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THE EARLY DIAGNOSIS OF PULMONARY
By T. E. OERTEL, M.D., AUGUSTA.
It would almost seem that one should premise a paper upon the above subject with an apology for its presentation. This for two reasons; first of which is, that the necessity for early diagnosis of tuberculosis is self-evident and needs no argument, and, secondly, because of the multiplicity of papers of like kind that are being read before various bodies, both lay and medical, and which appear in popular periodicals, as well as in our medical journals.
But in spite of these facts I do not crave your pardon, but rather claim your earnest attention, while I briefly outline a few of the facts relative to the necessity of early diagnosis of tuberculosis and the chief means at our disposal of arriving at this end.
In spite of all that has been said and written, it is unfortunately true that two classes of people need instruction in this matter. I refer to the medical profession and the people at large.
The medical man must take upon himself the task of educating the public, and unless he be competent there will result the disaster that always befalls when the blind essays to lead the blind.
No one will deny that the best results may be hoped for when tuberculosis is discovered in its incipient stage. No one who has had special experience in the treatment of
tuberculosis, but will sadly bear witness to the fact that in a very large majority of tubercular patients the diagnosis is not made until the disease has advanced to the second and often to the third stage.
In order that I may be intelligently followed, it may be well to define what is meant by the designating of certain stages in the progress of tuberculosis.
There is, of course, no hard and fast line in the matter, and yet it is necessary for us to have some sort of classification.
At the last meeting of the National Association for the Study and Prevention of Tuberculosis the committee on clinical nomenclature presented the following modification of Turban's scheme. The report of the committee was adopted, and the plan laid down by them should be followed in order to obtain uniformity of nomenclature in the United States.
To be used in connection with Turban's scheme of dividing the stages into I, II and III:
Slight initial lesions in the form of infiltration limited to the apex or a small part of one lobe.
No tuberculous complications. Slight or no constitutional symptoms (particularly including gastric or intestinal disturbances or rapid loss of weight.)
Slight or no elevation of temperature or acceleration of pulse at any time during the twenty-four hours, especially after rest. Expectoration usually small in amount or absent. Tubercle bacilli may be present or absent.
No marked impairment of function either local or constitutional. Localized consolidation moderate in extent with little or no evidence of destruction of tissue or disseminated fibroid deposits.
No serious complications.
Marked impairment of function local and constitutional. Localized consolidation intense; or disseminated areas of softening; or serious complications.
Acute Miliary Tuberculosis.-Turban uses the terms "open and closed tuberculosis" to indicate the presence or absence of tubercle bacilli from the sputum.
The report of the Massachusetts State Sanatorium for 1904 shows during the past five years a steady increase in the cure of incipient cases, which in the latter year reached 75.8 per cent.; a most flattering result.
I am compelled to quote further from this report, as follows: "When we state, as we are able to in recent years, that between 45 and 50 per cent. of all cases have left with the disease arrested, we are massing all our cases together. When we show that among the cases which seem to be really incipient between 70 and 80 per cent. leave with the disease arrested, it is only a proof of what we are constantly endeavoring to teach, viz.: not to wait until the symptoms are well marked, but to send patients at once, when the first symptoms appear."
These words show us that it is not alone in Georgia that tuberculosis is overlooked until it is well advanced. But in the incipient stage it is seldom recognized with us, especially if still closed. It behooves us to enquire into the reasons for this condition. To my mind they are not difficult to find.
A large number of persons with early tuberculosis have symptoms which are slight, which are attributed by them to things of less moment, and for which they do not consult the family physician until some more than usually severe exacerbation causes them to become alarmed and to seek medical advice. This is one very important reason why the disease is not sooner detected in many in
stances. For this condition there can be but one remedy, and that is the education of the general public relative to the question of tuberculosis. This subject is quite beyond the scope of the present paper, and must be dismissed with only the further statement that it devolves upon ourselves to so educate the public.
The other reason why early tuberculosis is so often undiscovered is quite as evident, and concerns us directly. I desire to be clearly understood, and I wish every doctor in Georgia were within the sound of my voice. This other reason is the incompetency of the doctor.
Do you consider, gentlemen, that this is a hard thing to say? I am ready to admit that it is not a pleasant thing, but I am ready to maintain that it is a true thing, and if I am correct in this, then it is high time that we set about altering such a condition.
You all know that tuberculosis kills more people than all other contagious diseases combined, excluding pneumonia. This being the case, it is the duty of the doctor to exclude tuberculosis in every case where there is a possibility of its being present.
The fact of the general prevalence and great frequency of tuberculosis should be ever before him, together with the further fact that it may present a symptom complex that may prove exceedingly difficult of solution.
I believe, however, that most of the cases of early tuberculosis that are overlooked by the physician are not recognized for the reason that the true condition was not suspected, or, if suspected, a waiting policy was pursued, rather than a vigorous endeavor to probe the question to the bottom. This codliver oil and wait-a-while form of treatment can not be too strongly condemned.
In any case of suspected tuberculosis it is the paramount duty of the attending physician to at the earliest moment
determine the true diagnosis. To calmly wait for a further extension of the pathologic process is nothing short of criminal.
Most common among the conditions with which early pulmonary tuberculosis is confounded are malaria and indigestion, with typhoid fever following a good third.
There is no more maligned creature in existence than the malarial parasite. It is no exaggeration to say that in this section fully one-half of the cases of tuberculosis one sees have been erroneously treated for malaria. An investigation of the case according to modern methods of diagnosis should lead to an early recognition of malaria in most instances. It is needless to say that microscopic examination of the blood is of first importance. How often this is done in cases of suspected malaria, I leave you to judge. This is not always possible, perhaps not always necessary I readily admit, but that it is not more generally possible is due to faulty equipment on the part of the general practitioner, who has failed to provide himself with the necessary apparatus and special knowledge that in these latter days he should have.
It will be well, then, to lay down the following dictum : In every case of malaria where the correctness of the diagnosis is not proven by the finding of the parasite in the blood or the immediate recovery of the patient under the administration of quinine, tuberculosis must be considered as a possible causation of the symptoms. Such a course will bring to light many a tubercular infection at a period when, with proper treatment, the patient may recover, when a further delay in a correct diagnosis would have put him beyond the pale of hope.
First again in importance is the microscopic examination of sputum for the tubercle bacillus, because when this organism is demonstrated the diagnosis is settled beyond peradventure.