SANATORIUM TREATMENT AND MILITARY SERVICE :

240

pleomorphic variably Gram-staining organism of diplostreptococcal type. In no case was growth obtained on subculture. The organisms described above are illustrated in the accompanying figures.

a

TABLE VII.

1. Large spores.-In A, sputum film ; B, sputum culture ; blood culture; D, urine ; E, faeces. 2. Hyphae.-In A, sputum film; B, faeces ; C, culture from large spores. 3. Coccal clusters and mulberry masses.-In A, sputum film; B, faeces ; C, urine. 4. Tetrads:cocci, bacilli.-In A, sputum film ; B, sputum culture; C, fasces; D, urine film ; E, urine culture; F, blood

C,

culture.

Conclusions from Bacteriological Examinations. employed were : (1) Broth; (2) 2 per cent. glucose broth; (3) 4 per cent. maltose broth ; (4) citrated Examination of material obtained from patients suffering broth; (5) sterile urine. The tubes contained 5 c.cm. of the from influenza has shown the presence of a mycotic organism. medium, and an equal volume of blood was added to each. It is possible that the disease is a mycosis-not In two cases the blood was in addition received direct in a necessarily in all cases a bronchomycosis, but perhaps in sterile tube before subcultures were made, and in one of these some an enteromycosis. there was a positive result, the growth being obtained on ’, The originality of these findings belongs to Captain Fry, serum-glucose agar from the broth subculture which had with whom I have performed experiments on animal inoculabeen incubated six days. Although in the other cases sub- tion and examination of material obtained post mortem cultures from the primary culture remained sterile, yet in 11 in man. out of the 12 cases organisms were seen in the primary Although the results obtained do not justify an assertion cultures after incubating for periods varying from 4 to 24 that influenza is a mycotic infection, they appear to demonhours. The results are shown in Table VIII. :— strate the fact that such an organism is present during the disease, and afford a means of unifying the seemingly TABLE VIII.-Blood Cultures. discordant results that have been obtained by other workers. The media

Bibliography.-1. Pfeiffer: Deutsche Med. Wchnsch., No. 2, 1892. 2. Klein: Loc. Gov. Board Report, C, 7051, 1893. 3. Abrahams, Hallows, and French: THE LANCET, Jan. 4th, 1919. 4. Whittingham and Sims: THE LANCET, Dec. 28th, 1918. 5. Braxton Hicks and Gray : THE LANCET, March 15th, 1919. 6. Little, Garofalo, and Williams: THE LANCET, July 13th, 1918. 7. Averil, Young, and Griffiths: Brit. Med. Jour., August 3rd, 1918. 8. Matthews: THE LANCET, July 27th, 1918. 9. McIntosh: THE LANCET, Nov. 23rd, 1918. 10. Fildes, Baker, and Thompson: THE LANCET, Nov. 23rd, 1918. 11. Gotch and Whittingham: Selter : Deutsche Med. Wchnsch., Med. 12. Brit. Jour., July 27th, 1918. Berl. u. Leipz., 1917, xliii., 1005. 13. Leichentritt : Deutsche Med. Wchnsch., Berl. u. Leipz., 1918. xliv., 1919-22. 14. Löwenfeld: Wien. klin. Wchnsch., 1918, xxxi., 1274-5. 15. Graetz: Berl. klin. Wchnsch., 1919, lvi., 46. 16. Bernhardt: Med. klin. Berl. u. Wien., 1918, xlv., 683. 17. Netter: Bull. Acad. de Méd., Par., 1918 3e sér., lxxx., 275-86. 18. Stephan : Münch med. Wchnsch., 1917, lxiv., 257. 19. Orticoni and Barbié: Bull. et mém. soc. méd. d. hôp de Par., 1918, 3e sér, xlii., 959-61. 20. Segale: Patholog. Genova, 1918, xi., 1. 21. Fletcher: THE LANCET, Jan. 18th, 1919. 22. Harris: THE LANCET, Dec. 28th, 1918. 23. Levinthal: Ztschrift. f. Hyg. und Infekt., Krankh., Jena, 1918, 861. 24. Fleming: THE LANCET, Jan. 25th, 1919. 25. Fleischmann: Ztschr. f. ärztl. Fortbild., Jena, 1918, xv., 425-31. 26. Ford Robertson: Brit. Med. Jour., Dec. 21st, 1918. 27. Nicolle and Lebailly: C. R. Acad. Sci., 607. 28. Gibson, Bowman, and Connor: Brit. Med. Jour., Dec. 14th, 1918, March 22nd, 1919. 29. Rose Bradford, Bashford, and 30. Leschke: Berl. klin. Wilson: Brit. Med. Jour., Feb. 1st, 1919. Wchnsch., 1918, lvi., 11. 31. Donaldson: THE LANCET, Nov. 23rd, Brit. Med. Dec. 21st, 1918, and Feb. 15th, 1919. 1918; Jour., 32. Rosenow: J. of Infect. Dis., Chicago, xxvii., No. 4, pp. 281, et seq. 33. Crookshank: THE LANCET, Feb. 22nd, 1919.

But grew from blood later, when

patient was bled.

t Agar and serum-glucose agar.

The subcultures from Case 135 grew equally well on agar and serum-glucose agar, in minute transparent dew-drop colonies, tending to become confluent. The sugar reactions were as follows : Glucose, acid ; lactose, acid ; maltose, acid ; mannite, nil; cane sugar, nil ;

salicin, nil; milk, alkaline ; gelatin, not liquefied. It therefore resembles very closely the coccus isolated from the urine in Case 170 ; the only difference being the late change produced in mannite in the urine coccus. Primary cultures of blood show the following stages: Large spores, small spores, hyphæ, cocci in clusters, pairs and diplostreptococcal form, Gram-negative bacilli and Gram-negative bacilli with Gram-positive tips ; and minute coccal forms which appear to be liberated from large spores, and which are approaching the limits of microscopic

SANATORIUM TREATMENT AND MILITARY SERVICE : AN ANALYSIS OF 47 CASES. BY EDWARD E.

PREST, M.A., M.D. CANTAB.,

MEDICAL SUPERINTENDENT. AYRSHIRE SANATORIUM; CONSULTING PHYSICIAN, AYRSHIRE COUNTY TUBERCULOSIS COMMITTEE.

THE following account of the adventures of a number of patients who had served in the various services during the war, after being treated in a sanatorium, may be of interest at the present time. It must not be supposed that this is the best which might be expected if the cases had been an earlier date, for many of these cases were not favourable, and in many symptoms had existed for prolonged periods before undergoing treatment, and the stage

treated at very

stated does not indicate necessarily the duration of symptoms, as some cases advance rapidly in a short time, There is difficulty in obtaining growth on subculture, but whilst others go on for long periods before much Most of these in one case the coccal form grew out, and had the same apparent destruction has taken place. morphological appearance as that seen in urine and sputum, cases were volunteers in the true sense, for most of them could have procured exemption by obtaining a certificate. although the sugar reactions varied slightly. They did not ask my advice before enlisting ; in some Pleurral Effusions. cases I should have attempted to dissuade them, Six cases were examined bacteriologically. Cells were and a number ought certainly to have been rejected. scanty, a few small lymphocytes and polymorphonuclears I think, however, it goes to show that were cases treated being found in the deposit after centrifagalisation. Direct at sanatoriums as soon as symptoms became recognisable films showed a few Gram-negative bacilli, and in one case and were persistent, it would become unnecessary to reject

visibility.

241 Pr.

or

Ab.

=

Presence

(+)

or

absence

admission ; (2)

on

( - ) of tubercle discharge.

bacilli :

(1) on

the ground that they had been in a sanatorium, and it follows from this that under ordinary peace conditions such patients would return to their former manner of life and old avocations. It should, of course, be understood that if passed as medically fit the country would have to take complete responsibility for their condition if they subsequently broke down. Had all sanatoriums spent their energies from their inception in treating early cases they might easily have produced a division of excellent soldiers ; as it is, the majority of the patients treated in sanatoriums are either dead or hopelessly unfit, and are requiring after-care.

I

men on

Analysis of Cases. which should not have been that the expense of treating these All these men for tuberculosis has not been excessive. cases were treated in the Ayrshire Sanatorium. I have only come across one case treated in the Ayrshire hospitals for advanced cases who enlisted, and he apparently made a bet that he would be taken, and he was passed Grade I. and saw some years’ service in the East ; he was finally invalided out of the Army with tuberculosis, and at the present time he is in fair condition. The occupations of the above when admitted to the sanatorium were as follows : Coal-miners, 14 ; labourers, 6 ; schoolboys, 5 ; engineers, shop assistants, painters, iron moulders, and railway clerks, 2 of each; groom, bleacher, cabinet maker, iron turner, brass finisher, iron-stone miner,

Except

in certain

enlisted, it will be

cases

seen

surfaceman, gardener, blacksmith, French polisher, mason, and agricultural labourer, 1 of each. One of these patients became a professional athlete after leaving the sanatorium, and is so engaged at the present time. One held a commission, another was offered a commission, 1 won the military medal, 1 was promoted on the field for valour, 2 were sergeants, and 3 were corporals. Three lost their lives in their country’s service, 8 were wounded, 3 gassed, One was discharged from the Army and 1 buried alive. because he was said to be suffering from valvular disease of the heart; he really had heart failure due to excessive fibrosis, and should not have been taken. Another had suffered from caries in the spine; this man did home service right through the war, and is at present working at a laborious occupation. One man was discharged ater an anti-enteric inoculation, and he has been working ever since. One was in hospital for some months, supposed to have pneumonia, but from the account he gave of himself he had evidently been suffering from an acute attack of tubercle ; this is a mistake which is constantly being made, and is the cause of not a few incorrect death certificates. This man is now at his old work after seeing a good deal more of service. It will be noted that 14 had tubercle bacilli in their sputum, one reacted to tuberculin, and of those in whom bacilli were not found 12 were in the second stage and two in the third. In closing I may remark that 28 had been in the sanatorium in 1913 or previous years, and had been engaged in their ordinary occupations for some time before war broke out. Finally, I would remark that the sacrifices of these men will not have been made in vain if they teach us that those who have had the misfortune to contract tuberculosis may be worthy of a better fate than to be segregated, but let it be understood there can be no worse place for an uncured tuberculous patient in war time than the Army. LONDON

HOSPITAL :

OLD

STUDENTS’ DINNER.-

The old students’ dinner will be held on Thursday, Oct. 2nd, at Princes’ Restaurant. Sir Bertrand Dawson will preside. This will be the first reunion of old students since the outbreak of the war. Application for tickets should be made to one of the honorary secretaries, Mr. Hunter Tod, 11, Upper Wimpole-street, W. 1, or Dr. Charles H. Miller, 32, Devon shire-place, W. 1.

KING’S

* Acute. t Laryngeal. (a) Present betore admission. (b) sputum on discharge. (c) Reacted to tuberculin under treatment.

No

jI

COLLEGE

HOSPITAL

MEDICAL

SCHOOL

LONDON).-The following elections to have been made :-Burney Yeo scholarships : J. W. Hirst, Gonville and Caius College, Cambridge ; C. F. T. East, New College, Oxford. Senior Scholarship and Todd prize : E. A. L. Crichlow, M.R.C.S., L.R.C.P. Jelf medal: H. Kamal, M.B., B.S., M.R.C.S., L.R.C.P. Tanner prize: Miss D. E. P. Jolly.

(UNIVERSITY scholarships

OF