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COMMON ERRORS OF DIAGNOSIS IN ACUTE INFECTIOUS DISEASES.
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analysis of the report. No less than 60 out of the 80 a febrile intestinal catarrh. It is therefore advisable municipalities showed a deterioration of work as to make a bacteriological examination of the blood in compared with the previous year. The Director of every febrile disease in infancy which does not show Public Health gives two reasons for this discreditable the characteristic features of alimentary intoxication performance. " It will be impossible to improve the or meningitis. In discussing the diagnosis of scarlet personnel of vaccinators," he says, " unless local fever Dr. Kleinschmidt again insists on examination bodies make up their minds to pay them adequately of the whole of the body, for it is through neglect or to give them at least a living wage." There is no of this simple precaution that numerous errors of dearth of candidates, but " the low pay offered diagnosis have been committed, special attention makes the posts unacceptable to any but the incom- being paid to the inner side of the thighs, Scarpa’s petent." In the second place, the Revenue authorities triangle, and the inner side of the upper arms. In and the magistracy should realise their responsibility rudimentary cases of scarlet fever these sites alone and show a more sympathetic attitude towards the may be affected, and it is therefore not sufficient to vaccination staff. It is ridiculous, for instance, that examine the chest only for the presence of a rash.
I
In the section on measles the writer emphasises the of examining the mouth in every febrile disease of children, for the presence of Koplik’s " spots, as well as for the measles enanthem, which consists of irregular, dark-red patches on the soft and hard palate. The difficulties of diagnosing noneruptive measles, of which an example was recorded2 in THE LANCET many years ago by Dr. J. D. Rolleston, are also discussed. Like most physicians, with an extensive knowledge of the acute exanthemata, Dr. COMMON ERRORS OF DIAGNOSIS IN ACUTE Kleinschmidt does not believe in the existence of the fourth disease, as described by Filatow and Dukes. INFECTIOUS DISEASES. On the other hand, he maintains that erythema IN the instructive series in course of publication infectiosum, which is apparently unknown except in under the editorship of Prof. J. Schwalbe of Berlin on German-speaking countries, is more deserving this title. diagnostic and therapeutical errors and their preven- In dealing with erysipelas, Dr. Kleinschmidt draws tion, a special volumehas recently appeared on acute attention to the frequency with which beginners infectious diseases in childhood written by Dr. H. mistake the erythematous zone which normally Kleinschmidt, director of the Hamburg University appears round the vaccine vesicles between the Children’s Clinic. The diseases discussed are the seventh and eighth days for erysipelas-an error commoner infections, which are classified in four main particularly to be avoided at the present time when groups, according as the respiratory organs (pertussis, vaccination is being performed on an extensive scale influenza, diphtheria), alimentary canal (enteric, in this country. In the section on Heine-Medin’s dysentery, mumps), or nervous system (tetanus, disease Dr. Kleinschmidt draws attention to the cerebro-spinal fever, Heine-Medin’s disease) are chiefly occurrence of rashes in the prodromal stage, and points affected, the fourth group consisting of the acute out that the former belief that acute anterior polioexanthemata. In his introduction Dr. Kleinschmidt myelitis was a frequent sequel of measles or scarlet emphasises the fact that with the onset of an acute fever has been abandoned in favour of the view that infection children are very liable to develop gastro- scarlatiniform or morbilliform eruptions may be intestinal symptoms, so that the occurrence of associated with infantile paralysis. vomiting, refusal of food, and, especially in young children, diarrhoea may lead to a mistaken diagnosis of PRIMITIVE BACTERIOLOGY. gastro-intestinal catarrh. A careful examination of the whole body should therefore be carried out before IT is debated whether the ancient Hindus or the such a diagnosis is made. In particular, inspection of the throat and testing the urine should never be Chinese were the first to excogitate from their inner omitted. The conditions most likely to be mistaken consciousness the existence of bacteria. There is for pertussis are simple catarrh in a spasmophilic child, no claim, we believe, for any earlier guess-work. In and spasmodic cough due to glandular tuberculosis or the Vedantic writings there exist representations of germs or microbes, and these at some remote date epidemic influenza. On the other hand, abortive or were copied into the Batak manuscripts of Java. atypical cases of pertussis, which are apt to occur in the The pictures in these manuscripts, which may be of fail be One first months to life, often recognised. seen in some Oriental libraries, are painted upon bark frequently finds in family practice that the mother or servant is the first to develop an attack and to infect and resemble the dashes, dots, loops, and twists of a the the children. The diagnosis of influenza, Dr. large and loosely written shorthand. The dates of Kleinschmidt remarks, is only too readily used as a MSS. and their Vedantic source must be very ancient, cloak for the practitioner’s uncertainty of diagnosis. but no exact evidence on the point is forthcoming. The principal diseases which must first be excluded More definite is the news from the China of the period of the Anglo-Saxon "Heptarchy, which now are tuberculosis, typhoid fever, and acute leukaemia. Myths and Legends of The frequent occurrence of morbilliform and especially comes to us in the pages of scarlatiniform rashes in influenza may also be mislead- China," the author of which, Mr. Chalmers Werner. is one of the most learned of living Sinoing. While admitting that errors of diagnosis in of Pekin,This fine work, published in the course of last logists. are sometimes to the inevitable, diphtheria owing contains a very interesting year by Harrap atypical character of the attack or unusual localisation section entitled and Co., Myths of Epidemics, in which we have of the process, Dr. Kleinschmidt maintains that they an illustration representing " the plague-disseminating are most frequently due to failing to examine the umbrellas." These umbrellas, which are of the throat. It is through such a sin of omission that familiar Chinese kind, are being floated into the air of are at first treated cases as many diphtheria mumps by Lu Yueh, President of the Ministry of Epidemics, -a point, curiously enough, not mentioned by the writer-and it is not until an advanced stage, when and in private life an old Taoist hermit. He stands on antitoxin is powerless to arrest the disease, that its the wall of a fortress, a bearded figure, for in these true nature is recognised. At no age is enteric fever so antique Chinese illustrations most of the male personbearded, robust, and resembling facially the likely to be overlooked as in infancy, when, owing to ages are Ainus of Japan. His pleasant purpose in hairy the irregular and often remittent type of fever and the absence of pea-soup stools it is liable to be mistaken for floating the plague-disseminating umbrellas into the air is to infect the mythic hero Yang Jen, who has 1 Diagnostische und Therapeutische Irrtümer und deren deeply offended him in his official capacity as minister Verhütung: Kinderheilkunde. Akute Infektionskrankheiten m Kindesalter. 2 THE LANCET, Dec. 10th, 1904, p. 1640. Leipzig: Georg Thiemer. an armed Mahommedan should be able to assault a vaccinator in the discharge of his duties and then be let off with a fine of Rs.25. As the Government it is useless for the King Institute and Order says, the vaccination staff to do their best in what is after all a mission guaranteeing the safety of the entire Presidency, if local bodies themselves refuse to profit by the labour and guidance of these authorities."
importance
analysis of the report. No less than 60 out of the 80 a febrile intestinal catarrh. It is therefore advisable municipalities showed a deterioration of work as to make a bacteriological examination of the blood in compared with the previous year. The Director of every febrile disease in infancy which does not show Public Health gives two reasons for this discreditable the characteristic features of alimentary intoxication performance. " It will be impossible to improve the or meningitis. In discussing the diagnosis of scarlet personnel of vaccinators," he says, " unless local fever Dr. Kleinschmidt again insists on examination bodies make up their minds to pay them adequately of the whole of the body, for it is through neglect or to give them at least a living wage." There is no of this simple precaution that numerous errors of dearth of candidates, but " the low pay offered diagnosis have been committed, special attention makes the posts unacceptable to any but the incom- being paid to the inner side of the thighs, Scarpa’s petent." In the second place, the Revenue authorities triangle, and the inner side of the upper arms. In and the magistracy should realise their responsibility rudimentary cases of scarlet fever these sites alone and show a more sympathetic attitude towards the may be affected, and it is therefore not sufficient to vaccination staff. It is ridiculous, for instance, that examine the chest only for the presence of a rash.
I
In the section on measles the writer emphasises the of examining the mouth in every febrile disease of children, for the presence of Koplik’s " spots, as well as for the measles enanthem, which consists of irregular, dark-red patches on the soft and hard palate. The difficulties of diagnosing noneruptive measles, of which an example was recorded2 in THE LANCET many years ago by Dr. J. D. Rolleston, are also discussed. Like most physicians, with an extensive knowledge of the acute exanthemata, Dr. COMMON ERRORS OF DIAGNOSIS IN ACUTE Kleinschmidt does not believe in the existence of the fourth disease, as described by Filatow and Dukes. INFECTIOUS DISEASES. On the other hand, he maintains that erythema IN the instructive series in course of publication infectiosum, which is apparently unknown except in under the editorship of Prof. J. Schwalbe of Berlin on German-speaking countries, is more deserving this title. diagnostic and therapeutical errors and their preven- In dealing with erysipelas, Dr. Kleinschmidt draws tion, a special volumehas recently appeared on acute attention to the frequency with which beginners infectious diseases in childhood written by Dr. H. mistake the erythematous zone which normally Kleinschmidt, director of the Hamburg University appears round the vaccine vesicles between the Children’s Clinic. The diseases discussed are the seventh and eighth days for erysipelas-an error commoner infections, which are classified in four main particularly to be avoided at the present time when groups, according as the respiratory organs (pertussis, vaccination is being performed on an extensive scale influenza, diphtheria), alimentary canal (enteric, in this country. In the section on Heine-Medin’s dysentery, mumps), or nervous system (tetanus, disease Dr. Kleinschmidt draws attention to the cerebro-spinal fever, Heine-Medin’s disease) are chiefly occurrence of rashes in the prodromal stage, and points affected, the fourth group consisting of the acute out that the former belief that acute anterior polioexanthemata. In his introduction Dr. Kleinschmidt myelitis was a frequent sequel of measles or scarlet emphasises the fact that with the onset of an acute fever has been abandoned in favour of the view that infection children are very liable to develop gastro- scarlatiniform or morbilliform eruptions may be intestinal symptoms, so that the occurrence of associated with infantile paralysis. vomiting, refusal of food, and, especially in young children, diarrhoea may lead to a mistaken diagnosis of PRIMITIVE BACTERIOLOGY. gastro-intestinal catarrh. A careful examination of the whole body should therefore be carried out before IT is debated whether the ancient Hindus or the such a diagnosis is made. In particular, inspection of the throat and testing the urine should never be Chinese were the first to excogitate from their inner omitted. The conditions most likely to be mistaken consciousness the existence of bacteria. There is for pertussis are simple catarrh in a spasmophilic child, no claim, we believe, for any earlier guess-work. In and spasmodic cough due to glandular tuberculosis or the Vedantic writings there exist representations of germs or microbes, and these at some remote date epidemic influenza. On the other hand, abortive or were copied into the Batak manuscripts of Java. atypical cases of pertussis, which are apt to occur in the The pictures in these manuscripts, which may be of fail be One first months to life, often recognised. seen in some Oriental libraries, are painted upon bark frequently finds in family practice that the mother or servant is the first to develop an attack and to infect and resemble the dashes, dots, loops, and twists of a the the children. The diagnosis of influenza, Dr. large and loosely written shorthand. The dates of Kleinschmidt remarks, is only too readily used as a MSS. and their Vedantic source must be very ancient, cloak for the practitioner’s uncertainty of diagnosis. but no exact evidence on the point is forthcoming. The principal diseases which must first be excluded More definite is the news from the China of the period of the Anglo-Saxon "Heptarchy, which now are tuberculosis, typhoid fever, and acute leukaemia. Myths and Legends of The frequent occurrence of morbilliform and especially comes to us in the pages of scarlatiniform rashes in influenza may also be mislead- China," the author of which, Mr. Chalmers Werner. is one of the most learned of living Sinoing. While admitting that errors of diagnosis in of Pekin,This fine work, published in the course of last logists. are sometimes to the inevitable, diphtheria owing contains a very interesting year by Harrap atypical character of the attack or unusual localisation section entitled and Co., Myths of Epidemics, in which we have of the process, Dr. Kleinschmidt maintains that they an illustration representing " the plague-disseminating are most frequently due to failing to examine the umbrellas." These umbrellas, which are of the throat. It is through such a sin of omission that familiar Chinese kind, are being floated into the air of are at first treated cases as many diphtheria mumps by Lu Yueh, President of the Ministry of Epidemics, -a point, curiously enough, not mentioned by the writer-and it is not until an advanced stage, when and in private life an old Taoist hermit. He stands on antitoxin is powerless to arrest the disease, that its the wall of a fortress, a bearded figure, for in these true nature is recognised. At no age is enteric fever so antique Chinese illustrations most of the male personbearded, robust, and resembling facially the likely to be overlooked as in infancy, when, owing to ages are Ainus of Japan. His pleasant purpose in hairy the irregular and often remittent type of fever and the absence of pea-soup stools it is liable to be mistaken for floating the plague-disseminating umbrellas into the air is to infect the mythic hero Yang Jen, who has 1 Diagnostische und Therapeutische Irrtümer und deren deeply offended him in his official capacity as minister Verhütung: Kinderheilkunde. Akute Infektionskrankheiten m Kindesalter. 2 THE LANCET, Dec. 10th, 1904, p. 1640. Leipzig: Georg Thiemer. an armed Mahommedan should be able to assault a vaccinator in the discharge of his duties and then be let off with a fine of Rs.25. As the Government it is useless for the King Institute and Order says, the vaccination staff to do their best in what is after all a mission guaranteeing the safety of the entire Presidency, if local bodies themselves refuse to profit by the labour and guidance of these authorities."
importance