CHAPTER VII.

CHRONIC TUBERCULOSIS.

TUBERCULOSIS. - A diathetic disease attacking the organs generally May be acute or chronic-Yellow infiltrated tubercle of Laennec not true tubercle-Grey and yellow granulations may co-exist in the same organ-Differences between them-Changes in tubercle-The tuberculous and scrofulous types-Distinet, but not antagonistic. Symptoms. Of chronic tuberculosis-Shapes of chest. Diagnosis.-In Infants-Value of the thermometer-In older children. Causes. The result of a constitutional tendency-Exciting causes-Inoculation of tubercle.

Prevention.

Treatment.-Climate-Exercise-Fresh air-Diet-Attention to digestive organs-Astringents-Alkalies-Cod's liver oil and tonics not to be given too early.

TUBERCULOSIS, a diathetic disease giving rise to the formation of tubercle, is in children exceedingly common. Its existence is indicated by certain general symptoms. Following or accompanying these general symptoms are other local symptoms, showing the presence of tubercle in one or more organs of the body, and the disease is then called pulmonary, bronchial, mesenteric, phthisis, &c., according to the organ of which the local symptoms predominate. The child differs from the adult in a tendency to a general formation of tubercle. The lungs constantly suffer, but they do not suffer alone the membranes of the brain, the bronchial and mesenteric glands, the pleura, peritoneum, liver, spleen, in fact all the organs of the body exhibit a nearly equal readiness to be invaded by this, the anatomical expression of the general disease, and to suffer simultaneously from the same morbid condition. The local symptoms are, however, usually confined to one or two organs, the lesions of the others, less severe or less noticeable, being only discovered by postmortem examination.

MILIARY TUBERCLE.

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Tuberculosis may be either acute or chronic in its course. When acute, it is invariably attended by the development of miliary tubercles in the organs generally. When chronic, the same result may take place; but sometimes we find in these cases early symptoms arising from the lungs with evidence of consolidation, and eventually of softening and excavation. These changes are found after death to be due to the presence of a morbid yellow material which, differing in character from ordinary miliary tubercle, is regarded by many pathologists as the result of scrofulous inflammation, and hence bears the name of scrofulous pneumonia. This material is the infiltrated yellow tubercle of Laennec and his followers. It is true that we often find in the same lung every degree of pathological formation between true miliary tubercle and the dense masses resulting from scrofulous inflammation, but one of the results of miliary tubercle is to excite inflammation around it: lobular pneumonia is set up, and the deposit, instead of becoming absorbed, as occurs in pulmonary inflammation attacking a constitutionally healthy patient, tends, in one of scrofulous habit, to soften, break down, and excite ulceration in the tissues around. The masses will accordingly be large or small, according to the extent of pulmonary tissue involved in the inflammation.

Miliary tubercle occurs in two forms, the grey and the yellow granulation.

Grey granulations consist of grey, round, hard, elastic, dense masses about the size of a millet seed, which on section of the lung are found projecting from the cut surface. They resist pressure, and are not easily crushed by the nail. The colour is grey and semi-transparent, and in the centre they often contain a black point or a small quantity of yellow tuberculous matter.

The yellow granulation is rather larger than the grey. It is of a bright yellow colour, and on pressure is not crushed, but flattens out like recent false membrane. It is evidently

the result of degeneration of the grey granulation, for every stage can be traced in the change from the one form to the other. The grey granulation first turns white: an opaque yellow spot then appears in the centre: this extends until the whole substance is converted after a time into a yellow mass. This degeneration of the grey granulation sometimes goes on so rapidly that the tubercle seems to have been yellow from the first, the processes of formation and of degeneration appearing to take place simultaneously. Thus, in a rickety child of twenty months old, in whom death took place from acute tuberculosis after an illness of seven weeks, the lungs were found to be stuffed with miliary yellow tubercles, none of which were larger than a hempseed, the greater number being very much smaller. There was no grey tubercle anywhere. Usually, however, the yellow and the grey granulations co-exist in the same lung. The granulations, scattered at first, become collected together as the morbid process goes on more rapidly, so as to form masses of tubercle of variable form and size. The bulk of these masses is no doubt increased by the occurrence of pneumonia, the deposit of which degenerating and becoming yellow, is indistinguishable by its naked eye or microscopic characters from true tubercle.

Besides the lungs, tubercles are found in the parenchyma of solid organs, as the liver, spleen, kidney, brain, &c. They may also occupy the serous and mucous membranes, the lymphatic glands, the bones, muscles, and external areolar tissue. In the case of acute tuberculosis, the greater number of these tissues appear to suffer, and are found after death studded with grey granulations. When the disease is more chronic, several of them may escape: the granulations are then more commonly yellow, and are often grouped into masses. Occasionally only one or two organs are found to be affected with tubercle, but this is the exception. In such cases the tubercle is seated in the lungs and the bronchial glands, these two organs far surpassing the others in their

د.

CONFORMATION OF BODY.

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proneness to be invaded by this morbid change. The processes of tubercular formation and degeneration appear to go on with greater rapidity in some organs than in others. Thus it is not uncommon to find in the same subject grey granulations in the liver, yellow granulations in the lungs, and in the lymphatic glands masses of yellow substance resulting from the aggregation of miliary tubercles.

The difference between grey and yellow tubercle consists in the greater proportion of fat elements contained in the latter. As the fatty degeneration continues, the yellow tubercle becomes softer and softer, the softening process beginning either in the centre, or at a point on the surface, and being very much influenced by the degree of softness and humidity of the tissue in which it is contained; the more yielding and the moister this may be, the quicker does the change take place. At the same time the surrounding tissue suppurates; becomes infiltrated with cheesy matter, the result of inflammation; and a cavity containing a purulent fluid is formed, the consequences resulting from which vary according to the organ in which this change occurs.

Sometimes a different transformation takes place; the tubercle, instead of softening into a purulent-looking fluid, shrinks, and hardens into a cretaceous mass, by absorption of its fluid constituents.

These changes will be more fully described in considering the anatomical characters of pulmonary phthisis.

Children who are disposed to be the subjects of tuberculosis are often distinguished by certain peculiarities, which are held to constitute a type of the tuberculous diathesis. They are tall for their age and slightly made; the skin is delicate and transparent-looking, allowing the superficial veins to be distinctly seen; the face is oval, and the features generally regular. The complexion is usually clear, but not always; the face is sometimes covered with freckles; and Dr. Gee is of opinion that amongst the poor children of London the existence of freckles is evidence of very singular

value of a tubercular tendency.* These children are often remarkably good-looking, with large,, bright, intelligent eyes, long eyelashes, and soft silken hair. The limbs are straight; the wrists and ankles small. The nervous system is highly developed, and the general organisation delicate. The teeth are cut betimes; they walk and talk early; and the fontanelle often closes before the end of the second year.

If we compare this type of body with the peculiar conformation considered to be characteristic of the scrofulous diathesis, we notice remarkable differences. Here the face is more rounded than oval; the complexion is dull and pasty-looking; the skin thick and opaque. The face is not so comely as in the preceding type, although it is by no means necessarily ill-favoured; the features are large; the lips full; the alæ of the nose thick; and the nostrils expanded, so that the nose looks broad. The tongue is often large. The ends of the long bones are full, and their shafts thick. The fingers are often clubbed. The belly is large and prominent. In such children there is great activity of all the epithelial structures. The hair and nails grow rapidly; the skin generally is rough and scaly; and there is often a remarkable development of hair, which is seen as a thick down on the forehead, cheeks, ears, and along the spine. There is constant secretion from the nose ; the skin about the lips is subject to crack, and to become sore; the eyes often look weak, even when not inflamed; and there is great tendency to ophthalmiæ, inflammation of tarsi, catarrhs, certain skin diseases, irritation and inflammation of the lymphatic glands, to caries of the bone, and to a low form of pneumonia.

These two types of body are very distinct, but they are not antagonistic. Tubercular formation may occur as an accompanying phenomenon of either, and either may be

Quoted from a Clinical Lecture on Phthisis, delivered by Dr. Gee, at the Ormond Street Hospital for Sick Children.