Chronic Tuberculosis.

Synonyms.—Phthisis Pulmonalis; Consumption; Chronic Pulmonary Tuberculosis; Chronic Ulcerative Tuberculosis.

Pathology.—A post-morten will reveal quite a variety of conditions. The apices of the lungs are the most frequent seat of the tubercular deposit, and from here the invasion proceeds till more or less of the entire lung is involved. The earliest tubercular deposit is generally formed from an inch to an inch and a half below the apex, and nearer the posterior than the anterior surface.

The first effect of the bacilli or toxin, however, is felt in the smaller bronchial tubes. As the disease progresses, the air-cells become filled with the same products, which caseate, and when a section of the diseased part is made, we see a yellow or grayish surface. Later several of these nodules coalesce, forming a tubercular mass, which, undergoing necrosis, forms a cavity. These cavities vary in size and character. Some contain material of firm consistency; others, where the material is soft, lose all trace of organization; while still others contain a disgusting, purulent fluid, the result of mixed infectious material and broken-down tubercle.

The blood-vessels resist for some time the destructive force of the tubercle, and it frequently happens that a cavity will be crossed by one or more blood-vessels. Later, even these give way, sometimes accompanied bv profuse hemorrhage. Again there will be areas where the tubercles are encapsuled. The bronchial glands are enlarged and contain tubercles.

The pleura is nearly always involved, with a fibrinous exudation, and the walls are frequently thickened by adhesions and the presence of tubercles. Tubercular infiltration often takes place in the larynx, and rarely in the pericardium. There is usually fatty infiltration of the liver. The intestines show ulceration with infiltration in many cases.

Invasion.—Few diseases present such a wide range of symptoms as chronic tuberculosis. This is due to the various ways in which it begins.

Gradual Invasion.—In many patients the invasion is so gradual that it is with difficulty we can trace its beginnings. It has been noticed that the general health has been giving way, the appetite has been capricious, the secretions irregular, and the patient looks anemic, with an ashen color of face. The strength fails from day to day, the breathing is hurried after slight exertion, and the patient's condition is aptly expressed in the popular phrase, "going into a decline."

The symptoms are those of malnutrition, and weeks, or even months, elapse before local symptoms are present.

Bronchitis or Influenza.—Next in frequency to the gradual invasion is an attack of bronchitis or influenza.

There may have been a catarrhal condition of the bronchial tubes resulting in frequent attacks of bronchitis, each lasting a little longer and being more persistent, the general health being gradually undermined, and, before the physician or patient is aware, tuberculosis has made its inroads.

Pleurisy.—Sometimes the first complaint is a sharp pain in the side, pleuritic in character; or a dry pleurisy, with friction murmur and pain in apex, may be first recognized: or the pulmonary lesion may foster an attack of pleurisy with effusion, and though this is gradually absorbed, pain remains in the apex or under the shoulder-blade, and the cough persists.

Laryngitis.—At other times it begins with a laryngeal irritation, loss of voice, a hoarse cough, and some soreness of the throat. Although the local symptoms arc of the larynx, many times the foci are of the lungs, and such an onset should arouse suspicion in the physician, and cause him to make frequent and careful examination of the lungs.

Hemorrhages.—While hemorrhage from the lungs does not always signify tuberculosis, it should always be regarded with grave suspicion; for it may be the first evidence of the disease, the tubercular invasion of the lung already having begun,

In some cases, the disease progresses rapidly from the first hemorrhage; at other times there will be intervals of weeks or months between the hemorrhages, to be finally followed by phthisical symptoms.

Osler speaks of a few, but very important, class of cases where the disease makes serious inroads before there are any marked symptoms to betray the disease.

These latent forms usually occur among the laboring classes, and a man may work for some time with a cavity formation in the apex of his lung, and not be aware of it.

Malarial Fever.—In malarial sections it is not uncommon to mistake the earlier phases of pulmonary tuberculosis for malarial fever. The regularity of the chills, fever, and sweats masks the condition so true to life that the real lesion is overlooked.

Symptoms.—Since the symptoms are so varied according to the different modes of onset, a clearer idea will be gained by dividing the symptoms into two classes, local and general.

Local.—Cough.—One of the earliest, most persistent, and most important symptoms is the cough, which not only announces the early stage, but usually continues throughout the disease. At first it is generally dry, short, and hacking, to be followed by an expectoration of glairy mucus, requiring some exertion for its removal; this gradually changes to mucopurulent material.

The cough, not infrequently, occurs in paroxysms, which greatly exhaust the patient. There seems, however, to be but little relation between the severity of the cough and the gravity of the disease; for in one person there is but little sensitiveness of the respiratory apparatus, though the lesion is severe, while in another, although the lesion is but slight, there is extreme sensitiveness. The cough is usually more pronounced in the mornings and evenings, and after partaking of food and drink, in the latter case often resulting in vomiting.

Pain.—Pain is the unpleasant symptom of any disease, and, if persistent, adds to the gravity of the case. While it may be absent from beginning to end, it is generally present at some stage of the disease. It may be a sharp pain in the apex, or a stitch in the side, especially on taking a full inspiration. If pleurisy be present, the pain is lancinating or stabbing in character. Again, a common- location of the pain is under the shoulder-blade or between the shoulders.

Expectoration.—The sputum varies as to quantity, quality, color, consistency, and odor, depending upon the rapidity with which the destructive process takes place, and also the form, whether or not there be mixed infection. At first it is white and frothy, or glairy, tenacious, and streaked with blood. This soon changes to an opaque and yellowish color, soon followed by a mucopurulent material. At times there will be soft, cheesy particles of a grayish color, which aids one materially in the diagnosis.

Where cavities form, the sputum becomes heavy, lumpy, coin-shaped, nummular, and of a greenish-yellowish color. There is a slight, sweetish, sickening odor in some cases, while in others there is but very little. Where there is mixed infection, there may be marked fetor. In the earlier stages there may be considerable bronchial mucus mixed with the expectoration. In children and very old people the expectoration is very scanty.

In examining the sputum for bacilli, the grayish, cheesy particles should be taken, as they are rich in germs. To obtain elastic fibers, which is now regarded as of additional value, boil equal parts of the sputum and a solution of caustic soda; empty into a conical-shaped glass, and cover with cold water. The sediment can then be carefully examined for this product. Where calcification has taken place, there may be spit up with the mucus, particles of chalky material as large as a pea.

Hemoptysis.—Hemorrhage from the lungs varies very greatly in quantity and time. Some patients pass through all phases of the disease without the suspicion of a hemorrhage. Other patients will show this alarming condition early in the disease, but as the case advances it disappears entirely; while another class of patients will "spit blood" more or less frequently during the entire progress of the disease.

In the early stages the hemorrhage is rarely ever profuse and never dangerous, while those occurring in the advanced stage may prove fatal, though this is very rare. The blood is usually bright red and frothy, characteristic of hemoptysis. The mucus may be simply streaked or tinged with blood, or it may be decidedly rusty. Hemorrhage most frequently occurs after mental excitement, or physical exertion, or paroxysm of coughing, though sometimes it occurs without any apparent cause. Thus, in one of my patients, the hemorrhage invariably occurred in the night, he being awakened by a choking sensation, which was due to the pressure of the blood.

In the milder forms it follows the cough, while at other times it seems to flow to the upper part of the larynx and into the pharynx, and is simply spit out. The hemorrhage is due, in the early stages, to hyperemia, and the blood exudes from the feeble vessels, most likely, due to pressure from tubercular deposits. After cavity formation, there may be erosion of a larger vessel, when the hemorrhage becomes alarming and very rarely fatal. In a practice of twenty-five years I have met with but one fatal hemorrhage in this disease; this in a child ten years old, who died in five minutes after the rupture of the blood-vessel.

Hemorrhage from the lungs, while not necessarily an evidence of tuberculosis, should always be regarded with grave suspicion, and cause careful and repeated examinations on the part of the physician.

Dyspnea.—In the early stage of the disease there is little suffering from "shortness of breath," unless preceded by active exertion. In the later stages, however, it often proves one of the most distressing conditions.

General Symptoms.—Fever.—One of the earliest symptoms, even before the cough, is an elevation of temperature, and if it remains constant for days, with a progressive decline in health, it is one of the most reliable evidences of the dread disease. The first evidence of the toxin in the blood is to produce fever, which varies in character. In one it will be of the continued type, while in another it will be remittent or intermittent in character, or again partake of both, being decidedly irregular. In fact, the irregular character of the fever in tuberculosis is one of its characteristics.

The continued form prevails more frequently during the early stage, while the remittent is found during the later stages. When cavity formation occurs, attended by profuse night-sweats, the intermittent prevails. The intermittent is also seen in the early stage, if the patient has been subject to malarial fever, or lives in a distinctly malarial section, and care must be taken not to mistake this intermittent fever for a paludal fever.

Pulse.—The pulse is increased in frequency, is small, easily compressed, and in the later stages may be sharp and wiry.

Anemia.—The enfeebled vitality is accompanied by feeble digestion and assimilation. As a result of the excess of waste over supply, and the imperfect elaboration of blood, anemia is a necessary result. The pale or ashen color, often made more prominent by the bright red, hectic flush of cheek, is recognized, even by the laity, as belonging to phthisis.

Night-Sweats.—While night-sweats may appear early as the result of enfeeblement, it is more marked during the cavity formation period. At first these are but slight, the head and neck becoming moist, then confined to the thorax and upper extremities. At times they become very profuse, and the night-dress, and even the bed-clothing, are quite wet. These usually come on after midnight, in the early morning hours, though they may occur during the day when the patient drops asleep.

Emaciation.—Another characteristic of phthisis is the loss of flesh. Several factors combine to bring about this result. First the fever, for during any fever the waste exceeds the supply, and consequently there is general atrophy. This is doubly true in phthisis; and in all those cases where there is seeming improvement, where the patient, for a brief period, gains in weight and strength, it will be found to take place during the afebrile stage.

Loss of appetite, whereby insufficient food is taken to counteract the waste, is common. The early enfeeblement of all the forces is seen in a feeble digestion and assimilation. The result is, that the tissues are rapidly used up, without a corresponding renewal. The emaciation is in the adipose tissue first, and then the histogenetic. Where the fever is prolonged for months, it is extreme, and the patient becomes a veritable living-skeleton. With the loss of flesh there is a corresponding debility.

Gastro-Intestinal Disturbance.—The stomach early feels the force of the toxin, which is seen in the furred tongue. There is frequent nausea and sometimes vomiting, especially in the advanced stages and after a paroxysm of coughing. Often the tongue, which is narrow, elongated, reddened at tip and edges, speaks of an irritable stomach, which is attended by some pain and tenderness in the epigastric region. Small ulcers in the mouth are frequent, and are annoying to the patient.

Diarrhea.—While diarrhea may occur early in the disease, it is usually found in the advanced stages, and is one of the serious complications, adding greatly to the prostration. These unfortunates often have painful hemorrhoids or fistulas, which later increase the suffering and still further lower the vitality of the already reduced system.

Nervous System.—"Hope springs eternal in the human breast," is certainly true in this class of patients, and they are ever planning for the time when they shall regain their health, are easily encouraged with any favorable symptom, while changes for the worse are regarded as only temporary. Derangements of the nervous system are quite rare.

Complications.—An acute pneumonia is not an infrequent complication, while a diseased pleura is nearly always found at some stage of the disease. One of the most distressing complications is the involvement of the larynx. The husky voice or persistent attempt to clear the throat announces its presence. As the disease extends, aphonia becomes more complete, and the patient swallows with difficulty. Finally when ulceration extends to the epiglottis and walls of the pharynx, swallowing is no longer possible, food and fluids return through the nose, and the patient literally starves to death.

Physical Signs.—Inspection.—The eye reveals, to the skilled physician, definite and important conditions, characteristics that either tell of phthisis or of one susceptible, to the disease.

The chest is long, narrow, and flat, with increased width of the intercostal spaces. The scapula stand out prominently like wrings, while the epigastric angle is usually acute. Where cavity formation has taken place, there is flatness, the most frequent place being over the left apex. We are to remember, however, that part of this is due to atrophy of the chest muscles. This chest is known as the "paralytic" or "phthisical chest." The respiration is diminished in all stages, but particularly over the apex.

Palpation.—The expansive power observed in inspection can be verified by palpation. By placing the palms on corresponding-portions of the chest, one can readily gauge the expansive power of each. Especial attention should be paid to the clavicular areas, both above and below the clavicle. Vocal fremitus will be increased over the infected area, while the sense of touch reveals tactile fremitus. At the base this vocal fremitus may be diminished or entirely absent, due to a pleural exudate.

Percussion.—The normal resonance is masked in proportion to the defect in expansion and areas of tubercular deposits. The early changes will be noted immediately above and below the clavicle. Similar points of the two sides must be compared both during inspiration and expiration and while breathing is suspended. Areas for careful examination are the supraspinous fossa and interscapular space.

Where the early deposit is near the surface, dullness will be recognized, but where the deposit is deep-seated and surrounded by emphysematous cells, the condition may be overlooked. When the cavities of the apex are thin-walled, the "cracked pot" sound will be heard. If carefully performed, much may be learned by percussion; but if carelessly done, but little information will be gained.

Auscultation.—If carefully performed, the knowledge obtained by auscultation is a valuable aid in diagnosis. Feeble respiratory sounds replace the normal rhythm in the early stage, and are suggestive as to the condition of the apices, or there may be a prolonged expiration during the early stage; while an interrupted respiration, the "cogged-wheel" form, may replace those already mentioned.

We are not to forget, however, that feebleness of respiration may be due to pleural exudates or thickening of the chest-walls, by tumors, edema, etc., and that prolonged respiration, while important, may result from a certain degree of bronchial narrowing, which, while it does not prevent a free entrance of air, hinders its exit, and that the interrupted or cogged-wheel breathing may occur in bronchitis.

As the disease advances, the inspiratory murmur becomes harsh, changing to a bronchial or tubercular character as consolidation increases. On deep inspiration, there may be a few dry clicks, evidence of unsoftened tubercle. With the progress of the disease there is increased secretion in the bronchial tubes, the result of progressive bronchitis, and crepitant and subcrepitant rales are heard. When the secretion is profuse, there is a loud mucous rhonchus. As cavities form, the cavernous and amphoric sound is heard. As the pleura becomes involved, pleuritic friction is heard.

Signs of Cavities.—While large cavities are generally easily recognized, there may be cavities that have never been discovered during life. may be quite sure of a cavity, if persistent bronchial breathing occurs over a limited area combined with little dullness on percussion. The cracked-pot sound is heard when a cavity 'connects with a bronchus and is superficial.

In well-developed cavities gurgling rales may be heard, and the breathing is amphoric in character. Vocal resonance is frequently increased. Wintrich first called attention to the increase of the tympanitic character of the percussion note, when the mouth is opened and closed, also to change of position. Retraction in the interclavicular region becomes prominent when the cavity is in the apex. Where a cavity is empty and superficially located, vocal fremitus is increased. Pectoriloquy is often heard with these conditions.

Diagnosis.—It is essential that we make as early a diagnosis as possible; for, if recognized in its incipiency, there is some hope of effecting a cure, especially if the patient is in a position to profit by the suggestions of the physician as to change of environment, change of climate, etc.

When a patient shows a progressive decline in flesh and strength, with a daily elevation of temperature from a half degree to a degree and a half, a hacking cough, more severe on rising in the morning, occasional pain in chest, particularly over the apex, and if he has had a hemorrhage, the case is decidedly suspicious. In such a case the sputum should at once be examined, and if the bacilli are found, the diagnosis is quite certain.

The presence in the sputum of elastic fibers shows the destruction of the lung tissue has begun, and is additional evidence of the dread disease. When the disease has progressed sufficiently for cavities to form, the chest to become flat, night-sweats to appear, and emaciation to become marked, the diagnosis is of but little use, as the destructive changes are so marked that but little if any benefit can be expected from medication.

Fibroid Phthisis.—Definition.—Fibroid phthisis is that condition where the normal lung" tissue is replaced by fibrous connective tissue, resulting in contraction and induration, and where a microscopic examination reveals tubercle. Chronic interstitial pneumonia is now classed as fibroid phthisis, there being no tubercle present, at least not till near the end of the disease.

Pathology.—The replacement of lung substance by connective tissue usually begins in the apex, more rarely in the middle lobe, and gradually extends downward till the whole lung is involved. As the disease progresses, the lung becomes contracted and indurated. As a result of this, the chest of the affected side becomes flat, and the shoulder drops. But one lung may be affected, the opposite fellow becoming hypertrophied as a compensation. There is often dilatation of the larger bronchi and thickening of the pleura.

Symptoms.—The symptoms depend, to some extent, on the manner in which it begins. Thus Clark Hadley and Chaplin describe three forms of the disease: first, a pure fibroid phthisis, where no tubercle exists; second, a tuberculo-fibroid, where the tubercle develops first, to be followed by the connective tissue; and, third, the fibro-tubercular form, where the tubercle follows the fibroid change.

Cough is one of the earliest and most persistent symptoms, coming- on in paroxysms, and attended by expectoration of a mucus, sero-mucus, or purulent material. The paroxysms are more persistent in the morning. There is but little if any fever. The patient gradually loses flesh and strength. There is some pain in the affected side, and dyspnea follows slight exertion.

On inspection, we notice that the affected side is nat or sunken, and that the shoulder droops. Auscultation reveals a bronchial sound, while percussion gives more or less dullness, the result of induration and the effacement of the air-cells. Where tubercles are present the symptoms are similar, with the addition of a slight fever and a more purulent expectoration. Sweating is not so profuse in the fibroid form as in the ulcerative phthisis, but hemorrhages are more frequent and also more serious. Albumen is often present in the urine, and dropsy is frequently seen, especially of the feet, and occurs in the later stages. The disease is decidedly chronic, lasting from ten to thirty years.

Diagnosis.—The diagnosis is not always easy. Coming on insidiously, with little or no fever, the disease is not early suspected. The persistent paroxysmal cough, the frequent hemorrhage, the dyspnea on slight exertion, the pain and sinking in the affected side, with drooping of the shoulders, are symptoms that determine its true character.

Tuberculosis of the Serous Membranes.—Tuberculosis of the serous membranes, pleura, peritoneum, or pericardium, may be either primary or secondary, though many times it will be very difficult, if not impossible, to distinguish the one from the other.

Pathology.—The anatomical changes are the same as those that take place in ordinary inflammations of serous membranes, with the addition of tubercular material, distributed throughout the exudations. The effusion is generally fibrinous, changing to a purulent character with the advance of the disease; at times it is hemorrhagic.

Etiology.—This form is acute, is usually the result of local disease of the bronchi, mediastinum, or, if in woman, of the fallopian tubes, inoculation taking place through these parts. If chronic, it generally follows the extension of tuberculosis of some contiguous organ.

The Pleura.—Symptoms.—These will depend upon the form, whether acute or chronic. If acute, the invasion may be sudden and announced by a chill, followed by febrile reaction. The breathing is shallow and attended by sharp, lancinating pains. A short, dry cough adds to the suffering of the patient. The symptoms, in the early stage, are the same as those found in acute inflammation of the membrane.

The chronic form comes on more insidiously, and is the result of extension from the pulmonary lesion. In addition to the general symptoms which have preceded, there is pain of a more or less acute character and a sense, of fullness of the affected side. All the symptoms of the combined lesion are now intensified, and the disease runs a rapid course.

The Pericardium.—This form may be acute or chronic, and may occur at any period in life. The morbid lesions are the same as those just considered. The acute form is rarely primary, and follows an affection of the bronchial or mediastinal lymph-glands. As these glands are more frequently involved in children, this form will be more often observed in young people. The symptoms, either acute or chronic, will be similar to those of acute or chronic pericarditis. In addition, there will be the general and progressive emaciation, together with the destructive changes so familiar in general tuberculosis. This form is not frequent.

The Peritoneum.—This form is usually found as an extension from some adjacent viscera, though in rare cases it is seen as a primary lesion. It is often part of a general miliary tuberculosis, though the chronic ulceration and fibroid are not uncommon. The young are far more susceptible than the old, and it is comparatively rare after middle life, though no age is exempt.

The negro race is more prone to this disease than the white race, and females than males, owing to the frequency with which the fallopian tubes are the seat of the primary lesion.

The disease is very often the result of tuberculosis of the intestines or of the mesentery; again we see it following tuberculosis of the liver and pleura. Peritoneal involvement is not a rarity.

The frequency with which disease of the ovaries and tubes occur, has already been mentioned.

Symptoms.—The symptoms are not unlike those of tabes mesenterica; in fact, are often preceded by disease of the intestines and mesenteric lymphatics. They are also those of peritoneal effusion in general.

Among the local symptoms are tympanites, pain more or less intense, tenderness on pressure, and sometimes a well-outlined tumor of a plastic exudation can be outlined.

Among the most prominent general symptoms are emaciation and anemia.

The temperature varies, though usually not very high; while a subnormal temperature not infrequently accompanies the lesion.

Anders regards pigmentation of the skin as a prominent symptom, and one that should early attract the physician's attention to the peritoneal condition. Ascites is frequently present, though the effusion is not often large.

Diagnosis.—Unless the peritoneal involvement is preceded by tuberculosis of some other part, as the pleura, lungs, intestines, or pelvic viscera, the diagnosis is extremely difficult, especially if the temperature range is nearly normal. If there is a continued elevation of temperature, and a transverse tumor below the transverse colon, with emaciation and anemia, there should be but little trouble in the diagnosis.

Tuberculosis of the Alimentary Canal.—Of the Lips.—This is a very rare site for tuberculosis, and when it is, it is usually as an ulcer associated with pulmonary or laryngeal disease. The ulcer is extremely sensitive, and not unlike a chancre or epithelioma. It is only recognized by the aid of the microscope.

Of the Tongue.—This, like the preceding, is usually associated with disease of the larynx or neighboring parts. It occurs as an irregular ulcer at the base of the tongue, though in rare cases the tip may be involved. It closely resembles a syphilitic ulcer, and requires great care in the diagnosis. The salivary glands seem to possess an immunity, though not quite absolute, as cases have been recorded.

Of the Palate.—This is seen in the form of miliary tuberculosis, and appears as a superficial ulceration of the tonsils, which requires a microscopic examination to reveal its true character. Like those just considered, it is commonly associated with tuberculosis of other parts, through the pharynx. In phthisis pulmonalis, during the latter stages, it is not uncommon to have ulceration of the larynx and epiglottis as a complication, and where this takes place the pharynx is nearly always involved. The ulceration is not always extremely painful, but often renders deglutition impossible, and the fluids are returned through the nose. The last days of life are rendered distressing, and the patient literally starves.

Esophagus.—The few cases recorded have been the result of extension from the larynx.

Stomach.—This rarely, if ever, is seen as a primary lesion. It may occur as a miliary or chronic caseous variety. The ulcers may be single or multiple, and involve the mucosa, though perforation has been recorded. The symptoms are pain, nausea, and vomiting, especially after eating. These symptoms may exist with tubercular laryngitis; but if hemorrhage occurs with the vomiting, and there be tuberculosis of the other parts, the probability is that there is tuberculosis of the stomach.

Intestines.—This, in the adult, is nearly always secondary to tuberculosis of the lungs, about fifty per cent of chronic ulcerative phthisis having- this as a complication. In the child, however, it is frequently seen as a primary lesion or following a peritoneal disease. Any part of the small or large intestine may be involved, the ileum being the favorite seat of the location. This variety, together with enteric fever, is the common cause of the ulceration of the intestines. Beginning in Peyer's patches, the tubercles are formed, caseate, turn yellow, and suppurate, forming ulcers. These are irregularly oval, their, greater diameter being in the short axis of the bowel.

The symptoms are those of catarrh of the bowels, especially in children; with the diarrhea, there is colicky pain, and the stools consist of blood, pus, and fecal matter. There is fever, and the emaciation is marked. Night-sweats occur, and the evidence of tuberculosis can hardly be overlooked. In such cases the lungs should be carefully examined for tuberculosis.

Tuberculosis of the Liver.—Tuberculosis of the liver is almost invariably secondary to lesions of other organs; namely, of the lungs, pleura, or peritoneum. It is generally of the miliary form, and the distribution is quite general. The liver is pale and slightly enlarged, the tubercles are yellow, both being stained from the bile and necrosis. Hanot describes a tuberculous cirrhosis where the tubercle is entangled in connective tissue and fatty degeneration. "The liver is lobulated and furrowed by fibrous glands, which almost convert it into a lobated liver." If the patient has been a hard drinker, there often is seen the fatty hypertrophic, tuberculous liver, which is characterized first by gastro-intestinal disorders, hyperemia of the liver, cough, fever, and night-sweats, to be followed later by pronounced hepatic disorders.

The diagnosis is made by a careful physical examination of the liver, which will be found to. be enlarged, firm, hard, and irregular. Pressure causes pain, ascites may be present, while the symptoms of perihepatitis and peritonitis are nearly always present.

Tuberculosis of the Genito-Urinary System.—The attention of the profession has been directed to the genito-urinary tract in recent years by the surgeon and gynecologist as a seat for tuberculosis. Although rare, it may be primary or secondary, and may be either miliary or caseous. Any part of this system may be involved, and sometimes the extension is so rapid that the primary seat can not be determined.

Tuberculosis of the Kidney.—Tubercular nephritis is that condition where the tubercle bacilli develop in the inflammatory products, resulting in the formation of tubercular tissue. The inflammation usually begins in the mucous membrane of the pelvis and calices, gradually extending to the parenchyma, till more or less of the organ is replaced by the degenerated material. The tubercle may caseate and soften, or calcification may occur, the intervening space being converted into fibrous tissue. The other kidney is very apt to become involved, if not tuberculous, at least by a low form of nephritis and more or less of degeneration of its tissue and blood-vessels. Tubercular nephritis may be complicated by tuberculosis of other parts of the genito-urinary tract, by tuberculosis of the peritoneum, or, in fact, by tuberculosis of any other part of the system.

Symptoms.—The urine is more or less scanty, and contains, at different times, blood, pus, epithelium, tubercle bacilli, and, when the other kidney is the seat of chronic nephritis, albumen and casts are present. Pain of a dull, aching character over the affected organ may be constant, or there may be paroxysms, occurring at intervals. The kidney may become enlarged, so that the tumor mass may be readily felt. As the disease advances, the general symptoms characteristic of tuberculosis are seen; viz., hectic fever, night-sweats, and general emaciation.

Tuberculosis of the ureters and bladder may be a complication extending from the kidney, but rarely, if ever, occurs as a primary lesion. The same may be said of the prostate gland and vesiculse seminales.

Tuberculosis of the Testicle.—This form of the disease may be either primary or secondary, and occurs more frequently in early life than in later years. In twenty cases reported by Julian, twelve were under two years of age. Tubercle of the testes is most often confounded with malignant growths and syphilis. A careful examination of the body at large and a complete family history are important, before a diagnosis is made.

Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus.—These organs are usually involved secondarily, although, in rare cases, they are the seat of the primary lesion. This is especially true of the tubes, while that of the ovary and uterus will always be found in connection with general tuberculosis.

Tuberculosis of the Circulatory Apparatus.—This occurs as the result of the pulmonary lesion, and is not found as a primary disease.

Diagnosis.—If the bacilli of Koch is the real cause of tuberculosis, as generally accepted by the profession, the most certain diagnostic feature would be the finding of the bacilli in the sputum and other excretions. The reaction obtained by injecting tuberculin is also regarded as positive evidence of the presence of tuberculosis.

The family history is of great value in the early stages. The increased temperature, the gradual loss of flesh and strength, the general evidence of malnutrition, the hectic fever, night-sweats, the cough, hemorrhage, and emaciation confirm and render plain the diagnosis.

Prognosis.—While tuberculosis is generally regarded as one of the incurable diseases, we are to remember that it is not necessarily fatal; that the presence of the bacilli does not mean that tuberculosis has become an established fact. These micro-organisms may gain entrance into the system, but, failing to find a soil suitable for their propagation, are cast out, and but little harm results.

Post-mortem examinations have revealed again and again the presence of healed foci, showing conclusively that persons have recovered from tuberculosis. When, then, may the prognosis be favorable, and when unfavorable? Certain forms are less destructive, and the prognosis may be quite hopeful.

Tuberculosis of the lymphatics and also of the osseous system do not seem to possess the virus in such a malignant degree as other forms, and the tendency is often toward health. Tuberculosis of certain organs which can be removed by the surgeon, may be permanently relieved, such as bone affections, the mammary gland, the ovary, the uterus, the testicle, and glandular enlargements. These may be said to be the hopeful cases. Also when the family history is of good report and the previous health of the patient has been good; when digestion and assimilation are first-class and the elaboration of a good blood is going on. With these conditions the germs fail to make headway, and the prognosis is good. Also where the temperature remains normal or rises for but a short time each day, and where there is no hemorrhage.

An unfavorable prognosis would be where the conditions were just opposite to those above mentioned. Bad family history, gradual and progressive debility, feeble digestion and assimilation, hemorrhage repeated at intervals, cough more aggravated at night and early in the morning, and rapid emaciation,—these are conditions which would be recognized as unfavorable and almost necessarily fatal, especially where the environments are bad.

Treatment.—Prophylaxis.—If the generally accepted theory is true, that the bacillus is responsible for the disease, then all will agree that the destruction of the micro-organisms is one of the most important steps in preventing, not only the further spread of the disease, but also in limiting its ravages where it already has a foothold, thereby preventing reinfection.

It has been estimated that a patient suffering from pulmonary tuberculosis will expectorate, during the twenty-four hours, about seven billion of the bacilli; this from a patient who is still able to walk about and mingle with his fellow-men. The disgusting habit of expectorating on the floors of rooms, street-cars, and public buildings and sidewalks, should be discouraged by every means possible. The danger from this source should be taught in every school, and the children be impressed with the fact that herein lies one of the greatest menaces to the human family; for this is the one disease that is the scourge of humanity.

Patients confined to the house should be provided with spit-cups that can be easily cleaned or burned. If walking about, Knopf's pocket sputum-flask, made of aluminum, is very desirable. The sputum, when not burned, may be treated with a five per cent solution of carbolic acid, which successfully destroys the germs in thirty seconds. All utensils for sputum and secretions should be thoroughly boiled or cleansed with this acid solution.

Spitting in the handkerchief should also be discouraged, unless they are Japanese paper handkerchiefs and are immediately burned. Patients should also be instructed not to swallow any of the sputum, and thus avoid reinfection. Consumptives and all delicately inclined should avoid smoking, as there is danger in the virus coming from the consumptive cigar-maker, whose saliva is used to point the cigar. Dr. J. C. Spencer, of San Francisco, has demonstrated the presence of bacilli in various specimens of cigars, and though the nicotine may kill the germs it has also been proven that the dead bacilli contain a specific poison which is still capable of doing harm to the tissues.

Milk being a common source of infection, should be boiled or sterilized before use by the tubercularly inclined patient. The same may be said of tubercular beef, it should be thoroughly cooked. Kissing should be discouraged among all phthisically inclined, for while the virus is generally found more virulent in dried sputum, the breath from any diseased person can not be said to be health-producing. Where the sewage is defective, the excretions should be treated with carbolic acid solution before being emptied in a vault or even buried in the ground.

Delicate babies should not be intrusted to a wet-nurse unless it is known that she is perfectly free from tuberculosis; neither should they nurse from a tuberculous mother. Those phthisically inclined should live much in the open air, and all indoor occupations should be discouraged; also such trades where fine particles of dust are inhaled. Delicate children should be carefully guarded during the convalescent period of infectious disease, as the danger of tubercular infection is much greater at this time.

The diet should be wholesome, and sweetmeats, pastries, etc., should be restricted. Such exercise and gymnastics should be encouraged as develop the respiratory muscles and increase lung capacity.

To avoid frequent colds, the throat and neck should be bathed in cold water daily, followed by brisk rubbing with coarse towels. When possible, the sleeping apartment should be roomy and well ventilated, and the patient should sleep in a single bed. A change from the city to the country, or, better still, to a high and dry altitude or to an equable climate, is to be recommended where such advice can be followed.

In selecting a change of climate, one should go where there is a maximum of sun and a minimum of moisture, and where the temperature is equable. Such a climate is ideal for the tubercular patient. He must be much in the open air. Such a climate may be found in Arizona, New Mexico, and Southern California. Colorado has also earned a well-deserved reputation for respiratory diseases. Many are permanently benefited by a sojourn in the Adirondacks, while the mountains of the Carolinas and Georgia have proved curative. Texas, with its wide extent of territory, furnishes sections where tuberculosis is unknown and where patients recover.

Where, with such a wide range of territory, shall we send our patient? This is not always easy to determine. If the patient be fairly robust, the Adirondacks will be ideal, as will be Colorado; if more delicate and less able to resist shock, the sunny, dry, and equable climate of New Mexico, Arizona, or Southern California, will be more desirable. In fact, much depends upon the effect that the climate has upon the individual. If it improves the appetite, enables the patient to sleep, and invigorates generally, and the patient increases in flesh, he has found his climate, and should abide there; if, on the other hand, there is no gain in flesh, the patient sleeps poorly, and the appetite is not increased, he must move on; but wherever he goes, he must be much in the open air.

After cavity formation, hectic fever and night-sweats appear, the patient should not be allowed to leave home, as the change usually hastens the fatal termination, and, besides, depriving him of the comfort and pleasure of home and friends during his last hours.

Treatment of the Disease.—The treatment of tubercular patients will depend largely upon the stage of the disease. In the earlier stages our object would be to improve the general health, and get a better elaboration of blood; in other words, to raise the vital force of the individual to such a point that the soil will not grow or develop the poison or germ, and in this way bring about a cure. Thus it is a question of nutrition.

Hygienic measures will form a great aid in the curative action of remedies; for I believe that very many cases, if seen in the early stages, can be cured. The treatment is usually quite plain. A little medicine; plenty of pure, fresh air and sunshine; gentle exercise, not enough to produce weariness; a tonic for the digestive apparatus; means to establish the secretions; a remedy for the cough,—and the patient, if curable, will soon show the effects of the treatment.

One great axiomatic truth that the physician should never lose sight of, is that any remedy which disturbs the stomach should at once be withdrawn. A good appetite and a good digestion are requisite for improvement; hence codliver-oil should seldom be prescribed. Once in perhaps a hundred cases, will you find a patient who can take codliver-oil and not disturb his stomach, and for such patients this remedy is permissible. Nevertheless I am inclined to believe that good, sweet breakfast bacon, and the fat of beefsteak and roast-beef, will prove just as efficient as the oil, and is at the same time not only more palatable but more easily assimilated.

Creosote is another agent which must be carefully administered or gastric disturbance will follow, which will be far more harmful, than the slight benefit derived from the remedy.

Arsenic is one of the agents which we will very early administer in the disease. Fowler's solution, twenty drops in four ounces of water, a teaspoonful every four hours, will prove of great benefit.

Veratrum.—These two remedies, Fowler's solution and veratrum, were almost invariably used by the late Dr. A. J. Howe. His method was to give arsenic one day and veratrum the next, and his success with these remedies was very marked. Veratrum is given in this case, not as a sedative, but for its alterative effect, there being few better remedies.

Nux Vomica and Hydrastis will be found useful where the appetite is poor and digestion feeble.

Howe's Acid Solution of Iron.—Where an acid is indicated,—red tongue, and mucous membranes,—drop doses of this preparation three times a day, will be found beneficial. It sharpens the appetite, and tends to arrest the excessive waste of tissue.

Cough.—The cough is one of the most distressing features of the early disease. Stillingia liniment in drop doses is very effective in relieving this troublesome symptom. A drop on a lump of sugar every one, two, or three hours, will secure rest from cough, and also restore the voice. In some cases it will give better results used as an inhalation. Squeeze a sponge out of hot water, and drop a few drops of the liniment upon it, and then hold over the mouth.

If there is pleuritic pain with the cough, bryonia will be found useful. In the later stages, codein and ipecac will give relief, but heroin, one-twelfth grain, every three, four, or five hours, will prove the most successful in the advanced cases.

For the fever, frequent sponging with warm water, and, incidentally, the indicated sedative should be given.

Night-Sweats.—Aromatic sulphuric acid, from ten to thirty drops at bedtime, is found useful. Also 1/100 grain doses of atropia. Camphoric acid in twenty-grain doses has proven quite beneficial. Picrotoxin in 1/60 grain doses may also be given with benefit.

Diarrhea.—Subnitrate of bismuth in mint-water, or the sub-gallate bismuth with opium, will prove reliable agents for this troublesome complication.

Hemorrhage.—Gallic acid in five-grain doses is a very positive agent. Where the hemorrhage is of a passive character, give carbo-veg.; oil of cinnamon on sugar, or equal parts of cinnamon and erigeron, are remedies which will be of certain benefit. Mangifera indica is another excellent agent in passive hemorrhage.

The diet should be carefully selected. Milk, in some form, should be taken liberally. One patient will do well on sweet milk, another on buttermilk, while a third will need koumiss. Eggs may be taken freely. Where fats can be taken and digested, they should form a part of the patient's diet. A change of air or a sea-voyage, where the patient is able to comply with such a prescription, is the best tonic.

Tuberculosis: Tuberculosis of the Lymph Glands - Acute Pneumonic Phthisis - Chronic Tuberculosis

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.