“We had one case that was examined sixty-seven times before tubercle bacilli were found, and this was a far advanced case, with both lungs involved from top to bottom, and cavities in each lung.
“We have at the present time (September 14, 1914) a patient in the Sanatorium, with both lungs diffusely involved, with a huge cavity in her left lung, expectoration about two boxes daily, whose sputum was examined twenty-four times, with only three positive findings.
“These advanced cases with a lot of bronchial secretion are usually the ones in which it is difficult to find tubercle bacilli in one or two examinations.”
The nurse, therefore, should send in specimens frequently, every week or so, and should never be satisfied with a negative report. As we have said before, finding the bacilli is proof positive that the patient has tuberculosis, but not finding them is no proof to the contrary. Countless lives have been sacrificed by considering a negative return as evidence that the patient was not tuberculous.
The nurse should carry in her satchel specimen bottles for collecting sputum. These bottles are provided by the Health Department. If the nurse has been called to a patient by the Federated Charities, or through some similar source, or if the patient is one whom she herself has discovered, she may send the specimen to the laboratory on her own initiative. But if the patient is already under the care of a physician who has not made a diagnosis, the nurse may call upon him and ask if she may take such a specimen to be examined. This courtesy will doubtless ensure better co-operation and understanding, but if the physician refuses, the nurse is then in an awkward position. In a short time she will learn the various physicians of her district, those whom she may call upon, and those whom she may not, and she will learn to exercise considerable discretion concerning them.
Valuable as these sputum examinations may be in the case of a positive finding, they should never take the place of a careful physical examination. It is only when this examination is not to be had, when the diagnosis can be obtained in no other way, that the nurse will be obliged to rely upon sputum examinations alone in dealing with her patients. A positive sputum should confirm the diagnosis made by physical examination—it is not, or should not be, the only means of obtaining this diagnosis. Therefore, the fact that a Health Department is equipped to make sputum examinations should never for a moment supplant the dispensary, in charge of a specialist or expert. A specialist is able by auscultation, percussion, and an ear finely trained to detect changes in the breath sounds, and to recognize tuberculosis weeks before the diagnosis is confirmed by sputum findings. In this way it is possible to place a patient under treatment long in advance of the time when the average physician would have recognized the disease—an advantage to the patient and to the community as well.
Tuberculin Tests. There are two tuberculin tests commonly used, which enable the specialist to diagnose doubtful cases. These are the eye and the skin test. Strictly speaking, the public health nurse has nothing to do with these tests, since they are entirely within the realm of the physician, but she should at least understand their significance. The Von Pirquet, or Skin Test, consists of inoculating the forearm with a drop of tuberculin of a certain strength. A positive reaction is manifest by a slight redness appearing within twenty-four hours and this may persist for a day or two, after which it disappears. This test has no value in the case of adults, since all adults are supposed to possess some slight tuberculous focus, and therefore a reaction has no significance. In the case of children, however, a positive skin test has some value. Children are not as a matter of course supposed to possess tubercular foci, and a positive reaction would therefore indicate that they have become infected. A reaction, however, gives no indication as to the location of the focus—it only proves its existence.
The Calmette, or Eye Test, has more importance. A drop of tuberculin is placed inside the lower eyelid of one eye, and if a reaction occurs, it does so within twenty-four hours. The conjunctiva becomes slightly red and inflamed, which condition persists for a day or two and then disappears. In adults as well as children, this is a positive indication of tuberculosis—not necessarily of a mere latent focus, but of a possible lesion which must be watched and guarded against. It gives no indication, however, of the location of the lesion.
These tests are useful to specialists in helping them to highly refined diagnoses. Dr. Hamman, however, questions the validity of these extremely early diagnoses, unless they are confirmed by sputum findings. If the bacilli are not found the diagnosis rests entirely with the examiner, and is therefore dependent upon the personal equation.
Registration of Cases. Most States have laws which require the notification of infectious diseases, including tuberculosis. This means that all physicians are required to report their cases of tuberculosis to the Health Department, filling in a card, more or less complex, in which is set forth the patient’s name, age, address, occupation, and the duration and stage of the disease. In Baltimore, the nurses also are allowed to register their tuberculous patients in this way, with the city as well as the State Health Department. The card used is the same as that used by the physicians, but with this difference—since a nurse is unable to make a diagnosis herself, she is required to place in the corner of the card the name and address of the physician or dispensary responsible for the diagnosis. In this way the authorities are enabled to know how many patients are under the nurses’ supervision, and the sources of the diagnosis.