cot HX00033723 ' ■ ■ .- I* y *• - • .. *■ ," -< - II ' r . ' ; ... Ir-' Columbia ^nibersfitp inttcCitpofJ^etoPorfe College of Plipsiiciansi anb ^urgeon£( l^eference ILihvavp ON DISEASES LUNGS AND PLEURiE IKCLUDING TUBERCULOSIS AND MEDIASTINAL GROWTHS Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/ondiseasesoflungOOpowe PLATE XXVIII. The Gidematons Pleura — a stage in the formation of the thickened Pleura. Frontispiece THE CEDEMATOUS PLEURA— A STAGE IN THE FORMATION OF THE THICKENED PLEURA The specimen shows a section through the left lung. The upper lobe is much shrunken and shows advanced pulmonary tuberculosis, including a large cavity. Extensive tuberculous disease is also present in the lower lobe. Over the upper lobe and in the great fissure, the pleural layers are seen to be separated and the space crossed by fine vascular loops ; the interveriing meshes are filled with serous fluid, and the whole presents a gelatinous appearance. As yet the pleural membrane itself is hardly at all thickened. The dense fibrous thickening which results at a later stage may be seen in Plates XXX. and XXXI. From a boy aged seventeen, who died from chronic pulmonary tuberculosis with terminal miliary tuberculosis of lungs and kidneys, and with tuberculous lesions in the larynx and intestines. (From the Museum of the Brompton Hospital f natural size.) PLATE XXVIII . • ON DISEASES OF THE LUNGS AND PLEURy^ INCLUDING TUBERCULOSIS ^ MEDIASTINAL GROWTHS BY SIR R. DOUGLAS POWELL, Bart. K.C.V.O., M.D. LoND., F.R.C.P. Hon. D.Sc. Oxon ; M.D. Dublin; F.R.C.P. I., LL.D. Aberd. and Birm. PHYSICIAN IN ORDINARY TO H.ll. THE KING : CONSULTING PHYSICIAN AND EMERITUS LECTURER ON MEDICINE TO THE MIDDLESEX HDSl'ITAL ; CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST AT BKOMPTON, AND TO THE VENTXOR HOSPITAL ; KNIGHT OF CiRACE OF THE ORDER OF ST, JOHN OF JERUSALEM AND P. HORTON-SMITH HARTLEY C.V.O., M.A., :\I.D. Cantab.. F.R.C.P. LATE FELLOW OF ST, JOHN's COLLEGE, CAMBRIDGE ; PHYSICIAN WITH CHARGE OF OUT-PATIENTS TO ST. BARTHOLOMEW'S HOSPITAL ; SENIOR PHVSICIAN TO THE HOSPITAL FOR CONSUMP- TION AND DISE.^SES OF THE CHEST AT BROMPTON ; MEMBER OF COUNCIL (l.ATE HON. SEC.) OF THE KING EDWARD VII. SANATORIUM ; CONSULTING PHYSICI.^N TO THE DANESWOOD SANATORIUM SIXTH EDITION WITH ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO. 1921 7^-^- . / I Printed in England PREFACE TO SIXTH EDITION Another nine years have elapsed since the last edition of this work and twenty-eight years since the appearance of the fourth edition. In the course of this time the last word has been said on antiseptic methods in surgery and more tardily in medicine, methods upon which so much of modern treatment of pul- monary disease is based, and in still greater degree its prevention. During this period bacteriology has made great strides, and has succeeded in elucidating many problems dealing with pathological and therapeutic action. If in the latter respects, though rich in other fields of work, bacterio- logical research has been less fruitful in practical results in the field of lung diseases, it must be gratefully acknowledged that such investigations have served to deepen our insight into the pathology of these diseases and the problems of immunity, and have in no slight degree rendered more clear our outlook for future treatment. As in recent editions, fairly full references to literature on the subjects dealt with have been appended to each chapter, but the authors have not hesitated to express as definitely as pos- sible their own conclusions after due consideration of the views of others. Some of the older references have also been retained in view of historic interest and continuity. Several new clinical cases have been introduced in illustra- tion of some of the varieties of phthisis, and also of other diseases, but many of the old cases have been preserved as clinical pictures the outlines of which have not faded with time. Reference to tuberculin has been considerably shortened VI PREFACE TO SIXTH EDITION in acceptance of the lessened value attached to its use except in special cases. In prescribing" this remedy the cubic milli- metre has been adopted as the basis for dosage instead of the cubic centimetre as in former editions. New chapters have been added on Gunshot Wounds of the Chest, Chylothorax, Massive Collapse of the Lung-, Sporo- trichosis, and Artificial Pneumothorax; and surgicat methods have been more fully dealt with in connection with certain diseases. The Authors haxe gratefully to acknowledge the help of Professor Bainbridge, Dr. H. M. Gordon, Dr. W. Jobson Home, Dr. L. S. T. Burrell, and Professor Gask in revising the proofs on certain subjects and giving valuable criticism and suggestions thereupon. Professor Karl Pearson and Dr. Brownlee have also favoured the Authors with valuable advice in connection with the aetiology of phthisis, and have revised and completed to date the diagrams illustrating its epidemiology and prevalence. Recent figures showing the standardised death-rate from phthisis have been courteously supplied by the Registrar- General. The Authors' thanks are also due to the Medical Research Council for permission to reproduce drawings from their publications which are referred to in the text. The Index of the volume has been somewhat shortened in the able hands of Miss A. Newbold, and finally the Authors have most gratefully to acknowledge the services of Miss E. F. Parry in revising and arranging the text of the whole book. LoXDOX, October, 1920. PAGE CONTENTS CHAPTER I ON SOME ESSENTIAL POINTS IN THE ANATOMY AND FUNCTIONS OF THE LUNGS The anatomy of the lungs. Pulmonary circulation. Respiratory function and mechanism. Respiration in the new-born child. The contractile powers of the lungs ; their residual tension. Elastic resilience of chest walls acting as an inspiratory force. Schema for demonstrating the respiratory movements. Statics and d3mamics of respiration. Lymphatics and nerves of the lung CHAPTER n THE PHYSICAL EXAMINATION OF THE CHEST The chest; its shape, measurements and mobility. Pneumatometry Spirometry. Vital capacity : influence of body-weight thereon. Topography of the chest, with anatomical figures - - - 22 CHAPTER ni THE PHYSICAL EXAMINATION OF THE CHEST (continued) Physical exploration. Inspection, movements, etc. Palpation ; vocal fremitus. Methods and theory of percussion. Table of terms. International nomenclature of physical signs. Ausculta- tion. Breath-sounds, healthy and morbid ; their probable mechanism and significance. Adventitious sounds. Voice- sounds. Auscultatory percussion. Roentgen rays - - 23 CHAPTER IV EXAMINATION OF THE SPUTUM Main sources. Quantity; reaction; consistence; colour. Bronchial casts. Microscopic examination. Red and white blood-cells. Epithelium. Elastic fibres. Curschmann's spirals. Tonsillar casts. Crystals, Micro-organisms, Adventitious and extraneous matters - - - - - - - - - 66 vii viii CONTENTS CHAPTER V DEFORMITIES AND DISEASES OF THE CHEST WALLS I'AGE The pigeon breast. The rickety and alar chests. Pleurodynia. Aponeurotic rheumatism. Myalgia. Intercostal neuralgia. Herpes zoster. Periostitis, perichondritis, and osteo-myelitis. Costal Abscess. Fascial creaking - - - - - 7^ CHAPTER VT DISEASES OF THE PLEURA : PLEURISY Position and connections of the pleura ; its lymphatic system. Clas- sification of pleurisies. Fibrinous pleurisy : pathology and symptoms. Diaphragmatic variety : symptoms. Treatment - 85 CHAPTER Vn SERO-FIBRINOUS AKD HEMORRHAGIC PLEURISY Acute sero-fibrinous pleurisy : aetiology ; evidence of tuberculous origin of primary cases; cytological and chemical characters of the fluid ; symptoms ; signs — cardinal, supplementary, and those indicative of nature of fluid ; diagnosis ; prognosis ; treatment. Paracentesis thoracis: — selection of spot; method of perform- ing ; the syphon ; Potain's aspirator. Chronic sero-fibrinous effusion ; treatment by oxygen-replacement. Hsemorrhagic pleurisy - - - - - - - - - 90 CHAPTER Vni SUPPURATIVE PLEURISY J^tiology and bacteriology ; symptoms and physical signs ; fectoril- oquie afhoniqtie; pulsation of the fluid. Special varieties of empyema : foetid, tuberculous, and encysted or localised. Diag- nosis ; prognosis; treatment. - - - - - - 118 CHAPTER IX PNEU.MOTHORAX : HYDRO- AND PYO-PNEUMOTHORAX ^Etiology. The tuberculous variety : nature of the opening, of the gas, and of the effusion ; symptoms ; physical signs — hyper- resonance, alteration of breath-sounds, displacement of heart; X-ray appearances ; course and prognosis ; diagnosis ; treatment. Illustrative case of pyo-pneumothorax of long duration - - 133 CONTENTS IX CHAPTER X HEMOTHORAX — GUNSHOT WOUNDS OF THE CHEST PAGE Hasmothorax in civil life : aetiology, symptoms, physical signs, and treatment. Haemothorax following wounds of the chest. S3miptoms of onset ; peculiarity of physical signs ; course varying according as the haemothorax remains sterile or not. Treatment of sterile haemo- thorax : question of paracentesis ; prognosis. Tre-. -l-> ^ n] a H B 43 (0 . X! (U &. S i-i (1) n -a >> rt -^j XI &D tuO c '^ 3 cn n -.^ o a. (u ^ J . c o > a « c > O I-i i-t c o en CO o (u ^t ^ o ^ £ fi M ™ < x; be r| g a3 bc a, o y .2f.S a^S5 g^ a« 55 (ii iJ 43 -l-J « o e 43 13 O CO C 'to 43 J3 TJ cd o c O (U 10 >> XJ c8 "^3 6 4) 43^ bo^ bjo g 'u 3 .^ 43 to cn ° rt3 to to -M to cl O G a to 3 O -4-> cd S 43 to Xi u o « C 43 2 lu S i^ m •^ 1^ CTi •n 3 , fa B u- t/j (H c t/; e5 M in en b b b ^O "^ o M O O 71- rr, m O fO O O b O O rn O b O O b o 4) D o o CO to 3 3 PI N IJ o o ca ca t/3 to 43 4) (U 43 0000 ca ca ca ca CO to to to 4) 4) 4) 4) 0000 ca ca ca ca to to to to 43 43 O O ca ca to to 80 « -o IS -c> 13 13 C 3 I 1 n-j 13 13 13 u o c a PO N M N I I I I S -O (S 'O 43 4) o o ca c8 to CO fciJ Pd^ait^ oiidoiy^ Pi^ jcti I3l3l3l3 1313 •T113 nSCa S3 u u I I I I I I II O O . ca o 13 13 u m 13 B 13 S XI XI •t-i 13 B XI 13 B XI 13 a X to 13 a Xi 13 a XI in 3 O 3 a <5 a to M 0-- ° % <" a. ca E o 3 'o la- O 3 f5 ;S a ■4-J *-* O «i S "^ 3 « 2 E ■§ « 43 13 13 'U 43 £'« "Ja ca (J 43 be I- Ja-lg^ 1-1 to ca -^ 13 43 >-< ^^ 5-3 ca CO i-i fa ca E o a 'o Ja- U CO u X to to X XI u X o to u X m CO X! CO u XI O V < CO 00 cn in •^ ^ VO v^ M VO m ^ fri ^ ta S' fa ^ ^ S" fa" 6 M c^ tn ^ m VO t^ 00 o^ M ANATOMY AND FUNCTIONS OF THE LUNGS II expansion, which he attributes to muscular action, is not obtained in the dead animal. The appended table contains the details of ten post-mortem examinations made by one of us to estimate the extent to which the chest wall would expand of its own resilience when relieved from the traction of the lungs.'"" The difficulty of finding the thoracic organs perfectly healthy in the dead subject is well known, and out of the ten cases operated upon, in only four instances were they approximately so.* The experi- ments were performed after the manner of Salter by taking a fine tube, A (Fig. 3), ex- panded below and having stretched across its expanded extremity, B, a piece of caout- chouc provided with a projecting button, C. The instrument, having been filled with col- oured fluid, was so adjusted that the button was accurately applied to the third cartilage, the integuments having been previously reflected from the front of the chest. The level of the fluid having been noted on the Scale D attached to the stem, the thorax was cautiously opened, and an immediate rise of the coloured fluid was observed. A simple calculation enabled one to ascertain the actual expansion registered. The results of the experiments will be seen in the table ; in the four comparatively healthy cases the expansions (forward movement) measured were 1-63 mm., 2-143 nim., 239 mm., and 3-19 mm. respectively. These figures, small though they are, correspond pretty well with the limits of expansion of the ribs during calm breathing. Thus Hutchinson calculated the costal movement in health at xV to I line = I to 2 mm.; Sanderson gives i"6 mm. Our own measurements, nineteen in number, recorded in the paper above referred to,'"* by an instrument with writing lever, * Professor Keith, in his reference to these experiments, omits to note that only in these four cases were the lungs approximately healthy, their action in the other cases being impaired by oedema, emphysema or pleuritic effusion. Fig. 3. — Instru- ment FOR ESTI- MATING Expan- sion OF THE Chest Wall 12 DISEASES OF THE LUNGS AND PLEURA would give rather a higher figure — viz., 2 to 3 mm. It would appear, then — and this is the point to which we wish especially to direct attention — that in health, throughout ordinary inspiration, the limit of thoracic recoil, which we may call the reserve capacity of the thorax, is barely reached; and, there- fore, that the sole resistance to he overcome by the inspiratory muscles is that of the lungs. This elastic help at the beginning and hindrance at the com- pletion of the respiratory act is a spring-hke function of the chest wall, the importance of which has not been duly recognised. 1^- fc? t H Fig. 4. — Diagram Model of the Chest. In order more clearly to show the main physical conditions present in the chest, and how they are modified, (a) during normal respiratory movements, and (&) in certain diseases, the above schema or diagram-model of the chest was designed (Fig- 4). The schema consists of a cylinder of glass, closed at each end by a metal plate screwed on and perforated for the admis- sion of certain tubes. A central partition, EF, made of sheet india-rubber, divides the cylinder into two air-tight compart- ments, each of which, as will be presently seen, represents one-half of the thorax. ANATOMY AND FUNCTIONS OF THE LUNGS 1 3 Tube D represents the trachea, and is connected with an elastic bag (c), representing the (left) lung. Tube G com- municates with the space between the lung and the wall of the chamber, which space, therefore, corresponds to the pleural cavity. This tube is connected with a mercurial manometer, the free end of which, L, is open to the normal atmospheric pressure. Tube B also communicates with the same (pleural) space, and is provided with a stopcock and a mouthpiece. Exactly the same parts are repeated on the opposite side of the partition, EF, which therefore represents the medias- tinum. The apparatus must be ascertained to be thoroughly air- tight. Then, by partially exhausting the air from chamber A througli tube B (trachea tubes D and D' remaining open), we cause the bag c to expand to C, the mercury in the mano- meter, HKI, to rise towards the chamber, and the mediasti- num, EF, to become convex, as indicated by the dotted line. By closing the stopcock B we maintain all the parts in this position. If, next, we repeat the same process on the opposite side — partially exhausting chamber A' through B' until the mercury r is at the same level as I, the bag c' will expand to C, the mediastinum, EF, will again become vertical, and by closing stopcock B', the parts will be maintained in this position of equilibrium on the two sides. In the schema thus arranged, we have the conditions of the healthy chest rudely but accurately imitated. The two cham- bers represent the two sides of the chest, each containing a semi-expanded lung, C, C, surrounded by a pleural cavity, A, A' (here greatly exaggerated,* the cavity being rather potential than real in the healthy chest), each cavity being separated from that on the opposite side by the mediastinum EF, which is common to both and equipoised between them. The walls of the natural thorax are, however, as we have seen, elastic or resilient in every part, although much more stiffly so than the lungs. We cannot exactly represent this resilience of the thoracic walls in our schema. The only parts * This is unavoidable, since the walls of the schema are rigid, and if the bags fitted accurately, their further expansion in inspiration could not be represented. No fallacy is hereby introduced, however. 14 DISEASES OF THE LUNGS AND PLEURA of our apparatus which are at liberty to yield to the excess of external atmospheric pressure over that within the pleurae are the small surfaces of mercury at H, H'. Hence the eleva- tion of the mercury, HI, H'T, towards the chamber on each side, multiplied by the area of apertures G, G', and divided by that of the whole surface of the chamber, would represent in millimetres the amount of recession of each portion of the thorax, provided each portion were equally resilient. In considering this subject, we must not forget the dia- phragm, which constitutes the floor of the chest, and which, owing to its resistance being weaker, yields far more than any other portion of the chest wall to the traction of the lungs, so that a recession of an inch on the part of the diaphragm is equivalent to the recession of only i or 2 mm. on the part of the ribs or cartilages. And yet it must be remembered that the diaphragm is not per se elastic, and that the limits of its actual tension are therefore very narrow. The elastic recoil of the diaphragm, in fact, depends mainly upon the spring of the cartilages to which it is attached. It is thus obvious that this muscular membrane must be drawn upwards and held in a state of tension by the lungs during the respiratory pause, their traction being in turn counter- balanced by the weight of the abdominal organs. Our mer- curial columns, therefore, after all, very conveniently and fairly represent the whole thoracic resilience in a lump sum. Having thus, with the aid of our schema, reviewed the statical conditions of the chest, the dynamics of respiration may be easily demonstrated. In order to imitate an inspiration, aspiration must be made simultaneously through the tubes L and L', thus representing the contraction of the diaphragm and inspiratory muscles on the two sides. This can be conveniently done by means of a syringe attached to a branched caoutchouc tube afifixed to the extremities L, L' of the manometers. As the mercurial columns rise up the limbs L, L' of the manometers, representing the expansion of the thorax, the lungs C, C enlarge by the entry of air through trachea tubes D and D'. " It will be observed that during the first part at least of inspiration the weight of the two columns of mercury, HI, HT, tells in favour of the inspiration. This weight of mer- ANATOMY AND FUNCTIONS OF THE LUNGS 1 5 cury corresponds, as before said, to the outward resilience of the thoracic walls, and counterbalances the elastic traction of the lungs. This is a fact, well shown in the schema, and which has been already stated in the proposition, that in health the resilience of the chest wall is in favour of inspiration. Moreover, from the observations on the dead subject to which we have already referred, it would appear that this elastic aid to inspiration obtains throughout the act in calm breathing. Respiration is thus rendered smoother and less laborious, elasticity entering as an important item into the inspiratory, as it has been long known to do into the expiratory act. The conditions present in the chest, as shown by the schema, must now be further examined in so far as they affect heart and circulation. The disposition to the formation of a vacuum in the intra- pleural space A, equal to the weight of the column of mer- cury HI, causes an aspiration towards that cavity which was at first shown by the convexity of the mediastinum EF (dotted line) ; and, there being a similar and equal aspiration towards the pleural cavity on the opposite side of the mediastinum, it follows that there is a constant determination of blood towards the cavities and walls of the heart — a hollow organ situated within the mediastinum, and communicating by a system of tubes with parts outside the thorax (see Fig. 5). This central attraction is forcibly overcome by the muscular contraction of the heart, but resumes its sway at the termina- tion of systole, aiding the return of blood to the flaccid heart cavities, and encouraging the flow through the coronary vessels. This aspiration towards the heart, it must be remem- bered, is in health a constant force, increased during inspira- tion, held in momentary subjection during the more forcible muscular contraction of the heart, and not wholly extin- guished even at the end of ordinary expiration. In the subjoined drawing (Fig. 5), which depicts a some- what more elaborate diagram model of the chest (but essen- tially corresponding with that illustrated by Fig. 4), the mediastinum is represented by a double layer of caoutchouc enclosing a space. With this is connected the manometer, D, which shows at a glance the negative pressure to which the heart is constantly subjected through the traction of the lungs from either side. i6 DISEASES OF THE LUNGS AND PLEURA (u . ri t« ., « *-" ^ w i; S '^ 2 « ■ V3 (A c -a oj c .^ g x.ti s_ I s « rt Jd o 3 j_i (U ... -O u <;j: o.S OJ c « . ^ " fe ^ ° < ^-"^ rt o 3 - o J= _ — O— 0) ■" o*;5 •S « ^ M , =^ c gj 3 - ^' C C O. c rt <-■ o .S.S-S-t;^ o a, IJ2. < 5 % S 3 S f "^ . .— . « Jl *^ w ^ " " c E — C bo-r rv t^ O C ^ - ;s, § 5 s 'S o 5, biO > y M S^^"^ S »J S rt a, i2 01 3 '^J-^ly '*^ oj-i^ a.a o h. ui u ■ C S. & bo 1 8 3 4-» (u ^'r « o a> •-" u « ? .2 ""^ ^ O <5 in O-o " 3 bo Wl c.s •«i;wrt-"„3f:! c e - i> w-Q g „ O.S C tyi C - 3 .rt rt O. 3 O ANATOMY AND FUNCTIONS OF THE LUNGS 1 7 The reserve capacity of the chest to which we have referred, and which leads it, under certain circumstances and within certain limits, to enlarge without muscular effort from with- out or pressure from within, is a most valuable safeguard, and serves in some diseases to protect the lungs from pressure during temporary conditions of inflammation or engorgement. If, for example, we look at a case of pneumonia, we find that, whereas on the healthy side the play of the chest wall is natural or increased, on the other side it is annulled. There is no retreat with expiration, and inspiration is checked by pain. On post-mortem inspection, we find the fine granula- tions of lymph evenly spread upon the pleural surfaces, show- ing no sign of pressure. The patient suffers little pain, except when he coughs or attempts to draw a deep breath. In fact, as the inflamed and consolidating lung increases in bulk, the thoracic wall, thereby released from its elastic- traction, retreats to the position of inspiration; and this reserve capacity of the thorax is rarely exhausted in pneumonia, so that the swollen and tender lung as a rule escapes com- pression. Similarly, in temporary engorgement and oedema of the lungs the consequences would be much more serious were it not for this reserve capacity of the thorax, which protects the organs from compression, save in extreme cases. In emphysema the lungs are rarely enlarged so as to be com- pressed by the ribs, the thoracic resilience being entirely neutralised only in very extreme cases. With regard to emphysema, sl diminution of the elastic spring of the chest wall is one of the first important features of the disease. In the normal chest, a deep breath is drawn by first making a deep expiration and then a deep inspiration. In emphysema the power of making a deep expiration is par- tially or entirely lost; the resei-ve capacity of the thorax is taken up, and it is in this direction that the trouble of em- physematous people Hes. Regarding emphysema as in many cases essentially a disease of a degenerative kind, we must observe in the constant traction of the thorax upon the lungs a determining cause of their enlargement, as the chest gradually expands to the Hmits of its reserve capacity. If, on the other hand, as is often the case in early life, the 18 DISEASES OF THE LUNGS AND PLEURA chest walls be soft and feeble, they cannot properly expand, and a small, narrow, or distorted chest results. Lymphatics. — We have preferred to pass on from the con- sideration of the general structure of the lungs to a discussion of the mechanism of the respiratory function, and even, by way of illustration, to refer to some morbid states of per- verted respiratory mechanism, before completing the anatomi- cal description of the lungs by speaking of their lymphatic and nerve supply. This has been done with the view of bringing together those points of anatomy and function which are most concerned in the production of physical signs and symptoms. In the lymphatic and nervous apparatus of the lungs we have, so to speak, the drainage and function-regulating systems, whose workings are for the most part hidden from us, to be brought to light mainly through the manifesta- tions of disease. And, in truth, the important part played in pathology by the complex lymphatic system of the lung, as disclosed to us by the researches of the late Sir John Burdon- Sanderson-' and Dr. Klein," has become more clearly dis- cerned with a better knowledge of the origin and extension of pulmonary diseases. The lymphatics of the lung take their origin partly in a net- work of fine vessels which ramify in the connective tissue sup- porting the pulmonary lobules, partly in the mucous mem.- brane of the bronchi. Those vessels which surround the lobules on the surface of the lung, communicate with the lymphatics of the visceral pleura, and both are drained by the superficial collecting trunks, which course over the surface of the organ and terminate in the glands at its root. The lymphatics, originating in the deeper lobules and in the bronchi, communicate with those on the surface of the organ, and are drained by the deep collecting trunks, which, under the name of "perivascular" and "peribronchial" lymphatics, accompany the pulmonary vessels and bronchi, to end also in the glands of the hilum. The communication which exists between the superficial lymphatics of the lung and those of the visceral pleura shows how easily organisms may be carried to this membrane, and thus lead to its infection, even though recent research casts ANATOMY AND FUNCTIONS OF THE LUNGS IQ some doubt upon the existence in the human subject of "stomata," whereby direct communication between the in- terior of the serous membrane and the lymphatics of the lung and pleura was believed to be established. Another point of great interest insisted upon by Professors Poirier and Cuneo/' whose work on the lymphatic system has added much to our knowledge, is that the lymphatics of the pleural and peritoneal surfaces of the diaphragm communi- cate freely with each other, and that the one can be easily injected from the other. The frequent spread of infection between the two serous sacs is thus explained. Of great importance, too, is their observation that certain lymphatic vessels from the liver pass directly to, and drain into, the sub- pleural lymphatics of the diaphragm, thus explaining the frequent occurrence of pleurisy as a sequel to abscess and other infective diseases of the liver. Nerves. — The nerve-supply to the lungs is derived from the anterior and posterior pulmonary plexuses, which are formed by the interlacement of branches from the vagi, joined by others from the sympathetic, chiefly from the inferior cer- vical ganglion, the annulus of Vieussens, and the ganglion stellatum. The nerves from these plexuses accompany and supply the bronchi and vessels, and then appear to end by forming a delicate network, the ultimate fibrils of which are distributed upon the alveoli. REFERENCES. ' (i) " Observations on the Anatomy of the Lungs," by Thomas Addison, M.D., Physician to Guy's Hospital. Transactions of the Royal Medical and Chirurgical Society, 1841, vol. xxiv., p. 146. (2) "A Collection of the Published Writings of the late Thomas Addison, M.D., p. 2, New Sydenham Society's edition, 1868 vol. xxxvi. ^ Die direkte Laryngoshofie, Bronchoskopie, und CEso-phagoskofie, von Dr. Med. et Phil. W. Briinings, p. 216*. Wiesbaden, 1910. ^ "The Structure of the Lung," by W. S. Miller, Journal of Morphology, Boston, 1893, vol. viii., p. 165. * {a) The Bronchi and Pulmonary Bloodvessels, by William Ewart, M.D . London, i88g. [b) Loc. cit., p. 63. 20 DISEASES OF THE LUNGS AND PLEURA •' Traite d'' Anatomic Humaine, par P. Poirier and A. Charpy, tome iv., 2nd fascic, p. 486. Paris, 1903. * " The Causes of Absorption of Oxygen by the Lungs," by C. Gordon Douglas, M.B., and J. S. Haldane, M.D., F.R.S., Proceedings of the Royal Society, May, 1910. Series B., vol. Ixxxii., p. 331. ' For a brief reference to Dr. Hensley's lectures, see " Effects of the Circulation in the Lungs in Distending the Air-Vesicles," British Medical Journal, 1872, vol. i., p. 677. ' " Bemerkungen zur Physiologie der Athembewegungen und des Kleinen Kreislaufes," von Leo Liebermann, in Wien, Allgemeine Wiener Medizinische Zeitung, 1872, No. 5, p. 36. ' "On the Elasticity of the Lungs," by James Carson, M.D., Philo- sofhical Transactions of the Royal Society, 1820, part i., p. 29. " " Beitrage zum Mechanismus der Respiration und Circulation im gesunden und kranken Zustande," von F. C. Donders, Zeitschrift fiir Rationelle Medicin, 1853, N.F., Band iii., p. 290. " Lectures on "Dyspnoea," by Hyde Salter, M.D., F.R.S., deUvered at the Royal College of Physicians, The Lancet, 1865, vol. ii., p. 142. '^ " Ueber die Druckverhaltnisse im Thorax bei verschiedenen Krank- heiten," von Dr. M. Perls, Deutsche Archiv fiir Klinische Medicin, 1869, Band vi., p. i. " See A Textbook of Physiology, by William H. Howell, Ph.D., M.D., LL.D., p. 606. Philadelphia and London, 1907. '* " Ueber die Athmung in der Lunge," von Dr. L J. Mtiller, Arbeiten aus der Physiologischen Anstalt zu Leipzig, mitgetheilt durch C. Ludwig, 1869, p. 74. _ '* " On the Probable -Rhythmical Contraction of the Bronchial Muscular Coat as a Factor in Pulmonary Diseases," by P. Watson Williams, M.D., Lond., Bristol Med. Chir. Journal, vol. xxi., 1903, p. 6. See also Encyclo- fcedia Medica, vol. ii., 1899. '• " On the Capacity of the Lungs, and on the Respiratory Functions," by John Hutchinson. Transactions of the Royal Medical and Chirurgical Society, 1846, vol. xxix., p. 137. " Further Advances in Physiology, edited by Leonard Hill, M.B., F.R.S., p. 192. London, 1909. '^ Lemons sur la Physiologie comfarie de la Res-piration, par Paul Bert, p. 359. Paris, 1870. ^° Gesajjimelte Beitrage zur Pathologic und Physiologic, Band i. ; Ex-peri- mentelle Untcrsuchungen, von Dr. L. Traube, pp. 138-142. Berlin, 1871. [a] " On Some Effects of Lung Elasticity in Health and Disease," by R. Douglas Powell, M.D., Transactions of the Royal Medical and Chirurgical Society, 1876, vol. lix., p. 165. [b) Loc. cit., p. 170. (i) "Report on the Communicability of Tubercle by Inoculation," by Dr. Sanderson. Tenth Re-port of the Medical Officer of the Privy Council. London, 1869. 20 ANATOMY AND FUNCTIONS OF THE LUNGS 2 J (2) " Further Report on the Inoculability and Development of Tuber- cle," by Dr. Sanderson. Eleventh Re fori of the Medical Oficer of the Privy Council. London, 1869. -^ The Anatomy of the Lymphatic System, part ii., " The Lung," by E. Klein, M.D. London, 1875,. ^^ Traite d^ Anatomie Humaine, par P. Poirier et A. Charpy, tome ii., p. 1248. Paris, 1909. CHAPTER II PHYSICAL EXAMINATION OF THE CHEST Before proceeding to physical examination, preliminary in- quiries have to be made into the health history of the patient, the circumstances which have led up to his present illness, and the chief symptoms which give him distress. In the course of these inquiries the appearance and manner of the patient may be noticed; and the experienced physician, skilled in the physiognomy of disease, will thus gain information of great value as a clue to the often confused story of the patient, and in suggesting to him further questions. It would be folly to attempt to learn from a book the physiognomy of disease. Clinical study, an habitually careful scrutiny of the features and postures of actual sufferers, will alone enable us to appreciate it. The student will early dis- tinguish the aspect of turgid lividity and laboured breathing of chronic bronchitis with dilated heart, from the pallor, anxiety, throbbing vessels, and dyspnoea with restlessness, of advanced aortic regurgitant disease. The hectic look of phthisis, the grave drawn lineaments of asthma, the puffy pallor of albuminuria, may in their more marked degrees be soon recognised even by the beginner. The finer traits and markings of disease, however, require more experience for their detection, and are of even more value in suggesting inquiries and often in leading one to suspect the presence of disease before sufficient signs can be found to justify a posi- tive diagnosis. Incipient tuberculosis and obscure aneurism may be named as two instances in which the features of ill- ness sometimes suggest a more guarded diagnosis than the physical signs would at first seem to warrant. The relationship between physical signs and the diagnosis 22 PHYSICAL EXAMINATION OF THE CHEST 23 of pulmonary disease is, again, of a strictly practical kind, although depending upon acoustic principles; and he who would become a successful auscultator and a good diagnos- tician must study auscultation in association with morbid anatomy. Thus will the stethoscope reveal to him at the bedr side, in most cases, an accurate picture of the lung, heart or pleura under examination, as though the organ were exposed to his view. This intimate association in the mind between physical signs and the lesions which give rise to them is only to be acquired by combined clinical and post-mortem observa- tion; no amount of reading or clinical work alone will suffice for its attainment. It is the object of a textbook, however, to supply certain data for comparison, and to lay down principles and methods upon which a satisfactory exploration of the chest is best founded. Shape of the Chest.— It is impossible in a word to describe the shape of the chest, but it may be said in the adult to be conical from above downwards, flattened in front, and grooved in the posterior median hne, so that the antero-pos- terior diameter is about one-third less than the transverse. In the child these two diameters are more nearly equal. The shape of the upper portion of the chest is obscured by the pectoral muscles extending from the upper arm to the clavicle and ribs, giving it a somewhat square outUne. In the female the apparent form of the thorax is still further altered by the mammary development. Measurements of the Chest.— All departures from the nor- mal, whether in shape, size or mobihty, can be generally observed by inspection, but for accuracy in recording measure- ments are needed. For this purpose the double tapes and the cyrtometer are of value. The former instrument was introduced into clinical use by the late Dr. Charles J. Hare, Physician to the University College Hospital, and consists of two tapes connected by a central piece for adaptation to the spine, from which point each tape is graduated. The back piece being carefully held over the spinous processes, and a mark being made exactly in the median line of the sternum, the two tapes are brought round the chest at the same level and with moderate firmness of application, to overlap one another at the front line, A comparative measurement of 24 DISEASES OF THE LUNGS AND PLEURA the two sides is thus at once read off, the sum of the two measurements giving the total circumference. By holding the tapes lightly the expansion of the chest can be measured during calm breathing, and by making the patient take a deep breath, followed by a full expiration, the total expansibility is ascertained; also, what is equally of value, the contractility of the chest beyond the point of ordinary expiration. Finally, a comparison in all these respects can be made between the two sides. By means of the cyrtometer, a tracing of the circumferen- tial outline of the chest is obtained. This instrument, in the form of jointed whalebone, was first employed by Woillez.^ Its most convenient form is that suggested by Dr. Gee,- and consists of two pieces of thin lead piping- connected by a hinge of rubber tubing. The hinge is carefully applied over the spinous process at the level required, and the piping moulded round the chest until the two ends cross one another in the median line in front; a mark is then made and the instrument allowed to fall away from the chest, being held by the flexible joint. It is subsequently adjusted in position on a sheet of paper, and "sternum" and "spine" being marked, the pencil is carried round the inner circumference, and an exact outline of the shape of the chest is thus obtained, any comparative or general alteration being readily observed. Callipers are sometimes used for taking comparative antero- posterior measurements, but, owing to many practical diffi- culties, they are not of much value for clinical purposes. The circumference of the chest varies considerably in different individuals and within the range of health. Thus, Walshe^ noted in adult males of medium height measure- ments rang-ing between 27 and 44 inches in the circumference taken opposite the sixth rib. Such extreme measurements are, however, exceptional. The admirable statistics of Baxter,* dealing, without selection, with over 300,000 of the adult male population of the United States, between the ages of eighteen and forty-five, at the time of the American Civil War, show the average circumference of the chest to be between 33 and 34 inches (see table, p. 27). For cHnical pur- poses these absolute measurements do not teach us much. Relative measurements of the two sides are, however, of value in certain diseases attended with enlargement or dimi- PHYSICAL EXAMINATION OF THE CHEST 2$ niition of the chest on one side, and in such cases cyrtometer tracings are helpful in giving exact information also as to shape. The mobility of the chest is of more importance than its mere size, as it affords a better indication of vital capacity. In the healthy adult the difference between extreme inspira- tion and extreme expiration should not be less than 2^ inches, as measured by the tapes at or about the level of the nipples. It may amount to as much as 5 inches. The difference should be nearly equally divided between the two sides, a slight excess in favour of the right being of no importance. Vierordt,' indeed, states that in right-handed persons there is constantly an excess of from i to i^ centimetres (about •1 inch) on the right side. In calm breathing, however, the actual movement of the chest is very small, averaging in the healthy male (according to Walshe) ^ inch : the expansion of any one spot of the chest surface not exceeding 2 to 3 millimetres, as already shown (p. 12). The whole subject of mensuration will be found duly discussed in Walshe's treatise, to which we have already referred. For detailed researches respecting the movements of individual ribs, we must refer the reader to Dr. Ransome's^ monograph on stethometry, and Dr. Arthur Keith's' more recent work on the subject. Pneumatometry. — The power ordinarily employed by the inspiratory and expiratory forces during calm breathing, and that which they are capable of exercising during extremest effort, have been carefully estimated by various authors, and especially by Waldenburg.^ Pneumatometry and Spirometry are most fully discussed in his work, and later researches have added but little to our knowledge of the subject. The instrument employed by Waldenburg consisted of a manometer provided with a naso-oral mask so padded as to fit with accuracy, each limb of the manometer measuring about 12 inches (270 millimetres), and being half filled with mercury. For calm breathing the mercurial surface would indicate a difference of from i to 2 millimetres. With forced inspira- tory effort the mercury could be maintained at a minus pres- sure of 2^ inches (60 millimetres), nearly double this pressure being momentarily obtainable. The expiratory force ex- 26 DISEASES OF THE LUNGS AND PLEURiE ceeded the inspiratory by 20 to 30 millimetres — i.e., with forced expiratory effort 3^ inches (90 millimetres) of positive mercurial pressure might be maintained, and, momentarily, as much again. Marked variations from the healthy standard are met with in disease, and in two directions : 1. The inspiratory power is diminished whilst the expira- tory {except in extreme cases) rem^ains normal. This type is observed in phthisis, even in the earliest stages of that disease. It is found also in laryngeal, tracheal and bronchial obstruc- tions, and to a less extent in pneumonia or in pleuritic effu- sion. 2. The expiratory pressure is lowered, the inspiratory re- maining normal or being even increased, or subnormal, but in all cases remaining relatively higher than the expiratory. This type obtains in emphysema, bronchitis and asthma, also in diseases of the abdominal organs which impede the play of the expiratory muscles. Spirometry. — In the healthy adult at rest the respirations number from sixteen to twenty per minute; they are some- what slower during §leep than when awake, and are readily accelerated by movements, effort, or excitement of any kind. With each act of calm breathing there is an influx into the chest, followed by a corresponding efflux, of some 500 c.c. (30 cubic inches) of tidal air. If the inspiration be an un- usually deep one, an additional 1,500 c.c. of so-called com- plemental air may be inhaled; while, conversely, after a normal expiration 1,500 c.c. of reserve or supplemental air may be still further expelled, if a very forcible expiratory effort be made. The sum of these three, representing the amount of air which can be expelled by the deepest expira- tion following the deepest inspiration, constitutes the vital capacity of the individual, and in a healthy Englishman of average build amounts to rather more than 3,500 c.c. (210 cubic inches). Even then, however, the lungs are by no means airless, some 1,000 c.c. of residual air being still re- tained within them, which can never be expelled during life. These facts were originally worked out by Hutchinson,®'' by means of an instrument called the spirometer, which consisted essentially of a graduated gasometer nicely balanced and pro- vided with a mouthpiece, through which the patient could PHYSICAL EXAMINATION OF THE CHEST V breathe into the meter previously set at zero. By a series of elaborate investigations, he arrived at the following impor- tant conclusions, which have not been altered or materially added to since his original paper. Hutchinson found that the vital capacity varied with the height in a very definite manner, as will be seen by the sub- joined table : Vital Capacity. Hutchinson. Circumference of Chest. Height. From From Weight. (Number of Cases examined in Brackets ) Observation. Calculation. Baxter. ft. in. ft. in. cub. in. cub. in. lb. in. 5 o to 5 I 174 174 120 30-8 (1,674) 5 I .. 5 3 2 ., 5 2 3 177 189 182 190 126 133 } 3I-I (9.871) 5 3 .. 5 5 4 ,, 5 4 5 193 201 198 206 136 142 1 31-9(36,989) 5 5 ,, 5 5 6 ., 5 6 7 214 228 214 222 145 148 } 32-9 (76,157) 5 7 ,. 5 5 8 .. 5 8 9 229 237 230 238 155 162 } 33-6(94,450) 5 9 ,. 5 5 lo ,, 5 lO II 246 247 246 254 169 174 1 34'2 (64,591) 5 II „ 6 o 259 262 178 347 (25.500) In the table the two columns of vital capacity — one taken from a number of observations, the other from calculation — are so nearly identical that we may take it that every inch in stature above 5 feet should add 8 cubic inches to the vital capacity. The last column has been added to show the cor- responding circumferential measurements of the chest. Hutchinson^* further showed that body-weight influences the vital capacity. At the height of 5 feet 6 inches the vital capacity increases in the ratio of i cubic inch per pound, as the body-weight rises from 105 pounds to 161 pounds (ii| stone). Above this Hmit, however (up to 196 pounds, or 14 stone), as the person becomes heavier the capacity dimin- ishes in the same proportion, losing i cubic inch per pound as the weight increases. After thirty and up to sixty years of age, there is a decrease of nearly i^ cubic inches per year of age. In disease the vital capacity decreases from 10 to 70 per cent. This diminution is dependent upon, but not directly proportional to, the extent Qf breathing surface encroached upon, since the lung or por- 28 DISEASES OF THE LUNGS AND PLEURA tion of lung remaining healthy may take a compensatory action (Waldenburg). Topography of the Chest. — For convenience in clinical ex- amination and description, the chest is mapped out into cer- 1 2 3 4 5 Fig. 6 (from Quain's "Anatomy"). A, Upper margin of sternum = intervertebral disc between second and third dorsal vertebras; B, second costal cartilage = fifth dorsal vertebra; C, infrasternal depression (xiphisternal articulation- intervertebral disc) between ninth and tenth dorsal vertebra (spine of the eighth dorsal vertebra). The lines of longitudinal parallels are indicated by figures and arrows above the diagram. N.B. — The line of the secondary fissure should run more horizontally across the chest at about the level of the fourth rib. tain regions. These are sufficiently indicated by the terms employed, viz. : Anteriorly, the supraclavicular, clavicular, infraclavicular. mamary and inframammary regions, on the right and left sides respectively. PHYSICAL EXAMINATION OF THE CHEST 29 In the median line, the suprasternal, upper sternal and lower sternal regions. Laterally, the axillary and infra-axillary regions. Fig 7 (FROM Quain's "Anatomy"). X, Seventh cervical spine = apex of lung ; A, commencement of great fissure (apex of lower lobe)=tip of spine of second dorsal vertebra — i.e., 2 inches below summit of lung; B, bifurcation of trachea — lower part of body of fourth dorsal vertebra, or between the third and fourth dorsal spines (level of junction of manubrium and gladiolus sterni anteriorly); C, long axis of spleen = tenth rib; D, base of lungs^tenth dorsal spine; E, upper end of left kidney = eleventh dorsal spine, the right being \ inch lower; X=first lumbar spine. The lines of longi- tudinal parallels are indicated by figures and arrows above the diagram. Posteriorly, the upper scapular (supraspinous), the lower scapular (infraspinous), the interscapular and the basic regions on each side. 30 DISEASES OF THE LUNGS AND PLEURA For the purpose of more accurately noting for future refer- ence the locality of any particular physical signs, there is no better or simpler plan than that of employing imaginary Hues and levels drawn upon the chest surface (see Figs. 6 and 7). Thus the chest can be mapped out in latitude and longitude Fig. 8. — Showing the Relation of the Thoracic Viscera to the Chest Wall. (After Professors Merkel and Thane, slightly modified.) by parallel vertical lines drawn from summit to base through the mid-sternal (i), parasternal (2), sterno-nipple (3), nipple (4), anterior axillary (5), mid-axillary (6), posterior axillary (7), m,id-scapular (8), interscapular (9), and vertebral lines (10), intersected by parallel lines drawn horizontally at the levels of the several rib cartilages in front and the several spinous pro- PHYSICAL EXAMINATION OF THE CHEST 31 cesses behind, with the addition of nipple level, ensiform, level, etc. A careful observation of the accompanying diagrams (Figs. 6 and 7) will impress upon the memory the main features in Fig. 9. — Showing the Relation of the Thoracic Viscera to the Chest Wall. (After Professors Merkel and Thane, slightly modified.) the topography of the chest organs and of those of the abdominal viscera in immediate relation v/ith the chest. Mar- ginal references are made at certain levels to facts of topo- graphy, which it is of some importance to bear in mind in clinical work. It will be observed that the upper or anterior 32 DISEASES OF THE LUNGS AND PLEURA lobes of the lungs occupy most of the front aspect of the chest, whereas posteriorly the lower or posterior lobes cor- respond with nearly the whole surface. The relations of the thoracic viscera to the chest wall are shown more in detail in Figs. 8 and 9. REFERENCES. ^ Recherches Clitiiques sur VEmfloi d'un Noveau Procede de Mensura- tion dans la Pleuresie, par E. J. Woillez. Paris, 1857. ^ Auscultation and Percussion, by Samuel Gee, M.D., p. 11. London, 1S70. 3 Diseases of the Lungs, by W. H. Walshe, M.D., F.R.C.P., fourth edition, p. 30. London, 1871. ■* Statistics, Medical and Anthro-pological, by J. H. Baxter, A.M., M.D. Washington, 1875. ^ A Clinical Textbook of Medical Diagnosis, by Oswald Vierordt, M.D., Professor of Medicine at the University of Heidelberg, translated by Francis H. Stuart, M.D., p. 163. London, 1891. ^ On Stethometry : a New and more Exact Method of Measuring and Examining the Chest, with Some of its Results in Physiology and Practical Medicine; also an Affendix on the Chemical and Microscofical Examina- tion of Resfired Air, by Arthur Ransome, M.D. London, 1876. ' " The Mechanism of Respiration in Man," by Dr. Arthur Keith, with bibliography, in Further Advances in Physiology, edited by Leonard Hill, M.B., F.R.S., p. 182. London, 1909. ^ Die fneumatische Behandlufig der Resfirations- und Circulations- krankheiten, von Dr. Med. L. Waldenburg. Berlin, 1880. ^ [a] " On the Capacity of the Lungs and on the Respirator}' Functions,'' by John Hutchinson, Transactions of the Royal Medical and Chir- urgical Society of London, 1846, vol. xxix., p. 137. [b] Loc. cit., pp. 164 and 174. CHAPTER III PHYSICAL EXAMINATION OF THE CHEST [Continued] In physically exploring the chest, inspection, palpation, per- cussion and auscultation are successively employed. Inspection. The chest should always, if possible, be uncovered, so that a general view of its conformation can be obtained. We may thus observe the broad, well-formed chest of robust health, or the small, narrow, long chest adapted to small lungs, with antero-posterior and lateral diameters diminished, costal angle* narrowed, and ribs unduly oblique and approximated; or, again, the thorax may be expanded, with widened inter- costal spaces, straightened ribs, increased costal angle, and deepened antero-posterior diameter — making up the round- shouldered, barrel-shaped chest suited to the accommodation of enlarged lungs. Further, the thorax may be distorted by various kinds of spinal curvature, by rickets in. early life, or by continued pressure in any particular direction. Finally, there may be local flattenings or bulgings of the chest walls, due to alterations in the subjacent viscera, and giving rise to a want of symmetry on the two sides. The jnovcments of the chest are of great importance in diagnosis. The free and equable expansion of the chest implies the free entry of air into the lungs ; on the other hand, relative immobility or recession of any portion of the chest during inspiration signifies that the entry of air to the corres- ponding portion of lung is, from some cause, retarded or impeded. In cases of general obstruction to the entry of air, whether by impediment at the main air-passage or through- * The angle formed by the inferior margins of the chest at the ensiform cartilage. This angle should measure nearly go degrees. 33 3 34 DISEASES OF THE LUNGS AND PLEURA out the bronchial tract, there is universal recession of all the soft parts during- inspiration — the supraclavicular regions sink downwards, the hypochondria recede, and the intercostal spaces deepen during the effort to expand the chest against atmospheric pressure. When the difficulty of expansion, whether from intrinsic disease of the lung or pleura, or from obstruction of air-passages, is restricted to one side of the chest or to a portion of one lung, the restrained expansion during inspiration is limited to that portion. Thus from inspection alone we may often form an opinion as to the seat, and even surmise the nature, of the disease present. Various instruments which have already been referred to — callipers, cyrtometer, double tapes — are valuable for the pur- pose of recording differences in shape and measurement, but the information which they are useful in recording is at once obtained by the eye of the trained observer. By inspection we thus learn : (i) whether a patient be large- chested or small-chested; (2) whether the shape of the chest be good and symmetrical, deformed, flattened, or bulged in any of its parts; (3) whether its movements be free and equable, or irregular and restricted, generally or locally, and whether increased or diminished in frequency. Lastly, any surface markings, such as enlarged veins, tumours, or abnor- mal pulsations, will at once attract the eye and be duly noted. Palpation. Palpation is employed in aid both of inspection and per- cussion. (a) During preliminary inspection of the chest the position of the heart's apex-beat should invariably, and as a matter of habit, be ascertained, and any deviation from its normal posi- tion — viz., the fifth intercostal space half an inch to the sternal side of the left nipple Hne — should be noted. (b) Any local bulg'ing or tumour will naturally be manipu- lated to ascertain its relation with bone or soft structure, whether it be solid, fluctuating, or pulsating; also any tender- ness will be observed. (c) The expansion, symmetrical or otherwise, of the two sides will be observed by placing the hands evenly on the two sides of the chest. PHYSICAL EXAMINATION OF THE CHEST 35 (d) In connection with percussion the observer should notice differences of resistance as well as of tone. (e) Increase or diminution of vocal znbration or fremitus will be noted over any spot of altered resonance by applying the hand, and making the patient utter some resonant words, such as " ninety-nine." Vocal fremitus is increased by consolidation of lung, pro- vided the bronchi be not occluded; diminished by much thick- ening of the pleura, by obstruction of the main bronchus, or by air in the pleura ; annulled by fluid in the pleura, if in suffi- cient quantity. The loudness or feebleness of the voice, as well as height or depth of pitch, must of course be taken into account in judging of fremitus, and corresponding parts on the two sides should always be compared. Any vibration from above can be checked by applying one hand lightly and edgewise to the chest above the part which is being palpated. (/) Loud, coarse, bronchial rales may cause the chest walls to vibrate perceptibly, producing rhonchal fremitus; some- times cavernous or large crackling rales will do the same. Pleuritic friction may likewise be perceptible to the hand — friction fremitus. In cases of effusion into the pleural cavity, or in hydatid cysts n^ar the surface, fluctuation may some- times be elicited. Pp:rcussion. Percussion is the method by which we test the resonance of various parts of the thorax, and compare it with that which experience has found to obtain in health. The varying deg'rees of resonance depend upon the relative amount of air and soHd structure subjacent, and upon other causes to be incidentally noticed. It is interesting- to note that while inspection and palpation have been practised since the earliest times, percussion, as a means of diagnosis in diseases of the chest, is of compara- tively recent origin. It was first employed by Auenbrugger,^ a Physician of Vienna, in 1761, but its importance was mis- understood, and it was not until 1808, ten years before the discovery of auscultation by Laennec, that Corvisart, of Paris, Laennec's teacher, brought Auenbrugger's forgotten work to notice, and the method came into general use.-" 36 DISEASES OF THE LUNGS AND PLEURAE Method of Percussing. — It is best to use the fingers only for percussing. One finger of the left hand should be placed firmly upon the chest so that the two last phalanges are accurately applied to the part percussed. With one or two of the fingers of the right hand, semi-flexed, the percussion should be made, so that the stroke fall vertically upon the applied or pleximeter finger. Be it observed: — 1. That the pleximeter finger be applied accurately and with sufficient firmness. 2. That it be applied precisely in the same manner and to the same spot on the corresponding sides of the chest in comparing them; for instance, the finger must not be applied along the intercostal space on one side, and across the ribs on the other. 3. The percussion stroke must be made from the wrist, quite vertical to the surface percussed, and in comparing two spots the force of percussion must be the same. These con- ditions cannot be nearly so well preserved if percussion be made from the elbow. 4. As a rule, the percussion stroke should be light. The precise limits of dulness, whether in chest or abdomen, can- not be ascertained by hard percussion, since the vibrations of collateral parts are too strongly elicited. It is laid down in most textbooks that percussion should be made " stac- cato," the percussion finger not being allowed to rest upon the pleximeter. This, we are convinced, is an error, which is avoided by non-observance by nine out of ten of the best manipulators in actual practice. It is sometimes, of course, advisable to employ the lightest possible staccato percussion, and it is also sometimes necessary to employ hard percussion to elicit dulness or resonance of deep-seated parts. 5. The sense of touch must be used equally with that of hearing in percussion, and the degrees of resistance appre- ciated by the pleximeter finger are to be carefully noted. In this way the hardness and want of resilience over dense sub- jacent tissues may be readily felt. Various pleximeters and plessors are used by some observers, modifications of those originally designed by Piorry.^ The simplest pleximeter consists of a piece of ivory some two inches long and half an inch broad, the plessor being a small hammer with an india-rubber tip to the striking PHYSICAL EXAMINATION OF THE CHEST 37 surface. These instruments may be of value in demonstrat- ing to a class, but their employment by students should not be encouraged for three reasons : 1. We may rely upon having our fingers with us, but are apt to leave detached instruments behind. 2. Patients when very ill are frightened* or annoyed by instruments, and may be readily hurt by them. 3. The important reason is, however, that in using such instruments we deprive ourselves altogether of the informa- tion gained by the sense of resistance. Some physicians are inclined of late to take to the pleximeter, still using the fingers as the plessor; but inasmuch as it is the pleximeter finger with which we chiefly appreciate resistance, the objection in greatest measure still holds good. The position of the patient during physical examination of the chest by percussion and auscultation is of importance. If not in bed, the sitting posture, with the back supported by a cushioned chair, is the best for examining the front o'f the chest; if in bed, the semi-reclining posture with the back firmly supported. Whilst the back is being examined the patient should be directed to lean slightly forward, and to let the arms fall loosely down between the knees, in which position the suprascapular regions, at which the summits of the lungs aj-e situated, are best exposed. If the patient stoops forward too much with folded arms and bent back, the respira- tory movements are impeded, and a very considerable amount of dulness may be developed at the right base by the thrust- ing backwards of the upper posterior surface of the liver. Each region of the chest surface should be systematically tested by percussion, the two sides of the chest being at all points compared. Not only, however, must the two sides of the chest be thus compared from above downwards, but per- cussion should be employed from side to side across the sternum, so as to define the limits of the anterior margins of the lungs from either side. By this means valuable informa- tion is often elicited in cases of consumption, new growths, and pleuritic effusions. It is useful in practice, having ascer- tained the lower limit of resonance, to direct the patient to make a full inspiration and expiration whilst repeated light percussions are being made. The pleximeter finger can fol- low up and down the level of resonance, and in this way 38 DISEASES OF THE LUNGS AND PLEURA valuable information as to the mobility of the diaphragm and expansibility of the bases of the lung can be obtained. In the healthy chest we obtain during moderate expiration superficial cardiac dulness. This corresponds roughly with a triangular area, marked off by a line curving outwards towards the apex, from the lower margin of the fourth left costal cartilage at its junction with the sternum, by a second line running vertically down the centre of the sternum, whilst the base is formed by a horizontal line passing from the apex-beat to the mid-sternum. On firm percussion the deep cardiac dulness may be elicited as high as the third left carti- lage and the rig^ht margin of the sternum. Stomach note is obtained at the sixth costal cartilage in the left mid-sterno- nipple line; and in the left postero-axillary line a small area of dulness extending from the ninth to the eleventh rib and reaching to within two inches of the middle line posteriorly, marks the situation of the spleen. On the right front of the chest, in the nipple line, liver dulness is elicited below the level of the sixth rib, and on deep percussion, for a rib higher; posteriorly about two fingers' breadth of dulness at the extreme right base marks that portion of the liver which is here in contact with the chest wall. Lung resonance is obtained anteriorly as high as the supraclavicular fossa, and posteriorly extends upwards to the level of the seventh cer- vical spine, i.e., about one and a half inches above the level of the clavicle. It is in these higher regions of the chest, corresponding" with the apices of the lungs, that the first evidence of tuberculous disease is usually detected. In disease the percussion note is altered in various ways, as may be seen from the following table, which includes all the terms used in a technical sense, which are necessary for describing" the sounds met with in diseases of the chest. They are — with one or two unimportant additions — those which were carefully selected by the late Dr. Mahomed and by Dr. Douglas Powell, acting as English members of a committee nominated at the International Medical Congress held in London in 1881, to endeavour to simplify the terminology o; auscultation for international use. PHYSICAL EXAMINATION OF THE CHEST 39 Terms. PALPATION. Vocal fremitus. Normal. Increased. Diminished. Absent. Rhonchal fre- mitus. Friction fre- mitus. PERCUSSION. Normal reso- nance. Increased re- sonance. Tympanitic resonance. Skodaic re- sonance. Impaired re- sonance. Absence of resonance. Amphoric re- sonance. Definition. The transmission of laryngeal vibrations to the chest wall, ap- preciable by the hand. Transmission of the vibration of rhonchus to the hand applied to the chest. Transmission of the vi- brations of pleuritic friction. An arbitrary term sig- nifying the varying degrees of resonance of the different parts of the chest within the range of health. Drum-like note. A peculiar form of tym- panitic resonance of high pitch and great clearness. The modified impair- ment of resonance sometimes elicited over a cavity, and often accompanied by " cracked -pot sound {hniit depot/ele). Synonyms. • • • ■ Hyper-resonance. Relaxed lung note. Dulness of different degrees. Hardness. Wooden percussion. Absolute dulness. Tone- lessness. Flatness. Tubular note. Common Significance. Consolidation of lung. Bronchial obstruction, or separation of lung from parietes by thickened pleura. Effusion of fluid or air in the pleural cavity. Partial obstruction of larger bronchi. Bron- chitis. Pleuritic roughening. Health : — needs confir- mation by other signs. Air in the pleural ca- vity. Lung in contact with chest wall rel.-i.\ed, but not compressed, by moderate effusion into the pleura. Cen- tral consolidation in pneumonia will some- times produce this note. Incomplete consolida- tion ; coexisting in- creased resistance may often be appre- ciated during per- cussion. Consolidation of lung, or its displacement by fluid or tumour. Pulmonary excavation near the surface and freely communicat- ing with the bronchi. Normally obtained on • percussing the trachea with the glottis open. 40 DISEASES OF THE LUNGS AND PLEURA Terms. Definition. AUSCULTA- TION. Breath-sounds. Vesicular. Exaggerated. Weak. Suppressed. Interrupted. Prolonged expiration. Broncho- vesicular. Bronchial. Inspiratory sound soft and breezy ; expira- tory sound shorter, weaker, or even ab- sent. There should be no perceptible pause between the inspiratory and expi- ratory sounds. Intensified normal breath-sound, due to increased movement of tidal air. Deficient movement of tidal air. Inspiratory sound par- tially or completely divided into two or three sounds. Expiration lengthened to or beyond duration of inspiration. The vesicular part of the breath - sound being partially an- nulled, the tubular or glottic portion of that sound is heard with greater distinctness, especi- ally during expira- tion which is pro- longed. A blowing breath-sound, the inspiration and expiration being about equal in pitch and duration, and distinctly divided. Placing mouth in pKJsition to pro- nounce word com- mencing with gut- tural ch (x), and drawing breath to and fro, imitates the sound with exact- ness (.Skoda). Synonyms. Normal breath-sounds. Puerile. Compensatory. Supplementary. Feeble. Partial sup- pression. Absence of breath- sounds. Jerking. Wa\-j'. Cog- wheeled. Respira- tion saccadic. Common SiGNIFICANXE. Harsh. Coarse, tubular. Sub- Healthy lung. Tubular. Blowing. Tracheal. May be high-pitched or whif- fing, medium, or low- pitched. Increased function. When heard over a portion of one lung signifies compensa- tory action to make up for deficiency or disease elsewhere. Normal in young children, and in adults during violent exer- cise of the lungs. Diminished function. Lung distant from .sur- face, or bronchus ob- structed. Irregular expansion of lung from partial consolidations^ about small bronchi ; but often of purely ner- vous origin through irregular contraction of muscles. Partial consolidat'on of lung or partial ob- struction of bronchi. Commencing consolida- tion. Some authors use the term as descriptive of the roughened breath- sound of dry catarrh of the larger bronchi. (Heard normally in neighbourhood of bronchi.) Hepatisation or con- densation of the lung. (Heard typically over trachea.) PHYSICAL EXAMINATION OF THE CHEST 41 TERiVIS, Breath-sounds {continued). Cavernous. Amphoric. Adventitious .sounds. Rales. Varieties — I. Dry rales. Sonorous rale. Sibilant rale. Sonoro-sibi- lant rale. Stridor. 2. Moist rales. Small bub- bling rale. Medium and large bubbling rales. Definition. A blowing breath-sound of hollow quality, most so in the expi- ratory portion, which is usually of lower pitch than the in- spiratory. Similar to the above, but -.vith blowing character and hol- lowness intensified. Adventitious sounds produced in the bron- chi and lungs under diseased conditions by the passage back- wards and forwards of the tidal air. A low-pitched, loud, snoring sound, pro- duced by partial ob- struction in a large bronchial tube, which imparts vibrations to the air-current. A high-pitched, whist- ling sound, produced in the same manner as the rhonchus, but in a smaller tube. The commingling of the two former sounds. A coarse, vibrating rhonchus, generated at the larynx, or by pressure on the tra- chea or main bron- chus. Moist sounds or rattles, produced by the bub- bling of air through fluid in the bronchi or lung. A rale produced by the bubbling of air through fluid in the finer bronchi, and more or less muflled by transmission through spongy lung. Similar rales generated in the larger tubes. Synonyms. Rhonchus. Sibilu Stridulous rhonchus. Common Significance. Liquid rales. "Mucous rales " of Laennec. Tracheal rattles. Pulmonary excavation, or condensed lung with dilated bron- chus. Large pulmonary cavity ; sometimes heard in pneumo- thorax. Bronchitis of the larger air-tubes. Bronchitis, or spas- modic narrowing of the medium or fine tubes. Pressure of a malign " nt or aneurismal tu- mour upon trachea or main bronchus, sometimes produced by laryngeal para- lysis. Capillary bronchitis. Pulmonary oedema. Bronchitis of the larger tubes. Secretion col- lecting in trachea during last moments of life. 42 DISEASES OF THE LUNGS AND PLEURA Terms. Adventitious sounds {con- tinued). Small crack- ling rale. Medium crackling rales. Larger crack- ling rales. Gurgling rales. Clicking sounds. 3. Fine-hair cre- pitation. Metallic tinkling. Splash, Definition. Synonyms. A fine rale produced in the minute bron- chioles of consoli- dated lung, consist- ing of numerous small, sharply de- fined crackles, chiefly audible during in- spiration, but in less degree w.th expira- tion. Similar to above, but of larger size. Crackles of larger size, and fewer in number, produced in connec- tion with minute pul- monary cavities. Larger and more liquid rales, produced in- connection with cavi- ties of medium and large size. Single sounds, or few in number, mostly limited to inspira- tion, and of sticky, semi-fluid character. A minute dry crackling sound, in which the crackles are infinitely small and even, and occupy chiefly the latter part of inspira- tion ; produced by the separation of sticky alveolar walls which had previously been in contact. The metallic resonance sometimes imparted to a moist sound by a large pulmonary or other cavity. The sound may be gene- rated in the cavity or resonated from a bronchus in connec- tion with It. The succussion of air and fluid in a large cavity, produced by the shock of cough or by shaking a patient, with the ear applied directly to the chest wall. Subcrepitant rale. Crepitations. Crepi- tant rale. Sharp crepitations. Cavernous rales. Pneumonic crepitation. Hippocratic succussion sound. Common. Significance. Thin fluid in minute bronchial tubes, with consolidation of the surrounding lung — e.g., resolving pneu- monia. Resolving pneumonia, broncho - pneumonia, or softening tubercle. Softening tubercle. Cavity in the lung. Commencing softening of tuberculous de- posits in the lung. Early stage of pneu- monia. The sound is sometimes heard in a certain degree of pulmonary oedema, and during the first two or three deep inspirations over a portion of lung not recently used — e.g., the extreme bases in bed - ridden pa- tients. Pneumothorax, or large pulmonary cavity. A large cavity contain- ing air and fluid. Hydro- or pyopneu- mothorax. PHYSICAL EXAMINATION OF THE CHEST 43 Terms. Adventitious sounds {con- tinued). Bell sound. Friction. Dry friction. Moist friction. VOICE-SOUNDS Normal. Increased or diminished. Annulled or absent. Bronchophony Pectoriloquy. ^gophony. Amphoric echo. Definition, A metallic ring heard on sharp percussion over a pneumo- thorax, commonly elicited by the use of coins. A rubbing sound pro- duced by the move- ments of two sur- faces of the pleura which are in contact and inflamed. A sound often closely imitating moist cre- pitation, produced by the attrition of sur- faces covered by soft, moist lymph. The sound of the voice transmitted through the healthy lung. Synonyms. Bruit d'airain. Leathery or creaking friction. Dry rmb. .Spongy friction. Fric- tion crepitus, etc. The loud transmi.ssion of the laryngeal vi- brations, apart from articulation. The clear transmi.ssion of articulate sounds. Heard best during whispering, when bronchophony (which usually, but not always, accompanies it) is excluded. A modified Ijroncho- phony, having a high-pitched, tremu- lous character, pos- sibly due to the transmission of the upper tones or har- monics, the funda- mental tones being intercepted. An echoing character accjuired by the voice sounds when conveyed through a large air-containing cavity. Metallic echo. Common Significance. Pneumothorax. Pleurisy. Heard at commence- ment and at termina- tion of pleuritic attack. Sometimes heard over upper confines of re- cedsnt effusion and in other conditions of thick, moist pleuritic exudations. Lung separated from chest wall by fluid or growth. Pulmonary consolida- tion. Cavity in the lung. A close imitation of the sonnd—pectori- loguie apho7tique — may be sometimes heard through a pleuritic effusion (sero • fibrinous) on making the patient whisper roughlj'. Pleuritic effusion. Pneumothorax. 44 DISEASES OF THE LUNGS AND PLEURA J30 _,(u"oc.Svh C 2^ ,'i^'2^>'-'«§ t «2 -StJ^-S-S-^-- J • 'o S U -n >< "m "It O rt u . I-. \. o ^ rt a .c^ s -5- M) « « 6 « S2 g ^^o rib 5^ . -I^- s-s »^ - roeOcL,B3uiy+ji^ 'T-i-" Ho Crrt dC g is "^-^ti^l 111 i^-^- 2= ° ° V Lh rt I) E 3 d 3 oS c«So?^^c o-og g^-B rt, ^Jl^3.Sf^C8 < fa > ^ I nidi's --§•§§ I ^ |S •§>>.- S 2 S rt ?? cn a /'ca3 C(U[-i::3c^t'5 ... PHYSICAL EXAMINATION OF THE CHEST 45 01 ^H .3 .C Ul 0) to (U O o o 3 rnag oyen hiqu rfic re. -0) -0) O C/5 en n..-B > 03 3 O 30 « 3 a) su rf) fort vesicu que a ou Si ^ ^ ^^ a 3 ■g "^6 x-g en O Bru mch: gros imb: impl 3 4-> "S, .s ■"3 3 Ph5-S en « - (n tement metallique, cussion Hippocrat ttement. -a B i S. ffle btonchique ) profond ; (c) do piration rude bro ffle cavitaire am usical ou metallii ffle cavitaire si 13 o en 3 en tn 3 .13 o c o .3 cn -4-» 3 ■53 ement larynge. ) tracheal ; (b) bi es humides : (a) ) fins ; (a) avec ) sans timbre ou gouillement. quements : {a) se es crepitants. •aj 3 rt a X X nchophonie. toriloquie. ophonie. J3 3 -c> u) 3 E 3 o o a s~ ^^;3^e 2S .5^2 'o'o ^ f^ CD en Cc^ 'in Pd OU« Hi/)fe >> ■0 0) c .'i CO -I.* CO o tn 3 ■■a u -a "o .s o I ■IS CO o en 3 :ca u 9i be 3 v CO " 3 m S lA (fi (J • •^ be en .ir' a M en 3 2 '3 b03 r3 0) en .in 3 !2 « 2 tn be (U ..I .S6 o --^ 73 ^ en 2 eg O J3 y 3 o .y i; _ 3 .i: (O u, (U 3 Jr! 4) ;:3 en be iJ M^ 3 a> en S eg O J3 2 3 >- « 3 « lU a a (/) 4) T3 3 4> •a I (=: l 3 • ^ 4; 'b 4) O — . - o o o n 1-1 - >- 4) M 3 c« .-o (It Q •3—' , 3 o • T) o a 4) iH .2 «eQ ■t-i > o ca " 5 o 3 I- X . . f 3' u" &, J en be 3 CO nj - oc/3 I 13-S 1- ^-3 o o ca -^ *^ >-^ r^ r^ (11 Q q 3 -S 3 U « H-l H > 10 >o f^ 00 en 3 O a 4) > ca U di CO 5 c o ca to — , O en i-i 3 O . 3 • 2 O .3 <" o ,-^ 3 « O ^-^ -3 o 73 So i- 100 o a be f>^ :§ -a 3 3. .H . 3 :=:'« 9 ca ^"IJ *j eg Q ca o o > 4J O o 3 «, is , ca "5 . <-> t! O O > i^ 3 O O 4) en 3 .i .3 3 M ?i 3 -a ^ ^ CO B -^ e 1 - ~ sis s ■" o o ," '^ ^ O Cli f: 3 3 3 +^ O O 3 _ 3 b p tj 5e ' i? -I' Ijj 46 DISEASES OF THE LUNGS AND PLEURA Theory of Percussion. — The exact explanation of the sounds elicited by percussion of the chest in varied conditions is by no means easy, but four factors are concerned in their pro- duction. These are — (i) the proportion of air and solid under percussion; (2) the range of vibration of the chest wall; (3) the vibration of the air within the region covered by the chest walls, whether contained in the lung, bronchi, pleura or stomach; (4) the tension of the air within the chest. The late Dr. C. J. B. Williams and Dr. Bristowe both regarded the percussion note as primarily due to the vibration of the chest wall, and as modified only by the conditions of the underlying cavities or viscera so far as they afford vary- ing degrees of impediment to the chest wall vibration. This view cannot be accepted in its entirety, seeing that percus- sion of the lung outside the body yields a note closely resem- bling that of the thoracic sound. It is evident, therefore, that the resonant note over healthy lung must be produced in great part by the vibrations of the air within the lung itself, though these vibrations are doubtless supplemented by those originating in the chest wall. Conversely, in disease, when the lung is rendered solid by inflammation, or compressed by fluid, the vibrations of the chest wall, so far from being rein- forced, are damped, and a dull percussion note results. But although the rhythmic vibrations of the chest are not the only factors in the production of the resonant note of health, as was once held, their importance must not be over- looked, for in disease, and even within the range of health, there are many states in which impairment of resonance is to be accounted for only by a diminished resilience of the chest wall. Thus, many robust people, soldiers especially, have rigid resisting chest walls, and percussion in such persons yields a diminished sound. On the other hand, in children and in delicate persons, with thin elastic ribs, we may obtain an amount of resonance which may even mask a certain degree of underlying disease. Again, in cases of deformity of the chest, such as lateral curvature of the spine, the note over the prominence of the ribs posteriorly is generally, as the late Dr. Hilton Fagge pointed out, much impaired, although the underlying lung be healthy, a fact which can only be explained by the diminished vibrating capacity of the chest wall. PHYSICAL EXAMINATION OF THE CHEST 47 We may now turn to the last factor of which we have spoken, the tension of the air within the chest. This is of less importance than the preceding ones, but, nevertheless, must be taken into consideration. Thus, in the well-formed chest of the young adult, and within the range of normal conditions of quiet breathing, we obtain over the pulmonary regions that degree of resonance and clearness of percussion which is typical of health. At any stage of the inspiratory act, however, the percussion note is somewhat deadened by. closure of the glottis and compression of the chest by the expiratory muscles, the tension of the confined air being increased, and its vibratility and that of the chest wall dimin- ished. In pneumothorax, again, with free communication with a bronchus (when, therefore, the air has approximately the normal atmospheric tension), we obtain a deep-toned per- cussion note, the so-called "tympanitic resonance." If, how- ever, the communication with the lung be only by a valvular opening, admitting the entry, but not the escape, of air, increased tension of the air and of the chest wall results, with corresponding deadening of the note. Auscultation. This method of physical examination was not wholly un- known to the ancient Greek physicians, who were in the habit of applying the ear directly to the chest,^ and had thus dis- covered the creaking sound of pleural friction, and also the succussion splash. Curiously enough no further progress was made, and with the dark ages the method fell into oblivion, until Laennec, in the early years of the last century, rediscovered it, and worked out its appHcation to disease even in its minutest details. To him, therefore, belongs the honour of being regarded as the true discoverer of auscultation, and the publication of the first edition of his great work, " Traite de I'Auscultation Mediate," in 1819, must ever remain a land- mark in the history of medicine. Auscultation may be practised by using the unaided ear applied directly to the chest, or separated from it only by a towel (immediate auscultation), or by employing a stetho- scope, either solid or flexible, to convey the sounds from the chest wall to the ear (mediate auscultation). 48 DISEASES OF THE LUNGS AND PLEURA In England the latter method is commonly employed, the binaural flexible stethoscope being now generally used. But it should be remembered that though this instrument pos- sesses great advantages in that it can be used with greater ease and rapidity than the single stethoscope, yet the latter conveys the sounds with greater exactness to the ear, though some of their loudness is lost by their passage through the instrument. In certain circumstances immediate auscultation may be preferred, as when in an advanced case of emphysema the breath-sounds are extremely weak; but the difficulty of localising the exact spot auscultated by the unaided ear mili- tates against the more general adoption of the method, which nevertheless is much practised by certain French physicians of distinction. The student should lose no opportunity of familiarising himself with all three methods of auscultation, and be ready to use each as occasion may require. Theory of Auscultation. — It is generally agreed that, with the exception of normal vesicular inspiration, all varieties of breath-sound, whether healthy or morbid, are generated in the larynx, and modified in their transmission through the different media which, normally or abnormally, intervene between that organ and the point of observation. Concerning the vesicular murmur, there has been much diversity of opinion. It has been urged by some that this also is nothing more than laryngeal breathing, altered by its transmission through layers of spongy and badly conducting" lung". Others, on the contrary, attribute to the inspiratoi-y por- tion a double origin, and believe it to be in part a glottic sound, more or less modified by conduction, and in part produced within the lung itself by the formation of a "fluid vein," as the air passes from the terminal bronchus into the expanded infundibula beyond. The latter view seems, on the whole, the more correct, and our knowledge of this subject may be summed up in the following" propositions : I. The vesicular respiratory murmur should be regarded as a sound having a double mechanism, being made up of (a) a bruit produced by the passage of air to and fro through the glottis, and reverberated downwards through the bronchial tubes; (b) an infinite number of minor bruits similarly pro- duced at the openings of the pulmonary infundibula. The PHYSICAL EXAMINATION OF THE CHEST 49 expiratory portion of the murmur is almost entirely of glottic mechanism. 2. All other breath-sounds are due to the conduction of the glottic bruit (or laryngeal breath-sounds) above mentioned, through media of different kinds, forms and densities; any local currents of air being only so far operative inasmuch as they serve to assist conduction. Let us now consider the matter in greater detail. Vesicular Murmur — Normal Breath-Sound. — It was origin- ally thought, as the name, indeed, implies, that the vesicular murmur was produced solely by the entry of air into the air- vesicles of the lung. Very soon, however, this view was opposed, and in 1834 Beau' sought to prove that tracheal, vesicular, bronchial and cavernous breath-sounds resulted from the conduction to the surface of the lung of a single sound which was produced in the superior air-passages. The situation at which this sound originates is no doubt the glottis, for here the air passes rapidly backwards and forwards through a small aperture into a larger cavity, giving rise, therefore, to a vibrating column of air, " a fluid vein," and the production of a sound. This laryngeal breath-sound is heard loudly in the trachea, and is traceable down the bronchi as far as they can be followed. It is clear, therefore, that it must enter at least into the formation of the vesicular mur- mur. And that it does so is proved by the fact that when the larynx is much ulcerated, and the formation of a fluid vein rendered thereby more difficult, or when the organ is entirely eliminated, as by an old tracheotomy and the perma- nent wearing of a tube, the vesicular murmur over the lung becomes extremely weak. It may be added, also, in support of the part played by the glottis in the origin of the vesicular murmur, that, as shown by Laennec and Beau, in animals with long necks, such as ruminants, the respiratory murmur is much more feeble than in carnivora, though here, possibly, differences in structure and functional activity come into play. From the above considerations there can be no doubt that the vesicular murmur is to a large extent an altered glottic sound. Is it not, however, in part at least, also pulmonary, produced by the air being thrown into vibration as it passes from the minute terminal bronchi into the larger infundibula of the lung? The chief objection urged against this view 4 5o DISEASES OF THE LUNGS AND PLEURA was the belief long entertained that the tidal air did not pass beyond the finest bronchi, and consequently that the currents of air drawn at each inspiration into the infundibula, in obedience to their enlargement with the expansion of the chest, must be so slight and of so low a velocity, as to be incapable of generating a fluid vein and the production of a sound, though the necessary physical conditions are actually present. When we consider, however, the number of infundibula pre- sent in the lung (the alveoli have been estimated by the late Professor MacAHster at 355,000,000), it is evident that the in- finite repetition of even the very faintest sound must become important, and materially contribute to the respiratory murmur. Further, it was pointed out by the late Dr. Wash- bourne,^ in his Croonian Lectures, that it had been demon- strated that the upper air-passages and the ramifications of the bronchial tree possess a capacity of only 140 c.c. and can there- fore only accommodate about one-third of the 500 c.c. of air inhaled. The remainder of the tidal air must, therefore, directly enter the infundibula, and, the conditions necessary for the formation of a fluid vein being present, a murmur should arise. That some portion of the vesicular murmur is actually pro- duced in this way is strongly supported by the observations of Bondet and Chauveau,* which have never been contra- dicted, as well as by the experiments of Dr. J. F. Bullar.' The former observers experimented upon a horse suffering from pneumonia, which affected the lower half of the left lung. On auscultating the animal, exaggerated breathing Avas heard over the right lung and over the upper half of the left, tubular breath-sound being distinct over the lower or affected half of the left lung. These preliminary observations made, the trachea was opened by an incision twenty centi- metres in length, and the following phenomena were noted : 1. On auscultation over the trachea below the incision, the wound being held widely open, the inspiratory bruit was almost completely lost, and the expiratory sound but faintly audible^ 2. On auscultation over the consolidated lung, whilst the wound in the trachea was held widely open, no tubulor sound could be heard during inspiration, and only a faint, brief, and PHYSICAL EXAMINATION OF THE CHEST 5I abortive sound during expiration. Over the rest of the lung and over the opposite (sound) lung, however, the normal respiratory sounds were clearly heard. It should be added that a musical reed was introduced into the trachea, and that the artificial voice-sound so produced, though inaudible over the healthy lung, was heard distinctly over the consoHdated area, thus proving that a possible source of fallacy — viz., the blocking of the left lower bronchus by blood-clot — did not exist. It would seem, therefore, from these considerations, that the pulmonary element does take an important share in the production of the normal respiratory sound, and is, indeed, the cause of its characteristic quality. Abnormal Breath-Sounds. — IVeakness of breath-sound may simply arise from feebleness of the muscular chest move- ments. Often, however, it is the result of disease, and is perhaps best observed when a small pleural effusion partially compresses the lung. In emphysema, also, when the expan- sion of the lung is impaired owing to the over-distension and atrophy of its tissue, which characterises the disease, the respiratory sounds are weakened. Suppression of Breath-Sounds. — When a lung is separated from the surface, and compressed by a sufficient layer of fluid, or has its bronchus occluded from any cause, suppression of the breath-sounds follows. Even in cases of considerable effusion, however, a certain amount of breath-sound is heard over the upper part of the chest, the fluid naturally gravitating to the lower portion of the thorax, so that the upper area of the lung escapes compression. When the lung is separated from the thoracic wall by thickened adhesions, and, as is usually the case, is indurated and collapsed, the breath-sound is partially suppressed, the glottic bruits being only very im- perfectly conducted. Exaggerated Breathing. — This is heard in the healthy child. More rapid breathing, more rapid passage of air through the glottis and into the lungs, and greater thinness of the chest walls, are the conditions upon which this enhanced breath- sound depends. The expiration is generally rather prolonged, and both sounds are coarser than ordinary. Exaggerated breath-sound is usually, in health, limited to children of tender years, and hence its synonym " puerile breathing," but some 52 DISEASES OF THE LUNGS AND PLEURA persons preserve this quality through adult life. This variety of breathing is heard over the sound side in cases in which the respiratory function of one lung is in abeyance from any cause. It may be similarly heard over one portion of a lung, the remainder of which is diseased. Hence another synonym, " compensatory breathing." It indicates respiratory vigour, and is so far of good augury, inasmuch as it shows that an enlarged lung, or portion of a lung, is not merely dilated, but also functionally more active — a most important fact to ascer- tain in cases of one-sided chest disease. Jerking, Wavy and Cogged Breathing ("cog-wheeled respiration ") are varieties to which different authors have attached very different importance. In jerking or wavy breathing the inspiration, instead of being a continuous sound, is two or three times interrupted. The expiration is rarely affected in this way, and may be normal, or simply harsh and somewhat prolonged. One so frequently meets with jerking respiration in nervous people that, when un- accompanied by other morbid sounds, but little importance should be attached to it. The following are some of the commoner abnormal conditions under which it may occur : (i) It may be due to irregular action of the respiratory muscles under conditions of pain, as in pleurodynia, pleurisy, and myalgia. (2) It may be the result of hysteria and other nerve disorders. (3) It may be produced (mostly on the left side) by cardiac pulsation, its rhythm being then synchronous with that of the heart. (4) In certain cases it may be accounted for by textural diseases of the lung itself, or by pleural adhe- sions, which lead to a want of uniformity in pulmonary elas- ticity and expansile power. For this reason it may sometimes be met with in phthisis at quite an early stage of the disease, A remarkable instance of wavy cavernous breathing was observed by one of us in a case in which the entering bron- chus to a large cavity was partially occluded by a small pul- monary aneurism projecting into its lumen close to the cavity, and thus alternately stopping and permitting the cavernous sound. The death of the patient from sudden haemoptysis, a few hours later, verified and explained the observation.'" Prolonged Expiration. — Prolongation of expiration is per- haps the most important, as it certainly is the earliest of the signs of commencing consolidation of the lung. It marks PHYSICAL EXAMINATION OF THE CHEST ,53 the transition between vesicular and bronchial breath-sound, and it indicates that over a certain extent of lung the factors, which normally lead to the production of the vesicular sound, are partially, at least, in abeyance, tending therefore to the predominance of the unaltered glottic sounds, with their dis- tinctive characters and proportion. Thus, with prolongation of the expiration are associated other characteristics of the glottic element. For example, division between inspiration and expiration (divided respiration) may be often noticed; and as the expiration becomes more prolonged, equalling, or even slightly exceeding, the inspiration, the vesicular quality of the breath-sounds gradually disappears, the breathing acquiring at first a harsh, and later a true bronchial character. Indeed, all stages between simple prolongation of the expira- tion and true bronchial breathing, in which the glottic sounds are conducted in all their intensity, may be observed. To certain of these intermediate stages the terms "harsh," "vesiculo-bronchial," "transitional," or "indeterminate," have been applied. Bronchial Respiration. — This variety of respiratory murmur is heard normally at the lower part of the trachea, and in less degree in the first intercostal space for a short distance on either side of the sternum. In many subjects, especially, as Laennec pointed out, those who are very thin, it may be heard over the interscapular regions, from the last cervical vertebra to the level of the third or fourth dorsal, owing to the proximity of the trachea and large bronchi in this region. As a morbid sign it is heard in its most characteristic form over a lung consolidated by acute pneumonia. Bronchial breath-sound possesses a peculiar penetrating and blowing character, and, as Skoda pointed out, can best be imitated by placing the tongue in the position to form the consonant "ch" (hard x), and drawing the breath to and fro. It differs, also, from vesicular breathing in that expiration is often as loud and long as inspiration, and that the two stages of respiration are separated from each other by a perceptible pause. It varies in intensity according to the degree of con- solidation and the permeabiHty of the bronchial channels. Laennec was of opinion that the sounds originated in the affected lung, but it is now admitted that they are in reality generated in the larynx, and thence conducted down the air- 54. DISEASES OF THE LUNGS AND PLEUSLE passages into the chest, and so to the observer's ear. The following are the reasons for this beUef : 1. The breath-sounds heard over the larynx, and produced there, possess all the characteristics of bronchial breathing, and differ from the latter chiefly in their greater intensity. 2. In pneumonia, in which this form of breathing is espe- cially heard, the lung is impacted by a coagulated substance which fills it, and maintains it in the state of permanent inspiration, a condition which forbids the entry of air. The formation, therefore, of a fluid vein and the production of a sound within the .affected lung is, under these circumstances, impossible. 3. The experiment of Bondet and Chauveau upon the hepatised lung of the horse, to which we have already referred, points strongly in the same direction. These observers, on holding widely open the wound in the trachea, caused the respiratory bruit heard over the hepatised lung to disappear, whilst over the sound lung the respiratory murmur was scarcely at all modified. It would appear, then, that the two conditions for the pro- duction of bronchial breath-sound are consolidation of lung and patency of bronchi. Any obstruction of the main bron- chus will obscure the sound, and, we may add, separation of the consolidated lung from the parietes, whether by fluid or thickened pleura, will render it less distinct. In some rare cases of pneumonia the breathing is suppressed owing to the exudation overflowing from the alveoli into the small bronchi, and thus occluding them. Bronchial breath-sound may be produced by other than diseases of the lung. A mediastinal tumour, whether aneurismal or cancerous, situated between the thoracic wall and a bronchus, will yield the sound, the vibrations within the tube being conveyed through the sub- stance of the tumour almost unaltered to the chest wall. By many writers the term tubular is used as synonymous with bronchial, tubular and bronchial breathing being thus interchangeable names. .Some, however, restrict the term "tubular" to that variety of bronchial breathing which is high-pitched and whiffing in character, such as is often heard over a pulmonary cavity. Laryngeal and Tracheal Breathing, heard on auscultation over the larynx and trachea respectively, possess in a marked PHYSICAL EXAMINATION OF THE CHEST 55 degree, as Laennec pointed out, the characteristics of bron- chial breathing, and differ only in the greater loudness and intensity of the sounds. Cavernous Breath-Sound. — This consists of a hollow inspiratory and expiratory sound, which has been compared to the sound produced by blowing- into the cavity formed by the two hands. The expiration must especially be attended to in listening' for this variety of breath-sound; it is wavering, hollow, and prolong'ed. We agree with the late Dr. Austin Flint in attaching- importance to the fact that the expiration is of lower pitch than the inspiration, as serving to distin- guish cavernous respiration from bronchial, in which the inspiratory and expiratory are of similar pitch. Cavernous breathing is heard over pulmonary cavities, which are of a certain size (larger than a filbert), which are in part at least empty, and which communicate freely with one or more bronchi. As to the mechanism of this sound, it cannot be denied that it may be imitated by breathing- into the hollow of the two hands, a fact which suggests that within the chest it may be produced by the air entering and leaving a large cavity. But it may be stated at once that in general this is not the case. Cavernous breathing is nothing more than bronchial breath- ing modified by the resonating- properties of a large cavity; but though the vibrations which produce it must pass from the bronchus to the cavity, to be there modified and acquire that reverberating-, " cavernous " quality which distinguishes this form of breathing", it is not necessary for the air itself to enter, nor, indeed, would this be always possible, owing to the unyielding character of the cavity walls. That the sound is not dependent upon such entry is further supported by the fact that the cavernous quality is heard very loudly during expiration, whereas the expulsion of air from a cavity could not give rise to the formation of a "fluid vein" and the pro- duction of a sound. In short, cavernous breathing is pro- duced by the conduction of the laryngeal vibrations into a cavity, and their consequent modification, the entry of air into the cavity not being an essential factor in the process. Amphoric Breathing. — This is really a variety of cavernous breathing, the cavity being- large, superficial and thin-walled. It may be imitated by breathing into a large jar or amphora, 56 DISEASES OF THE LUNGS AND PLEUR/E whence the derivation of the name. In cases of pneumo- thorax in which the opening is free, this form of breath-sound is heard to perfection, but, as with cavernous breathing, pene- tration of the air into the cavity is not essential (Gee).^* Adventitious Sounds. — With regard to the various adven- titious sounds heard within the chest, we have based our classification upon that originally suggested by Laennec, The term " rale " is thus retained as a general name to include the numerous added sounds which in disease are produced within the air-passages and lungs by the act of respiration. Of rales there are three chief varieties : 1. The dry rale, with its subdivisions, rhonchus and sibilus. 2. The moist or liquid rale — " mucous rale " of Laennec — with its subdivisions, bubbling, crackling, gurgling and cavernous rale. 3. The fine-hair crepitation. In listening for these adventitious sounds, our attention will be attracted mainly to the inspiratory portion of the respiratory act, during which they are as a rule best heard, whilst modified breath-sounds are most characteristically heard during expiration. Concerning the mode of formation of these sounds, some are simple, and require but little explanatory comment, Rhonchi and sihili are but musical notes of higher or lower pitch, depending upon vibrations of air set up in tubes par- tially obstructed by local thickenings of their lining mem- branes, by mucous collections or pellets adhering to their sides so as partially to obstruct them, or, finally, by spasmodic narrowing- of the tubes themselves. It will be observed that all these causes of sibilant and sonorous rales within the chest are of a temporary or transient nature, and accordingly these sounds are very inconstant, appearing and disappear- ing, or shifting from one spot to another, even whilst the patient is under examination. Thus, a vigorous cough, clear- ing the tubes of mucous collection, will often for a time remove a sonorous rhonchus, while the sibilant sounds in asthma, or bronchitis with spasm, will be partially or wholly removed by the inhalation of chloroform or ether. It must further be noted that in all cases the true respiratory murmur is obscured and enfeebled by the presence of these rhonchi, to return on their removal; and it is a matter of great impor- PHYSICAL EXAMINATION OF THE CHEST 5/ tance in practical auscultation to observe whether the respira- tory murmur is altogether thus obscured, or whether the air penetrates more or less through the rales into the vesicular tissue. Stridor is a variety of rhonchus in which the vibrations are very coarse, and the sound produced rough and low- pitched. It is best heard during inspiration. It may be occa- sioned by some paralytic affection of the glottis, which pre- vents the cords from being drawn apart during inspiration, and allows them partially to flap together, and thus to vibrate. It is in other cases produced by the pressure of a tumour directly upon the trachea or a main bronchus. The vibra- tions which produce stridor, and those of the stronger forms of rhonchus, are so coarse as to be perceptible to the hand applied to the surface of the chest, thus producing rhonchal fremitus. Liquid or Moist Rale. — This variety of rale, described by Laennec under the heading " Mucous Rak," is produced, as he pointed out, by the bubbling of air through fluid, of what- ever nature, contained either in the bronchi or in cavities in the lung. The sound may be exactly imitated by blowing into soapy water with a pipe or straw. These rales differ in character according to the bubbles which produce them, and were accordingly classified by their discoverer into " large," " medium," and " small." They are much modified also by the condition of the surrounding lung. Thus, if the air- vesicles around are healthy, as in bronchitis, they have a "bubbling" quality. If, on the other hand, there is more or less consolidation, they acquire a more sharply defined char- acter, and are spoken of as "crackling" rales. If, again, they are formed in connection with a cavity, they become echoing and reverberating, and are termed " gurgling " or " cavernous." The Crackling Rale, " humid crackling," " humid clicking," or "sharp crepitation," is significant of fluid in the tubes, together with the presence of more or less consolidation in the surrounding lung. This rale is heard in broncho-pneu- monia, and very frequently in the softening stages of phthisis, in which the bronchial tubes are filled with liquid debris from the softening foci, and are themselves surrounded by patches of solid lung. In character it is a sharply-defined, moist 58 DISEASES OF THE LUNGS AND PLEURA sound, consisting of two or three inspiratory and one or two expiratory elements, the respiratory murmur being itself often masked or replaced by the crackles. The sound varies much in sharpness of definition, according to the condition of the pulmonary tissue. If this be in a state of massive tuberculous consolidation, as in the most acute form of phthisis, the clicks are strongly conducted, and metallic in character. In other cases, when the softening nodules are more widely separated by spongy and tolerably healthy lung tissue, the crackles are muffled and more or less obscured. Over portions of lung which are functionally inactive under ordinary circumstances of respiration, owing to fibroid change or pleural thickening, no moist sounds may be heard when softening takes place until a sharp cough has forced air into the tissues and produced them. This is a most important point to remember in auscultation. Cavernous Rale — Gurgling Rale. — This is nothing but a crackling rale of large size, and of a loud, reverberating quality. Bubbles bursting- in a cavity will no doubt account for the formation of such sounds, as we may perceive on listening over a secreting cavity whilst the patient coughs, when we hear the splashing' and gurgiing sounds resulting from the forcible commingling of air and fluid. But in large and comparatively dry cavities we can hardly imagine any such commingling to take place during- ordinary or deep breathing, even supposing that air passes backwards and for- wards into the cavity with any appreciable current, which is not necessarily the case. In truth entry of air into the cavity is not essential to produce the sound, since any moist rales in the associated bronchi will be heard with exaggerated intensity over the cavity, and in this way no doubt many gurgling or cavernous rales are produced. Should the cavity be of sufficient dimensions, and the rale very fine, it may then take on special characteristics, and acquire the qualities of metallic tinkling, a sound aptly com- pared by Laennec to that produced by striking a metal vessel with a pin. It is entirely erroneous to suppose — as may be demonstrated frequently on post-mortem inspections— that this variety of rale is significant of pneumothorax only; it may be well heard over a large cavity, and its mechanism is probably the same in both instances — viz., the reverberation PHYSICAL EXAMINATION OF THE CHEST 59 through a large, thin-walled, and empty cavity of a very fine moist rale produced in the bronchus or fistulous channel lead- ing to the cavity. Fine-Hair Crepitation. — Great difference of opinion has prevailed respecting the nature and mechanism of this variety of rale. All observers agree that it is best heard in the first stage of pneumonia, and some regard it as the pathogno- monic sign of that disease. This sound may be defined as composed of a variable, sometimes immense, number of sharp crackling- sounds of minute size, all perfectly similar to each other, and rapidly evolved in puffs more or less prolonged. The sounds are dry in quality, and coexist exclusively, except in rare cases, with inspiration, and, once established, remain persistent until superseded by other phenomena. The late Dr. C. J. B. Williams's description of the sound, as resem- bling that produced by slowly and firmly rubbing a lock of hair between the finger and thumb close to the ear, has been generally accepted. The fine-hair crepitation may, however, occur in conditions other than pneumonia. Thus it may be heard in healthy chests, when we auscultate the bases of the lungs of those who have been confined to bed, and instruct them to take a deep breath, thereby opening up alveoli which have been for a time disused. In disease it may occur in cases of pul- monary collapse, in certain degrees of pulmonary oedema and in the first stage of pulmonary apoplexy; although it must be confessed that in these conditions the sound does not pos- sess that sharpness which characterises it in pneumonia, and which is attributable to the increasing density of the sur- rounding lung. Whereas in pneumonia the sound is accom- panied by bronchial breathing, in other conditions it is as a rule unattended by any breath-sound. The sound is appar- ently produced by the separation of sticky aveolar walls which have previously been in contact, and in pneumonia the actual state of the lung which gives rise to it may be assumed to be one of cedematous exudation from inflammatory con- gestion. When the exudation into the air cells is complete and consolidated, the crepitation ceases. A reference may be made to one other variety of rale described by Laennec, the Dry Crackle, " craquement ou rale crepitant sec a grosses bulles." This was believed by 6o DISEASES OF THE LUNGS AND PLEURA him to have a special character, and to be pathognomonic of emphysema. In this view he has not been confirmed by later observers. The term has long been in use at the Brompton Hospital as descriptive of the few inspiratory crackles regarded as significant of commencing tuberculous softening. Pleural Friction. — This sound has been known from the earliest times, having been described by the Hippocratic writers, who compared it to "the grating or creaking of a leather thong."* Curiously enough its significance was mis- understood by Laennec, who believed the "bruit de frotte- ment ascendant et descendant," as he termed it, to be the result of intralobular emphysema.^' Its true relation to pleurisy was demonstrated a few years later by Reynaud.'- Friction is produced by roughening and inequalities of the pleural surfaces, so that the two layers no longer g'lide smoothly upon each other. It is well heard, therefore, in the early stages of pleurisy, when the pleurae are roughened, but still in contact. The sound may occur over any area of the chest, but is best heard over the lower portions, since here the movements of the pleural surfaces are most exten- sive, owing to their proximity to the diaphragm. In character the sound may resemble the creaking- of a piece of leather, dry friction^ or it may be softer in character and more like a moist rale, the term moist friction being then appHed to it. Friction may accompany both inspiration and expiration, and it is usually best heard at the end of inspiration and the com- mencement of expiration. If the pleura in contact with the heart be inflamed, the sound may be synchronous with the beat of the heart, and suggest pericarditis. Pleuro-pericardial friction, however, as the sound is then termed, may be dis- tinguished from true pericardial friction by the influence upon it of the respiratory movements, a deep inspiration or a deep expiration materially modifying the sound. Yoice-Sounds. — Enough has been said in the earlier part of this chapter respecting the mechanism of breath-sounds to make it clear that there can be no good reason for any mystery as to the way in which voice-sounds are produced, * " If the lung falls against the side, the patient coughs ... a heavy weight seems to exist in the chest, and sharp pains sting him ; and it grates like a leather thong, and stops the breath" (Hippocrates, " De Morbis," ii., § 59). PHYSICAL EXAMINATION OF THE CHEST 6l or in which they are intensified or annulled under different morbid conditions of the lungs and pleurae. There can be no doubt that they are produced in the larynx, and conducted thence downwards through the bronchial tubes. These chan- nels in the normal state are held patent by the elastic traction upon them of the surrounding lung, and they serve, there- fore, as so many speaking-tubes, although the direction of the current of air during articulation is not favourable to the best possible conduction. The rapid subdividing of the tube and the embedding of the branches in an ill-conducting material is, moreover, highly unfavourable to conduction of sound, and were it not for the shortness of distance, the voice-sounds would not be audible at all. As it is they are conducted to the ear in a muffled manner, and to the buzzing sound so produced the term normal vocal resonance is applied. If the glottis be destroyed by tuberculous or syphilitic disease, the voice-sound is, of course, annulled, and even the whisper sound is impaired, showing that the •glottis is also concerned in its production. If the main bronchus on one side be compressed or occluded, the voice-sounds are annulled on that side, and vocal vibrations, which are merely palpable sounds, are similarly obscured. A like result also follows if the pleura be filled with fluid, or the chest walls be very fat, both conditions actings as a barrier to the transmission of the vibrations. If, on the other hand, the termination of the tubes be surrounded by a better conducting material, as in pneumonia, the sounds will be conducted to the surface of the chest with their laryngeal qualities but little altered, and they will be heard loudly and clearly as though one were listening directly over a bronchus. Bronchophony, in short, will be produced. If, again, a large bronchus, instead of being subdivided into innumerable smaller and diminishing branches, abruptly terminates in an empty cavity occupying the area of its former distribution, then the voice and whisper sounds transmitted downwards will be no longer muffled by the normal lung tissue, but will be loudly heard over the region of the cavity, giving rise to bronchophony and whis- pering pectoriloquy. In certain cases of pleural effusion, and sometimes in pneu- monia, the bronchophony has a high-pitched, nasal and trem- ulous character, and is then spoken of as cugophony. The 62 DISEASES OF THE LUNGS AND PLEURA late Dr. Stone advanced the view, which has since been gen- erally accepted, that the peculiar character of this voice-sound is to be ascribed to the suppression or partial suppression of the fundamental tones, and the accentuation of the higher overtones or harmonics. He further believed that for this change to take effect the presence of fluid is essential, the slower vibrations being unable to penetrate the Hquid, while the more rapid vibrations of the higher notes are transmitted. This view, in so far as it presupposes the presence of fluid, has been disputed on experimental grounds by Sir Frederick Taylor," who suggests that in all cases the change is pro- duced by the compression of the hronchial tubes, whether by fluid or by some exudation into the alveoli, so that their shape becomes altered, and whereas normally they resonate the lower harmonics, now they can resonate only the higher ones. The tremulous, bleating character of the sound he would regard as simply the result of discord produced by the presence of " beats " occurring between the higher harmonics thus rein- forced. The hypothesis is an interesting one, especially as it attempts to explain what is undoubtedly a fact — namely, the not uncommon occurrence of segophony in cases of pneu- monia, quite apart from any effusion into the pleural cavity. It is to be remarked, however, that in cases of moderate effu- sion, in which the aegophony is heard to perfection, the bronchial tubes are not compressed, as we have elsewhere pointed out. Amphoric or metallic echo is a voice-sound which is often heard in cases of pneumothorax. It is probably to be regarded as a reflected sound, due to the impingement of vibrations against the walls of a large echoing cavity. It is best heard in cases in which the communication with the pleura is very small. Auscultatory Percussion.— T/i^ Bell Sound, or hndt d'airain, is a physical sign which we really owe to Trousseau,'* though it is probable that Laennec was to some extent cognisant of it. It is elicited by auscultation over a large cavity containing air, while an assistant percusses with two coins over the same region. The ringing sound thus produced differs markedly from the dull thud which alone is heard over the adjacent lung. In cases of pneumothorax the bell sound is often heard to perfection; but it may also be heard over large, PHYSICAL EXAMINATION OF THE CHEST 63 smooth-walled, pulmonary cavities, or a distended stomach. Subphrenic abscesses or hydatids with decomposing and gaseous contents may also give rise to it. The peculiarly ringing and musical quality of the sound arises from the air in the cavity responding to, and vibrating in unison with, one of the tones comprised in the sound pro- duced by striking" the coins. The note being thus " resonated " or reinforced, and the vibrations following each other at regular intervals, a musical character results. The fact that the bell sound is not always heard over a pneumothorax, or, having once been heard, may disappear, is probably to be explained by alterations in the size of the cavity (fluid tending to replace the air), or by variations in the tension of the con- tained air. In this way the fundamental tone of the cavity becomes altered, and reinforcement of the coin sound is ren- dered difficult. The combination of auscultation and percussion just described has been employed for very many years, but more recently a modification of the method has been introduced with the hope of ascertaining more exactly the limits of the organs within the chest, and especially of the solid organs, where these are in contact with other substances which also yield a dull note to percussion. The method is based upon the belief that the vibrations of the struck coins, or of a tuning-fork placed upon the chest wall, are conducted over the chest partly through the parietes and partly through the underlying viscera, and it is asserted that, so long as the stethoscope is confined to the organ over which the pleximeter coin or tuning-fork is placed, the sound is heard with com- paratively little diminution in loudness; but so soon as the limit of the viscus is overstepped, or we pass from one lobe of the lung to another, a corresponding hindrance to the pas- sage of vibrations occurs, and the sound at once loses much of its intensity. We have tested this method, but have not been able to satisfy ourselves of its accuracy. Roentgen Rays. After examining the chest in the manner which we have described, it is sometimes advisable to supplement our methods by the employment of the X-rays. For the applica- tion of Professor Roentgen's discovery to the diagnosis of 64 DISEASES OF THE LUNGS AND PLEURA diseases of the chest we are much indebted to the pioneer work of Dr. Hugh Walsham. The patient may be examined by means of the screen (radioscopy), or a photograph may be taken (radiography). With the former, in addition to the shadows which alone are represented in a photograph, a lightening and deepening of the shadows during inspiration and expiration respectively can sometimes be observed; the movement of the heart and diaphragm can be also studied, as well as the pulsation of any abnormal tumour which may happen to be present. But in a doubtful and difficult case a photograph (radiogram) should not be neglected, since shadows are often thus demonstrated with greater dis- tinctness. In certain chest diseases the rays prove of great assistance. Thus, in a case in which the diagnosis lies between aneurism and new growth, an examination with the screen may reveal the sharply-defined pulsating shadow so suggestive of the former. Similarly, the presence of a foreign body in the chest may be shown, and its situation accurately localised by the stereoscopic method invented by the late Sir Mackenzie Davidson. Again in hydatid disease of the lung the X-ray appearances are often characteristic. In pneumothorax the appearances seen are instructive and interesting, but, as ordinary cHnical methods are generally sufficient for the diagnosis, the rays are here of less assistance. In regard to the early diagnosis of phthisis, symptoms and physical signs have in our experience manifested themselves as a rule before any characteristic X-ray appearances. , alveolar epithelium; b, myelin forms; c, ciliated epithelium; d, crystals of calcium carbonate ; e, haematoidin crystals and masses ; /, /', white blood-corpuscles ; g, red blood-corpuscles ; k, squamous epithelium. (Eyepiece III., Objective 8a, Reichert.) present, and have no pathological value. When the sample is very liquid, clear, and contains only these cells and no other form of epithelium, it may be concluded that the specimen consists of saliva only. 2. Ciliated or Columnar Cells (Fig. 11, c) are derived from the greater part of the respiratory passages, including the posterior nares. When seen in large numbers, they indicate a catarrh of the passages. Cilia are only found attached to them when the inflammatory process is very acute. 3. Alveolar Cells (Fig. 11, a, a', a") from the air-vesicles of the lung are but rarely seen in a perfect condition. They are elliptical in shape, each containing one nucleus, which usually requires acetic acid to render it visible. The protoplasm of the cells is finely granular, and often contains pigment par- ticles. Not uncommonly they are observed to be undergoing 72 DISEASES OF THE LUNGS AND PLEURA fatty degeneration, and occasionally are so altered as to be hardly recognisable, their protoplasm being replaced by large, highly refracting particles, named by Virchow " myelin drop- lets " (Fig II. b), which may also be floating free in the sputum. Alveolar cells are found in connection with various diseases, and neither they nor the myehn droplets have any diagnostic value. Elastic Fibres, when present, can nearly always be found in opaque portions picked out from the sputum as above directed. Another method generally adopted is that introduced by the late Dr. Samuel Fenwick." The whole of the sputum for twenty-four hours is collected and boiled for a few minutes in >h- Fig. 12. — Elastic Fibres obtained from Sputum after a Dose of Tuberculin had been administered. a beaker, with an equal quantity of a solution of caustic soda, 20 grains to the ounce, and occasionally stirred with a glass rod, until it becomes diflluent. As soon as it is quite liquid, the mixture is thrown into a conical glass containing several times its bulk of water. In a short time a deposit will have settled, and portions of it may be removed with a pipette and placed under a microscope, when the elastic fibres will readily be recognised. The liquid may, if necessary, be centrifugalised. Care must be taken not to boil too long, or the fibres them- selves will become swollen and ultimately dissolved. The characteristics of these fibres (Fig. 12) are their sharp- ness of outline, indestructibility, dichotomous branching, and general contour marked by wide curves and loops. By these EXAMINATION OF THE SPUTUM 73 appearances they may generally be distinguished, but some- times threads of cotton or the mycelium of fungi may resemble them somewhat closely. Under these circumstances resort must be had to differential staining, elastic fibres taking a brownish-violet colour with acid solution of orcein, and resist- ing decolourisation on subsequent treatment with acid alcohol, whilst other matters are but faintly stained. The late Sir Andrew Clark was the first to insist upon the important conclusions that may be derived from a minute examination of the elastic fibres. If they form complete sheddings of the alveoli, the morbid process is a very acute one, and destruction of the lung is proceeding rapidly. In more chronic conditions only small "tailed" pieces will be found, which have lost their elasticity. Fibres may sometimes be found which have been re- tained in the lungs for a long period (one to two years), and have become encrusted with lime salts (Fig. 13). Such in- crustations disappear if a little dilute acid be run under the -cover-glass. Although met with chiefly and in largest numbers in the sputum of phthisis, elastic elements are also found in the expectoration from cases of pulmonary abscess, and occa- sionally in that of patients suffering from bronchiectasis or pneumonia. In cases of gangrene of the lung they are not met with as often as might be expected, being destroyed by the ferments formed in the process. Their presence in the sputum definitely indicates disintegration of lung tissue. Occasionally elastic fibres, unlike those which we have been describing, are seen in straight bundles. If the individual fibres composing these are fine, they probably come from the bronchi or larynx; but if coarse, food-matter is probably their source, and this will be corroborated by the presence of small portions of muscular tissue adherent to them. Larger fragments of lung tissue, in the form of dark grey masses, with tags and shreds, are occasionally met with under Fig. 13. — Elastic Tissue ENCRUSTED WITH Lime Salts. 74 DISEASES OF THE LUNGS AND PLEURA similar circumstances to the above; and in cases of deep ulceration of the larynx portions of cartilage may be loosened and expectorated. Curschmann's Spirals. — These bodies, first carefully described and figured by Curschmann," have, as their name indicates, a peculiar spiral form. They may be recognised by the naked eye in the sputum as little whitish twisted bodies about an inch long and -^ inch broad, and occasionally very much longer (Fig. 14). Under the microscope they are found to consist of a central highly refracting- wavy thread, around which is coiled a network of fine fibres having a spiral arrange- ment, the whole being surrounded by mucus in which are em- bedded numerous leucocytes (Plate II.). In other cases the central thread is not visible, and the spiral appears to be composed of the en- veloping coil only; in others, again, the central thread alone may be seen. Chem- ically, the central thread would seem to be composed of fibrin, the spiral meshwork encir- chng it being closely allied to mucin. The spirals were first observed in sputum coughed up during attacks of spasmodic asthma, and were considered to be diagnostic of that condition; but they have since been discovered in the expectoration of simple bronchitis, phthisis, pneumonia and oedema of the lungs, and probably indicate nothing more than a catarrh of the finest bronchial tubes. Tonsillar Casts. — In cases of follicular tonsillitis casts of the tonsillar crypts are not infrequently found in the sputum. When teased out they are seen to consist of fine fibre-like bodies of varying length; more usually they occur in Fig. 14. — Showing Naked-Eye Appearance IN THE Sputum of Curschmann's Spirals. fragments. PLATE II CURSCHMANN'S SPIRALS The lower drawing, which may be compared with Fig. 14, illustrates a spiral under a low degree of magnification. The coiled appearance of the spiral is well represented. (After Curschmann.) In the upper drawing a spiral is seen under a higher power. In the centre is a highlj' refractive thread, around which a deli- cate festoon is coiled, the whole being surrounded by mucus, in which man}' cells are enibedded. (From a drawing by Dr. W. C. Fowler, x 96.) PLATE II ■ *^- IS^ Curschmann's Spirals. To face p. 74. EXAMINATION OF THE SPUTUM 75 Crystals. — Crystals of various forms are occasionally met with in sputum, the best known being the " Charcot-Leyden crystals" (Fig. 15). These occur as colourless pointed octahedra, and are identical with those sometimes seen in the blood in leuksemia. Their chemical nature is uncertain. Clinically their significance is small, for though found, often in considerable numbers, in the sputum after an asthmatic paroxysm, they, Hke the spirals, may also occur in connection with phthisis, bronchial catarrh and plastic bronchitis, as well as other diseases. They would seem to arise from the dis- integration of the cellular elements in the sputum. Cholesterin crystals are principally associated with collec- FiG. 15. — Charcot-Leyden Crystals, from a Case of Asthma. (From a drawing by Dr. W. C. Fowler : X 400.) tions of pus in pulmonary abscess, empyema and foetid bronchiectasis, but are not confined to these conditions. Crystals of fatty acid appear as long slender needles, often formed into rosettes. They are very common in the sputa of bronchiectasis and gangrene of the lungs, but in small numbers occur in any muco-purulent expectoration, especially if it has been kept in a warm place. Crystals of hasmatoidin are brownish-yellow or red in colour, and take the form of rhombic prisms (Fig. 11, e). They indicate that blood has been retained for some time in the air- passages, and are numerous after an haemoptysis. Crystals of tyrosin, oxalate of lime and triple phosphates, occasionally occur, but their presence is of no significance. 76 DISEASES OF THE LUNGS AND PLEURAE Micro-organisms. — In addition to the bodies which we have so far described in the sputum, numerous micro-organisms are to be found. Some of these, such as the tubercle bacillus, the streptococci, the pneumococcus, varieties of the streptothrix group, and many others, are pathogenic in nature, and play a fundamental role in the aetiology of pulmonary disease. It is not our purpose in this chapter to describe these organisms. To many we shall refer again, when the diseases originated by them are discussed, and for a more detailed description we must direct the reader to special works on bacteriology. Others are saprophytic in nature, or if pathogenic, very feebly so. We may, for instance, find in the expectoration the long bacillary threads of a variety of leptothrix, or little packets of cocci forming cubes of eight produced by certain strains of sarcinae. Neither possess any pathological signifi- cance, though a hasty observer might mistake the former for leashes of elastic tissue. Varieties of saprophytic moulds may also be encountered in the sputum, and one has been described by the late Mr. Coppen Jones^ which occurs not uncommonly in phthisis, in which disease also the tetrads, or groups of four cocci, formed by the Micrococcus tetragenus, are fre- quently to be found. Occasionally the thrush fungus, Oidium albicans, embedded as a rule in masses of epithelial debris, is present in the expectoration. Adventitious Matters. — The sputum sometimes contains other substances than those already referred to. In a few cases these bodies are of much diagnostic importance; for instance, the fragments of new growth sometimes coughed up in the course of malignant disease of the lung, the booklets of hydatids, the ova of the lung fluke, Paragonimus Ringeri, in endemic haemoptysis, and the hairs occasionally yielded by mediastinal dermoid cysts. Of pathological interest also are the white cretaceous masses coughed up by certain phthisical patients. It must not be forgotten that the sputum may contain matters which are purely extraneous, such as grape-skins, nutshells, orange-pips, linen, cotton, silk or woollen fibres, particles of animal and vegetable tissues, starch granules, fat, and so forth. These are obviously accidental, and have only found their way into the spittoon by chance; but, unless their EXAMINATION OF THE SPUTUM yj nature be recognised, they are likely to be mistaken for some of the pathological constituents of the expectoration, which we have already described. REFERENCES. ^ Clinical Diagnosis, by Rudolf v. Jaksch, M.D., edited by- Archibald E. Garrod, M.D., p. 165. London, 1905. ^ Ueber eine neue Art von Grasgriinem Sputum," von Dr. Ottomar Rosenbach (zu Jena), Berliner Klinische WochenscJirift, 1875, p. 645. ^ "A Case of Cholo-Haemothorax," by T. R. Elliott, F.R.S., F.R.C.P., and Herbert G. M. Henry, M.D., British Medical Journal, 1916, vol. i., p. 9. * Nicolai Tulfii Amstelredamensis Observationes Medicae, apud Danielem Elzevirium, Amstelredami, p. 116, 1672 ^ " On the Detection of Lung-Tissue in the Expectoration of Persons affected with Phthisis," by Samuel Fenwick, M.D., Transactions of the Royal Medical Chirurgical Society, London, 1866, vol. xlix., p. 209. * " Ueber Bronchiolitis Exsudativa und ihr Verhaltniss zum Asthma nervosum," von. H. Curschmann (in Hamburg), Deutsches Archiv fiir Klinische Medicin, 1883, Band xxxii., p. i. ^ " Ueber einen neuen, bei Tuberkulose haufigen Fadenpilz," von A. Coppen Jones, F.L.S., in Davos, Centralblatt fiir Bakteriologie und Paracitenkunde, Jena, 1893, Band xii., p. 697. CHAPTER V DEFORMITIES AND DISEASES OF THE CHEST WALLS Tpie shape of the chest is nicely conformed, as a rule, to the condition of the lungs. Thus we have the small, long thorax with oblique approximated ribs associated with small lungs; the large, expanded, barrel-shaped chest with emphysematous lungs; and the local flattening or enlargement met with in certain pulmonary or pleuritic diseases. To these we shall have occasion to refer again. We may now consider certain alterations in the shape of the chest which deserve special attention. 1. The Pigeon Breast. — On the surface of the chest in the inframammary region of each side there exists an area, having the fifth space in the nipple line for its centre, which is un- supported by muscles. This space occupies the interval between the insertions of the pectoralis, the serratus, and th,e rectus m.uscles, and in any obstruction to the entry of air into the lungs, the atmospheric pressure is here least supported by muscular action. Hence, in young children in whom the ribs and cartilages readily yield in any condition of general dyspnoea, this part of the chest on each side becomes depressed and the sternum tilted outwards. Repeated bronchial attacks thus give rise to the prominent sternum and depressed inferior and lateral thorax which persist and constitute the pigeon breast, a deformity which is intensified by the drawing in of the lower chest by the action of the diaphragm along its zone of attachment. 2. In the Rickety Thorax a more or less deep groove corre- sponds on each side with the junction of the ribs and their cartilages, there being here a knuckling in, so to speak, of the ribs, causing the sternum to come forward with undue promi- nence. This is due to atmospheric pressure depressing the 78 DEFORMITIES AND DISEASES OF THE CHEST WALLS 79 softened and unresisting portions of the ribs and their adjacent cartilages. 3. The Alar Chest. — It has been known since the time of Aretaeus,* and possibly was recognised even before, that in patients suffering from phthisis, or merely predisposed to this disease, the chest is often small and narrow. As a consequence there is insufficient breadth of support for the scapulae, the superior angles of which are thrown forward and inward by the weight of the arms, and the inferior angle tilted outwards. The effect upon a thin subject, when viewed from behind, is thus to produce a winged appearance, to describe which the terms "alar " or " pterygoid " have been employed. Another deviation from the normal in the shape of the chest is the cup-like hollow, which is from time to time seen over the lower portion of the sternum and the adjacent cartilages. This is sometimes produced by occupations, such as that of a shoemaker, in which persistent pressure is made upon the lower sternal region. The deformity also occurs in a marked degree when no history of pressure can be obtained, and may then be attributed to obstructed respiration during childhood.- Lastly, we may mention a deformity due to a deficiency of the clavicular portion of the pectoralis major muscle on one side, of which we have seen some examples. A remarkable flattening, or rather hollowing, below the clavicle is thus occa- sioned, suggestive of grave internal lesion. The true cause of the depression is, however, at once rendered obvious by making the patient grasp the back of a chair with both hands and attempt to lift it, when the existing muscular fibres start into action, and the defect is declared. Let us now turn to the diseases of the chest walls, which are of importance chiefly from the frequency with which they simulate more deeply-seated lesions. Pleurodynia {-n-Xevpa, the side, dSuv?/, pain). — This may be due to rheumatism; m^yalgia, or intercostal neuralgia. The symptoms are very similar in all these conditions, but more particularly in the two first named, and there can be no doubt * Aretffius' {circa a.d. 50) thus describes the chest of phthisis : " . . . the whole shoulder-blades apparent like the wings of birds. . . . The habits most prone to the disease are the slender ; those in which the scapulae protrude like folding-doors, or like wings ; in those which have prominent throats ; and those which are pale and have narrow chests." 8o DISEASES OF THE LUNGS AND PLEURA that aponeurotic rheumatism and myalgia are conditions fre- quently associated and difficult to distinguish. Pleurodynia commonly begins quite suddenly with severe pain of a tingling or burning character much aggravated by respiratory move- ments, especially those of deep inspiration or tussive expira- tion. The pain may be situated at any part of the chest, but a common seat is over the insertion of the pectoral muscle in front, or at the margin or sides of the chest where the recti and serrati muscles are attached. When the pain is lateral, it is limited to one side. ' The breathing of the patient is hampered, and may even be greatly distressed by the severity of the pain. Aponeurotic Rheumatism is not common before thirty, although it may occur in young people of distinctly rheumatic diathesis. It is frequently consequent upon direct exposure to cold, especially in persons coming from hot rooms and when overheated by exertion. Middle-aged and elderly people, who are the subjects of gout and allied rheumatic affections, such as lumbago and sciatica, are specially liable to this affection. Myalgia, except in so far as muscular tenderness is inevitably more or less associated with the preceding condition, is gen- erally traceable to strain. It sometimes occurs in whooping- cough, and very commonly in the course of phthisis. Unquestionably the disease has in most instances a definite pathology in the rupture of some minute muscular fibres. Intercostal Neuralgia is a more definite ailment than either of the above, and occurs more especially in females, at two periods of life, and in two formis. (i) It is very common in young women in the form of inframammary neuralgia, in which the pain is referred to the surface of the chest below the left breast. This affection is most generally associated with anaemia attended with leucorrhoea, amenorrhoea or other menstrual disturbance. (2) It also occurs in persons of middle or advanced middle life and, again, is more common in females. In this form the pain is of a very severe stinging or burning character along the course of the peripheral distribution of one or more of the intercostal nerves. It may last for days or even weeks, and then be followed by the appearance of the characteristic eruption of herpes zoster, after which the pain is soon mitigated, or subsides altogether. This disease appears to be commonly associated with the rheumatic or gouty diathesis. Although most common in females of DEFORMITIES And diseases of the chest walls 8 I middle age, it is by no means limited to them, and may some- times be observed in quite young people. The pain attendant upon herpes zoster in the young, however, is not often severe, and rarely precedes the appearance of the eruption by any considerable time. Diagnosis. — The distinctive signs of pleurodynia, when care- fully considered, are quite sufficient for diagnosis : 1. The disease per se does not raise the temperature, in which fact we have one very important element in the diagnosis from pleurisy. 2. There is usually decided tenderness on pressure over the seat of pain. In intercostal neuralgia this tenderness is very superficial and is best elicited by gently pinching up the skin. The tenderness may be observed, too, not only over the point most complained of, but also in the lateral spinal region corre- sponding with the distribution of the posterior cutaneous branches of the affected nerves. In cases in which the pain is chiefly situated below the left breast, the patient usually presents other signs of' ansemia. In myalgia the pain is markedly elicited by bringing the muscles affected into action, asking the patient, for example, to grasp the back of a chair, thus bringing the pectoral muscles into action, or to raise himself in bed or turn on one side so as to involve other muscles. In aponeurotic rheumatism and in myalgia there is also tenderness on firm pressure over the muscles in the inter- costal spaces. 3. The respiratory movements are restrained by the pain, and respiration on the affected side is correspondingly weak; but it is of vesicular character, and unattended with any friction sounds. One may sometimes hear, however, mus- cular vibratile sounds, due to the voluntary restraint exercised upon this side by the patient. The percussion resonance is unaltered. Pleurisy and pericarditis are the two conditions most simu- lated by pleurodynia. In phthisical subjects, where there is perhaps already existing pyrexia, it is often difficult to be sure that there is not some dry pleurisy, but here the diagnosis is not very important. Aponeurotic rheumatism of the front of the chest is distinguished from pericarditis by the absence of the physical signs proper to that disease. Treatment. — Intercostal neuralgia in young anaemic subjects 6 82 DISEASES OF THE LUNGS AND PLEURA requires general treatment by iron, quinine, arsenic, and fresh air, with generous diet; also local treatment by soothing applications, such as belladonna plasters, or chloroform liniment (3 parts) with belladonna liniment (i part), sprinkled on lint or flannel backed by oiled silk. Menthol, dissolved in liniment of chloroform (3i. in §i.), may be applied in a similar manner, or the Linimentum Aconiti Compositum containing equal parts of the liniments of aconite, belladonna, and chloroform. Aconite and belladonna may also be efficaciously applied in the form of the Chloroformum aconiti, or Chloroformum belladonnee of Messrs. Squire, the remedy being painted with a camel's-hair brush over the painful part. Another prepara- tion which sometimes gives relief when painted on the skin is " Kasemol," which is believed to contain menthol, methyl salicylate, the oils of mustard and sassafras and the essential oil of camphor. In the herpes zoster form of inter- costal neuralgia, before the eruption appears, the same reme- dies may be used; afterwards the local application must be used with caution. In this latter variety of neuralgia, the pain is often very severe and intractable, and subcutaneous injec- tions of morphia and atropine may be required. Local deple- tion by leeches will always give temporary relief, but in the anaemic form of neuralgia this method of treatment is not to be advised. The myalgic forms of pleurodynia are best treated by keeping the affected side of the chest at rest by strapping, as for dry pleurisy. Aponeurotic rheumatism may often at once be cured by the application of a well-made mustard poultice kept on for twenty minutes. In the case of any rheu- matic diathesis, general remedies, especially iodide of potas- sium with quinine and salicylates or aspirin, will be required. Periostitis and Perichondritis of Sternum and Ribs. — This is a disease which comes under the notice of the physician not very infrequently, and which sometimes gives rise to perplexity in diagnosis. It is generally the result of syphilis, typhoid fever or tubercle, and is occasionally met with in the course of pulmonary phthisis. When due to tubercle, the tuberculous process may start as a small area of central caries in the middle of the rib (Fig. 16), and then spread through the bone to the periosteum; or it may commence near the surface, and attack the superficial layer of bone and the periosteum simultaneously. In which- DEFORMITIES AND DISEASES OF THE CHEST WALLS 83 ever way it starts it eventually forms an abscess, which as a rule points forwards; but if the disease has commenced on the inner aspect of the rib or sternum, a large collection of pus may form here, separating the pleura from the ribs, compres- sing the lung, and simulating most closely an empyema. These cases are, happily, rare, and as a rule the formation of a small swelling over the sternum or an adjacent rib, accom- panied by but little pain, is the first sign which attracts the patient's attention and causes him to seek advice. If treated at once surgically by evacuation of the pus and removal of any dead bone, the disease is generally cured; but if left untreated, Fig. 16. — Tuberculous Osteo-Myelitis of Rib. The specimen shows the outer surface of the fourth right rib and cartilage, and also the appearances seen when a section was made and the parts opened outwards. A central area of disease is visible, the size of a pea, which communicated during life with a costal abscess by the small hole seen in the figure. Removed by operation from a man suffering from chronic pulmonary tuberculosis. (From the Brompton Hospital Museum.) the pus may burrow and cause extensive lesions. We have seen complete necrosis of the sternum thus produced. In the case of typhoid fever, the inflammation, whether in connection with the sternum or a rib, is generally produced by the direct action of the typhoid bacillus, though sometimes it is the result of secondary infection by the pyogenic micro- organisms.^ The symptoms resemble those of the tuberculous cases, although they may terminate in spontaneous resolution. In a case of this kind seen by one of us some time ago, the symptoms, local prominence over the first two ribs, obscured breath-sounds, some venous engorgement, and great tender- 84 DISEASES OF THE LUNGS AND PLEURA ness, were traceable to an attack of typhoid fever four or five months previously, and suggested at first the diagnosis of a local abscess or empyema. The lady, however, ultimately, though slowly, recovered, without operation, under repeated and prolonged change of air and other remedies. In syphilis, periosteal nodes over the sternum (especially its upper portion) and over the ribs are not uncommon; more rarely gummata breaking down into ulcerating sores may be observed. Tubercle or malignant disease may be suspected, but it should be a rule in any doubtful case to administer a course of antisyphilitic treatment. Occasionally pulsation may be conveyed to a softened gumma, and suggest the diagnosis of aneurism. Fascial Creaking. — Before concluding this chapter, we must mention a very curious physical sign, the so-called fascial creaking which may be heard, especially over the supraspinous and scapular regions. This phenomenon is attended with a certain amount of pain. We have met with cases of this kind which have been treated with great perseverance for many weeks by blisters and iodine counter-irritants, under the impression that the patients were suffering from chronic pleurisy. The condition is, however, so far as we have been able to observe, a permanent one, and is only important in diagnosis. If the attention be once awakened to the possi- bility of the sounds being extrathoracic, the diagnosis can be confirmed by making the patient stop breathing and by Hsten- ing whilst the shoulder is shifted about, when the creakine will still be heard. REFERENCES. ^ The Extant Works of AretcEus the Caffadocian, edited and translated by Francis Adams, LL.D. " On the Causes and Symptoms of Chronic Diseases," bk. i., chap, viii., p. 311, London, 1856. * Auscultation and Percussion, by Samuel Gee, M.D., p. 32, fourth edition, London, 1893. ' On the Typhoid Bacillus and Typhoid Fever, by P. Horton-Smith (Hartley), p. 64. London, 1900. CHAPTER VI DISEASES OF THE PLEURA Pleurisy. The pleura on each side of the chest is a closed serous cavity or sac intimately applied to, and in organic union by its outer surface with the lung and the costal parietes. The internal surface of the sac is Hned with endothehum, the costal and parietal portions being in close contact, lubricated merely by some moist serous secretion. This contact or apposition is maintained by atmospheric pressure bearing upon the interior of the lung and the exterior' of the chest wall, which more than counterbalances the constant tendency of the two surfaces of the sac to spring apart from the opposite elastic tractions of the lung and thoracic wall. The pleura is well provided with bloodvessels, which are derived from the bronchial, internal mammary and inter- costal arteries. The lymphatics consist of two series, the one forming a network beneath the surface endothelium, the other situated in the cellular tissue subjacent to the pleura. Both series communicate freely with each other. In the visceral portion of the pleura the lymphatics communicate, as we have indi- cated elsewhere (see p. i8), with the pulmonary lymphatics, and both are drained by the superficial collecting trunks into the bronchial glands at the hilum of the lung. The parietal pleura, so far as its costal portion is concerned, is drained by the deep intercostal lymphatics, and thus by the internal mammary vessels and glands; the lymphatics of the mediastinal pleura terminate in the posterior mediastinal glands. The communication of the superficial and deep intercostal lymphatics, and the connection of the former with the lymphatics of the chest wall, explains, as Poirier 85 86 DISEASES OF THE LUNGS AND PLEURA and Cuneo' point out, the affection of the axillary glands which is sometimes observed in deep-seated thoracic disease. The important connection existing" between the lymphatics of the pleural and peritoneal surfaces of the diaphragm, and also between the lymphatics of the liver and those of the diaphragmatic pleura, has already been referred to (see p. 19). When we regard the position and connections of the pleura, its extensive endothelial surface, the conditions of negative pressure in which that surface is ever maintained, and its richness in lymphatics, we cannot wonder that it should fre- quently become the seat of disease, nor that it should be ont of. the chosen sites for the manifestation of lesions resulting from blood infection. Few are the autopsies after adult, age in which one fails to find some imperfections in the pleura; few are the cases of septic or pygemic poisoning in which this membrane is not actively 'involved. Pleurisy, as the physicians of the early Roman Empire knew full well, is an inflammation of the pleural membrane; " Under the ribs, the spine, and the internal part of the thorax, as far as the clavicles" — so writes Aretseus^ — "there is stretched a thin, strong membrane, adhering to the bone. . . . When inflammation occurs in it . . . the affec- tion is named pleurisy." Clinically, however, cases differ much among themselves, and various forms of the disease are recognised. A classification based upon bacteriology alone would not give an adequate presentment of the disease in its varying characteristics. It has not as yet been shown that in all cases a micro-organism is responsible for it, although no doubt it is so in the great majority of instances. Again, the same microbes, for example, the pneumococcus or the tubercle bacillus, will produce at different times and in varying circumstances quite different forms of pleurisy. We shall, therefore, under the common heading "Inflammation of the Pleura," describe the aetiology and characters of the following groups, viz.: (a) Plastic or dry pleurisy; (b) Pleurisy with effusion, whether sero-fibrinous, hjemorrhagic or purulent. I. Fibrinous, Plastic, or Dry Pleurisy. — This variety of pleurisy consists in an inflammation of the membrane, lead- ing to the exudation of lymph, usually over a limited area of its , surface. Beyond this stage the inflammatory process does not pass, and after a time the lymph is absorbed, or DISEASES OF THE PLEURA 87 adhesions form, binding' the surfaces to each other. The disease may be either primary — occurring", that is to say, in the absence of any evident lesion of the lung — or secondary to the spread of inflammation (whether tuberculous or other- wise) from the lung or chest wall, or to some general blood infection. True primary cases are rare, many of those which at first seem to be of this nature proving eventually to be the result of tuberculous disease of the lung which has not as yet given rise to symptoms. Pathology. — The pathology of the disease may be briefly described as consisting in the first place of hypersemia of the pleura; within a very few hours the normal glistening appear- ance of the surface is lost; it becomes cloudy, as though breathed upon, and gradually covered with a layer of exuded lymph. Both the costal and visceral layers are thus affected, and the result of the movement of the two surfaces upon each other is to roughen them, causing the effused lymph to present numerous httle elevations and pittings, like the fretted surface of a lake. At this point the disease may come to a standstill, and the exuded lymph be gradually again absorbed. The pleura in this case once more becomes smooth, but the site of the old lesion is generally revealed by a thickening and opacity of the membrane, and sometimes by a sHght radiated pucker- ing, due to the formation of a thin layer of fibrous tissue. More often the lymph exuded is not simply absorbed, but vascular loops extend into it from the pleural vessels on either side, which meet and inosculate,, giving- rise to the formation of permanent adhesions. As a rule, these are not of great density, but where there is much shrinking of the lung, as in many cases of phthisis, they become, as we have shown elsewhere,'' stretched and filled with fluid, and present a gelatinous aspect (Plate XXII., Frontispiece). Organisa- tion slowly follows, and leads to the formation of firm and dense adhesions, which measure not uncommonly at the apex of the lung J inch or more in thickness. On rare occasions, without previous disease of the lung, tubercle attacks the pleura, and gives rise to a somewhat similar condition, termed by the late Sir William Osier* "chronic adhesive tubercular pleurisy." In this disease the pleura over the whole lung; becomes, by the gradual develop-- 88 DISEASES OF THE LUNGS AND PLEUR/5: ment of tubercles, greatly thickened, measuring', perhaps, i to I inch across. On section, the tissue is found to consist of fibroid material, with small areas of interspersed caseation. The condition is a very rare one, and we remember to have seen only one example, which was probably of this nature. Symptoms.— The symptoms of acute dry pleurisy set in as a rule somewhat suddenly. The patient complains of cough and pain in the side, increased on deep breathing. The tem- perature is found to be somewhat raised, reaching perhaps 100° or 101°. The percussion note is natural, and the breath- sounds vesicular, though weak and uneven. The diagnosis depends upon the detection of a friction sound, the charac- teristics of which have been already described (see p. 6q). This is heard over the seat of pain, generally in the lower posterior or lateral regions of the chest. The disease gener- ally lasts but a few days, when the temperature falls and the friction sound disappears. If the pleurisy be secondary to some other disease, such as pneumonia, pulmonary infarct, phthisis, or gangrene, its symptoms will merge into those of the primary disease, but, as a rule, some pain in the side (in pneumonia often of great severity) will be complained of, and a friction sound is generally detected. Diaphragmatic Pleurisy. — When the pleurisy is restricted to the surface of the diaphragm, the symptoms present certain peculiarities. The onset of the disease is marked by severe pain in the lower portion of the chest corresponding to the insertion of the diaphragm. The pain, as Gueneau de Mussy pointed out, is especially felt along the tenth rib, extending from the anterior extremity to the sternum and ensiform cartilage. Sometimes it radiates to the back and shoulders. The hypochondrium is tender on pressure. Respiration is hurried, but the diaphragm on the affected side is kept motion- less, since every contraction aggravates the pain. The patient is feverish, and looks ill and anxious, but a careful physical examination at first reveals nothing to account for the some- what alarming symptoms, which may after a short time decline, and recovery take place. If effusion follows, the characteristic signs will suggest the true nature of the disease. It is easy for the physical signs of diaphragmatic pleurisy to be overlooked, and in purulent cases the diagnosis may be made only on a sudden discharge of pus through the lung. DISEASES OF THE PLEURA . 89 We must add that, though the disease generally manifests itself by severe symptoms, it may be masked by the other conditions present. We have seen a case of phthisis in which the autopsy revealed a tuberculous diaphragmatic empyema containing- half a pint of pus, although during life there had been no symptoms to suggest the presence of such a com- plication. For the points which should be attended to in forming a diagnosis between pleurisy, intercostal neuralgia and rheu- matism we must refer the reader to what we have already said upon the subject (see p. 81). Treatment. — In many cases of dry pleurisy immediate relief is given by firmly strapping the affected side, so as to restrain its movement, as first recommended by the late Dr. Roberts. A useful clinical test as to the amount of relief which may be thus expected is obtained by observing the effect of steady and firm pressure by the hand upon the affected side. In some cases strapping cannot be borne, either on account of its increasing the pain or from the fact that, as may happen in phthisis, the pleurisy has supervened on the side most available for respiration. Under such circumstances the application of a small blister, with or without a hot linseed poultice superposed, will give relief or, if the pain be severe, three or four leeches may be applied. In cases associated with pneumonia the latter remedy is of great value. An opiate or subcutaneous injection of morphia may be em- ployed if necessary, simultaneously with one or other of the above remedies. REFERENCES. ' " Systeme Lymphatique," par P. Poirier et B. Cuneo, Traite d^AnatoViie Humaine, par P. Poirier et A. Charpy, tome ii., p. 1245. Paris, 1909. ^ The Extant Works of Aretceus the Ca-p-padocian, edited and translated by Francis Adams, LL.D., " On the Causes and Symptoms of Acute Diseases," book i., chap, x., p. 255. London, 1856. ^ " Case of Chronic Tubercular Disease of the Lungs, illustrating one Mode of Production of Thickening of the Pleura," by R. Douglas Powell, M.D., Transactions of the Pathological Society of London, 1868-69, ^'^^- ^^'-i P- 59- ^ " Tuberculous Pleurisy," being the Shattuck Lecture of the Massa- chusetts Medical Society. By William Osier, M.D. Boston, 1893. (See " Collected Reprints," Third Series, by William Osier, M.D.) CHAPTER VII SERO-FIBRINOUS AND HEMORRHAGIC PLEURISY Acute Sero-Fibrinous Pleurisy. Sero-fibrinous pleurisy does not differ in its early stages from the acute dry pleurisy just considered. The pleural surfaces are inflamed and lymph is exuded; but whereas in dry pleurisy this constitutes the whole disease, in the variety now under consideration there is, in addition, an effusion of fluid, for the most part serous in nature, and sometimes amounting- to many pints in quantity. .etiology. — This disease may occur in the course of other maladies, such as phthisis, rheumatic fever or pneumonia. In these cases the pleurisy Avould seem to depend upon the agency of the micro-organism which has produced the original disease. When occurring in association with malig- nant disease of the lung, effusions into the pleura are due perhaps as often to obstruction of bloodvessels and lym- phatics as to definite inflammation of the serous membrane. Pleurisy, in common with other serous inflammations, also occurs in the course of acute and chronic Bright's disease, but the effusion into the pleura met with in this disease is more frequently of a passive nature. Concerning the primary cases, in which the pleurisy appar- ently arises de novo, and which constitute the bulk of all sero-fibrinous effusions, it was held until recently that expo- sure to cold or draught was the chief factor in their causation, whence the term picuritis a frigore. This view we now know to be incorrect, and no doubt the great majority of such cases are really tuberculous in nature. In certain instances, however, a pleurisy which to the naked eye appears serous in character, though the microscope will, as a rule, show excess of polymorphonuclear leucocytes in the fluid, is due to the 9P SERO-FIBRINOUS AND HEMORRHAGIC PLEURISY QI presence of the pneumococcus or, as in the recent influenza epidemic, to the streptococcus, although in most cases these give rise to a suppurative pleurisy. The evidence upon which is based our belief as to the tuber- culous nature of most primary serous effusions may be sum- marised as follows : (i) If we trace the after-history of these cases, we see that in many of them apparent recovery is shortly followed by the development of phthisis; thus. Dr. Hedges,^ following up 130 cases from St. Bartholomew's Hospital, found that within six years or less "43 per cent, had either died of phthisis or other tubercular lesion, or presented signs of the former disease." Very similar results were obtained by Dr. Barrs,^ and more recently by two Swedish observers, Drs. Allard and Koster.^ The conclusion, therefore, that the pleurisy in these cases was in reality tuberculous from the first is strongly suggested, and is further strengthened by the fact that in certain rare cases, such as those recorded by Kelsch and Vaillard,* in which the patients died, tubercles have been found in the serous membrane. (2) An examination of the fluid by staining methods affords confirmatory evidence. If the fluid withdrawn by aspiration be examined without special preparation, bacilli are as a rule not found. If, however, we follow Dr. Jousset's^ method, and allow the fluid to clot, then digest the clot with artificial gastric juice, and finally stain films made from the centri- fugalised liquid, tubercle bacilli can often be detected. Jousset himself claimed to have demonstrated them in seventeen successive cases of primary serous pleurisies. (3) Inoculation experiments tell a similar tale, provided large enough quantities of fluid be injected. Netter*^ found that in eight cases out of twenty of primary sero-fibrinous pleurisy he was able to induce tuberculosis in guinea-pigs by injecting into- the peritoneal cavity i to i| c.c. of the fluid withdrawn by aspiration. Eichhorst,'' using a larger quantity (15 c.c), produced tuberculosis in 65 per cent, of his cases; while Le Damany,' by injecting 10 to 50 c.c, and in one case even 300 c.c, was successful in forty-seven out of fifty-five cases, or 85 per cent. These statements are not gainsaid, and we are driven, therefore, to the conclusion that by far the greater number 92 DISEASES OF THE LUNGS AND PLEURAE of cases of primary sero-fibrinous pleurisy are in reality tuberculous in nature — a fact which must greatly influence our after-treatment of the malady. Morbid Anatomy — Nature of the Fluid. — As we have seen, the morbid changes are at first similar to those observed in the plastic or dry variety of the disease. Hyperaemia first occurs, to be followed shortly by roughening of the surface and the deposition of lymph. Effusion, however, then takes place, which, as it increases, separates the surfaces more or less widely from each other. The fluid thus effused is clear, yellowish in colour, from the presence of serum-lutein, and alkaline in reaction. It is highly albuminous, and on stand- ing undergoes spontaneous coagulation; but the amount of fibrin which separates out is never great. On microscopical examination, leucocytes are seen, also a few large cells, derived from the endothelium lining the pleural surface, together with a fair number of red corpuscles. The leuco- cytes, as Widal and Ravaut' were the first to show, are mostly small mononuclears, and so constant is their presence in great excess in cases of tuberculous pleurisy," except in its earliest stage, that a cytological examination will be found of value when considering the diagnosis of any case. It should be stated, however, that in cases of malignant pleurisy a similar excess of small mononuclears is often to be observed.* According to Professor Halliburton,'^ whose researches have been confirmed by other observers, the average chemi- cal composition of the fluid may be given as follows, the corresponding figures for passive effusions (chronic renal and heart disease) being quoted for comparison ; Specific Gravity. Total Proteids per Cent. Fibrin. Serum Globulin. Serum Albumin. Acute pleurisy ... 1021 Hydrothorax ... 1014 1 4 "5903 17748 o'0473 o-oo86 2-0007 06138 2-2II2 1-1558 * If the fluid, after withdrawal from the chest, cannot be at once examined by the pathologist, it is well to add one-quarter its volume of a citrate solution of the following composition : Sodium citrate ... ... ... ... 1-5 grms. Sodium chloride ... ... ... ... 0-85 grms. Distilled water ... ... ... ... 100 c.c. In this way clotting is prevented and the cells are preserved- SERO-FIBRINOUS AND HEMORRHAGIC PLEURISY 93 From these figures it will be seen that in acute sero-fibrinous pleurisy the fluid is of higher specific gravity and richer in proteids than in non-inflammatory effusions, whilst the yield of fibrin is also greater, leading to more rapid coagulation of the fluid. The proportion of serum albumin to serum globulin is variable, and possesses no clinical importance. In cases of chronic pleurisy, according to the analysis of Mehu,'- the fluid would seem more closely to resemble that of hydrothorax. Symptomatology. — The following description of the disease will apply chiefly to the common primary variety, the pleuritis a frigore of older writers; but the symptoms and physical signs of cases complicating other diseases do not differ in any essential particular. The symptoms and signs of sero-fibrinous pleurisy are in accordance with its pathology, and are divided into three stages : (i) the stage of hyperaemia and commencing exuda- tion; (2) the stage of effusion; (3) the stage of absorption and convalescence. Pains in the side and shivering are the two symptoms which usher in the attack, and either may precede the other by a few hours. The pain is that of an acute " stitch " in the side, usually felt in the lower axillary or inframammary region, but sometimes referred, and especially in children, to a much lower point in the abdominal wall to which the ter- minal cutaneous twigs of the aft"ected intercostal nerves are distributed. The pain interferes with the respiratory move- ments, which are restrained and shallow, the patient inclin- ing to the affected side so as to lessen its movement. The shivering is of variable severity, sometimes very sharp and decided — a true rigor — at other times amounting only to recurring chills. It is stated that the rigors of pleurisy are repeated, whilst in pneumonia one severe shivering occurs at the commencement of the disease; but in neither case is this statement more than generally speaking correct. There is occasional dry, interrupted cough. The temperature as a rule rises rapidly to about 102° or 103° (see Figs. 17 and 18), the face is anxious and pale, the pulse small and moderately frequent. The fever has never the marked character of that of pneu- monia, and the flushed cheek and burning skin so charac- teristic of the latter disease are rarely present. In a word, 94 DISEASES OF THE LUNGS AND PLEUR/E s Ml 1 V X 1 --• UJ •< > t' ^ ^ 1 — S3 uJ S UJ S "^ > ^ x^ 1 1 <]: :>■ ^ ^ 1 K UJ •=^ ^ ^ 1 ;>i 1 w UJ S •ci -^■ ■>»■ .... ^ 1 s uJ S. < < io" ^ X '^ a UJ £ •C 'HA. si"' .... ^ ^ CO uJ £ .... .... .... .... ..•c 'l ' 1 ^ ^ r; ul y 1 ^ ^ y 1 £ Ul £ ^ 1 ^ ^ <, 1 in ul £ f ' ^ ^ _,^ 1 2 UJ .... .... .... .^. .... 1 ■ -♦- 1 .... * ^ to ul «( 1 ^ ¥ b M uJ £ «; 1 t ^ ■ > 1 = ul £ eC 1 ^ ^ :» 1 g ul £ «r -^ 1 t ^ > 1 1 m Ul S * •>^. . 1 ^ > > 1 CO s S|sai udoej P 1 ^ ^- * 1 r- ul 2 ( H y 1 ..1. 1 ^ ^ u> UJ S 1 1 * ^ ^ » 1 w UJ S K 1 ^ ^ *s. 1 'J UJ £ .... .... '^ ^ 1 t • -1 • 1 .... t ^ to UJ £ ... ffr; ^ 1 ^ X^ -y* 1 CS] UJ £ » 1 « v< ^; 5» 1 i - UJ £ e %■ 1 ■ •! • 1 .... .... > ^ CO ui •i 1 ^^ ^ 3Ut o CO Ul 2 •z 1 *^ ^ .:;* 1 g UJ £ 1 b 1 1 ^ ^ t»a [n\0'. ■qv s ul £ a pi-. - . \ U| -~^ 1 1 ^; "^ Ae |I|E pa( CM £ 1 1 \ \ 1 ^ S ul £ , 1 < \ ^ \ 1 )» to CM ul £ \* \ \ 1 > % S Ul S 1 ( \ \ 1 \ ^s 1 1 1 1 §|l§ fe JO 1 w K a H H ^ H <: >< H ^. ci w U H H iJ < CM T. H (— 1 lb Zh-l < w w H D m O ^ < ^ ^ n 00 33 N ^ C4 M m < u w Q P^ u5 tn a tb X o PL, n OS O o z n • tn w (V en fii m W H O H Z « w n a o H c < -f « a fV li < H -L, 0. ti ? z U a; w H < ;i< H w ix, t-i a ti Ul H U3 M O J" O o K en H <: H »— ( Cl, tn O X 2 a o a a; < o z o u a, 'n 1 S D O !k t^a; Ik w mw o p^ SERO-FIBRINOUS AND HEMORRHAGIC PLEURISY 95 « "J »^ -« ■ '" ^ Cvi g 1 ■* '^^ •F > 1 ^ ~ s'"- 1 m UJ • 4 • »"' ^ cv. g-. 1 ^ « i^. •^ ^ » " S 1 .... .... .... .... ,... ..5 1 :>.■ .... \ o i^ .. "HT i" .... \ ^ 2 ^'^ o> "J... 4 • DO '^.... •^ 1 ^ " S >' r- '^.... <( ^ ~ s >! D '^.... f 1 . .1 • ^ - £ > 1 « ''J ^ ^ - S • t '^ .... * S- ^ " £ 5» 0*^ .... ■ S .... .... .... .... .^ •i- .... .... ^ ^ Hi f 1 \ ' S } 1 _UI \ 1 s ^ 1 .•^ .... " 2 .... ..< >■ • . ^. 1 ■■\- 1 .... .... e .... .... 5 > .... J .... .... ^ B^'J .... ^ 2 y 1 f .'^ .... / 1 ^ 2 „,-.( CV 1 U a ^ 1 ^ 2 > ' — . .,,^ 1 uJ ^ s> "^ o 2 1 c UJ 1 1 1^ — ^ s "•■ 1 ■■> 0! UJ ts > .... ^ 2 ■■• b SP ui ..,, 1 •< '^ ^. « i^ .2_; i'--i ■■l 1 1 H| "S "1 "1 I 1 «jf§ '^ s O H c u s<: o pq " K w H m o H H <: o M Z m O hJ t> o w m D H < z o ° o o u o • w z w P^ 5 9 w w^ (^ , h-l w H O z . o H W S K ^ s ■■ 5 [* o "^ ^ s <; H H (X) > « -^ < J >. ffi < At least 24 months ... Sero-purulent fluid. 4 months 5 7 .. 8 II II . • • > > ... Air with pus. Symptoms.— In speaking of the symptoms of pneumo- thorax, we have especially in mind that most coinmon form due to perforation of the pleura in the course of tuberculous disease. The reader will easily recognise variations from this type. In well-marked cases the principal symptoms are sudden acute pain in the side, followed, or rather attended, by great dyspnoea and shock. The pulse becomes frequent, feeble and small, the respirations relatively more frequent than the pulse, and the voice feeble or suppressed. As a result of the shock, just as in perforation of the intestine, PNEUMOTHORAX 141 the temperature of the body may fall. But such a primary fall is rarely a marked feature, and is very often absent. More commonly the temperature at once rises, and in some cases the rise is rapid and marked, forming a noticeable feature of the temperature chart (see Figs. 23 and 24). The patient is often conscious of " something having given way," and feels a peculiar trickling, cold sensation, associated with the pain in the affected side. Occasionally, also, there is Fig. 23. — Chart illustrating the Rapid Rise of Temperature which is OFTEN associated WITH THE DEVELOPMENT OF PNEUMOTHORAX. (From a male patient, J. B., aged twenty-one.) great hyperassthesia in this region. The patient frequently changes his position : he may sit up or recline, with the head raised, and with an inclination to the sound side, or, again, he may assume the sitting posture with slight inclination for- wards, and with the elbows resting upon the knees, and this is the position most commonly chosen. There is nothing absolutely characteristic about these symp- toms except, perhaps, the suddenness with which they may M DISEASES OF THE LUNGS AND PLEUR.E supervene; but in marked cases the alarmed, anxious, and distressed countenance, the evident urgency of the dyspnoea, usually amounting to orthopnoea, and the small whispering voice, are in themselves strikingly suggestive. All the symp- toms may, nevertheless, be most closely simulated in an attack of acute pulmonary congestion supervening upon already advanced tuberculous disease. On the other hand, in not a few cases, and especially those in which the lung affected has Dale My. Aug 28 29 30 81 1 2 3 4 5 6 7 8 9 10 it 12 13 H Tunc M E M E ME M:E ME ME ME m;e MiE ME M E me ME ME ME M:E ME M E lOG" 105" 104-° ■3103° ? 102° 1 101° 100° 99° 98 97° :; , :;i: ■"""t"' :£; ;i £;; ■ ■•; -;••■■ .:q:: ;;;;!;;;; ''.■''-'■''' ■ ■ ■ ; i: f ■ ! ■ . . J... ..'.:i..... :::t:::: ..*..^.,".. I.'.... ! ±: 'Z~Z'-. ■:;p ; . ..*... - I- ■ ■■■^- ..4.... 1 i . ..-.i' : ...\ -f i . 1" e; ....k—. :;:l::::: ' li... li ''._.;,.', -'-^■" •'■■r- ,:..i.... "..',.... ■f' '■■■■■ :.. :;: . 1 1 1- ;.■...". ::.!::: ...,|.., ■;;[" — 1 — ■ ' ::t: ;""t ■" ::}:: ' I..!., ■ '"'■■; ■" 1^ i ....(.,.- y ■ ji ...-,..... [■■■ ■i ::: '■■.t ' ■ ....;. "I- ■ ...i-, , 'rz \'[Y' \ ::! : ¥■ 'zi: ...il 1 n ■] A '■r J-- ■ V ■ -r ■■ • -V- . ...i Uj'': 1 ...j. / -■?;;_ '".]'.- \ --i-- ;|;l];; / ■■]■■ ! ■■ j!" ■ w 1^ tr 1.. • ::}:: :;;];;;- ... i., .. ,|..j ..\.- . ■■■■?■■■■ •4- ...... "'-".'C 1 4..,.. .4 '.... ....;. . ■f ;;;';t-;; ".'.':\' . ■ 1- - i ■■■ r- ...IZ ^ ■ ! -i ■ ■ ■i f- ' : -■ 1 \ / ^ ^» ^ ' : i ■ ■;;■];■■■ ■ T ■;;;T;;; :±: -.,... :i';. ■■"■?■* ■ f ■■•■(■ ■ ;■■ ■ '■;■;'■ ■■4-- :::E ...-.|r.... 5tr ::t;: ;3:: ;:!'l" ../i .. :a:: :::::::: *■ Fig. 24. — Chart illustrating the Rapid Rise of Temperature which NOT UNCOMMONLY ACCOMPANIES THE OnSET OF PNEUMOTHORAX. (From a male patient, W. H., aged nineteen.) been already extensively destroyed, there may be an almost entire absence of any symptoms to mark the onset of the complication. In such cases disturbed action of the heart may be the chief trouble of which the patient complains. Physical Signs. — The physical signs of pneumothorax are very definite, and can rarely be mistaken for those of any other disease. We will enumerate the chief of them, and dwell more fully upon those which are essentially important. PNEUMOTHORAX 143 In a well-marked case the affected side is enlarged, the shoulder raised, the intercostal spaces effaced, and but little or no movement is perceptible with respiration, whilst the opposite side labours with the rapid breathing, its soft parts receding with each inspiration. The heart is displaced towards the sound side, and the abdominal organs are depressed. The percussion note is greatly hyper-resonant or truly tympanitic, where, perhaps, it had before been impaired. Respiratory murmur is either absent or very feeble, and at one or two points more or less distant amphoric breathing may be heard, with metallic whisper and echo on coughing. Pectoriloquy is scarcely ever present. Metallic tinkling may be observed, especially after cough. Vocal fremitus is either absent or much diminished. On applying the stethoscope over one point of the area affected, whilst at another per- cussion is made with coins or other hard substances, a pecu- liar ringing sound, the bruit d'airain or bell sound (see p. 62), is heard. This is very characteristic of pneumothorax, though occasionally also heard over large pulmonary cavities. Later, when effusion of fluid has occurred, there is dulness over the lower portion of the affected side, with hyper-reson- ance above, the distribution of dulness and resonance shifting with the altered position of the patient. The presence of such movable dulness is highly suggestive, the level of the fluid in a case of simple pleurisy shifting in a very slight degree, and that only in the earlier stages. On placing the ear against the chest, and giving the patient a somewhat abrupt shake, a splashing sound may be distinctly heard, which is very characteristic of hydro- or pyo-pneumothorax.* This " succussion splash " may be observed in cases of pneu- mothorax in which no other evidence of fluid has been forth- coming. The explanation is simple. The moment pneumo- thorax occurs, the diaphragm on the affected side becomes flaccid and more or less concave, being drawn downwards by the weight of the abdominal organs, and in this concavity a certain quantity of fluid may collect without yielding per- cussion dulness. In cases in which the intrapleural tension * The directions given in the Hippocratic writings for eliciting this sound are as follows : " Place the patient on a firm seat, and let an assistant hold his arms ; then, shaking him by the shoulders, listen on which side the splash is heard " {De Morbis, ii., § 47). 44 DISEASES OF THE LUNGS AND PLEUR/E Fig. 25. — Drawing made at the Autopsy of a Case of Pyo-Pneumo- THORAX with MARKED INTRAPLEURAL PRESSURE, SHOWING THE Diaphragm extending down to the Umbilicus, and forming a Large Abdominal Tumour, greatly displacing the Liver and Stomach. When the Chest was punctured, and the Air allowed to escape, the Diaphragm became relaxed, and the Tumour disappeared. (Note.— The drawing was made from near the feet, and the chest is accordingly somewhat foreshortened.) is considerable this depression of the diaphragm may become extreme. Thus, in the case of pyo-pneumothorax illustrated in Fig. 25 it formed a large sausage-shaped tumour, convex PNEUMOTHORAX 1 45 towards the abdomen, extending" nearly to the umbilicus, and dislocating the liver to the left. On puncturing- the chest and allowing the air to escape, the diaphragm became relaxed, and the tumour disappeared. In cases in which the quantity of fluid present is consider- able intercostal fluctuation may sometimes be observed. In other cases, on sharply percussing immediately below the line of contact of resonance and dulness, a thrill, significant of fluid vibrations, may be detected. Such are the signs of pneumothorax, of which those of cardinal importance are the following: (i) hyper-resonance; (2) absent, feeble, or amphoric respiratory sounds; and (3) dis- placement of the heart. These three signs alone are suffi- cient to render the diagnosis certain, and their presence can be ascertained by a physical examination, which will not add to the distress of the patient. Let us now consider each of them in greater detail : 1. The degree and extent of the hyper-resonance depend upon the quantity and tension of the air that has escaped into the pleural cavity. The note has usually a drum-like quality, which is characteristic; but in cases in which the ten- sion of the air is great the vibration of the chest walls is less free, and the tympanitic note becomes somewhat deadened. The boundaries of hyper-resonance include the sternum, and may extend beyond it towards the healthy side; if the left side be affected, the normal cardiac dulness is altogether effaced. As a rule, the whole lung- is collapsed, save per- haps at the summit, where there are frequently some old adhesions. In some cases, however, adhesions are so strong and extensive as to limit the pneumothorax to a small por- tion only of the pleural cavity — usually the base or the lower anterior and axillary region. In such cases of "partial pneu- mothorax " — and they are by no means uncommon, nine out of our nineteen cases being of this type®* — the hyper-reson- ance will be limited to the corresponding- portion of the chest. As the symptoms are rarely urgent in these patients, the com- plication may pass unnoticed. 2. The character of the breath-sounds varies according to the nature of the opening. Over the greater portion of the affected side the respiratory sounds are as a rule annulled, and where the opening is small and quite valvular no auscultatory 10 146 DISEASES OF THE LUNGS AND PLEURAE sounds may be detected at any point, although very often, even in these cases, at one spot a faint and distant hollow inspiratory sound may be heard on careful auscultation. In cases, however, in which the opening through the pleura is free, the entry and exit of the air to and from the pleural cavity gives rise to a variety of amphoric breathing— not loud, but peculiarly large and of metallic quality— which can rarely be mistaken. This amphoric breathing is most audible at some one portion of the chest nearest to the seat of perfora- tion. It is commonly best heard at the mammary or upper or lower scapular region, and is conducted more or less dis- tinctly from this point. With a free and patent opening the expiratory portion of the amphoric sound is peculiarly dis- tinct. In these latter cases with free opening, the voice- sounds may be attended with a metallic echo quite peculiar, whereas in the, more valvular cases the voice-sounds are not conducted at all. Metallic tinkling is frequently present, and is a useful additional sign — one, however, which may at times be heard very clearly over large pulmonary cavities. Feeble and more or less modified breath-sounds are heard at the apex, where there are still adhesions, and immediately after the occurrence of perforation, friction sounds may develop over portions of lung as yet in contact with the thoracic wall. 3. Displacement of the Heart. — M. Gaide"' was the first to describe displacement of the heart as an important sign of pneumothorax. It is, indeed, a constant and, save in excep- tional cases in which the base of the opposite lung is con- solidated, an essential sign of perforation of the pleura, and it is singular that it should have escaped the notice of such acute clinical observers as Laennec and Louis, Its occur- rence simultaneously with that of the perforation, noticed but not explained by M. Gaide, is a fact that would of itself cast suspicion upon the usual acceptance of the sign as being • necessarily one of pressure. The cardiac displacement may be observed within a few minutes of the perforation, and is due, in the first instance, to the sudden removal from the mediastinum of the elastic traction of the lung which has collapsed, and the consequent unopposed traction upon it of the other lung. If the opposite lung be not soHdified, the heart may from this cause alone be carried beyond the median PLATE VI Radiogram of Chest in a Case of Right-Sided Pyo-Pxeumothorax (Taken by Dr. Stanley Melville.) ^u^horax. To face p. i^ PYO-PNEUMOTHORAX The radiogram shows the appearances met with in a case of right- sided pyo-pneumothorax, the radiogram being taken with the patient in the standing position. The heart and mediastinum are drawn somewhat to the left, and the left lung shows evidence of tuberculous infiltration. The deep shadow of the fluid, with horizontal upper limit, is well seen on the nght side, together with the bright air-containing space above. The right lung is collapsed along the vertebral column, except at the apex. From a man aged twenty-six. who suffered from pulmonary tuberculosis. PLATE VI PNEUMOTHORAX J 47 line. Thus, we have recorded two cases, and have seen several others, in which the heart was displaced to the right of the sternum, yet in which, as proved post-mortem by the manometer, no intrathoracic pressure existed.'^ On a screen examination by the X-rays the affected side is seen to be brighter or more transradiant than the sound side, owing to there being now less tissue to oppose the passage of the rays (see Plate VI.). The shadow of the collapsed lung may be observed by the side of the vertebral column, and the displacement of the heart, already detected by physi- cal examination, will be confirmed. If fluid be present as well as air, the appearances seen are striking. In the erect posture the upper portion of the chest, where the air is now collected, will show the increased translucency characteristic of pneumothorax, the lower portion yielding the dark shadow of fluid. The line of demarcation between the two is sharp and clear. Further, the level of the fluid, unlike that of a simple pleural effusion, is absolutely horizontal — a water- level in any position which the patient may assume. This fact, when observed, is of great importance, and proves the presence of a cavity within the chest containing air and fluid. The upper level of the fluid, whether serum or pus, is rarely still, and this is especially the case if the disease be left-sided, the surface showing* continual rippling movements conveyed from the heart, and presenting a very striking pic- ture. On shaking the patient, the fluid is seen to dash against the sides of the pleural cavity and to rebound, form- ing waves, which accurately explain the mechanism of the succussion splash. Course and Prognosis.— In the majority of instances pneu- mothorax occurs towards the close of the disease, when the patient is already dying of extensive pulmonary lesions. It is as a rule, therefore, of grave augury, although the practice of early evacuating the air from the distended pleura has considerably diminished the immediate danger of the complication.'^ Should the patient survive this primary danger, the heart and circulation gradually become accustomed to the altered conditions, and in the most favourable cases the air, after a few weeks, becomes absorbed, the lung re-expands, and the heart returns to its normal position. Such an event 148 DISEASES OF THE LUNGS AND PLCURiE is not uncommon when pneumothorax occurs in persons apparently healthy, or in whom the lesions of pulmonary tuberculosis are so slight as to give no physical signs. But in cases of manifest phthisis such recovery, though we have known instances of it, is rare. Fluid, usually of a serous or sero-purulent nature, generally becomes effused. This may after some weeks be reabsorbed, the air at the same time dis- appearing. More commonly it happens that the fluid remains, and if the perforation in the pleura has healed, and the lung- is unable to expand, the case becomes converted into one of chronic hydrothorax. This latter termination is, however, exceptional. As a rule, when a hydro-pneumothorax has been established, the condition remains unchanged for months, or even in exceptional cases for years,* until the patient dies from the spread of the primary disease, or more rarely from the sudden onset of acute foetid pleurisy, putrefactive organ- isms having found access to the pleura. We have more than once met with cases in which the occurrence of pneumothorax has seemed to arrest the activity of the disease in the lung affected, and to prolong life. Of fifty-eight cases of pneumo- thorax collected from the post-mortem records of the Bromp- ton Hospital, the greatest durations of life were twelve, eight, seven, five, four and a half, and four months in six cases respectively. The shortest durations were ten minutes, fifteen minutes, and six hours. We have been speaking so far of the prognosis of pneumo- thorax when secondary to pulmonary tuberculosis. In other conditions the outlook must vary with the cause. In cases of gangrene of the lung, the rupture of septic infarcts, and bronchiectasis the result is almost always fatal, partly on account of the primary disease and partly from the severe septic inflammation originated in the pleura. In cases of emphysema, on the other hand, and of empyema bursting into the lung, the prognosis is more favourable, provided that in the latter case the pus is freely evacuated by surgical measures. Diagnosis.— There is as a rule but little difficulty in dis- tinguishing a case of pneumothorax, in which the effusion of * The experience of Dr. Morse," who records six instances of recovery out of fourteen cases of tuberculous hydro-pneumothorax with serous effusion, is most exceptional. PLATE VII Radiogram of a Case of Pyo -Pneumothorax Subphrenicus, viewed from the Front. (Taken by Dr. Hugh Walsham.) To face p. 149. JlasmoJa n't liA" _ , , , .' bri.c^it air-con tafii 11? 'ndi :)SC -PNEUMOTH<>RA-; Si. Bl'HKENi< 35^neath- the vlfiult of the diaphragm, on its right ■■ ^pa..e, her. ;■(.:•:•'! i'cifew )>\ jw, along .vvhidi, on shaking ating the ■•]-\>f'A limit vf th,- m., CSS conta woberfS noiaufta iBioalq zuom >o •qu bsriaoq mssidqaiO: ebiBW (Ufisnsd ,i(iJvBD 9d) ni irA gainifiinoo ,ni:gci({q6ib 2uq biic (is f^^ I$SfsJi;!^sqqo IsJnosboH DittsdqaBe 3ff| riiaoqsrtt f ) I nir ■..■■ t M".- J .1; I j\j I ' ; c- ; V, I • ber.i afh the diaphvagm the stoma; ■om a man aged forty, who suffered from a subphrenic abscess asscciated with intrahepatic suppuration. PLATE VII PNEUMOTHORAX 1 49 air is extensive, from any otker morbid state. Emphysema is the only other affection in which we obtain hyper-resonance and enfeebled breathing combined. But in emphysema the disease affects both hmgs, the note lacks the drum-like quality found in pneumothorax, the respiration is never quite sup- pressed, it is not amphoric in quality, and the heart is not laterally displaced. It is sometimes very difficult to distinguish between a local- ised pneumothorax and a large thin-walled pubnonary cavity. Such cavities may yield almost tympanitic resonance and metallic tinkling, whilst the bell sound, movable dulness, and succussion splash may all, though rarely, be elicited, as in a case which we have recorded.^" But localised pneumo- thorax is most commonly situated at the lower portion of the thorax, and in this situation such a largS pulmonary cavity as could be confounded with it is of most rare occurrence, unless it be continuous from the apex downwards, in which case the heart's beat would be felt on the affected side. Except for the position of the heart, the X-ray appearances of total excavation of the lung may exactly resemble those of a hydro- or pyo-pneumothorax.-' Occasionally a diaphragmatic hernia, with escape of stomach and colon into the left side of the chest, and with displacement of heart to the right, may simulate a pneumo- thorax. But here a bismuth meal and X-ray examination will reveal the true nature of the case. Another source of error is the occurrence of an abscess beneath the diaphragm containing both air and fluid, a con- dition originally described by Leyden- under the name pyo- pneumothorax subphrenicus. This is most often secondary to perforation of a gastric or duodenal ulcer. The abdominal symptoms in the preceding history of the case, the absence of cough, expectoration, and of pulmonary signs in the upper portions of the chest, together with the comparatively slight cardiac displacement, are points which should help to direct diagnosis aright. An X-ray examination, provided the patient's condition permit, gives valuable confirmatory evi- dence, revealing the fixed condition and upward displacement of the diaphragm, and beneath it the presence of a cavity containing air and fluid (see Plate VII.). But the cases which we have seen most often mistaken for 150 DISEASES OF THE LUNGS AND PLEURA pneumothorax have been those of advanced phthisis, in which acute congestion has rapidly supervened at the base of the comparatively sound lung. Pain limits the movements and lessens the sounds over the newly affected part; there is con- siderable high-pitched resonance on percussion; and the symptoms, setting in suddenly and acutely, may be precisely those of pneumothorax. But on careful auscultation breath- sound and rhonchus can be heard; the heart is not displaced, nor is the percussion note truly tympanitic. Sometimes, also, at first sight the dyspnoea of asthma resembles that of pneumothorax, and with general hyper- resonance we may have in asthma an absence of respiration over portions of the chest. But the portions of lung so affected will vary in position, perhaps, even whilst we are listening, and the general wheezing rales elsewhere present, together with the history of the case and the effect of treat- ment, will prevent any real difficulty in diagnosis. Again, we have seen more than one case of hysterical dyspnoea suggest- ing pneumothorax, but the expression of countenance cannot be simulated, and a moderately careful physical examination will lead to a right conclusion. The diagnosis of pyo-pneumothorax from simple empyema is not difficult, the succussion splash and the marked shifting of the dulness and resonance with change of posture, as well as the X-ray appearances, being quite characteristic of the former. Nevertheless, we must remember that certain cases of apparently pure empyema have their origin in perforation of the lung, the rupture having closed and the air undergone complete absorption. But the diagnosis in pneumothorax does not consist merely in separating it from other diseases, but also in distinguishing the kind of perforation that has taken place and the probable existence or not of air-pressure within the thorax. The dis- covery of amphoric (to-and-fro) breathing strongly suggests that the opening is a free one, admitting the ready passage of air both ways, and that, consequently, no air-pressure is present. On the other hand, the complete absence of all breath-sounds, with increasingly urgent dyspnoea, distended side, and greatly displaced and oppressed heart, are equally significant of a valvular opening and of increasing intra- thoracic pressure. PNEUMOTHORAX 151 Treatment. — Life is threatened on the occurrence of pneu- mothorax hy shock, asphyxia, and exhaustion, and these are the special indications for treatment. The shock, which is -due to the sudden lesion of a vital organ and to the sudden dislocation and impeded action of the heart, must be treated by the administration of a stimulant, but above all things by an opiate. Opium is most valuable in calming the nervous system and in lessening the sense of dyspnoea. A dose of morphia may be given subcutaneously, and the treatment con- tinued in the form- of a pill of opium with camphor. Increas- ing pressure within the chest, if present, must be treated by the timely introduction of a fine trocar. For this purpose a Southey's trocar with fine rubber tube attached may be employed. The tube should open below into boracic lotion to prevent the entry of air into the chest during inspiration, but in emergency any fine instrument may be used. This trifling operation gives great and, curiously, sometimes lasting relief. If necessary, it may be repeated. After the excess of air has been removed, the side may be strapped so as to control inspiratory movement. A broad band of strapping firmly applied over the lower ribs, and reaching some two or three inches beyond the middle line in front and behind, is sufficient to attain this end. Positive pressure is brought about within the pleura by the thoracic wall on the affected side becoming expanded to the position of extreme inspiration, and then recoiling upon the air pent up in the pleura. By diminishing the inspiratory movements we may hope to prevent this ex- cessive accumulation of air, with all its attendant conse- quences. As a rule pneumothorax occurs in persons already reduced in flesh and blood by previous illness. If the accident should occur at an earlier period of the disease, the venous engorge- ment, lividity, and general circulatory distress resulting from the embarrassment and dilatation of the right side of the heart, will be correspondingly marked. In such cases free dry- cupping will give great relief. The portal system being the great reservoir for retarded blood, an occasional saline aperient is of value in pneumothorax, and also serves to correct the constipating effects of opium, the administration of which in repeated small doses is on other grounds desirable for. the first. few days. 152 DISEASES OF THE LUNGS AND PLEURiE When effusion has occurred, we must not be in too great a hurry to withdraw it, provided it be of the usual serous or sero-purulent variety, since a certain delay will assist in clos- ing the rupture in the pleural membrane. But should pressure symptoms ensue, we may remove a portion, care being taken not to produce a negative pressure in the pleura, lest the rupture recently healed be reopened. The syphon may, therefore, be employed, or, if the aspirator be used, the fluid must be allowed to flow with as little suction as possible. If the fluid returns, a second paracentesis may be performed ; but, should this also fail, it is better as a rule to suspend active treatment. The patient suffers little, and, provided the disease in the other lung be fairly quiescent, he may live for many months, or occasionally for some years, in that con- dition, dying at length from the spread of tubercle in the opposite lung, or from the invasion of the larynx and more distant parts. Should the patient, however, complain of the weight in the chest caused by the effused fluid, relief may be given, and possibly some expansion of the lung effected, by paracentesis followed by oxygen replacement,-^ as described when speak- ing of cases of chronic pleurisy (see p. 114). But we must re- member that in cases of pneumothorax any traction exerted upon the lung must be gentle lest the perforation which has now closed should reopen, with the attendant danger of septic infection. In a case of pyo-pneunvothorax when the fluid is distinctly purulent and contains pyogenic micro-organisms, and pyrexia is present, paracentesis should be performed and repeated if necessary, but if the patient continues to lose ground, incision and evacuation of the pus, with subsequent drainage, is our only course, provided the general condition does not forbid. In certain cases thus treated the perforation in the pleura has closed, and the lung has re-expanded, though a fistula may per- sist.^' Should the expansion of the organ be incomplete, and the chest not fall in sufficiently, later on a modified Estlander's operation may be required. We have known a remarkable case in which this was successfully performed. Each case must, however, be separately considered, and treated on its own merits. If there is little or no fever, and the patient's condition be satisfactory, it will be wiser to leave well alonc> PNEUMOTHORAX 1 53 to perform paracentesis from time to time when required, but not to proceed to more drastic surg-ical measures. How long cases of pyo-pneumothorax not operated upon may continue to live is well exemplified by the history of the following patient : Mr. T., aged twenty-nine, was first seen in 1902. His father had suffered from " weak lungs," and died early, but the family history was otherwise satisfactory. He was delicate as a child, but became robust at sixteen, and excelled at sports, being accustomed to con- tend in fift3'-mile bicycle races with success. In 1895 he was passed as medically sound for the public service, but for family reasons he entered upon a commercial career in London. In 1897 he married, and four children were born, one of whom died at birth, and one of tuberculous meningitis at fifteen months. In 1901 he contracted repeated " colds," and in December of that year he developed early tuberculous trouble at the left apex, with tubercle bacilli in the sputum, and, by the advice of his family physician and a consultant, went to Torquay, where he improved considerably for a time. On May 9, 1902, he was sent to Sir R. Douglas Powell by Dr. Edwin Smith, of Tooting. Consolidation of the upper third of the left lung was found, but the constitutional symptoms were mainly in abeyance. The alternatives of his remaining in town with pre- cautions and of his taking a voyage were considered and negatived, and treatment at a sanatorium for at least three or four months was strongly advocated, with a hopeful prognosis. Some creosote was prescribed. In September of that year he returned from a four-months course of treatment at a Hampshire sanatorium, having gained i stone in weight (9 stone 2 pounds), with a normal temperature and only slight morning cough. He could walk ten or fourteen miles a day. Although the physical signs at the left apex remained, with some coarse crackles, the right lung had expanded across the sternum. He went to Bournemouth, where he bought a house, and remained with his wife and family. In January, 1903, his weight was 9 stone 6 pounds, the disease quiescent, with some fibroid changes. Tempera- ture normal. In June, 1904, he reported that he had early in the year had some relapse of symptoms. His child had died from tuberculous meningitis, and he had suffered from pleurisy, with loss of weight. For the last six months, however, his temperature had been normal, and his present weight was 9 stone 4 pounds. In May, 1905, he developed pneumothorax on the left side below the fifth rib in front and behind, followed later by fluid effusion. He was exceedingly ill for some time, and at the end of four months was only just able to stand. He then again improved rapidly, and after nine months reported himself as better than before the pneumo- 154 DISEASES OF THE LUNGS AND PLEUR.E thorax. His -cough had disappeared, he had gained weight, and the temperature was normal. The signs of pneumothorax, howeyer, persisted. His letter, written on July 9, 1906, contains the fol- lowing interesting passage : " Of the thirteen patients of a group taken when I was at the sanatorium (in 1902), nine are dead. Of the remaining four I am one; of two I am doubtful, and one is really soundly cured, and he is the careless one who plays hockey in Ire- land. ... I have just noticed we were thirteen ! . . . I have been through more than any of those who died, but I think it has much to do with will-power, and not allowing oneself to worry." In regard to this psychical aspect of the matter, Mr. T. deprecates the practice of enjoining patients to take their temperature three times a day, adding: "When it is up, they worry until it goes higher. I went to 105-2°, but I did not mind. A sensitive girl would have died of fright. I am a layman, I know, but I feel that mind is half the battle one way or another." In June, 1907, Mr. T. was seen again in consultation with Dr. Hyla Greves, and he was found still to present all the physical signs of pyo-pneumothorax, communicating with and discharging through the lung. The question of opening up the pleura, with removal of some of the ribs, with the hope of closing the cavity, was carefully considered, and was reluctantly abandoned as a measure that would probably have had an immediately fatal result. He was advised to evacuate the pleural cavity as far as possible by natural means and at stated intervals. With his usual determination he set to work to carry out directions by a process of " tilting-up," as he expresses it, " lying on a lounge-chair with head on the floor and legs up the back of the chair," thus inducing cough and expectoration. In February, 1909, Mr. T. wrote that since June, 1907, he had " tilted up " twice and later three times a week, and had brought up altogether about lo-l gallons of pus, carefully measured, but that at the date of writing he expectorated only about -| pint each time. Recently there had been intervals of perhaps a week without expectoration, " the safety-valve having struck work," as he describes it, during which time he became " depressed, weak, and austere. The block then gives way, and at the next attempt at evacuation there is a sudden rush, and i^ pints of pus may be brought up." In a later letter, in May, 19 10, he states that he is much better, expectorating only about an eggcupful every day, though the total amount evacuated by the tilting process had now reached 15 gallons. On October 25, 1910, Dr. Hyla Greves writes : " At the present time Mr. T. 's condition is very fairly good, considering all he has gone through. The left side of the chest has fallen in greatly, and the pneumothorax cavity correspondingly diminished in size, the amount of expectoration discharged by ' tilting up ' being comparatively small. The right lung shows very few indications of disease, but there are a few moist sounds in the upper lobe. Some months ago he had a PNEUMOTHORAX 1 55 good deal of abdominal pain and discomfort, and I feared the possi- bility of tuberculous disease of his intestines, but careful dieting and having his teeth put into proper order has apparently got rid of this condition. He is able to take a moderate amount of walking exercise daily." The patient continued under Dr. Greve's skilful and inspiriting care and kept fairly well, but the disease in the right lung made progress, and signs of a cavity developed in the upper lobe. On April 22, 1912, Mr. T. had his first attack of haemoptysis, the blood probably coming from the right lung. The haemorrhage recurred on several occasions and greatly reduced his strength. He died in June, 1912. This case is in some respects a remarkable one of endurance and will-powder in contending against a disease which would certainly have sooner proved fatal in a less sanguine and determined man, and on this account appears worthy of record. The death-rate incidentally mentioned amongst his sanatorium contemporaries is interesting. REFERENCES. ' " Dissertation sur le Pneumothorax, ou les Congestions Gazeuses que se forment dans la Poitrine," par M. Itard, Presentee et Soutenue a VEcole de Mcdecine de Paris. Paris, 1803. (Quoted by Laennec. We have been unable to obtain a copy of the original essay.) * Train de f Auscultation Mediate et des Maladies des Pouvions et du Caur, par R. T. H. Laennec, troisieme edition, tome ii., p. 414. Paris, 1831. ^ " Zur CEtiologie des Pneumothorax," von Dr. Alois Biach, in Wien, Wiener Medizinische Wochenschrift, 1880, p. 6, etc. * See the Bradshawe Lecture on " Pneumothorax," by Samuel West, 'M.D., Lancet, 1887, vol. ii., p. 353. ^ The Diseases of the Lungs, by James Kingston Fowler, M.D., F.R.C.P., and Rickman John Godlee, M.S., F.R.C.S., p. 627. London, 1898. " "Pneumothorax without Urgent Symptoms, followed by Recovery; subsequent Death of the Patient from Dissecting Aneurism of the Aorta," by W. H. Ranking, M.D., F.R.C.P., British Medical Journal, August 25, i860, p. 665. ' See papers on this subject by Dr. Douglas Powell in The Medical Times and Gazette for January and February, 1869. * Abstracted from the annual " Reports of the Post-Mortem Examina- tions " made at the Hospital for Consumption and Diseases of the Chest, Brompton. ' [a) Re-port on the Work of the Pathological De-part7nent of the Br om ft on Hospital during the Three Years 1900 to 1903, by P. Horton-Smith (Hartley), M.D., p. 12. London, 1903. {b) Loc. cit., p. 25. " See Fourth Edition of this work, London, 1893, p. 155. " " A Contribution to the Pathology of Pneumothorax," by Samuel West, M.D.„ Lancet, 1884, vol. i., p. 791. 156 DISEASES OF THE LUNGS AND PLEURA " "On Some Effects of Lung Elasticity in Health and Disease," by R. Douglas Powell, M.D., Transactio7is of the Royal Medical and Chir- urgical Society, 1876, vol. lix., p. 179. " " Observations on Air found in the Pleura in a Case of Pneumothorax, with Experiments on the Absorption of Different Kinds of Air introduced into the Pleura," by John Davy, M.D., F.R.S., Philosophical Transactions of the Royal Society of London, 1823, p. 496, and 1824, p. 257. " (i) " Untersuchungen zur Gasometrie der Transsudate des Menschen," von Dr. C. Anton Ewald, zu Berlin, Archiv fiir Anatomic, Physiologic, und Wissenschaftliche Medicin (Reichert und Du Bois- Re3'mond), p. 422. Leipzig, 1876. (2) " Ueber ein leichtes Verfahren, den Gasgehalt der Luft eines Pneumothorax und damit das Verhalten der Perforations-offnung zu bestimmen," von Dr. C. A. Ewald, Charite-Annalen, ii. Jahrgang, 1875, p. 167. Berlin, 1877. " " Contributions to Morbid Anatomy," No. iv., by Andrew Duncan, jun., M.D., The Edinburgh Medical and Surgical Journal, 1827, vol. xxviii., p. 302. " " Observations Cliniques Recueillies a I'Hopital Saint-Antoine," par M. A. Gaide; "Observations de Pneumothorax," Archives Generales de Medecine, tome xvii., p. 345. Paris, 1828. " " Cases illustrating the Manner in which the Heart is displaced in Pneumothorax," by R. Douglas Powell, M.D., The Medical Times and Gazette, August 21, 1869, p. 218. '* How rapidly fatal pneumothorax usually proved before the intro- duction of paracentesis and the evacuation of the air is indicated in the following paper, " The Prognosis of Pneumothorax, with Some Statistics as to the Mortality and Duration, and an Account of a Series of Cases of Recovery," by Samuel West, M.D., Transactions of the Medical Society of London, 1897, vol. xx., p. 103. " " An Analysis of Fifty-one Cases of Pneumothorax," by John Lovett Morse, A.M., M.D. (Boston), The American Journal of the Medical Sciences, May, 1900, p. 503. ^^ "A Case of Pulmonary Tuberculosis with extensive Excavation simu- lating a Pyo-pneumothorax," by P. Horton-Smith Hartley, St. Bartholo- meiv^s Hospital Reports, vol. 1., 1914, p. 121. ^^ [a) " A Case of Phthisis with complete Cavitation of the Left Lung," by D. W. Carmatt Jones, M.D., M.R.C.P., and E. S. Worrall, M.R.C.S., L.R.C.P., The Lancet, 1913, vol. i., p. 1445. [b) Dr. V^oxxs\\,Proceedings of the Royal Society of Medicine, Electro- therapeutical Section, April, 1913, vol. vi., p. 113. ^^ " Ueber Pyopneumothorax subphrenicus (und subphrenische Ab- scesse)," von E. Leyden, Zeitschrift fUr Klinische Medicin, 1880, vol. i., p. 320. ^^ " Surgery of the Lung and Pleura," by H. Morriston Davies, M.A., M.D., M.C., F.R.C.S., pp. 62, 46. London, 1919. =t See (i) The Surgery of the Chest, by Stephen Paget, M.A., F.R.C.S., p. 323. Bristol and London, 1896. (2) Diseases of the Organs of Respiration, by Samuel West, M.D., F.R.C.P., vol. ii., p. S60. London, 1909. CHAPTER X HEMOTHORAX— GUNSHOT WOUNDS OF THE CHEST By the term Hsemothorax is meant the effusion of pure blood into the pleural cavity, the condition being distinguished from haemorrhagic pleurisy, in which the inflammatory exudation is merely tinged with blood. Haemothorax may be secondary to disease, or result from injury, such as fractured ribs, but is most commonly a sequel of gunshot wounds of the thorax, and as such has been of frequent occurrence during the recent war. The amount of blood poured out varies from a few ounces to several pints, according to the extent of the wound and the source of the haemorrhage, whether coming from lung, aorta, intercostal or internal mammary artery. As Colonel Elhott and Major Henry* have shown, the blood rapidly clots, but, owing to the cardiac and respiratory move- ments, the clot is not, as a rule, massive, and the fibrin is deposited as a layer upon the pleural surfaces. If the flviid be removed from the chest and tested for fibrinogen none will be found, showing that clotting has, in fact, occurred, and that the fluid is really defibrinated blood. As a result of the irritating action of the blood a low degree of pleurisy follows, and serous fluid is poured forth, mixing with and diluting the haemothorax. Haemothorax in Civil Life. In civil life haemothorax is not common, and is then perhaps most often the result of fracture of rib with lacerated pleura. Another cause is the rupture or leakage of an aortic aneurism into the pleural cavity. Ulcerative erosion penetrating the aorta, intrathoracic veins, or intercostal arteries has also been described as a rare precursor of this condition (Watson). In 157 158 DISEASES OF THE LUNGS AND PLEURA malignant or tuberculous disease haemorrhagic pleurisy, as we have already seen, is not uncommon; but definite haemor- rhage into the pleura is rare. In scurvy, purpura, and the malignant forms of the specific fevers, the fluid effused into the pleura may be somewhat blood-stained, but here also a true hsemothorax is exceptional. It sometimes happens that with the blood air makes its way into the pleural cavity, and a Immopncumothorax results, an uncommon condition in civil practice, of which but few cases are recorded. In an interesting paper Dr. Newton Pitt' described a case due to the rupture of an emphysematous bulla, and referred to three other cases from the post-mortem records of Guy's Hospital. In two of the latter the condition resulted from a laceration of the lung (without fracture of the ribs) following a crush, and in the third from the rupture of a phthisical cavity through the pleura, this event being followed shortly afterwards by haemorrhage from an ulcerated vessel in the cavity wall, leading both to haemoptysis and to the effu- sion of blood within the pleura. Symptoms. — The symptoms of haemothorax unassociated with wounds do not differ materially from those of other pleuritic effusions, unless the haemorrhage be profuse, in which case restlessness and distress, a rapid and irregular pulse, and other signs of internal haemorrhage are superadded. The physical signs are indistinguishable from those of other exudations into the pleura, and except when caused by injury, the condition is rarely suspected until exploratory puncture reveals its nature. The rapidity with which the fluid collects might in some cases, however, suggest a suspicion as to the true state of affairs. Treatment. — If the haemothorax result from the leaking of an aortic aneurism, clearly we should not interfere unless great displacement of heart and increasing dyspnoea render para- centesis imperative, since the pressure of the effusion will tend to check the further flow of blood. In other cases, if the effusion be large, paracentesis may be employed, earlier recovery having been observed during the war from the with- drawal of the fluid. Each case must be judged upon its merits, it being borne in mind that, if the primary disease permit recovery, the blood will be gradually absorbed by natural mearks, though this process may be slow. Should signs of HEMOTHORAX 1 59 suppurative pleurisy supervene from infection of the pleura, surgical treatment must not be delayed. Hsemothorax following Chest Wounds. As we have stated, hsemothorax has been of frequent occurrence during the war, and it may be said to be the common sequel of a gunshot wound of the chest. In such cases the blood comes, as a rule, from the injured lung, more rarely from a damaged intercostal or internal mammary artery. It is not uncommon for a small quantity of air to be present also in the pleura during the early stages, and for the case to be strictly a haemopneumothorax, but the quantity of air is rarely large, and it is in most cases rapidly absorbed. Symptoms and Physical Signs. — A certain degree of shock always follows a wound of the chest. In grave cases it is severe, and it is estimated that, taking all chest wounds together, an early mortality of from lo to 15 per cent, results from shock and primary haemorrhage.'^ In large open wounds exposing the pleural cavity, so that air is sucked in at each inspiration, so called Traumatopnoea, shock and respiratory distress prove fatal unless relieved by surgical treatment; but in simple through-and-through wounds of the chest, or those in which a small missile is retained, these symptoms soon abate, and the case becomes one of hsemothorax, though we must add that an effusion of blood into the pleural cavity does not necessarily occur in all such cases. Haemoptysis is of frequent occurrence, and may recur for several days, but unless it arises from damage to a larg'e vessel, when it may be rapidly fatal, it is rarely troublesome. The physical signs of haemothorax resulting from a pene- trating- wound of the chest are sometimes those of pleural effusion — namely, impaired note, diminished vocal fremitus, breath-sounds and voice-sounds, with displacement of heart towards the sound side, and if the effusion be of sufficient extent, enlargement of the affected side. As Sir John Rose Bradford^ has, however, pointed out, in many cases the signs are different, and the affected side, though dull over the effu- sion, is retracted and almost motionless, and the diaphragm elevated. Bronchial and even cavernous breath-sounds with bronchophony and aegophony are heard over the area of fluid, and above this level, marked skodaic resonance. These l6o DISEASES OF THE LUNGS AND PLEURA signs have often led to the mistaken diagnosis of traumatic pneumonia, but the heart's apex-beat, be it noted, is usually displaced towards the healthy side. It would appear that these peculiar signs are the result of an underlying massive collapse of the lung, ■* """^ ^° a condition which will be dis- cussed more fully in Chapter XX. Course. — The blood poured out in a case of gunshot wound of the chest rapidly reaches its maximum, owing partly to the collapse of the lung, which checks the outflow, and partly to the deposition of fibrin, which soon occurs, and which tends, by forming" adhesions, to circumscribe the effusion. There is still some dyspnoea on recovering from shock, but it is not urgent, nor is cough as a rule a troublesome symptom. Moderate pyrexia may persist for some little time. Provided, hozvever, the hamothorax remains sterile, these symptoms gradually subside, and the fluid is slowly absorbed. In some 25 per cent, of chest wounds sepsis unfortunately occurs,* a complication twice as frequent when the wound has been caused by shell fragment as by machine-gun or rifle bullet." The infecting organisms are attached to the missile, or are introduced with fragments of clothing, or come from within from the lacerated lung. Of loi cases of septic hgemo- thorax investigated by Colonel Elliott and Major Henry,^ in rather less than 20 per cent, the organisms isolated were the pneumococcus, Pfeiffer's bacillus, and the M. tetragenus, coming presumably from the respiratory tract : in the re- mainder, streptococci, staphylococci, and anaerobic gas-form- ing bacilli, of which B. perfringens was the most frequent, were found, gas-forming organisms occurring in nearly half of all the infected cases. Continued pyrexia, restlessness, a rapid pulse, and in some cases a furred tongue, will suggest the occurrence of sepsis; but to make certain the fluid removed by exploratory puncture must be examined bacteriologically, both by staining and culture. Colonel Elliott and Major Henry^ found that in 90 per cent, of the infected cases organisms could be detected in films stained with methylene blue and by Gram's method, and that the finding of a stout Gram-staining anthrax- like bacillus was very suggestive evidence of anaerobic infec- tion. Cultures should, however, be made in all cases. In patients infected with anaerobic organisms the amount of HEMOTHORAX l6r gas produced within the chest may be considerable, and the pressure as much as + 15 to +20 cm. of water.^ Such cases simulate closely, and have been mistaken for simple hcsmo- pneumothorax under the impression that the air had entered the pleura from the pulmonary wound. Exploratory puncture, and the withdrawal of fluid, often foul-smelling and contain- ing infecting organisms, will decide the diagnosis. The occurrence of sepsis is a grave complication, for whereas cases of simple hsemothorax, which fortunately number three- quarters of the whole, gradually make a complete recovery, of those in which sepsis occurs nearly half die.* ''"'* ^* Treatment. — (a) Without Operation. — If the haemothorax is small, reaching not higher than the angle of the scapula, it may be left alone. The fluid is absorbed and the lung ex- pands, and the patient is in most cases fit for duty in two to three months. The same policy of non-interference may be followed in regard to larger effusions, and it is astonishing how quickly in some cases the blood is absorbed; but statistics show that recovery is hastened by aspiration. This had previously not been regarded as correct treatment owing to the fear that secondary hemorrhage might result if the compressing action of the fluid were withdrawn. Experience in the Great War has, however, shown that this fear is unfounded, and if the effusion is a large one it is wise to aspirate. As much of the fluid as possible should be removed, but complete evacuation of the fluid is not necessary, since what is left will be dealt with easily by the pleura. Captain Fortescue-Brickdale'- has shown that of cases of haemothorax admitted to the Centre for Gunshot Wounds of the Chest at Southmead, Bristol, 42 per cent, of the large non-aspirated cases recovered completely in two months or less, and 84 per cent, of those which had been aspirated, showing the value of aspiration in hastening recovery. In patients with a small hsemothorax, about 90 per cent, recovered in two months or less, whether aspirated or not. There remains to consider certain rare cases of non-infected hcemothorax, in which the blood-clot is a massive one, and the fibrin not whipped out and deposited as usual on the pleura. In such cases aspiration fails, or is only successful to a limited extent, and if the hsemothorax be a large one it has been II l62 DISEASES OF THE LUNGS AND PLEURA suggested that the pleura should be opened in the manner to be described later, the clot evacuated, and the chest again closed. In view of the fact that, provided sepsis does not supervene, the patient will, with the aid of pulmonary exercises and movements probably in the end make a complete recovery, this course is hardly to be recommended as a routine measure. (b) With Operation. — We have so far concerned ourselves with the treatment of cases of haemothorax following chest wounds which remain uninfected, and they number about 75 per cent, of the whole. If properly treated the prognosis in these cases, as we have seen, is good. Should the haemo- thorax become infected, rib resection and drainage must be undertaken, but the outlook in such cases is gloomy. Colonel Elliott "^ ^"d >i having shown that nearly half the patients succumb, and of the survivors one-third are more or less dis- abled, and eventually invalided from the army. We are, therefore, faced with the question whether by surgical means we cannot prevent infection, and thus avoid the mortality associated v.ith this complication. Any opera- tion for this purpose must be undertaken early, as soon as the patient has recovered from the initial shock, and will involve excision of the external wounds of the soft parts, the removal of splinters of ribs and, if necessary, resection of broken portions, the cleansing of the pleural cavity from blood and clot, the extraction where possible of the missile, the excision or cleansing of the lung wound, and, lastly' the closmg of the chest. To effect these objects a portion of rib IS excised, when, with the help of a retractor, sufficient space will be obtained for the introduction of the hand within the thorax and the carrying out of the necessary manipulations Into the details of the operation we do not propose to enter and must refer the reader to the writings of Colonel Cask and others, references to which will be found at the end of this chapter. We may add, however, that severe though the operation sounds, it is, in fact, attended with less shock and a smaller fall m blood-pressure than is often associated with abdominal operations.' ^"''^^ Before the War such operations were rarely undertaken, from the belief that unless some form of pressure chamber, such as those devised by Sauerbruch and Willy Meyer, was H.EMOTHORAX l63 employed to prevent pneumothorax and collapse of the lung when the chest was opened, sudden death would follow. Recent experience has shown that this fear is groundless, and it is estimated that during- the Passchendaele fighting in the summer and autumn of 1917, 38 per cent, of the chest wounds were operated upon on the lines indicated above.'* It is clear, however, that as sepsis occurs in only a quarter of the cases, and as recovery in uninfected haemothorax may be antici- pated, a rigid selection must be made, those chosen for operation being the cases in which, from the nature of the wound and of the missile, sepsis is most likely to super- vene. In the opinion of Colonel Gask, the more important indications for operation are: a ragged external wound; compound fracture of the ribs; continued bleeding; an open wound leading into the pleural cavity with insuction of air at each inspiration; the retention of a large foreign body; and pain, out of proportion to the injury, and often due to in- driven splinters of bone, which so often lead to sepsis. We may say in conclusion that there can be no doubt that in cases of gross injury, such as those in which the chest is open, or in which a large foreign body is retained, or those which contain large indriven fragments of bone or clothing, opera- tion is urgently demanded and often life-saving. No patient, on the other hand, with a small and clean-cut wound, in whom the foreign body is of small dimensions and of smooth surface, and whose general condition is good, should be submitted to operation. Between these two groups there must be many intermediate cases in which treatment must depend upon a careful consideration of all the surrounding circumstances. In certain of these patients, provided the services of a surgeon experienced in chest work are available and the conditions for operation satis fact 01-y, a complete operation, as sketched out above, may be sanctioned, for there can be little doubt that in the hands of those who have especially devoted themselves to chest work such operations have led to a saving of life, though the results from the army as a whole, quoted by Colonel Elliott,'' are less encouraging. If, on the other hand, the indications for operation are not so clear, and the surround- ing circumstances less favourable, then it will be better merely to excise the external wound, to remove fractured portions of ribS, and then to close the wound, treating the 1 64 DISEASES OF THE LUNGS AND PLEURAE hemothorax, if necessary, by aspiration, and, should sepsis arise, to resect and drain the pleural cavity. We may add that we have treated the subject dealt with in this chapter at some length, because there can be no doubt that the lessons learnt in the war in regard to the surgery of the chest will be soon applied to the maladies and injuries of civil life. It is essential, therefore, that both physicians and surgeons should be well acquainted with the subject. As an illustration we may quote the following case, which recently came under ouf notice : The patient, a dustman, aged forty-eight, during the course of his work ran a needle into his back. This disappeared within the chest, and caused him at first but little inconvenience, but a few days later (on November 6, 19 19) he was seized with sudden pain in the right side, and came to St. Bartholomew's Hospital, where he was seen by one of us. On examination he was found to have surgical emphysema over the lower part of the right lung, with signs suggestive of the presence of a limited quantity of air in the pleural cavity. The screen examination, however, revealed nothing abnormal. He was admitted under Sir Archibald Garrod, and an X-ray plate showed later the presence of a needle in the lower por- tion of the right chest. On November 14 Mr. Gask operated, the anaesthetic used being chloroform and oxygen. Four inches of the sixth rib in the right axillary and anterior regions were excised and the chest fully opened. Air was found to be present in the pleural cavity, and in the lower portion of the semi-collapsed lung the needle was at once seen, half embedded, half exposed. Except for a little lymph round the site of the puncture, the lung appeared healthy. The needle was extracted and the wound closed. The operation was followed by a small collection of clear serous fluid at the right base and a low degree of pyrexia lasting twelve days, but recovery was otherwise uneventful. This case shows the value of such methods of surgical treatment, for there can be little doubt that had the case been left alone, suppuration, with its accompanying dangers, would have ensued. REFERENCES. * " A Case of a Rapidly Fatal Haemopneumo thorax, apparently due to the Rupture of an Emphysematous Bnlla," by G. Newton Pitt, M.D., Transactions of the Clinical Society of London, igoo, vol. xxxiii., p. 95. ^ " Haemothorax," by Colonel Sir John Rose Bradfopd, K.C.M.G., C.B., F.R.S., and Captain T. R. Elliott, F.R.S., The British Journal of Surgery, vol. iii., No. 10, 1915, p. 247. H.EMOTHORAX 1 65 ^ ■' Infection of Haemothorax by Anaerobic Gas-Producing Bacilli " (A Report to the Medical Research Committee), by Lieut. -Colonel T. R. Elliott, F.R.S., and Captain Herbert Henry, M.D., British Medical Journal, March 31 and April 7, 1917. ^ " Le Collapsus pulmonaire contro-lateral dans les Plaies de Poitrine," par le Colonel Sir John Rose Bradford, K.C.M.G., Bulletins et Mcmoires de la Societe Medicate des Hofitaux de Paris, Mai 31, 1917. ^ " On Gunshot Injuries of the Chest with Especial Reference to Hasmo- thorax,'" by Sir John Rose Bradford, K.C.M.G., C.B., F.R.S., British Medical Journal, August 4, 1917. " " Some Statistical Results of the Treatment of Chest Wounds," by T. R. Elliott, F.R.C.P., F.R.S., The Lancet, September 8, 1917, ii., p. 371. ' " Remarks on Penetrating Gunshot Wounds of the Chest, and their Treatment," by G. E. Cask, D.S.O., F.R.C.S., and K. D. Williamson, M.D., M.R.C.P., British Medical Journal, December 15, 1917. * "War Surgery of the Chest," by Captain A. L. Lockwood, M.C., and Captain J. A. Nixon, British Medical Journal, January 26, and February 2, 1918. ° Lemons de Chirurgie de Guerre, Publiees sous la direction de CI. Regaud (Service de Sante Militaire, centre d'Etudes et d'Enseigne- ment Medico-chirurgical de Bouleuse). Masson et Cie, Paris, 1918. '" " Massive Collapse of the Lung as a result of Gunshot Wounds, with Especial Reference to Wounds of the Chest," by John Rose Bradford, Quarterly Journal of Medicine, vol. xii., Nos. 45 and 46, October, igi8- January, 1919. " " The Early Treatment of Gunshot Wounds of the Chest," by Colonel G. E. Gask, D.S.O., Surgery, Gynecology, and Obstetrics, January, 1919, pp. 12-16. '- " Statistical and Clinical Report on 600 Cases of Gunshot Wounds of the Chest," by J. M. Fortescue-Brickdale, M.D., M.R.C.P., Medical Research Committee, Statistical Report, No. 4, February 27, 191 9. '■'' "Remarks on Chest Wounds from a Physician's Notebook," by J. A. Nixon, C.M.G., M.D., F.R.C.P., British Medical Jotirnal, April 5, 1919. 1' " Gunshot Wounds if the Chest," by Colonel T. R. Elliott, F.R.S. Printed by the British Medical Association. Abstract in British Medical Journal, April, 1919, i., p. 442. " " Surgical Aspects of Gunshot Wounds of the Chest," by Colonel G. E Gask, C.M.G., D.S.O., British Medical Journal, April, 1919, i., p. 445. CHAPTER XI CHYLOTHORAX The occurrence of effusions into the serous cavities which have an appearance resembling that of milk, but which are non-purulent in nature, has been known since the year 1633, when Bartolet' described a pleural effusion of this character, ft is only in comparatively recent years, however, that the subject has attracted much attention. .Such collections are met with most often in the peritoneum, less frequently in the pleura, and only very rarely in the pericardium. They sometimes occur simultaneously in both peritoneum and pleura. Chylothorax is undoubtedly a rare condition, and in a recent paper Dr. Mackenzie Wallis and Dr. Scholberg- were only able to collect sixty cases which have been recorded since the year i860. Effusions of this nature may be divided into two groups • (i) True chylothorax, (2) Pseudo-chylothorax, in both of which the naked-eye appearance of the fluid may be very similar. In the first variety, the true chylous variety, the fluid has become milky owing to the fact that as a result of injury or pressure upon the thoracic duct, a rupture of its walls has occurred, and chyle has found its way into the pleural cavity. The milky colour, in fact, is due to the presence of free fat. In the pseudo-chylons form, on the other hand, as Dr. Scholberg and Mr. Mackenzie Wallis have shown, the milky appearance results from the presence in the pleural fluid of a special compound or "complex," a lecithin-globulin or, as in the case recorded in this chapter, a cholesterin-globulin compound, of which we shall speak more fully later. The physical and chemical characters of the fluids in these two groups are somewhat different, and, fol- lowing the investigations by Dr. Scholberg and Dr. Mac- kenzie Wallis, may be briefly given as follows : 166 CHYLOTHORAX 167 The True Chylous Variety. 1. The fluid tends to accumulate rapidly, and in consequence large quantities are removed by para- centesis. 2. In colour it is generally yellow- ish-white. Emulsification is not perfect. 3. The degree of ofalescence is more or less constant at successive tappings. 4. The fluid -possesses an odour corresponding to the odour of the food digested. 5. Putrefaction occurs on stand- ing. 6. A creamy layer generally forms on standing, owing to the amount of fat present. 7. The specific gravity generally exceeds 1-012. 8. The freezing point is depressed about -0-51° C, the figure thus approximating that for chyle. 9. No change occurs on filtering through filter paper. On centrifu- galisation the fluid creams and may partially clear. On filtering through a Pasteur candle the milky colour remains. 10. Microscopically, many fine fat globules, staining with osmic acid and Sudan III. are seen, but very few cellular elements. 11. On shaking the fluid with ether and a little fotash the fat is dissolved and the fluid clears. 12. The total solids vary consider- ably, but are usually greater than 4 per cent. 13. The total protein-content gener- ally exceeds 3 grm. per cent., and of this amount serum-albumen forms the largest fraction, globulin occur- ring only in traces. The Pseudo-chylous Variety. 1. The fluid collects more slowly, the volume of the fluid varying with the exciting pathological con- dition. 2. In colour it is pure milky-white. The solution forms an almost perfect emulsion. 3. The opacity often increases or diminishes at successive tappings; and may entirely disappear. 4. The fluid is odourless. 5. It long resists putrefaction, probably owing to the presence of lecithin. 6. A cream may or may not form, and this does not affect the opales- cence. A sediment frequently settles out. 7. The specific gravity is gener- ally less than 1-012. 8. The depression of the freezing point ranges from -o- 56° to -0-61° C, thus corresponding to the figures for blood-serum. 9. No change occurs on filtering through paper, nor on centrifugali- sation ; but on filtering through a Pasteur candle the fluid clears. 10. Microscopically, the quantity of free fat is variable ; numerous fine, highly refractive granules (lecithin-globulin complex) are seen, which do not stain lihe fat. Cellular elements may be numerous and often contain fat ; sometimes they are scanty. 11. Shaking with ether and potash may dissolve some fat, but the opalescence remains. 12. The total solids rarely exceed 2 per cent. 13. The protein-content varies be- tween I and 3 per cent., the serum- globulin occurring in appreciable quantities. i68 DISEASES OF THE LUNGS AND PLEURA The True Chylous Variety. 14. Mucinoid substances are absent. 15. The jni-content is generally high, varying from 0-4 to 4 per cent. The fat corresponds in all its proper- ties to the fat contained in food. 16. Of the lipines, cholesterin is invariably found, and lecithin only occurs in traces. 17. There is no evidence of the presence of a lecithin-globulin com- plex. The Pseudo-chylous Variety. 14. Mucinoid substances are some- times present. 15. The fat-content is generally loiv and may be present in traces only; in its melting point and chemical composition it proves to be pathological fat. 16. The most characteristic li-pine is lecithin; cholesterin is occasion- ally present. 17. The lecithin is mainly com- bined zvith the globulin, and the suspension of this complex is the cause of the milkv appearance. If this complex be removed by filtra- tion through a Pasteur filter, or be precipitated by half-saturation of the fluid with ammonium sulphate, or as the result of the removal of the salts by dialysis, the opalescence at once vanishes. 18. The salts and organic sub- 18. The salts and organic sub- stances present approximate the stances correspond closely to those values found for chyle obtained from of lymph and serous fluids, the thoracic duct. Note. — The figures given for specific gravity, total solids, and total proteiji-content must be taken as relative only, and may be found con- siderably higher if the pleura be the seat of much inflammatory change. We thus see that in the true chylous variety the opales- cence is due to the presence of chyle, and to the large amount of fat present, under the microscope many fine fat globules being seen, which stain with osmic acid and Sudan III., and often show Brownian movements. If the fat be removed by shaking with ether and potash, the opalescence vanishes. In the pseudo-chylous form, on the other hand, though fat may be present, the opalescence is not due to it, and does not disappear on shaking with ether and potash, but results from the suspension in the fluid of a combination of globulin with lecithin (or cholesterin), which appears under the microscope as numerous fine, highly refractive granules, which do not stain like fat. Dr. Scholberg and Dr. Mackenzie Wallis proved this by half saturating the milky fluid with ammonium sulphate, a precipitate being produced, which on investiga- tion proved to be composed of globulin and lecithin. On filtering the precipitate a clear fluid resulted. A similar CHYLOTHORAX 1 69 result also followed the filtration of the milky fluid through a Pasteur filter, which kept back the lecithin-globulin com- plex, and yielded a clear filtrate. That the abo^e complex is held in suspension by the inorganic salts present was proved by exposing the fluid to dialysis. As the salts were in this way removed the complex was precipitated and the fluid cleared. Etiology. — Of the two varieties of chylothorax, true and false, the peeudo-chylous form is probably the one most frequently met with. The causes which produce chylothorax of the true chylous type may be reduced to two : (a) Increased pressure within the thoracic duct, for the most part the result of obstruction due to malignant growth (more rarely filarial in nature), leading to backward flow of the chyle along- the pulmonary and pleural lymphatics, whence access to the pleural cavity is easy. (b) External violence resulting in ruptttre of the thoracic duct and presumably of the pleura. Of these two causes the former is the more important. The pseudo-chylous form would seem to occur most often in connection with malignant disease and tuberculosis^ and it has been suggested that the lecithin, the presence of which in the fluid we have seen to be so important, is set free as the result of cell-destruction taking place during- the course of the disease. The lecithin subsequently finds its way into the serous cavity, where it unites with serum-globulin to form the complex which produces the milky appearance. A study of the literature shows that, taking all cases of chylothorax together, nearly half are found to be dependent upon new growth, tubercle and injury being the next most common causes. Chylothorax occurs in either sex and at all ages. It is, however, somewhat more common in the male, partly perhaps as the result of the greater liability of males to injury. As regards age, the youngest case recorded is that of a child, aged five months, the condition being the result of injury; the oldest patient was aged sixty-seven, the chylo- thorax in her case following upon new growth. Thirty-one cases out of forty-eight occurred between the ages of twenty and fifty. I/O DISEASES OF THE LUNGS AND PLEURA Sympt07ns.— The symptoms of chylothorax are in no wise distinctive. The side gradually fills with fluid, and, if suffi- cient in amount, displacement of the heart follows. The tem- perature is generally not raised, and the patient complains of little or nothing beyond some shortness of breath on exertion. It is not indeed until an exploratory puncture is made that the peculiar character of the fluid is recognised. Its nature might be suspected, however, if a fluid of like character had already been withdrawn from the peritoneum. Prog>wsis. — The prognosis in a case of chylothorax of whatever type is serious, the primary cause of the condition, whether growth, tuberculosis, or injury, being in itself of serious augury. The presence of the milky effusion does not materially add to the gravity of the condition, unless the resulting respiratory distress calls for repeated paracentesis, in which case the drain of fluid from the circulation may hasten the downward course of the original malady. Recovery, however, in cases not malignant in nature, is by no means unknown. It has been met with in many cases produced by injury, and may occur in others secondary to disease. Thus in a case recorded by Mr. Penn Milton,^ which occurred in a patient suffering from early phthisis, recovery ensued after a single aspiration, in which 300 ounces of milky fluid were removed from the right side of the chest. Again, in a boy, aged thirteen, suffering from Hodgkin's disease, whom one of us had the opportunity of seeing whilst under the care of Dr. Ormerod' at St. Bartholomew's Hospital, the chylothorax — in this case of the true chylous variety and on the right side — disappeared after three aspirations had been performed. In this and similar cases the recovery is probably due to the enlargement of the anastomosing lymph branches, which connect the thoracic with the right lymphatic duct. Diagnosis. — The milky fluid withdrawn in cases of chylo- thorax has been mistaken for thin pus, and we have known resection advised in such a case before the mistake was realised. The distinction is readily made if attention be given to the following points. If the fluid be pus, (i) numerous cells will be seen under the microscope, the number corre- sponding to the opalescence. (2) Centrifugalisation will yield a deposit of cells at the bottom of the tube and a clear supernatant liquid. (3) Filtration through filter paper will CHYLOTHORAX 171 keep back the cells and yield a clear filtrate. In all these points the purulent fluid differs from the milky fluid of chylo thorax. We may perhaps mention here, as causing- a possible error in diagnosis, that anomalous condition described by Dr. Samuel West,* in which the pleura contained several pints of cream-like fluid, the appearance of which was due to numerous bright refractive globules composed chiefly of calcium phos- phate. At the autopsy, which was made by one of us, numerous larger irregular masses of similar structure were found, mostly free, but some attached to the pleura, giving the pleural cavity, especially in its basal portion, the appear- ance of a " chalk-pit." Treatment. — In chylothorax, whether of the true or false variety, we should not be in too great a hurry to intervene. In the true chylous form, if the heart be much displaced and dyspnoea urgent, paracentesis must be performed; other- wise it is best to wait, and to trust to the establishment of the collateral circulation. As we have seen, this may occur even after one or two tappings. In cases of the pseudo- chylous variety the effusion should be treated on ordinary lines as though it were a simple serous effusion, the milky character altering neither the outlook nor the treatment of the condition. Aspiration should therefore be performed from time to time as occasion requires. Notes of a Case of Pseudo-chylothorax occurring in A Patient suffering from Hodgkin's Disease.*^ We may perhaps focus what we have said by briefly describ- ing- the following case of pseudo-chylothorax, the patient having been under our care in the Brompton Hospital : A. H., ai^ed thirty-five, railway guard, was admitted into the Brompton Hospital on September 12, 1913, complaining of weakness and pains in his chest. He had suffered in 1901 from left-sided pneumonia and pleurisy, but from this he completely recovered and remained well until March, 1913, when he began to complain of debility. He continued his work until July, when, owing to increas- ing weakness and pain in the left side of the chest, he was obliged to relinquish it. About this time also he began to complain of cough and expectoration and to suffer from shortness of breath and night sweats. There was some little loss of weight. On September 12 he was admitted into the hospital. 1/2 DISEASES OF THE LUNGS AND PLEURA Condition on Admission.— The patient looked ill. His temperature was swinging, rising at night to between ioo° and ioi° F. Pulse, 120. Respiration, 32. On examining the chest the signs of a large left-sided pleural efifusion were observed. The left side was dull from apex to base, with very weak breath-sounds and diminished vocal vibrations ; the heart was displaced about a finger's breadth to the right of the sternum. The note at the right apex was slightly impaired, but no added sounds were audible. The abdomen contained some little free fluid. The spleen was markedly- enlarged, the organ reaching down to the umbilicus and presenting a very definite edge. There was no enlarge- ment of the external lymph glands. The bowels were somewhat loose. The urine and other organs were natural. On September 13, the day following his admission, the left side was explored and a syringe full of milky fluid withdrawn. This presented a pale yellowish-white colour, and suggested at first sight pus, but proved on analysis (see p. 174) to be a pseudo-chyothorax. On September 19 aspiration was performed, and 49 ounces of a similiar fluid were evacuated. The note now became resonant in front to below the nipple, but the breath-sounds remained weak. The opalescent fluid withdrawn was sterile, and gave the following differential count : 80 per cent, small lymphocytes, 10 per cent, large lymphocytes, and 10 per cent, polymorphonuclear cells ; and as about this time tubercle bacilli were found in the sputum, the case was considered to be one of pulmonary tuberculosis, with tuberculous pleurisy, in which the fluid presented the pseudo-chylous character. The spleen was also regarded as tuberculous in nature, studded in all probability with caseous masses, although the rarity of such a condition in the adult was fully recognised. After the paracentesis the temperature continued hectic and the side rapidly refilled, the heart becoming again displaced, and the left side measuring | inch more than the right. On September 26 paracentesis was performed a second time, and three pints of milky fluid withdrawn. The cytological ,<:ount was very similar to that found on September 19; no tubercle bacilli could be discovered in the fluid. The blood-count on October 2 showed 3,700,000 red cells ; haemoglobin, 80 per cent. ; leucocytes, 4,000. The differential count showed some diminution in the lymphocytes, with corresponding increase in the polymorphonuclear cells, but was other- wise normal. On October 7 paracentesis was again performed, and three pints of opalescent fluid withdrawn. On cultivation this proved to be sterile, and no tubercle bacilli could be found in it. Cytological examination showed it to contain : small mononuclears, 81 per cent. ; large mononu- clears, 10 per cent. ; polymorphonuclears, 9 per cent. The temperature still continued to swing, reaching 100° F. at night, but the patient suffered little. Towards the end of the month dyspnoea returned (respirations, 32; pulse, 128), and as the heart was displaced paracentesis was performed on October 29 CHYDOTHORAX I73 for the fourth time, three pints of the opalescent fluid being removed. From this date the patient gradually became weaker and was troubled with diarrhoea. The chest filled again, and there was some dyspnoea, but no real distress. At the end of November he became worse, with delirium and incontinence of urine and faeces, and died peacefully at 7 p.m. on November 30. Post-Mortem Examination.— The autopsy, made by Dr. R. A. Young, showed that the diagnosis of tuberculosis made during life, based largely on the reported finding of tubercle bacilli in the sputum, was incorrect. No evidence of tuberculosis could be discovered in lungs, pleurjE, or spleen, but the patient was found to be the subject of a diffuse asd extensive growth, thought at first to be sarcomatous, but which microscopical examination proved to be lymphadenomatous in nature. The following are the more detailed findings : Body. — Much emaciated. Chest. — On opening the chest the right pleural cavity was found to contain 8 ounces of clear serous fluid — the pleura itself was natural. The left pleural cavity contained about two pints of slightly opalescent fluid, much less milky than on the occasion of the last paracentesis, a month before death. Dense adhesions were present at the apex, and one band of adhesions was present over the lower lobe, but the pleura was elsewhere shiny and appeared natural. The Lungs. — The left lung was markedly collapsed, and on section was slaty blue and airless. The right lung showed a considerable degree of emphysema, and was very oedematous throughout ; a few adhesions were present at the apex. No tuberculous foci were found in either lung. The larynx, trachea and bronchi were natural. The bronchial and anterior mediastinal glands were markedly enlarged, and showed secondary deposits of growth, but no naked-eye evidence of tubercle. The pericardium and heart were natural. On removing the heart and lungs a mass of growth, of firm con- sistency, was seen to extend over the four lower thoracic vertebrae, and to form a sheath over the lower and contiguous portion of the thoracic aorta. It also extended for some little distance under the adjacent portion of the left pleura. The thoracic duct was not dis- covered, being embedded in the growth around the aorta and in the dense adhesions at the apex of the left lung. Abdomen. — The peritoneal cavity contained about 100 ounces of blood-stained serous fluid. On removing the contents a large mass of growth was found, nearly 2 inches in thickness, surrounding the whole of the abdominal aorta and the common iliac arteries. The growth extended widely in all directions behind the peritoneum and infiltrated the bodies of the second and third lumbar vertebrae, which presented in parts a rough worm-eaten appearance. The left suprarenal gland was embedded in the growth and infiltrated by it. The liver was enlarged and contained numerous soft vascular growths. A gland, enlarged by growth, lay upon the gall-bladder, and others in a similar condition were seen along the lesser curvature of the stomach. Those along the upper margin of the pancreas wer^ 174 DISEASES OF THE LUNGS AND PLEURA much enlarged and occupied by growth, but the pancreas itself was free. The spleen was greatly enlarged, weighing 22 ounces. Its surface was irregular from the presence of numerous growths within its surface. On section it was found to be riddled with growths, which were dark in colour, probably from haemorrhage into their substance. The stomach, intestines, bladder, prostate and testicles were normal ; the kidneys were enlarged and slightly fatty. • The recepta- culum chyli could not be found, all the structures in its neighbour- hood being densely infiltrated with growth. The naked-eye appearances, thus described, suggested that the disease was a retroperitoneal sarcoma with numerous secondary growths. The following report, however, by Dr. Young upon the microscopical character of the sections showed that in fact it was a case of lympha^enoma : Report upon the Microscopical Characters of the Growth BV Dr. R. a. Young, M.D., F.R.C.P. " A Portion of the Main Retroperitoneal Mass of Growth.- — The section presented the characteristic appearances of true Hodgkin's disease or lympho-granuloma ; the reticulum was abundant, and there were numerous typical giant cells. Under the one-twelfth power some of the cells in the reticulum showed eosinophile granulation. There was very little degenerative change, but some haemorrhage was observed in parts of the section. Sections of mediastinal and bronchial glands, and of the growths in the liver, spleen, and left suprarenal showed a similar miscroscopical character." Report by Dr. R. L. Mackenzie Wallis upon the Milky Fluid withdrawn from the Pleural Cavity. " The fluid was milky in appearance, presenting a pale yellowish- white colour. It was odourless, and presented a specific gravity of 102 1. Reaction alkaline. It did not cream on standing. The opalescence was not removed by filtration or centrifugalisation, but was removed by passage through a Pasteur filter. Chemically its composition was as follows . Total solids Inorganic ash Serum albumen ... Serum globulin ... Total nitrogen Fat and lecithin ... Cholesterol Sugar 'Nucleo-proteid Mucin ... Sodium chloride ... Ratio of albumen to glo- bulin, nearly ... 4-560 per cent. 0-821 2-020 „ ) Total protein - » ) 3'57 P^r cent. >) J) r-55 0-58 o-o6 0-052 absent. J) absent. a trace only. 0-43 per cent. CHYLOTHORAX 175 Conclusion. — The fluid in its physical properties behaves exactly like a pseudo-chylous fluid — i.e., it does not cream, the opalescence is un- affected by filtration or centrifugalisation, but is removed by passage through a Pasteur filter. The opalescence is apparently due to the occurrence of globulin united to cholesterol and lecithin, the former being in greater quantity. In its chemical composition and physical properties the fluid behaves exactly like a pseudo-chylous fluid, but differs from those previously described in the preponderance of cholesterol over lecithin — the figure for the lecithin being too small to warrant inclusion as a definite entity. The fluid would appear, therefore, to be a true pseudo-chylous pleural fluid, and not derived from rupture or obstruction of the thoracic duct." REFERENCES. ' Quoted by Dr. Rotmann : " Ueber fetthaltige Ergiisse in den grossen sevosen Hohlen," von Dr. Rotmann, Zeitschrift fur Klinische Medicin. Berlin, 1S97, p. 416. ^ " On Chylous and Pseudo-chylous Ascites," Parts I. and II., with Bibliography, by R. L. Mackenzie Wallis and H. A. Scholberg, The Quarterly Journal of Medicine, April, 1910, vol. iii., No. 11, p. 301; and January, igii, vol. iv., No. 14, p. 153. * "A Case of Chylothorax," by J. Penn Milton, M.R.C.S. (Eng.), L.R.C.P., British Medical Journal, 1907, vol. ii., p. 1210. * " Clinical Lecture on a Case of Lymphadenoma (Hodgkin's Disease), with Chylothorax," by J. A Ormerod, M.D., St. Bartholomew'' s Hospital Journal, April, 1907, p. 98. * " A Case in which the Pleura contained several Pints of Calcareous Mortar-like Fluid," by Samuel West, M.D., Transactions of the Clinical Society of London, 1906, vol. xxxix., p. 42. ^ " Chylothorax, with Notes of a Case of the Pseudo-chylous Variety," by P.Horton-Smith Hartley, C.V.O., M.D., F.R.C.P., St. Bartholomeiv' s Hosfital Journal, January, 191 5, p. 58. CHAPTER XII BRONCHITIS— BROISCHIAL CATARRH Acute bronchitis consists in an active inflammation of the mucous membrane of some portion of the bronchial tract. Etiology. — The disease is especially prevalent in northern latitudes, in exposed and elevated situations, and in districts where moisture of atmosphere as Avell as a low temperature and cold winds prevail. In our British climate these condi- tions are but too well fulfilled, and bronchitis is endemic amongst us. January, our coldest and dampest month,* is that in which it is most prevalent; but from the variable temperature and cold winds which characterise our spring, bronchitis is then also of common occurrence. In our autumn it is less preva- lent, although persons with a tendency to recurrent bronchitis are often attacked each year as the colder weather comes round. The incidence of bronchitis is influenced by age, sex, occu- pation, and conditions of life, chiefly in so far as these cir- cumstances favour exposure to the known exciting causes of the disease or diminish the resisting power of the individual. During the first dentition some children have repeated attacks of bronchial catarrh coincident with the eruption of each tooth, just as other children suffer from catarrh of the nasal or intestinal tract, and from the time of dentition onwards throughout childhood bronchitis is common. This is to be accounted for partly on grounds of lessened power of resistance, partly in consequence of dentition itself, and in part also from the frequently impaired nasal development * The statistics of Mr. Campbell Bayard' show that at nearly all the English stations the mean temperature, as also the mean minimum tempera- ture, reaches its lowest in January, and the mean relative humidity its maximum. 176 BRONCHITIS — BRONCHIAL CATARRH 1/7 and obstructed nasal passages of children, which necessitate oral breathing. Adenoid growths in the posterior nares are the most common cause of such obstruction in both sexes, and are especially prevalent in the Jewish race. The abnormal method of breathing thus entailed not infrequently remains a bad habit through life, and is a fertile source of chest troubles by the direct manner in which the air is permitted to enter the bronchi and lungs, unwarmed and unfiltered by its passage through the nares. Old people have but feeble powers of resistance, and bron- chitis is very prevalent and fatal amongst them. The male sex is more exposed to the causes which lead to bronchitis than the female, and suffers more accordingly. Cachexia of various kinds, gout, syphilis, phthisis, alco- holism, or Bright's disease, must also be ranked amongst the predisposing causes of the disease, one or other of these maladies being often at the root of the more protracted and recurrent cases. Certain forms of heart disease, such as mitral regurgitation and, in a still greater degree, mitral stenosis, also predispose to bronchitis by obstructing the return of blood from the lungs, thus causing mechanical con- gestion of these organs and of the smaller bronchi. Heredity has a certain influence in the causation of the disease. Recurrent bronchial catarrh, associated with asth- matic symptoms, and with more or less emphysema, is well known to be an hereditary affection, and may occur very early in life. The winter bronchitis to which many individuals become subject at certain periods of life also runs markedly in families, and is, no doubt, really a phenomenon of prema- ture senility. But, with these exceptions, it cannot be said that bronchitis is hereditary, and our own observations would lead us to the opinion that, when the predisposition is appar- ently seen running through the children of certain famihes, it is often connected rather with enlarged tonsils or imper- fect development and adenoid affections of the nasal passages, which necessitate oral breathing, than with any inherited delicacy of the bronchial membrane. Of all the exciting causes of bronchitis, depression of tem- perature is the most important. The attack commonly super- venes upon exposure to sudden changes of temperature or to cold, wet winds, especially in depressed conditions of the 12 1/8 DISEASES OF THE LUNGS AND PLEURA system, when the patient has been overheated by exertion or exhausted by mental fatigue or shock. A draught of cold air, affecting a very limited portion of the body, or the chilling of the feet from sitting' in wet boots may be sufficient to pro- duce it. Bronchial attacks frequently begin with " colds in the head," and many people have a morbid state of the naso- pharyngeal membrane, which tends to the production of stag- nant and unhealthy mucus, harbouring- the germs of catarrhal and influenzal diseases. This is an important point to remember in the treatment, or rather the prevention, of recur- rent bronchial catarrh. Another factor of great importance in the causation of the disease is the inhalation of irritating particles, and certain occupations which are very dusty prove harmful in this respect. These trades have been divided by Hirt' into five classes, according as the dust is (i) metalHc (as with file- cutters and knife-grinders); (2) mineral (as with potters, masons, and cement-workers); (3) vegetable (as with coal- miners, tea-packers, fret-cutters, and fiax-dressers); (4) animal fas with wool-carders and furriers); and (5) mixed (as with street-sweepers)— an interesting classification, in that it indi- cates how various are the kinds of dust which may be at fault and how numerous are the occupations affected. In a later chapter (Chapter XV.) we shall describe a case of dust bron- chitis and asthma produced by the inhalation of rosewood dust. It is instructive to note, however, that of those who are exposed to irritating mechanical influences of this kind many escape unharmed; and Hirt has further observed that among those at first attacked the inhalation, if continued, may after a time fail to excite catarrh, the workmen becoming, as it were, acclima- tised to their conditions. On the other hand, in noting the history of patients who have suffered from irritative bron- chitis, we have found instances in which the fathers of the patients had passed their lives at the same occupation with- out complaint, the second or third generation thus seeming m some cases to become more vulnerable to the given influences. But the evil effect of dust is not Hmited to certain occupa- tions. Many a fresh catarrh in cases of confirmed pulmonary disease may be traced to dusty winds or to the irritating fogs, which so frequently prevail in London and its neio-h- BRONCHITIS— BRONCHIAL CATARRH 179 boiirhood, and which prove so deadly a scourge to elderly bronchitic subjects. Bronchitis, again, is closely connected with many of the specific fevers. Thus, measles, whooping-cough, typhoid fever, and smallpox are attended by it usually in the early periods of the disease. Bronchial catarrh, sometimes of a very obstinate character, and yielding only to specific treat- ment, is a not infrequent concomitant of the eruptive period of syphilis; and in influenza acute bronchitis often forms an important element in the disease. Blood mingled with septic matter inhaled into the bronchial tubes during an attack of haemoptysis or during tracheotomy may set up bronchitis, and a virulent form, attended with profuse expectoration, is occasioned by the passage over the bronchial surface of acrid septic matters from foetid pulmonary or pleural cavities. Bronchitis and broncho-pneu- monia are also well known and sometimes fatal complications of surgical operations, the irritating effects of certain anaes- thetic vapours, such as ether, upon the bronchial mucous membrane, and the aspiration of saliva into the air passages during the administration of the anaesthetic, especially when this is accompanied by much struggling and cyanosis, being probably the determining factors.^ Bacteriology. — In the preceding paragraphs we have enumerated the more important factors concerned in the pro- duction of bronchitis. It must be clearly understood, how- ever, that for the most part these are but predisposing- causes which, by their weakening influence, favour the growth of micro-organisms which play a preponderating role in the development of the disease. Of the organisms which may be at fault, the pneumococcus and the streptococcus are the most important; but Pfeiffer's bacillus of influenza and the micrococcus catarrhalis are not infrequently present, and no doubt take their share in the aetiology of the disease. Occasionally other organisms are found in the bronchial secretion, such as the staphylococcus aureus and albus, the bacillus pyocyaneus, or the diphtheria bacillus, the latter even in the absence of any clinical evidence of diphtheria. In certain cases one or other of the micro- organisms mentioned may be found in pure culture in the bronchial exudation and must then be held responsible for l80 DISEASES OF THE LUNGS AND PLEUR.E the attack; but in the majority of cases this is not so, and the bronchitis— at all events, in its later stages— results from a mixed infection by two or more organisms, among which the pneumococcus, streptococcus, Pfeiffer's bacillus, and micro- coccus catarrhalis figure most prominently. In tropical climates, as shown by Castellani* and others, bronchitis is sometimes produced by a spirochsete {Broncho- spiro.chcetosis), the organism Being found in large numbers in the sputum. It would appear probable also that in these climates bronchial catarrh is not uncommonly due to the presence in the air passages of hyphomycetes and other fungi (Broncho-mycosis).^ The so-called "tea-factory cough," com- mon in Ceylon, is probably an affection of this nature. Morbid Anatomy. — The characteristic appearances of acute catarrh are but rarely to be observed post-mortem, but they may sometimes be seen in perfection in the trachea during life by means of the laryngoscope. 1. In the first stage there is hypersemia of the mucous membrane, with oedema of the basement layer. The affected membrane is minutely injected, swollen, and unduly lacerable, and presents in severe cases, especially in young children, minute haemorrhages. Upon hypersemic swelling of the mucous follicles depends in part the temporary check to secretion, which characterises the early stages of bronchitis, the ducts of the follicles being also to some extent occluded by the swollen condition of the mucous membrane which they traverse. 2. The mucous flow is soon increased, however, and is mingled with sanious exudation from the vessels, sheddings of columnar epithelium, cubical or small round cells derived from multiplication of the deeper cells of the epithelial layer, and with pus cells. Thus is constituted the muco-purulent secretion of bronchitis, thin and glairy at first, thicker and more opaque after a few days. To the naked eye the appear- ance of the mucous membrane is now more slaty in hue, covered with secretion, sanious or thick, according to the stages referred to. 3. The tissues of the bronchial tubes beneath the basement membrane do not remain passive whilst these active processes are going on in the layers above them. As demonstrated by the late Professor Hamilton,* the connective-tissite cells BRONCHITIS — BRONCHIAL CATARRH l8l multiply, and the endothelium of the lymphatic spaces of the inner and outer fibrous layer proliferates. The products of such proliferation do not, however, find their way to the sur- face, being unable to penetrate the basement membrane, but collect in the interstices of the cellular tissue, and fill up the lymph paths along which they slowly course towards the bronchial glands. By these processes thickening of the bronchial membrane is effected, together with some indura- tion of lung texture spreading from the bronchial sheaths. Clinical Varieties of Bronchitis. Like many other diseases, bronchitis may present itself in atii acute or in a chronic form; and these, again, may appear under various disguises. The following classification em- braces the chief varieties met with in practice : 1. Acute Bronchitis — (a) Acute tracheo-bronchitis (affect- ing the larger and medium-sized tubes; the common form of the disease in the adult). (b) Capillary bronchitis, or suffocative catarrh (occurring mostly in children, and affecting chiefly the smaller tubes). (c) Acute asthenic bronchitis (occurring at the extremes of life, but especially in the aged. In it the toxic symptoms are marked). (d) Purulent bronchitis — an acute variety of bronchitis, occurring sometimes in epidemics, and marked by a copious purulent expectoration, in which Pfeiffer's bacillus of influenza is often found. It is met with, however, also in a chronic form. 2. Chrcwic Bronchitis— C/?ro«/c muco-purulent catarrh. 3. Peculiar Forms of Bronchitis (which may be either acute or chronic). — (a) Pituitoiis catarrh, or bronchorrhoea serosa. (b) Bronchitis sicca — dry catarrh — catarrhe sec. (c) Elastic bronchitis. Acute Tracheo-Bronchitls. The symptoms which usher in an acute catarrh of the large bronchial tubes--the form in which bronchitis usually mani- fests itself i-n the adult— are commonly those of an ordinary cold in the head. Chills of a creeping character, never l82 DISEASES OF THE LUNGS AND PLEUR.E amounting to a rigor, occur from time to time on the first day, and are attended with a feehng of malaise, a somewhat hurried pulse, slight soreness of the throat, sneezing, and coryza. The temperature is raised a degree or so above the normal, but, although there is thirst, aching, perhaps pains in the limbs, and a considerable sense of feverishness, the febrile phenomena are really very slight in adults, though more decided when the disease occurs in young children. After some twenty-four or forty-eight hours, the patient complains of a soreness, or, as it is often more accurately described, a rawness behind the upper sternum, accompanied by a sense of constriction or oppression in this region. The cough is frequent and dry, and is attended with more or less pain of a rending character. The voice is deepened, and sometimes husky or suppressed, and the breathing is perceptibly quick- ened. On the second or third day secretion takes place, and with the expectoration of a thin aerated mucus the patient soon experiences a marked sense of relief. In fact, the pyrexial stage has already passed, the pulse is quiet, the cough loose, and expectoration easy, the mucus expelled becoming more opaque and semipurulent. Gradually the secretion subsides and the cough lessens, until in a week or ten days it disappears, except that in the morning, on first awaking, the patient still feels some oppression in the chest, which is not relieved until he has brought up some purulent mucus. As regards physical signs, we may hear a few dry, sonorous rhonchi vibrating through the chest, obviously produced in the larger tubes; but in some cases, when these tubes alone are affected, there may be a total absence of all physical signs. When the secretion is more established, the rhonchi, which are symmetrically distributed over both lungs, become looser, modified or, for the moment, removed by cough, and accom- panied, especially over the base of the lungs, by scattered, muffled, bubbling rales. The percussion note over the chest is unaltered. Capillary Bronchitis, or Sufifocative Catarrh. This form of the disease may be met with at all ages, but is most frequently seen in children. In them the power of coughing is at a minimum, and the septic secretion of the BRONCHITIS — BRONCHIAL CATARRH 1 83 larger bronchi, in which the disease begins, finds its way rapidly through deep inspiratory efforts or by gravitation into the finer tubes. These quickly become blocked, and the characteristic signs of the disease, merging insensibly into those of broncho-pneumonia, become developed. Thus dyspnoea soon becomes marked, the nares expand with each inspiration, the lips are cyanosed or even livid, and the face assumes an anxious and distressed expression. The tem- perature usually reaches 101° or 102°, although in feeble or old people there may be considerable systemic shock, with general prostration and reduced temperature. The pulse- rate is increased, but not in proportion to the respiration. The cough is frequent, and is very soon accompanied by the expectoration of a viscid adhesive mucus difficult to dislodge. The digestive functions are impaired, the tongue furred, the bowels confined, and the urine often loaded with lithates. On inspecting the chest, the thoracic movements are observed to be increased, since it is mainly with the com- paratively unaffected front and upper portions of the lungs that the patient breathes. The resonance on percussion is everywhere unimpaired, and it may be even increased. Fine bubbling rales are audible over both posterior bases, and to a much less extent, or not at all, over the upper and anterior portions of the chest, where, however, sibilant and sonorous sounds prevail. This distribution of the rales in bronchitis is mainly a question of gravitation, and, as the late Dr. Walshe pointed out, even in bronchitis of mild type, and not involving to any extent the capillary tubes, we may still hear fine rales at the posterior bases from gravitation of the secretion to the smaller tubes. After a few days, if the patient have sufficient strength, the signs of the disease gradually lessen, and convalescence in due time becomes established; but the bronchi long remain weakened and liable to a fresh attack, unless carefully shielded from exposure. In severe cases, after struggling for some days, the signs of cyanosis and asphyxia increase, the patient passes into a drowsy condi- tion, and death soon follows. The diagnosis of bronchitis of this degree depends upon the symmetrical distribution of fine bubbling rales not asso- ciated with any percussion dulness or bronchial quality of breath-sound, and with but a moderate rise of temperature. 1 84 DISEASES OF THE LUNGS AND PLEURA The diseases which may be confounded with it are pulmonary cedema, miliary tuberculosis of the lungs, and acute phthisis. If oedema be limited to the lungs it must be dependent upon cardiac defect, the history and signs of which render the case clear. Miliary tuberculosis, on the contrary, may be easily mis- taken for bronchitis, since the physical signs are almost identical. Nevertheless, careful examination will put us on our guard. Thus, it is not uncommon in tuberculosis to find that, though the lungs are stuffed with miliary tubercles, there may be comparatively few moist sounds, and these often quite as marked at the apex as at the base. If, therefore, in a given case we find excessive dyspnoea, cyanosis, and great prostration, apparently out of all proportion to the physical signs, the suspicion of miliary tuberculosis of the lungs should at once suggest itself. The temperature is not dis- tinctive, since in tuberculous cases it is by no means neces- sarily high. Evidence of previous pulmonary disease at one apex would cause the diagnosis to lean strongly towards tuberculosis. In children especially, acute phthisis of the caseous broncho- pneumonic type may lead to difficulty in diagnosis. This variety of the disease not infrequently follows whooping- cough or measles, and, from the diffuse signs of bronchitis to which it gives rise, may for a time be confounded with simple catarrh. Later, more or less pneumonic crepitation, patchy, tubular breathing and larger clicks, are superadded to the simple rales, and the signs become distinctly more advanced at some one portion of the chest, whether base or apex. But here again the diagnosis between a simple bron- chitis passing on into broncho-pneumonia and the tuber- culous variety of the disease is by no means easy. The history of the onset after measles or whooping-cough, the longer duration of the disease, and its steadily downward course, should suggest its tuberculous nature. A bacterio- logical examination of any sputum that can be obtained or of the fseces should by no means be neglected. Acute Asthenic Bronchitis. This is a malady commonly met with at both extremes of life, and in the aged especially it is one of the most fatal of BRONCHITIS — BRONCHIAL CATARRH 1 85 diseases. It is marked chiefly by the rapidity of its course and the severity of its toxic symptoms. The following fairly characteristic example may be related in illustration of the salient features of the disease :' Mrs. M — '■ — , a widow, aged seventy-six, of thin, spare build, and of previous good liealth, was dining out with friends on the evening of December 27, feeling in her usual good health and spirits. She had never before suffered from any chest illness, but it was believed that on her way home she became chilled. Mrs. M , however, appeared well the next morning, but towards the latter part of the day (28th) felt drowsy and somewhat chilly. She became more obviously ill in the course of the evening, the breathing being quickened and oppressed, and towards midnight her symptoms became so aggravated that the doctor was sent for. She was now found to be in a state of profound collapse, with small, feeble pulse, cold extremities, low temperature, and sweating surface. The respirations were quick and shallow, the countenance anxious, and the mucous membranes somewhat cyanosed. No morbid sounds save a few wheezing rhonchi were to be heard over the chest. A free recourse to brandy and other stimulating remedies rallied the patient so notably that the friends became hopeful, and the doctor plied his remedies and planned out food, physic, and stimu- lants with a cheery exactness. By the following evening the chest signs had become more marked, short inspirations being followed by prolonged wheezing expirations, the pulse keeping steady at about 90 beats a minute. The cough and expectoration were now troublesome and difficult, preventing, as the night advanced, more than brief snatches of sleep. The body temperature rose to about 100°, and it was observed that the patient wandered in slight delirium, from which, however, she could readily rouse herself. Fine bubbling rales were now, at the close of the second or third day, audible over the chest, most abundantly and most definitely at the posterior bases, where but very little air could be heard to penetrate. The respiratory movements were peculiar, at each inspiration the chest being lifted quickly by the action of the auxiliary muscles, whilst the bases of the thorax receded. A long wheezing expiration followed each inspira- tion, apparently produced by the downward recoil of the chest upon the diaphragm, which had been pushed upwards to meet it by the contraction of the abdominal muscles. Tracheal rattles soon became developed, removable at first by cough, but soon to return. The pulse quickened, the patient became more exhausted, with muttering delirium or incoherence, and death closed the scene at about the seventieth hour. Such is a sketch of the phenomena presented by a case of this fatal malady, the characteristic features being: (i) the almost fatal collapse at about the twelfth hour from the first 1 86 DISEASES OF THE LUNGS AND PLEUR.E shock of the disease; (2) the rallying of the patient, and the oncoming of the signs of general bronchitis, attended with slight febrile reaction; (3) at about the third day the appear- ance of laboured, ineffectual breathing, with signs of filhng of the lower bronchi, indicative, no doubt, of exhaustion of the nerve centres. The forcible respiratory efforts, far beyond the strength of the patient, which appear at this last and fatal stage, and continue to the end, are very noticeable, and it is rare indeed for recovery to ensue in any case in which this character of breathing has once been observed. But such grave forms of the disease are not limited to the aged, for young children not infrequently succumb to the first shock of bronchitis, being overwhelmed before their illness seriously attracts the attention of their parents. A considerable proportion of the infants brought to our hos- pitals dead, or in a dying condition from sudden illness, are found post-mortem to present no other lesions beyond the signs, very slightly marked, of early bronchitis. A few petechial spots in the mediastinum, pericardium, or pleura, may testify to the brief struggle of the little patients. Purulent Bronchitis. Attention has recently been drawn to a form of acute bronchitis, which has occurred in epidemic form among our troops both in France'' and in England,^ and which is char- acterised by the expectoration of abundant nummular sputa composed almost entirely of pus. The amount may reach as much as fifteen ounces in the twenty-four hours. These cases, first described by Drs. Hammond, Rolland, and Shore,' are sometimes very acute, and for a time sug- gest pneumonia; but the sputum, never really rusty, soon acquires its characteristic appearance. Tachycardia, dyspnoea, and cyanosis, often of a "heliotrope" tint, are prominent symptoms, and the patient not uncommonly dies in about a week from cardiac failure, the smaller bronchi and bronchioles being found after death to be filled with purulent exudation. In other cases, less acute, the malady may last some weeks, the temperature varying from 101° to 103°, and here again cyanosis and respiratory distress are marked features. In the early stages moist sounds are heard scattered over the lungs, to be succeeded later by signs of broncho-pneumonia. BRONCHITIS — BRONCHIAL CATARRH 1 8/ In such cases the patient wastes and often sweats, and the disease maybe mistaken for acute tuberculosis. The mortahty in the epidemics which we have been describing has been severe, but of the less acute cases many recover. Bacteriologically the cases are of interest, for in the majority the Pfeiffer's bacillus of influenza has been found in the sputum, associated in many instances with the pneu- mococcus. In an epidemic occurring among a draft of troops from New Zealand," in which the purulent bronchitis occurred as a complication of measles and rubella, Pfeiffer's bacillus and the streptococcus were the organisms most often present. In view, however, of the evidence recently brought forward by Sir John Rose Bradford and Drs. Bashford and Wilson,'" suggesting that a filter-passing virus may be the cause of influenza, the presence of the Pfeiffer's bacillus can- not be held as proof that these cases of purulent bronchitis are truly influenzal in nature. It must not be supposed, moreover, that "purulent bron- chitis " is met with only in epidemics, though these have naturally directed especial attention to its occurrence. We have met with more than one instance of subacute bronchitis in which the sputum has had this special character, though the amount expectorated has not reached the large quantity recently described, and in which the pneumococcus was pre- sent in pure culture. We know also of the case of a gentle- man, aged between eighty and ninety, who during the few years preceding his death had several attacks of subacute bronchitis, each accompanied by the expectoration of char- acteristic purulent sputum, which continued also between the attacks. On two occasions this was found to contain a pure culture of Pfeiffer's bacillus. Lastly, as we shall see, copious purulent expectoration is sometimes associated with the later stages of a chronic muco-purulent catarrh, and to this condi- tion the terms purulent bronchitis or broncho-blennorrhoea have long been applied (see p. 191). Prognosis in Acute Bronchitis. — From what we have already said it will be understood that the outlook in acute bronchitis of whatever degree, when occurring in adults, is, generally speaking, favourable. Capillary bronchitis in very old and very young people, and still more so the acute asthenic and "purulent" forms, are, on the other hand, fre- t88 diseases of the lungs and pleura quently fatal. Nevertheless, there is, perhaps, no disease the mortality of which is more influenced by treatment. Treatment. — Taking capillary bronchitis in the adult as our text in regard to treatment, our first thought should be to see that the room is adequately warmed. For this purpose a fire and steam-kettle are necessary, so as to raise the tempera- ture of the room to about 62°, and immense relief is given to the patient by this means alone. Due care must be taken, however, to insure a proper and constant supply of fresh air, as well as to preserve a uniform temperature. The use of the steam-kettle is not only to moisten the air of the room — itself a point of no small importance when the cough is irritable and the expectoration viscid — but because in most bedrooms it is the only possible means of raising the tempera- ture and maintaining it during cold weather at the desired height. A large mustard or mustard and linseed poultice should be applied to the front of the chest or to the back, and followed up by hot hnseed applications or cotton-wool to the chest. In children a jacket poultice is often very useful, but one must not forget that, both in young or weakly children and in old people, a linseed poultice wrapped round the chest may be a very serious impediment to free thoracic movements, and in such cases it is often more judicious to have recourse to cotton-wool covered with oil-silk and an occasional mustard or mustard and linseed pouUice to keep the blood determined to the surface. Pouhices are indeed valuable in the hands of the careful and skilled attendant; otherwise, hot cotton-wool applications, with the occasional help of a stimulating poul- tice, are much to be preferred. Pine or thermogen wool are more stimulating than ordinary cotton-wool, and are to be recommended especially for old people. Where the constant attention of a skilled nurse is not possible, antiphlogistine apphcations are especially useful, not requiring frequent renewal. For convenience, and to save fatigue in the use of poultices, the nightdress should be cut down the middle, and brought together with tapes or safety-pins. As regards drugs, a saline mixture with ipecacuanha is the best with which to begin. In strong aduhs antimony wine is very useful, especially in the early dry stage of the catarrh, and should be given in small doses at frequent intervals! BRONCHITIS — BRONCHIAL CATARRH 1 89 Apomorphine, in aV to yV grain doses, is often, and especially in cases where there is some degree of bronchial spasm, a valuable substitute for ipecacuanha or antimony in the pre- scription. In old people, on the other hand, carbonate of ammonia is generally required. The special danger in infants arises from the possible occurrence of pulmonary collapse and broncho-pneumonia. These are due to the inability of children to expectorate, and the consequent plugging of the bronchi with secretions, which are drawn into the correspond- ing alveoli during vain inspiratory efforts. The timely administration of ipecacuanha emetics, if the secretion be abundant, will in some cases avert this danger. Friction with stimulating liniments, such as the ammonia or acetic turpen- tine liniments of the Pharmacopoeia, further diluted, if neces- sary, with an equal quantity of olive oil, is of great service in young children after the first stage has passed. In old people danger arises principally from exhaustion, with atony of the bronchial tubes. To avert these dangers we must from the first support the patient by the frequent administration of nutritious liquids and by the timely employ • ment of stimulants in carefully regulated doses. Of all alcoholic stimulants, brandy is certainly the best for this pur- pose, though we have at times found whisky, with hot peppermint-water, an excellent stimulating expectorant. The administration of opiate remedies in bronchitis should, as a rule, be avoided, and absolutely so in cases in which lividity of lips shows already defective aeration of blood. For young children and old people opium should never be used in bron- chitis. As a sedative at night, bromide of ammonium, with aromatic spirits of ammonia, is one of the best we can choose. Chloral is not very suitable in acute cases, but a small dose combined with bromide of ammonium will sufifice to give rest without risk of unduly depressing the heart's action. When there is much lividity, with restless, muttering delirium, oxygen inhalations may be used with much success, securing short, refreshing sleeps, and maintaining nerve and cardiac power. When the heart fails, and symptoms of overloading of the right ventricle present themselves, digitalis may be usefully given, stimulants must be persevered with, and dry- cupping may be tried with advantage. In certain cases in which there is marked venous plethora, with a weak and fail- 1 90 DISEASES OF THE LUNGS AND PLEURA ing heart's action from an overburdened right ventricle, venesection is attended with manifest reHef. Next to avoiding a fatal issue, our efforts should be directed to prevent the case passing into the chronic stage, which is especially to be feared in those who have suffered from previous attacks. When the acute symptoms are past, some patients at once convalesce without any special treatment; in others the secretion continues abundant and purulent. In such cases the saline mixture must be given less frequently or changed for a more stimulating expectorant containing senega and ammonia ; and a mixture containing some mineral acid, with calumba or quinine, may be taken twice a day. The turpentine acetic liniment is of great value in this stage, its usefulness being probably in part due to inhalation of the turpentine vapour. Meanwhile the bodily strength must be well maintained, and for this purpose cod-liver oil may be prescribed. In cases in which there is a tendency to frequent catarrh the naso-pharynx should be looked to, and will often be found to be in a catarrhal condition and to lodge unhealthy muco- pus, which may be sometimes observed in the posterior naso- pharynx. We are in the habit of advising in such cases the use of a lotion consisting of chloride of sodium oi., salicylate of soda3i., or borate of sodium 3i.ss., hazeline 3iii., glycerine 5iii., and rose-water to §viii. : one tablespoonful to a wineglass of warm water for a nasal douche : or a choice can be made from the various collunaria of the London hospitals." Chronic Bronchitis — Chronic Muco-Purulent Catarrh. This is met with most frequently in elderly people, but it is by no means unknown in adult life, and occurs not very rarely even in children whose nutrition is markedly impaired. It may sometimes originate in an acute attack from which recovery has been incomplete, and may in this way be traced back to measles or whooping-cough, from which the patient suffered several years before. Many cases in the adult, how- ever, cannot be traced to a primary acute attack, and the disease is then chronic from the commencement. This may be observed in patients who are otherwise healthy, but in some the disease is associated with a constitutional malady, such as gout or chronic nephritis. In not a few cases BRONCHITIS — BRONCHIAL CATARRH IQI alcoholism is the true factor in causation. In others, exces- sive smoking- and inhaling- or a dusty occupation are respon- sible for the continuance of the malady. Cough and the expectoration of muco-purulent sputum, with possibly some dyspnoea on exertion, though the latter depends upon the resulting emphysema rather than upon the bronchitis itself, are the principal symptoms of which complaint is made. These are always more marked in winter than in summer, and in early cases they disappear entirely as the warmer weather comes round. As regards physical signs, there are two factors responsible for them — first, the bronchial catarrh, with mucous secretion causing- the breath-sounds to be modified by rales and rhonchi; and, secondly, more or less associated emphysema of the lungs, causing- a tendency to extension of pulmonary resonance beyond its normal limits (see Emphysema). At first the patient suffers but little inconvenience from his complaint. In the early morning, on first waking-, he may be troubled with cough, but after the tubes have been freed from the secretion which has accumulated during sleep, he will remain practically undisturbed for the remainder of the day. But with the progress of the disease his hours of immunity become lessened, and this is especially the case whenever the weather is damp, cold, and foggy. The amount of cough will, however, vary to some extent, according to the char- acter of the sputum. Whenever this is viscid and difficult to expectorate, the cough will become more trying; whenever it becomes more loose, the symptoms are alleviated. The sputum in a typical case consists of mucus mixed with pus. Sometimes these are mingled more or less uniformly; in other cases the pus predominates, and is at times seen floating in separate coin-hke masses in the mucus and saliva. Such " nummular sputum " does not necessarily indicate the existence of bronchial dilatation. At a later period of the disease the amount of sputum may be greatly increased, and the terms " purulent bronchitis," and " broncho-blennorrhoea,"* have been employed to indicate the condition (see p. 187). At other times the expectoration becomes offensive. In the * Blenna, like phlegma, pituita, and mucus, was, as the late Dr. Gee'^" minded us, but one of the terms used haphazard by the ancient physicians to signify the sputum, whether transparent or opaque. remin 192 DISEASES OF THE LUNGS AND PLEURA absence of bronchiectasis this symptom rarely lasts for more than a few days or a week, and then gradually passes away. It is of no serious import, and probably results from the sputum becoming temporarily more viscid than usual, leading to its retention within the bronchi sufficiently long for putre- factive changes to set in. The condition of the mouth and teeth as a possible source of the fcetor should be investi- gated. Of the existence of a special form of putrid or foetid bron- chitis, in which, without any organic lesion, such as bron- chiectasis or gangrene of the bronchial membrane, the secre- tion is continuously offensive, we do not feel convinced. A feculent odour is stated, however, to occur sometimes in cases of pulmonary streptotrichosis. At first, as we have said, the patient's nights are but little disturbed by his complaint; but later, as the secretion becomes greater in amount, attacks of dyspnoea, which closely resemble the paroxysms of true asthma, break his rest. With sleep thus disturbed, and with the disease making gradual pro- g'ress — now slowly, now more quickly — under the influence of intercurrent and more acute attacks, the patient's strength gradually ebbs, though it is surprising how long the combat is maintained. At length the fatal issue is ushered in by an exacerbation of the disease, or by gradual failure of the right side of the heart to withstand the extra strain thrown upon it by advancing emphysema. Treatment. — In cases in which the cough is dry and there is difficulty in expectorating the phlegm, relief will often be given by a mixture containing vinum ipecacuanhse, potassium bicarbonate, and potassium iodide, for one of which, in cases requiring stimulation, we may substitute ammonium car- bonate. Chloride of ammonium is often also of great value. When, on the other hand, there is much muco-purulent expec- toration, considerable advantage may be gained by the use of tar, of which good preparations are Guyot's Eau de Goudron (oi.j or Bell's Liquor Picis Aromaticus (t1\xx. to 3i.), in plain or alkaline water, such as that of Vichy or Ems ; or Jozeau's capsules may be preferred. In this stage, also, the resinous preparations, such as oil of turpentine and tere- bene, or the oil of sandal wood, are sometimes useful. For the paroxysms of asthma iodide of potassium and stramonium BliOl>JCHITfS — BROisrCHIAL CATARRH 1 93 will generally prove effective, as in simple asthma. We have not been greatly impressed with the value of vaccines in the treatment of chronic bronchitis. But in many cases of chronic bronchitis it is best to leave the bronchial membrane alone, and to direct treatment towards improving dig"estion and appetite and the general nutrition. In this connection we must emphasise the value of cod-liver oil, which, in small doses of one or two teaspoon- fuls three times a day, with or without malt extract, we have often known to be of great service. With the cod-liver oil, if desired, creosote (Til v. to H^x.) may be combined. The above are at best but palliative measures, which assist the patient in resisting the damp and fogs so associated with our climate, and to which the malady is in great part due. These can only be avoided by wintering in one or other of our brighter, warmer, and more sheltered health resorts, or by spending the season abroad. In England the health resorts upon the South Coast prove most beneficial, and among them we may number Penzance, Falmouth, Torquay, Sidmouth, Lyme Regis, Bournemouth, Ventnor, and Hastings, at all of which the climate is suitable. For those living in the Northern and Midland counties, Tenby, Colwyn Bay, and Llandudno may be recommended, since at these places the winter temperature is moderately warm and abun- dance of sunshine is experienced; at the two latter places the background of hills affords protection from the northern winds to which, from their geographical position, these stations are exposed. Grange and Southport, on the Lan- cashire seaboard, are also suitable. Of the inland resorts, Malvern, and Bridge of Allan are, perhaps, the best adapted to the treatment of the disease. In Ireland, Rostrevor on Carlingford Lough, St. Ann's, Blarney, near Cork, or Glengariff, may be suggested.'^ Should the patient be sent abroad, one or other of the health resorts on the French or ItaHan Riviera, such as Hyeres, Cannes, Nice, Mentone, or San Remo, may be chosen. Of places farther south, Egypt was popular before the war, and, provided the patient avoid Cairo and stay at Mena House, Helwan, or Assuan, where the pure desert air, with jits stimulating qualities, brilliant sunshine, and great dryness, may be enjoyed, no better selection could possibly be made 13 194 DISEASES OF THE LUNGS AND PLEURA by those who can go so far. But whether the patient winter in Egypt or on the Riviera, he must remember that in neither case will it be wise for him to return to England until the beginning of May. Otherwise, the biting east winds of spring will not be avoided, an attack of acute bronchitis may follow, and all the benefit derived from wintering abroad be nullified. In summer a course of treatment at Mont Dore, or if the patient be gouty, at Ems, may in certain cases be taken with advantage. Peculiar Forms of Bronchitis. The varieties of bronchitis were classified by Laennec according to the amount and character of the expectoration. He thus recognised, in addition to the ordinary muco-purulent form, a type in which the secretion was peculiar and exces- sive, " pituitous catarrh," and another, in which the expectora- tion was very scanty, and to which he applied the name " catarrhe sec." To these we may add a third, the so-called "plastic bronchitis." I. Pituitous Catarrh. (Bronchorrhoea Serosa). — This form of bronchitis was first described by Laennec. " Pituitous catarrh," he wrote,^*" " is a catarrh in which the expectoration is colourless, transparent, stringy, frothy on the surface, and which, when the foam has been removed, resembles white of egg whipped up in water." Later he states that the flux is always abundant. To this description we may add that the characteristic sputum, or pituita, is non-albuminous, thus dis- tinguishing it from the highly albuminous " serous expectora- tion," which is brought up in cases of acute oedema of the lung, and which resembles it exactly in naked-eye appear- ance (see pp. 114 and 355). Pituitous expectoration occurs sometimes in cases of tuberculosis of the lung, whether miliary or otherwise, and in certain varieties of pulmonary cancer. In the cases which we are now considering the malady is a primary affection, uncon- nected with any pre-existing disease. Primary pituitous catarrh may be acute or chronic, although both forms of the disease are excessively rare. In the acute form the patient, who may previously have been in perfect health, is suddenly seized with great oppression of the chest and cough, and dyspnoea rapidly ensues. Large quantities of BRONCHITIS — BRONCHIAL CATARRH 1 95 colourless frothy sputum (four pints in one instance referred to by Laennec) are brought up, and suffocation may be imminent, or may actually occur. More commonly, after some hours of intense distress, the symptoms gradually abate, and the patient recovers, though he remains liable to a second attack, possibly some months hence. The disease is of exceedingly rare occurrence, but has been known to attack people of all ages, even Httle children. Should the patient die, the autopsy reveals nothing but a slight reddening of the bronchial mucous membrane. The chronic variety is less rare than the acute, and is most apt to occur in the aged, although adults are not free from attack. The chief symptom is the expectoration of large quantities of characteristic sputum, amounting' possibly to four or six pints a day. The general health of the individual may not suffer for years, and as the great bulk of the sputum is sometimes brought up in a morning and evening attack, a fairly active life is not incompatible with the disease. In other cases, as in the following, recorded in his Lumleian Lectures by the late Dr. Gee,'^* the patient is completely incapacitated : " A Japanese, twenty-five years old, came over as a ship's steward to England, and immediately upon his arrival began to suffer from shortness of breath and cough : a new thing for him. After these symptoms had lasted for fourteen weeks, he was admitted to the hospital. There was much dyspnoea and most abundant expectora- tion of pituita. Tubercle bacilli were not found. The physical signs were those of bronchitis. For days together he seemed about to die from suffocation, but under very careful treatment he improved until, without any obvious cause, the symptoms recurred in full severity. Another improvement was followed by another relapse, and more than four months had passed away since his admission ere he could be discharged fairly convalescent. This was on May 8, but on June i6 he was readmitted, with all his former symptoms ; he went out on July i6. On December 5 he was readmitted once more, and the time of the year w^as probably the reason why we could not get rid of him till February 25. He had now been a patient on and off for more than a year, and, as there seemed no end to this sort of thing, the Sister of the ward got up a small subscription and shipped him off to the Antipodes." 2. Bronchitis Sicca (Catarrhe Sec). — Dry catarrh, or, as it is better termed, " bronchitis sicca," was, like pituitous catarrh, first described by Laennec, and, according to him, consists 196 DISEASES OF THE LUNGS AND PLEURA anatomically in a swelling of the mucous mem.brane of the smaller bronchi, with but little secretion. The swelling is sometimes so intense as to occlude the tubes, whilst in other cases the remaining lumen is obstructed by small semitrans- parent pearly-grey masses of secretion the size of a hemp or millet seed, to which Laennec gave the name of "crachats perles" {"sputa margaritacea," pearly sputum).^"* Clinically, the disease is more often of the chronic than of the acute type, and produces at first but few symptoms, the patient being merely somewhat short of breath, and bringing up in the morning, with an occasional cough, a few pellets of pearly sputum. As the disease advances, the breath becomes shorter, the cough more troublesome, and gradually em- physema developes. Every now and then acute attacks are experienced. These last, perhaps, three or four days, during which the cough and dyspnoea are accentuated, and then, with the expectoration of an increased amount of the character- istic sputum, the symptoms gradually subside. Sometimes an acute attack occurs quite apart from any pre-existing disease, and by its sudden onset and marked dyspnoea gives rise to g'reat anxiety.^' 3. Plastic Bronchitis.— This disease is characterised by signs of bronchitis, the occurrence of a plastic exudation into the bronchial tubes, and the appearance in the sputum at recurring intervals of the casts so formed. Cases were observed by Galen and others of the early writers, but our actual knowledge of the malady dates from the appearance of Lebert's monograph in 1869.^'^ The disease is of very rare occurrence, and twice as common in the male as in the female. It may occur at any age from infancy to advanced life, but most of the recorded cases have commenced between the ages of fifteen and fifty. Appearance and Nature of the Casts. — The branching casts, which we associate with the disease (Plate VIII.), are not seen as such in the sputum. When expectorated, they are gener- ally rolled up, and appear as rounded masses covered with mucus, the true nature of which is apt to be overlooked, and it is not until they are floated out in water and carefully unravelled that they are proved to be moulds of the bronchial tubes. A perfect cast, extending sometimes to the most minute ramifications of the bronchial tree, may be as much PLATE VIII iffUJi CASTS EXPECTORATED IN PLASTIC BRONCHITIS The plate shows representations in actual size of the casts expectorated in this disease. That on the right, from a woman who attended the Brompton Hospital, illustrates the extension of the plastic inflammation into the finest bronchial tubes ; that on the left, from a girl aged ten, a patient at St. Bartholomew's Hospital, shows the great size, to which such casts may attain. The history of this second case, from the Museum Catalogue, is as follows : " The girl had suffered from intermittent attacks of fibrinous bronchitis since her seventh year, the present attack being the seventh. The illness would commence suddenly with cough, headache, and malaise. After four or five days of such illness, which was attended by moderate fever and dyspnoea, she would expectorate casts like those seen in the specimen, with immediate relief of symptoms. The average duration of an attack was about four weeks. The physical signs before the discharge of a cast consisted of impaired percussion resonance over the area concerned, with abolition of breath and voice sounds, and dis- placement of the heart towards the affected side. Discharge of a cast temporarily restored the physical signs in the chest to the normal. The child left the hospital well some seven weeks after the onset of the present attack." > < u !z; o w H CO < Q H « o H U ad 63 CO H CO < BRONCHITIS — BRONCHIAL CATARRH ig7 as seven inches long, but often they are smaller than this, and not infrequently are expectorated in separate little pieces. In appearance they are white or yellowish in colour, and are sometimes semi-transparent. The diameter of the casts varies, but at their maximum they are rarely larger than a goose-quill. On section, some prove to be soHd; in others a lumen is found. When examined under the microscope, the cast is seen to consist of an outer layer, with numerous concentric laminae, among"st which leucocytes are found embedded. In some cases, the laminae are seen to be formed into separate cylinders, suggesting "that the exudation starts in the fine bronchi, and is then gradually pushed up into the larger tubes " (Bettmann).'""^ The chemical constitution of the casts has given rise to much discussion. It was long thought that they were com- posed chiefly of fibrin, and some undoubtedly are of this nature, the material staining by Weigert's method, and pre- senting the chemical characteristics of this substance. In other cases, though a few threads of fibrin may be present, the great mass consists, not of this material, but of mucin.'* Since, therefore, in a given case the cast may prove to consist of either substance, the name " fibrinous bronchitis," often used to indicate the disease, is hardly applicable. With regard to the site of formation of the casts within the bronchi, Bierman states that this may be inferred from the length of the intervals between successive points of bifur- cation, and Dr. Ewart's researches into the structure of the bronchial tree would corroborate this. It is important to remember that the bronchi of the upper lobe are peculiar in presenting short and rapidly branching- segments as com- pared with the elongated tubes of the lower lobe. The calibre of the casts would also be of assistance in deciding the ques- tion of site. Altiology. — The causation of the malady is still obscure. The few post-mortem examinations which have been recorded have revealed nothing beyond slight desquamation of the epithelium of the affected bronchi, together with enlargement of the mucous glands. Bacteriology has given but little assistance. In the casts pneumococci,' streptococci, and Staphylococci have been discovered, but, as they are also found 198 DISEASES OF THE LUNGS AND PLEURA in simple bronchitis, their presence cannot explain the peculiar features of this variety. The Klebs-Loffler bacillus is never found, thus proving- that the complaint has no connection with diphtheria. In certain cases plastic bronchitis has occurred during the course of pulmonary tuberculosis or of morbus cordis. But neither of these diseases appears to possess a casual relation- ship, and at present the true pathology of the malady remains obscure. In some cases, as in one that has come under our notice, a gouty source will be found in associated arthritic phenomena. The malady is doubtless analogous in some respects with the mucous colitis with which we are more familiar. Symptoms. — In the majority of cases the disease is asso- ciated with chronic bronchitis, which, having lasted for some months or years, is at last complicated by the occurrence of a plastic exudation. The cough becomes violent and as a rule paroxysmal; the dyspncea may be extreme; and, finally, after some hours, relief is obtained by the expectoration of masses, which, on floating out in water, prove to be bronchial casts. After the attack the patient generally remains better for some days, though still coughing up fragments of casts, until gradually his breathing again becomes more oppressed, the cough more hard and paroxysmal, and a second attack is experienced, followed perhaps at intervals by others. With each attack a mild degree of pyrexia may be associated, and haemoptysis sometimes precedes the appearance of the casts. After a time the patient recovers, though still remaining the victim of chronic bronchitis; but after years of apparent immunity, he will, perhaps, suffer a recurrence of the plastic attack. Indeed, the tendency of the disease to recur forms one of its most noticeable features. In less common cases plastic symptoms may complicate an attack of acute bronchitis— the first from which the patient has suffered— but in other respects this variety of the disease, which is sometimes spoken of as acute, does not differ from' the more chronic type already described. Physical Signs.— The signs of the disease are very indefinite, being simply those of general bronchitis, with perhaps a cer- tain degree of dulness, resulting from collapse, with very feeble breath-sounds over the area of bronchi affected. These signs may be heard over any part of the lungs, since any por- BRONCHITIS— BRONCHIAL CATARRH 1 99 tion of the bronchial tract may be affected, but they are more common at the base. In certain cases, when the cast has become loosened, but not yet expectorated, a coarse, dry, clicking sound — the so-called ventil-gerdusch or bruit de drapeau — has been described as heard on auscultation, due, it is believed, to the flapping backwards and forwards of the free edge of the cast during respiration."* But this sign is, in our experience, exceptional, and the recognition of the disease must rest on the symptoms rather than on the physical examination of the patient. Diagnosis. — Diphtheria, poisoning with ammonia fumes, or exposure to superheated steam, may all produce a mem- branous exudation into the bronchial tubes; but in none is the disease likely to be confounded with the malady now under consideration. Again, after haemoptysis semi-organ- ised blood-casts are sometimes expectorated; but their reddish colour and the history of their occurrence explain their pathology. The possibility of a foreign body in the bronchus sometimes arises, and then requires a fresh scrutiny of the his- tory of illness and special examinations, to which we shall hereafter refer (Chapter XIV). Plastic bronchitis, in fact, is not difficult to diagnose when its presence is suspected. When, therefore, in a given case a patient suffers from attacks of dyspnoea, which are relieved by the occurrence of expectora- tion, this should always be carefully examined for casts, any suspicious rounded mucoid masses being teased out and unravelled in water. If this were done more frequently, it is probable that the disease would be recognised as less rare than at present, since, in a certain number of cases in which casts have been discovered, the attacks of dyspnoea have been but slight, and by no means characteristic. Prognosis. — As we have already stated, the tendency of plastic bronchitis is to recur, and by thus leading to em- physema, to curtail the duration of life. In the majority of cases the attack itself does not prove fatal; nevertheless, a study of the literature shows that the danger of an immediately fatal issue has been underestimated. When this occurs, it is due to suffocation from the dislodgment of an extensive cast, which becomes impacted in the larynx — an accident most to be feared in the very old or very young, in whom cough is least effective." 200 DISEASES OF THE LUNGS AND PLEURA Treatment. — During the attack our endeavour must be to assist the patient in expectorating- the casts. To this end the air should be warmed and moistened by a steam-kettle, and, if dyspnoea be urgent and suffocation imminent, an emetic may be given. Iodide of potassium in moderate doses is of service in loosening the casts and in preventing their fresh formation, and a prolonged course is indicated in cases of a markedly recurrent character. It is possible that a vaccine prepared from the bronchial secretion might prove of value. REFERENCES. ' " English Climatology, 1881-1900," by Francis Campbell Bayard, LL.M., F.R.Met.Soc, Qtiarterly Journal of the Royal Meteorological Society, January, 1903, vol. xxix.. No. 125, p. i. For further details in regard to climatology for periods varying from thirty to forty years ending 1910, see " Monthly Normals of Temperature, Rainfall, and Sunshine," the Meteorological Office, London, IQ15. ^ Die Krankheiten der Arbeiter, Erster Theil ; Die StaubinJialations- Krankheiten, von Dr. Ludwig Hirt. Breslau, 1871. See also " Industrial Pneumonoconioses, with Special Reference to Dust-Phthisis," Milroy Lectures. 1915, by Edgar L. Collis, M.B., Public Health, August to November, 1915. ' The Annual Oration of the Medical Society of London on " Post- operative Lung Complications," by William Pasteur, M.D., F.R.C.P., Transactions of the Medical Society of London, vol. xxxiv., 191 1, p. 379. * [a) Manual of Tropical Medicine, by Aldo Castellani, M.D., and Albert J. Chalmers, M.D., F.R.C.S., D.P.H., 2nd edition, London, 1913, p. 1283. [b] " Notes on ' Castellani's Bronchospirochastosis,' with Report of a Case," by G. A. Lurie, M.D., Journal of Trofical Medicine, December, 1915, p. 269. [a) " Note on the Importance of Hyphomycetes and other Fungi in Tropical Pathology," by Aldo Castellani, M.D., British Medical Journal, 1912, vol. ii., p. 1208. {b) Manual of Trofical Medicine, by Aldo Castellani, M D., and Albert J. Chalmers, M.D., F.R.C.S., D.P.H., 2nd edition, London, 1913, p. 1284. " On the Pathology of Bronchitis, Catarrhal Pneumonia, Tubercle, and Allied Lesions of the Human Lung, by Professor D. T. Hamilton dd 1^ et seq. London, 1S83. ' ^^' "^^ ' '= Purulent Bronchitis-a Study of Cases occurring amongst the British Troops at a Base in France," by J. A. Hammond, M.B., William' Rolland, M.D., and T. H. G. Shore. M.B., M.R.C.P., The Lancet 1917 vol. 11., p. 41. ■ .' 9 BRONCHITIS — BRONCHIAL CATARRH 201 (a) " Purulent Bronchitis : its Influenzal and Pneumococcal Bacteri- ology," by Adolphe Abrahams, M.U., M.R.C.P., Norman F. Hallows, M.B., B.Ch., J. W. H. Eyre, M.D., M.S., D.P.H., and Herbert French, M.D., F.R.C.P., The Lancet, 1917, vol. ii., p. 377. (b) "A Further Investigation into Influenzo-Pneumococcal and Influ- enzo-Streptococcal Septicaemia : Epidemic Influenzal ' Pneumonia ' of Highly Fatal Type and its Relation to Purulent Bronchitis," by Adolphe Abrahams, M.D., M.R.C.P., Norman F. Hallows, M.D., D.P.H., and Herbert French, M.D., F.R.C.P., The Lancet, 1919, vol. i., p. I. " Purulent Bronchitis complicating Measles and Rubella," by Lieut. - Colonel W. M. Macdonald, B.Sc, M.D., M.R.C.P., Major T. R. Ritchie, M.B., and Lieut. J. C. Fox, M.R.C.S., and P. Bruce White, B.Sc, British Medical Journal, 1918, vol. ii., p. 481. " " The Filter-Passing Virus of Influenza," by John Rose Bradford, E. F. Bashford, and J. A. Wilson, with an Appendix by F. Clayton, the Quarterly Journal of Medicine, vol. xii.. No. 47, April, 1919, p. 259. " The Pharmacopoeias of Thirty of the London Hospitals, by Peter Squire. London, 1910. '" [a) Medical Lectures and Aphorisms, by Samuel Gee, M.D., p. 70. London, 1902. [b] Loc. cit., p. 74. " For a careful study of the suitability of the various health resorts, reference may be made to The Climates and Baths of Great Britain and Ire- land, being the Report of a Committee of the Royal Medical and Chirur- gical Society of London, vols. i. and ii. London, 1895 and 1902. " (a) Traite de V Auscultation Mediate et des Maladies des Poumons et du Cceur, par R. T. H. Laennec, troisieme edition, tome i., p. 151. Paris, 1831. {b) Loc. cit., p. 161. " For an interesting example of this condition, see The Collected Works of Dr. P. M. Latham, New Sydenham Society edition, vol. ii., p. 118. London, 1878. " " Ueber das Vorkommen fibrinoser Entziindungs-Producte in den Bronchien und Lungen-Alveolen — Ueber fibrinose oder pseudo-membranose Bronchitis und Pneumonie — Bronchitis fibrinosa. Bronchitis pseudo- membranacea — Pneumonia fibrinosa," von Dr. Lebert, Deutsches Archiv fiir Klinische Medicin. Leipzig, 1869, vol. vi., p. 126. ^" [a] " Report of a Case of Fibrinous Bronchitis, with a Review of all Cases in the Literature," by Milton Bettmann, M.D., The American Journal of the Medical Sciences, 1902, vol. cxxiii., p. 304. {b) Loc. cit., p. 313. For a review of the evidence on this subject, and a bibliography thereon, see Dr. Musser's report in Diseases of the Bronchi, Lungs, and Pleura; NothnagePs Encyclopedia of Practical Medicine, p. 158, Englisl^ edition, Philadelphia and London, 1903. For report of a fatal case in a boy, aged six, see British Medical Journal, 1915, vol. ii., epit. No. :^i2. CHAPTER XIII NARROWING AND DILATATION OF THE BRONCHI Narrowing of the Bronchi.— G^wera/ narroimng of the bronchi is practically only met with as a consequence of swelling of the mucous membrane in catarrhal affections or exudative maladies such as plastic bronchitis and diphtheria. Doubt- less cases may occur in which there is some general diminu- tion in the calibre of the bronchial system, but they are not recognisable during life. Localised narrowwg of a bronchus may arise from: (i) Cicatricial contraction of an ulcerated surface within the bronchus; (2) contractile sclerosis of the bronchial sheath at one or more points; (3) invasion of the calibre of the bronchus by malignant growths; (4) pressure upon the bronchus by enlarged glands, growths, hydatid or aneurismal tumour. Let us now consider these causes in further detail. (i) The cicatricial changes ensuing upon ulceration are amongst the very rare causes of bronchial narrowing, and are almost always of syphilitic origin. (2) In association with the more chronic indurative form of phthisis, it is not uncommon to find at certain points bronchial tubes narrowed or even obliterated by what may be regarded as cicatricial growths involving the sheath of the bronchus. This change may occur at points adjacent to tuberculo-fibroid nodules, or at the entrance to cavities which have undergone considerable or complete contraction and are surrounded by a zone of cicatricial induration in which the entering bronchus is involved. In this way partially con- tracted cavities are not infrequently closed. Sometimes when a cavity becomes thus shut off by* occlusion of its communicating bronchus, the purulent contents subse- quently inspissate into a creamy debris, which at a later period becomes cretaceous. In other cases the purulent secretions 202 NARROWING AND DILATATION OF THE BRONCHI 203 increase, and, becoming pent up, cause elevation of tempera- ture and other signs of abscess; finally, when they attain to a certain degree of pressure, the narrowed bronchus yields, and a discharge takes place, after which accumulation again commences. (3) and (4) The invasion of malignant growths and the pressure of tumours are amongst the most common causes of obstruction to the main bronchi; and are of too obvious a mechanism to require further exposition. The necessary consequences of narrowing of a bronchus at any point are (a) more or less complete retention of secre- tion behind the obstruction; (b) variable changes of a destructive kind in the lung itself. In cases in which the secretion is derived from the bron- chial mucous membrane, the lung, not being- as yet involved, it is thick, viscid, and muco-purulent, and collects in such quantities as to distend the bronchi behind the obstruction. When sufficient distension has taken place, a paroxysmal cough will expel through the narrowed orifice a certain por- tion, the overflow, so to speak, of the collection, in the form of thick, viscid, and more or less nummulated sputa, gener- ally not offensive. The condition of lung that attends narrowing of a bronchus is in the later stages one of airless collapse, to be followed shortly by more or less thickening and fibrosis of the pul- monary structure, with dilatation of the tubes behind the stricture. As contended by the late Dr. Pearson Irvine,' and more recently, in his Bradshaw lecture by Dr. Newton Pitt,^ dilatation of the affected lung, sometimes even suflficient to suggest pneumothorax, may be the primary consequence of pressure upon the bronchus, the effect of the narrowing being to impede expiration, whilst inspiratory effort is successful. Such primary dilatation is, however, but rarely seen, and it is probable that so soon as secretion begins to collect behind the obstruction, the air-cells can no longer be penetrated by air, whilst that which remains in them must slowly be expelled or absorbed. Secondary changes of a destructive character not infrequently ensue in a lung, the main bronchus of which is thus occluded by pressure, changes which were thought by the late Sir William GulP to arise from disturbed innerva- tion through pressure upon the pulmonary plexuses. But 204 DISEASES OF THE LUNGS AND PLEURA there can be little doubt that in the great majority of cases we must trace these changes, not to any nervous influence, but to the retention of secretions which necessarily become more or less septic— a condition analogous to that met with in the kidney in old-standing hydro- or pyonephrosis, and also in other obstructive urinary diseases. The Symptoms and Signs of bronchial narrowing need only be considered with regard to those cases in which the constriction is situated at one or other main bronchus. In these cases the signs of narrowing of the bronchus some- times present themselves before the cause of the narrowing can be precisely made out. Relatively feeble breath-sounds of harsh or blowing quahty over one lung, most frequently in the upper interscapular region of the affected side, are the first signs to be observed. The percussion note, at first unaltered, becomes of higher tone over the affected area, the vocal fremitus and resonance being at the same time lessened. The exaggeration of the vesicular breathing on the healthy side is in marked contrast with its feebleness and Avant of vesicularity on the opposite side. Soon a further sign, stridor, makes its appearance. At first slight, and only heard occasionally, it gradually becomes more marked, until even when at rest each inspiration, and to a less degree each expiration, is attended with a coarse, stridorous noise. Sometimes, too, we may notice recession over the affected side, a sign which, in conjunction with the preceding, is most suggestive. As the case proceeds, the feebleness of the breath-sound becomes increased to final extinction, while the diminished mobility and shrinking of the side, with impaired percussion note, becomes more definite. From the first there is cough, which may be of laryngeal type, from involvement of the nerves of the larynx concur- rently with the bronchial compression. The cough is, more- over, generally spasmodic in character, the passage of the thick sputa through the stricture giving rise always to more or less, sometimes to very severe, paroxysms of dyspnoea. As pulmonary collapse proceeds, pleuritic pains and the signs of dry pleurisy present themselves, and, with advancing dulness, may lead the observer away from the right diagnosis. The heart is, uncovered and shifted towards the affected side, NARROWING AND DILATATION OF THE BRONCHI 205 unless its position be otherwise determined by the pressure of a tumour. In the most common class of cases, those in which the narrowing- is due to the compression of an aneurism or malignant growth, other signs of pressure, ocular, laryngeal, and so forth, will as a rule be present, thus throwing helpful light upon the nature of the affection. It is in cases of this kind also that assistance may be looked for from an X-ray examination, a definite pulsating aneurismal tumour, for instance, being sometimes revealed, when from the physical signs alone it would have been impossible to arrive at a cer- tain diagnosis. In cases of syphilitic narrowing there will be the history of syphilis, the signs of narrowing, and the absence of those of tumour. In an interesting case that has come under our notice, in which the left bronchus was almost obliterated, and the lower portion of the trachea narrowed by syphilitic cicatrices, in addition to an absence of the signs of aneurism, it was observed that the patient's distress was greatly increased by an attempt to lie in the prone position, and that he felt most easy when erect and walking about the room.. In aneurism the patient's troubles are much increased by movement, whilst the prone position sometimes gives ease from the falling forward of the aneurism and the consequent relief of pressure. Treatment. — The cause of the constriction, be it aneurism or syphilis, must be appropriately treated; and in most cases much may be done in the way of giving ease. Reg'ulated doses of chloroform for inhalation are valuable in relieving spasmodic cough and in aiding expectoration. For this purpose a few drops of chloroform at a time may be placed upon absorbent cotton-wool in a small bottle to be sniffed. We have also known a pungent vapour, such as strong peppermint essence in hot water inhaled through the nostrils, to give relief. In cases in which the paroxysmal dyspnoea arises from compression of the bronchus by aneurism, nitro-glycerine (i minim of the liquor trinitrini) will assist by lessening tension within the sac. Expectorant remedies are worse than useless. Chloral and paraldehyde give more promise of usefulness than opiates. Indeed, chloral in small repeated doses is a most valuable drug in lessening 266 DISEASES OF THE LUNGS AND PLEURAE the spasm which always intensifies the symptoms in cases of narrowing- of the main bronchus, thus giving' time for other remedies, such as iodide of potassium and mercury, to take effect. When the main bronchus is involved the prognosis is of the gravest character. Dilatation of the Bronchi — Bronchiectasis. — This affection consists in a manifest widening of the bronchial tubes over a more or less limited area. It is by no means a common disease, and occurs much more frequently in males than in females. It is more rare among the well-to-do than among the poor. No age is exempt from it, but, as indicated by the following statistics, compiled from the records of the Brompton Hos- pital by Dr. D. Barty King, it is most common between the ages of ten and forty. We must note, however, that in this table the incidence of the disease in the first decade of life is probably underestimated, owing to the fact that the number of children admitted into the Brompton Hospital is limited. Table showing the Age-Incidence in Sixty Cases of Bronchiectasis FROM All Causes." Age. Number of Cases. Per Cent. o-io ... I 1-6 I0-20 ... 14 233 20-30 15 25"0 30-40 16 26-6 40-50 8 13-4 50-60 4 67 60-70 ... 2 3 '4 Total ... 60 lOO'O Morbid Anatomy.— Anatomically, the disease appears in two chief forms : the cylindrical and the sacculated. In cylindrical or fusiform bronchiectasis the dilatation involves some length of the tubes, varying from a few inches to a system of tubes ramifying through an entire lung. The enlargement is uniform throughout the length of tubes affected, though sometimes at the distal end of the tube there may be a further ampullary dilatation. In sacculated PLATE IX CYLINDRICAL BRONCHIECTASIS The specimen shows the left lung cut open and the sides turned back. On the left hand the specimen has been untouched ; on the right the bronchi have been opened up to show the general cylindrical dilatation. On examining the left-hand portion, the lung is seen to present the appearance of being filled with ovoid cavities, which varied in size from a bean to a bantam's egg. An examination of the right-hand portion, however, shows that these apparently separate cavities are in reality sections cut at varying angles of the bronchi, which throughout their course are dilated in a cyhndrical manner, with in some cases a further terminal expansion. Between the dilated bronchi the lung tissue has undergone fibrosis. The pleura is everywhere ad- herent, but not much chickened. From a man aged twenty-one, who suffered 'from bronchi- ectasis with much cough and foetid expectoration, and who died from an abscess in the right frontal lobe. The right lung con- tained some patches of recent broncho-pneumonia, but the bronchi were not dilated. The spleen showed lardaceous degeneration. (From the Brompton Hospital Museum. {% natural size.) PLATE X r. I A Saccular Bronchiectasis. To face p. 207. SACCULAR BRONCHIECTASIS The drawing shows a portion of the left lung in a condition of advanced saccular bronchiectasis. The lung is shrunken, and its substance has given place to smooth-walled cavities of various size, separated from each other by trabeculae of fibrous tissue, in which, under the microscope, a few pulmonary alveoli may still here and there be detected. The pleural layers are adherent. Microscopical examination showed the cavities to be formed by dilatation of the bronchi and bronchioles ; their walls were lined by granulation tissue, with no trace of epithelium remaining. The- right lung was emphysematous, and contained in its lower lobe a few cavities similar to those on the opposite side. The heart was dilated and drawn over to the left. From a man aged twenty-eight, who died of heart • failure, after suffering for twelve months from shortness of breath, and for three weeks from dropsy. (From the Museum of St. Bartholomev/'s Hospital, -l natural size.) PLATE X NARROWING AND DILATATION OF THE BRONCHI 20; bronchiectasis a restricted portion of a tube is enlarged to a globular form, from a quarter of an inch to an inch in diameter. The whole caHbre of the tube is generally involved, and the dilatation may be solitary or there may be many scattered through the lung. Small openings lead from the rounded and apparently closed distal side of the sacs to fine tubes, the branchlets of the widened bronchus. The illus- trations (Plates IX. and X.) show the naked-eye appearances presented by these two varieties of the disease. Of the two forms, the cyHndrical is by far the more common, though it may be combined with a certain degree of saccular dilatation. It is probable, indeed, that not a few of the cases which have been described as saccular have been in reality examples of the cylindrical form in which the tubes have been cut at varying angles, thus giving in a section of the lung the appearance of more or less rounded cavities of different size. In such cases it is only by slitting up the bronchi throughout their length that the true nature of the case becomes apparent (see Plate IX). In other instances, again, in which a bronchus does open directly into a large sacculated cavity, we must hesitate before assuming that the cavity in question is necessarily of simple bronchial origin, even thoug'h there may be definite evidence elsewhere of dilatation of the tubes. Not uncommonly it is due, in part at least, to gangrene, whereby the walls of adjacent bron- chiectatic cavities are destroyed, thus producing extensive and irregular excavations. These sometimes closely resemble true pulmonary vomicae. The distinction is made post- mortem by finding in the cavity walls remnants of cartilage, which reveal the original nature of the dilatation. Bronchiectasis, whether cylindrical or saccular in nature, may be met with in any area of the lung, and in any lobe; but it is most common in the lower lobe, since here retention of secretion, a potent factor in the aetiology of the disease, is more liable to occur than in the upper lobes, where gravita- tion assists in emptying the tubes. Out of fourteen cases of simple bronchiectasis (unassociated with tubercle) in which the autopsy was made by one of us,^ in two only was the disease limited to the upper lobe; in a third it was most marked in this situation, though affecting- other lobes as well. In the remainder the disease had apparently commenced, as 208 DISEASES OF THE LUNGS AND PLEURA usual, at the base of tlie lung. But at the time of death, the condition is not commonly Hmited to the lobe first affected. Thus, if we add to the 35 cases from the Brompton records quoted by Sir J. Kingston Fowler,^" the 14 more recent ones referred to above, we obtain a total of 49 autopsies. Analysing these, we find that in 31 cases (63 per cent.) both lungs were affected at the time of death, in 18 {-^y per cent.) one lung only; in only 12 cases (24' 5 per cent.) was the lesion limited to one lobe. We may add that when the disease passes from one lung to affect the other, it is again the lower lobe which is usually first affected, the tendency of the disease being to extend from below upwards. Etiology. — If we exclude certain rare cases of congenital origin, which are probably to be regarded as malformations or errors of development, it may be said that bronchiectasis is never a primary disease. It is dependent upon either increased pressure within the tubes or traction upon their walls, a necessary phase in all cases being some structural change in the bronchial tissues. The causes may be classified under three headings : (i) bronchial; (2) pulmonary; and (3) pleural; the relative impor- tance of which may be gauged from the following table based upon the records of the Brompton Hospital, which we have taken from Dr. Acland's paper.* Table showing the Causes or Antecedent Conditions, as far as could BE ascertained, IN Forty Cases of Bronchiectasis, verified by Post- mortem Examination. Disease. 1 i Number of Cases. 1 Percentage. 1. Chronic bronchitis Chronic cough since childhood ... Bronchial stenosis- Tumour ... Aneurism ... Foreign body 2. Pneumonia 3. Pleurisy 11 1 4 5 600 -77-5 17-5; lo-o 12-5 Let us now consider the various causes in more detail. I. Bronchial. — From the table which we have just given, it will be evident that affections of the bronchi play by far NARROWING AND DILATATION OF THE BRONCHI 209 the most important role in the aetiology of bronchiectasis. " Chronic bronchitis " and " chronic cough " account for more than half (60 per cent.) of the cases quoted, and bronchial stenosis is responsible for another I7'5 per cent., making a total of 77' 5 per cent., thus leaving only 22 per cent, to be accounted for by pneumonia and pleurisy. In regard to the relation of chronic bronchitis to bron- chiectasis, there can be little doubt that the disease is deter- mined by two factors : (a) changes of an inflammatory kind occurring in the deeper layers of the bronchial mucous mem- brane, to which we have referred in the chapter on bronchitis ; (b) the rending force of the cough distending the tubes, the elasticity of which has already become permanently impaired. It is the state of nutrition of the walls of the bronchial tubes which is the determining factor as to whether they will yield or not under the stressful conditions of chronic cough. In cases in which the texture of the walls has been damaged by inflammatory change bronchiectasis is apt to occur, and it is in this regard that any condition involving retention of secre tion has so damaging an influence. Thickening of the sur- rounding lung tissue which to some extent accompanies the dilatation proceeds further after the bronchiectasis is estab- lished. The inhalation of a foreign body into a bronchus is not of common occurrence, hence bronchiectasis is not often pro- duced in this way. But the possibility that a foreign body may be at the root of the malady must be borne in mind in every case, since its early detection and removal by bronchoscopy may be the means of curing the patient, or at least preventing the occurrence of more than a mild degree of bronchial dilatation. As we shall point out in the succeeding chapter (see p. 232), the symptoms due to the inhalation of the foreign body may be slight, and therefore in every case of bronchiectasis careful inquiry must be made as to any history suggestive of such an occurrence. In the museum of the Brompton Hospital may be seen specimens of bron- chiectasis due to such different matters as a molar tooth, an ear of corn, and in two cases a piece of bone, in one of which 'there was no history of the inhalation. It is interesting to note that a tumour growing from the interior of the bronchus and partially occluding it may act 14 210 DISEASES OF THE LUNGS AND PLEURA. like a foreign body and lead to bronchiectasis, though such primary growths are of great rarity/ 2 and 3. Pulmonary and Pleural. — When the vesicular tex- ture of a lung is obliterated by permanent collapse or fibrous growth, the tendency of the inspiratory force is to widen the bronchial tubes which traverse that lung; and as the con- densed tissues in which the tubes are embedded further con- tract, the widening becomes more marked. Secondaiy to a pneumonia more often broncho-pneumonic in character, or a dry pleurisy, a portion of a lung, perhaps a whole lobe, will thus in certain cases become condensed by connective-tissue growth, which extends from the pleura along the interlobular septa and from the sheaths of the bronchi and vessels. The fibrous overgrowth thus produced has been termed chronic interstitial pneumonia (see Chapter XIX.). The pleura] surfaces under these conditions are almost invariably adherent, and the lung being held attached at its cir- cumference by the adhesions, and its bronchial tubes fixed at the root, it is clear that when the thoracic wall has receded, and the surrounding organs, thoracic and abdominal, have approximated as far as possible, any further con- traction of the lung must drag upon the bronchial tubes and extend their calibre in all directions. As the result, the medium and subcapillary tubes embedded in the depth of the lung become widened out into fusiform and globular cavities, the finest tubes becoming extensively obliterated in the course of the contractile disease. In cases of thoracentesis for old-standing empyemata, bron- chiectasis amounting to complete loculation of lung may arise in a manner not essentially different from that just described. In such cases obliteration of the pleural cavity is finally effected from above downwards by the gradual growth of adhesions agglutinating the pleural surfaces. The^'paren- chyma of the lung is, however, in these cases irretrievably condensed, so that the degree of enlargement of the organ necessary to fill the remaining thoracic space is only to be obtained by widening out the bronchial tubes, and further contraction of the fibrous lung must continue to have the same effect. Thus the lung in some cases comes to be a ' mere shell, enfolding bulbous bronchial cavities. In congenital collapse of any portion of the lungs— a^d^c- o td H O W u <: « <: w <1 Q w < ACUTE BRONCHIOLECTASIS {The " Honeycomb Lung ") The drawings show the appearance of the lung. On the outer surface numerous bullae are seen, while the cut section presents a general honeycombed appearance, due to the presence of innumerable small cavities. Microscopical examination proved that these v/ere dilated bronchioles, with inflamed and infiltrated walls. There was a marked degree of acute emphysema, but no evidence of tubercle. From a child aged three and a half years, who died of acute bronchitis after an illness of only twelve days. (From the Museum of St. Bartholomew's Hospital. Natural size.) PLATE XI NARROWING AND DILATATION OF THE BRONCHI 211 tasis pulmonum — the bronchial tubes ramifying through that portion are widened. Bronchiectasis having been induced as a result of one of the causes described above, certain further changes now occur in the dilated tubes. The secretions in them tend to accumulate, partly from the altered shape of the tubes and the destruction of their ciliated epithelium, and partly owing to the hardened tissue, by which they are surrounded, render- ing effectual expulsion with cough impossible. Decomposi- tion of the stagnant secretion generally follows, resulting in septic inflammation of the cavity walls and of the adjacent parts. It is in this stage that neighbouring bronchiectatic cavities may coalesce from softening or gangrene of their walls, and thus give rise to the irregular excavations of the lung to which we have referred. We have spoken hitherto of chronic bronchitis as a cause of bronchiectasis, but we must add that in young children acute bronchitis may also lead to dilatation of the tubes. In this case, however, as shown by Dr. Sharkey^ and others, the dilatation commonly affects not the larger bronchi, but the bronchioles, giving to the lung a curious worm-eaten appearance — the so-called "honeycomb lung" — owing to the innumerable small saccular cavities distributed throughout (Plate XL). These also appear on the surface of the organ as small round transparent-looking vesicles. This variety of the disease, in its marked stages at least, is not common, and is of little importance clinically, since it cannot be dis- tinguished from the antecedent bronchitis. From its some- what special features it has been named " acute bron- chiectasis" or " bronchiole ctasis." It is possible that there may be a recovery, partial at least, from this acute dilatation of the tubes. Symptomatology.— The symptoms of bronchiectasis differ much in different cases, and may, indeed, be entirely absent. Thus at the autopsy of a patient who died of acute bronchitis we have found marked cyHndrical dilatation of the bronchi in the right upper lobe, though there had been no symptoms referable to this during life, and though the disease had evidently been of some standing. No doubt the site of the affection and the good drainage afforded to the tubes were responsible for this immunity from symptoms. 212 DISEASES OF THE LUNGS AND PLEURA As a rule, the patient is not so fortunate, and symptoms manifest themselves, at first not very serious, but gradually becoming more urgent. One of the earliest noticed is cough, v^ith attendant expectoration. This is at first muco-purulent in character, and not great in amount. As the disease advances, the cough increases, and with it the amount of sputum, until at last large quantities— a pint or more in the twenty-four hours — may be expectorated. The manner of its expulsion is often characteristic. The patient may not expectorate for some hours, and then perhaps, after some movement which disturbs the contents of the over-full tubes, he will begin to cough, and with more or less violent paroxysms, frequently attended with retching, will rapidly bring up several ounces. We have even seen the expectora- tion discharged through nose as well as mouth, so severe and distressing may be the paroxysms. Such attacks may occur at any time, but are most frequently observed in the early morning, on first waking, the secretion having accumulated in the tubes during the hours of sleep. The sputum, though becoming more abundant, may for long remain untainted; but sooner or later it be- comes foetid, and is often extremely offensive. Whiffs of foul gas frequently precede and attend the expectoration. In a case recorded by Trousseau* "the smell of the patient's breath was such as to render pestiferous the whole of the suite of rooms occupied by him, and even the staircase leading to them was redolent of the same stench;" and this is no highly-coloured description of what is some- times observed. Although, however, the foetor of the sputa when first brought up may be so great, it is curiously evanescent, owing to the volatile character of the substance to which the odour is due. If placed in a glass and allowed to stand for a few hours, the sputum will be found to resolve itself into three layers — an upper frothy scum, a greenish watery layer, and at the bottom of the tube a grey purulent deposit, containing pus cells, Charcot-Teyden crystals, crystals of fatty acids, together with numerous micro-organisms, and often horribly offensive small yellowish masses — the so-called " Dittrich's plugs." In spite of the distressing symptoms, the general health of the patient long remains surprisingly good. The features PLATE XII PCLMOXAEV OsTEO-ARTHROPATHV. To face p. 213. PULMONARY OSTEO-ARTHROPATHY The X-ray photograph of the right arm and wrist reveals the layers of new bone which are formed beneath the periosteum in this disease. They are visible on the shafts of the lower third of the radius and ulna, and along the shafts of the metacarpal bones. To a less degree they were also present on the first and second phalanges. From a male patient, G. V., aged thirty-one, a compositor, the appearance of whose hands and wrists are shown in Fig. 26. He suffered from bronchiectasis originating in chronic bron- chitis, and brought up as much as 197 ounces of offensive sputum during the week. ^Vhen admitted into the Brompton Hospital in 1902, the right lung was found to be extensively affected, and the left to some extent also involved. The fingers were markedly clubbed, and the lower ends of both forearms and of both legs above the ankles v/ere enlarged. The knee and ankle joints were somewhat swollen and tender, and contained fluid. X-ray examination showed that a layer of new bone surrounded the shafts of the lov/er third of the radius and ulna, and of the tibia and fibula on either side, and was also present on the metacarpals and the metatarsals, and to a less extent on the phalanges. The sputum was examined on many occasions for tubercle bacilli, but none were found. There was no evidence or history of syphilis. After staying eight months in the hospital, he left but little improved ; but shortly afterv/ards his cough and expectoration abated greatly, and when seen in July, 1904, he was only bring- ing up a very little incffeni^ive sputum. The enlargement of }ii ; bones was less marked, and X-ray examination .showed that t'.:o deposits of nev/ bone v;crc thinne.-^ Ihov.jh denjcr, than befcrr. lie died at home about tv.o venrs ip.ter. PLATE XII NARROWING AND DILATATION OF THE BRONCHI 213 are somewhat puffed and suffused, and there may be some slight Hvidity of colouring in lips and cheeks, the fades thus differing much from that often presented by the emaciated sufferer from tuberculosis. For some time there may be no pyrexia, and except for a little dyspnoea on exertion and the foetor of the breath and expectoration, there would be nothing to prevent the patient from following his ordinary avocation. At this stage clubbing of the fingers and toes makes its appearance, and in certain cases also a bulbous condition of the nose. The clubbing sometimes reaches a high degree, and becomes a point of some importance in diagnosis, though we have known cases of bronchiectasis in which it has been but little m^arked. Signs of pulmonary osteo -arthropathy may also in some cases be observed. The subperiosteal deposition of new bone is chiefly noticeable in the neighbourhood of the wrists and ankles — the forearms and legs, also the metacarpal and metatarsal bones, being the parts commonly involved. The changes, which are clearly apparent in an X-ray photograph (Plate XII.), lead to an enlargement with some tenderness of the affected areas (Fig. 26). Hemoptysis is not uncommon, and copious and even fatal attacks have been known to result from rupture of an aneurism of a branch of the pulmonary artery traversing the wall of the ectasia. Such are the symptoms during what we may call the second stage of the disease. Sooner or later constitutional symptoms make themselves apparent in the form of recurrent attacks of irregular fever, lasting perhaps a fortnight or more, and probably produced by septic absorption from the foetid con- tents of the dilated tubes. These undermine the patient's strength, but he rarely wastes, as in a case of phthisis. Finally the end is ushered in by the advent of septic broncho-pneu- monia, or perhaps by the onset of cerebral (or cerebellar) abscess. So well known, indeed, is the occurrence of this latter complication that it should be a rule at once to suspect It, if any cerebral symptoms develope in a patient suffering from bronchiectasis. Septic absorption and diffuse general bronchitis are less common terminations of the disease. In cases in which the bronchial dilatation is secondary to pressure or contraction of a main air tube, the expectoration IS often very viscid and mucoid, and not as a rule foetid. It is expelled with considerable difficulty in successive thick masses 214 DISEASES OF THE LUNGS AND PLEURA after violent attacks of coughing, at such times as there shall have been sufficient accumulation to force the narrowed passage. Fig. 26.— Photograph showing the Marked Clubbing of the Fingers, AND Enlargement of the Wrists and Adjoining Parts character- istic OF Pulmonary Osteoarthropathy. (From a male patient, G. V., aged 31, who suffered from bronchiectasis.) Physical Signs.— These, like the symptoms, vary in different cases, and no special sign can be said to be pathog- nomonic of the malady. NARROWING AND DILATATION OF THE BRONCHI 21 5 In bronchitic cases we may find at first merely a few sharp and persistent clicks at the base of one lung. As the disease progresses, and as fibrosis of the pulmonary tissue advances, the note over this region becomes gradually flattened and impaired, and the chest a little retracted. Later the heart is displaced towards the affected side. Signs of a cavity will now be discovered — bronchial breathing, bronchophony, and whispering pectoriloquy — which may suggest to the ear a single sacculated cavity, but which experience recognises as in all probability significant of several adjacent dilated tubes, with intervening lung converted into fibrous tissue. The situation of these signs will depend on the position of the cavij;y, but they are often best heard near the angle of the scapula or in the adjacent region of the axilla. Sometimes the "veiled puff" of Skoda may be heard, in which the inspiratory murmur, at first indistinct, becomes, as inspiration deepens, suddenly loud and bronchial. It is probably pro- duced by the sudden removal of some obstruction in the tube communicating' with a cavity," and cannot therefore be regarded as pathognomonic of bronchiectasis. In the signs themselves, therefore, there is nothing peculiar, but their variability and the way in which they alter, being now pronounced and now obscured, according as the bronchi are filled or empty, is a point which should be noticed. Such rapid alteration, if observed, would strongly suggest bron- chiectasis, for no other cavities possess such facilities for speedy evacuation and refilling. In cases in which neighbouring dilatations have coalesced, a considerable area of excavation may be produced, and we have even known almost the whole of the lower lobe to be converted into one large, evil-smelling cavity. In such cases cavernous breath-sounds and gurgling rales, with pec- toriloquy, may be distinctly heard, and the percussion note acquires a perceptibly tubular character. The symptoms under these circumstances become more severe and hectic, nutrition suffers, and diarrhoea, with red tongue, is observed. Elastic tissue is now to be found in the sputum, but not tubercle bacilli, unless, as sometimes happens, there be an associated tuberculous infection. Duration of the Disease. — Bronchiectasis, owing to its anatomical characters, is not a disease from which we may 210 DISEASES OF THE LUNGS AND PLEUR.^ expect recovery. At the best, all that we may hope for is that, by preventing decomposition of the sputum, we may be able to arrest its further progress. In nearly all cases, in spite of treatment, the disease gradually advances, although its duration varies much in different individuals, in some cases being exceedingly chronic, in others running a comparatively acute course. Diagnosis. — Basal phthisis may sometimes be mistaken for bronchiectasis, especially in the early stages, when the upper part of the lung is not yet attacked. Basal phthisis, however, is rare; nevertheless its occurrence will serve to remind us that no case can be diagnosed with certainty as one of bron- chiectasis unless repeated examinations of the sputum by the most careful methods have proved the absence of tubercle bacilli. It will, of course, be borne in mind that tubercle may become engrafted upon bronchiectasis, although this is uncommon. A more important question is the diagnosis between bron- chiectasis and a localised einpyema rupturing into a bronchus. The two diseases have many features in common, and the diagnosis is sometimes a matter of great difficulty, especially when the empyema is small and at the diaphragmatic surface of the lung. The history of the case is important, especially the gradual appearance and laminated character of the expec- toration, in contrast with its sudden and purulent outburst in empyema. A normal leucocyte blood-count will point strongly against suppurative pleurisy, but a leucocytosis is of less diagnostic value, being sometimes also present in bronchiec- tasis. An X-ray examination will occasionally indicate the presence of one or more cavities at the base of the affected lung, and thus aid in diagnosis, but as a rule, the thickening of the lung tissue around the dilated tubes leads to the formation of a general basal shadow, which is in no way distinctive. As we have already indicated, a foreign body may be the cause of the bronchiectasis. A patient once came before one of us in the outpatient room at the Brompton Hospital com- plaining of cough of several weeks' duration. Examination revealed only a few crepitations, with slightly impaired note at one base. The diagnosis of tubercle or bronchiectasis was discussed, but before the former could be finally excluded the NARROWING AND DILATATION OF THE BRONCHI 21/ patient removed all doubt as to the nature of the disease by coughing up the vertebra of a rabbit. Recovery ensued. The case illustrates the necessity of remembering the possi- bility of such an occurrence, even though no history of it be volunteered. Treatment. — In considering the treatment of bronchiec- tasis our first duty is to exclude as far as possible the presence of a foreign body. If there be the slightest reason to suspect this, a bronchoscopic and X-ray examination must be made, and if the body be discovered an attempt made to extract it, which will often be successful. This subject is more fully discussed in the next chapter. When the foreign body is thus early removed, recovery or great amelioration of symptoms will ensue. In other cases, and we fear they are the great majority, though we may not be able to cure the disease, yet consider- able alleviation can at least be given to the patient by appropriate treatment. The chief symptom of which complaint is made is the offen- sive character of the breath and of the sputum. This may be best combated by means of the creosote vapour bath, origin- ally suggested by Dr. Arnold Chaplin." To carry out this treatment a bare room is required, with a concrete floor if possible, and without any furniture or hangings which would be damaged by the creosote vapour. On the floor stands an iron tripod, supporting a metal dish or pan, into which commercial creosote is poured. Under the dish a Bunsen burner or spirit-lamp is placed for the purpose of volatilising the creosote, care being taken not to use too strong a flame, lest the creosote catch light. Should this accident occur, the flame may easily be put out by means of a little sand, which it is well to keep always in readiness. Both tripod and spirit- lamp are best placed on a metal tray, in case the evaporating dish should be overturned. When all is ready, the patient enters the room. He should be clad in a linen overall, and should be provided with a piece of lint or a handkerchief to protect his eyes. The Bunsen burner is then lit, and the fumes of the creosote begin to rise. The irritating effect of the vapour is soon felt by the patient, who commences to cough, and in this way succeeds in bringing up a large quan- tity of phlegm, to a great extent emptying his tubes. The 2l8 DISEASES OF THE LUNGS AND PLEUH/E special action of the creosote now comes into play, the vapour being enabled to reach and act upon areas of the bronchial tract, which, having been freed from secretion, are in a con- dition to benefit by the cleansing property of the antiseptic. Treatment should be commenced by a "bath" every other day, the patient remaining in the vapour for a few minutes only. Very soon a daily bath may be given of half an hour's duration, or longer, for a course of five or six weeks, and afterwards at gradually increasing intervals. As a result of this treatment it is often found that a very sensible diminution in the foetor of the sputum results, while sometimes the odour entirely disappears. Hand-in-hand with the improvement, a progressive diminution in the amount of the sputum may be observed, as in an instructive case recorded by Sir J. Kingston Fowler." In other cases, though the fcetor may diminish or disappear, the quantity of sputum remains the same. In others, again, the treatment seems to fail. Should it not be found possible to commence the creosote baths at once, we would recommend as a palliative the use of some antiseptic inhalation, given in a Coghill's respirator. The following- formula, long in use at St. Bartholomew's Hospital, is a useful one : Creosoti, tincturse iodimitis, acidi carbolici, astheris, and spiritus vini rectificati, aa 3i. The inhalation may be practised several times a day, and often does good in diminishing foetor of the sputum. Many cases of bronchiectasis can be kept fairly drained for years by the simple expedient of devoting half an hour two or three times a day to expectoration, by leaning over with head low, so as to allow any accumulated fluid to gravitate towards the area of glottic sensitiveness. Internally, the administration of creosote, or of such drugs as turpentine, oil of sandal wood, and copaiba, the volatile oils of which are excreted by the bronchial mucous mem- brane, does some good, but the amelioration produced is com- paratively slight. We have in some cases prescribed with advantage garlic, either the clove itself or the Syrupus Allii Aceticus, as suggested by the late Dr. Vivian Poore.'^ Some patients bear the drug well, but others resent the penetrating odour of garlic which becomes imparted to the breath. Another plan of treatment, recommended by the late Sir T. NARROWING AND DILATATION OF THE BRONCHI 2ig Grainger Stewart," Mr. Colin Campbell/* and others, con- sists in injecting- various solutions into the trachea through the larynx by means of a special syringe. The following formula was used by Grainger Stewart'^ for such intra- laryngeal injections : Menthol ... lo parts. Guaiacol ... ... ... ... ... ... ... 2 ,, Olive oil 88 „ One drachm to be injected once or twice daily. We have tried this and other solutions, and have found benefit to result in certain cases, the fcetor of the sputum sen- sibly diminishing under the treatment. A little practice will enable the operator to guide the syringe over the epiglottis and through the vocal cords before making the injection. Should the excessive quantity of the sputum be a source of trouble and annoyance to the patient, an attempt may be made to lessen it by diminishing the daily quantity of liquid taken. In some cases, where the absence of adhesions permits it, the performance of an artificial pneumothorax, and the com- pression of the lung by the introduction of nitrogen, as described in a later chapter, gives considerable relief. In this way the bronchi are compressed, and the accumulation of secretion and the absorption of toxines prevented. The rehef is, however, not permanent, and can only be maintained by keeping up the positive pressure by the reintroduction of nitrogen at intervals varying from two to four weeks. Never- theless, as a means of giving temporary relief, the method deserves consideration. Surgical Treatment. — The condition of a patient suifering from bronchiectasis is sometimes so pitiable that it is not surprising that attempts have been made to give relief by sur- gical intervention. Opening and draining of the cavity was first attempted, especially in cases in which the signs apparently pointed to a single large cavity at the base of the lung. In performing the operation, which is carried out as when dealing with a pul- monary abscess (see p. 361), it must be remembered that not infrequently, even in severe cases of bronchiectasis, the pleural layers are not adherent over the affected portion of the lung. Accordingly, after resection of ribs, and before opening the 220 DISEASES OF THE LUNGS AND PLEURAE pleura, the visceral and parietal layers must be stitched together, thus minimising the risk of infecting the pleural cavity when the lung is incised. Experience, however, showed that it is quite rare for a single cavity to be present, and that several bronchi are, as a rule, dilated, so that drainage of one can hardly be expected to effect a cure. Nevertheless, one or two successful cases have been recorded^^ in which complete recovery has resulted, and in others a certain amount of relief — albeit temporary in char- acter — has been given. As a result of the operation the amount of sputum diminishes, the cough becomes less harass- ing, and fever, if present, tends to subside. Thus, in a case which occurred in the practice of one of us^*^ — the first, we believe, of the kind in which the operation was performed— it was very striking to note the extraordinary effect upon the cough and expectoration brought about by draining the cavity. Although the amount of discharge through the drain- age-tube did not exceed two ounces, the expectoration, which had previously amounted to sixteen or twenty ounces per diem, was reduced to almost nothing, proving how much of it must have been secreted by the ascending bronchial tract, in response to the irritation produced by the passage over it of the offensive discharge from the dilated portion of the tubes. But the relief obtained is, unhappily, often but temporary; the other dilated and undrained bronchi tend still further to enlarge, the offensive sputum again increases, and the old symptoms recur. More recently attempts have been made to secure adequate collapse of the lung and diminution in size of the dilated tubes by means of a more or less extensive resection of ribs, while leaving the pleura intact. The soft parts then come to form the covering of the chest wall and the lung falls in. We have seen the operation successful, and the patient's symptoms greatly improved, but the procedure is not free from risk, and we have known a fatal result to follow. Moreover, great deformity of chest results, though this may be to a large extent hidden by a properly adjusted support. Another operation sometimes performed in these cases, especially when the disease is not limited to the lower lobe, is that of "rib mobilisation" as devised by Wilms. This con- sists in the removal of one to two inches of the posterior por- NARROWING AND DILATATION OF THE BRONCHI 221 tion of the ribs from the first to the ninth or tenth inclusive, and, at a later stage, a similar length of the first five to seven costal cartilages anteriorly. To diminish shock, an interval of a few weeks should be allowed between the operations. As a result the side of the chest falls in, the dilated bronchi col- lapse, and the symptoms, especially the cough and offensive sputum, are greatly amehorated. A successful case of this kind was shown at the Clinical Section of the Royal Society of Medicine in 1915 by Mr. Morriston Davies." But here again the procedure is not free from risk. Neither form of operation should, therefore, be undertaken without the most careful consideration, but if the patient's life is rendered burdensome to him by the quantity of foul expectoration brought up by incessant attacks of coughing, then an opera- tion on the lines indicated should be seriously entertained. REFERENCES. ^ " Destructive Pneumonia due to Compression of Bronchus by Aneurism of Aorta," by J. Pearson Irvine, M.D., Transactions of the Pathological Society of London, 1877-78, vol. xxix., p. 36. - " The Bradshaw Lecture on the Results of Bronchial Obstruction," by G. Newton Pitt, M.D., F.R.C.P., British Medical Journal, 1910, vol. ii., p. 1845. ^ " On Destructive Changes in the Lung from Diseases in the Medi- astinum invading or compressing the Pneumogastric Nerves and Pulmonary Plexus," by William Gull, M.D., Guy'' s Hosfital Re-ports, third series, 1859, vol. v., p. 307. * " Bronchiectasis : a Clinical Study," by Theodore Dyke Acland, M.D., F.R.C.P., The Practitioner, London, April, 1902, Old Series, vol. Ixviii., P- 379- * Re-port on the Work of the Pathological Department of the Brompton Hospital during the Three Years, April, 1900, to April, 1903, by P. Horton- Smith (Hartley), M.D., Table viii., p. 33. London, 1903. ° {a) The Diseases of the Lungs, by J. Kingston Fowler, M.D., F.R.C.P., and Rickman John Godlee, M.S., F.R.C.S., p. 126. London, 189S. {b) Loc. cit., p. 139. ' "A Pedunculated Intrabronchial Tumour (Sarcoma) causing Bron- chiectasis," by J. A. Braxton Hicks, M.D., Proceedings of the Royal Society of Medicine [Medical Section), vol. vii., pt. 2, p. 189, 1914. * " Acute Bronchiectasis," by Seymour J. Sharkey, M.D., St. Thomas''s Hospital Reports, New Series, 1892, vol. xxii., p. 33. " Lectures on Clinical Medicine, by A. Trousseau, New Sydenham Society edition, vol, iii., p. 124. London, 1870. 222 DISEASES OF THE LUNGS AND PLEUR.E " Auscultation and Percussion, by Samuel Gee, M.D., sixth edition, p. 105. London, 1908. " "Remarks on the Treatment of Foetid Expectoration by the Vapour of Coal-Tar Creasote," by Arnold Chaplin, M.D., British Medical Jotirnal, 1895, vol. i., p. 1371. ^2 Nervous Affections of the Hand, and Other Clinical Studies, by George Vivian Poore, M.D., p. 276. London, 1897. " " On the Treatment of Bronchiectasis," by T. Grainger Stewart, M.D., British Medical Journal, 1893, vol. i., p. 1147. " (i) " The Treatment of Respiratory Affections by Means of Large Medicinal Injections through the Larynx," by Colin Campbell, M.R.C.S., Transactions of the Royal Medical and Chirurgical Society, 1895, vol. Ixxviii., p. 39. For a discussion upon the paper, see British Medical Journal, 1894, vol. ii., p. 1238. (2) " The Treatment of Phthisis by Intratracheal Injection of Large Quantities of Izal," by Colin Campbell, M.R.C.S., Transactions of the British Congress on Tuberculosis, vol. iii., p. 406. London, 1902. '° (i) " Two Cases of Bronchiectasis treated by Paracentesis, with Remarks on the Mode of Operation," by C. Theodore Williams, M.D., and Rickman J. Godlee, M.S., F.R.C.S., Transactions of the Royal Medical and Chirurgical Society, 1886, vol. Ixix., p. 317. (2) The Diseases of the Lungs, by James Kingston Fowler, M.D., F.R.C.P., and Rickman John Godlee, M.S., F.R.C.S., p. 422. London, 1898. '^ " On a Case of Basic Cavity of the Lung Treated by Paracentesis," by R. Douglas Powell, M.D., and R. W. Lyell, F.R.C.S., Transactions of the Royal Medical and Chirurgical Society, 1880, vol. Ixiii., p. '>)Z?>- '" [a) " Bronchiectasis treated by Rib Mobilisation (Wilms)," by H. Morriston Davies, M.C., Proceedings of the Royal Society of Medicine {Clinical Section), vol. viii., p. -i,-^, 1915. See also — {b) " Surgery of the Lung and Pleura," by H. Morriston Davies, M.A., M.D., M.C., F.R.C.S., p. 208. London, 1919. ■ CHAPTER XIV ON FOREIGN BODIES IN THE AIR-PASSAGES, AND ESPECIALLY IN THE BRONCHI Although nothing of a definite kind appears to have been written upon the subject of foreign bodies in the air-passages at an earHer period than the end of the sixteenth century, there are indications in literature that the occurrence was not unknown to ancient observers. And doubtless particles of food have " gone the wrong way " occasionally, since the earhest times, from careless eating-, under conditions of mental excitement, or in paralysis of the larynx. The ordeal by eating of consecrated bread, which obtained in this country in the early Middle Ages, and the allied mystical trials prevalent in Eastern countries many centuries before, probably had their real basis in that dryness of mouth and irregular action of the muscles of deglutition and respiration produced by excite- ment, which favour the occurrence of choking attacks from intrusion of food into the larynx. The death of Earl Godwin has in fiction been attributed to this cause.^ More strictly within the cognisance of medical history, observations of this accident were recorded by writers at the end of the sixteenth and in the seventeenth centuries, and in 1644 tracheotomy was first definitely advocated^" for the removal of foreign bodies from the air-passages, although the operation appears not to have been actually performed for this purpose until fifty years later. The literature of this limited subject is vast, and the cases quoted are innumerable, involving much repetition. No such admirable exposition of the main symptoms and signs of tracheo-bronchial obstruction has appeared since that by Stokes* in his work on Diseases of the Chest, published in 1837. 223 224 DISEASES OF THE LUNGS AND PLEURA etiology. — The circumstances under which foreign bodies obtain access to the larynx are simple enough. Such acci- dents are common in children with their ancestral tendency to use the mouth as a prehensile organ, and are met with even in adults in eating. Thus, a boy play- ing with a pea-shooter inhales one of the peas into his larynx; a farm-hand, holding a stalk of barley or bearded wheat between his teeth, has his attention distracted, and the object passing into his mouth is propelled back- wards to the fauces by the action of the tongue upon its salient bristles and becomes inhaled into the larynx; a workman, whilst eating rabbit-pie or Irish stew, talks or laughs, and a fragment of bone readily slips " the wrong way." Again, a man smoking a pipe, whilst riding a bicycle or on horseback, may in a sudden fall from an accident, or in an epileptic or syncopal attack, break the stem in his mouth, and inhale it into his larynx. Such are some of the many inci- dents that have actually resulted in the intrusion of a foreign body into the larynx. Such accidents occur through mere carelessness or frolic, or under any conditions leading to sudden inspiration whilst the mouth is occupied and the patient off guard, as in laughing, coughing, receiving a sudden blow on the back, and the like. They may occur also through impaired sensibility of the protecting laryngeal aper- ture, be it during the temporary insensibility of deep sleep, anaesthesia, or epileptic, apoplectic or syncopal attacks. Dental, pharyngeal and nasal operations under anaesthesia are not uncommon sources of this accident — a tooth, a septic portion of membrane or growth, or a pledget of lint, besides blood and other fluids, thus obtaining entry to the larynx. In cases of ulcerative destruction of the epiglottis or larynx, foreign material, and especially fluids, readily obtain access to the trachea; and a similar accident may also occur in paralysis of the glottic appendages, as from diphtheria, bulbar paralysis, and advanced cerebro-spinal lesions. Liquids in the form of drinks, corrosive fluids, pus, blood, tuberculous matters or portions of growth, may thus pene- trate through the larynx to the bronchi and lungs. Corrosive fluids, hoAvever, rarely penetrate beyond the larynx, where they set up at first acute spasm and then inflammatory oedema, ON FOREIGN BODIES IN THE AIR-PASSAGES 225 which Speedily produces suffocation, unless relieved by tracheotomy. A septic broncho-pneumonia or bronchitis not infrequently results from the inhalation of fluids, be they gas- tric, sanguineous, or purulent. Except in an academic sense, and for the purpose of com- plete classification, the occurrences attendant upon the recep- tion of liquids into the larynx are scarcely within the scope of our subject, and may therefore be dismissed without fur- ther comment. We may dismiss, too, with a bare mention, those uncommon cases in which matters foreign to the air- passages are introduced into the tubes from below the glottis by ulceration from neighbouring parts; for example, the rup- ture of suppurating tuberculous bronchial glands into the upper air-passages, leading to the intrusion into them of caseous or cretaceous tuberculous masses. The rupture of abscess or hydatid of the lung, pleura, or neighbouring parts, or the bursting of an aneurism into the bronchial tracts, may also be simply mentioned. Our chief concern is with the intrusion through the glottis of extraneous and more or less solid bodies. We cannot classify these foreign bodies better than after the manner adopted by Dr. Hoffmann,*'' and in the table on p. 226 we have ventured to summarise under the same headings an analysis of the cases from his tables and from the supplementary one of Dr. Musser, of which sufficient details are given with regard to certain points of special interest. It will be noted that the table does not show the result of the modern method of treatment by bronchoscopy, but, on the contrary, the mor- tality among cases operated upon and not operated upon before its introduction. A further group might be added to those mentioned, which would include living bodies, such as Ascaris lunibricoides, leeches, small fish, etc., which have in rare instances found access to the air-passages. From a consideration of the data to which we have referred certain interesting conclusions may be drawn : Age. — The accident is more common in children and young people. Thus, of the 210 cases tabulated, 140 occurred under twenty years of age, of which 68 were under five years. Sex. — The male sex predominates. Of 177 cases in which the sex is mentioned, 118 were males and 59 females. 15 226 DISEASES OF THE LUNGS AND PLEUR/^. w O < H 2; u a 5 H 9 o 9 ^S z Zm , w h « w tf w M U) H m 2 D W Q ;S , z (n Z fe W <: o < CO W) < w Oh Sfii Qi £«^ i-f [^ Z o < Q "* U \bstracte ortality, Broncho Q PQ ^S ft z ° ^ > w O 3c/3 t— 1 w W W 01 ei O o < Z In (/) Q >J i-i S O <: z H n W Q w" o ?5^ ffi w ^£ 5o •-< '^ N >^ q h bj o "^ o tn H "» ^ >• o d ^ 1^ p t^ p Th io M O vb OH H ro O ro -^ ro •paia ro ro ■<1- 00 oo i O ro H 1 "^^ t^ CO M M N H e o „ a, %^ o. O •AlIIEUOJ\[ aSEJU33J3(J O ro VO O ?" y^ b t^ vb N t^ t^ ro ro N to N ro •paiQ ro lo -^ ro ro 00 •paj3AOD3H f- ^ " 2 °° o 00 uaquin^ O t^ lO lO w M VO H P4 H 00 M T3 o b b to p •paiQ 1 00 1 m >o 00 M 'l"J 1 00 •jnjsssaDng VO Ov 1 00 ro (N 1 H VO to uaquin^ O 0> 1 -4- 0^ H PO 1 N 01 00 •XUA-XB-J 1 VO 1 H 1 i "t^ •B3HD«JX ro , t. 1 H 1 c 2 C3 •pslBlS JOU apig VO O O r. ^ \ ^ •y^T 00 0\ ro ro t«. N H v8 •mSiH -^ % "* ^ ^ O >< JOU xag w M PO ro •31BU13j[ H <0 Tj- CO VD ro H to •3IEH VO CTi O H N H >0 H N l-l 00 M t-l •saE3^ oz J3A0 00 0\ ro lO lO o japun t^ P) VO CTi 00 ro M ■siBaA £ wpuQ to JO VO lO t-. OO VO •ssSEQ JO jaquiii^ O VO IO o^ O M O M T^ N o M Class 1. : Smooth round pieces of metal or glass (coins, bullets, etc.) Class II. : Hard, ir- regular, sharp, and pointed objects (needles, bones, splinters, etc.) Class III. : Soft, rough bodies (heads of grain, etc.) Class IV. : Bodies that swell in water (fruit- seeds, beans, etc.) Class V. : Hard fruit- seeds that do not swell in water (plum- stones, etc ) Total ON FOREIGN BODIES IN THE AIR-PASSAGES 22/ Position of the Foreign Body. — Of the 210 cases tabulated, the foreign body occupied the trachea in 21, and the larynx in 7. In the remaining 182 it had passed beyond the trachea into one of the bronchi. The substance may be impacted in the glottis, or in the ventricles of the larynx, or in the sub- glottic space, and in some cases in which it has passed down- wards into the bronchus it has been projected from below again into the glottis. Having reached the trachea, the body may be fixed or movable there, and in the latter case a par- ticular sign audible on auscultating the larynx and trachea — the bruit de grelottement ou de soiipape — has been described as produced by the friction of the foreign body against the glottis and sides of the trachea.'* It is a vibratile sound, com- parable in some cases to that produced by the sudden applica- tion of the plug (soupape) to the upper orifice of a water-pipe. Of the 130 cases in the above table in which definite information is given, in 70 the body entered the right bronchus, in 60 the left. And this is, perhaps, not far from the true proportion, although it has generally been believed, for the reasons first given by Stokes, that the predominance in favour of the right bronchus was greater, the chief reasons being the somewhat wider lumen of the right bronchus, its more vertical direction, and the greater aspiratory power attributed to the right lung. Stokes further pointed out that "the projection or septum dividing the right and left bronchi is not in the mesial line, but decidedly to the left of it, so that a body passing through the glottis will be thus directed into the right bronchus."^ Pathology. — The changes in situ wrought by the foreign body vary with its shape and texture. If soft and smooth, it may produce no immediate consequence; if hard, rough or pointed, such as fragments of bone, glass or metal, a certain degree of scarification of the membrane is caused, and often immediate capillary haemorrhage or contusion, with speedy ulceration, will ensue. Again, the condition of the body, whether clean, foul, or septic, will much influence its irritant effects. Bodies that remain within the precincts of the larynx or trachea cause so much dyspnoea and spasm of the glottis that their speedy removal or the death of the patient generally prevents further local pathological change. Where they 228 DISEASES OF THE LUNGS AND PLEURA penetrate into the comparatively insentient lumen of the bronchus, they may for long remain undisturbed. Under these circumstances, it is not common for the lumen of the tube to be completely occupied; the body generally becomes attached to one side, and by its pressure and irritation sets up some superficial ulceration, in the depression of which, covered by tenacious mucus, it nestles. The further and most important changes brought about by the presence of the foreign body occur, first, in the lung territory of distribution of the affected bronchus; secondly, in the pleura and in other parts of the same and the opposite lung; and, thirdly, through septic poisoning and embolic infarction in other parts and organs of the body. These later effects of impaction, which, however, commence very soon, are the result of the partial (or complete) obstruction of the bronchus, retention of bronchial secretions, and their con- tamination by septic organisms. In this way bronchitis, peri- bronchitis, bronchiectasis, fibrous inflammation of the lung, and other consequences, ensue. The characteristic sequel to an obstructed bronchus is bronchiectasis, but there is this peculiarity in the change fol- lowing upon the reception of a foreign body, that the bron- chiectasis so originating at once becomes foetid. This is not the case with a bronchiectasis that results from partial or complete occlusion by a living tissue, as from the pressure of an aneurism or the intrusion of a growth, provided, of course, that no ulceration or sloughing at the constricted part follows upon the local pressure. The fact is that a foreign body is either septic from the first or very soon becomes so. It then constitutes a focus of septic irritation; the mucous secre- tions that are poured out become contaminated and purulent, and the contamination spreads downwards through the bron- chial tract. Further, owing to the obstruction to the lumen of the bronchus, although it be but partial, the bronchial secretions beyond can never be completely expelled, and a fermenting residue remains. The result is analogous to that which occurs in the urinary bladder when the outflow is par- tially obstructed. A septic bronchitis is thus produced, with hyperplasia of the submucosa and peribronchitis; the tubes completely lose their tonicity, and passive dilatation follows. The trouble then extends to the lung, to its alveoli and connec- ON FOREIGN BODIES IN THE AIR-PASSAGES 229 tive tissue, spreading from the bronchial sheaths. Chronic inflammation and pulmonary fibrosis result, causing a shrink- ing of the lung texture, and a further widening through trac- tion of the tubes. The rending effects of coughing may have something to do with the dilatation of the tubes in those cases in which the obstruction is incomplete. In some cases an acute pneumonia may supervene at an early date, but this is rare, except when tracheotomy and exploration of the bron- chus have been practised. The subsequent phenomena, such as pleurisy, broncho- pneumonia, empyema and pulmonary abscess, which fre- quently supervene, are of septic origin. In cases which run their course unrelieved, it is common for one or more of the bronchial dilatations to ulcerate, producing pulmonary cavita- tion; and in some instances a fistulous tract will be found to extend from one of such cavities to the surface of the lung, leading to empyema or possibly to pyopneumothorax, or, if the pleura be adherent, penetrating to the costal parietes and there producing an abscess. Such a fistula is pathologically identical with those which in other regions lead from bony or other necrotic sequestra. Lastly, the superior portions of the same lung, and later the opposite lung, become involved in a greater or less degree of bronchiectasis, and in broncho-pneumonic changes of a septic origin, due on the one hand to extension of the morbid processes, and on the other to inhalation of morbid products. Clots from thrombosed and contaminated veins may become detached and conveyed to distant parts as septic emboli, and abscess of the brain from this cause is a not very rare sequel. Symptoms. — The relation of a case, which occurred before the introduction of bronchoscopy, and which, from the diffi- culty, if not impracticability, of treating it, ran its course to the end, will perhaps be the most interesting way of bringing together the main symptomatic features of this grave malady. Mr. T. S., aged fifty-one, a dark, pale man of slender build, in practice as a dentist, had been under observation in 1900 for an attack of renal colic which had not recurred. At 11.30 p.m. on November 29, 1901, a cold, foggy night, he was eating some Irish stew at his home in Bromley, when he felt a piece of bone go " the wrong way." He was seized with severe choking dyspnoea, and at once rushed out, without extra wrap, to a neighbour, Dr. Ilott, who 230 DISEASES OF THE LUNGS AND PLEURAE found him livid and aphonic. An examination of the pharynx with eye and finger revealed nothing. A probang was passed down the oesophagus, after which he said he felt relieved and went home, and Dr. Ilott did not see him again for some months. When seen by Sir R. Douglas Powell within a few weeks of this occurrence, he complained of a cough, not attended with any special characters, which he dated from his accident. No physical signs could be detected, except some relative feebleness of respiratory sounds over the right scapular region, and he was himself not clear that the bone had gone into his trachea, or whether his cough was not attributable to a chill caught on the cold night of his attack whilst waiting at the doctor's door. He went out soon after this to his practice in the South of France, but the cough continued, and within six or eight weeks of his first seizure the expectoration had become copious, purulent, and offen- sive. He passed through the winter, however, fairly well, and had not lost materiall}' in flesh or strength by the autumn of 1902. Dr. Ilott had seen him in August, and his chief complaint then and afterwards was of purulent and very foetid expectoration, which came on, and, as he expressed it, " welled up " into his mouth when- ever he stooped, as, for instance, in lacing his boots. The chest was everywhere resonant, and on auscultation no morbid signs were detected, except deficient respiratory murmur over the lower part of the right lung. The note of him on November 4, 1902, was that there was a small area of dulness in the right interscapular region, involv- ing the base of the scapula opposite the spinous process ; that the respiratory murmur here was weak and semi-bronchial, with a few fine rales ; and that over the right lung below the sounds were deficient and attended with slight inconstant wheeze. The probability of there being a piece of bone impacted in the bronchus was fully recognised, there being still a doubt, however, whether it might not have made an abscess diverticulum from the oesophagus. The patient's own sense of an obscure discomfort led him more than once to express a doubt whether the bone might not h.ave lodged in some point of his oesophageal tract. Dr. Ilott sent him to Dr. Walsham, who took two skiagrams, and recognised a shadow on the right side of the cardiac shadow. Dr. Walsham was kind enough to send the prints, which were excellent, but did not, in our opinion, satisfactorily locate any foreign body. The late Sir James Mackenzie Davidson also was so good as to devote much time and care to the case, with an equally negative result. Mr. S. continued at his work, and did not complain of any paroxysms of cough or dyspnoea, but only of the annoyance of the expectoration and fcetor of breath. The expectoration was examined on several occasions in the autumn of 1902. It consisted of almost pure, thin, difBuent pus, foul-smelling, and containing very little mucus. Numerous micrococci were present, but no tubercle bacilli nor elastic tissue elements. At this time he was seen in consultation with PLATE XIII Foreign Body in Beoxchus. To face p. 231. FOREIGN BODY (J'lECE OF BONE) IN BRONCHUS, LEADING TO CYLINDRICAL BRONCHIECTASIS, SEPTIC BRONCHO-PNEUMONIA, AND DEATH FROM PNEUMOTHORAX At A a piece of bone is seen embedded in the main bronchus to the lower lobe of the right lung. Below this the bronchi are dilated in a cylindrical manner, and at B the dilatation expands into a cavity the size of a walnut. Adjoining this, septic broncho- pneumonia had occurred, leading to pneumothorax, and a glass rod is seen passing from the dilated bronchus through the softened lung and through a perforation in the pleura the size of a sixpence. At C oth»r smaller bronchi are seen dilated and cut across. From a gentleman, Mr. T. S., aged fifty-one, whose case is described in the text, with the result of the autopsy (see p. 229). {From the Brompton Hospital Museum, -i natural size.) PLATE XIII ON FOREIGN BODIES iN THE AIR-PASSAGES 23 1 Sir Rickman Godlee, but it was decided that no surgical interference could be recommended, as the exact locality of the foreign body, if present, could not be demonstrated. He went out to the South again after Christmas, and returned with more evident signs of advanced disease upon him. His finger- ends were enlarged, he had lost flesh considerably, and in the course of the summer he had had several attacks of rather severe haemop- tysis. In June, 1903, his temperature was raised, his breathing quicker, and the expectoration copious, foetid, and frequently blood- stained. There was impaired resonance at the right base, and over an area in the mid-scapular line in the region of the ninth and tenth ribs the respiration was distinctly cavernous at times, with rales of a liquid or sucking character. Some pleuritic friction was also audible, and a few crepitations were heard at the left base. The question of surgical interference was again considered with Sir Rickman Godlee, and Sir James Mackenzie Davidson took another skiagram. On this occasion a distinct square shadow could be seen corresponding with the area over which cavernous breathing was audible, and which moved up and down with deep respiratory move- ments, but this was not thought to be due to the presence of a foreign body in that position. About July 30 he had a severe haemorrhage, for which Dr. Ilott treated him, and on its subsidence, at the request of Dr. Ilott, his admission was secured into the Brompton Hospital. He became rapidly worse, however, and on August 10 was seized with acute pain in the side, and was found by Dr. Kidd to have developed pneumothorax, followed by rapid effusion. Sixteen ounces of thin, purulent fluid and some air were drawn off to relieve distress. He died on August 14. Post-mortem Examination by Dr. H-S. Hartley. — The right lung was collapsed, except for adhesions at the apex and in the region of the diaphragm. The pleural cavity contained air and about one pint of thin pus. An opening in the pleura, the size of a sixpenny-piece, was found near the base of the lower lobe in the posterior axillary line (Plate XIII). The patch of lung here presenting was softened, and in it a hole was found, which admitted a large probe, and which communicated with the main bronchus to the lower lobe. In this bronchus, about an inch from its commencement, a triangular piece of bone, | by f inch, was found ; it lay in an ulcerated patch, and could be removed with ease. The bronchi below were cylindrically dilated and much congested, with foul-smelling contents, the chief bronchus expanding near its extremity into a cavity of about the size of a walnut, which corresponded in situation to the point over which cavernous respiration was heard during life. From the lower end of this cavity there extended a sinus downwards and outwards to an area of broncho-pneumonic softening at the surface of the lung, where the perforation had occurred. The lung tissue of the right lower lobe had undergone fibrosis. The bronchi in the upper and middle lobes 232 DISEASES OF THE LUNGS AND PLEURA above the piece of bone were distinctly dilated, but less so than in the lower lobe. In the left lung the bronchi to the lower lobe were dilated and in- flamed, and those in the upper lobe were a little larger than natural. This (left) lung showed but little fibrosis, but presented patches of septic broncho-pneumonia. This case, when we look back upon it from the end to the beginning, illustrates most of the features characteristic of the presence of a foreign body in the bronchus, and in the course of comments upon each set of symptoms as they presented themselves we shall be enabled to bring before the reader the main features of the disease. We have (i) a definite choking attack. (2) A lull into com- parative comfort, with a vague sense of general uneasiness or irritation. (3) A cough then comes on, which may or may not — but in this case did not, at all events, in the earlier periods — present special features. (4) The expectoration becomes more copious and offensive. (5) The physical signs, at first very obscure, gradually assume the characters of chronic basic one-sided bronchiectasis, with fibrosis of the lung. (6) Haemoptysis occurs towards the end of the illness. (7) Some acute incidents, usually of septic origin, such as broncho-pneumonia, abscess, empyema, in this case pneumo- thorax, bring the sufferings of the patient to an end. (8) The X-rays may or may not, according to its structure, reveal the presence of the foreign body. In this case they did not do so. A stormy onset, an acute choking fit, is the rule in cases of foreign bodies entering the trachea, but the intensity of the attack varies much with the character of the body inhaled and the state of the patient. It is obvious that a rough, angular and hard substance will excite much more irritation than one which is smooth, rounded, or soft. In some cases the body is inhaled when the patient is asleep, or under an anaesthetic, or in a fit, and in this way may excite no preliminary spasm. Thus, a molar tooth was found post-mortem by our colleague Dr. Young in the bronchus of a patient who had died with uraemic convulsions in the Middlesex Hospital. It had prob- ably become dislodged in the nurse's endeavour to prevent the clenching of the jaws in the convulsions during which the patient died; it had caused no symptoms, and had evidently only been in the bronchus a short time before death. A piece ON FOREIGN BODIES IN THE AIR-PASSAGES 233 of tooth-filling or an extracted tooth may similarly be inhaled into the bronchus during a dental operation under an anaesthetic. A few years ago one of us was consulted in the case of a gentleman with severe incessant and paroxysmal cough, attended with the expectoration of a glairy, blood-stained mucus. He had been riding in the Park, and was supposed to have had a fit, causing him to fall off his horse. He was carried home insensible, and on return of consciousness pre- sented the symptoms described. There were crepitations, which were regarded as due to blood within the tubes at the left subclavicular region, with very feeble breath-sound. The case had not the characters of tuberculous disease, but no history of foreign body could at the time be elicited, although carefully inquired for. He was not seen again by us after the first few days of his illness until some three months later, when, having suffered meanwhile from a severe cough and increasingly purulent expectoration, he had expelled with a severe paroxysm a pipe mouthpiece about f inch long. He now recalled to mind that he was smoking a pipe at the time of his accident ! The practical point, then, in all cases is never to pass over without most careful scrutiny any history of attack suggestive of the inhalation of a foreign body, or any occurrence pre- ceding the development of symptoms that may suggest the possibility of such reception. The lull of symptoms that often follows the initial dyspnoea for some days, and even some weeks, and which is due to the penetration of the foreign body beyond the sensitive terri- tory of the glottis into the comparatively insensitive bronchus, tends to put the doctor and the patient off guard as to the true nature of the cause. In the case of Mr. S., he himself and some who saw him in the earlier stages were, for this reason, sceptical as to the foreig'n body having entered his larynx, and were inclined to attribute his coug'h to a bronchial cold caught from exposure on that November night. A diagnosis, therefore, of the presence of a foreign body having been made, it is not to be put aside by, nor is safety to be augured from, a temporary absence of further symptoms. Many authors since the time of Louis have borne witness to the intervening periods of calm that often occur between the first 234 DISEASES OF THE LUNGS AND PLEURA attack and the occurrence of secondary symptoms. Dr. Hoff- mann'** observes : " In many cases, after an initial violent fit of coughing, weeks and months may elapse during which the patient's comfort is not disturbed." There was not in this case anything distinctive about the cough, but in many others, such as that of the gentleman alluded to who inhaled the pipe mouthpiece, the cough is very paroxysmal, and has even been mistaken for whooping- cough.^ Sometimes, as in the case of a child recorded by Mr. Kellock,^ the patient, after the first severe paroxysm, will have intervals of comfort for some hours, but will wake up in the night, or be seized after crying with intense dyspnoea and lividity. It is evident that in these cases the foreign body becomes projected from its nidus in the relatively insensitive bronchus towards the larynx, which is supplied by the sensi- tive superior laryngeal nerves. As the case goes on, if the foreign body remains, the cough continues, and is accompanied by expectoration, at first mucous, but soon becoming purulent, and then foetid, and more and more copious in amount. A symptom which was so pronounced in the case which we have described, namely, the welling up into the throat of foetid purulent matter on stooping, is a more or less prominent feature of bron- chiectasis, and we presume that it was due in this case to the positional displacement of the foreign body permitting the more or less pent-up secretion from below to pass. Haemoptysis is sometimes an early symptom. More fre- quently it occurs in the later stage, and it is naturally most common in those cases in which hard, irregular bodies have been inhaled. The physical signs are as a rule slight to the point of obscurity. Should the body be movable in the trachea, the bruit de grelottement, already described, may be audible, but otherwise feebleness of breath-sound over one lung below the seat of the obstruction is the only constant early sign. There may soon be developed, as in the case of Mr. S., at and about the point of obstruction, an area of impaired per- cussion note, with fine rales, due to hyperaemia in the neigh- bourhood of the offending body. Some variable sibilant or mucous sounds are scattered over the affected side. If the obstruction be at all complete, the movement on that side will ON FOREIGN BODIES IN THE AIR-PASSAGES 235 be obviously lessened. Later some dulness will be found at the base of the lung; perhaps some friction may be heard, or the signs of effusion may gather there. As a rule, as the illness proceeds, the signs become those of a gradual con- densation of the lung, varying from time to time from mere silence to patchy bronchial or even cavernous breath-sound and localised pectoriloquy, always, however, on the scale of weakened breath-sound, and indicative of a fibrotic and bron- chiectatic lung. An empyema may form, or an abscess may develope in the lung, or a fistula may extend from the obstructed bronchus through the chest wall, causing a thor- acic abscess or a purulent pneumothorax, as happened in the above related case. At first the signs are always one-sided; later on, towards the end, septic incidents occur in the other lung or in distant parts, cerebral abscess being not infre- quently observed. Diagnosis. — The diagnosis rests upon an accurate history of seizure, followed by the symptoms and signs of an incom- plete obstruction to the function of one lung, with bronchial irritation, and subsequently bronchiectasis and fibrosis. It will often happen that the patient is only brought to us in the later stage of fibrosis and bronchiectasis, and then the. difficulties may be great in distinguishing the case from one of abscess of the lung, empyema, or phthisis. An examination into all its features will, however, usually lead us to recog- nise that we have to deal with a one-sided bronchiectasis, and we must from that proceed carefully to inquire into the his- tory of attack, and for any circumstances that may point to the reception of a foreign body. It must be remembered that a large proportion of cases of bronchiectasis are one-sided; but when a one-sided bronchiectasis comes on apparently as a primary disease, and cannot be explained by a history of an antecedent bronchitis, pneumonia, or pleurisy, the possible presence of a foreign body should be carefully inquired for. It is, again, to be remembered that the second lung becomes involved in the later stages of all cases, whatever the source of the bronchiectasis may be. An examination by the X-raiys should be made, but in diagnosis too much must not be expected from this source. When the foreign body is metallic or of pebbly character, as in Class I. in our table, in some cases of Class II., and perhaps 236 DISEASES OF THE LUNGS AND PLEURA in Class V., it will be well shown up and located in a skiagram. But when the obstruction is of cartilaginous or fleshy- material, or if, being of bony structure, it be impacted beneath the shelter of the scapula, it may be impossible to detect it by this means. Looking back upon the case described, due weight was perhaps not attached to the difficulty of demon- strating the bone in this position. At the time at which Mr. S. was under observation the method of bronchoscopy or the direct examination of the interior of the trachea and bronchi, first brought into practical use by Killian, was in its infancy. It is now famiUar to all physicians interested in laryngological and chest work, and it is in cases like the present that it is of especial value. Had it been available, the piece of bone would, in all probability, have been detected, and, judging from the loose manner in which it lay in the bronchus at the autopsy, its removal by a little careful manipulation would have been possible. The method should be employed in all cases in which doubt remains as to the presence of a foreign body. Its value in treatment we shall consider later. Prognosis. — The reception of a foreign body into the air- passages is a serious occurrence, the gravity of which varies with the nature of the material inhaled. Excluding from our reckoning such trivial matters as small breadcrumbs, flies, etc., that may pass into the trachea and occasion only tem- porary inconvenience, a glance at the table on p. 226 shows that the total mortality among 128 cases not operated upon was 37-5 per cent., reduced to 31-4 per cent, if we include those treated by operation, and that this mortality corre- sponds closely with that of the 106 cases in Class II. of hard, irregular bodies. This latter class includes the greatest number, and is, therefore, perhaps the most trustworthy for percentages. The bodies included in it (teeth, bones, pipe- stems, needles, peg-top points, etc.) are highly irritating, and often directly septic. In Classes IV. and V. the foreign bodies are of a kind likely to become, either by their primary form (plum-stones, etc.) or their secondary swelling when soaked (wheat, maize, beans, etc.), more tightly jammed into the bronchial calibre. The least harmful bodies seem to be the smooth impermeable bodies, such as coins, bullets, buttons, beads, etc., giving a mortality of 15 per cent.; but the number ON FOREIGN BODIES IN THE AIR-PASSAGES 237 of these cases is comparatively small from which to draw percentage conclusions. In regard to the influence of the older methods of operative treatment upon the mortality, we may note that of 82 cases in which operative treatment — mostly tracheotomy — was adopted, 22 per cent, died; whereas, of 128 cases in which no operation was attempted, 37-5 per cent. died. Treatment. — Two principles are laid down by Sir F. Semon and Dr. Watson Williams^ in their article upon the presence of foreign bodies in the air and upper food passages : first, no foreign body the presence of which has actually been detected should be permitted to remain impacted, without an attempt to remove it by every justifiable means, even although at the time it may not produce active symptoms; secondly, no attempt should ever be made forcibly to ram down an angular or pointed foreign body. It is unnecessary after what has already been said to dwell upon these rules of practice. When the foreign body has penetrated to the bronchi, the first dictum still holds good. These being the fundamental ideals with regard to treat- ment, we may describe the main methods of procedure as follows : If the first paroxysm has passed, and the services of an operator skilled in bronchoscopy are available, a search should be made without delay by this method for the foreign body, and its removal attempted. With the recently improved manipulative methods and instruments designed by Killian, Briinings, Von Schrotter, and others, the facilities for extrac- tion have been greatly increased, and the attempt is now successful in the majority of cases. The pipe-stem referred to in the above-quoted case, although ultimately expelled by Nature's efforts, might readily have been detected by bron- choscopy, and would probably have been easily removed by this means. Whether superior or inferior bronchoscopy should be per- formed — the former being the introduction of the tube through the mouth and glottis, and thus into the trachea and bronchi; the latter its introduction through a previously per- formed tracheotomy wound — must depend upon various con- siderations, the most important of which are the size and character of the foreign body, but we may add that in the 238 DISEASES OF THE LUNGS AND PLEURA majority of cases superior (or per-oral) bronchoscopy will prove successful. Professor von Eicken/ of Freiburg, reported in 1909 upon 303 patients of all ages (195 children under fifteen and 108 adults) treated by superior or inferior bronchoscopy. Of this number, in 233, or 76-9 per cent., the foreign body was located and extracted, and recovery ensued. In 36 (ii"9 per cent.) the result was only partially successful, the lung being in many cases already so diseased that, in spite of the successful removal of the foreign body, death could not be averted, and at most only partial improvement followed. In 34 (ii"2 per cent.) the operation was unsuccessful, the foreign body in several cases not being found, or its removal proving imprac- ticable. Included in this group are also four patients who succumbed to cocaine-poisoning, and one who died under chloroform. Two children also died of suffocation from the fracture of the foreign body (a softened bean) during an attempt at its removal by superior bronchoscopy, and the consequent inhalation of the fragments. Since 1909 the results of this method of treatment have improved with advancing experience, and at the 17th Inter- national Congress of Medicine held in London in 1913, Dr. Chevaher Jackson,^ who introduced the discussion on this subject, reported that in the last 182 consecutive cases of bronchoscopy for foreign bodies which he had had under his care, in 177 the foreign body was successfully removed. In 3 only had the patient died — a mortality of vj per cent. Dr. Jackson uses only per-oral bronchoscopy, being unconvinced of the advantages attributed to tracheotomic bronchoscopy, while the disadvantages are many and obvious. Without pressing the actual figures too far, we may note that these results contrast most favourably with those obtained by older methods of treatment, as recorded by the late Mr. Durham,'" Weist," Preobraschensky," and others, and as indicated on our table on p. 226, and there can be no question that direct examination and extraction is the right procedure to adopt, provided the surrounding circumstances permit. When, however, the requisite instruments and skill are not available, and if the first paroxysm has passed, and if we know also that the foreign body is of the smooth, hard variety, referred to in Class I. of our table, simple inversion, ON FOREIGN BODIES IN THE AIR-PASSAGES 239 or inversion with tracheotomy, may be tried. Under this treatment the patient is inverted v^^ith slapping or thumping shocks between the shoulders. This should only be done with instruments ready at hand for tracheotomy should the paroxysm of dyspnoea consequent on displacement of the body to the glottis be too severe. In a considerable number of cases the foreign body has been thus expelled. A famous instance of the kind, in which, however, tracheotomy was performed, is that recorded by Sir Benjamin Brodie" of the celebrated engineer Brunei, who, whilst playing with some children, inhaled a half-sovereign into his bronchus. On the sixteenth day, the patient having been placed prone, with his head and shoulders slanting down- wards, "he immediately had a distinct perception of a loose body slipping forward along the trachea. A violent, con- vulsive cough ensued. On resuming the erect position, he again had the sensation of a loose body moving in the trachea . . . towards the chest." Two days later, in presence of Dr. Chambers and some other colleagues, the experiment was repeated by means of an inclined, hinged platform. On striking the back with the hand over the right bronchus, with the head lowered to an angle of 80 degrees with the floor, violent cough was set up without result, and the experiment was twice repeated, on the third time causing such an alarm- ing degree of choking that it was not further proceeded with. A week later tracheotomy was performed, and forceps intro- duced in an attempt to seize the coin, but without result. The tracheotomy wound was kept open, and after a further delay of ten days the patient was again inverted, and after two or three strokes on the back the coin was expelled through the mouth. "No spasm took place in the muscles of the glottis, nor was there any of that inconvenience and distress which had caused no small degree of alarm on the former occasion." In cases of angular bones, pointed instruments, and bodies of hke nature, if more modern methods of treatment be not available, tracheotomy should be performed, and an attempt made to extract the body by means of slender forceps, or, perhaps, a loop of silver wire. Pneumotomy,^'' or the cutting- down through the chest wall directly upon the foreign body, is an operation which, though by no means so hazardous as formerly, is yet not free from risk, and should be reserved for 240 DISEASES OF THE LUNGS AND PLEUR^: those rare cases in which other methods have failed. We have, on page 164, related a successful case bearing upon this subject. REFERENCES. ^ Harold, or the Last of the Saxon Kittgs, by Bulwer Lytton ; see also The History of the Norman Conquest of England, by Edward A. Freeman, M.A., 1868, Note W to p. 351, vol. ii., and Appendix, p. 6io. Freeman's account renders it clear that Earl Godwin died of cerebral hffimorrhage. ^ {a) " Corps Strangers du Larynx et des Voies Aeriennes," par F. Guyon, Dictionnaire Encyclofedique des Sciences Midicales, pp. 698 and 725, deuxieme serie, tome i., 1872. (b) Guyon, loc. cit., p. 713. ^ A Treatise on the Diagnosis and Treat7nent of Diseases of the Chest, by WiUiam Stokes, M.D., 1837, New Sydenham Society edition, part i., p. 234. London, 1882. * [a] " Diseases of the Bronchi, Lungs, and Pleura," by Friedrich A. Hoffmann, M.D., of Leipzig, Nothnagel's Encyclofedia of Practical Medicine, English edition, edited, with additions, by John H. Musser, M.D., p. 37. Philadelphia and London, 1903. {b) Loc. cit., p. 70. * " On the Effects produced by the Retention of Foreign Bodies for Lengthened Periods in the Bronchial Tubes," by Rickman John Godlee, M.S., F.R.C.S., Transactions of the Royal Medical and Chirurgical Society, i8g6, vol. Ixxix., p. 201, Case 3. ' " A Case of Foreign Body (Haricot Bean) impacted in the Left Bronchus : removal by Operation," by Thomas H. Kellock, F.R.C.S., The I^ancet, 1902, vol. ii., p. 1322. ^ " On Foreign Bodies in the Air and Upper Food Passages," by Sir Felix Semon, K.C.V.O., M.D., F.R.C.P., and P. Watson WiUiams, M.D., Allbutt and Rolleston's System of Medici7ie, vol. iv., part ii., p. 326. London, 1908. * " Die direkte Laryngo-Tracheo-Bronchoskopie," von Carl von Eicken (Freiburg i. Br.), Die Deutsche Klinik, 1909. See also " Direct Methods of Examining the Air and Food Passages," by Carl von Eicken, M.D., British Medical Journal, 1910, vol. ii., p. 1613. ' " Recent Progress of Endoscopic Methods as applied to the Larynx, Trachea, Bronchi, CEsophagus and Stomach," by ChevaUer Jackson, M.D., Transactions of the lyth International Congress of Medicine, London, ■1913, Sections 15 and 16, p. i. " " Foreign Bodies in the Air-Passages," by Arthur E. Durham, Esq., A System of Surgery, edited by T. Holmes, M.A., and J. W. Hulke, F.R.S., third edition, vol. i., p. 765. London, 1883. " " Foreign Bodies in the Air-Passages," by J. R. Weist, M.D., of Richmond, Indiana, Transactions of the American Surgical Association, Philadelphia, 1883, vol. i., p. 117. ON FOREIGN BODIES IN THE AIR-PASSAGES 241 *^ " Uober Fremdkorper in den Athmungswegen," von Dr. S. S. Preobra- schensky in Moskau, Wiener Klinik, 1893, Nos. 8-10. " " An Account of a Case in which a Foreign Body was lodged in the Right Bronchus," by Sir Benjamin C. Brodie, Bart., F.R.S., Transactions of the Royal Medical and Chirurgical Society, June, 1843, vol. viii., p. 286. " {a) "A Case of Pneumotomy for Foreign Body," by Thomas H. Kellock, M.C., Proceedings of the Royal Society of Medicine [Clinical Section), vol. vi., p. 64. 1913. (b) "Pneumotomy for Foreign Body," by Noel Braham, F.R.C.S. (Edin.), British Medical Journal, 1914, vol. i., p. 1123. 16 CHAPTER XV ASTHMA On more closesy regardng the several varieties into which asthma is divisible for clinical convenience, it will be observed that they represent merely aetiological subdivisions of a disease which consists essentially of a paroxysmal dyspnoea from disturbed innervation of the bronchi, leading to spas- modic contraction of these tubes. Pathology. — The theory that asthma is thus the result of bronchial spasm, though held by many authorities from Laennec onwards, has not been universally accepted, some believing that the disease is due to a sudden swelHng of the bronchial mucous membrane from turgescence of its blood- vessels; others that it results from a special form of inflamma- tion, a " bronchiolitis exudativa " (Curschmann), affecting the smallest tubes. For a consideration of the numerous other theories which have been held from time to time concerning the true nature of the disease, we must refer the reader to Salter's'" standard work, in which these theories are well related. That true spasmodic asthma is a malady in which the nervous system is closely concerned is supported by the following cHnical considerations : 1. An attack of asthma may supervene in the course of a few minutes, or even seconds, in a person in whom there can be found no evidence of chest disease. 2. Of the organic lesions which can be said in different cases of asthma to have led up to the spasmodic seizures, there are none which singly or combined are proper to that disease. Asthma, it is true, leads on to certain pathological conditions recognisable during Hfe, notably emphysema, chest deformity, cardiac disease, and visceral congestions; but these lesions are distinct mechanical consequences after long con- tinuance of the disease, and in their eadier stages are totally 242 ASTHMA 243 inadequate to account for the asthmatic phenomena. We have elsewhere drawn attention to the intimate analogy between pure asthma and vaso-motory angina, especially in these respects.* 3. The family histories and mental proclivities of many asthma patients, the capriciousness and intermittent character of their attacks, recall to mind such affections as neuralgia, migraine, epilepsy, and emphasise the part played by the nervous system in the pathology of the disease. We may now pass to a consideration of the question whether a spasm of the muscular tissue of the bronchioles, the contractility of which was originally demonstrated by the late Dr. C. J. B. Williams,^ is the cause of the asthmatic attack. The arguments in support of this theory have received very cogent and, as it appears to us, convincing sup- port, from the work of Professors Brodie and Dixon.* These observers have shown, by means of an ingenious method of recording the volume of air entering and leaving the lung at each respiratory act, that peripheral stimulation of the vagus leads in the corresponding lung to a contraction of the muscular walls of the bronchi and a constriction of their lumen, resulting in a great diminution of the volume of air inhaled. With this change an over-distension of the lung, as in asthma, was frequently observed. There can be no doubt, therefore, that under the influence of the nervous system marked changes of calibre in the bronchioles can be produced, and Dr. Watson Williams^ is of opinion that the asthmatic paroxysm is due to an exaggeration of the con- traction stage during expiration of the normal respiratory rhythmic movements of the bronchi, to which we have referred earlier (see p. 8). The influence of drugs was next investigated, and Drs. Brodie and Dixon found that the injection of muscarine and pilocarpine led to great constriction of the bronchioles due to peripheral stimulation of the vagal nerve-endings, and that if atropine, hyoscyamine, or hyoscine were then injected, dilatation at once supervened from paralysis of the same nerve-endings. The experiments with muscarine were espe- cially interesting, for the animal under observation suffered * See Table comparing Asthma with Angina Pectoris Vaso-motoria, in Sir Richard Douglas Powell's article on " Angina Pectoris."-'' 244 DISEASES OF THE LUNGS AND PLEURA from a typical asthmatic paroxysm, with dyspnoea, distended chest and scattered sibilant rales, until the injection of atro- pine cut short the attack. The experiments with chloroform and ether were also instructive, the results showing that these drugs, when absorbed through the bronchial mucous mem- brane, led to paralysis of the nerve-endings, thus explaining their good effect in the treatment of the disease. Of great importance, too, was the observation that a definite reflex contraction of the bronchioles could be obtained by stimula- tion of the nasal mucous membrane. The theory of bronchial spasm would appear, therefore, adequate to explain the asthmatic attack. Drs. Brodie and Dixon draw attention also to certain facts which militate against the theory of vascular turgescence, which has found in the past not a few supporters. They point out, in the first place, that it is illogical to assume that a sudden and marked vascular engorgement may be expected in the bronchi, simply because it occurs from time to time in the nasal mucous membrane, seeing that the structure of the two is quite dissimilar. "The nasal mucous membrane," they remind us, "especially over the inferior turbinate bone and lower nasal passages, is extremely vascular, and in many parts large venous plexuses are found encircled by bundles of muscular fibres, thus forming a sort of cavernous erectile tissue (Klein). The bronchial mucous membrane, on the other hand, is thin, and possesses what is, in comparison, a relatively insignificant blood-supply." Again, in the artificial asthma produced by muscarine, the bronchi were not found engorged, nor was any excessive secretion found in them. Further, the marked turgescence of the bronchial mucous membrane, produced by the experiment of clamping the pul- monary vein, never gave rise to diminution of air entry at all comparable to that seen when the bronchioles were made to contract. The little pellets of sputum which are expectorated towards the end of an attack of asthma should not be regarded as a sign of bronchitis, but are to be attributed rather to mechani- cal hyperaemia, induced by disturbed intrathoracic pressure acting for a considerable time upon the obstructed tubes. etiology. — A considerable number of cases of asthma are attributable to inherited predisposition, and in many instances ASTHMA 245 what is termed a " neurotic family history " obtains, although evidence of direct inheritance of asthma may be wanting. Epilepsy, insanity, neuralgia, hysteria and asthma, are indeed diseases all within the range of interchangeability in famihes. Asthma is said to be more common in males than in females, though this does not happen to be in accord with our own experience, and it is stated by Dr. SaUer and others to occur most frequently in the first decade of hfe. It is, however, often first manifested between puberty and early middle life, and in females about the menopause. Cases com- mencing in middle or later Hfe, and they are not very infre- quent, have in our experience mostly supervened upon influenza, others from the gouty plethora induced by undue liberahty in diet, and a few — one notable instance — from nervous exhaustion consequent upon the cares and work of official life. In connection with the setiology of asthma, especially that variety commencing in early life, eczema will occasionally be recorded; in later hfe sometimes urticaria. Exciting Causes of Asthma. — In the most characteristic cases of asthma the exciting causes of the attack are opera- tive in a patient with an idiosyncrasy, often hereditary, which is manifested in an undue sensitiveness of his respiratory centres. The exciting causes are of central or reflex origin, and are often toxic in nature. We may first consider toxic causes, since they are often associated with the others. It has recently been shown by Dr. John Freeman® and by Dr. I. Chandler Walker' of Boston, and others, that in many cases the asthmatic attack is in reality of anaphylactic origin, the patient being hypersensitive, anaphylactic, to some pro- tein, which may be present in pollen, animal hairs, food, or bacteria, and which, when absorbed, so affects him as to pre- cipitate the seizure. Dr. Walker examined 400 patients suffering from asthma, and found that 191, or 48 per cent., gave a positive skin test, as shown by a marked urticarial wheal produced on scarifying the skin through a solution of the protein in question, thus proving the patient sensitive to the variety of protein tested. With regard to the class of protein at fault, it has been shown that hypersensitiveness to a food protein, whether of cereals (and especially wheat), or egg, or milk, is more frequently to be observed in cases commencing in infancy, 23 of Dr, 246 DISEASES OF THE LUNGS AND PLEURA Walker's 34 cases being under two years of age. In later years, when caused by food protein, the asthma is more often attributable to other articles of diet, such as fish or potato. The same relationship to age of onset is true, but in a less degree, in regard to the protein present in hairs (chiefly those of the horse, less commonly the cat), or that occurring in feathers, which appears to be responsible for a good many cases of asthma commencing before the age of ten, and less often as the age of onset advances. Sensitisation to pollen protein, producing so-called "hay asthma," is more common in cases commencing in young subjects, but is by no means limited to such patients; while bacterial toxines, notably of staphylococcal or streptococcal origin, may be associated with asthma occurring at any age. We may here note, as probably of analogous explanation, the alarming symptoms of dyspnoea, failure of respiration, and collapse, which have sometimes quickly followed the subcu- taneous injection of serum, whether anti-diphtheritic or other, when given for therapeutic purposes in asthmatic subjects, who are often anaphylactic to horse serum. Of 28 such cases collected by Dr. Gillette,* 15 proved fatal (see p. 264). Presumably these protein bodies act directly upon the medullary nerve centres, and perhaps asthmatic phenomena sometimes observed in renal disease from retained urinary products may be similarly caused. We have already alluded to the effect of muscarine. It is only possible — so far as present technique serves — in some 48 per cent, of patients to trace asthmatic attacks to such proteid sensitisation. The tests in the remainder of Dr. Walker's cases proved negative. Other cases we must refer to the more obvious sources of reflex irritation. In some cases excitation of some point of the naso-pharyngeal tract may be at the origin of the trouble. The asthma has thus been traced to the presence of polypi, adenoids, or sinus disease, and treatment of the nasal affection has led to a dimi- nution in the number of attacks. We have also met with a few well-marked cases in which the asthma paroxysm has commenced with a turgid state of the turbinate membrane, causing complete occlusion of the nares. In other cases, again, asthmatic attacks arise from more direct bronchial irritation, as in bronchitis, plastic bronchitiSj or from inhala- ASTHMA 247 tion of inorganic dust, or exposure to acrid vapours, or to certain atmospheric influences to which the patient may be peculiarly sensitive. Amongst other reflex causes are gastro-intestinal disturb- ances, especially flatulent distension of stomach or bowels, and loaded colon; but it would be difficult to affirm how far the influence of certain proteins may not also be concerned in this causation. Less common sources of reflex irritation are connected with uterine disturbances, whether menstrual or climacteric, and those derived from excitation of cutaneous nerves. Cutaneous affections, especially of the eczematous type, are not infrequent precursors of asthma in young children, and the late Sir Andrew Clark was of opinion that asthma occa- sionally originated in an urticarial condition of the air- passages. The emotional causes which may be responsible for the attack no doubt act in a reflex manner, impulses originating in the cerebrum stimulating the lower centre in the medulla. We have recorded an interesting case in which asthma, vaso- motor angina, and menopausal sweatings have shown an interchangeability.-* Clinical Varieties of Asthma. — In accordance with the vary- ing nature of the exciting cause, diverse clinical varieties of the disease have been described, of which the following may be mentioned : (i) Idiopathic, Essential, or True Spasmodic Asthma. — This has been held to include those cases of true neurosis in which no lesion, whether pulmonary or other, can be found, and in which the exciting cause of the attack, if any can be recog- nised, is some mental or emotional disturbance, for example, mental shock, violent emotion, severe anxiety; or, if material, one of a very slight and ephemeral kind, such as a brilliant light, a transient odour, the momentary application of cold to the surface, and the like. This form of asthma, as already said, can be best compared to neuralgia, epilepsy, migraine, perhaps also mania. The neurosis is inherited either directly or through some of the alHed forms mentioned. The attacks are more distinctly periodic than in any of the other forms of asthma, and with the completion of each attack the peculiar neurosis often seems to be for a time worn out. 248 I3ISEASES OF THE LUNGS AND PLEUR.^ (2) Catarrhal or Bronchitic Asthma. — In this variety catarrhal symptoms precede and attend those characteristic of asthma, the dyspnoeic phenomena being due to direct irritation of the bronchial nerves, or more probably, as we have seen, to their reflex excitation. Bronchitic asthma is but a catarrhal affection of the bronchial tubes in a subject predisposed to asthma; the special character of the disease being derived from the individual peculiarity, not from the catarrhal affection which commonly arises in the ordinary way. In this affection during the acute stage the spasm and consequent dyspnoea are more or less continuous. Sub- sequently, with the greater freedom of secretion and expec- toration, the dyspnoea occurs chiefly in the early morning after a few hours' sleep, when the accumulation of mucus in the tubes is greatest, and with its expulsion the spasm ceases. In cases of old-standing emphysema fresh bronchial catarrh is often attended with dyspnoeal seizures of an asthmatic character which are due to obstruction of the tubes by mucus disturbing the, at all time?, unstable respiratory equilibrium of the emphysematous subject. Only in popular parlance can such cases be called "asthma." (3) Of dust asthma we shall detail a well-marked example arising from the inhalation of wood dust (see p. 264). Other irritants have similar effects upon a certain proportion of those exposed to them. (4) Hay asthma is a variety of the disease which is often associated with that intense catarrh of the conjunctivae and of the nasal mucous membrane which is termed "hay fever." The researches carried out at Hamburg, under the direction of Professor Dunbar,' and since by many other observers, have greatly extended our knowledge of the aetiology of this com- plaint, and have shown that, in patients whose nervous system is sufficiently receptive, the pollen of very many grasses, plants, and flowers is capable of producing the attack. Among these we may mention rye, oats, barley, meadow-sweet, golden rod, chrysanthemum, and aster. In England the complaint is chiefly produced by the pollen of hay (Anthoxanthum odoratum), in Germany by that of the flowering rye; in either country the early summer months. May to July, are those in which the disease is met with. In America, in addition to the attacks in early summer, a severe ASTHMA 249 form of the complaint is met with in the autumn, the so-called "autumnal catarrh," which is produced by the pollen of cer- tain grasses which flower at this season of the year. The pollen of the various plants in question contains, as demonstrated by Professor Dunbar, an active protein, soluble in saline solution, minute doses of which produce in sensitive subjects the symptoms of the malady, and must therefore be regarded as its cause. The pollen floating in the air finds its way into the eye or nose, its protein is extracted and absorbed, and thus gives rise to the lachrymatibn, sneez- ing, and running from the nose which form so familiar a picture. In a smaller proportion of cases, and generally some hours later during the night, an attack of asthma follows. (5) Nasal asthma, as the name implies, comprises that group of cases to which we have already alluded, in which the asthma has been traced to a definite source of irritation within the nose. In such cases relief may be given by opera- tive treatment, a question to which we shall recur later. (6) The term peptic asthma includes those cases in which the asthmatic attacks bear a definite relation to gastro- intestinal irritation, flatulent distension of the stomach, and so forth, and it is not to be doubted that many cases of asthma met with are in this sense manifestations of dyspepsia. The class of peptic asthma may, however, with great prac- tical utility be enlarged. Thus, Salter^* expressed the belief that the introduction of food frequently gave rise to asthma, not by irritation of the alimentary canal, but by absorption into the veins of materials perfectly normal to the stage of the digestive process, but which in the asthmatic stimulated the unduly sensitive pulmonary nervous system to produce spasm; and in this connection we must recall that certain articles of diet, especially saccharine substances and other carbohydrates, prove unsuitable to some asthmatics. We have already alluded to cases, chiefly of children, in which the patient is anaphylactic to the protein of certain foods. In the gouty subject, the blood circulating- through the nervous centres is charged with imperfectly changed and effete material, and attacks of "gouty asthma" may thus originate. It may well be believed, too, that in cases of loaded colon asthma is sometimes set up by the absorption of toxines and putrefactive matters, 250 DISEASES OF THE LUNGS AND PLEURA (7) Cardiac asthma belong-s to a different group from that which we have been considering-. It is in reahty a con-se- quence of heart failure, whether the resuh of fatty and senile degenerations or of valvular disease with incomplete or dam- aged compensation. Most commonly the attacks occur during sleep or towards the morning, when the blood-pressure and general vitality are low. Signs of passive congestion of the bases of the lungs, more especially on one side, may generally be detected, and some blood-staining of sputa is not in- frequently observed to follow the attack. (8) In urmnic asthma oedema of the lungs is generally present. We have seen cases, however, in which the morbid material in the blood seemed to be more directly the excitant, thus bringing them more into line with true asthma. Symptomatology. — The subjects of asthma present, in the advanced periods of their malady, a characteristic physiog- nomy. Thin, of nervous temperament, grave-featured, with sHghtly depressed angles of the mouth, high-shouldered and round-backed, they carry the impress of suffering in feature and build, and one is sometimes surprised at the power of work, keenness of wit, and capacity for enjoyment with which these persons are gifted. It requires many severe attacks, however, to bring about these characteristic appearances, and in the intervals between the earHer seizures there may be nothing in the physiognomy of the patient symptomatic of asthma. In the later periods of the disease, and at an earlier date after a recent attack, there may be quickened breathing, accompanied by slight wheezing, very perceptible to the observer, although the patient would consider himself quite free from dyspnoea. There is another type of asthmatic, which may perhaps be distinguished as the gouty, in which the patient is full-fleshed, with excess of adipose tissue, especially about the abdomen, the general build suggesting the short-necked " apoplectic " subject, rather than the thin stork-like aspect of the victim of the more neurotic form of the disease. The distinction is one of considerable practical importance. ■ The Attack. — Patients with true spasmodic asthma may be seized at any time of the day or night, but more frequently the attack comes on at night after the first sleep. A certain feel- ing of oppression about the chesty attended perhaps with some ASTHMA 251 wheezing, may give warning of the approaching seizure ; more rarely the attack comes on almost instantaneously, and with- out warning. The sense of oppression may partially awaken the patient or give rise to some disturbing dream, and he either starts up in a fright with the fit of dyspnoea full upon him, or more gradually awakens to the increasing difificulty of respiration. A severe attack of asthma is, to the inexperienced, truly alarming to witness; the expression of face, pale, staring, anxious, and distressed; the mouth slightly opened, its corners twitched downwards with each brief effort at inspiration, whilst the neck muscles start forward in violent convulsive action. The shoulders are rounded, the body inclined for- wards, and the hands rigidly grasp some firm object to fix the scapular and humeral attachments of the chest muscles. With the powerful inspiratory jerk thus effected the thorax is lifted en masse, but the deepening of the supraclavicular hollows and depressed lower thorax, sternum, and epigastrium, bear witness to the small penetration of air into the lungs in response to all this effort. Expiration is still more difficult, for the expiratory force is, so to speak, beaten in detail. The air-current in inspiration starts towards points of obstruction with a force proportional to expansion. In expiration, how- ever, each infundibular current is obstructed whilst 3/et a feeble stream; the expiration is thus prolonged, laboured, and but feebly and gradually effected, when, without a moment's pause, the quick, short, powerful inspiratory jerk again takes place. The actual number of respirations per minute may not be increased, and is sometimes diminished; the pulse is, how- ever, invariably quick, small, and often irregular and vacillat- ing, and there may not infrequently be noticed a distinct hesita- tion or failure of the pulse wave with each inspiratory effort. In earlier attacks, more especially, there is great restless- ness and frequent change of posture, with a disposition to lose self-control in the desperation of air-hunger. But the experienced asthmatic assumes and maintains some favourite attitude. The severity of attack may last from a few minutes to many hours, but it will be observed that even in the most urgent cases there are intervals of partial relaxation, during which the breathing becomes more easy, to be followed shortly by full intensity of spasm. 252 DISEASES OF THE LUNGS AND PLEUR.E Towards the close of the attack cough comes on, and with the expectoration of some viscid mucous pellets the dyspnoea is greatly mitigated. The body temperature during the seizure is depressed, cold sweats break out over the forehead, and the features become dusky and partially cyanosed. In very severe cases capillary haemorrhages into the conjunctiva have been noticed (Walshe). The mind rarely becomes even for a moment clouded, and only in early cases does the patient sometimes lose that self-control which is of so much service to him in the struggle. The urine is generally abundant, pale, and of low specific gravity, and the solid constituents are lessened (Ringer). The subsidence of the attack is generally gradual, but sometimes almost sudden, with more or less expec- toration, and the exhausted sufferer falls into a troubled sleep. Physical Signs. — During the attack the thorax is semi- expanded, with but little movement in response to the respira- tory efforts; the percussion note is resonant, and more or less of the emphysema type. Careful percussion is, however, im- possible and useless. Auscultation reveals but little or no breath-sound, beyond a short wheeze in response to the sharp inspiratory jerk, whilst the expiratory murmur is wholly obscured by prolonged cooing sibili of varying note. The heart's impulse can be best felt, and sometimes strongly so, at or below the ensiform cartilage. The amount of expectoration varies with the intensity and duration of the attack. The most characteristic expectoration consists of Httle pellets about the size of a pea, and " of the consistence of jelly or thick arrowroot, of a pale grey colour, of an opalescent transparency, and a saltish taste" (Salter). When carefully examined and unfolded these pellets will be found to contain casts of the finest bronchial tubes, con- stituting the peculiar formations known as Curschmann's spirals, which have already been described (p. 74). In almost all cases, too, on careful search, especially if the sputum has been kept for some hours before examination, Charcot-Leyden crystals will be met with (p. 75), sometimes within the spirals, sometimes free. As already indicated, neither crystals nor spirals can be regarded as pathognomonic of the disease. The asthmatic sputum contains in addition large numbers of eosinophile cells, and a considerable increase of these cells will also be found in the blood during the asthmatic attack : ASTHMA 253 their number may reach as high as 25 per cent, of the total leucocyte count. Slight haemoptysis is occasionally, but rarely, observed in severe cases of asthma. Where pulmonary oedema or con- gestion follows upon a severe paroxysm the expectoration is more abundant, consisting of a frothy, sometimes sHghtly blood-stained, mucus. After a serious attack of asthma much prostration and fatigue are experienced from the severity and duration of the struggle and from want of food and sleep. These symptoms will soon be recovered from, but renewed attacks commonly ensue at short intervals, until at the end of a certain series the malady appears to be for a time exhausted. More or less wheezing rhonchi generally persist for some hours or days, and in severe cases it is common to find at the bases some fine bubbling rales. The percussion signs and chest conformation at this period are those of acute pulmonary emphysema, varying in degree according to the severity of the attack. After a succession of attacks there is an amount of emphysema of the lungs, with oedema of their bases, and fatigue of the right ventricle of the heart, which requires some time and treatment to remove. From single attacks, even although very severe, the patient after a night's rest may feel quite restored. In other instances the attacks are brief, but return each night; these are usually cases in which the paroxysm is controlled by some remedy, and although jaded by disturbance of rest, such patients are able to pursue their daily w^ork or pleasure. Periodicity of seizure is usually a marked feature of asthma. The seizures may be daily, weekly, monthly, yearly, or at other tolerably regular intervals. A patient may suffer a series of daily seizures, and then enjoy a certain interval of freedom. It will be observed, however, with asthma, as with epilepsy, that as time advances the attacks, unless influenced otherwise by treatment, tend to become more frequent, although less severe, a number of minor seizures being interpolated between the more regular attacks, the gradually increasing emphysema rendering the intervals less and less defined. In the earlier years of true spasmodic asthma patients are able in the intervals of attack to take part in sports and exercises, which make large demands upon the respiratory 254 DISEASES OF THE LUNGS AND PLEURA powers. As the disease continues from year to year, however, it gradually entails other symptoms significant of definite pul- monary lesions; shortness of breath, and more or less wheez- ing continue through the intervals; the physical signs of emphysema remain permanent, and visceral congestion and associated dyspeptic symptoms become manifested. The heart especially suffers, its right ventricle becomes dilated, systemic venous fulness ensues, and, finally, oedema of extremi- ties, abdominal dropsy, with enlarged and hardened liver and albuminous urine, supervene (see chapter on Emphysema, p. 271). In a certain number of cases of asthma, on the other hand, the lungs give way, an atrophic form of emphysema appearing, which proceeds to coalescence of vesicles with adjacent pulmonary fibrosis. Should this occur at one or both apices, the condition may readily be mistaken for chronic phthisis. In yet other cases pulmonary tuberculosis super- venes, with the onset of which the paroxysms of asthma may wholly cease. The Prognosis of asthma proper is estimated by ascertaining the amount of physical damage which the patient has as yet sustained to lung and heart, for it is through complications re- ferable to these org-ans that life is commonly shortened. Asthma per se never kills, for when the paroxysm actually threatens life the spasm yields; nor is the asthmatic prone to some of the diseases, such as cancer, tubercle, Bright's disease, which in others shorten life. His own peculiar malady is enough for him to contend with, and it enforces upon him a compara- tively sheltered life. Asthma is, in fact, compatible with a life of medium length and of much usefulness, but of much suffering and self-denial. Family longevity should be inquired into in regard to prognosis. Infantile asthma, especially, if not definitely inherited, sometimes ceases at about puberty, and asthma of a gouty or influenzal origin is frequently cured by appropriate treatment. Treatment. — There is no disease which is so extensively " quacked " as asthma. Persons who are the victims of the pure neurosis are amongst the most restless of mankind; their temperaments are often of the highly-strung, nervous type, and whilst they are gifted with much courage, endurance, and determination, they possess little faith, many friends, and much credulity. The practitioner who would guide these suf- ASTHMA 255 ferers must himself have clear opinions respecting the salient points in treatment, and must be patient in hearing and endeavouring to understand the experience of each individual. The treatment of asthma may be considered under the fol- lowing headings : 1. Specific Treatment. — When consulted by an asthmatic patient, we must recall what we have said as to the aetiology of the disease, remembering- that in a proportion of cases it is the result of sensitisation to some particular protein. Care- ful inquiry must accordingly be made as to the patient's asso- ciation with horses, cats, or cattle, and the use of feather beds or pillows. The question of pollen irritation must also be considered. In those cases especially in which the attacks have commenced in infancy, the possibility of sensitisation to some special food protein must be borne in rnind, and some- times the withdrawal of white-of-egg from the diet, or the substitution of goats' for cows' milk, will effect a great im- provement. If the asthma is connected with bronchitis, the possible cause must be looked for in bacterial protein. After due observation such suspected factors may be scrutinised by the pathologist with the aid of the cutaneous test, and the particular protein, if any, discovered. If the malady be traced to a food protein, the special food must be eliminated from the diet, to be afterwards introduced tentatively and in regu- lated quantities, with a view to establishing immunity; if to an animal, pollen, or bacterial protein, desensitisation may be effected by gradually increasing doses of the appropriate vaccine. 2. Climatic Treatm^ent. — This consists, in the first place, in the removal of the patient from those external surroundings which appear to have led up to his attack, to more favourable conditions of residence — e.g., from a dusty to a pure atmo- sphere; from a cold, damp house or locality to a dry soil and a well-ventilated and cellared house, with no trees in the imme- diate vicinity. To tell with precision what locality will suit a given indi- vidual with asthma is very difficult. There are idiosyncrasies in each case, and no asthmatic should burden himself with a house until he has first tested the locality by residence there for some time. There are, however, certain climates which are most likely to prove beneficial for asthma patients. 256 DISEASES OF THE LUNGS AND PLEURAE (a) Bournemouth, the St. George's Hill neighbourhood of Weybridge, and the Farnborough and Bagshot districts, with their sandy soil and pine vegetation, may be named amongst English localities as places which are under all circumstances preferable to cold, damp neighbourhoods, and which are peculiarly adapted for the purest forms of asthma in which the neurosis is most marked. Abroad, Arcachon may be simi- larly recommended during the winter and spring months. (b) Torquay, St. Mary Church, Pau, Cimiez, Hyeres, Men- tone, Algiers, Algeciras, Grand Canary, and Santa Cruz (Teneriffe) may be mentioned as varied resorts adapted for winter residence for the mixed catarrhal forms of asthma. (c) Experience teaches a certain number of asthmatics that a sea voyage does most for them, and in such cases the cure may best be thus started. This plan is especially suited for cases of dust and hay asthma, as also for those in which the first seizure has been traceable to a nervous system broken down by anxiety, overwork, or excesses. (d) In young subjects, with as yet no marked emphysema, the pure rarefied airs of St. Moritz, Davos, Montana, and Arosa yield good results in winter, and in the hot months they may be resorted to with advantage by some older patients. In this connection we may perhaps add that we have known an asthmatic subject to remain quite well when residing for some years at Arequipa in Peru, at an altitude of 12,000 ft., but the attacks returned as soon as he again came to live at an ordinary level. Ilkley, Ben Rhydding, Dartmoor, Malvern, and Hindhead, are suitable situations in the summer season for convalescent asthmatics. (e) A considerable number of asthma patients do best in towns, being chiefly those who have removed from more or less damp localities surrounded by trees. As a rule asthmatics should repair to large towns or seaside resorts in the late autumn, and perhaps the late spring. 3. Medicated Airs and Baths. — In cases of catarrhal asthma, in those of influenzal origin, and in those in which a gouty element or an association with eczematous eruptions or urticaria can be observed, a summer course of three or four weeks' duration, at Mont Dore, Aix-les-Bains, Allevard-les- Bains, or Dax, but especially at the first-named, will often be attended with long-continued benefit. Minute traces of ASTHMA 257 arsenic mingled with the vapours at the Mont Dore baths are regarded as answerable for their good effects, and at Allevard the sprayed air of the inhalation chambers is decidedly charged with sulphuretted hydrogen. This latter treatment is most adapted for the chronic bronchitic forms of the disease; at the other places probably the sweating of the skin and bron- chial membranes constitutes the chief remedial factor. The course at one of these bathing resorts should be followed up by an after-cure at some more bracing place, such as Eaux Bonnes, Cauteret, Spa, or the Swiss mountains, or, in this country, at Ilkley, Ben Rhydding, Braemar, or other moorland districts of Yorkshire or Scotland. A course of Turkish baths for those who cannot go abroad sometimes proves of great service. We have in some instances seen much benefit from the use of the compressed-air baths at the Brompton Hospital (see p. 281), but we can only mention this as an empirical fact. 4. Regulation of the Digestive Function. — Not less impor- tant than the selection of a suitable climate is the careful regu- lation of the digestive functions of the asthmatic. In not a few cases the cause of the attacks is associated with the habitual ingestion of an excessive quantity of food, and if this be diminished the frequency of the paroxysms will be greatly curtailed. In other instances the exciting cause is some error in digestion which requires careful regulation and attention, and in all cases the digestive function ultimately suffers, and reacts unfavourably upon the spasmodic troubles. Very slow eating should be strictly enjoined, and the staple food, includ- ing a moderate quantity of meat, should be taken at the mid- day meal, only the lightest possible diet being allowed later in the day. In some cases where farinaceous foods ferment, a more nitrogenous dietary, approximating to the " Salisbury " system, may be recommended. In all cases it is wise to sub- stitute for bread with the meat meals unsweetened rusks, or Huntley and Palmer's breakfast biscuits, or baked toast. In cases in which there is excess of uric acid or urates, and a disposition to flatulent dyspepsia, cutaneous eruptions, and so forth, sweet wines, raw fruits, sugar, cooked butter, and pastry should be excluded from the dietary. An alkaline bitter may often be taken twice a day with great advantage when the tongue is red and coated, bismuth being added when there is gastrodynia. 17 258 DISEASES OF THE LUNGS AND PLEURA The liver and bowels require careful attention, very small doses of mercurial being useful from time to time, whilst in these, as in all neurotic subjects, large doses of this drug are positively harmful. Calomel, given occasionally in half-grain doses at night, is esipecially valuable. A sulphate of soda saline should be taken in hot fluid in the morning after each dose of mercurial. In other cases a teaspoonful of Pulvis rhei co. at bedtime will prove beneficial. If the rectum be loaded, relief should be effected by enemata rather than by violent aperients. When the tongue is fairly clean, or at all events when the practitioner is satisfied that the primce vice are acting efficiently, a course of arsenic is often of great service. 5. Attention to Other Sources of Peripheral Irritation. — What we have urged in regard to the digestive functions applies also to other organs, and if any definite source of peripheral irritation exists, it should receive attention. The condition of the nasal cavities should always be carefully investigated, since improvement, sometimes even permanent cure, has resulted from the removal of a polypus or the treat- ment of sinus suppuration or some other obvious defect. In the absence of any such gross lesions we should hesitate to advise prolonged or serious nasal treatment, for although transitory amendment may follow upon the shock or distrac- tion of any operative measure, no benefit of a permanent character results unless there be some definite condition to be amended. The application, however, of the galvanic cautery to various points upon the nasal mucous membrane, especially of the septum, not uncommonly gives temporary rehef, and as the procedure is a simple one, it may be tried in obstinate cases. Treatment of the Paroxysm.— Most commonly the practi- tioner makes his first acquaintance with the asthmatic patient when the paroxysm is at its height. A few questions as to duration of attack, preceding attacks, and circumstances and symptoms immediately antecedent to the present seizure, will suffice to direct a rational and safe treatment. When irritating matter is present in the stomach, whether in the shape of undigested food or irritant catarrhal mucus, an emetic of twenty grains of ipecacuanha, or a subcutaneous injection of j\ to ^ grain of apomorphia, will give prompt ASTHMA 259 relief by its removal. Warm water with a little carbonate of soda should be given to encourage a thorough clearance of the stomach. In cases of catarrhal asthma, during the paroxysm, ten minims of ipecacuanha wine, with fifteen minims of ethereal tincture of lobelia, given every half-hour for two or three doses, then every hour or two hours, will often prove service- able. The hquid extract of grindelia robusta (u.s.p.) in fifteen- minim doses may be sometimes substituted for the lobelia. In the choice of sedative remedies, a careful judgment must first be arrived at as to the amount of tubal catarrh and secre- tion present. The well-known "cures" of asthma appear to owe their efficacy partly to an evacuant, partly to a sedative, action. The fumes from burning the " Himrod," " Potters," " Green Mountain," "Chester" and other similar powders, first excite more or less cough, after which, and especially if expec- toration be effected, the spasm yields. A powder containing four drachms of powdered stramonium leaves, two drachms of powdered nitre, a similar quantity of aniseed, and five grains of tobacco is a very efficacious combination, much used at the Brompton Hospital. A teaspoonful of this powder should be made into a conical heap on a plate, lighted at the summit, and the fumes inhaled through a large inverted funnel. In the more purely nervous forms of asthma, when as yet there is no secretion present, sedative remedies must be used. By closely shutting the room and filling it with the fumes of nitre* the asthmatic sufferer will sometimes gain relief and rest. Salter considered nitre thus used a powerful sedative, but it must be confessed that its mode of action remains obscure. Its efficacy, however, in certain cases is unquestionable. In other cases speedy relief has been obtained by spray- ing the nasal cavities with a solution of adrenalin chloride, I in 2,000, or by the subcutaneous injection of i to 5 minims of the I in 1,000 solution, the adrenalin paralysing for a time the nerve endings, thus allowing the bronchioles to dilate. Extract of the posterior lobe of the pituitary body, which is * Take four ounces of nitrate of potash dissolved in half a pint of boil- ing water, pour out into a soup plate, immerse in the solution thick blotting- paper, dry, and cut in squares of four inches. A little chlorate of potash, about half a drachm to the ounce, may sometimes be usefully combined with the nitre. 26o DISEASES OF THE LUNGS AND PLEUR/E stated to act like adrenalin, but to have a more lasting effect, is helpful in some patients. In the full height and intensity of attack nitrite of amyl, iodide of ethyl,* or chloroform, may be inhaled with temporary advantage, and the true spasmodic nature of the affection will be well demonstrated by the complete subsidence of the sibilus under the influence of chloroform. The effect of these drugs is, however, as a rule very evanescent, and their use is only desirable to mitigate extreme symptoms. Strong coffee some- times distinctly relieves spasm, and "eupnine" a solution con- taining caffeine and iodine, may be given in drachm doses in water, and repeated in half an hour, with a like result. Nitro- glycerine and nitrite of sodium have also been recommended. Joy's cigarettes and Savory and Moore's datura tatula cigarettes will, provided the patient can inhale the smoke into the lungs, in many cases give great reHef to the urgent symp- toms, their efficacy being due to stramonium and, probably, some opium combined. Another remedy much used by the public is " Dr. Tucker's Asthma Specific," a liquid which is inhaled as a very fine spray from a vaporiser or atomiser, and which is often effective in relieving the spasm. An analysis of its contents, made by Dr. Willcox,^" showed each fluid ounce to contain cocaine 2'28 grains, atropine o'S/ grain, sodium nitrite i5'25 grains, a certain quantity of balsam or gum-ben- zoin, between 20 and 30 per cent, by volume of glycerin, together with traces of mineral ingredients, vegetable colour- ing matter, and so forth. This mixture when inhaled often gives great relief, but it contains potent drugs, and its use has sometimes been attended with disquieting symptoms. It should be employed, therefore, with caution, the tendency to its use becoming a habit being also remembered. An analogous remedy is the Xebula hyoscinse co. of the British Pharma- ceutical Codex. In severe cases an almost unfailing remedy is morphia used subcutaneously in doses of from ^ to | grain. Morphia is a remedy which, from the immediate relief it affords, is apt to be given somewhat recklessly, and to be called for per- emptorily by the patient, without counting the cost in after consequences. The drug should be used with caution, for * Convenient five-drop capsules of this drug, enclosed m silk, similar to those of nitrite of amyl, can be obtained. ASTHMA 261 not a few casualties have arisen from its employment. In catarrhal cases it should not be employed, and in the most purely neurotic cases, for the relief of which it is best adapted, it is a demoralising remedy. In fact, the employment of mor- phia in asthma is exactly comparable to its use in neuralgia; prompt in relieving, it lowers nerve tone, hampers secretion, and increases liability to recurrence. The tendency of the patient is to have recourse increasingly to its use for trivial attacks, until custom renders a large and dangerous dose necessary. In certain cases the drug is required; they are exceptional, however, and the most strenuous efforts should be made by the practitioner in such cases to remove his patient out of the conditions to which the asthma appears attributable. Hypodermic injections of atropine, yot to ^ grain, either alone or in combination with morphia, are sometimes useful. More recently heroin has been used with good results, in doses of 1^2- to I grain of the hydrochloride, given subcutaneously and repeated in an hour if necessary. But here again there is a danger of the use of the drug degenerating into a habit. Chloral in full doses of ten or twenty grains every four or six hours is also efficacious in pure asthma, and it may be used in the catarrhal forms; its administration, however, requires strict medical supervision and very precise directions. It may sometimes usefully be given in small doses in com- bination with iodide of potassium and other drugs. In cases of catarrhal asthma especially, and in some other less-defined cases, one of the most valuable remedies is iodide of potassium, in combination with stramonium. The iodide is especially indicated in those cases in which there is a nightly paroxysm, but in which there is also a perceptible dyspnoea and wheezing throughout the day. Three to five grains of iodide of potassium, with | grain of extract of stramonium, should be given every three or four hours during the day, e.g., 8 a.m., 12 noon, 3 p.m., 6 p.m., 9 p.m., so as to administer some fifteen to thirty grains of the salt and one to two grains of the extract by bedtime. The addition of small doses, 2V grain, of apomorphia to the mixture is sometimes helpful. After a day or two when the patient suffers slight iodism, and the physio- logical effect of the stramonium upon pupil and throat becomes apparent, the medicine may be continued in half doses. In the many cases in which this line of treatment proves valuable 262 DISEASES OF THE I.UNGS AND fLEUR^ it should be commenced on the first approach of asthma phenomena. Another remedy which we have found of use in warding off asthmatic attacks is " GrindeHne," which contains small doses of grindelia robusta, euphorbia, liq. trinitrini, and potassium iodide. A drachm in water should be given every six hours. In some cases in which asthma has been contracted in malarious climates, or in which a neuralgic element is traceable, quinine may be usefully given in com- bination with iodide of potassium. Five grains of salicylate of quinine in pill (with citric acid) may be taken three times a day, either at separate times or with each dose of iodide. In hay asthma the use of pollantin, the specific serum pro- duced under the direction of Professor Dunbar®'^' (see p. 248), has been found of some value. The dry powdered serum should be sniffed up into the nose on first waking in the morning, and again several times during the day, whenever the slightest sign of an attack appears. The pollantin, whether in the dry or liquid form, should also be applied to the eye if necessary. General precautions, such as sleeping with the windows closed during the hay-fever season, should not be omitted. In cer- tain cases the results to the hay fever and the hay asthma from this specific treatment have been gratifying, the patient having been, for a time at least, freed from his complaint. In other instances failure has resulted, or some amelioration only obtained. Should the patient come under observation during the winter or spring, a course of preventive subcutaneous inoculation with " Pollacine " (a liquid extract containing the pollen pro- tein) may be tried,* it having been first shown by a positive ophthalmic reaction that the patient is a sufferer from true hay fever. In certain cases considerable relief is thus given during the succeeding summer. Relief from the itching of the eyes and the sneezing which are so often associated with hay asthma may be obtained by inhaling from a handkerchief a solution containing camphor 3ss., menthol 3i., paroleine si., or by lightly plugging the anterior nares with cotton-wool moistened with a solution of four grains of hydrochloride of cocaine in one ounce of a I in 10,000 solution of adrenalin hydrochloride. The plug * Outfits, prepared in the Inoculation Department of St. Mary's Hospital, are supplied by Mp.«;srs. Parke, Davis and Co. ASTHMA 263 should be inserted in the early morning on rising, and again during the day, whenever the earhest signs of an attack are noticed. If any highly sensitive spots be discoverable in the nasal mucous membrane, they may be cauterised. Atten- tion must be paid to the digestion and the general health, and in some cases a sea voyage may be prescribed v^^ith advan- tage, or a short residence at one of our seacoast places, such as Yarmouth or other exposed marine station. Alcoholic stimulant should only be given in asthma when necessary as a restorative and in small doses. Strong coffee is of great value as a restorative after a severe paroxysm, and, as we have seen, in some cases it distinctly relieves spasm. Caffeine (two or three pills of 2J grains each, made with glycerine of tragacanth) may be taken for the same purpose. After an attack of asthma, especially if it has been severe and has left any pulmonary oedema behind, it is a good prac- tice to give small doses of digitalis (five to ten minims three times a day) to restore tone to the heart and small vessels. At this period arsenic is a most valuable nerve tonic. The digestive system now requires careful attention, since the secretions will necessarily have become disordered by the drugs used for the relief of the paroxysms, and by the venous congestion of viscera attendant upon the impeded pulmonary circulation. It is probable, too, that the function of the pneu- m.ogastric nerve becomes seriously enfeebled for a time by the attack and the remedies employed. Some pepsin and hydro- chloric acid after food, in combination with nux vomica or quinine, given an hour or two before food, will, prove service- able. The most careful consideration must immediately be given, however, as to whether the patient can be moved to a more suitable locality, and this may in some cases be wisely effected, even in the midst of an attack. The Use of Vaccines as a Prophylactic Measure. — In some cases of asthma of a distinctly catarrhal type, which begin with " colds," influenza attacks, and the Hke, and cases in which there is chronic bronchial catarrh with asthmatic paroxysms, the use of an appropriate vaccine is attended with decided benefit. The vaccine should be carefully prepared from the sputum of the subject, the M. catarrhaHs being- in many cases the principal organism, associated perhaps with the staphylo- coccus, streptococcus, pneumococcus, or Pfeiffer's bacillus. 264 DISEASES OF THE LUNGS AND PLEURA The vaccine is given at first in moderate doses twice a week, and gradually increased according to the degree of reaction, the larger doses being prescribed at first once a week or ten days and then once a month. The treatment requires to be continued for several months, and perhaps renewed from time to time, selecting a few weeks precedent to the times at which the patient is most Hable to his attacks. It is impor- tant to remember that in the use of these, as indeed of all vaccines, a period of quietude of several hours should succeed each injection. It is thus convenient to give the injection about teatime, and to enjoin that the patient remains in bed until noon of the following day, by which time the degree of reaction, if any, will have been noted. We have already enjoined great caution in the use of sera therapeutically in asthmatic subjects, whom it is well first to desensitise (see p. 319). We may, perhaps, conclude this chapter with an account of the two following- cases. The first is an example of bronchitis and asthma produced by the inhalation of rosewood dust, in which the effect of treatment was very striking. William C , aged thirty-eight, residing in London, was a man of temperate habits, married, witli one child living ; his wife had had one miscarriage, but there was no history of syphilis. He had been for twenty years employed as a fret-cutter. Four years previous to admission into the Brompton Hospital he had had an attack of bronchitis, and since that time he had suffered constantly from cough, with suffocative attacks nearly every night. Patient had never had haemoptysis, but had lost flesh considerably. His father died of rheumatic gout, and his mother of dropsy. There was no phthisis in the family. On admission patient complained of cough, which became worse, and was attended with severe attacks of dyspnoea at night. Expectoration moderate ; occasional night-sweats ; appetite poor ; bowels constipated. He was a tall and fairly well-built man, with a somewhat suffused countenance and breathless look. The chest was well formed, but expansion with inspiration was impaired. The percussion note over the front of the chest was hyper-resonant, the resonance extending on the right side a hand's-breadth below the nipple, on the left side over the normal area of heart's dulness, and inferiorly to the costal margin. Diffused sibilant rales were audible front and back, and at the posterior bases some mucous rales were heard. When seen on January 26 the patient had been in hospital three days, and was ASTHMA 265 suffering, as before admission, from nightly attacks of dyspnoea and from troublesome cough. He was on the ordinary full diet -of the hospital. The " Mistura Potassii lodidi cum Stramonio " of the hos- pital Pharmacopoeia, containing three grains of iodide of potassium, J grain of extract of stramonium to each dose, was now ordered to be taken at 12 noon, 4 p.m., 8 p.m., and 12 midnight, the diet remaining the same, and from the next night he had no serious dyspnoea. On January 31 a note is entered : " Patient feels much better, and dyspnoea almost gone. Cough easier." February 3 : " Has not felt suffocating sensation for the last six nights." He continued the mixture, however, for a month, and then took it in half doses for another fortnight. On February 8 respirations were free and un- accompanied by rale, and by the end of the month the cough had disappeared. On leaving the hospital at the beginning of March his weight was 9 stone 2 pounds, an increase of seven pounds since his admission. It should be observed in this case, as in many others, that mere rest from his dusty occupation did not sufifice for the patient's recovery, although doubtless, had he remained in pure air a sufficient length of time, he might have recovered without treatment. His attacks had the paroxysmal character peculiar to asthma, coming on towards the small hours of the morning — i.e., after a certain period of repose — whilst the breathlessness and cough of the bronchitis and attendant emphysema were constant through the day. Having regard to the period at which the dyspnoea became distressing, the stramonium and iodide of potassium mixture was so ordered that by midnight he had taken in the course of twelve hours a grain of stramonium extract, and twelve grains of the iodide. The effect, as we have seen, was striking and immediate. The mechanism of the dyspnoea was obvious. The man had an unduly secreting, and probably a somewhat thickened, bronchial tract, with great irritability of the bronchial muscular apparatus, and con- stant tendency to spasm of the tubes. At a certain time after repose secretion would accumulate and give rise to spasm. The hypersensi- tiveness upon which the bronchial spasm depended was at once lessened by the stramonium, whilst the iodide had a more permanently altera- tive action upon the mucous membrane and its secretion. The patient left the hospital well, but after a time, failing to find other work, was reduced to the necessity of recommencing his old employment, and soon had a return of all the old symptoms, for which he was treated elsewhere by ordinary remedies (ether and expector- ants) without avail. We have, however, since seen him in fairly good health, having for some time abandoned his former work. In the trade of fret-cutting the operator has constantly with his mouth to blow away the fine wood-dust that collects upon his work, and thus necessarily inhales much of the dust. The patient above referred to stated that he could distinguish by the taste the different kinds of wood< and he found rosewood (the taste of which he com- 266 DISEASES OF THE LUNGS AND PLEURA pared to cayenne pepper) to be the most irritating. Walnut-wood was more astringent and bitter, but less irritating. Asthmatic paroxysms are not infrequently associated with bronchial catarrh, and the following is the epitome of a case in which a chronic bronchial catarrh of gouty incidence, with heightened blood-pressure and some degree of arterio- sclerosis, was so associated, the special feature of the case being the constant presence in the sputum of numerous casts varying in size from the smallest filaments to those having a diameter of J inch (Plate XIV.). The case was that of an unmarried lady, aged sixty-six, seen by Sir Douglas Powell, in consultation with Dr. George Smith of Henl^, in July, 1919. There was no inheritance of an asthmatic kind, and, although for many years subject to repeated colds, she had never had an attack until her present illness. This began in January, 1914, with attacks of violent sneezing, which recurred every few days without apparent reason and were not influenced by remedies. Between the attacks her health was good. The spring and early summer months were spent on the Italian Riviera, at Naples, and in Rome and Florence. Her first attack of asthma occurred at Naples late in the spring, and continued in Rome and Florence. The attacks were attended with complete obstruction of the nasal passages, presumably from conges- tion of the mucous membrane covering the turbinate bones, and with difficulty in speaking or swallowing during the attacks. Severe paroxysms of coughing followed. The worst attacks occurred between 4 and 8 a.m. ; those less severe between 4 and 8 p.m. At Florence she was laid up for six weeks with bronchitis, and on convalescing she was passed on to Ems, where she had a relapse. Finally she suffered a terrible ten days' journey home at the commencement of the war. Vaccines were repeatedly employed on the Continent, prepared from the sputum. There seems to have been some uncertainty as to the nature of the microbe, and no relief was derived from the vaccines. From 1914 the ashmatic paroxysms became increasingly frequent, and the only remedy that gave relief was adrenalin, 5 minims sub- cutaneously of i in 1,000 solution. She had been accustomed to take this four or five times daily for relief of the paroxysms. In May, 1919, she underwent an operation, quite unconnected with the air passages, and, as is so common in asthma, her dyspnoeic troubles entirely cleared away for seven weeks ! During the three weeks previous to the consultation in July the symptoms had been gradually returning, and in the past fortnight there had been several hours of violent sneezing with nasal obstruction and with threatenings of the bronchial, asthma — symptoms, in fact, identical with those with which her illness commenced in 19 14. PLATE XIV CASTS FROM THE BRONCHIOLES FROM A CASE OF BRONCHITIC ASTHMA The drawing shows in their actual size numerous small bronchial casts of the thickness of thin string or cotton, white and forkedi forming collections like bunches of thin white ribbon. They were expectorated by a lady, aged 66, of gouty diathesis, who suffered from asthma associated with bronchial catarrh and raised blood- pressure. The case is described in the text (p. 266). PLATE XIV Casts from the Bronxhioles from a Case of Bfonchitjc Asthma. To face p. 266. ASTHMA 267 At the time of the consultation the expectoration was considerable in quantity, mucoid and frothy, and containing numerous tangled strings or casts, which in the earlier part of her illness were sometimes " as thick as pencils," but were now mostly small, quite white, forked, and of the thickness of thin string or cotton, forming collections rather like bunches of little white ribbons. Fearing she might have a spasm during examination, the lady had taken 5 minims of adrenalin twenty minutes previously. The breathing was quiet, and there was no cough during the interview ; the pulse 84, of notably high tension, the blood-pressure being found to be 95 diastolic and 205 systolic. The heart's apex beat was slightly to the left of the normal, the sounds clear, and the second sound heavy and accentuated. There was some slight sclerosis of the vessels. The lungs were a little emphysematous, and over the bases posteriorly fine crepitating rales were heard, which diminished, but did not disappear, after several deep inspirations. The finger-ends were enlarged with gouty arthritis, and it was elicited that the lady had always been gouty and had had several distinct attacks of gout in the feet. Dr. Smith subsequently made several examinations of the blood- pressure apart from adrenalin influence, and found the average pres- sure about 165 ; sometimes over 180 ; once as low as 140. The patient had lately been living in rooms, with stuffy furniture and insufficient air, and a removal to Peppard Common, with wheel- chair and quiet exercise, together with iodine and eliminative treat- ment, proved beneficial. On her return home, however, although con- tinuing the better hygienic conditions, the symptoms relapsed, but with less severity. The drawing in Plate XIV. was taken from a specimen of sputum expectorated in January, 1920. The report stated that " the sputum consists of mucus in which are whitish strings of varying size. These consist of mucoid material, with a tough, tenacious, possibly fibrinous, core, in which are a few bronchial cells and abundant leucocytes, but no alveolar cells. The prevailing organism seen in a stained film was a Gram-negative bacillus of coliform appearance, but there were also a very few cocci." The case was complicated with epithelioma quite unconnected with the pulmonary organs. During the last few weeks of her life, appar- ently under the influence of salicylate of soda, the patient was again relieved of all asthmatic symptoms. It must, however, be recorded that during this time she had several smart haemorrhages from the malignant growth, in one of which she died in the spring of 1920. There was, as shown on two examinations, no marked association with bacterial organisms, and consequently, as one might expect, vaccines proved of no avail. REFERENCES. {a) On Asthma: its Pathology and Treatment, by Henry Hyde Salter. M.D., F.R.S., London, 1868. [b) Loc. cit., p. 46. 268 DISEASES OF THE LUNGS AND PLEURA ^ (a) Article on "Angina Pectoris," by Sir R. Douglas Powell, Bart., K.C.V.O., M.D., F.R.C.P., Allbutt and Rolleston's Sysiem of Medicine, vol. vi., p. 170. London, 1909. {b) Loc. cit., p. 166 (Case 3 — Mrs. F.). ^ " Report of Experiments on the Physiology of the Lungs and Air- tubes," by Charles J. B. V\fiUiams, M.D., F.R.S., Report of the Tenth Meeting of the British Associatiojt for the Advancement of Science, p. 411. London, 1841. * (i) " Contributions to the Physiology of the Lungs " (part i.), "The Bronchial Muscles : Their Innervation and the Action of Drugs upon Them," by W. E. Dixon, M.D., and T. G. Brodie, M.D., Journal of Physiology, 1903, vol. xxix., p. 97. (2) " The Pathology of Asthma," by T. G. Brodie and W. E. Dixon, Transactions of the Pathological Society of Lotidon, 1903, vol. liv., p. 17. * " On the Probable Rhythmic Contraction of the Bronchial Muscular Coat as a Factor in Pulmonary Diseases," by P. Watson Williams, M.D. (Lond.), Bristol Med. Chir. Journal, vol. xxi., 1903, p. 6. ^ " Toxic Idiopathies," by John Freeman, M.D., British Medical Journal, 1920, vol. i., p. 403. ' (fl) "A Clinical Study of 400 Patients with Bronchial Asthma," by I. Chandler Walker, M.D., Boston Medical and Surgical Journal, 1918, vol. clxxix., p. 2S8. {b) " The Treatment of Bronchial Asthma with Proteins " (with bibliography), by I. Chandler Walker, M.D., The Archives of Internal Medicine, vol. xxii., 1918, p. 466. ' " Untoward Results from Diphtheria Antitoxin, with Special Refer- ence to its Relation to Asthma," by H. F. Gillette, M.D., Therapeutic Gazette, 1909, p. 159. ° (i) See " Zur Serumbehandlung des Heufiebers," von Dr. A. Liibbert Therafeutische Monatshefte, December, 1904, p. 605. ■ 2) " Hay Fever : Recent Investigations on its Cause, Prevention and Treatment," by R. Ashleigh Glegg, M.B., Journal of Hygiene, 1904, vol. iv., p. 369. 10 ti Tucker v. Wakley and Another," evidence by Dr. William Henry Willcox, The Lancet, 1908, vol. i., p. 338. CHAPTER XVI PULMONARY VESICULAR EMPHYSEMA Pulmonary vesicular emphysema may be defined as a dilata- tion of the air-cells and infundibula of the lungs, with antece- dent or associated atrophic changes, or, more briefly still, as a dilatation of the lung proper with textural atrophy. In its acute form this disease may affect persons of any age, but is especially apt to occur in children as a complication of whooping-cough or capillary bronchitis. In its chronic and more permanent form it affects most commonly persons in middle or advanced middle Hfe. Atrophic or senile emphysema, which scarcely merits consideration as a variety of the disease, affects only aged people, and is, indeed, but a part of the senile state. Pathology. — The perfectness of the function of respiration consists quite as much in the power of contracting as in that of filling the chest, and it is this power of contracting the chest that is lost in emphysema. The lungs, having lost their reserve elasticity, no longer tend further to contract at the completion of expiration; nay, expiration is never completed; the thoracic parieties and diaphragm, instead of being drawn inwards by the traction of the lungs, recoil simply to their position of repose, and oppose their dead weight to the in- spiratory muscles instead of aiding the action of these muscles by their elastic rebound. Hence, in extreme emphysema the inspiratory act, commencing at the point where in health calm inspiration would end, has to overcome (i) what remains of the elastic resistance of the lungs ; (2) the inertia and the resistance of the parietes, instead of, as in health, having to deal with the elastic resistance of the lungs alone, and being in this work aided by the outward spring of the ribs (see p. 9). Consequently, in marked cases the breathing is always forced, and more or less difficult. 269 2/0 DISEASES OF THE LUNGS AND PLEURA Let us now briefly recount the conditions present in emphy- sema, making such additional comments as seem called for. 1. The lungs in all cases of decided emphysema are per- manently expanded to about the position of ordinary inspira- tion, their elasticity being, so to speak, relaxed to this point. The enlargement commences, as pointed out by Rindfleisch,"^ in the infundibula, and, according to Dr. Arthur Keith,^ affects this portion of the lung chiefly. As a result of these changes, the pulmonary vascular system becomes lengthened. In acute emphysema loss of tone from repeated over-distension, e.g., during paroxysms of coughing, is the chief defect present, and, in young persons especially, is speedily recovered from. 2. The texture of the lung is to a greater or less extent impaired. In cases of long-standing emphysema resulting from re- peated attacks of asthma or bronchitis, what may be regarded as the second stage of the disease is entered upon; and the lung suffers in nutrition and elasticity. Many of the small bloodvessels become obliterated, withering backwards from their capillaries, a result due in part to primary degenerative changes in the capillaries, and in part to atrophic changes consequent upon the narrowing and stretching to which the vessels are subjected as the lung enlarges. Concurrently with these changes the alveoli atrophy, the portions between adjacent infundibula or alveolar spaces become thinned and finally give way, and the spaces here and there coalesce to form blebs or small cavitations, with thread-like remnants of vessels crossing' them, resembling in miniature the trabeculse of tuberculous cavities. Where the disease has resulted from oft-recurrent catarrhs, commonly with a history of a distinct attack of bronchitis at the commencement, ill-developed fibrous tissue, the result of repeated and long-continued con- gestion and nuclear proliferation in the submucous layer, toughens the lung texture, assists in impairing elasticity, and partakes in the subsequent degeneration. Similar changes occur in the local emphysema developed about old tuberculous centres in the lung. In cases of constitutional or hereditary origin the atrophic changes, whether originating in fatty degeneration of the pulmonary epithelium, or of that of the vessels of the lungs. PULMONARY VESICULAR EMPHYSEMA 27 1 or in a primary degeneration and rupture of the elastic fibres — and on these points authorities are by no means agreed'' — would appear to precede or accompany the catarrhal phe- nomena. This impairment of the texture of the lung renders any dilatation, however induced, more or less permanent. In these cases of primarily impaired lung- texture, enlargement of the chest to the limits of thoracic resilience takes place quite insidiously, and the chest thus assumes permanently, by imperceptible degrees, the position of moderate inspiration. It must not be forgotten, too, that the ribs themselves, and especially their cartilages, often prematurely undergo textural changes of a degenerative kind, the result of which is an increased rigidity and a straightening of the rib arch, and so an enlargement of the thorax. 3. In consequence of the relaxed elasticity of the enlarged lungs, they no longer exercise any traction upon the medias- tinum except during inspiration. Hence an important, because constant, aid to the return of blood to the heart is lost. Many authors go farther than this, and hold that the large lungs in emphysema are, so to speak, pent up in the chest, and exercise pressure upon the heart which lies between them, and upon the ribs and diaphragm which enclose them. A little reflection and clinical observation will, however, render it clear that this supposed pressure of the lungs upon the surrounding parts is, if not impossible, of infinitely rare occurrence and minute in degree. The enlarged thorax, flattened diaphragm, and lowered heart, are all phenomena due to defective recoil of the lungs, not to their active disten- sion, and are to be observed in health on the lungs being inflated during deep inspiration, a position which is retained in emphysema. 4. In addition to the negative impediment to the circulation referred to in the preceding proposition, there is a positive impediment in the stretched, and in part obliterated, capillaries of the lungs. 5. In consequence of the two last-mentioned conditions, the venous system is overfull, and the overworked right heart thickens. The increased power of the right ventricle at length becomes, however, inadequate to contend against the ever- present resistance to the pulmonary circulation, a resistance 2/2 DISEASES OF THE LUNGS AND PLEUR.E which is from time to time accentuated during attacks of bronchitis or asthma, and the whole venous system becomes engorged. With general venous congestion the return of blood from the coronary veins is impeded, and the heart muscle suffers in nutrition, undergoing fibroid degeneration. This in its turn leads to imperfect contraction of the ventricles, and causes them to yield gradually before the heightened blood-pressure. Hence follows a greater degree of venous stagnation and engorgement, especially in the hepatic and portal systems. Venous haemorrhages tend to occur, and oedema, commencing in the legs, sooner or later sets in. 6. Another effect of the relaxed state of the lung in extreme emphysema is to interfere with that condition of permanent patency in which the small bronchi are normally held by the constant traction of the elastic lung upon them from all sides. In emphysema this traction becomes neutralised during' ex- piration, and in more advanced cases collapse of the bronchioles must then occur, thus accounting for the laboured and obstructed character of that portion of the respiratory act. 7. Amongst the consequences of emphysema, those which are of the nature of compensation must not be forgotten. So ready are the adaptations of our economy to altered circum- stances, that it may be said that emphysema alone does not kill, (a) As the capillaries become partially obliterated, fresh communications are opened up with the neighbouring vessels corresponding to them by the formation of anastomotic loops, or by the widening of communications already existing. The pulmonary and systemic veins, we may remember, com- municate normally on the walls of the smaller bronchi, and with the formation of pleuritic adhesions, so common in this disease, loops of new vessels connect the pulmonary with the systemic circulation; and especially along the insertion of the diaphragm and margins of the sternum, fringes of enlarged vessels mark the connection between the two circulations. Thus, in some measure the pressure of the pulmonary circula- tion is eased, (b) The hypertrophy of the right ventricle of the heart above alluded to is, up to a certain point, of a strictly compensatory nature, serving to overcome by augmented power the increasing impediment to the pulmonary circula- tion. Thus, for a time at least, equihbrium is maintained, to be disbalanced again and again, however, by intercurrent PULMONARY VESICULAR EMPHYSEMA 273 attacks of bronchitis or other cause of overstrain, until at last the limits of compensatory recuperation are passed. Etiology. — When we come to inquire how this over-expan- sion of the air-vesicles is produced, we are met by various explanations, no one of which alone is sufficient to account for all cases. Sir William Jenner* demonstrated that ex- piratory effort during straining" or coughing, particularly the latter, is an efficient cause of general emphysema, those portions of lung which are least supported, viz., the apices and anterior margins, and also the parts corresponding with the comparatively yielding intercostal spaces, becoming- first affected. But with the production of emphysema in these portions of the lungs, a shifting of the relationship between the lung and the thoracic surface takes place, and parts which were originally in apposition with the ribs come to be opposed to interspaces, and in their tutn yield before the distending force of air pent up and compressed during cough.^' Following this view, it has been believed that the playing upon wind-instruments is an occupation likely to lead to emphysema from the expiratory efforts involved. The ex- perience at the Foundling Hospital would, however, suggest that in young and healthy subjects this is not the case. At this institution many of the boys are trained for the regimental bands, and Dr. J. C. Swift, for many years Medical Officer to the hospital, informs us that over a period of more than twenty years only one case of emphysema developed among nearly 600 boys so trained. The subsequent health also of these boys in the army has been good. Other authorities, commencing with Laennec,^ have held that inspiratory pressure is the chief factor, and in the pro- duction of local emphysema it is undoubtedly an important agent. Thus, if one lung be disabled or bound down by some inflammatory process (as old pleurisy or chronic pneumonia), the other lung perforce becomes more capacious; whether this extra capacity shall be derived from true hypertrophy or mere dilatation (emphysema) depends upon the nutritive vigour of the patient. During bronchitis certain of the air- * Sir William Jenner (Reynolds's System of Medicine, vol. iii., p. 478) refers to Mendelssohn as having in a paper, " Der Mechanismus der Respiration und Circulation," in 1845, anticipated him in his view re- specting emphysema. The authorship and advocacy of the view in this country rests, however, with Sir W. Jenner. 18 274 DISEASES OF THE LUNGS AND PLEURA tubes may become occluded by mucus, and the inspiratory force then operates as a distending power upon the remaining portions of the lung until the deficiency in air-space is com- pensated. Thus, in the words of Rindfleisch,^* who adopted the late Sir William Gairdner's" inspiratory theory in regard to the production of emphysema, "during the antecedent bronchitis, first one, then another bronchial tube is plugged with secretion, and so first one, then another segment of the lung is subjected to an abnormal degree of [inspiratory] dis- tension," until at length general emphysema is produced. Dr. Gee,'' in his Lumleian Lectures, also advocated the in- spiratory as being the chief factor in the production of emphysema. An impartial view of the matter renders it clear to us that each of these theories is valid and applicable to a considerable number of cases, now one and now the other predominat- ing. But both inspiratory and expiratory theories imply the presence of some pre-existing bronchitis, or some local lesion disabling a portion of the lung, conditions which are wanting in a considerable proportion of cases. In truth, the emphysema frequently precedes the bronchial affection, although it is subsequently aggravated by the attacks of bronchitis; and admitting with the late Dr. Green- how^ and others that a failure of nutrition is, in a large propor- tion of cases, the predisposing cause of emphysema, we need go but little farther to explain the occurrence of that disease in its earlier grades. The effect of damaged nutrition of the lungs is to impair their elasticity and traction upon the thoracic walls. As we have elsewhere shown (see p. ii), the thoracic resilience tends to expand the chest from i to 3 millimetres in each direction; in proportion, therefore, as the lungs lose elasticity, they yield to this resilience of the thoracic wall, and to the weight of the abdominal organs dragging upon the diaphragm, and thus the lung is expanded to such a degree that any further extension will suffice to cause symptoms of dyspnoea. Calcareous degeneration affecting the cartilages and ribs, referred to by Freund,® causing loss of elasticity of these parts, may lead, for reasons already given, to a rigid enlargement of the chest cavity. This change takes place pari passu wath, or may even precede, the loss of pulmonary elasticity, and thus plays a part in the aetiology of the disease. PULMONARY VESICULAR EMPHYSEMA 275 It is from this latter view of its mechanism that one can appreciate the fact that in emphysema the chief defect consists in the lessened power of contracting the chest, and thereby emptying the lungs. The act of expiration is never com- pleted; there is too much residual air constantly in the lungs, and inspiration is short and jerking, the act commencing where it should end. The force of expiration, as estimated by the manometer, is remarkably lessened in emphysema, whilst that of inspiration remains normal, or may even be increased (Waldenburg),'° the relationship between inspiration and expiration being thus, in this respect, the reverse of that obtaining in health. The vital capacity of persons with emphysema is, as might be supposed, greatly curtailed. Varieties of Pulmonary Vesicular Emphysema. The distribution of pulmonary vesicular emphysema may be local or general, and, as above shown, it may vary in degree between wide limits. Local Pulmonary Vesicular Emphysema. — This may be met with as a dilatation of the lung, accompanied by more or less atrophic changes, around old cicatrising nodules of disease, contracting- cavities, or points of pulmonary collapse. The site of the emphysema is here determined by that of the primary lesion, on which its presence mechanically depends. Whilst the effect of the emphysema is clinically to mask the physical signs proper to the consolidation, it brings no com- pensatory advantage to the patient, since the emphysematous portions of the lung are deficient in respiratory function. Again, it sometimes happens that a whole lung is disabled by destructive disease, by permanent collapse from long- continued fluid pressure or interstitial fibrous growth. In these cases it is inevitable that the opposite and originally unaffected lung shall enlarge, and fortunately in many in- stances this enlargement is really of the nature of compen- satory hypertrophy; there is, that is to say, greatly increased mobility of the side, the respiratory murmur is loud and puerile over the whole extended area of the lung, and the patient's breathing powers are fairly maintained. We may, therefore, safely assume in such cases increased function corresponding with increased size, which is at least the clinical 2/6 DISEASES OF THE LUNGS AND PLEUR/E definition of true hypertrophy. On minute examination we believe that a corresponding development of lung texture, with increased blood-supply, and an absence of the atrophic changes of emphysema, would be found.^^ In other cases, however, in which the lung disablement has occurred in a subject of broken constitution, whether from hereditary tendency, prolonged fever, faulty habits, or com- paratively advanced age at the time of attack, the " sound " lung, whilst enlarging to the clinical outline and pattern of hypertrophy, does not yield to auscultation evidence of vigorous breathing, but a feeble diluted breath-sound, want- ing in concentrated vesicular quality. The expanded side lacks mobility, and rustling crepitant sounds may be heard at different points, especially near its anterior margin. The patient has not the signs of improved aeration, he presents a livid tinge about the peripheral parts and extremities, and his enlarged lung has brought no corresponding relief to his breathless condition. Here we have a dilatation of the lung mechanically induced, and attended with atrophic changes, a condition which constitutes emphysema. General Pulmonary Vesicular Emphysema — i. Large- Lunged Emphysema. — This is the condition of typical symmetrical emphysema, to the description of which this chapter is chiefly devoted. It is only necessary further to say, or rather to repeat, that there are really two groups of cases included in the variety — viz., (i) that in which the disease is distinctly secondary to recurrent bronchitis or to chronic lung" overstrain, and in which the degenerative changes super- vene, and render the lesion permanent; (2) that in which the atrophic changes are primary, and the bronchitis and other phenomena are secondary. The latter cases are either hered- itary or are induced by intemperate living, gout, syphilis, or other acquired cachexia. 2. Small-Lunged or Senile Emphysema. — This resembles the second group of the last variety in being an emphysema of essentially atrophic origin. It is, however, but the atrophy of old age most obvious at the lungs, but present everywhere. The pathology of this disease, if such it can fairly be called, is identical with that of the preceding, save that it supervenes in lungs already small and shrunken with the general atrophy of the body. Persons thus affected are prone to bronchial PULMONARY VESICULAR EMPHYSEMA 277 attacks, and their heat-sustaining powers are very feeble ; but under good conditions of warmth and clothing, with careful living, and a moderate amount of stimulants, they may enjoy life to even beyond the average age. Symptomatology. — The clinical phenomena presented by cases of marked emphysema are only in comparatively small part significant of the emphysematous lung, being largely due to attendant and for the most part secondary lesions. The physical signs will be sufficiently indicated in the description of the following extreme case of the disease : George D , oil and colour warehouseman, aged about fifty, was admitted into the Brompton Hospital under the care of Dr. Douglas Powell. The patient was a tall man, with no hereditary tendency to phthisis, but of gouty parentage on the father's side. He had up to three years before admission never been laid up with any illness. At that time he had an attack of bronchitis, and since then had complained of shortness of breath and cough, constant in the winter, attended with frothy and viscid expectoration and with a sense of constriction below the ribs. He had never spat blood nor suffered from hectic, but had lost and then regained flesh rapidly. His principal symptoms on admission were great shortness and difficulty of breathing, the head and face becoming congested, almost cyanosed at times, during attacks of dyspnoea and cough. He had no pain, but the sense of constriction below the ribs, already men- tioned, was marked. His appetite was bad, digestion tolerably good, bowels irregular, sleep fair. Physical Signs. — Pulse 86. Temperature normal. Great oedema of lower extremities and scrotum. Chest greatly expanded. Res- piration slow and forced. Respiratory movements mainly thoracic, and extraordinary muscles of respiration prominently employed. Intercostal spaces above the nipple level slightly depressed during inspiration, becoming quite level with the ribs on expiration. Below the nipple level the intercostals were greatly depressed during in- spiration, becoming level with the ribs or even slightly puffed out- wards during expiration. The seventh and eighth ribs yielded inwards with inspiration. The heart's impulse was most per- ceptible at left costal margin at the level of the tip of the ensiform cartilage. Girth of chest on each side above nipple level, 18 inches ; at the level of base of ensiform cartilage on the right side, i8f inches, and on the left side, 18^ inches, with | inch extreme inspiratory ex- pansion. The whole chest was resonant down to the margin of the ribs both in front and behind. At the posterior bases on both sides fine bubbling rales were heard, principally with inspiration. Similar rales were also heard over the lower two-thirds of the right and left fronts. Apices clear. Cardiac sounds unattended with 2/8 DISEASES OF THE LUNGS AND PLEURA bruit. Abdomen somewhat distended, and containing a small quantity of fluid. Liver depressed. The subjoined tracings show well the nature of the respiratory movements in this case. They were taken by a simple apparatus, consisting of a straight rod connected by a flexible joint with an expanded button to apply to the chest, the other end writing upon a horizontal sphygmograph plate previously smoked. Tracing Fig. 27 represents the movement of the sternum at the level of the third cartilage, the patient sitting in a chair, with his back Fig. 2-]. — Tracing of Respiratory Movements in Emphysema, showing Total Forward Thrust at Third Mid-Sternum. resting against a flat board. It is equivalent to exaggerated thoracic breathing, although the patient was inspiring in the degree natural and necessary for him. Tracing Fig. 28 was taken on the seventh rib in the lateral region right side, and shows a distinct recession (c, c, c) during each inspiration. This was, perhaps, due to the bases of the lungs being in some measure disabled by secretion, but the disablement and collection of secretion were undoubtedly in greatest measure owing to the inaction of the diaphragm in consequence of the flattening of its arch. The thoracic movement was certainly Fig. 28. — Tracing showing Recession in Emphysema [c, c, c) during Inspiration, Seventh Rib, Axillary Line. somewhat in excess in this case from the same cause, but in most cases of emphysema the respiration becomes thoracic rather than abdominal. The patient died, after he had been in the hospital three weeks, from general dropsy and cyanosis. The post-mortem examination revealed the usual phenomena of large dilated heart, with right side most affected, the tricuspid orifice measuring 65 inches in circumference ; large emphysematous lungs, PULMONARY VESICULAR EMPHYSEMA 279 the emphysema most marked at the anterior and upper parts and in the right lung, together with oedema and slight congestion at both bases. The bronchial tubes contained a frothy thin fluid, but there were no signs of active bronchitis. The spleen was hardened, the kidneys mechanically congested, and the liver enlarged and fatty. Treatment. — It will be obvious from what has preceded that the treatment of emphysema is mainly palliative, consist- ing of the prevention of fresh catarrhs, asthma, and bron- chitis, the avoidance of over-exertion and straining occupa- tions, the escape from dusty, irritating atmospheres, and, when possible, the timely migration to more genial climates during the winter or early spring months. We cannot cure the disease, but we may by judicious measures arrest textural decay, and prevent fresh overstrain. Emphysema, let us again remark, is never fatal, within the normal period of human life, save by its complications, but it is the factor which endangers recovery from many diseases. In the dietetic treatment we must so far restrict ingoings as to adapt the resulting products to (i) the needs of a necessarily limited muscular activity and a diminished metabolism; (2) to a somewhat retarded circulation through the lungs, the result of capillary obliteration; (3) to a lessened oxygenation and a corresponding tendency to plethora of venous blood. A restricted, well-assorted dietary, and the maintenance in fair activity of the eliminatory functions of the skin, kidneys, and bowels, will fulfil the double indication of avoiding sur- charge of the economy by waste materials and diminishing the tendency to venous plethora, visceral congestion and over- work of heart. With regard to the treatment of emphysema by drugs, there are certain clear indications to be followed. Measures for the regulation of secretions have been alluded to, and are of great importance, but require no further detailed description. Intercurrent attacks of bronchitis or asthma will require appropriate treatment, but except at such times one should, so to speak, forget the lungs in the medicinal treatment of this complaint. Dyspnoea is not always to be regarded as an indication for ether nor a bronchial wheeze for squills. We must rather have careful regard to the general condition of the patient, and especially to vessel and heart tonicity. Iron, 28o DISEASES OF THE LUNGS AND PLEURA arsenic, and strychnia are the best general tonics, and should be given in small doses for lengthened periods, say for a month at a time, with intervals of rest from drugs. The arseniate of iron is an excellent preparation for our purpose, e.g., in -^ to J gr. doses, with ^ gr. of extract of nux vomica and some pepsin, twice a day after food. A little aloes may be added if necessary, or an occasional morning dose of aperient waters advised, with more rarely a mercurial, with the view of main- taining equilibrium in the portal system. Ten drop doses of jtincture of perchloride of iron, with a little strychnia, twice a day, will often prove of value in restoring muscular tone to the heart and to the bronchi, after any fresh attack of bron- chitis or asthma involving renewed strain upon the right ventricle. Occasionally at these times it is desirable to give digitalis in moderate doses for a few weeks; five minims three times in the day is usually quite sufficient for the purpose. In the advanced stages of emphysema and its concomitant affections, when the limbs become dropsical, the abdomen full, the viscera engorged, and — what is the key to the whole situa- tion — ^with the right ventricle fluttering at the epigastrium, the pulse small, irregular, and intermitting, and the jugulars dis- tended and filling from below, absolute rest in bed, the free administration of digitalis, with diuretics and diffusible stimu- lants, will sometimes still serve to rescue such patients from impending death. The flow of urine freely returns, the pulse steadies, and the dropsy subsides under this treatment. Albuminuria, usually more or less present under these condi- tions, is no contra-indication to the use of blue pill, which, given in combination with squill and digitalis for three or four successive nights, will frequently give a start in the direction of improvement. The heart is the failing link in the phenomena present, and digitalis is the remedy, but it sometimes taxes our ingenuity and resolution to give the drug in a combination in which it can be borne. The digitoxin preparations, such as Nativelle's digitaHne and Hoffmann's dig-alen, are sometimes usefully substituted for the more Galenic preparations. Some patients may take strophanthus better than digitalis, and the changes may be rung upon these two drugs. Convallaria may be tried as an alternative, but is by no means equal to either of the preceding in influencing heart and vessels. In the employ- PULMONARY VESICULAR EMPHYSEMA 281 ment of these medicines' pains should be taken to specify such preparations as are standardised and reliable. Aerotherapentics. — Much has been written and many obser- vations made upon the treatment of emphysema and allied complaints by means of compressed and rarefied air. The idea is no new one, having been advocated by Nathaniel Hen- shaw in the seventeenth century in his interesting little work entitled " Aero-Chalinos ; or, A Register for the Air,"^^ but it is chiefly to Waldenburg" that we are indebted for the modern employment of the method. Theoretically, expiration into rarefied air would appear in emphysema the more hopeful method, the rarefaction tending to extract the air from the distended lungs, and thus render easier the succeeding inspira- tion. In practice, however, better results are obtained from the use of compressed air. The treatment may be carried out in two ways : the patient may use a portable apparatus, of which Waldenburg's modification of Hutchinson's spirometer is the best known," and by means of an appropriate adjust- ment secure the due compression or rarefaction of the air to be respired. Experience has, however, hardly borne out the hopeful results at first claimed from the use of such instru- ments, and as the continual adjustment of the necessary mouthpiece is often unpleasant to the patient, the method is now but little used. More satisfactory results are obtained by the use of the com- pressed-air bath, in which the whole body of the patient, and not merely the surface of his respiratory tract, is subjected to the influence of the compressed air. Since the early experi- ments of Tabarie the method has been gradually improved, until the present satisfactory chambers have been devised. These may be seen at numerous places on the Continent, and notably at Reichenhall, in Bavaria. A detailed description of the one installed at the Brompton Hospital will be found in Dr. Theodore Williams's work on " Aerotherapeutics.""" It consists essentially of a chamber made of wrought iron yV inch thick, provided with iron door and plate-glass windows, sufficiently strong to resist the pressure to which the whole will be subjected, and containing chairs and tables for the con- venience of the patients. The chamber is provided with a pump for compressing the air (worked in this case by steam), and a receiver containing cotton-wool, through which the air 282 DISEASES OF THE LUNGS AND PLEURA is filtered. It may be made of any size; that at the Brompton Hospital will accommodate three or four patients, whilst others have been constructed to hold twenty. The patient takes his seat in the chamber, prepared for a stay of two hours. The pressure of the air is then very gradu- ally raised, until at the end of half an hour it exceeds the normal by ten pounds, or two-thirds of an atmosphere. At this point it is allowed to remain for an hour, and is then gradually reduced, until at the end of the second hour the normal has again been reached. If care be not taken to alter the pressure very gradually, various unpleasant sensations referable to the throat and membrana tympani will be experi- enced; but no danger of caisson disease need be anticipated, since to produce the latter affection it has been shown that a reaction from a pressure exceeding three atmospheres is necessary. The baths should be given every other day at first, and then every day, a course lasting from six weeks to two months, after which they may be continued at longer intervals. As a result of this treatment, there can be no doubt that cer- tain cases of emphysema do improve considerably. The cough and expectoration lessen, the chest diminishes in cir- cumference, and cardiac and liver dulness tend to return to the normal ; the breathing at the same time improves, so that the patient is able without distress to take exercise, which before would have been impossible. How exactly these changes are brought about is not quite clear; it may be that they result from a beneficial action of the compressed air upon the bronchi, leading to a constriction of their bloodvessels and a diminution of secretion and spasm, rather than from any direct action upon the alveoH themselves. Favourable results, such as we have described, must not, however, be looked for in every case; nor can it be predicted from the symptoms or physical signs what the result will be in any given instance. Although the method of treatment is empirical, it is one, nevertheless, which may be tried if the requisite facilities are available. Climatic Treatment. — It is generally held that elevated climates are unsuitable for patients with emphysema, inasmuch as such patients must breathe more deeply to obtain the same amount of oxygen from a rarefied atmosphere. From PULMONARY VESICULAR EMPHYSEMA 283 the following considerations, however, it would appear that such an atmosphere is much less unsuitable to emphysematous patients than one might at first assume. In the first place, it must be remembered that with an abun- dant air-supply only a very small proportion of the oxygen is used for respiratory purposes; in other words, expired air is not nearly exhausted of its oxygen. Secondly, although the air of elevated regions is rarefied, its particles are more actively mobile, and oxygenation is relatively quickened ; thus, Tyndall and Frankland^^ demonstrated that the loss of weight of a candle burning on Mont Blanc at an elevation of 12,000 feet is identically the same as that of another candle of similar dimen- sions burning in the valley of Chamounix below. Thirdly, the circulation through the lungs, as elsewhere, is carried on at less pressure in elevated regions, and the heart, tuned originally to lower latitudes, finds relief in this way. The above considerations are interesting, because they show that on theoretical grounds a certain amount of emphysema need be no bar to residence in a higher altitude if this be otherwise indicated. And this agrees with our practical ex- perience, for we have known not a few cases of chronic phthisis with varying degrees of emphysema to do well in the High Alps. Nevertheless, we should not advise such climates for the more usual cases of chronic bronchitis and emphysema. For these, a warm climate near the sea-level is to be recom- mended, where the patient may take sufBcient exercise with- out the exertion of hill-climbing, and where the danger of recurrent attacks of bronchitis is diminished as far as possible. Such conditions are to be found at many of our own health resorts, such as Falmouth, Ventnor, or St. Leonards ; or abroad at such stations as Mentone, Bordighera, or San Remo, on the Riviera. In Egypt, Grand Canary, or Madeira, the con- ditions are also favourable. Surgery. — During the last few years an attempt has been made, notably by Professor Delbet, of Paris, to deal sur- gically with emphysema^^ by the performance of chondrec- tomy — that is to say, the excision of certain rib cartilages with their perichondrium, on the assumption that loss of elasticity of the framework of the chest referred to by Freund (see p. 274) is the most important element in the malady. In certain cases relief has been given, but the operation is not free from 284 DISEASES OF THE LUNGS AND PLEURAE danger, and we believe that the cases are rare in which such treatment can justifiably be entertained. Interstitial or Interlobular Emphysema. This condition depends on the escape of air into the connec- tive tissue surrounding the lobules, bronchioles, bronchi, and bloodvessels, and also that beneath the pleura. It is caused by wounds of the lung tissue, or by rupture of the air-vesicles during severe attacks of cough or other straining efforts. It is most common in childhood during the paroxysms of whoop- ing-cough and other diseases associated with violent and pro- longed coughing, but we have known it to occur in the course of phthisis. If limited to the lung, the air appears as small beads in the interlobular tissue; but under the pleura it may form blebs of considerable size (Plate XV.). It further tends to pass into the mediastinum, and thence into the cellular tissue of the neck, producing surgical emphysema, whence it may even extend over the trunk. In rare cases it has led to pneumothorax. If left alone the air is usually absorbed, but if there is great ten- sion this may be relieved by puncture or incision of the skin, when the air escapes. If uncomplicated and limited to the lung, the condition gives rise to no clinical symptoms or physical signs, and is only dis- covered at the autopsy. REFERENCES. ' (a) A Manual of Pathological Histology, by Dr. Eduard Rindfleisch (New Sydenham Society edition), vol. ii., p. 7. London, 1873. {h) Loc cit., p. 7. ^ (i) "The Mechanism of Respiration in Man," by Arthur Keith, M.D. (with bibliography), being an article in Further Advances in Physi- ology, edited by Leonard Hill, M.B., F.R.S., p. 182. London, 1907. (2) "Why does Phthisis attack the Apex of the Lung?" by Arthur Keith, M.D., The London Hosfital Gazette, January, 1904. ^ See article on " Emphysema and Atelectasis," by Prof. Friedrich A. Hoffmann, in Nothnagel's Encyclopedia of Practical Medicine (English edition), edited by John H. Musser, M.D., pp. 258-263. Philadelphia and London, 1903. * " On the Determining Causes of Vesicular Emphysema of the Lung," by William Jenner, M.D., F.R.C.P., Transactions of the Royal Medicql Qnd Chirurgical Society, 1857, vol. xl., p. 25, PLATE XV INTERSTITIAL EMPHYSEMA On the surface of the lung numerous air-bubbles are seen, from the rupture of alveoli and the escape of air into the tissues beneath the pleura. From a male child aged nine and a half months, who died from whooping-cough. The section of the lung showed patches of broncho-pneumonia, but no vesicular emph^'sema. (From the Museum of St. Bartholomew's Hospital. Natural size.) PLATE XV Interstitial Emphysema. To face p. PULMONARY VESICULAR EMPHYSEMA 285 * Traiti de V Auscultation Mediate et des Maladies des Poumons et du (Jceur, par R. T. H. Laennec, troisieme edition, tome i., p. 292. Paris, 1831. ^ On the Pathological Anatotny of Bronchitis, and the Diseases of the Lung connected with Bronchial Obstruction, by W. T. Gairdner, M.D., p. 57, etc. Edinburgh, 1850. ' Medical Lectures and Aphorisms, by Samuel Gee, M.D., fourth edition, p. 127. London, 1915. * On Bronchitis and the Morbid Conditions connected ivith it, by Edward Headlam Greenhow, M.D., F.R.S., second edition, pp. 233-237. London, 1878. ° Der Zusammenhang gewisser Lun genkr ankheiten mit frimdren Ri-pfen- knor-pel-Anomalieen, von Dr. Wilhelm Alexander Freund (zu Breslau). Erlangen, 1859. '" Die P nemnatometrie und Sfirometrie, von Dr. L. Waldenburg, p. 56, 1880. " See cases recorded by [a] the late Professor Coats, Manual of Pathology, by Joseph Coats, M-D., p. 739 (London, 1895); also [b] by Dr. Wethered, "A Case of Hypertrophy of the Lung," by Frank J. Wethered, M.D., Transactions of the Pathological Society of London, 1897, vol. xlviii., p. 34. '^ Aero-Chalinos : or, A Register for the Air, by Nathaniel Henshaw, M.D., F.R.S., the second edition. Printed for Benj. Tooke at the Ship in St. Paul's Churchyard, London, 1677. " Die Pneumatische Behandlung der Respirations- und Circulations- Tzr ankheiten, in Anschluss an die Pneumatotnetrie, Sfirometrie und Brust- messung, von L. Waldenburg. Berlin, 1875. '* See [a] Aerotherapeutics, by Charles Theodore WiUiams, M.D., p. 98, London, 1894. [b] " Artificial Aerotherapeutics," by C. Theodore WiUiams, AI.D., Allbutt and Rolleston's System of Medicine, vol. v., p. 35. London, 1909. '^ See On the Curative Effects of Baths and Waters, by Dr. Julius Braun, edited by Hermann Weber, M.D., p. 59. London, 1875. '" See [a) " Freund's Operation in Pulmonary Emphysema," British Medical Journal, January 8, 1910, epitome No. 20, p. 6. {b) " Le Thorax et I'Emphyseme : la Chondrectomie," par E. Douay, Annales de la Clinique Chirurgicale du F'rofesseur Pierre Delbet. Paris, 1914. [c] " Operation for Emphysema," British Medical Journal, 1916, vol. ii., p. 428. [d] Surgery of the Lung and Pleura, by H. Morriston Davies, M.A., M.D., M.C., F.R.C.S., p. 246. CHAPTER XVII PNEUMONIA Acute lobar pneumonia, or, as it is inaptly termed by German writers, "croupous pneumonia," may be defined as an acute specific disease, characterised by inflammatory consolidation of some portion of one or both lungs. In a sense, pneumonia and inflammation of the lungs are synonymous terms, but the latter expression by no means covers the whole pathology of the disease. In many, if not in all cases the micro-organisms responsible for the malady pass into the blood-stream, and under certain conditions specific complications in distant organs, such as the meninges of the brain or the internal ear, result. In all cases, too, the poisons elaborated in the lungs are rapidly absorbed, and to their toxic effects many of the most characteristic symptoms are due. In every case, therefore, the disease affects the whole system to a greater or less extent, and any conception which regards it as limited to the lungs must be erroneous. We have to deal, in fact, in pneumonia, with a blood infection as well as a local inflammation. .etiology — Individual Predisposition. — No age is exempt from pneumonia, but the malady is more prevalent at that period between twenty and forty, when persons are most ex- posed in the active struggle of life. The male sex is more frequently attacked than the female in proportion of three to two, and at the period of life referred to the prevalence is twice as great amongst males (Longstaff^). Depressed vitality, arising from debauchery, intemperance, over-fatigue, anxiety, insufficient food, or overcrowding, renders the in- dividual more prone to attack. Some persons are especially liable to the disease, and one attack favours the disposition to future recurrences. In rare cases as many as thirteen, fifteen, sixteen, or even twenty-eight attacks have been recorded.-'" Pre-existing Diseases. — Chronic disease of any kind, but 286 PNEUMONIA 287 especially alcoholism, albuminuria, and gout, increases the liability to pneumonia. But, curiously enough, the presence of already existing chronic lung affections, such as phthisis, asthma or bronchitis, does not appear to render the subject more liable to the disease. A plethoric state of body seems to favour its occurrence, and to add much to the severity of the attack. Surgical injury and the shock resulting from severe accidents are not infrequently followed by its appear- ance, especially in old people. Climatic Influences. — Cold seasons, great variations of tem- perature and rough piercing winds bring about pneumonia. The disease is thus comparatively rare during the summer from June to October, but with the advent of winter its frequency increases, until its maximum incidence is reached in February or March, when in this country the east winds are most severely felt. It is to be observed that a merely low external temperature is not so favourable to the occurrence of pneumonia as ex- posure to great variations. Indeed, it is stated that pneu- monia is more common in hot than in cold climates. Chill from undue exposure to draughts, cold winds, and the like, is the most common exciting cause of pneumonia, and the disease not infrequently arises in workmen who, getting warm at their work in the sunshine of a May day, throw off coverings and become chilled by a north or north- east wind, of which they were before unconscious. Not only are most of the sporadic cases to be accounted for in this way, but a certain number of the epidemic occurrences of the disease in modern times are thus explained, individual suscep- tibility and special exposure being the predisposing circum- stances. The epidemic related by Assistant-Surgeon Welch^ as affecting the 22nd Regiment, stationed at New Brunswick, may be quoted as an example. The troops, who had been stationed at Malta for six years, were transferred during cold wintry weather to New Brunswick. Of the total strength of 652 men, 52 were soon attacked with pneumonia, 12 cases occurring in January, the month of greatest cold, and 31 in February and March, when temperature fluctuations were most marked. Of the 652 men, 330 were housed in the "Exhibition building," a large, cold, draughty wooden struc- ture, freely exposed on all sides, and of these 38 (or 11-5 per 288 DISEASES OF THE LUNGS AND PLEURA cent.) developed the disease. The remaining 322 were quartered in suitable and warmer barracks, or in married quarters, and of these only 13 (or 4 per cent.) were affected; whilst among 152 women and children only 2 cases occurred. Of the whole 52 cases, Welch attributed 27 to cold draughts and lowness of general temperature, 7 to sleeping on mattresses carelessly stuffed with damp snowed straw, 5 to exposure to great cold at night, and 6 to chill whilst perspir- ing from strong exercise. In the remaining 7 cases the direct exciting cause was obscure. The facts here recorded are striking, and emphasise the important part played by "ex- posure " in the production of the disease. Injury. — In a small proportion of cases a blow on the chest has seemed to be the direct exciting cause of acute pneumonia, and such cases have been styled "traumatic" or "contu- sional " pneumonia.* But, apart from these, we have met with cases that have been apparently attributable to the shock following injury to another part of the body, and we may note that a similar phenomenon has been observed in the case of massive collapse of the lung (see p. 346). Septic Influences.— 2E.\.\o\ogicdi\ researches, and especially the evidence brought together by the Committee of Collective Investigation of the British Medical Association/ leave no room for doubt that cases and groups of cases of pneumonia are to be met with which are dependent upon faulty sanitary conditions, and especially exposure to sewer-gas emanations. Whenever several persons in a house are attacked, either together or in quick succession, the possibility of such a cause should at once suggest itself. The disease, when thus arising, is apt to be of a somewhat different type from the more ordinary variety, and merits the term "septic pneu- monia," under which we shall describe it. Direct Infection. — There is evidence to show that, under certain circumstances, pneumonia may be communicated directly by one person to another. The Collective Investigation Committee, in answer to a special request for information as to the aetiology of pneumonia, received about one hundred replies, in eighty of which no other cause than exposure to cold could be assigned for the attack. The twenty remaining replies are abstracted in the Record^" and amongst them nine observa- tions are included in which there was apparent transmission PNEUMONIA 289 of the disease from one member of a family to others, in at least one of which the evidence is very strong. The difficulty is, of course, the usual one of separating cases of several persons being attacked in consequence of exposure to a common cause from those in which the first attacked has transmitted the disease to others. In the epidemic at New Brunswick already referred to no suspicion of communication of the disease by infection is mentioned, and similarly with one of the two epidemics described by Surgeon-Major Maunseir in North- West India. Several striking instances of the apparent origin of pneumonia by contagion are, how- ever, quoted by Drs. Sturges and Coupland^ from various authors, and others have since been recorded.' Some of these are convincing, as when a person has acquired the disease after nursing a sufferer from pneumonia, and, having been sent to a distant home, other cases have at once arisen among the members of the fresh family previously in perfect health. Cases such as these — and not a few have now been recorded — are difficult to put aside, and we must conclude that in certain circumstances, when the virus is especially active or the system more than usually receptive, the disease may be spread by direct infection. Indeed, it is not improbable that, were the sputum in pneumonia less viscid, and were it there- fore easier for infected droplets to be coughed into the air, and thus inhaled, the disease would be more often communi- cated in this manner. In this connection it should be noted that the pneumococci responsible for the attack disappear from the mouth as a rule within three to four weeks after recovery, but they have been known to persist as long as three months."'' Bacteriology. — Bacteriological research has demonstrated that in the great majority of cases of lobar pneumonia, perhaps 95 per cent, the pneumococcus discovered by Talamon and further studied by Frankel is to be found in the lung, and often it is the only organism present. That it is capable of producing pneumonia is shown by the fact that if a culture be injected into the lung of a sufficiently resistant animal, such as the dog or sheep (Gamaleia"), acute lobar pneumonia, identical with that occurring in man, results. We are justified, therefore, in regarding the pneumococcus as the specific cause of the disease in the vast majority of cases. 19 290 DISEASES OF THE LUNGS AND PLEUR/E In a small percentage of patients other organisms may be responsible, such as the pneumo-bacillus of Friedlander, which has occasionally been found in pure culture in the lung, or the pyogenic cocci which are sometimes alone present in so-called "septic pneumonia." The preponderant role played by the pneumococcus in cases of acute lobar pneumonia is demonstrated by the follow- ing figures, which give the setiological agents concerned in 480 cases of the disease treated at the hospital of the Rocke- feller Institute in New York, in which the bacteriological findings were fully worked out 10* Diplococcus pneumoniae Friedlander 's bacillus Pfeiffer's bacillus (of influenza) Streptococcus pyogenes Streptococcus mucosus Staphylococcus aureus Mixed infections, with combinations of Staphylo- coccus aureus, Friedlander's bacillus, Pfeiffer's bacillus, Streptococcus pyogenes, and Streptococcus viridans 454 3 6 7 Total ... ... ... ... 480 In the sputum or in films made from the pneumonic exudation the pneumococcus presents the appearance of small cocci, often arranged in pairs, the two ends of which are generally somewhat pointed. It thus acquires a lancet-shaped appearance, and has been accordingly termed the Diplococcus lanceolatus. The organism stains by Gram's method, and, when growing- in the tissues, is surrounded by a definite and characteristic capsule. To demonstate this in the sputum, a portion should be dried on a cover-glass and stained with methylene blue, then washed and mounted in water. In this way, as the late Professor Kanthack showed, the capsule is easily brought into view. At a temperature of 37° C. cultures may be obtained without great difficulty, and on agar they present a characteristic appearance, forming small round transparent masses, which have been compared to drops of dew. Below 24° C. but little growth occurs. Pneumococci are most easily demonstrated in those areas of the lung which are in the earliest stage of the pneumonic process and in a condition of acute inflammatory congestion. But they are not confined to the lung, and may be found in PNEUMONIA 291 the pleura or pericardium, when these tissues have become infected and inflamed by direct extension. Often also they are present in the blood, and in this way may be responsible for a malignant endocarditis, a meningitis, an otitis or arthritis, or some other and distant complication. We have spoken hitherto as though the pneumococcus were a single organism of unvarying character, but recent re- searches at the Rockefeller Institute in New York have revealed that, just as in the case of the streptococcus and the colon bacillus, more than one type of pneumococcus may be recognised. Differentiation of the strains can be made by the agglutination test, using sera prepared by the inoculation of various strains of pneumococci, and in this way three types (I., II., and III.) may be easily separated. A fourth variety, which does not agglutinate with any of the standard sera, but which, like other pneumococci, is soluble in bile, has also been isolated. The following table, taken from the valuable mono- graphs of the Rockefeller Institute to which we have referred, shows the frequency of occurrence in New York, as well as the percentage mortality, caused by each variety or type : "^ Incidence in New York of Various Types of Pneumococcus and resulting mortality. Type. I II. III. IV. We thus see that pneumococci of Types I. and II. are responsible for 64 per cent, of all cases of acute lobar pneu- monia occurring in New York, and that the majority of deaths from this disease are due to their agency. Few cases of pneumonia are produced by organisms of Type III., but their virulence is great, and nearly half the patients attacked die. Type IV. is responsible for nearly a quarter of the cases of pneumonia, but the mortality is less, a fatal termination occurring in only 16 per cent, of those attacked. An identifica- tion of the type of pneumococcus present in any given case has thus an obvious bearing upon prognosis, as well as upon the question of specific treatment, to which we shall refer later. We may add that in the pneumonia which occurs so frequently in South Africa among the natives working in the Incidence. Per Cent. Mortality Per Cent, 33 31 12 24 25 32 45 i5 292 DISEASES OF THE LUNGS AND VLEVRJE gold mines, Dr. F. S. Lister'^ has established other varieties of pneumococci, in addition to those discovered by the workers at the Rockefeller Institute, one of which he finds to be of frequent occurrence and of high case mortality. In addition to being present in the tissues of patients suffer- ing from pneumonia, the pneumococcus, as Pasteur" first showed, may be found in the saliva of not a few healthy people (Netter^*). The researches of the Rockefeller Insti- tute would appear to indicate that such pneumococci belong for the most part to Type IV., the least virulent of the various strains, and that, except in convalescents and "contacts," organisms of Types I. and II., which are responsible for the majority of cases of pneumonia, are but rarely met with. Nevertheless, the fact that pneumococci do occur in the mouths of nearly 40 per cent, of normal persons"'^ is a fact which helps to elucidate a good deal that has hitherto appeared obscure in the aetiology of pneumonia, and it is not difficult to understand how cold, wasting" diseases, or alcoholism may predispose or give rise to the disease, provided the specific germ is already present within the body, ready to take advantage of the local vascular changes or lowered resistance which favour its growth. Pathology and Morbid Anatomy.— The morbid anatomy of pneumonia consists, in the first place, of an acute hypersemia of the affected lung, resulting in a fibrino-corpuscular exuda- tion into the alveoli, sometimes including the smaller bron- chioles, and forming a film upon the pleural surface. This exudation, coagulating in situ, fixes the lung in a state of immovable expansion, more densely solidified than it could be by any artificial injection with coagulable fluid. In the attainment of this second stag-e of "hepatisation" all the severity of the disease is manifested, and on its completion the disease proper is at an end. Thirdly, with liquefaction and absorption of the morbid products, convalescence becomes established. A normal pneumonia is thus artificially divisible into three stages. The first stage begins with the rigor, and ends with the appearance of definite signs of consoHdation. It may be termed the stage of initial fever with pulmonary engorge- ment, and it lasts from two to five days. If death should PNEUMONIA 293 occur at this stage, the affected lung is found to be in a condi- tion of inflammatory oedema, heavy, engorged with florid blood, pitting on pressure, and still crepitating. On section, abundant blood-stained and frothy serum exudes. Pulmonary hyperaemia and fluid exudation are the conditions present. When the pneumonia occurs in very cachectic subjects, scattered pulmonary haemorrhages may be found. A mere outburst from engorged vessels at some one time, however, is not necessarily associated with disease of a specially low Fig. 29. — Section of Lung in Pneumonia -. Latter Period of Red Hepatisation. type. It must be observed that throughout the febrile period of pneumonia there is an advancing area of lung thus affected. The second stage — that of pulmonary hepatisation — emerges from the former, and terminates in from forty-eight hours to five or six days. It is characterised by continued high temperature, and by increasing signs of consoHdation of lung. In this stage of red hepatisation the affected portion of lung is bulky, heavy, and solid to the feel. The pleural surface is more or less covered with a thin layer of soft, finely granular lymph which can be readily scraped off, exposing the glistening pleura beneath. In some cases this layer is com- plete, of some thickness, and of yellowish opacity. On sec- 294 DISEASES OF THE LUNGS AND PLEURA tion, the lung is firm and dry, presenting a red granular surface, which is readily broken by the pressure of the finger. A little frothy secretion may be present in the bronchial tubes, the mucous membrane of which is injected. If the cut surface be scraped, and the juice thus obtained be examined, casts of the alveolar passages and bronchioles will be found. A portion cut from the consolidated lung sinks at once in water. A thin section from the consolidation shows the alveoli, infundibula, alveolar passages, and sometimes the smallest divisions of the bronchi, to be occupied by red blood-discs and leucocytes entangled in the meshes of coagulated fibrin (Fig. 29). The alveolar wall is not changed beyond some- times showing slight swelling of its epithelium, a few cells of which may be shed. Towards the latter portion of this stage there is more or less emigration of leucocytes through the alveolar walls. In cases in which the pulmonary inflam- mation supervenes upon long-continued hypostatic conges- tion the consolidation is softer, darker, and more spleen-like in appearance, and has been called " splenification of lung." The term "hypostatic pneumonia" is also applied to this condition. Third Stage. — That of resolution. The commencement of this stage is characterised in normal cases by a remarkably rapid fall of temperature, attended with profuse sweatings or other critical phenomena, and the signs of commencing lique- faction of the elements of the lung consohdation. The lung now assumes a greyish aspect, with some red patches still remaining. On section, the granular appearance is at first maintained. Later, the whole lobe becomes of a dirty greyish- yellow colour and much softer. This stage of pneumonia is spoken of as grey hepatisation. The microscopical appearances are at first characterised at this stage by an extensive emigration of leucocytes. The exuded products then undergo degeneration, the fibrinous strands becoming completely disintegrated, the red corpuscles decolourised, and finally both red and white cells more or less broken down by fatty changes. The change in colour ob- served on the post-mortem table from red to grey hepatisa- tion is brought about partly by these alterations, partly through compression of the pulmonary capillaries by the pressure of the exudation. PNEUMONIA ^ 295 As a rule, the alveolar walls remain intact, beyond, perhaps, manifesting slight swelHng of their epithelial lining, and the emulsified products are readily removed, chiefly by absorp- tion, but in part also by expectoration. In some cases, hov^- ever, the texture of the lung is involved in the inflammatory change, the alveolar v^alls become infiltrated with leucocytes, and the reparative stage of grey hepatisation is changed for that of suppurative disintegration of the lung itself. This un- toward event, spoken of as "purulent infiltration," must be regarded as a complication rather than as a feature of pneu- monia. It is doubtful whether recovery can take place when this condition has been established. Should it occur over a localised area, an abscess of the lung results. The portion of lung affected in pfieumonia is most commonly the base on one side, the right being more frequently affected than the left. It is rare for both bases to be simultaneously attacked, but it is common for the second base to become in- volved in the course of the disease. Perhaps the frequency with which this happens has been exaggerated from the fact that both tubular breath-sound and crepitant rale may be audible at one base by reflection from a corresponding point of the other. The upper lobe is attacked in a goodly proportion of cases, more commonly so in children than adults; amongst the latter are included the more cachectic cases, whether from alcohol or other causes, which generally run a graver course. It must be borne in mind that the above description of the three stages of pneumonia relates to the pathology of each portion of lung attacked, but pneumonia frequently attacks successive portions of lung, when the morbid anatomy and symptoms of the three stages will be confused and over- lapping. It must be further noted that, apart from definite complica- tions, a certain degree of cloudy swelling of the kidneys, liver, and heart is commonly to be observed, as in other specific fevers. Some swelling of Peyer's patches is also occasionally noticed. Symptomatology. — The invasion of pneumonia is generally sudden, and is usually marked by a distinct rigor. Often, however, the attack is preceded by a few days of what may be regarded as prodromal symptoms, malaise, bronchial catarrh, anaemia, coated tongue, and slightly icteric tint of 296 DISEASES OF THE LUNGS AND PLEURA skin. It is not uncommon for patients to have been out of sorts, depressed, dyspeptic, catarrhal, with torpid liver func- tions and loaded urine, for some weeks previous to an attack of pneumonia; but this is only another way of saying that they have been qualifying for an acute illness, the exact nature of which is determined by other circumstances, and which, by timely attention to the general health, might have been altogether avoided. In place of the rigor which ushers in pneumonia, there may be, especially in children, convulsions or vomiting. The tem- perature rises with great rapidity from the time of the rigor; severe headache, and even somewhat violent delirium, may be present; the eye is as a rule bright, conjunctivae sometimes icteric, face notably flushed, breathing hurried and regular, and attended with action of nares. The pulse is from the first always quickened in pneumonia, and especially so in young people, but not proportionately to the breathing. It must be recognised, however, that temperament and habitual pulse frequency have to be taken into account in estimating this symptom. There may be severe gastric disturbance, with slight jaundice, in the early days of the disease. Of local symptoms, pain and dyspnoea are those which chiefly attract attention. The general symptoms often precede the appearance of physical signs by a very perceptible interval of time, even five or six days, during which, on examining the chest, no dulness is to be found. The breath-sounds at one base have, how- ever, at a very early period a peculiar rough, harsh quality, very like that of exaggerated breathing. A few hours later the characteristic fine hair crepitation may be abundantly evident, whilst the percussion note, although shortened and heightened in pitch, is as yet by no means dull. In other cases the physical signs of complete consolidation may develope so rapidly as to render any previous stage un- noticeable. Description of a Case. — For convenience of description of the general aspect and physical signs of pneumonia, we will commence with the second or third day after the rigor, the time at which the practitioner is most commonly called upon to see such a case, and at which as a rule there is not much room for doubt as to its nature. PNEUMONIA 297 The flushed look and burning skin; the hurried, noiseless breathing; the rapid but regular pulse; the frequent short cough, half-stifled from pain; the dryish thickly coated tongue; and the singular prostration of the patient form a group of signs which, supervening speedily upon a well-marked fit of shivering, cannot be otherwise interpreted than as charac- teristic of an attack of ordinary acute basic pneumonia in full intensity. A crop of herpes will often be observed upon the lip. On closer examination the respirations are found to number about forty in the minute. They are not obstructed, but are usually attended with well-marked action of the nares. The pulse is 120, the temperature 104° (Fig. 30). On inspecting the chest, its movements are seen to be chiefly one-sided; but there is no apparent difference in size on the two sides, and the heart is found beating in its normal position. The movements of the affected side are voluntarily restrained by the patient, and a severe pain referred to this part often cuts short the cough or any attempt to draw a full breath. The percussion signs in front are not materially altered. On auscultation, the respiratory murmur is found to be weaker on the affected, exaggerated on the healthy side. Posteriorly over the base of the diseased lung the percussion note is dull, but not without some wooden quality of tone quite distinct from the dead flat note of effusion. The dulness extends upwards to a variable height, and over the dull portion the vocal fremitus is increased, the respiration is characteristically bronchial or tubular, the voice-sounds well conducted and bronchophonic, whilst the peculiarly explosive fine inspiratory crepitation of pneumonia is heard, especially towards the upper limits of dulness. If there be any expectoration, it is scanty, viscid, frothy, and more or less rust-coloured from blood-staining. It contains an excess of chlorides, and is deficient in phosphates. The urine is scanty and concentrated, and as in certain other febrile states, notably typhus and typhoid fever, is very deficient in chlorides, owing to their increased retention in the body.^* A similar condition has been noted in acute phthisis. In about half the cases the urine yields a thin cloud of albumin, and in a small percentage definite nephritis, with blood-casts, is observed. The blood shows peculiar changes. Its clotting power is 298 DISEASES OF THE LUNGS AND PLEim^ 1 I1 |3 28000 27 26000 25 24.000 23 22.000 21 20.000 18.000 17 16.000 15 14.000 13 12 000 11 10000 8.000 7 6 000 1 1 1 a> < m < { Z9 03 ' in E a 1- 0^- t^ 02 < |( < i 1 1 1 )> :.: S9 OE □ n.* -*■ 2 Q. pa f^ i N 91 n ozi i I « z < to H ^ V 91. oz ' fn a. CO ( 'I::: ■w tz < < 1 fe ■-■ C3 1-3 i 0. / / / "l^. ZL fZ ^ < - - / / v.. *8 VZ ^ / i 2 Q. 1 ./. . . - (>■ ZL frZ 9Z / t ■ r < !^ rf" 88 f > • J 2 a < CO /' ®^ . ta OS ^ / ~i / ^ T^ m / ■ - - J^ ■i^ vz ^ a < J f - 1 PZ 1 1 K zs / ^ !^ -^v- > 93 8Z / / . an 2 a s < / fl • — " - Ml ss ^ / .... ...^ / ^ Sll Z£ f J- 2 a < ; 4 < 311 8E / ^ f ^ i ' P?JP SJP.* frOI ZE V \ > ■CJ 2 0. 2 < V -^ r^ 26 Ot? ^ ^IPi ■!.0,^ ^- ' — 1 i [ '^ >• t-B 83 1? 1 1 ^ .i-;— * in CO 2 D. to __j>?;a., T ■ fjpP'Afif ariij Ell 8Z ^ ^ uir* 5?. ouoi:: ■ • 1 V 2 < A < -■■ "■^ ..... 96 *Z fl 3 \ fi^ - — ■ \ „.--^ 9E ? ■a. ps pe^ ■> ^-\ ■•|-q -^H ' — '••• .„.l-.... —f- fl ,..,,, . "f"^ ;■■" . :.i. . ■ •;- ■ ;- - -'- "•■'■"- ... ( - ..„i. — ■■■;-■■ '1 l\ r ■ * ■ 1 "JiZ A ■p\ ■■- ' 1 1 "-<■' '^ 1 ■ 1 .,., . .. j... ^.'.... ^ 1 5 1 101° ;!. '" f- \r .■..+'. ::t: '..]'..■ f ;:,;:;; :) :: r -A 1 T" --■■- -1- —4 :;■;: %" ^ • ;".: r EB ._'n. .. ..f ._. J ..- 99° Sermill , Mbodr 1 :\i / ... -■■ '-■t ::f: ....^.-.. .— i.-.- ...j_... '.'., ..L „.4.-. "■r-- ... ........ ""1"*"' "T" "" / ._ "" ..„i .- • ^ / ; 1 ; : 1 ''• . / ■ IS .._;._ -' ■ -^ ■ - 1- ■ ■ i ■ ^ T • 070. . "i— ...;.,, ,...,... ..,..| .. . ....|..... .._t . .... -!• ■—(■-- ... -r- ■i- ..i-_ — *.-; " ;•;• ■:t: "t 1 : ! Pulse —- i-- ^ ^ ; .,_; . .. ~ 1 •~ . " 1 .4... _ ...i-_- '.'Z'C .... ::::!:::; . ...| -- ....(..... "~X'.. - ..>. ... //z /2J /08 /Off 3& ^ sz so Fig. 31. — Chart showing the Temperature Record of M. L., aged Nineteen, who suffered from Septic Pneumonia. B=cool bath; Q = quinine (10 grains); * = salicylate of soda (20 grains every four hours). Post-Mortem : no lesions of typhoid fever were found. The upper lobe of the right lung was solid, except at its extreme apex and along the anterior edge. On section, the general appear- ance was that of red hepatisation, the central portions being of a lighter colour than the rest, and inclining to grey. Several dark wedge-shaped patches were also seen (recent haemorrhagic infarcts) in the neighbourhood of which the vessels were found thrombosed. Right middle lobe : soft and crepitant. Right loxver lobe : quite solid, in appearance resembling the upper, and containing also some infarcts. 304 DISEASES OF THE LUNGS AND PLEURA Left upper lobe : rather dark in colour, showing consolidation with considerable oedema and some infarcts. Left lower lobe: fairly crepitant, except for a patch of consolida- tion at its upper and one at its lower edge. Heart : ante- and post-mortem coagula in cavities of both sides. Muscular tissue firm. The diagnosis was in this case at first very uncertain, and even when pulmonary signs made their appearance they were of that scattered description not incompatible with their being a part of the manifestations of typhoid fever. The enlargement of the spleen, again, pointed in the same direction ; and, although there were, with one doubtful exception, no spots present, one or two relaxed pale motions were passed. At the date at which the case was observed neither the leucocytosis nor the agglutination test was known, but the extent of the pulmonary lesions led to the diagnosis of septic pneumonia, which proved correct. Migratory, Creeping, or Wandering Pneumonia. — This variety, which has been well described by the late Professor Dreschfeld," probably does not differ essentially from the septic variety, of which the case just related is an example. Here again we have a more insidious onset, a more fluctuating type of temperature, and an incomplete crisis or termination (when not fatal) by lysis. The physical signs show a consolida- tion involving successive contiguous portions of one lung, and then extending to the other in the same manner, or in other cases attacking different portions of the lungs. Bronchitis as a marked feature is absent. The illness is of an asthenic type, less sporadic, and more liable to attack families and groups of people under certain unhygienic conditions. Dr. Dreschfeld found in his fatal cases that sections of portions of the lung- more recently attacked teemed with encapsuled diplococci, some situated in the exudation within the alveoli, others occupying the interstitial tissues. Although more numerous than in ordinary pneumonia, they were not otherwise dis- tinctive. Latent Pneumonia. — Cases are sometimes met with in hospital and private practice, but mostly in the former, in which, with characteristic rise of temperature and symptoms suggestive of pneumonia, often including rusty sputum, there are yet from first to last no physical signs which would warrant a diagnosis of this disease. In such cases there is probably some deep central patch of consolidation. In other instances PNEUMONIA 305 the symptoms are but slightly marked, so far as they point to chest disease, and only at the autopsy is the pneumonia dis- covered. Cases of this type not uncommonly arise at the closet of malignant or surgical maladies. Influenzal Pneumonia. — This variety of the malady, with which, owing to the recent epidemics, we are now unhappily so familiar, is essentially of the nature of a broncho-pneu- monia, and will be considered in the succeeding chapter (see p. 331). Unusual Terminations of Pneumonia. — Although as a rule the consolidation of pneumonia clears up with fair uniformity in the inverse order of its formation, it certainly does not do so in all cases, and detached islets of resolving exudation some- times give rise to physical signs — largish clicks and circum- scribed blowing sounds — which it may be almost irnpossible to distinguish from those of pulmonary disintegration, A careful examination of the sputa for elastic tissue and tubercle bacilli is then essential. In other patients resolution may proceed very slowly, and the lung remains for some weeks, or even months, in a con- dition of consolidation. Such delayed resolution is most apt to occur in alcoholic subjects, and may eventually clear up. In many cases, however, the lung is left somewhat thickened and oedematous, giving rise to those permanent crepitations wdiich are heard over the base of one lung in certain elderly persons. In exceptional instances fibrosis of the lung tissue, leading later to bronchiectasis, takes place. Another termination of the pulmonary disease sometimes met with in pneumonia is diffuse suppuration, or purulent in- filtration, of the lung (see p. 295). The symptoms which attend this fatal change are of a typhoid type : the fever continues and shows a fluctuating range ; the tong'ue becomes dry, brown and tremulous; the prostration is marked and attended with muttering delirium; rig"ors, sweating, and sudamina may be present. The redux crepitations normal to the period of disease are replaced by coarse liquid rales; the respirations become increasingly rapid^ and attended with laryngeal rattle, and the pulse rapid and compressible. Death soon terminates the scene. Abscess or circumscribed suppuration of the lung is occasionally met with. The purulent collection is usually, 20 306 DISEASES OF THE LUNGS AND PLEURA although not necessarily, a small one ; the walls are generally- soft, and the surrounding lung tissue in a condition of dis- integration. In other cases several small foci of suppuration are present. The condition, like that of purulent infiltration, is generally due to secondary invasion of the lung by the pyogenic cocci, but may result from the unaided action of the pneumococcus. The symptoms attending the formation of an abscess are sometimes slight, but continued pyrexia and rigors, followed by sweatings, towards the latter period of the disease would suggest suppuration. But it not infrequently happens that the first sign which enables us to recognise this complication is the discharge of the abcess through the bronchus, and the sudden expectoration of a large quantity of pus, which may be very foetid and amongst which irregular fragments of lung tissue and elastic fibres are to be found. This having occurred, cavernous breath-sound and gurgling rales will be heard over a portion of the consolidation where the breath-sounds were perhaps before suppressed. Recovery from this complication may take place, but the outlook is always serious. For a further consideration of the subject we must refer the reader to Chapter XXII. Gangrene of the Lung is also a condition which from time to time presents itself in the later stages of pneumonia in cachectic subjects, and particularly in the intemperate. It is more frequently met with in apex pneumonia in the adult. The symptom which characterises the onset of gangrene is foetor of breath, and there may be no other sign of the complication, for the sphacelus need not be large, and until it has been evacuated no appreciable cavity may exist. The disintegration of the sphacelus is attended with darkened foetid sputa, which on microscopical examination will sometimes be found to contain fragments of lung tissue and elastic fibres, not, however, so frequently as might be anticipated, for reasons which we have already given (p. 73). Gangrene is a very grave complication, though not necessarily fatal. Implication of Other Organs.— In the majority of cases com- plications affecting other organs are produced, as we have seen, by the dissemination of the pneumococcus, which may reach its destination either by the lymph tracts, as in empyema, or through the blood, as in meningitis, endocarditis, or arthritis, PNEUMONIA 2>o7 In rare instances they are produced by the ordinary pyogenic organisms. If we examine the statistics from the various London hospitals, brought forward in the discussion upon " Pneumonia and its Comphcations" at the Royal Society of Medicine, introduced by Dr. Hector MacKenzie,^" we find that such complications are in reality uncommon. The incidence of the more important of them is shown in the following table, which we have compiled from the London statistics above referred to, and which relate to 7,394 cases of the disease, of which 1,592 cases died, giving a total death-rate of 2V^i. Table showing the Frequency and Mortality of the More Important Complications of Pneumonia, based upon the Recent Experience OF THE Chief London Hospitals. Complications. r Frequency of Occurrence among 7,394 Cases. Mortality among the 7,394 Cases. Actual. Per Cent. Actual. Per Cent, of Total Per> those affected. centage. Empyema 258 3-48 83 32-17 1-12 Pleurisy, with serous effusion 114 I '54 13 11-40 0-17 Pericarditis 243 3-28 172 70-78 2-32 Endocarditis 62 0-83 54 87-09 073 Meningitis 23 0-31 22 95 '65 0-29 Peritonitis 23 0-31 16 69-56 0-21 Gangrene of lung ... 31 o"4i 26 83-87 0-35 Abscess of lung 24 0*32 19 79-16 0-25 Arthritis 29 0-39 5 17-24 0-06 Otitis media 25 o"33 4 16-00 0-05 Venous thrombosis . . . 28 o'37 4 14-28 0-05 Colitis 14 o-i8 7 50-00 0-09 Parotitis 4 o'05 I 25-00 0-0 1 Peripheral neuritis ... 4 o'o5 I 25-00 o-oi Of the above complications pleurisy is a more or less essential concomitant of pneumonia. When pronounced, however, it forms a serious comphcation of the disease, the suffering which it entails adding greatly to the exhaustion of the patient. Moreover, in cases in which the pleura is so decidedly involved the temperature does not as a rule subside with the abruptness typical of pneumonia. In some cases an effusion forms, either of the sero-fibrinous or purulent variety. In the case of a serous effusion, which is less common, the liquid is as a rule soon reabsorbed. The purulent variety (empyema) is generally heralded by a secondary rise of 308 DISEASES OF THE LUNGS AND PLEURA temperature after the critical fall : the pus must be evacuated without delay, and if this be done, the prognosis in the majority of cases is favourable. Of the 258 cases in the above table, recovery took place in 175, or 68 per cent. Almost as often as empyema do we meet with pericarditis as a complication of pneumonia, and statistics show that it is a very serious one. The danger must not, however, be exaggerated, for the inflammation may be limited to a fibrinous patch, which is discovered unexpectedly by hearing the friction sound during the daily examination of the patient, and under suitable treatment the condition sometimes clears up quickly. If extensive, the complication is an index of a grave variety of pneumonia, and the case often terminates fatally. A purulent effusion, or pyopericardium, may develope. This dangerous complication, much more rare than the corre- sponding affection of the pleura, generally occurs somewhat late in the disease, and is not necessarily preceded by any friction sound, or accompanied by fever. Thus we have known it to arise after pneumonia in an abstemious and previously healthy man of twenty-four, and to" be indicated only by a gradually enlarging area of cardiac dulness and an increasing irregularity and feebleness of the pulse. The temperature, which in this case had fallen to normal on the fourteenth day, did not, during the development of the cardiac symptoms, rise above 99° up to the time of the patient's death, nineteen days later. Indeed, so slight were the signs and so gradual the increase in cardiac dulness, that the case was regarded during life as one of dilatation of the heart, and it was not until after death, when the pericardium was found to be full of pus, that the true nature of the lesion was revealed. Endocarditis of the mahgnant type is a rarer but more dangerous complication than pericarditis. In some cases it manifests itself by a return of fever some little time after the temperature has become normal, by sweatings, rigors, and- by the development of cardiac murmurs and symptoms; but more often the objective signs are obscure. It attacks chiefly the left side of the heart, and the aortic valves more frequently than the mitral, and is more apt to occur when an old endo- cardial lesion is present. Meningitis may occur either during the course of the pneu- PNEUMONIA 309 monia itself or very shortly after the crisis, when a secondary rise of temperature, with meningeal symptoms, indicates its presence. It is a rare complication, nearly always produced by the pneumococcus, and is speedily fatal. Among other complications sometimes met with, may be mentioned suppurative peritonitis, which is always of grave augury. Of more favourable outlook are arthritis^ which affects especially the knee and shoulder, and otitis media. Both are purulent in nature, and sometimes, but not always, the result of pneumococcic infection. Suppurative parotitis, on the other hand, is more often produced by the staphy- lococcus aureus. Venous thrombosis, colitis, and peripheral neuritis are com- plications also met with from time to time. Prognosis. — Each year more than 20,000 persons die in England and Wales from pneumonia, a mortality sufficiently great to place the disease in the front rank of those dangerous to life. Advanced age and alcoholism are the most important states unfavourable to recovery. Pre-existing chronic diseases, such as Bright's disease or diabetes, are likewise very un- favourable elements in prognosis. It is also a relatively fatal malady in those whose nervous systems have been exhausted by previous mental anxiety or overstrain. The severity of attacks varies much in individual cases, and in the pneumonias prevalent in different years. At St. Bar- tholomew's Hospital, in the ten years 1906 to 191 5, there were admitted 2,113 cases, with 255 deaths, a death-rate of 12 per cent., the mortality varying in the different years from 8-6 to 14-9 per cent. But above this percentage of fatal cases there is a highly fluctuating margin in which elevation or depres- sion of the death-rate is greatly dependent upon treatment. In each case the extent and character of the disease must be taken into account. It will be obvious that double pneumonia is much more serious than single. The prognosis is also more grave in the septic forms which we have described, but such cases differ greatly among themselves, and we have no statistics by which their mortality can be exactly compared with that of ordinary pneumonia. The danger in these cases arises more from the general state than from the extent of lung involved. In children pneumonia generally runs a favourable course, and the consoHdation melts away some- 3IO DISEASES OF THE LUNGS AND PLEURAE times with astonishing rapidity. Apex pneumonia is a some- what more dangerous variety than the basic form in that it is more prevalent amongst alcoholic and cachectic subjects. Herpes, especially on the lips, is a not uncommon accom- paniment of pneumonia. Geissler" observed it in 182, or 43-2 per cent., of his 421 cases, and showed that the mortality was considerably less among those in whom the complication occurred. This observation agrees with our own experience. A temperature above 105°, a pulse over 120, and respira- tions over 40, are significant of a serious case. Delirium is always a grave symptom, and in intemperate subjects delirium tremens is apt to occur, especially, perhaps, in the apical variety of the disease. A brick-dust rustiness of sputa is the usual degree of san- guineous tinge in the first days of the disease. A darker and more prune-juice colour is, however, sometimes observed in old people, and in them it is not necessarily of unfavourable augury. Decided haemoptysis is rare in pneumonia, and was regarded by Walshe as significant of tubercle. We have, however, seen several examples in which rather sharp haemopytsis has occurred, and in which the disease never- theless ran a favourable course, without any evidence of tuberculous infection. The absence of any colouration of sputa in otherwise well-marked pneumonia would lead us from experience to fear a tardy or incomplete convalescence. Treatment. — Before speaking of treatment, it is important again to observe that pneumonia varies greatly with regard to severity and type in different epidemics, and that the subjects are individuals varying, perhaps even more widely, in constitution and powers of resistance. Hence, while there may be a general plan of treatment best adapted to steer the patient through the dangers of this disease, there is room for much diversity in detail, and no one system of treatment can be accepted for all cases. Before all things it must be re- membered that the physician has to deal with a general disease, a specific infection, as well as with a local expression of that disease, the inflammatory condition in the lungs. The difiticulties and dangers which arise are grouped about the four consecutive periods of the malady — those of hyper- cEinia, consolidation, crisis, and resolution. Absolute confinement to bed in a good well-ventilated room PNEUMONIA 3 1 1 of moderate temperature, and the attendance of a careful, obedient nurse, are of the first importance in the treatment of all cases of pneumonia. I. Stage of Hypercemia.— In the first stage of the disease (a) shock, (b) pyrexia, (c) pulmonary congestion, and (d) pain are the indications which direct our treatment. The shock at the commencement of the disease, immedi- ately after the rigor, is often considerable, especially in old people and youngs children, although it is rarely so marked as in certain cases of acute bronchitis. Alcoholic stimulants may be needed at this period, but quietude in bed and nutri- tious soup are the best restoratives. A few doses of bromide with aromatic ammonia may be required. In this pyrexial stage of pneumonia the bowels should be well cleared by a few grains of calomel and a saline aperient, after which a mixture containing liquor ammonii acetatis and citrate of potash should be prescribed. In this way blood- pressure is relieved, and pulmonary congestion lessened by natural elimination from the skin, kidneys and bowels, instead of by emptying the arterial into the venous system, as is effected by drugs of the aconite class when given in sufficient doses. These latter remedies were fashionable twenty years ago, but as the favourable issue of the disease commonly turns upon the maintenance of heart power and vessel tonicity, and since both are lowered by aconite and its allies at the very outset — sometimes, indeed, beyond recall — their administra- tion cannot be recommended. The pyrexia of pneumonia is of brief duration, and, it must never be forgotten, is normal to the disease. If, therefore, the temperature, which should in all cases be carefully watched and recorded, does not mount above 104°, it requires no energetic interference at this stage. Sponging with tepid water, to which a little sal-volatile or Rimmel's toilet vinegar has been added, will slightly moderate it, and be comforting to the patient. Cool drinks and saline medicines will be similarly useful. In children, who can be lifted about with ease, the temperature may be kept under by the warm bath at 90° employed as often as may be necessary, with small doses of quinine. In adults this measure is in private practice more difficult and disturbing to carry out. It may be replaced by "cradling" — that is to say, lifting the sheet from off the "312 DISEASES OF THE LUNGS AND PLEURA patient on to a cradle placed over the bed, and, if necessary, suspending from its central rib india-rubber bags containing ice (" ice-cradling "). If the temperature reach 105°, a powder or cachet containing 2\ grains of quinine and 5 or 7 grains of aspirin, four or six times in the twenty-four hours, should be given to the adult. In some cases, where the pyrexia is high, and bearing in mind its real origin in bacterial toxaemia, quinine may be given per rectum in 5 or 10 grain doses in the form of suppository made with coca-butter, morning and evening, supplementai-y to or in replacement of that taken in the mixture. Should the temperature rapidly rise in spite of the remedial measures above suggested, the cold pack or the cool bath — • i.e., at 80° or 70° — must be employed. Ice-bags to the head are useful for adults in aid of antipyretic measures. The pain of pneumonia, which indicates the seat of lesion and aggravates dyspnoea, should be treated by local rather than general measures. Opium or the subcutaneous use of morphia may be necessary in exceptional cases, but they are not desirable means of combating this symptom. Hot poultices frequently renewed, due care being taken to apply them with as little disturbance of the patient as possible,* are, on the contrary, valuable remedies in relieving pain by lessen- ing vascular tension in the pleura. This they effect by dilating the superficial capillaries of the intercostal vessels concerned. Antiphlogistine is a convenient substitute for poultices, especi- ally where skilled nursing is not available, since an appHcation of the antiphlogistine paste, covered with a layer of warm cotton-wool, can be left applied for twelve hours without further disturbance of the patient, giving support and having a decided stimulating effect. When the pain is severe, from four to a dozen leeches may be employed with great relief, and it is sometimes well to encourage the bleeding by the immediate renewal of poultices or fomentations. The condi- tion of the patient, and especially the evidence of any venous plethora, as indicated by lividity, and hardness of pulse, will guide us with regard to the number of leeches. In country or colonial practice cases may very possibly be met with in which a venesection to eight or twelve ounces may be useful at the first onset of pneumonia. In cases of severe pain, * See direction under this heading in chapter on Bronchitis, p. i88. PNEUMONIA 373 where leeches are not desirable, a blister of three or four inches square, applied under the poultice, is often valuable. Cold applications are recommended by many physicians; we cannot say that we have been at all impressed with their utility, except in cases in which the fever is excessive or prolonged, when they are useful in relieving pain and reducing pyrexia. The diet of the patient must consist of nutritious fluids, milk, strong beef-tea, mutton or chicken broth, with perhaps some farinaceous thickening. The milk may be diluted with effervescing water or flavoured with tea or coffee. Cream is sometimes a useful addition to the dietary. The food and stimulants should be given at intervals of about two hom-s, and in reasonable quantities, adapted to the exigences of the case. It has occurred to us not infrequently to see a patient overdone with food, his circulation overloaded, and the abdomen distended from the daily ingestion of many pints of fluid, at a time when the respiratory functions are almost in abeyance, the right heart already embarrassed, and elimina- tion of unused material difficult. Four or five ounces of fluid food every two hours is usually ample for all requirements. As a rule stimulants are not needed in the treatment of this stage of pneumonia, but in cases of asthenic or typhoid type, with high fever, delirium, tremulous tongue, and rapid com- pressible pulse, they must be prescribed in sufficient and properly regulated doses, the alcohol being given alternately with a mixture containing carbonate of ammonia. The habits of the patient must be borne in mind in estimating the quantity of stimulant required. In cases of low type, in which the features of the disease remind one of idiopathic erysipelas, it may be good practice to place the patient at once on twenty- or thirty-minim doses of tincture of iron, with half-ounce doses of liquor ammonii acetatis, and this plan in alcoholic cases will sometimes answer without the aid of alcohol. To this prescription five minim doses of strychnia may often be added with advantage. 2. Stage of Consolidation. — The next period for treatment is that of consolidation of the lung. At this stage of the disease, from the fourth or the fifth day to the crisis, life is most usually threatened in severe cases by failure of the heart or hypersemia of the sound lung, not truly inflammatory {r\ 314 DISEASES OF THE LUNGS AND VLEITRM nature, but the result of heart failure and loss of vascular tone. It is sometimes now advisable to substitute for the salines ammonia and bark, in other cases iron with acetate of ammonia. Excessive pyrexial symptoms must be met as before. In severe cases stimulants are necessary, and they may often be usefully combined with quinine. Two- to five- grain doses of quinine should be given, so that the patient takes from ten to twenty grains in the twenty-four hours, and as much brandy or wine as his symptoms demand. If signs of failure of heart are observed, and often in antici- pation of such arising, small doses of digitalis (five to ten drops of the tincture) should be added, either to the stimulant or to the mixture. With regard to the usefulness of moderate doses of drugs of the digitalis class in this period of pneu- monia, whilst speaking from convincing experience of the fact, we would point out that their use is consistent with the most rational aim in the treatment of the disease. Salines, poultices, and leeches have the common object of lessening pulmonary congestion, easing arterial tension, and depleting the venous side of the circulation. Supporting foods and, when necessary, alcohol, quinine, and digitalis unite in main- taining heart power and tonicity of vessels at the period when these tend to fail. In cases at this stage in which the area of consolidation is large, and in which hypersemia and ensuing cedema of the sound lung are present, the patient is in danger from abolition of respiratory function, from failure of heart, and from ex- hausted nervous system. In such cases oxygen inhalations are indicated. These are given for two purposes — first, to sustain heart power; and, secondly, to maintain respiratory function. Oxygen acts in the first case by increasing the aeration of the blood circulating through the lung, of which freshly oxygenated blood the left ventricle receives the first supply through the coronary vessels. In this way heart nutrition is maintained, and removal of waste products from the cardiac muscle is promoted. For this primary purpose ox3rgen requires to be given early in the disease, on the first - suggestion of heart failure, and in doses of ten minutes* inhalation every hour or two hours. Thus administered, oxygen has the power of lessening cardio-respiratory and PNEUMONIA 315 nervous fatigue in a manner analogous to that observed by- Colonel Flack and others from its employment during and after aerial flights at great altitudes or of long duration, as w^ell as after great and prolonged athletic efforts." Under this treatment the pulse will often be found to diminish in frequency, to increase in force, and the patient will obtain snatches of refreshing sleep. If the symptoms are more urgent, the oxygen, as recommended by Dr. Willcox and Professor Collingwood,^^ may be made to pass through a wash-bottle containing absolute alcohol, a small portion of which, being carried over with the gas, is absorbed by the lung and conveyed directly to the heart. The stimulating effect of this procedure upon the pulse is sometimes very marked. For the second purpose, that of maintaining respi- ratory function over a crisis, oxygen is administered at a later period of the disease, and must then be given more or less continuously. Under such conditions of oxygen inhalations an opiate may in urgent cases be given to induce sleep, when otherwise its administration would be attended with grave danger. Strychnia, administered hypodermically or otherwise, is of great value in stimulating a failing heart. Caffeine and theo- bromine come next to it. These remedies act partly by in- creasing arterial tone, and so retaining a larger proportion of blood in the arterial system, including the territories of the nerve centres, and partly by their indirect stimulating action upon the cardiac muscle and nerves. In some cases in which the pulse is peculiarly soft and running, pituitary ex- tract has in our experience been used with advantage. For the threatened pulmonary failure above referred to we have found a combination of twenty-grain doses of confec- tion of turpentine with ether and ammonia very useful, strychnia, either alone or in combination with digitalis, being alternately given in the alcoholic stimulant. Should signs of dilatation of the right heart supervene, with marked cyanosis and failing pulse, venesection to ten or fifteen ounces may be practised. . At this period of the disease the patient is often unable to sleep, or is the subject of a busy delirium. Oxygen, as we have seen, may be beneficial in inducing sleep, and relief is sometimes given by an ice-bag resting hghtly on the head. 3l6 DISEASES OF THE LUNGS AND PLEURA or by a band of linen wrung out of ice-cold water and fastened round the forehead. Powerful hypnotics must on no account be ordered, but a mixture containing twenty grains of chlor- alamide and twenty grains of sodium bromide may be prescribed, or a drachm of paraldehyde, repeated, if necessary, in an hour. It must be remembered that these patients can in the zenith of their attack only obtain sleep in brief snatches, and the utmost care must be taken by the attendants to avoid the shghtest cause of interruption of such restorative in- terludes. It is a small detail to notice, but one by which much comfort may be given to the patient, especially at this stage, when the respiratory passages are dry, hot, and often sore — viz., to direct the nurse to anoint the aperture of the nostril with a little olive oil, which, by trickling into the passages, keeps them lubricated. Of much greater importance is a careful atten- tion to the hygiene of the mouth, which should be frequently rinsed, and the tongue and gums cleansed with some refresh- ing antiseptic lotion. We have little doubt that neglect of this precaution is responsible for some relapses of the disease from reinfection. At the stage of the disease now under consideration the symptoms and signs reach their acme, and the strength of the patient its ebb; the crisis is anxiously waited for, and is not tmattended with dangers of its own. 3. Period of Crisis. — The rapid fall of temperature that occurs when crisis is well marked in pneumonia, and the copious sweating or other phenomena attending it, are frequently associated with considerable shock and exhaus- tion. Failure of heart and pulmonary oedema are the special sources of danger. These must be met by carefully support- ing the patient, temporarily increasing the stimulants to any necessary amount, and by giving moderate (three-grain) doses of quinine in combination perhaps with small doses of digitalis. Sometimes strychnia is more useful than quinine at this period. Port-wine may often be substituted for brandy. The dangerous symptoms associated with crisis pass in a few hours, although sometimes for a day or two the tempera- ture remains subnormal. At the termination of crisis it is often wise to suspend medicinal treatment altogether for a time, regulating the diet to longer intervals; but until critical PNEUMONIA '317 discharges have ceased, no important alteration should be made. No active measures should be taken to arrest such discharg'es. 4, Resolution Stage. — During the early part at least of this fourth period of pneumonia (as we have artificially divided the phases of that disease) the same recuperative measures should be continued, strict rest in bed being still enjoined, the dietary being gradually improved, some soHds allowed, and the stimulants (if any used) cautiously curtailed, and changed to port-wine or malt-liquors. The condition of the tongue will be the guide on these points. The secretions from the kidney and bowel must be looked to, for it must be remembered that inflammatory products are being absorbed and eliminated. After a few days, simple quinine or quinine and iron tonics, or a little mineral acid twice daily, may be usefully employed. The resolution as a rule proceeds steadily and satisfactorily. In some cases, how- ever, as already pointed out, a secondary and recurrent rise of temperature, with slight chills and sweatings, attends the process. Quinine must then be steadily continued, or, if this drug disagree, arsenic may be tried, the patient being kept strictly at rest. After a consolidation has cleared up, it is not uncommon for there to be some return of crepitation over the seat of past pneumonia; this, which is doubtless due to local atonicity of vessels favouring a passive congestion, is best treated by the employment of tincture of iron internally. An analogous con- dition is not infrequently met with in acute nephritis, in the course of convalescence, which may lead to temporarily in- creased albuminuria without any associated rise of tempera- ture. Counter-irritants are occasionally useful in resolving pneu- monia, and two or three grains of iodide of potassium, in com- bination with citrate of iron and quinine, will sometimes hasten convalescence in indolent cases. Change of air is needed to complete convalescence, and in no disease is it more important that perfect recovery should be effected. The only conditions that need be specially ob- .. served wnth regard to such change are the avoidance of damp, low-lying, ill-drained localities, and the choice of places where the patient can obtain exercise on level ground. Some 3l8 DISEASES OF THE LUNGS AND PLEURA patients will recover best at the seaside; others, of a more nervous temperament, often do better inland. Sphacelus of the Lung. — In rare instances it happens that the expectoration in pneumonia becomes foetid or distinctly gangrenous. In sHght cases such antiseptics as formalin solution or eucalyptus may be inhaled, but there is no more potent disinfectant than strongly pushed oxygen inhalations. When the sloughing of the lung is extensive, and a gan- grenous cavity is formed, it will be necessary to call in surgical assistance (see p. 365). In puruleni infiltration of the lung we cannot do more than try to support the patient by bark and ammonia, wine and food. In circumscribed abscess we must endeavour to keep the abscess cavity as empty and disinfected as possible, by change of posture, and the use of disinfectant inhalations as for sphacelus, and at the same time to maintain the patient's strength. Surgical interference may again in these cases be necessary, but it should not be too hastily adopted, the abscess frequently contracting under ordinary treatment (see Chapter XXII. In the treatment of septic pneumonia, quinine, sometimes iron, and a liberal allowance of stimulants, are our most reliable remedies. Specific Treatment. — With the discovery of the diphtheritic serum and the recognition of its valuable curative properties it seemed reasonable to hope that a similar serum mig^ht prove of equal value in cases of pneumonia. Various antipneu- mococcic sera have accordingly been prepared, but though an encouraging case has been met with from time to time, the results obtained by their employment have on the whole been disappointing. The recent work of the Rockefeller Institute, to which we have alluded, and the success obtained by Dr. Men^yn Gordon in the treatment of cerebro-spinal fever have, however, opened a new and more hopeful vista. Dr. Gordon-' showed that the meningococcus, like the pneumococcus, could be differentiated by the agglutination test into four main groups or types, and that if in a given patient the type of meningococcus present was determined and the patient treated with the serum appro- priate to this type, so-called "monotypical serum," then the results were highly satisfactory, the mortality being reduced PNEUMONIA 319 from 60-70 to 12 per cent. As in the case, however, of the monotypical antipneumococcic serum to be mentioned later, the results have been better in Type I. cases than in those infected by other varieties of the meningococcus. Apparently the presence in the serum of sufificient anti-endotoxic capacity is an essential factor. Work on similar hues has been carried out at the Rockefeller Institute in the case of the pneumococcus with promising though less striking results. As we have seen (see p. 291), at least four types of pneumococcus have been differentiated in New York, and sera corresponding to Types I., II., and III. have been prepared. Of these, the sera produced by the injection into horses of Types II. and III. appear to be in- effective, but in regard to the serum of Type I. it is different. If patients suffering from pneumonia due to a pneumococcus of this strain are treated with the corresponding serum the mortality is much diminished. Of 107 cases thus treated eight only died, a mortality of 7-5 per cent, as contrasted with a death-rate of 25 per cent, before the serum treatment was introduced."-^ To be effective, the serum must be given intravenously and in large doses, so that a sufificient concentration of antibodies may be effected. An injection of 90 to 100 c.c. of serum, slowly administered, is recommended as soon as possible, this dose to be repeated every eight hours until a favourable result has been effected. On an average 250 c.c. of the serum are thus given.'"*' With these large doses symptoms of anaphylaxis'"'^' may manifest themselves, if the patient be highly sensitive to horse serum, and in every case before injecting the serum the sensibility of the patient should be tested by means of the intradermal skin test, and even if negative, a subcutaneous injection of ■;^ to i c.c. of the serum should be given, which is effective in producing desensitisation in patients who are but slightly hypersensitive. If the skin-test be positive, showing the patient to be highly sensitive, then the serum must be given every half hour, at first subcutaneously and then intravenously, in extremely small doses, commencing with 0-025 c.c, doubling the dose at each injection. Such a thorough desensitisation is a lengthy process, but it has only been found necessary in about 2 per cent, of the cases. Mild symptoms of serum sickness also manifest themselves 320 DISEASES OF THE LUNGS AND PLEURA in nearly half the patients treated with the serum, some one to two weeks after the injections, and in about lo per cent, the attacks are severe. It is possible that as more potent sera are produced, obviating the necessity for such large doses, these troublesome complications may become less frequent. It is obvious also that at the present phase of experience observations such as these could he carried out only under strict control and in hospital practice. We have said enough, however, to show that, based as it now is on scientific principles, the outlook in regard to the serum treatment of pneumonia is more favour- able than it was a few years ago, and that further develop- ments may confidently be expected. Following the lines advocated by Sir Almroth Wright, pneumocGccic vaccines have also been employed. The usual procedure has been to give in the adult an initial subcutaneous injection of from 20 to 30 millions of stock pneumococcic vaccine, and to follow this up by the use of an autogenous vaccine from the patient's sputum as soon as this can be pre- pared. We have employed such vaccines in many cases of pneumonia, but are not satisfied that we have seen any marked improvement follow their use. If cautiously given they appear to be without harmful effect. We have also tried sensitised vaccines — that is to say, vaccines (by preference autogenous) previously treated by being placed for some time in contact with antipneumococci serum, after the method of Besredka, and perhaps with more encouraging results. 25 REFERENCES. ^ " Memorandum on the Incidence of Fatal Pneumonia," by G. B. Longstaff, M.A., M.B. (Oxon), F.S.S. See The Collective Investigation Record, edited for the Collective Investigation Committee of the British Medical Association by Professor Humphry, M.D., F.R.S., and F. A. Mahomed, M.B., F.R.C.P., vol. ii., p. 102. London, 1884. ^ {a) See " Pneumonie Lobaire," par M. le Dr. Netter, Traite de Medecine publiee sous la direction de MM. Bouchard et Brissaud, deuxieme edition, tome vi., p. 487, 1901. [b) Lac. cit., p. 486. ^ " Remarks on Pneumonia," by Assistant-Surgeon Welch, Army Medical Department; Report for the year 1867, vol. ix., Appendix IX., p. 329. London, 1869. * Traumatic Pneumonia and Traumatic Tuberculosis, by F. Paxkes Weber, M.A.~ M.D., F.R.C.P. London, 1916. PNEUMONIA 321 * See " Epidemics of Pneumonia, British and Foreign " ^with Biblio- graphy), by Dr. Octavius Sturges and Dr. Sidney Coupland, in The Collective Investigation Record, vol. ii., pp. 5-26. London, 1884. ^ {a) " Analysis of the Returns. Note on the Etiology of Pneumonia," Collective Investigation Record, vol. ii., p. 60. London, 1884. See also (b) " Epidemic Pneumonia," British Medical Journal, 1912, vol. i., p. 1432. ^ (i) "An Epidemic of Pneumonia in the Punjab," by Surgeon-Major S. E. Maunsell, Collective Investigation Record, vol. ii., p. 77. London, 1884. (2) " Remarks on a Second Epidemic of Pneumonia occurring in the Punjab, Bengal, 1882-83," by Surgeon-Major S. E. Maunsell. Collective Investigation Record, vol. ii., p. 93. London, 1884. ' The Natural History and Relations of Pneumonia: Its Causes, Forms, and Treatment, by Octavius Sturges, M.D., and Sidney Coupland, M.D., second edition, p. 329. London, 1890. ' (i) Diseases of the Organs of Respiration, by Samuel West, M.D., second edition, vol. i., p. 253. London, 1909. (2) " Some of the Less Common Aspects of Pneumonia," by Sir Thomas Oliver, M.D., British Medical Journal, 1910, vol. i., p. 1033. " (a) " Acute Lobar Pneumonia : Prevention and Serum Treatment " (with Bibliography), by Oswald T. Avery, M.D., H. T. Chickering, M.D., Rufus Cole, M.D., and A. R. Dochez, M.D., Monographs of the Rockefeller Institute for Medical Research, No. 7, October 16, 1917, p. 93. New York, 1917. (d) Loc. cit., p. 7. (Z- ((f) Loc. cit., p. 90. (£) Loc. cit., p. 35. (/) Loc. cit., p. 79. {g) Loc. cit., p. 68. (h) Loc. cit., pp. 62-64. • " " Sur rfitiologie de la Pneumonic fibrineuse chez I'Homme," par M. N. Gamaleia, Annales de VInstitut Pasteur, 1888, vol. ii., p. 451. *2 "An Experimental Study of Prophylactic Inoculation against Pneu- mococcal Infection in the Rabbit and in Man," by F. S. Lister, M.R.C.S., L.R.C.P., The South African Institute for Medical Research (No. viii.), p. 6. Johannesburg, 1916. " " Note sur la Maladie nouvelle provoquee par la salive d'un enfant mort de la rage," par M. Pasteur, Bulletin de VAcadimie de Medecine, Paris, 1881, 2'"<> serie, tome x., p. 94. " See (i) " Observations on Metabolism in the Febrile State in Man," by G. C. Garratt, M.D., Transactions of the Royal Medical and Chirurgical Society, 1904, vol. Ixxxvii., p. 163. (2) " Chloride Metabolism in Pneumonia and Acute Fevers," by Robert Hutchison, M.D., Journal of Pathology and Bacteri- ology, 1898, vol. v., p. 406. " See " A Clinical Lecture on a Case of Acute Sthenic Pneumonia left without Treatment," by E. A. Parkes, M.D., The Medical Times and Gazette. London, i860, p. 184, 21 322 DISEASES OF THE LUNGS AND PLEURA ^8 " Contribuzione sulle polmoniti massicce," pel Dottor Luigi M. Petrone, Lo Sferimentale, Firenze, 1882, vol. 1., p. 449. " " Contributions to the Etiology of Continued Fever," by Charles Mur- chison, M.D., Transactions of the Royal Medical and Chirurgical Society, 1858, vol. Xli., p. 221. 18 " Pythogenic Pneumonia," by Thomas Wrigley Grimshaw, A.M., M.D., and John William Moore, M.D., The Dublin Journal oj Medical Science, 1875, vol. lix., p. 399. " "On Creeping Pneumonia (Pneumonia Migrans) and its Relation to Epidemic Pneumonia," by J. Dreschfeld, M.D., F.R.C.P., The Medical Chronicle. Manchester, 1885, vol. ii., p. 353. ^o " A Discussion on Pneumonia and its Complications," Proceedings of the Royal Society of Medicine (Medical Section), November and December, 1907, vol. i., Nos. 1 and 2. ^1 " IJber die prognostische Bedeutung des Herpes bei der Pneumonie," von Dr. H. Th. Geissler (zu Leipzig), Archiv der Heilkunde. Leipzig, 1861, Band ii., p. 115. 2" "Reports on the Physiological and Medical Aspects of Flying made to the Medical Research Committee," by Lieut. -Colonel Martin Flack, R.A.F., Nos. I and 4, February and November, 1918. 2' " The Therapeutic Use of Alcohol Vapour mixed with Oxygen," by W. H. Wilcox, M.D., F.R.C.P., and Professor B. J. Collingwood, M.D., British Medical Journal, 1910, vol. ii., p. 1408. '^ The S feci fie Treatment of Cerebrospinal Fever, with an Analysis of the Reforts on the First Ninety Cases treated with Monotyfical Sera, by T. G. M. Hine, M.D., with Introductory Note by M. H. Gordon, C.M.G., M.D., Medical Research Committee, London, January 28, 1919. ^^ See " Results Obtained with Sensitised Vaccine in a Series of Cases of Acute Bacterial Infection," by H. M. Gordon, M.D., Proceedings of the Royal Society of Medicine, 1913., vol. vi. (Therapeutical and Phar- macological Section), pp. 153-176. CHAPTER XVIII BRONCHO-PNEUMONIA Broncho-pneumonia, or lobular inflammation of the lung, affects certain lobules of the organ and their associated bron- chioles. The inflammatory lesion is not, however, always strictly confined to separate lobules or groups of lobules, for in some cases more diffused areas of lung become affected, until, perhaps, a whole lobe may be involved. .ffitiology. — Broncho-pneumonia may occur as a primary disease, apart from any pre-existing bronchitis or other antece- dent condition, and as such is most frequently met with in infancy and early childhood. This variety, to which the late Dr. Samuel West^ drew attention, is less common than the secondary form, and in its clinical features resembles closely the lobar pneumonia of the adult, and like the latter would appear to be produced by the pneumococcus. Secondary hroncho-pneufnonia, whether consequent upon simple bronchitis, measles, whooping-cough or diphtheria, is also most commonly observed in infancy and early childhood, and occurs especially among the badly-nourished children of the poor. As a disease secondary to influenza, phthisis, tracheotomy, pyaemia and allied conditions, it may occur at any age. In the great majority of cases the malady is produced by the inhalation of septic material of varied nature into the finest bronchi and alveoli. In those cases in which bronchitis is already present, the inflammation of the alveoli may be attrib- uted to extension, or to the aspiration of infected secretions from the bronchi backwards, or their projection into the alveoli during deep respiratory or tussive efforts. In phthisis the aspiration of blood or sputum in the course of expectoration frequently sets up in a similar manner new centres of lobular inflammation and infection. After trache- 323 324 DISEASES OF THE LUNGS AND PLEURA otomy also, when the mechanism of cough and expectoration is impaired through defect in the glottis, altered blood, puru- lent secretions and septic matters are easily inhaled into the lungs, and give rise to lobular pneumonia. Closely connected with the preceding is the so-called " deglutition pneumonia." In this variety, either during coma or from paralysis of the larynx, food and secretions from the mouth, or even the stomach, pass the glottis, and, failing to excite the usual expiratory efforts, reach the finest bronchi, and thus produce broncho-pneumonia. The pneumonia which sometimes follows surgical operations has no doubt, in part at least, a similar explanation, since it has been shown that during anassthesia mucus and saliva may be inhaled into the air- passages, but the nature of the anaesthetic, the skill with which it is administered, and the disturbance of respiratory movements, also play a part.^ Broncho-pneumonia of a septic type may follow the inhala- tion of the virulent gases now used in warfare. This is especially apt to occur in the case of mustard gas — dichlor- ethyl-sulphide, (C2H4C1)2S, the vapour leading first to a destruc- tion and sloughing of the mucous membrane of the trachea, bronchi and bronchioles, and then to a secondary invasion of organisms from the sloughing surfaces, producing broncho- pneumonia and sometimes death. Analogous to this are the cases in civil life in which catarrhal pneumonia has followed exposure to acrid vapours, such as the pungent smoke from a burning building. Septic organisms may reach the alveoli through the blood, as in pysemia, septicaemia, and in certain forms of tuberculosis. In such cases the lesions affect vascular rather than bronchial areas. Bacteriology. — With the possible exception of the rare cases which follow the inhalation of pungent vapours, broncho- pneumonia, however arising, is always produced by the action of micro-organisms. No one organism, however, is always at fault, but under different circumstances now one and now another may produce it. From the observations of Dr. Wollstein^ it would appear that primary broncho-pneumonia, like lobar pneumonia in the adult, is to be attributed to the action of the pneumococcus. Broncho-pneumonia secondary to bronchitis is traceable to a BRONCHO-PNEUMONIA 325 variety of organisms often acting in conjunction, among which the pneumococcns and the streptococcus pyogenes figure most prominently, and less frequently the staphylococcus pyogenes aureus and albus, the micrococcus catarrhalis, the influenza bacillus, and other organisms, as shown by Dr. Eyre's* extended observations. With regard to the broncho-pneu- monias which occur in the course of specific fevers, we have pointed out elsewhere^ that the inflammation may be produced by the specific micro-organism of the disease (homologous infection) or by a mixed specific and pyococcal infection (mixed infection); in rarer cases it results from the action of the pyogenic cocci or other organisms only (heterologous infection). The following bacterial classification of broncho-pneumonia, based upon that which we ventured to offer some years ago, at the suggestion of the late Professor Kanthack, illustrates these points :^ The Bacteriology of Acute Broncho-Pneumonia. I. — Primary — ^produced by the pneumococcus. II. — Secondary : Pneumococcus Streptococcus pyogenes Staphylococcus aureus and albus Bacillus influenzse Micrococcus catarrhalis Micrococcus tetragenus Bacillus of Friedlander, etc. 2. Occurring in the Course of Various Specific Infections, such as Diphtheria, Influenza, Pertussis, Measles, Scarlet Fever, Typhoid Fever, Tuberculosis, and Plague. (a) Homologous — produced by the specific organism of the disease. (&) Mixed infection — specific and pyococcal. (c) Heterologous — produced by secondary pyococcal infection. Morbid Anatomy. — The bronchi are always more or less in- flamed, and in the secondary form, with which we are chiefly concerned, are filled with thick muco-purulent secretion. As the inflammation extends, portions of collapse are found in various parts of the lung, in others patches of inflammation; but the collapsed portions themselves are often attacked with pneumonia. The pneumonic patch feels like a hard nodule in the substance of the lung. If of small size, it will be seen on section to be more or less conical in shape, with the base I. To Bronchitis — - The infection is often a mixed one. 326 DISEASES OF THE LUNGS AND PLEURA towards the periphery of the lung and projecting above the surrounding surface, thus distinguishing it from a patch of collapse. If of larger size, the pleura over it is often involved. The portion of lung affected is dark red in the earliest stages, and then gradually assumes a greyish colour. The cut surface is soft, breaks more easily than the normal lung, and is finely granular. On squeezing it a reddish juice exudes, with perhaps a drop of purulent secretion from the central bronchus. Adjoining patches tend to coalesce, and thus the greater portion, and indeed the whole, of one lobe may become affected, forming the confluent or "pseudo-lobar " variety of the disease. In cases of septic origin, such as may occur after Fig. 32. — Section of Lung : Broncho-Pneumonia. operations on the mouth and tongue, small abscesses, from central softening of the patches, are often found, surrounded by consolidated lung. The microscopical appearances in a case of broncho-pneu- monia differ somewhat, according to the acuteness of the process and the nature of the irritant. In an acute case, in its earliest stage, the appearances will closely resemble those of acute lobar pneumonia; indeed, as the late Professor Kanthack first insisted, it is anatomically incorrect to draw any hard-and- fast distinction between them. Thus many of the alveoli will be found to contain red and white blood-corpuscles, and not uncommonly a fibrin network, whilst the epithelium lining the alveoli is swollen and granular. At a later stage, or in less acute cases, with which, perhaps, we are more familiar BRONCHO-PNEUMONIA 327 (Fig. 32), numerous desquamated and swollen epithelial cells, mingled with leucocytes, are found occupying the alveoli, but fibrin and red corpuscles are not visible. Later, as resolution proceeds, the cells undergo fatty degeneration, and the products are removed, partly by absorption and partly by expectoration. Symptomatology. — Cases of primary broncho-pneumonia occurring" in young children run a course very similar to that of lobar pneumonia. The disease sets in suddenly, perhaps with a convulsion ; the temperature remains high, and falls by crisis on about the seventh day, after which the child rapidly recovers. The signs of bronchitis are less marked than in the secondary variety, and physical examination reveals small scattered areas of consolidation. The disease would appear, in . fact, to be a pneumococcic inflammation of the lung analogous to the lobar disease in the adult, but which in the child takes on a lobular form. In describing the clinical features of secondary broncho- pneumonia, under which are included the majority of cases seen, we shall have in our mind especially cases of infantile type, such as those arising in association with bronchitis or whooping-cough. Clinically, two forms of this disease are met with, the disseminated and the confluent. I. The Disseminated Form. — In this variety the symptoms are those of capillary bronchitis, which invariably coexists. In young children the distinction between the two diseases is often impossible, and is practically of but little importance. When the disease supervenes, however, upon a less urgent bronchitis, its access is marked by a rise of temperature, an increased dyspnixa, and a greater rapidity of pulse. Shivering is rarely to be noted in young children, and its analogue, convulsion, is, so far as our experience goes, uncommon in this form of pneumonia. The rise of temperature is generally above 102°, but although the range or average of temperature is above that of bronchitis, it is less maintained and more fluctuating in character than in croupous pneumonia. The dyspnoea, at first urgent, with flushed face and working alae nasi, and with a characteristic " expiratory giimt," becomes less apparent as the strength of the little patient fails and his nervous centres become less sensitive in the struggle. Pallor of countenance 328 DISEASES OF THE LUNGS AND PLEURA with perhaps a faint tinge of Hvidity appears, and the skin becomes moist and even perspiring. The rapidity of breathing continues, however, or increases, and on uncovering the chest and abdomen, recession of soft parts with inspiration is observed. The pnlse becomes more frequent and of lessened force. The tongue is from the first thickly coated, the lips dry, the urine scanty and depositing lithates, and the bowels dis- ordered, constipated, or, it may be, relaxed. The physical signs of this disseminated form of the disease are not very characteristic. The percussion note is either un- altered or is somewhat raised and of semi-tympanitic quality. Auscultation reveals fine sub-crepitant or small bubbling rales scattered over both lungs, most abundant at the posterior bases. Over other parts of the lungs a patchy distribution of the rales may sometimes be recognised, and is then of value in diagnosis. The rales are persistent, not being appreciably cleared by cough, and are often better heard immediately after cough. ' The breath-sounds are notably enfeebled and masked. Patches of tubular breathing may sometimes be discovered. Should recovery take place, the pyrexia, which often lasts two to three weeks or longer, gradually subsides with con- siderable fluctuations, the physical signs clear up, the tongue cleans, appetite returns, but strength is only slowly recovered. This form of broncho-pneumonia is, however, of a grave character, often proving fatal, and in all cases leaving behind pulmonary delicacy. Indeed, the disease may be said rarely to occur in children who are of good stock and in good previous health. 2. The Confluent Form. — This form of the disease, some- times also spoken of as " pseudo-lobar," does not essentially differ in its pathology from the preceding, but the adjacent lobules of a large portion of lung, sometimes involving the whole lobe, are affected, thus producing more or less dense consolidation. This variety may be associated with ordinary bronchitis of catarrhal origin, and often occurs in the course of whooping-cough. We have also met with it in certain cases of heart disease, and as a compHcation in pulmonary tuber- culosis. The symptoms of the disease are identical with those of the preceding variety, except t-hat pleuritic pain is more commonly experienced on the side attacked. The physical signs are BRONCHO-PNEUMONIA 329 somewhat different. The pulse and respirations are similarly quickened, and the signs of obstructed inspiration are observed, but not symmetrically, the expansion on the affected side being, in cases in which the disease is at all extensive, notably diminished. Most commonly the posterior and lower portion of one lung is affected, and over this region the per- cussion note is distinctly impaired, in the earlier stages having a somewhat skodaic quality, but as the lobules coalesce becoming more toneless. Vocal fremitus in young children is of no value, and children who are seriously ill with broncho- pneumonia rarely cry; but if produced under auscultation, the cry is bronchophonic in character, with a tendency towards segophony. The breath-sound over the consolidated area is weak and bronchial, being considerably masked by abundant sub-crepitant rales of sharply-defined or metallic character. The disease may affect both sides, but as a rule the opposite lung is affected with bronchitis only, or it may be with a few centres of disseminated pneumonia. The temperature and other phenomena in this form of the disease are the same as in the preceding. There is a greater tendency for this variety of broncho- pneumonia to become chronic, and to run a long course of perhaps many months, terminating in pulmonary fibrosis with bronchiectasis or in pulmonary tuberculosis. The mere extent of the disease in the early stage may, however, prove fatal; in other instances it proceeds to suppurative destruction of lung and to the death of the patient. The signs of suppuration are increased prostration, adynamia, maintained rapidity of pulse, fluctuating temperature, and hectic sweatings, with rapid loss of flesh. The rales become larger, more bubbling, even gurgling, in character; and although children rarely expec- torate, it is obvious that much secretion comes up to the throat, and irritative diarrhoea with slimy stools frequently supervenes as the result of it being swallowed. Treatment. — The treatment of broncho-pneumonia is mainly that of bronchitis. In the disseminated form of the disease it is doubtful if poultices are of any service, and it is most im- portant that the respiratory movements be allowed as free play as possible. In the more localised confluent form poulticing is sometimes useful. The timely use of emetics in whooping- cough will sometimes avert the occurrence of broncho-pneu- 336 DISEASES OF THE LUNGS AND PLEURA monia, but it must be allowed that the disease is often started by the imprudent exposure of children with whooping-cough to cold winds under the delusion that in this disease such exposure is harmless or beneficial. A careful nurse or mother who understands how to hold a child during the paroxysms of whooping-cough, so as to permit the fullest play to the respiratory muscles, may help much in averting pulmonary collapse and subsequent pneumonia. The room should be kept at a temperature between 62° and 65°, the air moistened, and in some cases the addition of a little tar water or the compound tincture of benzoin to the bronchitis kettle is useful. The temperature of the patient, if high, can be kept within bounds by the occasional use of the warm bath (90" to 95°), and the head may be sponged with water, cooler than this, but not cold. The secretions must be kept clear, the patient well supported by milk, cream, and properly-made beef-tea,* and when stimulants seem requisite, they should be liberally given. In all septic cases stimulants are required. Port-wine is an excellent stimulant, and may be combined with a few minims of the tincture of bark or with small doses of quinine, or brandy may be added to the milk or broth. Careful support of the patient and good nursing are of the utmost importance in these cases. In regard to drugs, ammonia and ipecacuanha are useful in loosening expectoration, when this indication exists. In cases, on the other hand, in which bronchial secretion is overabundant and the breathing thereby embarrassed, tincture of belladonna in two-minim doses every three or four hours is sometimes distinctly helpful. In cases associated with whoop- ing-cough the spasmodic symptoms are also relieved by bella- donna, and with such patients a few minims of the Syr. Allii Aceticus (U.S.P.) may be added to the mixture, garlic'^ being a remedy of old standing in whooping-cough. In the convalescent stage of the disease the practitioner must bear in mind its common association with rickets and a * Beef-tea may be made as follows : Place i pound of lean meat, cut up small and sprinkled with salt, in a deep dish or pudding-basin. Cover with I pint of cold water, and leave a couple of hours near the fire. After straining it will be ready for use. The liquid must not be boiled, or the albumin will be precipitated, and the nourishing properties of the beef-tea greatly impaired. BRONCHO-PNEUMONIA 33 1 delicate family history, also the frequency with which remnants of disease are left behind in the lungs or bronchial glands. Cod-liver oil with steel-wine containing a few minims of syrup of the iodide of iron are now valuable, and a change of air, to a warm seaside place if possible, is very important. Influenzal Pneumonia. Before concluding this chapter we must make a more detailed reference to the pneumonia which is so frequent and serious a complication of influenza. In all epidemics it will be observed that a large proportion of the cases are complicated by bronchial catarrh, sometimes of the purulent type (see p. i86), or even a broncho-alveolar catarrh, of which the peculiar explosive inspiratory crepitation over one or both bases or scattered patchily over the lungs is the most characteristic sign. This may clear ofi, but in many instances it passes into the more grave condition of pneumonia. In influenza, as we have seen, this is of the catarrhal type, and the areas of con- soHdation, which in some cases are small, in others large and confluent, are set in a lung which is deeply congested, the seat of scattered haemorrhages, relatively airless, and exuding blood-stained fluid on section. This condition of hsemorrhagic cedema is the most striking pulmonary lesion of severe influenza, and may, as Sir John Rose Bradford'' suggests, be its essential pulmonary manifestation, following the invasion of the body by the influenza virus, possibly the filter-passing organism which he, in conjunction with Drs. Bashford and Wilson, has described. The pneumonia which follows would, on this view% be a complication due to a secondary infection by streptococci, pneumococci and Pfeiffer's bacillus of in- fluenza, acting upon a lung already damaged by the primary disease. We must add, however, that the bacteriology of the disease still remains obscure. In the recent epidemic of influenza Drs. Abrahams, Norman Hallows, and Herbert French,* estimated that pulmonary complications were present in 20 per cent, of their cases, in 8 per cent, of which the complications were of sHght or medium severity, and in 12 per cent, of a serious nature, one-half to two-thirds of the latter proving fatal. Influenzal pneumonia is always associated with an asthenic general condition; nor is this to be wondered at if we accept 332 DISEASES OF THE LUNGS AND PLEUR.E the observations of Dr. Wilson'' that the filter-passing virus is present in the blood from the early stages of the disease. In other cases a streptococcic septicaemia is present; less fre- quently the pneumococcus or Pfeiffer's bacillus is discoverable in the blood. This general septicaemia more frequently over- whelms the patient in the earlier stages than in ordinary pneumonia, and exercises, throughout its course, a baneful adynamic influence. The local processes, moreover, tend more frequently to pass on in severe cases to suppurative destruction of the lung. The temperature chart, as a rule, is wanting in the features characteristic of ordinary pneumonia, assuming more of the septic type. Drs. Abrahams, Norman Hallows, and Herbert French, have also noted and beautifully illustrated the peculiar lividity which they characterise as " heliotrope cyanosis," and the droop of the eyelids observed in the most grave examples of the disease, significant of the serious blood changes and the grave nervous prostration which are present. Neither dyspnoea nor undue rapidity of pulse have been marked features of the malady, but haemoptysis, varying from a streaking of the sputum to several ounces of pure blood, has been of frequent occurrence, and is no doubt to be explained by the congested and oedematous condition of the lung to which we have referred. Epistaxis has also been common, as also some degree of nephritis, marked by albuminuria and the presence of epithelial cells and tube casts in the urine, but without oedema. The physical signs in the lungs vary with the severity of the disease and the extent of the consolidation, and are not characteristic. Such are the more important features of influenzal pneumonia, which will be sufficiently in the recollection of our readers. The perfectly honest frankness with which Drs. Abrahams, Norman Hallows, and Herbert French confess the inade- quacy of all measures to save the really desperate cases of influenzal pneumonia must not be reg"arded by the practitioner as a counsel of despair, and should not discourage treatment. When all is admitted, it is but to confess that influenza is a serious disease, that in grave epidemics it has a mortality of from 6 to 8 per cent., and that this mortality is principally yielded out of the 20 per cent, of cases with definite lung complications. The point in treatment is to endeavour to BRONCHO-PNEUMONIA 333 prevent cases from arriving at this desperate pass, although admittedly the endeavour is sometimes fruitless. The general lines of treatment for severe cases of pneu- monia, as set forth in this and the preceding chapter, hold good, but in the light of the special gravity underlying general infection and the undoubted contagiousness of this form of pneumonia, the following supplementary measures of treat- ment will be found useful ; 1. Measures of Protection and Precaution against In- fection. — The patient's room should be thoroughly ventilated, properly cleansed and kept free from dust, and maintained at a temperature of 55° to 60°. Nursing attendants should wear masks of a double fold of butter-muslin with a thin layer of alembroth wool inserted across mouth and nose. The patient's mouth should be kept cleansed by the use of a mouth-wash several times a day, consisting of permanganate of potash, I in 4,000; or tincture of iodine, 3i- to the pint; or solution of peroxide of hydrogen, 20 vol., a teaspoonful to the half tumbler; or the compound glycerine of thymol of the Pharmaceutical codex, diluted with four or five parts of water. In the case of patients too weak to rinse the mouth, the gums and tongue should be brushed over with the solution by means of a camel's-hair brush, scalded after each such use. Nurses and attendants should use similar mouth-washes and gargles as a preventive. The sputum must be received in a vessel containing a dis- infectant. 2. To combat excessive pyrexia and septicaemic incidents from 5 to 10 grains of quinine should be administered in a cocoa-butter suppository morning and evening. If the patient should be very restless, or the suppositories be rejected, ^ grain of opium may be administered with one or both the suppositories. Tepid- or hot-water sponging with eau-de- Cologne should be employed, and supplementary to this such antipyretics as aspirin 7 to 10 grains in combination with anti- pyrine, 2 grains, may be given from tim_e to time as required. In some cases it is wise to prescribe considerable doses of perchloride of iron, as recommended in septic pneumonia (PP- 302, 313). 334 DISEASES OF THE LUNGS AND PLEURA Stimulants should be freely used, a tablespoonful of brandy every three, four, or six hours as indicated. Nourishing liquid foods should be given at intervals of two to three hours, the stimulant being mixed with the food when convenient. Tea and coffee should be allowed and cool drinks at pleasure. The primae viae should be cleared, and a simple lavement used from time to time to cleanse the rectum when rectal medication is being employed. Probably a neutral saline lavement is the best. The use of oxygen is to be recommended as an auxiliary, in cases especially where the heart is disposed to fail, and sometimes in combination with subcutaneous doses of strychnia. REFERENCES. ^ Diseases of the Organs of Resfiration, by Samuel West, M.D., second edition, vol. i., p. 349. London, 1909. - " Post-Operative Lung Complications," by William Pasteur, M.D., F.R.C.P., Transactions of the Medical Society of London, vol. xxxiv., i9"> P- 379- ^ (i) " The Bacteriology of Broncho- and Lobular Pneumonia in Infancy," by Martha Wollstein, M.D., The Journal of Exferimental Medicine, New York, 1901-1905 ; vol. vi., p. 391. See also (2) The Diseases of Infancy and Childhood, by L. Emmett Holt, M.D., fourth edition, p. 532. London, 1907. * " The Bacteriology of Acute Lobular Pneumonia and Broncho- Pneumonia," by J. Eyre, M.D., Allbutt and RoUeston's System of Medicine, vol. v., p. 175. London, 1909. ' " On the Bacteriology of Acute Broncho-Pneumonia," by P. Horton- Smith (Hartley), M.D., St. Bartholomew's Hospital Reports, 1897, vol. xxxiii., p. 25. ° See " Garlic in 'Whooping-Cough," by T. Mark Hovell, British Medical Journal, 1916, vol. ii., p. 15. See also ibid., p. 692. ' " The Filter-Passing Virus of Influenza," by John Rose Bradford, E. F. Bashford, and J. A. Wilson, with an Appendix of Clinical Notes by F. Claj^on, the Quarterly Journal of Medicine, vol. 12, No. 47, April, 1919. P- 259- ^ " A Further Investigation into Influenzo-Pneumococcal and Influenzo- Streptococcal Septicaemia, Epidemic Influenzal ' Pneumonia ' of Highly Fatal Type, and its Relation to ' Purulent Bronchitis,' " by Adolphe Abrahams, M.D., Norman Hallows, M.D., D.P.H., and Herbert French, M.D., F.R.C.P., The Lancet, 1919, vol. i., p. i. CHAPTER XIX CHRONIC INTERSTITIAL PNEUMONIA OR CIRRHOSIS OF THE LUNG— PNEUMOKONIOSIS Interstitial pneumonia is but rarely a primary disease. The connective tissue with which the lung is penetrated and clothed, which sheathes and supports its vessels and bronchi and which holds together its lobules, necessarily takes part in the parenchymatous, bronchial, and pleuritic affections of the organ; and interstitial pneumonia with but few exceptions is only met with as a consequence of bronchitis, pleurisy, or pulmonary inflammation, whether tuberculous or otherwise, and does not encroach seriously beyond the limits of the original malady. In a small number of cases it has its origin from the deposition in the lung of particles of irritating dust — a variety of the disease to which the name "pneumokoniosis" has been applied. Chronic interstitial pneumonia is, perhaps, best seen in con- nection with bronchiectasis or in cases of fibroid phthisis, but is not infrequently a sequel of broncho-pneumonia, much more rarely of true lobar pneumonia. As a rule a considerable area of lung is involved, it may be the whole of one lower lobe, and sometimes also the upper lobe. In other cases, as, for example, certain of those arising from the inhalation of irritating particles, the areas of cirrhosis may be circumscribed, smaller, and scattered throughout the lungs. The morbid changes met with in pulmonary cirrhosis are fairly uniform in all cases, and consist of condensation and collapse of the alveoli of the lung, through invasive over- growth of its connective tissue, (a) spreading in branching tracts from the thickened sheaths of the bronchi or vessels towards the periphery of the lung; (b) extending inwards along the lobular interstices from the thickened subpleural connective tissue; or (c) radiating from the scar-tissue about 335 336 DISEASES OF THE LUNGS AND PLEURA some centre or centres of retrogressive pulmonary lesion. In the more rare cases in which the affection follows acute lobar pneumonia resolution has failed to occur, and gradually the affected area becomes converted into a dense fibrous mass. Microscopically it is found that enormous multiplication of the nuclei proper to the connective tissue, with a variable degree of extravasation of leucocytes, constitutes the first stage. This is followed by the conversion of the nuclear tissue into fibres (Fig. 33), at first spindle-shaped, and with nuclei still staining deeply with carmine. These nucleated fibres gradually elongate and interlace with one another to form Fig. 33. — Section of Lung : Chronic Interstitial Pneumonia; Nuclear Proliferation passing into Fibrous Tissue. fibrous tracts or bands in which the original nuclei become more scarce, and no longer take the stain well. New vessels are formed, but in no great abundance. The tissue at first, in the cellular stages, comparatively soft and pink-looking, becomes gradually more dense, opaque, pale and dry, whilst at the same time specks of pigment are deposited, giving an ash-grey hue to the whole. The various stages of connective- tissue proliferation, resulting in dense fibrous tissue, can best be observed in pleuritic thickening. Alcoholism and syphilis, and especially alcoholism, are the conditions peculiarly conducive to the occurrence of fibroid CHRONIC iNTERSTITIAL PNEUMONIA 33/ changes in the lung", whenever such changes are favoured by the occurrence of inflammatory or congestive attacks. The clinical features of fibroid disease of the hmg are necessarily somewhat varied. Condensation of lung texture, impairment of pulmonary function, and contraction phe- nomena are, however, essential factors in the clinical present- ment of pulmonary fibrosis, no matter whether the lesion be seated at the apex or base or in the central portions of the lung, though they may be at times somewhat masked by the presence of compensatory emphysema. Dulness and retraction, with diminished mobility of the part affected, are therefore invariable features. Flattening of the chest walls, raising of the diaphragm, and drawing of the mediastinum towards the affected side, are to be observed in varying degree in different cases. The breath-sounds are enfeebled, and their vesicular character spoiled or altogether wanting. Vocal fremitus is always diminished, and in those cases in which the extension is chiefly from the pleura it is more or less completely annulled. The contractile changes, which always ensue upon pulmonary fibrosis, produce more or less widening of the bronchial tubes, especially in those cases in which the process has extended either from the periphery, or starting from the centre has reached the periphery. In some cases these tubes are so enlarged and bulbous as to constitute bronchiectatic cavities appreciable to auscultation. The symptoms are mostly of a negative kind — breathless- ness, to some extent due to deprivation of lung; disturbed heart's action, from the right ventricle being burdened by the increased resistance to the circulation through the contracted lung; and cough, variable in degree according to the presence or absence of bronchitis, paroxysmal in character, and often terminating in vomiting, these features being due to the mechanical difficulty of clearing mucus from widened tubes set in rigid inelastic lung, with no air-containing lobules beyond them. Besides these general characteristics it may be said that, both as regards symptoms and physical signs, the fibroid lung gives but a modification to the clinical features of those diseases, such as chronic bronchitis, pleuritis, pneu- monia, bronchiectasis, etc., of which it may form a part, and to some one of which it is generally to be ascribed. 22 338 DISEASES OF THE LUNGS AND PLEURAE In diagnosis the fibroid lung is to be differentiated from more active lesions, but, except in the case of local empyema, difficulty seldom arises, and here it can, as a rule, be cleared up by exploratory puncture. It sometimes, but rarely, happens that a bronchus becomes entangled in the contractile fibroid lesion, giving rise to signs and symptoms suggestive of aneurism or malignant disease compressing the tubes. Pneumokoniosis. Before leaving the subject of chronic interstitial pneumonia, that somewhat rare variety must be referred to which results from the inhalation of certain forms of irritating dust, and to which the name " pneumo- or pneumonokoniosis " has been appHed.^ When speaking of bronchitis, we saw that it might some- times be traced to a similar cause, and we have described (p. 264) a case of dust-bronchitis, with asthma and em.physema, which illustrated the form of disease most commonly met with amongst those engaged in dusty employments. In certain cases, however, after the bronchitis has persisted for some time, and the ciliated epithelium has thereby become damaged and its functions impaired, the dust particles find their way past the bronchi into the alveoli of the lung. Thence they pass between the cells lining the air-vesicles, and so into the lymph channels and connective-tissue spaces of the alveolar walls. Here irritation is set up, leading to the formation of fibroid material, which at first thickens the walls of the air-spaces, and later produces fibroid nodules or bands of various size (Plates XVI. and XVII.). These may again unite, until a large portion of a lobe, or indeed a whole lobe, may become consolidated. The various kinds of dust differ much in their irritative properties, though their effects upon the lung, when ultimately produced, are pathologically of a similar nature. Coal dust is comparatively innocuous, and cases of true anthracosis, with fibroid changes in the lungs, are now rare, and even when met with it is probable that the fibrous changes are due to the stone dust from the strata in which the coal is embedded rather than to the coal dust itself. In these patients the expectoration is often highly charged with carbon, and is spoken of by the miners as " black spit." A simple discolora- ■irfj ni f)3>lTf, ': <^ y -' I ■■...(, PLATE XV r jbon fan£ PNEUMOKONIOSIS The drawing represents a portion of a left lung which shows the effect of the inhalation of irritating particles. The lung is denser and firmer than natural, as the result of diffuse fibrosis, and nodules of dense fibrous tissue having a bluish-black colour are seen scattered throughout it, but mostly in the upper lobe. Many of these nodules are separate and discrete, as at A ; but at the lower part of the upper lobe they have coalesced into a large mass, B. No tuberculous lesions were found in the lung. The pleura is not thickened. On microscopical examination the general diffused fibrosis was found to be especially marked in the neighbourhood of the bronchi. From a man aged forty-nine, who was engaged in the Sheffield cutlery trade, and who died of cerebral hiemorrhage. (Fioni the Museum of St. Bartholomew's Hospital. 2 natural size.) PLATE XVI Pneumokoniosis. To face p. 338. CHRONIC INTERSTITIAL PNEUMONIA 339 tion of the lungs from deposition in them of particles of carbon is, however, extremely common in those who work in coal, as, indeed, it is to some degree in all who live in large and smoky- cities. Calmette" and his pupils have contended that such staining is produced, not by direct inhalation, but by absorp- tion from the alimentary canal of ingested carbonaceous O ^ eS" Q \ ^ <> o Fig. 34.— Drawing showing Larger Particles of Silica isolated from A Silicotic Lung, x 1,000. The Line below represents 10 ^, the Circle a Red Blood-Corpuscle. (After Dr. John McCrae.*) particles, but his work has not been confirmed by recent observers,^ and we may confidently adhere to the old respi- ratory theory as to the origin of anthracosis and, a priori, of other forms of pneumonokoniosis. A much more dangerous form of dust is that consisting of fine particles of silica, which from its insolubility and the pointed and angular character of its particles, which are to be 340 DISEASES OF THE LUNGS AND PLEURA found in situ in the lungs (see Fig. 34) is peculiarly irritating. To the resulting pneumokoniosis the name silicosis has been applied. Silica is met with geologically as quartz, quartzite, and flint, and siliceous dust is thus set free in the blasting and drilling carried on in the quartzite gold-mines of South Africa, giving rise to the disease known as "gold-miner's phthisis."^' Silicosis is also met with among stonemasons, mill-stone builders, and potters, and among those working with ganister* (Plate XVII.), a hard quartzite rock used on account of its "great resistance to heat for lining Bessemer and steel con- verters in ironworks" (Oliver).^'^ Particles of iron may occasionally produce similar changes in the lung tissues, but such cases of siderosis, as they are called, are not common. In the various forms of steel grinding it is the dust from the grindstone rather than from the steel in which the danger lies (Plate XVI.). In true siderosis the lung tissue may be of a reddish-yellow colour, from the deposition of peroxide of iron. Such are the more important conditions under which pneumokoniosis occurs, and it is satisfactory to know that it is decidedly less frequent now than in former years, owing to the precautions which are being taken by wet-grinding, exhaust fans, and similar expedients, to protect the workman from the baleful influence of the dust. ^'ym/'^om^.— Pneumokoniosis is generally insidious in its onset. A cough developes and the breath becomes short, but there is little wasting and no night-sweating, and constitu- tional symptoms are not marked. The signs, in fact, are those of bronchitis and emphysema, with which the disease is generally complicated. Provided that the fibroid areas are small and scattered, as in the variety described as " generalised nodular fibrosis," there may be no impairment of note and no alteration of breathing. The emphysema may, in fact, mask the disease. An X-ray examination will, however, in many cases show clearly defined mottling (Plate XVIII.), the shadows being more sharply defined and deeper than those observed in pulmonary tuberculosis, in which the mottling has a somewhat hazy and blurred appearance. Later, when larger areas of fibrosis have developed, the signs which we have already described at the beginning of this chapter as significant of this condition — dulness, retraction PLATE XVTI PNEUMOKONIOSIS (SILICOSIS) COMPLICATED BY TUBERCLE The drawing shows the lung tissue to be much firmer than natural, as the result of diffuse fibrosis, which on microscopical examination was seen to commence around the bronchioles. In addition, numerous sharpty-defined, hard, greyish-blue fibrous nodules, about a quarter of an inch in diameter (B), are seen scattered through the lung. Upon these lesions tubercle appeared to have become engrafted, and at A. near the base of the upper lobe, a large tuberculous cavity is found. At the apex of the lung smaller foci of tuberculous disease are visible. From a ganister miner, who had suffered for many years from fibroid disease of the lung, and who for some time had been unable to follow his occupation. Death resulted from empyema and acute pericarditis of pneumococcal origin. (From the Museum of St. Bartholomew's Hospital, j^ natural size.) PLATE XVII Pneumokoniosis (Silicosis) complicated by Tubercle. To face p. 340. CHRONIC INTERSTITIAL PNEUMONIA 341 with diminished mobility of the affected side, and so forth — will make their appearance. If the patient continues at his work, the disease gradually progresses, bronchial dilatation is apt to ensue, and death results, often from an intercurrent attack of acute bronchitis or pneumonia. The duration, how- ever, varies with the nature and amount of the dust inhaled. Thus Dr. Oliver places the duration of life after commence- ment of symptoms at from five to six years among the rock- drillers in the South African gold-fields, and at about fifteen years among steel-gTinders, while coal-miners live still longer. It has been found in South Africa that if in the early stages of the disease the miner gives up his underground occupation and takes to open-air work, arrest of the malady and great improvement in the general health not uncommonly results. In not a few cases the disease terminates earlier, owing to infection by the tubercle bacillus, the tuberculous disease in these cases running its course with the formation of cavities, although the fibroid features still remain (Plat§ XVII.). It is, perhaps, unnecessary to add that pulmonary tubercu- losis of an ordinary type is frequently developed in young operatives in dusty factories, and especially among those in whom there is a family predisposition. In such the dusty atmosphere and confinement in ill-ventilated rooms strongly favour the development of the malady. These cases do not present any unusual features. In conclusion, we may give the notes of the following case, which illustrates certain of the features of this interesting malady : A. H. H., gold-miner in South Africa, aged thirty-two, single, was admitted into the Brompton Hospital under the care of one of us in April, 1915. He came of healthy parentage, there being no history of tuberculosis in the family, and his own health in the past had been good. In 1902 he commenced work as a " driller " in the gold-mines near Johannesburg, his place being at the " dead end " of the mine gallery, where exposure to dust was greatest. All went well with him for 8-1 years, when he began to suffer from shortness of breath and cough. These symptoms increased, and at one time kept him away from work for two months. Expectoration had never been more than slight in amount. He coptinued at his occupation until March, 1914, when he gave it up and came to England. Since his arrival he had lived in Kilburn, residing at home, but doing no work. His cough, however, 342 DISEASES OF THE LUNGS AND PLEURA became worse, and a year later (April, 1915) he entered the Brompton Hospital. On admission he was found to be a man of somewhat poor physique. Height 5 feet 9 inches, weight 10 stone 2J pounds. He was short of breath on exertion, the respirations even at rest being generally over 20. Pulse 84 ; temperature normal. His cough was very troublesome, and he suffered from time to time from bouts of coughing lasting perhaps half an hour. The phlegm was scanty and viscid, and difficult to expectorate. Tubercle bacilli were never found, though the sputum was examined on four occasions at the hospital, once by the antiformin method. On physical examination, no marked signs of emphysema were apparent, and the heart was natural. The air-entry over the front of the chest was satisfactory, but at the back the percussion note over the base of each lung was somewhat impaired, the vocal vibrations increased, the respiratory murmur weak, and numerous small rales were audible after coughing. On the left side these signs extended to the mid-scapular region. The fingers were not clubbed. The patient was examined by Dr. Melville under the X-rays, and the characteristic findings are shown in Plate XVHI. The upper parts of the lungs are seen to be fairly free from disease, but in the lower two-thirds numerous small discrete, sharply-defined, and rounded shadows are seen, with, in places, larger and darker areas of shading, the former corresponding to scattered areas of nodular fibrosis, the latter to more extensive changes of a similar nature. The patient stayed nearly two months in the hospital, and then returned home. He had no pyrexia, and gained 4 pounds in weight, and, on leaving, his cough was somewhat easier, and the moist sounds at the right base were fewer in number. Otherwise his condition was not materially changed. In September he went to Eastbourne, and a month later was taken ill in a picture palace. He returned to London at the end of October, and died on November 12th, 1915, of bronchitis and heart failure, the end being preceded by distressing attacks of dyspnoea. This case shows the long period — in this case more than eight years — w^hich may elapse before symptoms of pneu- mokoniosis manifest themselves, in spite of continued ex- posure to the baleful influence of the dust. The characteristic X-ray appearances and the chronic nature of the malady, with fair retention of general health, are also demonstrated. REFERENCES. ' In regard to the subject of pneumonokoniosis, reference should be made to : (a) Diseases of Occufation, by Thomas Oliver, M.D., F.R.C.P., p. 298. London, 190S. Also — PLATE XVIII X-Ray Api'earances in a Case of Gold-Miner's Phthisis of Medium Severity, SHOWING Numerous Small Discrete and Rounded Shadows, with, in Places, Larger and Darker Areas of Shading, the Former corresponding to Scattered Areas of Nodular Fibrosis in the Lungs, the Latter to More Extensive Changes of Similar Nature. (From the case of A. H. H., recorded in the text.) To face p. 342. CHRONIC INTERSTITIAL PNEUMONIA 343 (b) " The Etiology and Prevention of Pneumonokoniosis," by Thomas Oliver, M.D., being a contribution to " A Discussion on Diseases of the Lungs caused by Dust," British Medical Journal, 1908, vol. ii., p. 481. (c) The late Dr. Greenhow's original investigations into the subject published in [a) Public Health Re-ports for 1860-61 ; (6) the Transac- tions of the Pathological Society of London, vols, xvi., xvii., xx., and xxi. Many of Dr. Greenhow's specimens will be found in the Museum of the Middlesex Hospital. (d) " The Hygienic Aspect of the Coal-Mining Industry in the United Kingdom," Milroy Lectures, 1914, by Frank Shuffiebotham, M.A., M.D., The Lancet, 1914, i., pp. 1731, 1799- {e) " Industrial Pneumonoconioses, with Special Reference to Dust Phthisis," by Edgar L. Collis, M.B. (Oxon), Milroy Lectures, 1915, reprinted from Public Health. ^ For an interesting account of Calmette's experiments, see the Caven- dish Lecture on " The Etiology of Pulmonary Tuberculosis," by Sir William Whitla, M.D., LL.D., British Medical Journal, 1908, vol. ii., p. 61. ^ The Causes of Tuberculosis, by Louis Cobbett, M.D., F.R.C.S., pp. 142-151. Cambridge, 1917. " " The Ash of Silicotic Lungs," by John McCrae, Ph.D., F.I.C., South African Institute for Medical Research, Johannesburg, 1913. " See [a) " Miner's Phthisis : Recent Investigations," by Drs. Watt, Irvine, Johnson, and Steuart, The Medical Journal of South Africa, vol. xi., 1916, pp. i, 15. {b) " Silicosis (Miner's Phthisis) on the Witwatersrand," by the same authors. Pretoria, 1916; and a review thereof in the British Medical Journal, 1916, vil. ii., p. 653. ° " Report on Portions of Lung from a Ganister Miner," by F. W. Andrewes, M.D., F.R.C.P., Annual Report of the Chief Inspector of Factories and Workshops for the Y ear 1900, p. 487. London, 1901, CHAPTER XX COLLAPSE OF THE LUNG— MASSIVE COLLAPSE We have pointed out (p. 203) that in cases of stenosis of a bronchus, collapse of the lung to which it is tributary is apt to follow, the mechanism being that, as secretions accumulate behind the obstruction, air can no longer penetrate to the lung-, whilst what remains is expelled or absorbed. In bronchitis and in broncho-pneumonia in weakly persons and in children, whose chest-walls are lax or wanting in muscular support, collapse of lobules of the lung is frequently to be observed. Mucous collection in the tubes, whilst permitting air to escape, is obstructive to its entry to the lobules, which thus gradually become deflated. In whooping-cough in young children, attended with bronchitis or broncho-pneumonia, scattered collapse of the lung having this mechanism is one of the most dreaded complications, and is one of the causes of the broncho-pneumonic centres so frequently attendant upon the disease. Collapse of the lung from external pressure, such as from effusion into the pleura, of whatever kind, is more accurately spoken of as compression of the lung, although in the earlier stages the lung recedes before the effusion by virtue of its elasticity, and only later begins to be com- pressed. Intrathoracic growths may cause collapse and com- pression of the lung directly, or by partial occlusion of the bronchi may produce first collapse and compression, and secondly fibrosis and even disorganisation of the lung, especially in cases in which the vessels or nerves are involved. In pleuritic cases the pleura may become thickened and may bind down the collapsed lung. Still further changes may result in bronchiectasis or bronchiectatic cavitation of the lung. These conditions have been sufficiently alluded to in 3^1 COLLAPSE OF THE LUNG 345 connection with the diseases in which they occur, and require no further mention here. Massive Collapse of the Lung. There is another form of collapse of the lung which has an entirely different, perhaps more than one, origin, and which is most probably due to paretic failure of the inspiratory power of the chest-wall on one or both sides. "Massive" or lobar collapse of the lung has been defined by Dr. Pasteur,^ who first described the condition, as a total deflation of a large area of lung-tissue of sudden onset, due to failure of inspiratory power, and attended by definite physical signs and symptoms. After referring to the papers of Professor Keith, 1903, and Dr. Halls Dally, 1908, on the mechanism of respiration, he draws the conclusion that " expansion of the lungs takes place under the influence of two forces, costal and diaphragmatic, and that the overlapping between their two spheres of action roughly corresponds to the position of the great fissure, the costal force acting mainly above and the diaphragmatic force mainly below it." Massive collapse is always attendant upon serious failure of inspiratory power, and there are two well- defined varieties — namely, (i) Cases in which collapse is due to paralysis of the essential muscles of inspiration, and is a local result of a general motor failure, as in diphtheritic or in ascend- ing paralysis. In these cases the collapse is more or less sym- metrically bilateral. (2) Cases in which the collapse supervenes suddenly without any general cause, and in which it has apparently a reflex origin, being traceable to some shock or injury to the thoracic wall, or to some more distant part. In this class the cases are for the most part unilateral. Thus the paralysis of the respiratory motor mechanism in massive collapse of the lung may be of direct or reflex (inhibitory) causation. Group I. — This group of cases includes those first ob- served by Dr. Pasteur in connection with post-diphtheritic paralysis, principally in children, in which the paralysis in- volved the diaphragm. In these cases the lungs gradually collapse towards the foetal position, and unless nervous power is speedilyrestored to the inspiratory muscles, death ensues. In such cases the deflation is more or less symmetrical, affecting 346 DISEASES OF THE LUNGS AND PLEURA the bases of the lungs, but may involve almost the whole of one or both lungs. The physical signs, owing to the general condition of the patient, are difficult to investigate with accuracy, and the consolidation, with its signs of feeble or annulled breath-sounds and variable rales, is commonly attrib- uted to pneumonia, broncho-pneumonia, or pleuritic effusion. Pyrexial symptoms are, as a rule, irregular ; they may be want- ing, and are never very marked. A notable recession of the chest-wall may be observed, whilst the arch of the diaphragm is raised, the cardiac area being likewise displaced upwards. The condition of the patient is that of general failure, and death may arise from apnoea or syncope. In some cases, how- ever, the respiratory muscles recover their action, and rapid improvement follows the restoration of the pulmonary function. Group II. — The interest of the cases just described lies in the fact that their observation led Dr. Pasteur to the investi- gation of other cases of collapse of the lung, of the second group, of greater importance, and the interpretation of which is more difficult.^* In these cases, which attracted much atten- tion in connection with gunshot wounds in the recent war, and to which we have referred in Chapter X., collapse of the lung follows upon an injury, it may be to a distant part, or to some portion of the chest-wall not necessarily connected with or even on the same side as the portion of lung affected. If on the same side as the injury to the chest, the condition is spoken of as "homolateral collapse"; if on the opposite side, as " contralateral." In other cases the collapse has followed abdominal operations. The collapse may be associated with such conditions as pleurisy, or be complicated with embolism or haemothorax of the same or opposite side, or may pass on to some form of pneumonia; but these are compHcations upon which we need not in the present place dwell further. Clinical Features. — Being commonly one-sided, the physical signs are more striking and conclusive than in the previous group of cases. There is flattening and diminution in size of the chest on the side affected, with depression rather than expansion during inspiration; the arch of the diaphragm is raised, and the heart displaced towards the affected side, unless, as in some traumatic cases, direct injury has caused an effusion of fluid on this side. The respiratory murmur. COLLAPSE OF THE LUNG 347 at first weakened over the affected area, becomes more or less intensely bronchial, and is attended with crepitations and later with large mucous or even gurgling- rales. On the opposite side the movements of inspiration are increased, the resonance extends beyond the normal confines towards the middle line, and the breath-sounds are exaggerated. The collapse of the lung supervenes within twenty-four or forty-eight hours of the injury. Dyspnoea, variable in degree, sometimes very urgent, is the first symptom, and in severe cases is accompanied by more or less shock. The temperature usually rises within a few hours to ioo°, or even to 102° or 103°, but is of no characteristic type. There is a short cough, rather persistent, at first dry, afterwards attended with a viscid, clear, mucoid expectoration, later becoming more abundant and muco-purulent in character. Haemoptysis is unusual, and Dr. Pasteur states that it never occurs in pure massive collapse. Sir John Rose Bradford- found it a more frequent symptom in his cases, w^hich were, however, mostly secondary to gunshot injury of the chest- wall, in the phenomena of which massive collapse is, in his experience, a frequent and an important factor. In favour^ able cases of reflex origin, as in those of central origin in which nerve function is restored, the symptoms gradually abate and disappear. When fatal, death is usually due to the primary nerve cause of the collapse, or to complications. etiology. — It must be admitted that it is rather assumed than actually proved that paralysis of the inspiratory muscles, either as a part of some general paralysis or of reflex inhibitory origin, is the primary cause of massive collapse of the lung. The cases which originally attracted Dr. Pasteur's attention were, as we have seen, those attendant upon diphtheritic paralysis; they were mostly bilateral or symmetrical, and would seem to be of paralytic origin. The unilateral cases, occurring as they do as sequels of such lesions as surgical operations for appendicitis, hernia, salpingectomy or chole- cystectomy (Pasteur)^*; or after such injuries as gunshot wounds, not necessarily penetrating, of the thoracic or abdominal wall, or, as recorded by Sir John Rose Bradford, of the pelvis or thigh, appear to admit no other possible aetiology than that of a reflex nervous inhibition, the precise route of which requires, however, further observation to elucidate. 348 DISEASES OF THE LUNGS AND PLEURA Mechanism. — The pathology of the disease consists essen- tially of an airless collapse of the lung, which may involve the whole of one lobe or even the entire lung, or it may affect considerable portions of both lungs. Various explanations of the mechanism by which this collapse is brought about have been suggested. Of these, expiratory deflation and bronchial contraction, with absorption of air from the alveoli, are the chief.* Assuming the primary cause of massive collapse to be a paralysis of the inspiratory muscles, and more particularly of the diaphragm, the mechanism of its occurrence does not seem difficult of comprehension. The condition of the lung would rapidly be reduced to that of complete de- flation, as shown in five of Dr. Pasteur^s eight cases in which an autopsy was made, and in the following manner: (i) The chest-walls, being paralysed, would fall in towards the foetal position, following the lung, which (2) would collapse to the position of elastic quiescence; (3) the respiratory efforts consequent upon the need of air would result in increased expansile movements of the unaffected side. This would have two effects — (a) Atmospheric pressure would bear on all sides, thoracic, diaphragmatic, and mediastinal, tending to produce more complete collapse of the affected lung; (b) the forcible expansion of the sound side of the thoracic cavity, whilst drawing extra air in through the main bronchus proper to that lung, would also aspirate air from the bronchus of the affected lung, and thus any residual air would be gradually but rapidly removed. The mechanism of the second clinical feature of massive collapse — namely, displacement of the heart to the affected side (in one-sided cases unaccompanied with effusion) — is also readily explained. The same mechanism by which the chest is retracted and the lung collapsed must necessarily tend to draw the heart over to the affected side. As a clinical feature this displacement appears somewhat exaggerated, being in part apparent and relative only, inasmuch as (a) the thoracic cavity on the affected side is diminished and its walls approxi- mated towards the median line : hence the margin of the chest- wall and line of the nipple are approximated to the correspond- ing side of the heart; (b) the heart is also uncovered by the * For a full discussion of the mechanism of this form of lung collapse reference should be made to Sir John Rose Bradford's paper,' and to a inore recent paper by Dr. J. Charlton Briscoe." X I— I < Oh D O (I. Q m Cd en O H [I. H 2 W s W o a. O <: • 3 <: O K H o Z p w H (I. O 0. < J pj o O w > MASSIVE COLLAPSE OF THE LUNG, WITH CARDIAC DISPLACEMENT A glance at the plate, which is taken in outline from Sir J. Rose Bradford's paper^, illustrates the approximation of the chest wall on the side affected to the median line ; the uncovering of the heart on this side and its overlapping by lung on the sound side ; the total effect being to exaggerate the shifting of the heart to the affected (left) side. The details are added to the original photograph. A, heart in dark shadow. B, lighter shadow fading to right (overlapping lung). B', darker than B. but less so than A. C. C, diaphragm. Measurement i — 2 = 2 '25 inches. I— 2'= 2-6 " " ■ opposite second cartilage. 3-4'- 2-5 ,. \ ^^ The left nipple, not marked in the original plate, is hypothetically placed lower and nearer the median line in accordance with shrink- ing of the chest on this side. PLATE XIX COLLAPSE OF THE LUNG 349 withdrawal of the margin of the collapsed lung; (c) on the other side the heart's area is overlapped by the encroachment of the sound lung, A reference to the second and third radio- graphic illustrations of Sir John Rose Bradford's paper, and especially the third, which we reproduce (Plate XIX), shows this well. How far bronchial contraction, of reflex origin, may be concerned in the production of some cases of massive collapse secondary to gunshot injury of the chest-wall it would be difficult to say. Colonel Elliott* appears to attach considerable importance to it as a cause of asphyxiative dyspnoea following upon injury. We should regard it as a separate condition from massive collapse, seeing" that in asthma, the most striking clinical result of bronchial spasm, we witness not collapse, but expiratory dyspnoea and overdistension of the lung vesicles. In the local collapse of a portion of the lung, due to the occlusion of the middle division of the bronchus supply- ing the lower lobe, which is described by Colonel Elliott, the mechanism is separate and distinct from that of massive col- lapse and requires no further comment. Dr. Charlton Briscoe^ is inclined to attribute post-operative collaps-e to the half of the diaphragm concerned and its asso- ciated muscles being put out of action owing to " inflammation of the muscle or of the pleural membrane covering it," and also regards the recumbent posture as an agent in the produc- tion of the collapse. It must be observed, however, that in many cases the injury is quite distant from the aifected lung, and that pleurisy is not in other cases operative in producing the phenomena. Before concluding this chapter we may allude to another cause, which has been held to account for more or less extensive collapse of the lung — namely, the excitation of the so-called lung reflex. Dr. Abrams describes " dull areas " due to the contraction of the lung as being produced by sharp percussion of the chest surface, preferably over regions in proximity to sternum and spine. Areas of dulness thus produced are circumscribed, last but a few minutes, and are immediately replaced by resonance if similar percussion be appHed over the epigastrium. This phenomenon he desig- nated the "lung reflex of contraction." Previously he had described a dilatation of the lung which he believed to follow 350 DISEASES OF THE LUNGS AND PLEUR.E "the application of any cutaneous irritant, whether mechanic, chemic, or electric," to the chest-wall.* He conceives that the phenomena are due to reflex contrac- tions or relaxations of the circular and longitudinal fibres of the musculature of the bronchi. That such contractions and relaxations of the bronchial muscles are operative in the normal respiratory function and in some of its disturbances in disease is most probable, and to this we have referred in earlier chapters (see pp. 8, 243), but we venture the opinion that these observations on the lung reflexes require more convincing repetition and demonstration. They have, however, attracted attention, and Sir James Barr* regards them as largely responsible for contralateral collapse, and speaks of the excitation of the lung reflexes by vigorous friction over the chest as clearing up conditions of extensive pulmonary collapse. The Diagnosis of massive collapse depends, as will have been sufficiently indicated, upon the rapid development of physical signs of consolidation of the lung, enfeebled breath-sounds, contraction or immobility or depression of the affected side with, in unilateral cases, displacement of heart towards that side, and laboured and exaggerated breathing on the sound side. These signs may, however, be obscured by such compli- cations as pleuritic effusion. The Prognosis is mainly dependent upon the caiuse. In cases of central nervous origin, such as those following upon diphtheritic paralysis or ascending paralysis, the prognosis is grave, although by no means necessarily fatal. In traumatic cases secondary to surgical, gunshot or other injuries, the prognosis, so far as the condition of lung alone is concerned, is favourable, danger arising from associated lesions or com- plications. Treatment consists in sustaining the patient, careful nursing, and the employment of remedies appropriate to the conditions with which the collapse is associated. Aeration will be usefully aided and heart power supported by the use of continuous or intermittent oxygen inhalations. Strychnia is perhaps the other remedy of greatest value. COLLAPSE OF THE LUNG 35 1 REFERENCES. *• {a) " The Bradshaw Lecture on Massive Collapse of the Lung," by William Pasteur, M.D. (Lond.), F.R.C.P., Tke Lancet, November 7, 1908, p. 1351. See Also [b) " Active Lobar CoUapse of the Lung after Abdominal Operations," by the same author, The Lancet, October 8, 1910, p. ic8o. ^ " Massive Collapse of the Lung as a Result of Gunshot Wounds, with Especial Reference to Wounds of the Chest," by John Rose Bradford, K.C.B., M.D., F.R.S., Quarterly Journal of Medicine, vol. xii., Nos. 45 and 46, October, 1918; January, 1919. ^ Discussion of Gunshot Wounds of the Chest," by Colonel T. R. Elliott, Proceedings of the Annual Meeting of the British Medical Association, Section of Surgery, British Medical Journal, April 12, 1919, p. 442. * " The Mechanism of Post-operative Massive Collapse of the Lungs," by J. Charlton Briscoe, M.D., F.R.C.P., Quarterly Journal of Medicine, vol. xiii., No. 51, April, 1920, p. 293. ^ " The Blues (Splanchnic Neurasthenia), Causes and Cure," by Albert Abrams, M.D., Heidelberg, New York, 1908, pp. 244, 247. ° " The Physics of the Chest and their Relation to Disease and Injuries of the Thoracic Organs," by Sir James Barr, M.D., F.R.C.P., British Medical Journal, April 19, 1919, p. 471. CHAPTER XXI CEDEMA OF THE LUNGS CEdema of the lungs consists of an escape of serum from the vessels into the texture of the organ and into its alveolar and bronchial spaces. As a chronic condition it is of common occurrence, and is familiar to every practitioner; but it may also occur, though much more rarely, suddenly, and in an acute form, very alarming in its intensity, and often speedily fatal. The two forms must be discussed separately. I. Chronic Pulmonary (Edema.— Of this variety there are many causes, but they range themselves naturally under two heads : (i) disturbance of circulation; (2) morbid conditions of the blood. Thus, we may have mechanical oedema from retarded circulation, which may be due to mere feebleness of heart, or obstruction to the passage of blood through the lungs, as in emphysema, mitral stenosis, mitral regurgitation, or pressure on the pulmonary veins from tumours. Again, the powerful inspiratory efforts to draw air into the lungs through the constricted passages in croup, asthma, and other extended bronchial obstructions, cause an afflux of blood, resulting in some cases in-more or less oedema of the lung textures. In pneumonia and other acute inflammations oedema is a consequence of the active hyperaemia attendant upon the early stage of inflammation. Later, as we have elsewhere pointed out, the oedema in this complaint is not infrequently the direct result of cardiac failure, and is thus, in great part at least, mechanical in nature. It not infrequently also persists for some considerable time after the acute inflammation of the lung has passed away, owing to impairment of vessel tonicity. Pulmonary oedema may also be produced by all those morbid conditions of the blood which impair the nutrition of the vessel walls and favour the escape of serum through them. 352 CEDEMA OF THE LUNGS 353 Of these conditions albuminuria is the most important, but scurvy, purpura, and anaemia may also be mentioned. Morbid Anatomy. — CEdematous lungs are large, heavy, wet, indented by the ribs, pitting on pressure, and on section exuding from their texture and tubes an abundant, frothy serum, sometimes blood-stained. These characters are especially marked at the bases or most dependent parts, and, indeed, may only be apparent there unless locally determined in other situations. CEdema affects both lungs, but most commonly one side is more affected than the other, owing to the posture adopted by the patient. It is very usual also to find that one or both pleurae contain an undue amount of serum. Except at the extreme bases, and when very thoroughly waterlogged by old-standing oedema, the lungs are more or less crepitant, and portions removed will float in water. Under the microscope, the alveoli are found filled with serous fluid, which presents after hardening a finely granular appearance, and stains faintly with eosin. Some epithelial shedding may also be observed in the alveoli ; otherwise the texture of the organs is unchanged. Symptomatology. — The symptoms of chronic oedema of the lungs are mingled with those of the other diseases of which the condition is but a consequence. Dyspnoea, straining cough, with copious thin watery mucoid sputa — sometimes, in cases of acute congestion, tinged or streaked with blood — are the chief symptoms. The patient sits up supported in bed, the respiratory movements are thoracic, " lifting" in character, the bases of the chest receding with inspiration. The front of the chest is hyper-resonant, the posterior bases more or less dull. Over the posterior aspect of the lungs, extending from the base upwards, the respiratory sounds are enfeebled or annulled, and fine bubbling rales are heard, chiefly with inspiration. These sounds closely simulate pneumonic crepitation, emphy- sema crackle, and the crepitation of air penetrating a collapsed lung; the distinction must be drawn by attention to associated percussion and auscultatory phenomena. Prognosis. — Chronic pulmonary oedema is usually of grave significance. In chronic Bright's disease and in cardiac dropsy it is one of the later phenomena. In those forms of heart disease, however, which tell directly upon the circulation 23 354 DISEASES OF THE LUNGS AND PLEURA through the king a certain degree of pulmonary oedema may precede general dropsy, and may long persist without further consequences. It is very common to find a certain amount of pulmonary oedema as a permanent condition in old people with feeble hearts and emphysematous lungs, and we have met with several persons in whom slight oedema sounds have for years persisted on one side, probably as the result of a past inflam- matory attack. No doubt some of these cases are explained by an oedematous condition of the connective tissue uniting the pleural surfaces over a lung that has been the seat of former inflammation. The supervention of oedema of the lungs in acute bronchitis or pneumonia is of grave augury, pointing as it does to cardiac failure. Treatment. — The treatment of oedema from failing heart is referred to in the chapter on pneumonia. In cases of local oedema from loss of tone of vessels after inflammation, iron, mineral acids, and sometimes small doses of digitalis, are of great value. In other cases derivative treatment is called for. The vegetable diuretics, juniper, scoparium, caffeine, and theobro- mine sodio-salicylate (diuretin), with digitalis, and moderate doses of the iodide and neutral salts of potash, are then valu- able; and watery purgatives and diaphoretics should be used in turn. The exact nature of the case, whether renal or car- diac, will indicate the proper selection of remedies; in cardiac cases we rely more upon diuretics and digitalis, with occa- sional small doses of mercurial and saline aperients; in renal cases our derivative treatment is rather effected through the bowels and skin by brisk watery aperients and sudoriflcs, including air baths. Dry-cupping sometimes gives much relief, especially in obstructive cardiac disease, and in emphysema with dilated heart. In all cases a tonic supporting line of action is necessary. 2. Acute Pulmonary (Edema. — This condition, which has been recognised for many years in France, but to which until recently but little attention has been paid in this country, differs much from the chronic form which we have hitherto been discussing. In civil life it is perhaps best known as a rare sequel to paracentesis of the chest, when it gives rise to the so-called "albuminous expectoration "^; but, as we shall see, it occurs sometimes quite apart from pleurisy or paracentesis. (EDEMA OF THE LUNGS 355 The sufferer from this malady, who may have been apparently in his usual health, is suddenly seized with extreme difficulty in breathing, and an agonising sense of impending dissolution; cyanosis follows, and very soon, in characteristic cases, a frothy exudate is coughed up, the amount being often so large and so intimately mixed with air that the foam wells from nose and mouth. On auscultation, abundant crepitations are heard throughout the chest. The duration of the attack varies. The patient may die suffocated within a few minutes, but more often the symptoms last from one to six hours, and then gradually subside. In not a few instances the attacks show a disposition to recur.^ In other cases, after endeavour- ing for some time to clear his tubes, by constant efforts of cough the patient's strength fails, he becomes unconscious, and dies. After death, the lungs are commonly found in a condition of great oedema, exuding much serous fluid on section. The expectoration is characteristic. It is large in amount, and when collected often measures one or two pints, and as much as two litres has even been recorded. After being allowed to settle, it separates into two layers, an upper frothy layer, and a lower layer, somewhat viscid, translucent, and yellowish or yellowish-green in colour, resembling in appear- ance the fluid removed from the pleura by paracentesis. It contains large quantities of albumin and globulin, and some- times becomes solid on boiling,* thus contrasting with the non-albuminous sputa of pituitary catarrh (see p. 194). If the patient recovers from the first attack — and generally he does so — he is very liable to suffer from further attacks, any one of which may prove fatal. The malady is happily a rare one, though probably not so uncommon as is usually supposed. As Dr. Riesman^ insists in his interesting paper, it occurs more often in those who are the subject of arterio-sclerosis, heart disease, or renal disease, and, as Dr. Leonard Williams* and others have pointed out, it is not infrequently associated with high blood-pressure, especially in persons of middle life or advancing years. We have seen several such cases associated with a blood-pressure * For further details we may refer to a paper by one of us relating to this subject, in which a chemical analysis of the expectoration by Dr. Hurtley will be found recorded.^ 356 DISEASES OF THE LUNGS AND PLEURAE of 190-225. It has been observed also in the course of typhoid, rheumatic and scarlet fever, and during influenza and pneu- monia. As we have already said, it is one of the well-known, though rare, complications of paracentesis of the chest, the damaged vessels permitting increased transudation when the pressure of the effused fluid has been removed (see p. 114). In cases of extreme effusion the condition may sometimes be observed to be commencing- in the other lung. The cause of the attacks, which are apt to occur at night, and not infrequently during sleep, is not very clear. The most plausible explanation would appear to be that offered by Professor Welch,^ of Johns Hopkins University, according to which the condition is due to a comparative enfeeblement of the left ventricle of the heart, so that it discharges, with each systole, rather less blood than it receives from the right side through the pulmonary veins. The pulmonary system thus becomes overdistended, and acutely oedematous from transuda- tion. Such a condition, we miay add, is a not uncommon contributory factor to the fatal result in angina pectoris. Treatment. — When first called to a case of this kind an injec- tion of morphia gr. |, strychnine gr. /o> ^^^ atropine gr. j^ should be given. The mental distress is quieted by the morphia, the heart is stimulated by the strychnine, and the pulmonary exudation perhaps to some extent checked by the atropine. In some cases, especially those in which the blood- pressure is high, venesection to ten or twelve ounces is indicated. On the cardiac theory this should give rehef to the exhausted heart, and in practice it has been found to do good. It may in some cases be supplemented by leeches or dry- cupping of the chest. If the heart is beginning to fail, diffusible stimulants or strychnine subcutaneously must be freely administered. Inhalations of oxygen will also be found useful, but the oxygen must be given continuously during the serious symptoms. In cases with recurrent attacks a course of diuretics may be prescribed, on the assumption that some toxic factor may be at work, and with a view to assist elimina- tion by the kidneys. Irritant Gas Poisoning. Although acute oedema of the lung, as we have seen, is uncommon in civil practice, it is otherwise in war since the OEDEMA OF THE LUNGS 35/ introduction of poison gas in April, 1915. Both chlorine and phosgene (COCI2) are pulmonary irritants, and when inhaled they produce an acute pulmonary oedema of inflammatory nature, which is often fatal.® On first exposure to the gas the soldier at once experiences a catching of the breath and choking, and a feeling of inability to breathe freely. Vomiting and cough soon follow, and after an interval, which may vary from a few minutes to some hours, corresponding to the concentration of the gas and the dura- tion of the exposure, inflammatory reaction occurs in the lung- tissue, leading to acute oedema and the appearance of the characteristic albuminous expectoration. Cyanosis soon manifests itself, or with phosgene more often a pallid type of asphyxia, symptomatic of cardiac failure. If the patient survives for forty-eight hours, he will usually recover, though convalescence may be tardy, and some degree of bronchial catarrh is apt to persist. Treatment must be on lines similar to that advised in cases occurring in civil practice, morphia, however, being withheld, unless urgently demanded by the patient's anxiety and distress. In view o£ the conditions of active service, it must be especially remembered that rest and zvarmth are fundamental factors in the treatment, each helping to diminish metabolic activity, and thus to lessen the need for oxygen from which the patient is suffering. Venesection, if the case be a cyanotic one and the right heart dilated, and oxygen inhalations, with strychnine and diffusible stimulants when required, will again constitute our main lines of treatment. REFERENCES. '■ " Albuminous Expectoration following Paracentesis of the Chest," by P. Horton-Smith Hartley, M.D., St. Bartholomew'' s Hos-pital Re forts, 1906, vol. xli., p. 77. ^ " Paroxysmal Pulmonary CEdema and its Treatment," by Alfred Stengel, M.D., The Ainerican Journal of the Medical Sciences, New Series, vol. cxii., 191 1, p. 1. ^ " Acute Pulmonary CEdema, with Special Reference to a Recurrent Form," by David Riesman, M.D., The American Journal of the Medical Sciences, 1907, New Series, vol. cxxxiii., p. 88. " " Acute Pulmonary CEdema," by Leonard Williams, M.D., The Lancet, 1907, vol. ii., p. 1606. 358 DISEASES OF THE LUNGS AND PLEURA ^ (i) " Zur Pathologic des Lungen Odems," von Dr. W. H. Welch, aus New York; Archiv fur Pathologische Anatomie und Physiologic und fiir Klinische Medicin. Herausgegeben von Rudolf Virchow. Berlin, 1878, Band Ixxii., p. 375. See also — (2) " Edema : a Consideration of the Physiologic and Pathologic Factors concerned in its Formation," by S. J. Meltzer, M.D., American Medicine, p. 195. Philadelphia, U.S.A., 1904. ^ For a study of gas-poisoning reference should be made to {a) The Reports of the Chemical Warfare Medical Committee, published by the Medical Research Committee, Nos. 1-8, 1918, and the Atlas of Gas-Poisoning (191 8) which accompanies them. See also {b) " Gas-Poisoning : Pathological Symptoms and Clinical Treat- ment," by Leonard HiU, M.D., F.R.S., Transactions of the Medical Society of London, vol. xxxix., 1916, p. 114. CHAPTER XXII ABSCESS AND GANGRENE OF THE LUNG Abscess of the Lung. Circumscribed suppuration of the pulmonary tissues may arise from a variety of causes, the most important of which are acute inflammation, whether lobar or broncho-pneumonic, especially in the subjects of diabetes or chronic alcoholism; wounds of the thorax; lodgment of foreign bodies; circum- scribed gangrene; pyasmic infarctions and other infective emboli. It may also arise from extension of suppuration from adjacent parts, e.g., suppurating bronchial glands, mediastinal abscesses, empyema; or it may result from a malignant growth of the oesophagus ulcerating into the lung. In acute lobar pneumonia abscess formation is rarely met with except in broken and debilitated constitutions, and a history of long indulgence in alcohol is usually to be obtained. The abscesses are generally of small size, numerous and irregular in shape, though sometimes a single larger abscess may be found. Broncho-pneumonia is more frequently followed by suppura- tion than is true lobar pneumonia. The broncho-pneumonia is generally septic in nature, produced by the passage over the insensitive glottis of acrid discharges from suppurating wounds or cancerous sores in the mouth, or of decomposing particles of food when the patient is in a state of coma. The areas of suppuration are usually multiple and small. Multiple abscesses are, however, most commonly produced by infective emboli, especially in pyaemia. These set up areas of acute septic lobular pneumonia, which rapidly undergo suppuration, giving rise to small abscesses, which are often thickly disseminated throughout both lungs. Symptoms. — The formation of pus in the lungs, as in other organs, is usually attended with severe rigors and pyrexia 359 360 DISEASES OF THE LUNGS AND PLEURA and with symptoms of great prostration. The appearance of the patient, the high temperature, and rapid breathing, suggest that the lung is the seat of inflammation, but the first evident symptom of an abscess may be the sudden expectoration of pus with fragments of lung tissue. Physical Signs. — If the abscess be of any size, and com- municate with a bronchus, the signs observed will be dulness on percussion, with gurgling rales and the other indications of cavity. In more minute and scattered abscesses the signs are often indefinite and slight, or may be those of softening of the lung. To X-ray examination the abscess will produce a shadow, more characteristic if, as is sometimes the case in larger cavities, much air be contained as well as pus. Treatment. — The treatment of pulmonary abscess consists generally in the pursuance of the remedies for the diseases that may have led up to it, and particularly is this the case with those grave forms of disseminated abscesses associated with pyaemia. Quinine or bark and mineral acids are useful. Dis- infectant inhalations are also of service, and in circumscribed cases especially the patient should be encouraged to evacuate the contents of the abscess cavity from time to time. Under such ordinary measures of treatment, with good ventilation and change of air at the earliest moment, abscess of the lung sometimes heals, perhaps more frequently than is generally supposed. Surgical Intervention. — In other cases the question of opera- tive treatment by opening and draining the abscess must be considered. This may be recommended if definite signs of localised abscess cavity are present, and if after a period of observation there be no amelioration in the patient's symp- toms, as indicated by a fall of temperature and a lessening of the expectoration. Much depends upon the seat of the abscess, basic cases, owing to the difficulty of natural drainage, more often requiring interference. The records dealing with cases of this kind treated surgically by incision and drainage are most encouraging. Two success- ful cases were published in 1889 by Dr. S. Smith^ and by Mr. J. D. Harris," and these are among the earliest cases recorded in England. The recent figures of Garre and Quincke^ show that out of 182 cases treated by operation, 148 were cured and 34 died, a mortality of 175 per cent. ABSCESS AND GANGRENE OF THE LUNG 361 (i) To Define the Outline of the Cavity. — The position and outline of the cavity are first defined as accurately as possible, both clinical and X-ray methods of examination being em- ployed. For this purpose a circle should be drawn upon the chest to include the centre of greatest intensity of physical signs. Then, using a stethoscope with a small chest-piece, this centre should be gradually approached from all sides, and a mark made at each point where pectoriloquy and cavernous breath-sound are first distinctly recognisable. In this way an outer circle is drawn, marking off a larger area. Further, the limits of dulness should be defined, and the position of other organs, the heart and diaphragm especially, taken into careful account. (2) Exploration. — The physician having thus marked out the area for exploration, and having controlled his results as far as possible by X-ray examination, a puncture should be made with an exploring needle-syringe, with not too fine a needle, through the central part of the inner circle, pushing the needle boldly in and quite vertically to the surface at the spot chosen. Several points may be thus explored should the first puncture not be successful. The sign of success is the withdrawal of purulent material, showing that the cavity has been struck; and the character of the fluid, whether foetid or otherwise, can now be ascertained. The instrument should be introduced, an inch and a half or two inches in the first place, and the syringe exhausted; if no matter appears, the needle should be pushed in farther, and then slowly and cautiously withdrawn, the operator testing each depth from the surface, and also endeavouring to ascer- tain by lateral movements the resistance of tissues and degree of fixity of the instrument. The length of the exploring needle should be known beforehand, so that its depth of penetration may at any time be calculated. In the event of failure to strike the cavity, it is probably best to desist from further measures, but a fearless and thorough exploration should be made at several points. Further Steps in the Operation. — If the withdrawal of even a few drops of discoloured fluid or pus show that the cavity has been reached, the needle may be retained in situ as a guide or withdrawn at the discretion of the surgeon. A portion of two ribs, one above and one below the site of 362 DISEASES OF THE LUNGS AND PLEURA puncture, should next be excised, care 'being taken not to wound the pleura. Since it is impossible to say whether the pleura is adherent or not, a circle of stitches two inches in diameter, as recommended by Sir Rickman J. Godlee,* to whose writings we must refer the reader for further surgical details, should be inserted around the site of puncture, uniting the pleural layers and penetrating the lung to the depth of half an inch. In this way the cavity of the pleura is completely shut off. The pleural layers are then divided, and if the needle has been withdrawn, the position of the pus is again locahsed by the exploring syringe. Sinus forceps are now passed along the directing needle until the pus is reached, then opened out and withdrawn, so as to rend open the cavity with the least risk of serious haemorrhage. The finger can now be inserted, the cavity thoroughly explored, its dimensions in different directions ascertained, and a sufficiently large drainage-tube introduced. Smart haemorrhage will sometimes occur during this opera- tion, as might be expected, but on air being freely admitted it usually soon ceases; if not, the wound must for a short time be plugged. We have not yet seen more than enough bleeding to cause momentary anxiety. Still, it is most desir- able to avoid as much as possible the use of cutting instru- ments in dealing with the lung. In some cases, although the exploring syringe gives evidence of having reached the cavity, it cannot be located at the operation, the needle having perhaps become displaced. Under these circumstances it is best to leave in a drainage- tube in the hope that the cavity may finally discharge through it. This happened in a successful case of Dr. Cayley's, which was operated upon by Mr. (now Sir Alfred) Pearce Gould.^ The treatment subsequent to the operation must be carried on in accordance with ordinary principles, and the special circumstances of each case. Gangrene of the Lung. Death of a portion of the substance of the lung may occur under two forms — (a) circumscribed; (b) diffuse. (a) The circumscribed form is that usually seen, the gan- grenous area being distinctly defined, and varying in size from that of a nut to a considerable patch involving the ABSCESS AND GANGRENE OF THE LUNG 363 greater part of one lobe. The lower lobes and superficial parts of the lungs are most frequently affected. The necrosed portions of the pulmonary tissue become moist, soft, pulpy, of a bluish-green or blackish colour, and evolve a peculiar and highly offensive odour. These portions consist of altered lung elements and blood-corpuscles, together with amorphous debris. The limits of the dead tissue are indicated by a zone of hyperaemia and consolidation. The necrotised lung may slough and be discharged through a bronchus, leaving a ragged cavity behind. Frequently, however, the pleura is in- volved, and the foetid material may find its way into the pleural cavity, unless, as sometimes happens, adhesions have previously formed between the pulmonary and parietal layers. (b) In the diffuse form there is no line of demarcation between the dead and healthy tissue, but inflamed, congested, and gangrenous lung are all mixed up together. The greater portion of one lobe, or of an entire lung, may be involved, or perhaps both lungs may be affected at several points. Etiology. — Necrosis of a portion of the lung is the result of obstruction of vessels and deprivation of blood-supply. It may be secondary to inflammation of the pulmonary tissue, however produced, or be merely mechanical in origin as from embolism of a branch of the pulmonary artery. Gangrene, with its characteristic signs, implies the presence of secondary putrefactive changes in this necrotic area. Gangrene may sometimes arise as a complication of acute pneumonia, especially when occurring in drunkards or those suffering from diabetes. Pysemic emboli, or the inhalation of foetid discharges from a cancrum oris or malignant growth in the mouth, or the bursting of a neighbouring abscess into a bronchus, may also give rise to it. In the insane it is not infrequently observed, possibly from the inhalation of food during its passage over an imperfectly sensitive glottis; and for a similar reason it sometimes occurs after tracheotomy. Retention of putrid bronchial secretion, with secondary septic broncho-pneumonia, may also produce it, as seen in bron- chiectasis. Gangrene may also be caused by wounds of the chest, and the lodgment in the lung of foreign bodies, such as bullets and pieces of cloth. It may complicate such debilitat- ing diseases as smallpox, typhus fever, and the like, when the condition may be generally traced to thrombosis of a branch 364 DISEASES OF THE LUNGS AND PLEURA of the pulmonary artery. Pressure of mediastinal growths and aneurism, which interferes with the circulation through the lungs, is another cause. Whatever the preceding condi- tions, it must be repeated that thrombosis or embolism block- ing a branch or branches of the pulmonary artery is the penultimate occurrence. Bacteriological examination reveals the presence in the gangrenous tissue of numerous varieties of micro-organisms. Among those that may be found we may mention the pyo- genic cocci, whether staphylococci, streptococci or pneumo- cocci, the bacillus proteus vulgaris, bacillus coli, bacillus pyocyaneus, and many others, among which may be included various anaerobic organisms. In several cases it is interest- ing to note that acid-fast bacilli, allied to the tubercle bacillus, have been discovered.* These organisms no doubt all play a part in producing the inflammatory condition which leads to the death of the lung tissue, or in originating the secondary putrefactive changes; it is evident that no one organism can be held responsible for the condition. Symptoms. — The most characteristic symptoms of gan- grene of the lung are the peculiarly offensive odour of the breath associated with the copious expectoration of foetid and discoloured sputum containing lung tissue. Foetid empyema, post-pharyngeal or other foetid abscess, might possibly be confounded with gangrene of the lung; but the condition most likely to be mistaken for it is old-standing bronchiectasis suddenly becoming foetid from necrosis of portions of mucous membrane, and from this it is to be dis- tinguished by the previous history of the case and the presence of elastic fibres in the sputum. Such fibres are not, however, invariably found in gangrenous sputum, for reasons which we have already explained (see p. 73). The general symptoms are extreme depression, asthenia, and collapse, and the termination is usually fatal. Haemoptysis from the opening up of bloodvessels is not uncommon, and we have known it to be the direct cause of death. Fever is more or less of the irregular suppurative type. Physical Signs. — In the early stages the auscultatory signs are indistinct and not to be relied upon; but later, if the gangrene be circumscribed and near the surface, the physical signs are dulness over the affected area, with gurgling rales. ABSCESS AND GANGRENE OF THE LUNG 365 accompanied by an amphoric quality of breath-sound. The distinctness of these signs varies, however, according to the position of the cavity and its degree of freedom from shreddy gangrenous tissue. X-rays, as with pulmonary abscess, may sometimes give an indication of the cavity, but here again much depends upon the presence of air as well as pus within the cavity and upon the condition of the surrounding lung, whether much consolidated or not. Treatment. — This should be nourishing and stimulating, alcohol being freely given. Antiseptics internally are of little use ; but inhalations of creosote, carbolic acid or eu- calyptus, such as that sug"gested in an earlier chapter (p. 218), should be employed. Under such treatment in a certain pro- portion of cases the sphacelus may be expelled through the bronchial tubes, the cavity contract and the patient make a good recovery. But such instances are unfortunately rare, and in cases of circumscribed gangrene with symptoms of hectic, in which the locality of the gangrenous cavity can be fairly defined, surgical treatment should be attempted. If operation be performed early, and the cavity be opened and drained in the manner already described (see p. 361), the outlook is greatly improved. Thus, in his address at the French Surgical Congress as far back as 1895, M. Reclus^ pointed out that, whereas the mortality from gangrene, if un- treated, was probably not less than 75 per cent., the figures after operation showed a death-rate of only 38-5 per cent, among 83 cases treated. The more recent figures of Garre and Quincke^ are still more favourable; of 281 cases, 197 were cured, with 84 deaths, a mortality of 293 per cent. It is to be observed, however, that the cases which would be selected for operation are not consecutive cases of gan- grene of all sorts, but those, such as we have spoken of above, in which the cavity is fairly restricted and defined. Neverthe- less, the figures indicate that in suitable cases surgical inter- vention is both justifiable and proper. In cases of diffused gangrene surg-ical treatment is of no avail. REFERENCES. 1 " Gangrenous Abscess of the Lung treated by Incision and Drainage : Recovery," by Solomon C. Smith, M.D., The Lancet, 1889, vol. ii., p. 113. 366 DISEASES OF THE LUNGS AND PLEURA ^ " A Case illustrating the Value of Surgical Treatment of Pulmonary Cavities," by J. Delpratt Harris, M.R.C.S., British Medical Journal, 1889, vol. i., p. 994. ^ The Surgery of the Lung, by C. Garre and H. Quincke, 2nd edition, 1912 (translated by David M. Barcroft, M.D.). London, p. 133. * Operations upon the Thorax and its Contents, by Rickman J. Godlee, M.S., F.R.C.S., A System of Operative Surgery, by various Authors, edited by F. F. Burghard, M.S., F.R.C.S. London, 1914, p. 723. * " A Case of Gangrene of the Lung following Necrosis of the Temporal Bone, the Result of Scarlet Fever ; Treatment by Drainage : Recovery," by W. Cayley, M.D., and A. Pearce Gould, M.S., Transactions of the Royal Medical and Chirurgical Society, London, 1884, vol. Ixvii., p. 209. ^ See " Acid-Proof Bacilli in Five Cases of Pulmonary Gangrene" (with bibliography), by W. Ophuls, M.D., The Journal of Medical Research, Boston, U.S.A., 1902, vol. viii., p. 242. ' " Chirurgie du Poumon (Plevre exceptee)." Rapport par le Dr. Paul Reclus, Neuvieme Congres Frangais de Chirurgie, Paris, 1895, p. 50. A translation of this article, though without the tables, will be found in Mr. Stephen Paget's work. The Surgery of the Chest, p. 443. Bristol and London, 1896. CHAPTER XXIII -HYDATID DISEASE OF THE LUNGS Hydatid disease, though rare in the United Kingdom, is prevalent in AiistraHa, New Zealand, Iceland, the Shetland Isles, and in the Argentine. Next to the liver, which is affected in more than half the cases of hydatid disease, the lung is most frequently the seat of the parasite.* In Australia the lung- is attacked in about i6 per cent, of the cases re- ported.^" In Europe the proportion is not so high, Neisser's statistics of 900 cases placing the percentage of the pulmonary variety at 7'4,^'' and in Iceland it is said to be even less.^" In the British Isles the lung is rarely affected, and chiefly amongst those who have resided in Australia and New Zealand. The disease is most prevalent in the male sex. It may occur at any age, although it is rare below the age of ten and above that of fifty. It is more frequent in the right than in the left lung; this preponderance in favour of the right side being most marked amongst cases of basic distribution. Sometimes the acephalocysts are multiple, and affect both lungs. The bases or central portions of the lungs are most commonly affected, but one or both apices may be attacked. The cysts may be found entire or broken in the bronchial tubes on their way to expulsion; they have also been found in the pulmonary arteries and right side of the heart, having been conveyed there from some distant point. The pleural cavity is rarely the primary seat of hydatid. The source of the disease, as of hydatids in other organs, is the introduction of the ovum of Tcenia echinococcus dis- charged from the alimentary canal of the dog. In England * We are greatly indebted in our remarks on " Hydatid of the Lung " to the writings of the late Dr. Davies Thomas, of Adelaide, and also to the lectures of Dr. A. A. Lendon, of the same State. 367 368 DISEASES OF THE LUNGS AND PLEURAE this small parasite, the total length of which is only one- quarter of an inch, is extremely rare. In Australia, on the contrary, the late Dr. Davies Thomas found it in nearly 40 per cent, of the stray dogs examined by him,^" the parasite having been acquired by their feeding- on the offal of sheep or cattle, the most common intermediate hosts, infected with the disease in the bladder-worm stage. The ovum usually effects its entrance into man throug^h drinking-water, finding its way to the lungs from the digestive canal, after passing en route through the liver and the right heart. The above facts ex- plain the great prevalence of hydatid disease in Australia, and especially in the country districts of the southern portion of the Continent, for there we find countless herds of cattle and flocks of sheep, as well as innumerable dogs, many of them already infected; while the water-supply, consisting often of unprotected surface pools, is not infrequently open to direct contamination by the dogs themselves. All the conditions necessary for the spread of the disease are thus at hand. The morbid anatomy of an hydatid tumour of the lung is after the same pattern as that of similar cysts elsewhere, the external investment being furnished by the more or less smoothed, thickened, and condensed pulmonary tissue. The investment of the pulmonary hydatid is thus in the lung very vascular, and with it one or more bronchial tubes may com- municate. In the lung more often than the liver the cysts are sterile and contain no daughter cysts. Symptoms. — The symptoms and signs of hydatid of the lung may be conveniently divided into : (i) those presented by the tumour before rupture; (2) those which occur during and after rupture. I. Before Rupture. — Unbroken cysts which have not attained considerable size may give rise to no recognisable signs; and so slow and insidious is their growth that even large tumours may exist for a long time unsuspected. Cough, haemoptysis, pain, and dyspnoea, are the chief symptoms that may be present in this stage, and may lead to a mistaken diagnosis of phthisis. The cough is dry, teasing in character, sometimes attended with slight bronchial expectoration; occasionally it is dis- tinctly paroxysmal, and has a laryngeal croupy character. Haemoptysis, although often met with at this stage, is usually PLATE XX X-Ray Photograph of a Case of Hydatid Disease of the Lung, showing the well-defined rounded shadow so suggestive of this condition. To face p. 369. HYDATID DISEASE OF THE LUNGS 369 but slight in amount, from a mere streak or staining of the sputum to a teaspoonful or so, and is due to active pulmonary congestion set up by the growing- parasite in its immediate neighbourhood. Pain is not felt except when the cyst has approached near enough to the surface to involve the pleura; but before this period an ill-defined uneasiness may be experienced. The dyspnoea is inappreciable except in the case of a large cyst, or one situated near the root of the lung. The centric pressure symptoms of an hydatid are, however, never very marked. The physical signs before rupture may, in cases of small or deeply-seated cysts, be completely obscured. Over tumours of larg'er size, and nearer the surface, a certain degree of fulness is to be observed, with effacement of the intercostal spaces over a limited area. Percussion dulness, having a very definite and circular outline, is obtained over this region, beyond which there is normal or modified pulmonary resonance. A certain degree of elasticity may be appreciated on percussion over the most central point, amounting possibly to " hydatid thrill," a rare sign, however, in hydatid cysts of the chest, and in no way pathognomonic, since we have known it well marked at the superior level of the fluid in pyopneumothorax, and perfectly elicited in a case of hydronephrosis. Over the region of dulness vocal fremitus and respiratory murmurs are enfeebled or absent; and in some cases pleuritic friction is present over the tumour. Displacement of the heart and other organs may occur. In association with these more or less positive signs and symptoms there are the important facts of the absence of pyrexia, the but slight interference with general health and nutrition, and the very insidious and ill-defined onset of the disease. The position of the physical signs is sometimes of value in diagnosis, when they present in the mammary or axillary, infrascapular, or some other unusual situation not commonly affected by more ordinary lesions. Of great assistance also is an X-ray examination in disclosing the hydatid, the cyst commonly appearing* as a circular shadow clearly defined from the surrounding lung, and presenting a picture which is almost diagnostic (see Plate XX.). A blood examination often shows a leucocyte count within the normal, but revealing- an increased proportion of eosino- 24 3/0 DISEASES OF THE LUNGS AND PLEURAE phile cells, from 6 per cent, upwards. Such an eosinophilia is not, however, invariably present, nor is it of itself diagnostic, since it is observed in the presence of other animal parasites, as well as in asthma and certain diseases of the skin. The comple- ment-fixation test,* a method of diagnosis upon the lines of the Wassermann reaction for the detection of syphilis, is as a rule positive in echinococcus disease, but even with the best tech- nique a similar result has occasionally been observed in the absence of such affection. A negative reaction also does not exclude the presence of the disease, and should be expected if suppuration of the cyst has taken place. The reaction, there- fore, cannot be entirely relied upon. The removal through a fine trocar of the characteristic hydatid fluid of low specific gravity (1005-1007), rich in chlorides and free from albumin, containing possibly some booklets, would solve the diagnosis.- This step, however, should never he taken until the surgeon is prepared for the rapid evacuation of the cyst, and this for reasons to be presently mentioned. The following cases illustrate well the main clinical features presented by hydatid of the lung before it has ruptured : Case i. — Mr. G., aged about thirty, came under the observation of Dr. Douglas Powell on October 14, 1891, on account of a cough and sanguineous expectoration. He was a well-developed spare man, who had lived most, if not all, of his previous life in Sydney. He had never been robust, but since he had come on business to this country in 1887 his health had improved. Two years previously he had influenza, with " catarrh of the right lung," for which he went to St. Leonards, and it was there stated to him, by the late Dr. Cooke, that his right lung was weak, but not definitely diseased, and on examination of his sputum no tubercle bacilli were found. He re- gained health, and remained well through the winter of 1890, although he again found it expedient to spend six weeks of that winter at St. Leonards, his own home being in or near Cambridge. In the spring of 1891 he caught a fresh cold, and since June, when he had a mild pleurisy, he had suffered from cough and morning expec- toration, often streaked with blood. For some weeks past the expectoration had been more considerable, diffused, muco-purulent, and more or less stained with blood. Specimens of the sputum examined on October 15 and 17, 1891, were described as follows : " October 15 : Purulent, blood-stained; no tubercle bacilli; few micro- organisms of any kind. In unstained specimens epithelial debris, small in amount, from buccal-respiratory tract. October 17 : Two samples having the same character ; purulent, blood-stained ; no HYDATID DISEASE OF THE LUNGS 371 tubercle bacilli ; in unstained specimens pus cells, many undergoing fatty degeneration, also large lymph cells degenerated; large zooglcea groups of micrococci; very few epithelial elements." The physical signs are shown in the annexed diagram (Fig. 35). Some fulness was observed on the right front of the chest from the second to the sixth rib-space ; over this area, and extending laterally to the anterior axillary line and to the left margin of the sternum, the percussion note was dull in the centre, shading off at the margin, so as to present a rounded outline. Over the dull space the respiratory murmur was annulled, vocal fremitus diminished, and voice not con- ducted. Along the upper margin of dulness, in the subclavicular B A- FiG. 35. A, Centre of dense dulness and fulness of surface; B, area of lighter dul- ness, with annulled breath-sound and fremitus marking limits of tumour ; C, shell of lung, giving high-pitched resonance, weak respira- tion, and a few fine rales ; D, liver dulness, between which and area of tumour there is a narrow zone of resonant lung, giving weak but vesicular breath-sound; E, heart's apex-beat a little to left of the ' normal. regions, the percussion note was high-pitched, tubular, and the respiratory murmur weak and accompanied by a few fine rales. At the lower border, between it and the liver dulness, there was also a narrow area of resonance and weak but vesicular breath-sound. The left lung was enlarged to include the left half of the sternum and covering the precordial region. The heart's apex-beat was slightly to the left of the normal point. Posteriorly, on the right side, the respiration was weakened over the upper half, with some fine conges- tion rales at the extreme apex, and some similar rales at the base ; the percussion note in the interscapular region was slightly raised. The diagnosis of hydatid of the lung having been made, aspiration, 3/2 DISEASES OF THE LUNGS AND PLEURA at that time a recognised method of treatment, was advised, and this was performed between the fourth and fifth ribs by the late Dr. Lucas, of Cambridge, on November 4, one pint of clear hj'datid fluid being removed by the instrument. Five minutes later another pint tinged with blood came with a rush from the throat, and for some days afterwards Mr. G. had a bad cough, spitting up cyst membrane and foetid pus. The expectoration for some weeks amounted to a pint and a half each day, .but gradually diminished to half a pint, then ceased. When seen again on February 9, 1892, he had no cough, his general condition was good, and he was again on his way to St. Leonards. There was slight fulness and want of resonance in the right second space ; otherwise nothing was notable beyond some weakness and harshness of breath-sound. Dr. Lucas, in a letter dated December 12, 1892, reported him as being in robust health. Case 2. — Mr. X., aged twenty-three, was born in New Zealand and had lived there all his life until, in September, 19 16, he left for England as a member of the New Zealand Expeditionary Force. He was a healthy, well-grown man, and had always enjoyed good health. He had previously been engaged in office work. His illness commenced in March, 1917, when serving in France. The first symptom complained of was pain in the lower part of the left side, accompanied by slight pyrexia lasting for a few days. This was followed by cough with phlegm, which was sometimes streaked with blood. These symptoms continued, and on June 2 he had a sharp attack of haemoptysis, and on June 13 a second attack, on this occasion bringing up several ounces of blood. Except for the slight and passing pyrexia referred to above there had been no rise of temperature. The sputum was examined for tubercle bacilli, but they were not found. He was invalided home to England and admitted to a base hospital, when the diagnosis of pulmonary tuberculosis was made and sanatorium treatment recommended. He was, however, transferred to the New Zealand General Hospital at Walton-on-Thames, where the possibility of hydatid disease was recognized, in view of the frequent occurrence of this malady in the Dominion, and on being X-rayed the regular, well-defined shadow of the C3'st was at once seen, thus confirming the diagnosis. On June 29, through the courtesy of Colonel Myers and of the New Zealand Authorities, one of us had the opportunity of visiting the hospital at Walton-on-Thames, in which at the time were five cases of hydatid of the lung, and found the physical signs in the case of Mr. X. to be as follows : On the front of the chest percussion and auscultation were natural. On the back a somewhat oval area of dulness was present, involving the lower scapular and interscapular region on the left side, extending from the fourth to the eighth rib posteriorly, as indicated at A, Fig. 36. For some distance around" this the note was flattened (B, Fig. 36), but below this to the bottom of HYDATID DISEASE OF THE LUNGS 373 the chest the percussion note was resonant. Over the dull area the vesicular murmur was but feebly heard, and vocal vibration was diminished. No bronchial breathing or moist sounds were audible. On examination the patient with the X-ray screen, a well-defined shadow the size of a cocoanut, with regular outline, having all the appearance of a hydatid cyst, was clearly visible. From its better definition when viewed from behind, it was clear that the cyst was nearer the posterior than the anterior wall of the chest, thus agreeing with the physical signs. The diagnosis having been made, it was decided to treat the case by resection of rib and drainage, as described in a further paragraph (see p. 377). The operation was successfully performed on June 30, and on August 8 Mr. X. was evacuated home to New Zealand, con- valescence being somewhat retarded by infection of the wound, which manifested itself a week after the operation. Fig. 36. — Diagram showing the Physical Signs of Hydatid of the Lung AS met with in Mr. X., aged Twenty-three, whose Case is described IN THE Text. 2. Rupture of the Cyst. — Spontaneous rupture of the cyst into the bronchial tubes takes place in about half the cases, into the pleura in 5 per cent., and more rarely into the pericardium, pulmonary vein (Wilson Fox), or through the diaphragm (Dupuytren). It must be remembered also that an hydatid cyst of the liver may rupture upwards and the contents be expectorated. Sudden pain, intense dyspnoea, and the expectoration of a large amount of watery blood-stained fluid, often having a peculiar and unpleasant taste, are the symptoms which imme- diately attend upon rupture of the sac into the lung. In some cases the lungs are so completely flooded as to overwhelm the patient and cause immediate death. In other cases the churn- 374 DISEASES OF THE LUNGS AND PLEURA ing and rattling of the fluid and air in the chest can be heard, and after a desperate struggle the bronchial tubes become sufficiently cleared, when rapid amendment of symptoms takes place. Together with the fluid a greater or smaller number of daughter cysts may be expelled, and sometimes immediately, but more often at a subsequent date, the cyst wall may be expectorated entire, or more commonly in fragments, with symptoms of threatened suffocation. In some cases death has resulted from impaction of a portion of the cyst wall in the glottis. It frequently happens that with these alarming- symptoms the real nature of the disease is for the first time disclosed, the expectoration of the hydatid membrane or daughter cysts being especially characteristic. Hooklets and scolices are frequently to be found in the expectorated fluid on microscopical examination, and frag- ments of the cyst membrane reveal also the peculiar lamination so characteristic of hydatid, which remains unchanged long after the death of the parasite. Haemoptysis, much more profuse in quantity than in the earlier stages of the disease, may occur at the time of rupture, or at a subsequent period. It is due to the tearing away of the cyst membrane from its vascular capsule, from which, at the moment of collapse, the support and even pressure of the distended cyst is suddenly removed. This intracystic pressure was ascertained by Dr. Thomas ^* in several cases of hydatid cyst to measure from lo to 12 inches of water, and in one case, in which the cyst was large enough to bulge, and was therefore compressed by the thoracic wall, it amounted to 25 inches during inspiration, 30 inches during expiration. Haemoptysis is thus one of the most constant and important symptoms of hydatid of the lung, occurring at some period in about four- fifths of the cases. As a rule only slight in degree at the earlier stages, it is often severe and repeated, sometimes even fatal, after the rupture of the sac. Course of the Disease. — From time to time, as we have indicated, small hydatid cysts are unexpectedly met with in the lung after death, shrivelled and infiltrated with salts, and with their fluid contents partially absorbed and inspissated. But such instances of the death of the parasite, though not infre- quent in the liver, are rare in the lung, and only occur in cysts of very small dimensions, which have probably given rise to HYDATID DISEASE OF THE LUNGS 3/5 no symptoms. Dr. Lendon/* indeed, goes so far as to say that there is " no case on record in which a cyst diagnosed as such during life has been left alone, and has been found after the death of the patient to have undergone retrograde change." In considering treatment, therefore, such a happy event must not be anticipated. Hydatid cysts, indeed, large enough to give rise to symptoms and physical signs, and to be diagnosed as such, tend to enlarge, and finally to rupture, exposing the patients in that event to the danger of being suffocated by the sudden flooding of the bronchial tubes. Of the large proportion of cases in which death is not caused by suffocation at the time of rupture, many recover; the cyst wall is gradually expectorated, and, the surrounding lung expanding, the cavity becomes closed. In other cases, after a longer or shorter interval, suppuration of the capsule takes place, and a pulmonary abscess, sometimes of a very foetid type, results. The emaciation, hectic, occasional haemoptysis, severe cough, and often profuse expectoration that characterise the later stages of hydatid disease, in combination with the physical signs of excavation of the lung and of great bronchial irrita- tion, especially on the side affected by the parasite, are at first sight suggestive of advanced pulmonary tuberculosis. A careful examination into the history of the case, however, including the sudden commencement of expectoration as a copious outburst of blood-stained watery or semi-purulent fluid, having a peculiar and unpleasant taste, and the discovery of the physical signs of a cavity in some situation unusual in phthisis, will arouse suspicions as to the true nature of the disease. A careful daily observation of the sputum, which is, moreover, often foetid, may lead to the discovery of mem- branous shreds or the more typical " gooseberry skins," of which microscopic examination will reveal the structure to be that of hydatid cyst. Diagnosis. — From the early occurrence of haemoptysis and cough hydatid disease of the lung may be mistaken, as we have seen, for phthisis. If situated in the lower part of the lung it may simulate a pleuritic effusion, and the more so as some degree of pleurisy with slight effusion not uncommonly accompanies the cyst-formation, though not, as a rule, suflficient to obscure the X ray picture. 3;6 DISEASES OF THE LUNGS AND PLEURA The possibility of hydatid affection should be borne in mind in patients coming from Australia and New Zealand or any country in which the malady is common, and an X-ray examination of the chest should be made in all doubtful cases. In the later stages of the disease, when suppuration has occurred, the case has to be discriminated from advanced phthisis, suppuration of the lung, and other alHed conditions. A repeated examination of the sputum is then of great value. Treatment. — A review of the statistics of cases left untreated would place the natural mortahty of the complaint at between 50 and 60 per cent.^ The disease cannot, therefore, be left alone, and medicinal remedies being of little use, recourse must be had to more active methods of treatment. Until recently, paracentesis of the cyst and the evacuation of as much of its fluid contents as possible, thus causing the death of the parasite, was the method usually employed. Under this line of treatment certain cases no doubt recovered which under the expectant treatment would have died, but in some cases death has directly followed the operation*^ (Plate XXI.). This arises in certain instances from the trocar becoming blocked by a portion of the cyst wall or by a daughter cyst, and failing therefore to extract more than a few ounces of fluid ; when the instrument is withdrawn, the elastic cyst retracts, and the contents are discharged into the cavity in which it lies, thus flooding the bronchi and leading to suffocation, as in spon- taneous rupture.* In other cases it is probable that the paracentesis produces not merely a fine hole in the cyst wall, but a tear in the chitinous envelope, thus more easily leading to the escape of the contained fluid. For the above reasons paracentesis can no longer be recom- mended, and we should in all cases in which the cyst is accessible proceed at once to the radical operation of incision and removal, which constitutes the proper treatment of such cases. For similar reasons, exploratory puncture for diag- nostic purposes, even with the finest needle, should not be countenanced until resection of a rib has been performed and the surgeon is ready at once to incise the cyst. Moreover, * It is interesting to note that the blocking of the trocar by a cyst during paracentesis was a condition well known to ancient writers (see Aretaeus, On the Causes and Symptoms of Chronic Diseases, book ii., chap, i., p. 337, Sydenham Society edition). PLATE XXI ,U>^-' i.ox HYDATID OF THE LUNG The drawing shows the left lung of a boy aged nine years. In the lower lobe is seen a lajrge cavity about three inches in diameter, in which lies collapsed and coiled up a solitary hydatid cyst (A). From the cavity a communication with the left bronchus had been effected by an ulcerated aperture, through which a bristle has been passed. By this means the fluid within the hydatid made its way into the bronchial tract after puncture of the cyst, and caused death by suffocation. The pleura over the outer aspect of the cyst is covered with recent lymph. From a patient who presented symptoms and signs suggestive of pleurisy with effusion. Paracentesis was performed, but only a few drachms of clear watery fluid were evacuated. The boy almost immediately began to cough, and brought up 3 or 4 ounces of clear frothy fluid. He died of suffocation within eight minutes of the paracentesis. The case is recorded by the late Dr. Bristowe in the Transactions of the Clinical Society, ,1891, vol. xxiv., p. 73. (From the Museum of St. Thomas's Hospital. | natural size.) PLATE XXI - A Hydatid of the Lung. To face p. 376. HYDATID DISEASE OF THE LUNGS 377 since the introduction of the X-rays exploratory puncture has become unnecessary, for hydatid cysts present, as we have said, a picture which is strongly suggestive of the disease. Operation having been decided upon, resection of a rib must be performed and the pleural layers united by suture. The cyst must be then boldly and freely opened with the aid of expanding forceps, and its fluid contents allowed to escape quickly, to avoid the flooding" of the lung which might other- wise result. To assist the evacuation, it is wise to turn the patient well over on to the affected side at the moment of incising the cyst. The chitinous envelope can as a rule be easily detached from the surrounding lung and the cyst with- drawn. The wall of the cavity should then be swabbed with a I per cent, solution of formalin to render it aseptic, and thus prevent post-operative recurrence from the growth of an escaped scolex.^ The cavity and wound in the chest-wall may then be closed, but should it prove impossible to evacuate the cyst, or should suppuration have occurred, drainage must be undertaken. The results of this method of treatment are very satisfactory. To quote only those of more recent date, we find that of 99 cases reported upon by Garre and Quincke,* 78 recovered and 21 died, a mortality of 21 '2 per cent. Guimbellot,' collecting cases from the literature, found that among 223 patients treated by thoracotomy, 194 were cured and 29 died, a death-rate of 13 per cent. Dividing the cases into those in which the cyst was healthy at the time of the operation, and those in which suppuration had occurred, the statistics yielded a mortality of 8'2 per cent, in the case of the former, and of 19 per cent, in the latter. These figures contrast favourably with the death-rate of 55 per cent, among patients left untreated. The value of radical surgical treat- ment as indicated by the earlier statistics of Dr. Thomas-* is thus amply demonstrated. Should spontaneous rupture occur, each case must be treated on its merits. As we have seen, many such patients eventually recover, gradually coughing up the membrane and evacuating the cyst. But if suppuration has set in, and if, in spite of a generous supporting diet and the administration of such remedies as bark and mineral acids, the patient is evidently losing ground from hectic and profuse expectoration, it will be wise to treat the case surgically, and to open and drain the 3/8 DISEASES OF THE LUNGS AND PLEUR/E cavity on the lines already indicated for abscess of the lung (see p. 361). If the hydatid cyst be in the pleural cavity, a condition of rare occurrence, it will probably be mistaken for a pleural effusion until exploratory puncture reveals the true nature of the case. Resection of a rib and evacuation of the cyst is then the proper method of treatment. REFERENCES. ' la) Hydatid Disease, by John Davies Thomas, M.D., F.R.C.S., p. 122. Adelaide, 1884. {b) Loc. cit., p. 21. ^ [a) Hydatid Disease, by the late John Davies Thomas, M.D., F.R.C.S., edited by Alfred Austin Lendon, M.D., vol. ii., p. 38, Sydney, 1894. [b] Loc. cit., vol. ii., pp. 142, 160, 161. ° [a] See Clinical Lectures on Hydatid Disease of the Lungs, by Alfred Austin Lendon, M.D., p. 116. London, 1902. {b) Loc. cit., p. 23. ^ [a] See L. C. Zapelloni (// Policlinico, Rome, 1915, sez. Chirurg., xxii.), British Medical Journal, 1916, i., Epit. No. 29. {b) Injection, Immunity, and Specific Therapy, by John A. Kolmer, M.D., D.Ph., M.Sc, p. 524. Philadelphia and London, 1917. ' The Surgery of the Chest, by Stephen Paget, M.A., F.R.C.S., p. 411. Bristol and London, 1896. ^ See, amongst others : (i) " Case of Living Hydatid of the Lung, in which Aspiration was followed immediately by Subcutaneous Emphysema and by Suffoca- tion due to the Rush of Hydatid Fluid into the Bronchial Tubes," by J. S. Bristowe, M.D., F.R.S., Transactions of the Clinical Society of London, 1891, vol. xxiv., p. 73. (2) A " Case of Hydatid of Lung which proved Fatal by Rupture into a Bronchus Nine Hours after Treatment by Aspiration," by Hector W. G. Mackenzie, M.D., Transactions oj the Clinical Society of London, 1S92, vol. xxv., p. 215. ' " Observations on the Treatment of Hydatid Disease from the Points of View of (i) Prophylaxis, (2) Aspiration or Tapping, and (3) the No-Drain Operation of Bond and Others," by L. E. Barnett, F.R.C.S., Professor of Surgery, University of Otago, New Zealand Medical Journal, May, 1914, p. 145. * Surgery of the Lung, by C. Ga.rre and H. Quincke, second edition. Translated from the German by David M. Barcroft, M.D., p. 214. Lon- don, 1912. ' Sur le Traitement Chirurgical des Kystes Hydatiques de la Plevre et du Poumon. These pour le Doctorat en Medecine, par Marcel Guimbellot, p. 40. Paris, 1910. CHAPTER XXIV INTRATHORACIC DERMOID TUMOURS Sir John Bland-Sutton* classifies those dermoid tumours as " sequestration dermoids," which arise in detached or se- questrated portions of surface epithehum. They occur chiefly in situations where, during embryonic life, coalescence takes place between skin-covered parts, namely, along the median line, in front or behind. The thoracic dermoids of this type occur in two situations : — (i) On the anterior aspect of the sternum, usually in the middle line, about the junction of the first and second sternal pieces, where they present as external tumours. (2) In the thoracic cavity. Sir John Bland-Sutton would regard such intrathoracic dermoids as due to the sequestration of a piece of skin during the development and junction of the two halves of the sternum, and the subsequent dislocation backwards of the involved portion to the deep surface of the bone. Here it may remain indefinitely dormant, or become active and gradually enlarge to form a cystic tumour. Such cysts are probably always mediastinal in their commencement, and may so remain throughout their course. In other cases the tumours rapidly enlarge, extending their boundaries, not passively by mere distension from within of accumulating contents, but actively, so that the term dermoid growth, rather than dermoid cyst, should be applied to them. As they enlarge they are apt to become closely adherent to the pericardium and pleura and to penetrate deeply into the lung, where they become so embedded that their original connection with the mediastinum is obscured. A communication with the lung or a bronchus may at any time be established, and on the accession of air into the cavity suppuration is liable to ensue. On section, such tumours are found to contain sebaceous material, and often hairs. In other cases the cyst contains in 379 380 DISEASES OF THE LUNGS AND PLEURA addition such structures as muscle, cartilage, bone or teeth, and would then belong pathologically to a different category, and should be classified among the teratomata. Intrathoracic dermoids, including teratomata, are very rare, and Dr. Batty Shaw and Dr. Williams,-'' in their paper dealing with this subject, were only able to find records of thirty-five authentic cases, a total recently brought up to fifty-two by Dr. Pohl.^ From an analysis of these cases the following facts appear. The sexes are affected equally. In some of the cases the tumour has remained of small size and has been only found by accident after death. In others symptoms have supervened which caused the patient to seek advice. The age at which such symptoms manifest themselves varies, being sometimes as early as sixteen, though " in by far the larger number the age was between twenty and thirty years." Careful cross-question- ing may, however, elicit the fact that hairs have been ex- pectorated for some years previously; this had occurred in one case on many occasions since the patient was sixteen years of age, and in another at fifteen, the earliest age at which it has been recorded. This symptom, which was present in seven of the thirty-five cases referred to above, is a most characteristic feature of the disease, and should always be carefully inquired for. It is of importance also as showing that a communication exists between the interior of the cyst and the air-passages, with the danger of suppuration which such a communication entails. Other symptoms, such as cough, expectoration, shortness of breath, and sometimes haemoptysis, are produced by the enlargement and irritating effects of the cyst, which not uncommonly reaches the size of a child's head, or even larger. The temperature is as a rule but little raised, unless suppura- tion or septic pneumonia ensue. Fever, night-sweating, and wasting then supervene. In some cases, as in that to be immediately related, an empyema occurs, and may entirely mask any characteristic signs. The physical signs — impairment of note over the tumour, with weak or absent breath-sounds, diminished vocal resonance and vocal vibrations — offer nothing characteristic. It is stated that compression of veins is much less common than in cases of malignant growth in the mediastinum, a point of some INTRATHORACIC DERMOID TUMOURS 38 1 diagnostic importance. It occurred, however, in a marked degree in a case reported by Dr. Mouat.* The X-rays, provided the surrounding lung and pleura be still healthy, reveal a somewhat rounded shadow, with margin well defined, except perhaps on the inner side, and without pulsation. Such a picture might lead the observer to consider the possibility of a dermoid cyst, but in the absence of the expectoration of hairs, or of an exploratory operation, the exact diagnosis must remain a matter of uncertainty. The disease, if untreated, marches slowly to a fatal termina- tion, more than half the patients dying before the age of thirty. The end is brought about by suppuration, septic pneumonia, pulmonary tuberculosis, and sometimes with symptoms of pressure ; in other cases the cysts have been known to rupture into the pericardium and the superior vena cava. The average age at death in seventeen cases collected by Drs. Batty Shaw and Williams"" was thirty-two, the youngest patient being twenty, the oldest sixty. Drugs are of no avail in the treatment of this disease, and surgical intervention must be considered. Of seven cases thus treated, quoted by the above authors, in one, in which the cyst was small, complete enucleation, with recovery of the patient, was effected. But such a result is exceptional. In most cases, before the cyst has given rise to decided symptoms, and thus come under observation, it has already attained considerable dimensions, and has formed attachments to the pericardium, lungs, pleura, or diaphragm, so that its complete removal is impossible. For a similar reason complete retraction of the cyst walls after operation is unlikely. Nevertheless, greajt diminution in size of the cavity has followed incision and drainage in most of the cases operated upon, the patient being left with a small fistula only. In one case alone, and that the earliest, was the result unsatisfactory. In view, therefore, of the steady progress of the disease to a fatal termination, if not actively treated, the question of surgical intervention should always be carefully considered. The details of the following case, sent to Dr. Douglas Powell by the late Dr. Sturges, of Beckenham, and seen by him six years later with the late Sir Lauder Brunton and Sir Rickman Godlee, will illustrate the more important features of the 382 DISEASES OF THE LUNGS AND PLEURA disease, althovigh, as we shall presently point out, in view of later investigations there is some room for doubt whether its real origin may not have been teratomatous. In this instance it will be noticed that but little retraction of the cavity took place after operation. At the first consultation in 1881, the lady, aged twenty-nine, pre- sented all the signs and symptoms of a purulent effusion into the right pleura, which had supervened upon an acute right pleurisy the preceding May. There were no physical signs to differentiate the case from an ordinary empyema, the presence of pus being inferred from the prolonged duration and hectic character of the symptoms. Exploration, with a view to thoracentesis, was advised, but was deferred, as the lady was on her way to the South of France. The operation was then still further postponed, and, a few months later, rupture through a bronchus took place, and a large quantity of matter was expectorated. The empyemic cavity partially contracted, the expectoration gradually diminished, and the lady regained strength and flesh, and subsequently married. Mrs. W. was not seen again by Dr. Powell until six years later, in June, 1887, when Sir Lauder Brunton consulted him about her, she having somewhat failed of late, losing flesh, showing a daily, although slight, rise of temperature, and presenting a trace of albumin in the urine. The side was now considerably contracted, the ribs approxi- mated, and the signs of the empyemic cavity occupied the antero- lateral region of the lower right chest, extending also somewhat back- wards, where it was bounded above by a downwartf slanting line skirting the angle of the scapula. There was still nothing about the case to suggest any other diagnosis than that of an old empyema cavity communicating with the lung through a bronchial fistula. It was agreed that the cavity should be drained from without, and, on June 18, this was effected by Sir RIckman Godlee, who excised a portion of the sixth rib in the anterior axillary line, having previously punctured at this point, where there was some tenderness, and found pus. About an ounce of pus escaped, and some caseous, putty-like- looking stuff was removed. The patient again improved, but the discharge from the wound continued. On August 9 the cavity was again explored. At Its orifice a hair was noticed, and on introducing a small sponge into the cavity a number of hairs were found to adhere to it, and subsequently a handful of matted hairs and putty-like debris was removed. The nature of the case was now for the first time apparent, and the patient, on being questioned, stated that she had coughed up two hairs since the previous operation, and also on one or two occasions long previously, and that her brother, who had been dressing the wound, had observed one or two on the dressings. On carefully exploring the cavity In the light of this new discovery, its irregular interior was found to be due to finger-like processes consisting of INTRATHORACIC DERMOID TUMOURS 383 excrescences of fibro-cellular tissue covered with skin, from which the hairs were growing. At a subsequent operation in September the opening was enlarged by excising a portion of a third rib, and one of these processes was removed close to its base by Paquelin's cautery, and other small ones ligatured and removed by scissors.* It was found that the cavity extended up to the apex of the thorax, and that the wall of the cyst was intimately connected with the surfaces of the lung and diaphragm. The internal parts were some- what freely cauterised, and the skin of the thorax was then sutured to that of the dermoid cyst, and the cavity looselv plugged with boracic lint. Under this skilful handling by the surgeon the patient rapidly improved, although discharge remained and required daily irrigation. The patient held her own, wintering at San Remo for two or three years, and finally died from drain poisoning at some mountain resort in the summer of 1891. In this case, in the absence of post-mortem examination, we may infer that the malady started in the upper mediastinum by extension from a remnant of dermal tissue involuted and detached, and for a time embedded in the tissues. The first effect of its active growth and intrusion into the pleural cavity was to set up pleurisy and empyema, the dermoid growth gradually extending to occupy much of the cavity. The empyema, with which it was complicated, then perforated the pulmonary pleura and thus permitted some of the hairs from the growth to escape through the lungs. A case of " dermoid growth of the lung " closely resembling that above described was brought before the Pathological Society by Dr. Cyril Ogle," in which the cyst was embedded in the lower lobe of the left lung, occupying a cavity of about four inches in diameter, and communicating freely with the left bronchus. The contents were of the usual character, including five or six stalked, tongue-like processes with short hairs growing upon their surfaces. The stalks were united and appeared to grow from the wall of the cyst, but the united stem could be traced upwards into the mediastinum at the level of the left innominate vein. Embedded in the common stem or core a large tooth was found, and this fact places the case amongst those of teratomata. The specimen was taken from a man, aged twenty-eight, who had died of hjemoptysis. Although it may be regarded as in the highest degree probable that some intrathoracic dermoid growths have their origin in " the inclusions of portions of the primitive epiblast during the closure of embryonic clefts" (Shattock^"), it is 384 DISEASES OF THE LUNGS AND PLEURA likely that a further and more complete examination of such cases as that of Mrs. W., above related, may prove that the majority of them are really teratomata, abortive embryos, whose origin is explained on the theory of embryo-genesis put forward by Mr. Shattock.^* The structural resemblances between the cyst described by Dr. Cyril Ogle and the one which we have above related are great. It was only on close post-mortem examination in Dr. Ogle's case of the stalk whence the fleshy, hair-covered processes projected that a tooth was found. In our case the patient died of another malady, no autopsy was made, and the only structures examined were some of the fleshy processes removed by Sir Rickman Godlee. REFERENCES. ' Tumours, Innocent and Malignant, by Sir John Bland-Sutton, LL.D., F.R.C.S., sixth edition, p. 524. London, 1917. ^ {a) "A Case of Intrathoracic Dermoid Cyst," by H. Batty Shaw, M.D., and G. E. O. WiUiams, M.B., The Lancet, 1905, vol. ii., p. 1325 (with bibliography). See also (b) " Case of Mediastinal Dermoid," by G. E. O. Williams (intro- duced by Batty Shaw, M.D.), Transactions of the Clinical Society of London, 1906, vol. xxxix., p. 210. ^ The following papers give a nearly complete record of the cases published up to the year 1914.: [a] " Beitrage zur Genese. Pathologie und Diagnose der Dermoid- cysten und Teratome im Mediastinum anticum," von Dr. Bruno Dangschat, Beitrage zur Klinischen Chirurgie, vol. cxxx., 1903, p. 692. {b) " tJber Mediastinal-Dermoide," von Dr. W. Pohl, Deutsche Zeiischrift fiir Chirurgie, vol. cxxx., 1914, p. 481. * " Case of Suppurating Dermoid of the Mediastinum," by Thomas R. Mouat, M.B., British Medical Journal, 1909, vol. i., p. 90. ^ See Sir Rickman Godlee's paper dealing with the case — " Dermoid Cyst of the Right Side of the Chest communicating with a Bronchus," by Rickman J. Godlee, M.S., Transactions of the Royal Medical and Chirurgical Society, 1889, vol. Ixxii., p. 317 — in which the curious processes excised are figured. * "Dermoid Growth of the Lung," by Cyril Ogle, M.D., Transactions of the Pathological Society of London, 1897, vol. xlvii., p. 37. ' {a) " An Acardiac Acephalous Ovarian Embryoma, with Remarks on the Pathogenesis of the so-called Dermoid Cyst of the Ovary," by S. G. Shattock, Transactions of the Pathological Society of London, 1907, vol. Iviii., p. 273. [b) Loc. cit., p. 303. CHAPTER XXV SYPHILITIC DISEASE OF THE BRONCHI AND LUNGS Bronchial Syphilis. The respiratory organs may become affected in the secondary or tertiary periods of syphilis. In the eruptions of secondary syphilis the bronchial mucous membrane is sometimes involved. It is true that the positive evidence of macular syphilis of the bronchial tubes is incomplete, and not confirmed by post- mortem observation; but very decided symptoms of bronchial catarrh are so frequently met with in association with the secondary cutaneous rash of syphilis and the corresponding throat affections that it is impossible to escape the conviction that a specific catarrh of the respiratory tract is present in such cases. Moreover, condylomata may occasionally be visible in the larynx. The catarrhal symptoms and mottled cutaneous eruptions of syphilis, together with a certain degree of pyrexia, may be mistaken for those of measles. We have not observed asthma in association with the bronchial eruption in syphilis. Syphilitic ulceration of the bronchial tubes is of rare occurrence during the secondary period of the disease, and is only occasionally to be met with in association with tertiary lesions. When a main bronchus or the bifurcation of the trachea is the seat of a syphilitic ulcer, paroxysmal cough and dyspnoea, with scanty expectoration occasionally streaked with blood, may be expected, and the diagnosis would be helped by the observation of other phenomena of syphilis. The ulcer may perforate the trachea or bronchus, and produce mediastinal or pulmonary abscess; or a branch of the bronchial artery may be opened up, leading to severe or fatal haemor- rhage. But the tendency of the syphilitic ulcer is, after deep erosion of the tissues, to cicatrise, causing contraction and 385 25 386 DISEASES OF THE LUiSTGS AND PLEURA deformity of the tubes affected, and leading later to bron- chiectasis and fibrosis of the lung. We have already alluded to narrowing of the bronchi as one of the dreaded conse- quences of syphilis (see p. 205). Syphilitic ulceration of the smaller tubes is of occasional occurrence, and may extend into the lung, producing peribronchial pneumonic consolida- tions. The clinical recognition of bronchial syphilis rests upon (i) the presence of symptoms of broncho-pulmonary disease which are not in the order of those characteristic of simple bronchitis or phthisis; (2) the history of the patient and the manifestation of the syphilitic cachexia in other directions; (3) the rapid amendment, provided the disease be not too far advanced, that ensues upon antisyphilitic treatment. . Pulmonary Syphilis. Syphilitic lesions are, however, not confined to the bronchi, but may occur in the lungs themselves, both in the con- genital and acquired forms of the disease. In the days anterior to the discovery of the tubercle bacillus this affection was believed to be of common occurrence ; but it is now known that many of the supposed cases were in reality tuberculous in nature, and that the disease is of some rarity. Sir J. Kingston Fowler,^ after a careful inspection of the museums of the London hospitals and of the Royal College of Surgeons, was unable to find more than " twelve specimens which are believed to illustrate syphilitic lesions of the lungs," and of these he excluded two as very doubtful examples. This museum experience, however, would only in a measure coincide with the clinical experience of the disease, since cases recognised will often yield to appropriate treatment. On referring back to clinical notes of 1,323 male patients suffering from various diseases, none of them hospital cases, and of the age of twenty and upwards, seen by one of us, 53 cases presented a definite history of syphilis; out of this number there were 5 cases of lung syphilis — viz., 3 cases of gummatous fibrosis, one of catarrh associated with cutaneous maculae, and one of acute pyrexial lung- syphilis, described later in the text (p. 389). On the other hand, out of the same series of cases there were 320 cases of pulmonai-y tuberculosis, in which only in 3, or less than I per cent., was a syphilitic history apparent. PLATE XXII Congenital Syphilitic Pneumonia. Tof ace p. 387. CONGENITAL SYPHILITIC PNEUMONIA The illustration shows " a right lung affected with syphilitic pneumonia. All the lobes are equally affected, the lung tissue presenting a white hepatised appearance. There is no evidence of any recent inflammation of the pleura, nor any adhesion of the lobes to each other. The surface of the lung is rough and nodular. " Microscopical examination revealed a generalised interstitial inflammation with marked thickening of the adventitial coat of the arteries. A few of the alveolar spaces have expanded, and contain numerous desquamated cells." From an infant who only lived for a quarter of an hour. A bullous eruption was present on its body, and the hands and feet were partly denuded of epithelium. The lungs were entirely solid, and the liver and spleen were enlarged. (From the Museum of St. Bartholomew's Hospital. Natural size.) PLATE XXII 'If J TVM {y?t:^ft' haii Ay ruj iiiJUOO b^b'jr SYPHILITIC DISEASE OF THE BRONCHI AND LUNGS 387 Congenital Syphilis.- — In this form of the disease gum- matous nodules are occasionally met with; but more often the lesion is found to take on a more diffused form, producing the so-called " white pneumonia," or " white hepatisation," of Virchow, as seen in the syphilitic foetus or new-born child. A lung affected with syphilitic pneumonia is heavy and solid, of greyish-white colour, and smooth on section (Plate XXII.), thus presenting a very different appearance from the granular, friable surface seen in ordinary pneumonia. Microscopically, the alveolar walls are found thickened and infiltrated, showing diffuse chronic interstitial inflammation. The adventitia of the arteries is thickened, and the alveoli are filled with shed epithelium and round cells, often in a state of fatty degenera- tion.- With proper staining, spirochaetes, often in very large numbers, may be demonstrated in such lungs. Congenital syphilitic lung disease in infants is a matter more frequently of post-mortem than of clinical observation, the cases in which it occurs being generally fatal within a very few hours of birth; hence it is of small clinical importance. No doubt congenital syphilis has something to do with catarrhal and even tuberculous lesions which develope in later childhood and adult life, but the measure of its influence in such affections cannot be definitely traced. Acquired Syphilis. — The lung is attacked by this form of syphilis generally in from four to six years or more after the primary infection, but we have known twelve years to elapse before its manifestation. The diffused form of the disease, seen in the foetus and in new-born children, is rarely, if ever, met with, gummata or their results being the common manifes- tations. These may occur in any part of the lung, this irregularity of site being a distinctive feature. In appearance they resemble gummata in other parts, and, as in the liver, present at first a rose-grey appearance. Unlike the tubercu- lous nodule, which is non-vascular, the gumma contains vessels, and its nutrition is thus for a time assured. Gradu- ally, however, the vessels undergo the changes known as endarteritis obliterans, the blood-supply becomes cut off, and the fibro-cellular elements, of which the gumma is composed, undergo caseation. In this way are produced the yellow caseous masses, surrounded by the fibrous capsule, with which we are more familiar. Softening and breaking down occasion- 388 DISEASES OF THE LUNGS AND PLEURA ally ensue, but the cavities so formed, unlike their tuberculous counterparts, are rarely large. More often the gummatous mass becomes converted into fibrous tissue, which, radiating into the lung around, causes puckering and scarring of the viscus. There can be little doubt that cases occur, perhaps with greater frequency than is suspected, in which syphilis of the lung, with destructive changes, softening and excavation, associated with hectic phenomena and wasting, remains un- treated, being from the first mistaken for tuberculous disease. We must admit, however, that the majority of cases believed by older writers to be of this nature were in reality instances of true pulmonary tuberculosis occurring in syphilitic subjects, while a few, as in a good example to be seen in the Brompton Hospital Museum,'' are the result of syphilitic stenosis of the trachea or bronchi, leading (like other varieties of stenosis) to the formation of bronchiectatic cavities and cirrhosis of the lung. Symptoms. — The symptoms of pulmonary syphilis are often obscure, and may readily be confounded with those of ordinary inflammatory conditions. Gummatous nodules have been found in those who during life presented no evidence of pulmonary disease. The symptoms generally present are those of chronic indurative disease of the lung or pleura — a paroxysmal cough with difficult expectoration, of obstinate continuance uninfluenced by ordinary remedies, and associated with but little emaciation and no pyrexia. Pleuritic pains are often present. The presence of such symptoms in a person bearing the marks or giving a history of syphilis would be very signi- ficant. It not infrequently happens, however, that some peculiarity or incongruousness in the symptoms or physical signs leads to the suspicion of a syphilitic taint, the surface marks of which are obscure, and the history of which is at first denied, either intentionally or through ignorance. In such cases a Wassermann's test of the patient's blood may prove of value. Hcemoptysis is rare in the early stages, and when it occurs is highly suggestive of tuberculous complication. Cases, moreover, do occur, such as one to be presently related, in which more acute symptoms present themselves, including a remittent pyrexia, and such cases very closely resemble tuber- culosis. SYPHILITIC DISEASE OF THE BRONCHI AND LUNGS 389 Physical Signs. — The most characteristic physical signs are those of localised pulmonary induration — flattening, dulness, or a sense of hardness on percussion, with enfeebled breath- sound of blowing quality, with few or no moist sounds. Some bronchial clicks, or, more commonly, a superficial crackle of pleuritic or subpleural source may be heard. Such signs, when presented at some unusual situation, as about the mammary or inframammary or infraspinous region, are very suggestive. It is certain, however, that in some cases the physical signs are not localised in any unusual spot, but present themselves at one or other apex, and under these circumstances the diagnosis from chronic tuberculosis is most difficult. The presence of considerable one-sided indurative disease of the lung, of chronic course and not traceable to any preceding acute attack, in a person who has not been engaged in any dusty employ- ment, and whose sputum contains no tubercle bacilli, should lead to a suspicion of syphilis. Having arrived thus far, a careful inquiry into the history, an examination for surface marks of the disease, and a Wassermann test, will usually clear up the case. The sputum should also be examined for spirochaetes. Syphilitic gummata, as we have said, sometimes soften and produce cavities, which are small, however, and often too deeply seated for recognition. In such cases severe haemoptysis may occur from the rupture of a large vessel. Should the larynx be involved, an examination will disclose the cleanly cut and widely destructive ulceration of syphilis, or in later and less active stages the evidence of scarring and deforming cicatricial changes. The following case illustrates the great similarity which may hold between syphilis and tuberculosis : Mr. P., aged thirty-one, engaged in commerce, was seen by one of us in consultation with Dr. Bulger, of Holloway, on August 4 and 5, 1909. He admitted of no illness until he began to feel unwell and to cough in the beginning of January, 1909. His cough continued, he lost flesh, and at Easter there was some staining of the expectora- tion. The cough became more severe in April, and since the middle of June he had been in bed on account of increasing weakness and a daily rise of temperature. The expectoration was examined in May with a negative result as regards tubercle bacilli. The opsonic index for tubercle was found to be 062. He was thin and hectic-looking ; his teeth and gums were in a bad condition, and pyorrhoea alveolaris was present. 390 DISEASES OF THE LUNGS AND PLEURA On careful examination an area of dulness in the right scapular and interscapular region was discovered, extending from the second to the sixth rib. Over this area the breath-sounds were feeble, and some scattered moist crepitations were audible. These signs, with the symptoms, were regarded as indicative of pulmonary tuberculosis, although it was recognised that the duration of the case, the com- parative paucity of the physical signs, and the absence of tubercle bacilli, confirmed by a further examination of the sputum, were anomalous features. The question was duly considered whether the trouble was a sequel of influenza or a consequence of oral sepsis, removal to a sanatorium was advised, and accordingly Mr. P. was sent to the Cotswold Sanatorium, under the care of Dr. Kincaid, to whom we are indebted for the further history of the case. It was on August 13, during his sojourn there, that the important further fact in the medical history was elicited, namely, that about two years previously he had had syphilis, for which he had been continuously under treatment for twelve months. On admission to the sanatorium the mouth was found to be foul, and as it had been suggested as possible that the pulmonary infection was secondary to oral sepsis, and as on further examination no tubercle bacilli were found in the sputum, a dental surgeon was called in and the mouth cleared. The temperature and other symptoms, however, remained (Fig. 37). On or about September 10 headache became a marked symptom, and on September 14 Dr. Kincaid observed a definite swelling over the right frontal and parietal bones, having the characters of a syphilitic node. The temperature, as seen by the chart, continued to rise daily to 100° or 102°. Iodide of potassium, which had been commenced on first eliciting the syphilitic history, on August 13, but could only be tolerated for four days, was steadily resumed on September 14. The physical signs and symptoms now began rapidly to clear up. Mr. P.'s general health improved, his temperature became normal, and continued so during the remain- ing eight weeks of his stay at the sanatorium, with the exception of the two or three occasions on which mercurial injections were used, which gave rise to so much local irritation that they were discontinued. He left the sanatorium in the middle of December, 1909, having gained 3 stone in weight. There was only slight dulness remaining at the apex of the lower lobe of the right lung, and the cranial swellings had completely subsided. Dr. Bulger reported in October, 1910, that since his return home he had continued well, and had resumed his work ; and again in 1916 and at the end of August, 1918, that he was in good health. The clinical interest of this case is obvious. There was some difference of opinion as to whether it was one of a chronic septic condition, in which the lung became involved, or of tuberculosis. The specific history, carefully concealed from his family attendant, was, at the time that he was first seen, revealed by no external sign. Hence the hectic features of the case, the cough, with on one occasion SYPHILITIC DISEASE OF THE BRONCHI AND LUNGS 39 1 blood-stained sputum, and the depressed opsonic index of resistance with regard to tubercle, were strongly in favour of the tuberculous view, which the absence of tubercle bacilli from the sputum on several examinations did not wholly refute. Nor did the pyrexial symptoms Date A"^l 7 8 9 10 n 12 13 H 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 101° ^103° ■5 2 102° i 101° 100° 99° Sormal , 98° 97° Weight- ME ME ME M E ME M F, K r. ME ME M E ME ME ME M E ME ME M E M E M E M E ME ME M E M t M E ,:;■,. ■■ : V - ! - ' -1'--- i ■'•■■■*■ ■■■■!*■-■ ■ i ■ ■.■.■.;j.v.: ■■■■i-- ..-..,..„ Li.. I ; /T ■^ ■ i -,4 I " I ■I -.. . -J,, .... { . \ ; '.■ ■ 1 -Z z'f.:. ■"■■(-:■ ^ ,•}. 'l 1 ■■•■i ... lTH ■»^ 7 ^ T h h I ■|1 t i. ;, i. 1 :, ■■- .. ,.i, , ■R i- y\ 1 1 fi ,.,.i. ,1 1 f k f / / ^ / / 1 \l ii li' A \t 71 1 / ,f i7 f y/r V 1/ 1 / ■ j- 1 1 ■1- \^ r k I :;■]= t .3:: ! 1 h. y 1 I 1: V ^- - i - 'i ■ !■■ . 1 — ■ ];■■ -y- .....j.,.. ■i- ....j.... •4- - ...4... ....!.... -f- ■! ■ 'f .,i. .. ■! :.?§ ■■■\ ! ... j . ..; '' 1 .; . :,..i...... ■ ' : „ ..: ... ..^... ....j..... i .... •"S <— r.. .";^. ■ \ • \: '\E ... .!-.... .:.':..: , 1 4; 1.:' -':'. ..:. . . : . ' ,. . ■ . .;,... ■■■- ; i-. ,;. ; - X" ■ ■ Sept 1 2 3 4 S 6 7 B 9 10 11 12 13 1+ 13 16 17 18 19 20 21 22 83 24 25 26 27 M E ME ME ME M E |J|E ME M E ME M E M E M E M E M E M E M E M E M E M E M E M E M E|M E M E ME M E M E <» -a 1 :.}.- ;-■ ; ; ■ ;. ... ■ 5 f 4. : 1 .- it :. ■ ■ ■ a?.: :j.: :£ - ^ ;. -t A ..,.:.... .. ^ A ^ ""'A / tI ps *^ ■-.>■■ 7 / 3 rh l^ t -■■ r ^ ^ /- ^ y-J ^ i si- i F r-t v\ " 'T ( A K It t n < .±:: ; ........ ■■ ' w V / / \t / i.A A / ■fs >/ .;.... -f t- ■ V H V / y V V V: -it :^ . , . . ;^ ^-Ol T7- — ^ :3:: A -^ j ^ ... ,j.,. . ^ ^ ' 1 ■ ■■■J ■* L ■ 1 y . ' Fig. 37. — Temperature Record of the Case of Syphilitic Disease OF THE Lung described in the Text. promptly yield when, under the best hygienic circumstances, it was possible to clear the mouth, until the manifestation of definite external syphilitic phenomena imperatively indicated the use of iodide of potassium. 392 DISEASES OF THE LUNGS AND PLEURA Treatment. — In the treatment of pulmonary syphilis it is well to commence with a course of salvarsan, provided that the heart and kidneys, and especially the liver, appear to be healthy. Neo-salvarsan is perhaps the best preparation to use, but if it cannot be obtained, galyl or neo-arsenobillon should be substituted. In the adult 06 to 09 gramme of neo-salvarsan may be injected intravenously with full antiseptic precautions once a week until six injections have been given. During the course mercury and iodide should also be prescribed. If the administration of mercury by the mouth causes bowel irrita- tion, 5 minims of sterilised mercury cream (containing i grain of metallic mercury in 5 minims) may be injected once a week into the muscles of the buttock, three or four days after each of the salvarsan injections; or the drug" may be administered by inunction. After the above course of injections the salvarsan and mercury should be stopped, but the iodide continued. After two months, if the Wassermann reaction is still positive, another course of mercury and salvarsan should be prescribed, and the iodide afterwards continued with intermitting courses of mercury, the Wassermann reaction being- tested from time to time. In some cases a few seasonal courses at Aix- la-Chapelle may be recommended, and in all the general health of the patient must be well looked to and maintained. Pulmonary Tuberculosis in Syphilitic Subjects. More common than true pulmonary syphilis are those really hybrid examples of tubercle engrafted upon a more or less strongly marked syphilitic cachexia, in which the phenomena of syphilis are manifested with, and in a measure modify and control, those of phthisis. Cases of this kind present certain peculiarities. They are usually of the caseous pneumonic type, being one-sided, with rapidly advancing consolidation and softening, although arrest and fibroid changes may ultimately take place. Haemoptysis is an early and an urgent symptom in a large proportion of cases, the haemorrhage being severe and recurrent. The evidences of lardaceous change in other organs present themselves at a relatively early period, and with greater proportional frequency than in the other forms of phthisis. The patient may present other marks of syphilis, such as cicatrices upon the tongue or throat, nodes, cutaneous scars, or pigmentation. His build and conformation of chest SYPHILITIC DISEASE OF THE BRONCHI AND LUNGS 393 are often not those of ordinary phthisis, and the complexion has the earthy, kistreless pallor of the syphilitic, rather than the hectic aspect of the phthisical cachexia. In other cases the patient presents the aspect typical of advanced consump- tion, although the pulmonary lesions discoverable are but slig'ht; in such instances excessive activity in anti-syphilitic treatment may have prostrated a patient of tuberculous con- stitution. The treatment requires a judicious combination of anti- syphilitic with hygienic measures, which may prove successful in arresting the disease. REFERENCES. . ' The Diseases of the Lungs, by James Kingston Fowler, M.D., and Rickman John Godlee, M.S., F.R.C.S., p. 429. London, 1898. ^ See— (i) "Congenital Syphilis of the Lungs," by Alfred W. Sikes, M.D., F.R.C.S., The Journal of Obstetrics and Gyncecology of the British Emfire, March, 1905, vol. vii., p. 194. (2) " A Case of Infantile Interstitial Pneumonia," by A. W. Sikes, M.D., Transactions of the Obstetrical Society of London^ 1906, vol. xlvii., p. 74. ^ Specimen No. 91. See Catalogue of the Museum of the Bromfton Hospital, by Percival Horton-Smith (Hartley), M.D., F.R.C.P., and William Thomas Mullings, M.D. Adlard and Son, 1904. CHAPTER XXVI STREPTOTRICHOSIS (ACTINOMYCOSIS) OF THE LUNG AND PLEURA History of the Disease. — Streptotrichosis or actinomycosis, as it is still termed by many writers, whether attacking the lung or other organs, is no new disease; but until comparatively recent years cases of it would seem to have been mistaken for such varying maladies as cancer, osteosarcoma or tubercle. The parasite was apparently first observed and figured by von Langenbeck of Kiel in 1845, '^^ ^ case of caries of the spine, though the observations were not made known until many years later by Dr. James Israel.^ In about 1855 it was independently observed and figured by the late Sir Thomas Smith,^ though here again the drawings were not published until comparatively recently. Lebert,^ in 1857, was the first actually to publish a description and illustration of the parasite, the organism in this instance being obtained from a case of pulmonary disease supposed to be cancerous, which terminated in abscess of the chest-wall. It was not, however, until 1878 that IsraeP first definitely drew attention to the disease in the human subject. In the following year Ponfick,* showed the parasite to be closely allied — he believed identical — with the organism described by Bollinger,^ in 1877, as the cause of the disease in cattle. From its radiate appearance, Hartz, a colleague of Bollinger in the Chair of Botany, had given to this latter organism the name " actinomyces," or " ray fungus."* The Parasite. — Recent research has shown that the disease is produced not by a single parasite, as was once supposed, but by several organisms which are members of the streptothrix group. This group belongs to the Hyphomycetes, or lower mould fungi, and to the genus Discomyces, and is charac- terised by the following features, with which the writings of Mr. Alexander Foulerton^ have made us familiar. The 394 PLATE XXIII. Fig. 2. Streptothrix Disease (Actinomycosis). To /ace page 395 STREPTOTHRIX DISEASE (ACTINOMYCOSIS) Fig. I. — Specimen showing a small streptotrichial mass com- posed of a network of finely-branched mycelium ; from the pus of an abscess in the chest wall connected with an empyema. ( X lOIO.) Fig. 2. — Sputum from a case of streptotrichosis of the lung, showing the presence of scattered branching threads of a variety of Streptothrix. ( x loio.) (Drawings by Mr. S. A. Sewell from preparations by Mr. Alexander G. R. Foulerton, F.R.C.S., stained by Gram's method and counterstained with eosin;) PLATE XXIII STREPTOTRICHOSIS OF THE LUNG AND PLEURA 395 organisms consist essentially of filaments, which show true branching- (Plate XXIII.), and are thus sharply distinguished from the Schizomycetes, or fission fungi, as represented by ordinary bacteria. The filaments in their growth tend to cohere, and to form little masses presenting a felted mesh- work of finely branched mycelium (Plate XXIII., Fig. i). They stain well by Gram's method, and in their early stages take the stain homogeneously throughout their length. Later the protoplasm within the sheath, which bounds the filament, tends to segment, and to present the appearance of longer or shorter rods, some of them still showing lateral branching. In the terminal filaments this segmentation is sometimes very marked, and rows of small round spores, still staining by Gram's method, are produced, the appearance closely resembling that of a chain of streptococci. Finally the sheath breaks down, and the spores and rod segments become free. From time to time, when growing in the tissues, the mycelial mass may be seen to be surrounded by a radiating zone of club-shaped bodies, which do not stain by Gram's method, but may be counterstained by such dyes as orange-rubin or picric acid (Plate XXIV.). These " clubs " are probably not organs of fructification, as originally believed, but degenerate forms, produced when the soil in which the parasite grows is not especially favourable. In man their presence is very variable; in cattle they are more common. In the discharges from actinomycotic lesions the organisms are often visible to the naked eye as characteristic scattered granules of greenish-yellow colour and of the size of small pinheads. They may be detected by tilting the pus along the side of the test-tube, or by spreading the sputum over the surface of a glass dish; but if not specially searched for they will almost certainly be overlooked. The granules are often very numerous, but their number tends to vary a good deal in the same case at different times. Under the microscope each little grain will be found to consist of a meshwork of the finely branched Gram-staining mycelium already described (Plate XXIII., Fig. i), with possibly a zone of clubs surround- ing it (Fig. 41, p. 402), but this is not common in man. In a certain proportion of cases, however, the organisms are more disseminated, and do not form in the sputum the characteristic granular masses which are visible to the 396 DISEASES OF THE LUNGS AND PLEURA naked eye. In such cases they may be most easily detected by staining by Gram's method and counterstaining with eosin. The branched mycelial threads of the variety of streptothrix present are in this way stained blue, and stand out well against the pink background (Plate XXIIL, Fig. 2). An attempt should then be made by cultivation and animal experiment to complete the identification of the parasite, though the task may be by no means easy, since certain varieties of streptothrix grow only with great difficulty on artificial media. We may add that some of the strains prove acid-fast, staining like the tubercle bacillus. Distribution. — Members of the streptothrix group have been found as saprophytes in water, in air, and especially in soil, and they have also been frequently met with in association with certain grasses and plants. In animals they have been found to be the cause of disease in many of the mammalia, notably in cattle; and in man several species have been isolated. Mr. Foulerton^* succeeded in differentiating ten varieties of streptothrix organisms in a series of fifty-three cases investi- gated by him. If the tubercle bacillus be classified as a streptothrix, in support of which a good deal of evidence may be advanced (p. 422), the pathogenic interest of the g'roup becomes enormously increased. Pathological Anatomy. — As the result of the introduction and growth of one or other species of streptothrix, an inflam- matory reaction of the tissues is induced. Around the fungus, and about any centres whither its offshoots may be conveyed, the structure of the affected organ becomes densely infiltrated with granulation tissue, in which epithelioid cells, and some- times giant cells, may be seen. This is at first freely permeated with new vessels, but caseation, degenerative softening, or suppuration speedily ensue, coupled, however, with some tendency to repair as shown by the formation of fibrous tissue. The disease in these respects closely resembles tubercle, but it differs, as we shall see, in the remarkable disposition shown by it to transgress the bounds of the organ affected, and to involve adjacent parts. The malady is further spread by the trans- ference of the elements of the fungus through the blood- stream to distant localities, where secondary foci of the disease are generated. Clinical Features. — Streptotrichosis primarily affecting the lung or pleura — and it is sometimes difficult to say in which it STREPTOTRICHOSIS OF THE LUNG AND PLEURA 397 has really commenced — is a comparatively rare disease, though no doubt cases have been overlooked. More usually the lung is affected secondarily, by direct extension from the liver or other adjacent organs. The following case, in which the disease probably originated in the pleura and spread thence to the lung, will serve conveni- ently to bring together the more important clinical features. It is interesting to note that this was apparently the first case in this country in which the disease was recognised during life.* Case I. — George W. H., a thin, well-featured boy, aged nine, with bright eyes, dark hair, long eyelashes, and somewhat hectic appear- ance, was admitted into the Brompton Hospital on October 8, 1888, under the care of Dr. Douglas Powell, complaining of pain of a pleuritic character below the right nipple. The boy was of healthy parentage, his father, mother, and three brothers and sisters being all well, but there were cases of tubercu- losis amongst the uncles and aunts on both sides. His father worked at a dairy as milker and carrier. The boy himself had enjoyed good health up to four months before admission. His parents attributed the commencement of his illness to a blow behind the ear received at school early in June, which kept him at home for a week, with headache and constipation. He returned to school, however, until the holidays commenced, in July, when he was sent to Brighton for a month, but returned only slightly better in August. For the six weeks following his return from Brighton the boy accompanied his father two or three times a week to the cowshed, where there were about 150 cows, remaining there two or three hours at a time. The father knew of no illnesst which had lately affected any of the cows and was sure that none had died during the past year. It was to- wards the end of August, six weeks before admission, that he com- plained of languor, disinclination to work or play, and some pain and tenderness of the right side of the chest when touched or washed. A little later he developed slight headache, with some hacking cough, but with no expectoration or haemoptysis. Throughout his illness he had gradually lost flesh, and during the last month he had had night-sweatings and his breathing had become shorter. On admission the right side of the chest was obviously larger (i inch by measurement) than the left, and restricted in movement. About the mammary region the intercostal spaces were obliterated * The case is recorded in the Transactions of the Royal Medical and Chirurgical Society.^ t Professor Crookshank and Mr. Taylor visited the dairy on Novem- ber 17, and found the cows looking healthy, and were assured by the owner and by two of the milkers whom as well as the boy's father they questioned, that there had been no cases of "wens" or " clyers " or other manifestations of streptothrix disease on the farm. 398 DISEASES OF THE LUNGS AND PLEURA by a smooth and rather hard swelling of the tissues, having its centre in the fifth space in the nipple line (Fig. 38, A). The swelling was exceedingly tender and slightly oedematous, but at this time no distinct fluctuation could be felt, nor was there any blush of redness on the surface. On sitting the boy up, the head was observed to be inclined to the affected side, and the scapular angle correspond- ingly tilted inwards, the spine being slightly curved in the dorso- cervical region, with concavity to the right. In the posterior axillary line a second larger swelling was observed, corresponding with the seventh, eighth, and ninth ribs (Fig. 39, B). This swelling was also tender, brawny to the touch, and suggestive of the early stage of a Fig. 38. — Diagram showing the Physical Signs in the Case of Streptotrichosis of Lung and Pleura described in the Text. A, Pointing of prominent and softened tissues below the nipple (the lateral bulging and shading extending beyond the confines of thorax proper shows infiltration of the chest wall); C, skodaic resonance; D, systolic murmur. pointing empyema. The heart's apex-beat was half an inch to the left of the nipple line. The percussion note on the right side was resonant, of somewhat skodaic quality, to the second place in front (Fig. 38, C) ; below that point, dull, the dulness being complete at the fourth cartilage. Pos- teriorly there was dulness from the lower third of the scapula to the base. It was observed, however, that the upper line of dulness was not horizontal, but slanted downwards towards the spine, so as to be at a lower level there than in the mid-scapular and axillary lines. In the subclavicular and superior scapular regions the respiratory murmur was weak but vesicular, but over the dull area generally the STREPTOTRlCHOSIS OF THE LUNG AND PLEURA 399 breath-sounds were absent and the vocal fremitus was lost. On the left side the resonance and respiration were good. A short systolic murmur was audible at the right third cartilage (Fig. 38, D) ; otherwise the heart-sounds were natural. The liver dulness blended with that of the thorax, and did not extend below the cartilages, nor could the margin of the liver be felt. The spleen was normal. From the hectic temperature and symptoms and the physical signs above related the case was regarded as one of empyema. Two punctures with a fine needle, however, in the fourth and fifth spaces in the anterior axillary line produced only a little blood. October 15. — Whilst under chloroform for more complete explora- FiG. 39. — Diagram showing the Physical Signs in the Case of Streptotkichosis of Lung and Pleura described in the Text : Posterior View. At B infiltration and bulging of chest wall are shown. tion, but before any puncture was made, the patient expectorated about half a dozen sputa of bright blood. A fine trocar was intro- duced by Mr. (Sir Rickman) Godlee at the centre of the posterior bulging, and some drops of blood came out through the cannula, which on examination contained only fibrin and blood-cells. The temperature from this time onwards is shown on the chart (p. 400). The patient as a rule slept and took food fairly well, and was very placid and cheerful, being free from pain except when touched or on coughing. The cough was troublesome, but without expectoration. By the end of the month he had notably lost flesh since admission, and the appearance of hectic was more marked. The swellings had become more prominent and were distinctly elastic; and extending 400 DISEASES OF THE LUNGS AND PLEURA PLATE XXIV. Fig. 1. Fig. 2. Strep tot hrix Disease (Actinomycosis). To face fage 401 STREPTOTHRIX DISEASE (ACTINOMYCOSIS) OF THE LUNG AND PLEURA Fig. I. — Specimen from pleura under low power, (i" obj.) Fig. 2. — The same more highly magnified. (J' obj.) a. Central network of branching mycelium. b. Palisade of clubs. c. Surrounding dense fibro-nucleated tissue, plenti- fully supplied with bloodvessels. (From drawings by Dr. Wynter ; stained by Weigert's modi- fication of Gram's method and orange rubin.) PLATE XXIV STREPTOTRICHOSIS OF THE LUNG AND PLEURA 40I downwards and slightly forwards from the original seat of the pos- terior swelling was a pyriform bulging, three inches in length, with the larger end depending, which yielded semi-fluctuation over its whole area, but no impulse on cough. There was some redness over the posterior swelling. The physical signs remained much the same. Two glands, slightly enlarged and movable, were to be felt in the right axilla, and on this side of the neck along the anterior margin of the sterno-mastoid some slightly enlarged glands were also per- ceived. On the opposite side the glands were not enlarged. The systolic murmur at D was distinct, short, and rough. Except for slight labial herpes on admission the patient had no sores on the face or mouth. The milk molars were much decayed, but the permanent teeth sound. At this time it was thought that there was malignant growth in the thorax, but the idea of there being pus in the pleura was not wholly abandoned. On November i the upper and posterior of the two swellings was thoroughly explored with the aspirator by Mr. Godlee, but only some soft caseous material was found in the cannula. An incision was made into the swelling, and a large collection of similar material with some fresh blood was found between the ribs and the skin. An inch of the sixth rib above the incision was removed, the pleura incised, and the opening having been dilated by dressing forceps, the finger was passed in, and entered a soft collection of the same material as had been found outside. No limitation of the mass could be felt ; some partially clotted brain-like material mixed with blood escaped, but there was no actual flow of fluid matter. The bleeding was con- siderable. Strips of lint soaked in sublimate lotion — i in 2,000 — were inserted to plug the wound, and a dressing of carbolic gauze was applied. A little blood was expectorated towards the end of the operation. November 2. — The patient passed a fairly good night; there had been no haemorrhage, and he was comfortable. Portions of the crude material removed on the previous day were examined by Mr. Taylor. Fresh sections taken from the brain-like material were made the same evening and stained with alum-carmine. The structure generally was found to be of the nature of granulation tissue, finely fibrillated, giving at parts a sponge-like appearance and containing many vessels. There were also observed several deeply stained bodies having the recognisable characters of actinomyces. At the earliest opportunity specimens hardened in alcohol were stained by Gram's method, and the fungus was demonstrated in its entirety, exhibiting both threads and clubs, the latter, however, not taking the stain (Plate XXIV.). A purulent discharge escaped from the wound, which was treated with iodoform and antiseptic lotions. November 10. — It was found that the lower swelling communicated with the upper, and it subsequently burst externally through a small opening leading to a sinus which communicated with the upper 26 402 DISEASES OF THE LUNGS AND PLEURAE wound. On pressing on the surrounding tissues thick blood-stained pus freely escaped, and was seen to contain innumerable minute white granules resembling the bodies found in bovine actinomycosis (Fig. 41). Professor Crookshank, who was kind enough to assist us in the investigation of the case, collected the pus, and inoculated a number of tubes of various nutrient media. The surface of the wound was also covered with yellowish-white granules, glistening and not readily removed. When scraped off, the material was found to contain iodoform from the dressings and abundant ray fungi. The boy remained free from pain, cheerful, and placid, but his emaciation increased, and the pulse quickened to 130, although the respirations were quiet. There was no enlargement of the liver. The upper level of dulness reached the second rib, and the level did not alter with position. Some rather fine crackles were heard over the second and third ribs, with very weak breath-sound. Posteriorly the dulness Fig. 41. — Streptotrichosis of Lung and Pleura. Cover-Glass Prep- aration FROM THE Pus, UNSTAINED, MOUNTED IN GLYCERINE, X 350 (about), SHOWING THE RADIATING ARRANGEMENT OF THE CLUBS AROUND THE More Confused Mycelial Centres. reached to the middle of the scapula, above which level the breath- sounds, although weak, were fairly good. On injecting carbolic lotion into the wound the patient coughed and expectorated a frothy muco-purulent sputum. November 16. — Under chloroform two anterior abscesses were opened, and the opening below the original incision was enlarged. Thick yellowish pus with characteristic granules escaped freely ; and there was considerable haemorrhage, causing some degree of collapse. A little of the mare solid material was removed by scraping. Professor Crookshank was present with sterilised tubes, and took a considerable quantity of pus and thick material for inoculation into animals. The whole of the right thorax was more or less puffy, and along the ribs, both above and below the front incision, were several points of fluctuation. The wounds all had a languid appearance, edges purplish, granula- tions pale and large; a thickish pus adhered to them in places, on STREPTOTRICHOSIS OF THE LUNG AND PLEURA 403 which, and on bare granulations, were seen minute dirty yellowish granules, varying much in size, one of them as much as a millimetre across. These were readily shown by microscopic examination to be portions of fungus. As yet no growth had protruded from the wounds. Many granules were visible on the dressings, and some doubtful spots were seen in the expectoration, which was still scanty. November 20. — On this date the fungus was found in the sputum for the first time. No tubercle bacilli had at any time been detected. The urine, of specific gravity 1028, acid, gave a decided indican reaction, and rapidly manifested decomposition, but contained neither albumin nor sugar. With some variations from day to day, the boy gradually lost ground, becoming more emaciated and pale. December 18. — Several swellings had appeared upon the back, all of which fluctuated, but as they were not painful, they were not incised. The wounds from the former incisions presented a thick, yellowish-white, slightly glistening surface, and similar masses were fungating through other places in which abscesses had spontaneously given way. Through January there was some general improvement in the patient, and the activity of the growths seemed somewhat checked, but after several partial rallyings and relapses, he sank exhausted on February 26, i88g. Abstract from the Post-Mortem Report^" — Thorax. — A large mass of soft material was found to occupy the pleural cavity of the right side from about the level of the second rib downwards. It was very soft, pultaceous, and canary-coloured, much resembling coarse, badly-made mortar, and appeared to consist of the same material in varying stages of degeneration. Between the base of the lung and the liver there was a large amount of similar material, with which the diaphragm appeared to have become incorporated. In the upper part of the pleura there were some recent adhesions. Lungs. — Right : the lower anterior part of the lower lobe and the middle lobe were converted into tough fibrous material, which had an irregular interlobular distribution, the bands of which enclosed small pinkish areas like altered lung tissue. Here and there in the midst of the fibrous growth there were irregular, canary-coloured masses like that above described. The upper lobe was plentifully studded with grey nodules, the size of a hemp-seed, some slightly pigmented, and exactly resembling tuberculous nodules. Left lung : aerated throughout, but containing scattered nodules, of the size of a pea to a small Spanish nut, which, on section, had the characteristic canary-coloured appearance. Abdomen. — Between the liver and diaphragm there was a collec- tion of pultaceous matter similar to that described above. The liver itself appeared healthy, but on section about one inch below the upper surface an abscess the size of a small orange was dis- covered, having a fibrous tissue wall about half an inch thick. The 404 DISEASES OF THE LUNGS AND PLEURA contents consisted of tenacious yellow pus, which had a trabeculated appearance. The right lateral sides of the dorsal vertebrae were covered over by the growth and superficially eroded. Some of the ribs, between which the growth had passed to reach the outside of the chest, were also eroded. Nothing worthy of note was found in any other of the organs. Remarks. — The setiological history of this case does not throw any definite light upon the exact mode in which the malady originated. The occupation, however, of the father, and the fact that the lad apparently often accompanied him in his visits to the cowsheds, rendered possible an infection from a vegetable source, which is often observed in these cases. Even after post-mortem inspection it was not easy to decide exactly where the disease originated, although it is clear that it flourished chiefly in the lower two-thirds of the pleural cavity, in- filtrating the chest wall and fungating through the cutaneous surface, denuding the- adjacent vertebree, and commencing to invade both the diaphragm and pericardium. The lung was collapsed backwards and upwards, toughened and fibroid, containing also many centres of the parasitic disease, but there was not sufficient evidence of any considerable primary fungus disease of the lung with subsequent cicatrisation. On the contrary, the post-mortem evidence rather favoured the view of the compressed lung having become the seat of a secondary actinomycosis ; the left lung, otherwise healthy, also presented centres of a similar kind in an early stage. On the whole, it would seem probable that the organism, having gained entry through the respiratory tract, had been conveyed through the lymphatics to the pleural surface, and there germinated and flourished in inflammatory materials derived from the pleural layers and their subjacent tissues, the bulk of the growth being in the thoracic wall. The clinical features of the case, both as regards the symptoms and signs, were in the first instance those of empyema. On puncture, however, no pus could be obtained, and on further exploration the evacuation of semi-clotted material, resembling a mixture of fluidi- fied brain-substance and blood, quite unlike anything which had in our experience been removed from cases either of intrathoracic growth or empyema, seemed to justify the removal of a portion of the rib for more thorough exploration of the pleura. The case now presented the appearance of some degenerating growth, but certain signs which have been above related — and especially the somewhat slanting and shifting upper line of dulness and the skodaic resonance below the clavicle— led us still to retain the hope that there might be some fluid collected behind a thick, caseous layer in the pleura, or possibly con- nected with some degenerated growth in the pleura, such as we had once before met with in a case of dermoid tumour of the lung. At STREPTOTRICHOSIS OF THE LUNG AND PLEURA 405 the end of the exploration, however, we returned to the belief that we were dealing with an anomalous degenerated and softened malignant growth of extreme vascularity. It was only on careful examination by Mr. Taylor of the material removed that a diagnosis was arrived at. The following' case also possesses features of sufficient interest to be here recorded : Case II. — Mrs. C, aged forty-five, five years married, no family or pregnancies, was first seen by Sir R. Douglas Powell, in consultation with her friend and family attendant, Dr. Waithman, towards the end of April, 1903, on account of a severe pain of a neuralgic charac- ter in the right shoulder and radiating therefrom. Mrs. C. had suffered from epileptic attacks, for which she had taken bromide, the last fit having been about February, 1903. She had also had some slight uterine troubles ; otherwise she had never been ill until an attack of supposed whooping-cough in 190 1, which was followed by some pleurisy, with cough and night-sweatings, which gave rise to the suspicion of commencing tuberculosis. The cough was not attended by any expectoration. She spent the winter of that year at Nice. The winter of 1902 was passed in Egypt, going by dahabieh up to Luxor, and during that time Mrs. C. suffered greatly from the pain in the shoulder, which was regarded as a rheumatic neuritis and treated by salicylates, and by increasing doses of morphia given sub- cutaneously. During her stay at Luxor it was stated by Dr. Appleby, under whose care she then was, that her evening temperature was never below 100°, sometimes 102°, and that she had heavy night- sweatings. The above treatment was continued on her journey home, via Naples, during which she underwent great suffering. The history of the pleuritic attack and the irregular pyrexial and hectic manifesta- tions were in support of the belief that her illness was tuberculous. When first seen by Sir Douglas Powell, in April, 1903, on her return from Egypt, some impairment of the percussion note was observed below and over the right clavicle, and the breath-sounds were noted to be harsh and wavy, and a few rales were heard. On sitting the patient up and passing the hand over the supraspinous region on this side attention was at once attracted to a fulness, and on deepening the pressure, considerable tenderness was elicited; a sense of elastic tension was appreciable, but no distinct fluctuation. The fulness was also apparent on inspection, compared with the other side. An abscess connected either with caries of the upper dorsal vertebrae, or growth, or actinomycosis, was diagnosed, and as the pain was very severe, rendering nights sleepless, except after strong doses of morphia, and days wellnigh intolerable, the aid of Mr. (Sir Rickman) Godlee was sought. He made an incision between the superior angle of the scapula and the spinal column, passing deeply through the 406 DISEASES OF THE LUNGS AND PLEURA several layers of muscles, until finally some purulent matter welled forth, which on examination revealed the characteristic grains of actinomycosis. The pleura was reached, and found adherent, there being no pleural collection. There was no obvious connection between the abscess and the lung, but the fact that the lung was involved in the disease was inferred from the physical signs. No expectoration was at this time obtain- able for examination, and only later were the characteristic granules discovered in the sputum. The pain was at once so far relieved that no further morphia was necessary. The abscess continued, however, for a long time to discharge through a fistulous tract. After recovery from the first operation the patient was put upon iodide of potassium in doses of 30 grains a day, afterwards increased to 60 grains. Mrs. C. went to Scarborough in July, 1903, and subsequently to her home in Yorkshire, living out of doors. She gained weight and improved generally, but towards the end of September Dr. Fisher, of Skipton, reported : " For the past ten days Mrs. C. has not been quite so well, suffering more pain in her chest and tenderness all over the side. She cannot localise it. Five or six days ago pleuritic friction could be distinctly heard just behind the shoulder-joint; to-day it is almost gone, and she has less pain and discomfort. Her cough is still troublesome at nights, but there is no expectoration. Since September gth her temperature, normal in the morning, has ranged from 99° to 100° in the evening. Between August i and Septembei' 19 she has gained in weight from 11 stone 3 pounds 2 ounces to 11 stone II pounds 7 ounces. She takes from three to four pints of milk each day, also her full doses of the iodide. Last week she had two or three profuse perspirations at night. The wound in the back is still open and discharges a little. She is out in the garden in her chair each fine da)'." Dr. Waithman saw her about this time and agreed with the above note, and after consultation with Dr. Fisher and Sir R. Douglas Powell, it was decided for her to go to Torquay for the winter. When passing through town in October, 1903, a second in- cision, opposite the infraspinous portion of the scapula, was found necessary to relieve some pent-up pus, and a third operation was required in February, 1905, eighteen months later, before the wounds finally healed. In the later periods of surgical treatment, the details of which were carried out With Mr. Godlee's usual care and resourcefulness, and require no special mention, peroxide of hydrogen lotion was syringed into the wounds, and subsequently iodoform emulsion, but on no occasion did any such lotion find entry to the lung. The purulent discharges were repeatedly examined, and always showed the char- acteristic granules and microscopic appearances of streptotrichosis, including the club-shaped bodies. The sputum, which at first could not be obtained, was found on October 23, 1903, to present the following characters : it was com- posed of viscid mucoid material, with streaks of muco-pus ; and STREPTOTRICHOSIS OF THE LUNG AND PLEURA 407 contained also some small opaque grains of a yellowish colour, the largest about the size of a small pin's head. Microscopically examined the granules were found to consist of a felt-work of mycelium, which retained the Gram stain, and from which projected some more refrac- tive bodies (presumably clubs). No tubercle bacilli were present. The iodide of potassium was, with occasional breaks, continued for the two years of treatment. Hygienically Mrs. C. was treated on fresh-air lines, mainly between Yorkshire and the South of England. The wounds finally healed in 1906. Her lung signs, which never gave serious trouble, cleared up, and her weight increased from 10 stone in June, 1903, to between 11 and 12 stone, at which it has since remained. Except for occasional epileptic seizures she has since continued in good health, and Dr. Waithman informs us that she is well at the present time, June, 1919. Mrs. C. was not a horsewoman, and beyond visiting the home farm, there was no special connection with straw or herbage. Chief Features of the Disease. — Since the occurrence of the first of the two cases above recorded, not a few instances of primary streptothrix disease (actinomycosis) of the lung or pleura have been described, and the malady is probably more common than is usually supposed. Some years ago Dr. Samuel West" collected thirty from the literature, three more have occurred at the Brompton Hospital,"" and during the years 1900-1912 Mr. Foulerton^" himself observed fourteen at the Middlesex Hospital. The disease may occur at any age, and, as with strepto- trichosis of other organs, is more often met with in the male than in the female. Both lungs may be affected, but the left is more commonly the seat of the disease than the right, and usually, though by no means always, the lower part of the lung is first attacked. The infection may, however, commence at the apex, as in the second case which we have described, and the disease then closely simulates pulmonary tuberculosis. This occurred also in one of the Brompton cases,"* in which the physical signs at the right apex were strongly suggestive of early tuberculous disease, and were believed to be of that nature until streptothrix granules were found in a secondary abscess, and were then at once looked for and discovered in the sputum. At the autopsy in this case the appearance of the lung, showing fibrosis, most marked at its upper portion, with areas of softening and scattered patches of broncho-pneu- monia," closely resembled that seen in cases of pulmonary tuberculosis. In other instances the areas of individual disease 4o8 DISEASES OF THE LUNGS AND PLEURiE are larger, and the involvement of adjacent lung less marked than is commonly seen in tuberculosis^- (Plate XXV.). If the pleura be affected an empyema generally results, in the pus from which the parasite is found. The occurrence of pultaceous material in the pleural cavity without suppuration, as in the case above related, is not common. In its intimate pathology, as we have seen, streptotrichosis is closely allied to tubercle, yet in one important feature it shows a striking difference, namely, its disposition to invade beyond the borders of the organ first attacked, and to pass " across country," so to speak, through adjacent tissues to other parts and other organs. In this way the lung is not infrequently invaded through the diaphragm from the liver, and in this way, too, arises that infiltration of the chest wall and the formation of those secondary abscesses which are so often seen in streptotrichosis of the lung and pleura. Sir Rickman Godlee'^" calls attention to the small amount of pus generally contained in the abscesses, and their "indefinite spongy walls, easily breaking down before the finger in all directions, and bleeding very freely," features which he regards as characteristic. There is one other feature of the complaint to which we must refer, namely, the tendency for the organisms to pass into the blood-stream, and to set up infective abscesses in distant parts, such as the brain, liver, and kidney. This "pysemic form" of the disease, as it is termed, is not very uncommon, and the same disposition has been observed when other organs than the lung are primarily attacked. Diagnosis.— Pulmonary streptotrichosis should at once be suspected if in a patient with symptoms of chest disease induration or suppuration of the chest wall makes its appear- ance. The finding of the parasite in the pus or sputum will complete the diagnosis. It should be a rule also to bear the possibility of strepto- trichosis in mind in all cases which suggest pulmonary tuberculosis, and especially if the signs be atypical or basal in character, but in which repeated examination of the sputum has failed to reveal the presence of tubercle bacilH. In all such cases careful search should be made for streptothrix organisms. Treatment. — Pulmonary streptotrichosis in the human PLATE XXV :iTAJS STREPTOTRICHOSIS OF LUNG The drawing showr a section of the right lung. Near the base of the lower lobe a large white mass of irregular outline is seen, composed of casej-.ting material honeycombed with suppurating foci. Similar smaller masses are seen scattered through the lobe ; some were also f ounc in the middle lobe, but none in the upper lobe or in the left lung. Microscopical examination of the purulent material from the lung revealed the presence of a Gram- staining and acid-fast streptothrix, which grew well on artificial media and was pathogenic to guinea-pigs and rabbits. It closely resembled the organism originally described by Eppinger. From a porter aged sixty-seven, who died after an acute ill- ness of five weeks' duration. The case is described by Dr. J. M. Bernstein in the Proceedings or the Royal Society of Medicine, vol. ii. (Pathological Section), p. 271. (From the Museum of the Royal College of Surgeons. Natural size.) PLATE XXV Streptotrichosis of Lung. To face p- 408 STREPTOTRICHOSIS OF THE LUNG AMD PLEURA 409 subject, if untreated, tends to pass rapidly from bad to worse. It is important, therefore, at the earliest moment to commence treatment with considerable doses of iodide of potassium, the only drug which has so far been known to exert any influence upon the disease. The administration of the drug should be pressed, twenty to forty grains being given three times a day, and sometimes even larger doses may be prescribed with advantage." In many cases associated suppuration calls for surgical treatment, and ver}" favourable results have in some instances followed this combination of medicine and surgery. It cannot be said, however, that iodides are always successful, for the drug has in some cases seemed to produce no effect. This may possibly be due to the special variety of streptothrix concerned in the disease, but probably also to the malady not being recognised and boldly attacked at a sufficiently early stage. These measures may be supplemented by vaccine therapy. At first a stock vaccine should be employed, to be replaced later by an autogenous vaccine, if it be found possible to grow the streptothrix discovered in the patient. Cases of streptotrichosis have been successfully treated on these lines, ^* but we have known of others in which no apparent benefit has resulted. In many cases, all attempts at cultivation have failed, so that the preparation of an autogenous vaccine has been impossible. The patient's diet should be nutritious and sustaining, port- wine or brandy being freely given when indicated, with such drugs as bark, quinine, or other tonics. Special symptoms must be treated as they arise. REFERENCES. '■ " Neue Beobachtungen auf dem Gebiete der Mykosen des Menschen," von Dr. James Israel, VircJiow's Archiv, 1878, voL Ixxiv., pp. 15 and 50, Plate IIL, Fig. 9. ^ " A Fading Record : Early Observations on the Ray Fungus by Mr. Thomas Smith, F.R.C.S.," by A. A. Kanthack, M.D., M.R.C.P., St. Bar- tholomew's Hosfiial Journal, 1896, p. 50. ^ Traite d'Anatomie PatJiologique Getter ale et Sfeciale, par le Docteur H. Lebert, tome i., p. 54. Paris, 1857. See also Lebert's Atlas, tome i., Plate n., Fig. 16. * Die Actinomycose des Menschen, von Dr. E. Ponfick. Berlin, 1882. * " Ueber eine neue Pilzkrankheit beim Rinde," von O. Bollinger (in Miinchen), Centralblatt fiir die M edicinischen Wissenschaften, 1877, No. 27, p. 481, 410 DISEASES OF THE LUNGS AND PLEURAE * For a full bibliography of the subject up to 1906, see the article on "Actinomycosis (Streptotrichosis)," by Theodore Dyke Acland, M.D., Allbutt and Rolleston's System of Medicine, vol. ii., part i., p. 324, 1906. ' [a] " Some Observations on a Series of Seventy-eight Cases of Strepto- thrix Infection," by Alexander G. R. Foulerton, F.R.C.S., Proceed- ings of the Royal Society of Medicine (Surgical Section), 1913, vol. vi., p. 132. (b) The Streptotrichoses and Tuberculosis (being the Milroy Lectures for 1910), by Alexander G. R. Foulerton, F.R.C.S. London, 1910. (c) " The Pathology of Streptothrix Infections," by Alexander G. R. Foulerton, F.R.C.S., Allbutt and Rolleston's System of Medicine, part ii., vol. i., p. 302, 1906. {d) " On the GcMeral Characteristics and Pathogenic Action of the Genus Streptothrix," by Alexander G. R. Foulerton and C. Price Jones. Transactions of the Pathological Society of London, 1902, vol. liii., p. 56. * " On a Case of Actinomycosis Hominis," by R. Douglas Powell, M.D., F.R.C.P., Rickman J. Godlee, M.S., F.R.C.S., and H. H. Taylor, F.R.C.S., with an appended " Report on the Morphology of the Fungus," by Edgar Crookshank, M.B. Transactions of the Royal Medical and Chirurgical Society, 1889, vol. Ixxii., p. 175. ' (a) The specimen is preserved in the Museum of the Brompton Hospital. See Catalogue of the Museum of the Bromfton Hosfiial, by Percival Horton-Smith (Hartley), M.D., and William Thomas Mullings, M.D., Specimen No. 89. London, 1904. {b) Loc. cit. Specimen No. 90. " " Case of Primary Actinomycosis of the Pleura in a Child of Six, with a Table and Analysis of Recorded Cases of Primary Actinomycosis of the Lung and Pleura," by Samuel West, M.D. Transactions of the Pathological Society of London, 1897, vol. xlviii., p. 17. " (a) "A Series of Cases of Actinomycosis," by Rickman J. Godlee, M.S., F.R.C.S., The L.ancet, 1901, vol. i., p. 3. {b) Loc. cit. Case 2. '" " A Fatal Case of Streptotrichosis with Primary Lesion in the Lungs — the Organism Pathogenic for Animals," by J. M. Bernstein. Proceedings of the Royal Society of Medicine, 1909, vol. ii. (Pathological Section), p. 271. '^ " Some Cases of Actinomycosis, with Especial Reference to Treat- ment by Potassium Iodide," by R. B. Wild, M.D. British Medical Journal, 1910, vol. ii., p. 851. " [a) " A Case of Actinomycosis (Streptotrichosis) of the Lung and Liver Successfully Treated with a Vaccine," by William H. Wynn, M.D., British Medical Journal, 1908, vol. i., p. 554. {b) " A Case of Actinomycosis Treated by a Vaccine," by John Collie, M.D., J. P., ibid., 1913, vol. i., p. 991. (c) "Vaccine in Mediastinal Actinomycosis," by W. S. Malcolm, M.D., ibid., 1916, vol. ii., p. 488. CHAPTER XXVII SPOROTRICHOSIS This disease was first described by Schenck^ in 1898 in the case of a man aged thirty-six, attending the Johns Hopkins Hospital, Baltimore, and has since been chiefly studied in France by de Beiirmann^ and his pupils. It is produced by various closely allied filamentous spore-bearing fungi belong- ing, like the Streptothrix, to the Hyphomycetes or lower mould fungi, but to the genus Sporotrichum. The varieties usually met with are the Sporotrichum Schencki and the Sporotrichum Beurmanni, which are possibly identical, but others are described. In the pus and tissues the parasites are found chiefly as short oblong forms resembling bacilli. When cultivated these yield a delicate septate branched mycelium which soon shows spore formation, the spores being arranged in clusters around the end of a filament, or less commonly along its sides. The organisms stain with the usual dyes and grow well at room temperature on Sabouraud's glucose-peptone gelatine, which should be used for their isolation. The parasite is found widely disseminated in nature, and has been detected on lettuces, potatoes, grain, bark, and thorns, and is thus easily conveyed to man. Infection usually occurs in patients with lowered vitality, and is produced through an abrasion of the skin, but in the pulmonary cases inhalation may be the mode of entry as in the case of a woman who attributed her complaint to her dusty occupation in a coffee mill. The characteristic lesion manifests itself as a small hard nodule or gumma in the subcutaneous tissue, which after some enlargement undergoes central softening and abscess-forma- tion, or becomes converted into an ulcer. The ulcer is of chronic type, and suggests a syphiUtic or tuberculous origin, 411 412 DISEASES OF THE LUNGS AND PLEURA The lesions affect chiefly the limbs, and especially the hands and arms, but the disease may become disseminated and affect the face as well as the trunk.-^ Sporotrichosis is not, how- ever, confined to the subcutaneous tissues, and may attack the bones and joints, the muscles, the epididymis, the eye, the mucous membranes of the mouth and larynx, and occasionally the lung, in which case the symptoms usually suggest a chronic pulmonary tuberculosis. The following case of the rare pulmonary variety of the disease, which recently occurred in Paris, has been recorded by Drs. Schulmann and Masson : ^ A workman, aged thirty-six, developed in 191 1 an eruption on the face, neck, and chest, soon spreading to the extremities. The erup- tion was of chronic type, suggesting syphilis, but the Wassermann test was negative. The gummata enlarged, and in pus obtained from one which had softened the sporothrix was found. The patient was treated with iodide of potassium with benefit, though recovery would appear to have been slower than is usually the case, but in January, 19 13, it is stated that the lesions were all cicatrised with the exception of one on the leg, and in March, 1914, that, save for some conjunctivitis, recovery was complete. The patient appears to have remained well until May, 1916, when, during service in a munition factory, he began to cough and expec- torate, to lose weight and to become febrile. Pulmonary tuberculosis was diagnosed, but tubercle bacilli were never discovered in the sputum. Some improvement followed visits to Cannes and Mentone, and he was able for a short time to resume work, but in November, 1917, it became necessary to discharge him from military service, and his symptoms becoming aggravated he was in May, 1918, admitted to hospital at Bicetre. He was then much emaciated and his appear- ance strongly suggested phthisis. Examination of the chest showed extensive loss of resonance over the right lung, especially marked over the centre of the chest, with moist sounds at each apex. X-rays revealed diffused shadowing over the right lung, with some mottling, and in the left lung, extending from the heart region almost to the diaphragm, the well-defined shadow of a somewhat deep-seated oval tumour was visible. No tubercle bacilli could be found in the sputum. The history of the former cutaneous lesions now raised the suspicion of pulmonary sporotrichosis, and the diagnosis was effected by lung puncture into the point of maximum dulness on the right side of the chest; the drops of blood-stained fluid thus removed were in- oculated upon Sabouraud's medium and the Sporotrichum Beurmanni recovered, apparently in pure culture. This case proves that pulmonary signs and symptoms re- sembling those of phthisis may be produced by the action of SPOROTRICHOSIS 413 the sporothrix, and renders it probable that other cases in which sporotrichosis has been diagnosed from the discovery of the parasite in the sputum may have been true examples of this disease. It must be remembered, however, that the sporothrix may sometimes occur as a saprophyte in the pharynx, and thence find its way into the sputum, so that its mere presence in the expectoration is not in itself conclusive evidence that the pulmonary disease is of this nature. Diagnosis and Treatment. — The possibility of pulmonary sporotrichosis must be borne in mind, especially when, in addi- tion to symptoms of chest disease, chronic cutaneous lesions, suggesting a tuberculous or syphilitic nature, are present. If the Wassermann test be negative, the pus from one of the softening nodules should be examined, and if the sporotrichum be present it will be demonstrated without difficulty by cultiva- tion on Sabouraud's medium at room temperature. The diagnosis may be confirmed by the sporo-agglutination re- action, on the lines of the Widal test for typhoid fever, an emulsion of the spores of the sporotrichum being used instead of the bacillary emulsion. If left undiagnosed, the disease, which is of a very chronic nature, will gradually extend. If detected early, it is readily amenable to treatment, yielding quickly to the administration of iodide of potassium. This drug should be given internally and also applied in a weak solution to the sores. Dr. de Beurmann states that in early cases and in otherwise healthy subjects cure may be expected in four to eight weeks. REFERENCES. * " On Refractory Subcutaneous Abscesses caused by a Fungus possibly related to the Sporotrichia," by B. R. Schenck, M.D., Johns Hofkins Hosfital Bulletin, December, 1898, p. 286. ^ [a] " On Sporotrichosis," by Lucien de Beurmann, British Medical Journal, 1912, ii., p. 289. See also — {b) Les Sforotrichoses, par de Beurmann et Gougerot. Paris, 1912. [c) " Les Mycoses," par de Beurmann et Gougerot, Nouveau Traiti de Medecine et de Therafeutique, par A. Gilbert et L. Thoinot, vol. iv., p. 383. Paris, 1910. ' " Etude Clinique d'un Cas de Sporotrichose Pulmonaire (Presentation de Malade)," par M. M. Ernest Schulmann et A. Masson, Bulletins et Memoires de la Societe Medicale des Hofitaux de Paris. Paris, 1918,. p. 776. CHAPTER XXVIII ASPERGILLOSIS In the preceding chapters we have discussed the results of infection of the lung by various members of the streptothrix and sporothrix groups, parasitic organisms which belong to the Hyphomycetes or lowest order of mould fungi. We have now to consider the malady aspergillosis, pseudo-tuberculose aspergillaire, as it is termed by French writers, in which the malady is caused by mould fungi somewhat more highly developed and belonging to the family Perisporacidae.^" The term " pneumonomycosis," or mould disease, sometimes used, would thus, strictly speaking, include all three diseases. More than one member of the genus aspergillus have been found in the sputum and in the lungs in various diseases, such as pulmonary tuberculosis, bronchiectasis, and malignant disease. The presence of the parasite is generally noted only towards the end of the illness, and is not associated with any distinctive symptoms. Such cases of secondary aspergillosis, as they are called, consequently possess but little practical importance. Of greater interest is primary aspergillosis, which is usually produced by the action of the Aspergillus fumigatus. This variety of the disease, as proved by Dr. Renon,^ to whose writings we are much indebted, is met with chiefly among the pigeon-feeders and hair-combers in Paris, who use in their work grain and flour, which are apt to be contaminated with the spores of the organism. Clinically the malady may present various forms. It rhay sometimes resemble an acute broncho-pneumonia, and termin- ate fatally in two or three months, the lungs after death showing numerous patches of consolidation, in many places broken down into small cavities. Or, again, as in the case 414 ASPERGILLOSIS 415 reported by Drs. Arkle and Hinds/ in which the mycelium was found for the most part growing "in the walls of the alveoli and in the substance of the lung itself," it may present the signs and symptoms of a rapidly progressing emphysema with alarming attacks of dyspnoea, in one of which the patient referred to died. Two cases of membranous bronchitis of a very chronic type have also been traced to the presence of the parasite (Obici,* Renon and Devillers"" ). Most commonly, however, the disease presents symptoms and signs which, like its pathological lesions, strongly re- semble those of pulmonary tuberculosis. It may thus set in with cough and haemoptysis, loss of weight, impairment of appetite, and increasing debility. Night-sweats also occur, and fever is often present, the temperature reaching 100° or 101°. The sputum is muco-purulent. On examining the patient, slight impairment of note at one or other apex may be observed, with blowing breathing. Later on signs of softening and cavity formation become apparent, as the con- solidations break down. The course taken by this form of the disease is usually a chronic one, sometimes extending over several years, periods of quiescence alternating with those of activity. Recovery is by no means unknown, arrest being brought about by a form of fibrosis, as in tuberculosis of the lungs. An interesting example of this variety of the disease was recently observed by Dr. Holden,^ of Denver, Colorado, although in this case the parasite was the Aspergillus nidulans, which differs morpholgically from the Aspergillus fumigatus in the branching of its sterigmata. The patient was a married lady, aged forty-seven. Her symptoms, cough, sputum, loss of weight, clubbed fingers, and hectic fever, suggested phthisis, and the physical .signs, commencing at the right apex and spreading downwards and attacking to a less extent the left apex, supported this diagnosis. Tubercle bacilli were, how- ever, never found, and later the mycelium of the Aspergillus nidulans was discovered in the sputum. She died, greatly emaciated, after an illness lasting two years. An interesting feature of the case was the enlargement of the cervical and axillary glands, which at one time led to a suggestion of Hodgkin's disease. On section one of the glands was found to show no evidence of glandular structure, but to be con- 4l6 DISEASES OF THE LUNGS AND PLEURA verted into fibrous tissue, between the fiibres of which the parasite could be seen in large numbers on microscopical examination. Diagnosis. — From what we have said it will be evident that the disease cannot be diagnosed during hfe by any cHnical examination. Its recognition must depend upon the dis- covery of the parasite in the sputum. This may sometimes, as in a case recorded by Dr. Solmersitz," be detected by the naked eye in the form of little masses, the size of a pin's head, resembling the grains met with in streptothrix disease, and, like the latter, consisting of a feltwork of branching mycelium. But more commonly it is first discovered in specimens of the sputum stained with such simple dyes as methylene blue, thionin, or safranin, when it appears in the form of branching mycehal threads, with spores scattered in and around. The threads have somewhat thicker walls, and are more irregular in shape than those usually met with in streptothrix infection, which they otherwise closely resemble. The aspergillus may sometimes also be demonstrated in unstained sputum which has been spread upon a slide, and treated with a solution of 20 per cent, potash. To identify the parasite thus discovered, cultures from the sputum, expectorated into a sterilised vessel, must be made. For this purpose Sabouraud's agar medium (containing i per cent, peptone and 4 per cent, crude glucose), on which the aspergillus grows well at room temperature, may be used, or Raulin's medium,^* an acid liquid containing sugar, which, while favourable to the growth of mould fungi at 37° C, is inimical to that of ordinary bacteria. In this medium, if Aspergillus fumigatus be present, a mycelial growth will be noticed on the second day, starting from the particle of sputum introduced. A few days later this will reach the surface of the liquid, when it will quickly give rise to a whitish velvety veil, upon which after a few hours spores will develope, when its colour will change to a bluish-green, and later to a brownish-black. This colour of the culture will serve to dis- tinguish Aspergillus fumigatus from other members of the genus, which have also been met with in sputum. To com- plete the identification of the organism intravenous injections of the spores must be made, preferably into the vein of a rabbit's ear. If the parasite be the Aspergillus fumigatus, ASPERGILLOSIS 417 the animal will succumb in six to eight days with general dissemination of the fungus. Should the patient die, the parasite thus discovered in the expectoration will also be found in the lung', unless the case be a very chronic one, scattered through the foci of disease, sometimes appearing as small white or brownish patches visible to the naked eye. In addition to the mycelium, spore- bearing hyphae, with spores still attached, may also be dis- covered in the bronchi and alveoli. Treatment. — No specific drug treatment is known, and the patient's resistance must be strengthened by abundance of fresh air and good food. Symptoms must be met as they arise. Cod-liver oil has been found of great value, and arsenic and iodide of potassium should be tried, since they have been found by Renon to lengthen the duration of life in animals experimentally inoculated with the disease. In the less acute cases much may be hoped from such measures of treatment, and recovery may result. REFERENCES. ' [a] Practical Bacteriology^ Microbiology, and Serum Therafy (Medical and Veterinary), by Dr. A. Besson. Translated by H. J. Hutchens, D.S.O., etc., p. 694. London, 1913. {b) Loc. cit., p. 38. ^ (a) Etude sur V As-pergillose chez les Animaux et chez V Homme, par le Docteur Louis Renon. Paris, 1897. [b) " L'Aspergillose, Maladie Primitive," par M. le Docteur Louis Renon, XIII'^ Congres International de Medecine, Section de Path- ologie Interne. Paris, 1900, p. 312. (. '"'m ^^^ss^f^*-- ,-^^ Fig. 2. #^" Fig. 3. ' \- i, Tubercle Bacilli in Sputum and Cavities. To face />age 426 ETIOLOGY OF PULMONARY TUBERCULOSIS 427 bacilli are often sparse and rather difficult to find. Large fields may be traversed without discovering- them. Their presence, however, cannot be doubted, for this material, when inoculated, is virulent in producing" tuberculosis. 4. In the granulations of miliary tuberculosis in the human subject bacilli are very generally, but not invariably, to be found, and often only in small numbers (Plate XXVII., Fig. i). 5. The bacilli may sometimes be found in the blood in advanced cases of the disease, and occasionally even in the early stages." They are frequently also to be discovered in the stools,'^ whether from swallowed sputum or intestinal lesions. Channels of Infection.— The virus of tubercle may enter the body by infection of the ovum (congenital infection), or through the skin (inoculation), the food-passages (ingestion), or the air-passages (inhalation). 1. Congenital Injection. — It has been urged by Baumgarten that phthisis is usually acquired by direct infection of the ovum, the bacillus being* conveyed to it by means of the spermatozoa, or more commonly through the blood of the mother, travers- ing the placenta and thus reaching the foetus. Dr. Cob- bett,^^" in his work on the causes of tuberculosis, concludes that congenital infection is of more frequent occurrence than is commonly supposed. Foetal tuberculosis visible to the naked eye is rare, whether in men or animals, and experiment has shown that in the great majority of cases tubercle bacilli are absent from the tissues- of the foetus, though more extended observations in regard to stillborn children of tuberculous parents are required. The new-born child rarely reacts positively to the von Pir- quet^'' tuberculin test. Further, the view of congenital infec- tion presupposes a latent period, often of many years, before the g'erm takes on active growth and symptoms of tubercu- losis arise. The theory may be accepted, as Dr. Sitzenfrey^^ has shown, as an explanation of certain cases of phthisis occurring in early childhood, but it cannot be held to explain the general incidence of the disease, either in children or the adult. 2. Inoculation. — Only very rarely can phthisis in man be attributed to this cause. Laennec himself, however, is said to have been infected in this manner, and similar cases are 428 DISEASES OF THE LUNGS AND PLEURJE recorded from time to time.^* At the Brompton Hospital the following- case occurred : H. M., aged sixty-two, for twenty years pathological assistant, whilst staining some sputum in June, igoo, ran a pen covered with virulent expectoration into the flexor tendon sheath of the middle finger of his right hand. Tuberculous tenosynovitis resulted, but the trouble was arrested by the timel)^ scraping out of the disease within two months of the primary infection. ^^ He then returned to his work, and remained well until the spring of 1904, when he lost weight, developed cough and malaise, and, on examining his sputum, found tubercle bacilli therein. His chest was examined by one of us, and slight impairment of note was discovered at the left apex, but no adventitious sounds. He was admitted into hospital, and later went to the Brompton Hospital Sanatorium at Frimley, in Surrey. After some months' treatment he lost his cough, the bacilli disappeared from the sputum, and he was discharged with the disease arrested. There was no recurrence, and he lived com- fortably, on a pension, until he developed epithelioma of the larynx, of which he died in March, 1915, at the age of seventy-seven. In this instance it would seem probable that at the time of the injury a small focus of tuberculous disease formed in the lung, and that later, when his resistance diminished, it took on fresh activity, and made its presence apparent. Such cases are, however, quite exceptional. 3. Inhalation and Ingestion. — Until recently it was always believed that inhalation was the main channel of infection, ingestion playing quite a subsidiary role. The reasons for this belief were as follows : (a) Numerous observers, Koch himself included, showed that pulmonary tuberculosis could be produced in animals by the inhalation of pure cultures of tubercle bacilli, or of pulver- ised sputum from phthisical patients. Bruno Heymann,^" further, has actually demonstrated, by staining, the presence of tubercle bacilli in the pulmonary alveoli of g"uinea-pig"s killed two hours after an experimental inhalation. This observation, we may add, derives confirmation from the work of Ballin,-' who, experimenting- with the spores of Aspergillus funiigatits, proved their presence microscopically in the alveoli after half an hour's inhalation, and within three hours they were found penetrating the alveolar walls. (b) The view received support also from the fact that enormous numbers of bacilH may be present over long periods PLATE XXVII TUBERCLE BACILLI IN ACUTE MILIARY TUBERCU- LOSIS OF LUNG, AND IN PUS FROM A TUBERCU- LOUS EMPYEMA. Fig. I.— Acute Miliary Tuberculosis. — Lung : two alveoli which have become fused together ; alveoli filled with large epithelioid cells ; tubercle bacilli in large numbers between the cells, and in a few instances within the cells (a. a.). (From a preparation by Dr. Percy Kidd. x 400. This plate appears also in the Transactions of the Royal Medical and Chinirgical Society, 1885, vol. Ixviii., p. 114.) Fig. 2. — Empyema of- Tuberculou.s Origin. — Pus removed from the interior of the pleura, showing abundance of bacilli. (From a preparation by Mr. H. H. Taylor, F.R.C.S. X400.) P; A %.< > . S ^ \ \ / •1 V / - \^\f PLATE XXVII. O ^ o Q Fig. 1. ^/ .:> / ■•ri\ ii \^-\. ^i- / / \- r\ \ / y< / w / -/ \ /. \ . / u Fig. 2. Tubercle Bacilli in ac7de Miliary Tuberculosis of Lnvg and in pus from a Tuberculous Empyema. To face page 428 ETIOLOGY OF PULMONARY TUBERCULOSIS 429 of time in the sputum of a consumptive patient, in some cases, as computed by Professor Cornet, reaching the total of 7,200,000,000 a day, although a certain proportion of them may be no longer living-. It seemed most reasonable to believe that some of the organisms thus so profusely ejected find access to other persons by means of the respiratory tract. (c) Birch-Hirschfeld, Schmorl, and others demonstrated that in very early cases the primary lesion was sometimes found in the walls of the fine bronchi, whence it spread by aspiration to the alveoli. The above facts are strongly in favour of the view that the sputum is the chief source of danger in the spread of phthisis, and that the main source of infection is by inhalation. Both Koch and Cornet believed, and with them Kohhsch's" more recent experiments are in accord, that the mode of this infection is by discharged sputum becoming dried and mingled with dust, the dust thus contaminated being wafted into the air by sweeping, traffic and winds, and in this way becoming inhaled. Cornet disbelievesr in moist sputum as a cause of phthisis. Professor Fliigge, of Breslau, and his pupils, on the other hand, maintain that the infection more frequently arises from the direct inhalation of the fine droplets of infected sputum which, as they have shown, are scattered into the air by the consumptive patient in loud speaking, and more so in coughing and sneezing. Seeing that such droplets may remain suspended in the air as long as five or six hours, and as Dr. M. H. Gordon^^ has shown, may be conveyed to gTeat distances, in one case as far as 71 feet from a person speaking vehemently, ample opportunity is given for their inhalation. In quiet reading or speaking, however, no such ejection appeared to occur. It has recently been shown, however, by Dr. Chausse^* that such droplets, which consist mostly of saliva, contain but very few tubercle bacilli, and that experimentally it is difficult to infect guinea-pigs when exposed to such droplets by allowing patients to cough repeatedly into the box in which the animals are confined, and this when the expectoration of the patients was proved to contain an average of 60,000 tubercle bacilli in each milHgramme of sputum. Of 79 animals so exposed, only one acquired tuberculosis. On the other hand, it proved easy in Dr. Chausse's hands to infect guinea-pigs by the inhalation 430 DISEASES OF THE LUNGS AND PLEURA of dried dust derived from the handkerchief used by a con- sumptive patient, if this, after partial drying- for forty-eight hours, was shaken in the box containing" the animals. Several handkerchiefs from different patients were used, and in all 41 guinea-pigs out of 73 exposed acquired tuberculosis. With- out denying that in circumstances of great intimacy, as when two or more patients occupy the same bed, infection by droplets may become operative, the experiments quoted indicate that under ordinary circumstances dust infection, derived often from the patient's clothes, bed-linen and person, is the more important factor in the spread of the disease. That inhalation directly into the air-passages, whether of sputum-infected dust or droplets, is not the sole or even the chief method of infection is, however, maintained by some observers on the following grounds : (a) It is well known that if suitable animals, such as guinea-pigs, calves or pigs, be fed with tuberculous material, lesions of the intestinal tract will result, with secondary involvement of the mesenteric glands and later of other organs of the body, among which the lungs may be included. Such involvement of the intes- tine often occurs in phthisical patients who swallow their sputum, and primary intestinal tuberculosis in children is no doubt also due to the ingestion of tuberculous matter, (b) The work of numerous observers also shows that under certain circumstances, without producing any local lesion, the bacilli may pass directly through the wall of the alimentary tract, or, as indicated by Dr. Walsham,-^ in his Weber-Parkes Prize Essay, through the tonsils to the lymphatic glands, and thence to other organs. Thus, in a case observed by Dr. Sidney Martin, in which a pig was fed on meat from a tuberculous cow, no lesion of the tonsil resulted, but the glands below the jaw on the right side were involved, and the lungs were also infected; the other organs remained natural. In analogous cases in man it is probable that the bacilli reach the lungs by means of the blood-stream, there appearing to be in the human subject at least no direct lymphatic connection between the cervical glands and the lungs or pleurae. ""^ In other experi- ments the mesenteric glands have alone been affected, the bacilli having passed through the intestinal wall without leav- ing any trace of their passage. It may be admitted, there- fore, that the lungs are in some cases infected by bacilli which ETIOLOGY OF PULMONARY TUBERCULOSIS 43 1 have been swallowed, and have entered the system from the alimentary tract. Von Behring^s theory, which affirmed that pulmonary tuber- culosis, though not congenital, originates commonly in early childhood through the ingestion of infected milk, the germ developing and the disease appearing only in adult life, is negatived by the fact that in nearly all cases, as we shall show, phthisis is produced by bacilli of the human, not the bovine, type. Calmette and his pupils, among" whom may be mentioned Vansteenberghe and Grysez," following von Behring's theory, urge that infection through the alimentary canal is not the exception but the rule, and that phthisis does not result from the direct inhalation of tubercle bacilli into the lung, but that the organisms, whether in infected dust, droplets, or tuber- culous milk, are swallowed, and then pass to the mesenteric glands, and so to the lungs. Calmette bases his conclusions, which he has voiced at various congresses, on experiments designed to show that phthisis, or tuberculosis confined to the lungs and thorax, can be produced by the introduction of tubercle bacilli into the alimentary tract, and that pulmonary anthracosis is not, as is commonly believed, the result of the inhalation of carbon particles, but is really of intestinal origin. His results, however, have not been confirmed by Dr. Cobbett'^* and other observers, who show clearly that pulmonary anthracosis as well as phthisis are both in the great majority of cases the result of an inhalation infection, though it is not denied that in cases of alimentary infection the lungs may eventually become involved when the disease, after affect- ing the mesenteric glands, has become generalised. This conclusion is supported by a series of experiments by various observers, notably by Findel" and Alexander,-* which prove that a much larger dose of bacilli is necessary to produce infection through the alimentary than the respiratory tract. We may conclude, therefore, that the old view is correct, and that in the aetiology of phthisis the main channel of infection is by inhalation, ingestion playing only a minor role. Milk Infection. — The question of the derivation of human tuberculosis through milk or butter from infected cows is one of importance, involving as it does large farming interests and State measures of a preventive kind. In considering this 432 DISEASES OF THE LUNGS AND PLEUR/E question, we must carefully separate from such cases those in which from dirty surroundings milk becomes contami- nated by tuberculous dust, thus coming within the category of contaminated foods. The question now under discussion is solely concerned with milk from diseased cows, the organism of infection being the bovine tubercle bacillus, the milk thus coming within the category of diseased foods, such as tuber- culous meat. There have been two Royal Commissions deaHng inter alia with the subject of tuberculous milk, and both reported strongly in favour of tuberculosis arising from its ingestion. Since the publication of the Report of the second Commis- sion^" in 1907, much work has been carried out in differentiat- ing the bacilli, whether of human or bovine type, which are to be found in the various forms of tuberculosis, and we are now in a position to speak with some precision on this subject. In the first place, it has become clear that fatal bovine infec- tion in the adult is of extreme rarity, hut that in children under five years of age it is not uncomm^on. Dr. Cobbett,^" to whose work we are much indebted, calculates that about one- third of all fatal cases of tuberculosis in children under the age of five is attributable to a bovine source, presumably infected milk, and that in the year 191 1 (the returns for which he used in his calculations) rather over 3,000 deaths could be traced in England and Wales to this cause. This conclusion is based on the following evidence. Bacilli of bovine type have not hitherto been found in the pulmonary lesions of phthisis. In the sputum from nearly a thousand cases examined, in only four were bovine bacilli found, the organisms in all the rest being of the human type. It is clear, therefore, that with but rare exceptions, pulmonary tuber- culosis in the adult, which accounts at the present time for 7P per cent, of the deaths from all forms of tuberculosis, is produced by bacilli of the human type, and is the result of infection from human sources, and in our efforts towards the eradication of the disease this cardinal fact must be borne in mind. With regard to other forms of tuberculosis, according to Dr. Cobbett some 17 per cent, of cases of general tubercu- losis (including meningitis) and 50 per cent, of cases of fatal abdominal tuberculosis are caused by bovine bacilli, both ETIOLOGY OF PULMONARY TUBERCULOSIS 433 occurring- mostly in children. In tuberculosis of the cervical glands, which is not generally fatal, 50 per cent, of the cases in England would appear to result from a bovine infection, and perhaps 70 per cent, in Scotland, the incidence of such infection being much higher in child- hood than in the adult. Of cases of bone and joint tubercu- losis, one in five may be attributed in England to the bovine type of bacillus, and in Scotland a higher proportion, in each case the percentage in childhood being much greater than in the adult. From an analysis of the figures. Dr. Cobbett con- cludes that roughly 6 per cent, of all cases of fatal tuberculosis may be attributed to the bovine bacillus, such cases occur- ring for the most part in young children, and two-thirds of them being' of the abdominal variety, including" ulceration of the bowel, tuberculosis of the mesenteric glands, and tuber- culous peritonitis. When we remember that in addition to these fatal cases much suffering and permanent crippling is caused in the non-fatal attacks, especially those of bone and joint tuberculosis, a considerable proportion of which are produced by the bovine bacillus, we see that the danger from infected milk, though of minor importance when we view the subject as a whole, is yet one by no means to be ignored. It is fortunate that it may be obviated by Pasteurising the milk or raising it to the boiling-point. It is interesting to note that the ethnographical data collected by Dr. Bruno Heymann^^ support the conclusion thus arrived at on bacteriological grounds that the role played by infected milk in the dissemination of pulmonary tuberculosis is a negligible one, and that this form of tuber- culosis is, in fact, spread, as we have urged, by the inhalation of infected material derived from human sources. This ob- server showed that in various countries, such as Greenland, the Gold Coast, and parts of Roumania, where milk cannot possibly be obtained, or where, as in Egypt, it is too dear for the natives to buy, consumption is nevertheless rife, and other forms of tuberculosis are often met with. Further, in the Faroe Islands and in Japan, tubercle of all kinds had long been frequent, though perlsucht has only recently been intro- duced. The Question of Contagion.— There arises out of a considera- tion of the various methods of infection the grave question 28 434 DISEASES OF THE LUNGS AND PLEURiE as to how far pulmonary tuberculosis is a contagious disease, how far it arises from a person-to-person infection analogous to that by which the contagia of measles, smallpox, and other such diseases are most commonly conveyed. The belief by many physicians in the contagiousness of phthisis is not merely of laboratory origin, dating from the demonstration of the tubercle bacillus : it has existed throughout the history of medicine. In a sense it is true, in another sense it is greatly exaggerated. It is true in the sense that if the opportunities for infection are intimate and prolonged, and proper precau- tions against the spread of the disease are not forthcoming, so that massive doses are absorbed, as happens but too frequently in the "overcrowded and insanitary dwellings of the poor, then direct infection may, and no doubt does, occur. Of patients belonging to the lower middle and working classes admitted to the Brompton Hospital, only about one-third would appear to be aware of any history of personal infection, if we may judge from the loo patients under the care of one of us, in whom this point was inquired into by Dr. Wijeyeratne. He found that 2"/ of these loo patients gave a definite history of exposure to domestic, and 8 to extra- domestic infection, at some time previous to the onset of their disease, making a total of 35 per cent. In the remaining 65 no history of the kind could be obtained. In certain of the cases the exposure to known infection had occurred several years before, and it must not be forgotten that small tuber- culous lesions, such as a caseous area in a lymphatic gland, or a quiescent nodule in the lung, may remain dormant for long periods, to break into active disease under conditions of anxiety and strain, and in this way the origin of cases of phthisis may sometimes be traced back to infection in earlier years of life. It must be clearly understood, however, that the contagious character of the malady, thus admitted under certain circum- stances, is of a totally different order from that met with in the common contagious diseases such as measles and scarlet fever. In the latter a short, even a momentary, contact with the patient is sufficient to convey the disease. In phthisis, on the other hand, the contact must be intimate, repeated, and prolonged to be effective, and even then, if the patient has been properly trained in the disposal of the sputum and ETIOLOGY OF PULMONARY TUBERCULOSIS 435 the use of the handkerchief when coughing, and regard had to cleanhness in the surroundings, and to proper ventilation and adequate nursing when the patient is bedridden, there is fittle or no risk of infection. In the upper classes tubercu- losis is, as a rule, acquired rather by the inhalation of dust from public waiting-rooms, railway-carriages, trams, omni- buses and the like, in which tubercle bacilli derived from infected sputum have not infrequently been found. One of us can, however, recall the case of a wealthy man suffering from consumption and living in a large house, whose dirty habits led to the infection of his two daughters, who both died of the disease, although his wife escaped. Similarly the habits in regard to spitting of the North American Indians, so graphically described by Dr. Quevli^^ of Tacona, and of the natives of South Africa, with their ignorant disregard of all the rules of hygiene, explain the rapid spread of the disease among these people. Wherever, also, the disease is freshly introduced, there the standard of immunity ranges low. It is interesting to note that the mouthpieces of public tele- phones, even when used by consumptive patients (as shown at the Brompton Hospital Sanatorium, at Frimley), have been found on investigation to be free from tubercle bacilli, and should not be regarded, therefore, as sources of public danger, provided they are kept properly clean.* That the danger of personal infection is not great if proper precautions are taken is indicated by the fact that in con- sumption hospitals and large sanatoria the disease is not abnormally prevalent amongst the officials and servants. The observations of the late Dr. Theodore Wilhams,^^ upon the health of the staff of the Brompton Hospital showed that at this institution during the years 1846 to 1882 — a period when open-air treatment was not practised, and when the ventila- tion of portions of the hospital was not all that could be desired — phthisis did not develope among the staff, whether physicians, assistant physicians, clinical assistants (house physicians), or nursing and general staff, some of whom had lived for many years in the hospital, more frequently than * This statement is based upon reports by Dr. Klein, and more recently by Dr. Spitta, which have been courteously placed at our disposal by the Postmaster-General. 436 DISEASES OF THE LUNGS AND PLEURA might be expected in any large institution not especially devoted to consumption, or, indeed, in any urban population. This conclusion was based upon the records of several hundred persons whose life-histories were traced for many years after leaving the institution by the then Resident Medical Officer, the late Mr. Vertue Edwards. More recently Dr. Theodore Williams'*'* published statistics of the medical staff of the hospital from 1882 to 1909, which yielded similar conclusions, though it should be noted that among the Death 1 1 — r 1 1 [ 1 1 1- Rate ^^^^^*^ Phthiais Death Rates. Males ""^^ t^^ ENaLANoiWAi.ti 1651-1910 3(500 "•"••. // / ,9°.-'' x^v 3.000 it i .' ^y^ -1 1 ^X-- "•■■:V ! ! .■••■ .y ZflOO .7/ .•• / r i .V y .s^.y '/ ■ ■■ y .-^ ' ■•••N;-N\\ '//■•■■/ y '-v^A iioa ^^ v \ ^■:\\ toco ^■*^: 500 y A3= Period 1 • 1 1 1 1 1 1 1 1 1 1 1 • 10 15 20 2i 30 35 40 43 30 i5 60 65 ro '5 60 t VV Fig. 42. From Dr. Brownlee's Report to Medical Research Committee, 1918, diag. ii. In this and the following diagram (i) the general decline in death- rate from phthisis is shown in successive decades ; (2) the curves also show the far greater decline at the earlier ages and the greater rela- tive mortality, especially amongst males, between the ages of 35 to 55 in the later decades. porters, whose duty it was to handle and sterilise the linen and sputum, two deaths from phthisis had occurred. From these observations, which have been confirmed by the results from other consumption hospitals, it seems clear that the danger of personal infection is not a great one, provided that common-sense precautions are taken. The observations of Sir Hugh Beevor^* upon the prevalence of phthisis in the rural districts of Norfolk during three succeeding decades (1861 to 1890) are also interesting in this respect. The figures show that in each decennium the death- ETIOLOGY OF PULMONARY TUBERCULOSIS 437 rate from phthisis in these small rural populations (varying in number from 2,000 to 6,000) was in each remarkably constant, nearly always falling within 10 per cent, of the mean rate for that of all the rural districts, and never showing those marked irregularities which are met with in the case of the common epidemic or infectious diseases. The figures indicate, as Sir Hugh Beevor points out, that, given fairly satisfactory surroundings, the influence of case-to-case infection sinks in importance, other contributory or favouring factors playing the chief role. The steady line of decline of the tuberculosis Death Rabes pe Mill 4,500 3^00 J.000 2,500 2,0na 1,000 Phthisis Death Rates. Females ) England 8c Wales I85I-I9I0 •V- / • ^ Age Pertod 10 15 20 25 30 a ■''0 4i 50 55 60 65 fO '5 80 Fig. 43. From Dr. Brownlee's Report to Medical Research Committee, 1918, diag. iii. death-rate through successive decades (see Figs. 42 and 43) is further evidence that the contagious element in the malady no longer resembles, either in type or degree, that obtaining in the ordinary contagious diseases. Marital or Conjugal Tuberculosis. — Evidence in favour of personal infection has been deduced from the cases in which the disease has been communicated from husband to wife, and vice versa; and the remarkable series collected by the late Sir Hermann Weber''' of nine consumptive husbands who lost eighteen wives, one of these pathological Bluebeards being 438 DISEASES OF THE LUNGS AND PLEURA responsible for four, another for three, four others for two, and three for one each, was very striking. Such dramatic experience is, however, quite unusual, and the exact conditions under which these people were living are not stated. Certainly in the upper classes, in our experience, conjugal tuberculosis is uncommon. This view is, however, by no means generally accepted. Dr. Ernest Ward,^*^ Tuberculosis Officer for South Devon, has recently reported a series of cases to illustrate the frequency of conjugal tuberculosis, amounting to over 50 per cent., in his district amongst the working and lower middle classes; but the associated conditions are not stated, and we can only con- jecture the degree of overcrowding or general insanitation that could produce such results, and to which the parents of households would, of course, be exposed with some excess of intensity. Statistics on larger lines are completely adverse to such restricted experiences, and when closely scrutinised suggest that any slight increase of vulnerability observed in such cases depends upon other factors besides mere contiguity. Dr. Longstaff" has pointed out that, seeing how prevalent con- sumption is, it must happen, in the ordinary course of events, that husbands and wives will die of the disease, not very infrequently within short periods of each other, without any question of infection arising. Basing his results on mathe- matical calculations deduced from the Registrar-General's Reports, he estimated that the prevalence of conjugal tuber- culosis was not greater than might be expected as a matter of coincidence. The late Dr. E. G. Pope, Professor Karl Pearson, and Miss Elderton,''* also investigated the subject in an elaborate statistical memoir, and concluded that consumption in husband and wife does occur more frequently than can be explained by the doctrine of chances, and that there is some sensible but slight infection between married couples. On a further analysis of the statistics of Dr. Pope, comparing them with calculations of his own and of Miss Elderton and others engaged in his laboratory. Professor Pearson" con- cludes that for the middle and professional classes there is a definite marital relationship of persons with simi- larity of constitution and of physical and psychical attributes y$:T10L0GY OF PULMONARY TUBERCULOSIS 439 which is due to unconscious selection in mating". To this dis- position towards marriage manifested by persons having similar constitutions and attributes he gives the name " assor- tative mating," and he thinks that it may account for the slight excess of liability to infection which he finds to exist amongst married people. This relationship or correlation holds g'ood for eye colour, general health, tone of voice, for certain neuroses, including insanity, and other features which cannot in any sense be regarded as of infectious origin. The index of similarity or correlation for married people of the same social status with reg"ard to phthisis — that is, their rela- tive vulnerability to that disease — is almost identically the same as that for the main features just named, and may be represented by the decimal 0*24 to 0"28. The index falls in both cases as we descend the social scale, being 0'i6 for the prosperous poor and entirely negligible for the very poor. It seems clear, then, that the increased tendency of married couples to become both affected with phthisis, sHght as it is, is not wholly attributable to direct infection, but also to an increased vulnerability to distributed or environmental infec- tion. A similar conjugal disposition to insanity is to be noted, only with increased force — 0'3o; and to alcoholism with still greater intensity — 07. Dr. Goring*" concludes from his separate researches that " there is no evidence of marital infec- tion." " The incidence of phthisis in both husband and wife noted by Pope, Greenwood, and others, may be due to assorta- tive mating." Another point of great importance in the incidence of phthisis as bearing upon the question of direct marital infec- tion, and a fortiori of person to person infection generally, is the fact pointed out by Karl Pearson^"'' that the probability of the offspring of a tuberculous father or mother being tuber- culous is far greater than the probability of a wife or husband being similarly attacked. "The father is twice as dangerous to the child as the husband to the wife ! The mother is only very slightly more dangerous than the father at very early ages." Heredity wauld thus seem to be the supplementary factor involved in assortative mating, which may account for the slightly increased number of instances in which husband and wife are both involved in tuberculosis. And Professor Pear- 440 DISEASES OF THE LUNGS AND PLEURAE son, in confirmation of this, finds that there is an appreciable excess or concentration of heredity to tuberculosis amongst the forebears of married people; the stocks from which they are drawn having a correlation in this respect of 0-30.^^'^ It is worthy of special note that amongst the very poor, \vhere assortative mating practically does not obtain, tubercu- losis is much more prevalent than amongst the middle and professional classes, the intensity of the environmental infec- tion from overcrowding and the diminished resistance from adverse conditions of life already considered no doubt accounting for the difference, conditions which are intensified in the conjugal relationship. If we accept the views put forward in the above sections their bearing on prevention is obvious. The consumptive patient who is properly trained and willing and able to carry out instructions is no real source of danger. Still less should such patients, Avho need our sympathy, be regarded as lepers to be shunned. On the other hand, the selfish or ignorant patient who disregards all precautions, or the sufferer who from increasing weakness, lack of proper nursing, and over- crowded surroundings is incapable of doing what is required, becomes a grave danger to his fellows. In such cases, volun- tary segregation and the admission of the patient to a home, or hospital is the fine of treatment indicated. Sir Arthur Newsholme" draws an interesting parallel between the increase of institutional treatment and the decline of the phthisis death-rate during the latter half of the last century. An increased provision of beds for advanced cases is, how- ever, still urgently needed in not a few localities. We shall further consider this question in the next chapter. REFERENCES. ^ Anatomical Report by Professor G. Elliot Smith, F.R.S., and Dr. D. E. Derry, The Archaological Survey of Nubia, Bulletin No. 5, Cairo, 1910, p. 21. - " Pott'sche Krankheit an einer agyptischen Mumie aus der Zeit der 21 Dynastic (um 1,000 v. Chr.)," von Grafton Elliot Smith und Marc Armand Ruffer, Zur Historische Biologie der Kranlzheitserreger , 3 Heft, Giessen, 1910, p. 9. ^ A Supplementary Anatomical Report by Dr. F. Wood Jones, The Arch ecological Survey of Nubia, Bulletin No. i, Cairo, 1908, p. 38. * Museum No. 182, B and C. ETIOLOGY OF PULMONARY TUBERCULOSIS 441 5 See " Etudes sur la Tuberculose : preuves rationnelles et experimentales de sa specificite et de son inoculabilite," par J. A. Villemin, Professeur agrege a I'Ecole imperiale du Val-de-Grace. Paris, 1868. " For original experiments bearing upon this point, and for an admir- able resume of the recent literature of the subject at the time, see "A Pre- liminary Note of Some Experiments on the Etiology of Tuberculosis," by Dawson Williams, M.D., The Transactions of the Pathological Society of London, 1884, vol. xxxv., p. 413. ^ " The Streptotrichoses and Tuberculosis " (being the Milroy Lectures for 1910), by Alexander G. R. Foulerton, F.R.C.S., D.P.H., F.C.S., p. 44. London, 1910. » (i) " The Chemical Constitution of the Tubercle Bacillus," by Dr. W. Bulloch and Dr. J. J. R. Macleod, The Lancet, 1901, vol. ii., p. 81. (2) " The Morphological and Physiological Variations of the Bacillus Tuberculosis and its Relations [a] to Other Acid-Fast Bacilli ; (6) to the Ray Fungus and Other Streptothricese," by William Bulloch, M.D., Transactions of the British Congress on Tuberculosis , London, vol. iii., p. 494. (3) "The Chemical Constitution of the Tubercle Bacillus," by William Bulloch, M.D., and J. J. R. Macleod, M.B., Journal of Hygiene, 1904, vol. iv., p. I. ■* " " An Enquiry based on a Series of Autopsies into the Occurrence and Distribution of Tuberculous Infection in Children and its Relation to the Bovine and the Human Types of Tubercle Bacilli respectively," by A. Stanley Griffith, M.D., Reports to the Local Government Board, London, igi4, p. 107. '" See " Reports on the Work by Dr. Stenhouse Williams," Fifth Annual Refort of the Medical Research Committee, 1918-1919, London, 1919, p. 3=;. " " Effect of Exposure to Liquid Air upon the Vitality and Virulence of the Bacillus Tuberculosis," by Harold Svifithinbank, Transactions of the British Congress on Tuberculosis, London, 1902, vol. iii., p. 657. '^ " On the Distribution of the ' Tubercle Bacilli ' in- the Lesions of Phthisis," by Percy Kidd, M.A., M.D., Transactions of the Royal Medical and Chiriirgical Society, 1885, vol. Ixviii., p. 87. " See " Ueber des Vorkommen von Tuberkelbazillen im Kreisenden Blute und die praktische Bedeutung dieser Erscheinung," von F. Jessen and Lydia Rabinowitsch, Deutsche Medicinische Wochenschrift, 1910, p. 1116. '* See " The Specific Diagnosis of Pulmonary Tuberculosis," by A. C. Inman, M.A., M.B., The Lancet, 1910, vol. ii., p. 1748. i« (a) The Causes of Tuberculosis, by Louis Cobbett, M.D., F.R.C.S., Cambridge, 1917, p. 134. {b) Loc. cit., pp. 145-150. (c) Loc. cit., chap, xxvi., p. 657. " " Die Bedeutung der Geflugestuberkulosebazillen fiir die Tuberculose des Menschen," von Dr. E. Lowenstein, Tuberculosis, Berlin, vol. xiii., 1914, p. 211. See also British Medical Journal, 1913, vol. ii., Epit., No. 126. 442 DISEASES OF THE LUNGS AND PLEURA ^^ Die Lehre von der Kongenitalen Tuberkulose mit besonderer Beriick- sichtigung der Placentartuberkulose, von Dr. Anton Sitzenfrey. Berlin, 1909. " Dr. Heron, in his work on Evidences of the Communicability of Con- sumftion (London, 1890), in an appendix, gives details of a large number of cases of tuberculosis derived from accidental inoculation by direct injury from broken spittoons and other means. ^° For a more detailed account of the case by the late Mr. Stanley Boyd, see the Clinical Journal, June 26, 1901, p. 147. 2" " Versuche an Meerschweinchen iiber die Aufnahme inhalierter Tuberkelbazillen in die Lunge," von Dr. Bruno Heymann, Zeitschrift fUr Hygiene und Infektionskrankheiten, Leipzig, 1908, Band Ix., p. 490. ^^ " Das Schicksal inhalierten Schimmelpilzsporen. Ein Beitrag zur Kenntniss des Infektionsweges durch Inhalation," von Dr. Ballin, Zeit- schrift fiir Hygiene uttd Infektionskrankheiten, Leipzig, 1908, Band Ix., P- 479- ^^ " Untersuchungen iiber die Infektion mit Tuberkelbazillen durch Inhalation von trockenem Sputum-Staub," von Dr. Kohlisch, Zeitschrift fiir Hygiene und Infektionskrankheiten, Leipzig, 1908, Band Ix., p. 527. " (i) " Report on a Bacterial Test for estimating Pollution by Air," by Dr. M. H. Gordon, Annual Re fort of the Medical Oficer of the Local Government Board for the Year 1902-03, London, 1904, p. 421. (2) Refort on an Investigation of the Ventilation of the Debating Chamber of the House of Commons, by Dr. M. H. Gordon. London, 1906. ^* See three valuable memoirs on this subject by P. Chausse, Annales de Vlnstitut Pasteur, tome xxviii., 1914, pp. 608, 720, 771. ^* The Channels of Infection in Tuberculosis, being the Weber-Parkes Prize Essay, 1903, by Hugh Walsham, M.A., M.D., F.R.C.P. London, 1904. ^^ See " The Importance of the Upper Respiratory Tract in the Etiology of Cryptogenetio Infections, especially in Relation to Pleuritis," by George Bacon Wood, Fourth Annual Refort of the Henry Phiffs Institute, Philadelphia, 1908, p. 163. ^' " Sur rOrigine Intestinale de I'Anthracose Puhnonaire," par P. Van- steenberghe et Grysez, Annales de Vlnstitut Pasteur, 1905, tome xix., p. 787. 28 '< Vergleichende Untersuchungen iiber Inhalations- und Fiitterungs- tuberkulose," von Dr. H. Findel, Zeitschrift fiir Hygiene und Infektions krankheiten, Leipzig, 1907, Band Ivii., p. 104. ^° " Das Verhalten des Kaninchens gegeniiber den verschiedenen Infektionswegen bei Tuberkulose und gegeniiber den verschiedenen Typen des Tuberkelbacillus," von Dr. Joh. Alexander, Zeitschrift fiir Hygiene und Infektionskrankheiten, Leipzig, 1908, Band Ix., p. 467. ^° Second Interim Refort of the Royal Commission affointed to inquire into the Relatiotis of Human and Animal Tuberculosis, London, 1907. ETIOLOGY OF PULMONARY TUBERCULOSIS 443 ^' " Weitere Beitrage zur Frage iiber die Beziehungeo zwischen Sauglingsernahrung und Tuberkulose," von Dr. Bruno Heymann, Zeit- schrijt fur Hygiene und Infektionskrankheiten, Leipzig, 1908, Band Ix., p. 424. ^^ {a) "A Lecture on the Infection of Consumption," by C. Theodore Williams, M.A., M.D., F.R.C.P., British Medical Journal, 1909, vol. ii., p. 433. {b) Loc. cit., p. 435. ^^ "The Contagion of Phthisis," by C. Theodore Williams, M.A., M.D., F.R.C.P., British Medical Journal, 1882, vol. ii., p. 618. ^* Rural Phthisis and the Insignificance of Case-to-Case Infection, by Sir H. R. Beevor, Bart., M.D., F.R.C.P. London, 1900. ^^ " On the Communicability of Consumption from Husband to Wife," by Hermann Weber, M.D., Transactions of the Clinical Society of London, 1874, vol. vii., p. 144. 3" " Conjugal Tuberculosis," by E. Ward, M.D., F.R.C.S., The Lancet, 1919, vol. ii., p. 606. See also a leading article in The Lancet, 1919, vol. ii., p. 651, and various letters relating to this subject. ^' Studies in Statistics, by George Blundell Longstaff, M.A., M.B., F.R.C.P., p. 384. London, i8gi. '^ A Second Study of the Statistics of Pulmonary Tuberculosis : Marital Infection, by Ernest G. Pope, Karl Pearson, F.R.S., and Ethel M. Elderton (Drapers' Company Research Memoirs). London, 1908. ^' Tuberculosis, Heredity, and Environment, by Karl Pearson, Galton Professor of Eugenics, University of London. 1912. [a] Loc. cit., p. 19. (b) Loc. cit., p. 16. " On the Inheritance of the Diathesis of Phthisis and Insanity, by Ch. Goring, M.D. (Drapers' Company Research Memoirs : Studies in National Deterioration, vol. v., p. 24). London, 1909. ■*' The Prevention of Tuberculosis, by Sir Arthur Newsholme, K.C.B., M.D., F.R.C.P., London, 1908, chap, xxxv., p. 266, etc. CHAPTER XXX PULMONARY T\JBERCi:LOSlS—(Con/iiiued) etiology — (Continued) Let us now consider the conditions which bring about that aptitude for the reception of the bacillus which, in view of the manifold opportunities of infection, is of such paramount im- portance. I. Constitutional Liability.— Apart from all other aetiologi- cal considerations, the constitutional liability to tuberculosis must be taken into account, this constitutional tendency being most purely and strikingly manifested in hereditary, less completely so in acquired, liability. We do not main- tain the first, and it would be absurd to argue the second as being independent of the surrounding climatic and social conditions which we have yet to discuss; but when these have been allowed for, there still remains to be considered the personal element in the disease — the character of the soil as opposed to that of the seed — which in many cases exercises an influence which cannot be gainsaid. The constitution of a man has been defined by one of us as " his build, the integrity or otherwise of the tissues of which each part of his body is made up, and the wholesomeness or otherwise of the juices with which they are bathed; the sum of his vital force, his cell-quickening power, which shall bear the call of judicious expenditure for a long or but a brief period of time."^ This material and dynamic constitution is born with the infant, developed during the period of growth, and maintained with waning completeness during the wear and tear of subsequent life. Hereditary constitutional defect means unsoundness of original construction with regard to some organ or tissue at birth. Acquired constitutional defect means that some part of the human mechanism has suffered deterioration from deficient supply of the needs of growth 444 ETIOLOGY OF PULMONARY TUBERCULOSIS 445 and function, through wilful or involuntary exhaustion of vital powers, or from imperfect recovery from acute disease. Inherited Tendency to Phthisis. — In considering this ques- tion, it has been usual to quote statistics showing that, of those suffering from consumption, many have lost a parent or some near relative from the same disease, and to gauge the degree of danger from the resulting figures. Thus, in the first medical report of the Brompton Hospital, of the i,oio patients investigated, a history of consumption in one or other parent (and sometimes in both) was obtained in 246 cases, or 244 per cent. Dr. C. J. B. Williams and Dr. Theodore Williams,- again, taking only their private patients, found that, of 1,000 cases carefully investigated by them, 120 gave a parental history of the disease, while in 484 some near relative had fallen a victim. The conclusion at which they arrived was that "direct hereditary predisposition" might be traced in 12 per cent, of the cases, and "family predisposition" in 48 per cent. ; and this estimate, coming from the upper classes, who are protected from many of the more potent causes of the disease, they were inclined to accept as a fair statement of the influence of hereditary predisposition. Our own experi- ence would be in accord with these results. One of us,^ looking back upon the histories of 450 cases of consumption taken consecutively from case-books of a few years previously, found 208 cases with a definite history in the family, 123 with a negative history, and 119 in which the history was not re- corded (most of these latter would be negative). Of the 208 cases with positive histories, in 43 several direct relations were affected (father and mother, 4; father and grandparents, 2; father and brother or sister, 5; mother and brother or sister, II; two or more brothers and sisters, 20; brother and grand- parents, i). In 30 and 33 cases respectively the father or the mother was affected, yet in 4 instances only were both involved, and we should regard this as in excess of our general experience. More complete data were collected from 383 patients at the Crossley Sanatorium, Delamere Forest, by Dr. W. C. Rivers, and were discussed in an interesting memoir by Professor Karl Pearson,* who, however, was careful to point out that the investigation was preliminary, and that his conclusions needed confirmation from more extended data. After a 446 . DISEASES OF THE LUNGS AND PLEURA detailed analysis of the figures by modem statistical methods, he concludes : " The diathesis of pulmonary tuberculosis is certainly inherited, and the intensity of inheritance is sensibly the same as that of any normal physical character (e.g., stature, span, cubit, eye-colour) yet investigated in man. ... A theory of infection does not account for the facts." He is further "inclined to think that the risks run, especially under urban conditions, are for tuberculosis, as for a number of other in- fectious diseases, so great that the constitution or diathesis means almost everything for the individual whose life cannot be spent in self-protection." A reference to the paragraph on "marital infection" in the preceding chapter will bring to mind that the marital relation- ship, in the more intellectual classes at all events, by virtue of the unconscious sexual attraction of constitutional affinities, brings into close association persons with a somewhat stronger strain of hereditary predisposition to tubercle infec- tion, and that amongst them there is therefore an increased vulnerability to any environmental conditions tending to tuberculosis. Let us now ask ourselves how far Professor Karl Pear- son's conclusion is supported by clinical experience. All physicians who have seen much of phthisis will be able to recall instances in which one member after another in a family falls a victim to the disease, and this after the individuals have grown up and separated widely. A striking example of this has come under our notice. A lady, the wife of a country gentleman in good position, died of consumption at the; age of forty-eight, leaving fifteen children. Five of these (daughters) married and left home, and subse- quently died of the same disease at the approximate ages of forty-eight, forty-nine, thirty, twenty-seven, and twenty-six respectively. In addition, one unmarried daughter developed consumption and died at San Remo at the age of nineteen, and one son developed phthisis in India, and died in Australia at the age of twenty-seven. We may add that at the date at which the facts were brought to our notice two g'randchildren, aged thirty-three and eighteen (children of the daughters above referred to who died of phthisis at the ages of forty- eight and twenty-six respectively), had also developed con- sumption. /ETIOLOGY OF PULMONARY TUBERCULOSIS 447 It will be urged by those who oppose the doctrine of heredity that the seven out of the fifteen children, who thus developed phthisis, acquired the disease because they were infected from their mother in comparatively early life, the organisms then remaining dormant for years. Such a proposi- tion is not impossible in view of the fact that living and virulent tubercle bacilli may be found post-mortem in caseous and even calcareous foci in persons who during hfe had not wittingly suffered from tuberculosis.* Even, however, if we accept the correctness of the assumption, we have to ask why these patients eventually developed active pulmonary tuberculosis. Phthisis is an exceedingly common complaint, and the opportunities of infection under ordinary conditions of civilisation seem infinite. The observations of Naegeli show that of post-mortem examinations made between the ages of eighteen and thirty, 96 per cent, gave evidence of having been at some time infected, and that above thirty no individual is free : yet the disease does not develope save in a restricted percentage of the population. It appears to us that the only answer lies in the doctrine of heredity, the inheritance, as it has been termed, of a "tuber- cular diathesis," rendering the soil of certain family constitu- tions more suitable for the growth of the bacillus than that of others, so that, when infected with a suitable dose of the virus, such individuals succumb when their more fortunate brethren escape. This doctrine is no fantastic one, and is only what we might expect if we consider the matter from a biological standpoint. The bacillus is a member of the vegetable kingdom, and it is notorious how selective such organisms are. As Sir James Crichton-Browne has truly said: "The seed of certain plants will grow only in a clay soil, while those of others will sprout only in sand or chalk ; and mushrooms, which are not remotely allied to the fission fungi or bacteria, are nice in their taste, and refuse to increase and multiply on an exhausted bed or one of unsuitable material; while they flourish copiously when their spawn is spread on an appropriate nidus." So it is with the tubercle bacillus, which exhibits this same selectiveness. It refuses to grow in broth or on agar-agar, and yet, if a little glycerine be added, growth at once takes place. That some sHght modification of the soil in certain famiUes should favour 448 DISEASES OF THE LUNGS AND PLEUR.E or inhibit the growth of the organism is to us, therefore, not surprising. If this doctrine be true, we should expect that the different races of mankind, following the example of the animal kingdom, would exhibit a different liability to disease. There is some evidence to show that this is so, though here again it is difficult to separate the race factor from the other elements in the causation of the disease. It is admitted, how- ever, in America that the negro is very liable to consumption, and that, when acquired, it runs in him a rapid course. Among the Jewish race, on the contrary, the mortality from phthisis, both in London and New York, as in most of the great cities of Europe, is shown by statistics to be less than that of the native population, and it is not impossible that this lower death-rate is due in part at least to diminished racial proclivity.^ Major Johnston, of the Indian Medical Service, has also shown that among the races which compose the Indian Army there is a marked variation in the incidence of pulmonary tuberculosis, ranging from 73 per 10,000 among the Gurkha soldiers to 17-8 and iS^o per 10,000 among the Sikhs and Mahrattas respectively. He considers that the racial factor plays a definite share in this varying liability.'' It is thus clear that inheritance is an important factor in the aetiology of phthisis, and that it manifests itself in a special idiosyncrasy of the tissues in certain families and races whereby they become more than usually favourable to the growth of the tubercle bacillus. It is only right to add that the effect of this factor is to tend to eliminate the more sus- ceptible, and in the course of generations to increase immunity amongst the survivors.* 2. Climatic Causes. — Phthisis flourishes, as we have said, in every climate, and it is not possible to point to any country which has a monopoly of the disease. True, the death-rate from consumption differs much in different regions, but this would seem to depend in great part not so much upon vary- ing meteorological data as upon other factors which favour the incidence of the disease. Wherever the population is scattered and leads an open-air life, there the disease is less frequent. Wherever overcrowding is rife, and the evils of civilisation are apparent, there it is more common. There are, however, certain climatic factors which deserve consideration. ETIOLOGY OF PULMONARY TUBERCULOSIS 449 (a) AltiUide. — Evidence exists to show that phthisis, though it occurs at high altitudes, is less frequent there than at lower levels. This fact was noted by Dr. Jourdanet,^ a French physician living in Mexico, and also by the late Dr. Archibald Smith, who practised at Lima, and it was their observations, including the good effects of the higher regions on those who acquired phthisis in the plains, that led to the development of the Swiss Alpine resorts. Dr. Huggard'" pubhshed the following statistics dealing with the prevalence of tuberculosis among the native population in the Canton Grisons, at different altitudes, in the year 1895 : Figures from the Cantc^nt Grisons, showing Diminished Prevalence of Tuberculous Diseases with Increasing Elevation. Number of Communes. Elevation above Sea-level in Metres. Population. Average Population of Commune. Affected with Tuber- culosis (480 of the 690 Cases were Examples of Phthisis). Per Thousand. [a) 15 ... {b) 40 ... {c) 64 {d) 19 285- 599 600- 999 1,000-1,499 1,500-1,880 20,369 20,935 25,346 10,291 1358-0 5234 396-0 541-6 246 204 182 58 12-48 9-74 7-i8 5-64 The table indicates, as Dr. Huggard states, "that the pre- valence of tubercular disease diminishes steadily with altitude, although the communes of greatest altitude are more populous than the two groups of communes next below them." The figures for the higher regions of Switzerland for the years 1905-1909, published by Dr Schmid,^' Director of the Swiss Ministi-y of Health, also show a diminution of the death-rate from phthisis and tuberculosis in general as the altitude increases. It would seem not improbable that the deeper respirations required at these higher elevations, leading to improved blood-supply and better nutrition of the lungs, may explain the diminished incidence of the disease. Dr. William Gordon,'^" of Exeter, casts doubt upon the influence of mere elevation, and would attribute much of the good effects to the absence of high and rain-bearing winds. These conditions can, however, only be said to hold good during the winter season when the snows have fallen. (h) Dampness of the Soil. — The independent researches of 29 450 DISEASES OF THE LUNGS AND PLEURA the late Sir George Buchanan" in England, and of the late Dr. H. I. Bowditch^"* in the United States, pointed many years ago to a relationship between phthisis mortality and wetness of soil, the death-rate rising with the dampness of the subsoil. Sir George Buchanan'^ also observed the converse as one of the results of improved surface drainage — namely, that the death-rate from phthisis fell as the drying of the subsoil took place. These results have been criticised, but the observations of Dr. William Gordon,'-"^ of Exeter, to which we referred more fully in our last edition, lend some support to the theory. It may be said in brief that towns, villages, hamlets, or houses situated at or near undrained localities on heavy, impermeable soils or on low, level ground, and whose sites, consequently, are kept damp, are more suitable for the development of con- sumption than those which are placed on dry or rocky ground, or on light porous soils, where the redundant moisture can easily escape.^*' (c) Exposure to. Wind. — The influence of wind in relation to phthisis was first drawn attention to by the late Dr. Haviland.^' More recently Dr William Gordon," has devoted much atten- tion to the subject, investigating especially the effect of wind upon the mortality from phthisis in the various districts of Devon. The conclusion at which he arrives is that "popula- tions exposed to strong prevalent rainy winds have a higher death-rate from phthisis than populations sheltered from them." Dr. Brownlee finds this to hold especially with the "young adult type" of phthisis. The matter is difficult to prove, so many other factors having to be weighed and dis- counted. The ill-effects of winds may be in part direct, but are perhaps more largely due to the closing of doors and win- dows to which their violence often leads. 3. Injury. — Cases of phthisis occasionally come before us in which the symptoms have followed an injury to the chest. We can recall a remarkable case of the kind, that of a medical man, aged 44, of robust physique, who dated his attack definitely from being crushed against a tree in Scotland by the backing of his motor- car, which he had not sufficiently " braked." .Some ribs on both sides were broken, and double hydrothorax followed, with effusion into the pericardium and pneumonia of the left lower lobe. In the blood- stained mucus expectorated a few tubercle bacilli were found. When sent to Sir Douglas Powell by Dr. Burton, of Blackheath, three months later, in December, 1909, there was some shrinking of the left side ■ib, a ni sv| I ^ ^ M -«-* .a -*-> m s o , ^ w„ X Is M c 2 J C3 on «" 1 . ■*-j "^ c^ (U u >> J-I t>4 8 ^ o ■~ s. Ul «-) .to V u ^a S S :/) « \) k> CJ '-) f^ l-H s the of it 2J 1 ^ ■ S c ^ 1 £ .2 V >> v*-l -tJ •ii taken resenta Pi 6 ' a- C3 (1) * ~<1 S 1 = 'ui ^ Vj >■ a o « in Cfi^^ -^ ,J2 s =y I-* ^J >> o f^ ^ v ETIOLOGY OF PULMONARY TUBERCULOSIS 45 1 and dulness over the apex, with a few crackles extending to the fourth rib. He went to a sanatorium, where the sounds became dry, and he put on four pounds in weight. Six months later, although greatly improved, there were still a few bacilli to be found. Dr. Burton sent a final note of this case, stating that, in the summer of 1910, " he had no further trouble with his lungs, and was able to shoot, and could walk most of us off our legs." In 1912 he was seized with acute appendicitis, and died of peritonitis after operation. Dr. Burton knew him well. His health had always been good up to the time of his accident. His mother died at an advanced age; his father early in life, but the cause of death was unknown. He had three children, one of whom died of tuberculosis, aged nineteen. The subject of "traumatic tuberculosis" has been recently discussed by Dr. Parkes Weber," and it is probable that the cases are to be explained by the injury lighting into activity a latent focus of disease. 4. Social Conditions. — Amongst the general predisposing causes of tuberculosis may be enumerated insanitary condi- tions of life; debility ensuing- upon acute illnesses; debility attendant upon chronic diseases, such as alcoholism, syphilis, anaemia, and gastric affections; hereditary predisposition and mental unsoundness. With regard to most of these factors there is no need for any special remark. It is fully admitted, and in accord with general experience, that those affected with chronic disease and those who are weakly from incomplete recovery from acute illness are prone to be attacked by tuber- culosis ; that is to say, their resistance to tuberculous infection is for the time, or permanently, lessened or broken down. An examination of both climatic and industrial condi- tions predisposing to pulmonary tuberculosis cannot fail to convince anyone how largely they are connected with conditions that fall under the heading of "sociology," as, indeed, we have already indicated when discussing the ques- tion of contagion. Phthisis is essentially a scourge of what we call civilisation. Its rarity among nomadic tribes and aboriginal races in all climates, its prevalence in industrial, as compared with agricultural localities, point to social rather than to climatic influences as predominant in the aetiology of the disease. All the depressing conditions of life — anxiety, mental strain, disappointments, poverty, bad sanitation, overcrowding, alcoholic excess, debauchery — are concentrated at the centres of civilisation. The weakly 452 DISEASES OF THE LUNGS AND PLEURAE are helped to live; scrofula, syphilis, rickets, and catarrhs, prevail; the general tone of health is depressed; recovery from acute specific diseases, such as measles, whoop- ing-cough, influenza, and from inflammatory chest diseases, is less complete, and germs, putrefactive and other, are so rife that special precautions against them are necessary to secure the healing of wounds. All that we know about phthisis would lead us to expect its greater prevalence under these conditions, and such we find to be the case. It is comforting, however, to find from statistical evidence that, with improved sanitation and a general increase in the Diagram showing Death-Rate pee Million living from {a) All Forms OF Tuberculosis,, (i>) Phthisis ; England and W.^les, 1859-1908, corrected for Variations of Sex and Age Constitution. No^e.—The darker shading refers to phthisis. (From the Registrar- General's Annual Report.'^) wage-earning capacity of the labouring classes, there has been a marked and up to recently a continuous decline in the death- rate from this disease. This is well brought out in the above diagram, taken from the Seventy-first Annual Report of the Registrar-GeneraV whereby it will be seen that the stan- dardised death-rate from phthisis, and also from all forms of tuberculosis, has been steadily decreasing. Sixty years ago, it will be noted, the annual death-rate from consumption was 26 per 10,000 living, between two and three out of every 1,000 people dying annually of the disease. In 1908 it was only 11-15, barely more than one person in every 1,000 falling a victim. ETIOLOGY OF PULMONARY TUBERCULOSIS 453 Through the courtesy of the Registrar-General we are enabled to give the corresponding figures for succeeding years, thus bringing the table up to date. The standardised death-rates for phthisis per 10,000 persons living are as fol- lows : 1909, 10-63; 1910. 988; 1911, 10-31; 1912, 9-91; 1913, 9-60; 1914, 9-93. It must be noted that there has been some check in the rate of decHne since 1895, and since 1914 a posi- tive rise, due mainly, though perhaps not wholly, to war con- ditions, the following- being the death-rates for the war years : 1915, 11-53; 1916, 12-30; 1917, 13-83; 1918, 15-20. These figures, for reasons given in the Registrar-General's Report for 1917, exagg-erate the increase in the mortality from tuberculosis which has undoubtedly occurred, both among males and females. We shall again refer to this subject. 5. Age. — Pulmonary tuberculosis may occur at any age, its heaviest incidence being between the ages of twenty-five and forty-five. The late Dr. Bulstrode,-" in his valuable report on " Sanatoria for Consumption," pointed out the important fact that the age of maximum mortality from phthisis has become postponed, and now occurs between the ages of forty-five to fifty-five in males, and thirty-five to forty-five in females, instead of between twenty and thirty-five, as was the case in the middle of the last century. This is well shown in the diagrams which we have reproduced (pp. 436, 437) from Dr. Brownlee's"^ recent paper, which demonstrate also that the fall which occurred during the latter half of the last century has been most marked in the young adult period of life. Dr. Brownlee finds that the age-period of phthisis is not con- stant, as generally supposed, for different parts of the country, being, for instance, much earlier in the Shet- land Islands than in London, and he draws the conclusion that it is "not one disease due to one organism, but a group of diseases due to a group of organisms, just as enteric fever and dysentery have proved to be." He speaks of three types or varieties, the "young adult type," the "middle-age type," and the " old-age type," in which the commonest ages of death are from 20 to 25, 45 to 55, and 55 to 65, respectively. The hypothesis is supported by the fact that the two former types at least have a markedly different geographical distribution within the British Isles. An examination of Dr. Brownlee's interesting diagrams suggests the possibility that the varia- 454 DISEASES OF THE LUNGS AND PLEURA tions of the phthisis mortality in certain districts are due to occupational causes rather than to some specific difference in the tubercle bacilli. Nor must it be forgotten that the inci- dence of the disease must be reckoned on an average as occurring some years before its mortality, and that with improved methods of treatment this interval between incidence and mortality is steadily lengthening. This postponement of the age of maximum mortality is, however explained, a fact of great importance, in that the victim dies at an age when his family is less dependent upon him, and does not so inevitably lead to that privation among the children which so often is responsible for the further spread of the disease. The excep- tional conditions of war service under which so many of our young soldiers have lately acquired tuberculosis may tem- porarily, in some degree, modify the age of maximum mortality. 6. Oyercrowding. — Taking the proportion of two persons to a room in tenements of not more than five rooms, as the limit of occupational sanitation, and reckoning, all numbers above that proportion in percentages of overcrowding, it has been shown by Sir Shirley Murphy that in London the death- rate from consumption advances directly in ratio to the over- crowding. This is demonstrated in the following table, taken from the Report of the London County Council : ^^ Phthisis Death-Rates in Relation to Overcrowding. London, 1901-1909. {Taking two persons per room in five-room tenements as the basis.) Proportion of Over- crowding in Each Group of Sanitary Areas. Crude Phthisis Death-rate per 1,000 Persons living. Standard Death-rate. Factor for Correction for Age and Sex Distribution. Corrected Death-rate per 1,000 Persons living. Corrected Death-rate (London, 1,000). Under 7-5 per cent. 7-5 to 12-5 12-5 ,, 20-0 20-0 ,, 27-5 Over 27-5 I '034 1-320 i"4i3 1-924 I "953 17T8 1-705 I -771 1-805 I -651 1-00991 I -01 761 0-97969 0-96124 I 05090 1-044 1-343 1-385 1-850 2-052 709 912 941 1,256 1.394 London 1-472 1735 I -ooooo 1-472 1,000 ETIOLOGY OF PULMONARY TUBERCULOSIS 455 From the above figures it is to be seen that in groups of sanitary districts in London with under 7-5 per cent, of over- crowding the corrected death-rate from phthisis was 1044 per 1,000 people hving. As the overcrowding increased, so did the phthisis death-rate, until, with 27-5 per cent, or more of overcrowding, the corrected death-rate reached 2-052. The importance of overcrowding as a factor in the spread of the disease is also shown by the fact that in Aberdeen,-^ as stated in 1916 by the Medical Officer of Health, fully one-half of the cases of phthisis notified were found to be occupying the same bed with other inmates, and that at least two-thirds were sleeping with others in the same room. A very similar condition would appear to prevail in Bradford."' 7. Dusty Employment. — The effect of dust inhaled in the pursuit of various employments was carefully investigated many years ago by the late Dr. Greenhow,-' and his conclu- sions as to its baleful influence and the excessive mortality from lung diseases and phthisis which results from it, have been borne out by later observers. This subject we have referred to in the chapter deal- ing with pneumonokoniosis, and we may recall that it is in the trades in which the dust particles are hard and gritty, such as gold-mining, tin-mining and lead-mining, and among cutlers, potters and grinders, that the danger is greatest. Soft particles, such as coal dust and the animal dusts produced from bone, horn or ivory, are less' harmful, and, indeed, among coal-miners the mortality from phthisis is below the average. These facts are illustrated by the researches of Dr. John Tatham,-'^ who showed that for the three years 1890 to 1892 the death-rate from phthisis among- potters, lead- miners, cutlers and file-makers was between three or four times that of the agricultural labourer, whilst among tin- miners it was nearly five times as great, and these figures are fully maintained in the recent Reports for 1918 and 1920 by Dr. Brownlee. The mortality, in fact, among tin-miners proved higher than that of any other trade examined, the other four mentioned coming next in order of frequency. Dr. Tatham's figures show also in the dusty trades a greatly increased mortality from other diseases of the respiratory organs. The observations of Dr. Scurfield,-' Medical Officer of 456 DISEASES OF THE LUNGS AND PLEURA Health for Sheffield, are also of importance, demonstrating that although the total death-rate from tuberculosis in Sheffield shows nothing peculiar, yet on analysis it is found that the male death-rate is much greater than that for England and Wales, while the female mortality is much smaller. Further examination shows that the excessive mortality from phthisis among the Sheffield males is due to the great prevalence of the disease among the grinders, and to a less extent among the cutlers. The following figures abridged from his table are instructive, showing that amongst the grinders half the mortality is due to consumption, and two- thirds to diseases of the respiratory system, as opposed to one-sixth and one-third respectively among the total male population of the town. The same holds good with the Cornish miners.^* Mortality at Sheffield among Male Workers in Certain Trades DURING the Seven Years (1901-1907). Occupations. Numbers. Mortality (Rate per Thousand living). All Causes. Phthisis. Respiratory Diseases. Grinders Cutlers Tailors Printers Joiners 3.868 3,889 941 487 2,286 30-9 300 21-4 17-3 13 '9 15-0 6-0 1-4 3-8 17 5-6 7-0 4'i 2-6 2-6 All males (1905-6-7) — l6"2 2-6 21 A consideration of the above facts can leave no doubt as to the danger resulting from the inhalation of irritating dusts, the damaged lung being thereby rendered more easily a prey to invasion by the tubercle bacillus. 8. Alcohol. — This is believed by many to be a potent factor in the aetiology of the disease, and French statistics are quoted as showing a parallelism between the death-rate from tubercu- losis and the amount of alcohol consumed. In England, according to our experience, the majority of phthisical patients show no evidence or history of alcoholism, and for ourselves we doubt whether alcohol is per se a favouring agent to tubercle. There can be no question that, if taken in such excess as to produce the di&eases of chronic alcoholism — Diagram I.— Showing the Percentages of FIG. 44 Phthisis Deaths to Total Deaths of Persons from all Causes, ,,,„,\S< 1J5, ,L 1671 L 1691 1701 1711 1721 1731 l?4l 1751 1761 177, 176. ^1 .801 IBI. 1621 .631 m, l»S. .661 IB7. IBBI 1091 ,90. ,9., .9,9 Diagram 11 -Shoiviso I'ercisniaoi! of P,iT,i,s,s Deaths 10 Total Deaths from ale Causes, London. .S51.1919, Subdivided fob Males, Females, and Pebsoms. (Dr. Bbownlee,) .•CABSI351 I8S5 .SSI 1366 137. 1875 .88. 1836 1891 1896 1901 1906 1911 1916-19.9 Diagram 111,— Showing Deaths from Phthisis as Percentage of Deaths from all Causes. England and Wales. (Prof. Karl Peakson,) 14 13 13 '~A --xA \ / * -V-; •^ v ^y' — v^ «r^ A ^--s^ /\ /==^ / \ \ / "-V_^ / 1 1^ - 1 £8 ■ -v h* -T a 6 5 2-5 Facta Royal ry Legislation following upon Commission Reports 1820-1845. Per od of ge eral Sa nitary Re ■form Perioc S of Spec anilatio ial Anti- ifi Treat Bacteria ment Ans|835 40 45 60 55 60 65 70 75 80 85 90 95 .900 05 ETIOLOGY OF PULMONARY TUBERCULOSIS 457 cirrhosis, alcoholic bronchitis, pharyngitis, or peripheral neuritis — it does beget a tendency to the accjuisition of tubercle; even then, however, the disease is apt to run a chronic course. A more important way in which chronic alcoholism favours tuberculosis is indirectly by leading people into dirty, ill-ventilated, and contaminated drinking-places, in which the virus of tubercle is diffused. 9. Insanity. — Mental unsoundness is, again, in all probabihty only indirectly operative in the aetiology of phthisis, insane patients being admitted into asylums which have been in the past to a certain extent insanitary and overcrowded, and which are liable, from the habits of such patients, to specific contami- nation. The yearly average of 1,809 deaths from phthisis in lunatic asylums which obtained in 1912 to 1914 increased to 5,605 in 1918,^" no doubt attributable to the overcrowded con- ditions that prevailed during the war. 10. Epidemic Features. — We may finally ask whether behind and beyond all the aetiological factors we have been consider- ing there may not be some other influence at work controlling the incidence of tuberculosis. We annex a diagram (Fig. 44) from Dr. Brownlee's Report in 1918 to the Medical Research Committee on the Epidemiology of Phthisis,"^ in which he illustrates the curve of death-rate from the disease in London, which he has traced from the Registrar-General's Reports and such information as is available before they were instituted. Diagram I. depicts a long epidemic wave of phthisis through the whole of the eighteenth century, reach- ing its height at the commencement of the nineteenth cen- tury, when for about thirty years it fluctuated, accounting for between 26 per cent, and 20 per cent, of the total deaths, and then declined to about 10 per cent, at the end of the century. Professor Karl Pearson also, in general agreement with Brownlee, further shows that within the period covered by the Registrar-General's Reports, from 1841 up to 1910, there is evidence of the disease being in some manner governed by influences other than those of mere environment. As will be seen, the curves of mortality for the whole country given in Diagram III. show a moderate declension during the first thirty years in which the Factory Laws were in force ; a more decided decHne during the second period of twenty-five years, from 1865, when general sanitary reform prevailed; and 45 B DISEASES OF THE LUNGS AND PLEURA then a failure proportionately to respond in the third period of twenty years to the special sanitary and therapeutic measures based upon a recognition of the specific cause of the disease. This latter check in the declension of the death- rate, it will be observed, began before the war, and although increased to a positive rise in death-rate during" the war, is not wholly attributable to that cause. The general death-rate, on the other hand, remained constant through the first period of factory laws, and then fell steadily and without check through the second and third periods; in the last period, indeed, the decline being still more marked. When we come to analyse these somewhat discouraging results in the light of the detailed statistical researches related in Dr. Brownlee's two reports and in Professor Karl Pearson's records, to which we have extensively alluded, some very instructive facts are disclosed, and some interesting speculations are raised relating to the prevalence and biology of tubercle. We have already referred to the three types into which Dr. Brownlee believes phthisis to be separable. He finds that the main decline for the last sixty years, up to 1910, has been due to a diminished mortality — from 1-52 to 024 per cent, for males, or nearly 7 to i — amongst the lives of the young adult type (age twenty to twenty-five); the middle- age type, of the period between thirty-five and fifty-five, main- taining practically the same mortality during that time — i' 12 to I -16 per cent. The decline in mortality amongst the younger lives has been most marked in towns; in country districts and exposed situations the disease amongst them being propor- tionally more prevalent. Wind and weather and subsoil take an important part in its aetiology, the interesting diagrams in Dr. Brownlee's first report (1918) showing its prevalence in our wind-stricken districts of North Scotland, Wales, and Devon- shire.^^" It is, on the other hand, but little affected by insanitary environment. Amongst the lives of the middle-age type the decline in death-rate has been much less manifest, and has been in closer conformity with the general death-rate. This type pre- vails especially in urban districts, and a glance at Dr. Brown- lee's diagrams will show a much closer association with indus- trial conditions. All the occupational causes of phthisis are mainly operative towards the middle periods of life. And it is .ETIOLOGY OF PULMONARY TUBERCULOSIS 459 in accord with experience that hereditary influence is a more important factor in the young adult period, whilst in the middle-age period the disease is more definitely acquired, from prolonged exposure to adverse environment, combined with other exigencies in the struggle and harassment of middle life. There are some considerations that militate against any dog- matic acceptance of the first two types of phthisis as having been fully established. Dr. Brownlee suggests them without dogmatism. In his statistics, which are of death-rates only, some qualification is perhaps needed from the fact that many young people afflicted with chest delicacy or actual disease in urban districts are sent away to the country, whilst many cases "recover" under treatment, and with a recurrence in later years such cases tend to load the middle-age group. It would appear, from a due consideration of all the circum- stances of aetiology, that the tubercle bacillus is sufficiently ubiquitous to render all persons liable to attack; and, indeed, most persons under civilized conditions of life are at some time or other attacked; but that under conditions of concen- tration of the poison in overcrowded localities and in dirty and dust-laden environments the contagion may be so strong as to be operative against the resistance of those who have no original constitutional liability to the disease. The here- ditary factor tends, on the one hand, to increased vulnerability to early attack, and, on the other, to gradual increase of im- munity of the race by extinction of the more susceptible and survival of the more resistant. The biology of the tubercle bacillus has yet to be traced to its probable saprophytic ancestry, and the morphology of its parasitic phases to be further disclosed, before we shall be in a position fully to understand its various types and degrees of virulence, the reactions of its host, the animal organism, with regard to it, and the abiding source of its continuance through the ages. As remarked by the Research Committee in their introduction to Dr. Brownlee's first report of 1918, the decline in mortality in past decades "is most naturally to be regarded as the ebb of a long epidemic wave, to be succeeded perhaps — indeed, probably — by the rise of the next wave in its turn, unless science can find the way of interference, and its explanation can only be given by further study." 460 DISEASES OF THE LUNGS AND PLEURAE Our primary efforts — perhaps better directed — to maintain its decadence must not be relaxed; but tlie true biology of the disease has yet to be found. REFERENCES. ^ " On the Causative Relations of Phthisis," by R. Douglas Powell, M.D.^ British Medical Journal, 1884, vol. ii., p. 701. 2 Pulmonary Consumption, by C. J. B. Williams, M.D., LL.D., F.R.S., and Charles Theodore Williams, M.A., M.D., second edition, p. 62. London, 1887. ^ Lecture to the Twenty-second Congress of the Royal Sanitary Institute at Glasgow, July, 1904, " On the Prevention of Consumption," by Sir R. Douglas Powell, Bart., K.C.V.O., M.D., F.R.C.P., Journal of the Royal Sanitary Institute, vol. xxv., p. 354. * A First Study of the Statistics of Pulmonary Tuberculosis, by Karl Pearson, F.R.S. (Drapers' Company Research Memoirs : Studies in National Deterioration). London, 1907. ^ The Causes of Tuberculosis, by Louis Cobbett, M.D., F.R.C.S., pp. 70-72. Cambridge, 1917. s " Tuberculosis and the Jew," by W. M. Feldman, M.B., B.S. Lond., The Tuberculosis Year Book and Sanatoria Annual, London, 1913, vol. i., p. 48. See also an interesting article entitled " Tuberculosis among Jews," British Medical Journal, igo8, vol. i., p. 1000. ' " Tuberculosis in the Indian Army : Its Incidence as Affected by Locality, Racial Proclivity and Service Generally," by Charles A. Johnston, M.B., CM., D.P.H., British Journal of Tuberculosis, London, January, 1908, vol. ii., p. 20. 8 See " The Laws of Heredity," by G. Archdall Reid, M.B., F.R.S.E., pp. 453, 455. London, 1910. In various parts of his interesting work Dr., Reid alludes to this subject. ^ Le Mexique et VAmerique Troficale, par D. Jourdanet, p. 295. Paris, 1864. " Handbook of Climatic Treatment, by William Huggard, M.D., p. 124, London, 1906. ^^ " Die Tuberkulosesterblichkeit der Schweiz und die zur B'ekampfung der Tuberkiilose daselbst im Letzen Jahrzehnt gemachten Anstrengungen." von Dr. Schmid, Direktor des Schweizerischen Gesundheitsamts in B'ern, Tuberculosis, Berlin-Charlottenburg, vol. xi., 1912, p. 357. ■■^ [a) " The Influence of Soil on Phthisis as illustrating a Neglected Principle in Climatology," by William Gordon, M.A., M.D., F.R.C.P., British Medical Journal, 1909, vol. ii., p.. 840. (^) The Influence of Strong, Prevalent , Rain-bearing Winds on the Prevalence of Phthisis, by Williajn Gordon, M.A., M.D., F.R.C.P. London, 1910. .ETIOLOGY OF PULMONARY TUBERCULOSIS 461 (c) " The Influence of Strong, Prevalent, Rain-bearing Winds on the Course of Phthisis," by William Gordon, M.D., F.R.C.P., Brtitsk Medical Journal, 1912, vol. i., pp. 291 and 773. [d] " The Place of Climatology in Medicine," being the Samuel Hyde Memorial Lectures for 1913, by William Gordon, M.A., M.D., F.R.C.P. London, 1913. ^^ " Report by Dr. Buchanan on the Distribution of Phthisis as Affected by Dampness of Soil," Re-port of the Medical Officer of the Privy Council, London, 1867, p. 57. ^* Consumftion i^i New England, or Locality One of its Chief Causes, by Henry I. Bowditch, M.D. Boston, 1862. ^5 " Report by Dr. Buchanan on the Results which have hitherto been gained in Various Parts of England by Works and Regulations designed to Promote the Public Health," Refort of the Medical Officer of th'e Privy Council, London, 1866, p. 40. ^^ Seventh Detailed Annual Report of the Registrar-General in Scot- land, p. xlviii. 1'^ The Geographical Distribution of Disease in Great Britain, by Alfred Haviland, M.R.C.S., etc., late Lecturer on " The Geographical Distribution of Disease" in St. Thomas's Hospital, London. Second edition. London, 1892. 1^ Traumatic Pneumonia and Traumatic Tuberculosis, by F. Parkes Weber, M.A., M.D., F.R.C.P. London, 1916. ^^ Seventy-first Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales, p. ci. London, 1909. 2" Re-port on Sanatoria for Consumption and Certain Other Aspects of the Tuberculosis Question, hy H. Timbrell Bulstrode, M.D. (Supplement to the Thirty-fifth Annual Report of the Local Government Board, 1905-06), p. 42. London, 1908. '^1 An Investigation i^tto the Epidemiology of Phthisis in Great Britain and Ireland, by John Brownlee, M.D., D.Sc. (Director of the Statistical Department, Medical Research Committee). London, 1918. {a) See also Part iii. London, 1920. ^^ " Report of the Medical Officer of Health of the County of London for the Year 1909," London, p. 58. 23 See British Medical Journal, June, 1916, vol. ii., p. 886. '^ "Alcohol, Housing Conditions, and Consumption," by Harold Vallow, M.D., British Medical Journal, 1914, vol. i., p. 477. 25 i 1 1 ij ■ h d9 , •A "< V P 1 : 1 ■^ - V. ': 82- » A \^A / « f\ / V ^ V<^ L^ ,/^, ; ; -- I 1 / k / il \ / y\ V l-^ ' \ ; V l/ 4\ ■ 1 l\ 'l\ ■ ', i / \i ; "'. 1 r .. J ' , V \ r r 11 / ■ i ] i ■ :, '-. - 1 \ 1 i. : 1/ y: i / v^ /■ / ^M^^ V^ ■ •■' ilMi \ -" '' w - 1 , 1 i 1, ; • i 1 ' ■" : -• J •; \ ^ - _L ._ ■. _;_ 1 _1_ ■ ■y ^ ^. % ' WZ-^Z *J 52 ^mm 32 SZ «_ — E "^ lI zzz — ~ =n :rr = I] i::^ — zS?^ _ M ^ ^^J% m Decern ber ja. ..or- > ' M5 16 r? ' IS , 19 20 21 ■ 22 23 24 , 25 |26 j27 28 29 ,30 31, 1,2 3|4jSi6 14 IS 16 17 70~ 16 19 20 21 l22 23 24 25 38- ^0-^ 42-'; '-*4'*! *^ 48*' 50"* :52' 54-; , 56-' 58- 68- 72- 74^ 76- 78" M E H E M E ^t £,M EH E,H EIM E HE M E M E H EjM E H EiH E M E H EiM E,M E HE ME M E 1 E M E ME M E M E H E M E HEME M E HE M E .- ■- I ! : ! -'' .'' ] 1 1 i ; ' 1 * I -^ '.- T ] — f- 1- 4 7 j" E .;- T ; 1. v ^ ■6 -1 6 T3 d 6 -f .-;- 1 I ? ". .: I V f • u ■ J i t- J ' i o : -4 " i ■t ■ r - -T I J 6 -jrn T3 o T3 O 6 1 o ^ i 4- - P t. ' i - 1 T T ; i 1 A A ; -;■ .:' f h 1 ■ j i 1 1 , 1 i 4 i ) 1 1 ( / >A \/^ ^ y ^ i V /] V- ^ / >/• > \i ^ •^ A 1 1 > -1 A 1 / / A 1 / 1 V :;^ 1 - V V : -' 1 - Vi i V- V V V V. \ >;- r - 1 ■ , I .' j - 1 r i ! - ; V i ■' j j i 1 1 -i 1 1 r "' -r "T. I > i ■f r }■ ; i- ! ]- i \ !^ i t L ; 1 -] P i ^^ 'M, ■J 3T 3T 3"; 3Ti 3T,« 311 3J -1 ^ '^ L^ ^ sTTliT Z,f It 3t 3> 5* 26:27 11 12 13 ■ ■^ 15 16 17 18 : 19 Uo ',11 22|23 24 + 5 6 7 20" 8 10 11 12 13 14 15 16 17 18 19 ■^ 80- 96- 39" ilM- 103- :io4-i .|io6~ 09- 18'* 22- 24" 26" t»- 130- 131- 1 M EH E H E M E H e;h EiHEiME.M E H E M E,H E;H E M E h E ME H E H E H E ME H E ME ME ME HE M E H E M E ME M E H E H E HE ! V J ■ i i .« _3 tc . t^ ' 3 ;«i .; j! ■% 4 4 -5 ■s 4 -S -s ;5 4 ^ ^ < u C u c -§ -':" C <9 "( 5 -'r" ^t 3 en ■ % ■JZ " -s d -s o -s ■8 6 6 -s _■§ c ■4 I. a 3 3 ■1 3- 3 ■ ^ in ■a. =3 \ - -. ■r- - r • - ) t ': ■f f :. ■'; - : > >/ -y /^ / .^ . -^ -^ H ^ ^ A r ^ ^ /^ -'^ 'n fl A r ^ « % r[ v'V ^/ y v/ V ^ / '-\ / / / / y^ / ^ / V / >/- /i H-Jk i ^/ V V \! y i/ ^^\. r 1 1 1 'j^- '^Sr ^ ^ i ■^ IL-" 317 i 3 Ml 3.T i$^ ■i&^>- ■^yy^^^i^y^i^.^^^ f^' ^ ^y~~\ ^ iS- Si i*s§Tiir ^ijlftf t*^ ^t^ t^y, i|. ' f^ .ir2^ ZQ^ •»4— 1 51 3,f 3iii 311 3^ 3-T. 35 3F, 3'-. 3-1 3+ T.: 3 71 3i! 'iT 3T 37 13 T ^3T- 3T JT ^> '3? 3' 3T 31 ^^ 37 LU Fig. 48. — CH.4RT SHOWING THE TEMPERATURE RECORD OF T. W., DETECTIVE Sergeant, aged Thirty-six, who suffered from Acute Pneumonic Phthisis. THE VARIETIES OF PULMONARY TUBERCULOSIS 483 Hospital, and is shown in the annexed chart (Fig. 48). It will be seen to be continuously raised, but of somewhat remittent type. On admission to Brompton on the twentieth day of his acute illness his temperature was 102-6°, pulse 88, respiration 28. His height was 5 feet io| inches, but owing to his condition he could not be weighed on admission. There was, however, no history of loss of weight. Some night-sweating was observed, and his sputum was muco-purulent in character and contained tubercle bacilli. In the right lung there were no physical signs of disease, but in the left lung an area of consolida- tion was present, as shown by impaired note, bronchial breath-sound, and bronchophony, extending from the third to the sixth rib in front. Over this area consonating rales were audible. Posteriorly the note was impaired from the apex of the left lung to the angle of the scapula, and moist sounds were heard over this region. The patient was placed upon absolute rest, but the temperature remained irregularly raised for the next week, and then became lower, but for many weeks it oscillated between 99° and 100°, and it was not until the middle of February, 1915, that it became normal (see Fig. 48). The physical signs did not alter materially for a consider- able time. On December 16 friction was audible in the left axilla, but on December 30 it had disappeared. By the middle of February the signs of consolidation had diminished, the note over the left front was less impaired, and bronchial breath-sound was only audible at times. There were still, however, moist sounds over the front of the left lung, extending to above the clavicle. Posteriorly the signs were much as on admission, impairment of note with moist sounds being present over the upper half of the left lung. The cough was now slight and the sputum scanty, but tubercle bacilli were still present. During January and February he was treated with increasing doses of creosote up to a maximum of 25 minims twice a day in two drachms of cod-liver oil. From January 15 to January 22 and from February 12 to 24 he received also a daily subcutaneous injection of sodium cacodylate gr. |. The case had now taken a more favourable turn, and hopes of recovery were entertained. On March 22, however, he had a serious haemoptysis, bringing up a pint of blood, followed by a rise of temperature to 104°. The pyrexia lasted for a fortnight, and the temperature then remained irregularly raised for some weeks, and it was not until the early part of May that it again became normal. The signs in the lungs had now increased, moist sounds being audible at the left base and also over the right middle lobe and the adjacent part of the upper lobe. The note at the right apex was also now impaired. His weight, which before the haemoptysis had risen to 11 stone 7 pounds, had now fallen to 10 stone 7 pounds. In this condition he remained till June 30, when he was transferred to the Brompton Hospital at Frimley in the hope of further improve- ment. His temperature, however, soon rose again. He was confined to bed, suffered a good deal from dyspepsia, lost weight, and left for 484 DISEASES OF THE LUNGS AND PLEURA his home near Shrewsbury on September 30, where he died a few weeks later in November, 1915, just a year after the commencement of his acute illness. It is possible that but for the haemoptysis the improve- ment previously noted might have been maintained. Case III. — Mrs. X., aged twenty-nine, married, but without children, was first seen by Dr. Hartley in October, igii, in consultation with Dr. Rose of New Barnet. There had been no history of tuberculous trouble in her family, but she herself had never been robust, and six years previously her left kidney had been removed for tuberculous disease, with secondary involvement of the bladder. The operation was successful, and she lost her symptoms and regained her health, remaining well until June, 191 1, when she began to suffer from cough, with some muco-purulent expec- toration. She did not think she was losing weight. Her height was 5 feet 3 inches ; weight 8 stone 125 pounds. There were no sweats or haemoptysis, ^n physical examination the percussion note at both apices was found to be impaired ; some rhonchi were audible over the lungs, but no added sounds were heard at the apices. There appeared to be no fever, and the sputum on two examinations did not reveal tubercle bacilli. A diagnosis of bronchial catarrh with arrested tuber- culous lesions at the apices was made, and under treatment by expec- torant mixtures and cod-liver oil she soon recovered her health, losing cough and phlegm and gaining in weight. She remained well until March 2, 1915, when she contracted influenza complicated by bronchitis. The sputum was scanty and purulent, and contained mostly pneumococci. Tubercle bacilli, though searched for on two occasions, were not found. On March 14, 1915, she was seen at Hadley Wood by Dr. Hartley, in consultation with Dr. Evill, who was attending her in the absence of Dr. Rose on war service. Her temperature was still raised and of intermittent type, varying from 98° in the morning to 101° at night. The tongue was furred, there was some sweating, and the impairment of note observed in 191 1 was still manifest at the apex of the right lung; the note at the left apex was now fairly natural. Signs of general bronchitis were audible over the lungs, and at the left base there was obvious impair- ment of note, with bronchial breath-sound and sticky rales. A diag- nosis of influenzal pneumonia was made, and as Mrs. X. was holding her own, a hopeful prognosis was given. The temperature, however, as may be seen from the " average chart " (Fig. 49), which dates from the third day of her illness, did not fall, and was of a somewhat hectic type, and bronchial breath-sounds still remained audible below the angle of the left scapula. The question of a vaccine was considered, and for this purpose the sputum was examined by the late Dr. Stans- feld, who found no tubercle bacilli or influenza bacilli, but a bac- terial flora among which streptococci now largely predominated. A streptococcal vaccine was prepared and three doses given without effect. THE VARIETIES OF PULMONARY TUBERCULOSIS 485 On April 17 the patient was again seen in consultation with Sir Thomas Horder and Dr. Evill. Her temperature still remained raised to over 101° at night, and her cough was irritable. The tongue, how- ever, was clean and the patient looked fairly well. There were still a few signs of general bronchial catarrh, but the note at the right base showed now only slight impairment. At this base, however, many crepitations were audible after coughing. The patient's appearance, general condition, and the continuing pyrexia strongly suggested tubercle, and it was decided that a further examination of the sputum should be made, and on this occasion tubercle bacilli were discovered by Dr. Stansfeld in considerable numbers. The case, therefore, was now proved to be one of arrested tuberculosis of the apices, with a Fig. 49. — " Average Chart " showing the Weekly Temperature Record OF Mrs. X, aged Twenty-nine^ who suffered from Acute Pneumonic Phthisis. (The record is obtained by taking the average of the morning and also of the evening temperatures during each week.) recent acute invasion of the base of the left lung under the influence of an influenzal attack. The patient was placed en absolute rest and treated on full open-air lines, and on April 21 was moved to a shelter built for her in the garden. From May 4 to May 20, June 3 to 12, and from June 23 to 29, she was given a daily subcutaneous injection of sodium caco- dylate, gr. |, but the pyrexia still continued, though on a somewhat lower level. On June 29 Mrs. X. was seen again in consultation with Dr. Evill. 486 " DISEASES OF THE LUNGS AND PLEURAE By now the disease in the left lung had spread, and it was clear that the whole lung was involved, impairment of note and scattered crepitations being audible all over. The right lung was free from disease, except for the apical impairment of old standing. The cough was troublesome, the sputum purulent, and the fingers showed slight clubbing. The patient was placed on intensive iodine treatment, being given 20 grs. of iodide of potassium at 8 a.m., and an ounce of chlorine water in freshly prepared lemonade at 12, 2 and 4 p.m. Under this treatment the fever gradually abated and the temperature reached normal on August 17, having been raised for four and a half months. On October 23, the temperature still remaining normal, the patient was moved to the Linford Sanatorium in the New Forest, and placed under the care of Dr. Felkin. Here, after a short stay, the temperature again began to rise and the cough and sputum increased. The case still appeared one-sided, and it was decided to attempt an artificial pneumothorax ; but though six punctures were made, the attempt failed owing to the presence of widespread pleural adhesions. On January 25, 1916, Mrs. X. was seen in consultation with Dr. Felkin. She was evidently much weaker, with hectic flush on the cheeks and a temperature of 101°. The pulse was rapid and soft, the sputum considerable in amount and containing tubercle bacilli in large numbers. A cavity, extending from the left clavicle to the fifth rib, was present in the upper lobe, and there was a second excavation at the apex of the lower lobe behind. The upper half of the right lung was also now invaded by active tuberculous disease. Under the cir- cumstances it was obvious that no operative procedure could be con- sidered, and that the patient's condition was one of great gravity. Garlic was prescribed without avail, and the patient died a few weeks later, just a year from the commencement of her illness. This case illustrates the temporary improvement vv^hich may- be observed in cases of this kind, and then the active extension of the disease in the other lung, which sometimes takes place and carries off the patient, even though the surroundings are all that can be desired. The failure to effect an artificial pneumothorax, owing to the presence of extensive pleural adhesions, will also be noticed. The supervention of caseo-pneumonic tuberculosis, running a rapid course, was formerly not infrequent in diabetes. The statistics brought forward in 1883 at a discussion on diabetes at the Pathological Society^ showed that about 35 per cent. of the cases terminated in pulmonary tuberculosis, most commonly in the second to the fourth years of the disease, and that in a still larger proportion — nearly one-half — pul- monary lesions were present. In the present day, when the death-rate from phthisis is about half what it was in 1883, such THE VARIETIES OF PULMONAJRY TUBERCULOSIS 487 figures are too high, nor does the compHcation, in our experience, now run as a rule such a rapid course in diabetic patients. Nevertheless, the possibility of the development of pulmonary tuberculosis must always be borne in mind when treating a case of diabetes, since in this disease the vitality of the tissues is lowered, and the patient becomes more prone to invasion by the tubercle bacillus. The lesions are more apt also to occur in situations other than apical, the base of the lung being not uncommonly attacked. All pulmonary lesions in diabetes are not, however, tuber- culous. In some having clinical features suggestive of phthisis, tubercle bacilli are not found, and the destructive lesion is a species of sloughing pneumonia. 2. Disseminated Form. (i) Florid Phthisis. Synony^ns : Phthisie Galopante. Broncho-Pneumonic variety of Caseous Tuberculosis. In other cases, of happily rare occurrence, acute tubercu- losis attacks both lungs, commencing simultaneously in many centres. This form of the disease, which is most common in young adults, and perhaps more frequent in women than in men, bears the same relationship to^ the preceding variety that disseminated bears to confluent broncho-pneumonia, and is characterised by the rapid softening of the caseous foci and by marked destruction of lung texture. The symptoms are not essentially different from those of the more ordinary confluent form of acute phthisis which we have just described, but the dyspnoea is more urgent, and the progress to a fatal issue rapid, and as a rule unbroken. The flushed face, bright eyes, and alert mind contrast with the apathy, pallor, and prostration of acute miHary tuberculosis, and the physical signs at first of acute bronchial catarrh with the rapid development of numerous centres of consolidation, softening, and excavation, are equally characteristic. The rapid breaking down of the broncho-pneumonic centres, occurring first at the apices, is a striking* feature, distinguish- ing this from more simple forms of broncho-pneumonia. After death the lungs are found to present numerous areas of greyish-pink granular consoHdation, with yellow caseous centres broken down into small cavities communicating widely with enlarged, more or less eroded, and acutely in- 488 DISEASES OF THE LUNGS AND PLEURA .flamed bronchial tubes. No miliary granulations of tubercle are to be seen, although the smaller yellow centres may at first sight resemble them. Except on grounds of clinical accuracy, the distinction between acute disseminated phthisis and acute miliary tuber- culosis is of little importance, for the prognosis in both is about equally fatal within a short period of from four weeks to two or three months. The high and fluctuating temperature, hectic sweatings, purulent, sometimes blood-stained, and soon nummulated sputa containing elastic tissue and bacilli, in association with the physical signs, will render it impossible, except in the earliest stage, to confound this disease with acute bronchitis. In some cases, as in other varieties of rapidly progressing pulmonary tubercle, the temperature assumes the inverse type with evening instead of morning remissions. An inquiry into the family history of a case of acute dis- seminated phthisis will frequently elicit evidence of a decided phthisical taint. The following sketches illustrate the phenomena character- istic of this form of the disease : Case I. — A woman aged thirU'-one had had " inflammation of the lung's " two years previously, but had sufl^ered from more or less cough, with frothy expectoration, for three years. She knew of no family predisposition to phthisis. Four weeks before admission into hospital she expectorated a small quantity, two teaspoonfuls, of blood, and the sputa continued to be tinged for five days. She had since suffered from night-sweats, emaciation, cough, and pain in the side and between the shoulders, of which symptoms she complained on admission. The pulse was 112; the tongue furred; catamenia regular. The physical signs on admission were harshness at the right apex, with subcrepitant rales ; at the left, jerking breath-sound with prolonged expiration. She decreased rapidly in weight, losing 3^ pounds between October 26 and November 14. On November 8 the physical signs were noted as unchanged. On the 2ist she was much worse, had a red, tremulous tongue, a rapid pulse, great breathlessness, and much heat of skin. She could with difficulty stand from the trembling of her limbs and weakness. Sub- crepitant rales were found diffused throughout the right side behind, with some defect in resonance not amounting to dulness. The temperature taken night and morning from this date showed a maximum morning height of 103°, avei ge ioi-6°; maximum evening temperature 104°, average 102-3° ; difference between the average morning and evening temperature 0-7°. On the frequent occasions THE VARIETIES OF PULMONARY TUBERCULOSIS 489 when observed in the middle of the day, the skin was uniformly hot, and the pulse very rapid, usually about 120. Meanwhile the pulmonary physical signs advanced, the crepitations became more abundant, and extended through both lungs. There were signs of breaking down at the right apex, though the presence of a cavity could not be ascertained with certainty. On December 19 there were present " diffused blowing respiration, with sonorous rhonchus and scattered crepitations, more abundant at the bases, with some dulness ; high temperature, and much dyspnoia." On December 15 the patient began to be troubled with diarrhoea, which continued more or less to the last. The emaciation and loss of power rapidly increased, the smooth red tongue became white with aphthous patches, and she gradually sank, having never evinced, however, any delirium or other morbid brain symptoms. Post-mortem, the lungs were found studded with racemose groups of tubercle undergoing caseation and softening, and surrounded by ill- defined areas of pneumonia ; the right apex was breaking up into small cavities. There was no miliary tubercle on the pleural surfaces. The continued fever, the great and early prostration, the presence of physical signs at the apex, and later of diffused crepitations over the lungs, without any defined dulness, rendered the diagnosis of pulmonary tuberculosis being the prevaiHng lesion a tolerably certain one; but the case was differentiated from one of acute mihary tuberculosis by the early presence of marked pulmonary signs and a less degree of general prostration than often accompanies the latter disease, which is also attended by muttering delirium. There was, however, but little satisfaction to be derived from this reflection, for the prognosis was, so far as present knowledge could decide, inevitably fatal. Case II. — W. A., van-boy, aged sixteen, was admitted into the Brompton Hospital under the care of one of us on August 18, 1913, complaining of cough, expectoration, and night-sweating. There was no history of tuberculosis in his family, and he stated that he himself had been quite well until three months previously, when he began to suffer from cough. On admission he was found to be febrile, having a morning temperature of ioo-8°, which rose in the evening to 102-2°. His cough was troublesome, especially at night, and a good deal of yellow phlegm was expectorated, in which tubercle bacilli were discovered. The bowels were regular. The physical signs in the chest indicated invasion of the whole of the right lung, as shown by diminished mobility and general impairment of note, with scattered crepitations. Signs of excavation were also present below the clavicle. On the left side the percussion note was impaired from the apex to the third rib in front 490 DISEASES OF THE LUNGS AND PLEURA Fig. 50.— Temperature Chart of W. A., Van-Boy, aged Sixteen, who SUFFERED FROM ACUTE CaSEOUS TUBERCULOSIS OF THE BRONCHO-PNEU- MONIC TYPE. THE VARIETIES OF PULMONARY TUBERCULOSIS 49 1 and over the upper third of the lung posteriorly, and over these areas sharp crepitations were audible. After admission the pyrexia continued, the temperature, as shown in the annexed chart (Fig. 50), being of the high remittent type. The patient complained of some pain in the right side, but otherwise suffered little. His cough continued and he grew weaker. His pulse and respiration increased in rapidity, the former on September ig being 136, the latter 44. Meanwhile the signs of excavation in the right lung were extending, and on September 19 a large thin-walled cavity, involving the whole of the apical portion of the lung and yielding a bell sound, was observed. A few days later he became cyanosed and dyspnoeic, and some oedema of the feet appeared. The pyrexia continued. On September 26 physical signs of pneumothorax of the right side were observed, its onset being probably indicated by a sudden fall in the temperature on September 22. On October 3 the pneumothorax had become practically complete, as indicated by a tympanitic note, bell sound and loud amphoric breathing heard over the right side of the chest. The loudness of the amphoric breath-sound suggested that the opening into the pleural cavity was large and patent, and such the autopsy proved to be the case. In addition to the air some fluid was also now present in the pleural cavity, as revealed by the succussion splash and movable dulness. The temperature remained raised until October i, when with increasing weakness it fell gradually to normal. The patient was now very dyspnoeic and cyanotic at times, and died on October 6. At the autopsy a pyopneumothorax was found occupying the right side of the chest, with the exception of its apical portion, where the pleurae were adherent. The right upper lobe contained a large excava- tion, which communicated with the pleural cavity by a hole situated in the lower and anterior portion of the lobe, the size of a threepenny piece, and having thickened edges. Besides air the pleura contained 20 ounces of pus. In addition to the large cavity present in the right upper lobe, a second excavation of considerable size and containing much purulent material was found in the left upper lobe. The right middle and lower lobes were thickly studded with coalescing areas of caseous broncho-pneumonia, and in the left lower lobe similar, though less extensive, changes were observed. The larynx showed ulceration of the right vocal cord, and the trachea was extensively ulcerated. The bronchial glands were enlarged and caseous. The case is an interesting one, as showing the rapid pro- gress to a fatal termination w^hich marks this variety of pulmonary tuberculosis — in this instance the duration being four and a half months. The ulceration of larynx and the occurrence of pneumothorax should also be noticed, since, as we have pointed out elsewhere/ these complications are rather 492 DISEASES OF THE LUNGS AND PLEURA more common in the acute variety of the disease now under consideration than in ordinary chronic phthisis. (2) Acute Miliary Tuberculosis. The following case of miliary tuberculosis, the clinical features of which we will sketch, will serve to emphasise the - fact that the tuberculous lesions of this variety of the disease run their course to a fatal issue with little or no softening, and also to illustrate the close clinical resemblance which may exist between some cases of acute miliary tuberculosis and typhoid fever : Case I. — Elizabeth G , aged thirty-four, a pale, sallow, grave- featured woman, with slight malar flush, was admitted into the Mid- dlesex Hospital in March, 1885, complaining of cough and increasing weakness, with some pain of a pleuritic character in the left side, with which she had been troubled for three months. For a week she had been confined to bed with headache, cough, and some oedema of the feet. On examination, only a few scattered bronchitic rales were dis- covered in the chest, the splenic dulness was increased, and the abdomen was observed to be full and tympanitic. The pulse was 100, small, feeble, regular ; respirations 18 ; temperature 102-4°. The tongue was red and raw looking, and coated in the centre with a thin fur. No spots of a tj^phoid character were found on the abdomen, but numerous sudamina were observed scattered over the chest and abdomen. The temperature ranged above 100°, daily reaching 102°, and frequently 103°, but was kept more or less modified by antipyrine, administered whenever it rose above 102°. Up to April 20 no further chest signs were observed ; there was then noted slight dulness and crackle after cough over the right sub- clavicular region, and some superficial crepitant rales at the angle of the right scapula. Diarrhoea was not present, but the abdomen con- tinued prominent and tympanitic, and there was some tenderness on pressure, especially over the splenic region. On April 25 the spleen was felt to extend below the costal cartilages. On May 7 there were signs of a little fluid in the peritoneum, and palpation of the abdomen gave a sense of soft resistance, as though from matting together of intestines by adhesions. Obscure crepitation was heard below the second cartilage on the right side, becoming more manifest and moister at the anterior base. On the left side some crepitations were heard in the mammary region. There were sub- crepitant rales at both posterior bases. The cough was troublesome, expectoration scanty and viscid. The sputum was carefully examined on several occasions without discover- THE VARIETIES OF PULMONARY TUBERCULOSIS 493 ing any tubercle bacilli. No diarrhoea was at any time present. The oedema of the legs increased, and the patient lapsed into a semi- conscious state, her temperature moderating somewhat, but keeping above the normal. In this condition she lingered, until death ensued on June 30, three months after her admission. The post-mortem examination revealed miliary tuberculosis of lungs, pleurae, spleen, kidneys and peritoneum, with adhesive peritonitis. There was a small nodule of old disease at the apex of the right lung. None of the tubercles had softened. This patient's sister had ten years previously died of rapid phthisis. Some of those who observed this case from time to time were doubtful as to whether it was one of enteric fever or tuberculosis. The continued fever, swollen abdomen, en- larged spleen and marked adynamia, were certainly suggestive of enteric fever, nor from experience could it be said that the absence of diarrhoea, was sufficient to negative such a diag- nosis. In both diseases, too, the leucocyte count in the blood is diminished. At the period at which this case was observed, the aid of Widal's test was not available. The temperature, however, although maintained at a high level, was of too fluc- tuating a type to correspond with the assumed period of typhoid. Moreover, the hectic flush is rarely, if ever, seen, and sweatings of sufficient severity to produce sudamina are, in our experience, equally uncommon in early typhoid. The pulmonary signs were at first quite compatible with either disease. As time went on it was apparent that an adhesive peritonitis with slight effusion was present, and the further development of chest signs rendered the diagnosis secure. Cases are, on the other hand, sometimes met with in which the catarrhal pulmonary signs in the early weeks of enteric fever mislead to a diagnosis of acute tuberculosis, a mistake which, by preventing the strictness of dietary suitable for the former disease, may seriously hazard recovery. Enlargement of the spleen is an important sign in favour of enteric fever, since tuberculous disease of the spleen, although present in the case related above, is not usual. Later on in enteric fever the pulmonary signs fade, whilst the enteric phenomena be- come more marked. It is to be observed that in the case which we have recorded, as in others of the same type, a careful examination of the expectoration for bacilli on several occasions gave a negative 494 DISEASES OF THE LUNGS AND PLEURA result, a failure depending upon the absence of softening of the miliary tubercles in the lung. Occasionally, however, they may be found, as in an interesting case under the care of one of us, in which, though nineteen successive examinations of the sputum by Dr. Wethered proved negative, bacilli were yet found by him on the twentieth occasion, to disappear again on the twenty-first. On the death of the patient soon afterwards the lungs were found studded with miliary tubercles. It is instructive to observe that the post-mortem examina- tion of E. G. revealed some old-standing mischief at the apex of the right lung. Miliary tuberculosis is in truth a secondary disease, there having been most commonly in adult cases a previous abortive attack of phthisis, and when this is not so, some caseous remmant of a tuberculous lesion will be found elsewhere in the body. In children the primary focus is more often a caseous bronchial gland. The following case is an example of that variety of the malady in which the pulmonary signs are more prominent : Case II. — Mrs. L. D., housewife, aged twenty-eight, was admitted into the Brompton Hospital under the care of one of us on June lo, 1918, with the following history. She came of a healthy family, no members of which were known to have died of tuberculosis, and she had herself always been strong and well until the previous March, when she had a miscarriage. This was followed by abdominal pain in the right and left iliac regions, which did not, however, persist. In April she began to be troubled by cough, with some phlegm, and this was followed by nausea, failing appetite, night-sweats and wasting. Since May 13 she had attended the Out-Patient Department at the Brompton Hospital, and on May 21 tubercle bacilli were found in the sputum. For the twelve days pre- ceding her admission to the hospital she had again complained of pain in the right iliac fossa, made worse by any movement. On admission on June 10 she was found to be much emaciated. Height 5 feet 4 inches ; weight 6 stone 13I pounds. She was flushed and breathless; temperature 10 1- 6°; pulse 124; respiration 32. Her cough was very troublesome and persistent, and at times she suffered from distressing paroxysms of coughing, but sputum was absent or very scanty. Three days after admission a small quantity was obtained, and in it tubercle bacilli were again discovered. The physical signs were interesting. The percussion note over the upper part of each lung, both anteriorly and posteriorly, was impaired, and moist sounds were audible over the upper and middle lobes anteriorly and down to the angle of the scapula behind. One or two rales were also heard over the base of the left lung. Pain and tender- THE VARIETIES OF PULMONARY TUBERCULOSIS 495 ness on palpation were present in the right iliac fossa. A vaginal examination showed nothing abnormal. In view of the physical signs, and also the finding on two occasions of tubercle bacilli in the scanty sputum, which, as we have seen, is rare in miliary tuberculosis, the diagnosis of acute caseous tuberculosis of the broncho-pneumonic type, rather than miliary tuberculosis, was made, a point, however, of academic rather than practical interest, in view of the grave nature of the prognosis in either case. The abdominal pain was thought to point to a possible appendicitis of tuberculous origin. After admission the pyrexia continued, and, as shown in the chart (Fig. 51), was of the continuous type with some remissions. There Fig. 51. — Chart showing the Temperature Record of Mrs. L. D., AGED Twenty-eight, who suffered from Acute Miliary Tuberculosis AFFECTING THE LUNGS AND OtHER OrGANS. was disinclination for food and some vomiting, but the abdominal pain gradually disappeared. On June 26 the patient, who was now very breathless and much weaker, complained of pain in the right side of the chest, and friction was detected over the lower and anterior part of the right lung. A few days later the heart showed signs of dilatation. On July 3 the friction had disappeared, but fine crepitations were now heard over the whole chest, both back and front, pointing to general involvement of the lungs. On July 6 the patient passed into a semi- conscious condition, the pulse became feeble, and she died the same day. - At the autopsy both lungs were found riddled throughout with miliary tubercles, yellowish in colour. Some recent pleurisy was visible 496 DISEASES OF THE LUNGS AND PLEURA in the lower part of the right lung in front, accounting for the friction sounds heard during life. Miliary tubercles were present in the spleen, and in the peritoneum in the region of the caecum, duodenum, and liver, with some peritonitis, thus explaining the abdominal symptoms which had been obser\'ed. There was no ulceration of the intestines or the appendix, and no focus of old disease could be discovered in the lungs. The bronchial and mediastinal glands were enlarged and caseous. The duration of the disease in this case would appear to have been about three months. xA,s no focus of old disease could be found in the lungs, it is probable that some of the larger caseating miliary tubercles softened and broke down, thus accounting for the presence of tubercle bacilli in the sputum during Hfe. The blood-infection which caused the terminal miliary tuberculosis would appear to have originated in one of the caseating bronchial or mediastinal glands. The treatment of acute tuberculosis of the lungs, as of the other varieties of phthisis, will be fully considered in later chapters, when the question of prophylaxis is also discussed. REFERENCES. ' The Blood: a Guide to its Examination and to the Diagnosis and Treatment of its Diseases, by G. Lovell Gulland, M.D., and Alexander Goodall, M.D., p. 287. Edinburgh, 1914. ^ " A Personal Experience of Galloping Consumption," by R. Mander Smyth, M.D., The Practitioner , 1901, vol. Ixvii., p. 36. ^ " Discussion upon the Morbid Anatomy of Diabetes," Transactions of the Pathological Society of London, 1883, vol. xxxiv., p. 328. * Re-port 071 the Work of the Pathological Defart?nent of the Bromfton Hosfital during the Three Y ears Afril, 1900, to Afril, 1903, by P. Horton- Smith (Hartley), M.D., F.R.C.P., p. 20. McCorquadale and Co., Ltd., London, 1903. CHAPTER XXXIII ON SUBACUTE TUBERCULOSIS OF THE LUNGS In a certain not large proportion of cases of pulmonary tuber- culosis the disease, instead of assuming the acute and rapid confluent or disseminated forms above described, follows a more insidious course, in which the destructive changes are effected by a drier and more gradual necrosis. In these cases great thickening of the alveoli, grey induration, in which some individual granules of tubercle may or may not be distinguish- able by the unaided eye, is substituted for the more usual and rapidly caseating tuberculous process, although some points of caseation may here and there be observed. We have, in fact, a local pulmonary tuberculisation of slower and more insidiously destructive progress than caseous pneumonia, so far as the lung is concerned, but more obstinately and con- tinuously invasive; more prone to be succeeded by early im- plication of the other lung, supposing both are not from the first affected; more quickly followed by disease in other organs, particularly the larynx and intestines; and, in short, though a subacute or chronic disease, yet one of more early average termination than the corresponding pneumonic form of phthisis. To this form of the disease we have in our former editions given the name of pulmonary tuberculisation. The condition is one intermediate between acute and chronic tuber- culosis of the lung, and having some special features of its own.'^' This form of tuberculosis spreads through the lung from apex to base, with a well-defined grey advancing margin, to which the hig'hly vascular but crepitant lung tissue immedi- ately beyond presents a striking- contrast. On examining, * A good illustration of this condition, of lung will be found in Wilson Fox's Atlas of the Pathological Anatomy of the Lungs, Plate XVII., Fig. i ; but the figure is reversed, the disease being apical. 497 32 498 DISEASES OF THE LUNGS AND PLEURA however, more minutely with a lens, the alveolar walls are found considerably thickened to some little distance (perhaps half an inch) beyond the defined margin, though the alveolar spaces are not occupied with catarrhal cells — at least, not uni- formly so or to any material extent. A few outlying patches or nodules may often be observed, evidently of infective origin. The aspect and insidiously invasive character of the lesion most resembles lupus of the cutaneous surface; and since this comparison was first made in the 1878 edition of this work, lupus has been shown to be a truly tuberculous affection. The following may be stated as the clinical features most distinctive of this form of phthisis, which is especially im- portant from the difficulties attendant upon its early recogni- tion, and on account of its relentless, although gradual, course. The origin and progress of the disease are peculiarly insidious, with gradually increasing- malaise and anaemia, nocturnal cough, and irregular fever. In many cases the temperature is persistently though shghtly raised. In others it is at times elevated, during which periods there are fresh accessions of disease. The non-febrile intervals are of vary- ing duration, the fever in this respect presenting no important difference from that which is observed in the more ordinary forms of phthisis, except that the completely apyr^xial intervals are more rare and of shorter duration. The physical signs are more characteristic. Instead of catarrhal signs proceeding to well-marked dulness and coarse crepitation or crackling, we find a continued weakness of respiratory murmur, with impaired expansion or actual flatten- ing, while moist sounds may be altogether absent, or a few crackles may alone be elicited on cough. The percussion note becomes hardened, and we may be surprised by the appear- ance (having omitted to examine the patient for a week or two) of some feeble, blowing respiration, of hollow quality, still very dry, which increases in the same obscure way until an unmistakable cavity is present. This formation of a cavity by a process of dry necrosis is characteristic of pulmonary tuberculisation. Huskiness of voice, or actual aphonia, is commonly one of the early symptoms in this variety of consumption. The huski- ON SUBACUTE TUBERCULOSIS OF THE LUNGS 499 ness may clear off, but the voice remains more or less per- manently altered in quality. Too hasty a diagnosis must not, however, be made from this symptom, lest a grave prognosis be founded upon a simple laryngeal catarrh, although in many cases the larynx is actually involved. The digestive organs are as a rule affected early. The tongue may present a scanty white fur on a very red ground, with prominent red papilla, an appearance which is significant of intestinal lesion, and still more so if the fur clears off in patches, leaving raw- looking glazed surfaces. Soon the symptoms characteristic of this lesion — alternating diarrhoea and constipation, with colicky pains, especially after food — make their appearance. Patients who are the subject of this form of tuberculosis are usually of slender figures and good features, and among them are those more interesting examples of consumption or decline that novelists prefer to describe.* This variety is, however, amongst the more rare forms of phthisis. The physical signs steadily, although, as already said, in- sidiously progress, and the average duration may be pretty safely reckoned as within two years of the first appearance of definite signs, although exceptional cases last longer, and it may be hoped that more may do so under modern methods of treatment. The intestinal or laryngeal complications cause great distress towards the last, and hasten the fatal termina- tion. The following case, which was seen by one of us in consultation at Harlesden, may be sketched as an example coming within the category of this variety of consumption : Miss W , aged nineteen, a typist, had been losing flesh for three or four months, with increasing weakness, which obliged her to relinquish business eight weeks ago. There was a history of an acute abdominal illness three years previously, with symptoms attributed to colitis, from which, however, she quite recovered. The only symptom complained of in her present illness, except the weakness and the loss of flesh, was relaxation of the bowels, which had been fairly constant, but kept in check by bismuth and occasional opiate medicines. The doctor stated that " the temperature had never been above the normal." The pulse had, however, always been notably quickened, 100 to 120. There had not been any cough beyond an occasional clearing of the throat in the morning, nor any expectoration. The catamenia had * We may perhaps recall as examples Paul Dombey and " Smike " among Dickens's characters^ and Marguerite Gautier of Dumas. 500 DISEASES OF THE LUNGS AND PLEURA been absent for twelve months. The girl's aspect — her delicate features and complexion, with large lustrous eyes, long eyelashes, slight hectic flush, and notable emaciation — presented the features of what was formerly described as "decline " in medical literature and in fiction. There had never been any haemoptysis. The stools had not been observed to contain mucus, nor to present any soapy, fatty, or other special appearances. At the time of consultation — about 4 p.m. on December 16, 1910 — the temperature taken for several minutes in the mouth was found to be 99'4°, and, on further questioning, the doctor who, owing to the patient's small means, had not had the advantage of a nurse to observe this symptom closely, admitted an occasional temperature of 99° or a little higher — a temperature often, but erroneously, regarded as " about normal." The pulse was quick and small ; the abdomen was retracted, and over an area of some 4 square inches below the margin of the liver there was some tenderness on palpation, with slight resistance as compared with the left side, and impaired resonance on percussion. The margins of this resisting area were irregular and not sharply defined, and it was regarded as due to matted intestines and omental thickening. Neither liver nor spleen was enlarged. There was no swelling over the pancreas, no thickening or tenderness over the caecum. The thorax was small and the muscles wasted, and over an area in the left anterior axillary region, commencing at the outer third of the second rib in front, and extending downwards outside the nipple line to the level of the fourth rib, and backward to the mid-scapular line, the percussion note was dull. Over this region the respiratory murmur was weak and of a muffled bronchial quality, which in the mid-area became markedly cavernous, although still feeble; the voice-sounds and whisper here were pectoriloquous. But few rales were heard, only two or three coarse crackles. Elsewhere over the lungs on both sides the note was resonant and the breath-sounds weak but vesicular. With great difficulty a small sample of sputum was obtained, watery in character, with a few opaque shreds. This was carefully examined before and after treatment with antiformin, but no tubercle bacilli were discovered. In its peculiar insidiotisness, in the obscurity of develop- ment of physical signs, and their notable dryness even until so near the end, and in the absence of associated catarrhal sounds and symptoms, this case is fairly typical of the form of tuberculosis now under consideration. So obscure were the signs and symptoms that, whilst one physician had a short time previously expressed the view that the lung was involved, two others had regarded the case as one of disease of the pancreas. There could be no doubt, however, from the present physical signs, as to the case being one of pulmonary ON SUBACUTE TUBERCULOSIS OF THE LUNGS 501 and abdominal tuberculosis, the lung being the seat of grey indurating tuberculisation, with dry necrosis, resulting in ex- cavation at the centre, the site of the lesion being, however, somewhat unusual. The abdominal lesion presented the features of an intestinal matting, with tuberculous ulceration of the mucous membrane of the coils. It was obvious that a fatal termination mig'ht be expected within a few weeks. At a second consultation, on December 31, the patient was notably weaker, the area of pulmonary consolidation had extended, and a few more liquid rales could be heard. She had had an acute attack of pain in the upper right abdominal region, and the tenderness here was more marked. The tongue was red, smooth, with some aphthous points. Some sputum was again obtained with difficulty ; it was of mucoid, frothy character, and on examination tubercle bacilli in fair numbers were found irregularly distributed through it. The patient died on January 11, 191 1. There are two points to be noted further in this case. In all probability the temperature on more accurate observation would have been found to present a daily rise to 99° or 100°. No doubt, too, the abdominal complication, as usual, helped to obscure the chest signs ; but involvement of other organs, whether of larynx or intestine, is a specially common feature in this variety of phthisis. CHAPTER XXXIV CHRONIC TUBERCULOSIS OF THE LUNGS The subject of this form of tuberculosis has usually been depressed in health, through tardy convalescence from some other disease, bad living, mental anxiety, or overwork; he has had a persistent, though it may be a slight, cough for a longer or shorter time, and has been losing- weight. Pyrexia is one of the earliest and most important signs that the pulmonary trouble is more than that of a mere catarrh, and haemoptysis, however slight— even, it may be, only a mere streak in the morning sputum— is of serious significance. The pyrexia may not amount to more than a slight evening rise of tempera- ture, but it is attended with malaise and increased cough at night. At this stage the physical signs are but slight. The percus- sion note at one apex is slightly impaired, with perhaps some diminution in the width of the normal isthmus of resonance above the clavicle (Kronig^s sign). The respiration is also weaker, and the inspiration wavy, or even jerking. There are usually a few rhonchi present, which, if limited to that apex, are very significant ; and, ini addition, there is heard at the extreme summit of the lung (supraclavicular or supraspinous region) a peculiar crumpling sound at the moment of cough, which differs both in time and degree from the crepitant sound audible at a somewhat later stage with the first inspiration following a cough. These physical signs — and their early recognition is of much importance — are those of a broncho-alveolar catarrh limited to one apex. Such an apical catarrh is not necessarily tuber- culous in nature, but should always be regarded with the gravest suspicion, and when taken in conjunction with symptoms of emaciation, quick pulse, and evening pyrexia, affords strong evidence of early tuberculous disease. An immediate examination of the sputum for tubercle bacilli 502 CHRONIC TUBERCULOSIS OF THE LUNGS 503 is now imperative, and, if negative, should be repeated on at least two occasions, and with the help of concentration methods (p. 574). The importance of such an early and thorough examination of the sputum, and especially of that portion coughed up on first waking-, in all cases in which there is the slig'htest suspicion of tubercle cannot be too strongly emphasised, for, as we shall see, our chance of arresting the disease varies to a great degree with the stage at which it is recognised, and proper treatment commenced. Too much stress also must not be laid upon a negative result, in the presence of the symptoms mentioned, unless the sputum has been examined on several occasions. In this connection we may refer again to the case of miliary tuberculosis of the lungs which we have already described, in which, with simple stain- ing, tubercle bacilli were first found in the sputum on the twentieth examination. In children and others who swallow their expectoration, it is sometimes possible to discover the bacilli in the stools (p. 574). In the early stages of phthisis a blood-examination shows, as a rule, some degree of anaemia, the red corpuscles being- diminished and the colour index lowered, though not to the degree met with in chlorosis. Leucopenia is usually also present, the diminution in the number of leucocytes affecting chiefly the polymorphs, so that a relative increase of the lym- phocytes occurs. As the disease progresses, and cavitation and hectic ensue, a leucocytosis is often observed, possibly reach- ing 20,000 or more, the polymorphs becoming increased. In the opinion of some observers a total increase of the lym- phocytes is at this stage a hopeful element in prognosis. Arneth has drawn attention to a change in the blood pic- ture occurring in phthisis, as well as in other infectious diseases, and which is indicated by an increase in the blood in the number of neutrophile leucocytes containing one or two subdivisions of the nucleus, and a diminution of those with three or more. This change occurs early in phthisis, and tends, though with some curious exceptions, to become more marked as the disease advances and to lessen as the patient's condition improves. As Dr. H. A. Treadgold' shows in his interesting paper, in which he gives the results of his observations at the Brompton Hospital, further investi- gation is required before we can decide upon the value of 504 DISEASES OF THE LUNGS AND PLEURA the Arneth count in the diagnosis and prognosis of pul- monary tuberculosis, but for the present we may accept that while the persistent presence of the Arneth blood-picture in marked degree would indicate a serious condition of the patient, its absence does not necessarily "warrant a good prognosis. In the acute stages of phthisis the systemic blood-pres- sure is commonly lowered,^ ranging often between 90 and 100 mm. Hg. This is mainly attributable to depressed car- diac function from excessive absorption of tuberculous toxine, a similar lowering of blood-pressure having been noticed after a suitable injection of old tuberculin. When the disease becomes chronic and quiescent a recovery to normal systemic pressure may often be observed, and is of good augury in prognosis. We may add that a raised blood- pressure is no bar to infection, and we have known cases of arterio-sclerosis with high blood-pressure develope chronic pulmonary tuberculosis. The disease tends insidiously to progress. The malaise, anaemia, nocturnal cough, and irregular fever increase, the physical signs, at first so obscure at one apex, gradually advance, and the other lung rarely escapes involvement. In a certain proportion of cases, probably larger than is generally supposed, the larynx becomes affected. So far as the pyrexia is concerned, there is nothing- char- acteristic to describe. During periods of activity the tempera- ture is elevated, reaching, it may be, 100° or 101° at night, and falling to normal in the morning. Possibly also for a few days it may take on the inverse type, the morning- record being higher than the evening; but, as we have already pointed out (p. 488), this as a rule occurs only in the rapidly progressing forms of the disease. The non-febrile intervals are of varying and sometimes of long duration. The main features of an average case of this form of con- sum.ption, its physical signs, and some of its aetiological and other factors that have a bearing upon prognosis, are illus- trated in the following sketch. It will be observed that the patient comes under observation, not at the commencement, but, as such cases so often do in practice, at a fairly pro- nounced although still comparatively early stage of the disease. CHRONIC TUBERCULOSIS OF THE LUNGS 505 A tall, thin, worn, anemic woman, aged twenty-nine, came to the hospital for advice on account of lung symptoms. She was suckling a child seven weeks old, with which she had become pregnant eleven months after the birth of twins, and whilst still suckling the survivor of them. Since her last confinement she had been suffering from increasing debility, shortness of breath, loss of flesh and cough, with yellow expectoration, recently tinged with blood. There were also occasional night-sweatings. Her chest was narrow and somewhat flattened, with deficient general mobility, but without any local depression or restraint of movement. The resonance at the left apex was impaired, the respiratory sounds there being harsh and wanting in vesicularity, and attended with some moist crepitations down to the second rib. Elsewhere the breath-sounds, though wanting in power, were of vesicular quality. The pulse was quick and weak, appetite indifferent, but digestion fairly good. The patient inherited a disposition to consumption, having lost her mother from it when she was two years old ; her sister had also suffered from an early stage of the disease. She was unable to leave her home, and could only be induced to partially wean the child. Under tonic treatment, however, with cod- liver oil and a few lozenges to relieve the cough at night, she decidedly improved, gaining in health and strength, and putting on flesh rapidly. A month later the moist rales were no longer audible, except after cough, which elicited a few crackles. There now appeared a slight degree of flattening below the left clavicle, more distinct on deep inspiration. The respiratory sounds were feeble, while on the opposite side they were exaggerated, and careful percussion defined the margin of the healthy lung as extending slightly beyond the median line at the upper sternum. There was no evidence of a cavity at the left apex, nor of any extension of the area of disease. The pulse was quiet but weak, the appetite improved. Such is a brief account of an average case, which suggests the following considerations : (i) The patient, with a phthisical family history, debilitated by adverse conditions — in this case rapid pregnancies and depressed circumstances of Hfe — presented herself, suffering from a wasting illness of three months' duration, attended with definite chest symptoms. We can but rarely, at the moment of first seeing such a patient, know the range of temperature or whether there be tubercle bacilH in the sputum; but the history of night-sweatings and wasting would assure us of the one, and the character of the physical signs renders an exam- ination for bacilH in such a case of less importance, for these signs reveal a definite lesion at the apex of the lung, which, under such circumstances, is almost always tuberculous. 506 DISEASES OF THE LUNGS AND PLEURA (2) After a few weeks' treatment, even under the adverse circumstances of a case only treated as a hospital out-patient, a notable improvement was observed in the general condition of the patient, and two pulmonary signs presented themselves of clinical importance in the same direction. These were (a) the fact that, with diminished crepitations, showing a lessened activity of the disease, a commencing flattening and an impaired mobility of the chest over the part affected was observed; and (b) that, on careful percussion, to define the margin of the healthy (right) lung, it is found to extend towards the affected side up to and a little beyond the median line. These two signs — ^late flattening, coincident with lessened activity of disease (as contrasted with early flattening- from sheer loss of lung substance), and compensatory expansion of the sound lung encroaching upon the region of the affected side — are of considerable value in favour of the hopeful prognosis of the case. (3) The patient's history illustrates an important point in aetiology, the fact that a lowered resistance favours the attack, and reminds us of another important point in prognosis, namely, that the more unfavourable the circumstances which have led up to the illness, the better prospect is there of re- covery if they can be removed or mitigated. " It is true that privation, excess, errors in habits of life, the sedentary occu- pations, the pernicious influence of certain trades, grief, anxiety, and the other wasters of vital powers, will not suffice to induce consumption in all, or even in the greater propor- tion of individuals ; for these agents, so universally prevalent, are part of the daily lot or of the daily errors of many more than fall victims to consumption. But it is also true that, if to any or all of these conditions that of inherited tendency to phthisis be superadded, very few indeed escape the disease.'"' This remark is well borne out by the above, amid numberless other cases which must be familiar to physicians, although we now know that the acquired or inherited impairment of resistance operates by increasing the receptivity to a definite infection which may have the average wide distribution to which all are exposed, or, again, which may be more concen- trated by general insanitation or specifically infected sur- roundings. Most cases of " cured " early-stage phthisis are of the kind PLATE XXIX .sXs^ Arrested Tlberculosis. To face p. 507. ARRESTED TUBERCULOSIS ' The drawing shows the posterior half of the left lung. The upper lobe is seen to be considerably shrunken and converted into a dense fibroid, partly pigmented mass, containing one or two very small cavities, in one of which a little calcareous matter was found. No recent tuberculous disease is seen. The right lung also showed arrested disease — in the upper lobe a contracted cavity the size of a filbert, surrounded by fibroid material ; and in the lower lobe some scattered pigmented tubercles of old stand- ing, together with a small calcareous patch at the apex. From a man aged fifty-one, who died from acute bronchitis, complicated with aortic regurgitation and extensive atheroma of the aorta. The tuberculosis in the lungs had undergone com- plete arrest. (From the Museum of the Brompton Hospital, f natural size.) PLATE XXIX CHRONIC TUBERCULOSIS OF THE LUNGS 507 above related. The arrest of the disease may be of long- or even permanent duration, but the lesions which remain in the lung, although quiescent, still contain entombed within them organisms capable of fresh germination should the conditions again prove favourable. Hence the previous health-history of the patient helps us much in the prognosis in each in- dividual case. Those cases in which the pulmonary delicacy is distinctly inherited are the least hopeful; those, again, in which the attack has been most distinctly provoked by adverse conditions of a definite and remediable kind are the most favourable. Of course, in each case the extent of lung involved and the intensity of the disease, to be ascertained only by physical examination, must, as already pointed out, most materially enter into the question as to outlook. The patient whose history we have been considering suffered a second attack after the lapse of some months, with extension of disease, involvement of the other lung, and ulti- mately a fatal termination. Such is the average tendency in cases of this type, a disposition to arrest and to recurrence. It must be here remarked, however, that with arrest of disease a certain degree of immunity is gradually established, and provided the resistance be not broken down by premature return to the vicissitudes of current life this immunity may result in complete ability to withstand the test of acute influenzal and other illness. Transition from Ordinary Chronic to Fibroid Phthisis.— All cases of chronic pulmonary tuberculosis present some evidence of repair, some attempt at arrest of the disease by the formation of protecting zones of fibrous tissue (Plate XXIX.). In patients in whom the natural resistance is great, this fibrosis may become a marked feature, and in extreme cases may warrant the appellation " fibroid phthisis," a condi- tion which we shall presently consider. It must be remem- bered, however, that such fibrosis constitutes but a very imperfect form of repair. It is, in fact, the replacement of a hig-her by a lower form of tissue, which may be regarded as cicatricial, and which often proceeds to bring about deformi- ties and other morbid conditions of its own. The following case exemplifies fairly well the transition stages between simple chronic pulmonary tuberculosis and ■508 DISEASES OF THE LUNGS AND PLEURA fibroid phthisis, a transition pathologically easy, and clinically often to be observed : John B , aged twenty-nine, a butcher's assistant, came under the notice of one of us as an out-patient at the Brompton Hospital. He was a broad-chested, powerfully-made man, of medium height and florid complexion. He had led a rough but sober life, having followed his present business, which included the slaughtering of animals, for some years in Australia, and had enjoyed excellent health until shortly before Christmas, when, after getting wet, he caught a severe cold, which was followed by a cough, which had since increased, unin- fluenced by treatment. Up to and at the time of his attendance in the following March he was still continuing his employment, but he now did so with difiiculty, complaining of his cough and of increasing weakness, with decided emaciation. His father had died of consump- tion, brought on subsequent to the patient's birth by intemperance; there was no other hereditary tendency to the disease. His chest, as before said, was broad and well-formed, without flattening or obvious impairment of expansion. The heart's apex-beat was in the natural situation. At the left clavicular and subclavicular regions the percussion note was dull, the dulness extending to the fourth rib ; posteriorly the resonance was defective at the left supra- spinous fossa. Scattered over the dull regions there was coarse crepitation, mingled with a larger humid crackle. These moist sounds were abundant, and masked to a great extent the respiratory murmur, which was decidedly harsh, but not distinctly bronchial. Its vesicular quality became gradually restored as the stethoscope was passed downwards. At the posterior base there were some scattered sibilant rales. On the right side the percussion note was good, and the breath- sounds were natural. The physical signs at the present stage showed consolidated lobules of blocked alveoli, which were softening with varying degrees of rapidity, the coarse crepitation answering to the redux crepitation of pneumonia, the larger click being due to more profound destruction of tissue (softening). On the occasion of his first visit the pulse was quick and the tongue red, and although there was no elevation of temperature at the moment, it is probable that it rose slightly towards evening. The patient was treated with an alkaline mixture containing small doses of iodide of potassium, and with cod-liver oil. A few weeks later the expansion of the left side of the chest was found to be decidedly impaired, the dulness had increased in hardness, but not in extent, and was very marked, especially between the left margin of the sternum and the mid-clavicular line. In the space marked out by these two vertical lines (left sternal and mid-clavicular) the respiration was extremely feeble, and not attended with rales ; the heart's impulse was diffused upwards to the second interspace, though the apex was only half an inch higher than natural. CHRONIC TUBERCULOSIS OF THE LUNGS 509 To the left, again, of the mid-clavicular line the respiration was still feeble, and the rales much diminished, the dulness being somewhat greater than before. At the apex posteriorly there was bronchial respiration with imperfect pectoriloquy ; the bronchial rales at the base had cleared up. The resonance of the right lung extended to the left margin of the sternum. The physical signs showed — 1. That the disease had not extended; on the contrary, the signs of bronchial irritation at the base had cleared up. 2. That a wasting" of the, parenchyma of the lung had taken place; a small cavity had formed at the apex, with collapse and agglutination of air-cells elsewhere, thus causing a con- siderable reduction in the bulk of the lung and retraction of its anterior margin from the median line; so that between the left sternal line and a line drawn from the point of junction of the inner and middle third of the clavicle to the apex of the heart there was probably at this date no lung at all. 3. That an encroachment of the enlarging right lung, a slight shifting of the heart to the left, and a flattening of the chest wall had ensued to make up for the lost space. The flatten- ing was, however, as yet very slight, and not noticeable until the patient drew a breath. The man had powerful parietes, and in such cases the displacement of heart and encroachment of the opposite lung precede, often for a long time, any obvious flattening. It was remarkable with what rapidity these changes were taking place, and there can be no doubt that, after consider- able lung destruction, the connective tissue of the bronchial, perivascular, and pleural sheaths was undergoing rapid development, and that the case was, in fact, lapsing into an early stage of fibroid phthisis. That the disease was not yet arrested seemed probable from the patient still losing slightly in weight and becoming more anaemic; but it had clearly become Hmited. During the next month (May), although taking an acid preparation of iron, with a little quinine, and the oil, he lost two pounds in weight. Notwithstanding this, he had improved generally ; the cough and expectoration had diminished, and he felt stronger. On June 8 he was still better, and had regained one pound since the last report. He had very little cough ; all moist sounds had disappeared except a slight pleuritic rale on cough at the outer side and a little above the left nipple. He steadily improved up to August, five months after his first attendance at the hospital, when he was lost sight of. 510 DISEASES OF THE LUNGS AND PLEURA REFERENCES. ^ " The Significance of Arneth's Reaction, with Particular Reference to Pulmonary Tuberculosis." By H. A. Treadgold, M.D., The Lancet, 1920, vol. i., p. 699. ' " The Role of the Cardio-vascular System in Pulmonary Tuberculosis." By Sir R. Douglas PoweU, Bart, K.C.V.O., M.D., F.R.C.P., TU Lancet, 1912 vol. ii., p. 1415. ^ Eleme?its of Prognosis in Consumption, with Indications for the Pre- vention! and Treatment. By James Edward Pollock, M.D., p. 340. London, 1865. CHAPTER XXXV. CHRONIC TUBERCULOSIS OF THE l.\J^GS— Continued Fibroid Phthisis. fuE term " fibroid phtliisis " has been productive of much dis- cussion. It was orig-inally introduced by the late Sir Andrew Clark^ to " embrace all those cases, whether local or consti- tutional, which are anatomically characterised by the presence, in a contracted and indurated lung traversed by more or less dilated bronchi, of fibroid tissue and of a tough fibrogenous substance, together with cheesy deposits or consolidations, and usually small cavities, commonly found about the middle and lower parts of the affected organ." The term is such a neat, concise and clinically useful one, that it has been gener- ally accepted, with some reservations as regards the strict pathology of the disease as originally enunciated by its author. Indeed, at the present day its use is restricted to cases of pulmonary tuberculosis of an extremely chronic type, in which the resistance of the patient is considerable, and the forma- tion of much fibrous tissue, with its attendant consequences, has resulted. The prominent symptoms and signs by which cases of fibroid phthisis are distinguished are : increasing contraction and immobility of the affected side; traction of organs to that side; deadened percussion note and weakened breath-sounds of more or less bronchial quahty, at parts intensely bronchial or cavernous; breathlessness; dragging pains; paroxysmal cough; occasional hectic, but general absence of fever; very chronic progress; long-continued one-sidedness of the disease, and correspondingly slow failure of nutrition. Such symptoms and signs bring the cases within the definition of phthisis, but phthisis of a special type. 511 512 DISEASES OF THE LUNGS AND PLEURA The conditions presented post-mortem are those of a con- tracted, toughened, indurated, and usually pigmented lung, surrounded by a greatly thickened adherent pleura contain- ing one or more rigid, dense-walled cavities, dilated bronchi, and cheesy encapsuled nodules. On minute examination this condition of lung is found to have been produced by a growth of two kinds pervading its texture : (i) a connective-tissue proliferation, resulting- in the formation of bands and processes of fibrous tissue, derived from the sheaths of vessels and bronchi and the subpleural and interlobular tissue of the lung; (2) a more important nuclear growth originating in a fibroid transformation of the individual tubercles, and resulting in the formation of broad tracts of fibroid tissue, which thicken the walls of the alveoli, compress, and finally efface them, unless they have been previously stuffed with their own inflammatory products. (3) In some small foci the process proceeds to slow caseation and softening. In other cases, as in that described in the previous chapter, a considerable destruction of the lung may have preceded the fibrosis. The products of these processes become intimately mingled, but it is the tuberculous element which gives to the disease its peculiar clinical features, and renders the name " fibroid phthisis " appHcable to it. Numerous examples may be found of this somewhat inclu- sive disease, ranging from the most typical cases to those which are almost indistinguishable from ordinary chronic phthisis. We have described in the preceding chapter a case of simple chronic pulm.onary tuberculosis, in which the^ transi- tion into one of early fibroid phthisis was traced. It would not be difficult, however, to find examples in which the reverse takes place, the clinical characters of fibroid phthisis being gradually changed by subsequent activity of the tuberculous process, and all the features of the special variety becoming merged in the diffuse pulmonary destruction. Thus in a boy, to whose case allusion was made in a former edition of this work, the disease beg^an with tuberculous destruction of a certain portion of lung, upon arrest of which the marked phenomena of pulmonary fibrosis supervened, and finally, again, active destructive changes set in, quite obscuring the fibroid characters, and resulting in death from pneumothorax. CHRONIC TUBERCULOSIS OF THE LUNGS 513 The following case is a fair example of the variety of tuber- culosis now under consideration : George P., a sawyer, aged forty-three when he first came under observation as an out-patient at the Brompton Hospital, was a thin man, with dark hair, having no hereditary predisposition to lung disease, except that his father had suffered from " asthma." He had had slight cough for years, and in the preceding winter had been laid up for six weeks with " inflammation of the right lung." Since that time the cough had been continuous, and there had once been slight haemoptysis. The cough was now paroxysmal, causing retching and often rejection of food ; expectoration difficult, abundant, and of a pink tinge. He had lately been losing weight. The digestive functions were fairly good ; the pulse a little hurried ; there was no fever. Fig. 52. On inspecting the chest, cardiac pulsation was visible at the fourth right interspace (Fig. 52, C) to left of right nipple. This side was diminished in size and much restricted in movement, the intercostal spaces deepening with inspiration, while the left side expanded freely, with an uplifting movement of the shoulder. On careful examination, the apex of the heart was found a little to the left of the ensiform cartilage. On percussion, the right side in the nipple-line anteriorly was dull to the second rib (A), comparatively resonant to the fourth, and below this point it v^as again toneless. The resonance of the left lung extended to the right of the sternum, as indicated in the diagram. The line of this resonance (D) sloped upwards to the episternal notch, being displaced in a downward direction by cardiac dulness at the fourth 33 514 DISEASES OF THE LUNGS AND PLEUTLE cartilage. Hepatic dulness barely reached the costal margin. There was dulness throughout the axillary region and posteriorly from apex to mid-scapula, the note having a tubular quality in this latter region. Below the mid-scapula there was fair resonance to the ninth rib, though less and harder than on the opposite side; the lower two or three inches on the right side gave a flat note on percussion. The percussion note over the whole left side, including the region of normal cardiac dulness and extending across the median line, as above indicated, was full and good in front and behind. The auscultatory signs were in agreement with those of percussion. Above the clavicle on the right side the respiration was amphoric and dr}' ; below the clavicle weak and bronchial to the base, with some rather large moist rales, friction and bronchophony^ At one spot, corresponding with the second and third ribs in the nipple-line (B) the breath-sound was of tracheal quality, with scanty cavernous clicks and pectoriloquy. In the upper axillary region the respiration was amphoric, and the voice-sound pectoriloquous ; in the supraspinous fossa and interscapular regions, cavernous-blowing with pectoriloquy. Blowing respiration extended to the angle of the scapula, where it became weaker and gradually annulled at the base. The vocal fremitus was generally increased on the right side. Respiration throughout the left lung was exaggerated and vesicular. At the end of six months the patient had improved in flesh, appear- ance, and in strength, but complained greatly of cough, and expec- torated much pink phlegm. Breath short on exertion ; cough caused retching, but no rejection of food; appetite fair; digestion not very strong ; bowels regular. Fingers observed to be clubbed. The additional physical sign noted at this date was a distinct short systolic bruit at the point of maximum cardiac impulse, not appreciably increased by pressure nor confined to that spot, being also audible at the apex. Measurements of chest : from mid-sternum to nipple, right side, 4 inches; semi-circumference, 15I inches; expansion, | inch. Left sterno-nipple measurement, 4I inches; semi-circumference, 16 inches; expansion, 5 inch. We may, by way of summary, aided by a glance at the figure (reduced as accurately as possible from a sketch taken at the time upon an outline diagram), interpret the above detailed physical signs as indicating at this period a general induration of the right lung, with much contraction, its anterior margin having receded considerably from the median line, exposing the pericardium, and having also shrunk away from the upper surface of the liver. Its upper lobe, and a portion of its lower, were extensively excavated, the cavities being old, tolerably dry, and shrunken with the general con- traction of the lung. The pleura, judging from the hardness of percussion, feebleness of breath-sound, and fixity of chest CHRONIC TUBERCULOSIS OF THE LUNGS 515 walls, was probably greatly thickened. The liver was drawn up within the costal margin, and the heart considerably dis- placed to the right, its axis being, however, but little altered. His chest was repeatedly examined during the many subsequent months of his attendance at the hospital, but beyond some variation in the dryness of the sounds, there was no important change in the physical signs. The urine was more than once examined, but was always found free from albumin. The left lung remained healthy, and though the patient continued thin and cachectic-looking, with a troublesome cough, he held his ground fairly well, and rather improved in general health. At times the expectoration would become very abundant, and occasionally of a pink colour, probably due to fresh irritation and slight sanguineous discharge from the walls of the old cavities. The most troublesome symptom throughout the case, and one which is common in greater or less degree to all those cases of tuberculosis in which indurated thick- walled cavities are present, was the paroxysmal cough terminating in vomiting, occurring especially after meals. On ceasing attendance at the hospital, after a period of nine months, the patient, though not free from cough, continued for a time to improve, but he soon afterwards began again to emaciate, and the vomiting with cough returned. He again attended in January the following year for three months, and improved. The above-related case represents very well the main features of fibroid disease of the lung. The indurative disease supervened presumably upon an acute tuberculous pneumonia affecting the upper part of the right lung, and manifested it- self with tolerable rapidity, the characteristic symptoms and signs being fully developed within six months of the termina- tion of the acute disease. The question as to the rapidity with which this disease may advance is one of great interest, and requiring further observa- tion. We cannot but think that, reasoning from the morbid appearances found in the post-mortem room, we are apt to regard such diseases as older than the clinical history will warrant us in beHeving; on the other hand, though it is probable that the fibroid induration of the lung may proceed with great rapidity to such a stag"e of shrinking as to produce marked clinical signs, its subsequent progress is very slow and difficult to measure, consisting mainly in the further harden- ing of an already indurated lung, the gradual widening of the bronchial tubes, and filling up of the loose oedematous areolar tissue between the separated pleural layers by dense fibrous 5l6 DISEASES OF THE LUNGS AND PLEURA growth. We can readily perceive, therefore, how its earHer stages, which are attended with striking alterations in physical signs, may be passed through with comparative rapidity, while the later progress is necessarily slow and difficult to estimate. No doubt the mechanical conditions of the cavities to which we have referred, and which render the removal of expectora- tion difficult, have much to do with the production of vomit- ing, and cause it to be a particularly common symptom in these cases; but the reception of food into the stomach has seemed to be in many cases so constantly followed by cough ending in vomiting as to render this mechanical explanation in- sufficient, and we have been led to attribute it to an undue reflex irritability of the pneumogastric nerve. The following notes of a patient who had been under obser- vation at the Brompton Hospital for more than forty years illustrate the great chronicity which this form of the disease may sometimes attain : E. P. was admitted, at the age of seventeen, into the hospital, under the care of our colleague, the late Dr. Pollock, in November, 1877, for cough and weakness of seven years' duration, having also had slight haemoptysis in 1874. On her mother's side there was a predisposition to phthisis, her maternal grandmother and uncle having both died of this complaint ; and twelve years later, in 1889, her mother herself succumbed to it. The physical signs on admission were, to quote Dr. Pollock's note, "on the right side dulness, flattening, and cavernous breathing, with gurgling and humid crepitations to the anterior base and in the axilla. In the supraspinous fossa some cavernous sounds were heard. The respiration was tubular in the interscapular region. Some crackles were heard at the posterior base. The left lung reached to the right border of the sternum; no abnormal sounds were heard over it." On January 17, 1878, the right lung was found to be dry, except for a few fine crackling sounds after cough in the infraclavicular region. The posterior base was clear. In February, 1878, the patient left the hospital greatly improved, her weight now being 7 stone 3I pounds, a gain of 6| pounds since admission. After leaving, she remained fairly well for some years, though suffering on and off from cough. In 1892 she again entered the hospital, under Dr. Mitchell Bruce, and again derived benefit. On October 9, 1899, she came under Dr. Hartley's observation at the hospital, complaining that her cough had been worse lately and her breath shorter. Her general condition was fair, though her appetite was poor. Her height was about 5 feet 3 inches, her weight 6 stone CHRONIC TUBERCULOSIS OF THE LUNGS 517 II pounds. On examination, tlie right side was flattened with but very poor expansion, and yielded all over a markedly impaired note to percussion. The heart was drawn to the right side of the sternum, and pulsation extended as far as the right anterior axillary line (Fig. 53, A). Cavernous breath-sounds were heard over extended areas of the right lung, with scattered crepitations. The left lung seemed free from disease and to be hypertrophied, extending for about an inch to the right of the sternum (B). There was no clubbing of the fingers. The diagrams (Figs. 53 and 54) show the condition of the chest, which was but little different from that observed by Dr. Bruce in 1892. Fig. 53- In June, 1900, she had improved in every way, although her cough continued. In January, 1901, her weight was still 6 stone 11 pounds, and her physical signs showed no change, except that now some crepitations were heard at the apex of the left lung posteriorly. In the expectoration, which was never very large in amount, a few tubercle bacilli were found. From 1901 to 1906 the patient was under our observation from time to time, and, on the whole, somewhat improved. In May, 1903, her weight was 7 stone 6^ pounds, and in May, 1906, 7 stone 8 pounds. On the latter date crepitations were still audible at the left apex, but 5i8 DISEASES OF THE LUNGS AND PLEURA showed no signs of extending. She was still able to carry on her occupation as a needlewoman. Since igo6Bhe has lived in London, and has kept fairly well, though subject to bronchial attacks in the winter, when her cough and breathing become troublesome. Apart from these attacks she has had very little cough or phlegm. In 1910 she suffered from an abscess in the right breast, which her doctor regarded as tuberculous. It discharged for about twelve months and then healed. On February 25, 1920, she came at our request to the hospital for examination. Her age was now fifty-nine. She looked well in herself, but was somewhat short of breath on exertion. Weight, 7 st. 25 lbs. > Fig. 54. There was but little change in the pulmonary condition. The right lung was contracted and excavated, and the right side ex- panded but little on inspiration. The note at the left apex was still slightly impaired, and a few moist sounds were audible in this region, but there appeared to have been no extension of the tuberculous disease since her last appearance in 1906. The heart was drawn over to the right side as before, but the blood-pressure was now distinctly raised, measuring in the right brachial, in the sitting posture, 170 mm. Hg. The second aortic sound was rather forcible. The urine was of low specific gravity, and contained no albumin or sugar. The spleen and liver were not enlarged, and there was no CHRONIC TUBERCULOSIS OF THE LUNGS 51.9 diarrhoea, or any evidence of lardaceous degeneration. Her sight was beginning to fail, and she was now unable to continue her needle- work. This case is of great interest in that the signs have been traced, through a period of forty-three years, from an apical disease to one involving the whole lung and coming into the category of fibroid phthisis. In spite, also, of the long duration of the case, the affection of the opposite lung remains but slight. She appears indeed to have long attained arrest of the tuberculous disease, and for some thirty years to have enjoyed fair health, though possessing only one functionating lung. Prognosis. — The outlook in fibroid phthisis varies with the somewhat diverse cases grouped together under this headings. The disease, however, may be said to be very chronic, and capable in a considerable number of cases of permanent arrest. There are, however, certain points to be taken into account in estimating the duration of a case. The cachexia may be marked, almost resembling" that of some cases of cancer. The wall of a chronic cavity may be traversed by a large vessel, which, yielding on its unsupported side, forms an aneurism, and gives rise to recurrent or fatal haemoptysis. Out of eight well-marked cases in which post-mortem examinations were made by one of us, haemoptysis was the cause of death in two.^ The opposite lung in most cases becomes in course of time involved at the apex with secondary tubercle, but this is usually of the grey miliary type, and generally chronic or quiescent. This is exemplified by the case of E. P., above related, and also by that of a patient who was brought by one of us before the CHnical Society so far back as 1868. In association with chronic destructive lesion of the left lung, this patient had also distinct evidence of involvement of the apex of the opposite lung, and, in addition, a small quantity of albumin in the urine. He subsequently, however, led a rural life, and his health yearly improved. The right limg became greatly enlarged, the disease in the left remaining perfectly obsolescent, and the patient was in 1885 in good flesh and, to all appearance, in robust health. In the later stages lardaceous changes in various organs, especially the spleen, liver, and kidneys, commonly supervene, and may lead to the death of the patient. Of the three most 5^0 DISEASES OF THE LUNGS AND PLEUR/E characteristic cases in which we have made post-mortem examinations, in one there was extensive lardaceous degenera- tion of liver and spleen with granular kidneys; in another of the spleen only. Albumin in the urine, absent in the above-related case, is often the earliest clinical evidence of this change. The condition of health and physique maintained by some patients is remarkably good. We have notes of a postman presenting exceedingly well-marked signs of this form of tuberculosis, who almost entirely lost his cough while attend- ing the hospital, and was able to resume his duties, walking fourteen or fifteen miles a day; and we might mention some other patients capable of considerable physical exertion on level ground. Persons who for many years have had one lung dormant or " gone," as they usually describe it, are not uncommonly met with, and belong to this category. Mention has already been made of two such cases, and we can also recall, amongst others, that of a lady who for thirty years had her left lung similarly affected. This patient led a sheltered but useful life, and rarely suffered from pulmonary symptoms of any kind. Her chief complaint from time to time was of failure of heart's action, causing chilliness and a disposition to fainting, with occasional attacks of great cardiac oppres- sion, which, but for the absence of any severe pain, would be described as angina. There was no evidence in this case of valvular disease or decided dilatation of heart, but the organ was uncovered by the retracted left lung, and the sounds were feeble. We have observed in many chronic left-sided cases of tuberculosis great functional disturbance, or rather irrit- ability of heart, doubtless attributable to its being less supported and protected by lung than in health. REFERENCES. * "A Case of Fibroid Phthisis," by Andrew Clark, M.D., Transactions of the Clinical Society of London, 1868, vol. i., p. 188. ^ For an account of these cases, see (i) " Three Cases of Phthisis with Contracted Lung," by R. Douglas Powell, M.D. (Case I.), Transactions of the Clinical Society of London, 1869, vol. ii., p. 181. (2) " Some Cases illustrating the Pathology of Fatal Haemoptysis in Advanced Phthisis," by R. Douglas Powell, M.D. (Table, p. 58, Case I., F. W.), Transactions of the Pathological Society of London, 1871, vol. xxii., p. 41. CHAPTER XXXVI TUBERCULOUS EXCAVATION OF THE LUNG— THE CAVITY STAGE OF PHTHISIS The excavation stage of some cases of phthisis is so pro- longed, and the symptoms are so decidedly grouped about the cavity, that at some schools it is the custom to name them cases of "cavitation." Whilst we do not regard such a term as admissible in any formal sense, however appropriate it may be as a colloquial expression in clinical teaching, there are yet many points in the diagnosis and treatment of different kinds or conditions of cavities which are worthy of considera- tion in a separate chapter. We have seen that destruction of lung is the essential ana- tomical feature of pulmonary tuberculosis. In the most rapidly fatal cases the destruction takes place simultaneously at many centres, or involves such an extent of lung as to render hopeless any effort at repair or compensation. But in a large proportion of cases the disease affects principally one apex, the active symptoms attendant upon the pulmonary consolidation and softening after a time subside, the appetite returns, and the patient begins to regain strength and flesh. The cough still continues, however, and auscultation reveals the existence of a cavity at the apex concerned, the disease being now usually described as having advanced from the first (consolidation) through the second (softening) to the third (cavity) stage. If these terms were strictly employed in a structural or anatomical sense as regards the lungs only, they would not be objectionable ; but, in fact, they are too often extended in their application to the whole disease as it affects the patient, and therefore become fruitful of error and misunderstanding. These so-called stages of phthisis have reference merely to 521 522 DISEASES OF THE LUNGS AND PLEURA the local effects of that disease, involving perhaps a fiftieth part or, it may be, a large portion of one or both lungs; they have no meaning as apphed to the present or prospective duration of the disease. A man with a big cavity is frequently better off as regards life and health prospects than one with a " first stage " patch of disease no larger than the area of a shilling. A cavity once formed is so much lung gone, and it is for many reasons better that the irremediably diseased portion should be cleared out than that it should remain as a centre for fresh irritation, which may break down or infect the system at any time. Our anxiety as regards the immedi- ate prognosis rests upon the condition of the outlying portions of the affected lung, and still more upon the degree of integrity of the opposite lung. Yet the student rarely looks beyond a cavity, upon the discovery of which he is apt to classify the case and to decree the fate of the patient. The physician, too, is often beset by anxious inquiries from relatives and friends as to the existence or non-existence of a cavity, upon which they base their hopes and fears, and upon his capacity to dis- cover which his reputation is registered in their estimation. These terms, then, being inaccurate and misleading, should never be used in their general sense. To resume, however, the special subject of the present chapter. Cavities may be considered under four heads : (i) the recent cavity; (2) the quiescent cavity; (3) the secret- ing cavity; (4) the active or ulcerous cavity. I. Recent CaYity. — The recent cavity is the first result of the breaking down of caseous nodules in the lung. In cases of sufficient intensity these undergo softening and liquefac- tion in few or many centres. We do not, however, obtain any physical sign of the production of a cavity until communica- tion is effected with a bronchus and some of the softened matter is expelled. From this moment we have cavities existing- in the lungs and accessible to the air during respiration. To yield the auscultation signs which are regarded as necessary for diagnosis, a cavity must have the dimensions of a walnut, or larger, and must communicate freely with a bronchus. But on comparing our clinical notes with post- mortem observations we shall find the former most commonly inadequate if we have awaited the presence of cavernous TUBERCULOUS EXCAVATION OF THE LUNG 523 breathing and pectoriloquy, and such-like orthodox signs, before admitting the existence of excavation. The pulmonary consolidations break down into cavities in one of two ways, which are not, however, essentially different. In the first case, many minute lobular centres of softening are found which yield to auscultation moist crackling or humid clicking sounds; these increase in size -and abundance as the softening centres extend and coalesce into larger cavities, until finally we have cavernous rales. The respiratory murmur which — bronchial with the first consolidation — had become weakened and more or less masked by the moist sounds, be- comes again audible, but much altered in quality, assuming the more or less distinctly cavernous character. Whispering pectoriloquy now becomes marked, and in some cases a characteristic succussion of air may be heard on coughing, the so-called " post-tussive suction." On percussion, the note over a cavity is usually impaired owing to consolidation of the surrounding lung, but over extensive excavation with thin walls, tubular or amphoric resonance may be obtained (p. 39), with possibly the bruit-de-pot file, if the cavity be near the surface, and if it eommunicates freely with a bronchus. Perhaps the large majority of phthisical cavities form and increase in the way thus briefly sketched, but in some cases they are produced in a slightly different manner. It may happen that we fail to obtain distinct evidence of pulmonary softening for a time, when troublesome dry cough and hectic symptoms point strongly to its presence. There may be dul- ness, harsh breathing, and some fine spongy crepitation, increased after cough, but none of those distinct clicks characteristic of pulmonary softening. Then the patient will suddenly, in the course of the night, perhaps, expectorate a considerable quantity of purulent matter, and we find evidence — cavernous rales, etc. — of the existence of a cavity. The ex- planation of these phenomena is obvious enough; a nodule of consolidation of appreciable dimensions, but rarely exceed- ing a walnut in size, becomes uniformly caseous, and then softens in its centre and gradually liquefies throughout before communicating with a bronchus, when its fluid constituents are at once expelled, and auscultatory evidence of the exist- ence of a cavity becomes abruptly developed. In the post- mortem room we may often cut through such softening 524 DISEASES OF THE LUNGS AND PLEURA nodules in all stages of ripeness for exit; they sometimes undermine and rupture through the pleura, and may well be designated caseous abscesses. The following case, alluded to by one of us in a clinical lecture delivered at the Brompton Hospital,^ illustrates the rapid formation of a cavity at the right apex, and the cicatrisa- tion and clearing up of signs and symptoms which may some- times follow : A. W., a pale, scrofulous-looking girl, who was in attendance at the time of the lecture, had been under observation at the hospital since March, 1872, when, at the age of fifteen, she first came as an out- patient. She had then a somewhat loud cough, which had troubled her all the winter, but there were no other definite symptoms and no discoverable pulmonary signs. Her family history was good, but she had been delicate since an attack of measles in childhood. She recovered on ordinary treatment, but returned in October, 1874, and again improved, but was ailing during the winter. In the spring of 1875 her principal complaint was of a painful affection of the left breast ; she still had no definite pulmonary signs or symptoms beyond general delicacy and slight cough. In June she had whooping-cough rather severely ; and six weeks after she still whooped with the cough, which was attended with thick, difficult expectoration. On again examining her chest, one was somewhat surprised to find dulness, with marked cavernous breathing and some gurgling below the right clavicle ; moist crepitant rales were also rather sparsely scattered over the posterior base. Fever and hectic symptoms were now marked. The prognosis appeared grave, and she was recommended to obtain an in-patient's letter. She did not come into the hospital, howevei, until January, 1876, and mean- while improved as an out-patient. In the preceding October no moist sounds were audible, and on admission into the ward in January her chest was examined with great care, and on several subsequent occasions, but nothing beyond some harshness and feebleness of breathing at the right apex could be discovered. After leaving the hospital in 1876 she remained well for a consider- able time, and early in 1883 was married. In the course of that year she had a miscarriage, and afterwards suffered much from menor- rhagia. In May, 1885, she again came under observation, with cough, especially during the night and in the morning, and some loss of flesh. She was nursing entirely a child eight months old. At the right apex, the seat of former mischief, there was slight dulness and some deep crackling and catarrhal rales, but no evidence of a cavity. A few bronchitic rales were scattered over the chest on both sides. The breath-sounds below the left apex were not quite satisfactory. Shortly after this she ceased to attend, and was lost sight of. TUBERCULOUS EXCAVATION OF THE LUNG 525 This case would appear to have been one of solitary caseous abscess at the right apex, the contents of which were exper- torated, cicatrisation of the resulting cavity then ensuing, in a manner analogous to that sometimes seen in suppurating glands of the neck. It may be urged that as tubercle bacilli were not found — the date of the observation precluding this — the case must remain a doubtful one ; but its subsequent course supports the diagnosis, and we have since observed a very similar case in private, in which bacilli were discovered, and which we will now very briefly relate. A gentleman, aged about twenty-five years, was at a French watering-place, and on the night of his departure was dancing to a late hour, and only allowed himself time to rush in evening clothes to the boat of departure for London. He was much heated, and became severely chilled on the voyage. The next day he was seized with rigor and very severe pain in the left upper scapular region. He presented the signs of ac«te pneumonia, but when seen at Maidenhead in con- sultation with Dr. Moore within a few days of his attack, the pain in the shoulder continued, and there were notable cavernous breath-sounds and gurgling over the spinous region of the left scapula. The tempera- ture was high and fluctuating, with marked night-sweating, and a considerable amount of muco-purulent expectoration of a very foetid odour was being discharged. In a word, the signs and symptoms were those of an abscess in the upper and back portion of the left lung. The peculiarity of site and the general aspect of the case led to a careful examination of the sputum, which revealed the presence of tubercle bacilli in abundance. Nevertheless, to be brief, this gentleman made a fairly rapid and complete recovery, and, some fifteen years later, had married, and was in excellent health, having since engaged in big-game shooting in Africa, and having effected an insurance on his life at ordinary rates. The case is a modern analogue to the preceding one, and may be rightly described as an example of tuberculous abscess of the lung. Similar cases have also been reported by other observers, and post-mortem observation leaves little doubt that such abscesses occur more frequently than positive clinical experience would indicate, although they are rarely single and uncomplicated, as in the above instances. It should be especially added that when a second attack occurs it often does not affect, as in the case of A. W., the part of the lung originally attacked, but some other portion of the same lung or the opposite apex. With the softening of the pulmonary textures the expec- 526 DISEASES OF THE LUNGS AND PLEURA toration ceases to consist of mucus. It is no longer viscid, tenacious, and more or less frothy, but contains opaque specks and purulent streaks, and, gradually becoming more purulent, each sputum is moulded in its escape through the air-passages and clothed with a thin layer of mucus to form a more or less isolated nummular mass. With the enlargement of the cavities the sputum becomes more diffluent. As the expec- toration increases in abundance, it becomes also easier, and the patient describes his cough as being looser, but soon complains of the amount of expectoration. At an early period, when the centres of excavation are as yet minute, a careful examination of the sputum (p. 72) will reveal the presence of elastic tissue (Fig. 55), which has in- deed almost exactly the same significance as that of the Fig. 55. — Elastic Tissue from Phthisical Sputum. Woodcuts from photographs taken by the late Mr. F. Fowke. x 170 (about). physical sign of moist crackling. Tubercle bacilli are at this stage always present, and generally in abundance. A cavity of recognisable dimensions having been formed, it may increase indefinitely by solution of fresh tissue and by the coalescence with it of smaller cavities; or it may cease to extend. In the latter case it may continue to secrete much purulent fluid for a long time, or it may become quiescent and undergo more or less contraction. The ordinary method of extension and enlargement of cavities by softening down of fresh pulmonary tissue into the original cavity, and by the merging of adjacent smaller excavations into one larger one, requires no further comment. It is obvious that all trabecu- lated cavities have been formed in this way, the trabeculae being the remnants of the septa which formerly partitioned the smaller cavities from one another. TUBERCULOUS EXCAVATION OF THE LUNG 527 There is, however, another theory, advanced by the late Professor Rindfleisch,- to explain the enlargement of bronchial and other cavities, which we must notice here, although there are many and important objections to its acceptance. Accord- ing to this theory, the obstruction of numerous small bronchi by the pulmonary consolidations necessitates during inspira- tion an increase of the air-pressure upon the interior of the bronchi in front of the obstruction, and also upon the interior of cavities, thus leading to their dilatation. Professor Rindfleisch conceived that the soft walls of recent cavities readily yield before this increased air-pressure, and thus enlarge towards the pleural surface, condensing the tissue around them. When we consider, however, that the influx of air into the lungs does not take place in any constant quantity, but awaits the aspiration dependent upon the expansion of the thoracic cavity, we see that this theory cannot apply to the enlargement of phthisical cavities nor even to ordinary cases of bronchiectasis. For in both these morbid states, but especially in phthisis, the lung is more or less consolidated or thickened, and having its pleural surfaces adherent, at least over those portions which are excavated, resists expansion more than in health. In vigorous people with healthy lungs the utmost available inspiratory force only exceeds by from two to three inches of mercury that necessary to expand the lung. In phthisis this reserve force is much diminished, and the vital capacity of the chest much lessened, so that we have less air entering the lungs and at less pressure. Hence it would seem that the inspiratory force, effective in producing certain forms of emphysema, can have but little appreciable action in dilating pulmonary cavities. We have not observed in phthisis, except in advanced cases with marked dyspnoea, any excessive effort with inspiration ; the muscles of inspira- tion, indeed, lessen in vigour with the general wasting. During cough, however, the intercostal spaces over a super- ficial cavity become noticeably bulged, and with the stetho- scope we may hear the air forcibly rushing into the cavity, so that doubtless the repeated cough has a tendency to dilate cavities somewhat, though even this is only an auxiliary force in effecting their enlargement. The temperature chart of a case of phthisis with recently formed and extended cavities depicts, as we have seen, a 528 DISEASES OF THE LUNGS AND PLEURA markedly hectic type of fever (Fig. 46, p. 478). The tempera- ture mounts up to a considerable height, from 101° to 103° in the course of some hours during the day, the maxi- mum being usually attained at some period between 2 p.m. and 10 p.m. From this point a fall ensues to below the normal, the subnormal curve culminating usually towards the early hours of the morning. The range of temperature is sufificiently indicated for clinical purposes by observations taken two or three times a day, provided we are careful to note the period of the day at which the fever is highest, and to record a daily observation at that time. We must be further careful to remember that a normal morning tempera- ture means, in these febrile cases, a subnormal early morn- ing temperature, as this has an important bearing upon treatment. In a certain number of cases cavities, and especially those having their origin in caseous abscesses, cicatrise and become obliterated. Laennec described this as the natural mode of healing, and seemed to regard phthisis as incurable in the first stasre of the disease. Taking the term cavity in its strict sense as meaning any loss of pulmonary substance, however small, cicatrisation is probably common; nay, we find post-mortem evidence of the cicatrisation of cavities large enough to come within clinical recognition, but they may be surrounded by other cavities and disease centres, which continue to enlarge and render cicatrisation of one amongst them of little avail. We have, however, alluded to a case in which a caseous cavity formed and cicatrised under observation, the patient remain- ing well for more than fifteen years afterwards. 2. Quiescent Cavity. — It more commonly happens that a cavity, having attained certain dimensions, becomes quiescent, all progress of the pulmonary disease being arrested; its walls then condense and toughen by the development of fibrous tissue, so as to shut it off from the surrounding lung. The contents of the cavity become less and less abundant, the sounds yielded to auscultation more and more dry, until no moist sounds at all are heard even on deep breathing, but only a few clicks and a characteristic succussion of air when the patient coughs. This kind of cavity at once begins to shrink somewhat in size, its walls becoming denser and thicker by a cicatricial process (Plate XXX.); the corresponding chest PLATE XXX ARRESTED TUBERCULOSIS WITH TOTAL EXCAVATION OF LUNG The drawing shows a vertical section through the left lung, the parts being then opened out. The whole of this lung is now represented by the cavity seen, which measured three inches in length, two inches in breadth. Into this open the two main divisions of the left bronchus, the positions of which are indi- cated b}' the glass rods. The cavity had greatly shrunken and become " quiescent." The pleura over, it is dense and much thickened. From a boy aged eighteen, who was admitted into the Brornp- ton Hospital suffering from acute bronchitis, and who died of the same four days later. The left side of his chest was greatly fallen in, and the heart was much drawn over to the left. The right lung was enlarged, and showed evidence of former tuber- culous disease. At the autopsy evidence of acute bronchitis was found, but none of active tuberculosis. (From the Brompton Hospital Museum. Actual size.) PLATE XXX Arrested Tuberculosis with Total Excavation of Lung. To face p. 52S. TUBERCULOUS EXCAVATION OF THE LUNG 529 wall flattens, and the heart and opposite lung encroach towards the affected side, to make up for the loss of space. If the surrounding lung be tolerably sound it will become expanded around the cavity, so that the latter, if only of moderate size and not very superficial, may become altogether obscured. It is very common post-mortem to see a longitudinal fold or wrinkle upon the surface of the lung bounded by expanded vesicular tissue, and on making a vertical section through such a wrinkle, we cut across a more or less deeply seated cavity which has evidently undergone contraction or possibly cicatris- ation. Even superficial cavities may become in this way lost to clinical observation. There are in the Brompton Hospital Museum some examples of such a condition, which is well but rudely depicted in Laennec's work.^ That even large cavities may cicatrise and become per- manently obliterated is a fact ascertained, as we have seen both by clinical and post-mortem observation, although its occurrence is no doubt rare. It is, however, quite common for the physical signs of a cavity which has undergone a certain degree of contraction to disappear, and be replaced by simply suppressed or very feeble (conducted) breath-sound. This does not necessarily arise from the cavity becoming obHterated, but from the bronchus with which it communi- cates becoming narrowed or occluded by the dense cicatricial growth in the cavity wall, in which the sheath of the bronchus partakes. Such a cavity, although it may, perchance, com- municate with a few collateral minor bronchial tubes, is practi- cally or completely closed, and this is the next best thing to its being obliterated. It diminishes in size, and ceases to take any further part in the production of pulmonary symptoms. In this period of cicatrisation tubercle bacilli are present in greatly diminished numbers, or may be altogether absent, un- less there be other excavations or tuberculous lesions present which are less quiescent. We have observed clinically the complete loss of all signs over a cavity of considerable size, and their return after a few days, showing that a temporary closure of the bronchus had taken place, probably from a plug of mucus. The periodically abundant and foetid expectoration found in some cases in which there can be discovered no signs of excavation is due to the cavity only communicating obliquely with a bronchus, 34 530 DISEASES OF THE LUNGS AND PLEURA SO that the secretion becomes pent up for some time before it can find an exit. 3. Secreting Cavity. — This is usually a cavity of tolerably old date which has ceased to extend, and is unaccompanied by active pulmonary disease. It is dense-walled, and is lined by a smooth opaque pyogenic (false) membrane, which can be readily scraped off, exposing a hig'hly vascular, dusky red, sub- jacent surface. The trabeculae, which are numerous, present the same vascular surfaces and false membranes. Such cavities may go on indefinitely secreting a diffluent creamy pus; they yield gurgling sounds, with marked amphoric breathing, and dull tubular percussion note. There is either no fever, or it is trivial, consisting of a slight rise of temperature only at night. The tongue is clean, with a tendency to redness and loss of epithelium. Although the appetite usually continues good, the patient slowly loses ground, and acquires the sharp hungry features peculiar to chronic phthisis, with clubbing of the fingers and toes, and a tendency to lardaceous degenera- tion of organs. Diarrhoea is apt to supervene, and trouble- some sickness is sometimes occasioned by the cough. These cases are serious, but are less common now than formerly. In favourable cases the secretion dries up and the cavity becomes quiescent. Unfavourable cases gradually fail from lardaceous disease of other organs or from recurrent diarrhoea. Also there is, in these cases especially, the danger of some of the abundant secretion becoming inhaled during cough into portions of the same or of the opposite lung as yet unaffected, and thus setting up fresh centres of disease. Haemoptysis is not common from either the quiescent or the secreting cavity, but it sometimes occurs in a dangerous and unexpected manner from the rupture of an ectasia or aneurismal dilatation projecting from the unsupported cavity side of a large pulmonary vessel. 4. Ulcerous Cavity. — This last kind or condition of cavity, which is also more rarely met with in these days of aseptic treatment, originates in the usual way, and may have been quiescent or merely secreting" for some time, when, from ex- posure to septic influences, or from other causes, it assumes a state of active ulcerative extension. We have known such cases to be endemic in a ward which was overcrowded, and to have ceased on a bed being removed. It cannot, indeed, be TUBERCULOUS EXCAVATION OF THE LUNG 53 1 too carefully remembered in the treatment of tuberculous affections of the lungs that all such patients have internal wounds or sores, which, unlike most other internal affections, are accessible to the contamination of foul air, and that septic processes may be readily set up in them, which are apt to be recognised only as "intercurrent pneumonias^' or other local inflammations. Ulcerous cavities are angry-looking, deep dusky red on their inner surfaces, often studded with hgemorrhagic points or ulcerative erosions; they are highly trabeculated and very irregular in shape, but sharply demarcated from the lung tissue by a thin vascular wall. They contain a copious blood- stained purulent secretion, which, when expectorated, is mixed with the ropy mucus from the intensely vascular bronchi which communicate with them. The lung tissue surrounding the cavity is eng-orged and oedematous, and at distant parts of the lungs pneumonic centres may be found, which evidently owe their origin to the inhalation of the acrid secretions from the cavity. In such cases sharp fever is present, with quick pulse, furred tongue, and a tendency to typhoid symptoms. The expectora- tion is usually mixed with blood, or dark altered clots may be removed from the cavity. Sometimes copious haemorrhage takes place from the erosion of a large vessel. The prognosis in cases of ulcerous cavity is always grave and hazardous, but if it be borne in mind that the aggrava- tion of symptoms is to be explained rather by insanitary con- ditions surrounding the patient than by an accession of genuine tuberculous activity — in other words, that the condi- tion is septic rather than tuberculous — an appropriate measure of treatment corresponding- to this view will often consider- ably amend the prospects of the patient. The treatment of these conditions will be dealt with in a later chapter (p. 688). REFERENCES. ' " Clinical Lectures on Excavation of the Lung in Phthisis," by R. Douglas Powell, M.D., Lecture IL, The Lancet'; 1877, vol. i., p. 119. ^ " Chronic Tuberculosis — Phthisis," by Professor Rindfleisch. Ziemssen's Cyclofadia of the Practice of Medicine, vol. v., p. 679. London, 1875.' ^ Traite de V Auscultation mediate et des Maladies des Poumons et du Coeur, par R. T. H. Laennec, troisieme edition, tome iii., planche ii., Fig. 4. Paris, 1831. CHAPTER XXXVII THE COMPLICATIONS OF PULMONARY TUBERCULOSIS Laryngeal, Aural, and Intestinal Tuberculosis. The complications met with in the course of tuberculosis of the lungs are many and varied. The relative frequency of the most important, as deduced from the autopsies of 263 consecutive cases (188 males, 75 females) of chronic pul- monary tuberculosis, in which the post-mortem examinations were made by one of us, is shown in the following table : Table showing Relative Frequency of the More Important Complica- tions OF Chronic Pulmonary Tuberculosis, based upon 263 Con- secutive Autopsies (188 Males, 75 Females). Males. Females. Total. Per Cent. Per Cent Per Cent. Larynx— tuberculous ulceration of « 547 469 52*6 Trachea- 27-1 200 25-1 Main bronchi — ,, ,, 12-2 io"6 II-4 Pneumothorax 7 '4 4-0 6-4 Pleurisy— (i) acute sero-fibrinous 6-3 4-5 (2) suppurative (empyema) 2'I 2-6 2-2 Pulmonary aneurism 10 '6 5-3 g-i Fatal haemoptysis 9-0 4-0 7-6 Pericarditis — tuberculous 21 I '5 Veins — thrombosis of 10 6-6 2-6 Peritonitis — tuberculous 37 2-6 34 Intestines — tuberculous ulceration of 61 -3 6i-3 61 -3 Fistula iw a«o 1-6 II Lardaceous disease of viscera 9 "5 i3'3 IO-6 Kidneys — (i) miliary tuberculosis of ii-i 9'3 io'6 (2) ulcerative tuberculosis of ... 2-6 I '3 2-3 Suprarenals — tuberculous disease of 2-1 2-6 2-3 Bladder — tuberculous cystitis i-o — 07 Male generative organs — tuberculous disease of 47 — affecting (i) body of testicle I"0 — (2) epididymus 3-2 — — " (3) vesiculae seminales ... 2-6 — • — (4) prostate 3-2 — • — ' Female generative organs — tuberculous disease of io'7 — affecting (i) ovaries — 27 — (2) Fallopian tubes — loy — (3) endometrium — 6-7 — Meningitis — tuberculous 2-6 2-6 2-6 532 THE COMPLICATIONS OF PULMONARY TUBERCULOSIS 533 Let us now consider some of the above complications in more detail. Laryngeal Tuberculosis. It sometimes happens in the adult that pulmonary tubercu- losis is ushered in with laryngeal symptoms, and the variety of the disease thus arising ranks amongst the most fatal and distressing of all. Strictly speaking, the term " laryngeal phthisis " should be applied only to those very rare cases in which the tuberculous lesion of the larynx is primary; but in practice it is more loosely employed to include all those cases in which laryngeal symptoms constitute an early and striking feature. This latter employment of the term is not only more convenient, but is also more in accordance with the general pathology of the disease; for althoug'h in many instances it is the affection of the larynx which first attracts attention, yet even in these cases the lungs speedily show obvious involvement, so that to attempt more rigidly to restrict the term would imply, what is not the fact, that there is a phthisis which begins and ends with laryngeal disease. In the analysis of our consecutive autopsies upon cases of chronic pulmonary tuberculosis,^" in 247 of which the larynx was examined, we found naked-eye evidence of involvement of the larynx in 130, or 52'6 per cent.; in 89 cases, or 360 per cent., the ulceration was " extensive." Probably the latter figures represent more nearly the percentage of cases in which symptoms referable to the larynx are complained of during life. The sexes would appear to be affected equally, but it is remarkable how exceedingly uncommon the complication is in children. The following table, based upon our 247 autopsies, shows certain further points of interest in regard to the condition : Table showing the Lesions met with in the Larynx after Death in 247 Cases of Chronic Pulmonary Tuberculosis. Larnyx — Tuberculous ulceration, total cases Slight ulceration Extensive ulceration ,, laying bare left arytenoid ... ,, ,, ,, right arytenoid ,, ,, ,, the thyroid ,, destroying upper portion of epiglottis OEdema of glottis Number of Cases Affected. Percentag 130 4i\ 89/ 526 i6-6\ 360/ 30 121 20 81 I 0-4 18 70 3 12 534 DISEASES OF THE LUNGS AND PLEURA Tuberculous disease of the larynx most commonly arises as a complication in advanced pulmonary phthisis. It is, how- ever, by no means restricted to such cases, and it has been shown at the King Edward VII. Sanatorium, Midhurst, by Sir StClair Thomson,- that even in the early cases included in Group I. 137 per cent, showed evidence of laryngeal involve- ment, the percentag-e rising to 27' i among the patients in Group II., and to 408 in Group III. The way in which the larynx becomes affected has been much debated, but there can be little doubt that it is the result of direct contact of the sputum with the mucous membrane, the expectoration tending to cling to any crannies and crevices that it meets with in its passage outwards. The bacilli possibly sometimes enter the laryngeal tissue through super- ficial erosions, or pass through the unbroken mucous mem- brane, as in the case of the intestinal wall. But Dr. Jobson Horne^ has demonstrated that they may enter through another portal, the ducts of the muciparous glands of the submucosa; and very probably this is the most common mode of entrance, since, as he points out, the parts of the larynx richest in glandular structures, such as the arytenoid eminences, and especially the interarytenoid region, are also those most vulnerable to tuberculous infection. The bacilli having gained access to the larynx, the progress of the disease is similar to that in other organs. Tubercles form in the submucosa, producing tumefaction and oedema. Later, caseation and softening occur, with the production of minute ulcers, which, by their coalescence, form larger ones, the floors and walls of which are the seat of fresh tuberculous deposits. The morbid appearances seen with the laryngoscope during life vary according to the period of the disease. In the early stage a marked and general anaemia of the laryngeal mucous membrane is often present, which, if it does not form part of a general anaemia, should be regarded as very suggestive of tubercle. In other cases the larynx is hyperaemic. Later, as the tubercles enlarge, infiltration and oedema become visible to the naked eye. The positions in which these appearances are first seen differ. Our own experience would lead us to place the first signs in the interarytenoid space or in the aryepiglottic folds, and this is in accordance with the experi- THE COMPLICATIONS OF PULMONARY TUBERCULOSIS 535 ence of Dr. Home/ who, in a careful analysis of 359 consecu- tive cases of pulmonary tuberculosis, found that the parts were affected in the following order : Interarytenoid space ... ... ... in 176 cases. Arj'tenoid eminences (bilaterally) ... ... ,, 139 ,, Ventricular bands (bilaterally) ... ... ,, 57 ,, Epiglottis (free edge) ... ... ... ,, 30 ,, The early changes which thus present themselves in the interarytenoid space, and which are so important from a diagnostic point of view, are perhaps hardly as yet sufficiently appreciated. They may consist merely of a slightly irregular swelling of the mucous membrane, resulting from the deposi- tion of tubercle beneath; but in the majority of cases the swelling is more marked, and in a few, definite tuberculous tumours will be found, pale and with irreg'ular edges, which constitute perhaps the only evidence of laryngeal tuberculosis. As the oedema increases, characteristic changes may be produced, the swelling over the arytenoids and in the ary- epiglottic folds presenting the well-known " pear-shaped " ap- pearance, while the epiglottis may become pale and swollen, or, as it has been termed, " turban-shaped." Ulceration later supervenes, the favourite seat being over the glottic aspect of the arytenoid cartilages, where a ragged ulcerous hole is often found, at the bottom of which after death the denuded and roughened cartilage may sometimes be felt. The interarytenoid space, the ventricular bands, the vocal cords and epiglottis are also frequently the seat of ulceration, and we have seen instances in which ulceration has extended deeply from the anterior junction of the vocal cords to produce perichondritis of the thyroid cartilage with involve- ment of the subcutaneous cellular tissue. Ulceration in the more deeply seated parts may or may not be observed by the laryngoscope, but intense injection of the mucous membrane is often visible. In advanced cases the orifice of the glottis may be seen distorted by ulceration and thickening, the cords being involved in the havoc so as to render their approxima- tion impossible, and the arytenoid articulations on one or both sides participating in the disease. In this stage, purulent secretion collects in the ventricles and about the cords. With severe ulceration of the larynx, it is common to find a similar condition of the trachea, and less often of the 536 DISEASES OF THE LUNGS AND PLEUR/E bronchi. In the trachea the ulceration tends to spread from minute points, and gives a pecuHar moth-fretted appearance to the surfaces. In other cases the ulcers are larger, and frequently surrounded by a brilliant red zone of injection; eventually the tracheal cartilages are often laid bare. Symptoms. — The sufferings of the victim of larnygeal phthisis are great and varied. One of the first symptoms that attracts attention is an alteration in the tone and quality of the voice. It becomes husky and usually deepened. VocaHsa- tion is uncertain, the voice sometimes falling into a husky whisper, to reappear with deep, reverberating tone when an increased effort is made in speaking. In some cases, however, even at the earliest stage, the voice is suppressed from an in- ability to approximate the cords. This may be due to general loss of muscular and nervous tone, or may result, as Dr. Home has shown, from an inflammation of the laryngeal muscles, a myositis, which impedes their functional activity. In less early stages, again, it may possibly be mechanical, the result of the presence of a tuberculoma in the interarytenoid space, such as we have described, or in rare cases arising from com- pression of one or other recurrent laryngeal nerve, the right, as a rule, from apical pleurisy, the left by enlarged and probably tuberculous glands. If the laryngeal disease be only slight, and the patient's lung- trouble be quiescent or show signs of healing, there may be no other symptoms, and, with suitable treatment, including absolute rest to the voice, the laryngeal as well as the pulmonary disease may become arrested. Sir StClair Thomson^ estimated at the King Edward VII. Sanatorium that arrest of the laryngeal disease was obtained in one-fifth (20'7 per cent.) of the cases. But, encouraging though this is there can be no question that the prognosis in phthisis, at whatever stage of the disease, is rendered much more grave by the presence of the complication, the mortality among such patients being considerably greater than in the case of those whose larynx remains unaffected. As the disease in chest and larynx progresses, the patient's condition becomes a pitiable one. He loses flesh, suffers from sweats and evening fever, and experiences oppres- sion of breathing, which may amount to serious dyspnoea, both respiration and pulse being quickened, A troublesome teas- THE COMPLICATIONS OF PULMONARY TUBERCULOSIS 537 ing cough of a harsh, dry character is complained of, which is attended with pain and a sense of rawness in the throat, and with scanty and difficuU expectoration. Pain on deglutition is a frequent symptom, and it is still more characteristic when described as shooting upwards to the ears, causing in them " pricking sensations." On deep pressure in the upper tracheal region some tenderness is elicited. As the disease pro- ceeds and the ulcerative destruction of the larynx extends, the aphonia becomes complete, and the cough most distressing and paroxysmal. At this period the lung disease has usually proceeded to excavation, and the expectoration is more abun- dant; effectual cough is, however, almost impossible, in conse- quence of the patient being no longer able to bring about its essential condition, closure of the glottis. Deglutition, is now difficult and painful, from the pharyngeal muscles com- pressing the tender and swollen parts, and from the irritable, stiffened, and often ulcerated epiglottis failing effectually to guard the laryngeal aperture. The fauces and tonsils may be normal in appearance, but they are often pale, and drier than natural, with their small subcapillary veins too well marked. The back of the pharynx is frequently granular, even abraded, with streaks of viscid mucus adherent to the surface. The mucous glands are too prominent. A distinct ulcer, having the characteristic raised irregular margin and granular ash-coloured surface of the tuberculous ulcer, may sometimes be seen at the back of the pharynx or behind one of the tonsils. In rare cases an ulcer appears upon the tongue, or on the inside of the cheek, especially about the orifice of the parotid duct. Such cases may suggest syphilis, but are by no means necessarily of this nature, although careful inquiry on this point should always be made. Diagnosis. — In well-marked cases of tuberculous laryngitis the diagnosis is not difficult. The diseases which most simu- late it are chronic alcoholic or irritative catarrh, especially that variety produced by excessive cigarette-smoking, syphilitic disease, and hysterical aphonia. More rarely it has been mis- taken for malignant growth. With regard to the first-named — the chronic catarrh arising from drink, dust, or smoking — the absence of fever, the presence of a definite exciting cause, and the laryngoscopic 538 DISEASES OF THE LUNGS AND PLEURA signs of general catarrh without local thickening or ulcera- tion, are usually sufficient to distinguish it from laryngeal tuberculosis. Alcoholic and smoker's catarrh are, moreover, always associated with a similar affection of the pharynx. In the absence, however, of a definite exciting cause, a catarrh v.'hich does not speedily clear up under appropriate treatment should always be viewed with suspicion. In any doubtful case the sputum must be examined; tubercle bacilli are invariably present in the tenacious, glaiiy mucus expelled in cases of tuberculous laryngitis which have proceeded to ulceration. In syphilis, during the secondary stage, the larynx may present a condition of catarrh, but the general symptoms of the disease should in this case guide the diagnosis aright. In the tertiary stage gummatous swellings, either localised or diffused, may make their appearance. They are usually deep red in colour, and soon proceed to ulceration. Such ulcers are deeper and more sharply cut than those occurring in phthisis ; they are also much less painful. Gummata may occur in any portion of the larynx, whether in the region of the arytenoids, the true or false vocal cords, or elsewhere; but a favourite seat is the epiglottis, leading to the extensive destruction which is so suggestive of syphilis, although it may occur as the result of tubercle. Much contortion or deformity from cicatricial change should also lead to a suspicion of syphilitic disease. A rapid improvement under a course of iodide of potassium or salvarsan will assist the diagnosis. Passing to functional aphonia, it not infrequently happens in early phthisis, as we have already indicated, that the voice from time to time is weak and whispering from inefficient adduction of the cords, and the patient shows all the symptoms of a functional loss of voice. The larynx may be anjemic, but often presents no other sign of tuberculosis, although it is probable that in many cases tubercles have already formed. Whenever a patient, therefore, presents symptoms of func- tional aphonia, the possibility of tuberculosis should be borne in mind, especially if the aspect or family history renders such a disease likely. The lungs must be examined with great care, and the weight and temperature chart closely observed. It has sometimes happened that the tuberculous tumours to which we have referred, and which are not by any means limited to the interarytenoid region, have been mistaken for THE COMPLICATIONS OF PULMONARY TUBERCULOSIS 539 malignant growths, and operated upon accordingly. In such cases, if, after careful examination of the lungs and of the sputum, as well as of the appearances of the larynx and the situation of the tumour, doubt still remains, a portion of the mass must be removed for microscopical examination. Another condition which may be sometimes mistaken for laryngeal tubercle is a warty excrescence from one or other cord, a condition causing partial aphonia and one not un- commonly associated with cough and pulmonary catarrh. Laryngeal examination and removal of the growth will settle the diagnosis and cure the symptoms. The treatment of laryngeal tuberculosis will be considered in a later chapter (p. 697). Tuberculous Disease of the Middle Ear. This manifestation of tuberculosis, though not uncommon in infants under two years of age, is rare as a complication of phthisis in the adult, though we have met more than one instance of it. When occurring in connection with phthisis it manifests itself by deafness in the affected ear, accom- panied by discharge, but ivithont pain. It is thus distin- guished from the more common septic variety of acute otitis media, in which earache is at the commencement a prominent feature. On examination the tympanic membrane is seen to be reddened, swollen and thickened, an index of a similar condition of the mucosa lining the tympanic cavity, and a perforation is often visible. The discharge is apt to be watery and curdy, and tubercle bacilli may be found in it. The prognosis as regards hearing in the affected ear is poor, but if the pulmonary tuberculosis becomes quiescent and the patient's general health remains satisfactory, the lesion in the ear will probably undergo arrest and the discharge cease. Treatment consists in the employment of sanatorium and other methods calculated to benefit the lung disease and to raise the vitality of the patient. The ear should be care- fully cleansed by the daily use of peroxide of hydrogen, Except when especially exposed to dust, as in motoring, the meatus should not be closed with cotton-wool, the fresh air having a beneficial action on the lesion in the ear, just as it has upon the lungs.^ 540 DISEASES OF THE LUNGS AND PLEUILE ' Intestinal Tuberculosis. Ulceration of the bowels is sometimes met with as a primary disease in young children. It is a very common complication of phthisis — indeed, it may be said to be one of the attendant lesions of the disease. Of the 263 consecutive cases alluded to in our table (p. 532) it was present in 61-3 per cent., both sexes being affected equally. Excluding the appendix, intestinal tuberculosis is scarcely ever met with in adults except in association with tuberculous disease of the lungs, and is commonly due to the swallowing of the infected sputum. It most usually complicates the later stages of the disease, but it may, like laryngitis, occur at an early period, at a time when pulmonary physical signs — always somewhat masked during- diarrhoea — are difficult to detect. Anything that tends to derange the digestion and the bowels favours the occurrence of the complication. Tubercle bacilli are present in the intestinal lesions, and may be discovered in the evacuations. The disease commences with inflammatory swelling of certain of the follicles of the small or large intestine. Casea- tion follows, and the softened products discharge into the intestine, leaving an ulcerous recess behind. Both in sections of the ulcerated tissues and in the discharges from their surfaces tubercle bacilli are found. On the peritoneal surface of the bowel, over the site of an ulcer thus established, flakes of lymph are often to be seen, and inflammatory adhesions may be formed with an adjacent coil of intestine. The outline of the ulcer can be distinguished shining through the peritoneal surface, and over its base granulations of tubercle are to be observed. These granulations are connected with the lymphatic vessels, some of which form white lines or streaks over and about the site of the ulcer. The ulcer is at first circular in shape, and soon comes to have the characteristic thickened edge and irregular warty base which distinguish it from the typhoid ulcer. It tends to enlarge in a transverse direction, beyond the limits of the giand follicle, in which it originated, the ex- tension following the direction of the vessels, and being deter- mined by the formation of tubercles in their sheaths. Whether the ulcers be single or in groups depends upon the THE COMPLICATIONS OF PULMONARY TUBERCULOSIS 54 1 glands, whether soHtary or agminate, which are attacked. Peyer's patches are favourite seats of ulceration. In them irregular serpentine ulceration arises by extension and coales- cence from several centres, often leaving small tracts or islets of mucous membrane intact. All the gland follicles of a patch are by no means necessarily affected; the ulceration may only involve a certain number of them, extending transversely to the mucous membrane beyond. In the caecum, too, the ulceration is often very extensive, the whole of the mucous membrane being eroded for several inches, with the exception of small islets or streaks here and there, which have escaped and stand out prominently, indicating the original extension of the ulcerative process from many centres. More or less general hyperasmia of the mucous membrane, very variable in amount at different tirhes and in different places, attends the ulcerative process. Considerable general thickening of the large intestine is sometimes also present. As already mentioned, local peritonitis commonly attends the intestinal lesion, and adhesions are frequently formed. Perforation of the bowel occasionally occurs, sometimes lead- ing to the escape of fascal matter and to general peritonitis, sometimes to the establishment of a fistulous communication between adherent portions of intestine, and, again, in other cases producing collections of pus localised by surrounding adhesions. These processes are strictly analogous with those which occur in connection with the pleural surface of the lungs in phthisis. Drs. W. S. Fenwick and DodwelV from inspec- tion of the records of the Brompton Hospital, found 25 instances out of 2,000 cases of phthisis (i"2 per cent.) in which perforation occurred from this cause. Our own post-mortem observations^* gave a very similar result — viz., 3 cases out of 263 autopsies, or a percentage of i"i, the perforation in each of these instances occurring in the ileum. We may add that we have three times known general septic peritonitis to result from deep tuberculous ulceration of the bowel, but without perforation. The lower two or three feet of the ileum and the caecum are almost invariably the portions of bowel involved in tuber- culous disease, but the ulceration may extend both above and beyond these points to the duodenum and the rectum. The appendix also is frequently affected, and tuberculous appen- 542 DISEASES OF THE LUNGS AND PLEURA dicitis is not of uncommon occurrence as a primary malady. The following table shows the relative frequency with which the different portions of the bowel were attacked in our series of autopsies, in 6i'3 per cent, of which tuberculous ulceration of the bowel was present : ^^ Table showing the Relative Frequency with which Tuberculous Ulceration was found in Different Portions of the Bowel in 263 Cases of Chronic Pulmonary Tuberculosis. Duodenum Jejunum Ileum Cfficum . . . Appendix Colon Rectum ... Fistula in ano Number of Cases. 10 53 • 125 . 114 . 98 • 83 35 3 Percentage. 3-8 20-3 47-8 43-6 37-5 31-8 13-4 It will be seen that the ileum, caecum, and appendix are the favourite seats of ulceration. We may add that in 109 cases, or 41 '7 per cent., ulcers were found in both the small and large intestine; in 19, or 7"2 per cent., they were restricted to the small intestine; in 24, or 9"2 per cent., to the large; and in 8, or 3 per cent., they were found only in the appendix. Symptoms. — The usual symptoms of ulceration of the intes- tines are diarrhoea and pain in the abdomen. There is nothing at first which can be noted as peculiar in the character of the diarrhoea; the stools are pale and loose, resembling those of ordinary intestinal catarrh, and occasioned doubtless by the presence of such catarrh. There may be some nausea; the tongue is furred, with red tip and edges and prominent papillae, and the patient complains of thirst. The pain is usually referred to the umbilical region ; it is of a colicky nature, and no marked tenderness is present over any special area of the abdomen. There is notable irritability of the whole mucous tract, and the taking of food, and more often warm drinks, into the stomach causes the bowels soon to act. The loose- ness is, however, at this stag"e tolerably amenable to treatment, and for a time the motions become natural, or the patient is even constipated. Soon, however, a relapse takes place, and the diarrhoea is more obstinate than before. Now some decided tenderness may be felt on deep palpation, most likely in the right iliac region; the motions become more scanty, THE COMPLICATIONS OF PULMONARY TUBERCULOSIS 543 some mucus is passed with them, a speck or two of blood may be observed, or a teaspoonful or more may escape. Anything approaching to copious haemorrhage is, however, rare. The tongue becomes red and patchy from loss of epithelium; it may present short transverse fissures on each side of the median line. The further symptoms vary with the seat of the principal ulceration. If this be limited to the ileum, the diarrhoea may for a long time be held in check by treatment; but the bowels are irritable, the abdomen somewhat prominent in the um- bilical region, and tender. If the ulceration, on the other hand, has its principal seat in the caecum, the tenderness over that region is more marked, the diarrhoea is difficult to control, blood and mucus are frequently present in the stools, and the patient acquires a pinched look and rapidly loses flesh. Ulcer- ation extending farther down the colon to the rectum is signified by more distinctly dysenteric symptoms, pain and tenderness over the arch of the colon, more frequent mucous stools with tenesmus; the gastric symptoms, on the other hand, are less marked, and considerable appetite, with a fairly clean tongue, is often retained. It is easy to note down these symptoms, as they occur in case after case of this dreaded complication; but it is much more difficult to fix upon any symptom, if any, indeed, exist, that is positively characteristic of ulceration. The plain rule is, in patients with tuberculosis, always to treat intercurrent diarrhoea as though it were due to commencing ulceration of the intestines. But in some cases the diarrhoea precedes, or at the time of observation altogether masks, the lung symptoms ; and it is remarkable how completely even decided pulmonary disease may be thus obscured. The cough and expectoration may cease or become trivial, and the dryness of the pulmonary tissue gives an exaggerated " vesicularity " to the respiratory murmur that masks existing defect. The recognition of this fact is of much importance in diagnosis, the alternation in prominence between the chest and abdominal symptoms being characteristic of intestinal tubercle. It is unnecessary to dwell upon the later stages of this disease : rapid wasting and exhaustion from the constant un- controllable diarrhoea, a depression of the previously some- 544 DISEASES OF THE LUNGS AND PLEURA what raised temperature, aphthous mouth, and lividity of extremities, are the closing symptoms. It is a fact worthy of note that even extensive ulceration of the intestines may exist without any diarrhoea. Dr. Walshe^ observed : " Not only may pretty extensive ulceration exist in the ileum without pain, either spontaneous or elicited by pressure, but with a confined state of bowels. Again, I have known, in a case running an acute course, marked abdominal pain and tenderness, conjoined with obstinate constipation, where, after death, the bowels — in spite, too, of the frequent use of purgatives — contained abundant solid faeces, and the ileum was extensively tuberculised and ulcerated." In the Pathological Transactions for 1868, a case of chronic phthisis with extensive and deep ulceration of the ileum is recorded by one of us,^ in which constipation was a marked symptom throughout the patient's illness; and we have met with other instances. There is no doubt that the diarrhoea is, to a large extent, dependent upon irritative catarrhal in- flammation of the mucous membrane in the neighbourhood of the ulcers, and this is probably the reason that it is a more prevalent symptom in the late summer and autumn months than in the winter. In some cases, however, the ulcerations are so deep as extensively to destroy the muscular coat, and thus materially to interfere with the peristaltic movements of the intestines. In others of a more acute kind the peritoneum may be much involved, and the muscular coat paralysed. An analogous state of things in both these respects sometimes obtains in typhoid fever, in which it is not at all uncommon for constipation to be present throughout, and we have known such cases to terminate fatally by perforation. These latter considerations bring home to us the great im- portance of a very careful treatment of constipation in phthisis. We have seen perforation occur from the too hasty adminis- tration of a couple of colocynth and mercurial pills for con- stipation, which was present together with ulceration. The stronger purgatives should, therefore, only be administered with great caution, and the symptom should, in fact, be always combated with the utmost gentleness. For a full considera- tion of the treatment of this important complication we must refer the reader to a later chapter (p. 694). THE COMPLICATIONS OF PULMONARY TUBERCULOSIS 545 REFERENCES. • ' (a) Re-port on the Work of the Pathological Department of the Bromfton Hospital, April, 1900, to April, 1903, by P. Horton-Smith (Hartley), M.D., p. 10. McCorquodale and Co., Londoiij 1903. [b) Loc. cit., p. 12. (^) Loc. cit., p. 14. ^ (a) "Three Years' Sanatorium Experience of Laryngeal Tubercu- losis," by Sir StClair Thomson, M.D., F.R.C.P., F.R.C.S., British Medical Journal, 1914, vol. i., pp. 801, 818, and 828. See also — (3) " The Prognostic Importance of Tuberculosis of the Larynx," by Sir StClair Thomson, The Lancet, 1919, vol. ii., p. 689. ^ Contribution to " A Discussion on the Treatment of Laryngeal Tuber- culosis," by W. Jobson Home, M.D., British Medical Journal, 1905, vol. ii., p. 1188. " " The Channels of Infection in Tuberculosis, and the Part played by the Lymphatic Glands in arresting, modifying, or propagating the Infec- tion, and in preventing Recurrence of the Disease, considered v/ith Refer- ence to the Throat, Nose, and Ear," by Jobson Home, M.D., The Journal of Laryngology, Rhinology, and Otology. London, 1907, vol. xxii., p. 281. * [a) For a discussion on the subject of " Tuberculosis of the Auditory Apparatus," see Proceedings of the Royal Society of Medicine, Otological Section^ 191S) vol. viii., p. 15. See also — (b) " The Clinical Diagnosis and Surgical Treatment of Tuberculosis of the Temporal Bone," by W. Jobson Home, M.D., M.R.C.P., British Medical Journal, 1903, vol. ii., p. 77. " " Perforation of the Intestine in Phthisis," by W. Saltau Fenwick, M.D., and P. R. Dodwell, M.B., The Lancet, 1892, vol. ii., p. 133. ' A Practical Treatise on the Diseases of the Lungs, by Walter Hayle Walshe, M.D., 4th edition, p. 434. London, 1871. ' " Lung and Portion of Intestines from a Case of Chronic Phthisis," by R. Douglas Powell, M.D., Transactions of the Pathological Society of London, 1868, vol. xix., p. 81. 35 CHAPTER XXXVIII ON HEMOPTYSIS HEMOPTYSIS or blood-spitting maybe defined as the expector- ation of blood from or through the lungs or bronchial tubes, and must be distinguished from false or spurious haemoptysis, in which the blood is derived from the naso-pharyngeal or buccal mucous membrane. The causes of haemoptysis may be thus enumerated : 1. HcEfnorrhage from the Pulmonary Artery or its Capil- laries — (a) Rupture or wound of the lung from external violence. (b) Active hypersemia of the lungs, whether inflammatory or induced by violent effort or excitement. Such active hyper- asmia may be primary as regards the lungs, or may supervene or be attendant upon disease, such as tubercle, cancer, hydatid, paragonimiasis (see p. 76), etc., already present in them. In very rare cases it may be vicarious in nature. (c) Mechanical hypersemia of the lungs, secondary to heart disease, pulmonary overstrain, as in whooping'-cough, em- bolism of one of the branches of the pulmonary artery, or pressure upon the pulmonary veins from tumours, such as enlarged glands, growths or aneurism. (d) Changes in the blood, whether toxaemic, purpuric, scor- butic or otherwise, resulting in capillary haemorrhages. (e) Necrotic division of vessels in the course of softening of consolidations, such as are met with in phthisis, syphilis or cancer. • (/) Aneurismal dilatation, or simple erosion of branches of the pulmonary artery exposed in the course of excavation of the lung, or ulceration of the bronchial mucous membrane. (_g^) Atheroma of the pulmonary artery within the lung. 2. Hcefnorrhage from, the Bronchial Artery or Capillaries — (a) Capillary haemorrhage from the bronchial membrane of 546 ON HEMOPTYSIS 547 hypersemic origin, or resulting from excessive blood-pressure, hemophilia, purpura, scurvy, or toxaemic conditions. (b) Ulceration or erosion of a branch of a bronchial artery. 3. Hcemorrhage from the Aorta or One of its Great Branches. — Aneurism rupturing through the lung or into a bronchus. The above enumeration will suffice to remind the reader that haemoptysis is a symptom attendant upon many morbid conditions of heart, lung-s, vessels and blood. For the most part this symptom is included and sufficiently discussed in the descriptions of the diseases in which it occurs. In some cases of phthisis, however, haemoptysis, from its profuseness, frequent recurrence, and secondary consequences, takes so important a part as to merit separate consideration. Taking out of the above Hst the causes of haemoptysis operative in phthisis, they will be found to be : (i) active or inflammatory hyperaemia; (2) morbid conditions of small vessels; (3) erosion or aneurismal dilatation of larger vessels. Active or inflammatory hyperaemia is generally present in early phthisis, and is a prominent feature in the exacerbations of the disease. Haemorrhage is by no means necessarily attendant upon this condition, and does not usually amount to more than coloration or streaking of the sputum. In the very earliest stage of the disease, however, as it affects successive portions of the lung, the minute vessels are softened and more or less narrowed, or even completely closed by tuberculous growth. From this combination of softened vessel wall and increased local blood-pressure rupture may ensue, or it is not impossible that it may result from minute aneurismal dilatation, after the manner described by Charcot and Bouchard in cases of cerebral haemorrhage, but such a condition has not yet been demonstrated in the lung. The very considerable haemoptyses in the earlier periods of phthisis, and many of the intercurrent haemorrhages, are attributable to one or other of these morbid conditions of the small vessels, in conjunction with, or independent of, active hyperaemia. Such a haemorrhage may be one of the first symptoms of pulmonary tuberculosis, and it was this fact which led many of the older physicians, from Hippocrates downwards, to believe in the reality of a phthisis ab hccmoptoe, in which the 548 DISEASES OF THE LUNGS AND PLEURA disease was thought to originate in a bronchial or puhnonary haemorrhage, the inhaled blood irritating the lung, and lead- ing subsequently to the morbid changes characteristic of tuberculosis. As the destructive changes in phthisis advance, the larger vessels of the affected portions of the lung become softened and then torn across, and although as a rule their lumen has already been obliterated by previous thrombosis, it occasion- ally happens that such is not the case, and more or less serious hsemorrhage ensues. Aneurism of a branch of the pulmonary artery is a common source of fatal, and no doubt frequently also of non-fatal, haemoptysis. The first reported case of pulmonary aneurism was, we believe, that published by Dr. Fearn^ in The Lancet, February 6, 1841. Attention was later attracted to the subject by the cases of Drs. Cotton^ and Ouain,^ pubHshed in 1866. These aneurisms are usually situated on a pulmonary vessel which has become exposed as it crosses the wall of a cavity, the aneurism forming a projecting sac from the vessel into the cavity. Loss of support of the vessel on the cavity side, and chronic inflammatory changes in its walls, are the causes which lead to their formation. In size they vary from that of a pea to an unshelled walnut. They may be found at any age, provided the conditions suitable for their occurrence are present, but they occur most frequently in chronic quiescent cavities of old date, where the conditions for their production are most favourable (Plate XXXI.). It is to be noticed that in chronic phthisis especially (see p. 504) the general blood- pressure may remain relatively high, and clinical evidence is in favour of the probability of this being more marked on the pulmonary side.* Aneurisms are, however, sometimes met with in association with recent disease (Plate XXXIL), although the vessels are more apt to become occluded in such acute processes. In a series of 2-^ cases of fatal haemoptysis occurring in phthisis which we have recorded,^ in 13 the aneurisms occurred in cavities of some standing, with obvious fibrosis around; in the remaining 10 the process was a much more recent one, the surrounding lung being the seat of active tuberculous disease. It occasionally happens that a considerable aneurism of the pulmonary artery occurs in a lung in the earliest stage of PLATE XXXI RUPTURED PULMONARY ANEURISM IN A CHRONIC CAVITY The drawing shows a section of the left lung. The organ is shrunken, and the pleura over it dense and greatly thickened. The upper lobe is seen to be in a condition of almost total excava- tion, and to communicate with a large cavity in the lower lobe, on the anterior wall of which an aneurism (A), the size of a small marble, is situated. This had ruptured near its upper portion, and at the autopsy the lung was found filled with recent blood-clot. From a man aged twenty, a shop-assistant, who suffered from chronic pulmonary tuberculosis of two years' standing. During the last week of his life he suffered on three occasions from haemoptysis, bringing up 7, 14, and 5 ounces respectively. In the right lung a second aneurism, unruptured, but of very similar size to the one here depicted, was found (Plate XXXII.). (From the Brompton Hospital Museum. § natural size.) PLATE XXXI '%i^ Ruptured Pulmonary Aneurism in a Chronic Cavity. To ftvce p. 548- ON HEMOPTYSIS 549 tuberculous disease, affording some reason for the belief that the arterial wall is first affected, leading to the production of an aneurism which nestles in a pulmonary recess or cavity of its own formation. In a case of this kind recorded by the late Dr. Cayley,*" which one of us had the opportunity of seeing, profuse and recurrent haemoptysis was for some few weeks the only evidence of pulmonary disease. Death occurred from early and acute disseminated tubercle. Aneurism of the pulmonary artery may present through the wall of a bronchus, as in a case recorded by one of us in the Pathological Society's Transactions,^ but we are not aware of any cases of aneurism of the bronchial arteries having been reported. The majority of cases of fatal haemoptysis have been found to be due to the rupture of a pulmonary aneurism in a cavity. Ulcerative erosion or rupture of large pulmonary vessels with- in cavities accounts for the remainder. Bronchial hsmorrhag-e to any serious degree is now gener- ally regarded as of rare occurrence. Slight haemoptysis of this type may be observed in cases of bronchitis, and in the plastic form, accompanied by violent paroxysms of coughing, the loss of blood may be considerable. It may occur also in association with the haemorrhagic diathesis, in purpura, and in certain malignant fevers, especially variola. Sometimes it is met with in gouty subjects and in alcoholism, associated with a heightened g'eneral blood-pressure. Syphilitic or tuberculous ulceration of the air-tubes leads frequently to slight haemoptysis, more rarely to copious haemorrhag"e from erosion of a larg'e bronchial or pulmonary vessel. A case once came under our notice in consultation in which very profuse haemoptysis, which had been regarded as due to the rupture of an aortic aneurism, was present. Only slight physical examination was possible at the time, but no sign of aneurism could be found; the presence of a greatly enlarged liver suggested the possibiHty of syphilis, and the diagnosis was hazarded of a syphilitic ulceration of a main bronchus causing the haemorrhage. Vigorous mercurial in- unction and the administration of iodide of potassium inter- nally resulted in the recovery of the patient, and the syphilitic view was afterwards fully confirmed. Although it is not uncommon for haemoptysis to be appar- 550 DISEASES OF THE LUNGS AND PLEURAE ently called forth by some unwonted effort or excitement, it is by no means so caused in the majority of cases. Dr. Wilks drew attention to the frequency with which haemoptysis occurs during the night, and perhaps two-thirds of the cases may be said to occur during quietude, and the rest, with but rare ex- ceptions, only during that degree of physical effort or mental excitement usual in ordinary life. Symptoms. — Hemoptysis is too obvious a symptom to re- quire description. The blood expectorated may amount to no more than the slightest streaking or staining of the sputum, or several pints may be brought up. In cases of decided haemoptysis the patient is conscious of a gurgling sensation in the bronchial tubes, upon which, with a succession of short coughs, the blood is expelled in red, more or less frothy sputa. When more profuse, the blood may pour from the mouth in a stream, only partially interrupted by short gasping coughs. Such haemorrhage may prove at once fatal from its very profuseness, but it is more common in fatal haemoptysis to observe only a comparatively small amount of blood actually expectorated, the patient at once succumbing to faintness and suffocation from the overwhelming of the air-passages with blood. These latter phenomena of sudden and fatal haemorrhage scarcely ever occur except in tuber- culosis of some standing, which has resulted in pulmonary excavation and erosion or aneurism within a cavity. The blood in haemoptysis is usually bright red, frothy, coagulating in the receiving vessel in flattened lumps. When very copious, it may at the moment of expulsion be dark and venous-looking, but this is exceptional. After the occurrence of an haemoptysis, the sputa are blood-stained for some hours, or two or three days, the colour being at first bright and then becoming darker. Sometimes dark, grumous-looking clots are expelled in small quantity from the lung without any previous haemoptysis, a slight oozing having taken place, and the blood being retained for some time before expectoration. In .cases of haemoptysis the shock to the system is often marked, especially in first attacks. The patient is agitated and alarmed, the features pallid, the expression anxious, pulse feeble and small, voice partially suppressed, temperature lowered even to subnormal. Reaction soon takes place, how- ever, and, especially under the often injudiciously restorative PLATE XXXII PULMONARY ANEURISM ASSOCIATED WITH RECENT TUBERCULOUS DISEASE The drawing shov/s the upper portion of the right lung. This is the seat of much scattered tubercle of recent date and in the stage of caseation. In the centre of the lobe is a cavity *he size of a small marble, completely filled by an aneurisn. (A), which is unruptured, and had given rise to no signs during life. The two halves of the aneurism are shown in section. From a man aged twenty, a shop-assistant, who suffered from chronic pulmonary tuberculosis of two years' duration, and who died from the rupture of a second aneurism, situated in a chronic cavity in the left lung, which is figured in Plate XXXI. (From the Brompton Hospital Museum. Natural si^e.) PLATE XXXII Pulmonary Aneurism associated with Recent Tuberculous Disease. To face p. 550. ON HEMOPTYSIS 551 treatment of anxious friends, is ominous of fresh haemorrhage. The pulse becomes large, jerking, and more or less dicrotic, the face flushed, and the conjunctivas ghstening. The sense of weakness and prostration after early hsemoptysis is often pro- longed, and bears no necessary relationship to the amount of blood lost. The mental effect is also sometimes great; we have known even functional paraplegia to ensue after a slight haemoptysis. The temperature, as already remarked, is almost invariably depressed at the first outbreak of haemoptysis. Recovery, however, soon ensues, and the temperature returns to its former level — febrile in those with active disease, normal in cases of quiescent phthisis. In apyrexial cases the tempera- ture may be sometimes observed to rise about the third day, and this may be then attributed to secondary broncho-pneu- monia from inhalation of blood and septic matter. Diagnosis. — The diagnosis of hemoptysis by a skilled observer present at the time of its occurrence can never be difficult. 1. The blood is distinctly coughed up, is more or less aerated, and either pure or mixed with expectoration. 2. After haemoptysis there is generally a staining of the sputa for a few hours or days. 3. Blood expectorated from the lungs is never watery and non-aerated. 4. In doubtful cases inquiries should be made for epistaxis, and the gums and pharynx carefully examined (see Spurious Haemoptysis). 5. Hasmatemesis is frequently associated with a straining, retching cough; but the history of the case, the colour of the blood, and the absence of chest signs, are sufficient for diagnosis. In haemoptysis the blood is usually alkaline; in haematemesis it is always acid. 6. Only the g'entlest possible measures in the way of physical examination are justifiable in cases of haemoptysis. Percus- sion must be altogether avoided. The heart-sounds should be listened to, and the breath-sounds over the front of the chest auscultated, without, however, allowing any deep inspirations or other efforts on the part of the patient; by means of a flexible stethoscope the bases of the lungs may be sufficiently explored without disturbing his position. 552 DISEASES OF THE LUNGS AND PLEURA There will usually be no difficulty in recognising at one or other apex more or less crepitant or bronchial gurgling rales, significant of the source of bleeding. The pulse and temperature should be carefully noted, as they furnish the needful indications for treatment. Prognosis. — In all cases of early or primary haemoptysis a hopeful immediate prognosis may be given, since it is the rarest possible occurrence for such attacks to prove fatal. In haemoptysis occurring in a case of quiescent phthisis in which there are known to be excavations present, the immediate prog- nosis must be guarded; but however profuse the haemorrhage, an absolutely fatal prognosis is never justifiable. The fact of the first outburst not having proved immediately fatal always suggests the possibility of recovery, for it is certain that aneurismal haemoptysis is sometimes completely re- covered from, the aneurism eventually becoming firmly con- solidated. An ultimate prognosis is a much more responsible matter, and should never be given until the patient has sufficiently rallied to allowl of a careful physical exploration, and a survey of all the facts of his case. Excluding heart disease, mechanical injury, overstrain as from whooping-cough, acute sthenic pneumonia, and morbid blood conditions, haemoptysis in the vast majority of instances means the presence of pulmonary tuberculosis, and it is one of its most important positive signs. Numbers of people doubt- less make a complete recovery after haemoptysis, but such recovery is only permanent in those of good constitutional resistance, who can and will accept the warning and place themselves under new and more suitable conditions of life; Lightly considered and carelessly treated, haemoptysis is but the precursor of grave destructive disease. Recurrent Haemoptysis.— The phenomena characteristic of recurrent haemoptysis are : I. The presence of a localised pulmonary lesion presenting no symptoms of activity. 2. Repeated attacks of sudden and severe outbursts of haemorrhage at short intervals, not preceded by any febrile symptoms, and not necessarily attended or followed by any extension of disease. We may briefly allude to the following case as illustrative of this form of haemoptysis : ON HEMOPTYSIS 553 In May, 1867, there first came under the notice of Dr. Douglas Powell at the Brompton Hospital a man, aged twenty-seven, described as a fitter, who had been ailing for some years with occasional cough. He complained of pain in the chest and bad cough, but, he stated, without expectoration ; he had had streaky haemoptysis several times. He was doubtful whether he had lost weight ; the appetite and diges- tion were good, the bowels regular, and the pulse slow. His father, an intemperate man, had died of consumption at the age of forty-four. The patient himself had always been a tolerably steady man of very active habits. He was of sanguine temperament, clear complexion, medium height, and slight though robust build. A striking feature about him, and worthy of note, was his extreme excitability — an almost superfluous energy of character, which led him to do everything with exaggerated effort. At the date of his first attendance there was present at the left apex some dulness, with a few clicks. On June 28 he had considerable haemoptysis, which was repeated on August 3, and again on the 8th, when a pint of blood was brought up, and a note was entered of the existence of a small vomica at the left apex. From this date the haemorrhage continued in smaller quantities until the 17th, when it gradually subsided. It was on this date that, having regard to the continuance of the haemoptysis and its repeated occurrence at intervals, together with the absence of any corresponding progress in the pulmonary physical signs, which were still limited to the summit of the left lung, the existence of a small aneurism of a pulmonary vessel in this situation was first suspected. He ceased attendance at the hospital at Christmas of the same year, having greatly improved in health. The patient continued " well," as he expressed it, and at work, until October, 1868, when he returned to the hospital with slight cough, and stating that he had recently expectorated blood, but not so much as on previous occasions. At this date there was " dulness anteriorly on the left side to the mamma, with high-pitched bronchial breath-sound, pectoriloquy and cavernous cough; sounds dry; some crepitus at angle of left scapula." He had another slight attack of haemoptysis in November, and at Christmas was admitted into the hospital, where he remained a month, during which time he was frequently cautioned against displaying so much energy in doing the most trivial thing, and coughing with such unnecessary violence. He had no appreciable expectoration, and left the hospital feeling well. No pyrexial symptoms had ever been observed in this patient, and during a slight attack of haemoptysis, whilst in hospital, the tempera- ture was observed to be normal. He was not again seen until August, 1870, when, having remained quite well and at work until a few days previously, he expectorated half an ounce of blood. The physical signs were still limited to the apex. 554 DISEASES OF THE LUNGS AND PLEURA The patient ceased attendance in October, and continued pretty well until March 4, 1871, when he again attended with haemopt3'sis. Although still spitting blood freely, he, quite against orders, attended personally from Battersea on March 8, and brought up a considerable quantity of blood in the out-patient room. This attack proved the most prolonged and desperate one he had yet had, and nearly terminated fatally. The haemorrhage continued with frequent outbursts of half a pint until the 30th, from which date the attacks abated in violence, apparently rather from lack of blood-supply than from the efficacy of remedies, which, however, were steadily persisted in until April 13, when there had been no considerable hsemoptysis for a week. He again attended personally, though with great difficulty from his extreme weakness, on May 4. At this date there was noted at the left apex " retraction of lung, dulness, cavernous respiration, and rhonchus (slight)." Posteriorly there was " diffused crepitation, with some defective resonance." This was the first occasion on which the lung had appeared to suffer from the effects of haemoptysis. The cough was troublesome, especially in the morning ; and on the nth he was ordered ether and ammonia expectorant, lest his violent and unaided efforts at expectorating should lead to a fresh opening of the probable aneurism, which seemed to be the only conceivable source of such profuse and repeated haemorrhage. It was extraordinary to note the rapidity with which the patient regained flesh, strength and colour, although butcher's meat was only allowed every other day; stimulants were cut off, and abundance of milk alone permitted. He continued to take mineral acids and cod-liver oil. He did not at all approve of the diet ; but from previous experience of his rapid blood- making qualities, one was convinced that a more generous regimen would have led to a return of the hsemorrhage. On June 8 he had one comparatively slight attack of haemoptysis, and on the 29th the physical signs showed enlargement of the right lung, the margin of which reached across the median line ; there was still some irritative bronchitis at the left base, indicated by diffused submucous rales. December, 1871. — Beyond an occasional tinge in the morning expectoration, the patient had had no more haemoptysis, and had returned almost to his usual health, though the breath was shorter. Since June he had taken no oil, but for a few weeks some digitalis was added to his mixture. The restricted diet had been continued, though less so of late. This man did not attend the hospital ag"ain, but was seen about occasionally, and apparently well, during- the next five years. The case exemplifies well the main features of re- current haemoptysis — viz. : (i) repeated copious hgemorrhage, obviously arising from disease localised at one portion of the lung; (2) pulmonary disease, chronic in its course, and but ON HAEMOPTYSIS 555 little influenced directly by the haemorrhage ; (3) the hgemop- tysis, though it may prove directly fatal, being accompanied by no severe fever or secondary pneumonia, and from it the patient frequently making a speedy recovery. The pathological condition common to all these cases of recurrent haemoptysis is that of a slowly forming cavity, or one formed by a very localised process of an active character, in the walls of which pulmonary vessels still patent are exposed. On such a vessel an aneurism then forms, projecting on the cavity side of the vessel. It will be observed that the case above described did not begin with haemoptysis; the man had had some dry coug'h, and occasional streaky sputum, for some years previously; and a few days after the first considerable haemorrhage a vomica was found at the left apex, where some two months previously there was consolidation and softening. All cases of this kind are, however, not necessarily tuber- culous. For example, we have met with an aneurism in a bronchial dilatation, and in another instance an abscess in the lung was attended with all the features of pulmonary aneur- i,smal haemoptysis, from which the patient ultimately re- covered. The danger in cases such as these is from the rapid outburst of blood, which at once floods the bronchi and may asphyxiate the patient. In other cases the actual amount of haemorrhage is the cause of death on the first occasion. Nothing is, how- ever, more striking than the recovery of some patients from what appears to be the most hopelessly profuse haemoptysis. Nature apparently seizing the moment when, from faintness, the blood is at a standstill, to heal the breach by the formation of a coagulum. Hence the importance in treating such cases of withholding all stimulants till the latest moment. Rokitan- sky refers to another mode of arrest of the haemorrhage from a large vessel in a cavity — viz., by the cavity becoming blocked by coagulum, which thus compresses the vessel. We have seen an instance, post-mortem, in which the apex of the right lung- was converted into a blood-cyst as large as a lemon, which was quite closed, and which had been produced by haemorrhage into a cavity. REFERENCES. ^ " Aneurism of the Pulmonary Artery," by S. W. Fearn, Surgeon, F.G.S., etc. (Derby), Tke Lancet, 1840-41, p. 679. 556 DISEASES OF THE LUNGS AND PLEURAE ^ " Case of Phthisis — Fatal Haemoptysis from the Rupture of a Small Aneurism of a Branch of the Pulmonary Artery (under the Care of Dr. Cotton)," Medical Times and Gazette, 1866, vol. i., p. 37. ^ " Varicose Aneurysmal Dilatation of Two Small Branches of the Pulmonary Artery. Rupture of One of Them. Death by Sudden Haemop- tysis in a Case of Phthisis," by Dr. Quain, Transactions of the Pathological Society of London, 1866, vol. xvii., p. 79. * " The Role of the Cardio-vascular System in Pulmonary Tuberculosis," by Sir R. Douglas PoweU, Bart., K.C.V.O., M.D., F.R.C.P., The Lancet, 1912, vol. ii., p. 1415. * Re-port on the Work of the Pathological Defartment of the Brom-pton Hospital during the Three Years April, 1900, to April, 1903, by P. Horton- Smith (Hartley), M.D., Table V., p. 22. London, 1903. •^ " A Case of Haemoptysis treated by the Induction of Pneumothorax so as to collapse the Lung," by W. Cayley, M.D., Transactions of the Clinical Society of London, 1885, vol. xviii., p. 278. '' " Some Cases illustrating the Pathology of Fatal Haemoptysis in Advanced Phthisis," by R. Douglas Powell, M.D., Transactions of the Pathological Society of London, 1870, vol. xxii., p. 47. CHAPTER XXXIX ON FALSE OR SPURIOUS HEMOPTYSIS By true haemoptysis is meant, as we have seen, hsemorrhage from or throug'h the lungs; either from the lung texture proper, or from the lining of the bronchial tubes ramifying through the lungs, or more rarely from some external source, the blood being discharged throug'h the lung's. By false or spurious haemoptysis is meant the spitting of blood which has escaped from some portion of the mucous membrane lining the nasal, buccal, or pharyngeal passages. Perhaps the true anatomical line of division between true and false haemoptysis would be at the glottis, for below this point the mucous membrane assumes the ciliated columnar epithe- lium characteristic of the bronchial tract, whilst above the epithelium is of the squamous kind. In true haemoptysis, with the exception of those rare cases in which the haemorrhage comes from the larynx or trachea, or from some external source the blood escapes from the pulmonary or bronchial vessels; in false haemoptysis from branches of the carotid trunks. The parts whence the blood of false haemoptysis is usually derived are the nasal mucous membrane, the pharynx, the gums and dental alveoli. The following are the more im- portant conditions under which this phenomenon is met with. I. In cases of decided epistaxis some of the blood commonly trickles down the back of the throat, and excites cough, by which it is removed in clots and with staining of the saHva; the source of haemorrhage is obviously, however, the nasal membrane, and no real difficulty in diagnosis ever arises. It is only in cases in which the nasal haemorrhage is but slight, and attended with little or no escape of blood through the anterior nares, that there is any probability of the affection being mistaken for haemoptysis. This occurrence may happen 557 558 DISEASES OF THE LUNGS AND PLEURA at night, and the patient wake up spitting blood. The absence of fever and of pulmonary physical signs, and the detection of blood mingled with the nasal mucus when expelled, or of coagula in the nasal passages, will render the diagnosis in these cases also clear. 2. Ulceration of the throat, especially when malignant, may lead to copious haemorrhage, and in these cases, again, no difficulty is hkely to arise in the way of diagnosis. 3. A class of cases is now and again met with which occa- sions much trouble to the practitioner, and requires decision in management. These are cases of feigned or hysterical haemop- tysis. Such are nothing more nor less than downright attempts at imposition, the blood being produced either by sucking the gums, or by pricking" or incising them. The late Sir George Johnson^ referred to the case of a young girl sent up to King's College Hospital by a lady interested in her, with an elaborate history of symptoms, including blood-spitting. The character of the expectoration, which consisted of un- aerated saliva mixed with fresh blood, was sufficient to indicate its source, and on examining the mouth with a bright Hght, about twenty fine cuts or scratches were discovered on the mucous membrane covering the hard palate. A sharp repri- mand and a short course of shower-baths and steel tonics speedily removed the symptoms. In some hysterical cases, however, we have known the blood-stained saliva to be liighly aerated, probably produced by sucking the gums after injuring them with a needle. The appearance and the physiognomy of the patient are generally sufficient to excite suspicion, and other hysterical symptoms are usually present. 4. A morbid state of the gums, a degree of pyorrhoea alveolaris, frequently arises from want of due attention to the teeth, or from the presence of decayed stumps in the alveoli. On gently pressing the edge of the gums, pus escapes from beside the affected teeth, and on the slightest touch or friction blood exudes from the mucous membrane, which is swollen and congested, a hvid line running along the margin of the p'um A similar condition arises from the effects of certain drugs, especially mercury and, to a much less degree, lead and iodide of potassium. In these cases there is fcetor of breath, and an inspection of the gums and teeth at once suggests the ON FALSE OR SPURIOUS H/EMOPTYSIS 559 probable source of the blood-spitting, which is usually insig- nificant in amount, and unaccompanied by any cough or chest symptoms. The treatment of these cases falls partly within the province of the dental surgeon; it consists in the employment of astringent tooth-powders, of which one of the best for the purpose is composed of finely powdered kino one part, to three or five of prepared chalk, with or without a little animal charcoal. Another preparation which we have found of much value in cases of pyorrhoea is a lotion composed of liquefied carbolic acid, three minims; liquor potassse, three minims; and rosewater to the ounce. This should be applied to the gums on a pledget of cotton-wool several times a day. Any decayed teeth must be removed or stopped. More or less dyspepsia is usually present in these cases, partly arising, no doubt, from the condition of the gums and teeth, and a stomach cough, added to the staining of the sputum, may suggest to the patient that he is consumptive. 5. An insufficient supply of vegetable food, a common dietetic error among all classes of people in towns, leads to a spongy, congested state of the mucous membrane of the mouth and fauces, of the same kind as that which, in a more intense degree, is associated with the other lesions character- istic of scurvy. This is one of the common causes of spurious haemoptysis. The relaxed condition of the throat, resulting in the secretion of an undue amount of viscid mucus, gives rise to cough, and the mucus expectorated, or rather hawked up, from the pharynx, together with the saHva from the mouth, is from time to time tinged with blood. It is often difficult to distinguish this form of false from true haemoptysis. In- deed, the condition of the mouth is but a sample of that of the mucous membranes generally; and the larger bronchi, if affected with catarrh, are apt to yield a viscid and slightly stained secretion. We have observed in some cases of phthisis a staining of the expectoration, which has seemed to have arisen in the samic way. In the cases under consideration there are no pulmonary signs to be discovered even after a veiy careful examination. The haemorrhage is never in large quantity, and it consists of a tingeing or streaking of sputum, which is distinctly made up of mucus mixed with saliva, giving rise to a dirty red fluid 560 DISEASES OF THE LUNGS AND PLEURA containing some little streaks or clots of blood. On micro- scopic examination, squamous epithelium cells are seen in abundance, and red blood-corpuscles are but thinly scattered over the field. The patient complains of the taste of blood in the mouth, and this is especially disagreeable after sleep. The nutrition is not good, the muscles are flabby and wanting in tone, and the patient feels languid and out of sorts. There is commonly some ansemia present. A most favourable prognosis may confidently be given in these cases, if we are quite satisfied as to the absence of any pulmonary sign. In treatment the diet must be attended to, an abundance of fresh fruit and vegetables being added. Five or ten grains of citrate of iron should be ordered in fresh lemon-juice two or three times a day, and cod-liver oil may often be given with g'reat advantage. Some tannin solution should be used as a garg'le, and to rinse the mouth. A pleasant mouth-wash and gargle to use night and morning consists of Hazeline gii., Glycerini Boracis sii., Eau-de-Cologne §1., Aquam Rosas ad §viii. ; one tablespoonful to a wineglass of water to rinse the mouth, and some undiluted lotion dropped on to a soft badger's-hair toothbrush previously dipped in water, to brush the gums. In cases of phthisis in which we suspect this morbid condi- tion of the bronchial mucous membrane to be present, fresh lemon-juice, a not unpleasant vehicle for cod-liver oil, is valuable. 6. In certain cases of ansemia, attended with all the other phenomena of that disease, the mucous membrane of the mouth and fauces, although pallid in appearance, exudes a sanguineous fluid, which, mixed with the saliva, causes spurious hcemoptysis. There is in these cases, so far as one can discover, no definite bleeding-point to be seen, but in the course of twenty-four hours a considerable amount of blood will transude through the vessels. The transudation is ordinarily very slow, and in the daytime is scarcely noticed; but during the night some accumulation takes place, and, on waking, the patient expels perhaps an ounce or more of bright red unaerated fluid, containing a few coagulated films, giving an appearance closely resembling that of currant jelly and water. Some of the sanguineous fluid often escapes from the ON FALSE OR SPURIOUS HEMOPTYSIS 56 1 mouth upon the pillow during sleep. The patients suffering from this affection are mostly females. Amongst other symptoms of anaemia the menstruation is disordered or suppressed, and commonly, but not always, at the menstrual period the escape of blood from the mouth is considerably increased. Probably from the same cause — an increased blood-pressure finding- relief at the surface of least resistance — any extra exertion is apt to produce an increase in the sanguineous flow. The real pathology of these cases is, how- ever, confessedly obscure; but this is the variety of false haemoptysis for which we are most often consulted. The patients are short of breath ; they sometimes have a hard cough, and complain of pain in the left side and considerable prostra- tion, which symptoms, with increasing pallor and blood- stained expectoration, are quite sufficient to persuade them and their friends that they are consumptive. In such cases the greatest pains must be taken to exclude the presence of tuberculosis. The sputum, however scanty, must on several occasions be carefully examined for tubercle bacilli, if necessary, using concentration methods (p. 574), and a watch kept upon the patient's weight and temperature. As regards physical diagnosis, the respiratory sounds will usually be found to be weak and partly suppressed from want of muscular power. The percussion is, however, even on the two sides, and the respiration, although feeble, is vesicular. The character of the cough, both as heard through the stetho- scope and otherwise, is usually quite distinct from that of chest disease. Moreover, all the signs of anaemia are present, venous hum, arterial murmurs, and so forth, and the "pain in the chest " is, without much difficulty, ascertained to be either inframammary neuralgia or gastrodynia. Some patients with this form! of spurious haemoptysis have plenty of colour in the cheeks, and are plump rather than emaciated ; but they never- theless present other evidences of anaemia. The careful observation of a large number of these cases for long periods enables us to say that it is very unusual for them to develope phthisis. The condition calling for treatment is the anaemia. More fresh meat must be taken, and, if necessary, some hydrochloric acid and pepsin added to aid digestion. In some cases there is considerable disorder of stomach present, which must be 36 562 DISEASES OF THE LUNGS AND PLEURA first set right before the remedies appropriate to angemia can be given. These remedies are the astringent forms of iron. Cold salt baths or sea-bathing allowed only for a very brief time — one or two minutes — and immediately followed by vigorous friction, are most useful in the convalescent stage. Abundance of fresh air and out-of-door exercise is, of course, to be insisted upon. The patients and their friends are often much afraid of fresh air, and the cases have usually at the period at which they come under observation been aggravated by confinement in warm and ill-ventilated rooms. If, as often happens, there are decayed teeth present, setting up irritation in the gums, and increasing the disposition to haemorrhage, these should be attended to. Some calcium lactate may be given with syrupus calcii lacto-phosphatis, and a little reduced iron with the meals. 7. General haemorrhage from the whole mucous membrane of the mouth is sometimes seen in haemophilia. As in the variety described under the preceding heading, no per- ceptible lesion is discoverable in the mucous membrane, but the haemorrhage in this case is usually so considerable ' in amount as to prevent any possibility of mistaking its nature, and other signs of the disease may be present. Such are the more important conditions under which spurious haemoptysis is met with. In all cases, however, in which the cause is not apparent, a very careful examination of the pharynx, back of the tongue, and of the laryngeal region should be made with the laryngoscope. In this way it has happened that a small area of ulceration has been found, for example, on the posterior aspect of the tongue, on treat- ment of which the blood-spitting has ceased. REFERENCE. ^ " Clinical Remarks on Three Cases of Malingering, namely, Two Cases of Pretended Blood-Spitting or Vomiting, and One of Suppression of Urine," by George Johnson, M.D., Medical Times and Gazette, 1862, vol. i., p. 428. CHAPTER XL ON OTHER IMPORTANT COMPLICATIONS OF PULMONARY TUBERCULOSIS Tuberculous Meningitis. — This fatal complication of pul- monary tuberculosis occurs as part of a secondary and general- ised miliary infection. When the meninges of the brain are involved in this outbreak of tubercle, the special symptoms that arise are so grave as to set aside from view all other conditions present. A notable feature about tuberculous meningitis, when it complicates phthisis, is the uncertainty and insidiousness of its supervention. It is happily a somewhat rare complication — occurring- in only 7 of our 275 autopsies^" — yet there is no case of phthisis, and no stage of any case in which the condi- tions for its possible occurrence are not present Thus a child may have a small apex lesion, which has resulted in some local induration and flattening, with complete subsidence of all •symptoms; she has steadily improved, and is regarded by her parents as well, although the doctor pronounces her chest still to be delicate, when suddenly she developes brain symptoms, which terminate fatally within three weeks. Such is a common history. We will briefly relate one or two cases which may be re- garded as typical of their kind. Case i. — George B., aged twelve, a thin, pale, neglected-looking boy, was admitted into hospital on August 26 with a history of recent bronchitis and presenting the remains of a broncho-pneumonia, with some hectic symptoms. On September 18 vomiting commenced, occurring after food, and attended with some diarrhoea, a coated tongue, and a slight rise of temperature (99°). The vomiting became more frequent, and persisted through the next seven or eight days. The face was flushed, the skin hot and perspiring. No headache was complained of. On the third day of these symptoms the urine yielded, 563 564 DISEASES OF THE LUNGS AND PLEURA on boiling a heavy cloud of phosphates, a sign which we have observed in other cases of the disease. On the tenth day (September 27) the patient became unconscious, and the following note was made : " Pulse 76, irregular, lips dry, tongue furred. Expression of face drowsy, suspicious. Will not answer questions. Tries to put out tongue when sharply told to do so, but fails. Is slightly delirious. Respirations 20 in the minute, temperature ioo-8°. There is slight occasional twitching of the left arm and pectoral muscle. When aroused drinks oatmeal-water with avidity. Evidently tries to answer questions put to him but fails to do so. At 9 p.m. twitching of both arms and legs observed, with picking at bedclothes, and grasping at nothing. Has not vomited after taking cream and brandy ; pulse 80 ; temperature 100°. " On the eleventh day, September 28, temperature 100-2°, pulse 80, the patient more restless. Fingers continually working, scratching, or pulling at teeth. Muscles of neck and back rigid. At 4 p.m. : movements of arms and legs more violent. Rigidity of back more marked; temperature 102-2°; bowels open from medicine; motions loose. September 29 : temperature 101-2°, pulse 80, weaker. Slight external strabismus of left eye. September 30 : 10 a.m., temperature 102-4; 7 p.m., 103°, pulse 120. Eyes roll slowly from side to side, pupils dilated. October i and 2 : morning temperature ioi-6°. Emaciation increasing. Some resistance to extension of arms. Con- junctivae more sensitive, pulse 130, regular. Patient lingered for a week longer in much the same state, and then sank on the twenty-first day. The post-mortem revealed the usual evidence of meningeal tuberculosis. In this case the insidiousness of onset v^^as well illustrated. During- the first days of the attack no headache was com- plained of, nor did the boy at any time suffer much from this symptom. Obstinate vomiting resisting all treatment was up to the time of unconsciousness the only definite symptom, and its significance was at first obscured by other evidences in tongue and bowels pointing to gastric derangement. Later, twitchings and irregular movement of the limbs, with increas- ing unconsciousness, rigidity of neck, strabismus, and blind- ness were present in this, as in most other cases of meningitis. Case 2. — In this case, that of an adult, aged thirty-three, with advanced phthisis, the first symptoms were headache and confusion of vision, which latter was ascribed to yoo grain hyoscyamine given in a cough linctus. The pupils, however, were not dilated. The patient vomited twice in the course of the next two days, and on the fifth day twitchings of the flexor tendons were observed. Two days later the pupils became unevenly contracted. The patient became drowsy ; he could not find words to answer questions. He died on the nineteenth ON COMPLICATIONS OF PULMONARY TUBERCULOSIS 565 day after the commencement of symptoms, irregularity of pulse and breathing, drowsiness, and variable twitching of the limbs, being observed towards the end. The following propositions embrace what is reliable in the diagnosis of this complication, sometimes so startling, at others so insidious, in its onset. 1. Persistent headache and vomiting are the most common first sy}nptoms of the disease. They may or may not he com- bined. They are usually associated with furred tongue and disordered bowels, which tend to mask their significance. The headache of tuberculous meningitis does not affect with constancy any particular portion of the head. It is sometimes frontal, often over the crown of the head, occasionally at the back or on one side. Although always a sign to cause anxiety when it occurs at all severely or persistently in phthisis, yet it is never, even when associated with vomiting, sufficient to enable us to form a diagnosis. In several cases we have found headache so severe, persistent, and, taken together with the general aspect of the patient, so apparently characteristic of meningitis, as to have led us to feel very apprehensive as to its real significance; yet again and again our suspicions have proved to be unfounded. On the other hand, in the majority of cases of true tuberculous meningitis that have come under our observation, other suspicious symptoms have been asso- ciated with the headache until the appearance of more decided signs removed all doubt. Hence headache or vomiting, although not sufficient for diagnosis, are signs which, if not readily relieved by treatment, should always arouse grave suspicions. 2. Disordered vision, impaired memory, and confusion of ideas are signs which, taken in association with headache, are almost diagnostic; the supervention of muscular twitchings or convulsions is of the highest significance. Any or all of these signs may closely follow the appearance of headache or vomiting. They may, one or more of them, constitute the first symptoms of the disease. Paralysis of the third or sixth nerve usually occurs among the later symptoms, when the effused lymph and contractile tissue drags and exer- cises pressure upon the nerves. Ophthalmoscopic examina- tion of the fundus may yield a valuable positive result, but the absence of tubercles in the choroid signifies little, as they are 566 DISEASES OF THE LUNGS AND PLEURA present in only a minority of cases. Thus, choroidal tubercles were found in only fourteen out of forty-seven consecutive cases (29-8 per cent.) examined post-mortem at St. Bartholo- mew's Hospital, and during, life they are discovered even less frequently." 3. Drowsiness deepening into coma, hut often with intervals of consciousness, is the most constant of the later symptoms of tuberculous meningitis. It depends upon effusion into the ventricles. 4. Irregular pulse and irregular respiration are amongst the occasional early signs of tuberculous meningitis. Both irregularity of the pulse and of the respiration are not uncommon after the period of coma, but they are then signs of little importance. A marked irreg'ularity of the pulse occurring, however, early in the attack is of greater signifi- cance than is usually recognised. The pulse is commonly rather slow than quick, sometimes markedly infrequent. The respirations are rarely affected during the early stages of the disease. 5. The temperature is as a rule not much elevated. It is more often raised towards the end of the attack, its rise being apparently associated with secondary inflammatory lesions. It is of little or no value in diagnosis. 6. Kernig's Sign. — A common symptom met with in menin- gitis is that known as Kernig's sign. By this is meant the inability to straighten the patient's leg when the thigh is placed at a right angle to the trunk, owing to contraction induced in the calf muscles. The sign is not, however, limited to meningitis, and its diagnostic value is correspondingly diminished. 7. Lumbar Pimcture.— In cases of doubt the diagnosis is much aided by a lumbar puncture. If tuberculous meningitis be present, the fluid withdrawn will be found to be clear or faintly turbid. The albumin-content is increased, so that no long'er a " faint haze " is observed, but a definite ring at the line of junction when the cold nitric acid test is applied, and on boiling with an equal quantity of Fehling's solution no reduction is now obtained. If a film from the deposit ob- tained by centrifugalisation be stained, lymphocytes will be usually found to form the great majority of the cells present. When cultivated on ordinary media the fluid is sterile, but ON COMPLICATIONS OF PULMONARY TUBERCULOSIS 567 tubercle bacilli may often be demonstrated if the small fibrinous clot, which in many cases forms on standing, be teased out on a slide and stained by the Ziehl-Neelsen method, as recommended by Dr. Graham Forbes.^ In these respects tuberculous meningitis differs from other varieties of acute meningitis. In the latter the fluid will be found more turbid, owing to the greater number of cells present, and the differential count shows that polymorphonu- clear leucocytes predominate. On staining films various organisms, whether meningococci, pneumococci, streptococci or others, will be observed, and their presence will, as a rule, be confirmed by cultivation. In health the cerebro-spinal fluid is clear, and almost free from cells. 8. The blood-count shows, as a rule, a leucocytosis, the in- crease in number of the white cells, which may early in the course of the disease number 12,000, being chiefly due to the presence of polymorphonuclear cells. The duration of this disease is varied; it may terminate in a few hours, or days, or weeks, and is generally fatal before the twenty-first day. Patients will sometimes linger for many days in a state of complete insensibility from effusion into the ventricles. It is not infrequent for a deceptive amend- ment of symptoms of short duration to take place before the fatal issue. Lardaceous Disease. — In about lo per cent, of cases of phthisis lardaceous changes are found at the autopsy in certain organs. The table on p. 568 shows, in detail, the results obtained in 263 cases of chronic pulmonary tuberculosis upon which autopsies were performed by one of us at the Brompton Hospital during the years 1900 to 1903.^* In these statistics, it should be added, we are alluding to the coarse degrees of lardaceous degeneration demonstrated to the naked eye by the iodine test; in a considerably larg-er percentage micro- scopic examination would have revealed a trace of the condition. The figures given below closely agree with those quoted by Sir J. King'ston Fowler" from records taken at the same hos- pital during the years 1893-94. It would seem, however, that formerly lardaceous disease was more often met with. Thus, in ninety-nine post-mortem examinations, made consecutively at the Brompton Hospital by one of us in the years 1869 to 568 DISEASES OF THE LUNGS AND PLEURA 1875, it was found in twenty cases, eight male and twelve female, or in about 20 per cent, of the whole, a difference in percentage from that in the table below, which is possibly to be attributed to the more hygienic conditions under which the disease is now treated, and the diminished liability, therefore, of the patients to be infected with virulent secondary organ- isms. In the twenty patients just referred to the pulmonary disease had a maximum duration of sixty-six months, a minimum of four months, with a mean of twenty-six months. The spleen was affected in nineteen of the twenty cases. Table showing the Frequency of Occurrence of Laedaceous Disease IN Chronic Pulmonary Tuberculosis, and the Organs chiefly affected, based upon 263 Consecutive Autopsies (188 Males, 75 Females). Males. 1 Males per Cent. Females. Females per Cent. Total. Total per Cent. Present in 18 i 1 9"5 10 13 3 28 10 -6 Analysis of above — Spleen affected 14 7'4 8 10-6 22 8-3 Kidneys „ II j 5-8 7 93 18 6-8 Liver II ' 5-8 6 8-0 17 6*4 Intestines ,, 7 ; 37 6 8-0 13 4'9 Stomach ,, 4 21 3 4-0 7 2-6 From the figures above quoted it will be seen that in lar- daceous disease following tuberculosis of the lungs the spleen is the organ most commonly affected, and after this the kidney and liver in about equal proportions. Less frequently the intestines, stomach, and suprarenals, and occasionally other organs — such as the lymphatic glands, the thyroid, testes, etc. — show the characteristic change. This especial vulnerability of the spleen is, perhaps, peculiar to cases originating- in phthisis; for we may remark that in 118 cases collected at St. George's Hospital by the late Dr. Dickinson,^, of which forty-three at most originated in phthisis (suppuration of various kinds and syphilis accounting for the remainder), the order of frequency was as follows : kidneys affected in 95 cases; spleen in 76; liver in 65; intestines in 35; stomach in 9. The lardaceous change in phthisis is no doubt connected with the suppuration which is taking place in the lungs and the imperfect drainage and consequent absorption of toxines, which is inseparable from this condition. In this connection ON COMPLICATIONS OF PULMONARY TUBERCULOSIS 569 it is interesting to recall that the change has been produced experimentally in animals by Krawkow, Alan Green/ and others, as the result of the inoculation of attenuated cultures of pyogenic org^anisms or their toxines. Lardaceous disease may be recog'nised as a complication in phthisis by the detection of an enlarged spleen, which presents below the cartilages, firm and smooth on palpation. The liver also may be found large, smooth, and hard, with well-defined and rigid marginal outline. In many cases albuminuria is the first sign, considerable in amount, and accompanied by hyaline casts and a variable degree of dropsy. It only rarely happens, and chiefly in the fibroid variety of phthisis, that the lardaceous disease causes death, and in these cases the fatal result is due to kidney complication. In a few instances the intestinal mucous membrane is gravely involved, and obstinate diarrhoea exhausts the patient. The appearance of the change is often associated with chronicity. Albuminuria. — The presence of albuminuria is rare in the early stages of phthisis. Later on it may result from simple chronic nephritis or lardaceous degeneration, both, however, less common now than formerly, or tuberculous disease of the kidney and pelvis (or other portion of the urinary tract), the so-called scrofulous disease of the kidneys described by earlier writers. (a) Lardaceous degeneration of the kidneys is not common in phthisis, and is somewhat less frequently observed than a similar affection of the spleen. It occurs in the more chronic cases, and is often associated with a like affection of other organs. A considerable degree of renal dropsy may attend the albuminuria arising from this cause, and the abdomen is generally enlarged from the presence of an amyloid or amylo- fatty liver. Diarrhoea is often a marked symptom in this form of phthisical albuminuria, and sometimes uraemic vomiting and convulsions occur, but much less frequently than in other forms of nephritis. (b) Another cause of albuminuria and renal phenomena in tuberculosis is a form of nephritis, parenchymatous in nature, in which the kidney is somewhat enlarged, its capsule adherent, the organ softer than natural, and less dry on section, presenting a swollen cortex of a mottled appear- 570 DISEASES OF THE LUNGS AND PLEURAE ance from points and streaks of fatty deg"eneration. This kidney does not give the amyloid reaction. The albuminuria is considerable in amount, and there is a tolerably copious sediment from the urine, containing abundant epithelial and fatty casts. This form of renal complication is perhaps of less frequent occurrence than formerly. It is much more serious than the lardaceous form, being attended with scantiness or suppres- sion of urine, obstinate and exhausting vomiting or diarrhoea, or pulmonary oedema and asthmatic phenomena, and other g'rave ursemic symptoms. (c) The kidneys necessarily partake in the pathology of acute miliary tuberculosis, and in patients dying of chronic phthisis the occurrence of a few miliary tubercles in the kidneys is by no means uncommon. In our own autopsies we found such tubercles, visible to the naked eye, in 28 out of 263 cases of chronic pulmonary tuberculosis, a percentage of io"6; whilst Dr. Joseph Walsh,^" examining 60 cases, was able to demonstrate their presence microscopically in 35 (58 per cent.). In conformity with these results, we may add that Drs. Ravenel, Walsh, and Smith^* have proved that in advanced phthisis tubercle bacilli not infrequently pass into the urine, and by inoculating guinea-pigs with the washed sediment of two litres, they were able to demonstrate their presence in 14 out of 17 cases. Bacilli may thus find a nidus in the kidney, and give rise to a few miliary tubercles. Ulcerative tubercu- losis of the organ, however, with its attendant caseating masses and vomicae, is rare as a complication of phthisis. Out of 263 autopsies, we only found such a complication in 6. Its occurrence is indicated by lumbar pain, increased frequency of micturition, and especially by the presence of a thick deposit of pus in the urine, in which tubercle bacilli will be found. Like some other tuberculous manifestations, it is more common as a primary local affection, upon which pulmonary disease may later be engrafted. The occurrence in the urine of the ordinary diazo-reaction or of the dimethyl-amido-benzaldehyde reaction, introduced by the late Professor Ehrlich,* possesses little chnical signifi- cance. Fistula. — Fistula in ano occurs in a small proportion of cases of pulmonary tubercle, and in our series of 263 autopsies ON COMPLICATIONS OF PULMONARY TUBERCULOSIS 57 1 it was only observed on three occasions.*'' In our experience the compHcation is almost entirely limited to males. The same causes which give rise to fistula in the healthy subject may produce it also in the sufferer from phthisis. It may thus be sometimes traced to fish or rabbit bones, or other irritating objects in the bowel, or result from the exposure of the parts to cold and wet. Two special methods are described by authors by which this complication may arise — viz. : (i) From tuberculous infection of the rectal mucous membrane by swallowed sputum or ulcerous discharges from a higher portion of the bowel. A local ulceration is thus set up, which, by extension outwards, causes ischio-rectal abscess. (2) In other, and probably more numerous cases, the tuberculous disease commences in the submucosa, extends outwards into the ischio-rectal fossa, and only later perforates the intestine. The ischio-rectal abscess thus produced lacks as a rule the acute inflammatory symptoms which are generally associated with the non-tuberculous variety of the disease. It is, on the contrary, often of a chronic type, giving' rise to but few symp- toms, and it may not be until external rupture occurs that the patient is led to seek advice. Treatment. — Fistula may occur early in the course of phthisis, when the pulmonary signs are but sHght. More commonly it makes its appearance when the malady is more advanced and cachexia already marked. In cases of this kind the complication becomes of secondary importance, and, un- less causing much additional suffering and exhaustion, it should not be interfered with by operation. In slighter cases, each one must be judged upon its merits. If the discharge be small in amount, the patient suffering little, and the fistula causing but trifling inconvenience, we should not advocate surgical interference; for it must not be for- g-otten that the effect of the anaesthetic and the operation it- self exercise a depressing influence upon the patient, which is not infrequently manifested by increased activity of chest disease. There is some evidence also to show that in certain cases a kind of alternation exists between the activity of the fistula and that of the pulmonary disease — an old clinical observation possibly explained by the recent researches of Sir Almroth Wright. 572 DISEASES OF THE LUNGS AND PLEURA There are instances, however, in which the local inconveni- ence and suffering- from the fistula and the mental distress are so great as to necessitate some operative measures, and in such cases surgical treatment must be carried out. REFERENCES. ^ {a) Refort on the Work of the Pathological Department of the Bromfton Hospital during the Three Years April, igoo, to April, 1903, by P. Horton-Smith (Hartley), M.D., pp. 19 and 21. London, 1903. (6) Loc. cit., p. 16. (! :T\ \ ■ ^ 1 \ 1 ^ ^v_^ ..^ ?s •--•— • »-^ \ ' \ / \ ■ ,^y^\- .^/: i > L^;/:'.V V^ ■ : : ; N/' i . ■^ ^ : '■\ „/ \ '■ ■-: f '-- •r; ?-r ' I ■ : ; : ; : : : - ) ; ; J>W.^^ 7b ss Si SO ;%:» JbiOU ««.sss,s 71 •)£ SJ.f'O &.S St iw imm'ijb w 9B TS'9(- 9Z&b')0 9b /nP9', SS,K 8S 72 72 SO oa i2 8SS0 ^r^pua^r^/ 20 20 i;/A zo 20 2'f 2i 21. Sf. 20 20-20 2i 21^ 2U 20 20 2 i. 21. 20 20 3i 21,21, 20 20 22 20 22 20 21, 21, 22 22 22 20 20 20 20 20 20 24 Fig. 57. — Showing a " Mild" Reaction produced by an Injection of 10 c.MM. Old Tuberculin. The temperature remained a little raised for four days before returning finally to normal. THE DIAGNOSIS OF PULMONARY TUBERCULOSIS 58 1 }'eb. March Dale 26 27 28 1 2 3 4 P. M, A M P M. A M- P M, A . M p. M A.M. p. M. A.M. P.M. A.M. P. M . 107 wi 105 1(1+ 103' 102' 101' 100 99" 36' 97' 1\6\/0 2 \6 \;o 2\6\I0 S\b\ro ?l6|/0 2I« l«? 2 1 6 I/O 2 16 I/O 216 I/O ? 16 I/O 2|6|/0 S\6\I0 ? 16 I/O \Z\ - ^^; ■ ; ■!■ I : ^ \\ :^- -g: : i : : /v -« • ■ Ma ^ ^ ^f^,^^ • Mv^ ; \^ : /^ kM M ■ / ^\ >-V ■ :\ V: : V ; : : ^ - - W- V- '• ■ • ^ ■ V- ■ ■ ■P- ■ i - '• ; \>^': Fig. 58. — Showing a " Moderate " Reaction accompanied by Increased Cough and Phlegm, produced by an Injection of 5 c.mm. Old Tuber- culin. f'eb. March Date. 26 27 26 1 2 3 4 p. M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P. M. A.M. p. M. A. M p. M . 10/ ]0< 105- 104' 103' 102' 101' lOd 99- 98* 97- £" ie I/O 2 16 I/O 2 16 1/0 « 16 I/O 2l6|/fl » 1 6 I/O Z 1 6 1 /O 2 16 I/O J |6 I/O 2 16 I/O £ 16 I/O e|6 I/O 2|6|» ':5; . .^"r^ ; mV > --%>^\ J'u/^'^ 6i. 7S 72 SO SO \7X\6a 6S-_72 76 /Ci ;/367/6 'izu wi^m 96 S8 7» &k &0 /cc S4 iO 72 &I. (-072 66 bl. 72 71 72 72 Respi^^:/uTi lO.ZO 9.0 10 iO .w le 20 20 U 2i.,26,?8 30^i 'JU 2/. IL was 20 2i' 22. .V W.m 16 20 ■20 20-20 10 20 20 Fig. 60.— Showing an Unusually Severe Reaction, produced by an Injection of 10 c.mm. Old Tuberculin. 582 DISEASES OF THE LUNGS AND PLEURA We may add that no rise of temperature should be con- sidered as a reaction unless it amounts to at least 1° F. above the highest temperature recorded during the days immediately preceding the injection. Moreover, slight rises, unless accom- panied by constitutional symptoms, should be regarded with suspicion, and the matter decided by a further injection of tuberculin, the quantity last given being repeated before pro- ceeding to the higher doses in the scale. A definite reaction to tuberculin such as we have described indicates almost with certainty a tuberculous focus within the body. A negative reaction to the test, on the other hand, unless the patient be in the last stages of phthisis, and thus unable to react — when, we may add, the test should not be appHed — is very strong evidence against the tuberculous nature of the disease. The g'eneral reaction, however, with which we have been dealing, does not do more than demonstrate the existence of a tuberculous focus somewhere in the body. It does not prove that it is in the lung, nor does it, as a matter of fact, prove that the focus is in a condition of activity, seeing that the observa- tions of Madison,^ Franz,* Max Beck,* and others prove that, at least among the working classes, latent lesions may be revealed by the test in from 40 to 61 per cent, of individuals who show no sign or symptom of tuberculosis. But should the patient have been suffering from cough, wasting, or other symptom suggestive of pulmonary tuberculosis, with some indefinite signs in the lung, it is not unreasonable to suppose that the focus is situated actually in the lung itself, and that the lesion is an active one. This assumption is rendered almost certain if, as not infrequently happens with the more severe reactions at any rate, signs of a focal reaction in the lung make their appearance. These are manifested by pain over the chest, increased cough, and possibly by the expectora- tion of a little phlegm, in which tubercle bacilli may make their appearance for the first time. On auscultating the chest, crepitations are sometimes also heard at a spot where before the signs had been indefinite. These focal signs are due to the congestion and inflammatory reaction which are well known to occur at the seat of the tuberculous disease as the result of the injection of tuberculin, and which have been demonstrated so frequently in cases of lupus. THE DIAGNOSIS O^ PULMONARY TUBERCULOSIS 583 The occurrence of this focal reaction is thus of great impor- tance, for, should it accompany the general reaction, it proves the existence of a tuberculous lesion in the lung itself, and enables the physician to recommend without hesitation impor- tant measures of treatment, of the necessity of which he may up till then have been in doubt. In other cases a negative result to the subcutaneous test has enabled us to exclude the presence of tubercle, and thus allay anxiety and avoid unneces- sary expense. The tuberculin test should not, as we have said, be used in febrile cases; nor, we may add, in cases in which there has been recent haemoptysis, owing to the increased local conges- tion which results. It should be withheld also in patients with kidney disease, in those suffering from epilepsy, and those greatly debilitated from whatever cause. Mild laryngeal disease is no contra-indication to its use. If care be exer- cised in these respects, and in the dosage and administration of the tuberculin, we believe that the test may be safely em- ployed, and in our own experience we have never observed harm to arise from it. It should not, hozvever, be used, save in those cases in which more light in diagnosis is for special reasons urgently needed. The Cutaneous and Conjunctival Test. — In the last edition of this work we considered in some detail the cutaneous and conjunctival tests, with which the names of von Pirquet and Calmette are usually associated. Experience has, however, shown that the cutaneous test is too dehcate, responding- to latent lesions, and thus commonly giving a positive result in healthy persons other than infants and very young children. It is therefore of no value in the diagnosis of phthisis. The conjunctival test, besides being of very uncertain value," is apt to set up serious conjunctival trouble, and is not therefore to be recommended. The Opsonin Test.— This method of diagnosis was intro- duced by Sir A. E. Wright,' and is based upon the estimation of the relative quantity of opsonin present in the serum of the suspected person, and a comparison of the amount with that observed in healthy individuals. Into the technique of the test we do not propose to enter farther than to say that it consists in bringing into contact measured quantities of the serum of the patient, white blood-corpuscles from a healthy person, 584 DISEASES OF THE LUNGS AND PLEURA and an emnlsion of tubercle bacilli, and allowing them to remain in the incubator at 37° C. for a quarter of an hour. At the end of this period a film is made, which is stained with carbol-fuchsin, decolourised with acid, and then counterstained with methylene blue, when the number of bacilli taken up by the leucocytes is counted. A similar procedure is then carried out, using the serum of a healthy person (or a mixed serum from several healthy people) as a control, and the number of bacilli within the cells again enumerated. The figure obtained in the case of the patient's serum, divided by that obtained when using the control or healthy serum, constitutes the " opsonic index," and gives the measure of the quantity of opsonin present in the serum, which, it is thought, so affects the bacilli as to enable them to be absorbed with readiness by the white corpuscles. It has been shown by Professor Bulloch and others that the index among- healthy persons varies between 0*8 and i-2, and that consequently any figures within these limits must be regarded as coming within the normal. It has also been demonstrated that an injection of tuberculin produces a marked variation in the index, causing a rise or fall, according as a positive or negative phase has been produced. Turning to pulmonary tuberculosis, the work of Dr. Inman and others has shown that in active disease, even when the patient is at rest, the index often varies markedly from day to day, swing- ing on either side far beyond the normal. The patient is pre- sumably absorbing from his focus of disease irregular quan- tities of tuberculin, and is living in a succession of positive and negative phases, that is to say, of depression or exaltation of the opsonic index. This variation of the index is weh seen in the following chart (Fig. 61), from a patient in the Brompton Hospital suffering from active pulmonary tuberculosis, ob- served by Dr. Inman, which we have taken from his Weber- Parkes Prize Essay for 1909. Such cases of active disease are usually, however, already diagnosed on other grounds, and these spontaneous changes in the index when at rest become, therefore, of comparatively little value for purposes of diagnosis. In early stages of the disease, on the other hand, the opsonic index is much more stable. In a certain proportion of cases of phthisis, as in other varieties of local tuberculosis, the index may be low. THE DIAGNOSIS OF PULMONARY TUBERCULOSIS 585 and if sufficiently below the limits of health this fact may become of diagnostic importance ; but in other patients the index under ordinary conditions may be within the Hmits of health. Under such circumstances, however, Dr. Inman has shown that active exercise, such as hard walking for an hour or manual labour, often produces a variation in the index, a fall or rise beyond the normal, owing, very probably, to an auto-inoculation of tuberculin from the focus of disease. In healthy persons no such variation is produced. These facts Dote March. 4 5 6 r ft 9 10 1-7 1-9 1-5 1-4 1-3 1-2 J-1 1 0-9 0-8 0-7 0-6 0-5 / / Av / / N / / \ i A \ f /\ \ 1 7 / ^ x/ \J ^ 0-3 Fig. 61. — Chart showing the Variations in the Opsonic Index of a Patient suffering from Active Pulmonary Tuberculosis when at Rest in Bed (Dr. Inman). are well shown in the accompanying charts (Figs. 62 and 63) from patients at the Brompton Hospital observed by Dr. Inman, and taken from his Weber-Parkes Prize Essay. Variations in the index following exercise such as we have been describing are commonly observed in cases of early phthisis, and when they occur, as they often do, in suspected cases, they may be regarded as evidence very suggestive of the presence of a tuberculous focus, a focus, moreover, not latent like those revealed in many cases by the tuberculin test, but one which is active, and from which toxines are being absorbed, and which therefore requires treatment. This con- clusion has received support by carefully following up certain of the patients at the Brompton Hospital who had given sus- picious physical signs, and who had yielded a positive result 586 DISEASES OF THE LUNGS AND PLEUR.E to the opsonin test. In twenty of these patients repeated examination of such sputum as could be obtained was made, and in nine of them tubercle bacilli were eventually discovered before they left the hospital. 1-7 1-6 1-5 14 1-3 1-2 11 I 0-9 0-8 0-7 0-6 0-5 04 03 9 a.m. 11 a.m. 12-0 12-45praj N -^ - — S Pa.m. lia.rn. 120 12-4-5PUJ1 ^j^ Fig. 62. — Showing that in He.-\lthy People Active Exercise producer NO Vari.\tion in the Opsonic Index (Dr. Inman). Between 11 a.m. and 12 an hour's hard walking exercise was taken. 4 p.m. 5p.m. 6p.in. Tp.in. lOpm. 11 p.m. 120 12-30p.m 1-7 1-6 1-5 1-4 1-3 1-2 11 1 0-9 08 0-7 00 0-5 0-4 0-3 Patit atu^ ;and betive^ en 11a m. Pat I e/itA eptin bed. and! Itooh anti ?arsl ia.rd walkl iiQ e^ lercu >e. ^^ .... ^ / / ■ &• — ^- .....«/... ©^ Fig. 63. — Showing, in the Case of a Patient suffering from Early Pulmonary Tuberculosis, an Index within the Normal so long as the Patient remained at Rest, but Marked Abnormal Variation produced by Exercise (Dr. Inman). Other evidence of the reliability of the test is afforded by the fact that, as Dr. Inman has shown, and as we have pointed out elsewhere, the variations in index produced by exercise THE DIAGNOSIS OF PULMONARY TUBERCULOSIS 587 may be observed to cease when, as the result of treatment, complete arrest of the disease has been attained. We have now to ask ourselves how far the opsonin test which we have been discussing, and which we believe may be relied upon in the hands of observers well accustomed to its use, is fitted, by reason of the difficulties of its technique and other causes, for general adoption. In this connection we must draw attention to some interesting- observations by Dr. E. C. Hort,* who sent to various pathologists of proved ex- perience specimens of blood drawn at the same time from cer- tain patients, and then compared the indices obtained. These showed in many cases gTeat variation. To take one example, that of a patient suffering from pulmonary tuberculosis with well-marked physical signs, and with tubercle bacilli in the sputum, the opsonic indices returned by three observers were as follows: (a)=0'88; (b)=i-iy and i'34 (two specimens of the same blood); (c) = 2-^,4. Two observations were thus within normal limits; the other two were abnormal, and pointed to a diagnosis of tuberculosis. The difference between the highest and the lowest indices amounted to as much as 1-46. We have seen the same discrepancy in observa- tions from the same specimen of blood made by three observers in a case in which there was no tuberculosis present. In view of such results, we can only conclude that, though the method appears valuable in the hands of a very limited body of experts, it is not suitable for general employment. It would be interesting to ascertain the relative phagocytic power in groups of persons reputed to be more or less susceptible to tuberculosis, such as town dwellers, country dwellers, those living under conditions of overcrowding in various degrees, alcoholics, feeble-minded, epileptics, diabetics and the insane, as giving insight as to the mechanism of their proclivity to the disease. Other Specific Tests.— We may now briefly refer to certain other specific tests for the presence of tuberculosis, which, like the opsonic test, depend upon the detection in the patient's blood of various specific substances produced in response to the invasion of the tissues by the tubercle bacillus. They are of great scientific interest, but cannot be said to be as yet of much practical importance. Among them we may mention : (a) The C omplement-Fixation Test. — This test, in the words 588 DISEASES OF THE LUNGS AND PLEURA of Dr. Inman, depends upon the fact that if a foreign albumin be introduced into an animal, specific antibodies are produced and can be demonstrated in the blood. Bacteria are such foreign albumins, and so are red blood-corpuscles. It is due to this latter fact that the so-called complement-fixation test has been made possible. Solution of red cells may be produced by bringing them into contact with the serum of an animal previously injected with the same type of red cells, so long as a sufficient amount of complement, a substance normally present in blood, is added. In the process union takes place between complement, red-cell-antibody and red cell. The mixture is known as a " Hasmolytic system." If tubercle bacilli are brought into contact with a serum con- taining antibodies to the tubercle bacillus, and a sufficient amount of complement is added, union takes place between the complement, tubercle antibodies and tubercle bacilli. The complement-fixation test consists in bringing' together tubercle bacilli, the patient's serum and complement. After a suitable lapse of time, to allow of union taking place in the event of tubercle antibodies being present in the patient's serum, red cells and red-cell-antibodies are added. In those tubes containing serum which possesses tubercle antibodies no haemolysis can take place, for the necessai*y complement is already " fixed " in the combination — complement, tubercle anti-body and tubercle bacillus. The reaction is then said to be positive. The test has, however, not proved of much value in practice, since as Dr. Inman," Dr. Radchffe,'" and others have shown, it is negative in a certain proportion of early cases of phthisis, and as the late Dr. Meek" has proved, it may remain positive in patients with arrested disease who have been free from symptoms and in excellent health for several years, showing that a positive reaction does not necessarily indicate active disease. (b) The Precipitin Test and (c) the Cobra Venom Test,^^ which we described in our last edition, possess also a scientific rather than a practical value. (d) The Agglutination Test, which has been found so valu- able in typhoid fever, was applied to tuberculosis by Professors Arloing and Courmont"^ some years ago, and they have re- THE DIAGNOSIS OF PULMONARY TUBERCULSSIS 589 corded several successful results in a series of papers dealing with this subject. In other hands, including our own/* the method has not been found to give reliable results in prac- tice, and we cannot therefore at present recommend it. If, however, the difficulties in obtaining^ a culture yielding a satis- factory emulsion of tubercle bacilli can be overcome, the possi- bilities of the test are great. Although these tests must for the present be regarded as mainly of laboratory interest, they are nevertheless of value in helping to deepen our insight into the intimate pathology of the disease and the modus of its immunity, and probably in furnishing some clue to its prophylaxis and treatment in the future. Conclusion. — We may, in conclusion, sum up the main facts with which we have dealt in this chapter, and indicate the pro- cedure which we should adopt in arriving- at a diagnosis in any doubtful case of pulmonary tuberculosis. The aspect of the patient is important, and careful inquiry should be made into the history of the illness, including such symptoms as coug^h, loss of weight, and sweating. The existence of pyrexia is of great moment, and its presence or absence must be definitely decided by a night and morning record of the temperature for a period of a week or more, if necessary. The chest should be carefully examined, and great stress must be attached to abnormal physical signs, such as slight impairment of note at one apex and weak or harsh breathing, with or without a few moist sounds after cough, signs which are commonly observed quite early in the disease. Speaking from our own experience, we may say that a history such as we have indicated, if accompanied by slight pyrexia and by abnormal apical signs, is almost diagnostic of pul- monary tuberculosis, and the examination of the sputum but confirms the conclusion. Nevertheless, in all cases the expectoration should be examined, and the diag-nosis, upon which far-reaching and expensive methods of treatment may depend, placed, if possible, beyond doubt. For this purpose it is best to have the early-morning sputum tested for tubercle bacilli by ordinary methods of staining on three successive days; if the result be negative, the antiformin or some other concentration method should then be employed. In most cases of this kind, 590 DISEASES OF THE LUNGS AND PLEURA even if it be stated that there is no sputum, a Httle can be obtained if the patient is directed to carefully collect any par- ticles which he may cough up in the early morning- on first waking, aided if need be by a few doses of an expectorant mixture. In children who swallow all sputum it is sometimes possible to detect the bacilli in the stools, which in such cases should be examined by the antiformin method. We have known this test prove successful. Should it not be possible to demonstrate the presence of tubercle bacilli, even after the most rigorous search, and the diagnosis remains seriously in doubt, further tests may be em- ployed. In some cases help may be derived from the X-rays; but as a rule in early cases of phthisis too much must not be expected from this method of examination, which is by no means free from fallacies. Of some assistance is a determination by a skilled observer of the opsonic index before and after exercise, when in many cases of tuberculosis an excursion beyond the normal can be obtained. But, for reasons which we have given, the method is not suitable for general employment, and in all cases the results obtained must be most carefully considered in the light of clinical observation. In afebrile cases, when the need for a more certain diagnosis is pressing, the subcutaneous tuberculin test may be employed, and for such cases it should be reserved. The occurrence of a general and constitutional reaction indicates a tuberculous lesion somewhere in the body, but not necessarily an active one; signs of focal reaction in the lung, which are alone diag- nostic, and which must be carefully watched for, point to pul- monary involvement. In the cases which we are considering a negative result to the test would exclude the diagnosis of pulmonary tuberculosis. Von Pirquet's cutaneous reaction is too deHcate to be of value; and the conjunctival test is not to be recommended. REFERENCES. The Extant Works of Aretczus the Caf-podocian, edited and translated by Francis Adams, LL.D., Sydenham Society edition, p. 309. London, 1856. THE DIAGNOSIS OF PULMONARY TUBERCULOSIS 59 1 ^ (i) " Antiformin, ein bakterienauflosendes Desinfektionsmittel," von Prof. Dr. Uhlenhuth und Dr. Xylander, Berliner Klinische Wochenschrift, 1908, p. 1346. See also (2) " The Specific Diagnosis of Pulmonary Tuberculosis," by A. C. Inman, M.A., M.B., The Lancet, 1910, vol. ii., p. 1747. ^ Quoted by Dr. Lawrason Brown, " The Diagnosis and Therapeutic Use of Tuberculin," Boston Medical and Surgical Journal, July 23, 1908, vol. clix., No. 4, p. 97. * " Ergebnis mehrjahriger Beobachtungen an tausend im Jahre 1901-02 mit Tuberkulin zum diagnostischen Zwecke injizierten Soldaten," von Oberstabsarzt Dr. Karl Franz (Wien), Wiener Klinische Wochenschrift, 1909, p. 991. ^ " Ueber die Diagnostische Bedeutung des Koch'schen Tuberkulins," von Dr. Max Beck, Deutsche Medicinische Wochenschrift, March 2, 1899, P- 137- " " The Conjunctival Reaction to Tuberculin in Arthritic Diseases," by T. S. P. Strangeways, Bulletin of the Committee for the Study of Sfecial Diseases, Cambridge, 1908, vol. ii., p. 125. ' Studies on Immunisation, and their Afflication to the Diagnosis and Treatment of Bacterial Infections, by Sir A. E. Wright, M.D., F.R.S., p. 150. London, 1909. " " Can Opsonic Determination be relied on in Practice?" by E. C. Ilort, B.A., B.Sc, M.R.C.S., Edin., British Medical Journal, 1909, vol. i., p. 400. ^ "The Diagnosis of Pulmonary Tuberculosis," by A. C. Inman, M.A., M.B., Oxon, The Lancet, 1914, i., p. 1446. '" " The Diagnostic Value of the Complement Fixation Reaction in Tuber- culosis," by James Mcintosh, M.D., Paul Fildes, M.B., B.C., and J. A. D. Radcliffe, M.B., B.Ch., The Lancet, 1914, ii., p. 485. " " A Preliminary Enquiry as to the Value of the Complement Fixa- tion Test in Tuberculosis," by Leonard S. Dudgeon, F.R.C.P., W. O. Meek, M.B., B.S., and H. B. Weir, M.A., The Lancet, 1913, i. p. 19. '^ [a] " La Reaction d' Activation du Venin de Cobra et la Recherche des Anticorps (Bordet-Gengou) dans le Serum et dans le Lait des Sujets Tuberculeux ou Suspects de Tuberculose," par A. Calmette, L. Massol, et M. Breton, Comftes Rendiis Hebdomadaires des Seances et Memoir es de la Societe de Biologie, Paris, 1908, vol. ii., p. 648. {b) " Ehfahrungen iiber die Praktische Verwertung der Komplement- bindung und anderer Bakteriologischer und Serologischer Unter- suchungen bei der Diagnose der Lungentuberkulose," von Dr. Joh. V. Szaboky, Zeitschrift fiir Tuberkulose, 1909, Band xiv., Heft 4, p. 249. (f) " On the Modern Procedures for the Early Diagnosis of Tuber- culous Infection," by Professor A. Calmette, Transactions of the Sixth [Washington] Congress on Tuberculosis, special volume, p. 73 Philadelphia, 1908. 592 DISEASES OF THE LUNGS AND PLEURA 13 " The Agglutinating Power in Tuberculous Patients — Serum Diag- nosis — Serum Prognosis " (with bibliography), by Professor Paul Cour- mont, Transactions of the Sixth International Congress on Tuberculosis {Washington), vol. i., part i., p. 528. Philadelphia, 1908. ^'' " The Agglutinating Reaction in Cases of Pulmonary Tuberculosis," by P. Horton-Smith (Hartley), M.D., and H. W. Armit, M.R.C.S., L.R.C.P., Transactions of the British Congress on Tuberculosis, vol iii.,. p. 151. London, 1902. CHAPTER XLII GENERAL OBSERVATIONS ON THE PROPHYLAXIS AND TREATMENT OF PULMONARY TUBERCULOSIS The prophylaxis of pulmonary tuberculosis, generally speak- ing", does not essentially differ from that of other diseases; all measures that tend to increase constitutional vigour also diminish mortality from consumption. On glancing through the chapters on Etiology, however, it will be seen that there are certain conditions, specific and other, which especially favour the occurrence of tuberculosis more than of other diseases, and that the tendency to the disease is inherited in a certain proportion of cases. By amending those conditions, especially overcrowding, sedentary employment, dusty occupations and intemperance, which favour the incidence of phthisis, and by taking extra precautions in all cases of hereditary predisposi- tion, we do the best that can be done, generally speaking, in the way of prophylaxis. There are those amongst physicians and sanitarians who are still disposed to minimise hereditary influence in phthisis, but without doubt, in our opinion, it should be taken into account in considering the question of marriage. There are cases in which the disease has manifested itself so strongly in both the contracting families as to make marriage absolutely undesirable. Other less decided cases must be considered on their respective merits. General Precautions. The child of a consumptive mother should be weaned early, and should, when possible, have a carefully selected wet-nurse. If a healthy foster-mother be provided, the child should be suckled entirely until eight or nine months old. If the alterna- tive of a wet nurse be not adopted, careful hand-feeding by 593 38 594 DISEASES OF THE LUNGS AND PLEURA humanised or other artificially prepared milk must be em- ployed, attention being- paid to an adequate provision of the requisite vitamines. The hygiene of the nursery must be strictly looked to, especially with regard to the avoidance of dust, the free admis- sion of air without draughts, the provision of a separate cot or bed for the child, and abundance of air-space in the night nursery. Milk, which should be boiled or properly pasteurised, must form a large item of the dietary throughout childhood, the other elements — saccharine, farinaceous, nitrogenous and saline — being duly provided. Careful attention to the skin, by the use of a tepid bath at least once a day, warm, light all-wool underclothing, loosely fitting and made to cover the chest to above the clavicles, and abundant outdoor exercise, are the principal means of securing sound health. The plan of keep- ing delicate young children with naked legs, arms, and upper chest, with the view of hardening them, is too obviously absurd to need further comment. It is, perhaps, at the present time unnecessary to add that the nurse herself must be healthy and strong, and free from any suspicion of tuberculous disease. At the period, about the age of eight, when children begin to go to school, the question comes whether a day-school or boarding-school shall be selected; and in most instances it is decidedly preferable that delicate boys, and perhaps girls, should be sent away from home to a carefully-managed pre- paratory school, than that they should attend a day-school from their own homes. The divided responsibiHty in matters of hygiene, food, clothing and the like, the hurried meals, irregularity in exercise, and increased exposure to cold and wet in bad weather, which attendance at day-schools involves, are full of risks. There is also no doubt that dehcate children, from the extra solicitude which has been necessary in rearing" them, become whimsical and mofi3idly self-conscious at about this age, and the regularity and discipline of school life is good for them. The school should be favourably situated on a well- drained soil in the countr}', at the seaside, or in the neighbour- hood of the sea. The modified sea climate of Bournemouth suits children well, also the high ground of St. Leonards, Ramsgate, Broadstairs, Folkestone, and many other places. The experiment of sending delicate children to the Swiss mountain resorts is of doubtful expediency. It can only be TREATMENT OF PULMONARY TUBERCULOSIS 595 prudently tried in cases where abundant means will permit of the best conditions and supervision. Whooping-cough and measles are antecedent to a large proportion of cases of tuberculosis in children, and the utmost care should be taken to insure complete convalescence from these diseases. An undue irritability of the lymphatic glandular system is often to be observed in children prone to phthisis, and the glands, when enlarged, not infrequently undergo caseation, and remain, as it were, magazines of tuberculous poison. Hence all sources of gland irritation, decayed teeth, eczemas, eruptions on the scalp, catarrhal affections of the bowels and bronchi, should be carefully and promptly treated. Enlarged tonsils and adenoids should also receive attention. Chicken- pox in children often leaves behind troublesome sores about the head and body, which are very likely to lead to glandular enlargements, and the utmost care should be taken during this disease to cleanse and protect all pustules which are large and likely to ulcerate. In cases in which the glands become caseous and suppurate it is better, if possible, to make a clean excision of the gland, or at least to remove all caseous matter by thorough scraping; less scarring is thus caused than by simple incision, and the danger of infection of other glands by retained caseous material is removed. Short courses of cod- liver oil and steel wine or Parrish's Food should be given to delicate children, extending over three or four weeks, at inter- vals during the winter and spring, and especially after the occasional catarrhs to which they are all liable. There is some foundation in experience for regarding the succeeding periods of seven years as critical in matters of health : there are certainly grouped about the first and second dentition, and the periods of adolescence and manhood, developmental changes and associated external circumstances of life which favour the occurrence of certain diseases, and peculiarly of tuberculosis. Between the ages of fifteen and twenty-one phthisis is very liable to develope in those predisposed, and an opportunity may be taken after the completion of school education, or at the end of the college career, to secure a period of six or twelve months to be devoted to the establishment of sound health. Many plans may be devised with this view, suited to the cir- 596 DISEASES OF THE LUNGS AND PLEUR/E cumstances and means of the patients and their friends. A long sea voyage with a responsible companion is one of the best measures, or twelve months' residence on a farm in a healthy part of this country or one of the colonies. With girls it is more easy to arrange a series of visits to healthy parts of the United Kingdom or abroad, where an outdoor life can be, to a great extent, secured. The future profession or business of a youth may during this time be determined upon, sedentary pursuits being avoided, and those en- couraged which are associated with an active outdoor hfe. There are some cases, however, and they are not very uncom- mon, in which, with tuberculous predisposition, the mental faculties are keen, whilst the bodily conformation is not. such as to withstand, or respond to, a rough physical life. In such cases a sheltered life is to be recommended, with such pursuits as the individual is best qualified for, and with such precau- tions in the way of hygiene, exercise, and climatic change as may be possible and best adapted to the case. The experienced physician can recognise in many such cases that the fund of vitality is small, and that to attempt to lay it out on an ambi- tious scale, with a view to large or long-continued returns, is to risk the loss of the whole. " Neglected colds " enter into the history of a large propor- tion of cases of phthisis. The best routine treatment of an acute catarrh in a delicate person during the first twenty-four hours consists of repeated doses, at short intervals, of citrate of ammonia or potash, the patient remaining in bed or in a warm room. Frequent fomentation of the nasal passages with hot water should be adopted, and a hot foot-bath and a little Dover's powder given at night. Besides hot-water fomentations, the local treatment of a nasal catarrh consists in the use of some antiseptic inhalation, spray or douche. The vapour of equal parts of the oil of eucalyptus and eau-de- Cologne may be inhaled, or the glycerine of thymol douche employed, or various antiseptic drugs. In two days quinine may be commenced, the patient still remaining indoors. After about the third or fourth day, when all febrile symptoms have subsided, a week's change to some accessible seaside place will commonly cure the catarrh. Sometimes at the first onset of the malady a few fairly full doses of quinine will arrest it; a combination with ammonia in the form of the ammoniated TREATMENT OF PULMONARY TUBERCULOSIS 597 tincture is particularly useful. Every effort must be made to prevent a catarrh from lingering- or becoming- chronic. In all cases of acute inflammatory chest affections occurring in patients with tuberculous tendency the utmost care should be taken to insure complete recovery, and it often takes a long- time thoroughly to effect this. It is well, if such attacks are repeated, to advise that the ensuing winter be spent in taking a voyag'e, or at a health resort adapted to the circumstances and case. In patients in whom there is an inveterate tendency to recur- rent catarrh, whether influenzal or otherwise, it may be desir- able to ascertain the organism of infection — Bacillus catar- rhalis, Pfeiffer's bacillus, the pneumococcus or other — and to prepare a vaccine to be used at appropriate intervals, with a view to increase the resistance to these organisms, and thus ward off the attack. General Observations on Treatment. There is much in the treatment of phthisis which is in com- mon with the treatment of other diseases. The four following points should, however, be especially remembered with regard to pulmonary affections : 1. During respiration samples of the surrounding air are constantly being brought into contact with the extended respiratory surface, some portions of which surface are, in the cases under consideration, more or less lacerated or suppur- ating, and bathed in muco-purulent matters, ready to decom- pose, and abounding- in specific g'erms. The remembrance of the facts embodied in this statement is enough to emphasise most strongly the importance of all hygienic measures calculated to keep the air pure, and free from organic and inorganic dust, and the necessity of abun- dant cubic space being allotted to such invalids, even beyond the requirements of others. 2. All the blood of the body passes through the lungs, the pulmonary circulation in this respect balancing the systemic. From this fact flow two or three considerations in the treat- ment of phthisis. (a) Any conditions which hurry the general circulation cause an unduly proportionate stress of blood-current through 598 DISEASES OF THE LUNGS AND PLEURAE the lungs, and hence the importance, during active disease of these organs, of muscular and mental quietude. (b) In chronic pulmonary lesions in which the disease, having effected a certain measure of destruction, is stayed, and the patient is regaining strength, flesh, and colour, a point is not infrequently attained when there arises a relative systemic plethora, the blood-volume and systemic metabolism out- balancing the vascular and functional capacity of the lungs. Fresh pulmonary hgemorrhage, congestions, dyspepsias, diar- rhoea, are the natural consequences which tend to rectify this perverted balance, but which, once started, rarely stop within salutary bounds. Timely moderation in tonics, and a re- consideration of the dietary and exercise, will avert such disasters. 3. The general circulation includes the local, and as the blood-current passes through the tuberculous lesions the toxines of the tubercle bacilli and other attendant organisms are taken up in greater or less proportion, according to the activity of the local processes and the flow of blood. This absorption of toxines under the influence of the accelerated blood-current during active exercise may overwhelm the re- sistance of the patient, raise his temperature, and prostrate his nerve-power. With perfect quiescence absorption is lessened, the index of resistance is raised, and the temperature lowered. In chronic lesions exercise may be so regulated by observa- tion of the temperature range as to produce immunity by securing duly adjusted toxic absorption. We shall more fully discuss this important matter in the next chapter. 4. Considerable tracts of lung are in health held in reserve for temporary service on occasions of unwonted exertion. It is the development and bringing into daily action of such reserves that constitutes a most important element in arrest of, or "recovery" from, phthisis. This development can be encouraged at the fitting time by graduated exercise on the incline, by residence at high altitudes, or by both combined, perhaps also by the use of apparatus such as we have referred to when discussing "pneumatometry " (p. 25). Mere expan- sion of lung', however, be it remembered, does not constitute compensatory development ; there must be also increase of capillary circulation and nutrition. The cautious stimulation of blood-pressure and respiratory function gained by regulated TREATMENT OF PULMONARY TUBERCULOSIS 599 exercise most efficiently aids the natural tendency to the changes desired. The Hygiene oe the Sick-Room. — This is a matter of the utmost importance in the treatment of phthisis. The dwelling- rooms of the patient should be of good size, lofty, and well ventilated, with a free exposure to the south or south-west, and sheltered from the north and east ; for the bedroom a south-east aspect is the best, giving- better morning sunlight. The windows should be kept widely open day and night. French windows are preferable, as they can be adjusted to protect against any prevailing hig"h wind, whilst permitting free entry of air. The furniture should be sufficient for com- fort, without superfluity. Carpets and curtains should be easily removable, so as to be shaken and dusted out of doors. All sweeping of carpets should be strictly prohibited in the invalid's rooms, and the floors and furniture should be kept free from dust by the use of cloths rendered damp by Sanitas fluid or other weak solution of a cleansing kind. Washing chintz coverings to the furniture are greatly to be commended, and two or three well-chosen patterns will afford a change from tim.e to time, grateful and cheering" to an invalid much con- fined to a suite of rooms. Every few months rooms much occupied should be thoroughly cleansed, the walls and ceilings fresh papered, or hme-whited and coloured. If papered with "Salubra" paper, they should be thoroughly washed with some disinfectant solution such as cyllin (4 ounces to a gallon of water). Much irritation, cough, and increased activity of disease, will be avoided by these simple measures, and the more the patient is confined to his rooms, the more essential is it that strict attention should be paid to them. In the presence of broken and highly absorbent surfaces deprived of the means of rejecting' harmful matters, the mechanical irritation of inert dust, and the septic influence of putrefactive and other organisms, are fertile of mischief. Gas-hghting- should be forbidden in the living--rooms. The patient must have a separate bed, springy, with horsehair mattress, not curtained, and sufficiently, but not heavily, covered. In bed-ridden cases it is often a good plan to have two beds in occupation, so that a change may be made from one to the other. The clothing of the patient should be warm and light, and even in the 600 DISEASES OF THE LUNGS AND PLEURA warmest season thin woollen or silken garments should be worn next the skin. A reference to the chapters on Etiology will emphasise the importance of adopting every possible measure of cleanliness with reg'ard to the disposal of the expectoration from con- sumptive patients; for, directly or indirectly, this is the great source of danger. We are in the habit of advising for bed- ridden cases a bib kept moist by a weak formalin solution, which serves as a constant and salutary inhalant and to catch and diminish the infectivity of any spray which may result from coughing. As a further precaution, a Japanese handker- chief should be brought across the mouth when expectorating. The employment of suitable spitting" vessels is to be insisted upon, and the proper disinfection of such vessels and the efficient destruction of their contents is equally important. Spittoons of various patterns may be used, the essential point being that they contain a liquid, not a dry, disinfectant. Sputum is only dangerous when dry, so that some liquid in the receiver is of the first importance, the exact nature of the liquid being- comparatively immaterial — Sanitas or weak car- bolised solutions may be used; cyllin (Jeyes' fliuid), i in 400, is also effective, and not expensive. The next point of importance is the cleansing of these vessels and the destruction of their contents. Destruction by fire is one of the best and easiest ways of dealing with the sputum, which in private cases, when the amount is quite small, can be simply poured on to the fire; or a spitting-cup may be used, consisting of a metal frame, into which fits a stiff and water-tight paper case shaped like a spittoon, capable of holding a disinfectant; this, after use, can be lifted out of the frame, burnt, and replaced by a fresh one. When larger in amount, so that there may be a possible risk of the sputum falling unburnt through the fire into the grate beneath, and here becoming dried and a source of danger, it is best to pour the sputum, mixed with the disinfectant, into the water-closet and thus into the drainage system. In hospitals and sanatoria, where the amount of sputum to be dealt with is greater, special methods have to be employed. At the Brompton Hospital a cremator was erected, and for some years the sputum was destroyed in this manner. The method was effective, but the cremator was found to need such TREATMENT OF PULMONARY TUBERCULOSIS 6oi constant repair that another method had to be devised. That now in use consists in subjecting the sputum to superheated steam (250° F.) for a period of twenty minutes in an apparatus devised for the purpose. After sterihsation, the steam is turned off, and the disinfected sputum is allowed to cool down nearly to 100° F., when, by opening a valve, it is allowed to pass by gravity into the drain. This apparatus, devised by Dr. Paterson, at the time resident medical officer, and Mr. Kirkland, consulting engineer to the hospital, has now been in use for some years, and is found to work simply and well.^ A duplicate, installed at the King Edward VII. Sanatorium, Midhurst, has given equally good results. Glass, china or metal spitting- vessels, when emptied, must be scalded out, and cleansed with washing-soda and water. Consumptive patients, when out of doors or travelling", should- carry suitable pocket flask spittoons. The habit of expector- ating into handkerchiefs should be avoided as much as pos- sible, and handkerchiefs so used should be frequently changed, and at once thrown into some convenient receptacle contain- ing a disinfecting fluid, then scalded and sent to the wash. For bed-ridden patients an abundant supply of small squares of linen, butter-muslin or Japanese paper should be at hand on a vulcanite tray or glass slab, and should be burned when used. All these precautions, it must be especially remembered, are sanitary measures, to be adopted in the interest of the patient himself, who is the most susceptible to unhygienic surround- ings, as well as of others in his neighbourhood. With such measures of careful hygienic cleanliness, which can be easily carried out without fuss or ostentation, any anxiety as to the contagiousness of the disease may be allayed. Dietary. — The dietary of the phthisical patient is a very im- portant question, which we shall consider in detail in a later chapter. We may here, however, say that it must be framed on a liberal scale, so as to contain a due share of animal and vegetable food and salts. The appetite and digestive powers of the patient are in many cases sufficient guides as to the amount of food to be taken. The results of Debove's method of feeding phthisical patients artificially by means of an cesophageal tube showed, however, many years ago, what clinical observation also teaches, that appetite often fails when the system is, nevertheless, ready and able to assimilate much 602 DISEASES OF THE LUNGS AND PLEUR/5: larger quantities of food. This fact is especially to be recol- lected during the hectic period of phthisis, when it is most important to sustain the patient by nourishment, given in much larger quantities than inclination would prompt him to call for, and yet without resorting to that forced dietary which w^as formerly in vogue, and which is now justly dis- credited. In cases of quiescent phthisis the natural appetite returns, and patients as a rule take food with avidity. Sometimes, when flesh and blood are being rapidly regenerated, and a ten- dency is observed for the body-weig'ht to pass beyond the lung capacity, it is advisable to restrict the dietary somewhat, by diminishing malt liquors, substituting fish for butcher's meat, and suggesting some restrictions in the amount of fluids and solids taken. Coated tongue, quickened pulse and respira- tion, restlessness, dyspepsia, and increased breathlessness on effort, will, in the absence of any fresh lesion, lead to the recog- nition of this condition, already referred to as one of relative plethora. The digestive system of tuberculous patients requires care- ful attention, and in m^any cases treatment mainly consists in establishing a working equilibrium between the digestive powders on the one hand, and the quantity and quality of food taken on the other, the aid of medicines being called in to support digestive powers and to correct digestive failure. A fertile source of dyspepsia is the swallowing of expectoration, and patients should be carefully warned of this. From time to time certain special kinds of diet have been suggested as curative of phthisis, such as the milk cure, the whey cure, koumiss treatment, the grape cure, and the like. None of these measures of treatment will, as " cures," bear examination, much of the benefit being- attributable to the healthy surroundings of the "cure," and it is now admitted that such cures are only adapted to a limited number of favour- able cases of the disease. This limited number of favourable cases of phthisis, it must, indeed, be confessed, make the repu- tation of every health resort and " cure " in turn, and attract to them many other cases for which they are not suited. The exclusive use of milk is not adapted for the treatment of any form of consumption, but in all cases, and especially in young subjects, milk to the extent of from one to two pints, TREATMENT OF PULMONARY TUBERCULOSIS 603 boiled or pasteurised, may be taken daily by those who can digest it until the body-weight is a httle above the normal height-weight ratio. Cow's milk (undiluted or skimmed), ass's milk, goat's, mare's, or fermented mare's milk (koumiss), may be used. In some cases whey may be preferred; its nutri- tive value is not large, but for those who cannot take other forms of milk it may be tried, especially in cases in which there is a considerable loss of salts in night perspirations. Koumiss, the fermented milk of mares, has from all time been used as a beverage by the inhabitants of the steppes of Southern Russia, the best koumiss being prepared from pas- ture-fed mares which have not been put to work. Ssamara is the steppe district where Russian koumiss of the best kind is rnade, and the best quality is obtained in May, June and July, when the climate, clear, dry, and aromatic, is said to be very beneficial. A glass or two is taken in the early morning', three or four glasses in the forenoon, and as manv in the after- noon. No other drink should be taken, and no sweets or alcohol in any other form, the meals consisting of a liberal allowance of mutton, poultry, eggs, butter and bread. The treatment must be commenced with caution, and should extend over a period of two or three months, as much time as possible being spent in the open air, riding or walking. We fear it will be some years before Russia can be visited for purposes of health, and the koumiss cure is not therefore likely to attract at the present time many patients from this country; nevertheless, the beverage is one which will be found useful on occasions, certain patients retaining it when the stomach will tolerate nothing- else. True koumiss made from mare's milk is difficult to obtain in London, but a substitute prepared from cow's milk is supplied by various dairies. The following formula, kindly supplied to us by the late Dr. Charles, of Cannes, may be found useful : '" Home-made Kouiniss. — Fresh milk to be just boiled, then, when nearly cold, put into champagne quart bottles, leaving enough room to shake it up easily; add a teaspoonful of crushed lump sugar, and a piece of German yeast* about the size of a hazel-nut — i.e., 20 grains; cork with new corks, and tie down with wire or string ; keep in a cool * The German yeast can be obtained from any baker who makes Vienna or fancy bread. It soon putrefies, and should therefore be used fresh ; but if placed in a cup loosely covered up with paper, it will keep a week. 604 DISEASES OF THE LUNGS AND PLEURA place, lying down, and shake twice a day. The koumiss will be ready to drink on the sixth day in average weather, earlier in hot, and later in cold, weather. A thinner koumiss is made from skimmed milk. This more resembles the koumiss made from mare's milk. Most people can digest that made from unskimmed, and for them it is a mistake to use skimmed milk. All the bottles, corks, etc., must be scrupulously clean." The Grape Cure. — This is especially carried on at Meran, Botzen, Montreiix, and some other resorts in Europe, during September and October. Professor Lebert- recommended half a pound of grapes to be taken early in the morning, at 7 a.m., and again at 5 p.m., and, after a few days, a third quan- tity at II a.m.; following this, if the fruit be well borne, the total quantity taken each day may be gradually increased to 2 pounds, this being the safe limit to which this treatment can be carried in phthisis. The diet at other meals must be Hght, digestible, and unstimulating. There is no doubt that cases of phthisis are frequently not allowed sufficient vegetable food and salts in their dietary, and when and where grapes are in season the substitution of them for the intermediate meals may often be of value, especially in cases of hectic asso- ciated with torpidity of the bowels. Exercise. — This must be taken or withheld in accordance with the patient's strength and the activity and stage of the disease. In the active phases of the malady, with elevation of temperature, quick pulse, and hurried breathing, all symptoms will be intensified by exercise, and complete muscular rest must be enjoined, in association with the best air conditions that can be provided. In connection with the digestion of food, rest is of great importance, and in many cases of phthisis we are in the habit of enjoining as a minimum of rest one hour reclining- after breakfast, one before and one after luncheon, and a fourth from six to seven, the patient "being about" and taking- such exercise at other times as may be advised. By means of revolving- shelters, tents, sheds, bath-chairs, mov- able beds,'^ and appropriate arrangement of wraps, all the advantages of open air may be obtained without exercise in suitable climates and seasons ; and much care in room hygiene on the lines already laid down will compensate for extra time spent indoors in consequence of bad weather, or in advanced * One of Ward's, Aldermann's, or Carter's mechanical bed-chairs is a great luxury as an addition to the sick-room furniture. TREATMENT OF PULMONARY TUBERCULOSIS 605 cases. In early stages of quiescent cases an outdoor life is to be advised, and those occupations and climates selected in which this can be best attained. For further details we must refer the reader to the chapters on Climatic Change and Sanatorium Treatment. REFERENCES. ' For a full description of the Apparatus see " The Sterilisation of Tuberculous Sputum and Articles infected by the Tubercle Bacillus," by Thomas Kirkland, M.I.C.E., and Marcus S. Paterson, M.B., The Lancet, 1906, vol. ii., p. 426. ^ Quoted by Dr. Burney Yeo in the chapter on " The Grape Cure " in his work on Climate and Health Resorts, p. 313. See also Climatotherafy and Balneotherapy, by Sir Hermann Weber, M.D., and F. Parkes Weber, M.D , p. 621. London, 1907. CHAPTER XLIII TREATMENT OF PULMONARY TUBERCULOSIS IN ITS EARLY STAGES Sanatorium Treatment. Tuberculosis of the kings may, as we have indicated, mani- fest itself as an acute form of the disease, associated with high fever, and marked by rapid spread of the tuberculous process. This variety must be treated by absolute rest in bed on fresh- air lines, the strength being maintained by an abundant dietary, and the special symptoms relieved by appropriate medicines (Chapter XLVII.). vSuch cases are, however, not now before us, and we have in this chapter to consider the lines which should be adopted in the more ordinary cases in which the onset of the disease is insidious, marked, perhaps, by cough, wasting, or haemoptysis, in which the process is less active, and fever, if present, is only slight in degree. With regard to such cases, the first essential is to place the patients under the best hygienic conditions obtainable, and to secure for them an abundance of the purest air. The diet must be ample and nutritious, not in great excess, but duly proportioned to the body-weight. As convalescence becomes established, gradually increasing exercise should be prescribed under careful observation. Such treatment may be carried out in a patient's own home, if it be satisfactorily situated, and cL carefully-trained nurse be available. Medical practitioners are now becoming in increasing numbers sufficiently well versed in the management of these cases. It is not often, however, that the home conditions are entirely satisfactory, and we have no hesitation in saying that in the majority of instances it is best for the patient to go for a time to a sana- 606 TREATMENT OF PULMONARY TUBERCULOSIS 607 torium, where he will receive the individual attention which his case requires, and where he will be educated in the life which he must live after returning home. It is not our purpose here to describe in detail the construc- tion of a sanatorium. Such institutions, foreshadowed by George Bodington^ in 1840, and Henry McCormac- in 1855, and brought into practical operation by Brehmer at Gorbers- dorf, and Dettweiler at Falkenstein, are now to be found in greater or less numbers in most civilised countries. They con- sist essentially of buildings specially designed to enable the patient, when within doors, whether in a bedroom, dining or recreation room, to live almost as it -were in the open air. To this end the patients' rooms are built facing towards the south ; the rooms are large and airy, and the window-space of unusual size. A veranda in front, on to which the windows open, and on which the patient may lie out during the rest-hour, is an advantage. By the construction of an open corridor to the north, into which the doors of the sleeping-room, and the win- dows above them, open, a continual circulation of air in the room is obtained. To avoid undue dampness, care is taken, in selecting a site for the sanatorium, to choose a dry subsoil, often in pine and heath-clad districts, but with the trees not too near the buildings. Protection from wind is usually secured by rising ground to the north, and often also by belts of trees to the north and east, which, if sufficiently dense, form an effective screen. To facilitate cleaning, and to preclude the harbouring of infected dust, all corners in such buildings should be rounded and the furniture simple, and of such a kind as may be easily wiped over with a damp cloth. Carpets should be avoided, but slips of rug may be allowed for comfort. On first being- received into such an institution, the patient should be kept in bed for about a week, so that a careful estimate of the activity of the disease may be obtained. If the temperature prove normal, the patient may then be allowed up for a short time in the day, the duration to be gradually extended, provided always that the extra exertion does not lead to any febrile reaction. Later on exercise ma,y be per- mitted, beginning, perhaps, with a quarter of a mile slowly walked each day. If all goes well, this is gradually increased, and soon the patient is able to enter into the life of the institu- 6o8 DISEASES OF THE LUNGS AND PLEURA tion, in which each hour is mapped out for him under careful supervision. At the King- Edward VII. Sanatorium, near Mid- hurst, the daily programme, as set forth in the " Daily Routine •and Rules for Patients," is somewhat as follows : 7.30 a.m. Gong is sounded. Patients take their temperatures and get up. Baths, hydrotherapy, etc. 8.15 ,, First breakfast gong. 8.30 ,, Breakfast gong. 9-9.30 ,, Leisure. Books can be obtained from the Librarian. 9.30 ,, Gong is sounded. All patients must go direct to their rooms, or to that part of the balcony immediately outside their rooms, and rest on their chairs until they have been seen by their medical oiEcers. 10-12 noon. Rest or exercise as prescribed. On one day in each week patients will attend in the consulting-room at this hour for examination. 12 ,, Gong is sounded. All patients must go direct to their rooms. 12-1 p.m. All patients must rest in their rooms or on their balconies. No talking is allowed. 1 ,, First luncheon gong. 1.15 ,, Luncheon gong. 2-2.30 ,, Leisure. 2.30-4 30 ,, Rest or exercise as prescribed. 4.30 ,, Tea in entrance-hall. [5-6 ,, Recreation hour for music, games, etc. 6 ,, Gong is sounded. All patients must go to their rooms as at twelve o'clock. 6-7 ,, Rest hour. 7 ,, First dinner gong. 7.15 ,, Dinner gong. 8-9.30 ,, Recreation. 9.30 ,, All patients must go to their rooms. 10 ,, All lights out. With reference to the above, we would insist that the hours of " leisure " and " recreation " are not to be spent in violent amusements, which may be as tiring as any exercises pre- scribed. During these hours the patient's time is more his own. He is allowed to amuse himself, play chess, draughts, dominoes, and so forth, or at certain times such simple games as putting, clock-golf, or bowls. Music and singing are allowed under careful supervision, for it must be remembered that both entail muscular exertion, which, if carried too far, may do harm. With regard to the body temperature, which patients are TREATMENT OF PULMONARY TUBERCULOSIS 609 rightly taught at sanatoria to take themselves, we may here remark that much discussion has been evoked as to the relative merits of mouth and rectal temperatures. The superiority of the latter has been warmly upheld by Dr. Otto Walther of Nordrach and his followers, and the rectal method is now in use at many sanatoria. There can be little doubt that the temperature so registered does more nearly represent the temperature of the body than that taken in the mouth, groin or axilla. Further, it is not subject to certain fallacies, such as the cooling of the mouth by talking, great external cold, or by a cool wind blowing upon the cheeks, by all of which the mouth temperature may be affected. Theoretically, there- fore, the rectal method may be defended. It is, however, naturally repugnant to many patients of refinement, and in practice we believe that it is unnecessary, since any abnormal rise of temperature, to 99° or higher, is accompanied by sub- jective symptoms such as headache, loss of appetite, and other feelings of malaise. Under such circumstances the patient, if properly instructed, will take his temperature without delay and with especial care, and thus insure a correct mouth-read- ing. Working on these Hues, satisfactory results have been obtained at the Brompton Hospital Sanatorium at Frimley, and we think that they go far to prove the adequacy of mouth temperatures. Exercise and Work.— In the early years of the treatment, in accordance with the practice at Nordrach, walking was the only serious exercise permitted at most sanatoria. It was thought that in this way the needful exercise was supplied with less strain upon the chest and lungs than would be the case with muscular exercises involving the arms and their attach- ments to the chest wall. At Nordrach walking was extended in suitable cases to some sixteen miles or more a day, and, with the hilly surroundings and the graduated walks thus obtained, the results were very satisfactory. Walking is, how- ever, apt to become monotonous, unless great variety of country is at hand ; and experience has now shown that other forms of muscular exercise may be employed instead, without danger to the patient, and in many cases, indeed, to his immense benefit, both moral and physical. At the Brompton Hospital Sanatorium at Frimley for patients of the poorer classes, Dr. Marcus Paterson, the 39 6lO DISEASES OF THE LUNGS AND PLEURAE Medical Superintendent, devoted great attention to this sub- ject, and devised and, with the approval of the Visiting Staff, put into practice a system of graduated labour, suited to the needs of the various patients. The labour is commenced as soon as it is seen that a patient can walk six miles a day with- out ill effects. The grades of work and exercise may be sum- marised as follows : (i) Walking from half a mile to six miles daily; (2) carry- ing baskets of mould or other material, picking up wood, watering plants, etc.; (3) using a small shovel, cutting grass borders, hoeing, etc.; (4) using a large shovel, digging broken ground, mowing grass, etc.; (5) using a pickaxe, trenching, mixing concrete, felHng trees, etc.; and (6) similar work to that prescribed in Grade 5, but for six hours daily instead of four as in the case of the preceding grades. In addition to the tasks thus allotted to them, the patients make their own beds, change their bed-linen, clean their wards and windows, polish the corridors, keep the dining-halls clean and the brass-work bright, and wash their plates, knives and forks after meals.^ The following account gives, in Dr. Paterson's words,"* a more exact description of the amount of work done in certain of the grades : " Grade 2. — Basket-work is subdivided into three sections. In the first the patient carries a load of about 12 pounds in weight a distance of 50 yards up a gradient of i in lo-y — i.e., rising 14 feet in that distance. Such patients carry in a day eighty loads, or, in other words, they will carry 8|- hundred- weight a distance of 50 yards. ... In the second section the weight carried is about 18 pounds, the conditions being the same, and these patients carry about 13 hundredweight per day. In the third section the weight carried is 24 pounds. A patient on this work carries during the day about iy\ hundred- weig"ht for the same distance. " Grade 3. — The small shovel is the ordinary coal scoop pro- vided with a long handle. Patients commencing on this grade of labour will dig 2 tons of earth a day, and raise it 7 feet into a cart, and as they increase in strength will in a day Hft about 4 tons the same height. " Grade 4. — The large shovel is the ordinary shovel used by a navvy. Patients on this grade will dig and lift about 6 tons a day a distance of 7 feet. TREATMENT OF PULMONARY TUBERCULOSIS 6ll " Grade 5. — Pickaxe-work is the hardest work possible, and consists of breaking unbroken ground, excavating, etc. Con- crete-mixing comes under the heading of pickaxe-work, as, although the large shovel is used, the work is heavier than moving sand or mould. " When a patient has been on a grade of labour for about three weeks, his fitness for harder work is considered. If the temperature has been normal, the weight satisfactory, the appetite g"ood, and if he is feeling well (this to be determined by watching- the way in which he performs his work), then he is put on harder work." On these lines, the patients have carried out much useful work at the sanatorium, although many of them had before been engaged in clerical and sedentary occupations and had not been accustomed to manual labour. A reservoir capable of holding 500,000 gallons has been excavated and concreted. Trees have been cut down and sawn into firewood, the sana- torium has been painted, a kitchen-garden trenched and cul- tivated, and the grounds kept in order, each class of work being correlated to a certain grade of labour in accordance with the extent of muscular effort involved. The results of this method of treatment have been gratify- ing. A large proportion of the patients, many of them the subjects of extensive but quiescent pulmonary disease, have been able to pass through all the grades of labour, and to do six hours of the hardest navvy work daily before leaving, during the last three weeks foregoing the hour's rest before dinner and supper, so that on returning home they are in a position to recommence work at once. As the labour is increased the patient's general condition improves, his cough and sputum diminish, and may eventually disappear. Espe- cially we would emphasise the fact that in our experience the method, under the supervision of a careful Medical Super- intendent, is free from risk. Haemoptysis, contrary to what might have been expected, is not common, and from our ex- perience at the Daneswood Sanatorium, we are inclined to think that it is less frequent than before the introduction of this form of treatment, which is also in use, though in a some- what modified form, at this institution. It sometimes happens, indeed, that a patient, when moved to a given grade, may find the work at first too much, or in his 6l2 DISEASES OF THE LUNGS AND PLEURA eagerness to get well, may do more than he ought. Such conditions reveal themselves by headache and by a slight rise of temperature (a mouth temperature of 99-0° in men or 996° in women is regarded by Dr. Paterson as the " danger signal "), and if not checked would no doubt lead to extension of the lung disease. If the patient, however, is put to bed at once, kept at " absolute " rest, and treated in this respect as completely as if he were suffering from typhoid fever, after three or four days the temperature will again reach normal, and after the lapse of a few more days he may be able to return without ill effect to that grade of labour which before proved excessive. Such events emphasise the importance of the graduation of the labour and of the constant supervision of a skilled medical officer. In other and less successful cases it may not be pos- sible, even after several attempts, for the patient to proceed beyond a certain low grade of labour. In addition to the medical value of the treatment, we should like to bear testimony also to its immense moral effect upon the patients. The earlier sanatorium regime, especially when much rest and little exercise was practised, was not calculated, it must be admitted, to make them anxious to return to work, even though physically fit when discharged from the institu- tion. Discontent in the sanatorium itself, owing to lack of occupation, was also by no means infrequent. Under a system of graduated labour, when its object has been fully explained, all is chang-ed. The patients become cheerful, and take an interest in the scheme, which is at once economically produc- tive and an agent in their recovery, and when they leave the sanatorium they are willing and in many cases able to recom- mence work at once. For these reasons the method has now been generally adopted in this country in sanatoria for the working classes, and with some modifications has also been introduced into certain private sanatoria. We may now consider how the good effects resulting from a scheme of graduated labour are produced. It might be imagined that the result was simply due to the better general nutrition of the patient following upon a proper and due degree of exercise. This no doubt plays its part, but the observations of Dr. Inman, the Superintendent of the Labora- tories of the Brompton Hospital, indicate that this is by no TREATMENT OF PULMONARY TUBERCULOSIS 613 means all, and that we are really dealing with a carefully graded auto-inoculation of tubercuHn in gradually increasing doses, and with, in favourable cases, an immunising response on the part of the patient. Dr. Inman made numerous ex- aminations of the blood in the cases under treatment, and he has shown that while early cases of tuberculosis with signs of activity exhibit marked variations in the opsonic index as the result of exercise (see p. 585), similar to those produced by a dose of tuberculin, those who had passed through the highest grade of work, and had lost cough and sputum, and whose disease was clinically arrested, showed no such sensitiveness of the index, but yielded an opsonic chart exactly resembhng that of ordinary healthy individuals. He was able also in certain individual cases to trace this change in the index from abnormal to normal by examining the blood at different stages of the treatment, the index becoming normal when the disease is arrested, and when exercise no longer leads, as he beHeves, to absorption of tuberculin. His observations are of great interest, and support his contention that we are really dealing with auto-inoculation of tuberculin, and subsequent immunisa- tion. This view is, moreover, sustained by the fact that, as he has demonstrated, exertion in these cases produces a response to the tuberculous opsonic index only, that relating to the staphylococcus showing no variation. Diet. — We may now pass to the question of the diet which should be given in cases of phthisis suitable for sanatorium treatment. Not so very long ago it was the fashion, especially in certain German sanatoria, greatly to overfeed such patients, and at Grabowsee'^ the calorie value of the proteids, fats, and carbohydrates in the diet amounted to 1,200, 2,200, and 2,100 respectively, giving a total calorie value of 5,500. At Falken- stein^, on the contrary, the similar figures were 530, 1,120, and 1,050, with a total value of 2,700. Overfeeding is in contravention of a principle already laid down ; that the body-weight and blood-volume cannot for long transgress the respiratory capacity without a corrective dis- turbance often difficult to control. Some few years ago Dr. Bardswell and Dr. Chapman, in conjunction with Professor Goodbody,^ made some important observations at the Bromp- ton Hospital upon metabolism in phthisis, and especially in 6i4 DISEASES OF THE LUNGS AND PLEURA connection with the overfeeding which the disciples of Dr. Walther of Nordrach were at the time zealously upholding. Their results showed that " very large diets gave unsatisfac- tory results, as, although weight was gained, it was only at the expense of the general health, indicated by failure of appetite, more marked digestive disturbances, increased intestinal putrefaction, and in one case vomiting." Further, "this gain of body-weight was not associated with any more satisfactory progress in the tubercular lesion than was obtained with the smaller diets''^ — an opinion which will be fully confirmed by physicians who have examined patients returned from sana- toria at which the system was practised, perhaps two stone above weight, but so breathless as to be scarcely able to cross the room. As a result of such observations, excessive over- feeding has now been largely given up. In choosing a diet for a sanatorium patient, who is, as a rule, somewhat below weight, we shall not go far wrong if, as recommended by Dr. Bardswell and Dr. Chapman, who have devoted considerable attention to the subject, we choose a diet suitable for an average person in good health, but increase the proteids therein by 30 per cent., and the total energy-value by a similar amount. The extra calories required over and above that supplied by the increased proteid may be made up by the addition of either carbohydrates or fats — preferably, perhaps, the latter, when we remember how easily even very large quantities of fat are absorbed by phthisical patients. On these lines the diets at the King Edward VIL Sanatorium were constructed by Dr. Bardswell, then Medical Superin- tendent, and the results obtained have proved very satis- factory. The diets possess approximately the following nutritive values : Proteids (in grammes). Fats (in grammes). Carbo- hydrates (in grammes). Calories. Men Women 144 126 160 160 270 220 3,186 2,814 In detail the diets are as follows TREATMENT OF PULMONARY TUBERCULOSIS 615 STANDARD DIETS IN USE AT THE KING EDWARD VII. SANATORIUM. Men. Women. Time. Diet. Quantity. Diet. Quantity. 7.30 a.m. Milk \ pint Milk 2 pint. 8.30 a.m. Breakfast. Breakfast. Porridge (with milk) i pint Porridge (with milk) 1 pint. Egg I (4 days Egg I (4 days a week) a week). Meat (A), etc. 2 oz. Meat (A), etc. i^ oz. Bread 2 oz. Bread ih oz. Butter \ oz. Butter i"oz. Tea, coffee, mar- Tea, coffee, mar- malade, etc. q.s. malade, jam, etc. q.s. 1.T5 p.m. Luncheon. Luncheon. Meat (B) 3 oz. Meat(B) 2\ OZ. Pudding (suet or Pudding (suet or milk) 5 oz. milk) 3 oz. Bread 2 oz. Bread i^ oz. Butter h oz. Butter \ oz. Potatoes and vege- Potatoes and vege- tables, or salad q.s. tables, or salad q.s. Stewed fruit, jam, Stewed fruit, jam, etc q.s. etc. q.s. Cheese and biscuits q.s. Cheese and biscuits q.s. 4.30 p.m. Tea (optional). Tea, bread and but- ter, sandwiches, Tea (optional). Tea, bread and but- ter, sandwiches, or cake q.s. or cake q.s. 7-15 p.m. Dinner. Soup or fish (op- tional) Dinner. Soup or fish (op- tional) Meat (C) 3 oz. Meat(C) 2\ oz. Pudding (milk or Pudding (milk or suet) 5 oz. suet) 3 oz. Bread 2 oz. Bread I2 oz. Butter h. oz. Butter i oz. Milk ipint Milk 1 pint. Potatoes and vege- Potatoes and vege- tables q.s. tables q.s. Stewed fruit, jam. Stewed fruit, jam, etc. q.s. etc. q.s. Cheese and biscuits q.s. Cheese and biscuits q.s. 9.30 p.m. Milk 2 pint Milk I pint. 6l6 DISEASES OF THE LUNGS AND PLEURA N.B. — The weights given are the minimum quantities which are pre- scribed ; second helpings of meat, pudding, and butter are allowed, if asked for. We may add that during and since the war margarine has been substituted for butter. Meat (A). At breakfast, on different days of the week, one of the follow- ing is provided : Bacon, ham, fish, tongue, or sausage. Meat (B). At lunch this consists of one of the following : Roast or boiled beef, hot or cold. Roast or boiled mutton, hot or cold. Beefsteak and kidney pudding, stewed steak or Irish stew, or liver and bacon. Chicken, roast lamb, veal, or pork occasionally. Meat (C). At dinner this consists of one of the following : Hot roast or boiled beef, hot roast or boiled mutton, hot roast lamb. When the sanatorium was first opened in 1906 a further half-pint of milk was given with luncheon, but after some experience this was discontinued, it being found that patients taking this quantity of milk tended to become too fat. The proper calorie value of the diet was maintained by increasing the helping of porridge at breakfast and the suet intake, and by the addition of extra vegetable proteid in the form of peas, beans, or lentils. On the dietary so modified it is found that patients below their normal weight usually gain about i^- to 2 pounds a week. When some 6 pounds above their average normal weight, the diet is somewhat diminished, the amount of milk being still further reduced. For the industrial classes, accustomed to fewer but larger meals, it is found at the Brompton Hospital Sanatorium that it is better to give the requisite nourishment in three solid meals — breakfast (8.15 a.m.), dinner (i p.m.), and supper (6.30 p.m.), with a cup of tea at 4.30— rather than in smaller quantities at more frequent intervals. Should the temperature rise during the treatment, and the patient be confined to bed, the diet need not necessarily be altered; but if the appetite fail, it may be tempted by varying the food. Thus, fish, chicken, sweetbread or mince may be ordered instead of the more sohd joints, whilst the milk and suet puddings are replaced by junkets, custards, and jellies. Alcohol is but rarely required by patients undergoing sana- torium treatment, but should the appetite flag, or the case "hang fire," a glass of Burgundy, port wine, or good beer at lunch and dinner may sometimes be prescribed with advantage. It is in these cases that the rest-hour preceding lunch and TREATMENT OF PULMONARY TUBERCULOSIS 617 dinner becomes of especial value, and it is a good rule with such patients to insist on its continued observance for some considerable time after returning- home. Medicinal Treatment. — The Dispensary at a sanatorium does not usually play a very important role. The early cases with but little active disease, which are best suited for the treat- ment, improve, as a rule, rapidly without medicine, though from time to time a mixture for dyspepsia, or more commonly a simple laxative, may be required. In the smaller percentage of active cases, which are to be found in all such institutions, drugs are of greater value, and their administration will be considered in a later chapter (p. 671). The question of com- bining tuberculin with sanatorium treatment will also be discussed (p. 711). After a stay at a sanatorium for a certain time there are many people who may with advantage continue to live a country life, pursuing similar, but less rigid, lines of treat- ment. For such mitigated and, so to say, "peripatetic" cases of phthisis, which are often to be found at health resorts, it is our custom to lay down some such rules as the following : They should take one hour's rest after breakfast, one before and one after lunch, and one before dinner. Their diet should be generous, and, if necessary, before the morning walk we would prescribe an ounce or two of raw-meat juice.* The afternoon tea may be directed to be made with milk instead of water, and at night, and perhaps also in the early morning, some malted milk food, such as Horlick's or MelHn's, may often be taken with advantage. Due exercise, regulated by the patient's strength, must be taken, and the open-air plan of treatment continued. On lines such as these consumptives belonging to the upper classes not uncommonly maintain their health, even though the pulmonary disease may be advanced. REFERENCES. ^ An Essay on the Treatment and Cure of Pulmonary Consumftion, by George Bodington, surgeon. London, 1840. Reprinted by the New Sydenham Society, 1901, vol. clxxiii. * This may be best prepared by squeezing the juice from half a pound of mutton or beef previously just browned at the fire to give the taste of cooking ; it may then be served in a coloured claret glass, with one or two teaspoonfuls of port wine to flavour, and taken with a biscuit or finger of sponge cake. 6l8 DISEASES OF THE LUNGS AND PLEUR.E ^ On the Nature, Treatment, ayid Preve7ition of Pulmonary Consumption, and incidentally of Scrofula, with a Demonstration of the Cause of the Disease, by Henry McCormac, M.D. London, 1855. ^ The description is taken from — (i) The Sixty-eighth Annual Report of the Hospital for Consumption, Brompton, 1909, p. ix. (2) " Graduated Labour in Pulmonary Tuberculosis," by M. S. Pater- son, M.B., Transactions of the Sixth International Congress on Tuberculosis [Washington). Philadelphia, 1908, vol. i., part ii., p. 886. * " Graduated Labour in Pulmonar}' Tuberculosis," by M. S. Paterson, M.B., Transactions of the Sixth International Congress on Tuberculosis [Washington). Philadelphia, 1908, vol. i., part ii., p. 890. ^ " Diet in Tuberculosis," by Professor Irving Fisher, New Haven, Conn., Transactions of the Sixth International Congress on Tuberculosis [Washington). Philadelphia, 1908, vol. i., part ii., p. 694. ■^ " On Metabolism in Phthisis," by Francis W. Goodbody, Noel D. Bardswell, M.D., and J. E. Chapman, L.R.C.P., Transactions of the Royal Medical and Chirurgical Society, 1901, vol. Ixxxiv., p. 35. ' Diets in Tuberculosis, by Noel Dean Bardswell, M.D., and John Ellis Chapm^an, M.R.C.S., L.R.C.P., p. 37. London, 1908. * (i) Diets in Tuberculosis, by Noel Dean Bardswell, M.D., and John Ellis Chapman, M.R.C.S., L.R.C.P., p. 59. London, 1908. See also (2) First Annual Report of the King Edward VII. Sanatorium, 1906- 1907. CHAPTER XLIV TREATMENT OF PULMONARY TUBERCULOSIS IN ITS EARLY ST AO'ES— [Continued) Results of Sanatorium Treatment. We have sketched in broad outline the sahent points in sana- torium treatment, and we have pointed out that for the great bulk of the population this treatment cannot be efficiently carried out except in sanatoria, at all events for the first few months; after which time the experience gained in personal management may enable patients of suflicient self-control and resources to continue the treatment at their own homes or in other convenient places. We cannot too strongly emphasise the educational value of sanatoria in inculcating hygienic methods of life, not only upon the patient himself, but upon all with whom he is brought in contact. Let us now ask what are the results which have been obtained by this means, and how far it may be regarded as an advance on methods previously in vogue; and first of all let us consider the question in its relation to the industrial classes, in whom the conditions of life after leaving the sanatorium are often far from satisfactory. Results of Sanatorium Treatment Among the Industrial Classes. — That treatment in a sanatorium is not, as was at first believed by some, a panacea for all forms of pulmonary tuberculosis, and in whatever stage of the disease, is now generally admitted. The experience of all who have to do with sanatoria, as well as the statistics from numerous institutions brought forward by Dr. Bulstrode' in his report upon this subject, unite in proving that it is only in the early cases that the most hopeful results can be expected. Advanced cases may derive temporary 6ig 620 DISEASES OF THE LUNGS AND PLEURA benefit, and leave with gain in weight, and not a few with temporary restoration of working power. But after a few months, or it may be a year or two, the majority again break down, and succumb to their disease. This was well shown by Dr. John Gray in his " Summary of Results of the First Eight Years' Working of the Stanhope Sanatorium, Weardale, Durham"- — an institution opened in 1900 for the treatment of consumptive patients belonging to the industrial classes. He gives a table showing that, of 317 patients admitted during the years 1900-1908 with advanced disease (Stage III., Turban), not more than 130 were enabled to return to work after leaving the institution, and these, in most cases, followed it for a few months only. Within four years the bulk of the patients were dead. Occasionally such patients live longer, and may even surprise the physician by their vitality; but such an event is not of frequent occurrence. In another table Dr. Gray shows that, of 267 patients admitted to the same sanatorium with early pulmonary tuberculosis (Stage I., Turban) during the same period, 239 were enabled to return to work after their discharge, and that in 1908 only 46 of the 267 patients admitted during the preceding eight years were known to be dead, 136, or rather more than 50 per cent., being still at work. These conclusions have been universally confirmed, and it is in fact obvious that advanced cases of phthisis have already run their course half-way, or it may be two-thirds, towards the end before they come under the sanatorium regime, and that the fullest advantage of this regime can only be looked for in those who are admitted to treatment at the earliest period. Every effort must accordingly be made to persuade those suffering from phthisis to apply for treatment when still in the early stage of their disease, since the best results, whether immediate or enduring, are thus most likely to be secured. We have dealt with this question in much greater detail in our last edition, and may here briefly say that the general result of treatment in industrial sanatoria is that from 50 to 60 per cent, of the cases taken in the early stage are capable of working from four to five years after leaving the sanatorium (see references ^ *, ^ and ^), the margin of difference chiefly depending upon the conditions of life to which they return. TREATMENT OF PULMONARY TUBERCULOSIS 62 1 On the other hand, most of the advanced cases would be dead within four years.^ The Importance of Efficient After-Care. — The value to be derived from sanatorium treatment, whether among the industrial classes or the well-to-do, depends in fact upon the efficiency of the "after-care." If the patient returns to the unsatisfactory conditions, whether in his work or at home, under which he acquired the disease, the improvement or arrest obtained at the sanatorium will infallibly be of short duration. This is shown in the better results obtained by Dr. Burton-Fanning^ at the Kelling Sanatorium, Norfolk, where special care was taken from the first to obtain suitable em- ployment for the patients after their discharge, and also by the similar results obtained among the employes of the Prussian and Hessian Railway Companies^ quoted in our last edition. The beneficial effect of improving the work and environ- ment of the patient has also been recently demonstrated at the Brompton Hospital Sanatorium at Frimley. For this pur- pose the late Dr. Meek,'' whose untimely death is much to be deplored, contrasted the after-histories of two groups of patients, in whose sputum tubercle bacilli had been found, and who were discharged from the sanatorium in 191 5. In the first group, 32 in number, the patients were dis- charged with apparent arrest of the disease, and returned to the homes and working conditions under which they had previously broken down. Two years and a few months later 15 (46-9 per cent.) were still at work, 8 (25 per cent.) were alive but unable to work, and 9 (28-1 per cent.) were dead. In the second group of cases the disease was somewhat more extensive, and in 23 tubercle bacilli were still present on dis- charge, but the patients, 44 in number, left the sanatorium capable of doing a reasonably full day's work, and having a fair chance of maintaining working-capacity in healthy sur- roundings. Of these 44 patients, 29 effected a change of both residence and occupation, 5 a change of occupation only, and 10 found situations at their former employment, but in more suitable localities. In most instances the new work and sur- roundings were far from ideal, but constituted a marked im- provement on their former conditions. After a few months over two years, 35 (81-4 per cent.) were well and at work; 6 (13-9 per cent.) were well and at work, but had been obliged 622 DISEASES OF THE LUNGS AND PLEUILE to have time off for illness ; i (2-3 per cent.) was fairly well, but not at work; and i (2-3 per cent.) had died. The figures quoted show the value of improving the work and environment of the patient on his return home. We have similarly been much impressed by the manner in which patients, whose health has been seriously undermined by ex- tensive disease, but who have been taken on to the permanent staff of the sanatorium and have thus continued to hve under the best conditions, are able for long periods to retain their health and working- capacity. Several such patients are on the staff of the Frimley Sanatorium, and some have worked there continuously for eleven years. In another instance a skilled engineer was under the care of one of us at the Frimley Sanatorium during the year 1908, having extensive disease of the right lung; the following year he was appointed head engineer at one of our best-known sanatoria, and has remained in good health, working there continuously ever since. It is the object of " colonies," such as the Cambridge- shire Tuberculosis Colony at Papworth Hall, under the supervision of Dr. Varrier Jones, to provide the patients who go to live there with suitable work under the best hygienic conditions, and we must wish success to this and similar insti- tutions which recognise the fundamental importance of effi- cient after-care in the treatment of phthisis. In country districts the inexpensive shelters of wood and canvas desig^ned by Dr. Lyster,* of Great Baddow, near Chelmsford, which can be erected in the cottage garden, and in which patients can sleep, are helpful in promoting the con- tinuance of the after-care. Hints in Regard to Change of Work and Environment. — In advising upon the question of any change in work and environment after the patient leaves the sanatorium, care must be taken in the first place to see that the new work will be sufficient, w4th any other resources available, to enable the patient to obtain a living- wage, and thus the full nourish- ment which his case requires. For this reason, as we have pointed out elsewhere,* it is generally a mistake to advise the patient to give up his former occupation and to undertake, « * The following paragraphs are quoted from an address delivered by one of us before the Inter-Allied Conference on the After-Care of Disabled Men,' 191 8. TREATMENT OF PULMONARY TUBERCULOSIS 623 without any previous experience or training, work upon the land. The wages are not high, the housing accommodation is too often poor, and the work is at times exceedingly arduous. It is carried on also under conditions of exposure, and the hours at certain seasons are very long. As a result, only the exceptional case can stand it without breaking down, and it is not suitable for the average consumptive on leaving the sanatorium. We may add that it is not a life which pos- sesses g'reat attractions for the former town-dweller. In many cases, owing" to the difficulty of finding a new occu- pation, and the fact that under such circumstances the man will at first be untrained, and therefore capable, for a time at least, of earning only a low wage, the wisest course is to allow the patient to return to his former avocation, pro- vided it be not clearly and obviously unsuitable to a consump- tive patient, changing, hozvevcr, the environment zvhenever possible. Thus, a clerk may return to his clerical work, but should obtain, if possible, a post in the country or at the sea- side. Similarly, a bank clerk may often be transferred to a country or seaside branch. A railway porter should apply for removal from a city to a country station, and a policeman to a suburban division, while a carpenter may obtain work as an "estate carpenter." Should it be necessary, owing to the special circumstances of the case, to find a fresh occupation for a patient, then one must be chosen in which the work is carried on under good conditions, and as much in the open air as possible. When- ever possible, too, the employe should be to some extent his own master in regard to the number of hours worked each day, and the ability to take a day off from time to time, should he not be feeling quite up to the mark. In this way his strength is conserved, and the danger of a breakdown lessened. In deciding on the exact occupation, the various trades should be considered. For example, in the building trade the work of a painter or decorator, a builder, a bricklayer, a car- penter or joiner may all be permitted, by preference, however, in a smaller rather than a larger town. Wood-carving or wood-road laying may similarly be sanctioned. In the transport trades a man might take up the work of a coachman, cab-driver, chauffeur, taxi-cab driver, motor-van 624 DISEASES OF THE LUNGS AND PLEURA driver or motor-cleaner, but experience shows that the work of an omnibus- or tram-conductor or driver is generally too arduous in these days of large vehicles and rapid driving. Railway-ticket-collecting- and certain forms of mechanical work on the railways are also suitable. Although the work of an agTicultural labourer is not, as we have seen, to be advised, certain lighter forms of work on the land may be recommended, such as market and flower-gar- dening, fruit-growing, hurdle-making, forestry and woodman's work. The occupation of a game-keeper, park-ranger, park- attendant or lodge-keeper is also excellent, but the number of such posts is limited. Other light occupations which may be mentioned are those of a traveller, an insurance or commission-agent, rent-collec- tor, canvasser (though in individual cases they may involve too many hours' walking), commissionaire and bookstall- attendant. Window-cleaning is not to be recommended, owing- to possible risk of haemorrhage. The above list of occupations is by no means exhaustive, and is given only as an indication of the kind of occupation which may be recommended. For married men, we have often suggested that, if the wife is capable and has some knowledge of country life, some business, in which she can assist, may be entered u^on in a country or village district. We have drawn attention to the fact that relapse is only too common if the patient returns to the depressing conditions under which he acquired the disease. The converse is also trife, and Dr. Picken has drawn attention to the fact that not a few soldiers who first showed evidence of phthisis in the army, and who had tubercle bacilli in the sputum, are still working regularly a year or two after discharg-e, and without having- had the benefit of sanatorium treatment. In many the physical signs would now appear to be very slight. This result, as Dr. Picken" suggests, may well be attributable to early recognition and acceptance of the disease, and also to the fact that many of the patients possessed a fairly strong natural immunity to tuberculosis, and only contracted the disease under abnormal war conditions of mental and physical strain and exposure to infection. When removed from these conditions, the natural recuperative powers effect a cure. The Value of Sanatorium Treatment am,ong the Indus- TREATMENT OF PULMONARY TUBERCULOSIS 625 trial Classes. — It is pertinent now to ask how the results of sanatorium treatment among the working classes compare with those met with in patients of a similar class who have not had the advantage of institutional treatment. Such a comparison is by no means easy to make, since adequate data are not available. Moreover, with improved medical treatment and the generally increased well-being of the industrial classes, coincident with the rise in wages which took place in the latter half of the nineteenth century, the prognosis of consumption has improved materially since Laennec and Louis a century ago placed the duration of the disease at about two years. Even in 1849, when the first medical report of the Brompton Hospital was published, the outlook was not much better than in Laennec's time, for of 215 cases which had terminated fatally in the hospital, the duration of 168 (78' i per cent.) was under two and a half years, and only 6" 5 per cent, of the patients lived longer than four years. Sixteen years later the researches of our late colleague. Dr. Pollock," showed that the outlook was more favourable. Of 3,566 phthisical patients observed by him, only 129 (3-6 per cent.) had died within two and a half years; in the remainder the condition of the patients was still on the whole "favourable to the expectation of hfe for a considerable term." In 1903 Dr. Stadler,^^ of Marburg, from his observation of 670 male and female patients during the years 1893-1901, was led to place the mean duration of life in cases of phthisis occurring among the working-class population of Marburg and its neighbourhood at between six and seven years. Messrs. Elderton and Perry,^^ working under the auspices of Professor Karl Pearson, pubHshed in 1910 a statistical memoir dealing with this subject, in which they compared the results from sanatorium treatment with those obtained in pre- sanatorium days, using for the latter the data collected by the late Dr. Pollock and the late Dr. Theodore Williams. It should be noted, however, that the patients of Dr. Williams were private cases, and did not belong to the working classes. The conclusion arrived at was that "the mortality among sanatorium patients does not show any improvement over that of earlier days." The authors admit, however, that the comparisons are difficult by reason of the way in which the 40 626 DISEASES OF THE LUNGS AND PLEURA older figures were given. In a more recent publication deal- ing with the private patients of the late Dr. Austin Flint in the United States between 1845 ^^^ 1870, Messrs. Elderton and Perry ^* draw attention to the fact that for reasons given any comparison between sanatorium results and presana- torium records is open to considerable criticism, and conclude that, while hoping and thinking that some improvement has taken place, it is far less than has sometimes been stated. Our own experience would lead us to the conclusion that for incipient and early stage cases amongst the industrial classes superior immediate results are obtained in sanatoria, and that those results may be maintained for many years under favourable conditions of working life. The securing of these conditions constitutes the grave problem to be faced, and to this subject we have referred above. Sanatoria for the industrial classes are not adapted for patients with advanced disease, nor for cases of pulmonary tuberculosis in an acute stage, nor for those more active cases, numbering, perhaps, some 10 per cent, of the whole, which steadily progress in spite of every form of treatment. Such patients are better in a hospital, and we believe that the best results can only be obtained when, as at Brompton, the sana- torium and hospital are hnked together. In the hospital the patients can be carefully observed and g'rouped, those with fever and active disease being treated and nursed at the parent institution, those in an early and more quiescent stage, in whom a few v/eeks' observation gives promise of arrest of the disease, being drafted to the sanatorium. For patients with advanced disease further accommodation is required, and some suitable modification of portions of our existing poor-houses and infirmaries might easily be effected to assist in meeting the requirements. Results of Sanatorium Treatment among the Wealthier Classes. — In patients belonging to the wealthier classes, whose circumstances after leaving home are, as a rule, much more favourable for the maintenance of health, the outlook, as might be expected, is more hopeful. Dr. Noel Bardswell,'' in 1910, published the results which he obtained at the Mundes- ley Sanatorium in regard to the 241 male and female patients treated by him at that institution during the five years 1901 TREATMENT OF PULMONARY TUBERCULOSIS 627 to 1905. These patients were unselected, and were admitted consecutively. His figures demonstrate clearly that with the well-to-do, as with the poor, the best results can only be looked for if treatment is commenced early. If also we examine the early or, as they are called, incipient cases, following the American method of classification, and note the results on January i of the fifth year after treatment in those discharged during. the period 1901 to 1904, we obtain results which are comparable with those which we have already quoted. We find in this way that of 54 patients belonging to this group, 48, or 88"8 per cent., were still aHve and fit for work between four and five years after their discharge, as compared with the approximate figures 50 and 60 per cent, obtained at the Stanhope and Kelling- Sanatoria. The results obtained over a period of twenty-one years at Dr. Trudeau's " Adirondack Cottage Sanitarium " in New York State, an institution which in some respects resembles the King Edward VII. Sanatorium at Midhurst, though the patients are of a somewhat higher social standing, were analysed statistically by Dr. Lawrason Brown and the late Mr. E. G. Pope.'^ They refer to 2,261 patients admitted in all stages of the disease. The immediate results were as follows : Table showing the Condition on Discharge of 2,222 Patients admitted INTO THE Adirondack Cottage Sanitarium, New York State, U.S.A. Condition on Admission. Number of Patients. Condition on Discharge. Apparently- Cured (per Cent.). Disease Arrested (per Cent.). Disease Active (per Cent.). Died in the Sanitarium (per Cent.). Incipient cases Moderately advanced ... Far advanced 620 1.329 273 56 12 3'- 46 16 II 40 78 0"03 2-00 6 "00 The above figures demonstrate once again that for even the immediate results to be successful treatment must be com- menced early. They also bring out the important fact, to which we have already referred, that even in early cases arrest is not by any means a certainty. Thus, of the 620 " incipient" 628 DISEASES OF THE LUNGS AND PLEURA cases, 68, or ii per cent., were discharged with the disease still showing signs of activity. The further results, showing the after-histories of those who left the sanatorium (a) "apparently cured" (519 cases), (b) with "disease arrested" (890 cases), (c) with "active disease " (835 cases), may perhaps be best set forth in the fol- lowing diagram, taken from Dr. Lawrason Brown and Mr. Pope's paper. The curves, based upon the Adirondack figures, show for 1,000 persons of each of the three groups, the numbers surviving at the end of successive years, the curves so obtained being compared with the expected death- rate of the general population. Diagram showing the Numbers surviving at the End of Each Year, OUT OF (I.) 1,000 Persons in the General Population; (II.) 1,000 discharged "Apparently Cured" from the Adirondack Cottage Sanitarium; (III.) 1,000 discharged "Arrested"; (IV.) 1,000 dis- charged with " Active Disease." 900 too JOO 600 too too 300 too VO ' g 3 » f i ? » » 11> 11 K 1? 1». 15 li 17 H 1? M \ [~~~ -_ ■ — , \ ^ — -— -^ V N ~~~~ ji. \ \ \ -^ ■-^ \ ~~- \ ^ -— TTT ^ ^ \ '~~" ■^ \ \ If we study the curves shown above, it will be seen that the patients who have been discharged " apparently cured " (Curve II.) possess an outlook of a very hopeful kind, the number surviving at the end of fifteen years being about 750 out of every 1,000, as opposed to 850 per 1,000 of the general population. A glance at the table on the preceding page will, moreover, show that of the 620 patients admitted in the in- cipient stage of the disease, whom careful diagnosis should at the present day at once bring under treatment, 56 per cent., or more than half, were discharged "apparently cured," and possess therefore this favourable prognosis. Curve III. further reveals that the patients who were dis- charged with "arrested" disease, which group includes 32 per cent, of the incipient cases, still possessed an average expec- TREATMENT OF PULMONARY TUBERCULOSIS 629 tancy of life of between seven and eight years. In only II per cent, of early cases was the outlook gloomy, as shown by the rapid fall to the base line of Curve IV. Such results are satisfactory, and demonstrate what may be hoped for from sanatorium treatment in the upper classes, whose members are able to carry on the treatment after leav- ing the institution, and in whom the disease has been detected and brought under treatment in an early stage. With the more advanced cases the future is proportionately less bright. Data derived from the Records of the King Edward VII. Sanatorium, Midhurst. — A newer method of estimating* the results of sanatorium treatment was followed by Dr. Noel BardswelV^ in collaboration with Mr. J. H. R. Thompson, a Fellow of the Institute of Actuaries, under the auspices of the Council of King Edward VII. Sanatorium, Mid- hurst, and carried on since 1914 with the countenance and aid of the Medical Research Committee of the National Health Insurance, who have borne the expense of publishing the results. The lines of the investiga- tion are similar to those adopted by Messrs. Elderton and Perry^* in their study of the results obtained at the Adirondack Sanitarium to which we have alluded. The cases are grouped " i," "2," "3" for each sex, according as they are in the "incipient," "moderately advanced," or "far advanced" stage. The cases include all those, 1,707 in num- ber, which were discharged from the sanatorium, after not less than eight weeks' treatment, during the eight years 1907-1914. With such diligence has the inquiry into the after-history of the cases been prosecuted that in only 3-5 per cent, has it failed to be obtained. The important feature in the inquiry is the comparison made at each year of the mortaHty among the various groups of patients with that which would have been expected had the groups been samples of the general popula- tion corresponding as to age and sex. We must refer the reader to the full report, with its numerous elaborate tables, and need here only give the results. They are briefly as follows : I. The mortality experienced by patients after sanatorium treatment is very heavy, the death-rate, even for patients admitted in the early stage (group i), being nearly six times, that of patients admitted with moderately advanced disease 630 DISEASES OF THE LUNGS AND PLEURA (group 2), over sixteen times, and that of patients admitted with far advanced disease (group 3) thirty-eight times greater than the rate for the population of England and Wales. 2. The results for male and female patients show no material difference, but the mortality is relatively greater at the younger ages at discharge. 3. The results at Midhurst are generally similar to, and are confirmed by, those obtained by Messrs. Elderton and Perry^* from their actuarial investigation of the patients at the Adirondack Sanitarium in New York State to which we have already referred. 4. Another important conclusion is that the mortality is greatest during the first two or three years, following dis- charge, the excess mortality being subsequently materially reduced, so that for group i at least the rates for durations of six to eight years after discharge are not seriously above the normal. This is shown in the following diagram taken from Dr. Bardsweli and Mr. Thompson's paper : JO- Groufl I Ma/es , . . — -^ Croup Z ' \ Fema/es — Jf ■3a en /i-mo/es ja ' V 4.1 / \ S ^^' 2i- Z£ p 1 1 ' T) f I « 1 \ y lj\ 1 a ^ 20 / \ * 20 X A \ ^ W /' \ \ 1 \ ' ** 1 \ * g /r- IS \ '-^ IS ** < \ ' / \ ' / ^0' •0 \ 1 / /o- *^ cd « -Av" \ v. \i s- ' '' * \ / * \ s ■ s '\ \ '-0 \ — . , — . . — . i — . 4 — —0 o / ! 3 * s e 7 e z 3 a i 6 r B Number of Years elapsed since Discharge. Fig. 64. — Diagram showing the Ratio of Actual to Expected Deaths, determined according to the number of years which have elapsed SINCE Discharge from the Sanatorium, and indicating that the Mortality is greatest during the First Three Years, and that this Period is therefore the Critical One from the After-History Point of View. TREATMENT OF PULMONARY TUBERCULOSIS 63 1 It follows from the above that the first three years are the " critical period " for patients after discharg'e, and that during this time they must take no liberties with themselves, but do all in their power to continue to live on sanatorium lines. 5. Another valuable conclusion is that for patients dis- charged with the disease arrested, the subsequent mortality is not very different for groups i, 2, and 3, showing that in such cases the extent of the disease on admission is of minor im- portance ; but that on discharge, if the disease be not arrested, the condition at the commencement of treatment g'overns the prospect of longevity. Thus in making a prognosis the con- dition on discharge is at least of equal importance to that on admission. 6. In their report Dr. Bardswell and Mr. Thompson show that in two-thirds of the patients the disease commenced insidiously, and in one-fifth with haemoptysis, and that in the latter patients the mortahty experienced was lighter. This is in accordance with general experience, and is due in part at least to the early recognition of the disease which haemo- ptysis entails, and the more prompt treatment which generally follows. 7. As might be expected, the records prove that patients with laryngeal as well as pulmonary tuberculosis experience substantially higher rates of mortality than cases not so com- plicated; but in the comparatively uncommon cases of early laryngeal tuberculosis, associated with but sHght lung- trouble, the outlook is not unfavourable. 8. The results further show that the prognosis is materially improved if tubercle bacilH disappear from the sputum before discharge. Whenever possible, therefore, treatment should be continued until a negative sputum has been obtained. 9. Lastly, it is interesting to note that, as Messrs. Elderton and Perry^* also found in their study of the Adirondack patients, the prognosis in a g-iven case is not made worse by a consumptive family history. Messrs. Elderton and Perry point out that this does not mean that the children of tuberculous parents are ,not more likely to acquire the disease than patients without such family history, but that if an individual possesses the type of constitution suitable for the development of tuber- culosis, it is immaterial whether such constitution is traceable to the parents or due to disease or some other cause. 632 DISEASES OF THE LUNGS AND PLEUR/E In conclusion, we would repeat that we have for clearness' sake spoken above of sanatorium treatment as representing treatment in a sanatorium. We have already, however, pointed out that a certain proportion of the well-to-do can secure the conditions of such treatment in their own homes, or at least can secure the after-care treatment on the same lines at an earlier period and for a longer time than can less favoured persons. Indeed, we would urge that sanatorium treatment is only the enforcement of proper hygienic measures under medical supervision. It will be within the experience of physicians to have seen cases of pulmonary tuberculosis amongst both out-patients and the better classes who, without any formal sanatorium treat- ment, but simply acting under advice, have recovered from this malady. We are ourselves aware of many such cases of complete recovery, standing the test of twenty to thirty years of time, and it may be of interest to quote the two following, in each of whom, however, climatic change formed an element in the treatment : Case I. — Mrs. X. consulted Dr. Douglas Powell in October, 1891, on account of some haemoptysis. There had been pre- ceding symptoms of only a few weeks' duration. The physical signs showed early lesion at one apex, but the sputum revealed the presence of tubercle bacilli in fair numbers. The lady went to St. Moritz in November, and remained there for the winter. She greatly improved, and completely lost her cough. She lived a careful life under Dr. Holland's observation at St. Moritz, but was under no " sanatorium " regime. She returned to St. Moritz in January of the following year for a couple of months as a measure of precaution, but not on account of any return of symptoms. She resumed her professional work. In 1894 she again came under obser- vation with a severe attack of enteric fever with relapse, and has since then passed through other severe illnesses. She has never, however, had any return of chest symptoms, and is now (1920) in fairly good health, having recently accomplished a visit to America. Case II. — An ofificer, aged 35, had a severe hasmoptysis in 1887, followed by cough and expectoration, with tubercle bacilli present in the sputum, and other symptoms of early tuber- culosis. There were pyrexial signs, dulness and slight crepita- tion at the right apex. He was a man of athletic build, 6 feet 2 inches, although rather narrow-chested for his height. After a period of treatment he went by sailing-ship round the Cape to Australia and New Zealand, starting at the end of September, arriving in Melbourne TREATMENT OF PULMONARY TUBERCULOSIS 633 on December 22. He returned by steamer, spent a short time at Aix-Ies-Bains, and arrived home at the end of May, 1888. He did not gain much by the voyage, and spent the winter of 1888-89 at St. Moritz, with benefit, and the following winter on the Riviera, and after that went to India and round the world. There were no sana- toria available in those days, but he was a man of temperate habits and self-restraint, and led a careful sanitary life. By advice he relin- quished the army on his return from abroad and went to live on his own estate in the North, and having all the attributes of a sports- man and a country gentleman, he spent his leisure time fishing, shoot- ing, etc. He regained health, and in course of time he could out-walk his keepers grouse-shooting, shooting over dogs, and deer-stalking. Except for an occasional attack of influenza, his health has remained excellent. In January, 19 19, he had a bad attack of influenza with bronchitis, and on one occasion in the earlier days of this attack a specimen of sputum sent for examination by his medical adviser was reported to contain " a very few tubercle bacilli." On another examination within a week, however, the report was negative, and when seen by one of us at the end of February the report on a specimen of sputum was " no tubercle bacilli were seen in this mucous sputum after a pro- longed search." He had completely recovered, and there were no physical signs beyond slight impairment of percussion note over the right apex. He was now 67 and leading the same active country life. Here is a case of recovery from tuberculosis and acquired immunity of thirty-two years' duration, developed under healthy conditions of life and maintained under medical advice intelligently pursued, although not with the system and formality of sanatorium therapy. We have no doubt that the visit to the Engadine started the cure, as has been the case with others in our experience. Assuming the accuracy of the report as to the presence of a few bacilli on one occasion during the last influenzal attack, we do not think it a matter for surprise, although when examined on other occasions, and within a week and again in a month, no bacilli were found, for it is quite conceivable that a catarrhal attack affecting an old quiescent lesion might loosen from it some effete products containing bacilli. In any case, the immunity is shown in their failure to gain ground. We have alluded to other cases treated on similar lines and enjoying many years of immunity, and we might mention not a few more, some with a very considerable degree of lesion, but they by no means invalidate our opinion that, taking numbers, and considering the conditions under which tubercu- losis is most generally acquired and prevalent, sanatorium treatment is the best and most rational average treatment of the disease. We only note that many isolated cases have informally, and as it were by chance, by the adoption of some- 634 DISEASES OF THE LUNGS AND PLEURA what similar lines, foimd immunity. One result of the institu- tional treatment of phthisis has been to educate the public and the profession in sanitary methods of self-management in this disease, and to it we owe much of the improvement of those who do not rigorously adopt the regime. REFERENCES. ^ (a) On Sanatoria for Consumftion and Certain Other Asfects of the Tuberculosis Question^ by H. Timbrell Bulstrode, M.D., Supplement to the Report of the Medical Officer to the Local Government Board for 1905-1906. London, 1908. [b] Loc. cit., p. 664. ^ See Tenth Annual Re fort of the Society for the Prevention and Cure of Consum-ption in the County of Durham. Sunderland, 1909. ^ The O fen-Air Treatment of Pulmonary Tuberculosis, by F. W. Burton- Fanning, M.D., second edition, p. 147. London, 1909. * Statistic der Heilbehajidlung bei den Versicherungsanstalten und zugelassenen Kasseneinrichtungen der Invalidenversicherung fiir die Jahre 1904, 1905, 1906, 1907, 1908, Amtliche Nachrichten des Reichs- Versicherungsamts, 1909, 2 Beiheft, s. 9^-96. Berlin, 1909. ^ Heilbehandlung von Versicherten und Fiirsorge fiir Invalide bei der Landes-V ersicherungsanstalt der Hansestddte im Jahre 1908, s. 24, Liibeck, 1909. ® Pensionskasse fiir die Arbeiter der Preussisch-H essischen Eisenbahn- gemeinschaft. Jahresbericht, 1908, s. 8. Druck von H. S. Hermann, Berlin. ' " The Value and Limitations of Sanatorium Treatment as regards the Working Classes," by W. O. Meek, M.S., S.B., The Lancet, 1917, vol. ii., P- 785- * See " The Tuberculosis Problem in County Areas," by A. H. Hogarth, M.B., British Medical Journal, 1910, vol. ii., p. 596. ' "The Care of the Tuberculous Soldier," by Major P. Horton-Smith Hartley, C.V.O., M.D., F.R.C.P., Reforts of the Inter-Allied Conference 071 the After-Care of Disabled Men, London, 1918, p. 266. ^" " The Expectation of Life in Pulmonary Tuberculosis, with Special Reference to Pension Assessment," by Ralph M. F. Picken, M.B., D.P.H., The Lancet, 1919, vol. ii., p. 106. " The Elements of Prognosis in Consumftion, by James Edward Pollock, M.D., p. 70. London, 1865. ^^ " Der Einfluss der Lungentuberkulose auf Lebensdauer und Erwerbs- fahigkeit und der Werth der Volksheilstatten-behandlung," von Dr. Ed. Stadler, Deutsches Archiv fiir Klinische Medicin, 1903, Band Ixxv., p. 412. '^ A Third Study of the Statistics of Pulmonary Tuberculosis. The Mortality of the Tuberculous and Sanatorium Treatment (Drapers' Com- pany Research Memoirs), by W. Palin Elderton, F.I. A., and S. J. Perry, A. LA. London, 1910. TREATMENT OF PULMONARY TUBERCULOSIS 635 '■* A Fourth Study of the Statistics of Pulmonary Tuberculosis : the Mortality of the Tuberculous : Sanatorium and Tuberculin Treatment,'''' by W, Palin Elderton, F.LA., and Sidney J. Perry, A. LA. London, 1913. " The Expectation of Life of the Consumftive after Sanatorium Treat- ment, by Noel D. Bardswell, M.D., p. 12, etc. London, 1910. " " The Ultimate Test of the Sanatorium Treatment of Pulmonary Tuberculosis, and its Application to the Results obtained in the Adirondack Cottage Sanitarium," by Lawrason Brown, M.D., and E. G. Pope, Zeitschrift fiir Tuberkulose, 1908, Band xii., Heft 3. " Pulmonary Tuberculosis : Mortality after Sanatorium Treatment. A Report on the Experience of the King Edward VII . Sanatorium, Mid hurst, by Noel D. Bardswell, M.V.O., M.D., F.R.C.P., and John H. R. Thompson, F.LA. National Health Insurance, Medical Research Com- mittee, London, 1919. CHAPTER XLV ON CLIMATIC CHANGE IN THE TREATMENT OF PULMONARY TUBERCULOSIS We must preface what we have to say in regard to the benefits to be derived from climatic changes with the warning that, owing to recent legislative enactments, the scope of this valuable method of treatment has been considerably curtailed. In the Dominions of Australia and New Zealand, in Canada and the United 'States, the immigration laws now forbid suf- ferers from tuberculosis to enter the country if the disease be in an infectious stage, and at the present time (May, 1920) the subjects of pulmonary tuberculosis, in whatever stages, are not allowed admission into the Union of South Africa. Pre- cautions are also taken to insure that no patient shall become a charge upon public funds. In every case, therefore, we should advise the intending traveller or settler to take the precaution of communicating before he leaves England with the chief medical officer of the Commonwealth Medical Bureau at Australia House, Strand, or the corresponding authorities attached to the New Zealand, Canadian, United States and South African Emigration Offices in London, so as to assure himself that he will be permitted to land on arrival at his journey's end. It should be borne in mind also that, although the ensuing pages are written more especially with reference to pulmonary tuberculosis, all other chest diseases in which change of climate is desirable are taken into account. We have seen in the last chapter that in the majority of cases of early phthisis it is well to recommend, for a time at least, sanatorium treatment. By this means the patient is taught in a practical manner how best to conduct his life, and is safely guided through the earlier and often febrile period 636 ON CLIMATIC CHANGE 637 of his disease, during which, without the minute and careful supervision which forms so essential a feature of the sana- torium regime, he would be liable, through imprudence or ignorance, to aggravate his trouble. Until the more acute symptoms have completely passed away and the malady has become quiescent, a sanatorium in England, which does not involve a long journey, is to be preferred. When, however, after some months, this stage has passed, and when the temperature has become normal, and remains so even after a considerable degree of exercise, then cHmatic change, whether combined with further sana- torium treatment or not, may be considered. The climatic resorts to which such patients may be sent differ with the time of year, the nature of the case, and the temperament of the patient. It is difficult at the present moment to classify these resorts with exactness; but there are certain indications for selection generally applicable, which we will endeavour to point out. Elevated Climates (above 3,000 Feet). — The first ques- tion which often presents itself for decision is whether to send the patient to an elevated chmate or not. It will clear the ground, therefore, if we first briefly consider these climates, and the cases that should and should not be sent to them. Alpine Stations.— The most important of these are Davos (S,ioo feet) and Arosa (5,900 feet) in the Canton Orisons; St. Moritz (6,000 feet) in the Upper Engadine; Montana (5,000 feet), above Sierre, in the Canton Valais; and Ley sin (4,800 feet), not far from Aigle and the Lake of Geneva. At a lower level, and therefore with a somewhat milder climate, we may mention Les Avants (3,200 feet), Caux (3,500 feet), and Chateau d'CEx (3,260 feet), all situated in the Canton Vaud, not far from Montreux. At Davos there are various sanatoria to which the patient may be sent, if thought desirable, including the one upon the Schatzalp, situated 1,000 feet above Davos itself; there are also good hotels fairly well adapted for pursuing sanatorium lines of treatment. At Arosa there are several sanatoria and good hotels. At Montana the Palace Hotel, originally built as a sanatorium, has been recently reconverted to its original use, and is now run on sanatorium lines; the cHmate is very dry, with abundant 638 DISEASES OF THE LUNGS AND PLEURA sunshine, but the air is not so still as at Davos. St. Moritz is better adapted for increasing the resistance of persons not as yet actually attacked.^ It is during the winter months that the properties of these climates, which are regarded as remedial in phthisis, are especially manifested. These properties are : (i) low atmo- spheric pressure, some five inches of mercury below the barometric measurement at the sea-level; (2) dryness of atmo- sphere; (3) purity of air, as shown by freedom from organic and inorganic dust; (4) aseptic qualities by virtue of freedom from org'anic germs and the relatively large proportion of ozone present; (5) low temperature of the air; (6) increased transparency to the sun's rays, both illuminating and chemical (diaphaneity and diathermancy), from the thinness and clear- ness of the atmosphere and the diminished amount of aqueous vapour contained therein; (7) stillness of the air, in conse- quence of which its coldness is less felt. In the meteorologi- cal table on p. 643 certain of these factors are demonstrated. The beneficial effects of these climates are attributable to the rarefaction of the air as a stimulant to the respiratory function; to its aseptic qualities, by virtue of which putrefac- tive and fermentative processes are hindered; and to the vivi- fying influence of the brilliant and warm sunshine, which enables patients to be much out of doors. One effect of the climate is seen in the blood-count, which normally at Davos registers six milHon red cells, with a percentage of haemo- globin ranging to 105 per cent, or even higher. The diaphaneity and diathermancy of the rarefied atmo- sphere of these high regions is an important fact, to which Dr. Denison and Sir Hermann Weber^ were among the first to draw attention. By virtue of this quaUty, due especially to the smaller amount of aqueous vapour present in the atmo- sphere, the rays of the sun pass throug-h with increased readi- ness, powerfully affecting objects exposed to them, although heating the air itself but little during their passage. Dr. Denison^ put the matter shortly by giving the following rule of increasing diathermancy of air, viz. : " For each 1,000 feet rise in elevation there are about four degrees greater differ- ence between the temperatures in the sun and in the shade on perfectly clear days at 2 p.m., as recorded by the black metallic-backed thermometers, other influences than those of ON CLIMATIC CHANGE 639 sun and shade being excluded." Sir James Dewar has shown tlie intensely destructive power of the ultra-violet rays upon morbific organisms, and these rays are in the higher alti- tudes more potent because less obstructed. Improved sanguification and nutrition, expansion of un- affected parts of the lungs, and restriction of the limits of diseased areas, are results obtained in a striking degree in successful cases by residence in these locahties. They are, however, rigorous climates, and it must not be forgotten that, potent for good in well-chosen cases, they are also active in working mischief to those whose condition is not well adapted for them. It cannot, moreover, now be claimed, as was once asserted, that these climates possess any exclusive power, by virtue of rarefaction of atmosphere, of developing healthy lung and contracting diseased areas. We have known patients recover under the most diverse climatic conditions, and have often observed the development of unaffected lung proceed to the utmost possible limits in patients who have never been at a higher level than the galleries of the Brompton Hospital. Such patients have found their own salvation in acquired immunity. The physical state common to all such cases is contraction of the hmits of disease, and compensatory en- largement of the opposite and of the free portions of the same lung, and we doubt the possibihty of exceeding the compen- satory development that may be observed in these favourable cases of phthisis arrested in the plains. Nevertheless, the statistics of Dr. Theodore Williams,* the results of treatment in the Swiss sanatoria,^ and our own experience would sanc- tion the view that in suitable cases these good results may be best obtained by high-altitude treatment, and we are only now desirous of pointing out that rarity of atmosphere, although it may be an auxiliary, is by no means an essential condition for bringing about this much desired end. We have else- where emphasised the importance of distinguishing between merely enlarged or dilated lung and truly hypertrophied lung, in association with localised or arrested disease of some other portion. There is no advantage, but much the contrary, in producing emphysema in phthisis. The cases suitable for treatment at elevated resorts are those of threatened disease and. locaHsed tuberculosis in the early and the quiescent stage, especially when associated with 640 DISEASES OF THE LUNGS AND PLEURA a languid temperament and a moderate degree of anaemia. Cases of hereditary tendency, defective thoracic conformation and capacity, incomplete recovery from acute or subacute inflammatory affections of the chest, whether pleuritic or parenchymatous, are pecuHarly adapted for such treatment. Cases of more advanced tuberculous disease, if it be restricted and inactive, are also suitable, provided that the patient have sufficient vitality to respond to the extra demand made upon his system by the rigorous climate. It is important that the reserve lung be sound, not emphysematous, and that the heart and vessels be healthy. Cases which have commenced with hemoptysis, and in the course of which haemoptysis has from time to time occurred from active or passive congestions, are not thereby disquali- fied for residence in high climates, but a few weeks should elapse before removal there. For cases of recurrent haemor- rhage, however, in which an ectasia or aneurism of a pul- monary vessel in a localised cavity is suspected, such climates should not be suggested. The following conditions are also unsuitable for residence in high altitudes— viz., the acute stage of phthisis in any form; the erethic* constitution in any stage of the disease; cases in which the larynx is affected; patients with advanced phthisis; those in whom the tuberculous disease is complicated by marked emphysema, albuminuria, or intestinal ulceration, or associated with signs of general bron- chial irritation; those in whom the malady makes its appear- ance in later life. The winter season is the best to choose for residence in these localities, but in those cases in which benefit is experi- enced, continued residence through the summer at about the same elevation, and a second winter in the same locaHty, should be decidedly advised. A third or fourth year may sometimes be thus well spent. In cases of mere delicacy or threatened disease during convalescence from some acute chest malady, a single short period of residence may suffice. In early-stage cases, which have derived benefit from a single winter, the good result is often maintained by two or three months' return to the same locality for several succeeding winters. In this practical world but few people can afford * Nervous, irritable subjects, neuralgic, dyspeptic, bad sleepers, with habitually quick pulse and dry, harsh skins. ON CLIMATIC CHANGE 64 1 to live indefinitely in idleness above the clouds ! Persons who have recovered after a season or two at the Alpine sta- tions may sometimes live and earn a living in the highlands of South Africa, to which we shall refer later. Patients should as a rule proceed to their proposed winter- quarters on high ground not later than the end of October, so that they may avoid the dampness and fogs which at this season of the year are so characteristic of our English climate. They should not return home before the commencement of May, the winds in England during April often proving very trying". It is a not uncommon practice for patients to leave the high Alpine resorts in March, when the snow is melting, and to stay at some lower level, such as Thusis, Pronwn- togno, Ragatz, or Glion, before returning home. But such a practice is not essential. It is most important to warn patients against wandering about in a restless fashion, visit- ing other European stations at the end of their treatment in high altitudes. Our experience is that such cases often suffer relapse, and return in much the same condition as that in which they left home. Surgical Tuberculosis.— The benefits to be derived from a residence in Alpine stations are not confined to cases of pul- monary tuberculosis, and, as Rollier''^ and others have shown, remarkable results are obtained at Leysin (4,800 feet) in sur- gical tuberculosis, including affections of the bones, joints, spine and glands, and also such manifestations as tuberculous peritonitis and disease of the genito-urinary tract. In such cases, in addition to the general climatic influence, direct treatment is carried out by gradually exposing the whole body, as well as the part affected, to the immediate action of the sun's rays for increasing periods of time, and to this form of treatment the name "Heliotherapy" has been appHed. The Rocky Mountains. — Among- the elevated resorts in North America may be especially mentioned the Rocky Moun- tain stations, Colorado Springs and Denver, situated in Colorado State at an elevation of between 5,000 and 6,000 feet. Three miles from Colorado Springs, and facing Pike's Peak, the Cragmor Sanatorium has been built at an elevation of 6,100 feet. The climate of this region resembles in many respects that of the Swiss resorts, but, as may be seen by a study of the meteorological data (p. 643), it is several degrees 41 642 DISEASES OF THE LUNGS AND PLEURA warmer in winter, the mean temperature for the six months at Denver being 36-5° F., as compared with 27'2° F. at Arosa, and 25'9° F. at Davos. Snow, consequently, is not often seen. A much gTeater amount of sunshine is also enjoyed, but against this must be set the fact that the region is decidedly more windy, and dust-storms, often of a peculiarly irritating character, are not infrequently met with. Other stations in the Rocky Mountains are Oracle (4,500 feet) in Arizona, and Santa Fe (7,000 feet) and Las Vegas (6,400 feet) in New Mexico. Manitou Park (7,500 feet) and Estes Park (6,800 feet), in Colorado, are also favourite summer resorts.^ South American Andes. — At Jauja, Tarma, Huancayo, in the Peruvian Andes, at Santa Fe de Bogota, and at Quito, in Ecuador, not far from the equator, all at an elevation of about 10,000 feet, the effects of a highly rarefied air are obtained with a temperate, equable and brilliant climate.^ Only in rare instances, however, would one suggest such elevations for invalids. The South African Highlands. — These highlands possess climates of the greatest value for the sufferer from tubercu- losis, though at the present time such cases are not welcomed in the Union. The benefits of the climate may, however, be enjoyed by those who have merely an inherited tendency to the affection, and such patients may here develope into robust health, the dry, warm summer and temperate winter climates, which these high upland reg'ions possess, rendering them suitable for permanent residence, more especially for those who desire to escape our cold winters. Before recommending South Africa for prolonged residence, we should remember that the ordinary necessaries of life in that country are expen- sive, and that employment may not be easy to obtain. Unless, therefore, a patient possesses private means, or has friends in the country, or some definite work in view, we may well hesi- tate before suggesting a residence there, however suitable on other grounds the case may seem. It is, perhaps, hardly necessary to add that it is absolute folly for those in active or advanced consumption to think of venturing upon the fatigues and risks of so long a journey, and it would be exceedingly improper to advise them to do so, even were it probable that they would be permitted to land. Private sana- ON CLIMATIC CHANGE 643 K W P « W ffi H Z w z w a H z h <: H < Q w ffi J H <: tj (I. J « w H W ^ W K H z > w ^ qc < H •s ^ c 3 ffi m" m" h Vi < ■*-i ul >. t^mThNt^l mrooi-ifoioo 1 c ci 1000 fOTj-l Tj-T^CTiOOOfOt^l > H M Z >i5 c 1 in ro too Ot^ Ma\I>-OHOiOt^ 3 JilOmONC^OO 1 Mrt-miOrOWCTiO -c <& < ^ CSCJtHM MMMMM MM V c ^ 2 ■i-l c rj Tt-ioOM 1 1 rr)iOMvo-*C\>OM w 'Z-a OJ 1) 5 MO VO C^ 1 1 t^ t^OO 00 00 lOvO CO J3 bc «K Ph t- 3 T3 SJ r^ N ro t-vo N vo «-) bJO d ^. > < £ MMoirnMNlMaD'oCTibiol 1 3 « UNMMNMMMI-I MN Q 0. 5 (U S] M onoo t>. n 'm b b io *m w i) t^ in § p a bi b b N b 00 vb in iooo t^ t^oD roi) < p CO u JjO^-t^opwpcolO_■^^^Oom rt bJoMCOOOf^MMMO-^NINdt^t^ 1- 3 S p J3 «j M M ro O^OO N t^ M U-) ^t-OO fa 5) t^OO lO O\C0 OOt^NoblNrON 0) loto'OioTj-^Tj-Tj-'^T^romN N CX p 6 . H p3 3j vo 00 CTvvo vo in invo o o t^ c tad mco Tj- T^ t^vo oD inN bvoo biNO) 4) V inininin-^'^^Ti-T^mrocs n m S P ui d 3J ro _M p ^p t^ ro invo CO t^ M P bi t-^ i>-vo o^ a>o t^ "*- m in M (u invo ■n"nTr-^Th^Tj--^cnfnN n P Jj p ro _M vp Tj-^o n cy, r^oo O O ro ^ Minforno •^'^N roKinrobiN b> dvo^oo loininiot-^Tt-fOfON P ' m •3 ° 1 Kt^, ?> o — ' -op R^ 6- be o S. ^ o 6 .2 c -S ID > n3 v^ m en C o rt o b^ CI, tn a 3 ^ O m 03 E n o 3 CUD O S tn n tu o3 be '-' " aj"^ ID S (U -C aj ,cl ID 3^ E ~ .00 O ^ O .- o "t^ !-i CO >, g g OJ .^^ ""•" S E"^ fH l-I ^ +-J OJ '"1 (D P en -*-• '■^-' "n; Q^ O ° 3 ^ S Ti.a " rt s b -k- M — ^ ID ri .-I XI -i "^^ ^ 03 •"iS 3 3 cd ■ij o.uth, Torquay, Falmouth, Penzance and Tenby (south side), may be selected by those not well situated at home; of these places the air of Teignmouth, Torquay, Falmouth, and Tenby, is softer than at the others, and more suitable for cases with dry, harsh skins and irritable mucous membranes. It is to be remembered that, whereas at Hastings, St. Leonards, and Ventnor the coast residences should be chosen, and the uplands only in special instances, at Torquay, on the other hand, the quay residences are cold, damp and misty from defective sun exposure and imperfect circulation of air, whilst the terraces on the slopes are comparatively warm, sunny and dry. St. Mary Church, a suburb of Torquay, suits some people better, being more withdrawn from the sea. Bournemouth is a sea climate, much modified by the exten- sive moorlands behind it and the pine growths, amidst which ON CLIMATIC CHANGE 659 many of the best houses are placed, although of late years the spread of the town has, unfortunately, led to the cutting down of many of these trees. The habitations are more isolated and stand farther back from the sea than at other places, and these facts render the climate a happy mixture of marine and moorland, suitable for many people with whom a more purely sea air disagrees. An asthmatic or bronchial element would sugg"est Bournemouth in preference to other places. In point of warmth Bournemouth is not to be preferred to any of the other South-Coast resorts; like most other large places, how- ever, such as Torquay and Hastings, it possesses many shel- tered nooks well known to resident practitioners — indeed, these places may be said to be " full of climates ! " The Riviera, that narrow strip of land bordering the Mediterranean, and bounded and protected on the north by the Maritime Alps, extends from Hyeres eastwards. The portion between Hyeres and Genoa is known as the Western Riviera, or Riviera di Ponente, and constitutes the Riviera proper; most of the well-known health resorts are situated in it. From Genoa to Spezzia, or even to Leghorn, runs the Eastern or Levantine Riviera. This at the present time is less well known, and in pre-war times was less expensive; but its climate, though moister and possibly somewhat colder, does not otherwise differ materially from that of its western rival. The Riviera climates have in common the advantages of warmth, brilliancy, and comparative dryness. They are easily accessible, and the larger resorts possess excellent accommo- dation. They differ among themselves in exposure to wind, especially the cold north-west wind or mistral, and also in the degree of prevalence of dust. Certain of these points are brought out by the meteorological data which we have col- lected (see table, p. 643). From these it will be seen that the mean temperature for the six winter months (November to April) at Nice, Cannes, Mentone, and San Remo varies between 50-0° and 52-0°, that of London (Regent's Park) being 41-9°, whilst Hastings, Bournemouth, and Torquay yield means of 42-5°, 43-8°, and 45-1° respectively. Records are wanting to enable us to compare accurately the amount of sunshine on the Riviera with that of other stations, but that it is greatly in excess of that enjoyed at English resorts, 660 DISEASES OF THE LUNGS AND PLEURA and, owing to the dryness of atmosphere, of a brilliancy rarely seen with us, may be accepted. The rainfall during the winter months may be taken at about 17 inches (Nice, 15-5 inches; Cannes, 19' i inches), which is somewhat in excess of that at Regent's Park (11 '31 inches) and of Hastings (i4'5o inches), but not very different from that of Bournemouth (i5'93 inches) and of Torquay (i7'37 inches). Nevertheless, owing to the rain coming rather in storms, and the sky then clearing, the number of rainy days on the Riviera is materially less than in our own climate. Thus, at Nice, Cannes, and Mentone, there were respectivelv 43, 43, and 47 rainy days during the six winter months, while in London (at Regent's Park), Torquay, and Hastings they amounted to 83, 90, and loi during the same period. The dryness of the atmosphere is further indicated by the records of mean relative humidity at 9 a.m.. Dr. Marcet's figures for six winters at Cannes yielding a percentage of 73, as com- pared with 82 and 84 for Torquay and Regent's Park respec- tively. Such are the more important characters of the cHmate of this favoured region, and experience shows that one or other of the resorts along its shores is generally suited for those cases for whom the elevated stations are not desirable. Phthisical patients with poor general vitality will do best tc spend the first winter, at all events, in the Riviera. In some cases, also, in which the necessity for change of climate occurs when cold weather has already set in, it is more prudent to select one of the warmer resorts, with the view, perhaps, of higher ground in the ensuing autumn. There are, moreover, some early-stage cases of phthisis, complicated with threatened or actual laryngeal or bowel trouble, in which the prognosis is grave, and in which the cold air of the mountains is not to be advised. In such cases, provided the patient can go abroad with every comfort and accompanied by his family or nearest friends, rehef of symp- toms and lessened activity of progress may be effected by a visit to one of the sheltered Riviera resorts. Children and young adults, especially girls, with a delicate family history, who have had acute bronchial or pulmonary affections, may, by one or two winters spent in the Riviera, completely and permanently recover. To elderly people, ON CLIMATIC CHANGE 66 1 again, with phthisis, in whose tissues senile decay has already commenced, these warmer climates are admirably adapted. A most important point to be borne in mind by those who send invalids to the Riviera is that warm woollen undercloth- ing should be enjoined, and that they should be especially warned to be within doors half an hour before sundown, a fall of several degrees of temperature taking place abruptly at this time. The patient should accordingly never run the risk of being belated out of doors without special wraps, although, properly clothed, he may often with advantage go out ag'ain later in the evening. Of the Riviera resorts, the following, as we pass from Hyeres eastwards, are the more important : Hycres. — The west end of Hyeres is the best part, its eleva- tion permitting of superior drainage. Somewhat removed from the sea, Hyeres enjoys a slightly modified sea climate, and is partially protected from winds by the chain of islands parallel to, and two or three miles distant from the shore. The climate is accordingly more soothing than many of the Riviera stations, and excitable people of the "erethic" type will probably do better here than elsewhere. Some forms of asthma, bronchitis, and emphysema, are also benefited. From November to February the climate is at its best, and during this period may be recommended for cases of advanced but quiescent tubercle, and those complicated by albuminuria. In February and March the mistral is sometimes severely felt. Costebelle, two miles south of Hyeres, on the Hermitage Hill, 200 feet above the town, is quieter and less dusty. It possesses excellent hotel accommodation, and may be recom- mended for the same class of cases for which Hyeres is suited. There are excellent golf-links in the district. Cannes. — For prolonged residence Cannes affords the most varied attractions, perhaps, of any of the Riviera stations. Yet in the pleasures of its social life lurks a danger to the invalid ag"ainst which he must be on his guard; for he must ever remember that his object is to regain his health, and that this can only be effected by rigidly ordering his Hfe aright under proper medical supervision, by keeping early hours, and by eschewing for the most part the numerous gaieties for which the season at Cannes is famous. The upland parts of the town, away from the shore, are best suited for residence. 662 DISEASES OF THE LUNGS AND PLEURA The climate (see table, p. 643) is decidedly bracing and bril- liant, though somewhat changeable. Cases of quiescent phthisis, of strumous type, with lax secreting membranes and non-pyrexial sweatings; cases of anaemia, senile forms of bronchitis, emphysema, asthma; and persons, both young and old, recovering from acute chest disease, do well here. For patients, on the other hand, of highly nervous temperament, with a disposition to sleeplessness, Cannes is not so well suited. In this large district there are many climates, and it is safest to take local advice as to any precise locality for prolonged residence. Cimiez, a suburb of Nice, is well suited for cases of asthma, for neuralgic patients, and bad sleepers. It is less liable to variable winds than the town of Nice. For elderly people Nice has the advantage of level walks and promienades and town life, with the brilliant Riviera sunshine; and there are many sheltered parts in the Carabagel quarter, in which more delicate patients will find protection from cold winds. Beaulieu, situated between Nice and Monte Carlo, is won- derfully warm and sheltered, and is admirably suited for patients needing such a winter climate. Monte Carlo and Les Moulins, in the Eastern Bay of the principality of Monaco, are amongst the choicest spots of the Riviera for residence, the dwellings being between 200 and 300 feet above the sea-level, well protected from mistral by mountains behind, yet with abundant air circulation. These places are to be recommended, however, only for wealthy people in limited numbers. Cap d'Ail La Turbie, in the neighbourhood, where there is a good hotel, is well adapted for pulmonary convalescents without any declared disease. Mentone. — This resort, especially the East Bay, is warmer and more sheltered than the other stations, with the exception of Beaulieu, and yet has a good circulation of air. Many real invalids accordingly make their winter-quarters here. The mean temperature for the six winter months may be taken as 52° (Bennett). A glance at the table on p. 643 will show that this is slightly higher than the corresponding figures for San Remo, Cannes, and Nice. Mentone is well adapted for resi- dence in cases of chronic bronchial catarrh, gouty bronchitis, and phthisis with albuminuria. Asthmatics frequently also do well in Mentone. Cases of somewhat advanced phthisis find ON CLIMATIC CHANGE 66^ this locality soothing; and persons who lead, from cardiac diseases or other causes, lives of enforced inactivity will often profit by sojourn here. Patients in whom haemorrhage is a marked feature are not well suited for this very marine climate, a more inland locality being better adapted to them. The West Bay of Mentone is somewhat fresher and more bracing than the East, but the sanitation of both districts is equally good. Cap Martin, a bracing peninsular suburb of Mentone, with an excellent hotel, is well adapted for wealthy convalescent patients. San Reino is a charming station, which has grown steadily in popularity. It occupies a sheltered position some eight miles east of Bordighera, itself a growing- health resort. Its winter climate (see table, p. 643) resembles that of Mentone, although, as we have seen, it is a trifle colder and not so well protected from wind. It is admirably adapted for fairly quiescent cases of consumption, especially those associated with a languid and feeble circulation. Cases of heart disease and emphysema do well at this resort, where a long stretch of level walk extends along the front and through the newer part of the town. In aadition to the stations which we have named, there are many other places worthy of note along the northern coast of the Mediterranean. Such are Alassio and Pegli, on the Western Riviera; Nervi, Porto fino, Rapallo, and others on the Eastern or Levantine Riviera, the latter not as yet fashion- able, and consequently, before the war, more moderate in price. Algeciras and Malaga, on the south coast of Spain, and Monte Estoril in Portugal, not far from Lisbon, may also be mentioned. All have their merits, and at Nervi and Porto- fino and Algeciras good hotel accommodation may be ob- tained. On the way to the Riviera, Arcachon, Biarritz, and Pau may be mentioned. Arcachon, in the district of the Landes, some thirty miles south-west of Bordeaux, although colder than the more southern stations, is well adapted for many cases of arrested pulmonary tuberculosis with excitable rather than depressed nervous system. The winter villas amongst the pines are the most suitable, and riding exercise can be enjoyed amongst the interminable pine forests, which afford consider- 664 DISEASES OF THE LUNGS AND PLEURA able shelter from the spring winds. Some cases of chronic phthisis with excessive secretion do well here. The climate is also well adapted for asthma. Biarritz^ on the shores of the Bay of Biscay, some sixteen miles from the Spanish border, possesses a highly marine climate. It is suitable in the late autumn and early winter and later spring months for threatened cases of consumption, especially in children for whom the bracing effect of the Atlantic breezes may be desired. It is too much exposed to wind for most cases of declared disease. People with a dis- position to neuralgia do not do well here. Pau, an inland station in the Basses-Pyrenees, about sixty miles south-east of Biarritz, possesses a winter climate some five degrees colder than that of the Riviera; its rainfall and humidity are also gTeater. The atmosphere is, however, very still, and winds are but Httle prevalent. Cases of chronic bronchial and laryngeal catarrh, and some elderly patients who do not flourish at the Riviera climates, are better here. It is a sedative climate, with magnificent surroundings and sheltered walks and drives, and many social attractions. Algiers, on the southern shores of the Mediterranean, has a mean winter temperature of 587° (see table, p. 643), between 8° and 9° higher than that of Cannes or Nice, but its climate is moister than that of the Riviera resorts. The rainfall, 23 inches from November to April inclusive, is also greater, whilst the days on which rain falls are nearly double, eighty-four (almost identical with that of London), as opposed to forty-three at Nice and at Cannes. Algiers is, however, but little affected by mistral, and rarely visited during the winter and spring months by the dusty south wind or sirocco. The climate is suitable for cases of chronic bronchitis, em- physema, quiescent phthisis, even if somewhat advanced, and for some cases of asthma. For all these affections the Mus- tapha Superieur quarter of Algiers is to be selected. Egypt. — The warm, very dry winter climate of Eygpt, with its pure desert air, brilliant sunshine, low degree of humidity, and but scanty rainfall — factors well brought out by the meteorological data relative to Helwan, which we have incor- porated in the table on p. 643 — would seem to offer consider- ON CLIMATIC CHANGE 665 able advantages to the consumptive, and certain cases find relief there. Egypt is perhaps best suited for patients v^ith quiescent disease but continuing secretion, which tends to diminish and dry up under the favourable climatic conditions. It is, however, less easy at the Egyptian resorts than at other places which we have considered to insure that continuous medical supervision which is so essential for successful treat- ment, or for the patient to carry out the regime laid down for him, even if so minded. Moreover, experience has shown that the majority of cases of early phthisis, provided they have sufficient vitality, do better in a more bracing climate. Still, we have known cases do well in Egypt, and their lesions to remain arrested after spending" some winters there. This climate is more specially adapted for the chronic bronchitic and asthmatic invalid. Those who go to Egypt in search of health should eschew Cairo, with its gaieties and dust, and go to Mena House or Hclwdn, not far from Cairo, or to Luxor or Assouan* on the banks of the Nile farther south. Dahabieh excursions up the Nile may be suggested as an interesting change for the wealthy, although under no circumstances can a winter in Egypt be passed without considerable expense. The Egyptian season ends in April, when the weather be- comes too warm. Patients should not then hurry back directly to England, very possibly to find there the winter which they have successfully eluded so far, but should be advised to stay at some intennediate station, perhaps in Sicily, at one of the Riviera resorts, or on the Italian lakes, at, for example, Varese or Lugano, until the end of May, when the return home may be sanctioned. Meran in the Austrian Tyrol or Vernet-les- Bains in the Pyrenees may also be recommended. Another feasible plan is to take the P. and O. boat to Gibraltar, and cross over to Algeciras, where excellent accommodation can be found at the hotel. Madeira and its principal town, Funchal, enjoy a warm, moist, and equable climate, abundant sunshine, and freedom from dust. The temperature records, as will be seen from the table on p. 643, correspond closely with those of Algiers. Thus, the mean winter temperature at Funchal is 59"9°, as compared 666 DISEASES OF THE LUNGS AND PLEURA with 587° at Algiers; while the range is slightly less (127°, as against 13°). The winter rainfall is, however, smaller, and the number of rainy days materially less (fifty-three, as opposed to eighty-four). As compared with the Eng'lish sta- tions, the mean winter temperature at Funchal is some 15° higher than that of Torquay, and 18° higher than that of London (Regent's Park). The winter rainfall is considerably greater, but the number of rainy days materially less (fifty- three as opposed to ninety at Torquay, one hundred and one at Hastings). A noticeable feature of the cHmate is its equabiHty and the slight difference between the mean temperatures throughout the year. At Funchal the mean for the six winter months (November to April) is 59'9°; for the six summer months (May to October), 677°. In former times when equability and warmth were regarded as of the first importance in the treat- ment of phthisis, Madeira, with its warm marine climate, beau- tiful vegetation, and comparatively easy accessibility, was much resorted to. The patients, however, from the Brompton Hospital who were sent to winter there yielded unsatisfactory results, only three out of the twenty deriving benefit, and the statistics published by the late Dr. Theodore Williams* in his Lettsomian Lectures in regard to his Madeira patients were also unfavourable. At the present time opinion is in favour of a colder and more stimulating climate, provided the patient can respond, as leading more readily to the arrest of disease. In cases of emphysema, and of phthisis with a good deal of attendant bronchitis and emphysema, and especially in those of older years in whom the disease has supervened upon long- standing winter cough, the climate of Madeira will be found well adapted for residence. Patients with irritable cough and but little expectoration, or with laryngeal trouble, provided it be not too advanced, may also find rehef here, such cases being as a rule unsuitable for high altitudes. For many bron- chial and some asthmatic affections, particularly those asso- ciated with renal unsoundness, Madeira is peculiarly suited. At different elevations from Funchal, up to a height of 2,000 feet, more bracing accommodation can be obtained than in Funchal itself, so that, owing to the coolness of the summer the patient need not hurriedly leave the island the moment the winter has ended, but is enabled to remain in comfort until ON CLIMATIC CHANGE 66/ May or early June, when he can more safely return to Eng- land. The absence of dust and of mosquitoes is especially to be emphasised as a feature of this climate. The Canary Islands possess a climate which resembles that of Madeira, but is somewhat warmer, less moist, and more dusty. It may be recommended for similar cases. Oratava, in the island of Teneriffe, or Las Palmas, in Grand Canary, are suitable for a lengthened stay; and the latter especially so in cases in which a rheumatic element is present. We have observed Santa Cruz, at the foot of Oratava, to be especially suitable for asthmatic cases. California. — The climate of that portion of the State of California which lies south of Point Conception between the mountains and the Pacific, is characterised by mildness, the winters being warm and spring-like, with abundant sunshine, whilst the summers are cool. The rainfall is a small one, but the humidity, owing to the influence of the ocean, is not par- ticularly low, and fogs in the morning and evening are by no means infrequent. The climate at the various resorts will be found to differ somewhat according to local conditions, and especially with their greater or less proximity to the coast; but, taking the meteorological data of the city of Los Angeles as an example, we may note that in point of temperature the records (see p. 643) show a climate which, so far as this feature is con- cerned, closely approximates to that of Madeira. Thus, at Los Angeles the mean winter temperature is 57' 1°, at Funchal, 59-9°; the mean summer temperatures being in each case 677°. The daily range — in winter, 21-2° at Los Angeles — is, however, considerably greater. The brilliant sunshine enjoyed by the Californian resorts is also demonstrated by the records, which show that as much as 3,219 hours were recorded during the year, 1,457 o^ which occurred in winter. For comparison, we may add that the yearly totals at Bournemouth, Torquay, and Hastings amount to 1,717, 1,731, and 1,783 hours; and for the six winter months, 572, 568, and 580 respectively. The rain- fall at Los Angeles is only 15-6 inches, and the number of rainy days throughout the year not more than forty. A glance at the table on p. 643, and at the more detailed tables printed in the appendix to the last edition of this work, will show 668 DISEASES OF THE LUNGS AND VLEVRM how favourably these figures compare with those of other stations. With a genial climate of this nature, the health resorts of Southern California will be found to afford winter-quarters suitable for those phthisical patients with low vitaHty, or with disease too advanced for the American altitudes, or for whom those chmates are for other reasons undesirable. Among- the resorts we may mention Sa?i Diego and Santa Barbara, on the Pacific coast, Pasadena, some twenty miles inland, not far from Los Angeles, and Sierra Madre, in the same region. At Monrovia, sixteen miles from Los Angeles, there is a well-known private sanatorium. These stations are too far removed from England for tem- porary resorts, but are available for American invalids, some of whom after their recovery may decide to make their per- manent residence in such localities, and perhaps find light and satisfactory outdoor occupation in connection with fruit- farming- and the cultivation of oranges and lemons, for which California is famed.*^ Spring (March, April, and May). — Our islands can boast of but few localities suitable for chest invahds during spring. There are, however, numerous nooks and corners with sunny exposure and protection from cold winds, where on porous soil and at a moderate elevation residences exist or might be built, singly or in small groups, suitable for invalids who are unwilling or unable to go farther. At some of our seaside places, such as Bournemouth, the Isle of Wight, Torquay,' St. Mary Church, Tenby or Grange, sheltered spots can be found. Bridge of Allan, by Stirling, N.B., is a spring station of considerable merit, and here, on the southern slope of the hill, protected from the north and east, are houses and a well- found hydropathic establishment with sheltered walks. Throughout the Continent the same difficulty presents itself to a greater or less degree with regard to the avoidance of irritating cold spring winds. With the exception, however, of this occasional drawback, most felt during February and March, the whole Riviera is at its best during the spring season. Parts of Mentone, Beaulieu, Monte Carlo, Bor- dighera, San Remo, and some sheltered portions of Hy^res, are the most protected; but it is, perhaps, scarcely wise, on ON CLIMATIC CHANGE 669 account of occasional cold winds, to shift quarters that are otherwise suitable. Grasse (1,000 feet), a bracing hill suburb of Cannes, nine miles from the coast, is a good, late spring resort. Les Avants, above Montreux, is also protected. Many patients who have spent the winter at the Riviera are tempted at this season to move on to Florence (where, how- ever, the spring winds are much felt) or to Rome. In the case of pulmonary invalids this is not to be sanctioned. Madeira, the Canaries, and Algiers are not affected by severe spring winds; but the latter place becomes too warm for residence in the later spring. Arcachon and Pau are fairly good spring climates. At this season of the year a voyage to the West Indies may often be recommended for convalescents from acute chest diseases. Summer {June, July, and August). — In the summer months the travelled and tired invaHd will generally do best to return to his home and famiUar haunts, friends, and diet. June is a favourable month for visiting certain health resorts and baths, such as Ems, Aix-les-Bains, Aix-la-Chapelle, Allevard-les- Bains, Royat, Mont Dore, Eaux Bonnes, but chiefly for the treatment of special throat or other symptoms, to be incident- ally alluded to elsewhere. After a period of treatment, such as we have sketched out, the patient may have regained his health sufficiently to allow of his return to work. We have pointed out in a former chapter (p. 622) that it is better for him, if he has been a city dweller before, to alter the environment and to live in future in the country or some small county town. If, how- ever, his occupation must be carried out in a large city, then he should live out of town or in some healthy suburb. For those whose work lies in London, we may recommend such localities as Hampstead, Highgate, Golder's Green or Hendon. In the case of those who can live farther afield, the neighbourhood of Croydon, Purley, W oldingham, Oxted and Tamworth may be recommended amongst others, or the Chilterns in the neighbourhood of Chorley Wood, Great Missenden, and Amersham. We have also known not a few patients derive benefit from living at Westcliff-on-Sea or Southend, where long week-ends may be enjoyed, and whence there is a good train service to London. 670 DISEASES OF THE LUNGS AND PLEUR/E In choosing a residence regard must be had to dryness of locality, abundant sunshine, and protection from prevalent winds. Trees must not be in too close proximity to the house. REFERENCES. '■ For a consideration of the meteorological data bearing on these differences, see the article on " The Climate of the Midland Counties," by P. Horton-Smith (Hartley), M.D., in The Climate and Baths of Great Britaitz, vol. ii., p. 119. London, 1902. ^ See " What Influence has Climate on the Treatment of Consumption and how far can Cases be Grouped for Treatment in Certain Climates?" by C. Theodore Williams, M.D., Transactions of the British Congress on Tuberculosis, vol. iii., p. 14. London, 1901. ^ " Treatment of Tuberculosis at Sea," The Lancet, 1909, vol. i., p. 1188. * For a consideration of the differences in climate between these four stations see the meteorological data given in " A Clinical Lecture on Mitral Regurgitation," by P. Horton-Sm^ith (Hartley), M.D., The Clinical Journal, February 12, 1902, p. 271. * The Influence of Climate in the Prevention and Treatment of Pulmonary Consumption, by Charles Theodore Williams, M.D. London, 1877. " For a more detailed description of the climate and of the health resorts of California we must refer the reader to — (i) " The Health Resorts of the United States," by S. Edwin Solly, M.D., in Dr. Hale White's Textbook of Pharmacology and Therapeu- tics, p. 958. London, 1901. {2) A Handbook of Climatic Treatment , by William R. Huggard, M.D,, p. 266. London, 1906. CHAPTER XLVII TREATMENT OF PULMONARY TVBERCVLOSIS— (Continued) Acute First-Stage Cases — Active Softening and Formation of Cavities — Summary. Acute First Stage. — In the active periods of the more acute forms of tuberculosis, so long as there are signs of recent consolidation, with maintained pyrexia, rapid pulse, trouble- some cough and expectoration, the latter perhaps blood- stained, patients require complete rest, careful nursing, and treatment under open-air conditions, until the acute period of the illness subsides. At this time the patient is receiving discharges of bacillary toxines into his blood; his antitoxic reaction is strained, and his phag"ocytic powers overwhelmed by the heavy doses of the poison. The hurried action of the heart and breathing and frequent cough all bear testimony to the necessity for quietude; any movement or change from passive recumbency still further quickens the breathing, raises the blood-pressure, and helps to waft into the blood-current the poisons which are being locally elaborated. The diet should be nutritious and plentiful, and two or three pints of milk should be given each day, in addition to such light solid food as can be borne; for it generally hap- pens that the patient has emaciated and is considerably below his normal height-weight ratio. Stimulants, unless the appe- tite fails, are as a rule better avoided. The secretions must be cleared, and in cases where the circulation is much quick- ened and the skin dry and hot an effervescing saline mixture may be given every four or six hours. Presently an alkaline mixture should be substituted, and to it may be added, when the temperature has abated, hypophosphite of soda, to be taken three times in the twenty-four hours. When pain is 671 6/2 DISEASES OF THE LUNGS AND PLEURAE complained of, some epispastic solution should be painted over the part affected, or in acute cases two or three leeches applied. The night perspirations at this early period of the disease are rarely of a severe character, and especially is this the case since the introduction of the open-air regime, and it is wise as a rule not to check them by any drug treatment. If the temperature at night range high, it may be moderated by tepid sponging and quinine, and half a grain of opium may be given if the cough causes restlessness. In other cases a cachet containing 7 grs. of aspirin and 3 grs. of phenazone will check the fever and soothe the erethism with which it is attended. Under such treatment the pyrexia will in favourable cases subside, or at least be reduced to a moderate evening rise of temperature to 99° or 100°, which may persist for some considerable time. Restraint of the movements of the chest over the affected area by lung spHnts and other appliances has been suggested ; but the normally slight expansile movements of the apices become further restricted in disease without mechanical aid, and the object of rest to the part is sufficiently secured by insisting on that freedom from effort or exercise which shall secure the most complete quietude possible to the respiratory and circulatory systems during the first febrile period of the disease. It is of great importance to relieve disturbing night cough, a symptom distressing to the patient, and destructive of that functional rest of the lung which we are desirous to secure. The following mixture may be usefully prescribed for this symptom : Nepenthe 3 i., Codeinae gr. i., Syrupi Chloral Hydratis 3vi., Mucilaginis Acacise, gi.ss., Syr. Pruni Vir- ginianas gss., Aquam Chloroform! ad 5vi., of which one table- spoonful should be sipped from the spoon at bedtime, and half a dose similarly taken once or twice in the nig-ht. It will often be observed that the cough remains trouble- some, while the pulmonary signs are greatly improving, and all secretion sounds rapidly drying up. This irritable cough, which is so frequently attendant upon the subsidence of pul- monary disease, should be checked by the patients themselves as much as possible. This they can do to a great extent, but they may be assisted, if necessary, to secure rest at night by TREATMENT OF PULMONARY TUBERCULOSIS 673 some such mixture as we have mentioned above, or with the help of one or two morphine and ipecacuanha lozenges. The morning cough in these cases, and, indeed, in many others, is the most troublesome. It is, however, the natural conse- quence of a good night's rest, and should never be checked by a sedative, since the matters suitable only for elimination, if retained, considerably impede respiration, become highly irritating, and set up further inflammatory and specific trouble in the lungs. A cup of hot coffee, tea or milk, taken before rising, will greatly facilitate expectoration. If this does not suffice, a small dose of ether and ammonia should be given, . or if the phlegm be viscid and difficult to cough up, a mixture containing Ammonium Carbonate gr. iii.. Sodium Bicarbonate gr. vii.. Spirit of Chloroform nix., distilled water to half an ounce, to be taken in an equal quantity of hot water on first waking. The old-fashioned remedy of rum and milk taken early in the morning is also useful for this purpose; a dessert-spoonful of rum to a claret glass of warm milk being sufficient. On the subsidence of fever, or in more serious cases its abatement to an evening rise of temperature only, cod-Hver oil may be given, and some tonic containing arsenic, iron, mineral acid or alkaline bitter, as the general and particular features of the case may suggest. In many cases such tonics are not indicated, and in any case it is rarely necessary to give more than two doses a day, at times carefully specified with regard to the meals, according to the drugs prescribed. The question of allowing the patient up and of permitting exercise may now be considered; but as a rule no relaxa- tion should be permitted until both morning and evening temperatures have been normal for some two or three weeks. He may then be promoted to a couch on the balcony, or in the Liegehalle or garden shelter, and finally the effect of graduated exercise will be observed. Perhaps the best way to begin is to allow a quiet walk of five minutes out of the hour, until the required amount, be it ten, fifteen, twenty, or more minutfes of daily exercise, has accumulated. The patient is now in a condition suitable for removal to a sana- torium, where he will have the advantage of that constant medical supervision which is so desirable in the treatment of his case, and especially necessary in graduating the daily 43 6/4 DISEASES OF THE LUNGS AND PLEURA amount of exercise which may be safely permitted (see p. 606). The Uses and Administration of Cod-Liver Oil. — The advo- cacy of the use of cod-liver oil in phthisis by the late Drs. C. J. B. WiUiams and Hughes Bennett gained for this remedy a recognised value second to none other in the treatment of the disease, and from the statistics of the Brompton Hospital, pubhshed in the First Medical Report"^ (1849), as well as from the results obtained in private cases and recorded by Dr. Theo- dore Williams,^ there can be no doubt that at the time of its introduction, and as an adjuvant to the methods of treatment then in vogue, it was of great value. At the present day, when, by a more bracing regime and a more generous diet, the tissue metabolism of the patient is already being stimu- lated to the full, its value is less marked. It is, however, still indicated when the patient is below weight and does not respond well to ordinary treatment, and it is especially useful among the poor, when the diet is not all that can be desired. Cod-liver oil has been sometimes regarded rather as a food than a medicine, and its easy assimilation and absorption render it no doubt a valuable nutrient. In the recent shortage of butter and cream and other fatty foods, cod-liver oil alone or combined with malt extract has been a useful resource. In some way, also, cod-liver oil appears to affect favourably the patient's metabolism in a manner that cannot be altogether accounted for by the quantity taken, assuming it to be only a food — one to four teaspoonfuls two or three times a day being the average dose. The observa- tions of Dr. Wells,^ which have since been confirmed, suggest that in addition to its easy absorption, it possesses the power of "increasing the absorption of the other fats of the foods to a marked degree," and also leads to a diminished excretion of nitrogen, and thus to an increased storing up of proteid within the body. It would seem also from the experiments of Drs. Williams and Forsyth* that the unsaturated fatty acids, of which the oil is almost entirely composed, tend to produce a disintegration of the waxy envelope which sur- rounds the tubercle bacillus, thus possibly leading to its more easy destruction in the blood and tissues. Cod-liver oil would appear further to have a special power of aiding the regenera- tion and nutrition of the cells lining the respiratory tract, and TREATMENT OF PULMONARY TUBERCULOSIS 675 to be of great service in clearing up the intercurrent catarrhs which are so frequent in those prone to tubercle. To its value in chronic bronchitis we have already alluded (see p. 193). The best time for taking- cod-liver oil is soon after meals, when the stomach is occupied by food in a condition prepared for escape through the pylorus, for it is beyond the pylorus that the oil becomes absorbed; but some patients will in prac- tice be found better able to assimilate the remedy at other times. In children, and sometimes in adults, the syrupus ferri phosphatis co. of the B.P.C., or steel wine are excellent vehicles, and various other agreeably flavoured tonics may be combined with the oil, such as quinine wine with a little hypo- phosphite of soda or lime, or phosphoric acid and strychnia with syrup of orang'e. Certain additions may sometimes with advantage be made to cod-liver oil : thus, a drop of creosote or too grain of strychnia (Williams) are valuable correctives. In a few cases it will also be found that the addition of an alkali by emulsi- fying the oil will enable it to be better borne and absorbed;* and there are now many excellent and comparatively palatable emulsions of cod-liver oil made in combination with malt extracts. Of these a simple emulsion of oil and malt extract in equal parts can usually be well borne, a dessert-spoonful or more two or three times a day being- prescribed. The Emulsio Olei Morrhuse Co. of the B.P.C. contains 50 per cent, of oil, and is an elegant preparation which may be recommended for persons of delicate digestion. The most favourable periods for giving oil are the apyrexial intervals of phthisis. In small doses, however, the remedy can sometimes be taken with advantage, if not during the period of continued fever, at least during the more prolonged hectic of the disease. If for any reason cod-liver oil cannot be taken, trial may be made of Sodium Morrhuate, a preparation lately introduced by Sir Leonard Rogers,^ and containing the sodium salts of the unsaturated fatty acids of which cod-liver oil is com- posed. Small doses, commencing with \ c.c. of the 3 per cent, solution, and increasing by 2-4 minims at each injection to 2 c.c, are given subcutaneously two or three times a week. * Brompton formula : Mist. Olei Morrhuae Preparata. ^. Olei Morrhuaj 5vi., Liq. Ammoniae Fort, itiii., Olei Cassiae nii., Syrupi 3ii. Dosis 3ii. 6/6 DISEASES OF THE LUNGS AND PLEURA Intravenous injections, beginning with ^ c.c, are then recom- mended, and should be cautiously increased. Should a febrik reaction occur the dose should be diminished. We have tried the preparation by subcutaneous injection and seen benefit result, but have not ourselves given it intravenously. Creams and fats may be also prescribed. A piece of mutton suet allowed slowly to dissolve in a tumbler of milk, warmed by standing on the hob or in a slow oven, is an old- fashioned remedy for phthisis; the milk thus treated should be filtered through muslin before being taken. Olive oil taken alone, or with salads or sardines, is an imperfect sub- stitute for cod-liver oil. Of general tonic remedies in the early periods of phthisis, arsenic is one of the most valuable. The arseniate of iron or small doses of arsenious acid may be given in pilules with food twice a day. The late M. Jaccoud recommended t'o grain of arsenious acid to be taken in pill form at the commence- ment of two principal meals, increasing the dose each week by two pilules, until six, eight, or ten are taken daily; this treatment being- continued for two or three months unless signs of intolerance of the drug are shown. After this period the dose should gradually be diminished. This remedy is especially valuable in cases in which iron is not well borne. If under the arsenical treatment appetite fails, the tongue becomes coated, digestion painful, or the bowels relaxed, it must be at once restricted or withdrawn. Unless specially indicated, strychnia and quinine are of no particular service at this period. The hypophosphites are of undoubted value, and also iron in small doses and for short courses. Period of Active Softening and Formation of Cavities. — Dur- ing this period the particular symptoms to be regarded are : (i) pyrexia; (2) nervous prostration and bodily exhaustion; (3) certain special symptoms — viz., wasting, anorexia, night- sweats, cough and expectoration, haemoptysis and intercurrent pleurisies. Pyrexia. — The fever at this period of phthisis, often hectic in type, is probably, as we have seen (p. 467), dependent in most cases upon the active growth of the tubercle bacillus, and the absorption of the tuberculous toxines so found. In a smaller proportion of cases true secondary infections are pre- TREATMENT OF PULMONARY TUBERCULOSIS 677 sent, and the organisms responsible take their share in the production of the pyrexia. With regard to the treatment of such cases, we must re- member that the growth of the tubercle bacillus and of the pyogenic and other org'anisms, with which it may be asso- ciated, is most favoured at the noiTnal body temperature, and that the presence of fever may not improbably be regarded as to some extent a protective factor tending to inhibit activity and growth. It is probable also that phagocytosis is more active, and that protective bodies, such as antitoxins, bacteriolysins and agglutinins, are produced more readily when a moderate degree of fever is present than at the normal temperature of the body." Whilst the growth of the bacillus and attendant organisms is most favoured by a normal tem- perature, the higher ranges of temperature, on the other hand, are associated with a neg'ative phase, during' which the phagocytic and other protective functions of the blood are depressed. Our treatment of fever, therefore, must be cautious, and should be directed chiefly to heightening the resisting power of the patient by means of a generous diet and the stimulating effect of fresh air, thus enabling him to form additional pro- tective substances and to check the growth of the tubercle bacillus and of other organisms which may be associating themselves in its activity. This effort on the part of the patient may be assisted by certain drugs, such as arsenic and iodine. Arsenic itself cannot be given in these cases in sufficient doses to diminish the temperature in any striking degree, but it has a marked influence upon some of the most distressing symptoms attendant upon the fever; and it sometimes in a striking manner improves the g'eneral condition of the patient. This drug is most indicated in those cases in which daily recurring chills are complained of. Three to five drops of the liq. arsenicalis or of the arseniate of soda solution, or gr. ~ to gr. I of the arseniate of iron three times a day, will often suffice to prevent the recurrence of these chills. Arsenic must be given with, or immediately after, meals. Another preparation of arsenic which we often prescribe, and which is less toxic and can therefore be administered in larger doses, is the cacodylate of soda (sodium dimethyl- 6/8 DISEASES OF THE LUNGS AND PLEURA arseniate). This may be given by the mouth in doses of half a grain three times a day, or, better, by hypodermic injection, the patient receiving siibcutaneously each day for fourteen days a single f-grain dose, dissolved in i c.c. (17 minims) of sterilised water. An interval of ten days should then be allowed before reverting to the injections. During the treat- ment due observation should be kept upon the knee-jerks and the fields of vision to insure that no adverse effects are being produced upon the nervous system, though we have never known such to occur. The cacodylate of soda appears to us to be more effective than simple arsenic, and when the fever has not been severe we have several times known it to abate, and the temperature to become normal after two or three courses of injections. In other cases, especially when there has been a syphilitic taint, we have obtained benefit from injections of neo-salvarsan.' Should arsenical treatment fail, or the patient be averse to the injections, we should advise that trial be made of the intensive iodine treatment, introduced by Dr. David Curle.^ This treatment consists in prescribing 20 grains of Potassium Iodide in half a pint of water after breakfast, and four hours later an ounce of Aqua Chlori in half a pint of freshly pre- pared and sweetened lemonade, thus effectually masking the nauseous taste of the chlorine. The dose of chlorine water is repeated at intervals of two hours until three doses have been given, and after two or three weeks a fourth dose may be added. The chlorine liberates iodine from the potassium iodide in the blood, and any beneficial effect is thought to be due to the antiseptic action of the nascent iodine thus pro- duced. Should symptoms of iodism manifest themselves, 30 grains of Sodium Bicarbonate should be given every two hours, and, if the symptoms continue, the treatment should be stopped; but we have not often observed this complication. We have tried this method on many occasions, and though we have never observed any sudden fall of temperature to fol- low its use, we have in not a few cases of moderate pyrexia observed a gradual lowering of the fever, and sometimes its complete subsidence, after some weeks of treatment. During this hectic period iodoform, creosote, and tar have been recommended for internal administration on account of their antiseptic properties. We have ourselves found them TREATMENT OF PULMONARY TUBERCULOSIS 679 of more value in the apyrexial period (see p. 687). When there is much local disturbance of stomach and upper bowel, how- ever, small doses of creosote, in combination with opium, are sometimes of considerable service. Antipyretics must be employed with care, and should be prescribed with the idea of moderating' fever when excessive, rather than of suppressing it altogether. It sometimes hap- pens, however that the good effect upon the temperature per- sists after the discontinuance of the drug. The following antipyretic remedies may be considered : (a) Quinine. — In from three to five grain doses, taken in milk and between meal-times, quinine is often of value in con- trolling hectic and in sustaining- the patient. A tablespoonful of whisky may often with advantage be added. (b) Phenazone, antifehrin, phenacetin, and allied drugs of well-known power in reducing temperature, are to be used in phthisis with great caution, and in carefully calculated doses prescribed at definite times with a view to moderating exces- sive peaks of temperature. In many cases they cause con- siderable nervous depression, with profuse sweating", and sometimes vomiting; in others they merely postpone the pyrexial rise to a later period of the day, and weaken the control of the nerve centres, thus exaggerating pyrexial fluc- tuations. In small doses, however, such as five grains of phenazone, or two to three grains of phenacetin, in combina- tion with quinine, salicin or aspirin, these drugs are some- times of assistance. (c) Cryogenin (meta-benzamine-semicarbazide) is also of value in this direction. It is best given in cachet form in doses of seven or ten grains, about three hours before the maximum daily temperature is reached, and is often success- ful in producing a decided diminution of fever. No untoward symptoms seem to accompany its use, though, as with others of these drugs, its effect is too often temporary.^ The evening temperature can sometimes be sufficiently moderated without medication by the employment of tepid sponging with a solution of dilute acetic acid one part, water, at a temperature of about 85°, six parts, and eau-de-Cologne I part. As an adjuvant to other remedies, especially when there are night-sweats', this apphcation is of value. 680 DISEASES OF THE LUNGS AND PLEURA In the comparatively rare cases in which a true secondary infection is present (see p. 467), if the fever continues in spite of treatment, a cautious attempt may be made to check its progress by means of an appropriate vaccine. We have not, however, observed much benefit from this Hne of treatment. Acute cases of the kind which we are considering, provided the disease is restricted to one lung, are sometimes greatly benefited by the induction of an artificial pneumothorax, a method of treatment which we shall consider in a later chap- ter (p. 719). This form of treatment should always, there- fore, be borne in mind, and must be carefully considered, as soon as it has been shown that the pyrexia is not yielding to more ordinary methods of treatment. Cough : its Local and General Treatment. — Except for cases in which throat symptoms are prominent, sprays are of Httle value, since it is very doubtful whether they penetrate beyond the larynx or main bronchi. There is no doubt, however, that by the inhalation of the dry vapours of volatile antiseptics much advantage may be gained in this stag'e of the disease. The effect of such inhala- tions is to lessen expectoration and to relieve cough; and one of their chief functions is to diminish the necessity for cough mixtures." Certainly the cough linctus treatment of this eliminative period of phthisis, by continually lulling cough and deranging stomach, is the very worst that could be devised. Our great objects are to get rid of the effete pro- ducts of caseous liquefaction and suppuration, and to keep the pus-secreting surface as disinfected as possible without harm- ing the patient in the process. The cavity contents are, it is to be remembered, in contact with living tissue, which has a retarding influence upon bacterial activity; and it is from this point of view that we look to general tonic and hygienic measures as operative in aid of our more special medication. The majority of patients find close naso-oral respirators irksome, but can wear the more open and lighter pattern devised by the late Dr. Burney Yeo for a longer time and with less fatigue. The pattern long in use at the Brompton Hospital is of this type, and consists of perforated zinc, bound round the edge where in contact with the face with chamois leather. A small receptacle is provided for the cotton-wool, which must be moistened with the solution for inhalation. TREATMENT OF PULMONARY TUBERCULOSIS 68 1 This respirator is inexpensive, and may be obtained from Messrs. Maw and Sons. Other forms are those of Coghill and Roberts. A good inhalant consists of a mixture of the following : Tincture of Iodine 3i., Liquefied Carbolic Acid 3ii., Creosote 3ii., Spirit of Ether 3i., and Spirit of Chloroform 3ii. We have also found three drachms of eucalyptol or olei pini sylvestris to the ounce of rectified spirit, or spirit of chloroform, a good combination : twenty drops on the wool of the respirator, to b-e used for half an hour to an hour or longer, after the first morning expectoration, in the middle day and in the evening. If the cough be troublesome, one drachm of oil of bitter almonds may be added to the one-ounce solution, and double strength spirit of chloroform used as the solvent. If the patient be able by assuming a dependent posture and by a determined effort more completely to clear the cavities before the use of the respirator, it is well to do so. This must be decided at the discretion of the doctor. In some cases the respirator may be worn almost constantly, such "continuous inhalation" of antiseptic vapour being thoug"ht by the late Dr. Lees to exercise a direct inhibitory effeqt upon the activity of the tuberculous process in the lung". We have ourselves never seen such inhalation produce in febrile cases any marked alteration in the temperature chart, and believe that the good effect is restricted to a lessening of the bronchial catarrh and its attendant cough. Another valuable prescription from the Brompton Hospital Pharmacopoeia is the following : Menthol 3ii., Creosote 3i.ss., Spiritfis Camphorse oi.ss., Spiritum Rectificatum ad gi. In some cases, especially when the cough is frequent and expec- toration abundant, a large bib may usefully be employed, sprinkled with a weak formalin solution (2^ to 5 per cent.). This has the double advantage of serving as an antiseptic inhalation, weak but constant, and of catching the spray of the cough in bedridden patients. A good sedative inhalation, especially when the larynx is involved, is produced by placing a few crystals of menthol in a dry tumbler and immersing it in hot water. In cases also where there is much tracheal irritation, causing incessant cough, ten or twenty drops of chloroform, inhaled from a smelling"-bottle or a handkerchief stretched across the open 682 DISEASES OF THE LUNGS AND PLEURA mouth, will give great relief; but this remedy must be used with caution and watchfulness. * It must be remembered that cough is the only means by which the phthisical lesions can be drained of their deleterious products, and cough cannot therefore be smothered by sedative remedies without damage to the patient. There are certain times and kinds of coughing which call for special treatment, particularly (a) the irritable and ineffec- tual cough, (b) the night cough, (c) the early-morning cough. (a) The irritable and ineffectual cough, in which only a very scanty expectoration follows after prolonged and ex- hausting efforts, can to some extent be controlled by the patient himself, and he should be encouraged to repress it as far as possible. In other cases treatment is indicated, and the symptom may be best modified by the use of one or other of the sedative respirators above mentioned. A small dose of opiate, such as five minims of nepenthe, or heroin gr. yV, may for a time be added to the day mixture. These irritable coughs generally mean that caseating and softening lesions have not yet established communication with the bronchi, and with this occurrence the cough becomes looser and more easy. (b) Night cough requires sedative treatment by opium, chloral, heroin or codein. A combination of small doses of these drugs, made up to a tablespoonful with mucilage and chloroform water (see p. 672), is often valuable, and may be repeated in half-doses once or twice in the night if necessary. The Pilula Ipecacuanhse cum Scilla of the Pharmacopoeia is also useful. When the cough is described as very "tight," an opiate may be taken in an alkaline effervescing draught at bedtime. (c) The morning cough, to which we have already alluded (p. 673), requires quite a different treatment; it should never be checked by sedatives. Its severity and the amount of expectoration are generally in inverse proportion to the quietude of the night. Expectoration and clearance of cavities should be encouraged by hot stimulating drinks, such as a cup of hot coffee or milk (with perhaps a liqueur glass of cog'nac or rum), or a dose of ether and ammonia. Some- times a hot, stimulating poultice over the sternum is useful; for example, a linseed poultice, with powdered camphor, in proportion of one ounce camphor to one pound Hnseed. It TREATMENT OF PULMONARY TUBERCULOSIS 683 is an advantage if the lungs can thus be cleared before break- fast, as there is then less tendency for the cough to induce vomiting. We may here allude to the highly irritating effects upon the stomach of the products of caseous softening and cavity secretion, when swallowed. Some patients, delicate- minded females and sensitive men, feel a reluctance or a timid- ness in expelHng the products of their disease; children espe- cially fail to do so. This inability or unwillingness to eject the sputa is a fruitful source of stomach and bowel troubles, and of local tuberculosis ; a simple warning will often prevent the necessity for special medication. A pleasant antiseptic mouth-wash should be used after the morning expectoration. Night-sweating. — This is a symptom which usually calls for treatment from time to time during the eliminative period of phthisis, but is of much less frequent occurrence since the introduction of the open-air lines of treatment. It arises from two principal causes — viz., fever and nervous exhaustion, these causes being commonly combined, but the one or the other predominating in different cases. There are innumerable empiric remedies for night-sweats, all of them successful in certain cases. They should not, how- ever, be used until such rational measures, as are indicated by the causative conditions above alluded to, have been adopted. The patient must be steadily supported by nourishment dur- ing the day, and some readily digestible food, such as strong- beef essence, given the last thing at night. Fever must be moderated by tepid acid sponging at bedtime (a wineglassful of aromatic vinegar with eau-de-Cologne to a tumbler of water), and a third dose of the quinine, or acid tonic in use may be given a little before bedtime. In many cases we have found a mixture containing two grains of quinine sulphate and twenty minims of dilute hydrobromic acid of value. If these means prove insufficient, then aid may be sought from specific remedies. Extract of belladonna gr. |, or atropine gr. TOcy, may be given in the form of pill at night either alone or in combination with quinine. If the cough is troublesome, hyoscyamine gr. i^ may be preferred. When the hectic has lasted some time, and has resulted in much nervous ex- haustion, strychnia is useful in full doses at bedtime, but this remedy is sometimes unfortunate in causing wakefulness. 684 DISEASES OF THE LUNGS AND PLEURA Four-grain doses of oxide of zinc, or two grains of valerianate of zinc will sometimes answer alone or in combination with belladonna. In cases in which night-sweating is observed to be preceded by shallow breathing and slight livid pallor, strychnine is especially indicated. A current of oxygen occasionally broug'ht near the patient during sleep may also prove of service. Agaricin gr. tV, and camphoric acid gr. xv., are other remedies of occasional value, their good effect being appar- ently due to their depressing action upon the nerve-endings to the sweat-glands." It is of the utmost importance to have some easily assimi- lable food, such as good cold beef-tea or beef-essence, ready to hand, should the patient wake up, and especially with night perspiration, for the sweats are profoundly depressing from the large quantity of saline material discharged, and the nervous exhaustion thus induced tends to perpetuate their nig'htly recurrence. The immediate supply of a stimulating salt-containing food tends to remedy the loss and to prevent its recurrence. Patients liable to night-sweating should wear a thin flannel loosely-fitting over-gown, and a fresh night- dress should always be ready aired for changing. General Summary. — Throughout the variable but often pro- longed period of suppurative fever through which the patient has to pass during the softening and elimination of the caseous products in the more active forms and periods of phthisis, the lines of treatment to be followed may thus be summarised. (a) The patient must be kept absolutely at rest in bed, and open-air lines of treatment strictly enforced. If the condi- tions are satisfactoiy, this can be well carried out in the patient's own home, a shelter being erected in the garden, in which he may lie out, and, even under favourable conditions, spend the night. Treatment in a sanatorium in this stage of the disease is not essential, and, indeed, cases of this kind are not altog'ether welcome in such institutions, requiring', as they do, additional attention and nursing. In cases where the home is situated in the midst of damp and unhealthy sur- roundings, a rem.oval to a high and dry locality, or to the seaside, with sunny exposure, cannot fail, ceteris paribus, to TREATMENT OF PULMONARY TUBERCULOSIS 685 be beneficial. No climatic change of any radical kind is indi- cated for this period of the disease. For the poorer classes our larg"e special hospitals are admirably adapted. Unfortu- nately febrile cases of the type considered in this chapter are not always welcome even here, but it is clearly the duty of every such hospital to provide for a certain percentage of such patients. In every county there should also be told off a certain portion of the infirmary, so reconstructed as to afford especial comfort and good hygienic conditions, and thus adapted for active as well as advanced cases of phthisis. (b) The patient must be steadily supported by an abundant and well-assorted dietary, rich in fats and nitrogenous ele- ments. If milk can be borne, one or two pints should be taken daily, as the patient is usually somewhat wasted. In some cases a light wine or beer, or other form of alcohol, is of value. (c) Particular symptoms — pyrexia, dyspepsia, sweatings, cough, and expectoration — will suggest the hne of medicinal treatment, which must be determined upon after careful con- sideration of the whole case, and not lightly changed. A written sketch of the dietary and times of taking medicine will be a useful guide to friends and nurses, and a wholesome check against mixtures " every four hours " and cough Hnctus " occasionally," besides pills for night-sweats, and local appli- cations, a wholesale medication, which if persisted in cannot fail to be disastrous. REFERENCES. ' The First Medical Re-port of the Hospital for Consumption and Diseases of the Chest, p. 38. London, 1849. ^ Pulmonary Consumption, by C. J. B. Williams, M.D., and Charles Theodore Williams, M.D., second edition, p. 336. London, 1887. (i) " The Digestibility of Fats and Oils, etc.," by John W. WeUs, M.B., British Medical Journal, 1902, vol. ii. p. 1222. (2) The Influence of Cod-Liver Oil on Tuberculosis, by J. W. Wells, M.B. Manchester, 1907. [a] " The Influence of the Unsaturated Fatty Acids in Tuberculosis," by Owen T. WilHams, M.D., and Charles E. P. Forsyth, M.B., British Medical Journal, iQOQj vol. ii., p. 1120. [b) " Cod-Liver Oil and its Action in Phthisis," by Owen T. Williams, M.D., M.R.C.P., ibid., 1912, vol. ii., p. 700. 3 686 DISEASES OF THE LUNGS AND PLEURA ^ "A Note on Sodium Morrhuate in Tuberculosis," by Sir Leonard Rogers, Kt., CLE., M.D., F.R.C.P., F.R.S., British Medical Journal, 1919, vol. i., p. 147. ^ " Ueber schadliche und niitzliche Wirkungen der Fieber-temperatur bei Infektionskrankheiten," von Fr. Roily, MUnchener Medizinische W ochenschrijt, 1909, April 13. ' " On the Use of Neo-salvarsan in Active Pulmonary Tuberculosis," by P. Horton-Smith Hartley, C.V.O., M.D., F.R.C.P., The Lancet, 1914, vol. i., p. 1602. * [a) " Observations on the Action of Iodine, and also on Nev^r Methods of Using It," by David Curie, M.D., The Practitioner, vol. Ixxxix., 1912, p. 846. (b) " The Treatment of Phthisis by Intensive Nascent Iodine Adminis- tration," by Edward G. Reeve, M.R.C.S., L.R.C.P., The Practioner, vol. xcL, 1913, p. 391. ° See " On the Use of Cryogenin in Phthisis,'' by James Calvert, M.D., St. Bartholomew's Hosfital Re-ports, 1907, vol. xliii., p. 51. " See " Antiseptic Inhalation in Pulmonary Affections," by J. Sinclair Coghill, M.D., British Medical Journal, 1881, vol. i., p. 841. ^^ See " Use and Abuse of Drugs in Tuberculosis," by Professor W. E. Dixon, M.A., M.D., F.R.S., The Practitioner, January- June, 1913, p. no. CHAPTER XLVIII TREATMENT OF PULMONARY TUBERCULOSIS— {Con(inued) The more Quiescent Period — Contracting, Secreting, and Ulcerous Cavities — Fibroid Stage. In dealing with the pathology of pulmonary tuberculosis, we pointed out how the disease, in most of its varied mani- festations, shows a disposition to periods of quiescence; and it is during- these periods, sometimes occurring in the earlier stages, sometimes after a prolonged hectic stage resulting- in completed excavation of a large portion of a lung, that an appropriate and definite treatment may succeed in producing permanent arrest. It is at these periods also that most may be expected from climatic change (see p. 636). In these stages the preparations of creosote and its con- geners, especially guaiacol, are of distinct value. The use of these remedies, long since suggested and abandoned, was resuscitated when the specific nature of tubercle was finally demonstrated. Bouchard and Gimbert in France,^ and Som- merbrodt^ in Germany, appear to have been the first to re- introduce them, and they were long in use by the French physicians before they became seriously employed in this country. Their value in many cases of phthisis, and especially at the stages indicated, cannot be doubted, although the exact mode by which their effect is produced remains obscure. Creosote and guaiacol may be prescribed in the form of capsules, containing- from one to three or more minims. A two-minim capsule should be taken, in the first instance, im- mediately after food three times a day, and the dose gradually increased. Some patients can take the drugs better when held in solution by rectified spirit, and flavoured by a liqueur or bitter. Cod-liver oil is another good vehicle; doses up to 10, or even 20 minims of the creosote being dissolved in two 687 688 DISEASES OF THE LUNGS AND PLEURA drachms of the oil, to be taken twice a day after food. Most patients are able in this way to tolerate the required dose of the drug without derangement of the stomach. It is not as a rule necessary to prescribe very large doses of the drug', but moderate doses should be persisted with for a long time. Other formulas which we have found of practical value have been the following : (a) J^ Guaiacol carbonatis, Guaiacol benzoatis vel Styracol 5i-ss. Calcii hypophosphitis ... ... ... ... 5ss. Pulvis Tragacanthte Co. ... ... ... ... 5i- Misce bene, adde guttatim : Syr. Pruni Virginianae vel Elixir Aurantii (U.S.P.)... §ss. Syr. Calcii Lacto-phosphatis vel Syr. Hypophos- phitum Co. ... ... ... ... ... oi- Aquam Chloroformi ... ... ... ... ad gvi. One tablespoonful in water or liquid malt three times a day soon after food. (b) 1^ Creosoti Carbonatis ... ... ... ... 3iv. Tinct. Gentianse Co. ... ... ... ... oi"^- Syr. Pruni Virginians ... ... .'.. ... ad §iii. One teaspoonful in a wineglass of water or malt extract after food three times a day. Increase the dose by five drops each second day up to two teaspoonfuls by measure. It is sometimes desirable, in patients with delicate digestion, to secure that the creosote preparation shall pass throug'h the stomach undissolved, to be absorbed from the intestinal tract. This may be effected by the use of " proposote," a combination of creosote and phenyl-propionic acid introduced by Messrs. Parke Davis and Co. Proposote is insoluble in water and acids, but is decomposed by alkaline fluids into creosote and phenyl-propionic acid. It is best prescribed in capsules, 10 minims corresponding to 5 minims of creosote. The idea of destroying the tubercle bacillus by any inter- nally administered antiseptic has been abandoned, and the effects of creosote treatment, when successful, are recog- nised as chiefly to diminish expectoration, to lessen waste of tissues, and to render them less susceptible to tuberculous acti\nty. Quiescent, Secreting, and Ulcerous CaYities. — We may now pass to a consideration of the cavities, which form so con- spicuous a feature in many cases of phthisis. In certain patients, after the pulmonary disease has ceased to extend, TREATMENT OF PULMONARY TUBERCULOSIS 689 the cavities, varying in size and number, become quies- cent, and slowly contract, yielding less and less secretion. In these cases of drying and contracting cavity the cough becomes irritable, and the patient frequently complains of its "tightness," having been accustomed to easy expectoration whilst the secretion was abundant. He should be encouraged by explaining to him the favourable nature of the cause of his difificulty, and directed to check, so far as possible, by an effort of will, the tendency to violent cough. Sedative cough mixtures, or the addition of iV gr. of heroin to the day mix- ture, etc., injurious whilst the expectoration was abundant, now, judiciously timed, become of much value. More or less morning expectoration persists for a considerable time after the cough has ceased during the day, and should not be checked by sedatives. It must not be forg'otten, too, that the morning expectoration may for months, and even for years, contain a certain number of more or less ill-conditioned tubercle bacilli which do not necessarily affect the patient's general well-being, since they are shut off by the dense fibroid surroundings of the cavity. The further hygienic, climatic, and medicinal treatment of cases of this kind must be con- ducted on general principles. It is of great importance to keep such patients in a pure atmosphere, since they are most sensitive to all septic condi- tions. Under unfavourable hygienic circumstances the cavi- ties become secreting, and other surrounding centres of disease take on fresh activity. Moorland, sea, and mountain air are all suitable for these cases, and one or other should be advised in accordance with the special indications (see chapters on Chmatic Change). As the patient's strength improves, the development of the sound portions of the lungs may be encourag-ed by carefully regu- lated exercise on rising ground. It is in this latter phase, provided the extent of lesion be not too great, that moun- tain resorts prove so valuable. Secreting Cavities may, as already pointed out, persist from the acute stage, or be developed by renewed activity of the lining of cavities which had become quiescent. The objects which we have in view in the treatment of such cases, are — (i) to lessen secretion; (2) to promote its evacua- tion ; and (3) to disinfect the cavities. 44 690 DISEASES OF THE LUNGS AND PLEURA Counter-irritation is useful over the cavities in the form of strong iodine applications, or flying bhsters, or perhaps a blister kept open for a time by savin ointment. A course of mineral acids, in combination with bark or astringent iron tonics, with cod-hver oil, is from time to time needed. It is in these cases in which, with Httle or no pyrexia, there is yet considerable secretion from cavities, that the preparations of tar, creosote, or eucalyptus may often be given in moderate doses with great advantage. Tar may be best prescribed in a morning and evening dose of the eau de goudron of Guyot, from 3ss. to 3i.ss. in a wineglass of plain or some mineral water (Ems, Bourboule, Vichy), to which a little warm milk, and, if necessary, cognac may be added; a single, or at most two, doses of tonic being given during the day. The tonic may from time to time be varied or omitted, but the tar pre- paration should be persisted in for weeks or months. Bell's Liquor Picis Aromaticus, in doses of twenty to forty minims (2 to 5 grains of tar), is also a useful and not unpleasant preparation ; or the tar^may be prescribed simply as a pill. In cases, especially, of intercurrent catarrh, causing an increased secretion from quiescent cavities, five or ten drops of a mixture of equal parts of oil of eucalyptus and pure terebene, taken on sugar three times a day between meals, may be prescribed with advantage. When the secre- tion is very abundant and the condition of the patient de- pressed, we have found oil of eucalyptus, held in solution with a drachm of rectified spirit, with the addition of glycerine and a little dilute phosphoric acid and quinine, a useful com- bination. Subcutaneous, or rather intramuscular injections of creo- sote or guaiacol, dissolved in sterilized oil, have been em- ployed in this, and also in the more active stage of phthisis. We have had opportunities of noticing the results of this method of treatment, but have been by no means convinced of its superiority; the imagination of the patient cannot fail for a time to be impressed, but at the cost of considerable discomfort, and in some instances of no little positive suffer- ing", local necrosis sometimes occurring at the seat of injection. If the opsonic index with regard to any particular organism in the sputum (whether streptococcus or other) is found to be TREATMENT OF PULMONARY TUBERCULOSIS 69I depressed, it may be raised by the employment of a suitable vaccine, under which treatment the amount of secretion will sometimes diminish. Sedative cough mixtures are directly contra-indicated except at bedtime, and then solely for the purpose of procuring rest. Seaside resorts, the more bracing of the Riviera stations, are the climates most suitable for these cases in the first place, but many will after a time continue to make better progress in the dry Alpine or South African highlands, provided the other indications for such climates are fulfilled (see Chap- ter XLV.). Ulcerous Cavities. — Cases of ulcerous or active cavities are always to be regarded as probably due to insanitary surround- ings, and such evil conditions must be first looked to and remedied. These cases are of an erysipelatous type, and under the more recent methods of hygienic treatment are now rarely met with; they are best treated by quinine in full doses, or perhaps tincture of iron, and locally by sedative inhalations of carbolic acid, conium, and chloroform, with hot-water vapour.* After the more active general symptoms have lessened, if the blood-stained and copious expectoration lead us still to infer that the walls of the cavity are hypersemic, if not ulcer- ated, the best treatment will be found to be free counter-irri- tation. A blister should be applied over the site of the cavity, and should be kept freely discharging for a week or ten days by means of savin ointment dressing. We have seen the active local symptoms completely subside under this treat- ment, and the expectoration, from being abundant and san- guineous, become scanty and viscid, apparently consisting of bronchial mucus only. With regard to the possibility of surgical intervention in the treatment of phthisical cavities, we must refer the reader to a later chapter (p. 728). Chronic and Fibroid Stage.— The management of the chronic and fibroid stages of pulmonary tuberculosis consists chiefly in the prevention of fresh catarrhs, which may lead in turn to the further spread of disease. To this end all insani- tary conditions must be avoided, clothing should be suitable, * Chloroformi mx., Succi Conii 3i., Glycerinum Acidi Carbolici ad 5ii., Aq. Bullientis gviii. — Bromfton Hosfital Pharmacofxia. 692 DISEASES OF THE LUNGS AND PLEURA and the diet nutritious but not stimulating. When prac- ticable, also a more genial climate should be selected, thus insuring protection from irritating fogs and cold damp winds. Iodine applications, soothing or antiseptic inhala- tions (carbolic acid being particularly useful when there is any foetor of expectoration), seem the best local remedies. The general condition, including that of digestion, and the nature of the cough and amount of expectoration, supply us with indications for the administration of appropriate drugs — iron, cod-liver oil, strychnia, alkalies, tonics, creosote, etc. — or warrant the withdrawal of all medicines. There is only one special remark concerning the treatment of these chronic indurative cases of phthisis, during the often extended period of quiescence, which seems called for, and it is this : that, having lived to acquire their immunity, such cases do not require the persistent administration of tonic medicines and cod-liver oil, although needing careful sur- veillance, and for several years, where practicable, carefully selected climates to suit the different seasons of the year. They improve immensely under such remedies up to a certain point, which may be readily recognised by the medical atten- dant, and cannot be better described than by saying that it amounts to the most perfect health attainable by a patient who has had a certain area of respiratory surface cut off. If beyond this point we persevere with iron and oil, and too nourishing or stimulating a diet, we may still further increase weight and heighten colour, but the pulse quickens, the patient gets more short of breath, he becomes, in a word, plethoric, and liable to pulmonary congestion and haemoptysis, or to dyspepsia and diarrhoea. A rapid neutralisation of all the good results obtained, with great danger of fresh, and perhaps fatal renewal of the old disease, is thus the conse- quence of too great anxiety to arrive again at a degree of health and bodily vigour which is impossible wth a per- manently damaged lung. The treatment of pulmonary tuberculosis occurring in the course of diabetes calls for no detailed comments. In such cases a considerable abatement in the regime for diabetes is usually necessary, and codeia, quinine, and cod-liver oil are indicated. TREATMENT OF PULMONARY TUBERCULOSIS 693 REFERENCES. ' " Note sur I'Emploi de la Creosote vraie dans le Traitement de la Phthisie Pulmonaire," par MM. Ch. Bouchard (de Bicetre) et Gimbert (de Cannes), Gazette Hebdomadaire de Medecine et de Ckirurgie, 1877, No. 31, p. 486. ^ " Ueber die Behandlung der Lungentuberkulose mit Kreosot," von Professor Dr. Julius Sommerbrodt (in Breslau), Berliner Klinische Wochen schrift, 1887, No. 15, p. 258. CHAPTER XLIX TREATMENT OF THE COMPLICATIONS OF PULMONARY TUBERCULOSIS Ulceration of the Bowel — Laryngeal Tuberculosis — HsBmopty sis — Vomiting — Intercurrent Pleurisy — Meningitis . Ulceration of the Bowel. — In the treatment of ulceration of the bowel in phthisis it may be usefully remembered that the mere presence of such ulcers does not necessarily cause diar- rhoea, this symptom, when present, being due to increased peristalsis set up by an active condition of the ulcer, or to attendant catarrhal inflammation of the adjacent mucous membrane. We have thus two conditions to bear in mind in the treatment of tuberculous ulceration of the bowels — viz. : (i) acute ulceration, the first stage of the disease, in which the ulcers are in process of formation or activity; (2) chronic ulceration, associated with diarrhoea alternating' with con- stipation, or with attacks of intercurrent looseness of bowel arising from errors of diet. Acute Ulceration.— In this condition, the symptoms of which have been already described (see p. 542), the diet must be carefully regulated, so as to give as Httle residue as pos- sible. The patient must be kept warm in bed, and food restricted to milk and a httle good beef-tea or meat essence. Four or five ounces of milk, citrated if necessary, should be allowed every two hours, and at certain intervals the milk may be replaced by beef-tea, half a pint of which, equivalent to half a pound of meat (see p. 330), may be allowed in the twenty-four hours. The milk can be given warm or cold, in accordance with the desire of the patient; sometimes a little crushed ice may be added, or it may be boiled with rice and strained, when six ounces should be allowed instead of four. If further nutriment is required, the milk should be 694 TREATMENT OF PULMONARY TUBERCULOSIS 695 thickened three or four times a day with a Httle plasmon or sanatogen. In other cases Beng'er's, or other pancreatised or malted farinaceous food, may be prepared with the milk twice or thrice daily. Sometimes koumiss in the third degree of fermentation (see p. 603) may be substituted for milk. The beef-tea can be varied with veal-tea, chicken or mutton broth, and the latter may occasionally with advantage be added to the milk. After a few days, rusks and a little tea may be allowed, and the diet slowly improved through such grades as custards, ground-rice puddings, invalid turtle, scalded bread-and-milk, pounded chicken, and the like. As the diet is improved, the intervals between the times of taking food should be increased to three or four hours. In some cases a small quantity of stimulant in the form of brandy, added to each second quantity of the milk, is of ser- vice, or a little old port wine may be allowed. During the acute period now under consideration, and whilst any tenderness remains, the patient will be best in bed, and a pine wool pad, or calorigen or thermogen wool, should cover the abdomen. When there is marked tender- ness over the region of the caecum, a small blister may with advantage be applied in this situation under a poultice. In medicinal treatment it is of importance, first of all, to clear away any irritating- matter from the bowel, and the administration of from one to two drachms of castor oil, well shaken up with two ounces of hot milk, and a dessert-spoon- ful of cognac added, will prove of service. It is often a good plan to give a small dose, half to one grain, of calomel two hours previous to the dose of oil. After the lapse of a few hours, to allow the effect of these medicines to take place, ten or fifteen grain doses of bismuth, with half a grain of ipecacuanha, and ten grains of sulphccarbolate of soda in mucilage and chloroform water, is a good routine treatment. After some eight or twelve doses, a httle chalk mixture should, if needed, be added in place of the soda. Sometimes cerium will answer better than bismuth, and in cases of pain- ful peristalsis small doses of opium are needed. When there is much tympanites and tenderness, five minims of glycerine of carbolic acid, thirty minims of the solution of perchloride of mercury, and five minims of tincture of opium, with compound tincture of chloroform, a little sul- 696 DISEASES OF THE LUNGS AND PLEURA phocarbolate of soda, and some aromatic water every four hours for a day or two, may be of g'reat service. In some of these cases carbonate of guaiacol will be found useful, especially after the more acute stage has passed. It is the greatest possible mistake to treat tuberculous diar- rhoea with astring'ents and opiates as a matter of routine, and without very carefully looking" to the diet. This treatment is on a par with that of pulmonary lesions by sedative cough mixtures, and only serves to mask symptoms whilst the tuber- culous lesions are spreading- and deepening. Chronic Ulceration. — In this condition, if diarrhoea super- vene upon previous constipation, or if the appearance of the motions and coated tongue lead to the inference that scybal- ous or irritating materials are present in the bowels, a dose of castor oil or compound rhubarb powder should first be given, the dietary carefully gone over although VN'ith less strictness than in the acute stage, and a course of bismuth and soda or chalk prescribed. In severe cases twenty grains of bismuth and five grains of Dover's powder is a useful combination, or ten grains each of bismuth and compound kino powder may be given every three or four hours. In a much more limited number of cases sulphuric acid and opium answer better. When there is much tenderness and tympanites, a combination of carbolic acid, mercury, and opium, as above stated, may be given for a day or two. A layer of pine wool quilted on flannel should be kept firmly applied to the abdomen. On the subsidence of active symptoms a little calumba, cascarilla, or quinine, may be given twice a day in combination with fluid bismuth; or five-grain doses of hypophosphite of lime may be prescribed with ten minims of Liquor Calcis Saccharatus in calumba or chiretta infusion. Constipation is very apt to follow upon diarrhoea in cases of ulcerative disease, and a collection of solid faeces tends to re- awaken the activity of the ulcers. The smallest available dose of laxative should therefore be prescribed when necessary, one drachm of castor-oil being frequently sufficient when taken well emulsified in hot milk. The diet may be modified, and a little fruit, cider or light beer allowed to correct the tendency to constipation, care being taken to exclude fibres, pips, seeds and skins of fruits and vegetables. In cases where TREATMENT OF PULMONARY TUBERCULOSIS 697 the third-stage koumiss has been taken during the period of diarrhoea, a return to medium koumiss may be suggested as less astringent. The above plan of treatment will be found most generally- efficacious in cases of moderate intensity of acute and of chronic intestinal ulceration, and during periods of intercur- rent diarrhoea. In certain cases of chronic ulceration with diarrhoea, which have not yielded to ordinary methods of treatment, although the general health is fairly maintained, encouraging results have been obtained with heliotherapy (see p. 641). Cases of tuberculous peritonitis have also been thus influenced favourably.^'^ In advanced cases the diarrhoea must, as far as possible, be restrained by careful diet, but our therapeutical resources are often taxed to the utmost, and in vain, to effect more than a passing" relief. A remedy which scarcely ever fails to give temporary relief, even in the worst cases, is the starch and opium enema. Some acetate of lead may be added to this enema, or the lead and opium suppository may be employed with advantage. In more chronic cases and those of great severity we still have a large armoury of more decided astrin- gents to fall back upon, amongst which acetate of lead and sulphate of copper (gr. |), with opium, hold a high place. But the vegetable astringents — kino, catechu, hsematoxylin, tannic acid, Indian bael — may be each in turn tried in com- bination with opium, with decided, but often only temporary, benefit. The aromatic chalk and opium powder of the Phar- macopoeia given in a mixture containing tincture of catechu, is a favourite remedy in these cases. Although all the vege- table astringents owe their efficacy to the tannin they con- tain, yet there is some peculiarity in each, and when one has failed another will often succeed, again in its turn to lose its virtues in the particular case. Almost all these cases require opium in addition to the astringent, and sometimes opium alone given in the solid form is the best remedy. Laryngeal Tuberculosis.— The treatment of tuberculosis of larynx, although in many cases unsatisfactory, is by no means so gloomy a procedure as is sometimes imagined. The car- dinal principle to be observed is to give rest to the larynx by checking cough and enjoining silence, keeping the patient meanwhile under the best hygienic conditions possible. Pro- 698 DISEASES OF THE LUNGS AND PLEURA vided the pulmonary lesion be of favourable type and amenable to treatment, arrest of the laryngeal disease not infrequently occurs, and we have known not a few cases of laryngeal tuberculosis, some of which had proceded to ulcera- tion, thus undergo arrest. We may now sketch out the treatment in greater detail. If the laryngeal trouble shows itself when the pulmonary disease is in a comparatively early stage, and this is by no means uncommon, treatment in a sanatorium should be advised, since in addition to such local measures as may be required, the patient will have also the benefit of the general regime. As we have pointed out in a former chapter, the sana- torium chosen should not in this instance be at too high an altitude, or in too cold and bracing a locality. An attempt must also be made to insure as complete rest as possible to the parts by urging the patient to refrain from all unnecessary coughing. An irritable cough may often be allayed by the use of an antiseptic inhalation, containing- menthol and creosote, or other remedies, as we have indicated in an earlier chapter (p. 681), and we must refer the reader to what we have there said in regard to the treatment of this symptom. Measures to check unnecessary coughing must be supple- mented by enjoining a period of absolute silence. In some cases this may be enforced for as long as five or six months, but its duration must depend a good deal upon the tempera- ment of the patient. Occasionally it leads to considerable mental depression, and must then be shortened. Such patients can, of course, converse by writing, and any monotony and depression may be lessened by reading cheerful literature. Should the laryngeal affection be unaccompanied by much infiltration or oedema, the patient can be instructed in the method of intralaryngeal heliotherapy, directing the sun's rays on to the larynx by means of a laryngeal mirror held in position by himself.^ If there be much infiltration of the parts, the method is contra-indicated, since reactive swelling will follow the treatment and might lead to dangerous dyspnoea.^* In these cases, as we have already mentioned, the internal administration of creosote or guaiacol is often helpful. In regard to direct treatment, too great a dilig^ence in the use of local applications to the larynx is to be deprecated, and TREATMENT OF PULMONARY TUBERCULOSIS 699 as a general principle topical applications, except in the form of soothing sprays or inhalations, are better avoided. A simple remedy which often gives relief, by removing irritating secretion from the upper region of the larynx, is a spray of Ems water, slightly warmed by standing in a tumbler of hot water. In certain cases, however, when there is persistent swelling and infiltration of the larynx, which does not yield to the simpler methods of treatm_ent which we have sketched out, puncture with the galvano-cautery in one or more situations may be sanctioned, with a view to induce sclerosis of the adjoining parts and thus imitate Nature's method of healing. We have seen benefit from this procedure, and carefully car- ried our, have not known it lead to harm. The free curetting of ulcerated surfaces sometimes practised is not a method of treatment which we can recommend ; we have known rapid spread of the pulmonary disease and death to follow such a procedure. The plan also of treating ulcers of the larynx by the direct application of lactic acid, 50-75 per cent., formerly so much employed, has of late fallen out of favour as not being in harmony with modern methods of treatment. If the ulceration be extensive and diffused, palliative treat- ment is as a rule alone possible. When there is much pain the persistent use of external counter-irritation will be found most beneficial, especially when combined with that complete rest to the larynx which pain always calls for. A small blister, the size of a shilling, should be daily appHed over the region of the larynx for several days, so as to keep up constant, but not too severe, counter-irritation. Perhaps, however, the most distressing symptom which attends advanced tuberculous laryngitis is dysphagia, which so often follows ulceration of the epiglottis. This may be reheved by the application of a 10 per cent, solution of cocaine to the throat, or by allowing gelatine lozenges, containing 5 per cent, of the drug slowly to dissolve in the mouth shortly before meals. Burroughs Wellcome's or Oppenheimer's atomiser, charged with parolein and cocaine (5 per cent.), with a little morphine or chloral, will also afford great relief i m many cases. In others an insufflation, composed of iodoform and boric acid (gr. i of each), and morphine acetate (gr. i), may be recommended. 700 DISEASES OF THE LUNGS AND PLEURA Orthoform is another preparation which we, in common with other observers, have found very valuable in these cases. It is a synthetic product analog'ous to cocaine, but without its toxic defects; it relieves the pain very decidedly in many cases, and seems to produce no injurious results. The remedy may therefore be entrusted to the patients themselves, who should be directed to place a little of the powder on the palm of the hand, then cover it with the broadened end of a Leduc's auto-insufflator* (Fig. 65), the other end of which has been previously placed in the mouth and hooked over the back of the tongue; a deep breath is then taken, when the inhaled air draws the powder through the tube, and distributes it over the surface of the larynx. If there be much inflammatory secretion over the ulcerated surfaces, resorcin may be added to the orthoform in the pro- portion of resorcin one part, orthoform three parts. If the Fig. 65. — A Leduc's Glass Tube for the Inhalation of Powders into THE Larynx (Reduced to Half-Size). dysphagia results merely from swelling of the larynx, with- out ulceration or abrasion of the surface, orthoform is of less value. In such cases insufflations of another synthetic pro- duct of a similar order, ancssthesin, used in the same manner as orthoform, will often prove successful. When the pain in swallowing is severe, an injection of alcohol (about i c.c. of a solution consisting of 2 grains of hydrochloride of eucaine B. in an ounce of 80 per cent. alcohoP) into one or both superior laryngeal nerves often gives striking relief. This results from the partial anaesthesia of the larynx, which is brought about, and which lasts for a considerable time. Patients in this stag"e sometimes swallow their food with greater ease when lying" on one side or on the back; others again swallow best when lying with the head over the side of the bed, and sucking the liquid through a tube from a cup * These simple and inexpensive glass tubes, which the patients soon learn to use with ease, may be obtained from Messrs. Maw and Sons. TREATMENT OF PULMONARY TUBERCULOSIS /OI placed at a lower level. In other instances nutrient enemata should supplement for a time the ordinary method of feed- ing; they help to give rest to the diseased parts, and lessen the distressing sense of exhaustion from which the patients often suffer. When extensive ulcerative destruction of the vocal cords is present, the most distressing symptoms arise from the strain of cough and the mechanical difficulty of expectorating. These truly terrible symptoms are most difficult to relieve. When they arise a few drops of chloroform, or thirty drops of equal parts of chloroform and menthol, may be placed on a handkerchief or sprinkled on blotting-paper in a wide-mouthed smelling-bottle or tumbler, and inhaled. Finally, recourse must be had to morphia to lessen the acuteness of the distress. Tracheotomy is very rarely necessary in cases of tubercu- lous laryngitis. Occasionally, however, the swelling of the parts becomes so extreme, perhaps from superadded septic inflammation, that it cannot be avoided. The effect of tracheotomy is to render expectoration almost impossible, and hastens rather than hinders the progress of the case. Aphthous Mouth and Throat is a distressing compHcation of advanced phthisis, and one especially apt to occur in cases associated with diarrhoea. It may be warded off for a long time by careful cleansing of the mouth each time food is taken with weak boracic lotion, or with tepid water, just made pink with toilet Condy, to which a few drops of eau-de-Cologne have been added. A weak glycerine of thymol lotion is also useful. Pregnancy and Lactation. — We may perhaps consider at this point the effect which pregnancy has upon tuberculosis of the lungs. There can be little doubt that this complication has not by any means that uniformly bad effect upon the pul- monary disease with which it has been sometimes credited. During the pregnancy the general health is not uncom- monly improved, and we have known patients, the subject of quiescent disease, go through more than one confinement without any harmful result. More than ordinary care must, of course, be taken in regard to rest and diet during the period of gestation, and the confinement should not be allowed to be unduly prolonged. In such cases we should not interfere in any way with the pregnancy. 702 DISEASES OF THE LUNGS AND PLEURA It is later, with lactation, that the danger arises, the drain on the mother's system lowering her resistance and tending to light into activity the pulmonary disease. It is our practice, therefore, to forbid the suckling of the child by the phthisical mother except perhaps for the first few days. It is well also to bear in mind that though the danger of preg"nancy itself may have been exaggerated, yet a large family may have indirectly a bad effect upon the mother in that it must almost certainly mean less opportunity for rest and for that careful regulation of her life which is so essential for the maintenance of arrest, and among- the poor too often also insufficient food.* Haemoptysis. — In speaking- of the treatment of haemoptysis, we have in mind the causes of hsemorrhag'e already indicated as operative in phthisis — viz., active hyperasmia, diseased small vessels, and erosion or aneurismal dilatation of large vessels. The two former conditions account for most attacks of primary hsemoptysis and for such intercurrent attacks as are preceded by, or attended with the symptoms and signs of fresh accession of lung disease; the latter condition being answerable for the severe and sometimes fatal haemorrhage proceeding from cavities, most commonly in the later stages of the disease. Primary and Intercurrent Hcemoptysis. — Shock is a marked symptom in early haemoptysis, especially in first attacks. The agitation of the patient must be calmed by the confident assur- ance of the absence of immediate danger, and all measures of treatment should be carried out without bustling about or whispering. The doctor will often treat his patient best by quieting anxious friends. The recumbent posture, with head and shoulders slightly raised by pillows, should be adopted, with light coverings and warmth to the feet. Ice should be given, and all stimulating restoratives strictly for- bidden. Indeed, the early faintness which so commonly super- venes, when short of actual syncope, should be encouraged rather than prevented, since it involves a low tension in the pulmonary system, a condition favourable to the formation of a clot, which may close the bleeding vessel. In all cases of hsemoptysis the aspect of the patient and character of pulse should be noted, the temperature taken, and the stethoscope lightly applied over the front of the TREATMENT OF PULMONARY TUBERCULOSIS 703^ chest, no extra effort of breathing being allowed; the heart's sounds should also be carefully listened to. All these observa- tions can be made without disturbing the patient in the least, and information as to the attack can be gained from friends. There are different types of cases to be observed, for which different plans of treatment are indicated. In a considerable proportion of cases there is pallor, with drawn features, chilly surface, and small, thready, quick pulse, significant of com- bined nervous shock, loss of blood, and constitutional feeble- ness. In such cases opium is of great value, a small hypo- dermic injection of morphia rapidly calming the agitation and quieting the heart's' action. It must be administered, however, with caution, and not in sufficiently large doses to check all cough, lest the danger of broncho-pneumonia from the retention of infected material be aggravated. The bowels should be attended to, and later may, if necessary, be kept freely open, the pressure of the blood in the general and also in the pulmonary circulation being thus controlled. For this purpose a drachm of sulphate of magnesium, three or four times a day, may be prescribed. For some days the patient must be kept absolutely at rest in bed, not being allowed to rise on any pretext, and not encouraged to talk by the visits of sympathising friends. His food should be Hght, and should consist of two to three pints of cold, or at least only just warm, milk each day, with a little bread and butter, junket or custard. If he desires it, he may be allowed some ice to suck. Under this treatment the haemorrhage will often cease; should it continue, other remedies must be considered, but in g'auging their value we must remember that cases of primary haemoptysis as a rule subside without much trouble, and any remedy used in a sufficiently large number of cases will gain a reputation. Salt and water was long held by the Brompton nurses as of great efficacy. Of the special remedies of value, the nitrites may first be mentioned. The inhalation of amyl nitrite leads to the dila- tation of the peripheral vessels, and thus to a lowering of tension in both general and pulmonary systems. So much is this the case that in the experiments upon dogs of MM. Pic and Petitjean^ the lungs became white and anaemic within two or three minutes of the amyl nitrite injection, and according 704 DISEASES OF THE LUNGS AND PLEURA to these observers, if a cut was made in the organ at the moment of the injection, the copious haemorrhage resulting was stanched as though by the application of a ligature. The effect was said to last about five minutes. Amyl nitrite is thus usefully inhaled at the first onset of the hsemorrhag'e, the anaemia of the lung and the fall in pulmonary pressure assisting in the formation of a clot, and sealing the bleeding point. A patient who has had haemoptysis may be advised to carry the capsules in his pocket, to be used in the event of any emergency arising. The effect is, however, transitory, and if the blood-pressure is estimated to range above the normal, two-grain doses of sodium nitrite may often be usefully employed to ease it to a lower level. Erythrol tetranitrate or nitro-glycerine may be prescribed for the same end. In certain cases five-grain doses of ipecacuanha, repeated every one or two hours for a few doses, as recommended by Sir Robert Philip, prove valuable. We have ourselves never been tempted to adopt Trousseau's plan of giving an emetic to arrest haemoptysis. Oil of turpentine is another remedy which is often found useful, although its mode of action is not clear. It should be given in twenty-minim doses every four hours, and may be combined with three minims of oil of cloves, two drachms of mucilage of acacia, and cinnamon water to one ounce, care being taken to examine the urine from time to time during its administration for the presence of albumin. Many other drugs have been recommended for haemoptysis. Thus, calcium chloride and calcium lactate, in doses of ten to fifteen grains three times a day, have been thought by some observers to increase the coagulability of the blood, and to be thus indicated. We have tried them on many occasions, and in more frequent and larger doses than the above, but have not convinced ourselves of their utility. In former days tannic and gallic acid and acetate of lead were also much employed, but a study of their phar- macological action renders it more than doubtful whether they possess that remote astringent and haemostatic effect with which they were once credited. Their astringent action on the bowel is directly opposed also to the requirements of the case. We have found tincture of hamamelis (nixl.) in TREATMENT OF PULMONARY TUBERCULOSIS 705 combination with a like dose of hydrobromic acid every six- hours of a certain value in cases of haemoptysis when the first outburst has passed. Another remedy which formerly enjoyed a great reputation is ergot, given at first in a full dose (one or two drachms of the liquid extract in iced water), and twenty to thirty minims every hour afterwards for a few doses. The action of this drug' is to stimulate organic muscle, including that of the arterioles; but whilst thus constricting small vessels, it at the same time, as shown by the late Dr. Andrew, raises both pul- monary and systemic blood-pressures, and any good effect upon the pulmonary arterioles is thus to some extent coun- teracted. Nevertheless, we have known it apparently instru- mental in arresting haemoptysis in cases in which other reme- dies had failed. More recently adrenalin has been advocated with the idea of constricting the pulmonary vessels, and thus closing the bleeding point; but Drs. Brodie and Dixon" have shown it to be not capable of producing this result, and Dr. Langdon Brown^ records that "in an animal killed by a fatal dose, while all the other tissues were anaemic — from the general peri- pheral constriction — the coronary vessels were distended with blood, and the lungs showed a condition of the most intense congestion, being a deep plum colour." Its use is therefore contra-indicated. The continuous application of ice to the chest for early or intermittent haemoptysis, a remedy much used, is in our opinion to be deprecated. We have never observed it to do good, and have seen cases in which it appeared to do much harm. For the haemoptysis which sometimes occurs in persons with venous plethora and males of intemperate habits, and which not uncommonly ushers in a rapid inflammatory form of phthisis, a drachm of sulphate of magnesium, with fifteen minims of aromatic sulphuric acid, may be prescribed with advantage every four hours until the secretions become free and watery, and in some cases it is well to begin with a mer- curial. In very exceptional cases of this kind depletion from the arm may be advised. In patients in whom there is distinct evidence of syphilitic cachexia full doses of iodide of potassium, with or without 45 ^o6 DISEASES OP THE LUNGS AND PLEURA mercury, should be combined with the more usual methods of treatment. In these cases the haemoptysis is sometimes very severe, and yet yields readily to treatment. In the early stages of phthisis, as we have seen, active inflammatory hyperaemia is commonly present, and may give rise to haemorrhage, which does not usually amount to more than a coloration or streaking of the sputum. The recum- bent position of the patient during sleep is a factor tending to increase the hyperaemia, and if the head and shoulders be raised to an angle of 45 degrees with the trunk, the haemop- tysis will in some cases cease. ^ Slight staining of the expectoration, or even a small quan- tity of fresh blood, not infrequently appears during the eliminative periods of the pneumonic forms of phthisis. Such occurrences need occasion no modification of treatment, being due to the breaking across of trabecular vessels of small size, already partially occluded. As a matter of precaution stricter quietude must be enjoined for a short time after any such occurrence. Mixed sanguineous expectoration in cavity cases is best combated by free counter-irritation by the application of a blister, and subsequently dressing the surface with savin ointment for a week or ten days. Summary. — In an ordinary case of primary haemoptysis our treatment, therefore, would be to reassure the patient and his friends, to give a dose of morphia, and later some such slight astringent as tincture of hamameHs, in combination with hydrobro^mic acid in iced water. If amyl nitrite be at hand it should be inhaled during the attack. Should the haemorrhage be more severe and repeated, small doses of nitrite of sodium may be given for a couple of days to ease the blood-pressure. In other cases in which the haemorrhage continues, whilst the blood-pressure is low, turpentine or erg'ot may be prescribed. The patient should be kept at absolute rest, and the diet should consist of cooled liquids, and such semi-solids as cus- tard, blancmange, and bread and butter. We should soon, however, begin cautiously to feed our patient, avoiding only hot fluids. It is of the utmost importance that the bowels should be kept clear, and in certain cases attended with plethora sulphate of magnesia and dilute sulphuric acid are the best medicines. Under this treatment the haemorrhage is as a rule quickly controlled, and we have never known it TREATMENT OF PULMONARY TUBERCULOSIS 707 necessary in the class of case which we are now considering, to resort to artificial pneumothorax. Recurrent Hcsmoptysis. — In the treatment of this form of haemoptysis, which, it will be remembered, is generally due to the rupture of an aneurism in a pulmonary cavity, the same general principles which we have already sketched out must be adhered to. Absolute rest must be insisted upon, cough and excitement allayed by opium, and arterial tension reduced by nitrites, saHnes, or the other remedies to which we have alluded. In this way Nature is assisted in forming a coagu- lum at the seat of rupture, and the haemorrhage is checked. The tendency to recurrence of haemorrhage in these cases must be remembered, and care must be taken not to allow the patients to move about too soon. In those patients, too, who are gifted with rapid blood-making powers, and who pick up flesh with great rapidity after haemoptysis, a judicious ab- stinence from butcher's meat and the complete withdrawal of stimulants may ward off or postpone the next attack. The haemorrhage in this form is far more profuse than in primary haemoptysis, and is often immediately fatal. In some instances, as in that of the patient whose case we have re- corded (p. 553), it recurs again and again, until the patient arrives at the lowest ebb compatible with life, when the bleed- ing vessel is stanched by coagulum, and recovery commences. In some other cases, however, the patient dies suddenly from combined syncope and blocking- of the air-passages, with the expectoration of only a very small amount of blood. It is in this class of case, in which the haemoptysis is severe and repeated, and the patient's life in danger, that treatment by artificial pneumothorax is of value (see Chapter LI.). By this means the lung is collapsed, pressure is exerted upon the bleeding- point, and the formation of clot facilitated. We have known several cases thus successfully treated, and have no hesitation in advising- the performance of the operation pro- vided we can be reasonably satisfied, from the physical signs and symptoms, as to the side from which the haemorrhage is proceeding. It - sometimes happens, however, that with advanced disease in one lung", the patient's sensations tell him that the blood is coming from the other and less affected lung, and this is not impossible, for in rapidly advancing cases we have known aneurism to form in the lung much less exten- 708 DISEASES OF THE LUNGS AND PLEURAE sively diseased. Under such circumstances the treatment must be abandoned, the extensive involvement of the other lung forbidding us to entertain the idea of compressing the more healthy side. With reference to prophylactic treatment, patients suffering from phthisis, who have chronic cavities, and have had warn- ings of haemoptysis, should be cautioned against unnecessary and especially sudden muscular efforts calculated rapidly to raise the blood-pressure, and should therefore avoid hurry- ing upstairs, walking fast, hastening to catch trains, and so forth. Spurious HcBinoptysis. We have dealt with the treatment of this non-pulmonary form of haemorrhage in the chapter devoted to its description (see p. 557). Yomiting with Cough. — This distressing symptom is espe- cially characteristic of the more indurative forms and stages of the disease, and its successful treatment is attended with much difficulty. The symptom is primarily due, as we have pointed out (p. 516), to the mechanical difficulty in expelling secretions from cavities and bronchial tubes which are sur- rounded by dense, tough, airless consolidations; and, secondly, it is distinctly to be observed in many cases that there is undue irritability of the vagus, giving rise to cough directly food is taken into the stomach. Any catarrhal condition of this organ must be treated by alkalies, bismuth, and hydro- cyanic acid taken an hour before meals, and even in the absence of catarrh this alone may relieve the symptom by rendering the mucous membrane less responsive to nervous influences. A mixture containing five grains of Alum, five minims of Liquor Potassae, and Peppermint water to an ounce, is also sometimes helpful in these cases. If there appears to be a hyperaesthetic condition of the vagus, a little hydrocyanic acid with ten-minim doses of the Liquor morphinae hydro- chloridi, taken half an hour before the principal meals, either alone or with bismuth and soda, may succeed in preventing the cough. In other cases, again, we have found a course of strychnia as a nerve tonic of value." The patient should keep strictly at rest for an hour or so after meals. Intercurrent Pleurisy.— Intercurrent pleurisy at the upper half of the chest is best treated by the appHcation of small bhsters or the Liquor Epispasticus. If the pain be rather of TREATMENT OF PULMONARY TUBERCULOSIS 709 a dull aching than of a sharp pleuritic character, and if physical signs point to the presence of fresh pulmonary trouble, the more gradual effect of iodine applications is to be preferred. The Tinctura iodi fortis should be painted over the part each day or second day for two or more applications, a layer of pine-wool covered with oiled silk being' kept con- stantly applied over the part painted. It must be remem- bered that some skins are much more sensitive to iodine than others, and in such cases, and especially in children, the Tinc- tura iodi mitis will be found sufficiently strong. When some portion of the lower half of the chest is affected with pleurisy in the course of phthisis, the prompt apphcation of a long piece of Leslie's strapping three or four inches broad, so as to extend round the affected side to a couple of inches beyond the median Hne in front and behind, will, by restraining respiratory movements, at once relieve pain, and often arrest the local inflammation. This treatment is of great value in many cases, and is to be particularly advised when, in addition to the signs of pleurisy, superficial crepitations with a few liquid clicks suggest that liquefac- tion of caseous pneumonic centres is proceeding close under the pleura. The timely apphcation of strapping in such cases may, by relieving the lung from the shock of cough, avert pneumothorax. Some patients cannot bear this appli- cation, however, and the rough clinical test of its probable usefulness in any given case is to hold the side with steady pressure of the hand, and see whether relief from pain is thereby obtained. When strapping is not tolerated, the apph- cation of a few leeches, or a small bhster, with a hot hnseed poultice over it, will speedily give rehef, and this line of treat- ment may be followed with advantage when the pain is severe. Tuberculous Meningitis.— The early stages of tuberculous meningitis are, as already pointed out (p. 563), very insidious and obscure, and it must be confessed that the progress of this fatal malady is beyond our control. Some of its more distressing symptoms may, however, be mitigated. A brisk calomel purge should first be given, and if pain in the head be a marked symptom, it will be reheved by the application of cold lotions or the ice-cap. In severe cases relief will be afforded by the apphcation of leeches to the temples. The 710 . DISEASES OF THE LUNGS AND PLEURA room should, in the earHer stages of the disease, be darkened; care must be taken to relieve the bladder if necessary. Full doses of bromide and smaller doses of iodide of potas- sium seem sometimes to give rehef. When twitchings are present, chloral should be given in combination with the bro- mide. Should convulsions threaten, the chloral should be sufficiently pushed to avert, if possible, this symptom, so dis- tressing to friends, although, happily, unfelt by the patient, the remedy being administered in a little water or barley- water by the rectum, if it cannot be taken by the mouth. A few whiffs of chloroform sometimes appear to restrain con- vulsions. Considerable relief may be given in many cases by lumbar puncture, the excess of fluid effused into the ventricles being thus drained away, and pressure symptoms for a time relieved. The tapping should be repeated if necessary. REFERENCES. * [a) La Cure de Soldi, par Dr. A. Rollier, pp. 171 and 154. Paris- Lausanne, 1914. [b) Loc. cit., p. 184. ^ " Contribution a la Pratique de Heliotherapie Laryngee," par R. Alexandre, Archives Internationales de Laryngologie, d^Otologie, et de Rhinologie, 1912, tome xxxiii., p. 388. * " The Treatment of the Dysphagia of Laryngeal Tuberculosis by Alcohol Injections into the Superior Laryngeal Nerve," by J. Dundas Grant, M.A., M.D., F.R.C.S., The Lancet, 1910, vol. i., p. 1754. * See also an interesting note on " Pregnancy and Tuberculosis of the Lungs," British Medical Journal, 1915, vol. i., p. 348. ° (a) " De Quelques Applications Nouvelles de la Medication Vaso- motrice au Traitement des Hemoptysies d'Origine Pulmonaire chez les Tuberculeux," par MM. A. Pic et G. Petitjean, Lyon Medical, 1906, tome cvi., p. 309. [b] " Effets compares du Nitrite d'Amyle sur la Grande et la Petite Circulation," par MM. A. Pic et G. Petitjean, Comftes Rendus Hebdomadaires des Seances et Memoires de la Societe de Biologie, 1906, tome i., p. 131. ' " Contributions to the Physiology of the Lungs, Part II., On the Innervation of the Pulmonary Bloodvessels ; and Some Observations on the Action of Suprarenal Extract," by T. G. Brodie, M.D., and W. E. Dixon, M.D., Journal of Physiology, 1904, vol. xxx., p. 476. '' Physiological Principles in Treatment, by W. Langdon Brown, M.D., p. 22. London, 1908. * " The Rational Treatment of Capillary Haemoptysis in Phthisis," by Charles GaskeU Higginson, British Medical Journal, 1905, voL ii., p. 577. ^ " The Use of Strychnia in the Vomiting of Phthisis," by R. Douglas PoweU, M.D., The Practitioner, 1868, vol. i., p. 312. CHAPTER L SPECIFIC TREATMENT OF PULMONARY TUBERCULOSIS We have in the preceding chapters considered the treatment which should be adopted in dealing with the various forms of pulmonary tuberculosis. Apart from the combating of special symptoms, the lines of treatment suggested are, broadly speaking, designed to shield the patient as far as possible from the absorption of excessive doses of toxines, whilst at the same time his vitality is stimulated and his strength sus- tained, and the formation of protective substances in the blood and tissues thus increased. We have now to discuss whether there is any specific treatment which will play a more direct part in our fight against the disease. The inhalation of bactericidal sprays, heated air, stable emanations, compressed and rarefied airs, sulphuretted hydro- gen, the administration of sulphuretted waters and gases by the mouth and per rectum, the subcutaneous injection of anti- septic drug's of all sorts, have been tried by able and sanguine observers, but the results obtained have not been such as to warrant our dwelling' any further upon them. Many of these remedies may take a humbler place in the treatment of par- ticular symptoms, but none have the slightest value as specific measures against the malady. The fundamental object in the treatment of tuberculosis is, as already explained, to obtain immunity to tuberculous activity by fortifying and maintaining resistance to further attack. Vaccines are employed in acute and chronic diseases of infective origin with the object of securing- immunity by increasing opsonic and other antimicrobial means of resistance and stimulating phagocytic activity. It is doubtful, however, whether they are of value in the acute phase of any illness, such as pneumonia, scarlet fever, typhoid, tuberculosis, etc., 711 712 DISEASES OF THE LUNGS AND PLEURAE for in this phase of such diseases the blood is already over- whelmed with the toxines from the microbic activity respon- sible for the disease. Before exposure to infection, however, and possibly during the incubation period of some infective diseases, an appropriate vaccine may be of value by artificially stimulating resistance to the toxine in question. In some chronic infections also, when resistance has reached a low ebb, a stimulating reaction may be thus provoked with advantage. Tuberculosis is a malady in which, during its acute phases, the svstem is already more than adequately charged with toxines from the bacillus. In the sub-acute and chronic stag"es, again, there are always patches of sub-active bacillary lesions or centres of quiescent disease, for the most part not walled off from the general lymphatic system, so that the patient, if we may so express it, is rather " over salted " than otherwise, and it is only necessary to flush the centres of disease by an excessive activity of circulation through exer- cise, mental excitement or anything that hurries the breathing and heart's action, to produce such an extra absorption of tuberculous toxine from the lesions as shall cause a reactive rise of temperature. Thus is explained the importance in tuberculosis of rest treatment when the disease is active, and graduated exercise treatment when the disease is passive; and such are the grounds on which doubt is cast on the general utiHty of tuber- culin in this disease, and on which an insight is obtained as to how immunity is, in many cases, acquired. There are, however, exceptional cases of pulmonary tuber- culosis and of local tubercle situated in other parts than the lungs — as, for example, in bones, in glands and in other positions — in which tuberculin may be employed, and the following are, briefly, in such cases the methods to be pur- sued : ' Varieties of Tuberculin. — Many varieties of tuberculin .are now to be obtained which differ from one another in their mode of preparation and in their chemical features. Clinically, however, the results obtained from their employment are not very dissimilar. The more important are the following : I. Old Tuberculin — Tuherkulin Alt. — This was the prepara- tion used by Koch in 1890 in the treatment of the patients SPECIFIC TREATMENT OF PULMONARY TUBERCULOSIS /1 3 who thronged to Berlin in that memorable year. It is pre- pared from a culture of human tubercle bacilli which have been grown for some six weeks in 5 per cent, glycerine broth. This is boiled for one hour to kill the bacilli, and the fluid concentrated to one-tenth of its volume by evaporation at a temperature not exceeding 70° C. The bacilli are then separated off by filtration. The golden-brown, somewhat viscid liquid thus obtained is Old Tuberculin, which contains the toxines which are soluble in 50 per cent, glycerine. One c.c. of this preparation is regarded as equivalent to one gramme (1,000 mgr.). 2. Alhumose-Free Old Tuberculin (A.F.). — This resembles Old Tuberculin in all respects except that it is grown upon a proteid-free medium, contains no albumose and is believed therefore to be less toxic in its effects. 3. Denys' Tuberculin — Bouillon Filtre (B.F.). — This differs from Koch's Old Tuberculin only in the non-concentration of the broth culture. The culture of human tubercle bacilli at the end of six weeks' growth is filtered, and the unboiled, un- heated filtrate constitutes Denys' tuberculin. Professor Denys beheves that in this way deterioration of the toxines is pre- vented. 4. New Tuberculin — Tuberculin Rest (T.R.)^ — This is pre- pared by grinding dried human tubercle bacilli in an agate mortar, extracting with distilled water, and centrifugalising. The upper layer, called by Koch "T.O." (Tuberculin Obersi), closely resembles Old Tuberculin. The lower layer, or re- mainder (Rest), which thus contains the pulverised and par- tially extracted bodies of the bacilli, is suspended in water containing 20 per cent, glycerine to prevent decomposition, and constitutes New Tuberculin, or T.R. Each cubic centi- metre contains 2 milligrammes of solid matter derived from 10 milligrammes of dried bacilli. T.R. thus differs materially from Old Tuberculin, which contains, as we have seen, not the bacillary bodies, but those substances derived from them, which are soluble in 50 per cent, glycerine. 5. New Tuberculin — Bacillary Emulsion (B.E.) — This was introduced by Koch in 1901, and consists of pulverised human bacilli, not extracted in any way, but suspended in equal parts of water and glycerine. Each cubic centimetre of the prepara- tion contains 5 milligrammes of soHd matter. 714 DISEASES OF THE LUNGS AND PLEURA In addition to the above, we may mention the Sensitised Bacillary Emulsion (S.B.E.) and Professor Beraneck's Ttiber- culin, which, with many other varieties of tuberciiHn, prepared in different ways, some from human and some from bovine, strains of bacilli, contain different proportions of the intra- and extracellular toxines. Although differing in their composition and in their strength, all varieties of tubercuHn have this in common, that they contain undoubted toxines, and that by their use an attempt is made to call forth an active response on the part of the organism and an increased production of protective sub- stances. The process aimed at, in fact, is the production of an active immunisation, in which the cells of the body must play their part, as opposed to the passive role assigned to them when a poison within the body is neutralised by the introduction of an antitoxic serum. Of the above varieties of tuberculin the New Tuberculin (T.R.) and Denys' Tuberculin are the milder preparations. With all, however, the clinical effects are not very dis- similar, and in each case our aim should be, by commencing with very small doses, and by increasing the dose very gradu- ally, to avoid the production of any clinical " reaction," whether indicated by fever, malaise, pains in the joints or back, increase of cough and sputum or other manifestation. We may add that New Tuberculin (T.R.) is a much more expensive preparation than the Bacillary Emulsion, and on this ground the latter is to be preferred. Dosage. — Tuberculin is best given by subcutaneous injec- tion, -01 c.mm. ( 100000 c.c.) of Old Tuberculin, A.F., T.R., or B.E., being a common dose with which to commence. The following scheme of dosage, on the lines suggested by Drs. BandeHer and Roepke,^ we have found useful as a guide in practice, it being understood that in the event of any clinical reaction occurring a longer interval than usual must be allowed before the next dose, which should also be somewhat smaller than the dose which caused the reaction. Should no reaction follow the reduced dose, the amount of tuberculin should again be gradually increased. If the doses are increased too rapidly, a condition of hypersusceptibility (" anaphylaxis ") to the tuberculin may be developed, which it is important to avoid. SPECIFIC TREATMENT OF PULMONARY TUBERCULOSIS /1 5 Scheme of Dosage for the Administration of Tuberculin (o.t., a.f., t.e., and n.e.) by subcutaneous injection. An injection to be given every alternate day, commencing with -ooi c.mm. (a millionth of a c.c.) and proceeding as follows : •OOI, -003, -006 c.mm. .•01, "03, -06 c.mm. •I, -15. -2, -3, -5, -7 c.mm. Then continue with an injection twice a week. I. 1-5. 2, 3, 5, 7 c.mm. 10, 15, 20, 30, 50, 70 c.mm. Finally, if no contra-indication exists and time allows, an injection to be given once a week as follows : 100, 150, 200, 300, 400, 600, 800, 1,000 c.mm. (i c.c). The maximum dose may be repeated several times at increasing intervals. Cases suitable for Treatment. — There can be little doubt, both on the theoretical grounds already hinted at (p. 712), and in view of the practical results obtained at Mid- hurst, to which we shall shortly refer, that the value of tuberculin as a remedial agent in the treatment of phthisis has been greatly overestimated. It may, however, still be prescribed in exceptional circumstances. It may, for example, be given, when other treatment has failed, in qi.iies- cent apyrexial cases in which improvement has proceeded up to a point and then come to a halt, or in cases in which, in spite of a stationary and fair weight, and an absence of pyrexia, the pulmonary disease slowly and insidiously extends. It must be remembered that in order to produce a good result tuberculin must call forth an active immunising response on the part of the patient, and a certain degree of vitality is therefore essential for its successful administration. In febrile cases the remedy is contra-indicated, the reactive power of the patient being already stimulated to the full by the excessive doses of toxine which are being absorbed. Results of Treatment.— In attempting to decide upon the value of tuberculin in the treatment of phthisis, we must at once recognise that g'reat caution must be exercised in basing an opinion upon individual cases. It has been our lot from time to time when treating cases in the wards to be struck with the improvement shown by a patient receiving tubercuhn, and we have been inclined to attribute the result 7l6 DISEASES OF THE LUNGS AND PLEURA to the specific treatment, until a few beds farther on we have met with a patient in an almost similar condition untreated by tuberculin^ in whom the improvement has been equally rapid. Had the first patient been the only one under observa- tion, it would have been difficult to avoid overestimating the possible value of the remedy. Our experience is not excep- tional. The capacity for improvement under better condi- tions of feeding and hygiene is a marked feature in many phthisical cases, and we must accordingly gauge the result of treatment not so much by impressions derived from indi- vidual patients, as by a careful inquiry into the effect pro- duced in a large series of cases, and by the permanency of the results obtained. In this connection we must refer to the careful investiga- tion in regard to the value of tuberculin treatment recently made on actuarial lines at the King Edward VII. Sana- torium, Midhurst, by Dr. Bardswell and Mr. Thompson.^ These observers compared the results obtained in 384 male and female patients belonging to groups i and 2 (incipient and moderately advanced cases), who had tubercle bacilli in the sputum, and who were treated at the sanatorium over a period of three years, during which sanatorium methods only were employed, with a series of 352 comparable cases admitted during the three succeeding years, when tuberculin was also being administered. Of these 352 cases 238 received a course of tuberculin in addition to sanatorium treatment. If tuber- culin were an efficient aid to treatment, its value should be shown by an improvement in the general results obtained. The tuberculin used, we may add, was almost exclusively Albumose-Free Old Tuberculin (A.F.) and Koch's Bacillary Emulsion (B.E.), and the method of administration that of BandeHer and Roepke, and in the last year the reactionless method of SahH and Trudeau, both of them methods of recog- nised repute. The results obtained were as follows : (i) hnmediate Results. — The condition on discharge of the patients belonging to the two series was practically the same, the percentage of those recorded as " arrested or much improved," "improved," "stationary or worse" being very similar. (2) Sputum Records. — The percentage of patients in whom SPECIFIC TREATMENT OF PULMONARY TUBERCULOSIS /I/ tubercle bacilli disappeared from the sputum during treatment in the sanatorium showed a close agreement in the two series, 26-3 per cent, of the patients during the control period, who received sanatorium treatment only, losing their tubercle bacilli, as compared with 267 per cent, of those treated during the tubercuHn years. This point is of importance since, as we have indicated elsewhere (p. 631), patients who lose their bacilli during treatment at the sanatorium have a better prog- nosis than those in whom tubercle bacilli persist. (3) Subsequent Results. — With regard to the after-histories of the patients, compared in each case up to four years after discharge, it was found that the ratio of "actual" to "ex- pected deaths " was i8-o per cent, for the patients who during the control period received sanatorium treatment only, and iS'i per cent, for those treated during the tuberculin period. These results show that tuberculin, when given in the manner adopted at Midhurst, and as an adjunct to sanatorium treatment, had no appreciable effect, either favourable or unfavourable. It is interesting to note that Messrs. Elderton and Perry,* after an actuarial study of the valuable data from the Adiron- dack Sanitarium, in New York State, arrived at a somewhat similar conclusion — namely, that, while it was not possible to say that there was no case in which tuberculin might not be of use, its value as judged from the subsequent mortality of the patients had not been proved. It is clear, therefore, that tuberculin can no longer be re- garded as having the specific value at one time attributed to it, and its employment, as we have already indicated, must be correspondingly restricted. Serum-Therapy.— In addition to the method of active im- munisation aimed at by the treatment with tubercuHn, an attempt has been made to effect a passive immunisation by means of serum-therapy, whereby protective bodies prepared in other animals are brought to the immediate assistance of the patient. Of such sera the best known are those of Maragliano and of Marmorek. Neither have, however, ful- filled the hopes with which they were introduced, and they are now but little used. The Specific Treatment of Mixed and Secondary Infections In an earlier chapter (p. 467) we have given reasons for be- 71 8 DISEASES OF THE LUNGS AND PLEURA lieving that in certain rapidly progressing cases of phthisis the fever and the spread of the disease are due in part to the agency of organisms other than the tubercle bacillus, and attempts have been made, by isolating such organisms from the sputum and producing appropriate vaccines, to cut short their activity, to the relief of the patient and the improvement of his symptoms. The results have, however, been disap- pointing, and, as we have already pointed out, but little must be hoped from vaccines in the acute stages of the disease, when the body is already receiving excessive doses of the microbial poisons. More perhaps may be expected in chronic cases in checking excessive cough and bronchial excretion, which, as we have seen, are often the result of secondary infection by pathogenic organisms. REFERENCES. ^ " Ueber Neue Tuberkulin Praparate," von Robert Koch, Deutsche Medicinische W ochenscJirijt, 1897, No. 14, p. 209. ^ Lehrbuch der Sfezifischen Diagnostik und Therafie der Tuberkulose jiir Arzte und Studierende 5 Auflage, von Dr. Bandelier (in Schomberg bei Wildbad) und Dr. Roepke (in Melsungen). Wiirzbur^, 1913. ^ " Pulmonary Tuberculosis : Mortality after Sanatorium Treatment," by Noel D. BardsweU, M.V.O., M.D., F.R.C.P., and John H. R. Thompson, F.I. A., Medical Research Committee Re-port. London, 1919. ^ " A fourth Study of the Statistics of Pulmonary Tuberculosis : the Mortality of the Tuberculous : Sanatorium and Tuberculin Treatment," by W. Palin Elderton, F.I. A., and Sidney J. Perry, A. I. A., Drapers' Com- pany Research Memoirs. London, 1913. CHAPTER LI TREATMENT OF PULMONARY TUBERCULOSIS BY (i) ARTIFICIAL PNEUMOTHORAX, (2) SURGICAL INTERVENTION Artificial Pneumothorax. In the preceding chapters we have discussed the hygienic and climatic treatment of pulmonary tuberculosis, the use of tubercuHn, and the value of drugs. In certain cases of a fairly well-defined kind, in which, in spite of all efforts, the disease makes progress, and especially in some in which recurrent haemoptysis is a well-marked feature, the question of inducing an " artificial pneumothorax " presents itself, and must now be considered. By this method air or gas is introduced under strict anti- septic precautions into the pleural cavity by means of a special apparatus, and the lung is collapsed, thus rendering it passive, allowing active lesions to cicatrise and heal, while at the same time absorption of toxine is lessened. If there has been haemorrhage, the pressure tends to prevent its recurrence. In the earlier days of the treatment nitrogen was the gas employed, but experience has shown that it possesses no advantage over air, which is not absorbed more quickly, and air is now commonly used. The practice of introducing oxygen at the first injection, with a view to diminish the risk of gas embolism, appears to be based upon a misconception and to possess no practical advantage. The experiment was apparently first made by the late Dr. Cayley in the year 1885 ^^ ^ case of haemoptysis, to which we have already referred, the pneumothorax in this instance being produced by incision through the chest wall. For the modern developments of the method and its present technique we are indebted especially to Professor Forlanini of Pavia, Professor Brauer of Hamburg, and Professor Saugman of 719 720 DISEASES OF THE LUNGS AND PLEURAE Vejlefjord in Denmark, and in this country to Dr. Clive Riviere/ to whose work we may refer the reader for many technical details. Technique. — For the introduction of the air some simple portable apparatus is required. Several have been intro- duced, among which we may mention that of Dr. W. Parry Morgan,^ but the one devised by Dr. Lillingston and Dr. Vere Pearson^ may be recommended as simple and eifective, and, with some slight modifications, is now in use at the Brompton Hospital (Plate XXXIII.). It consists of a needle connected by rubber tubing to a bottle containing air, the " gas bottle," and by means of a cross-piece with a mano- meter, whereby the pleural pressure is measured. The gas bottle itself is connected with a "pressure bottle" containing a coloured antiseptic solution, such as i in i,ooo perchloride, by the lowering or raising of which the outflow of gas into the pleural cavity can be regulated. Between the needle and the cross-piece connecting with the manometer a piece of glass tubing containing sterilised cotton-wool for filtering the air is inserted, and a second between the cross-piece and the gas bottle. It is well also to insert, as we have done in the figure, a short length of glass tubing not far from the needle, so that when the instrument is used for gas-replace- ment (p. 114) the entry of fluid into the tubing may at once be detected, should this occur. The fourth limb of the cross- piece, to which in Plate XXXIII. a short piece of rubber tubing with clamp is attached, has been added at the sugges- tion of Dr. L. S. T. Burrell to facilitate refilling of the gas bottle with air, should this be necessitated during the progress of the operation. For the initial operation and for the first few reinflations the patient must be in bed. A suitable site for the puncture is to be found in the lower axillary region, as, for example, the sixth space in the mid-axillary line, since here, as we have pointed out in dealing with paracentesis thoracis, the parietes are thin and the intercostal spaces roomy, and adhesions are less likely to be present. If, however, ad- hesions prevent the introduction of air, attempts must be made in other regions in the lower part of the chest, such as the eighth or ninth space below the angle of the scapula, where physical signs indicate but little disease. If three or PLATE XXXIII Apparatus for performing Artificial Pneumothorax devised by Dr. Vere Pearson and Dr. Lillingston (Slightly Modified). ^°ral7cTntimil'r^.'- Jj^^ '■?^'1'"S "f 'l?^i"t^^-pleural pressure, the manometer scale is graduated in a simn^r^?: ■• ■ "'u °' ^u " ?• 'u^ T^'r '" '^^ •'"^'^ ^-^P^^^d to the air being accompanied bv a smiilar fall or rise in the other limb, the figures give the pressure in cc. of water ^ To face p. 720. TREATMENT OF PULMONARY TUBERCULOSIS Jll four punctures prove fruitless, owing to the presence of widespreading- adhesions, the operation must be abandoned. Professor Saugman" met with faihire in 43 of his 138 cases. The selection of the pneumothorax needle is of importance. At first a pointed needle was used, but with this there is some danger of wounding the lung, with the pos- sibility of gas embolism when the air is introduced, and there can be no doubt that an instrument such as that devised by Dr. Riviere"^ is better for the initial opera- tion. This consists of a trocar and cannula, the latter of 1-8 millimetres ('072 inch) gauge, with a side-opening near the tip, and with a sharpened cutting end. The trocar and cannula are carefully introduced to a depth of about f centimetre, when the shoulder of the cannula will have passed through the skin. The trocar is then withdrawn and the tap of the needle closed. The cannula with its sharpened circular end is slowly pressed onward until the pleura is reached and the sudden " snap " is experienced, which indicates that the parietal pleura has been perforated. This will be confirmed by the sudden appearance in the manometer of a negative pressure of some 10 centimetres of water, and a definite respiratory fluctuation of from 4 to 8 centimetres. The depth at which the pleura is situated will naturally vary with the thickness of the parietes ; in thin subjects it may be only I centimetre from the surface, and Professor Saugman has never found it at a greater depth than 3 centimetres. When it is thus made clear that the needle is in the pleural cavity air may be introduced. On the first occasion about 400 c.c. are often sufficient, but the amount must depend to some extent upon the size of the chest and the ease with which the lung collapses. At the end of the first inflation the intrapleural pressure should still be slightly negative. When, however, the operation is done to check haemoptysis, 1,000 c.c. should at once be introduced. The air at first is somewhat quickly absorbed from the pleura, and further inflations must be made at intervals of a fevv^ days, later at intervals of a week, then a fortnight,, and at last, when the pneumothorax is well established, at intervals of four to eight weeks or even longer. The amount of air introduced at each refill is gradually in- creased, so that at the fourth or fifth inflation, when the lung is completely collapsed, the intrapleural pressure at the 46 722 DISEASES OF THE LUNGS AND PLEURA termination of the operation should measure about + 5 centi- metres of water. The object of the treatment is to obtain, without undue stretching of the mediastinum and without dis- comfort to the patient, as complete a collapse of the lung as possible, so that when examined by the X-rays it may be seen lying by the side of the vertical column. The dates of further refills, and the quantity of gas introduced, should be controlled when possible by noting on the screen whether the lung remains collapsed or shows a tendency to re-expand. The presence of bands of adhesions, which prevent complete collapse of the lung and militate against the efficiency of the treatment, are also brought into evidence by X-ray examina- tion. For the reinflations the trocar and cannula may be again used, or, if desired, a pointed needle, such as that devised by Professor Saugman, since the needle will now enter a cavity already containing air, and there is not, therefore, the same risk of wounding the lung as at the first operation. The needles should be kept in absolute alcohol and dried before use by passing through the flame, thus rendering them aseptic and insuring that the lumen is free from fluid, and capable at once of registering the intrapleural pressure. The performance of an artificial pneumothorax is not en- tirely free from risk, since occasionally, at the moment of perforating the pleura, the patient becomes faint and the pulse and respiration irregular, and in a few cases such an attack has terminated fatally, death being attributed to reflex spasm of the cardiac or cerebral vessels. To this condition the terms "pleural reflex" and "pleural shock" have been applied, and its occurrence has been noted in other mani- pulations of the pleura, notably irrigation, and for this reason we have advised against this procedure save in very exceptional circumstances (p. 129). Experimental evidence suggests that the danger of pleural reflex is diminished by proper anaesthesia, and in performing artificial pneumothorax it is well always to give a sedative, such as an injection of morphia (gr. ^) or omnopon (gr. ^) half an hour before the initial operation, and carefully to ancesthetise the site of puncture right down to the pleura with a sterilised 2 per cent, solution of novocaine in normal saline. At the refill the sedative is not usually needed, but the local anaesthetic should be employed. TREATMENT OF PULMONARY TUBERCULOSIS 723 The danger of gas embolism from the introduction of air into a vessel of the lung has with improving technique been largely eliminated, and the accident should be of the greatest rarity/ provided that care be taken never to introduce the air until the negative pressure and the respiratory excursion, as registered by the manometer, prove that the needle is free in the pleural cavity. Duration of Treatment. — How long the treatment should continue and the compression of the lung be maintained is a matter in regard to which there is some difference of opinion, and there is at the present time a tendency to lengthen the duration of treatment. It is generally felt, how- ever, that eighteen months to two years is a wise minimum, and that in more serious and advanced cases this may be extended to three or even four years, inflations being given at the later stages at intervals of six to eight weeks or even longer. During the period of compression the lung under- goes some degree of fibrosis, and it is possible that it may not fully expand when the treatment is discontinued, so that the chest falls in to some extent. Complications. — During the course of treatment two com- plications may be met with which we must now consider. These are pleurisy and perforation of the lung. I. Pleurisy. — This is a common complication of artificial pneumothorax, and occurs, it is estimated, in nearly half the cases, especially those in which the disease is acute in char- acter or advanced in degree. It is usually attended with effu- sion, which is as a rule serous in character, sterile on culture, and containing tubercle bacilli. Later the fluid sometimes becomes purulent. The complication occurs most commonly within the first three months; in other cases at some later period during the course of treatment, possibly not until the third or fourth year. The symptoms are sometimes very shght, but in other cases the onset is sudden, with pyrexia and pain in the side, the temperature remaining raised for two or three weeks or more, and thea falling gradually to normal, as in the case of a simple pleurisy with effusion. The rapid effusion of fluid in such cases may raise the intrapleural pressure and em- barrass the respiration, and thus necessitate the withdrawal of some of the air; but in our experience the occurrence of 724 DISEASES OF THE LUNGS AND PLEURAE effusion, when the febrile stage has passed, is often helpful rather than the reverse to the patient, by tending to keep the lung collapsed and thus allowing of refills at longer intervals. 2. Perforation or Rupture of the Lung is fortunately an event of rare occurrence, though we have seen at least one instance, and several are recorded by Dr. Sachs,® Drs. Marshall and Craighead^ and other observers.^ It is apt to occur where adhesions prevent more than a partial pneumo- thorax, and the lung is thus stretched and unprotected. It is perhaps surprising that the accident should not occur more often in such cases, when it is remembered that the pleural surfaces are deliberately separated by the air intro- duced, and thus the formation of adhesions over patches of advancing disease, which so often prevent pneumothorax, is no longer possible. The accident occurs sometimes in cases of active disease; in others the patient has been doing well and leading perhaps too active a life, when the stretched portion of lung gives way. The onset of the complication is marked by sudden pain in the side and high fever; and death often quickly follows from septic pyopneumothorax. The following is a brief note of the case which came under our own observation : B. E. P., aged twenty-four, shop assistant, was admitted into the Brompton Hospital on June 19, 1912, under the care of Dr. Hartley, suffering from pulmonary tuberculosis, of a year's duration, affecting the whole of the left lung and the upper part of the right. Tubercle bacilli were present in the sputum. The case proved febrile, the temperature being irregularly raised, generally to 100° and sometimes higher. After some four months' treatment it became clear that the patient was not making progress, and an artificial pneumothorax was decided upon. This was per- formed by Dr. Hartley on November 5, the left pleura being punc- tured in the eighth space in the line of the angle of the scapula, and 200 c.c. of nitrogen, which gas we were at the time using, introduced. On November 7, 11, and 19, reinflations were given, 200, 375, and 300 c.c. of nitrogen being respectively introduced. The highest pleural pressure reached was +2; on the last occasion at the end of the inflation it was — 1|. During this time the patient improved somewhat and the temperature was rather lower. The X-ray report by Dr. Melville showed a partial pneumothorax, the lung being adherent above the third rib, and in the region of the diaphragm. On November 20 the patient experienced a sudden pain and feeling of " tightness " in the side, and the temperature rose. Two days later the pulse was 144 arid the temperature 103°. The physical TREATMENT OF PULMONARY TUBERCULOSIS 725 signs of a partial pneumothorax persisted, as also the pyrexia, and the patient gradually became weaker. On December 18 she began to cough up purulent expectoration, amounting on one day to 5xx., and this continued until death on December 23. Rupture of the lung into the cavity of the artificial pneumothorax, with pyopneumo- thorax and expectoration of the pus, was diagnosed, but the patient was too ill for surgical treatment. At the autopsy a partial left pneumothorax was found, the lung being adherent over its upper third. A small perforation of the visceral pleura leading into the lung was discovered at the apex of the left lower lobe, and the pleura contained 4 ounces of pus. Two or three cavities, the size of a walnut, were present in the left upper lobe, with more recent infiltration of the lower lobe, and scattered areas of disease throughout the whole of the right lung. Cases Suitable for Treatment. — From what we have said in the preceding paragraphs it is evident that treatment by arti- ficial pneumothorax is not entirely devoid of risk, though modern methods of procedure have reduced this most materially. This being so, it must be agreed that no case should be submitted to treatment until a full trial has been given to more ordinary methods. If, however, the patient fails to respond to rest, sanatorium treatment, and medicinal remedies, then the question of an artificial pneumothorax should be considered, nor should this consideration be unduly delayed. The initial operation and early refills are often best carried out at a sanatorium, since here the patient has the hygienic and other advantages associated with such an institution. The cases for which the method is especially suitable are those in mhich the disease affects chiefly one lung, so that when this is collapsed the diseased areas are at once brought under the influence of the treatment. In such patients, when other methods have failed, an artificial pneumothorax some- times brings the temperature down in an almost dramatic manner, with a corresponding improvement in the patient's symptoms, although in our experience the fall is usually more gradual, a normal temperature being reached only after several inflations. We have also seen benefit from the treatment in patients with chiefly unilateral disease of a less acute type than the above, but in whom any attempt to increase the exercise or work allowed leads to a set-back, whether indicated by a 726 DISEASES OF THE LUNGS AND PLEURAE rise of temperature, a rapid pulse, or increased cough and sputum. The method is of great value also in the case of patients, generally with somewhat advanced disease, who are the sub- jects of repeated haemoptysis, pointing to the presence of a pulmonary aneurism. In these cases the performance of an artificial pneumothorax will check the haemorrhage, which may not recur, provided that the compression is duly main- tained. In cases of acute pneumonic phthisis the method holds out less hope, since here we are dealing with extensive and massive areas of caseation, yet in one such case we have known a gratifying result. We have also under observation at the present time a case of rapidly extending phthisis, not confined to one lung, with continuous high temperature, and in which the outlook appeared " hopeless," yet here compres- sion of the most affected lung, though soon complicated by acute pleurisy with effusion, has led to great improvement in the patient's condition and a gradual fall of temperature to normal. Two somewhat similar instances are recorded by Professor Saugman.* Such cases are no doubt excep- tional, and we would emphasise again that it is for patients in whom the disease is chiefly conflned to one lung or those whose life is endangered by repeated and uncontrollable hcemoptysis that the treatment is especially suitable. Early laryngeal disease is no bar to the treatment, but it should not be advised in the case of patients with intestinal tuberculosis, weakened myocardium, or other serious complications. Results of Treatment. — We have indicated that in suitable cases the immediate results obtained by the induction of an artificial pneumothorax are sometimes very satisfacory, the patient improving- greatly during the continuance of the treatment, being enabled to lead an active life, and not infre- quently losing his cough and phlegm, while tubercle bacilli disappear from the sputum. With the cessation of the treatment these good results not seldom persist, the lung expanding to a greater or less degree, but the permanence or otherwise of the results will depend largely on the after-care. The patient must not regard himself as cured. Tubercle bacilH are still present in the lesions, and the disease will break out afresh if he be not TREATMENT OF PULMONARY TUBERCULOSIS 727 content to carry out, though in a modified manner, the mode of life which he has learnt at the sanatorium. In other cases, though the immediate results may be encour- aging, the disease in the other lung gradually extends and the patient finally succumbs. In others, again, the treatment fails, because the presence of adhesions prevents the due compression of the lung. It will be interesting, in conclusion, to quote the results which have been obtained at the Berks and Bucks Sanatorium by Dr. Esther Carling^' after eight years' experience of the method. The figures given below are brought up to date (June 30, 1920), Dr. Cading having courteously supplied us with the additional data, and verified the figures. The patients treated belonged to the working classes, and were all advanced or acute cases, with more or less unilateral disease. Ah had failed to respond to ordinary sanatorium treatment, and in all "the outlook was thoroughly bad." Of the 54 cases submitted to the treatment, in 12 it was not possible to effect a pneumothorax, and of these 12 patients 10 are now dead. Of the 42 in whom compression of the lung was effected, 23 are dead. In more detail the results in these cases are as follows : (a) In 12 the treatment failed and the disease progressed unchecked, until the death of the patient. This group, it should be noticed, included all the cases in which the lung was incompletely collapsed. {h) In 8 temporary improvement was manifested. Of these 8, 2 are dead, and the remaining 6 are at home, but unable to work. {c) In 22 marked improvement occurred. Nine of these patients have, however, since died. The remaining 73 have returned to their old occupation, or to a moderately active and useful life. Five of these 13 are continuing treatment by periodical return to the sanatorium or to the Tuberculosis Officer for reinfla- tiqns. Considering the type of case treated and the difficuhies of efficient after-care in view of the class of patients dealt with, so marked and lasting an improvement in 13 out 728 DISEASES OF THE LUNGS AND PLEtJR.^: of 42 patients must be regarded as a hopeful and encouraging achievement. Surgical InterYention. We have now to ask ourselves whether it is possible to assist in any way the 30 per cent, of cases which, though suit- able on medical grounds for treatment by artificial pneumo- thorax, are yet unable to benefit from it owing to the presence of widespread adhesions. Thoracoplasty. — For a few of them some form of extra- pleural thoracoplasty may be considered, whereby varying lengths of the ribs (but not the entire ribs) from the first to the tenth or eleventh are removed on one side. The opera- tion, which is infinitely more grave than that of artificial pneumothorax, is best done in two stages, so as to diminish the shock, and should be performed when possible under local anaesthesia, especial care being taken to anaesthetise the various intercostal nerves. With the avoidance of a general anaesthetic the risk of aspirating septic secretions into the healthy lung when the diseased lung collapses is greatly diminished, and the danger of the operation lessened. We have known one or two notable examples of the suc- cessful performance of the operation, with great and lasting benefit to the patient; but the operation is an exhausting one, and even in skilled hands has a mortality of about 10 per cent. It should never, therefore, be contemplated until other methods of treatment have failed and until an artificial pneumothorax has proved impossible. Professor Bull' of Christiania has recently pubHshed a record of 37 cases, of which 4 died as a result of the opera- tion, and 1 1 are stated to have achieved a " curative result," by which is meant that the patients were at work, afebrile, and with the sputum no longer containing tubercle bacilli. Professor Saugman'" also reports the result of 40 cases treated at the Vejlefjord Sanatorium, 22 of which were oper- ated upon by himself. Of these 40 patients, 4 died as a result of the operation, 12 are still in the sanatorium, and 13 are able to work, though of these 6 are capable of Hght work only. In regard to the type of case operated upon, 29 of the patients showed some degree of fever, but it is to be noted that the cases chosen for operation were for the most TREATMENT OF PULMONARY TUBERCULOSIS 729 part of the chronic type, with disease chiefly one-sided. In- deed, Professor Saugman expressly states that acute cases are not specially suitable, as so often active and progressive tuberculosis has already commenced in the other lung, which unilateral collapse will not check. Rib Mobilisation. — Another operation which diminishes the volume of the chest and allows considerable collapse of the lung is that introduced by Wilms, and known as " rib mobilisation." We have referred to this when considering the treatment of bronchiectasis (p. 220), and need only add that it is an operation which, while having the same object and effect as thoracoplasty, is somewhat less hazardous, though by no means free from danger. It should therefore be considered when serious surgical intervention is contem- plated, though no doubt the particular experience of the surgeon will be the important factor in deciding upon the exact method of operation. In our opinion these drastic surgical procedures should only be considered in cases of pulmonary tuberculosis where all other methods, including artificial pneumothorax, have failed, and where the disease, if febrile, is not of a very acute type and chiefly restricted to one lung, or, if more chronic, keeps the patient a more or less permanent invalid. If the patient appreciates the deformity of chest which will result and the danger of the operation, and decides to take the risk, then the operation may be sanctioned, provided the heart and other organs are healthy and the general vitality of the patient sufficiently good. In our experience this favourable combination of circumstances is not often met with. Opening and Drainage of Tuberculous Cavities. — The sur- gical procedures which we have found of value when dealing with abscess and gangrene of the lung (p. 360) are seldom profitable in the case of tuberculous cavities. Such cavities are rarely single, and are, moreover, usually situated at the apex or upper part of the lung, so that drainage per vias naturales is fairly well maintained, and the chief reason for interference is in the majority of cases not present. Cases from, time to time, however, do present themselves in which the extent of excavation, the superficial position of the cavity, and the large amount of secretion, with irritating and exhausting cough, suggest external drainage, and in 730 DISEASES OF THE LUNGS AND PLEUR.E some instances an attempt is made by nature to find an external vent by perforation of the chest wall. If in such cases all other means have failed, and the patient's pitiable condition demands interference, opening and drainage may be considered. An interesting case of this kind, under the care of Dr. John Hastings and Mr. Robert Storks," was operated upon as long ago as 1844. The cavity, a large left apical one, was incised through the second intercostal space, and a drainage- tube inserted, with immediate relief to cough and expectora- tion. Since then other selected cases have been treated in a similar way,^^ and not infrequently with some amelioration of symptoms. But the operation cannot be looked upon as more than a palliative, and one which may alleviate the patient's most distressing symptoms, the harassing cough and abundant expectoration. Under the modern hygienic methods of treatment such large secreting cavities are not common, and intervention is now rarely called for. REFERENCES ^ {a) Pneumothorax Treatment of Pulmonary Tuberculosis, by Clive Riviere, M.D., F.R.C.P. London, 1917. See also — (6) Tubercle, 1919, vol. i., p. 114. ^ " Artificial Pneumothorax : Fundamental Defects in the Accepted Technique of inducing Pneumothorax and how to Remedy Them," by W. Parry Morgan, M.A., M.B., B.Sc, the Lancet, 1914, vol. ii., p. 90. ^ " Apparatus for the Production of Artificial Pneumothorax," by S. Vere Pearson, M.D., British Medical Journal, 1913, vol. ii., p. 1098. ^ " On the Results of the Pneumothorax Treatment of Phthisis," by Professor Chr. Saugman, Seventeenth International Congress of Medicine. London, 1913. Section of Medicine. Part ii., pp. 463 and 477. ^ " The Dangers of Artificial Pneumothorax," by B. Slivehnan, M.D.,. the New York Medical Journal, 1919, vol. cix., p. 187. ^ " Artificial Pneumothorax in the Treatment of Pulmonary Tubercu- losis : Results obtained by Twenty-four American Observers," by Theodore B. Sachs, M.D., the Journal of the American Medical Association, 191 5, vol. Ixv., p. 1 861. ' " Spontaneous Pneumothorax during the Course of Induced Pneumo- thorax," by M. I. Marshall and J. W. Craighead, American Review of Tuberculosis, 1917-1918, vol. i., p. 540. * " The Value of Artificial Pneumothorax : Impressions after Eight Years and Fifty-four Cases," by Esther Carling, M.D., Tubercle, 1920. vol. i., p. 411. TREATMENT OF PULMONARY TUBERCULOSIS 73 1 ' " Videre erfaringer om behardlingen av Lunge-tuberkulose med extra- pleural thorako-plastik," by Peter Bull (Christiania), Norsk. Mag. for Laegevi-denskaben, 1919, 80, p. 1105. (See Tubercle, 1920, vol. i., p. 330.) " " Thoracoplasty in the Treatment of Pulmonary Tuberculosis," by Professor Chr. Saugman, Tubercle, 1920, vol. i., p. 305. " " A Case of Tuberculous Excavation of the Left Lung treated by Perforation of the Cavity through the Walls of the Chest," by John Hastings, M.D., and Robert Storks, Esq., Surgeon, the London Medical Gazette, December 20, 1844. '^ The Surgery of the Chest, by Stephen Paget, M.A., F.R.C.S., pp. 331 and 446. Bristol and London, 1896. CHAPTER LII TREATMENT OF PULMONARY TV BERCULOSIS— {Concluded) Epitome. Tt may be useful now to epitomise what we have said in regard to the treatment of pulmonary tuberculosis. We have shown, in the first place, what hygienic and climatic measures may do, and it may be said that the limit of their efficacy has now been fairly ascertained. We have further indicated what can be effected by the use of vaccines, sera, etc., and although these remedies have on the whole proved very disappointing, they have yet led us better to appreciate the mechanism of immunisation, and have enabled us to perceive that it is through the absorption of what may be called autogenous toxines, derived from lesions present in tuberculosis, that immunity is largely de- rived; and that duly regulated methods of hygienic exercises are the means of restraining such absorption within such limits as may bring about the end desired — immunity from further attack — and thus allow existing lesions to heal. We have traversed the field of drug treatment, and have here, too, experienced many disappointmicnts in the failure, time after time, of reputed specific medication. It must be noted, however, that amidst the debris of discarded remedies we may yet find encouragement for present hope and further research. For the treatment of the symptoms of the disease, cough, wasting, exhaustion, and special symptoms that may arise, we have many appropriate remedies. One class of drugs, also, seems to us to give promise of continued useful- ness — namely, the antiseptic group of remedies, especially the creosote group, and perhaps also the derivatives of arsenic, as tending to check the activity of, if not to destroy, the Bacillus tuberculosis and its associated organisms, and to • 732 TREATMENT OF PULMONARY TUBERCULOSIS 733 render them more amenable to phagocytic and other attack. Finally, we have seen that in artificial pneumothorax, whereby the lung is collapsed and placed at rest, we possess a method of treatment which is valuable in a certain propor- tion of cases when other methods have failed. We may claim, therefore, that, since our last edition was published, progress in treatment has been made, and we must hope that the day is not far distant when research will place in our hands a specific means, whether medicinal or other, wherewith to combat the disease. This must be the aim of investigators, and we cannot believe that the hope is chimerical. CHAPTER LIII ON ABSCESS IN THE MEDIASTINUM Suppurative mediastinitis is a somewhat rare disease, and is probably never of primary origin. The causes of abscess in this situation may be thus enumerated : 1. Gunshot wounds.^ 2. Injury to the sternum. 3. Post-st€rnal syphilitic node. 4. Perforation of the oesophagus or injury from the impac- tion or penetration of foreign bodies, or malignant growth. 5. Septic causes, whether pyaemic in nature, or associated with enteric fever, or arising by extension from pneumonia, gangrene of the lung, streptothrix disease of the lung and pleura, or tracheotomy. 6. Glandular suppuration, most commonly in association with tuberculous disease, but sometimes occurring after whooping-cough. 7. Suppurating hydatid. 8. Caries of the spine. Symptoms. — The presence of a wound, the history of a blow or of some astiological factor of the kind alluded to in the above list, and the discovery of symptoms and signs pointing to mediastinal inflammation, are the elements of diagnosis in this often obscure disease. Pain and tenderness, pressure signs only very moderate in degree, and pyrexia, are the symptoms most worthy of notice. The pain is seated behind the sternum or between the shoulders, and radiates from these regions. Paroxysmal cough of the laryngeal type, a certain amount of obstruction to venous return, and some pain or difficulty in swallowing, are the pressure phenomena which may be observed in cases of abscess of considerable size. The pyrexia assumes the hectic type, and is attended with rigors and sweatings. 734 ON ABSCESS IN THE MEDIASTINUM 735 In abscess of the anterior mediastinum a certain degree of fulness over the superior sternal region may be noticed on inspection, and sometimes there is also a red blush over the sur- face, and a slight cedema masking the outlines of the carti- lages and spaces. Some obscure impulse may be communicated from the aorta, and, in cases in which there is a large collec- tion of pus behind the sternum, this impulse may closely simulate that of aneurism. There is dulness on percussion over the region of pain and swelling, with unduly conducted tracheal breath-sound. In cases in which the aortic sounds and impulse are conducted, it is important to make several examinations at times when the patient is at rest and free from cardiac excitement. In posterior abscess there is often prominence and tender- ness over one or two of the dorsal spinous processes. The percussion and auscultation signs are very obscure, so that the frequent association of spinal caries, with its characteristic external signs, is of much importance in diagnosis. X-ray examination may be of assistance by demonstrating vertebral disease, and defining the outline of the abscess. If left alone, the abscess may point externally or rupture into the pleura, pericardium, lung or bronchus. In posterior cases it sometimes burrows along the vessels between the pillars of the diaphragm, and finally points in the iliac or femoral region. Most commonly anterior mediastinal abscesses either point externally or burst into a bronchus. Two cases which simulated abscess in the mediastinum, but which proved to be an aneurism and new growth respectively, will be found re- corded in the succeeding chapter. Treatment. — In the earlier stages fomentations should be employed, especially in those cases in which there is any external tenderness. In cases connected with caries of the spine the appropriate treatment for that affection must be adopted. Complete rest is in all cases necessary. The patient requires to be well supported by general treatment, and quinine may be administered for the control of hectic. When the abscess is within reach of surgical treatment it should be evacuated. Cases, however, in which a communi- cation with a bronchus has taken place should not be inter- fered with hastily, as the abscess may thus become completely evacuated and heal spontaneously. 736 DISEASES OF THE LUNGS AND PLEURA Chronic mediastinitis and indurative mediastino-pericarditis require but little notice in this work, since they fall rather into the domain of cardiac diseases. The main symptoms, those of gradual heart failure, are chiefly due to thfe adherent peri- cardium which is so frequently present, although the picture is sometimes complicated by obstruction of the great venous trunks, owing to the cicatricial changes in the fibrous tissue in which they are embedded. REFERENCE. ' For examples occurring in the recent war see British Medical Journal, 1916, vol. ii,, Epit., Nos. 39 and 47. CHAPTER LIV INTRATHORACIC TUMOURS Tumours within the chest may commence in the mediastinum and thence invade the lungs, or originate in the lungs and spread secondarily to the mediastinum. We shall, accord- ingly, consider the subject under the two headings : (i) mediastinal tumours, (2) tumours of the lung — according as the disease commences in one or other situation. Tumours of the Mediastinum. Various growths, both innocent and malignant, may be met with in the mediastinum. Of these the great majority are malignant in nature. Thus, Hare,^ out of 520 published cases which he collected from 1830 onwards, found only 7 examples of fibroma, 11 of dermoid cyst, 8 of hydatid cyst (in most of which the mediastinal origin was doubtful), 3 of lipoma, 3 of enchondroma; and even these figures indicate, probably, too high a percentage, the uncommon cases having naturally found their way more readily into literature. Of mahgnant tumours, the older statistics of Hare^ and Wilson Fox^ suggested carcinoma as the more frequent cause, but they were based largely upon cases of early date, when exact methods of examination were not at hand. Modern observations show that the new growth met with in the mediastinum is commonly sarcomatous in nature, and for the most part lympho-sarcomatous in type''; and this agrees with our own experience.* It is upon this form, therefore, the usual variety of mediastinal tumour, that our description of the disease will be based. To the simple tumours we do not propose to refer further. Apart from dermoid and hydatid cysts, which are described elsewhere in this work, these tumours, whether of the lung or mediastinum, are extremely rare, and only from their slow growth and less severe symp- 737 47 738 DISEASES OF THE LUNGS AND PLEURA toms can they be distinguished from those of more malignant character. Malignant growth may commence in various structures of the mediastinum. The usual seat of origin of sarcoma is in the lymph glands, either in those situated anteriorly in the upper part of the mediastinum (the superior mediastinum of anatomists), or posteriorly in the bronchial glands, or, more rarely, in the true posterior mediastinal glands. In a certain proportion of cases the growth originates in the remains of the thymus gland, and occasionally it commences in the periosteum of the vertebrae, or in the general connective tissue. When arising- in the glands, the growth, having once broken through the capsule, tends rapidly to infiltrate the neighbouring parts, involving the pericardium and extending along the vessels and bronchi towards the root of the lung. Thence in the majority of cases it invades that organ (more commonly the right lung), spreading into its substance along the course of the bronchi, and eventually forming a large pinkish-white and fairly firm mass, often the size of a cricket- ball or even a child's head, which much distorts the natural shape of the parts. The appearance of the growth, with its radiating, bulbous prolongations, is illustrated in Plate XXXIV. Carcinoma of the mediastinum is of rare occurrence. It sometimes occurs as an invasion from neighbouring parts, especially the oesophagus, or it may be secondary to growth in other organs, such as the stomach and liver. The mediasti- num having become involved, the lung may be invaded later, as in the case of sarcoma. Sarcomata of the mediastinum may occur at any period of Hfe, from early childhood up to old age, but between the ages of twenty and fifty they are most common. Above fifty they are rare. The ages of those patients who died of this disease, and upon whom we have ourselves performed autopsies, were 19, 24, 26, 42, 45, 47, 48 and 62, respectively. Sarcomata are of more frequent occurrence in males than in females, although no satisfactory reason can be given for this curious fact. True carcinoma, on the other hand, rarely occurs before middle life and seems to attack the sexes equally. Symptoms. — The symptoms of mediastinal growth are due to the presence of a foreign mass within the thorax, diminish- PLATE XXXIV SARCOMA Or THE MEDIASTINUM INVADING THK LUNG The drawing shows the posterior portion of the right lung. The lower lobe is seen to be occupied by a large whitish mass of new growth, which originated in the bronchial glands, and spread thence into the right lung, especially the lower lobe, extending along the line of the bronchi by various tentacle-like processes. The growth, which proved on microscopical examina- tion to be a lympho-sarcoma, had invaded and almost obliter"ated the right bronchus, and wa^ also invading the pericardium and the wall of the right auricle. The right upper lobe was involved, but the left lung was free from growth. Secondary deposits were present in both suprarenals and in the left ovary. The right pleura showed some loose adhesions and contained a little fluid. In addition to the sarcomatous disease, the apex of the right lung was the seat of recent tubercle. In the lower lobe was some acute broncho-pneumonia. From a woman aged forty-two, who two months before her death was admitted into the Brompton Hospital with signs of right pleural effusion. Thirty ounces, and later twenty-six ounces, of serous fluid were withdrawn, and ten days before death ten ounce- of blood-stained fluid. Death occurred after attacks of urgent dyspnoea. (From the Museum of the Brompton Hospital. | natural size.l PLATE XXXIV Sarcoma of the Mediastinum invading the Lung. To face p. 738. INTRATHORACIC TUMOURS 739 ing breathing- space, compressing- vessels and nerves, and thrusting aside or invading important passages, organs and tissues. The first symptoms which usually attract the patient's attention are cough and gradually increasing shortness of breath. The cough, at first dry and teasing, or attended with slight and difficult muco-purulent expectoration, presents no special peculiarity; but later, when the growth compresses the trachea or bronchus, it acquires a pecuhar " clanging " or " brassy " character, which the experienced ear at once detects. With complete paralysis of the vocal cord, following compres- sion of the recurrent laryngeal nerve, the cough loses its ex- plosive character and becomes husky or " bovine " in char- acter. As the disease progTesses, the expectoration becomes more abundant. When the growth has invaded the lung, the sputum may be sanguineous, and it sometimes resembles " red- currant jelly," the mucus coughed up being very intimately mixed with blood; but this latter form of sputum is by no means- so essential to the disease as is sometimes supposed. In certain cases profuse hsemoptyis has been observed, an event sometimes preceded by the coughing up of fragments of the growth, although this is of unusual occurrence. In rare cases the haemoptysis has proved fatal. Pain in the chest is another early symptom of which the patient often complains. It is sometimes of the darting char- acter peculiar to new growths, and, if the brachial plexus be involved, may not be restricted to the chest, but referred to the shoulder or radiate down the arm. More generally, how- ever, there is a sense of oppression in the chest rather than of actual suffering, except in cases complicated with pleurisy. The more distinctive pressure symptoms manifested by mediastinal growths arise from compression of the blood- vessels and lymphatics, the trachea and bronchi, the oesophagus and nerves. On anatomical grounds it follows that a tumour originating in the anterior mediastinum will compress the veins, while one originating in the bronchial glands will first compress the posterior mediastinal structures, giving rise to dyspnoea, laryngeal paralysis, ocular symptoms and dysphagia. The early pressure signs will therefore enable us in some degree to locaHse the position of the tumour. Towards the end of the disease, with the spread of the growth, the pressure symptoms become more general. 740 DISEASES OF THE LUNGS AND PLEURA The growth affects differently the arteries and veins, the thick elastic walls of the former resisting its encroachment, whilst the thin walls of the veins are easily compressed and their lumen invaded, the mass sometimes appearing as a warty elevation within them. Inequality of the radial pulses is, accordingly, not often met with, whilst symptoms of com- pression of the superior vena cava or innominate vein, such as oedema, puffiness and lividity of the head, neck, and arms (especially the right side), together with enlargement of the veins over the upper part of the chest, are common. In aneurism, where the disease affects the arterial wall itself, the reverse holds good. When the trachea or its main divisions are definitely com- pressed, cough and dyspnoea become very marked, the cough assuming the clanging or husky quality already described. Stridor also developes, and the attacks of dyspnoea acquire a most distressing- paroxysmal character, in one of which the patient may succumb. These attacks are generally due to a plug of mucus accumulating near the point of compression and blocking- the lumen of the tube. Dysphagia is a symptom more often complained of in growths than in aneurism. The oesophagus, however, is so lax an organ that it may be stretched to a considerable extent over a mass of growth without any great difficulty in degluti- tion resulting, and, provided it be not invaded, it is rare for this symptom to give rise to serious trouble. The recurrent laryngeal and the sympathetic are the nerves more commonly affected. Thus, abductor paralysis of one vocal cord, to be discovered only by largyngoscopic examina- tion, and later complete paralysis, with weakening and hoarse- ness of the voice and husky cough, may be observed. This, however, is by no means so frequently present as in aneurism; indeed, we have on more than one occasion seen the nerve completely embedded and appar- ently lost in a mass of growth without its function being impaired. Ocular signs are more common. If the fibres of the sympathetic, which arise from the upper dorsal roots, be compressed and destroyed, the pupil will be unable to dilate, and will appear smaller than its fellow. SHght drooping of the eyelid, narrowing of the palpebral fissure, retraction of the eyeball, and interference with sweating on INTRATHORACIC TUMOURS 741 the affected side of the head and neck, other well-known signs of sympathetic paralysis, are sometimes also observed. The interference with sweating may be easily demonstrated by dusting the part with powdered charcoal after an injection of pilocarpine. On the healthy side the powder adheres to the sweating surface; on the affected side it is easily blown away.^ Such are the chief symptoms which may be noticed in a case of mediastinal growth. Emaciation, excepting in those rare cases in which the oesophagus is early obstructed, is not a marked feature, although in all cases some loss of weight occurs. True cachexia is most uncommon. Pyrexia of a low and somewhat irregular type is often present; but in such cases the growth is rarely found after death to be uncompli- cated, bronchiectasis or a slowly disintegrating form of septic broncho-pneumonia being most often discovered, and to these pathological changes, rather than to the growth itself, we must attribute the pyrexia, since in other cases fever may be entirely absent for weeks tog'ether. Physical Signs. — The physical signs met with in a case of mediastinal growth will vary much, according to the extent of the disease. If the growth be recent, and confined merely to the glands, there may be no symptoms or definite signs, or at most some impairment of note over the manubrium sterni or the upper interscapular region behind. But as a rule distinct physical signs appear before death. We must note at once, however, that these signs are not necessarily due directly to the presence of the growth, but may be the result of pulmonary collapse, pneumonia, or bronchiectasis, with thickening of the lung texture, produced by the obstruction of bronchi by growth which has invaded their walls. The occurrence of a secondary effusion, either from pleurisy or compression of veins or lymphatics, often also complicates the physical signs. Bearing these facts in mind, we may now attempt to draw a cHnical picture of a case of some little standing. A shghtly staring, suffused, and anxious expression of countenance is most commonly to be observed, and in marked cases the aspect assumes that of semi-strangulation, pitiable to witness, the swollen and oedematous head, neck and upper limbs contrasting with the natural appearance of the lower 742 DISEASES OF THE LUNGS AND PLEURA half of the body. The respirations are quickened, the pulse generally somewhat accelerated, whilst the temperature remains normal, or is but sHghtly febrile. When the anterior portion of the mediastinum is involved, as is the case in many instances, some prominence of the upper sternum may be noticed. Enlargement of the glands at the root of the neck or in the axilla (see p. 86) should always be carefully sought for, this sign being- of material assistance in diagnosis. The heart is displaced in a direction varying- with the position of the growth. Most commonly it is simply thrust to one side, but sometimes the base is lowered, and the apex tilted upwards and outwards. At other times the growth extends from above downwards between the sternum and the heart, or, again, forwards from behind that org'an; and we have met with an instance in which the heart was thus borne for- wards, compressed and fluttering, against the anterior chest wall. Over the region of the tumour there is percussion dulness, which, having- been first observed in the area of the mediasti- num, soon comes to encroach upon the limits of the lung. A careful percussion of the outHnes of the dulness will in most cases reveal that the middle line of the chest has been trans- gressed — a fact of considerable diagnostic importance. A certain impulse communicated from the aorta may often be felt by the hand or appreciated by the stethoscope over the dull area; its knocking rather than expansile character can usually, but not always, be distinguished from that of aneurism. The heart sounds are well conducted by the growth, and a soft systolic murmur or souffle is occasionally to be heard over some portion of the dull region. The respiratory sounds heard over the tumour differ accord- ing as the bronchus is still patent or is obstructed by the growth, which sooner or later penetrates the lumen of the tube. In the former case bronchial breathing, sometimes of an intense character, in other cases obscured by stridor, is heard over the dull area, and vocal resonance and possibly also fremitus are increased. If bronchial obstruction has occurred, then the respiratory murmur is enfeebled or annulled, and both vocal fremitus and resonance disappear. In such cases, on placing the hands evenly on the two sides over the lower regions of the chest, impairment of mobility INTRATHORACIC TUMOURS 743 may be observed on the affected side during deep inspiration. Enfeeblement of breath-sounds over one lung is sometimes of diagnostic significance in cases in which there are as yet no other signs of mediastinal growth. As the disease advances, in cases in which vital passages are not so immediately invaded as speedily to terminate hfe, the lung becomes more involved from root to periphery, until the whole side is completely dull. The chest may be dis- tended from the pressure of the growth, but retraction of the side is by no means uncommon, either from shrinking of the growth itself or as the result of secondary collapse of the lung. Should the side be distended and the case be now observed for the first time, it may be impossible to distinguish it from one of extensive pleuritic effusion, for the heart is displaced, as it would be by fluid in the pleura, and vocal fremitus, resonance, and breath-sounds are all suppressed. The introduction of a fine trocar which fails to strike fluid^i. and is felt to penetrate and to be fixed by solid tissues, is the*^ only means of effecting- diagnosis, although careful examina- tion will often reveal outlying islets of resonance correspond- ing- with thin areas of lung encrusting the periphery of the growth. An X-ray examination may help to elucidate the diagnosis, the growth being revealed as a non-pulsating shadow with somewhat irregular and ill-defined edge; but in other cases effusion into the pleura, either mechanical from pressure upon the azygos veins, or of inflammatory origin, complicates the signs and symptoms of the tumour, and obscures the X-ray picture. Such effusions are often blood-stained, but this has no great significance, the fluid in cases of simple pleurisy being often of similar nature. Of more diagnostic importance is the cytological character of the fluid. In simple pleurisy with effusion a cytological count generally sho^ys, as we have seen (p. 92), a predominance of small lymphocytes. In malignant disease small lymphocytes are also present in large numbers, and the count may closely resemble that of a simple pleural effusion. It sometimes happens, however, when the pleura itself is invaded, that there may also be observed cells of large size and irregular shape, often vacuolated in appear- ance, and with the nucleus pushed to one side, giving a 744 DISEASES OF THE LUNGS AND PLEURA " signet-ring- " appearance (see Plate XXXV.). If such cells are numerous and collected into groups, the picture presented is one very suggestive of maHgnancy. A short account of the following cases will illustrate certain of the points emphasised in the preceding para- graphs: Case I. — On March 27, 1904, one of us saw, in consultation with Sir Thomas Smith, and later with Sir A. Pearce Gould and Dr. Whit- tick, a lady, aged forty-eight, who complained of painful and difificult deglutition, with radiating pains about the sternum and to the shoulders. The history of her illness, rather obscure and indefinite, was as follows : . The lady was of active habits, a good and fearless rider, and, except for some severe hunting accidents, had enjoyed excellent health. Two years before she had a bad fall from her horse, but made a good recovery. In November, 1903, she suffered from influenza, fol- lowed by pains below the left breast, round the chest, and down the back and leg, which were regarded as due to influenzal neuritis. In February, 1904, she consulted her physician for symptoms of acid dyspepsia, with occasional slight pyrexia (100°), gastric pains and intercostal tenderness. There was pyorrhoeal affection of the gums, and the chest and shoulder pains were attributed to " a septic infec- tion from alveolar pyorrhoea irritating the fibrous tissues of the pleura and oesophagus." Sufficient importance was, perhaps, not attached to the difficulty in swallowing, or, rather, the sense of constriction opposite the third piece of the sternum, attended with pain of a radiating character, which had existed for some weeks, until it amounted to an obstruction, and which, on Sir Thomas Smith's first seeing the patient on March 26, rendered partial feeding by the rectum necessary. At this time a short cough had supervened, and there was occasional retching with the removal of mucus, slightly tinged with blood and containing some purulent opacities. On March 27 the following conditions were noted : The patient had passed a restful night owing to morphia, but there had been slight retching of lightly stained mucus. The countenance was pale, with no marked anxiety of feature; respirations quiet, although sHghtly quickened; breath notably foetid. The pulse was small and com- pressible (she had been fed by enemata for the last sixteen hours). There was also occasional slight cough with expectoration of mucus containing a few pus and blood corpuscles. On giving her a little milk to drink, an evident difficulty in the passage was experienced at about the junction of the upper and middle third of the oesophagus, and some pain was complained of in the effort of swallow- ing. The milk was not, however, returned. Over an area cor- responding with the upper portion of the sternum to the level of the third cartilage, and extending to the left for an inch beyond the PLATE XXXV CELLS FROM A CASE OF PLEURAL EFFUSION OF MALIGNANT ORIGIN The cells were obtained by centrifugalising the fluid removed from the pleura during life. From a female patient, aged forty- seven, who died from new growth of the lung and pleura. The large size of the cells, their irregular shape, dropsical appear- ance, and the expression of the nucleus to one side, producing a " signet-ring " appearance, suggested the presence of malignant growth, which was confirmed at the autopsy. (Drawing by Dr. I. C. Maclean, from a preparation by Dr. A. C. Inman; stained by Giemsa's modification of Romanowsky's stain. X 750.) PLATE XXXV. Cells from a case of Pleural effusion of malignant origin. To /ace page 744 INTRATHORACIC TUMOURS 745 sternal margin, there was dulness, and, on application of the hand, a slightly heaving impulse, which was more distinctly appreciated by the finger-tips pressed into the interspaces at the left sternal margin. The expansile impulse was still more evident to the ear, using the solid stethoscope, and with each impulse there was a bruit de souffle closely resembling in character the placental murmur. The heart's position was normal, and there were no altered cardiac sounds. The respiration over the left front was weak and sub-bronchial in quality, and generally over the left side posteriorly the percussion note was less full and the respiration weakened, becoming in the lower interscapular region somewhat bronchial in quality and accom- panied by a few crepitations. On the right side, both in front and behind, the respiratory sounds were exaggerated. The diagnosis arrived at was that there was a soft and rapidly growing and very vascular tumour in the anterior mediastinum, pressing upon and more or less involving the oesophagus, and com- mencing to invade the rest of the lung. In the male subject an aneurism, especially of the dissecting kind, might have been more seriously in question, particularly with the history of a severe hunting accident ; but there were no signs of alteration of the cardio-vascular system and no accentuation of, or murmur with, the second sound of the heart. The possibility of a pulsating mediastinal abscess had more carefully to be considered ; and, although the bruit seemed to be so distinctly intrinsic to the tumour, and there was an absence of any marked excursion of temperature or hectic symptoms, still, the possibility could not altogether be ignored, and the patient volun- teered the statement, without any suggestive questions, that she felt a throbbing as of an abscess within her chest. It was agreed that some exploration should be made, and Sir A. Pearce Gould was asked to see her on the following morning with this intention. Meanwhile Dr. Hugh Walsham was requested to take a skiagram, from which the evidence of the conditions being due to growth, not fluid, was strengthened. On March 29, after careful consultation, it was decided that the safer, as well as the more satisfactory, plan was to raise the sternal end of the pectoral muscle, and make an incision through the intercostal space. An aneesthetic was given, and the sternal attachment of the muscle having been divided, the second cartilage was exposed, and on cutting through the space it was at once obvious that a soft growth was underneath. The second cartilage was excised with a view to relieve pressure, which enabled the growth to be further examined, and the wound was then closed and stitched up. The structure of a fragment of the growth removed proved on examination to be that of a round- celled sarcoma, extremely vascular and presenting numerous haemor- rhagic extravasations. Some decided temporary relief was afforded by the removal of the cartilage, and the consequent diminution of internal pressure, and the lady took some food afterwards with but little difficulty. She died, however, nine days after the operation. 746 DISEASES OF THE LUNGS AND PLEURA Case II. — The following case shows the disease com- mencing with the features of simple pleural effusion, as so often happens : Mrs. T., aged fifty-six, was seen with Dr. Farr on November 5, 1909. She had suffered from influenza twelve months previously, and had been ailing since. In the previous August she went to Llan- drindod. On October 29 the respirations were stated to have been 28, and some friction was heard over the pericardium. At the time of the consultation on November 5 there was a paroxysmal cough, but no expectoration ; the temperature was 99° ; the urine phosphatic. On examination the right side of the chest was found to be dull over the anterior base, and the left dull to the angle of the scapula. On November 10 the dulness had extended upwards on the left side. Skodaic resonance was elicited below the clavicle, and over the upper confines of dulness behind at the mid-scapular region the breathing was tubular ; the dypsnoea was considerable. The physical signs thus far pointed to simple effusion, and a pint of fluid was with- drawn, tinged with blood, which it was thought might be due to the rupture of a small vessel during the operation. By November 20 the effusion had again increased up to the clavicle, and grave doubts were now expressed as to growth being in the background, owing to the slightness of the febrile reaction, the insidious onset of the illness, and the blood-stained fluid. A further tapping was recommended. This resulted in the withdrawal of but twelve ounces of fluid, which, according to the report of the Clinical Research Association, " contained a moderate amount of blood and a small clot, also coagulated lymph, and many small masses com- posed of cells of variable size and more or less irregular shape. Cells mostly rounded, much vacuolated, and degenerated. No pus cells, tubercle bacilli, or other organisms were found. The characters of the fluid are almost pathognomonic of growth." Dr. Farr added, in sending the report: " I think the growth has much increased; she is now so much distressed with urgent dyspnoea that I have com- menced morphia injection." The patient died shortly after. Case III. — The following case was one in which the diag- nosis of mediastinal growth emerged through that of em- physema and dilated heart, from which the patient had for ten years been known to suffer : Mr. O., aged forty-eight, was seen with Sir Malcolm Morris in October, 1905, the patient having been under observation since 1896 for emphysema. In November, 1905, he was sent to Torquay, where he became less well, with increasing difficulty of breathing, especially at night; he also had some attacks of dark haemoptysis of not more than half an ounce in amount. At the end of August, 1906, he was again seen, and the signs obser\^ed were those of general emphysema, INTRATHORACIC TUMOURS 747 but with less fulness of note over the right side, and, over the lowest three ribs posteriorly, dulness, regarded as due to collapse of lung from pressure of a somewhat enlarged liver, which was palpable for two fingers' breadth below the costal margin. The right side of the heart was dilated, and a systolic murmur was audible at the apex. On November 8, 1906, he was again examined with Sir Malcolm Morris, when a notable absence of breath-sound was observed over the right side of the chest, and some dulness was noted in the right interscapular region. The first diagnosis of emphysema, mitral incompetence, dilated heart, and pulmonary infarction, was now supplemented by that of posterior mediastinal growth to which the haemorrhagic attacks were attributable. The disease made rapid progress to a fatal issue. The temperature hovered between the normal and 99°. Case IV. — The following case, one of aneurism of the transverse aorta, presented many of the features of medias- tinal grow^th, or possibly of abscess behind the sternum, and therefore may perhaps be usefully introduced here : Captain C, aged fifty, was seen with Dr. Humphrey on March 4, 1897. There was a history of syphilis, and he had led physically a strenuous life. In February, 1895, he had laryngitis, and suffered for twelve months from some asthmatic symptoms. In September of that year he coughed up three-quarters of a pint of pus, and since then had had eight similar attacks, the last in December, 1896. The expectoration had been purulent since then, but not foetid, and occasionally more purely bronchial mucus had been expectorated. Of late he could only sleep in the sitting posture. His weight had diminished from 11 stone to 9 stone 12 pounds. The features were congested to turgescence, and there was very considerable distress in breathing. Over the manubrium sterni, and a little to right and left of it, there was dulness, and pulsation was felt over a small area corresponding with the inner end of the second cartilage and left space. Posteriorly, in the interscapular region on either side and over the spine as far as the fourth process the breath- sounds were notably bronchial. As. regards the diagnosis in this case there was some difference of view, that which appeared to us most probable being that of a saccu- lated aneurism presenting from the back part of the transverse aorta, pressing upon the lower trachea, and causing muco-purulent secre- tion to accumulate behind it; the other view being that there was an abscess or growth in the upper substernal region connected with the bronchus, and having pulsation communicated to it from the vessel. This latter view was favoured by the report of an X-ray examination. The patient's symptoms becoming aggravated, it was decided, in consultation with Sir Alfred Pearce Gould, to explore the upper medi- 748 DISEASES OF THE LUNGS AND PLEURA astinum, and on March 30, 1897, Sir Alfred trephined the manubrium sterni, and dissected down to the aorta. " No abscess or swelling was detected; the aorta appeared very large, and pulsation was felt all round the finger." The wound was then closed. On April 10 the patient went to Brighton. "The operation did neither good nor harm; if anything, he was more comfortable afterwards." From a report kindly furnished by Dr. Halstead, who had the care of Cap- tain C. for some time before the operation and subsequently at Ramsgate, it appeared that there was no discharge of pus after the operation, with the exception of a few drachms in July, until about a fortnight before his death, during which time Captain C. brought up daily approximately four ounces of muco-pus and suffered much distress. He died from exhaustion on September. 26, 1897. Diagnosis. — The diagnosis of tumour of the mediastinum, as soon as symptoms seriously draw attention to the case, is not as a rule difficult, since pressure signs and symptoms are incompatible with any other form of pleuritic disease or pul- monary consolidation, nor are they present in any decided degree even in extreme pericardial effusion. The conditions which most simulate tumours in this region are abscess of the mediastinum and syphilitic stricture of a main bronchus. With abscess the temperature, hectic pheno- mena, possible history of injury, the character of the pain, and the attendant inflammatory phenomena, will usually clear up the difficulty, although we have already described a case in which abscess decidedly entered into the question of diagnosis, and another case in which the diag'nosis between an abscess beneath the sternum and an aneurism was only decided in favour of the latter, and contrary to the interpre- tation of an X-ray examination, after a portion of the sternum had been trephined. The distinction of syphilitic stricture of the main bronchus or lower trachea from an obscure medias- tinal tumour of small dimensions strangulating these parts is most difficult. Still, the limitation of pressure signs to one system and the absence of any discoverable signs of tumour, together with a history of syphilis, should at least aid the diagnosis sufficiently to suggest a definite treatment, the effects of which may, perhaps, though not necessarily, throw further light upon the case. Having excluded mediastinal abscess and syphilitic stric- ture, and arrived at the conclusion that a tumour is present, we have yet to determine whether it be aneurism or growth. INTRATHORACIC TUMOURS 749 In favour of growth the following- are the more important points: (i) the age of the patient (if below twenty-five); (2) the presence of an extensive area of superficial dulness; (3) the presence of decided venous obstruction; (4) the absence of marked disease of the arteries, of characteristic pulsation, diastolic shock, tracheal tugging, and a history of syphilis; and (5) the history or presence of tumours in other situations. In a doubtful case an X-ray examination should always be made. With growth we see a shadow, which in early cases, before pulmonary and pleural com- plications have set in, fades gradually at the edges, and presents no clear evidence of pulsation; with aneurism we may perceive a tumour clearly defined in shape, and evincing definite expansile pulsation, a combination which, when clearly visible, is very characteristic. The diagnosis of new growth from pleural effusion, which is sometimes so difficult, must be settled, as we have seen, by the exploring syringe; but we must remember that the two are not infrequently combined. In such cases a microscopic examination of the cells present in the fluid (see p. 743) may prove of value, as in one of the cases which we have just recorded. With regard to the nature of the growth, it is to be remem- bered that, if the disease be primary in the mediastinum, it will probably be a sarcoma, and the younger the patient, the more likely is this to prove the case. Should the disease be secondary to a growth elsewhere, it will be of the same nature as the primary disease. Prognosis. — Malignant disease of the mediastinum is inevit- ably fatal, but its duration varies much. Of sixty cases occurring at the Brompton Hospital, investigated by Dr. J. N. MacBean Ross,^ the average duration of life from the date of the first symptom complained of was thirty-two weeks, the maximum duration being eighty-eight weeks, and the minimum nine. Death is generally the result either of gradual exhaustion or of suffocation, the patient in the latter case dying after prolonged attacks of dyspncea. Less com- monly it is due to haemoptysis, sudden syncope, or cerebral tumour. At the post-mortem the disease may be found restricted to the mediastinum and lung, but it is more com- mon to discover secondary growths elsewhere, the liver, pan- 750 DISEASES OF THE LUNGS AND PLEUR.E creas, suprarenals and kidneys being the organs most com- monly attacked. Treatment. — The cases of mediastinal new growth which we have been considering are beyond the reach of surgery, and their progress is not influenced by drug treatment. X-rays and radium^ are not capable of arresting the disease, but we believe that in more than one instance we have seen the progress of the malady checked and the fatal issue some- what postponed by the use of one or other of these remedial agents. We accordingly- as a rule advise in these cases a course of radium or X-ray treatment. The' more distressing symptoms complained of, including the paroxysms of dyspnoea, must be relieved by sedative remedies. A combination which we have used with consider- able advantag'e, at least for a time, is one of iodide of sodium, from three to five grains, and chloral, live to ten grains, taken four or six times in the twenty-four hours. Morphia, in com- bination with atropine, must also be employed and pushed if necessary. Temporary relief to the dyspnoea may also be given by oxygen. Should an effusion into the pleura occur, it must be" aspirated, if it definitely increases the diffi- culty of breathing; otherwise it is best left alone, for it does no harm, and if removed, it will almost certainly recur. Tumours of the Lungs. In the description which we have just given of mediastinal tumours we have shown that in the great majority of cases, before death occurs, the disease spreads into the lung, and forms there a mass of growth, often of very considerable size. We have now to consider those tumours which may affect the lung irrespective of the mediastinum, or only spread into the latter at a later date. Tumours of the lung proper, like those of the mediastinum, may be innocent or malignant. Among the former, fibromata, lipomata, and others, have been described; but they are all so excessively rare, grow so slowly, and cause so few symptoms, that the group possesses no clinical importance, and we shall not again refer to them. Hydatids, dermoid growths, and gummata we have described elsewhere. Primary Carcinoma of the lung is not so rare as is com- PLATE XXXVI Secondary Chondro-Carcinoma of Lung. To face p. 751. INTRATHORACIC TUMOURS 751 monly supposed, Dr. Adler''' having recently collected 374 examples. The disease, hke mediastinal new growth, is more common in males than in females, and usually occurs in patients over the age of forty. It originates most commonly in the epithelium of the bronchi, more rarely from the cells lining the alveoli, and gives rise either to a large mass within the lung, or, as in a case which we have recorded,'* to an infiltration of a portion of the organ. In other cases the growth commences in the bronchi near the root of the lung and soon gives rise to symptoms of compression. In secondary cases, which are often met with, the tumours gen- erally form numerous separate masses, scattered throughout both lungs in a fairly symmetrical manner, and on section varying in size from that of a threepenny-piece to a shilling or even larger (Plate XXXVI.). In rare cases the secondary growths may be extremely small and very numerous, so as to resemble miliary tubercles, and to this condition the name "carcinomatosis" has been applied. Primary sarcoma originating in the lung is undoubtedly very rare, most cases which seem at first to suggest this origin proving on investigation to be examples of mediastinal disease, with subsequent invasion of the organ. Nevertheless, true examples occur from time to time. In such cases the growth forms as a rule a solid mass, which more or less replaces the lung tissue of a whole lobe, whilst the bronchial and mediastinal glands remain unaffected, or show signs merely of recent invasion. Secondary sarcomata, on the other hand, are com- mon, and they, too, Hke secondary carcinomata, are generally multiple and bilateral. Occasionally, however, they take the form of single massive tumours, which give rise to all the symptoms of pleural effusion. Of the large displacing tumours, osteo- or chondro-sarcomata are the most common, and are generally secondary to affections of bone or joints. Symptoms.— Vv'imdiry malignant disease of the lung pre- sents symptoms which closely resemble those which we have seen to occur in mediastinal new growth. Cough and short- ness of breath, often paroxysmal in character, and pain in the side, are commonly complained of; emaciation is not a marked feature, and pyrexia in uncomplicated cases is usually absent. The sputum is from time to time blood-stained, and decided 752 DISEASES OF THE LUNGS AND PLEURA haemoptysis may occur. Symptoms of venous compression and pressure on the nerves and large air-tracts are, however, less frequent and longer delayed than in ordinary mediastinal tumours, although, if the patient survive and the mediastinum become affected, they may make their appearance. The physical signs, again, are in no sense characteristic. Over the portion of lung affected impaired note, weak breath- ing", and diminished vocal vibrations, or in other cases bron- chial breath-sounds and bronchophony, according as the bronchus is obstructed or free, will be the signs ehcited. In other words, we have a gradual consolidation of the lung, usually of the lower lobe, proceeding from above downwards, with, in most cases, weakened breath-sounds and hasmorrhagic sputum. An X-ray examination, provided it be undertaken early in the course of the case and that there is no effusion into the pleura, discloses the shadow of the tumour, some- what irregular in outline, and often with an ill-defined edge. Later, with associated collapse of the lung and other pul- monary and pleural changes, the X-ray picture becomes obscured. Secondary growths in the lungs from a primary focus in some distant organ, even when numerous and scattered through both lungs, not uncommonly remain latent, the con- dition being first discovered on the post-mortem table. When, however, the growth forms, as it occasionally does, a large single mass, physical signs often suggesting a pleural effusion will make their appearance. In duration and mode of death cases of primary malignant growth in the lung do not differ materially from those in which the mediastinum is first attacked. Eight to ten months is the average duration of the disease; gradual asthenia and suffocation the common precursors of death. Treatment will be similar to that for mediastinal growth (p. 750). In cases diagnosed quite early, in which the disease appears localised and the mediastinum not as yet involved, surgical intervention has been essayed in a few cases, the tumour and affected lobe of the lung being removed. In one case^* the patient's life was apparently somewhat prolonged, but the operation is so grave and hazardous that there can be but very few cases for which it would be suitable. INTRATHORACIC TUMOURS 753 REFERENCES. ^ Mediastinal Disease, by H. A. Hare, M.D. Philadelphia, 1889. ^ Treatise on Diseases of the Lungs and Pleura, by Wilson Fox, M.D., F.R.S., p. 1167. London, 1891. ^ " Some Observations upon Primary New Growths of the Mediastinum from the Study of Sixty Cases," by J. N. MacBean Ross, M.D. (Edin.), The Edinburgh Medical Journal, 1914, N.S., vol. xiii., p. 444. , * Re-port on the Work of the Pathological Defartjnent of the Brom-pton Hospital during the Three Years 1900-1903, by P. Horton-Smith (Hartley), M.D., p. 30. London, 1903. ^ " Intrathoracic Tumours and Aneurysms in their Clinical Aspect," by Graham Steell, M.D., F.R.C.P., The Lancet, 1911, vol. ii., p. 1610. ^ {a) Primary Malignant Growths of the Lungs and Bronchi, by I. Adler, A.M., M.D., p. 14. London, 1912. [b) Loc. cit., p. 108. 48 INDEX OF AUTHORITIES Abrahams, Adolphe, 201, 331, 332, 334 Abrams, Albert, 349, 351, 472 Acland, T. Dyce, 208, 221, 410 Adams, Francis, 84, 89, 590 Addison, Thomas, 19, 466, 473 Adler, I., 75i, 753 Alexander, J., 431, 442 Alexandre, R., 710 AUard, 91 AUbutt and RoUeston, 410 Andrew, 705 Andrewes, F. W., 343 Appleby, 405 Aretaeus, 79, 86, 89, 573 Arkle, C. J., 415, 417 Arloing, 589 Armit, H. W., 572, 592 Arneth, 503 Aron, 8 Auenbrugger, L., 35, 65 Avery, Oswald T., 321 Babes, 422 Baccelli, 120, 132 Ballin, 428, 442 Bandelier, 714, 718 Barcroft, D. M., 366, 378 ' Bardswell, N. D., 613, 614, 618, 626, 629, 630, 631, 635, 716, 718 Barnett, L. E., 378 Barr, Sir J., 115, 117, 350, 351 Barrs, A. G., 91, 116 Bashford, E. F., 187, 202, 331, 334 Battle, W. H., 132 Baumgarten, 427 Baxter, J. H., 24, 32 Bayard, F. Campbell, 176, 220 Bayle, 420 Beau, 49, 65 Beck, Max, 582, 591 Beevor, Sir Hugh, 436, 437, 443 Behring, von, 431 Bennett, Hughes, 674 Bernstein, J. M., 410 Bert, Paul, 9, 20 Besson, A., 417 Bettmann, Milton, 197, 201 Beurmann, L. de, 411, 413 Biach, Alois, 134, 155 Bierman, 197 Birch-Hirschfeld, 429 Bodin, E., 418 Bodington, George, 607, 617 Bollinger, O., 394, 409 Bondet, A., 50, 54, 65 Bouchard, C, 131, 320, 547, 687, 693 Bowditch, H. I., 109, 450, 461 Boyce, R., 418 Boyd, Stanley, 442 Bradford, Sir J. Rose, 159, 164, 165, 187, 201, 331, 334, 347, 348, 349, 350 Braham, Noel, 241 Brauer, 719 Braun, Julius, 285 Brehmer, 607 Breton, M., 591 Brickdale, J. M. Fortescue-, 161, 165 Brissaud, 131, 320 Bristowe, J. S., 46, 378 Brodie, Sir B., 239, 241 Brodie, T. G., 243, 244, 268, 705, 710 Brown, G. Gordon, 644, 652 Brown, W. Langdon, 705, 710 Brown, Lawrason, 591, 627, 628, 635 Brown, A. Samler, 644, 652 Browne, Sir J. Crichton-, 447 Brownlee, 436, 437, 450, 453, 455, 457, 458, 459, 461 Bruce, Mitchell, 516 Briinings, W., 19, 237 Brunton, Sir Lauder, 381 Buchanan, Sir G., 450, 451 Buhl, 421 Bull, Peter, 728, 731 Buller, J. F., 50, 65 Bulloch, W., 423, 441, 584 Bulstrode, H. T., 453, 461, 619, 634 Burghard, F. F., 366 Burrell, L. S. T., 720 Burton, 450 754 INDEX OF AUTHORITIES 755 Calmette, A., 339, 343, 431, 579. 583, 591 Calvert, James, 686 Campbell, Colin, 219, 222 Canti, R. G., 471 Carling, Esther, 727, 730 Carson, J., 7, 20 Castellani, Aldo, 180, 200 Cayley, V/., 362, 366, 556, 719 Celsus, 420 Chambers, A. J., 200, 239 Chaplin, Arnold, 217, 222 Chapman, J. E., 613, 614, 618 Charcot, 547 Charles, 603 Charpy, A., 20, 21, 89 Chausse, P., 429, 442 Chauveau, A., 50, 54, 65 Chickering, H. T., 321 Clark, Sir Andrew, 73, 247, 511, 520 Clayton, F., 201, 334 Coats, Joseph, 285 Cobbett, Louis, 343, 427, 431, 432, 433, 441, 460, 473 Coghill, J. Sinclair, 686 Cole, Rufus, 321 Collie, Sir John, 410 CoUingswood, 35, 322 Collis, G. L., 343 Cornet, 429 Corvisart, 35 Cotton, 548, 556 Coupland, Sidney, 132, 289, 321, 476 Courmont, Paul, 589, 592 Craighead, J. W., 724 Crookshank, 397, 401, 402, 410 Cuneo, B., 19, 85, 86, 89 Curie, David, 678, 686 Curschmann, H., 77, 242 Dally, Halls, 345 Dangschat, Bruno, 384 Davidson, Sir Mackenzie, 64, 230 Davies,H. Morriston, 114,117, 221, 222 Davy, John, 139, 156 Delbret, Pierre, 283, 285 Delorme, E., 129, 132 Denison, Charles, 638, 652 Derry, D. E. J., 419, 440 D'Espine, 44 Dettweiler, 607 Devillers, Louis, 415, 417 Dewar, Sir James, 639 Dickinson, W. H., 568, 572 Dieulafoy, 109 Dixon, W. E.,'243, 244, 268, 686, 705, 710 Dochez, A. R., 321 Dodwell, P. R., 541, 545 Donders, F. C, 7, 8, 20 Douay, G., 285 Douglas, C. Gordon, 5, 20 Dreschfeld, J., 304, 322 Dudgeon, L. S., 591 Dunbar, 248, 249, 261, 262 Duncan, Andrew, 156 Durham, A. E., 238, 240 Dupuytren, 373 Edwards, Vertue, 436 Ehrlich, P., 423, 570 Eichhorst, 91, 116 Eicken, Carl von, 238, 240 Elderton, Ethel M., 438, 443 Elderton, W. P., 625, 626, 629, 630, 631, 635, 717, 718 Elliott, T. R., 77, 157, 160, 162, 163, 164, 165, 349, 351 Ellis, Calvin, 117 Estlander, J. A., 132 Evill, 484, 485 - ■ , Ewald, C. Anton, 2, 19, 44, 139, 156, 197 Eyre, J. W. H., 201, 325, 334 Fabyan, Marshall, 117 Fagge, Hilton, 46 Fanning, F. W. Burton, 621, 634 Farr, 746 Fearn, S. W., 548, 555 Feldman, W.M.,460 Felkin, 486 Fenwick, Samuel, 72, 77 Fenwick, W. Saltan, 541, 545 Fildes, Paul, 591 Findel, H., 431, 442 Fisher, Irving, 618 Fisher, 406 Flack, Martin, 313, 322 Fieurens, 6 Flint, Austin, 44, 55, 65 Flugge, 429 Forbes, J. Graham, 567, 572 Forlanini, 719 Forsyth, C. E. P., 685 Foster, Balthazar, 117 Foulerton, A. G. R., 394, 396, 407, 410, 441 Fowler, Sir J. Kingston, 135, 155, 208, 218, 221, 222, 386, 393, 470, 473, 567, 572 Fowler, W. C, 75 Fox, J. C, 201 Fox, Wilson, 117, 373, 737, 753 Frankel, 289 Frankland, 283 Franz, Karl, 582, 591 Freeman, Edward A., 240 Freeman, John, 245, 268 French, Herbert, 201, 331, 332, 334 Freund, W. A., 274, 283, 285 Friedrich, 422 756 DISEASES OF THE LUNGS AND PLEURA Gaide, A., 146, 156 Gairdner, Sir W. T., 274, 285 Galen, 420 Gamaleia, N., 289, 321 Garland, G. M., 103, 117 Garratt, G. C, 321 Garre, C, 360, 365, 366, 377, 378 Garrod, Sir A. E., 77, 164 Gask, G. E., 162, 163, 164, 165 Gautier, E., 418 Gee, Samuel, 24, 32, 56, 65, 84, 105, 191, 195, 201, 22r, 274, 285 Geissler, H. T., 310, 322 Ghon, Anton, 471, 473 Gilbert, A., 413 Gillette, H. F., 268 Gimbert, 687, 693 Glegg, R. Ashleigh, 268 Godlee, Sir RickmanJ., 128,222,231, 240, 362, 366, 381, 384, 393, 399, 401, 405, 408, 410, 572 Goodall, A., 476, 496 Goodall, E. W., 268 Goodbody, F. W., 613, 618 Gordon, M. H., 318, 322, 429, 442 Gordon, W., 449, 450, 460, 461, 652 Goring, C, 439, 443 Gougerot, 413 Gould, Sir A. Pearce, 132, 362, 366, 744, 745, 747 Grant, Sir J. Dundas, 710 Graves, 122 Gray, John, 620 Green, Alan B., 569, 572 Greenhow, E. H., 274, 285, 343, 455, 461 Greg, 577 Greves, Hyla, 154 Griffith, A. Stanley, 424, 441 Grimshaw, T. W., 302, 322 Grysez, 43r, 442 Guimbellot, Marcel, 377, 378 Gull, Sir William, 203, 221 Gulland, G. L., 476, 496 Guyon, F., 240 Haldane, J. S., 5, 20, 462 Halliburton, W. D., 92 Hallows, Norman, 201, 331, 332, 334 Halstead, 748 Hamilton, D. J., 180, 181, 200 Hammond, J. A., 186 Hare, Charles J., 23 Hare, H. A., 737, 753 Harris, J. Delpratt, 360, 366 Harris, Thomas, 117 Hartley, P. Horton-Smith, 84, 117, 155, 156, 175, 221, 231, 334, 355, 357, 393, 410, 473, 481, 484, 516, 545, 556, 572, 592, 634, 670, 686, 724, 753 Hartz, 394 Hastings, J., 730, 731 Haviland, Alfred, 450, 461 Hedges, C. E., 91, 116 Henry, H. G. M., ^j, 157, 160, 165 Henshaw, Nathaniel, 281, 285 Hensley, P., 6, 20 Heron, 442 Heymann, Bruno, 428, 433, 442, 443 Hicks, J. A. Braxton, 221 Higginson, C. G., 710 Hill, Leonard, 20, 284, 358 Hinds, F., 415, 417 Hine, T. G. M., 322 Hippocrates, 60, 65, 133, 420, 547 Hirt, Ludwig, 178, 200 Hoffmann, F. A., 225, 226, 234, 240, 280, 284 Hogarth, A. H., 634 Holden, G. W., 4x5 Holland, 632 Holmes, T., 240 Holt, L. Emmett, 334 Horder, Sir Thomas, 485 Home, W. Jobson, 534, 535, 545 Hort, E. C, 591 Hovell, T. Mark, 334 Howell, W. H.,20 Huggard, William R., 449, 460, 561, 652, 670 Hulke, J. W., 240 Humphrey, 320 Hutchens, H. J., 417 Hutchinson, John, 8, 11, 20, 32 Hutchinson, Robert, 321 Ilkeston, Lord, 109 Ilott, 229 Inman, A. C, 441, 584, 585, 588, 591, 6x2, 6x3 Irvine, 343 Irvine, J. Pearson, 203, 22 x Israel, James, 394, 409 Itard, X33, 155 Jaccoud, X34, 676 Jackson, Chevalier, 238, 240 Jaksch, Rudolf von, 68, 77 Jenner, Sir William, 273, 284 Jessen, F., 44X Jessop, Walter H., 572 Johnson, 343 Johnson, Sir George, 558, 562 Johnston, Charles A., 448, 460 Jones, D. W. Carmalt, X56 Jones, A. Coppen, 76, Tj, 422 Jones, C. Price, 410 Jones, P. C. Varrier, 622 Jones, F. Wood, 420, 440 Jourdanet, D., 449, 460 Jousset, Andre, gx, 1x6 INDEX OF AUTHORITIES 757 Kanthack, A. A., 325, 326, 409 Keith, Arthur, 9, 11, 25, 32, 270, 284, 345 Kellock, Thomas H., 240, 241 Kelsch, A., 91, 116 Kidd, Percy, 231, 426, 441 Killian, 236 Kincaid, 390 King, D. Barty, 206 Kirkland, Thomas, 601, 605 Klein, E., 18, 21, 244, 424, 435 Knox, Alexander, 652 Koch, R., 421, 422, 428, 578, 579, 712, 713,718 Kohlisch, 429, 442 Kolmer, John A., 378 Koster, 91 Krawkow, 569 Laennec, R. T. H., 35, 41, 47, 49, 53, 55, 56, 57, 58, 59, 60, 62, 65, 133, 146, 155, 194, 195, 196, 201, 242, 273, 285, 421, 427, 474, 528, 529, 531, 625 Langenbeck, von, 394 Latham, P. M., 201 Lebert, H., 201, 394, 409, 604 Le Damany, 91 Lees, David B., 681 Lendon, A. A., 367, 375, 378 Levaditi, 422 Leyden, E., 149, 156 Liebermann, L., 6, 20 Lillingston, Claude, 720 Lister, F. S., 321 Lockwood, A. L., 165 Longstaff, G. Blundell, 286, 320, 438, 443 Lord, F. T., 131 Louis, 146, 233, 625 Lowenstein, 441 Liibbert, 268 Lurie, 200 Lyell, R. W., 222 Lyster, 622 Lytton, Bulwer, 240 MacAlister, Professor, 50 MacCormac, Henry, 607, 618 McCrae, John, 339, 343 McCrae, Thomas, 131 Macdonald, W. M., 201 MacDonnell, 122 Mcintosh, J., 591 Mackenzie, H. W. E., 307, 378 Maclean, 122 MacLeod, I. J. R., 423, 441 Madison, 582 Mahomed, 38, 44 Malcolm, W. S., 410 Marcel, 660 Martin, Joseph S., 462 Martin, Sidney, 430 Masson, A., 412, 413 Masson, L., 591 Maunsell, S. E., 289, 321 Meek, W. O., 588, 591, 621, 634 Mehu, 93 Meltzer, S. J., 358 Melville, 342, 724 Metchnikoff, 422 Miller, W. F., 2, 19 Milton, J. Penn, 170, 175 Moller, 424 Moore, Sir, J. W., 302, 322 Moore, 525 Morgan, W. Parry, 720, 730 Morland, Egbert C, 579 Morris, Sir Malcolm, 746, 747 Morse, J. Lovett, 148, 156 Mouat, T. R., 381, 384 MUller, I. J., 8, 20 Murchison, C, 302, 322 Murphy, Sir Shirley, 454 Musser, John H., 116, 201, 225, 226, 240, 284 Mussy, Gueneau de, 88, 132 Naegeli, 447 Neisser, 367 Netter, 91, 116, 119, 131, 292, 320 Newsholme, Sir Arthur, 440, 443 Nixon, J. A., 165 Obici, Augusto, 415, 417 Ogle, Cyril, 383, 384 Oliver, Sir Thomas, 321, 340, 341, 342, 343 Ophuls, W., 366 Ormerod, J. A., 170, 175 Osier, Sir William, 87, 89, 134, 131, 132 Paget, Stephen, 125, 132, 156, 366, 378,731 Parkes, E. A., 321 Pasteur, 321 Pasteur, William, 200, 334, 335, SS'^, 349, 350 Paterson, Marcus S., 601, 605, 609, 610, 612, 618 Pearson, Karl, 438, 439, 443, 445, 446, 457, 458, 460, 462, 625 Pearson, Leonard, 418 Pearson, S. Vere, 720, 730 Perls, M., 7, 20 Perry, S. J., 625, 626, 629, 630, 631, 634, 635, 717, 718 Petitjean, G., 703, 710 Petri, 424 Petrone, Luigi M., 322 Philip, Sir Robert, 704 758 DISEASES OF THE LUNGS AND PLEURA Pic, A., 703, 710 Picken, R. M. F., 624, 634 Piorry, P. A., 36, 65 Pirquet, von, 578, 583 Pitt, G. Newton, 158, 164, 203, 221 Pohl, W., 380, 384 Poirier, P., 19,20, 21, 85, 86, 89 Pollock, J. E., 510, 516, 625, 634 Ponfick, E., 394, 409 Poore, G. Vivian, 218, 222 Pope, E. G., 438, 443, 627, 628, 635 Potain, III Powell, Sir R. Douglas, 20, 38, 44, 65, 89. 117, 132, 153, 155, 156, 222, 243, 266, 268, 277, 302, 381, 397, 405, 406, 410, 450, 460, 473, 510, 520, 531, 545, 553. 556, 632, 710 Preobraschensky, S. S., 238, 241 Quain, Sir R., 548, 556 Quevli, 435 Quincke, H., 360, 365, 366, 377, 378 Rabinowitsch, Lydia, 441 Radcliffe, J. A. D., 468, 473, 588, 591 Ranking, W. H., 135, 155 Ransome, Arthur, 25, 32 Ravaut, 92, 116 Ravenel, Mazyck P., 418, 570 Reclus, Paul, 365, 366 Reeve, Edward, G., 686 Regaud, C, 165 Raid, G. Archdall, 460 Renon, Louis, 414, 415, 417 Raynaud, 60, 65 Riesman, David, 355, 357 Rindfleisch, Eduard, 270, 274, 284, 527, 531 Ringer, 252 Ritchie, T. R., 201 Rivers, C. W., 445 Riviere, Clive, 119, 472, 473, 579, 721, 730 Roberts, 89 Roe, Hamilton, 109, 117 Roentgen, 63 Roepke, 714, 718 Rogers, Sir Leonard, 675, 686 Rokitansky, 555 Rolland, W., 186,200 Rollier, A., 641, 710 Roily, 686 Rose, 484 Rosenbach, Ottomer, 68, 77 Ross, E. Athole, 116 Ross, J. N. MacBean, 749, 753 Rotmann, 175 Ruffer, M. A., 419, 440 Sabouraud, 411, 413, 416 Sachs, Theodore B., 724 Sahli, 716 Salter, Hyde, 7, 9, 11, 20, 242, 245, 249, 252, 259, 267 Sanderson, Sir J. Burdon, 11, 18, 20, 21, 465 Saugman, C, 719, 721, 722, 726, 728, 729, 730, 731 Saxer, F., 418 Schenck, B. R., 411, 413 Schmid, 449, 460, 652 Schmorl, 429 Scholberg, H. A., 166, 167, 168, 175 Schrotter, von, 237 Schulmann, A., 412, 413 Schultze, 422 Scurfield, H., 455, 462 Selous, F. C, 650, 652 Semon, Sir F., 237 Sharkey, Seymour J., 211, 221 Shattock, S. G., 383, 384, 420 Shaw, H. Batty, 380, 381, 384 Sherrington, C. S., 9 Shore, T. H. G., 186, 200 Shufflebotham, 343 Sikes, Alfred W., 393 Silvius, 420 Sitzenfrey, Anton, 427, 442 Skoda, 53, 103 Slivelman, B., 730 Smith, 570 Smith, Archibald, 449 Smith, Edwin, 153 Smith, G. Elliott, 419, 440 Smith, George, 266 Smith, Solomon C, 360, 365 Smith, Sir Thomas, 394, 409, 744 Smyth, R. Mander, 481, 496 Solly, S. Edwin, 652, 670 Solmersitz, F., 416, 417 Sommerbrodt, J., 687, 693 Spitta, Harold R. D., 435 Squire, Peter, 201 Stadler, E., 625, 634 Stansfeld, A. E-, 484, 485 Steell, Graham, 753 Stengel, Alfred, 357 Steuart, 343 Stewart, Sir T. Grainger, 219, 222 Stokes, William, 117, 122,223,227,240 Stone, 62 Storks, Robert, 730, 731 Strangeways, T. S. P., 591 Sturges, Octavius, 289, 321 Sutton, Sir John Blaud-, 379, 38-4 Swift, J. C, 273 Swithinbank, H., 425, 441 Szaboky, J. v., 591 Talamon, 289 Tatham, John, 455, 461 Taylor, Sir Frederick, 62, 65 INDEX OF AUTHORITIES 759 Taylor, H. H., 397, 401, 402, 405, 410 Thayer, W. S., 117 Thoinet, L., 413 Thomas, J. Davies, 367, 368, 374, 377, 378 Thomas, R. Arthur, 462 Thompson, J. H. R., 629, 630, 631, 635, 716, 718 Thomson, Sir StClair, 534, 536, 545 Traube, L., 9, 20, 103, 122 Treadgold, H. A., 503, 510 Trousseau, A., 62, 106, 109, 115, 117, 212, 221, 704 Trudeau, 716 Tulp, Nicholas, 69, 'jy Tyndall, 283 Uhlenhuth, 574, 591 Vaillard, L., 91, 116 Vallow, Harold, 461 Vansteenberghe, P., 431, 442 Vierordt, Oswald, 25, 32 Villemin, J. A., 421, 441 Virchow, 72, 387 Waithman, 405, 406 Waldenburg, L., 25, 28, 32, 275, 281, 285 Walker, J. Chandler, 245, 246, 268 Wallis, Mackenzie, 166, 167, 168, 174, 175 Walsh, Joseph, 57o, 572 Walsham, Hugh, 64, 230, 430, 442, 745 Walshe, W. H., 24, 25, 32, 183, 252, 310, 545 Walther, Otto, 481, 609, 614 Ward, Ernest, 438, 443 Washbourne, J. W., 50, 65 Watson, 157 Watt, 343 Weber, F. Parkes, 320, 451, 461, 605, 651 Weber, Sir Hermann, 285, 437, 443, 605, 638, 651, 652 Weir, H. B., 591 Weist, J, R., 238, 240 Welch, 287, 320 Welch, W.H., 356, 358 Wells, John W., 674, 685 West, Samuel, 155, 156, 171, i75, 321, 323, 334, 407, 410 Wethered, F. J., 285, 494 Wheaton, S. W., 418 White, P. Bruce, 201 Whitla, Sir William, 343 Whitlick, 744 Widal, 92, 116 Wild, R.B., 410 Wijeyeratne, 434 Wilks, Sir Samuel, 550 Willcox, W. H., 260, 268, 315, 322 Williams, C. J. B., 46, 59, 243, 268, 445, 460, 674, 685 Williams, C. Theodore, 222, 281, 285, 435, 436, 443, 445, 460, 625, 639, 652, 654, 666, 670, 674, 685 Williams, Dawson, 441 Williams, G. E. O., 380, 381, 384 Williams,, Leonard, 355, 357 Williams, Owen T., 685 Williams, P. Watson, 8, 20, 237, 243, 268 Williams, Stenhouse, 424, 441 Williamson, K. D., 165 Wilms, 220, 729 Wilson, J. A., 201, 331, 332, 334 Woillez, E. J., 24, 32 Wollstein, Martha, 324, 334 Wood, E. B., 442 Worrall, G.S., 156 Wright, Sir Almroth, 320, 57i, 583, 59i Wynn, W. H., 410 Xylander, 574, 59 1 Yeo, Burney, 605, 680 Young, R. A., 173, 174, 232 Zapelloni, L. C, 378 INDEX Aberdeen, Medical Of&cer of Health, overcrowding and phthisis, 455 Abrahams, A., Hallows, Norman, and French, Herbert, estimate of the fre- quency of pulmonar}' complications in influenza epidemic, 331; "helio- trope cyanosis " in influenzal pneu- monia, 332; mortality in influenza epidemics, 332 Abrams, Albert, " the lung reflex of contraction," 349 Abscess of liver, tropical, character- istic expectoration in, 68 Abscess of lung: causes of, 359; foreign bodies in air-passages and, 235; haemoptysis in, 555; in broncho- pneumonia, 326; in intrathoracic growth, 359; in pneumonia, 305, 306, 307; in phthisis (the caseous abscess), 524; physical signs, 360; symptoms, 359; treatment, medicinal, 360; — -, surgical, 360; steps in the operation, 361 ; results, 360; tuberculous or caseous, 524 Abscess of mediastinum, 734 {see also Mediastinitis, suppurative); of rib, tuberculous, 83 Acid-fast bacilli, 423, 424; in gangrene of lung, 364 Ackland, T. D., causes or antecedent conditions in forty cases of bronchi- ectasis, 208 Actinom3?cosis, 394 ; see Streptotrichosis Addison, Thomas, anatomy of the lung, I, 2; inflammatory process in pulmonary tuberculosis, 466 Adenoid growths and chest troubles, 177; reflex exciting cause of asthma, 246 Adirondack Cottage Sanitarium, tables showing condition of patients, 627, 628 Adler, I., primary carcinoma of lung, 751 Adrenalin chloride spray in asthma, 259; contra-indicated in haemoptysis, 705 Adventitious matters in sputum, 76 Adventitious sounds: definition and common significance, 41; inter- national nomenclature, 45 ; mode of formation of, 56; see Rales jEgophony, definition and common significance, 43; in broncho-pneu- monia, 329; in haemothorax, 159; in pleural efiusion, 61, 102; over con- solidated lung, 61, 62, 102; theory of production of, 61, 62 ^rotherapeutics in emphysema, 281 etiology of pulmonary tuberculosis, 419-462 ; see Pulmonary tuber- culosis, (ztiology African Highlands, South, climate and description of, 642-650; for phthisi- cal patients, 641, 644-647, 691; immigration laws as to admission of tuberculous patients, 636 Agglutination test in phthisis, 589 Aix-la-Chapelle for piilmonary syphilis, 392 Aix-les-Bains for catarrhal asthma , 256; summer health resort, 669 Alar chest, 79 Alassio, winter health resort, 663 Albuminous or serous expectoration: in acute pulmonary oedema, 353, 354; following paracentesis of chest, 114 Albuminuria and liability to pneu- monia, 287; complicating phthisis, 569; in fibroid phthisis, 520, 569; in influenza pneumonia, 332; unsuit- able for high climates, 640 Alcohol as cardiac stimulant {see Individual diseases); injections into superior laryngeal nerve in tuber- culosis of the larynx, 700 Alcoholism and abscess of the lung, 359; and bronchitis, 177; and de- layed resolution in pneumonia, 305 ; and fibroid changes in the lung, 336; and liability to pneumonia, 287; haemoptysis in, 549 Alexander, Dr. John, researches on respiratory and alimentary infection in tuberciilosis, 431 760 INDEX 761 Algeciras as winter resort, 663; climate of, 643, 664; for asthma, 256 Algiers as winter resort for asthma, 256, 664; for chronic bronchitis, 664; for quiescent phthisis, 664; unsuit- able in late spring, 669 Alimentary canal, tuberculosis infec- tion conveyed through, 430, 431 Aliwal North, South Africa, for phthisis, 645 ; sulphur springs, 646 AUard and Koster on tuberculous pleurisy, 91 Allevard - les - Bains for catarrhal asthma, 256; summer health resort, 669 Alpine altitudes after pleurisy, 108; for treatment of phthisis, 283, 637- 641 ; for treatment of surgical tuber- culosis, 641 Alveolar cells in sputum, 71 Alveoli, pulmonary, 3, 50 Amersham, suitable locality for per- manent residence, 669 Amoeba of dysentery in tropical abscess of the liver, 68, 69 Amphoric breathing, 41, 45, 55 Amphoric or metallic echo, 43, 62 Amyl nitrite in haemoptysis, 703, 706 Anaemia and false or spurious haemop- tysis, 560; of larynx in laryngeal tuberculosis, 534 Anaerobic organisms in haemothorax, 160; in foetid empyema, 123 Anaesthesin in laryngeal tuberculosis 700 Anaesthetic, choice of, in surgical operations in cases of chest disease, 128; broncho-pneumonia resulting from, 324 Analogy between asthma and vaso- motory angina, 243 Anaphylaxis in asthma, 245 ; in serum treatment of pneumonia, 319; in tuberculin treatment, 714 Anatomy of bronchi, 2, 3; of lungs, I, 2 Andes, South American, in treatment of phthisis, 642 Andrew, Dr. J., ergot in haemoptysis, 705 Aneurism: aortic, rupturing into pleura cause of haemothorax, 157; com- pression by, causing narrowing of bronchi, 202, 203; — pulmonary gangrene, 364; simulated by em- pyema pulsans, 122; — - simulating mediastinal tumour, 747; — • points of distinction between, 748, 749; pulmonary, cause of hemoptysis in bronchiectasis, 213; — , in pulmonary tuberculosis, 548; — , mode of formation, site of, 548; — , present- ing through walls of bronchus, 549 Anthoxanthum odoratum, pollen caus- ing hay asthma, 248 Anthracosis due to inhalation of coal- dust, 338; pulmonary, an inhala- tion infection, 431 Antiformin method for finding tubercle bacilli, 574 Antimony wine in bronchitis, 188 Antiphlogistine in pneumonia, 312; in purulent bronchitis, 188; in sero- fibrinous pleurisy, 107 Antipneumococcic serum in pneumonia, 318 Antipyretics in the treatment of phthisis, 679; • — of influenzal pneumonia, 333 Antiseptic inhalations in treatment of bronchiectasis, 218; in phthisis, 680, 681 ; in laryngeal tuberculosis, 698 Aphonia in subacute tuberculosis of lungs, 499 Aphthous condition of mouth and throat in advanced phthisis, treat- ment of, 701 Apomorphine in acute bronchitis, 189; in asthma, 258, 261 Aponeurotic rheumatism, 80, 81 Arcachon as spring health resort, 669; for asthma and phthisis, 256, 663 Arequipa (Peru) for asthma, 256 Aretaeus, description of phthisical chest, 79; description of case of advanced tuberculosis, 573; on pleurisy, 86 Argentine, hydatid disease of the lungs in, 367; La Cumbre district, suitable for consumptives, 650 Arkle, C. J., and Hinds, F., on asper- gillosis, 415 Arloing, Professor, agglutination test, 589 Arneth's blood picture in phthisis, 503, 504 Aron and Hutchinson, residual tension of the lungs, 8 Arosa for asthma, 256; for phthisis, 637; mean winter climatology of, 642, 643 Arrest of pulmonary tuberculosis of many years' duration, with illus- trative cases, in acute pneumonic phthisis, 481; in chronic pulmonary tuberculosis, 632-634; in fibroid phthisis, 516-519; see also Sana- torium treatment, results of Arsenic in asthma, 258, 263; in asper- gillosis, 417; in emphysema, 280; in febrile cases of phthisis, 677, 732; in pneumonia, 317 762 DISEASES OF THE LUNGS AND PLEURA Arterial supply of bronchi, 2, 3 Arterio-sclerosis and acute pulmonary oedema, 355 Arthritis and pneumonia, 306, 307, 309 Artificial pneumothorax : apparatus for performing, 720; cases suitable for, 680, 707, 725, 726; complications occurring during treatment, 723; - — , gas embolism, 723; — , perforation or rupture of lung, with illustrative case, 724 ; — , pleural reflex or pleural shock, 722; — , pleurisy, 723; dura- tion of treatment, 723; results of treatment at Berks and Bucks Sanatorium, 727; risks attending treatment, 722; technique, 720 Ascarus lumhricoides in air-passages, ,225 Aspergillosis, 414; diagnosis, 416; identification of parasite, 416; illus- trative case, 415; primary and secondary forms, 414; symptoms, 415; treatment, 417 Aspergillus fumigatus, 414-416; ex- perimental inoculation of, 428 ; nidulans, 415 Aspiration, in; see Paracentesis Ass's milk in pulmonarj' tuberculosis, 603 Assuan for bronchitis, 193; for quies- cent phthisis in winter, 665 Asthma, 242; cstiology, 244; age and sex incidence, 245 ; animals, 246 ; — , rela- tion to cats, 246 ; — , horses, 246 ; due to spasm of muscles of bronchioles, 242; exciting causes of the attack, 245-247; — , anaphylactic origin of, in some cases, 245 ; due to hyper- sensitiveness to foreign protein emanating from animals, bacteria, or plants, 246; — -, dust inhalation, 247, 248; illustrative case due to rosewood dust, 264; • — , emotional causes, 247; — , inherited predis- position, 244; — , reflex irritation, 246; from alimentary tract, 247; from bronchial tract, with illus- trative case, 266; from nose, 246; from uterine region, 247; blood, eosinophilia in, during attacks, 252; bronchial casts in, 252; — , with illustrative case, 266; clinical varie- ties of, 247; — , animal asthma, 245, 246; — , bronchitic or catarrhal, 248, 266; — , cardiac, 250; • — , dust, 248; with illustrative case due to rose- wood dust, 264; — , gouty, 245, 249; — ,hay, 246; " autumnal catarrh" in America, 249; from pollen of Anthoxanthum odoratum and other plants, 248; relation to hay fever, 248; treatment, 262; local, 262; by, " Pollacine," 262 ; by pollantin, 262 ; sea-voyages in, 263; ■ — , horse, 246; — , nasal, 249; — , peptic, 249; — , spasmodic (idiopathic or essential),, 247; — , ursemic, 250; eczema, urti- caria, and, 245; emphysema and, 242, 248, 253; food-proteins and, 245; hjemoptysis in, 253; heredity and, 244; influenza and, 245; inter- changeability of vaso-motor angina, menopausal sweatings, and, 247; menopause and, 245; pathology, 242; — , absence of distinctive morbid changes, 242; — , Curschmann's " bronchiolitis exudativa," 242; — , theory of vascular turgescence of bronchial mucous membrane, 242; periodicity of attacks, 253; physical signs in, 252; prognosis, 254; sputum, 252; — , appearance of Cursch- mann's spirals in, 252; — , eosino- philia in, 252; — , Leyden's crystals in, 252; symptomatology, 250; — , characteristic physiognomy of patient, 250; — , description of the attack, 250; treatment, (i) general: climatic, 255; dietetic, 257; medi- cated airs and baths, 256; medi- cinal, 258; of digestive functions, 257; of nose, 258; of other sources of peripheral irritation, 258 ; specific, 255; vaccines, 255, 263; (2) of hay asthma, 262, 263; (3) of the par- oxysm, 258: "asthma-cures," 259, 260; medicinal, 258; powders for burning, 259 Atelectasis pulmonum and bronchiec- tasis, 210, 211 Atheroma and haamoptysis, 546 Atomiser, 699 Atropine in acute pulmonary oedema, 356; in asthma, 243, 261 Auenbrugger, percussion first used by, 35 Aural tuberculosis, 539 Auscultation: combination of methods of percussion and, 63; definition and significance of sounds heard by, 39, 40; immediate and mediate, 47; international nomenclature, 44; not wholly unknown to ancient Greeks, 47; theory of, 48 Auscultatory percussion bell sound, 62; use of method for defining out- lines of organs untrustworthy, 63 Australia, hydatid disease of lungs in, 376; sea- voyages to, restrictions as to landing of tuberculous patients, 636, 656 INDEX I^Z Autumn, climatic treatment of phthisis in, 653 " Autumnal catarrh," 249 Avian tuberculosis, 426 Babes and Levaditi on streptothrix nature of the tubercle bacillus, 422 Baccelli, Professor, pectoriloquie apho- nique, 102, 120 Bacillus : coli in gangrene of the lung, 364; — in foetid empyema, 123; Friedlander, in broncho-pneu- monia, 325; — in lobar pneumonia, 290; of leprosy, 423; perfringens in septic haemothorax, 160; PfeiiJer, in bronchitis, 179; — , in influenzal pneumonia, 331, 332; — , in lobar pneumonia, 290; — , in purulent bronchitis, 187; — , in septic haemo- thorax, 160; proteus vulgaris in gangrene of the lung, 364; pyo- cyaneus in bronchitis, 179; — in gangrene of the lung, 364; tuber- culosis, 421 ; see Tubercle bacillus Badenweiler, Black Forest, health resort for phthisis, 651 Bagshot for asthma, 255 Ballin, experimental inoculation of A spergillus fumigatus ,428 Bandelier and Roepke, scheme of tuberculin dosage, 714-716 Bardswell, Noel, diet at King Edward VII. Sanatorium, 615; results of treatment at the Mundesley Sana- torium, 616 Bardswell and Chapman, J. E., diet for phthisical patients, 614; — and Goodbody, F. W., metabolism in phthisis, 613 Bardswell and Thompson, J. H. R., results of sanatorium treatment at the King Edward VII. Sanatorium, 629; results of tuberculin treatment as practised at the King Edward VII. Sanatorium, 716, 717 Barkly East, South Africa, for phthisis, 646 Barr, Sir James, lung reflex contrac- tions and contralateral collapse, 350; use of adrenalin chloride in chronic sero-fibrinous effusions, 115 Barrs, A. G., on tuberculous nature of acute sero-fibrinous pleurisy, 91 Bartolet on chylothorax, 167 Basal phthisis, 470; diagnosis from bronchiectasis, 216 Bashford, E. F., Bradford, Sir J. Rose, and Wilson, J. A., filter-pass- ing virus in influenza, 187, 331, 332 Bath: compressed air at Brompton Hospital in treatment of asthma, 257; — , in treatment of emphysema, 281, 282; tepid and cool, to reduce pyrexia in broncho-pneumonia, 330; — , in pneumonia, 311, 312 Baumgarten, congenital infection in tuberculosis, 427 Baxter on chest measurements, 24, 27 Bayard, Campbell, statistics on English climatology, 176 Bayle, the " tubercular nodule " of phthisis, 420 Beau on the vesicular murmur, 49 Beaufort West, South Africa, for phthisis, 644 Beaulieu, Riviera, for phthisis, 662 ; spring health resort, 668 Beck, Max, on reaction to the tuber- culin test, 582 Bed of consumptive patient, 599 Beef-tea, how to make, 330 Beevor, Sir Hugh, prevalence of phthisis in Norfolk, 436, 437 Behring, von, alimentary infectioa in phthisis, 431 Belfast, Transvaal, sanatorium for phthisis, 644 Belladonna in broncho-pneumonia, 330 Bell's Liquor Picis Aromaticus for secreting cavities, 690; in chronic bronchitis, 192 Bell-sound [Bruit (Vairain), 43, 44; in ■ pneumothorax, 62; in subphrenic abscess, 63; over pulmonary cavi- ties, 63 Bendigo, New South Wales, for phthisis, 657 Benger's food in acute ulceration of bowel, 695 Bennett, Hughes, and Williams, C. J. B., cod-liver oil in phthisis, 674 Ben Rhydding for asthma, 256 Beraneck's tuberculin, 714 Bert, Paul, experiments on elastic pressure of lungs and expansion of chest wall, 9 Besredka method of vaccine treatment, 320 Bethlehem, Orange Free State, for phthisis, 649 Bettmann, M., on plastic bronchitis, 197 Beurmann, de, on sporotrichosis, 411, 413 Biach, aetiology of pneumothorax, 134 Biarritz, autumn and winter health resort for phthisis, 664 Biermann on plastic bronchitis, 197 Birch-Hirschfeld, observations sup- porting the view that infection in phthisis is by inhalation, not in- gestion, 429 764 DISEASES OF THE LUNGS AND PLEURA Birds, tuberculosis in, 426 Black Forest for phthisis, 651 Blarney for chronic bronchitis, 193 Bleeding; see Venesection Blisters; see Counter-irritation Bloemfontein, Orange Free State, for phthisis, 674 Blood-changes: in acute pneumonic phthisis, 476; in asthma, 254; in bronchiectasis, 216; in chronic pul- monary tuberculosis, 503; in em- pyema, 121; in hydatid disease of lungs, 369, 370; in pleurisy with effusion, 121; in pneumonia, 298, 299, 476; in tuberculous meningitis, 567 Blood-pressure: in phthisis, 504, 548; high tension in acute pulmonary oedema, 355 Blood-vessels of the lungs, 4, 5 Blue Mountains, Australia, for phthisis, 657 Bodington, George, in 1840 fore- shadowed sanatorium treatment, 607 Bogota, South American Andes, for phthisis, 642 Bollinger, parasite of streptotrichosis, 394 Bondet and Chauveau, observations on the production of the vesicular murmur and bronchial breath- sound, 50, 54 Bone and joint tuberculosis, propor- tion due to bovine infection, 433 Bordighera, Riviera, as spring health resort for phthisis, 658 Boshof, Orange Free State, climate of, 648 Botzen for grape cure, 604 Bouchard, C. H., and Gimbert, creosote and guaiacol in phthisis, 687 Bournemouth for asthma, 256, 659; for bronchitis, 193, 659; for delicate children, 594; mean winter tem- perature, 659; phthisis in autumn, winter, spring, 654, 658, 668 Bovine tuberculosis, 425; danger from infected milk, 431; infection from, causing bone and joint tuberculosis, 433; — , tuberculosis of mesenteric glands, 433; — , tuberculous peri- tonitis, 433; — , ulceration of the bowel, 433; see also Perlsucht Bowditch, H. I., dampness of the soil and phthisis, 450; paracentesis thoracis, 109 Bowel, acute ulceration of, 694; diet in, 695; drugs in, 695, 696; treat- ment, 696; — , chronic ulceration of, 696; drugs in, 696, 697; treatment and diet, 696, 697 Bradford, overcrowding and phthisis in, 455 Bradford, Sir John Rose, on haemo- thorax, 159; on massive collapse of the lung, 347, 349; on purulent bronchitis, 187; — , Bashford, E. E., and Wilson, J. A., on filter-passing virus in influenza, 187, 331, 332 Braemar for asthma, 257 Brandy in acute ulceration of bowel, 695; in broncho-pneumonia, 330; in influenzal pneumonia, 334; in pneumonia, 316; in streptotrichosis, 409 Brauer, Professor, artificial pneumo- thorax, 719 Breathing; see Breath-sounds Breathing exercises and after-treat- ment of empyema, 129 Breath-sounds, definition and signi- ficance of, 39-41; international nomenclature, 44, 45; mechanism of production and disease-association of, 48-56; varieties of : abnormal, 51; amphoric, 41, 45, 55; blowing, 40; bronchial, 40, 53, 54; broncho- vesicular, 40, 53; cavernous, 41, 45, 55; cog-wheeled, 40, 45, 52; com- pensatory, 40, 44, 52; diminished, 44; exaggerated, 40, 44, 51; harsh, coarse, subtubular, 40, 53; inter- rupted inspiration, 40, 45; indeter- minate, 53; jerking, 40, 45, 52; normal vesicular murmur, 40, 49; partial suppression of, 40; prolonged expiration, 40, 44, 52; puerile, 40, 44, 51; suppressed, 40, 44, 51; tracheal, 40; transitional, 53; tubu- lar, 40, 45, 54; vesicular, 40, 49; vesico-tubular, 45, 53; wavy, 40, 45, 52; wavy cavernous, 52; weak, 40, 44, 51 Brehmer, introduction of sanatorium treatment for phthisis, 607 Brickdale, Fortescue, on haemothorax, 161 Bridge of Allan for bronchitis, 193; spring health resort, 668 Brighton for phthisis in autumn, 654 Bright's disease and bronchitis, 177; and pleurisy, 90; and pneumonia, 287, 309 Bristowe, J. S., on theory of percussion, 46 Broadstairs for delicate children, 594; for phthisis in autumn, 654 Brodie, Sir Benjamin, removal of foreign body by inversion and tracheotomy, 239 INDEX 765 Brodie, T. G., and Dixon, W. E., bronchial spasm as cause of asthma, 244; effect of adrenalin in haemopty- sis, 705; experiments with drugs in asthma, 243 Brompton Hospital for Consumption: cases of streptotrichosis at, 407; compressed-air baths at, 257, 282; first medical report, family history of phthisis, 445 ; frequency of occur- rence , of lardaceous disease in phthisis, based on autopsies at, 567, 568; health of staff and risk of acquiring phthisis at, 435; methods of dealing with sputum at, 600, 601; mortality statistics at, 625 ; observa- tions on the opsonic index of phthisical patients at, 585-587; per- centage of cases of tuberculous pneumothorax at, 137; relative frequency of more important com- plications of phthisis at, 532; statis- tics of age-incidence and of causes of bronchiectasis from, 206, 208 Brompton Hospital Sanatorium, Frimley: graduated labour at, 609; non-infectivity of telephone mouth- piece used by patients at, 435 Bronchi, anatomy of, 2, 3; dilatation of, 206 (see Bronchiectasis); general arrangement of , 2 ; narrowing of, 202 ; — , causes of, localised or general, 202; — , cicatricial ulcerative con- traction and, 202; — , invasion of bronchus by malignant growth, 202 ; — , pressure by malignant growths, or aneurism, 202, 203, 205; — , symptoms and signs of, 202 ; — , syphilitic ulceration and, 202, 205; — , treatment, 205 Bronchial breathing, 40, 53, 54 {see Breath-sounds, bronchial); casts, 69; — in asthma, 265 ; — in diphtheria, 69; — in pneumonia, 69; — in plastic bronchitis, 196; catarrh and influenza, 331; — and pneumonia, 295 [see Bronchitis); contraction and massive collapse of lung, 349 ; glands, tuberculosis of, 471, 472; spasm and asthmatic attack, 244 Bronchiectasis, 206; (etiology, 208; resulting from atelectasis pulmonum (congenital collapse of lung), 210; — bronchial stenosis, 208, 209; — chronic bronchitis, 209 ; — fibrosis of lung, whether of pulmonary or pleural origin, 210; — foreign body in bronchus, 209, 216 {see also Chapter XIV., with illustrative case, 229); age-incidence in, 206; anatomy, morbid, of, 206; — , area of lung affected in, 207; -— , destructive ex- cavation of lung in, 207, 211, 215; — , gangrene of lung in, 211; — , varieties of: "cylindrical" and "saccular," 206, 207; cerebral ab- scess in, 2x3; clubbing of fingers and toes in, 213; death in, from cerebral abscess, 213; — , from septic broncho-pneumonia, 213; diagnosis, 216; — , from basal phthisis, 216; — , itom localised empyema, 216; Dittrich's plugs in, 212; duration of disease, 215; general health long remaining good in , 2 1 2 , 2 1 3 ; physical signs in, 214, 215; pulmonary osteo- arthropathy in, 213; sputum in, characteristic manner of expectora- tion of, 212; — , large in amount, 212; — , offensive in character, 212; — , resolving on standing into three layers, 212; symptoms, 211-214; " veiled puff " of Skoda, 215; treat- ment, 217; — , antiseptic inhalations in, 218; — , creosote vapour baths in, 2x7; — , internal administration of drugs, 218; — , intratracheal injections, 219; — , postural evacua- tion of cavity-contents, 218; — , removal of foreign body from bronchus, 217; — , surgical: draining of cavities, 219; thoracoplasty, 220; Wilms' operation of " rib mobilisa- tion," 220 Bronchiolectasis (acute bronchiec- tasis), 211; following acute bron- chitis in young children, 211; the honeycomb lung, 211 Bronchitis (bronchial catarrh), 176; aetiology, 176; — , after surgical operations, 179; anatomy, morbid, of, 180; bacteriology of, 179; classi- fication and clinical varieties of, i8r; — , acute asthenic bronchitis, 184; with illustrative case, 185; — , acute tracheo-bronchitis, 181; signs and symptoms, 182; — , capillary bron- chitis (suffocative catarrh), 182; diagnosis, signs, and symptoms, 183, 184; — , catarrhe sec (bronchitis sicca), 195 : sputa margaritacea, pearly sputum, 196; • — , chronic (chronic muco-purulent catarrh), 190; signs and symptoms, 191, 192; — , pituitous catarrh (bronchorrhoea serosa), 194; sputum resembling " serous expectoration," but not albuminous, 194; illustrative case, 195; — , plastic bronchitis, 196; aetiology, 197; appearance and nature of casts, 196; physical signs and symptoms, 198; treatment, 200; — , 766 DISEASES OF THE LUNGS AND PLEURA purulent bronchitis, i86, 191; bac- teriology of, 187; chronic form, 191; epidermic form among troops, 186; — , putrid and foetid bronchitis, 192 ; prognosis in acute, 187; treatment of acute, 188-190; of chronic, 192; climatic, 193; medicinal, 192; of plastic, 200 Broncho-blenorrhoea, 187, 191 Broncho-mycosis, 180 Bronchophony, definition and signifi- cance, 43; international nomen- clature, 45; method of production, 61 Broncho-pneumonia (lobular pneu- monia): cztiology, 323-324; — , acrid vapours, 324 ; — -, after surgical opera- tions, 324; — , aspiration of food, 324; — , bronchitis, 323; — ■, hsemop- tysis, 551; — , infectious diseases, 323; — , influenza, 331; — , phthisis, 323; — , poison gases, 324; — , ana- ! tomy, morbid, of, 325; — , forma- j tion of abscesses in lung in cases of i septic origin, 326, 359; bacteriology, | 324; — . homologous, heterologous, and mixed infection in, 325; micro- scopical appearances, 326; varieties j of: primary, 323, 327; resembling lobar pneumonia, 327 ; — , secondary, 323 J 327; confluent and disseminated forms, with respective signs and symptoms, 327-329; pseudo-lobar type, 328; tendency to delayed resolution of lung, and formation of pulmonary fibrosis, 329; — , treatment, 329; see also Influenzal pneumonia, 331-334 Bronchorrhoea serosa {see Catarrh, pituitous,) 194 Bronchoscopy in bronchiectasis, 217; diagnosing foreign bodies in air- passages, 209, 236; for removal of foreign bodies in bronchi, 209, 238 Broncho-spirochsetosis, 180 Brown, A. Samler, Guide to South Africa, 644 Brown, Langdon, effect of adrenalin on blood-supply of lungs, 705 Brown, Lawrason, after-history results of patients at Adirondack Cottage Sanitarium, 627 Browne, Sir J. Crichton-, selective growth characteristics of vegetable organisms, 447 Brownlee, Dr., the fall in the death- rate from tuberculosis at varying ages and in different localities, 436, 453; exposure to wind and phthisis, 450; types or varieties of phthisis: the middle. age type, 453, 458; the old-age type, 453; the young adult type, 450, 453, 458; on the epi- demiology of phthisis in Great Britain and Ireland, 457, 458; relation of various occupations to phthisis, 455 ; report on phthisis death-rates, 436, 437, 455 Bruit d'airain {see Bell-sound), 143; de drdpeau in plastic bronchitis, 199; de grelottement ou de soupape {see Foreign bodies), 227, 234; de pot file, 39; — in tuberculous excavation of the lung, 523 Briining, use of bronchoscopy for removal of foreign bodies from air- passages, 237; X-ray photograph showing normal distribution and arrangement of the bronchi, Plate facing p. 2 Buchanan, Sir George, dampness of the soil and phthisis, 450 Bucks and Berks Sanatorium, results of artificial pneumothorax at, 727 Buhl on specific nature of tubercle, 421 Bull, Professor, cases of thoracoplasty in phthisis, 728 Bullar, J. F., experiments on produc- tion of the vesicular murmur, 50 Bulloch, Professor W., on acid-fast properties of the Bacillus tuber- culosis, 423; on the opsonic index, 584 Bulstrode, H. T., age of maximum mortality in phthisis, 453; report on sanatorium treatment, 619 Buluwayo, Rhodesia, climate of, 650 Burrell, L. S. T., apparatus for arti- ficial pneumothorax, 720 Butter bacillus, 424; conveyance of tuberculosis by means of, 431 Cacodylate of soda (sodium dimethyl- arseniate) injections in febrile cases of phthisis, 677, 678 Caffeine for asthma, 263 ; in pneumonia, 315 Cairo to be avoided for phthisical patients, 665 Calcium chloride and calcium lactate in haemoptysis, 704 Calcutta in winter for phthisis, 657 California, climate of, 667 Callipers for comparative chest measurements, 24, 34 Calmette, Professor, alimentary in- fection in tuberculosis, 431; cobra venom best for tuberculosis, 588 ; con- junctival tuberculin test, 579, 583; on the production of anthracosis, 339 Calomel in asthma, 258; in pneumonia, 311. INDEX 1^1 Cambridgeshire Tuberculosis Colony, Papworth Hall, 622 Campbell, Colin, treatment of bronchi- ectasis by intralaryngeal injections, 219 Canada, immigration laws as to ad- mission of tuberculous patients into, 636, 656 Canary Islands: climate of, 667, 669; for asthma, 256; for chronic bron- chitis and emphysema, 283; for phthisis, 667, 669 Cancer and haemoptysis, 546 Cannes, Riviera, winter climate of, 643, 659, 661; for anaemia, asthma, senile bronchitis, emphysema, phthisis, 193, 662 Canti, R. G., tuberculosis of bronchial glands secondary to lung focus, 471 Cape of Good Hope, Province of, South Africa, for phthisis, climate of, 644 Cape Town unsuitable for chest invalids, 644 Cap Martin, Riviera, for wealthy patients, 663 Carcinoma of lung, primary and secondary, 750, 751 ; of mediastinum, 737, 738 " Carcinomatosis " of lung, 751 Carling, Dr. Esther, results of artificial pneumothorax at Bucks and Berks Sanatorium, 727 Carson, James, on residual tension of the lungs, 7 Castellani, A., on organisms found in bronchitis in tropical climates, 180 Casts, bronchial, 69; in asthma, 265; in diphtheria, 69; in plastic bron- chitis, 196 ; in pneumonia, 69 Cat, tuberculosis in the, 425 Catarrh, "autumnal" in America, 249; bronchial (see Bronchitis), 176; dry, 195; of nasal or intestinal tract and dentition, 176; pituitous, 194 Catarrhal or bronchitic asthma, 248 Catarrhe sec, 195, 196 Cauteret for asthma, 257 Caux for phthisis, 637 Cavernous breathing, 55 (see Breath- sounds); rale, 42, 58 (see Rales) Cavities in phthisis: causing total ex- cavation of lung, and suggesting pneumothorax, 149; cicatrisation of, 529; physical signs of, 523; the quiescent, 528-530; recent, 522-528; secreting, 530; ulcerous cavity, 530; treatment of, 588-6gi; — , surgical, 729 Cayley, W., case of gangrene of the lung treated by drainage, recovery, 362; case of haemoptysis treated by the induction of pneumothorax so as to collapse the lung, 549, 719 Cells in sputum, 70, 71 Celsus' description of phthisis, 420 Cerebral abscess and empyema, 125; (or cerebellar) abscess in bronchi- ectasis, 213 Ceres, South Africa, climate of, 645 Channels of infection in pulmonary tuberculosis, 427-433; congenital, 427; ingestion and inhalation, 428- 431 ; inoculation, 427; milk infection, 431-433 Chaplin, Arnold, creosote vapour bath in bronchiectasis, 217 Chapman, J. E., Bardswell, N., and Goodbody, F. W., metabolism in phthisis, 613 Chapman and Bardswell, N., diet for phthisical patients, 614 Charcot-Leyden crystals, 75; in asthma, 252; in bronchiectasis, 212 Charles, Dr. (Cannes), formula for koumiss, 603 Chateau d'CEx for phthisis, 637 Chausse, Dr., inhalation infection in phthisis, 429, 430 Chest, alar, 79; cup-like hollow de- formity of, 79; deformity from deficiency of clavicular portion of the pectoral muscle, 79; diagram model of, 12; effect on heart and circulation of conditions in, 15; expansion of, on puncturing pleura after death, 11; inspection of, and what it leads to, 33, 34; measure- ments of, 23; movements of, 33; palpation of, 33 (see Palpation); percussion of, 33, 35; — , method, 35 (see Percussion); physical conditions, of, 12; pigeon-breasted, 78; physical signs and position of organs in healthy, 38; position of patient during examination of, 37; reserve capacity of, 17; rickety, 78; shape of, 23, 78; stomach note in healthy, 38; topography of, 28, 29. See also under " Thoracic " Chest walls, diseases of, 79; — , aponeurotic rheumatism, 80; — , intercostal neuralgia, 80; — , myal- gia, 80; — , periostitis and peri- chondritis of sternum and ribs, 82- 84,734 " Chester " powder for asthma, 259 Chexbres, Switzerland, autumn health resort, 654 Child, state of lungs in new-born, 6 Children, bovine tuberculosis in, 432, 433; broncho-pneumonia in, 327; pneumococcic pleurisy in, 118; post- 768 DISEASES OF THE LUNGS AND PLEURA diphtheritic paralysis and massive collapse of the lung in, 345 ; suitable schools and places for delicate, 594 Chilterns, the, suitable for permanent residence for phthisical patients who have regained health, 669 Chloral in asthma, 261; in bronchial narrowing, 205; in bronchitis, 189; in mediastinal tumours, 750 Chloralamide in pneumonia, 316 Chloride of ammonium in chronic bronchitis, 192 Chlorine poison gas and acute pul- monary oedema, 357 Chloroform, inhalation of, in asthma, 244, 260; in narrowing of bronchi, 205; in surgical operations in cases of chest disease, 128; in relief of severe symptoms in tuberculous laryngitis, 701 ; in tuberculous menin- gitis, 710; to relieve cough in phthisis, 681 Cholesterin crystals in sputum, 75 ; in chronic pleural effusion, 114 Chorley Wood suitable for permanent residence for phthisical patients who have regained health, 669 Chronic and fibroid stage of pulmonary tuberculosis, 502-520 [see Tuber- culosis); — bronchitis, igo {see Bronchitis) Chylothorax, 166; aetiology, 169; age and sex incidence in, 169; causes producing, 169; prognosis, 170; treatment, 171; varieties: the true and pseudo-chylous forms, 166; means of distinguishing between, 167; illustrative case of the pseudo- chylous variety, 171 Cimiez, Riviera, suitable for asthmatic patients, 256, 662 Cirrhosis of the lung, 335 ; see Pneu- monia, interstitial Clacton-on-Sea suitable for phthisical patients in autumn, 653 Clark, Sir Andrew, definition of fibroid phthisis, 511; insistence on im- portance of examination of sputum for elastic fibres, 73 ; on aetiology of asthma, 247 Clicking sounds, 42, 45 Cliftonville, Margate, suitable for phthisis in autumn, 653, 654 Climatic change in the treatment of piilmonary tuberculosis, 636-670 ; Algiers, 664; Alpine stations, 637; Andes, the South American, 642; Argentine, La Cmnbre district of, 650; California, 667; Canary Islands, 667; Egypt, 664; European stations of medium elevation, 651; Great Britain {see Great Britain, health resorts); immigration laws restrict- ing travel, 636, 656; India, hill- stations of, 650; Madeira, 665; Riviera, the, 659-663; Rocky Moun- tains, 641; South Africa, 642; — , Province of Cape of Good Hope, 644; — , of Natal, 645; — , of Orange Free State, 647; — , of Transvaal, 649; voyages, sea, in, 654-658; see also Health Resorts \ Clothing of consumptive patient, 599 Clubbing of fingers in bronchiectasis, 214 Coal-dust causing anthracosis, 338 Cobbett, Louis, calculations as to the amount of bovine tuberculosis occurring in children and adults, 432, 433; congenital infection in tuberculosis, 427; criticism of Pro- fessor Calmette's experiments de- signed to show that pulmonary tuberculosis is the result of alimen- tary infection, 431 Cobra-venom test in phthisis, 588 Cod-liver oil and its administration in phthisis, 674; — with creosote, 675, 687; — with other vehicles, 675; its effect upon metabolism and upon the tubercle bacillus, 674; in asper- gillosis, 417; in broncho-pneumonia, 331; in chronic bronchitis, 193 Cod-liver oil emulsion, Brompton Hospital formula, 675 Coffee in treatment of asthma, 260, 263 Coghill's respirator, 218, 681 Cog- wheeled respiration, 52 Cold pack or cool bath in pneumonia, 312 Colds, neglected, and phthisis, 596; treatment of, 596 Colitis as a complication of pneu- monia, 307, 309 Collapse of lung, 344, 345 ; massive or lobar in character, 345 ; — , aetiology, 347; — , clinical features of, 346, 347; — , contralateral and homo- lateral, 346; — , diagnosis, 350; — , mechanism of production, 348; — , operations and, 346; — , physical signs, 346; — , prognosis, 350; — , treatment, 350; — , varieties: Group I., 345; Group II., 346 Collective Investigation Committee, British Medical Association, evidence as to personal contagion in pneu- monia, 288 Collingwood, B. J., and Willcox, W. H., therapeutic use of alcohol vapour mixed with oxygen, 315 INDEX 769 Colonies, immigration laws restricting admission of tuberculous patients into, 636, 656 Colony treatment of phthisis, 622 Colorado Springs, Rocky Mountains, for summer and winter treatment of phthisis, 641, 642 Colwyn Bay suitable for bronchitis, 193 Complement-fixation test in hydatid disease of the lungs, 370; in pul- monary tuberculosis, 587 ; in syphilis, 388, 392 Compressed-air bath; see Bath, com- pressed-air Conjugal or marital tuberculosis, 437 " Consumption " an appropriate term, 420 Consumption hospitals and question of personal infection, 435 Convulsions in children in pneumonia, 296; in tuberculous meningitis, 565 Copaiba in bronchiectasis, 218 Cornet, Professor, tubercle bacilli in sputum, 429 Cornish miners and excessive mor- tality from phthisis, 456 Corvisart, employment of percussion, 35 Costal abscess, 83; angle, 33 Costebelle, Riviera, suitable for phthisis, 661 Cotton, aneurism of pulmonary artery, 548 Cough : after inhalation of foreign bodies, 233, 234; and hsematemesis, 551; and mediastinal tumours, 739, 740; clanging, brassy, or husky character in empyema, 123; in bronchial narrowing, 204; in hy- datid disease of the lungs before rupture, 368; in laryngeal tuber- culosis, repression of, 698; in phthisis, irritable and ineffectual, 682; — , morning, special treatment of, 682; — , night, special treatment of, 682; — , relief of, in acute first stage, 672; — , repression of, in quiescent cavity period, 689; — , treatment of, local and general, 680 ; — , with vomiting, 516; treatment of, 708 "g» Counter-irritation in laryngeal tuber- culosis, 699; in pneumonia, 313, 317; in pleurisy, 8g, 108, 708; in secret- ing and ulcerous cavities, 690, 691 Coupland, Sidney, sketch of elastic tissue and fragment of small vessel from expectoration of patient with rapidly forming cavities, 476; evi- dence of personal contagion in pneumonia, 289 Courmont, Professor, agglutination test, 589 Cows, tuberculosis in, 425; see Bovine tuberculosis and Perlsucht " Crachats perles," 196 "Cracked-pot sound" (bruit de pot fele), 39 Crackling rales, 42 "Cradling" to reduce pyrexia, 311, 312 Cragmor Sanatorium, Colorado Springs, 641 Craighead, J. W., and Marshall, M. I., on perforation or rupture of lung complicating artificial pneumo- thorax, 724 Cremator at Brompton Hospital for disposal of sputum, 600 Creosote group of drugs, use of, in bronchiectasis, 218, 219 Creosote in chronic bronchitis, 193; in gangrene of the lungs, 365; in laryngeal tuberculosis, 698; in pul- monary tuberculosis, 687, 688, 732; vapour bath in bronchiectasis, 217, 218 Crepitation (crepitant rale), definition and significance, 42; international nomenclature, 45; fine hair, 42, 59, 296, 297; redux, in pneumonia, 300 Crossley Sanatorium, statistics dealing with the hereditary factor in pul- monary tuberculosis at, 445, 446 Croydon suitable for permanent resi- dence for quiescent cases of phthisis, 669 Cryogenin in pyrexial cases of phthisis, 679 Crystals in sputum, 75 Cuneo, B.; and Poirier, P.; see Poirier, P., and Cuneo, B. Cupping, dry, in bronchitis, 189 Curie, David, intensive iodine treat- ment of phthisis, 678 Curschmann, " bronchiolitis exuda- tiva," 242; spirals in asthma, 252; — in sputum, 74 Cutlers and phthisis, 455 Cyrtometer, the, 24, 34, 102 Dally, Halls, mechanism of respira- tion, 345 Damoiseau's curve, 98 Dampness of soil, influence of, on phthisis mortality, 450 Daneswood Sanatorium, exercise and work at, 611 Darjeeling, India, climate of, 650; for phthisis, 657 Darling Downs, Queensland, for phthisis, 657 49 770 DISEASES OF THE LUNGS AND PLEURA Dartmoor for asthma, 256 Datura tatula cigarettes for asthma, 260 Davidson, Sir Mackenzie, stereoscopic method of X-ray examination, 64 Davies, H. Morriston, case of rib- mobilisation in bronchiectasis, 221; on oxygen replacement following aspiration in chronic sero-fibrinous effusion, 114 Davos, Switzerland, cases of phthisis suitable for treatment at, 639; features and special climatic pro- perties of, 637-639, 642, 643; for asthma, 256 Davy, John, gas analyses in pyo- pneumothorax, 139 Dax for catarrhal asthma, 256 Debove's method of feeding phthisical patients, 601 Decortication of lung, operation for, in old-standing empyemata, 129 Delbret, Professor, surgical treatment of pulmonary emphysema, 283 Delirium tremens in pneumonia, 310 Delorme's operation for decortication of the lung, 129 Denison, C, law of increasing dia- thermancy of air with rising alti- tude, 638 Dentition, bronchitis in infants at time of first, 176 Denver, Colorado, for phthisical patients, 641 ; winter climate of, 642, 643 Denys' tuberculin, 714 Dermoid tumours, intrathoracic, 379; age and sex incidence, 380; fatal termination if untreated, 381; illus- trative case, 382; relation to tera- tomata, 380, 383, 384; sites of, 379; symptoms, including expectoration of hairs, 380; treatment, 381; — , surgical, 381 Derry, D. E., and Smith, EUiott, evidence of tuberculosis in early Egyptian skeletons, 419 Dettweiler, introduction of sanatorium treatment for phthisis, 607 Devonshire moorland districts suit- able for phthisical patients in autumn, 653 Dewar, Sir James, destructive power of ultra-violet rays upon bacteria, 639 Diabetes: and abscess of the lung, 359; and caseo-pneumonic tuberculosis, 486; and relation to pulmonary tuberculosis (discussion at the Pathological Society), 486; and sloughing pneumonia, 487 Diamethyl-amido-benzaldehyde reac- tion in phthisis, 570 Diaphragm: depression of, in pyo- pneumothorax, 143, 144; effect of pleural effusion upon, 99, 103; hernia of, leading to symptoms suggestive of pneumothorax, 149; lymphatics of, communication be- tween pleural and peritoneal sur- faces of, 19; movements of, in phthisis, 575; not elastic per se, 14; yielding capacity to traction of lungs, 14; pleurisy of, 88 Diaphragmatic pleurisy, 88 Diarrhoea in intestinal tuberculosis, 542 ; in lardaceous degeneration com- plicating phthisis, 569; in suppura- tive pleurisy, 120; tuberculous, treatment of, 694-697 Diathermancy of air in high altitudes, 638 Diathesis, the tubercular, 445-448 Dichlor-ethyl-sulphide (mustard gas), producing broncho-pneumonia, 324 Dickinson, W. H., on the organs chiefly affected in lardaceous disease, 568 Diet; in asthma, 257; in pneumonia, 313; — , restraint in, 313; in pul- monary hsDmoptysis, 703; in pul- monary tuberculosis, 601, 604; — , calorie value of, 614; — , early stages, 613-616; — , period of softening and formation of cavities, 685; — , standard diet at the King Edward VII. Sanatorium, 615; — , in tuberculous ulceration of the bowel, 694-696 Dieulafo}', paracentesis thoracis, 109 Digitalis in asthma, 263; in bronchitis, 189; in emphysema, 280; in oedema of the lungs, 354; in pneumonia, 314, 315, 316 Diphtheria, bronchial casts in, 69; followed by broncho-pneumonia, 323. 325 Diplococcus lanceolatus and Diplo- coccus pneumonice ; see Pneumo- coccus Discomyces, genus to which the streptothrix belongs, 394 Dittrich's plugs in sputum of bronchi- ectasis, 212 Diuretics in recurrent pulmonary oedema, 356 Dixon, W. E., and Brodie, T. G.; see Bodrie, T. G., and Dixon, W. E. Dodwell, P. R., and Fen wick, W. S., perforation of the intestine from tuberculous ulceration of the bowel in phthisis, 541 INDEX 771 Dog, muscular tissue in lung of, 8; tuberculosis in, 425 Donders, residual tension of the lungs, 7,8 Douglas, C. G., and Haldane, J. S., on mechanism of absorption of oxygen by the lungs, 5 Dreschfeld, Professor, migratory, creep- ing, or wandering pneumonia, 304 Drowsiness in tuberculous meningitis, _ 566 Dry crackle of Laennec, 59 Dry-cupping in pulmonary oedema, 354, 356; in pneumothorax, 151 Dunbar, Professor, setiology of hay asthma, 248; poUantin, specific serum for hay asthma, 262; treat- ment of hay asthma, 262 Durban, Natal, climate of, 647 Durham, Arthur, mortality from foreign bodies in air-passages, 238 Dust: as exciting cause of asthma, 247; illustrative case from rose- wood dust, 264; as exciting cause of bronchitis, 178; and of pneumo- koniosis, 338; ■ — , infected, an im- portant factor in the spread of tuberculosis, 429, 430; occupations rendered harmful by, 178, 338, 340 Dyspepsia from swallowing expectora- tion, 602 Dysphagia in mediastinal tumours, 740; in tuberculous laryngitis, 699 Dyspnoea: hysterical, 150; in medi- astinal tumours, 740, 750; in pneu- monia, 296; in pneumothorax, some- times suggesting asthma, 150 Ear, tuberculous disease of the middle, 539 Eastbourne for autumn treatment of phthisis, 654 Eau de goudron (Guyot) for secret- ing cavities, 690; in chronic bron- chitis, 192 Eaux Bonnes for asthma, 257; summer health resort, 669 Eczema and asthma, 245 Edwards, Vertue, health of staff at Brompton Hospital, 436 Effusion, pleural: acute sero-fibrinous, 90; commonly tuberculous in nature, 90-92; chronic sero-fibrinous, 114; complicating mediastinal growths, 743; physical signs of, 97-105; see also Pleurisy Egypt: as health resort, climate of, 664-665; suitable for bronchitic asthma, 665; — for bronchitis and emphysema, 193, 283; — for certain cases of chronic phthisis, 665 Ehrlich' s diamethyl-amido-benzalde- hyde reaction, 570 Eichhorst on tuberculous pleurisy, 91 Eicken, Professor von, removal of foreign bodies by superior or in- ferior bronchoscopy, 238 Elastic fibres in abscess of the lung, 306, 360; in gangrene of the lung, 364; in phthisis, 476, 488, 526; in sputum, 72, 73 Elderton, Ethel M., Pearson, Karl, and Pope, E. G., on frequency of con- jugal tuberculosis, 438 Elderton, W. P., and Perry, S. J., conclusions as to the value of tuber- culin treatment at the Adirondack Sanitarium, 717; results of sana- torium treatment, 625, 626 Elliott, T. R., bronchial contraction and massive collapse of lung, 349; — , and Henry, H., on haemothorax, 157, 160 Ellis's letter S curve in pleural effusion, 98 Emetics in whooping-cough to avert broncho-pneumonia, 329, 330 Emphysema, general, pulmonary vesi- cular : large-lunged emphysema, 269 ; aBtiology, 273-275; associated with asthma, 242, 248, 253, 254; — , chronic bronchitis, 191 ; — , pneumo- koniosis, 340; — , phthisis, not suitable for elevated climates, 640; atrophic changes of lung in, 270, 271, 275; compensatory changes in, 272; failure of right heart in, 271, 272; loss of lung elasticity in, 274; pathology and morbid anatomy of, 269; sex-incidence in, 269; symp- tomatology, with illustrative case, 277, 279; texture of lungs impaired in, 270; treatment of, 279-283; — , climatic, 282; — , compressed-air baths in, 281; — , medicinal, 279; — , surgical, 283; varieties of: small- lunged or senile emphysema, 276; wind instruments and, 273 Emphysema: interstitial or inter- lobular, 284; — , associated with whooping-cough and phthisis, 284 Emphysema, local pulmonary vesi- cular, 275 Emphysema, surgical, 135, 284 Empyema, or suppurative pleurisy, 118; aetiology, 118; bacteriology, 119; blood-count in, 121; course, if untreated, 125; determination of the purulent nature of the effusion in, 121; diagnosis, 125; physical signs of, 120; pulsation of fluid in rare cases simulating aneurism, 121; 772 DISEASES OF THE LUNGS AND PLEURiE rupture through bronchus, 125; leading sometimes to pneumothorax, 135; S3'mptoms of, 119; treatment of, by resection and drainage, 127; — , during convalescence, 129; — , nature of anaesthetic to be used during operation, 128; — , of old- standing cases by lung decortication or thoracoplasty, 129, 130; — , when associated with influenza, 130; varie- ties of : double, 130; — , foetid, r23 — , localised or encysted, 124; — mediastinal and diaphragmatic, 124 r25; — , migratory or wandering 125; — , pulsating, 121, 122; - tuberculous, 123, r3r; in association with dermoid cyst of the chest 382; — , foreign body in bronchus 235; — , influenza, 130, 131; — phthisis, r3i; — , pneumonia, 307 — , streptotrichosis, 408 Ems for gouty bronchitis, 194; summer health resort, 669; water spray in laryngeal tuberculosis, 699 j Enchondroma of mediastinum, 737 I Endocarditis, malignant, in pneu- 1 monia, 306-308 Enema, nutrient, in laryngeal tuber- culosis, 701 ; starch and opium, for ; diarrhoea, 697 England, hay asthma in, 248; health resorts in [see under Great Britain) Eosinophilia in asthma, 252; in hj'datid disease of the lungs, 369, 370 Epistaxis and false haemoptysis, 557; in influenzal pneunionia, 332 Ergot in haemoptysis, 705 ; 706 Estcourt, South Africa, climate of, 647 Estes Park, Colorado, summer resort for phthisis, 642 Estlander's operation: in pyo-pneumo- thorax, 152; in suppurative pleurisy, 130; in bronchiectasis, 220 Ether in confection of turpentine in pneumonia, 315; inhalation of, leads to relaxation of bronchial spasm and removal of sibilant sounds ! in asthma, 56; paralysis of nerve- endings in bronchi from inhalation of, 244; unsuitable as an anassthetic in chest disease, 128, 324 Ethyl, iodide of, in asthma, 260 Eucalyptus in secreting cavities, 690 " Eupnine " in asthma, 260 Ewald, analysis of air-contents in pneumothorax, 139 Ewart, W., researches into structure of bronchial tree, 2, 197 Exercise and work in sanatorium treatment, grades of, at Frimley Sanatorium, 609, 610 Expectoration: albuminous or serous > in acute pulmonary oedema, 353, 354; — , following paracentesis of chest, ri4; see also Sputum Exploring syringe, use of, in suppurat- ing pleurisy, 121; — , in abscess of the lung, 36r Eyre, J. W. H., bacteriology of acute broncho-pneumonia, 325 Fagge, Hilton, on percussion note, 46 Falkenstein, Taurus Range, sanatorium for phthisis at, 65 r; calorie value of diet at, 613 Falmouth for chronic bronchitis and emphysema, 193, 283; for winter treatment of phthisis, 654, 658 Fanning, Burton, after-results of treatment at KeUing Sanatorium., 621 Farnborough for asthma, 256 Faroe Islands, prevalence of tuber- culosis in, though Perlsucht only recently introduced, 433 Fats in treatment of phthisis, 676 Fearn, S. W., describes first case of aneurism of pulmonar}' artery, 548 Fenwick, Samuel, method of detecting elastic fibres in sputum, 72 Fenwick, W. Saltan, and Dodwell, P. R., perforation of the intestine from tuberculous ulceration of bowel in phthisis, 541 Fibrinous bronchitis, 197 Fibroid phthisis, 5ir; see Phthisis, fibroid Fibroma of mediastinum, 737; of lung, 750 Fibrosis of lung, 467; see also Pneu- monia, interstitial Filter-passing virus in influenza, 331, 332 Findel, researches on respiratory and alimentary infection in tuberculosis, 431 Fine-hair crepitation, 56; in pneu- monia, 297, 300 Fingers, clubbing of, in bronchiectasis, 2r4 Fistula in ano in pulmonary tuber- culosis, 570; rarely occurring in females in this disease, 571; treat- ment of, 571 Flack, effect of oxj^gen during and after aerial flights and prolonged athletic efforts, 315 Fleuren's nceud vital, or ganglion of life, 6 Flint, Austin, on cavernous breath- sounds, 55; on duration of life in INDEX 773 consumptive patients in pre-sana- torium days, based upon the records of his private patients, 626 Florence, Italy, unsuitable for phthisis, 669 Fliigge, Professor, theory of infection in phthisis by "droplets" of in- fected sputum, 429 Focal reaction to tuberculin test, 582 Foetid bronchitis, 192; see also Bron- chitis Foetor of breath and sputum in bronchiectasis, 212; in foetid bron- chitis, 192; in gangrene of the lung, 364; treatment of, 192, 193 Foetus, state of lungs in, 6; rarity of tuberculosis in, 427 Folkestone suitable for phthisis in autumn, 654; for school for delicate children, 594 Food, tuberculosis conveyed by, 430- 433; entering air-passages causing deglutition pneumonia, 324; see also Diet Forbes, J. Graham, method of detect- ing tubercle bacillus in cerebro- spinal fluid, 56/ Foreign bodies in air-passages, 223- 241; age-incidence in patients, 225; causing abscess of lung, 359; — bronchiectasis, 228; cough following inhalation, 229, 232, 233; diag- nosis, 235 ; — , by bronchoscopy, 236; — ■, by X-rays, 235 ; historical ac- couirt, 223; pathology, 227; physical signs of, 234; — , " bruit de grelotte- ment," 234; position of, 227; — , rarely in larynx, 227; — , occasion- ally in trachea, 227; — , gener- ally in bronchus, 227; prognosis, 236; rough and angular cause more irritation than round and smooth, 232; scrutiny of history of attack suggesting inhalation important, 233; sex-incidence in patients, 225; statistics, 226; symptoms, case illustrating, 229, 232; — , lull in, following initial dyspnoea, 229, 232, 233; treatment by removal by bronchoscopy (superior or in- ferior), 237, 238; — , by inversion of patient with tracheotomy, 239; — , by tracheotomy and forceps, if other means not available, 239; — , by pneumotomy, 239; — , general principles, 237 Forlanini, Professor, artificial pneumo- thorax, 719 Formalin, effect of, on Bacillus tuber- culosis, 425 Forsyth, C. E. P., and Williams, O. T., experiments with cod-liver oil eluci- dating its action in phthisis, 674 Foulerton, Alexander, cases of primary streptothrix disease (actinomycosis), 407; researches on streptotrichosis, 394 Foundling Hospital, boys trained for regimental band in, showing absence of emphysema, 273 Fowl, tuberculosis in common, 426 Fowler, Sir J. Kingston, case of pneumothorax resulting from a ruptured emphysematous bulla, 135 ; on frequency of occurrence of lardaceous disease in chronic pul- monary tuberculosis, 567; on extent of lung affected in bronchiectasis, 208; on localisation of lesions in phthisis, 470; on pulmonary syphUis, 386 Fox, WUson, atlas of pathologica anatomy of the lungs, 497 ; malignant tumours of the mediastinum, 737 Frankel, study of pneumococcus, 289 Frankland on rarefied air, 283 Freeman, John, and Watson, J Chandler, anaphylactic origin of asthmatic at ack, 245 Fremitus: friction, 35, 39, 441 rhoncal, 35, 39, 44, 57; — , and stridor, 57; vocal (vocal vibration), 35, 39, 44 French, Herbert, Abrahams, A., and Hallows, Norman; see under Abra- hams, A., Hallows, Norman, and French, Herbert Freund, W. A., calcareous degenera- tion of cartilages and ribs as a cause of emphysema, 274; operation for pulmonary emphysema, 283 Friction, pleural, 43, 45; — , ^Y and moist varieties of, 60; — , Hippo- cratic description of, 60; pleuro- pericardial, 5o, 96 Friedlander's bacillus in broncho- pneumonia, 325 ; in pneumonia, 290 Friedrich, observations showing the streptothrix nature of the Bacillus tuberculosis, 422 Frimley Sanatorium, diet at, 616; graduated labour at, 609, 610; non- infection from telephone mouthp ece used by patients at, 435 Funchal, Madeira, climate of, 665, 666; climatological data from, 643; see also Madeira Furniture of sick-room, 607 Gaide, displacement of heart in pneumothorax, 146 Gairdner, Sir William, inspiratory theory of emphysema, 274 774 DISEASES OF THE LUNGS AND PLEURA Galen, description of phthisis by, 420; plastic bronchitis observed by, 196 Galvano-cautery in laryngeal tuber- culosis, 699 Gamaleia, acute lobar pneumonia ex- perimentally produced in sufficiently resistant animals, 289 Gangrene of the lung, 362; aetiology, 363; bacteriology of, 364; circum- scribed and diffuse, 362, 363; com- plicating acute pneumonia, 306, 363; leading to pneumothorax, 148 ; physical signs, 364; symptoms, 364; treatment: medicinal, 365; surgical, with recent results of, 365 Garland, G. M., on stomach note in pleural effusion, 103 Garlic in bronchiectasis, 218; in whooping-cough, 330 Garre, C, and Quincke, H., mortality after surgical treatment of gangrene of the lung, 365 ; results of surgical treatment of abscess of the lung, 360 ; results of surgical treatment of hydatid disease of the lung, 377 Gas embolism, danger of, in treatment by artificial pneumothorax, 723 Gask, Professor, on surgical treatment of hsemothorax, 162, 163 Gee, S. J., case of pituitous catarrh, 195; inspiratory theory of emphy- sema, 274; modification of cyrto- meter, 24; on meaning of term " blenna," 191; on physical signs of receding pleural effusion, 105 Geissler on herpes in pneumonia, 310 Ghon, A., on primary lung focus in bronchial gland tuberculosis in children, 471 Gimbert and Bouchard, C, on the use of creosote and guaiacol in phthisis, ■687 Glands, bronchial, tuberculosis of, 471, 472 GlengarifE suitable for bronchitis, 193 Glion, Switzerland, for phthisis, 641, 651 Glottis, effect on voice of destruction of, 61 Goat's milk in phthisis, 603 Godlee, Sir Rickman J., details of surgical operation in abscess of lung, 362; emp3'ema, site of incision for, 128; on pulmonary streptotrichosis, 408 Gold Coast, tuberculosis rife in, though milk unobtainable, 433 " Gold-miner's phthisis," with illustra- tive case, 340-342, 455 Golder's Green suitable for permanent residence for phthisical patients who have regained health, 669 Goodbody, F. W., Bardswell, N., and Chapman, J. E., 613; see BardsweU Gorbersdorf, Silesia, sanatorium for phthisis, 651 Gordon, Mervyn H., on types of the meningococcus and the use of " monotypical serum " in treatment of cerebro-spinal fever, 3r8; — , on the dissemination of droplets in speaking and declaiming, 429 Gordon, William, influence of damp and wind on phthisis, 449, 450 Goring, C, on marital infection and " assortative mating," 439 Gould, Sir A. Pearce, and Cayley, W., case of pulmonary abscess treated surgicall5% recovery, 362 Gout and bronchitis, 177; liability to pneumonia, 287 Gouty asthma, 245, 249; subjects and haemoptysis, 549 Graaf Reinet, South Africa, climate of, 645 Grabowsee Sanatorium, Germany, diet at, 613 Gram's method of staining, 395, 396 Grand Canary suitable for asthma, 256; — for chronic bronchitis and emphysema, 283; see also Canary Islands Grange for bronchitis, 193 ; for phthisis, in spring and autumn, 654, 668 Grape cure, 602, 606, 651 Grasse, spring health resort, 669 Gray, John, results of sanatorium treatment at the Stanhope Sana- torium, Weirdale, Durham, 620 Great Britain: health resorts of, 193, 256, 257, 653, 654, 658, 668, 669; — , for asthma, 256, 257; — , for bronchitis and emphysema, 193, 283 ; — , for phthisis in autumn, 653, 654; spring, 668; summer, 669; in winter, 658; suitable localities for permanent residence near London for phthisical patients who have regained health, 669 Great Missenden suitable for perma- nent residence for phthisical patients who have regained their health, 669 Green, Alan, experimental production of lardaceous disease, 569 Greenhow, E. H., dust inhalation and phthisis, 455; failure of nutrition in emphysema, 274 Greenland, tuberculosis rife in, though milk unobtainable, 433 " Green Mountain " powder for asthma, 259 INDEX "775 Greytown, South Africa, climate of, 647 Griffith, Stanley, cultivation of tubercle bacillus, 424 Grindelia robusta in asthma, 259, 262 " Grindeline " in asthma, 262 Grinders and phthisis, 455, 456 Grisons Canton, table showing preva- lence of tuberculosis at varying altitudes in, 449 Grocco's paravertebral triangle of dulness, 104 Grysez and Vansteenberghe, P., ex- periments on channels of infection in pulmonary tuberculosis, 431 Guaiacol in laryngeal tuberculosis, 698 ; in quiescent phthisis, 687, 688 Guimbellot, M., results of thoracotomy in hydatid disease of the lung, 377 Guinea-pig, tuberculosis in, 425 Gull, Sir W., on destructive changes in the lung following pressure on bron- chus, 203 Gulland, G. L., and Goodall, A., leuco- cyte count in acute pulmonary tuber- culosis, 476 Gunshot wounds of the chest, 157-165 (see under Haemothorax); leading to massive collapse of lung, 346; - — suppurative mediastinitis, 734 Haematemesis, diagnosis of hsemop- tysis from, 551 Haemophilia, haemorrhage in, causing true and spurious haemoptysis, 547, 562 Haemopneumothorax, 158; simulated by septic haemothorax containing gas-forming organisms, 161 Hcemoptysis: false or spurious, 546, 557-562; — , anatomical line of divi- sion from true haemoptysis, 557; — , conditions under which it occurs, 557; — , diagnosis from true, 561; — , dietetic errors a cause of, 559; — , — , feigned or hysterical 558; ■ — , treatment, 559-562 Haemoptysis: true, 546; appearance of the blood expectorated, 550; causes of, 546; definition of, 546; diagnosis from haematemesis and spurious haemoptysis, 551 arising from active hyperaemia, 547; from aneurism of pulmonary artery, 547, 549; from erosion of vessels, 547 cases ending fatally, 548, 549; — , first symptom of pulmonary tuberculosis ("Phthisis ab haemop- toe"), 547 in acute pneumonic phthisis, 476; — , in fibroid phthisis, 519; — , in phthisis complicated by syphilis, 392; — , in quiescent phthisis leading to " recurrent haemoptysis," with illustrative case, 552, 555; special treatment of, 707 occurring in abscess of lung, 555; in asthma, 253; in bronchiectasis, 213; in bronchitis, 549; in foreign bodies in air-passages, 234; in gan- grene of the lung, 364 ; in hydatid disease, 374; in influenzal pneu- monia, 332; in intrathoracic der- moid, 380; in malignant disease of the lung, 752; in malignant disease of the mediastinum, 739; in pneu- monia, 310; in pulmonary syphilis, 388, 549; in wounds of the chest, 159; in pulmonary tuberculosis, 547, 556; prognosis, 552; — , treat- ment of, 702-708; absolute rest in, 702, 706; by artificial pneumothorax, 707-719; diet in, 703-706; drugs in, 703-706; summary of, 706; type of case unsuitable for treatment at high altitudes, 640 Haemothorax, 157-165; amount of blood effused in, 157; definition of, 157 Hemothorax following wounds of the chest, 159; — , bacteriology, 160; ■ — •, course: if sterile, 160; if septic, 160; ■ — , physical signs sometimes attended by presence of massive collapse, 159; — , symptoms, 159; - — , treatment : by aspiration, if sterile and large, 160; by thoraco- plasty, removal of foreign body, and cleansing of parts, if sepsis likely to ensue, 162; special indications for operation, 163; illustrative case, showing value of method, 164 Haemothorax occurring in civil life, 157; — , aetiology of, 157; — > symp- toms, 158; — , treatment, 158 Hair-combers of Paris, aspergillosis amongst, 414 Haldane, J. S., and Douglas, C. G., on absorption and secretion of oxygen by the lungs, 5 Halliburton, Professor W. D., on chemistry of pleural effusions, 92 Hallows, Norman, Abrahams, A., and French, H.; see under Abrahams, A ., Hallows, Norman, and French, Herbert Hamamelis, tincture of, in haemoptysis, 704 Hamilton, Professor, morbid anatomy of bronchitis, 180, 181 Hammond, J. A., RoUand, W., and 776 DISEASES OF THE LUNGS AND PLEURA Shore, T. A. G., on purulent bron- chitis, i86 Hampstead for phthisical patients who have regained health, 669 Hare, C. J., double tapes for chest measurement, 23 Harris, J. D., successful treatment of abscess of lung by drainage and incision, 360 Harrismith, South Africa, climate of, suitable for phthisis, 649 Hartley, P. H.-S.: bacterial classifica- tion of broncho-pneumonia, 325; climate of seaside resorts and that of inland regions compared (the climate of the Midland counties), 653) 670; differences in climate between Egyptian health resorts, 665, 670; relative frequency of more important complications of pul- monary tuberculosis based upon autopsies at Brompton Hospital, 532, 545; size of opening in pneu- mothorax, 138; table showing the frequency of occurrence of lardace- ous disease in chronic pulmonary tuberculosis, and the organs chiefly affected, 568, 572; case of artificial pneumothorax followed by rupture of the lung, 724 Hartz, the actinomyces or ray fungus, 394 Harz Mountains suitable for phthisis, 65r Hastings, chief climatic features of, 643, 659; suitable for bronchitis, 193; — , for phthisis, 654, 658 HavUand, wind exposure in relation to phthisis, 450 Hay asthma; see Hay fever Hay fever, causation and symptoms, 248; treatment and prevention, 261 Headache in tuberculous meningitis, 565 Health resorts for pulmonary tuber- culosis, 637-670 {see Climatic change in treatment of pulmonary tuber- culosis); in chronic bronchitis, 193, 194, 665; in emphysema, 283; suit- j able for asthma, 256, 257, 664, 665; | see also Great Britain, health resorts of Heart: disease of, a cause of acute pulmonary oedema, 577; — , predis- posing to bronchitis, 177; displace- ment of, in haemothorax, 158, 159; — , in hydatid disease before rupture, 369 ; — , in massive collapse of lung, 346, 348, 350; — , in mediastinal tumour, 742 ; — , in pleuritic effusion. 99; — , in pneumothroax, 143, 145, 146 Heart, effect of chest conditions on, 15 ; failure in pneumonia, 316 Hedges, C. E., on the tuberculous nature of acute pleurisy with effusion, 91 Heliotherapy, 641; in surgical tuber- culosis, 641 ; in tuberculous peri- tonitis and chronic ulceration of the bowel, 697; intralaryngeal, in tuber- culosis of the larynx, 698 "Heliotrope cyanosis" in influenzal pneumonia, 332 Helwan, feature of winter climate at, 643, 664, 665; winter resort for asthma, chronic bronchitis, em- physema, and quiescent phthisis, 193, 283, 664, 665 Hendon, healthy suburb for arrested cases of phthisis, 669 Henry, H., and Elliott, T. R., on haemothorax, 157, 160 Henshaw, Nathaniel, " Aero-Chalinos ; or, A Register for the Air," 281 Hensley, Philip, on mode of production of first respiration in new-born child, 6 Hernia, diaphragmatic, r49; see under Diaphragm Heroin in asthma, 261; in cough of phthisis, 689 Herpes in pneumonia, 297, 310; zoster and intercostal neuralgia, 80, 82 Hessian railway companies, results of sanatorium treatment, 621 Heymann, Bruno, ethnographical data showing phthisis to be produced by human, not bovine, infection, 433 ; experiments proving that inhaled tubercle bacilli enter the pulmonary alveoli, 428 Highgate, healthy suburb for cases of arrested phthisis, 669 Hilum tuberculosis, 471-473, 575 " Himrod " powder for asthma, 259 Hindhead suitable for asthma, 256 Hippocrates, description of pleural friction, 60; phthisis described by, 420; phthisis ab hcemopioe, 547; the succussion splash, r33 Hirt, dust-producing trades and bron- chitis, 178 Hobart, Tasmania, climate of, 656; for phthisis, 657 Hodgkin's disease, case of pseudo-" chylothorax associated with, 171 Hoffmann, F. A., subsidence of symp- toms after inhalation of foreign bodies, 234; — , and Musser, table INDEX 777 of statistics as to foreign bodies in air-passages, 226 Holden, G. W., case of pulmonary and glandular aspergillosis, 415 Honeycomb lung, the, 211 Home, Jobson, mode of invasion of larynx in laryngeal tuberculosis, 534; cause of loss of voice in early laryngeal tuberculosis, 536 Horse and asthmatic attacks, 246; tuberculosis in the, 425 Hort, E. C, opsonic index in phthisis, 587 Huancayo, Peruvian Andes, for phthisis, 642 Huggard, W. R., prevalence of tuber- culosis in the Canton Grisons, 449 Husbands, consumptive, effect on wives, 437 Hutchinson, John, calculation of costal movement in health, 11; mechanism of healthy breathing, 9; use of spirometer, 26; variation of vital capacity with age, height, and weight, 27; — , and Aron, residual tension of lungs, 8 Hydatid cyst: in mediastinum, 734> 737; in pleural cavity, 378; surgical treatment, 378 Hydatid disease of the lungs, 367-378; age and sex incidence in, geographi- cal distribution, method of infec- tion, and morbid anatomy, 367, 368; before rupture of cyst : clinical features of the disease, with illus- trative cases, 368-373; course of disease, 374-375; death of cyst, rarity of, 375 ; diagnosis by physical signs, X-ray examination, 369; — from phthisis and pleural effusion, 375; eosinophilia and complement- fixation test in, 370; haemoptysis in, 368, 369; treatment of, by incision and evacuation, not paracentesis, 376, 377; rupture of cyst and after, 373; excretion of cyst membrane ("gooseberry skin"), booklets, and scolices, 374, 375; simulating ad- vanced phthisis, 375; symptoms during and after rupture, 373, 375; treatment by opening and draining cavity, if medicinal means fail, 377 Hydatid thrill, 369 Hydro-pneumothorax : occurring in cases of tuberculous pneumothorax, 140; outlook of, 148; physical signs of, 143; — , movable dulness, 143; — , succussion splash, 143; X-ray appearances, 147; treatment, 152; — , by paracentesis, 152; — , by oxygen replacement, 152; see also Pneumothorax Hydrothorax, chemical nature of fluid in, 92; chronic, following pneumo- thorax, 148 Hyeres, climate of, 661; for asthma, bronchitis, and emphysema, 193, 256, 661 ; for phthisis, 661 , 668 Hygiene of the nursery, 594; of the sick-room, 599, 600, 601 Hyper-resonance, 39; in pneumo- thorax, 145 Hyphomycetes, or mould fungi: and B. tuberculosis, 422; and streptothrix group of organisms, 394; and sporothrix group of organisms, 411; occurring in bronchitis in tropical climates, 180 Hysterical dyspnrea, 150 Ice-bag: contra-indicated in haemop- tysis, 705; in pneumonia, 312, 315; in tuberculous meningitis, 709 " Ice-cradling," 312 Iceland, hydatid disease of the lungs in, 367 Ilkeston, Lord, danger of syncope m pleurisy with effusion, 109 Ilkley for asthma, 256, 257 Immigration laws restricting use of climatic change and sea-voyages in treatment of phthisis, 636, 656 India, hill-stations of, climate of, 651; North-West, epidemics of pneumonia in, 289 Indian races, varied incidence to tuber- culosis in, 448 Industrial classes, value of sanatorium treatment among, 624, 625 Infants, acute asthenic bronchitis in, danger of, 184, 186; bronchitis in, at first dentition, 176 Infection, channels of, in pulmonary tuberculosis, 427-433 Infections, secondary, in pulmonary tuberculosis: see Secondary infec- tions Influenza: complicated by bronchitis, 179; — by empyema, 130, 131; - — by pneumonia, 331-334: bacterio- logy of, 331; special symptoms and signs of, including epistaxis, hemop- tysis, " heliotrope cyanosis," and nephritis, 332; treatment, 333; leading to acute pulmonary oedema, 356; to asthma, 245; to increased activity of pulmonary tuberculosis, 468 Injury leading to chylothorax, 169; to pneumonia, 288; to pulmonary tuberculosis, 450, 451 778 DISEASES OF THE LUNGS AND PLEURA Inman, A. C, effect of exercise on opsonic index, 612, 613; observa- tions on the opsonic index in active and quiescent phthisis, 585, 586; on complement-fixation test, 588 Innsbnick for phthisis, 654 Intercostal fluctuation in pleural effu- sion, 102; in hydro- or pyo-pneumo- thorax, 145; neuralgia, 81 International Medical Congress, Lon- don, 1881, 38 International nomenclature of phj'sical signs, 44 Interstitial pneumonia, 335; see Pneu- monia, interstitial Intestines: lardaceous disease of, in phthisis, 567-569; tuberculous ulcera- tion of, 540; — , appearance of site of ulcers, 540-542; — , attributable in children in part to bovine infec- tion, 433; — •, common complication in phthisis, 540; — , perforation of bowel in, 541; — , symptoms of, 542- 544; constipation in, 544; diarrhoea in, 543; — , treatment, 694-697 Intrathoracic growths; see Medias- tinum, tumours of, 737 ; and Lungs, tumours of, 750 Iodine: as inhalant, 218, 681; applica- tions [see Counter-irritation); in- tensive treatment in active pul- monary tuberculosis, 678 Iodoform in hectic period of phthisis, 678 Ireland, health resorts for bronchitis, 193 Iron: perchloride of, in septic and influenzal pneumonia, 313, 333 Irvine, J. Pearson, primary dilatation of the lung following bronchial nar- rowing, 203 Israel, James, published first case of human streptotrichosis (actinomy- cosis), 394 Italian Lakes in spring for phthisis, 665 Itard, M., first described pneumo- thorax, 133 Jaccoud on pneumothorax, 134 Jackson, Chevalier, per-oral broncho- scopy for removal of foreign bodies from air-passages, 238 Japan, tuberculosis in, 433 Jauja, South American Andes, for phthisis, 642 Jaundice and pneumonia, 296 Jenner, Sir W., expiratory theory of eniphysema, 273 Jewish race and adenoid growths, 177; lowered phthisical mortality among, 448 Jeyes' fluid as disinfectant, 600 Johannesburg, climate and description of, 649 Johnson, Sir George, case of feigned haemoptysis, 558 Johnston, Major C. A., tuberculosis in the different races composing the Indian Army, 448 Jones, Coppen, on the streptothrix nature of the Bacillus tuberculosis , 422 Jones, Varrier, Medical Superintendent of the Cambridgeshire Tuberculosis Colony, Papworth Hall, 622 Jones, Wood, tuberculosis in Egyptian mummy, 420 Jourdanet, D., effect of altitude on the treatment of phthisis, 449 Jousset, A., method for detecting tubercle bacilli in pleural fluid, 91 Joy's cigarettes for asthma, 260 Jozeau's capsules in chronic bronchitis, 192 Kanthack, A. A., demonstration of capsule of pneumococcus, 290 ; microscopical appearances of bron- cho-pneumonia, 326 Karroo Tableland, South Africa, for phthisis, 644 Keith, Arthur, enlargement of the pulmonary infundibula in emphy- sema, 270; share taken by the abdominal muscles in normal ex- piration, 9; on the mechanism of respiration, 345 ; on stethometry, 25 Kelling Sanatorium, after-results of treatment of phthisis at, 621 Kellock, T. H., foreign body in left bronchus successfully treated by pneumotomy, 234, 240 Kelsch, A., and VaiUard, L., on tuber- culous nature of acute pleurisy with effusion, 91 Kernig'ssign in tuberculous meningitis, 566 Kidd, Percy, on distribution of Bacillus tuberculosis in lesions of phthisis, 426 Killian, introduction of bronchoscopy for diagnosing foreign bodies in air- passages, 236, 237 Kimberley for phthisis, 646 King, D. Barty, table of age-incidence in bronchiectasis, 206 King Edward VII. Sanatorium, Mid- hurst, daily routine for patients at, 608; observations on mixed and secondary infections in pulmonary tuberculosis at, 468; percentage of cases of early phthisis with laryngeal INDEX 779 involvement, 534, 536; practical re- sults of tuberculin treatment at, 715, 716; standard diets at, 615 Klein, E., pathology of lymphatic system of lung, 18; reports on public telephones and tuberculosis, 435 Koch, R., discovery of tubercle bacillus, 474; introduction of sub- cutaneous tuberculin test, 578, 579 Kohlisch, dried sputum the chief source of infection in phthisis, 429 Koster and Allard on tuberculous pleurisy, 91 Koumiss cure at Meran, 651; in acute ulceration of bowel, 695, 697; in pulmonary tuberculosis, 602, 603; method of preparing at home, 603 Krawkow, experimental production of lardaceous disease, 569 Kronig's sign in tuberculosis of lungs, 502 Labour, graduated, in sanatorium treatment, 610-613 Lactation, danger to phthisical mother from, 701, 702 Lactic acid in laryngeal tuberculosis, 699 La Cumbre, Argentine, suitable for consumptives, 650 Ladybrand, South Africa, climate of, 648 Laennec, bronchial breathing, 53; cicatrisation of lung cavities, 528, 529; classification of adventitious sounds, 56; — of varieties of bron- chitis, 194; description of dry crackle, 59, 60; discoverer of aus- cultation, 35; infection of tuber- culosis conveyed by inoculation, 427; inspiratory theory of emphysema, 273; laryngeal and tracheal breath- ing, 54, 55; metallic tinkling, 58; mucous rale, 41, 56, 57; phthisis a specific disease, 474; pleural friction, 60; pneumothorax, simple or essential, 133, 134; prognosis as to duration of consumption, 625; specific nature of tubercle, 421; vesicular murmur, 49 Laingsburg, South Africa, for phthisis, 644 Langenbeck, von, first observer of parasite of streptotrichosis, 394 Lardaceous degeneration in phthisis, 567-569; — , organs affected and symptoms, 568, 569; — , pathology of, 568; — , in empyema, 125; ■ — , experimental production of, 569 Laryngeal breathing, 54, 55 Laryngeal tuberculosis; see Larynx, tuberculosis of Larynx: as generator of the bronchial breath-sound, 54; foreign bodies in, 223-227; malignant disease of, 538, 539; syphilis of, 538; voice-sounds produced by, 6r Larynx, tuberculosis of, 533; affection of voice in, 536; anaemia of, 534; complicating pulmonary tubercu- losis, 534; diagnosis, 537; — , from alcoholic or irritative catarrh, 537; — , from hysterical aphonia, 537, 538 ; ■ — , from malignant growths of, 539; ■ — , from smoker's catarrh, 537; — , from syphilis, 537, 538; frequency of occurrence in phthisis, 533, 534; laryngological appearances in, 534, 535; morbid lesions found post- mortem in, 533; sex-incidence in, 533; symptoms, 536; treatment of, 697-701; - — , by absolute silence and checking of cough, 698; — , by medicinal means, 699-701 ; ■ — , of cough, 701; — , of dysphagia, 699, 7or ; — , caution as to use of local applications and surgical inter- ference in, 698; — , on sanatorium lines, 698; — ■, tracheotomy in, 701; tuberculous tumours in, 535, 538; ulceration of trachea and bronchi in, 535, 536 Las Palmas, Canary Islands, for phthisis, 667 Las Vegas, New Mexico, for phthisis, 642 Lausanne for phthisis, 651 Lead-mining and phthisis, 455 Lebert, Professor, first description and illustration of parasite of strepto- trichosis, 394; on grape cure, 604; on plastic bronchitis, 196 Le Damany on tuberculous nature of pleurisy with effusion, 91 Leduc's auto-insuftiator, 700 Leeches as foreign bodies in air- passages, 225; in treatment of acute pulmonary oedema, 356; — of pleurisy, 107, 709; — of pneumonia, 312 Lees on treatment of phthisis by antiseptic inhalations, 681 Lendon, A. A., hydatid disease of the lungs, 367, 375 Leprosy, acid-fast bacillus of, 423, 424 Leptothrix in sputum, 76 Les Avants for phthisis in spring, 669 Les Moulins (Monaco), climate suit- able for phthisis, 662 Leucocytes in sputum, 70, 71 780 DISEASES OF THE LUNGS AND PLEURA Leucocytosis in bronchiectasis, 216; in cavitation stage of phthisis, 503; in empyema, 121 ; in pneumonia, 298-299, 476; in tuberculous menin- gitis, 567 Leucopenia in acute pneumonic phthisis, 476; in early stages of phthisis, 503 Levaditi on streptothrix nature of Bacillus tuberculosis, 422 Leyden, E., pyo-pneumothorax sub- phrenicus, 149 Leysin, Alpine station for treatment of surgical tuberculosis, 641 LUlingston and Pearson, Vere, ap- paratus for artificial pneumothorax, 720 Lipoma of lung, 750; of mediastinvma, 737 Lister, F. S., varieties of pneumo- cocci in pneumonia amongst South African natives, 291, 292 Living bodies {Ascaris lumbricoides , etc.) in air-passages, 225 Llandudno for bronchitis, 193 Lobelia, ethereal tincture of,, in asthma, 259 Lobular inflammation of lung [ses Broncho-pneumonia), 323 Lobules of lung, 3, 4 London County Council Report on Phthisis Death-Rates in Relation to Overcrowding, 454 London, Regent's Park, climatological features of, 643, 659, 660 LongstafE, G. B., on conjugal tuber- culosis, 438; on pneumonia, 286 Lord, F. T., micro-organisms in sup- purative pleurisy, 119 Los Angeles, California, climatological features of, 643, 667; suitable for pleurisy, 119; for phthisis, 668 Lotni Bhowali Sanatorivma, India, 651 Louis, prognosis on duration of con- sumption, 625 Lugano for phthisis in spring, 665 Lumbar puncture in tuberculous meningitis: in diagnosis, 567; in treatment, 710 Lung, abscess of, 359 {see Abscess of lung); cirrhosis of, 335 {see Pneu- monia, interstitial); collapse of {see Collapse of lung), 344; honey- comb, 211; tumours of, 750; • — ■, innocent, 750; — , malignant, 750- 752; — , physical signs, 752; — , symptoms, 751; — , treatment, 752 Lungs, anatomy and functions of, 1-19; 13'mphatics of, 18; nerves of, 19; state of, in foetus, 6 Luxor for phthisis in winter, 665 Lyme Regis for bronchitis, 193 Lymphatics: of diaphragm, liver, and pleura, connections between, 19, 86; of pleura, connections of, 85, 86; of pleural and peritoneal surfaces of diaphragm, communication be- tween, 19; pulmonar}', 18; — , com- munication with Ij'mphatics of visceral pleura, 18 Lymphocytes in tuberculous menin- gitis, 566 Lyster, A. E., shelters for consump- tives, 622 MacAlister, Alexander, size of lumg lobules, 4; estimation of number of pulmonary alveoli, 50 MacCormac, Henry, foreshadowed sanatoria, 607 MacDonneU, pulsation of fluid in suppurative pleurisy (empyema pul- sans), 122 Mackenzie, Hector, statistics of pneu- monia and its complications, 307 MacLeod, J. J. R., and Bullock, W., acid-fastness of Bacillus tuberculosis, 423 Madeira, climate of, 643, 665, 666; suitable for bronchitis and emphy- sema, and phthisical patients with irritable cough and early laryngeal trouble, 283, 666 Madison, Franz, reaction to tuberculin test, 582 Malaga for phthisis, 663 Malvern for asthma, 256; for bron- chitis, 193; for phthisis, 653 Manitou Park, Colorado, for phthisis, 642 Maragliano serum for tuberculosis, 717 Marcet, W., mean relative winter humidity at Cannes, 660 Mare's mUk in phthisis, 603 Margate for autumn treatment of phthisis, 653; for recovery from empyema, 130 Marine, maritime, and inland climates for phthisis, 653-670 Marital or conjugal tuberculosis, 437 Marmorek serum for tuberculosis, 717 Marshall, M. I., and Craighead, J. W., perforation of rupture of lung fol- lowing artificial pneumothorax, 724 Martin, Sidney, experimental tuber- culosis in pigs, 430 Massive collapse of lung, 345; see Collapse of lung, massive Masson, A., and Schulmann, M. E., case of pulmonary sporotrichosis, 412 Maunsell, Surgeon-Major, epidemics of pneumonia in North-West India, 289 INDEX 781 Measles and bronchitis, 179; and broncho-pneumonia, 323; followed by acute tuberculosis, 184 Meat juice, raw, method of prepara- tion, 617 Mediastinitis : chronic, 736; suppura- tive, 734; —, signs of, 734; — > simu- lating intrathoracic tumour, 748; — , treatment, 735 Mediastinum, abscess of, 734; see Mediastinitis, suppurative Mediastinum, tumours of the, 737; — , innocent, 737; — , malignant, 737; diagnosis, 748; illustrative cases, 744-748 ; physical signs, 741 ; pressure symptoms, 739; prognosis, 749; treatment, 750 Medical Research Committee, the, 457, 629 Medicated baths for asthma, 256 Meek, W. O., complement fixation test, 588; value of change in work and environment following sanatorium treatment among the working classes, 621 Mehu, analysis of fluid in chronic pleurisy with effusion, 93 Melbourne unsuitable for chest dis- eases, 656 Mellin's food for consumptives, 617 Mena House, near Cairo, winter resort for asthma, bronchitis, and quiescent phthisis, 193, 665 Mendelssohn's theory of emphysema, 273 Meningitis: in pneumonia, 306-308; tuberculous, 563-567; — ■, aetiology: human and bovine bacilli in, 432; — ■, diagnosis by lumbar puncture, 566: by character of cerebro-spinal fluid and presence of tubercle bacilli in, 566; — , illustrative cases, 563, 564; — , insidious onset of, 564; — , symptoms, 565; — , treatment, 709 Meningococcus, types of, 318; treat- ment of meningitis by appropriate monotypical serum, 318 Menopausal sweatings, vasomotor an- gina, and asthma, interchangeability of, 247 Menopause and asthma, 245 Menstruation and spurious haemop- tysis, 561 Menthol in hay asthma, 262; in relief of cough in phthisis, 681 Mentone, climate of, 643, 662; for asthma, 256; for bronchitis and emphysema, 193, 283; for phthisis, 663, 668; mean winter temperature, 643, 659, 660 Meran for grape and koumiss cure, 604, 651; for phthisis in spring, 651, 665 Mercury in asthma, 258; in pulmon- ary syphilis, 392; in tuberculous ulceration of bowel with tympanitis, 695, 696; Mesenteric glands, tuberculosis of, without intestinal lesions, 430; presence of bovine bacilli in, 433 Metallic echo, 43, 62; tinkling, 42, 45, 58; — , in pneumothorax, 143; — , in large tuberculous cavities, 149 Metchnikoff, E., on streptothrix forms of Bacillus tuberculosis, 422 Meyer, W., and Sauerbruch, pressure chambers to prevent collapse of lung in chest operations, 162, 163 Micrococcus catarrhalis in bronchitis, 179, 180; in broncho-pneumonia, 325 Micrococcus tetragenus in broncho- pneumonia, 325; in infected haemo- thorax, 160; in sputum, 76 Micro-organisms in sputum, 76 Middlesburg, South Africa, for phthisis, 645 Midhurst; see King Edward VII. Sanatorium, Midhurst Milk: channel of infection in tuber- culosis, 431-433; — . danger elimi- nated by pasteurising or boiling, 433; fermented {see Koumiss); in phthisis, 602; in sanatorium diet, 616; malted, for consumptives, 617, 695; with rum, to aid morn- ing cough in phthisis, 673 Miller, W. S., diagram of lung lobule, 2 ^ Milton, Penn, case of chylothorax, 170 Miners, gold, lead, and tin, and phthisis, 455, 456; and puenmo- koniosis, 338-342, 455 " Mist bacillus," acid-fast properties of, 424 Mixed infections in pulmonary tuber- culosis; see Secondary infections Moddersfontein, sanatorium for phthisis at, 644 Moffat for phthisis in autumn, 653 Moller and acid-fast bacilli, 424 Monrovia, California, sanatorium at , 668 Montana for asthma, 256; for phthisis, 637 Mont Dore, 256, 257; for bronchitis, 194; for catarrhal asthma, 256; for phthisis, 669 Monte Carlo, resort for phthisis, 662, 668 Monte Estoril, near Lisbon, for phthisis, 663 782 DISEASES OF THE LUNGS AND PLEURA Montreux autumn resort for phthisis, 654; for asthma, 256; for grape cure, 604 Moorland districts in autumn for phthisis, 653, 689 Morgan, W. Parry, apparatus for arti- ficial pneumothorax, 720 Morland and Riviere on method of prescribing tuberculin, 579 Morphia in asthma, 260; in acute pulmonary cedema, 356, 357; in hcemoptysis, 703, 706; in pneu- monia (in exceptional cases), 312; in tumours of the mediastinum, 750 Morse, J. L., recovery from tubercu- lous hydro-pneumothorax, 148 Mouat, T. R., on compression of veins in intrathoracic dermoids, 380, 381 Moulds in sputum, 76, 180; see also Streptotrichosis, 394; Sporotrichosis, 411; and Aspergillosis, 414 Mountain air in after-treatment of empyema, 129 Mouth as source of foetor, 192 ; haemor- rhage from mucous membrane of, a cause of spurious haemoptysis, 558- 562; hygiene of, in pneumonia, im- portance of, 316; washes, 333 Miiller, I. J., muscular tissue in lung of dog, 8 Mummy, Pott's disease in Egyptian, 419 Mundesley Sanatorium, results of treatment at, among the wealthier classes, 626 Murmurs, cardiac, in pleural effusion, 100; respiratory (see Breath-sounds and Fremitus) Murphy, Sir S., overcrowding and tuberculosis, 454 Muscarine, constriction of bronchi and asthmatic attack produced by ex- perimental injection in animals, 243 Musser and Hoffmann, F. A., table relating to foreign bodies in air- passages, 226 Mussy, Gueneau de, on diaphragmatic pleurisy, 88 Mustard gas, inhalation of, producing septic broncho-pneumonia, 324 Myalgia of muscles of chest-wall, 80 " Myelin droplets " in sputum, 72 Naegei, post-mortem evidence of tuber- culosis, 447 Nairn for phthisis in autumn, 653 Napier, New Zealand, for phthisis, 657 Nasal asthma, 249; catarrh, 190; operations leading to presence of foreign bodies in air-passages, 224; polypi a cause of asthma, 246 Naso-pharyngeal disease and asthma, 246; catarrh, lotion for, 190 Natal, climate of, 646 Nebiola hyoscinae co. in asthma, 260 Needle for use in artificial pneumo- thorax, 721 Negro, American, liability to con- sumption, 448 Neisser, relative frequency in Europe of hydatid disease of the lung, 367 Nelson, New Zealand, for phthisis, 657 Neo-arsenobOlon in pulmonary syphilis, 392 Neo-salvarsan in active phthisis, 678; in pulmonary syphilis, 392 Nephritis complicating pulmonary tuberculosis, 569; in influenzal pneu- monia, 332 Nerve-supply to lungs, 19 Nervi, Italian Riviera, for phthisis, 663 Netter on tuberculous nature of primary sero-fibrinous pleurisy, 91; on bacteriology of empyema, 119; on pneumococcus in saliva of healthy people, 292 Neuralgia, intercostal, 80, 81 Neuritis, peripheral, as complication of pneumonia, 307, 309 New-born child rarely reacts posi- tively to tuberculin test, 427 Newquay for phthisis, 654 Newsholme, Sir A., on provision of institutional treatment and decline in phthisis death-rate, 440 New York, incidence in, of various types of pneumococci, with resulting mortality, 291 New Zealand, climate of, 657; immi- gration laws as to admission of tuberculous patients into, 636; suit- able for phthisis, 656, 657 Nice, for bronchitis, 193; for elderly patients, 662; mean winter tem- peratiure at, 643, 659; rainfall at, 660 Night-sweating in pulmonary tuber- culosis, treatment of, 683 Nitrites in asthma, 259; in haemop- tysis, 703, 706, 707 Nitre fumes: in asthma, 259; formula for production of, 259 Nitrogen formerly used in production of artificial pneumothorax, 719 Nitro-glycerine in asthma, 259; in bronchial compression from aneur- ism, 205 ; in haemoptysis, 704 Nomenclature, international, of physi- cal signs, 44 Nordrach Sanatorium for phthisis, 651 INDEX 783 "Note" obtained by percussion; see under Resonance Nottingham Road, Natal, sanatorium for phthisis, 644 Nursery, hygiene of the, 594 Occupational diseases from inhalation of irritating dusts, 178 CEdema, acute pulmonary, 354; aetio- logy, 114, 354-356; albuminous expectoration in, 354; cause of the attack a relative failure of the left ventricle, 356; irri- tant gas poisoning and, 356, 357; symptoms, 355; treatment, 356, 357; — , chronic pulmonary, appearance of lungs in, 353; due to disturbances of circulation, 352; due to morbid condition of blood, 352; symptoms, 353; treatment, 354 (Esophagus, compression of, by medi- astinal tumours causing dysphagia, 740; foreign bodies in, or malignant growths of, leading to suppurative mediastinitis, 734 Ogle, Cyril, case of teratoma of lung, 383 Oidium albicans in sputum, 76; see Aphthous condition of mouth, 7or Old age and bronchitis, 177 Oliver, Sir T., duration of life in pneumokoniosis, 341 Opium and lead suppositories in diarrhoea of phthisis, 697; and starch enemata in diarrhoea of phthisis, 697; see also Morphia Opsonic index: as indication of secondary infection, 690, 718; value in diagnosis of pulmonary tuber- culosis, 586, 587; variations of, in active phthisis and in early quiescent cases following exercise, 584-586 Oracle, Arizona, for phthisis, 642 Orange Free State, climate of, 647 Orange-rubin stain for clubs in strepto- trichosis, 395 Oratava for chest diseases in winter, 667 Ormerod, J. A., case of chylothorax, 170 Orthoform insufflation in laryngeal tuberculosis, 700 Orthopnoea in pleuritic effusion, 97 Osier, Sir W., case of acute suppurative tuberculous pleurisy, 124; " chronic adhesive tubercular pleurisy," 87 Osteo-arthropathy, pulmonary, 213 Osteomyelitis of rib, tuberculous, 84 Osteo- or chondro-sarcomata of lung, 751 Otago, New Zealand, for phthisis, 657 Otitis media in pneumonia, 307, 309; of tuberculous origin, 539 Overcrowding and tuberculosis, 454 Oxygen: and gas as anaesthetic in chest operations, and in cases of chest disease, 128; in performance of artificial pneumothorax, 7x9; in treatment of acute pulmonary oedema, 356, 357; — massive col- lapse of lung, 350; — mediastinal tumour, 750; — pneumonia, 314, 318, 334 "replacement" in cases of pleurisy with effusion, 114, 131; — orhydro- pneumothorax, 152 Oxted suitable place near London for permanent residence for phthisical patients who have regained health, 669 Paget, Stephen, case of migrating or wandering empyema, 125 Paignton for phthisis in autumn, 654 Palpation, account of, and how em- ployed, 34, 35; definition and signi- ficance of, 39; international nom.en- clature relating to, 44 Papworth Hall colony for treatment of phthisis, 622 Paracentesis thoracis: in chylothorax, 170, 171; in hemothorax, 158; in pleuritic effusion, 109; method of performing, no; — , danger of acute oedema of lung and " albuminous expectoration " if carelessly per- formed, 114, 354; not permitted in cases of hydatid of lung, 376 Paragonimiasis and haemoptysis, 546 Paraldehyde in bronchial narrowing, 205; in pneumonia, 316 Paralysis, post-diphtheritic, and mas- sive collapse of lung, 345 Paraplegia, functional, following haemoptysis, 551 Paravertebral triangle of dulness, 104 Parotitis and pneumonia, 307 Pasadena, California, for phthisis in winter, 668 Pasteur, W., definition and description of massive or lobar collapse of lung, 345-348 Pasteurising or boiling milk as a precautionary measure, 433 Paterson, M. S., system of graduated labour introduced at Frimley Sana- torium, 609, 610; — , and Kirkland, T., apparatus for disposal of sputum at Brompton Hospital, 601 Pau, climate of, 664; for catarrhal asthma, 256; for phthisis, 669 Pearson, Professor Karl, " assortative 784 DISEASES OF THE LUNGS AND PLEURA mating " an important factor in conjugal tuberculosis, 439; bio- logical properties of the tubercle bacillus a factor in explaining the incidence of tuberculosis, 457, 458; on inherited diathesis of pulmonary tuberculosis, 445, 446; probability of tuberculosis developing in offspring of tuberculous father or mother, 439 ; — , Pope, E. G., and Elderton, Ethel M., on conjugal tuberculosis, 438 Pearson, Vere, and LUlingston, ap- paratus for artificial pneumothorax, 720 Pecioriloquie aphonique in pleural effusions, 120 Pectoriloquy in acute pulmonary tuber- culosis, 476; in bronchiectasis, 215; in phthisical cavities, 523; whisper- ing, definition and significance of, 43, 61 Pegli, winter health resort, 663 Penzance for bronchitis, 193; for phthisis in winter, 658 Peppermint essence in aiding expec- toration in bronchial narrowing, 205 Percussion: definition and significance of, 39; first employment of by Auenbrugger, 35 ; international nomenclature, 44; method and description of, 35-37; note, varieties of, see Resonance; theory of, 46; see also Auscultatory percussion, 62 Peribronchial and perivascular lym- phatics, 18; — phthisis, 471 Pericarditis in empyema, 125; in pneumonia, 307, 308 Perichondritis of sternum and ribs, 82 Periostitis of sternum and ribs, 82 Perisporacidffi, familj- of moulds to which the aspergilli belong, 414; see Aspergillosis Perls, M., on residual tension of lungs, 7,8 Perlsucht in cattle, 425 ; only recently introduced to Japan and Faroe Islands, though human tuberculosis long rife, 433; see Tuberculosis, bovine Perry, S. J., and Elderton, W. P., conclusions as to value of tuberculin treatment at Adirondack Sanitarium, 717; results of sanatorium treat- ment, 625-626 Petitjean, G., and Pic, A., effects of amyl nitrite upon pulmonary blood- supply, 703 Petri and Rabinowitsch, acid-fast butter bacillus, 424 Phagocytosis more active with low degree of pyrexia, 677 Phenacetin, use of, in pyrexia, 679 Phenazone, use of, in pyrexia, 679 Philip, Sir R., ipecacuanha in haemop- tysis, 704 Phosgene poison gas and acute pul- monary cedema, 357 Phthisic galopante, 474 Phthisis, acute pneumonic, 474, 475- 487; illustrative cases, 481-486; recovery from, 481; temperature charts of, 478, 480, 482, 485; treat- ment of, 671; — , basal, 470; diag- nosis from bronchiectasis, 216; — , chronic, 502 (see Tuberculosis, pul- monar}', chronic); — ■, fibroid, 511; chronicity of, 516; illustrative case of forty-three years' duration, 516; lardaceous changes in various organs in late stage of, 519, 520; prognosis, 519; symptoms and signs of, 511; transition from chronic pulmonary tuberculosis to, illustrative case, 507- 509; — , florid or "galloping con- sumption," 487; especially in j'oung adults, 487; illustrative cases, 488- 491; rapid progress to fatal ter- mination, 491; temperature charts, 490; gold-miner's, 340-342; — "laryngeal," 533; — , "peri-bron- chial," 471; see also Tuberculosis Pic, A., and Petitjean, G., effects of amyl nitrite upon pulmonary blood- supply, 703 Picken, R. M. F., recovery of dis- charged phthisical soldiers without sanatorium treatment, 624 Picric acid stain for clubs in strepto- trichosis, 395 Pietermaritzburg, climate of, 647 Pigeon-breast, causes of, 78 Pigeon-feeders in Paris, aspergillosis amongst, 414 Pigs, tuberculosis in, 425; experi- mental, 430 Pilocarpine, experimental injection of, causing constriction of bronchioles, 244 Pine wool in bronchitis, 188 Piorry's pleximeter and plessor, 36 Pirquet, von, cutaneous tuberculin test, 578, 583, 590; rarely positive in new-born chUd, 427; too delicate for use in adults, 583 Pitt, Newton, primary dilatation of lung following pressure on bronchus, 203; cases of haemopneumothorax, 158 Pituitary extract in pneumonia, 315; of posterior lobe in asthma, 259 Plan for spending twelve months away from England, 657 INDEX 785 Plasmon in tuberculous ulceration of bowel, 695 Plastic bronchitis, 196; see Bronchitis, plastic Pleura: anatomy and description of, 85; irrigation of, in empyema an exceptional measure, 129; lym- phatics of, connections of, 85, 86; mortar-like fluid in, in large quanti- ties, 171 ; oedematous, how produced, 469; separation of layers of, in indurative piilmonary tuberculosis, 469; thickening of, in pulmonary tuberculosis, 469 Pleural effusion : circumference of chest in, 102; displacement of organs in, 99, 102, 103; malignant in nature, 743. 746, 749; physical sign of cardinal and supplementary, 99; see. Pleurisy Pleural friction ; see Friction, pleural Pleural reflex, 722 ; following irrigation of pleura, 129; in treatment by artificial pneumothorax, 722 Pleural shock, 722; following irriga- tion of pleura, 129 ; in treatment by artificial pneumothorax, 722 Pleurisy, 85-131; "chronic adhesive tubercular" (Osier), 87; — , dia- phragmatic, 88; — , dry, fibrinous, or plastic, 86-89; diagnosis from pleurodynia, 81; pathology of, 87; symptoms, 88; treatment, 89; variety of, diaphragmatic, 88; — , hcBfnorrhagic, 115; — , malignant, 743. 746, 749 sero- fibrinous, acute, 90-116; aetio- logy, tuberculous nature of, in most cases, 90-92; chemical pathology of fluid effused, 92-93; cytology of fluid effused, 92; diagnosis, 105; fluid sometimes blood-stained, 115; physical signs, cardinal and supple- mentary, of pleural effusion, 97- 105; prognosis, 106; skodaic re- sonance in, 103; symptoms of, 93; temperature charts of, 94-95; treat- ment, 106; in early stages, 106, 107; in stage of effusion, 107; para- centesis, 109; indications for inter- ference in, 109; method of perform- ing paracentesis, no; risk of acute oedema of lung and albuminous ex- pectoration if carelessly performed, 114, 354 sero- fibrinous, chronic, 114; rare at present time, 114; treatment by oxygen replacement, 114; — , suppurative, 118-131; see Empyema Pleuritis a frigore, 90, 93; see Pleurisy Pleurodynia, causes of, 79; diagnosis of, 81; treatment of, 81 Pleximeter, description of, 36; use of finger as, 36 Pneumatometry, 25-26 Pneumococcus : capsule of, demonstra- tion of, 290; characters of, 290; chief causative agent of lobar pneumonia, 290; in the blood in, 291, 299; in sputum, 290; producing many complications in, 306; — types of, incidence of such in pneu- monia in New York and South Africa, with resulting mortality and prognosis, 291; — treatment by appropriate serum, 318; in broncho- pneumonia, 324, 325; in pulmonary tuberculosis, 467; in suppurative pleurisy, case percentage, 119; in saliva of healthy individuals, 292; in serous pleurisy due to, 91 Pneumokoniosis, cetiology, 338-340; due to inhalation of dust, 338; dust- producing occupations causing, 340; prevalence of, declining, 340; prog- nosis and expectation of life in, 341 ; symptoms, 340; — , those of bron- chitis and emphysema, 340; — ,'with illustrative case of gold-miner's phthisis, 341 Pneumonia, chronic interstitial, 335 ; see Pneumonia, interstitial Pneumonia, interstitial (cirrhosis of lung), 335; aetiology, 335; associated with bronchitis, pleurisy, and pul- monary inflammation, 335; due to inhalation of dust, 335; clinical features of, 337; microscopic find- ings and morbid changes in, 335, 336; section of lung showing nuclear proliferation in, 336; see also Pneu- mokoniosis Pneumonia, lobar, or " croupous," 286, 320; abscess in, 305, 318; atiology, 286; — , climatic influences, 287; — , individual predisposition, 286; — , injury, 288; — , personal infection, 288; — , pre-existing diseases, 286; — , septic influences, 288; anatomy, morbid, of, 292; bacteriology of, 289; — , predominant role of pneu- mococcus in {see also Pneumo- coccus); clinical description of case, 296; crisis in, 299, 300; delayed resolution in, 304; diagnosis, 300; gangrene in, 306, 318; leucocyte count in, 298, 299; physical signs in the various stages, 296-300; portion of lung affected in, 295 ; prodromal symptoms of, 295, 296; purulent infiltration or diffuse sup - 50 786 DISEASES OF THE LUNGS AND PLEURAE puration in, 295, 305; severity of the disease varying mucti in different years, 309; stages of, 292-294; — of consolidation, 310, 313, 314; — of convalescence, 317; — of crisis, 316; — of hyperaemia, 310, 311; — of resolution, 310, 317; symptoma- tology, 295, 296; temperature in, 293, 294, 296, 299, 300; — , chart of, 298; treatment, alcoholic stimu- lants in, 311, 313-315, 316, 317; — , dietetic, 313, 314; — , drugs in, 311-317; — of complications, 318; — of pain, 312; — of pyrexia, 311, 312; — of shock during crisis, 316; — of sleeplessness, 315, 316; — , oxygen in, 314, 315; — , serum in, " monotypical," 319; — , method of administration, 319; — , risk of ana- phylaxis and serum sickness, 319; — , vaccines in, 320; varieties of: con- tusional, 288; creeping, 304; hypo- static, 294; influenzal, 305, 331, 334; latent, 304; migratory, creeping, or wandering, 304; septic, 288, 302, 318; — , with illustrative case, 302; traumatic, 288; — , diagnosis from hemothorax and massive coUapse of lung, i5o Pneumonia, lobular, 323; see Broncho- pneumonia Pneumonomycosis, disease caused by moulds, 414 Pneumothorax, r33-i55; cBtiology, 133; pulmonary tuberculosis the common cause of, 133-136; bell-sound heard in, 62, 143; communication between lung and pleura, patent or valvular, 138, 139; — , size and position of opening, 138; diagnosis, 148-150; — , from asthmatical dyspnoea, 150; — , from diaphragmatic hernia and escape of stomach and colon into chest, 149; — , from emphysema, 149; — , from hysterical dyspnoea, 150; — , from large pulmonary cavities, 149; — , from pyo-pneumo- thorax subphrenicus, r49; — , from X-rays, 147, 149; fluid effused into pleura in, nature of, 140; gas effused into pleura in, analysis of, 139; intrapleural pressure in, 139; local- ised or partial in character, 149; metallic tinkling not alone signifi- cant of, 58; physical signs in, 142- 146; prognosis: in cases secondary to phthisis, 147; in conditions other than phthisis, 148; symptoms, 140; — simulated by acute pulmonary congestion in advanced tuberculous disease, 142; temperature charts in, 141, 142; treatment, 151-155; — , by evacuation of air, 151; — , by para- centesis, 152; — , by opium, 151; — , by oxygen replacement, 152; — , of pyo-pneumothorax, 152-155; see also Hydro- and Pyo-pneumothorax and Artificial pneumothorax Pneumothorax, artificial, 719 ; see Arti- ficial pneumothorax Pneumotomy, 239 Pohl, W., statistics of intrathoracic dermoids, 380 Poirier, P., and Cuneo, B., on the lymphatics of the lung, pleura, and diaphragm, 19; on the connection of the lymphatics of the lung and pleura with those of the chest wall, 85,86 Poison gas and acute pulmonary oedema, 357; and septic broncho- pneumonia, 324 PoUactne inoculation for hay asthma, 262 PoUantin in treatment of hay asthma, 262 Pollen, cause of hay asthma, 248; protein present in, 245 Pollock, J. E., on duration of life in phthisis, 625 Polypi, nasal, a reflex exciting cause of asthma, 246 Ponfick on parasite of streptotrichosis, 394 Poore, Vivian, garlic in treatment of bronchiectasis, 218 Pope, E. G., Elderton, Ethel M., and Pearson, Karl, on conjugal tuber- culosis, 438 Pope, E. G., and Brown, Lawrason, results at Adirondack Cottage Sani- tarium, 627 Portofino, Eastern Riviera, for phthisis, 663 Potain's aspirator, description and uses of, 111-113 Potassium, iodide of: and stramonium in asthma, 192, 262; in aspergillosis, 4r7; in chronic bronchitis, 192; in haemoptysis with syphilitic cachexia, 705, 706; in plastic bronchitis, 200; in pneumonia, 317; in pulmonary oedema, 354; in sporotrichosis, 413; in streptotrichosis, 409; — :, leading to spurious haemoptysis, 558 ; in tuberculous meningitis, 710 " Potter's " cure for asthma, 259 Potters, mortality among, from phthisis, 455 Poultices in acute bronchitis, 188; in confluent broncho-pneumonia, 329; INDEX 787 in pneumonia, 312; in sero-fibrinous pleurisy, 107 Powell, Sir R. Douglas : case of chronic tubercular disease of the lungs illustrating one mode of production of thickening of the pleura, 89, 473; " Clinical Lectures on Excavation of the Lung in Phthisis," 531; case of deep ulceration of ileum in phthisis, with constipation a marked feature, 544, 545; "Note on the Value of Baccelli's Sign — Pectori- loquie Aphonique — in the Differential Diagnosis of Pleural Effusions," 132 ; on displacement of the heart in pleural effusion, 100, 117; "On a Case of Actinomycosis Hominis," 410; on pneumothorax, 155; "On Some Effects of Lung Elasticity in Health and Disease," 20, 156; " On the Causative Relations of Phthisis," 460; some cases illustrating the pathology of fatal haemoptysis in advanced phthisis-, 65, 520, 556; table comparing asthma with angina pectoris vaso-motoria, 243, 268; " The Role of the Cardio- Vascular System in Pulmonary Tuberculosis," 510, 556; " The Use of Strychnia in the Vomiting of Phthisis," 710; " Three Cases of Phthisis with Con- tracted Lung," 520; — , and Lyell, R. W., case of basic cavity of the lung treated by drainage, 220, 222; — , and Mahomed, Dr., sounds met with in diseases of the chest, 38, 44; — , and Sturges, Dr., case of intrathoracic dermoid tumour, 381- 383 Precipitin test in phthisis, 588 Pregnancy, effect of, upon pulmonary tuberculosis, 701, 702 Preobraschensky, S. S., mortality from foreign bodies in air-passages, 238 Pressure signs in pleuritic effusion, 102; in intrathoracic tumours, 739; in suppurative mediastinitis, 734 Prpmontogno for phthisis in spring, 641 " Proposote " in phthisis, 688 Prune-juice sputum, 68 Prussian and Hessian railway com- panies, results of sanatorium treat- ment, 621 Psoas abscess following untreated suppurative pleurisy, 125 Pterygoid chest, causes of, 79 Puerile breathing, 40, 44, 51 Pulmonary osteo-arthropathy, 213 Pulsation of fluid in suppurative pleurisy, 121 Pulse irregular in early tuberculous meningitis, 566 Pulvis rhei co. in asthma, 258 Purley for permanent residence for phthisical patients who have regained health, 669 Purpura, hsemoptysis in, 546, 547, 549; causing chronic pulmonary oedema, 353; Purulent bronchitis, 186, 191 ; see under Bronchitis Pus cells in sputum, 70 Putrid bronchitis, 192 Pyaemia: and abscess of the lung, 359; and gangrene of the lung, 363; and septic broncho-pneumonia, 323, 324 Pyogenic organisms, for presence of, in lesions and sputum, see individual diseases Pyo-pericardium in pneumonia, 308 Pyo-pneumothorax : setiology, 134, 135, 148, 229, 231; cases occurring in course of pulmonary tuberculosis, 140; outlook, 148; — , course of disease sometimes prolonged, with illustrative case, 152-155; physical signs of, 143; — , movable dulness, 143; — , succussion splash, 143; treatment, 152-155; X-ray appear- ances of, 147; see also Pneumothorax Pyorrhoea alveolaris and spurious hcemoptysis, 558; treatment, 559 Pyrenees in spring, 665 Pyrexia in active pulmonary tuber- culosis, treatment of, 676-680; to some extent a protective factor, 677 " Quack " treatment of asthma, 254 Quain, Sir R., aneurism of pulmonary artery, 548 Quartz dust, danger of silicosis from, 340 ; see Pneumokoniosis Quevli, Dr., spread of tuberculosis among North American Indians, 435 Quincke, H., and Garre, C, mortality after surgical treatment of gangrene of lung, 365 ; results of operation on abscess of lung, 360; results of operation for hydatid disease of lung, 377 Quinine in abscess of lung, 360; in broncho-pneumonia, 330; in hectic periods of phthisis, 679 ; in influenzal pneumonia, 333; in nasal catarrh, 596; in pneumonia, 311, 314, 316, 317; salicylate of, in asthma, 261 Quito for phthisis, 642 Rabbit, tuberculosis in, 425 Rabinowitsch and Petri, acid-fast butter bacillus, 424 788 DISEASES OF THE LUNGS AND PLEURAE Race-incidence of pulmonary tuber- culosis, 448 Radcliffe, J. A. D., mixed and secon- dary infections in pulmonary tuber- culosis, 468 ; complement-fixation test, 588 Radiography and radioscopy in chest disease, 64; stereoscopic method introduced by Sir Mackenzie David- son, 64; value of, in diagnosis, 64; see also X-raj's in diseases of the chest Radium in mediastinal tumours, 750 Ragatz for phthisis in spring, 641 Rales, bronchial, definition and com- mon significance of, 41, 42; inter- national nomenclature of, 45; — , explanatory', 56-58; varieties of: bubbling, 41, 45, 56; cavernous or gurgling, 42, 45, 58; — , in abscess of lung, 360; — , in gangrene of lung, 364; — , in tuberculous excavation of lung, 523; clicking, 42, 45, 57; crackling, 42, 57> 58; crepitant, 42, 45; dxjy 41, 56; moist or liquid, 41, 56, 57; rhonchi, 41, 45, 56; sibilant, 41, 45, 46; sonorous, 41, 45, 56; suijcrepitant, 42 Ramsgate for autumn treatment of phthisis, 653; suitable for schools for delicate children, 594 Ranking, W. I., recovery from case of pneumothorax apparently due to ruptured emphysematous bulla, 135 Ransome, Arthur, monograph on stethometry, 25 Rapallo for phthisis in winter, 663 Raulin's medium for cultivation of aspergilli, 416 Ravaud and Widal on cytology of acute sero-fibrinous pleuritic effusions, 92 Ray fungus, 394 Reclus, P., surgical treatment of gangrene of the lung, 365 Regent's Park, meteorological data at, 643> 659, 660 Registrar-General's Seventy-First An- nual Report on Tuberculosis, 452, 453. 461 ReichenhaU, Bavaria, compressed-air baths at, 281 Relaxed lung note, 39, 98, 103; see Resonance, skodaic Renon, L., on pulmonary aspergillosis, 414; on treatment of aspergillosis, 417 Resonance: defiiution and significance of, 39; international nomenclature, 44; explanatory theory of, 46; varieties of, 39; — , absence of, 39, ^ 44; — , amphoric, 39, 44; — , dimin- ished or impaired, 39, 44; — , increased, 39, 44; — , normal, 39; — , skodaic (relaxed lung note), 39; in pleurisy with effusion, 98, 103; in pnemnonia, 39; — , tubular, 39; — , tympanitic, 39, 44, 47; — , vocal, 61 ; see Voice-sounds. See also Percussion Respiration, " cog-wheeled," 52; dyna- mics of, demonstrated by diagram model of chest wall, 12-16; divided, 53; function and mechanism of, 5-12; — , costal and diaphragmatic factors in, 345; irregular, in early tuberculous meningitis, 566 Respiration saccadee, 40; see under Breath-sounds Respirators, oro-nasal, various forms of, 680, 681 Respiratory centre, action of, 6; movements, mechanism of, 5-17; — , effect upon lesions of pulmonary tuberculosis, 469; murmur; seeunder Breath-sounds and Respiration Rest in treatment of phthisis, 607, 612, 712 Reynaud, pleural friction, 60 Rheumatic fever and acute pulmonary oedema, 356 Rhodesia, climate of, 650 Rhonchi, 41, 45, 56; see also under Rales Rib mobilisation, Wilms' operation, in bronchiectasis, 220; in phthisis, 729 Rice boiled with milk and stained in acute ulceration of bowel, 694 Rickets and broncho-pnemnonia, 330; and deformity of chest wall, 78 Riesman, D., on acute pulmonary oedema, 355 Rigor and abscess of the lung, 359; in pleurisy, 93; in pneumonia, 292, 295, 296 Rindfleisch, E., on expansion of lungs in emphysema, 270; inspiratory theory of emphysema, 274; theory to explain enlargement of bronchial and other cavities, 527 Riverina, New South Wales, for phthisis, 657 Rivers, W. C, statistics of pulmonary tuberculosis at Crossley Sanatorixun, Delaware Forest, 445, 446 Riviera: climate of, 643, 659; cloth- ing suitable for, 661 ; health resorts along, 659-663; mean winter tem- perature of, 659; rainfall of, 660; suitable for certain cases of bron- chitis, 193, 660-663; — of phthisis, 660-663, 691 INDEX 789 Riviere, Clive, on artificial pneumo- thorax, 720; bacteriology of sup- purative pleurisy, 119; hilum tuber- culosis, 472; special pneumothorax needle, 721; — , and Morland, on method of prescribing tuberculin, 579 Roberts, F., on strapping the chest in pleurisy, 89 Rockefeller Institute: bacteriological findings in acute lobar pneumonia, 290; observations on types of pneumococcus met with in pneu- monia, 291, 292; presence of pneu- mococcus in blood in pneumonia, 299; treatment of pneumonia by monotypical serum, 3r9 Rocky Mountains, resorts in, for treatment of phthisis, 641-642 Roe, Hamilton, on paracentesis thoracis, 109 Roentgen rays, 63, 64; in chest exami- nation, 64; see also X-rays Roepke and Bandelier, scheme of tuberculin dosage, 714, 716 Rogers, Sir L., on sodium morrhuate, 675 Rokitansky on arrest of hjemorrhage in haemoptysis, 555 Rolland, W., Hammond, J. A., and Shore, T. H. G., on purulent bron- chitis, 186 RoUier, results obtained at Leysin in the treatment of surgical and other forms of tuberculosis, 641 Rome unsuitable for phthisical patients, 669 Rosenbach on grass-green sputum, 68 Rosewood dust causing asthma and bronchitis, with illustrative case, 178, 264 Ross, J. N. MacBean, statistics of cases of malignant disease of the mediastinum, 749 Rostrevor for bronchitis, 193 Roumania, tuberculosis in, 433 Royal Commissions on tuberculosis, 432 Royat, summer health resort, 669 Ruffer, Sir A., and Smith, Professor Elliott, Pott's curvature in Egyptian mummy, 419 Rum and milk in phthisis, acute first stage, 673 Sabouraud's glucose media for isola- tion of sporothrix and aspergUlus organisms, 411, 416 Sahli and Trudeau, reactionless method of administering tuberculin, 716 St. Ann's for bronchitis, 193 St. Bartholomew's Hospital: after- history of cases of pleurisy with effusion, 91; bacteriology of em- pyema, 119; mortality from lobar pneumonia varying from year to year, 309 St. Blasien for phthisis, 651 St. Leonards for chronic bronchitis and emphysema, 283 ; for permanent or winter residence for phthisis, 658; suitable for schools for delicate chUdren, 594 St. Mary Church for asthma, 256; for phthisis, 654, 658, 668 St. Moritz for asthma, 256 Salines in haemoptysis, 705, 706 " Salisbury " dietary in asthma, 257 Salisbury, Rhodesia, climate of, 650 Salt and water in haDmoptysis, 703 Salter, H. H., on asthma, 242, 245, 249, 259; on the elasticity of the chest walls on inspiratory force in breathing, 9; residual tension of lungs, 7 " Salubra " paper in sick-room of phthisical patient, 599 Salvarsan in pulmonary syphUis, 392; in phthisis, 678 Sanatogen in acute ulceration of bowels, 695 Sanatoria: construction of, 607; in Denmark, 728; in England, 445, 609, 611, 622; in Germany, 609, 621, 651; in India, 651; in South Africa, 644 ; in Switzerland, 637; in United States, 627, 628; see also Sanatorium treatment Sanatorium treatment: cases suitable for, 606; unsuitable for, 626; daily routine, 608; diet, 6i3-6r7; standard diet in use at the King Edward VII. Sanatorium, Midhurst, 614-616; exercise and work in, 609; detailed scheme of graduated labour at the Brompton Hospital Sanatorium at Frimley, 609-611; importance of efficient after-care, 621; with hint's in regard io change of work and environment, 622-624; results of treatment, 619; — amongst the industrial classes, 619-626; — failure of, in advanced cases, 620; — amongst the wealthier classes, 626- 631; see also under Sanatoria Sandalwood, oil of, in bronchiectasis, 218; in chronic bronchitis, 192 Sanderson, Sir J. Burdon, calculation of costal movement in calm breathing during health, 11; origin of tuber- culous granulations in sheaths of minute bronchi, 465; part played 790 DISEASES OF THE LUNGS AND PLEURAE in pathology by lymphatic system of lung, 1 8 San Diego for phthisis in winter, 668 Sanitas for use in sick-room, 599, 600 San Remo, climate of, 663; mean winter temperature at, 643-659; spring and winter treatment of bronchitis and emphysema, 193, 283; — of phthisis, 663, 668 Santa Barbara, California, for phthisis, 668 Santa Cruz for asthma, 255, 667 Santa Fe, New Mexico, for phthisis, 642 Santa Fe de Bogota, Andes, for phthisis, 642 Sarcinse in sputum, 76 Sarcoma of mediastinum {see Medias- tinum, tumour of), 737; of lung, 751 Sauerbruch and Meyer, W., pressure chamber to prevent collapse of lung in chest operations, 162, 163 Saugman, Professor C, artificial pneu- mothorax, 719, 721, 722, 726; results of thoracoplasty at Vejlef jord Sanatorium, 728 Savin ointment in secreting cavities, 690 Scarborough for phthisis in autumn, 653 Schatzalp, Davos, Sanatorium, 637 Schede's operation in old-standing empyemata, 130 Schenck, B. R., first description of sporotrichosis, 411 Schizomycetes, or fission fungi, 395 Schmid, altitude and tuberculosis, 449 Schmorl, primary lesion in fine bronchi in early phthisis, 429 Scholberg, H. A., and Wallis, R. L. Mackenzie, on true and pseudo- chylothorax, 166, 168 Schools for delicate children, suitable seaside localities for, 594 Schrotter, von, on bronchoscopy, 237 Schulmann, M. E., and Masson, A., case of pulmonary sporotrichosis, 412 Schultze on streptothrix forms of the tubercle bacillus, 422 Scolices in fluid expectorated in hydatid disease of the lungs, 374 Scurfield, H., on excessive mortality in Sheffield from phthisis among grinders and cutlers, 455, 456 Scurvy a cause of chronic pulmonary oedema, 353 Sea-bathing in spurious haemoptysis, 562 Sea climate, characteristics of, con- trasted with those of mountain val- leys, 655; voyages as a precaution against phthisis, 596, 597; — for hay asthma, 256; ■ — ■ in treatment of phthisis, 654-658; — , legislative restrictions as to landing, 656; — not ideal form of treatment, 654, 655 Secondary infections in pulmonary tuberculosis, 467, 468; use of vaccines in, 690, 691, 718 Selous, F. C, climate of Mashonaland, 650 Semon, Sir F., and Williams, P. Watson, treatment of foreign bodies in air and upper food passages, 237 Serum treatment : in asthma, danger of grave anaphylactic symptoms fol- lowing, 246; of pneumonia, 319; — by monotypical serum, 319; sickness following treatment, 319, 320; of pulmonary tuberculosis, 717 Sharkey, S. J., acute bronchiectasis ' (bronchiolectasis), 211 Shattock, S. G., on the teratomatous nature of certain intrathoracic der- moid tumours, 383, 384; evidence of tuberculosis in early Nubian skele- tons, 420 Shaw, H. Batty, and Williams, G. G. O., statistics of intrathoracic der- moid tumours, 380, 381 Sheep, tuberculosis in, 425 Sheffield, excessive mortality from phthisis at, among male workers in certain trades (grinders and cutlers), 456 Shelters for consumptive patients, 622 Sherrington, C. S., on share taken by the abdominal muscles in normal expiration, 9 Shetland Isles, hydatid disease of lungs in, 367 Shock in pneumonia, 311; pleural, in irrigation of pleura, 129; in artificial pneumothorax, 722 Shore, T. H. G., Hammond, J. A., and Rolland, W., on purulent bronchitis, 186 Sibilus, 41, 45, 56; see also under Rales Sicily for phthisis in spring, 665 Sick-room, hygiene of, 600 ; importance of cleanliness in, 601 Siderosis from inhalation of iron dust, 340 Sidmouth for bronchitis, 193 Sierra Madre, California, for phthisis, 668 Silicosis from inhalation of quartz dust, 340 Silvius, early observations on morbid lesions of phthisis, 420 INDEX 791 Simon, Sir John, on specific nature of tubercle, 421 Simons Town, South Africa, for phthisis, 644 Sitzenfrey, A., on congenital infection in tuberculosis, 427 Skegness for phthisis in autumn, 653 Skoda on character of the bronchial breath-sound, 53; the veiled puff in bronchiectasis, 215 Skodaic resonance, 39 ; in pleurisy with effusion, 98, 103; in pneumonia, 39 Smallpox and bronchitis, 179; and gangrene of the lung, 363 Smegma bacillus, 423, 424 Smith, Archibald, on altitude and phthisis, 449 Smith, Professor Elliott, and Derry, D. E., caries of the spine in early Egyptian skeletons, 419 Smith, Professor Elliott, and Ruffer, Sir A., Pott's curvature and hip disease in Egyptian mummies, 419, 420 Smith, S., successful treatment of abscess of lung by incision and drainage, 360 Smith, Sir T., parasite of strepto- trichosis, 394 Smoking, excessive, causing laryngeal catarrh, 537; diagnosis from tuber- culosis of larynx, 728 Smyth, R. Mander, personal experi- ence of galloping consumption, 481 Sodium morrhuate injections in phthisis, 675, 676 Solmersitz, F., on aspergillosis, 416 Somerset East, South Africa, climate of, 645 Sorgo on mixed infections in phthisis, 468 South Coast of England for bronchitis, 193 Southend suitable locality for per- manent residence near London for phthisical patients who have re- gained health, 669 Southey's trocar, use of, in pneumo- thorax to relieve air-pressure, 151 Southport for bronchitis, 193 Spa for asthma, 257 Sphacelus of the lung in pneumonia, 306; treatment of, 318 Spirocha3tes in pulmonary syphilis, 387, 389, Spirometer, Hutchinson's, 26 Spirometry, 26 Spitta, H. D., reports on possible danger of public telephones in the spread of tuberculosis, 435 Spitting and the spread of tuberculous infection, 435 Spittoons and liquid disinfectant, 600; varieties of, 600 Splash; see Succussion Spleen, situation and physical signs of normal, 38 Splenification of lung, 294 Sponging to reduce pyrexia: in hectic periods of phthisis, 679; in influenzal pneumonia, 333; in lobar pneumonia, 311 Sporothrix parasite of sporotrichosis, 413 Sporotrichosis: characteristic lesions of, 411, 412; diagnosis and treatment, 413; illustrative case, 411; sporo- agglutination test in, 413; symptoms resembling phthisis, 412, 413 Sporotrichum Beurmanni, 411; Schencki, 411 Spring treatment of phthisis, 668 " Sputa margaritacea " in bronchitis sicca, 196 Sputum: adventitious matters in, 76; " albuminous " or " serous " fol- lowing paracentesis of chest, 114; — , in acute pulmonary oedema, 353, 354; apparatus for disposal of, 601; Bacillus tuberculosis in, 76, 429, 574; — , cultivated from, 424 [see also Tubercle bacillus); bronchial casts in, 69; cells in, 70; contact with mucous membrane resulting in laryngeal tuberculosis, 534; con- sistence and colour of, 67, 68; crystals in, 75 ; Curschmann's spirals in,- 74; elastic fibres in, 72, 73; — in abscess of lung, 306, 360; — - in gangrene of lung, 306, 364; — in pulmonary tuberculosis, 476; ex- amination of, 66, 67; foetid character of, in bronchiectasis, 212 ; — " foetid bronchitis" 192; — in gangrene of lung, 306, 364; fragments of lung tissue in, 75, 74, 306; in acute pul- monary oedema, 353, 354 [see Albuminous expectoration); in asthma, 244, 252, 253; in bronchiec- tasis, 212, 217; in chronic bronchitis, 191; in false hsemoptysis, 561; in haemoptysis, 550; in hydatid disease of lung, 375; in gangrene of lung, 364; in intrathoracic growths, 739; in pneumonia, 297, 299, 300, 306; in purulent bronchitis, 186; in tropical abscess of liver, 68; in ulceration of larynx, 74; inhalation of, leading to spread of lesions of phthisis, 470; " myelin droplets " in 72; micro-organisms in, 76; num. 792 DISEASES OF THE LUNGS AND PLEURA mular, 191; prune-juice, 68; quan- tity of, 67; " red-currant jelly," 739; source of infection in phthisis, 429; sources from which derived, 66; swallowing of, a cause of dyspepsia in phthisis, 602 ; tonsillar casts in, 74 Ssamara, Russian Steppes, for koumiss treatment, 603 Stadler, Dr., mean duration of life in phthisis, 625 Staphylococci, for presence of in lesions and sputum, see individual diseases Starch and opium enema for diarrhoea, 697 Steam-kettle in acute bronchitis, 188; in broncho-pneumonia, 330 Stenosis, mitral, and chronic pul- monary oedema, 352 Stereoscopic method of X-ray exami- nation, 64 Sternum, injury to, causing medias- tinal abscess, 734; perichondritis and periostitis of, 82-84 Stethometry, 25 Stethoscope, biaural flexible, 48 Stewart, Sir T. Grainger, treatment of bronchiectasis by intralaryngeal in- jections, 219 Stimulants, abstinence from, in recur- rent haemoptysis, 707; see Alcohol and Alcoholism Stokes, W., foreign bodies in air- passages, 223, 227 Stomach note in health, 38 Stone, theory of production of aego- phony, 62 Stools, detection of tubercle bacilli in, 574, 590 Stramonium in asthma, 192, 259-261 Strapping of chest in pleurisy, 89, 709 Streptococci, for presence of, in lesions and sputum, see individual diseases Streptotrichosis (actinomycosis) of lung and pleura, 394; age-incidence, 407; chief features of, with illustra- tive cases, 397-407; feculent odour of sputum in, 192; history of disease, 394; mistaken in earlier times for cancer, osteo-sarcoma, or tubercle, 394; pathological analogy of, 396; parasite of, 394, 408; — , distribution of, 396; — , morphology and staining properties of, 395 ; pyaemic form of, 408; simulating pulmonary tuber- culosis, 396, 407; temperature chart of case of, 400; treatment, 408; — , medicinal, surgical, and vaccine, 409 Stridor in bronchial narrowing, 204; in malignant mediastinal growths, 740 Strophanthus in advanced emphysema, 280 Strychnine: in cod-liver oil, 675; in night-sweating of phthisis, 684; in pneumonia, 3r3, 315, 316, 334; in vomiting with cough in phthisis, 708 Sturges, Dr., and Coupland, on spread of pneumonia by contagion, 289 Sturges, Dr., and Powell, Sir R. Douglas, intrathoracic dermoid tumour, 381-383 Succussion splash, definition and signi- ficance of, 42; in hydro- or pyo- pneumothorax, 143; international nomenclature, 45; in total excava- tion of lung, 149 Summer treatment of phthisis best at home, 669 Sun, exposure to direct rays of, inimical to tubercle bacUlus, 425 Suppositories, lead and opium, for diarrhoea, 697 Surgical emphysema, 135, 284 Sutton, Sir J. Bland-, sequestration dermoids, 379 Sweating in pulmonary tuberculosis, treatment of, 683 Swift, J. C, absence of emphysema in Foundling Hospital boys trained for regimental bands, 273 Swiss Alpine resorts for asthma, 256; for phthisis, 637; showing diminished prevalence of tuberculosis with in- creasing altitude, 449 Swithinbank, Harold, on resistance of Bacillus tuberculosis to low tempera- tures, 425 Syphilis: associated with pulmonary tuberculosis, 392, 393; predisposing to bronchitis, 177; to fibroid changes in lung, 336; of bronchi in secondary stage of disease, 385; causing bron- chial catarrh, 385; simulating measles, 385; treatment, 392; — in tertiary stage, 385; causing ulcera- tion of bronchi, 385; and later stenosis and bronchiectasis, 205, 386; simulating mediastinal tumour, 748; treatment, 392; of larynx, 389; diagnosis of, from laryngeal tuber- culosis, 538; of lung in acquired syphilis, 387; formation of gummata, 387-389; haemoptysis in, 546, 549; physical signs and symptoms, 388, 389; suggesting tuberculosis, 389; illustrative case, 389-391; tempera- ture chart of, 391; treatment, 392; — in congenital syphilis, causing " white pneumonia," 387; of sternum and ribs, 84; causing mediastinal abscess, 734 INDEX 793 Syringe, exploring; see Exploring syringe Syrupus Allii Aceticus in bronchiec- tasis, 218 Tabarie, compressed-air bath, 28r Tcenia echinococcus and hydatid dis- ease of the lungs, 367 Talamon, discoverer of pneumococcus, 289 Tamworth for residence for phthisical patients who have regained health, 669 Tapes, double, for chest measurement, 23, 34 Tar in chronic bronchitis, 192; in secreting cavities, 690 Tar-water in bronchitis-kettle in broncho-pneumonia, 330 Tatham, John, death-rate from phthisis in dusty trades, 455 Taylor, Sir Frederick, on mode of production of aegophony, 62 Tea-factory cough, r8o Teeth, condition of, as source of fcetor, 192; decayed, a cause of spurious haemoptysis, 562 Teignmouth for phthisis in winter, 658 Telephones, public, and tuberculosis infection, 435 Temperature, taking of, relative merits of mouth and rectum methods, 609 ; see Pyrexia Tenby for bronchitis, 193; for phthisis, 654, 658, 668 Teneriffe for asthma and phthisis, 255, 667 Teratoma of lung, 380; see Dermoid tumours, intrathoracic Theobromine, cardiac stimulant in pneumonia, 315 Thermogen wool in treatment of bronchitis, 188 Thomas, J. Davies, and hydatid disease of the lungs, 367, 374, 377 Thompson, J. H. R., and Bardswell, N., results of sanatorium treatment at the King Edward VII. Sana- torium, Midhurst, 629; results of tuberculin treatment as practised at the King Edward Sanatorium, Mid- hurst, 716, 717 Thomson, Sir StClair, percentage of cases of phthisis in the various stages showing^ laryngeal involve- ment at the King Edward VII. Sanatorium, 534; — , prognosis of such cases, 536 Thoracic recoil, 8-12; reserve capacity, 12; resilience, 10; tension, 8-12; see also Chest and Chest walls Thoracocentesis leading to develop- ment of bronchiectasis, 210 Thoracoplasty in bronchiectasis, 220; in phthisis, 728; in pyo-pneumo- thorax, 152 ; in suppurating pleurisy, 130; see also Wilms' operation Thrill in hydatid disease, 369; in pneumothorax, 145 Thusis for phthisis in spring, 641 Timothy grass bacillus, acid-fast, 424 Tin-miners, mortality from phthisis among, 455 Tobacco in asthma powder, 259 Torquay for asthma, 256; for phthisis in spring, autumn, and winter, 654, 658, 668; winter climate of, 643, 659 Total excavation of lung in phthisis simulating pneumothorax, 149 Trachea, ulceration of, in laryngeal tuberculosis, 535 Tracheal breathing, 40, 54 Tracheotomy for removal of foreign bodies from air-passages, 237, 239; in laryngeal tuberculosis, 701 ; lead- ing to septic bronchitis and broncho- pneumonia, 179, 323, 324 Transvaal Province, climate of, 649 Traube on causation of pulsation in empyema pulsans, 122, experiments on thoracic expansion, 9 ; on stomach note in pleural effusion, 103 Traumatic pneumonia, 288; tuber- culosis, 450, 451 Traumatopnoea, 159 Treadgold, H. A., on the significance of Arneth's blood-picture in pul- monary tuberculosis, 503, 504 Trocar, for evacuating air in cases of pneumothorax, 151; special, for performance of artificial pneumo- thorax, 721 Trousseau, danger of sudden death in cases of pleurisy with effusion, 106; emetics to arrest haemoptysis, 704; on foetid breath and expectoration in bronchiectasis, 2r2; on para- centesis thoracis, 109; on the bell sound or bruit d'airain, 62; on the significance of haemorrhagic effusions into the pleura, 115 Trudeau and Sahli, reactionless method of administering tuberculin, 76 Tubercle bacillus, 431; acid-fast pro- perties of, 423; antiseptics and, 676; avian variety of, 426; biological characteristics of, 424, 425 ; bovine variety of, 426, 433 (see Tubercu- losis, bovine) ; branching forms of, 422 ; channels of infection [see Tuber- culosis, channels of infection); club formation of, 422; cultivation of, 794 DISEASES OF THE LUNGS AND PLEURA 424; — , from sputum, 424; distinc- tion of, from other acid-fast bacilli, 424; distribution of, in the lesions of phthisis, 426; hum.an variety of, 426; morphology of, 422; presence of, in cerebro-spinal fluid in tuberculous meningitis, 367; — , in empyema, 123; — , in hydro- andpyo-pneumothorax, 140; — , in pleurisy with effusion, 91 ; — , in pulmonary tuberculosis, distribution in lesions of, 426; in blood, 427; in caseating areas, 426; in miliary tubercles, 427; in sputum, 426, 429; in stools, 427, 540, 574; staining of, 423; — , by Ziehl- Neelsen method, 423; — , by con- centration methods, 574; "types" or varieties of, described by Dr. Brownlee, 453 Tuberculin: dosage, scheme of, 714, 715; method of prescribing, 714, 716; patients to whom it may be given, 715; preparations of : albumose-free (A.F.), 713, 7i6; Beraneck's, 714; Denys' Bouillon Filtre (B.F.), 713, 714; bacillary emulsion (B.E.), 713, 714; New Tuberculin Rest (T.R.), 713, 714; Oberst (T.O.), 713; Old (Tuber- kulin Alt), 712; tests: conjunctival, 583; cutaneous (von Pirquet's), 583; subcutaneous: dosage for, 579; reaction, focal, 582; — , general, 586; temperature records of, 580, 581 Tuberculosis: ancient Egyptian skele- tons showing evidence of, 419; aural, 539; avian, 426; bovine, 425; — , characteristics of bacillus, 426; — , disease in cattle known as " Perlsucht," 425; — , varieties of tuberculosis in man attributable to, 432, 433 — , with resulting mortality, 433; bronchial gland, 471, 472; channels of infection, 427; — , con- genital, 427; — , ingestion, 428; — , through milk and butter, 431; — , inhalation, 428; — , inoculation, 427; — , with illustrative case, 428; chylothorax and, 169; conjugal, 437; death-rate, for all forms of, in England and Wales, compared with that of phthisis, 419, 452; foetal, 427; " hilum," 471, 575; intestinal, symptoms of, 540; — , treatment of, 694 {see Intestines, tuberculous ulceration of); laryngeal, symptoms of J 533; — ) treatment of, 697 {see Larynx, tuberculosis of); marital, 437; miliary, 492 {see under Pul- monary tuberculosis) ; pulmonary {see Pulmonary tuberculosis) ; trau- matic, 450 Tuberculosis, pulmonary : cstiology, 419-462; — , age-incidence in, 453; — , alcohol and, 456; — , altitude and, 449; — , asthma and, 254; — , Bacillus tuberculosis exciting cause of, 421 {see Tubercle bacillus); butter a source of infection, 431 ; — , channels of infection, 427; con- genital, 427; ingestion, 428; inhala- tion, 428; inoculation, 427; with illustrative case, 428; — , climatic factors in, 448; — , constitutional liability, 444; — , contagion, ques- tion of, 433; — , dampness of soil and, 449; — , death-rate from, gradual decline of, until 1914, 453; — , diabetes and, 486; — , dusty employments and, 455 ; — , epi- demiological factors associated with, 457; — , hereditary factor in (the tubercular diathesis), 445; — , in- fluenza and, 468; — , injury and (traumatic tuberculosis), with illus- trative case, 450, 451; — , marital relationship and (marital or con- jugal tuberculosis), 437; — , mental unsoundness and, 457; — , milk as source of infection, 431; — , over- crowding and, 454; — , personal infection and, 434; — , social con- ditions and, 451; — , syphilis and, 392 Tuberculosis, pulmonary, anatomy, morbid, and pathology of : granula- tion of tubercle, the, 463 ; — , tending to undergo caseation, 464; — , fibroid degeneration, 465 ; — -, with secon- dary fibrosis of lung, 467; mechanical effects of the rigid chest wall and respiratory movements, 469; mixed and secondary infections in, 467; site and spread of the tuberculous lesions, 470; with consideration of " hilum tuberculosis," or " peri- bronchial phthisis," 471 Tuberculosis, pulmonary, classification and clinical varieties of: acute pneumonic phthisis (syn.: caseous pneumonia; lobar form of caseous tuberculosis), 475-487; distinction from lobar pneumonia, 475-477; illustrative cases, 481-486; prognosis grave, but case of recovery recorded, 481 ; temperature charts of, 478, 480, 482, 485; treatment, 671, 726 {see Treatment); — , chronic (syn.: chronic phthisis) : blood changes in, 503; blood-pressure in, 504; cavity stage of, 521-531 {see Cavities); INDEX 795 early symptoms and physical signs, 502; illustrative case, 505-507; physical signs when disease fairly pronounced, 505, 5o6; pyrexia in, 504; thoracic flattening at later stage, with compensatory expansion of sound lung, a hopeful sign in prognosis, 506; transition to fibroid phthisis, 507; with illustrative case, 508, 509 {see Treatment); — , fibroid phthisis, 511 {see Phthisis, fibroid); — , florid phthisis (syn.: galloping consumption; acute broncho-pneu- monic form o£ caseous tuberculosis); anatomy, morbid, of, 487; illustrative cases, 488-491 ; occurrence of laryn- geal tuberculosis and pneumothorax in, 491 ; progress rapid and outlook most grave, 488; pyrexia in, with chart, 490; — , sometimes " in- verse " in type, 488; resemblance of case to one of acute miliary tuber- culosis, 488; symptoms and physical signs, 487, 488; treatment, 671 {see Treatment); — , miliary, 492: diag- nosis from acute bronchitis, 184; — from enteric fever, 493 ; — from acute disseminated phthisis (florid phthisis or galloping consumption), 489; difficulty in detecting tubercle bacUli in the sputum, 494; duration of disease, 496; fatal outlook, 492; illustrative cases, 492, 494; — , with temperature chart, 495; sometimes secondary to old-standing pulmonary tuberculosis, 494; treatment, 671 (see Treatment); — , subacute (syn.: pulmonary tuberculisation) : ana- tomy, morbid, of, 497, 498; illus- trative case, 499-501 ; insidious origin and progress of, 498; ob- scurity of development of physical signs, and notable dryness of, 500; prognosis grave in, 497; pyrexia slight in, 498, 501; treatment, 671 {see Treatment) Tuberculosis, pulmonary, complica- tions : albuminuria, 569 ; aural tuber- culosis, 539; fistula in ano, 571; haemoptysis, 546 {see Haemoptysis, true); intestinal tuberculosis, 540 {see Intestines); ischio-rectal abscess, 571; lardaceous degeneration, 567- 569; — -, organs affected and symp- toms, 568, 569; — , pathology of, 568; laryngeal tuberculosis, 533- 539 {see Larynx, tuberculosis of); meningitis, 563-567 {see Meningitis, tuberculous); pleurisy, dry, 709; — , with effusion, 90; pneumothorax, 133; table showing the relative fre- quency of the more important com- plications occurring in chronic pul- monary tuberculosis, 532 Tuberculosis, pulmonary, diagnosis : clinical methods of the first im- portance — viz., early physical signs, 573; evening temperature, 574; symptoms, 573; opsonic test, 583- 587; other specific tests (at present mainly of scientific interest), 587, 589; — , agglutination test, 589; — , cobra-venom test, 588; — -, comple- ment-fixation test, 587, 588; — , precipitin test, 588; procedure adopted by authors, 589, 590; sputum, examination of, for presence of tubercle bacilli, 574; — , by con- centrative methods, 574; — , by routine methods, 574; tuberculin subcutaneous test (for special cases), 579-583; X-ray examination, 575- 578 Tuberculosis, pulmonary, mortality : death-rate from, in England and Wales from 1859-19x8, 452, 453; total mortality from, in England and Wales in 1918, 419 Tuberculosis, pulmonary, prognosis : arrest of prolonged duration, with illustrative cases, 516, 652, 633; outlook in first half of nineteenth century, 625 ; deaths after sana- torium treatment among the patients at Industrial Sanatoria, 620; — at the King Edward VII. Sanatorium, Midhurst, 629, 630; — • at the Mundesley Sanatorium (wealthier patients), 626, 627; varying with the clinical type of the disease: fatal in miliary tuberculosis, 492; grave in acute pneumonic phthisis, 481; and pulmonary tuberculisation, 497; most grave in florid phthisis, 488 Tuberculosis, pulmonary, treatment : by artificial pneumothorax, 719- 728 {see Artificial pneumothorax); climatic, 636-670 {see Climatic change in the treatment of pulmonary tuberculosis); dietetic, 601-603, 613- 617; general and preventive, 593- 605 ; — , need of hospital beds for advanced cases, 440; in acute stage, 671-684; in chronic and fibroid stage, 691-692; in more quiescent period, 687; of aphthous mouth and throat, 701; of cavities, secreting, 689; — , and ulcerous, 691; of cough, 680- 683; — , with vomiting, 708 {see Cough); of fistula in ano, 571; of haemoptysis, 702-708 {see Haemop- tysis, true); of lactation, 701; of 796 DISEASES OF THE LUNGS AND PLEURiE lar5Tigeal tuberculosis, 697-701 [see Larynx, tuberculosis of); of menin- gitis, 709; of night-sweatmgs, 683; of pleurisy with effusion, no; — , dry, 708; of pregnancy, 701; of pyrexia, 676; of ulceration of bowel in, 694-697; of vomiting with cough, 708; sanatorium, 606- 617; — , results of, 619 {see Sana- torium treatment); specific by anti- tuberculous sera, 717; — , by tuber- culin, 712-717 {see Tuberculin); — , by vaccines, 680, 717, 718; surgical, 728; — , by drainage of cavities, 729; — , by rib mobilisation, 729; — , by thoracoplasty, 728; sea-voyages in, 654-658; therapeutic, by anti- pyretics, 679; — , by antiseptic in- halations, 681; — , by arsenic, 676, 677; — , by cod-liver oil, 674; — , by creosote, 678, 687; — ,byguaiacol, 687; — , by intensive iodine, 678; — , by iodoform, 678; — , by sodium cacodylate, 677, 678; — , by sodium morrhuate, 675 ; — , by tar prepara- tions, 678 Tucker's asthma cure, 260 Tulp, Nicholas, on bronchial casts, 69 Tumours, intrathoracic, 737; medias- tinal, 737 {see Mediastinum, tumours of); of the lungs, 750; see Lung, tumours of Tunbridge Wells for phthisis in autumn, 653 Turkish baths for asthma, 257 Turpentine, confection of, with ether and ammonia in pneumonia, 315; in bronchiectasis, 218, 706; in chronic bronchitis, 189; in hsemop- tysis, 704; liniment in bronchitis, 189 Tyndall, John, on properties of rarefied air, 283 Typhoid fever and acute pulmonary oedema, 356; and bronchitis, 179; and gangrene of the lung, 363; periostitis from, 83 Tyrol, Austrian; see Meran Uhlenhuth and Xylander, antiformin method for detecting tubercule bacilli, 574 Ulceration of the bowel, tuberculous, 540; see under Intestines Ulcerous cavities in phthisis, 530; treatment of, 691 Ultra-violet rays, destructive power of, upon bacterial organisms, 639; upon the tubercle bacillus, 425 United States, immigration laws as to admission of tuberculous patients into, 636 Urine in pneumonia, 296, 297, 299 Urticaria and asthma, 247 Uterine disturbances and asthma, 247 Vaccines as prophylactic in asthma, 263; in chronic bronchitis, 193; in lobar pneumonia, 320; in secondary infections in pulmonary tuberculosis, 680, 690, 691, 718; in streptotri- chosis, 409 Vaillard, L., and Kelsch, A., on the tuberculous nature of acute pleurisy with effusion, 91 Vansteenberghe, P., and Grysez, ex- periments on channels of infection in pulmonary tuberculosis, 431 Vapour bath, creosote, in bronchiec- tasis, 217, 218 Varese, spring health resort for phthisis, 665 Variola, bronchial haemoptysis in, 549; followed by pulmonary gangrene, 363 Vasomotor angina, menopausal sweat- ing, and asthma, interchangeabUity of, 247 Veal tea in acute ulceration of the bowel, 695 Vegetable astringents of value in diarrhoea resulting from tuberculous ulceration of bowel, 697; dust and bronchitis, 178 " VeHed puff " of Skoda, 215 Vejlefjord Sanatorium, Denmark, re- sults of thoracoplasty at, 728 Venesection in acute pulmonary oedema, 356, 357; in bronchitis with failing right heart, 190; in rare cases of hasmoptysis, 705; in pneu- monia with faUing right ventricle, 312, 315 Ventil-gerdusch {bruit de drapeau), in plastic bronchitis, 199 Ventnor for chronic bronchitis, 193; for phthisis, 634 Vernet-les-Bains, spring health resort, 665 Vichy water with tar preparations in chronic bronchitis, 192; in secreting cavities in phthisis, 690 Vierordt, observations on mobUity of chest, 25 Villemin, observations on the specific nature of tubercle, 421 Virchow on " white pneumonia," or " white hepatisation," in congenital syphilis, 387; the " myelin droplets " in sputum, 72 INDEX 797 Viscera, abdominal, displacement of, in pleural effusion, 99; thoracic, rela- tion to chest wall, 30, 31, 38 Vision, disordered, in tuberculous men- ingitis, 564, 565 Vital capacity, variation with age, height, and body weight, 27 Vocal vibrations, 35, 39, 44; fremitus, 35j 39. 44; resonance, normal, 61; — , method of production of, 61 (see Voice-sounds); rest in laryngeal tuberculosis, 698 Voice-sounds, normal, definition of, 43 ; impaired in disease of larynx, 61 ; method of production of, 61; see also ^gophony, Bronchophony, and Pectoriloquy Vomiting, early symptom of tuber- culous meningitis, 564, 565; with cough in phthisis, 516; — , treat- ment of, 516, 708 Voyages, 654-658; see Sea-voyages Waldenburg, L., apparatus for treat- ment of emphysema by rarefied and compressed air, 281; diminished force of expiration in emphysema, 275; method of pneumatometry, 26 Wallis, R. L. Mackenzie, report upon, and analysis of, milky fluid from a case of pseudo-chylothorax, 174; and Scholberg, H. A., on true and pseudo-chylothorax, 166-168 Walsh, Joseph, on the presence of tubercle bacilli in the urine of patients suffering from advanced phthisis, 570; on the presence of tubercles in the kidneys of patients who have died of chronic phthisis, 570 Walsham, H., researches on tuber- culosis of the tonsils, 430; on the use of X-rays in chest examination, 63, 64 Walshe, W. H., on haemoptysis in pneu- monia, 310 ; on the influence of gravity in the distribution of rales in bron- chitis, 183; on variations in health of chest measurements and expan- sion, 24, 25 Walther, Otto, advocating taking of rectal temperatures in phthisis, 609 ; overfeeding and walking exercises as practised at Nordrach, 609, 614 Ward, Ernest, on conjugal tubercu- losis, 438 Warwick, Queensland, for phthisis, 657 Washbourne, J. W., on air-capacity of upper air-passages and of bron- chial tract, 50 Wassermann test and sporotrichosis, 413; in pulmonary syphilis, 388, 392; see also Contplement-fixation test Watson, J. Chandler, and Freeman, John, on the anaphylactic origin of asthmatic attacks resulting from hypersensitiveness to a foreign protein, 245 Wavy cavernous breathing, 52; see under Breath-sounds Weaning of children advised early in phthisis, 593 Weber, F. Parkes, on traumatic pneu- monia, 288; and traumatic tuber- culosis, 451 Weber, Sir Hermann, cases of infection of wives by consumptive husbands, 437; on diaphaneity and diather- mancy of air in high altitudes, 638 Weist, J. R., mortality from foreign bodies in air-passages, 238 Welch, Assistant-Surgeon, on epidemic of pneumonia among troops at New Brunswick, 287 Welch, W. H., on causation of acute pulmonary oedema, 356 Wells, J. W., on effect of cod-liver oil upon metabolism, 674 West, Samuel, cases of primary strep- tothrix disease (actinomycosis) of lung and pleura, 407; on calcareous fluid in the pleura, 171 ; on primary broncho-pneumonia, 323 Westcliff - on - Sea for residence of phthisical patients who have re- gained health, 669 West Indies, voyage to, in spring, for patients convalescent from acute chest diseases, 669 Westminster, Orange Free State, climate of, 648 Wet-nurse for child of consumptive mother, 593 Wethered, detection of tubercle bacilli in case of acute miliary tuberculosis on twentieth attempt, 494 Weybridge for asthma, 256 Weymouth for phthisis in autumn, 654 Whey in phthisis, 602 " White hepatisation," or " white pneumonia," in congenital syphilis, 387 Whooping-cough : complicated by bronchitis, 179; — by broncho-pneu- monia, 323, 328; — by collapse of lung, 344 ; — by pulmonary vesicular emphysema, 269; — by surgical emphysema, 135; followed by pul- monary tuberculosis, 595; simulated by foreign body in air-passages, 234 ; use of emetics to avert broncho- pneumonia, 329 798 DISEASES OF THE LUNGS AND PLEURA Widal and Ravaut on cytology of acute sero-fibrinous pleural effusions, 92 Wijeyeratne, Dr. F. C. de F-, on personal infection in pulmonary tuberculosis, 434 Wilks, Sir Samuel, on frequency of occurrence of hEemoptysis during night, 550 Wnicox, W. H., analysis of Tucker's asthma specific, 260; and Colling- wood, B. J.,on the use of oxygen and absolute alcohol in pneumonia, 315 Williams, C. J. B., on the contractility of the bronchioles, 243; on fine-hair crepitation, description of, 59; theory of the percussion note, 46; and Bennett, Hughes, on the value of cod-liver oil in phthisis, 674; and Williams, C. Theodore, on hereditary predisposition to con- sumption, 445 WUliams, C. Theodore, on aerothera- peutics, 281; on cod-liver oil, its value in phthisis, 674; on health of staff at Brompton Hospital, 435, 436; on mortality from phthisis in pre-sanatorium days, 625; on results of treatment in the high Alps, 639; on sea-voyages, good results from, in phthisis, 654; unsatisfactory results of treatment of phthisis at Madeira, 666 Williams, G. E. O., and Shaw, H. Batty, statistics of intrathoracic dermoid tumours, 380, 381 Williams, Leonard, association of high blood-pressure and acute pulmonary oedema, 355 Williams, O. T., cod-liver oil and its action in phthisis, 675 ; and Forsyth, C. E. P., the influence of unsaturated fatty acids in tuberculosis, 685 Williams, P. Watson, on normal rhythmical expansion and contrac- tion of the bronchioles during respira- tion, 8; increased expiratory con- traction explaining the asthmatic paroxysm, 8, 243 ; and Semon, Sir F., treatment of foreign bodies in air and upper food passages, 237 Williams, Stenhouse, on the vitality and virulence of the tubercle bacil- lus, 424, 425 Wilms' rib-mobilisation operation in bronchiectasis, 220; in phthisis, 729 Wilson, J. A., Bashford, E. F., and Bradford, Sir J. Rose, filter-passing virus in influenza, 187, 331, 332 Wind, influence of, on phthisis, 450 Winter resorts in England suitable for phthisis, 658, 659 Wives, effect of consumptive husbands upon, 4:J7 Woillez first employed cyrtometer, 24 Woldingham suitable for residence for phthisical patients who have re- gained health, 669 - Wolff-Eisner and Calmette, conjunc- tival tuberculin test, 579, 583 WoUstein, Martha, bacteriology of broncho-pneumonia, 324, 325 Wounds of the chest, 157; see Hsemo- thorax Wright, Sir Almroth, opsonin test introduced by, 583; vaccines in pneumonia, 320; see also Vaccines Wynberg, South Africa, for phthisis, 644 X-rays in diseases of the chest, 64; in abscess of the lung, 360; in aneurism of the aorta, 205 ; in bronchial-gland tuberculosis, 576; in bronchiectasis, 216; in foreign bodies in brorichus, 232; in gangrene of the lungs, 365; in gold-miner's phthisis, 342; in hilum tuberculosis, 474, 575; -in hydatid disease of the lung, 369; in interlobar pleurisy, 124; in mediastinal tumour, 743, 749; in pleurisy with effusion, 121; in pneumokoniosis, 340, 342; in pneu- mothorax, 147; in pulmonary tuber- culosis, 471, 575-578; in pyo- pneumothorax subphrenicus, 149; in suppurative pleurisy, 121; treat- ment by, of intrathoracic growths, 750; see also Radiography and Radioscopy in chest disease Xylander and Uhlenhuth, antiformin method for detecting tubercle bacilli, 574 Yarmouth for asthma, 263 Yeo, Burney, on the grape cure in phthisis, 605; respirator for inhala- tion of volatile antiseptics in phthisis, 680 Yorkshire moors for asthma, 257; for phthisis in autumn, 653, 689 Young, R. A., microscopical report on case of Hodgkin's disease associated with pseudo-chylothorax, 174 Ziehl-Neelsen method of staining tubercle bacilli, 423 H. K, LEWIS AND CO. LTD., 28 GOWER PLACE, LONDON, W.C. I Date Due FEB 2 Q 195]