The pathogenesis and prognosis of tuberculous pleurisy with effusion

Although the main purpose of tiffs presentation is a discussion of the pathogenesis and the immediate and the remote prognoses of acute primary tuberculous pleurisy with effusion, it seems important to start with brief comment on the varied tuberculous conditions with which pleural effusion may be associated. Our Scandinavian colleagues, notably Hjelm and Laurell ( i93i) , Laurell (i935) and Muller, Lofstedt (I945) have developed roentgenographic techniques which have revealed surprisingly small amounts of pleural fluid under equally surprising circumstances. Pictures made in the horizontal side position or the inclined side position put the costal gutter at the lowest point and make it possible to demonstrate a small amount of fluid accumulating in this position. All this has been well set forth by Ingemar Hessen ix] in his monograph on 'q~he Roentgen Examination of Pleural Fhfid'. Small effusions are not very infrequent in association with miliary tuberculosis of the lungs but here the effusion is of little clinical significance since the pulmonary lesion and the disseminated nature of the disease are most menacing. The significance of bilateral effusion as a manifestation of disseminated tuberculous infection did not escape older clinicians. This type of effusion is not infrequently associated with extrathoracic tuberculosis especially in the American Negro (Jones and Dooley [2]. It is well known that any person who has or has had manifest pulmonary tuberculosis may have an attack of pleurisy with effusion. The Germans call this 'bcglcits' or pleurisy associated with or complicating phthisis. hnportant as this may be, it is not the type of pleural effusion here under consideration. Nor at the moment are we interested in the effusions associated with artificial pneumothorax. In passing, however, it might be noted that artificial pneumothorax is fiastlosing in popularity in America even though it seems that the specific antibiotics have made tuberculous empyema, the dreaded complication of artificial pneumothorax, almost non-existent. Clinicians of fifty years ago viewed acute pleurisy with effusion with complacency. Frequent failure to find tubercle bacilli in the fluid, illness of short duration, complete disappearancc of the effusion, ignorance of pulmonary lesions ~ yet unrevealed by the roentgen ray, apparent perfcct recovery all deludcd physicians and therefore their patients into false sccurity. An acute scrofibrinous pleurisy with undemonstrated aetiology was called 'idiopathic', if tuberculous origin was proven it was still 'a happy accident' since immediate recovery was practically assured. At the very outset, let me state my conviction in summary fashion. Acute serofibrinous pleurisy .with effusion (the term idiopathic should be discarded) is in the vast majority of circumstances tuberculous in origin, is a dominant local manifestation of a disseminated infection if not a disseminated disease, is closely associated with primary infection and therefore one of the early clinicat manifestations of tuberculous disease, is not infrequently associated with extrathoracic tuberculosis, and foUowed by remote relapse in an important percentage of cases in pre-chemotherapeutic years and therefore should not be treated with complacency but vigorously with adequate rest and chemotherapy.