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Au Independent Monthly Magazine
Organized at Council Bluffs, Iowa, September 27, 1888. Objects: "The objects of this
* * 78 Service Stars
THE MEDICAL SOCIETY OF
"Keep tho Home Fires Burning'
"Follow the Flag"
10. C. GEBHART. ........... St. Joseph
"Carry On" the work of the Society
processes which they produce, has been greatly
extended. The causative microorganism and the Original Contributions
method of its transmission has now been proven
for most of our common infections. Resulting [EXCLUSIVELY FOR THE MEDICAL HERALD.)
from this research, many diseases which formerly seemed inevitable are now prevented and
likewise many which were considered incurable HE PRESENT STATUS OF THE TUBER
are now successfully treated. CULOSIS PROBLEM*
Of the many diseases which have been the FRANCIS M. POTTENGER, A. M., M. D., L. L. D. recipients of intensive study during this period, Monrovia, Cal.
none has received more attention than tubercu
losis. While we must acknowledge disappointThe past quarter of a century has witnessed
ment in not yet being able to announce simple ne almost complete revolutionizing of medical
methods for its prevention and a positive specience. The development of clinical medicine cific remedy for its cure, yet we are able to reas gone for the most part hand in hand with
port that very important progress has been he development of the laboratory. This has not made. The knowledge so far gained, if propbeen due to the fact that all possible progress erly applied, will exert a gratifying influence utside of the laboratory has been made, but both upon the morbidity and mortality of this
fact that the immediate past has world-wide scourge. een so preeminently an age in which laboratory As a result of the intensive study of tuberesearch has predominated, that clinical medicine culosis during the past few years, many importas been more or less content to apply laboratory ant facts have been established which may be inacts to clinical disease instead of making the terpreted with varying degrees of optimism. The ainstaking study of the patient that it should. viability of the bacillus outside of its host; the
By this intensive specialization our knowl- general prevalence of the disease, both as an dge of the various diseases and the pathological infection and as a clinical entity; its chronicity,
Read by invitation before the thirty-first annual particularly after reaching the open stage; and meeting of the Medical Society of the Missouri Valley, maha, Neb., September 19-20, 1918.
the fact that it may be transmitted through milk, one of the most important articles of diet; make throw of the theory of heredity, and the the prevention of infection, for the present, a thronement, in its stead, of the idea of postma very difficult matter. These facts emphasize the infection, we emphasized the danger of cont necessity of controlling the morbidity as well to such an extent that it was assumed that as mortality: first, by preventing tuberculous in danger in associating with those ill of tuber fection from becoming clinical tuberculosis; and, losis was great and universal. In the minds second, by curing as large a number as possible those who were least conversant with the nat of those who are suffering from the clinical dis- of the disease, even a casual association w ease.
one open case was considered sufficient for This presupposes a diagnosis of clinical fection to occur. This idea was the parent tuberculosis as early as it can be made, and the an unjust and unwarranted phthisiophob immediate intelligent application of those meas- which caused all kinds of injustices to be da ures which are helpful. To this end the patient to the tuberculous patient. We now believe thi who has the disease must be as carefully studied there is no danger in casual contact, and that as the disease which has the patient. While only time when considerable infection occurs is hoping for the laboratory to give us a remedy childhood. of similar specific action to antitoxin in diph- Pathologists had known for many ve theria, quinine in malaria, and arsenic and mer- that the glands of children, particularly thd cury in syphilis, we must not remain idle. We who lived under bad conditions, were frequen can probably make most advancement during infected with tuberculosis. It was not until this time by carefully studying the patient and discovery of the cutaneous and ophthalmic learning how the disease affects him and how berculin tests, however, that we really had a these influences may be avoided or counter- definite idea of the universality of tuberculo acted.
infection in early childhood. These tests appli My work as a clinician has particularly led to large groups of children in many differe me into the study of the patient, although I have countries, revealed the surprising fact that not neglected the study of the disease in its body cells of from 50 to 100 per cent of childr varied aspects. I was early convinced that bet- were sensitized to the tubercle virus before th ter methods of diagnosis and more successful were fifteen years of age; in other words, fre results in therapy were necessary if tuberculosis 50 to 100 per cent of the children tested, varyi was to be coped with; and now, after several according to the groups, had already been years of close observation and study, I believe fected with the tubercle bacillus. I am able to show a certain amount of definite We now were able for the first time to und progress which points the way to a better under stand tuberculosis. It is a disease which ga standing of the patient who has tuberculosis, and access to the body during childhood, but whi offers an explanation of the manner in which the may remain quiescent for years and then ber disease affects him. Clinical tuberculosis which active and produce clinical tuberculosis. appears to be such a complex disease may be were aided in this understanding by the fa analyzed in such a manner as to satisfactorily ex which were being coincidentally discovered plain nearly all of its many and varied symptoms. the field of serology and immunity. We the This knowledge facilitates diagnosis. It helps learned that an insection is followed by an i us to appreciate the early signs of activity and creased resistance or relative immunity. TI to differentiate between activity and quiescence was made evident by studying groups of tube in borderline cases. It further is of aid in ap- culous patients. While nearly all children a plying a rational therapy. Before entering upon infected, comparatively few become clinical this interesting and important discussion I wish tuberculosis during their early years. Those w to recall some of the more important phases of do during the first year or two of life, nearly a the subject which have been studied during the die of acute forms of the disease. By the tin past few years, and to place before you what I the age of six or seven years is reached, resistan believe to be the best teaching at the present begins to be evident and there is a tendency fd time; remembering that until the subject is the disease to become chronic; and after the ag thoroughly understood, all supposed facts are of fifteen years, tuberculosis shows itself pa subject to change.
ticularly as a chronic infection. It becomes mo
chronic in the later decades than in the earli Phthisiogenesis
ones, which demonstrates that resistance develop One of the most important and far-reaching with association with the bacillus. acquisitions to our knowledge of tuberculosis is It is now the concensus of opinion that th that with reference to the subject of phthisio- clinical tuberculosis which is found so often afte genesis. We had at the beginning of our in- the fifteenth year of life is produced by bacill tensive study of the subject, classed tuberculosis whose antecedents entered the body of the in among the chronic infections; but, in the over- dividual during its early years, and that they their antecedents have lived in the tissues and 3. The x-ray. The status of the x-ray is en able to multiply and produce the active still a matter of discussion. Unwarranted confisease. It is further believed that, other condi- dence is often put in it; and I have personally ons being equal, the more massive the infection seen many worthless plates, the interpretation of e greater the danger of the individual develop- which was permitted to seal the patients' fates. g clinical disease. This emphasizes the import- The x-ray should not be depended on alone. It ice of keeping children from associating inti- should be interpreted in conjunction with a careately with those afflicted with open tubercu- fully taken clinical history and a good physical sis or from drinking milk from tuberculous examination. ttle.
The x-ray has been of great aid in studying Source of Infection
hilus infections, this portion of the lungs being
extremely hard to examine by means of percusIt is now believed that the principal source
sion and auscultation. A negative opinion based infection is some human being who has open
on an x-ray examination should never be acberculosis, although cattle as a source of dan
cepted in the face of a positive symptomatology s is well established. It is generally believed
and positive physical examinations. A diagnosis at 10 or 12 per cent of tuberculosis in children
should not depend on any one examining proceddue to the bovine bacillus, having been trans
ure. It should be arrived at by a process of reaitted through milk. I would suggest, however, at the amount might be much greater for these
soning. gures are based on the percentage of lesions
4. Tuberculin Tests. The tuberculin tests, which bovine bacilli are found, and do not take
like the x-ray, have exerted a beneficial influence to consideration the possibility of bovine ba- upon diagnosis. They have caused physical exli changing to human bacilli after years of
aminations to be made with greater care and have owth in human tissues. It seems to me most
shown that the diagnosis can be made earlier obable that bovine bacilli, growing on human
than was formerly believed. The value of the il for a long period of time (years) might
tuberculin test depends on the principle developed ange their morphology and characteristics of
in immunological studies, that active infection owth, and become undistinguishable from the
creates active resistance on the part of the body iman bacilli, the same as they change when
cells. While the evidence of resistance as shown own on different media in the laboratory. The
in the sensitiveness of the body cells persists in esumption of danger from the bovine bacillus
tuberculosis after the infection becomes quiesso strong that there can be no rational excuse
cent, yet my experience in that class of cases in r not using every means for the eradication of
which the test should be of great value-early berculosis from our dairy herds, and for not
clinical cases before destruction of tissue has irizing all milk from cows which have not
taken place—confirms the above stated immunoccessfully passed the tuberculin test. Never
logical pinciple and warrants the assertion that eless, we still recognize that the greatest dan
any cutaneous reaction to any of the tuberculin t lies in human beings suffering from open
preparations which comes on promptly, and berculosis.
reaches a maximum of 34 to 1 c.m. within the
first twenty-four hours, should be interpreted Diagnosis
as meaning that that patient at that time, or in My remarks on diagnosis, prognosis and the recent past, was suffering from an active erapy, shall be confined to pulmonary tuber- tuberculous lesion. losis. The advances made in the diagnosis of One reason why these tests are not more valberculosis in recent years has been due: 1, to uable is because of the variability of the tubere fact that a larger group of men have been lin used. They differ in their antigen content. ving their attention to the disease and so have This can best be overcome by employing several come more proficient in making examinations different preparations for each test. emselves and have stimulated others to greater 5. The Manner in which Tuberculosis Afterest; 2, to a better understanding of the na- fects the Patient Through the Visceral Nerves. Te of the disease through the recent studies in The original studies which I have made along thisiogenesis ; 3, to the x-ray ; 4, to the tuber- this line have led to the discovery of important Tin tests; and 5, to a study of the manner in facts which are just beginning to be appreciated. nich tuberculosis affects the patient through Through them I have been able to explain, clas2 visceral nerves.
sify and evaluate well known symptoms and 1 and 2. Statements 1 and 2 need no discus- physical signs; to suggest several new diagnoson. It stands to reason that increased interest, tic signs; and to point out sources of error in actice in examination, and a better understand the old established methods of examination, parg of the nature of the disease, will aid in mak- ticularly percussion. These studies, therefore, g better diagnoses.
make diagnosis easier and more accurate.
The basis of my study is: First, that tuber- which we have hitherto laid greatest stress culosis is a chronic infectious disease which diagnosis, now that we understand their caus passes through variable degrees of activity and are in no wise characteristic of tuberculos quiescence, and is during such periods of activity They are present in conditions of neurastheni accompanied by some degree of toxemia; and, They indicate that the central nerve cells as second, that it affects the patient who is infected or have been, the recipients of harmful stim reflexly through the nerves which supply the lation. They further indicate a preponderatis lung, and generally through the action of the periphereal expression through the sympathet toxins upon the nervous system. In this, I am nerves. They are most pronounced duris dealing with primary activities and not the sec- periods of activity of the disease, and disappe ondary action which results from disturbed func- except they be due to nerve instability or son tion.
other toxemia when the disease process becom This study has led me to offer a classification quiescent. of symptoms as follows:
This group of symptoms, then, when due GROUP I
a tuberculous process, should be considered
evidence of toxemia only. Their absence or di Symptoms Due to Toxemia
appearance does not indicate the absence Malaise.
Digestive disturbances tuberculosis. The symptoms due to toxemia a Feeling of being run (hypomotility and hy
of diagnostic value in tuberculosis only whe down.
posecretion). Lack of endurance. Loss of weight.
accompanied by symptoms of a reflex nature Loss of strength.
Increased pulse rate. those due to the disease per se, or by evidend Nerve instability. Night sweats.
derived by physical examination. Temperature.
The symptoms of a reflex nature, Group 1 Blood changes.
are based entirely on the visceral neurology d GROUP II
the lungs. Symptoms Due to Reflex Causes
The lungs are supplied by sympathetic nerve
from the upper five or six segments of the tho Hoarseness.
Circulatory disturbTickling in larynx. ances.
acic portion of the cord, and these carry th Cough.
Chest and shoulder impulse caused by inflamed pulmonary tissu Digestive disturbances pains.
back to the same segments of the cord, whend (hypermotility and hy- Flushing of face.
it is transmitted upward into the cervical s6 persecretion).
Apparent anemia. Loss of weight.
ments to mediate with the cervical spinal nerve
causing muscular contraction through the moto GROUP III
and pain through the sensory roots. The chid Symptoms Due to the Tuberculosis Process Per Se area of pain is in the third and fourth cervic Frequent and protracted Pleurisy.
zones which includes the areas of the neck an colds. Sputum.
shoulder down anteriorly to the second rib, an Spitting of blood.
posteriorly to the spine of the scapula. This i
the only subjective symptom caused by refle The above symptoms noted in Group II, with impulses traveling from the inflamed lung ove the exception of apparent anemia, are all sub the sympathetic nerves. jective in character. To these should be added The lungs are also supplied by the vagi three important reflex objective symptoms, or nerve which belongs to the parasympathetic STE what are more commonly classed as physical tem. Through it the lungs are brought into re signs, thus: one, the diaphragm reflex which flex connection with many other structures an shows as a limited motion of the side of the organs supplied by parasympathetic nerves an chest which is the seat of inflammation; second, produce symptoms in them. All of the commo the motor reflex, affecting the muscles of the reflex symptoms in tuberculosis point away frog shoulder girdle, showing as an increased tension the lung and toward those organs which a of the sternocleidomastoideus, scaleni, trapezius, bound most closely reflexly with it—the laryn levator anguli scapulae and rhomboidei; and, stomach, intestines, and heart. Patients with third, the trophic reflex which shows as a de- tuberculosis are apt to consult the laryngolog generation of the muscles above mentioned and and gastroenterologist rather than the tubercoalso of the skin and subcutaneous tissue over the losis specialist. neck, shoulders and chest as low as the second The parasympathetic reflex on the part rib anteriorly, and the spine of the scapula pos- the larynx shows as a disturbance in sensation teriorly.
and motion, producing local irritation, cough This grouping shows each symptom in some hoarseness, and certain disturbances in phonithing of its true value and in its relationship to tion. The disturbed function found in the gastro other symptoms. I desire to emphasize that the intestinal canal in chronic pulmonary tuberct group of symptoms due to toxemia, the ones on losis, is the same that is found in chronic ga
ladder and chronic appendix affections. It in diminished motion is the lessened elasticity of anifests itself as a tendency to hypermotility the infiltrated lung. Diminished motion of the ad hypersecretion. The parasympathetic reflex chest wall, if acute pleurisy, chronic pleurisy with h the part of the heart sometimes shows, par- adhesions, and a chronically contracted lung can cularly when the patient is at rest, as a pro- be ruled out, is practically always due to a motor bunced bradycardia; at other times the vagus reflex affecting the muscles of the shoulder ction results only in instability.
girdle and diaphragm, particularly the latter, It is characteristic of the symptoms belong caused by inflammation of the pulmonary tissue ng to the reflex group that they remain, varying on the respective side. When inflammation exf course in prominence, as long as the patho- ists in both lungs, the diminished motion may bgical process remains unhealed; and, when be about the same on both sides (although this ombined with some symptom of Groups I or II, is rarely true), and may be difficult to determine. uggest the lung as the source of the stimuli. While the muscles of the shoulder girdle show
The symptoms of Group III, those due to the this pulmonary motor reflex, and enter slightly uberculous process per se, are those which are into the production of diminished motion, their host definitely due to tuberculosis. They are diagnostic value lies particularly in the fact that learly always accompanied by other symptoms the increased tension (spasm) which affects them Selonging to Groups I and II, and nearly always is readily detected on palpation. nean an active tuberculous lesion.
Diminished respiratory motion over one side A careful analysis of the symptoms of pa- of the chest with accompanying increased tenlients suspected of tuberculosis, according to sion of the muscles of the shoulder girdle, parthis grouping, will suggest the correct diagnosis ticularly the sternocleidomastoideus, trapezius, in nearly 90 per cent of cases.
levator anguli scapulae and rhomboidei, on the Aside from the subjective symptoms of re- same side, can nearly always be safely interpreted flex origin above mentioned, there is a group of as being due to a motor reflex caused by active objective reflex symptoms or physical signs inflammation of the underlying lung tissue. In which are of great diagnostic value in pulmonary examining for the tension of the muscles of the tuberculosis. These are for the most part pro- shoulder girdle, one should bear in mind that duced through the sympathetics mediating with normally the muscles on the side of the hand used the spinal nerves, and belong to the same group most are larger and tenser than normal in those of viscero-genic reflexes as chest and shoulder who continually use the arm for heavy work such pains, mentioned above in Group II. These are: as the blacksmith; and that they are not so thick 1, the diamphragm reflex (spasm), producing but longer and at times less tense than normal in diminished motion of the side ; 2, the motor reflex others. (spasm), affecting the muscles of the shoulder Whenever the lung has been the seat of a girdle, particularly the sternocleidomastoideus, chronic inflammation, the muscles which show scaleni,` pectoralis, trapizius, levator anguli tension (spasm) while the process is acute, and scapulae and rhomboidei; and 3, the trophic re- the skin and subcutaneous tissue over the neck, flex which manifests itself in the skin and sub- shoulders and chest, as low as the second rib cutaneous tissues through the cervical sensory anteriorly and spine of the scapula posteriorly, nerves, and in the muscles through the cervical show degeneration. They lose their tension and motor nerves which mediate with the afferent elasticity and feel doughy to touch, and become sensory sympathetic nerves from the lungs. reduced in volume.
The objective reflex symptoms or signs pos- The importance of these physical changes in sess great diagnostic value. Like the subjective the muscles and subcutaneous tissue and skin is symptoms in Groups I and II, above enumerated, (1) that they definitely point to the lung as the these are expressions of the manner in which the organ in which the stimuli arise; and (2) they disease process, in the lung, is manifesting itself, may be detected by sight and touch. in disturbed function, through the pulmonary The importance of their recognition does not visceral nerves.
stop with their diagnostic value but extends to The diaphragm which, under ordinary condi- the effect which they have upon the data obtained tions of health, descends freely with each inspira- upon percussion and to a lesser degree upon tion, is already partly contracted when the lung auscultation. Remembering that the resistance is inflamed because it is reflexly stimulated by transmitted to the finger and the sound elicited the impulses which travel to the cord and are on percussion, depend upon all tissues which lie there transmitted to the phrenic nerves; conse- in the direction of the percussion stroke, it is quently, during the act of inspiration the total evident that not only the amount of soft tismovement of the diaphragm on the side of the sues but their tension must be taken into considinflamed lung is less than normal. This gives a eration if percussion data are to be correctly diminished motion of the chest wall on the side interpreted. of the lung which is diseased. A further element This brief outline of the manner in which