Remarks on APICAL AND SUBAPICAL TUBERCULOSIS
Authors: M. Fishberg
Journal: BMJ (1929)

PA\THOLOGIC' anatomists an1d clin;icia1s have 1known for m1]an1v vears that the niuilmber of people withi tuberculous lesions iii the luings is miuielh hiiogler tlhani that of thoose suffering( anid dvliig fr'omii actual tuiberecilous disease.Apical tuberculosis -active, qumiesceift, completely cicatrized, or calcified-is a baiiial incideiital fiiidinig at necr,opsies of pelrConls W-ho liave suiecliibled to anly otller disease, and ining life have citlfer inot knowlln at all thlat they ha(d lutng, troublle or coni- sidered tlleir puiliiionary symiptomiis of little if any signlifi- cance.Of the 60 to 90 per ce)t, of tiuberculious foci ol)served iii rouitinie nieeropsies, 30 to 60 per cenit.are founiid to hia.ve beeni " obsolete."In other words, it appears tlfat a lairge proportion of tubereulonis lesions of the luinfgs Iweal spoiftaneouslv.Tliis conifir ms tIme commoni obIserva- tiOln of clinicianlls, wlho often finid unileqiiivocal symptomlUs and signls of apical lesions, yet tile patients are getting along fairly well witl or witlhout treatmenit.These are facts lkliow-n to all whlo havegiven this subject tlhouglhtful attenitioni in thteir routine w^ork in sanatoriulm,s, in dispeiisaries, and i lniprivate l)lar'tice, anid miiay-be considered clinical platitudes.Ouir great problemii lhas been to dlifferenitiate these benigmi case.s from the niumiiier osis otlhers that are progressi-e and recqulire treatmient, l)e it climatic, inistitutionial, or operative.Heretofore we lheld to the dictum-n oi shouLild I say dogma?--that wheni there are clmanges in tile reson-ance anid breath so(luids, perhlapl')s also soamle adv-enititiou-s sounds, over the rec,ion of the Ilmga ab)ove time second or first rib, tlle patient is ttibercuiloums; if there are also sueli constitutional sofliptoins as cougll, loss of w-eight, fever, haemoptosis, etc., tllere is no doubt that tilere is ani activ-e lesion wlicll muiList l)e eared for in accordance w-itli the principles of mo(lerni phitliisiotbuerapy.Oim the otlier liland, if the signis iindicate l f esion lower than tIme apex, the chances of its beingC tuberculons are reimiote; at amiv rate, conisiderable circuim- spection miuilst be exercised before pronouncing the patienit t uberculoums.Du1ring tile first years of wide application of tlhe Roentgen rays in tIle diagnosis of puliimonarv pathology tlhese diagnocstic plinicip)les appeared to lIave beeni coni- firmed.Biut wi-itlh tIme mimore imiviersal use of the Roentgen alas there lhas takleni place du'iimig the past five years a ialdical chanige in ouur views of thle early localization anid evolution of tuiberceu-louis lesions in time lungs.It has been olbserved that iii a decidedly notew-orthy lvroportion of active This niew doctrimie of suil)ciavicilar localization of tuiberculous lesionis is quite old wh-lieni oi--e considers time w-ork of se;veral British pathologists an d cliciicis.Ill hlis -MTadle in op enling, a (ielflFsion il t e Seion of Ttifbercilosis at tile Anii,ia-Meeting of the British Medical Associatin2, ieldl at kantichester, July, 1929.' Goulistoniiani Lectures of 1882 on " Puilmon-airy Cavities," AN'illiam Ewartl is very exl)licit inI his description of the s-calle(d apex lesion,'' which he foun(d below the