- Email: [email protected]
THE AFTER-HISTORY OF 500 CONSECUTIVE TUBERCULOSIS DISPENSARY CASES.
807 CASE 2.-Peritoneal haemorrhages; old right pleurisy; atrophy of liver ; degeneration of kidneys ; spleen enlarged ; haemorrhage from stomach. CASE 3.-Small mesenteric, subpericardial and subpleuritic hæmorrhages; liver weight 32 oz. ; spleen weight 8 oz. ; gastric haemorrhages. of neck; CASE 4.-Petechial hæmorrhage skin mesenteric hoemorrhages; pleuritic haemorrhages; blood in stomach + + + ; mass size of walnut in tail of pancreas, containing black, mucilaginous matter, (?) old blood; liver about one-third normal size, fibrous ; congestion of ileum with film coating it ; spleen not enlarged. CASE 5.-Mesenteric haemorrhages ; spleen enlarged and diffluent ; kidneys-slight chronic nephritis; haemorrhage under capsule of pancreas ; pericardial haemorrhages; a pint of haemolysed blood in stomach; intestines contain blood; liver normal size, nutmeg appearance due to degeneration of parenchyma, less friable than normal; broncho-pneumonia. CASE 6.—Hæmorrhage in mesentery; old adhesions, left apex’; liver smaller than normal; spleen enlarged and diffluent ; kidneys enlarged; slight chronic nephritis; blood in stomach; slight myocardial degeneration of heart. CASE 7.-Mesenteric and pericardial haemorrhages; liver two-thirds normal size, nutmeg appearance, fibrous ; spleen small and diffluent ; small heemorrhages under kidney capsule and under pancreas; blood in stomach. CASE 8.-Parenchymatous degeneration of liver, also kidneys ; superficial erosions of stomach.
THE
AFTER-HISTORY
OF
500
CONSECUTIVE
TUBERCULOSIS DISPENSARY CASES. BY F. GARLAND
COLLINS, M.R.C.S., L.R.C.P. LOND., D.P.H.,
TUBERCULOSIS OFFICER FOR THE COUNTY BOROUGH OF WEST HAM MEDICAL ADVISER TO THE WEST HAM INSURANCE COMMITTEE.
THE following statistics were compiled after re-examinations or investigations made during the latter end of the year 1919 and the beginning of 1920 of the cases recorded, which were first examined by me at the West Ham Tuberculosis Dispensary between the months of June and December, 1914. At that time (i.e., over five years ago), with the exception of patients sent for diagnosis by a medical practitioner, only notified cases of pulmonary tuberculosis and their contacts were dealt with at this institution. Of the 500 cases examined, 238 were recently notified cases, 218 contacts -of those cases, and 44 were " request " cases. Notified cases.—Under this class were 153 males and 85 females; amongst this number were 18 cases which proved not to be tuberculous, including
patients suffering from carcinoma of the oesophagus, carcinoma of the rectum, syphilis, diabetes, nephritis with oedema of the lungs. One very doubtful case left the district whilst undergoing Summary. observation at the dispensary. (1) Fifty-eight cases of delayed poisoning followOf the 219 cases, 95 were of type 1., 67 ing administration of salvarsan and mercury were of type II., andpositive 57 of type III. (Types 1., II., and observed. Forty-seven of these showed symptoms III. correspond to the Turban-Gerhardt classificareferable to the liver-namely, jaundice, decreased Their after-history is shown in Table A :tion.) digestive power, and liver atrophy. Eight of these TABLE A.—Notified Cases. were fatal (see Schedule) and at autopsy showed marked atrophy of the liver. Atrophy of the liver may be marked in cases which ultimately recover. This condition can be diagnosed by X rays. (2) Dermatitis occurred in eight cases. Five were severe
with marked exfoliation. was observed
(3) Peripheral neuritis
in
two
cases. was present in over 50 per cent. Œdema was found in two cases. In addition to dispensary or domiciliary treat(5) The onset of the symptoms seldom occurred until five weeks after the administration of salvarsan ment, 61 cases of type 1., 48 of type II., and 23 of had ceased. type III.-in all 132 cases-were treated in sana(6) The earliest symptoms of salvarsan poisoning torium or hospital for periods varying from one of the liver were-bile in the urine, albuminuria, month to one year, the average time being four loss of appetite, and jaundice. These symptoms months. Contacts.—The majority of cases under this should be looked for in all patients receiving salvarsan treatment, and on their appearance the heading were children of school age, owing to the aversion of presumably healthy adults to attend for administration of salvarsan should cease. (7) By X ray examination atrophy of the liver TABLE B.—Contacts. may be diagnosed at an early stage. (8) Where evidence of liver damage"is present the diet should be reduced to a minimum. (9) Dermatitis with atrophy of the liver occurred in one patient who received arsenic in the form of Fowler’s solution, rrw. (10) We believe these were cases of delayed arsenical poisoning. We are indebted to Hon. Captain Lachlan Gilchrist, C.A.M.C., for much help in the examination of the liver by X rays ; and to Captain James H. Howell, C.A.M.C., who was in charge of the jaundice wards at No. 16 Canadian General Hospital for several months, for his painstaking work on the examination; chiefly the more "weakly" contacts cases and for keeping accurate records ; and to were seen-i.e., those who by reason of a cough or H. 14 B. No. Captain Hetherington, pathologist, Canadian General Hospital, who performed the some indefinite ailment induced the parent to suspect the possible presence of tuberculosis. Many autopsies on our fatal cases.
(4) Albuminuria
of the
cases.
808 more females than males made up this class, the Though of limited scope, I have ventured to former numbering 131 andthe latter only 87, and publish these statistics in the hope that they may yet of the 33 cases which proved to be definitely be of general interest and possibly prove of some positive 19 were males and only 14 females, 27 being utility. Note.— Many reports recently published from of type 1., 5 of type II., and 1 of type III., with afterhistory as shown in Table B. Only 7 contacts various districts do not show such promising received sanatorium treatment owing mainly to results as those above recorded. In this respect the absence of beds available for children. it may be of interest to note that this district " Request" Cases.-Of the 44 cases sent for was one of the first to adopt the medical inspecdiagnosis (25 males and 19 females), exactly one- tion of school children and also the feeding of half were found to be tuberculous, 12 being of necessitous school children, in addition to being type 1., 6 of type II., and 4 of type III. Their one in which the National Insurance Act has after-history is shown in Table C. 13 of these been in working order since 1912. cases received sanatorium treatment. The positive cases from all three classes taken UNUSUAL CASES OF together show the approximate percentages given in Table D. INTESTINAL OBSTRUCTION.1
TABLE D.—Combined List
of Positive
Cases.
BY J. A. CAIRNS
FORSYTH, M.Sc., M.B.; CH.B., F.R.C.S.,
SURGEON TO THE FRENCH
HOSPITAL, AND SURGEON TO OUT-PATIENTS,
ROYAL WATERLOO HOSPITAL FOR CHILDREN AND
WOMEN, LONDON.
The comparatively small percentage of type I. recorded as having received residential institutional treatment is due to the considerable number of children in this class for whom no institution was available; nearly all these children had dispensary treatment. Only a proportion of the adult cases " tabulated as arrested" have been verified by examination at the tuberculosis dispensary, but in practically every case the person is doing fulltime work (industrial or household) and is not in need of medical treatment. All doubtful cases were kept under observation at the dispensary for varying periods before a definite diagnosis was made. Tuberculin was not used either as a diagnostic or curative agent, in any one of this series of cases. Periodical visits were paid to each case by the tuberculosis nurse to advise and encourage the best practicable hygienic measures in the home. It is regrettable that such a considerable number of cases left the district and cannot be traced, as these would have somewhat modified the figures under the headings of arrested and dead, but the large migratory population of the industrial district from which the cases under consideration were drawn has been further augmented by wartime and post-war conditions. Conclttsions.
IN the treatment of intestinal obstruction, whether acute or chronic, the surgeon must always be prepared for surprises, for there is probably no other department in the whole of surgery where the diagnosis of the underlying cause is so difficult to foretell. This is easily understood when one considers the manifold possibilities for mischief within the abdomen. Apart from purely intrinsic causes, the bowel may be impeded in its functions by many conditions of extrinsic origin. To enumerate these would take a long time, and I do not propose discussing them, since after all the exact diagnosis of the causal factor, in the vast majority of cases of intestinal obstruction, is only of academic importance. Some time ago I reviewed the numerous cases of intestinal obstruction that had come under my observation. They included many cases of exceptional interest, and, on summing up the series, it was rather surprisinct to find that in many instances the exact cause of the obstruction was only revealed at the operation. From the series I have chosen four cases to illustrate the difficulties with which one may have to contend, both in diagnosis and operative treatment. Two of the cases came under the care of Sir A. Mayo-Robson while I was his assistant, and I have to thank him for permission to record them. The other two occurred in my own practice. CASE 1. Acute angulation at the hepatic flexure from pericoLitis; rupture of the tœniœ coli of the cœcum.—The patient was a man, aged 62, who for some years had
suffered from mucous colitis. On a recent visit to South Africa and Egypt he had been very ill from dysentery. may be drawn :When seen by Sir A. Mayo-Robson the patient com. 1. That pulmonary tuberculosis may be cured if plained of pain and discomfort in the lower abdomen, treated in its early stages. and stated that he was passing undigested food and 2. It is only the early case that derives any mucus. The bowels were acting irregularly, and the permanent benefit from sanatorium treatment patient noticed that with a morning action he had (with rare exceptions) ; hence the futility of abdominal discomfort for the rest of the day. There less pain when the bowels acted in the clogging the sanatoriums with the more advanced was much and he was always better when constipated. evening, of case. type The patient came into a nursing home and the 3. Much more strenuous preventive measures rectum and were examined by the sigmoidoshould be adopted-e.g., additional suitable open- scope, but sigmoid undue redness and beyond hypertrophy air schools and institutions for very advanced of the mucous membrane nothing abnormal was cases. detected. Two days later he was suddenly seized 4. There is a sad lack of suitable institutions for with acute griping pain in the right iliac fossa,
From the above
analysis the following conclusions
the tuberculous child. 5. A certain percentage of positive adult contacts must escape detection while the disease is yet in its early stage.
marked
There
collapse, followed by slight
was
some
distension
in that
accompanied by
1 Abstract of a lecture delivered before Medicine on Jan. 28th. 1920.
region. rise of
the Fellowship of
THE
AFTER-HISTORY
OF
500
CONSECUTIVE
TUBERCULOSIS DISPENSARY CASES. BY F. GARLAND
COLLINS, M.R.C.S., L.R.C.P. LOND., D.P.H.,
TUBERCULOSIS OFFICER FOR THE COUNTY BOROUGH OF WEST HAM MEDICAL ADVISER TO THE WEST HAM INSURANCE COMMITTEE.
THE following statistics were compiled after re-examinations or investigations made during the latter end of the year 1919 and the beginning of 1920 of the cases recorded, which were first examined by me at the West Ham Tuberculosis Dispensary between the months of June and December, 1914. At that time (i.e., over five years ago), with the exception of patients sent for diagnosis by a medical practitioner, only notified cases of pulmonary tuberculosis and their contacts were dealt with at this institution. Of the 500 cases examined, 238 were recently notified cases, 218 contacts -of those cases, and 44 were " request " cases. Notified cases.—Under this class were 153 males and 85 females; amongst this number were 18 cases which proved not to be tuberculous, including
patients suffering from carcinoma of the oesophagus, carcinoma of the rectum, syphilis, diabetes, nephritis with oedema of the lungs. One very doubtful case left the district whilst undergoing Summary. observation at the dispensary. (1) Fifty-eight cases of delayed poisoning followOf the 219 cases, 95 were of type 1., 67 ing administration of salvarsan and mercury were of type II., andpositive 57 of type III. (Types 1., II., and observed. Forty-seven of these showed symptoms III. correspond to the Turban-Gerhardt classificareferable to the liver-namely, jaundice, decreased Their after-history is shown in Table A :tion.) digestive power, and liver atrophy. Eight of these TABLE A.—Notified Cases. were fatal (see Schedule) and at autopsy showed marked atrophy of the liver. Atrophy of the liver may be marked in cases which ultimately recover. This condition can be diagnosed by X rays. (2) Dermatitis occurred in eight cases. Five were severe
with marked exfoliation. was observed
(3) Peripheral neuritis
in
two
cases. was present in over 50 per cent. Œdema was found in two cases. In addition to dispensary or domiciliary treat(5) The onset of the symptoms seldom occurred until five weeks after the administration of salvarsan ment, 61 cases of type 1., 48 of type II., and 23 of had ceased. type III.-in all 132 cases-were treated in sana(6) The earliest symptoms of salvarsan poisoning torium or hospital for periods varying from one of the liver were-bile in the urine, albuminuria, month to one year, the average time being four loss of appetite, and jaundice. These symptoms months. Contacts.—The majority of cases under this should be looked for in all patients receiving salvarsan treatment, and on their appearance the heading were children of school age, owing to the aversion of presumably healthy adults to attend for administration of salvarsan should cease. (7) By X ray examination atrophy of the liver TABLE B.—Contacts. may be diagnosed at an early stage. (8) Where evidence of liver damage"is present the diet should be reduced to a minimum. (9) Dermatitis with atrophy of the liver occurred in one patient who received arsenic in the form of Fowler’s solution, rrw. (10) We believe these were cases of delayed arsenical poisoning. We are indebted to Hon. Captain Lachlan Gilchrist, C.A.M.C., for much help in the examination of the liver by X rays ; and to Captain James H. Howell, C.A.M.C., who was in charge of the jaundice wards at No. 16 Canadian General Hospital for several months, for his painstaking work on the examination; chiefly the more "weakly" contacts cases and for keeping accurate records ; and to were seen-i.e., those who by reason of a cough or H. 14 B. No. Captain Hetherington, pathologist, Canadian General Hospital, who performed the some indefinite ailment induced the parent to suspect the possible presence of tuberculosis. Many autopsies on our fatal cases.
(4) Albuminuria
of the
cases.
808 more females than males made up this class, the Though of limited scope, I have ventured to former numbering 131 andthe latter only 87, and publish these statistics in the hope that they may yet of the 33 cases which proved to be definitely be of general interest and possibly prove of some positive 19 were males and only 14 females, 27 being utility. Note.— Many reports recently published from of type 1., 5 of type II., and 1 of type III., with afterhistory as shown in Table B. Only 7 contacts various districts do not show such promising received sanatorium treatment owing mainly to results as those above recorded. In this respect the absence of beds available for children. it may be of interest to note that this district " Request" Cases.-Of the 44 cases sent for was one of the first to adopt the medical inspecdiagnosis (25 males and 19 females), exactly one- tion of school children and also the feeding of half were found to be tuberculous, 12 being of necessitous school children, in addition to being type 1., 6 of type II., and 4 of type III. Their one in which the National Insurance Act has after-history is shown in Table C. 13 of these been in working order since 1912. cases received sanatorium treatment. The positive cases from all three classes taken UNUSUAL CASES OF together show the approximate percentages given in Table D. INTESTINAL OBSTRUCTION.1
TABLE D.—Combined List
of Positive
Cases.
BY J. A. CAIRNS
FORSYTH, M.Sc., M.B.; CH.B., F.R.C.S.,
SURGEON TO THE FRENCH
HOSPITAL, AND SURGEON TO OUT-PATIENTS,
ROYAL WATERLOO HOSPITAL FOR CHILDREN AND
WOMEN, LONDON.
The comparatively small percentage of type I. recorded as having received residential institutional treatment is due to the considerable number of children in this class for whom no institution was available; nearly all these children had dispensary treatment. Only a proportion of the adult cases " tabulated as arrested" have been verified by examination at the tuberculosis dispensary, but in practically every case the person is doing fulltime work (industrial or household) and is not in need of medical treatment. All doubtful cases were kept under observation at the dispensary for varying periods before a definite diagnosis was made. Tuberculin was not used either as a diagnostic or curative agent, in any one of this series of cases. Periodical visits were paid to each case by the tuberculosis nurse to advise and encourage the best practicable hygienic measures in the home. It is regrettable that such a considerable number of cases left the district and cannot be traced, as these would have somewhat modified the figures under the headings of arrested and dead, but the large migratory population of the industrial district from which the cases under consideration were drawn has been further augmented by wartime and post-war conditions. Conclttsions.
IN the treatment of intestinal obstruction, whether acute or chronic, the surgeon must always be prepared for surprises, for there is probably no other department in the whole of surgery where the diagnosis of the underlying cause is so difficult to foretell. This is easily understood when one considers the manifold possibilities for mischief within the abdomen. Apart from purely intrinsic causes, the bowel may be impeded in its functions by many conditions of extrinsic origin. To enumerate these would take a long time, and I do not propose discussing them, since after all the exact diagnosis of the causal factor, in the vast majority of cases of intestinal obstruction, is only of academic importance. Some time ago I reviewed the numerous cases of intestinal obstruction that had come under my observation. They included many cases of exceptional interest, and, on summing up the series, it was rather surprisinct to find that in many instances the exact cause of the obstruction was only revealed at the operation. From the series I have chosen four cases to illustrate the difficulties with which one may have to contend, both in diagnosis and operative treatment. Two of the cases came under the care of Sir A. Mayo-Robson while I was his assistant, and I have to thank him for permission to record them. The other two occurred in my own practice. CASE 1. Acute angulation at the hepatic flexure from pericoLitis; rupture of the tœniœ coli of the cœcum.—The patient was a man, aged 62, who for some years had
suffered from mucous colitis. On a recent visit to South Africa and Egypt he had been very ill from dysentery. may be drawn :When seen by Sir A. Mayo-Robson the patient com. 1. That pulmonary tuberculosis may be cured if plained of pain and discomfort in the lower abdomen, treated in its early stages. and stated that he was passing undigested food and 2. It is only the early case that derives any mucus. The bowels were acting irregularly, and the permanent benefit from sanatorium treatment patient noticed that with a morning action he had (with rare exceptions) ; hence the futility of abdominal discomfort for the rest of the day. There less pain when the bowels acted in the clogging the sanatoriums with the more advanced was much and he was always better when constipated. evening, of case. type The patient came into a nursing home and the 3. Much more strenuous preventive measures rectum and were examined by the sigmoidoshould be adopted-e.g., additional suitable open- scope, but sigmoid undue redness and beyond hypertrophy air schools and institutions for very advanced of the mucous membrane nothing abnormal was cases. detected. Two days later he was suddenly seized 4. There is a sad lack of suitable institutions for with acute griping pain in the right iliac fossa,
From the above
analysis the following conclusions
the tuberculous child. 5. A certain percentage of positive adult contacts must escape detection while the disease is yet in its early stage.
marked
There
collapse, followed by slight
was
some
distension
in that
accompanied by
1 Abstract of a lecture delivered before Medicine on Jan. 28th. 1920.
region. rise of
the Fellowship of