the tubercle bacillus would not permit us to speak thus when referring to incipient infection. Long before the sudden and violent hemoptysis; months before the huskiness of the voice is noticed by the friends; through many days before the fever burns and many nights before the sweating drenches, certain changes are occurring which would lead the watchful physician to suspect the presence of this hidden enemy. I have thought it best to emphasize this point, inasmuch as hemoptysis, vomiting, huskiness of the voice, fever, chills and night sweats are symptoms of established, advanced or even complicated infection rather than of incipient tuberculosis. The onset is, therefore, usually insidious, perhaps preluding these above-named symptoms by many months; is difficult of recognition as a diseased condition, but is invariably of constant and typical symptomatology which may usually be identified if the physician is on the lookout for the condition and gets right down to business when making his examination. There is a notion among the laity and indeed among some physicians, which I heard very eloquently expressed some weeks ago by a street faker, who was trying to scare some old farmers into buying his "wonderful catarrh medicine." "Gemmin, gemmin," he said, "Here is a bottle of getah medicine. Now do you know what getah is? It's when your nose and mouth fill up with stuff and ye hawk and spit from morn till night. But when ye go to sleep, ye forgit to hawk and spit, and it runs down into yer stumick and gives ye consumption." Now this idea of incipient tuberculosis has been laid at the door of our medical forefathers; but such an accusation is unjust, for listen to a few words from men who have labored before the existence of bacteria was known and died before their study was made a science. Austin Flint, that great student of tuberculosis, in 1868 (fourteen years before Koch announced to the world his discovery) called attention when speaking of special points of diagnostic importance, to a "cough and expectoration, not succeeding an attack of acute bronchitis, and not connected with chronic pharyngitis; the cough at first dry and afterward, an expectoration.” Let us go back eleven more years and hear Barclay in his classical description, venture, "It must be regarded as unfavorable when cough has begun without preceding catarrh or coryza, but has been from the first, dry and hackingchanged for one accompanied by thin mucilaginous, rice-water sputa, and that form of ex pectoration has been followed by thick yellow phlegm." SYMPTOMS OF INCIPIENT INFECTION Now the most common "first symptom" is, alas, one which is not of startling abruptness nor in fact usually brought to the attention of the physician until others have appeared-I speak of a slow but steady loss of weight. But it is often our good fortune and, indeed, the good fortune of the patient that this fact is detected even though he may consult us in regard to other matters of health. Here is an example: A young lady averaged 100 pounds in the summer and 105 pounds in the winter. During the past winter she did not gain her usual 5 pounds, but on January 1 weighed something like 98 pounds. She remained apparently in excellent health and good spirits; but during the month of January lost 2 more pounds and in February 3 pounds. Few people watch so closely alterations in their weight, but this young lady consulted her physician on this very point, though scarcely alarmed. The physician questioned her closely, but was able to bring out no history of suspicious symptoms. "No," she declared, "I have not coughed," but even as she finished the sentence, cleared her throat with a rasping sound. A complete examination followed and there was no question but that the tubercle bacillus had commenced his dreadful work. Another woman complained that she had lost no more weight than her sister, whereupon the physician replied, "But, madam, you have no weight to lose while your sister has plenty to spare." If I were to submit this question to a vote in your society, there is no doubt in my mind but that you would place it at the head of the list as most important in the diagnosis of early tuberculosis. As I have said, the patient has either unfortunately failed to keep tab on his weight or has not appeared for advice until other symptoms have thrust themselves on his attention. I am inclined to regard languor as a symptom of importance secondary only to loss of weight; but in this connection I do not wish to be misunderstood. Languor is not typical of tuberculosis, except that it appears very early in this disease-much earlier than in the anemias in which it is a more constant symptom in the late stages. It may be defined as a "happy languor" as contrasted to the "anxious languor" of the other cachexias. As the older writers have expressed it, the patient may boast of excellent health while every movement of the body gives token of feebleness and languor. His voice is weak as he states that he never felt better in his life; and he grasps your hand feebly as he tells how much work he can do. This brings us to a third symptom of perhaps no less importance, but so opposed to the concepts of pathology and symptomatology as to lead us astray very quickly unless we are on the lookout. While our patients with cold in the head, rhinitis, sinus disease and asthma, buy lung cures and pester us with the never-dying delusion that surely their days are numbered; our consumptives are brought to us for diagnosis, dying, but stubbornly maintaining that they never felt better in their lives. Now there are, of course, exceptions to this statement; but I pass them over without comment for fear even a terse description might lessen the emphasis which I would place on the usual class. What relation the tubercle bacillus bears to the opium poppy, I do not know, but, in truth, I have come to believe that the essential poison of this germ resembles very much in its action our drug morphin. Let me point out some of these similarities: 1. The chronic intoxication which gives to the morphin fiend a feeling of well-being, varies but little or not at all from that of the consumptive. 2. Either person remains happy in this sweet but damning influence. 3. Either person grows deceitful or even lies that he may not by his own lips convict his master. Fear of exile from those not infected does not cause this symptom; for it was observed many years before the contagiousness of tuberculosis was known. 4. The morphin fiend loses all regard for conventionalities; the consumptive cares not whom he may infect. 5. In either, there is an abulia, or a deficiency of will power. I will give up morphin! I will carry out your advice and treatment! Alas, the poppy and the tubercle bacillus do not will it. 6. Certain physical signs and symptoms resemble each other very closely-though perhaps I am carrying this comparison a bit too far. Apply De Fursac's physical symptoms of morphinomania and behold a classical picture of consumption-loss of flesh, diarrhea or constipation, pallor of the skin, muscular asthenia, tremors, etc., symptom by symptom. And for the chills, fever, sweats and more rapid death, these are not in the plan of Koch's bacillus; but as I shall show below, the result of secondary infection by the staphylococcus or other germs. Morphin is a cruel master; no less so the tubercle bacillus which eliminates a poison that, though doubtless of different chemical composition, is identical in action. The tubercle bacillus is a true parasite; and its usual aim is to keep the patient alive as long as possible. He And what of the consumptive bliss? The victim, though languid, does not realize it. appears to be in a brown study and perfectly happy. Ofttimes, like the morphin fiend, he loses his sexual desires and sexual powers very early, though this is not invariably the case. He is not forced to seek his poison, but this is supplied by the willing micro-organism. He passes through an euphoria, a true honeymoon of rapture which may be even more marked in the later stages of the disease. If pains are present he does not complain, unless they grow unbearable. Unlike the drug slave, he does not sleep away his time, but usually goes to the opposite extreme. He likes to work, he lives in pleasant reverie and ambition, ideas come easily, worry disappears and life assumes a smiling aspect. Recall that this is not only a happy languor, but the patient, doubtless unconscious of the fact, becomes deceitful. Do not ask your patient if he has had a hemorrhage, but put a leading question-"When did you notice blood last?" or "Of course, you have coughed up a little blood, but I suppose in no large quantities?" It is remarkable how unwilling patients are to confess; and this cross-questioning must be clever indeed to make certain the point. They will conceal, at the command of the bacillus, this blood from their friends, or will explain its presence by a history of nose-bleeding. As our fourth symptom in importance, we may place cough. Now true cough is by no means an early manifestation of tuberculosis, except when this disease complicates pneumonia or whooping-cough. Tuberculosis rarely or never is secondary to diseases of the bronchial tubes, though this fact is usually overlooked. A husky cough is not an early symtpom in true pulmonary tuberculosis. It may appear as the first pronounced symptom, but surely other manifestations have preceded it many months. Again, the husky bark of a tuberculous laryngitis may give warning that pulmonary involvement is to be expected later. I have mentioned above that this is a dry cough. It is in fact so dry at first that it can scarcely be termed a cough, but rather an "ahem" or clearing of the throat. It might be inferred that the patient is nervous and ill at ease. It is best, therefore, to watch him when he is not aware of this scrutiny. Change the subject, give him a paper to read and leave the room to fix up the medicine; and then play eavesdropper. Later the cough becomes moist and presents other features which scarcely concern this paper. I usually assume a cough to be tuberculous until proved otherwise. The patient may experience some pains, but he usually makes no mention of them to the physician; and here, again, is an evidence of the damning intoxication. Close inquiry may often bring out the fact that these pains are present, but not severe, and are of a roving character. They are usually located about the shoulders and upper portions of the chest. As sixth in importance, I would describe a very constant though baffling symptom-accelerated breathing. Normally the count varies from sixteen to twenty in the temperate regions. A count above these figures is of considerable importance, but easier said than done. Invariably the patient will be cognizant that you are counting his respiration. Did you ever try to breathe naturally? You cannot do it. I have attempted different methods, but usually met little success. Other examinations of the chest or, indeed, the entire front of the body, bring out alterations in the respiration rate. I have failed to eliminate the voluntary factor by pretending to take the pulse. Just at present, I believe that I am accomplishing my aim by pretending to measure the head. For this purpose, I stand back of the patient in position where I may count the inspirations and then make a large number of measurements with a pelvimeter, but pay no attention to these simply devoting all my time to counting respirations, dropping a remark now and then in regard to the position of the head. Concerning hemoptysis, I have spoken. Though not constantly among our earliest symptoms, its presence is of value in a diagnosis, especially if drawn from a reluctant patient by clever cross-questioning. These constitute the chief earliest symptoms of pulmonary tuberculosis. Let me hastily review: 1. Slow but progressive loss of weight when patient does not have it to spare. 2. A happy and deceitful languor and physical inability. 3. A morphin-like euphoria, abulia and selfishness. 4. A dry hack or clearing of the throat. 5. Roving pains about the upper chest, concerning which the patient offers no complaint. 6. Accelerated breathing. 7. Hemoptysis, a history of which is often difficult to obtain. True enough, other symptoms may appear early, but have less diagnostic value, and are subject to many variations. I shall list these briefly: 1. Diarrhea or constipation. Before taking up the physical signs, let me briefly dismiss several symptoms which appear in established and advanced phthisis, and which have no place in this paper. I refer to chills, fever, night sweats and vomiting. By nature, the tubercle bacillus is a selfish germ, seeking not the company nor the assistance of other bacteria, but preferring to work alone and hidden from these. In fact, he doubtless considers them his enemies; and I am certain that he actively destroys many of them when they attempt to keep him company. A notable instance is seen in whey-like fluids of cold abscesses where the true pus germs, when introduced, are quickly destroyed. But after considerable involvement of the lung has taken place, the tubercle bacillus, finding much freedom, appears to permit certain forms of staphylococci and other germs to make their home in the deserted cavities. These newer arrivals multiply rapidly and lead to the formation of true pus with its attendant chills, fever and sweats. You have been told that the tubercle bacillus may (by virtue of treatment or unknown reason) suddenly cease his work of devastation and lie potential for weeks, months or even years. You may have apparently witnessed this phenomenon in your practice, but be not deceived. So long as a tubercle bacillus is present, just so long is he attempting to slay your patient. Remissions in the course of tuberculosis may be explained by the destruction of the specific micro-organisms or of secondary invaders. Leave but one acid-proof bacillus freed from restraining influences and he will spare not a second to kill endothelium, coagulate blood and dare the lymphocites to destroy him. PHYSICAL SIGNS AND TESTS The idea that pulmonary tuberculosis cannot be diagnosed save by the presence of certain physical signs, clings to the average physician as obstinately as the old man of the sea did round Sinbad's neck. From what I have said concerning the symptoms, it follows that the idea is wrong and is likely to lead to a diagnosis only of the established, advanced, and complicated cases. Henry Sewell has declared that the natural history of pulmonary tuberculosis, involving as it does gradual alteration by insensible steps of the normal structure, size and elasticity of the thoracic viscera, would seem to imply that we can never hope to determine by physical means the very advent of the disorder, However, certain physical signs may aid us at times, even in the earliest cases. I am inclined to name as the most important of these a local increase of the temperature, directly over the portion of the lung involved. Suppose that the right apex has been invaded by the tubercle bacillus, the skin directly over the point shows a higher temperature than in other locations. The thermometer must be reliable and very accurate. The bulb of the ordinary clinical thermometer may be rolled into a fold of the skin. As I shall indicate below, the skin of the consumptive early loses its thickness, so that this manipulation is easily carried out. Butler recommends the use of a special instrument, the base of which has been flattened or coiled so as to present a large surface for contact with the skin. Although the local increase of temperature when present is of great importance, its absence is very frequently observed and does not speak against the presence of phthisis. As a sign of importance secondary only to the above, a remarkable thinning of the skin is noted. As the weight of the body decreases, so do the storehouses of subcutaneous fat melt away. The skin may often be picked up as if it had no attachment to the fascia, long before the clearing of the throat is noticed. I wish to lay third emphasis on a sign which was described by Austin Flint many years ago, but, like many other good things, has been dropped by the wayside. The scapula on the affected side is often restrained in its movement upward during inspiration, and seems tightly bound in its lowest position. The patient's chest is stripped-as, indeed, it should be for all these examinations and the excursions of the scapulæ carefully noted and compared, both in ordinary and forced inspiration. For this measurement, I usually request the patient to sit in a chair with a low back, and the latter is taken as the base line for the measurements. The other physical signs you all know, and need no special treatment outside the average text-book. That their value may not be overlooked, I am listing them without comment: 1. Fine and persistent crackling râles over point of lung involved. These may be heard during the cough or immediately afterward; also at the end of a forced inspiration. A little potassium iodid given a few hours preceding the examination may aid in bringing out these râles. 2. Slight diminution in diaphragmatic excursion on the side affected. 3. Diminished vesicular breathing or even bronchovesicular breathing over point involved. 4. Whispered voice may sometimes be heard over point involved. 5. Lagging of chest wall on involved side during inspiration and expiration. THE TUBERCULIN REACTION use. Now that our first great enthusiasm over tuberculin as a diagnostic aid is past, we find ourselves limiting our assertions or making them but half-heartedly. My experience with tuberculin has been disappointing, and I am not afraid to acknowledge this. The critic has told me that I do not know how to use tuberculin, but let us return the problem to the research worker until we can make and prove diagnostic statements after its Others are backing down somewhat more slowly, and as I read this, I am perfectly aware that the positive tuberculin reaction means "obscure tuberculosis"-if you wish to be in style-obscure tuberculosis. Here is a soft cushion for the fall. Many of us, however, have hit the ground heavily and nursed our bruises quietly. Obscure tuberculosis? This may be defined, so we are informed, as a positive reaction in an individual presenting neither symptoms nor signs of tuberculosis. Well, what are you going to do about it? Watch him closely, for he may develop the disease. And neglect the man who fails to show the reaction? The truth will out. Hear Butler, a man to whom we all listen when we are searching for the practical things in diagnosis: "A person without symptoms or physical signs, who reacts to tuberculin does not require treatment for tuberculosis." THE SPUTUM EXAMINATION After an examination of hundreds of specimens, I feel safe in saying that tubercle bacilli are always loosed into the sputum before fever appears (reference to the ulcerative or usual form of tuberculosis). Osler says that bacilli and elastic tissue may be present without definite physical signs and may come from a very small focus not discoverable on examination. There is an impression among many physicians that tubercle bacilli are found only in the later stages of phthisis, which conclusion is certainly erroneous. Now here is just the explanation of the idea. In therapeutics, only the specific drugs appeal to us, while in the field of diagnostics we are determined to call only the pathognomonic symptom or sign to our aid. It takes broader men, however, to practice medicine, as we find daily to our sorrow. Because tubercle bacilli have not been found in every bit of saliva, at every examination and in every patient whether with ulcerative or other forms of the disease—yes, even often in sputa of putrid bronchitis and what not; because this bacteriologic procedure has not stood all these unjust tests it is often inferred that the examination is worthless. Apply the same criticism to any one symptom or any one sign which I have mentioned and it sinks as surely as a snow fortress beneath a torrid sun. If but one drop of true sputum can be obtained, it is usually possible by certain methods, to demonstrate the presence of these germs. Nor does the diagnosis of tuberculosis from a laboratory standpoint rest alone on the finding of Koch's bacillus; and a proper report does not end with a curt "positive" or "negative" scrawled on a printed form. Now, did you know that tuberculosis was often diagnosed and that on sputum findings alone, at least twenty years before the tubercle bacillus was formally charged with a share in the disease? What of the presence of elastic tissue or "coughed-up lung?" What of the presence of well-preserved elements or those undergoing a dry or coagulation necrosis as contrasted to the wet or suppurative changes noted in putrid bronchitis? What of the presence of erythrocytes or of hemoglobin? What of the negative evidence supplied by mucous spirals, heart failure cells, etc.? What of the presence or absence of serum albumin, as I shall show below? What of the presence of tyroid or granular masses which show by their peculiar staining characteristics their true nature? What of the presence of large numbers of mononuclear cells-true tuberculous pus? What of calcified material? What of lung sand and stones? What of the Hagemann specific test? What of the inocula tion of egg medium? What of the diagnostic inoculation of guinea pigs? The man who examined the sputum was blind to all else but the presence or absence of acid-fast rods. The report says "Negative." We are prompted to reply by question, "Negative what?" Now let us return to a consideration of the bacillus itself and some of the difficulties attending its identification. Presume, if you will, that we close our eyes to all other findings, valuable though they may be, and limit our endeavors to and finding of the little rod. Is this as difficult and disheartening a procedure as some would have us believe? Scarcely; still we must not always expect to find long delicate rods, occurring invariably in clumps, but often attenuated, or capsule-like forms or exalted, or coccus-like varieties. I must not forget to emphasize several recent methods of sputum analysis which bid fair for a place among our standard tests. I refer to the Lissilur and Prirey serum-albumin test which is under certain conditions specific even before the bacilli appear and to which I have given attention in other papers: to the inoculation of egg albumin and to the new Hagemann test which is apparently a specific one as well as easily per formed. Finally, before finishing my examination of a patient, I invariably ask myself this question: "Why should not this be a case of pulmonary tuberculosis?" This, indeed, is a wise question. Here is a patient with build which we regard as suspicious, or with a hereditary taint. This man has worked in an elevator and his lungs have been bombarded by irritant dusts. This boy has been kicked in the side by a horse. This woman has made shirts in an attic or this one has bottled beer in a basement or guzzled it in a gutter. This young lady has nursed her consumptive mother or has exposed herself to colds too numerous to mention. Here is an important point, and I wish to make a prediction. We have recently learned that leprosy is acquired only by repeated exposure and repeated infection; and this discovery has opened up a new book in the science of bacteriology. Recall the close family relation. between the two acid-fast bacilli. Furthermore it mals may be sensitized to leprosy. I am conhas been found that by the tubercle bacillus anivinced that only by repeated infection do many of us acquire pulmonary tuberculosis. If I do not see it incorrectly, the autopsy proves as much, and I am not so certain but that it may be seen in practice. Here is the prediction: that the laboratory proof will soon be forthcoming that repeated |