Pre-tubercvjlar ar\d Pre-bacillary
Stages of Goasvimptiorv
A Consideration of the Early Diagnostic Signs of Pulmonary
Tuberculosis—A Plea for the Recognition
of Premonitory Symptoms.
CHARLES MANLY, A. M., M. D.
Read before The Colorado State Medical Society, and before the
Alumni Association of The Denver fledical College.
.4. J. Ludditt , Printer , 1409-11 Lawrence St., Denver, Colo.
THE PRE=TUBERCULAR AND PRE-BACILLARY STAGES OF
A CONSIDERATION OF THE EARLY DIAGNOSTIC SIGNS OF PUL¬
MONARY TUBERCULOSIS—A FLEA FOR THE RECOGNITION
OF PREMONITORY SYMPTOMS.
CHARLES MANLY, A. M., M. D.. DENVER.
The steady decrease in the mortality from consumption
during the years of the decade just passed is attributable not so
much to improved methods of treatment as to a better knowl¬
edge of the disease itself and the methods which have been put
forth towards its prevention. The importance of an early diag¬
nosis in such cases as must arise is apparent.
In attempting a paper under the difficult title of “ Pre-
Tubercular and Pre-Bacillary Stages,” I will not arouse unnec¬
essary antagonisms or limit the freedom of preconceived
opinions by essaying to state just what part the bacillus plays
in this degenerative process. The pathological enthusiasm
aroused by the discovery of Koch’s bacillus should not blind
us to the fact that there are other elements than the bacillus
and the changes which, by its presence, are wrought in the
tissues and fluids where it domiciles. There are other elements.
[ say, necessary to the production of this disease.
The bacillus is ubiquitous, yet only a part of the human
race falls victim to its ravages. The individual equation is the
necessary factor. Some individual weakness is necessary to be
added to the bacillus. This weakness may be inherited or ac¬
quired. The question of hereditary influences has already
been ably considered by Dr. Ruedi. Many persons with inher¬
ited tendencies escape the disease even after prolonged expo¬
sure, until some impairment of the general health opens the
door to the invasion of infecting bacilli. Certain inherent con¬
ditions, I believe, followed by certain incipient stages consti¬
tuting a negative intoxication (recognizable) precede the devel¬
oped symptoms of established phthisis, just as a stage of
intoxication precedes the lethal symptoms of a large dose of
— 2 —
There is something in the physique of these individuals
necessary to the production of phthisis — something preceding
bacillary infection — something which realizes the fact of that
infection and makes it possible, and a something which, being
the “ personal equation,” determines the course and character
Jhv. aShav/<ji»-o\ and effect of such infection. This condition of health I have
S^kctyV dared to call “ the pre-tubercular stage.” It has been variously
sfmvctu^roJ^ described in the past as, by Dr. Rokistansky, “the phthisical
* habitus,” by others as the “ tuberculous predisposition,” “ sus¬
ceptibility,” “favorable soil,” “lack of resisting power,” “tuber¬
cular diathesis,” “ good culture medium.” There are still other
forms of expressing this same condition of ill health. “That
condition which makes the human tissues a receptive soil — a
favorable ‘ culture medium 1 for the tubercle bacillus- that con¬
dition which of old was called ‘diathesis’ and now ‘suscepti¬
bility ’ is itself a disease—a departure from the normal — and I
believe it to be the most important element in the morbid corn-
plexus termed tuberculosis. It is the element requiring the
greatest care in prophylaxis the most intelligent and faithful
treatment.” — S. Solis Cohen.
But what do these terms mean? Metsehnikoff attempted
to show that it is all summed up in a lack of leucocytes to de¬
stroy the elements of contagion—a weakness in the microbe¬
killing activity of these blood scavengers. Others claim that
“ susceptibility ” consists of a want of certain bio-chemical con¬
stituents of the tissues, fluids and blood plasma. A generally
embryonal condition of the connective tissues — abridgment of
the lymph spaces and increase in the solids of the blood. Dr.
Cutler advances the theory of “acid dyspepsia” — an acetic acid
fermentation resulting in a yeasty condition of the blood.
Others admit that “inherent weakness” is modified tu¬
berculosis, the bacillus being transmitted with the ovum, lying
dormant for years, and held in abeyance awaiting a favorable
opportunity to develop. Such opportunity is afforded when the
surrounding tissues are enfeebled, either by an injury or by some
“critical period” of life, when it develops into genuine tuber¬
These definitions and theories as to the pre-tubercular
stage are inadequate. We seek, therefore, to overcome the diffi¬
culty by defining the condition as one of impaired or defective
nutri tion. "
In tuberculosis, generally the first symptom is loss of
weight. This is usually the most prominent symptom, and one
which is directly proportionate to the progress or severity of
the disease. Nutrition is defective in quantity, which leads to
atrophy and wasting. It is altered in quality, causing deteriora¬
tion and softening of the tissues.
The diagnosis of this condition is most difficult. Incipient
tuberculosis, simulating, as it does, almost every other disease, is
not easily distinguished, especially from typhoid fever. It is
often mistaken for gastric disturbances and rectal stricture.
The changes in the lungs themselves may be small or great,
but they are generally confined to the periphery where it is not
noticeable, or where the bronchial tubes are concerned, a mis¬
taken diagnosis of bronchitis is made. But as in the first and
second stages the disease is so thoroughly masked at times as
to awaken no suspicion, so in the pre-bacillary stage, the same
condition obtains, and the diagnosis should be made objectively.
The rational signs are of great weight.
After catarrhal pneumonia, or “La Grippe,” or concomit¬
ant with a chronic irritation due to foreign substances inhaled
incidental to an occupation like cigar making, or coal mining,
or any sort of mill work, we find a condition aptly described as
“ chronic inflammation ” and vulgarly known as “ phthisic,” “ win¬
ter cough,” etc. We know the change in the pulmonary tissues
consists as follows: “ Cells, the product of inflammation, accumu¬
late in the alveoli and bronchi, and crowd upon each other, be¬
coming densely packed, and thus by mutual pressure are de¬
stroyed, and cause at the same time decay (or injury to) lung
Such conditions we all know present but little auscultatory
information, but auscultation is not diagnosis, or, as an eminent
authority has expressed it, “ I esteem rational symptoms as of
greater weight than those signs eliminated by auscultation.”
Associated with progressive loss of weight, nutrition suf¬
fers from a loss of appetite and the well known languor which
precedes typhoid fever. Patients have often said to me, “ I feel
exhausted when I awake. A few hours in the early morning I
j, ' u feel stronger, at 11 o’clock exhausted again, and the same
faJiaMA dU/r/v a t 4 in the afternoon.’’ One cannot claim that such a state-
<&. ment of symptoms is pathognomonic of any particular disease,
but I do say it is especially true of phthisis.
Perhaps in no class of cases is the element of lassitude so
marked and so diagnostic as in children, who, though they may
not be the offspring of tuberculous ancestry, may have the so-
called predisposition stamped upon them, in belonging to a
large family of children born of a mother whose periods of lac¬
tation lapped over the periods of pregnancy four or five months
The physician who fails to diagnose the pre-tubercular stage
with incipiency in such a child at any time when loss of weight
and appetite and languor are the symptoms, or when the child
has a chronic cough incidental to measles or pertussis, such a
failure is a double wrong to the physician's judgment and to the
It may not be amiss to dwell again upon the importance of
careful diagnosis in these cases of measles and whooping cough.
When measles exhibit a decided tendency to pulmonary in¬
flammation, the distance to phthisis is not great. The respiratory
murmurs may never return to normal clearness. Associated
with the frequent relapses into bronchial troubles we find in¬
duration and caseation with diminished expansion. This is
evidenced by a short but easy cough, rapid respiration without
But this is not the time or occasion for the description of
the tuberculous child.
I will not attempt to discuss at length the histology or
pathology of this condition of health. Nor will 1 take up the
subject of treatment which is practically that of phthisis itself,
and will be discussed in a succeeding paper. But I will pass
at once to my conclusions.
That there is a pre-tubercular stage.
That it is something more than mere pre-disposition or
That it is a mitigated form of consumption.
That it is either hereditary or acquired.
That other things being equal, continued loss of weight is
suspicious of oncoming tuberculosis.
That the key note of this condition is impaired nutrition.
I wish to deprecate the preponderating importance given to
the bacillus, whereas this condition of health occupies the posi- ♦
tion of a primary etiological factor, to which the bacillus is sec¬
ondary in importance.
I wish to deprecate the supercilious superficiality with
which many physicians veil the seriousness of this condition
under the name of “ bronchitis.”