POINTS OF POSSIBLE MEDICO - LEGAL INTEREST IN CERTAIN CASES OF DISSEMINATED MILIARY TUBERCULOSIS
PHYSICIAN TO THE GERMAN HOSPITAL. IN disseminated miliary tuberculosis there may be doubts as to the medico-legal aspect of the case during life, the doubts being afterwards completely cleared up by a postmortem examination; but in other cases points of medicolegal interest may first attract attention at the time of the necropsy. Instances of the first class are sometimes afforded by tuberculous meningitis supervening in adults. The following is an example. CASE 1.-A German, aged nineteen
... aged nineteen years, was brought to the German Hospital suffering from fever and delirium. He could answer no questions and there was no history obtainable. The physical signs were not quite the same over both pulmonary apices and this caused tuberculous meningitis to be suspected. There was, however, much albuminuria-a condition not usually associated with tuberculous meningitisand neither ophthalmoscopic examination nor special nervous symptoms helped us. It was therefore possible that the patient had taken some poison acting on the kidneys and nervous system. He died some days later, and the postmortem examination cleared up the diagnosis. Tuberculous meningitis was found, together with old and recent tubercle in the lungs, and miliary tuberculosis of the mucous membrane of the glottis. The kidney affection was parenchymatous, probably due to the bacillary toxins which had to be excreted. Cases of tuberculous meningitis in adults are probably not rare in which, if there were absence of past history, a temporary suspicion of poison or foul play might be entertained. In the foregoing case the absence of past history and the presence of much albumin in the urine led to doubt in the diagnosis. In such cases the doubtful points are cleared up by the post-mortem examination. It is, however, the second class of cases to which I wish to draw attention-cases of disseminated miliary tubercle in which pathological questions of medico-legal interest occur at the time of the necropsy. Their importance arises from the fact that a blow or injury to quiescent tuberculous nodules in any exposed region of the body may give rise to acute miliary tuberculosis of the lungs, thus bringing about death in persons previously in apparent health. Tne following is a typical example. CASE 2.-A well-built man, a German, aged thirty-three years, was admitted under my care at the Garman Hospital on April 5th, 1897. He had fever (temperature 103-6 F.), vomiting, great dyspnœa and cyanosis, intense dryness of the throat, and scanty expectoration, in which a trace of altered blood pigment was at one time visible. On examining the lungs no definite signs of consolidation could be made out, but a certain amount of fine inspiratory crepitation was heard over both sides, and the case seemed to be one of acute double pneumonia before the outer parts of either lung had become hepatised. The history was that ten days before admission, when on board ship on his way back from the Transvaal, he received a blow on the left testis, which was followed by local and general symptoms. After five days his condition improved somewhat, but two days previously to admission he had a rigor and pains over the whole of the body. Except for some slight improvement soon after admission, due to rest and cessation of the vomiting, his condition underwent but little change. The dyspnœa, and orthopnoea increased and the fever remained continuous till he died, practically suffocated, on April 20th, about twenty-five days after receiving the blow on the testicle. In the meantime, owing to the absence of any crisis, and since there were no signs of definite hepatisation of the lungs, we had come to suspect that the pulmonary disease was one of acute miliary tuberculosis. The crepitations were variable ; on one occasion distinct inspiratory crepitations could be heard below both clavicles. The sputum was examined for tubercle bacilli with negative results. The urine contained a little albumin. At the necropsy both lungs were found to be engorged with blood and absolutely stuffed with miliary tubercles. There was some fibrosis from earlier disease at both pulmonary apices. The bronchial lymph glands were enlarged, and besides miliary tubercles in the pleuræ there was evidence of older pleurisy, especially over one lung. The left epididymis (i.e., where he had received the blow twenty-five days before his death) contained a softened, caseous nodule, smaller than a small cherry. The cerebral meninges contained no tubercles, nor were tubercles found in any other organs, except a few minute ones in the renal cortex below the capsule. The liver might, of course, have contained microscopic tubercles though no macroscopic ones were found. The heart was distended with blood, but showed no evidence of disease. The spleen was somewhat enlarged and pulpy ; it weighed nine ounces and contained one small white infarct. In this case I think there can be no doubt that the tubercle spores were by the injury set free from the old caseous focus in the epididymis, and were carried by the venous blood to the right heart. Many of the spores were then caught up in their passage through the lungs, and thus gave rise to the miliary pulmonary tuberculosis. This theory amply explains why the pulmonary tubercles were practically all about the same size, why they were uniformly distributed throughout every part of the lungs, and why there was not evidence of general miliary tuberculosis in other parts of the body. A few of the microbes had, however, certainly passed through the pulmonary circulation, otherwise we should have found no miliary tubercles in the kidney. Moreover, by careful microscopic examination we might have found evidence of commencing tubercles in other organs. Similar cases were observed prior to the discovery of the tubercle bacillus and gave rise to various inquiries as to the possible relation between the injury and the lung disease. A remarkable example was the following, which I have from my father, and which occurred at Bonn about 1849.