In this Practitioner article by Dr. Brian Thompson of the Clare Hall Sanatorium there are some useful and interesting observations. The normal bronchial tract secretes, it appears, an average of 10 oz. in twenty-four hours. This secretion, raised by ciliary action, runs insensibly into the oesophagus, mixed with saliva. It is too easy to see, therefore, how in sufferers from pulmonary tuberculosis–apart from deliberate suppression (whether for aesthetic reason or from sheer laziness) of expectoration–infected material may get into the stomach, and tubercle bacilli may appear in large numbers in the faeces.
At Clare Hall Sanatorium no patient is regarded as “negative” until gastric lavage has proved him such. Out of 114 patients with pulmonary tuberculosis, who either had no sputum or whose sputum, after repeated examination both by direct smear and after incubation, was “negative”, 35 per cent were found to be “positive” after examination of the gastric contents. This is clearly, from the public health point of view, a matter of utmost importance.
Drenching night sweats are according to Thompson, quite uncommon among consumptives. [They are probably found almost exclusively in very advanced “hectic” cases.] Young children get heavy night sweats from a number of (often trivial) causes. They sweat more readily than adults when at rest.
A warning is directed against being deceived by the appearance of health in the tuberculous. “Progressive, destructive tuberculosis may be accompanied by good nutrition and physical well-being, and even by normal temperature and pulse rate, after rest in bed has brought control of the actual “toxaemia.” [Apropos of “normal temperature”, the thermometer should be used in these cases three times a day, including a 3 to 4 p.m. recording– a precaution not always observed in general practice.].
As regards blood examination, blood-sedimentation rate may be increased, and this usually significant; and the polynuclears may be increased.
The subcutaneous test for tuberculosis, it is good to learn, has been generally dropped. In the digesters view it is distinctly dangerous as likely to light up quiescent focus, as appeared in a case quoted in a former batch of “digests”. It is also now known, Thompson says, that sensitivity to tuberculin bears no definite relation to present disease. Patients in the last stages of lung infection often entirely lose their sensitivity to tuberculin.
A note of warning is sounded on physical examination as a means of determining activity in an established lesion. Crepitations heard over such a lesion used to be considered proof of exudate in the alveoli; but it is realised now that thickened pleura or compensatory emphysema around the lesion may account for the abnormal sounds. Moreover, fine rales may actually arise not in the lung-alveoli but in the bronchi.
Mitral infection is clearly not as rare as has been thought. The radiological studies of Opie and McPhedran (1932) has shown significant tuberculosis in the consorts of the phthisical to the extent of 46.6 per cent of husbands and 35.5 wives.
“Almost equally fallacious”, says Thompson, “is the so- called law of Marfan, which states that ” tuberculous lymphadenitis in the neck tends to protect from subsequent pulmonary tuberculosis,” Wallgren (1922) in a follow-up of 78 cases operated on for tuberculous cervical glands, found 13 who had developed pulmonary tuberculosis. [Yes, but they had been operated on. Suppose they had not been operated on ? ].
The freely expressed view that the fatality rates of patients discharged from sanatoriums now are no better than those of thirty years ago should be qualified by the strong probability that formerly many of the patients were really suffering from bronchiectasis, unresolved pneumonia, nasal sinusitis, or bronchitis. And there is no doubt of the value of artificial pneumothorax in enrolling “the growing army of patients living and well, many of them usefully employed, all of them sputum- negative and harmless to their fellows”.
