View report page

135
Report of the County Medical Officer—Education.
In the vast majority of cases, however, the examination showed shadows cast by enlargement of glands
at the roots of the lungs, or in the mediastinum. These glands may be primarily tubercular, or the
enlargement may be due to lesions in the lungs so small that they escape detection during life.
In the latter class of case definite shadows were found localised to the roots of the lungs, some
of these were globular in shape, others extended along the larger bronchi from the enlarged glands,
some were extremely dense and therefore probably calcareous. These shadows are found so
frequently in this class of child that it might be argued that they are physiological and not pathological.
A number of healthy children who have been sent to the hospital for hernia or accident, in
some of whom the Von Pirquet reaction had been tried and was found to be negative, do not show the
shadows described, but merely the normal linear shadows due to the larger bronchi.
The following are notes on 29 cases investigated in children aged 5-14 years.
The Von Pirquet reaction could not be tested owing to these children being seen at
ordinary school inspections.
All the children were thin and of poor nutrition and in ill-health.
One child had a tubercular knee.
One had an old tubercular hip.
Cough was a symptom in most of the cases and was marked in 11 cases. It was worse
at night, and if of long standing, was more marked in the winter.
In one case the signs were occasionally present.
In one case they were definite.
The glands of the neck had been removed in 30 cases.
The glands of the neck were palpable in 2 „
Night sweats in 2 „
Family history of tuberculosis in 12 „
X-ray results.
Shadows at root of both lungs :
Right and left equally 14 cases.
Right more than left 3 ,,
Left more than right 6 „
At root of right lung only 3 ,,
At root of left lung only 3 „
It seems certain that the X-ray appearances above described are produced by disease, in the
region of the bronchial glands. It is reasonable to suppose that the shadows are due to tubercular
lesions, for two reasons. First, shadows were constantly present in the children, who gave a positive
reaction to Von Pirquet's test. In these children the general symptoms mentioned earlier were
present, and some of them had signs in the lungs. Secondly, no shadows were found in children
who reacted negatively to the same test, and in whom there were no symptoms or physical signs of
tuberculosis.
It is extremely difficult to diagnose the exact condition present in any given case ; indeed,
the shadows may be caused by any one or more of the following conditions :—
(1) Enlargement of the bronchial glands—with or without calcification.
(2) Fibrous thickening around the glands.
(3) Healed tuberculous foci in that part of the lung near the glands.
(4) Active tuberculosis in the same situation as (3).
The differences in the shadows are doubtless due to the varying conditions, which may be
present. One cannot at present, say positively from the appearance on the screen what stage of
the disease is indicated.
Dr. A. C. Jordan, writing in the "British Medical Journal," 31st August, 1912, p. 484, maintains
that in the vast majority of cases pulmonary tuberculosis commences at the roots of the lungs, and
spreads to the apices along the bronchi. He supports his conclusion by comparing results of examination
of the lungs after death with the X-ray shadows produced. This view has given rise to a good
deal of discussion and there does not seem enough evidence to support it. On the other hand,
however, the enlarged glands may be secondary to lesions in the lungs.
Whichever view is adopted, it is evident that the recognition of these X-ray appearances as
pathological and not physiological is of the utmost importance : if the shadows are found, when there
are no physical signs in the lungs, the case is in an early stage, when treatment may reasonably be
expected to be more beneficial than if left till the disease is further advanced and has caused such
pulmonary involvement as to be recognised by physical signs in the chest.
The diagnosis of early pulmonary tuberculosis in children is always difficult: physical signs are
frequently absent; sputum is difficult to obtain. The X-rays are of assistance, but it is difficult to say
whether the lung or only the glands are affected, and whether the presence of a shadow indicates
tuberculosis of one or both. These children, if left in their homes with poor food and worse accommodation
will almost certainly develop pulmonary tuberculosis. The ideal treatment for these children
is a prolonged stay—at least a year—at a residential open air school, where they could sleep out. In
addition to ordinary school work, the elder ones should do a certain amount of supervised physical
work, and play games such as cricket and football, the temperature being always taken after exercise,