[From Causes of Consumption, 1899]

CHAPTER II.

RE-BREATHED AIR—PREVIOUS DISEASE—HEREDITY.

RE-BREATHED AIR.-The deleterious effect of breathing impure air has long been known. Baudelocque long ago asserted that the breathing of impure air is the great cause of scrofula. Carmichael (1810) supports this. and instances the Dublin House of Industry, where one ward, 60 feet long, and 18 feet broad, contained 38 beds, each containing four children, where consumption was so common that it was believed to be contagious.

Carnelly, Haldane, and Anderson, state that in Dundee the phthisis-ratio increased as the herding together and foulness of atmosphere increased. Parkes ¹ gives us the case of two Austrian prisons.

" In the prison of Leopoldstadt, at Vienna, which was very badly ventilated, there died in the years 1834-47, 378 prisoners out of 4,280, or 88 per 1,000; and of these no less than ago, or 51·4 per 1,000, died from phthisis; there were no less than 42 cases of acute miliary tuberculosis.

In the well ventilated House of Correction in the same city, there were in five years (1850-54) 3,037 prisoners, of whom 43 died, or 14 per 1,000; and of these 24, or 7·9 per 1,000, died of phthisis."

The statistics gathered from the British army and navy, both at home and abroad, equally prove that our soldiers and sailors, though well clothed, well fed, and not over worked, were formerly terribly subject to phthisis.

The following table shows the mortality in the army from 1830 to 1874:

TABLE III.-Mortality per 1,000 strength.

The marked improvement in the later years is very prominent. The greater part of the mortality was due to phthisis, and although a number of minor sanitary reforms have been carried out, the great reform has been in the greater air-space allotted per man in barracks.

Parkes well puts the case when he says: " Usually a person who is compelled to breathe such an atmosphere," speaking of impure air, " is at the same time sedentary, and, perhaps, remains in a constrained position for several hours, or possibly is also underfed or intemperate. But allowing the fullest effect to all other agencies, there is no doubt that the breathing of the vitiated atmosphere of respiration has a most injurious effect on the health. Persons soon look pale, and partially lose their appetite, and after a time decline in muscular strength and spirits. The aëration and nutrition of the blood seem to be interfered with, and the general tone of the system falls below par. Of special diseases it appears pretty clear that pulmonary affections are more common. Such persons do certainly appear to furnish a most undue percentage of phthisical cases, that is, of destructive lung-tissue disease of some kind." According to Williams, ² 3,214 men became inmates of the Brompton Hospital in 10 years, and of these 1,812, or more than half, had indoor employments; and among his own out-patients the number of those who plied their trade in close, ill-ventilated rooms, and during long hours, was very great-clerks, compositors, tailors, shoe-makers, among men, and milliners, and dress-makers, among women. These were attacked at an early age.

The youngest practitioner must have repeatedly seen the ill-effects of our over crowding in workshops, The following instances, are samples from my own experience.

Some years ago, Thomas C_, a young Manxman of excellent physique, left the Island for Liverpool to follow his trade as a tailor. He worked in a small ill-ventilated workshop in the heart of the city. One at least of his fellow-workmen was suffering from phthisis. His health began to fail, and he soon developed marked symptons of phthisis, including hæmoptysis and even a fair amount of pulmonary hæmorrhage. The tailoring was given up, and improvement slowly set in. Since then several years have elapsed, and he has followed an out-door life, with the result that he is once more in vigorous and robust health, and has been exposed to the severest inclemencies of weather, both in this country and in America, without the slightest return of the old symptoms.

Some years ago Charles K_, a Manxman also, consulted me. He had been a tailor in Liverpool for 12 months, but had been sent back to the Island by a doctor whom he had consulted, suffering from incipient phthisis. A summer here and a course of tonics, set him up once more in good health and apparently cured him. I strongly advised him to seek employment of an out-door nature, and got him an agency in an Assurance Company in the Isle of Man. He soon gave this up, however, and went to Glasgow to follow his old trade. The workshop at which he was employed was in a small attic, lighted by a sky-light which was supplemented by gaslight. In this small room 14 men worked. Two of the men were unmistakably suffering from phthisis and were expectorating blood-stained sputum promiscuously. Another had a very bad cough.

Six months later Charles K returned to the Island, a mere shadow of his former self, with pronounced physical signs of phthisis and abundant hæmoptysis. He gradually sank, and died after being bed-ridden for about a year. In both these cases, I attribute the phthisis to the breathing of impure air, air, moreover, laden in all probability with tubercle bacilli, since we may safely assume that the sputum expectorated by the consumptive workmen would contain such germs.

In summing up, we may say that all the evidence and experience of physicians goes to prove that the breathing of impure air, especially such air as is impure by repeated breathing, is one of the most fruitful causes of phthisis.

INFLUENCE OF PREVIOUS DISEASES.-Phthisis is often seen to supervene on various diseases, and it will be well to see in what way, and to what extent these predisposing diseases act. There are two ways that suggest themselves, namely, by lowering the vitality of the body generally, and weakening its resistance to disease ; and by forming lesions that are eminently adapted to admit the tubercle bacillus into the system. It is not always easy to say in which of these ways a particular disease may favour the onset of phthisis ; but in some diseases at least the method is plainly suggested.

We are taught by our bacteriologists that the body, when healthy, resists and casts off, or absorbs and renders innocuous, germs of disease that otherwise would have serious and even fatal results. We often come across individuals who invariably catch any infectious disease that comes their way, whereas others pass through the most severe epidemics with impunity. No doubt this is accounted for by idiosyncracy ; but apart from these cases one may roughly say that resistance to disease varies with the general health.

ANÆMIA.-Every. practitioner must note how frequently he is consulted by young women suffering from anæmia, and how often he has to look upon such cases with gravity, as indicating a condition of body eminently suitable for the onset of phthisis, as subse- quent developments only too often prove. So common in fact is the opinion among the laity, that phthisis is often ushered in with anæmia, that the cessation of the catamenia is considered a sufficient cause, by the patients themselves, to warrant them in seeking a medical examination for the express purpose of deciding as to whether they are consumptive or not.

In what way anæmia predisposes to phthisis is not quite clear. We know, however, that it lowers the vitality, and produces a listless and apathetic condition that prevents the amount of exercise being taken that would otherwise be indulged in, and so reduces the extent and force of the respiratory acts. As a. result of this diminished movement, there is a diminished aëration of blood, and, in certain conditions of health, a tendency to stagnation of the blood-stream, especially in the pulmonary capillaries of the apex of the lung. This stagnation may lead to injury to the vessel-walls, and even to a slight leakage. We have then, in the lung apices, a very favourable condition for the lodgment and growth of the tubercle bacillus. Moreover, a blood that is poor in corpuscles will naturally be poor in that power of absorption which is supposed to aid so materially, in rendering innocuous the various germs of disease.

TIPHOID.-Typhoid is well-known to be, in many cases, a forerunner of pulmonary consumption. Murchison ³ says : " An attack of pythogenic fever is often followed by tubercular deposit in the lungs "; and again, " in my experience, acute tuberculosis of the lungs is a far more common complication or sequela of pythogenic fever than of typhus, and it is intelligible why this is the case, when we recollect the more protracted duration of the former malady and the greater emaciation it entails. Louis records four fatal cases of pythogenic fever in which the lungs were found studded with recent tubercles. Bartlett also observes that consumption is a common sequela of this fever in America." It is well to remember that the organs most frequently affected in typhoid fever, viz., the solitary glands, the Peyers patches, and the mesenteric glands, are also frequently the seat of tubercular disease. The wasting and emaciation also, which is so prominent a symptom in both these diseases, seems to be dependent on a disordered state of the lymphatic system, especially the lacteals. This has led Gueneau de Mussy, Villemin, and other French writers to really doubt the genuineness of these so-called typhoid cases, and rather to suggest that they were cases of acute tuberculosis. There ought to be no question about the matter now, however, since a bacteriological examination of the stools would clearly reveal the presence of the tubercle bacillus in the one case, and of the micrococcus of typhoid fever in the other.

Since it has been proved that tuberculosis may be produced by the introduction of the specific bacillus in food, it will be readily seen that the absorption of such bacilli will be rendered a comparatively simple matter, when the intestine has been more or less denuded of its protective coat by the ravages of typhoid fever.

The lesions associated with PLEURISY, PNEUMONIA, and CHRONIC BRONCHITIS, and the varied changes produced in the lung tissues by the irritants inhaled in workshops, where fine particles of steel, flint, glass, etc., are disseminated in the atmosphere, provide in many cases a suitable nidus for the bacillus.

Among the diseases which act by exhausting the system, and lowering the vitality, we must include SCARLET FEVER, MEASLES, MISCARRIAGE, and OVER-LACTATION.

The effects of MENTAL DEPRESSION have been well described by Laennec. * He savs :-" I had under my own eyes during a period of ten years, a striking example of the effect of the depressing passions in producing phthisis in the case of a religious association of women, of recent foundation, and which never obtained from the ecclesiastical authorities any other than a provisional toleration, on account of the extreme severity of its rules. The diet of these persons was certainly very austere, yet it was by no means beyond what nature could bear ; but the ascetic spirit which regulated their minds was such as to give rise to consequences no less serious than surprising. Not only was the attention of these women habitually fixed on the most terrible truths of religion, but it was the constant practice to try them by every kind of contrariety and opposition, in order to bring them, as soon as possible, to an entire renouncement of their own proper will. The consequences of this discipline were the same in all ; after being one or two months in the establishment, the catamenia became suppressed, and, in course of one or two months thereafter, phthisis declared itself . . . . during the ten years that I was physician of this association, I witnessed its entire renovation two or three different times, owing to the successive loss of all its members with the exception of a small number, consisting chiefly of the superior, the gate-keeper, and the sisters who had charge of the garden, kitchen, and infirmary. It will be observed that these individuals were those who had the most constant distractions from their religious tasks, and that they also went out pretty frequently into the city on business connected with the establishment.

HEREDITY AND CONSUMPTION.-Many of our most eminent scientists have devoted much time to the question of heredity, and have come to conclusions varying between the two extremes of Louis, on the one hand, who says "Nous n'avons recueilli aucun fait en faveur de l'hérédité de la phthisie ;" and of Baumgarten, on the other, who goes so far as to say ⁵ : "Tuberculosis may remain latent, under certain circumstances, during the whole of life, without interfering with living functions in any observable degree." Since such diversity of opinion exists, it will perhaps serve our purpose better to briefly review the various pronouncements of some of our leading authorities. Niemeyer does not consider that the disease itself is transmitted, but rather that the tendency to consumption may be inherited if the parent were consumptive at the time of begetting the offspring. " But it is not," he says, "the malady which causes inheritance, but the weakness and vulnerability of constitution, which had already laid the foundation of consumption in the parents, or which had arisen in them in consequence of that disease ;" also, " I do not hesitate to say, in spite of all assertions to the contrary, that it is by no means proved that tuberculosis, in the strictest sense, is an inheritable disease ;" and, again, " Quite as decidedly as we have opposed the evidence that tuberculosis is inheritable, must we pronounce in favour of a frequent occurrence of an inherited disposition to pulmonary phthisis."

Dr. Walshe came to the conclusion that the percentage of inherited cases of phthisis was no higher than that of the tuberculised portion of the population generally, and that, therefore, the significance of heredity in relation to the disease was trifling. Landouzy and Martin have shown that it is possible to produce tuberculosis by means of the seminal fluid of tuberculous guinea-pigs. Bacilli have also been found in human semen. Lannelongue believes in intra-uterine infection of the feetus, and cites cases in support, and ascribes the rare occurrence of the disease in children to the virus being in a latent state.

Baumgarten places this disease in the same category as syphilis and leprosy, and considers heredity to be the cause of by far the greater part of all tuberculosis, and mentions a number of pathologists, whose researches he contends materially substantiate this conclusion. Chief among them we may name Landouzy, Martin, Marchand, Bollinger, Queyrat, and Lannelongue.

Villemin believes that the disease itself is not inherited, but only the " aptitude to contract the disease."

The very varied percentages of inherited consumption which have been published by the different authorities is due to the various degrees of relationship included

The 1,010 cases of the Brompton Hospital Report included only parents, and gave an average of 24·4 per cent.

Dr. Fuller's 385 cases included also grandparents, uncles, and aunts, and gave 59 per cent.

Dr. Cotton's 1,000 cases included parents, brothers, and sisters, and gave 36·7 per cent. ; and Dr. Pollock's 1,200 cases, reckoned on a similar basis, gave 30 per cent.

Dr. Williams gave an analysis of 1,000 cases 'which he investigated, and which is rather instructive.

Of these 1,000 cases, 484, or 48·4 per cent., were attributed to hereditary influences The details are as follows:-

The number of purely hereditary cases, that is, with parents alone affected, was only 12 per cent., a result much at variance-as Dr. Williams points out-with that obtained by Drs. Cotton and Fuller, who made the first Bromptonl Hospital Report, and arrived at the figures, 24*1, and 257, respectively. Continuing, Dr. Williams considers his estimate more reliable, as his cases were among the better class, and would be freer from other causes of consumption which would naturally surround the poor. Transmission is more common through the mother than through the father. The first Brompton Report places the relative proportion as between mother and father, at two to one, while the table above shows that while 67 mothers transmitted, only 43 fathers did so.

This of course is a result that one would naturally anticipate, since the father's influence is only exercised at conception, while the mother's is exercised during gestation, and possibly extends through lactation. Under the title " Duration of Phthisis and Certain Conditions which Influence It," published in the " Medico-Chirurgical Trans- actions," Williams goes on to show that heredity, to a certain extent, decides the age at which consumption starts in the offspring. His conclusions were arrived at by careful investigation of the age at which the 1,000 private cases were attacked, -and are as follows

TABLE III.

It will thus be seen that family predisposition causes the disease to break out at an earlier age.

Dr. Reginald Thompson ⁷ proves that those affected with double heredity are more susceptible to the disease than those with single, and this applies equally to both sexes; also double heredity renders the disease more acute and more fatal.

Dr. Williams briefly sums up the results of his investigations as follows:-

I. Family predisposition prevails among, and exercises a more decided influence on, females than males, and the former have a greater power of transmission than the latter.

II. Fathers transmit more frequently to sons, and mothers to daughters, than the converse.

III. Paternal inheritance, whilst most unfavourable for the males, is less so for females, as it generally includes an increase of resisting power.

IV. Maternal inheritance is unfavourable for both sexes, but most so for the males.

V. Double heredity exercises the greatest influence, and affects sons more strongly than daughters.

VI. Family predisposition does not directly shorten the duration of the disease.

VII. It precipitates the onset of the disease, and thus shortens the duration of life

Footnotes

1 Parke's Practical Hygiene. de Chaumont, p. 161.

2 Pulmonary Consumption, 2nd. Ed., 1887.

3 A treatise on Continued Fevers of Great Britain.

4 Diseases of Chest., Sir John Forbes's translation, p. 334.

5 Recherches sur la Phthisie, p. 532.

6 Lehrbuch der Pathologischen Mykologie, p. 631.

7 Family Phthisis, p. 25.

Any comments, errors or omissions gratefully received The Editor HTML Transcription © F.Coakley , 2006