Why the Late Entry Into the Sanatorium?

¹ Hawthorne, Wisconsin

A. Summing up this entire paper we may say that the methods of diagnosing tuberculosis at the present time are:

1) The patient-physician relationship in which, because an individual suffers with symptoms, he consults a physician and is examined by him. Provided that suspicion is sufficiently aroused, an x-ray is taken.

2) The work of sanatoria and Public Health officials, Tuberculosis Associations, private physicians and local groups, among contacts. These workers realize that from 15 to 30 times as much tuberculosis is found among individuals who are in direct contact with a tuberculous person as in the general population. Examination of contacts is usually done by means of the x-ray. Some few still cling to the idea that tuberculin tests should be made first and those that are positive be x-rayed. Many authorities now agree that the x-ray is the only safe method to depend on, regardless of the tuberculin reaction, particularly in adults.

3) X-ray studies of the chests of normal individuals at various times during life, such as, before obtaining employment, at the time of marriage, before undergoing long educational careers, during the high school years and on entering and leaving college.

4) Tuberculin testing, which is responsible for approximately 5 to 10 per cent of the cases in sanatoria being brought to light.

B. We have shown the relative inefficiency of the physical examination and of symptoms in either leading us to the diagnosis or in clinching the diagnosis. Where the findings are negative, little or no reliance can be placed upon either of these factors.

C. The expensive and questionable wholesale tuberculin-testing of school children, with subsequent x-raying, without adequate investigation of the contacts which these children make, is to be looked upon as digging for lead when gold lies on top of the ground.

D. The 99 per cent efficiency in minimal cases and the almost 100 per cent efficiency in moderately and far-advanced cases, make the x-ray the chief instrument of diagnosis. We realize that the practical disadvantage of high cost prohibits large scale, application to the point where it is an efficient weapon in locating the disease. From the public health standpoint, consideration should be given to the combination of tuberculin testing the children and their contacts, together with the x-raying of those whose chests appear suspicious of active infection by fluoroscope.

Lastly, the more widespread the use of the x-ray is made economically possible by means of the paper film and miniature celluloid film.

In conclusion, as Dr. J. Arthur Myers has stated so ably, "Therefore, in arriving at final diagnoses of diseases of the chest, we must constantly keep in mind that no single phase of the examination is adequate. While the x-ray is of great value in locating lesions, it remains just one part of an examination of which there are many important parts. The final diagnosis in many cases is reached only when one has brought together all available evidence so that the clinical picture of the disease is complete." It is obvious that no one test or group of tests now available can make the diagnosis 100 per cent certain. Until such a time arrives that a test is devised which is 100 per cent infallible, every factor must be considered as a facet in the jewel which makes the diagnosis. Until more skepticism is evinced toward negative findings of the physical examination and the tuberculin test, and greater reliance is placed upon the fluoroscope, the miniature x-ray films and the standard x-ray, there will be little change in the dark picture of late cases entering the sanatorium.