The Diagnosis of Pulmonary Tuberculosis in the Absence of Bacteriological Confirmation"

Administrative Difficulties.* By I V O R DAVIES

Medical Superintendent of Kelling Sa~zatorium, Holt, Norfolk. Lale Offcer, Metropolitan Borough of Hammersmith

Tuberculosis

Some years ago, at the end of my first year as a Tuberculosis Officer, I was struck by the difficulty that the just evaluation of the T.B. minus group of cases presented in compiling my annual returns. I was prompted, therefore, to carry out an investi- gation in which I made a study of such a group of cases in the decade I926-i935, and my results have been published (Davies, I937). In this paper some repetition of statements that I made in my previous publication is inevitable, and hence, for the sake of brevity, I propose to tabulate the administrative difficulties connected with the T.B. minus group of cases into five headings.

(A) DIFFICULTIES ASSOCIATED WITH NOTIFICATION.---These are chiefly found in the dispensary service, not so much when the notification is justly applied as when it is erroneously made. A person so notified is immediately branded with the stigma of notification, is said to be tuberculous, and is unjustly regarded as infectious. The family is subjected to the multiple and sometimes duplicated visitation from the Dispensary and Public Health Staff, the patient usually loses his occupation and wends his weary way into a sanatorium. On his return; the visitations are renewed and his dispensary observation continued over a period of years until finally his name is 'written off' the register as 'cured'.

I have yet to be convinced of the accuracy of statistical records of annual cures of pulmonary tuberculosis; rather do I envisage the enormous number of cases sheltering under the title of 'T.B minus', and who recover from a disease which they never had. All this is because the standard for notification is so vague and not suffici- ently exacting. At the present time, when a medical man is 'of the opinion', not necessarily born of proof, that a person is tuberculous he must notify the patient as s u c h .

We all know that the clinical features and modes of onset of early phthisis are so varied and often unrecognizable that clinical evidence alone is too weak to bear the burden of responsibility for notification. Though the clinical picture may vary, tuberculosis produces very definite radiological and pathological features. Con- sequently I maintain that before any notification should be accepted the diagnosis should be conclusively proved in at least two out of the three possible lines of investi- gation, clinical, radiological and pathological.

We are all familar with the amount of administration required and the number of forms to be filled in when any notification is received, so that all erroneously notified cases, submitted to the same routine, mean unnecessary work and time which could have been more profitably spent otherwise. The more one sees of

*A paper read before the Tuberculosis Association, May I9th , ~939

14 TtlBERCL F. October 1939

tuberculosis, the more surprises one gets with regard to the early case, and the more one realizes the futility of clinical dogmatism.

(g) DIFFICULTIES IN REGARD TO DE-NOTIFmATmN.--The facility with which tuberculosis is erroneously diagnosed and notified is only surpassed by the difficulty in de-notification even after the proved non-existence of a tuberculous lesion.

In order to de-notify such a case, it is necessary to trace the original notification and obtain the consent of the medical man concerned--this is an admission of an incorrect diagnosis and not readily given. Assuming, however, that courage gives way to reason and this consent is obtained, the Medical Officer of Health must agree to the de-notification, then the County Medical Officer of Health, and finally the Ministry. In the event of the original person making the notification not being traced, tile task resolves itself through the same channels into making the de- notification on the grounds of proved non-existence of tuberculosis, or as 'diagnosis not confirmed'; and, candidly, I find this latter the easier way out. One among many that I could quote, the following example illustrates this point :

Some years ago I was asked to see a hospital porter who complained of cough and nmcoid sputum. Following a clinical examination, serial x-rays and twelve negative sputum tests, my original diagnosis of bronchial catarrh was considered to be confirmed. He was sent to a chest hospital and one positive sputum was recorded along with twenty-four negative tests--he was accordingly notified and sent to a sanatorium.

On his return he attended the dispensary and his records, which accompanied him, showed that there was no definite clinical or radiological evidence of tuberculosis, and all further sputum tests were negative. I still refused in my own mind to regard him as tuber- culous and hinted as much in my periodic reports.

To settle the matter an independent opinion was sought and my diagnosis of non- tuberculous disease was supported. He was de-notified and reinstated in his old occupation, but not until the lapse of two years, much inconvenience financially and the unjust stigma throughout.

The only evidence for this notification was one positive sputum in fifty specimens. ' O n e swallow does not make a Summer' neither does one positive sputum, as sole evidence, make a diagnosis of pulmonary tuberculosis, since the sources of error and contamination in the preparation of slides are too obvious and numerous to permit one positive test alone to be the deciding factor in the absence of other corroborative evidence. Two or three tests at intervals should be positive to be conclusive.

One is struck by the frequent copying of diagnosis and classification from one form to another, as a patient in the T.B. minus group is transferred from one institution to another or from one district to another, without the slightest question being raised as to the evidence in support of that diagnosis.

(C) DIFFICULTIES ASSOCIATED WITH CLASSlFICATION.--This may at first glance be regarded as a contradiction of terms, since all cases diagnosed as pulmonary tuber- culosis in the absence of bacteriological confirmation, must of necessity be classified as T.B. minus. Sometimes, however, these cases find their way into the T.B. plus classification without any record of a positive test. This, I discovered, occurred in those patients who were transferred from one district to another, and was in reality due to the varied methods of recording symptoms on printed charts. We have all seen the printed list of symptoms on primary examination sheets, and noted that some clinicians denote the presence of particular symptoms with qualified words, some indicate by ticks and others by plus signs. It is quite obvious, therefore, that a

October I939 TUBERCLE 15

plus sign in the latter system of recording, should mean that sputum is present as a symptom, but it is equally obvious that others may misinterpret this as indicating that the sputum is positive. In this way a T.B. minus case is incorrectly newly classified into the T.B. plus group, with the corresponding inaccuracy in statistics.

(D) DIFFICULTIES ASSOCIATED \u TREATMENT ARRANGEMENTS.--(i) A patient in the T.B. minus group, whether justly so or otherwise, but in any case non-infectious, can only receive treatment under a Tuberculosis Scheme in either a chronic hospital ward for tuberculous patients or in a sanatorium, even though he may only require a short period of institutional treatment. All convalescent homes and similar short period treatment institutions are closed to him. This fact I regard as one of the strongest points supporting the establishment of preventoria, where thorough investigations and observations can be carried out.

(ii) A patient in this same group, erroneously notified, always receives incorrect treatment and a sanatorium bed is unnecessarily occupied.

This is borne out by Dr. Lissant Cox who found that he rejected 59 per cent of children aged o-15 years referred to his dispensaries as suspicious cases of tuber- culosis, and thereby he curtailed the number of juvenile beds in the sanatoria.

(iii) All doubtful cases should receive full investigation before coming to the sanatorium since the facilities for these investigations are not always available at such an institution, and thus much administrative detail and correspondence would be saved. Moreover, to teach the non-tuberculous the sanatorium routine applicable to the tuberculous is neither correct treatment nor sound preventive doctrine.

(E) DIFFICULTIES IN RELATION TO PENSlONS.--(i) Several pensioners, after the last Great War, received their pensions for pulmonary tuberculosis and I refer to those in the T.B. minus group. With little or no treatment many of them are alive to-day, over twenty years after the cessation of hostilities.

Most of us have filled in the periodic reports M.P.X. 9. T for such pensioners with regular monotony and felt that we were dealing in reality with non-tuberculous cases. Because they were war pensioners we did not pursue the doubt too seriously, but nevertheless the administration in the dispensary and with the Ministry of Pensions still continued.

(ii) There were pensioners who received pensions for bronchitis and other non- tuberculous pulmonary infections and who, in the course of their travels, through lack of employment or inadequate food, suffered serious relapses of t h e original complaint and produced the triad of symptoms: cough, sputum, 'staining' or haemoptysis. They were frequently notified at casualty wards as tuberculous and admitted to the chronic ward. In the event of a fatal outcome the certificate stated that pulmonary tuberculosis was the cause of death. As the result of this, the widow received no widow's pension, since it would be stated by the Ministry that the pensioner died, not from the disability for which he was receiving a pension, but of another disease altogether. The enormity of the task and the mass of correspondence entailed in attempting to rectify this injustice must have been the unhappy experience of us all.

CONCLUSIONS

(i) With but very few exceptions, it is doubtful if a pulmonary lesion with per- sistently negative results in all three lines of investigation--clinical, radiological and bacteriological--can really be regarded as tuberculous.

I6 TUBERCLE October I939

(2) A plea is made for higher standards of notification, and conclusive evidence in at least two out of the three lines of investigation, before acceptance of that notification. This would eliminate the non-tuberculous cases erroneously notified, produce more accurate statistics, and reduce the serious psychological factors which are unnecessarily bestowed upon such patients.

(3) Greater facilities for, or access to, first-class pathological laboratories should seriously be considered by Local Authorities responsible for a dispensary service.

(4) A universal system of recording symptoms with the agreed omission of the positive sign.

(5) The establishment of preventoria is advocated for doubtful cases and in all cases in the T.B. minus group.

(6) The elimination of the non-tuberculous diseases should be the first consider- ation when dealing with this group, not only to prevent erroneous diagnosis and notification, but to ensure that these cases receive correct treatment, since many of them are as equally incapacitating as pulmonary tuberculosis.

REFERENCES Davies (I937) Tubercle, xvin, 48I.