The main objects of this investigation were grouped under two headings;
A. Points of practical importance to the
Tuberculosis Dispensary worker, and
B. Objects concerning the Aetiology of
It should be remembered that the statements
which follow apply only to persons up to 22 years of ago.
a. POINTS OF .PRACTICAL IMPORTANCE TO THE DISPENSARY WORKER.
It was desired to obtain some information on the value of the von
Pirquet reaction; to trace the course of disease, especially the
more benign types, in those children found to be suffering from
tuberculosis, and to evaluate the effect of treatment afforded by
such a scheme as that to which the writer is attached; finally, to
obtain some information on the life histories, subsequent to
examination, of those who, at the time of examination, are written
off the register as "Non-tuberculous", particularly to ascertain
the incidence of tuberculosis, subsequent to examination, among
contacts, with a view to deciding if periodical re- examination of
all known contacts would be a profitable procedure.
VON PIRQUET REACTIONS: Both the frequency and significance of
positive reactions vary with age. They are commoner in contacts
than in non-contacts but rather less frequently associated with
disease in the former than in the latter.
At least 75% of those suffering from tuberculosis
will give a positive reaction. It is fair to regard the prognosis
as bad in those with clinical evidence of tuberculosis but who
give a negative reaction.
During the first four years of life a positive reaction is a
strong indication of the presence of active disease. From four to
seven positive reactions become commoner but less significant.
At about the seventh year there is a sudden fall in frequency,
but both frequency and significance rise again slowly as puberty
approaches, the results becoming more significant at a slightly
earlier age in girls than in boys. About the fifteenth year, some
50. of those giving positive reactions show evidence of disease.
INCIDENCE OF TUBERCULOSIS: Tuberculosis occurs more commonly in
contacts than in the general population. If that portion of the
latter which attends a tuberculosis dispensary be taken as an
indication, it is commoner in females than in males. The
adolescent type occurs at an earlier age in females than in
males. The more benign typos of tuberculosis, such as disease of
the hilum, of the mediastinal and cervical glands appear to be
commoner in non -contacts than in contacts.
The prognosis for those diagnosed as suffering from disease
of the hilum and mediastinal glands appears good, but of course
the possibility of error in diagnosis in these cases is probably
greater than in any other type of lesion. In cases of disease of
the cervical glands the outlook is much less favourable.
The best results are obtained by institutional treatment.
Those who attend the dispensary do better than those who do not.
RE-EXAMINATION OF CONTACTS: Approximately 10% of those contacts
who were written off the register as non-tuberculous subsequently
developed tuberculosis (some of the others have not yet reached
adolescence; including an estimated figure for these the percentage
reaches 14). The average interval elapsing was 5 years. This is
ample justification for the re- examination of all known contacts.
b. OBJECTS CONCERNING THE AETIOLOGY OF TUBERCULOSIS:
On page 3 are recorded some of the problems in the aetiology of
tuberculosis on which it was hoped some light might be shed. These
problems included such items as,
•The relation between re-infection and immunity.
•The normal duration of allergy.
•The effect of re- infection
during a period of (a) allergy (b) anergy, etc;
•The effect of puberty on these states and the consequence
of infection when they are so modified.
It would indeed be rash to suggest that conclusive explanations
of such problems can be made from the little information which
has been obtained but the writer thinks that, on the evidence
collected, the following comments are justifiable.
Speaking graphically, the line of frequency of hypersensitiveness takes the form of a wave with a period which increases as
age advances. Its maximum height is reached about the sixth year
after which it falls suddenly. It is unlikely that children are
less in contact with sources of infection during the seventh and
eighth years than during the fifth and sixth and the writer
suggests that about this age a period of anergy begins to succeed
the period of allergy which followed previous infection.
Towards puberty hypersensitiveness again begins to become a
more common phenomenon. It is interesting to note that the more
benign types of disease tend to occur in the middle period of
childhood, that is about the period of suggested energy; while
more serious varieties occur in the early years and again towards
puberty, that is,to again make a graphic reference, on the rising
segment of the allergic wave.
Infection during the first four years is a serious matter.
After the 4th year, infection seems to produce some degree of
immunity, which, however, breaks down towards puberty. There is
some suggestion that the immunity produced by repeated infection
lasts somewhat longer than that obtained by casual infection.
There is also some suggestion that those who are not infected
during the first half of childhood are more likely to.infection
with production of evident disease during the later years than
those who have been previously infected.