the effusion 
is forming; the pulse rate is persistently increased. 

The different forms of exudation do not alter the clinical 
picture. Only tubercular empyema usually causes higher and 
more lasting fever with more marked daily remissions; though 
encysted purulent effusions may be quite without fever. However 
a free empyema may be quite without fever also, and a purely 
serous effusion may cause high fever. 

Bilateral effusions and pulsating pleurisy are very seldom 
met with in tuberculosis. 





TUBERCULOSIS OF THE PLEURA 201 


As to the course of tubercular effusions it may be first 
remarked that large effusions may form quite unnoticed by the 
patient. In other cases there may be only general symptoms, as 
heaviness, loss of appetite, gastric oppression, and other sym- 
ptoms which give rise to a suspicion of commencing phthisis. 
As the lung condition causing the effusion is often not recognized 
it will be very difficult to say how long the symptoms of the latter 
have lasted. 

There is no relationship between the character of the pul- 
monary tuberculosis.and the course of the tubercular pleurisy. 
Latent lung tuberculosis may be the starting point of pleurisy, 
and extensive cavities may leave the pleura unaffected. Very 
chronic phthisis may set up a most acute and frequently relapsing 
pleurisy, while rapid lung disease may be associated with very 
chronic pleurisy. The duration of tubercular pleurisy may be 
measured by weeks or months. The appearance of an effusion 
especially prevents an accurate forecast; just as pulmonary tuber- 
culosis has a variable course which cannot be foretold, so also 
has tubercular pleurisy. 

Tubercular empyema in adults occurs chiefly as a complica- 
tion of suppurative bone disease, or in connection with pneumo- 
thorax, pneumonia, or influenzal infection. |. Empyema causes 
severer symptoms usually than the non-purulent effusions. The 
fever is higher, ee warly intermittent, sometimes accompanied 
by chills; the weakness is greater, and the pulse very rapid. 
Sometimes there is slight oedema of the affected side. If the pus 
is not removed by operative measures in rare cases absorption 
and inspissation of the pus may occur. Usually the pus breaks 
through either into the lung, or more seldom into the peritoneum 
or other organs, or penetrates the chest wall (empyema _ necessi- 
tatis). From rupture into the lung a pyo-pneumothorax may 
result. 

A short account must be given of diaphragmatic, pericardiac, 
and interlobular pleurisy which are not uncommonly observed in 
tuberculosis either in the form of purulent or non-purulent 
inflammations. 

Diaphragmatic pleurisy is of definite practical importance as 
it may simulate abdominal disease, and the non-recognition of its 
purulent form may have severe consequences. The usual sym- 
ptoms of pleurisy are either quite absent or are not clear. The 
affection, which is localized between the base of the lung and the 
diaphragm, begins with pains in the side, painful vomiting, and 
slight difficulty of swallowing. An onset with severe dyspnoea 
or angina has been observed by Andral. On palpation the 


202 A CLINICAL SYSTEM OF TUBERCULOSIS 










































affected region is very tender. There are two most important 
points of tenderness. The first, described by Guéneau de Mussy 
as the ‘‘ diaphragmatic spot,’’ is a tender point at the point of 
intersection of a vertical line drawn through the outer edge of the 
sternum and a horizontal line at the level of the tenth rib. The 
second is along the course of the phrenic nerve in the neck on the 
same side. Further, there is the ‘“‘ respiratory abdominal wall 
reflex ’’ of A. Fraenkel, a sudden contraction of the upper part 
of the rectus muscle of the same side on deep inspiration, some- 
times also a reflex contraction of all the muscles of the abdominal 
wall. Other symptoms may be right-sided shoulder pain, pain 
on swallowing in the region of the cardiac orifice, gastric pains, 
vomiting, or hiccough. Osler recognizes as particularly charac- 
teristic of diaphragmatic pleurisy marked subjective symptoms 
with slight physical signs. A radiographic examination will 
make the condition clearer. A marked diminution or irregularity 
of the diaphragmatic. movement will be seen. Sometimes also 
bands of adhesions or projections or bends may be seen in the 
diaphragm ; while the complemental space is small and indistinct 
or quite unrecognizable. These changes in the diaphragm are 
not at all rare, and confirm the diagnosis of diaphragmatic 
pleurisy. 

Pericardial pleurisy is also of importance, left-sided dry 
pleurisy affecting that portion of the pleura that overlaps the peri- 
cardium. The symptoms consist of pain in the region of the 
heart, palpitation, and shortness of breath; while objectively weak 
or clear friction sounds are heard at the apex and left border of 
the heart, which accompany and partly obscure the heart sounds. 
They are characterized by being both diastolic and systolic, some- 
times they diminish with inspiration and become clearer with 
expiration, if the heart’s apex beat is weak or imperceptible, or 
is drawn in with systole. With the R6ntgen screen sometimes 
fine streaks are seen on the left side of. the heart shadow, occasion- 
ally in the form of a network. These thicken the heart shadow, 
and are put in movement with each pulsation; or they may pass 
from the heart to the shadow of the diaphragm. These cases are 
usually due to a chronic, relapsing, tubercular pleurisy; they 
cause confusion with cardiac disease on account of the breathless-_ 
ness and other symptoms, and not infrequently are ascribed to 
neurasthenia or cardiac hypochondriasis (Brecke). 

Interlobar pleurisy with effusion occurs when the edges of the 
lobes are glued together on account of previous inflammation; — 
fluid may then collect in the division between the two lobes, even 
to the extent of 14 pints or more. Sero-purulent and purulent 


if 


TUBERCULOSIS OF THE PLEURA 203 


exudations preponderate, and are not rarely found at autopsies as 
complications. There may also be large sero-fibrinous effusions, 
for the diagnosis of which a knowledge of the topographical 
anatomy of the interlobar sulci is necessary. I[¢ffusions of more 
than a pint usually can be detected at the side of the thorax in 
the axillary line; here they he directly against the parietal pleura, 
or are covered only by a thin layer of compressed lung, and may 
be reached with an aspirating needle. 

The onset is usually sudden, with stabbing pains, fever, 

chills, cough, and dyspncea. On physical examination there may 
be at first nothing detected, then dulness appears in the form of 
a slanting or transverse band following the line of the interlobar 
sulcus forwards from the vertebral column till it is lost in the 
liver or heart dulness. This band, which may be from # to 4 in. 
thick, is as it were suspended between two areas of resonance 
above and below. Traube’s space on the left side remains 
clear. On examining with the Rontgen ray the ‘* suspended ”’ 
shadow may be very clear, or it may be obscured or obliterated 
by old pleural thickenings. In more than 50 per cent. of cases 
the exudation makes a way into the lung, and is expectorated in 
mouthfuls, either in a sudden gush or by degrees. In interlobar 
empyema the expectoration is very foetid; the patient himself 
may recognize the commencement of the entry of pus into the 
lung by the foul taste or unpleasant smell of the expired air. 
The symptoms of interlobar pleural exudation, namely, a band of 
dulness between two resonant areas, a suspended radiographic 
shadow, and expectoration in mouthfuls are so _ inconstant 
and indistinct that the diagnosis is often very difficult and not 
uncommonly impossible. 
Tubercular pleurisy is often of subordinate 
clinical importance, when overshadowed by 
the existing pulmonary tuberculosis. But there are cases in 
which a diy pleurisy is the first symptom which brings the patient 
to the doctor, so that it is often of importance for early diagnosis. 
Pains in the front of the chest, stabbing pains in the side, sensa- 
tions of pressure or dragging over the apex of the lung are almost 
regular subjective signs in commencing pulmonary tuberculosis. 
They are dependent, since in the parenchyma of the lung there 
are no sensory nerves, usually on pleural changes. In tubercular 
patients, who have not had the slightest pain, one can be sure 
that the pleura is intact. On the other hand stabbing or dragging 
pains, which remain localized at a fixed spot, indicate pleural or 
sub-pleural changes. 

As a sign of miliary tuberculosis of the pleura Jiirgensen has 


Diagnosis. 


204 A CLINICAL SYSTEM OF TUBERCULOSIS 


described a particularly soft and delicate rub; it is usually masked 
by the louder respiratory sounds. 

The diagnosis of dry tubercular pleurisy is not difficult, if 
there is sufficient respiratory movement to rub together the pleural 
surfaces roughened by fibrinous exudation or by an eruption of 
tubercles. The friction sound thereby produced, from the lightest 
rub to the loudest grating or creaking sound, is not easily mis- 
taken. The pleural rub may be heard during the whole respira- 
tory phase, usually in inspiration, occasionally in expiration; in 
this it differs from the fine sub-crepitant rales over the apex, which 
are always loudest in the second half of inspiration, when the 
entering air reaches the bronchioles and alveoli. The pleuritic 
rub ceases when the breath is held; the more marked forms of 
friction can be felt. 

Rubs are not influenced by cough, but may often be increased 
by pressure on the intercostal space. They also seem to be nearer 
the ear and more superficial than the sounds produced in the 
lungs. At the same time it is possible to mistake the sound. We 
may mention here a fine crackling rale heard along the margin of 
the lung, especially in the axillary line between the fifth and 
eighth ribs. They are sometimes pleural, the result of a fresh 
fibrinous exudation, sometimes expansion rales from hypostatic, 
atelectatic or emphysematous changes in the lung. The latter, 
however, are only heard in the second half of inspiration or at the 
height of inspiration (Turban). Also cog-wheel and _ systolic 
vesicular breathing may be extremely like pleural sounds. A 
certain distinction sometimes cannot be drawn between pleural 
sounds and catarrhal rales; sometimes the pleuritic sounds dis- 
appear if the patient lies on his face. Also on radioscopic 
examination alterations of movement may be seen in dry pleurisy, 
so that Williams’s symptom, diminution of the diaphragmatic 
excursion on the affected side from mechanical hampering of 
pleural adhesions or from implications of the phrenic nerve in the 
apical pleura, may be observed. Pleural adhesions that throw no 
shadow cannot be diagnosed, but bands of adhesions are easy to 
recognize, if, for example, they fix the diaphragm or draw it into 
a prominence on deep inspiration. 

As the pleural surfaces become united the rub becomes 
weaker, and when adhesions are formed it can no longer be 
heard. Percussion also is usually negative. | Marked pleural 
thickening may cause dullness, like effusions; in opposition to the 
latter, however, they draw the chest walls in, and draw the neigh- 
bouring organs to the affected side. The R6ntgen rays show 
the pleural thickenings as broad plates, or isolated bands, the 







Ve Pei ered. 





TUBERCULOSIS OF THE PLEURA 205 


density of the shadow being proportional to the amount of light 
they absorb. If the thickenings lie near the screen, as when the 
light is transmitted from front to back, thick shadows will be 
seen; if they are further from the screen, as when the light passes 
from the back to front, the shadows will become less from the 
dispersion of the light. 

From changes in the underlying lung dry pleurisy can easily 
be distinguished by the displacement of the margin of the pleural 
surfaces. The fine crepitations along the margin of the lung in 
the anterior axillary line, which Burgart considers an early sign 
of apical tuberculosis, are often due to pleurisy. If the adhesions 
increase at the same time as the rub disappears there will be 
displacement of the lower margin of the lung. Kronig considers 
this sign, as has been mentioned before, of importance in the 
differential diagnosis between tubercular and non-tubercular apical 
induration. 

There is difficulty in diagnosing dry pleuritic changes of the 
upper part of the thorax, especially over the apex of the lung. 
Tenderness of the muscles of the shoulder girdle on pressure is a 
thoroughly unreliable sign. Friction sounds are produced here 
with difficulty, owing to the slight movement of the pleural sur- 
faces, and are often masked by other sounds. Pleuritic changes 
at the apex are also specially liable to cause adhesions. There- 


fore fine crepitations that appear to be produced close to the ear 


should be ascribed to the pleura, if they are not extra-thoracic 
adventitious sounds (produced in the shoulder-joint or muscles). 
Sometimes by physical means alone the diagnosis is not pos- 
sible. If an alteration in the position of the apex can be detected, 
if the side lags behind an inspiration, if the supraclavicular fossa 
is drawn in, and if the patient complains of pains or tenderness 
in this region, then the diagnosis of dry pleuritic adhesions at the 
apex may be made; and that in the vast proportion of cases is the 
same as a diagnosis of apical lung tuberculosis. So that these 
signs may be useful for early diagnosis. 

A differential diagnosis from intercostal neuralgia may be 
required. In this condition the pains are increased by bending 
the body to the affected side, which diminishes the pain of dry 
pleurisy. 

If after extensive examination there is a doubt as to the 
aetiology of dry pleurisy the subcutaneous tuberculin test should 
be employed. In cases of dry pleurisy the general reaction is 
often completed by a focal reaction; the patient complains of 
more pain in the suspected side, and the friction sounds become 
clearer and more extensive during the reaction. The result of 


206 A CLINICAL SYSTEM OF ‘TUBERCULOSIS 


such a focal reaction is quite free from danger... We have 
observed in our cases, which number some hundreds, that the 
disappearance of the reaction is accompaned by diminution of 
the previously existing pains and difficulty of breathing, and it 
never resulted in an inflammatory effusion. 

The recognition of a tubercular pleural effusion is usually 
easy. But there are cases in which there may be considerable diffi- 
culty in the differential diagnosis, especially if the previous history 
affords no indication as to how long the condition has lasted, 
or how it originated. Also in long-standing effusions there are 
often exceptional fibrinous and fibrous changes in the pleural 
cavity which obscure the diagnosis. 

Infiltrations of the lower lobe of the lung cause difficulty in 
the differential diagnosis. To distinguish pleural effusions from 
these Grocco’s paravertebral triangular area of dulness on the 
sound side is very valuable. This so-called Grocco’s triangle is 
met in cases of pleural effusion which are not encysted, reach 
the vertebral column and extend up as far as the eighth thoracic 
vertebra. There is on the sound side an area of dulness of 
triangular shape, which comes and goes with the effusion, and is 
never found in infiltration of the lung. 

The apex of the triangle, two sides of which are formed by the dome 
of the diaphragm and the vertebral column, lies at the level of the top 
of the fluid or deeper; the hypotenuse runs from this point in a sloping 
line downwards and outwards to the base of the lung; its outer end, which 
corresponds to the lower border of the lung, being about 1 to 3 in. from 
the middle line. The triangular duiness is best defined by the lightest 
percussion of the patient sitting up in bed; lying on the affected side causes 
it to disappear or become indistinct. 

The phenomenon was first observed by Grocco in 1902, and made more 
widely known by Rauchfuss in 1904. The cause of it is not yet clear. 
Examination with the Réntgen rays shows that it cannot be explained by 
displacement of the mediastinum; it is more likely to be due to an indirect 
influence affecting the note. The vertebral column acquires its norma! 
clear note from the air-containing lungs lying on both sides; when effusion 
is present the air-containing tissue is absent on one side, and the lower 
the percussion is carried downwards the more the vertebre and their 
immediate surroundings come under the influence of the fluid; at the upper 
border of the effusion the vertebrze still have a clear note from the lungs 
immediately above, but below this gradually fails (Nitsch). 


Grocco’s triangle is very valuable for differential diagnosis, 
especially in those cases in which for any reason a diagnostic 
puncture is not possible. It must be remembered that this para- 
vertebral dulness is absent in effusions undergoing rapid absorp- 
tion, and may be present with a cavity in the lower lobe. Ham- 
burger’s paravertebral dulness in the form of a band, that is 
obtained by strong percussion, 1s of no importance. 


4 
4 






















TUBERCULOSIS OF THE PLEURA 207 


For distinguishing between pleural effusion and croupous 
pneumonia the condition of the vocal fremitus is very valuable; 
it is increased in pneumonia, weakened or absent in effusion. 
The test fails in very feeble patients with a weak voice, and also in 
the not uncommon combination of pleurisy and pneumonia and 
in obstruction to the bronchus. For the diagnosis of pneumonia 
we must then rely on the sudden onset with chills, the continuous 
high fever, blood-stained sputum, the area of dulness following 
the outline of a lobe of the lung, the note not being absolutely 
dull, sometimes tympanitic, no paravertebral dulness on the 
sound side, the complemental pleural spaces remaining free, 
crepitant rales at the onset and resoiution, and loud bronchial 
breathing and bronchophony in the stage of hepatization. In 
favour of effusion there are absence of rigors, frequently a slow 
onset, irregular not very high fever, enlargement of the affected 
side, absolute dulness with upper limit horizontal or sloping 
downwards and forwards from the spine, Grocco’s triangular 
dulness on the sound side, dulness of the whole complemental 
pleural space, tympanitic note, bronchial breathing, and xgo- 
phony above the dull area. Circumscribed loculated effusions 
give various signs according to their localization. 

Tumours of the mediastinum often cause difficulty in 
diagnosis. Growths of the lung, which are much more frequently 
carcinomatous than sarcomatous, and mediastinal tumours, 
generally sarcoma or lympho-sarcoma, are characterized by a very 
gradual formation of an irregular, usually extensive, area of dul- 
ness; it often extends across the middle line, and is not only due 
to the presence of the tumour itself, but partly to concomitant 
atelectasis and partly to chronic inflammatory changes in the lung. 
As a consequence of stenosis of the bronchus, to the intense dul- 
ness is added considerable weakness or complete absence of the 
breath sounds, with disappearance or diminution of the rales and 
other adventitious sounds. So that dulness of a whole lower lobe, 
with weak breath sounds and vocal fremitus, may be ascribed to a 
pleural effusion, when it in fact is due to a carcinomatous nodule 
implicating the wall of the bronchus of the lower lobe, and com- 
pletely blocking its lumen, and to an indurative pneumonia conse- 
quent on the tumour. Intrathoracic tumours are generally 
revealed by neuralgic pains in the arm and shoulder, by dilated 
veins, or cedema in the skin of the chest, by symptoms of com- 
pression of the cesophagus or air passages, and by changes in the 
voice. Fever is usually absent. 

The diagnosis is still more difficult if the pleura itself is 
involved in the new growth. There is then a pleural effusion 


se = 









208 A CLINICAL SYSTEM OF TUBERCULOSIS 


formed which displaces the neighbouring organs and completely 
masks the changes in the lung. Aspiration is here of value, as 
in spite of the removal of the fluid there still remains a large 
amount of dulness, and the patient is not sufficiently relieved. 
The fluid is usually blood-stained, and in some cases of new 
growth contains characteristically formed elements indicative of 
tumour, which in rare cases can be recognized by the naked eye. 

In the microscopical examination of the cellular elements of pleural 
fluid care must be taken not to confuse simple pleural endothelial cells 
with tumour cells. ‘‘ Only groups of cells, the elements of which show a 


distinct polymorphism, such as is characteristic of tumour cells, must be 
relied on” (A. Fraenkel). 


Lastly, diagnostic difficulty may be caused by the rare form 
of primary tumour of the pleura, the endothelial cancer of the 
pleura, also known as pleuro-endothelioma. Apart from the 
rare cases in which thick fibrous infiltration with excavated raised 
nodules form in the pleura, pleuro-endothelioma may be recognized 
by the rapid, unhalting development and course of the disease, 
the effusion of a large quantity of blood, the rapid refilling of 
the pleura after aspiration, and the consequent small benefit there- 
from received by the patient. Sometimes an unusual amount of 
blood in an effusion drawn from a patient, who before and after 
the aspiration complains of excessive pain, usually from pressure 
of the nodules, is against tubercular pleurisy, and gives rise to 
a suspicion of pleuro-endothelioma. 

In every case the diagnosis of pleural tuberculosis in all its 
details is very difficult, and the R6ntgen ray examination is of 
much service. By this means it may be seen that even quite 
small effusions, which on inspiration are otherwise clear, darken 
the phreno-costal angle, as the fluid first fills the deepest part of 
the pleural cavity. With increasing effusion the upper limit of 
the fluid takes a curved shape (Damoiseau’s line), being higher in ~ 
the axilla than in front and behind. With large effusions, 
besides the marked darkening of the lung shadow, there may be | 
seen the characteristic displacement of the front of the mediastinum 
above and the posterior part below to the sound side, the heart 
being also changed in position. Only on the nature of the 
exudate the rays give no information, as the atomic weight of the 
constituents do not vary enough to affect the density of the 
shadow. 

Therefore the most careful physical and radiographic exam- 
ination does not indicate the character of the fluid. Baccelli’s 
sign, that on auscultation the whispering voice can be clearly 
heard through a serous effusion and not through a purulent one, 







Cee ee) a ee 












TUBERCULOSIS OF THE PLEURA 209 


is of some value, but not constantly so. Also the history of the 
disease and the course of the fever only give probable indications 
which frequently fail. 

The only sure information on this point is given by puncture. 
It is a procedure without danger, but not entirely without draw- 
backs. Exploratory puncture should be reserved for those cases 
in which the nature of the effusion is in question. Haemophilia, 
or a suspicion of bronchiectasis, or of abscess or gangrene of the 
lung are contra-indications. 


The technique of the exploratory puncture is as follows: The syringe 
should contain 5 to 10 c.c., and have a polished piston; it should be all 
of glass and capable of being boiled. The needle should be at least 23 in. 
long, which is long enough to enter the cavity at any point of the chest 
wall; its lumen should be at least 13 mm., so as to allow thick pus to be 
withdrawn. The ordinary hypodermic syringe is in no way suitable. 

Before use the syringe is to be boiled and tested with 34 per cent. 
carbolic acid solution. The point of puncture depends on the position of 
the effusion. It is best done below and behind in the eighth or ninth 
intercostal space in the scapular line; the thickness of the chest wall here 
in adults is about 13 in. If the puncture is made more in the axillary 
line it must not be below the seventh space. If one chooses the sixth space 
in the mid-axillary line the wall is only about 3 in. thick. The puncture 
must be made at the upper edge of a rib to avoid injury to the intercostal 
vessels. 

After the place has been chosen the skin must be disinfected with two 
applications of tincture of iodine, fixed with the left forefinger, also treated 
with iodine, and anesthetized with ethylchloride or injection of novocain. 
The needle is then quickly inserted in a horizontal direction for about 
2 in., and then more slowly advanced till the resistance suddenly ceases 
and the point is felt to be free in the pleural cavity. The piston is to be 
slowly withdrawn till the syringe is full of the fluid; the needle is then 
quickly withdrawn, and the puncture closed with strapping or collodion. 
If the skin is slightly displaced before the puncture the hole will be more 
securely closed. 

Failure may occur from introducing the needle not deep enough or too 
deeply; in the latter case there may be some blood-stained expectoration or 
some frothy blood in the syringe. If the diaphragm lies high it, or the 
liver, or the spleen, may be wounded. Success may be impossible on 
account of the needle entering an old adhesion, or being blocked with 
masses of fibrin or gelatinous exudate. In all such cases the needle may 
be moved forwards or backwards or reintroduced at another spot, if the 


assumption of an effusion is well founded. 


Bad effects from a puncture are very rare. Infection of the pleural 


cavity can be always prevented by proper precautions, as can also entry 


of air. The intercostal nerve and artery can always be avoided by proper 
technique. Puncture of the diaphragm, liver, or spleen, has usually no 
bad consequences; neither has entry into lung, if there are no suppurative 
Or gangrenous processes. In nervous, over-excitable, or cardiac patients, 
it is always advisable to make the process painless, preferably by an in- 


jection of novocain. 


The fluid obtained by puncture tells us if the effusion is 
is 


210 A CLINICAL SYSTEM OF TUBERCULOSIS 


serous or purulent, or whether it is clear, thick, hemorrhagic, or 
bad-smelling. A specific gravity below 1,015 is in favour of a 
passive transudation. A microscopic examination gives evidence 
of the presence of formed elements or bacteria. 

The bacteriological examination of the fluid is important. 
Apart from hydro- and haemothorax we must separate from tuber- 
cular pleural effusions those due to pneumonia, rheumatic and 
traumatic conditions, and staphylococcic, streptococcic, and 
streptothrix empyemata. In the majority of cases a careful 
physical examination will reveal the origin of the effusion, 
while a complete inquiry into the history of the case may 
show if it is tubercular. However, there are always some cases in 
which there is nothing to show the nature of the pleurisy, and in 
which other diagnostic aids are necessary. So that we are 
brought back to the further examination of the fluid withdrawn. 

Stained preparations of the centrifugalized deposit hardly 
ever give positive information in serous effusions, and in purulent 
exudations tubercle bacilli cannot regularly be discovered. By 
the use of the antiformin method on the one hand, and of Much’s 
modification of Gram’s method of staining on the other, positive 
results are obtained more often. Still at present bacteriological 
examination usually fails with serous effusions. 

Animal experiment may be employed in the form of intra- 
peritoneal injection of the fluid into guinea-pigs. The method 
is not absolutely certain, and takes at least three to four weeks 
to give a result ; but at the same time it is the best method we have. 
To exclude error 20 to 30 c.c. of the effusion should be removed 
from the pleural cavity and 10 c.c. injected into the peritoneal 
cavity of two or three guinea-pigs. 

Of new methods of the examination of tubercular and other 
pleural fluids we may mention the inoscopy of Jousset. In order 
to facilitate the recognition of the bacilli in the exudate it aims at 
setting them free from the clot so that they may be centrifugalized 
to the bottom. 

100 c.c. of the withdrawn fluid is allowed to stand till the fibrin clot 
forms spontaneously. This is washed with water, and digested with the 
tollowing fluid: Pepsin 1, glycerine 10, hydrochloric acid 10, fluoride of 


sodium 3, distilled water 1,000 parts. The mixture is placed in a thermostat 


for 2 to 3 hours at 38° C., or heated in a water bath for a short time 
at 50° C. The digested mass is then centrifugalized and the sediment 
examined. By this method Jousset found in twenty-three cases of pleural 
effusion, of which seventeen were not tubercular clinically, tubercle bacilli 


twenty-three times. It has rarely failed us in several cases tried. 


W olff-Eisner first described, and Widal has especially con- 
firmed, a form of cyto diagnosis, by estimating the proportion of 





FUBERCULOSIS OF TFHE PLEURA 211 


lymphocytes in the leucocytic contents of the effused fluid. If the 
lymphocytes preponderate it is in favour of tuberculosis; if the 
polynuclear leucocytes, then a non-tubercular septic inflammation 
is more probable. The observations of many authors show that 
50 per cent. and more lymphocytes in the fluid make the presence 
of tuberculosis probable but not certain. 


The fluid removed with aseptic precautions is centrifugalized, and the 
sediment is placed on an object-glass fixed and stained for a quarter of a 
minute with Loffler’s methylene-blue. 


Testing for tubercular empyema with Millon’s reagent has 
given us no good results. 

The subcutaneous tuberculin test is contra-indicated in pleurisy 
with effusion as long as there is any fever. Also after the fever 
has gone the tuberculin test is not always quite definite, since the 
focal reaction can hardly be detected in the presence of effusion 
or pleural thickening, and a general reaction may be caused by 
another tubercular focus in the body, e.g., in the tracheobronchial 
glands, that has nothing to do with producing the pleurisy. 
Miliary tuberculosis has an unfavourable 
prognosis. Dry tubercular pleurisy usually 
runs a favourable course. The fibrinous exudation becomes 
reabsorbed, or organized, or produces adhesions of the pleural 
surfaces. Darkenings and thickenings of the pleura are signs of 
commencing healing. Less favourable are the cases in which an 
eruption of tubercles occurs in the pleura over a pulmonary focus. 
The advance of the original disease makes improvement or cure 
unlikely. Sometimes a pleural fistula with pneumothorax is 
produced, or there may be an outbreak of miliary tuberculosis. 
More frequently dry pleurisy is the forerunner of an effusion. 
The observation of Ké6sters is important, that in cases of dry 
“idiopathic ’’ pleurisy more than 4o per cent. were attacked later 
by pulmonary tuberculosis, usually in the first five years after the 
pleurisy. 

In cases of tubercular pleural effusion the clear serous and 
sero-fibrinous forms are considerably more favourable than the 
purulent, and the non-hemorrhagic than the sanguineous, sup- 
posing that the original pulmonary tuberculosis to be in the same 
stage in each case. In cases of serous and sero-fibrinous pleurisy 
of a tubercular nature healing of the latent or initial pulmonary 
tuberculosis with recovery of the strength can usually be com- 
pletely secured by suitable treatment. There can to-day be no 
more doubt that the occurrence of a pleural effusion has a favour- 
able effect on the mischief in the lung, taking one case with 


Prognosis. 





212 A CLINICAL SYSTEM OF TUBERCULOSIS 


another, and not only so in advanced cases, but also in the 
frequent cases in which pleural effusion appears in the initial 
stages of pulmonary tuberculosis. The compression and immo- 
bilization of the lung by the effused fluid give a strong impetus 
towards an improvement of many of the symptoms. This is 
particularly so if the lung on the non-affected side is quite sound, 
or almost so, while on the side of the effusion there is considerable 
disease. It is on this that the treatment by the formation of an 
artificial pneumothorax is based. But it is certain that it is not 
only the compression and immobilization of the lung which give 
the impetus towards healing ; for the real initial pleurisy, in contra- 
distinction to the pleural complications of advanced phthisis, even 
if there is only slight effusion, runs a favourable course with 
great regularity. Besides the mechanical effects of the effusion 
there are also the chemical influence of the pleural reaction and 
lymphocytic reaction to be taken into account. K6niger correctly 
considers that the cases of pleurisy are the most favourable in 
which the pleural symptoms predominate, and distinguishes, 
according to the state of the temperature, between the cases of 
simple pleurisy and atypical forms, in which other tubercular pro- 
cesses, especially in the lungs, are a prominent feature. The first 
characterized by fairly continuous fever, regularly falling by lysis, 
is the more favourable pleuritic form; while the atypical cases of 
unfavourable prognosis are marked by irregular, intermittent 
fever, which falls slowly with a long sub-fibrile period, and are 
accompanied by marked sweating, prostrations, and other compli- 
cations, especially the appearance of tubercular foci elsewhere. 
In severe cases of bilateral pulmonary tuberculosis the appearance 
of pleurisy is an unfavourable sign, but not always so even then. 

Other important points in the prognosis are the general state 
of the constitution, the treatment that is employed, and the kind 
of life that the patient is to lead aferwards. Allard followed up 
200 cases of pleurisy, some as long as twenty-eight years after 
recovery, and observed that those who had a good fresh colour 
had a better prognosis than those who were pale, even if the pallor 
was associated with good muscles or corpulency. In a large 
proportion of cases tuberculosis appears on the same side as the 
pleurisy. It is important that patients with pleural effusion of 
tubercular origin should remain under treatment till both the 
pleural and lung symptoms have disappeared. The patient 
recovered from a pleural effusion should be treated according to 
Penzoldt ‘‘as a lung case with latent tuberculosis.’’ It would 
then be more rare for tubercular symptoms in one form or another 
to appear years after recovery from pleurisy. There can be no 








TUBERCULOSIS OF THE PLEURA 213 


doubt that the prognosis of tubercular pleurisy also depends on 
the social conditions of the patient, just as it does in pulmonary 
tuberculosis. 

The prognosis of tubercular empyema is much worse than 

that of serous effusion. It depends on the nature of the lung 
condition causing the empyema, and also on timely operative 
interference. In favourable cases healing may take place within 
four to six weeks, but it may also require many months. If 
operative measures are not employed at the right time the 
empyema may break through into the lung or exteriorly, and the 
prognosis becomes worse. Incomplete healing and formation of 
a fistula is usually followed by amyloid degeneration of the 
organs. 
The foundation of all treatment of pleurisy 
must be the general constitutional measures 
which have already been described in the chapter on Pulmonary 
Tubercle. They are also demanded for prophylactic reasons, 
since the treatment of the pleurisy will at the same time be con- 
ducive of healing of the primary lung mischief. Only after such 
a course of treatment can it be expected that the lungs will remain 
healthy ; so that in the course all such measures must be included 
as are required both for the pleurisy and for the conditions in the 
lungs which cause it. 

Treatment is useless for miliary tuberculosis of the pleura. 

Medical aid is often not demanded for dry tubercular pleurisy. 
If it is it will be on account of the stabbing pain, or irritating 
cough. Both require bodily rest, best taken in bed either lying 
on the back or sitting up. If the pains are slight, and there is 
no fever, and the other conditions are good, the open-air cure may 
be employed, all movement being forbidden. The patient must 
be kept in as complete a state of rest as possible, so as to diminish 
all mechanical irritation of the pleura; he requires careful atten- 
tion and nursing under favourable hygienic conditions. 

The rest will be assisted by a band of strapping 4 or 5 in. 
broad on the affected side. In order to limit the movements of 
the chest wall as much as possible it must be firmly applied during 
expiration, and must reach from the sternum to the spine. One 
may also employ several narrower straps overlapping each other, 
as recommended by Niedner. Compression by a bandage is of 
no service; it must either be fixed too firmly, or it slips away from 
the seat of pain. The strapping may cause eczema if the skin is 
sensitive ; and its removal is disagreeable if there are many hairs. 
Kuhn’s method of producing rest by fixing the arm is very useful ; 
the arm of the affected side is fixed by bandaging the wrist with 


Treatment. 


214 A CLINICAL SYSTEM OF TUBERCULOSIS 


a soft flannel bandage to the upper part of the thigh of the opposite 
side, which is slightly flexed. When the thigh is stretched out the 
arm will draw the shoulder down; the patient must lie rather on 
the affected side, so that the arm presses against the thoracic and 
abdominal walls, and considerably diminishes the movement of 
the chest wall and diaphragm on that side. Packing the affected 
side with sand-bags may also be used to diminish the movement. 

Moist compresses may be also applied to the affected side; 
they will both diminish the movement, loosen the expectoration, 
soothe the cough, and the nervous system, and promote 
reabsorption. Their action may be increased by the addition of 
alcohol. If there is marked dyspnoea compresses must not be 
used, as removing and changing them increases the difficulty of 
breathing. Hot fomentations, which are easy to renew, and often 
do good by producing hyperemia, may be then employed. In 
the same way electric baths and hot air baths act. For severe 
pains an ice-bag often gives the quickest relief. Neither hot 
fomentations nor ice-bags are useful in all cases; the reaction of 
the patient varies so much, that if no good is derived from one, 
the doctor may change to the other. 

As counter-irritants to the skin there are special applications 
which may be employed, especially painting with tincture of 
iodine, with iodoform-collodion (1 in 10), with guaiacol tincture 
of iodine (guaiacol 5 parts, tinct. iod. and glycerine aa 25 parts), 
mustard leaves and mustard plasters. For slight ambulant 
cases we recommend rubbing with iodo-vasogen, painting the 
painful area with oil of turpentine, and afterwards covering 
it with gutta-percha tissue, or, where obtainable, dry cupping. To 
promote absorption ointments may be rubbed in, especially 
hydrarg. ammon., potas. iodid. and guaiacol salicylate (10 per 
cent.). We do not value ointments highly for this purpose, and 
prefer to promote absorption of pleural exudates by the daily use 
of hot-air baths. 

Diaphoretic measures, such as drinking hot fluids, hot baths, 
and hot packs are almost entirely unsuitable for tubercular forms 
of pleurisy. Short radiant heat or hot-air baths may often be 
employed with good results. 

For internal treatment sodium salicylate in doses up to go gr. 
a day is to be highly recommended for the acute pains of dry 
tubercular pleurisy. Salicylates in smaller doses of 8 gr. a day, 
with or without iodides, may be given for long periods. Finkler 
has observed diminution and disappearance of the dulness and 
friction during its use. In the frequent cases in which the stomach 
does not support sodium salicylate well we order salipyrin (15 gr- 


TUBERCULOSIS OF THE PLEURA 215 


a day) or Dover’s powder (4 gr.) for diminishing the pains, and 
dionin or codein for the cough. We have often observed marked 
improvement after an undisturbed night’s rest; and as an in- 
flamed organ must have all the rest possible we often combine a 
moist compress at night with dionin drops, or a morphia bella- 
donna suppository (4 to § gr. of each). An injection of morphia 
or pantopon may be reserved for very restless cases with severe 
pain. 

Respiratory gymnastics with an apparatus or by methodical 
breathing exercises are best entirely omitted. As an acute pro- 
gressive pulmonary or pleural tuberculosis may be beginning 
under the guise of a pleural inflammation, the greatest care is 
necessary. Only when it is certain that the pleural condition has 
come to a standstill may light chest massage, lung gymnastics, 
or inhalation of compressed air be employed with the greatest 
caution. 

In cases in which dry pleurisy lasts a long time, and returns 
with more or less acute relapses, the question of introducing 
nitrogen gas may be considered, and we shall allude to it under 
the head of pleural effusions. As it both relieves the pains and 
prevents adhesions it has distinct advantages, and is not to be 
underrated. In conclusion an after-treatment in the high moun- 
tains is to be recommended for those cases in which it is possible. 

The treatment of tubercular pleural effusions is more compli- 
cated. On the one hand the collection of fluid indicates a greater 
danger of tuberculosis; on the other hand the treatment must 
partly depend on the amount of the pulmonary disease, on the 
general condition of the patient, or the state of the heart, &c. 

The measures recommended for dry pleurisy are all service- 
able for cases with effusion. Rest in bed is more absolutely 
indicated ; even when pains and fever are absent it is required to 
save the work of the heart as much as possible. If there is 
dyspnoea the back must be raised, and the patient allowed to 
remain in the most comfortable position. 

A large quantity of fluid in the diet is to be forbidden. Milk, 
on account of its slightly diuretic action, is the most useful drink. 
Salt foods are also diuretic; by a continual ingestion of large 
quantities of salt the fluids of the body are diminished, and the 
absorption of the pleural effusion stimulated; but this method of 
treatment is very lengthy and little employed. The food must be 
concentrated and easily digestible, and is best given in small and 
frequent quantities. 

The value of treatment by drugs is contested; in any case it 
is uncertain and not to be depended on. Drastic purgatives are 


216 A CLINICAL SYSTEM OF TUBERCULOSIS 


contra-indicated. | Constipation may be overcome with saline 
purges, which at the same time have a diuretic effect. Diapho- 
retics are useless; antipyretics and narcotics can usually be dis- 
pensed with. Sodium salicylate, salipyrin and aspirin may be 
employed in those cases, and in the largest doses possible, and 
also preparations of digitalis, with or without diuretin, liq. sod. 
acetat., or other diuretics. 

By these means, in cases where the pleura is capable of 
reabsorption, a diminution of the effusion can usually be 
obtained. But when the pleura is extensively affected internal 
treatment will altogether fail; as we can neither know, nor foretell, 
the condition of the pleura, these measures may be tried. 

In serous and serofibrinous effusions drawing off the fluid 
by means of a puncture must be considered. This procedure 
holds its place in the treatment of tubercular effusions. But the 
views have altered considerably as to the indications and time 
for using this method; also as to the amount of fluid to be with- 
drawn, and the advantages and disadvantages compared with other 
methods of removing the fluid. This can be understood when 
one thinks of the many different anatomical and clinical forms of 
pleural tuberculosis. No general rules can be laid down, as one 
case differs from another. We will content ourselves with giving 
an outline of the principles which experience has taught us, with- 
out going into details. 

The indications given by Trousseau for aspirating pleural 
effusions were: (1) Those endangering the life of the patient; (2) 
very large effusions ; (3) moderate effusions that show no tendency 
to absorption. The question is how far these indications, which 
generally hold good even to-day, are applicable to tubercular 
effusions. 2 

There is not the slightest doubt that tubercular effusions must 
be punctured if there is unmistakable danger to life from dyspnoea, 
cyanosis, or heart weakness. Very acute cases of pleurisy due to 
tuberculosis are scarcely ever met with. But it is common enough 
in cases of advanced pulmonary tuberculosis for even a slow and 
moderate effusion to be directly dangerous to life. Also in quite 
slight lung mischief a very large effusion, which causes dulness 
of the whole, or nearly the whole, of the anterior chest wall may 
cause vital danger from its amount, as it may in a non-tubercular 
person. If, for example, on tuberculosis of the left upper lobe 
and the right apex a very large right-sided effusion supervenes, 
there will be only the left lower lobe unaffected, and that is 
diminished in size from displacement of the heart. So that in 
cases of threatened danger to life, and in very large tubercular 





TUBERCULOSIS OF THE PLEURA 217 


effusions, the indications for puncture remain unaltered; but only 
a definite diminution of the effusion must be aimed at, and not 
more than 1$ to 34 pints in general removed. It is now agreed 
that large aspirations in cases of open, progressive, pulmonary 
tuberculosis are quite contra-indicated. 

There remains the third indication to be considered, whether 
tubercular effusions of medium size, which show no, or only a 
slight, tendency to absorption should be punctured. Further 
questions are how long the spontaneous absorption should be 
waited for, whether the drawing off the fluid is as advantageous 
as the irritation of the pleura by a simple puncture, whether punc- 
ture should be performed during fever, or whether the fall of 
temperature should be awaited, &c. Experience shows that in 
cases of tubercular pleurisy, if the puncture is performed during 
the period of acute inflammation, the fluid returns very often or 
very quickly. This is not a matter of indifference, but an obvious 
drain on the constitution of the tubercular patient. The disad- 
vantage of allowing the lung to be compressed for a long time 
does not apply to a tubercular lung, as it does to a sound one. 
On the contrary, it is certain that the rest afforded to a tubercular 
lung from the presence of an effusion in the great proportion of 
cases makes the course of the pulmonary disease more favourable. 

Thus a too early puncture may both be disadvantageous in 
itself, and a long wait may have a good effect on the tubercular 
lung from compression and immobilization. On these grounds 
we would defer the puncture of a moderate tubercular effusion 
till the fever has disappeared, or is lessening. This usually occurs 
from the end of the second to the beginning of the fourth week 
of the illness. This time also seems to be most favourable, as 
then the cells of the effusion consist only of leucocytes. We thus 
recommend neither early puncture before the second week, nor 
late puncture after the fifth; the latter is useless or even disadvan- 
tageous. The old maxim, that it was better to aspirate too soon 
than too late, is of no value nowadays for the treatment of 
tubercular effusions. 

The third indication of Trousseau must be now read, that 
moderate effusions are to be punctured if there is no sign of com- 
mencing absorption after the fever has fallen. With slight 
disease of the lung aspiration of a small quantity of fluid in the 
second week of the illness will stimulate absorption. In more 
severe cases of pulmonary tuberculosis in which cicatricial con- 
traction and fibrous thickening are rather to be desired than 
feared, since they hinder the action of the diseased lung for a 
longer period, puncture in the fifth week, or a slow reabsorption, 
is better than too early interference, 


218 A CLINICAL SYSTEM OF TUBERCULOSIS 


All the same these rules must be taken with a grain of salt. 
Apart from the fact that the nature of the effusion may alter, a 
change for the worse in the general condition, or in the state of the 
lung, due to the presence of the effusion, may demand an earlier 
puncture, in spite of the presence of fever. It will be then not seldom 
seen that the effusion does not return, and that the fever either at 
once or slowly falls, and a sudden change is made for the better. 
This more often occurs with true initial pleurisy, rather than in 
cases in which it accompanies advanced or rapidly progressing 
pulmonary tuberculosis. The more the case appears clinically as 
simple pleurisy, that is the more it takes the form of an idiopathic 
disease appearing suddenly in a healthy person, the sooner the 
‘aspiration can and must be made, and the more fluid, from 2 to 
34 pints, may be removed. 

The technique of the aspiration is on the whole the same as 
that of the diagnostic puncture; we refer to what was said on this 
subject before, and merely add that the doctor may use the instru- 
ment to which he is accustomed. A simple syphon with india- 
rubber tubing can be used in combination with Fraentzel’s trocar, 
or a two-way trocar of Stintzing or Fiedler. A simple aspiration 
syringe containing more than 100 c.c. may be employed, or an 
aspiration syringe with a two-way stop-cock. The complicated 
apparatus of Potain and Dieulafoy act by exhausting the air, but 
the simple instrument of Firbringer, in which syphonage is 
started by the mouth, is sufficient. 

The apparatus is not the important thing, but the proper use 
of it, and the observation of certain rules in drawing off the fluid. 
This must be in every case preceded by a diagnostic puncture. 
The pleural cavity must be securely shut off from the outer air 
during the procedure. For a serous effusion a simple syphon is 
sufficient, such as is formed by hanging from a cannula india- 
rubber tubing about a yard long, which dips into a vessel con- 
taining water on the floor. Sero-fibrinous and old thickened 
effusions cannot be removed without aspiration. | Caution must 
be employed, and the aspiration must not be forcible or active. It 
should be done slowly, so that the removal of fluid, which should 
not exceed 32 pints, takes about half-an-hour. If violent cough, 
dyspnoea, marked cyanosis, or pains in the chest make their 
appearance, the aspiration must be at once stopped. If that is 
not done sooner or later after the puncture albuminous expectora- 
tion may occur; it is brought up with strong attacks of coughing 
in the form of a mucoid serum, slightly tinged with blood, often 
to the amount of several pints. 






























TUBERCULOSIS OF THE PLEURA 219 


Albuminous expectoration occurs in consequence of great and rapid 
alteration of pressure in the pleural cavity from the puncture; this brings 
about a rapid expansion of the lung, with over-distension of the blood- 
vessels, and a consequent transudation into the alveoli. Effusions on the 
other side, adhesions, rigidity of the diaphragm, and abnormal size of the 
heart, are predisposing factors, and may conduce to a fatal issue in weakly 
patients. 


To obtain information as to the pressure conditions in the 
pleural cavity a glass tube may be fixed in the syphon apparatus. 
If this is held at the level of the site of puncture, the height of the 
fluid in it will show if there is positive or negative pressure in the 
pleural cavity. There is also no great difficulty in accurately 
measuring the intrapleural pressure by means of a manometer, 
which gives valuable information as to whether the needle has 
entered the fluid, or whether it must be pushed further in. After 
the puncture the patient must be kept absolutely quiet; an ice- 
bag or morphia may be ordered. 

In spite of all care there may be bad results from the punc- 
ture. Syncope, convulsions, hysterical and epileptic attacks, and 
paralytic symptoms have been observed. Sudden death from 
heart paralysis, anemia of the brain, thrombosis, and embolism 
has occurred. It must be said, however, that such events are 
very rare, and may occur in cases of pleural effusion without any 
interference. The fear of this must in no way dissuade the 
doctor from undertaking a necessary aspiration. Very cachectic 
tubercular patients require special care, especially in not removing 
too much fluid at one sitting. Nervous, highly irritable patients 
may be soothed by a preliminary injection of morphia; excitable 
persons may be controlled by hand. 

Instead of puncture and aspiration French writers have pro- 
posed to blow out the pleural effusion. The procedure consists 
in filling the pleural cavity during the puncture with sterile air 
or nitrogen, so that the lung only expands very slowly. It has 
been tried by many, including ourselves, and has been on the 
whole successful. 


The method described by Holmgren is as follows: A hollow needle 
is introduced into the tenth intercostal space and as much fluid removed 
as will flow spontaneously. A trocar is then introduced into the eighth or 
ninth space, and through this, with a two-way stop-cock, air is blown in. 
Owing to the pressure of the entering air large pleural effusions can be 
entirely removed without danger, as the lung is hindered from rapid expan- 
sion. After the fluid is entirely removed either the greater part of the 
air can be allowed to escape, or the compression on the lung may be 
maintained, the amount of air to be retained being determined by a mano- 
meter. In any case the air will diminish the tendency to adhesions and 
pleural thickening. 

Arnsberger recommends an early puncture in uncomplicated cases of 
serous or sero-fibrinous effusions: the whole effusion is to be cautiously 
withdrawn as far as possible, and nitrogen, best from 300 to 400 c.c., 
carefully hlown in, This will prevent the contact of the inflamed pleura] 


220 A CLINICAL SYSTEM OF TUBERCULOSIS 


surfaces, and the formation of adhesions, and will allow the later expansion 
of the lung to take place more rapidly on account of the lessened pleural 
changes. 

The technique in Wenckebach’s clinic is very simple, and can be 
carried out with Potain’s apparatus. After the fluid is removed the stylet 
is withdrawn from the cannula, a sterile pad of cotton wool is placed over 
the opening, and through this air allowed to enter. Nitrogen is only 
necessary if a longer compression of the lung is required. In general, it 
may be recommended to introduce only a volume of air or nitrogen equal 
to half that of the fluid removed; since it is possible that a fresh effusion 
may take place which, combined with the gas, would produce too great 
compression of the lung. 


The advantage of the use of air or nitrogen over simple 
puncture is that the symptoms due to too rapid expansion of the 
lung (cough, pain in the chest, albuminous expectoration, injury 
to the lung, hemorrhage, collapse) are avoided. More than the 
traditional three pints of fluid may be withdrawn; even the whole 
effusion may be removed. The puncture, also, need not be 
delayed beyond the third or fourth week, so that the duration of 
the illness is shortened. The formation of adhesions is hindered. 
Lastly, there need not be the same fear of unfavourable influencing 
a primary tuberculosis of the underlying lung by drawing off the 
fluid. . 
Puncture may be also necessary for haemorrhagic, or old 
serous and _ sero-fibrinous, effusions. Hemorrhagic effusions, 
which are not particularly common in tuberculosis, have a great 
tendency to return quickly. It is therefore best to postpone the 
puncture as long as possible, and to limit the amount withdrawn 
to 100 to 500 c.c. If there are respiratory or cardiac difficulties, 
only so much fluid need be withdrawn as to give relief to the 
patient. 

Old serous and sero-fibrinous tubercular effusions are. very 
difficult to draw off, since the fluid is very thick, and generally. 
only under slight, or even negative, pressure. Aspiration 
must therefore be employed for them; in preference to doing too 
much at one sitting, the puncture may be repeated. . As adhesions 
and loculations have often formed, puncture at different places 
will be necessary. . 

Bilateral effusions may require repeated punctures ; but some- 
times they do not, as on the withdrawal of one effusion the other 
may become spontaneously absorbed. In all these cases of 
hemorrhagic, old, or bilateral effusions we should now combine 
the puncture with the introduction of gas, especially nitrogen. 
If in spite of this combined procedure the serous or sero-fibrinous 
effusion frequently returns, washing out the pleural cavity with 
sterile fluid, or making an opening into the pleura, may be con- 
sidered, vio | 





TUBERCULOSIS OF THE PLEURA 221 


The frequent occurrence of rapid absorption of a serous 
effusion after a diagnostic puncture has led to the recommenda- 
tion to draw off only a small quantity (5 to 10 c.c.) at first, and 
then to wait and see if the opening up of the lymphatic spaces by 
the lowered pressure may not result in absorption. If this is not 
the case the second puncture can be done on the usual lines. We 
have not seen the lauded results in cases of tubercular effusions. 
Guilbert and Fehde have introduced the modification of systemati- 
cally withdrawing every day, or every other day, 5 to 10 c.c. of 
fluid, and then injecting it under the skin without completely 
taking out the needle; there should then be an extremely rapid 
absorption. It is very difficult to form an opinion on this proce- 
dure, which is called auto-sero-therapy. Some authors give it the 
first place in the treatment of serous pleurisy, both as regards 
efficacity and freedom from danger; but by others it is strongly 
condemned, as they consider that it causes considerable elevations 
of temperature and other bad results. Brodowsky observed good 
results from repeated puncture, without the subsequent injection 
of the aspirated fluid. If the effect is produced by the repeated 
mechanical irritation of the puncture, which gives a_ reflex 
stimulus to the pleura towards reabsorption, then it is a matter of 
indifference whether 10 c.c., or only 1 c.c., are withdrawn each 
time, and whether the fluid is afterwards injected subcutaneously 
or not. We ourselves have observed no good effect from with- 
drawing a small quantity of fluid at one puncture, followed by a 
second, with injection of the fluid; neither have we observed in 
recent cases of serous effusion the above-mentioned bad results, 
which are difficult to explain. 

The treatment of cases of tubercular serous pleurisy after the 
effusion has been drawn off must be different from that of the non- 
tubercular cases. While in the latter all must be done to produce 
as far as possible a restitutio ad integrum, and an expansion of 
the compressed lung, even to the breaking down of adhesions, in 
tubercular cases these things must not be aimed at, and adhesions 
and thickening of the pleura must be even counted on. If they 
occur, they must remain; quieta non movere. Therefore no 
pneumatic treatment must be employed. In these cases we should 
limit ourseives to the exercises and respiratory movements warmly 
recommended by Hofbauer and Escherich, which consist of mak- 
ing the patient sleep on the affected side at night, and several 
times during the day breathe for some minutes through the nose, 
while the trunk is bent to the sound side. In conclusion, the 
after-treatment of pleurisy, as long as the pulmonary tuberculosis 
is not healed, consists really in the treatment of the latter con- 
dition. 


222 A CLINICAL SYSTEM OF FUBERCULOSIS 


For the removal of pleural adhesions, which are causing 
contraction of the lung and mechanical displacement of the heart, 
Rothschild and Mendel have found good results from thiosinamin. 
{t can be obtained in the form of fibrolysin in sterile ampullz 
containing 30 minims (Merck); the subcutaneous and intra- 
muscular injections are absolutely painless and produce no cica- 
tricial tissue. ‘Three hours after the injection respiratory exercises 
should be begun. The therapeutic results are diminution of the 
thickenings, and improvement in the subjective symptoms. We 
have in several cases seen no result. The indications for its use 
also are limited. While Schnutgen considers quite recent cases 
as suitable, Rothschild excludes patients in bed, and those with 
fever, from the fibrolysin treatment. 

The specific treatment of tubercular pleurisy goes together 
with that of the lungs; there is no information on this subject 
in the literature. So long as dry pleurisy is accompanied by 
severe pains, or serous cases with high fever, tuberculin treatment 
is out of place. Generally it should be reserved for the after- 
treatment. 

For the treatment of tubercular purulent pleurisy, puncture 
with introduction of gas or washing out with fluid, syphon 
drainage of Bulau, and thoracotomy, especially with resection of 
rib, have been recommended. 

The radical operation of thoracotomy with resection of rib 
takes the first place, as it allows the removal of the purulent 
exudate to the last drop. But it has the great objection that it 
entails a pneumothorax, and therefore those parts of the lung, 
which are still capable of respiration, become collapsed. This is 
particularly serious if the other lung is extensively tubercular. 
It accounts for the bad results and often rapid aggravation, which 
may be observed after thoracotomy for tubercular empyema. The 
views as to the expediency of the operation for tubercular 
empyema are still at variance. Some are opposed to the operation 
on principle, others only if the pulmonary tuberculosis is ad- 
vanced. Baumler allows an operation as soon as pus-producing 
organisms are found in the exudate. Gerhardt, Stintzing and 
Laveran recommend the operation if the tuberculosis has lasted 
a long time and is not yet extensive. It may be remarked that 
the surgeons now hardly recommend thoracocentesis with rib- 
resection; it may be reserved for special cases, e.g., small 
loculated empyemas. R. Frank voices our opinion very exactly 
when he says that the removal of a piece of one rib has no 
effect in diminishing the size of the thorax, and is not necessary 
for emptying and draining the cavity. An empyema can usually 








TUBERCULOSIS OF THE PLEURA 223 


be without objection emptied by means of Bulau’s drainage; if 
it fails, or if it seems from the first that it will be insufficient, as 
in cases of chronic thickened empyema, then thoracotomy, with 
removal of part of one rib, will also be insufficient, and a thoraco- 
plastic operation with extensive rib resection will be required. 
We agree that this latter operation may be indicated, but only 
when the milder measures have failed. 

Biilau’s syphon drainage avoids producing a pneumothorax. 
Its object is, without making a communication between the 
_pleural. cavity and the outer air, to lower the pressure in the 
pleural cavity by continuous aspiration, and thus to favour the 
re-expansion of the lung, and at the same time to maintain a 
continuous outflow for the pus. The method consists of intro- 
ducing a tube into the pleural cavity without permitting entry 
of air, and fixing to this tube a syphon apparatus. 


According to Biilau, the instruments required are: (a) A trocar of 
about 6 mm. bore: (0) a Jaques’ catheter, which just fits in the cannula; 
(c) four feet of india-rubber tubing with a small weight at the end: (d) a 
glass tube of the length of a finger rather pointed at one end, to make the 
junction between the catheter and the rubber tubing; (e) two clips; (f) a 
small funnel for filling the syphen apparatus; (g) some dressing, bandages, 
and strapping. According to Frank, (2), (¢), (d) are better replaced by one 
piece of drainage tube, strong enough and smooth enough to pass through 
the trocar. The tube should be over a yard long, and its thoracic end 
should be rounded off and cut obliquely; 2 cm. from this end should be a 
large oval drain-hole. 


The technique of the operation is as follows: The skin is prepared 
with iodine, and anesthetized, together with the deeper parts, by injections 
of novocain and suprarenin. The skin having been opened with a _ short 
incision, the trocar is plunged into the pleural cavity, the needle withdrawn, 
and the catheter or drainage tube quickly passed down the cannula. The 
latter is then withdrawn over the catheter, which now alone, to the extent 
of some 4} in., passes through the chest wall. It must be first clamped, 
and then carefully fastened to the chest wall. The union is now made 
between the catheter and the tube filled with liquid, and the clamps re- 
moved. The pus now slowly flows into the vessel on the floor, while the 
lung should expand. 

The puncture may be made in the scapular line in the eighth to tenth 
space, in the posterior axillary line in the eighth, in the mid-axilla in 
seventh or eighth, and in the anterior axillary line in the fifth to seventh; 
the lowest point possible is to be generally chosen. The trocar is to be 
passed over the upper border of a rib, and the sudden cessation of resist- 
ance, which marks the entry into the pleura, must be looked for. The 
method of fastening the drain-tube to the thorax is very important. On 
both sides of the aperture silk sutures are passed through the skin; these 
are knotted, and tied round the drain. For further security these are fixed 
to the catheter by wrapping round both a small band of strapping, which 
latter may be further fastened to bands of strapping on the chest wall. 
By this means the drainage may remain undisturbed for two to four weeks. 

The vessel containing the fluid, of which Bulau has invented a special 
form, may be fastened outside the bed in such a position that there is a 
difference of not more than half a yard between the levels of the point 
of puncture and the fluid in the vessel. 

The flow of pus should not go on continuously. After the puncture 
only about 300 c.c. are to be at first removed; if attacks of coughing come 
on the flow must be stopped with the clamp. Every two to three hours the 


224 A CLINICAL SYSTEM OF TUBERCULOSIS 


clamps may be opened and about 200 c.c. allowed to flow, till the empyema 
is nearly empty. Then, for the first time, the tube may remain open. 

The most important parts of the after-treatment are maintaining a 
secure fixation of the drain, and attending to the overflow vessel. A 
change in the drain-tube during the whole treatment is not to be made, 
and is not necessary. During the first fourteen days the drain must under 
no conditions be allowed to come out, or to be pulled out during sleep; 
after that there is, as a rule, no dithculty in re-introducing it, as the 
passage is lined with granulations. When, after six to eight weeks, the 
daily amount of pus has fallen below 50 c.c. the vessel may be removed 
and the drainage-tube cut short, and later replaced by a smaller one, the 
discharge being received into a small dressing. The fistula is usually com- 
pletely closed after some months. If after six to eight weeks there is still 
much discharge, it is not likely that healing can be secured by simple 
puncture. It the tube becomes blocked it can usually be cleared by 
coughing, or by lowering the receiving vessel. Attempts at washing out 
usually do more harm than good. 


The drawbacks of the method are the possibility of the 
catheter slipping out, and the tedious watching and after- 
treatment required; sometimes the tube becomes blocked, the 
fistula enlarges, the temperature rises, &c. Therefore the treat- 
ment requires to be carried out in a hospital. Syphon drainage 
only answers in recent cases, in which there are no adhesions, 
and when the lung is still capable of re-expansion. Therefore 
its use for tubercular empyemas is decidedly limited. On the 
other hand, it presents great advantages, particularly the sim- 
plicity of the operation, without narcosis or an open wound, the 
avoidance of pneumothorax, and the encouragement to re- 
expansion of the lung. Weighing these considerations, syphon 
drainage has the advantage over the radical operation, which can 
be done if the former fails, or is not indicated. 

Lately Erhard Schmidt has specially recommended the com- 
bination of syphon drainage and aspiration for the treatment 
of tubercular empyema. By this means blocking of the drainage 
tube is obviated, and since an increased negative pressure 1s 
maintained continuously in the empyema cavity, there is an 
increased favourable action on the collapsed lung, and a 
hyperemic state of the pleura and lung is produced. 


For this method a flask, partly filled with sublimate solution, fitted 
with a three-way stop-cock, is necessary. One way communicates with the 
drainage-tube, another with an air- pump, and to the third a manometer 
is attached. The pleural cavity is subjected to the negative pressure daily; 
in the intervals the vessel is disconnected, and the patient can move about. 


Puncture, followed by washing out the pleural cavity, does 
not remove all the pus, or prevent it from reforming, even when 
as wide a trocar as possible is used for the aspiration and lavage. 
The method is so far palliative, as it greatly diminishes the 
quantity of the exudation, and therefore the pressure on the lung 
and the pains felt by the patient. Also by washing out with 





TUBERCULOSIS OF THE PLEURA 225 


a solution of salicylic acid (I in 1,000) the pus is made thinner, 
and a certain amount of antiseptic effect produced. 


For this an aspiration syringe, containing 200 to 300 C.c., must be 
fitted to a trocar with a stop-cock. The pus must be gradually withdrawn, 
without great alterations of pressure. The stop-cock is then shut, the 
syringe removed, emptied of pus, and refilled with the fluid at the body 


temperature. This is then carefully injected into the pleural Cavity and 
withdrawn again; the processes being repeated as required. 


By this proceeding one can succeed in making the pus much 
thinner, and in washing out the pleural cavity by degrees. Bad 
results are possible, but not probable if care is taken not to 
introduce more fluid than the volume of pus withdrawn; so that 
no great alteration of pressure should be caused. But both the 
aspiration of the pus and the introduction of the salicylic acid 
solution must be done slowly, and with the greatest caution. 

Finkler has made it possible to combine the method of punc- 
ture and washing out with a measurement of the pressure; by 
which means it may be seen if the pus can be allowed to flow out 
rather quicker, and thereby exert some force of expansion on the 
lung. 

Puncture with simultaneous introduction of air, as has been 
recommended for sero-fibrinous effusions, has been used, accord- 
ing to Forlanini and Wenckebach, also for tubercular empyemas 
with good result. In this case a larger trocar must be used, and 
it must be directed as deeply as possible into the pleural cavity, 
so that all the pus that can be is removed. The action of the 
air in blowing out the thick pus can be aided by first introducing 
salt solution under a measured pressure. Wenckebach has seen 
after repeated filling with air definite healing of chronic tubercular 
empyemas. The absorption of the air introduced produces a 
negative pressure in the pleural cavity, which favours the re-expan- 
sion of the lung. When this seems a particularly important point, 
the re-filling may be done with a gas more quickly absorbed, 
e.§. oxygen. Air, however, is always and everywhere at our 
disposal, and makes the formation of an artificial pneumothorax 
in cases of tubercular empyemas a simple matter, and produces no 
deformity on healing, as do extensive surgical measures. 

Therefore the treatment of tubercular purulent effusions must 
not be so much a matter of rule as it has been. There are various 
Suitable measures, which must be practically considered, if the 
tuberculosis has not advanced too far in the lungs, and if the pus 
is detected in time. As methods of choice we recommend for 
general use repeated withdrawal of the pus with simultaneous 
introduction of air, and puncture combined with washing out 


ES 





226 A CLINICAL SYSTEM OF TUBERCULOSIS 




























under measured pressure; sometimes a combination of both 
methods. 


2. TUBERCULAR PNEUMOTHORAX. 


By far the most frequent anatomical cause 
of pneumothorax is pulmonary tuberculosis. 
According to Rose 86 per cent., and to 
Gerhardt go per cent., of all pneumothorax cases are of tubercular 
origin. It is brought about usually by an ulcerating cavity in 
the lung, sometimes by slighter tubercular changes, reaching the 
pulmonary pleura, and incidentally breaking through. Through 
the fistula thus formed between the lung and the pleura air enters 
the pleural cavity, while the lung on account of its elasticity con- 
tracts. If adhesions exist between the lung and the chest wall 
the pneumothorax is partial; on the other hand in cases of total or 
free pneumothorax the whole side is full of air, and the lung 
becomes completely atelectatic. 

If the perforation becomes closed by lymph and by the col- 
lapse of the lung tissues, a closed pneumothorax is produced, 
which diminishes as the air is reabsorbed. If the opening has 
stiff walls, even when the lung is collapsed, the opening between 
the bronchus and the pleura remains patent. The pressure is then 
equalized, and the pneumothorax is open. 

If the pleural fistula is only closed on expiration, with each 
inspiration air will enter the cavity, without being able to escape 
on expiration, and we have the valvular or pressure form of pneu- 
mothorax, which is that most commonly produced by, and most 
characteristic of, tubercular disease. The stronger the inspira- 
tions are the more air will pass through the valve, till the pressure 
in the pleural cavity becomes positive. Even then strong cough- 
ing movements force more air into the pneumothorax, which 
produces complete collapse of the lung on the affected side. The 
combination of the considerably increased positive pressure on the 
diseased side, with elastic retraction of the sound side, produces - 
marked displacement of neighbouring organs, and difficulty of 
expiration. 

The air passing through the tubercular lung carries moulds 
and pathogenic organisms into the pleura. The contents of the 
cavity, containing tubercle and other bacilli, also enter the pleura. 
The never-failing result is the formation of a serous, or more often 
of a purulent, effusion in the form of a sero- or pyo-pneumothorax. 
The former may remain as such, or may become changed later 
into the purulent variety. 


Anatomical 
Changes. 


TUBERCULOSIS OF THE PLEURA 22 


In advanced phthisis, which has produced 
extensive pleural adhesions, pneumothorax 
may occur unrecognized, and remain long 
without causing any special symptoms, so that it is first dis- 
covered at the autopsy. 

But the clinical symptoms of pneumothorax are usually of an 
alarming nature. After the feeling of an internal laceration, 
severe pains, oppression, breathlessness, and cyanosis appear. 
The pulse is small and much accelerated; and collapse with cold 
sweats may occur. 

The further clinical condition depends on the form of the 
pleural fistula. The objective and subjective symptoms depend 
on the amount and pressure of the air in the pleural cavity, which 
are greatest in the valvular form of pneumothorax. The difficulty 
of breathing may take the form of orthopncea. The patient lies 
on the useless side, so as to make the greatest use possible of the 
sound one. The affected half of the thorax is markedly distended, 
and the intercostal spaces are filled up. The displacement of the 
mediastinum and heart to the sound side, and the diaphragm 
downwards, is very considerable. The pressure on the heart and 
large vessels causes marked cyanosis; and on the first day there 
may even be general dropsy. 

The percussion note is abnormally loud and deep, and in 
Open pneumothorax tympanitic. Pleximeter percussion gives a 
metallic clang. The breath sounds are suppressed, or of a weak 
bronchial or amphoric character. Often metallic tinkling sounds, 
and the noise of falling drops, are to be heard. Vocal fremitus 
is weak or absent, according to the amount of air and degree of 
compression. ‘The temperature is quite irregular. 

Sero- and pyo-pneumothorax cannot be distinguished from 
each other by the symptoms. Both cause moderate or high fever 


Symptoms and 
Course. 


with marked remissions; both increase the intrapleural pressure, 


and therefore the pains. Over the lower parts there is dulness, 
the limits of which are easily altered on change of position. On 
shaking the patient a succussion sound, and on sitting him up a 
deeper percussion note than when lying (Biermer’s change of 
note) may be detected. 

A tubercular pneumothorax may pursue a chronic or a very 
rapid course. A valvular pneumothorax may cause death in a few 
hours. This occurs especially in young individuals, since in 
them, owing to the elasticity of the chest wall, the bad effects of 
the increased pressure and displacement of the organs are more 
tapidly and severely felt (pneumothorax acutissimus). In opposi- 
tion to this there is the spontaneous tubercular pneumothorax, 


2258 A CLINICAL SYSTEM OF TUBERCULOSIS 




































which forms quite gradually, and may last for years without 
producing effusion or fever. 

The diagnosis of tubercular pneumothorax 
is usually made without difficulty from the 
characteristic subjective pains and the objective signs; frequently 
the condition can be recognized in a moment. Also its cause, on 
account of the advanced tubercular lung changes, is usually fairly 
obvious. Only the circumscribed partial pneumothorax can 
possibly be confused with a large cavity. Also a small pneumo- 
thorax may be difficult to recognize if it occurs in an atypical 
situation, or if it contains merely the scanty remains of what was 
once a large quantity of air. 

In all cases the Rontgen rays may be of diagnostic value in 
several ways. We may mention that owing to the displacement 
of the lung the rib shadows appear unusually clear; the shadow 
of the compressed retracted lung can be seen at the hilus; bands 
may be seen passing between the lung and the costal pleura, or the 
dome of the diaphragm; and the characteristic displacements of 
the neighbouring organs will be obvious, due more to the elastic 
pull of the other lung than to direct pressure of the escaped air. 
In sero- or pyo-pneumothorax there can be clearly seen the sharp 
horizontal upper limit between the air and the fluid, which moves. 
with each pulsation of the heart, or change of position of the 
patient. Also at the upper limit of the effusion can be seen a 
distinct respiratory rise and fall, the shadow rising with inspira-— 
tion and falling with expiration; this is the phenomenon of the 
paradoxical diaphragmatic movement. When the differential 
diagnosis of pneumothorax from large cavities is in question 
illumination must be tried both from behind, from before, and 
in an oblique direction. 

The further important diagnostic point whether the effusion 
is serous or purulent must be settled by an exploratory puncture. 
This may give rise to subcutaneous emphysema, from letting the 
air through the costal pleura, or to infection of the needle track 
in cases of pyo-pneumothorax. The temperature gives but very 
uncertain indication as to the nature of the fluid. | 
According to the observations of Ee 
Spengler, Rose, Unverricht, and others the 


t 


Diagnosis. 


Prognosis. 


prognosis of pneumothorax cannot now be considered as quite 
hopeless. Spontaneous healing has even been observed. All the 
same the mortality is somewhere about 80 per cent. According to 
the figures of West quite a large proportion die in the first twenty- 
four hours, and 60 per cent. in the first month after the occurrence 
of the pneumothorax. 


TUBERCULOSIS OF THE PLEURA 229 


In the first place the extent of the pulmonary disease must be 
considered in forming the prognosis of an individual case. 
Advanced, bilateral disease makes the outlook very black, while 
unilateral disease, even if extensive, may be favourably rather 
than unfavourably influenced by the occurrence of a pneumothorax 
on that side. 

Also the prognosis depends on the form of the pneumothorax. 
If the condition of the lung is approximately the same, the follow- 
ing differences may be drawn. A closed pneumothorax runs 
usually a better course than on open one, and an open one better 
than the valvular variety, which claims the most victims during’ 
the first few days. The very rare pneumothorax without effusion 
gives the best chance of recovery; next a partial one with an 
effusion. The uncommon sero-pneumothorax seems to recover 
with more difficulty than the purulent form, which is more imme- 
diately dangerous to life, but the after recovery from which is no 
more unlikely. 

The form of treatment to be employed is also important for 
prognosis. A therapeutic nihilism of an expectant character is 
usually synonymous with a more or less rapid fatal ending. 

In the treatment of tubercular pneumothorax 
the general constitutional measures, above 
all the careful and skilful nursing of the patient, are so important 
a factor that hospital treatment seems indicated. But the removal 
must be delayed till it can be done without doing harm. Heart 
weakness and collapse usually occur at the commencement ; they 
must be met by suitable stimulants (camphor, ether, digitalis, 
caffein, champagne, cognac, coffee). The further treatment 
depends on the form of the pneumothorax. 

In cases of valvular pneumothorax, which is clinically the 
most important form, it is of prime importance to diminish the 
difficulty of breathing, and to avoid attacks of coughing. These 
ends are best obtained by a morphia injection (3 gr.), which may 
be repeated if necessary. Bands of strapping are a support. 

If these measures do not bring about sufficient improvement, 
according to the advice of Unverricht, there must be no delay in 
making a wide thoracic fistula. This fistula must remain con- 
Stantly open, so as to produce an open pneumothorax, and to 
prevent a rise of pressure in the pleural cavity. This is the 
essential principle of the measure proposed by Unverricht. The 
Opening must be so arranged that it is not blocked in any part 
of the respiratory phase, thus obviating entirely the results of 
Taised pressure. 


Treatment. 


230 A CLINICAL SYSTEM OF TUBERCULOSIS 



































The technique of this very simple method is described by Unverricht 
as follows: An incision is made between the ribs and the largest possible 
drainage-tube introduced. At the outer end of the tube is fixed a wire cap, 
which is covered with a dressing and bandage, so as to receive any secretion 
there may be, but not to hinder the free communication with the outer air. 
A thin layer of gauze will not prevent this, while it will act as a filter for 
bacteria, and obviate the infection of the pleural contents. 

Unverricht has obtained by this method complete healing of 
tubercular pneumothorax. ‘There is, of course, the possibility of 
bacteria entering the open pleural wound and producing septic 
infection, but this may be neglected, as even then the course of 
healing is not hindered. 

Puncture, aspiration, and syphon drainage have no place in 
the treatment of valvular pneumothorax, as they produce only a 
temporary lowering of the pressure, prevent the spontaneous 
closure of the pulmonary fistula, and may even cause it to reopen 
when it has closed. 

In cases of closed pneumothorax without effusion, or only 
quite a small one, no operative interference is required. The 
reabsorption of the air may be awaited with antiphlogistic 
measures and morphia injections. 

Cases of sero-pneumothorax may at first be treated on 
expectant lines, when fever and threatening symptoms are absent,, 
and the effusion is only large enough to compress the lung in an 
advantageous way. If improvement and reabsorption of the 
effusion and air do not occur, then puncture with washing out.the 
pleural cavity, or replacement of the fluid by nitrogen, may be 
considered, The technique of these methods has already been 
described. 

For the treatment of pyo-pneumothorax there is a choice 
between introduction of air or nitrogen, puncture with washing out 
the cavity, thoracotomy, or thoracoplastic operation. The con- 
dition of the patient must govern the choice of the method. If 
the general condition is bad, the pulmonary disease advanced, and 
the heart does not admit of operative interference, then the milder 
means must be employed, especially one of the two first men- 
tioned. On the other hand, if the general condition is good, and 
if septic changes have taken place, then thoracotomy with rib 
resection is the rational treatment. It sometimes gives surprising 
results, especially if the other side is but little diseased, or prac- 
tically sound. But not uncommonly a fistula and purulent dis- 
charge remain after the operation; but this possibility should not 
prevent the operation being undertaken. If it is not done, 
secondary abscesses, spontaneous discharge of pus, internal 
fistula, and other incurable complications will occur, which should 
be prevented at all costs. Thoracoplasty must be reserved for a 


TUBERCULOSIS OF THE PLEURA 221 
last resort for old and total pyo-pneumothorax, in which there is 
a large purulent cavity. Also a fistula remaining after thoraco- 
tomy may require a radical plastic operation. 

It has been recently recommended that a direct attack should 
be made on the lesion causing the tubercular pyo-pneumothorax, 
and that the pulmonary fistula should be closed by suture, 
Sauerbuch’s differential pressure apparatus being used. Particu- 
larly encouraging results have not yet been obtained. 

The after-treatment of tubercular pneumothorax must be on 
the same lines as that for tubercular pleural effusions. 


CHAPTER IV. 


Tuberculosis of the Upper Ge 


Passages. 


THE nose and the naso-pharynx perform the functions of 
warming the entering air, of saturating it with moisture, and of 
freeing it from dust, so as to avoid as far as possible injurious 
effects to the lower air passages from cold, dry or contaminated 
air. It is obvious that a permanent defect of physiological nasal 
breathing must have a prejudicial influence on healthy lungs, 
which becomes more marked if they are diseased. Kronig’s 
apical induration (p. 81) may be mentioned here, and also the 
extreme view which ascribes the formation of the phthisical chest 
to hypertrophy of the pharyngeal tonsil. Although the latter 
theory will not stand a scientific test, it must be admitted that 
chronic obstruction to nasal breathing during youth may 
unfavourably influence the development of the thorax, and there- 
fore of the thoracic organs. Careful attention to the state of the 
nose and naso-pharynx is thus required, not only with those 
already suffering from tuberculosis, but for prophylactic reasons, 
especially with those of an hereditary tendency and scrofulous— 
and otherwise predisposed persons. 

Nasal polypi must be removed, hypertrophies of the turbinates 
diminished by amputation or the cautery, and slighter cases 
treated by the bloodless method of fracture and dislocation 
(Killian). If there is hindrance to the entry of air from inspira- 
tory sucking in of the nostrils, Feldbausch’s or some other 
dilators should be worn. Large spines and crests of the septum 
should be removed submucously; marked deviations of the 
septum should be submitted to the window-flap resection under 
local anesthesia; in slighter cases according to Killian breaking 
the nasal septum, and also one or both turbinates is sufficient. 
These operations, however, should be only done in cases of 








TUBERCULOSIS OF THE UPPER AIR PASSAGES 233 


tuberculosis, especially if the disease is open, when they are 
absolutely necessary ; if possible they should be postponed. We 
disagree with those enthusiasts who attack with hammer and chisel 
every deviation and spine of the septum in tubercular patients. 

In advanced hypertrophy of the pharyngeal tonsil, and also 
in cases of adenoid vegetations, we recommend removal of the 
obstructions, as they are a fertile source of recurrent catarrhs, and 
thus have a prejudicial effect on pulmonary tuberculosis; also 
they may become primarily or secondarily infected. The existence 
of tuberculosis of the lung is only a contra-indication if it 1s far 
advanced or complicated. 

The pathological changes that have been mentioned, by pro- 
ducing chronic obstruction to nasal breathing lead to drying of 
the mucous membrane, and thereby to chronic catarrh of the 
throat and larynx. This is the more unfortunate for the tuber- 
cular patient, as he has already a tendency to chronic inflammation 
of the upper air passages. <A repetition of such catarrhs may set 
up a persistent irritating cough, and the catarrh may descend 
into the lower tubes, and by lowering the resistance of the healthy 
epithelium give an impetus to the spread of the tubercular disease. 
From this point of view the non-tubercular affections of the upper 
air passages in phthisical patients demand careful attention; we 
will discuss the most common varieties in a few words. 

In the first place acute catarrh of the nose, throat, and larynx 
in cases of active pulmonary tuberculosis must always be regarded 
as a serious complication. An attempt must be made to prevent 
the spread to the lower air passages by means of general treat- 
ment, such as rest in bed, with a uniform temperature of the 
room, promotion of perspiration by tepid packs, antipyretics, 
diaphoretic and diuretic drinks, and mineral waters, and possibly 
incandescent light baths. For the local treatment of cold in the 
head we recommend with Spiess the early and repeated applica- 
tions of anzsthesin or orthoform. Also cocaine in the form of a 
spray, a tampon, or the insufflation recommended by Turban of 
cocaine 1, morphia .4, and boracic acid to 10 parts, has given us 
very good results. Patients are less willing to submit to Bier’s 
congestion, produced by an india-rubber band round the neck, 
which is a good treatment for all cases of inflammation of the 
upper air passages. In acute catarrh of the throat we have had 
the best results from painting with 1o per cent. silver nitrate once 
a day for several successive days, a gargle of salt solution being 
used directly afterwards to neutralize the excess. Ephraim recom- 
mends painting with antipyrin, quinine bichlor., and aq. 
dest.; after two to three applications of this the throat is 


234 A CLINICAL SYSTEM OF TUBERCULOSIS 


sufficiently anesthetic to permit painless galvano-cauterization. 
Less prompt are the effects of astringents like acetic acid, potas- 
sium chlorate, tannin, alum, iodine, &c. In acute laryngitis 
good results are obtained by inhalation of volatile oils (best 10 
per cent. menthol oil), of 1-2 per cent. tannin solution, and of 
weak salt solution, combined with alcoholic compresses. Blumen- 
feld recommends insufflations of calomel as the best local abortive 
treatment. In cases with a tendency to colds and chills the pre- 
vention must be carefully considered. 

Hypertrophic catarrh of the nose and throat requires local 
treatment. In acute cases the above-mentioned astringent 
powders and solutions, perhaps combined with sedatives, may be 
used. Painting with Mandl’s solution (iodine 1, pot. iodide 5, 
glycerine 25 parts) is to be specially recommended. Washing 
out the nose and naso-pharynx has been deprecated on account 
of the danger of injury to the epithelium; in open tuberculosis a 
tubercular infection of the middle ear is also to be feared. 
Chronic partial, or diffuse, swellings of the mucous membrane 
may be treated by the galvano-cautery, or by removal. We may 
mention that for these small operations Ephraim recommends 
submucous injections of 2 per cent. solution of antipyrin as being 
superior to cocaine, novacain, and alypin in quickness and dura- 
tion of action, in its capacity for being kept and sterilized, in being 
completely non-poisonous,. and in its price. We prefer the 
galvano-cautery to cauterization with chromic acid. In severe 
cases more or less prolonged relief may be given to the obstructed 
breathing by massage of the hypertrophied turbinate, or better 
by painting with 5-10 per cent. cocaine solution. The hyper- 
trophied follicles in granular pharyngitis are a frequent cause of 
cough irritation. They seem to be not uncommonly of a tuber- 
cular nature (Sokolowski). Painting with .5 per cent. silver 
nitrate solution or 20 per cent. menthol oil may relieve the 
symptoms. A more radical treatment is to seek for the painful 
and irritable spots in the fauces with a probe, and then to destroy 
them with tri-chlor-acetic acid, or to burn them with a pointed 
galvano-cautery so superficially that there is no injurious scar 
formation. 

Atrophic catarrh of the upper air passages or xerosis has a 
still closer connection with tuberculosis, since on account of the 
degenerative changes of the mucous membrane and the damage 
to the epithelium the powers of natural resistance are lost, and 
tubercle bacilli and other infectious organisms can more easily 
penetrate into the deeper air passages. Thus ozena is of 
importance both for the prevention and treatment of tuberculosis. 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 235 


The very effective treatment of ozena by means of Gottstein’s 
tampons, which are soaked in various drugs (balsam of Peru, 
ichthyol, hydrogen peroxide), is to be little recommended in tuber- 
culosis, on account of the prolonged obstruction to nasal breathing 
involved. The application of-electrolysis requires special instru- 
ments, as does vibration massage of the mucous membrane, whilst 
ordinary massage is difficult and tedious. We have found nasal 
douches of 2 per cent. guaiasan oil solution to be a very easy and 
successful mode of treatment. Also the powdered snuff (iodol 
crystals, tannic acid, and borax equal parts) used five or six times 
a day, recommended by Turban, has given us good results. In 
cases of marked atrophy of the turbinate it is advisable to insert 
small tampons as protection against dust and cold; for this 
purpose Sprenger’s porous india-rubber pellets, provided with an 
india-rubber thread, seem to us to be practical and easy to use. 
Dry pharyngitis requires care and the exclusion of external 
injurious agencies. The most appropriate treatment is painting 
with Mandl’s iodo-glycerine solution once or twice a_ week. 
Gargles of olive oil or weak salt solution with a little glycerine 
are useful; bedridden patients especially derive benefit from these 
mild measures. 

Catarrh of the larynx will be more fully considered with 
the diagnosis of laryngeal tuberculosis. For its treatment the 
astringent and sedative measures there given are applicable. 


1. TUBERCULOSIS OF THE NOSE. 


Tuberculosis of the nose most often takes 
the form of a solitary ulcer, which is usually 
situated on the anterior cartilaginous part of 
the septum. The ulcer is generally small, round, and superficial, 
has a characteristically indented edge, and a dirty rough base. 
Near to the edges, which are studded with small red granulations, 
typical nodules may be seen. 

The tubercular tumour is more rare, and is nearly always also 
localized on the cartilaginous septum. It forms a broad tumour, 
seldom projecting much, of very various appearance; it may be 
smooth, rough, or nodular, of a pale to dark red colour; the 
consistence may be soft or hard. The size usually varies between 
a small pea and a hazel-nut. Only very rarely have larger 
tumours been described. The tuberculoma soon destroys the 
cartilage, and grows in a similar way in the mucous membrane 
of the opposite side. The mucosa over it may remain unaltered, 
or more frequently becomes ulcerated. Later the tumour necroses, 


Anatomical 
Changes. 


236 A CLINICAL SYSTEM OF TUBERCULOSIS 


and in favourable cases may entirely disappear, leaving only a 
perforation. 

Diffuse infiltration and a granulating form of nasal tubercu- 
losis have also been distinguished. The diffuse infiltration may 
also have a granulating surface; it may lead to extensive thicken- 
ing and destruction of the septum. According to Gerber it is 
probably a form of primary tubercular perichondritis. 

Miliary tuberculosis and primary tuberculosis of the bony 
frame-work of the nose are very rare. 

Lupus of the nose is difficult to distinguish from tuberculosis 

clinically. It also has a predilection for the septum, and accord- 
ing to Gerber especially for the anterior angle of the nasal 
aperture, when it is frequently hidden by what is apparently 
eczema of the vestibule. The first nodules grow out from the 
nostril, and affect the exterior part of the nose. In later stages 
lupus takes the form of circumscribed or diffuse infiltration, and 
has a tendency to cause perichondritis and perforation. Also the 
turbinates, especially the lower, may be affected by diffuse lupoid 
infiltration; it is characteristic of lupus that on the raised surface 
besides irregular ulcers cicatricial changes are to be found, a 
combination very rare in tuberculosis. 
The clinical symptoms of nasal tuberculosis, 
especially at the commencement, are slight 
and not characteristic. They consist of 
moderate secretion and obstruction due to swelling or crusts, and 
depend upon the amount of the disease. 

The swelling extends as far as the lower turbinate, and often 
blocks the naso-lachrymal duct, through which the caruncle of the 
eye may become secondarily affected. Long-standing ulceration 
of the septum leads to perforation; which is particularly common 
with tuberculosis. In distinction from the idiopathic form of 
perforation, which may also be met with in phthisical cases, the 
edges are usually markedly swollen. 

Ulcers of the septum may spread to the upper lip, producing 
a simple inflammation, a tubercular infection, or scrofulous 
eczema. 

Tuberculosis of the nose is a comparatively rare disease, the 
conditions for the lodgment of tubercle bacilli being unfavour- 
able owing to the structure of the epithelium, the respiratory air 
movements, the secretion of nasal mucus, and certain reflex 
expulsive acts. Primary tuberculosis of the nasal mucosa has 
certainly been observed, especially in the form of tuberculoma. 
Usually the infection is secondary, rarely from the conjunctiva, 
most frequently from sputum from a diseased lung, and probably 


Symptoms 
and Course. 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 2 


/ 


o>) 


U 


sometimes from direct vaccination from an infected finger poked 
into the nose. Spread of disease to the surrounding bones and 
cavities is very rare. This form of tubercular disease, which is 
uncommon, usually begins in the bones themselves, empyema of 
one of the sinuses being secondary. Lupus of the nasal mucosa 
very often forms the starting point of lupus of the face, but 
secondary infection of the nose from outside is also frequently 
seen. 
The recognition of most of the secondary 
affections usually gives no difficulty, especi- 
ally when the primary disease is obvious. If there is an ulcer in 
the nose the overlying crusts must be first removed. The 
characteristic appearance of the ulcer has already been described. 
If part of the base is removed, tubercle bacilli, frequently in large 
numbers, can be generally found. If they are absent confusion 
may be caused with gummatous ulcerations; these, however, are 
usually situated on the vomer or plate of the ethmoid, and 
the edges are sharp, hard, and less granulating. They react 
promptly to iodides. The tuberculoma can hardly be confounded 
with a malignant tumour, for it seldom exists long by itself alone,. 
and has a great tendency to necrosis. The idiopathic perforation, 
which according to Siebenmann is the result of anterior rhinitis 
sicca, has in contrast with the tubercular perforation a smooth 
edge, while the syphilitic perforation is apt to spread on to the 
bony part of the septum. In all doubtful cases a microscopic 
examination of a piece of excised tissue, a local tuberculin 
reaction, or the result of iodide treatment should clear up the 
diagnosis. 

If the area of disease is sufficiently clearly defined, its 
radical removal is not difficult. In other cases relapses are the 
rule. But even then the prognosis is not entirely unfavourable ; 


in any case this must depend chiefly on the nature of the primary 
disease. 


Diagnosis. 


For large ulcers, infiltrations, granulations, 
and tumours the best treatment is energetic 
scraping under cocaine, with subsequent cauterization with con- 
centrated lactic acid. As a rule it is necessary to repeat the 
‘operation several times, as it is impossible to remove all the 
disease at once. Chromic acid and tri-chlor-acetic acid are much 
used as cauterizing agents. Hinsberg recommends the applica- 
tions of tampons soaked in various concentrations of lactic acid. 
Isolated tumours may be removed by the ring curette or by 
the hot or cold snare, and the base cauterized with the galvano- 
cautery, which also suffices for small ulcers and circumscribed. 


Treatment. 


238 A CLINICAL SYSTEM OF TUBERCULOSIS 


infiltrations. The after treatment can be carried out with lactic 
acid or a disinfecting or astringent powder. In healthy patients 
with perforation caused by a tuberculoma K6rner recommends 
excision of the whole of the diseased part of the septum; by 
which means he has always obtained an easy and lasting cure 
in two to three weeks. 

Tuberculin is warmly recommended by many writers, such 
as Onodi and Rosenberg. 

Lately Pfannenstill has published cases of cure of nasal lupus 
by internal use of iodide of potassium with inhalations of ozone. 
In the Finsen’s Light Institute Strandberg has confirmed these 
results, and has simplified the treatment by substituting tampons 
of 1 to 2 per cent. peroxide of hydrogen for the ozone. Korner 
is of opinion that the effective part of this treatment is the adminis- 
tration of iodide, which he uses for non-operable cases of diffuse 
tuberculosis and lupus of the nose and gullet. 

Lastly, Nagelschmidt has obtained surprisingly quick 
results in eight cases of nasal tuberculosis by means of the 
diathermic treatment, which will be described later in the section 
on Lupus. 


2. TUBERCULOSIS OF THE NASO-PHARYNX. 


Tubercular ulcers, and more rarely tumours, 
have been met with in the naso-pharynx. 
According to Moritz Schmidt the tumours 
usually grow from the back of the velum palatinum, where also 
tubercular ulcers may be situated, likewise on the pharyngeal 
tonsil and neighbourhood of the Eustachian tubes. The appear- 
ance of both these varieties resembles that described in the previous 
section. With superficial erosions and ulcerations there are 
deeper ulcers with a dirty grey base and swollen edges. The 
tumours are accompanied by a marked hyperplasia of the adenoid 
tissue, causing much swelling, which has but slight tendency to 
necrosis; later the tubercular tissue preponderates, in which, 
however, very few tubercle bacilli can be found. 

Tuberculosis of the pharyngeal tonsil is more frequent. It 
is noticeable that this, like the palatal tonsil, may be affected with 
tuberculosis without being swollen, or without presenting any 
naked-eye evidence of tubercle. It is an extremely mild form of 
the disease, ulceration is very rare. The lymphatic tissue con- 
tains tubercles and giant cells to a variable amount. Tubercle 
bacilli are usually very scanty. 


Anatomical 
Changes. 


Lupus also may occur in the naso-pharynx, usually in its — 


nodular, infiltrating form; it has a very slow course. It is very 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 239 


rarely indeed primary, usually being secondary to disease in the 
anterior part of the nose, in the soft palate, or in the posterior 
wall of the pharynx. Its favourite sites are, according to Seifert, 
the posterior edge of the septum, the nasal surface of the uvula, 
the posterior pharyngeal wall, the orifice of the Eustachian tube, 
and the pharyngeal vault. 

Tuberculosis of the naso-pharynx 1s com- 
paratively rarely observed in the living 
patient, it is usually found after death in 
cases of phthisis with miliary tuberculosis. In fifty phthisical 
corpses E. Frankel found tubercular ulcers in the naso-pharynx 
ten times; Dmochowski twenty-one times in sixty-four phthisical 
bodies, of which eight had miliary tuberculosis. Usually the 
affection is secondary and occurs in the last stage of lung disease ; 
probably it would be more often detected if posterior rhinoscopy 
could be regularly employed on these exhausted patients. There 
are no special clinical symptoms. Ulcers on the back of the palate 
may be recognized by spots of redness on the anterior surface. 
The lymphatic glands at the angle of the jaw and front of the neck 
are fairly often affected. Tuberculosis of the pharyngeal tonsils 
causes the same symptoms as chronic enlargement; cases of 
primary disease have been described, usually it occurs from 
infection from sputum. 

Tubercular ulcers and tumours may be 
recognized without difficulty with the mir- 
ror; but tubercular tumours may, however, be confused with a 
neoplasm or gumma; in these cases a histological examination 
must be made. Tuberculosis of the pharyngeal tonsil can only 
be revealed by the microscope, except perhaps in those rare 
cases in which there is necrosis and ulceration. 

The prospects of cure are conditional on 


Symptoms and 
Course. 


Diagnosis. 


Prognosi ; 
genesis the prognosis of the disease in the lung. 
and De os 
If the disease is circumscribed, local treat- 
Treatment. 


ment as required for nasal tuberculosis may 
bring about cure. With advanced disease in the lungs the treat- 
ment must be purely symptomatic. As tuberculosis of the 
pharyngeal tonsil is generally not recognized as such the treat- 
ment will be that of simple hyperplasia. The fear that after 
removal there will be frequent relapses has not been confirmed; 
but there is certainly a possibility of an ulcer forming on the raw 
surface left. By means of local applications of tuberculin 
Schnitzler produced destruction of large tubercular tumours in 
the naso-pharynx, and healing occurred to a large extent, and 
Trautmann obtained a complete cure by tuberculin injections 
continued for several months. 


A CLINICAL SYSTEM OF TUBERCULOSIS 


to 
4s 
@) 


3. TUBERCULOSIS OF THE LARYNX. 


According to Moritz Schmidt tuberculosis 
of the larynx occurs as infiltration, ulcera- 
Changes. tion, tumour or miliary tubercle. Any of 
these four forms may be present alone, or they may be combined 
in various ways. Lupus must be separately considered. 
Histologically infiltration is marked by considerable thicken- 
ing of the mucous membrane, affecting equally the mucosa and 
submucosa, which may become three or four times their normal 
thickness. The smallest nodules of infiltration appear of the 
size of a grain of millet or hemp, and are already recognizable 


Anatomical 


with the laryngoscope. The tubercles appear in the mucosa and — 


submucosa, generally in great numbers; they are always at first 
above the glandular layer, and are embedded in a fine or coarsely 
reticulated tissue, filled with numerous small round cells. The 
epithelium remains, till it becomes softened and_ ulcerated ; 
frequently an outgrowth from the superficial layers occurs, in the 
form of pendulous, papillomatous excrescences. As the disease 
advances the glands and vessels become involved, and the 
tubercles commence to caseate. 

To the naked eye the infiltration has a yellow or red colour, 
and is always more or less cedematous. It may remain for some 
time in this stage, or may undergo either reabsorption or ulcera- 
tion. The infiltration of the epiglottis, which seldom occurs 
without ulceration, may be either localized or may affect one- 
half or the whole of the cartilage, and causes marked swelling. 
When the whole edge of the epiglottis is infiltrated the swelling 
often has the shape of a turban or horse-shoe. As the swelling 
increases the epiglottis becomes rigid and immovable.  Infiltra- 
tion of the aryteno-epiglottic folds may occur on one or both 
sides; this also causes much swelling, which may be most 
marked in the region of Santorini’s cartilage. The movements 
of the folds and of the arytenoid cartilages are always diminished, 


and in severe cases lost. Infiltration of the posterior wall may. 


occur in several forms, either as a thick, diffuse, velvety softening, 
as several straight folds, as smooth, uneven, or cleft nodules, 
which may be sessile or pedunculated, and may project more or 
less far into the lumen of the larynx. The infiltration may be 
situated in the middle or side of the posterior wall, or may fill up 
the whole inter-arytenoid region, and attain such a size that it 
pushes in between the vocal cords, and prevents the closing of 
the glottis. Infiltration of the vocal cords may be at first partial 
on the free edge of one or both sides, particularly in the neigh- 



































Bandelier and Roepke, A Clinical System of Tuberculosis. Plate Vig 





Fusiform infiltration of the left Tumour-like infiltration of the Infiltration of the posterior 
vocal cord. left vocal cord. wall in its whole extent. 





Superficial ulceration of free Commencing ulceration on edges Extensive marginal ulceration of 
edge of right vocal cord. of both cords. Granulations on left cord. Infiltration of pos- 
the posterior wall. terior wall. 





Superficial ulceration of both Superficial ulceration of posterior Ring ulcer. 
cords. wall. 
After Krieg, “ Atlas of Diseases of the Larynx.” 


Bandelier and Roepke, A Clinical System of Tuberculosis. Plate VIII. 





(Edema of the posterior wall due Papillary outgrowth from the Extensive ulceration. Marked 
to ulceration. posterior wall with cedema. cedema of posterior part of the 
Ulceration of the posterior wall larynx. Slight swelling of an- 
and the cords. terior part of the cords. 
Big. 13. Fig. 15. 





ees 
Advanced ulceration of the Large, tumour-like outgrowth Ulceration of the anterior wall 
epiglottis. of granulations from left false of the larynx and the trachea. 
cord. Congenital abnormality 
of the epiglottis. 





Perichondritis of the cricvid Perichondritis of the right plate Lupus of the lower part of the 
cartilage. of the thyroid cartilage, spread- pharynx and entrance to the 
ing to the left side. larynx. 


After Krieg, “ Atlas of Diseases of the Larynx.” 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 241 


bourhood of the processus vocalis, which may become red, 
hemispherical, or slightly indented, or ragged and _ often 
resembling a papilloma (Schech). Circumscribed infiltration in 
the anterior angle of the glottis is considerably more rare, but 
according to Jurasz, in the absence of other changes, it is a very 
suspicious symptom. It is generally smooth, and situated either 
exactly at the angle of the glottis, or just above or below it; it 
lasts a long time without breaking down. With total infiltration 
the vocal cord has a cylindrical shape; it may attain the thickness 
of a pencil, so that it is difficult to distinguish the true and false 
cord; generally, however, a fine dark line marks the junction of 
the two and the entrance into the ventricle (M. ee ae 
Infiltration of the false vocal cord, often accompanied by ulcera- 
tion in the ventricle, produces a round or oval swelling, generally 
uneven on the surface; it is nearly always diffuse. The swelling 
may be considerable, and may fill the whole sinus Morgagni, and 
completely cover the vocal cord. When the infiltration is 
bilateral both cords may be hidden, and only a narrow, irregular 
cleft seen between the swollen false cords. The formation of 
fibercles in the false cords is usually very excessive; the 
prominent areas, according to Schech, consist of a conglomeration 
of tubercles. Infiltration of the mucous membrane of the ventricle 
assumes a special form, which may be mistaken for a prolapse 
of the mucosa. The comparatively rare subglottic infiltrations 
appear as light or deep red, elongated pads parallel to the vocal 
cords on one or both sides, more seldom in the form of a ring; 
they may reach a considerable size. 

Tuberculosis of the mucous membrane is not the only cause 
of infiltration at entrance of the larynx; it may be produced also 
by perichondritis. 

The tubercular ulcer of the larynx arises from an infiltration 
by softening of a superficial deposit of tubercle, and necrosis of 
the epithelium. The size and depth of the ulcer is very varied; 
the more superficial occur in the region of the squamous epithe- 
lium, the deeper in the cylindrical epithelium, especially where 
the glands are plentiful (Biefel). Sometimes there is only a sieve- 
like appearance of the mucous membrane. Necrosis of super- 
ficial infiltrations gives rise to a more or less extensive superficial 
ulceration which is characterized by a grey, or dirty yellow, 
spotted base, and irregularly indented, often swollen and under- 
mined, edges. Deep infiltrations reaching to the glands produce 
very serrated, crater-like ulcers, which may extend to the muscles 
or the perichondrium. All forms of ulcers may be covered with 
a very exuberant growth of granulations. They may become 

16 


242 A CLINICAL SYSTEM OF TUBERCULOSIS 


secondarily infected with other bacteria, especially streptococci 
and staphylococci. 

Ulcers of the epiglottis are usually situated on the lower side, 
and accompany infiltrations; more rarely they occur on the edges, 
usually as a consequence of perichondritis. If the ulcers are 
deep, necrosis and loss of substance of parts of the epiglottis 
ensue, leaving notches. In the region of the arytenoid cartilage 
and aryteno-epiglottic folds ulcers are only found in the later 
stages, either on the top of Santorini’s cartilage, or along the 
whole length of the fold, even entering the sinus piriformis. On 
the posterior wall ulcers have a special tendency to develop, and 
are often the first sign of laryngeal tuberculosis; in advanced 
cases they may cover the whole posterior wall, and cause con- 
fusion with papilloma on account of the cedematous granulations. 
If the ulcers are superficial the posterior wall may appear jagged, 
or eroded into clefts or furrows; if they are due to necrosis of 
deeper infiltrations the posterior wall is irregularly fissured, and 
contains crater-like depressions with steep, granulating edges. 
If the vocal cord is affected, single or numerous ulcers appear 
on its surface, surrounded by infiltrated tissue and granulations ; 
later they become confluent, and an elongated ulcer may form 
along the free edge, or on the under side. These long ulcers 
have at first a serrated, jagged, or nodular appearance, and later 
increasing infiltration of the cord develops, in which the opposite 
healthy cord lies, as Moritz Schmidt says, like a knife in its 
sheath; the edges are often studded with granulations, which 
may reach a fairly large size, and considerably obstruct the 
glottis. Even if the outer edge of the cord is also ulcerated 
there may still remain a raised band of non-ulcerated tissue in the 
middle. If the ulcers spread on the lower side of the cord, there 
will be swelling in the subglottic region, and the ulcers may 
extend on to either the posterior or anterior wall below the glottis. 
An ulcer is very likely to form on the processus vocalis, generally 
as the result of necrosis of an infiltration, more rarely from in- 
fection of a small wound. It forms a gutter-shaped depression, 
with a yellow base, and abrupt edges. According to Jurasz these 
ulcers have a regular, triangular shape, keeping strictly to the 
outline of the cartilage. They easily cause perichondritis of the 
arytenoid cartilage, since it is here very superficial and the sub- 
mucous tissue poorly developed. The swellings of the false cords 
also frequently form ulcers, which may be either superficial, 
causing punctate or sieve-like depressions in the mucous mem- 
brane, or deep in the form of more typical tubercular ulcers. In 
many cases the granulations are so luxuriant that the false cord is 
converted into a raspberry-like mass (Schech). 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 243 


In autopsies on advanced cases of phthisis the lowest part of 
the larynx is not uncommonly found to be ulcerated. Subglottic 
infiltrations usually break down late, and then produce a ring 
ulcer surrounding the whole glottis, or a mass of granulations 
causing obstruction. 

The tubercular tumour is histologically quite identical with 
infiltration, only it is less cedematous; no sharp line of division 
can be drawn between the two; but the infiltration is diffuse, and 
the tumour more circumscribed. The tumour may form by itself 
or in combination with other tubercular changes; it is not often 
primary. Outwardly the tumour resembles a fibroma or papil- 
loma. Its size varies between that of a lentil and a cherry; in its 
growth it is extremely slow. It is generally round or hemi- 
spherical, more rarely lobulated. Its surface may be either 
smooth and shining, or uneven and nodular. ‘The colour varies 
between white, grey and red. It very rarely appears on the 
epiglottis, if it does it is usually on the under side near the 
petiolus. On the vocal cord it usually necroses; probably the 
cases that have been described are rather outgrowths of granula- 
tions on the base of a more or less healed ulcer. The most fre- 
quent site is the sinus Morgagni and the false cord, where it can 
best be observed. 

The miliary form of laryngeal tuberculosis is a fairly rare 
disease. It occurs first on the epiglottis, the false cords, the 
posterior wall and the subglottic region. The granules are rarely 
observed, because they are either very quickly absorbed or necrose 
rapidly, forming a large ulcer. In general miliary tuberculosis 
the appearance of grey granulations on the larynx, for instance, 
on the cords and epiglottis, has undoubtedly been observed. 

Perichondritis is rarely primary, but is usually secondary to 
advanced disease of the mucous membrane. Septic organisms 
reach the perichondrium from the neighbouring ulcer and by 
setting up inflammation prepare the way for tuberculosis. On 
account of the purulent inflammation the perichondrium becomes 
loosened from the cartilage, which dies and is partly or entirely 
thrown off. In rare cases the pus may break through the mucous 
membrane internally, or externally through the skin. Perichon- 
dritis presents the appearance of tubercular infiltration. If the 
epiglottis is affected there is considerable swelling. As a rule, 
the edge of the cartilage first becomes bare; as the disease ad- 
vances the whole epiglottis may be destroyed. Perichondritis of 
the arytenoids is most often due to ulceration in the region of 
the vocal cords, as here the cartilage is only separated from the 
mucosa by scanty submucous tissue. A tense swelling is formed, 


244 A CLINICAL SYSTEM OF TUBERCULOSIS 











































which obliterates the contour of the arytenoid, and extends from 
the inter-arytenoid fold to the posterior part of the aryteno- 
epiglottic ligament. It encroaches on the lumen of the larynx 
and hides the posterior part of the cord. Ossification of the car- 
tilage, or inflammation and ankylosis of the arytenoid articulation 
usually occur early. Ulceration of the posterior wall may also 
lead to purulent inflammation of the arytenoid cartilage, which 
may spread to the plate of the cricoid, and produce subglottic 
swelling. Here also abscess formation and exfoliation of part of 
the cricoid may occur (Schech). Perichondritis of the thyroid 
cartilage often spreads through the cartilage from inside to the 
outside, and causes a rounded swelling, which can easily be felt 
through the skin; it may soften and discharge pus exteriorly. 

Killian describes a tubercular, hamatogenous infection of the 
laryngeal framework, which takes the form of perichondritis 
affecting the thyroid and cricoid cartilages and commencing at the 
spots where ossification centres form. If tubercle bacilli reach 
the marrow spaces of the ossification centre with their sluggish 
circulation, osteomyelitis and perichondritis will be set up. 
Masses of granulative tissue are formed, which caseate and 
necrose, and sequestra floating in pus may be the result. The 
mucosa remains for a long time intact, and is only displaced in- 
wardly towards the larynx, giving a characteristic appearance 
according to the localization of the disease. If the cricoid is 
affected there will be subglottic swelling; if the mesial part of 
the thyroid, an internal fistula is formed later with prominent 
edges, so that externally the disease can, hardly be recognized. 
These are the rare cases of so-called tubercular perichondritis, in 
which sequestra of the ossified thyroid or cricoid cartilages may 
be coughed up. 

If the tubercular changes are deep the intra-muscular con- 
nective tissue is also implicated, leading to waxy degeneration of 
the muscle, and then to alterations in the movements of the cords 
and pain on moving and swallowing. 

Lupus of the larynx appears most often in the form of nodules 
and ulcers. In non-ulcerating lupus the mucosa is studded with 
numerous, rather hard, pinkish spots of the size of a millet grain, 
which look like granulations. They mostly affect the entrance 
of the larynx, the much thickened epiglottis and aryteno- 
epiglottic folds, and the posterior wall. But generally the surface 
breaks down, so that irregular superficial ulcers are formed, which 
are distinguished from tubercular ulcers by being surrounded by 
lupoid nodules, and separated by characteristic scars. The in- 
filtrating form of laryngeal lupus has been more rarely described. 


TUBERCULOSIS OF THE UPPER AIR PASSAGES 245 


It starts in the much thickened epiglottis and spreads over the 
aryteno-epiglottic folds to the posterior wall, so that the whole 
entrance to the larynx presents a red, nodular infiltration, which 
may lead to considerable narrowing. On the posterior wall more 
often tumour-like infiltrations appear. When the true and false 
cords have been long affected with lupus, subglottic infiltrations 
and ulcers have been often described. 

One of the most common symptoms of 
laryngeal tuberculosis is alteration of the 
voice, which may vary between slight 
thickening of the voice to complete aphonia. But this alteration 
does not always correspond with the amount of disease. Even 
with slight ulceration the voice may be considerably affected, and 
—which is more important—it may hardly suffer at all in advanced 
disease. For this reason a laryngoscopic examination should be 
made in all cases of phthisis, and in all patients with the slightest 
suspicion of change in the voice. Frequently the voice of the 
phthisical patient is weak, even when the larynx is healthy, on 
account of general asthenia and weakness of the vocal and respira- 
tory muscles; in the later stages waxy degeneration of the 
muscles, which has already been mentioned, is a common cause 
of voice weakness. Parzesthesiz, such as feelings of scratching, 
tickling, stabbing, compression, dryness, or obstruction from 
mucus, are noticeable quite early, causing a continual need of 
clearing the throat or coughing. Paresis of the vocal cords may 
produce hoarseness, which, however, may also be due to chronic 
pharyngitis. Swelling, nodules, ulceration, inflammation of the 
cartilage, ankylosis of the joint, alterations of the muscles, or 
paralysis of the recurrent laryngeal nerve on one or both sides, 
may all cause various grades of alteration in the voice. With 
disease of the epigloitis, of the aryteno-epigloitic folds, and cir- 
cumscribed affections of the false cords and even of the posterior 
wall, hoarseness may be entirely absent. 

Pains in the region of the larynx are also a common sym- 
ptom; they may be spontaneous or occur on speaking or swallow- 
ing; they are due to ulcers, muscular infiltrations, involvement of 
nerves, perichondritis, &c. Pains on swallowing, which spread 
to the ear along the auricular branch of the vagus, indicate with 
fair certainty perichondritis of the arytenoid. Often the pains 
may be brought on by external palpation of the larynx; fixed 
painful spots have symptomatic importance. 

In advanced laryngeal tuberculosis with much swelling, diffi- 
culty of swallowing occurs. Other common causes of this are 
perichondritis of the epiglottis and arytenoids. The patients 


Symptoms and 
Course. 


246 A CLINICAL SYSTEM OF TUBERCULOSIS 


swallow frequently, especially when drinking, which causes much 
irritable cough; food and drink often come back through the nose. 
The pain on swallowing often leads to the refusal of food, but only 
in advanced cases. 

The cough is, as a rule, caused by the disease in the lungs. 
Even severe disease of the larynx does not necessarily cause 
cough; ulcers on the processus vocalis generally cause it, as do 
pendulous granulations on the posterior wall. The cough caused 
by swallowing has already been mentioned. A very teasing 
cough may be caused by the exposure of a nerve in the floor of 
a laryngeal ulcer. 

Expectoration, too, mostly comes from the lungs. Laryngeal 
secretion is generally slight, and rarely indicates the nature of the 
pathological changes. With extensive ulceration a thin, greyish 
green, sometimes sanguineous pus is excreted. Malodorous pus 
is produced by perichondral abscesses; it may contain necrotic 
tissue and portions of cartilage. The more advanced is the 
laryngeal disease, the more copious is the reflex secretion of 
mucus. Hzemorrhages from the larynx are only slight and have 
no special importance. 

The breathing is characteristically affected, if in consequence 
of much swelling, infiltration or oedema, a greater or less amount 
of stenosis is produced (laryngeal dyspnoea). 

Laryngeal tuberculosis occurs at every age of life; it spares 
neither early childhood, nor old age; but cases at such extremes 
are rare. M. Schmidt has seen it in a child of 1 year; Lublinski, 
Schech and M. Schmidt have reported cases over 70 years of age. 
It is most often met in the years between 20 and 4o, in which 
also pulmonary tuberculosis is commonest. Men are affected 
decidedly more often than the women. The reason for this is 
probably that the male larynx is more exposed to injurious in- 
fluences, such as tobacco, alcohol and the mechanical irritation of 
various occupations, than the female, though this view is not held 
by all observers. Statements as to the relative frequency of pul- 
monary and laryngeal tuberculosis are much at variance; this is 
entirely due to the different material on which they are based 
(reports from public and private sanatoriums, specialists, patho- 
logical anatomists). 

That laryngeai tuberculosis can be a primary disease must be 
admitted by supporters of the theory of infection through the air. 
Undoubted cases, supported by autopsy, are observed by example 
by Von Demme, E. Frankel, Orth. Doubtless a large number of 
the primary cases that have been reported are due to faulty 
diagnosis; especially the statements of French authors as to the 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 247 


frequency of primary laryngeal tuberculosis as a consequence of 
co-habitation with a tubercular individual, are to be received with 
caution. Usually the infection occurs secondarily through the 
sputum. The exhaustive animal experiments of Albrecht have 
proved with certainty that laryngeal tuberculosis, especially in its 
typical form, occurs in by far the majority of cases from contact 
infection with sputum, and that the tubercle bacilli, after injury 
and loosening of the epithelium, may penetrate into the sub- 
mucous tissue. The entry of bacilli into spots that have lost their 
epithelium was also considered by Orth to be the most common 
mode of infection; other authors believed that they could also 
penetrate the intact mucous membrane. The danger of infection of 
the larynx is the greater the more abundant the bacilli are in the 
sputum, the more frequently the latter is deposited in the larynx, 
the longer it remains there, and the more the larynx is in a state 
of irritation and inflammation. Certainly Albrecht has shown 
that tubercle bacilli carried to the larynx of rabbits in the arterial 
circulation produce a growth of tubercles in the mucous mem- 
brane and muscles. Haematogenous infection is therefore pos- 
sible; it must, however, only occur in rare, atypical cases. Simi- 
larly tubercular disease of neighbouring structures may provide 
the requisite conditions for lymphatic infection. The fact that 
laryngeal tuberculosis is most common in far-advanced lung 
disease, when the laryngeal epithelium is chronically inflamed, 
loosened and weakened by continual coughing, and perhaps also 
by the chemical action of the expectoration, is in favour of infec- 
tion by the sputum. It has been observed often enough that an 
abrasion of the larynx may become secondarily infected and form 
a tubercular ulcer, and that at symmetrical points on the cords 
contact ulcers form (Moritz Schmidt, Fischer), an observation 
that has been made also by ourselves. That there is a lateral 
correspondence between the disease in the lung and the larynx 
has been maintained, but not proved; to us it appears more than 
improbable. 

Blumenfeld’s observation that laryngeal tuberculosis as such 
seems to be inherited in certain families is worthy of notice; it 
corresponds with the inheritance of a locus minoris resistentiz in 
the lungs described by Turban in cases of phthisis. 

The course of the affection varies according to the pre- 
dominance of the disease in the lungs or larynx. Generally 
laryngeal disease only develops in severe cases of phthisis, often 
it first appears in the last act of the drama; then it merely plays a 
subsidiary part to the lung disease, and the latter has the more 
rapid progress. The patient dies of exhaustion, or cardiac or 
pulmonary complications. 


248 A CLINICAL SYSTEM OF TUBERCULOSIS 


Sometimes, however, the laryngeal tuberculosis is the prin- 
cipal disease, the pulmonary symptoms being in the background. 
Its progress then depends upon its nature and position, and 
whether cough or breathlessness, pain or difficulty of swallowing 
are prominent symptoms. The illness may terminate acutely from 
cedema of the glottis, or the patient may die slowly from ex- 
haustion. It has often been said that laryngeal patients are 
strikingly tough, and it is remarkable how long they often drag 
on, in spite of severe symptoms and deficient nourishment. 

The symptoms of lupus of the larynx are not different from 

those produced by the same clinical forms of laryngeal tuber- 
culosis. It is noticeable that pain is almost entirely absent, even 
in advanced ulceration. Primary lupus of the larynx is rare; as 
a rule the disease is secondary to lupus of the nose, the throat 
or the face. Lupus in the larynx, as elsewhere, has a marked 
tendency to cicatrisation. If it occurs at the entrance of the 
larynx it may cause marked stenosis. The infiltration leads, 
usually after a long time, to ulceration and perichondritis, the 
necrosis produced by the latter being almost confined to the 
epiglottis. 
The recognition of the various forms of 
laryngeal tuberculosis by means of the 
laryngoscope is easy, therefore the clinical symptoms that have 
been described have no special importance for diagnosis. With 
sufficient experience of the instrument even the deeper forms of 
the disease may be brought into view, perhaps with the assistance 
of cocaine. 

Some practical hints may not be without use here. Large 
tonsils should be pressed aside with a full-sized mirror; with 
sensitive patients quite a small mirror may be used. To see 
beneath a very pendulous or swollen epiglottis, if loud phona- 
tion of ah is not sufficient, one may stand in front of the sitting 
patient, or raise the epiglottis by pressure on the thyroid carti- 
lage, or by means of a probe after the use of cocaine. The 
posterior wall can be seen by the method recommended by Kil- 
lian, in which the patient stands and bends his head forwards, or 
the doctor may kneel in front of him. The lateral parts of the 
larynx, the cords when overhung with swelling of the false cords, 
and the sub-glottic region can be better seen if the patient’s head 
is bent laterally, and the mirror placed at the side of the uvula. 

The following points may help the avoidance of mistakes. 
A very pallid condition of the larynx has no importance if it is 
not in striking contrast with the normal colour of the other mucous 
membranes. Acute and chronic catarrh in tubercular patients 


Diagnosis. 





TUBERCULOSIS) OF THE UPPER AIR -PASSAGES 249 


may cause confusion with tubercular laryngitis on account of the 
redness and swelling. There is here always a possibility that 
tubercles may be found in the mucosa or sub-mucosa. <A chronic 
catarrh that resists all treatment is always suspicious of tuber- 
culosis. A diagnostic tuberculin reaction may produce a focal 
reaction and clear up all doubt. The fear of using tuberculin 
for an early or differential diagnosis on account of the danger 
of a focal reaction is not justified; the objective signs of this are 
usually only redness and swelling, and the subjective symptoms 
passing pains and disturbance of sensation. A spread of the 
disease in the larynx or even a necrosis of existing foci is cer- 
tainly never observed after a diagnostic injection; the dangers 
are merely theoretical. 

Unilateral inflammation of a vocal cord is always very 
suspicious; syphilis is the only disease that causes it besides 
tuberculosis. 

In phthisical patients catarrh and epithelial necrosis may 
occur in the vocal cords, and be confused with tuberculosis. 
The same is true of the erosions and raw areas occurring on the 
processus vocalis in pachydermia. 

Swelling and folds of the mucous membrane of the posterior 
wall of the larynx in chronic catarrh and pachydermia must not 
be considered to be tubercular, even if the surface appears 
softened or covered with secretion, or in pachydermia if it is 
much swollen and indented. The differential diagnosis from 
pachydermia is sometimes hardly to be established by the 
appearance alone; the age and other etiological factors, such 
as excess of alcohol or tobacco, chronic catarrh, or overstrain of 
the voice may decide, but in certain circumstances a micro- 
scopical examination will be required. It is useful to paint the 
suspected part with a cocaine-adrenalin solution, when the 
tubercular foci often show up distinctly from their pale sur- 
roundings. 

Moritz Schmidt draws special attention to the fact that some- 
times in laryngitis sicca the dry, firmly adherent, mucous 
crusts can look very like tubercular ulcers. By applying menthol 
oil or cocaine solution, and then directing the patient to cough, 
the crusts may be easily removed. 

The following criteria are of service in distinguishing 
between tubercular and syphilitic ulcers. Tubercular ulcers have 
an irregular, swollen appearance, a dirty spotted base, and soft, 
flat or raised, undermined edge, on which there are frequently 
small red granulations. Tertiary syphilitic ulcers, formed from 
breaking-down gummata, generally lie on a thickened base, and 


250 A CLINICAL SYSTEM OF TUBERCULOSIS 


seem to stand out, their edges are steeper, harder, and have less 
tendency to granulate; the infiltration is usually much firmer, 
and the mucosa much reddened. With regard to the situation 
of the ulcers it is worth noticing that syphilitic ulcers are seldom 
found on the posterior wall of the larynx, while tubercular ulcers 
prefer that spot. A tuberculin injection may show the true 
nature of the ulcer. 

In some cases of tubercular ulceration of the larynx tubercle 
bacilli may be found in the secretion, but not in all. It must 
be remembered that tuberculosis and syphilis may be combined, 
and that tubercular sputum may be by chance deposited on a 
syphilitic ulcer. Superficial cleansing of the larynx by syringing 
does not guard against such a diagnostic error. On the other 
hand a syphilitic ulcer can become infected with tuberculosis, so 
that a mixed form, difficult to recognize, is not so rarely pro- 
duced. 

The diagnosis of syphilis may receive considerable support 
from a positive Wassermann’s reaction; or if after the adminis- 
tration of large doses of iodide (30 to 75 gr. a day) a tendency 
to healing is distinctly recognizable within fourteen days; only 
very old cases require longer administration of iodide or the 
addition of mercury. <A therapeutic injection of salvarsan may 
be used in the same way, if it is not contra-indicated by putrid 
expectoration from the lung, heart changes, or other reasons. 
In mixed cases the cure of the ulcer is not complete, and the 
obstinacy of the parts remaining unhealed indicates the nature 
of the complication. The diagnosis from the result of treatment 
is also possible in doubtful cases of gummatous tumour and 


syphilitic perichondritis. Other syphilitic signs will not be 
lacking. 

Tubercular tumours must be diagnosed from _ fibroma, 
papilloma, and, above all, carcinoma. These neoplasms may 


so closely resemble the primary tubercular tumour that a positive 
diagnosis is not always possible. Only when cancer is situated 
on the vocal cord is it quite characteristic and not to be mistaken 
for tuberculosis. In later stages the difficulty increases from the 
formation of necrotic ulcers. The greater involvement of one 
half of the larynx, the preponderance of new formation over 
ulceration, as well as the hardness and rigidity of the infiltration 
indicate cancer. In spite of these points there are cases in which 
the diagnosis can only be firmly established by the course the 
disease takes, or by microscopical examination of an excised 
portion of tissue. In rare cases the simultaneous presence in 
the larynx of tuberculosis and cancer has been noted. Laryngeal 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 2 


on 
= 


lupus is distinguished in its ulcerous form from tubercular ulcers 
by the characteristic lupoid nodules which are always present in 
the neighbourhood, by the spontaneous scarring at various spots, 
and by the very slight pain produced even by large ulcers. 
Laryngeal lupus has much in common with syphilis, for example, 
the scar formation. Confusion can only occur in the rare cases 
of primary lupus, and then a test tuberculin injection or the result 
of iodide treatment will help to settle the doubt. 

That laryngeal tuberculosis has no tendency 
towards spontaneous healing is the opinion 
of the majority of laryngologists and tuberculosis specialists. 
The contrary opinion, which was expressed at the last congress 
of German laryngologists by Dreyfuss, Kiimmel, and Rumpf, is 
founded on the observation of recovery in cases of non-specific 
chronic inflammatory conditions, and so-called catarrhal laryn- 
geal ulcers in  phthisical patients. Nevertheless, recovery 
without artificial help is not so very rare, even with large infiltra- 
tion and ulceration. According to Killian this occurs chiefly in 
men whose occupation entails a life in the open air. It also 
occurs in patients with great natural powers of resistance, in 
whom the lung disease is also stationary, and who _ spare 
themselves and their larynx. There exists an unmistakable 
connection between pulmonary and laryngeal tuberculosis in 
regard to prognosis, and the former being the chief and 
fundamental disease, determines the whole prognosis. In 
accordance with this we see a relapse of the laryngeal disease 
accompanying activity of pulmonary tuberculosis. Certainly 
there are exceptional cases in which in spite of advance of the 
disease in the lungs the laryngeal tuberculosis becomes arrested 
or even cured, and the reverse may occur. The prognosis is 
bad if the mischief in both lung and larynx is advanced, and it 
is the more favourable the less severely the lungs are diseased, 
and the more localized the laryngeal affection. Fever, continued 
loss of appetite, severe pains which prevent the taking of food, 
perichondritis, and pregnancy are the most important complica- 
tions which impair the prognosis. Hereditary tuberculosis, 
according to Thost, Schech, and others, is less favourable, 
acquired disease more so. According to v. Baumgarten tubercles 
formed entirely of lymph-cells are the richest in tubercle bacilli 
and the most unfavourable, those formed of mixture of lymphoid 
and epithelioid tissues are poorer in bacilli and run a middle 
course, while those formed purely, or almost so, of epithelioid or 
giant cells contain the fewest bacilli, and offer the best prognosis 


(Schech). 


Prognosis. 


bo 
on 
bo 


A CLINICAL SYSTEM OF TUBERCULOSIS 


With the advances of laryngology and surgical treatment, 
the use of the galvano-cautery, and the modern application of 
specific treatment, the prognosis of laryngeal tuberculosis has 
improved as much as that of lung disease; but here, as in every 
form of tuberculosis, the important point is the earliest possible 
recognition and treatment of the disease. 

The prognosis of lupus of the larynx is bad if the disease 

is extensive. The prospects of a local cure are considerably 
better in circumscribed forms, especially as they are generally 
situated at the entrance of the larynx, and so are easily accessible 
for local treatment. 
Since 1880 a reaction has set in against the 
fatalistic conception of the incurability of 
laryngeal tuberculosis, which has put an end to therapeutic 
nihilism. Much of the merit for this belongs to Moritz Schmidt, 
Heryng, and Krause. During this time the treatment has under- 
gone many changes, and even now opinions as to the relative 
efficacy of, and the indications for, the different methods are at 
variance. It is obvious that the same method cannot give the 
same results in all cases; but the various lines of treatment may 
be so combined as to obtain many satisfactory results in cases not 
too far advanced. Much depends on the selection of the method 
most suitable to each individual case. But all measures must be 
applied with careful consideration of the disease in the lung and 
its prognosis. One should refrain from surgical treatment if the 
patient can receive no lasting benefit in spite of a good result 
from the operation. For this reason the patient must be first 
carefully observed and treated with all the general means at our 
disposal, until the prognosis with respect to the lung disease can 
be considered as hopeful. As a preliminary to all surgical 
operations the disease in the lungs must have become at least 
stationary, the general health improved, the body-weight 
increased, and the temperature nearly normal. Other cases call 
for conservative treatment, unless an operation is necessary to 
save life, or to relieve dysphagia. 

The local treatment may be medical, surgical, or physical. 
Of medical agents menthol is probably most used. It has a 
slight astringent, anesthetic, and vaso-constrictor effect, and exerts 
a favourable influence on specific and non-specific congestion, 
swelling, catarrh, and superficial ulcers. Menthol oil (10 to 20 
per cent.) may be dropped into the larynx, or it may be given by 
inhalation. A simple form of the latter is to pour some of the 
menthol oil on to boiling water, the steam to be inhaled through 
a funnel. As the hot menthol steam sometimes causes irritation 


Treatment. 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 25 


it is better to vapourize the menthol into the room by means of 
Frankel’s inhaler. B. Frankel himself has obtained very good 
results from its use, in advanced cases, and considers that if it is 
employed for a long time the number of operations required will 
be diminished, but our experience has not been so good. The 
simplest, cheapest, and most generally applicable method of 
diminishing the secretion, irritation, and cough is Hartmann’s 
inhalation mask, which has given us the best results. 


The wire-work of the mask, which can be obtained in a form something 
like a spectacle frame, is painted with a mixture of equal parts menthol and 
ether. After the latter has evaporated the former remains in the meshes 
of the wire netting in a more solid form and lasts for one or two days. 
The duration of the inhalation and the amount of menthol used must vary 
with the needs of the patient; the mask can be worn during work, and even 
during the night. By means of the mask prolonged inhalation of balsams 
for the treatment of bronchitis and bronchiectasis can also be carried out. 
Hartmann recommends for cases of phthisis with much secretion a mixture 
of creosote 1, ol. terebinth 20 parts, to alternate with the menthol. 

We have used the mask as a protection after laryngeal operations and 
to intercept the spray caused by severe coughs with much fluid secretion. 


Coryfin is recommended by many authors as a substitute for 
menthol. Its utility has been proved, but not its superiority over 
menthol, which still probably enjoys the greater popularity. 

Use may also be made of balsamic inhalations (balsam of 
Peru, oil of turpentine, and eucalyptus, &c.), and of sprays of 
borax (2-4 per cent.), boracic or lactic acids, tannin (1-2 per cent.), 
alum, &c. They act by cleansing the larynx and loosening the 
secretion. That freeing the mucosa from the tenacious, irritating 
secretion brings relief to the cough is shown by the widespread 
use of inhalations of mineral waters, such as Ems, and of weak 
bicarbonate of soda, and common salt solutions. The inhalation 
should take place with superficial breathing, the tongue being 
depressed or extended. The inhalers and spraying apparatus 
most in use have already been mentioned in the section on the 
Treatment of Pulmonary Tuberculosis; we consider Spiess’s 
apparatus to be the best and simplest. 

Of disinfectants and astringents in the form of powder there 
are iodol, aristol, thioform, pyoctanin, nosophen, &c., either 
alone or mixed with boracic acid. Killian considers 1odoform the 
most useful powder, and the least injurious to the appetite. All 
these measures have only a superficial action and serve to cleanse 
ulcers, lessen secretion, stimulate granulations, and prevent 
mixed infection. Superficial ulcers may thus be cured, but 
deeper ones seldom. The powders are gently blown into the 
larynx by means of an insufflator, the most suitable being those of 
M. Schmidt and Hartmann with changeable glass mouthpieces. 


354 A CLINICAL SYSTEM OF TUBERCULOSIS 


To alleviate pain, and especially difficulty of swallowing 
caused by extensive infiltration and perichondritis, anesthetics 
are required. Cocaine (5-20 per cent.) is always useful in solu- 
tion or in powder mixed with boracic acid. Newer substitutes 
avoid the toxic symptoms sometimes caused by cocaine, but their 
effect is not so intense; we prefer alypin, with or without 
suprarenin. A weaker, but more durable, anaesthesia is obtained 
by blowing on anesthesin, orthoform, propasin, and cycloform ; 
the latter has been well recommended, especially when combined 
with coryfin. The prolonged use of an ice-bag is at times very 
effective. Even in severe cases of dysphagia much relief may be 
given by C. Spengler’s liquor anzstheticus, a 5 per cent. alcoholic 
solution of anzsthesin, in combination with iodine or aromatic 
substances. The patient may himself paint the throat with it, 
or it may be used asa spray. Recently R. Hoffmann has recom- 
mended the injection of 1 to 2 c.c. of 85 per cent. alcohol warmed 
to 45° C. into the neck, at the point where the inner branch of 
the superior laryngeal nerve passes through the hyo-thyroid 
membrane between the hyoid and thyroid cartilage; after this the 
pain is often relieved for ten to twenty days, sometimes for as 
many as forty. We have had good results from the alcohol 
injections ; though we have seldom succeeded in obtaining so long 
an interval of painlessness, still we have observed considerable 
relief to the pain and dysphagia, even in quite hopeless cases. 
Blumenfeld obtains complete abolition of sensation by resection 
of the superior laryngeal nerve under local anesthesia. The 
bilateral division of the nerve had already been proposed and 
carried out with success by Avellis. 

Nevertheless there will always be cases in which opiates 
cannot be dispensed with; though the views on this matter are 
at variance. While Moritz Schmidt made extremely sparing use 
of morphine, as subcutaneous injection near the larynx and as 
insufflation, his pupil and colleague for many years, Spiess, uses 
it much more extensively in cases of inflammation and after 
operations. He not only proves that under its influence opera- 
tive wounds heal better, but that the local anzsthetic effect 
has a good influence on inflammation, and he thus extends the 
use of narcotics not only for laryngeal tuberculosis, but also for 
many other cases of inflammation of the upper air passages. 
Spiess has often seen surprising improvement in inoperable cases 
from sub-mucous injections of 2 per cent. sterile novocain solu- 
tion, given by means of a laryngeal syringe once or twice a day; 
and the same injection gives much relief in severe dysphagia. 
We are trying the effect of novocain injections; so far they have 





Cn 


TUBERCULOSIS OF THE UPPER AIR PASSAGES 25 


been of service to us in several cases as local anesthetics for the 
purpose of operation, as well as for the relief of pains. Kafemann, 
who supports Spiess’s views without exception, has lately recom- 
mended, on the grounds of his own extensive experience, the 
pantopon of Sahli as an almost ideal local anesthetic for inflam- 
matory and nervous affections of the upper air passages. 

The best caustic for tubercular ulcers is lactic acid, which 
was introduced by H. Krause, and has almost entirely superseded 
silver nitrate, tri-chlor-acetic acid, and chromic acid. It has an 
elective destructive action on tubercular tissue, and leaves 
unaffected mucous membrane practically intact. Therefore it is 
unreasonable to treat closed infiltrations with lactic acid, a proce- 
dure which has brought it undeserved discredit. For many 
laryngologists expressly warn against its use; Jurasz, for example, 
has seen much change for the worse after it. If it is desired to 
attack a closed infiltration an incision must first be made, as 
recommended by M. Schmidt. Lactic acid must be rubbed into 
an ulcer with moderate pressure by means of a small cotton-wool 
mop, the larynx having been first made insensitive. By the 
rubbing the soft necrotic tissue is mechanically removed, and the 
superficial part of the remaining disease sloughs off. By several 
repetitions of the caustic, the whole of the diseased tissue is 
gradually destroyed. For small ulcers very concentrated or pure 
lactic acid is used, for larger surfaces a 50 per cent. solution, or 
the strength may be increased from 25 to 80 per cent. The 
application must only be repeated when the grey sloughs have 
separated, and the local reaction has subsided, which usually 
occurs after eight to ten days according to the intensity of the 
cauterization. It is incorrect to paint the whole interior of the 
larynx with weak lactic acid solution, as is still sometimes done. 
As a substitute for lactic acid, which sometimes causes excessive 
irritation, Blumenfeld recommends the glycerine-ester of lactic 
acid. 


The monolactate (dional I) contains 54.8 per cent. lactic acid, is milder 
in its effects and sufficient for many cases. The dilactate (dional II) con- 
tains 76.3 per cent. lactic acid, and more nearly approaches this in its 
caustic effect, but causes considerably less after-pain. The most con- 
centrated preparation 1s the tri-lactate, which contains 87.7 per cent. lactic 
acid. lor extensive use we prefer dional II, with which we have had good 
results. 


Finally we may mention the internal administration of large 
doses of iodide of sodium, to be followed by inhalations of ozone 
or hydrogen peroxide lasting two to four hours, a method already 
mentioned under nasal tuberculosis, and by which Pfannenstill 


256 A CLINICAL SYSTEM OF TUBERCULOSIS 


has obtained remarkable results in severe cases of laryngeal 
ulceration. 

Surgical treatment, which has hitherto been much more 
effective than those already mentioned, aims at removing as far 
as possible all the diseased parts. | Circumscribed deep ulcers, 
infiltrations, and tubercular tumours are the most suitable cases 
for it. According to the position and nature of the disease the 
single or double curette, or the cutting forceps, may be employed. 
The operation must take place under thorough local anesthesia. 
If the parts are very irritable a preliminary injection of pantopon 
or morphia may be given. To the 20 per cent. cocaine solution 
that is used one or two drops of suprarenin may be added, which 
constricts the vessels and diminishes haemorrhage, localizes the 
action of the cocaine, and thus prevents toxic symptoms, and 
brings out the tubercular tissue by removing purely inflammatory 
redness. Suprarenin also has the advantage of being able in a 
great part to replace cocaine; if it is added in the proportion of 
1 to 1,000 a 5 per cent. solution of cocaine is sufficient to produce 
complete anzesthesia of the larynx (Bukofzer). Anaesthesia pro- 
duced by painting on a 20 per cent. solution of alypin, or inject- 
ing into the submucous tissue a 2 per cent. novocain solution, 1s 
less intense and lasting, but not so liable to be accompanied by 
toxic symptoms. The addition of suprarenin to fluid for injection 
must be made with caution, especially if the heart is affected. 
According to Ephraim anesthesia of the larynx may also be 
obtained by painting with 50 per cent. antipyrin solution, its 
action, however, is very slow, and varies much in different cases. 
The great advantage of antipyrin is that with its aid the concen- 
tration of the more toxic anesthetics may be considerably 
reduced ; thus 50 per cent. antipyrin in 10 per cent. alypin solution 
acts as quickly as 20 per cent. cocaine, according to Ephraim. 
After the operation it is advisable to cauterize the raw surface 
with lactic acid, which acts on any deeper tubercular tissue and 
prevents later haemorrhage. 

In cases of extensive infiltration in positions where radical 
operations cannot be performed, such as the epiglottis, the 
aryteno-epiglottic folds or the posterior wall, either the most 
affected part is excised, or scarification, incisions, or cuts with 
scissors are made at the point where the swelling is greatest; the 
surface of the wound being afterwards treated with lactic acid. 
This will be applied several times between the operations, which 
may require to be repeated more than once. Such operations 
have had good effect in removing severe pain on swallowing, 
which resisted other treatment. If the dysphagia is caused by 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 257 


severe infiltration of the epiglottis, then the free part of that 
cartilage must be amputated; for which purpose the red-hot snare 
is better than cutting instruments, as with its use troublesome 
hemorrhage is avoided. The removal of the epiglottis has no 
effect upon the deglutition movements; this is confirmed by the 
results of 240 such amputations, which Lockard-Denver has 
collected. 

If these endo-laryngeal operations offer no prospect of success, 
tracheotomy is recommended by many writers for the purpose of 
influencing the disease favourably by giving absolute rest to the 
larynx. This operation is very highly valued by M. Schmidt, 
who found that local treatment of the larynx was seldom neces- 
sary afterwards. It is only indicated in the more severe and 
rapid cases of laryngeal tuberculosis with slighter disease in the 
lungs. When the expectoration is abundant its expulsion 
through the cannula is very unpleasant, both for the patient and 
those near him. Besides being a curative operation, tracheotomy 
is also required as a palliative in all cases of stenosis. 

The experience of laryngo-fissure (thryeotomy) and sub-hyoid 
pharyngotomy has been less favourable. Both these operations 
can only be considered if the diseased foci are accessible in no 
other way, and then only if the lung disease offers a hope of 
recovery. 

Total extirpation of the larynx for tuberculosis has been 
successfully performed by Gluck; it is not generally recom- 
mended, however, as it is too dangerous for phthisical patients. 
Surgical treatment also includes electrolysis and galvano- 
cautery. Whilst the first has been generally abandoned on 
account of its slowness and difficulty, the latter enjoys increasing 
recognition. The galvano-cautery is employed for ulcers, and 
also, according to Griinwald, for the puncture of infiltrations. 
The operation must be done after the larynx has been thoroughly 
anesthetized in the way already described, the point of the 
cautery being raised to a white heat. For puncture the action 
must be continued till the point can be moved in the hole made, 
that is, for about 5 to ro seconds. The signs of reaction 
disappear in about two to three weeks, according to the extent 
and position of the disease, and the severity of the cauterization. 
The operation will perhaps have to be repeated several times. 
The range of usefulness of this method is almost without limits; 
there are practically no contra-indications to its employment ; its 
action can be limited exactly to the diseased area; it is easy to 
carry out, and is well supported. Griinwald, Jurasz, and Mann 
consider the principal advantages to be its deep action, the 


17 


258 A CLINICAL SYSTEM OF TUBERCULOSIS 


amount of reactive inflammation and hyperemia of the tissue, 
and in the resulting scar formation, which prevents the spread 
of the disease. Lately this method has been almost exclusively 
employed in the laryngological clinics of Freiburg and Bale. 
Killian also describes galvano-puncture as the one effective 
method for extensive and severe infiltrations; but he does not 
think it advisable to make more than two or three punctures at 


a sitting, as otherwise violent reaction, occasionally necessitating | 


tracheotomy, may occur. On the other hand, Siebenmann 
attempts to destroy all the diseased parts at one sitting, and this 
procedure has given him excellent results without complications. 
Halle, Frese, Ed. Meyer, and Noltenius are of the same opinion. 


Many warnings have been given against the use of the galvano- 


cautery for sub-glottic disease, as violent cedema may easily occur. 
We ourselves can warmly support the use of the galvano-cautery, 
which we have employed extensively; it can be combined with 
endo-laryngeal operations, such as curettage, and does not 
exclude other treatments, especially tuberculin. 

The physical methods include Bier’s hyperemia, sun-rays, 
Rontgen rays, radium and the diathermic treatment of Nagel- 
schmidt. 

The congestion treatment has been employed by Grabower 
by means of a rubber band, which is applied round the neck 
below the larynx for several hours a day; a large convex pad 
may be placed under it on both sides to increase the pressure 
on the veins in the neck. The treatment has given good results 
to various writers, and it is also recommended by Jurasz. The 
subjective symptoms, such as cough and dysphagia, are specially 
influenced, as we ourselves have noticed. 

Improvement has also been reported as a result of the direct 
exposure to sun-rays, which we can confirm from the experience 
of several cases. Besides the hyperamic effect of the sun’s rays 
there are various psychical factors introduced, such as faith in 
the healing powers of the sun and the benefit to the patient of 
being able himself to co-operate in the treatment, which should 
by no means be underestimated. Intelligent patients soon learn 
themselves to direct the rays of the sun into the larynx by means 
of an easily constructed mirror stand. 

Unfortunately in Germany there is not sufficient sunshine, 
especially in winter, for systematic treatment, for which reason 
the reports from places in the high mountains have been the most 
favourable. 

As there are no authoritative reports of bad results from either 
the hyperemic or sunlight treatment, both methods may be 








TUBERCULOSIS OF THE UPPER AIR PASSAGES 259 


recommended for all cases in which more effectual means cannot 
for some reason or other be used, and also as an after-treatment 
for operations to prevent relapses. An advantage of both 
methods is that they can be carried out for a long time by the 
patients themselves without medical supervision, when they have 
once had detailed instruction and experience. Moreover, if the 
patients apply the sun-rays themselves, they may, if they are 
observant, be able to detect early suspicious appearances in the 
mirror picture, and call in medical aid at the right time. 

The Rontgen rays are applied to the diseased part of the 
larynx by means of a specially constructed autoscope tube. There 
are many records of marked improvement, even cure, especially 
of lupus; possibly because lupus is principally situated at the 
entrance of the larynx and is so more accessible to the rays. A 
definite verdict upon this method cannot yet be given. There are 
still technical difficulties in its application, as the healthy tissue 
must be protected from the rays; the treatment makes great 
demands on the patience and will power of the sufferer. But the 
possibility of cure has been proved with certainty both on paiho- 
logical and anatomical grounds for tubercular disease of the 
larynx in rabbits by Brinings and Albrecht at the Freiburg laryn- 
gological clinic. For this reason attempts are constantly being 
made to apply the Rontgen rays from outside. The larynx is 
treated from both sides with the rays up to 1 to 2 erythema doses, 
and to obtain a sufficiently deep effect use is made either of a filter 
of aluminium, silver or leather, or the skin is first rendered 
anemic by an adrenalin-novocain injection. The results up to 
now encourage the continuation of these attempts. 

The radium treatment is still quite tentative and inadequate, 
but there is a better prospect now that special instruments have 
been made to introduce the radium to the diseased area. 

Nagelschmidt has obtained rapid healing of laryngeal tuber- 
culosis by means of the diathermic treatment, which will be 
described more fully under lupus; the reports hitherto received 
arouse the greatest hopes of this method for all tubercular diseases 
of the upper air passages. 

With the local measures directed against the disease in the 
larynx, general treatment of the patient must play a principal 
part, as the lungs are practically always affected at the same 
time. Whether this must be carried out in an institution or not, 
must be decided for each case separately. Certainly there are 
patients of such strong character as not to require constant 
medical supervision; but the assertion of experienced sanatorium 
doctors must be believed, that even the strictest institutional 


260 A CLINICAL SYSTEM OF TUBERCULOSIS 


discipline is not always sufficient to restrain careless optimism. 
We cannot recommend treatment in the patient’s own home. 
Though throat specialists are unanimous in stating that the 
favourable moment for local treatment of the larynx must not 
be allowed to slip by, yet we are glad to be able to say it cannot 
be asserted that there are many institutions in which this is now 
permitted. As soon as possible after an effectual operation 
general treatment must be carried out in a sanatorium or a health 
resort. The choice of place is chiefly a question of financial 
means; a place free from dust and wind, and with not too dry 
a climate, 1s preferable. 

The treatment at watering-places must not be forgotten. 
Mineral waters act both on the digestion and assimilation, and 
also on the catarrhal complications in the air passages. Though 
we consider that for lung cases other hygienic factors are much 
more important, still from our own experience we do not wish to 
undervalue the loosening of secretion and relief of the larynx 
which may be obtained from the use of mineral waters. The 
chemical combination of the water does not seem to us of great 
importance; the principal point is that expert local treatment of 
the tubercular larynx must be obtainable at the health resort. 

We consider that the sparing use of the larynx is part of the 
general treatment in a narrower sense. Every injury and un- 
necessary exertion of the diseased organ must ,be avoided by 
means of strict discipline of the cough, by suitable diet, by 
loosening the secretion with inhalations, and aqueous or alcoholic 
compresses to the neck, by the sparing use of codein, dionin or 
heroin, by the prompt treatment of accidental catarrhs of the 
throat and nose, &c.; whilst in all severe cases absolute silence 
should be maintained for some months wherever possible. Whis- 
pering is only to be allowed when absolutely necessary. The 
maximum rest to the larynx is of enormous importance, both in 
estimating the length of treatment and for prognosis. Clearly 
it can be more easily obtained in a well-disciplined institution 
than elsewhere. For incurable cases it is an unnecessary hard- 
ship. It need hardly be said that absolute silence for two to 
three weeks must follow every extensive endo-laryngeal operation. 

In suitable cases we consider specific treatment to be a most 
valuable part of the general management of cases of laryngeal 
tuberculosis. There have been good reports of the result of serum 
treatment. Very much larger and more satisfactory has been the 
experience of the various tuberculins, of which Koch’s deserve 
the preference. The method of use is the same as for disease — 
in the lungs, and the latter usually regulates the treatment, as — 





TUBERCULOSIS OF THE UPPER AIR PASSAGES 261 


it is the primary disease. The choice of case must be made with 
the most careful consideration of the state of the lungs and the 
general condition. The possibility of directly observing the in- 
fluence of tuberculin on the larynx as a means of control should 
be utilized after each injection. Early redness and_ swelling 
entirely disappear. Smaller infiltrations are easily reabsorbed, 
larger ones require a longer time, according to their position. 
There is a possibility of a reactive necrosis wherever the deeper 
tissue, which may be covered with more or less healthy mucous 
membrane, is already destined to break down. In such a case it 
is only a question of precipitating the natural fate of most infil- 
trations. Asa matter of fact a marked formation of ulcers under 
tuberculin has not been seen by competent observers. “Tubercular 
ulcers offer the condition most favourable to cure with tuberculin, 
especially those that are more superficial. Blumenfeld saw old 
torpid ulcers which had previously resisted all treatment, even 
lactic acid, heal under tuberculin. For larger ulcers, which are 
usually also accompanied by infiltrations, it is better to accept 
the help of surgical treatment. Diffuse infiltrations, which resist 
most treatments, even surgical, can often be considerably reduced 
by means of tuberculin. In cases of severe necrosing infiltrations, 
and of deep ulcerations and_ perichondritis, complicated with 
mixed infection, such as are usually only met with in severe cases 
of pulmonary tuberculosis, tuberculin is powerless and is better 
omitted. According to Edmund Meyer, on the other hand, it 
is a matter of indifference whether the disease takes the form of 
infiltration, ulceration or perichondritis, or whether all three forms 
are combined. It has been the almost universal experience that 
the treatment of laryngeal tuberculosis has been greatly improved 
by the aid of tuberculin. It must be clearly understood, how- 
ever, that the tuberculin treatment of laryngeal tuberculosis 
usually takes a long time, since there is generally also severe 
disease in the lungs, which draws, by virtue of its larger area, 
most or all of the tuberculin to itself, especially at the commence- 
ment of treatment, and only after the lungs are gradually satu- 
tated is the tuberculin free to act on the larynx. The fact may 
be emphasized that the use of tuberculin is by no means opposed 
to other therapeutical measures, and that we, as a result of large 
experience, most warmly recommend a combination of general, 
local and tuberculin treatment. 

Lupus of the larynx generally requires the same treatment as 
tuberculosis. As, for the most part, it is situated at the entrance 
of the larynx, in severe cases amputation of the epiglottis and 
excision of the infiltrated parts of the aryteno-epiglottic folds may 


262 A CLINICAL SYSTEM OF TUBERCULOSIS 


be considered. The best results have been obtained by Moritz 
Schmidt with the curette and lactic acid, and tuberculin has been 
to him a considerable aid. 

With regard to prevention of laryngeal 
tuberculosis in cases of open pulmonary 
disease advice has already been given in the sections on the treat- 
ment of the disease in the lungs and larynx. In general the 
cough and expectoration must be disciplined and treated if neces- 
sary, and the hygiene of the voice and larynx must be attended 
to, and a suitable diet given in cases of acute and chronic 
laryngeal inflammation in phthisical cases. The prophylactic 
value of tuberculin must not be underestimated. It acts on the 
mechanical irritation and inflammation of the larynx by relieving 
the cough, it lessens the expectoration and loosens the sputum, 
it decreases the opportunities of sputum being deposited in the 
cavity of the larynx, and above all it raises the biological powers 
of resistance of the laryngeal tissues to the tubercle bacilli. 


Prophylaxis. 


4. TUBERCULOSIS OF THE TRACHEA OF THE 
LARGER BRONCHI. 


In the trachea and larger bronchi tubercu- 
losis appears almost without exception in 
the ulcerating form. The number and size 
of the ulcers vary. In the trachea they may cover the whole 
tube, and produce necrosis of the cartilage, but as a rule they are 
superficial, and occur chiefly on the posterior wall. According 
to Cornet, tubercular tumours and lupus have also been found 
on the trachea. Caseating bronchial glands may break through 
from the exterior into the trachea or bronchi. 

A primary inhalation tuberculosis of the 
trachea or bronchi is extremely rare. Nearly 
always the ulcers arise from sputum infec- 
tion towards the end of life. Since they occur in _ phthisical 
patients in the last stages no special clinical symptoms can be 
recognized. Usually they are first revealed at the autopsy. 
In rare cases the ulcers may be diagnosed 


Anatomical 
Changes. 


Symptoms and 
Course. 


3 Diagnosis, 5 with the laryngeal mirror, but their recog- 
pee UCS Sagan nition is of no importance as the patient is 
Treatment. 


usually im extremis. The prognosis is 
absolutely bad. No special treatment is required, at the most it 
could be only symptomatic. Se 





CHAPTER -Y. 


Tuberculosis of the Digestive 


Organs. 


BEFORE considering the tubercular affections of the several 
organs we may take a short glance at certain non-tubercular 
changes which frequently occur in tubercular patients and have 
a distinct importance from the point of view of diagnosis, pro- 
gnosis, therapeutics and prophylaxis. 

The most frequent affections of the mouth in tubercular 
patients are stomatitis and dental caries. Stomatitis occurs in 
cachectic conditions, more frequently in children than in adults. 
Caries usually commences at the neck of the incisor teeth, and is 
much more often met with in tubercular than healthy people; in 
childhood it is even a pathognomonic symptom, since children 
with circular caries can be recognized as having the lymphatic 
diathesis. The importance of stomatitis and dental caries is that 
both interfere markedly with the nutrition of the patient. Carious 
teeth also offer a place of lodgment and entry of tubercle bacilli, 
and doubtless play a part in the production of tubercular glands 
in the neck. A most rigorous care of the mouth and teeth from 
childhood is therefore very important and necessary for the treat- 
ment and prophylaxis of tuberculosis. 

Of non-tubercular changes in the cesophagus, compression, 
decubital ulceration and traction diverticula may be mentioned. 
Decubital ulceration occurs in the last stages of phthisis, and is 
due to the weight of the larynx pressing the cricoid cartilage back 
against the vertebral column, and so producing a circular patch 
of necrosis of the mucous membrane at the junction of the 
pharynx and cesophagus. 

Traction diverticula develop in consequence of the pull on 
the cesophagus produced by inflammatory adhesions following 
retraction of tubercular disease in the glands, lungs and medias- 
tinal tissues. Much more frequently tubercular glands break 


264. A CLINICAL SYSTEM OF TUBERCULOSIS 


into the cesophagus as a result of periadenitis, and by their sub- 
sequent fibrosis and retraction drag out the wall of the oesophagus 
in the formeot-a funnel: 

Symptoms of cesophageal compression may be produced by 
an abscess from caries of spine and by large tubercular glands. 

The consequences of the changes are difficulty of swallowing 
and retention of food. There are usually no indications for treat- 
ment. | 

As the pseudo-dyspepsia of tuberculosis has already been 
described there remain to be considered those diseases of the 
stomach which may complicate tuberculosis, especially acute and 
chronic gastritis. The appearance of these complications is partly 
due to a constitutional weakness of the digestive organs. They 
are of great practical importance since they often lead the patient 
to consult the doctor on account of gastric pains, loss of appetite, 
wasting, &c., while the lung symptoms, such as cough and ex- 
pectoration, are more or less ignored. If a thorough general 
examination is not made the case is diagnosed and futilely treated 
as one of idiopathic gastric disease, until the primary tuberculosis 
reaches a stage in which it can no longer be overlooked. So that 
gastric symptoms demand a most complete examination of the 
whole body, especially of the lungs. 

The tendency of tubercular persons towards attacks of acute 
gastritis may be explained by the increased toxzemia, and particu- 
larly by the extreme sensibility of these cases to slight errors of 
diet, such as cold drinks, &c. The gastric symptoms come on 
acutely with pain in the region of the stomach, furred tongue, rise 
of temperature and diarrhoea. There is also excessive secretion of 
mucus with marked diminution of the free hydrochloric acid, 
while alterations in the motor functions of the stomach can be 
hardly recognized. 

In the treatment, complete abstinence as far as possible from 
all solid and soft foods for twelve to twenty-four hours is the 
most important point, only a little gruel, or some weak tea if 
there is much thirst, being allowed. Ordinary diet must be very 
cautiously resumed. In all cases rest in bed is required. In- 
dividual symptoms must be treated as the need arises. If the 
secretion of acid remains deficient, hydrochloric acid and pepsin 
must be ordered with the meals, while alkalis, if necessary, com- 
bined with belladonna, may be given for hyperchlorhydria. 

Chronic gastritis may be the result of an acute attack, or 
it may be a consequence of swallowing the sputum or of a toxic 
action on the mucous membrane; in advanced cases it is usually — 
due to chronic congestion of the mucous membrane of the 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 265 


stomach, which is a part of a general portal congestion. In 
tubercular patients it assumes particularly the atrophic form, with 
the consequent mechanical insufficiency of the muscles (gastric 
atony), dilatation of the stomach as a result of the stagnation of 
the contents, increased secretion of mucus and diminution or 
absence of the gastric absorption. According to Permin, 23 per 
cent. of tubercular patients in stage I, 34 per cent. in stage IT, 
meepers cent. in Stave Il], and 75 per cent. in the last stage 
suffer from deficiency or absence of acid in the gastric contents ; 
in the last class marked interstitial changes take place at least 
twelve to six months before death. Changes in the motile powers 
of the stomach are part of the general muscular weakness of tuber- 
cular patients, but occur with special frequency if over-feeding 
with large quantities of milk has been practised. The subjective 
and objective signs of chronic catarrh, atony and dilatation of 
the stomach, are not altered by the presence of tuberculosis. The 
motor and secretory functions of the stomach may be chemically 
examined in tubercular patients, if the passage of stomach tube 
is not contra-indicated. We may test the amount of acidity 
(three-quarters of an hour after breakfast, or three hours after 
lunch), the amount of mucus (best in the morning) and the motor 
powers of the stomach (six hours after food). Alterations of the 
secretion and motor power of the stomach with excess of mucus 
indicate gastritis, even if the nervous symptoms are very marked. 
In patients who object to the stomach tube and cases of advanced 
tuberculosis with loss of lung tissue and a tendency to hamor- 
rhage, the stomach may be mapped out after drinking a pint of 
fluid or inflated with carbonic acid gas (a teaspoonful of tartaric 
acid and bicarbonate of soda in a little water drunk quickly one 
after the other). The lowering of the motor function can also be 
detected by means of Ewald’s salol test. 

Tuberculosis and chronic gastritis often form a vicious circle, 
in so far as the tubercular mischief prevents the improvement 
of the gastritis, and this again influences unfavourably the tuber- 
culosis. Therefore the treatment is certainly difficult, but is most 
urgently needed. A rigid dietary is not suited for these cases. 
One should aim at an easily digestible diet, neither too dry nor 
containing too much fluid, neither too hot nor too cold, not too 
much at one time, but food to be taken more frequently through 
the day. Change of residence, entailing change of cooking and 
of climate, often has a good effect on the appetite. Hydro- 
therapy, massage, electricity, and psychical treatment must be 
employed in addition. In cases of motor weakness with much 
mucus and fermentation washing out the stomach with warm 


266 A CLINICAL SYSTEM OF TUBERCULOSIS 


Ems water is most useful. Mineral water treatment is to be 
recommended; in cases of gastritis with deficient acid secretion 
especially the saline waters of Kissingen and Wiesbaden, in 
hyperchlorhydria Karlsbad or Vichy; the water is to be taken 
warm in the morning. Of drugs the most useful are the 
astringent silver nitrate (} gr. in pill, 1 to 2 pills after food), or 
subnitrate of bismuth in large doses (150 to 200 gr. a day). In- 
dividual symptoms must be treated as they arise. 

Non-specific affections of the intestines in tuberculosis have 
somewhat similar effects to gastric catarrh; there is a special 
liability to acute and chronic catarrh, and to amyloid degenera- 
tion. 

Acute enteritis may occur in the early stages of phthisis 
in consequence of mechanical, chemical, or infectious irritation 
from the intestinal contents, and in weakly individuals is a 
serious, and often a fatal complication. 

Chronic enteritis may develop out of the acute form. More 
often changes in the intestinal mucous membrane and muscle 
and nerve apparatus develop in phthisical cases in consequence 
of toxic influences, and take the form of congestion, atrophy, 
inflammatory swelling of the mucous membrane, or atony of the 
intestinal muscles. Since these non-specific affections cannot be 
clearly distinguished from tubercular enteritis, their treatment 
will be considered with that of the latter condition. 

Amyloid degeneration of the intestines in advanced cases of 
phthisis not seldom accompanies tubercular intestinal disease. 
In consequence of circulatory disturbances amyloid ulceration of 
the mucous membrane often appears, especially in the lower part 
of the small bowel. The ulcers are smooth, and have sharp, 
punched-out edges, and the vessels in the floor of the ulcer. undergo. 
amyloid changes, so that it is not difficult to distinguish them 
from tubercular ulcers. The symptoms are vague, and the treat- 
ment is that for tubercular diarrhoea. 

Non-specific affections of the liver which are frequently met 
with in tuberculosis are fatty and amyloid degeneration and 
cirrhosis. 

Fatty liver, which is frequently found in autopsies on tuber- 
cular cases, arises, as in other forms of marasmus, from nutri- 
tional changes. Whilst the body fat diminishes, there is an 
excessive amount in the circulating blood, which causes a fatty 
deposit in the liver, and even a fatty degeneration of the liver 
cells. Ill-considered super-alimentation of phthisical patients, 
especially with fats, may assist in its production. Icterus is 
absent; in very advanced cases of fatty liver the bile pigments 
are diminished, or even absent. e 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 267 


Amyloid degeneration of the liver affects the connective 
tissue and blood-vessels, and the parenchymatous cells only 
secondarily by pressure. In advanced amyloid, like fatty de- 
generation acholia, a diminution of the bile with urobilinuria, 
may occur; jaundice and ascites are absent. The liver is very 
much enlarged, uniformly hard, and quite smooth. The distinc- 
tion between the fatty and amyloid liver cannot be made 
by palpation; but the changes in the spleen, intestines, and 
kidneys point to the correct diagnosis. 

The combination of hepatic cirrhosis with tuberculosis of 
other organs, especially tubercular peritonitis and miliary tuber- 
culosis, is very common. The question whether the cirrhosis is 
primary and the tuberculosis secondary, or whether the opposite 
is the case, can be now answered by saying that hepatic cirrhosis, 
especially the hypertrophic form, produces a marked predis- 
position to tuberculosis, while the cases in which a primary 
tuberculosis gives rise to interstitial hepatitis, either through the 
blood or through the peritoneum, are very rare. At the same 
time one can understand that chronic fibrotic lung changes 
may lead to venous stasis in the liver, and that in consequence 
of this stasis there may be a gradual overgrowth of connective 
tissue, producing what is known as the cirrhotic nutmeg liver. 
If the changes in the liver are more than slight, since they 
increase the cachexia, they will aggravate the prognosis. The 
nutrition is unfavourably affected, and the antibacterial and 
antitoxic functions of the liver injured. 


1. TUBERCULOSIS OF THE MOUTH AND TONSIL. 


The forms of tuberculosis of the mouth are 
superficial and deep ulceration, polypoid 
tumours, and lupoid infiltration. 

The ulcers, which are most common in the mucous mem- 
brane of the lips and cheeks, and along the edges of the tongue, 
commence as tubercles, which show through the epithelium, and 
afterwards caseate and break down, and by the confluence of 
neighbouring areas cause an obvious loss of tissue, covered by 
indolent, discoloured granulations. The edges of the ulceration 
are thin, uneven, eroded, and irregular, often studded with 
greyish tubercles; they are never sharply cut. 

The nodular tumour, which appears on the tongue, is soft 
and fragile, bleeds easily, is single or multiple, and of the size 
of a hazel to a walnut. Caseation of the nodule causes a cold 
abscess, which discharges externally, but only by a small slit- 
like opening. ; . 


Anatomica! 
Changes. 


268 A CLINICAL SYSTEM OF TUBERCULOSIS 


Lupoid infiltration may be due to lupus of the face 
spreading into the mouth; it presents a slightly raised, dark red 
unevenness with soft edges, which may last for a long time 
without superficial necrosis. 

Infection of the mouth is usually due to bacilli of the human 
type, though it has undoubtedly been observed from bovine 
bacilli received through milk. 

The great importance of thetonsils as a place of entry of 

the bacilli is now clear; they may be infected through the blood, 
the lymph, the sputum, the air, or the food. In a systematic 
observation of 100 tonsils removed from phthisical cases, we 
found not only old cretaceous nodules, but also recent tubercles 
with giant cells and bacilli, even when the tonsils were quite 
small and outwardly normal. Large caseous areas, and isolated 
tuberculosis of the tonsil, are rarer; when it occurs the caseation 
usually begins in the middle of the tubercle in a giant cell. Later 
ulceration develops, but not directly on to the surface of the 
tonsil, but first into one of the crypts, and from there it spreads 
to the surface. Lupus of the tonsil is rare; the primary form 
has only been twice observed with certainty. 
Tuberculosis of the mouth is localized in 
the tongue, the cheek, the lips, the palate, 
and the gums. The closed form usually 
does not produce symptoms, while tubercular ulcers according to 
their size and position cause dryness, burning, a feeling of a 
foreign body, salivation, abnormalities of taste, and pains. With 
more extensive ulceration there will be pain on mastication 
and swallowing, excessive mucus, continuous irritative cough, 
foetor from the mouth, and sometimes fever. If the tongue is 
painful, speech will be affected. The glands in the neck are 
regularly infected. 

The mouth is a rare place of localization for tuberculosis, as 
there are various agencies, such as the secretion of the saliva, the 
numerous vessels and wandering leucocytes, and the vast quantity 
of parasitic saprophytes, which hinder the development of tuber- 
culosis. But in the later stages of tuberculosis the resistance of 
the patient is considerably lowered, and there are a large quantity 
of tubercle bacilli constantly passing through the mouth. If 
infection occurs it may be either secondary from the sputum 
during the course of phthisis, or primary from the air or food. 
The infection may be carried by the food, the finger, a foreign 
body or instrument, and may enter through a defect or crack in 
the epithelium, or a wound in the gum. Particularly the bacilli 
may enter into the hole left by a tooth extraction, where being 


Symptoms and 
Course. 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 269 


cut off from the action of the saliva they set up a tuberculosis of 
the mucous membrane or alveolar lining, from whence they pass 
to the neighbouring lymphatic glands and set up a general infec- 
tion. The course is usually slow, especially in lupoid infiltration, 
and the nodular forms of tuberculosis of the tongue. In advanced 
phthisis there may be also amyloid disease of the kidney, bowel, 
and spleen. 

Tubercle bacilli may remain latent in the tonsil, and pass 

through it without the gland itself becoming tubercular, so that 
the importance of the tonsil as a place of entry of the tubercular 
infection cannot be estimated only by the macroscopic or micro- 
scopic detection of tonsillar tuberculosis. But this latter condi- 
tion 1s not so very uncommon, as there are many undoubted cases 
of primary tuberculosis of the tonsil. It can hardly be detected 
by the naked eye, since the organ is almost unaltered in appear- 
ance; it is not always enlarged, and rarely is diminished in size, 
but usually contains small yellow points. Only when breaking 
down and ulceration have occurred is the condition to be recog- 
nized with the naked eye. When the ulcers become superficial 
they are of the size of a lentil, round or oval, with a surface like 
bacon fat, their edges are sharply cut, rather elevated and red, 
while the tonsil itself is only slightly reddened. In lupus the 
tonsils are enlarged, with warty, stumpy, or conical projections 
from the surface. Ulcerations are rare. 
The diagnosis of tuberculosis of the parts 
of the mouth accessible to the eye is not 
difficult, especially if a tubercular affection elsewhere gives a clue 
to the cause of the disease in the mouth. 

Differential diagnosis must be made from herpes, aphthe, 
traumatisms, and especially syphilitic ulcerations, and gummatous 
and carcinomatous nodules. It must first be remarked that the 
tubercle bacilli are very difficult to discover, and are only of positive 
significance if they are found in the tissue. Herpes is character- 
ized by the serous vesicles. Aphthous plaques are larger, have 
a smoother surface, and heal quickly under treatment, as do also 
the traumatic ulcers due to a sharp tooth. The tubercular 
character of an ulcer in the mouth is indicated by its shallowness, 
atonic nature, the pale area round it, its irregular border, the 
yellowish grey granules near it, the absence of contraction, the 
slow course lasting for months or years, and the small amount of 
pain, with well-marked sensations of tension and dryness. Cancer 
is indicated by the crater-like floor and hard edges of the ulcer; 
while the ulceration of syphilis is multiple, very red, breaks down 
quickly, and has smooth, sharp, steep borders. 


Diagnosis. 


270 A CLINICAL SYSTEM OF TUBERCULOSIS 


There is much difficulty in the diagnosis of the nodular form 
of tuberculosis of the tongue from gumma and cancer. Severe 
pains spreading up to the ear, with large hard glands under the 
jaw, usually limited to one side, are in favour of cancer; small 
glands on both sides, and multiplication of the tumours indicate 
tuberculosis. Syphilitic antecedents, other venereal symptoms, 
and general swelling of the glands point toa gumma. Adminis- 
tration of iodides on the one handpor a tuberculin injection on the 
other, will clear up all doubt, as long as there is not a double 
infection with syphilis and tuberculosis. As a last resource in 
distinguishing carcinoma and tuberculosis a small piece of tissue 
may be removed for histological and bacterioldgical examination. 

Tonsillar tuberculosis in the presence of ulceration is much 

more difficult to distinguish from syphilis. Without microscopic 
examination of some scraped off secretion for spirochzete and 
tubercle bacilli it may not be possible. The closed form cannot 
be diagnosed by the eye. The tuberculin diagnosis or the results 
of treatment may be of help. Lupus is characterized by the size 
of the tonsil and its nodular surface. 
Although spontaneous healing of tubercular 
disease of the mouth has been observed, the 
prognosis is generally not good. This is because the primary 
disease often quickly infects the intestines or lungs, and the bacilli 
may penetrate into the jaw. 

The prognosis in tuberculosis of the tonsil is distinctly more 
favourable. 


Prognosis. 


Treatment must be directed first to the 
general condition and the primary disease. 
Hopeless cases will be limited as far as possible to a non-irritating 
diet, and the mouth washed out with disinfecting solutions such 
as peroxide of hydrogen, 1-3 per cent. potassium chlorate, borax, 
and boracic acid, while pain may be relieved by sucking ice, by 
painting with alypin (10-20 per cent.), or dusting on orthoform 
or anesthesin. Also 20 per cent. menthol, mentholorthoform, 
antipyrin, iodoform, balsam of Peru, and tincture of iodine are 
recommended for diminishing the soreness. If the nodule is so 
placed that it can be done without causing much damage, it 
should be anesthetized, and removed with a galvano-cautery, or 
the curette; in the latter case the base left should be carefully 
rubbed with 50-75 per cent. lactic acid. 

Tuberculosis of the mouth in patients with healthy, or only 
slightly affected lungs, should be treated without delay by a 
combination of general hygienic measures, tuberculin, and an 
energetic local treatment. Where possible the wide excision of 


Treatment. 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 271 


the disease, so that it does not return, should be performed. For 
tuberculosis of the gums the Rontgen-rays have been used with 
success. 

Tubercular tonsils should be removed. The remaining ulcer 
may be treated with the galvano-cautery and lactic acid. 
For prophylaxis a most careful attention to 
the mouth and teeth of children is required, 
also a thorough disinfection of all dental instruments. Barbers’ 
implements and instruments used for the teeth and mouth are 
still not properly attended to. There can be no doubt as to the 
necessity of removing all tonsils that cause a suspicion of tuber- 
culosis. On the other hand it is doubtful if large tonsils, which 
are causing no symptoms, should be excised, owing to the possi- 
bility of allowing the entry of a tubercular infection. The tonsils 
are valuable protective organs for the mouth, which should be 
preserved as long as they are causing no harm. But very large 
tonsils can no longer perform the function of protection. We 
therefore take the view that it is better to spare those tonsils that 
are causing no symptoms, and are not of an excessive size. 


Prophylaxis. 


2. TUBERCULOSIS OF THE PHARYNX. 


Tuberculosis of the mucous membrane of 
the throat consists of a superficial growth of 
thick granulation tissue, rich in vessels, and 
infiltrated with cells. In this tissue tubercles with epithelioid cells 
and scattered giant cells are found, while tubercle bacilli lie 
between the cells of the granulation tissue in large numbers. 
Macroscopically, tuberculosis of the throat may be observed in 
the miliary form and as a diffuse infiltration. Through the red 
and swollen mucous membrane the miliary tubercles show; as 
they break down ulceration of a markedly lenticular character is 
formed. 

Lupus of the throat also consists of a cellular infiltration of 
the mucous membrane, containing tubercles with large round 
and giant cells, which are often partly confluent. In its further 
course it may caseate and ulcerate; or some of the lupoid nodules 
may cicatrize, while others remain on the surface of the mucous 
membrane. 


Anatomica! 
Changes. 


Tuberculosis of the throat shows _ itself 
especially by sensations in the neck, which 
may be like the feeling of a foreign body, 
a dryness or burning, or a persistent scratching or stabbing pain, 
which is increased by mastication, by speaking, and particularly 


Symptoms and 
Course. 


272 A CLINICAL SYSTEM OF TUBERCULOSIS 


by swallowing, and which spreads up into one or both ears. 
The pain and swelling may so interfere with swallowing that no 
solid and very little liquid food can be taken. If the disease is 
situated in the soft palate, so that its movement is affected, the 
voice acquires a nasal tone; also fluids may be forced into the nose 
on swallowing. ‘The secretion of mucus in the throat is increased, 
so that the patient is tormented with a constant desire to hawk 
or swallow. Marked foetor is rarely absent. Swelling of the 
cervical and submaxillary glands can usually be detected; exist-, 
ing tubercular fever will be increased by the pharyngeal affection. 
The favourite point of localization is the soft palate, then the 
uvula and the posterior pharyngeal wall; also the whole oral 
portion of the pharynx may be ulcerated. 

Tubercular ulcerations of the throat are more superficial than 
deep, with a tallow-like base often covered with ' granulation 
tissue; the edges are sharply cut, and irregularly corroded. In 
the neighbourhood of the ulcer isolated, sub-miliary tubercles 
may be seen, which will form fresh ulcers by necrosing. Diffuse 
tubercular infiltration of the throat is rarer. It penetrates more 
deeply into the mucous membrane, and gives it a gelatinous 
appearance; in the neighbourhood of these infiltrations large 
tubercular nodules may be also seen. If the uvula is affected it 
becomes swollen to the size of the thumb, and studded with hard 
nodules; if it remains free it becomes atrophic and stumpy. If 
the ulceration and infiltration are extensive the palate and uvula 
are not infrequently destroyed, or the palate may become per- 
forated or adherent to the posterior pharyngeal wall. 

Tuberculosis of the throat may be met at any age; it is more 
common in youths and adult males. It is very rarely a primary 
disease. Rosenberg saw in 22,000 cases of disease of the throat, 
twenty-two cases of tuberculosis, of which three were primary ; 
Guttmann and others have also observed its primary occurrence. 
Secondary infection occurs most often from lung disease 
through the sputum, more rarely from the nose, the mouth or the 
larynx. Direct extension of tubercular laryngeal ulceration into 
the throat has been observed. In tubercular meningitis miliary 
tubercles are sometimes found in the throat. 

Lupus of the throat is also rare as a primary disease, but it 
has undoubtedly been observed in young individuals; when 
secondary it is usually combined with lupus of the skin, the nose, 
the mouth, or the larynx. It most frequently affects the soft 
palate or the uvula, more rarely the posterior pharyngeal 
wall. The affected part may have its movements affected, though 
disturbance of its functions scarcely ever occurs. Also sensation 
in lupus of the throat, in contrast with tuberculosis, is not at all, 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 273 


or only slightly, altered; even extensive lupoid disease is usually 
quite painless. 

Macroscopically there can be seen either a very red, granular, 
dry, and glazed mucous membrane, or small nodules up to the 
size of a pea on an anemic, non-inflamed surface. They are 
round, smooth, rosy-red, sometimes surrounded by a redder area, 
and may on healing leave bands of connective tissue. Caseation 
causes superficial or deep ulceration. 

The course of lupus of the throat is very variable; it may 

spread over the throat in several days, it may remain stationary 
for months or years, or fresh lupoid nodules may be seen near 
smooth, glazed cicatricial areas. 
The diagnosis of tuberculosis of the throat 
can usually be made without difficulty. The 
miliary, and even the submiliary, tubercles, which can be better 
examined through a lens, and especially the ulcer surrounded by 
miliary tubercles, are so characteristic that the diagnosis can be 
made during life. Also the search for tubercle bacilli in material 
removed from the surface of the ulcer often succeeds. Marked 
subjective symptoms never fail in tuberculosis. | Herpes and 
aphthe of the pharynx may be distinguished by their acute and 
favourable course. The mucous plaques of syphilis can on close 
inspection be easily separated from the lenticular ulceration of 
tuberculosis. The syphilitic ulcerations of a later period are more 
dificult to distinguish from tubercular ulcers; the former are 
deeper, have sharp worm-eaten edges, tend to cicatricial con- 
traction, are not surrounded by grey granules, and may last for 
weeks and months without causing considerable symptoms. 
Other manifestations of syphilis or tuberculosis, the administra- 
tion of iodide or tuberculin, or Wassermann’s reaction will cleat 
up the diagnosis in doubtful cases. 

The diagnosis of lupus of the pharynx from syphilitic and 
tubercular ulcerations presents some difficulty, especially if there 
are no other areas of lupus. The very indolent nature and 
extremely long duration of lupus are distinctive. The ulcerations 
of lupus differ from those of tuberculosis, in that the edges are not 
sharply cut and seem more raised, and the floor is covered with 
indolent, pale, warty granulations, and they are not surrounded 
by the characteristic grey tubercles. Cicatrized lupus nodules 
appear as irregular white or light brown depressions or elevations, 
without having the band-like appearance of syphilis. Detection 
of tubercle bacilli in the scrapings from lupoid ulcers is seldom 
possible; a histological examination of a piece of excised mucous 
membrane is more useful. 

18 


Diagnosis. 


274 A CLINICAL SYSTEM OF TUBERCULOSIS 


The prognosis of pharyngeal tuberculosis is 

Prognosis., generally unfavourable; but single cases 
occur in which the primary disease being completely healed the 
secondary lesion in the throat comes to a standstill. The secon- 
dary infection of the throat on account of the pain, difficulty of 
swallowing, and fever nearly always causes a rapid exhaustion. 
Also the passage of the bacilli from the pharyngeal lymphatics 
to the subdural space is not uncommon, and always fatal. 

The prognosis in lupus of the throat is better. Though 
relapses are common, there is but slight tendency to spread of 
the disease. The general condition is but little, or not at all, 
affected. 

In the treatment of tuberculosis of the throat 

Treatment. the first place must be given to scraping the 
ulcers with a sharp spoon, and an energetic destruction of the 
infiltration with a galvano- or thermocautery ; cauterization with 
lactic acid, silver nitrate, carbolic acid, chloride of zinc, or sodium 
formate may also be used. Michelson, v. Renvers, Rosenberg, 
and others have seen healing with tuberculin injections, while 
other authors have noticed spreading of the ulceration. Relief of 
symptoms may be given by painting with menthol, alypin, or 
cocaine, or by insufflation of orthoform or anzsthesin. Gargles 
may be used for disinfecting the throat, provided that gargling 
does not increase the pains. The diet must be most carefully 
supervised ; often artificial feeding is required. 

Lupus of the throat is also to be surgically treated with the 
sharp spoon, galvano- or thermocautery, if it shows no signs of 
spontaneous healing. Tuberculin has given good results in some 
hands, not in others. Symptomatic treatment is hardly necessary. 


3. TUBERCULOSIS OF THE CESOPHAGUS. 


The anatomical changes in tuberculosis of 
the cesophagus consist of ulceration, or in 

Changes. the development of single or disseminated 
spherical nodules of the size of a hemp-seed. The ulcers may 
remain small or become very large. Kiimmel and v. Schrotter 
have described ulcers of the cesophagus which occupied 4 to 4/5 
of the whole gullet. The thickened edges of circular ulcers may 
cause stenosis. 


Anatomical 


Tuberculosis of the oesophagus usually 
C causes no special symptoms ; sometimes pain 
PUESe: on swallowing, symptoms of obstruction, 


Symptoms and 


retro-sternal pains, and paralysis of the larynx are developed. — 


Dysphagia may be quite absent even in severe cases, at other 






























—_ 


TUBERCULOSIS OF THE DIGESTIVE ORGANS 275 


times it may be produced by quite small-and superficial ulcers. 
Primary disease has not been observed; there are about forty cases 
of secondary disease in the literature. Guisez in 500 cesophago- 
scopic examinations found tuberculosis of the gullet three times. 
The rarity of the condition is due to the resistance of the thick 
squamous epithelium, to the quick, easy passage of any sputum 
that may be swallowed, and to the frequent washing during the 
passage of fluids. The infection of the cesophagus from the 
interior is therefore very difficult. If it should occur it will be 
either due to a subepithelial spread from the pharynx or larynx, or 
to infection from swallowed sputum at some point that is deprived 
of epithelium. Predisposing causes are traumatisms and corro- 
sions, superficial ulcerations, traction diverticulum, and cancer. 
Infection through the outer wall is more common; caseating bron- 
chial glands or disease in the lung may directly affect the 
cesophageal wall, and cause extensive destruction and superficial 
ulceration of the mucosa. The next most common mode of infec- 
tion is the transference of infective material by the blood-stream 
and lymphatics from neighbouring organs. 

The diagnosis is so difficult that it has only 
succeeded in recent years during life from 
the help of the cesophagoscope. By this means the ulcers, with 
or without granulatious, and with scalloped edges, or tubercular 
nodules in the intact mucosa, or in the neighbourhood of an ulcer. 
become visible. The ulcers can be easily distinguished from. the 
very pale mucous membrane which surrounds them. Neverthe- 
less it is going too far to say that all tubercular patients with 
dysphagia, which cannot be accounted for by inspection of the 
throat or larynx, should be examined with the cesophagoscope. 
Even in the hands of the expert the use of the instrument in cases 
of pulmonary tuberculosis is fraught with difficulties and dangers 
(hemoptysis); and the gain would be slight. 

If there are symptoms of obstruction the differential diagnosis 
must be made from strictures due to corrosive poisons, syphilis 
and cancer; the latter is not rare in combination with pulmonary 
tuberculosis. Important also is the recognition of caseous tracheo- 
bronchial and mediastinal glands, since these are the most com- 
mon causes of tuberculosis of the gullet. With the help of the 
Rontgen-rays a probable diagnosis at least can be arrived at. 
The prognosis is uniformly unfavourable, 
since the disease in this situation interferes 
with the general treatment. 

Treatment by painting the ulcers with lactic acid has been 
attempted with the help of the cesophagoscope. This may relieve 


Diagnosis. 


Prognosis and 
Treatment. 


276 A CLINICAL SYSTEM OF TUBERCULOSIS 


the difficulty of swallowing, and if the ulcer is not too large may 
induce healing. But in most cases treatment will be limited to 
giving a suitable diet and to controlling the pain with opiates. 


4. TUBERCULOSIS OF THE STOMACH. 


Miliary tubercles, ulcers, and tubercular 
nodules have been observed. Besides the 
ulcerating and hypertrophic forms French 
authors have distinguished a purely inflammatory form, with sub- 
division into the mucous, the diffuse submucous, and the circum- 
scribed submucous sclerosis; the last is the most important, as it 
it always situated at the pylorus, and leads to stenosis. 

The tubercular ulcer of the stomach is the most important 
form, since both the granular and nodular varieties have a great 
tendency to necrosis. It is produced, as is the ordinary peptic 
ulcer, by circulatory changes, especially tubercular endarteritis 
of the supplying vessel. The pylorus is the site of predilection 
on account of its great richness in lymph follicles. The ulcer, 
which penetrates the mucosa and submucosa down to the muscle, 
may be single or multiple, may remain small, or may cover an 
area of 100-200 sq. cm., and more. The ulcer is irregular 
in shape or oval, usually at right angles to the long axis 
of the stomach. The edges are thickened by leucocytic infiltra- 
tion, and are undermined or overhanging, so that the tubercular 
gastric ulcer is funnel-shaped, with the apex of the funnel towards 
the mucosa and surrounded by caseous material; while the edges 
of the simple gastric ulcer are in steps. At the edge and base of 
the ulcer are typical miliary and submiliary tubercles. The ulcer 
being situated at the pylorus in consequence of fibrous changes 
it may cause pyloric stenosis and adhesions between the pyloric 
region, the liver, and the bowel. 

The submucosa in the neighbourhood of a tubercular gastric 
nodule is usually occupied with a hard infiltration, the underlying 
serous coat is usually unaffected. The nodular form of tubercu- 
losis of the stomach by setting up diffuse infiltration leads to a 
considerable diminution of the size of the organ. 

Miliary tuberculosis of the stomach causes 
no clinical symptoms. Even large tuber- 
cular ulcers may cause no marked sym- 
ptoms; in other cases vomiting and gastric pains, increased 
by pressure and food, may be produced. Hzamatemesis is 
rare; perforation, fistula, perigastritis, and cicatrical stenosis 
even rarer. -In any case the effects are much slighter, and 
more indefinite than those caused by simple ulcer. The 


Anatomical 
Changes. 


Symptoms and 
Course. 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 277 


comparative absence of pain has been explained by the 
deficiency of free hydrochloric acid. If the disease is situated 
at the pylorus, to the pain and frequent vomiting after food are 
added the symptoms of dilatation of the stomach with periodic 
increase in the motor insufficiency. As a consequence of the 
pyloric stenosis hypersecretion and hyperchlorhydria occur. But 
there are no specific symptoms to differentiate the condition from 
other forms of stenosis. 

Tuberculosis of the stomach is very rare, it has not yet been 
observed as a primary disease. This is due to the poverty of the 
gastric mucosa in lymph follicles, and to the fact that the motor 
functions of the stomach are usually increased in phthisis. 
Whether the normally acid contents of the stomach have a 
bactericidal action on the tubercle bacillus and so prevent infec- 
tion is still doubtful, but it is very probable. 

It is more often due to an infection through the blood-stream 
as a part of general miliary tuberculosis; but this form has no 
clinical importance. There is also the possibility of the infection 
spreading by contact from a neighbouring organ, e.g., the spleen, 
to the serous coat, and penetrating the muscular layer. Lastly, 
lymphatic infection may occur from tuberculosis of the glands or 
peritoneum. Infection of the stomach from intestinal] contents 
conveying tubercle bacilli by means of antiperistaltic action is very 
difficult to understand. The multiple ulcers, usually at the 
pylorus, which may occur in the final stages of intestinal tuber- 
culosis, are without practical interest. Gastric tuberculosis is 
more common in children than adults in consequence of their 
smaller powers of resistance, and greater liability to miliary 
tuberculosis. 

Tuberculosis of the stomach runs a chronic course. Perfora- 

tion and fatal peritonitis are very rare; still rarer is a fatal 
haemorrhage from erosion of a vessel. 
It may be remarked that phthisical patients 
may suffer from simple gastric ulcer, also 
that tubercle bacilli may settle in a carcinomatous affection of the 
stomach wall. The diagnosis of tubercular ulceration of the 
stomach can therefore never be made with certainty, but only as 
a probability. The nodular form of gastric tuberculosis will 
usually be either overlooked or considered to be cancer; the age 
of the patient may be of some help. 

With Petruschky and E. Fischer we recommend the diagnos- 
tic tuberculin injection; but it is only of value if it causes an 
undoubted focal reaction; Fischer has observed this in the form 
of an increase in the pains and nausea. 


Diagnosis. 


bo 


78 A CLINICAL SYSTEM OF TUBERCULOSIS 


It seems to us that the practical conclusion is that for the 
explanation of severe gastric symptoms in non-tubercular patients 
gastric tuberculosis need not be considered, and that in tubercular 
cases simple ulcer and cancer are more common than tubercular 


ulcerations. 
' The prognosis of gastric tuberculosis is, as 
Prognosis. = a ABT ; 
such, not unfavourable, since the occur- 


rence of perforation need not be feared; but the co-existence of a 
primary pulmonary or intestinal tuberculosis in nearly all the 
cases makes the outlook very bad. 

In the treatment of tubercular ulcers experi- 
ence fails us, so we are driven back on the 
measures for simple ulcer. Rest as complete as possible for the 
body and stomach, and a careful fluid or soft diet, not too great 
in amount, are to be recommended. Tepid compresses, sub- 
nitrate of bismuth (15 gr. three to five times a day, before food), 
silver nitrate in pills, combined if the pains are severe with 
orthoform or anzsthesin (1$ to 5 gr.) may be used. If the pains 
are excessive morphia and belladonna suppositories may be 
given. E. Fischer and Petruschky report healing with tuberculin, 
which may be used when there are no other indications for treat- 
ment, as long as the case is not hopeless for other reasons. If 
there is hamatemesis rectal feeding is required, or jeyunostomy 
may be called for. For perforation and marked stenosis an 
operation is also demanded. The nodular form may be treated 
with resection, the caseous glands being also removed. 


Treatment. 


5. TUBERCULOSIS OF THE INTESTINE. 


The richness of the intestinal mucosa in 
follicles is a predisposing cause of infection. 

Changes. The solitary follicles and the Peyer’s 
patches are the primary sites of tuberculosis, which therefore 
especially occurs in the lower part of the ileum, the caecum, and 
the vermiform appendix, and is more rare in the upper and lower 
parts; but any portion of the tube from beginning to end may be 
the seat of tuberculosis. 

Isolated or multiple nodules first appear in the follicles; they 
may calcify, but usually necrose one after the other, become con- 
fluent, and form tubercular ulcers, which may be roundish, 
elongated, or irregularly scalloped. The ulcer usually extends 
circularly in the direction of the vessels and lymphatics, and so is 
at right angles to the long axis of the bowel, in contrast to the 
longitudinal typhoid ulcer; it may extend right round in the form 
of a ring or girdle. 


Anatomical 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 279 


The edges of tubercular ulcers are usually raised and infil- 
trated; they are often undermined, studded with breaking-down 
granules. The ulcers are of variable depth, and may pass through 
the muscular and serous coats, and cause a perforation. Inflam- 
matory thickening of the serous coat and adhesion to the neigh- 
bouring organs are usually present, so that perforation into the 
free peritoneal cavity is rare. 

Tubercular intestinal ulcers have a great tendency towards 
connective tissue formation and cicatrization; the lumen of the 
bowel may thus be narrowed, or by the contraction of a circular 
ulcer a more or less severe stenosis may be formed. Such 
strictures usually form near ulcers, they are often multiple, and 
are of great clinical importance. 

Tubercular tumours, the hypertrophic form of intestinal 
tuberculosis, may be produced by an inflammatory tubercular 
infiltration of all the coats of the bowel. The serous coat is much 
thickened, the muscular layer hypertrophied, and on the mucosa 
are polypoid, shaggy, nodular, or diffuse thickenings. Inflam- 
matory adhesion to the neighbouring parts, cicatricial contrac- 
tion and strictures usually occur, which may lead to considerable 
narrowing of the bowel and chronic intestinal obstruction. This 
variety is usually situated at the ileo-ceecal region, and may 
formatumour. In the ascending colon the hyperplastic form has 
also been observed as isolated tubercuiar tumours. Both may be 
confused with cancer, especially if the peritoneum, the mesenteric 
glands, and the vermiform appendix are matted together into a 
regular, compact mass. 

Where the serous coat is absent, as in the rectum, abscesses 
and fistulae form around the bowel. At least 60 per cent. of all 
rectal fistulze are of tubercular origin; the majority of these are of 
the muco-subcutaneous variety. They betray their tubercular 
nature by the undermined edges, the flabby granulations, and the 
grey granules. 

Tubercular rectal polypi, which are rarer than tubercular 
rectal ulcers, may also be met with. A still rarer condition is 
lupus of the anal region. 

_ The pathological importance of intestinal tuberculosis is not 
yet exhausted. According to the observations of Senckenberg in 
the pathological institute at Frankfort, large quantities of tubercle 
bacilli are carried from the intestinal lesions by the portal circu- 
lation and thoracic duct to the lungs and general circulation. 
This overloading of the blood and lymphatics with tubercle bacilli 
accounts for many cases of miliary tuberculosis, and has a great 
influence on the course of pulmonary tuberculosis. It is now 


280 A CLINICAL SYSTEM OF TUBERCULOSIS 


certain that intestinal tuberculosis is a chief source of blood 
infection in chronic tuberculosis, and the fresh infection may 
aggravate the pulmonary disease. 

The clinical symptoms of intestinal tuber- 
culosis are not clear and uniform; they 
depend on, first of all, to what degree the 
intestinal nerves are implicated and irritated by the ulcers, and to 
what extent motor and sensory changes are produced. Further 
ulceration may cause symptoms connected with the peritoneum, 
or bleeding. 

Diarrhoea is the most important of the symptoms due to motor 
irritation. “Troublesome diarrhoea, especially if it is severe and 
resistant to treatment, and if it occurs at night, in phthisical 
patients, is always very suggestive of intestinal tuberculosis; it 
is produced by the caseation of the follicles and the attendant 
severe catarrh. The stools have a penetrating odour, they are of 
a light grey, clayey colour, and often contain mucus, undigested 
food, and much fat. Blood and pus cannot generally be recog- 
nized by the naked eye. 

The frequency of the stools depends on the position of the 
disease. In tuberculosis of the ileum they may not be frequent, 
or there may even be constipation, while with disease of the lower 
colon or rectum there is always diarrhoea. In the last stages, in 
consequence of tenesmus, the stools may be held back. 

The diarrhoea is almost always accompanied by peristaltic 
movements and loud borborygmi, which often cause peristaltic 
pains, and are signs of commencing stenosis. Tubercular 
intestinal ulcers, unlike gastric ulcers, cause no, or only slight, 
local pains, but there is tenderness on pressure in the region of 
the ceecum or navel. But if the intestines are overdistended by 
meteorism, persistent, spontaneous pains will be produced; the 
passage of mucus in cases of spastic constipation will also cause 
colicky pains, while the squeezing of hard fzecal masses through 
the ulcerated, partly contracted bowel may cause great agony. 
Slowly commencing, but persistent, localized pains are indicative 
of peritoneal irritation of the surface of the bowel, if they are 
associated with local tenderness, nausea, or vomiting, and a rise 
of temperature. If the serous coat becomes perforated there will 
be localized or diffuse pains, and perhaps rigors, and the clinical 
picture of local or general peritonitis, the amount of which is 
determined by the grade of matting and adhesions. 

Large hemorrhages are rare; they are characteristic of 
ulceration in the rectum. They are more often brought about by 
mechanical irritation than by erosion of the vessel wall, and are 


Symptoms and 
Course. 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 281 


usually very intense and persistent.  Slighter bleedings often 
occur, and the blood frequently cannot be recognized macro- 
scopically. 

The localization of tubercular ulceration in the vermiform 
appendix may produce the symptoms of appendicitis, and _ its 
consequences. In chronic cases board-like infiltrations, or 
abscesses, may form, with fistulz, either externally, or into the 
rectum, bladder, or vagina. Infiltrations round the rectum are 
very common, and lead to proctitis, and periproctitic abscesses 
and fistula. About a third of these are clinically cases of primary 
tuberculosis, and anal fistula are very common results. Rarely 
they may occur without symptoms; generally there is pain on 
pressure, especially at stool, which is relieved when the pus is 
discharged. The rectal and anal fistule keep up a chronic 
suppuration, frequently with slight fever, and after a time cause 
a certain amount of illness, if they are not dealt with surgically. 
These fistula, even in cases of intestinal tuberculosis, are not in 
all cases tubercular. 

Stenosis causes special symptoms, which from the point of 
view of treatment it is most important to recognize. In the 
small bowel cicatricial strictures are especially frequent; thus 
showing that tubercular intestinal ulcers have a greater tendency 
to heal than is usually thought. Slighter degrees are overcome 
by a compensatory hypertrophy of the muscle above the stricture ; 
and on account of the soft state of the intestinal contents and the 
effect of diarrhoea, in hurrying the ingesta through the constric- 
tion, it may not be noticed for some time. When compensation 
fails in consequence of increasing contraction, clinical symptoms 
of obstruction will be produced; distension of the bowel above the 
stenosis, general meteorism, difficulty of breathing on account of 
upward displacement of the diaphragm, marked peristalsis, 
nausea, periodic attacks of colic, and vomiting which may become 
fecal. The colic is characteristic. The tightly filled coils of 
bowel above the constriction stand out as stiff, often board-like, 
tumours. The pains and hardening come on in spasms, last 
several seconds, and then suddenly cease, while at the same time 
a noise indicates the passage of fluid and gas through the 
-stenosis. 

Whilst stenosis from cicatricial contraction of a circular ulcer 
_is much commoner in the lower third of the small intestine, 
obstruction due to the hypertrophic form of intestinal tuberculosis 
usually occurs in the ileo-czecal region, more rarely in the ascend- 
ing colon. Tleo-czecal tuberculosis at first only causes dull per- 
sistent pain and tenderness, and afterwards, in consequence of 


282 A CLINICAL SYSTEM OF TUBERCULOSIS 


advancing stenosis, colicky pains, as described above, and fzecu- 
lent vomiting. From the surgical point of view these ileo-czecal 
tubercular tumours have been divided into three stages; in the 
first stage there are pains in the right iliac fossa, symptoms of 
commencing obstruction alternating with diarrhoea, and a distinct 
muscular resistance over the caecum; in the second a tumour of 
the caecum can be felt and often seen, with a distinct border in its 
lower part; if no operation is performed the third stage with 
abscess and fistula is reached, leading sooner or later to an in- 
evitably fatal termination. 

Tuberculosis of the bowel is often primary; Heller and 
Wagner found twenty-eight such cases in 600 autopsies. Recent 
observations show that it is by no means rare in children and 
young people; but it is still uncertain whether the frequency is due 
to the propensity of children for putting anything within reach into 
their mouth, or to the large amount of milk taken, or to a greater 
permeability of the mucous membrane. The point of importance 
is that bovine bacilli, which are but slightly virulent for adults, 
may in children produce a primary intestinal tuberculosis. But 
we do not consider that food infected with bovine bacilli has much 
tendency to infect adults in general, and healthy adults in particu- 
lar. The mother’s milk so very rarely contains bacilli that it 
has no etiological importance. Other foods which are accidentally 
much infected with tubercle bacilli may of course produce intes- 
tinal tuberculosis. But more important are the tubercle bacilli 
which are inhaled, deposited in the mouth and then swallowed 
with the food, thus giving rise to deglutition tuberculosis. This, 
however, does not always occur in the intestine, since the bacilli 
can pass through the intact epithelium, and also the intestinal 
wall, without leaving any visible effects behind. 

Primary tubercular ulceration of the bowels usually has a 
strong tendency towards healing. But as this form usually occurs 
in children, who have but a small power of resistance to a general 
spread of infection, it runs, as a rule, an unfavourable course. 
The fatal ending is due to marasmus, or to general or meningeal 
tuberculosis. 

Secondary intestinal tuberculosis is much more common. 
Fisenhardt in 1,000 autopsies on tubercular cases found the in- 
testine affected in 567 cases. Since Bollinger’s figures show that 
of these 567 cases only three would be without tuberculosis in the 
lungs, it is clear that intestinal tuberculosis is a common com- 
plication of chronic phthisis, and that infection from swallowed 
sputum must be the most frequent cause of the disease. The 
anti-bacterial action of the digestive juices, the quick passage and 


—«-, 


ns & 


el. a a a) ie 


™ 
b, 








TUBERCULOSIS OF THE DIGESTIVE ORGANS 283 


slimy nature of the sputum, make it probable that infection only 
occurs when there is a great amount of bacilli, or but little food 
is being taken. These conditions are best fulfilled in the ad- 
vanced stages of phthisis with cavities, when the sputum is often 
swallowed. Less important factors are the swallowing of bacilli 
from outside, which have lodged in the mouth, the virulence of 
the bacilli, a feeble state of the tissues, and solutions of continuity 
in the mucosa. Infection of the bowel through the lymphatics, 
especially from the peritoneum, is rare; and rarer still is infection 
through the blood-stream as part of a general miliary tuberculosis. 

The course of secondary intestinal tuberculosis depends on 

that of the primary disease. The disease in the lungs may be 
‘severe and in the intestines slight, or the opposite may be the 
case, or both may be either slight or advanced. Arrest and im- 
provement are quite frequent, and healing may occur. Stenosis 
in the small bowel is always a sign of a tendency to healing, but 
it may be associated with other active ulcerations. On the other 
hand there are cases in which the diarrhoea cannot be checked, 
and the disease runs a rapid course. Wasting and anemia 
accelerate the disease in the lungs, even if it is only quite slight, 
and raise the temperature considerably. Complications such as 
perforation into neighbouring organs or the peritoneum, or in- 
fection of the mesenteric glands, hasten the end, often by starting 
a miliary tuberculosis. The frequent occurrence of the miliary 
form can be explained, since B. Fischer has shown that in cases 
of tubercular intestinal ulceration the blood is constantly over- 
loaded with tubercle bacilli. 
There is no particular difficulty in the 
diagnosis of intestinal tuberculosis if some 
of the above-mentioned symptoms occur with manifest tuber- 
culosis in another organ, especially the lungs. If this is absent 
the diagnosis may be very difficult. Fever, the appearance and 
constitution of the patient, the family history, and history of the 
disease, may point towards the tubercular nature of the intestinal 
symptoms. 

The detection of ulceration is very difficult, since it often 
causes no symptoms. Diarrhoea is absent in the earlier stages; 
in fact, constipation is just as common as an early symptom. 
Blood, pus, and tissue shreds can generally not be distinguished 
by the eye in the loose stools. Occult bleeding is so important 
for the diagnosis, especially if diarrhoea or other obvious signs 
are absent, that the feeces should be examined for blood. 


Diagnosis. 


The feces, after three days’ abstinence from meat, may be examined 
in the following simple way, recommended by Rodari: A piece of fecal 


284 A CLINICAL SYSTEM OF TUBERCULOSIS 


material of the size of a pea is placed with a glass rod in a few cubic 
centigrammes of water, and boiled to prevent fermentation. In a second 
test-tube, 3 c.c. of benzoin solution and 3 c.c. of a freshly-prepared 3 per 
cent. peroxide of hydrogen solution are mixed together. One or two drops 
of the fluid containing feces are added to this; if blood is present a grey, 
blue-green, or blue colour will appear. The test is very delicate. 


Tubercle bacilli cannot regularly be found in the excreta, even 
with the help of the antiformin method. The detection in cases 
of phthisis is not absolutely indicative of intestinal tuberculosis, 
since they may be due to swallowed sputum. Also tubercle 
bacilli may be accidentally swallowed and appear in the fzeces. 
The mere discovery of acid-fast organisms in the stools does 
not prove that they are tubercle bacilli. But although not con- 
clusive the discovery of the bacilli greatly strengthens the clinical 
diagnosis of intestinal tuberculosis, if there is no open disease 
in the lung; and the diagnosis gains in certainty if the bacilli 
are contained in portions of tissue. 

The very penetrating odour of the stools, and a marked in- 
dican reaction of the BEG, are only indicative of much intestinal 
putrefaction. 

If the diagnosis of intestinal tuberculosis is clear, frequent 
and severe hemorrhages point to the rectum as the seat of disease. 
The disease in the rectum, and also in the sigmoid flexure, can — 
be inspected with the sigmoscope ; the typical ulcerations, infiltra- 
tions and erosions of the follicles can be seen situated in a diffusely 
red mucosa, covered with pus and mucus, often bloodstained. 

Strictures of the bowel may be due to tuberculosis or syphilis ; 
tuberculosis in other organs indicates the former, the history and 
venereal symptoms point to the latter. Lately in the clinic at 
Bale the diagnosis of a tubercular stricture has been made by 
a radiogram, taken five to six hours after a bismuth meal, a time 
when a stricture of the small bowel in its lowest part will be 
most clearly seen. 

Heoceecal tuberculosis is difficult to diagnose; it may be 
confused with cancer or chronic perityphlitis, also with scybala, 
sarcoma, actinomycosis, right-sided floating kidney or renal 
tumour, gall-bladder disease, ovarian tumour, encysted fluid in 
connection with disease of the female genital organs, and lastly 
with tubercular disease of the small intestine, the pelvic bones or 
the spine. 

We may limit ourselves to the most practically important 
differential diagnosis between ileoceecal tuberculosis, chronic peri- 
typhilitis and cancer, but when all the points have been considered 
mistakes are still possible. This is specially so in the diagnosis 
between tuberculosis and cancer; even at an operation, or on the 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 285 


naked-eye examination of a specimen, a definite opinion may not 
be possible, and can only be given by the aid of the microscope. 

In favour of chronic perityphilitis are an acute onset with 
fever, &c., tenderness on pressure at McBurney’s point, the 
detection of a surrounding effusion by very light percussion, 
absence of symptoms of stenosis, normal size of the inguinal and 
crural glands, elevation of temperature of shorter duration, and 
especially the detection by palpation of a tender swelling of the 
shape of the vermiform appendix in the ileo-cecal region. 
Attacks of nausea and vomiting are also more common with 
chronic appendicitis. 

In favour of cancer of the cacum are the older age of the 
patient, sharp limitation of a movable compact tumour, rapid. 
cachexia, constant pain, slight or no symptoms of stenosis, blood 
in the stools, sometimes fresh and obvious, sometimes only on 
testing, absence or rarity of pus in stools, rise of temperature only 
in the last stages, and negative diazo-reaction in the urine. 

Points indicative of ileoczecal tuberculosis are the younger 
age of the patient, tuberculosis elsewhere in the body, very 
chronic course, often lasting several years, a stiff, more or less 
fixed, irregular infiltration of an elongated sausage shape, 
characteristic symptoms of stenosis (obvious intestinal peristalsis, 
alternations of obstruction and diarrhoea), and colic-like attaclss 
of obstruction, beginning with pains and peristalsis, then noises 
like a suction syringe, followed by subsidence of the pains and 
diminution in size of the abdomen. Small amounts of biood often 
appear in the stools, pus is more rare; tubercle bacilli can be 
frequently found, the temperature is raised, and the diazo-reaction 
positive. 

Stierlin recommends the use of radiography five to six hours. 
after a bismuth meal. Absence of the shadow of the caecum and 
ascending colon between the shadows of the lower ileum and the 
transverse colon is typical of early as well as of advanced cases ; 
so that the diagnosis may be made by the radiograph, when it 
cannot be clinically. Stierlin has confirmed all his cases of radio- 
diagnosis by an operation; and explains the absence of shadow in 
the affected cecum and colon by the fact that the contents are 
forced so rapidly through this part that sufficient bismuth cannot 
collect to cast a shadow; whereas normally there is a relative 
delay in the cecum. 

Test injections of tuberculin are generally of little value as the 
intestinal tuberculosis is nearly always secondary to disease else- 
where; but they may be used if there is no obvious primary 
disease, or if the tubercular nature of this is not obvious. It is 





286 A CLINICAL SYSTEM OF TUBERCULOSIS 


only contra-indicated if constant pain at localized spots points to 
areas of peritonitis due to deep ulceration. 

Perirectal abscesses and fistulae can be generally recognized 

by the finger and probe. A suppurating hemorrhoid or an 
abscess in connection with typhoid fever may give rise to diffi- 
culty. The rectal fistulae of diabetics are nearly always due to 
tuberculosis. A diagnostic tuberculin injection may irritate a 
tubercular fistula. 
The prognosis is always serious, and is 
absolutely bad in early childhood, and 
when the disease is secondary to an advanced pulmonary tuber- 
culosis. Only the primary form in young adults, and the cases 
secondary to limited and favourable lung disease show some- 
times healing or marked improvement. In nearly all cases the 
classical dictum of Hippocrates that ‘* diarrhea occurring in a 
case of consumption is fatal ’’ has not lost its truth. 

Ileoceecal tuberculosis is rather more favourable, since it 
usually occurs with disease in the lungs which is tending to 
connective tissue formation. 

Tubercular rectal fistula and abscesses with suitable treat- 

ment do well; but according to our observations they are fre- 
quently followed by pleural effusions. 
In the treatment of intestinal tuberculosis 
in phthisical patients it is first necessary 
to cut off the supply of material containing bacilli. The swallow- 
ing of sputum in older children and adults must be absolutely 
forbidden; in young children this is useless, and all treatment 
is therefore hopeless. 

The diet must be suitable and nourishing, but too much 
must not be taken at one time. Cases must be treated indi- 
vidually, and the patient must take as much milk, cream and fat 
as is suited to his case. 

As a strict diet in cases of acute diarrhoea, albumen water 
(the white of one to two fresh eggs in a cup of boiled water, with 
a little salt) may be specially recommended, also thick soups and 
weak tea and toast. 

In chronic cases of diarrhoea use may be made of pigeon, 
chicken or veal broth, thickened with oatmeal, groats or rice; 
or of spinach, asparagus, cauliflower or potatoes cooked with 
milk; or of white meat or fish. Prepared foods may be required. 
Fat meat and rich fish, salads, sugar, sweet fruits, and strong 
sauces are to be forbidden. When milk is well borne, that 1s, 
when it does not increase the diarrhoea, it may be ordered in 
frequent small quantities. The addition of one to two teaspoon- 


Prognosis. 


Treatment. 








TUBERCULOSIS OF THE DIGESTIVE ORGANS 287 


fuls of lime water or one of cognac may be an improvement, or it 
may be taken in tea, barley water, or cocoa. In other cases 
kéfir or yoghurt may be of service. It is useful to wash out the 
bowel by taking } pint of warm mineral water (Ems, soda, 
Carlsbad, &c.) early in the morning. Too much fluid, and 
especially cold drinks, must be forbidden. 

The dietetic treatment must be combined with absolute bodily 
rest, with hot packs, warm baths, and temperate frictions. 

The specific treatment may be employed if the state of the 
primary disease does not exclude it. But no dogma and no 
plan can be laid down with regard to any treatment. A sudden 
profuse diarrhcea may compel an alteration in the whole treat- 
ment. During the open-air cure the whole body must be kept 
properly warm by remaining in bed. Acute attacks render drugs 
necessary and compel the intermission of tuberculin treatment. 

A large number of drugs are employed, but not seldom they 
all fail. If administered during the attacks of diarrhoea alone 
they nearly always fail; they must be continued for weeks and 
months, but a change in the preparation may be frequently tried. 
Without giving a complete list we will name a number of drugs 
which are the most useful. The smaller doses are for children, 
the larger for adults. 

Preparations of tannic acid and tannalbin (15 gr.), tannigen 
(7 to 15 gr.), tannyl (15 to 45 gr.), tannoform (7 to 15 gr.), tanno- 
col (7 to 15 gr.), tannismut (15 gr.), can all be taken several 
times a day. Ewald recommends decoction of calumba with 
tannigen and salicylate of bismuth. 

Of the bismuth salts there are bismuth subnitrate (5 to 
15 gr.), the subgallate (5 to 15 gr.). The latter, dermatol, has 
been praised for its prolonged astringent action; according 
to our experience it should be given in amounts of at least go gr. 
a day; in severe cases in adults it may be given as bismuth sub- 
gallate 15 gr. with extract of opium or pantopon six times a day. 
Fleiner recommends in cases of rectal ulceration that insufflations 
of subnitrate of bismuth should be directly applied through the 
rectal speculum, or the same drug may be given as an enema 
with warm oil. In the rare cases in which tuberculosis is 
localized in the lower colon large starch enemata are useful. 

Liebermeister particularly recommends oxide of zinc (1 to 
3 gr.); Boas uses calcium carbonate and calcium phosphate 
(15 gr. of each in powder). 

In severe cases, especially with pain, opiates are necessary, 
unless they are contra-indicated by the tender age of the patient. 
Tincture of opium may be given in doses of 5 to 15 minims several 


288 A CLINICAL SYSTEM OF TUBERCULOSIS 


times a day. We recommend that small doses of 5 minims should 
be given every two hours. If tenesmus is present it should be 
given as a suppository. Opium should not be administered to 
infants, and with adults it should not be continued for more 
than three to five days at a time. In cases of colic due to stenosis 
morphia injections are the best treatment. Owing to its slight 
depressing effects on the respiratory organs, pantopon injections 
may be preferred (15 minims for adults, 4 to 7 minims in children, 
of a 2 per cent. solution). Pantopon may also be given in drops 
before food (for adults 10 to 30 drops of 2 per cent. solution three 
or four times a day, for children of 2 years 2 drops, and for each 
year 1 drop more up to 6). 

If blood is mixed with the stools gelatine may be given by 
the mouth (one dram of a 10 per cent. solution that has been 
boiled), and at the same time by the rectum in a small enema 
with bismuth and opium. The treatment by regular irrigation 
of the rectum and rectal application of subnitrate of bismuth 
employed by Jos. Muller may be useful in severe cases. 


An enema of two pints of warm water is given in the morning, which 
the patient must expel at once. An hour later, by means of an irrigator 
and a large soft india-rubber catheter, one to two dessert-spoonfuls of 
bismuth suspended in half a pint of warm water is run into the bowel; 
after ten to fifteen minutes the water is drawn off, while the bismuth remains 
in contact with the mucous membrane. If after prolonged use of this treat- 
ment pain is caused, five to ten drops of tincture of opium must be added. 


For regular washing out of the bowel mineral waters er 
disinfectant and astringent fluids may be employed, such as 
salicylic acid solution (1 in 1,000), tannin (5 in 1,000), or silver 
nitrate solution (4 in 1,000). 

The chronic constipation in early cases of intestinal tuber- 
culosis, and the diarrhoea and tenesmus due to accumulations in 
the lower bowel, frequently require treatment. The diet should 
be rich in cellulose, and should contain vegetables, stewed fruit, 
marmalade, brown bread, honey, and butter. Systematic 
administration of oil, which diminishes both the motor and 
sensory irritation, and has a favourable effect on the colon and 
rectum, should be ordered. 


For adults 4 to } pint of warm olive or linseed oil, in children one-third 
of that quantity, is introduced into the rectum with the patient in the left 
lateral position, which must be maintained for half an hour after; after 
1 to 2 hours more of rest in bed the patient goes to stool. Fleiner has 
obtained better results from the addition of creosote to the oil (1 in 100). 
John Miiller uses only 2 dr. introduced through a tube 8 in. long. 


There are no fixed indications for the surgical treatment of 





















iad i ha 


pe 


TUBERCULOSIS OF THE DIGESTIVE ORGANS 289 


intestinal tuberculosis. The general condition of the patient, 
the amount of the disease in the lung, the severity of the opera- 
tion required, and the duration of the anesthesia must all be 
considered. Cases of disseminated intestinal tuberculosis are 
unsuitable, and isolated ulcers only need operation when they 
are causing stenosis. In general it may be said that the results 
of operative treatment of tubercular intestinal ulceration are very 
bad, and that they must be so, since the ulcers are usually 
multiple. It would be well to limit operative interference, apart 
from the cases in which stenosis renders it absolutely necessary, 
to those forms of ileo-ceecal tubercular tumour, which are causing 
motor insufficiency of the intestines. Which operation to 
choose—extirpation, entero-anastomosis, or enterostomy with the 
formation of an artificial anus—must be decided after opening 
the abdomen. Radical extirpation can only be performed if the 
lung disease is not advanced, the tumour is movable, and not 
widely spread, the neighbouring lymphatic glands not infected, 
and the surrounding intestine is not adherent to the tumour. 


According to statistics of the St. Hedwig Hospital in Berlin, in 27 cases 
of ileocecal tuberculosis 22 radical operations were performed with 7 deaths 
(30 per cent.). Only twice could the caecum alone be resected; in all the 
other cases the ascending colon, in four also half the transverse colon, and 
in three the whole transverse colon, required removal; only three cases 
had also stricture of the small bowel (Eschenbach). 


Operative treatment, in spite of advances in surgery, is a 
very serious proceeding, partly on account of the very bad 
effects of the narcosis on the diseased lung. Nevertheless, 
according to the experience of Hofmeister, Kocher, Korte, and 
others, it is successful in a certain proportion of cases, so that it 
seems to be indicated if internal treatment fails, if the condition is 
causing pain, and if the patient desires the operation. But it 
should be limited to cases of ileoczecal tuberculosis with a good 
general condition. 

Perirectal abscesses are to be incised, the contents emptied, 
and the interior energetically cauterized. 

Fistula remaining after incision or spontaneous rupture, are 
also to be treated surgically. The position of most anal fistula 
in the subcutaneous and submucous tissue renders a superficial 
incision sufficient, without interference with the sphincter. In 75 
per cent. of the cases this leads to healing; and relapses after 
complete healing are rare after this operation. On the other 
hand the division of the sphincters, which is necessary for the 
laying open of deep fistulee, leads to prolonged insufficiency of 
these muscles, so that the surgical treatment of this form must 

19 


290 A CLINICAL SYSTEM OF TUBERCULOSIS 






















be reserved as an ullima ratio. Beck’s bismuth paste injections 
are to be especially recommended; they are considerably more 
successful in fistulze of the soft parts than in those of bone. 
Ulcers of the rectal mucosa lying near the skin are to be dealt 
with surgically. 

The prophylaxis of intestinal tuberculosis 
is that of tuberculosis of the whole diges- 
tive organs. It includes the prevention both of primary and 
secondary infections of these organs. It is of particular impor- 
tance in regard to the disease in childhood, and requires special 
measures. 

The hygiene of the mouth and teeth should be begun in 
childhood, and must last all through life. The stomach must 
be protected from repeated injurious actions of a mechanical, 
toxic, or thermal nature. Rapid eating, insufficient mastication, 
excessive ingestion of fluids, particularly of an alcoholic nature, 
over-hot or ice-cold foods and drinks are to be avoided. The 
bowel should receive its contents in a suitable form, and its 
peristaltic function should be regulated. Good teeth, a sound 
stomach, and regular bowels are the best defence against the 
lodgment of tubercle bacilli in the intestinal tract; they counter- 
act its predisposition to tubercular disease. 

In houses, sanatoriums, and cure-resorts in which phthisical 
patients live, special means (discipline of the cough and expec- 
toration, disinfection of the crockery, table utensils, and glasses) 
must be taken to diminish the possibility of a deglutition tuber- 
culosis. 

Supervision and control of the food-supply, especially of 
milk and dairy produce, must not be neglected, but must be 
undertaken officially. Laws dealing with the milk supply should 
regulate these matters; and must be enforced by competent 
district and veterinary inspectors. That the meat from tubercular 
animals, and the milk of cows with tubercular udders, is unfit 
and dangerous for human consumption is agreed. Efforts at 
rendering immune our cattle and milch cows are being made. 
Till such an end is reached sanitary police regulations for the 
diminution of tuberculosis among cattle and the prevention of 
transference of active bovine bacilli to men must be strictly 
enforced. ‘‘ Human tuberculosis can never disappear, as long 
as there is a constant transference of bovine bacilli from animals” 
to men.”’ (Orth). 

It is also important to prevent the infection of sound food 
supplies by human bacilli during transport. To this end 
phthisical persons should have nothing to do with the supply or 


Prophylaxis. 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 291 


cooking of food, and this is the more necessary as the human 
bacilli are even more dangerous for the human digestive tract 
than bovine bacilli. Those working in dairies and the milk trade 
should therefore be subject to official inspection. “The whole 
subject will be considered in connection with tuberculosis in 
children. 

. The prophylaxis of secondary tuberculosis depends on the 
means of prevention and cure of pulmonary tuberculosis. — In 
cases of open tuberculosis the doctor should repeatedly warn the 
patient not to swallow the sputum either from ignorance, indo- 
lence, or aversion to the sputum flask. It is not a hardship, 
but in the interests of the patient, that he should be informed of 
the bad effect of swallowing the sputum on the digestive organs 
and also on the whole constitution. These prophylactic measures 
are most important in childhood, and even compulsion must be 
used. 


6. TUBERCULOSIS OF THE PANCREAS. 


A typical miliary tuberculosis, but slightly 
rich in cells, may appear in the parenchyma 
Changes. or interstitial tissue of the pancreas; the 
individual tubercles are of the size of a millet or hemp seed, of 
a whitish yellow colour, they caseate rapidly, and form small 
cysts and larger cavities. Or there may be tubercular changes 
in the lymphatic glands, which lie in the pancreatic tissues, while 
the parenchyma of the pancreas undergoes swelling and sclerosis. 
There are no characteristic symptoms of 
tuberculosis of the pancreas. Sometimes 
Course. there may be a hard, slightly nodular 
swelling, without definite outlines, to be felt. The pancreas is 
affected secondarily; recent figures show that this occurs not 
uncommonly in general miliary tuberculosis, and in chronic 
pulmonary tuberculosis of childhood. The infection may take 
place through the blood, though the lymphatics, by direct con- 
tact, especially from infiltrated and adherent retroperitoneal 
glands, or from passage of the bacilli up the duct. 
: For the diagnosis the detection of symptoms 
Diagnosis. due to pancreatic disease is important. 
The most marked of these are glycosuria, imperfect digestion of 
fats shown by fatty stools, the detection of undigested muscle 
fibres in the stools, while jaundice is absent. 
The differential diagnosis must be made from cancer, sar- 
coma and gumma of the pancreas, also from cancer of the 
stomach ; the latter causes no pancreatic symptoms, and the mass 


Anatomical 


Symptoms and 


292 A CLINICAL SYSTEM OF TUBERCULOSIS 


does not disappear on inflation of the stomach, like the deeper 
pancreatic tumour. The age and history of the patient, the 
growth and mobility of the tumour, and the results of the iodide 
or tuberculin tests will in many cases lead to a probable diagnosis. 
The prognosis is, in spite of the usually 
chronic course, on the whole unfavourable. 
The condition aggravates the primary disease, and may extend 
to neighbouring organs (duodenum, pleura), or may lead to 
perforation. 


Prognosis. 


In cases of correct diagnosis with a good 
general condition and_ slight primary 
disease the treatment may be surgical. Our experience is still so 
slight that no definite indications are possible. The adminis- 
tration of pancreatin for its antibacillary action on the tubercle 
bacillus does not seem to us to promise well. 


Treatment. 


f TUBERCULOSIS. OF THE EIVER: 


The commonest change produced in the 
liver by tubercle bacilli is the formation of 
miliary tubercles, which are generally 
small, and difficult to recognize on account of the fatty degenera- 
tion of the organ; if the fatty changes are very advanced the 
tubercles may become absorbed. On account of the growth of 
surrounding connective tissue an extensive tubercular interstitial 
hepatitis is produced, which must be considered as an effort 
towards healing, and plays a part in the production of atrophic 
cirrhosis. We do not share the opinion of those French writers 
who consider that hepatic cirrhosis both in the atrophic form of 
Laennec and in the hypertrophic form of Hanot is usually of a 
tubercular origin; and we leave open the question whether the 
tubercular toxin by itself can produce a specific connective tissue 
hyperplasia of the liver. An intimate relationship between tuber- 
culosis and hepatic cirrhosis seems, however, undoubted. Also 
tubercular changes localized in the neighbourhood of the liver 
may by extension of inflammation lead to connective tissue over- 
growth in that organ. 

Not rarely the miliary nodules in the liver develop into the 
size of a pea or hazel-nut; and these nodular tumours may give 
an impression of metastatic growths. If they caseate small 
abscesses, the so-called liver cavities, are formed. Of great 
rarity is solitary and conglomerate tubercle of the liver, 7.e., an 
isolated mass of the size of the fist or larger, which consists of 
granulation tissue and necrosing nodules, containing epithelioid 
cells, typical Langhans’s giant cells, and tubercle bacilli. It has 


Anatomical 
Changes. 





ail 


TUBERCULOSIS OF THE DIGESTIVE ORGANS 293 


been called ‘‘tubercula permagna hepatis’’; and only about 
seven cases are known. Lastly, tubercular perihepatitis must 
be mentioned; it is a form of localized dry tubercular peritonitis, 
occurring on the surface of the liver. 

Th symptoms are very indefinite. Icterus 
is absent, or if it occurs it is due to tuber- 
cular glands in the hilus of the liver com- 
pressing the bile-ducts. Enlargement of the liver cannot usually 
be detected; only in the rare cases of the formation of a large 
nodule will pain and tenderness point to liver disease. More 
important is the occurrence of urobilinuria and the alimentary 
lavulosuria described by Strauss. As signs of hepatic insuffh- 
ciency they indicate that the parenchymatous cells of the liver are 
affected, but do not show whether these changes are themselves 
tubercular, or are merely the concomitants of tubercular disease 
elsewhere. 

Perihepatitis can be clinically recognized by a friction rub 
and tenderness on pressure over the liver. 

Tuberculosis of the liver according to Orth is never primary ; 

but there are sixteen cases of primary tubercular masses in the 
liver published. Asa secondary affection it is part of the general 
blood infection in miliary tuberculosis, or may be due to intestinal 
tuberculosis, in which condition a large number of tubercle bacilli 
are carried by the portal circulation to the liver. Also infection 
may occur through the biliary passages. Since in spite of these 
factors tubercular hepatitis is not common, and gross tubercle in 
the liver is very rare, the liver must have great powers of 
resistance to the tubercle bacilli. 
Since miliary and interstitial tuberculosis 
is very rarely observed during life, the 
diagnosis is indefinite. We may determine that the liver is more 
or less affected and functionless by recognizing the increase of 
urobilin or urobilinogen in the urine, and by detecting the 
presence of a lzevo-rotatory sugar after taking 50 to 100 grm. of 
leevulose. Hildebrandt observed undoubted levulosuria in a 
case of miliary tuberculosis of the liver from swallowing 50 grm. 
of levulose. 


Symptoms and 
Course. 


Diagnosis. 


Levulose is easily detected in the urine if the latter does not contain 
also grape sugar; the clear urine free from albumin is levo-rotatory, it also 
gives the reduction tests, and ferments with yeast. If the urine is heated 
with resorcin and hydrochloric acid, a red coloration and a darker pre- 
cipitate appear, the latter redissolves with alcohol, giving a redder colour. 
Urobilin can be detected if 2 to 5 drops of a 10 per cent. solution of 
chloride of zinc are added to the urine, and then an equal amount of 
ammonium chloride, which redissolves the precipitated oxide of zinc. If 


294 A CLINICAL SYSTEM OF TUBERCULOSIS 


the filtered fluid held in a test-tube against a dark background shows a 
green fluorescence urobilin is present. 

Urobilinogen can be detected by treating 5 c.c. of urine with 5 to 10 
drops of Ehrlich’s reagent (dimethylamidobenzaldehyde 1 part, hydrochloric 
acid 30 parts, water 25 parts). If there is much urobilinogen a red colour 
will be produced in the cold, which with normal urine only appears on 
heating. The reaction is positive in cases of diffuse cirrhosis and acute 
passive congestion of the liver, but it not uncommonly fails with cancer of 
the liver. 


The discovery of urobilinogen, urobilin, and lzvulose taken 
in conjunction with the other clinical signs may at least lead to 
a probable diagnosis. 

Further difficulty in the differential diagnosis is caused by 
the fact that tuberculosis of the liver may be a secondary to a 
gumma, abscess, or other diseases. In cases of tumour of the 
liver tuberculosis must be thought of, but can only be considered 
as the primary disease, if other more common conditions can be 
excluded with certainty. 

Brosnasiena Liver ohanges apps u0e anette the course 

of tuberculosis are an unfavourable sign. 

rcatment, They mean that the disease is no longer 

localized, and that the liver has lost its power of resistance and 
its assimilative functions. 

For isolated tubercular liver tumours surgical treatment may 
be considered, since wedge-shaped resection of the tumour and 
surrounding part of the liver has given good results. Generally 
the treatment of liver tuberculosis can only be directed against 
the primary disease; and as we are almost helpless against 
general tuberculosis and tubercular ulceration of the bowel, our 
treatment of secondary infection of the liver must be merely 
symptomatic. 


8. TUBERCULOSIS OF THE GALL-BLADDER. 


Primary tuberculosis of the gall-bladder 


eee occurs as a chronic ulcerative cholecystitis, 
anges an usually as part of an old inflammation, 
Symptoms. 


such as an empyema of the gall-bladder due 
to obstruction by stone. The gall-bladder may also be attacked 
by tuberculosis secondarily to disease in other organs, especially 
the lung, or as a part of miliary tuberculosis. The bile-ducts 
also may be infected by tubercle from the intestinal tract, and by 
the breaking-down of these tubercles the disease may be carried 


to the gall-bladder, and produce a circumscribed tubercular 
necrosis. 


The clinical symptoms are not characteristic; they may be _ 


‘ 








TUBERCULOSIS OF THE DIGESTIVE ORGANS 295 


altogether absent, or may be indistinguishable from those pro- 
duced by cholecystitis, with or without biliary colic. 

The bedside diagnosis is hardly ever pos- 
sible. At the most a progressive and very 
striking marasmus suggests some serious 
cause; and a diagnostic laparotomy will then decide whether this 
is due to cancer or tuberculosis. 

The treatment consists in chronic cases in total extirpation 
of the organ. But there is the danger, even in primary cases, 
that such an operation may set up an acute miliary or meningeal 
tuberculosis. When tuberculosis of the gall-bladder is com- 
bined with empyema and gall-stones the double operation of 
opening and draining, with later excision, may be considered. 
This can only be settled for each case separately, after the 
abdomen has been opened. 


Diagnosis and - 
Treatment. 


9. TUBERCULOSIS OF THE PERITONEUM. 


A sharp distinction between tuberculosis of 
the peritoneum and tubercular peritonitis 
is not possible, on account of the number 
of transitional cases. Nevertheless, according to the form of the 
tubercular infection the pathological picture is different. 

When an acute infection takes place through the blood count- 
less miliary granules appear on both surfaces of the peritoneum, 
especially in the neighbourhood of the liver and spleen. Since 
the duration of the disease is very short, acute miliary tubercu- 
losis of the peritoneum cannot form a large effusion. | When 
there is an effusion it may be sero-fibrinous, hemorrhagic, or 
purulent. Its counterpart is the acute circumscribed tuberculosis 
of the peritoneum, in which, owing to the previous formation of 
fibrous tissue, the production of tubercles and caseous nodules 1s 
limited to the area between two coils of bowel. | Tubercular 
perihepatitis and perisplenitis also belong to this category. 

More common and of more practical importance is_ the 
chronic tubercular peritonitis, which becomes gradually diffuse. 
According to the predominance of fibrous masses or of fluid 
exudation it may be described as dry or exudative. 

In the dry form the coils of bowels in consequence of con- 
nective tissue formation are united to each other, and to the other 
intra-abdominal organs by bands and membranes, and_ the 
omentum, as a result of contraction, is converted into a thick, 
lumpy mass. Different sections of bowel may become cut off or 
displaced, also quite large pseudo-tumours may be formed. 

In the exudative form the amount of fluid is greater than the 


Anatomical 
Changes. 


296 A CLINICAL SYSTEM OF TUBERCULOSIS 


plastic exudation. The effusion may be serous, sero-fibrinous, 
haemorrhagic, or more rarely purulent, and in different cases may 
vary from several hundred cubic centimetres to many litres. It 
may be freely movable, or may be loculated by fibrous adhesions 
into larger or smaller cysts. The exudate usually contains 
tubercle bacilli. 

If a tubercular intestinal ulcer breaks through into the open 

peritoneum, each form may become converted into an acute septic 
peritonitis. . 
The acute miliary tuberculosis of the peri- 
toneum owing to its rapid course is but 
little in evidence, or it is overshadowed by 
the severity of the general condition. In acute circumscribed 
tubercular peritonitis there will be spontaneous pain and tender- 
ness over the affected region, usually also interference with the 
functions of the bowel (diarrhoea or obstruction), and a friction 
sound. 

More characteristic are the symptoms of chronic, diffuse, dry, 
or exudative peritonitis. They consist of faintness, weakness, a 
sense of fulness in the abdomen, loss of appetite, pains in the 
back or abdomen, which come and go, and are seldom sharp, but 
if so are usually associated with diarrhoea. If an effusion forms 
the patient himself will often supply the information that in spite 
of general wasting the abdomen has become larger. Meteorism 
is a very common symptom in consequence of hindrance to the 
intestinal peristalsis; more rare are pain on micturition and 
retching. Vomiting may be due to severe meteorism or to colicky 
pains, or may be faecal in character if defaecation is obstructed 
by adhesions and contractions, so that obstruction and flatulent 
distension are produced. If the abdomen is much distended by 
fluid or meteorism, dyspnoea may occur. Fever is only rarely 
absent, but it runs no characteristic course; there are intervals 
free from fever, and the temperature usually rises higher during 
menstruation. The pulse is accelerated, also the respiration. 
The stools are loose; children not rarely have colourless, fatty 
stools. Jaundice may occur from obstruction to the bile-duct. 

The appearance of the abdomen will vary with the predom- 
inance of the dry or exudative form, or with the combination of 
fibrous adhesions and contractions with effusion. In thin 
children the thickening of the peritoneum can often be felt on 
pinching up a fold of abdominal wall. In adults there may be 
diffuse or localized resistance and pseudo-tumour, or if there is 
free ascites fluctuation will be obtained, which will vary with 
change of position; encapsuled fluid resembles a cyst. If there 


Symptoms and 
Course. 








TUBERCULOSIS OF THE DIGESTIVE ORGANS 2907 


is much fluid resistance and thickening, tumours can no longer 
be felt; but after the fluid is withdrawn they can be detected, 
especially the rolled-up and adherent omentum. In other cases 
in which meteorism is present, when the patient lies on his back 
there may be a tympanitic note over the whole of the abdomen, 
or the upper part may be resonant, while the lower and lateral 
parts are dull on account of the fluid. Or shrinking of the 
mesentery may cause a clear tympanitic note over the right side, 
while the left is dull. 

Tuberculosis of the peritoneum is a very common disease of 
the first part of adult life, after forty it becomes rarer. It occurs 
without any other tubercular disease which can be detected, but 
such cases do not prove the existence of a primary form, since 
the original focus may be impossible to discover. | Secondary 
tuberculosis of the peritoneum is due to tubercular ulceration of 
the bowels, to enlarged mesenteric and retroperitoneal glands, 
to tuberculosis of the lungs or pleura, or to acute general tuber- 
culosis. Whether in females genital tuberculosis plays a part 
is keenly discussed; in men infection hardly ever occurs by this 
route. 


The views as to the connection between peritoneal and genital tuber- 
culosis were fully discussed at the last German Gynecological Congress 
(191r). Kronig upheld the view that when both conditions occur together 
the peritoneal disease is primary, and that in the genital organs secondary 
by continuity, or that both infections occurred together from some third 
source producing a blood infection, and that a generalized peritoneal tuber- 
culosis hardly ever arises from disease in the genital organs. Albrecht 
considered as a result of 10,000 fost-mortem examinations, and from clinical 
examination and animal experiment, that the two conditions were frequently 
combined, and that either could give rise to the other; in one-third of the 
autopsies it could be seen that the genital disease gave rise to diffuse tuber- 
cular peritonitis, but that the peritoneal tuberculosis very rarely caused 
disease of the genital organs; also that in women, much more frequently 
than in men, a simultaneous infection of both organs through the blood 
occurs, since, owing to the intra-peritoneal position of the female organs, 
they are more largely supplied by the peritoneal vessels. 

Schlimpert in 3,514 autopsies found no case of isolated peritoneal 
tubercle, and no case of primary isolated genital tubercle. There are no 
cogent observations to show that peritoneal tuberculosis develops spon- 
taneously out of genital tuberculosis. The peritoneum is found affected 
much more often with severe tuberculosis of other organs. 


The course of peritoneal tuberculosis, apart from the acute 
miliary form and the complications introduced by ileus and per- 
foration, is, as a rule, slow; arrest and improvement, and even 
spontaneous cure are not rare. It has been computed that un- 
treated peritoneal tuberculosis leads to a fatal issue in 50 per 
cent. of the cases in one to six months, and in 25 per cent. in 
six months to five years. 


298 A CLINICAL SYSTEM OF TUBERCULOSIS 


In children, too, tubercular peritonitis may run an acute or 

chronic course. In about one-third of the cases it begins acutely, 
and may be mistaken for appendicitis, typhoid, or pneumococcal 
peritonitis. Ascites in children is usually due to tubercular 
peritonitis, though hepatic cirrhosis, syphilis, and obliteration of 
the portal veins must not be forgotten. 
In spite of the characteristic symptoms the 
diagnosis is sometimes only made with 
difficulty. The condition must especially be distinguished from 
chronic peritonitis of a non-tubercular nature, e.g., from trauma- 
tism, cancer of the peritoneum, hepatic cirrhosis, more rarely 
sarcoma, Ovarian cysts, and ascites due to heart, kidney, and 
infectious disease. 

Only a very exact history and a prolonged observation of the 
case will lead to a correct diagnosis. Experience shows that the 
large majority of cases of chronic inflammation of the peritoneum 
are of a tubercular nature, and with the discovery of a tubercular 
focus elsewhere in the body the diagnosis gains in certainty. 
Specially indicative of tubercular peritonitis are chronic, variable 
fever, pains and tenderness, the formation of an effusion, general 
wasting, and diarrhoea. 


Diagnosis. 


On the other hand neither the diazo-urinary reaction, nor 
a half-moon shaped area of dulness with free ascites, indicate 
tubercular disease. The tubercular nature of an ascites only 
becomes certain if tubercle bacilli can be demonstrated in the 
fluid either bacteriologically or by animal experiment. The 
latter has the great drawback that the intraperitoneal injections 
on animals take four to six weeks to give results. The attempts 
made to shorten this period by means of Bloch’s method of 
injecting the fluid into the subcutaneous tissues of a guinea-pig, 
the nearest lymphatic glands having been previously forcibly 
crushed, or by Oppenheimer’s modification of injecting the fluid 
directly into the liver, do not give sufficiently certain results. 

In the cases dangerous to life the diagnosis can be quickest 
made by an exploratory laparotomy; when the pathological 
changes can be directly inspected, their origin is usually clear. 
The exploratory operation is the more urgently indicated the 
greater the probability that the disease is tubercular; since in 
this case the laparotomy will also be of therapeutic value. 

If there is no effusion or exploratory operation is contra- 
indicated, a diagnostic tuberculin injection may remove doubt. 
The distinctive focal reaction is characterized by abdominal pain, 
great feeling of distension, nausea, vomiting, and frequently 
more or less profuse diarrhoea. For the differential diagnosis — 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 299 


between tubercular peritonitis and cancer, or chronic, non-tuber- 
cular affections the tuberculin diagnosis is indispensable. 

Lastly, it must be. noticed that tubercular peritonitis and 

hepatic cirrhosis not infrequently occur together, according to 
Seifert in 15.per cent. of the cases. Very often the cirrhosis 
supervenes on the peritonitis; on the other hand, tubercular 
peritonitis not uncommonly makes its appearance in the last stage 
of Laennec’s cirrhosis, its development being favoured by the 
prolonged weakening of the peritoneum from the portal conges- 
tion. 
The prognosis of tubercular peritonitis 
occurring in advanced phthisis is very 
unfavourable; g6 per cent. die. Also cases with ulcerative 
disease and purulent peritoneal effusions are of very bad pro- 
gnosis. On the other hand, a large percentage of cases of dry 
and exudative peritoneal tuberculosis become permanently cured, 
if the general condition and the nature of the primary disease 
allow it. Tubercular peritonitis complicating hepatic cirrhosis 
runs a very malignant course on account of the small powers of 
resistance of the patient. 

In childhood the prognosis is usually better than in adults; 
especially the ascitic and fibrous forms do well. Tuberculosis 
of other organs and mixed infections here again darken the 
outlook; and the more acute is the commencement the worse the 
prognosis. 


Prognosis. 


Both surgical and medical methods of treat- 
ment may be employed for tubercular 
peritonitis. So diametrically opposed are the views, that while 
the Norwegian surgeon Borchgrevink obtained spontaneous 
healing in 64 per cent. of the cases of tuberculous peritonitis, in 
the Strassburg clinic Rose observed a death-rate of 61.8 per cent. 
as a result of conservative treatment, and considers that the 
operative treatment is “‘ the only effective method of combating 
a hopeless, or almost hopeless, disease.’’ Both these seem to be 
extreme opinions, even considering the variable nature of the 
disease. Frank and others hold the middle view that since 
surgical treatment leads to good results, one need not be surprised 
that there are successful cases among those treated on conserva- 
tive lines. 

Surgical treatment consists in opening the abdomen, and 
removing the fluid through a laparotomy incision; a tubercular 
vermiform appendix, or a diseased ovary may be removed at the 
same time. The various theories that have been propounded to 
account for the good results thus obtained need not be separately 


Treatment. 


300 A CLINICAL SYSTEM OF TUBERCULOSIS 


considered, since there is none which covers the whole ground. 
Probably a reactive hyperemia and a passage of bactericidal 
leucocytes into the peritoneal cavity play the chief parts. In 
any case, the curative effects are undoubted. Konig first 
recorded in 1890 131 cases of simple laparotomy with 65 per cent. 
permanent cures, in 1893 R6rsch published 358 cases with 7o 
per cent. cures, in 1896 Margarucci 253 cases with 85.4 cures, in 
1899 Ebstein 218 cases with 78.8 per cent. cures. The dangers 
of fistuia and hernia after the operation are not great, and 
relapses are seldom observed. 


Zweifel, Rissmann, and others combine insufflations of iodoform into 
the peritoneum with the laparotomy. 

Recently A. Hofmann has recommended painting the parietal and 
visceral peritoneum with 10 per cent. iodine tincture before performing the 
toilette of the peritoneum. In dry, as well as in ascetic cases, this procedure 
leads to a hastening of the cure. Bad effects from the iodine or from the 


after-formations of adhesions have not been observed. The method deserves 
a further trial. 


Compared with laparotomy, puncture of the effusion, fol- 
lowed by washing out with sterilized physiological salt solution, 
and injections of iodoform (1 to 5 per cent. in emulsion at inter- 
vals of four to eight days) is not without danger, and gives poor 
results; the effusion rapidly returns. 

In cases of dry tubercular peritonitis Friedrich has had good 
results from the artificial production of ascites by means of 
glycerine injections, which produce a hyperemia. The injec- 
tions must take place at increasing intervals. The amount of 
glycerine is 20 to 25 grm. for children, and 30 to 35 grm. for 
adults. Erler recommends that a permanent subcutaneous fistula, 
lined with peritoneum, should be formed. 

The medical treatment of tubercular peritonitis must be based 
on general hygienic and dietetic treatment, and may best be 
carried out by specific administration of tuberculin (Ganghofner, 
Fr. Miller, Zoppritz, and others). With this method Birnbaum 
in Géttingen has obtained such convincing results that tuber- 
cular peritonitis need no longer be submitted to operation. In 
the Breslau clinic, where, on the other hand, all cases are 
operated on as soon as diagnosed, during convalescence, even 
six or seven days after the operation, injections of old tuberculin 
are begun; and Heimann does not hesitate to refer the good 
results, 54 per cent. permanent cures in women, both to the 
laparatomy and the tuberculin treatment. 

Rest to the body and hyperemia of the peritoneum may be — 
assisted by Priessnitz’s warm or alcoholic compresses; and re- 





TUBERCULOSIS OF THE DIGESTIVE ORGANS 301 


absorption may be stimulated by inunctions of mercurial oint- 
ment (30 to 60 gr. a day, till salivation commences), and 
systematic rubbings with soft soap. Constipation must be 
treated by diet and enemata, diarrhoea also by diet and by 
astringents, pains by alcoholic compresses and opiates, and 
meteorism by enemata of camomile. The effects of the internal 
administration of creosote preparations, of iodides as_ re- 
absorbents, of arsenic and iron as tonics, and of cinnamic acid are 
more than doubtful. On the other hand, it seems that exposures 
to deeply penetrating Rontgen rays have a good effect in cases 
that are no longer operable, and they should be always tried.* 

The question when medical, and when surgical, treatment 
is to be used is not easy to answer. It seems certain that tuber- 
cular peritonitis of itself seldom causes the death of the patient, 
and that expectant and operative treatments have about the same 
mortality. There has been an attempt to distinguish between the 
two sexes and to recommend the operation more for males, since 
this is the quickest method of cure, and gives better results in 
men than in women; on the contrary, the conservative treatment 
more often causes a cure in women than in men. Each case 
must be carefully individualized, and from its severity the opinion 
may be formed how long to persevere with medical treatment, or 
at what moment an operation is indicated. In any case surgical 
interference must be avoided if there is active, advancing, primary 
disease elsewhere, if there is much feebleness or heart weakness, 
or if the temperature is very high. Every case of tubercular 
peritonitis should not be at once treated with knife, but only if 
other means fail. Doerfler correctly says: ‘‘ We only operate 
now if, in addition to the ordinary symptoms of chronic peri- 
tonitis, there is daily hectic fever, which is weakening the patient, 
or if the course of an acute tuberculosis is so rapid that the 
patient retrogresses daily and there is a strong probability of a 
fatal issue unless energetic means are employed. It is clear that 
laparotomy must be kept only as a measure in reserve, which 
may aid the natural tendency of tubercular peritonitis to heal. 
Accordingly cases of simple, primary, exudative peritonitis, so 
long as the symptoms indicate that the fluid is merely serous, 
even if the ascites is abundant, may be treated for weeks, even 
months, conservatively, careful attention being of course given 
to the general condition, the amount of strength, and the resist- 
ance of the patient.’’ 


* The translator has seen very good results in cases of abdominal tuber- 
culosis from direct exposure to the sun’s rays at a high altitude. The chief 
disadvantages of this treatment are the length of time required and the 
expense involved. 


302 A CLINICAL SYSTEM OF TUBERCULOSIS 









































It is generally considered that laparatomy is indicated if the 
effusion is so great as to be dangerous, and is causing much 
respiratory distress, if it returns after simple puncture, if the 
effusion is purulent or caseo-purulent, if the bowel is stenosed by 
inflammatory changes, and if the tubercular peritonitis is accom- 
panied by tumour of the internal genital organs. In all suitable 
cases the combined general and specific treatment should be first 
tried, and the operation only performed if these fail. According 
to Doerfler, Hildebrandt, Thoenes, and others, the operation, to 
be successful, should not be done too soon; a similar conclusion 
as has been formed in regard to tubercular pleural effusions. On 
the other hand, for cases in which internal treatment fails, and in 
which the fever is hectic and the strength being lost, the opera- 
tion must not be delayed too long, till the state of the patient 
makes it hopeless. 

There is also a difference of opinion as to the treatment of 
tubercular peritonitis in children; it is only agreed that the ascitic 
form should not be punctured. Otherwise there are those who 
recommend that all cases should be operated on, except quite 
young children, or if there is generalized or pulmonary tuber- 
culosis. The supporters of the conservative treatment point, not 
without reason, to the statistics, which show that the prospects 
of a permanent cure after the operation are not brilliant; and 
they consider that the operation is quite unnecessary in the fibrous 
form. We do not take the extreme view that either one or the 
other method is the only correct treatment for children with 
tubercular peritonitis. We recommend rather an expectant in- 
dividual treatment, such as has lately been supported by 
Cassel. If in spite of suitable general treatment and the use of 
the proper internal and external remedies for several weeks there 
is persistent fever, if the swelling of the abdomen does not 
diminish but rather increases, and if, above all, the child is wast- 
ing, conservative treatment will not succeed, and the operation 
should be done, whatever form the peritoneal tuberculosis pre- 
sents. After the operation an attempt should be made to cure 
the peritoneal condition, as well as the latent or manifest primary 
tubercular focus, by a systematic tuberculin treatment. This is 
especially important with children to ensure a permanent result. 


10. TUBERCULOSIS OF HERNIAL SACS. 


Tuberculosis may appear as miliary, nodu- 
lar or diffuse thickenings of the hernial sac, 
more rarely of the hernial contents. If 
attacks especially the neck and the bottom of the sac. In recent 
hernias the tubercular process accompanies ascites. 


Anatomica! 
Changes. 


TUBERCULOSIS OF THE DIGESTIVE ORGANS 303 


Tuberculosis of the hernial sac causes 
periodic attacks of pain in the abdomen. 
It progresses gradually, and appears chiefly 
in male patients, and especially in children. It is nearly always 
secondary, but a primary disease is possible. It is associated 
with tuberculosis of the peritoneum, the mesenteric glands, the 
epididymis, and especially the bowel. 

The diagnosis is particularly difficult with 
adherent and irreducible hernias. The 
existence of intestinal or peritoneal tuberculosis, the detection of 
fluid, which according to the position of the body occupies the 
abdomen or the hernial sac, and a tenseness and unevenness of 
the hernial sac, may give rise to a suspicion of the condition. 
But generally it is first found at an operation. 

The prognosis is favourable; and the treat- 
ment is surgical, especially if there are 
symptoms of incarceration. The operation 
also allows the emptying of the ascites, and the removal of the 
tubercular tissue in the sac of the hernia. 


Symptoms and 
Course. 


Diagnosis. 


Prognosis and 
Treatment. 


CHAPTER VI. 


Tuberculosis of the Urogenital 
Organs. 


ACCORDING to the very extensive statistics of Posner, Heiberg, 
Saxtorph, and others, urogenital tuberculosis is found in 4 to 
5 per cent. of all autopsies. It may appear at any age, but 
particularly between 20 to 35, the time of the greatest sexual 
activity. In an overwhelmingly large proportion of cases it is 
a secondary disease. There are a sufficient number of cases of 
primary hematogenous infection to show that this, without 
doubt, sometimes occurs. On the other hand, it must be remem- 
bered that latent tubercular foci are only discovered with diffi- 
culty, and also that an apparently healed deposit may give rise 
to a virulent infection. The propagation of urogenital tuber- 
culosis usually takes place in a descending direction, following 
the course of the physiological secretions. 

Although the statistics give the frequency of tuberculosis of 
the urinary and genital organs together, yet either system may 
be affected separately ; it 1s agreed that in men the combined uro- 
genital tuberculosis predominates, while in women tuberculosis 
of the urinary occurs much less frequently than that of the genital 
organs. The anatomical arrangement in the two sexes accounts 
for this; in men the urethra serving as the excretory duct both 
for the urinary and sexual organs, it is obvious that disease of 
one system easily spreads to the other; while in women both 
systems are anatomically distinct. Although it is now under- 
stood that an isolated tuberculosis of most of the organs of the 
urogenital apparatus hardly ever occurs as a separate clinical 
disease, especially in men, yet each organ must be separately 
considered for the proper understanding of the mode of infection 
and propagation of the disease, and not least for the considera- 
tion of the treatment. Tuberculosis of the urinary organs of 





i 


ee, A a Ps th i dD 4 fe-e e 





TUBERCULOSIS OF THE UROGENITAL ORGANS 305 


women may be considered with that of men, since the conditions 
in the two sexes correspond; but the tuberculosis of the female 
genital organs must be separately treated. 

Tubercular affections of the external genitals need not be 
further considered. Tubercular granulations and _ ulcerations, 
and also lupus, have been observed both on the penis and scrotum 
and on the labia of the vulva. They are generally a secondary 
condition. 


A. Urogenital Tuberculosis of Men. 


1. TUBERCULOSIS OF THE URETHRA. 


Tuberculosis of the urethra follows the 
usual course of the disease in mucous mem- 
branes. The early stage has been but little 
observed, and has only been accidentally discovered as a com- 
plication. All forms of mucous membrane tuberculosis have been 
observed, from single tubercles and slight granulations to the 
severest ulcerations and caseating and necrotic nodules. Its 
usual sites are the most anterior and posterior portions of the 
tube, it is very rare in the membranous part and commonest in 
the prostatic urethra. An affection of the anterior urethra 1s 
relatively uncommon, and is usually slight, while the severe 
forms of the disease are situated in the posterior part and its 
adnexe, since the anatomical arrangement is here most favour- 
able to the lodgment and development of the bacilli. The 
disease in the posterior part is relatively frequent and 1s hardly 
ever absent in cases of long standing urogenital tuberculosis. 
It is usually combined with tuberculosis of the prostate, the 
vesicule seminales and the ejaculatory ducts, as may easily be 
understood on anatomical and physiological grounds. 

The clinical symptoms are pains on mic- 
turition, a purulent discharge, bleeding 
from the urethra, and later stricture. The 
disease may heal spontaneously, thus giving rise to a stricture, 
which is usually situated in the anterior urethra. The disease in 
the posterior part takes the form of advancing ulceration, with 
the formation of abscesses and fistula. These occur especially 
about Cowper’s and Littré’s glands, and have a therapeutic im- 
portance. 

The question whether there is a form of primary urethral 
tuberculosis cannot be answered with certainty; there is no un- 
doubted case recorded. But since in treatises on tuberculosis one 
finds the assertion that pulmonary tuberculosis may be caused 

20 


Anatomical 
Changes. 


Symptoms and 
Course. 


300 A CLINICAL SYSTEM OF TUBERCULOSIS 


by infection during oral coitus, the theoretical possibility of a 
primary urethral tuberculosis, as a consequence of normal con- 
nection with an individual suffering from genital tuberculosis,. 
must be admitted for both sexes. A secondary infection from 
another tubercular nodule somewhere in the body is naturally 
much more common. The anatomical position of the prostatic 
urethra, with its numerous glands, explains why it is frequently 
affected by bacilli from the kidneys, the testicles and vesiculz 
seminales. Although it is possible for tubercular disease to 
spread by continuity from the prostate or seminal vesicles into 
the posterior urethra, yet the reverse occurs much more often. 
Spread of disease from the posterior urethra to the neighbouring 
organs results in extensive destruction with the formation of 
large cavities, so that it joins together with disease in the pros- 
tate and vesicule seminales. 

The recognition of urethral tuberculosis is 
easy if tubercle bacilli can be discovered in 
the secretion. The staining differences between the tubercle 
bacillus and the rather straighter and thicker smegma bacillus 
are not absolute, but though the latter bacillus is fast to acids 
it is not usually so to alcohol and acids. 


Diagnosis. 


A. Weber recommends the following staining method as a means of 
differentiation: Stain in carbol. fuchsin, decolorize for ten minutes in 
absolute alcohol 97, hydrochloric acid 3 parts. Counter stain with a half 
dilution of alcoholic methylene blue solution. The smegma bacilli will be 
decolorized. The antiformin method also distinguishes between the two 
bacilli, since antiformin destroys the smegma bacillus, that is to say, its 
acid-fast membrane. 

The culture of smegma bacilli has up to now not succeeded. Accord- 
ing to C. Fraenkel, the supposed growth of smegma bacilli obtained by 
Laser and Czaplewski were really pseudo-dinhtheria bacilli, which nearly 
always are present in smegma. 

N.B.—For examination of the urine for tubercle bacilli, as an aid to the 
diagnosis of tuberculosis of the genito-urinary tract both in men and 
women, it is better that the sample should be obtained with the catheter, 
so that under suitable precautions confusion with smegma bacilli is 
prevented. 


If tubercle bacilli cannot be detected the disease must be 
distinguished from gonorrhoea, with which it has a great re- 
semblance. Sounding for stricture is of some value. But it 
must be here mentioned that gonorrhoea plays a prominent pre- 
disposing part for the various forms of urogenital tuberculosis. 
The urethroscope gives the surest information by which quite 
early tubercular granulations and ulcerations may be diagnosed — 
in the anterior or posterior urethra; and it is also of great value — 
for treatment. 








TUBERCULOSIS OF THE UROGENITAL ORGANS 307 


Spontaneous healing has certainly been 
observed; so that the prognosis of uncom- 
plicated cases is by no means unfavourable. Much depends on 
the early recognition and treatment of the disease; for both of 
which purposes the urethroscope is most useful. If there are 
complications and disease of other organs the prognosis of course 
is not so good. 


Prognosis. 


The treatment of disease of the anterior part 
of the urethra must be analogous to that 
for gonorrhoea, when the disease cannot be radically treated by 
scraping. The resulting stricture can be treated in. the usual 
manner. 

The local treatment of disease of the posterior urethra con- 
sists of instillations of weak sublimate solution, 1odoform emul- 
sions, or ichthyol, or careful washing out with disinfecting or 
astringent solutions may be performed. The passage of the 
instruments, since all treatment must be external, must be very 
carefully performed to avoid a spread of the tuberculosis or a 
secondary infection. A most careful asepsis is essential. The 
advice of a specialist should be always sought. Wath these local 
measures the general treatment must be joined. Consideration 
must be paid to complications. 


Treatment. 


2. TUBERCULOSIS OF THE PROSTATE. 


The affection of the prostate by miliary 
tuberculosis needs no special description. 
The chronic forms begin in one of the 
lateral lobes or in the urethral part of the prostate as separate 
nodules, which may coalesce and form a mass the size of a hazel- 
nut. This may either undergo fibrous changes, or may caseate 
and necrose. Even abscesses by reabsorption or by discharge 
may come to a standstill, and heal by fibrous encapsulation. Pro- 
gressive disease may lead to caseous infiltration of the one lobe 
of the prostate, or even of the whole organ, which on breaking 
down forms a large cavity involving neighbouring structures. 
The early stages of tuberculosis of the 
prostate cause only slight, or even no, local 
or general symptoms; enlargement of the 
gland from congestion, infiltration and softening are shown by 
feelings of pressure and pain, especially on defzecation and mic- 
turition, by frequent micturition, and later by a purulent dis- 
charge with blood in the secretion and in the urine. 

Primary disease as a sole localization of tuberculosis is 
only seldom found. Usually it is secondary, and occurs quite 


Anatomical 
Changes. 


Symptoms and 
Course. 


308 A CLINICAL SYSTEM OF TUBERCULOSIS 


frequently in the course of urogenital tuberculosis. The prostate 
being traversed both by the urethra and the ejaculatory ducts 
bacilli may reach the gland either from the kidneys or the testicles. 
The glandular tissue offers the bacilli a very favourable breeding 
ground, so that progressive, destructive changes are often met 
with. A gonorrhoeal infection particularly predisposes the pros- 
tate to tuberculosis, a point important both for prophylaxis and 
therapeutics. 

In severe disease of the urogenital tract the prostate plays 

an important part; caseous necrosis and abscess formation lead 
to the appearance of cavities; the necrosis may spread to the neck 
of the bladder, and communication may form with the bladder ; 
the disease may also spread to the membranous urethra and 
destroy it. The cavity filled with urine and pus may undergo 
secondary infection, and the septic changes may spread to the 
rectum and pelvic connective tissue. Miliary tuberculosis is 
observed relatively frequently. 
Prostatic tuberculosis leads quite early to 
an enlargement of the organ, which can be 
felt by the finger in the rectum. In the same way the nodules 
and areas of softening may be recognized. By the urethroscope 
quite early in the disease secretion from the glands can be recog- 
nized; this may be facilitated if necessary by pressure from the 
rectum. If the bacilli cannot be detected the condition must be 
separated from chronic prostatitis, probably due to gonorrhoea. 
There is no difficulty in recognizing advanced disease of the 
prostate. 


Diagnosis. 


Although spontaneous healing has been 
observed, even after caseation and abscess 
formation have occurred, and although the permanent results 
from proper treatment are often good, yet the prognosis is always 
serious. This depends on the virulence of the bacilli, the extent 
of the process, the tendency to spread, and the frequency of 
secondary infection. 


Prognosis. 


Since the disease is practically always 
secondary the removal of the primary mis- 
chief is the chief thing, without which no treatment can give good 
results. A local non-surgical treatment must therefore be carried 
out in all cases after the operative removal of the primary disease ; 
it is usually associated with the measures required for urethral 
tuberculosis. The chief point is to limit as far as possible the 
disease to the prostate. Prophylactic measures after gonorrhoea 
in phthisical patients, or persons predisposed by heredity, are of 
importance. 


Treatment. 





TUBERCULOSIS OF THE UROGENITAL ORGANS 309 


Surgical treatment comprises prostatectomy, opening the 
prostate, opening abscesses, and dividing or extirpating fistulze 
and excision of Cowper’s glands. All these operations require 
hospital treatment. Complete healing is rare; usually a fistula 
isoleft. 


3. TUBERCULOSIS OF THE VESICULA. SEMINALES. 


The disease begins as single or dissemi- 
nated tubercular nodules, which may lead to 
connective tissue formation, or if the disease 
advances to necrosis and abscess formation, or not so frequently 
to caseation. This form of the disease has a marked tendency to 
connective tissue contraction. Complete obliteration of the 
seminal vesicle with fibrous destruction of the duct has been 
observed. 


Anatomica! 
Changes. 


The clinical symptoms are only slight, and 
are often absent in the early stages; only 
when an abscess forms are severe radiating 
pains and feelings of pressure produced, especially on defaecation 
or micturition. 

Primary tuberculosis of the vesiculze seminales has been rarely 
observed, in this case the infection has occurred through the 
blood. The disease is much more often secondary to mischief in 
the prostate or epididymis. It is usually bilateral; and has a 
greater tendency to heal in this position than in any other organ 
of the urogenital system. If the disease is progressive and leads 
to an abscess, the infection never spreads by means of the 
ejaculatory duct to the urethra, but extends directly into the 
prostate. The upper part of the vas deferens may also become 
affected, but an extension to the epididymis has never been 
observed. 


Symptoms and 
Course. 


In the absence of complications the dia- 
gnosis is difficult, in more advanced cases 
it may be made by rectal examination. The tense and tender 
vesicle can be felt; and it has a doughy consistency on account 
of the purulent and caseous contents. 

On account of the great tendency to heal 
disease in this position is not so unfavour- 
able as in the prostate. But as in most cases it is a secondary 
affection, the prognosis largely depends upon the nature of the 
primary disease. 


Diagnosis. 


Prognosis. 


The treatment of prostatic tuberculosis is in 
many respects suitable for disease of the 
seminal vesicles, since as a rule the whole region is affected 


Treatment. 


210 A CLINICAL SYSTEM OF TUBERCULOSIS 


together. Since in many cases injection of iodoform emulsion 
into the vas deferens has given good results, this method may 
form a part of the surgical treatment. If the case is not improy- 
ing castration with extirpation of the vesiculze and vas deferens 
may be considered. There are no reports as to the results of 
tuberculin treatment; Casper considers that it should be tried 
before surgical measures are resorted to. 


4, TUBERCULOSIS. OF THE TESTICLE, THE EPIDIDYMIge 
AND THE VAS DEFERENS. 


Tuberculosis of the sexual gland usually 
begins in the epididymis in the form of one 
or more isolated firm nodules. The disease 
may remain stationary for a long time, or may lead to caseous 
infiltration of the whole organ. Also miliary tubercles may form 
in the testicle; they sometimes caseate, and like necrosing nodules 
in the epididymis usually discharge externally, leaving a fistula. 
The vas deferens is affected more frequently than the testicle, 
usually at the same time as the epididymis. The disease is not 
continuous, but appears in the form of single isolated nodules 
with healthy duct between. The nodules usually consist of a 
hard, infiltrated zone surrounding a caseous centre. 

The disease manifests itself clinically by a 
swelling of the epididymis, sometimes of 
the testicle, usually accompanied by more 
or less severe pains radiating up towards the groin. But swell- 
ing may occur entirely without symptoms; and the discharge of 
caseous nodules in soft, crumbling masses may occur without 
special pains. The fistula may last for months, even years, and 
apart from occasional exacerbations may cause no symptoms. 
When the disease spreads to the vas deferens the thickened, 
beaded tube can be felt, which is but slightly sensitive to pressure. 
The disease is usually limited to the lower part of the vas, the 
opposite to what is found when the infection spreads from the 
seminal vesicles. Further complications are secondary disease of 
the prostate and the seminal vesicles, and later of the urethra and 
the bladder. An ascending infection of the kidney is never 
observed. 

Tuberculosis of the sexual gland is a common disease; it is 
more often unilateral than bilateral, and in many cases is a 
primary disease, the infection doubtless occurring through the 
blood. According to Virchow it always begins in the epididymis, 
where the windings of the tube offer a favourable point of lodg- 


Anatomical 
Changes. 


Symptoms and 
Course. 





TUBERCULOSIS OF THE UROGENITAL ORGANS eu 


ment to the bacilli. In small children primary nodules are more 
often found in the testicle; according to Kraemer they are con- 
genital. The disease may set up tubercular peritonitis through 
an open processus vaginalis, by infection of the lymphatics; also 
lymphatic infection of the opposite gland is the rule. Trauma- 
tions and inflammations, especially gonorrhoea in an individual 
with hereditary tendencies, are predisposing causes. Sexual 
power may be long retained. 

; The disease may be difficult to diagnose in 
Diagnosis. its closed stages. The slight pain, and the 
craggy, nodular condition of the affected part are characteristic. 
Acute orchitis and epididymitis are very painful, and cannot be 
mistaken for tuberculosis. Chronic inflammatory conditions are 
more difficult to distinguish, and demand a very careful history 
and examination of the whole urogenital system and the rest of 
the body. An important point is that tuberculosis nearly always 
begins in the epididymis, while syphilitic disease of the epididymis 
alone is very rare. Gummatous nodules are situated in the 
testicle, they are but little tender on pressure, and may soften; 
also syphilitic disease is usually bilateral, and more often causes 
inflammatory changes and adhesions in the vas deferens. Test 
tuberculin injections may make the diagnosis certain by produc- 
ing focal symptoms, such as dragging pains up the vas, tender- 
ness, pain and swelling, and even suppuration in a diseased 
nodule. 

Spontaneous healing has been seen, even 
caseous nodules, which have discharged 
and emptied themselves, have become permanently healed with- 
out aid after a longer or shorter time. The results of conserva- 
tion and surgical treatment are very good, so that the prognosis 
on the whole is favourable. Extension to other organs does not 
often occur under proper treatment. On the other hand, after 
years of arrest, relapses and softening have been observed, and it 
cannot be denied that miliary tubercle quite often arises from 
disease of these glands. 

The opinions of surgeons as to the necessity 
of castration are by no means in agreement. 
Those who are in favour of the operation say that in 50 to 60 per 
cent. of the cases it leads to cure. Their opponents limit them- 
selves to the enucleation of diseased nodules combined with 
general hygienic and dietetic treatment, especially sea and sun 
baths. The possibility of the spread of tuberculosis must be 
considered. At the commencement of the disease a conservative 
treatment seems indicated. If this does not succeed, a uni- or 


Prognosis. 


Treatment. 


312 A CLINICAL SYSTEM OF TUBERCULOSIS 


bilateral castration with extensive resection of the vas and possibly 
also of the vesiculze seminales must be undertaken. 

In children the conservative treatment is usually recom= 
mended. In adults, too, it should take the first place, especially 
if the tuberculin treatment is employed, the curative action of 
which in tuberculosis of the testicle and epididymis is undoubted. 


5. TUBERCULOSIS OF THE URINARY BLADDER. 
Tuberculosis of the bladder usually begins 


Anatomical . ; : 
Ch in the mucous membrane of the base in the 
See neighbourhood of the trigone, close to 


one of the orifices of the ureters, as grey-red isolated 
granules with narrow red edges. These join together, caseate, 
necrose, and result in eroded ulcers with sharp and swollen 
edges. These small ulcers may also join together and be- 
come very extensive; however, they usually remain limited 
to the mucosa. So long as the ulceration is purely tuber- 
cular, tubercular granules will always be found near their 
edges. As a result of secondary septic infection the ulcers may 
gradually lose their tubercular character, and a severe inflam- 
matory cystitis supervenes. 
The initial eruption of tubercles causes 
practically no symptoms. When _ ulcers 
form an early hematuria may _ occur. 
The bladder is tender on pressure, and there are often 
spontaneous pains. The urine at first is clear and acid; 
later it contains blood and pus with tubercle bacilli. If the 
ulceration becomes more extensive there will be. frequent 
micturition with very painful spasms of the bladder. Very 
characteristic, too, is the intolerance of the bladder to wash- 
ing out. Advanced tubercular disease with the secondary 
inflammatory changes lead to inflammation of the deeper coats 
of the bladder and to interstitial contraction. The wall of the 
bladder becomes thickened, and the cavity much diminished. 
Passage of urine is then extremely painful, and incontinence is 
often present. Marked cystitis is accompanied with ammoniacal 
decomposition of the urine, giving it a putrid odour. 
Tuberculosis of the bladder is a very common disease. Its 
production depends upon some original primary disease. Not all 
the bladders through which tubercle bacilli pass become tuber- 
cular, so that a certain predisposition is necessary. Among 
predisposing causes are gonorrhoea, especially when it affects 
the bladder, traumatism, congestion, and retention of urine, 
particularly in individuals with an hereditary tendency. The 


Symptoms and 
Course. 





TUBERCULOSIS OF THE UROGENITAL ORGANS Ses 


occurrence of primary tuberculosis of the bladder has never 
been for certain observed. The secondary disease is usually a 
consequence of infection of the kidney. It is noticeable that the 
disease usually begins near the orifice of the ureter. Infection 
from the sexual organs more rarely occurs, in that case the 
disease commences near the internal orifice of the urethra. 
Extension of the tubercular disease towards the testicles according 
to recent observations never occurs, and that into the ureters and 
kidneys is very rare, and only occurs under special conditions, 
such as retention of urine. 

Since tuberculosis of the bladder is usually 
secondary to a primary focus in the kidney 
detection of tubercle bacilli in catheter urine is not conclusive, 
since they may originate in the kidney. The same may be said 
for blood or pus in the urine. On the other hand, bacilli may not 
be found; it has been stated by Casper that in tubercular disease 
of the bladder bacilli can often not be detected, and that the 
absence of all bacteria in the urine from a case of cystitis is very 
suspicious of tuberculosis. The absence of all other causes of 
cystitis is also of considerable diagnostic importance. As a last 
resource animal experiments are of service. 

For the recognition of advanced cases the obvious clinical 
signs are sufficient. The earliest possible diagnosis can be made 
by the cystoscope, by means of which the first deposit of tubercle 
round the mouth of the ureter can be detected, before any clinical 
symptoms are produced. According to Frank the earliest sign 
of disease of the bladder, even before the formation of tubercles, 
is that the orifice is no longer smooth and round, but is angularly 
distorted and funnel-shaped. This may either be a sign of simple 
chronic inflammation, due to purulent urine from an affected 
kidney, or of tuberculosis of the ureter. On the expediency of 
cystoscopy in tuberculosis of the bladder opinions are not agreed. 
In skilled hands all injurious effects may be avoided, and full use 
may be made of this valuable means of early diagnosis. 

The tuberculin test may be valuable by producing focal 
symptoms, such as painful and frequent micturition, and pains in 
the region of the bladder. 

Persistent catarrh of the bladder may be distinguished by 
the effect of treatment. Stone in the bladder can usually be 
easily recognized. Cancer of the bladder in its early stages 
causes most confusion if it occurs in a patient in middle life, and 
takes the form of an infiltration and not of a tumour. The micro- 
scopic examination of portions of tissue, and the further course 
of the disease will clinch the diagnosis. 


Diagnosis. 


ey 5 A CLINICAL SYSTEM OF TUBERCULOSIS 


Since the condition is secondary the pro- 
gnosis to a large degree depends upon the 
primary disease in the kidneys or testicles. If this assumes a 
favourable form, the prognosis of the bladder disease, especially 
in initial cases, will also be favourable. 

The non-surgical treatment aims rather at 
a mitigation of the symptoms by general 
measures, than at curing the disease itself. 

Spasms and pains may be relieved by warmth in various 
forms, baths, hot sitz-baths, hot compresses, &c. Narcotics 
frequently cannot be avoided; of these opium in a suppository or 
subcutaneously is most serviceable, not only on account of the 
relief of pain, but also of the sedative effect on the bladder. After 
the narcotics belladonna is the most useful drug. The combina- 
tion of narcotics with pyramidon (4 to 7 gr.) or antipyrin (7 to 
15 gr.) in suppository or enema with hot water has been much 
recommended. Antipyretics alone have a sedative effect on the 
bladder, only if necessary large doses of 25 to 30 gr. of antipyrin 
or 5 to 15 gr. of pyramidon must be used in a hot enema. 

Many authorities altogether refuse to employ local treatment 
for vesical tuberculosis. This is partly due to the extreme sensi- 
tiveness of the diseased bladder to manipulations, and the conse- 
quent painfulness of such treatment. There isenearly always a 
marked intolerance against washing out the bladder. Therefore 
one is usually limited to the instillations recommended by Guyon 
into the posterior urethra. According to Casper weak solutions 
succeed better than the concentrated instillations, only the intro- 
duction must be carefully performed with a syringe and soft 
catheter; 5 to 10 c.c. of the solution are often sufficient, and never 
more than 50 c.c. are to be used. He recommends first the 
introduction of 5 c.c. of a guaiacol and iodoform emulsion 
(guaiacol 5 parts, iodoform .5 to 5, and sterilized olive oil to 100 
parts). The instillation of lactic acid solution (up to 20 per cent.) 
is, according to him, very useful, but it is so extremely painful 
that he has ceased to employ it. As the principal remedy for 
vesical tuberculosis use has been made of sublimate, at first as 
instillations of 1 in 20,000 to 1 in 1,000, and as the spasm and 
pain diminish in increased quantities (5, 10, 50 c.c.), and weaker 
solutions of I in 10,000 to I in 5,000, once, or at most, twice a 
week. The fluid should remain in the bladder as long as the 
patient can bear it without great pain. Each application of the 
sublimate is followed by a painful reaction, so that it has been 
advised to keep the patient under morphia for one or two days. 
Carbolic acid had also been used in increasing quantities of 5 to 


Prognosis. 


Treatment. 


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TUBERCULOSIS OF THE UROGENITAL ORGANS 315 


50 c.c. of 1 to 6 per cent. solution, with good results, but it is 
excessively painful. 

Careful general treatment 1s necessary in this, as in all forms 
of urogenital tuberculosis. The beneficial effects of warm southern 
climates on the subjective symptoms has been often noticed. 
Creosote, guaiacol and ichthyol have been used internally, but 
the curative action of these drugs is not proved. Diuretic waters 
and large quantities of milk may be recommended. On account 
of their antibacterial action on the urine urotropin, helmitol, 
formotropin, salol, potassium chlorate, camphoric acid, and salicyl 
have been given, but they have no action on purely tubercular 
cystitis. 

If these measures fail, and if there are no contra-indications 
in the form of the primary disease, the general condition or the 
presence of other complications, then surgical treatment may be 
considered, upon which a final opinion cannot yet be pronounced. 
The results will depend upon which organ is the seat of the 
primary disease. Only after radical removal of this has surgical 
treatment of vesical tuberculosis a chance of bringing about a 
cure. After extirpation of the kidney spontaneous healing of 
tubercular disease of the bladder has been often observed, so that 
when possible this operation must take the first place after the 
general and tuberculin treatments. Barth found, with his suc- 
cessful operative cases of tuberculosis of the kidney and bladder 
after complete healing’ of the vesical ulceration, that though 
spasm and pain on micturition disappeared yet urgent micturition 
frequently lasted for years in spite of all treatment; therefore he 
recommends early nephrectomy before infection of the bladder 
occurs. Surgical treatment of tuberculosis of the bladder consists 
of opening the bladder from the perinaum or hypogastrium, 
removing, scraping, or cauterizing the diseased areas, and 
draining. It has often given good results. 

If the bladder is infected from the genital organs the opera- 
tion is more difficult, and the results more uncertain. After the 
removal of the tubercular nodules in the testicle, the surgical 
treatment of the disease of the prostate and its surroundings 
comes into question. Also the disease in the neck of the bladder 
is liable to be very severe. But if complete healing cannot be - 
brought about, even after the secondary operations which are 
often necessary, the surgical treatment will frequently cause a 
marked improvement of the severe pains. 

Lately remarkable results have been achieved with tuberculin 
treatment, so that it is being more and more recommended by 
those in a position to judge, especially after removal of the 
affected kidney. 


316 A CLINICAL SYSTEM OF TUBERCULOSIS 


6. TUBERCULOSIS OF THE KIDNEY AND URETER. 

Besides the specific tuberculosis of the kidney toxic affections 
often appear during the course of chronic phthisis. Such is the 
albuminuria, which frequently occurs from irritation of the kidney 
filter produced by the toxins of the tubercle bacillus circulating 
in the blood. It consists of a simple albuminuria without formed 
elements from the kidney being present. In this it differs from 
the rarer febrile albuminuria occurring during phthisis, which is 
chiefly observed with mixed infection, and only causes a slight 
amount of albumin in the urine. Lately the opinion has gained 
ground that tuberculosis is a very fertile cause of chronic paren- 
chymatous nephritis. Lastly in the cachectic stage of phthisis, 
especially if complicated with intestinal tuberculosis, amyloid 
degeneration of the kidney may appear. It generally goes with 
chronic parenchymatous or interstitial nephritis, so that the 
opinions of authors as to its sympioms differ. Usually the 
amount of albumin is rather diminished, and it frequently 
fluctuates. The urine is clear, of a light citron colour, and acid. 
Abundant albumin with scanty sediment is characteristic. 
General dropsy is very frequently present. Changes in the circu- 
latory apparatus only exceptionally occur, absence of cardiac 
hypertrophy is almost symptomatic. Signs of amyloid disease in 
the liver, spleen, and bowel can often be detected. 

The treatment is dietetic, and must depend on the original 

cause. Of drugs iodides, iron, arsenic and quinine, alone or in 
combination have been most used. 
Miliary . tuberculosis may occur in the 
kidney, where it produces no _ special 
symptoms. The chronic localized form 
begins, according to Israel, as a single nodule in one kidney, 
usually at one pole, more often the lower, at the junction of cortex 
and medulla. The initial tubercular foci multiply, join together, 
caseate, and necrose, and form a hollow cavity. In other cases 
the disease begins as a tubercular ulcer on one of the papillz of 
the pelvis of the kidney. The caseous infiltration on its spread 
involves first the medulla and papillz of the kidney, so that by 
necrosis an irregular cavity containing bands of parenchymatous 
tissue with eroded walls is formed, which in advanced cases takes 
the form of a single cavity, partly filled with caseous material. 
When the cortex of the kidney is similarly involved only a much 
enlarged sac, with a thickened fibrous capsule, is left. 

The softened caseous masses are discharged in the urine, and 
set up ulceration and caseous infiltration of the pelvis of the 


Anatomical 
Changes. 


kidney, and the ureter. In consequence of blocking of the 


ee eh hl lm 


| 















TUBERCULOSIS OF THE UROGENITAL ORGANS 317 
ureters by caseous material the urine will be obstructed, and the 
pelvis and ureter will become dilated. The walls of the ureter 
are not at first uniformly affected, but present a series of isolated 
nodules like the condition ofthe vas deferens. In advanced 
disease it is converted into a stiff tube, with cylindrical areas of 
excavation between firm, nodular infiltrations. In rare cases of 
advanced destruction of the kidney there may be complete obstruc- 
tion of urine. 

Isolated tuberculosis of the ureter is not met with. 

The initial disease causes no diagnostic 
symptoms. Inflammatory hyperemia, caus- 
ing swelling of the kidney, and stretching 
of the capsule, will evoke as early symptoms a feeling of weight 
in the kidney region, and pains, which may develop into attacks 
of colic, accompanied by vomiting. Bodily movements of 
various kinds may bring them on. The pains frequently extend 
down the ureter towards the bladder. The region of the kidney 
and ureter are usually tender on pressure. In early stages an 
enlargement of the kidney can frequently be detected on palpation. 
Precipitate micturition occurs frequently at night from reflex 
irritation; in early cases the amount of urine is usually 
increased. 

The alterations of the urine are important. The urine, which 
was at first clear, frequently contains blood, sometimes in profuse 
amounts, especially in ulceration of the papillz or pelvis. Only 
after the breaking down and discharge of a caseous nodule’ will 
the urine become thick, from the contained pus and caseous 
débris. The amount of albumin will depend on the amount of 
nephritic changes in the diseased kidney. In the sediment round 
cells, transitional epithelium from the urinary passages, free 
granules, caseous and fatty detritus, elastic fibres, phosphates, 
and tubercle bacilli, sometimes in characteristic plaits, can be 
recognized. The detection of the bacilli may be very difficult, 
and frequently first succeeds by experiments on animals. In 
cases of mixed infection streptococci may be found. 

The general health of the patient may remain for a long time 
unaffected. Fever and loss of weight may be absent. The 
differences in the course of the disease depend on the acuteness 
of the process and the way in which it spreads. Only in 
advanced cases do we meet with general symptoms, fever, affec- 
tions of the bladder, the sexual and other organs, hydro- and 
pyo-nephrosis, perinephritic abscess, or intestinal, vesical, and 
vaginal fistulz. 

Tuberculosis of the kidney practically always depends upon 


Symptoms and 
Course. 


318 A CLINICAL SYSTEM. OF TUBERCULOSIS 


the presence of another tubercular focus somewhere in the body. 
It is the most common form of urogenital tuberculosis, and 
according to recent researches it is the initial form which hemato- 
genous infection of this system takes. Ascending disease from 
the bladder and the lower parts of the urogenital system is much 
rarer; it may occur either from tubercle bacilli ascending the 
ureter in consequence of urinary stasis from obliterative ureteral 
infiltration, or from antiperistaltic contractions of the ureter 
(Wildbolz), or in the lymphatic system of the wall of the ureter. 
In quite half the cases the disease is unilateral, a very important 
fact. The disease of the second kidney may occur in consequence 
of infection through the blood, exceptionally even in an early 
stage of the disease of the first organ. As to the duration of the 
disease, its frequency, its predilection for either sex, and other 
questions the figures are not in accord. Barth considers that the 
kidney is relatively frequently affected during pregnancy and the 
puerperium, on account of the hyperzemia and congestion of the 
organ which then occurs; and he recommends that patients with 
pyuria at those times should be examined for renal tuberculosis. 
The difficulty lies less in detecting the 
disease as such, than in determining which 
kidney is affected. The surest means of recognizing the disease 
is the discovery of tubercle bacilli in urine obtained by the 
ureteral catheter; but it must be noted that phthisical patients 
with sound kidneys sometimes eliminate the bacilli circulating in 
the blood through the urine; this accounts for the fact that B. 
Bertier by inoculating the centrifugalized deposit of the urine 
from advanced phthisical patients into guinea-pigs obtained 
positive results in 33 per cent. of cases. If the urine is taken only 
from the bladder, tuberculosis of that organ must be excluded; 
cystoscopy is most useful for this purpose. Its use for the early 
diagnosis of vesical tuberculosis has already been mentioned; by 
its help the condition of the orifices of the ureters and their func- 
tions may be directly examined, and it is also valuable for 
treatment. In disease of the kidneys and ureters their peristaltic 
contractions are weakened; frequently the flow of turbid urine 
from the affected side can be directly observed; and often the 
ureteral papilla is characteristically inflamed, being swollen, 
distorted, very vascular, and even hamorrhagic, or ulcerated. By 
the use of the ureteral catheterism introduced by Casper the 
function of the kidneys can be examined separately. The func- 
tional activity of the two kidneys can be determined by the 
following methods: (1) by the estimation of the freezing point 
of the urine from the two kidneys; (2) by the phloridzin test 


Diagnosis. 





Z 
= 





TUBERCULOSIS OF THE UROGENITAL ORGANS 31G 


worked out by Casper, for comparing the power of sugar excretion 
of both kidneys after taking phloridzin; (3) by the indigo-carmine 
test of Volcker and Joseph; (4) by a similar test with methylene 
blue; and (5) by the diastase estimation of Wohlgemuth. The 
phloridzin test gives no reliable information in early stages. The 
indigo-carmine test has given the best results in Bier’s clinic. 

To accelerate the appearance of the coloration in the urine obtained by 
ureteral catheterization, it is recommended to allow the patient to become 
thirsty and to inject the indigo-carmine intramuscularly. Under normal 
conditions, after about five minutes, the first flow of bluish urine occurs; 


after about ten minutes the colour is deeper. In anamic patients on account 
of the prolonged absorption of pigments there is a delay; in feverish patients 


’ 


there is a definite acceleration of the reaction. If the coloured urine does 
not flow out of the ureter, the kidney is diseased. If only slight tubercular 
disease of the kidney is present the excretion of the pigment may be 
unaltered. 

The method is not applicable if in consequence of tuberculosis of the 
bladder the mouth of the ureter cannot be seen, and therefore the ureteral 
catheter cannot be passed, and when polyuria, as a consequence of cathe- 
terism, interferes with the test (joseph). 


Without the aid of cystoscopy and the ureteral catheter one 
has to be guided only by the clinical symptoms and the results of 
urinary analysis, so that the diagnosis becomes difficult, and the 
early diagnosis especially is often impossible. If an enlargement 
in the size of one kidney can be detected one must consider 
whether it is a compensatory hypertrophy of a sound organ. If 
there is obstruction to the flow of urine the tubercular focus may 
be completely shut off, and may entirely escape recognition with- 
out the use of the cystoscope and ureteral catheter. 

In all doubtful cases the diagnosis by tuberculin, properly 
employed, may give most useful information by producing a 
focal reaction (renal pain and bleeding). 

Also the Roéntgen-rays sometimes are very serviceable. For 
the perfection of the radiographic diagnosis of renal tuberculosis, 
according to v. Lichtenberg and Dietler, the so-called ‘* pyelo- 
eraphy ”’ is to be recommended, that is the X-ray examination of 
the pelvis of the kidney filled with 10 per cent. collargol solution. 
Doubtful cases can be certainly diagnosed in this way, and in 
cases already diagnosed bacteriologically the pathological condi- 
tion can be more completely recognized from the characteristic 
appearance of the more or less destroyed kidney and the changes: 
in the ureters. 

Under certain conditions the extraperitoneal exploration of 
the organ, splitting the capsule, and, if necessary, the kidney, 
even up to the pelvis, may be employed; which by many surgeons 
is preferred to a difficult catherization of the ureters, particularly 


320 A CLINICAL SYSTEM OF TUBERCULOSIS 


when the bladder is infected (IKkrabbel). The best authorities on 
this disease are adopting the recommendation of Rovsing of 
regularly exploring both kidneys, and, indeed, first that organ 
which seems to be most healthy. 

The differential diagnosis must be made from tumour and 
stone of the kidney and pyonephrosis. Malignant tumours 
usually appear later in life, and as a rule do not cause suppuration. 
Stone may be recognized by the frequent colic and the crystalline 
deposit in the urine. Both these diseases are usually free from 
fever. In the radiographic examination a distinction must be 
made between a stone and a calcifying tubercular nodule in the 
kidney. Tuberculin may here, too, help in the diagnosis, and the 
more as a renal calculus may be associated with tuberculosis. 
More difficult is the distinction between pyonephrosis and tuber- 
culosis of the kidney, especially of the pelvis. Daily bacterio- 
logical examination, and repeated inoculation experiments on 
animals, of the urinary sediment may be required to determine 
the presence or absence of tuberculosis. In all cases this is 
associated with some other tubercular focus in the body, and both 
conditions may be revealed by a subcutaneous tuberculin injec- 
tion. As the early diagnosis of renal tuberculosis is so extremely 
important for treatment all diagnostic methods may be required. 
Spontaneous healing of renal tuberculosis 
has not been observed for certain, but it is 
believed that small nodules may heal of themselves occasionally. 
Under symptomatic treatment B. Eichhorst saw several cases so 
far improved as to become free from clinical symptoms. The 
course of cases treated conservatively is usually very long, often 
extending over many years, till renal insufficiency or some other 
complication brings about the end. In bilateral disease the pro- 
gnosis is naturally much worse. Operative treatment brings 
about complete healing in something like 50 per cent. of the 
cases; the results of Israel with 63.8 per cent. of recoveries are 
even better, and as many as fifty of Casper’s sixty-seven cases 
were cured. The most important points in the prognosis are the 
early recognition of the disease, and the application of proper 
treatment. 


Prognosis. 


The internal treatment of renal tubercu- 
losis consists of dietetic and symptomatic 
measures, which should only be employed as an aid to other 
treatment, or as a makeshift, if the latter is refused. Most im- 
portant is a diet suited to the kidney; the cutting off of all 
seasoned, strongly spiced, irritating foods and all alcoholic 
drinks. If the bladder is affected, plenty of milk, alkaline 


Treatment. 





TUBERCULOSIS OF THE UROGENITAL ORGANS 321 


waters and buchu tea may be given. In bacterial infection of 
the urine, urotropin, salol, potassium chlorate, and boracic acid 
may be given, and the bladder may be washed out. Hemor- 
rhage requires absolute rest, a diet as dry as possible, ice-packs, 
and the internal use of suprarenal preparations. 

Surgical treatment consists of removal of diseased nodules, 
and of nephrectomy, if necessary, combined with ureterectomy ; 
though tuberculosis of the ureters heals of itself after removal of 
the kidney, according to Barth slowly in one to two years. Direct 
indications for the operation are dangerous hemorrhage, and 
persistent, severe colic. It is necessary for extirpation of the 
kidney that the other organ should be sound, or of sufficient 
working capacity, a fact which must be carefully determined by 
cystoscopy and ureteral catheterization. Bilateral disease is not 
always an absolute contra-indication, since removal of a much 
diseased kidney has been followed by spontaneous improvement 
in the other slightly affected organ. For bilateral disease 
nephrotomy, with removal of the caseous nodules, or partial 
renal resection, may be considered. Palliative nephrotomy, fol- 
lowed later by a radical operation, has given good results in 
reduced patients. 

According to Garré, one should forbid pregnancy in a 
nephrectomized patient; but numerous observations of French 
writers, lately reported on by Hartmann and Pousson, are in 
accord with the view of Israel that pregnancy has no unfavour- 
able influence on the remaining kidney, as long as it is healthy. 

Lately removal of the kidney in bilateral disease has been 
less favoured, on account of the marked results of tuberculin 
treatment; but the opinions of urologists and surgeons are still 
at variance. Tuberculin can, in early renal cases, bring about 
a complete cure, and in advanced cases continued improvement. 
Tuberculin treatment is indicated in bilateral disease, when opera- 
tion is refused, and as an after-treatment of renal operations, to 
clear up disease of the bladder and genital organs. Karo, who 
has energetically supported tuberculin treatment of renal tuber- 
culosis, reports the results of twelve cases, of which eleven were 
either cured or markedly improved; it may be also noted that 
tuberculin does not only act on the renal mischief, but also on 
the primary disease, and so may prevent an infection of the 
opposite kidney, or other spread of the tuberculosis. To sum up, 
in unilateral tuberculosis of the kidney the best treatment is 
removal of the diseased organ, followed by a systematic course 
of tuberculin, while in bilateral disease the latter may be em- 
ployed without surgical measures. 

21 


22 A CLINICAL SYSTEM OF TUBERCULOSIS 


Go 


Since radiotherapy, the favourable influence of which on 
other advanced, inoperable, tubercular, abdominal disease has 
already been mentioned, has in cases of bilateral renal disease 
repeatedly led to permanent improvement (Bircher), it should be 
combined with the specific treatment. 

Rollier has recorded quite astounding results of treatment by 
sun rays, even in hopeless cases of tubercular disease of the 
urinary organs. He begins by exposing the lower extremities 
to the sun, and gradually uncovering more and more of the body, 
till the patient is entirely exposed to the insolation. 

With all methods of treatment general hardening measures 
and all other hygienic factors are necessary. 


7. TUBERCULOSIS OF THE SUPRARENAL BODY. 


The disease begins with a formation of 
tubercles in the medulla. As the caseation 
advances the disease spreads to the cortex. 
The organ increases considerably in size, so that its normal 
weight of 5 to 8 grm. may be increased to 300 grm. or more. 
It is then converted into an irregular, nodular tumour. On sec- 
tion between the caseous areas a greyish-red tissue, consisting 
of still normal gland tissue, may be recognized, or the whole 
tumour may consist of caseous masses. Usually both sides are 
affected. The disease may involve the coeliac ganglion, and 
solar plexus of the sympathetic. 

Tuberculosis of the adrenals is the most 
frequent anatomical cause of Addison’s 
disease, which is not a pathological entity, 
but only the clinical representation of a definite symptom- 
complex. The symptoms develop gradually, and consist of 
weakness, pallor, digestive troubles, loss of appetite, vomiting, 
diarrhoea, wasting, characteristic pains in the loins, and pro- 
gressive loss of memory and psychical depression. A cardinal 
symptom, which rarely fails and which clinches the diagnosis, 
is a peculiar pigmentation of the skin, which begins as a dirty 
grey coloration, and develops into a deep bronzing. The mucous 
membrane of the mouth and throat may present patches of the 
coloration, which is then usually blackish. The sclerotics, palms, 
soles and nails generally remain free. 

The duration of this rare disease may be between several 
months and two or three years. Its course is progressive; a case 
at present under our treatment shows marked cyclical changes; 
periods of quite good general condition alternate with periods 
of giddiness, vomiting, marked weakness, and greatly increased 


Anatomical 
Changes. 


Symptoms and 
Course. 





TUBERCULOSIS. OF THE UROGENITAL ORGANS 323 


pigmentation of the skin. The patients generally die of ex- 
haustion. Men in middle life are most often affected. In 
about half the cases pulmonary tuberculosis is found. In a case 
reported by Werner the condition was associated with tubercular 
disease of the urogenital apparatus, whence by means of the 
retroperitoneal lymphatics the disease had spread. Much about 
the disease is still obscure. 

The recognition of Addison’s disease as 
such is easy, so soon as the typical pig- 
mentation of the skin is developed. It may, with probability, be 
ascribed to tuberculosis of the suprarenal glands, if tubercular 
disease of another organ can be detected. 

Tuberculosis of the adrenals is an incurable 
disease, and ends fatally. Treatment is 
useless, and purely symptomatic. We have 
seen no good results from tuberculin. 


Diagnosis. 


Prognosis and 
Treatment. 


B. Tuberculosis of the Female Genital Organs. 


Besides the special tubercular diseases, other affections of a 
non-specific nature may implicate the female genital organs during 
the course of chronic pulmonary tuberculosis, which have not 
only a symptomatic value, but also are important etiologically. 
The extremely frequent disturbance of the menstrual function 
must be first mentioned. Sometimes the menstruation, especially 
at the commencement of the disease, is profuse, sometimes it is 
scanty, and nearly always painful. Often it is absent for many 
months; not uncommonly it is replaced by leucorrhcea. Many 
of these cases suffer from more or less severe anemia. Amenor- 
thoea and dysmenorrhoea are frequently met with in latent, as 
well as in manifest, tuberculosis, as a consequence of intoxica- 
tion. They are often accompanied by rises of temperature, and 
may be suitably treated with tuberculin. Recognized types are 
pre-, inter- and post-menstrual fever. The connection between 
the temperature and menstruation is very complicated, and 
appears more so since attention has recently been paid to it. It 
depends on the problem of the secretion of the ovary, and its 
action on separate organs and the functions of the whole 
organism. It has a special diagnostic importance, but is of no 
value for prognosis. 

Endometritis, limited to the cervix or extending into the 
body of the uterus, is of symptomatic importance. Amenorrhoea 
is not uncommonly due to atrophy of the uterus, affecting only 
the body of the uterus. Catarrhal salpingitis is more frequently 


324 A CLINICAL SYSTEM OF TUBERCULOSIS 


observed. Atrophy of the ovaries may also occur. A symptom 
of those conditions, which are often combined, is leucorrhoea, 
which leads secondarily to erosion of the cervix. 

With or without atrophy of the uterus retroversions and 
retroflexions are often found, with relaxation of the ligaments, 
permitting prolapse of vagina and uterus, causing pains in the 
rectum and bladder. The changes are due both to the wasting 
of the patient and the consequent relaxation of the tissues, and 
in advanced pulmonary disease to venous congestion. 

Just as chronic phthisis may cause functional alteration and 
even pathological changes in the genital organs, so the existence 
of disease of the sexual organs, or even the action of the genital 
function, may undoubtedly affect the course of pulmonary tuber- 
culosis. A connection between menstruation and phthisis is seen 
in the fact that the catarrhal phenomena in the lung become more 
marked before and during the period, and often first appear then, 
a point of direct diagnostic value. It is not, however, justifiable 
to conclude that the menstrual function has an unfavourable in- 
fluence on pulmonary tuberculosis. The not uncommon periodic 
hemorrhages are worthy of notice; they either occur at the same 
time as a scanty menstruation, or replace it (the so-called 
vicarious menstruation). 

Severe and frequent menstrual hemorrhages on account of 
their weakening influence require careful treatment by rest, 
styptics, plugging, or curetting. The same treatment is required 
for metrorrhagia due to endometritis, submucous myoma, or 
tumour of the adnexe. 

All acute and chronic inflammatory conditions of the sexual 
organs, all displacements causing pain or discomfort, and all 
simple new growths, are more or less serious complications, while 
malignant growths cause a rapid advance of the tubercular disease. 
Their unfavourable influence on pulmonary tuberculosis is due to 
a lowering of the general power of resistance, on account of 
insufficient nutrition, of rises of temperature, of direct injury to 
the heart and lungs from circulatory congestion, and not least, of 
the nervous, neurasthenic and psychical disturbances, which are 
rarely absent in cases with disease of the genital organs. They 
are of special importance in cases of phthisis, for in no other 
disease is the prudent, patient, and constant co-operation of the 
sufferer so important for cure. 

All diseases of the genital organs also increase their suscepti- 
bility to the tubercle bacillus, and favour the development of a 
genital tuberculosis. This is especially true of gonorrhoea, which 
plays the same predisposing part for the sexual organs of women, 





TUBERCULOSIS OF THE UROGENITAL ORGANS 325 


as was described in the section on Male Urogenital Tuberculosis. 
The remarks which were then made as to primary and secondary, 
and ascending and descending, forms of infection also hold good. 


1. TUBERCULOSIS OF THE VAGINA. 


Tuberculosis of the vagina presents itself in 
the form of miliary granules, superficial 
erosions, and deeper ulcerations with sharp 
jagged edges—different stages of the same process. 

The clinical symptoms are slight, and may 
be absent. Increase of secretion first 
appears when the disease reaches a certain 
stage ; and the cause of it is usually accidentally discovered. The 
disease is mostly secondary. Primary cases confirmed by autopsy 
are not known, though their occurrence is possible. 
Characteristic tubercular nodules, or tuber- 
cle bacilli in the secretion, will make the 
diagnosis certain, and will distinguish tubercular from syphilitic 
ulceration. In doubtful cases a portion of the ulcer may be 
removed for microscopical examination, or inoculation on animals. 
Also the visible focal reaction to a diagnostic tuberculin injection 
may make the diagnosis certain. 

The prospects of cure are good of them- 
selves, but depend on the condition of the 
sexual organ which is primarily affected. 
Excision gives the most certain results. Small ulcers may be 
treated by cauterization and application of iodoform powder. A 
more important point is the treatment of the primary disease, on 
the success of which will depend the course taken by the vaginal 
affection. General hygienic treatment must be combined with 
tuberculin. Veit recommends the new tuberculin on the grounds 
of his own experience. To prevent spread of the infection sexual 
intercourse must be forbidden, and the bedding and clothing 
disinfected. 


Anatomical 
Changes. 


Symptoms and 
Course. 


Diagnosis. 


Prognosis and 
Treatment. 


2. TUBERCULOSIS OF THE UTERUS. 


Three varieties of uterine tuberculosis may 
be distinguished, the miliary, the intersti- 
tial, and the ulcerative forms. These are 
probably not essentially different, but depend merely on the stage 
of development. Tubercular endometritis begins with a deposit 
of miliary tubercles, especially at the fundus. As in all forms 
of mucous membrane tuberculosis by the breaking down of these 


Anatomical 
Changes. 


326 A CLINICAL SYSTEM OF TUBERCULOSIS 


ulcers are formed, which may affect any parts of the uterine 
mucosa. In advanced cases the whole endometrium is destroyed ; 
and the uterus is regularly enlarged, up to three times its normal 
size, from infiltration and hyperplasia of the muscular layers. 
In the uterine cornua nodular thickenings have been found. If 
the cervix becomes plugged, or obstructed by inflammatory 
swelling or retroflexion, the pent-up pus will produce _ pyo- 
metra. The thick secretion often contains caseous particles. 
Uteri have been found both in children and adults full of caseous 
masses. 

Tuberculosis of the cervix leads sometimes to a peculiar 
infiltration of the vaginal portion with papillary outgrowths of 
the size of a walnut to an apple; by the partial necrosis of these 
cancer of the cervix may be simulated. 

The clinical symptoms of early cases are 
slight and not to be distinguished from 
those produced by other forms of catarrhal 
inflammation. They consist of a mucoid or muco-purulent secre- 
tion, alteration of menstruation, and a muco-sanguineous dis- 
charge, which may increase into irregular haemorrhages. As the 
disease advances the uterus enlarges, without the appearance of 
typical symptoms. In the stage of pyometra the uterus is con- 


Symptoms and 
Course. 


verted into a spherical, fluctuating swelling. Sometimes the 
discharge in advanced cases contains characteristic caseous 
particles. 


Tuberculosis of the uterus is a fairly common disease. It 
may be primary, but it is rarely so. More often it is secondary 
to disease of the tube. 

Since tuberculosis of the uterus causes no 
unmistakable clinical symptoms the dia- 
gnosis must depend on the discovery of tubercle bacilli in the 
discharge, which is very difficult in the early stages on account 
of scarcity of bacilli. If the suspicion of uterine tuberculosis has 
been raised by the presence of disease in another organ, it can 
be confirmed in an early stage by the microscopic examination of 
the endometrium removed by curettage. A tuberculin injection 
may also clear up the diagnosis by producing a focal reaction in 
the form of uterine hamorrhage and pains. The tuberculosis of 
the vaginal portion, which takes the form of a papillary tumour, 
‘must be diagnosed by excising a portion of tissue, if bacilli 
‘cannot be found in the discharge and animal experiments fail. 

The prognosis depends upon whether the 
| uterus is the primary organ affected, 
whether the tubercular disease remains limited to the uterus, or if 


Diagnosis. 


Prognosis. 





TUBERCULOSIS OF THE UROGENITAL ORGANS 327 


not, what form the disease has taken in the other pelvic organs. 
In general it is good. 

Considering the possibility of ascending 
tuberculosis of the sexual organs originat- 
ing from the vagina, as shown by the experiments on animals of 
Bennecke, Jung, Bauereisen, and Menge, to which v. Franqué 
has lately drawn attention, more attention than hitherto should 
be paid to prophylaxis. In the first place sexual ‘intercourse 
should be forbidden, not only with men suffering from urogenital 
tuberculosis, but with all phthisical cases. Also the possibility 
of transference of the tubercle bacilli from the patient herself or 
from another person, by means of sputum, infected instruments, 
washing, &c., is to be remembered. This is of particular 
importance during abortion, labour, or the puerperium. 

So long as the disease is limited to the uterine mucosa a 
thorough curettage may lead to complete cure. Also when the 
disease has penetrated into the uterine wall scraping the ulcers 
may cause considerable improvement, by diminishing the puru- 
lent discharge and the bleeding. An after-treatment of washing 
out the uterus, plugging, &c., will be usually required. 

If the vaginal portion is diseased in the manner described, 
amputation of the cervix will be necessary, provided the mischief 
is limited to that part. If the uterus only is affected extirpation 
will cause a complete cure, but the condition is rarely sufficiently 
severe to demand this. If the uterine disease is secondary to that 
in the tubes this must be considered in planning the operation. 
Uterine tuberculosis being an open disease too much care cannot 
be taken to prevent the spread of infection. 

Careful general treatment is important. There are no reports 
of tuberculin treatment of isolated uterine tuberculosis. 


SEU BSERCULOSIS OF THE. TUBES. 


According to Wehmer there are two differ- 
ent forms of disease; the acute caseous, and 
the chronic miliary or fibroid varieties. 
The acute caseous form begins by a deposit of nodules in the 
mucosa, quickly destroying the mucous membrane, which with 
the thickened secretion forms a caseous pulp. The submucous 
and muscular layers are hypertrophied. In later stages the tubes 
are much twisted and dilated, and form stiff rolls, of the thickness 
of a finger. Their shape is very variable; they have been com- 
pared to a sausage, a club, a retort, a torpedo, or a rosary. The 
ampullary end of the tube is usually the most expanded. The 
ostium abdominale is in half the cases obliterated, in the others 


Treatment. 


Anatomical 
Changes. 


328 A CLINICAL SYSTEM OF TUBERCULOSIS 


it remains open. Adhesions to the surrounding organs usually 
occur later. The chronic miliary variety is characterized by an 
early closure of the abdominal opening, which leads to the forma- 
tion of a pyosalpynx. The destruction of the mucosa takes 
place more slowly. Numerous tubercular nodules form in the 
mucous membrane, but they have no tendency to rapid necrosis. 
The contents are at first a thin, serous fluid, which gradually 
becomes purulent and caseous. The necrotic masses are mixed 
with secretion and may induce a very characteristic hypertrophy 
of the wall of the tube. The chronic fibroid form is a variety of 
this in which there is only a very slight tendency to caseation, 
and the formation of fibrous tissue predominates over the deposit 
of tubercles. 

As the disease advances it may involve neighbouring organs ; 
miliary nodules and a membranous exudate appear on the 
serous coat of the tube, leading to matting together of the pelvic 
organs and intestines, to effusion into the peritoneal cavity, and 
later to extensive firm adhesions with the posterior surface of the 
broad ligament, the uterus, the pelvic wall, the bladder, the 
rectum, and the sigmoid. Gradually the pelvic organs are con- 
verted into an extensive, irregular mass. The extension of genital 
tuberculosis to the peritoneum, and their mutual connection, 
have already been described in the section on tuberculosis of the 
peritoneum. 

The clinical symptoms vary according to 
the .primary or secondary nature of the 
tubal tuberculosis, whether it is isolated or 
whether neighbouring organs are involved. In any case, they 
are not characteristic of tuberculosis, and furnish no sure ground 
for the recognition of the disease. The physical signs are of the 
greatest value. According to Hegar two different stages can be 
distinguished ; either the individual pelvic organs are still separate 
on palpation, or they are so matted together by exudation that 
they can no longer be distinguished from each other. The 
different shapes of the swollen tubes depend on the anatomical 
changes. They seldom reach the size of a goose’s egg, save in 
exceptional cases. The tubes may be considerably displaced; 
they may lie at the side of the uterus, or in the postero-lateral part 
of the pelvis, or even in the pouch of Douglas. According to 
Hegar it is characteristic of tuberculosis, in contrast to the usual 
forms of pyosalpynx, that the swelling occurs in the middle part 
of the tube, that it assumes a more irregular, polygonal shape, 
and that it is usually more solid, and may vary in consistency in 
different parts. Hegar also considers that a point of value is the 


Symptoms and 
Course. 


TUBERCULOSIS OF THE UROGENITAL ORGANS 329 


thickened, hard condition of the broad and_ utero-sacral liga- 
ments, and on their surfaces small, nodular tubercular deposits 
may be felt. Occasionally tubercular deposits may be palpated 
on the posterior wall of the uterus and the anterior surface of the 
rectum, generally only on rectal examination, as Sellheim has 
especially remarked; but similar nodules of a non-tubercular 
mature may occur, especially in chronic inflammatory adeno- 
myositis of the uterus. Exudation is rarely absent in advanced 
tubercular disease. 

Tuberculosis of the tube forms the greatest percentage of all 
cases of genital tuberculosis; according to Simmonds, Merletti, 
Targett, about 90 per cent. In most cases other parts of the 
genital tract are also affected, but the disease in the tube is usually 
the most advanced, and appears the oldest. As predisposing 
causes are the marked folding of the mucous membrane of the 
tube, the stagnation of secretion, the relative poor vascular supply, 
and lastly, the frequency of gonorrheeal affections. Usually both 
tubes are affected at the same time. The infection in exceptional 
cases may ascend from the vagina, but the descending form is 
more common. Primary disease of the tube has undoubtedly 
been seen, but is rare; much more often it is a secondary disease, 
the infection being conveyed by blood-vessels or lymphatics from 
some other focus in the body, or spreading by continuity from 
the peritoneum, the bowel, or the urinary organs. 

Though the physical signs give no certain 
indication for the recognition of the disease, 
frequently a probable diagnosis can be arrived at. The history 
of the patient, arrested development of the genital tract (Sellheim) 
detection of other organic tubercular disease, and prolonged 
observation may put it on a surer basis. The ‘‘abrasio 
mucose ’’ introduced by Sellheim as an aid to diagnosis in doubt- 
ful cases, and which has been further recommended by Kronig, 
since in about 50 per cent. of the cases it settled the diagnosis of 
tuberculosis of the adnexz, v. Franqué holds to be not permis- 
sible. He only allows it for small, hard, tubal thickenings, and, 
indeed, warns the practitioner entirely against this diagnostic 
measure. Effusions may be punctured through the vagina or the 
abdominal wall, and the discovery of tubercle bacilli or the result 
of animal inoculation will assist the diagnosis. There are cases, 
especially of the chronic variety of tuberculosis of the tube, which 
are not to be distinguished macroscopically from simple pyo- 
salpinx; microscopical examination alone gives the correct 


Diagnosis. 


‘diagnosis. There are very rare cases which microscopically 


appear to be purulent inflammation of the tube, and only in serial 
sections may tubercle bacilli be found. 


330 A CLINICAL SYSTEM OF TUBERCULOSIS 


The differential diagnosis must be made from gonorrhoeal 
pyosalpinx, and malignant tumours. A diagnostic tuberculin 
injection gives very valuable information by producing a focal 
reaction (pains and a feeling of weight and pressure), and is very 
often decisive, though lately observations of the unreliability of 
tuberculin reactions have been made by v. Franqué, Schlimpert, 
and Zoppritz. Only in rare cases will a diagnostic laparotomy 
or colpotomy be required. 

The prospects of healing of tuberculosis of 
the tube are not bad. Even when accom- 
panied by pulmonary tuberculosis healing under general hygienic 
measures has been observed. The prognosis has become much 
more favourable since the introduction of tuberculin treatment. 
Even in advanced cases a complete cure may be obtained by 
operation. The prognosis depends on the general condition of 
the patient, and on the stage of the disease of the other organs, 
especially of the lung, which usually accompanies tuberculosis of 
the tube. The occurrence of general miliary tuberculosis is rare. 
The prophylaxis is the same as for uterine 


Prognosis. 


Treatment. 


tuberculosis. 
On the expediency or necessity of surgical interference the 
views are divergent. Practical experience, and the realization 


that the tuberculosis of the tube is much more rarely primary than 
was previously thought, have led to a diminution of the scope of 
the operation. But there are renowned gynecologists, such as 
Kroénig, Bumm, Schauta, who are still complete adherents of 
operative treatment. Veit, who takes a more conservative stand- 
point, warns against all operative measures during the acute 
febrile stage. On the other hand, v. Franqué is a strong sup- 
porter of surgical measures for diced of the adnexz, and 
recommends operation when this is the only clinical tubercular 
localization, or if it is the most prominent, provided that it is 
not already in an old, quiescent condition. The advantages of 
a timely operation, which those experienced in the pathological 
anatomy of genital tuberculosis, such as B. Simmonds, also 
recommend, are, according to v. Franqué, that the patient is at 
once relieved from all symptoms and threatening dangers, and 
that the cure will last for years, or be permanent; while conserva- 
tive treatment, on account of the slight tendency to spontaneous 
healing, will in the best cases take a very long time, and in cases 
under unfavourable social conditions will not give the requisite im- 
petus towards healing. In favour of operative treatment have also 


been raised the arguments that there is a constant danger of the’ 


supervention of mixed infection from the bowel, that extra-uterine 



































+ 


TUBERCULOSIS OF THE UROGENITAL ORGANS 331 


gestation has frequently been observed with tuberculosis of the 
tube, that chronic tuberculosis predisposes to the development of 
carcinoma, that there is a possibility of the spread of the disease 
tc the surrounding organs, or to the lower part of the genital 
tract, and that if the uterine mucosa thus becomes affected the 
tuberculosis will become open, and be a constant danger to the 
patient herself and to those in contact with*her. At the German 
Congress of Gynecology, held in Munich in rg11, the majority, 
including Zweifel, Kustner, Fehling, Menge, Stoeckel, Sarvey, 
Gottschalk, Opitz, Wertheim, Stratz, &c., supported a more or 
less operative treatment. A more moderate and selective stand- 
point, taken by van Herff, Sellheim, and Sippel, is that the 
operation is indicated when in spite of conservative treatment 
there is no tendency towards arrest of the disease, and when coim- 
plications in other organs do not make the prognosis after 
operation doubtful. Special indications are severe pains, marked 
loss of strength, rapidly progressive disease, constant relapses on 
account of mixed infection, large collections of pus, continued 
fever, and threatened or actual perforation of the bowel. The 
operation consists of partial or total resection of the adnexe, on 
one or both sides; or of the radical operation (panhysterectomy) 
if the disease is more severe and extensive. On account of the 
better view obtained of the disease, the previous diagnosis being 
always incomplete, laparotomy is to be preferred to colpotomy. 
It is contra-indicated if there is advanced tuberculosis of the lungs 
or other organs, and if the genital tuberculosis is very extensive, 
and accompanied by dense adhesions. In these cases puncture of 
effusions, opening, and draining abscesses, and if there is 
secondary tubercular peritonitis, simple laparotomy, may be 
required. 

Recently in cases of genital and plastic peritoneal tuberculosis 
too far advanced for operation, marked improvement, and even 
cure, have been obtained by radiotherapy, as Bircher, Gauss, 
Spaeth, and others have remarked. 

Lastly general hygienic treatment, removai from the domestic 
sphere, complete rest to the sexual organs, and, if possible, treat- 
ment in a sanatorium, especially if the lungs are also affected, 
may give good results. The pains in the pelvis will require 
symptomatic treatment. 

The conservative treatment is more hopeful the sooner it is 
combined with tuberculin; it may bring about complete healing 
in disease of the adnexz as in tubercular peritonitis, a fact 
specially noted by Birnbaum, Prochownik, and Busse. Also 
Veit forcibly recommends the new tuberculin, with which he has 
seen better results in genital tuberculosis than with operation. 


to 


A CLINICAL SYSTEM OF TUBERCULOSIS 


(os) 
ios) 


4. TUBERCULOSIS OF THE OVARIES. 


Pfannenstiel and Orthmann distinguish 
tubercular peri-oophoritis and true ovarian 
tuberculosis. The former is part of tuber- 
cular peritonitis ; disseminated tubercular granulations, or a plastic 
exudation containing nodules, forming on the surface of the 
ovary, which itself is not diseased. These authors again divide 
the true ovarian tuberculosis into miliary and caseo-suppurative 
forms, which may be combined. The rarer miliary form can 
hardly be recognized at times by the naked eye. Particularly in 
cases of tubercular peri-odphoritis one finds in the ovary numerous 
very small tubercles. Bacilli are often very difficult to detect. The 
caseous variety with abscess formation is more common, and 1s 
usually situated in the stoma of the ovary, more rarely in a corpus 
luteum; it may be single or multiple. The caseous nodules may 
join together, suppurate, and form a cavity of the size of a goose’s 


ome o 
egg. 


¢ 


Anatomical 
Changes. 


Tuberculosis of the ovary is a fairly fre- 
quent disease. In about half the cases it is 
bilateral. In 267 cases of genital tubercu- 
losis collected by Kroemer the ovary was affected forty-two times ; 
Orthmann estimates that it is diseased in as much as 42 per cent. 
of the cases. Sometimes the infection occurs through the blood ; 
cases are described in which the ovary was alone diseased, and 
the rest of the genital organs healthy. As a rule the infection 
spreads from the tube by means of peritoneal tuberculosis. 
Fibrous encapsulation or complete atrophy of the ovary some- 
times prevents infection. The further fate of secondary ovarian 
tuberculosis depends on the course taken by the tuberculosis of 
the tube. 


Symptoms and 
Course. 


The rare cases of isolated ovarian tubercu- 
losis can hardly be diagnosed as such. The 
recognition of ovarian disease secondary to that in the tubes may 
be made by palpation, but it is without importance, as it hardly 
influences the prognosis or treatment. 
Prognosis and These both depend entirely upon that of the 
Treatment. tuberculosis of the tube. 


Diagnosis. 


5. TUBERCULOSIS OF THE BREAST. 


Apart from the rare form of miliary tuber- 


Anatomical “ene : 
Ch culosis of the breast occurring as part of 
ape general miliary tuberculosis, three different 


forms have been described: the disseminated, the confluent, and | 


TUBERCULOSIS OF THE UROGENITAL ORGANS 339 

the cold abscess. In the disseminated form a few small nodules 
of the size of a hazel-nut are scattered through the tissue of the 
breast, being completely isolated and surrounded by healthy gland 
substance. The confluent form, which is most often situated in 
the upper and outer quadrant of the breast, develops in the form 
of one or more infiltrating nodules, which grow very slowly, and 
may involve the whole mamma. The disease begins by a deposit 
of small, usually confluent, nodules in the interacinous tissue, the 
glandular tissue being only secondarily affected. The nodule 
softens and breaks through at one or more places, and discharges 
characteristic, soft, granular or crumbling masses. If several 
nodules co-exist, in the process of necrosis communications and 
fistula will be formed between the cavities. Quite early the 
axillary glands become swollen, and usually suppurate. The 
cold abscess is produced by a still slower process. It develops 
in the intermammary tissue, and is separated by a fibrous capsule 
from the health gland substance. 
In the rare disseminated form isolated, 
small nodules can be felt, without the gland 
being much enlarged. The overlying skin 
is nearly always unaffected. The disease lasts for years, and may 
result in spontaneous healing, in calcification, or in abscess for- 
mation. The most common confluent form of mammary tubercu- 
losis in the early stages sometimes only causes slight symptoms, 
so that the nodules are usually accidentally discovered when they 
reach a certain size. More often inflammatory irritation shows 
itself by pains or swelling of axillary glands. The nipple is 
frequently drawn in; the breast itself is nearly always freely 
movable. Softening is recognized by fluctuation; unless opened, 
pus will gradually discharge spontaneously. A cold abscess 
develops extremely slowly without any local inflammatory signs, 
and usually without alteration of the axillary glands. A fluctu- 
ating, circumscribed tumour can be felt. 

Mammary tuberculosis is relatively rare; generally it is a 
complication of pulmonary tuberculosis; the estimates of its fre- 
quency vary. At first it is exclusively unilateral. It occurs 
chiefly during the years of sexual activity. Infection through the 
blood, apart from miliary tuberculosis, is very rare. Extension of 
tuberculosis from the axillary glands, the ribs, and the pleura has 
been observed in a few cases. According to Cornet the infection 
most frequently occurs from outside, rarely by the entry of bacilli 
into the ducts of the glands, more often the bacilli enter by an 
excoriation, and are conveyed by the lymphatics which accompany 
the galactic ducts. This agrees with the interacinous develop- 


Symptoms and 
Causes. 


334 A CLINICAL SYSTEM OF TUBERCULOSIS 


ment of the early stages. Traumatisms and inflammations favour 
the occurrence of the disease. 

The recognition is easy if tubercle bacilli 
can be found in the secretion or in drawn- 
off pus. Tubercular disease in other organs may point to the 
cause of a prolonged, suspicious, inflammatory process in the 
breast. Retro-mammary abscesses usually develop more slowly 
and cause more pain, fever and swelling; and palpation shows 
that the abscess is not within, but behind, the breast. The closed 
form of mammary tuberculosis may be most easily mistaken for 
an early carcinoma. In favour of the latter will be the hardness, 
the shape and the painlessness of the tumour, the drawing in of 
the nipple, the adhesion to the overlying skin or fascia, and the 
carcinomatous glands in the clavicular region. A syphilitic 
gumma may be recognized by its rapid development and quick 
necrosis; other signs of syphilis are seldom absent; and it reacts 
promptly to anti-syphilitic measures. Adenoma, fibroma, and a 
cyst are more easy to distinguish; they are usually circumscribed, 
movable, painless, and do not suppurate. There may be great 
difficulty in diagnosis if tuberculosis is combined with cancer, 
adenoma or fibroma. 


Diagnosis. 


When the disease is limited to the breast, 
or when the affected lymphatic glands do 
not yet form an extensive mass, the prognosis is good. 
The best results are given by amputation 
Treatment. . of the breast. — Partial excision, scraping, 
&c., do not take the place of a radical operation, and do not 
prevent relapses, since the disease is always more advanced than 
seems to the naked eye. Amputation of the breast is to be the 
more recommended, as the chronic inflammatory condition offers 
a favourable ground of development to cancer. 


Prognosis. 


6. TUBERCULOSIS IN CONNECTION WITH MARRIAGE, 
PREGNANCY, THE PUERPERIUM, AND ABORTION. 


The consideration of genital tuberculosis, and the connection 
between tuberculosis and the genital organs must be completed 
by a review of the relationship between the disease and the sexual 
functions and their consequences. The periods of development 
and of sexual maturity are exactly the ages most favoured by 
tuberculosis. 

The alterations of menstruation during the course of chronic 
pulmonary tuberculosis have already been mentioned. Ovula- 
tion may be arrested as a consequence of the general bodily 
weakness. A permanent sterility may be produced by atrophy 





— 


es 


alll 


TUBERCULOSIS. OF THE UROGENITAL ORGANS 


Oo 


35 


of the ovary and the uterus, also by advanced tuberculosis of the 
genital organs. Conception is rendered more difficult ‘or even 
prevented by most of the non-tubercular affections of the genital 
organs that have been mentioned; but pulmonary tuberculosis of 
itself is no prevention of conception except in its terminal stages. 

There is now a consensus of opinion that pregnancy fre- 
quently makes manifest a latent tuberculosis, and aggravates an 
already existing disease. This is not only true for phthisis, but 
also for surgical tuberculosis and lupus, while urogenital tuber- 
culosis usually remains uninfluenced. Besides the social con- 
ditions, the grade and form of the disease are naturally of im- 
portance; early cases, closed cases, torpid, fibrous forms tending 
to encapsulation and contraction pass through pregnancy much 
better than severe, dangerous, open, diffuse, ulcerating, cavity- 
forming and advanced cases. But even in cases of the first 
category it happens often enough that after a good progress at 
first, with stationary physical signs, an acute exacerbation occurs, 
and that a single pregnancy irresistibly annihilates the best results 
of a prolonged sanatorium treatment. It is of practical import- 
ance that such a relapse may happen without warning during 
the second half of pregnancy, without the occurrence of fever or 
loss of weight or other bad symptom, an evidence of the difficulty 
of giving an accurate prognosis in individual cases. A satisfac- 
tory explanation of the evil effects of pregnancy on tuberculosis 
has not yet been found, they have generally been ascribed to the 
changes in the type of respiration and the blood supply of the 
lungs which take place during the latter months. According 
to Hofbauer’s researches causes of the increased predisposition 
are reduction of the lipolytic faculty of the serum with advancing 
pregnancy, hyperglycemia, and certain physical causes, such as 
hyperemia, increased lymphatic flow and peribronchial infiltra- 
tion. 

Still more injurious in its effects on tuberculosis than preg- 
nancy is the puerperium. 

This leads us first of all to the important question of pro- 
phylaxis. The dangers of the marriage of tubercular persons 
cannot be too forcibly impressed. The danger of infection be- 
tween married people has certainly been much underestimated, 
even by doctors. This is partly because statistics on this point 
have been drawn chiefly from the upper ten thousand; and the 
confined social conditions of the poorer classes have been too 
little considered. These statistics also err in that they are 
founded too much on the statements of the patients themselves, 
and that they do not sufficiently consider whether the tuberculosis 


330 A CLINICAL SYSTEM OF TUBERCULOSIS 


is open, and how long it has been so, and whether the patient 
was living with the husband during the time of the possibility of 
infection. The unreliability of these figures is increased by the 
fact that the health of the presumably unaffected husband is but 
very rarely confirmed by a medical examination, and that nothing 
is known as to his later history. The figures a Weinberg, col- 
lected from reliable mortality statistics, seem to us to be of more 
value; according to these the mortality of those married to a 
tubercular person was twice as great as the average. 

Marriage may have a beneficial influence on a tubercular 
man, since his material conditions may be improved, and especi- 
ally his food and general mode of life may become better and 
more regular. For him, too, sexual relationships may only be 
changed for the better, quite apart from the elimination of 
venereal infection. 

Things are very different for the woman patient. For her, 
too, indeed, the social conditions may be improved, if she has 
hitherto supported herself by her own work. But the conditions 
of cure become more unfavourable if the circle of her duties is 
enlarged. The commencement of sexual life cannot be considered 
to be entirely without influence. Consideration must be paid also 
to the possibility of the spread of the disease to a healthy part, 
to the dangers of pregnancy and childbed for the tubercular 
woman, to the possibility of transmitting the predisposition, and 
especially to the danger of infection of the child after birth, who 
generally has but small powers of resistance; the duty of the 
doctor, therefore, is to be most cautious in giving permission for 
marriage. The demand for a legal restraint of marriage seems to 
be still impracticable. More important and more practical is to 
aim at a general enlightenment on these questions, and to give 
warning and advice in individual cases. 

With regard to the infection of the female genital organs it 
may once more be mentioned that in the semen of phthisical 
patients, who are free from disease of the genital organs, tubercle 
bacilli have been found, that phthisical patients who have also 
tuberculosis of the genital organs long remain capable of connec- 
tion, that guinea-pigs with tuberculosis of the genital organs 
produce the same disease on the female, and that lastly there is 
danger for the woman of an ascending genital tuberculosis by 
contact infection from an infected husband. These facts justify 
prohibitive measures. 

With existing tuberculosis of the wife pregnancy is to be 
prevented till the disease is completely healed. Only when the 
lungs have given no clinical symptoms for two or three vears may 





TUBERCULOSIS OF THE UROGENITAL ORGANS 337 


ios) 


pregnancy be permitted by the doctor, and the lungs must then 
be carefully watched. There are various means of preventing 
pregnancy which may be employed. Lastly facultative steriliza- 
tion by dividing the tubes, or complete sterilization, may have to 
be considered. Lately Krénig and others have succeeded with 
sufficient doses of RO6ntgen-rays in obtaining sterilization with 
preservation of menstruation. Time will show whether ovulation 
can return, so that after a certain time conception may again be 
possible. i 

If pregnancy occurs with manifest, active tuberculosis artif- 
cial abortion is indicated. The bad effects on the disease will not 
be thereby always prevented, but the trial must be made. In 
early or inactive cases of tuberculosis the doctor may wait; if the 
objective signs or the general symptoms become worse, abortion 
must be then induced. The result of the tuberculin reaction 
cannot be used as an indication for this (Veit, F. Kraus, 
Kaminer); still less can one be guided by the conjunctival re- 
action, as recommended by E. Martin, who takes a positive 
reaction as showing strong powers of resistance, while he con- 
siders a negative result to indicate the induction of abortion. The 
capacity of resistance falls, or is extinguished, at the end of 
pregnancy, to be increased again during the puerperium. Stern 
is inclined to explain the negative results of cutaneous and con- 
junctival tests by a loss of antibodies accompanying pregnancy, 
on account of the saturation of the immune corpuscles with the 
serum rich in lipoids (Heynemann). In any case the explanation 
of the state of the tuberculin reaction during pregnancy is still 
very complicated, and the value of the reaction for diagnosis and 
prognosis is more doubtful than in the non-pregnant, so that a 
negative result is not always to be considered as an unfavourable 
sign. The experience that the induction of abortion does not 
prevent the aggravation of phthisis in all cases, and that in 
favourably situated, early cases pregnancy may be passed through 
satisfactorily, is against the radical view of Maragliano and 
Hamburger that abortion should be induced in all tubercular 
patients. With regard to the spontaneous interruption of preg- 
nancy in tuberculosis there are differences of opinion; abortion 
seems to occur rarely; premature birth is commoner, and the 
more so the more advanced is the tuberculosis. 

Artificial induction of premature labour has no advantage 
whatever over normal confinement; many gynecologists even 
think that it is more dangerous; we can support this view as the 
result of several experiences. Pankow and Kiipferle have lately 
deduced from the large, uniform, and continuous statistics of the 


a. 


338 A CLINICAL SYSTEM OF TUBERCULOSIS 


Freiburg Women’s Clinic that the results are relatively good if 
the induction is performed early; but the high mortality of 40 
per cent. of even the cases in Stage I indicates the gravity of the 
prognosis, when the disease becomes active in the second half of 
pregnancy. Pankow and Kiipferle draw the same conclusion as 
Kronig that one should not wait too long, and allow the most 
favourable time for interrupting pregnancy to pass. After the 
fifth month induction of labour must as a rule be avoided, except 
that it may be considered in the ‘interests of the child in extreme 
cases, or in patients who are rapidly going downhill on account 
of advancing disease or complications. In such cases with 
advanced pregnancy Henkel considers that the best and surest 
way of relieving the patient is total abdominal extirpation of the 
gravid uterus under lumbar anesthesia. The operation involves 
the least risk for the patient and the smallest possible loss of 
blood, a factor of extreme importance; the elimination of the 
puerperium also has a very important curative effect. 

Since the interruption of pregnancy often enough does not 
stop the aggravation of tuberculosis it has recently been authori- 
tatively recommended that the patient should be sterilized at the 
same time. It is not yet agreed whether a facultative sterilization, 
an extirpation of the uterus with or without the adnexez, or 
excision of the fundus (v. Bardeleben) is necessary. © The sup- 
porters of total extirpation take the ground that the internal 
secretion of the ovary has a bad effect on tuberculosis, and that 
castrated individuals often gain in weight marvellously. We 
cannot, however, refrain from observing that this gain in weight 
is chiefly due to a deposit of fat, and that this has not the impor- 
tance for the cure of tuberculosis that was formerly supposed, and 
that adiposity by itself even makes the prognosis of tuberculosis 
worse (p. 166). The question does not seem to us to be yet ripe 
for judgment, and a knowledge of the after results is much needed. 

The dangers of labour consist of circulatory congestion and 
of dyspnoea, which may lead to oedema of the lungs. Difficult 
labour and much bleeding may lead to the disease rapidly becom- 
ing worse, as often happens during the puerperium, even when 
pregnancy has been well borne. Miliary tuberculosis is not 
rarely met with during pregnancy and the puerperium. 

With regard to the desirability of suckling by the tubercular 
mother there is still a difference of opinion. The danger of trans- 
ference of tubercle bacilli to the infant from the mother’s milk is 
a very real one; according to observations on animals and humans 
the mammary glands have no special defensive power, and Cornet 
was able in several rare cases to find tubercle bacilli in the milk of 





TUBERCULOSIS OF THE UROGENITAL ORGANS 339 


tubercular women, who were not suffering from miliary tubercu- 
losis. Recent observations have shown that bacilli occur in the 
blood of phthisical patients much more frequently than was pre- 
viously thought; however, the number of bacilli is very small in 
early cases, for whom alone the question of allowing suckling 
need be considered. The danger of infection from the mother’s 
milk is very small compared with the much greater one of infection 
during the naturally intimate relationship between mother and 
child, provided that the tuberculosis is of the open form. Zeppert 
in particular has recently shown that the frequent occurrence of 
tubercular meningitis in the early years of life has no connection 
at all with breast feeding. 

What influence then has suckling on the maternal tubercu- 
losis, and how does it affect the child ? 

There are no exceptions to the rule that a mother suffering 
from advanced tuberculosis must be forbidden to nurse her child; 
and in all cases of maternal tuberculosis a wet nurse and separate 
rooms for the mother and child are to be recommended, where the 
material conditions allow. 

There are divergent views as to the right line to be taken in 
the large number of cases of open tuberculosis in the mother, 
whose general condition is good, and who is compelled to live in 
more or less close contact with the infant. The way in which 
infection takes place is here immaterial. The modern treatises 
on tuberculosis by Czerny and Keller are in agreement with the 
older authors in considering maternal tuberculosis as a contra- 
indication to suckling. Schlossmann takes the opposite view 
that the mother should nurse the child, who is usually poorly 
developed and of feeble resisting power, so as not to increase by 
artificial feeding the inevitable danger of infection. According 
to him the child at the breast can better withstand a tubercular 
infection, which would be certainly fatal to an artificially fed 
infant. Suckling is often directly advantageous to the mother by 
stimulating nutrition changes, and by usually preventing a fresh 
pregnancy. 

Considering the divergency of these views the recently 
published results of the exact observation made by Deutsch on 
nursing and non-nursing tubercular mothers and their offspring 
have the greatest importance. Besides healthy mothers used as a 
comparison he considered active, inactive, and suspicious cases of 
tuberculosis; the active cases had disease of the apex or upper lobe 
with favourable prognosis. Of the results of his examination the 
following are the most important :— 

(1) Suckling had on the tubercular mother only very rarely a 


340 A CLINICAL SYSTEM OF TUBERCULOSIS 


good effect, usually an unfavourable, and sometimes a destructive 
one. 

(2) Almost all the infected children had been suckled by 
tubercular mothers, while the children who were not suckled, even 
if there was an hereditary tendency, all remained healthy. 

The latter conclusion is surprising; and an explanation is 
difficult to give. If we do not suppose that the suckling mother, 
through her intimate contact with her offspring, increases the 
risks of the infection of the child, a view rejected by Deutsch and 
Schlossmann, we are driven to the conclusion that the milk of a 
tubercular mother contains a toxic substance, which in some way 
lowers the resistance of the child. Deutsch inclines towards this 
view, and at all events thinks that the opinion that the mother’s 
milk increases the resistance of the infant has been shaken. 

These conclusions show that the old teaching of universally 
forbidding suckling by tubercular women in the interests both 
of mother and child still holds good. The problem of infant 
mortality as a whole is so closely bound up with feeding by the 
mother, that the views advanced by Schlossmann in the case of 
tubercular women needed the proof of their correctness, which 
has been supplied by these extensive researches of Deutsch. 

If the tubercular disease in the mother is arrested then suck- 
ling may be allowed as long as both mother and child maintain 
their strength and good general condition; but both need con- 
tinued medical observation. A good condition and sufficiency of 
the milk are naturally necessary for the permission of suckling. 
An express warning must be issued against too long lactation, 
which weakens even a healthy person, and will aggravate an 
existing tuberculosis, or bring out a latent one. The warning is 
the more needed, as most women incorrectly believe that suckling 
is a certain preventative of another conception. 

The most dangerous complication of a pregnant, tubercular 
woman is laryngeal tuberculosis, which frequently appears, even 
when the lung disease is only causing quite few symptoms. 
Laryngeal tuberculosis during pregnancy has a marked tendency 
to rapid spread; the disease very rarely remains stationary or 
improves. Swelling of the connective tissue with slight cedema, 
and increased shedding and leucocytic infiltration of the epithelium 
have been observed. The possibility of sudden death from suffo- 
cation must be remembered, particularly during labour. A much 
higher percentage of patients die suddenly after labour than the 
reported cases indicate. Most of the children, which are poorly 
developed, die either at once or in the course of a few weeks. The 
local treatment of the larynx is almost hopeless, as is also curative 





es 


TUBERCULOSIS OF THE UROGENITAL ORGANS 341 


tracheotomy. If stenotic symptoms suddenly develop the opera- 
tion may prevent suffocation; the scanty reports are here also at 
variance. 

Only when the general condition is good and the laryngeal 
condition slight can the pregnancy be allowed to continue. If 
the laryngeal disease is becoming worse the pregnancy must be 
terminated as soon as possible. Wiauith healed laryngeal tubercu- 
losis pregnancy causes a danger of relapse. 


CHAPTER VII. 


Tuberculosis of the Vascular and 
Lymphatic Systems. 


1. TUBERCULOSIS AND THE BLOOD. 


SINCE the blood plays the chief part in 
Blood ee ; heh tna 
resisting any infection, if it becomes altered 
by disease the organism will be more or less 
predisposed to tuberculosis. In fact the tubercular infection 
particularly attacks persons thus weakened, as may be seen in 
chlorotic and anemic female patients. 

On the other hand, during the course of tuberculosis the 
blood becomes affected by the specific toxins and products of 
tissue destruction, and undergoes alterations which can be recog- 
nized. 

According to Grawitz the blood is affected in the following 
way in the different stages of tuberculosis :— 

Stage I.—Erythrocytes diminished, leucocytes unaltered, 
haemoglobin slightly reduced. 

Stage [1.—Without fever; erythrocytes unaltered, leucocytes 
moderately increased, haemoglobin unchanged. 

Stage II]].—With fever; erythrocytes much diminished, 
leucocytes much increased, haemoglobin reduced. 

It is to be noticed that in Stage I with women there is not 
rarely a reduction of haemoglobin, the number of red corpuscles 
remaining normal, and therefore the blood is the same as that of 
chlorosis. In Stage II there is sometimes a diminution of the 
total amount of blood—oligzemia—with a pale, dry, rough skin, 
and desiccation of the tissues. In the third hectic stage the 
leucocytosis increases with the duration of the fever and the 
advance of mixed infection, reaches its maximum in the so-called 
caseous pneumonia, and diminishes in the miliary form. 

tfowever, Arneth considers the simple blood count to be in- 
sufficient and deceptive. According to him the characteristic 


Changes. 





VASCUEAR AND. LYMPHATIC SYSTEMS 3453 


alterations in the blood of tubercular persons consist of a change 
in the neutrophile cells, the number of red corpuscles remaining 
normal and the number of white cells approximately so. Com- 
pared with normal blood, in which the leucocytes are 25 per cent. 
mononuclear and 75 per cent. multinuclear, the mononuclear cells 
are increased and the polynuclear neutrophile leucocytes 
diminished. This depends on the fact that the polynuclear cells 
are the chief carriers of antibodies and so perish in the fight 
against the infection, setting free their antibodies, which loss 
produces first a new formation of mononuclear cells, the latter 
being the youngest form. The majority of the workers on this 
subject on the whole agree with Arneth, but do not consider that 
this alteration of the neutrophile cells is a constant occurrence in 
tuberculosis. 

The discovery of tubercle bacilli in the blood was first made 
by Weichselbaum in the blood of three corpses dying from acute 
miliary tuberculosis. Meissel, Lustig, and Ritimeyer confirmed 
this for acute miliary tuberculosis during life. In chronic tuber- 
culosis the discovery of bacilli in the blood was first made by 
Jousset, Liidke, and especially G. Liebermeister as the result of 
numerous and careful observations, which showed that bacilli 
were very frequently to be found in the circulating blood of 
phthisical patients. Their detection is the easier, the more 
advanced and the nearer to the termination is the disease. Lieber- 
meister obtained positive results during the last twenty days of 
life in 75 per cent. of the cases, and in only 35 per cent. examined 
eighty days before death; lately the results in open tuberculosis 
have been even more definite. Schnitter found 32 per cent., 
Lippmann 44 per cent., Rosenberger in forty-nine cases, including 
five of miliary tuberculosis 100 per cent., and Kurashige in 155 
cases of tubercular lung disease of all stages (thirty-five in the 
first, sixty-five in the second, and fifty-five in the third stage), also 
100 per cent. of positive results. It was also discovered that it 
is not rare to find bacilli in the blood of even clinically slight 
easess Jessen, be. Rabinowitsch, and lately Sturm have found, in 
40 to 50 per cent. of cases still in the early stage, bacilli in the 
blood as a result of bacteriological and animal observations. The 
results are of importance for the explanation of many tubercular 
localizations, such as in the eye, the bones, and the joints, which 
previously were not clear; also for understanding the connection 
between tuberculosis and traumatism; and above all, for the 
proper recognition of pulmonary tuberculosis as a general disease. 

The serological properties of tubercular blood, phagocytosis, 
complement fixation of antibodies, agglutinins, precipitins, 


‘ 


344 A CLINICAL SYSTEM OF TUBERCULOSIS 


opsonins, anaphylactic reaction substances, &c., need not be con- 
sidered here, since at present they are either doubtful, or of no 
practical importance. 

In cases of diagnostic doubt, in which an 
abnormal condition of the blood is sus- 
pected, more information can generally be obtained from a stained 
blood preparation than from the more tedious blood counts. 


Diagnosis. 


We recommend the following method of obtaining a stained preparation 
of the blood: From the pricked finger the blood is allowed to flow spon- 
taneously, 7.e., without pressure. A small drop is received on a cover-slip, 
which has been passed three times through the flame, and covered with a 
second slip from half to one minute, the two slips being then rapidly drawn 
apart. The preparation having been dried in the air, it is stained for two 
minutes by the Jenner-May method, 7.e., with a 25 per cent. methyl-alcohol 
solution of eosin methylene blue, which- fixes the film at the same time. 
The slip is then placed in distilled water for one minute; then dried with 
blotting-paper and mounted in Canada balsam. (Jenner-May’s solution can 
be obtained ready-made, or it can be prepared as required from tablets; one 
tablet is to be firmly crushed in 1oo gr. chemically pure, acetone-free methyl- 
alcohol in a dry flask and dissolved by shaking; the solution is then filtered 
through a dry filter and placed in a carefully stoppered vessel.) 

With this method the following structures can be clearly distin- 
guished :— 

(1) The erythrocytes are red, and the nuclei of the nucleated red cells 
stained blue. 

(11) The leucocytes may be divided into :— 

(2) The mononuclear forms, with large, round, pale-blue nuclei and 
scanty protoplasm. 

(6) The polynuclear forms with the nuclei always blue, but the proto- 
plasm containing :—- 

(1) In the neutrophile cells rose-red or light-red granules (96.5 per 
cent.),. 

(2) In the eosinophile cells deep red granules (3 per cent.). 
(3) In the basophile cells intense blue granules (0.5 per cent.). 


2 
2 
J 


The discovery of tubercle bacilli in the circulating blood has 
great practical importance. It settles all doubt in uncertain cases, 
in which fever, night-sweats, and nerve changes raise a suspicion 
of tuberculosis, but contra-indicate test tuberculin injections. 

We recommend Kurashige’s modification of the Schnitter- 
Staubli’s method, which has the advantage of only requiring 
1 c.c. of blood. 


Blood to the extent of 1 c.c. is withdrawn from the median vein and 
added to 5 c.c. of 3 per cent. glacial acetic acid solution; after slight 
shaking the mixture is allowed to stand half to one hour. After centri- 
fugalization (at 3,000 revolutions for thirty minutes) 5 c.c. of undiluted 
antiformin are added to the sediment, which becomes clear either at once or 
after several minutes of vigorous shaking. The solution is again centri- 
fugalized till a little snow-white sediment comes down. This is so slight 
that the bottom of the glass appears only a little dulled. It is washed with 





VASCULAR AND LYMPHATIC SYSTEMS 345 


distilled water, and a preparation made and stained by Ziehl-Neelson’s 
method. If the sediment does not adhere well to the cover-slip it may be 
fixed with egg albumen water. The staining must be as short as possible, 
and the washing very carefully done. 


The changes in the blood described by 
Arneth do not indicate a bad prognosis. If 
the primary tubercular disease is_ still 
capable of treatment the administration of iron, or iron and 
arsenic (arsenferratose), or the natural waters of Durkheim, 
Pyrmont, Levico, Roncegno, may improve the condition of the 
blood. 

The presence of bacilli in the blood-stream does not generally 
indicate miliary tuberculosis; and has not such a sinister signifi- 
cance as has been generally supposed. All the same it is not a 
good sign, and demands a cautious and reserved prognosis. 
There is no way of eliminating the bacilli from the blood. 


Prognosis and 
Treatment. 


2. TUBERCULOSIS AND THE CIRCULATION. 


The vessels present in chronic cases of 


ie tuberculosis a thickening of the wall, 
Bhool) probably as a result of the action of the 
Symptoms. : 


toxins. Also arteriosclerosis and calcifica- 
tion of the inner elastic lamina have been observed in young 
phthisical patients; Pottenger found premature rigidity of the 
arteries frequently. The results of the changes in the vessel wall 
are alterations in the blood flow, congestion and thrombosis, the 
last especially in the veins, where it is not rare in cases of tubercu- 
losis. According to the researches of Liebermeister we may con- 
sider that there is a direct connection between the bacillamia and 
the thrombosis. It may now be considered as certain that it is 
not hyperzemia but sluggishness of the circulation which gives the 
chief impetus towards the occurrence and spread of tubercular 
disease; with acceleration of the circulation the area supplied 
remains strikingly free from tuberculosis, while slowing of the 
blood-stream has the opposite effect; it favours capillary throm- 
bosis, which is a predisposing cause of tuberculosis. 

Bacilli in the circulating blood may become adherent to the 
vessel wall, penetrate the intima, and set up tubercles in the wall 
of the vessel, which appear as white prominences of the size of a 
pin’s head to a hemp seed. Or the vessel may become involved 
from outside by contiguous disease, the bacilli growing by con- 
tinuity through the vessel wall inwards to the intima. Both 
varieties of vascular tubercles may occur in veins and arteries; it 
is not easy to say which is the commonest. 


340 A CLINICAL SYSTEM OF TUBERCULOSIS 


Vascular tuberculosis may either appear as drop-like out- 
growths (endangitis tuberculosa), or as infiltration followed by 
ulceration (tubercular ulcers of the vessels). 

The aorta is most likely to be affected from tubercular 
mediastinal and bronchial glands. If it is already arterio- 
sclerotic, large numbers of bacilli will be found in the upper 
layers of the atheromatous ulcers. Such an endaortitis tubercu- 
losa arises from the deposition of bacilli on roughened spots of the 
intima, where they multiply freely, and by becoming mixed with 
the blood-stream may set up miliary tuberculosis. 

There is a large literature on the connection between tuber- 
culosis and the heart. We may here limit ourselves to the most 
important facts. Firstly, there is the old view, supported by 
Brehmer and Beneke, and lately confirmed by Orth, that a pro- 
portion of tubercular patients, especially those of an asthmatical 
nature, have a heart below the normal size. Orthodiagtaphic 
examination of the patients at the Heidehaus Sanatorium showed 
that of normally nourished cases 62.5 per cent., and of badly 
nourished 88 per cent., had too small a heart, and this was true 
not only with advanced phthisis, but also with early slight disease. 
The heart also undergoes during tuberculosis a cachectic diminu- 
tion in size, analogous to the general wasting. The view that 
the smallness of the heart is one of the predisposing factors 
towards tuberculosis, is probably more correct than the theory 
that the reduced size of the heart is merely a consequence of 
an already existing tubercular infection. Alterations in the right 
side of the heart are usually due to complications of pulmonary 
tuberculosis, such as pleural adhesions, chronic bronchitis and 
emphysema; but in some cases hypertrophy of the right side may 
occur as a consequence of diminution of the circulatory area, 
brought about by indurative and ulcerative disease. 

Displacements of the heart due to pressure or traction may 
affect its functions. If this is shown merely by heart failure and 
pains in the cardiac region, it may not be possible to say if they 
are due to the mechanical displacement or to toxic action. The 
most important and frequent functional symptom, acceleration 
of the heart’s action or tachycardia, usually occurs as a con- 
sequence of toxzemia, it may be independent of fever and runs a 
parallel course with the severity of the disease. The abnormality 
of the regulating apparatus is also shown by variability of the 
pulse. Other signs of functional alteration of the heart which 
may be mentioned are want of clearness of the first mitral sound, 
a systolic apical murmur and fall in the blood-pressure, especially 
in advanced disease. 





— 


VASCULAR AND, LYMPHATIC SYSTEMS 347 


The teaching of Rokitansky that heart failure protects from 

pulmonary tuberculosis is not correct in this absolute form. It 
can only be said that mitral stenosis is accompanied by a 
diminished predisposition to tuberculosis, as is also mitral in- 
sufficiency, when in consequence of congestion it produces brown 
induration of the lung. The progress of an already existing 
tuberculosis will not be checked by heart failure; while tuber- 
culosis, especially if rapid, unfavourably affects the compensation 
of valvular disease. The statement that hypertrophy of the left 
ventricle is a preventative of tuberculosis is also too general; if 
tuberculosis is rare in cases of aortic disease and arteriosclerosis, 
it is due to the fact that these conditions chiefly occur in later 
life, in which tuberculosis more seldom appears. 
The juvenile form of arterial rigidity may 
best be seen in the temporal arteries ; though 
its clinical importance is not yet fully deter- 
mined. We consider the symptom to be quite unreliable. Thera- 
peutically the connection between tuberculosis and the circulatory 
organs must be remembered in relation to hydrotherapy, the 
specific treatment and Bier’s congestion hyperemia. 

The diagnosis of tubercle of the vessels is rarely possible, 
since the detection of tubercle bacilli in the circulating blood in 
no way indicates that the vessel wall is affected. Treatment is 
hopeless, since ulcerating tubercle of the vessel wall usually 
causes acute miliary tuberculosis. Tuberculosis of the aorta also 
either cannot be diagnosed during life, or is incapable of being 
influenced by treatment. 

The small size of the phthisical heart can be recognized by 
orthodiagraphic use of the Rontgen rays; if the measurements in 
two dimensions are considerably less than the average in 
people of the same size and weight, then it can be considered that 
the heart is too small. All the same, the size of the heart is a 
variable factor, depending on the sex, the age, the shape of the 
chest, and the state of the muscles; so that the diagnosis of 
reduction in the size of the heart is uncertain. The small heart, 
which is a congeniial abnormality or occurs during development 
as a constitutional abnormality, cannot be influenced by treat- 
ment. At the most systematic exercises in young persons may 
increase the working capacity of the small heart. 

Hypertrophy of the right ventricle can be recognized by a 
constant accentuation of the second pulmonary sound. If per- 
cussion shows a broadening of the absolute cardiac dulness to 
the right it must be considered whether it may not simply be due 
to an uncovering of a heart of normal size, such as frequently 


Diagnosis and 
Treatment. 


348 A CLINICAL SYSTEM OF TUBERCULOSIS 


occurs in consequence of retraction of the lung from cicatricial 
disease of the right apex. The treatment must be directed against 
existing complications in the lungs, so as to relieve as far 
as possible the obstruction to the pulmonary circulation. 

Functional alterations of a mechanical or toxic nature are 
accompanied by abnormal loudness of the heart sounds, by 
acceleration of the heart’s action, by variability of the pulse, and 
by want of clearness of the heart sounds at the apex or base. A 
constantly rapid pulse is of some importance for the early 
diagnosis of tuberculosis; also it is a very valuable prognostic 
sign. A fall in the blood-pressure also indicates activity of the 
disease, and is usually associated with clinically progressive 
tuberculosis. The prevention of functional heart symptoms is 
assisted by the proper treatment of tuberculosis and its toxic 
manifestations, especially by the addition of specific treatment to 
the general hygienic measures. 


3. TUBERCULAR PERICARDITIS. 


The changes consist of a deposit of whitish- 


Anatomical ; :; 
Come grey granules, chiefly on the inner surface, 
Changes and ey Joo A ae a 
which lead to chronic inflammatory ad- 
Symptoms. PEE : : ‘ 
hesions between the pericardium and the 


epicardium, or to an effusion. The fluid may be serous, purulent 
or hemorrhagic. 

Tubercular pericarditis may come on acutely or gradually; 
in the first case the symptoms being pains, breathlessness, 
cyanosis, and irregularity of the pulse. Later more severe 
dyspnoea, angina, vomiting and hiccough either lead to a rapid 
termination, or the case may subside into the chronic stage. The 
chronic cases are complicated with adhesion of the pleural sur- 
faces. | 

It is rarely a primary disease, being usually secondary to 
tuberculosis of a neighbouring organ, such as the glands or 
pleura; tubercular mesenteric glands may also perforate into the 
pericardium. Sometimes it occurs as part of a miliary tuber- 
culosis, also simple cases of pericarditis may become tubercular. 
Elderly persons are most often affected. 

On physical examination a pericardial rub, 
especially at the apex, increasing enlarge- 
ment of the cardiac dulness, weakening of the apex beat, and faint 
cardiac sounds may be detected in the acute form. In chronic 
cases enlargement of the cardiac area with absence of the respira- 
tory displacement of the lungs, systolic retraction of the apex, 
inspiratory swelling of the veins of the neck and a paradoxical 


Diagnosis. 





VASCULAR AND LYMPHATIC SYSTEMS 349 


pulse indicate adhesions of the pericardial surfaces. The pulsus 
paradoxus is produced mechanically; the pulse wave falls during 
inspiration, rises during expiration, and is highest in the respira- 
tory pause. 

The diagnosis of adhesive tubercular pericarditis thus de- 
pends on the following points: great congestion, oedema of the 
upper and lower parts of the body, and after the night’s rest fre- 
quently also of the face, marked dyspnoea, enlargement of the 
liver and ascites, systolic retraction of the apex and the intercostal 
spaces, paradoxical pulse, inspiratory swelling of the veins of the 
neck, diastolic collapse of the veins not being characteristic, and 
abnormal respiratory movement, since the normal displacement 
of the anterior chest wall forwards and upwards is much hin- 
dered. In doubtful cases a cardiogram may assist in the recog- 
nition of the condition. 

An exploratory puncture may give information in exudative 
pericarditis. A hamorrhagic effusion indicates that the peri- 
carditis is probably tubercular, especially if phthisis is also 
present and cancer can be excluded. Tubercle bacilli can only 
be rarely discovered; if the lymphocytes reach 50 per cent. or 
more of the cells in the fluid it is indicative of tuberculosis. 


To examine the lymphocytes a thin smear of the fluid should be made 
on a cover-slip, fixed by drying in the air, and stained with Ldoffler’s methy- 
lene blue. 


The treatment of acute tubercular peri- 
carditis consists of absolute rest in bed, the 
application of an ice-bag, and limitation of the intake of fluids. 
In the chronic form of pericarditis, to prevent the formation of ad- 
hesions, W. Alexander proposed to introduce nitrogen gas into 
the pericardial sac until the inflammation subsides. 

Effusions may be drawn off, if necessary, repeatedly. The 
trocar may be introduced ob liquely inwards in the fifth or sixth 
intercostal space at the left border of the pericardium just outside 
the mammary line; with the patient on his back in a raised posi- 
tion the effusion is to be very carefully drawn off. If repeated 
removal of the fluid causes no improvement, Wenckebach recom- 
mends that sterile air should be introduced, to about half the 
volume of the fluid that is withdrawn. The formation of fluid 
then gradually entirely ceases, and what is of great importance 
the formation of adhesions is prevented. 

For severe pains narcotics must be exhibited with heart 
tonics; a subcutaneous injection of $ c.c. of 1 per cent. morphia 
with }c.c. of digalen may be recommended. For congestion and 


Treatment. 


350 A CLINICAL SYSTEM OF -TUBERCULOSIS 


cedema digitalis, caffein and diuretin are indicated, for cardiac 
weakness stimulants. . 


4. TUBERCULAR MYOCARDITIS. 


The myocardium in cases of chronic tuber- 


Peasy Sei culosis frequently undergoes changes. In 
anges and = Gne-third of the cases of chronic phthisis 
Symptoms. 


v. Leyden found changes in the myocar- 
dium, resembling those met with in other infectious diseases. 
French authors, especially Raviart, Teissier, and others, consider 
the slight interstitial and parenchymatous lesions of the heart 
muscle to represent a specific toxic myocarditis, and explain with 
Poncet the absence of all specific histological appearances by say- 
ing that the condition is not due to the direct action of bacilli but 
to a remote effect of the tubercular toxin. Liebermeister was able 
in seven cases of such myocardial changes to demonstrate in six 
tubercle bacilli by animal inoculations. This seems to indicate 
that the heart muscle not being a particularly favourable spot for 
the deposition of tubercles, an extremely weak infection, such as 
occurs as a result of the bacillamia of phthisis, may cause chronic 
inflammatory changes, without any specific tubercular formations. 

But the myocardium may also be primarily affected by the 
formation of solitary tubercles in the wall of the ventricle. Also 
caseous degeneration of the cardiac muscle has been observed as 
an isolated form of tuberculosis; or the heart muscle may be 
thickly studded with tubercular granules and larger circumscribed 
caseous nodules without implication of the pericardium. More 
common is the extension into the heart muscle of tubercular 
disease of the pericardium; numerous nodules, thickest in the 
auricles, especially the right, may be found. 

The symptoms of tubercular myocarditis consist of cyanosis, 
dyspnoea, and other signs of heart failure. It generally runs a 
chronic course, and affects especially young people. 

The diagnosis usually causes great diffi- 
culty. Primary cases can only be suspected. 
Sometimes a weak, irregular, apical murmur and an accentuated 
second pulmonary sound may be heard. Wiaith extensive disease 
the heart is much enlarged. Cornet considers quickly changing 
murmurs and the rapid occurrence of severe collapse and cedema 
of the lungs to be pathognomonic. 

The treatment does not differ from that of 
non-tubercular myocarditis, and consists of 
rest, ice-bags, digitalis preparations and stimulants. 


Diagnosis. 


Treatment. 





VASCULAR AND LYMPHATIC SYSTEMS Sol 


5. TUBERCULAR ENDOCARDITIS. 


The views as to the occurrence of endo- 
carditis of a specific nature without histo- 
logical tubercular tissue are the same as for 
myocarditis. Hanot, Potain, and others 
uphold the view that the toxin circulating in the blood may pro- 
duce changes in the valves; and the tubercular origin of many 
cases of valvular disease, especially mitral stenosis, is beyond 
doubt. Dor was able, in a papillary excrescence on the mitral 
valve of a phthisical patient, to demonstrate tubercle bacilli by 
animal inoculation, although histologically no tubercles could be 
detected. The objection could be raised that such tubercle bacilli 
were only accidentally deposited on-the valve from the circulating 
blood. But the experiments of Bernard and Salomon do not 
support this objection; by direct injection of tubercle bacilli into 
the artery of a dog they produced small white beads on the 
endocardium of the left ventricle, which did not show micro- 
scopically a distinct tubercular character, but were like those 
found in spontaneous endocarditis. 

Tubercular endocarditis shows itself in various forms; as a 
verrucose valvular tuberculosis, in which Heller and others have 
found tubercle bacilli, as tubercular nodules on the mitral valve, 
and as a polypoid growth on the papillary muscle or endocardium, 
projecting into the vessel and analogous to one form of tuber- 
culosis of the vessels. 

Tubercular endocarditis occurs most often in young children 
in association with miliary tuberculosis. Clinical signs may be 
entirely absent; but when the disease affects a valve, the usual 
cardiac symptoms may be produced. 

A definite decision, whether a case of endo- 
carditis is tubercular or not, is hardly 
possible; but the existence of the specific form must be remem- 
bered. Endocarditis and tuberculosis by no means exclude each 
other, as was formerly thought. It has been clearly proved by 
animal experiment that tubercular endocarditis may be set up as 
a result of injection of tubercle bacilli, if the valves are previously 
slightly injured. The existence of a tubercular endocarditis may 
be supposed if endocardial murmurs, which are neither due to 
articular rheumatism nor to anemia, can be detected at the same 
time as tubercle bacilli in the blood. 

There is but slight tendency to healing. 
Treatment must be directed towards main- 
taining the strength of the heart and favouring compensation. 
There is as yet no experience of specific treatment; a careful trial 


Anatomical 
Changes and 
Symptoms. 


Diagnosis. 


Treatment. 


352 A CLINICAL SYSTEM OF TUBERCULOSIS 


would be justified in consideration of the powerlessness of other 
methods. 


6. TUBERCULOSIS AND THE LYMPH-STREAM. 


The lumph is even more closely associated 


ean with tuberculosis than the blood. We need 
SEES. (ah only mention here the habitus lymphaticus, 
Symptoms. oe 


lymphatism, and the exudative diathesis as 
transitional forms between the scrofula of children and tubercu- 
losis, also the importance of the lymphatic spread of tuberculosis, 
and the entry of tubercle bacilli into the lymph-stream of the 
thoracic duct. The last has been observed without the wall of the 
duct being affected. 

Tuberculosis of the thoracic duct appears in the form of more 
or less widely-spread small nodules, which on softening discharge 
an enormous number of bacilli into the circulation, and thus may 
form the starting point of miliary tuberculosis. 

The lymphatic vessels of the extremities, when affected by 
tubercular inflammation from their periphery, become changed 
into thickened, firm tubes, sometimes containing pus. 

The discovery of tubercle bacilli in the 
lymph-stream can hardly be made during 
life. If the tubercular lymphatic vessels are superficial they may 
be felt as nodular or beaded strings adherent to the skin. Their 
meaning cannot be doubtful if they occur near a tubercular focus; 
but if this cannot be found they must be distinguished from 
syphilitic or carcinomatous lymphatics. 

The treatment of tubercular lymphatics con- 
sists in their timely operative removal, 
along with the focus from which they originate. |The whole 
organism must then be treated on general hygienic and specific 
lines. 


Diagnosis. 


Treatment. 


7. TUBERCULOSIS OF THE LYMPHATIC GLANDS. 


The lymphatic glands, connected with the 
lymphatic vessels, thanks to their adenoid 
tissue and richness in lymphoid cells, 
seize upon and render innocuous entering tubercle bacilli 
at the cost of becoming themselves diseased. The primary 
form of the disease is due to the fact that the glands act 
in a great measure as a filter for the tubercle bacilli, and 
that those near the point of entrance do not allow the 
tubercle bacilli to reach the blood-stream or to infect other 
groups of glands, without themselves becoming diseased. There- 


Anatomical 
Changes. 





VASCULAR AND LYMPHATIC SYSTEMS 353 


fore in cases of primary disease of the glands the place of 
infection must be looked for in the region or organ, the lymph 
from which passes to those glands. There is another possibility 
of primary affection of the lymphatic glands through the blood- 
stream as described by v. Baumgarten. Even if there are only 
very few bacilli in the blood they have a special tendency to 
attack the glands. Since this occurs particularly in congenital 
tuberculosis, v. Baumgarten considers that many cases of tuber- 
cular gland disease have a congenital origin. 

The causes of the secondary forms of glandular disease are 
clearer. If once the glands become infected the disease may 
spread in stages from gland to gland. The infection spreads 
from a primary focus in the lungs, bones, skin, &c., by means of 
the lymph- or blood-stream, or by contact, to the regional lym- 
phatic glands. The recognition of this secondary glandular 
infection may lead to the detection of the primary disease. 

Pathologically, the tubercular disease in the glands may be 

either recent or old and calcareous. The bacilli entangled in the 
meshes of the reticulum usually set up in three to six weeks a 
swelling and distinct infiltration of the gland. Then central 
caseation occurs, and this may either soften and break down, or 
calcify. Even very slightly enlarged glands may contain in their 
parenchyma the smallest caseous foci, which may completely 
calcify or be enclosed in a fibrous capsule, so that they are no 
longer dangerous to the organism. If calcification or encapsula- 
tion does not occur, or if the tubercular focus breaks into the sur- 
rounding tissue, a hollow cavity, a vessel, or exteriorly, the tuber- 
cular virus will be spread. Even calcified lymphatic glands may 
contain bacilli in a virulent state. 
The clinical symptoms of tuberculosis of 
the lymphatic glands vary with the position 
of the glands. While infection of the 
external glands causes inflammatory swelling which can be seen 
and felt, and later redness and pain, tuberculosis of the internal 
glands often causes no, or only indefinite, symptoms. Tubercular 
changes at the point of entrance of the bacilli may accompany the 
enlargement of the glands. On the other hand, the organisms 
may pass through skin or mucous membrane, which is intact to 
the naked eye, without leaving behind any traces. 

If tubercular glands break externally a sinus is left, and tuber- 
cular ulcers may form along its track or at its external opening. 
At first bacilli can be rarely found in the discharge; with the 
growth of granulations the form of tubercle bacillus not staining 
by Ziehl’s method appears. 


23 


Symptoms and 
Course. 


354 A CLINICAL SYSTEM OF TUBERCULOSIS 


Primary and secondary tuberculosis of the lymphatic glands 

can be distinguished. Both have a great theoretical and practical 
importance, since the development of tuberculosis of an organ 
from a primary glandular tuberculosis is even more certain than 
the occurrence of a secondary glandular infection from primary 
disease in an organ. It is worthy of remark that primary glandu- 
lar tuberculosis has its greatest importance in childhood. With 
increasing age it becomes more rare, and in adults the glands are 
usually affected secondarily during the course of a chronic tuber- 
cular disease. 
Whether as many as go per cent. of all 
adults, as Naegeli, Lubursch, Schmorl, 
Hamburger, and others have said, are affected with tuberculosis, 
or only a smaller percentage, the fact remains that the lymphatic 
glands are the structures far most frequently attacked. This: 
frequency makes it impossible to enter into the diagnosis of all 
the different varieties. We may limit ourselves to the considera- 
tion of the bronchial and mesenteric glands, as types of internal 
glandular tuberculosis, and of the glands of the neck, as typical 
of surgical tuberculosis of the glands. Also the condition will be 
only described as it affects adults; children are separately con- 
sidered in Chapter XV. 

Bronchial gland tuberculosis is usually present, if there is any 
tubercular disease in the body (Hamburger). Primary disease is 
rare after the age of puberty; but it is also possible in adults for 
the endothoracic glands to become first affected, or for glands, 
which were infected in childhood and remained latent, to be the 
seat of active and manifest tuberculosis as a result of certain 
conditions, such as other infections, weakening diseases, trauma- 
tisms, &c. If the tracheo-bronchial glands, which receive the 
lymph from the lungs and the lower part of the tracheal mucous 
membrane, and are connected with the supraclavicular glands, 
become much enlarged, pressure symptoms will be caused. 
These vary according to the involvement of neighbouring nerves 
or organs. Pressure on the vagus may cause cough and vomiting; 
on the recurrent laryngeal paralysis of the cord and hoarseness ; 
on the sympathetic dilatation of the pupil on the affected side; on 
the trachea and bronchi oppression, dyspnoea, even orthopnoea 
and asthmatic attacks; on the superior vena cava fulness of the 
veins of the neck and chest, oedema and cyanosis of the face; on 
the aortic arch hypertophy of the heart; on the pulmonary veins 
congestion and a tendency to bleeding from the nose; and on the 
cesophagus dysphagia. Of the remaining signs Philippi puts 
those in the first rank which can be always detected in cases of 


Diagnosis. 





VASCULAR AND LYMPHATIC SYSTEMS 355 


tuberculosis of the bronchial glands, and in the second those 
which are only met with in some cases. The signs of the first 
rank include: extensive vertebral dulness between the spine and 
the scapula, which is separated by a resonant zone from the usual 
apical dulness; also parasternal dulness, usually most marked in 
the second intercostal space; shortening of the note over the cor- 
responding vertebree; marked increase of resistance especially 
over the hilus dulness; breath sounds of a more or less bronchial 
character, often accompanied with crepitations on loud coughing ; 
increase of bronchophony ; a positive result on Rontgen-ray exam- 
ination, consisting of lines of peribronchial infiltration. With 
active disease there is always also marked leucocytosis, which is 
increased by a tuberculin injection; the temperature is generally 
changeable, subfebrile, or intermittent; the v. Pirquet reaction is 
positive even with weak tuberculin solutions; and pleurisy of the 
margins of the pleura, which frequently relapses, in common. 
As symptoms of the second order Philippi includes pains in the 
back or front, tenderness on pressure, especially over the neigh- 
bouring vertebrze, paroxysmal dyspnoea, irregularity of the 
heart, alterations in the movements of the vocal cords, paroxysms 
of cough, stabbing pains in the side, pallor of the skin, various 
bronchitic signs, increase of vocal fremitus, want of clearness in 
the heart sounds over the large vessels, and accentuation of the 
second sound over the dull area. 

The differential diagnosis must be made from other forms of 
mediastinal tumour. The history, a sufficiently thorough examin- 
ation of the lungs, the R6ntgen-rays, and particularly the result 
of a test tuberculin injection will make the distinction possible. 
E. Neisser recommends palpation with a sound, direct pressure 
of which from the oesophagus may cause pain in the swollen 
bronchial glands. 

Tuberculosis of the mesenteric glands in adults usually arises 
from the cecum, more rarely from tubercular disease of the pelvic 
organs or the vertebrae, and produces hyperplastic nodular masses, 
which may be easily felt if the abdominal wall is relaxed. 
According to the observation of the surgical clinic of Jena these 
glandular masses are usually found in a triangular area, whose 
base is formed by the cacum and lower part of the ileum, and 
whose apex is at the second lumbar vertebra. Occasionally the 
course is acute, leading to perforation and peritonitis; usually 
the symptoms are indefinite, and consist of pains in the right side 
of the abdomen, perhaps spreading to the back, obstruction or 
diarrhoea, wasting and anemia. As the neighbouring parts 
become implicated the same symptoms are produced as by all 


350 A CLINICAL SYSTEM OF TUBERCULOSIS 


inflammatory conditions which affect both the peritoneum and 
bowel; and then the diagnosis is most difficult. A palpable 
tumour if formed may resemble many other conditions (cyst, 
lipoma, and echinococcus of the mesentery, aneurysm of the 
aorta, Ovarian tumour, tubal pregnancy, movable kidney, and 
various diseases of the vertebra). Even a recognition of the 
exciting cause of the disease will only indicate the actual condition 
to a certain extent. 

Tubercular glands in the neck may be felt as hard nodules 
of the size of a bean to a walnut. They may remain for long 
unaltered, or may penetrate between the soft parts of the neck, 
become adherent to the skin and their surroundings, or under the 
influence of bacteria from the mouth and throat they may soften 
and discharge exteriorly. Very rarely does tuberculosis produce 
large masses of glands in a short time, like scarlet fever and 
diphtheria. 

The differential diagnosis, whether swellings of the super- 

ficial glands are due to tuberculosis or syphilis, lymphosarcoma 
or lymphatic anzmia is often very difficult. Syphilis can be 
recognized by the history of the primary disease, the presence of 
other syphilitic symptoms, and the result of treatment. Lympho- 
sarcoma does not respect the limits of the glands, but breaks 
through into the neighbouring structures; microscopically the 
tumour formation is characteristic. True lymphatic leukaemia 
causes painless swelling of the glands and hyperplasia of the 
spleen and the bone marrow (as shown by the blood-cells), while 
in tuberculosis tenderness of the glands and fever are common, 
there is no swelling of the spleen or changes in the blood-celis. 
The tuberculin test here leaves us im the lurch, as leukaemic, like 
tubercular glands, may give a reaction. Hegeler has observed 
an enormous swelling of leukzemic glands from 2 c.mm. of tuber- 
culin. 
The prognosis of primary lymphatic tuber- 
culosis is better than of secondary, since in 
the latter the presence of the original focus 
indicates a more widely spread disease. 

The treatment must be based on general hygienic measures. 
To these may be added tuberculin, which should never be 
omitted in primary cases on account of its excellent results. Also 
in secondary disease of the glands a combination of specific and 
general measures will often lead to recovery. 

Small, superficial glands, which have not yet softened, may 
also be treated with cod-liver oil, iodides, and creosote prepara- 
tions internally, and ro per cent. iothion ointment or iodovasogene 
externally; though much must not be expected from their use. 


Prognosis and 
Treatment. 





VASCULAR AND LYMPHATIC SYSTEMS USF / 


Measures which produce marked irritation of the skin, especially 
painting with iodine, are better left alone. Frictions of the whole 
body with soft soap have, according to Kappesser, a good effect. 

Lately tubercular glands have been considered to be especi- 
ally suitable for Rontgen-ray treatment. According to Leonard 
the rays first destroy the tissue of the lowest vitality and develop- 
ment and convert it into connective tissue; thus the isolated 
nodules may be absorbed, and at the same time extension and 
breaking down are prevented. The local application of the rays 
has also.a general action; it probably sets free an autogenous 
vaccine or antibody. It is the general experience in Germany 
and elsewhere that tubercular glands, whether in the stage of 
simple hyperplasia, or if partly suppurating, caseating, and 
ulcerating may be favourably affected by the rays. The stage of 
hyperplasia gives ideal results; the glands without exception 
become converted into fibrous nodules; radiotherapy is here 
slower but more thorough than an operation, since the smallest 
glands are also attacked. It has been stated, not without 
grounds, that extensive glandular resections produce a marked 
diminution of the immunization of the organism, as shown by a 
very positive v. Pirquet reaction, and thereby open the way to 
fresh infections. Also the rays avoid the unsightly scarring of the 
neck in young individuals. Radiotherapy has, too, a cosmeti- 
cally good effect on suppurating, caseating, or ulcerating glands. 
Unbroken suppurating glands can be treated by letting out the 
pus through quite a small incision, and then applying the rays. 
Sometimes a sinus forms, but it closes in four to five weeks.. Also 
broken down glands that have already formed a fistula give with 
deep irradiations very fair results, especially compared with the 
ugly scars left after operations. The more superficial are the 
glands, the quicker do they subside. But it is also possible to 
affect even deep-lying glands, such as the tracheo-bronchial and 
mesenteric, with the rays, and to reduce them considerably. The 
X-ray treatment of glandular fistule is superior to all others. 
Here there is a marked tendency to cicatricial contraction; the 
sinus sometimes closes too soon, that is so quickly that some 
discharge may be pent up. Therefore in cases of deep glands 
the fistula should be kept open with a drain-tube till the nodule 
is healed. Of course the R6ntgen treatment must be learnt and 
practised. The command of a reliable apparatus is necessary, 
and, above all, the dosage must be attended to. It is also 
obvious that general and medical treatment must not be neglected 
at the same time. The best results are given by a combination 
of R6ntgen and tuberculin treatments, accompanied by diet, salt- 
baths, and sea or mountain air. 


(o>) 
on 
(oa) 


A CLINICAL SYSTEM OF TUBERCULOSIS 


If in spite of these measures the glandular tumours do not 
subside, or if they increase or lead to functional disturbance of 
some organ they must be removed surgically, if possible before 
they soften, become adherent to the skin, and reach such a size 
that their removal would entail extensive scarring. ~-Mohr recom- 
mends that after the removal of tubercular glands the congestion 
treatment should be employed to avoid complications or relapses. 
Softened glands may be treated with aspiration, followed by 
injection of 1 to 2 c.c. of 10 per cent. iodoform-glycerine, or by 
the suction method, only a small incision being made. Operation 
may be more readily performed on adults than on children, since 
in the former the glands seldom subside, and caseate more rapidly. 

Tubercular bronchial glands in the hilus of the lung, in spite 
of the difficulty of access and propinquity of nerves and vessels, 
do not remain noli me tangere for the surgeon. Thus Riedel 
removed from a patient aged 40, after a preliminary plastic 
thoracic operation, a caseous and calcified bronchial gland of the 
size of a pigeon’s egg, which was causing an abscess and fistula ; 
he employed drainage, and obtained healing. 

The treatment of mesenteric glands, which are complicated by 
disease of the intestinal canal, is surgical. [Isolated tubercular 
glands in the region of the czecum, after preliminary treatment 
with the Rontgen rays to render them anzmic, may be removed. 
When lymphomatous masses are diffused through the whole 
mesentery of the small bowel, at most the glands in which the 
disease is farthest advanced may be removed, which may have a 
good influence on those remaining. 


8. TUBERCULOSIS OF THE SALIVARY GLANDS. 


Tuberculosis of the salivary glands may 
appear as disseminated irregular nodules, or 
as a large, firm tumour of the size of a 
goose’s egg, which may caseate or become filled with mucoid 
saliva. In the first case mumps with abscess formation may be 
simulated, in the second tumour or cyst. Histologically epithe- 
lioid and giant cells are to be found, the latter being derived from 
the glandular epithelium. 
The disease usually occurs in the parotid, 
much more rarely in the submaxillary 
gland. In any case it is very rare, only 
about twenty cases being known, and usually occurs in otherwise 
healthy people as a primary disease. It usually remains entirely 
local and runs a very chronic course. 

The bacilli may enter by a carious tooth, an affection of the 


Anatomical 
Changes. 


Symptoms and 
Course. 





VASCULAR AND LYMPHATIC SYSTEMS 359 


gum, such as stomatitis and gingivitis, and probably also by the 
tonsil. The infection is carried by the lymph- or blood-stream, or 
travels up the duct to the gland. The tumour is generally quite 
indolent; not infrequently it causes neuralgic pains in the side 
of the face, the head, the eye or the ear. It may lead to a fistula. 
The regional cervical lymphatic glands always participate. 

The freely movable, firm, doughy, or fluc- 
tuating swelling is but little characteristic. 
Facial paresis and paralysis have been observed. The disease 
must be diagnosed from dermoid cysts, fibrosarcoma, syphilis, 
actinomycosis, and epidemic parotitis by a tuberculin injection 
or by a bacteriological or histological examination. 

Lately tuberculosis has been recognized as the cause of 

Mikulicz’s disease—a symmetrical swelling of the lachrymal and 
salivary glands. At least in certain cases, according to Fleischer, 
Mikulicz’s disease is nothing but a peculiar, modified form of 
tuberculosis. The earlier idea of its connection with pseudo- 
leukaemia is not confirmed. 
Since the disease is almost always primary, 
the prognosis is good. The treatment con- 
sists in an attempt to remove all the diseased 
tissue by operation; it may lead to complete recovery. 


Diagnosis. 


Prognosis and 
Treatment. 


9. TUBERCULOSIS OF THE THYROID GLAND. 


In phthisical patients the thyroid gland, 
apart from the frequent slight enlargement 
in the early stage, sometimes undergoes 
sclerosis of a non-specific nature, no doubt as a result of toxzemia ; 
in many cases this explains the tachycardia, and in others the 
marked tendency to adiposity. The specific changes consist of 
miliary granules scattered through the whole gland, or in one 
part of it. Solitary or multiple, larger tubercular nodules with 
caseation are rarer. 

Experimentally the thyroid gland, like the spleen, kidney 
or testicle, can be infected by direct injection of a small number 
of bacilli. Its susceptibility is, however, slighter, probably on 
account of its specific functional activity. 

The miliary form may be quite without 
symptoms, and may not even produce a 
perceptible enlargement. In other cases 
there may be distinct hardening to be felt, or there may be soft, 
fluctuating enlargement. The general condition is not thereby 
altered. Pains are absent, or are slight. Considerable swelling 
—it has been seen as large as a child’s head—leads to pressure 


Anatomical 
Changes. 


Symptoms and 
Course. 


360 A CLINICAL SYSTEM OF TUBERCULOSIS 


symptoms, such as stridor, difficulty in breathing or swallowing, 
hoarseness, paresis of the vocal cord, and alterations of the pupil. 
The neighbouring lymphatic glands are generally swollen. 

It runs an indefinite course. Chronic swelling may remain 
for months, or mixed infection with pains and fever may occur 
after some weeks. Breaking of a focus into a thyroid vein causes 
general miliary tuberculosis. 

Primary disease has not been observed. It regularly forms 
part of miliary tuberculosis. Infection of the thyroid may occur 
secondarily from pulmonary tuberculosis, and also frequently 
from disease of neighbouring lymphatic glands. 

The diagnosis depends upon the presence of 
tubercular disease in some other organ, on 
the enlargement of the thyroid, its tenderness and painfulness, on 
compression symptoms and on swelling of adjoining lymph 
glands. The differential diagnosis must be made from carcinoma. 
The prognosis is good in cases of isolated 
nodules; but if the whole gland is affected 
it is doubtful on account of interference with the glandular func- 
tions (myxoedema, cretinism). 

The treatment of single nodules is surgical, 
and in the other varieties symptomatic. 
French authors recommend that in all cases of tuberculosis in 
which there are signs of deficient thyroid secretion, the patient 
should be carefully treated with thyroidin. 


Diagnosis. 


Prognosis. 


Treatment. 


10. TUBERCULOSIS OF THE SPLEEN. 


The most common non-specific alteration of 
the spleen in phthisical cases is amyloid 
degeneration (sago spleen). 

The tubercular spleen presents different appearances accord- 
ing to its development being rapid or gradual; it may be uniformly 
full of countless small nodules, or irregular tubercle conglomera- 
tions of a caseous or suppurative nature may be formed, or both 
conditions may be present at the same time. The spleen is often 
enormously swollen, the surface is smooth, or may be slightly 
uneven or nodular. On microscopical examination giant cells 
can be regularly found, and tubercle bacilli not rarely. 

The spleen is always affected in acute 
general miliary tuberculosis; on the other 
hand, it is only rarely so in the ordinary 
course of chronic phthisis in adults. This is in striking contrast 
with the regularity with which it is affected in the other infectious 
diseases. It suggests that not only does the spleen destroy 
bacteria, but that it also produces during the course of chronic 


Anatomical 
Changes. 


Symptoms 
and Course. 





dae @ wdc Ga!) lett Gia is tis 





VASCULAR AND LYMPHATIC SYSTEMS 361 


tubercular infections protective, anti-tubercular substances, which 
account for the slight disposition of the organ for tuberculosis. 
Secondary tuberculosis of the spleen hardly causes any clinical 
symptoms. 

On the other hand, primary splenic tuberculosis, according 
to the publications of recent years, is a more frequent disease, the 
recognition of which is important, as a timely operation may lead 
to complete recovery. The following symptom complex has been 
described : Splenic tumour, considerable augmentation of the red 
cells, and cyanosis. But it must be remarked that it is only the 
splenic tumour which is characteristic of tuberculosis, since the 
cyanosis is generally not marked and the increase of red cells 
may be absent, and may occur from other causes. With the 
splenic tumour hemorrhagic ascites has been observed. Fever, 
wasting and general symptoms may be present or absent. 

Tubercular perisplenitis is of little importance clinically; it 
leads to firm adhesions, and shows itself occasionally by friction, 
which can be felt and heard. 

The course of tuberculosis of the spleen is usually chronic; 

acute cases end quickly in death. 
The diagnosis is difficult, especially that of 
the primary form, and in many cases im- 
possible. Not infrequently it is first made from the examination 
of an extirpated spleen. A test tuberculin injection may help to 
distinguish between chronic splenic hypertrophy and_ tuber- 
culosis. If this is contra-indicated or fails an exploratory 
laparotomy remains as a last resource. 

The differential diagnosis must be made chiefly from the 
other splenic tumours; leukamia (by the blood examination), 
pseudo-leukaemia (rather more chronic course, no fever, no tuber- 
cular antecedents), malaria (history and blood examination), 
syphilis (history and Wassermann’s reaction), amyloid disease of 
the spleen (chronic suppurative disease in some other organ), 
Banti’s disease (blood examination, cirrhosis of liver). Other 
tubercular symptoms and signs are in favour of tuberculosis. 

The primary disease has not a bad pro- 
gnosis if submitted to timely operation ; the 
secondary form is hopeless, being a sign of general infection. 

The treatment of the primary disease con- 
sists of extirpation. The operation is not 
only indicated by the good results given, but by the powerlessness 
of all other therapeutic measures ; according to the experience that 
has been acquired the spleen is not an indispensable organ and 
may be sacrificed when required. But the splenectomy must be 
done in time before the disease has spread to the liver. There 


Diagnosis. 


Prognosis. 


Treatment. 


362 A CLINICAL SYSTEM OF TUBERCULOSIS 


are fourteen cases of extirpation of the spleen for primary 
tuberculosis recorded, of which five were fatal. According to 
Kiimmell, the mortality of early splenic removal is reduced to 
12 per cent.; proper technique will give even better results. 


11. HODGKIN’S DISEASE. 


The most important anatomical changes of | 
Hodgkin’s disease, also known as pseudo- 
leukemia (Sternberg) or lymphomatosis 
granulomatosa (EF. Fraenkel) are situated in the lymphatic glands, 
both internal and external, and the spleen. The glands are con- 
siderably enlarged, and on section present a dull-grey, homo- 
geneous, hyaline appearance, with yellowish white spots, also 
white, fibrous nodules of connective tissue. Softening and sup- 
puration are either absent, or if they occur as a result of bacterial 
infection never affect the whole of the diseased gland. The spleen 
is generally enlarged, with bosses on the surface, and on section 
has an appearance so characteristic that it by itself indicates the 
disease. Its appearance has been likened to hard-bake or’ por- 
phyry, that is to say, in the dark-red splenic pulp are embedded 
numerous, large, prominent, round, angular or irregular masses, 
grey-white in colour, isolated or in groups. Similar nodules to 
those in the spleen have been found in the marrow of the long 
bones and especially the vertebrae, and perhaps also in the liver, 
lungs and other organs. The lymphatic tissue in the throat and 
intestinal tract remains unaffected (E. Fraenkel). According to 
Sternberg’s observation the nodules consist microscopically of 
inflammatory granulative tissue, containing small and large lym- 
phocytes, numerous eosinophile cells and plasma cells in variable 
number, also large epithelioid cells and peculiar giant cells, en- 
tirely different from Langhans type. This tissue displaces the 
normal parenchyma; gradually at spots it necroses, while at other 
places there is a tendency to the formation of fibrous tissue. 
The etiology of Hodgkin’s disease is not yet fully explained, 
though E. Fraenkel was able, in sixteen out of seventeen cases, to 
find rods and granules, which were antiformin fast and Gram- 
positive, but not acid-fast, and morphologically could not be dis- 
tinguished from Much’s granular form of the tubercle bacillus. 
Therefore the virus of Hodgkin’s disease is not identical with 
Koch’s tubercle bacillus, but resembles it very closely, and in 
this E. Fraenkel’s view approaches the older one of Sternberg. 
Hodgkin’s disease attacks first of all only 
one group of glands, generally those in the 
posterior triangle of the neck, which en- 
large, usually painlessly, and remain for weeks or months of 


Anatomical 
Changes. 


Symptoms and 
Course. 





VASCULAR AND LYMPHATIC SYSTEMS 363 


the same size. Then they begin, without obvious cause, to in- 
crease again, and now the lymphatic glands in other parts of the 
body begin to swell, such as those in the supra-clavicular fossa, 
the axilla, the groin, the thorax and the abdomen, without fol- 
lowing any definite order. The glands may become adherent to 
each other and to the skin and suppurate, if other infection 
occurs, but never of themselves; several may become firm and 
_ hard and diminish in size, while the rest remain swollen. The 
infection chiefly enters through the mouth. The course of the 
disease is usually chronic; the average duration being from twelve 
to eighteen months. It most commonly occurs between twenty 
and forty, men being affected rather more often than women. 

In Hodgkin’s disease, besides the enlarge- 
ment of one or more groups of glands, 
there are several other signs, which although not constant may 
help in the diagnosis. Frequently a firm splenic enlargement 
can be discovered, which has neither the size nor smooth surface 
of that of myelogenic leukemia. Another sign of importance, 
although present only in a proportion of the cases, is chronic 
relapsing fever, an intermittent type of fever, broken by periods 
of complete apyrexia, lasting for months. In other cases the 
fever runs a remittent or quite irregular course. The condition 
of the blood is by no means constant; in some cases there is an 
obvious polynuclear leucocytosis, which is of special diagnostic 
value if there is distinct eosinophilia; but there are also cases in 
which there is diminution of the white corpuscles. The tuber- 
culin test is not distinctive, since the glandular tumours react in 
both tuberculosis and Hodgkin’s disease. In such doubtful 
cases a histological examination may be made of a portion of 
excised gland; the appearances that have been described clear 
up the diagnosis. But if there is no perceptible enlargement of 
the peripheral lymphatic glands the disease will usually remain 
unrecognized. 


Diagnosis. 


The prognosis is thoroughly bad. The 
afebrile intervals must not be taken to 
mean subsidence of the disease. After 
months or years the patient is carried off by anzmia, cachexia, 
or some complication, not directly connected with the disease. 

Hodgkin’s disease can be influenced neither by surgical nor 
medical treatment. Tuberculin, R6ntgen-rays, and salvarsan 
have all failed, according to the experience in the Hamburg- 
Eppendorf hospital. The good results described by Nageli from 
the administration of arsacetin, E. Fraenkel considers not to have 
been proved. 


Prognosis and 
Treatment. 


CHAPTER VIL 


Tuberculosis of the Skin. 


BESIDES the specific tubercular affections of the skin, in the 
course of so chronic a disease as tuberculosis there are certain non- 
tubercular changes of the skin and its adnexz, which occur in 
consequence of its deficient functional activity in connection with 
the lowered nutrition, and which have some symptomatic value. 

The best known non-tubercular affection is pityriasis versi- 
color, produced by the Microsporon furfur, which has a predilec- 
tion for the badly nourished, easily perspiring skin of phthisical 
patients. The fungus, which grows only in the most superficial 
layers of the epidermis, attacks chiefly the chest and back, and 
there produces yellow or brown spots of varying size, which may 
join together to form large areas. In slight cases the spots will 
disappear with special attention to the skin and energetic appli- 
cation of soap. If this is insufficient, or if extensive areas of 
skin are involved, then more powerful chemical agents must be 
used, of which there are many of utility. The most frequently 
used are iodine, oil, and spirit of turpentine, 5 to 10 per cent. 
pyrogallic acid ointment, 10 to 20 per cent. crysarobin ointment, 
tar and sulphur as soap or ointment, and salicyl and resorcin 
ointments alone or combined. To prevent relapses the applica- 
tion must be used for a very long time, and the skin carefully 
watched. Of special importance is the disinfection of the linen 
and clothes. 

An undoubted nutritional disease of the skin is pityriasis 
tabescentium, which may attack consumptives like other cachectic 
patients. The skin is dry and brittle, the superficial layers of the 
epidermis scale off, leaving a smooth, lustreless surface, which 
seems dusty. The treatment must be directed against the cause 
of the malnutrition. The troublesome tenderness of the skin 
often requires local treatment by frictions with mild ointments or 
oils after a luke-warm bath. 

Yellow or brown spots of pigment, chloasma phthisicorum, 





TUBERCULOSIS OF THE SKIN 305 


often appear on the face, especially the forehead, the cause of 
which, as in other cachectic diseases, is not sufficiently explained. 

Alopecia capillitii is to be explained by the general cachexia, 
like the other atrophies of the skin. The hairs become atrophic, 
fall out, and in the last stages of phthisis produce complete bald- 
ness. 

The peculiar curvature of the nails is associated with circu- 
latory disturbance, and is often observed in phthisical patients 
in association with congestion of the pulmonary circulation. It 
was known to Hippocrates, and the condition has been termed by 
French authors the ‘‘ hippocratic finger.’’ The phenomenon is 
one stage of the clubbed (drum-stick) finger, which has the same 
etiology. 

The special varieties of cutaneous tuberculosis may be 
divided into two groups: the bacillary forms of tuberculosis of 
the skin, and the tuberculides. 

A.—The bacillary tubercular affections of the skin are those 
in which the bacilli can be discovered. The skin is very resistant 
to the tubercle bacillus; according to recent experiments on the 
unbroken skin, the bacilli will pass through the hair-follicles into 
the lymphatic spaces, without producing any local disease, which 
only occurs if the skin is first injured (Koenigsfeld). As the skin 
does not offer a favourable ground for their development, usually 
only a few bacilli will be found in serial sections. Probably the 
low temperature of the skin is one cause of this. Much more 
frequently than tubercle bacilli Much’s granules and rods have 
been recently found; for example, H. Boas and Ditlevsen only 
succeeded in finding bacilli straining by Ziehl’s method four 
times in twenty cases of lupus, while in all Much’s forms were 
found, especially in the giant cells. The most important of the 
true tubercular diseases of the skin are :— 

(1) Tuberculosis cutis propria. 

(2) Scrofuloderma. 

(3) Lichen scofulosorum. 

(4) Tuberculosis cutis verrucosa. 

(5) Tuberculosis cutis necrogenica. 

(6) Lupus vulgaris. 


1. TUBERCULOSIS CUTIS PROPRIA. 


Miliary tuberculosis of the skin was first 
Anatomical Borys 
observed in the dead body, histologically 
Changes and caver SIE ait ; 
es examined and described by Chiari. 
le : ' A careful clinical observation was 
made of this disease by Kaposi, whose name is often given 


366 A CLINICAL SYSTEM OF TUBERCULOSIS 


to it. In the early stages small, light-red or brownish-red, 
scaly nodules, or comedo-like bodies of the size of a poppy- 
seed, are found; they break down into miliary ulcers, which 
join together to form the typical ulcers of miliary tuber- 
culosis of the skin. These characteristic ulcers are situated 
especially at the junction of skin and mucous membrane, 
at the mouth, the anus, and the urethral orifice; they usually 
grow out from the mucosa, and affect the skin by con- 
tinuity. The ulcer is superficial, the base is covered with 
indolent, pale-red granulations, the edges are jagged and eroded. 
At the base and edges of the ulcer may be seen single or numerous 
small, comedo-like granules, the true miliary tubercles. In the 
tissue and discharge tubercle bacilli can usually be found 
easily ; they may be missed in cases in which the tubercles necrose 
rapidly. 

Ulcerating miliary tubercle of the skin is usually a disease 
of adult phthisical patients, and is a result of auto-infection; it 
may take weeks or months to develop. Cases of exogenous 
inoculation tuberculosis are rarely observed. 

In the literature there are described several cases of acute 
miliary tubercle of the skin accompanying miliary tuberculosis, 
which did not proceed to ulceration, but subsided spontaneously. 
The diagnosis is easy, if regard is paid to 
the primary cause. But also in the rare 
cases of primary inoculation tuberculosis the recognition of the 
characteristic skin affection was not difficult. 

The prognosis depends on the primary 
cause, and is bad when it occurs in cachectic 
cases. In patients who are still capable of resistance it is not 
absolutely unfavourable, and cases of spontaneous recovery have 
been seen. 


Diagnosis. 


Prognosis. 


When the primary disease still permits 
treatment, excision, cauterization or scrap- 
ing, followed by caustics, may be employed. 


Treatment. 


2. SCROFULODERMA. 
This form of tuberculosis of the skin con- 


Pain sists of a superficial, firm, defined, nodular 
spc am infiltration in the subcutaneous tissue, the 
ype. gumma scrofulosorum. At first the skin is 


movable over the nodules, with increase in size, and soften- 
ing of the nodules, the skin becomes adherent. The nodules 
raise the thinned and reddened skin, and break througn — 
at one or more points, forming a superficial, uneven ulcer, 





_ 


TUBERCULOSIS OF THE SKIN 367 


covered by indolent, yellowish granulations, and having thin, 
undermined, eroded edges. The pus is a thin fluid, contain- 
ing crumbly, necrotic masses; it dries into crusts, which do not 
usually remain long on account of the copious discharge. Tubercle 
bacilli cannot generally be found. In the neighbourhood new 
nodules form in a similar way, join together, and give rise to 
large ulcers, separated by bridges of healthy skin. These 
scrofulous ulcers may also form without previous nodules from 
suppurating or caseating lymph-glands, or from suppurative bone 
disease. Favourite sites are the neck near the mastoid process, 
the thorax, the bend of the elbow, the axilla, and the lower part 
of the leg. 

Scrofuloderma occurs chiefly at puberty, but has also been 

seen in later years in scrofulous persons. It has a marked ten- 
dency to spontaneous healing, leaving smooth, pale, irregular 
cicatricial areas, separated by healthy skin. If the ulcer has been 
deep, especially in the neck, there will be marked cicatricial con- 
traction. 
In the nodular stage it may be confused 
with a syphilitic gumma, and in the ulcera- 
tive stage, if bacilli are absent, with a syphilitic ulcer. The 
following points may be helpful: the syphilitic gumma is very 
firm, tender on pressure, much less torpid, and prefers the skin 
over the forehead and tibia. The syphilitic ulcer has hard, 
infiltrated, steep edges, which are not undermined; it usually has 
a characteristic circular or kidney shaped outline, and has a 
tendency to progress rapidly. The syphilitic affections react to 
mercury and iodides. 


Diagnosis. 


The prognosis of uncomplicated cases is 


Prognosis. wee: : 
6 good. If the ulceration is due to discharge 


from a gland or bone the prognosis depends upon the primary 


disease and the general constitution. 
The general treatment consists of ordering 
a good diet, rich in albumens and fats, an 
open-air life, sun baths, and possibly a visit to the sea. For 
internal use there are cod-liver oil, iodides, and arsenic. As 
reabsorbents, especially if the scrofulous nodules have not yet 
broken down, frequent applications of soft soap may be used, 
which generally have a good effect also on the disease in glands 
or bones. The nodules may also be treated with other reabsor- 
bents, such as mercurial ointment, iodine, potassium iodide, 
iodo-vasogen, iothin ointment, ichthyol ointment, &c. 

The best local treatment is surgical, consisting of timely 
incision if softening can be no longer prevented, scraping out 


Treatment. 


368 A CLINICAL SYSTEM OF TUBERCULOSIS 


the softened, necrotic masses, removing the undermined edges, 
so as to obtain a better cosmetic result, and plugging with iodo- 
form, xeroform, or dermatol gauze. Disease in the glands or 
bones may be surgically treated at the same time. Recently the 
Rontgen-rays have been used with extremely good results 
(Holzknecht, Lowenberg). 


3. LICHEN SCROFULOSORUM. 


Lichen scrofulosorum is characterized by 
small papules or nodules, of a yellow, pale- 
red or livid colour according to their age; 
they are slightly raised and are arranged 
in groups. By Neisser the disease has been named “ tubercu- 
losis milio-papulosa aggregata.’’ The consistency of the erup- 
tion, which nearly always develops in the hair follicles, is usually 
soft, but may be rarely firm. The surface is smooth and covered 
with loose, whitish scales. A hair often grows out through the 
papule ; if it is broken off, a depression may often be seen in its 
place. By the confluence of a group of papules and by thicken- 
ing of the scaly covering, plaques of various shape and size are 
often formed, resembling a rough, dry infiltration in which the 
separate papules are difficult to recognize. 

The favourite sites of the eruption are the back and the 
abdomen, more rarely the extremities or the face. The papules 
develop very slowly, and may remain for months and then be 
reabsorbed. After this, however, they may relapse, lasting a 
very long time. 

Severe cases may be complicated by scrofuloderma, lupus 
vulgaris, cold abscess, and lymphadenitis. Very often acne 
cachecticorum may also be found, especially in marasmic chil- 
dren. It has frequently been observed that the acne pustules 
may develop directly out of the lichen papules, wherefore this 
form of skin disease has been considered to be a variety of 
lichen scrofulosorum, and has been termed  scrofuloderma 
pustulosum. 

Lichen is found most often in scrofulous children. Recently 
it has been generally held to be a true tubercular affection of 
the skin, although not many authors have succeeded in finding 
tubercle bacilli or obtaining positive results from animal experi- 
ment. Besides the histological structure, the occurrence of a 
typical tuberculin reaction is in favour of its tubercular nature. 
According to Klingmiiller’s researches lichen may certainly be 
produced without the presence of bacillary elements or their 
debris by the action of the tubercular toxin alone. 


Anatomical 
Changes and 
Symptoms. 





TUBERCULOSIS OF THE SKIN 369 


The exanthem is very characteristic and 
easy to recognize. Nearly always other 
signs of scrofula are present. Papular eczema, in contrast to 
lichen scrofulosorum, causes much itching. Syphilitic lichen is 
more copper coloured, is arranged in segments of circles, and has 
a different localization. According to Neisser, Jadassohn, and 
others the lichen papules react to tuberculin, and after its use 
latent deposits in the skin may first become visible. 

The prognosis of the local skin affection is 
quite good. The general treatment must be 
directed against the scrofulous constitution. 
Internally cod-liver oil, iodides, and arsenic may be_ used. 
Irritating ointments are condemned by most dermatologists. 
Recently tuberculin has been employed with good results; for 
example by B. Klingmuller in the Breslau skin clinic. 


Diagnosis. 


Prognosis and 
Treatment. 


4. TUBERCULOSIS CUTIS VERRUCOSA. 


Tuberculosis cutis verrucosa was first des- 
cribed by Riehl and Paltauf as a true 
inoculation tuberculosis of the skin, gen- 
erally situated on the hand or forearm, and 
occurring in healthy adults. The affection never begins as a 
lupoid nodule, but as a small, brown spot, covered with smooth, 
white scales, in which state it may remain for months. Later it 
develops into a round plaque. By the confluence of several 
plaques a serpiginous form is produced, which has a tendency to 
grow at its periphery. The plaques are surrounded by a thin 
red zone, within which are small pustules; in the centre are little 
warty nodules, which attain a height of 5 to 7 mm. Between the 
small nodules are erosions and pustules, from which drops of pus 
can be pressed. Lupoid spots cannot be found in the neighbour- 
hood. The condition never leads to ulceration; it may either 
spread at the periphery, or subside spontaneously. It may last 
for many vears. After spontaneous healing a thin, superficial 
scar, presenting a sieve-like appearance, is left. 

The disease is produced by exogenous inoculation with 
tubercular material from phthisical patients, by auto-infection in 
tubercular individuals, by continuity from tuberculosis of glands 
or bones, and lastly, by infection with bovine bacilli. 

The recognition of this very characteristic, 
extremely chronic affection is easy, as it 
can hardly be mistaken for other conditions. 

The disease usually remains local, and the 
prognosis is good. Infection of the lym- 
phatics and regional lymphatic glands is rare. 


24 


Anatomical 
Changes and 
Symptoms. 


Diagnosis. 


Prognosis. 


A CLINICAL SYSTEM OF TUBERCULOSIS 


ioe) 
~r 
© 


The best treatment is excision, cauteriza- 
tion, or scraping, followed by the use of 
caustics. If surgical treatment is declined, Neisser recommends 
arsenical paste, Fabry a solution of salicylic acid and application 
of 10 per cent. salicyl-pyrogallic ointment, and Joseph 30 per 
cent. resorcin paste. These treatments are also successful, but 
are usually very slow. Good results are given by Finsen’s light 
treatment, and weak doses of Rontgen-rays have, according to 
Schmidt, Holzknecht, Stern, Dietlen, and others led to healing 
without scar formation. 


Treatment. 


5. TUBERCULOSIS CUTIS NECROGENICA. 


Post-mortem tuberculosis, considered by 


mi ; 
Rati sa many to be the same as tuberculosis verru- 
iret Mee cosa, which at all events it very much 
Symptoms. 


resembles, is found most frequently on the 
hand and forearm of anatomists, doctors, and mortuary porters. 
It appears as single or numerous nodules. It first comes as a 
small, circumscribed, red papule, on the surface of which a small 
pustule forms. The pustule dries, falls off, and leaves a slightly 
nodular base. The affection may appear to be healed, but 
usually a slight thickening can be felt at the spot, which in 
the course of a few weeks gradually increases, and develops 
into a warty, nodular, projecting tumour, with a thick horny 
covering. 

The infection spreads from the sebaceous glands and their 
surrounding tissue.. There is no doubt as to its tubercular 
nature. Whether a mixed infection favours its development is 
questionable. The local condition usually remains confined in 
the more superficial layers of the skin; but spread of the infection 
to the lymphatics often occurs. Since it usually appears in 
medical men, or in those closely in contact with them, its later 
developments are rarely seen. 

The infection as such can be recognized 
quite early. The condition is very charac- 
teristic and unmistakable. ; 
Since the disease, in opposition to tuber- 
culosis cutis verrucosa, has a tendency to 
spread to the lymphatics, the prognosis is serious if radical 
measures are not taken early. 

This consists entirely in the earliest pos- 
sible radical removal of the nodules by 
excision or cauterization. 


Diagnosis. 


Prognosis. 


Treatment. 


2 ae. 


2 


$ 
% 
; 





TUBERCULOSIS OF THE SKIN Sil 


6. LUPUS VULGARIS. 


The most important, most polymorphic, 
and most difficult to treat of the forms of 
tuberculosis of the skin is lupus. It is the 
most obstinate of these infections, and may 
last for decades. The lupoid processes appear in the more 
superficial layers of the cutis, especially in the papilla. Accord- 
ing to Jadassohn the infection of the skin may take place by 
exogenous inoculation, by auto-inoculation, by continuity, by 
infection through the blood, and by bovine infection. There are 
numerous reports of each method of infection in the literature. 
The correctness of the recent assertions from various sources that 
lupus generally depends on infection with the bovine type of 
tubercle bacillus, has small probability, on account of the close 
connection between lupus and tuberculosis of the internal organs; 
also the organism obtained from lupus tissue has usually the 
characters of the human type (in ten cases examined in the Berlin 
Institute for Infectious Diseases the human type was found seven 
times and the bovine type twice, while in one case human bacilli 
were found in one nodule and bovine in another). 

The earliest sign of lupus, and one that is very characteristic 
of all its manifestations, is the lupoid nodule. The tubercle 
bacillus after its entry into the skin produces inflammation and 
infiltration, thus forming a tubercle; a conglomeration of such 
tubercles is the lupus nodule which can be recognized by the 
naked eye. It appears as a spot of the size of a head of a pin 
lying in the skin, and is of a light brown or brownish-red colour. 
In hyperzemic tissue it is very difficult or impossible to recognize. 
If a small glass slide is pressed on the skin, so as to make it 
bloodless, the spot will be more apparent. Another character- 
istic sign is the soft consistency of the nodule, which one should 
not neglect to test with a probe; on account of its softness the 
probe easily enters the skin, and thereby produces a small drop 
of blood. 

From these initial nodules the various clinical forms of lupus 
vulgaris are developed, which wili be now shortly considered in 
proportion to their practical interest. We follow the description 
of Jessner. 

Lupus exfoliativus is produced by a thick collection of lupoid 
nodules, and presents a reddened, scaling, exfoliative surface, in 
which the brownish-red nodules can be more or less clearly 
recognized according to the amount of inflammatory hyperemia 
of the tissue. In its further course cicatrization occurs in the 


Anatomical 
Changes and 
Symptoms. 


372 A CLINICAL SYSTEM OF TUBERCULOSIS 


centre, from absorption of the nodules and connective tissue for- 
mation, while the disease advances at the periphery. The centre 
of the lupoid area then becomes slightly sunken, the redness 
disappears, and a white, superficial scar, which tends to contract, 
is gradually developed. The edges on the other hand, where the 
disease is advancing, always retain their early character. Its 
course is extremely chronic, the disease sometimes remaining 
stationary; ulceration is very rare. 

Lupus hypertrophicus sive tumidus, as its name denotes, is 
marked by much formation of connective tissue, which gives it a 
tumour-like appearance. The separate lupoid nodules form 
projections of various sizes. The surface is thus uneven, of a 
red or brownish-red colour, and of a shiny or scaly appearance. 
The softness of the swelling is characteristic, and the recognition 
of this by means of a probe is important for diagnosis. The 
nodules as a rule occur in groups near each other; but they may 
join together to produce a confluent swelling. The course of 
this form of lupus is also extremely chronic, and it may remain 
for years with hardly any advance; on the other hand, the 
tendency to contraction and cicatrization is very slight. 

When the surface of lupus hypertrophicus becomes horny 
and contains papillary thickenings, the rare form of lupus 
verrucosus Sive papillaris is produced. 

The third chief form is lupus exulcerans, beginning as quite 
small, individual ulcers as a complication of any of the other 
varieties of lupus, which maintain their own character as a rule 
for a long time. Lupoid ulcerations may be recognized by their 
soft, non-infiltrated edge, which is only rarely slightly under- 
mined, and their florid red base, which bleeds easily, and is 
covered with exuberant granulations. The discharge of pus is 
slight, sometimes crusts form. The granulations may be 
covered at times with a thin layer of epidermis, but this is always 
only a transitory condition. 

Lupoid ulcers spread extremely slowly at their edges; 
neighbouring ulcers may join. The advance as a rule only 
occurs at one part of the periphery. If cicatrization occurs at 
one side, while the ulcer spreads at another, the variety known 
as lupus serpiginosus is produced, the edges of which form 
segments of circles. The ulcers also may penetrate deeply, as 
is sometimes seen on the face, and lay bare the bones and — 
cartilage, and may even entirely destroy the latter, as occurs 
most often with the nose. 

Lupoid scars are, no matter from which form they result, 
generally white, soft and thin. Hypertrophic cicatrices are 





TUBERCULOSIS OF THE SKIN 373 


rarely seen. Very often fresh nodules develop in the scars, 
leading to a relapse. 

As serious complication of lupus may be mentioned, lupus 
elephantiasis, in which there is a hyperplasia of the connective 
tissue, that may give an appearance of true elephantiasis, 
especially in the lower part of the leg and the lobule of the ear; 
also lupus-carcinoma, which sometimes develops in the lupoid 
scars, and requires special attention. 

The site of lupus vulgaris is in an overwhelming proportion 
of cases the face. The area round the nasal aperture is a par- 
ticularly common site, but any other spot, e.g., the external ear 
and the eyelids, may be affected; the last spot is particularly 
dangerous, on account of extension of the disease to the con- 
junctiva. The point primarily affected is not usually the skin, 
but the mucous membrane of the nose, and extension of the 
disease to the mucosa of the upper. air passages is no rarity. 
On the grounds of his own observations and an examination of 
the literature Dresch found that of 218 cases of lupus of the face, 
in which the nose was examined, lupoid changes in the nasal 
mucosa were constantly found. Also according to Gerber the 
primary affection in cases of lupus of the face was generally in 
the vestibule of the nose, and particularly above the anterior 
nasal angle. Gerber considers this point is of the greatest 
importance, and believes that the treatment of lupus can only be 
completely effective when it is combined with rhinological 
measures, a conclusion with which Wichmann, Senator, 
Hollander, and others, agree. Of other parts of the body the 
skin of the forearm, the hand, the lower part of the leg, and 
the foot is most often affected, and the disease may here take 
any of its various forms. 

Lupus of the mucous membranes is not radically different 
from lupus of the skin, and is only affected by certain anatomical 
and physiological differences. The morphological forms of the 
disease are less sharply characterized and, as a rule, more difficult 
to distinguish. The typical initial stage consists of pale-red, 
soft nodules, generally slightly raised and showing through the 
mucosa. ‘‘ That which in the skin would be a flat or slightly 
raised lupus, in the mucous membrane takes the form of a 
plaque formed of nodules closely packed together, which is often 
regularly thickened, pale-red in colour, of a round or irregular 
form, very soft and bleeding easily. Its colour may become very 
much darker from accidental irritation. These nodules may go 
through the same changes as in the skin; they may heal in the 
centre and spread at the periphery by continuity or by the forma- 


B74 A CLINICAL SYSTEM OF TUBERCULOSIS 


tion of new nodules. They may become much thickened and 
then assume an opaque, whitish colour, or sclerose and become 
quite firm; or they may grow out from the surface and specially 
in the nose form tumour-like masses. Most of all they easily 
become eroded and ulcerated. The erosions may become rapidly 
covered, but the covering is very easily removed. The ulcers, as 
in the skin, assume very various sizes, shapes and depth. Also 
they may spontaneously heal with more or less scarring and loss 
of substance ’’ (Jadassohn). 

Lupus is a disease of young people, its origin probably 
dates back to childhood; more rarely it commences in later life. 
The disease attacks by preference the poor. This may be 
accounted for by the neglect of the early stage, the disease being 
painless, and the general health practically not altered. Whether 
lupus is more often primary or secondary, and what are its 
relationships with tuberculosis of other organs, there are differ- 
ences of opinion.. In any case scrofulous glands are very fre- 
quently found with lupus; also there is no doubt that a consider- 
able proportion of lupus cases die of pulmonary tuberculosis. 
The recognition of lupus is easy, so long 
as the characteristic lupus nodules are still 
visible. How in cases of hyperemia they may be brought out 
by pressure with a glass slide, and how their consistency may 
be tested with a probe, has already been described. The detec- 
tion of the nodules is more difficult in the presence of marked 
hypertrophic swelling or ulceration. Here they must be searched 
for in the recent edge and at cicatrizing spots. 

A confusion between exfoliative lupus and chronic eczema 
can be avoided if it is remembered that eczema is usually moist, 
itches much, never ulcerates and therefore leaves no scars. 
Psoriasis is distinguished by its position on the extensor surfaces 
of the limbs, by its smooth, silvery scales, and by never causing 
loss of substance of the skin. The distinction from lupus 
erythematodes can be made from the symptoms. 

Lupus hypertrophicus sive tumidus can hardly be confused 
with any other skin disease; the characteristic softness of the 
lupoid growth has already been mentioned. 

At first lupus exulcerans may be taken for a syphilitic ulcer, 
if lupus nodules cannot be found near the edge. The serpiginous 
form may be even more confusing. The soft edges and the base 
covered with florid, exuberant granulations are characteristic of 
lupoid ulcers, while syphilitic ulcers formed from gummatous 
infiltrations, frequently have waxy spots on edge and base, and 
on pressure are painful. If the ulceration affects the nose, as it 


Diagnosis. 





TUBERCULOSIS OF THE SKIN 


often does, it may be noted that the lupoid ulcers involve only 
the cartilage and nearly always stop at the bone, while syphilis 
has a preference for the bones, causing the sinking of the bridge 
and saddle-nose so characteristic of this disease. Further points 
for the differential diagnosis are naturally furnished by the other 
clinical symptoms. The histological examination of a piece of 
excised tissue or inoculation experiments on animals will also 
usually give useful information, but for the practitioner they are 
complicated and tedious in comparison with the more certain 
means of diagnosis—tuberculin. The cutaneous reaction in cases 
of lupus produces instead of the usual papule a large ill-defined 
swelling or lichenoid efflorescence at the site of inoculation, on 
account of the increased super-sensitiveness of the skin to tuber- 
culin. With small early lupoid patches it has been recom- 
mended to make the inoculation on the diseased tissue itself, 
which produces an unmistakably strong reaction, with redness 
and exudation, followed by induration or necrosis. Other 
cutaneous tests are superfluous, and the conjunctival test use- 
less, and contra-indicated if the lupus is situated near the eye. 
More characteristic and more generally useful is the effect of the 
subcutaneous test, which in early cases, as well as in the most 
advanced, gives a certain diagnosis in doubtful cases by the pro- 
duction of a typical focal reaction. For a full description of the 
tuberculin diagnosis in dermatology we may refer to our book on 
“ Tuberculin in Diagnosis and Treatment.”’ 

The prognosis of lupus in early cases is 
good; but even here one is never safe from 
relapses. The prospect of lupus of the skin is incomparably 
better than when the mucosa is affected, as in the latter case the 
disease is less accessible to treatment. With advanced disease 
the prospects of recovery are less bright, and depend upon the 
extent and depth of the disease, whether the mucous membrane 
is affected, the general condition, and the presence or absence of 
complications in other organs. Certainly the prognosis has dis- 
tinctly improved during the last two decades owing to the ad- 
vances of medical science. As in all other tubercular diseases, 
the prognosis is better the earlier the condition is recognized, 
and the more promptly radical measures are taken; so that early 
diagnosis and prophylaxis are of the greatest importance. 

So long as the treatment of lupus was purely 
medical the results remain unsatisfactory. 
Reabsorbents, mercury and iodides were usually employed. The 
use of surgical measures, the modern advances in dermatology, 
and the dawn of the second tuberculin era have combined to 


Prognosis. 


Treatment. 


376 A CLINICAL SYSTEM OF TUBERCULOSIS 


brighten the prospects of the treatment of lupus. Of the various 
treatments we will only describe those which are suitable for use 
by the general practitioner, while those which require the assist- 
ance of a specialist or demand complicated and costly apparatus 
will only be shortly touched upon. 

Surgical treatment consists of excision of the diseased foci, 
to be followed by a plastic operation in cases in which union of 
the edges of the wound does not take place naturally. To prevent 
relapses it is absolutely necessary to operate in sound tissues. 
The focal tuberculin reaction is very useful here to bring out 
with certainty the demarcation between diseased and healthy 
tissue. Plastic measures consist of the use of flaps or of 
Thiersch’s grafts, which permit the covering over of the largest 
gaps in the skin, and make possible extensive use of surgical 
treatment for lupus. There are a large number of reports of the 
permanency of the results; we may refer to the monograph of 
Lang and the comprehensive work of Spitzer and Jungmann, who 
have published the full results of 240 cases of lupus treated by 
operation. According to Lang it is necessary for excision that 
the diseased foci should be clearly marked out, and that it 
‘should be possible to cover the resulting defect of the skin with 
good cosmetic and functional results. The superficial extent and 
the depth of the disease are not of great importance in this con- 
nection; but almost all cases must be excluded from operative 
treatment in which the mucous membrane is much affected, as 
then radical measures are not possible; and also very anzemic, ill- 
nourished persons, who could not well support the shock and 
loss of blood. Lang has presented some remarkable cases of per- 
manent recovery to the Commission on Lupus. The utility of the 
operative and plastic measures may be best shown by the follow- 
ing figures: Of 308 cases examined under control, 256, after a 
single operation, remained free from relapses up to 16 years. 

When excision is no longer possible on account of the great 
extent of the disease Payr has recently successfully treated lupus 
of the trunk and extremities, by undermining the disease and 
raising it up in flaps from the subcutaneous tissue, whereby a 
deep effect is also produced. Strips of gauze soaked in balsam 
of Peru were drawn under the flaps and tied over them, the plugs 
being renewed about once a week. Recovery takes place after 
four to eight weeks, with good cosmetic results. 

Good results can be obtained by destroying the lupoid 
nodules with the galvano or Paquelin cautery under local anzs- 
thesia, particularly when they are small. With larger areas of 
disease there will be considerable scar formation, which is 





TUBERCULOSIS OF THE SKIN Oh 


naturally an objection to this method for disease seated on visible 
parts of the body. 

Scraping with the sharp spoon, either alone or combined 
with the previous method, has the advantage of easily removing 
the soft lupoid tissue, while the healthy and cicatricial areas offer 
more resistance. A radical removal of the diseased foci, however, 
cannot be always guaranteed by these methods, so that an after- 
treatment with chemical agents is usually carried out. 

Of the mask treatment recommended by Bier there have been 
very good reports; thus of late Knowsley-Sibley has described 
excellent results in properly selected cases. Caustics by them- 
selves have given good results, especially in exfoliative and 
ulcerative lupus; while in lupus hypertrophicus a preliminary re- 
moval of the swelling is necessary. Of caustics the pyrogallic 
acid introduced by Jarisch is particularly esteemed. It has an 
elective destructive action on the lupoid tissue, leaving the healthy 
and cicatricial areas unaffected. An ointment of 5 to 20 per 
cent. pyrogallic acid is used, generally’ combined with an anzs- 
thetic (orthoform or anzesthesia), till all the diseased tissue is 
removed ; for the after-treatment a weaker ointment of 2 to $ per 
cent. is used. 

Of other caustics chief use is made of Joseph’s 30 per cent. 
resorcin paste, Unna’s green lupus ointment (acid salicyl., liq. 
antim. chlor, aa 2 parts, creosote, extr. cannab. indic. aa 4 parts, 
adip. lanae 8 parts), or Unna’s caustic potash paste. Neisser saw 
good results from Cosme’s arsenic paste, also from ethylenediamin- 
cresol. Potassium permanganate in 2 to 10 per cent. solution is 
useful. Zinc chloride, lactic acid, carbolic acid, formalin, &c., 
are also used. | 

A marked advance in the treatment of lupus has been 
obtained by Finsen’s method and by the Rontgen rays, though 
according to Lesser both methods have their limitations, especially 
in cases of very extensive disease, when the mucous membrane is 
involved, and when there is much scarring from previous un- 
successful treatment. Also both methods in contrast to the 
surgical treatment are tedious and costly. 

Against the use of the R6ntgen rays it has been objected that 
it is difficult to fix the duration of the treatment satisfactorily. 
When the superficial layers of the skin seem to have long reached 
their normal state, there are still to be found signs of reaction in 
the deeper tissues. Scholz and Gassmann have in cases of 
Rontgen dermatitis seen injuries of the cutaneous vessels, con- 
sisting of degeneration of the intima, atrophy of the muscular 
layer, telangiectasis and complete obliteration of the vessel with 


378 A CLINICAL SYSTEM OF TUBERCULOSIS 


degeneration of the skin and subcutaneous tissue. It is not pos- 
sible to lay down accurate indications for the employment of the 
rays. Sometimes they fail altogether, sometimes their effect is 
good even in the most severe cases, which do not react to the 
Finsen treatment. They are best suited for ulcerations, and even 
more for much swollen, hypertrophic lupus of the skin and 
mucous membrane, and also as a preliminary for the use of the 
Finsen light, or lastly in combination with other methods. 

As to the best method for using the Rontgen treatment, and 
the quality and quantity of the rays that are to be employed, the 
views are divergent. The majority of those using the method 
now employ a milder system with soft or medium rays and careful 
observation of the exact doses by means of a reliable dosimeter, 
of which those of Sabouraud and Noiré are the most practical. 

The results of the Finsen light treatment are the most bril- 
liant, and at present are superior to those produced by the 
Rontgen rays. The cosmetic effects are particularly excellent. 
In contrast with the R6ntgen reaction the Finsen reaction can 
according to all observers be more certainly estimated; also the 
most difficult cases can be treated with this method, there being 
scarcely any contra-indication. | However, it also fails in deep- 
seated lupus, and in lupus of the mucous membranes, especially 
of the nose. 

It remains to be mentioned that both radium and mesothorium 
have been used with success. The results have been improved 
since suitable apparatus has been constructed to apply the radium 
to the cavity of the nose, the mouth, &c. 

A capsule constructed by Westphal, of Berlin, is most serviceable for 
the interior of the nose; for the mouth and throat the use of plates made 


from soft impressions by Claudius Ash, Sons and Co., of London, may be 
most recommended. 


The Finsen light treatment has led to the introduction of a 
series of methods, based on the same principle of employing the 
ultra-violet light rays in a more simple form. Such are the 
dermolamp, the iron-light, the uviol, and the quartz lamps, and 
the mercury light. The potency of these light apparatus in lupus 
is still uncertain, the quartz lamp recommended by Kromayer 
seems to be useful. 

Still other methods are scarification, needling, and electro- 
lysis, which no doubt are very useful for small lupus nodules, 
and give good cosmetic results. Also the various forms of freez- 
ing by means of ethyl chloride or a mixture of ethyl- and methyl- 
chlorides, liquid air, and recently carbonic acid snow are capable 
of curing lupus. 





TUBERCULOSIS OF THE SKIN 379 


The hot-air treatment of Hollander has, too, given good 
result, especially in extensive, superficial forms, and according 
to Neisser in those forms of disease in which the mucosa 1s also 
affected. The hot-air possesses the advantage that it destroys the 
diseased tissue, while healthy parts are left unaffected; it is not 
Capable, however, of any deep effect. 

A method which has given striking results is the diathermic 
treatment lately recommended by Nagelschmidt. A high fre- 
quency current is here employed, like that used in wireless 
telegraphy. The application can be measured and localized, so 
that it is capable of superficial or deep action. It causes a produc- 
tion of heat up to 70 to 80° C., which produces a coagulation of 
the tissues. The duration of the application varies according to 
the size of the diseased nodules from some seconds up to several 
minutes at the most. Generally one sitting is sufficient, it is rare 
for more to be required. The throwing off of the tissue takes 
place rapidly. This new treatment is suitable for all cases of 
lupus, and also for all other forms of tuberculosis of the skin and 
mucous membrane, including the deeper complications. 

Recently Pfannenstill has brought about remarkable recover- 
ies in severe cases of lupus of the skin and mucous membrane by 
the internal administration of iodide of sodium and the external 
application of ozone. These results have been confirmed by 
Strandberg in the Finsen Light Institute; the method has been 
still further simplified in cases of lupus of the nose by replacing 
the ozone by the local application of tampons soaked in hydrogen 
peroxide. 

In addition to the local measures the general treatment of 
the whole organism is naturally very important. The following 
factors are all of importance: a healthy dwelling, good food, a 
life in the open air, attention to the skin, possibly salt, baths or 
sea air, treatment of existing complications, especially the tuber- 
cular and scrofulous constitution, and medical treatment by cod- 
liver oil, iron, arsenic, iodide, &c. F 

To the general and other treatment of recent years tuberculin 
has been added, which we can hardly recommend too much to the 
practitioner for use in suitable cases, either alone or combined 
with other methods. Even in the first tuberculin era very rapid 
healing was seen. But afterwards, with the modern advances in 
the treatment of lupus, tuberculin was undeservedly by degrees 
dropped, until of recent years it has again been brought to the 
fore. We consider that tuberculin has special claims to be 
included in the treatment of lupus on account of its action on 
lupus of the mucous membrane (B. Frankel, Doutrelepont, 


380 A CLINICAL SYSTEM OF TUBERCULOSIS 


Lautsch, and others), where all other methods usually fail, and 
because lupus is often complicated with tuberculosis of the 
internal organs. In his report to the lupus section of the German 
Central Committee for combating tuberculosis, Wichmann states 
that tuberculin “‘ though not a sovereign remedy, yet is a very 
valuable aid and often an indispensable factor in the treatment of 
lupus.” 

There are a series of tuberculins which have been used subcu- 
taneously, especially the old tuberculin. A marked superiority of 
one preparation over the others has not been shown, though by 
several authors the effects of bovine tuberculins have been 
praised, the indications being drawn from the supposed bacterial 
etiology of lupus. Thus Moller recommends bovine tuberculin, 
especially where the human preparation has failed. In small 
lupoid nodules Nagelschmidt, by the production of a v. Pirquet 
papule in the diseased tissue itself, has produced healing over an 
area of several millimetres. Still more potent for the destruction 
of tubercular tissue is tuberculin in combination with other 
methods. Thus according to Senger no other treatment of lupus 
is as good as inunction of a 3 to 10 per cent. tuberculin ointment 
with vasinol, in combination with Rontgen rays. On the same 
principle Mtnch recommends the use of sun rays, to be followed 
by inunction of 1 per cent. old tuberculin lanolin ointment. 
Wolters records excellent results from local applications of pyro- 
gallic acid combined with tuberculin treatment; it seems that the 
tuberculin sets free the bacilli from the deeper parts, and the 
exudation carrying them to the surface, they can be destroyed by 
the pyrogallol. 

To sum up, we can say that the extensive, deep, and compli- 
cated forms of lupus should be treated exclusively by none of 
these methods alone, but that a combination of several forms of 
treatment is best employed in severe cases. These views are in 
accord with findings of the Lupus Commission. It remains to 
be seen whether the new diathermic treatment will fulfil the great 
expectations that have been formed of it. 

For an effective attack on lupus and other forms of tubercu- 
losis of the skin we especially desire that the treatment, though 
resting on a broad basis, should be centralized. Only a few lupus 
sanatoriums would be sufficient, considering the number of cases 
of the disease, to start a strenuous campaign, as the public sana- 
toriums have done for pulmonary tuberculosis. Since lupus is 
almost exclusively a disease of the poor, State aid would be neces- 
sary. By the formation of central committees for attacking lupus 
we are on the way towards this goal. 





TUBERCULOSIS OF THE SKIN 381 


B. The Tuberculides. 


The tuberculides have hitherto been regarded as being pro- 
duced either by the soluble toxins of the tubercle bacilli like the 
other toxic exanthemata, or by weakened or dead bacilli or their 
remains. ‘Thus, for example, Klingmuller saw as a result of the 
injection of tuberculin preparations lupus-like changes appear, an 
evidence that the substances dissolved out of the bacilli, or the 
remains of the living cells, may be the cause of a specific tissue 
reaction. Also Zieler was able with a dialysed tuberculin, which 
was free even from ultra-microscopic particles of bacilli, to evoke 
the same changes in the skin. Up to a little while ago tubercle 
bacilli could not be found in the diseased tissues. Quite recently 
more light has been thrown on the obscurity which surrounds the 
origin of this group of skin affections. The very careful observa- 
tions of Zieler on the causation of toxic skin conditions in tuber- 
culosis have led to the conclusion that the tuberculides are 
probably a weakened variety of bacillary skin tuberculosis, in 
which the bacilli in the skin as a rule rapidly perish. We there- 
fore come back to the old definition of Jadassohn of the tubercu- 
lides. According to the fundamental researches of Liebermeister 
tubercle bacilli may not only cause a typical histological tuber- 
culosis, but may also produce chronic inflammatory changes 
alone; this is true not only for the nerves, veins, heart, and 
kidneys, but also for the skin. A recent theory of Lewandowsky’s 
seeks to explain the genesis of tuberculosis of the skin in its 
various forms by the measure of immunity of the infected organ- 
ism. Besides the number and virulence of the tubercle bacilli, the 
antibodies of the organism play an important part. A massive 
dose of tubercle bacilli with failure of antibody production leads 
to miliary tuberculosis of the skin, numerous bacilli with scanty 
formation of antibodies cause multiple hzemotogenous lupus, 
while scanty bacilli with copious antibodies produce tuberculides, 
with rapid destruction of the infecting bacilli. The tuberculides 
are therefore, according to Lewandowsky, to be considered as a 
form of true cutaneous tuberculosis. The bacillary nature of some 
of the tuberculides has been placed beyond doubt by recent work. 
Particularly useful for settling this important question have been 
the antiformin method of Uhlenhuth and Much’s discovery of the 
granular form of tubercle bacillus. A complete explanation of 
all these debated questions may be expected shortly. Hitherto 
there have been very various views as to which of the forms of 
dermatitis appearing in tubercular patients are to be reckoned as 
tuberculides. According to Jadassohn the characteristic of tuber- 
culides lies in the frequent combination of the following clinical] 


382 A CLINICAL SYSTEM OF TUBERCULOSIS 


attributes; the individual nodules of disease run an extremely 
benign course, and have a marked tendency towards spontaneous 
involution; they are inclined to disseminate, forming more or 
less symmetrical affections covering extensive areas of the body ; 
they appear in batches, and affect particularly persons with 
chronic tuberculosis of the glands, bones, or skin. The most 
important tuberculides which we shall describe are the follow- 


ing :— 


(1) Erythema. 

(2) Acnitis and Folliclis. 

(3) Acne cachecticorum sive scrofulosorum. 
(4) Erythema induratum. 

(5) Lupus pernio. 

(6) Lupus erythematodes. 


There are still a series of diseases of the skin whose connec- 
tion with the tuberculides is extremely doubtful; such are pity- 
riasis rubra (Hebra), multiple benign sarcoids (Boeck), and 
angiokeratoma. It will not be necessary to describe those condi- 
tions. 


1. ERYTHEMA. 


Many authors have observed erythema in 


See ae cases of chronic lung tuberculosis, lupus, 
nee a and more rarely tuberculosis of the bones 
Symptoms. 


and glands; that appearing after a tubercu- 
lin injection forms large, sharply defined, red areas, which on 
account of their transitory character have received but little atten- 
tion. This skin affection is considered to be a tuberculide in its 
widest sense. It is produced by a tubercular toxin, just as the 
lichen eruption which may appear after a tuberculin injection. 
That these exanthemata, like all tuberculides, are closely asso- 
ciated with tuberculosis, is shown by the fact that they are never 
produced in non-tubercular persons by injections of tuberculin. 
It is obviously the result of a supersensitiveness of the skin of 
tubercular persons, our comprehension of the nature of which has 
been materially increased by the study of the local tuberculin 
reaction. 

The erythema is easy to recognize, and 
would be probably more often diagnosed it 
more attention was paid to these forms of 
skin affection. Being a harmless erythema 
treatment is unnecessary. 


Diagnosis, 
Prognosis, 
and Treatment. 





TUBERCULOSIS OF THE SKIN 


Go 
(oe) 
ioe) 


2. ACNITIS AND FOLLICLIS. 

Acnitis and folliclis described by  Bartheé- 
lemy and considered by him to be two 
different forms, have lately on account of 
the similarity of the pathological processes 
been thought to be a single disease, and included in the group of 
tuberculides as papulo-necrotic tuberculides (Jadassohn) or 
dermatitis nodularis necrotica (Torok). The necrotic processes 
develop partly in the upper layer of the subcutaneous tissue or the 
deeper part of the cutis, and partly in the superficial layers of 
the latter. The superficial changes in the skin consist of 
slight, raised, pale-red infiltrations of the size of a hemp- 
seed, which become hypereemic, increase in size, and necrose 
in the centre. In the middle can now be seen a greenish 
pustule of the size of a pin’s head, which after discharging or 
drying up forms a dimple-lke ulcer, and becomes covered with 
an adherent crust. An allied form is the papular or papulo- 
squamous tuberculide of infants described by Hamburger, which, 
though superficial and small, necroses in the centre and cicatrizes 
without tendency to ulceration, and is characteristic of tubercu- 
losis of infants. Hamburger and Lateiner were able in these 
tuberculides quite regularly to discover tubercle bacilli, which 
produced typical tuberculosis on guinea-pigs. Over the deeper- 
lying, hard, indolent nodules, which form extremely slowly, the 
skin is at first unaffected, and movable. Gradually the nodule 
becomes adherent to the cutis, and raises the epidermis, which 
becomes red. If it is not reabsorbed, after about fourteen days 
in the centre the first signs of necrosis appear as_ described above ; 
the hyperzemia is commonly more intense, and the dimpled ulcer 
rather deeper. The crust in both forms remains about fourteen 
days, in which time the inflammation has subsided and cicatriza- 
tion advances. When the crust falls off a sharply defined, round 
scar 1s seen of the size of the nodule; it is at first red, later 
pigmented, and lastly white and smooth. 

The nodules are usually scattered, but those that are super- 
ficial are more often in groups than the deep ones, and they there- 
fore have a greater tendency to become confluent. If this occurs 
thick infiltrations are found, with the same characters as the 
separate nodules. The symmetry of the condition is very charac- 
teristic. The deeper nodules are situated chiefly on the face, the 
ears, and the neck, while those that are superficial are met on 
the exterior surfaces of the extremities, especially on the elbow, 
hands, fingers, knee, foot, and toes. 

The disease has a very chronic course of months or years. 
The nodules usually appear in batches with long intervals 


Anatomical 
Changes and 
Symptoms. 


384 A CLINICAL SYSTEM OF TUBERCULOSIS 


between, often they can be seen lying together in all stages. 
Young and middle-aged people of both sexes are affected. 
Involvement of the hair-follicles or the sebaceous and sweat 
glands has not been proved; according to recent observations the 
disease spreads from the vessels, the condition thus being meta- 
static and embolic. The tubercular nature of a proportion of the 
cases is undoubted. 

There is no difficulty in recognizing the 
disease. Certain groups of syphilides have 
a great resemblance, but the necrosis is in them more marked, 
and the characteristic symmetry is absent. 

The prognosis is usually good, even in 
long-standing cases spontaneous healing 
may occur, though fresh relapses are pos- 
sible. Treatment is generally useless. Help may be obtained 
from good food, open air, iron, arsenic, quinine, cod-liver oil, 
iodide of iron, and possibly also iodide of sodium. 


Diagnosis. 


Prognosis and 
Treatment. 


3. ACNE CACHECTICORUM SIVE SCROFULOSORUM. 


At first intensely red, later livid, nodules 
and acne-pustules of the size of a pin’s head 
to a lentil develop in various parts of the 
body, particularly on the extensor surface 
of the legs and arms, the genital region, and lower part of the 
back, most often as a later development of lichen scrofulosorum, 
but also as a primary condition in cachectic and scrofulous per- 
sons. They are situated chiefly around a hair follicle, and have 
a bluish-red zone outside them. Beside them are usually residual 
white scars, which on pressure with a glass slide show no spots 
of pigment. Softening of the nodule and the formation of crateri- 
form ulcers only occur occasionally ; the remaining scars are then 
sharply cut, and have a violet and later a brownish colour. 

Since acne cachecticorum is usually met 
with lichen scrofulosorum, nearly always in 
a cachectic and scrofulous person, the diagnosis is not difficult. 
It differs from acne vulgaris in the absence of comedones. The 
eruption may be confused with syphilis, but it is not so thick and 
ulcerates rarely. According to recent observations it reacts in a 
typical way to tuberculin, after which improvement, even healing, 
may occur. 


Anatomical 
Changes and 
Symptoms. 


Diagnosis. 


The prognosis as regards the skin affection 
is good. For local treatment cod-liver oil 
‘and boracic acid have been recommended. 
More important is the general treatment directed against the 
causal condition. 


Prognosis and 
Treatment. 





TUBERCULOSIS OR” THE (SIGIN 305 


4. ERYTHEMA INDURATUM. 


The affection of the skin described by 


a hae Bazin as erytheme induré des scrophuleux 
ae and has a great resemblance to erythema 
ymptoms. nodosum, with which by many authors 


it has been incorrectly connected. There appear in_ the 
deeper part of the skin small, prominent, hard nodules, 
which are usually multiform and often arranged in circles; 
at first they are quite colourless, not tender on pressure, and 
cause no pain. Occasionally they may appear suddenly with 
pains. Their size is usually up to a walnut, and rarely much 
larger nodules have been observed. They are localized on the 
extremities, especially the shin; they may remain unaltered for 
years, and may disappear spontaneously. But generally they 
ulcerate. Gradually the infiltration softens, the surface becomes 
more swollen, and of a livid red colour. This breaks in the centre, 
discharges a sero-purulent fluid, and becomes covered with 
adherent scabs. The ulcers have a tendency to heal, but very 
slowly ; but they may also become deeper and take on the appear- 
ance of scrofuloderma. 

Erythema induratum attacks particularly young, weakened 
females, but men and older people are not exempt. It is often 
combined with other tubercular skin affections, and signs of 
scrofula. Its specific nature is not yet fully proved, but the local 
reaction to tuberculin and the typical tubercular histological 
structure of many cases point in this direction. But syphilitic 
and other diseases may have a share in its production. Very 
often it is due to an affection of the vessel, such as endarteritis or 
infarct, followed by necrosis. 

The diagnosis is not difficult, and must be 
made from erythema nodosum, which, how- 
ever, very rarely ulcerates. If the ulcers are deep scrofuloderma 
or an ulcerating gumma may be simulated. 

The disease is obstinate, but even very 
chronic forms are not unfavourable, since 
they tend to recover as soon as the patient is put under good 
hygienic conditions. 


Diagnosis. 


Prognosis. 


The chief points are improvement of the 
general mode of life, good food, and atten- 
tion to the skin. The affection being seated on the legs, rest in 
bed with the foot raised is required, with bandages and careful 
dressing if ulcers have formed. Thibierge and Weissenbach have 
lately cured five such cases by ambulant treatment with increasing 
doses of tuberculin, without other general measures. The results: 
were confirmed by Jeanselme and Choralier. 


25 


Treatment. 


386 A CLINICAL SYSTEM OF TUBERCULOSIS 


5. LUPUS PERNIO. 


In close connection with erythema indura- 
tion stands lupus pernio, which by many, 
especially French dermatologists, is now 
Symptoms. included under lupus erythematodes, there- 
fore we insert this description between those of the two allied 
conditions. The characteristic changes in the skin in this rare 
disease consist of bluish-red discoloration, not as a rule sharply 
defined, with a formation of firm nodules in the deeper layers of 
the cutis. On pressure with a glass slide the greater part of the 
discoloration disappears, leaving only greyish-brown spots, 
which at certain places may be more or less closely crowded 
together. After long periods telangiectasis may form. The 
nodular infiltrations by spreading at the periphery may become 
confluent, forming firm plaques; or they may involute spon- 
taneously, leaving a scar-like atrophy. As a most important 
point in determining the origin of lupus pernio Jadassohn has 
described the occurrence of typical lupus nodules on its surface 
or in its neighbourhood, wherefore he connects it with lupus 
vulgaris. reibich contests the tubercular nature of lupus pernio, 
since the cases observed by him gave no reaction to tuberculin. 
The disease is situated specially on the face (nose, cheek, 
ear), hands and feet, more rarely on the arm, back, or buttocks. 
The course is very chronic. The regular exacerbations in winter 
call to mind the chilblains of phthisical patients, which many 
authors consider also to have a specific tubercular character; the 
assumption of a common disposition of tuberculosis and pernio as 
a consequence of bad nutrition and circulation is probably correct. 
Lupus pernio is often combined with other tubercular skin 
diseases and tuberculosis of other organs, especially the joints, 
the tendon-sheaths, and the bones. 
The disease is characteristic. The pro- 


Anatomical 
Changes and 


Pp Diagnosis, q gnosis of the skin affection itself is not bad, 
ba at: ap but depends upon the complications. The 
eee treatment must be conducted on general 


lines, and requires no special description. 


6. LUPUS ERYTHEMATODES. 


The chronic form of lupus erythematodes is 


Anatomical a much discussed skin affection, which has 
Changes and been termed by Volkmann lupus  seborr- 
Symptoms. hoeicus, by Hebra seborrhocea congestiva, 


and by Unna ulerythema centrifugum. These synonyms indi- — 





TUBERCULOSIS OF THE SKIN 387 


cate both the prominent symptoms and the divergent views of 
dermatologists on the etiology of the condition. Whether the 
various forms can be due to one uniform cause must be left an 
open question. The histological changes begin by an inflamma- 
tion of the capillaries of the corium and papillz, leading to cell 
infiltration, epithelioid and glandular changes, and cicatricial 
atrophy. Many observers have noted its connection with the 
sweat glands, which in the diffusely infiltrated skin can be seen 
to be enlarged, and to have their walls thickened. Recently 
Arndt has discovered by means of the antiformin method tubercle 
bacilli and Much’s granules, so that now the long disputed tuber- 
cular nature has been proved for at least some of the cases. 

The characteristic early form of the condition is a round, 
red spot, on which is an adherent, dry, scaly or fatty seborrhoeic 
covering. On its under surface are one or more dimples, which 
correspond with enlarged openings of follicles. The process 
spreads centrifugally and very slowly, while in the centre a super- 
ficial, pale atrophy of the skin, which easily breaks down, appears 
without previous suppuration or ulceration. At one place several 
such spots may appear, and run together. Kaposi and most 
authors distinguish two chief varieties, the discoid and the dis- 
seminated or aggregated forms. The course is extremely slow 
and changeable, without the production of special symptoms. In 
severe cases deep, nodular infiltrations with dark coloration and 
thick crusts may form. 

The favourite site, as in lupus vulgaris, is the face, particu- 
larly the bridge of the nose and neighbouring parts of the cheeks, 
where it often assumes the butterfly form that is met with in other 
skin diseases. Also the ears, the neighbourhood of the eyebrows 
and the forehead may be affected, but very rarely the eyelids, the 
lips and the mucous membrane of the mouth. After the face the 
neighbouring part of the head is most often involved, leading to 
persistent falling out of hair in the diseased areas. More rarely 
the extremities are affected, but if so it is usually the fingers and 
toes which suffer. The disease usually attacks young, weak, 
anemic females, though older and stronger persons are not 
exempt. 

Occasionally an acute form of lupus erythematodes has been 
observed, in which with high fever and marked general disturb- 
ance there is a dissemination of numerous inflammatory nodules, 
especially over the face; it may even end in death. | 
Typical cases are easy to recognize, and an 
early form should always be sought for. In 
other cases the condition is not clear. The differential diagnosis 


Diagnosis. 


388 A CLINICAL SYSTEM OF TUBERCULOSIS 


must be first made from lupus exfoliativus. However, in the 
stage of the latter which it most resembles, the characteristic 
lupoid nodules can hardly be missed. Also the fatty, seborrhoeic 
covering is quite absent, whilst ulceration or deep scars are in 
favour of lupus. The covering in seborrhoeic eczema is not con- 
tinuous, and does not adhere so fast to the skin; this condition 
is not so sharply defined and leaves no scars. The butterfly form 
may be confused with acne rosacea, which, however, forms no 
seborrhoeic crusts, causes no scars, and is usually accompanied 
with acne pustules. Papular syphilides may be distinguished 
by their copper colour, the firmer infiltration, the more rapid 
course and the absence of seborrhoeic crusts. 

The prognosis of lupus erythematodes in 
regard to healing is difficult to make in 
individual cases. A treatment, which may be most successful in 
one case, may fail in another. On the other hand, even severe 
cases may recover spontaneously. The course of the disease is 
so changeable and unexpected that with all methods of treatment 
rapid relapses can never be guarded against. Chronic lupus 
erythematodes has never been observed to affect the general 
health. 


Prognosis. 


The best treatment is a combination of the 
internal administration of quinine, if pos- 
sible in large doses of 15 to 30 gr. a day, with daily local 
applications of tincture of iodine, till irritation is produced 
(Hollander). If with the appearance of inflammation an advance 
in the disease is seen, the iodine must be stopped. This principle 
applies to all methods of treatment. Good effects have also been 
ascribed to the internal use of phosphorus and arsenic, but they 
have not received general acceptance. 

Energetic rubbing of the diseased areas twice a day with 
soap spirit has been beneficial; after drying a 10 per cent. mer- 
curial or sulphur ointment may be applied, or the ointment may 
be used alone. Others do not employ ointments, and in conjunc- 
tion with internal remedies in early cases use cold compresses of 
lead lotion, and weak ichthyol solutions; in chronic cases strong 
ichthyol solution is recommended. 

As in lupus vulgaris, applications of hot air and the various 
freezing methods have given good results in lupus erythematodes. | 
Lassar advises that the glowing Paquelin cautery should be 
passed up and down over the diseased area without resting any- 
where. Hebra saw good results from frequent dabbing with 
equal parts of ether and alcohol. Also freezing twice a week with 
ethyl-chloride has sometimes produced a cure; according to the 


Treatment. 





TUBERCULOSIS OF THE SKIN 389 


recently published experience of the Bonn dermatological clinic 
the use of carbonic acid snow takes the first place of all methods, 
so that it should be applied to all fresh cases (LOhnberg). 

The more powerful remedies, which succeed in many cases 
of lupus vulgaris, must not generally be used for lupus erythema- 
todes; thus radical cauterization with pyrogallic acid and surgical 
treatment need hardly be considered. — Scarification, which was 
formerly much used, seems to be now quite given up. The many 
forms of light treatment have usually failed, but lately good 
results have been described from the use of Finsen light and 
radium. Hitherto very few observations have been made as to 
the effects of tuberculin. 

The general treatment must be adapted to the individual. 
Anemic and nervous disturbances and other predisposing 
causes must be attended to. The existence of a tubercular in- 
fection is to be particularly looked for. 


CHAPTER TXs, 


Tuberculosis of the Organs of 
Locomotion. 


1. TUBERCULOSIS OF THE MUSCLES. 


MUSCULAR tuberculosis is characterized by 
smooth or nodular tumours of the size of a 
pea to a hen’s egg, which lie within the 
muscle sheath, and between the displaced muscle fibres, and con- 
sist of tissue in a more or less advanced state of necrosis, contain- 
ing tubercle bacilli. There may be either typical epithelioid and 
giant cell tubercles between the muscle fibres, or, as in the form 
produced by secondary extension, there may be solely a firm in- 
filtration, with thick walls and caseation in the centre. Abscesses 
in the muscles of the abdominal wall have been found to be 
tubercular by the discovery of tubercle bacilli. Jonske found also 
in the intermuscular lymphatic glands of children with genera- 
lized tuberculosis specific changes with virulent bacilli, and 
tubercular foci, which escaped even very careful examination with 
the naked eye. On the other hand, the so-called *‘ nodular tuber- 
culosis of muscle affecting cattle’’ is according to recent re- 
searches either a form of pyobacillosis or of pseudo tuberculosis. 
Tuberculosis of the muscles either does not 
show itself at all, or only by interference 
with function, e.g., by difficulty in walking 
when it is situated in the quadriceps. The thirty to forty cases 
in the literature show that the muscles in the lower extremity in 
young people are chiefly affected. 

The primary development of tuberculosis in the muscles is 
hindered by the muscle juices and the lactic acid. The secondary 
form occurs by direct extension of the tubercular disease from a 
primary localization in bone or joint. 


Anatomical 
Changes. 


Symptoms and 
Course. 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 391 


An exact division between tubercular 
nodules, tubercular abscesses and_ tuber- 
cular myositis is more theoretical than practically possible. Be- 
yond the recognition of the already existing tuberculosis, for the 
diagnosis of extension into the muscle there are the movability 
of the tumour when the muscle is relaxed, and its fixation when 
the muscle is contracted, its spontaneous appearance in contrast 
with the intramuscular haematoma appearing after trauma, the 
spontaneous pain or tenderness on pressure, the situation below 
the fascia and the fact that the skin is unaltered and movable. 
The tubercular tumour of the abdominal muscles is_ painful, 
seldom larger than an egg, intimately connected with the 
abdominal wall, hard or fluctuating, does not move with respira- 
tion, and is fixed and seems to more or less diminish with con- 
traction of the muscle. Syphilitic gumma can be recognized by 
the history and result of treatment. The distinction from lipoma, 
fibroma, neuroma, and sarcoma will usually be possible. The 
chief point is not to forget the possibility of the occurrence of 
this rare condition. 


Diagnosis. 


The prognosis is good, though relapses 
are not rare. When there is also disease 
of the bones or joints this will govern the prognosis. 

The treatment consists of complete excision 
of the diseased nodule. The muscular sub- 
stance must not be spared. Injections of ro per cent. iodoform in 
glycerine are not to be recommended. Also simple incision and 
scraping give no certain results. Massage is contra-indicated. 


Prognosis. 


Treatment. 


2. TUBERCULOSIS OF THE TENDON SHEATHS AND 
BURSA. 


Three different anatomical forms of this 
variety of tuberculosis have been recog- 
nized. The first, hygroma, is characterized 
by the serous contents, in which, and also on the thickened 
fibrous capsule, the so-called melon-seed bodies are found. They 
are small, rounded, greyish-white, opaque, bodies of the size of 
a millet to a maize grain, which as a consequence of friction have 
been rubbed off the shaggy wall. The second form, the fungoid, 
presents diffuse, exuberant granulations, with thick masses of 
richly vascular connective tissue, the fluid being scanty and of a 
clear, turbid or hemorrhagic character. By the supervention of 
caseation the tubercular abscess of the tendon sheath or bursa is 
formed. The third and rarest variety is marked by great forma- 


Anatomical 
Changes. 


392 A CLINICAL SYSTEM OF TUBERCULOSIS 


tion of connective tissue with subsequent contraction. One form 
may change into another. . 
The clinical symptoms. are a feeling of 
deadness, dragging pains, weakness and 
limitation of movement of the affected part. 
The disease usually affects people in the third decade, who are 
hard manual workers. It most often appears at the flexor surface 
of the wrist or in the prepatellar bursa. Like tuberculosis of the 
muscle, it is not rarely primary, but more commonly it is a 
secondary metastatic condition, due to a lowering of the resist- 
ance of the tissues on account of some injury. It usually runs 
a very chronic course; often the disease spreads into the tendons 
themselves, or into neighbouring tendon sheaths or joints. Or 
the skin may become red and thinned, and gradually broken, 
whereby ulceration and fistulae are produced. The extension 
into the tendons causes them to be thickened, adherent or even 
destroyed. 


Symptoms 
and Course. 


The diagnosis rests on the presence of an 
indolent, fluctuating or doughy swelling at 
the site of one of the tendon sheaths. If free melon-seed bodies 
are present crackling may be detected. The discovery of tuber- 
culosis in another organ is important. The regional lymphatic 
glands are only exceptionally involved; fever is absent. The 
differential diagnosis must be made from sarcoma, which grows 
quickly and spreads from the bones, from fibroma, which does 
not fluctuate, and from gumma, which is usually situated on the 
extensor surfaces and yields to iodides. Tuberculin or an explora- 
tory incision will settle the doubt. 

The prognosis is not unfavourable if timely 
measures are taken, and is even good, since 
permanent limitation of movement can be thus prevented. 

The treatment of serous hygroma consists 
of puncture, injection of 10 per cent. 10do- 
form-glycerine and passive congestion. If this does not produce 
a cure, or if melon-seed bodies are present, a free incision should 
be made, the melon-seed bodies removed, and phenol applied after 
Menciére’s method. This consists of soaking all the affected 
parts with pure carbolic acid for one minute, neutralizing with 
alcohol, and then closing the tendon sheath and skin with suture. 
According to Wetterer tuberculosis of the tendon-sheath, even if 
it is accompanied by the formation of melon-seed bodies, reacts 
well to deep rays. The favourable action of the Rontgen-rays in 
these conditions when not deeply situated is due to their direct — 
action on the tubercular granulation tissue, which is twice as sensi- 


Diagnosis. 


Prognosis. 


Treatment. 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 393 


tive to the rays as normal skin, and can therefore be destroyed 
without cutaneous injury. ; 

In the fungoid form radical removal of the diseased mem- 
brane, that is excision of the affected tendon sheath, followed by 
treatment with glycerine of iodoform, is required. Since the 
functions of the tendons are often affected, in all cases quite early 
movements and massage are necessary. 

Recently Batzner, Jochmann, and others have recommended 
trypsin, a 1 per cent. solution of which is injected to the amount 
of I c.c. twice a week into the affected part. The trypsin solution 
takes the place of the leucocytosis which is absent in tubercular 
processes; in consequence of the action of the ferment hyper- 
emia with cellular infiltration and proliferation occur, the tuber- 
cular foci are peptonized and absorbed, while the more resistant 
cells in the healthy tissue are unaffected. According to Klapp 
and Brinig trypsin holds tubercular suppuration in check, and 
is Superior to all other methods in the treatment of tuberculosis 
of the tendon sheaths and bursez. The experience at the Kiel 
surgical clinic was not so good; hygroma and fungoid conditions 
of the tendon sheaths showed no tendency to recovery after tryp- 
sin injections; in fact in the case of the former condition they were 
followed by so much pain that the patients demanded an opera- 
tion. 


It is possible that these different results may be due to differences in 
the preparation. Batzner recommends as the most active, purest, and most 
durable preparation of trypsin that of Fairchild Bros. and Forster, of 
New York. 


From our own experience we can warmly recommend the 
trypsin treatment for these cases. It is easier to apply than the 
iodoform-glycerine method, the amount of each injection being 
so much smaller; it is followed by but little general or local 
reaction; toxic symptoms are absent; and it can be carried out 
as an ambulant treatment by the practitioner. 


3. TUBERCULOSIS OF THE BONES AND JOINTS. 


Tuberculosis of the bones and joints diminishes in frequency 
with advancing age; and both in children and adults it is quite 
rarely a primary disease. [Even when this form of disease occurs 
in an active form in children or adults free from hereditary 
tendency, when no point of entrance of the bacilli can be found, 
it is generally not the first localization of tuberculosis in the body. 

F. Konig found in 79 per cent. of the cases on post-mortem 
examination old tubercular foci in the lungs and glands, more 


394 A CLINICAL SYSTEM OF TUBERCULOSIS 


rarely in the urogenital tract, which were the source of severe or 
fatal tuberculosis of the bones or joints. But there still remains 
about 20 per cent. of the cases in which an autopsy does not reveal 
any old, primary nodules. Although not finding a tubercuiar 
focus in the dead body is not identical with freedom from tuber- 
culosis, one cannot deny under some conditions the possibility of 
primary tuberculosis of the bones and joints, especially in 
children, in whom scrofulous eczema of the skin, the easy vulnera- 
bility of the tissues, and permeability of the normal mucous 
membrane to tubercle bacilli, afford frequent opportunities of 
infection. 

With regard to the infecting agent recent observations have 
shown that in surgical tuberculosis, of which affections of the 
bones and joints are the most common, the bovine bacilli play a 
large part. Raw rightly draws attention to the marked difference 
in the course of pulmonary and surgical tuberculosis. The former 
is usually the only tubercular disease in the body, affects com- 
monly young adults, and claims most victims between 30 and 40 
years. The latter usually appears at several spots, affecting 
simultaneously the bones, joints, vertebra, or glands, and occurs 
chiefly in infants and children. It appears, therefore, that there 
are two different forms of infection, which resemble each other to 
a considerable degree, one being due to bacilli of the human type 
and the other to bovine bacilli. Raw saw no surgical tuberculosis 
in Siam, where cow’s milk is not- drunk. 

There is a fundamental difference between the articular tuber- 
culosis of children and adults, in so far as in children it is usually 
the first manifestation of the disease, while in adults as a rule 
there is an already existing, obvious tuberculosis of some organ. 
In both cases the bacilli reach the bone or joint from the primary 
focus through the circulation, more rarely by way of the lym- 
phatics. The hematogenous infection explains the occurrence of 
the disease in young persons without other obyious tubercular 
localization. |For the same reason the formation of tubercle in 
bones is connected with the nutrient vessel, the bacilli in the blood 
lodging most readily in the vascular tissue of growing bones. 
Traumatism, pregnancy, the puerperium, acute infectious diseases 
in childhood, especially measles and whooping-cough, are predis- 
posing causes. 

To sum up, we may say that a primary tuberculosis of the 
bones and joints is possible at any age, but that the secondary 
form is considerably more common, both in tubercular adults and 
apparently healthy children. | Whilst in the latter the primary 
focus usually lies latent in the bronchial glands, in adults it is 
usually in the lungs, and is manifest. 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 395 


The best arrangement will be to describe the anatomical 
changes, symptoms, course, and diagnosis of tuberculosis of the 
bones separately from the joints, and then to consider the pro- 
gnosis and treatment together. 

The tubercular foci in the bones appear in 


Anatomical different forms. 
Changes in Tubercular osteomyelitis of the phalanges 
Tuberculosis of nearly always occurs by itself in young indi- 
Bone. viduals; it has also been called spina 


ventosa. 

Rarefying ostitis, or caries of the bone in its strict sense, 
includes the infection of the spongy bone near the joints. By 
rarefication of the bony frame-work and growth of granulation 
tissue, a rounded or cylindrical defect is produced, in which lies 
a soft, crumbling sequestrum, embedded in granulations. If the 
disease advances it may break into a joint, or spread up the shaft 
and pass through the bone and periosteum (periosteal tubercu- 
losis). 

A tubercular wedge or infarct is formed if any artery in the 
bone is blocked by tubercular material. The infarct lies with its 
base towards the cartilaginous surface, and is yellow and hard; 
in consequence of circulatory disturbance it becomes loosened 
from its surroundings, and forms a yellow sequestrum, which its 
not rarefied, since the process occurs rapidly and acutely. From 
irritation by the sequestrum the surrounding bone becomes 
gradually broken down; the cavity grows larger, and the seques- 
trum is gradually dissolved, so that at last a large abscess without 
sequestrum remains. 

To these must be added the so-called proliferative, progres- 
sive tuberculosis of bone, which rapidly spreads in the Haversian 
canals from the shaft towards the joints, and quickly caseates. 

At the commencement of the disease all 


Symptoms and jocal symptoms are often absent; if pains 


+ ape of ¢ occur they are due to involvement of the 

! - ye aes ° 

er euos!s 0 neighbouring joint, the periosteum or the 
Bone ; 2d 


soft parts. When the periosteum 1s 
affected a swelling rapidly forms, with tenderness on pressure and 
cedema of the skin. As the disease spreads in consequence of 
thickening of the affected bone there will be swelling, pains, 
especially in tuberculosis of the bone-marrow, and obvious dis- 
turbance of function, the last as a consequence of foci forming in 
the epiphyses near large joints, such as the knee and hip. 
External discharge and fistulz occur secondarily, or if not, a cold 
or congestion abscess forms, which reveals the state of affairs. 
The general condition is usually but little affected, sometimes 


390 A CLINICAL SYSTEM OF TUBERCULOSIS 


‘ 


not at all; weakness and tiredness are the earliest signs. The 
temperature is commonly perceptibly raised; after rupture of the 
abscess it falls, but if mixed infection occurs it becomes much 
higher. In most cases the disease runs a chronic course, but it is 
not uninfluenced by the progress of the primary disease. 

The diagnosis is easy if it occurs in a super- 
ficial bone in a tubercular subject. There 
is more difficulty in the differential diagnosis 
of the primary form, and of those secondary 
cases 1n which the obvious disease is limited to the bone or bone- 
marrow. 

Tuberculosis attacks particularly the short bones of the fingers 
and toes, the carpus and tarsus, the sternum, the ribs, the verte- 
bree, and lastly the epiphyses of the hollow bones, while the 
diaphyses and all the flat bones are rarely affected. 

Tuberculosis of the phalanges of the fingers, the so-called 
spina ventosa, is characterized by a firm or elastic enlargement of 
the bone, by spontaneous discharge of a thin fluid, with caseous 
débris mixed with the pus, by fistula: with caseous base and under- 
mined edge, and by passage of the probe through the bone into 
the medulla. 

Tuberculosis of the long bones has a greater predilection for 
the epiphyses than other acute and chronic diseases. Acute 
infective osteomyelitis is also distinguished by its great painful- 
ness, by the uniform swelling without fluctuation or inflammation 
of the soft parts, and by the great disturbance of function. 
Metastatic and embolic inflammatory affections of bone occur as 
a result of pyzemia, enteric, scarlet fever, measles, &c. Chronic 
non-tubercular ostitis, periostitis, and osteomyelitis either develop 
out of the acute form, or follow an acute infectious disease (scarlet 
fever, enteric, &c.) first as a latent, then as a chronic, affection, or 
are due to syphilis or actinomycosis. 

A careful history and exact examination into the earliest 
symptoms will throw light on the subject. The presence of tuber- 
culosis in another organ, and a focal reaction after a test tuber- 
culin injection, indicate tuberculosis with certainty; while 
syphilitic antecedents, a positive Wassermann reaction, and the 
improvement under iodides indicate syphilis. Actinomycosis is 
rarer, and can be recognized by the sulphur yellow granules in 
the discharge, which is rather gelatinous and mucoid than puru- 
lent. 


Diagnosis of 
Tuberculosis 
of Bone. 


Some of the discharge containing granules is pressed between cover-slip 
and slide, and in the unstained preparation the irregularly-shaped clumps 
of mycelial threads with their stellate and club-shaped projections can be 
recognized. 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 397 


Tuberculosis of the ribs and sternum forms a very slowly 
growing, soft, painless swelling on the thoracic wall, which soon 
gives fluctuation; sometimes pains appear later. Branching 
sinuses facilitate the diagnosis; a cold abscess makes it more 
difficult. Pain and pressure behind the sternum and breathless- 
ness raise a suspicion of sub-sternal abscess. — Peripleuritic 
abscesses, which pass out through the intercostal space and 
fluctuate, are rare; they cause circumscribed dulness, below 
which is a resonant note, thus differing from empyemata. 

Tubercular spondylitis, which attacks specially children, and 
is met most often in the dorsal part of the vertebral column, causes 
as early symptoms tiredness on walking, sometimes dragging or 
stabbing pains in the back and legs, loss of appetite, peevishness, 
and sometimes in the evening slight rises of temperature, without 
any alteration in the shape of the vertebrae. Gradually the patient 
begins to spare the vertebral column, and to guard it against 
movements ; then pains on pressure or jarring appear. Wohlauer 
recognizes as the first symptom of lumbar spondylitis sciatic 
pains. Later, in consequence of compression of the spinal cord, 
the legs become paralysed, and the bladder and rectum are often 
affected. In less acute cases these paraplegic symptoms develop 
very slowly or not at all, for severe pains may be the only signs 
of pressure. In the second stage one or more of the vertebral 
processes distinctly project, and a curvature is formed. 

Cold abscesses are characteristic of spondylitis; in affections 
of the cervical vertebre retropharyngeal or retrotracheal abscesses 
may form, and with disease of the lower thoracic or upper lumbar 
column psoas, iliac, dorsal or gluteal abscesses. Sometimes mus- 
cular contractions develop; for example, in the psoas muscle, 
producing flexion and internal rotation of the leg. With disease 
between the atlas and occiput nodding becomes impossible, and 
if between the atlas and axis turning the head to the side is 
affected. © Spontaneous luxations and subluxations may _ also 
occur with spondylitis of the cervical vertebre. 

For the differential diagnosis it may be noted that arthritis 
and spondylitis deformans usually occur in elderly people, and 
that traumatic inflammation of the vertebrze most often is seen in 
men in the prime of life, and is not associated with suppuration 
and cold abscesses. Osteomyelitis is rare, and comes on acutely 
with high fever and localized pains. Syphilis in this position is 
extremely uncommon. 

The value of the subcutaneous tuberculin test for the recog- 
nition of tubercular disease of the bones has been already men- 
tioned. It has the advantage over v. Pirquet’s method that the 


398 A CLINICAL SYSTEM OF TUBERCULOSIS 


focal reaction indicates the localization of the disease. Neither 
the propagation nor the generalization of tuberculosis is to be 
feared from the tuberculin reaction. In connection with v. 
Pirquet’s cutaneous reaction the experience of Wilms may be 
mentioned, that it is absent in cases of fungoid tuberculosis 
wherever it is situated, also that it may be negative in persons who 
are not yet cachectic. It may be noted that the relatively favour- 
able form of bone tuberculosis gives a very intense reaction to 
tuberculin, a sign of the energetic response of the organism 
against the infection. Besides human tuberculin bovine prepara- 
tions are also useful, a fact in support of the view that surgical 
tuberculosis is largely due to a bovine infection. 

The tuberculin diagnosis should be followed as soon as 

possible by a Réntgen-ray photograph; examination with the 
screen is also very useful. 
The frequency of tuberculosis of the 
epiphyses is of importance in the produc- 
tion of disease of the joints. This condition 
by extension may break through the carti- 
lage, or may loosen or destroy it entirely, 
or may pass round it at the place of insertion of the capsule, and 
thus set up an intracapsular infection of the joint; this is the 
osteogenic form of tuberculosis of the joint. Tubercular disease 
in the bone may also by infection of the periarticular soft parts 
cause extracapsular disease; thus is produced a cold abscess, 
which may discharge externally, or break through into the joint. 
Thus we have a secondary osteogenic joint tuberculosis. 

According to earlier views quite three-fourths of all cases of 
tuberculosis of joints were infected from the bone. But recently 
it has been generally denied that primary synovial joint tubercu- 
losis is less frequent and important than the osteogenic form. 

Synovial tuberculosis generally arises from bacilli which are 
brought by the blood-stream to the capsule of the joint, the irri- 
tation of the synovial mucous membrane leading to a_ sero- 
fibrinous exudation, which is particularly rich in coagulative 
substances. The fibrin settles on the walls of the joint, becomes 
organized, and furnishes fresh ground for the formation of 
tubercles. Tubercular granulations are thus produced, which 
lead to destructive action on the tissues of the cartilage and bone, 
to thickening of the synovial membrane, and to caseation and 
suppuration. According to the predominance of one or the other 
process any tubercular inflammation of the joint may form 
hydrops tuberculosus, or the miliary, fungoid, or fibrous form of 
primary synovial tuberculosis. 


Anatomical 

Changes in 

Tuberculosis 
of the Joints. 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 399 


The most common form is the fungoid, in which flabby, red 
granulations studded with tubercles develop in the synovium, and 
the serofibrinous effusion changes into caseous, granular pus. 
Fungoid joint, white swelling, tubercular suppuration of the 
joint, and cold abscess are different names for the same patho- 
logical condition. 

The suppurative form occurs especially in the knee and hip, 
while the fibroid form, or caries sicca, generally is met in the 
shoulders. 

If the disease passes through the capsule of the joint, either 

periarticular inflammation, suppuration, or congestion is set up, 
as in tuberculosis of the bone. 
The early symptoms generally appear 
gradually, but the onset may be more or 
less acute. The first subjective symptom ts 
pain on use of the joint; the earliest objec- 
tive sign is a general swelling of the joint. 
As the pain increases the patient places the joint in the position 
in which it is easiest; and as result of mechanical and reflex 
irritations contractions may appear. If the disease progresses 
the swelling, fixation, and pain increase, and suppuration, with 
high fever, fluctuation and localized tenderness, appears. Spon- 
taneous luxation and cold abscesses make the disease more 
obvious, while a later stage is reached if the pus breaks through 
the skin and the disease becomes open. Secondary infection and 
long continued septic changes lead to amyloid degeneration of 
the kidney, liver and spleen. The general condition then usually 
changes considerably, the fever becomes less or greater, or may 
be entirely absent. Loss of appetite and diarrhoea augment the 
wasting of the already anemic patient. 

The course of the disease is slow, usually lasting several 

years. Children are most often affected. 
. According to Billroth tuberculosis most 
often attacks the knee, after that the hip, 
the foot, the elbow, the hand, the shoulder, 
and the fingers. 

The symptoms will differ according to the function and 
structure of the several joints; the following indications will be 
sufficient for the thoughtful practitioner. 

When the knee is affected the first sign of swelling will be 
that the hollows round the patella are not so clear on the affected 
as on the sound side; the contours become gradually effaced with 
increasing swelling till the typical fusiform appearance is pro- 
duced. In the early stage pressure or movement are required to 


Symptoms and 
Course of 
Tuberculosis of 
the Joints. 


Diagnosis of 
Tuberculosis 
of the Joints. 


400 A CLINICAL SYSTEM OF TUBERCULOSIS 


elicit pain. The swelling will feel firm or doughy according to 
the predominance of the disease in the ends of the bones or in 
the synovial membrane, and according to the amount of implica- 
tion of the periarticular tissues. The signs in suppuration of the 
joint are the same as in hydrops tuberculosus, viz., fluctuation 
with characteristic swelling and floating of the patella. As 
secondary results the following contractures may occur: (1) 
flexion with outward rotation; (2) abduction and genu valgum, 
according to whether the leg is rested or moved. Also luxation 
and subluxation backwards may appear, if the capsule is long 
distended with much fluid. 

Tubercular disease of the hip can be divided into three stages, 
which nearly always occur more or less distinctly. Bodily dis- 
comfort, slight tiredness, loss of appetite, and slight evening rise 
of temperature usher in stage I, in which the patient limps 
slightly, has slight pains on standing and walking, in the knee, 
more rarely in the hip or foot, and shows limitation of movement 
of the hip joint; typical in its regularity is also a dragging pain 
down the inner side of the thigh to the knee. In stage II the 
thigh becomes distinctly flexed, rotated outwards, and abducted; 
the thigh on an average being flexed to 135°, and the leg being 
apparently lengthened. Often a swelling or thickening of the 
joint can be detected, with tenderness or pain on pressing the 
trochanter, or on tapping the sole of the outstretched leg; also 
limitation of rotation, and pain on extension and rotation are 
characteristic. In stage IIl adduction, internal rotation, and 
more marked flexion, with an apparent shortening of the affected 
leg appear in consequence of changes in the joint, and atrophy of 
the muscles from disuse of the leg. The soft thickening of the 
capsule may give rise to pseudo fluctuation; and in the majority 
of the cases suppuration will occur, with perforation anteriorly 
(extensor abscess), or internally (adductor abscess); more rarely 
the abscess extends into the buttock, the perinzeum, or the pelvis. 
Obvious fluctuation or the formation of sinuses near the joint 
indicate the occurrence of purulent inflammation. Later a back- 
ward dislocation on to the ilium may occur, with a real shortening 
of the limb, on account of changes in the socket, destruction of 
the head of the femur, separation of the epiphysis or over-dis- 
tension of the capsule. Abscess formation or separation of the 
epiphysis are to be feared if, after a painless period, fresh pains 
appear. With the Rontgen-rays the circumscribed atrophy of 
the bone on the affected side is very characteristic of tubercular 
coxitis. 

Tuberculosis of the foot often attacks several joints of the 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 401 


tarsus at the same time. The ankle joint is most often affected. 
With effusion the foot takes a position of plantar flexion, and the 
joint capsule bulges at four points, anteriorly in front of the inner 
and outer malleolus, and posteriorly on each side of the tendo 
Achillis. Pain and swelling indicate disease of the other joints. 
The most common form is the fungoid, more rare is the exudative 
followed by abscesses and sinuses. 

In tuberculosis of the elbow joint, which is less often due to 
bone disease (head of the radius, olecranon, lower end of 
humerus) than in the other joints, the capacity of movement is 
gradually limited, especially pronation and supination. With 
pains, which are often severe, the joint swells, and becomes fixed 
at a right angle. The joint becomes spindle shaped, and the 
muscles atrophy. The surrounding tissues feel doughy, or soft 
and elastic; the skin is smooth and shining. On the dorsal 
surface on each side of the triceps tendon elongated swellings 
form, consisting of the swollen and infiltrated capsule. The 
swollen capsule is particularly obvious on the outer side between 
the olecranon and the head of the radius. It may either give a 
feeling of fluctuation (effusion) or a soft elastic sensation (granu- 
lations). The normal movement is often much limited; some- 
times there is abnormal lateral movement from loosening of the 
ligaments. If sinuses form, they are usually behind. Tubercu- 
losis of the elbow often follows injury in young people. 

Chronic inflammatory affections of the joints of the hand are 
almost without exception tubercular, gonorrhoea is the only other 
cause. Swelling, abscesses, and sinuses form. From gradual 
softening of the ligaments the hand becomes abnormally movable 
on the forearm, both to the radial and ulnar sides, also sub- 
luxation may occur. On passive movement crepitations may be 
detected. 

~ Tuberculosis of the shoulder joint is not common; in child- 
hood it is even rare. It appears usually as the fibroid form, or 
caries sicca, very rarely as a white swelling. The roundness of 
the shoulder is lost. An axillary luxation with falling-in of the 
soft parts below the acromion is simulated. In contrast with a 
true dislocation the thickened head of the humerus can be felt 
beneath the acromion. The alterations in shape occur gradually. 

Tuberculosis of the finger joints is very rare, it usually arises 
from a spina ventosa. Almost without exception it then takes the 
chronic synovial form, which finally leads to ankylosis. Some- 
times disease of the finger joints leads to an affection of the 
tendon sheaths. 


The differential diagnosis must be made from arthritis de- 
26 


402 A CLINICAL SYSTEM OF TUBERCULOSIS 


formans in older persons, from traumatic joint inflammation, 
which is shown by the history, from osteomyelitic affections, 
which run an acute course with high fever and severe pains, from 
gonorrhceal disease, which is usually bilateral and often very pain- 
ful, from rheumatic and gouty joints, which can be recognized by 
the results of treatment, from metastatic inflammations due to 
enteric fever, small-pox, scarlet fever, influenza, toxemia and 
pyemia, and lastly from syphilitic joints. 

For establishing the diagnosis there are also the Ro6ntgen- 
ray examination, and the use of tuberculin, especially by sub- 
cutaneous injection, so long as it is not contra-indicated by fever, 
marasmus or severe joint pains. The focal reaction consists of 
swelling and increased pain; tubercular sinuses, if present, dis- 
charge more freely. 

The prognosis of the disease either in bone 
Prognosis _ OF joint is the more favourable the smaller 
of Tuberculosis the tubercular focus at the commence- 
of Bones and ment of treatment, and the better the 
Joints. general condition. But in all cases there 
is a danger of a return of the disease, even after many years, 
except in those cases in which a successful operation has radically 
removed the whole focus. In the secondary cases the prospects 
of recovery also depend on the state of the primary disease. 
Tuberculosis of bone or joint is much more serious, for example, 
with advanced renal tuberculosis than with early disease in the 
lungs or glands. Wiauth this is connected the better prognosis in 
young people; the disease in children is much more often localized 
and uncomplicated. 

Under similar conditions the prognosis of tuberculosis of the 
bones is better than that of the joints. The recovery of the latter 
usually takes far longer; in purulent cases death from marasmus 
and amyloid disease is much commoner than in the fungoid. The 
prognosis is not the same for the different joints; it is worse in 
those which carry the most weight, and therefore disease in the 
hip and knee is the most unfavourable. Nevertheless, under 
suitable treatment 20 per cent. of cases of tubercular coxitis re- 
cover with a fully movable joint and perfect gait, and 50 per cent. 
of cases of tubercular inflammation of the knee result in ankylosis. 
Here the prognosis chiefly depends on whether the disease is open 
or closed; in the latter it is much worse on account of the danger 
of mixed infection in spite of every care. 

Thanks to modern methods of treatment the statement of 
Billroth is no longer true, that patients with healed tuberculosis 
of the joints do not live to become old, and that of children cured 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 403 


by operation only the minority reach puberty. But it still holds 
good that the gravity of tuberculosis of the bones and joints must 
not be underestimated. 

In the treatment it must not be forgotten 
that the power of resistance of the whole 
organism against the infection is lowered. 
It must ‘therefore be the first-care of the 
practitioner to employ general hygienic 
treatment, with the maximum of fresh air and sunlight. To these 
measures may be added cod-liver oil or malt extract, according 
to the individuality of the patient. In no case must one be con- 
tented merely to order increase of the food; on the contrary, over- 
feeding, especially if associated with deficient mastication and 
digestion, 1s to be avoided. Particularly the amount of meat 
must be limited, and the vegetables and fruits increased. Sea- 
air, mountain climate, salt and sun baths with frictions may all 
be useful aids, but they are not necessary for adults, and by them- 
selves they are ineffective. 

With the general constitutional measures must be combined 
local treatment of the affected bone or joint, in order to obtain 
healing with the least disturbance of the function and movement 
of the part. This local treatment may be surgical or conservative. 

The conservative method may be first considered. Rest and 
relief of pressure are necessary in all cases of tuberculosis of the 
joints or neighbouring bones, in order to diminish the pain on 
movement, and the injurious effects of direct pressure on the 
diseased part, and to prevent the shortening of muscles and liga- 
ments and therefore the occurrence of flexion. In joint tuber- 
culosis permanent extension, to separate the diseased joint sur- 
faces and to promote the absorption of effusion, is useful. 
Whether these ends are attained by orthopedic apparatus (Hess- 
ing’s bandage) or plaster of Paris, or by permanent or removable 
extension apparatus, is not so important as that the apparatus 
should fit well, give relief and prevent movement. 

The conservative treatment of the most frequently affected 
joints can be carried out as follows: In tubercular coxitis can be 
recommended the application of a long plaster of Paris case with 
an extension stirrup, reaching from the lower ribs to the ankle, 
by which strong extension can be produced. It is agreed that it 
is preferable to the short apparatus reaching to the knee of Dol- 
linger. The leg is to be put up in a position as nearly straight 
as possible; and the straightening must take place with great 
care, in old hip cases in stages, if necessary after sub-trochanteric 
osteotomy. When an abscess or sinus is present an opening may 


Treatment 
of Tuberculosis 
of Bones and 
Joints. 


404 A CLINICAL SYSTEM OF TUBERCULOSIS 


be made in the plaster case, while after this is removed Hessing’s 
bandage, or a light splint, is to be recommended. Tubercular 
disease of the knee may be treated either with a carefully fitted, 
removable splint, or by plaster of Paris, leaving the pelvis free 
and reaching to the ankle, a stirrup being added by which exten- 
sion can be applied if the pains are severe. If the stirrup is not 
employed the foot must be fixed with the plaster bandages. The 
apparatus must be applied in the most extended position possible. 
Faulty positions must be corrected by degrees without using 
force; in old cases with marked subluxation extra-articular, 
supracondylar osteotomy will be necessary. For the after- 
treatment Hessing’s apparatus will be useful. For the other 
tubercular joints the methods used must be modified according 
to the nature and position of the joint. Thus, if the foot is 
diseased, it must be fixed by plaster reaching from the knee to 
the toes, and possibly the apparatus may be strengthened by 
letting in a steel sole. For joint disease in the upper extremity 
extension may usually be omitted and the fixation procured by a 
splint. Rest of the vertebral column may be best procured by a 
plaster corset, embracing the pelvis, since the column partakes 
in every movement of the hips; if the disease is situated above 
the fifth cervical vertebra the head must be fixed. 

As aids to the conservative treatment there are the congestive 
hyperemia of Bier and the suction method of Klapp, which may 
be employed when the disease is so localized as to be suitable, or 
when cold abscesses or tubercular sinuses have formed. The con- 
gestion should be induced by means of an elastic bandage applied 
two to three times a day, in such a manner as to produce marked 
hypereemia, without the peripheral part becoming cold and with- 
out the production of pains or parzesthesiz. The length of the 
congestion periods has been lately considerably increased, and 
the bandage has also been employ ed through the night; an in- 
crease in the inflammation is thereby produced, which, like the 
use of tuberculin, leads to reabsorption, fibrous tissue growth and 
encapsulation. The congestion works the better the hotter the 
diseased area; it is therefore recommended to warm the affected 
part before the application of the bandage by means of alcohol 
compresses or hot-air baths. The diseased area must not be 
surrounded with bandages during the application of the treat- 
ment. The idea that this method favours the formation of 
abscesses appears not to be correct. Cold abscesses may be 
punctured or opened under aseptic precautions, but they must 
not be scraped with a sharp spoon; afterwards congestion is to 
be again used. If they are not scraped, mixed infection need not 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 405 


be feared. Small cold abscesses may also be treated by suction 
with the cupping-glass. After preliminary disinfection with 
iodine tincture the abscess is to be opened by a puncture with the 
scalpel, and the suction-glass applied at first every day, later 
once or twice a week. Tubercular fistulz can also be treated with 
the suction-glass, without being scraped with a suarp spoon. 
It is only necessary to cover the skin round the abscess or fistula 
thickly with lanolin-vaseline before the use of the suction or 
bandage, in order to prevent it being macerated and infected by 
the pus. To obtain good results the suction treatment must, as 
a tule, be applied for a long time. According to Bier, the ‘con- 
gestion method must not be used with iodoform injections. 

The oldest and still most popular of local applications is the 
injection of 10 per cent. iodoform-glycerine into the tubercular 
foci. The iodoform and glycerine are first separately sterilized 
by heating to 100° C., after cooling they are mixed in a sterile 
vessel, and every two to four weeks are injected in the amount 
of 2 to 10 c.c., according to the age of the patient and the size 
of the diseased focus or the joint; the latter is to be afterwards 
carefully moved and massaged. The effect of this, according to 
Heile, is to cause the leucocytes to collect and to form leucocytic 
ferment, and thereby to peptonize tubercular pus, so that it can 
be reabsorbed. Cold abscesses must be first treated by aspiration 
of the pus. After a time toxic symptoms, such as headache, 
sleeplessness, peevishness, hallucinations, nervous and _ gastro- 
intestinal symptoms, albuminuria, hematuria, must be looked 
for. Recently iodoform as the iodoform bone stopping of 
Mozetig-Moorhof has been more used for tubercular disease of 
the bones and joints. It is now agreed that this treatment con- 
siderably shortens the tedious process of healing, and that it 
avoids the formation of ugly, painful, deep scars reaching down 
and into the bone. The indications for and mode of employ- 
ment of this method in individual cases must be left to the judg- 
ment of the surgeon. 


According to the original directions the iodoform bone-stopping consists 
of 60 parts iodoform and 4o parts each of spermaceti and sesame oil. It 
must be sterilized with the following precautions: All three ingredients, 
which have been separately sterilized, are mixed in a sterile flask and heated 
in a water-bath to 80° C., to which temperature they are exposed for fifteen 
minutes. When the flask is removed the contents will have become liquid, 
and may be mixed by prolonged shaking. It is most important that the 
mass should solidify while the shaking is producing a thorough emulsion of 
the iodoform. At ordinary room temperature the stopping becomes a firm, 
yellow mass, which before use must be melted at a temperature of 60° C. 
The composition can be kept for a long time in a hermetically-sealed flask, 
and is ready for use in a few minutes. After being melted it must be well 


406 A CLINICAL SYSTEM OF TUBERCULOSIS 


shaken, and then poured into the prepared cavity. Toxic effects are only 
rarely observed, and then when large quantities of the stopping have been 
used. 


Into small foci of bone the trypsin solution that has already 
been mentioned can be injected in 1 per cent. solution; in many 
cases it acts very much better than the iodoform-glycerine. Good 
results have been observed from its use in fistulas, into which it 
can be injected, in ulceration of the soft parts when it 
can be injected or applied on sterile gauze, and in abscesses, into 
which it can be introduced after previous aspiration of the con- 
tents. By means of trypsin even primary foci that are accom- 
panied by erosion of the bone and very purulent sinuses may be- 
come healed, provided that they are accessible to the injections. 
Lexer, Sohler, Briinig, Schaack and others consider that trypsin 
injections are contra-indicated in joint disease, which is pro- 
ducing severe pains, fever and rigors, such as only occur in 
inveterate cases (separation of joint cartilage). | According to 
observations in the Berlin surgical clinic, on the other hand, even 
severe cases of suppurative joint disease with sinuses were healed 
by means of trypsin without other treatment, the destroyed carti- 
lage being regenerated and the functions of the joint maintained. 
Therefore trypsin is not only serviceable in the conservative treat- 
ment of tubercular disease of the bones and joints, but also as 
an adjuvant to radical measures; thus the use of trypsin in articu- 
lar and para-articular abscesses may improve operation results. 
In the Berlin surgical clinic the injections of trypsin were com- 
bined with injections of 60 per cent. alcohol. This latter is par- 
ticularly recommended for those cases in which a growth of thick 
and firm connective tissue is required, and in which exuberative 
granulations require to be reduced. To avoid pain, Klapp first 
injects 1 c.c. of } per cent. solution of novocain before the alcohol 
injection, which when possible should be given daily at several 
spots in the peritubercular tissue, and lastly into the tubercular 
focus; by constantly choosing fresh spots for injection he pro- 
duces a gradual diminution in the extent of the disease. 


Some English authors have recommended in place of iodoform- 
glycerine a solution of iodoform 5, ether 10, guaiacol and creosote 4a 2, 
olive oil 100 parts, with which they obtain healing in 95 to 908 per cent. of 
the: cases. 

Franke, W. Wolf, and others see in tincture of iodine an almost 
sovereign remedy for tuberculosis both of the bones and the soft parts; after 
evacuating the pus and removing the tubercular granulations with a sharp 
spoon, the whole wound is thoroughly wiped out with 10 per cent. tincture 
of iodine. 

Delvez and V. Winiwarter, in cases of closed tuberculosis of the bones, 
joints, or soft parts with intact skin and without softening or abscess 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 407 


formation, especially in early cases, inject liquid soap with an equal part 
of water or alcohol into the diseased tissue, generally to the amount of 
2 to 3 c.c., quite slowly through a hollow needle or fine trocar, and then 
apply immobilizing bandages. If the injection produces fairly severe pains, 
and next day a strong local reaction, it is not repeated for 8 to 10 days. The 
liquid soap acts as an antiseptic, without destroying the vitality of the 
tissues. 

Novoiodine has also been recommended for open tuberculosis with 
suppuration ; it 1s odourless, non-toxic, and has a strong deodorizing action, 
it diminishes the flow of pus, it drys up purulent wounds and sinuses, and 
leads to the formation of new, more healthy granulations. 

Inunctions of 10 to 25 per cent. iothion has been praised in tuberculosis 
of the joint without implication ot the bone. 

Carbenzyme, an aseptic carbohydrate ferment, is very useful as a powder 
for tubercular ulcerations of the soft parts, or injection as a 5 per cent. 
solution into tubercular fistula, abscesses, or ganglions. Since after a sub- 
cutaneous injection of radiolcarbenzyme a death from tetanus infection has 
been seen, it seems that the choice of this preparation is forbidden. In the 
Berlin surgical clinic sterilized carbenzyme in doses of .25 grm. in sealed 
glass tubes has been employed. 

Beck’s injections of bismuth paste (bismuth subnit. 30, cer. alb. 5, 
paraffin 5, vaseline alb. 60 parts), which has such a marked effect in bring- 
ing out the ramifications of tubercular fistulous tracks in the Rontgen 
picture, has not become generally accepted as a therapeutic agent. It may, 
however, be used in sinuses of the soft parts, which run a straight course. 
In extensive fistula connected with the bones or joints its results are dis- 
tinctly bad. There is also a danger of bismuth or nitrite poisoning, the 
first of which is not removed by substituting the carbonate for the nitrate of 
bismuth. 

Lastly, we may mention the conservative treatment of strumous dactyl- 
itis by means of pyrogallic acid ointment, which has been carried out at 
the Hamburg Sea Hospital; the diseased part is bathed daily for half an 
hour in sea water, and then bandaged with pyrogallic acid ointment, first 
Io per cent., then 5 per cent., when the skin becomes irritated, and lastly 
2 per cent. The treatment lasted three to four months; if fistule had 
formed a year or longer. The finger returned to its normal shape, and its 
movements were unaffected; its growth was not interfered with. Sometimes 
small sequestra were thrown off spontaneously; their early operative removal 
is always to be avoided. 


To the medical treatment belongs also the specific action of 
tuberculin. Alone it does not produce a cure, but in combination 
with the methods which have been described, it is a most powerful 
adjuvant for two reasons. Firstly, tuberculin facilitates the heal- 
ing of tubercular bones and joints through its specific action of 
producing local hyperemia. Further, it has a curative action on 
the primary focus in the bronchial or mesenteric glands, which is 
not always obvious, but which is dangerous to the patient and 
therefore demands treatment. Kraemer considers that its use is 
necessary for healed cases of surgical tuberculosis in order to 
prevent relapses. This can be explained by the fact that after the 
recovery of the disease in the bone or joint the latent focus in 


408 A CLINICAL SYSTEM OF TUBERCULOSIS 


some other part of the body is rendered innocuous by tuberculin. 
Since what we call a predisposition towards tuberculosis or weak 
constitution is much more often actually a latent tuberculosis, the 
good effect of an after-treatment with tuberculin can be fully ex- 
plained. The percentage of relapses in these cases, which is still 
high, will be considerably reduced by such a treatment. This 
standpoint has been lately taken by well-known surgeons, as 
Sonnenburg, Vulpius, and Wilms. The last named holds that 
it is the duty of the surgeon, even after a quite successful removal 
of a tubercular focus, to see if the organism gives a positive re- 
action to tuberculin, and if it does not, to give the patient a course 
of tuberculin, as a prophylactic measure against a relapse or a 
fresh infection with tubercle bacilli. Those surgeons who omit 
the use of tuberculin lose the assistance of a very effective remedy, 
more potent than iodoform, congestion or such other means, and 
the results of which can only be compared with those obtained by 
Ro6ntgen-ray treatment. Lastly, as to the selection of cases; 
Wilms considers that for the exudative form of tuberculosis, 
especially bone disease with fistulae or abscesses, the tuberculin 
treatment ‘‘is by no means necessary.’” But in the cases of 
fungoid tuberculosis, in which the cutaneous test is negative, or 
not markedly positive, the tuberculin treatment according to 
Wilms is ‘* not only expedient, but absolutely necessary.’’ Fun- 
goid tuberculosis certainly runs a relatively favourable course, 
but has a special tendency to relapse, and these relapses Wilms 
has seen less often after treatment with Koch’s old tuberculin. 
Other authors use the bacillary emulsion given by the same 
method as that generally employed for internal tuberculo-is; 
Rosenbach has recently recommended his tuberculin, which is 
biochemically weakened with the trichophyton fungus. Lenz- 
mann injects tuberculin with liquid paraffin into the tubercular 
focus, at the same time employing congestion, and has obtained 
very good results, especially in disease of the hands and feet. 
On the R6ntgen-ray treatment of bone and joint tuberculosis 
the experiences are so numerous and favourable that the use of 
penetrating rays can be fully recommended. Of its action we 
only know that on the one hand it increases the fermentative and 
autolytic processes in the tissues, and that on the other a marked 
fibrous contraction of the granulation tissue plays a part. The 
treatment is somewhat tedious, and requires to be learnt and 
practised, but gives very good results in disease of small bones 
and joints when the full action of the rays is possible. For larger 
bones it is more difficult, but it is by no means impossible to 
obtain recovery. Wilms prefers the use of deep Rontgen-rays 





TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 409 


for disease of the finger, hand, elbow, shoulder, rib, foot, 
and ankle; scraping and resection are confined to disease which 
is not yet extensive. Lately Wilms has combined the Roéntgen- 
ray and the tuberculin treatments. Iselin employs the deep rays 
particularly for disease of the hand and foot, also when the 
general condition is bad, and for fungoid joint disease of old 
people, while for children it is better not to employ it on account 
of the possibility of interfering with the growth. 

Radium has also been used for surgical tuberculosis, especi- 
ally for abscesses and fistula. French authors have recom- 
mended the introduction of small silver tubes containing radium 
sulphate into the tubercular tissue as superior to the superficial 
application of plates which have been covered with radium salts. 

Lastly, there is heliotherapy. Rollier has published extremely 
good results from exposure to the direct sun-rays at a high 
altitude (Leysin-sur-Aigle) in the surgical forms of tubercu- 
losis, especially in fungoid disease. Even tubercular disease of 
the vertebree and hip with fistulae recovered at Leysin with the 
action of the sun alone. Rollier’s figures showed in 369 cases of 
surgical tuberculosis that 87 per cent. were healed, 13 per cent. 
improved. Bardenheuer has employed treatment with sun-rays 
at Cologne according to Rollier’s method in ten cases of closed 
tuberculosis of the joints with good results. Particularly striking 
were the effects on fistulz following resection of joints; long- 
standing sinuses closed promptly. Jerusalem has in the Grim- 
menstein sanatorium successfully treated twenty-four cases of 
surgical tuberculosis with the sun-rays; also in Vienna the results 
were good. There are thus sufficient grounds for including sun- 
light, even in our latitudes, among the measures suitable for the 
conservative treatment of tuberculosis of the bones and joints. 

From the experience of orthopedic measures in combination 
with general treatment, congestion, iodoform, trypsin, tuberculin, 
R6ntgen and sun-rays, there can be small doubt that the conserva- 
tive treatment is gaining ground, and that now surgical treatment 
is relegated to the last place. 

Clearer indications are needed for the use of surgical treat- 
ment. The brisement force of the French authors, which aims at 
correcting faulty ankylosis by brute force, has now disappeared 
from use, as it contravenes the motto ‘‘ quieta non movere.”’ 
Even in obsolete joint disease forcible movement may stir up 
encapsuled foci and lead to miliary tuberculosis. 

The operations of arthrectomy, resection, exarticulation, or 
amputation are indicated if there is nothing more to be expected 
from conservative treatment. This is the case if severe general 


410 A CLINICAL SYSTEM OF TUBERCULOSIS 


disease (nephritis, amyloid disease) is also present, when post- 
ponement of the operation would entail great danger to the 
patient ; and also in those local conditions in which the resistance 
of the organism fails, so that life is endangered. ‘This is especi- 
ally the case with neglected suppurating sinus due to hip disease 
with mixed infection, when hectic fever and necrosis of the bone 
is present, and desperate cases of suppurative disease of the knee. 
On the other hand, it need hardly be said that an operation must 
not be done on patients in extremis, or on those who have not 
the strength to support it. 

Limbs, which after complete recovery from _ tubercular 
disease are left functionless, or partly so, may be submitted to 
surgical treatment, if it is certain that the sound parts are still 
capable of use. In paralysis from spondylitis tuberculosa, 
laminectomy, 1.e., the operative opening of the spinal canal by 
removal of the’ vertebral arches is indicated, provided that an 
exact localization of the disease is possible. The laminectomy 
may relieve the paralysis; and in many cases the spondylitis 
itself may be improved by scraping out the diseased foci in the 
vertebral bodies. There are 246 cases of laminectomy with 60 
per cent. of permanently good results recorded. 

Lastly, operative measures are indicated for circumscribed 
extracapsular and extra-articular disease, before it causes fur- 
ther damage by extension, provided that the tubercular focus 
can be thereby completely removed. But the indications must 
be sought in individual cases. For example, a young patient, 
who is living under favourable conditions of hygiene and diet, 
should be treated by conservative measures if the disease is in a 
less dangerous position, such as the hand, elbow, or foot. But 
if under the same conditions there is an isolated epiphysial focus, 
especially if it is endangering the knee joint, an operation will be 
indicated, all the more so if the patient is an adult. The social 
conditions of the patient must also be considered in a certain 
degree. Thus resection of the hip joint may be called for in a 
poor patient to shorten the duration of treatment, in spite of the 
inferior functional results. 

We have here given some outlines for the treatment of cuber- 
culosis of the bones and joints; but ‘‘the indications and 
technique will vary with the joint and with the form of disease ’’ 
(Konig). Therein lie the advantages of special experience and 
individual judgment, so that the most suitable measures may be 
selected and combined for each individual case. To the general 
practitioner falls first the diagnosis, and next the carrying out 
of conservative treatment under the advice of the surgeon. 


TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 411 


The preventative measures against tubercu- 
losis of the organs of locomotion may be 
summed up by saying that they consist of those which tend to 
the prevention of infection of children with tubercle bacilli, 
together with those means which may be employed for increasing 
the powers of the constitution in resisting infection. These ends 
will be especially favoured by a healthy parentage, and the avoid- 
ance of infection by food or diet in small children. Latent tuber- 
culosis of older children must not be overlooked. Lastly in all 
cases, including adults, the best prophylaxis of secondary joint 
infections is the healing of all primary foci in lungs, glands, &c. 
In open surgical tuberculosis the same care must be taken in 
dealing with the discharge and soiled dressings as is taken with 
the sputum in cases of open pulmonary tuberculosis. 


Prophylaxis. 


4. TUBERCULAR RHEUMATISM. 


Poncet first stated, in the year 1896, that, 
besides tuberculosis of the joints, there was 
a torm ‘of -“‘tubercular rheumatism,’ 
which was connected ztiologically with tuberculosis, but the 
symptoms of which were essentially the same as acute and 
chronic polyarthritis rheumatica. According to Poncet this 
tubercular rheumatism may be either due to the tubercle 
bacilli themselves or to their toxins. The cases of the first class 
are explained as differing from tuberculosis of the joints in that 
the bacilli are very scanty and weakened, so that they 
are no longer able to produce specific changes. This hypo- 
thesis seems plausible, since tuberculosis is not in absolutely 
every case limited to the formation of tubercles; but may take 
the form of simple inflammation of a serous, sclerotic, or hyper- 
plastic variety. Likewise it is possible to recognize, besides the 
true tubercles, in the same lobe of the lung exudative and inflam- 
matory processes, which are considered to be due to the action of 
the bacilli. In Kiittner’s clinic in Breslau tubercle bacilli were 
discovered in the blood of a typical case of tubercular rheuma- 
tism, the case being afterwards confirmed by autopsy. These 
observations support the view of the bacillary origin of tubercular 
rheumatism, and explain at the same time its connection with 
miliary tuberculosis. 

Or the pathological condition may be produced by a toxin 
produced by the tubercle bacilli and circulating in the blood, 
which by virtue of a special predisposition produces lesions in the 
joints, different from the changes produced by the bacilli them- 
selves. But it seems to us that it is not yet proved that a 


Anatomical 
Changes. 


412 A CLINICAL SYSTEM OF TUBERCULOSIS 


toxin can be formed in some tubercular focus in the body, such as 
in the lung, and can produce in some distant organ or joint purely 
inflammatory changes with leucocytic exudation and fibrin for- 
mation. 

Pathologically acute and chronic tubercular rheumatism can 
be distinguished. In the acute form there are simple inflamma- 
tory changes with thickening and vascularization of the synovia 
and serous exudation. The exudation, which has a_ strong 
tendency to fibrin formation, usually forms in larger joints, and 
causes oedema of the periarticular tissue. Miliary granules, 
tubercles, and bacilli are absent, but inoculation of the material 
sometimes gives positive results. , 

Chronic tubercular rheumatism sometimes takes the form of 
atrophic, poly- or mono- arthritis, which leads to deformities, and 
sometimes to dislocations, or may assume a plastic form with 
hyperostosis, producing arthritis sicca, ossificans, or ankylotica. 
In either case the same pathological changes affect the cartilage, 
the bone, and the periphery of the joint, without showing at any 
place the specific changes of joint tuberculosis. Ankylosis seems 
to occur from the formation of ivory outgrowths which lock the 
bones together, and diminish the movement of the joint more and 
more till it is lost. Poncet explains ankylotic spondylitis as a 
tubercular rheumatism of the spine of widely spread nature; in 
our judgment there are not sufficient grounds for this view; 
though not a small percentage of patients suffering from stiffness 
of the vertebral column die of pulmonary tuberculosis, yet on 
post-mortem examination no inflammatory changes are found in 
the intervertebral joints such as Poncet supposed (E. Fraenkel). 
Since in tubercular rheumatism neither ma- 
croscopic nor microscopic specific changes 
can be detected, its recognition depends 
upon the clinical symptoms. Poncet classifies tubercular rheuma- 
tism among the inflammatory forms of tuberculosis and dis- 
tinguishes three varieties. 

’ The arthralgias appear as vague, dragging pains, especially 
in the larger joints and the vertebral column, with pains on move- 
ment and pressure, which come and go spontaneously, pass from 
one joint to another, often affect several joints at the same time, 
and disappear, leaving no trace behind. The important points 
are the absence of all perceptible, objective symptoms, and the 
fugitive nature of the pains. 

The acute and subacute forms of tubercular rheumatisin 
usually appear clinically as acute rheumatic polyarthritis. Begiri- 
ning with fever, pains, and effusion into the joints, it affects now 


Symptoms 
and Course. 


TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 413 


this, now that joint, and comes and goes with a strong tendency 
to relapse. It may disappear entirely, or remain localized in 
a certain joint and become chronic. In the latter case the general 
condition gradually deteriorates, and the signs of a latent tuber- 
culosis (anzemia, wasting, weakness) appear, or tuberculosis 
becomes manifest in some organ. Acute tubercular rheumatism 
especially attacks people between 20 and 30 years. It appears 
also in children, and not rarely develops into typical joint tuber- 
culosis. Secondary acute tubercular rheumatism is not altogether 
rare. It is noteworthy that an improvement in the tubercu- 
losis 1s accompanied by an increase in the rheumatism. It is not 
uncommon for the onset of primary tubercular rheumatism to be 
so acute that the inflamed, red joints are extremely painful and 
quite motionless, and the general condition is like that at the 
onset of a severe infection or simulates miliary tuberculosis. 
Such cases usually end fatally, without the characteristic signs of 
acute or miliary tuberculosis being found at the autopsy. 

Chronic tubercular rheumatism may appear at any age, but 
usually during the second half of life; it may be the relic of an 
acute attack, or may take a chronic form from the first. Dry 
fibrous and osseous processes lead to chronic deformities and 
ankyloses, especially in individuals already suffering from inter- 
nal or external tuberculosis. Various transitional forms also 
occur. We may shortly mention the most important :*(1) Chronic 
osteo-arthralgias, in which there are vague pains, without defor- 
mities in bones or joints; (2) chronic polyarthritis with deformi- 
ties, in which there are attacks of pain and marked swelling and 
deformity of the joint, especially the hands and feet, and which is 
generally associated with a furtive visceral tuberculosis; (3) 
chronic polysynovitis, in which the burs and tendon sheaths are 
frequently also affected; (4) arthritis sicca of the aged, in which 
pains, crackling, and deformity appear during the course of a 
favourable fibroid tuberculosis; (5) ankylosing arthritis, which 
almost exclusively appears in persons with quite latent visceral 
tuberculosis, and in contrast to ordinary rheumatism leads to 
ossification and ankylosis. Damp, cold and traumatism are only 
concomitant causes for the ankylosing inflammation, which 
attacks one or more joints, sometimes slowly and furtively, but 
more often with fever, sweats, wasting, swelling, and pains. 
The mono-articular form affects particularly the hip. Patients at 
the age of puberty are specially attacked, though the disease may 
also appear later in life. : 

Apart from the purely articular changes, tubercular rheuma- 
tism may cause a series of rheumatic affections of other organs; 


414 A CLINICAL SYSTEM OF TUBERCULOSIS 


thus the heart, the serous membranes, the nerves, glands, uro- 
genital system, skin, muscles, fasciae, tendons, and subcutaneous 
tissue may be implicated. Poncet also ascribes abdominal pain 
without diarrhoea in tubercular cases to a toxic origin, and con- 
siders them as ‘‘ an equivalent of tubercular rheumatism.’’ Fur- 
ther, Poncet sees in the arthritic diathesis (arthritism) the effects 
of the tubercular toxin, and holds with Leriche that in each case 
of rheumatism it should first be considered whether it may not be 
tubercular. Likewise Barbier states ‘‘ that the patients presented 
themselves with rheumatism, but were found to be tubercular.”’ 
In a German work in 190g it was even asserted that urethral 
strictures were directly due to the action of the tubercular virus. 
Such fantastic views must be firmly discouraged. 

The frequency of tubercular rheumatism depends upon the 
view taken of the disease. If the attitude is sufficiently critical 
inflammatory changes due to tubercular toxin will be certainly 
fares 
A well-founded diagnosis of tubercular 
rheumatism is not easy, but is rather very 
difficult and nearly always uncertain, since on the one hand the 
symptom complex does not differ from that of ordinary rheuma- 
tism, and on the other there are no certain pathognomonic signs 
of tubercular rheumatism. 

The family antecedents and personal stigmata have some 
diagnostic value. If sweats are absent in acute cases, if primary 
angina does not occur, nor endocardiac signs in children, 
ordinary rheumatism will be less likely. French authors con- 
sider the course of the disease alone in tubercular cases to be 
characteristic; and that an articular rheumatism of a chronic 
nature, tending to relapse and leading to ankylosis, is generally 
of a tubercular origin. Still more difficult is the diagnosis in 
primary cases, where it would be of the most value. In general 
a suspicion may be raised of the tubercular aetiology of a case of 
rheumatism if the general state is much altered while the tem- 
perature is proportionately low, if the swelling of the joints lasts 
long and recovers slowly, if the inflammatory symptoms are 
slight with much swelling and little redness, and lastly, if the 
disease runs an atypical and unfavourable course, and is not 
influenced by salicylates. If the rheumatism occurs in a joint 
near a recent tubercular focus, its tubercular nature gains in 
probability. 

Test tuberculin injections are very valuable, especially in 
cases of primary tubercular rheumatism. Excessive doses of 
tuberculin may produce in healthy people effusion into the joints 


Diagnosis. 


“ae 


ee 


TUBERCULOSIS OF THE ORGANS OF LOCOMOTION 415 


solely as a result of toxic action. But if quite small doses of 
tuberculin increase the inflammatory signs in a suspected joint, 
while the general reaction is absent or only slight, it may be 
concluded that the rheumatism is tubercular. We have repeatedly 
seen after minimal tuberculin injections symptoms produced 
quite promptly, which could only be considered as focal reactions 
due to tubercular rheumatism. Also v. Hippel and Menzer have 
made the same observation. Poncet and Leriche recommend the 
agglutination method according to Courtmont as the most certain 
and convenient reaction. But this is not correct, since the 
agglutination test is both more uncertain and has no _ local 
diagnostic value. The Rontgen-ray examination naturally fails 
here. On the other hand examination of fluid withdrawn from 
the joint for lymphocytosis, acid-fast bacilli, and  Much’s 
granules, and inoculation of it on guinea-pigs, have in many cases 
been decisive. 

Cases of arthritis of toxic origin appearing during other 
infectious diseases (scarlet fever, puerperal fever, sepsis, syphilis, 
gonorrhoea) may be easily distinguished by the history and by 
clinical observations. 

The prognosis of tubercular rheumatism 
depends on the nature of the primary 
disease. When this is absent, or tends to heal, then the 
course of tubercular rheumatism is nearly always good. More 
doubtful is the prognosis in acute cases, and those becoming 
chronic, since they tend to the production of hyperplastic inflam- 
matory changes. Still worse is the prognosis in arthritis, which 
is becoming ankylosed. 

The patient with tubercular rheumatism 
must in the first case be treated on the 
general lines for tuberculosis. In acute cases the joint must have 
rest. The pains may be relieved by warm compresses, light 
chloroform frictions, turpentine vesicants, and especially Bier’s 
congestion, which usually acts promptly. Salicyl and its deriva- 
tives are as a rule useless. Poncet and others have warmiy 
recommended cryogenin in doses of 3 to 22 gr. a day. In the 
chronic forms contractions must be prevented by massage, and 
active and passive movements; at the same time mineral waters 
(Wiesbaden, Wildbad) both internally and as baths may be 
useful. Eckert saw in children good results from drinking and 
inhaling water giving radium emanations. But chief reliance 
must be placed on the combination of the general constitutional 
treatment with tuberculin, which latter by raising the powers of 
resistance to the toxin relieves the toxic symptoms and prevents 


Prognosis. 


Treatment. 


416 A CLINICAL SYSTEM OF TUBERCULOSIS 


the relapses of tubercular rheumatism. In one case, which was 
complicated by severe tubercular scleritis, v. Hippel saw with 
tuberculin treatment a most marked result; Menzer in another 
case after two months of tuberculin combined with warm baths 
observed that almost all the joints regained their full power of 
movement. 

Tubercular patients with a tendency to 
rheumatoid affections in the joints should, 
if their social conditions allow it, in the moist and cold seasons 
of the year move to a warm, dry climate. 


Prophylaxis. 


i Dea. 


CEA PAE Re x, 


Tuberculosis of the Nervous System. 


FRom the tubercular diseases of the nervous system the 
functional nerve changes, neuroses and pyschoses in tubercular 
patients must be distinguished. While the tubercular diseases of 
the nervous system are characterized either by tubercular changes 
in the nervous tissue, or by chronic inflammatory alterations 
without histological tuberculosis, due to the action of tubercular 
toxin; on the other hand functional and psychical alterations of 
the central and peripheral nervous system occur in phthisical 
patients from the interference with the organic functions, the 
dyscrasia, marasmus, and cachexia reacting on the nervous 
system. 

The question whether tuberculosis of the parents produces a 
predisposition to nervous affections in the children must remain 
open, so long as it is undetermined whether it js the disease itself 
or only the predisposition which is inherited. It seems to be 
accepted that in certain families tuberculosis and nervous disease 
alternate, that hysteria and tuberculosis often occur together, but 
that epileptics are particularly resistant to tuberculosis. Doubt- 
less alcoholism plays a large part in the production of psychical 
Symptoms in tuberculosis, since the alcoholic js both bodily, 
morally, and mentally weakened, is most prone to infection, and 
offers least resistance to it. 

We will consider first the tubercular diseases of the peri- 
pheral and central nervous system. 


1. TUBERCULAR NEURITIS. 


If tubercular disease involves the nerve 


Reece! either directly or by pressure, the nerve 
Changes an fibres will undergo chronic inflammatory 
Symptoms. : 


or atrophic changes. Thus the spread of 
inflammation from a tubercular lung or pleura may cause specific 


27 


418 A CLINICAL SYSTEM OF TUBERCULOSIS 

intercostal neuralgia, caries of the ribs may set up a true pressure 
neuritis of the intercostal nerves, caries of the atlas or axis may 
produce occipital neuralgia, and tuberculosis of the axillary 
glands neuritis of the brachial plexus. Also infection may 
spread from the apex of a tubercular lung to the brachial plexus, 
and many cases of ‘‘ rheumatism ’’ are due to a semi- or bilateral 
plexus neuritis of brachial origin. 

In the peripheral and cranial nerves tubercular neuritis like 
other forms may appear as either mono- or polyneuritis. Of 
the cranial nerves the auditory and optic are most frequently 
affected by tubercular neuritis. The pathological changes are 
not always the same. [ither tuberculosis of the ear, eye or skull 
bones may directly involve the nerve trunks, or intracranial 
tuberculosis may cause inflammatory changes in the nerves, or 
metastatic tubercles may be found in the nerve substance. Also 
in the cranial nerves that form of tubercular neuritis has been 
observed which is due to degenerative changes in the nerve 
fibres as a consequence of the action of tubercular toxin. In these 
degenerations of a toxic nature, which chiefly occur in the last 
stages of phthisis, bacilli cannot be found in the affected nerve 
trunks, in contrast with the leprous forms of neuritis. They are 
comparable with the forms of neuritis caused by alcohol and 
lead, or carcinomatous cachexia, and are due to atrophy and 
destruction of the nerve-sheath, which is followed later by injury 
to the axis cylinders. 

The vagus and sympathetic do not escape. Infection of the 
vagus in pulmonary tuberculosis usually takes place through the 
tracheobronchial glands. The symptoms consist of slowing of 
the pulse and respiration, cough, hoarseness, spasm and para- 
lysis of the larynx. Involvement of the sympathetic from apical 
lung tuberculosis leads to dilatation of the pupil on the same 
side, a symptom which can be brought out by Valsalva’s experi- 
ment and is of some value for the early diagnosis of pulmonary 
tuberculosis. Also intestinal symptoms and unilateral sweating 
of the head may in tubercular patients be ascribed to toxic action 
on the sympathetic. 

In the peripheral nerves, Pitres and Vaillard have distin- 
guished latent, amyotrophic and hyperesthetic tubercular neur- 
itis, according to whether the symptoms are absent during life, 
are motor (spasm, paresis or paralysis), or sensory (pains, 
hypereesthesia, pareethesia). ‘‘ Latent’? tubercular neuritis has 
no practical importance. Also the ‘‘ hyperzesthetic ’’’ form is not 
a weighty matter as long as pains are not produced, and neuritic 
pains in phthisical patients may occur without nerve changes. 


TUBERCULOSIS OF THE NERVOUS ‘SYSTEM 419 


On the other hand, the ‘‘ amyotrophic’’ form or symmetrical 
polyneuritis is a highly characteristic, but relatively rare, tuber- 
cular affection of the peripheral nerves. 

With tubercular neuritis of the cranial 
nerves there will be signs of irritation or 
loss of function, such as deafness and alteration of sight. If the 
peripheral nerves are affected alterations of sensation (hyper- 
zesthesia) will first appear, then motor and trophic symptoms. 
Among the last are herpes zoster and gangrene of the extremities, 
which has been observed as a result of tubercular neuritis. 

Tubercular polyneuritis produces the classical symptoms of 
multiple degenerative neuritis; peripheral paralysis, irritative 
sensory symptoms and motor ataxia. This is not surprising, 
since in most such cases the tuberculosis is complicated with other 
septic or toxic factors (alcohol, syphilis). 

According to Cassirer tubercular neuritis usually begins with 
weakness of the peroneal muscles; in the labouring classes the 
small muscles of the hand are often affected. Very often the 
lower extremities are solely affected, and may become completely 
paraplegic; the sphincters usually remain intact. The pains may 
be very severe or only slight. Paralyses sometimes develop quite 
painlessly. Sensation is in most cases altered, but sometimes 
only slightly. The tendon reflexes are absent or diminished ; very 
rarely are they increased. Occasionaily the facial, vagus or 
phrenic nerves are also involved, causing alterations in swallow- 
ing or breathing, or diaphragmatic paralysis. More common are 
vaso-motor, secretory or trophic symptoms, such as cyanosis of 
the hands, cedema, sweating or alterations in the nails. The 
earliest of the objective signs is the reaction of degeneration. 
Tubercular polyneuritis can thus be diagnosed, if in a tubercular 
subject motor paralysis leading to atrophy appear with alterations 
of sensation and reaction of degeneration. 

In making the differential diagnosis it must be clear that the 
symptoms cannot be due to changes in the central nervous 
system; very distinct and constant tenderness on pressure over 
one or more nerve trunks is in favour of-polyneuritis, and against 
a functional, irritative condition occurring in a tubercular subject. 
The decision whether the neuritis is due to tuberculosis is very 
difficult, since various ztiological factors may be combined, e.g., 
tuberculosis with alcoholism or malaria. In the last case the 
result of treatment with quinine may settle the question. In 
cases in which there is doubt as to the nature of the primary 
disease a tuberculin test may be decisive, and in that way may 
point to the probable cause of the nerve affection. 


Diagnosis. 


~ 


420 A CLINICAL SYSTEM OF TUBERCULOSIS 


Tubercular neuritis may, so long as it is 
confined to a single nerve or plexus, sub- 
side and disappear. Tubercular polyneuritis is less favourable. 
Sometimes the progress of the disease may be arrested for years. 
Implication of the vagus or phrenic usually is rapidly fatal. 
Where tubercular processes in_ bones, 
glands, &c., are causing injurious effects 
on neighbouring nerve trunks, surgical 
measures may be taken against the disease. 

Tubercular neuritis in all severe and recent cases demands 
absolute rest in bed, plentiful and easily digestible diet and 
regulation of the bowels. Careful and attentive nursing is in 
such cases a necessity. Severe pains may be met with dry or 
moist heat, cold or alcoholic packs, analgesics with or without 
morphia, and the constant current. Antipyrin, salipyrin, phena- 
cetin, aspirin, antifebrin, lactophenin, pyramidon, dionin, 
codein, &c., act better combined in frequent small doses than as 
large doses of a single preparation. Strychnine and arsenic may 
be used in combination with tuberculin, provided that the disease 
is not too widely spread. Arsenic preparations must not be 
ordered with the derivatives of creosote containing phosphorus, 
since with this combination toxic action on the peripheral nervous 
system has been seen. If the patient is strong and the disease 
at a standstill use may be made of diaphoretic processes, such as 
baths with active movements while in the bath, followed by 
massage, faradization, gymnastics and thermal baths. 

The prophylaxis consists in the avoidance of certain in- 
jurious factors tending to the production of neuritic disease in 
tubercular patients; such are cachexia, chronic alcoholism, and 
chills and wetting of the body, especially the lower extremities. 


Prognosis. 


Treatment and 
Prophylaxis. 


2. TUBERCULOSIS OF THE SPINAL CORD. 


The spinal cord and its membranes may be 


Pesaaieiiey" affected by primary or secondary tubercu- 
ae an losis; but secondary infection is much the 
ee ede more common. Up to now there are 


seventy-four cases of primary tuberculosis of the spinal cord in 
the literature. According to their localization they can be divided 
into the intra- and extra-dural forms. 

The more frequent occurrence of the extra-dural form, also 
known as pachymeningitis tuberculosa externa, is explained by 
the frequency of carious processes in the vertebree. From here 
the disease spreads by way of the intervertebral foramina or by 
breaking through the periosteal covering into the epidural space. 





| 


j 


TUBERCULOSIS OF THE NERVOUS. SYSTEM 421 


The disease now extends both upwards and downwards, forming 
caseous masses, or abscesses lined with greyish-red granulation 
tissue, which compress the cord and the venous plexus in its 
sheath. The granulations may also grow through the dura, and 
spread on its inner surface. Compared with disease spreading 
from the vertebrae primary tubercle formation on the outer sur- 
face of the dura is of very small importance. It generally covers 
a large surface of the dura without exerting much pressure on 
the cord or nerve roots; and this explains the rarity of spinal 
symptoms. 

Of the forms of intra-dural tuberculosis those that appear 
within the substance of the cord are of less practical importance 
than extra-medullary conglomerate tubercle, though according to 
Schlesinger the former are the most common variety of tumour of 
the cord. This is due to the fact that intra-medullary tubercle, 
like other benign forms of tumour, in its early stages displaces 
the tissues of the cord without infiltrating them, and therefore 
first produces symptoms from compression and softening when it 
reaches a considerable size. 

True extra-medullary conglomerate tubercle, i.c., a large 
nodule produced by the confluence of many miliary tubercles, 
generally grows out from the meninges, usually extends laterally 
and posteriorly in the direction of least resistance, and assumes 
an oval form. As it grows it compresses the cord, but rarely 
grows with its substance. This form of disease, compressing 
but not infiltrating the cord, is of importance from the thera- 
peutic standpoint, since such tumours can be removed by blunt 
dissection, though at first sight they appear to penetrate into 
the cord. 

The symptoms due to solitary and conglomerate tubercle 
begin with weakness, pains or paresthesia in one extremity.: At 
the commencement there is usually unilateral paresis, which in 
several weeks changes into motor and_ sensory paraplegia. 
Spasms are often absent, but irritative sensory symptoms rarely; 
later there may be total anesthesia. All the symptoms are incon- 
stant, and sometimes so little marked that it can only be said that 
there is some lesion compressing the cord at a certain spot. 

Tubercular myelitis as an individual toxic disease is rare; 
it occurs as a rule in tubercular patients with constant, hectic 
fever, who are already suffering from multiple peripheral neuritis, 
and causes paresis, atrophy and oedema. More common is the 
tubercular myelitis due to inflammation or softening of the cord 
as a direct result of tubercular spondylitis. The caries usually 
attacks one, more rarely several vertebrze, and produces a growth 


422 A CLINICAL SYSTEM OF TUBERCULOSIS 


of fungoid granulations, with caseation and suppuration in the 
body of the vertebra. When this becomes softened, it is dis- 
located from the pressure of the neighbouring vertebrae, and 
Pott’s curvature 1s produced. Rapidly produced dislocation and 
narrowing of the canal lead to compression symptoms and to 
compression myelitis ; the changes in the compressed cord usually 
here consist of congestion and cedema, rarely of specific tuber- 
cular disease. Deviation of the line of vertebre is by no means 
always the cause of the compression ; quite as often it is produced 
by an exuberant growth of tubercular granulation tissue, or by 
the cicatricial contraction of the same. 

The symptoms consist of constant pain on pressure over the 
affected part, and of irritation of the sensory nerves, which, 
according to the position of the disease, may cause girdle pain 
or neuralgia in the arms or legs on one or both sides. More 
severe compression causes paraplegia; if the pains also persist 
we have the condition known as paraplegia dolorosa. Compres- 
sion of a high grade leads to anesthesia. Alterations in the 
skin, the tendon reflexes, the bladder and the rectum then appear. 

Like the spinal cord, the medulla oblongata may be affected 

in disease of the occipital bone or first cervical vertebra. 
The diagnosis of tuberculosis of the spinal 
cord may be made without difficulty when 
it is a secondary affection and accompanied by obvious vertebral 
caries. Considerably more difficult is the recognition of solitary 
and conglomerate tubercle, especially of the primary  intra- 
medullary form; in the latter case not even a topical diagnosis 
may be possible, and it can be understood that of sixty-four cases 
of tuberculosis of the spinal cord, which were described up to 
the year 1906, only eight were correctly diagnosed during life. 
If the intra- and extra-dural nodules reach a certain size, they 
will produce meningitic or myelitic symptoms. The compres- 
sion symptoms are the same as those produced by true tumours 
and non-tubercular diseases of the cord. It need here only be 
said that there are certain clinical symptoms which are very 
important for deciding the question whether conglomerate 
tubercle develops primarily within the cord, or whether it is 
growing from the meninges and merely compressing the cord. 
Early symptoms connected with the nerve-roots, hyperzesthesia 
in certain root areas on one side, and later the typical picture of 
Brown-Séquard’s paralysis are indicative of disease commencing 
outside the cord and gradually compressing it. 

Conglomerate tubercle must be differentiated specially from 
gumma. The distinction between the two may be very difficult 


Diagnosis. 


J 
{ 
‘ 
q 





TUBERCULOSIS OF THE NERVOUS SYSTEM 423 


even on microscopical examination, and both may be clinically 
identical with true tumours. In such cases careful attention must 
be paid to the anamnesis, and general examination may lead to 
the detection of a primary tumour elsewhere, other tubercular 
disease, syphilitic manifestations, or echinococcal cysts, &c. 
Primary solitary and conglomerate tubercle 
of the spinal cord and tubercular myelitis 
have a bad prognosis. Better is that of tubercular compression 
myelitis, since ossification and recovery of vertebral caries is 
possible, and this is usually accompanied by improvement or 
arrest of the spinal symptoms. Also extra-medullary con- 
glomerate tubercle, even if it is producing severe compression 
of the cord, is not absolutely unfavourable, since it can be re- 
moved without damage to the substance of the cord. 

The treatment must be first of all general, 
with continued rest, and in cases of tuber- 
cular compression myelitis a prolonged period of lying on 
the back. Great care will be needed to prevent bed-sores, 
cystitis, &c. 

Spinal disease secondary to vertebral caries must be treated 
on conservative lines with extension as long as one can hope 
by immobilizing the diseased bones to arrest the disease. 
Stationary conditions can be treated with orthopedic apparatus 
and sea and salt baths. Drugs are useless, and surgical measures 
are only indicated if sequestra or abscesses can be diagnosed. 

Progressive compression demands an operation, whereby not 
too small an extent of the vertebral canal is opened. If this shows 
that intra-.or extra-medullary conglomerate tubercle is the cause 
of the compression, it must be removed in order to save life. 
This is not usually difficult, since the mass can usually be cleanly 
removed by blunt dissection. 


Prognosis. 


Treatment. 


3. TUBERCULOSIS OF THE BRAIN. 


Tuberculosis of the brain appears as 
greyish-yellow, caseous nodules, of a 
rounded or irregular shape, which affect 
particularly the deeper parts, especially the crus, the pons, and 
the cerebellum, and after them the cerebral hemispheres and 
region round the corpora quadrigemina. By the confluence of 
neighbouring small nodules conglomerate tubercles of the size 
of a walnut to a hen’s egg are produced, which on section are 
either uniformly caseous, or are divided into separate crumbly 
tubercular masses; calcification is rare. The smaller tubercles 
are not rarely encapsuled, while the larger are more diffuse and 


Anatomical 
Changes. 


424 A CLINICAL SYSTEM OF TUBERCULOSIS 


embedded in the white substance of the brain, and may give rise 
to diffuse caseous changes of entire brain areas. Solitary tubercle 
is relatively rare; it reaches the size of a pea to a cherry, not 
often of a hen’s egg. Reuz has seen one as large as a billiard 
ball in the left parietal lobe of a patient, aged 40, in whom the 
autopsy also revealed old, healed apical tuberculosis, tuberculosis 
of the right kidney and the left adrenal, and miliary tuberculosis 
of the peritoneum covering the kidney. Tubercles of the brain 
are usually multiple; there may be a dozen or more scattered 
in different parts of the organ. 

Tubercular abscess of the brain is a very rare affection; it 

appears in otherwise healthy persons and in those already tuber- 
cular; in the pus and in the abscess walls large numbers of 
bacilli can be found; usually it is complicated with tubercular 
meningitis. 
The clinical symptoms are those of other 
brain tumours: Pains in the head and uni- 
lateral convulsions are the most common, 
while those due to increase of intracranial pressure (vertigo, 
slowing of the pulse, vomiting, optic neuritis) are often absent 
owing to the small size of the tubercular nodule. If obliterative 
arteritis occurs in the foci, areas of white softening appear in the 
brain substance. The symptoms thereby produced will depend 
upon the position of the softening; they are generally paralysis, 
usually unilateral, with epileptiform convulsions (cerebral cor- 
tex), hemiplegia with crossed facial paralysis (pons), and stagger- 
ing gait and vertigo (cerebellum). 

Tuberculosis of the brain most often attacks children, 
especially those in the first year of life; solitary tubercle has 
even been found in children a few weeks old. According to many 
authorities tubercle is the most common form of brain tumour, 
it takes the third place in adults and the first in children. 

The latency of the condition is to be noticed. Even exten- 
sive cerebral tubercle may be completely latent during life and 
be first found on post-mortem examination. Also tubercles in 
one hemisphere may produce symptoms, while those in the other 
may not. Also the duration of the disease may be very variable; 
the period between the appearance of the first symptom and death 
may be measured by days or years. Acute cases not rarely end 
in tubercular meningitis, chronic ones in chronic hydrocephalus. 
The diagnosis rests on a careful history and 
the recognition of a characteristic group 
of symptoms, of which the most important are signs of scrofula 
or tuberculosis of the lungs, glands or joints, epileptic attacks 


Symptoms and 
Course. 


Diagnosis. 





ee ee ee 


Wa 


* 


TUBERCULOSIS OF THE NERVOUS SYSTEM 425 


followed by hemiplegia, gradual appearance of hemiparesis with 
tremor or contraction in one or both extremities, slowing of the 
pulse, rise of pressure in the spinal canal, strabismus, partial 
contractures, severe headache, frequent vomiting, mental changes 
and auditory hallucinations. 

The differential diagnosis must be made from glioma, sar- 
coma, carcinoma, psammoma, cysts, and gummata. Since test 
tuberculin injections are contra-indicated in cerebral cases, one is 
limited to the cutaneous test and the search for other tubercular 
foci in the body. 

On account of the possibility of spon- 
taneous healing by encapsulation or calci- 
fication the prognosis, especially in solitary tubercles, is not 
absolutely bad. The possibility of operative removal must also 
be considered in forming the prognosis. The case only becomes 
hopeless if signs of meningitis appear. 

If syphilis cannot with certainty be ex- 
cluded the treatment should begin with a 
trial of iodides. At the same time strengthening measures are 
indicated. Puncture of the brain or spinal cord are not to be 
neglected, since they have improved the results of operative 
treatment. Oppenheim was already, in 1902, able to collect thirty 
cases operated on with good results. But on the whole the con- 
ditions for operative interference are not so good as in spinal 
tuberculosis. The frequent multiplicity of brain tubercles, their 
usual situation in parts of the brain little accessible to surgical 
measures, the frequency of tubercular meningitis as a complica- 
tion, and lastly the tendency to implication of the surrounding 
parts of the brain limit the opportunities of surgery, and fre- 
quently compel a mere symptomatic treatment. Against severe 
pains in the head may be recommended ice-bags, bleeding, 
migranin, antipyrin, phenacetin, &c.; against convulsions seda- 
tives and narcotics, such as bromides and morphia, and pantopon, 
or better, dionin, codein or heroin. 


Prognosis. 


Treatment. 


4. TUBERCULAR MENINGITIS. 


Tubercular infection of the pia mater leads 
to the production of miliary tubercles, to 
hypereemia, inflammation, and _ cellular 
exudation. The further pathological changes are localized chiefly 
in the vessels of the pia mater, especially in the medium-sized 
arteries, in the adventitia of which typical tubercles form; in the 
media there are cellular infiltrations tending to necrosis, and the 
intima becomes raised by endothelial infiltration, whereby the 


Anatomical 
Changes. 


420 A CLINICAL SYSTEM OF TUBERCULOSIS 


lumen of small arteries may be entirely blocked. Tubercular 
meningitis affects constantly the cerebral cortex; small hamor- 
trhages in the form of rings round vessels undergoing hyaline 
degeneration appear in it. Sometimes the elastic coat of the 
vessel becomes ruptured, when larger hemorrhages occur. The 
base of the brain is more often and more severely affected than 
the convexity, hence the term basal meningitis. The area most 
affected is that between the chiasma and the medulla oblongata, 
reaching to the Sylvian fossze on both sides. The pia of the cord 
is frequently also affected, explaining the occasional spinal 
symptoms. Since there is usually serous effusion into the ven- 
tricles, the disease is also known as acute hydrocephalus. 
Primary meningeal tuberculosis 1s ex- 
tremely rare; it is still undecided if it may 
occur from the inhalation of tubercle bacilli 
through the nasal mucous membrane—as a rule it is secondary 
to tuberculosis of the lung, the pleura, the bronchial, or mesen- 
teric glands, the bones and joints, and the urogenital system, and 
not rarely to vertebral caries or solitary tubercle of the brain. 
Even calcified bronchial glands may be the starting point. The 
infection occurs by the lymphatics, the lymph-spaces in the 
nerves playing a part, or by the blood-stream. In the latter case 
the meningeal disease is part of general miliary tuberculosis. 
Acute infectious diseases, sexual development, traumatism and 
operations are predisposing causes. The disease occurs most 
often in children and young people; but it is not so rare in older 
persons as has been generally supposed. 

In the symptomatology of tubercular meningitis in adults 
the following points may be remarked. 

The prodromata consist generally of pains in the head and 
heaviness, more rarely of vomiting, sleeplessness, constipation, 
diarrhoea, and chills; also psychical depression, mysterious 
changes of character, and hysterical attacks not rarely are met 
with. 

The transition to manifest meningitis usually occurs gradu- 
ally, rarely suddenly. Then pains in the head, stupor, somno- 
lence, incoherence sometimes reaching the grade of a psychosis, 
and delirium with picking at the bed-clothes appear. Groaning and 
sighing are very common, the hydrocephalic cry is rarer, trismus, 
vomiting, constipation, or diarrhoea are not constant. Almost 
constant symptoms are retention of urine and rigidity of the neck, 
so that these in combination with headache and incoherence are 
of pathognomonic importance. 

There are many symptoms connected with the muscular and: 


Symptoms and 
' Course. 








TUBERCULOSIS OF THE NERVOUS SYSTEM 427 


nervous apparatus. Muscular rigidity appears more often than 
contractures; the patella reflex is usually increased, sometimes it 
cannot be elicited on account of muscular rigidity; there may be 
considerable differences between the right and left sides. Babin- 
ski’s reflex is as a rule positive. Convulsions and tonic or clonic 
spasms are often seen in the face, either alone or in combination 
with irritative symptoms in the extremities. It is not unknown 
for adults to have epileptiform attacks. The paralytic symptoms 
in the face and extremities are often at first of a spastic, later of a 
flaccid nature. Aphasia is not rare, sometimes it is marked. 
Hypereesthesia, rarely analgesia, may be present. 

Eye symptoms often occur, such as differences in the size and 
reaction of the pupil, ptosis, and strabismus, usually convergent. 
Optic neuritis is not often found. Choroidal tubercles are more 
common, but are not looked for often enough, as they have 
great diagnostic value. 

The temperature remains normal only exceptionally, it 
usually varies between 98.4° and 102° F., but may rise to 104° or 
over. Before death abnormally low collapse temperatures, which 
may be below 95°, are found. The pulse varies between 60 and 
120; at the end it may reach 200. The respirations are between 
20 and 40; Cheyne-Stokes’ breathing is not seen in the majority 
of the cases. 

The want of uniformity in the symptoms is well explained 
by the varying course of the disease, which has from the clinical 
point of view been divided into typical, atypical, rapid, protracted, 
localized, and other forms. In adults two chief forms can be 
distinguished. The acute variety usually complicates cases of 
pulmonary tuberculosis, who one day are found to have somno- 
lence, delusion, or some local symptom, fall gradually into a 
comatose condition, and die in a few days. On the other hand, 
there is a distinctly chronic form which may last for months. 
The disease is then situated chiefly at the convexity of the brain, 
especially in the neighbourhood of the falx. The symptoms 
consist of partial Jacksonian epilepsy, paresis, contractures of 
certain groups of muscles, and aphasia. 

With regard to the course of tubercular meningitis it may be 
noted that there are cases with some tendency towards spon- 
taneous recovery. This is shown by the fact that some cases 
exhibit more acute phases separated by periods of remission (O. 
Ranke). 

On account of the protean forms of the 
disease the diagnosis is often difficult and 
sometimes impossible. This is particularly so with older 


Diagnosis. 


428 A’ CLINICAL SYSTEM OF TUBERCULOSIS 


patients, in whom the clinical features are indistinct and 
transient. An important indication in all cases is Kernig’s 
sign; this consists of the impossibility with the patient in a sit- 
ting position of fully straightening the legs, the meningeal irrita- 
tion having produced a cramp in the hamstring muscles. 
Laségue’s sign has also some practical importance; this consists 
of the impossibility in the recumbent patient of flexing the hip 
to a right angle with the knees fully extended. In general the 
following three stages of the disease can be recognized. After 
more or less obvious prodromata the stage of cerebral irritation 
begins with pains in head, stiffness of the neck, vomiting, som- 
nolence, and delirium. Next follows the stage of cerebral 
pressure with stupor, slowing of the pulse, implication of the 
cranial nerves at the base of the brain, rigidity, or other changes 
in the extremities. The paralytic stage is the last, in which deep 
coma, disappearance of the contractures, increase in the pulse- 
rate, marked variations in the temperature, and Cheyne-Stokes 
breathing usher in the fatal termination. 

In non-tubercular, purulent meningitis there are no tubercles 
to be found in the choroid, and no tubercle bacilli in the fluid 
removed by lumbar puncture. But neither of these signs occur 
with regularity in tubercular meningitis. Lumbar puncture only 
gives positive results if bacilli can be found; but it is to some 
extent indicative of tuberculosis if the fluid contains a distinct 
excess of leucocytes, if the amount of albumin is raised above .5 
per thousand, and if there is distinct lowering of the freezing 
point. 


For performing lumbar puncture a sterile needle 7 to 9 cm., or for 
children about 5 cm. long is required. The patient lies near the edge of 
the bed on the left side, with the knees drawn up on the abdomen; a dis- 
tinct lumbar convexity with widening of the intervertebral spaces is thus 
produced. In meningitic children the puncture can also be made in the 
sitting position. The best point of entry is between the third and fourth 
lumbar vertebre; this is easy to find in thin people by counting the spinous 
processes. If this is not easy a horizontal line may be drawn between the 
upper limits of the ilium of the two sides, which will pass over the spine 
of the fourth lumbar vertebra, and above it the needle can be introduced. 
The spot is to be disinfected with tincture of iodine, and anzsthetized with 
a spray of ethyl chloride. In children the needle is introduced just under the 
spinous process in the middle line in a direction slanting slightly upwards. 
In stout adults it is better to introduce the needle 1 cm. to the right of the 
middle line, when the patient is lying on the left side, and to direct it 
slightly upwards and inwards. The fluid is received into a sterile glass; 
the removal of about 3 to 5 cm. is sufficient; it is not necessary to measure 
the pressure. After withdrawal of the needle the puncture may be closed. 

For examination of the fluid for tubercle bacilli, Engel recommends 
the following method: The fluid free from blood is to be put on ice for 
twenty-four hours, a delicate, cobweb-like clot then forms, which can be 





TUBERCULOSIS OF THE NERVOUS SYSTEM 429 


best seen against a dark background. The fluid is poured into a flat dish, 
and some of the clot transferred to a well-cleaned cover-slip, and thoroughly 
spread out. The preparation is dried in the air, fixed and stained in the 
usual way. The cells and bacilli contained in the threads of the clot are 
easy to find. 

The presence of lymphocytes in the fluid can be determined by stain- 
ing with Loffler’s methylene blue. 

For the estimation of the albuminous contents of the fluid in place of 
the somewhat cumbersome method of Nissl-Essbach that of Nonne and 
Apelt may be recommended, which consists of an examination for globulins. 
The fluid is mixed with an equal part of a saturated solution of ammonium 
sulphate, which normally in the cold gives no precipitate, but does so in 
organic diseases of the central nervous system on account of the pathological 
increase in the globulin content. 

The diagnostic importance of pressure measurement is not great, but it 
may confirm the clinical evidence of increased pressure. The spinal fluid 
is normally under a pressure of about 125 mm. of water in the lying, or 
410 mm. in the sitting position. If the former figure is raised to 200 or the 
latter to 500 or more it is indicative of meningitis. 


The cutaneous test is permissible, but of doubtful value in 
adults; the subcutaneous test is contra-indicated. 
The prognosis is not absolutely hopeless, 
since the possibility of recovery has been 
anatomically proved. Of recent years clinical observations of 
cases of recovery have multiplied. Thus Freyhan, Henkel, 
Barth, Gross, Claisse and Abrami, Archangelsky, Rumpel, 
Hochstetter, Riebold, and H. Stark have seen undoubted cases 
of tubercular meningitis permanently recover after repeated lum- 
bar puncture, and this is possible even in very severe cases. 
The treatment consists first in the applica- 
tion of ice and cold compresses to the head 
and neck, and in prolonged warm baths. Also inunction of 
mercurial or iodoform (1 in 10) ointment has been recommended. 
In cases in which purulent infection cannot be excluded with 
certainty use may be made of intravenous injections of collargol 
(5 to 10 c.c. of a 2 to 5 per cent. solution) every twenty-four hours 
with inunction of Crede’s silver ointment (15 to 45 gr. several 
times a day) into the skin of the back, which has been cleaned 
and rubbed with benzine, the part being after covered with 
flannel. By several authors the appiications of Bier’s bandage 
to the neck has been warmly recommended. In the stage of 
irritation narcotics can be hardly avoided, and in the paralytic 
stage inhalations of chloroform may be used to give relief, since 
recovery is no longer possible. Tuberculin is useless, and not 
without danger. 

Lumbar puncture has a palliative value, since it lowers the 
raised intracranial pressure, and thus diminishes the mechanical 


Prognosis. 


Treatment. 


430 A CLINICAL SYSTEM OF TUBERCULOSIS 


pressure effects in the medullary centres, and prevents degenera- 
tive encephalitis. The immediate results are improvement in the 
symptoms, with diminution or disappearance of the vertigo, 
delirium, headache, and rigidity of the neck. If done early one 
or two punctures will be enough, and as much fluid must be 
removed as to bring the pressure back to normal; in other cases it 
may have to be done every day or every other day. Riebold saw 
recovery after twenty-four punctures. In any case frequent 
lumbar puncture according to the observations of Henkel, 
Archangelsky, Rumpel, and others and the experience of the 
Leipzig medical clinic has such a good effect on the symptoms 
that it should be generally employed. Lumbar puncture should 
be as much used by the practitioner as puncture of the serous 
cavities. The technique is the same as for the diagnostic lumbar 
puncture. The amount of fluid to be withdrawn depends upon 
the pressure it is under. In general not more should be taken 
than will leave an approximately normal pressure of 120 mm. 
in the lying, and 4oo mm. in the sitting position. 


5. FUNCTIONAL NERVOUS CHANGES IN TUBERCULAR 
PATIENTS. 


Functional changes in the peripheral ner- 
vous system in phthisical cases are brought 
about by the alteration in the plasma. Irritative symptoms are 
usually sensory and consist of hyperzesthesia and paresthesia. 
Hyperesthesia of the skin and muscles and paresthesia often 
occur unilaterally over the affected lung. Hyperesthesia may 
also appear as a reflex set up by tubercular disease of an internal 
organ through the sympathetic and vagus in certain definite 
zones and areas in the skin. In this way also may be explained 
spinalgia, fibrillary muscular contraction, and certain vasomotor 
effects, such as circumscribed redness of the skin of the cheeks, 
rapid changes of colour, dermographia or urticaria factitia, and 
increased sweating. 

Certain groups of nervous symptoms may also be caused by 
tubercular disease of certain organs. We may mention the 
occurrence of symptoms of exophthalmic goitre with tuberculosis 
of the thyroid, of tetany with tuberculosis of the accessory 
thyroids, and of the marked nerve symptoms with tubercular 
disease of the adrenals. The changeable nature of the body 
temperature of phthisical patients belongs to this group of 
symptoms. Kohler ascribes the close connection in phthisical 
cases between the temperature and mental states to an increased 


Symptomatology. 





- “l= sari |—= ro 


nom wis 


TUBERCULOSIS OF THE NERVOUS SYSTEM 431 
irritability of the heat centres. Menstrual and premenstrual 
fever in tubercular women may also be a condition connected 
with the vasomotor nerves. 

The prognosis of functional alterations 1s 
good. The treatment consists of suggestive 
action on the skin by spirit frictions, paint- 
ing with iodine and iodo-guaiacol-glycerine, vesication, fara- 
dization, and hot-air baths. 

Also a general tonic and hardening treatment must be car- 
ried out, and at the same time psychical influence must be 
brought to bear on the patient. 


Prognosis and 
Treatment. 


6. NEUROSES AND PSYCHONEUROSES IN 
TUBERCULAR PATIENTS. 


Owing to the frequency of both neuras- 
thenia and tuberculosis a mere coincidence 
of the two diseases in one patient does not necessarily mean that 
they are in causal relationship. On the other hand there can 
be no doubt that even quite in the early stages of tuberculosis 
owing to the action of the disease on the central nervous system 
there is a condition of nervous irritability, which in cases of 
congenital or acquired nervous weakness may reach a grade ot 
distinct neurasthenia. Besides the nervous irritability a marked 
feature of the disease is an increased reaction to impressions 
arising outside or within the organism. 

The condition is of considerable practicable importance. 
Early tuberculosis may take the form of neurasthenia, and on 
the contrary purely neurasthenic symptoms, such as slight irrita- 
bility and tiredness, lack of appetite, night sweats, and head- 
ache, may simulate pulmonary tuberculosis. As a matter of fact 
both diseases are taken for the other; the neurasthenic is sent to 
the sanatorium, and the tubercular patient passes as a neuras- 
thenic. The views of sanatorium physicians as to the frequency 
of neurasthenia among the tubercular inmates vary considerably. 
According to Weygandt from 10 to go per cent. of the patients 
suffer from neurasthenic irritability, 50 per cent. have increased 
patellar and periosteal reflexes, while 70 to 75 per cent. have 
dermatographia; all these symptoms occurring much oftener 
than in non-tubercular people. An important practical point 1s, 
that in cases of neurasthenia in which the cause is not clear 
tuberculosis should be sought for. 

Hysteria and tuberculosis approach each other closely. Even 
a slight tubercular infection, and still more fever, anzemia, and 


Symptomatology. 


432 A CLINICAL SYSTEM OF TUBERCULOSIS 


inanition may in latent hysteria call forth such severe manifesta- 
tions that the symptoms of tuberculosis may be masked by those 
of hysteria; such a condition has been called *“‘ hysterical 
phthisis.’? On the other hand in hysterical patients bleeding 
from the gums and throat may simulate phthisis. This connec- 
tion must always be remembered in insurance cases presenting 
hysterical stigmata, or signs of traumatic neurosis. 

Hysteria appears in tubercular patients much more rarely 
than neurasthenia. Scherer in 1909 saw in his women’s sana- 
torium in 470 cases 201 examples of neurasthenia and 20 of 
hysteria, and in 1910 in 477 patients 287 with neurasthenia and 
31 with hysteria. This corresponds with our experience with 
male tubercular cases; to about ten neurasthenics there is only 
one hysterical case. Often the neurasthenia takes a hysterical 
tinge, or the two conditions may occur together as hystero- 
neurasthenia. 

All these nervous conditions occur more often in early than 
in late cases of tuberculosis, in women than in men, and in 
persons of the upper than in the labouring class. With advance 
of the tubercular disease the intensity of the nervous symptoms 
diminishes; Ritter observed this especially after a haemoptysis. 
It is characteristic of the neuroses in tubercular patients that they 
tend to assume a psychical character, and to become true psycho- 
neuroses more often than in non-tubercular people. In this 
connection the traumatic neuroses may be remembered; the 
spread of tubercular infection after an injury explains this con- 
nection. | 

From this we pass to the peculiarities of character and 
slighter psychoneuroses of tubercular persons. There are many 
injurious influences which act continuously and often for a long 
time. Besides numberless personal, family, psychical, and 
physical factors, there are the action of toxic substances, maras- 
mus, vasomotor changes in the brain, narcotics, and perhaps 
alcohol. All these influences not infrequently alter the psycho- 
logy of tubercular persons in such a way that they react extremely 
quickly to stimuli, that marked differences appear in their charac- 
ter from that of their healthy days, and an increase in the ideas 
and perceptions is to be observed; the mind of the tubercular 
person assumes, as Kohler has stated, a psychasthenic tendency. 

According to the generally received views of Heinzelmann 
two chief deviations from the normal psychical state occur : weak- 
ness of character and weakness of intelligence. These are shown, 
according to the individuality, environment, education, and 
breeding, by various changes in the psychical and affective 





TUBERCULOSIS. OF THE NERVOUS SYSTEM 433 


relationships of tubercular persons. The most frequent of these 
are: alterations of moods, frequent irritation and irritable weak- 
ness, a tendency to blissful emotions even if the original dis- 
position was quite the opposite, marked egoism and ego-centri- 


city, querulessness and grumbling, weaknesses of judgment and 
failure of the critical powers in distinguishing between things 
beneficial and injurious, and between meum and tuum, a tendency 
towards impulsive actions, periods of depression, optimism and 
self-deception, want of self-control, want of perseverance, over: 
estimation of physical powers, more rapid exhaustion of the 
mental faculties, failure of memory except in reference to the 
patient’s own condition, and lastly, increased reaction to sugges- 
tion. Particularly characteristic of nervous tubercular persons 
is pathological changeability of mood, which may pass through 
all phases from melancholy ill-humour to emotional gaity. 

The older view that the sexual desire of tubercular persons 

is increased is still largely held. From our own observations we 
incline to the conclusion that even in states of great general 
weakness an increased sexual irritability and excitability is not 
seldom found, but that it is not particularly characteristic of 
tubercular cases. The sexual power of male tubercular patients 
although physically weak, emissions, and masturbations during 
Sanatorium treatment, attempts at intercourse between the sexes 
in institutions which receive both men and women, in spite of 
their complete separation, and the statements of individual 
patients as to increase of sexual desires all prove but little. An 
increase in the libido sexualis of* inmates of sanatoriums can be 
better explained by the circumstances of the treatment, such as 
the life in the open-air, the inactivity and absence of muscular 
exercise, the general bodily stimulus given by baths, frictions, 
and douches, the over-feeding and excess of albumens acting on 
patients, who are usually at the age of the greatest sexual 
activity, and are generally free from pains, and who, if they are 
incurable, often wish to take advantage of all pleasures of which 
they are still capable. 
As to the prognosis of the neuroses and 
psychoses of tubercular patients it can only 
be said that they do not as a rule run the 
Same course as the primary disease. If the practitioner con- 
siders carefully and critically the subjective symptoms of his 
patients, he will not be at fault in forming a diagnosis and 
prognosis of individual cases. 

Besides the general treatment directed towards increasing the 
strength, the psychical management of the patient is of the 

28 


Prognosis and 
Treatment. 


434 A CLINICAL SYSTEM OF TUBERCULOSIS 


greatest importance. [Emphatic statements of the seriousness of 
the condition and the importance of rigid treatment will be 
especially needed. It will be generally necessary to remove the 
patient from the home surroundings, since these often have 
unfavourable influences both on body and mind. This measure 
is frequently needed even as a preventative. As a prophylactic 
also the sexes should be separated in sanatoriums; in public 
institutions it 1s most necessary. 


7. TUBERCULAR PSYCHOSES AND TUBERCULAR 
MENTAL DISEASE. 


Recent literature on psychiatry and tuber- 
culosis do not support the idea of a general 
tubercular psychosis. | Krapelin found that phthisis was very 
rarely accompanied by delirium. According to Binswanger 
tuberculosis only through loss of strength leads to conditions 
which are accompanied by the dementia of weakness. In the 
large material of sanatoriums only now and again in hundreds 
of cases will one see catatonia or maniacal delirium, the latter 
usually in the terminal stages of tuberculosis, and then the mental 
state may be due less to the phthisis than to a latent psycho- 
pathic disposition. 


Symptomatology. 


Still cases of moribund delirium, with wandering and slight 
excitement are taken as examples of a specific, tubercular insanity. 
Further, in advanced but not yet agonal cases of phthisis 
quite short transient periods of excitement in the form of acute 
hallucinatory paranoia with Stupor may be met with. Also 
asthenic wandering with motor excitement, talkativeness, and 
hallucinations, in fact the complete picture of acute amentia, have 
been seen by Riebold in severe tuberculosis. It is interesting 
that Loschke could produce quite similar symptoms on himself 
by inhaling the emanations from tubercle bacilli, and considered 
that it denoted a specific reaction of supersensitiveness. Apart 
from such isolated observations the mental symptoms in the 
majority of tubercular patients consist of motor excitement in the 
form of mania; it is almost like an increase of the well-known 
optimism and euphoria of tubercular patients into a psycho- 
pathological condition of maniacal excitement and delusions of 
grandeur. 

If the phthisical patient is a chronic alcoholic, he is more 
easily attacked by delirium tremens than a non-tubercular person. 
There can be no doubt that many tubercular psychoses are 
nothing else than alcoholic delirium in a tubercular person, to 
which the weakness of the whole organism is a_ predisposing 


aa 


TUBERCULOSIS OF THE NERVOUS SYSTEM 435 


cause. Alcoholic phthisical cases suffer also more severely from 
abstinence than non-tubercular alcoholics. We ourselves have 
so often seen an outbreak of delirium tremens from sudden and 
complete cutting off of alcohol on the entrance into sanatoriums 
of tubercular alcoholics, that we cannot doubt the existence of an 
abstinence delirium in these cases. 

If we decline to accept the existence of a general tubercular 
psychosis, but concede the occurrence of psychoses of a tuber- 
cular origin, the question arises how psychical alterations in 
tubercular persons can be explained. As in typhoid delirium and 
psychoses of sepsis, there is with the psychoses of tuberculosis 
an overloading of the whole organism with toxin, which is 
capable of considerably disturbing the mental faculties. Further, 
there is probably a connection between the frequent occurrence 
of tubercle bacilli in the circulating blood and the histological 
changes in the nerve-cells, vessels and meninges of the cerebral 
cortex, which are found in phthisical cases even when there is no 
mental disturbance. A certain acquired or congenital tendency 
towards psychical abnormalities may act as a predisposing cause 
in individual cases, and explains the specific toxic action of the 
tubercle bacilli on the central nervous system and especially the 
central cortex in cases of general weakness or in patients lowered 
by the use of alcohol or morphia. 

The question whether tubercular persons are responsible 
before the law may be answered in the negative for all actions, 
which are done in a state of delirium or amentia. Only in excep- 
tional cases will a combination of weakness of the intelligence 
and increase of the emotions give rise to a criminal tendency. 
In no case are the toxic effects of tuberculosis to be considered 
the same as those of alcohol in a criminal relationship. On the 
other hand, it may be possible to prove in criminal cases that the 
illegal act was done at a time when the character was altered by 
phthisis; if this is so the assumption of a partial irresponsibility 
or lessened responsibility will be justified, and must be considered 
in awarding punishment. 

The close connection between tuberculosis and mental disease 
is indicated by the following figures: according to an inquiry 
made by Wulff in 1893 in idiot asylums, 48.6 per cent. of all 
deaths were due to tuberculosis; in 15.3 per cent. of the idiot 
asylums from 80 to 100 per cent. of the deaths occurred through 
tuberculosis. In 1903, of the 507 inmates in the Rastenburg 
Idiot Asylum, forty died, one of enteric and thirty-nine of tuber- 
culosis. _In the Hamburg Asylum, with 761 paralytics, Fried- 
richsberg found 269 cases of phthisis, 7.e., 36.3 per cent. From 


436 A CLINICAL SYSTEM OF TUBERCULOSIS 


1877 to 1901 Hofheim found, in the Hessian Asylum, that 25.1 
per cent. of all the deaths were due to tuberculosis, and in the 
Hepperheim Asylum 22.4 per cent.; altogether tuberculosis 
occurs as a cause of death 3.9 times as often as in the mentally 
sound. The reason for these terribly high figures is in a small 
degree due to the still incompletely hygienic arrangements in 
asylums, and in a larger degree to the impossibility of dealing 
properly with the sputum of mental cases; it is usually swallowed, 
and often also some is smeared about. On the other hand, there 
is no marked affinity between any special form of mental disease 
and tuberculosis, such as exists between general paralysis and 
syphilis. Mental disease does not follow tuberculosis, but the 
latter follows the mental disease, and especially the removal of 
the patient to an asylum. That this is so is shown by the fact 
that while the number of phthisical patients afflicted with mental 
disease remains the same, the number of tubercular lunatics has 
very considerably .diminished, owing to the improvement in the 
hygienic conditions of asylums and the measures taken to isolate 
those infected and to disinfect the sputum, linen, &c. 

The prognosis of tuberculosis becomes 
worse if it is complicated by considerable 
mental disturbance. Also the course of 
mental disease is less favourable if the patient becomes infected 
with tuberculosis. 

The treatment.of psychoses in tubercular persons is not 
essentially different from that of those in the non-tubercular. 
Rest, good food, and plenty of fresh, pure air are the most 
important factors. The use of hydrotherapeutic measures must 
be strictly adapted to individual cases; in hopeless cases of tuber- 
cuiosis narcotics need not be withheld. The removal from a 
sanatorium to an institution for mental cases may be necessary, 
though quite exceptionally. For the prevention of abstinence 
delirium it is preferable in the institutional treatment of tubercular 
alcoholics to cut the alcohol off gradually. 

The treatment of tubercular lunatics in a special pavilion, 
apart from the general sanatorium, presents great difficulty, since 
in it a complete sub-division and separation of the tubercular 
cases, according to the form of mental disease would be necessary. 
It is simpler and cheaper to isolate the infectious cases in an 
asylum in separate rooms, and io see that in framing the 
measures suitable for the mental condition that the necessary 
hygienic precautions are not omitted. The prevention of over- 
crowding is still required in many asylums, with improvement 
in the ventilation and a more careful disinfection of the 
bedding, &c. 


Prognosis and 
Treatment. 





CHAPTER XE: 


Tuberculosis of the Eve. 


1. TUBERCULOSIS OF THE CONJUNCTIVA. 


Tuberculosis of the conjunctiva may appear 
in the form of small, miliary, grey or 
greyish-yellow granules, which may either 
be isolated or in groups, and have but slight tendency to necrosis ; 
or larger, rounded, papillary swellings may form, which ulcerate 
in places. Tubercular ulcers have a yellowish-red, tallowy base, 
or are covered with grey-red granulations. In their neighbour- 
hood may be often seen small granules or exuberant growths of 
the conjunctiva. The disease is usually situated on the con- 
junctiva of the lids and in the folds, more rarely on the bulb. 

Lupus of the conjunctiva is a separate condition. Lupoid 
ulcers are marked by their swollen edges and uneven base 
covered with granulations, which bleed readily. It is typical of 
the condition that it spreads from the skin to the conjunctiva, and 
like lupus of the skin tends to cicatrize at one point while it 
advances at another. 

Microscopically tuberculosis of the conjunctiva shows the 

usual changes found in the disease of the mucous membranes 
with tubercles containing Langhans’s giant-cells; tubercle bacilli 
cannot always be found in the sections. 
The disease usually affects only one eye. 
Young people are chiefly attacked. So 
long as only granules are formed no 
symptoms are produced. When ulcers appear the lids become 
swollen and a purulent discharge appears. The disease runs a 
very chronic course and may last for years. The tubercular 
ulcers slowly spread and show but slight tendency to healing. 
Spontaneous recovery is only rarely seen, and then relapses 
usually follow. The ulcers may spread from the conjunctiva to 
the bulb and in severe cases cause deep destruction of the lids. 
The pre-auricular lymphatic glands usually swell quite early. 


Anatomical 
Changes. 


Symptoms and 
Course. 


438 A CLINICAL SYSTEM OF TUBERCULOSIS 


Tuberculosis of the conjunctiva may be primary. In the 
majority of cases it follows direct infection from outside, and is 
generally a purely local disease. That it appears comparatively 
rarely, though tubercle bacilli very often reach the conjunctival 
sac, is doubtless due to the fact that the bacilli cannot penetrate 
the normal epithelium, so that a lesion is necessary for the occur- 
rence of infection. The idea of a bactericidal action of the 
tears (Valude) seems doubtful. Primary tuberculosis of the con- 
junctiva may long remain local; but it may be spread further 
by the lymphatics. Extension by continuity to the tarsus, the 
cornea, the lachrymal ducts and the nasal mucous membrane is 
rare. 

Secondary infection of the conjunctiva from neighbouring 

structures, especially the nasal mucous membrane, is more com- 
mon. The decision whether the disease is limited to the con- 
junctiva or not is very important for prognosis and treatment, 
since in the former case the diseased area can be radically re- 
moved. But if the eye is secondarily affected from the nose, 
complete recovery is much more difficult. 
The diagnosis can be usually made easily 
by the naked eye; but there are several 
other diseases of the conjunctiva which may be confused with 
tuberculosis, or which may mask it. According to Konigshofer 
nodules produced by trachoma, conjunctivitis follicularis and 
granulations of the conjunctiva will in many cases be found to 
be tubercular on bacteriological examination. The views as to 
the etiology of eczematous conjunctivitis (scrofula, phlyctenula) 
and its connection with tuberculosis and scrofula are still at 
variance. In the cellular infiltration giant-cells can be easily 
found, but tubercle bacilli never; also the condition usually does 
not react to tuberculin. In severe cases the disease may lead to 
extensive, deep infiltration of the cornea, sometimes ending in 
necrosis. The assumption of a special specific microbe is appa- 
rently unfounded. 

According to Fuchs the following ulcers may be confused 
with tubercular ulcers of the conjunctiva: ulcers in eczematous 
and pustular conjunctivitis, ulcers left after separation of necrotic 
tissue due to diphtheria, and after burns, those due to the infec- 
tion of small foreign bodies, to the necrosis of a chalazion, a 
pustule, or pemphigus vesicle, and lastly epithelioma; very 
rarely small syphilitic ulcers may have to be considered. 

The differential diagnosis may be made by the history, by 
the nature of the primary disease, by exclusion and by the result 
of treatment. A histological or bacteriological examination of a 


Diagnosis. 





TUBERCULOSIS. OF THE EYE 439 


small piece of excised tissue, or the inoculation of this into the 
anterior chamber of the eye of a rabbit will give certain results. 
In doubtful cases test tuberculin injections will be specially use- 
ful by producing a focal reaction. This is of the greatest im- 
portance from the point of view of treatment, especially of the 
tuberculin treatment, which is being increasingly favoured. The 
exact zetiological diagnosis is called for in the cases of eczematous 
conjunctivitis, which have been already mentioned, since tuber- 
cular phlyctenules according to Schutz and Vidéky can be cured 
by tuberculin and good food, while in cases of exudative 
phlyctenula tuberculin treatment has no effect, and over-feeding 
with albumens, fats, &c., is even contra-indicated. 

The prognosis in the first place depends 
upon whether the disease in the conjunctiva 
is primary. As long as it is limited to the conjunctiva the 
chances of recovery are not bad. Owing to the tendency to 
relapse, the radical treatment of the diseased foci does not always 
succeed. If the disease in the conjunctiva is secondary, or if it 
has already extended into the nose, the prospects of cure are 
not so good. 


Prognosis. 


Cases in which complete removal of the 
disease seems possible may be treated by 
excision, cauterization or scraping, followed by applications of 
caustics or iodoform powder. Lactic acid (25 to 30 per cent. solu- 
tion) has also been recommended. A general hardening treat- 
ment will often be necessary. Lundsgaard, by means of Finsen 
light, obtained very good results without any relapses in twenty 
cases of lupus and primary tuberculosis of the conjunctiva. 
Lately tuberculin has been increasingly used with success; 
Davids, Griffith, v. Hippel, Masing, Saathoff and Schwartz 
recommend its use. 


Treatment. 


2. TUBERCULOSIS OF THE CORNEA. 


Tubercular disease of the cornea usually 
takes the form of parenchymatous keratitis. 
Anatomically there is a thick infiltration of 
the posterior layers of the cornea, with a new formation of 
numerous vessels in the middle and posterior layers. The in- 
filtration implicates the ligamentum pectinatum, the iris and the 
ciliary body; however, the affection of the cornea is often so 
slight that it cannot be detected clinically. The histological 
recognition of typical tubercles has led to the now current view, 
that the disease is more often tubercular than was previously 
thought. It has lately been held that tubercular parenchymatous 


Anatomical 
Changes. 


440 A CLINICAL SYSTEM OF TUBERCULOSIS 


keratitis nearly always begins by the deposit of tubercle in the 
ligamentum pectinatum, and therefore that the keratitis is 
usually secondary. Cases of primary corneal tuberculosis with 
the development of peripheral tubercular foci, which gradually 
spread towards the centre and heal, leaving behind marginal or 
tongue-shaped opacities, and which sometimes also ulcerate, have 
indeed been described, but with doubtful correctness. 

According to the general view the clinical 
picture of corneal tuberculosis does not 
differ at all from that of typical keratitis 
parenchymatosa, which is evident from the nature of the anato- 
mical changes. The disease may, therefore, vary much in the 
form, extent, and intensity of the corneal deposits, and the amount 
of vascularization. The depth of the deposit and vascularization, 
the gradual spread of the infiltration till it reaches a usually con- 
siderable amount, and the absence of suppurative changes are 
typical. 

Sometimes corneal tuberculosis takes the form of sclerosing 
keratitis, in which tongue-shaped opacities spread out from the 
limbus into the deeper layers of the cornea. 

Corneal tuberculosis produces inflammatory symptoms, 
such as pains, photophobia or lachrymation. Nearly always 
there is more or less inflammatory complication of the uveal tract. 
It usually attacks both eyes, more often simultaneously than 
consecutively, and always runs a slow course. 

Very rarely are corneal ulcers produced by necrosis ee 

ing from the eranulations in the deeper layers to the surface; 
such ulcers may affect the larger part of the cornea. There are 
no clinical characteristics of tuberculosis; tubercle bacilli can be 
found in the discharge. Their course is usually very slow. 
The clinical diagnosis of corneal tubercu- 
culosis can only be made with difficulty, as 
there are usually no characteristic symptoms. The diagnosis 
gains in probability if hereditary syphilis, which causes 70 to 80 
per cent. of the cases of parenchymatous keratitis, can be 
excluded, and if there is tuberculosis of another organ or an 
hereditary tendency. The result of a test tuberculin injection is 
often of great importance. Enslin in cases of distinct lues 
without signs of tuberculosis never saw a reaction; on the con- 
trary in cases in which there was no sign of lues or in which 
both syphilis and tuberculosis were present, the general reaction 
was distinct, but there was no focal reaction. As characteristic 
of the tubercular form he reckoned the steep rise and rapid fall 
of the reaction curve, an observation which v. Hippel has con- 
firmed. 


Symptoms and 
Course. 


Diagnosis. 





eee eee 


——— 


TUBERCULOSIS OF THE EYE AAT 


The diagnosis of tubercular corneal ulcers, since they differ 
in no way clinically from non-tubercular forms, must likewise be 
made exclusive or by the use of tuberculin. Sometimes tubercle 
bacilli can be found in material taken from the floor of the ulcer. 
The prognosis of tubercular parenchyma- 
tous (interstitial) keratitis with regard to 
termination is favourable, since most cases recover with good or 
sufficient sight, but the disease may last for many months. Also 
the prognosis in tubercular corneal ulcers in the cases hitherto 
seen has been good, in no case was perforation met with. The 
prognosis in both forms and the duration of the disease has been 
distinctly improved since the introduction of tuberculin treat- 
ment. 


Prognosis. 


The treatment during the progressive stage 
consists in the use of a bandage or dark 
glasses, warm compresses, and in dealing with complications in 
the iris and ciliary body by means of atropine. In the regressive 
stage to assist in the clearing of opacities calomel powder, or as a 
stronger method, yellow precipitate ointment 1 to 4 per cent. can 
be employed. The remedies must be used for a long time, and 
be changed from time to time, since the eye becomes accustomed 
to them. Internally mercury, iodides, and diaphoretics can be 
used as reabsorbents. 

The local treatment of tubercular corneal ulcers is that of 
non-specific cases; in slight cases with not much discharge 
bandages, warm compresses, insufflations of iodoform, and 
atropine may be used. In severe cases operative measures, such 
as scraping or cauterization of the ulcers, after repeated applica- 
tion of 5 per cent. cocaine solution, are required. 

General treatment directed against the tuberculosis is also 
very important. Tuberculin treatment is specially indicated, and 
has given as good results as in conjunctival tubercle. With its 
use recovery has been seen by Busse, Davids, Dodd, Emanuel, 
Erdmann, v. Hippel, Laas, Lichtenstein, Rohmer, Saathoff, 
Schoeler, Ullmann, Wilder, and others. 

Ullmann and Schwartz have also seen good results with 
Marmorek’s serum in cases of scrofulous corneal disease. 


Treatment. 


3. TUBERCULOSIS OF THE SCLERA. 


Tuberculosis of the sclera appears as super- 
ficial and deep inflammation. To the 
naked eye it differs in no way from the non- 
tubercular processes. The same is true of the progressive and 
destructive forms of softening and necrosis. 


Anatomical 
Changes. 


442 A CLINICAL SYSTEM OF TUBERCULOSIS 


There are no clinical characteristic signs of 
tuberculosis of the sclera. It 1s a Ware 
disease, and usually arises from primary 
mischief in the iris or ciliary body, more rarely in the choroid. 
It usually assumes the form of deep scleritis with more or less 
circumscribed nodules. The so-called ‘‘ tuberculoma of the con- 
junctiva bulbi,’’ which is situated near the edge of the cornea, 
and forms a thick, tumour-like prominence, arises nearly always 
according to Reis not from the conjunctiva, but from the super- 
ficial layers of the sclera. Tuberculosis of the sclera attacks 
principally young people, but not children, and runs a very 
chronic course. Quite in early stages of the disease ectasia of 
the sclera and staphyloma may occur. Neighbouring parts of 
the eye may become implicated; severe injury may be produced 
by thick opacities in the cornea (sclerosing keratitis), by seclusion 
of the pupil, by opacities in the lens and vitreous, and by altera- 
tion in the shape of the eye with marked myopia and increase of 
pressure from ectasia. 


Symptoms and 
Course. 


The diagnosis of marked cases is easy; but 
slight ones may be difficult to recognize. 
Since the tubercular form of the disease has no special character- 
istics, the diagnosis must be made from the presence of other 
tubercular foci, or by means of tuberculin. According to v. 
Michel scleritis is usually due to tuberculosis or syphilis. 
Recently tuberculosis of the sclera has 
been cured by tuberculin treatment, so that 
a better prospect is opened up for a disease which was previously 
considered incurable. 


Diagnosis. 


Prognosis. 


Treatment till recently was quite ineffective, 
and consisted of the employment of the 
usual reabsorbent measures. The local treatment is sympto- 
matic, and must be directed against the complications in the 
cornea and iris. In later stages of the disease iridectomy is 
usually required. Of late good results and even complete 
recovery have been obtained with the use of tuberculins by 
Brandenburg, Busse, Davids, v. Hippel, Reis, and Schoeler. 
It is therefore necessary to arrive at a diagnosis as early as pos- 
sible by means of a test tuberculin injection, and then to lose no 
time in commencing tuberculin treatment. 


Treatment. 


4. TUBERCULOSIS OF THE IRIS AND CILIARY BODY. 


Tuberculosis of the iris and ciliary body is 
anatomically the best known form of tuber- 
culosis of the eye, since it is a result of 
experimental inoculation of tubercular material into the anterior 


Anatomical 
Changes. 


’ 
4 





TUBERCULOSIS OF THE EYE 443 


chamber of the eye of animals, and has been histologically 
studied in all stages. Three to four weeks after the infection the 
first signs of tubercular iritis appear in the form of small, grey 
granules. These increase, become confluent, gradually fill the 
whole anterior chamber, and finally break through externally. 
In man tuberculosis of the iris appears in quite analogous forms, 
either as disseminated, grey granules, affecting particularly the 
base of the iris, or as larger, conglomerate tubercles. | Some 
tubercles may disappear, while others develop. One of the 
human forms of tuberculosis of the iris can be most closely repro- 
duced in animals by the inoculation of sterilized tubercle -bacilli 
into the anterior chamber. 

The rarer form of solitary tubercle develops with or without 
the simultaneous formation of granules, and forms the granula- 
tion tumour, which was first described by v. Graefe in agreement 
with the views of Virchow. Haab first recognized the tubercular 
nature of this granuloma. 

In advanced tubercular changes histological tubercles can 
usually be recognized, but only with difficulty in early cases. 
On the other hand, recorded cases show that tubercle bacilli 
are very rarely found in sections. But also in non-tubercular 
disease of the uvea nodules with epithelioid and giant cells have 
been found, especially according to Axenfeld, Hirschberg, and 
Rochat in sympathetic ophthalmia. Therefore the tubercular 
nature of the nodular form of iritis, which according to Michael 
is aS common as the syphilitic variety (40 to 50 per cent. of all 
cases) is doubted in many clinics. Added to this such cases of 
iritis with formation of nodules not uncommonly heal spon- 
taneously. Therefore the anatomical changes alone are not 
sufficient for the recognition of specific tubercular disease. 
Disseminated tuberculosis of the iris and 
ciliary body appears as iritis (ciliary injec- 
tion, contractfon of the pupil, discoloration 
of the iris, precipitation and synechia), the most characteristic 
sign being the formation of nodules. It is a disease of youth, 
and is often bilateral. It runs a very chronic, variable course, 
and has much tendency to relapse. Inflammation of the iris 
cannot be well separated from that of the ciliary body. Hyper- 
zmia and exudation are the most common signs, while the 
inflammatory symptoms are generally very slight, as in the non- 
specific variety. The nodules may spontaneously disappear. 
The tubercular nature of cases of spontaneous recovery has been 
proved by the result of animal inoculation of excised portions. 
In progressing. relapsing cases the nodules increase, become 


Symptoms and 
Course. 





AAA A CLINICAL SYSTEM OF “TUBERCULOSIS 


confluent, and with severe disease may take the form of plastic 
iridocyclitis, leading to complete atrophy of the bulb. 

Solitary tuberculosis of the iris is likewise usually found in 
young people up to the age of 20; hitherto only unilateral cases 
have been seen. It appears as a new formation, with or without 
accompanying granules, and does not produce the symptoms of 
iritis. The swelling increases, breaks through the cornea and 
grows externally. It then necroses and the bulb atrophies. 
Solitary tubercles may appear in the ciliary body as in the iris. 

Tuberculosis of the iris and ciliary body is nearly always a 
secondary disease. Primary tuberculosis is only possible from 
infection through a perforating wound; Fuchs has observed such 
acase. All other cases recorded as primary must have been due 
to a hamatogenous infection of the iris from some other latent 
nodule, clinical symptoms of which are absent. According to 
Kriickmann. tuberculosis of the iris is often secondary to glandu- 
lar disease. It is very rarely seen with pulmonary tuberculosis. 
Since anatomical examination is often not 
sufficient to determine the specific tubercu- 
lar character of small nodules appearing in the iris, the clinical 
diagnosis is still less possible. Non-specific nodules are seen in 
many general diseases, such as leukaemia and pseudoleukeemia, 
also in sympathetic ophthalmia. The name ophthalmia nodosa 
has been given to a disease produced by the hairs of caterpillars, 
which may perforate the conjunctiva and cornea, enter the iris, 
and there produce severe inflammatory signs. The reddish- 
yellow nodules of syphilitic iritis papulosa, which are of the size 
of a pin’s head or larger, are not to be confused with the miliary 
grey, tubercular granules, shining through the surface of the iris. 
The diagnosis of tubercular iritis may be supported by finding 
other signs of tuberculosis, but cannot always be thereby made 
certain. 

Solitary tubercle may be mistaken for other non-pigmented 
swellings, e.g., sarcoma, syphilitic papule or gumma. The 
following points may be useful: tubercle usually appears before 
the age of 20, it contains no vessels, and near it small tubercular 
granules can be sometimes found. Syphilitic swellings are 
situated at the edge of the pupil or ciliary’ body, they may appear 
at any age, and contain a few vessels; other symptoms of syphilis 
may often be found, and they disappear under mercury. Sarcoma 
appears very seldom in young people, it causes iritis later than 
the other affections, and contains more numerous vessels. 

The diagnosis being so difficult it is now generally recog- 
nized that it is extremely important to use the subcutaneous 


Diagnosis. 





TUBERCULOSIS OF THE EYE 445 


tuberculin test, which may be followed by a focal reaction 
(increase of the irritative symptoms, photophobia, ciliary injec- 
tion, and according to v. Michel possibly an eruption of tuber- 
cles). 

Before the use of tuberculin treatment the 
prognosis was shortly as follows: slight 
cases may recover, not uncommonly spontaneously, while severe 
cases usually end in loss of sight and of the eye. Since v. Hippel 
has worked out the method of tuberculin treatment in these cases, 
the prospects of healing in the vascular tissue of the iris and 
ciliary body are quite good. FEven cases of tuberculosis of the 
iris, in which enucleation was being considered, were completely 
cured with retention of the sight. 

The symptomatic treatment consists of 
attacking the iritis with atropine, perhaps 
combined with cocaine, with warm compresses, and if the inflam- 
matory symptoms are particularly severe with application of 6 to 
10 leeches to the temple. 

The general treatment must be directed as early as possible 
against the tubercular constitution. In suitable cases inunction 
or diaphoretic treatment may be used. Operative measures are 
rarely required for isolated nodules only ; they sometimes succeed, 
but lead to a dissemination of tuberculosis. Occasionally good 
results have been obtained by the introduction of iodoform into 
the anterior chamber (Haab), by blowing air into it (ISoster), or 
by subconjunctival injections of hetol (Pfluger). In all severe 
cases enucleation of the eye was necessary, to prevent a further 
spread of tuberculosis. 

Since v.. Hippel published his results, tuberculin treatment 
has been generally employed: for tuberculosis of the iris and 
ciliary body with excellent results, so that enumeration of 
authorities and the records of cases is no longer necessary. 


Prognosis. 


Treatment. 


5. TUBERCULOSIS OF THE CHOROID. 


Tuberculosis of the choroidal membrane 
appears, like that of the.iris and ciliary 
body,. first in the form of disseminated 
or miliary tubercle, as one sign of general miliary tuber- 
culosis. The tubercles affect chiefly the posterior part of the 
eye in the neighbourhood of the veins, and may be either single 
or in numbers of thirty to sixty or more. The chronic form of 
tubercle of the choroid may appear as single areas of diffuse 
thickened granulation tissue or as solitary tubercle. Anatomical 
examination shows that the latter are formed of numerous 


Anatomical 
Changes. 


440 A CLINICAL SYSTEM OF TUBERCULOSIS 


granules lying close to each other, the ones in the centre being 
usually caseous. 

Miliary tubercles of the choroid appear in 
about 75 per cent. of all cases of miliary 
tuberculosis, often first in the last stages of 
the disease, and are of great diagnostic importance, since in 
doubtful cases they may determine the existence of miliary tuber- 
culosis. The eyes show outwardly no alteration; the patient may 
notice a difference in the sight. The diagnosis can only be made 
with the ophthalmoscope. Small yellow or pale-red spots with 
distinct contour are seen in the fundus. They increase in size 
within several days, and at the same time new ones appear. 
They reach at the most a third of the size of the optic disk. 

The chronic form may remain stationary for a long time as 
a diffuse thickening. It then resembles choroiditis disseminata. 
Small foci have been not rareiy seen to heal spontaneously. The 
disease may spread to the retina and cause it to become separated. 
Even a metastatic tubercular panophthalmitis has been observed 
by Luttge. 

Solitary tubercle of the choroid is a rare disease of young 
people, and has a chronic course. It is secondary to tubercular 
disease of other organs, especially the brain. If other tubercular 
foci cannot be found, it will be because they are latent. With the 
ophthalmoscope a large light-coloured swelling can be seen in the 
choroid. If small spots can be found near it, it will confirm the 
diagnosis. The only symptom is usually alteration of sight. A 
progressing solitary tubercle gives the subjective and objective 
signs of a growing tumour. The tubercle may perforate the 
sclera, and then necrose. 

Miliary tuberculosis of the choroid can be 
easily recognized by the ophthalmoscope, 
and in difficult cases leaves not a doubt as to the nature of the 
general condition. In contrast to the spots of choroiditis dis- 
seminata choroidal tubercles increase in size and number, and 
they are not pigmented. Under the ophthalmoscopic picture of 
disseminated choroiditis tubercular changes may be hidden. It 
is important for diagnosis that the ordinary non-specific form is 
seldom accompanied by other signs of tuberculosis (only five 
times in 238 cases according to Maier). In this form the tuber- 
culin reaction may establish the diagnosis; Haab saw in one 
case redness of the ciliary region and conjunctiva, and in another 
haemorrhage near the papilla. Solitary tubercle is more easy to 
recognize with the ophthalmoscope; the tubercle nature of the 
swelling is indicated by small, light spots near it (tubercular 


Symptoms and 
Course. 


5 


Diagnosis. 





TUBERCULOSIS OF THE EYE 447 


granules). In cases in which its growth is progressive it can 
be distinguished from other tumours, such as glioma, by the 
relatively early appearance of iritis. Also the proper use of 
tuberculin may produce a focal reaction. 

The miliary form, being part of general 
miliary tuberculosis, indicates a fatal end- 
ing. Tubercular inflammation appearing in the form of choroi- 
ditis disseminata often recovers spontaneously, so ,that its 
prognosis is not bad. The solitary form before the use of tuber- 
culin always ended in loss of the eye, and there was also the 
danger of the tuberculosis spreading. Now the prognosis is 
very much better. 


Prognosis. 


Apart from symptomatic treatment and the 
use of the usual reabsorbents the treatment 
of chronic choroidal tuberculosis in severe cases until lately con- 
sisted of enucleation of the bulb, or, if perforation of the sclera 
had occurred, better still in exenteration of the orbit, although 
operation was not resorted to in earlier cases on account of the 
possibility of spontaneous recovery. Of recent years the opera- 
tions have steadily declined, owing to the good results achieved 
by tuberculin. Cramer saw recovery in a large isolated tubercle 
of the choroid with severe damage to the cornea; Lubowski had 
a similar case. Axenfeld also saw a tumour-like tuberculoma 
of the choroid cured under tuberculin. Augstein, Busse, Diem, 
Herrenschwand, Schoeler, and Stock recommend, too, tuberculin 
treatment on the ground of its marked results. 


Treatment. 


6. OTHER TUBERCULAR EYE DISEASES. 


Of the other tubercular diseases of the interior of the eye we 
may shortly mention first the opacities and the rarer hemor- 
rhages of the vitreous, which occur without other opthalmoscopic 
signs. Apart from the fact that the vitreous is sometimes 
affected by tubercular disease in its propinquity, it may appar- 
ently be itself the seat of tuberculosis without neighbouring parts 
of the eye being implicated. This is shown by the experimental 
researches of Deutschmann. Axenfeld and Stock, on the grounds 
of their observations during the last ten years, have found that 
the vitreous hemorrhages of young people which frequently 
accompany retinitis proliferans are often due to tuberculosis. 
Hzmorrhages into the vitreous usually originate in the vessels 
of the retina, which are easily affected in tuberculosis, perhaps 
by the action of the toxin. Here again tuberculin has not only 
been useful for the diagnosis and the establishment of the 
etiology of the condition, but has also been effective in the treat- 


445 A CLINICAL SYSTEM OF TUBERCULOSIS 


ment. Cases of complete and lasting clearing of the vitreous 
with recovery of good sight have been often recorded, as by 
Schoeler and Igerscheimer. 

Tubercles are only found in the retina when the uvea and 
optic nerve are also affected. A very rare case of pure retinal 
tuberculosis, in which the whole extent of the retina was affected, 
while the choroid was only secondarily infiltrated, has been 
recently described by Komoto; on histological examination of 
the enucleated eye the disease was found to have begun in the 
neighbourhood of the papilla. 

A’ by no means rare affection is tuberculosis of the optic 
nerve, which, like most forms of ocular tuberculosis, attacks 
chiefly young people. The disease may attack the nerve at any 
point from the chiasma to the papilla, or the nerve sheath; it 
usually occurs with tubercular meningitis. With the ophthalmo- 
scope the signs of papillitis are usually found. Tuberculosis of 
the optic disk or the retina may appear in the form of a tumour. 
If an operation is considered, it can only be a question of enuclea- 
tion of the bulb or exenteration of the orbit. Tuberculin again 
offers a good prospect in this disease, which formerly could only 
be weakly resisted. There are many cases in which it has given 
good results in optic neuritis, papillitis, and retrobuibar neuritis 
of a tubercular nature (Scheuermann, Schnaudigel, Schoeler, 
and others). 

The bones, periosteum, and cellular tissue of the orbit, and 
the muscles and nerves of the eye may be affected by tuberculosis, 
which is usually secondary. In the external eye it is of interest 
that the chronic affection of the Meibomian glands, chalazion, 
has by many authorities been declared to be often tubercular. It is 
more probable that it may be a question merely of a foreign body 
tuberculosis in the thickened secretion or epithelial debris of the 
Meibomian gland. Tubercle bacilli are only found in rare 
cases; inoculation experiments nearly always fail. The differen- 
tial diagnosis must be made from tuberculosis of the tarsus, 
which originates in the conjunctiva and may appear as a 
chalazion. 

More important is tuberculosis of the lachrymal gland, ducts 
and sac, which again usually appears in young people. The 
infection occurs secondarily from conjunctival tuberculosis, or 
more often from the mucous membrane or bones of the nose. 
Occasionally the disease in the lachrymal sac may be the first 
sign of lupus of the nose; the recognition of the primary disease 
is important for prognosis and treatment. 

Tuberculosis of the lachrymal gland is characterized by the 


ee eee, eee 





TUBERCULOSIS OF THE EYE 449 


appearance of a usually hard swelling, which is not tender on 
pressure and may reach the size of an almond; it is found in the 
upper and outer angle of the orbit, and is movable, not adherent 
to the skin, but connected with the deeper parts. The duration 
of the disease varies much; inflammatory symptoms are nearly 
entirely absent. The diagnosis must be made from sarcoma. 
The treatment is surgical, and radical cure is difficult to obtain. 
There are up to now no observations on the result of specific 
treatment. 
Our knowledge of tuberculosis of the lachrymal sac has been 
considerably increased by Bribak’s work at the Freiburg Univer- 
sity ophthalmic clinic. he disease usually appears as a blen- 
norrhoea of the lachrymal sac, sometimes as a dacrocystitis with 
fistula. On the grounds of the frequency of the condition 
(twenty-five cases in the last year) it seems that tuberculosis of 
the lachrymal sac occurs much more often than is generally 
thought, and that it may be the only recognizable form of tuber- 
culosis from which the patient is suffering. Some observations 
show that the tubercular character could be more often detected 
if a series of sections were made. The cases are suspicious in 
which the discharge does not contain the usual septic organisms. 
Sometimes the symptom complex observed by Axenfeld decides 
the diagnosis; this consists of a doughy-elastic resistance, which 
does not disappear on pressure; and although there is epiphora, 
yet fluid can pass through the canals rather slowly yet without 
great hindrance into the nose. A focal reaction may be obtained 
after a tuberculin injection; and a general reaction is also valu- 
able, since in this case the dacrocystitis may be already tubercular, 
or will readily become infected. The best treatment is early 
radical removal of the diseased structure. Recovery spon- 
taneously or as a result of treatment is not impossible, but the 
physiological function of the lachrymal sac is usually destroyed. 
Relapses may be avoided by energetic application to the granula- 
tions, and if necessary, to neighbouring foci of caustics. 


7. TUBERCULIN IN DISEASES OF THE EYE. 


The views as to the frequency of tuberculosis of the eye are 
still divergent, since in many forms the tubercular etiology is 
not yet sufficiently recognized. According to recent observa- 
tions, especially those of Michel, tuberculosis plays a very much 
larger part in the production of diseases of the eye than was 
formerly thought. On the other hand we have seen that there 
are various diseases, appearing in the form of nodules, which 
neither clinically nor anatomically can be recognized as being 


29 


450 A CLINICAL SYSTEM OF TUBERCULOSIS 


tubercular; even tubercular ulcers clinically often have not the 
characteristics of tuberculosis. 

In such cases the use of tuberculin for the differential 
diagnosis is of the greatest importance and is generally employed. 

The cutaneous reaction is littke employed in ophthalmology 
and is not likely to be so. All the same a negative result is 
strongly against the probability of ocular tuberculosis. A ; 
positive result can only be of value for diagnosis when other 
tubercular foci can be excluded, and tuberculosis of the eye may 
be secondary to quite slight forms of disease. Therefore the 
cutaneous reaction has but little importance in ophthalmology. 

There is so much risk of causing severe mischief by the 
conjunctival reaction, when tuberculosis of the eye is present, 
that its use 1s altogether condemned by many ophthalmologists 
(Adam, Brons, Collin, Siegrist, Stargardt, Stuelp, Waldstein, 
and others). 

The subcutaneous method with a production of a focal 
reaction is of the greatest value, and may absolutely establish 


the diagnosis. The diagnostic injections, however, must be 
given with care. According to v. Hippel, who has had the 


largest experience of tuberculin in diseases of the eye, strong 
focal reactions are to be altogether avoided. He warns against 
commencing with large doses and against increasing them too 
rapidly, since in several cases of tuberculosis of the cornea 
necrosis of the layers lying over the diseased focus has been 
seen when the reaction has been too strong. v. Hippel therefore 
advises the following doses for diagnosis, deviating from the 
method of R. Koch: initial dose always 1 c.mm. of old tuber- 
culin; if that gives no reaction to be increased to 2 or 3 ¢.mm.; 
and final dose, 5 c.mm. In most cases a prompt and undoubted 
reaction will be thereby produced. In children according to the 
age correspondingly smaller doses are to be used. Stock and F. 
Schoeler think that in adults a higher dose than 1 c.mm. is hardly 
necessary for diagnosis. 

In the description of the various forms of tuberculosis of 
the eye we have mentioned that rapid healing with preservation 
of the sight has been obtained in the’ severest cases with tuber- 
culin treatment without the use of any other method. The effect 
of tuberculin is the more striking, since previously treatment was 
usually powerless to arrest most cases of tuberculosis of the eye. 

Old tuberculin has given good results; but preference must 
be given to the new tuberculin T.R.; and lately the bacillary 
emulsion has been recommended from many sides, as it seems 
to surpass T.R. in its effects, and particularly to prevent relapses. 


7 2 nee Es Cason. 





TUBERCULOSIS OF THE EYE 45! 


For the tuberculin treatment of diseases of the eye, v. Hippel 
has worked out a special method, which has generally been 
employed in ophthalmology. It consists in giving with care 
small doses, and avoiding strong reactions. The possibility of 
watching in the eye the focal reactions and the course of healing 
step by step, makes the employment of tuberculin practically 
easy in these cases, and gives indications for the doses, the in- 
terval between them, the maximal dose and the duration of the 
treatment. Kriickmann, Reis, Kuhnt state that those cases of 
tubercular disease of the eye are most influenced by tuberculin 
treatment which gave to very small doses distinct focal reactions. 
Further information can be found in our book on “ Tuberculin 
in Diagnosis and Treatment.’’ 

In suitable cases other methods of cure may be used in 
addition. F. Schoeler states that tuberculin increases the utility 
of other methods and makes the eye more tolerant of them. With 
regard to the energetic reabsorbent measures, it may be remarked 
that diaphoresis had better be avoided with recent inflammation, 
and inunction treatment only used in strong people, who are free 
from tuberculosis in other organs. If these measures are used, 
they must be employed carefully and gradually. 


CHAPTER X11. 


Tuberculosis of the Ear. 


ACCORDING to the copious literature aural tuberculosis is more 
common in children than in adults. Licci found in the bodies 
of tubercular children that 80 per cent. had open suppuration 
of the ear with bacilli, while in adult phthisical cases E. Frankel 
found that only 6 per cent. had macroscopic tuberculosis of the 
ear, and Habermann, with the use of the microscope, could only 
detect it in 23.8 per cent. In adults, males are affected consider- 
ably more often than females. Herzog found middle-ear disease 
in 31 per cent. of tubercular men and in g per cent. only of women ; 
in 14 per cent. of the men there was a direct connection between 
the disease in the ear and tuberculosis, and this was not so in one 
woman. According to Schwabach’s figures to 81.8 per cent. of 
cases of tubercular suppuration of the ear in males there were 18.2 
per cent. in females. 

Contrary to the still general view a very considerable per- 
centage of chronic inflammatory conditions of the ear are of a 
tubercular nature. It is necessary for the practitioner to take 
more interest in the diseases of the ear in general and aural 
tuberculosis in particular, as these cases are commonly, at 
present, left to specialists. : 


1. TUBERCULOSIS OF THE EXTERNAL EAR. 


The external ear. is the most exposed to 
infection by the tubercle bacillus. The 
auricle and the external meatus may be- 
come primarily infected through an excoriation of the skin. 
Secondary infection is also possible from discharge due to tuber- 
cular disease of the middle or internal ear, or from sputum in 
open pulmonary tuberculosis. In the outer ear there are three 
characteristic forms of tuberculosis: Lupus, tubercular peri- 
chondritis and nodular tuberculosis of the lobe of the ear. 


Anatomical 
Changes. 





TUBERCULOSIS OF THE EAR 453 


Eupusmoi~ the external’ sear causes: 0 
symptoms and does not differ in appearance 
from the disease in other parts of the body. 

Tubercular perichondritis generally causes burning and 
itching. It consists of a doughy swelling with a red elevation 
of the concha; the disease may break through externally or may 
spread inwards from the cartilage. The neighbouring lym- 
phatic glands swell and become tender. 

Nodular tuberculosis of the lobule of the ear forms a thick 
swelling of the size of a cherry-stone, which consists of small 
cell infiltration and small tubercles. The skin is of a bluish 
colour, and not movable. The neighbouring lymphatic glands 
are affected. 


Symptoms and 
Course. 


The diagnosis of lupus of the external ear 
can be made without difficulty, if tubercu- 
losis is thought of. We may refer to the chapter on tuberculosis 
of the skin. Doubt may be settled by a test tuberculin injection. 

Tubercular perichondritis is characterized by its slow de- 
velopment, the caseous pus containing tubercle bacilli and the 
fungoid granulations. After discharge of the pus typical ulcers 
and fistula may form, and if the cartilage becomes infected 
necrosis and sequestra. 

Nodular tuberculosis is localized to the lobule, and especially 

to the spot where it is pierced. This explains the limitation of 
this form to the female sex. 
In primary inoculation tuberculosis of the 
external ear the prognosis is good; in forms 
complicated with some other focus in the body it becomes worse. 
The treatment of lupus of the ear is the 
same as that of lupus of the skin. On 
account of the good cosmetic results a combination of light treat- 
ment and tuberculin is to be recommended; if this does not lead 
to complete recovery, surgical measures can be employed. 

Tubercular perichondritis and nodular tuberculosis are to 
be treated either by excision and by free opening of the nodules. 
If the cartilage is affected, deformity of the ear must be expected, 
unless a timely operation is performed. 


Diagnosis. 


Prognosis. 


Treatment. 


2. TUBERCULOSIS OF THE MIDDLE EAR. 


Tuberculosis of the middle ear must not be confused with the 
middle-ear suppuration of phthisical patients. The latter is not 
due to the tubercle bacillus, but. the pulmonary disease acts as a 
predisposing cause by producing acute middle-ear catarrh, and 
in keeping up the discharge. The middle-ear disease of tuber- 


454 A CLINICAL SYSTEM OF TUBERCULOSIS 


cular persons is characterized by the fact that very often, at the 
commencement of the disease, there is no marked reaction in 
the tympanic cavity. In its further course it tends to produce 
a reactive inflammation in the form of hyperplasia and sclerosis 
of the bony wall, or destructive processes may predominate. 

This is explained by the bad nutrition and diminished re- 
sistance of the phthisical patient. 

Tubercular changes in the middle ear may affect the tym- 
panic membrane, the tympanic cavity, the tube and the mastoid 
process. These different forms so often go together and arise 
from each other, that they must be considered at the same time. 
In the last stages of phthisis and in miliary 
tuberculosis true tubercles sometimes ap- 
pear on the tympanic membrane, which 
necrose more or less rapidly one after the other, and form small 
perforations; sometimes the drum is rapidly destroyed. A 
specific but mild variety of tumour-like formation on the drum 
has been also described by Preysing. But tubercular infection 
of the drum is rare compared with that of the tympanic cavity. 
The changes in the drum consist of swelling and redness fol- 
lowed by perforation, and all transitions between mild chronic 
inflammation and acute suppuration may be seen. After entry of 
the tubercle bacilli into the tympanic cavity the mucous membrane 
becomes studded with miliary tubercles of a grey or yellowish- 
white colour, which proceed to ulcerative necrosis and the forma- 
tion of granulation tissue. This gives rise to a more or less 
copious discharge, which under the influence of secondary septic 
organisms becomes purulent, and, if there is retention and de- 
composition, foetid. Spread of infection leads to destruction of 
the ligaments, to necrosis and separation of the ossicles, to caries 
of the wall of the tympanum or antrum of the petrous bone, 
to destruction of the labyrinth and to the deposit of tubercles 
in the facial nerve and therefore of facial paralysis. Also the 
meatus acusticus internus and the acoustic nerve may be im- 
plicated. 

Tuberculosis of the tympanum is not rarely the result of 
disease in the Eustachian tube, the infection either spreading 
by continuity from the mouth or pharynx to the mucous mem- 
brane of the tube, or being conveyed by the lymphatics from 
tubercular tonsils and spreading along the submucous lymphatic 
tissue of the tube. Tubercular ulcers of the tube spread deeply, 
often into the cartilage, and miliary tubercles may frequently 
be found near their edges. 

Like infection of the drum, tuberculosis of the mastoid 


Anatomical 
Changes. 





a 


aa Se ee 


TUBERCULOSIS OF THE EAR 455 


antrum usually occurs early in the course of tubercular middle- 
ear suppuration. There are also cases in which the disease of 
the antrum is not tubercular, although that in the tympanic 
cavity is. The mucosa of the mastoid antrum nearly always 
partakes in the same pathological changes as that of the tympanic 
cavity; it may become hyperzemic and swollen and furnish a 
discharge, which, like that in the tympanic cavity, may be 
mucoid, purulent or undergoing mixed infection. The interior 
of the antrum may become full of crumbly, caseous masses or of 
granulation tissue. By spread of the inflammation to the bone 
caries with its many results will be produced. 

Middle-ear tuberculosis may be the first 
manifest sign of tuberculosis in an other- 
wise healthy person; but this is rare. The 
primary disease occurs most readily in children, and in practice 
is limited to those cases in which chronic middle-ear suppuration 
offers a favourable ground for infection, which may occur either 
from outside through a perforation in the membrane or through 
the Eustachian tube. 

Secondary tubercular otitis media is much more common. 
It usually arises from the mouth or nasopharynx, material con- 
taining bacilli derived from the lung, larynx, mouth, pharynx 
or nose being conveyed through the Eustachian tube to the 
middle ear. This is favoured by forcible expiration, sneezing, 
hawking, choking, vomiting and blowing the nose with the nasal 
passages closed. That men are affected with middle-ear tuber- 
culosis much more than women is explained by the fact they are 
much more liable to all non-tubercular diseases of the upper air- 
passages. The great frequency of tubercular otitis media in 
weakened cases of phthisis is due to widening of the lumen of 
the tube in consequence of absorption of fat round the cartilage 
and of anemia of the mucosa, the tube thus becoming more 
permeable to particles of sputum. 

The Eustachian tube itself is not rarely the site of disease in 
adults; but more frequently in infants and children. 

An infection through the blood is possible, and has been 
proved anatomically, in disease of the mastoid. It is not yet 
decided whether tuberculosis of the mastoid antrum is more often 
primarily osteal, the infection occurring through the blood, or 
whether the disease more often starts in the tympanic cavity. 
The great frequency of the primary antral form in children is 
recognized; in them 15 per cent. of all cases of. inflammatory 
mastoid disease are tubercular. 

Isolated tuberculosis of the drum causes deafness and slight 


Symptoms and 
Course. 


456 A CLINICAL SYSTEM OF TUBERCULOSIS 


subjective auditory sensations, but no distinct pain. The course 
is very chronic, generally no progress in the disease is to be 
observed. 

True tuberculosis of the middle ear presents two well- 
marked forms. One variety progresses slowly. Wath slight or 
no pain, but perhaps with tinnitus and a feeling of obstruction 
in the ear, the drum becomes moderately inflamed and slightly 
red and swollen. Soon after multiple perforations of small size 
appear. These increase gradually, join together and produce an 
irregular defect, through which the inflamed mucosa of the 
tympanic cavity is visible. In other cases the perforations visibly 
increase, and the whole drum may be quickly destroyed, so that 
the handle of the malleus stands out; destruction of the ligaments 
and separation of the ossicles soon follow. It is rare for perfora- 
tions to be absent; if so, slight swelling and redness with feeling 
of pressure and gradual alteration of hearing may persist for 
months. Characteristic therefore of the gradual form of tuber- 
cular otitis media are the absence or slightness of pain, the scanty 
signs of inflammation of the drum, and the occurrence in the last 
stages of phthisis. 

The second form of middle-ear tuberculosis is quite different. 
It develops suddenly with severe, often unbearable, pains spread- 
ing to the teeth, and marked swelling of the drum with great 
alteration in the hearing. The drum is more or less rapidly 
destroyed, foetid pus is produced, which covers the granulations 
and necrotic areas, and the disease spreads to the bones, the 
antrum and the labyrinth. Thus the characteristics of this acute, 
fulminating form are sudden commencement, with severe pains 
and marked deafness, much inflammation of the drum and middle- 
ear and tendency to extension to the mastoid and internal ear. 

Lately Jorgen Moller has described a hitherto unknown form 
of middle-ear tuberculosis with the following characteristics ; 
marked deafness with subjective noises, considerable bulging 
and diffuse injection of the drum, which is of a dull whitish- 
yellow colour and very opaque; it is caused by diffuse tuber- 
cular infiltration of the drum and mucosa of the middle ear. The 
tubercular character has been proved by microscopical examina- 
tion of portions of the excised drum. 

The course of middle-ear tuberculosis cannot be described in 
general terms; that of neither of the first two forms can be 
reckoned on; in one case it may be favourable, in others a series 
of grave complications may arise in the blood sinuses, the carotid, 
the jugular vein and the endocranium; the latter are especially 
common in children. The development of miliary tuberculosis 





TUBERCULOSIS OF THE EAR A57 


from implication of the sinus and erosion of the carotid and 
jugular with fatal hemorrhage are very rare complications. 
Moller’s form runs a uniformly good course with a distinct tend- 
ency to spontaneous healing, but often only after more or less 
damage has been wrought. 

Tuberculosis of the Eustachian tube, as long as it is isolated, 
may produce subjective auditory sensations and a feeling of ful- 
ness in the ear. When it extends to the tympanic cavity the 
condition becomes clearer. 

Tuberculosis of the mastoid often causes no, or only very 

slight, symptoms, so that it can be easily overlooked. In the 
primary osteal form the whole mastoid process to the periosteum 
may be affected, without characteristic symptoms being produced. 
In children mastoid tuberculosis usually runs a purely local and 
favourable course. Facial paralysis is rare, and indicates, when 
it is present, extensive disease. Tuberculosis of the mastoid 
starting in the tympanic cavity usually runs a slow course, the 
discharge for a long time is slight, but usually foetid. When the 
secretion becomes very copious and offensive, a sequestrum must 
be thought of; there will be also pains in the head, tenderness 
on pressure, fever and general loss of strength. 
Tubereulosis- of the drum is easy, to 
diagnose on account of the yellow or 
yellowish-red granules of the size of a pin’s head, which stand 
out distinctly from the slightly reddened or pale tympanic mem- 
brane. As a result of caseous necrosis perforations are formed, 
through which the red or swollen mucous membrane of the 
middle ear can be seen. The appearance is typical of isolated 
tuberculosis of the drum in terminal phthisis. 

The diagnosis of tuberculosis of the middle ear is difficult 
as long as the drum remains unperforated; there is no discharge. 
The examination of the discharge is specially decisive if tubercle 
bacilli can be found. But this occurs in only one-third of all the 
cases of middle-ear tuberculosis; the bacilli can most often be 
found soon after the formation of the perforation; in later stages 
these are more rarely discovered, and then only with difficulty. 
They must not be confused with smegma bacilli and other acid- 
fast bacilli. According to Berardini tuberculosis can be distin- 
guished by the increase of lymphocytes in the discharge without 
other histological signs. 


Diagnosis. 


For the examination of aural discharge for tubercle bacilli the follow- 
ing method may be recommended: + After thorough cleansing and dis- 
infection of the external meatus this is to be plugged for twelve to twenty- 
four hours with sterile wool, and the discharge is then to be syringed out 


455 A CLINICAL SYSTEM OF TUBERCULOSIS 


with a little sterile water and collected. The particles are to be carefully 
spread on a cover-slip—when the discharge is copious it may first be treated 
with antiformin—and the preparation stained with carbol fuchsin and de- 
colorized for twenty-four hours in 3 per cent. hydrochloric acid in alcohol; 
it can then be counter-stained in the usual way, and the preparation 
thoroughly examined. Still more certain is the growth of a pure culture 
or inoculation on guinea-pigs. 

For the detection of large lymphocytes staining with Loffler’s methylene 
blue is sufficient. 





There are various signs in the appeaarnce of the drum, which 
are indicative of tubercular disease of the middle ear. MutItiple 
perforations are the rule in tubercular otitis, and very exceptional 
in the purulent form. The perforations are most often in the 
anterior and posterior lower quadrants, extensive destruction of 
the lower half of the drum frequently occurs. 

The otoscopic examination of the tympanic cavity also fur- 
nishes some information. First of all a rapid, steady, painless 
destruction of the whole middle ear without any general symptoms 
is indicative of tuberculosis. We find the mesial wall of the 
tympanic cavity most often affected, and the floor relatively 
seldom. The malleus and incus are diseased in the same fre- 
quency and intensity, while the stapes long remains intact, and 
is very rarely entirely absent. Other pathognomonic signs of 
tuberculosis are the rapid ulcerative destruction of the mucous 
membrane of the tympanic cavity, the adherent, discoloured layer 
on the wall, roughness of the bones with slight formation of 
granulations and foetid secretion, formation of small sequestra 
and the absence of epidermic growth over the mucosa. The 
changes will usually only be found with the help of the probe. 
But it must be emphasized that probing the ear is only to 
be undertaken by those practitioners who have had great ex- 
perience in instrumental examination of the ear, and who are 
certain of the topographical anatomy. 

The functional aural changes are more important for the 
practitioner. Even at the beginning of tubercular middle-ear 
disease there is marked and regular diminution of the hearing. 
In about a half of all such cases the whisper can only be heard 
within narrow limits, in the other half not at all; only about 
5 per cent. of the cases can hear at a distance of more than 16 in. 
When the whisper can be no longer heard the conversational 
voice is to be tried; and here the higher and lower tone- 
characters are to be distinguished. The lower tone characters 
(words like bruder, purpur, orgel, morgen, ohr, onkel, whr) are 
badly heard in all diseases of the middle-ear, but words with 
high tone character (like essig, messer, kissen, bissen, sechs) 





TUBERCULOSIS OF THE EAR 459 


only, as a rule, if the labyrinth is implicated. Since the latter 
is the case in nearly all cases of middle-ear tuberculosis, the loss 
of hearing of the higher tones is generally considerable.  Like- 
wise pathognomonic for tuberculosis is disproportion in the per- 
ception of the deeper tones of Bezold’s instrument and the voice; 
while the hearing is bad for the conversational or whispering 
voice; a deep note of the tuning-fork is generally heard sur- 
prisingly well. 

Lastly facial paralysis on the same side has some value for 
the differential diagnosis, since it is usually produced by ex- 
tensive bone disease with much swelling of the mucous mem- 
brane; it occurs very much oftener with tubercular suppuration 
than with non-tubercular; it generally lasts very long, and is 
often incurable. 

Tuberculin injections for diagnosis have been approved. by 
Schwartze, Lucae, Bezold, Schwabach and Fereri, in spite of 
the objection that the focal reaction in cases of middle-ear tuber- 
culosis generally causes great pain, and the focal reaction itself 
cannot be always harmless. In children the cutaneous test may 
be critically employed. 

For the diagnosis of tuberculosis of the Eustachian tube the 
use of the posterior rhinoscopic mirror is necessary, by which 
means tubercular ulcers and other changes at the pharyngeal 
opening are visible. [If the Eustachian catheter is used, bacilli 
may be found in discharge adhering to it. In any case the 
diagnosis is difficult and in early cases impossible. 

The conditions for the recognition of tuberculosis of the 
mastoid are not better. By external examinations the tubercular 
mastoiditis cannot be distinguished from the purulent form, and 
the diagnosis by tuberculin is contraindicated. It is not justifi- 
able to assume in the presence of middle-ear tuberculosis that 
inflammatory changes in the mastoid are necessarily tubercular ; 
that can only be certain if the lateral bony wall of the antrum 
is perforated, the neighbouring glands swollen. The primary 
bony form of mastoid tuberculosis is usually first diagnosed by 
operation; abundant granulations and a line of demarcation in 
the bone are against tuberculosis; formation of sequestra, which 
often involve a large extent of the centre or periphery of the bone, 
is in favour of tuberculosis. If the suppuration and growth of 
granulations lead to a fistulous perforation of the lateral bony 
wall, then the diagnosis may be made from the examination of 
the discharge; and the formation of a fistula is suggestive of 
tuberculosis, even if bacilli cannot be found. On the other hand 
sub-periosteal extra-dural abscesses point to non-tubercular 


460 A CLINICAL SYSTEM OF TUBERCULOSIS 


mastoid disease. The mastoid glands are constantly affected in 
tuberculosis, and only exceptionally so in non-tubercular otitis. 
The prognosis of tuberculosis of the 
Eustachian tube and the drum is like that 
of the middle ear, bad, when it occurs as a complication of 
advanced lung disease. On the other hand, tubercular disease 
of the middle ear, when the general health is good and the disease 
in the lung stationary or latent, may subside and recover to a 
certain extent, and the discharge quite cease, while the perfora- 
tion, deafness and whistling noises in the ear persist. But this 
is exceptional; the suppuration usually becomes chronic. In this 
lies the great danger, which must not be underestimated. In 
adults persistent tubercular suppuration of the middle ear leads 
in quite a third cf the cases to purulent disease of the labyrinth, 
while in children it still more frequently produces tubercular 
complications such as meningitis. 

For the same reasons mastoid tuberculosis due to disease of 
the tympanic cavity has an unfavourable prognosis, while the 
outlook in the primary bony form 1s not bad; since it is a local 
disease the chances of recovery are better than in tuberculosis 
of the middle ear. 


Prognosis. 


The treatment of tuberculosis of the middle 
ear must depend first of all on the nature 
of the primary disease. But in all cases paracentesis of an un- 
perforated drum is incorrect treatment. If the disease occurs in 
cases of phthisis in which a fatal termination is no longer to be 
prevented, careful syringing is alone to be employed. We re- 
commend with Bezold only one form of injection, a concentrated 
solution of boracic acid, which can be made as required by add- 
ing two tablespoonfuls of crystallized boracic acid to two pints of 
hot water; the fluid must be used at a temperature of 100° to 
106° F. When there are large defects in the drum, insufflations 
of boracic acid, iodoform or a combination of both (10 to 1) may 
be employed; less useful are insoluble powders such as dermatol, 
xeroform, aristol, nosophen, &c. The introduction of 10 per 
cent. iodoform emulsion and of iodine, pot. iodide and glycerine 
with guaiacol (iodine .2, pot. iod. 2, guaiacol 1, glycerine 20) 
has been recommended. J. Moller employs in the form of 
middle-ear tuberculosis described by him the energetic applica- 
tion of trichloracetic acid and lactic acid, when loss of substance 
has occurred. If the general health is good, such cauterizations 
and the use of chromic acid may be considered, but their applica- 
tion must be left to specialists. That the patient must be put 
under the best hygienic and climatic conditions possible goes 
almost without saying. 


Treatment. 





TUBERCULOSIS OF THE EAR 401 


The specific treatment of tuberculosis of the middle ear, the 
experiences of which were formerly bad, has lately given better 
results. Thus Voss, from the observation of several cases of 
chronic middle-ear tubercular disease, especially the so-called 
Suppuration of the mucous meme. considers them very suit- 
able for specific treatment. After long, fruitless treatment with 
other methods he cured such cases by systematic injections of 
bacillary emulsion. For acute tuberculosis of the middle ear we 
do not consider the tuberculin treatment suitable; Voss also 
recommends the greatest care. ; 

Of the physical methods of treatment we have found the 
various modifications of hyperemia to be most useful. Passive 
hyperemia from congestion of the head may be produced by an 
elastic bandage an inch broad carried round the neck, so that 
no pains are produced; if the patient is thin, pads may be placed 
under it; the congestion causes distinct swelling and discolora- 
tion of the face. For the production of active hypereemia in the 
region of the affected ear the hot-air douche may be used. Klapp, 
from his experience in the Bonn clinic, recommends Hahn’s 
apparatus, in which the funnel is provided with a ball-joint and 
the mouth of the hot-air tube with a wooden cover, so that the 
patient himself can direct the hot air on the affected ear, and can 
remove and replace it as necessary. The treatment should be 
commenced with a temperature of about 100° C., and raised at 
later sittings to 120° C. Pains must not be produced; marked 
headache, dizziness, and weakness are contra-indications. Hyper- 
eemia may also be produced by suction applied to the external 
meatus. It must be particularly noticed, that the amount of 
suction must be as little as possible, that it must never be started 
suddenly, nor continued too long. We have applied the suction 
glass at first for five minutes a day, and if the results are good 
increased to two periods of five minutes with a three-minute 


interval. By this means exacerbations in tubercular middle-ear 
disease can be often controlled, and the chronic condition 
improved. 


Tubercular ulcers at the entrance of the seenar tube may 
with the throat mirror be cauterized with 20 to 50 per cent. silver 
nitrate solution, and if not improved burnt with the galvano- 
cautery. Schwartze after two or three thorough applications 
Saw even very deep ulcers cicatrize in a week. Preliminary 
anzesthesia with 20 per cent. alypin solution and expert handling 
of the cautery are necessary in this procedure. 

Tuberculosis of the mastoid in strong patients with slight 
disease elsewhere requires surgical treatment, consisting of the 


462 A CLINICAL SYSTEM OF TUBERCULOSIS 


exposure and removal of the foci by the chisel or other radical 
means. Fever, severe night sweats, sleeplessness and copious 
suppuration may indicate operation even with advanced lung 
tuberculosis, since the ear disease increases the symptoms and 
the loss of strength. As to the time and form of the operation 
the specialist must decide. But the practitioner must seek his aid 
in time, 2.e., aS soon as the diagnosis is made, if it appears that 
the foci can be completely removed. The possibility of recovery 
is then not less in the primary bony form than in non-tuber- 
cular mastoiditis. 


3. TUBERCULOSIS OF THE INTERNAL EAR. 


Tubercular infection of the labyrinth, no 
matter by which route it is produced, leads 
to various changes according to the dura- 
tion and intensity of the infection. Acute and chronic labyrinthine 
inflammation can be distinguished. Tuberculosis of the laby- 
rinth may on the one hand lead to necrosis, and on the other 
new formation of connective tissue and bone may be found on 
post-mortem examination. The final result is mechanical injury 
to the labyrinth from reactive inflammation and suppuration. 
The internal ear is most often affected from 
tuberculosis of the middle ear or petrous 
bone, more rarely from tubercular menin- 
gitis. Tubercular infection through the blood has not yet been 
seen for certain. When the labyrinth is affected there are severe 
subjective sensations (noises of a whistling, throbbing, or beating 
character), and partial or complete deafness. Also the so-called 
‘labyrinthine symptoms ”’ (vertigo, disturbance of equilibrium, 
nausea, vomiting, auditory hyperzesthesia, and caloric nystag- 
mus) are more or less well marked. 

The injury to hearing and disturbance of static equilibrium 

vary according to the position and extent of the disease in the 
cochlear or vestibular part of the labyrinth, but on the whole they 
are extremely obstinate. 
The diagnosis of tubercular inflammation 
of the labyrinth rests on the discovery of 
hardness of hearing and deafness, with marked subjective 
auditory symptoms and of signs of increased irritation of, or of 
damage to the labyrinth. 

Whether certain qualitative methods of examining the hear- 
ing by means of Weber’s, Rinne’s, or Schwabach’s tests, and by 
Galton’s whistle can give reliable information as to the presence 
of tubercular disease in the labyrinth, has been long disputed. 


Anatomical 
Changes. 


Symptoms and 
Course. 


Diagnosis. 





TUBERCULOSIS OF THE EAR 463 


According to the views of many recent authors they can to a 
certain extent. The practitioner is therefore advised to test with 
a medium tuning fork (C,). The results which can be thus 
given are shortly as follows: In Weber’s test—placing the tuning 
fork on the crown of the head while it is giving its maximum 
vibrations—the patient will hear the sound in the healthy ear 
longer than in the other, or exceptionally the sound will only be 
heard by the healthy ear (“lateralization ’’); but the results of 
this test are not reliable for the diagnosis of labyrinthine disease. 
Rinné’s test—placing the vibrating fork on the mastoid process, 
and when it can no longer be heard there, bringing it close to 
the external ear—enables a comparison to be made between the 
air and bone conduction. In disease of the labyrinth it is usually 
positive, t.e., the air conduction lasts longer than the bone con- 
duction, a state which corresponds with the normal.  Rinneé’s 
test is only of diagnostic value in conjunction with Schwabach’s 
test. The latter consists of producing the maximal sound of the 
tuning fork, placing it on the vertex, and measuring the time 
from striking the fork till the sound is no longer heard. By this 
means the duration of the perception of bone conduction is 
measured, which for normal people with tuning fork middle C 
should be twenty-five seconds. In affections of the organs of 
auditory sensation the duration of bone conduction is shortened. 
Lastly, testing with the so-called Galton’s whistle shows a 
diminution of the perception of upper notes in labyrinthine 
disease. Therefore when the tuning fork note is lateralized to 
the sound side, when air conduction lasts longer than bone con- 
duction, when the duration of the perception through the bones 
is shortened, and lastly, when the upper notes are not heard, then 
any marked diminution in the audibility of the whispering voice 
must be due to labyrinthine disease. 

Even more important and not more difficult is the observa- 
tion of caloric nystagmus. This rhythmic movement constantly 
appears in ear diseases, and consists in a slow lateral movement 
of the eyeballs, followed by a rapid, jerky, backward movement, 
when thermal irritation (syringing the ears with cold or hot water) 
is applied to the vestibular apparatus; the irritation 1s conveyed 
to the semicircular canals, leads to changes in the flow and 
pressure of the endolymph in them, and so causes the move- 
ments of the eyes. According to Barany this caloric nystagmus, 
if water above the body temperature is used, is towards the ear 
that is being syringed, and if the water is below the body tem- 
perature the movement is towards the opposite side. While this 
caloric nystagmus can be produced with all healthy labyrinths, 


404 A CLINICAL SYSTEM OF TUBERCULOSIS 


if the latter is affected the nystagmus is increased, but if the semi- 
circular canals are completely destroyed by suppuration the 
nystagmus is lost. Therefore in existing middle-ear tuberculosis 
if there is a doubtful increase of the caloric nystagmus, it points 
to an extension of the disease to the internal ear; if no nystagmus 
is produced, the labyrinth in its vestibular portion is suppurating ; 
if there is also complete deafness, the cochlear portion containing 
the organ of Corti is probably also destroyed by suppuration. 
On this basis the condition of the labyrinth can be approximately 
determined, if the results of the tests in the affected ear are com- 
pared with the sound side. For comparing the results of the test 
it is useful to measure the time taken from beginning the 
syringing to the appearance of the nystagmus, or the amount of 
water required to produce the symptom. 


For testing for caloric nystagmus the following method may be used: 
The ear is best washed out by means of an irrigator with the patient in an 
upright, sitting position, and the head bent backwards 45° to 60°. The 
cold water at 20° to 30° C., and the hot at 39° to 45° C., must not be 
introduced at too high a pressure. The irrigation must often be continued 
for a minute or more before the nystagmus is produced; when this has 
occurred the flow of fluid must be stopped, as otherwise sudden dizziness, 
evacuation of the bowels, and vomiting may occur. Since the cold water 
is better borne than the hot, it is advised to commence with it. Obstruc- 
tions in the meatus (wax, plugs of wool, &c.), which hinder the action of 
the fluid on the labyrinth, must be first removed. 


When the introduction of fluid into the ear is contra-indicated 
by recent rupture of the drum or old defects, cold air can be blown 
in with Politzer’s bag. This procedure is of great practical 
importance for the detection of fistula of the semicircular canal. 
When in the horizontal canal a fistula has formed in consequence 
of carious destruction of the bony capsule, on air being blown 
into the meatus there will be horizontal nystagmus to the affected 
side, and on the air escaping, to the other side. 


For the production of ‘“ fistula symptoms” one must go carefully to 
work, and not raise the pressure of air in the meatus suddenly or by jerks, 
but slowly and gradually, to avoid damage to the semicircular canals and 
spread of infection from the middle ear. 


The further question whether the labyrinthine disease, when 
detected, is tubercular, must be determined by the occurrence of 
tubercular antecedents, or of active tubercular disease elsewhere, 
especially in the middle ear or petrous bone. In any case, the 
practitioner will do well in such cases to consult a specialist. 
This is important, in order that treatment may not be neglected; 
and also the diagnosis -may be very difficult if the disease is 
bilateral, or when the middle and internal ear are both affected. 





TUBERCULOSIS OF THE EAR 465 


eee With regard to hearing the prognosis is 
Snosts- bad. Also there is a tendency for the 
disease to advance, and especially to spread to the interior of the 
skull. 
In advanced cases of tuberculosis the treat- 
ment must be symptomatic, and is limited 
to counter-irritation of the skin in neighbourhood of the ear. For 
this purpose hourly frictions with spr. ammon. aromat., spirit. 
formicar., balsam Hoffmann aa, or applications of cantharides 
plaster to the mastoid process, the place being frequently changed 
(flying vesication), or spreading antimonial ointment on the bare 
skin have been recommended. In severe cases also the methodical 
use of leeches and cupping glasses may be ordered. Narcotics are 
to be used if necessary. 

If the general health is good the labyrinthine operation may 
be performed, which lately Urbantschitsch in a case of tubercular 
disease of the middle ear and labyrinth has carried out with good 
results. As to the indications and form of operation to be 
employed only experienced otologists can decide according to the 
nature of the individual case. 

The best treatment is preventative; i.e., the most careful 

management of cases of tubercular middle-ear disease. 
The prophylaxis of aural tuberculosis may 
be attended to in various ways. The cus- 
tom of introducing a dirty finger or sputum-infected articles 
(toothpick, handkerchief) into the ear is to be forbidden. 
Phthisical mothers must be warned against kissing their children 
on the ear, and also against wiping out the infant’s mouth with 
dirty fingers or handkerchiefs, or infecting the feeding bottle from 
sputum. Piercing the lobes of the ear, if performed, should 
be done with strict cleanliness; earrings worn by phthisical 
patients should be disinfected. Sneezing with the nose held must 
be reckoned as dangerous. The doctor must take care not to 
convey infection by catheters, bougies, or Politzer’s bag. 
Children with scratches and excoriations in the external ear 
should be treated till they are well, and any scrofulous symptoms 
at the same time attended to. Tubercular affections of the 
cervical giands and tonsils in children should receive special care, 
and, if necessary, be removed. Lastly, for the protection of the 
patient and others the infective discharge from the ear must be 
rendered harmless. 


Treatment. 


Prophylaxis. 


30 


CHAPTER XITL. 


Miliary Tuberculosis. 


IN contrast with the chronic course of phthisis in miliary 

tuberculosis there is an acute tubercular infection, in which the 
tubercle bacilli are spread broadcast, a formation of numerous 
tubercles in nearly all the organs rapidly ensuing. Only quite 
exceptionally is it a primary condition from external infection, 
which would require to be very massive. As a rule it is secon- 
dary and produced from within, being an auto-infection from a 
tubercular focus already existing in the body, which by opening 
into a blood-vessel or lymphatic suddenly floods a whole organ 
or the whole body with tuberculosis virus. One can distinguish 
acute miliary tuberculosis of a single organ, e.g., the lungs or 
serous membranes, and acute general miliary tuberculosis. 
The primary focus of a miliary outbreak 
may be a small and obscure caseous tuber- 
cular nodule, whose detection during life 
is impossible, and may be difficult even at the autopsy. Thus 
the condition may be considered to be due to a primary exogenous 
infection, whereas as a matter of fact it arises from an already 
existing, but latent, tuberculosis. 

The special ztiological question is hotly contested, whether 
the miliary outbreak is due to the sudden entrance of a large 
number of tubercle bacilli into the lymphatics or blood-stream, or 
whether the scattered bacilli, which are constantly entering the 
circulation, can multiply in the blood on account of an increased 
predisposition. Ribbert supports the latter view; he adduces the 
varying size and age of the miliary tubercles and the easy detec- 
tion of tubercle bacilli in the blood. As a point of entrance of 
the constantly renewed invasion of the blood by tubercle bacilli, 
he mentions the numerous tubercles in the intima of the arteries 
of the lungs. d 

On the other hand, Weigert, Benda and Cornet consider that 
the bacilli invade the blood in large numbers, particularly from 


Anatomical 
Changes. 





MILIARY TUBERCULOSIS 467 


the tubercles in the vessel wall. These tubercles of the vessel, 
which have already been described, were first noticed by 
Weigert especially in the large pulmonary veins, and by other 
authors in the veins in the rest of the body, and also in the 
heart, the aorta, the pulmonary artery, and the thoracic duct. 

It is also certain, that with the necrosis of tubercles in the 
blood-vessels and lymphatics and the formation of tubercular 
ulcers enormous numbers of bacilli enter the blood. | Almost 
regularly—in 95 per cent. of the cases—these tubercles and ulcers 
of the vessel wall can be discovered in miliary tuberculosis; on 
the other hand, they are absent when miliary tubercles are not 
present. 

The varying ages of the miliary tubercles noticed by Ribbert 
may be explained by the existence of several tubercles of the 
vessel wall causing infection. On the other hand, v. Hansemann 
has found that the larger and older miliary tubercles are absent 
in acute cases, and that in chronic cases of miliary tuberculosis 
they are no longer true tubercles, but caseous bronchitic nodules 
and small areas of caseous hepatization. Also in recent years 
tubercle bacilli have been found in the blood of chronic cases of 
tuberculosis much oftener than was previously thought, though 
miliary tuberculosis is not a frequent occurrence in phthisis. The 
organism is generally able to deal with and overcome the small 
number of bacilli which are constantly entering the blood, as 
explained by recent observations on the pathological and 
anatomical character of phthisis, while it succumbs to a sudden 
massive infection of the blood. It therefore seems that Weigert’s 
view of the ztiology of miliary tuberculosis rests on the better 
foundation. 

Tubercles of the wall of small vessels are not the only cause 
of miliary tuberculosis. Chronic aortic and arterial tuberculosis 
and sieve-like perforations of the veins from adjacent tubercular 
foci may also cause the condition. Without the vessel wall itself 
being diseased, miliary tuberculosis may be also caused by peri- 
vascular tubercular nodules rupturing into the lumen of a 
pulmonary vessel, by a small cavity opening into a vein, by 
rupture of a caseous gland into the aorta, or in connection with 
parturition and abortion. In the last-mentioned condition some 
form of genital tuberculosis, generally in the uterus, first brings 
about the abortion, and then by an opening into the vascular 
system of the uterus infects the whole body, especially the lungs. 

The localization of the miliary tuberculosis depends on the 
site of the rupture of the tubercle of the vessel wall; thus miliary 
tuberculosis of the kidney may be set up by a nodule on the 
renal artery, or of the lungs by a focus in the right side of the 


468 A CLINICAL SYSTEM OF TUBERCULOSIS 


heart, the vena cava, the thoracic duct, or the aorta; while general 
miliary tuberculosis arises from infection of the blood in the left 
side of the heart, e.g., from the pulmonary veins. Also the 
tubercle bacilli after rupture into the thoracic duct, which occurs 
particularly often, the vena cava or the pulmonary artery may 
first reach the pulmonary circulation, and then infect all the 
organs through the systemic system. 

Yo sum up, we may say of the etiology of miliary tubercu- 
losis, that tubercle bacilli lodged at some spot in the body there 
produce either no ill-effects on a chronic form of tuberculosis, 
but on entering the blood-stream in large numbers cause an acute, 
fatal condition. The degree, amount, and rapidity of these 
injurious effects and also the entry of bacilli into the circulation 
depend on various factors. Favourable to these conditions are a 
youthful age of the patient and everything that tends to mobilize 
the tubercle bacilli already existing in the body, such as inflam- 
matory swelling of the glands during measles and scarlet fever, 
operations on tubercular tissues, pregnancy, the puerperium, 
abortion, great mental disturbance, and traumatism. That 
miliary tuberculosis may be the indirect result of an accident 
affecting an existing focus is seen in a case in which a chronic 
encapsuled tuberculosis in the axilla after a severe bruise to the 
shoulder within three weeks led to a miliary infection of the 
lungs and meninges. 

-athologically, miliary tuberculosis is characterized by the 

appearance of miliary tubercles in numbers varying with the 
vascularity of the organ and its position in the blood-stream. 
The individual tubercles vary in size according to the duration 
of the disease from scarcely visible points to nodules, which are 
softening in the centre or throughout; they give the organ on 
section a characteristic granular appearance, on account of the 
numerous prominences generally surrounded with a red zone. 
These miliary tubercles are found more or less numerously in 
the spleen, kidney, liver, mucous membranes, meninges, choroid 
and serous surfaces; in the last position they not uncommonly 
produce a coating of fibrin, and effusion into the serous cavity. 
Infarcts may occur in the spleen or kidney and hemorrhages in 
the brain. The spleen is constantly enlarged, the liver fre- 
quently so. 
The clinical symptoms of miliary tubercu- 
losis are produced both by the general 
intoxication and the local damage caused 
in the individual organs by the formation of tubercles. This 
explains the indefinite, variable nature of the disease. 


Symptoms and 
Course. 





MILIARY TUBERCULOSIS 469 


The commencement is usually sudden, but may be gradual, 
lasting several days with prodromal symptoms, which may vary 
according to the localization. The typhoid, pulmonic, and 
meningeal forms have been distinguished. 

The typhoid symptoms are a consequence of general intoxi- 
cation, and consist of fever, increase in the pulse-rate, fall of 
blood-pressure, and bad general condition. The fever runs no 
characteristic course, it is usually high, continuous, remittent, or 
intermittent, sometimes also of the inverse type. In old patients 
the fever is usually absent or is only slight. The pulse is 120 
to 150 a minute, it is small, weak, and not uncommonly dicrotic. 
The blood-pressure is correspondingly diminished. | Bleedings 
from the nose, bowel, or retina are very rare. The bad general 
condition is shown by the complete loss of appetite, by persistent 
diarrhoea, and by the toxic effect on the nervous system. The 
softened spleen is constantly enlarged, sometimes to three or six 
times its normal size. Herpes, roseola, and albuminuria are more 
rarely seen. 

The pulmonic form of general miliary tuberculosis has the 
same symptoms as acute miliary tuberculosis of the lungs, the 
relative frequency of which is due to the fact that the lungs act 
as a filter to the tubercle bacilli in the blood. Besides the fever 
and rapid pulse the lung symptoms are prominent. They con- 
sist of frequent, generally dry cough, dyspnoea, and even 
orthopnoea. In marked contrast with the symptoms the physical 
signs are only slight, and consist of scanty, diffuse, catarrhal 
signs, of accentuated vesicular breathing, and of indefinite, 
rapidly changing, accessory sounds, chiefly numerous, fine rales, 
which can be heard quite early. According to whether the miliary 
nodules in the lung are small, but of the same size, or vary in 
development and caseation, the two forms of uniform or non- 
uniform pulmonary miliary tuberculosis can be distinguished. 
The amount of inflammation of the parenchyma of the lung and 
bronchial mucosa is different in the two varieties, and the amount 
of these changes again determines the presence of a mucoid or 
mucopurulent expectoration. The damage to the pulmonary 
circulation is shown by very accelerated, superficial breathing, 
acute distension of the lungs, and particularly characteristic 
cyanosis, especially of the nose and lips, with a very pale face. 

The symptoms are only clearly marked if the patient has also 
bronchopneumonia; if the lung parenchyma is not implicated, 
then extensive miliary tuberculosis of the lung may occur without 
symptoms. Towards the end cedema of the extremities occurs, 
and also involvement of the pleura and pericardium, producing 


470 A CLINICAL SYSTEM OF TUBERCULOSIS 


pains, friction rubs, and later effusion; the fluid is not uncom- 
monly hemorrhagic. 

In the meningeal form of miliary tuberculosis the general 

toxic symptoms, such as headache, vertigo, numbness, apathy, 
and stupor rapidly increase. Vomiting, sleeplessness, contrac- 
tion of the muscles of the neck, cramp, clonic spasms, delirium, 
frequent groans and cries, with fever and slightly increased but 
very weak pulse, point to the brain being affected. In this stage 
the discovery of tubercles in the choroid is of importance. 
The diagnosis of miliary tuberculosis is the 
more difficult the fewer local signs there 
are of the implication of various organs, especially at the begin- 
ning of the disease. In children and old people the objective 
signs of the pulmonary form are often so little characteristic that 
the diagnosis is more a matter of conjecture than certainty. Of 
special importance in such cases is the examination of the lungs 
with the R6ntgen-rays during complete cessation of respiration. 
The R6ntgen picture of miliary tuberculosis of the lung is par- 
ticularly characteristic at a time when other signs are still absent; 
and consists of a very typical, diffuse, fine marbling of the lung 
areas, which according to Levy-Dorn is due to inflammatory 
hypereemia round the miliary nodules. - If at the same time an 
old tubercular focus can be found at the apex or hilus of the 
lung, or anywhere else in the body, or if the history indicates a 
previous tubercular disease, our attention is the more directed 
towards miliary tuberculosis, and an examination of the blood 
for tubercle bacilli becomes specially necessary. This must be 
done early, if it is to be of value for diagnosis, since the bacilli 
can usually be found in large numbers in the circulating blood 
for only a short time after their entrance. The most suitable 
method of examining the blood has been described in Chapter 
Vit 

If there is a probability of the meningeal form of miliary 
tuberculosis the examination of the cerebrospinal fluid for tubercle 
bacilli is still more likely to be successful. |The process has 
been described in the chapter on Tubercular Meningitis. In these 
cases the ophthalmoscopic examination of the eye is also very 
important, since in 75 per cent. of them six or more tubercles can 
be found in the choroid, in the form of light, whitish-grey, or 
yellow, rounded or elongated spots with faded edges. 

The differential diagnosis must be made from pneumonia, 
intermittent fever, septicemia, acute mania, acute non-specific 
bronchitis (in old people), capillary bronchitis (in children), and 
from labour, abortion, and puerperal infection. By exclusion 
the correct diagnosis may be often arrived at. 


Diagnosis. 





MILIARY TUBERCULOSIS 471 


Very difficult is the differential diagnosis between general 
miliary tuberculosis and typhoid. Apart from the results of 
bacteriological and serological tests, the presence of a typhoid 
epidemic, a typical typhoid fever curve, a slow pulse at the com- 
mencement of the disease, the tongue at first with red edges and 
later diffusely red, the pea-soup diarrhoea, and a dicrotic pulse 
indicate typhoid; tubercular antecedents, exposure to tubercular 
infection, a tubercular focus in some organ, irregular fever, 
marked dyspnoea or cyanosis with slight signs in the lung, 
pleuritic or pericardial complications, herpes at the commence- 
ment, and early loss of strength are in favour of miliary tuber- 
culosis. Bronchitis, splenic tumour, leucopenia, and diazo- 
reaction may be present in the typhoid form of miliary tubercu- 
losis as in enteric fever. 

Puerperal disease is so difficult to distinguish from miliary 
tuberculosis that it has been strongly recommended that every 
case dying after child-birth should be examined post mortem, 
both for the purposes of accurate puerperal statistics and in the 
interests of the doctors attending confinements. This is an 
extreme view, but in all feverish conditions after child-birth 
miliary tuberculosis is to be thought of. Indicative of miliary 
tuberculosis, besides the already mentioned symptoms, are 
meningeal signs, absence of rigors, and the discovery of tubercle 
bacilli in the blood or of tubercles in the choroid; while in favour 
of puerperal fever are injuries in the genital tract, retinal 
hemorrhage, and the presence of septic organisms in the blood. 

The use of test tuberculin injections is strongly contra- 

indicated if there is even a suspicion of miliary tuberculosis, 
while the cutaneous test is found to throw no light on these 
cases. But a very positive conjunctival reaction is very much 
in favour of miliary tuberculosis. 
The prognosis is absolutely bad. Acute 
miliary tuberculosis is still incurable; in 
the several cases that have been recorded the correctness of the 
diagnosis is doubtful. Sometimes after a more chronic course 
lasting weeks or months, with periods of alternate improvement 
and relapse, the fatal issue is reached. This occurs especially in 
that form of pulmonary miliary tuberculosis in which the nodules 
are not uniform. 


Prognosis. 


The treatment of miliary tuberculosis is 
chiefly symptomatic; the strength must be 
maintained by a light, easily digestible fever diet, the heart 
supported by cardiac tonics, and the fever treated by hydriatic 
measures and drugs. If the fever prevents the taking of food, 


Treatment. 


472 A CLINICAL SYSTEM OF TUBERCULOSIS 







single doses of pyramidon (2 to 5 gr.) may be given two to three 
hours before food. Pains, severe cough, and breathlessness may 
be met with the ice-bag and morphia or its derivatives. 
According to v. Hansemann acute miliary tuberculosis, 
being the most definite form of tuberculosis, should respond to 
tuberculin treatment; but this is not true, for the simple reason 
that the organism in miliary tuberculosis is no longer capable of 
undergoing active immunization. The treatment of miliary 
tuberculosis by tuberculin is therefore not only useless, but is 
contra-indicated. 


CHAPTERS Xfv. 


Scrofula. 


AFTER the word scrofula had been used for 
decades as a general term for all chronic 
forms of inflammatory disease associated 
with swelling of the glands, Laennec identified it with tubercular 
disease of the glands, and Virchow with a special pathological 
constitution, connected with defective assimilation. The abnor- 
mality of assimilation consists in deficient utilization of the 
nutritional substances brought to the tissues by the blood-stream 
and in a defective tissue formation from the insufficiently utilized 
materials ; from this results an overloading of the whole lymphatic 
system. The nutritional defects in the tissues also explain their 
abnormal sensibility to external irritation and their marked 
tendency to react with inflammatory changes of a special charac- 
ter, which run a chronic course, relapse frequently, and show but 
slight signs of healing and formation of normal new tissue. The 
anatomical foundations of scrofula consist of hyperplasia, pro- 
liferation, and degeneration particularly in the glands, the 
lymphatic organs, the skin, the mucous membranes, the sub- 
cutaneous tissues, the bones, and the joints. 

The discovery of the tubercle bacillus has not advanced the 
comprehension of the pathological anatomy of scrofula much 
further, chiefly because the comprehension of scrofula, according 
to the presence or absence of tubercle bacilli, has undergone 
many changes and is still so differently considered by different 
authors, ‘‘ that one can scarcely find in two text-books the same 
definition, description and limitation of scrofula’”’ (Littler). We 
will return, therefore, to the question after considering the causes 
and nature of scrofula. 

The results of histological and bacteriological examinations 
of manifest cases of scrofula show that it is a separate disease, 
and distinguish it from tuberculosis. Neither in  scrofulous 


Pathology and 
AEtiology. 


474 A CLINICAL SYSTEM OF TUBERCULOSIS 


disease of the skin nor in the chronic lymphatic hyperplasia need 
tubercle bacilli or their special products of regressive meta- 
morphosis be found. Further, the result of the tuberculin test, 
which is the most definite and specific reagent for detecting 
tubercular infection, is negative in scrofulous children, and shows 
that the condition cannot be considered as identical with the 
tubercular disease of childhood. But Feer still considers that 
no typical cure of scrofula has been brought forward which did 
not react to the cutaneous test. 

It is certain that scrofulous children very frequently give a 
strong reaction to the cutaneous test, and that the characteristic 
eczematous, catarrhal and inflammatory hyperplastic changes in 
the skin, mucous membranes and lymphatic systems, not only 
sometimes, but even relatively frequently, develop into local and 
general tuberculosis. Further, the lymphatic glands, which are 
very typical of tuberculosis, even when they are only swollen, 
very often show tubercle bacilli on section or as the result of 
animal inoculation. According to Weichselbaum and his school 
a lymphatic gland infected with tubercle bacilli need not always 
show specific changes. 

In this debated question of the atiology of scrofula Cornet 
emphasizes the importance of the tubercle bacillus. He distin- 
guishes three forms of scrofula: a tubercular form caused by the 
tubercle bacillus, a non-tubercular pyogenic form and a mixed 
form of both infections. Thus in scrofula there is both a primary 
and constant congenital abnormality of constitution, and a 
secondary and variable but extremely important factor of bac- 
terial infection. According to the infection being with tubercle 
bacilli alone, or with pyogenic organisms, or with a mixture of 
both, follows the production of local or general tuberculosis of 
childhood, of pure scrofula, or of scrofulo-tuberculosis. In the 
last case it is not always possible to determine whether the tuber- 
cular infection is grafted on to a previously existing scrofulous 
condition, or whether the symptoms, which at first were con- 
sidered to be scrofulous, were not from the first due to an infec- 
tion with tubercle bacilli. This uncertainty does not change the 
fact, that every person who clinically is at first only suffering 
from scrofula, runs the danger of becoming tubercular, and that 
even the greater part of scrofulous children become tubercular. 

The further question arises, whether tubercle bacilli can enter 
the body of scrofulous persons and lodge there, without leaving 
behind any recognizable changes at the point of entrance, or 
whether the scrofulous changes in the skin and mucous mem- 
brane prepare the ground for their existence; and further whether 





SCROFULA 475 


in order to arrest the infection the glands must be previously 
altered by bacterial or toxic action or not. To these questions 
no certain answers can yet be given. 

Fhe simplest explanation of the connection between scrofula 
and tuberculosis is that of v. Baumgarten, who considers that 
they are both forms of congenital tuberculosis. 

According to Soltmann, only the liberated toxin -of the 
tubercle bacilli passes through the placenta from the mother to 
the foetus and produces a non-bacillary, hereditary, toxic tuber- 
culosis, which is scrofula. 

A. Czerny separates a symptom complex belonging to 
scrofula from tuberculosis, and designates it an exudative dia- 
thesis after making sure of its non-tubercular nature. The 
exudative diathesis of Czerny is therefore a non-tubercular form 
of scrofula, and is a congenital, abnormal tendency appearing 
in children, whose parents suffered from the same condition, from 
psychopathic disturbance, or from gout, diabetes or obesity, or 
more rarely from tuberculosis. The condition may show itself 
even in infancy either as malnutrition or as abnormal fatness, in 
both cases it is a consequence of the same defect in assimilation, 
especially mal-assimilation of fats. The principal signs of the 
exudative diathesis, according to Czerny, are ‘‘ cartographic ”’ 
tongue, porrigo, seborrhoea, prurigo, circular caries of the teeth, 
hyperplasia of the tonsils, tendency to frequent catarrh of the 
air-passages and phlyctenular conjunctivitis. 

Also Heubner distinguishes a symptom complex correspond- 
ing with the exudative diathesis, of a constitutional non-tubercular 
nature, and calls it lymphatism. 

Escherich speaks in such cases of a lymphatic constitution, 
and with Moro upholds the view that scrofula is nothing else than 
tuberculosis developing in the form of lymphatic constitution 
(status lymphaticus of Escherich, lymphatism of Heubner, 
exudative diathesis of Czerny and Moro). The exudative diathesis 
is to a certain extent the precursor of scrofula; the former being 
primary and congenital, and the latter a secondary, acquired 
condition, caused by tubercular infection. Only from. this 
diathesis can scrofula be produced, since in non-lymphatic (non- 
exudative) children the results of tubercular infection are shown 
by quite other symptoms. One can accept this definition of Moro 
and describe scrofula shortly as the tuberculosis of lymphatic 
(exudative) children. So much the more are we obliged to hold 
fast to the primary, decisive components, which are characteristic 
of the scrofulous habit, and to connect scrofula with a definite 
symptom complex, which is neither purely exudative nor purely 
tubercular. 


476 A CLINICAL SYSTEM OF TUBERCULOSIS 


For long have two clinical forms of scrofula 
been distinguished, the torpid and _ the 
erethistic. 

The torpid form is characterized by a heavy build, a faded 
colour, pasty appearance, coarse features, thick swollen nose, 
prominent lips, pendulous abdomen, visibly enlarged glands, 
sluggishness of the bodily functions and phlegmatic tempera- 
ment; it is the result of slow, deficient tissue changes. 

The erethistic type is shown by a slender build, delicate pale 
skin, scanty adipose tissue, slight muscles, sensitive vasomotor 
system (blushing and sudden pallor), blue sclerotics, bluish-white 
shining eyes, swollen lymphatic glands, active temperament and 
excitable nerves; it is the consequence of greatly accelerated 
tissue changes. 

In both forms the hyperplastic swelling of the glands is the 
most prominent feature. They are the best sign of the peculiar 
characteristics of scrofula, such as the exceptional irritability of 
the lymphatic elements or the tendency to proliferation. Thereby 
is produced congestion of the lymphatic vessels, and this in turn 
causes deficient nutrition in the glandular tissues, ending in 
caseation. 

The glandular swellings in the torpid form affect chiefly 
the peripheral glands, and in the. erethistic form especially 
the visceral glands, the bronchial more than the abdominal. 
The peripheral lymphatic swellings occur chiefly in the nape 
and side of the neck, and the region under the jaw, the 
axilla and groin are more rarely affected; the swelling is 
primary, and independent of any affection in the region draining 
into the gland; it occurs without fever or pain; the glands vary 
in size from that of a pea to a walnut, or larger; they swell up 
and subside again, and may disappear altogether, or remain in 
the same condition. The swelling of the glands of the neck may 
reach a high degree, so that the neck looks like that of a pig 
(scropha = sow, scrophula =a small pig); the glands may remain 
hard for a long time. If pyogenic infection of the glands occurs 
through the skin or mucous membrane, they suppurate and adhere 
to the skin, which becomes cedematous and of a bluish colour; 
finaliy they break externally and form sinuses, which discharge a 
whitish, flaky, purulent fluid, and at last heal, leaving extensive 
scars. Thus in the first stage of scrofula there is a primary 
hyperplastic lymphoma, which becomes secondarily infected with 
streptococci, staphylococci, or tubercle bacilli; only in the last 
case will the scrofulous lymphatic glands be tubercular. The 
form of tubercular infection of the glands has been further 


Symptoms and 
Course. 


- 3.0 s~s & 


% 





SCROFULA 477 


differentiated by Abramowski, in such a way as to explain the 
very considerable difference between the two forms of scrofula; 
he considers that the torpid form arises from the alimentary tract 
through infection with bovine bacilli, and that the erethistic form 
is produced by infection through the air passages with human 
bacilli. It is a hypothesis for which much may be said. 

The other characteristics of scrofula are the affections of the 
skin and mucous membranes. 

On the face can be seen in the region of the cheeks, chin, 
mouth, nose, eye, and ear, and more rarely on the hairy scalp, 
papular, vesico-pustular, squamous or seborrhoeic eczema (por- 
rigo). This eczema may lead to localized tuberculosis of the skin 
through entrance of bacilli. But one must not consider every 
case of chronic eczema, especially the eczema on the face and 
scalp of infants associated with digestive disturbance, to be due 
to scrofula. 

There are many scrofulous signs connected with the eye, ear 
and nose. Characteristic changes in the eyes are thickening of 
the edges of the lids, and inflammation of the Meibomian glands, 
conjunctivitis lymphatica, herpes of the conjunctiva and cornea, 
ulcer of the cornea, phlyctenular keratitis with the subjective 
symptoms of photophobia, blepharospasm and lachrymation; in 
the ears serous and seropurulent otitis media; and in the nose 
rhinitis, coryza, and ozzna. 

The irritating secretion from the mucous membrane leads 
further to other changes, such as the characteristic crusts, cracks, 
and swelling of the upper lip, moist eczema and impetigo of the 
external ear and meatus, of the inner and outer angle of the eye, 
in the eyebrow, eyelids and cheeks, and irregular arrangement 
of the eyelashes. Acne, furunculosis and subcutaneous abscesses 
with necrosis and ulceration may also occur. Changes in the 
skin of the trunk and extremities are not common. Chronic forms 
of urticaria, intertrigo and eczema of the skin folds (strophulus, 
lichen urticatus, intertrigo) and rarely diffuse furunculosis may 
be met with. 

Among the affections of the mucose chronic pharyngitis is 
a constant sign of scrofula. Compared with other forms it is 
characterized by swelling of the submucous lymphatic tissue, 
which in consequence of the longitudinal arrangement of the 
follicles leads to raised folds of mucous membrane on the posterior 
wall of the pharynx; the mucous membrane has a wavy appear- 
ance. The lymphatic ring is affected at the same time in the 
mouth and nasopharynx. The tonsils, the palatal tonsil and the 
crypts of the tongue are reddened and inflamed, and produce 


478 A CLINICAL SYSTEM OF TUBERCULOSIS 


a glairy, purulent mucus; the cartographic tongue and circular 
caries of the incisor and canine temporary teeth complete the 
picture. Adenoid vegetations also form part of the chronic hyper- 
plastic inflammation of the nasopharynx; but they must not be 
considered by themselves to be evidences of scrofula, since they 
frequently occur in children who are not scrofulous. Salge lays 
stress on this and recommends that adenoids without other signs 
of scrofula should be considered as the lymphatism of Heubner. 
With the increase in the size of the lymphatic organs, glands and 
tonsils the swelling of the thyroid and spleen must be classed. 

Other affections of the mucous membranes are the non- 
gonorrhoeal, seropurulent vaginal discharge and inflammatory 
infiltrations of the labia met with in girls and the balanitis of boys. 

More important are the frequently relapsing catarrhs of the 
larynx and air-passages with symptoms of pseudo-croup and 
catarrh of the bronchial mucosa followed by non-tubercular swell- 
ing of the bronchial glands; the latter in scrofulous children may 
produce asthmatic symptoms. 

Of similar importance are otherwise unexplained symptoms 
connected with the gastro-intestinal canal (dyspepsia, anorexia, 
oral foetor, periodic vomiting, attacks of mucous endocolitis, 
habitual constipation), and as a result of these conditions swelling 
of the mesenteric glands. 

Changes in the periosteum, bones and joints very soon 
assume the characters of local tuberculosis. In individual cases 
it is usually impossible to decide whether the chronic inflammatory 
changes were at first scrofulous, or were tubercular from the com- 
mencement. 

The most frequeni general symptoms of scrofula are as fol- 
lows: Alterations of nutrition, arrested growth, amyloid disease, 
occasional fever, secondary anemia and lymphocytosis. The last 
consists of a very marked increase in the large lymphocytes, the 
amount of which runs parallel with swelling of the glands, and 
distinctly diminishes as the scrofula improves. Implication of 
the nervous system is shown by enuresis, night terrors, migraine, 
and also by a distinct pallor of the skin and mucous membranes, 
which is not due to anemia. 

Scrofula is a very frequent disease of children; it attacks. 
females more often than males. The torpid form occurs particu- 
larly between 1 and 5 years, while the erethistic form is met more 
often in the first school ages and not rarely lasts over the period 
of puberty. Scrofula runs the course typical of a chronic disease. 
Cases are often seen in which it lasts from the first years of life 
to puberty, and then results in complete recovery. The torpid 





SCROFULA 479 


form usually runs a favourable course; not so the erethistic form, 
which tends to frequent relapsing catarrh of the air-passages and 
after a shorter or longer time to pulmonary tuberculosis. 

Monti distinguishes three stages of 
scrofula; but this rather makes the dia- 
gnosis more difficult than easier. We recommend that a picture 
of the disease as a clinical entity should be borne in mind, and 
the characteristic symptomatology recognized in the vulnerability 
of all the tissues, in the catarrhal and eczematous changes in the 
mucous membranes and skin and the inflammatory hyperplastic 
changes in the lymphatic system, in the obstinacy of the condi- 
tion and its ebb and flow, in its tendency to relapse without cause 
and in the multiplicity and combination of the local foci. It is 
of importance for the diagnosis, whether the parents in their 
youth suffered from scrofula or tuberculosis. There will then be 
usually no difficulty in the diagnosis, or only in the distinction 
between the exudative diathesis and lymphatism. - The cutaneous, 
percutaneous and subcutaneous tuberculin tests can also be used, 
but the conjunctival test for scrofula in young children 1s strongly 
contra-indicated. 

The differential diagnosis must be made from leukemic and 
pseudo-leukzemic swellings of the jugular glands, which are not 
adherent to the skin, have no peri-adenitic infiltration and do 
not swell and become painful with tuberculin. Also leukaemia 
can be distinguished by the blood examination. Secondary 
diseases of the regional glands are distinguished from primary 
scrofulous glandular tumours by the fact that they either rapidly 
subside with the condition which causes them, or, if they sup- 
purate, form a simple abscess, which quickly heals. 

Scrofulous eye diseases are recognizable by the nodular 
deposit in the conjunctival limbus and cornea. They begin with 
a conical efflorescence; at the apex of the cone ulcers form, and 
quickly heal, often in eight to fourteen days; but very frequently 
return, Sometimes in the same, sometimes in the other, eye. 
Phlyctenules of the cornea heal with or without opacities, accord- 
ing to the depth of the ulcer; the formation of pannus is rare. 
In all cases the characteristic points are the nodular, not diffuse, 
commencement in the outer part of the eye and the tendency “to 
relapse with the production of chronic inflammation of the lids 
and neighbouring skin. 

The decision whether otitis media is scrofulous, tubercular, 
or due to some other cause is not usually possible. Often the 
presence of eczema and changes in the eye and the nose, accom- 
panied by photophobia and chronic snuffling point to the scro- 
fulous origin. 


Diagnosis. 


480 A CLINICAL SYSTEM OF TUBERCULOSIS 


The diagnosis between scrofula and congenital syphilis may 

be particularly difficult. In favour of syphilis are eruptions on 
the skin in the neighbourhood of the giabella, the eyebrows and 
the chin, the presence of condylomata and radial scars in the 
mucous membranes, the localization of bone disease between the 
diaphysis and the epiphysial cartilage and in the skull and nose, 
very scanty growth of hair, absence of the eyelashes, brittle, thick 
nails and multiple but slight swelling of certain groups of glands. 
The results or treatment will also afford indications. 
The prognosis of scrofula is generally good, 
but less so if caseation of the glands has 
commenced. ‘The scrofulous eye changes leave behind no, or 
only slight, permanent injury to sight, but very rarely they may 
cause blindness. 

Monti’s statistics of scrofulous cases show that 70 per cent. 

recover and only 5 per cent. die. But if it attacks children, who 
are in a very bad state of nutrition and who are living under 
very unhygienic conditions, the danger of the supervention of 
tuberculosis is increased, especially if there is much exposure to 
infection. Also intercurrent diseases, such as inflammation of 
the lungs, catarrh of the bowels, anemia, rickets, &c., relatively 
frequently terminate fatally, as do acute infectious diseases 
(measles, scarlet fever, whooping cough, diphtheria), to which 
scrofulous children offer little resistance. It has been remarked 
that measles and whooping cough very frequently transform a 
latent tuberculosis into the florid type. 
In the treatment of scrofula the hygienic 
factors must take the first place. Often the 
removal from confined, damp, dark dwellings and from tuber- 
cular infected surroundings will be sufficient by itself to produce 
a marked change in the children. Among the poorer classes it is 
very desirable that scrofulous children should be removed for 
some time to healthy convalescent homes. 

The second place is taken by dietetics, particularly when 
dealing with exudative conditions. On account of the intolerance 
the children have of fats, especially that contained in milk, all 
forms of fatty food must be avoided. The supersensitiveness to 
milk fat even in sucklings may require a reduction of the fats in 
the mother’s diet, a diminution of the number of feeding times 
and a partial replacement of the mother’s milk by artificial food 
poor in fats and rich in carbohydrates. From the first year on- 
wards the daily amount of milk must be limited to a pint. Its 
place must be taken by carbohydrates in the form of fresh, green 
vegetables, potatoes, white bread, rice, fresh fruit and some meat, 


Prognosis. 


Treatment. 





SCROFULA 451 


while eggs taken regularly are unsuitable on account of the 
amount of fat in the yolk; the amount of butter must also be 
diminished as far as possible. The importance of this form of 
dietary in scrofula is considerable and has only recently been 
recognized. 

The physical factors in the treatment should include proper 
air, light, water and exercises. Also gymnastics, massage and 
electricity may occasionally be employed with good results. The 
physical treatment promotes the activity of the skin, regulates 
the circulation, increases the power of the respiratory muscles and 
the heart, hardens the system and accelerates nutritional changes. 
But it is necessary that this treatment should be’ regulated, 
especially the hydrotherapeutic measures. In cases of erethistic 
scrofula and weakly anazmic children one can begin with dry 
friction of the body (once or twice a day for ten to twenty 
minutes), proceeding after several weeks or months to tepid 
sponging, and only very slowly after the general condition has 
considerably improved using cold frictions. These measures 
should result in improved circulation of the skin, increased 
appetite and better temper. 

Equal care is required in ordering salt baths. The salt baths 
can be made with common salt or sea salt (1 to 2 Ib. in 12 gallons 
of water at 33° C. for quarter to half an hour). Specialists in 
diseases of children assert that in general too much use is made 
of baths. The fact is that under-nourished, erethistic, scrofulous 
children derive no good from baths, but rather harm, while fat, 
pasty cases are promptly influenced for the better. 

To a large extent the general treatment of scrofula is that of 
tuberculosis of children; therefore it is best carried out in 
special sanatoriums, where it can be combined with suitable 
discipline and education. 

The climatic treatment, for which the resorts on the North 
Sea are particularly suitable, and sea baths are mentioned in the 
next chapter. Here we need only refer to the sovereign effects 
of the sea in scrofula by quoting Baginsky’s opinion, that after 
centuries of experience with many thousands of children there are 
no measures known nearly as efficacious as the sea, “‘ which in 
its general effects has specific and incomparable properties.” 

Inunction treatment may also be used, especially if salt baths 
seem to be not yet applicable; its method of use is given in the 
next chapter. 

Of internal remedies cod-liver oil has long enjoyed a special 
reputation; but it must only be given in the cooler months 
of the year and in the absence of fever and diarrhoea. If the 

2a 


482 A CLINICAL SYSTEM OF TUBERCULOSIS 


pure oil cannot be taken, one of the numerous preparations con- 
taining it may be tried. Iron (syrup. ferri. iodid.), iodine and 
creosote may also be given. Guaiacol carbonate (2 to 5 gr. several 
times a day) alone or in cod-liver oil, creosotal (6 to 8 drops 
several times a day) and sirolin may also be ordered; but none of 
these remedies have much effect alone. For accelerating nutri- 
tional changes the internal use of chloride of sodium has been 
warmly recommended; the natural salt springs may be imitated 
by a combination of sod. chloride 20, sod. bicarb. 30, sod. 
sulphate 50 parts (15 gr. in half a pint of warm water). 

Systematic tuberculin treatment is indicated if the tuberculin 
test is clearly positive, showing the presence of a_ tubercular 
element. We recommend the use of either Koch’s old, or the 
albumose free preparation in afebrile cases, beginning with the 
smallest dose (.oor c.mm.), which must be slowly and carefully in- 
creased; more than 1 to 10 c.mm. should not be used; if necessary 
the treatment may be repeated after a pause. By careful specific 
treatment, with which harm can be never done, the whole consti- 
tution of the child will be made more resistant to scrofulous and 
tubercular influences. Salge noticed a marked improvement in 
the local scrofulous condition and the general state ending in 
complete recovery. The striking effect of tuberculin in scrofula 
has also been observed in the Cologne clinic for children 
(Dautwiz). The result of the tuberculin treatment at the Berlin 
University clinic for children in all scrofulous children, especially 
those which gave a strong v. Pirquet’s reaction, showed, too, a 
disappearance of the external signs of scrofula (phlyctenule, skin 
tuberculides), increase in the appetite, increase in weight, and 
improvement of the general condition. 

The local treatment of scrofulous affections of the skin and 
mucosz are important. Small patches of eczema may be treated 
with ung. hydrarg. precip. Large areas of eczema of a sebor- 
rhoeic nature on the face and head must first be cleansed with 
oil, and then treated with zinc paste (zinc oxid., amyl. aa 25, 
vaseline ad 100), or, if mecessary, the affected areas may be 
painted with 1o to 20 per cent. silver nitrate solution. Washing 
with water or any form of soap must be interdicted. If ulcers 
already exist, an ointment of argent. nitrat. .1 to .2, balsam 
peruv. I to 2, vaseline 20 parts may be used. 

For the affections of the eye (phlyctenula) yellow oxide of 
mercury or insufflations of calomel are used; if there is a suspicion 
of septic infection of the conjunctiva, it must repeatedly be 
cleansed with drops of zinc sulphate (4 per cent.). Recent 
corneal infiltrations and advancing ulcerations are to be first met 





. 
| 


SCROFULA 483 


with drops of atropine and lukewarm compresses (several times 
a day for one to two hours). Bandages are better not employed, 
except when deep ulcers of the cornea are present, and then only 
when ordered by specialists. 

Affections of the nasal mucous membrane, which generally 
start in the eye and relapse frequently, may be treated by wash- 
ing out the nose with 2 per cent. salt solution, or if the secretion 
is copious and foetid boracic acid or tincture of myrrh may be 
added, and sozoiodol (1 to 20 parts of starch) insufflated. Ulcers 
and numerous crusts are best treated with ung. hydrarg. precip., 
the crusts must be removed, and the ointment then laid on 
thickly. In ozzna irrigation is necessary to remove the crusts 
and secretion, we have had good results from } to 2 per cent. 
guaia-sanol solution. Turban recommends that after the irriga- 
tion a snuff of iodol, tannic acid and borax aa should be used, 
at first five to six times, later three times a day. 

The glandular tumours are best treated by conservative 
measures, since the loss of blood entailed by operative treatment 
is very bad for the patient, and there is also a danger of setting 
up miliary tuberculosis or meningitis. Only in softened glands 
with abscess formation, in very large swellings and those causing 
severe pressure symptoms are surgical measures indicated. With 
suppurating glands, which are nearly breaking through the skin, 
an attempt may be first made according to Calot by repeated 
punctures and compression bandages to produce a better cosmetic 
result than by operation. The outward application of iodine 
(sod. hydroiod. 2, lanolin 50, or iodol. pur. 3, lanolin 50), and 
of ung. potas. iodid and iothion-lanolin ointment is of service. 

The treatment of periosteal, bone and joint affections must 

follow conservative lines. Here it must not be forgotten that 
scrofula is essentially a constitutional abnormality, and that an 
improvement in the constitution must be the first aim of all treat- 
ment. This must chiefly be sought by removal from unhygienic 
surroundings, by regulating the diet and nutrition, by hardening 
the patient, and by preventing all forms of infection. 
The outlines given of the constitutional 
treatment show what is required for the 
prevention of scrofula. The prophylaxis of the secondary, tuber- 
cular component of the scrofulous condition is considered in the 
next chapter. 


Prophylaxis. 


CHAPTER 2 


Tuberculosis in Children. 


TuHar tuberculosis in children must be care- 
fully considered in relation to the efforts 
being made to check the progress of the 
disease in general, is shown by the results of post-mortem exami- 


Origin and 
Course. 


nation and the experience of the cutaneous tuberculin test. We. 


know that the frequency of tuberculosis in the dead body rises 
from about 15 per cent. in the first year of life, to 70 per cent. 
between the 11th and 12th years, that fatal tuberculosis augments 
in frequency with increasing age, and that even from 7 years old 
and onwards healed tuberculosis with cicatrization and calcifica- 
tion is found. Also it is known that the frequency of tuberculosis 
as a complication in those dying from other causes rises from 2 
per cent. in the first year, to over 50 per cent. between the 11th 
and 14th years, that non-fatal tuberculosis becomes more com- 
mon with increasing age, and that of the poorer population of 
large towns, who reach the age of puberty, up to 94 per cent. are 
infected with tubercle. 

From the facts the very important inference can be drawn, 
that tuberculosis is a children’s disease. In infancy it is certainly 
rare among those that are apparently healthy, but increases 
rapidly as the age progresses; it loses after the age of 7 its 
tendency to generalization, thanks to the increasing powers of 
resistance of the organism, and runs a more chronic course or 
even becomes healed. 

With the question of the origin of the tuberculosis of child- 
hood must be considered congenital tuberculosis, in which the 
tubercular changes already occur before birth, and hereditary 
tuberculosis, which results from the transference of the virus in 
the sperm from the male, or more frequently during intrauterine 
life from the mother, the organic changes, however, only appear- 
ing during extrauterine existence. However, in far the greatest 
number of cases of tuberculosis of childhood the infection was 





ee —_ 


Panne ADM DA A owe, 


TUBERCULOSIS IN CHILDREN 485 


contracted from outside after birth. Tuberculosis of the parent 
firstly acts by producing infection in the family, and secondly by 
producing an hereditary predisposition, i.e., an increased sensi- 
tiveness to external infection. In the same way in scrofula there 
is the same inborn predisposition for tuberculosis, which by many 
weakening influences (underfeeding, defective hygiene, children’s 
diseases, especially measles) is raised into an acquired increased 
sensitiveness to tuberculosis. 

With regard to the tubercle bacilli themselves there can be no 
doubt that the infection with the bovine type may be dangerous 
for children, and that the conditions for resisting the infection 
are the weaker the younger the child is. But the chief source of 
infection for the child remains the human type of bacilli. This 
is undoubtedly proved by the experiments of Gaffky and Rothe 
at the Berlin Institute for Infectious Diseases, who by the inocu- 
lation of mesenteric and bronchial glands of 400 children on 
‘guinea-pigs found that in seventy-eight cases a tubercular infec- 
tion was produced, in seventy-six of which a pure culture was 
obtained, being in seventy-five cases (98.7 per cent.) of the 
human, and in only one of the bovine type. Thus Koch’s view 
is completely confirmed, that the risk of bovine infection in 
children is considerably less than the danger of infection with 
human bacilli. 

The channels by which the bacilli enter the child’s body are 
known, only their relative importance is undecided. Certainly 
aerogenous infection plays an important part in children, but 
especially in infants and young children a less frequent one than 
intestinal or alimentary infection. This appears to be contra- 
dicted by the fact that in the above-mentioned seventy-eight cases 
in forty-two both groups of glands were affected, in fourteen only 
the mesenteric, and in twenty-two only the bronchial glands; the 
bronchial glands were thus affected oftener than the mesenteric. 
But this may be explained by the fact that in children the 
bacilli may enter by the digestive apparatus, while the first 
localization of tuberculosis appears in the glands of the respiratory 
organs. This may occur from human bacilli, which have 
entered the mouth, being either carried directly to the bronchial 
glands through the lymphatics, or reaching with the food the 
digestive apparatus may pass through the intestine and the 
regional lymphatic glands into the lymph-stream, by which they 
are carried to the bronchial glands, setting up there a primary 
disease, which may later spread either through the blood-stream 
or lymphatics. In any case the tuberculosis of children in an 
increasing frequency according to the age of the child is set up 


486 A CLINICAL SYSTEM OF TUBERCULOSIS 


by the entrance into the respiratory and digestive tract of tubercle 
bacilli derived from phthisical cases. 

The course of tuberculosis in childhood shows characteristic 
deviations from that in adults. This is due to the fact that the 
child’s organism has less power of resisting the same infection. 
Apart from the increased susceptibility to contagion in childhood 
the tissues of the child have less powers of reacting to the disease, 
and thus localizing, encapsuling, and overcoming it. It is this 
failure of reaction which explains the difference of the symptoms 
in children compared with adults (Engel). 

The forms of tuberculosis are also different at the various 

ages of childhood, that of infancy not being the same as in older 
children. The reason for this, according to the researches of 
Romer, is that the organism on becoming infected with tubercu- 
losis undergoes a marked change, which makes it more resistant 
to fresh infections with tubercle bacilli. The normally virgin 
soil of the tissues of infants reacts quite differently to a tubercular 
infection than the organism of older children, which has already 
generally been attacked by tubercle bacilli. The first standing 
unprotected, without specific material for defence, to a severe 
infection succumbs with acute or generalized tuberculosis. An 
infection, which has not proved fatal, gives, however, to the child 
a certain amount of immunity against fresh tubercular infection 
at a later time, so that a small number of tubercle bacilli are 
without effect on the protected organism, whilst a severe reinfec- 
tion lends to chronic pulmonary tuberculosis. Thus the develop- 
ment and cause of tuberculosis depends not only on the quantity 
of the bacilli, but also on the question whether the organism has 
previously been infected or not. By recent researches on immu- 
nity and tuberculosis the view of Romer has been completely 
confirmed, and the peril of infection for children who have still 
no specific protection against tuberculosis deserves much more 
attention than it has hitherto received. 
The tuberculosis of children spreads by the 
lymphatic system. It begins in the lym- 
phatic glands, and upon the reaction of these glands depends 
chiefly its further development. 

In infancy the lymphatic system is the part which has rela- 
tively the greatest powers of resistance. In spite of this it is not 
capable of withstanding the assaults of the tubercle bacilli; the 
tissue reaction is insufficient, and the glands fail to arrest the 
bacilli, which spread through the lymphatic system, attack other 
tissues, and without producing the characteristic local changes, 
constantly in infants cause a rapid, fatal ending. 


Pathology. 





ee a ee ae 


TUBERCULOSIS IN CHILDREN 487 


In older children the power of the lymphatic glands increases 
with the general resistance. The glands are better able to deal 
with the tubercle bacilli, and to shut off the infection from the 
rest of the body temporarily or permanently; also the extent of 
the disease in the glands is slighter. It leads to the occult of 
latent tuberculosis of childhood, affecting especially the bronchial 
glands; which latent tuberculosis as a result of traumatism and 
infectious disease may set up acute phthisis, meningitis, or tuber- 
culosis. This is possible because the occult tuberculosis in spite 
of its latency is active, the foci in the glands being recent, 
caseous, and not sufficiently encapsuled occasionally flare up and 
infect the whole body or individual organs. 

About the school age the resistance of the tissues still further 
slowly increases. As evidence of this we find that the bacilli are 
arrested in certain organs, which by their nature or growth are 
particularly liable to tuberculosis, such as the lungs, the bones, 
and the joints. Thus is explained the typical secondary tuber- 
culosis of mid-childhood. 

About the time of puberty appears a certain general power of 
withstanding tuberculosis, which limits the importance of the 
glands, which no longer play the chief part. The earlier occult 
foci are rendered inactive by calcification, and new infections 
follow the same course as in adults, that is, attack directly the 
organ most predisposed, namely, the lungs. But as these have 
not yet acquired the same power of resistance as in adults, acute, 
progressive pulmonary disease 1s more common. 

If we consider the pathology of tuberculosis of childhood in 
this way, the various differences in the course of the disease in 
children and adults will be understood. The lymphatic glands, 
especially the bronchial glands, are shown as the true centres. of 
infantile tuberculosis, from which the diseases may spread in 
various ways; either by continuity to the neighbouring lung 
tissue (periglandular caseous pneumonia), or by the lymphatics 
to various parts of the lung (lymphogenic tubercular peribron- 
chitis), or to a more distant part (mesenteric glands, bones and 
joints). A caseous, softened focus in a gland may also break into 
a bronchus, the cesophagus, or the blood-stream ; in the first case 
by aspiration a caseous pneumonia is produced, in the second an 
infection of the intestinal canal may be caused, and from the 
third there are two possibilities: either the infective material 
enters an artery of the lung and sets up disseminated pulmonary 
tuberculosis, or entering a vessel going to the heart (vein, thoracic 
duct) generalized miliary tuberculosis is thereby caused. In the 
following description only the forms of disease are described, 


488 A CLINICAL SYSTEM OF TUBERCULOSIS 


which differ from those met in adults, and are of practical 
importance. 

The diagnosis in children does not differ 
greatly from that in adults. There are a 
few general points which deserve attention. 
Firstly, the history or anamnesis is of particular importance, as 
showing if the child comes from a tubercular milieu. In the 
physical examination enlargement of the glands must be especi- 
ally sought for. | Percussion of the thorax must be done very 
lightly, but by finger to finger. The results of auscultation must 
be very critically examined, and the normal, increased, or puerile 
breathing must be remembered. ‘The bacteriological examina- 
tion in children is very unreliable, but the Rontgen-rays give 
clearer and more unequivocal results than in adults. 

Whilst the serological methods are all of doubtful value, the 
specific tuberculin tests, especially the cutaneous inoculation of 
v. Pirquet, are for children the method of choice. A positive 
result usually indicates tuberculosis, and a negative is with the 
greatest probability against it; the younger the child the more 
certain the result, so that in the first years of life a negative test 
excludes tuberculosis, while a positive result shows that the 
disease is active. In somewhat older children, and in cases in 
which the v. Pirquet reaction is not suitable, the intracutaneous 
injection of tuberculin is recommended; its technique is rather 
more difficult, but its results are more trustworthy. The con- 
junctival test is strongly contra-indicated in children. The older 
the child is, the more necessary becomes the original subcutaneous 
tuberculin injection of Koch. Its use has been described earlier, 
but in children half the larger doses suffice (.1, .5, 2.5, and 5 
c.mm.). The focal reaction is of more importance than the local 
tests and needle reaction recommended by Escherich. 

In the tuberculosis of infancy the most 
constant clinical symptoms are produced 
by the disease of the bronchial glands, 
which is usually primary. Secondary foci may appear in the 
lungs, leading to infiltration, but their appearance in infancy is 
rare. According to Ettlinger post-mortem examinations give the 
following figures for the tuberculosis of infancy: lungs, liver, 
and spleen are affected in 100 per cent., kidneys in 94.8 per cent., 
bronchial glands 81.6 per cent., intestinal tract 65.8 per cent., 
mesenteric glands 34.2 per cent., pleura 21 per cent., brain and 
pia mater 18.5 per cent., larynx and pericardium 5.3 per cent. 
Even in infants a few weeks old there have been seen tubercu- 
lides, phlyctenule, and bone tuberculosis; the appearance of 


Diagnosis and 
Clinical Forms. 


Tuberculosis 
of Infancy. 





TUBERCULOSIS IN CHILDREN 489 


tuberculides of the skin in infants infected with tuberculosis is 
very common. The course is often very acute, and the more so 
the younger the child at the time of infection; sometimes it lasts 
a few months. Even in the first half year of life the prognosis 
is not absolutely black, if the infection is slight. It depends, 
apart from the age of the patient, on the clinical course and locali- 
zation of the disease. Young children with afrebrile tuberculosis 
of the glands, bones, or joints not infrequently live, while if an 
internal organ, especially the lung, is affected, they always die. 
According to Pollak the mortality in the first half-year is 86 per 
cent., and 59 per cent. in the second. The severity of the infec- 
tion of infants seems to depend on the severity of the disease in 
the infecting person; also the quantity and virulence of the bacilli 
play an important part. There is a form of latent tuberculosis 
of infancy; it is therefore advisable, in cases in which the infant 
without obvious cause becomes pale and badly nourished in spite 
of suitable food, to employ v. Pirquet’s test. The local sym- 
ptoms are not usually distinct. When the lung is diseased cough 
and expectoration are absent, the breathing is superficial and 
accelerated, the pulse small and frequent, the temperature 
atypical, often subnormal, and death occurs with the characteris- 
tics of atrophy. In those infants who live through the first year 
the tubercular habitus is developed; it is therefore the conse- 
quence of an already existing infection. 
Up to about the age of 12 tuberculosis of 
Bronchial 
the bronchial glands takes the place of the 
Glands. apical disease of adults; when tuberculosis 
occurs in a child, it is usually present. Tuberculosis of the 
tracheobronchial and bronchopulmonary glands, with which the 
mesenteric glands are often involved, produces caseous or calcified 
swellings of the size of a walnut or larger. With the Rontgen- 
rays the calcified glands appear as foreign bodies of the shape of 
a projectile, and the caseous glands as less sharply defined 
shadows, the most swollen ones being generally impossible to 
recognize. There is as yet no agreement about the interpreta- 
tion of shadows about the hilus; but there is no doubt that for 
the diagnosis of disease of the bronchial glands the Rontgen-rays 
give the most information. The hilus shadow may be considered 
to be pathological if it is abnormally dark, broad, and contains 
an excessive number of shadow spots; more circumscribed, dense 
shadows indicate with certainty enlarged and diseased glands. 
Also in the hilus, tuberculosis of children, more frequently on the 
right than the left side, shadows may be seen, which join the 
main bronchus and the cardiac dulness, and from there spread 


490 A CLINICAL SYSTEM OF TUBERCULOSIS 


more or less irregularly into the middle of the lung areas; they 
are generally horizontal, more rarely run upwards or downwards; 
they indicate an extension of the disease from the lymphatic 
glands into the lung tissue in the neighbourhood of the hilus 
(Sluka). It is best to employ oblique illumination for the tracheal 
glands, and ventrodorsal illumination for the hilus of the lung. 

The most active symptoms of tuberculosis of the bronchial 
glands are limited, apart from infants, as a rule to the first years 
of life. 

Besides the unreliable signs afforded by the appearance and 
state of nutrition of the child the temperature, the pulse, the 
pupillary and ocular changes (sluggish reaction, exophthalmos, 
Graefe’s and Stellwag’s signs), and the changes in the digestion 
and appetite, the more constant signs produced by bronchial 
gland tuberculosis are Petruschky’s spinalgia, tenderness on 
pressure over the spines of the first to eighth dorsal vertebra, 
and circumscribed dulness at the side of the manubrium sterni 
and the sternoclavicular articulation with paravertebral dulness at 
the side of the second to fifth dorsal spines. Over the dull areas 
there are bronchophony, increased fremitus, altered breath sounds, 
and not rarely very loud tracheal breathing and stenotic mur- 
murs. Dautwiz considers that bronchophony with the whispering 
voice is the surest sign. 

Also Koranyi’s vertebral percussion and auscultation of the 
whispering voice over the vertebrae are useful in detecting 
enlarged bronchial glands. According to the exact observations 
of Michaelowicz in tracheobronchial tuberculosis of children 
there is dulness over the first to fifth thoracic vertebrz; the dul- 
ness over the first four vertebrae is due to the tracheal glands, 
while that over the fourth and fifth (in older children also the 
sixth) is due to enlarged glands about the bifurcation of the 
trachea. Auscultation over the vertebral column reveals increased 
loudness of breath sounds with bronchophony (D’Espine’s 
symptom). 

Very characteristic is a croupy, whistling cough of a very 
high note (bronchial gland cough) and particularly expiratory 
dyspnoea and expiratory rales. In the first years of life this is 
increased into an expiratory wheezing, which can be heard at a 
distance. It is the result of compression of the main bronchus, 
usually the right, in the short extent between the bifurcation and 
point of origin of the bronchus to the upper lobe. 

Less typical is a spasmodic cough like whooping cough, 
caused by pressure on the vagus and its branches. In such cases 
the diagnosis between whooping cough and tuberculosis of the 





TUBERCULOSIS IN CHILDREN 491 


bronchial glands may be difficult. The latter is indicated by the 
tubercular appearance, which in the earliest years is shown by 
wasting, the paralytic thorax, fine, dry skin, lanugo between the 
shoulder-blades, on the forearm, the legs, and temples, a deep 
blue iris with a dark ring, and the frequent combination of blonde 
hair with long dark eyelashes. 

The differential diagnosis has also to be made from asthma, 
adenoids, capillary bronchitis, and diphtheritic laryngeal paresis. 
Besides the Rontgen-rays in all cases the specific diagnosis, 
especially v. Pirquet’s test, is important. Since in the first years 
of life the disease in the bronchial glands is constantly primary 
and always active, the result of the cutaneous test taken in con- 
junction with the clinical evidence gives sufficient information 
as to the site and character of the disease. Only in older 
children the subcutaneous test cannot usually be dispensed with ; 
focal reactions in the bronchial glands are shown by increased 
cough, pains between the shoulder-blades, feeling of increased 
fulness in the chest and intense pain on percussion between the 
shoulder-blades. 

The prognosis of tuberculosis of the bronchial glands is the 
better the greater the age of the child at the time of infection; 
after the second year it is relatively favourable. But even older 
children run a danger of sudden generalization of tuberculosis, 
which is a sufficient reason for carefully examining the bronchial 
glands. 

: Tuberculosis of the mesenteric glands in 
Mesenteric ; : ; rere Ss 
childhood has the same importance for the 
Glands. digestive organs as bronchial gland tuber- 
culosis has for the lungs. On account of the permeability of the 
infant’s intestine to the tubercle bacillus, the disease in the 
mesenteric glands may be primary; though isolated tuber- 
culosis of the mesenteric glands is on the whole rare. More 
commonly they are secondarily affected from disease in the 
czcum, the lower ileum and the peritoneum. The diagnosis may 
be difficult, since the glands can only be palpated when they 
are large. It has been thought that, as a sign of mesenteric 
gland tuberculosis in children, the localized glandular tumours 
in the mesentery of the small bowel could be recognized without 
operation; but it is not so. If there is no inflammatory reaction 
around them, their clinical recognition is even more uncertain 
than in adults. If a tubercular history cannot be obtained, then 
the diagnosis will not be usually possible until continuous pains, 
often in paroxysms, with wasting, pallor and slight fever appear. 
If the mesenteric gland tuberculosis is the most prominent part 


492 A CLINICAL SYSTEM OF TUBERCULOSIS 


of the clinical picture, tabes mesenterica is spoken of. Sup- 
puration of the glands followed by rupture into the peritoneum 
is very rare. 
Tuberculosis of the external glands is a 
External e a i 
more favourable type of disease. The 

Glands. cervical, supraclavicular, extrathoracic, axil- 
lary, and inguinal glands are affected in the order given. 
In older children several of these groups may be affected at the 
same time, or the bronchial and mesenteric glands may also be 
infected; but general lymphatic gland tuberculosis is limited to 
the first three years of life. In children with any form of tuber- 
culosis the regional lymphatic glands are very frequently 
affected. But such glandular swellings should only be con- 
sidered to be tubercular, if the primary disease can be demon- 
strated and if the regional glands surpass in size and amount of 
disease the other swollen glands. 

Care is needed in ascribing swelling of the cervical glands 
to tuberculosis, since in children non-tubercular disease of the 
mouth and pharynx, leading to simple swelling of the regional 
glands, is common. Glandular tumours are also met in scrofula, 
leukeemia and Hodgkin’s disease. The axillary and inguinal 
glands are very frequently swollen in non-tubercular children, 
but marked swelling of the supraclavicular and extrathoracic 
glands indicate with more certainty tuberculosis of the pleura 
and lung. The tuberculin test is often indispensable. The 
specific focal reaction is shown by swelling and pains. The 
prognosis is good on the whole, since the glands, if they sofien 
and discharge, free themselves from the infective material. 
Tuberculosis of the lungs occurs quite fre- 
quently after the tenth year; it usually 
starts at the apex and spreads uniformly over both lungs. 
The diagnosis may be difficult, as a comparison with a 
sound lung is not possible. Marked induration and cavities do 
not form. 

In small children the disease in the lungs is usually secondary 
to the bronchial glands. The lower lobe is first affected, the 
pleura and pericardium often become infected. The apex often 
remains free. K. E. Ranke describes tuberculosis of lymphatic 
glands in the lung as particularly characteristic in the earliest 
years. It is a severe form, which appears chiefly in the first two 
years, and is marked by diffuse affection of the lymphatic tissue 
of the lung with relative freedom of the parenchyma. It is 
accompanied by diffuse bronchitis, which being a reaction of the 
lung to the bacillary infection is the more marked the acuter is” 


Lungs. 





TUBERCULOSIS IN CHILDREN 493 


the tubercular lung disease. So long as the process remains 
limited to the lymphatic glands of the lung, only the bronchitis 
can be detected on physical examination; the extrapulmonary 
glands are constantly enlarged, especially those in the neck and 
the side of the chest. 

That the generalized tuberculosis of the lymphatic glands 
of the lung described by Ranke occurs is undoubted, but it is 
often nothing else than a miliary tuberculosis of the lungs, 
spreading only through the lymphatics. The tendency to acute 
and rapid spread through the lymphatics is pathognomonic of 
phthisis in children. Therefore acute miliary tuberculosis of the 
lung and subacute caseous pneumonia occur in children more 
often than in adults. 

Acute miliary tuberculosis of the lung is difficult to diagnose, 
if the course of the disease has not been followed from the com- 
mencement. The primary focus in the lung, from which the 
acute disease originates, becomes masked by acute bronchitic 
signs. Tubercle bacilli cannot be discovered. We are therefore 
driven to rely on the general toxic symptoms. Atypical high 
fever (up to 105.5° F.), very frequent pulse (180), accelerated, 
dyspnoeic respirations (40 to 60), stupor, rapid wasting, enlarge- 
ment of the spleen, and petechiz of the abdomen indicate the 
gravity of the disease, while the signs in the lung are negative 
or simply point to a general diffuse bronchitis, which is only 
excluded by the severity of the general condition. The cutaneous 
test is allowable, but unreliable here; the subcutaneous test is 
contra-indicated. The prognosis is absolutely bad. 

Caseous pneumonia in children is easier to diagnose. With 
severe general disturbance catarrhal symptoms appear with 
cough, expectoration, shortness of breath and pain in the chest. 
The physical signs indicate inflammation in the smaller bronchial 
tubes, increasing infiltration, breaking down and destruction of 
the parenchyma of the lung. The cough becomes more violent 
and distressing, the sputum copious and purulent, but tubercle 
bacilli almost without exception cannot be discovered. At the 
same time night sweats, hectic fever swinging from 94° to 104° F., 
vomiting, diarrhoea, progressive emaciation and atrophy, make 
their appearance. If meningitis or cardiac weakness do not 
cause death rapidly, the child dies from carbonic acid poisoning 
caused by respiratory insufficiency. Transudation into the peri- 
toneum, cedema of the lower extremities and obliterative throm- 
bosis are terminal symptoms. In older children the disease may 
rarely become arrested, a growth of connective tissue, contraction 
and the formation of bronchiectasis taking place as in adults. 


494 A CLINICAL SYSTEM OF TUBERCULOSIS 


In these cases fever and cyanosis may diminish, but the low 
state of nutrition does not improve, the cough, dyspnoea and 
night sweats continue, the tubercular appearance remains, and 
in spite of the apparent improvement sudden death may occur 
without obvious cause, or at times with meningeal symptoms. 
The prognosis is absolutely bad, in spite of all treatment. 

The differential diagnosis must be made from the capillary 

bronchitis and broncho-pneumonia of children. The marked 
malnutrition, the hectic temperature, the respiratory insufficiency 
and the desiructive lung changes should settle any doubt. The 
cutaneous tuberculin test can also be applied, but the sub- 
cutaneous method is excluded by the fever. 
Tubercular pleurisy in childhood is_ par- 
ticularly difficult to diagnose, especially 
from pneumonia. The auscultation signs alone are in many cases 
not distinctive, since, contrary to the rule, the breath sounds in 
pneumonia may be weakened from obstruction to the bronchus, 
and in pleurisy may be loud and bronchial; the latter is par- 
ticularly the case in sacculated empyema and very large effusions. 
On percussion it is very often found in small children that in 
cases of pleurisy the whole of one side is dull, while pneumonic 
infiltration usually only affects one lobe, and disease of the lower 
lobe does not extend further than the anterior axillary line. 
Therefore extension of the dulness over the whole of one side 
or in front of the anterior axillary line indicates pleurisy, even 
if loud bronchial breathing conducted from the lung compressed 
against the trachea and bronchus is heard over it. The intensity 
of the dulness gives no certain information, neither does para- 
vertebral dulness on the sound side, nor paravertebral resonance 
on the affected side, nor the state of the vocal fremitus, which 
in children is difficult to examine. Serous pleurisy in children 
is usually of tubercular origin; the exudation then contains a 
larger number of mononuclear leucocytes, and, as Hamburger 
has lately emphasized, and as our own experience shows, never 
becomes purulent. ‘‘ Thoracic empyema is never of a_tuber- 
cular nature,’’ in contrast with pyopneumothorax, which in both 
adults and children is nearly always tubercular. In non-tuber- 
cular serous effusions the polynuclear leucocytes preponderate. 
The course of the fever, the way the disease commences, the 
general condition and the history do not always decide the 
question whether there is a tubercular serous effusion or a non- 
tubercular purulent one; a chronic empyema may be very easily 
mistaken for tuberculosis. In such doubtful cases a puncture 
must be made with a needle of not too small a bore. 


Pleurisy. 





« 
. 
Py 


TUBERCULOSIS IN CHILDREN 495 


Miliary tuberculosis at the commencement 
is very difficult to diagnose in children. 
Its distinction, for example, from a central 
croupous pneumonia may be impossible. For such cases Ham- 
burger recommends the use of the cutaneous tuberculin test. It 
is true that in miliary tuberculosis the child’s sensitiveness to 
tuberculin is considerably decreased, but it does not disappear 
altogether. The result is that only a very weak reaction appears, 
consisting of redness, but no, or only slight, exudation at the 
site of inoculation. Failing the cutaneous test, the needle-track 
method of Escherich may give a correspondingly weak reaction, 
-I increasing to 1 c.mm. of tuberculin being used. Redness 
without infiltration in the needle track is thereby produced. We 
consider that both tests are not sufficiently reliable, and that 
the latter may be even dangerous. 

Tubercular meningitis is the most common 
cause of death in children from 1 to 4 years 
old; to sixty such cases in children there are only eight in adults. 
This is no doubt due to the large amount of plasma, the increased 
nutrition and the copious blood supply in the rapidly growing 
brain of earliest years of life. 

The diagnosis in children, thanks to a distinct regularity in 
the course of the disease, is usually easier than in adults. In 
childhood it usually begins with cerebral symptoms, without 
tubercular disease in any other organ having become evident. 
The child, therefore, appears to have been previously healthy, 
only—a fact well worth noticing—the temperament having be- 
come more dull, peevish and_ self-centred. Suddenly violent 
cerebral vomiting, without nausea and unconnected with taking 
food, appears; high fever and other objective symptoms are still 
absent. If the vomiting is accompanied by constipation, the 
probability of meningitis will be increased; though diarrhoea 
does not exclude meningitis. Heubner considers it noteworthy 
that in children during the second week of the disease with 
marked slowing of the pulse there is also a fall in the temperature 
and respiration rate, so that in the three curves of respiration, 
temperature and pulse there is a fairly regular saddle-shaped 
depression. 

As the disease advances the effects of increased intracranial 
pressure appear; in children the paralytic symptoms are usually 
more marked than in adults. In infants the increased size and 
bulging of the anterior fontanelle makes the diagnosis easier. 
If the onset occurs with convulsions, as it may during the first 
and second year, it is noteworthy that purely functional spasms 


Miliary 
Tuberculosis. 


Meningitis. 


4906 A CLINICAL SYSTEM OF TUBERCULOSIS 


of an epileptic or tetanoid nature either produce no bulging of 
the fontanelle, or only during the attacks, and that persistence 
of the distension of the fontanelle between the attacks is indica- 
tive of meningitis. If the cranial sutures, as during the first 
months of life, are still yielding or open, instead of the distension 
of the fontanelle, there will be a separation of the bones of the 
skull. 

Kernig’s sign, 1.e., the incapacity to fully extend the legs 
while in a sitting position, cannot be looked for in infants; and 
Lasegue’s sign, which consists of the impossibility of fully ex- 
tending the legs while the patient is lying with the hips bent to 
a right angle, can only be relied on partially; in older children 
it supports the diagnosis of meningitis, but its absence has no 
importance. 

The neck phenomenon (le signe de la nuque) seems more 
important in children; Brudzinski found that it was absent only 
in one moribund patient out of forty-two cases of meningitis, 
while Kernig’s sign in the same cases failed twenty-two times. 
It likewise is a reflex symptom and is obtained by moving the 
head of the recumbent child forwards in a jerky manner with 
one hand, while the other hand is placed on the chest to keep 
the body flat; if the sign is positive, both the knees and hips 
become flexed, sometimes the legs are completely drawn up on 
the abdomen. Not so regularly in the meningitis of children 
can be found the contralateral reflex also described by Brudzinski, 
in which if one leg is strongly flexed passively there follows a 
similar flexion of the other leg. The result of numerous trials 
of these tests is that the appearance of the reflexes is in favour 
of meningitis, but their absence is not against it. 

In children the lumbar puncture clears up the etiological 
diagnosis in most, and according to some authors in all 
cases. The fibrinous clot which forms near the surface of the 
fluid removed by lumbar puncture must be very carefully 
examined; in cases of meningitis in children it is extremely 
delicate and contains in its meshes the bacilli often in large 
numbers, but sometimes a very few between numerous lympho- 
cytes. In any case it is easier to find the bacilli by staining the 
carefully removed clot than by centrifugalizing the fluid (p. 428). 
Lymphocytosis of the fluid is met with in children not only in 
tubercular meningitis, but also congenital syphilis, and the 
acute stage of poliomyelitis; it seems of itself to have no etio- 
logical significance. Mayerhofer and Sauber recommend the 
permanganate titration of the cerebrospinal fluid, since in 
tubercular meningitis the reduction power of the fluid in regard 








Spe 


i sagncaiied 4 babdy itn? 


TUBERCULOSIS IN CHILDREN 497 


to permanganate is very much increased even in the early stages 
of the disease (fourteen to sixteen days before death). The pro- 
cess is complicated and requires to be tried further before it can 
be recommended. 

The differential diagnosis must be made in children from 
certain forms of gastro-enteritis, and from acute infectious 
diseases, especially pneumonia, typhus and epidemic cerebro- 
spinal meningitis. In all cases the cutaneous test can be tried; 
according to Hamburger in tubercular meningitis the same results 
are obtained as have already been described in miliary tuber- 
culosis. Test tuberculin injections are absolutely contra-indicated. 

The prognosis is very bad. Especially the cases with early 

convulsions and head retraction run a rapid course; somnolence, 
fresh convulsions and coma appear and cause death in three to 
four days. 
Tuberculosis of the bones and _ joints, 
owing to its frequency, has great import- 
ance in childhood. According to Billroth 
a third of the cases occur during the first ten years of life. Boys 
are affected twice as often as girls, probably because they are 
more exposed to traumatic influences. Measles, whooping 
cough and scarlet fever have for long been considered as im- 
mediate causes. The disease of the bone is often the first mani- 
festation of tuberculosis in the child; it may be primary, but is 
usually secondary to an old latent focus. 

The bones most frequently affected in children are the long 
bones and the vertebre. 

Periostitis and ostitis often occur in children in the form 
of- tubercular dactylitis. The relative frequency of the painless- 
ness of the condition is remarkable. Tubercular spondylitis is 
particularly difficult to recognize in the early stages. Acute in- 
flammatory changes may occur without much pain. Or the little 
patient may refer the pains not to the back but to the intercostal 
region or abdomen. ‘‘ Abdominal pain with normal stoois 
always raises the suspicion of spondylitis, and demands a careful 
examination of the vertebral column ’”’ (F. Lange). It is charac- 
teristic that the patient holds the spine stiffly and uneasily, 
particularly if he wishes to pick anything up. Later the dia- 
gnosis can be made from the isolated prominence of one spine, 
or by the appearance of abscesses with necrosis and sequestra; 
the angular spine can be easily distinguished from the arched, 
rickety vertebral column. In all doubtful cases a good Ré6ntgen 
picture should be taken. 


The hip is the joint that is most frequently diseased in 
32 


Bones and 
Joints. 


498 A CLINICAL SYSTEM OF TUBERCULOSIS 


children; it is affected in one-third of ‘all cases of tuberculosis 
of the joints in childhood; 70 per cent. of the cases occur during 
the first ten years of life. Coxitis may be very difficult to recog- 
nize, if the foci have not yet broken into the joint. In the first 
two years they more often appear in the neck of the bone than 
in the epiphysis. Generally one or two enlarged lymphatic 
glands can be felt along the external iliac vein. Lameness, pain 

on movement and swelling may at first be absent. The first 
symptoms are often pain in the knee, and tenderness in the hip- 

joint on striking the sole of the extended foot. The best method 

of early diagnosis is by means of the Rontgen rays, which cannot 
generally be omitted; an atrophy of part of the bones within the 

joint will be shown. The direct diagnosis will become easier 
when the head of the femur or the acetabulum has become 
destroyed and the head has left the cavity. There will be then 
constantly a shortening of # to 1 in. and adduction of the leg, 

and the Rontgen rays will show clearly the alteration in the 
joint. It should be a rule in cases where there is pain in the 

hip or knee to think of coxitis. The hip-joint should be tested | 
as to function, muscular atrophy, swelling, tenderness and pain 
on movement, the length of both legs compared, the relation of 

the trochanter to Nélaton’s line determined, anda R6ntgen picture 
taken. In doubtful cases of synovial disease the subcutaneous 4 
tuberculin test may produce focal symptoms. 

After the hip, the knee, foot and elbow are most often 
affected; in all cases the disease usually begins in the bone. t 
These conditions produce no symptoms peculiar to children. The 
opinion of Poncet is worthy of notice, that the scoliosis which 
frequently appears between the ages of 8 to 12 is caused by 
tuberculosis; a weakened form of tubercular infection produces 
vertebral osteo-malacia, which forms the starting-point of 
scoliosis. Similar ‘‘ pretubercular’’ affections, according to 
Poncet, are also the osteo-articular deformities of youth, such as 
inflammatory flat-foot, genu valgum, coxa vara and radius cur- 
vus. This view, which relegates to the background the static 
and dynamic causes of these abnormalities, we must entirely 
refuse to support. 

The treatment of tuberculosis of children, 
at whatever age and in whatever form it 
appears, must be founded on a physical and dietetic basis. This 
can be systematically applied, apart from infants and the youngest 
children, for whom all treatment is nearly hopeless, best in sana- 
toriums for tubercular children, which in principle do not differ — 
from adult sanatoriums. Only the amount of the various factors 


Treatment. 





TUBERCULOSIS IN CHILDREN 499 


of the treatment (rest in the open air, exercise, hydrotherapeutics, 
diet and drugs) must be modified to suit the requirements of the 
child. Vhe school and the workshop are the only fresh factors 
in the children’s sanatorium, in which those that are slightly 
ill or merely convalescent can be instructed under medical super- 
vision, that it may be easier for them later in life to find suitable 
employment. 

The treatment of tuberculosis of children with tuberculin is 
of later date than the specific treatment of adults, but it has been 
now so well established by many workers, that there can no 
longer be any doubi as to its suitability under proper conditions. 
Tuberculin assists in bringing about recovery in cases of tuber- 
cular glands and in numerous cases of chronic tuberculosis, 
which can only be recognized by the toxic general symptoms and 
a positive result from the cutaneous test. Tuberculosis of the 
lungs in older children is only suitable for this treatment, when 
it takes the form of slight apical catarrh with but little dulness 
or shadow in the Rontgen photograph, or of slowly advancing 
induration. Slight fever and a low state of nutrition are then 
no contra-indication; but all acute and progressive cases of 
phthisis, and all the breaking down forms of lung tuberculosis of 
infancy should be excluded from specific treatment. It is neces- 
sary to begin with the smallest doses, which should be slowly 
and carefully raised till a large dose is reached. The very rapid 
increase in dose recommended by Schlossmann, Engel and Bauer 
till very large amounts are reached, is not necessary, since good 
results have been obtained with smaller doses. Also we cannot 
recommend the anaphylactic method, which consists of the repeti- 
tion of the same minute dose for months. For children the im- 
munizing method is the best, which by commencing with small 
doses and gradually increasing them aims at accelerating 1m- 
munization by increasing the focal inflammation and the forma- 
tion of antibodies. The effects, which often appear quickly, are 
improvement in the general condition, appetite and weight, in 
diminished rise of temperature, and in lessening of the cough 
and night sweats. These results have been confirmed in the 
Berlin University Children’s Clinic, where the children in the 
early stage of pulmonary tuberculosis treated by tuberculin 
showed, apart from the improvement in the general condition, a 
diminution in the cough, pains in the chest and night sweats, 
while diarrhoea was replaced by normal action of the bowels. 

In children as in adults the best and surest results will be 
obtained by a combination of sanatorium and tuberculin treat- 
ment. The sanatorium teaches the child hygiene, discipline, and 


500 A CLINICAL SYSTEM OF TUBERCULOSIS 
































order. Whether good results can be obtained in open cases of 
pulmonary tuberculosis the future must decide. In open cases 
before the school age at present no lasting results can be expected, 
so that they are not suitable for sanatorium treatment, which 
may be tried for older children with open disease if the history, 
social conditions, and physical signs are favourable. Advanced 
chronic cases and acute progressive disease should be excluded 
from children’s sanatoriums, as also should hopeless cases with 
tubercular or non-tubercular complications. In the sanatorium 
itself there should be a strict separation between the open and 
closed cases, since with children the proper hygiene of the cough 
and sputum 1s very difficult to carry out. Small institutions for 
‘children should refuse open cases on principle, larger sanatori- 
ums should provide for isolation and proper treatment of such 
cases. Besides in sanatoriums children with tuberculosis may be 
treated in forest homes, in open-air homes, at the seaside, by 
salt baths, in special children’s hospitals, or in special wards in 
general hospitals, or at home. 

Forest homes in the neighbourhood of large towns give good 
results for older children with closed tuberculosis. There they 
may rest and be carefully fed through the day, returning at night 
to their homes. The ambulant tuberculin treatment is also well 
suited to such cases. 

Open-air treatment may be carried out especially in the 
mountains with good results in the tuberculosis of children. A 
residence in such quiet, peaceful places is to be recommended for 
those children who at the seaside are tired, sleepless, “or feverish. 

A visit to the North Sea coast takes the first place for children 
with scrofula or tuberculosis of the glands and bones. The 
children’s institutions erected by societies admit poor children, 
but refuse cases of open tuberculosis. 

Simple salt baths and carbonic acid thermal salt baths are 
recommended for the treatment of glandular tuberculosis of 
children. They act by increasing the intake of oxygen and the 
excretion of carbonic acid, and thereby altering the nutrition. 
The salt baths are not suitable for the treatment of pulmonary 
tuberculosis in children, either alone or combined with the 
drinking of mineral water. 

Children’s hospitals only, as a rule, take cases of severe 
chronic or acute phthisis. They cannot undertake at the same 
time the alleviation of those seriously ill, and the treatment of 
those slightly affected, until special hospitals are built for tuber- 
cular children. ; 

The home treatment by the practitioner will be needed for 


TUBERCULOSIS IN CHILDREN 501 


children returning home from institutions, seaside, &c., not vet 
completely cured, and also for the large number of cases who on 
account of their age or for other reasons cannot be sent away. So 
that the general practitioner will daily meet cases of tuberculosis 
in children. The treatment must include a sufficiency of rest, 
light, air, and sun. The body may be regularly washed or rubbed 
with salt water, or baths may be given with common salt, sea- 
salt, or prepared salt. In the feeding a large part must be played 
by good milk. Diluted oatmeal gruel with butter, soups, fresh 
green vegetables passed through a hair sieve, and eggs may all 
be given. In children over three years old the diet more 
approaches that of adults. Milk and butter, fresh green vege- 
tables, fruits, farinaceous foods, puddings with cream, and meat 
juice may all be employed. 

Of drugs cod-liver oil is most serviceable in its various 
preparations, lipanin, ossin, Scott’s emulsion, malt extract, pure 
or with addition of calcium, iodine, or iron. The various pre- 
parations of creosote and guaiacol are not generally of much use; 
thiocol and sirolin can be employed. Arsenic is best entirely 
omitted. Kapesser’s soft soap treatment deserves especial men- 
tion; about a tablespoonful of sapo calinus is rubbed alternately 
into the front and back, it is then thinned with some warm water, 
and removed by washing or a bath after half an hour. The 
rubbing may at first be done every day, then every two or three 
days. The skin over the affected glands must not be rubbed. 

Since the localized tubercular foci in children are only 
slightly sensitive to tuberculin, specific treatment is very easy to 
carry out; and ambulant treatment for older children is therefore 
possible. Wherever a plentiful and suitable diet is possible, 
with a sufficiency of attention, light, air, and sun the practitioner 
has in a combination of the bath, soft soap, and tuberculin treat- 
ment an excellent weapon for attacking cases of tuberculosis in 
children, which are still capable of improvement, and of bringing 
about recovery in slight cases, perhaps after a long time. 

However, the practitioner will have to deal with many cases 
which resist all treatment, since the vis natura medicatrix is 
exhausted. Here symptomatic measures can be only applied to 
the fever, loss of appetite, exhausting cough, pains, hemorrhage, 
and diarrhoea, in the way that has already been described. We 
need here only say that narcotics (morphine, opium) must as far 
as possible be avoided in children, or only given to the older 
ones in small doses and not for long at a time. The less toxic 
preparations are always sufficient. 

In the treatment of tuberculosis of the bones and joints of 


502 A CLINICAL SYSTEM OF TUBERCULOSIS 


children it must be first noted that there is usually a limited, local 
form of the disease with favourable prognosis. Also that opera- 
tions in children entail a great danger of spreading the disease. 
Lastly, functionally perfect results are to be still less expected 
with the growing bones and joints of children than of adults, 
Under these circumstances general treatment and conservative 
measures are now recognized as being the most suited to the 
surgical tuberculosis of childhood. 

In the first place general treatment with rest, sun, good air, 
and good food is absolutely necessary. Climatic influences, such 
as long duration of sunshine, intense sun rays, and a prolonged 
stay at the seaside, have a good general effect, and also a quite 
special local action. On the other hand, a course of salt or 
thermal baths with the internal use of mineral water cannot 
remove the tubercular disease, certainly not in four to six weeks. 
It is more important that children with tubercular bones and 
joints should have good food, and remain the whole day in the 
open-air, if possible out of bed; such a course of treatment must 
be continued for months either in the summer or the winter with- 
out regard to the season. The hygienic and dietetic measures 
may be aided by the sunlight treatment, which has been brought 
into notice by Rollier at Leysin, and Bernhard at St. Moritz, and 
is becoming of greater importance. The effects of the direct 
action of the sun’s rays on the tubercular bones and joints of 
children are diminution of the pain, cleansing of open disease, 
and covering in of the ulcers. Closed tubercular foci need not 
be opened; the bactericidal powers of the sunlight at consider- 
able altitudes, with the general hardening effect of the climate, 
penetrate so deeply, that even fungoid disease and tuberculosis 
of the vertebrze can be healed, with retention of the power of 
movement of the joint. It is therefore chiefly from the surgical 
side that the wish is expressed that heliotherapy may be made 
available in a suitable mountain resort for those with small 
means, at any rate for the winter months, during which sun 
treatment at low altitudes is not possible. In Vienna and 
Cologne during the summer months experiments have been made, 
and very good results achieved. A long stay at the seaside will 
also obviate a large number of operations, and produce a cure of 
tubercular bone disease without deformity, such as can scarcely 
be obtained in large hospitals. 

In any case, the treatment must be as far as possible con- 
servative. According to the abundant experience of Hoffa the 
mortality is about the same with conservative and operative 
treatments, but the final functional results in those treated con- 


ee 





TUBERCULOSIS IN CHILDREN 503 


servatively was very much more favourable. [Every operation in 
childhood causes more or less mutilation, and therefore the ulti- 
mate utility of the limb is often very doubtful. Resections in 
children on account of injury to the growth of the bone in conse- 
quence of interference with the epiphyses must be regarded very 
seriously. 

The conservative treatment consisis in keeping the affected 
bone or joint at absolute rest. If the joint is diseased extension 
may be also applied, to draw the joint surfaces apart, and 
by relieving the pressure put them out of use. By exactly 
applied plaster bandages or suitable orthopedic apparatus the 
desired end is not difficult to attain. The best method of apply- 
ing conservative treatment to individual cases cannot be con- 
sidered here. The decision must often be made by a specialist, 
regard being paid both to the local and general condition. In 
view of the frequency of tubercular disease of the hip and knee 
we may emphasize the fact that resection of the hip-joint in 
children under 15 is now generally condemned, unless sup- 
purating sinuses with severe secondary infection are directly 
endangering the patient’s life; also non-suppurative disease of 
the knee is now better treated entirely on conservative lines; if 
suppuration has occurred in older children resection may be con- 
sidered, and in younger ones amputation, but in both cases only 
if all other means, especially sun-rays, have failed, and amyloid 
disease is commencing. Tubercular spondylitis must be treated by 
orthopedic measures, the use of which according to F. Lange 
‘“should not be left entirely to specialists, but can and must be 
adopted by all practitioners.”’ As long as the disease is recent 
and accompanied by severe pains, the best means according to 
Calot is plaster of Paris, preferably in the form of a jacket, 
which reaches to the head, is exactly modelled, and has a 
window cut over the angular projection, so that the deformity 
can be influenced by means of increasing pressure with a pad cf 
wadding. In no case must such a patient be left in the hands of 
the instrument maker, nor must spondylitis be treated with cor- 
sets. With the plaster treatment of acute cases must be joined 
the recumbent position, which must be maintained for months; 
in the French seaside institutions a lying-down, treatment in a 
padded wooden frame is favoured, in which by means of roll 
cushions a straightening of the vertebral column is obtained. 

The conservative treatment may be aided by injecting iodo- 
form glycerine (10 per cent.) into the tubercular focus every eight 
to fourteen days. For the first injection 75 gr. of the emulsion is 
sufficient; if the child bears the iodoform well, t.e., without 


504 A. CLINICAL SYSTEM OF TUBERCULOSIS 


eczema and toxic symptoms (headache, sleeplessness, peevish- 
ness, hallucinations) the next injection may be of 150 gr. For 
abscesses in connection with spondylitis the iodoform injections 
are also to be recommended. Remarks on the treatment by 
trypsin, Rontgen-rays, hyperemia, &c., will be found in Chapter 
ix: 

For the purpose of combining conservative and general 
treatment it is desirable that special sanatoriums should be built 
near large towns for cases of surgical tuberculosis of children. 
Such institutions have been built near Berlin, Hamburg, and 
Stuttgart. Tuberculin preparations are also used in them with 
good results. Hoffa has recommended the use of Marmorek’s 
serum. 

Yo recapitulate, we may say that there must be a combination 
of a hygienic and dietetic régime with conservative measures and 
specific treatment for cases of tuberculosis of the bones and joints 
in children: 

The practitioner, who is not able to make use of these 
requisite factors, must send his patients where these methods can 
be thoroughly carried out. It is certain from the first that the 
duration of treatment will be long—in spondylitis one to two 
years, in hip disease one to one and a half, in disease of the knee 
half to one and a half—and it is well to enlighten the relatives as 
to this. In spite of the importance of the sun, the sea or the 
mountains, the personality and capability of the doctor, by whom 
the treatment must be adapted to each individual case, is of the 
utmost weight. A pessimistic view of tuberculosis of the bones 
and joints of children is only taken by those who do not discover 
the condition early enough, or when proper measures have not 
been taken to prevent irreparable local and general disturbance. 
The casual removal of such cases for a few weeks to some place 
to ‘‘convalesce’’ without putting them under the care of some 
doctor, is to be thoroughly condemned. The after-treatment may 
be carried out at home, if the social conditions allow it. 

The awakening that is now taking place with regard to the 
care of cripples will have the result of making our surgical clinics, 
and general and children’s hospitals more than hitherto into sana- 
toriums for cases of surgical tuberculosis of children. 

' The prevention of tuberculosis of children 

Prophylaxis. as of adults must be directed towards raising 
the powers of resistance and diminishing the risks of infection. 
Suitable nourishment adapted to the age of the child, general 
care and hardening of the body, abundance of light, air and sun, 
sufficient rest, and plenty of exercise in the open-air increase the 





TUBERCULOSIS IN CHILDREN 3505 


resistance of the growing child to the tubercular infection, until 
it acquires a certain natural power of protection. With these 
measures are closely bound up those directed towards diminish- 
ing the risks of infection for the child. 

In the first place we put the hygiene and sanitation of the 
dwellings, particularly those occupied by tubercular families. 
‘“The most important problem in the prophylaxis of consumption 
is the saving of children in phthisical homes from severe tuber- 
cular infection’ (Roemer). To this end frequent disinfection of 
the sick-room and bedding of phthisical cases, with complete 
disinfection of the dwelling on change of residence or death of 
cases of open tuberculosis is in the first place required. In the 
first year of life the dwelling-house is almost the whole world for 
the child, and tuberculosis is specially a house disease, and dirt 
infection is very common in the earliest vears of life. For this 
purpose one must continue to agitate for legal compulsion for dis- 
infection of the homes of open tubercular cases, especially on 
change of residence. 

More important, but also easier than the attack on already 
existing tuberculosis, is the “‘ production of a race free from the 
disease.’ The prophylaxis must therefore begin in infancy. 
That there is a close connection between tuberculosis and infantile 
mortality is shown by the statistics of Hamburger and Sluka, 
according to which of the infants examined in the post-mortem 
room at Vienna 6 per cent. of those 3 months old were tubercular, 
17 per cent. of those between 3 and 6 months, and 22 per cent. 
of those between 6 and 12 months, and taking all those dying in 
the first year together 16 per cent. showed signs of tuberculosis. 
Therefore measures must be taken against infant mortality at the 
same time as against tuberculosis of childhood. It is perhaps 
more important to encourage healthy mothers to suckle their 
children than to forbid tubercular women from doing so, since a 
breast-fed child is more resistant to all infections, including 
tuberculosis, while a bottle-fed child in a tubercular milieu is a 
certain victim for tuberculosis. 

lt is the duty of the public health officials to look carefully 
into the supply of milk, and to see that it is free from bacilli, so 
that it can be taken in an uncooked state by children without 
danger. That action is necessary is shown by the observation of 
Schutz that in 1907 of the cattle slaughtered in Germany 21 per 
cent. were tubercular, and also by the fact that about ro per cent. 
of tubercular children have primary foci in the intestine. It is 
generally agreed that the prevention of the contamination of milk 
with bovine bacilli would reduce the number of cases of tubercu- 


506 A CLINICAL SYSTEM OF TUBERCULOSIS 


losis of the abdominal organs and cervical glands in children. 
Measures must be directed against the spread of tuberculosis in 
cattle, and the sale of the milk from a cow known to be tubercular 
must be prevented, whether the disease is situated in the udder or 
elsewhere. There still exist differences of opinion as to the 
diagnostic measures to be employed in excluding the milk from 
certain cows. Some hold that a general examination of the cows 
and an occasional bacteriological examination of the milk are 
sufficient, while others think that these methods are only reliable 
when combined with the tuberculin test for cows, whose milk is in- 
tended for children. It seems to us to be impracticable and going 
too far to exclude entirely the milk from allcows which have reacted 
to tuberculin. The observations of C. Bolle, Schlungbaum, and 
Schroeder showed, that of seventy-five cows who reacted to tuber- 
culin, only one gave milk, which produced tuberculosis when 
injected into a guinea-pig, so that the tuberculin test is con- 
siderably too severe. In cases of doubt the test may be employed, 
but in general a regular observation of milch cows and bacterio- 
logical examination of the milk at certain intervals will be 
sufficient. Vhe methods of obtaining and dealing with the milk 
and the way it is supplied in large towns require more careful 
attention than they have hitherto received. Central dairies 
should be established, with special arrangements for the chemical 
and bacteriological examination of the milk, and facilities for 
cooling and centrifugalizing it. The milk should only be sent 
out in sealed vessels, with the name of the producer visible on 
the label; also frequent and unexpected visits should be paid to 
the dairy. All these precautions should be the subject of regu- 
lations, such as the town of Hamburg has already passed. Great 
care must also be taken that in handling the milk it is not infected 
with human bacilli. Till we reach this stage, the only remedy is 
to boil the milk before it is used. It is an evil, since in the boil- 
ing certain changes take place in the milk which render it less 
digestible, but it is the lesser one, as the bacilli are thereby 
killed, if not rendered entirely harmless to children. 

Of great importance is the separation of tubercular adults 
from children, and tubercular children from healthy ones in the 
home and the school. It should be a matter of course that tuber- 
cular persons should not prepare meals, wash infants or their 
clothes, kiss children, be in close personal contact with them, and 
above all must not share a bedroom with them. But how often 
are those rules broken by tubercular mothers, sisters, or domes- 
tics! Besides the educative work of the tubercular dispensaries, 
and addresses given to mothers, sick and maternity nurses, and 





TUBERCULOSIS IN CHILDREN 507 


Poor-law doctors, there still remains much to be done. It is most 
necessary, as tubercular infection during the first year of life is 
nearly always fatal. 

Efforts must further be made to remove healthy children from 
infected families, to strengthen weakly children in holiday homes, 
and to place children suspected of scrofula or early tuberculosis 
in healthy country places, or in forest and seaside homes. The 
erection of more country homes for convalescent children is 
desirable, since such children are particularly liable to infection 
if they are left in unhealthy homes. 

Lastly, the schools must be considered. According to post- 
mortem records about 75 per cent. of children of school age show 
tubercular changes; at least 50 per cent. of all school children 
are in towns infected with tuberculosis, while the percentage of 
manifest pulmonary tuberculosis among school children is very 
much lower; according to Grancher it is about 1 to 17 per cent. 
Therefore care must be taken, in view of the compulsory nature 
of school attendance and the length of time the child spends in 
the school, that it does not directly or indirectly tend to spread 
the disease. It is necessary to exclude till cured cases of open 
tuberculosis among the teachers, scholars, and school attendants. 
Although Schmidt’s assertion, that tuberculosis of the lung and 
larynx has very much increased amongst teachers in the public 
schools, has not been confirmed, the necessity still remains of a 
careful superintendence of the teaching staff, the school build- 
ings, and the habits of those using them. 

Further the schools should take up more than hitherto the 
education of the public in hygienic questions and _ particularly 
with regard to anti-tubercular measures. The school doctor 
should carefully search out cases of lupus and other forms of 
tuberculosis, and also those suspected of the disease, for which 
a thorough co-operation with the teachers is desirable; and when 
necessary advice must be given to the parents and the school and 
municipal boards as to the requisite methods for the treatment 
and care of such children. It is also possible for the school suc- 
cessfully to oppose the ignorance of the cause of tuberculosis, 
to widen the knowledge of how the disease is spread, to awaken 
the desire for hygienic surroundings, to insist on cleanliness in 
the home as the foundation of all hygiene in the girls’ classes, 
to instruct the girls in the proper management and care of the 
house, and above all to awaken in both sexes a desire for a 
healthy life. 

If our young people are to be educated in this way, it is 
essential that the schools themselves should practically illustrate 


508 A CLINICAL SYSTEM OF TUBERCULOSIS 


the methods taken for the prophylaxis of tuberculosis. The site 
and construction of the school buildings should satisfy hygienic 
requirements, the cloak-rooms, &c., should be well arranged, the 
class-rooms frequently damp-cleaned to obviate dust, the light, 
air and temperature in the schoolroom should be regulated, the 
time-table should be so arranged that the bodily exercise of the 
children should not suffer, playgrounds must not be forgotten, 
school baths and school meals provided for poorer children, and 
finally the visits of the school doctor should be obligatory. These 
arrangements are still defective, especially in country districts 
and in the higher schools of towns; in the whole of Germany 
there are only 1,000 school doctors. 

With regard to the prevention of tuberculosis the introduc- 
tion of regular gymnastics and methodical breathing exercises 
in the open air between the hours of lessons is to be desired. 
In this way an increased power of resistance, both general and 
local, is produced, and at the same time many dangers of infec- 
tion outside the school are avoided. 

Another very important factor is the care and treatment of 
the teeth at the school age. Some of the general causes pre- 
disposing to tuberculosis (anzemia and digestive disturbances) 
are consequences of defective mastication. There can be no 
doubt that deficient mastication in childhood lowers the powers 
of resistance, especially to tuberculosis. On this account Kirch- 
ner demands that the children should be supervised by school 
dentists from the time of their entrance into school, and if they 
have not their own dentists that treatment should be provided. 
In larger towns dental clinics have been installed at the expense 
cf the community. But even if this is provided for, the care of 
the teeth between the years of 2 and 6, before the school age 
begins, must not be forgotten. 

Lastly we may here refer to a question of prophylactic and 
therapeutic nature which has lately been raised. The abnormali- 
ties of the upper thorax described by Freund and their import- 
ance in predisposing to tubercular disease at the apex of the 
lung have been already mentioned more than once. Klapp con- 
sidered this stenosis from a developmental standpoint and drew 
from it conclusions important for prophylaxis and therapeutics. 
With the phylogenetic and autogenetic changes connected with 
the assumption of the upright position the primitive keel-shaped 
thorax of the four-legged animal has been converted into the 
existing secondary, broad, more barrel-shaped form. Besides 
the immobilization of the apices of the lung and the consequent 
stagnation in the blood-vessels and lymphatics the circulation 





TUBERCULOSIS IN CHILDREN 509 
itself undergoes considerable changes from the adoption of the 
erect position, which affect unfavourably the blood supply to the 
apex of the lung. While Freund recommends the mobilization of 
the stenosis by means of chondrotomy of the first rib-cartilage, 
Klapp attempts to relieve the rigidity and constriction without 
an operation by means of the systematic crawling exercises de- 
vised by him, which in the treatment of vertebral scoliosis have 
already achieved remarkable results. There can be no doubt 
that the temporary exercise of going on all fours accompanied 
with methodical movements (crawling on the stomach) is con- 
siderably more effective than all the breathing exercises and 
passive movements. Further advantages of this method are that 
the upper part of the lung is rendered hyperemic, the whole 
respiratory musculature is strengthened, the thorax is gradually 
widened and the heart relieved by the fall of pressure in the 
horizontal position. 

We consider that the crawling treatment under proper con- 
trol of the technique has a very marked effect on the stenosis of 
the upper aperture of the thorax, especially if the chest is badly 
developed and deformed. ‘To realize thoroughly the capabilities 
of this method one should see with one’s own eyes in WKlapp’s 
Clinic how the stunted, deformed children of great towns, who 
have not merely the predisposition, but are mostly already in- 
fected with tuberculosis, undergo a powerful revolution of the 
whole organism. We wish, however, that the method should be 
chiefly used as a prophylactic measure in weakly children with a 
bad family history and with a paralytic, phthinoid, rachitic or 
scoliotic thorax, and consider that it should only be used thera- 
peutically in cases of endothoracic glandular tuberculosis and the 
very earliest forms of pulmonary tuberculosis in children. The 
most suitable places for carrying it out are children’s sana- 
toriums, where it should be controlled by the Rontgen rays and 
a lung specialist. 

The number of deaths from tuberculosis, which in childhood 
exceeds those from all the so-called children’s diseases, has not 
during the last thirty years so appreciably diminished in children 
as in adults. 

Certainly clinical, experimental and epidemiological observa- 
tions show that a slight tubercular infection during childhood 
gives immunity against a fresh infection. But this immunity is 
only relative, which fails against a severe reinfection. Therein 
lies the necessity of protecting children from severe family 
and house infections and of commencing the prevention of tuber- 
culosis with quite the youngest children. The further view sup- 


510 A CLINICAL SYSTEM OF TUBERCULOSIS 


ported by recent studies in immunity, that the prevention of 
tuberculosis must be essentially limited to the age of childhood, 


is still problematical. Certainly there is some truth in v. Beh- | 


ring’s dictum, that consumption in adolescents and adults 
‘“ should be the keynote of the song to be sung to infants in their 
cradle.’ But there is no necessity to adopt exclusively v. 
Behring’s view of the prophylaxis of tuberculosis. : 







ee 


LIST OF AUTHORITIES. 


For want of space it is impossible to name separately all the 


authors whose works have been consulted. It is more in keeping 
with the practical nature of this book to limit the references to 
the more important publications. For convenience these refer- 
ences have been divided according to chapters, and the list of 
authors arranged alphabetically. 


i) 


Go 


NI 


ive} 


10. 


Helv 


I. AEtiology of Tuberculosis. 


AUFRECHT. Uber die Lungenschwindsucht. Magdeburg, 1904. 


. BACMEISTER. Entstehung und Verhiitung der Lungenspitzentuberkulose. 


Deutsche med. Wochenschr., 1911, Nr. 30. 

vy. BAUMGARTEN. Welche Ansteckungsweise spielt be1 der Tuberkulose 
des Menschen die wichtigste Rolle? Deutsche med. Wochenschr., 
1909, Nr. 4o. 

BECKMANN. Das Eindringen der Tuberkulose und ihre rationelle 
Bekampfung. Berlin,- 1904. Verlag von S. Karger. 


. V. BEHRING. Uber alimentare Tuberkuloseinfektion im Sauglingsalter. 


Beitrage z. Klin. d. Tub., 1905, Bd. 3. Beitrage z. experimentellen 
Therapie, H. 5 u. 8. Vers. deutsch. Naturforscher u. Arzte, 1903. 


. BIRCH-HIRSCHFELD. Uber den Sitz und die Entwicklung der primaren 


Lungentuberkulose. Arch. f. klin. Med., 1899, Bd. 64. 


. BREHMER. Die Atiologie der chronischen Lungenschwindsucht. Berlin, 


1885. Verlag von A. Hirschwald. 

BURCKHARDT. Uber Haufigkeit und Ursache menschlicher Tuberkulose 
auf Grund von ca. 4000 Sektionen. Zeitschr. f. Hyg. u. Infektionskr., 
1906, Bd. 53. 

DEYCKE. Zur Biochemie der Tuberkelbazillen. Minch. med. Wochenschr., 
1910, Nr. 12. 

FLUGGE. Uber die nadchsten Aufgaben und Erforschung der Ver- 
breitungswege der Phthise. Deutsche med. Wochenschr., 1897, 
Nr. 42. ; 

— Die Verbreitung der Phthise durch staubformige und durch beim 
Husten verspritzte Tropfchen. Zeitschr. f. Hygiene u. Infektions- 
krankheiten., 1899, Bd. 30, H. 1. 


2. — Die Verbreitungsweise und Bekampfung der Tuberkulose auf Grund 


experimenteller Untersuchungen im _ hygienischen Institut der 
Koniglichen Universitat Breslau. 1893-1908. Leipzig, 1908. Verlag 
von Veit u. Co. 

FREUND, W. A. Uber Thoraxanomalien als Pradisposition zur Lungen- 
phthise und Emphysem. Berl. klin. Wochenschr., Igor. 1902, 
Aertsche. f- dub:, Bde 3% 

GRUBER. Vererbung, Auslese und Hygiene. Deutsche med. Wochenschr., 
1909, 46 u. 47. 


5. Hart. Die mechanische Disposition der Lungenspitzen zur tuberkulésen 


Phthise. Stuttgart, 1906. Verlag von F. Enke. 


51 


16. 


We 


2 A CLINICAL SYSTEM OF TUBERCULOSIS 


HART. Die Beziehungen des knéchernen Thorax zu den Lungen und 
ihre Bedeutung fiir die Genese der tuberkulésen Lungenphthise. 
Beitrage z Klin. d? fubs Bar 7 

HArT and HARRASS. Der Thorax phthisicus. Eine anatomisch-physio- 
logische Studie. Stuttgart, 1908. Verlag von F. Enke. 


. HUEPPE. Erblichkeit der Tuberkulose. Vers. Deutsch. Naturforsch. u. 


Arzte., 1901. 


. KocH, R. Die Atiologie der Tuberkulose. Mitteilungen a. d. Kais. 


Gesundheitsamt. Berlin, 1884. 


20. KOSSEL. Die Beziehungen zwischen menschlicher und tierischer Tuber- 


kulose. Bericht, erstattet auf dem VII. Interntionalen Tuberkulose- 
kongress in Rom. Deutsche med. Wochenschr., 1912, Nr. 16. 


. LaNbotIs, L. Lehrbuch der Physiologie des Menschen. Wien u. Leipzig, 


1893. Verlag von Urban und Schwarzenberg. 


. LUBARSCH. Uber den Infektionsmodus bei der Tuberkulose. Fortschr. 


d. Med., 1904, Nr. 16 u. 17. 


. MARTIUS. Vererbung der Tuberkulose. Vers. Deutscher Naturf. u. 


Arzte, Igol. 


. — Uber die Bedeutung der Vererbung und die Disposition in der 


Pathologie mit besonderer Beriicksichtigung der Tuberkulose. 
Kongr. f. inn. Med., 1905. 

NAEGELI. Uber Haufigkeit, Lokalisation und Ausheilung der Tuber- 
kulose. Virchows Archiv, Bd. 160. 


26. ORTH. Uber einige Zeit- und Streitfragen aus dem Gebiete der Tuber- 


kulose. Berl. klin. Wochenschr., 1904, Nr. 11-13. 


. RABINOWITSCH, L. Orth’s Vortrag tiber Rinder- und Menschentuber- 


kulose in der Gesamtsitzung der Konig]. Preuss. Akademie der 
Wissenschaften vom 8 Februar, 1912. 


. REIBMAYR. Uber die natiirliche Immunisierung bei tuberkulésen 


Familien. Miinch. med. Wochenschr., tgor. 


. RIBBERT. Uber die Genese der Lungentuberkulose. Deutsche med. 


Wochenschr., 1902, Nr. 17. 


. RIFFEL. Weitere pathogenetische Studien tiber Schwindsucht, &c. 


Frankfurt a. M., 1901. Verlag von Joh. Alt. 


. SCHMORL. Zur Frage der beginnenden Lungentuberkulose. Miinch med. 


Wochenschr., 1901, Nr. 50. 


. SOFER. Rasse und Immunitat. Politisch-anthropologische Revue, 1940, 


Bd. 8. 


. WESTENHOEFFER. Uber die Eingangspforten der Tuberkelbazillen. Berl. 


klin. Wochenschr., 1904, Nr. 7 u. 8. 


Il. Tuberculosis of the Lungs. 
(A) ANATOMY, SYMPTOMATOLOGY, DIAGNOSIS. 


. AUFRECHT. Pathologie und Therapie der Lungenschwindsucht. Wien, 


1905. Verlag von A. Holder. 


. BANDELIER. Die Tuberkulindiagnostik in den  Lungenheilstatten. 


Beitrage zur Klin. d. Tub., Bd. 2. 


. — Uber die Heilwirkung des Neutuberkulins, Bazillenemulsion (Agglu- 


tinationsuntersuchungen). Zeitschr. f. Hyg. u. Infektionskr., 1903, 
Bd. 43 


_ BANDELIER and ROEPKE. Lehrbuch der spezifischen Diagnostik und 


Therapie der Tuberkulose. 6 Auflage. Wiirzburg, igt1. Verlag 
von C. Kabitzsch. 


. COHN. Die anatomische Bedeutung der Lungenréntgenogramme und 


ihre Beziehungen zur R6ntgendiagnostik der Lungentuberkulose. 
Zeitschr. f. Tuberkulose, Ba: 17,81 


6. CORNET. Die Tuberkulose. Wien, 1907. Verlag von A. Holder. 
. EICHHORST. Handbuch der speziellen Pathologie und Therapie. Wien 


op) 


oO 


und Leipzig, 1891. Verlag von Urban und Schwarzenberg. 


. Grav. Zur Differentialdiagnose zwischen Lungentumor und Lungen- 


tuberkulose. Deutsches Archiv fiir klin. Med., Bd. 98 


. Hart. Uber sekundare Infektion mit Tuberkelbazillen und deren sapro- 


phytisches Wachstum nebst einigen Schlussfolgerungen. Deutsche 


med. Wochenschr., 1910, Nr. 27 






























10. 


LIST OF AUTHORITIES 513 


JESSNER. Hautveranderungen bei Erkrankungen der Atmungsorgane. 
Dermatolog. Vortrage fiir Praktiker, H. 22. Wiirzburg, 1g1!. 
Verlag von C. Kabitzsch. 


11. KAYSERLING. Die Pseudotuberkelbazillen. Zeitschr. f. Tub., Bd. 3. 


2. KOGEL. Uber die Frage chronischen Mischinfektion bei Lungen- 


tuberkulose. Deutsche med. Wochenschr., to11, Nr. 45. 


. KROENIG. ep uescian der rechten Lungenspitze. Deutsche 


Klinik, Bd. 


_ LOEWENSTEIN. iaescenalace Lagerung der Tuberkelbazillen. Zeitschr. 


f. Tub., Bd. 10. Deutsche med. Wochenschr., 1907, Nr. 43. 


. MucH. Uber die granulare nach Ziehl nicht firbbare Form des Tuber- 


kulosevirus. Beitrage z. Klin. d. Tub., Bd. 8, H. 1 u. 4. 


. — Nastin, ein reaktiver Fettkorper im Lichte der Immunitiatswissen- 


schaft. Miinch. med. Wochenschr., 1909, Nr. 306. 


. POTTENGER. Eee ep asults und Degeneration. Beitrs az kWline d: 


subse Bide 225, EH. 


. — Die WY ‘irkung der TE benealese aufs Herz. Beitrage z. Klin. d. Tub., 


Bd. 


. ROEPKE. aoe gegenwartige Stand der Tuberkulosediagnostik. Deutsche 


med. Wochenschr., rg11, Nr. 41 u. 42. 


. — Die Untersuchung menschlicher Se- und Exkrete. Beiheft zum 


Kalender fiir Medizinalbeamte. Berlin, 1902. Verlag von Fischer. 


. — Zur Diagnose der Lungentuberkulose. Beitrage z. Klin. d. Tub., 


Bde 2. 


. — Beitrage zur serologischen Diagnostik der Lungentuberkulose. Beitr. 


Zuri: id. Tub. ; Bd: 18, Ho 


. SAHLI. Lehrbuch der klinischen Untersuchungsmethoden. Leipzig u. 


Wien, 1902. Verlag von F. Deuticke. 


. SCHROEDER and BLUMENFELD. Handbuch der Therapie der chronischen 


Lungenschwindsucht. Leipzig, 1904. Verlag von Joh. Amb. Barth. 


. SPRAUCH. Uber bakteriologische Leichenblutuntersuchungen. Zeitschr. 


f. Hygiene und Infektionskrankheiten, Bd. 65. 


. TURBAN. Beitrage zur Kenntnis der Lungentuberkulose. Wiesbaden, 


1899. Verlag von F. Bergmann. 


. — Tuberkulose-Arbeiten. Davos-Platz, 1909. Verlagsanstalt Buch- 


druckerei Davos A.-G. 


. UHLENHUTH and XYLANDER. Antiformin, ein bakterienaufl6sendes 


Desinfektionsmittel. Berl. klin. Wochenschr., 1908, Nr. 209. 


. WALLER. Beitrage zur physikalischen Diagnostik. Nordiskt Med. 


Arkiv., 1909, Abt. 2. 


. WASSERMANN and BRUCK. Experimentelle Studien iiber die Wirkung 


der Tuberkelbazillenpraparate auf den tuberkulos_ erkrankten 
Organismus. Deutsche med. Wochenschr., 1906, Nr. 12. 


. WOLFF-EISNER. Friihdiagnose und Tuberkuloseimmunitat. Wurzburg, 


1909. ‘ Verlag von C. Kabitzsch. 


. ZIEGLER and KRAUSE. Rontgenatlas der pms vincsisulose. Wiirz- 


burg, 1910. Verlag von C. Kabitzsch. 
(B) PROGNOSIS, TREATMENT, PROPHYLAXIS. 


. BANDELIER. Die Leistungsfahigkeit der kombinierten Anstalts- und 


Tuberkulinbehandlung bei der Lungentuberkulose. Beitrage z. 
Klin. d.:Tub., Bd. 15 


. — Stand der spezifischen Behandlung der Tuberkulose. Bericht tiber 


die IV. Versammlung der Tuberkulose-Arzte in Berlin, 1907. 
Tuberkulosis, 1908, Bd. 


. BRAUER. Die chirurgische Behandlung der Lungenkrankheiten. Jahres- 


kurse fiir arztliche Fortbildung, 1910, H. to. 


. BREHMER. Die Therapie der chronischen Lungenschwindsucht. Wies- 


baden, 1889. Verlag von J. F. Bergmann. 


Die Behandlung der Lungenschwindsucht in geschlossenen ‘Heil- 


anstalten. Berlin, 1884. Verlag von Reimer. 


. DETTWEILER. Die Ernihrungstherapie bei Lungenkranken. v. Leydens 


Handbuch der Ernahrungstherapie und Diatetik. Berlin, 1897. 


. FRIEDRICH. Die chirurgische Behandlung der Lungentuberkulose. eke 


Kongr. der Internationalen Gesellschaft fiir Chirurgie in Briissel, 
IQII. 


33 


514 A CLINICAL SYSTEM OF TUBERCULOSIS 


4o. Jacos, P. Die Tuberkulose und die hygienischen Misstande auf dem 


41. 


No 


Lande. Berlin, 1911. Karl Heymanns Verlag. 

JESSEN. Uber den kiinstlichen Pneumothorax in der Behandlung der 
Lungentuberkulose und die reread dieses Verfahrens. Wuirz- 
burger Abhandlungen, Bd. XL., 7. Verlag von Curt Kabitzsch, 
Wirzburg. 


. Kots. Eine neue Methode zur Verengerung des Thorax bei Lungen- 


tuberkulose und Totalempyem nach Wilms. Mit Bemerkungen 
von Professor Wilms. Miinch. med. Wochenschr., 1911, Nr. 47. 


. Kraus, F. Die klinische Behandlung der Lungentuberkulose. Zeitschr. 


f. arztl. Fortbildung, 1911, Nr. 22 u. 23. 


. LANDERER. Die Behandlung der Tuberkulose mit Zimtsdure. Leipzig, 


1898. Verlag von Vogel. 


. LIEBE. Vorlesungen tiber Tuberkulose. Die mechanische und psychische 


Behandlung der Tuberkulésen. Miinschen, 1909. Verlag von 
J. F. Lehmann. 


. NAGEL. Tausend Heilstattenfalle. Beitrage z. Klin. d. Tub., Bd. 5. 
. PENZOLDT. Die Behandlung der Lungentuberkulose. Die Behandlung 


der Magenkrankheiten. Die Behandlung der Erkrankungen des 
Bauchfells. Handbuch der spez. Therapie inn. Krankheiten von 
Penzoldt u. Stintzing. Jena, 1909. Verlag von G. Fischer. 


. ROEMER. Tuberkulose-Immunitit, Phthiseogenese und_ praktische 


Schwindsuchtbekampfung. Beitrige z. Klin. d. Tub?  Bdiex7 bias 


. — Spezifische Uberempfindlichkeit und Tuberkuloseimmunitat. Bei- 


trage*z. Klin, d. Tub, Bd: 11. 


. ROEPKE. Die Tuberculinbehandlung in Klinik und allegemeiner Praxis. 


Zeitschrift ftir arztl. Fortbildung, 1911, Nr. 13. 


. -- Ambulante Nachbehandlung mit Tuberkulin nach der Heilstatten- 


behandlung. Bericht tiber die VII. Tuberkulosearzteversammlung 
in Karlsruhe, 1910. 


. — Die Desinfektion bei Tuberkulose. Reichs-Medizinal-Anzeiger, 1910, 


ING 273) ell 


4. 
. — Tuberkulose und Heilstatte. Beitrage zur Klinik der Tuberkulose, 


Bde tii 2o a 


. ROEPKE and StTuRM. Die Ernahrungstherapie in der Heilstatte. 


Zeitschrift fiir Tuberkulose, Bd. XVII, H. 1. 


. SAUGMANN. Behandlung der Lungentuberkulose mittelst ktnstlicher 


Pneumothoraxbildung. Beiheft zur med. Klinik, 1o11, H. 4. 
SPENGLER, C. Tuberkulose und Syphilisarbeiten, 1890-1911. Davos, 
1911. Verlag von H. Erfurt. 


. SPENGLER, L. Dauererfolge bei Behandlung schwerer einseitiger 


Lungentuberkulose mittelst kiinstlichen Pneumothorax. Miinch. 
med. Wochenschr., 1o11, Nr. 


. STRAUSS, H. Die Ernahrung der ‘Tobadeulesee: Bericht iiber die VI. 


Versammlung der Tuberkulose-Arzte in Berlin, 1909. 


_ Vv. STRUMPELL. Lehrbuch der speziellen Pathologie und Therapie der 


inneren Krankheiten. Leipzig, 1902. Verlag von F. C. W. Vogel. 


. WINTERNITZ. Tuberkulose und Hydrotherapie. Tuberkulosis. Vol. 10, 


Nr. 10. 


Ill. Tuberculosis of the Pleura. 


. BRAUER. Die Erkrankungen der Pleura. Lehmanns med. Atlanten., 


Bd: VII. 


. BRECKE. Beobachtungen iiber Pleuritis sicca. Med. Korresp.-Blatt des 


Wiirtt. Arztl. Landesvereins, 1911, Nr. 50 u. 51. 


3. FRANKEL, A. Zur Klinik der Lungen- und Pleurageschwiilste. Deutsche 


4. 


med. Wochenschr., 1g11, Nr. 11. 
FRANK. Uber die Behandlung der Thoraxempyeme nach Biilau. Med. 
Kilin:. 19oprs Na ae 


Aas GESELSCHAP. Uber die Behandlung der serésen Pleuritis mit Luftein- — 


5. 


blasung. Die Therapie der Gegenw art, 1910. Septemberheft. 
HocHuHaus. Indikation und Technik der. Pleurapunktion. Deutsche 
med. Wochenschr., 1909, Nr. 42. 


6. HOLMGREN. Ausblasung anstatt Aspiration von Pleuraergiissen. Mit- 


teilungen aus den Grenzgebieten der Med. und Chir., 1910, Bd. 22, 


jel ze 


eZ) 


10. 


LIST OF AUTHORITIES 515 


_ KONIGER. Beitrage zur Klinik und Therapie der tuberkulésen Pleuritis. 


Zeitschrift fiir Tuberkulose, Bd. 17, H. 6, und Bd. 18, H. 5. 
SACCONAGHI. Die interlobare exsudative Pleuritis. Wiirzburger Abhand- 
lungen, Bd. 10, H. 7. 
ScHMIDT, E. Heberdrainage mit Aspiration zur Behandlung tuber- 
kuléser Pleuraempyeme. Miinch. med. Wochenschr., 1909, Nr. 15. 
STINTZING. Behandlung der Erkrankungen des Brustfells und des 
Mittelfellraumes. Handbuch der spez. Therapie inn. Krankheiten 
von Penzoldt und Stintzing. Jena, 1909. Verlag von G. Fischer. 


11. — Pleuritis. Deutsche Klinik, Bd. 4. 


No 


aS 


2 a ts 


12. 


to 


TREUPEL. Der Pneumothorax und seine Behandlung. Deutsche med. 
Wochenschr., 1910, Nr. 15 


_ UNVERRICHT. Experimentelles und Therapeutisches tiber den Pneumo- 


thorax. Deutsche Klinik, Bd. 4. 


-__ Die klinische Erscheinungsform des Pneumothorax. Deutsche 


Klinik, Bd. 4. 

WENCKEBACH. Uber die Behandlung der chronischen Empyems mit 
kiinstlichem Pneumothorax.. Niederlandische Zeitschr. f. Heil- 
kunde, 1909, Nr. Io. 


_Witp. Ein Fall von Pleuritis diaphragmatica. Korrespondenzbl. f. 


Schweizer Arzte, 1899, Nr. 16. 


_ ZUELZER. Pleuritis diaphragmatica suppurativa. Miinch. med. W ochen- 


schr., 1898, Nr. 47. 


IV. Tuberculosis of the Upper Air Passages. 


_ BLUMENFELD. Die Tuberkulinbehandlung der Tuberkulosen der oberen 


Luftwege bei Erwachsenen. Zeitschr. f. Laryngologie, Rhinologie 
und ihre Grenzgebiete, 1911, Bd. IV, H. 4. 

EPHRAIM. Ungiftige Schleimhautandsthesie. Monatsschr. f. Ohren- 
heilkunde u. Laryngo-Rhinologie, 1o11, H. 09. 

FELLNER. Weiterer Beitrag zur Kehlkopfschwindsucht der Schwangeren. 
Miinch. med. Wochenschr., 1905, Nr. 1 


4. 
_ GRUNWALD. Die Therapie der Kehlkopftuberkulose. Miinchen, 10907. 


Verlag von J .F. Lehmann. 


/ HARTMANN. Zur Behandlung der Larynxtuberkulose. Verhandlungen 


des Vereins Deutscher Laryngologen, 1911. Wiirzburg, 1911. Verlag 
von C. Kabitzsch. 


._ HEYMANN. Handbuch der Laryngologie und Rhinologie. Wien, 1808. 


Verlag von A. Holder. 


. JURASZ.” Die Krankheiten der oberen Luftwege. Heidelberg, 1802. 


Verlag von K. Winter. 


_— Die Behandlung der Larynxtuberkulose. Deutsche med. Wochen- 


schm, 1607, Nr. 27. 


_ Kian. Uber die Behandlung der Kehlkopftuberkulose. Deutsche 


med. Wochenschr., 1912, Nr. 13 


_ MEYER, ED. Zur spezifischen und ‘Yokalen, Behandlung der Kehlkopf- 


tuberkulose. Verhandlungen des Vereins Deutscher Laryngologen, 
igit. Wiirzburg, roll. Verlag von C. Kabitzsch. 

ScumipT, M. Die Krankheiten der oberen Luftwege. Berlin, 1897. 
Verlag von Jul. Springer. 

Verhandlungen des Vereins Deutscher Laryngologen, 1911. Wiirzburg, 


1git. Verlag von C. Kabitzsch. 


V. Tuberculosis of the Digestive Organs. 


_ BANDELIER. Die Tonsillen als Eingangspforten der Tuberkelbazillen. 


Beitrage z. Klinik der Tub., Bd. 6 


___ Uber den Wert der Laparotomie bei Bauchfelltuberkulose. Beitrage 


z. Klin. d. Tub., Bd. 2. 


_ CURSCHMANN, H. Klinischer Beitrag zur Tuberkulose des Pylorus. 


Beitrage z. Klinik d. Tub., Bde 2: 


- DOERFLER. Die Bauchfeiltuberkulose und ihre Behandlung. Tubingen, 


1902. Verlag von Laupp. 


_ FLEINER. Durchfall, Darmkatarrh und Darmtuberkulose. Deutsche 


Klinik, Bd. s. 


516 : A CLINICAL SYSTEM OF TUBERCULOSIS 


6. 


Fhe 


Oo 


GRUNWALD. Atlas und Grundriss der Krankheiten der Mundhohle, des 
Rachens ‘und der Nase. J. F. Lehmanns med. Atlanten, Bd. 4. 
HILDEBRANDT, W. Uber die Beziehungen von Leberfunktion und Leber- 
kranheiten zur Tuberkulose. Intern. Zentralblatt f. d. gesamte 

Tuberkuloseforschung. IV. Jahrg., Nr. 


. HOFMANN, A. Uber die Pinselung des Bacitells mit Jodtinktur bei 


der tuberkulésen Peritonitis. Minch. med. W ochenschr., 1912 
Nr. Io. 


. KUDREWATZKY. Uber Tuberkulose des Pankreas. Prager Zeitschrift 


fiir Heilk., 1892. 3 
KUMMEL. Beitrag zur Kenntnis der tuberkuldsen Erkrankung des 
- Osophagus. Miinch. med. Wochenschr., 1906, Nr. to. 


. RUGE. Uber primaire Magentuberkulose. Beitrage z. Klin. d. Tub., 


Bide 

v. SCHROTTER, H. Zur’ Kenntnis der Tuberkulose des Osophagus. 
Beitrage z. Klin. d. Tub., Bd. 6. 

SIMMONDS. Uber Tuberkulose des Magens. Miinch. med. Wochen- 
schr., 1900, Nr. 10. 

STIERLIN. Die Radiogr aphie in der Diagnostik der Ileocékaltuberkulose 
und anderer Krankheiten des Dickdarms. Minch. med. Wochen- 
schr, tora, Nie 22% 

STRUPPLER. Uber das tuberkuldse Magengeschwir. Zeitschr. f. Tub., 
Bd. 


: Nictawadieneen des XIV. Kongresses der Deutschen Gesellschaft fiir 


Gynakologie (Bauchfelltuberkulose). Miinchen, 7-10 Juni, 1911. 

WEBER, A. Uber einen Fall von primarer Mundtuberkulose durch 
Infektion mit Perlsuchtbazillen. Mitinch. med. Wochenschr., 1907, 
Ni 36; 


VI. Tuberculosis of the Urinary and Genital Organs. 


BARTH. Uber Nierentuberkulose. Deutsche med. Wochenschr., 1911, 


Nig 25. 
V. BAUMGARTEN and KRAEMER. Experimentelle Studien tiber Histogenese 
und Ausbreitung der Urogenitaltuberkulose. Arbeiten auf d. 


Gebiete der path. Anat. u. Bakt., 1903, Bd. 4. 

CASPER. Die Tuberkulose der Harnblase und ihre Behandlung. 
Deutsche Klinik, Bd. 10. Zeitschr. f. Tub., Bd. 3. Deutsche med. 
Wochenschr., 1900, Nr. 41 u. 42 u. 1910, Nr. 46. 

- Lehrbuch der Urologie. Berlin u. Wien, 1910. Verlag von Urban 
u. Schwarzenberg. 

FELLNER. Tuberkulose und Schwangerschaft. Wiener med. Wochen- 

schr., 1904, Nr. 25-27. 


. FRANQUE. Zur Klinik der weiblichen Genitaltuberkulose. Med. Klinik, 


16Ort, INgs 27: : 
FRITSCH. Die Krankheiten der Frauen. Berlin, 1897. Verlag von F. 
Wreden. 


. HeGAR. Die Entstehung, Diagnose u. chirurgische Behandlung der 


Genitaltuberkulose des Weibes. Stuttgart, 1886. Verlag von F. 
Enke. Deutsche med. Wochenschr., 1897, Nr. 45. 


. ISRAEL. Chirurgische Klinik der Nierenkrankheiten. Berlin, 1902. 


Verlag von A. Hirschwald. 


. JORDAN. Zur Pathologie und Therapie der Hodentuberkulose. Beitrage 


Z Kin. de fubsBds 1 


. KLIENEBERGER. Uber die Urogenitaltuberkulose des Weibes. Inaug.- 


Diss., Kiel, 1890. 


. KRAEMER. Uber die Ausbreitung und Entstehungsweise der mannlichen 


Urogenitaltuberkulose. Deutsche Zeitschr. f. Chirurgie, Bd. 60. 


. V. LICHTENBERG and DIETLEN. Die Nierentuberkulose im Rontgenbilde. 


Mitteilungen aus den Grenzgebieten der Medizin u. Chirurgie, 1911, 
Bde 2s, ie srt. 


. MOSLER. Die Tuberkulose der weibl. Genitalien. Inaug.-Diss. Bres- 


lau, 1883. 

PANKOW and KUPFERLE. Die Schwangerschaftsunterbrechung bei 
Lungen- und Kehlkopftuberkulose. Leipzig, 1911. Verlag von G. 
Thieme. 





to 


LIST OF AUTHORITIES 517 


. POSNER. Infektionswege der Urogenitaltuberkulose. Zeitschr. f. Tub., 


Bd. 2. . Miinch. med. Wochenschr., 1900, Nr. 20. 


. SENATOR. Die Erkrankungen der Nieren. Nothnagels spez. Path. u. 


Ther. Wien, 1902. Verlag von A. Holder. 


. SENATOR and KAMINER. Krankheiten und Ehe. Miinchen, 1905. Verlag 


von J. F. Lehmann. 


. SIMMONDS. Uber Tuberkulose des Méannlichen Genitalapparates. 


Arch. f. klin. Med., 1886, Bd. 38. 


. STOECKEL. Zur Diagnose und Therapie der Blasen- und Nicrentuber: 


kulose bei der Frau. Beitrage z. Klin. d. Tub., Bd. 1. 


. TEUTSCHLAENDER. Die Samenblasentuberkulose und ihre Beziehungen 


zur Tuberkulose der iibrigen Urogenitalorgane. Beitrage z. Klin. 
d: Duby, Bd: 3 


. VEIT. Handbuch der Gynikologie. Wiesbaden, i910. Verlag von 
. fo} fo) 


J. F. Bergmann. 


. WEINBERG. Die Beziehungen zwischen der Tuberkulose noe bee anger- 


schaft, Geburt und Wochenbett. Beitrige z. Klin. d. Bd. 


. — Lungenschwindsucht beider Ehegatten. Beitrage z. Klin “d. Tube 


Bd. s. 


VII. Tuberculosis of the Vascular and Lymphatic Systems. 


. ARNETH. Die neutrophilen weissen Blutkérperchen bei Infektionskrank- 


heiten. Leipzig, 1904. 


. BRECKE. Zur Diagnose von Schwellungen ng endothorakalen Lymph- 


driisen. Beitrage z. Klin. d. Tub., Bd. 


. FRANKE. Uber die. primare Tuberkulose "ace Milz. Deutsche med. 


Wochenschr., 1906, Nr. 41. 


. Grav. Die Wechselbeziehungen zwischen der Lungentuberkulose und 


Erkrankungen des Herzens und der Gefasse. Intern. Zentralbl. f. 
Tuberkuloseforschung. ‘5. Jahrg., Nr. 5, 6, 8. 


5. FRAENKEL, EuG. Uber die sog. Hodgkinsche Krankheit. Deutsche med. 


ioe) 


Wochenschr., 1912, Nr. 14. 


. KURASHIGE. U ber das Vorkommen des Tuberkelbazillus im stromenden 


Blute der Tuberkulésen. Zeitschr. f. Tuberkulose, Bd. XVII., 


nel 
. LIEBERMEISTER. Der Nachweis der Tuberkelbazillen im _ kreisenden 


Blute. Verhandlungen des 24 Kongresses fiir innere Medizin, 10907. 
Miinch. med. Wochenschr., 1908, Nr. 36. 


. -— Studien tiber Komplikationen der Lungentuberkulose und tiber die 


Verbreitung der Tuberkelbazillen in den Organen und im Blute der 
Phthisiker. Virchows Archiv., Bd. 197, H. 3, S. 332. 


. PERMIN. Primadre Milztuberkulose. Hospitalstidende, 1909, Nr. 37. 
. SCHNITTER. Nachweis und Bedeutung der Tuberkelbazillen im str6men- 


den Phthisikerbilut. Deutsche med. Wochenschr., 1909, Nr. 36. 


_ SCHULZE, W. H. Uber Endocarditis tuberculosa parietalis. Zentralbl. 


feclligabath= uw: pathy Anat... Bd- 172 


. SCUGLIOSI. [solierte tuberkulése Perikarditis. Deutsche med. Wochen- 


schr., 1904, Nr. 24. 


. SORGO and Suess. Uber Endokarditis bei Tuberkulose. Wien. klin. 


Wochenschr., 1906, Nr. 7. 


_ Vv. ZEBROWSKI. Uber die subkutanen Lymphdriisen des Thorax bei 


Lungentuberkulose. Deutsche med. Wochenschr., 1910, Nr. 28. 


VIII. Tuberculosis of the Skin. 


. BANDELIER. Zur Heilwirkung des Tuberkulins. Heilung eines Lupus 


durch pean eters Beitrige zur Klinik d. Tub., Bd. 
Wale, HI. 


_ JESSNER. Dent iee che Vortrase fur “Praktiker. Hi 21. “Wairz- 


burg, 1909. Verlag von C. Kabitzsch. 


. KONIGSFELD. Uber den Durchtritt von Tuberkelbazillen durch die 


unverletzte Haut. Zentralblatt fiir Bakteriologie, Parasitenkunde 
und Infektionskrankheiten, Bd. 60, H. 1 u. 2. 

LANG. Der Lupus und dessen operative Behandlung. Wien, 1808. 
Verlag von Josef Safar. 


518 A CLINICAL SYSTEM OF TUBERCULOSIS 


6. 


NI 


oo 


> oo) 


. LEICHTENSTERN. Akute Miliartuberkel der Haut. Miinch. med. 


Wochenschr., 1897, Nr. 1. 
MRACEK. Handbuch der Hautkrankheiten. Wien, 1904. Verlag von 
A, Holder. 


. NAGELSCHMIDT. Die Behandlung des Lupus und der Schleimhaut- 


tuberkulose mittels Diathermie. Verhandlungen der III. Sitzung 
des Lupus-Ausschusses des Deutschen Zentralkomitees zur Bekaimp- 
fung der Tuberkulose. Berlin, tort. 

PaAyR. Behandlung des» Lupus von der Subkutis aus. Deutsche Zeitschr. 
f; ‘Chir. 1606; (Bd5 too: 

SPITZER and JUNGMANN. Ergebnisse von 240 operierten Lupusfallen. 
Wien, 1905. Verlag von Josef Safar. 


. ZIELER. Toxische Tuberkulosen der Haut. Arch. f. Dermat. u. Syph., 


Bd: 102: 


IX. Tuberculosis of the Organs of Locomotion. 


. Horra. Die Bekampfung der Knochen- und Gelenktuberkulose im 


Kindesalter. Tuberkulosis, Bd. 4. i 
Kapp. Die Heilkrafte der Hyperamie. Deutsche Klinik, Bd. 11. 


. — Die konservative Behandlung der chirurgischen Tuberkulose. 


Deutsche med. Wochenschr., 1909, Nr. 40. 

KONIG, F. Die Geschichte der Entwicklung der Gelenktuberkulose. 
Deutsche Klinik, Bd. 8. 

KRAEMER. Zur Tuberkulinnachbehandlung der chirurgischen Tuber- 
kulose. Med. Klinik, 1908, Nr. 4. 

LANGE. Spondylitis. Jahreskurse fiir arztl. Fortbildung, 1910. Sep- 
temberheft. 

LAuB. Ein Beitrag zur Frage des akuten tuberkulésen Rheumatismus. 
Zertschr, ft. -hubs, Bde-7: 

LUDLOFF. Wann und unter welchen Bedingungen hat die operative 
oder konservative Behandlung der chirurgischen Tuberkulose Platz 
zu greifen? 16. Internat. med. Kongress in Budapest. 

PONCET and LERICHE. Le Rhumatisme tuberculeux. Paris, 1909. 


. SCHAEFFER. Rezidivierende tuberkulése Polyarthritis. Zeitschr. f. 


Tub. Bde 33: 


. STEWART. Tuberculosis of bursal and tendon sheaths. Amer. Med., 


1906. April. 


. STRAUSS, M. Uber den tuberkulésen Rheumatismus der Franzosen. 


Med. Klinik, 1910, Nr. 23. 


. TILLMANNS. Lehrbuch der allgemeinen Chirurgie. Leipzig, 1893. 


Verlag von Veit and Co. 


. WETTSTEIN. Erfahrungen mit der Jodoformknochenplombe nach v. 


Mosetig-Moorhof. Med. Klinik, 1912, Nr. 5 u. 6 


. WILMS. Die Tuberkulintherapie _ bei chirurgischer Tuberkulose. 


Deutsche med. Wochenschr., 1911, Nr. 36. 


X. Tuberculosis of the Nervous System. 


. BONNINGER and ADLER. Intraduraler Konglomerattuberkel des Riicken- 


marks. Mediz. Klinik, 1911, Nr. 18 u. 10. 


. CASSIRER. Neuritis und Polyneuritis. _Deutsche Klinik, Bd. 6. 
. FISCHER. Uber tuberkulése Meningitis. Miinch. med. Wochenschr., 


1910, Nr. 20. 


. HEINZELMANN. Die Psyche der Tuberkulésen. Miinch. med. Wochen- 


schr., 1894, Nr. 5. 


. HENSCHEN. Behandlung der Erkrankungen des Gehirns und seiner 


Haute. Handbuch der spez. Therapie inn. Krankh. von Penzoldt 
u. Stintzing. 19009, Bd. 5. 


. JESSEN. Lungenschwindsucht und Nervensystem. Jena, 1905. Verlag 


von G. Fischer. 


. KGHLER. Tuberkulose und Psyche. Med. Klinik, torr, Nr. 47. 
. STEINERT. Zur Kenntnis der Polyneuritis der Tuberkulésen. Beitrage 


Zz Klin.-d. “Pub "Bd>s2- 


. Voss. Tuberkulose und Nervensystem. Med. Klinik, 1911, Nr. 24. 
. WEYGANDT. Der Seelenzustand der Tuberkulésen. Med. Klinik, 1912, 


NT 3) ul Ae 


LIST OF AUTHORITIES 519 


XI. Tuberculosis of the Eye. 


1. BACH, v. Grafes Archiv f. Ophthalmologie, Bd. 41. 


un 


= ( 


10. 


ie) 


ut 


. BRIBAK. Klinische und mikroskopische Beitrage zur Haufigkeit, sowie 


zur. Diagnose und Therapie der Trinensacktuberkulose. Klin. 
Monatsbl. f. Augenheilkranke, 1g1t. 


. Davips. Tuberkulinbehandlung§ der Husentubeskelee Klinische 


Monatsbl. fiir Augenheilkunde, 1909, Bd. 47. v. Grafes Archiv fiir 
Ophthalmol., Bd. 60. 


_ ENSLIN. Uber die ane iosicehe Verwertung des Alttuberkulins bei der 


Keratitis parenchymatosa. Deutsche med. Wochenschr., 1908, Nr. 
8 u. 


Q. 
. Fucus. Lehrbuch der Augenheilkunde. Leipzig u. Wien, 1897. Verlag 


von F. Deuticke. 


. GROENOUW and UHTHOFF. Beziehungen der Allgemeinleiden und 


Organerkrankungen zu Verdnderungen und _ Krankheiten des 
Sehorgans. Graefe-Saemischs Handbuch der gesamten Augen- 
heilkunde. Leipzig, 1904. Verlag von W. Engelmann. 


. V. HippeL. Tuberkulinbehandlung der Augentuberkulose. v. Grafes 


Archiv f. Ophthalmologie, Bd. 50. 


. Komoto. Ein bemerkenswerter Fall von Netzhauttuberkulose. Klin. 


Montsbl. f. Augenheilkunde, tott. 


. SCHIECK. Klinische und experimentelle owes uber die Wirkungen des 


Tuberkulins auf die Iristuberkulose. . Grafes Archiv f. Ophthal- 
mologie, Bd. 50. 

SCHOELER, F. Tuberkulin bei der Augentuberkulose. Klinisches Jahr- 
buch, 1909, Bd. 


XII. Tuberculosis of the Ear. 


. HAIKE. Die Fortschritte auf dem Gebiete der Tuberkulose des Ohres. 


Tuberkulosis, Bd. 4. 


. HENRICI. Die Tuberkulose des Warzenfortsatzes im  Kindesalter. 


Habilitationsschrift. Wiesbaden, 1904. 


. HERZOG. Klinische Beitrage zur Tuberkulose des mittleren und inneren 


Ohres. Beitrage z. Klin. d. Tub., Bd. 7. 


. JACOBSON and BLAvu. Lehrbuch der ‘Ohrenheilkunde. Leipzig, 1902. 


Verlag von Georg Thieme. 


. JANSEN. Die Entziindung des Mittelohrs und ihre Behandlung. 


Deutsche Klinik, Bd. 8. 


. Verhandlungen der Deutschen otologischen Gesellschaft in Frankfiirt a- 


M., to11. Jena. Verlag v. G. Fischer. 


XII. Miliary Tuberculosis. 


. CORNET. Die Tuberkulose als akute Infektionskrankheit. Deutsche 


Klinik, Bd. 2 


. V. HANSEMANN. Die Grodsse der Knoten bei akuter und chronischer 


=) as Zentr.-Blatt' fiir allg. Path. u. path. Anat., 
d 


_ LIEBERMEISTER. Uber verschiedene histologische Erscheinungsformen 


der Tuberkulose. Bericht d. XXVI. Kongr. f. innere Med., 1900. 


. RIBBERT. Uber die Miliartuberkulose. Deutsche med. Wochenschr., 


T1900, Nr. 1. 


. SILBERGLEIT. Beitrage zur Entstehung der akuten allgemeinen Miliar- 


tuberkulose. © Virchows Archiv., Bd. 1709. 
peeeet Die Miliartuberkulose.. Deutsche med. Wochenschr., 1897, 
r. 48. 


XIV. Scrofula. 


BIEDERT. Behandlung der Skrofulose. Handbuch der speziellen Therapie 
innerer Krankheiten von Penzoldt u. Stintzing. Jena, 1909. Verlag 
von G. Fischer. 


. CORNET. Die Skrofulose. Nothnagels  spezielle Pathologie una 


Therapie. Wien, 1900. Verlag von A. Hdlder. 


- w& 


ul 


13 


14. 


520 A CLINICAL SYSTEM OF. TUBERCULOSIS 


. Monti. Skrofulose. -Kinderheilkunde in Einzeldarstellungen. Berlin 


u. Wien, 1899. 

SALGE. Skrofulose. Handbuch der Kinderheilkunde von Pfaundler und 
Schlossmann. Leipzig, 1910. Verlag von F. C. W. Vogel. 

SITTLER. Klinische Betrachtungen itiber Skrofulose. Wirzburger Ab- 
handlungen, Bd. 9. Heft 11. 

SOLTMANN. Skrofulose und Tuberkulose der Kinder. Deutsche Klinik, 
Bids 7: 


XV. Tuberculosis in Childhood. 


. Dautwiz. Uber Diagnose und spezifische Behandlung der latenten endo- 


thorakalen Driisentuberkulose des kindlichen Alters. Beiheft z. 
» Med. Klinik, 1908, H. rr. 


. ENGEL. Die Pathologie der Kindertuberkulose. Beiheft z. Med. Klinik, 


1909, H. 11. 


. — Die (spezifische) Diagnose und Therapie der Kindertuberkulose. Med. 


Klinik, 1910, Nr. 10 u. 11. 


. HAMBURGER. Allgemeine Pathologie und Diagnostik der Kindertuber- 


kulose. Leipzig, 1910. Verlag von F. Deuticke. 

— Zur praktischen Diagnostik der Kinderpleuritis. Miinch. med. 
Wochenschr., 1911, Nr. 24. 

HEUBNER. Tuberkulosebekampfung im_ Kindesalter. Denkschrift d. 
deutsch. Zentralkomitee zum Internat. Tub.-Kongress. Paris, 1905. 


. Kiapp. Der Erwerb der aufrechten Korperhaltung und seine Bedeutung 


fiir die Entstehung orthogenetischer Erkrankungen. Miinch. med. 
Wochenschr., 1910, Nr. 11 u. 12. 

KoTHS. Meningitis der Kinder und Hydrocephalus. Deutsche Klinik, 
Bd. 7. 

MONTI. Tuberkulose. Kinderheilkunde in Einzeldarstellungen. Berlin 
und Wien, 18099. 

Moro.  Skrofulose. Jahreskurse fiir 4rtzl. Fortbildung,  1g1o. 
Juniheft. 


. POLLAK. Uber Sauglingstuberkulose. Beitrage zur Klinik der Tuber- 


kulose, Bd. 19, H. 2. 


. ROEMER. Weitere Versuche iiber Immunitét gegen Tuberkulose, 


zugleich ein Beitrag zur Phthiseogenese. Beitrage z. Klin. d. Tub., 
Bd. 13. 

SCHLOSSMANN. Die Tuberkulose im friihen Kindesalter. Beitrage z. 
Klin. dd: Pub: Bd: 6. 

TieETzZE. Die Behandlung der chirurgischen Tuberkulose im Kindesalter. 
Med. Klinik, 1908, Nr. 12. 


INDEX. 


ABORTION, induction of, 337 
Acne cachecticorum, 384 
Acnitis and folliclis, 383 
Actinomycosis of the lungs, 
Active immunization, 116 
Addison’s disease, 322 
Adiposity in pulmonary 
III, 166 
Adrenals, tuberculosis of the, 322 
Aerogenic infection, 6 
Etiology of tuberculosis, 
Age and tuberculosis, 94 
Agglutination test, 77 
Air baths, 104 
passages, 
232-262 
Albumen in the diet, 112 
— reaction in the sputum, 66 
Albuminuria in pulmonary 
culosis, 34 
-—, orthostatic, 34 
—; toxic, 316 
Alcohol and the diet, 114 
Alcoholism and tuberculosis, 
Alopecia, 365 
Ambulant treatment 
tuberculosis, 182 


86 


tuberculosis, 


I-17 


tuberculosis of 


upper, 


tuber- 


170, 192 


of pulmonary 





— — with tuberculin, 
Anaphylaxis, 78 
Animal experiments, 68, 210, 318 
— —, gland crushing of Bloch, 68 
—  —, intra-hepatic inoculation, 68 | 
Antibacillary prophylaxis, 186-1090 | 
Antiformin-ligroin method, 63 
Antiformin method, 61 | 
| 


185, 500 


Arsenic preparations, 132 
Arterial rigidity, juvenile, 347 
Artificial pneumothorax, 
Aspiration, see Puncture 
Asthma, 80 
Auscultation, 54-60 
Auto-sero-therapy in pleurisy, 221 
Auto-transfusion position of Jacoby, 
102 


124 


BACTERIOLOGICAL diagnosis, 60-69 

Balsam of Peru, 131 

Bandaging the limbs for hemoptysis, 
158 

Bloch’s gland crushing, 68 

Blood changes in pulmonary 
culosis, 32, 70, 342 


tuber- 


Blood, tubercle bacilli in the, 77, 96, 


343 
Blood-vessels, tuberculosis of, 345 
Bones, tuberculosis of, 395, 407, 503 
Bovine tubercle bacilli, 8, 282, 290, 
485 
Brain, tuberculosis of, 423 
Breast, tuberculosis of, 332 
Breathing exercises, 105, 221 
Breathlessness, 26, 162 
Bronchial elands, tuberculosis 
Se Shays 489 
Bronchiectasis, 19, 82 
Bronchi, tuberculosis of, 
Bronchitis, caseous, 20 
==, chronic; 80 
—, tubercular; 19 
Biilau’s syphon drainage, 
Burse, tuberculosis of, 301 


262 


PIGS? 3 
-=) 


C.-£cuM, see Ileo-cecal tuberculosis 

Calories required in the diet, 112 

Cancer of the lung, 83 

pleura, 207 

Caseous bronchitis, 20 

— hepatization, 20, 38 

-- nodules in the lung, 18 

Cavities, bronchiectatic, 19 

—, tubercular, 20, 23 

Central nervous system, changes 
pulmonary tuberculosis Pain 

— — —, tuberculosis of, 417-436 

Cervical glands, tuberculosis of, 356 

Chalazion, 448 

Character, changes of, 
97, 430 

Childbirth and tuberculosis, 334 

Childhood, tuberculosis in, 484-510 

Chloasma phthisicorum, 364 

Chondrotomy for pulmonary 
culosis, 122 

Choroid, tuberculosis of, 445 

Ciliary body, tuberculosis of, 442 

Cinnamic acid, 

Circulation and bercaieee 345 

Circulatory organs, alterations 
pulmonary tuberculosis, 3203 

Climatic treatment of tuberculosis, 
139-148, 500 

Clinical forms of pulmonary 
culosis, 87-91 

Cobra poison test, 78 


in 


in tuberculosis, 


tuber- 


in 


tuber- 


22 


Collapse induration of apex of lung, 


Si 232 
Complement fixation, 78 
Complications in pulmonary tuber- 


culosis, 97, 150-171 
Conjunctiva, tuberculosis of, 437 
Conjunctival tuberculin test, 70, 450 | 
Constitution and tuberculosis, 91 | 
Cornea, tuberculosis of, 439 
Couch, 235 1554. 187 
Crawling treatment of Klapp, 
Creosote preparations, 130 
Cutaneous tuberculin test, 69, 450 


508 





| 

Cyto-diagnosis of pleural effusions, | 
210 | 
DESERT climates, 144 ; 
Diabetes and tuberculosis, 165 | 


Diagnosis of pulmonary tuberculosis, 
41-86 
—, physical, 41 

—  —, bacteriological, 60 | 

by tuberculin, 69 | 

by Rontgen rays, 73 

by various methods, ae 

differential, 79 

Diapheseuiane phenomenon of Litten, 

43 
Diarrhoea, toxic, in pulmonary tuber- 
culosis, 34, 165 


Diathermic treatment of WNagel- 
schmidt, 259, 379 

Diazo reaction, 34, 95 

Dietetic treatment of pulmonary 
tuberculosis, 110-116 


— — intestinal tuberculosis, 286 
— — scrofula, 480 


Digestive organs in pulmonary tuber- 


culosis, 92 
—  —, non-tubercular changes of, 33, 
163 
— —, tuberculosis of, 263-303 
Dioradin. 133 


Disinfection of the dwelling, 188 

Dispensaries for tuberculosis, 184 

Douches in pulmonary tuberculosis, 
108 

Drug treatment of pulmonary 
culosis, 130-134 

Dyspepsia and tuberculosis, 33, 163 

Dy spnoea, see Breathlessness 


tuber- 


EAR, tuberculosis of the, 452-465 

Effusion, pleural, see Tuberculosis of 
the pleura 

Elastic fibres in the sputum, 24, 64, 


Emphysema, 20, 80 


Empyema, pleural, tubercular, 201, 
208, 222 | 
Endarteritis, tubercular, 345 | 


Endocarditis, tubercular, 351 

Enteritis in pulmonary tuberculosis, 
266 

Enterogenous infection, 7 


INDEX 


Eosinophile cells in thé sputum, 64, 


05 
Epididymis, tuberculosis of, 319 
Erythema, 382 
induratum, 385 
Eustachian tube, tuberculosis of, 457 
Exercise in the treatment of pul- 
monary tuberculosis, 103 
Expectoration, see Sputum 
Extra-pleural thoracoplasty, 127 
— in empyema, 223 
Exudative diathesis, 475 
Eye, tuberculosis of, 437-451 


FALLOPIAN tube, tuberculosis of, 327 

Fat in the diet, 112, 480 

Fever in pulmonary tuberculosis, 27, 

. 94) 150, 

Fistula, ischio-rectal, 279, 281, 
from the bones and _ joints, 
403 

+ glandular, 353, 357 

Finsen’s light treatment, 378 


289 
395, 


Flies as carriers of infection, 190 
Folliclis and acnitis, 383 
Formaldehyde disinfection, 188 


Frictions, moist and dry, 107 


GALL-BLADDER, tuberculosis of, 294 

Gastritis, acute and chronic, 264 

Gelatine injections for haemorrhage, 
159 

Glands in pulmonary tuberculosis, 46, 


303 

Goldscheider’s topography of the apex 
of the lung, 40 

Gout and tuberculosis, 167 

Granules of Much, 3, 65, 362 

Grape cure, 150 

Graphic record of physical signs, 59 

Grocco’s triangle, 206 

Guaiacol preparations, 130 

H 4 MATOGENOUS infection, 6 

Hzemoptysis, 21, 24, 37, 04 

—, treatment of, 157-162 

Handkerchiefs and expectoration, 187 

Health resorts and pulmonary tuber- 
culosis, 139, 178 

— in tuberculosis of childhood, 500 

Heart and tuberculosis, 346 

—- alterations of, in pulmonary tuber- 
culosis, 32, 54, 346 

Hepatization, caseous, of the lung, 20, 
38 

Heredity and tuberculosis, 9, 91 

Hernial sac, tuberculosis of, 302 

Hetol, 131 

Hilus changes and the R6ntgen rays, 
75 

Histology of tubercles, 4 

History of the patient in pulmonary 
tuberculosis, 40 

History of tuberculosis, 1 

Hoarseness in pulmonary tuberculosis, 
26 


INDEX 


Hodgkin’s disease, 362 

Home treatment of pulmonary 
culosis, 182 

a ine Gail dhoods, 500 

Hospital’ treatment of pulmonary 
tuberculosis, 180 

— — — — in childhood, 500 

House disinfection, 188, 505 

Housing and tuberculosis, 192 

Hydatid disease of the lung, 85 

Hydrotherapeutics and pulmonary 
tuberculosis, 106 

Hygienic and dietetic treatment of 
pulmonary tuberculosis, 98 


tuber- 


ILEO-C-ECAL tuberculosis, 279, 281, 285, 
289 

Immunity and race, 16 

Immunization, active, 116 

—, passive, 116 

Indicanuria in children, 34 

Induration of the lung, 19 

— of the apex of the lung according 
to Kroénig, 81 

Infants, tuberculosis of, 486, 488 

Infection, aerogenous, 6, 485 

—, hematogenous, 6 

—, enterogenous, 7, 485 

—, ante-natal, 10 

—, placental, to 


— from tubercular cattle, 190, 290, 
505 

— from the food, 190, 290 

— in childhood, 485, 505 

Inhalation treatment of pulmonary 


tuberculosis, 134 

— — laryngeal tuberculosis, 252 

— tuberculosis, 18 

Inoculation experiments, see Animal 
experiments 

Inoscopy, 210 

Inspection in pulmonary tuberculosis, 
41 

Intestinal changes in pulmonary 
tuberculosis, 33, 163, 266 

Intestine, tuberculosis of, 278-201 

Intra-hepatic inoculation of Oppen- 
heim, 68 

Iodine preparations, 133 

Iris, tuberculosis of, 442 

Ischio-rectal abscess, 279, 281, 289 

Isolation of tubercular patients, 188, 


190 

— of healthy children in open-air 
_ colonies, 507 

Italian lakes, 144 


JOINTS, tuberculosis of, 393-411 
— —, in childhood, 497, 502 


KEFIR treatment, 150 

Kidney, tuberculosis of the, 316-322 
—, non-tubercular changes in the, 316 
Kronig’s areas of resonance, 50 
Kihn’s mask, 138 


On 
to 
(oe) 


LABYRINTH, tuberculosis of, 462 

Lachrymal apparatus, tuberculasis of, 
448 

Larynx, catarrh of, 233 

==, lupus of, 244, 248; 251, 201 

—, syphilis of, 250 

—, swelling of, non-tubercular, 249 

—, tuberculosis of, 240-262, 340 

Lichen scrofulosorum, 368 

Ligno-sulphite inhalations, 136 

Ligroin antiformin method, 63 

Liver, fatty degeneration of, 266 

—, amyloid degeneration, 267 

=, CLErhosis ois 26755202 

—, tuberculosis of, 292 

Locomotion, tuberculosis of 
of, 390-416 

Loéffler’s chloroform method, 63 

Lumbar puncture in meningitis, 428, 
420 

Lung, abscess of, 82 

—, actinomycosis of, 86 

—, contraction of, 39 

—, echinococcus of, 85 

—, gangrene of, 82 


organs 


, syphilis of, 82 
, tuberculosis of, 18-194 
—, tumours of, 83 
Lupus erythematodes, 386 
— pernio, 386 
— vulgaris, 371-380 
— of the larynx, 244, 248, 251, 261 
— of the nose, 236 
— of the naso-pharynx, 238 
— of the throat, 272 
Lymphatic glands, tuberculosis of, 46, 
352, 492 
Lymphatic system, tuberculosis of, 352 
Lymphatism, 475 
Lymphocytic sputum, 79 


MARRIAGE and tuberculosis, 191, 334 
Mastoid process, tuberculosis of, 45 
Mediastinal tumour, 207 
Meningitis, tubercular, 425, 405 
Menstruation, alterations of, 323 
Mental disease in tubercular patients, 


7 


434 
Mesenteric glands, tuberculosis of, 
355, 491 


Middle ear suppuration in pulmonary 
tuberculosis, 453 

-— —, tuberculosis of, 454 

Miliary tuberculosis, 466-472 

— — in childhood, 495 

OL stnes ane 2m 

Milk and tuberculosis, 113, 290, 505 

Mineral waters, 148 

Mixed infection in pulmonary tuber- 
culosis, 21, 24, 65 

Mountain climates, 140 

Mouth, tuberculosis of, 267 

—, lupus of, 268 

—, non-tubercular affections of, 261 

Much’s granules, 3, 65. 362 


524 


Muscle, tuberculosis of, 390 
Muscular changes in tuberculosis, 35, 


HA ad 
Myocarditis, tubercular, 350 


NAILS, alteration of, in see 365 
Naso- pharynx, catarrh of, 
tuberculosis of, 238 

see Tumour 
alterations 


’ 
Neoplasms, 
Nervous. system, 

phthisis, 35 
— —, tuberculosis of, 417-436 
Neuritis, tubercular, 417 
Neuroses and tuberculosis, 431 
New growths, see Tumour 
Night sweats, 31, 154 
North Sea climate, 145, 481, 
Nose, catarrh of, 234 
tuberculosis ye 235 
, lupus of, 236 


of, in 


500 


3 


OBESITY, see Adiposity 

(Esophagus, decubital ulcer of, 263 
—, traction diverticula, 263 

—, tuberculosis of, 274 

Open-air treatment, 100 

Opsonic index, 77 

Optic nerve, tuberculosis of, 448 
Ovary, tuberculosis of, 332 
Over-feeding, 111 


PACKS, chest, 1009 
Palpation in pulmonary tuberculosis, 
4 
Pancreas, tuberculosis of, 2 
Paravertebral resection of 
rib, 124 
Parotid, tuberculosis of, 358 
Passive immunization, 116 
Pectoriloquy, 59 
Percussion, 47 
Percutaneous tuberculin test, 70 
Peribronchitis, tubercular, 19 
Pericarditis, tubercular, 348 


the first 


Perichondritis, tubercular, in the 
larynx, 243 

— —, in the external ear, 453 

Perihepatitis, tubercular, 293 

Periproctitis, tubercular, 281 

Perisplenitis, tubercular, 361 

Peritoneum, ‘tuberculosis of, 295-302 


Persucht bacilli, see Bovine tubercle 


bacilli 
Pharynx, catarrh of, 


=, tuberculosis Pp beer 
lupus of, 

Phosphaturia ee pulmonary _ tuber- 
culosis, 34 

Phthisical build, 4I 

Phthisis, fibroid, 19, 39 


—, chronic induration, 38 
PeLLOTIG aan 

—, pneumonic, 38 

—, atypical, 30 


INDEX 


Physical diagnosis of pulmonary 
tuberculosis, 41-60 
| Pityriasis, versicolor, 364 
—, tabescentium, 364 
Pleura, thickenings of, 196, 204 


, tumour of, 208 

—, tuberculosis of, 22, 76, 195-231 
leurisy, diaphragmatic, co 

—, with effusion, 199, 208, 

—, interlobar, 202 

—, pericardial, 202 


| 
| 
| 
| 
| 


a) dry, 199, 203, 213 

—, tubercular, anatomical changes, 
195 

— —, symptoms and course, 197 

— —-, treatment, 213 

Pneumatic treatment of pulmonary 
tuberculosis, 137 

Pneumoconiosis, 81 

Pneumonia, caseous, 20, 493 

—, aspiration, 20 

—, chronic, &1 

Pneumothorax, artificial, 124 

—, tubercular, 22,70, 9220 

Polyneuritis, tubercular, 418 

Predisposition, 11, 174, 191 

—, inherited, 11 

—, acquired, 13, 103 


local, 13 

general, 15 

mechanical, of the lung apices, 14 
racial, 16 

Pregnancy and tuberculosis, 334-341 
Prognosis in pulmonary tuberculosis, 


86-98 
Prophylaxis of pulmonary tubercu- 
losis, 186-194 


—. intestinal tuberculosis, 290 

— tuberculosis in childhood, 504-516 
Prostate, tuberculosis of, 307 
Pseudo-tubercle bacilli, 4, 64, 86, 306 


Psychical treatment of pulmonary 
tuberculosis, 99 : 
Psychology of tubercular patients, 


3 
Psychoses and psycho-neuroses, 431 
Puerperium and tuberculosis, 338, 471 
Pulse in pulmonary tuberculosis, 6, 
32, 93 
Eu e in pleurisy, 209, 216 
, followed by introduction of gas, 
21Q,, 225 
, followed by washing out, 224 
in sero- and pyo-pneumothorax, 
230 
Pylorus, tuberculosis of, 276 
Pyo-pneumothorax, 226 


RACE and immunity, 16 
Radium treatment, 133, 259, 378, 400 
Rectal fistula, tubercular, 279, 281, 289 
—  polypus, tubercular, 279 
| Resistance, increased and diminished, 
| 13-17, 190, 505 
| Rest treatment, 101 





INDEX 


Retina, tuberculosis of, 448 

Rheumatism, tubercular, 411 

R6ntgen rays in diagnosis, 73 

= treatment’ by, 259, 3025 3575 
3775. 408 


SALINE injections for hemoptysis, 160 
Salivary glands, tuberculosis of, 358 
Salt baths, 481, 500 
= springs inhalations, 137 
Sanatoriums for adult cases of pul- 
monary tuberculosis, 171-177 
for tubercular children, 495 
Schools and tuberculosis, 507 
Sclerotic, tuberculosis of, 441 
Scrofula, 473-483 
Scrofuloderma, 366 
Scrofulo-tuberculosis, 474 
Sea climates, 145 
— voyages, 146 
Sero-pneumothorax, 226 
Serum prognosis of pulmonary 
culosis, 96 
Sex and tuberculosis, 93 
Sexual organs, tuberculosis of, 305- 
334 : : 
Skin, alterations of, in tuberculosis, 
35, 44, 304 
—, tuberculosis of, 364-389 __ 
Sleeplessness, treatment of, 162 
Social conditions and tuberculosis, 97 
Soft soap inunctions, 501 
Specific treatment of 
tuberculosis, 116-122 
Spinal cord, tuberculosis of, 422 
Spleen, tuberculosis of, 360 
Spondylitis, tubercular, 397, 407, 503 
—, ankylotica, 412 
Sputum, 23, 60, 246 
, examination of, 60-69 
, concomitant bacteria, 21, 24, 65 
, albumin reaction of, 66 
, lymphocytic contents, 79 _ 
—, prognostic, importance of, 95 
) 
’ 
’ 


tuber- 


pulmonary 


treatment of, 155 

hygiene of, 187 

stimulation of, 67 

— flasks and napkins, 187 

Stadia of pulmonary tuberculosis, 88 

Staining methods in examination of 
the sputum, 61 

State, the, and tuberculosis, 189 


Statistics of tuberculosis, 186 
Stomach cough, 33 
— —, alterations- of, in pulmonary 


tuberculosis, 33, 163, 264 
—- —, tuberculosis of, 276 
Struma, see Scrofula 
Subclavicular murmurs, 59 
Subcutaneous tuberculin test, 72 
Submaxillary gland, tuberculosis of, 


358 

Sun baths, 104 

= ie in laryngeal tuberculosis, 
eae 
12) 











525 


Sun rays in surgical tuberculosis, 409, 
502 

Surgical + treatment of 
tuberculosis, 122-130 

Syphilis and tuberculosis, 168 

Syphon drainage of Bulau, 223 


pulmonary 


Tarsus, tuberculosis of, 401 
Teeth, care of, 290, 508 
—, caries of, in tuberculosis, 263 
Temperature in pulmonary tubercu- 
losis, 27, 94, 150 : 
Tendon sheaths, tuberculosis of, 391 
Testicle, tuberculosis of, 310 
Thoracic duct, tuberculosis of, 352 
measurement, 47, 92 
Thoraco-plasty, extra-pleural, 128 
for empyema, 223 
Thoracotomy, with rib 
empyema, 
— for pneumothorax, 230 
Thorascopy, 200 
Thorax, changes in the, 13, 42, 47, 80 
Throat, see Pharynx 
Thyroid gland in pulmonary tubercu- 
losis, 46 
— —, tuberculosis of, 359 
Tongue, tuberculosis of the, 
Tonsil, hyperplasia of, 233, 
—, tuberculosis of, 267 
—, lupus of, 268 
Trachea, tuberculosis of, 262 
Transitional forms of pulmonary 
tuberculosis, 20, 38 
Tropical climates, 147 
Tubercles, formation of, 4, 18, 
Tubercle bacillus, 2-4 
, paths of entry of, 5-8 
, different forms of, 9 
, methods of staining, 60 
—, and cells of sputum, 63, 95 
’ 
’ 


resection for 


QI.) 


21 


prognostic importance of, 95 
pseudo forms of, 4, 64, 86, 306 
—— angthe bloodss775) 90.5343 
Tuberculides, 381-389 
Tuberculin in the diagnosis of pul- 
monary tuberculosis, 69-73 
—- =. of eye. disease, 450 
of tuberculosis of childhood, 
488 
Tuberculin tests, cutaneous, 69 
— —, percutaneous, 70 
—, conjunctival, 7o 
—, subcutaneous, 72 
—, indications and _ contra-indica- 
tions, 73 
—, prognostic value of, 096 
treatment of pulmonary 
culosis, 116-122” 
in sanatoriums, 175 
in health resorts, 178 
in hospitals, 181 
, ambulant, 185 
of laryngeal tuberculosis, 260 
of tuberculosis of the eye, 449 


tuber- 


526 


Tuberculin treatment of scrofula, 482 

— — inchildhood, 499 

Tumours of the lung, 83 

— mediastinum, 207 

== pleura, 208 

—— larynx, 250 

Tympanic cavity, tuberculosis of, 453- 
462 


UPPER air passages, acute catarrh of, 
233 : 

—— = hypertrophic catarrh of, 234 

= ———, atrophic catarnhyof, 234 

=| —, tuberculosis) of, 232-262 

Ureter, tuberculosis of, 316 

Urethra, tuberculosis of, 305 

Urinary apparatus, alterations of, in 
pulmonary tuberculosis, 34 

— bladder, tuberculosis of, 312 

— organs, tuberculosis of, 304-323 

Urogenital organs, tuberculosis of, 
304-341 





INDEX 


Uterus, tuberculosis of, 325 
non-tubercular, diseases of, 323 


b) 


VAGINA, tuberculosis of, 325 

Valvular pneumothorax, 226 

Vascular system, tuberculosis of, 343- 
350 

Vas deferens, tuberculosis of, 310 

Vaso-motor, changes in pulmonary 
tuberculosis, 35 

Vesiculze seminales, 
309 

Vessel wall, tuberculosis of, 21, 345, 
406 

Vitreous, tuberculosis of, 447 

Vocal fremitus, 45 


tuberculosis of, 


WASTING, 35 

Watering-places, 148 

Weight of body, 115 

Whey treatment, 150 

Winter health resorts, 142-145 





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