Consumption, DECLINE (in medical language, Phthisis, Tuberculosis), is a condition well recognised by the laity as by the physician. Strictly speaking, the name includes a group of affections, but it is generally used to indicate pulmonary consumption (phthisis pulmonalis)—i.e. a more or less rapidly advancing process of lung destruction, associated with progressive emaciation and other characteristic signs and symptoms. This is a disease of grave importance, from its frequency and fatal tendency. It has been estimated that consumption is responsible for nearly one-seventh of the total mortality of Europe. Consumption appears to have committed its ravages from the earliest times, and its distribution is probably universal, though far from equal. Thus, statistics show consumption to be less common in the Hebrides and Shetland Islands than on the mainland of Scotland, while the unanimous verdict of Icelandic physicians has been that consumption occurs relatively seldom in their island. It is not easy to propose any fixed rule regarding its distribution. Latitude as such seems of less importance than might be expected. The mean level of temperature has little connection with its occurrence, though apparently, in tropical countries, the course of the disease is more rapid. The most probable explanation of the comparative immunity of certain districts and countries is to be found rather in the minimal amount of moisture present. Wetness of the soil is a factor of the greatest importance, as was shown by the researches of Bowditch in America, Buchanan in England, and Milroy in Scotland. Their united testimony was that the number of cases of consumption varied directly with the degree of dampness of the soil. Elevation also exercises an important influence; and, other things being equal, the more elevated the district, the less favourable will it be to the occurrence of consumption. The explanation of this is probably to be found in the combined purity and rarity of the atmosphere.
Though consumption was early recognised as a definite disease, and its clinical course fairly well studied, much obscurity has rested over the question of its causation. About no disease has opinion so persistently fluctuated. Definition was first rigidly attempted by Bayle and Laennec, who held that consumption was essentially due to the presence in the lung of little granular masses of varying size and character, which were named Tubercle (q.v.). On the other hand, Andral, Virchow, and Niemeyer maintained that only a limited number of cases were to be so explained, and that consumption was most frequently induced by a process of chronic inflammation of the lung. This view gave scientific basis to the popular belief in the effects of neglected cold. Medical opinion was divided between those main lines until 1882, when Koch announced the fact that he had discovered an organism, which he believed to be present in all cases of consumption proper. This organism—the Bacillus tuberculosis—is a minute rod-like structure, capable of cultivation outside the human body, and easy of demonstration in the expectoration of consumptive patients (see BACTERIA). Clinical and experimental evidence has since corroborated the truth of Koch's assertions, and the bacillar origin of consumption has been pretty generally accepted, so that the older teaching has been subjected to much modification. Although this is so, considerable difference of opinion remains as to the relation of other factors to the bacillus. Some observers are even yet inclined to think that certain cases of consumption may be satisfactorily explained apart from the bacillus. This view is very questionable.
As regards the lung itself, the resultant condition is more or less uniform, varying in degree according to the stage of the disease. The process is one of gradual disintegration, in which two phases may be recognised: (1) Consolidation, when the affected lung feels relatively solid, and the normal vesicular structure can be but imperfectly distinguished; (2) excavation, when the consolidated mass in part breaks down, leaving irregular spaces, varying in size, presenting an uneven, secreting surface. The cavities (vomicæ) tend to be largest towards the upper part of the lung. Associated with these changes in the lungs, grave disturbance appears in other organs, notably in the stomach and intestines, the liver, and the kidneys.
While accepting the bacillar origin of consumption, it is impossible to overlook the predisposing influence exerted by certain conditions. The list of such factors is a large one. Pre-eminent among them is Heredity (q.v.). Undoubtedly there exists in many families a tendency to weakness—i.e. a less power of resistance—of the respiratory organs. This may be transmitted through several generations. This want of vital balance in the respiratory apparatus is manifested by recurring 'colds,' without apparently sufficient cause. It is not difficult to realise how the bacilli take root, and flourish more readily under such conditions. It is a Diathesis (q.v.) or disposition which is inherited, rather than the disease. Greater difficulty is experienced when the question of actual transmission of the disease is considered. Though certain facts, indeed, point to the conclusion, it cannot be said that a congenital infection of child by mother has yet been demonstrated in man. The so-called scrofulous diathesis, in which there is a tendency to a low form of glandular inflammation and degeneration, has been cited in favour of this view. The inter-dependence of scrofula and consumption cannot be denied. Sex seems to have little bearing in reference to consumption. Similarly of little value is the popular belief that the disease is more frequent in the offspring of consanguineous marriages. It is, however, to be borne in mind that such unions necessarily double the chance of a particular family taint being reproduced. Age is a factor of greater moment. It may be said that consumption makes its appearance most frequently between the ages of fifteen and thirty. It frequently attacks persons beyond thirty, but in very young children it is not common. A most important part in the causation of consumption is undoubtedly played by improper sanitary conditions. This is evidenced by the much greater prevalence of consumption in towns and other crowded centres. The statistics of mortality in England illustrate this. In the counties whose industry is chiefly agricultural, the death-rate from consumption is comparatively low, while in Lancashire and other more largely manufacturing counties the rate is high. Badly built, overcrowded dwellings and workshops, with insufficient ventilation and damp, afford the most suitable conditions for the development of consumption. All physicians are agreed that 'perhaps no cause exerts such a decided influence on the production of consumption as the privation of fresh air and exercise.' No better illustration of this can be cited than the excessive mortality from consumption which was at one time recorded in British and foreign prisons. Thus at Millbank Penitentiary, during the seventeen years from 1825 to 1842, the annual mortality from consumption was reckoned at 13 per 1000. The vicious influence of these factors is, of course, increased enormously when, in addition, poverty and want are present. It must be admitted, too, that sedentary occupations generally predispose to consumption. Thus tailors, seamstresses, and similar workers are especially prone to the disease. More especially is this true of occupations whose performance necessitates the inhalation of dust particles—e.g. stone-masonry, knife-grinding, metal-polishing, wood-carving, &c. The dust particles act as irritants of the fine structures which line the air passages and vesicles, inducing chronic changes, which, in turn, are liable to lead to consumption.
The bacillar doctrine has given fresh impetus and scope to the important inquiry as to the contagiousness of consumption. On this subject the evidence is conflicting. The large experience of consumption hospital physicians, such as that of the Drs Williams at Brompton Hospital, points decidedly towards the negative view. On the other hand, the statements of most careful observers, who have again and again recorded cases of infection, are strong in the opposite direction. An unprejudiced review of the facts seems to justify the conclusion that, although consumption is a communicable disease, it is so within certain limits—i.e. the contact and intercourse which, apart from other causes, expose to risk, must be of an extremely close nature. Probably the expectoration of phthisical patients affords the best means of transmission.
There remains the interesting question, whence do the bacilli make their appearance? This is a difficult problem. The fact that the organs of respiration are more especially affected, seems to point to the conclusion that the bacilli are present in the air. But their presence there is not easily proved. On the other hand, the expectoration of consumptive patients is found to be loaded with the organism. It has further been demonstrated that the bacillus occurs abundantly in the milk of cows suffering from tubercular disease of the udder; and meat obtained from the carcasses of tubercular animals, particularly the liver, kidneys, and glands, cannot be regarded without suspicion. The prevalence of abdominal consumption in young children has been attributed to the ingestion of the bacilli by means of milk. It has further been shown that tubercular disease may be induced through an open wound, to which the bacilli have obtained access.
The symptoms of consumption cannot be fully discussed in the present article. As seen in advanced cases, they are pretty generally appreciated by the non-professional eye; but at first they are treacherous and frequently remain undetected. The early symptoms vary much. There may be nothing but a gradual loss of strength, it may be of flesh; there may be a slight discharge of blood from the throat or chest; there may be a more or less persistent, tickling cough; there may be breathlessness, with or without pain in the chest; or there may be little save an increased tendency to take cold easily, with but tardy power of throwing it off. Or again, the slow beginnings may be expressed by a gradually progressing pallor, and, in the female, by diminution or cessation of the menstrual discharge. Any of those conditions, especially when they show themselves in the adolescent or young adult, are to be viewed with suspicion, and regarded as a sure indication that medical help is necessary. The more experience physicians have in the treatment of consumption, the stronger becomes the conviction that many lives might be saved, if only an opportunity were afforded of arresting the disease at an early stage. It is peculiarly at this point that the greatest skill and prudence are required from the physician. The appreciation of the signs which indicate the presence of consumption, both at this early stage and later, must be left in his hands, and cannot, of course, be treated of here. The later symptoms of consumption are better defined, and are, unhappily, too well known. They are, more particularly, cough, expectoration of a more or less thick, opaque substance, of varying colour, from whitish-gray to green, sometimes of blood, shortness of breath, pain in the chest, gradually advancing emaciation and loss of weight and strength, profuse sweating, especially in sleep, feverishness, diarrhoea. As the disease advances further, there frequently occur swelling of the feet and sores about the mouth. Accompanying these symptoms, grave changes occur within the lungs. These are appreciated with ease by the trained observer. It should be added that all the above-mentioned symptoms must not be looked for in every case of consumption. The type varies endlessly, and some cases run towards a fatal issue with relatively few signs or symptoms, while anatomically the disease is the same.
The duration of consumption varies greatly. In a certain proportion of cases the destructive process is very rapid, and, if unchecked, may lead to death within a few weeks. To this variety the name Galloping Consumption has been applied. The great majority of cases are extremely chronic, and the disease seems from time to time to become stationary. Consumption may terminate fatally only after many years.
As to the curability of consumption opinion has differed much. For long—and, unfortunately, to a considerable extent at the present day—consumption was regarded as incurable, and treatment adopted in the direction of palliation. More recently, however, the view of its curability, maintained both by Laennec and Niemeyer, leaders of opposite schools of pathology, has received fresh life through Koch's discovery. During the last few years many cases of recovery have been recorded. If those who have reported such have sometimes been affected with that peculiar hopefulness—spes phthisica—which is a frequent attribute of the consumptive patient, it must be regarded as a more pleasing indication than the apathy which was formerly too often displayed in respect of such patients, as evidently appointed to die. There is, moreover, reason to hope that we are on the eve of greater possibilities. Never was attention so keenly directed to this once neglected problem. In illustration of this may be cited the institution at Paris in 1888 of an International Congress, which is to meet once in two years for the consideration and elucidation of all questions relating to consumption, with a view to its prevention and treatment. Meanwhile, it may be affirmed that consumption, if suitably treated in the early stage, is curable; that occasionally more advanced cases are cured, and that for all cases much may be done in the way of prolonging life and relieving suffering. The popular mind must be disabused of the idea of the hopelessness of consumption.
The treatment of consumption is one of the most complicated problems which the physician has to face. In its wide sense, it involves a consideration of some of the largest questions relating to social and individual hygiene. From the prophylactic point of view, it includes the study of all points bearing on the causation of consumption. Only thus can the attempt be made to cope effectively with the evil on the large scale. A knowledge of the dependence of consumption on overcrowding, vitiated air, improper ventilation, and other insanitary conditions, ought to lead the responsible authorities to adopt and enforce such regulations as will remedy the evil. Within recent years much has doubtless been effected in this direction. The legislature has taken in hand several departments of this work; and employers, in many instances, have shown a proper interest in the welfare of their employees. But more remains to be done. There is need of increased popular instruction, so that working-people and others may themselves appreciate the dangers which they run by neglect of simple precautions. Further, having regard to the communicability of consumption from the lower animals to man, means should be devised whereby the milk from tubercular cows may be excluded from the market, and the flesh of tubercular animals condemned. These provisions have been embodied in the recommendations of the Paris congress (1888), that tuberculosis in animals should be included in the list of contagious diseases, the animals seized and destroyed, and dairies and milk-houses be subjected to strict scrutiny by competent officers. The danger of phthisical expectoration as a means of transmission has been already alluded to. It is therefore advisable that this, whenever possible, be destroyed by burning, or rendered innocuous by scalding or other satisfactory method.
In respect of the treatment of individuals, much may be expected from prevention. Though lacunæ exist in our knowledge of the life-history of the tubercle bacillus—more especially as regards its access to, and development in, the human body—there is good ground for believing that general depreciation of the system is a favouring factor of much importance. Hence all measures are to be adopted which will place the body under as good conditions as possible, more especially when there is suspicion of a family tendency towards consump- tion. Open-air exercise, varied according to circumstances, light gymnastics, friction of the skin, and bathing, unless contra-indicated, are to be commended. Sufficient sleep, abundant and regular meals of simple nourishing food, and warm light clothing are essential. Exposure to chills or damp must be strictly avoided, and the utmost care taken that no 'cold' be allowed to persist. If a cough continue, or any other symptom of consumption show itself, medical advice should be obtained at once.
When consumption is distinctly present, there are two lines open to the physician—the defensive and the offensive—and rational treatment should combine these. In carrying out the former, an attempt must be made to improve the general condition, so that effective resistance may be offered to the invasion of the bacillus. For this purpose all means of fattening the body should be adopted; and of these, par excellence, cod-liver oil, which has come to be regarded almost as a specific for consumption. As Dr C. J. B. Williams says: 'The beneficial operation of cod-liver oil extends to every function and structure of the body.' Fatty foods, butter, cheese, cream, milk, koumiss, glycerine, &c. are similarly of service. Care must be taken to maintain the appetite. The moderate use of alcohol, in one form or another, is advisable. Attention should be bestowed on the carrying out of those general hygienic rules which have been indicated. The chest should be gently expanded by such means as reading, singing, and regulated open-air exercise. Disadvantageous climatic and atmospheric conditions are to be removed, where possible. This is specially of importance in our moisture-laden climate. Often a change of residence from seaside or city to the highlands proves beneficial, or, where the disease is pronounced, removal from the northern to a more temperate zone. Where comparatively short journeys can alone be contemplated, Bournemouth, Hastings, Ventnor, Torquay, Penzance, and other places on the southern shores of England may be thought of. Where longer ones are possible, the variety is immense, from the Mediterranean and Atlantic stations to the slopes of the Rocky Mountains. In many cases a sea voyage is best; but this is contra-indicated under certain conditions, and should never be undertaken without medical advice. In connection with all these plans, wise consideration will be given to the fact that apparent advantages are unfortunately counterbalanced by disadvantages which are less easily gauged. While much benefit is to be expected in suitable cases, it is unnecessarily cruel to send a patient to die away from home. The offensive method of treatment rests on the hypothesis of the opposition offered by certain drugs to the life and development of the bacillus. The first vague feeling after such a system found expression in the various respirators, whose efficacy has from time to time been vaunted. There are, however, grave objections to the use of these. Firstly, such instruments of necessity render the movements of respiration less easy; and secondly, it is questionable whether, in the diseased state of the lungs, much of the antiseptic influence reaches the diseased portion. More recently an attempt has been made to introduce into the body certain drugs, which experiment indicated as antagonistic to the life of the bacillus. These have been administered by the mouth, by the rectum, subcutaneously, and by injection into the air passages directly. Thus creosote, iodoform, terebene, sulphurous acid, menthol, and other drugs, have been exhibited. The method is still on trial. Most encouraging reports have been published from time to time, but it cannot be said that certainty of result has yet been attained. For the relief of suffering and the palliation of distressing symptoms, an endless number of remedies might be named. No disease taxes more fully the patience and resource of the physician, and, apart from the general lines indicated, each case must be regarded individually.
Consumption in the Lower Animals.—The consumption of the lower animals has been proved to be essentially the same disease as that occurring in man. Its immediate dependence on the tubercle bacillus has been established. It affects the bovine species more especially. It is comparatively rare in the sheep, and very rare in the horse and dog. Pigs, rabbits, and poultry are extremely susceptible to the disease. The same class of causes appears to give rise to it. Its extreme frequency in cows is probably referable to the more or less confined life which these animals lead in comparison with the horse and dog. The udders of the tubercular cows frequently exhibit signs of the disease, and in those cases the Bacillus tuberculosis has been demonstrated in the milk. It is a question whether the bacillus is found in the milk of tuberculous animals apart from such local disease. But the probable communicability of the disease from the lower animals to man makes it desirable that consumption should be included among the contagious diseases, so that tubercular cattle may be destroyed. The symptoms presented by tubercular animals are in the main similar to those seen in man, and in the later stages are recognised without much difficulty. At first, however, consumption is less easily distinguishable—a fact which renders legislation on the subject extremely difficult.