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 PUBUC 
 HEALTH 
 LIBRARY 
 
Physician's Note Book 
 
 ON 
 
 The Early Diagnosis of 
 Pulmonary Tuberculosis 
 
 Bureau of Tuberculosis 
 
 California State Board of Health 
 
 California 
 
 State Printing Office 
 
 1916 
 
PUBUC 
 HEALTH 
 
 This pamphlet has been prepared at the request 
 of a number of physicians. It is the doctor who 
 recognizes the incipient case of tuberculosis, who 
 holds the key to the solving of this most serious of 
 all diseases. The records returned from the county 
 hospitals show many times an early history of 
 malaria, which undoubtedly was inci^lient tubercu- 
 losis. 
 
 The Bureau of Tuberculosis is indebted to Dr. 
 Robert A. Peers, of the California State Board of 
 Health, and Dr. William P. Lucas, of the Medical 
 College, University of California, for the text of this 
 book. 
 
TNE EARLY DIAGNOSIS OF PULMONARY TUBERCULOSIS. 
 
 By Robert A. P^ers, M.D., Colfax, 
 Member California State Board of Health. 
 
 The experience of anti-tuberculosis workers in the 
 past has been that one of the most discouraging things 
 to be contended with is that a majority of patients do 
 not come under observation or apply for treatment until 
 the disease has progressed to such a stage as to render 
 a cure doubtful. Even if there is a good outlook for 
 improvement, the late stage of the disease means many 
 months or years of invalidism or semi-invalidism with 
 the attendant loss of time and money, to say nothing of 
 the thwarted ambitions or physical sufferings of the 
 patient. Many diseases are self-limited and run a certain 
 course or take a certain length of time irrespective of 
 whether discovered early or late. Tuberculosis, on the 
 other hand, is a disease in which early discovery is prac- 
 tically all important. Usually the earlier the diagnosis, 
 the shorter the period of forced inactivity. One month 
 saved in the making of a diagnosis and the commence- 
 ment of treatment may mean an arrest of the disease many 
 months earlier than if discovered later. It may mean 
 the difference between death and recovery. Many cases 
 of tuberculosis should be diagnosed as such months 
 before the correct diagnosis is really made. This is 
 not infrequently the fault of the patient. Through igno- 
 rance of the importance and significance of his symptoms 
 he frequently does not apply for relief until already in 
 an advanced stage. Frequently he may be the victim 
 of self-medication, taking cough medicines and tonics 
 until so ill that relief can be merely palliative. The 
 Bureau of Tuberculosis is endeavoring to reach this 
 class of patients by education of the masses. It is to 
 be regretted that only too frequently the fault lies with 
 the members of the medical profession. The early 
 
 22766 
 
 393246 
 
diagnosis of tuberculosis is not always an easy matter; 
 frequently it is one of great difficulty. The Director of 
 the Bureau of Tuberculosis felt that it might be of bene- 
 fit and aid in securing of earlier diagnoses if the members 
 of the medical profession were each presented with 
 the following brochure which will call attention to 
 some of the aids in making a diagnosis of tuberculosis 
 in adults and children. As most cases of tuberculosis 
 in adults assume the pulmonary type, the remarks under 
 this heading will deal with the diagnosis of pulmonary 
 tuberculosis. 
 
 At this time it might be well to call attention to a 
 few general facts regarding tuberculosis under the fol- 
 lowing headings : 
 
 (1) Prevalence. 
 
 (2) Resemblance to other diseases. 
 
 (3) Danger signals. 
 
 (1) It is estimated, and with good reason, that nearly 
 every human being, in countries where tuberculosis is 
 prevalent, at some time becomes infected with pulmonary 
 tuberculosis. Only a percentage of those infected, how- 
 ever, develop the disease. Unfortunately, it is not pos- 
 sible to know the time of infection of any particular 
 individual nor to determine who will, or who will not, 
 develop the disease sufficiently to require treatment. 
 
 Because of these facts, it is necessary to consider each 
 individual a potentially tuberculous person and to bear 
 this in mind in the diagnosis of our own patients. In 
 addition, we do know that one death in seven in our 
 State is due to tuberculosis. Thus each physician can 
 be certain that, if the present death rate is maintained, 
 one in seven of his clients will die from tuberculosis, 
 while an even higher percentage of those seeking relief 
 at his hands will be suffering from this disease. These 
 facts, therefore, should be borne in mind whenever mak- 
 ing a diagnosis of a medical case or of a surgical case 
 wherein tuberculosis is a possibility. 
 
(2) Now, as to a number of diseases which have 
 symptoms similar to those frequently observed in tuber- 
 culosis and with which tuberculosis is sometimes con- 
 fused. The principal ones are malaria, typhoid fever, 
 chronic bronchitis, unresolved pneumonia, asthma and 
 la grippe. 
 
 Malaria : 
 
 In the early stages of tuberculosis, when the disease 
 is not extremely acute, there is often present a symptom 
 complex which is not at all dissimilar to malaria. There 
 is the same lassitude and loss of ambition, headache, 
 tendency to tire easily, a feverishness, especially in the 
 afternoon, and, in many cases chilliness or even definite 
 chills. When the chill and fever occurring in the after-' 
 noon are followed by sweating at night the diagnosis 
 is even more obscured. The lack of the presence of 
 Plasmodia in the blood, the failure of the symptoms to 
 clear up under quinine treatment, and the careful taking 
 of a history and a painstaking examination should enable 
 us to rule out malaria and reach the proper decision if 
 the patient is tuberculous. 
 
 Typhoid Fever: 
 
 Not a few cases of tuberculosis of the acute type 
 simulate very closely typhoid fever. Here the absence 
 of a positive widal reaction or a negative blood culture 
 for the bacillus typhosus should put us on our guard. 
 Again, a careful history followed by a closely observed 
 and well-kept clinical chart will be of great aid. The 
 pulse rate in tuberculosis is more rapid than in typhoid, 
 the temperature is more irregular, there is absence of 
 the laboratory findings seen in typhoid cases and there 
 is not the usual typhoid convalescence. In these cases, 
 and likewise in those simulating malaria, there is almost 
 always a daily cough, very slight maybe and limited to a 
 morning clearing of the throat, but still sufficient to help 
 
 2—22766 3 
 
US to arrive at a diagnosis. The X-ray, tuberculin tests 
 and laboratory examination of the sputum will all be of 
 aid, but too much reliance must not be placed upon 
 them to the exclusion of other evidence. This is par- 
 ticularly true of the X-ray and of tuberculin tests which 
 should be interpreted by experts. The one thing to 
 remember above all others is that a negative sputum 
 does not mean that the patient has not tuberculosis. 
 .When tubercle bacilli are present in the sputum, their 
 presence indicates tuberculosis somewhere in the respir- 
 atory tract. Their absence from the sputum means 
 nothing more than that they were not found on the 
 slides examined. 
 
 Nevertheless, whenever there is any sputum to be 
 obtained it should be very thoroughly and carefully 
 examined for tubercle bacilli. A failure to have the 
 sputum examined when patients expectorate is a breach 
 of trust on the part of the physician. 
 
 Chronic bronchitis, unresolved pneumonia, asthma and 
 chronic la grippe are all diseases which exist and with 
 which we will come in contact. Experience has shown, 
 however, that the majority of cases of chronic bronchitis 
 are in reality cases of tuberculosis ; that pneumonias fail 
 to resolve usually because there is an underlying tuber- 
 culosis ; that many cases diagnosed as asthmatic are not 
 asthmatic but that the dyspnoea and violent coughing 
 attacks are due to tuberculosis (especially is the latter 
 true where extensive disease or extensive fibrosis have 
 so distorted the bronchi as to render difficult the expecto- 
 ration of sputum) ; chronic la grippe is almost always 
 tuberculosis. The diagnosis in these cases can be cleared 
 up often only after a thorough history has been taken; 
 after the patient has been carefully watched for days or 
 weeks ; only after many examinations and by calling to 
 our assistance every laboratory aid. These the patient 
 is entitled to, and the physician will find that the results 
 obtained amply repay him for his trouble. 
 
(3) There are many danger signals which are very 
 common in tuberculosis and which should cause the 
 physician to think of the possible existence of this 
 disease. Some of them appear quite early while others 
 appear later. Lack of space will allow merely an 
 enumeration of the principal of these. The enumera- 
 tion is not in the order of their importance, nor of their 
 appearance : 
 
 (1) A tendency to tire easily, especially in the after- 
 noon when formerly there has been no fatigue doing 
 work of a similar character. 
 
 (2) A tendency to slight and irregular temperature, 
 especially in the afternoon. A temperature of 99.2, 99.4 
 or 99.6, occurring frequently, is very strong evidence of 
 a chronic toxemia. The most common toxemia is a 
 tuberculosis toxemia. 
 
 (3) A steady loss of weight when this can not be 
 explained by changes in diet or character of work, or 
 in other ways. 
 
 (4) The presence of a chronic cough or clearing of the 
 throat, especially in the morning, after laughing, loud 
 talking, or singing. This combined with 1, 2 and 3 is 
 very suspicious, and such a patient should be considered 
 suffering from tuberculosis until proved free from that 
 disease. 
 
 (5) Likewise, spitting of blood should be considered 
 a sign of tuberculosis unless proved otherwise. 
 
 (6) Attacks of pleurisy, unless in conjunction with a 
 definite pneumonia, or following an injury to the chest 
 wall, or in other" cases when the cause is definitely shown 
 to be other than the tubercle bacillus, should be con- 
 sidered as tuberculous. Pleurisy with a serious effusion 
 
 ■ is practically always of tuberculous origin. 
 
 (7) The presence of night sweats is very significant 
 and while usually seen in advanced cases, is not infre- 
 quently seen in the early stages. 
 
 (8) A rapid pulse without sign of cardiac disease is 
 very frequently, almost always found even in early 
 
tuberculosis. This is shown especially after slight 
 exercise when there is very likely to be slight dyspnoea 
 also. 
 
 There has been no attempt to outline in this booklet 
 a method of examination nor of history taking. These 
 can be found in the textbooks on the shelves of every 
 physician. There is no royal road to a diagnosis and no 
 short cuts to be made. A diagnosis must be made upon 
 the history, the symptoms, the findings at examination, 
 and the laboratory reports. Study and experience alone 
 will enable us to assign to each of these its proper rela- 
 tive position in regard to importance in each case. The 
 physician must also be willing to take time to secure 
 histories of his caseS;, he must take the time to examine 
 his patient, and he must be able to interpret what he 
 finds. He must not make a diagnosis on any one 
 symptom or finding unless it is the discovery of tubercle 
 bacilli in the sputum, but must study and correlate all 
 the findings in order to arrive at the proper conclusion. 
 
TUBERCULOSIS IN INFANCY AND CHILDHOOD. 
 
 William Palmi:r I^ucas, M.D. 
 Professor of Pediatrics, University of California. 
 
 The more the subject of tuberculosis is studied the 
 more certain it seems that a clear definition should be 
 made between infection and disease. When we see 
 statistics stating that 80 per cent to 90 per cent of chil- 
 dren have tuberculosis by the time they are 14 years 
 of age this must mean tuberculous infection and not 
 tuberculous disease. We know that infection is very 
 prevalent in children, but infection fortunately does not 
 mean disease. It simply means that somewhere the 
 tubercle bacilli have gained entrance and have found a 
 definite lodging place, usually in some group of glands, 
 as the cervical or bronchial glands. Here the tubercle 
 bacilli may remain dormant for years producing no 
 symptoms nor any general systemic reactions. 
 
 The Von Pirquet reaction merely shows the presence 
 of infection. It does not necessarily mean disease. 
 This is a very important point to have in mind when 
 considering the value of the Von Pirquet reaction. 
 
 Tuberculous disease has varying manifestations, de- 
 pending on the age of the child. Infection in the first 
 year very often leads to disease. Statistics show that 
 about 80 per cent of the children who are infected in the 
 first year of life, sooner or later have the disease, and a 
 large percentage of these die, either from general mili- 
 ary tuberculosis or from miliary tuberculosis and tuber- 
 cular meningitis as an accompanying manifestation of the 
 widespread tuberculous process. Tuberculous disease in 
 the first two years is a very serious and fatal condition. 
 Fortunately it is easier to limit infection during these 
 first two years than later because contact with tuber- 
 culous individuals can be definitely regulated during. 
 
 ;;7 
 
this period, as all infants should nurse, or if they have 
 milk, should have certified milk, and the two main 
 sources of infection, contact and infected milk, can be 
 easily controlled. 
 
 The symptoms of tuberculous disease in infancy are 
 often very difficult to determine. They usually have to 
 do with loss of appetite or loss in weight, and no definite 
 localizing symptoms until very late, when in a large 
 proportion of cases of miliary tuberculosis meningeal 
 symptoms appear. If the infection starts from perito- 
 neal glands we have symptoms pointing to the abdomen 
 and intestinal tract, with diarrhea and frequent digestive 
 disturbances, with increased size of the abdomen. In 
 these cases, either the massive glands can be felt or the 
 presence of fluid can be easily determined. 
 
 If the disease manifests itself during infancy in the 
 bony system, the prognosis is very much better. Here 
 we find dactylitis and occasionally involvement of the 
 hip joint toward the end of the second year. 
 
 Involvement of the cervical glands, infection coming 
 through the tonsils and adenoids, is not as frequent 
 during infancy as it is during early childhood, though 
 during the second year we see it not infrequently. 
 From the standpoint of disability and mortality this 
 probably is the most hopeful type of tuberculous disease 
 met with in infancy, as properly treated it can be kept 
 localized, and if necessary the glands can be completely 
 removed though this is not always indicated. 
 
 Tuberculous disease in childhood (from 2 to 14 years) 
 has a varying symptom complex. Usually we can elicit 
 a history of exposure in the home, probably through 
 some member of the family or a caretaker or an indi- 
 vidual who has had frequent and direct contact with 
 the child. 
 
 Infection which develops into disease is rarely gained 
 from street contact; undoubtedly a good deal of infec- 
 tion is so developed, but these are usually so timed that 
 the child develops enough immunity not to have it 
 
progress into a diseased condition, and we may feel 
 fairly confident that where a child develops tuberculous 
 disease it has been brought into frequent contact with 
 a tuberculous individual or has repeatedly taken infected 
 milk. 
 
 Certain diseases are most important, both in infancy 
 and childhood, as being predisposing causes for the 
 development of tuberculous disease. We consider 
 whooping-cough and measles as definite predisposing 
 factors in tuberculous disease. This presupposes the 
 presence of tuberculous infection either previous to 
 whooping-cough or measles, or very shortly following. 
 These diseases lower the resistance of the child to 
 tuberculous disease. The danger from these infectious 
 diseases, and others that involve the respiratory tract, 
 or for that matter any prolonged infection that lowers 
 the resistance of the child, is that it becomes more pos- 
 sible for the tuberculous infection to develop into tuber- 
 culous disease. This is the main reason why the recog- 
 nition of infection is so important and the prevention 
 of any infectious diseases becomes more important 
 in infants and children who have tuberculous infections. 
 
 The diagnosis of tuberculous disease in childhood is 
 either very easy or very difficult to make. It is easy 
 when the history of exposure is definite and where the 
 physical findings are clear cut, such as we get in 
 tuberculous disease of the bony system, as Potts' disease, 
 or tuberculosis of the hip or tuberculous peritonitis, 
 but it is often very difficult to make a definite diagnosis 
 of tuberculous disease where the symptoms are not 
 localized. In such cases, persistent loss of weight or 
 failure to gain consistently, listlessness, easy fatigue, loss 
 of appetite or irritability are further suggestive 
 symptoms. A tendency to repeated colds or bronchitis, 
 with or without night sweats, is not infrequently present. 
 
 The examination of such children would show a very 
 irregular temperature, sometimes elevated in the morn- 
 ing, sometimes at night and sometimes continuous. The 
 
main characteristic of the temperature is this irregu- 
 larity, usually above 99°, not often running over 100° 
 or 101 ° unless the symptoms are pronounced. The pulse 
 is usually rapid, in fact vaso-motor changes are often 
 a pronounced feature. The child will flush easily or 
 pale easily and at other times be normal. A moderate 
 amount of anemia with pallor is usually present, the 
 blood showing a picture of moderate secondary anemia. 
 The digestive symptoms, in addition to the loss of 
 appetite, are demonstrated by attacks of intestinal indi-. 
 gestion either accompanied by diarrhea or constipation, 
 and the child has a coated tongue. 
 
 Repeated physical examinations of the chest usually 
 give certain definite persisting signs. Over the area of 
 the bronchial glands there is definite resistance, paraver- 
 tebral dullness is definite. D'Espine's sign in children 
 old enough to whisper, is present as far down as the 
 fifth or sixth dorsal vertebra. Often there are definite 
 areas, either at the apex or base on one or both sides 
 where there are persistent slight changes, and the 
 presence of fine rales over a limited area found on 
 repeated examinations are very suggestive. Increased 
 vocal and tactile fremitus in the neighborhood of 
 enlarged glands is common. Enlarged thoracic veins 
 from pressure by these enlarged glands is not as fre- 
 quent a finding as one would expect. 
 
 The X-ray findings in such cases are always most 
 helpful and illuminating. The extent of the process as 
 shown by the X-ray is usually more extensive than that 
 brought out by our physical examination, and in the 
 presence of a strongly positive tuberculin test, it is 
 safe in this large group of indefinitely diseased children 
 to make a positive diagnosis of tuberculous disease. 
 
 The sputum is rarely obtainable in children, though in 
 older children, by taking throat swabs, these very often 
 will bring up thick mucus secretion in which the tubercle 
 bacilli are easily demonstrated when there is no sputum 
 at all. 
 
 10 
 
It must not be forgotten, however, that most of these 
 symptoms can arise from other conditions, but when 
 they exist a very careful study of each case should be 
 made before we are justified in ruling out tuberculous 
 disease. 
 
 The treatment of tuberculosis in infants and children 
 necessarily varies with age, with the extent and severity 
 of the infection and with the localization of the disease. 
 If it is general, as it usually is in early infancy, very 
 little can be done by treatment. 
 
 The main reduction in mortality during infancy must 
 depend upon the prevention of infection, not on the hope 
 of bringing about a cure, because the resistance to tuber- 
 culosis in infancy is very low and hard to develop. The 
 older a child gets, the more hopeful is treatment if the 
 condition is recognized early. 
 
 The treatment of tuberculous disease of any organ,, 
 of course, must depend on what organ is involved. 
 Usually the disease in childhood is prolonged, at first 
 being very insidious ; even when definitely localized in 
 the bony system, or in the kidneys or glandular system,, 
 its course is a prolonged one. 
 
 Three important points to be observed in treatment 
 are : first the conservation of energy. This means that 
 the child must be kept quiet, must not be allowed to- 
 become fatigued, which is often one of the prominent 
 symptoms of the disease, the child becoming irritable 
 on account of its fatigue. It is often striking to note 
 how the appetite and general resistance of a child will 
 improve with a definite daily regime which conserves 
 to the utmost the child's energies and prevents over- 
 exertion or excessive stimulation, so that quiet is also 
 a necessary factor in this first phase of the treatment. 
 
 The second important consideration is diet. This 
 should be one which the child can easily digest. It is 
 wise to remember that forcing food, especially food 
 rich in fat, may cause definite intestinal indigestion 
 because the digestion of fats is definitely diminished in 
 
tuberculosis, especially tuberculosis of the intestinal tract. 
 It is remarkable how, often when the child has had no 
 appetite, simply putting it to rest in a quiet, congenial 
 atmosphere with all friction and excessive stimulation 
 removed, the appetite will improve without giving any 
 medication. Iron assists in bringing the muscular tone 
 of the child as well as its appetite to a better condition. 
 The digestive capacity of the child should be carefully 
 watched in order that derangement may not be caused. 
 
 Third, a most important point in the treatment is 
 fresh air and sunlight. The child should be out of doors 
 as much as possible while awake as well as when at 
 rest. The value of sun baths has been clearly demon- 
 strated. Sun rays have not only a marked tonic effect 
 but undoubtedly stimulate definite reactions in the body, 
 especially in the bony and glandular systems, and as 
 these two systems are the most often involved in child- 
 hood the application of sun rays becomes most important. 
 This form of treatment should be carefully supervised, 
 however, as over stimulation may do more harm than 
 good. Carefully increasing the dosage of sunlight, not 
 only to the infected area but exposing the child stripped 
 both front and back to the direct sun rays, protecting 
 it while taking the sun bath from the wind, is a very 
 important feature of outdoor treatment. This is a form 
 of treatment which should be used in this State much 
 more than it is. 
 
 Tuberculin treatment is of some value both in gland- 
 ular and bony tuberculosis in children. It is, of course, 
 of no value in generalized tuberculosis in infants, 
 and it is only of value where it is very carefully and 
 intelligently administered. There can be no rules laid 
 down as to its administration; each case must be con- 
 sidered separately. Certainly it should not be given in 
 such dosage as to cause marked reactions. That amount 
 should be given which simply stimulates production of 
 immunity, but does not cause any marked constitutional 
 reactions. 
 
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