Practical tuberculosis; a book for the general practitioner and those interested in tuberculosis

Front matter

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Contents

CHAPTER PAGE

I. History of Tuberculosis 13

II. Predispositions to Tuberculosis 16

Introduction

There are today many books to be had dealing with the subject of tuberculosis. The majority of these books are very lengthy and deal with the many theories of tuberculosis ; and while they are indispensable to the specialist and research worker, still they do not appeal to the general practitioner, who is looking for information that will be of practical value in his cases in question, especially from the standpoint of diagnosis and treatment.

The author fully realizes the great part to be played by the general practitioner in the Antituberculosis Campaign, and also realizes that many of these practitioners have not had adequate training in the branches of tuberculosis as understood today.

Numerous papers on the different phases of tuberculosis have been published in nearly all the medical journals; however, these articles are widely scattered and very easily mislaid.

There are a few small books on the subject of tuberculosis, which are more practical for the general physician than are the larger works, but there seems to be room for one more such book. It is the hope of the author that the practical considerations in the different chapters of this small book will tend to help the general physician to be more on the lookout for the practical than the theoretical when considering his tuberculosis patients.

J. B. McKnight. 11

Chapter I Histoey Of Tuberculosis

In the early medical writings, before the Christian era, there is on record a great deal about the consumptive : the person with the wasted body; the cougher and spitter.

For many years " consumption " was the name given to the conditions where there was a consuming of the body. It was known that consumption was not found in the savage, but in those who lived a community life.

Observers in those times found that those who presented these symptoms of consumption died. The disease was thought to be inherited, since it appeared in generation after generation in the same family. It was also known to be a disease of early adult life.

At this time nothing was known of the cause or effect of the disease in the body; physicians made their diagnosis from the symptoms, which were those of the last stages of the disease. On account of their previous teachings, many physicians of today follow the example of earlier observers, with the result that they do not diagnose their cases until they are advanced and hopeless.

The practice of postmortem examinations came into vogue something over a hundred years ago, and among these cases examined postmortem were many consumptives, with the result that the bodies of these consumptives were found to contain, especially in the lungs, small grayish or yellowish cheesy structures. These small areas were called " tubercles. ' '

It was shown that consumption was caused by the growth and development of these tubercles, though there was no strict definition of the condition known as consumption, nor of the condition wherein a few scattered tubercles were found, which today is known as "incipient tuberculosis." Physicians were only able to diagnose the disease by symptoms which today are recognized as those of advanced tuberculosis or consumption.

Very few physicians listened to the chest. Laennec, however, developed the arts of auscultation and percussion and compared the findings with pathologic conditions found at autopsy.

By animal experimentation Villemin produced tuberculosis in the animals infected with tubercles from the consumptive's lungs. Others confirmed the results of his experiments.

In 1882, Eobert Koch isolated a bacillus which he named the ' ' tubercle bacillus, ' ' and proved it to be the cause of tuberculosis.

History 15

Since that time many remedies have been given in an effort to cnre tuberculosis, without any direct results. Prevention of tuberculosis by education is the object of antituberculosis workers today, as is also early diagnosis, and the institution of treatment at the earliest possible moment.

Chapter II Predispositions To Tuberculosis

For many years we have been taught that the predisposing causes of tuberculosis such as lack of nourishment, impure air, excesses of all kinds, as well as certain diseases, such as typhoid fever and scarlet fever, made one susceptible to tuberculosis.

In view of recent researches along the lines of immunity, it is evident that some of our ideas regarding the predisposing causes of tuberculosis were, to a great extent, erroneous. The fact that so many people today show that they have had an infection or disease makes one feel that the tubercle bacillus is harbored by the entire human race, and that the predisposing causes do not predispose to infection, but determine to a certain extent the amount and severity of the disease.

We are aware that the tubercle bacilli which are scattered on the virgin soil produce greater destruction than do those which fall where others have fallen. We recall Webb's experiment where he found it possible to inject as many as 150,000 living tubercle bacilli into a guinea-pig at one time, following previous graduated injections, without producing disease, whereas ordinarily so small a number as twenty bacilli would cause disease and death in the guinea-pig.

Predispositions 17

We can also recall the number of cases of tuberculosis that follow colds of different severity, including genuine influenza. We cannot in a practical way particularize on predisposing causes of tuberculosis, since we do not know at the present time whether these causes work directly or indirectly, whether the predisposition is a result of mechanical changes in cells and tissues or whether it is due to an increased expenditure of energy. It is very probable that any agent or condition which affects the cells of the body individually or collectively interferes with their power of resisting invading microorganisms and their toxins.

Eealizing the difference in the reactivity of different individuals, their different habits and inheritances, and also realizing the difference in virulence of different strains of tubercle bacilli, we reallize the impossibility of standardizing any predisposition to tuberculosis ; and it is evident, furthermore, that what would be predisposing causes for one would not be predisposing causes for another.

A life lived according to the demand of nature, as taught by physiologic laws, would prevent, to a great extent, these predisposing causes, relative as they are, and the opposite would also be true.

For many years the physician and the layman thought one had to be "run down" in order to contract tuberculosis. Without a doubt, this run-down condition is a result of the infection by the tubercle bacilli and not a cause of the infection.

There is no doubt that any person will develop tuberculosis if he will inhale, ingest or pick up in any other way a sufficient number of virulent bacilli at one time.

The evidence of acute infection in persons with lowered resistance, due to fatigue or getting the body chilled unduly, makes one feel that the same condition would predispose to tuberculosis, and that the question of one's resistance may often be answered by a consideration of one's energy.

Chapter III The Cause Of Tuberculosis

In 1882, Robert Koch discovered the tubercle bacillus and proved it to be the cause of tuberculosis. While it is evident that Villemin, Conheim and others were working along the same theoretical lines regarding the cause of tuberculosis, still Koch developed the technic for demonstrating the bacilli.

There are three generally recognized types of tubercle bacilli : human, avian and bovine. The biologic activities of each are slightly different as well as the morphologic appearance. The human and the bovine are more alike than the avian and bovine or the avian and human.

The tubercle bacillus is about one ten-thousandths of an inch in length and one hundred-thousandths of an inch in width. It is rod shaped and multiplies by fission ; it is nonmotile and very resistant to the ordinary stains. This power of resistance to stains is claimed to be due to a waxy substance in the bacillus.

At times the tubercle bacillus presents a beaded appearance, and some authors think that this type is found in very sick patients. Often, the bacilli present a branched appearance and are sometimes confused with the streptothrix.

In staining the tubercle bacillus the Ziehl-Neilsen stain is the one most frequently used, although in sputum work, Gabbett's stain has been used to a good advantage. Urine sediments can be examined after being stained and treated with both acid and alcohol in order to rule out the smegma bacillus which resembles the tubercle bacillus. * The virulence or disease-producing properties of one strain of bacilli is different from another, as is also the length of ]if e. Cornet found that tubercle bacilli, found in a room which had been inhabited by a consumptive six years previously, were still virulent. Krause has shown that bacilli live for a long time in caseous lungs which have been buried in the ground. Virulent bacilli have been found in the old calcified lesions of a tuberculous person.

It has been estimated that an advanced consumptive expectorates millions of tubercle bacilli in twenty-four hours. This is ample reason for having the tuberculosis patients cover their mouths when they cough and expectorate into covered sputum cups that are kept away from flies.

It has been estimated that direct sunlight kills tubercle bacilli in from one-half to two hours and that indirect sunlight takes a little longer. The effect of cold is only to retard the growth of the tubercle bacillus and not to kill it. The growth of the tubercle bacillus is naturally slower than that of most germs and requires special media for its growth.

The Cause 21

Many general practitioners consider that tubercle bacillus must be present in the sputum before pronouncing a case tuberculous. This idea is a fatal one for many patients of these physicians. When it is possible to demonstrate bacilli in the sputum, the disease is, as a rule, quite far advanced. Many physicians have felt certain from the history of their case that it was tuberculosis, but not finding the tubercle bacillus, have waited until when it was eventually demonstrated the patient was in the advanced stage with little hope for improvement from treatment.

In order for tuberculosis to be transmitted from person to person there must be some continuous cycle of the bacillus transmission from person to person or from animal to animal or from animal to person. The tubercle bacillus can only live in animal tissues. Being nonmotile it requires a carrier. In the case of the young baby, this may be the milk of tuberculous cattle, when it is not pasteurized, or contaminated articles placed into the baby's mouth. In the older person there are many other ways in which the bacillus may be carried from one person to another : by hand-shaking or touching anything that a careless consumptive has touched, or by inhaling the spray from a tuberculosis patient's mouth while coughing. Flies are also great carriers of the disease.

It is not definitely known just how the tubercle bacillus enters the system. It is very probable that infection results from many different methods of entrance of the bacillus into the body. Many authors assert that the inhalation method is the most frequent, and others, the ingestion method, and still others, that the bacillus first enters into the lymphatic structures of the upper respiratory tract.

We should, by every possible means, overcome all chances of occurrence of infection by isolation of the careless and incorrigible consumptive, and by sterilization of all foods which come from questionable sources.

Tubercle bacilli have been found in practically every place where a careless tuberculosis patient has stayed and also in eating utensils, towels, bed clothing and articles contaminated by such a patient.

Feces of tuberculosis patients contain many bacilli which have not lost their virulence during their passage through the acid of the stomach and the rest of the alimentary tract.

Tubercle bacilli are killed by boiling, by different germicidal agents and by sunlight. They thrive in dark, dirty corners. It is the custom of people to expectorate in dark, dirty corners, thereby facilitating the growth of the bacilli. Hogs frequently contract tuberculosis from cattle by being fed on the milk of tuberculous cattle and also from eating substances contaminated by the feces of the tuberculous cattle.

Chapter IV Diagnosis Of Tuberculosis

Most of the literature of today dealing with tuberculosis emphasizes the importance of early diagnosis. We should not necessarily try to diagnose early tuberculosis but we should try to find active tuberculosis.

Physicians, who have examined many patients, remark that it is impossible to find the adult person with absolutely normal sounding lungs. There are adventitious sounds, or abnormal breath, or voice sounds in every case that a physician examines if he will but put the necessary time into the examination. That many of these signs are due to the activities of the tubercle bacillus is very probable; hence, if one is to treat all cases with abnormal chest signs, one will be treating the entire adult population.

It is impossible to standardize things tuberculous so that one can hit every case, but for all practical purposes one can make a diagnosis of activity if provided with a summary of the case, and if common sense is exercised. Too often the physician depends on the chest signs alone in diagnosing activity when he should have had the temperature, pulse and weight charts, as well as the history and laboratory findings, to help to decide the stage of the disease.

In diagnosing activity, the toxic symptoms are the most important from a practical standpoint. The^tirgd-i eeling is the first symptom complained of, as a rule; then nervousness, lack of endurance, loss of appetite, loss of weight and strength, and night sweats. Fever and anemia are also frequently noted. The rapid pulse and the elevated temperature are very frequent symptoms of activity, and it is necessary for the temperature and pulse to be taken, especially during the afternoon, because the patient often exhibits fever at certain times of the day and during the remainder of the day the temperature is normal.

Cough, hoarseness, pain in the chest and circulatory disturbances are further symptoms; but it must be remembered that it is possible to have tuberculosis and never cough; in fact it must be remembered that very few tuberculosis patients exhibit all the signs of tuberculosis even during their entire illness.

Expectoration of blood and sputum are further symptoms of tuberculosis, and often the spitting of blood is the symptom that brings the patient to see the physician. Too often, in the past, the physician has told the patient that the blood was from the throat or bronchial tubes, and the patient has been only too glad to believe this statement, with the result that when he learns the truth about his con-

Diagnosis 25

dition he loses all regard for the physician's ability. Many tuberculosis patients give expectoration of sputum as the first symptom noticed, and this symptom has all too often been blamed on bronchitis or asthma or some other respiratory affection.

Cessation of menstruation is often a result of tuberculosis, as are also irregularities in menstruation, anemia and chlorosis.

Pain in the chest, or in fact any abnormal sensation in the chest, should be considered possibly due to tuberculosis. Physicians seem to have the idea that sharp knife pains must be present before they can say a patient has pleurisy. Patients, when asked if they have pleurisy, will a great many times say no. Further questioning regarding pain brings the answer that they have had pain in the chest for a long time. When the physician questions a patient about pleurisy, he must explain that any abnormal pain or burning feeling in the chest may be due to pleurisy.

Abnormalities in the appearance of the chest, hectic flushing of the cheeks, and clubbed fingers are often found, but more often in the advanced cases ; hence, the physician should not rely on these symptoms in determining the presence of early disease.

In considering observation we can often get information as to the presence of complications. The barrel-shaped chest is found in emphysema; asthmatics present the stooped attitude; pleural effusions cause distention and immobilization to a certain extent; as does also a spontaneous pneumothorax, the differentiating point being that in spontaneous pneumothorax there is a tympanitic note on percussion whereas in pleural effusion the note is flat ; also in spontaneous pneumothorax there is a distention of all intercostal spaces if the rupture is complete.

Palpation and percussion are both of practical value in making a diagnosis, since the physician's sense of touch is often better trained than his sense of hearing. It is best to percuss the patient's chest while in different positions, because one can often differentiate between a movable effusion and a consolidation by this method and in no other way, except by the x-ray.

The examiner must be comfortable and relaxed and have the patient in the right frame of mind. Furthermore, he must not be in a hurry when he is attempting to make a diagnosis on a suspected tuberculosis patient, and his mind must be free and concentrated on the case. Having the patient stripped to the waist is very necessary. It is best for the physician to develop a certain routine of examination and to follow this without omissions.

Some physicians take the history first, but I prefer to examine first and then take the history, since one is apt to be biased by what the patient says, and furthermore, it stimulates a physician to find what there is in the chest, thus having his own mental picture of the diseased process. This is especially

Diagnosis 27

true if he has to compare his findings with those of another expert.

My method of procedure is first, while the patient is standing up with chest bared, to observe the chest while at rest and also during expiration and inspiration. I compare the two sides and make notes of any differences in the anatomy or physiology as well as in the general tone, and in the condition of the skin.

Following the observation, the chest is palpated, taking notice of the resistance of the tissues, and also the sound-conducting properties, Next the chest is percussed with both hard and soft strokes and notice is taken of any disparity in the two sides or in the different areas in the same side. Auscultation comes next, first during normal breathing to observe any modified breath sounds and to time the appearance of the adventitious sounds, then with deeper breathing to bring out the sounds missed before. Following the deeper breathing the patient is made to expel the air from the lungs and then cough twice gently while the lungs are empty, with the mouth covered with a tissue to prevent spraying the room with bacilli. It is remarkable how this cough following expiration brings out the latent rales. If physicians would only use this method they would often find more involvement than is found with ordinary breathing. During auscultation the chest is gone over systematically, starting at the right apex covering the front of the right lung, then the front of the left from apex to base, and then the back in the same way, comparing if necessary different locations. A hairy chest is a great obstacle in examination, and this should be shaved or the hairs should be moistened with soap and water.

After completing the chest examination the ears, nose, throat and glands of the neck are examined. Finally, the history is taken, after having charted down the physical findings. Students of tuberculosis should make their own examinations, chart them, and then compare them with those of their instructor. A study of the normal chest is, of course, necessary before a study of the abnormal is made ; the student will find that all vesicular breathing is not the same in force, but may be similar in character.

It is often necessary to observe a case of some length of time before a correct diagnosis can be made, especially in cases with complications which would cause adventitious sounds of their own accord, and also in cases in which one knows that there are abnormal signs in the chest, but is not positive that these signs are due to active tuberculosis. In these doubtful cases the patient should be given the benefit of the doubt ; the physician should try to prove that the condition is not tuberculous, instead of trying to prove that it is tuberculous and instituting treatment while making proof.

The physician in the future must rely on the sub-

Diagnosis 29

jective symptoms in the diagnosis of active tuberculosis ; by this the author does not mean only the general practitioner, but also the specialist. The teachers of tuberculosis in the past have been, to a certain extent, the cause of the delay in diagnosis in tuberculosis, for the reason that they have had their students listening for crepitant rales and paying too much attention to the chest without enough attention to the toxic symptoms. Tuberculosis specialists today can tell much more about the activity of a case by considering these symptoms than by prolonged examinations with the stethoscope.

It must be remembered that the case that has the least amount of trouble in the chest may be in a worse condition than the one with advanced lung signs. This, of course, is because the advanced case has, during his long time of disease, walled off his foci and also developed his antitoxin. Dr. Allen K. Krause has told us that a tuberculosis patient's death is due to an accident, hence, there are good reasons for considering the advanced case more optimistically than has been our custom heretofore. A little exercise in the incipient case has innumerable times been the cause of the accident resulting in death. The wall of defense around the focus of infection has not been strong enough, and, as a result of exercise, this wall had broken down, allowing the bacilli to escape, with the eventual production of a caseous pneumonia, miliary tuberculosis, or some other acute tuberculous infection, and death.

Persistence is the keynote of the subjective symptoms. The physician must be suspicious of tuberculosis in all his cases and look for the tired feeling, pain in the chest, cough or weak voice, spitting of blood, slight loss of appetite, weight and strength, nervous instability, lack of muscle tone, indigestion, elevated temperature and pulse at some time during the day, especially in the afternoon.

The x-ray is a valuable help in diagnosis, but must be used by one who is trained in lung examinations and plate reading. Very few men can read an x-ray plate properly. Tuberculin is an agent that has been used for diagnosis too often, if anything, as it probably has activated many inactive foci, with consequent death in a number of instances. Eegarding tuberculin, Dr. Knopf says: "No tuberculin test should be resorted to if subjective and objective signs and symptoms or sputum examinations have been sufficient to demonstrate an active tuberculosis ; and the one who wishes to resort to the tuberculin test should first familiarize himself with the relative value of the tests now used and the precautions which should be exercised to avoid the errors or complications which might arise through injudicious use. ' '

The practical value of the skin test is questionable in adults. This test being a test for anti-

Diagnosis 31

bodies naturally would not prove when the infection causing the antibodies took place, and our present knowledge of tuberculosis shows that in some cases 50 per cent of the children at the age of six years react to the skin test. Dr. Bartlett found this to be the case in the von Pirquet Survey in Framingham, Mass.

I have frequently found that patients with sputum bacteriologically positive for tubercle bacilli, with apparently good resistance and with signs of far advanced disease although not apparently active, would not give a positive skin test.

The complement-fixation test is of some value, but only in conjunction with other signs and symptoms. Dr. Lawrason Brown and Mr. Petroff have shown that guinea-pigs give a positive complement fixation three days after infection experimentally, but it is not known what length of time must elapse in order to obtain a positive complement fixation in the human body, after infection. It is to be hoped that future experimentation by these men and others will remove the present difficulties from this standpoint.

The diagnosis of tuberculosis in very young children is very difficult so far as stethoscopy is concerned and so far as the toxic symptoms are concerned. A history of contact is a great help. Skin tests and x-ray examinations are valuable. Presence of enlarged glands, which cannot be attributed to other conditions and which persist, are valuable aids in the diagnosis. Sweating of the head, continual bad disposition, fever, rapid pulse, deranged stomach, and poor general appearance are frequent symptoms of tuberculosis in the very young.

It is very difficult to get sputum for examination from the very young ; but my experience with my own baby who died at the age of ten months with tuberculosis after a three months' sickness, proves that one should examine the stools of these very small children for the bacilli of tuberculosis, being careful to differentiate, of course, from other acidfast bacilli.

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Chapter V Physical Signs

It is impossible to tell by the physical signs alone how recent an abnormal condition in the lungs may be or how long such a condition has existed. If it were possible to examine every person at stated intervals, physicians, no donbt, would be able to compare physical signs from time to time and add to the present knowledge of these signs.

One can, however, tell by physical signs the extent of involvement, and this, coupled with a study of the other symptoms : history, x-ray examinations and laboratory reports, is a great help in the summary of the case.

Often the case with the largest amount of involvement and, from a standpoint of physical signs the one with apparently the most activity, is the one that offers the best prospects of recovery, when all other factors in the case are considered.

In order for the general practitioner or the student of tuberculosis to appreciate intelligently the physical signs in tuberculosis, it is necessary for him to understand the anatomy and physiology of the lungs. It is not necessary thoroughly to understand the minute anatomy in anything except the structural unit of the lungs, but the knowledge of the general makeup of the lungs is essential in order to understand the production of abnormalities in breathing and adventitious sounds.

It is necessary for the physician to have a clear mental picture of the extent of the lungs in the chest, their general shape and appearance, as well as their relation with other structures nearby.

In order to understand the abnormal physical signs, it is necessary first to study the normal chest. When we stop to consider the different breath sounds in the normal lungs, we are impressed with the difference in character of these sounds. This is probably one reason why it is so difficult for the beginner to learn the normal; that is, there is no absolute normal and the line of demarcation between the normal and abnormal is often very much blurred. Age, occupation and the place of residence, as well as habits and inheritances, all enter into the anatomic shaping of the respiratory tract; consequently we have a difference even in the normal physical signs which the specialist often finds difficult of classification.

Concentration of the attention of the examiner on what he is doing is one of the necessary helps in eliciting the chest sounds, and he must be able to hear and have a stethoscope that is comfortable to the ears and auditory canal. Many general practitioners are experts on chest examinations, although they cannot explain always the pathologic conditions producing these abnormal signs.

Physical Signs 35

Physicians have often told me that it was impossible for them to study tuberculosis on account of lack of material. It is not the number of cases examined and treated that makes the tuberculosis specialist ; but it is the amount of time spent on a few cases, and the amount of study and interest in each case, that qualify the examiner eventually to be a specialist. So far as lack of material is concerned, it is very evident that a physician would have a very poor practice, who did not have at least twenty tuberculosis patients under his supervision each year, although in most cases these patients are treated for other diseases.

The physician, undertaking a study for the practical signs, must acquaint himself with some of the physical qualities of sound. It is necessary to ascertain the pitch, quality, rhythm, intensity and duration of the inspiratory and expiratory sounds in the normal in order best to compare them with the abnormal. In some cases with slight involvement, it is most difficult to differentiate the normal from the abnormal on account of mechanical or other conditions which change the anatomic makeup of the lungs. The intensity of all sounds is increased or diminished according to the rapidity and force of the respiratory acts. The normal vesicular respiration is on inspiration a soft diffused sound of a breezy character, gradually developed and continuous, and of low pitch. The expiratory sound in vesicular breathing is not vesicular but feebly blowing in quality, with lower pitch and less intensity than that in inspiration. The expiration is usually not more than one-fourth the length of inspiration, being absent in many cases.