Friday, July 22, 2016

1819: Laennec says consumption can be cured

Dr. Rene Laennec might have become interested in diseases of the lungs because his own mother died of tuberculosis when he was only five-years-old.  Of course it may simply have been his desire to help people who lived under the gloomy cloud created by the grim diagnosis of the disease.

While he specialized in diseases of the chest, he would end up spending more time studying consumption than any other disease, perhaps becoming the first to describe the disease as curable. (1, page 6)

He referred to it as pthhisis pulmonalis in his 1919 book "Mediate Auscultation," dedicating three full chapters to the disease.  He said it results in the development of "species of accidental production" called the tubercle in the lungs. (2, page 283)

He said the ancients described an "accidental production" as any abnormality, and used the term "tubercle" to describe an accidental production in the lungs, such as a cyst or cancerous growth, that resulted in phthisis or wasting away.  (2, page 283, 310)

Laennec, however, recommended tubercle only be used to describe tubercles of consumptive patients. (2, page 283)

He described the tubercle:
Whatever be the form under which the tuberculous matter is developed, it presents at first the appearance of a grey semi-transparent substance, which gradually becomes yellow, opaque, and very dense. Afterwards it softens, and gradually acquires a fluidity nearly equal to that of pus; it being then expelled through the bronchi, cavities are left, vulgarly known by the name of ulcers of the lungs, but which I shall designate tuberculous excavations. (2, page 285)
He said in most cases the disease results in extreme emaciation, which is why the ancient Greeks referred to it as phthisis, wasting away.  (2, page 304)

He said the internal organs other than the lungs are usually of normal length, but of lessor diameter.  The chest is "usually narrow and sometimes evidently contracted." The skin is usually very pallid and pale.  (2, page 306)

He said:
"The emaciation then makes rapid progress toward complete marasmus (severe malnutrition).... The nose becomes sharp and drawn; the cheeks are prominent and red, -- and appear redder by contrast with the surrounding paleness; the conjunctiva of the eyes is of a shining white or with a shade of pearl blue; the cheeks are hollow; the lips are retracted, and seem moulded into a bitter smile; the neck is oblique and impeded in its movements; the shoulder blades are projecting and winged; the ribs become prominent, and the intercostal spaces sink in, particularly on the upper and fore parts of the chest. Sometimes even the whole chest seems contracted...; and this may actually be the case, particularly when the disease is very chronic, owing to the contraction and tendency to cicatrization of large tuberculous excavations. The belly is flat and retracted; the larger joints and those of the fingers, appear enlarged from the falling away of the neighboring soft parts; and even the nails become incurvated, in consequence of the absorption of the pulpy extremities of the fingers. No other disease gives rise to so complete emaciation as phthisis,—except cancer and continued fever of long duration. (2 page 372)
The patient sometimes complains of a "guggling sound," which Laennec attributes to the softening the the tubercles.  This is often expectorated, resulting in sputum similar to that produced during a fit of common catarrh. (2, pages 375-377)

The disease generally presented with obvious signs and symptoms.  The earliest symptom was a dry cough, which may be confused with dry catarrh. Haemoptysis, fever, chills and night sweats are other prominent symptoms. Some patients are known to require a change of sheets several times in a night. (2, pages 369-272)

Most people, including most physicians, during the early 19th century had a very gloomy view of this disease, as most who were diagnosed with it perished as a result of it.  The medical prognosis, therefore, was not very good.  (2, pages 319-320)

However, Laennec explained that the ancients believed "phthisis" started as a result of chronic inflammation, and they probably came to this conclusion because an early symptom of the disease is a slight dry cough that could easily be contributed to a dry catarrh (common cold). (2, page 319, 320, 369)

This chronic inflammation resulted in the gradual formation of pus in pulmonary tissue.  They believed this was curable, especially in the early stages. (2, pages 319-320)

This was pretty much the common perception of phthisis all the way up to the late 19th century when pathological anatomists discovered tubercles in the lungs of patients with phthisis.  (2, page 369)

Yet once physicians started studying pathological anatomy, they learned that this was not true, that once one developed tubercles (like cancer) the prognosis was poor, with death almost certainly imminent. (2, pages 319-320)

Laennec seemed to disagree with this notion, believing instead that, while the disease was not curable during the early stages of the disease, it was curable in the latter stages, that is, he said, "after the softening of the tubercles and the formation of an ulcerous excavation."  (2, page 321)

He said:
The formation of the semi-cartilaginous membrane on the surface of tuberculous excavations, must be considered, in my opinion, as a curative effort of nature. When completely formed, it constitutes a sort of internal cicatrix (a scar of a healed wound) analogous to a fistula, and is, in many cases, not more injurious to health than this species of morbid affection. All the persons whose cases I noticed above, died of diseases not referable to the pulmonary organs. They had all lived a greater or less number of years in a very supportable state of health, being merely subject to chronic catarrh. Some indeed had more or less of dyspnoea, but without any fever or emaciation. (2, pages 321-322)
Essentially, he believed that early on in the disease the tubercles were soft, and these were not curable. However, later in the disease scar tissue formed, either by fistula or cicatrix.  This hardened tissue acts as a natural barrier against the disease. (2, page 336)

While essentially cured, the patient may still present with symptoms. Generally, he believed those cured by fistula developed a chronic catarrh occasioned with sputum production that was sometimes copious; and those cured by cicatrix developed a dry cough that was not frequent, not severe, and not much of an inconvenience to the patient. (3, page 337)

He even gave examples of patients cured of consumption.
In a lady, formerly a patient of M. Bayle, fourteen years since, and whose case was decidedly consumption, (as appears from M. Bayle's notes in her possession,) the sign of pectoriloquy (particular lung sound made by a tubercle) is most distinct. This lady recovered beyond all expectation; she is now stout, and the only symptom she has at all referable to the lungs, is a slight cough. I have no doubt that the cartilaginous excavations above described exist in this person's lungs.
In July of 1817 he attended to a lady of 48 who had been in good health until the age of 30 when she became subject to severe attacks of catarrh and became quite emaciated.  Upon assessment he observed her breathing was diminished over the upper right chest.  By this, and by the appearance of her sputum, he diagnosed her with tubercles in the early stages.  As the treatment he applied leeches and more.  (2, pages 325-326)

Her symptoms were unchanged until February of 1818 when her cough increasingly distressing with thick yellow sputum.  He said:
I did not see the patient during this attack, which she looked upon as a cold; but I visited her in the beginning of April, and upon examining her chest I found most distinct pectoriloquy at the anterior and upper part of the right side. I was convinced by this that the supposed catarrh (the cold) had been the discharge of the softened tuberculous matter. The sound of respiration was good over the whole chest; and even in the vicinity of the pectoriloquous spot; the pulse was not frequent and the heat moderate. On this account I entertained hopes of her recovery, and prescribed ass's milk. The cough and expectoration progressively lessened, the flesh and strength returned; and, in the beginning of July, my patient had regained every appearance of the most perfect health. (2, page 326)
The pectoriloquy continued, although he suspected that it would, offering proof that she had suffered and survived a bout of consumption.  (2, page 322)

Laennec listed hundreds of various remedies used by the ancients and moderns, and he said any of these are worthy of trying, so long as the patient tolerates them, and this included bleeding with leeches and cautery by the application of caustic potass on several locations of the body.

The medicinal list also included a long list of expectorants, purgatives, etc.  It also included the inhalation of fumes, air of cow houses, oxygen, hydrogen, etc. (for a longer list of Laennec's remedies check out my post 1819: Laennec remedies for consumption.

The remedy he was most fond of, however, was change of situation.  (2, page 392)

Laennec said that the ancients observed that consumption was sometimes cured by the seaside, and that they often recommended sailing to their phthisical patients. He said Areteaus recommended sailing and the air of the seashore, Celsus recommended a voyage to Egypt.  (2, pages 243-394)

This was an idea recently picked up by English physicians, who often sent their phthisis patients to Maderia.   (2, page 343)

There was one case early on in his career, long before he had invented the stethoscope, whereby a patient of his was diagnosed by both himself and Dr. Bayle as having chronic catarrh.  However, upon a change of air, or a move to the seaside, he was cured.

Several years later, and after he had use of the stethoscope, he had another opportunity to assess this patient.  He said:
Since then I have had an opportunity of satisfying myself, by means of the stethoscope, that our patient had had more than a mere catarrh. His respiration is quite perfect throughout the whole chest, except at the top of the right lung, in which point it is totally wanting. On this account, I am certain that this portion of lung had been the seat of an ulcerous excavation, and that this had been replaced by a complete and solid cicatrice. The health of this gentleman continues good, although he has often occasion to speak in public. He has sometimes a little dry cough, on the change of weather, but takes cold very seldom. (2, page 340)
Yet while medicine may offer benefits to the consumptive, it does not offer a cure. The only means to a cure, he said, was nature.  (2, page 396)

So while he began his career under the belief there was no cure for consumption, his own experience and assessment skills proved that this was not always the case. He learned that there was a cure for consumption...
...or at least, for such a suspension of their symptoms as may be deemed almost equal to a cure, as the individuals may enjoy such a state of health as may enable them to fulfill all the duties of civil life, for several years, or until a fresh development of tubercles produces a fresh and final seizure. (2, page 337-338)
Patients who were thus "cured" might still have some symptoms, such as episodes of catarrh or a cough, but may otherwise "live in a supportable state of health." Others may have dyspnea, but without the fever and emaciation. (2, page 322)

As one final note to this discussion, Laennec said:
My experience leads me to deem such cases to be extremely common: those related above occurred to me in the course of some months: and I have since met with many others. (2, page 340)
Laennec was, therefore, among the first physicians of his era to speculate that consumption was a curable disease.  This subject would be further investigated by his pupil, Francis Ramadge.

It was perhaps due to his passion to learn about this disease that cost him his own life.  He would end up one of the many victims of consumption at the young age of 45.

  1. Ramadge, Francis Hopkins, "The Curability of Consumption: the reprint of a series of papers, presenting its most prominent and important practical points in the diagnosis, prognosis, and treatment of the disease," 1850, London, Printed by W. Clowes and Sons
  2. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood
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