For nearly four years there have been no bacilli found in the sputumn after numerous examinations. There is a persisting bronchial cough at intervals, with occasional expectoration. The examination of the chest shows no indication of an existing tuberculous process, although fibroid changes are readily detected. Case 4.-A young man, aged nineteen, consulted me in May, 1899, his illness having developed ten months previously as an acute pneumonia involving the major portion of the left lung. The patient was sent originally to Las Vegas, New Mexico, in company with a physician and trained nurse, and two months later to Arizona, Koch's tuberculin being used daily for a prolonged period. Following an initial gain while in the Southwest there ensued a persistent elevation of temperature, loss of weight and strength, followed by several recurring hemorrhages. Upon arrival in Colorado there was a loss of thirty-two pounds in weight, the temperature was 104° F. in the afternoon, and the pulse rarely below 120. Numerous bacilli were found in the sputum. There were signs of massive consolidation in the left front from the apex to the fifth rib, with moist râles throughout, and semidry clicks in the left axilla. In the back, bubbling râles were heard to the very base, with an area of well-defined consolidation extending from the apex to the middle of the interscapular space. On the right side there was slight consolidation at the apex, with moist râles to the second rib, and scattered areas of infiltration with moisture throughout the front. Fine clicks were heard in the right interscapular space. In view of the age, the active advanced process in one lung, the more recent invasion of the other, the hemorrhagic tendency, persisting fever, and rapid pulse, the prognosis could scarcely be other than unfavorable. There developed, however, a gradual resolution of the consolidated areas, and a lessened activity of the tuberculous process, as shown by the slighter amount of moisture, diminution of cough and expectoration, fewer bacilli, and increase of weight and strength. Three and a half years ago, after five years' constant medical observation, the patient had gained nearly sixty pounds, and there was entire absence of cough and expectoration. Examination of the chest failed to disclose any tuberculous activity whatever, there remaining only a somewhat prolonged high-pitched expiration, tubular in quality at the left apex. without moisture. During the past three years he has resided much of the time in Illinois. At present, nearly nine years after coming under my observation, the arrest is complete. Case 5.-A boy, nine years old, arrived in Colorado June 1, 1903, exactly three months after the development of acute bronchitic symp toms. Following the initial onset he remained eight weeks in bed with a persisting fever and moderate cough. At the end of two months. accompanied by his parents and family physician, he went to New Mexico, remaining thirty days. During this period there had been a progressive rapid decline. At the time I saw him he was greatly emaciated, weighing exactly fifty pounds. His average afternoon temperature was 101.5° F.; there was marked dyspnea on exertion, the appetite was exceedingly poor, pulse 124, and there was a persisting cough without expectoration. There were signs of consolidation throughout the entire left lung, with moist râles upon easy respiration from the apex to base, front and back. In view of the age, the history of the development of an idiopathic pleurisy, undoubtedly tuberculous, the continued fever, the great emaciation, and physical signs, an unfavorable prognosis was rendered. The exclusive care of the child was committed to a trained nurse, and an unbroken regimen was maintained for a period of two years and one month. During this time the child exhibited most remarkable improvement in spite of the fact that at the end of four months he contracted a typhoid fever which was of eight weeks' duration, and was followed in the second year by an acute fulminating appendicitis, operated during the first twenty-four hours. He was discharged as cured in June, 1905, there being not the slightest trace of moisture recognized after repeated examinations of the chest, although fibroid tissue proliferation was extensive. His general condition was excellent in all respects, his weight approaching eighty pounds. He has remained well ever since. He Case 6.-A man, forty-one years old, came to Colorado in September, 1904, nine months after an acute pneumonia, which was followed by severe persisting cough and continued fever with night-sweats. In the mean time he had experienced a severe hemorrhage and lost much weight and strength. The sputum had been loaded with bacilli. had gained eighteen pounds in a well-known health resort, but exhibited persisting elevation of temperature, with occasional chills and severe sweats. Although remaining in bed during day and night for months, there was subsequent loss of weight, with increased cough and expectoration. The condition of the patient was pronounced entirely hopeless by an eminent physician. Upon arrival in Colorado examination of the chest disclosed extensive active tuberculous infection of each lung. On the right side moist râles were heard in front to the third rib, and in the back from the apex to the very base. On the left side there was well-marked consolidation in the upper portion, with but slight moisture in front, but with coarse râles in the back from the apex to the lower angle of the scapula. A further decline was exhibited during several weeks. The temperature was constantly elevated, chills and night-sweats were frequent, and there resulted greater loss of flesh and strength. The cough was extremely distressing, the expectoration copious, containing numerous bacilli, the temperament markedly nervous, the patient apprehensive and discouraged. The active, widely disseminated tuberculous infection, the unmistakable evidence of sepsis, impaired digestion with entire absence of appetite, the weak and rapid pulse, and the general prostration were sufficient to justify, almost without reserve, an unfavorable prognosis. After several months a gradual improvement was observed which has continued without interruption. In September, 1905, one year after coming West, there was but little or no expectoration, fever had been absent several months, a gain of forty-five pounds in weight had been established, and the pulse was uniformly of good character. At the present time it is impossible to discover any physical signs attributable to an existing tuberculous process, no moisture being recognized after careful exploration, although fibrous tissue change is marked. The patient has engaged in an arduous legal practice in an unfavorable climate during the past two years, devoting the summer season to rest and recreation in the mountains of Colorado. At the time of his resumption of work examinations of the sputum failed to disclose the presence of bacilli. They have been discovered at intervals since then, but not invariably. Case 7.-A young lady, eighteen years old, consulted me in June, 1896, immediately upon coming to Colorado. Her illness was of one and one-half years' duration, during which time she had spent several months in the White Mountains and in Asheville. There were great emaciation and pallor, dyspnea upon the slightest exertion, nausea and daily vomiting with diarrhea, pulse 120 to 130 at rest, cough exceedingly severe, expectoration purulent and copious. Upon examination the entire left lung was found to be involved. There were signs of pronounced consolidation throughout, coarse bubbling râles on easy breathing from apex to base, front and back, with a cavity nearly the size of a fist in the front of the left upper lung. There was nothing in the history or condition to furnish a warrantable basis for the slightest encouragement. Her age was against her, she was profoundly septic, and her powers of resistance were evidently exhausted. Cavity formation had already taken place, and softening was rapidly going on in a lung partially consolidated from apex to base. She has remained under my observation during the ensuing ten and one-half years. Without entering upon a tedious recital of her detailed progress I will state that during the greater portion of this period she conformed to a strict régime. Resulting improvement was noted from time to time, despite the fact that her circumstances were limited and only absolute necessities permitted. Her eight years of unremitting effort and patience sufficed to bring about a complete arrest. At that time there was but little cough, and the expectoration essentially bronchial in character. She had gained forty-three pounds in weight, had shown no constitutional symptoms for one or two years, and the examination of the chest revealed no evidence of existing tuberculous activity. Examination of the sputum was entirely negative. She was married to an army officer very shortly afterward, and for over a year led the gay and strenuous social life incident to a military post in close proximity to a large city. At the time of her departure for the Philippines I was privileged to make a careful physical examination. In spite of her late hours of social dissipation it was found that there had developed no renewed activity of her former infection. A large cavity persisted in the upper left front without moisture. No râles could be heard in any portion of the lung, which, through the lapse of years, was found to have undergone extensive fibrosis. There was occasional cough, but the sputum was subjected to examination with continued negative results. In connection with the foregoing reports there are several important facts to be borne in mind: (1) That these cases are selected merely to illustrate the possibility of arrest in far-advanced cases, and that other instances of improvement equally striking can be cited. (2) That the cases here described were considered without exception, by other physicians and by myself, as being utterly hopeless by virtue of every consideration which ordinarily influences prognosis. (3) That these patients have not simply undergone improvement with the ultimate outcome as yet uncertain, but, in the process of years, have secured a complete arrest of the tuberculous trouble, with entire absence of physical signs, sputum, and bacilli, and restoration to former usefulness and activity. (4) That the necessity for the practice of strict economy has been no insuperable barrier to the acquirement of complete arrest in a suitable climate under a proper régime. (5) No claim is made that the results obtained were referable entirely to climatic influences. It is contended, however, that such results in equally desperate cases are impossible of attainment in what may be regarded as relatively unfavorable climates, no matter how perfect the régime. (6) No special methods of treatment were employed other than those familiar to every physician of experience in the management of pulmonary tuberculosis. (7) No credit for results obtained is assumed other than that which may relate to an unremitting personal attention to detail, and an adaptation of means to ends at times somewhat radical. (8) No case is here reported that is not entirely subject to confirmation by the attending physicians, whose names are not cited in the report. As logical conclusions from such results it may be stated, first, that no physician can assume with positiveness to pronounce death sentence upon any case, no matter how desperate the apparent extremity. Second, that each case strictly on its merits is entitled to a determined, painstaking, and aggressive effort to secure arrest. It follows that while the rich are abundantly able to combat the disease through such means as their medical advisers may counsel, the poor, deprived of such advantages, are justly entitled, at the hands of the State, to adequate hospital provision in an effort to preserve life, rather than to be instructed merely as to the proper method of passing their remaining days. PART V COMPLICATIONS INTRODUCTION IN a book of this character it is particularly desirable to review the various complications observed in the course of pulmonary tuberculosis in the light of their clinical significance. It is not designed to limit the consideration of complications to tuberculous infections of other organs or remote parts of the body, but to include, as well, the intercurrent non-tuberculous affections which exert a modifying influence upon prognosis. From a practical standpoint the coëxisting tuberculous processes in other regions are of especial importance and will be considered in some detail. Tubercle bacilli may be distributed to various portions of the human system through the medium of the blood-stream; to the pleura, pericardium, lymphatic glands, and certain other regions through the lymph-channels; to the pharynx, stomach, and intestines through the process of ingestion; and to the larynx, in some instances, through direct contact with the expectoration. In the following consideration of coëxisting tuberculous infections the grouping of the various complications is attempted as far as practicable in accordance with their supposed pathogenesis. Through the agency of the circulation as a route of distribution the bacilli are deposited not only in remote and widely separated regions sometimes involving an entire organ or part of an organ, but also are disseminated throughout the body. The general distribution of the bacilli by the blood-stream gives rise to the clinical recognition of what is known as acute miliary tuberculosis. SECTION I ACUTE MILIARY TUBERCULOSIS CHAPTER XLV GENERAL CONSIDERATIONS THIS condition is characterized by the presence, in an infected organ or in many organs, of innumerable, grayish-red tubercles, the size of a millet-seed, which are evidently of simultaneous deposit and exhibit the same degree of development. The present clear conception |