THE COLUMBUS MEDICAL JOURNAL VOL. XXX. AUGUST 1906. No. 8 THE DIAGNOSIS AND TREATMENT OF INCIPIENT PULMONARY TUBERCULOSIS.* BY JOHN DUDLEY DUNHAM, A. B., M. D., COLUMBUS, OHIO, Lecturer on Diseases of the Stomach, Starling Medical College, The prevalence and high mortality of pulmonary tuberculosis are considerations of sufficient importance to arrest the earnest attention of physicians. Our attitude toward pulmonary tuberculosis in the past may well be illustrated by a sociologic problem. Efforts to reform the criminal class have been until recently directed to the confirmed "dyed-in-the-wool" criminal, and, as we know, with indifferent success. The present method of reclaiming the criminal is to begin with the babes of the submerged tenth and the criminal class. Through the day nurseries, the kindergartens, the higher schools, and in some localities the Junior Republics, efforts are put forth to overcome the hereditary predisposition to vice and to supply a proper training along moral lines. Failure to secure the embryonal criminal does not dishearten the worker in charities. For their energies are directed to the youth who have only begun the vicious life, and have not become chronic offenders. The analogy is quite obvious. In the treatment of the tubercular, just as in the treatment of the criminal, success is greatest when the disease is recognized early, and vigorous and systematic measures are employed. *Read before the Coshocton County Medical Society. In this exposition of the subject it is not my purpose to belittle the work done to cure those already far advanced in the disease, but rather to emphasize the importance and striking results attained by a very early recgonition of pulmonary tuberculosis. The statement that many lives now lost could be saved by an early diagnosis is a well known truism. There are, however, certain obstacles which interfere to some extent with the early recognition of this disease. The pathology of the process in the lung offers a partial explanation. The entrance of the tubercle bacillus into the lung is followed by an extended period of new growth of a chronic nature. Necessarily this is not associated with any physical signs in the beginning. This explains the long period of quiescence, before physical signs may be observed in the chest. The only symptoms in this stage may be the general constitutional signs of malaise, lack of ambition, and a condition which patients describe as "not quite up to par." The attitude of physicians toward the patient's condition often interferes with an early diagnosis. Our hurried and superficial diagnoses cause us to refer to patients as in ill health, as suffering with malaria, or predisposed to tuberculosis, when in reality they have chronic pulmonary phthisis. That we may diagnose tuberculosis early we must recognize the error of former views, which held that a transition often occurs from some form of bronchial or lung disease into tuberculosis. Until recently the opinion prevailed that an old bronchial catarrh, pleurisy, croupous inflammation of the lungs or catarrhal pneumonia could readily become tubercular. In many instances, however, the fact is that the above mentioned conditions are simply manifestations of tubercular invasions. By such a view the inception of the tubercular infection was erroneously said to occur with the appearance of the secondary invasion of the pyogenic bacteria associated with hectic, night sweats, destruction of pulmonary tissue and great prostration. Individuals suffering from scrofula lose the value of proper treatment unless we recognize and act upon the knowledge that scrofula is only another manifestation of an infection by the bacillus tuberculosis. A patient who complains of a slight indisposition, malaise with an occasional cough, can rarely state when his trouble began. If one is persistent in securing the history of these patients he can usually elicit the statement that at some previous time there was a rather persistent cold with a cough which disappeared only after ten days or two or three weeks. He will further state that the above mentioned condition had nothing to do with the present indisposition, as he recovered from that cold months or even years ago. Since the first persistent cold he may say that he has seemed to "take cold" more easily. This introduces the first point to which I wish to direct your earnest attention, viz: The great importance of the much-abused term, a cold. How often do we in the practice of our profession dismiss a respiratory disturbance in a well-developed, apparently healthy patient as only a little cold? The persistence of the patient, however, who perhaps feels there is more than a little cold in his trouble, may at last secure our belated attention to a careful examination. Gentlemen, we should address ourselves to a very careful examination of persons who are afflicted with this common malady. It should be our uniform custom to make a physical examination of the chest in these cases to determine any change in the respiratory sounds, and to determine the presence of apical dullness. At the same time a careful search should be made in the sputum for tubercle bacilli and elastic tissue. I am firmly convinced from my observation that in a large class of tubercular persons the first evidence of the disease which we may secure is to be had by a careful examination of those who seem to be rather more subject to colds than the normal individual. I do not wish to convey the idea that persons who have lost weight and are actually ill from such apparently simple ailments should be carefully investigated. Even the most careless practician will be aroused by such cases. For those who are apparently in good health, but subject to a bronchial difficulty, do I bespeak a more painstaking investigation. If the German dictum: "Jederman hat am ende ein bischen tuberculose" expresses the truth, then it behooves us to recognize as early as our powers will permit all incipient cases of pulmonary tuberculosis. Routine examinations of sputum should be carried out just as consistently as similar investigations of the urine. We may examine many specimens of urine before we find one which indicates a beginning renal inflammation, but the results to the patient are worth all the negative tests. It is even more helpful in routine sputum examinations. Numerous startling surprises have presented themselves to me in both these fields, and the results, I may say, fully justify the time spent in the many negative tests. Differentiation of incipient tuberculosis from malaria is readily made by the examination of stained specimens of the blood. The absence of malaria from a community should receive more consideration as a presumptive sign against such a diagnosis. The digestive symptoms so often found present should not be misleading. Vomiting or nausea is often one of the first symptoms of tuberculosis. In such instances chemical examination of the stomach contents after test meals will often prove that tuberculosis is the fundamental disease. Chronic gastritis is perhaps the most confusing condition. An atrophy of the gastric glands supervenes all too frequently upon pulmonary tuberculosis. It is by no means always true that catarrh of the stomach is the explanation of digestive disturbances in the tubercular. Increased acidity is also observed, and at times ulcer of the stomach. When ulcer of the stomach is complicated by pyloric stenosis a condition approaching starvation is produced. The reduction of the bodily resistance is the beginning of tubercular disease of the lungs at times. In the service of the Doctors Hamilton at Mt. Carmel Hospital I had the opportunity to study two cases of this character. The tuberculosis clearly followed the stenosis. Both patients were unmarried women, 25 and 32 years respectively. Gastroenterostomy was performed in both individuals, followed by increased resistance against the tubercle bacillus. From their present condition there seems to be little doubt that a cure will be effected. Let us consider briefly the physical signs of early phthisis: (1) A constant and evident diminution of respiratory murmur at one apex, with marked deficiency of respiratory movement on the affected side. (2) Sometimes we find moist rales over the apex. (3 A prolonged expiratory sound, often harsh in character, is noted. (4) Decided dullness of the apex on repeated examination. (5) Evident contraction over one apex as shown by supraclavicular percussion. There is no one sign which gives conclusive evidence except the presence of tubercle bacillus. One should not hesitate, however, to make a positive diagnosis when repeated examinations fail to show the bacillus. The customary single test of the sputum when negative is not sufficient. The physician should make his own examinations, where possible, and they should be repeatedly done until bacilli are found. The sputum in one of my cases showed the tubercle bacillus only after fifteen examinations were made. In this case a diagnosis had been made previous to the discovery of the bacillus in the sputum. The condition of the pulse in incipient tuberculosis is instructive. Even before clear evidence of trouble in the lung may be shown the pulse will be found to increase to a greater extent after slight exertion than is found in health. The history, the physical signs and the general condition of the patient must be considered together in diagnosing incipient tuberculosis. When there is little expectoration and the tubercle bacillus is not found, and very slight changes are to be made out by percussion and auscultation, the diagnosis is difficult. A patient who presents himself with a dry cough, accentuation of the second sound of the heart at the second right interspace, malaise, possibly some loss of weight and appetite, even though there is no change to be noted in the lung—such a patient should be regarded with suspicion. When we reassure such a person with the statement that he is a little run down or has a little malaria we do our pa |