Primary Tuberculosis in Childhood
Authors: W F GAISFORD
Journal: New England Journal of Medicine (1954)

The problem of tuberculosis in infancy and childhood? especially in infancy?is still far from being solved. The British Paediatric Association published a report (1943) on  The Early Diagnosis of Intrathoracic Tuberculosis in Childhood, and this report gave rise to considerable criticism on the part of the various tuberculosis organizations. Arising out of this a joint meeting of the Tuberculosis Association and the British Paediatric Association was held, and, in spite of the friendly spirit evident, it was clear that each party viewed the problem . in an entirely different light. The Tuberculosis Association members quoted figures from their official returns, both of morbidity and of mortality, which were totally at variance with the clinical experience of the paediatricians, and in the main their conclusion was that  childhood tuberculosis is not of great importance to the public health services, and their plea was for the paediatricians to preserve a sense of propor tion! Now, there must be some explanation for this divergence of views about both the incidence and the importance of the condition. Are paediatricians wrong in stressing the matter as they do? Are they making too much fuss about something of less importance to the community than adult phthisis? I do not think so. Anyone working among children, and particu larly in children's hospitals, and seeing the scores of infants dying of tuberculous meningitis must realize the gravity of the situation, considering that the majority of such infants die within three months of their initial infection and that every year thousands of infants and children are infected by phthisi cal adults. Although the majority pass through their primary infection and are none the worse for it, and although only a very small proportion progress to tuberculous meningitis, yet * there is much pain and illness due to bone, joint, and kidney disease following a primary infection, as th? records of any children's hospital will show. It is interesting that the American public health administra tors take a view similar to that of our tuberculosis authorities. Plunkett (1939) estimates that it costs 40 times as much to find a case of childhood tuberculosis as it does an adult case, and he therefore recommends investigating only children from known tuberculous households?which is what obtains gener ally in this country. Nelson (1942) says, further: One must recognize the necessity of being selective in the expenditure of the efforts of public health agencies and the need for directing activities into the channels which will be productive of the greatest good to the general population. Why is there this divergence of views? I think the tuber culosis officers do not get a fair view of the picture as paedia tricians see it. Many cases are missed : many more are never seen by the tuberculosis officer ; they are sent direct into hospital or to the out-patient department, and there their notification is either intentionally or inadvertently overlooked. Few convalescent homes will admit cases of tuberculosis even though they are certified as non-infective, as most of them are, and prolonged convalescence is an integral part of their treat ment and it is unwise for them to go to sanatoria, where there is a risk of their coming into further contact with open tuber culosis. Furthermore, from a practical point of view, it would be impossible for tuberculosis officers, under existing condi tions, to deal with all the cases, even if there were adequate accommodation. Diagnosis Primary tuberculosis is important because it is the com monest manifestation, because it is often difficult to diagnose, because it most easily leads to the tracing of the adult infector, and because when adequately treated it gives excellent results. As is well known, it is usually intrathoracic and due to direct droplet infection or, in the case of crawling infants, to infected dried dust from the floors or carpets of a house where a phthisical adult lives. The ordinary symptoms of adult tuberculosis?cough, fever, night sweats, loss of weight, sputum and haemoptysis?are not common symptoms in primary tuberculosis in infants or children.