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High altitude and tuberculosis
!it\O
[October, 1921
TCBETICLE
HWB ALTITn )]·; A:\]) 'ITBEHCTLl lSlS . By O.
AM ltE H\,
:\I.D.Arosa (Switzerlnnd.)
M,,,licol Su perini end cn t
fir the A ltein
Srt/tfr /o ri ulII . . I mw .
'rIl E chief properties or the high-altitude climata which arc of value in th e treatment of tuberculosis are as follows :r it e LOI/) Barometric ]'ressIl1·1' .-'l'he barometri c pressure diminishes correspondingly to the elevation above sea-level, and th e diminut ion is influenced by the temperature of the ail'. Th e partial pressure of oxygen is diminished. '11/1' Lr)1I' Tcmpcratur« III tll,. ./ ;,..-'l'he diminuti on takes place with arit hmetical progression corresponding to th e increase of elevation above sea-level, not depending upon the geograpbical latit ude. In the winter month s th ere is an " inversion" of th e above-mentioned fact of temperatu res ; th e snow covcring th e ground. th e temperature of th e air over high plateaux and slopes becomes warm er correspondingly to the increasing alti tude. During the night th e ground and the nearest part s of the atm osphere are cooling, and th e nppel' air-parts are gett ing warm ail' from still higher part s. 'I'hi s fact has great importan ce for th e healthresorts at high altitudes, as in th is way th e air-minimum never becomes too low. At high altitudes there is always an equal cold temperat ure in winter and no heat in summer. T he rl"!l l/ t.~ s and pur it!l of th e 11ir are most iJ~lportan t. Of courss, at high altitudes, too, the latter is influenccd b'y existence or. non-existence of dense human dwellings, chimn eys, h ct?l'Ics, steam engmes, &c. But th e pollut ion of the air is worked off Cjlll.ckly by the tr emendous sunpower at the altitudes. The snow which covers th e g ro ~lII d f'ron; November unt il April causes nearly absolute frce~?11l ~ronl dnst III th e ail'. Th e {(Irge amount of sunshiue w~rk s most efficac iously OIL account of th e dry and pure air a~d th~ mten:s1ty .of the. warm sun-rays a~d of th e light-rays. 'I 'he duration of sunshine IS a 11Igh one. Large pine woods also help to free th~ air ?f dust and giv.e l~rotecti on fro~Jl th c winds. The " F(ihn" is a special kind of wind, falling down WIth heavy pressure from th e tops of the mountains ; it is a W1Lrm wind which helps to melt th e snow in spring. 'I'he time of snow-melting at th e Alpine health-resorts is by no means a bad ODe ; stat istics have shown tha t the meteorological conditions for lung-pati ents just at that time of the year arc always superior to those of lower nltitudes, The p!l!/si(){o(Jiwl effects caused by th e above-mentioned meteorological propcrties have been studied in an ample way. Paul Bert (18H2) mentioned th e increase of hremoglobin and Vialilt th e augmentation of th e red blood corpuscles at high altitu des. Miescher, th e physiologist at ll:'tle, and his collaborators Egger , Jaquet, Karcher, Suter, Veillon, have proved th e accuracy of these observations. Similar conclusions have been arrived at by HiilUi sch and 1\1 ercier at Arosa, l\ iindig, Meyer, Turban and others at Davos. Cohnheim who at first attacked th e above-mentioned Iacts, after experiments on employee of the .J ungfrau Hailway, came to th e conclusion " t hat the first-menti oned authors were right and that a real
October, 1\")21 J
HIGH ALTITT;DE AND TDBERCTTljOSrS
:i81
new formation of red blood corpuscles takes place at high altitudes." Also more recent experiments on flyers (Meyer and Syderhelm) confirm the fact of a real new blood formation, caused by the diminished partial pressure of oxygen in the air. It has been shown (Ruppnnner) thf1t besides the augmentation of the red blood corpuscles the lymphocytes and the large mononuclear cells are increased in number, whilst the granular lencocytes and the total amount of the leucocytes are diminished. 'I'he viscosity of the blood is increased (Staubli, Wanner). The respiration and circulation are greatly influenced because of the diminution of the pressure of oxygen. The bad effects during the time of the so-called acclimatisation are, therefore, dyspnoea and palpitation. The maximum and minimum blood pressure are usually not altered at high altitudes, and there are only small individual fluctuations. Patients with a hypertonic pressure can even get a lower blood pressure after a long stay at the altitudes (Staubli and my own observations). The vital capacity of the chest remains unaltered, whilst the circumference of the chest is distinctly increased (Theod. Williams, Tecon, Amrein). The importance of these physiological facts in the treatment of tuberculosis is widely known. Of course, the high altitude climate may never be considered as a panacea, hut climate helps a great deal in the fight against disease and the best treatment in the best possible climate will always have the best results. In analogy with syphilis we have to regard tuberculosis as a constitutional disease. The primary effect generally arises in childhood with infection of the regional lymphatic glands, i.e., that of the bronchial By further development-the secondary stage-the glands develops. tubercle bacillus reaches the lymph-vessels and the blood-vessels and finally, in the tertiary stage, the real focal lesion (e.g., pulmonary tuberculosis) develops. The treatment of all these stages depends upon the individual resistance, and in the increasing of this resistance the high altitudes stand in the first line of defence. But one has to individualise in this respect. Delicate children and young weak people derive an enormous benefit at the high altitudes. A great many of those cases are, of course, already infected with tuberculosis, and they all do wonderfully well up in the mountains. In the case of pulmonary tuberculosis the most promising cases are naturally the early ones, but the more intensive and extensive affections, with total infiltrations of the upper lobes, &c" show good improvement if too big destructive processes have not already started. The best forms for high altitudes as elsewhere, are the indurative and fibrous ones. Fever in itself is no contra-indication; but if permanent fever, beyond 101'!) 0 F., with high pulse with more than 120 is present (Philippi), the high altitudes ought to be excluded. On the other hand, patients who have been laid up with fever at home for a considerable time often lose it astonishingly quickly on coming to the mountains. Pleural effusions are absorbed well, but dry, obstinate pleural irritation may get worse owing to deep breathing. Also the dry catarrhs of the upper air-passages, such as chronic rhinitis and pharyngitis atrophicans, may get worse. Laryngeal tuberculosis, generally regarded as a strict
582
']'CBEIlCLE
LCkLoIJl'l', 1!)~1
centra-indication till SOIlW years ngo, may dn ycry well. hut it depends upon the state of the lungs and 11pon l'egul:1l' medical control and care (sanatorium). 'I'urban not Davos had ;1;P, pCI' cent. durable results Iron, lal'yngeal tuberculosis, Intestinal tuberculosis generally hits to rank as 11 contra-indication, but good l'efiUlts are known, The same is to I)e sn.id of mogenit:d tuberculosis. Hut peritoneal tuberculosis is now looked upon favourably, thanks to the systomatically and methodically well-dcvelops.j heliotherapy. Otitis media tuberculosa generally is iruprovcrl. 'I'ho experiences of the last ten to twenty years have proved more and more that there is no contra-indication of the high altitudes against well, compensated heart diseases, and cases of weakness of the heart-muscle and nervous tachycardia luay do vcry well. 'I'hey must rest a lot at the beginning and be trained very slowly afterwards with increased exercise, But there must be a good compensation in valvulnr troubles and the ht,art not so be weakened as to work with its reserve powers only. I'atientj, sllffering from 1I10re advanced arterio-sclerosis, especially that, of the coronal'y arteries, must not be sent to the high altitudes, .\nx·wia iR generally improved, especially secondary ana-rnir, and chlorosis, Slight anremias and malaria-cachexia answer very satisfactorily to the high_ altitude treatment. One of the most satisfactory diseases Iron: a high_ altitude point of view is bronchial asthma. Many asthmatics have settled down at high places to remain there permanently free of attacks and to get really cured. In conclusion, the following types of disease arc absolutely contm., indicated. Advanced pulmonary tuberculosis with a permanent pulse of IilO and more and fever of 101':j ) F, and more, advanced laryngeal tu ber, culosis, tuberculosis of the kidneys-especially if combined with advanced pulmonary tuborculosis-i-advanced intestinal tuberculosis and advanced emphysema, non-compensated valvular lesions of the heart, advanced arterio-sclerosis, advanced gout, advanced diabetes. advanced ann-una, and psycho-neurosis. Our results in Arosa, based on inquiries sent to k(W former private patients to he answered personally or if possible by a doctor, are aB following :One to nine years after the treatment at Arosa there were still lit> per cent, lasting results; HH)!) per cent. negntive; 1;')';n per cent. deaths. 80'48 per cent, of the durable results belonged to stage I 12·01 " " " " " " " 11 1'51 " " " " " " "Ill k:Hio " showed at the beginning of the treatment no fever. 8:2'21 " had a pulse of less than 100 per minute. 40'8G " of all attended patients still showed physical signs at site of old lesions, as shown by doctors' certificates. ;3'1'14 still had ']'.13.'s in the sputum. " of all patients are still suffering from diverse sub, IH'43 " jective symptoms, and ;lO " a r e still getting treatment from time to time. The lasting and durable results were obtained chiefly in the age between 2U and ;30 years (i.e. :jUl per cent.), and with patients Who
October,l H21]
DIW PI'E D SIIOU I,D1: n
A~D
1'1lT III SI S
:;88
started t reatm ent within the first six months after th e beginning' of th e disease (i .e., J f'(jl) p CI' cent . of [1]] durable result s.) I;;-\ ·[:.! per cent. are enjoying fu11 and total working capacit y. " are suffering from reduction of working capacity. and 10';-1 1 :!' ,)ll " are totally incapacitntcd. Change of profession was given in ·1· Uti per cent. Change of residence was given in V'Oti per cent.
DH Ol'P1W SlTOL LD EH AS A SlG !\ OF 1':,\ltLY !'l fTHI SI S, By J ,\~ms A, D EL m~ (; E , 0 .13 .1': . (Mil, Div.), ::'>L1 U '.S., L.ILC.l'., D .ll.H.
.-1.,.,,-,,,,,,,
TII "(' }'(·II I" « is " ./li(·tI'. ijlll d hmi,./,-.
Ix view of the frequency with which so-called " Dropped Shoulder" occurs as a sign of early apicul pulmonary tuberculosis, the small space devoted to it in most of the standard WOdi S on diseases of the chest is very sllrprising, but almost equally so are the exaggerated claims as to its diagnostic infallibility which have been put forward by recent writers. 'l' hc fully developed sign- it has recentl y been referr ed to in th e pages of this journ al by Iiivers [1l - is of course well known to all clinicians, consisting as it does of a definite lowering of th e upper outline of the shoulder and of the acromial end of the clavicle, but it is the less wellmarked variety that it is th e more importan t to recognise. I n this type, the amount of act ual shoulder-drop is extremely slight, in many cases indeed hardl y pcrceptibls : what catches th e eye is some slight but defi nite asymmetry of the shoulders which on closer inspection resolves itself into :0 ) .\ slight straightening of the normal curve of the upper border of the t rapezius on one side ; (Q ) an apparent lengthenin g of th is border as compared with that of th e opposite side (this length ening is only apparent , not actualj : (3) excessive prominence of the acromion process on this side, when the patient is viewed from behind . Given th e sign. all observers agree that it may be evidence of early apical pulmonary tuber culosis, but the fact that it frequently occurs from other causes seems to be generally overlooked. It frequentl y arises from occupational causes and on this account is often seen amongst clerks, and Lacoste describes it as being well marked in the majority of violinists. I have also frequentl y observed its occurrence in healthy school children solely from posture, having found it present at one examination and absent at another a few days later. 'Whether congenital causes can bring it about in children and adult s is a point upon which I am at present undecided. I have under observation a considerable number of school children with healthy famil y histories, no symptoms, and in whom I can find no signs of pulmonary tuberculosis, but who neverth eless show a very
[October, 1921
TCBETICLE
HWB ALTITn )]·; A:\]) 'ITBEHCTLl lSlS . By O.
AM ltE H\,
:\I.D.Arosa (Switzerlnnd.)
M,,,licol Su perini end cn t
fir the A ltein
Srt/tfr /o ri ulII . . I mw .
'rIl E chief properties or the high-altitude climata which arc of value in th e treatment of tuberculosis are as follows :r it e LOI/) Barometric ]'ressIl1·1' .-'l'he barometri c pressure diminishes correspondingly to the elevation above sea-level, and th e diminut ion is influenced by the temperature of the ail'. Th e partial pressure of oxygen is diminished. '11/1' Lr)1I' Tcmpcratur« III tll,. ./ ;,..-'l'he diminuti on takes place with arit hmetical progression corresponding to th e increase of elevation above sea-level, not depending upon the geograpbical latit ude. In the winter month s th ere is an " inversion" of th e above-mentioned fact of temperatu res ; th e snow covcring th e ground. th e temperature of th e air over high plateaux and slopes becomes warm er correspondingly to the increasing alti tude. During the night th e ground and the nearest part s of the atm osphere are cooling, and th e nppel' air-parts are gett ing warm ail' from still higher part s. 'I'hi s fact has great importan ce for th e healthresorts at high altitudes, as in th is way th e air-minimum never becomes too low. At high altitudes there is always an equal cold temperat ure in winter and no heat in summer. T he rl"!l l/ t.~ s and pur it!l of th e 11ir are most iJ~lportan t. Of courss, at high altitudes, too, the latter is influenccd b'y existence or. non-existence of dense human dwellings, chimn eys, h ct?l'Ics, steam engmes, &c. But th e pollut ion of the air is worked off Cjlll.ckly by the tr emendous sunpower at the altitudes. The snow which covers th e g ro ~lII d f'ron; November unt il April causes nearly absolute frce~?11l ~ronl dnst III th e ail'. Th e {(Irge amount of sunshiue w~rk s most efficac iously OIL account of th e dry and pure air a~d th~ mten:s1ty .of the. warm sun-rays a~d of th e light-rays. 'I 'he duration of sunshine IS a 11Igh one. Large pine woods also help to free th~ air ?f dust and giv.e l~rotecti on fro~Jl th c winds. The " F(ihn" is a special kind of wind, falling down WIth heavy pressure from th e tops of the mountains ; it is a W1Lrm wind which helps to melt th e snow in spring. 'I'he time of snow-melting at th e Alpine health-resorts is by no means a bad ODe ; stat istics have shown tha t the meteorological conditions for lung-pati ents just at that time of the year arc always superior to those of lower nltitudes, The p!l!/si(){o(Jiwl effects caused by th e above-mentioned meteorological propcrties have been studied in an ample way. Paul Bert (18H2) mentioned th e increase of hremoglobin and Vialilt th e augmentation of th e red blood corpuscles at high altitu des. Miescher, th e physiologist at ll:'tle, and his collaborators Egger , Jaquet, Karcher, Suter, Veillon, have proved th e accuracy of these observations. Similar conclusions have been arrived at by HiilUi sch and 1\1 ercier at Arosa, l\ iindig, Meyer, Turban and others at Davos. Cohnheim who at first attacked th e above-mentioned Iacts, after experiments on employee of the .J ungfrau Hailway, came to th e conclusion " t hat the first-menti oned authors were right and that a real
October, 1\")21 J
HIGH ALTITT;DE AND TDBERCTTljOSrS
:i81
new formation of red blood corpuscles takes place at high altitudes." Also more recent experiments on flyers (Meyer and Syderhelm) confirm the fact of a real new blood formation, caused by the diminished partial pressure of oxygen in the air. It has been shown (Ruppnnner) thf1t besides the augmentation of the red blood corpuscles the lymphocytes and the large mononuclear cells are increased in number, whilst the granular lencocytes and the total amount of the leucocytes are diminished. 'I'he viscosity of the blood is increased (Staubli, Wanner). The respiration and circulation are greatly influenced because of the diminution of the pressure of oxygen. The bad effects during the time of the so-called acclimatisation are, therefore, dyspnoea and palpitation. The maximum and minimum blood pressure are usually not altered at high altitudes, and there are only small individual fluctuations. Patients with a hypertonic pressure can even get a lower blood pressure after a long stay at the altitudes (Staubli and my own observations). The vital capacity of the chest remains unaltered, whilst the circumference of the chest is distinctly increased (Theod. Williams, Tecon, Amrein). The importance of these physiological facts in the treatment of tuberculosis is widely known. Of course, the high altitude climate may never be considered as a panacea, hut climate helps a great deal in the fight against disease and the best treatment in the best possible climate will always have the best results. In analogy with syphilis we have to regard tuberculosis as a constitutional disease. The primary effect generally arises in childhood with infection of the regional lymphatic glands, i.e., that of the bronchial By further development-the secondary stage-the glands develops. tubercle bacillus reaches the lymph-vessels and the blood-vessels and finally, in the tertiary stage, the real focal lesion (e.g., pulmonary tuberculosis) develops. The treatment of all these stages depends upon the individual resistance, and in the increasing of this resistance the high altitudes stand in the first line of defence. But one has to individualise in this respect. Delicate children and young weak people derive an enormous benefit at the high altitudes. A great many of those cases are, of course, already infected with tuberculosis, and they all do wonderfully well up in the mountains. In the case of pulmonary tuberculosis the most promising cases are naturally the early ones, but the more intensive and extensive affections, with total infiltrations of the upper lobes, &c" show good improvement if too big destructive processes have not already started. The best forms for high altitudes as elsewhere, are the indurative and fibrous ones. Fever in itself is no contra-indication; but if permanent fever, beyond 101'!) 0 F., with high pulse with more than 120 is present (Philippi), the high altitudes ought to be excluded. On the other hand, patients who have been laid up with fever at home for a considerable time often lose it astonishingly quickly on coming to the mountains. Pleural effusions are absorbed well, but dry, obstinate pleural irritation may get worse owing to deep breathing. Also the dry catarrhs of the upper air-passages, such as chronic rhinitis and pharyngitis atrophicans, may get worse. Laryngeal tuberculosis, generally regarded as a strict
582
']'CBEIlCLE
LCkLoIJl'l', 1!)~1
centra-indication till SOIlW years ngo, may dn ycry well. hut it depends upon the state of the lungs and 11pon l'egul:1l' medical control and care (sanatorium). 'I'urban not Davos had ;1;P, pCI' cent. durable results Iron, lal'yngeal tuberculosis, Intestinal tuberculosis generally hits to rank as 11 contra-indication, but good l'efiUlts are known, The same is to I)e sn.id of mogenit:d tuberculosis. Hut peritoneal tuberculosis is now looked upon favourably, thanks to the systomatically and methodically well-dcvelops.j heliotherapy. Otitis media tuberculosa generally is iruprovcrl. 'I'ho experiences of the last ten to twenty years have proved more and more that there is no contra-indication of the high altitudes against well, compensated heart diseases, and cases of weakness of the heart-muscle and nervous tachycardia luay do vcry well. 'I'hey must rest a lot at the beginning and be trained very slowly afterwards with increased exercise, But there must be a good compensation in valvulnr troubles and the ht,art not so be weakened as to work with its reserve powers only. I'atientj, sllffering from 1I10re advanced arterio-sclerosis, especially that, of the coronal'y arteries, must not be sent to the high altitudes, .\nx·wia iR generally improved, especially secondary ana-rnir, and chlorosis, Slight anremias and malaria-cachexia answer very satisfactorily to the high_ altitude treatment. One of the most satisfactory diseases Iron: a high_ altitude point of view is bronchial asthma. Many asthmatics have settled down at high places to remain there permanently free of attacks and to get really cured. In conclusion, the following types of disease arc absolutely contm., indicated. Advanced pulmonary tuberculosis with a permanent pulse of IilO and more and fever of 101':j ) F, and more, advanced laryngeal tu ber, culosis, tuberculosis of the kidneys-especially if combined with advanced pulmonary tuborculosis-i-advanced intestinal tuberculosis and advanced emphysema, non-compensated valvular lesions of the heart, advanced arterio-sclerosis, advanced gout, advanced diabetes. advanced ann-una, and psycho-neurosis. Our results in Arosa, based on inquiries sent to k(W former private patients to he answered personally or if possible by a doctor, are aB following :One to nine years after the treatment at Arosa there were still lit> per cent, lasting results; HH)!) per cent. negntive; 1;')';n per cent. deaths. 80'48 per cent, of the durable results belonged to stage I 12·01 " " " " " " " 11 1'51 " " " " " " "Ill k:Hio " showed at the beginning of the treatment no fever. 8:2'21 " had a pulse of less than 100 per minute. 40'8G " of all attended patients still showed physical signs at site of old lesions, as shown by doctors' certificates. ;3'1'14 still had ']'.13.'s in the sputum. " of all patients are still suffering from diverse sub, IH'43 " jective symptoms, and ;lO " a r e still getting treatment from time to time. The lasting and durable results were obtained chiefly in the age between 2U and ;30 years (i.e. :jUl per cent.), and with patients Who
October,l H21]
DIW PI'E D SIIOU I,D1: n
A~D
1'1lT III SI S
:;88
started t reatm ent within the first six months after th e beginning' of th e disease (i .e., J f'(jl) p CI' cent . of [1]] durable result s.) I;;-\ ·[:.! per cent. are enjoying fu11 and total working capacit y. " are suffering from reduction of working capacity. and 10';-1 1 :!' ,)ll " are totally incapacitntcd. Change of profession was given in ·1· Uti per cent. Change of residence was given in V'Oti per cent.
DH Ol'P1W SlTOL LD EH AS A SlG !\ OF 1':,\ltLY !'l fTHI SI S, By J ,\~ms A, D EL m~ (; E , 0 .13 .1': . (Mil, Div.), ::'>L1 U '.S., L.ILC.l'., D .ll.H.
.-1.,.,,-,,,,,,,
TII "(' }'(·II I" « is " ./li(·tI'. ijlll d hmi,./,-.
Ix view of the frequency with which so-called " Dropped Shoulder" occurs as a sign of early apicul pulmonary tuberculosis, the small space devoted to it in most of the standard WOdi S on diseases of the chest is very sllrprising, but almost equally so are the exaggerated claims as to its diagnostic infallibility which have been put forward by recent writers. 'l' hc fully developed sign- it has recentl y been referr ed to in th e pages of this journ al by Iiivers [1l - is of course well known to all clinicians, consisting as it does of a definite lowering of th e upper outline of the shoulder and of the acromial end of the clavicle, but it is the less wellmarked variety that it is th e more importan t to recognise. I n this type, the amount of act ual shoulder-drop is extremely slight, in many cases indeed hardl y pcrceptibls : what catches th e eye is some slight but defi nite asymmetry of the shoulders which on closer inspection resolves itself into :0 ) .\ slight straightening of the normal curve of the upper border of the t rapezius on one side ; (Q ) an apparent lengthenin g of th is border as compared with that of th e opposite side (this length ening is only apparent , not actualj : (3) excessive prominence of the acromion process on this side, when the patient is viewed from behind . Given th e sign. all observers agree that it may be evidence of early apical pulmonary tuber culosis, but the fact that it frequently occurs from other causes seems to be generally overlooked. It frequentl y arises from occupational causes and on this account is often seen amongst clerks, and Lacoste describes it as being well marked in the majority of violinists. I have also frequentl y observed its occurrence in healthy school children solely from posture, having found it present at one examination and absent at another a few days later. 'Whether congenital causes can bring it about in children and adult s is a point upon which I am at present undecided. I have under observation a considerable number of school children with healthy famil y histories, no symptoms, and in whom I can find no signs of pulmonary tuberculosis, but who neverth eless show a very