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DR. EILEEN HARVEY : DYSENTERY AS A CAUSE OF SUDDEN DEATH

the more usual operation and has the advantage that bile flows into the intestine instead of to the surface. It has this further point in its favour : if no operation is performed on the gall-bladder at the same time the wound may be completely closed, whereas such a piece of technique after supra-duodenal choledochotomy is very risky. During the final stages of any operation 10 per cent. carbon dioxide in oxygen is given, and this is repeated for ten minutes in each hour for several hours after the patient has returned to bed. I think two good effects are promoted by this : first, the lungs are more fully inflated by the deeper breathing, and atelectasis (which is probably the beginning of much post-operative chest trouble) is discouraged ; secondly, better oxygenation of the blood is provided. I think there is no doubt that anoxoemia is responsible for some of the fall in blood pressure which follows many anaesthetics and particularly spinal administration. In addition, many of the special methods employed in pre-operative preparation should be carried on in the after-treatment as a routine. ,

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The ileum showed increased prominence of Peyer’s patches from above downwards ; towards the csecum there was evidence of early ulceration. In this area the mucosa was covered with closely packed white nodules of hyperplastic lymphoid tissue, and these formed a definite ring around the ileocaecal valve. The whole of the large bowel showed intense proliferation of the lymphoid elements, which appeared as prominent white dots. The lower bowel was filled with liquid faeces. CASE 3 (male, aged 3 years) appeared well when he went to bed; he woke up at 6 A.M., vomited once and passed a loose stool with no obvious blood ; diarrhoea continued The temperature was 101°-103° F., but until midday. his condition did not cause his doctor anxiety until the evening, when he became very collapsed and died at

midnight.

At the post-mortem examination he was a well-nourished male child. The small bowel contained yellowish fluid faecal matter, and the lower part of the large bowel was ballooned out with a large liquid stool containing mucus but no blood. Peyer’s patches throughout the ileum were very prominent but showed no signs of necrosis ; the mucous membrane of the lower few inches of the ileum and csecum and the whole of the large bowel showed an intense proliferation of the lymphoid elements but no actual ulceration. A ring of lymphoid tissue similar to that described in the previous cases was found round the ileocaecal valve. References.-1. Graham, E. V. : Surg., Gyn., and Obst., 1918, CASE 4 (male, aged 6) suffered from diarrhoea of sudden xxvi., 521. 2. Flint, E. R.: Brit. Med. Jour., 1930, i., 1041. onset which affected the whole family simultaneously. 3. Idem.: Brit. Jour. Surg., 1923, x., 509. This boy collapsed and died within 12 hours ; the rest of the family recovered. Cultures from the stools of a sister yielded B. dysenterice Sonne. Post-mortem examination showed the intestines distended DYSENTERY AS A CAUSE OF SUDDEN with gas ; the contents were fluid, with some mucus but no obvious pus or blood. Peyer’s patches throughout the DEATH ileum were very prominent but showed no signs of necrosis. The lower six inches of the ileum showed intense proliferaBY EILEEN HARVEY, M.R.C.S. ENG. tion of lymphoid elements, increasing towards the caput caicum where the hyperplasia almost surrounded the bowel. ASSISTANT PATHOLOGIST AND MEDICAL REGISTRAR, THE ROYAL There was considerable reddening and oedema of the large HOSPITAL, WOLVERHAMPTON bowel. CASE 5 (male, aged 65 years) had been in poor health for THAT dysenteric infection may prove rapidly fatal, some time; he ate some pork at midday with the rest of his family and was taken ill at midnight with diarrhoea and so rapidly in fact that in certain cases there may vomiting, and died within 24 hours. He had no rise of not be time for the development of any symptoms temperature during the illness. The other members of of the disease, does not seem to have been previously the family escaped without severe symptoms. Postshowed the same lymphoid hypernoted. The following cases are recorded with a mortemofexamination the ileum and the ileocaecal valve which was plasia view to drawing attention to this point. Every noticed in the other cases. case was the subject of a coroner’s inquiry. In COMMENT two of them death occurred suddenly, and no cause The most feature on post-mortem examinastriking was apparent before the post-mortem examination ; all tion common to the cases was the presence of a in the remaining three it was evident that some form of cedema around the and of intestinal infection was the cause of death. ring lymphoid hyperplasia ileocaecal valve ; this varied in size and extent from CASE RECORDS case to case ; in some it extended for several inches CASE 1 (male, agedB:I years) retired to bed, apparently up the ileum and down the caecum. In some cases in normal health, but woke up at 3.30 A.M., vomited the ring was complete, in others not entirely so, copiously and died within one and a half hours. but in every case it was a striking feature. No At post-mortem examination the body was that of a wellnourished male child. The cranial and thoracic cavities record of this appearance has been found in descripshowed nothing abnormal. The spleen was rather enlarged tions by other workers of post-mortem examinations and firm in consistency, and on section the cut surface cases of dysentery. Charles and Warrengive showed numerous white dots marking enlarged and probably on a account of the detailed necrotic Malpighian corpuscles. The stomach contained findings in fatal cases in the some clear yellow fluid ; the mucous membrane appeared Newcastle epidemic but, though they describe healthy. The whole of the small bowel from the jejunum folliculitis of the large bowel, which was also noted downwards contained a great deal of thick mucus. In the ileum the Peyer’s patches were prominent and showed in the cases recorded above, they do not mention evidence of early necrosis of lymphoid elements ; towards the intense lymphoid hyperplasia at the ileocaecal the lower end of the ileum small patches of lymphoid valve. A possible explanation of this discrepancy proliferation in the mucosa became evident ; these increased is that the ileocaecal hyperplasia may be a feature downwards until the last few inches before the ileocaecal valve were thickly studded with them, and at the valve itself of the most fulminating cases, of which all those there was a definite ring of lymphoid proliferation and recorded above were examples. hyperplasia. This hyperplasia diminished rapidly from Cultures were taken from the mucosa and contents the valve downwards ; the lower part of the large bowel the bowel at several different levels and from the of was filled with liquid fseces. in each case, but no organisms of any pathospleen CASE 2 (male infant) appeared well when he was put to

bed but was found dead a few hours later. importance were isolated. Failure to identify At post-mortem examination the body was that of a these from any of the cases may be attributable to the well-nourished infant; there were small petechial haemor- fact that in no case was the post-mortem examination rhages scattered over the face and neck. The brain made until the second were The heart and normal. . substance was soft. day after death and in some lungs In the abdominal cavity there were numerous enlarged cases not until the third. On account of this failure soft mesenteric glands. The spleen and liver appeared normal; the kidney showed cloudy swelling. Nothing 1 Charles, J. A., and Warren, S. H. : THE LANCET, 1929, abnormal was seen in the stomach, duodenum, or jejunum. ii., 626.

logical

MR. HAROLD BARWBLL : TUBERCULOUS LARYNGITIS

191

exists of the nature of the infecting unusual tendency to attacks of simple laryngitis, The fact that B. dysenteriae Sonne was partly from the strain of coughing and partly from isolated from a sister who had been ill at the same time infection by secondary organisms in the sputum. On as Case 4 makes it likely that in this case, at any rate, the other hand, a tuberculous lesion, perhaps in the the infecting organism was of the Sonne type. posterior commissure or at the upper aperture, does In 1926 Fraser, Kinloch, and Smith2 reported an not necessarily cause any symptoms in an early stage, outbreak of dysentery in Aberdeen. In 1929 Charles and the disease can, therefore, neither be diagnosed and Warren1 recorded a similar outbreak in nor excluded by the patient’s symptoms alone, but Newcastle. Various other writers have described only by laryngoscopy. smaller epidemics. The attention of this departInvasion of the larynx is usually the result of the ment was directed to the matter by an outbreak in the entrance of tubercle bacilli contained in the sputum children’s ward of the Royal Hospital in 1928, and directly through the epithelium, and takes place most since then there have been two smaller outbreaks. In spite of the attention FIG. 5 FIG. 1 that has been drawn to epidemics of bacillary dysentery in the last few years, there does not appear to be general recognition of the fact that the disease is endemic in this country. It is well recognised that in certain cases of Shiga and Flexner infection the toxaemia may be so everwhelming( as to bring about a very early fatal no

definite

proof

organism.

termination. Charles and Warren have recorded several cases of the sort, but the Sonne bacillus has in the past usually been regarded as only mildly toxigenic. Fulminating infection with rapid death due to B. FIG. 1.-Tuberculous infiltration of vocal cords. dysenteriae Sonne, as in Case 4, does FIG. 5.-Epithelioma of vocal cord. not appear to have been reported before. That death should occur as The ilhestrations are taken from" Diseases of the Larynx," by Harold Barwell, third edition, 1928. Oxford University Press. the result of a dysenteric infection without the abnearance of the cardinal symptom of diarrhoea, as in Cases 1 and 2, does often in the neighbourhood of the vocal process where not seem to have been previously noted. This the mucosa is thin, closely applied to the cartilage, possibility should be borne in mind in cases of and liable to abrasion from coughing. The earliest lesions are, therefore, most often found at the level sudden death in children. of the glottis and tend to spread from behind forwards The post-mortem examinations on all the cases recorded were made by Dr. S. C. Dyke, pathologist to the hospital, along the vocal cord, or backwards to the posterior at the instance of Mr. J. T. Higgs, coroner for South commissure. The upper aperture is seldom involved Staffordshire, and of Mr. A. C. Skidmore, coroner to the before the glottis, although not infrequently swelling borough of Wolverhampton. I am indebted to the coroners of the arytenoids is the first lesion to attract attention, concerned for permission to publish the cases ; to Dr. D. E. S. the and to Dr. M. of for W. Cunningham, material; Upper Gornal, epiglottis is rarely attacked until the rest of Wallace, of Wolverhampton, for the history of Case 3; and the larynx has been extensively affected. It is often to Dr. Dyke for access to his notes and for advice and said that pallor is a characteristic feature of tuberassistance. culous laryngitis, but this is only partly true. Many consumptive patients are anemic, and then the TUBERCULOUS LARYNGITIS: larynx, together with the other mucous membranes, will also be anaemic ; in other cases the colour is THE IMPORTANCE OF EARLY DIAGNOSIS normal or reddened from coughing and irritation by the sputum. Tuberculous granulations are usually BY HAROLD BARWELL, M.B. LOND., F.R.C.S. ENG. CONSULTING SURGEON FOR DISEASES OF THE THROAT AND EAR, pallid, the margins of ulcers are not hypersemic, and ST. GEORGE’S HOSPITAL ; LATE LARYNGOLOGIST, MOUNT arytenoid infiltrations are pale; but the unaffected VERNON HOSPITAL FOR DISEASES OF THE CHEST portions of the larynx have no characteristic colour, and very often tuberculous infiltration on the cords, TUBERCULOUS laryngitis is pre-eminently a disease ventricular bands, and especially on the epiglottis, in which early diagnosis is all-important for successful has a deeply congested red coloration. Granulations treatment. As it is, with exceptions so rare as to be are typically of a soft, gelatinous appearance ; when negligible, a complication of pulmonary tuberculosis, it healing occurs there is but little fibrosis or deformity, can normally be recognised early if it is looked for ; in contradistinction to the lesions of syphilis or lupus, and I wish here to urge again, as I have done for over and stenosis causing dyspnoea is extremely rare. 25 years, that all phthisical patients must have their CLINICAL VARIETIES larynges inspected at regular intervals of a few months, whether or not they have symptoms referred to the As any part of the larynx may be affected, the throat, and that they be sent to a laryngologist if this clinical picture is very variable, but for the sake of complication cannot be excluded with certainty. A clearness five types may be described. good many consumptives suffer from hoarseness, or 1. In the " chorditic " type the vocal cords are have a characteristic weak voice ; this is often merely affected, and hoarseness and aphonia are principally the result of asthenia, but these patients also have an early symptoms. The lesions are seldom symmetrical. and redness confined to one cord is not due 2 Fraser, A. M., Kinloch, J. P., and Smith, J. : Jour. Hyg., Swelling to 453. 1926, xxv., simple laryngitis ; it may be caused by traumatism,