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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 ins 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 berculosis, although cattle as a source of dan- cepted in the face of a positive symptomatology
on an x-ray examination should never be acs is well established. It is generally believed at 10 or 12 per cent of tuberculosis in children
and positive physical examinations. A diagnosis
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 man 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 f 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
on promptly, and I lies in human beings suffering from open preparations which comes 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. re 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 sin tests; and 5, to a study of the manner in facts which are just beginning to be appreciated. rich tuberculosis affects the patient through Through them I have been able to explain, clase 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 diagnosin. 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 neurasthen accompanied by some degree of toxemia; and, They indicate that the central nerve cells a 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.
lation. They further indicate a preponderati 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 durir 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
a tuberculous process, should be considered GROUP I
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 evideng Nerve instability. Night sweats.
derived by physical examination. Temperature.
The symptoms of a reflex nature, Group Blood changes.
are based entirely on the visceral neurology 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 thor 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, when (hypermotility and hy- Flushing of face.
it is transmitted upward into the cervical seg persecretion).
Apparent anemia. Loss of weight.
ments to mediate with the cervical spinal nerves
causing muscular contraction through the moto GROUP III
and pain through the sensory roots. The chie Symptoms Due to the Tuberculosis Process Per Se area of pain is in the third and fourth cervica 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
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 se 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 commos the motor reflex, affecting the muscles of the reflex symptoms in tuberculosis point away from 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 laryngologs generation of the muscles above mentioned and and gastroenterologist rather than the tubercor also 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 sensatima teriorly.
and motion, producing local irritation, cough. This grouping shows each symptom in some- hoarseness, and certain disturbances in phonthing 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 tuberc group of symptoms due to toxemia, the ones on losis, is the same that is found in chronic gas
ladder and chronic appendix affections.
It in diminished motion is the lessened elasticity of manifests itself as a tendency to hypermotility the infiltrated lung. Diminished motion of the ind hypersecretion. The parasympathetic reflex chest wall, if acute pleurisy, chronic pleurisy with in the part of the heart sometimes shows, par- adhesions, and a chronically contracted lung can licularly when the patient is at rest, as a pro- be ruled out, is practically always due to a motor nounced bradycardia; at other times the vagus reflex affecting the muscles of the shoulder action results only in instability.
girdle and diaphragm, particularly the latter, It is characteristic of the symptoms belong- caused by inflammation of the pulmonary tissue ing to the reflex group that they remain, varying on the respective side. When inflammation exof course in prominence, as long as the patho- ists in both lungs, the diminished motion may logical process remains unhealed; and, when be about the same on both sides (although this combined with some symptom of Groups I or II, is rarely true), and may be difficult to determine. suggest 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 tuberculous process per se, are those which are into the production of diminished motion, their most definitely due to tuberculosis. They are diagnostic value lies particularly in the fact that nearly always accompanied by other symptoms the increased tension (spasm) which affects them belonging to Groups I and II, and nearly always is readily detected on palpation. mean an active tuberculous lesion.
Diminished respiratory motion over one side A careful analysis of the symptoms of pa- of the chest with accompanying increased tentients 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
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 pulmonary tuberculosis expresses itself through whole, and are poorly adapted to all patients. the visceral nerves, emphasizes the importance of except those who will approach treatment with this line of study as an aid to diagnosis.
an intelligent understanding and cooperation. If Prognosis
only there were some specific medicine to give The prognosis in tuberculosis has greatly im- or some specific remedy to inject, then tubercuproved with our increased knowledge: (1) of the losis could be treated successfully by physicians disease, and (2) of the tuberculous patient. I de- generally; but until our scientists give us some sire to emphasize a fact that should be self evi- such measure, practitioners in general will condent but which seems to be generally overlooked; tinue to say that they are unable to cure tuberthat is, that these early tuberculous infections culosis by open air and food, and will continue do not always become quiescent, but without to feel pessimistic regarding its eradication; and producing a frank clinical disease, manifest them- its successful treatment will have to remain in selves as clinical entities in the way of interfer- the hands of those who give the disease special ing with the growth and development of the study. child. While they may not extend and produce There are two elements in the healing of tuactive open tuberculosis, yet the bacilli multiply berculosis: (1) the local stimulation of the focus and invade adjacent tissues and produce toxins of disease by the reaction which takes place bewhich prove particularly detrimental to the nerv- tween the bacillary products and the antibodies ous system of the child, and often, sooner or formed by the patient's tissue cells; (2) the later, cause open clinical disease.
formation of defensive substance, both general These cases should be sought out and treated. and specific, by the body cells. They respond readily. I have found no type of The bacillary products which unite with the tuberculosis in which the prognosis is so good. antibodies and produce focal reaction may be Children, relieved of active infection before the
furnished by the patient himself from the bacilli age of puberty, often go on to a normal develop- which cause his infection; or may be introduced ment.
from without in the form of products known as Early clinical tuberculosis should nearly al- tuberculins. The specific stimulation of the ways heal, under ideal conditions. It will heal focus of disease by this reaction is a very importin probably 20 per cent of cases by such simple ant factor in healing. Tuberculin when adminmeasures as change of occupation, rest and tonic istered intelligently will supplement the products measures. If only we knew what patients were furnished by the patient himself, and will hasten included in this 20 per cent, we would save them healing. My experience in its employment for time and expense, but we have no way of judg- many years leads me to believe that it will add ing; so it is our duty to treat every case of early at least 20 or 25 per cent to the average patient's clinical tuberculosis as serious, and provide those chances of cure; and in many will be the deterafflicted with the intelligent aggressive treat- mining factor in healing. ment which will restore health to nearly all. Whether tuberculins are used or not, the main This is all the more important and urgent because point in cure is the life that the patient lives, the prognosis rapidly decreases as the disease ex- Resistance must be kept high for a prolonged tends; whereas 80 to 90 per cent can secure an period of time, until healing takes place. How arrestment of their disease in early clinical tu- long this will be differs with the character and berculosis; the percentage drops to 50 to 70 in extent of the process; the underlying nervous, moderately advanced cases; and 30 to 40 in the psychic and physical reactibility of the patient; advanced. These figures apply to patients treated the ability of the physician to outline an intelliunder the best of conditions and with a whole- gent and sufficient line of treatment; and the hearted cooperation. Treatment under less fa- willingness and ability of the patient to give a vorable conditions without full cooperation will whole-hearted cooperation. produce results correspondingly less favorable. enough under the best conditions, and is much
prolonged under less favorable circumstances. Treatment
Early cases require from six months to a year It is impossible to give more than a few gen- of treatment and should be under observation for eral principles of treatment without making this a year longer; moderately advanced cases require paper far too long. While it is unfortunate that from two to six months longer for treatment, and we have not as yet found a remedy for tubercu- a correspondingly longer period of observation; losis which ranks with mercury and salvarsan in and far advanced cases can rarely be dismissed in syphilis, quinine in malaria, and antitoxin in less than ten or twelve months, some even being diphtheria, yet there is much room for encour- compelled to spend two or three years in obtainagement in treating this disease by present day ing an arrestment,, after which they must still methods. Unfortunately present methods re- be observed for a period of two years or more. quire much time devoted to treatment, are not The patient who desires to recover from tugenerally understood by the profession as a berculosis must be willing to accept disappoint
ents, practice self denial, and cooperate until . complishment because of the rapidity with which e disease heals. He must not have the attitude examinations must be made. Colonel Bushnell, at he is working for health to please his physi- who has long been a careful student of tubercuan; on the other hand, he must know that the hysician is the instructor who is teaching him losis, set as the standard for exclusion, all applind helping him to play his own game.
The cants in whose chests are found "determinate" ame is worth it only because it offers hope of
rales. While this does not take into consideraeward.
tion the finer diagnostic work which has de
veloped during the past few years, it does elimIf only the difficulties which are attendant inate most of the frankly tuberculous at the bepon obtaining a favorable result in this disease ginning. If sufficient help were obtainable to t any time after it has become a clinical entity, inquire into the clinical history with reference nd the comparatively greater difficulty of doing to such symptoms as blood spitting, pleurisy, o when the disease has become advanced, could frequent and protracted colds, cough, and general e impressed upon both laymen and the members nerve instability and loss of strength, examinaf our profession, so that physicians would be tions would be made more accurate.
A point onsulted early and early diagnosis would be that could well be considered in determining nade, then the time and money spent in the whether a suspicious case should be taken into reatment of tuberculosis would be reduced by the army or not, is whether he is going to better one-half; the percentage of favorable results his condition by entering the army. If so, he vould be increased three-fold: and invalidism could be taken with little risk; if not, he should vould be immeasurably reduced. This can be be rejected. A farmer boy in question should accomplished even with our present imperfect be eliminated; on the other hand, the city dweller method of treatment, which, as previously men- who will be put on healthful outside exercise, cioned, amounts to making the patient live so that should profit by it. nis resisting power may be maintained at a high level in order that his body cells may respond
The effect of caring for the rejected draft uvith large quantities of defensive bodies and to men and the soldiers who return, should have an keeping him so living until the diseases has time important influence on the amount of tubercuto heal.
losis found in civil life. The problem of the re
turned tuberculous soldier has several important Factors which aid in keeping resistance high, angles: 1, immediate efficient sanatorium care are such as open air, good food in sufficient for all who can be helped ; 2, infirmary treatment quantities, properly regulated rest and exercise, for those severely ill; 3, proper care after disheliotherapy, hydrotherapy, various medicinal charge from the sanatorium. tonics, procedures which relieve symptoms and
Realizing that tuberculosis heals slowly, treatcomplications, among which must be mentioned artificial pneumothorax, and carefully applied attainment of a definite result. After this result
ment should not be for a set period; but for the psychotherapy. Each of these will, when prop- has been attained, then suitable light work with erly applied, add its five, ten or twenty per cent compensation should be provided, so as to turn to the patient's chances of cure. None of them
the soldiers back into society capable of self supshould be considered as a "cure" for tubercu
port. If those who have secured a favorable losis in itself. All are aids when properly em
result were given some light employment at ployed, and many even can do harm when em
which they could work part time and remain ployed in a wrong manner. I do not hesitate to
within their strength over a sufficient period of assert that what seems so simple a measure as
time to permit the disease to fully heal, relapses "exercise,” wrongly applied, has been responsible would be reduced to a minimum. The period of for more deaths in tuberculosis than any other time would vary from one year to several years, single measure.
according to the individual concerned.
Tuberculosis and the Soldier
The war should have a beneficial effect upon
the tuberculosis problem in the United States. The world war brings several important prob- While the disease must be expected to increase in lems as far as tuberculosis is concerned: i, the the European states in which the war has lowered problem of excluding active tuberculosis from the status of living and at the same time brought the army; 2, the care of soldiers who become such overwhelming nerve depression, in America actively tuberculous; 3, the influence of the war it should decrease because of our added opporon the problem as found in civil life.
tunity of determining those who are infected be
tween the ages of 18 and 46, and because of the The exclusion of tuberculosis from the army care which is being given to rejected applicants is greatly to be desired and yet difficult of ac- and which will be given to returned soldiers.