Consumption, in popular acceptation, and as used by physicians, a term denoting certain affections of the lungs, involving in general more or less destruction of these organs, together with progressive emaciation, and in a very large proportion of cases ending fatally. The term has been sometimes used to denote affections of other organs, but its meaning is now restricted as just stated; and although the word pulmonary is often prefixed, this word is understood wherever the term is used alone. The name derives its significance from the consuming effects as regards the lungs, and the wasting of the whole body. Another popular term is "the decline," which has a similar significance. A technical name is phthisis, or phthisis pul-rnonalis, the etymological sense of which is the same as consumption. Tuberculous or tubercular disease of the lungs, and pulmonary tuberculosis, are other synonymes, relating to certain characteristic morbid products within the lungs. There are still other designations which late writers have proposed, namely, tuberculous pneumonia, cheesy pneumonia, chronic lobular pneumonia, and catarrhal pneumonia.
All these concur in calling the disease a pneumonia, that is, an inflammatory affection of the lungs; and the different words prefixed are intended to distinguish this disease from other forms of pneumonic inflammation. The importance of this disease is evident when its fatality and prevalence are considered. The proportion of recoveries from it is small. It prevails to a greater or less extent in almost every portion of the globe, and if those diseases which prevail as epidemics or endemics be excluded, it occasions a larger proportion of deaths than any other disease. Statistics show that of the population of Great Britain, France, Germany, and Russia, numbering less than 200,000,000, the annual deaths from this disease are about 870,000; and that of the people inhabiting the globe at least 3,000,000 die each year from this disease. - In the great majority of cases consumption is of long duration; it is therefore eminently a chronic affection. There is, however, an affection called acute consumption, acute phthisis, or acute pulmonary tuberculosis, which runs a rapid course. It is always fatal, and the duration may not extend beyond a few weeks, and sometimes death takes place within a few days from the first manifestations of disease. This affection is extremely rare.
Prominent symptoms are rapid breathing, distress from a sense of the want of breath (dyspnoea), a livid coloration of the lips and face, together with more or less cough and expectoration. With these symptoms are associated high fever, as denoted by the pulse and the temperature of the body, great prostration, loss of appetite, and progressive exhaustion. After death the lungs are found filled with small round bodies which, from their resemblance in size to millet seeds, are commonly known as miliary tubercles. Other names are gray tubercles and semi-transparent granulations. The latter name is applicable to them only at an early period after their production. In a short time they become opaque and comparatively of soft consistence. Some pathologists of late propose to limit the term tubercles to these bodies, and consider that their presence is essential in order to constitute a truly tuberculous affection. Consumption in its ordinary form, that is, as a chronic affection (the sense in which the term will be used in the remainder of this article), is distinguished by other and widely different changes found after death. Generally the lungs contain cavities more or less numerous and varying in size, called by the older writers vomica.
These are irregular in shape, and frequently they communicate with each other. Of course they involve an amount of destruction of the pulmonary structure proportional to their number and size. In addition to cavities, usually portions of the lungs are found to be solidified by the presence of a morbid product which has been known as yellow and crude tubercle, or tuberculous infiltration. This is now generally regarded as an inflammatory product, and hence the propriety Of calling the affection a form of pneumonia. The point of departure of the process of inflammation which occasions this product is supposed to be the membrane lining the air cells of the minute bronchial tubes. This product undergoes a cheesy degeneration, so called because it has the consistence of cheese. At length it softens so as to become changed into a thick liquid resembling purulent matter or pus. Ulceration then takes place, the liquefied product is discharged into the bronchial tubes, and it forms a certain proportion of the matter which is expectorated, leaving cavities.
As a rare exception to the general rule, the discharge takes place into the pleural cavity, giving rise to a perforation of the lung, and as a consequence to the affection known as pneumo-hydrothorax. In most cases, after death from consumption, the several stages of the characteristic changes in the lungs are associated, because different portions of the organs are affected at successive periods of time. It is a law of the disease, to which there are occasional exceptions, that the upper part of one lung is first affected; but shortly afterward the upper part of the other is invaded; the affection then extends downward after variable intervals. Hence it is that often different sections of the lungs represent the series of changes which have taken place. In addition to the changes just noticed, in most cases miliary tubercles are found, being sometimes few in number and sometimes abundant. There is evidently some pathological connection between these tubercles and the other changes; but, as regards this connection, the views of different pathologists differ; some considering the tubercles as preceding and giving rise to the other changes, and some regarding the latter as primary, and standing in a causative relation to the former.
Further morbid changes generally found on postmortem examinations are those denoting pleurisy. As a rule, affected portions of the lungs are adherent to the walls of the chest, this being a result of circumscribed pleuritic inflammation; and in some cases the pleurisy gives rise to an effusion of liquid in greater or less quantity between the pleural surfaces, in other words within the cavity of the pleura. - The disease in the majority of cases is developed slowly and often almost imperceptibly. Usually cough is the primary pulmonary symptom. It is at first slight and dry, after a variable period becoming more marked and accompanied by expectoration. The early cough and expectoration represent a circumscribed bronchitis. As the disease progresses, the expectoration becomes abundant, consisting of mucous secretions, the liquefied tuberculous product, and purulent matter. Spitting of blood (hcemop-tysis) is sometimes the first symptom pointing to the pulmonary affection. This symptom in some cases precedes the cough, and perhaps occurs when the health is apparently perfect. It is absent in a minority of the cases of consumption, and is apt to occur repeatedly, and in some cases a great number of times at variable intervals.
The quantity of blood expectorated varies, being sometimes small and sometimes profuse. In some very rare instances the loss of blood is the immediate cause of death. In general, however, there is no danger from the haemorrhage, and, so far as its apparent effect upon the progress of the disease is concerned, it is favorable. Statistics show that out of a considerable number of cases, the disease is non-progressive, or progresses slowly, in those in which the spitting of blood is frequent and profuse. Pain in the chest is not infrequently entirely wanting, and it is seldom a prominent symptom. The pulmonary affection in itself occasions no pain; when it occurs it is due to the pleurisy which is developed as a complication of the affection of the lungs. The pain which denotes pleuritic inflammation is short and stitch-like, and is referred by the patient to the upper part of the chest, or beneath the shoulder blade. Pain of this description occurring at intervals denotes successive attacks of circumscribed pleurisy; the pain, however, is rarely sufficient to occasion much inconvenience.
The frequency of respiration is in proportion to the extent of the pulmonary affection, and the breathing becomes panting on exercise; but it is not common for patients to suffer greatly from a sense of the want of breath. With these symptoms referable to the chest are associated symptoms which it is customary to distinguish as constitutional. The pulse is more or less accelerated, and the heat of the body, as determined by the thermometer, increased. These constitutional symptoms are marked in proportion as, the disease is actively advancing. Paroxysms of hectic fever occur daily in the afternoon, often commencing with a chill, and generally ending with profuse perspiration. Perspirations are of frequent occurrence without being preceded by marked febrile paroxysms, especially during sleep, whence they are known as night sweats. Chills also, or chilly sensations, are not infrequent without being followed by fever and sweating. Sooner or later the appetite fails, and there is sometimes an invincible repugnance to food. The digestion is sometimes disordered, but in many cases the food which is taken occasions no ailments referable to the stomach.
As the pulmonary disease advances, there is progressive reduction of the weight of the body, ending at length in notable and sometimes extreme emaciation; and the muscular strength proportionally decreases. In females the menses diminish and at length cease. Diarrhoea is sometimes a prominent symptom, and occurring in a late period, it has been called, from the exhaustion which it occasions, colliquative diarrhoea. The ends of the fingers sometimes become enlarged or bulbous, forming the " clubbed fingers" which are quite characteristic of this disease, although they are occasionally observed in other affections. Dropsical swelling of the feet and lower limbs is a symptom belonging to a late period of the disease. It is a remarkable fact that the mental faculties usually remain intact, with the exception that the effect of the disease upon the mind is such as often to impair the ability to appreciate the fact of the existence of a serious affection. Patients frequently, even when the disease is far advanced, entertain confident expectations of recovery. They may refuse to believe that there is any danger, and perhaps are forming plans which involve prolonged life and health when it is evident to all around them that they are on the verge of the grave.
The duration of the disease in fatal cases is extremely variable. In some exceptional instances it runs a comparatively rapid course, ending in a few weeks. In such cases it has been called "galloping consumption." It rarely ends within a period of three months; it is by no means uncommon for it to extend to two or three years; and it not very infrequently lasts from 10 to 20 years. The writer has known an instance in which the disease existed for 40 years, proving fatal at the end of this period. - The diagnosis of consumption is now, with the aid of indications furnished by auscultation and percussion, made with facility and positiveness. It may be diagnosticated at an early period, before it has made much progress. Moreover, the extent to which the lungs are affected and the amount of lesion are determined with great precision. The symptoms belonging to the clinical history which are especially diagnostic, in addition to a persistent cough with more or less expectoration, are spitting of blood, stitch-like pains at the summit of the chest, irregularly recurring chills, a frequent pulse, rise of the temperature of the body, an increase of the number of respirations per minute, perspiration during sleep, febrile exacerbations or hectic paroxysms, and progressive emaciation.
The signs obtained by auscultation and percussion are those which represent the morbid physical conditions incident to the disease, namely, solidification of portions of the lungs, the presence of liquid in the air tubes, roughening of the pleural surfaces with lymph, and the existence of cavities. Certain complications are significant as regards the diagnosis, such as chronic laryngitis, giving rise to huskiness and not infrequently loss of voice; tuberculous ulcerations of the intestines, causing persistent diarrhoea; perineal fistula, and chronic inflammation of the peritoneum. On the other hand, there are certain affections which appear to exert a protective influence against consumption. The disease is rarely developed in those who suffer from asthma, pulmonary emphysema, and the structural affections of the heart which produce notable disturbance of the circulation. - Our knowledge of the causes of consumption is still obscure. The popular belief is that the disease is caused by "taking cold," that is, follows a bronchitis. The study of a large number of cases fails in furnishing support for this belief. It is quite certain that a cold, whenever it appears to enter into the causation, acts only as an exciting cause, and is not sufficient in itself to produce the disease.
Nor does the disease often follow acute inflammation of the lungs or pneumonia. This statement also applies to pleurisy. Statistics have shown that those who have contracted chests are not in consequence more liable to become consumptive. A hereditary influence undoubtedly enters often into the causation, persons whose parents or grandparents have been tuberculous being more likely to die of consumption than others. Moreover, facts show that sometimes, when progenitors have not been tuberculous, there is an innate constitutional tendency to consumption. As an illustration of this statement, the following may be cited: Five children of parents who were living and well died with consumption on arriving at ages of from 22 to 24; they were all the children of these parents, and none of the progenitors of the latter had been known to die with consumption. Here must have been a congenital tendency, and there is no evidence that this tendency was inherited. A predisposition relates to age. In the great majority of cases the disease is developed between the ages of 20 and 30 years; no age, however, is exempt from a liability to it. Climate has a manifest influence.
Consumption prevails much more in climates which are humid and subject to frequent alternations of cold and heat, than in those which are dry and uniformly either warm or cold. Prof. Bowditch has ascertained that in the state of Massachusetts cases of consumption are especially numerous in situations in which the atmosphere is rendered humid by streams or marshes. A high altitude affords protection against the disease. A French writer, Jac-coud, states that observations for 15 consecutive years warrant him in asserting that in Alpine situations elevated 4,000. feet tuberculosis is almost unknown; and Dr. Hjaltelin, who resides in Iceland, affirms that the inhabitants of that country enjoy exemption from consumption. Statistics prove that the disease prevails especially among persons whose occupations involve a sedentary life and confinement within doors, such as clerks and printers. A conclusion to be deduced from what is known of the causation is, that causative agencies exert their influence by producing a constitutional deterioration, the essential nature of which is unknown. This condition, when it constitutes a predisposition to consumption, is called the tuberculous diathesis, and when sufficient to give rise to the disease it is called the tuberculous cachexy.
An interesting and important discovery bearing on the causation of tuberculous disease was made in France in 18G5, by Villemin. He demonstrated by a series of experiments that tuberculous disease may be communicated by inoculation from man to certain animals, namely, rabbits and guinea pigs. These experiments have been repeated with the same result by others. It appears, however, that inoculation with morbid matter other than that from the tuberculous products is also followed by the development of tubercle. Were it true, as assarted by Villemin, that tuberculous products only are capable of producing the disease by inoculation, and that therefore these products must contain a specific morbid material of the nature of a virus, the fact would lend strong support to the opinion that consumption is to be reckoned among the contagious diseases. This opinion has been heretofore held by some, being based on instances of persons who live in close companionship, especially as husband and wife, becoming successively affected. The study of a large number of cases with reference to this point, however, affords but little evidence of the disease being communicable. - Consumption ends fatally in the great majority of cases.
This well known fact leads to an underestimate of the number of cases in which recovery takes place. Cases are not extremely infrequent in which the progress of tuberculous disease ceases before the lungs have become greatly damaged. The traces of an old tuberculous affection are not very uncommon in bodies examined after death from other and various diseases. This arrest of the progress of the disease sometimes takes place spontaneously, that is, under circumstances which seem to denote an inherent tendency to recovery. Small tubercles in the lungs may undergo the calcareous degeneration; the organic matter which they contain is absorbed, leaving the mineral portion, and in this form they may be expectorated. These so-called " obsolete tubercles," or pulmonary calculi, sometimes expectorated in great numbers, are thus evidence that there has existed a tuberculous affection which, instead of progressing, has undergone retrogression. There is reason to believe that a small amount of tuberculous products may be entirely absorbed. But even when the tuberculous affection is considerable, and has advanced to the formation of cavities, recovery is by no means impossible.
If fresh tuberculous products do not take place, in other words, if the tuberculous cachexy no longer continue, the cavities may cicatrize; and patients recover with a certain amount of permanent injury which, as the quantity of lung in health is greater than is required in ordinary breathing, is only felt when there is an unusual demand for the respiratory function, as in taking active exercise. Even if recovery do not take place, tuberculous cavities sometimes remain almost or quite innocuous, and under these circumstances the affection is so far mitigated that life and comfortable health may be maintained for an indefinite period. - There are no known specific remedies for the cure of consumption.
This is not saying that medicines are not often useful. At the present time the remedies which are in vogue, and which in certain cases are more or less serviceable, although having no specific virtue, are the various vegetable and mineral tonics, the hypophosphites, arsenic, and cod-liver oil. The latter is perhaps a food rather than a medicine. But measures relating to diet, regimen, and climate, and other sources of hygienic influence, are vastly more important than any medicaments. The great object of treatment is the removal of the constitutional condition of which the pulmonary affection is the local expression; that is, the tuberculous cachexy. With reference to this object, all available means of strengthening and invigorating the system are to be employed. The diet should be as abundant and as nutritious as possible, embracing fatty articles of food in as large a proportion as the appetite and digestion will allow. Living out of doors as much as possible is an important part of the hygienic treatment. The writer is cognizant of several cases in which persons in advanced consumption recovered after adopting a savage life, that is, roughing it and living in the open air.
Long vovages are often useful, and sometimes seem to effect a cure, instances of which have repeatedly come under the writer's observation. On the other hand, the disease sometimes pursues a favorable course under hygienic circumstances which would not be considered as conducive to this end. This statement will apply to some hospital cases. Unquestionably climatic influences are often useful, and a change . from an unfavorable to a favorable climate is sometimes apparently instrumental in effecting a cure. That such a change is not curative in the majority of cases does not militate against this statement, for consumption will end fatally in a very large proportion of cases in spite of all the measures which, with our present knowledge, can be brought to bear upon the patient. If a change of climate be made, the desirable qualities of that to be selected are dryness, uniformity, elevation, and the absence of malaria. A dry, uniform, cold climate is suitable for some cases, and for others one which is dry and warm is more favorable. It is not always easy in particular cases to decide whether it is best to choose a warm or a cold climate. Perhaps the best criterion is the previous experience of the patient as to the influence upon health and vigor of the summer or the winter season.
In making a change of climate, various circumstances are to be considered, such as the resources for occupation and recreation which different places offer, the feelings of the patient with respect to absence from home and separation from friends, the supply of the proper articles of diet, and the influence of associations. With reference to the latter, the moral effect of going to a place in which consumptive patients congregate is often unfavorable. As a rule, consumptive persons should not be encouraged to deprive themselves of the comforts of home whenever the symptoms are such as to preclude a reasonable expectation of benefit. Another important rule is, that if notable benefit be derived from a change of climate, the patient should not hasten to return, and it is desirable that the change be permanent. Various details which cannot here be fully considered enter into the hygienic management. The body should be well protected against changes of temperature, but an excess of clothing is to be avoided. Consumptive persons are not more likely to "take cold "than persons in health, and in general colds do not have a pernicious influence on the progress of the tuberculous affection. Sponging the body with cold water daily, followed by brisk rubbing with a dry towel, is generally useful.
The use of alcoholic stimulants, wine, spirits, or malt liquors, the choice being determined by the taste and experience of the patient, is often signally beneficial. As to the expectation of their utility in particular cases, the immediate effects are to be relied upon. In so far as they have a cordial effect, without producing upon the circulation and nervous system those effects which are understood by the term stimulation, they will be likely to be useful; and some consumptive patients are able to take the so-called alcoholic stimulants without those effects, in quantities which in health would cause intoxication. Taken under the restriction just stated, there is little or no danger of patients becoming addicted to their use. This, however, affords no warrant for their use with this object in view, except in well marked and undoubted cases of the disease. Finally, it is to be remarked that, treated after the plan which has been sketched, consumption is not fatal in so largo a proportion of cases as formerly, when bleeding, cathartics, severe counter-irritation, restricted diet, and confinement within doors constituted the measures of treatment.
A striking change is also manifest as regards the longer duration of the disease, and the maintenance of strength up to a short period before death in the cases which end fatally. It is an important consideration that the measures of treatment now generally pursued, when they do not effect a cure, promote a better tolerance of the disease, prolonging life, and contributing to the comfort of the patient while life continues.