Consumption

Consumption, a popular term which may be considered as the equivalent of phthisis pulmonalis, one of the most fatal diseases in many parts of the globe, and notably so in this country. The mean annual death-rate from phthisis amounts to about two per 1,000 living persons; perhaps a better idea of the ravages worked by the disease may be obtained from a statement of the result of an elaborate calculation made from the Registrar-General's returns, which is that of 1,000,000 children born upwards of 114,000 die of phthisis. The growth of knowledge as regards the disease has been attended by many changes in nomenclature, and it may be well to briefly discuss the meaning of such expressions as consumption, phthisis, tubercular disease of the lungs, bacillary phthisis, and the like.

The term consumption was originally somewhat indiscriminately applied to several forms of disease in which wasting or emaciation was a prominent symptom. The patient was said to be consumptive, to be in a decline, or to be suffering from phthisis (a word derived from the Greek and signifying a consuming or wasting away). Inasmuch, however, as loss of flesh is a phenomenon common to so many forms of disease, in order to be more precise it became customary to indicate the particular part of the body which was supposed to be especially involved by the morbid process. Thus we still hear the expressions consumption of the bowels and consumption of the lungs (pulmonary consumption) used; and the terms phthisis laryngea and phthisis pulmonalis are not infrequently employed, to indicate that the main symptoms present point to implication of the larynx or of the lungs respectively.

The study of morbid anatomy revealed the fact that the progress of "phthisis" was in many instances associated with the development of what were called "tubercles." These tubercles were studied for the most part as they appeared in the lungs, and they were described as being of two varieties, the grey miliary tubercle and the yellow cheesy tubercle. Laennec maintained that tubercles were deposited from the blood, that at first they formed minute grey rounded semi-transparent masses (miliary tubercles), and that these by their coalescence and by the occurrence of degenerative processes gave rise to the opaque yellow masses. From the resemblance of the latter to cheese the degenerative process was spoken of as caseation. Laennec's views met with much opposition, it being held that the sequence of events detailed by him only obtained in a limited number of instances, while it was maintained that in many cases the caseous masses resulted from chronic inflammation of the lung substance, altogether apart from the deposit of miliary tubercle. The application of the microscope to the study of the diseased tissues threw further light on the matter, and for a while it was held that true pulmonary phthisis was distinguishable in all cases by certain definite microscopical appearances, the most characteristic of which was the presence in the midst of the growing tubercle of what was known as a "giant cell." Difficulties presented themselves, however, in connection with this solution of the question, and until a few years ago it was still maintained by many that the tubercle was the result of previous inflammation, and not that, as Laennec held, the inflammatory processes were caused by the deposit of tubercle. In other words, Laennec's attempt to define the condition of things by the naked-eye appearances of the diseased lung, and the further attempts to define it by the special microscopic appearances, were held not to cover all the ground, and something was yet wanting to establish the new species of disease. Meanwhile, the inoculability of tubercle was demonstrated, its infectious nature began to be discussed, and at length came the discovery which seems to have solved the problem. Koch in 1882 announced that the disease was due to a micro-organism, the bacillus tuberculosis. The new test was soon found to eclipse all that had preceded it, countless observers have verified by the methods elaborated from that originally employed by Koch, the invariable presence of this bacillus in the affected tissues in the type of malady under consideration; and it is now customary to class as a definite species of disease all those cases in which the existence of the bacillus can be proved.

Of course it must be borne in mind that the bacillus tuberculosis attacks other organs besides the lungs; indeed, the pulmonary mischief rarely presents itself without co-existing involvement of other parts of the body. In other words, the lung disease is part and parcel of the general affection tuberculosis. Still, for convenience sake, it is well to adopt a term for those instances where lung symptoms predominate, hence the retention of the expressions phthisis pulmonalis (or simply phthisis) and pulmonary consumption. If it be desired to indicate that the disease is associated with the presence of Koch's bacillus, the adjective bacillary is sometimes employed, to exclude certain maladies in which wasting accompanies lung disease, and there is no evidence of the existence in the diseased tissues of the typical micro-organism.

Causation. Few situations are absolutely free from phthisis. On the whole it is more common in temperate climates than in very cold or very hot regions. Mountainous districts often enjoy comparative immunity, and the researches of Buchanan and Bowditch have proved the common association of marked prevalence of the disease with dampness of soil. As regards sex, males are more frequently affected than females, if ages between five and twenty-five years, in which the reverse holds, be excepted.

The disease affects persons of all ages; very young children are, however, rarely attacked, and the mortality is at its maximum in people between 35 and 45 years of age. Heredity appears to act as a predisposing cause. The influence of occupation is marked; those employed indoors in crowded workrooms, and persons exposed to an atmosphere charged with mineral or organic dust, are specially liable to attack. Insufficient ventilation is known to be a factor of immense importance apart from other defects, as is clearly shown by the evidence afforded by barrack rooms, back-to-back houses, and the overcrowded alleys and courts of great cities. Phthisis has been attributed to the consumption of the milk and flesh of animals affected by the bacillus, and probably with justice. The relative immunity of the Jewish race may be alluded to in this connection. As regards the influence of season of the year, it may be remarked that the largest number of deaths occur in the spring months.

Symptoms. The most common early symptoms are cough and loss of flesh. There may be spitting of blood, and sometimes an attack of haemoptysis (q.v.) is the earliest indication to cause alarm; the larynx may be involved almost from the first, giving rise to loss of voice; vomiting sometimes occurs, and some febrile disturbance may be noted. The symptoms of the established disease are continued cough with mucopurulent, perhaps blood-stained, expectoration, hectic fever, with night sweats, and rapid loss of flesh. The circulation is enfeebled, dropsy may be present in slight degree, and a characteristic clubbed condition of the ends of the fingers is frequently produced. Diarrhoea may be exceedingly troublesome. The patient is often exceedingly hopeful as to the result of his illness, even when his condition is obviously becoming more and more serious.

The development of tubercle elsewhere than in the lungs may considerably modify the aspect of the disease; laryngeal, cerebral, renal, and peritoneal complications may be specially alluded to. The physical signs of consumption cannot be discussed here in any detail. Suffice it to say that tubercular mischief is more apt to occur at the apices than in other portions of the lungs. If rales are detected on auscultation over the upper parts of the lung on either side and remain limited to such situation, the circumstance is regarded with the utmost suspicion. When the tubercular infiltration has made some progress, and when the affected portions of lung commence to break down with the formation of cavities, definite alterations in the percussion note and character of the breath and voice sounds heard over the site of the mischief occur. The diagnosis is definitely confirmed in many instances by the discovery of the presence of the tubercle bacillus in the sputum.

The treatment of phthisis may be considered under two heads: preventive and curative. Preventive treatment will doubtless receive much more attention in the immediate future than has hitherto been accorded to it. The remarkable reduction of the phthisis death-rate in the army as the result of the adoption of improvements in ventilation and of an increased allowance of cubic space per head in barracks points in an unmistakable manner to the desirability of devoting attention to such matters. Moreover, phthisis is an infectious disease, and should be treated as such. Next to nothing is being done at the present time in the way of securing the disinfection of sputum, and the question of the communicability of the disease through the medium of milk, meat, and the like is only just beginning to force itself to the front. As regards curative treatment, it is now fully recognised that consumption in its early stages at any rate is not necessarily a fatal disease; much depends, however, upon the circumstances of the patient. If he can be removed to favourable hygienic surroundings, and can be well fed and cared for, there is a considerable chance of arresting the progress of the mischief. It is obvious, however, that to winter in a mild climate, or to go on a sea voyage, are plans of treatment beyond the reach of the majority of sufferers. In the case of workers in towns of scanty means the conditions are, it must be confessed, very unfavourable; still even here if the disease be incipient, and the best precautions available be taken, a successful result may be hoped for. If the mischief is of some standing, the look-out is very bad save for those who can afford to completely change their conditions of life.

Since the establishment of the bacillary origin of the disease many attempts have been made to devise some plan of attack which should prove fatal to the micro-organism, without injury to the patient. The so-called antiseptic treatment of phthisis seems to have done some good; the latest method devised by Koch in 1891 seems to have been somewhat prematurely adopted, and to have led to no beneficial result.