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Arnold C. (Arnold Carl) Klebs.

Tuberculosis; a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention and treatment online

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In another case there was consolidation between the spine and the
angle of the scapula beautifully shown by the fluoroscope, Avith constant
harassing cough, but with very little expectoration and no fever.

This patient had received a test dose of tuberculin from other hands,
and was said to have reacted positively.

Here also iodid removed all symptoms rapidly, and for the six
months during which I was able to follow the case there was no return,
probably justifying the diagnosis of sy2:)hilis.

The obstinate cough has been supposed to be a diagnostic sign of
pulmonary syphilis, but as it is not different from the cough produced
by enlarged bronchial glands, and as these exist often in syphilis, its
diagnostic value is doubtful. The therapeutic diagnosis by the use of
iodid of potash is very relialile. Xot only the symptoms, but, to be cer-
tain, all signs must disappear, as otherwise one may have removed the
syphilitic element but left l)ohind a coexisting tuberculous lesion.

The destructive form the M^riter has not seen, and it is said to be ,
very rare, but can go on to cavity formation. The sclerotic form is
marked especially by dyspnea, or even pseudo-asthma, but this cannot
be considered characteristic, as the same can occur in fibroid phthisis,
from which it is impossible to differentiate it. Aside from the dyspnea
there are physical signs of fibrosis with bronchostenosis, and, as would
be expected from the nature of the lesions, iodids have no effect.

To recapitulate the points on which one can base a diagnosis of pul-
monary syphilis, they are the existence of syphilitic infection, laryngeal
or pharyngeal lesions, less constitutional symptoms than we would expect
in tuberculosis, moderate or no fever, and, chiefly, the therapeutic test
of mixed treatment, with subsequent observation of the case. On account
of the harmful effect of iodid of potash on tuberculosis one should not
resort to it unless suspicions are very strong.

Malignant disease of the hings, whether carcinoma or the much rarer
sarcoma, is fortunately uncommon, few clinicians having seen many
cases.

When located in the apices or running a slow course it may be very



DIFFERENTIAL DIAGNOSIS 359

difficult of diagnosis, but as the large majority are secondary to malig-
nant growths elsewhere the diagnosis is usually facilitated.

In view of its occurrence secondarily a very careful history and a
thorough examination of the body for cancerous growth is necessary.

Aside from this the points deinanding attention are as follows. They
are apt to be central or basal in location, present a more marked and
more rapidly developing exhaustion than tuberculosis, while the wast-
ing, on the contrary, is less pronounced than the signs would seem to
justify. The waxy pallor of the cancerous cachexia is suggestive if
present, but may be absent till later; the infiltration develops very rap-
idly, sucli a rapidity in tuberculosis being accompanied by severe con-
stitutional symptoms, and the dyspnea comes on early and is more
marked than in filjroid plithisis.

Pain in the chest is more common and far more severe, while fever
is usually absent. The cough is very variable, some authors reporting
it hard and obstinate, some moderate, due probably, as in syphilis, to
the greater or less involvement of the bronchial glands.

The expectoration is scanty and the currant-jelly expectoration, held
by some to be typical, can be entirely absent, though there is a marked
tendency to bloody expectoration.

Symptoms of pressure on the veins or lymphatics are common, so
that we can have dilated bunches of small veins in the thorax, and in
late cases enlarged glands, especially above tlie clavicle and in the axilla,
can be found. Pleuritic effusions are common, but share with tubercu-
lous effusions a tendency to bloodiness. Tlie physical signs are not
very characteristic, though Fraenkel thinks that the lack of corre-
spondence between the flatness on percussion (with greatly increased
resistance) and the insignificant breath changes— i. e., weakened breath-
ing and few or no rales — is a sign of great value.

If cancer cells are found in the sputum they are, of course, decisive,
but this does not often occur. However, as has been said in connection
with echinococcus disease and fungous disease, in doubtful cases the
sputum examination must be thorough, histologic as well as bacteriologic.

Heart lesions wliieh cause congestion of the lung and hemoptysis,
chiefly mitral stenosis, are at times diagnosed as tuberculosis, but a
careful and systematic study of our cases should make this mistake
impossible.

Malaria is a very common, ])robal)ly the most common, source of
error in diagnoses which exclude tuberculosis erroneously.

Every year one sees many cases which have been treated for longer
or shorter periods for malaria when the disease was a more or less
incipient tuberculosis, and while in a malarial country where so many
cases of irregular fever are seen, and where so many are really atypical



360 DIAGNOSIS

malaria, this is perhaps natural, it is, now that the microscope is avail-
able to all and can so easily settle the question, no longer excusable.

Blood examinations must, it need hardly be said, be thorough and
frequent, and the recognition of the plasmodium certain and positive
before we can afford to treat a slow, irregular, remitting fever as malaria
and exclude tuberculosis entirely.

The therapeutic test of quinin, while valuable, must be made with
caution, as it will often suppress a tuberculous fever for a time.

Moreover, it should be standard practice in every case of such sus-
picious fever to examine the sputum and the lungs most carefully and
repeatedly, and if necessary one should resort to tuberculin.

Typhoid fever is frequently given in a history as the beginning of
a tuberculosis, but it is probable that some of these cases were merely
the acute beginning of a case that later took on a more chronic
course.

The diagnosis of acute miliary tuberculosis from typhoid fever is one
of the most difficult in medicine, and often can only be made at the
autopsy, hence in every case of suspected typhoid of slightly atypical
course we should take care to exclude this possibility. The Widal reac-
tion is here of great value if past typhoid can be excluded. Ausculta-
tion is not of great assistance owing to the frequency of pulmonary signs
in typhoid.

The temperature in acute miliary tuberculosis is much more irreg-
ular as a rule and may intermit entirely, and tends to marked remis-
sions, the respiration is hurried, the face anxious, and there is an omi-
nous cyanosis. Osier states that " leucocytosis is more common in miliary
tuberculosis than in typhoid, in which leucopenia is the rule." The
typhoid bacillus can be cultivated from tlic stools or the blood.

Persistent anemia, or especially chlorosis or neurasthenia or dys-
pepsia, are so often tlie initial symptoms of tuberculosis, and so many
incipient cases are treated for these diseases, that the possibility of tuber-
culosis should be kept in mind. Chlorosis is so often accompanied by
slight fever and so often precedes tuberculosis that the view of some that
it is really a tuberculous condition seems reasonable, and the use of tuber-
culin justified.

In neurasthenia and dyspepsia the thermometer is valuable, and the
all too common custom of explaining away a cough that cannot be
stopped as a " stomach cough," and of treating it with anodyne cough
mLxtures, cannot be too strongly reprobated.

If a cough exists it has some physical cause, which in the large
majority of cases can be discovered and removed, and no physician is
doing his duty to his patient who fails to make a thorough physical
examination into its cause.



ON THE RECOGNITION OF STAGES 361

ON THE RECOGNITION OF STAGES

If the results of the study of tlie SA'mptoms and signs of our cases
are to be utilized in widening our knowledge of this disease, if the
observations of many separated observers are to be correlated into a
complete whole, it is essential that we have a system of classification
for our cases by stages which shall be used by all physicians in their
work. Many such S3'stems have been suggested (Petruschky, Brehmer,
Koniger, etc.), but that put forward by Turban in the A'ear 1899 has
been generally recognized as the best and most practical, and it forms
the basis of the classifications in use to-day. In Europe the Inter-
national Anti-Tuberculosis Association has modified it by adopting part
of the scheme of Gerhardt ('01), and in this country the iSIational Asso-
ciation has used it as the basis of their classification, but has modified
it by adding to it certain clinical data, while Trudeau has a system of
his own in which also he combines anatomical and clinical facts in classi-
fying his cases. It is probable that the system of the International Anti-
Tuberculosis Association, more or less modified, will finally be universally
adopted, and hence it should be familiar to all workers in this line.
While retaining the anatomical basis of Turban's scheme almost entirely,
this so-called Turban-Gerhardt scheme modifies it by noting the condition
of each lung separately, and makes one or two other slight changes. Kay-
serling, speaking of it, says that " this is a material improvement, as one
thereby gets immediately a plastic image of the case in hand ; especially
in studying results is it a great advantage that we know of each case —
which side of the lung is diseased, and to what degree — for only thus is
it possible at a reexamination to determine if the cure is persisting."

While in Turban's original scheme the first stage was limited to
changes of the volume of one lobe or two half lobes, in the new it is
limited to changes reaching to the level of the clavicle in front and the
spine of the scapula behind, save in cases of unilateral trouble, when
the second rib is taken for the lower limit.

Further, in the new classification the presence of considerable cavi-
ties places the case in the third stage, and the stage of any cases must
be judged by the condition of the most seriously afl^ected lung.

The jS'ational Association for the Study and Prevention of Tuber-
culosis ap))ointed a committee to arrange a classification, of which Y. Y.
Bowditch and, later. Ij. Brown were chairmen, and this committee has
reported a classification which has been generally adopted in this coun-
try, and which, while based on the scheme of Turban, is imjiroved and
amplified by the addition of certain clinical data without which they
considered his scheme scarcely comprehensive enough.

Below I give the classifications of Turban-Gerhardt, of the Xational
25



362



DIAGNOSIS



Association, and of Trudeau in parallel columns for ease of comparison.
In looking over these the excellence of Turban's idea is evident, and it is
not remarkable that it has been popular, but the clinician in using it will
find himself hampered by its failure to take notice of the clinical condi-
tion of the case, which is of such paramount importance in classifying it.

The anatomical condition alone cannot by itself give us a complete
idea of the state of the case; daily one sees patients with quite extensive
signs, who are yet in excellent general condition and with practically
no symptoms, while some very severe cases can have very scanty phys-
ical signs. Indeed, were we obliged to use only one or the other, I
believe we would find that symptoms are usually a safer guide to a
patient's condition than signs, and I do not believe that any classifica-
tion for general use can omit certain clinical data from its plan.

If the physician will use a proper system of classification he will
find it an easy matter to divide his cases into three stages, botli in the
commencement and at the end of treatment, and it is earnestly to be
hoped that all physicians in reporting cases in the medical press will
be careful to classify them in this wav.



Turban-Gerhardt



Disease of slight se-
verity, limited to small
areas of one lobe, that,
for instance, in case
of affection of both
apices, may not extend
beyond the spine of the
scapula and the clav-
icles; in case of affec-
tion of one apex, fron-
tal, beyond the second
rib.



National Association
7. Incipient (fnvorahle)

Slight initial lesion
in the form of infil-
tration, limited to the
apex or a small part of
one lobe.

No tuberculous com-
plications, slight or no
constitutional symp-
toms (particularly in-
cluding gastritis or in-
testinal disturbances or
rapid loss of weight).
Slight or no elevation
of temperature or ac-
celeration of pulse at
any time during the
twenty-four hours, es-
pecially if at rest.
Expectoration usually
small in amount or ab-
sent. Tubercle bacilli
may be present or ab-
sent.



Trudeau

7. Incipient

Cases in which both
the physical and ra-
tional symptoms point
to but slight local and
constitutional involve-
ment.



ON THE RECOGNITION OF STAGES



363



Turbax-Gerhardt

//

Disease of slight se-
verity,' more extensive
than I, but affecting at
most the volume of one
lobe; or severe disease,^
extending at most to
the volume of one half
lobe.



National Association

77. Moderately
Advanced

No marked impair-
ment of function,
either local or constitu-
tional. Localized con-
solidation, moderate in
extent, with little or no
evidence of destruction
of tissue. Or dissem-
inated fibroid deposits.
No serious tuberculous
complications.



Trudeau

77. Advanced

Cases in which the
localized disease proc-
ess is either extensive
or in an advanced
stage, or where, with
a comparatively slight
amount of pulmonary
involvement, the ra-
tional signs point to
grave constitutional
impairment or to some
complication.



777



777. Far Advanced



III. Far Advanced



All cases extending
beyond II, and all such
with considerable cavi-
ties.



Marked impairment
of function, local and
constitutional. Local-
ized consolidation, in-
tense or disseminated
areas of softening, or
serious tuberculous
complications.



Cases in which both
the rational and phys-
ical signs warrant the
term.



• By disease of slight severity is to be understood: disseminated ff)ci manifested
by slight dullness, impure, rough, feeble, vesiculobronchial or bronchovesiciilar
breathing, and fine or medium riiles.

2 By severe disease is to be understood: compact infiltration, recognized by
great dullness, very weak bronchovesicular or bronchial breathing with or without
rales. Considerable cavities, to be recognized by tympanitic sound, amphoric
breathing, and extensive coarse consonating rales, come under Stage III. Pleu-
ritic dullness, if only a few centimeters in extent, is to be left out of account; if
it is extensive, pleuritis should be especially mentioned under tuberculous compli-
cations.

The stage of the disease is to be indicated for each side separately. The case
as a whole is to be classified according to the more diseased side. For example,
R II, L I = Stage n.



364 . DIAGNOSIS

CONDITION ON ARRIVAL AND ON DISCHARGE

(National Association)

A. On arrival:

1. Extent of Disease. (Pvit here Turban's scale or Turban-Gerhardt.)

2. How long sick?

3. General condition : (a) favorable; (h) unfavorable.

4. Digestion: (h) unimpaired; (y) impaired.

5. Pulse (rate).

G. Temperature: (E.) 101° F. or over; (F.) 99° to 101° F.; (N.)
Normal.

7. Bacilli: (+) present; (0) absent.'

8. Tuberculous complications.

9. Other complications.

10. Classification of case. (Here put National Association classifica-
tion.)

B. On discharge:

Progressive. (Unimproved.) All essential symptoms and signs un-
abated or increased.

Improved. Constitutional symptoms lessened or absent, physical signs
improved or unchanged, cough with bacilli usually present.

Arrested. Absence of all constitutional symptoms, expectoration with
bacilli absent or not, physical signs stationary or retrograding.
This for at least three months.

Apparently cured. All constitutional symptoms with expectoration
and bacilli absent for three months, signs of healed lesions.

Cured. Same for two years under ordinary conditions of life.
(Also note A 3 to A 9 inclusive.)



'Wilson of Baltimore has well suggested A'^, " no sputum examination made,"
to cover the large number of cases in which this has been neglected.





filOcfj/teJ /rvm ^/ovsse/



Figs. 84 and 85. — Suspect Case in Anemic, Slender Youth. No fever. Slight cough.
No expectoration. (Case E. Z.)




TVToc// ^/eJ from tJocss-ef

6.k^. 'OS"



?r)<idi/i'e<S Jnni >/o^SSC/.



Figs. 86 and 87. — Incipient Case. Four months' course. BacilH present. General
condition favorable. Digestion unimpaired. Temperature normal. Pulse 80.
(Case C. D.)

365




IVTodi 1^ leJ from (Joessc/

C.IM- 'oS"



7n<>t////'eJ /rem \/oesse/.



Figs. 88 and 81). — Incipient Case, Chiefly Posterior, Extent I. Note slight
pleurisy under left scapula. (Case Y.)




■ TVod i f leJ from cfoessef

CLM. 'OS"



Figs. 90 and 91.— Stage I. (Case G. B.)



363




Tnodi/ifi /rtm Joesst

TVTod i f leJ from fJoGssel

' CA-M- 'o^

Figs. 92 and 93.— Stage I. (Case F. K. S.)




JVod I f leJ from tJoQSSel

C.i-M. 'OS"



?noj,/ieJ /ior» Joeae/.



Figs. 94 and 95,



—Incipient Bilater.^l Case. (Case X.)



367




TVTod I f led from tJoGS-^el

' C.l^l 'OS-




/ne</,//eJ ^rtm t/oeise/.



Figs. 96 and 97. — Incipient Case, but with Disseminated Lesions and Laryngeal

Involvement. (Case W. B.)




VR-f



TVTodifisJ from t/oesse/

CLM. 'oS"




?nac/f/iei /rtnt i/oesse/.

Figs. 98 and 99.— Stage II. (Case Mrs. W.)



368




VR-^




Figs. I'JO and 101.— Stage II. Left Basal Pleurisy and Limited Motion.

(Case R. S. W.)





TVToc/i f leJ from tjoeiief 11/ , -

ClM 'Of ^<&,/,eJ />„„, Joesse/

*

Figs. 102 and 103. — Stage II. Of Long Duration with Retrogressions and
Exacerbations. (Case J. L. W.)

369




TVTodifieJ fronx.fjoessel

C.ZA/. v^r.






Figs. 104 and 105. — Stage II. Beginning Softening, Later Excavation.

(Case W. G. B.)




^o</i//eJ /rtni ^/ofSSe/.



Ci./^ 'OS'
Fig.s. 106 and 107. — Stage II. (possibly III.), Beginning Softening. (Case E. M.)
370




JVTod, fie<^ from (Joesse/



^adi/ifj /i-tm ^/oeSie/



Figs. 108 and 109. — Stage III. (Left), I. (Right). Fibroid Phthisls. Unfavorable con-
dition. Temperature norinai. Bacilli present. Note dislocation of heart. (Case R. S.)



Vf^




VR#



JVodifieJ from Ooessc/

CLM. '05



7l'itdi/if4 /fm \/ofSie/.



Figs. 110 and 111. — Stage III. Softening of Consolidated Right Apex. (Case Z.)

371




Ivrod/'fieJ fromcToesse/ ' '^ 7no,/,/,e<l //•«», Joes se/.

C.l.M- 'OS"

Figs. 112 and 113.— Stage III. (R. III., L. I.). Cavity R. U. A. (Case G. P.)




Figs. 114 and 115.— Stage III. Cavity (R) and Fluid at Base (L). (Case C.)
373



VR-I




TVTodifieJ from (Joessel



^"cfz/zeJ //oni Joesse/.



Figs. IIG and 117. — St.^ge III. Rapidly Spreading, Softening. Obstinate fever,

reduced by rest. (Case H.)




TVTodi fieJ from (Joessef

CAM. 'OS"

Figs. 118 and 119. — Acute Tuberculous Pneu.vionia, Stage III., Illness Six Weeks.
Hopeless. Note retractions at apices. (Case B. I.)

373




DIAGNOSIS




TVodifieJ front (Joesse/ ^odi/iei />»ni Joesif/.

CIM. '05"

Figs. 120 and 121. — Acute Miliary Tuberculosis. Three months' duration.
Just before death. (Case Mrs. S.)



ON RECORDING FINDINGS

If we are to classif}' all our cases carefully it is very important that
there sliould be some uniformity in recording our findings. For this
purpose the physician should have good outlines of the anterior and
posterior aspects of the chest on which graphically to record the con-
dition of the lung, as well as charts of the mouth, nose, and larynx for
recording the condition of tlicse parts. It is better to have these all on
one sheet of paper, on the other side of which are spaces for the facts
noted on inspection, palpation, and mensuration. Personally I prefer
three chest outlines — one for fluoroscopy, one for percussion, and one
for auscultation — since this gives ample room ; but if, as Trunk advises,
we use the pencil for recording percussion and the pen for recording
auscultation, both can be recorded on one diagram ; hut fluorosco]jy
needs a separate one, on which shadows, limitations of outlines and of
motion, etc., can be noted.

The chest diagrams here given I have based on the standard ana-
tomical works of Poirier-Charpy and of Joessel. The upper inner apex
outline is better given as concave above and convex below, rather than
as in the charts, but any such small details can easily be changed in



ON RECORDING FINDINGS 375

an}' diagrams for which the?e charts serve as a basis, and from experi-
ence I can recommend them as not onl)' correct, but conveniently large,
tlie fault of using too small a diagram, and thus crowding our findings,
being one to be avoided.

The facts to be noted under inspection are : General build ; nourish-
ment, complexion, and skin; eyes, hair, and nails; teeth, gums, and
tongue, dyspnea; glands, heart, stomach, respiratory motion, form of
chest — its length, breadth, and depth. Under palpation, vocal fremitus
in the different parts of tbe chest, and the condition and rate of the
pulse and the apex beat. I'nder mensuration should be noticed degree
of the temperature, height, weight, and vital capacity, and tape meas-
urements, and there should be a line on each side of wliich to lay out
the lead-tape tracings of the two halves of the chest. There should also
be on this chart the condition on arrival and on discharge, according
to the scheme of the Xational Association, as already given. So much
for the physical examination chart. Turning to methods of recording
the findings, the graphic method is now so generally used that its
advantages need not be dwelt upon liere. Enough to say that it gives
at a glance the condition of the physical signs, enables us to compress
much information into a small space and to localize the various signs
far more sharply than can be done if we try to describe them in writing.
Probably the l)est-known system of signs is that of Sahli. But desirable
as it is that all should use a similar notation if possible, this system
has some faults and has been variously modified by different clinicians.
Probably every man, whatever plan he follows in the main, will modify
it in particulars to suit his own ideas, and the system I have devised,
while being both simple and convenient, is given chiefly as a suggestion
to others in developing their own systems. It is based in part on that
of Sahli, and especially on the excellent plan of Trunk. Whatever
signs we use must be capable of being easily and quickly drawn, must
be unlikely of confusion with other signs, and must not be too complex.
The percussion findings are noted by shadings of various intensity, the
limit of dullness being marked by a heavier line, but I have added
" Slit." for short percussion note and " Impd." for impaired resonance,
neither of which can be indicated by shadings, and both of which are
of diagnostic importance.

Under auscultatory signs I have adhered to the rectangle of Sahli,
the vertical limb representing inspiration, the horizontal, expiration;
but as in hasty drawing it is very easy to miscalculate the length of
the base line, and thus to make expiration appear prolonged when it is
not, I have added a hypotenuse to the right angle, so that any pro-
longation beyond the normal is quickly seen and easily indicated. More-
over, since the heaviness of the lines is used to indicate the intensity



376 DIAGNOSIS

of the breatli sound by some, the thickness of this hypotenuse can
serve as a standard of thickness, and any increase or decrease of the
tliickness of the other two lines can be noted by comparison with this.
Tiie plan of indicating the pitch of the expiratory and inspiratory
sounds by the angle made by the lines with the horizontal, which, as
far as I know, was first used by Page, has advantages, but cannot be
well combined with Sahli's right angle, and as the other is simpler and
easier of use I have adopted it. To indicate feeble breathing by light
lines is unadvisable, since mistakes can be made in drawing the line,
so that I use an F inscribed in the triangle for this purpose as clearer;
but to indicate puerile breathing I use a triangle with all three sides
very heavily marked, which cannot be mistaken. Absence of breath



Online LibraryArnold C. (Arnold Carl) KlebsTuberculosis; a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention and treatment → online text (page 40 of 97)