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The Clinical Interpretation of Aids to Diagnosis.
311
The Clinical Interpretation of
Aids A Series of
to
Diagnosis.
Special Articles contributed by Invitation.
LXII.—INTERPRETATION OF REPORTS
ON
LESIONS OF THE EYE. PART II.* IN the first part of this article I dealt with definite organisms. When questions arise on the inter-
pretation of the results of tests, such as the Wassermann reaction or Pirquet’s test, the answers The modern tendency to rely are less easy. more and more on laboratory tests and less and less on clinical experience and knowledge imposes a responsibility on the bacteriologist which is unfair both to him and to the patient. It must be reiterated that. laboratory tests, no matter how reliable, form only part of the data essential for correct diagnosis.
ment for examination, my last figures worked out at 3 per cent., due to a more critical definition as to what was a gonococcus in the slides examined. Perhaps even this is too high a percentage. The difficulty of detecting the gonococcus amongst the debris of pus cells, spermatozoa, and organisms in the smear is so great that a definite statement is rarely possible. However, when pus has been found in the prostate or vesicles, treatment has to be carried out in spite of inability to find the gonococcus in the discharge, and the condition is labelled gonorrhoeal iritis. The report made on a prostatic massage will often record the finding of all sorts of other organisms, streptococci, staphylococci, pneumococci, colon bacilli, and diphtheroids. These are probably the results of secondary infections and must be taken into consideration when arranging a course of treatment. This should consist of (1) the symptomatic treatment ordered by the ophthalmic surgeon, such as atropin, leeches, hot bathing, &c., t (2) specific treatment, such as vaccines, prostatic and (3) treatand vesicular massage, irrigation, &c. ; ment to clear up other septic foci.
-and of Rheumatic Pains. Rheumatic was at one time frequently applied to what we now know is often gonorrhoeal iritis. The Wassermann Reaction. It often happens that a patient is sent to a laboratory Rheumatism is almost always present in the history for a Wassermann reaction. The result is positive- of patients who come with gonorrhceal iritis. Con.and without any further consideration the patient is sidering the small percentage of cases in which the gonococcus is found it is naturally open to debate as to passed on to a V.D. department, the eye condition whether these cases should or should not be diagnosed being labelled " syphilitic." Further consideration as iritis. I myself use this classification, gonorrhceal that the condition is due to may prove eye septic teeth and the positive Wassermann to a congenital because the cases of iritis in which I find pus in the taint which requires no treatment. It is the clinician’s material from the prostatic massage are the cases to gonococcal vaccine. The reaction job to elucidate these facts, not that of the person whichbereact one of exacerbation of the existing iritis, or may test. I am the not that it is making wrong suggesting to treat a patient with a positive reaction as a one of rapij cure of the condition. I believe that is a toxic condition and that the - syphilitic, but only that it is wrong to label an eye gonorrhceal isiritis in the eye. Dr. E ric Riddle, not gonococcus present disease as syphilitic on a positive Wassermann reaction when he was working with me at Moorfields, made the alone. observation that it was quite rare to find gonorrhoeal Reports on Patients with Iritis. iritis in who had clean mouths, or perhaps The interpretation’ of the reports on investigationsit would patients be better put that people with septic teeth designed to elucidate the cause of iritis is clifficult.were more likely to get gonorrhceal iritis than those The causes are so many and varied that it is oftenwith clean mouths. This may account for the impossible to say with certainty what variationcomparative rarity of the condition in private practice from the normal is responsible for the iritis. Itand certainly one of the first things to do in treating may be accepted that iritis and iridocyclitis are, as athese cases is to have the mouth attended to. rule, the result of toxic irritation due to some distant septic focus. It is, indeed, rare to examine a patient Tuberculin Tests. without finding some septic focus, a suspicious tooth, The tests for tuberculosis of the eye are few, and of infected sinus or antrum, a collection of pus behind little real value as proof tests. The only one of any a deflected septum or septic tonsils ; any of them may real value is the subcutaneous injection of tuberculin, be the cause (and equally may not be the cause) of with resulting focal, local, and general reaction, but the iritis. There is one cause of iritis in men which this test is practically debarred from use in eye work, should always be inquired into-viz., gonorrhoea. since it is inadvisable to risk stirring up a tuberculous In women gonorrhoea] iritis is extremely rare. I haveI a focal reaction. The graduated Pirquet test, eye lay The history of gonorrhoea, hownever seen a case. human and bovine tuberculin, is of some value using all ever, is not enough, and in my V.D. department if the results are used with discrimination, although the other causes of iritis are gone into before the the test cannot definite information like the of an for evidence old gonorrhoeal subcutaneous test.give patient is examined infection. Gonorrhoeal iritis seldom occurs during i If the result of the test is taken into consideration the acute urethritis stage of the disease, and the with the clinical evidence it is of help in young average time after the acute attack of gonorrhoea art which the iritis appeared worked out at 9 years patients, and in adults may be a useful guide as to the in one series of 250 cases, and 14 years in another type of tuberculin to use in treatment. The presence of a positive Pirquet test does not mean that the eye series. condition is a tuberculous one. Significance of Pus and GonococciS. H. BROWNING, M.R.C.S. Eng., Having assessed - the importance of any other ’septic foci the next step is to examine the patient Bacteriologist to and Lecturer on Bacteriology and Medical for evidence of a residual gonorrhcea. Urethritis and Officer i/c V.D. Dept. to the Royal London Ophthalmic Hospital. gleet are rare at this stage of the disease, and it is only when we come to the examination of the material expressed by prostatic and vesicular massage that evidence of the original infection appears. It is HOSPITAL COOPERATION.—As the result of a quite usual to find pus in considerable quantities, but Conference of representatives of the voluntary hospitals in the is quite unusual to find the gonococcus, and although County of Durham a committee of ten was appointed to -at one time I was finding the gonococcus in 9 per join with a similar number of members of the medical staffs cent. of the cases of rheumatic iritis sent to my depart- of those institutions to meet the Durham County Council to
I
*Part I. appeared last week.
discuss questions of hospital service arising out of the provisions of the Local Government Act.
The Clinical Interpretation of
Aids A Series of
to
Diagnosis.
Special Articles contributed by Invitation.
LXII.—INTERPRETATION OF REPORTS
ON
LESIONS OF THE EYE. PART II.* IN the first part of this article I dealt with definite organisms. When questions arise on the inter-
pretation of the results of tests, such as the Wassermann reaction or Pirquet’s test, the answers The modern tendency to rely are less easy. more and more on laboratory tests and less and less on clinical experience and knowledge imposes a responsibility on the bacteriologist which is unfair both to him and to the patient. It must be reiterated that. laboratory tests, no matter how reliable, form only part of the data essential for correct diagnosis.
ment for examination, my last figures worked out at 3 per cent., due to a more critical definition as to what was a gonococcus in the slides examined. Perhaps even this is too high a percentage. The difficulty of detecting the gonococcus amongst the debris of pus cells, spermatozoa, and organisms in the smear is so great that a definite statement is rarely possible. However, when pus has been found in the prostate or vesicles, treatment has to be carried out in spite of inability to find the gonococcus in the discharge, and the condition is labelled gonorrhoeal iritis. The report made on a prostatic massage will often record the finding of all sorts of other organisms, streptococci, staphylococci, pneumococci, colon bacilli, and diphtheroids. These are probably the results of secondary infections and must be taken into consideration when arranging a course of treatment. This should consist of (1) the symptomatic treatment ordered by the ophthalmic surgeon, such as atropin, leeches, hot bathing, &c., t (2) specific treatment, such as vaccines, prostatic and (3) treatand vesicular massage, irrigation, &c. ; ment to clear up other septic foci.
-and of Rheumatic Pains. Rheumatic was at one time frequently applied to what we now know is often gonorrhoeal iritis. The Wassermann Reaction. It often happens that a patient is sent to a laboratory Rheumatism is almost always present in the history for a Wassermann reaction. The result is positive- of patients who come with gonorrhceal iritis. Con.and without any further consideration the patient is sidering the small percentage of cases in which the gonococcus is found it is naturally open to debate as to passed on to a V.D. department, the eye condition whether these cases should or should not be diagnosed being labelled " syphilitic." Further consideration as iritis. I myself use this classification, gonorrhceal that the condition is due to may prove eye septic teeth and the positive Wassermann to a congenital because the cases of iritis in which I find pus in the taint which requires no treatment. It is the clinician’s material from the prostatic massage are the cases to gonococcal vaccine. The reaction job to elucidate these facts, not that of the person whichbereact one of exacerbation of the existing iritis, or may test. I am the not that it is making wrong suggesting to treat a patient with a positive reaction as a one of rapij cure of the condition. I believe that is a toxic condition and that the - syphilitic, but only that it is wrong to label an eye gonorrhceal isiritis in the eye. Dr. E ric Riddle, not gonococcus present disease as syphilitic on a positive Wassermann reaction when he was working with me at Moorfields, made the alone. observation that it was quite rare to find gonorrhoeal Reports on Patients with Iritis. iritis in who had clean mouths, or perhaps The interpretation’ of the reports on investigationsit would patients be better put that people with septic teeth designed to elucidate the cause of iritis is clifficult.were more likely to get gonorrhceal iritis than those The causes are so many and varied that it is oftenwith clean mouths. This may account for the impossible to say with certainty what variationcomparative rarity of the condition in private practice from the normal is responsible for the iritis. Itand certainly one of the first things to do in treating may be accepted that iritis and iridocyclitis are, as athese cases is to have the mouth attended to. rule, the result of toxic irritation due to some distant septic focus. It is, indeed, rare to examine a patient Tuberculin Tests. without finding some septic focus, a suspicious tooth, The tests for tuberculosis of the eye are few, and of infected sinus or antrum, a collection of pus behind little real value as proof tests. The only one of any a deflected septum or septic tonsils ; any of them may real value is the subcutaneous injection of tuberculin, be the cause (and equally may not be the cause) of with resulting focal, local, and general reaction, but the iritis. There is one cause of iritis in men which this test is practically debarred from use in eye work, should always be inquired into-viz., gonorrhoea. since it is inadvisable to risk stirring up a tuberculous In women gonorrhoea] iritis is extremely rare. I haveI a focal reaction. The graduated Pirquet test, eye lay The history of gonorrhoea, hownever seen a case. human and bovine tuberculin, is of some value using all ever, is not enough, and in my V.D. department if the results are used with discrimination, although the other causes of iritis are gone into before the the test cannot definite information like the of an for evidence old gonorrhoeal subcutaneous test.give patient is examined infection. Gonorrhoeal iritis seldom occurs during i If the result of the test is taken into consideration the acute urethritis stage of the disease, and the with the clinical evidence it is of help in young average time after the acute attack of gonorrhoea art which the iritis appeared worked out at 9 years patients, and in adults may be a useful guide as to the in one series of 250 cases, and 14 years in another type of tuberculin to use in treatment. The presence of a positive Pirquet test does not mean that the eye series. condition is a tuberculous one. Significance of Pus and GonococciS. H. BROWNING, M.R.C.S. Eng., Having assessed - the importance of any other ’septic foci the next step is to examine the patient Bacteriologist to and Lecturer on Bacteriology and Medical for evidence of a residual gonorrhcea. Urethritis and Officer i/c V.D. Dept. to the Royal London Ophthalmic Hospital. gleet are rare at this stage of the disease, and it is only when we come to the examination of the material expressed by prostatic and vesicular massage that evidence of the original infection appears. It is HOSPITAL COOPERATION.—As the result of a quite usual to find pus in considerable quantities, but Conference of representatives of the voluntary hospitals in the is quite unusual to find the gonococcus, and although County of Durham a committee of ten was appointed to -at one time I was finding the gonococcus in 9 per join with a similar number of members of the medical staffs cent. of the cases of rheumatic iritis sent to my depart- of those institutions to meet the Durham County Council to
I
*Part I. appeared last week.
discuss questions of hospital service arising out of the provisions of the Local Government Act.