Auscultation reveals an increased and perhaps a broncho-vesicular quality
TUBERCULOSIS. 1 57
of the spoken voice, the breathing has become more bronchial in character
and the expiration is further prolonged and is blowing in quality. Ultimately
the breathing and voice, as the consolidation becomes more pronounced and
of greater extent, become bronchial. Rales due to pleuritic and bronchial
inflammation are also present.
The signs revealed during the third stage by inspection are those of the
second in a more advanced condition; the wasting is still more apparent, the
retraction of the chest is more marked, the respiratory movement more re-
stricted. The surface temperature is perceptibly increased, the skin may be
moist if sweating is present and the vocal fremitus is further exaggerated.
The dulness on persussion is often increased to flatness and upon the occur-
rence of cavity formation becomes tympanitic, amphoric or "cracked pot" in
character if the lesion is near the surface. The note may be unchanged if
the cavity is small and deeply-seated. Wintrich's sign is pathognomonic;
given a cavity communicating with the bronchus the note elicited by per-
cussion is Ipwer in pitch with the mouth shut than with open mouth.
Auscultation reveals the presence of moist rales resulting from the softening
and breaking down of the tuberculous deposits. Over cavities the breathing
is cavernous or amphoric and the voice possesses similar quantities; pector-
iloquy upon whispering or speaking aloud may be present. The amphoric
quality is given to the breathing if the cavity walls are firm and smooth, while
with softer waUs a cavernous quahty is transmitted to the voice. Gurgling
rales may be caused by the air passing through the fluid contents of a cavity.
The diagnosis of chronic phthisis presents difficulties during the early stages
only; unfortunately the presence of the bacillus in the sputum is not likely
to occur until there is ulceration or disintegration of the tuberculous nodules.
It is most important that the diagnosis should be made as early in the disease
as possible for at this time treatment, properly applied, is able, in most instances
to effect a cure. The early physical signs upon which stress should be laid
are the presence of slight dulness and diminished breathing and prolonged
expiration at the apices, together with whispering bronchophony, a trans-
mission of the heart sounds toward the apices and an accentuation of the
pulmonary second sound. These last three signs are obtainable two to three
months before the X-ray will give a shadow. An increased rapidity of the
pulse, slight evening rises of temperature coupled with a flushed cheek, a
dilated pupil and perhaps loss of flesh are always suspicious. Streaks of
blood in the expectoration, though these may come from the naso-pharynx,
should always lead the physician to make a most careful physical examination.
It may be stated that the patient in whom a pulmonary haemorrhage is an
early symptom is fortunate since it induces him to consult the medical man
and to watch his condition most carefully.
The tuberculin test may be employed in dubious instances; it is without
158 THE INFECTIOUS DISEASES.
danger and is usually reliable. Its technique is as follows: A hypodermatic
injection of 5V of ^ grain (o.ooi) of piu-e tuberculin is given. Should no
febrile reaction ensue within 10 or 12 hoiurs the dose is doubled 2 or 3 days later
and is progressively increased until yV of a grain (0.005) ^^ given. If no
rise of temperature is evident after this dosage tuberculosis is probably absent.
The agglutination and serum tests advocated by Arloing and Courmont
may prove to be very useful. Early in the disease the Rontgen ray has only
a limited use in the diagnosis since the only noticeable abnormality is a
diminished excursion of the diaphragm upon the affected side. Areas of
consolidation are indicated by distinct shadows and special infiltrations may
be evidenced by a blurred appearance upon the plate.
In this disease, associated with the tuberculous process, is a productive
inflammation of the lung resulting in an increased growth of fibroid tissue.
Its onset is gradual and it may occur following chronic ulcerative phthisis or
it may be engrafted upon a tuberculous broncho-pneumonia or pleurisy.
The lung is firm, tough and grayish on section as a result of the over-growth
of fibrous tissue; the bronchi may be dilated and bronchiectatie cavities are
often present; tuberculous cavities are observed at the apex; cheesy foci
surrounded by fibrous tissue may be present; in the two last lesions tubercle
bacilli are to be found. While one lung is in the condition described the
other may be emphysematous or contain miliary tubercles. The right heart,
and sometimes the left as well, is hypertrophied and there may be amyloid
degeneration of the viscera.
Sjanptoms. Cough is present and is frequently paroxysmal, but this, with
the other symptoms, emaciation, fever, etc., is less pronounced than in ulcer-
ative phthisis. The sputum is often profuse, owing to the presence of bron-
chiectatie and other cavities, and may be foetid. Bacilli are less easily found
than in ordinary chronic phthisis. Pulmonary haemorrhage may occur and
oedema of the feet may result from failure of the heart's action. The coiurse
of the disease is usually protracted.
Physical Signs. The chest wall over the diseased lung is sunken and
the heart may be displaced owing to retraction of the lung. The intercostal
spaces are narrow and the area of the cardiac apex beat may be much enlarged.
The characteristic percussion note is dull and high-pitched; vocal fremitus
is diminished. Auscultation may reveal the presence of cavities especi-
ally at the apices, elsewhere there areas of bronchial breathing and increased
vocal resonance unless the pleura is thickened. Bronchiectatie cavities
may be present in the middle or lower lobes. The signs of emphysema may
be noted in the other lung and cardiac murmurs are not infrequent.
TUBERCULOSIS. 1 59
The Prognosis of Chronic Pulmonary Tuberculosis.
In the ulcerative as well as in the fibroid form of the disease, although the
duration of the latter type is longer, the prognosis is serious, but it is certain
that many subjects of pulmonary infection with tuberculosis do spontaneously
recover. This is proven by the numberless autopsies, in deaths from other
causes, in which healed tuberculous lesions are found. In these the tuber-
cles have undergone fibroid or calcareous degeneration. In the encapsulated
caseous masses while the process may be considered inactive it cannot be
said to have wholly ceased to exist. Even patients in whose sputum bacilli
and elastic tissue have been demonstrated, have recovered; consequently in
the light of the above stated facts we may safely say that pulmonary tuber-
culosis is a curable disease.
The cases in which the prognosis is most favorable are those with good
heredity, previous robust health and good digestion, slow invasion, only slight
febrile movement and sHght pulmonary involvement. When the initial inflam-
mation is pleuritic, recovery may be considered probable, while the oppo-
site is true of cases with frequent pulmonary haemorrhages.
The average duration of the disease differs, being, according to the statis-
tics of different observers, from two and a half to seven years. Proper treatment
will, in the great majority of instances, render the patient more comfortable
and materially prolong his life.
Prophylaxis. This consideration is quite as important as treatment, for
in the light of our present knowledge the disease is distinctly preventable in
The public should be educated by such means as those employed by
the Department of Health of New York City, and pulmonary tuberculosis
should be considered a reportable disease on account of its infectious
character. The following is a copy of a circular issued and circulated by
the New York Health Department indicating the attempt that is being
made to awaken the masses to the importance of the crusade against
" Consumption is a disease of the lungs, which is taken from others, and is
not simply caused by colds, although a cold may make it easier to take the
disease. It is caused by very minute germs, which usually enter the body
with the air breathed. The matter which consumptives cough or spit up
contains these germs in great numbers â€” frequently millions are discharged in a
single day. This matter, spit upon the floor, wall or elsewhere, dries and
is apt to become powdered and float in the air as dust. The dust contains
the germs, and thus they enter the body with the air breathed. This dust
is especially likely to be dangerous within doors. The breath of a consump-
tive does not contain the germs and will not produce the disease. A well
l6o THE INFECTIOUS DISEASES.
person catches the disease from a consumptive only by in some way taking
in the matter coughed up by the consumptive.
" Consumption can often be cured if its natiire be recognized early and if
proper means be taken for its treatment. In a majority of cases it is not a
"It is not dangerous to live with a consumptive, if the matter coughed up
by him be promptly destroyed. This matter should not be spit upon the floor,
carpet, stove, wall or sidewalk, but always, if possible, in a cup kept for that
purpose. The cup should contain water so that the matter will not dry, or
better, carbolic acid in a five percent, watery solution (six teaspoonfuls in a
pint of water). This solution kiUs the germs. The cup should be emptied
into the water closet at least twice a day, and carefully washed with boiling
" Great care should be taken by consumptives to prevent their hands,
faces and clothing from becoming soiled with the matter coughed up. If they
do become thus soiled, they should be at once washed with soap and hot water.
Men with consumption should wear no beards at all, or only closely cut mus-
taches. When consumptives are away from home, the matter coughed up
should be received in a pocket flask made for this purpose. If cloths must
be used, they should be immediately burned on returning home. If hand-
kerchiefs be used (worthless cloths, which can be at once burned, are far
better), they should be boiled at least haK an hour in water by themselves before
being washed. When coughing or sneezing, small particles of spittle con-
taining germs are expelled, so that consumptives should always hold a hand-
kerchief or -cloth before the mouth during these acts; otherwise, the use of
cloths and handkerchiefs to receive the matter coughed up should be avoided
as much as possible, because it readily dries on these, and becomes separated
and scattered into the air. Hence, when possible, the matter should he received
into cups or flasks. Paper cups are better than ordinary cups, as the former
with their contents may be burned after being used. A pocket flask of glass,
metal, or pasteboard is also a most convenient receptacle to spit in when away
from home. Cheap and convenient forms of flasks and cups may be purchased
at many drug stores. Patients too weak to use a cup should use moist rags,
which should at once be burned. If cloths are used they should not be carried
loose in the pocket, but in a waterproof receptacle (tobacco pouch), which
should be frequently boiled. A consumptive should never swallow his expec-
" A consumptive should have his own bed, and, if possible, his own room.
The room should always have an abundance of fresh air â€” the window should
be open day and night. The patient's soiled wash-clothes and bed linen
should be handled as little as possible when dry, but should be placed in water
until ready for washing.
" If the matter coughed up be rendered harmless, a consumptive may frequently
not only do his usual work without giving the disease to others, but may also
thus improve his own condition and increase his chances of getting well.
"Whenever a person is thought to be suffering from consumption, the
Department of Health should be notified and a medical inspector will call
and examine the person to see if he has consumption, providing he has no
physician, and then, if necessary,^ will give proper directions as to treatment.
" Rooms which have been occupied by consumptives should be thoroughly
cleaned, scrubbed, whitewashed, painted or papered before they are again
occupied. Carpets, rugs, bedding, etc., from rooms which have been occupied
by consumptives, should be disinfected. Such articles, if the Department of
Health be notified, will be sent for, disinfected and returned to the owner
free of charge, or, if he so desire, they will be destroyed.
"When consumptives move they should notify the Department of Health.
" Consumptives are warned against the ?nany widely advertised cures, specific
and special methods of treatment of consumption. No cure can he expected
from any kind of medicine or method, except the regularly accepted treatment,
which depends upon pure air, an out-of-door life and nourishing food.''
Legislation with reference to the sanitary condition of tenement houses,
to the inspection of the sources of our meat and milk supply and against
promiscuous expectoration is a necessary step in prevention, as well as thorough
disinfection of rooms and their contents after occupation by tuberculous
individuals and the estabhshment of municipal, state or even federal sana-
toriums and tuberculosis dispensaries. At least one of the hospitals of New
York City has a corps of visiting nurses who go to the houses of patients who
are under treatment at the institution's out-patient department and instruct
the family in the necessity of cleanliness, in the care of sputum, etc.
The sputum being the chief means by which the disease is disseminated
should be thoroughly and at once destroyed. It should be received into earthen
or enamel-ware cups in which a i to looo solution of mercury bichloride or
a 4 percent, solution of carbolic acid is constantly kept; where it is impossible
to procure these germicides water should be substituted since the bacilli
unless dried are not carried by the air, or the patient may expectorate into
bits of old muslin or even a Japanese napkin which is to be immediately
burned. The burnable pasteboard sputum cup is a useful and safe appli-
ance. All permanent receptacles for sputum should be scalded out with
boiling water at least once a day.
The proper care of delicate children whether born of tuberculous parents
or not is most important. The tuberculous mother should not nurse her
child and the general surroundings of the predisposed infant should be of
the most healthful character. Catarrhal diseases are much to be feared,
consequently the child should not be allowed out of doors upon cloudy, damp
l62 THE INFECTIOUS DISEASES.
days during the cold months and the condition of the upper air passages
should be kept as healthful as possible. The importance of the removal
of adenoids and h}^ertrophied tonsils cannot be over-estimated. Proper
clothing â€” woolen next the skin â€” should be vt^om. After the child's bath,
sponging with cold water â€” 60Â° to 70Â° F. (15.5Â° to 21Â° C.) â€” is an excellent
method of hardening. The diet should be plentiful, plain and nourishing
and a Hking for milk, if not already present should be cultivated. All ill-
nesses, no matter how insignificant should be carefully treated and the admin-
istration of such tonics as iron, especially syrupus ferri iodidi, arsenic and
codliver oil may be attended with benefit. As the child grows older he should
be encouraged to lead an out-door life, exposirre to cold and wet, however,
being avoided, and in the pursuance of gymnastic and respiratory exercises.
When it becomes necessary to choose his life-occupation one which will tend
to keep the subject in the open air as much as possible is to be preferred.
Protection by Immunization. Von Behring claims to have discovered a
method of immunization of man which is sure, rapid and without danger.
He believes that the immunizing substance is contained in the bodies of the
tubercle bacilli and acts by combining with certain living cellular elements.
His theories have been proven . by animal experimentation and he believes
that it is possible by the same methods to protect the human subject against
tuberculous infection. The discovery is not to be given to the world until
further experimentation and clinical study have been carried out. A state-
ment like the above coming from Professor von Behring carries much weight.
Treatment. Pulmonary Phthisis is an infection and should be treated
as such. The patient's life should be regulated and his condition watched
as carefully as in enteric fever or diphtheria. Each patient is a law unto
himself consequently no one method is applicable in all cases and seldom
does any single method succeed in a given case, the best results being obtained
by a combination of appropriate modes of treatment. Climatic treatment,
dietetic treatment, drug treatment, each has a distinct place but we should
not be satisfied to employ them singly; we should use all means at our dis-
posal, keep up the patient's nutrition, constantly watch him in every phase
of his disease and work continuously to benefit him. The special consider-
ations are to improve the nutrition by proper hygienic mode of life and feed-
ing; to arrest the tuberculous process; and to relieve the unpleasant symp-
toms as they arise.
a. Climatic Treatment. When it is possible to remove the patient, a suitable
climate should be sought as soon as the diagnosis is suspected. The ideal
climate is dry, of equable temperature and one which affords the largest
number of sunny days; such a one is, however, impossible to find since no
dry climate possesses an equable temperature, consequently we should select
a region the meteorological characteristics of which approach as nearly as
possible to this ideal. In many instances it will be impossible to choose a
climate for a given case and the only possible method of selection is to experi-
ment until one is found in which the patient does well. In general it may be
stated that an altitude of from 2000 to 2500 feet is more favorable than a
low lying region. Another important consideration is that the patient must
not be sent to a place where good accommodations and food cannot be
Evans gives the following useful classification of climates.
1. Cool moderately moist climate, general elevation 2000 feet â€” the western
slope of the Appalachian range, the Adirondacks, Catskills, Alleghanies, and
2. Moderately warm and moist climate, elevation 2250 feet â€” Asheville,
N. C; Aiken, S. C; Marietta and Thomasville, Ga.
3. Warm and moist climateâ€” the coast regions of Florida and Southern
4. Warm and moderately dry climate, elevation about 2000 feet â€” South-
western Texas and Southern California inland.
5. Cool and moderately dry cUmate, elevation about 1000 feet â€” Min-
nesota, Nebraska and Dakota.
6. Cool and dry climate, elevation 4000 to 7000 feet â€” Montana, Wyoming,
Colorado, Northern New Mexico and Western Kansas; Davos and St. Moritz,
7. Warm and dry climate, elevation 3000 to 5000 feetâ€” Southern New
Mexico and Southern Arizona.
The Adirondacks are a very favorite resort for the tuberculous of the vicinity
of New York City and even though the elevation is considerable the per-
manence of an estabhshed cure is not jeopardized by a return to sea-level.
The patients who do best at an altitude are those in whom the disease has not
gone on to cavity formation and whose nutrition is good; the opposite is
true of advanced cases especially if emphysema or cardiac weakness is present.
Such conditions usually contraindicate removal to a high altitude and the
patient is more likely to be benefited by a moist and warm climate than by
one which is cold and dry. In conclusion it may be stated that Hfe in the
open air is essential in whatever climate the patient may be.
Hygienic treatment consists in first securing ventilation and simlight.
The dwelling should be situated upon high rather than low ground and should
be as accessible to the sun as possible. The importance of the latter consid-
eration is shown by the fact that case after case of tuberculosis continued to
occur in certain houses in Massachusetts until the removal of the numerous
trees which shaded them. After this was done the disease disappeared as
if by magic. Proper drainage is important and the patient's apartment should
be one to which the sunlight has access for as much of the day as possible.
164 THE INFECTIOUS DISEASES.
Ventilation by a fire place is to be advised and the patient should sleep with
the windows open even in the coldest weather, but protection from draughts
must be secured. The air within the sleeping-room should be identical
with that out of doors.
During the day the patient should spend as much of the time in the open
air as possible and should take such exercise in moderation as the condition
of his circulatory apparatus will allow. Sitting in the sunlight should be
encouraged but it is better to keep in motion if the physical condition permits.
The employment of hydrotherapeutic treatment as a cturative measure
may be neglected; it is however important in prophylaxis. Daily baths,
however, should be taken in order to keep the skin and circulation active.
Cool water may be used but not unless the rub dov^n after the bath is suc-
ceeded by a good reaction. The risk of chiUing the body should not be taken.
Breathing exercises are important and by their means the lung capaciy
and chest expansion are capable of a considerable increase. They consist
in taking several successive deep breaths, the patient standing upright in the
open air meanwhile. Each breath is held for a few seconds and then slowly
exhaled. In proper cases, the condition of the heart permitting, calisthenics
in moderation are excellent. The exercises which make up the " setting up
drill" of the United States Army may be employed.
The patient's clothing is an important consideration, wool of weight varied
according to the temperature should be worn next the skin at aU seasons
of the year, both day and night. As a sleeping dress nothing is better than
pajamas of flannel or a night-gown reaching to the feet.
The open-air treatment has been of late much exploited and is undoubtedly
a method of great value. It may be employed at home in the city or country,
or in institutions. It may be difficult to carry out in the city but if the phy-
sician insists upon its importance it will be possible to overcome many obsta-
cles. The roof or back yard may be used upon pleasant days, and an ordinary
steamer chair provided with cushions and blankets makes an excellent couch
if it is necessary that the patient recHne. Days upon which it is not advisable
to send the patient actually out of doors he should recline, warmly WTapped,
if necessary, before the open window of his apartment which should be the
most sunny and airy room in the house. At night the windows should be
open so that unless the weather absolutely forbids the patient spends practi-
cally all his time in the open air. Such symptoms as fever, sweats and haemop-
tysis should not be allowed to interfere with the treatment.
The sanatorium treatment has recently been developed to a considerable
degree. The great advantage of institutional treatment is that the patient's
mode of life is in every way regulated upon the Unes most beneficial to him.
Exercise, sleep, diet, amusement, etc., are arranged in accordance with the
most hygienic methods. Emphasis must be laid upon the importance of
the establishment of pubhc sanatoriums near large cities so as to be avail-
able for early cases and those of moderate means.
Tent life for the tuberculous. This mode of treatment is only another phase
of the out-of-door fresh air method. Tents or tent cottages may be con-
structed according to any desirable plan and life in these is practically an
existence in the open air.
Dietetic treatment is perhaps the most important consideration in the
management of pulmonary tuberculosis but presents certain difficulties.
The importance of proper feeding cannot be too strongly emphasized; the
well-nourished organism is able to throw off tuberculous infection and it is
certainly probable that the poorly nourished organism which is the subject