TB - PH - PREY MED 2 
MANUAL FOR DIAGNOSIS AND OF PTTJ^ON'HT 
T * r 
TUBERCULOSIS 
PUBLIC HEALTH AND 'WELFARE TECHNICAL BULLETIN 
PH&W GHQ, SOAP APO 500 
JANUARY 1947 
1, Foreword 
The purpose of this manual is to present certain facts 
concerning the diagnosis and treatment of tuberculosis. These 
facts are to be presented as simply as possible. They will also be 
translated into Japanese so that they will be available also to the 
Japanese physician. The Military C-overnment* medical officers will 
have a similar copy in English, In this way, both groups will have 
the same material, rrith it, they con coordinate their work for the 
control of tuberculosis in Japan, It is necessary that a brief re- 
view of the epidemiblogy, etiology and particularly, pathology of' 
tuberculosis be made. Behind any diagnosis or plan for treatment, 
there must be the basic knowledge of these important phases of this 
disease, 
2, Introduction 
SOAP has'recognized the seriousness of the tuberculosis 
situation in Janan. The number of cases is increasing in Japan due 
to the exigencies of war and its.effect upon the economy and the 
health of the people, Yhile accurate statistics for the past three 
years are not available, it is known that both the mortality and 
morbidity have definitely increased in that'time, and that there arc- 
many more detive' clscs of ■'tubdrcalbbio than,orn reported throughout 
the country. 
Undpr the direction of PH M ”r, SCIP, a definite set of 
policies have been established. These have been planned in five 
steps. They are already activated at the present time. 
First, in an effort to encourage the'return to the 
hospitals of oatients with active tuberculosis, a survey of the 
nutritional status of hospital patients has been made. Sources of 
■ food have been found and arrangements for financial aid for medical 
care of these patients while in the hospital have boon established. 
The Ministry of Public Health and T'rclf are. is fesoonsible for the 
procurement of this food and money. By these means the active sourcv 
of infection is removed from the.'-.hone and the patients are offered 
the opportunity to find time'to permit the arrest of their infection 
and recovery of their health. It has been found that marked variation in diagnostic 
methods and treatment of tuberculosis exists in Japan, In on effort 
to coordinate those factors, this manual was produced. It will be 
recommended to the Japanese physician,* This is the second step in 
the program which is already activated. 
Together with the two previously discussed steps, the 
third measure of continued ease finding.and individual control nos 
been maintained in the health centers, Associated with this part 
of the program is the establishing of the school lunches which was 
begun in December 1946, This is a corrective and supplemental feed- 
ing and has an educational value in proper dietetics and nutrition. 
The mass examination of school children by means of X-ray and the 
Montcau test is already in progress and is being widely encouraged. 
It is under the supervision-of the Ministry of Health and Welfare. 
It is through these efforts, based upon case finding, that the posi- 
tive eases arc followed into the home and instruction in methods of 
control is given there. Through the press, through discussion with 
various medical and lay groups, information has been and will be 
given emphasizing the control of tuberculosis in the home and the 
value of hospital care for all active cases. 
This same program, begun with the children of Japan, will 
be expanded as a fifth step to include various groups of workers 
throughout the country, 
3-r Epidemiology 
Before the onset of vrorld -'Tnr II, Japan and Finland had a 
death rate in tuberculosis of 200 per 100,000 per year. This figur 
was four times the rate found in Denmark, the Netherlands, iustrail 
New Zealand and the United States of America: (less than 50 per 100, 
000),England and Wales, Italy, and Sweden had between 50 
and 100 per-100,000, The Philippines, ‘Duerto Pico and Chile had ovc 
250 per 100,000 per year. There has been n decline in the United 
S'tates from 202 per 100,000 in 1900 to less than 40 per 100,000 in 
1946, Due to the marked shift in population throughout la nan, end 
the loss of records of vital statistics due to the exigencies of war 
later figures for Japan have been unavailable. Thus, recent vital 
statistics for Japan arc not to be quoted. However, it is known 
that the number of deaths from tuberculosis reported have definitely 
increased up to 1943 in both the first'two vears of life and in the 
adolescent period. An estimate of 200,000 deaths from tuberculosis 
in this present year in Japan is a startling: figure. 
Therefore, it is necessary to review the predisposing 
factors which play a role in the development of tuberculosis aid of 
such a death rate. The scientific minds of Japan face many problem0 
as n result of its rapid national growth. The lost important of 
these is to combat the fatalistic viewpoint'and superstition coneon 
ing tuberculosis, and to create a realistic, hopeful approach to it. 
control,. Other nations'have clone it, and Japan can also do itthrough 
education of its people. 
2 Tuberculosis is not —is not—a hereditary disease nor is 
there any inherent tendency to this infection. It, is purely a 
communicable disease,' It is definitely transmitted from one 
individual to another. It is true that certain factors do pre- 
dispose to its occurrence, Tsey are social-and economic, and not 
hereditary factors. The state of nutrition, the presence of 
fatigue, and the occurrence of other acute infections, which break 
down the defenses of the body and permit invasion by the tubercular 
infection all clay supportive roles. Various other factors such as 
over crowding in poor housing and the resultant lack of fresh air 
and sun light all have a part in its development, Ang ignorance 
of simple rules which prevent its transmission is the greatest 
offender of all, "rith these conditions in mind, it is not difficult 
to understand the marked rise in the number of deaths from tuber- 
culosis in the first three years of life. It is in these years in 
which the seed of tuberculosis is sown. It lies dormant through- 
out childhood only to sprout up again in the adolescent period. It 
produces the'second peak of morbidity and mortality records of 
this disease. One might almost say tuberculosis is a disease of 
childhood which produces its effect in adolescence or young adult- 
hood, 
4. Etiology 
Tuberculosis in caused by the mycobacterium tuberculosis, of 
which there are four'types; the human, bovine, gallinaceous and 
reptilian. Of these, the first two types are the most common in- 
vaders, and in Japan it is the human type in the majority of cases, 
5• Pathology 
The major route of'invasion is by inhalation. There are other 
lines such as ingestion, through wounds', through the faucial 
tonsils and by transplancental transmission. The infected breath, 
cough or sputum of the'tuberculous mother or members of the family 
is a continual menance. The common cup'and the common chop stick 
are excellent transmitters of infection, At no time in life is 
the individual exposed as in infancy. The infant itself has a 
greater susceptibility to tuberculosis duo to the constant’exposure, 
It has a lesser immunity with which to combat the invasion. Since 
the infection plays so important a. role in' childhood, it’is at 
this level that the approach to its control must be made; The 
pathology of the infection must be thoroughly understood, because 
all plans for treatment arc based solidly on that knowledge. The 
portal of entry is through the epithelial surfaces. The bacilli 
pass through the epithelium. Some of the bacilli remain at the 
port of entry and there establish the primary focus which is, a 
small area of bronchopneumonia, Others of the bacilli are picked 
up by the wandering cells. In them, the bacilli arc carried along 
in the lymph stream to the lymph nodes which drain the particular 
area involved,. The lymph nodal invasion together with the primary 
focus compose the primary complex. The histological picture of 
the tuberculous invasion- occurs in the following patterns: First, ' 
there is a reaction of the tissues to the presence of the organisms. 
This produces an accumulation of the polymorphonuclear oells at the 
site of the Invasion. Thev surround the organisms as a first line 
of defense, As a second line, oertrin epithelioid cells surround 
the tubercle bacilli to form concentric whorls. These crer te the 
typical tubercle formation, These tubercles nay 'be individual ■ or 
develop in’no does, A third line of defense is laid down ns the 
lymphocytic cells and gient calls surround the tubercle, /ifter 
the tubercle is’ferried, a degenerative stage develops, The oente 
of the tubercles becomes softened (casested) and liquifies. This 
liquified notorial is absorbed into the lymph strean. Deposition 
of calcium occurs within the mass of the tubercle. Just before 
oolcification•occurs is the tine of the greatest clinical danger. 
•it this stage, three processes may occur; one, the lesions ag*7 be 
progressive and spread beyond the original point of invasion; 
second, due to progression, with caseation and liquifaction of the 
area, an erosion into a bronchus nay develop; and third, the org- 
anisms may be carried by erosion through the wall of a blood 
Vessel into the blood strean. The lymph nodes nay caseate and 
liquify with resultant ulceration. The tuberculous material may 
be split into the bronchial tree with a further invasion of other 
pulmonary areas, A fourth and more remote danger may occur before 
calcification is established. It is the general infection which 
is the result of hematogenous and or brochogenic spread. Is a re- 
sult of these processes, generalized or military tuberculosis 
develops, Is the bacilli are swept in the blood stream through- 
out the entire system, multiple tubercle formation occurs in any or 
all tissues. It is. always a complication of active primary tuber- 
culosis and hence is more frequent in infancy. Ill organs'of the 
body are invaded, as well as cm7 serous membrane, However, in the 
primary infection, the lesions mo*7 be arrested at the level of the' 
trocheo-bronchial lymph nodes. Hotrogressive processes take place, 
with the deposition of calcium or fibrous residues which remain 
permanent. This arrest is dependent upon several factors such as 
resistance of the tissues and the degree of acquired immuhity, 
In adolescence and early adult life, reactivation of 
quiescent lesions occurs. These arc the result of the pathology 
which is established at the time of the primary infection. Old 
apical lesions flare up to form a progressive ulcerative stage, or 
previously quiescent lymph nodes break down. The pathological 
changes in the gland results in ulceration and liberation of more 
tubercle bacilli into .the blood stream or brinchii. Consequent 
further infections develop in now areas. The disease progresses 
by repeating, over and over, the same process which occurs in the 
primary lesion; that is, egt.cns.ion of the lesion from the new site- 
of infection-by progression, then as a result of central caseation,’ 
liquifaction, ulceration, to-bronchogenic or hematogenous extension. 
Lesions may be of varying ages and stages’ of progression as a 
result of succeeding ulcerations into hematogenous and bronchial 
fields. The extent of the general systemic response with the 
appearance of toxic symptoms is dependent; upon the number of 
tubercle bacilli which are thrown in the circulation at one’time, 
together with the extent of liquifaction which has occurred. 
At adolescence or in adult life, a completely new in- 
fection may occur due to the inhalation - of tubcfdo’ bacilli after 
the primary infection is completely arrested and the above mentioned 
chain of pathologic procedures occurs. The infection v.'hioh develops in adolescences is on exuda- 
tive process in contrast to the proliferative one which is topical 
of the primary infection. In adolescence, the infection tends to 
localise itself, to form! cavities, and not to further invade the 
glands, 
'Repair is node in the adolescent and adult stages by 
fibrosis, in contrast to calcification in the primary‘infection. The 
lesions are usually apical in location in the older age group of 
oases while the infection of the crinar-T lesions in infancy are 
connonly in the lower lobes. 
It will be noted that the sane nrocess occurs both at the 
point of invasion through the epithelial surfaces and within the 
lynph glands. The tendency of the lesions in the urinary complex 
is to heal. It is of paramount importance to beep this in mind in 
all pulmonary lesions in children. 
As the tubercle forms, or as a lymph gland enlarges, it 
may obstruct a bronchus,' This produces an atelectasis distal to the 
point of the obstruction, A plug of .mucus nay cause the development 
of the sane condition, "rith the colic use of a portion of the lung 
distal to the obstruction,’shifting of the mediastinal contents nay 
occur. 
Cavities in the parenchyma iay develop in a primary lesion; 
or if a tuberculous pneumonia is arcsent in an atelectatic area,'a 
cavity may be formed as a result of the caseation and absorption, 
6, Diagnosis 
The-approseh to any diagnosis, and oartiou1ar1y, thot of 
tuberculosis, still rests firmly upon the recognized basis of.- 
thorough history taking, complete physical examination,* adequate 
laboratory studies and Roentgenograma correctly interpreted and 
associated with the history and clinical findings. It is important 
to emphasize, that the laboratory'findings and T-ray reports are to 
bo considered merely os supportive evidence of the two paramount 
basic steps; a good history and a complete physical examination. 
It is always advisable to maintain.a regular oroccdurc in 
developing the history in order to miss no important saint. 
. . a. Got the chief complaint (C,C.)«~ It is often a 
vagud one but an effort should bo: made to’ discover that one which 
causes the patient the greatest annovance. Remember, a patient does 
not know that the various symptoms'are related to each other. The 
symptoms of which he complains at the time, of the visit arc the most 
outstanding in his mind, ’Trou must romember that his first symptoms 
may have-been forgotten. It is the examiner’s tack to arrange these 
statements in their correct order. 
5 (1) Tuberculosis should be considered os a possible 
cause in:- 
, ✓ 
(a) Any potieht with vogue symptoms, weight loss* 
malaise, easy fatigue, persistent cough. 
(b) In any patient, especially a young one, with 
recurrent attacks of grippe. 
(c) In any patient with a typical or unresolved 
pneumonia* 
(d) In any patient with cough and expectoration 
lasting over six weeks, 
(c) In any patient who spits blood, 
(f) In any patient with pleurisy, especially with 
effusion. 
(g) In any patient with unexplained fever. 
(h) In any patient with mild or obscure lesions 
such as; 
lm Persistent lymph adenopathy 
2, Fistula in ano 
3_. Chronic laryngitis and hoarseness. 
There is another .approach to the diagnosis of 
tuberculosis, 
(2) Tuberculosis case-finding in apparently healthy 
pe 3ple. 
There is 
(a) Routine X-ray examihation of chest, 
(b) With or without previous tuberculin test, 
(c) Positive X-ray findings require as follows: 
_1, Complete history 
2; Complete P, E. 
_3. Complete tuberculosis laboratory study, 
'(b) Get the history of the present illness (G.P.I.) 
r—ember, of what does the Patient complain? This is the basis 
for the history of symptoms. Remember that the patient does not 
know the pathology of tuberculosis; you do. You know the point 
of primary focus and the routes of invasion along which the in- 
fection precedes, ■ It is task to establish that point of 
primary focus if possible, and from there move into the history. 
Since 9-5% of tuberculosis is usually found in the respiratory 
system--and if the chief complaint leads into that cystem--ono 
6 begins the history with those questions which involve that Sj jem, 
Discovery of the dote of onset of symptoms of tuberculosis is 
difficult because it is so atypical; but ask the question, "When 
did this stgiptom, the chief complaint, first appear?" Then make 
a thorough inquiry as to the presence or absence of the foilowing 
points: 
(1) Fatigue and lassitude. 
They begin at what time of day? Does the patient 
awake rested and restored to energy? 
(2) Is there noted any loss of staying power? 
(3) He there been any loss of weight or is the weight 
at a standstill? What was the last weight and when was the patient 
weighed? 
(4) Does any rise in temperature occur? And at what 
time of day does it develop? 
(5) H s the patient noted any nights sweats? 
*(6) Is there any chilliness? 
i 
(7) Docs the patient complain of any chest pain or 
"pleurisy”? 
(8) Is there any coudh? Or even any clearing of the 
throat early in the morning? When does the cough occur? Docs 
exertion increase the extent of the coughing9 rThat is its duration? 
(9) Is there any sputum? What are its characteristics? 
or mucoid? Color? Increased amount at any time of day? 
Quantity in twenty-four hours9 
(10) Has there been any hemorrhage or even any slight 
streaking of the sputum with blood9 At what time of day docs it 
occur? What is the color and quantity of blood lost9 
(11) Is there any dyspnoea on exertion? 
(12) Is there any wheezing respirations or stridulous 
breathing? 
(13) Has any hoarseness of aphonia developed? 
(14) Has the patientfs family noted any pallor?- 
(15) Is there any cardio-vasicular instability? 
(16) Has the patient noted any episodes of illness, re- 
peated in character, like grippe? 
Since sputum may be coughed up and swallowed, it follows 
that the G.I, system would become readily involved. Therefore, q review of the symptomatology .of thet system would be the next 
lino of inquiry'with particular omphasis upon the following, points; 
(1?) Is there any capriciousness or loss of appetite? 
(IB) Is there any no uses or vomiting, especially follow- 
ing severe coughing in the morning? 
(19) Are there any colicy pains throughout the abdomen? 
(20) Has there been any alteration in bowel function? 
Has there been any diarrhea alternating with constipation? 
Recalling the close association between the respiratory 
and cardio-vascular systems, the following questions should be 
asked: 
(21) H"s there been noted any cyanosis of the lips 
or nails? 
(22) Has there been any variability in the pulse rate? 
Then since the spread of. tuberculosis is also by the 
lymphbhcmatogenous route, review the symptoms of the genito-urinary 
tract. 
(23) Is there any localized pain, tenderness or enlarge- 
ment in the lumbar regions? 
(24) Is there an?/ frequence of urination? 
(25) la taero any pa inf ul urinct ion9 
(26) How long have these svmatoms continued to.be . 
present9 
And upon the same basis, inquiry into any symptoms in- 
volving the nervous system should be investigated—even though 
nervous and psychic reactions are usually absent-asking inquiry 
concerning: 
(27) Headache 
(2B) Change in diso os i t ion 
(29) Increased irritability, 
c. Past medical history (P,H,H,)« Since the foundation of 
(f "• a m o tuberculosis is I" id in ohiIdhood, pa r tic ula r da re should 
be taken in acquiring the past medical history (P.H.H.) •, T ■' Ping 
any chock up program as in a mass 0° so-finding campaign where there., 
may be no history of any present illness, it is vitally .important 
that the past medical history bo thoroughly dome, H member, the 
death rate is high from-tuberculosis in the first two years of 
life, and that in Japan, contact with the infection in the home is in time, to and constant. Inquire definitely concerning any and all 
of the following conditions which have an effect unon activating 
any quiescent lesions and list then in chronological order., 
(1) Any bronchopneumonia in the first two years or a 
prolonged enteritis9 
(2) Diphtheria9 vras the child immunized against it? 
T'rhcn9 vhict dosages? And how many? 
(3) Snailpox? Was there any vaccination? 
(4) Measles? 
(5) Pertussis? Any immunizations9 
(6) Scarlet fever? 
(7) Diarrheal diseases9 T'Tas there any immunizations? 
(B) Ohio Irene ox? 
(9) Typhoid or Paratyphoid fever? 
.(.10) Grippe or influenza9 
(11) Pleurisy? 
(12) Special inquiry should be made in Japan concerning 
the use of B.C.G, The date of the injection and the dose given 
should be accurately determined, 
d, Men s t r ua1 hist orv. If the patient is a soman; inquiry 
should be mode as to the age of onset of menstruation, its regular- 
ity, its flow as to amount, color, freedom from clotting; the 
presence of pain and its time of occurrence in relation to the 
menstrual cycle, T'rith a married woman, the history of her Pregnan- 
cies and particularly if miscarriages have occurred is of vital 
importance. It is f esc women that so often have r. pulmonary 
hemorrhage and reinfection following a delivery. And. if she is an 
older woman, the age and character of her menopause, 
c. The fa.mi 1 v history (P,II.) , The family history (P.H,) is of 
great importance since family life in -Japan is so intense. Patients 
arc in very intimate contact with tuberculosis* in their own homes,' 
It must be recalled that the family ma■7 not, or may not be willing, 
to recognize the presence of tuberculosis in its midst. They may 
not know of it even if recognized by a physician. Ho may have 
diagnosed it as*pleurisy to avoid offending the sensitivities and 
losing his ease, or to assist in their intimate family affairs; 
such as the marriage of a daughter. Inquiry should be made concern- 
ing the tuberculous symptoms among members of the family, particular- 
ly concerning the loss of infants in the first two years of life. 
It is worth recalling that children under five years usually contract tuberculosis within the hone, over five years, outside of it. 
Moke inquiry concerning- other'chronic discuses- in thyo. familyFor . 
oxin tipi e, diabotcr me Hit us so Often predis coses ..to v. c-tivr tion of, 
a quiesepnt tuberculous lesion, 
At this point in the history inquire about conditions in 
their home or at their work, their node of life, their social 
status and their dietetic regime in this present period of national 
recovery. 
Any mixture of racial strains would be interesting from 
the standpoint of racial susceptibility to the disease. Any 
familial conditions which'may be oresent would bo included here, 
remembering that in Japan, tuberculosis is considered by. many 
people as a hereditary condition. 
It will be remembered that in the outline of a history 
as cited above, emphasis is laid throughout upon tuberculosis, 
while other equally important points leading to other diagnoses 
have not been stressed. However, it is not to be overlooked that 
other conditions may be of great hnortnnco since they arc factors 
which reduce the patient’s resistance and increase his susceptibility 
to tuberculosis. 
Acting upon the suggestion of several of*the younger 
medical officers of the Military Government teams, the following 
disoussion of tho symptoms wns dcva 1 oa:d ~nd so arrangod that the 
numerical headings of both the questions in the history and dis- 
cussion of those points wore the sane, 
f, Keep in mind Primarily the pathology and the various steps 
in its development. Study the order of appearance of the symptoms 
and associate then with the pathology, 
(l)-(2) Fatigue, lassitude, loss of staying power may bo 
the first symptom a patient notes. At first it is observed late 
in the afternoon, but gradually moves earlier‘and earlier in the 
day. Increasing the rest hours fails to help. These arc the most 
common symptoms of toxemia. 
(3) height loss is gradual. None is noted at'first and 
some patients say they have gained a little early in the illness. 
It may he rapid in the acute fibrile stage. Fat is lost first, 
then muscle and finally atrophy of. the skin occurs, 
(4) Temperature, Its presence indicates a toxemia, it 
may not appear until a few months have passed, ■ It may be subnormal 
or normal ip the morning, but reaches its high point between 1600 
and 2000, Its onset -is insidious and dependent upon the extent of 
the pathology causing toxemia. There may bo a, wide swing if the 
patient develops an acute tuberculosis pneumonia, or in advanced 
eases, there may be morning rise instead of an afternoon one, 
(5) Night sweats arc not an early symptom. They .arc a 
constitutional one. They occur often .only when the temperature is 
elevated or there is much exhaustion. Drenching prostrating sweats arc present with marked cavitation and supnerative prac-csscs. . 
(6) There is usually no chilliness except when there is 
an acute onset ns in pulmonarTr tuberculosis pneumonia. This 
absence of chilliness is a diagnostic point of value from a 
pneumonia, 
(7) Chest pain, spoken of as pleurisy, and it is oo, 
because it is an indication of an’inflamed pleurat so often it is 
the first symptom of tuberculosis'. It also occurs as an early 
symptom in acute oulmonary tuberculosis pneumonia. There may bo a 
sense of constriction of the chest rather than pain with each 
respiration. It varies markedly in character from slight to severe 
pain, from dull to stabbing, from acute to recurrent, and it is in- 
creased by respiratory effort. The pleurisy is usually close to the 
site of the lesion which is a diagnostic point. However, it nay 
be referred to the shoulder or to the belly if it should be diaphra- 
gmatic in location. The acute pain does not persist but a sensitive- 
ness nay continue to bo annoying. If the condition becomes chronic, 
a constant ache or soreness may continue in the side, aggravated hy 
damp weather or fatigue and noted for many :rcars after the lesion 
has bee one quiescent, 
(8) The cough is the most common local symptom. However, 
it may not be a prominent symptom early in the process and docs 
not appear until ulceration of'the lesion into the 
bronchi has occurred. However, it ip more prominent in the early 
morning on awakening. It may be merely clearing of the throat. If 
the lesion should lie close to the pleura, a cough may .appear which 
is completely unproductive due to reflex action. As ulceration 
develops, the cough becomes more and more productive and may be 
very annoying in the later stages, even interfering with eating and 
sleeping, A change occurs in its character with involvement of the 
larynx. It becomes painful and annoying and the sound assumes a 
stridulous character. 
(9) A study of scutum helps in determination of the 
activity of the lesion. Early in the disease there may be but a 
little shiny mucus. Later, as progression occurs, the quantity and 
the frequency of expectoration increases, but may vary from time to 
time. There may be a few patches of muco-pus in the morning. Any 
abrupt'onset indicates an ulceration into a bronchus of a pulmonary 
lesion. There may be a decrease by occlusion of a bronchus followed 
by a sudden release of a large quantity of sputum. The quantity 
may bo 30 cc with an increase up to 90 cc. Advanced eases may have 
up to 350 cc daily. The sputum in'the acute oulmonary pneumonia is 
purulent, greenish yellow in colon. It'is sticky, tenacious, and 
on standing docs not separate in Hamever, as the condition 
improves the greenish color disappears and the consistency becomes 
much more like mucus, 
(10) Hemorrhage, It is not an early sign,. It is due to 
an ulcerated lenion into a bronchus or to weakening by ulceration 
of the walls of blood vessels in the wall of a cavity or even re- 
lease of pressure upon the superficial vessel walls. About 50$ of oraacs sjiow., signs of hemorrhage, Many patients note a sense of 
congestion in thc; chest or'complain of a bubbling sensation in 
the side effected before the hemorrhage occurs* The quantity is 
usually snail though it dcoonds on the size of the vessel which 
is ruptured. Copious bleeding is not rare and nay amount to 60- 
360 pc, It may bo merely a. pinkness, a streaking or snot ting of 
the morning scutum which is the’most common tine of its oocarrenoc 
though it may occur at any time. Massive fatal hemorrhages, 
however, are r~re, It nay be -associated with the occurrence of 
the menstrual- cycle, The hemorrhage results in a pneumonitis of 
varying intensity and duration. It may be regressive or pro- 
gressive, the latter associated with reinfection and so over- 
whelming' thet death nay occur. Not'only nay it rupture into a 
bronchus, but into a pleural cavity, thus masking the extent of 
the "hemorrhage, ■ 
(11) As to the occurrence of Dyspnoea, it is not an 
early symptom. There may be some slight increase of respiratory 
rate as a manifestation of toxemia in a febrile stage, it .also 
indicates a rapid accumulation of fluid in a aleurisy, 
(12) wheezing and stridulous breathing "re symptoms 
which late, usually when cavitation has occurred, or due 
to changes in the size and shape of the bronchi as’the result of 
cicatricial contractions, secondary to ulcerations, 
(13) Hoarseness always develops late as a rule because 
the laryngeal involvement is usually secondary to infections 
occurring primarily lower down in the respiratory tree.. If it is 
a persistent symptom, it indicates involvement of the ,larynx it- 
self and is associated with the complaints of dryness and tickling 
(14) The family or the or.tieot himself nay that lie 
seems quite pale. It is a condition which occurs late in the 
disease. So often it is associated with intestinal tuberculosis 
or amyloidosis. 
(15) A tachycardia is noted in the midst of the disease. 
Earlier the rate is regular hut ■"■ftor exercise, it fails to re- 
turn ns quickly to a normal level. The tension of the vessel is 
poor and the oulsc is often associated with a low systolic figure 
in blood orassure, The poor vascular tone loads to clamminess 
and coldness of hands and.feet, bluish nails and lips, 
(16) There is one t ypo of on so t of tub0 re ulosi s w hich 
resembles grippe. There is mild muscle ache,together with other 
sy;rotOms of this condition. The attack may last several weeks 
but tends to be recurrent. This may lord to -n« error in diagnosis, 
(17) G-astr0-intcstina 1 symptoms arc usually vrguc. 
Variability of the'apoetito is a constitutional 
symptom. It indicates n toxemia. Vomiting is unusual but may 
occur after or during eating should the patient strain while 
coughing. Since the mirulent material coughed up from the lungs 
12 is tnrnllrwotly n mild inflammation of the gostrie nacous membrane 
nay develop. 
(18) A severe coughing paroxysm, especially in the 
no ruing an y c ousc v oni t ing, 
(19) When oolicy pe ins are late s yap tons, they arc 
associated with alternating diarrhea and constipation. Ulcerations 
in the bowel is strongly suggested, 
(20) Ulceration in the bowel develops late. It is usually 
in the lower portion of the ilouru It is indicated by alteration 
in bowo1 func tion, 
(21) Cyanosis of lips and nails varies in its appearance 
depending upon the type of onset. T -y are an indication of any 
acute congestion through the lung fields. It will be noted in an 
a cute oulai one r y tuberculosis, 
(22) The pulse rate nay remain elevated r,ftcr the temper- 
ature has reached normal. It is an indication of the presence of 
activity, 
(23) Renen.bering the pathology--that other organs arc in- 
vaded by hematogenous rOuto--it is necessary to inquire concerning 
gonito urinary symptoms, ' They may be-the first indication of any 
tuberculosis re-infection. Therefore, pain, tenderness and swelling 
in the lumbar space should lead one to consider tuberculosis as a 
possible diagnosis, 
(24) The frequency of urination indicates, of course, an 
irritation of the bladder which is secondary to infection higher 
in the genito-urinary system, 
(25) The same holds true for painful urination.' 
(26) The above symptoms arc prolonged in tuberculosis 
beyond the usual tine of recovery of a simple cystitis, 
(27) Prol ong c d hea d a c he na y be a g a in the f i r s t in die a t i on 
of a hematogenous spread indicating a beginning meningitis, while 
it is a complication usually appearing in childhood, it can and. does 
develop in the adolescence and adult period. Toxic' psychosis are 
unusual, 
(28) (29) The same holds true concerning these noints as 
of headache, 
while mcnorrhea la unusual, it docs develop in tuberculosis, 
may bo delayed in a girl with tuberculosis and is often 
scanty and irregular in older women, VThilc a tuberculous woman can 
• become pregnant, fertility is somewhat impaired, and abortion docs 
occur spontaneously in the more advanced stages. No alteration is 
libido Op potentia colundi if found in the earlier or middle stages 
of the' disease. gf in. this manual if is hardly more them necessary to list 
the differential diagnoses. 
1; . Bronchopneumonia 
2, Lung Abscess 
3, Bronchiectasis 
4, Cancer of Lung 
5* Emphyzoma and Pulnonary Fibrosis 
■ ' 6, Mycoses 
7* Pulmonary Lesions secondary to cardiac disease 
8. Suppuration in structures contiguous with the ■ 
. .lungs, 
7. Phy sic a 1 E xa :ii n t t i on 
a, It is well'to re.ao.ubcr that physical signs arc'those 
which the examiner finds. They do hot belong in the history. A 
planned procedure is (absolutely necessary to avoid'missing any signs 
of tuberculosis in structures other than the lungs. 
The obvious points of a -physical examination' hardly 
need to be discussed; however, there arc many points in conducting 
an examination which help much to coupletc the picture. 
An old adage to remember is ,rStop* LookJ Liston1,?T 
Stop, to record, the f in dings while doing the examine tion. 
Look, at the patient, end see at what you are looking. 
Listen, to the-sounds you hear in the patient (and what ho 
says) . 
b. Good light, a quiet room, and a Comfortable patient arc 
paramount for a good physical examination. Physical examinations 
arc being done in Jr.pan'without any attempt to obtain any of these 
necessary prerequisites. It is nee necessary to uncover the patient 
completely, but it is necessary to arrange f o clot that every 
portion of the is uncovered at some one time during the examina- 
tion. Observation in clinics, hospitals and health centers in Japan 
has made it * necessary to emphasize these points. In the examination 
of children, always leave any annoying or painful procedures to the 
last, 
(1) Start at the top of the head and proceed downward. While' 
the lung fields arc of primary interest in most tubercular patients, 
there nay be indications of its spread into ever’7 portion of the 
head and neck. Leek for eye changes, variations in mucus membra nos’ 
of nose, mouth and throat; variations in the skin texture -ind color. 
Observe the voice for changes. Inquire concerning any deafness. 
Learn to use a tongue depressor properly, . Signing is unnecessary. 
Put the depressor at the-base of tonsil on the lateral aspect of the 
tongue and push the tongue obliquely forward. Cheek the-’ lymphatic 
glands of the neck in both anterior and posterior groups,’ 
14 (2) The familiar four steps of procedure of a ohysical 
examination of the lung fields will be observed. These,'you recoil, 
"’are:-Inspection, Palpation, -Percussion, end 1 us col tot ion. Do not 
denend on ne.nory; write down your findings at once, 
♦ 
Do the posterior aspect of the chest 'first. It avoids 
the' i-mediate embarrassment which a patient feels, and more import-' 
ant, one docs not fail to examine the posterior aspect of the chest. 
If they don’t turn their backs, you don’t examine a chest. T* " use 
of a diagram of the thorax helps immehscly, ”A picture is worth 
a thousand words” so say the Japanese. If there is nO printed form, 
the following suggestions are helpful, (See addenda). 
Chest exa minat i on - 
•Place the patient if he is ambulatory with his back to 
the light, or if a bed patient, the foot of the bed toward the light, 
and note the following points:- 
(a) Inspect ion - 
1. The alignment of the spine, 
2, The alignment of the shoulders, 
3* The movement of the scapulae. Do they move in.unison 
or is there a lag upon one side with deep inspiration? 
4. Are the int e rspaces cqua1 b i1a t orally9 
r • 
5* Arc there any retractions of the interspaces? 
(b) Palpation - 
Place the thumbs together with the fingers spread over 
the thorax, at the 10th thoracic vertebra. Have the patient take 
a deep breath and check the basal movements for equality of expan- 
sion. 
Tactile Fremitus, M"ny examiners exert too much 
pressure. Use merely the tics of the fingers or the lateral'aspect 
of the hand and keep the touch extremely light. Don’t press,touch, 
(c) Percussion - 
Use a skin pencil or marker. Keep the percussion light. 
The hand is not a hammer. Strike the blow with one finger, ferk 
in a quiet room so that the sound of percussion is the outstanding 
sound. Compare both sides as percussion is done. Remember one can 
feel a difference in tension of the underlying tissues. At both 
bases, percuss in the 9th interspace rs the diaphragm’moves downward 
with deep inspiration to check diaphragmatic movement. d. ■ Auscolta tion - 
..Have a quiet roo'i, and listenl Conduct the-auscoltation 
in a regular fashion preceding from above downward, and compare 
both sides, observing vocal resonance, whispering pectoriloquy 
and breath sounds. It is advisable to -ahe notes as one finishes 
each chase of the examination. 
(3) Then, turn the patient to. face the examiner. Do the 
cardiac ‘ examination first, and xa he the necessary records. The 
same principles of inspection, palpation, percussion and a us- 
coltation should be followed in regular order. Again carry out 
the some technique of examination of the lung fields anteriorly 
as had been followed posteriorly. And again no Ice notes of each 
stage of the procedure. Follow the same orocedtires while doing 
a cardiac examination. 
(4) The abdominal examination. The patient should lie down 
on a covered table. If the examiner’s hands are. warn (and clean), 
muscle spasm is less likely to interfere with deep palpation. The 
patient can be taught to drop the jaw and breathe through the 
mouth with very shallow respirations, thus avoid abdominal splint- 
ing, There is no difference in which quadrant'the examination is 
begun so long as a regular routine is observed. Recall the pa th- 
ology of abdominal tuberculosis 'with resultant peritonitis in 
its various types and stages, Re me iber the patient complains of 
pain; you find tenderness. 
(5) Then check the genitalia and ana 1-regions, A painful 
hemorrhoid nay be on early fistula in ano, or a painful testes an 
e a r ly t ubc r c ul ous e p i d i dymi t is , 
(6) Any change in the reflexes, sensitivity of skin or cornea; 
any paralysis or any other neuroilogical sym/oton may indicate an 
c a rly t ub o re ul os i s m en i ng i t i s , 
(7) Recalling that by hematogenous spreads r-nj portion of the 
osseous system may be also involved, a slight blow on the ton of 
the head with the patient in a sitting position jars the seine. 
This may localize a point of pain within the vertebral column. 
There may be tbndorness or palpation, or pressure over the skeleton 
or there may bo a .change in posture or gait, 
(a) The discovery of an apical lesion usually' occurs 
in adults, but it may occur in the age group from 7 to 14 years. 
Cavitation nay occur early .even in the primary lesion or if caseous 
material is carried by bronchogenic spread, it may develop in the - 
early years as well as in the adolescent or adult period. Plan for diagram of the thorax. 
Draw a bracket. 
This represents the clavicles. 
Drew a perpendicular line 
from the center of the bracket 
to represent the sternum. 
R-‘member the 1st ribs join 
the clavicle and sternum to 
draw the half circles. 
Remember the next $ ribs 
all meet the sternum, so 
continue downward. 
The nipple lies in the 
4th interspace in 
mid clavicular lino. 
Posteriorly, the diagram is 
drawn as follows: Draw 
a perpendicular line. 
Draw two curved lines to 
represent the thoracic wall. 
Ten ribs extend from spine line 
to the thoracic wall line. 
The upper inner angle of the 
scapula is in the 3nd inter- 
space in the mid thoracic line, 
(a) The lower angle of the 
scapula in the 8th interspace, 
(b) The acromuim process of the 
scapula is'distal to the 2nd inter- 
space. ( G ) , Plan for diagram. 
By filling lii the interspaces with various densities, the 
extent at du3Inesh or' percussion can be indicated.,. • ' 
Pleural rub is indicated,fcy7 
. * o 
'. t' 
Crepitant Rales by , 
-• ’ 
C oa r s e Rale S' by -t ‘ y J 
t Laboratory Studies 
The sedimentation rate of the rod blood cells is increased as 
long as there' i-s a progression of the tuberculosis lesion associat- 
ed with fever, regardless of the phase of the disease. There also 
occurs an increased sedimentation rote in pregnancy after the thirf. 
to fourth month, in cancer corresponding with the degree of mal- 
ignancy, and in localized infections which show an increase in 
leukocytic count. 
In the early stages of tuberculosis, there is no cha'ngc in the 
blood picture; but as the later stages develop, a hypochromic 
anemia appears. In a tuberculous pneumonia, a Icuooytosis up to 
15,000 develops with on increase in the polymorphonuclear and mon- 
onuclear cells.with-a decrease in the lymphocytes, but in the 
usual tuberculous infection, the total count will alter but little. 
It shows an increase in the lymphocytic’and monocytic cells with 
decrease of the polymorphonuclear cells, 
a, Sputum 
The finding of tubercle bacilli establishes s positive 
diagnosis,' These appear in the'scutum alone- or intermixed with 
hemorrhage, in the spinal fluid, in the discharges from eroded 
lymph'nodes or osscus sinuses, in the pleural fluid, or in the 
urine. It is difficult to obtain a • satisfactory specimen of scutum 
unless the patient' is.'adequately trained. The sputum must bo 
actually coughed up from the trachea when the bronchial tree is 
first cleared in the' morning. In chjldr.cn and infants, gastric 
washing must be ‘'done before gastric peristalsis has begun, early 
in the morning, 
b, The Tuberculin React ion 
A study was done at the Bcllvuc Hospital in New York'City 
covering; a period of five years (from 1930 to 1936) on 11,000 
children. Their ages included the period from birth to 12 years. 
This study showed a steady increase in the rate of positive tuber- 
culin reactions with each increasing year of age. 
The tuberculin reaction is based upon an allergic rcsconsc of the tissues to the- presence of the tubercle baoilli. .The Monteaux' 
■which is on intro cut cncous test, is prof erred in the United, States, 
is the one which is commonly done in. Jr nan, .Old tuberculin is 
•rused. In the first test, 0,1 cc of 1 to 10,000 or 1 to 1,000 
dilution is used, and 0,1 of a l.to 100 dilution in the second 
test. The reaction is read in hours, A nositive reaction is 
•.an elevated, reddened, indurated area, at least 0,5 on in diameter, 
or there hoy be several nanulos a noear at the citv of the inject- 
ion, A pseudo reaction a noears as a reddened area rathout 
elevation. There is also a generalized systemic reaction. About 
anj existing tuberculous lesion, a localized reaction na r occur 
and the activity of that lesion nay be increased'by the tuberculin 
reaction. One nay have false positive, reactions, which arc most 
marked in the first 24 hours, due to too largo doses of tuberculin. 
A positive tost indicates that an individual has been in- 
fected with tuberculosis and is sensitive to its proteins. It 
docs not indicate the presence or .the extent of an activity. 
A negative reaction indicates a possibility that there h>s 
been no tuberculous' infection. However, the reaction nay be nega- 
tive because; first, it .nay bo too early in the ncriod of invasion; 
second, in the terminal stages of the disease; third, if there is 
a parked dehydration or severe wasting or severe febrile stage; 
four, the existence of a tuberculous lesion which is thoroughly 
calcified and healed; five, the dose of tuberculin being too snail, 
9 There arc other la bora t'Ory studies of interest but not of 
d ia gn ost i o imp o rta nc e, 
t9♦ Roentgenoara chip Diagnosis 
The greatest value of roentgen ogre, phi c studies lies in the 
ability to observe the progress of t-c pulmonary lesions. To re- 
view the roentgenograms of oulnonary lesions in the various age- 
groups, the-appearance of the urinary lesion shall be briefly con- 
sidered first. Recalling the pathological changes as formerly 
described, one must romember that the primary lesion is usually 
small; less than 3 rum. in diameter and nay be too small to show, 
upon the R-ray film, or it may not be calcified at all. The 
primary lesion lies usually in the periphery of the lower lobes 
though it nay develop anywhere in the lung fields; ITcwcvcr, there 
may be an extensive involvement of much of a lobe, and the density 
upon the film may vary. vrhcn this lesion is healed, the R-rny 
findings may show merely bands of fibrous tissue through the lung 
field and calcified area, the C-hon’s tubercle. It must also be re- 
called that the pathology indicates a surerd from the uri iar7 Ics- 
?ion to the traciio-bronchial lymph nodes. It may require lateral 
or’oblique ■films to show t'esc nodes which have boo one enlarged, 
* If the urinary lesion is not do ions treble, duo to its small 
size or lack of calcification ■the hilar nodes may slow no calcification. The primary lesion may be demonstrable, but the 
lesion be too early for calcification in.the lymph nodes'to occur; 
But if the Ghon * s tubercle, the calcified primary lesion, is scon, 
calcification in the lymph nodes is usually found also. This is 
the primary complex of the disease. 
Should a lesion be seen in the parenchyma of the lungs and no 
involvement'of the lymph nodes bo found, the lesion is orobably 
tuberculous. A positive tuberculin reaction increases the possib- 
ility of the lesion being tuberculous, 
'The primary lesion may produce a wide-spread reaction in a 
lung, but no calcification in the lynch nodes may be seen, A 
bronchus nay be obstructed by a tubercle or by an enlarged lymph 
node. An atelectasis distal to the point of obstruction may re- 
sult and other thoracic structures may be seen to be displaced. 
Yet, the hilar nodes may or may not show any calcification. The 
density of an atelectasis is the sane throughout the involved area. 
With a miliary tuberculosis, with or without a demonstrable 
primary lesion, the hilar nodes show no calcification because the 
condition develops too swiftly. With a osseous bronchopneumonia, 
the nodes show calcification since the orogress of the lesion is 
developed'more slowly. The disposition of this lesion'is over a 
wide area, often involving the entire area of the lung. 
The contour of calcified, lesions arc more irregular. Because 
of the irregular deposition of the calcium in them, they vary in 
their densit'7, Goocidiosdosis and his topi—smoris also cause cal- 
cification in the lung fields. 
As to enlargement of the ly. iph glands, Hodgkin’s Disease or 
lymphoblastoma may be the cause. If the tuberculin reaction is 
also positive, a biopsy is required to clear the dip miosis . 
The great advantage of roentgen studies is that serial studies 
of the lung fields'in pulmonary tuberculosis can be conducted over 
a period of months. If there is but little change in the appear- 
ance, tuberculosis * is apt to be the cause. In low grade broncho- 
pneumonia, however, a serial study will show definite change from 
time to time. 
It is worth noting that laboratory findings are combined with 
the roentgenogrophic studies in arriving at a diagnosis. 
10 Treatment 
The treatment of tuberculosis requires the "long look' oherd:T, 
It is not the immediate condition which is clone i •up Or tent, but it 
is the potcntirl dangers which must not be forgotten. Planning 
for that treatment is based upon a thorough knowledge of the under- 
lying pathology. The ■ patient * s physical condition is of nri/iary 
imp or t a nee, but “ the social, c c on o: li c a nd p c r s one 1 ph'~ sos nus t a is o 
be kept in mind. a, After a case study is complete, the first question which 
arises is nDoos the- patient require treatment?” There is a group 
of these patients who do not, T'*cso arc the patients in whose St- 
ray studies, calcification of the primary complex :s seen, but they 
have had no signs of activity for years. There is a second group 
whose X-ray studies show old fibrotic changes at the aoiccs but 
who are perfectly well. There is a third group whose-X-ray finding 
show the soars in tie lung fields of former infections, T?ith extra 
pulmonary lesions as well; but both areas are completely healed. 
However, the ooinion of complete healing must be a guarded one, 
since the center of the calcified \ass may still be composed of 
caseous material in which virulent bacilli may bO’fiund, A yearly 
o he c k-up o f tho s c cases i s a dvi s abio. 
In Japan as well os in the United States, there are two 
groups which may bo considered border—lino groups; (-) those over 
20 and those under 20, (In'the. United States over or under 25 
years). In the first group, the X-ray may show changes from one- 
examination to another. There may be individuals who have a 
slight fever, malaise, easy fatigue or weight loss whoso lesions 
arc apparently calcified. The fibrosis about the lesion may or 
may not have thoroughly encapsulated the infection in this older 
ago -group, ’Thether or not this group requires treatment depends 
upon their laboratory and. X-ray findings, A check once a month 
for several months, gathers evidence upon which to plan their 
treatment, A:g patient should be treated whose X-ray film shows 
lack of calcification (a poorly outlined soft shadow) in its out- 
line because the lesion is unstable and always potentially danger- 
ous , 
In the second group, those under 20 years, the X-ray findings 
alone arc enough to decide upon treatment. These studios should 
be done at two weck intcrva 1s. Any instability* of thc 1osions 
demands bed rest and, in the younger individual, stricter study. 
The oldfer group of patients can bo kept at work and-follow? a daily 
routine. Records should bo kept of the temperature, pulse and 
respiration every fourth hour, and the laboratory work done every 
one to three weeks. Any instability, either progressive or re- 
gressive, means treatment. If it is found in a youth or a young 
adult', it is a'definite indication that study'and treatment should 
be done in bed, even if there arc no symptoms, These require very 
careful laboratory studios for the presence of tubercle bacilli, 
and negative findings do not—do not --mean that treatment is not 
required. The laboratory work is observed in many places through- 
out Tokyo area is not thorough enough to rule out the presence of 
the tubercle bacilli in the sputum. 
There is a group who definitely should be under treatment* 
These Bhow the five important clinical smmptons and signs, - fever, 
malnutrition, fatigue, cough and hemorrhage. These constitute all 
patients of whatever age group with clinical smm.ptoms of activity, 
patients with new lesions, or whose lesions have not -ct been 
stabilized, and patients whose lesions leave been reactivated. This 
classification is based upon that of Dr, J, Burns A bars on. 3m. the treatment of the nriicry lesion, remember msny of 
these patients show no symptoms rt nil in relation t.o the lung 
fields. Hr?over, it is in this eye group that one /mst continually 
recoil the re nidity of spread through the hematogenous route with'" 
the appearance of sy no toms ,and signs in other systems—gastro- 
intestinal, ‘nervous, osseous, rcncl--unrolated directly; to ’them 
lung fields. Do not fail to recall f c most important cause of 
meningitis in the first three years of life is tuberculosis,nor 
that gastro-intcstinal symptoms mry be tuberculous in origin. Heap 
in mind the close family relationship in the young individual in 
the presence of infection. All active or notenticily active eases 
who have a chance to recover should be kept in bed, A delay of a 
week or months in beginning treatment means loss of irrecoverable 
ground. Begin treatment as soon as the lesion is discovered. 
Rather treat a * quiescent lesion until it is proved otherwise than 
lose a patient, Don’t ’"a.it for a cavity and the potential hemorr- 
hage from its walls, Avoid the cavity formation if nossiblc by 
insisting or complete rest. The sane situation exists in "oung 
adolescents who have a reinfection superimposed upon a healed 
primary lesion, or an activation of a primary lesion which was 
previously arrested, Re -ember the ”long loo’", ahead” which the 
pathology demands — the look to see possible* caseation, liquificat- 
ion, erosion, hemorrhage and further spread. 
Tuberculosis is a disease with which a patient must learn to 
live. He .must realize that recovery is a Glow process and that it 
will take time, while it is a difficult t ~sk to explain the heal- 
ing of tuberculosis simply, it can and must be done and the patient* 
must understand it. He must accept the diagnosis and make the 
necessary adjustments in his work and habits of life. He -must 
understand his symptoms and know what* to do‘ whod and as they 
appear. He must realize that dole” of treatment for weeks or months' 
means danger, and the earlier the lesion and younger the patient,* 
the greater is the necessity that treatment bo instituted at once. 
The treat/lent must be pi-"mined a cc or ding to the stage of the tuber- 
culosis and the condition of the mtient, 
When an adult patient has a*chronic tuberculosis, immediate 
treatment may bo often postponed, and the hopeless and elderly 
patients with long standing lesions may have -more delay than a 
young and a c t ivc pa t i c nt, 
b. There is still but one chief principle in the treatment of tuber 
o ul os is and that is rest. And one heist understand why rest is so 
important from r pathological angle• Rest decreases the motion of 
the lungs and aids in healing of the lesion. Rest decreases 
respiratory rate ana. amplitude. Rest decreases the circulatory rate 
and amount of blood passing through the lungs, Rest decreases 
toxemia. Rest reduces the amount of infected air inhaled into 
health lung areas, Rost maintains a good circulatory tone thus 
the danger of hemorrhages through increased permeability of capillaries and friability of vessels, R*st maintains a good 
intestinal tone with adequate absorption. And rest is rest in 
bed, day and night, not one'step'to be permitted] avoiding rest- 
lessness or unnecessary movement; *nd ‘local rest of the thorax 
may be obtained by splinting the‘affected"side eigher by nhysical 
means or surgical intervention,‘ Rest must also be mental as well 
as physical, .1 man or woman can scarcely rest when he must lie in 
bed and worry about his family’s food or lodging. 
The duration of the bed rest is based*on’the X-ray studies 
and bacteriological examination. Its duration is'from two to 
twelve months. To get up too early moans relapse, 
A systematic check-up‘should be established to include the 
following guides: 
(1) A collection of a twenty-four specimen of sputum twice* 
a week to determine the quantity, and check for tubercle bacilli, 
(2) X-ray studies from once a week to once a month for six 
months, 
(3) Leucocyte count and sedimentation rate every second week, 
(A) height is to be taken every second, week unless the pat- 
ient is too ill, 
(5) Temperature, taken rsotally, every second hour, day and 
night until the high ooint is determined; then every fourth hour, 
(6) Pulse record should be made every fourth hour because its 
instability Is'an indication of toxemia long after t: e temperature 
becomes stable, 
'(7) Hec.ord the appearance, general condition, rea-ction ti 
fatigue, eliminative functions and any appearance of the symptoms 
and, signs already discussed. 
Prolongation of the rest period of treatment until the lesion 
is securely walled off within a, fibrotic capsule is definitely 
better than permitting the lesions to progress to the requirement 
of pneumothorax or potential hemorrhage, Activity must be assumed 
very gradually, only after the check-up indicates that, stability 
has been reached. One should begin*with fifteen minutes a day 
out of bed on a chair for two weeks’, and then gradually increasing 
the time and the extent of activity, 
c. The dietetic goal toward witch Japan must work in the feeding 
of her adult tuberculosis patients is a 2000 calorie diet with pro- 
tein of 65 gnu ’ . 
23 Recommended Daily Allowances for Specific Food Nutrients 
for Tuberculosis Patients 
Calories ,'.’2,000 
Protein '65 g. 
Calcium , . , . . . , . , , 0;65 g.’ 
Iron . , . ' '.12.0 mg. 
Vitamin A . .5900C'International Units 
Thiamine .......... i;5 xog. 
Riboflavin .......... 2.2 mg; 
Niacin . , . .' 15.0 mg; 
Ascorbic acid . , 100 to 125 mg. 
while it is at present impossible to supply the Japanese with 
the above diet, one should know what is acceptable for this condi- 
tion. Sun baths and helio therapy are contraindicated in pulmonary 
tuberculosis. However, they have their place in tuberculosis of 
bones and joints and the Rollier sun treatment and air baths can 
be given with excellent healing and tonic effects in this type of 
tuberculosis. 
a. Drugs find their best use in their control symptoms, Uxpect- 
oronts do not help and disturb the appetite and interfere with 
nutrition. It is well known that in Japan, cert: in drugs are con- 
sidered to bo specific in the treatment of tuberculosis but opinions 
of their vhlme varies markedly among the Japanese chysicians. 
Streptomycin is being studied-for its effect in the United States 
as well as Promin and Diazone, which are sulfa comounds, but re- 
ports are incomplete, r 
e. There is always the important question, when is the tubercular 
process arrested? The National Tuberculosis Association in 
America has established the following criteria, ”The process' is 
arrested when, for at least six months, the lesions have remained 
apparently healed, no tubercle bacilli have been demonstrable, and 
the patient has been symptom free under conditions of moderate 
physical activity”. These patients should be checked once a month 
for four months,-then everrr three to six months for two mars, and 
then once a year, and then gradually assume his occupation. This 
regime covers a- period of two years, and if he remains 
for that period, the occurrence of relapse is greatly minimized, 
f, Rost alone may be ineffective in the patient with cavitation. 
Collapse therapy is a distinct aid in these cases. vrith the collapse 
of the lung, the walls" of ~ the ■ 1 hr blight snr.cofita*ctJ"withm 
each pthorj* the respiratory Mvc meat of the lung is limited and the 
rate of flow of the blood and lymph through the infected area is 
decreased. Pleural adhesions may interfere with adequate collapse. 
This therapy is of the greatest advantage in a chest in which there 
is cavitation in one lung with no adhesions and with little or no 
activity on the opens itc side, with hemorrhage from the wall of a 
cavity, collapse therapy will help control it. And even in far 
advanced cases, it can be used to advantrue for the same purpose. 
24 It is necessary here only to mention thet pncumoPGimitoncirm, 
pc re lysis of the henidiaphragm end th ore copies ty hove been, done 
to put the lane; field at rest, 
g, Children and adolescents should be haspita.lizcd because 
they'require close study and control to no into in their rest treat- 
ment, They can receive the proper training in self-care in associa- 
tion with other companions facing the sonic problem. They profit 
by the obi cot lessons about them when patients have failed to 
maintain their rest treatment. They are happier among their own 
age groups and their education can br continued as a group. 
The moderately advanced or e sc s with cavities'should be 
hospitalized bcca use ,Cf the da ng c r of compile a t i on s, 
The far advanced elderly patient could remain at home for his 
own comfort as long as he is not a source of infection to the 
family or too great c. drain upon the family economy, 
n. Climate itself is not nearly as important as it was formerly 
considered to be, ’yith the present crisis in Japan, it is almost 
impossible to transport patients to climates said to be suitable 
for their particular oases, One •lakes the effort to - keep them as 
comfortable as possible in the localit r in •'••hieh they arc living, 
1. The cough usually responds to rest. It may require codieno 
0,015 every four hours to control it ' t • the beginning, and p. rhmps 
even a hypnotic at night. Steam inhalations me of use, and a 
hot drink in the mSrning is helpful, 'Postural drainage mill clear 
the bronchial tree. Patients can be trained to control the, cough 
and to avoid straining, 
j, 'rrith the onset of hemorrhage there should be absolute rest in 
bod, lying upon the affected sice. The hemorrhage decreases over 
a period of several days. Reassurance means much tS the patient 
and codienc decreases the irritation from the cough. 11, Hess Hxaminrtions 
a. In Japan,’entire schools arc pivon mess examinations in 
the health centers. The children ere brought by their teachers, 
they arc arranged in order according to a’list,'stripped to the 
waist, and T-rey films ere taken on 35 mm, film. These films arc . 
developed, road, end any suspicions cases of tuberculosis ere furthe 
studied by doing o. sedimentation rate and c Montesu tost. Should 
the laboratory studies increase the suspicion of tuberculosis, the 
patient is followed in the clinic and in his own home, 
b, Based upon these ease findings, the public health nurses 
from that clinic in which the examination is done, should make ro- 
per: ted home visits, It her first one, she should discuss the con- 
tagiousness of the disease. She must begin to fight the fatalism 
and superstition with which Japan has accented this disease. She 
must insist that every member'of that household report to the 
health center for examination. She should explain that the Govern- 
ment is prepared to carry out these examinations free of charge if 
the family is unable to pa r for them, (It has come to tho attention 
of the Public Health and Haifare Section of SG1P that because of.a 
patient’s inability to pay, those individuals arc ignored or neg- 
lected in the health centers. Their visits are repeatedly post- 
poned and cursorily done. Necessary supervisory action will he 
taken to correct this practice,) The nurse should he able to in- 
struct the family concerning home care of the patient until such- 
time as he can he hospitalized. She must also instruct them on 
how to protect the members from the tuberculous infection during * 
this period of pre-hospitrlization, She must instruct the paticiit 
so that he (or she) realizes that lie is the source of infection, 
H c must bo helped, to see how he can check its sprad in the family. 
He must assume that responsibility. He must realize that the 
greatest sign of affection he can express toward the family is by 
refraining from inti-irtc oontret, Tlic nursc shou 1 d adviso the 
family to follow certain simple rules for .the protection end care 
of its members, 
(1) The patient should be trained to cover his face every 
time ho coughs and sneezes with a paper tissue or cloth, 
(2) Hr. should bo taught to collect all sputum in paper or 
cloth which can bo burned after it is placed in a paper bag. These 
paper bags can be made from newspapers and folded according to the 
diagram at the end of this section. The nurse should know how to 
Told’such a bag. If paper is not available, ti o covered cups can be 
used, "Then a cup becomes filled, the cup and its contents can he 
dropped into a pail containing 5m Lyson solution (25 oc of Imsol to , 
500 cc of water) and soaked for four hours and then washed out with 
warm water and thoroughly rinsed. The Lysol can bo obtained through 
the prefectura1 office. (3) The patient should have his own cup, bowl, plate and 
chop sticks. His food should be served to him in- his individual 
dishes, and under no c ire instances should he oat from the c ornon 
dish with his own chop sticks or drinl from a common cup. The 
patient’s dishes and utensils should, be washed separately from 
those of the fa rally with soap and hot water, 
(4) The patient should ha.vc his own individua 1 cloth.cs , 
towels, toilet articles, tooth brush and toys and sources of 
aauseaont, T‘ me must be kept separate from the family articles, 
H-- should be trained to acquire a nossossivonoss for these articles 
as a .natter of protection for the rest of the family. 
(5) Because the hands ere constantly before the face and 
soiled with saliva, the patient should be trained always to wash 
his hands before catiny and after counting and. sneezing. 
(6) The patient should have his own room if possible. It 
least he should have his own bed and the bod covering should be so 
designed that they can be removed, soaked in 5m Lysol solution and 
washed at least twice a week. They should not be shared with.~ny 
other member of the family, A suspended curtain across a portion 
of the room may give him at least separate space and act as a re- 
minder to the family that special care is required. His room- 
should be sunny if possible. Moist denning of the room should 
always be done so that the dust infected with tubercle bacilli is 
not carried throughout the house, 
(7) Especially mist both patient and the older members of 
the family bo trained to protect infants, children and the adoles- 
cents from intimate contact with the patient, 
< It must bo kept in mind that home treat rent is far from 
i do a1 a nd that h o s pi ta 1i zat ion sho uld b c ina isted on as quic kly a s 
transportation to the hospital can be obtained. Home care is 
merely an emergency measure and should bo considered, so at all 
times. It is through segregation of the tuberculosis patient in 
a hospital adequately equipped to care for the patient lies the 
hope of control of tuberculosis in Japan, PREPARATION OF PAPER CUPS 
Fold oncTTiclf oT*B back 
os in the third diogrna. 
Note that the folded 
edge of the newspaper 
i s t ow a r d t li c r i a; ht, 
Fold ot 2 to y. B over A, 
Note thnt the paper 
is turned so that the 
bock of sort A shores, 
Fold along the dotted 
lines to form C, D and 
E, 
Note thet E is tucked into C, 
Open to torn the cun or bog. 
.■1 scooiio. such, cup ecu be c onstrueted ■ nd used us r, coyer. 
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