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(Charity Hospital), As a Pathologic Rarity, One Or Two Dr of the great deal of gas and distress, crying most ANOMALIES OF TUBERCULOSIS IN THE and six stools a day, passing green, irritating day HIGHLANDS OF COLOMBIA which, under the microscope, were seen to contain con¬ siderable fat. The mother had considerable gas in the A NEW DIAGNOSTIC SIGN IN INCIPIENT CASES bowels. The analysis showed: fat, 1.4 per cent.; lactose, 8 per cent., and protein, 1.07 per cent. JORGE VARGAS S., M.D. Although no single component was excessively high, Professor of the General Pathologic Clinic, National University of the relative proportions of the fat, lactose and protein Colombia were abnormal. In this instance after weaning, the NEW YORK a of cow's baby straightened out on simple formula of the of observed milk. Physicians early part this century a curious evolution of tuberculosis in the Colom- In another instance a was being fed by a wet- great baby bian These have an elevation of nurse who also gave her own baby the breast after Highlands. highlands about 11,800 feet above sea level, and are inhabited the foster-baby received what it needed. It was by noticed that the wetnurse's an Indo-Spanish race which numbers very few Indians although baby gained and descendants of the it was uncomfortable and a good part of the many pure conquerors. rapidly, The an of time had stools. As time went on the highlands have average temperature undigested from 14 to 16 C. 57.2 to 60.8 with an inex- fosterbaby did not receive enough milk and was given (or F.), all of the wetnurse's milk. It then commenced to haustible fertility, and are not very thickly populated. Both men and animals in this have indigestion, and it was found on analysis that progress admirably the additional milk, namely, the end of the milk of region, notwithstanding deficient hygienic conditions the contained 8 per cent fat. After a wet- inherited from our Castilian fathers. nursing, I wish to describe the invasion of tuberculosis in nurse with poorer milk was obtained, there were no symptoms of indigestion, and the baby gained weight these places, which a few years ago were almost free in a normal manner. of the Koch bacillus. Today the region is infested SUMMARY with this terrible malady, but with pathologic peculiari- ties different from what in the zone. 1. Mixed of milk taken before and. after prevails temperate samples to tuberculosis is the con- or the entire amount of one breast, must be Immunity produced by nursing, stant of antibodies nodes or other a of milk for production by lymph taken to obtain characteristic sample tuberculous tissues. In the of It should be drawn at 9 or 10 a. m. highlands Colombia, analysis. certain forms of tuberculosis are most common because 2.. Accurate methods of chemical analysis must be the race does not possess to tuberculosis in used. Clinical laboratory tests cannot be depended immunity any The of these is to me of on because of their inaccuracies. degree. study problems the greatest importance. In the years from 1896 to 311 Beacon Street. 1899, I was shown in the clinic of my teacher, Dr. Josue Gomez, in the Hospital de Caridad of Bogota ABSTRACT OF DISCUSSION (Charity Hospital), as a pathologic rarity, one or two Dr. John Foote, Washington : I think all the great pedia- cases of pulmonary tuberculosis. On the other hand, trists have written about the necessity of milk examination. there were frequent cases diagnosed as tuberculous Soranus of Ephesus was the first He described the thumb¬ peritonitis. Numerous necropsies demonstrated the nail test in the second century, A. D. Breast milk varies truth of his assertions. Dr. Gomez attributed this on when the milk is taken, whether at the begin¬ depending to various causes. I believe that it was ning, the middle or the end of the nursing, and the quality phenomenon tuberculosis of the mesenteric in men who of the milk often depends on the time of day or whether it lymphatics inva¬ is taken from one breast or the other, so the matter of mak¬ did not have ancestral immunity. This made the ing a milk analysis involves many considerations. This was sion of the tuberculosis more rapid so that the action pointed out clearly by Dr. Abt in a splendid monograph a of the antibodies did not stop the rapid peritoneal inva¬ few years ago. The thumbnail test of Soranus was quite as sion. Probably, then, the lungs were kept almost accurate as some of our modern lactometer estimations of immune, the mesenteric ganglions being the place the quality of breast milk derived from a single sample. selected by the first tuberculous invasion. The inva¬ : am convinced that Dr. James D. Love, Jacksonville I sion in these organs not immune per continuitatem the routine examination of breast milk as commonly prac¬ occurred with a which did not the with a lactometer more-often leads us than not. rapidity permit tised astray of antibodies. A mother may state that her milk is thin and bluish in development I have served as appearance and she submits a specimen for exarrtination. We During the last four years pro¬ may find that this milk is deficient in fats and apparently is fessor in the same clinic and have observed hundreds not a milk on which the baby will thrive; and yet the baby of such cases. There were three things that called my is thriving and taking on weight. Too often we base our attention especially to the curious nature of the disease estimate on examination of a given specimen of milk. As in the.highlands of Bogota: the rapid cavity formation, Dr. Foote has said, the milk in the morning will differ very the forms, and the tuberculous meningitis. materially from an afternoon specimen. If the baby is nurs¬ miliary ing every two or three hours, the milk carries materially N. N., a man from the country, aged 24, had vomited blood more fat than if the baby is nursing every four hours. I two months before admission, while at his farm, without merely wish to make the point that unless an examination is feeling previously ill. He felt better a few days later, con¬ made properly and the milk is selected from at least two or tinued his work at the farm, and having vomited blood again three specimens in the course of the day, the routine exam¬ forty days afterward, went to Bogota and took a bed in the ination of milk as performed by the average physician will Hospital de Caridad. often lead to erroneous conclusions. While making the morning rounds, my intern and my chief Dr. Fritz B. Talbot, Boston : The appearance of the milk head of the clinic showed me that case as gastric hemorrhage really does not tell you anything. We have seen milks that with vomiting. The man had powerful muscles and a per¬ have been very yellow, looked very rich, and yet they have fect frame, with not a single degenerative stigma. He was had only 0.9 per cent, of fat in them. a beautiful example of that hardened and healthy type of our Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/28/2015 country. On examining him, simple percussion revealed to It is well known that to auscultation, inspiration is me the existence of a cavity larger than a dove's egg in the noisy and expiration silent. The murmur is produced, apex of the left lung. The auscultation confirmed my diag¬ not only by the expanding of the pulmonary vesicles, nosis. There was nothing else; not an enlarged lymph node; but because each column of air in the flute¬ not even a noise besides the breaking strange cavity phenomenon. like which forms each bronchial subdivision has Based on previous cases observed in my clinic I gave a fatal point to a musical prognosis. In fact, ten or twelve days later my patient died produce sound. This sound is helped also in a hemoptysis, and the necropsy revealed, as the only because the column of air subdivides itself in the thick tuberculous lesion, the cavity previously diagnosed. In this and narrow tubes. The normal exhaling, however, is case, as in eight or ten others, the man was free from silent. Now the of a person at rest, who of respiration hereditary tuberculosis, not having in any other part his breathes with the mouth open (as in the position of body a tuberculous lesion that might have produced anti- tuberculins. auscultation) and heard near the mouth, presents a phenomenon quite opposite : the exhaling is more noisy Tuberculous meningitis also belongs to the not than the inhaling. This exhaling murmur is produced uncommon form of acute tuberculosis generally in the larynx and pharynx, these organs being the first occurring in the sick—more often in women—while obstacles that the outcoming column of air finds in convalescing from great hyperpyrexia, principally from which it can produce a musical sound. We see, then, typhoid fever. It is not unusual, observing the cases that almost all exhaling reenforcement that is found in attentively, to find that the bed next to the meningitis auscultation is originated in the larynx, the trachea, and patient is occupied by a tuberculous patient, although the thick bronchial tubes. The ear that auscults hears on examining the meningitis patient no tuberculosis has them, thanks to the fact that they pass through pul¬ Here new been found. is ground, not previously monary tissues more dense which allow sounds to pass immune, in which, as in the case of a child, the malady better.
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