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The relations between extrapulmonary and pulmonary tuberculosis
418
TUBERCLE
Abstracts.
PULMONARY T U B E R C U L O S I S . RUSSELL, W. T., and SALMON, G. Pulmonary Tuberculosis in Wales between 1911 and 1931. Jo~lrn. of Hygiene, 1934, 3~t, 380. This interesting statistical study is based on data contained in the Annual Report.s of the :Registrar-General. I t establishes the existence of a mortality from phthisis in Wales much higher than in England, associated also with a higher mortality from all other forms of respiratory disease. Ia 1928-1931 the Welsh mortality, which was most accentuated in the rural districts, was 56 per cent. in excess of that in England. Changes in the age-incidence of the mortality are reported, but the possible significance of these changes is largely discounted by the lack of any separation of the data according to sex; as the female phthisis mortality is much earlier in life than the male, any modifications of the sex distribution of the populations due to migration would tend to cause such changes. The phthisis mortality both in the urban and rural parts of individual counties is correlated inversely with the migration of the population. Counties affected by migration had higher death-rates, Whereas those affected by immigration had a lower mortality from the disease. The high mortality is mainly in four counties--Cardigan, Carnarvon, Carmarthen and hlerioneth (see p. 406). The mortality is not correlated with general hygienic conditions. Overcrowding is no greater in Wales than in England, and the correlation between this variable and the phthisis mortality both in the urban and rural areas of Wales is negative. Where families under the age of 16 were large--which m~y be taken as an index of nutritional insufficiency--the mortality tended to be low, instead of high. Nor could conclusive evidence be found that occupation was a sole d0termining consideration: But there are urban and rural areas in Wales where the incidence of phthisis is excessive; attention should now be directed to the anthropological characteristics of the populations concerned.
[June, 1935
In this connection possibly consideration should be paid to the blood groups in the populations, a "factor which Bradbury claims to be related to tuberculous manifestations (see T~lbercle, December, 1934, pp. 113-119). 12EISNER,D. The Relations between Extrapulmonary and Pulmonary Tuberculosis. ATner. Rev. Tub., 1934, 30, 875. Various observers have noted the apparent resistance to pulmonary tuberculosis of patients with skeletal tuberculosis, tuberculous lymphadenitis or lupus vulgaris. Asehoff and Roessler have comparatively recently stated thal~ there exists a positive antagonism between the so-called surgical forms of tuberculosis and pulmonary lesions. In the present comprehensive study the writer analyses the pulmonary findings in a large series of patients suffering from extrapulmonary forms of tuberculosis, with a view to ascertaining whether or how far such an antagonism exists, and further in what manner, if at all, the pulmonary lesions present in extrapulmonary tuberculosis differ from those in purely pulmonary cases. Among the conclusions arrived at were the following : In nearly half the cases studied (the material consisting chiefly of skeletal and genito-urinary lesions), the lungs were either entirely free from changes or at most presented evidence of an. obsolete primary focus. The differential analysis of the pulmonary changes from a morphological standpoint showed that some two-thirds of the cases with positive findings exhibited among the most prominent~ features discrete, nodular productive disseminations with a bilateral symmetrical distribution. The analysis of the material from the clinical standpoint showed timt only abolat one-filth of the total presented evidence of active pulmonary lesions. The pulmonary changes in extrapulmonary tuberculosis evidently represent in the majority of eases a part of a chronio progressive endogenous generalisation. Nodefinite antagonism could be noted between extrapulmonary and pulmonary involvement, as regards the actual frequency of the puhnonary changes; but the writer found a distinct antagonism in
J u n e , 1935]
1"Un~OmtRY TUBERCULOSIS
relation to the reinfection types of puhnonary tuberculosis, moreespeeially to the active and progressive forms. Attention is drawn to the fac~. that pulmonary tuberculosis presents a definitely more pronounced antagonistic relation to non-pulmonary involvement than tim converse, since manifest extrapulmonary lesions are conspicuously rare in the common forms of pulmonary tuberculosis. Extensive and progressive pulmonary tuberculosis is not a frequent cause of death in patients with extrapulmonary lesions, this fact affording additional evidence of the comparatively benign and non-progressive character of the pulmonary involvement in these cases. From the clinical and practical standpoint, it is pointed out that because of the particular frequency of clinically latent forms of pulmonary involvement in extrapulmonary lesions, X-ray examination may be the only way to decide the diagnostic issue. FELLOWS, H . H . Significant Active P u l m o n a r y Tuberculosis in the Apparently H e a l t h y Adult. Amer. Journ. Med. Sciences, 1933, t88,533. The writer, who is Assistant Medical Director, Metropolita n Life Insurance Company, New York, explains that up to seven years ago, in spite of a careful physical examination of applicants for employment in the H o m e Office of ~his Company, and in spite of the fact that any such persons either admitting a history of a condition associated with pulmonary tuberculosis or presenting u n u s u a l physical signs, received an X-ray examination of the chest, yet it was no~ unusual to detect advanced pulmonary tuberculosis in an employee shortly after a negative physical examination. An attempt was therefore made to determine (a) whether they were dealing with a type of disease of r a p i d onset and progression, or (b) whether their method of physical examination of the chest was inadequate. While the ideal method would be a routine X-ray film of each individual, both before employment and at each annual re-examination, the expense of this was considered prohibitive unless it was proved to be necessary. As a substitute, fluoroscopes were installed,
419
and each medical officer was trained to make a fluoroscopic examination of the thorax in addition to the usual physical examination. The experience gained with the fluoroscopic examination as carried out during the past seven years has convinced the medical staff of the great importance of this method. By its means 141 cases of puhnonary tuberculosis were discovered, the group including an encouragingly large proporLion of minimal cases. The majority of the cases (65 per cent.) were discovered before the patients became clinically ill, and before physical signs were evident. The diagnosis was confirmed at the Metropolitan Lifo Insurance Company Sanatorium in 131 cases (93 per cent.), and by the H o m e Office Medical Division, or outside agencies in the remaining 10 cases. Ninety-two patients (65 per cent.) were either completely free of symptoms or had only one symptom, not ia itself pathognomonte. Of the 131 cases who went to the sanatorium, 25 had a positive sputum, 12 a positive guinea-pig test, and 4 gave both at some time during the course of their treatment. Seventythree of the 131 sanatorium cases first had X-ray examinations because of a slightly suggestive history ; 28 of these had a positive sputum or guinea-pig test or both. Of the remaining 68 who had X-ray examinations because of fluoroscopic findings or as a routine re-examination, 13 had positive sputum or guinea-pig test or both, during treatment. In the whole series there were only 26 known or questionable cases of contact. WAGNER, H. S. Symptoms as a Measurement of Tuberculous Activity. lgew England Journ. Medicine, 1934, 21t, 237. 4~ Of the constitutional symptoms, fever, rapid pulse-rate, weakness, emaciation, loss of appetite, and sweating, the last four are usually the first to lessen as general improvement begins. Fatigue or sense of exhaustion is a serious symptom if there is little remission and a nervous element can be ruled out. T h r e e symptoms, cough, expectoration and hmmoptysis, have to do with the presence of tubercles as they enlarge
TUBERCLE
Abstracts.
PULMONARY T U B E R C U L O S I S . RUSSELL, W. T., and SALMON, G. Pulmonary Tuberculosis in Wales between 1911 and 1931. Jo~lrn. of Hygiene, 1934, 3~t, 380. This interesting statistical study is based on data contained in the Annual Report.s of the :Registrar-General. I t establishes the existence of a mortality from phthisis in Wales much higher than in England, associated also with a higher mortality from all other forms of respiratory disease. Ia 1928-1931 the Welsh mortality, which was most accentuated in the rural districts, was 56 per cent. in excess of that in England. Changes in the age-incidence of the mortality are reported, but the possible significance of these changes is largely discounted by the lack of any separation of the data according to sex; as the female phthisis mortality is much earlier in life than the male, any modifications of the sex distribution of the populations due to migration would tend to cause such changes. The phthisis mortality both in the urban and rural parts of individual counties is correlated inversely with the migration of the population. Counties affected by migration had higher death-rates, Whereas those affected by immigration had a lower mortality from the disease. The high mortality is mainly in four counties--Cardigan, Carnarvon, Carmarthen and hlerioneth (see p. 406). The mortality is not correlated with general hygienic conditions. Overcrowding is no greater in Wales than in England, and the correlation between this variable and the phthisis mortality both in the urban and rural areas of Wales is negative. Where families under the age of 16 were large--which m~y be taken as an index of nutritional insufficiency--the mortality tended to be low, instead of high. Nor could conclusive evidence be found that occupation was a sole d0termining consideration: But there are urban and rural areas in Wales where the incidence of phthisis is excessive; attention should now be directed to the anthropological characteristics of the populations concerned.
[June, 1935
In this connection possibly consideration should be paid to the blood groups in the populations, a "factor which Bradbury claims to be related to tuberculous manifestations (see T~lbercle, December, 1934, pp. 113-119). 12EISNER,D. The Relations between Extrapulmonary and Pulmonary Tuberculosis. ATner. Rev. Tub., 1934, 30, 875. Various observers have noted the apparent resistance to pulmonary tuberculosis of patients with skeletal tuberculosis, tuberculous lymphadenitis or lupus vulgaris. Asehoff and Roessler have comparatively recently stated thal~ there exists a positive antagonism between the so-called surgical forms of tuberculosis and pulmonary lesions. In the present comprehensive study the writer analyses the pulmonary findings in a large series of patients suffering from extrapulmonary forms of tuberculosis, with a view to ascertaining whether or how far such an antagonism exists, and further in what manner, if at all, the pulmonary lesions present in extrapulmonary tuberculosis differ from those in purely pulmonary cases. Among the conclusions arrived at were the following : In nearly half the cases studied (the material consisting chiefly of skeletal and genito-urinary lesions), the lungs were either entirely free from changes or at most presented evidence of an. obsolete primary focus. The differential analysis of the pulmonary changes from a morphological standpoint showed that some two-thirds of the cases with positive findings exhibited among the most prominent~ features discrete, nodular productive disseminations with a bilateral symmetrical distribution. The analysis of the material from the clinical standpoint showed timt only abolat one-filth of the total presented evidence of active pulmonary lesions. The pulmonary changes in extrapulmonary tuberculosis evidently represent in the majority of eases a part of a chronio progressive endogenous generalisation. Nodefinite antagonism could be noted between extrapulmonary and pulmonary involvement, as regards the actual frequency of the puhnonary changes; but the writer found a distinct antagonism in
J u n e , 1935]
1"Un~OmtRY TUBERCULOSIS
relation to the reinfection types of puhnonary tuberculosis, moreespeeially to the active and progressive forms. Attention is drawn to the fac~. that pulmonary tuberculosis presents a definitely more pronounced antagonistic relation to non-pulmonary involvement than tim converse, since manifest extrapulmonary lesions are conspicuously rare in the common forms of pulmonary tuberculosis. Extensive and progressive pulmonary tuberculosis is not a frequent cause of death in patients with extrapulmonary lesions, this fact affording additional evidence of the comparatively benign and non-progressive character of the pulmonary involvement in these cases. From the clinical and practical standpoint, it is pointed out that because of the particular frequency of clinically latent forms of pulmonary involvement in extrapulmonary lesions, X-ray examination may be the only way to decide the diagnostic issue. FELLOWS, H . H . Significant Active P u l m o n a r y Tuberculosis in the Apparently H e a l t h y Adult. Amer. Journ. Med. Sciences, 1933, t88,533. The writer, who is Assistant Medical Director, Metropolita n Life Insurance Company, New York, explains that up to seven years ago, in spite of a careful physical examination of applicants for employment in the H o m e Office of ~his Company, and in spite of the fact that any such persons either admitting a history of a condition associated with pulmonary tuberculosis or presenting u n u s u a l physical signs, received an X-ray examination of the chest, yet it was no~ unusual to detect advanced pulmonary tuberculosis in an employee shortly after a negative physical examination. An attempt was therefore made to determine (a) whether they were dealing with a type of disease of r a p i d onset and progression, or (b) whether their method of physical examination of the chest was inadequate. While the ideal method would be a routine X-ray film of each individual, both before employment and at each annual re-examination, the expense of this was considered prohibitive unless it was proved to be necessary. As a substitute, fluoroscopes were installed,
419
and each medical officer was trained to make a fluoroscopic examination of the thorax in addition to the usual physical examination. The experience gained with the fluoroscopic examination as carried out during the past seven years has convinced the medical staff of the great importance of this method. By its means 141 cases of puhnonary tuberculosis were discovered, the group including an encouragingly large proporLion of minimal cases. The majority of the cases (65 per cent.) were discovered before the patients became clinically ill, and before physical signs were evident. The diagnosis was confirmed at the Metropolitan Lifo Insurance Company Sanatorium in 131 cases (93 per cent.), and by the H o m e Office Medical Division, or outside agencies in the remaining 10 cases. Ninety-two patients (65 per cent.) were either completely free of symptoms or had only one symptom, not ia itself pathognomonte. Of the 131 cases who went to the sanatorium, 25 had a positive sputum, 12 a positive guinea-pig test, and 4 gave both at some time during the course of their treatment. Seventythree of the 131 sanatorium cases first had X-ray examinations because of a slightly suggestive history ; 28 of these had a positive sputum or guinea-pig test or both. Of the remaining 68 who had X-ray examinations because of fluoroscopic findings or as a routine re-examination, 13 had positive sputum or guinea-pig test or both, during treatment. In the whole series there were only 26 known or questionable cases of contact. WAGNER, H. S. Symptoms as a Measurement of Tuberculous Activity. lgew England Journ. Medicine, 1934, 21t, 237. 4~ Of the constitutional symptoms, fever, rapid pulse-rate, weakness, emaciation, loss of appetite, and sweating, the last four are usually the first to lessen as general improvement begins. Fatigue or sense of exhaustion is a serious symptom if there is little remission and a nervous element can be ruled out. T h r e e symptoms, cough, expectoration and hmmoptysis, have to do with the presence of tubercles as they enlarge