current literature

Current Literature R E V I S T A DE T U B E R C U L O S I S DEL

U R U G U A Y . VOL. viii No. 2 1939

Valor semiologico del signo radial dura en los estados infecciosos de etiologia tuberculosa. (Symptomatological value of the hard radial in tuberculous infections.) A. R. Gin6s. lol.

*Hemoptisis consecutivas a cutireacciones practi- cadas en tubereulosos pulmonares. (Haemoptysis following eutireactions in pulmonary tuberculosis.) F. D. Gomez andJ . C. Negro. Io6.

*Cuerpo fibrinoso intrapleural. (Intrapleural fibrinous body.) J. C. Negro and A. R. Ginds. 11 I.

Nuevo contribuci6n a la patogenia de los derrames controlaterales en el curso del neumotorax. (A fresh contribution to the pathogenesis of contralateral effusions in artificial pneumothorax.) J. C. Negro and A. R~ Gin6s. 115.

*Tomografia pulmonar (II) Ouistes a6reos. (Pul- monary tomography (II) Air cysts.) S. Grezzi. 119.

*Atelectasia masiva posthemoptoiea por tuberculosis pulmonar. (Massive atelectosis following tuberculous haemoptysis.) A. C. Artagaveytia. i~ 9.

*Tuberculosis y silicosis. (Tuberculosis and silicosis.) R. A. P. Blanco and J. C. Dighiero. i39.

Eficacia del cloruro de sodio por ingestidn en los vdmitos y estado nauseoso de los tuberculosos pulmonares. (Efficacy of sodium chloride by mouth in vomiting and nausea in pulmonary tuberculosis.) F. D. Gdmez and A. R. Gin,s. I46.

*][,as hemorragias digestivas graves y mortales en ie tuberculosis gastrointestinal. (Severe and fatal haemorrhages in the digestive tract in gastrointestinal tuberculosis.) R. A. P. Blanco and J. A. Sciuto I49.

*Epitelioma intrabrdnquico a evolucidn lenta. (Intrabronchial epithelioma of slow course.) J. A. Sciuto, R. A. Caimi andJ. C. Dighiero. x59.

*Diagnostico radiologico de los quistes pulmonares. (Radiological diagnosis ot pulmonary cyst.) S. Grezzi. 165.

*Consideraciones que se desprenden del estudio de 51 casos de asociacidn tuberculosis y embarazo. (Remarks on 51 cases of the association of tuberculosis and pregnancy.) A. Sarno and A. C. Artagaveytia. I87.

*Eritema polimorfo y tuberculosis pulmonar. (Erythema multiforme and pulmonary tubercu- losls.) R. A. P. Blanco and J. C. Dighiero. 2o 3.

*Un nuevo caso di silicosis a forma tumoral. (A new case of silicosis simulating a tumour.) R. A. P. Blanco and F. G. Capurro. 2o 9.

*Nuevos casos de hemoptisis consecutivos alas dermo- reaceiones tubereuffnicas. (New cases of haemoptysis following tuberculin cutireactions.) J. C. Negro and A. R. Gin6s. '213.

*Sobre un ca.so de infiltrados l~biles. (On a case of transient infiltrations.) M. F. Vignoli and N. Caubarr~re. 215.

*Accidenti nervioso de puncidn en el neumoperi- tones. (Nervous complication of puncture in pneumoperitoneum.) J. C. Negro. 292.

*Congestiones pulmonares provocadas por el sol. (Pulmonary congestion caused by the sun.) A. R. Gin's. ~2 5.

Haemoptysis following cutireactions in pulmonary tuberculosis.--The authors, who describe an illustrative case in a child aged 12, carried out 1,475 cutireactions in 6I 7 cases of tuberculosis, and tbund that in I5, more or less profuse haemoptysis occurred in from 20 to 72 hours after the test.

Intrapleural fibrinous body.--The authors, who record a case in a woman, aged 23, undergoing artificial pneumothorax, state that only two examples of this condition occurred in their practice among 33 ~ cases of artificial pneumothorax.

Pulmonary tomography (II) Air cysts.--A record of two cases in men aged 52 and 6o in whom tomography proved infinitely superior to the standard method of radiological examination.

Massive atelectasis following tuberculou~ haemoptysis.--A record of a case in a man, aged 28. The author maintains that the frequency of this condition would be found to be greater if radiography was carried out in all cases immediately after haemoptysis, as the atelectatic zones become rapidly supplied with air in most cases.

Tuberculosis and silicosis.--The authors record two cases in patients, aged 36 and 42, in whom there was no doubt as to the existence of tuberculosis, whereas the presence of silicosis was doubtful. From the forensic aspect the patients could be regarded as examples of silicosis, owing to the nature of their occupation ; whereas, from the medical point of view the association of silicosis with pulmonary tuberculosis was doubtful.

Severe and fatal haemorrhages in the digestive tract in gastro-intestinal tuberculosis.--A record of two cases. The first was one of severe and fatal haemorrhage from the intestine in a youth aged I8, in whom multiple ulcers were found in the caecum post mortem. The second case, whose age is not given, was one of repeated haematemesis. The stomach showed the appearance of linitis plastica on radiographic examination.

Intrabronchial epithelioma of slow course.-- A record of two cases in men, aged 51 and 52. In the first the disease lasted one year and three months, and in the second the

36_0 TUBE

patient was in a fairly good condition after the disease had lasted eighteen months. Radiological diagnosis of pulmonary cysts.--

A radiological diagnosis may be possible in some and impossible in others. A complete radiological examination is required, including radioscopy, radiography in diff- ent positions, diagnostic pneumothorax and tomography. Tomography, which is a safe and inexpensive method, should be performed before the intratracheal injection of lipiodo] and diagnostic pneumothorax.

Remarks on 51 cases of the association of tuberculosis and pregnaTicy.--The authors' conclusions are as follows: (I) The general course of the disease depends upon the anatomo-clinical form of tuberculosis ; (2) the exudative and fibro-exudative forms of tuberculosis, usually show a progression of the lesions, during pregnancy and still more so in the puerper ium; (3) these forms may run a favourable course if treated properly; (4) patients treated by artificial pneumothorax do not show a reaction, either during pregnancy or the puerperium ; (5) in the productive forms of tuberculosis pregnancy does not entail any special complications, local or general ; (6) in these forms multiple pregnancy may cause a change in the favourable prognosis ; (7) forms with cavities do not indicate a bad prognosis from the mere existence of cavities, especially when they are accessible to active surgical t reatment ; (8) in cases in which the onset of tuberculosis coincides with the commencement of pregnancy the prognosis depends on the probability of carrying out an active treatment of the tuberculous process. The same may be said of tuberculosis which sets in during the puerperium. Nine tuberculous patients who had been cured by artificial pneumothorax may become pregnant without any special complications.

Er~thema multiforme and pulmonary tuberculos#. record of the case of a man, aged 3 o,

who suddenly developed polyarthritis followed four days later by typical erythema multiforme, and a few days afterwards by erythema nodosum. The intradermo- reaction was strongly positive, and tubercle bacilli were found in the sputum. The authors' conclusions are as follows: (i) Tuberculosis sometimes plays a part in the aetiology of erythema multiforme ; (2) in the.presence of erythema multiforme the possibility of tuberculous infection should

R C LE August-September I 9 4 o

be considered under the following circumstances : (a) A strongly positive tuberculin reaction; (b) the coexistence of papulo- necrotic tuberculides with erythema multiforme; (c) the cGexistence or subsequent appearance of pleuro-puhnonary lesions; (d) the absence of any other obvious cause. A new case of silicosis simulating a tumour.--

Silicosis may sometimes show a radiographic picture simulating carcinoma of the lung. The diagnosis in such cases may be settled by radiography, bronchoscopy, bron- chography with lipiodol and histological examination of the sputum. In the most difficult cases, the authors have obtained excellent results by examination of the cells obtained by puncture of the lung.

New cases of haemoptysis following tuberculin cutireactions.~A record of 3 cases in which a tuberculin cutireaction was followed by haemoptysis in twenty-four hours in one and in forty-eight hours in the other two. The reactions were positive in all. One of the patients had never had haemoptysis before. The practical conclusion is that in tuberculous patients the cutireaction should always be carried out under medical supervision.

On a case of transient infiItrations.--A record of a typical case of Loeffier's syndrome, i.e. transient pulmonary infiltration with eosinophilia in a girl, aged 7" The eosinophilia ranged from 8 to 5 per cent. Nervous complication of puncture in pneumo-

peritoneum.--A record of an apparently unique case in a Woman, aged 34, in whom puncture in pneumoperitoneum was followed by an ictus similar to that sometimes seen after artificial pneumothorax. Recovery took place in a few hours.

Pulmonary congestion caused by the sun.-- A record of two cases, one in a girl, aged II and the other in a youth aged x S, of transient pulmonary congestion which followed prolonged exposure to the sun on the sea-coast during the summer. The author agrees with Wieland in regarding many cases of Loeffler's syndrome as due to the same cause.

ARCHIVOS A R G E N T I N O S DE ENFERMEDADES DEL APARATO R E P I R A T A R I O Y TUBERCULOSIS VOL. vzt Nos. 7 AND 8 JULY-AuGusT, ~939

*Tumores primitivos malignos broncopolmonares. (Primary malignant bronchopulmonary tumours.) .I. Palacio and E. S. Mazzei. 189,

Augus t -Sep tember i94o

Nos. 9 AND IO SEPTEMBER-OCTOBER

*Tumores primitivos malignos broncopulmonares. (Primarymalignant bronchopuhnonary tumours.) J. Paiacio and E. S. Mazzei. 243.

*Pleuresias contralaterales en la colapsoterapia. (Contralateral pleurisy in collapse treatment.) J. L. Bouilla and E. Kozameh. 262.

Primary malignant bronchopulmonary tumours.-- The authors review the literature, including the history, frequency, age, sex, ante- cedents, pathogenesis, morbid anatomy, histology and clinical aspects and record their observations on I I2 cases of pr imary malignant growths of the lungs which occurred among 9,352 necropsies performed at the Tel~maco Susini Institute of morbid anatomy at Buenos Aires between i897 and I936. The ages of the patients ranged from 26 to 75, 94 .6 per cent being in men and less than 6 per cent in women. In 6o per cent the tumour was present in the right lung and in 4 ~ per cent in the left. In 5 ~ per cent the upper lobe was affected, in 2 5 per cent the lower, in 8 per cent the middle lobe and in the remaining 17 per cent there was a diffuse distribution of the lesions. The distribution of metastases was as follows : tracheo-bronchial adenopathy 25 per cent, hilar adenopathy 3 ~ per cent, cervical adenopathy 3 per cent, pleura 4 per cent, diaphragm 6 p.er cent, pericardium 6 per cent, opposite lung IO per cent, liver 2o per cent, suprarenals 22 per cent, brain 14 per cent, kidneys ~8 per cent, mesenteric glands 2 per cent, Douglas's pouch I per cent, and pancreatic glands i per cent.

Contralateral pleurisy in collapse treatment.- The authors who record four illustrative cases in patients, aged from 13 to 26, state that contralateral pleurisy is tuberculous in character, as is shown by the clinical symptoms, its lymphocytic nature, the positive result of inoculation and the morbid anatomv. Its occurrence is rare, its percentage being between i and 2. Its prognosis varies, but should always be guarded. Treatment depends on the inten- sity of the effusion, dyspnoea, presence of toxic symptoms and the existence or otherwise of subjacent pneumonia. When the dyspnoea is intense and the symptoms of intoxication are severe, the effusion should be evacuated, while subsequent measures will depend on the necessity or otherwise of replacing the fluid by gas or of making a bilateral pneumothorax,

T U B E R C L E 363 Nos ! I AND I2 NOVEMBER-DECEMBER

*Radiologia clinica del cancer broncopulmonar. (Clinical radiology of bronchopulmonary cancer.) J. Palacio and E. S. Mazzei..079.

Clinical radiology of bronchopulmonary cancer.- The authors discuss this subject under the following headings : (I) Radiology of the pr imary process in the lung; (2) Radi- ology of complications, such as dia- phragmatic paralysis, atelectasis, pleural effusion and cavity formation ; (3) tomo- g r aphy ; (4) radiology after artificiM pneumothorax ; (5) radiology after irra- diation ; (6) bronchographic radiology.

R E V I S T A ESPANOLA DE T U B E R C U L O S I S

VOL. IX No. 6I MARCH, I940

*Los propagaciones intrabrdnquicas de la tuberculosis pulmonar. (Spread of pulmonary tuberculosis into the bronchi.) J. M. I. Parga and F. S. de Leon. I57,

El movimemo pendular del mediastino en la colapsoterapia bilateral, (Pendulum movement of mediastinum in bilateral collapse therapy.) J. Zapatero and V. Mingarro. I66.

*Las perforaciones pulmonares y el peligro de los neumotorax incompletos. La toracoplastia com- plementaria. (Perforations of the lung and the danger of incomplete pneumothorax. Supple- mentary thoracoplasty.) J. J. Carbaio and S, G. Blanco. 186.

*Sobre la broncoespiroquetosis de Castellani. (On Castellani's bronchospirochaetosis.) A. H. Diaz. 2I 3 .

*La clinica de las neoplasias malignas. (Clinical aspects of malignant growths of the lung.) V. Lambea. 2t8.

Spread of pulmonary tuberculosis into the bronchi.--In a study of 543 cases of pulmonary tuberculosis in adults, the authors found only 12 patients, who in their stay in a sanatorium developed fresh lesions in areas hitherto healthy on radiological examination, and in whom the probable mechan- ism of formation was the spread of infective matter by the bronchi. In none of these cases was collapse treatment employed, nor was tuberculin given in any instance. All showed tubercle bacilli in the sputum, which in IO cases was very profuse, and I I had a n intense cough. The original lesions were situated in the upper third of the right lung in Io cases and in the upper third of the left lung in 2. Of the Io cases with pr imary lesions in the right lung, a lesion was found in the opposite lung in 7, while in the other 3 there was a lesion on the same side.

364

Perfo~'alioJ~s of the lung and the danger of h~complete pt~eumolhorax. SupptemeJzla,y thoracoplasty.--A record of 5 cases in patients, aged from r 9 to 37. Perforations of the lung which occur in the course of artificial pneumothorax kept up for a long period, give rise to a fistulous pneumothorax, which if left to palliative treatment may end fatally. Artificial pneumothorax, which is inadequate owing to the presence of dense adhesions, should not be continued indefi- nitely, since it endangers the life of the patient. The adequate treatment in such cases consists in prophylaxis by means of thoracoplasty, which facilitates closure of the cavity, and removes the risk of perfora- tion of the lung. The post-operative course of thoracoplasty under these circumstances is milder than in patients who have not undergone artificial pneumothorax.

Castellani' s bronchospirochaetosis.--A record of three typical cases. The first which was that of a man, aged 4 I, was an example of the acute pseudo-influenzal form. The second, which was that of a man, aged 24, was an example of the chronic form simulating pulmonary tuberculosis, and in the third which was in a man, aged 57, there was an association of Vincent's disease with pulmonary tuberculosis. In Castellani's bronchospirochaetosis, as in Vincent's disease, arsenical treatment is that most frequently employed either by mouth or injection.

Clinical aspects of malignant growths of the lung.--A clinical lecture dealing with errors in diagnosis, frequency of the disease, age and sex, symptoms including fever, haemoptysis, pain and nervous syndromes ; complications, such as atelectasis and pleurisy, haematology and bronchoscopy.

VOL. IX NO. 62 APRIL, i94o

*ParJ.llsis nerviosas perif~ricas consecutivas al empleo terap6utico de las sales de oro. (Peri- pheral neuritis following treatment by gold salts.) A. C. Alvarez, P. C. de la Torre and E. S. Martinez. 24r.

*Sobre el aumento brusco de tamafio de las cavidades tuberculosas y discusi6n de su patogenia. (On the sudden increase in size of tuberculous cavities and discussion of their pathogenesis.).]. C. Suque. 250.

*Nuestra experiencia sobre el neumot6rax extrapleural. (Our experience of extrapleural pneumothorax.) P. Recondo. _o62.

*Estudio de la medula 6sea en la tuberculosis pulmonar. (Study of the bone-marrow in pulmonary tuberculosis.) E. R, Ferngndez. '27,o.

TUB ~ R e LE Augus t -Sep tember 194 ~

Patogenia de las tuberculosis pulmonares hemgticas. (Pathogeuesis of haematogenous pulmonary tuberculosis.) . I . M . I . Parga. 279.

Peripheral Jzeuritis" followbg treatme**t by gold salts.--A record of" two cases in which the diagnosis was based on the absence ofanv other factor, the rapid disappearance of the paralysis after suspension of the treatment, the presence of other signs of intolerance for gold salts (colic and dia- rrhoea), and the report of similar cases in the literature. The first case was that of a woman, aged 29, with bilateral fibro- caseous pulmonary tuberculosis, who developed bilateral musculospiral paralysis after intravenous injection of a total amount of I T8" 5 cg. sanocrysin. The second case was that of a man, aged 54, with fibroid pulmonary tuberculosis, who developed right facial paralysis after intravenous injection of a total dose of 2"51 g.

On the sudden increase in size of tuberculous cavities and discussion of their pathogenesis.--A record of case in a girl, aged 19, of sudden increase in size of a cavity in the right lung, which was incompletely compressed by artificial pneumothorax, owing to the presence of multiple adhesions. Rapid return to its normal size took place in the course of twenty days. The increase in size was attributed to a valvular obstruction on expiration of the drainage bronchus which was probably caused by an exacerbation of the lesions.

Our experience of extrapleural pneumothorax.-- A record of six cases. The indications for performance of extrapleural pneumothorax are as follows : Recent lesions, or at least lesions which are not surrounded by dense fibrous walls, and patients in whom thoracoplasty is indicated, but whose general condition or the presence of lesions in the opposite lung forbids its performance. The operation of extrapleural pneumothorax is relatively simple, but the difficulties increase with its maintenance. The early results are good, but its efficacy must be estimated by the remote results, extrapleural pneumothorax having to be kept up for two years in the case of recent lesions, and for three or four years in those of old standing. I f extrapleural pneumothorax fails and thoracoplasty has to be performed, it should be carried out at once, owing to the technical difficulties and the failures likely to occur in the presence of muscu!o- pleuro-pulmonary adhesions,

August-September 1 9 4 ~ T U B E

Study of the bone-marrow in pulmonary tuberculosis.--Fernimdez made a study of the bone-marrow in 51 cases of pu lmonary tuberculosis with the following results: (I) No myeloblasts nor promyeloblasts were encountered. (2) Degenerative changes in the nucleus and protoplasm were found and generally corresponded to the extent of the parenchyma involved and the gravity of the clinical condition. (3) The relation of the immature to the mature forms was approximately i to Io, this pro- port ion being low in the severe forms and high in the mild ones. (4) There was a dis- sociation between the bone-mar row and the blood as regards the monocytes and eosinophils. While the former were re- markably scanty in the bone-marrow and were constantly found in the blood, the latter were found in the bone-mar row sometimes in increased amounts, and were scanty in the blood. (5) There were no remarkable changes in the lymphocytes and plasma cells. (6) The average number of red cells was 22 '6 per cent. No megaloblasts were seen. (7) There was a certain parallel- ism between laboratory data (sedimentation rate, blood-count and presence of bacilli) and the findings in the bone-marrow.

N O R D I S K M E D I C I N No. 17 APRIL 27, 194o

*Sanocrysin--og vitaminbehandling red ledlidelse ledlidelse (og tuberkulose). (Sanocrysin and vitamin treatment in joint disease and tuberculosis.) K. Secher. 82I.

Sanocrysin and vitamin treatment in joint disease and tuberculosis.--Like other observers Secher found a low ascorbic acid content in the blood in several conditions and especially in joint disease and tuberculosis. Administrat ion of vitamins and especially ascorbic acid removed the risk of thrombo- penia and reduced the risk of dermatitis to a minimum. The presence of large quantities of ascorbic acid in the blood facilitated the administration of large doses of sanocrysin both in joint diseases and tuberculosis, and gave rise to better results. In conclusion Secher shows that the changes in the carbohydrate metabolism demonstrated by Pemberton are due to a lack of ascorbic acid.

No. I9 MAY I I, I94 ~ *Om arterielle an/imi nos barn. (On arterial anaemia

in children.) B. Hamne. 9o5 . On arterial anaemia in children.--Hamne,

R C L E 365 who records i i cases in children aged from 7 to I2, states that the arterial anaemia described bv Bjure and Laurell in adoles- cents, m a y ' a l s o occur in children. Early t reatment by suitable diet, rest and abdo- minal support will not only cure the condition, but will also prevent the onset of pu lmonary tuberculosis.

VOL. Vl No. 2. ~ JUNE I , I94 o *Tuberkuloseunderokelsen av skolepersonalet i Oslo.

(Examination for tuberculosis of the school staff at Oslo.) G. Hertzberg. 985 .

*De medicinska indikationerna f6r thorakoplastik. (The medical indications tbr thoracoplasty.) J. Lundquist and A. Odelberg. 989 .

Examination for tuberculosis of the school stq~ at Oslo.--The staff of the pr imary schools at Oslo consists of the following four g roups : (I) public school teachers ; (2) business school teachers ; (3) school hygienists ; and (4) school attendants. The percentage morbidi ty among the different groups was as follows: public school teachers i .I, business school teachers o, school hygienists I, and school at tendants 2"I. Destructive forms of pu lmonary tuberculosis were found in 0. 4 per cent of the public school teachers, and in 0. 7 per cent of the school attendants.

The incidence of tuberculosis, therefore, was the same among the public school teachers as that of the populat ion of Oslo, while that of the school attendants was higher.

The medical indications for thoracoplasty.--The authors record their observations on 83 cases of thoracoplasty, 52 of which were in men, and 31 in women, at the Solliden Sanator ium during the period i932-38. Dur ing the first part of this period total paravertebral thoracoplasty was performed in two stages, while during the later par t thoracoplasty was combined with resection of the transverse processes.

The immediate mortality, i.e. death within three weeks of the operation, was 7.2 per cent and the late mortal i ty x5" 7 per cent more. The general indications for operat ion were a good general condition, normal temperature, stable or rising weight, and stationary or falling sedimentation rate. The falling in of the affected half of the thorax is not indispensable, but was noted in two-thirds of the author 's cases, exclusive of the fibro-ulcerative

366

lesions with cavitation. The prognosis was the same in both groups. The presence of bilateral lesions is not an

absolute contra-indication. The authors treated I8 cases of active lesions on the opposite side, 6 of which showed cavities. In the last group bilateral thoracoplasty was performed in 3, with a good result in 2. Most of the cavities were situated in the pulmonary apex, 79"5 per cent became free of bacilli after the operation.

After being kept under observation for three and a half years, 6" 9 per cent were still ill, lO- 3 per cent were capable of light work and 55"5 were quite well.

VOL. vI No. 23 JUNE 8, I940

*Ore Forekomsten af Pneumococcer nos Pneumo- coepneumoni-reconvalescenta. (On the occurrence of pneumococci in convalescence from pneumoeoecal pneumonia.) M. Pedersen. IO39.

*Ore obduktionsmittofaran (spee. TBC) och dess f6rhindrande samt n8gra ord om inkubation- stiden vid aerogen medsmitting med bovin TBC (On the danger and prevention of infection (especially luberculosis) during necropsies, and a few words on the incubation period in aero- genous infection with bovine tubercle bacilli.) R. F. 0hnell. IO45.

O n the occurrence of pneumococci in convalescence ./kom pneumococcal pneumonia.--Pedersen made 736 examinations of 73 patients with pneumococcal pneumonia for the presence of pneumococci in the sputum or throat swab, with the following results. In some patients the pathogenic strain of pneumococcus was found for a few days only, while in others it was present for weeks or months. Eight days after admission the pathogenic strain of pneumococcus persisted in 5 ~ per cent at least, and seventeen days after admission in at least 25 per cent. One third of the patients were discharged with the pathogenic type still in their respiratory passages. Pedersen concludes that con- valescents form part of the sources which maintain and spread infection among the population.

On the danger and prevention of infection (especially tuberculosis) during necropsies, and a .few words on the incubation period in aero- genous infection with bovine tubercle bacilli.--A record of a case of bovine pulmonary tuberculosis and erythema nodosum in a veter- inary student, who was probably infected during a post-mortem examination. The incubation period was about a fortnight.

w u B t R c L E Augus t -Sep tember 194 ~

J O U R N A L DE M E D I C I N E DE LYONS No. 487 APRIL 2O, X940

*La ndphrite chronique urdmigbne tuberculeuse ldsions folliculaires bilatdrales et dissemindes.

(Chronic tuberculous uraemigenic nephritis with bilateral and disseminated follicular lesions.) P. P.-Ravault, M. Girard, and R. Gendreau. I39.

Chronic tuberculous uraemigenic nephritis with bilateral and disseminated follicular lesions.- The writers point out that there are Ibm' groups of cases which may fairly come under the heading of a chronic tuberculous uraemigenic nephritis: (I) bilateral and diffuse sclerous nephritis, without any specific histological characteristics, but of which the tuberculous origin is confirmed by the clinical context (pulmonary, glandular, or osseous tuberculosis) ; (2) a group of amy- loid diseases which, attacking the renal parenchyma and bringing about not only degenerative changes in glomeruli and blood-vessels but also a marked sclerous reaction, lead in the later stages of their course to certain cardio-vascular bruits and above all to uraemia; (3) a g roup - -by far the most important-- represented by sclerous nephritis associated with or consecutive to surgical renal tuberculosis; (4) a form characterized by multiple tuberculous follicles and a diffuse interstitial nephritis. These follicles, more or less numerous, are buried in a diffuse bilateral sclerosis usually with an atrophic tendency, of which the tuberculous nature is irrefutably demonstrated. This form of chronic tuberculous uraemigenic nephritis, with bilateral and disseminated follicular lesions, is rarely met with, and hence the report of a typical case of this kind is of some interest.

The patient, a wolnan aged 34, gave a six-months' history of muscular contrac- tions of the hands and arms which were diagnosed as tetany, and for the last two months jaundice, accompanied by vomiting and pain in the epigastrium, shoulders, and lumbar region. The ~etiology of the nephritis could not be determined at first, and in view of increasing uraemia with no improve- ment in the clinical symptoms, a right de- capsulation was carried out. Biopsy suggested the tuberculous origin of the disease. Two months later the patient died from uraemia with progressive azotaemia. At autopsy unmistakable multiple tuberculous follicles were found, a diffuse interstitial nephritis with considerable glomerular and vascular lesions. No other tuberculous foci

August-September I94O T U B E

were found, in spite of most careful search, and the writers throw out the suggestion that this may possibly have been a case of true pr imary renal tuberculosis.

No. 488 MAY 5, 194o

*Le traitement des cavernes pulmonaires tubercu- leuses par le drainage et l'aspiration endo- cavitaire de Monaldi. R6sultats remarquable obtenu sur une caverne gdante. (The treatment of tuberculous pulmonary cavities by drainage and Monaldi's endocavitary aspiration. Remark- able results obtained with an enormous cavity.) Bonafd and R. Acquaviva. I61.

The treatment of tuberculous pulmonary cavities by drainage and Monaldi's endocavitary asp#a- tion. Remarkable results obtained with an enormous cavity.--The external drainage of pulmonary cavities, permitting direct endocavitary aspiration, is a new therapeutic method, and one which was greeted with some scepticism owing both to the fear of consequences from the inevitable pulmonary t rauma and to the possibility of tubercular- izing the thoracic wall. Nevertheless, the method is capable of giving such remarkable results that the writers show four radiograms of the successful treatment by this method of an enormous cavity occupying practically the whole of the left hemithorax. The third radiogram, taken four days after the drainage of the cavity, showed an amazing reduction in the size of the cavity, proving that this was not a simp]e destructive lesion which had obliterated five-sixths of the parenchyma of the left lung, but was one in which the high intracavitary pressure had provoked an extensive atelectasis around the lesion. Drainage had thus enabled the peripheral pulmonary parenchyma, hither- to in a state of atelectasis, to recover its normal expansion. In the fourth radiogram, four months later, the cavity was seen to have been reduced to a quarter of its initial size, and for a quarter of its height the parenchyma was fully re-expanded. Con- tinuous endo-cavitary aspiration has been instituted in the hope of bringing about a complete cure of this gigantic lesion which had at first appeared far beyond any possibility of therapeutic treatment.

VOL. xxI No. 491 JUNE 20, 1940

Calcifications pleurales s6quelles tardives des hdmothorax traumatiques. (Pleural calcifications as late sequelae of traumatic haemothorax.) Hugonot. 226,

Although calcareous concretions of the

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pleura have been recognized for a long time, their presence has until recently only been established at autopsy. The writer in the course of special x-ray examinations of ex-service men for pension tribunals, discusses four such cases which came under his notice. In all these the pleural concretions were of the common calcareous plaque type, situated posteriorly, usually elliptical in shape with its long axis parallel to the spine. The thickness of the plaques was variable, ranging from a few ram. to 3 cm. All the writers who have studied pleural calcifications are agreed that their formation postulates, to begin with, a chronic inflammation of the pleura, mechanical or infectious in origin, leading to the formation of adhesions or symphyses. Secondarily, this fibrous tissue undergoes a hyaline degeneration, and the collagenous fibres become transformed into an amor- phous substance, unorganized and without cells or vessels. I t is in this degenerated and ill-nourished tissue that after a lapse of time which may range from one to fifteen years, a calcareous infiltration develops. This is clearly seen by a study of the plaques, calcified in the centre, hyaline and fibrous at the edges, continuing without a line of demarcation into the neighbouring serous membrane. Histologically these plaques differ from ossifications found in muscular osteomata; they are simply diffuse deposits of calcium salts in cicatricial adhesions. Any factor of pleural irritation, whether sub- acute or chronic, may lead to more or less permanent neoformations, or, com- paratively rarely, to calcareous infiltrations. These infiltrations are, however, relatively much more frequent following a traumatic haemothorax, as in war wounds of the thorax with resulting loss of blood. All four of the cases now reported were of this type, whereas the writer had met with only two other cases of pleural concretions, with a different history, one being consecutive to a sero-fibrinous pleurisy, and one a cyst with calcified walls consecutive to an intervention for amoebic abscess.

These pleural calcifications do not appear to add in any way to the gravity of the case. They are well tolerated, and the prognosis depends on the nature and extent of the concomitant pleuro-pulmonary lesions.

368

J O U R N A L OF P A T H O L O G Y AND B A C T E R I O L O G Y

VOL. LI JULY I94O

*Choleslerol pleural effusion. H. H. Moll and F. S. Fowweather. 37

Cholesterol pleural effusion.--The authors note that the condition is a rare one, only 44 cases having been found in the literature up to I929 .

They describe a case in a man who had had a pleural effusion at I7; at 27 this recurred, and the fluid, removed through a greatly thickened pleura, was haemorr- hagic, with a heavy sediment of red cells, leucocytes and cholesterol crystals, leaving a greenish fluid above with a glistening film on the surface; all bacteriological examinations were negative: the initial cholesterol content was o.26 per cent, but fell with successive aspirations to o.o 9 per cent. Two years later the effusion again recurred, the cholesterol content this time being o'18 per cent, while the protein was 6. 4 per cent, made up of 3"o per cent albumin and 3"4 per cent globulin.

Cholesterol pleural effusions are chronic and associated with marked pleural thick- ening, so that pressure symptoms are usually absent, though pain in the chest and dry cough may occur; a distinctive feature of the fluid is the sheen caused by the cholesterol crystals.

The aetiology is similar to other chronic effusions, evidence of tuberculosis having been found in about half the cases, and all except one have been in adults; the concentration of cholesterol in the effusion appears to be independent of the blood cholesterol.

In analysis of fluids in which no crystals were present, cholesterol concentration of over o.I per cent have often been found, with protein contents up to 6 per cent; what, therefore, determines the presence of cholesterol in crystalline form?

For various reasons haemorrhage into the fluid does not appear to be the determining factor.

Desbordes and others, examined the power of pleural fluids to absorb or precipitate cholesterol when placed in contact with the crystals; old fluids had a marked precipi- tating power, but it only occurred when they came into contact with solid cholesterol, i.e. they were super-saturated. Once precipitation has taken place by some chance, it is therefore likely to continue; they found that this power depended on

T U B E R C L E August -September 194 ~

changes in the albumin/globulin ratio; in early effusions, when the cholesterol tends to dissolve, the albumin is greatly in excess of the globulin, but the ratio changes as the fluid ages in situ, until finally cholesterol tends to be crystallized out: they therefore came to the conclusion that the albumin/ globulin ratio was the deciding factor in determining whether the fluid dissolved or precipitated cholesterol ; Desbordes' figures for these ratios are given, and the authors' case is shown to fit in with the group where precipitation of cholesterol would tend to occur.

The condition of cholesterol pleural effusion does not, therefore, differ from other chronic effusions, except that, as the age of the fluid increases, there is a progressive tendency for cholesterol to precipitate out, until chance contact with the solid causes this to occur, or even, in extreme cases, spontaneous precipitation takes place.

VOL. L1 SEPTEMBER, 194o

*Pneumoconiosis in coal trimmers. J. Gough. 277. *The silica content of tissues, with and without

silicotic lesions. E. J. King and T. H. Belt. 269. *The silieotic nodule in human and experimental

silicosis a comparative study. T. tt. Belt, A. A. Ferris and E.J. King. 263.

Pneumoconiosis in coal trimmers.---Trimmers work in an atmosphere thick with coal dust ; this dust has been regarded as fairly innocuous, but the author concludes that its accumulation may lead to severe lung fibrosis.

The material was drawn from autopsies on twelve trimmers who had been exposed to steam-coal dust for many years, but had not worked in the mines where they might have come into contact with other mineral dusts. These are divided into five in whom pneumoconiosis was the main cause of death, three with marked fibrosis but dying of other conditions, and four with mild fibrosis.

The cases are all described individually, with histories, autopsy findings and histological reports, and good photographs of x-rays, lungs at autopsy and microscopical features are given.

The pneumoconiosis of coal trimmers shows two types of fibrosis, the discrete nodular and the massive; the former type was present in all the cases described, and the latter in the seven most severe ones. Often almost whole lobes were fibrosed and jet black, the upper, middle and hilar areas of the lungs being most affected, occasion-

Augus t -Sep tember I94O

ally with cavities containing black fluid. Histologically carbon was the most prom- inent feature in the smallest nodules, but in larger ones fibrous tissue was abundan t ; the fibres were arranged radially, in contra- distinction to the concentric arrangement of silicosis, and the tissue was apparently not so dense as in this latter disease. Some of the nodules contained blood-vessels and bronchi within them, while others showed air spaces or surrounding emphysema.

In the massive areas of fibrosis, tl 'e carbon lay between, rather than in, the bundles of fibres, which were thick and acellular, and the distribution suggested diffuse fibrosis from the outset rather than coalescing nodules.

Although these few cases probably represent only a small percentage of the deaths in the industry, they show that there is a high incidence of lung fibrosis among coal trimmers, since not one of them wholly escaped it, and in five it was the direct cause of death. The autopsy findings were practically identical with the anthraco- silicosis met with in coal miners, and both differ in certain respects from pure silicosis ; although the pure coal dust breathed by the trimmers contains a small amount of silica, it appears possible that the carbon itself is responsible for the particular type of fibrosis produced, though at least twenty- five years' exposure is necessary to produce a disabling lesion.

The author 's conclusion regarding the pathogenesis of this fibrosis cannot be precise, but there is no doubt that in trimmers, prolonged exposure to coal dust in high concentrations leads to a pneumoconiosis similar to that accepted as anthraco- silicosis in coal miners.

The silica content 4" tissues, with and without silicotic lesions. - - The article records a quantitative study of the silica content of lungs and root glands of human subjects, both silicotic and non-silicotic ; the purpose is to show that the presence of abnormal quantities of silica in human tissues does not necessarily point to a diagnosis of silicosis, nor lead to the presence of the specific silicotic nodule.

The lungs of thirty-five persons with long exposure to siliceous dusts and the bronchial glands of one hundred and thirty without such exposure were studied, chemical analysis and micro-incineration being used.

In the analysis of lungs from the first

TUBERCLE 369

group, high percentages of silica were found both in those with frank silicosis, and in those with no histological evidence of the disease, and almost as low values were found amongst the silicotics as amongst the non-silicotics; tables are given to demonstrate the authors' findings.

Although other workers have come to the same conclusion, the view ~till prevails that excess of silica in the tissues means silicosis. This belief cannot be accepted. Although it may be argued that qualitative differences in the inhaled dust may account for this discrepancy, cases fi'om the same occupation are represented in both the silicosis and non-silicosis groups in this article, so that the degree of silicosis appears to be independent of the concentration of silica. The cases in which no special exposure to siliceous dusts had occurred were taken from the routine hospital autopsies, and were chosen so that all age-groups were represented; root glands were examined because these had been found to be the natural reservoirs of silica in normal individuals.

Embryonic tissues contain a very small percentage of silica, but even in the first decade of life considerable amounts accu- mulate in the bronchial lymph nodes, and with advancing age this shows a marked increase. The lungs only show normal amounts of silica, even in those individuals with large accumulations in the glands.

The large amounts of silica in the glands have not produced silicotic lesions and only a small amount of fibrous tissue, in spite of the fact that in older people much of this silica must have been present for many years. These deposits may represent the accumulation of the most insoluble--and therefore least harmful--particles, and there is no doubt that the lungs can handle small amounts of dust without damage. I t is necessary, therefore, to know the nature of the siliceous material as well as its total concentration, so that a basis may be established for the relationship between the production of fibrosis and the presence of mineral matter. An investigation into this question is now in progress.

The authors find no evidence of a direct association between the concentration of silica and the degree of fibrosis, though in silicotic lungs silica was always in excess of o '2 per cent. Good photomicrographs are included.

370 T U B

The silicotic nodule in human and experimental silicosis--a comparative study.--The authors set out to compare what they consider the representative silicotic nodule of animals with the nodules found in human silicosis; although they are in certain respects comparable, they have certain notable differences. Though this may be partly due to their different duration, the authors consider that they have found evidence of a genetic difference in the lesions.

Their material consists of twenty-three rats in which they produced silicosis by exposure to rock crystal dust for varying lengths of time, intratracheal injection being the method used. The lesions were compared with lungs from two hundred and fifty cases of human silicosis, both ' a c u t e ' and chronic. In each case, sections were submitted to micro-incineration and the usual histological methods.

The human nodule is a very chronic lesion composed of acellular material concen- trically arranged, with a fibrous capsule. There is no uniformity in the amount of silica in each nodule, nor is the size proportional to the silica content, but the pattern of tile silica ash is very constant. There is an outer halo of dust inside which is a clear zone, representing the capsule. This latter ring is a constant and typical feature of the human lesion; other inor- ganic dusts do not produce this dust-free fibrous capsule.

The animal lesion is something like the human in morphology and distribution. There are differences in size and appearance of fibrous tissue, which can be explained by lack of maturi ty in the animal lesions, but this does not account for certain structural differences, e.g. in the arrangement of the fibres and presence of spaces, which suggest an intra-alveolar rather than an interstitial origin.

The early stages of the animal lesion are briefly sketched, and the authors do not find reason to believe that the human lesion ever passes through stages resembling the early experimental ones, though they suggest that the matter of dosage may account for this.

Micro-incineration shows that, in the animal lesion, silica is scattered uniformly through the nodule and the amount is proportional to its size. There is no silica- free capsule nor outer halo of dust, such as is seen in the human lesions, even those of ' acute ' silicosis. The suggestion is made

E R C L E Augus t -Sep tember 194o

that this difference may be due to an addi- tional factor in the human disease, e.g. infection. Very good photomicrographs are included with the article.

T H E M I L B A N K M E M O R I A L FUND Q U A R T E R L Y

VOL. XVIII No. 3 JOLY r94o *Mortality in the children of tuberculous house-

holds. Miriam Brailey. 222. The writer in this paper analyses the risk

of mortality in the children of families containing an adult known to be suffering from pulmonary tuberculosis, the data being those from an out-patient clinic for child- hood tuberculosis connected with the Johns Hopkins Hospital. The children were observed for varying periods of time both before and after the establishment of contact with such a patient, and the question studied was, whether the risk of dying subsequent to the onset of familial contact was greater than it was before any known contact existed. Dr Brailey describes the necessary procedure carried out to enable an accurate comparison to be made, allowing for the recognized decline of mortality with time. The children of 285 families (I38 white and 147 coloured) were included in this study. I t was found that after the establishment of known contact, white children to age 2o suffered Io deaths from tuberculosis when the calculated Baltimore mortality rates would give an expected rate of only o-6. Thus the observed mortality from tuberculosis, once contact began, was I5"6 times greater than the community mortality from tuberculosis. In the coloured families, 37 deaths from tuberculosis were observed subsequent to contact, against 4"8 expected deaths, giving an observed mortality 7.8 times greater than that anticipated had the city rates been in force. I t is pointed out that the lower ratio of observed to expected deaths from tuberculosis for the coloured was due solely to their higher community attack rate from tuberculosis; for it had been shown earlier in the study that risk of dying from tuberculosis contracted from birth to age 2o by those who have had contact with adult tuberculosis is three to four times greater for coloured children than for whitc. Finally, in both white and coloured families, after the establishment of contact, the highest mortality from tuberculosis under 2o years of age occurred in children under three years of age, with the highest case- fatality in infants under one year.

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