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Tuberculosis in childhood: its ˦tiology and prognosis as shown by the stomach lavage method of obtaining tubercle bacilli
J a n u a r y , 1931]
TUBERCULOSIS IN C]~IILDHOOD
Ahsfracts. TUBERCULOSIS IN CHILDHOOD. SOURDILLON, EDITH. Sur los premieres manifestations eliniques ou radiologiques de la tuberculose pulmonaire ehez l'enfant. Th~se de Paris, 1932, :No. 314. This thesis contains the histories of 110 cases of pulmonary tuberculosis in children, aged from 40 days to 14 years seen in the tuberculosis dispensary and er6che of the H6pital Beaujon, :Paris. The writer's conclusions are as follows : :pulmonary tuberculosis appears to be very frequent in the child, if one is not content with a clinical examination, but makes a systematic radiologicM study of the patient as well. The source of infection can usually be discovered. The incubation period in six cases in which it could be discovered ranged from five to eight weeks. The clinical symptoms were well marked in one-fifth of the cases, abortive in one-fifth and latent in two-thirds. In one-fifth of the cases there-were no clinical signs and the lesion was discovered by radiological examination only. I n half the cases the general signs were very marked, con~sisting in high or continued fever, loss of ilesh and malnutrition, and in a quarter of the cases functional signs, such as persistent or paroxsymal cough, were present. In two-thirds of the cases, whether general or functional, signs were present or not, no stethoscopic signs were detected. The splenopneumouie form of disease which was frequent in infants and the rule in older children showed a natural tendency to recovery, whereas the bronchopneumonic form which was also frequent iu tim infant, showed a pro. gressive tendency to a fatal issue. Treatment mainly consisted in rest, good food, light and fresh air. FRIED~IAN, A., ESSERMAN, A. L., and BLACK, 5I. tI. Tubercle Bacilli in the Sputum of Children Free from l~Ianifcst, Pulmonary Tuberculosis. Journal o~ l*cdiatrics, 1933, % 283. I n the present study gastric washings were carried out on 60 children in residence at" the Children's Division of Che bl~tional Jewish Hospital, Denver, the ages ranging from 4 to 15 years. :Fifty-
1G5
one of these children were admitted as preventorium patients and nine for tuberculosis of joints, no child in the series revealing clinical or radiographic evidence of pulmonary infiltration. :Forty-four in the group were tuberculin reactors, and only 17 presented definite X-ray evidence of the childhood type of infection. Of these 60 children only two boys aged 8 and 9 years respectively showed tubercle bacilli in their sputum. Each of these two gave a Ilistory of contact with the tuberculous, was a reactor to tuberculin, had only doubtful X-ray evidence of nodular type of infectioni and was free from cough, expectoration, fever and tendency to colds. The tubercle bacilli could not be detected by examination of a pharyngeal smear obtained after forced coughing, nor even by direct examination of the homogenised sediment of t h e gastric washings. They were found only upon guinea-pig inoculation of the homogenised sediment. The inoculations were repeated four months later, with the same result of causing tuberculosis in the injectec] animals. The authors on the basis of this study point out that the guinea-pig inoculation of gastric sediment evidently constitutes the most reliable method of detecting the tubercle bacillus in the case of young children. They suggest also that it is desirable in the event of an initial negative result to repeat tim inoculation two or three times. The discovery of tubercle bacilli in the sputum of tuberculin-positive children who betrayed no clinical or radiological evidence of tuberculosis of the lungs is significant, and suggests the justifiability of assuming that ~ small percentage of children in every group of positive reactors has tubercle bacilli in the sputum, notwithstanding the absence of cough and other symptoms or signs of active pulmonary tuberculosis. COLLIS, W. R. F., and BROCKINGTON, C.F. 'tuberculosis in Childhood: its ..zEtiology and Prognosis as shown by the Stomach Lavago Method of obtaining Tubercle 13aeilli. Lancet, 1933, i, 127. The stomach lawtge method of detecting tubercle bacilli in sputum has been extensively used since it was first
166
TUBERCLE
described by Meunier in 189~o. I~ is now evident that children in the late secondary state (generalised lung or miliary tuberculosis) more often than net have tubercle bacilli in their sputum, and, on the whole, the younger the child with generalised tuberculosis the easier it is to find tubercle bacilli in the sputum. There is evidence to show that the early secondary state is also, though in a less degree, accompanied by tubercle bacilli in the sputum, e.g., Armaud-Delille showed that 60 per cent. of 500 children with only radiographical lung shadows to suggest the possibility o[ tuberculosis had tubercle bacilli in the sputum. The present report consists el an analysis of the resulbs of stomach lavage in 70 children and infants under the age of 11 years, these cases being divided into five main groups: (1) Seventeen children showing paratuberculous lesions, such as erythema nodosum, phlyctenular coniunetivitis and pleurisy, together with X-ray signs of focal lung reactions or enlarged hilus shadows. Five of the 17 yielded tubercle bacilli as shown by guinea-pig inoculation, the animals being killed after six weeks. (9.) Seventeen contact cases--eifildren who had recently been exposed to infection from relations with open phthisis, and who gave positive tuberculin reactions but no o~her evidenceof tuberculosis. One of these children was positive, namely, the sister of a child with erythema nodosum who herself had had a positive stomach lavage. (3) :Eleven miscellaneous cases suspected of tuberculosis in the wards of a hospital by the physicians in charge. Three of these, a child with an intra-eranial tumour, a child wi~h asthma, and a child with abdominal tuberculosis, were positive. (4) Seven cases of generalised tuberculosis, three of whom were positive. (5) Eighteen control cases, most of whom were negative to tuberculin. All these gave negative results. Of tile 12 positive cases the oldest child was 10 years and the youngest 3 months. Two case reports are given to 9illustrate various importantpoints, tile f i r s t showing the importance of the recognition of erytbema nodosum and other paratubereulous conditions as
[ J a n u a r y , 1934
clinical evidence of primary tuberculosis, and the need in such circumstances of search for the source of infection ; and the second case illustrating the value in diagnosis of tim lavage method in doubtful cases of tuberculosis in childhood.. 9 Tim results of this investigation together with those of other workers, 9prove the existence of tubercle bacilli in the sputum of certain children, although the percentage frequency With which such positive sputa occur in the primary and early secondary sta/~es carlnot as yet be accurately gauged. All but one of the children in this study with early lesions from whom tubercle bacilli were obtained revealed their condition by the coincident occurrence of erythema nodosu,n or phlyctenular conjunctivitis. The question of prognosis in children who are shown by this method to have open hmg lesions has no~ yet been completely settled. Tim prognosis in children in the early secondary state where tubercle bacilli were not found in the sputum by t h e ordinary method, but only by tlie lavage method, was no worse than in these in whom the bacilli could not be demonstrated at all. I n from 6 to 14 months after the first positive stomach lavage none of the children has shown general symptoms of the disease, and in a follow-up of some 24 cases of .paratuberculosis (erythema nodosum and phlyc~enular conjunctivitis) occurring during the last four years at the Hospital lor Sick Children, only three were found to have developed any frank tuberculous lesion. :Fuller investigation will also be needed to obtain a clear idea of the prognosis of children with primary tuberculosis with positive sputum, but it appears likely to be good, provided suitable environment, food, fresh air and rest are secured. An appendix to this paper describes the technique of the stomach lavage, the writers emphasising its definitetJess, its delicacy, and its reliability. GOLDI3LOOM, A. Tuberculosis in Children. Canadian Medical Association Journal, 1933, 28, '2.86 Tuberculosis in very young infants is usually a rapidly fatal disease, however
TUBERCULOSIS IN C]~IILDHOOD
Ahsfracts. TUBERCULOSIS IN CHILDHOOD. SOURDILLON, EDITH. Sur los premieres manifestations eliniques ou radiologiques de la tuberculose pulmonaire ehez l'enfant. Th~se de Paris, 1932, :No. 314. This thesis contains the histories of 110 cases of pulmonary tuberculosis in children, aged from 40 days to 14 years seen in the tuberculosis dispensary and er6che of the H6pital Beaujon, :Paris. The writer's conclusions are as follows : :pulmonary tuberculosis appears to be very frequent in the child, if one is not content with a clinical examination, but makes a systematic radiologicM study of the patient as well. The source of infection can usually be discovered. The incubation period in six cases in which it could be discovered ranged from five to eight weeks. The clinical symptoms were well marked in one-fifth of the cases, abortive in one-fifth and latent in two-thirds. In one-fifth of the cases there-were no clinical signs and the lesion was discovered by radiological examination only. I n half the cases the general signs were very marked, con~sisting in high or continued fever, loss of ilesh and malnutrition, and in a quarter of the cases functional signs, such as persistent or paroxsymal cough, were present. In two-thirds of the cases, whether general or functional, signs were present or not, no stethoscopic signs were detected. The splenopneumouie form of disease which was frequent in infants and the rule in older children showed a natural tendency to recovery, whereas the bronchopneumonic form which was also frequent iu tim infant, showed a pro. gressive tendency to a fatal issue. Treatment mainly consisted in rest, good food, light and fresh air. FRIED~IAN, A., ESSERMAN, A. L., and BLACK, 5I. tI. Tubercle Bacilli in the Sputum of Children Free from l~Ianifcst, Pulmonary Tuberculosis. Journal o~ l*cdiatrics, 1933, % 283. I n the present study gastric washings were carried out on 60 children in residence at" the Children's Division of Che bl~tional Jewish Hospital, Denver, the ages ranging from 4 to 15 years. :Fifty-
1G5
one of these children were admitted as preventorium patients and nine for tuberculosis of joints, no child in the series revealing clinical or radiographic evidence of pulmonary infiltration. :Forty-four in the group were tuberculin reactors, and only 17 presented definite X-ray evidence of the childhood type of infection. Of these 60 children only two boys aged 8 and 9 years respectively showed tubercle bacilli in their sputum. Each of these two gave a Ilistory of contact with the tuberculous, was a reactor to tuberculin, had only doubtful X-ray evidence of nodular type of infectioni and was free from cough, expectoration, fever and tendency to colds. The tubercle bacilli could not be detected by examination of a pharyngeal smear obtained after forced coughing, nor even by direct examination of the homogenised sediment of t h e gastric washings. They were found only upon guinea-pig inoculation of the homogenised sediment. The inoculations were repeated four months later, with the same result of causing tuberculosis in the injectec] animals. The authors on the basis of this study point out that the guinea-pig inoculation of gastric sediment evidently constitutes the most reliable method of detecting the tubercle bacillus in the case of young children. They suggest also that it is desirable in the event of an initial negative result to repeat tim inoculation two or three times. The discovery of tubercle bacilli in the sputum of tuberculin-positive children who betrayed no clinical or radiological evidence of tuberculosis of the lungs is significant, and suggests the justifiability of assuming that ~ small percentage of children in every group of positive reactors has tubercle bacilli in the sputum, notwithstanding the absence of cough and other symptoms or signs of active pulmonary tuberculosis. COLLIS, W. R. F., and BROCKINGTON, C.F. 'tuberculosis in Childhood: its ..zEtiology and Prognosis as shown by the Stomach Lavago Method of obtaining Tubercle 13aeilli. Lancet, 1933, i, 127. The stomach lawtge method of detecting tubercle bacilli in sputum has been extensively used since it was first
166
TUBERCLE
described by Meunier in 189~o. I~ is now evident that children in the late secondary state (generalised lung or miliary tuberculosis) more often than net have tubercle bacilli in their sputum, and, on the whole, the younger the child with generalised tuberculosis the easier it is to find tubercle bacilli in the sputum. There is evidence to show that the early secondary state is also, though in a less degree, accompanied by tubercle bacilli in the sputum, e.g., Armaud-Delille showed that 60 per cent. of 500 children with only radiographical lung shadows to suggest the possibility o[ tuberculosis had tubercle bacilli in the sputum. The present report consists el an analysis of the resulbs of stomach lavage in 70 children and infants under the age of 11 years, these cases being divided into five main groups: (1) Seventeen children showing paratuberculous lesions, such as erythema nodosum, phlyctenular coniunetivitis and pleurisy, together with X-ray signs of focal lung reactions or enlarged hilus shadows. Five of the 17 yielded tubercle bacilli as shown by guinea-pig inoculation, the animals being killed after six weeks. (9.) Seventeen contact cases--eifildren who had recently been exposed to infection from relations with open phthisis, and who gave positive tuberculin reactions but no o~her evidenceof tuberculosis. One of these children was positive, namely, the sister of a child with erythema nodosum who herself had had a positive stomach lavage. (3) :Eleven miscellaneous cases suspected of tuberculosis in the wards of a hospital by the physicians in charge. Three of these, a child with an intra-eranial tumour, a child wi~h asthma, and a child with abdominal tuberculosis, were positive. (4) Seven cases of generalised tuberculosis, three of whom were positive. (5) Eighteen control cases, most of whom were negative to tuberculin. All these gave negative results. Of tile 12 positive cases the oldest child was 10 years and the youngest 3 months. Two case reports are given to 9illustrate various importantpoints, tile f i r s t showing the importance of the recognition of erytbema nodosum and other paratubereulous conditions as
[ J a n u a r y , 1934
clinical evidence of primary tuberculosis, and the need in such circumstances of search for the source of infection ; and the second case illustrating the value in diagnosis of tim lavage method in doubtful cases of tuberculosis in childhood.. 9 Tim results of this investigation together with those of other workers, 9prove the existence of tubercle bacilli in the sputum of certain children, although the percentage frequency With which such positive sputa occur in the primary and early secondary sta/~es carlnot as yet be accurately gauged. All but one of the children in this study with early lesions from whom tubercle bacilli were obtained revealed their condition by the coincident occurrence of erythema nodosu,n or phlyctenular conjunctivitis. The question of prognosis in children who are shown by this method to have open hmg lesions has no~ yet been completely settled. Tim prognosis in children in the early secondary state where tubercle bacilli were not found in the sputum by t h e ordinary method, but only by tlie lavage method, was no worse than in these in whom the bacilli could not be demonstrated at all. I n from 6 to 14 months after the first positive stomach lavage none of the children has shown general symptoms of the disease, and in a follow-up of some 24 cases of .paratuberculosis (erythema nodosum and phlyc~enular conjunctivitis) occurring during the last four years at the Hospital lor Sick Children, only three were found to have developed any frank tuberculous lesion. :Fuller investigation will also be needed to obtain a clear idea of the prognosis of children with primary tuberculosis with positive sputum, but it appears likely to be good, provided suitable environment, food, fresh air and rest are secured. An appendix to this paper describes the technique of the stomach lavage, the writers emphasising its definitetJess, its delicacy, and its reliability. GOLDI3LOOM, A. Tuberculosis in Children. Canadian Medical Association Journal, 1933, 28, '2.86 Tuberculosis in very young infants is usually a rapidly fatal disease, however