- Email: [email protected]
AMŒBIC DYSENTERY IN INFANCY
1171 in
a
group of Yale
University graduate
and under-
situated
usually
in the
zone
between the middle and
graduate students, most of whom come from the outer thirds of the media. There was no accomnorth-eastern part of the United States. In this panying inflammatory reaction, nor any fibrosing selected population the incidence of rheumatic heart process in the neighbourhood. Where the necrosis disease proved to be 8-2 per 1000 for the under- was complete a cleft was left filled with a colloidThis mucoid degeneration is not material. graduate group and 11-4 per 1000 for the graduate group. Both these rates lie below the figure which dependent on thickening in the vasa vasorum, and the authors estimate to be the average rate for the is certainly not syphilitic. Many years ago H. M. general population in the same areas-namely, 15 per Turnbull2 found it to be more commonly associated 1000-but the differences are hardly large enough with cardiovascular hypertrophy and high blood to suggest much social distinction. On the other pressure. Klotz and Simpson, in discussing the pathohand differentiation of the economic status of the genesis of the condition, do not refer to high blood students, based upon the type of school from which pressure and cardiovascular hypertrophy, although they were drawn, does afford evidence of a lower in each of their five cases cardiac hypertrophy was incidence amongst persons of ample means even in present, and from the data which they give would this fairly homogeneous population. Among the appear to be a reaction to hypertension. Local men who had attended expensive boarding-schools spasm of the vasa vasorum would seem to be a the incidence of rheumatic heart disease was only plausible cause for the medial lesion, but it is difficult 5-8 per 1000, whereas it was 12’5 per 1000 among to assess the importance of toxins and dietary those from high schools. This study is the first of deficiencies, which are factors suggested by the a series which Paul and Leddy hope to make in authors. differently selected populations. The importance of the problem needs no emphasis, for there can be AMŒBIC DYSENTERY IN INFANCY little doubt that detection of the connecting link AMŒBIC dysentery is comparatively rare in between poverty and acute rheumatism would Western Europe, whereas infantile diarrhoea due materially contribute to the prevention of the disease. to other causes is common ; hence sporadic cases of the former in infants are apt to go undiagnosed. Not only are the symptoms very variable, but the SPONTANEOUS RUPTURE OF THE AORTA appearance of the stools is often not characteristic. SOME observers believe that it is possible for the An epidemic in the Brefotrofio in Messina between normal aortic wall to rupture when subjected to an the months of March, 1931, and January, 1932, extreme degree of strain ; this is denied by others throws light on both the clinical character and who hold that the pressure of the blood within the pathology of the disease in infancy, since many cases vessel cannot possibly reach a level sufficient to came under observation which in the absence of an produce rupture unless the wall is weakened by some epidemic might not have been recognised. From disease process. There are similar differences of the clinical aspect, Prof Guido Izar3 finds that in opinion about rupture of the aortic valve. Some infants during the first year of life the condition 120 cases of rupture of this valve after strain or is more likely to be fulminating ; the cases may present trauma have been reported, but it is open to question peritoneal, gastric, or choleraic symptoms, or be of if in any one of them the valve and neighbouring septic or toxic type. Over the age of 1 year, children aortic wall have been proved normal. Experi- may show any of the features of the disease as it mentally, enormous pressures are required to rupture occurs in adult life, though metastatic abscesses are the tissues of the aorta and its valve when these rare; the condition may simulate typhoid or organs are normal, and it seems impossible that appendicitis, or present the classical picture of these pressures can ever be reached in the living. ileocolitis. Of 30 post-mortem examinations, 4 were In a paper dealing with " spontaneous " rupture of on infants of under 1 month and 23 on infants between the aorta, Oskar Klotz and Winifred Simpson1 1 and 10 months, while in 3 the child was between describe five cases in which the rupture occurred in 1 and 2 years old. For the most part the lesions tissues showing little or no pathological lesion on in those over 5 months of age were of the ulcerative superficial examination, but which showed definite or necrotic type found in adults, except that the defect on microscopy. Three of the patients were ulcers were much smaller-often only a pin’s head under 40, and the oldest was 54. In all there was a in size, with undermined edges and necrotic bases. clean-cut tear of the aortic intima, through which In the younger babies, however, the whole of the the blood had forced its way and burrowed into the colon showed a diffusely catarrhal condition with media, where a dissecting aneurysm was produced hyperaemia or haemorrhagic lesions, but without between the outer and middle thirds of this coat. actual ulceration. Therapy in the infant presents a In all but one case the rupture was in the ascending more difficult problem than in the adult, since arsenic aorta within a few centimetres of the aortic valve ; is poorly tolerated and must be administered with in the exception the rent was in the descending caution ; Izar has found that even small doses of thoracic portion. External rupture into the peri- emetine may give rise to toxic symptoms and result
like
____.
cardium or pleural cavity was usual. The rupture is attended by symptoms of extreme severity, and the picture is very like that seen in a severe attack of coronary thrombosis. Death within a few hours or days is the rule, but Klotz and Simpson believe that it is possible for a dissecting aneurysm to heal. The intima of the aorta in these cases is remarkably free of disease, and it is not until the vessel wall is examined microscopically that any lesion is discovered. The characteristic lesion was revealed here, and consisted in patchy or diffuse necroses, 1 Amer. Jour. Med. Sci., October, 1932, p. 455.
rapid fall Paralysis is
in blood pressure and cardiac failure.
recommends
a
in
undoubtedly occurs. He dosage of 5 mg. emetine per of body-weight, given in a ten-day period, or a kg. daily dosage of 3 mg. of stovarsol per kg., given each day for 14 days, for infants up to 1 year old. In place of emetine, rectal injections of 5 eg. of powdered ipecacuanha and 1 eg. of thymol in 50-100 c.cm. water can be alternated with injections rare
but
total
of 2-5 eg. iodoform in 50 to 100
c.cm.
olive oii.
2 Quart. Jour. Med., April, 1915, p. 201. 3 Riforma-Med., 1932, xlviii., 1435.
a
group of Yale
University graduate
and under-
situated
usually
in the
zone
between the middle and
graduate students, most of whom come from the outer thirds of the media. There was no accomnorth-eastern part of the United States. In this panying inflammatory reaction, nor any fibrosing selected population the incidence of rheumatic heart process in the neighbourhood. Where the necrosis disease proved to be 8-2 per 1000 for the under- was complete a cleft was left filled with a colloidThis mucoid degeneration is not material. graduate group and 11-4 per 1000 for the graduate group. Both these rates lie below the figure which dependent on thickening in the vasa vasorum, and the authors estimate to be the average rate for the is certainly not syphilitic. Many years ago H. M. general population in the same areas-namely, 15 per Turnbull2 found it to be more commonly associated 1000-but the differences are hardly large enough with cardiovascular hypertrophy and high blood to suggest much social distinction. On the other pressure. Klotz and Simpson, in discussing the pathohand differentiation of the economic status of the genesis of the condition, do not refer to high blood students, based upon the type of school from which pressure and cardiovascular hypertrophy, although they were drawn, does afford evidence of a lower in each of their five cases cardiac hypertrophy was incidence amongst persons of ample means even in present, and from the data which they give would this fairly homogeneous population. Among the appear to be a reaction to hypertension. Local men who had attended expensive boarding-schools spasm of the vasa vasorum would seem to be a the incidence of rheumatic heart disease was only plausible cause for the medial lesion, but it is difficult 5-8 per 1000, whereas it was 12’5 per 1000 among to assess the importance of toxins and dietary those from high schools. This study is the first of deficiencies, which are factors suggested by the a series which Paul and Leddy hope to make in authors. differently selected populations. The importance of the problem needs no emphasis, for there can be AMŒBIC DYSENTERY IN INFANCY little doubt that detection of the connecting link AMŒBIC dysentery is comparatively rare in between poverty and acute rheumatism would Western Europe, whereas infantile diarrhoea due materially contribute to the prevention of the disease. to other causes is common ; hence sporadic cases of the former in infants are apt to go undiagnosed. Not only are the symptoms very variable, but the SPONTANEOUS RUPTURE OF THE AORTA appearance of the stools is often not characteristic. SOME observers believe that it is possible for the An epidemic in the Brefotrofio in Messina between normal aortic wall to rupture when subjected to an the months of March, 1931, and January, 1932, extreme degree of strain ; this is denied by others throws light on both the clinical character and who hold that the pressure of the blood within the pathology of the disease in infancy, since many cases vessel cannot possibly reach a level sufficient to came under observation which in the absence of an produce rupture unless the wall is weakened by some epidemic might not have been recognised. From disease process. There are similar differences of the clinical aspect, Prof Guido Izar3 finds that in opinion about rupture of the aortic valve. Some infants during the first year of life the condition 120 cases of rupture of this valve after strain or is more likely to be fulminating ; the cases may present trauma have been reported, but it is open to question peritoneal, gastric, or choleraic symptoms, or be of if in any one of them the valve and neighbouring septic or toxic type. Over the age of 1 year, children aortic wall have been proved normal. Experi- may show any of the features of the disease as it mentally, enormous pressures are required to rupture occurs in adult life, though metastatic abscesses are the tissues of the aorta and its valve when these rare; the condition may simulate typhoid or organs are normal, and it seems impossible that appendicitis, or present the classical picture of these pressures can ever be reached in the living. ileocolitis. Of 30 post-mortem examinations, 4 were In a paper dealing with " spontaneous " rupture of on infants of under 1 month and 23 on infants between the aorta, Oskar Klotz and Winifred Simpson1 1 and 10 months, while in 3 the child was between describe five cases in which the rupture occurred in 1 and 2 years old. For the most part the lesions tissues showing little or no pathological lesion on in those over 5 months of age were of the ulcerative superficial examination, but which showed definite or necrotic type found in adults, except that the defect on microscopy. Three of the patients were ulcers were much smaller-often only a pin’s head under 40, and the oldest was 54. In all there was a in size, with undermined edges and necrotic bases. clean-cut tear of the aortic intima, through which In the younger babies, however, the whole of the the blood had forced its way and burrowed into the colon showed a diffusely catarrhal condition with media, where a dissecting aneurysm was produced hyperaemia or haemorrhagic lesions, but without between the outer and middle thirds of this coat. actual ulceration. Therapy in the infant presents a In all but one case the rupture was in the ascending more difficult problem than in the adult, since arsenic aorta within a few centimetres of the aortic valve ; is poorly tolerated and must be administered with in the exception the rent was in the descending caution ; Izar has found that even small doses of thoracic portion. External rupture into the peri- emetine may give rise to toxic symptoms and result
like
____.
cardium or pleural cavity was usual. The rupture is attended by symptoms of extreme severity, and the picture is very like that seen in a severe attack of coronary thrombosis. Death within a few hours or days is the rule, but Klotz and Simpson believe that it is possible for a dissecting aneurysm to heal. The intima of the aorta in these cases is remarkably free of disease, and it is not until the vessel wall is examined microscopically that any lesion is discovered. The characteristic lesion was revealed here, and consisted in patchy or diffuse necroses, 1 Amer. Jour. Med. Sci., October, 1932, p. 455.
rapid fall Paralysis is
in blood pressure and cardiac failure.
recommends
a
in
undoubtedly occurs. He dosage of 5 mg. emetine per of body-weight, given in a ten-day period, or a kg. daily dosage of 3 mg. of stovarsol per kg., given each day for 14 days, for infants up to 1 year old. In place of emetine, rectal injections of 5 eg. of powdered ipecacuanha and 1 eg. of thymol in 50-100 c.cm. water can be alternated with injections rare
but
total
of 2-5 eg. iodoform in 50 to 100
c.cm.
olive oii.
2 Quart. Jour. Med., April, 1915, p. 201. 3 Riforma-Med., 1932, xlviii., 1435.