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PROGNOSIS IN PULMONARY TUBERCULOSIS.
747 Wales did not exceed 75 per million of the esti- observed. Closely connected with this subject is another mated population, whereas the mean annual death-rate aspect of tuberculosis which promises to claim nuch from this disease in the 10 years 1871-80 was equal attention in the near future-namely, the alleged occurrence to 326 per million. In the county of Durham, however, the of traumatic tuberculosis. It may be remembered that art a death-rate from enteric fever in 1908 was equal to 146 per meeting of the Life Assurance Medical Officers’ Association million, against an average rate of 186 per million in the held in May of this year Dr. F. Parkes Weber read a paPt-T five preceding years, and in Auckland, Easington, and on Traumatic Tuberculosis, Traumatic Pneumonia, and Houghton-le-Spring districts of that county the rate from Traumatic Pleurisy. He divided cases in which tuberthis diseaQe in 1908 exceeded 300 per million. The above- culosis is said to have been caused by accident into three mentioned statistics point conclusively to the serious sanitary groups: (a) Cases in which a decided traumatism of some shortcomings in all the counties containing extensive colliery kind is followed by signs of either acute disseminated districts. Much sanitary improvement may be expected to miliary tuberculosis or acute metastatic localised tuberresult from the compulsory appointment of county medical culosis ; (b) cases in which signs of pulmonary tuberculosis. officers of health, but the value of these appointments would follow or are first noticed after a supposed injury to the be much increased by independent investigation by Local Government Board inspectors of the long-existing defective housing conditions in many of the colliery districts.
PROGNOSIS IN
PULMONARY TUBERCULOSIS.
lungs ; (e)
cases
in which
an
injury
to bones
or
joints
or
parts of the body other than the lungs is followed by signs of tuberculosis more or less localised to the region of the trauma. We agree with Dr. Weber in the opinion that in the majority of cases " traumatic tuberculosis " may be explained as the rendering manifest and active of a preexisting tuberculosis, however limited in extent, quieseent, and latent the former lesion may have been.
THE problem presented to a practitioner in attempting to arrive at a prognosis in a case of pulmonary tuberculo-is is generally accepted as being a most difficuh one. The varied course of the disease in different individuals renders the quesTHE TENTH REPORT OF THE SLEEPING. tion exceedingly complex, and it is only by carefully conSICKNESS COMMISSION. detail and of the case that an sidering every aspect opinion In the British JournaZ of Tuberculosis for can be given. THE Tenth Report of the Sleeping Sickness Commission, July of this year Dr. R. C. Macfie draws attention to some recently issued, contains some 13 contributions by the Compoints which are of importance in connexion with this sub- missioners and their fellow workers in this country respectject. He points out that prognosis in pulmonary tuberculosis ing work done from August, 1908, to December, 1909. Several is difficult because there are but few means of estimating of the papers have already appeared in the Proceedings of either the virulence of the seed or the fertility of the soil, and the Royal Society, and we have commented upon some of yet a correct estimate of both is essential to a correct them in the columns of THE LANCET. The subjects dealt. opinion. One case may show a very small incipient lesion with include the experimental treatment of trypanosomiasis, and yet have received a very large dose of virulent bacilli ; the development of T. gambiense in Glossina palpalis, another may exhibit a very large lesion and yet show very sleeping sickness in Uganda and the duration of infectivity few toxic symptoms. Some patients appear to have a very of the tsetse-fly after removal of the shore population,. mild affection and yet, having "poor resistance," succumb Glossina palpalis as a carrier of T. vivax, and amakebe,. rapidly. Likewise, disease apparently arrested may, without a disease of calves in Uganda. In other papers relatingdiscoverable cause, suddenly flare up again, and acute trouble to what are regarded as newly discovered trypano-may as suddenly and inexplicably subside. We agree with Dr. somes, Colonel Sir David Bruce and his colleagues on. Macfie that a mere microscopic count of the bacilli is futile, the Commission make some observations on the classification for there is no proved constant relation between the number of trypanosomes, which they say is at present in a state of of bacilli discoverable and the virulence of the disease, and, chaos. They point out that the three most important further, mixed infection may any day quite alter the state of questions to be borne in mind in classifying these parasites affairs. Dr. Macfie believes that in the majority of cases a are : (1) The animals they are capable of infecting ; (2) the correct prognosis can be given, but only if all the circum- gravity of the infection ; and (3) the carrier of the infectionstances of each case be duly considered and weighed, as we i, To these also may be added consideration of the morphology have already suggested above. All physicians who have of the trypanosome, its cultural characters, if any, and the had extended experience in the treatment of phthisis will results of cross inoculation experiments. It is suggested that agree with him in his statement that it is useless to try to if these several facts could be set down for each trypanosome forecast the future if we confine our observations to the encountered in Africa, the classification of the African physical signs. We think, however, that the following species might then be successfully attempted. Only for a sentence requires modification : "The division of cases so few species-e.g., T. gambiense and T. brucei—do we often made, according to extent of lung lesion, is a very possess such data. As regards a special trypanosome dissuitable classification for a pathological museum, but is quite covered in a horse at Zanzibar by Dr. A. Edington) the misleading for most other purposes ; and the first thing the Commissioners, who made a careful investigation in’;o the prognostician has to learn is that the lesion by itself has very claim that it was a new species, come to the conclusion that. limited prognostic value." The expression "extent of lung it is probably T. dimorphon. But they admit that an lesion " is rather ambiguous ; taken with the context, " stage link in the chain of evidence is wantingof the disease"would have been more appropriate. For the identity or non-identity of the carrier. instance, the fact that four lobes are involved would The Commissioners also describe two new trypanosomes, influence the prognosis more than the fact that a cavity to the first of which they give the name of T. ingens, was present in one lobe, provided that in the latter owing to its extraordinary appearance. It was founcl instance the other lobes were not affected. The contention in the blood of a reed-buck in Uganda, afterwards in a bushthat the pulse-rate and temperature are at least as im- buck, and later still in an ox. As the wild animals fed in portant in prognosis as any estimation of rules, rhonchi, the same pasture as the ox, it is not surprising that the and the like is perfectly correct, and fewer mistakes in latter animal became infected. Up to the present the prognosis would be made if the temperature curve carrier of T. ingens has not been discovered. The second a’1d general condition of the patient wera more carefully trypanosome, to which the name of T. elephantis has been
important namely,
PROGNOSIS IN
PULMONARY TUBERCULOSIS.
lungs ; (e)
cases
in which
an
injury
to bones
or
joints
or
parts of the body other than the lungs is followed by signs of tuberculosis more or less localised to the region of the trauma. We agree with Dr. Weber in the opinion that in the majority of cases " traumatic tuberculosis " may be explained as the rendering manifest and active of a preexisting tuberculosis, however limited in extent, quieseent, and latent the former lesion may have been.
THE problem presented to a practitioner in attempting to arrive at a prognosis in a case of pulmonary tuberculo-is is generally accepted as being a most difficuh one. The varied course of the disease in different individuals renders the quesTHE TENTH REPORT OF THE SLEEPING. tion exceedingly complex, and it is only by carefully conSICKNESS COMMISSION. detail and of the case that an sidering every aspect opinion In the British JournaZ of Tuberculosis for can be given. THE Tenth Report of the Sleeping Sickness Commission, July of this year Dr. R. C. Macfie draws attention to some recently issued, contains some 13 contributions by the Compoints which are of importance in connexion with this sub- missioners and their fellow workers in this country respectject. He points out that prognosis in pulmonary tuberculosis ing work done from August, 1908, to December, 1909. Several is difficult because there are but few means of estimating of the papers have already appeared in the Proceedings of either the virulence of the seed or the fertility of the soil, and the Royal Society, and we have commented upon some of yet a correct estimate of both is essential to a correct them in the columns of THE LANCET. The subjects dealt. opinion. One case may show a very small incipient lesion with include the experimental treatment of trypanosomiasis, and yet have received a very large dose of virulent bacilli ; the development of T. gambiense in Glossina palpalis, another may exhibit a very large lesion and yet show very sleeping sickness in Uganda and the duration of infectivity few toxic symptoms. Some patients appear to have a very of the tsetse-fly after removal of the shore population,. mild affection and yet, having "poor resistance," succumb Glossina palpalis as a carrier of T. vivax, and amakebe,. rapidly. Likewise, disease apparently arrested may, without a disease of calves in Uganda. In other papers relatingdiscoverable cause, suddenly flare up again, and acute trouble to what are regarded as newly discovered trypano-may as suddenly and inexplicably subside. We agree with Dr. somes, Colonel Sir David Bruce and his colleagues on. Macfie that a mere microscopic count of the bacilli is futile, the Commission make some observations on the classification for there is no proved constant relation between the number of trypanosomes, which they say is at present in a state of of bacilli discoverable and the virulence of the disease, and, chaos. They point out that the three most important further, mixed infection may any day quite alter the state of questions to be borne in mind in classifying these parasites affairs. Dr. Macfie believes that in the majority of cases a are : (1) The animals they are capable of infecting ; (2) the correct prognosis can be given, but only if all the circum- gravity of the infection ; and (3) the carrier of the infectionstances of each case be duly considered and weighed, as we i, To these also may be added consideration of the morphology have already suggested above. All physicians who have of the trypanosome, its cultural characters, if any, and the had extended experience in the treatment of phthisis will results of cross inoculation experiments. It is suggested that agree with him in his statement that it is useless to try to if these several facts could be set down for each trypanosome forecast the future if we confine our observations to the encountered in Africa, the classification of the African physical signs. We think, however, that the following species might then be successfully attempted. Only for a sentence requires modification : "The division of cases so few species-e.g., T. gambiense and T. brucei—do we often made, according to extent of lung lesion, is a very possess such data. As regards a special trypanosome dissuitable classification for a pathological museum, but is quite covered in a horse at Zanzibar by Dr. A. Edington) the misleading for most other purposes ; and the first thing the Commissioners, who made a careful investigation in’;o the prognostician has to learn is that the lesion by itself has very claim that it was a new species, come to the conclusion that. limited prognostic value." The expression "extent of lung it is probably T. dimorphon. But they admit that an lesion " is rather ambiguous ; taken with the context, " stage link in the chain of evidence is wantingof the disease"would have been more appropriate. For the identity or non-identity of the carrier. instance, the fact that four lobes are involved would The Commissioners also describe two new trypanosomes, influence the prognosis more than the fact that a cavity to the first of which they give the name of T. ingens, was present in one lobe, provided that in the latter owing to its extraordinary appearance. It was founcl instance the other lobes were not affected. The contention in the blood of a reed-buck in Uganda, afterwards in a bushthat the pulse-rate and temperature are at least as im- buck, and later still in an ox. As the wild animals fed in portant in prognosis as any estimation of rules, rhonchi, the same pasture as the ox, it is not surprising that the and the like is perfectly correct, and fewer mistakes in latter animal became infected. Up to the present the prognosis would be made if the temperature curve carrier of T. ingens has not been discovered. The second a’1d general condition of the patient wera more carefully trypanosome, to which the name of T. elephantis has been
important namely,