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TUBERCULOSIS IN GLASGOW
901
suggest, therefore, that in this not only are Bact. coli 0-55 time, present
at the : B5 strains over Bact. coli 0111 : B4, but that the preponderating 0-55 : B5 strains a.re of the H2 type. Bact. coli prevalent Flagellar antigen determinations provide a means of undertaking more detailed epidemiological studies of the Bact. coli types associated with infantile diarrhoea and vomiting. Inclusion of H-antigen typing is of advantage in cross-infection investigations5 made in a particular locality, and may also be of value, in view of the occurrence of these Bact. coli types in cities as far apart as Nagoya and London, in the study of the possible spread of these strains from one country to another. St. Ann’s General Hospital,
the results
area
JOYCE WRIGIIT.
London, N.15.
CARDIAC ASTHMA on his patient who had 67 attacks of cardiac asthma is surprising. That the condition should recur so frequently would appear to refute his conclusion that morphine is the drug par excellence in cardiac asthma." It is unusual for a hypertensive patient to survive the first attack of cardiac asthma for more than two years, but during this time attacks may not only be aborted but lessened. in frequency by administering aminophylline, which has been shown to alleviate pulmonary
SIR,—Dr. Kynaston’s comment (April 4) "
congestion-perhaps
most
strikingly
in
hypertensive
left
ventricular failure, but no less effectively in aortic stenosis and mitral stenosis and also to a lesser extent in
pulmonale. Aminophylline (theophylline with ethylene diamine) is effective intravenously but of little use by any other route. My own practice in treating cardiac asthma is to combine injectio mersalyl B.P. 2 ml. with 18 ml. injectio aminophylline B.P. (containing 045 g. aminophylline), given during 10 minutes, provided that the patient has shown no intolerance of intramuscular mersalyl. I should appreciate enlightenment as to whether my impression that slow intravenous injections of mersalyl are safer than quicker injections is well founded. cor
BRIAN WEBBER. AN UNUSUAL TYPE OF HERNIA
SIR,—I have just read Mr. Howard’s article (Feb. 21). This reminds of age
on
me
of
a
West African
man
of about 40 years
whom I
operated two years ago in Nigeria. complained of pain in his left groin for 6 months
He had and of swelling in each groin for many years. There were small, rounded lumps in each inguinal region over the site of the external ring ; they were soft and partly reducible and had a cough impulse. At operation a mass of fat presented at the external ring. It was about 7 cm. in length and placed above the cord and separate from it. On dissection I found, to my surprise, that there was no hernial sac associated with the cord, but that there was a narrow sac inside the mass of fat ; and this sac had its neck directed medially and its fundus laterally. It was in fact lying obliquely in the line of the inguinal canal, but with its neck at the external ring instead of the internal ring. Careful dissection of the neck showed that this passed through a small circular aperture in the conjoined tendon just deep to the place where the upper crus of the external ring meets the reflected inguinal ligament. Muscles and tendons were in good condition and the aperture had every appearance of being congenital in origin. The sac was too narrow to admit the little finger and was 6 em. in length. A pair of artery forceps passing down the sac and through the neck entered the abdominal cavity in the direction of the fundus of the bladder, and the forceps could not be turned into any other direction while in this situation. The sac contained a little clear gelatinous fluid only and had evidently never been stretched by the entry of gut into it, at least in adult life. The cord and testis were of normal appearance and size. Operation on the 5.
Wright, J.
Mschr. Kinderheilk.
1953, 101, 108.
other side revealed an identical type of hernia, and I could find no explanation why only one side had caused him pain. In each case, the sac was tiedat the neck and removed, and the small aperture in the conjoined tendon closed by one stitch. This aperture was just medial to the pubic tubercle, and about 3 cm. above it. ’
This hernia had every appearance of being congenital, but I am quite unable to explain its site. After finding it I had plenty of opportunity to examine other cases of indirect inguinal hernia in Africans of the same tribe, but found nothing about their conjoined tendons to give a clue. It resembles in site a supravesical hernia, but I have so far found nothing in accounts of rare hernias that quite compares with it. The resemblance of this hernia with that described by Mr. Howard lies in the fact that both simulated indirect inguinal herniation and both came through minute openings in the transversalis and internal oblique muscle planes, although these openings were widely divergent. J. R. ROSE Methodist Hospital Superintendent. Segbwema, Sierra Leone. TUBERCULOSIS IN GLASGOW
SIR,—There has been much speculation about the incidence of tuberculosis in Glasgow, but a short by one not acquainted with local conditions will soon reveal some of the most important causes. The housing conditions of many of the people are They have been appalling by Southern standards. described on many occasions. However, a visit with a general practitioner to an unselected patient in Anderson Ward revealed a little of this problem. The patient, a boy of six, the eldest surviving child in the family, was in bed in the " house."
high visit
This was of the usual Glasgow type-one all-purpose room with the parents’ bed in an alcove and another very small room just big enough to take the double bed in which all the children slept. The " house " was approached through a dark, damp corridor and then up three flights of the common stairway, ill lit, with a common" lavatory on.each floor. Off this floor five doors led to five houses," each of which held a minimum of four people.
The patient, who had a temperature of 102°F, was ill with his sixth episode of bronchopneumonia. The mother was eight months pregnant and the father had just arrived home from Territorial Army training. He told us a little of their housing problem. They had been on the housing list for eight years. Twelve months previously, when the wife was in hospital having their fourth child, the rats were so troublesome that they took possession of the children’s room and consequently the family slept in one large bed. Two days after the mother returned from hospital the newly born child was overlain and died. No open inquiry is held in Scotland in such The parents assured me that their circumstances. conditions were better than those of many others. Thousands of families live in such conditions, and it is to circumstances such as these that many patients return when hospital treatment for tuberculosis is finished. I was amazed to learn that no consultant in tuberculosis had yet been appointed to the whole region of South-west Scotland, of which Glasgow is the centre. I met a doctor who as senior hospital medical officer is in charge of 350 beds and has many clinic responsibilities as well. There has been little or no secondment of nurses from general hospitals to sanatoria or other hospitals where tuberculosis is treated. I was told that a doctor, prominent on administrative committees, had stated that if secondment from general hospitals was accepted he would withdraw his daughter from nursing. If this is the attitude which obtains in influential quarters there seems little hope of an intelligent approach to the nursing problem of tuberculosis.
902 It may be
thought impertinent
for
someone
from the
South of England to make comments on this situation, but the problem of tuberculosis in the British Isles is surely indivisible. The pathetic housing programme must receive the most urgent attention in Government circles, and, at the same time, the medical and nursing profession in Glasgow should rise to meet the demands of their local population. It is essential that the facts should receive the widest publicity in the national press and on the air, in order that there may be quickening of response to this tremendous human need. Central Middlesex Hospital, London, N.W.10.
HORACE JOULES.
EPIDEMIOLOGY OF STREPTOCOCCAL INFECTIONS
SIR,—In their very interesting review of the epidemiology of streptococcal infections in your issue of April 11, Professor Dingle, Professor Rammelkamp, and Dr. Wannamaker refer to their finding that, in a number of instances, infections due to hæmolytic streptococci of type 12 have been particularly commonly followed by acute glomerulonephritis. It is clearly of considerable interest to see whether a similar association can be shown in Britain. The Streptococcal Reference Laboratory at Colindale and the regional laboratories of the Public Health Laboratory Service at Cambridge, Cardiff, and Oxford would be very glad to collaborate with paediatricians or others who may have an opportunity of making such an investigation and to undertake the type identification of group-A streptococci that have been isolated in circumstances suggesting that they may have initiated an attack of nephritis. Streptococcal Reference Laboratory, Public Health Laboratory Service, Colindale, London, N.W.9.
R. E. O. WILLIAMS.
TRAINING OF PHYSIOTHERAPISTS
SIR,—Prominence has been given lately in medical to the training of physiotherapists, and we feel that certain points ought to be clarified. Physiotherapists in this country belong to three groups : (1) the Physiotherapists Association, (2) the Faculty of Physiotherapists, and (3) the Chartered Society of Physiotherapy. The Cope report, drawn up by a committee of nine members, six of whom were in active association with the Chartered Society, whereas the other two bodies were not represented, recommended hospital authorities to employ exclusively members of the Chartered Society, and the first circulars of the Ministry of Health were drawn up in this spirit. The injustice of this report, however, has been rapidly realised ; and the Minister of Health stated in Parliament on March 19 that the Cope report would not be implemented, and that he would further withdraw the temporary instructions in the Ministry circular referring to the employment of chartered physiotherapists, and make new regulations fair to all associations. We are at a loss to understand this tendency of the Chartered Society to monopolise physical treatment in this country. Apart from- the fact that it goes against the liberal principles that dominate medical work, nothing has demonstrated the superiority of the members of the Chartered Society over those of other associations of physical-treatment practitioners. We must emphasise that hospitals employing members of the Physiotherapists Association and the Faculty of Physiotherapists are perfectly satisfied that the training of members of the association and the faculty is not inferior to that of the Chartered Society. The education plan formulated by the Physiotherapists Association, and supported by education authorities, experienced teachers, and the medical profession, provides for the cooperation of technical colleges and
journals
Physiotherapy training schools of a university, and the physiotherapist’s qualification should be a recognised university diploma. The real aim is to enable the physiotherapist to take his place as an accepted member of a medical team, receiving alike the support of the medical profession and the confidence of the public. A. P. CAWADIAS
teaching hospitals. should be
part
President.
S. S. KNIGHT
Physiotherapists Association, 31, Dover Street. London, W.1.
General Secretary.
PHARMACEUTICAL ADVERTISEMENTS SIR,—Could not the British pharmaceutical serve
firms
community even further by including in all copious advertising matter the price of the prep. the
their aration advocated ?’? Of course, the resulting reduction in profits would mean less funds for research, but I venture to suggest that, on balance, the community would benefit more. A. W. ANDERSON. ENLARGED HILAR GLANDS
SIR,—It is to be
that your annotation on this as a catalyst, and promote subject (April 18) some useful reaction amongst those of your contributors who are interested in a problem which is still very much in the melting-pot. It would be of great interest to know how frequent these cases of asymptomatic hilar-gland enlargement really are in this country, and how they fit in to the broader general picture of hilar adenopathies in young It is well known that bilateral hilar-gland adults. enlargement at this age is much more common in Scandinavian countries than in the British Isles. In recent years large series of such cases have been reported, from Sweden in particular.
hoped
may act
Lofgren, for example, has made a special study of the question, and he has recently publishedtwo papers in collaboration with Lundback, in which 212 cases of "the bilateral hilar lymphoma syndrome " are studied in relation to (1) age and sex incidence, and (2) tuberculosis and sarcoidosis. Of these patients, 161 were women and 51 men ; and in 113 cases the syndrome was associated with erythema nodosum (107 females, 6 males). The maximum incidence was found in the age-group 25-29. In the female group, a relation to pregnancy and lactation was observed in some cases.
In 100 cases tuberculin sensitivity was absent, even to 1 mg. of tuberculin. Complications, tuberculous in type, developed in only 1 case. A diagnosis of sarcoidosis could be established by histopathological examination on an average in 26.4% of cases ; but during the later stages of the investigation, 23 out of 49 cases (47%) were proved to be sarcoidosis.
The conclusion drawn is that this syndrome is indeof tuberculosis from the point of view of aetiology. The authors interpret it as being a manifestation of sarcoidosis, and more exactly, as the primary stage of pulmonary sarcoidosis. Our own short paper2 reported 6 cases of bilateral hilar-gland enlargement, all in relatively young women with erythema nodosum. In 5 cases the Mantoux reaction was positive, and in the 6th it was negative at 1 in 10,000. There was a history of recent pregnancy in 2 cases. No clinical manifestations of sarcoidosis were found, though, if it had been possible to make the intensive search for biopsy material mentioned by Lofgren and Lundback, the result might have been different in some cases.
pendent
Chaves
and
Abeles,3
whose
paper,
entitled Transient
Undiagnosed Intrathoracic Lymphadenopathy in Apparently Healthy Persons, you mention, lay down as criteria for their cases the spontaneous regression of enlarged glands and the absence of evidence of pulmonary or other visceral involvement throughout the period of observation. From the large volume of material available for screening, coming from 1. 2.
Lofgren, S., Lundback, L. Acta. med. scand. 1952, 142, 259. Dunner, L., Hermon, R. Brit. med. J. 1952, ii, 1078. 3. Chaves, A. D., Abeles, H. Amer. Rev. Tuberc. 1953, 67, 45.
suggest, therefore, that in this not only are Bact. coli 0-55 time, present
at the : B5 strains over Bact. coli 0111 : B4, but that the preponderating 0-55 : B5 strains a.re of the H2 type. Bact. coli prevalent Flagellar antigen determinations provide a means of undertaking more detailed epidemiological studies of the Bact. coli types associated with infantile diarrhoea and vomiting. Inclusion of H-antigen typing is of advantage in cross-infection investigations5 made in a particular locality, and may also be of value, in view of the occurrence of these Bact. coli types in cities as far apart as Nagoya and London, in the study of the possible spread of these strains from one country to another. St. Ann’s General Hospital,
the results
area
JOYCE WRIGIIT.
London, N.15.
CARDIAC ASTHMA on his patient who had 67 attacks of cardiac asthma is surprising. That the condition should recur so frequently would appear to refute his conclusion that morphine is the drug par excellence in cardiac asthma." It is unusual for a hypertensive patient to survive the first attack of cardiac asthma for more than two years, but during this time attacks may not only be aborted but lessened. in frequency by administering aminophylline, which has been shown to alleviate pulmonary
SIR,—Dr. Kynaston’s comment (April 4) "
congestion-perhaps
most
strikingly
in
hypertensive
left
ventricular failure, but no less effectively in aortic stenosis and mitral stenosis and also to a lesser extent in
pulmonale. Aminophylline (theophylline with ethylene diamine) is effective intravenously but of little use by any other route. My own practice in treating cardiac asthma is to combine injectio mersalyl B.P. 2 ml. with 18 ml. injectio aminophylline B.P. (containing 045 g. aminophylline), given during 10 minutes, provided that the patient has shown no intolerance of intramuscular mersalyl. I should appreciate enlightenment as to whether my impression that slow intravenous injections of mersalyl are safer than quicker injections is well founded. cor
BRIAN WEBBER. AN UNUSUAL TYPE OF HERNIA
SIR,—I have just read Mr. Howard’s article (Feb. 21). This reminds of age
on
me
of
a
West African
man
of about 40 years
whom I
operated two years ago in Nigeria. complained of pain in his left groin for 6 months
He had and of swelling in each groin for many years. There were small, rounded lumps in each inguinal region over the site of the external ring ; they were soft and partly reducible and had a cough impulse. At operation a mass of fat presented at the external ring. It was about 7 cm. in length and placed above the cord and separate from it. On dissection I found, to my surprise, that there was no hernial sac associated with the cord, but that there was a narrow sac inside the mass of fat ; and this sac had its neck directed medially and its fundus laterally. It was in fact lying obliquely in the line of the inguinal canal, but with its neck at the external ring instead of the internal ring. Careful dissection of the neck showed that this passed through a small circular aperture in the conjoined tendon just deep to the place where the upper crus of the external ring meets the reflected inguinal ligament. Muscles and tendons were in good condition and the aperture had every appearance of being congenital in origin. The sac was too narrow to admit the little finger and was 6 em. in length. A pair of artery forceps passing down the sac and through the neck entered the abdominal cavity in the direction of the fundus of the bladder, and the forceps could not be turned into any other direction while in this situation. The sac contained a little clear gelatinous fluid only and had evidently never been stretched by the entry of gut into it, at least in adult life. The cord and testis were of normal appearance and size. Operation on the 5.
Wright, J.
Mschr. Kinderheilk.
1953, 101, 108.
other side revealed an identical type of hernia, and I could find no explanation why only one side had caused him pain. In each case, the sac was tiedat the neck and removed, and the small aperture in the conjoined tendon closed by one stitch. This aperture was just medial to the pubic tubercle, and about 3 cm. above it. ’
This hernia had every appearance of being congenital, but I am quite unable to explain its site. After finding it I had plenty of opportunity to examine other cases of indirect inguinal hernia in Africans of the same tribe, but found nothing about their conjoined tendons to give a clue. It resembles in site a supravesical hernia, but I have so far found nothing in accounts of rare hernias that quite compares with it. The resemblance of this hernia with that described by Mr. Howard lies in the fact that both simulated indirect inguinal herniation and both came through minute openings in the transversalis and internal oblique muscle planes, although these openings were widely divergent. J. R. ROSE Methodist Hospital Superintendent. Segbwema, Sierra Leone. TUBERCULOSIS IN GLASGOW
SIR,—There has been much speculation about the incidence of tuberculosis in Glasgow, but a short by one not acquainted with local conditions will soon reveal some of the most important causes. The housing conditions of many of the people are They have been appalling by Southern standards. described on many occasions. However, a visit with a general practitioner to an unselected patient in Anderson Ward revealed a little of this problem. The patient, a boy of six, the eldest surviving child in the family, was in bed in the " house."
high visit
This was of the usual Glasgow type-one all-purpose room with the parents’ bed in an alcove and another very small room just big enough to take the double bed in which all the children slept. The " house " was approached through a dark, damp corridor and then up three flights of the common stairway, ill lit, with a common" lavatory on.each floor. Off this floor five doors led to five houses," each of which held a minimum of four people.
The patient, who had a temperature of 102°F, was ill with his sixth episode of bronchopneumonia. The mother was eight months pregnant and the father had just arrived home from Territorial Army training. He told us a little of their housing problem. They had been on the housing list for eight years. Twelve months previously, when the wife was in hospital having their fourth child, the rats were so troublesome that they took possession of the children’s room and consequently the family slept in one large bed. Two days after the mother returned from hospital the newly born child was overlain and died. No open inquiry is held in Scotland in such The parents assured me that their circumstances. conditions were better than those of many others. Thousands of families live in such conditions, and it is to circumstances such as these that many patients return when hospital treatment for tuberculosis is finished. I was amazed to learn that no consultant in tuberculosis had yet been appointed to the whole region of South-west Scotland, of which Glasgow is the centre. I met a doctor who as senior hospital medical officer is in charge of 350 beds and has many clinic responsibilities as well. There has been little or no secondment of nurses from general hospitals to sanatoria or other hospitals where tuberculosis is treated. I was told that a doctor, prominent on administrative committees, had stated that if secondment from general hospitals was accepted he would withdraw his daughter from nursing. If this is the attitude which obtains in influential quarters there seems little hope of an intelligent approach to the nursing problem of tuberculosis.
902 It may be
thought impertinent
for
someone
from the
South of England to make comments on this situation, but the problem of tuberculosis in the British Isles is surely indivisible. The pathetic housing programme must receive the most urgent attention in Government circles, and, at the same time, the medical and nursing profession in Glasgow should rise to meet the demands of their local population. It is essential that the facts should receive the widest publicity in the national press and on the air, in order that there may be quickening of response to this tremendous human need. Central Middlesex Hospital, London, N.W.10.
HORACE JOULES.
EPIDEMIOLOGY OF STREPTOCOCCAL INFECTIONS
SIR,—In their very interesting review of the epidemiology of streptococcal infections in your issue of April 11, Professor Dingle, Professor Rammelkamp, and Dr. Wannamaker refer to their finding that, in a number of instances, infections due to hæmolytic streptococci of type 12 have been particularly commonly followed by acute glomerulonephritis. It is clearly of considerable interest to see whether a similar association can be shown in Britain. The Streptococcal Reference Laboratory at Colindale and the regional laboratories of the Public Health Laboratory Service at Cambridge, Cardiff, and Oxford would be very glad to collaborate with paediatricians or others who may have an opportunity of making such an investigation and to undertake the type identification of group-A streptococci that have been isolated in circumstances suggesting that they may have initiated an attack of nephritis. Streptococcal Reference Laboratory, Public Health Laboratory Service, Colindale, London, N.W.9.
R. E. O. WILLIAMS.
TRAINING OF PHYSIOTHERAPISTS
SIR,—Prominence has been given lately in medical to the training of physiotherapists, and we feel that certain points ought to be clarified. Physiotherapists in this country belong to three groups : (1) the Physiotherapists Association, (2) the Faculty of Physiotherapists, and (3) the Chartered Society of Physiotherapy. The Cope report, drawn up by a committee of nine members, six of whom were in active association with the Chartered Society, whereas the other two bodies were not represented, recommended hospital authorities to employ exclusively members of the Chartered Society, and the first circulars of the Ministry of Health were drawn up in this spirit. The injustice of this report, however, has been rapidly realised ; and the Minister of Health stated in Parliament on March 19 that the Cope report would not be implemented, and that he would further withdraw the temporary instructions in the Ministry circular referring to the employment of chartered physiotherapists, and make new regulations fair to all associations. We are at a loss to understand this tendency of the Chartered Society to monopolise physical treatment in this country. Apart from- the fact that it goes against the liberal principles that dominate medical work, nothing has demonstrated the superiority of the members of the Chartered Society over those of other associations of physical-treatment practitioners. We must emphasise that hospitals employing members of the Physiotherapists Association and the Faculty of Physiotherapists are perfectly satisfied that the training of members of the association and the faculty is not inferior to that of the Chartered Society. The education plan formulated by the Physiotherapists Association, and supported by education authorities, experienced teachers, and the medical profession, provides for the cooperation of technical colleges and
journals
Physiotherapy training schools of a university, and the physiotherapist’s qualification should be a recognised university diploma. The real aim is to enable the physiotherapist to take his place as an accepted member of a medical team, receiving alike the support of the medical profession and the confidence of the public. A. P. CAWADIAS
teaching hospitals. should be
part
President.
S. S. KNIGHT
Physiotherapists Association, 31, Dover Street. London, W.1.
General Secretary.
PHARMACEUTICAL ADVERTISEMENTS SIR,—Could not the British pharmaceutical serve
firms
community even further by including in all copious advertising matter the price of the prep. the
their aration advocated ?’? Of course, the resulting reduction in profits would mean less funds for research, but I venture to suggest that, on balance, the community would benefit more. A. W. ANDERSON. ENLARGED HILAR GLANDS
SIR,—It is to be
that your annotation on this as a catalyst, and promote subject (April 18) some useful reaction amongst those of your contributors who are interested in a problem which is still very much in the melting-pot. It would be of great interest to know how frequent these cases of asymptomatic hilar-gland enlargement really are in this country, and how they fit in to the broader general picture of hilar adenopathies in young It is well known that bilateral hilar-gland adults. enlargement at this age is much more common in Scandinavian countries than in the British Isles. In recent years large series of such cases have been reported, from Sweden in particular.
hoped
may act
Lofgren, for example, has made a special study of the question, and he has recently publishedtwo papers in collaboration with Lundback, in which 212 cases of "the bilateral hilar lymphoma syndrome " are studied in relation to (1) age and sex incidence, and (2) tuberculosis and sarcoidosis. Of these patients, 161 were women and 51 men ; and in 113 cases the syndrome was associated with erythema nodosum (107 females, 6 males). The maximum incidence was found in the age-group 25-29. In the female group, a relation to pregnancy and lactation was observed in some cases.
In 100 cases tuberculin sensitivity was absent, even to 1 mg. of tuberculin. Complications, tuberculous in type, developed in only 1 case. A diagnosis of sarcoidosis could be established by histopathological examination on an average in 26.4% of cases ; but during the later stages of the investigation, 23 out of 49 cases (47%) were proved to be sarcoidosis.
The conclusion drawn is that this syndrome is indeof tuberculosis from the point of view of aetiology. The authors interpret it as being a manifestation of sarcoidosis, and more exactly, as the primary stage of pulmonary sarcoidosis. Our own short paper2 reported 6 cases of bilateral hilar-gland enlargement, all in relatively young women with erythema nodosum. In 5 cases the Mantoux reaction was positive, and in the 6th it was negative at 1 in 10,000. There was a history of recent pregnancy in 2 cases. No clinical manifestations of sarcoidosis were found, though, if it had been possible to make the intensive search for biopsy material mentioned by Lofgren and Lundback, the result might have been different in some cases.
pendent
Chaves
and
Abeles,3
whose
paper,
entitled Transient
Undiagnosed Intrathoracic Lymphadenopathy in Apparently Healthy Persons, you mention, lay down as criteria for their cases the spontaneous regression of enlarged glands and the absence of evidence of pulmonary or other visceral involvement throughout the period of observation. From the large volume of material available for screening, coming from 1. 2.
Lofgren, S., Lundback, L. Acta. med. scand. 1952, 142, 259. Dunner, L., Hermon, R. Brit. med. J. 1952, ii, 1078. 3. Chaves, A. D., Abeles, H. Amer. Rev. Tuberc. 1953, 67, 45.