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Some clinical types of tuberculosis
442
TUBERCLE
[July, 1933
SOME CLINICAL TYPES OF TUBERCULOSIS. By L. S. T. ]3URRELL, M.D.Cantab., F.R.C.P.Lond. _Physician to the Royal Free Hospital and to the Brompton Hospital for Consu,mption and Diseases of the Chest.
V. THE patient, a man, aged 45, caught influenza in January, 1933. His daughter and one of the servants were in bed for a few days about the same time with a similar attack and his wife had just recovered from one. The doctor noticed that he had purulent sputum and on examination of the chest heard bronchial breathing over the upper par.t of the right lung in addition to a few rhonchi scattered all over the chest. The sputum was found to contain tubercle bacilli in large numbers. After four days the temperature fell to normal as it had done in the other cases in the household, rhonchi were no longer heard, the cough improved and the sputum lost its purulent appearance and became mucoid and frothy. A second sputum examination was made and no tubercle bacilli were found. A fortnight after the onset of the illness the patient felt well and had no cough or sputum, but on his doctor's advice consulted a physician before returning to work. H e had a past history of hmmoptysis when aged 33 and working in the city. H e had served during the W a r and had always thought himself a first class life until the sudden large h~emoptysis occurred in 1921. H e was kept in bed for three weeks and then saw a physician who told him he had tuberculosis in the upper part of the right lung and advised him to go into a sanatorium. H e did not do thls but stayed at his aunt's house in the country for three months spending his time sitting in the garden and leading a very lazy life. H e then returned to work and did not miss a single day through illness until the recent attack of influenza eleven and a half years later. On examination in :February, 1933, he was seen to have some flattening of the upper part of the chest on the right side and there was impairment of the percussion note and bronchial breathing over that area. Radioscopy showed a slight degree of fibrosis and a small cavity in the upper zone of right lung. l i e was told that he would probably be fit to return to work after a short holiday. H e went to Switzerland for three weeks and on his return was still free from cough or sputum and there were no changes in the X-ray or clinical signs. H e was therefore advised to return to work and resume his normal life, but to keep under the supervision of his doctor and to have periodic X-ray examinations. COMMENTS. In 1921 the cause of the h~emoptysls was correctly diagnosed tuberculosis and it was sound advice to recommend a sanatorium because there he would have been under constant medical supervision. It often happens, as in this case, that no active disease follows h~emoptysis and it is not, therefore, necessary to insist on the patient going into a sanatorium provided he can be kept under strict medical supervision, but he mast be
July, 1933]
SOME C L I N I C A L TYPES OF T U B E R C U L O S I S
443
carefully watched because there is a very real danger of activity and a rapid spread of disease after h~emoptysis. The advantage of a sanatorium is that such spread would at once be detected and artificial pneumothorax or the appropriate treatment started without delay. Sanatorium treatment does not, however, prevent a subsequent recrudescence of the disease. In this case, for example, the patient would still have had a relapse after influenza in 1933 even if he had followed his doctor's advice and gone into a sanatorium twelve years previously. It was right to let him go back to work on his return from the country in 19~1, but he should have been overhauled every three or six months for the next three years. The return of the tubercle bacilli after influenza in 1933, shows that the old lesion has never completely healed although the patient kept free from symptoms and led a perfectly normal life. On his recovery in 1933, I think it was wise to advise him to return to work and the probability was that he would keep fit without further relapse. Any attempt to treat the cavity by pneumothorax or surgical means would have been wrong, although such treatment might become necessary if any activity or spread of the disease occurred. VI. In 1913 a young man, aged 20, had a brisk hsemoptysis. H e was told that the blood came from his throat, had no special treatment and after a few weeks was leading his normal life again. The next year he got a commission in the Army and served throughout the War. In 1919 he had a large ha~moptysis and at that time crepitations were heard over the middle zone of the right lung. The signs cleared up and when he was X-rayed some three weeks later no definite lesion was seen in the lungs. In 1920, he had two severe h~emoptyses, one in April and the other in September, but he recovered and kept well and at work until 1924, when he had another hmmoptysis which lasted for ten days and he lost over two pints of blood. Crepitations were heard all over the right lung and at the base of the left, but after a fortnight there were no signs except a few crepitations after cough over the region of the right root. X-ray showed an opacity suggesting a slight degree of fibrosis in the upper part of the right middle zone. Artificial pneumothorax was advised, but after obtaining another opinion the patient refused this on the grounds that the hsemoptyses were far apart and he was so well between them. During 1925 he had two more h~emoptyses, but they were not severe, indeed he did not call in a doctor for the last one but stayed in bed and all was well after a few days. In May, 1926, he developed a right-sided pleurisy, which was followed by an effusion. A sample of the liquid was taken and found to be clear ~nd to contain a large number of ]ymphocytes, but no tubercle bacilli or other organisms. The temperature was raised for several weeks and the effusion was large, causing considerable displacemen~ of the heart and mediastinum. It was not aspirated, however, although a consultation was held as to the wisdom of gas replacement and the establishment of an ~rtificial pneumothorax. After ten weeks the temperature was normal,
444
TUBERCLE
[July, 1933
the effusion had mostly been absorbed and the patient was sent to a sanatorium where he remained for three months. Except for a slight dry cough during the pleurisy he had no cough throughout and he never had any sputum. On leaving the sanatorium X-ray showed fibrosis in the right middle zone, but there were no symptoms. The patient returned to his work and had no further h~emoptysis or illness during the last six-and-a-half years. COMMENTS.
Except during the actual h~emoptysis no special treatment was indicated until 1924. At that time there were definite clinical and X-ray signs of disease in the right lung, and its collapse by artificial pneumothorax was very properly considered. After the temporary collapse of the lung by pleural effusion there was no further h~emoptysis, so pneumothorax would very likely have succeeded. The pleural effusion indicated activity in the lung and a course of sanatorium was a wise proceeding in order to allow the lesion to heal. Afterwards there was no reason why he should not return to work provided he kept under medical supervision for the next few years. VII. This patient developed a right pleural effusion in 1928 when he was 22. H e had previously been exceptionally strong and well, was keen on boxing and Rugby, and was a first-class all-round athlete. After a few weeks he had recovered, but went into a sanatorium for three months. It was then arranged for him to travel round the world for the sake of his health before he settled down to business. A fortnight before he should have sailed, however, he developed pleurisy on the left side and this also led to an effusion. H e was treated by rest and it was absorbed shortly, as in the first case without aspiration, although on both occasions a sample of the liquid was taken and found to be clear yellow with a large proportion of small lymphocytes. In view of the second effusion he was advised not to go round the world lest he developed another manifestation of tuberculosis whilst he was a long way from home. It was November and he was keen to go to Switzerland for the winter sports. H e was advised that he would have to take rest hours, live quietly, and not go in for the more violent sports, but that he could skate and do certain sports approved by his doctor in Switzerland. H e did not want to go into a sanatorium and was not pressed to do so, but he went to an hotel in a well-known Swiss resort and put himself under the care of a doctor. It was noticed that he was rather slack, especially for a young man who previously had been so full of energy, but he did a little skating, luging and dancing, and lived a fairly normal though quiet life. Towards the end of December he had a mild attack of influenza, but was up and about again in a fortnight. In :February he again had a febrile attack, and although he was in bed for only four days he felt very weak afterwards and lost weight. In March he began to have attacks of giddiness and vomited on two or three occasions. H e also had transient diplopia and severe headaches, but there was no cough or sputum and the
July, 1933]
SOME CLINICAL T~'PES OF TUBERCULOSIS
445
temperature was normal. He improved for a time, and it was thought that the symptoms were the result of influenza. In May he returned to England, and although he said he felt better and stood the journey well, he was wasted and looked extremely ill. He felt giddy and occasionally saw double, though no physical signs were found on examination of the nervous system. He had no cough or sputum, but fine crepitations were heard over the lower half of both lungs and X-ray showed a fine powdery mottling all over both lungs. A diagnosis of miliary tuberculosis with meningitis was made in spite of the fact that there was no pyrexia. I n June he became confined to bed and began to cough and suffer from increasing dyspncea, and this was followed by delirium and loss of consciousness, and he died in July. COMMENTS.
The first pleur~l effusion was rightly diagnosed as tuberculous, and it was wise to send the patient to a sanatorimn in order to allow the lesion to heal firmly. After this, it was probable that he would keep well and his proposed trip round the world was quite justifiable. The second attack, however, showed that he had active disease and further lesions from a blood-infection were not unlikely, so that it was wise to keep him under medical supervision and not let him go too far from home. Had he been kept in bed it is possible, but by no means certain, that miliary tuberculosis would not have developed. He made a complete recovery from the second pleural effusion and there were no clinical or X-ray signs of disease, so that there certainly did not appear to be any indication for keeping him in bed for a long period. The first febrile attack in Switzerland was probably tuberculosis, although a diagnosis of influenza was natural in view of the fact that there was an epidemic at the time. Even if it had been recognised as a tuberculous manifestation, I think at that stage no treatment would have been of any avail. The second febrile attack should have been recognised, but by that time a general tuberculosis was definitely established.
THE MORBID ANATOMY AND HISTOLOGY OF ASBESTOSIS. By S. ~OODHOUS~ GLOYNE, M.D., D.P.H., Pathologist, Citg of Lolldol~ Hospital for Diseases of the Heart aT~d Lu1~gs, V~ictor~ Park.
I.--INTRODUCTION. THE word asbestosis was introduced into medical literature by Cooke V1] and Stewart McDonald E2] to designate the type of pneumonoconiosis induced by the inhalation of asbestos dust. The history of the discovery of the asbestosis body itself and the study of the disease is now so well documented that further reference to it is unnecessary. Bibliographies will be found in the work of Merewether [3], Pancoast and Pendergrass ~4~, Gardner and Cummings [5], and Gloyne [6].
TUBERCLE
[July, 1933
SOME CLINICAL TYPES OF TUBERCULOSIS. By L. S. T. ]3URRELL, M.D.Cantab., F.R.C.P.Lond. _Physician to the Royal Free Hospital and to the Brompton Hospital for Consu,mption and Diseases of the Chest.
V. THE patient, a man, aged 45, caught influenza in January, 1933. His daughter and one of the servants were in bed for a few days about the same time with a similar attack and his wife had just recovered from one. The doctor noticed that he had purulent sputum and on examination of the chest heard bronchial breathing over the upper par.t of the right lung in addition to a few rhonchi scattered all over the chest. The sputum was found to contain tubercle bacilli in large numbers. After four days the temperature fell to normal as it had done in the other cases in the household, rhonchi were no longer heard, the cough improved and the sputum lost its purulent appearance and became mucoid and frothy. A second sputum examination was made and no tubercle bacilli were found. A fortnight after the onset of the illness the patient felt well and had no cough or sputum, but on his doctor's advice consulted a physician before returning to work. H e had a past history of hmmoptysis when aged 33 and working in the city. H e had served during the W a r and had always thought himself a first class life until the sudden large h~emoptysis occurred in 1921. H e was kept in bed for three weeks and then saw a physician who told him he had tuberculosis in the upper part of the right lung and advised him to go into a sanatorium. H e did not do thls but stayed at his aunt's house in the country for three months spending his time sitting in the garden and leading a very lazy life. H e then returned to work and did not miss a single day through illness until the recent attack of influenza eleven and a half years later. On examination in :February, 1933, he was seen to have some flattening of the upper part of the chest on the right side and there was impairment of the percussion note and bronchial breathing over that area. Radioscopy showed a slight degree of fibrosis and a small cavity in the upper zone of right lung. l i e was told that he would probably be fit to return to work after a short holiday. H e went to Switzerland for three weeks and on his return was still free from cough or sputum and there were no changes in the X-ray or clinical signs. H e was therefore advised to return to work and resume his normal life, but to keep under the supervision of his doctor and to have periodic X-ray examinations. COMMENTS. In 1921 the cause of the h~emoptysls was correctly diagnosed tuberculosis and it was sound advice to recommend a sanatorium because there he would have been under constant medical supervision. It often happens, as in this case, that no active disease follows h~emoptysis and it is not, therefore, necessary to insist on the patient going into a sanatorium provided he can be kept under strict medical supervision, but he mast be
July, 1933]
SOME C L I N I C A L TYPES OF T U B E R C U L O S I S
443
carefully watched because there is a very real danger of activity and a rapid spread of disease after h~emoptysis. The advantage of a sanatorium is that such spread would at once be detected and artificial pneumothorax or the appropriate treatment started without delay. Sanatorium treatment does not, however, prevent a subsequent recrudescence of the disease. In this case, for example, the patient would still have had a relapse after influenza in 1933 even if he had followed his doctor's advice and gone into a sanatorium twelve years previously. It was right to let him go back to work on his return from the country in 19~1, but he should have been overhauled every three or six months for the next three years. The return of the tubercle bacilli after influenza in 1933, shows that the old lesion has never completely healed although the patient kept free from symptoms and led a perfectly normal life. On his recovery in 1933, I think it was wise to advise him to return to work and the probability was that he would keep fit without further relapse. Any attempt to treat the cavity by pneumothorax or surgical means would have been wrong, although such treatment might become necessary if any activity or spread of the disease occurred. VI. In 1913 a young man, aged 20, had a brisk hsemoptysis. H e was told that the blood came from his throat, had no special treatment and after a few weeks was leading his normal life again. The next year he got a commission in the Army and served throughout the War. In 1919 he had a large ha~moptysis and at that time crepitations were heard over the middle zone of the right lung. The signs cleared up and when he was X-rayed some three weeks later no definite lesion was seen in the lungs. In 1920, he had two severe h~emoptyses, one in April and the other in September, but he recovered and kept well and at work until 1924, when he had another hmmoptysis which lasted for ten days and he lost over two pints of blood. Crepitations were heard all over the right lung and at the base of the left, but after a fortnight there were no signs except a few crepitations after cough over the region of the right root. X-ray showed an opacity suggesting a slight degree of fibrosis in the upper part of the right middle zone. Artificial pneumothorax was advised, but after obtaining another opinion the patient refused this on the grounds that the hsemoptyses were far apart and he was so well between them. During 1925 he had two more h~emoptyses, but they were not severe, indeed he did not call in a doctor for the last one but stayed in bed and all was well after a few days. In May, 1926, he developed a right-sided pleurisy, which was followed by an effusion. A sample of the liquid was taken and found to be clear ~nd to contain a large number of ]ymphocytes, but no tubercle bacilli or other organisms. The temperature was raised for several weeks and the effusion was large, causing considerable displacemen~ of the heart and mediastinum. It was not aspirated, however, although a consultation was held as to the wisdom of gas replacement and the establishment of an ~rtificial pneumothorax. After ten weeks the temperature was normal,
444
TUBERCLE
[July, 1933
the effusion had mostly been absorbed and the patient was sent to a sanatorium where he remained for three months. Except for a slight dry cough during the pleurisy he had no cough throughout and he never had any sputum. On leaving the sanatorium X-ray showed fibrosis in the right middle zone, but there were no symptoms. The patient returned to his work and had no further h~emoptysis or illness during the last six-and-a-half years. COMMENTS.
Except during the actual h~emoptysis no special treatment was indicated until 1924. At that time there were definite clinical and X-ray signs of disease in the right lung, and its collapse by artificial pneumothorax was very properly considered. After the temporary collapse of the lung by pleural effusion there was no further h~emoptysis, so pneumothorax would very likely have succeeded. The pleural effusion indicated activity in the lung and a course of sanatorium was a wise proceeding in order to allow the lesion to heal. Afterwards there was no reason why he should not return to work provided he kept under medical supervision for the next few years. VII. This patient developed a right pleural effusion in 1928 when he was 22. H e had previously been exceptionally strong and well, was keen on boxing and Rugby, and was a first-class all-round athlete. After a few weeks he had recovered, but went into a sanatorium for three months. It was then arranged for him to travel round the world for the sake of his health before he settled down to business. A fortnight before he should have sailed, however, he developed pleurisy on the left side and this also led to an effusion. H e was treated by rest and it was absorbed shortly, as in the first case without aspiration, although on both occasions a sample of the liquid was taken and found to be clear yellow with a large proportion of small lymphocytes. In view of the second effusion he was advised not to go round the world lest he developed another manifestation of tuberculosis whilst he was a long way from home. It was November and he was keen to go to Switzerland for the winter sports. H e was advised that he would have to take rest hours, live quietly, and not go in for the more violent sports, but that he could skate and do certain sports approved by his doctor in Switzerland. H e did not want to go into a sanatorium and was not pressed to do so, but he went to an hotel in a well-known Swiss resort and put himself under the care of a doctor. It was noticed that he was rather slack, especially for a young man who previously had been so full of energy, but he did a little skating, luging and dancing, and lived a fairly normal though quiet life. Towards the end of December he had a mild attack of influenza, but was up and about again in a fortnight. In :February he again had a febrile attack, and although he was in bed for only four days he felt very weak afterwards and lost weight. In March he began to have attacks of giddiness and vomited on two or three occasions. H e also had transient diplopia and severe headaches, but there was no cough or sputum and the
July, 1933]
SOME CLINICAL T~'PES OF TUBERCULOSIS
445
temperature was normal. He improved for a time, and it was thought that the symptoms were the result of influenza. In May he returned to England, and although he said he felt better and stood the journey well, he was wasted and looked extremely ill. He felt giddy and occasionally saw double, though no physical signs were found on examination of the nervous system. He had no cough or sputum, but fine crepitations were heard over the lower half of both lungs and X-ray showed a fine powdery mottling all over both lungs. A diagnosis of miliary tuberculosis with meningitis was made in spite of the fact that there was no pyrexia. I n June he became confined to bed and began to cough and suffer from increasing dyspncea, and this was followed by delirium and loss of consciousness, and he died in July. COMMENTS.
The first pleur~l effusion was rightly diagnosed as tuberculous, and it was wise to send the patient to a sanatorimn in order to allow the lesion to heal firmly. After this, it was probable that he would keep well and his proposed trip round the world was quite justifiable. The second attack, however, showed that he had active disease and further lesions from a blood-infection were not unlikely, so that it was wise to keep him under medical supervision and not let him go too far from home. Had he been kept in bed it is possible, but by no means certain, that miliary tuberculosis would not have developed. He made a complete recovery from the second pleural effusion and there were no clinical or X-ray signs of disease, so that there certainly did not appear to be any indication for keeping him in bed for a long period. The first febrile attack in Switzerland was probably tuberculosis, although a diagnosis of influenza was natural in view of the fact that there was an epidemic at the time. Even if it had been recognised as a tuberculous manifestation, I think at that stage no treatment would have been of any avail. The second febrile attack should have been recognised, but by that time a general tuberculosis was definitely established.
THE MORBID ANATOMY AND HISTOLOGY OF ASBESTOSIS. By S. ~OODHOUS~ GLOYNE, M.D., D.P.H., Pathologist, Citg of Lolldol~ Hospital for Diseases of the Heart aT~d Lu1~gs, V~ictor~ Park.
I.--INTRODUCTION. THE word asbestosis was introduced into medical literature by Cooke V1] and Stewart McDonald E2] to designate the type of pneumonoconiosis induced by the inhalation of asbestos dust. The history of the discovery of the asbestosis body itself and the study of the disease is now so well documented that further reference to it is unnecessary. Bibliographies will be found in the work of Merewether [3], Pancoast and Pendergrass ~4~, Gardner and Cummings [5], and Gloyne [6].