Some clinical characters of tubercle

SOME CLINICAL CHARACTEHS OP TUllEHCLE By

vr.

C. Rrvsns, M.R.C.S., D.r.H.

Tub~rclll0,i, Officer,

Bar7l,zey District; lVest Ricling of Yorkshire,

Tlmnu are certain clinical characters of tuberculous disease which do not get enough a.ttention; they are not brought out collectively, Do proceeding possible in nearly every form of t~e disease, and one which seems to result in a strengthening of the outlines of our general impression of tuberculosis. Such characters are: the existence of a predisposition or diathesis, the retiological influence of trauma, the phenomena of muscular spasm and atr~~hy, the vicissitudinous course, an9, finally, the strong tendency to recidivism, These five are taken as being a.t present inadequately recognised, which is the same as saying' that otherwise one would not be justified in troubling the reader with them. But to deal hero with all would be impossible; we shall have plenty on our plate with the last (our only. Trauma as a contributory cause of tubercle is fully acknowledged in some varieties of tho disease. The common antecedent, in bone and joint lesions, of a. knock or sprain is mentioned in all general text-books ; and so is the common history of a rather bad fall preceding meningitis. But only in the fullest of them does one read that direct violence often precedes tuberculous peritonitis; and even the writers of the latter have not made up their minds whether injury to the thorax favours the evolution of phthisis. This is strange, for specialists have long been clear on that point. Brehmer [1J, writing in 1885, quotes earlier monographs in which Ilurpriso is expressed at any doubt about it. The phthisis, starting perhaps from a. localised contusion pneumonia, mostly supervenes on the injured side, n useful indication in med ico-legal work In adult tuberculous testicle, too, the lesion often dates from an injury to the part, while trauma. is mentioned in the rotiology of Addison's disease. Similarly, muscular atrophy and spasm are classical signs in sur~lcl).l tuberculosis. Wituess the flexor (psoas) spasm, or the "bol).rdill~ , of a tuberculous spine; likewise the wasted buttock in hip disease. Unlortunately lor patients, they are not yet classical sigus in phthisis. Yet the ' .. Hchulter-Phiillomen " in consumptives, and the droopinp on tho affected side of the scapula, point of shouldor and nipple, as noted by Kronig [2J (which is generally accompanied by distinct wasting of the trapezius), nrc known to those abreast of the literature of tuberculosis. So are Piecher's description of the increased irritability of the thoracic muscles overlying tuberculous loci, and Pottenger's description [3] of spasm and degeneration of the muscles of neck and thorax in pulmonary tubercle. In the case of phLhis.is it is surely allowable to connect all these signs, to say that a tuberculous lung apex is often nccompanied by fibrillary contraction, or l1y atrophy, of the neighbouring muscles, and that whether or not the ., de{;cneration" and "pulpy change'" that Potten~er describes occur ill th08El niuscles, certainly atrophy often does - which atrophy seems a likely cause of the characteristic local deformity seen so often When itr; appearance is known, for it is plausible that the wasted trnpezius allows the shoulder to sag. 31

452

TUBERCLE

[July, 1920

Nervous influence-a reflex irritation from the chronically inflamed 1ung tissue, in which the sympathetic, the spinal cord segment, and the motor nerves to the muscles are concerned-may indeed be responsible for these changes, since pain in the shoulder often occurs, and 0. diminution of pi~~ ment in the areola of the corresponding nipple, which, by the wey, : is sometimes smaller than its fellow. As for the muscular spasm of surgical tuberculosis, what is usually advanced as its cause is that it is protective, being Nature's way of securing rest of the joint affected. There are several objections to this theory. Spasm may be seen, so it is said, in the neighbourhood of tuberculous cervical glands. Again, protective immobiliso.tion is 110 way of accounting Cor muscular atrophy, which would make 0. joint looser rather than firmer. Further, such an exr.lanation as "Nature's way of securing rest," is teleological, not pathological. Certain processes of infla.mmation may by natural selection have been evolved to therapeutic ends, but we need a closer explanation than that. All good clinicians agree that the wastinc of the neighbouring muscles in morbus coxa: cannot be primarily traced to disuse, as it is so early 0. physical sign. It is certainly an early one in phthisis, and moreover can arise fairly quickly, In three cases In which I have had opportunity of timing its appearance, in all it occurred in under four months, and in one instance within ten weeks. This speedy occurrence is against the atrophy being 0. sequela of continuous spasm in tho war that atrophy of any tissue ensues upon continuous pressure. On the whole the nervous influence theory of Pottenger applies best to the U Schulter. Pbiinomen" (to take that as n useful collective term)-and it rna)' also apply largely to the muscula~ phenomena of surgical. tubercle. .~~or .the point I would urge, not havmg seen It elsewhere raised, 18 this i thn& these two things are one; that tlse muscular spasm and atrophy tcitha tuberculous joint are, iu all l)robalJility, much the same as those tcit1& a tuberculous lUlIg apex j although at tho same time one would not denv weight to the ideo. of protective immobilisation, seeing that lDuscula'r spasm is much more in evidence round a diseased joint than round non articular bone lesions, or, indce.d rou~d an affecte~ a.(>ex. " One cannot leave this subject Without mentioning ltS 111gb diagnostic

signlflcunco. Hero is n. case in which right-sided trapezius n.tropby and shou1l1cr drooping constituted almost the o~ly physical signs; th~re were ~n addition very slight prolonging of ~xplrnt1on Just below the nght claviclo, and a trif1iD~ llnrro~ins of the rigbt band of apI,cal reson~nce, of course hi"bl)' equivocal findings. On the str.ength of this deformity I sent the patient. several years f!.go to the sanatorium, \V.here the resident made out tbo right lung to be clear, and marked something out the lelt apex. Sho rclapsetl not long nCter her return from there, and n year Inter nothing socmc
July, 1920J

TUlll':RCLE

&equent recrudescence of the disease." I To this characteriatic is due the fact that tuberculosis has made the fortunes of so many quacks and semiquacks, and has deluded honest men until there is "no drink or stink ,. which has not been vaunted as a. remedy for it. The fallacy of post hoc, propter hoc is nowhere so potent as in phthisio-thernpeutics. Recidivism bas long been raeognised in surgical tubercle, but only lately in phthisis, for the good reason that until lately practically no consumptive recovered. '-0 that practically 110ne could relapse. The advent, some twenty years ngo, of the hygienic-dietetic treatment, in other words, the snnatori Ulll , arrested lung tubercle in many persons; and when some of these, 11M might hue been predicted, lost their health again from a lighting-up of the disease, the sanatorium came in, rather unfairly, for a chorus of

Illume. But the results in surgical tubercle were also marred hv recidivism. Not so much so; for the consumptive, who is the commones; tuberculous patient, is unluckily also the one most prone to bnckalide. 'I'hrmain reason for the irregular course, either upward or downward of tuberculosis is of course the exactness of its inverse variation with' till' subject's general health, receding when that is improved, and via vusa. Hut it is not the only reason. An exacerbation of scrofula will occur III time" with rosy cheeks. A tuberculous larynx will get worse when t}lf> lung i,a mending and the p~tient pl~ttillg on ~eight, or iJllpr?\"(! under OppOSIte oonditions , lupus Will heal III one dying of conaumpt.nm or hipI Jlall
II.

Blumenfeld,

454

TUDERCLE

disease. The explanation of these last instances is, however, probably purely bacteriological. These four clinical phenomena-Trauma, Muscular Signs, Vicissitude Recidivism-to what do they point? . Pro?ably to high nll.t?rn.l inllnunit)~ to the disease. I should not be surprised If they were rare In tuberculous lunatics or in patients of so~e non-Western races, like negroes or Polynesians. It 'would also be interesting to hear from a syphilologist or lepro1ogist of anything analogous to be found in the other infective granulomata. REFERENCES. (1] DREnMER. .. Die Aetiologie der chrcnischen Lungenschwindaueht," 1885 401 [2] KRONIG . Die deutsche Klinik , a~~ Eingange des XX Jahrhlmderts, 11: 581: [3) POTT~mGER. Beitrtiqo lur Klmtk der Tuberkulose, Bd. 20, 1.

n.

SHORTER COMMUNICATIONS. THE (( PRETUBERCULOUS By Major F.

GARLAND CoLLINS,

II

CHILD.

M.n.C.S.Ellg., L.R.C.P.Lond., D.P.lI.

Tub"rculo,i, Officer for t1L~ County Borouqh; of lreat Ham, MedicaZ Advi,er to tk« We,t Ham Insurance Committee• .. PRETUDERCULOUS II is a somewhat indefinite term, hard to define clearly and cupable of a 'wide interpretation.; .there ~re 'indeed Il: few noted medical men who deny that such 0. con~ltlO11 exists and mQ.llltll.in that there is no ~alI-way house to tuberculosis. In ~y .o wn experience tho . weight of evidence has been su.n~cIently .0verwhelm1D~ to convince Inc of "he existence of such a condition, of ItS prevalence amcngst : childrcl and of its vital importance. ), DEFINITION.

It is of course well known . that if from a~y cause a child's vitalit). remains materially lowered, not only tuberculosis but any other illness is especially prone to occur, though fro~ this rell.~0!l alone no child should be considered pretuberculous. But If In. addition some or all of . the Iollowing conditions persist, viz., frequent lise of temperature from some indefinite cause, enlarged lymphatic glands, loss of weight or failure to [IUl on weight, chronic bronchial catarr~,. loss of appetite, c~rious teeth wilh stomatitis, or general strumous condition, then such a. child m,igbt Well be termed pr~tuberculous; more. espec~~lly If wI~b t~e foregomg IS associated a family history of tuberculosis, or conta~t With a tuberculous person l'houlih incomplete, the above statement wl1~ serve as a rough guide as t~ wha.t IS usually meant by a pretuberculous child. PnOGNOSIS AND TREATMENT.

Not all such cases develop tuberculosis, as a certain percentage or them have a high degree of resistance an~ readily respond to ordinary treatmellt. and care. 'Vha.t however 18 practically sure IS that the mnjority of Such