THE BROOKLYN MEDICAL JOURNAL PUBLISHED MONTHLY BY THE MEDICAL SOCIETY OF THE COUNTY OF KINGS. EDITORIAL COMMITTEE: JOSEPH H. RAYMOND, M. D., ALEX. HUTCHINS, M. D., JOSEPH H. HUNT, M. D., GLENTWORTH R. BUTLER, M. D., FRED. D. BAILEY, M. D. VOL. IV. No. 4. BROOKLYN, N. Y., APRIL, 1890. Single copies 25 cents. $2 a year, in advance. ORIGINAL ARTICLES. A CRITICISM OF THE WEIGERT HOT AIR TREATMENT OF PULMONARY TUBERCULOSIS. BY WALES L. CARY, M. D., Physician to the Brooklyn Throat Hospital. Read before the Medical Society of the County of Kings, November 19, 1889. The presentation at this date of a criticism of the Weigert method. without clinical data demands a word of explanation. The original study of the subject was undertaken in connection. with the development of the pulmonary department of the Brooklyn Throat Hospital with a view to the introduction there of the most approved apparatus for treating consumptives. The conviction of inefficiency and possible detriment was so strong that no treatments were instituted, and the elaborated theoretical condemnation has waited, in essentially its present shape, the passing of the summer recess and the following sessions of the society having a full programme. Recent abundant clinical reports confirm the conclusions to be hereinafter stated in our recapitulation; though as yet no one has, to our knowledge, pointed out the reasons for failure nor indicated the probability of detriment in attempts at pulmonary sterilization by heat. For the information of such as have not seen the original and sub sequent articles upon the subject of the treatment of pulmonary tuberculosis by inhalations of hot air, as proposed by several clinicians, but most prominently introduced by Dr. Louis Weigert, of Berlin, we may state that the apparatus is adapted to the administration of air heated, in the respiratory tube, up to 320° to 5c0° F., and delivered to the patient during from one to four hours, at one or two daily sittings, thus determining "a temperature of 112°F. in the expired air." The possibility of sustaining respiration and unimpaired health under these conditions is argued from the necessity for certain artisans to bear a temperature greater even than that sustained in the Russian bath, in which the atmosphere is heated up to and even beyond 212° F. The object sought is a gradual destruction of the tuberculous bacilli by this interrupted sterilization, and that it is attained is evidenced, according to the brochure cited above by "1. Removal of dyspnoea. 2. Lessened cough. 3. Primary increase, secondary decrease and subsequent entire disappearance of expectoration. 4. Cessation of fever. 5. Cessation of nightsweats. 6. Increase of appetite. 7. Accession of body strength. 8. Entire stoppage of the progress of the disease. 9 Disappearance of bronchiectases. 10. Clearing of infiltration. II. Ces ation of hæmoptysis. 12. Removal of catarrhal symptoms. 13. Cicatrization of cavities. 14. Increase of weight. 15. Primary increase, subsequent decrease, and finally complete absence of tubercular bacilli, together with a gradual decrease and later an entire disappearance of pus corpuscles and elastic fibre from the sputa." The theory by which all this benefit is obtained rests upon the following conditions affecting the bacillus: "Its temperature optimum is 99.5° F. **** at 101.3° they hardly grow at all ***** at 107.6° their development ceases altogether." The treatment is attended by "an accelerated pulse for the first minutes only, an elevation of temperature of the whole body 1° to 2° F., which is maintained for about an hour after cessation of treatment; the general health remains undisturbed." Let us take for consideration the various points of this monograph, beginning with the temperature at which the bacillus is most readily developed within the vital organism. It is generally known that in culture experiments the impregnated medium is maintained between. 37° to 38° C., i.e., 98.6° to 100.4° F., the temperature first proposed by Koch as that at which the bacillus tuberculosis develops most rapidly; but that there are variations in the conditions necessary to produce the best results when the culture material is changed is also recognized by bacteriologists,1 and that a more ready growth occurs at 1 Outlines of Bacteriology, Shakespeare, in Cycloped. of Dis. of Children. a higher temperature when a living organism is the seat of the infection seems borne out by comparative pathology and the natural history of the disease in man. In the course of studies for the establishment of the relation of Koch's bacillus to tuberculosis, various animals have been utilized and many degrees of susceptibility noted, which, being analyzed, seem to warrant the inference of a dependence of this varying inoculability upon differences in the normal temperatures of the animals in question. The higher the body heat the less resistance presented to the infecting agent. In this connection we will cite an article by Dr. Blaine,' who quotes the experience of several European experimenters upon the inoculability of various animals, giving the percentage of successes. To this table we have appended a column, giving the normal temperature of each. We are not blind to the fact that the ratios of relative susceptibility and temperature are not absolutely constant, particularly in the case of the rabbit and guinea-pig; but the tendency is distinctly shown. Some of these discrepancies may be due to an inconstant degree of virulence of the infecting material. Such varying virulence is indicated by a second table quoted by Dr. Blaine, which summarizes the results of inoculation-experiments performed with tubercular material from animals of several species, and to be in accord with our view of the interrelation between body-heat and bacillary virulence, inoculations from the high-temperatured animals should produce the greatest percentages of success. Each of these tables, omitting a designation of both the source of the natural and the subject of the experiment, is open to inaccuracies, but the general result seems consistent. And all seeming fallacy would be removed could we have been informed, if perchance it were so, that, for instance, the high-temperatured rabbits (103°) were inoculated with an attenuated virus, perhaps from man; and thus the low percentage (31) would be accounted for. Or on the other hand, the guinea-pigs, with a normal temperature of 102.4°, which if inoculated with similar virus should be lower in the scale than the rabbits may have been subjected to the intensified poison of fowl, and the resulting high ratio (83) be confirmatory instead of mildly confuting. This varying virulence we conceive as conforming to the general biological law of increased or diminished strength of successive generations as their progenitors were matured under favorable or adverse environ ment. Dr. Brush, in a very instructive article on Bovine Tuberculosis, * quotes an experiment of Toussaint, who found general tubercular infection to occur more rapidly and the disease to culminate in death after a shorter period if the inoculating material were heated for a time even as high as 137° F. Further evidence of the favorable influence exerted upon bacillary growth by elevation of the temperature of its containing soil may be drawn from the frequent development of tubercle in the periphery of a lung subjected to the increased local inflammatory temperature of pleurisy, the heat being greater in the immediate vicinity of the inflammatory activity than throughout the body or rest of the lung, and greater than from the symptomatic fever alone. We do not now refer to the general dessemination of tubercular infiltration, but to the local "subpleural foci" described by Jacoud.' In the same way we should account for the "phthesiogenic tubercular pleurisy" of Renaud, believing the fibrino-serous inflammation to be primary and determinant of the development of such spores or bacilli as had lain quiescent awaiting such an exciting cause of activity. A more or less general pulmonary tuberculosis dependent upon excitation by the attendant fever being determined by the extent to which the infecting agents had previously gained a foothold within the lung. Having thus submitted evidence from a general biological stand ♪ Westbrook, N. Y. Med. Jour., June 9, 1888. 6 Pul. Tuberculosis, Prof. H. Von Ziemssen, p. 7; also Park, Am. Jour. Med. Sc., xcviii., No. 1, p. 27. point and from comparative pathology that the "best temperature" for the intrapulmonary development of tubercular bacilli is much above the normal temperature "of the human body" (Weigert), and that at all intermediate degrees up to 109.9°, the fowl's norm., which with an addition of 4° or 5° of fever heat produces a temperature even as high as 115, the bacillus is still active. We may be permitted to refer to the natural history of the disease as observed in man to see if there will be from this source confirmatory or controverting testimony. Ringer, whose studies of temperature in phthisis have made him an acknowledged authority, says: Hyperthermia is a constant prodrome to all tubercular deposit, that it is most elevated during and in direct ratio to the tuberculization." Roberts notes that "the thermometer is particularly important in detecting the early stages of the disease and in indicating the degree of its activity." Niemeyer considers "fever is the most formidable enemy," and Bartholow, in the last edition of his Practical Medicine, writing in the light of bacteriological knowledge which was denied the earlier observers, says: "Fever heat is an index of the rapidity with which the morbid process is proceeding. If the fever is slight the bacilli are imperfectly formed *** the number of bacilli is in direct ratio to the intensity of the disease, and when this is slow the bacilli are small, and those present contain no spores." Flint and many authoritative clinicians express views of close interaction between these factors, but even if fever is not an excitant of bacillary activity, it is at least a cause contributory to their numerical increase and perfection. It is furthermore common experience that the period of incubation is long where the inoculation has occurred upon a merely catarrhal mucous membrane or in a debilitated organism, both being unattended by fever, but more rapid during febricula or as sequent to acute disease, many of which furnish the conditions of catarrh, fever and debility. In forming a prognosis the type of fever is also considered particularly significant. If now tubercular bacilli develop with greater certainty, reproduce their kind more numerously and induce their pathogenic effects under 115° of heat and are even morphologically more perfect under temperatures of 106°-110°, surely an artificial intrapulmonary temperature of "101.3°" cannot "diminish their activity," nor can "107.6° arrest their development altogether." There is in all tuberculosis a remittency, which is shown by Koch' to be automatic by reason of local variations in pathological activity caused by changed physical conditions, favoring or retarding removal of material upon which the bacilli have acted, extracting all the pubulum adapted to their nourishment. 7 New Syden. Soc. Rep., 1882. |