records. Instances of pneumonokoniosis are frequently cited to illustrate the alleged development of indigenous tuberculosis in spite of favorable climatic conditions. The actual morbid processes consist of a more or less severe chronic bronchitis, emphysema, bronchiectasis, varying degrees of pneumonokoniosis, with often genuine cavity formation resulting from anemic necrosis, and secondary circulatory disturbances. The tubercle deposit, if present, is often quite insignificant in comparison with accompanying pathologic changes. These cases are found to develop almost exclusively in sections of the State devoted to the mining industry, i. e., in sparsely settled regions on mountain sides where tuberculosis seldom exists. Predisposing causes are found in the prolonged hours underground and the constant breathing of an atmosphere, not only deficient in oxygen, but vitiated by impurities. The air, not being in motion, becomes more or less devitalized and is breathed over and over again. In addition to the partial asphyxiation and the frequent extreme dampness, exciting causes relate to exhalations from the candles confined within a relatively small air-space, and the smoke resulting from the blasting powder, which is difficult of complete removal despite modern efforts toward ventilation. The necessarily constrained position during the greater portion of the day, the frequent wetting of the feet, the alcoholic habits, immoderate exercise at high altitudes, and the unhygienic surroundings when not at work, constitute important supplemental features. The conditions. are quite dissimilar to those obtaining in the production of coal-miner's consumption, stone-cutter's disease, grinder's or potter's phthisis, and the like, in that the sole essential factor is not the irritation produced by the inhalation of fine particles of dust. Chronic catarrhal processes take place in the bronchial mucous membranes, followed by emphysema. which results from nutritional changes in the pulmonary tissues, and from an increased intra-alveolar pressure during violent attacks of cough. Moderate fibrous tissue proliferation is superinduced in some cases, but by no means to the extent observed among followers of other occupations responsible for the production of pneumonokoniosis. While the distinguishing feature is the chronic bronchitis and emphysema, there frequently supervenes bronchiectasis, both of the cylindric and saccular varieties. Its development is due in part to the frequent paroxysmal cough, the weakening of the bronchial wall from emphysema, and the more or less continuous pressure exerted by stagnating secretions. The bronchiectatic cavities correspond largely to the fibrous tissue proliferation and the contraction changes external to the bronchial wall. Through the process of ulceration of the mucous membranes these bronchiectases may be transformed into genuine pulmonary cavities. These may develop also by reason of necrotic softening of the tissues, more particularly when the pneumonokoniosis is pronounced. In this event they are more likely to increase in size and have greater bearing on the subsequent course, especially if communicating with a bronchial tube. Secondary to the pulmonary changes there ensue marked circulatory disturbances, manifested by venous engorgement and enlargement of the right heart.

Symptoms referable to this group of chronic pathologic conditions are of gradual development and relate chiefly to dyspnea, cough, and expectoration, followed by loss of weight and strength, with gradually increasing cyanosis. The cough is frequent and unattended at first

with much expectoration. Later it becomes more distressing and paroxysmal in character, particularly after the formation of bronchiectases or pulmonary cavities. There exists no definite relation between the degree of bronchial irritation and the extent of fibroid change in the lung. The sputum is frequently quite frothy, light, and devoid of pigmentation, becoming more purulent with the increasing periodicity of cough. Under these conditions the characteristic separation into distinct layers may be noted. Little of practical value attaches to its bacteriologic examination, save that the occasional presence of tubercle bacilli denotes a final incidental complication.

The dyspnea, which at first is noticeable only upon slight exertion, becomes progressively worse, until the patient is induced to seek relief at lower elevations.

The cyanosis is usually out of proportion to the physical evidences of cardiac and respiratory embarrassment. Impaired appetite and digestive disturbances result in diminished nutrition, increasing weakness, and night-sweats. There is rarely any elevation of temperature save during temporary acute exacerbations.

Hemorrhages are not infrequent, and may vary from slight bloody discolorations of sputum to a sudden fatal loss of blood.

The physical signs upon inspection may consist of the characteristic changes in the configuration of the thorax commonly ascribed to emphysema, with frequent unilateral or bilateral retraction of the apices and occasional capillary dilatation upon the chest front. There are often percussion-signs of partial consolidation at the apices, but in many cases the resonance is intensified and somewhat tympanitic throughout the entire pulmonary area. Fine and medium-sized moist râles may be heard in all portions of the lung, though more frequently at the bases and almost always on each side. The breath-sounds are invariably somewhat diminished in intensity, corresponding to the degree of emphysema. The dulness is occasionally unilateral, in which event there often are localized changes in pitch, quality, and rhythm, and bubbling râles. Signs suggestive of pulmonary cavities may be recognized in almost any portion of the lung, as in tuberculosis. There is no invariable predilection as to the site of the cavity formation.

In comparison with simple chronic bronchitis and emphysema, or with ordinary cases of interstitial pneumonia, the course of the disease is short, rarely lasting over four or five years. This may be accounted for to some extent by the influence of altitude, the usual unwillingness and inability of patients to avail themselves of change of residence, and their greatly diminished resistance from habits of dissipation. While considerable relief is usually experienced on going to lower elevations, the unfortunate issue is delayed but temporarily, the prognosis almost always being unfavorable.

CHAPTER XXVIII

TERMINATION

STRICTLY speaking, the ultimate termination is recovery or death, but a large number of cases cannot properly be included in either class. While not actually cured, they are none the less enabled, for indefinite periods, to pursue a life of useful endeavor within the bounds of considerable physical activity. In its technical sense complete recovery is relatively infrequent save in the most incipient cases, as the infected area is scarcely capable of restoration to its previous condition. The very conception of an enduring arrest carries with it the necessity of fibrous tissue proliferation and encapsulation, but it' is unreasonable to deny, because of resulting anatomic change, the attainment of complete recovery. A permanent arrest of the tuberculous lesions is no less a cure despite a remaining indurative process than recovery from variola with resulting facial blemishes. It is entirely warrantable to regard patients as cured who, during a period of two or three years, present no physical signs of even a dormant infection, exhibit no subjective symptoms, and display an invariable absence of tubercle bacilli. It is not contended that bacilli may not exist in the pulmonary tissues of such patients, but the non-development of any signs or symptoms suggestive of their presence during a prolonged period may be construed as sufficient evidence of their practical surrender. Many patients fail to succeed in the acquirement of complete arrest, and yet possess undiminished vigor and activity. It is common. in health resorts to observe a large class of individuals who have achieved apparent arrest of the active process. Many of these with entire disappearance of subjective symptoms exhibit renewed energy and industry, yet at intervals display a few apical signs, with attenuated bacilli in the expectoration. I have under my care several patients who have remained in Colorado for thirty years or more, and who present every outward and physical manifestation of perfect health, although occasionally submitting bacteriologic evidences of a remaining quiescent deposit.

MODES OF DEATH

For some unexplainable reason death from consumption has ever been thought to be particularly horrible and revolting. It is possible that the idea of a lingering illness, a so-called "dying by inches," has suggested to the popular mind an exaggerated notion of the physical distress during the final agony. There is no reason to believe that the dissolution of the consumptive is attended with a greater physical struggle or mental anguish than is experienced by other victims of the grim destroyer. In many cases the prolonged duration of the illness, rather than making death harder to bear, is instrumental to a degree in preparing the sufferer to bear the inevitable with fortitude and resignation. With many the end is a welcome relief from the burdens and hardships incident to their illness. Patients of this class, far from approaching their demise with fear and trepidation, long for eternal rest with a courage and calmness incapable of simulation.

Many times have I been impressed most profoundly by the remarkable resignation of the consumptive, who, with unclouded intellect, has responded to the last summons. It has appeared that the very nature of the illness has tended to dispossess the end of its ordinary terrors, and to render the anticipation of the supreme moment but a deferred solace for bodily ills. Many, it is true, preserve a demeanor of indifference in the face of impending death, while others, with halting tread and protestation, are dragged to their doom. Fortunately, mental hebetude sometimes comes to the rescue, followed by mild delirium and coma, and the patient sinks gently to the final sleep. The demise of the consumptive, as a general rule, is singularly quiet and peaceful, devoid in large measure of the struggle and anguish characterizing a fatal termination of other diseases. It has been my observation that the only conspicuous deviation from this manner of departure occurs among pulmonary invalids overtaken by death as a result of intercurrent complications. This is particularly true in pulmonary hemorrhage, bronchopneumonia, edema of the lungs, pneumothorax, cardiac dilatation, and occasionally tuberculous meningitis.

The end may be sudden and violent, as during severe pulmonary hemorrhage. At such a time the patient is drowned in his own blood, and may expire almost immediately from asphyxiation, the suffering being but momentary. Dissolution may take place suddenly from other causes, as cardiac weakness or bronchopneumonia. I have witnessed two instances of sudden death following light percussion of the precordial region in cases of cardiac dilatation.

In bronchopneumonia of septic origin following pulmonary hemorrhages the patient is at first restless, anxious, and excitable. After a few days this changes to apathy, stupor, mild delirium, and sometimes coma. In some instances of death from aspiration pneumonia the sensorium remains unimpaired to the last, and the air-hunger becomes extreme. This may happen also in pneumothorax, and almost invariably in pulmonary edema. In such cases the suffering is more intense than can be imagined or described. Dreadful paroxysms of cough sometimes suffice to expel foamy and bloody expectoration, causing the disappearance, for the time being, of the ominous tracheal rattle.

In acute pneumothorax and in bronchopneumonia without edema there may be no expectoration whatever. At times there is insufficient. strength to effect the expulsion of the expectoration, which, if present at all. sticks to the lips and dorsal aspect of the tongue or adheres tenaciously to its base and to the posterior wall of the pharynx. The mouth and lips are exceedingly dry, and the masses of sputum are extracted only by means of a cloth or swab. The struggle, which is horrible to witness or contemplate, continues without abatement until merciful death claims its own. As a general rule, however, it seems to be a beneficent provision of nature that the vast majority of consumptives, after months and years of lingering illness, are permitted to succumb to the dread disease without sthenic manifestations.

PART III

PHYSICAL SIGNS

INTRODUCTION

PULMONARY tuberculosis produces a greater diversity of morbid conditions within the lungs, and hence exhibits a greater variety of physical signs, than any other respiratory affection. There is scarcely an objective manifestation observed in the course of the various pulmonary diseases which may not be exhibited by the consumptive as a direct result of the pathologic change incident to the tuberculous process or to associated complications. Thus an accurate recognition of the physical signs accompanying the varying degrees of tuberculous infection can be secured only from a thorough understanding of the principles of physical diagnosis as applied to all intrathoracic distur bances. The confusion resulting from an incorrect terminology, the frequent errors of technic in conducting physical examinations, and the faulty interpretation of various combinations of physical signs are often responsible for the non-recognition of gross pathologic lesions, and suggest the expediency of introducing a preliminary section devoted to physical diagnosis in general. In view of the difficulties often encountered regarding many important features relating to the physical examination of the chest, it seems desirable to outline a course of procedure emphasizing the essential principles of diagnosis pertaining to pulmonary conditions.

In no other department of medicine is there demanded such a degree of skill as in the recognition of obscure pulmonary affections. In all respiratory diseases a precise conception of the condition can be obtained only through an exhaustive and systematic examination of the patient.

While during student life dispensary facilities may be depended upon to furnish the means of acquiring a more or less practical familiarity with the making of physical examinations, these clinical opportunities will scarcely suffice for a thorough understanding of the subject unless preceded and accompanied by competent instruction concerning the principles and facts of physical diagnosis. To obtain practical proficiency it is highly important that a preparatory course of didactic or text-book instruction should be provided not only as to the physical signs themselves, but as well to the rationale of their production. Thus, in addition to the recognition of abstract physical signs, the beginner should be made to appreciate the relation of the various phenomena. thus observed to the morbid conditions which they represent. Although no single physical sign may be said to characterize definitely any pathologic state of the tissues within the thorax, yet the grouping of several associated signs in connection with essential facts pertaining to the history and symptoms, permits the differentiation of the various conditions. It is not permissible within the limited scope of this section to do other than review important features of diagnosis.