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BRONCHIECTASIS IN PULMONARY TUBERCULOSIS
870 traces the transmission of Huntington’s chorea in America for three hundred years from a group of three men and their wives, emigrants from the village of Bures in Suffolk in the year 1630. We may congratulate ourselves on their loss, for though Bures to-day offers no examples of an interesting disease, there can be no doubt that Wilkie, Nichols, and Jeffers and their progeny were undesirable characters, and would nowadays be classified as belonging to the social problem group. New England, more austerely, took most of them for witches. Wilkie and Nichols were brothers, and their family became linked with that of Jeffers by marriage. The pedigree chart compiled by Dr. Vessie shows not only the members afflicted with chorea but those tried in colonial courts for misconduct or witchcraft. His brief quotations from the records of the day are keyholes through which the reader catches a glimpse of unbearable ignorance and cruelty. He tells how, at the hanging of the wife of Nichols, a young woman called Mary Staplies had the courage to examine the body for witch marks and to declare roundly that the dead woman was no more a witch than she was herself. For this piece of common sense she was in turn indicted as a witch. Irving Lyon described the essential features of the disease in 1863, but it bears Huntington’s name from the fuller account which George Huntington gave of it in 1872 ; he saw his first cases when riding with his father while he was still a boy, and later described how they came upon two women, " twisting, bowing, grimacing," and how he stood "in wonderment, almost in fear." Both his father and his
had become familiar with the disease in of their professional experience. It is transmitted directly from parent to child, and is associated with atrophic changes in the corpus striatum and cerebral cortex, the symptoms developing in adult life. Even Dr. Vessie, in the present year of grace, refers to the " diabolical evolution " of the disease, and it is not difficult to concede something devilish in a condition so relentless.
grandfather
the
course
BRONCHIECTASIS IN PULMONARY TUBERCULOSIS BRONCHIECTASIS is too often regarded as a disease sui generis, as if it were a form of bronchial inflammation due to more or less specific parasites or organisms. But the bronchial tree cannot be conveniently separated from its anatomical surroundings in this way. When we consider the pathology of pulmonary tuberculosis it would indeed be surprising if the bronchial walls were unaffected by the tuberculous infiltration and ulceration which is going on around them, and indeed they are not. Pulmonary tuberculosis is often associated with a greater or less degree of bronchial dilatation; it is indeed one of the common causes of bronchiectasis, though this has been almost forgotten. Clinicians of an older genera-
tion, whose study of post-mortem material was perhaps more careful because the autopsy chamber were well of the connexion. It may well be that one of the reasons why attention has been withdrawn from the study of the bronchi in tuberculous conditions is the introduction of lipiodol. It is usually considered undesirable to employ lipiodol in pulmonary tuberculosis on account of its supposed congestive action. As a consequence, while all other bronchiectatic conditions have been the subject of careful radiographic study, tuberculous bronchiectasis has been neglected. It is no doubt undesirable to inject a foreign substance-even an oil as bland as lipiodolinto bronchi adjoining or taking part in active
represented their only special department,
aware
tuberculous disease, but there is no reason to suppose that lipiodol has any deleterious action in chronic phthisis. Its judicious employment by Dr. A. Dufourt and Dr. P. Etienne-Martin and his colleagues at Lyon has resulted in an illuminating study of bronchial dilatation in pulmonary tuberculosis,l which has led them to pay tribute to Grancher’s work on the subject only half a century ago.2 Leon Bernard3 has distinguished three groups of tuberculous bronchiectasis : (1) secondary to certain acute tuberculous processes including lesions of " "
"
"
or type ; spleno-medullary epituberculous (2) accompanying fibrocaseous disease; (3) associated with the more chronic forms of fibroid phthisis. It is surprising to learn that bronchiectasis has been observed at Lyon after lesions of acute benign type, for as a rule whether the lung clouding observed in radio-
grams of this condition is due to atelectasis the result of pressure from an enlarged bronchial gland, to a non-specific response around a tuberculous focus, or to an area of tuberculous broncho-pneumonia, more or less complete resolution is the rule, and any evidence of consequent fibrosis is slight. Such a sequel has not been noted in any of the cases reported by English writers. Bronchial dilatations following fibrocaseous disease seldom form an important part of the pathological picture, but some degree of bronchiectasis is not uncommon in the vicinity of cavities. Sometimes, as Dufourt and Etienne-Martin have demonstrated, lipiodol may show a bunch of glove-finger dilatations pendant below a large vomica, and a similar process may involve the whole of a lower lobe when the upper lobe is excavated. Advanced types of bronchiectasis are, however, best seen in the more chronic forms of fibrosis, and the massive scarring which sometimes follows a prolonged course of artificial pneumothorax treatment is a possible cause.
Recent research has thus proved that Grancher was correct in attributing to tuberculosis an important role in the production of bronchiectasis. It should not be forgotten, however, that though the latter may result from the former, bronchiectasis may precede tuberculous infection of a damaged lung. - Bronchiectatic cavities are the breeding places of a multiplicity of organisms among which a few tubercle bacilli may obtain a lodgment. But the conditions in which they find themselves are usually unfavourable to their development, and this probably explains the occasional expectoration of Koch’s bacilli by patients who are suffering from bronchiectasis, and reveal no other evidence of tuberculous disease. a
HAFFKINE’S PLAGUE VACCINE
IN
a
recent
monograph4 Lieut.-Colonel
J.
Taylor,
I.M.S., director of the Haffkine Institute in Bombay, describes the
origin
and
development of the vaccine prevention of plague,
introduced by Haffkine for the
and the results obtained with it. Plague was first recognised in Bombay in Sept., 1896, and within three months Haffkine had succeeded in protecting rabbits against a virulent culture by injecting them subcutaneously with a broth culture of B. pestis killed by heat. Haffkine next tried this vaccine on himself, receiving in the flank 10 c.cm. of a broth culture of B. pestis sterilized by exposure for an hour to 70° C. There was some local pain and a rise of temperature to 102° F., but this soon passed off and the experiment demonstrated that the pro1 Arch. Méd. Chir. de l’Appareil Resp., 1932, vii., 310. 2 Gaz. Méd. de Paris, No. 146, April, 1878. Bronchiectasie et Tuberculose, Paris Méd., Sept. 28th, 1929,
3
p.257.
4 Indian Medical Research
Memoirs, No. 27, March, 1933.
had become familiar with the disease in of their professional experience. It is transmitted directly from parent to child, and is associated with atrophic changes in the corpus striatum and cerebral cortex, the symptoms developing in adult life. Even Dr. Vessie, in the present year of grace, refers to the " diabolical evolution " of the disease, and it is not difficult to concede something devilish in a condition so relentless.
grandfather
the
course
BRONCHIECTASIS IN PULMONARY TUBERCULOSIS BRONCHIECTASIS is too often regarded as a disease sui generis, as if it were a form of bronchial inflammation due to more or less specific parasites or organisms. But the bronchial tree cannot be conveniently separated from its anatomical surroundings in this way. When we consider the pathology of pulmonary tuberculosis it would indeed be surprising if the bronchial walls were unaffected by the tuberculous infiltration and ulceration which is going on around them, and indeed they are not. Pulmonary tuberculosis is often associated with a greater or less degree of bronchial dilatation; it is indeed one of the common causes of bronchiectasis, though this has been almost forgotten. Clinicians of an older genera-
tion, whose study of post-mortem material was perhaps more careful because the autopsy chamber were well of the connexion. It may well be that one of the reasons why attention has been withdrawn from the study of the bronchi in tuberculous conditions is the introduction of lipiodol. It is usually considered undesirable to employ lipiodol in pulmonary tuberculosis on account of its supposed congestive action. As a consequence, while all other bronchiectatic conditions have been the subject of careful radiographic study, tuberculous bronchiectasis has been neglected. It is no doubt undesirable to inject a foreign substance-even an oil as bland as lipiodolinto bronchi adjoining or taking part in active
represented their only special department,
aware
tuberculous disease, but there is no reason to suppose that lipiodol has any deleterious action in chronic phthisis. Its judicious employment by Dr. A. Dufourt and Dr. P. Etienne-Martin and his colleagues at Lyon has resulted in an illuminating study of bronchial dilatation in pulmonary tuberculosis,l which has led them to pay tribute to Grancher’s work on the subject only half a century ago.2 Leon Bernard3 has distinguished three groups of tuberculous bronchiectasis : (1) secondary to certain acute tuberculous processes including lesions of " "
"
"
or type ; spleno-medullary epituberculous (2) accompanying fibrocaseous disease; (3) associated with the more chronic forms of fibroid phthisis. It is surprising to learn that bronchiectasis has been observed at Lyon after lesions of acute benign type, for as a rule whether the lung clouding observed in radio-
grams of this condition is due to atelectasis the result of pressure from an enlarged bronchial gland, to a non-specific response around a tuberculous focus, or to an area of tuberculous broncho-pneumonia, more or less complete resolution is the rule, and any evidence of consequent fibrosis is slight. Such a sequel has not been noted in any of the cases reported by English writers. Bronchial dilatations following fibrocaseous disease seldom form an important part of the pathological picture, but some degree of bronchiectasis is not uncommon in the vicinity of cavities. Sometimes, as Dufourt and Etienne-Martin have demonstrated, lipiodol may show a bunch of glove-finger dilatations pendant below a large vomica, and a similar process may involve the whole of a lower lobe when the upper lobe is excavated. Advanced types of bronchiectasis are, however, best seen in the more chronic forms of fibrosis, and the massive scarring which sometimes follows a prolonged course of artificial pneumothorax treatment is a possible cause.
Recent research has thus proved that Grancher was correct in attributing to tuberculosis an important role in the production of bronchiectasis. It should not be forgotten, however, that though the latter may result from the former, bronchiectasis may precede tuberculous infection of a damaged lung. - Bronchiectatic cavities are the breeding places of a multiplicity of organisms among which a few tubercle bacilli may obtain a lodgment. But the conditions in which they find themselves are usually unfavourable to their development, and this probably explains the occasional expectoration of Koch’s bacilli by patients who are suffering from bronchiectasis, and reveal no other evidence of tuberculous disease. a
HAFFKINE’S PLAGUE VACCINE
IN
a
recent
monograph4 Lieut.-Colonel
J.
Taylor,
I.M.S., director of the Haffkine Institute in Bombay, describes the
origin
and
development of the vaccine prevention of plague,
introduced by Haffkine for the
and the results obtained with it. Plague was first recognised in Bombay in Sept., 1896, and within three months Haffkine had succeeded in protecting rabbits against a virulent culture by injecting them subcutaneously with a broth culture of B. pestis killed by heat. Haffkine next tried this vaccine on himself, receiving in the flank 10 c.cm. of a broth culture of B. pestis sterilized by exposure for an hour to 70° C. There was some local pain and a rise of temperature to 102° F., but this soon passed off and the experiment demonstrated that the pro1 Arch. Méd. Chir. de l’Appareil Resp., 1932, vii., 310. 2 Gaz. Méd. de Paris, No. 146, April, 1878. Bronchiectasie et Tuberculose, Paris Méd., Sept. 28th, 1929,
3
p.257.
4 Indian Medical Research
Memoirs, No. 27, March, 1933.