1901 Journal of the American Medical Association (JAMA)  
By the title of this article is meant that variable period in pulmonary tuberculosis which precedes the presence of tubercle bacilli in the sputum. It is not synonymous with the term "pretubercular stage," which has reference either to an inherited or acquired predisposition merely, or to a latent tuberculous process. The prebacillary stage, as here defined, is oftimes of long duration. Concerning the stage of enclosure Allbutt1 observes that an examination of the sputum can not help us
more » ... not help us decisively in tuberculous endobronchitis. In my own experience the bacilli were sometimes not found in the sputum for months, or even a year, after the apparent onset. Turban2 examined the sputum in the first stage in 408 cases and failed to find tubercle bacilli in 59.8 per cent. It may be safely affirmed, then, that an antecedent well-characterized clinical stage is often observed. Eich-horst3 forcibly remarks, "Certainly one finds off and on undoubted cases of pulmonary tuberculosis in which tubercle bacilli are missed, a daily examination of the sputum notwithstanding." It must be conceded that unless other methods of diagnosticating pulmonary tuberculosis than the demonstration of tubercle bacilli in the sputum be resorted to, not a small minority of cases would go unrecognized, some for months, or even a year, and some forever. While emphasizing this class of cases, it is not my desire to attempt to shake professional trust in the sputum-test, which in the majority of cases, perhaps, enables clinicians to form a positive diagnosis at an early stage of the disease and in cases not otherwise solvable, but on the other hand, to urge that it be repeated at short intervals in clinically suspicious cases. Percy Eidd4 has indicated certain clinical groups of cases in which the true nature of the complaint may be masked by a generalized bronchitis, or laryngitis and the like, in which a sputum examination yields the earliest positive information. I am relieved of the necessity of dwelling at length on many of the more remote early manifestations of the disease by reason of the elaborate and accurate descriptive writings of Ruehle,5 See,6 and others. Brief attention, however, will be invited to the practical points bearing on diagnosis that have been emphasized by some of the older writers and the value of which personal observation and experience has tended to corroborate and strengthen. Heredity.-The influence of heredity is still incontrovertible, although less potential than was held previous to Koch's startling and revolutionizing discovery. Whilst the progeny of tuberculous parents often suffer, it is, as a rule, owing to an extrauterine or post-fetal infection, direct transmission being the exception. G. Hauser,7 after reviewing at length the work of previous writers on direct inheritance, reaches the conclusion that there are but 18 authentic instances on record. He declares that the theory of the baeillary inheritance of tuberculosis rests on insufficient evidence. But, though intrauterine infection is extremely rare, and though there is practically no hereditary tuberculosis, there is a hereditary predisposition which invites infection. Hence, a somewhat different role, although one of considerable importance, is assigned to heredity. We are not concerned at present writing with the many evident methods of infection that may be operative from the time of birth and cause so striking a similarity between post-natal and ante-natal tuberculosis. This fact, however, coupled with the long period of latency of tuberculosis in childhood, must be recollected in deciding from the appearance of an individual, first, whether he has the habitus phthisicus, and secondly, whether it is really inherited. For example, as the result of an unfavorable environment, particularly if combined with bad habits, this predisposition may be acquired. E. 0. Otis8 pertinently affirms that heredity means poor vitality from birth and that subjects who manifest the same conditions without the influence of heredity are predisposed to a like extent. I have, however, frequently been able to satisfy myself that individuals possessing a robust build are, if they belong to affected families, more prone to the disease than apparently similar constitutions in persons who have no tuberculous family history. Indeed, I fear that in consequence of the modification of professional opinion in recent times relative to the question of heredity there is danger that too little attention is now, and will be in future, given to the family history. The point of greatest practical importance is that the immigration and lodgment of bacilli are distinctly favored in a predisposed organism as compared with one that is perfectly normal; hence, this hereditary influence, when clearly present, is not only of etiologic but also of diagnostic importance. Allbutt1 says : "Every physician engaged in practice among the classes in which family history can be acquired is morally convinced of the bias of many families to tuberculosis, however healthy their circumstances may appear; a bias often revealed in each of their members on the attainment of a certain age." The personal history, however, surpasses in point of import the family history. The age of the patient is Downloaded From: by a Michigan State University User on 06/10/2015
doi:10.1001/jama.1901.52470020001001 fatcat:vt7h4ueeynb2pdp7nb3aexdxua