Current Topics The Treatment of the Enteric Fevers By HAROLD COOKSON, m.d., m.r.c.p. (From the Practitioner, Vol. CXLII, June 1939, p. 683) The enteric infections comprise typhoid and paratyphoid fevers. The former is due to infection with Bact. typhosum and the latter to infection with Bact. paratyphosum A, B or C; in this country paratyphoid infections are most commonly with Bact. paratyphosum B, less frequently with A and only very rarely with C. Typhoid fever proper is the most severe of these infections and the prevalence of epidemics has been greater in the last few years. The mortality in many other acute infections has been considerably reduced by the introduction of new methods of treatment, but that of typhoid fever is still about 10 per cent or more, and its fatality rate is higher than that of most other acute infections commonly occurring in this country. The treatment of the enteric infections can be conveniently considered from four aspects:?(1) prophylactic, (2) general, (3) symptomatic and (4) specific. Prophylactic The patient must be strictly isolated and domiciliary treatment should not be lightly undertaken. If satisfactory accommodation and the services of nurses specially trained in the care of infectious cases are not available in the home, removal to hospital is to be strongly advised. While handling the patient the attendants must wear gowns and wash thoroughly in soap and water afterwards. His bed and personal linen must be soaked in 1 in 20 solution of carbolic acid before being boiled, and crockery, enema syringe, bedurinal, thermometer, stethoscope and pan, any instrument used on the patient must be efficiently disinfected. Stools and urine may be regarded as more or less pure cultures of the infecting organisms and must be treated with the greatest care. The urine should be mixed with an equal volume and the stools with twice their bulk of 1 in 20 carbolic solution and allowed to stand for several hours before being poured down the drain. If the patient should take a bath the water is afterwards treated with chloride of lime (1 lb. to 50 gallons of water) and allowed to stand for half an hour before being discharged, and sponging and washing water should be dealt with on similar lines. Sputum, vomit, discharge from the ears or abscesses, or any other wound which may be present, require disinfection. All these precautions are continued until bacteriological examination of the stools and urine is negative on three consecutive occasions, the specimens being collected at intervals of not less than three or four days. If bacilluria or positive stool cultures persist for a long time during convalescence, the individual is regarded as a possible chronic carrier. The Vi agglutination test recently suggested as an aid to the detection of true chronic typhoid carriers may prove to be of practical value. Urinary carriers may respond to treatment by urinary antiseptics, such as liexamine, mandelic acid, sulphonamide or one of its derivatives. Whether or not hexamine and sulphonamide are also effective against biliary carriers has not yet been established. General In any

treatment

infection the emphasis on general treatment in which skilled nursing plays a large part, varies inversely with the value of the specific treatment available, and the potency of the latter in enteric infections is not yet so high as to displace the general acute

treatment from its important position. The patient is nursed in a well-ventilated, barely furnished room) kept at about 60?F., and on a narrow bed with a hair mattress and one pillow. So long as the temperature is raised, one sheet and one blanket are adequate covering. Smooth sheets not only add to comfort but lessen the risk of injury to the skin, which should be rubbed frequently with spirit over the pressure points. The buttocks should be washed and powdered after each bowel action. To prevent cracked lips, vaseline, liquid paraffin, or camphor ice may be applied, and the mouth should be cleaned after each feed. The patient is not allowed out of bed until the temperature has been normal for one to two weeks, depending on the severity of the attack. The high and prolonged fever makes it necessary to supply large amounts of fluid and to try to maintain nutrition by a diet of adequate calorie value. An increase in temperature of 1?F. raises the basal metabolic rate by about 7 per cent; in most cases of typhoid fever with temperature of 102-104?F. the metabolism will be increased by about 30 per cent. With the all-fluid diet as formerly used under-nutrition was inevitable, and it is now believed that a more liberal diet can often be taken with advantage and without intestinal the to increasing liability haemorrhage. After haemorrhage from peptic ulcer, f?r example, there are observations which suggest that immediate feeding with milk in small quantities or even light solids has no harmful effect. The diet to be aimed at for the average adult patient with enteric fever is one containing 3,000 to 4,000 calories (or 30 cal. per lb. body-weight) and the fluid intake should amount to four to eight pints daily, though it is not always possible to attain these levels. It is also necessary to see that the diet is balanced not only in regard to protein, fat and carbohydrate, but also in its content of the accessory food factors. Milk or milk substitutes may still form a considerable part of the diet, but in addition the following can usually pe

lactose, butter, egg, toast, biscuits* rice potato, pudding) custard, junket, blancmange, cream soup, gruel, apple sauce, milk chocolate, and ice-cream. After a preliminary period of twenty-four hours of two-hourly milk feeds, flavoured with tea, coffee or cocoa, the above-mentioned additions may be gradually made until an intake of 3,000 or more calories is reached. The table at the end shows the general lines of such a diet, though adaptation to the individual patient's tastes and condition will be necessary. Between feeds plain water and barley water can be given ad lib., also lemonade, orangeade, or other fruit drinks with added lactose or glucose. Extra vitamins are called for, particularly y> and although the latter will be supplied in fresh fruitjuice drinks, the pure vitamin in solid form should also be given as ascorbic acid 100 mgm. daily in a milk feed. Vitamins A, B and D are conveniently given as some potent fluid preparation. Alcohol*0 given:

cream,

mashed

drinks

of

any

kind

are

contra-indicated

unless

the

patient has been used to considerable quantities. 1? stuporose patients adequate feeding by mouth may be impossible and feeding by a tube passed through the nose into the stomach may be attempted. No addition

to the diet as outlined is made until the temperature has been normal for a few days, when it is gradually increased. If any symptoms of relapse appear, the diet is at once reduced to the former level. Hydrotherapy.?In patients with high temperatures, the former rigorous treatment by cold baths and ice packs has now been superseded by more moderate measures, and the tepid sponge is the most satisfactoryIf the temperature is accompanied by toxaemia, the

761

CURRENT TOPICS

Dec., 1939] limbs,

chest, abdomen and back are sponged and dried by one, using water at about 90?F., and repeating the procedure four-hourly if necessary. The tepid sponge is contra-indicated if there has been intestinal hremorrhage or if severe meteorism is present, and if one

Phlebitis has occurred the affected limb is not disturbed. Tepid sponging is not contra-indicated by pneumonia. Symptomatic treatment referable to almost every organ in the body may occur in the enteric fevers, and it will be possible to mention the treatment of only the more common ones. For constipation, which is more frequent than diarrhoea, simple enemas are indicated, the purgatives of any kind must be forbidden. diarrhoea if excessive calls for extensive reduction in the diet; diluted citrated milk may be given and a starch and opium enema, or a gentle colonic wash-out with water. Meteorism, resulting from fermentation and poor intestinal tone, is controlled by reducing the carbohydrate intake; counter-irritation to the abdominal wall in the form of turpentine stupes may be applied, but drugs which stimulate motor activity in the intestine, such as pituitrin or eserine, are best avoided, and the so-called intestinal antiseptics are of no value. Oral sepsis must be guarded against by fiequent cleaning between feeds, stimulation of salivation with diluted lemon-juice, and by keeping the lips soft with some oily preparation. When intestinal hmrnorrhage occurs food and fluid are withheld for twenty-four hours, and an injection of morphine is given if the patient is restless. The various proprietary h&moplastic sera are of questionable value. After haemorrhage large doses of vitamin C should be given, either orally or intravenously, 500 mg. daily by either route, since deficiency of this substance is believed to increase the fragility of the capillaries and to delay the healing of wounds. Severe degrees of vitamin-C deficiency were found by Portnov and Wilkinson in association with haemorrhage from peptic ulcer, fntestinal perforation demands immediate surgical mtervention. The pain of pleurisy, which is not uncommon, and that of non-suppurative cholecystitis, which is rare, may be relieved by local hot applications. ~t pneumonia develops, and the hypostatic form is the most frequent, the patient should be propped up a^d, in the presence of purulent expectoration, a drug of the sulphonamide series may be of some value. A orug of this group should also be considered if local Peptic complications arise, such as otitis, arthritis and superficial and inflammatory foci, but surgical drainage Will be called for if a definite abscess forms. For hrornbophlebitis the limb is raised, bandaged over Wool and immobilized. Hexamine has usually been Siven for bacilluria, but the condition may be symptomless and the drug may do more harm than good by irritating the urinary tract with the production plQt haematuria. Retention of urine, if not relieved by fomentations over the bladder and an enema, is ''eated by catheterization. Headache and insomnia respond to hydrotherapy, but if not, small doses 9' bromide and one of the barbiturates may be given. .n Protracted severe cases with delirium an adequate 1'itake of fluid by mouth is generally impossible and is in such cases that the signs of peripheral cuculatory failure, especially a rapid and feeble pulse, ?re likely to appear. For this condition intravenous 111 fusions of glucose saline, by the drip method if Possible, are of great value. Drugs cannot be expected ?, mfluence this condition to any great extent, but injection of ephedrine (1 grain) combined h adrenaline (5 minims) or one of the several Proprietary substances chemically allied to ephedrine be more effective in raising blood pressure than J^ay ?se reputed to act by stimulation of the_ medulla, :.Uj. as strychnine and coramine. Digitalis is contra1(hcated unless there is coincidental heart disease with -ongestive failure. Injections of suprarenal cortical 'Xtract may be used for the asthenia, and low bloodI ''fissure of the later stages of the illness, and gooa esults have been claimed from the routine use of this xtract combined with large doses of vitamin C.

Symptoms

_

njay

H^cutaneous

_

Blood transfusion.?Transfusion of blood has a place in treatment under certain conditions. For severe or repeated intestinal haemorrhage which produces symptoms of shock immediate transfusion is advisable with stored blood of group 0. Prolonged cases with severe toxaemia and some anaemia due to repeated small haemorrhages or to the chronic toxaemia may benefit from blood, preferably from a donor who has been actively immunized by T.A.B. vaccine rather than from a subject convalescent from the disease, and in epidemics it is usually easy to find a suitable donor. A further injection of vaccine into the donor twentyfour hours before withdrawing the blood is recommended by Bower but usually such delay is inadvisable. If an immunized subject is not available, antityphoid blood from an serum should be given along with ordinary donor. Against transfusion it might be objected that it would increase the tendency to venous thrombosis, to which embolism may be a sequel. In practice this complication is not found to be more frequent in the transfused cases, nor does the increase in the volume of circulating blood aggravate bleeding from the intestine; on the contrary it appears to have The blood is citrated and given a haemostatic effect. in amounts of 100-300 cubic centimetres (3-10 oz.) or in larger quantities if the drip method is employed. Specific

treatment

An ordinary vaccine of Bact. typliosum has sometimes been used during the course of an enteric infection, but a good case for its value has not been made out. The use of vaccine is liable to be followed by a severe reaction and, if the symptoms are already serious, this may be dangerous. Vaccines modified by bacteriophage or by incubation with typhoid convalescent blood, by which methods the organisms are lysed, are held to be superior to the ordinary vaccine, but they appear nevertheless to have similar disadvantages. It is doubtful if these methods produce effects other than those resulting from non-specific protein shock. Antityphoid serum.?Antisera have been used in many countries for at least thirty years, but until recently these have had little success, a fact which is explained by lack of knowledge of typhoid antigens and antibodies. Without this knowledge the preparation and standardization of a potent serum are not possible. To-day, however, as a result of the intensive investigation of typhoid antigens by Felix and his co-workers, it is known that a virulent strain of the organism produces the two antigens termed Vi and O, and that to be effective an antiserum must contain the two appropriate antibodies. The serum now prepared by the Lister Institute (supplied by Messrs. Allen and Hanburys) contains these antibodies in high concentration as shown by the agglutination titres of 1 :3,000 or more for Vi antibody (against strain Watson) and 1 : 20,000 or more for the O antibody (against strain 0.901). The serum will protect mice against otherwise lethal injections of live Bact. typhosum and also against the effects of massive doses of dead organisms, and the several reports so far published on its clinical effects have all been favourable. One of these reports deals with a trial in seventy-three patients in 1936, and a beneficial effect was noted on both toxaemia and temperature in a significantly high proportion of cases. Since that time the potency of the serum has been increased considerably, the tit-re of the O antibody being doubled and that of the Vi antibody more than trebled. The serum should be given as early as possible in the course of the disease, either intramuscularly or intravenously, diluted with normal saline if the latter route is used. For an adult three or more doses of 33 cubic centimetres each should be injected at intervals of twenty-four hours. For children smaller doses suffice. The beneficial effect of the serum is usually manifest not later than a day or two after the third injection. If at that time there is still no improvement and the condition of the patient is causing anxiety, it is advisable to give further doses of the _

serum.

THE INDIAN MEDICAL GAZETTE

762

If the patient is known to be allergic or to have received some form of serum previously, desensitization should be carried out by repeated small doses of the serum (0.01, 0.1, 0.2, 0.5 cubic centimetre) subcutaneously at half-hour intervals, and followed by a similar series of injections intravenously. In severe cases the intravenous route is preferable and serum may be conveniently given in a glucose saline infusion. When in spite of precautions the injection is followed by symptoms of anaphylactic shock, adrenaline 5 minims subcutaneously should be given. In practice anything more severe than a rash as an untoward reaction to the serum is rare. For good results early use of the serum in full doses is advisable; in late in the viscera and cases with severe toxic changes nervous system, this method can only be relatively of small value, though serum is useful at the onset of a relapse. The serum is of no value in the treatment of paratyphoid fever.

Specific prophylactic treatment with vaccine of typhoid contacts is a matter which is still controversial, but such persons may be safely given protection by injection of the antiserum. The protection thus conferred will, however, last only for a short period (about two weeks). The dose is 33 cubic centimetres intramuscularly for an adult and 7-20 cubic centimetres for children according to age. Chemotherapy.?The success attained by sulphonamide and its derivatives in the treatment of acute infections with B. coli of the genito-urinary tract and of the portal vein in man, and of B. coli septicaemia in animal experimental infections, suggests that these drugs might also be effective in infections of the enteric group, as the organisms concerned are morphologically similar. In mice a single dose of sulphonamide was found to give protection against Bact. typhosum and also against Bad. paratyphosum B, but its precise value in the treatment of human infections, if any, will depend on the results of extensive which observation. are not yet available. Theoretical considerations would suggest that early treatment with this type of drug combined with antiserum might be the most effective method. On the earner state preliminary reports give promise that the action of sulphonamide and its derivatives may be of importance. In a case reported by Barer typhoid bacilluria cleared up following the administration of sulphonamide, treatment though with previous hexamine and with ammonium mandelate had failed to sterilize the urine. This patient, however, was recovering from an attack of typhoid fever, and was not a true chronic carrier. Of greater significance is Bazin's report of a chronic fecal carrier of Bact. paratyphosum B, in whom the liver bile still gave positive cultures after cholecystectomy, but in whom sulphonamide caused the disappearance of the organism from feces and bile after hexamine had failed.

Diet in enteric Severs

(3,000 calories) 6 a.m. 8 a.m.

Milk, 5 Gruel, 7 butter, sugar

oz.

1 or

butter, i 10 a.m. 12 noon.

2 p.m. 4 p.m. 6 p.m.

8 p.m. 10 p.m.

cream, 1 oz.; lactose, A oz. {e.g., milk, 2 oz.; farex, 1 oz.; teaspoonful; barley water, 5 oz.; salt to taste); toast, 1 slice;

oz.;

oz.

Cocoa, 8 oz. Vegetable cream soup with salt, 8 oz.; egg, 1; toast, 1 slice; butter, J oz.; chocolate blancmange, 6 oz. Malted milk, 8 oz. Milk, 5 oz.; cream, 2 oz.; lactose, i oz. Milk toast (milk, 4 oz.; cream, 2 oz.; toast, 1 slice; butter, \ oz.; salt); toast or bread, 1 slice; butter, | oz.; egg, 1; cup custard, 4 oz. Eec-nog, 1 glass. Milk, 5 oz.; cream, 1 oz.; lactose, | oz.

[Dec.,

1939

Distribution of Fluorosis in India and in

England By D. C. WILSON (Abstracted from Nature, Vol. CXLIV, 22nd July, 1939, p. 155)

Endemic fluorosis has been described in many different parts of the world. Dental fluorosis is found with waters having a fluorine content of one part per thought million, and in the United States considerable ' has been given to the elimination of mottled enamel by improving water supplies. Stiff backs and other signs of toxic fluorosis are found when the halogen exceeds three parts per million, and in North Africa, where the amount of fluorine in the soil is considerable, attention has been directed to the agricultural and veterinary, as well as to the human aspects of the problem. Industrial fluorosis among aluminium workers who handle cryolite has been described in Denmark. In Arizona, Smith and others found that fluorine plus diet deficiency was a more potent cause of mottled enamel than fluorine alone. India. Endemic fluorosis has been recognized among men and animals in the Madras Presidency, and fluorine has been found in the well water. In the adjacent areas of the Nizam's dominions, I, with the assistance of Dr. B. K. Badami, director of Veterinary Services, Hyderabad, found dental fluorosis among cattle, children in the Mabubnagar district. The bone lesions with moreover, in this area develop exostoses, which clinically resemble those found among animals suffering from toxic fluorosis, incurred whilst grazing near aluminium factories in Denmark. During the past few years I have examined more than 9,000 children in various parts of the Punjab, ana and in certain clearly defined areas I have found evidence of dental fluorosis in the milk and permanent teeth. These areas include the eastern parts of the Mianwali district, villages near Sargodha, HundewajJ around Sangla Hill, in and near Chiniot, villages around Kasur, villages near Ferozepore, and certain and Hissar. I found that ^the villages between Bhiwani teeth were most ' mottled' among children from the lowest social classes, who showed also irregularity 111 the size of the individual teeth. Stiff backs and elbows have been observed among village children who used deep well water in the neighbourhood of Kasur. The Irrigation Research Institute, Lahore, at my request, kindly had water from a number of wells in the Kasur area_ analysed, and obtained from nil to four parts fluorine per million. All the places where dental fluorosis has been detected in the Punjab are situated on the IndoGangetic alluvium, which is of practically the same composition all over the Province, and there is no reason to suppose that this alluvium contains any fluorine. Geodetic research, however, has shown existence of a ridge of rock causing shallowing of the alluvium. The places from which I have collected records of clinical fluorosis may fairly be said to he over this buried ridge. Dr. Heron considers it reasonable to think the rocks forming the ridge include lavas, and associated granites and rhyolites. England. Dental fluorosis has been described a Maldon and in certain other parts of Essex. Essex waters have been found to contain fluorine up to si* parts per million, and on a visit to that county I foui]f that cases of mottled enamel may be met with 111 many different areas. Mottled teeth have also been described from parts of Somerset and Suffolk, and haYe been noted at Ashford, Kent, and at Leicester, and Derbyshire near Ghesterfield. At Brampton, Oxfordshire, where I am living w'1!,? on leave from India, I noticed dental fluorosis in adul and children in different parts of the Mr. Ainsworth very kindlv came to Bampton and ha confirmed my findings. Fluorine has now been f?.uni in Bampton well water. I have also recognize numerous cases of dental fluorosis among people wn have been born and spent most of their lives in tn Marston Valley, Bedfordshire. Analysis has sho^

tJlC

..

v^aJfeg

that the

fluorine

'

knotts' clay in the Marston Valley has

a

content of more than 450 parts per million. We do not know the source of the fluorine m toe o Ji Parts of England where human fluorosis is found, ine

brownish-yellow ?with

flecks and spots of pigment, together the dull white opaque areas of dental fluorosis are easily recognized, and if borne in mind, may )e noted possibly in other areas.

Life-story

of

Simple Herpes

(From the Lancet, 18th March, 1939, p. 647)

It has long been recognized that clinically herpes tails into two main groups, idiopathic and symptomatic. ?Before the causal agent was shown to be a filtrable present in the fluid of the vesicles it was thought that, in the symptomatic cases, the herpetic eruption Wa.s the work of the organism responsible for the in the Primary pneumococcus condition?e.g., Pneumonia. This hypothesis, however, failed to explain t"e idiopathic cases. The demonstration of the virus the situation: the idiopathic group now jeversed became understandable on the basis of infection from Without, even though this was not always easy to establish; but in the symptomatic group no such ]Qterpretation was possible, for in the vast majority a recent extrinsic infection could be ruled out. Two Possible explanations were accordingly put forward: that sufferers from symptomatic herpes are carriers 01 herpes virus, which is activated by conditions such pneumonia, malaria, and protein shock; second, iiat the primary disease gives rise to changes that the evolution of herpes virus de novo. The Wt to most virus workers, j ter_ hypothesis, unpalatable its exponents, but the former more reasonable xplanation was not long in finding support. In 1922 evaditi, Harvier and Nicolau demonstrated herpes "rus in the saliva of healthy persons, and two years Bu sacca isolated it from the conjunctival sac. Jiis proved the existence of carriers of herpes virus Jt was soon shown that, judging by samples, about +, ?~thirds of the population have herpetic antibody in th?ir serum. By the investigations of Andrewes and arrnichael and of Brain a close correlation between i current herpes and the possession of herpetic antibody established. ^urnet and Miss Lush have taken the epidemiolo usually most marked on the exposed parts, is very disfiguring. It is due to the deposit of metallic silver in the epidermis and true skin. The same discolora' tion occurs in the nail-beds and, as it may be the earliest manifestation of argyria, it should always be looked for. If found, the administration of si]ver' whether externally or internally, should be stopped a once before the skin has become permanently discoloured. In cases of chronic mercurial poisoning a brownish" black discoloration, much darker than in argyria, may occur. It is due to the formation of sulphide 0 mercury in the tissues. A blue-black discoloration the nails due to hwmoirhage under them is veiy common. It is most often due to an injury, but bleeding diseases, such as purpura, haemophilia an tn scurvy, spontaneous haemorrhages may occur under nails, and in these cases they usually occur unde^ several of the nails. In tabes dorsalis also hsein0'^ rhages may appear suddenly in all the nails of the toein association with lightning pains. Haemorrhage under the nails, preceded by neuralgic pains, may als occur in diabetes. If the haemorrhage in these cases is extensive tn ma. pressure of the blood enclosed under the nails cause considerable pain which can be relieved byr ing holes in the nails. In severe injuries haemorrhage the nail may become loose and be she some weeks later, but in most cases the blue-blac mark gradually moves down the nail till it disappea 1 at the tip. It takes about five months for such a ma to travel the whole length of the nail. -n A jet-black discoloration of the nail occurs diabetic and other forms of gangrene, but as the wno of the tip of the finger or toe is usually affected black discoloration is not limited to the nail. _

.

.

J*j

.

_

^lt

.

Changes

in shape

colour the nails may altered in shape and size in various Clubbing of the fingers and toes in chronic and cardiac conditions is well known, and when t'loccurs the nails become curved from above downwa and from side to side. The opposite condition m< ^ also occur when the nails are either flat or holloa

Apart from

become

any alteration in

wa^ pulmonj1^

Dec., 1939] ?ut,

765

CURRENT TOPICS

as what is known spoon-nail (kottonychia). In it the nail-plate is concave instead of .being convex. In mild degrees of the condition the is merely flatter than normal, but in fuHj''developed cases the centre of the nail is concave whilst the lateral edges and free margin are slightly raised and projecting. The surface of the nail is usually smooth, but some degree of longitudinal lining may be Present. The edges of the nail-plate are somewhat thickened and raised up off the nail-bed. All the nails may be definitely affected, but in mild degrees of the condition the change is limited to the thumbs and ?refingers. In patients who suffer from alopecia areata a flattening or slight concavity of the nails of the forefingers and sometimes also of the middle fingers and thumbs is very common. The cause of spoon-nail not known. It may occur in association_ with nutritional anajmias. As most of the persons in whom it occurs are of the highly-strung type, the nervous system may play some part in the etiology. Fragility and splitting of the nails is another fairly common condition. Some persons are born with nails tt'ftich are brittle and tend to split and break off at '?he free ends. A similar condition may also_ be acquired by prolonged contact with chemicals, especially alkalies, used in the course of work. By too Sequent manicuring or the application of chemicals to remove coloured nail-enamels women may cause a ?-oitening and splitting of the nails. There is also the condition known as egg-shell nail in which the nail*s s0^' semi~transparent, bends easily and splits t u the end. This particular change has been reported n association with arthritis, peripheral neuritis, leprosy, and hemiplegia. A somewhat similar condition also occurs occasionally in late syphilis, producing onychia syphilitica sicca. In this condition all the nails are ttected. They are dry, atrophic and tend to split. may be the only visible sign of syphilis, but the '^gnosis can be confirmed by the Wassermann

producing

*jail

js

faction.

As it has been shown that the keratin of the nail high sulphur content the administration of is indicated in all the atrophic conditions of the nails. ,

si'Y a sulphur

presence of the scar the origin of the ridge is easily recognized. There is also a rare congenital family

defect of the nails in which all the nails of the hands and feet show an atrophic condition with a definite raised longitudinal ridge running down the centre of each nail. It looks as if each nail had been gripped with a pair of forceps and squeezed so as to make the centre rise up into a ridge. This condition, curiously enough, is always accompanied by complete absence or extreme smallness of the patellae. Why this should be and what the connection is between the nails and the patella is not known.

longitudinal lining of the nails lines, usually known as Beau's lines. They appear on the nails as a result of previous interference with the growth of the nail-matrix. They consist of a superficial depression running across each nail. Appearing first at the base, as the nail grows, they slowly move along the nail-bed till they disappear at the tip of the nail. As a complete nail takes from Almost

are

as common as

transverse

five to six months to grow, one can calculate from the position of the line when the lesion occurred. These lines may be due to a local cause, in which case all the nails are not usually affected, or to some general disturbance in which all the nails of the hands and feet are equally affected. The local causes are inflammatory lesions in the region of the growing nail-matrix as in eczema, psoriasis, general exfoliative dermatitis (especially after the administration of arsphenamine preparations), paronychia, and trauma. Of the general causes the commonest are acute infections, such as erysipelas, influenza, pneumonia, scarlet fever, measles, and typhoid fever; but any condition in which the general vitality is temporarily lowered, such as from loss of blood, especially at confinements, prolonged and severe

sea-sickness,

nerve

shocks,

epileptic

attacks,

and diabetes, may cause Beau's lines to appear. When the causative factor is repeated a succession of these lines may result and the distal part of the nail may become loose and drop off.

exophthalmic goitre,

Shedding

and

atrophy

Shedding of the nails without any previous alteraj tion in them or in the skin around them may also Certain individuals shed their nails regularly occur. Lines of the nails Many of these once a year for no apparent reason. Longitudinal striation of the nails is a very common cases have a family history of this peculiarity. In ondition in adults past middle life. In slight cases epidermolysis bullosa, in which trivial injuries give rise ls to the formation of large blisters in the skin, the nails merely an exaggeration of the normal longitudinal 1(Jges of the nail-bed, but in well-marked cases it is frequently fall off, presumably after previous slight ?c?mpanied by splitting of the nails (onychorrhexis) injuries. The nails may also be shed after fevers, ? the_ free margins, it is common in persons who are especially scarlet fever, in tabes dorsalis, and in root of a diabetes. In extensive skin diseases, such as exfoliative t ^sorbing from a focus of infection at the 9th or in the bowel. dermatitis, pemphigus foliaceus, extensive eczema, and Une of the most marked cases of this condition which alopecia areata, a similar loosening and shedding of j ever saw was in a patient who was discovered to the nails is apt to occur. In all these conditions the ave a chronic abscess of the appendix. When this | nails grow in again completely. ?.s opened and drained all the nails became loose, Another frequent change in the nails is atrophy. f J off and were replaced by normal smooth nails, The nails become small and mis-shapen, so that only to cases due to focal infection lining of a deformed or thinned stump is left to represent them. th e addition nails is seen in gout and nervous diseases such as Some degree of atrophy is nearly always present in and hemiplegia. It is also associated with the the nails of the third, fourth, .and fifth toes. This is of probably due to the constant wearing of shoes. th 1?11 an.^ scaTlty hair of myxoedema. Dryness or ' Sometimes atrophic nails may be a congenital condiwith histreless nails showing longitudinal cases of vitamin-A a^so seen tion in which only traces of nail substance are seen. dpfi -Ver?e It is usually associated with other ectodermic defects ?n?y. Similar changes in the nails have also been fp Adminis*n deficiencies of vitamins B and D. such as extreme thinness or absence of scalp hair. ?f the appropriate vitamins in these cases will Such persons have difficulty, owing to the absence of i-p^+n tore the nails to normal. the nails, in picking up small objects and doing certain these cases, in which the splitting of the ends forms of work such as sewing. Although not necesof +1 sarily associated with any mental condition this change Pa^s ^ marked, the condition might be confused WifVi the nails also in the nails is fairly frequently seen in mentally snl'f ringworm of the nails, in which and break off. In ringworm all the nails are defective children. It may also be an acquired condi>yl tion and may follow injuries, scars from disease, ajly never affected. There are always some of th j6 nails which are quite normal. If there is any frostbite, sclero-dactylia, Raynaud's disease, radiodermatitis, and syphilis. It also occurs in hyperubt,. examination of pieces of the splitting nail under ? cases. such in will reveal the fungus microscope thyroidism and exophthalmic goitre and has been raised longitudinal ridge running down one reported after nerve injuries, in leprosy, tabes dorsalis, hail SIngle only is fairly commonly met with. This is the syringomyelia, and in prolonged debilitating diseases r nail from previous such as cancer. Another of the rarer causes is tetany dj? ofora scar at the base of thethe nail-fold at the As the line of injury. following destruction or extirpation of the parathyroids. bacfaSe dSe of the nail is puckered and irregular from the '

.

j^ritis tr-f

tr?r

.

766

THE INDIAN MEDICAL GAZETTE

In all these conditions the atrophy

of

the

nails

is

permanent.

An appearance of atrophy of the nails may be produced by the patient. In cases of nail-biting the nails may be so bitten down that they look small and atrophic. The skin around them is often swollen and inflamed so that the nails appear to be sunk below the normal level and look smaller than they really are. There is also another condition allied to nail-biting which is usually seen in adults of nervous temperament. These persons are constantly picking at the free edges of their nails, so that small pieces become chipped off, making the nails much shorter than normal. In all prolonged itchy skin diseases, such as chronic eczema and neurodermatitis, the nails of the fingers may be worn down at the tips to a straight line or even show This is due to the constant scratching. a concavity. In addition to the alteration in the shape of the nails the surface becomes smooth and burnished from the constant rubbing. It is a very good index of the amount of scratching indulged in by the patient. Thickening and hypertrophy The last condition which must be mentioned as of diagnostic value is a thickening and hypertrophy of (1) simple the nails. It occurs in four groups: thickening of the nail substance, (2) subungual hyperkeratosis, (3) thickening in chronic nail inflammations, and (4) onychogryphosis. In simple thickening the nails become gradually thicker and thicker towards the free ends so that a very hard horny peg, greenish or blackish in colour, is produced. The surface of the nail is smooth and regular or only slightly longitudinally lined. Congenital cases of this condition have been recorded, but in chronic eczema with hyperkeratosis of the palms and soles this nail change is not infrequently seen. In subungual hyperkeratosis a horny mass grows from the nail-bed and pushes up the overlying nailplate. This change may occur by itself, but it is usually an accompaniment of a chronic skin disease such as eczema and psoriasis. If it occurs unaccompanied by a local skin eruption the possibility of its being due to chronic arsenical poisoning or general paralysis should always be remembered. The horny mass under the nail is usually fairly soft and can be scooped out. The condition must not be confused with yeast infections under the nails, in which the nail always has a dark greenish or bluish colour and the material which can be scooped out from under the nail is much softer than in hyperkeratosis. Examination microscopically and by culture will also show the presence of yeasts. In all chronic inflammations of the nail-bed and infections of the nail-folds round the nails there is a gradual overgrowth of the nail substance so that the nail becomes considerably hypertrophied. This usually occurs irregularly, producing lumpy thickening of the nails. It is seen in ringworm of the nails and in all types of paronychia and naturally its treatment should be that of the condition causing it. Of all the hypertrophies of the nail one of the commonest and most striking is onychogryphosis. It may affect all or only a few of the nails. In nearly all cases it is limited to the toe-nails and is especially apt to affect the nail of the great toe. Whenever it occurs on the finger-nails the practitioner should always eliminate syphilis by having a Wassermann done. In onychogryphosis the nail becomes greatly overgrown and irregularly thickened. It is usually of a brownish, greenish, or blackish colour and as it grows it becomes bent over and curved like an animal's horn. It is so hard that the patient cannot cut it, so that it is often allowed to grow to great lengths. It is found usually in elderly persons and be associated with deformities of the toes, may especially hallux valgus. It has been noted in association with peripheral neuritis, leprosy, tabes, and hemiplegia. Pituitary and thyroid dysfunctions may be responsible for a very few cases, but in the majority oi cases there is no evident cause except want of cleanliness and neglect. _

[Dec.,

1939

Ulcerative Colitis By STANLEY 0. AYLETT, b.sc., m.b. (Lond.), f.k.c.s. (Eng.) (From the Medical Press and Circular, Vol. CCII, 5th July, 1939, p. 17) The many theories as to the aitiological cause of this condition and the many methods by which it is treated are indicative of our lack of knowledge of the condition and disappointing results often following its treatment. And yet, although by many it is regarded as a hopeless and intractable condition, treatment along various lines and the liberality of mind to change one specific method, if that is not suitable, will yield dramatic improvements, and often cures. Ulcerative colitis is an inflammatory condition extending either the length of the colon or sometimes limited to its lower part only. It tends to run a prolonged and chronic course, often with sub-acute exacerbation, although the onset of the disease is sometimes acute. Death may result from complications such as htemorrhage, perforation into the peritoneum or general exhaustion and toxaemia. Various organisms, such as the staphylococcus, streptococcus, pneumococcus, B. proleus and B. VV?" it cyaneus, have all been isolated from the stools, but is very doubtful whether these are primary causative organisms or whether they are responsible for secondary invasion. There does seem no doubt, however, that the pneumococcus can give rise to a form of ulcerative colitis associated with the discharge of the rather typical greenish pus, and Lockhart-Mummery has recorded a case in which, following appendicostomy f?r the condition, the wound around developed an infection from which the pneumococcus was isolated. Some of the cases have had in the past a dysenteric infection and in others, even without a previous history, the dysentery bacilli are probably the offending organisms, as treatment with potyvalent antidysenteric serum produces rapid improvement. But in the majority of cases it is impossible to find any bactetyO" logical or. serological evidence to support the view expressed by some that the dysentery bacilli are the usual cause of ulcerative colitis. The same applies to the amoeba. There is no doubt that some cases of ulcerative colitis are the result ot an amoebic infection which has been missed, and Tradkin has described a case which for twenty-eight years had been treated as a non-specific ulcerative colitis but in which, by examination of material aspirated from an ulcer, the amoeba was isolated. Treatment with emetine injection cleared the condition, but it is hardly fair to suggest that the majority other ulcerative colitis cases may be due to a missed amoebic infection, especially in view of the fact that emetine rarely produces good results. Bargen has brought forth abundant evidence that the disease is due to diplostreptococcus which in some eighty per cent of cases at the Mayo Clinic, he has been able to isolate from the bowel. In some severe cases he has been able to grow this organism from the blood, and intravenous injection of the organism has in animals, he states, produced lesions akin to those occurring in the human colon. It is fair to state, however, that many investigators believe that these lesions are not identical with those of ulcerative^ colitis and can be produced by the injection of a variety ?j organisms into the blood stream. Bargen believes tha the origin of these diplostreptococci is in the upper air cavities, such as the sinuses, the tonsils and the teeth, and has isolated the organisms from such situationsIt is well known that an accentuation of the disease, with perhaps death in some cases, may ensue on sucn operations as tonsillectomy or the extraction of teetfl in cases suffering from ulcerative colitis, and this he believes to be due to a sudden liberation of these organisms which have previously been fairly wel limited in these situations by the reaction of the bodyBy immunizing horses against a variety of strains o the diplostreptococcus he has produced a polyvalen antiserum which, injected intramuscularly, or in severe .

.

?j .

Dec., 19391 cases intravenously, 1 cubic centimetre

in small doses starting with have produced good results. These results from the serum in other hands, however, have ?jot been reproduced, and in an extensive trial at the Gordon Hospital much disappointment was experienced. Some workers have tried to incriminate a deficiency ]n vitamins, especially vitamin A, as the causation of 'he disease, as there is ample evidence of the failure ?f the absorption of these and other essential food substances in severe cases, but, as Bargen rightly points out, these theorists are probably putting the proverbial cart before the horse, as owing to the Pathological changes occurring in the colon and the rapidity with which the whole intestine evacuates, the deficiency is the result of the condition, not the condition of the deficiency. An attempt has been made to incriminate the internal secretions of the ductless glands, but without any definite evidence. One thing is certain, however, and that is that worry, anxiety and shock undoubtedly increase the severity ?t the condition. In the September crisis we were impressed with the large number of cases which returned to the Gordon Hospital, cases which had been previously restored to a fair degree of good health. One Jewish refugee from Austria had been free from s.Vmptoms until he suddenly learnt of the removal 01 s?nie of his friends by the Nazis, when immediately a11 his old trouble recurred. The disease is rare in children, in whom a poor Prognosis must be given, most cases occurring round "bout the age of thirty. Occasionally a minor epidemic ?i the disease is noted, as occurred recently in a Prominent public school. I had occasion to see two Previously-fit young men who went on a camping noliday in Scotland and drank some unboiled stream ^ater. Both developed on their return typical ulcerate colitis, from which no specific organisms could be cultured. It seemed here that undoubtedly the source .

?* mfection was an extraneous one, probably infected ^ater. The patient comes up complaining of the onset of

associated with the passage of blood and diarrhoea, " Pus. the blood sometimes being mixed intimately with J?Us, fecal material, and in other cases appearing in jelly.'ke clots. There is often associated dull aching pain the abdomen, but tenesmus, except in cases where rectum is grossly involved, is conspicuous by its at>sence. The diarrhoea is not such in the true sense the word, because most times it consists of the the i^ere passage of blood and pus, and in some cases o\yels may actually be constipated. Eight to ten 'Sits to the closet are common and, in severe cases, ^venty or more may be reported each day. There is ?.?neral malaise and feeling of listlessness and exhauslQn, increasing anaemia and loss of weight and appetite, -md aii reflecting themselves in the pale, rather muddy Ppearance of the skin and the worried expression that Patient presents to the physician. The pulse is r^.e ainful iliac colon is often palpable in ulcerative colitis. is _jrctal examination, if that part of the intestine touch a saggy, r, ,?cted, will reveal to the experienced fil ^edematous mucosa, and, on withdrawal of the Si ^er'. ^ is seen to be covered with blood and pus. ^?idoscopy and x-ray examination should always oe out. The former investigation is usually rp^lled oarded as the province of the specialist, but a little soon gives th G .lCe in less difficult cases to examine ot I] e Jnvestigator facility with this instrument. Any or Morgans, common forms, such as Yeoman's in th^* -^e used, and the patient should be examined out lateral position, this tending to straighten tho Pelvic colon. An anaesthetic is unnecessary m most Ca es, but a preliminary washout some hours before is

JV

-

?

767

CURRENT TOPICS

of value. The essential point in using a sigmoidoscope is never to press even gently on the instrument unless the lumen of the bowel is always in view. If this point is remembered there is no likelihood of pushing the instrument through the wall of the bowel. Usually the scope can be passed to a distance of about 10 inches or so, the limit being reached at the right angled bend of the pelvic colon. Obviously, as the colon bends abruptly through 90 deg., no lumen, when this point has been reached, will be visible and no effort must under any circumstances be made to pass beyond this level. In the early stages the bowel wall is seen to be red and inflamed with small areas of ha>morrhage and ulceration. In later stages the ulcerated areas are increased in size, oozing pus and blood, and if gently swabbed with cotton-wool granulating areas will be So extensive may this ulceration be that little seen. mucosa is left, and most of the surface is covered with necrotic tissue. Radiologically the colon appears to be rather spastic with a loss of the haustrations normally seen, and often an irregular margin, due to the ulceration present, is observed. It is advisable to do a blood count and hajmoglobin estimation and, in addition, a fractional test meal should be carried out as in some cases there is hypoor

ac-hlorhydria.

Treatment The mildest of these

cases

should be treated with

respect. Investigation of material obtained from swabbing the ulcers or examination of the faeces will eliminate such specific causes as the amoeba or the dysentery bacilli, which will respond to appropriate trea tment.

There is no doubt that these cases best respond if, when initially seen, a period of bed is advised? warmth, rest and freedom from worry being essential adjuvants to recovery. The diet must not be reduced for long periods to too low a level as this will only accentuate the wasting, but nutritious low residue food given at frequent intervals should be ordered. It is argued by some that within limits the diet makes no difference, as the residue, by the time the colon is reached, from a, mutton chop is probably no more than from a glass "of Bengers. This may be true of the normal intestine, but where the rapidity of evacuation is so markedly increased, as in most cases of ulcerative colitis, it certainly does. Periodic confinements of the diet to fruit juice and bland fluids only for a couple of days are of value. Various drugs may be tried, such as belladonna, to reduce the spasm of the gut, small doses of opium to diminish the constant diarrhcea, and kaolin also is of value in this respect. In those cases where constipation is an association of the condition, we have found Kaylene 01. of value. Prontosil has been tried with apparent improvement in some patients. Red gum, of trial. In an endeavour gr. x, t.d.s., is also worthy to alter the flora of the intestine lactic acid bacilli have been introduced, and one of the best forms of administering these is by means of lacteol tablets. Two of these should be dissolved in a little milk, or some milk sugar, overnight and the mixture drunk the following morning. A starch and opium enema is another method of attempting to control the diarrhoea. The use of Bargen's serum has been referred to and vaccines made from any diplostreptococci isolated from the bowels should be given after this. Blood transfusions in some cases work wonders. A search should be made for any focus of infection in the teeth, the tonsils or the sinuses, but active intervention should be resisted until some alleviation of the condition has been obtained as a severe and perhaps fatal flare up may result if treated during the active

phase.

There is

doubt, however, that the bulwark of colonic lavage, and to be of Value must be efficiently carried out. A large container holding about a gallon and a half of fluid is suspended some two feet above the level of the patient's buttocks, no

treatment lies in

THE INDIAN MEDICAL GAZETTE

768

the patient lying on a couch in the left or rights lateral position. The rubber tube from the container is connected to a large bore T-shaped glass tube the vertical limb being attached to a tube running into a bucket, and the other horizontal limb to a large bored rectal tube, which, after being greased, is inserted three or four inches inside the rectum. At first only a few ounces of fluid are allowed to run in, the tube leading to the bucket being compressed. This is then released and compression exerted on the tube leading to the container, so that the fluid runs out from the patient's rectum through the rectal tube and enters the limb of the T-shaped tube and thence into the bucket. When the washout from the lower part of the sigmoid and rectum is returned clean, irrigation is carried out farther up by allowing more fluid, up to about threequarters of a pint, to flow in gradually, and this is then allowed to return. Never must fluid be run in to the extent of causing the patient more than slight discomfort as it is possible by so doing to rupture the bowel. As regards the fluids used for irrigation, in the verysevere types probably normal saline^ is best. This should be followed by such antiseptics as Albargin 2 per cent, Yatren 2 per cent, Dettol drachms 1 to 2 pints of water, or potassium permanganate in 1 in 10,000 strength. We have obtained good results in some cases using a solution of adrenalin drachms iii to iv to a pint of saline, and others report equal satisfaction using cod-liver oil. The frequency of the washouts must be controlled_ by the course of the disease, daily irrigations being given in the severe cases, this being reduced gradually until perhaps the patient has a treatment once or twice a fortnight. Surgical interference, which will take the form of an appendicostomy, is advised by some at an early stage in the disease in order that the bowel can be irrigated more thoroughly, but we believe that efficient colonic irrigation in most cases is equally satisfactory. Rarer complications, such as stricture or multiple polyposis, may also require surgical intervention, but these are only seen in later cases. Perforation, of course, will require immediate laparotomy. The treatment of this complaint will require a degree of patience and perseverance that would tax that of Job himself, but the results, if not in every case cures, are worthy of time laboriously spent. _

_

A Study of the Economics of Pneumonia: The Costs of Diagnosis and Treatment of 625 Cases in New York City By J. HIRSH (Abstracted from the Public Health Reports, Vol. LIII, 9th December, 1938, p. 2154) Both disease

medically

and_ economically pneumonia is a with serious attendant consequences. It accounts for well in excess of 450,000 cases of illness a year in the United States, approximately 25 per cent of which are fatal. This toll exceeds that of any other communicable disease. In an effort to determine the amount and nature of the costs of diagnosis and treatment incurred by pneumonia patients, a study of the records of 625 pneumonia cases in_ New York City was undertaken. 1. The median total cost of pneumonia treatment for our whole group of patients was $34.16. Hospitalization constituted 42 per cent of the total cost for all cases; physicians' services, 28 per cent; serum therapy, 16 per cent; and other services, 14 per cent. 2. The following median costs illustrate the wide range between different' types of accommodation: Ward, $123.64; semi-private, $183.14; private, $224.08; home. $93.04. 3. If_ the total cost is divided according to the type of services rendered, we find that for ward cases, hospital care constituted 40 per cent of the total; for semi-private, 53 per cent; for private, 50 per cent. Physicians' services comprised 22 per cent of the total

ward cost; 26 per cent of the semi-private; 35 per cent of the private; and 62 per cent of the home. Serum

[Dec.,

1939

24 per cent of the total ward cost; of the semi-private; 5 per cent of the private; and 10 per cent of the home. The cost of other services' constituted 15 per cent of the total for ward cases; 10 per cent for semi-private; 10 per cent for private; and 28 per cent for home. for ward 4. The median cost of hospital care patients was $50.75; for semi-private patients, $98.45; for private patients, $116. 5. The median cost of physicians' services in the different accommodations was as follows: Ward, $34.60;

therapy comprised 11

per

cent

semi-private, $123.75; private, $141.28; home, $94.18. 6.

The

median

cost

of

serum

for

those

cases

receiving it was: Ward, $59; semi-private, $85; private, $50.40; home, $37.50. 7. Approximately one-third of the cases studied had total costs less than $100; another third between $101 and $200; one-third from $201 to over $451. This last included several unusually high-cost cases, group mounting to over $1,550 in one case. 8. In the hospitalized cases, with the exception of the ward cases, the two major items of cost are hospitalization and physicians' services. The cost of the latter, however, is much less than the cost of _

hospitalization. 9.

a

For

the_

ward cases, serum therapy total cost than

larger portion of the

constituted physicians

services. 10. Two major items comprise almost the total cost for home cases?physicians' services and nursing care. The reasons for this are (1) that there are no hospitalization charges, and (2) that the treatment is usually symptomatic, with the result that the expenditures for serum and other special therapies have been practically nil. 11. The large low-cost group is principally the result of the great proportion of fatalities early in the course of the disease. Seventy-six per cent of the total number of deaths in the hospitals occurred within the first 5 days. [This abstract is included for the benefit of medical officers who receive complaints regarding the high cost of the treatment of pneumonia in India; they niay find these figures useful for quoting to those who control their funds.?Editor, I. M. G.] _

Current Topics.

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