EARLY DIAGNOSIS OF TUBERCULOSISAuthor(s): DAVID TOWNSENDSource: The Public Health Journal, Vol. 6, No. 7 (JULY, 1915), pp. 333-335Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/42005413 .

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EARLY DIAGNOSIS OF TUBERCULOSIS

By DAVID TOWNSEND, M.D.

AS

tuberculosas ease and the

is onset such a

so prevalent

insidious, dis-

it ease and the onset so insidious, it is essential, in making our diag-

nosis, to constantly bear in mind the pos- sibility o<f its presence. It is safe always to think of it, if for no other reason than to exclude it, in this way fewer mistakes in diagnosis will be made and fewer cases overlooked. No matter what the symp- toms may be, a thorough chest examina- tion should be made, especially is this true of the first visit and where there is a tu- berculous history; the disease is often found where least expected. Individual symptoms do not mean tuberculosis, it is only lby carefully weighing the data ob- tained by a careful history of the case in all its aspects and a careful examination, that we are enabled to make our diagnosis. In cases of doubt, it is always safer to treat the case as if it really were tuber- culosis ; if this is done there will 'be fewer advanced cases. In making our examin- ation three things are essential, chest ex- amination, sputum examination and the registration of the pulse and temperature.

Family -history, as to tuberculosis, is al- ways important. The previous history of a patient should be carefully studied, as well as his mode of living and occupa- tion. (In this connection, a history of personal contact with a person who has had tuberculosis, particularly if it be an advanced 'case ; (history of previous cases in same 'house may be of assistance.) Underfeeding, deficiency of sunlight, de- fective ventilation, mental overwork or fatigue and physical exertion from what- ever cause, occupations where there is much dust mixed with the inhalation of impure atmosphere, dissipation with dis- regard for the laws of health, irregular meals, bad home surroundings as to dirt, filth and overcrowding, all predispose to the disease. Attacks of fever, transitory in type, especially if present in the after- noon, or a mild fever persisting for some weeks without any apparent reason, par- ticularly if accompanied by malaise, one or more attacks of pleurisy, no matter

!how remote, amd a previous history of bronchitis, if unilateral, as well as fre- quent colds, are always suspicious.

The symptoms of early tuberculosis are somewhat indefinite and usually extend over a more or less protracted period. The earliest symptom may be the coughing up of blood. A slight cough, which may be no more than a hack, with or without ex- pectoration, may be present or may pre- cede the attack for weeks or months. The cougih may be constant or intermittent. The sputum, if any, is usually at first mu- cous and greyish in color and be present only in the early morning or after fatigue or exertion and is brought op, either by cough or simply clearing the throat, or there may be only a feeling of fullness in the throat. There are disturbances of cir- culation with rapid pulse, disturbances of digestive tract, accompanied by foul smelling stools, disturbances of nervous system, the patient is easily excited, red- dens easily 011 being spoken to and sweats profusely on examination. There may be, and usually is, loss of weight, loss of energy, and a slight rise of temperature, in the morning or afternoon, or after meals or exertion. There may be a sus- ceptibility to catarrhal attacks, which start as a cold in the head or laryngitis, and gradually work downwards and final- ly settle in the affected area in the lung or lodge in the bronchus, giving bron- chitis, which runs a more or less protract- ed course. This tendency may exist for months before tuberculosis is suspected or the bacilli appear. Such cases are suspi- cious, to say the least, especially with a tuberculous history. Pain over the af- fected area brought out on pressure may. exist for some time, is either constant or remittent, it is usually limited to the apices and is neuralgic or rheumatic in type, leading to the diagnosis of rheuma- tism or neuralgia, or it may be found be- tween the scapulae. It is either localized or when present in the apices extends to the shoulder and down the arms. The pain is due to a localized pleurisy.

333

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334 THE PUBLIC HEALTH JOURNAL

Examination of the patient, in doubt- ful eases, is best made in the early morn- ing, before the patient is up, and subse- quent examinations should always be made at the same hour. The chest .should be completely bared and the patient plac- ed in a strong light, this is essential for the detection of /whatever abnormalities may exist. The general condition of the skin, as to nutrition and appearance and the shape of the chest is important. The skin is drier than normal, and the thorax is narrow with slight depth, but great length, with wide intercostal spaces, with a thin layer of fat or slight muscular dev- elopment. The scapulae are prominent, and their inner edges protrude more than nor- mal, giving a winged L._*ped appearance. There may be local~fiattenings or depres- sions and a retraction of one apex, or emphysematous pads aibove -clavicle. The muscles of the neck and thorax on light percussion are found to ¡be more rigid than on sound side (Pottenger's sign) and ac- cording to him indicates fresh active dis- ease. Swelling of the thryoid is seen ear- ly in the disease. On mensuration the chest should measure in circumference one half the height, if less, then we have a weak chest and one predisposed to tuber- culosis. On respiration, especially on in- spiration, the affected side or apex lags, expansion of the chest is restricted and the excursion at the base of the lung, 011 affected side, is usually limited, and espe- cially so if the disease is extensive. The more recent the disease the more evident the limitation.

Percussion. - The note shortens at first, ¡then goes on to dullness; with increased infiltration it may fbe slight or relative or intense and absolute, that is the underly- ing tissues are more or less airless,' or it may be tympanitic, as a result of dimin- ished tension. This is best brought out on light percussion. Percussion over clavi- cles in unilateral apical disesae will de- termine the affected side. The chest should be systematically percussed from apex downward and each side o'ver same areas, carefully comparing each area in turn. In cases of doubt at apex, com- mence at bottom of chest and percuss up- wards, in this «way one "will gradually pass from the normal into the abnormal area. Percussion informs us of the density of

tissue and must be made with ausculta- tion for accurate results.

Auscultation. - The patient should breathe through the nose and easily and a little deeper than normal. (As in per- cussion, both sides are to he 'compared in corresponding areas.) The ibreath sounds are not clear, or they may <be hoarse, vesi- cular, and are often, vibratory in charac- ter. This may exist even before percus- sion reveals any changes. Weak inspira- tion is next in impórtance, care should be taken that this is not due to nasal ob- struction or a plugging of a bronchus. Cog wheel respiration, due to large areas of defective function in neighborhood of in- filtrations, may he present, and if confin- ed to one apex means tuberculosis. In early conditions expiration is frequently unchanged but, as a rule, it becomes markedly bronchial later than inspira- tion. As soon as infiltration is establish- ed it becomes more bronchial in charac- ter. Prolonged expiration is 'characteris- tic. Diminished respiration at apex, un- less due to nasal obstruction or a plugged ibronehus, in the young, means activity, in the adult a healed lesion. As soon as con- traction takes place you get a narrowing on the apical outline. Rales may not come until late in the disease; the dis- ease may exist for a long time solely , in form oí chronic infiltration, as shown 'by auscultation and percussion. Rales, if present, consist of a simple click at end of inspiration or persistent fine crepita- tions, or may ibe 'brought out often only after repeated coughing, followed 'by a deep inspiration. They may take the type of a sharp groan or »whine. They are commonly heard a'bove or below clavicle anteriorly or posteriorly above scapulae or at 'bases or over bronchus or in axilla. In the latter area other conditions may give rise to some signs, therefore we should be cautious in making a positive diagnosis of tuberculosis in this area, and only after repeated and careful examina- tions and weighing of all the data in our possession. (A chronic pneumonic pro- cess at apex is tuberculous, if at base the diagnosis is made from the fact that there is no crisis and the process does not 'dear as it should.) Rales, which on repeated examination are constantly heard limited to a definite area, are suggestive. Whis-

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EARLY DIAGNOSIS OF TUBERCULOSIS 335

pered voice sound is important and is an even more accurate guide than spoken voice, for the detection of infected areas. A subclavian mumur, systolic blowing mumur, heard over the subclavian artery, more often aibove than (below clavicle, in- dicates apical tuberculosis. This is pro- duced by adhesions of both pleural sur- faces to each other and to the wall of the subclavian artery.

Repeated sputum examinations in all suspected cases are indicated and essen- tia^ and should 'be done as routine mea- sure. Absence of bacilli does not exclude tuberculosis and the presence usually in- dicates a more or less advanced stage of the disease.

In doubtful cases tuberculin may be employed, as follows :

(a) Skin test, Vpn Pirquet, of more rvalue in children than in gtdults.

(b) Conjunctival test - 'Too dangerous to be employed as a routine.

(c) Subcutaneous test - Dose for first injection, 2 cmm. The reaction consists of :

1. Reabtion at point of injection. 2. Febrile reaction-rise of Io F. 3. General reaction^-èeadache, malaise,

chill. 4. Reaction at seat of disease - increas-

ed activity. The felbrile and general reactions nre

most often met with and the focal reac- tion is the most trustworthy. Tuberculin is contraindicated in the following condi- tions :

1. Tem. 99.2° F. oral or 99.8° F. rectal. 2. Recent hemorrhage from mouth. 3. Heart disease. 4. Kidney disease. 5. Epileipsy or severe cases of hysteria

or neurasthenia. 6. Miliary or active tuberculosis. 7. Diabetes or arteriosclerosis. 8. Convalescents and persons weakened

'by severe disease. X-ray is often of the greatest value in

clearing up obscure conditions in the lungs, and should 'be employed, when pos- sible, in air doubtful cases.

In closing, I wish to say just a 'word regarding the type of cases suitaible for admission to the sanatorium. The fol- lowing may be of service :

(a) Cases with early physical signs in whom there is no evidences of tempera- ture, even after exertion.

(b) Cases where the lesion is not far advanced, which has existed for o<ver six months, and where no temperature is evi- dent except after exertion and then only a small rise. -

All other cases are best kept under ob- servation at home and then if they im- prove may be given a trial later.

THE GARDEN "God Almighty first planted a garden" Says Bacon; and lie does

not omit to add by implication. 'Go thou and do likewise. 99 That man who finds in a garden his chief pleasure, his work, his rest, his recreation, is to be envied for he is creating one of the "-Purest pleasures" for himself and others that can be known to mortals. What satisfaction can equal that of plucking your own roses.

Selected.

Flowers are the beautiful hieroglyphics of nature, with which she indicates how much she loves us.

Goethe.

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