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Full text of "The pre-tubercular and pre-bacillary stages of consumption : a consideration of the early diagnostic signs of pulmonary tuberculosis : a plea for the recognition of premonitory symptoms"

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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 
CONSUMPTION. 

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 
opium. 



— 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¬ 
culosis. 


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 
tissue.” 

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.” 




-4- 


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 
each year. 

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 
patient’s confidence. 

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 
evident dyspnoea. 

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. 


—5 — 


Conclusions: 

That there is a pre-tubercular stage. 

That it is something more than mere pre-disposition or 
susceptibility. 

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.”