MENINGITIS—A Review of One Year's Cases from an Active Children's Hospital Service

Fifty-six cases of bacterial meningitides, other than tuberculous, observed in a period of one year on an active children''s hospital medical service were reviewed. All age groups were involved but most commonly infected were patients in the first year of life. There was no inordinate incidence of infection with any one kind of organism in any specific age bracket, except possibly for infection with enteric organisms which in the present series occurred preponderantly in infants less than six months old. Meningococcus and H. influenza type B were the most common organisms; they were the infecting agents in 71 per cent of cases. Of the immediate complications noted, subdural effusions were the most common (23 per cent of this series). In all except two cases, effusion was resolved by multiple aspirations. In two cases craniotomy was done with good results. Ten electroencephalograms were made and all were abnormal. In most of the patients, multiple antibiotic and chemotherapeutic drugs were used, parenterally during the first few days of hospitalization and then orally as tolerated. Intraspinal therapy was not given. Four of the 56 patients died.     

SUMMER DIARRHEA IN THE SAN JOAQUIN VALLEY

In laboratory, epidemiologic and clinical studies of 85 patients with diarrhea admitted to the General Hospital of Fresno County and the San Joaquin County Hospital during part of the summer of 1949 the following features were noted:1. Cultures were positive for Shigella in about 45 per cent of the cases in the San Joaquin County Hospital and in about 15 per cent of those in the Fresno County Hospital.2. In 80 per cent of cases in which there was gross blood in the stools before the third day of hospitalization, Shigella grew on cultures. No gross blood was noted in 27 per cent of cases in which Shigella was demonstrated.3. The cases in which Shigella was demonstrated did not differ greatly from the others with regard to fever, leukocytosis, or response to therapy.4. Salmonella organisms were not grown on cultures in any case.5. Most of the patients were infants younger than one year of age.6. Poor socio-economic and hygienic conditions characterized the households from which these county hospital patients came.7. Household follow-up studies indicated that there had been one or more instances of diarrhea among household associates of approximately half the hospitalized patients at some time during the month prior to admission.     

Cerebral atrophy; clinical manifestations in adults

A study was made of the cases of 200 patients with demonstrated cerebral atrophy. In patients under 70 years of age cerebral atrophy was twice as common in men as women. Over 70 years the ratio was reversed. The incidence of cerebral atrophy was relatively high in the age group 35 to 50. Convulsions were present in more than a third of the 200 patients. Neurological abnormalities were present in 51 per cent of the entire series. Significant personality deviations were observed in 31 per cent. Although the electroencephalogram was abnormal in many patients, it appeared to be of little aid in the diagnosis of the cerebral atrophy. The spinal fluid did not seem to be consistently altered in any significant or diagnostic manner. Most of the patients in the 35 to 50 year age group did not have the symptoms characteristic of Alzheimer's disease, and in only a few cases did the symptoms resemble those of other recognized disease entities.     

CEREBRAL ATROPHY — Clinical Manifestations in Adults

A study was made of the cases of 200 patients with demonstrated cerebral atrophy. In patients under 70 years of age cerebral atrophy was twice as common in men as women. Over 70 years the ratio was reversed. The incidence of cerebral atrophy was relatively high in the age group 35 to 50.Convulsions were present in more than a third of the 200 patients. Neurological abnormalities were present in 51 per cent of the entire series. Significant personality deviations were observed in 31 per cent. Although the electroencephalogram was abnormal in many patients, it appeared to be of little aid in the diagnosis of the cerebral atrophy. The spinal fluid did not seem to be consistently altered in any significant or diagnostic manner.Most of the patients in the 35 to 50 year age group did not have the symptoms characteristic of Alzheimer''s disease, and in only a few cases did the symptoms resemble those of other recognized disease entities.     

PERFORATED PEPTIC ULCER—Selective Gastric Resection in Emergency Treatment

In a series of 240 cases of perforated peptic ulcer prior to 1952 there was a total mortality of 17 per cent. This included cases treated conservatively as a planned procedure or because of other morbid conditions and undiagnosed cases, all ending in death.In cases treated by simple suture, mortality was 2.6 per cent for patients under 50 years of age and 17 per cent for those over 50, the rate rising very steeply with each decade over 50.From 1953 through 1959 selective gastric resection was carried out, the operation being done in all cases of perforated gastric ulcers, of chronic duodenal ulcers and of perforations associated with hemorrhage.During this period 303 perforated ulcers were treated, with a mortality of 15.5 per cent. Patients with associated morbid conditions and those admitted moribund and died, or died undiagnosed were again included.In this series also the mortality increased steeply from age 50 onward.Gastric resection was carried out in 148 cases of perforated peptic ulcer with a mortality of 6 per cent. In 105 cases under 60 years of age there were no deaths but in those over 60 the mortality rate was 21.8 per cent. Results in the patients who had resection, as determined after three years of observation, compared favorably with the results in patients who were treated by suture.The mortality of perforated ulcers in females was higher than in males.Emergency gastric resection has a definite place in the treatment of perforated peptic ulcer.     

CIRRHOSIS OF THE LIVER—Clinical Course in 2,377 Patients at San Francisco General Hospital

The records of 2,377 patients with Laennec''s cirrhosis were reviewed for the period 1947-1957. The chief presenting symptom was ascites in 46 per cent, bleeding in 23 per cent, coma in 18 per cent, jaundice in 9 per cent, and both jaundice and ascites in 4 per cent. Nearly half of the patients died during the period under study—one-third from hepatic failure, one-third from gastrointestinal bleeding, and one-third from other causes, most of which were related to alcoholism.Massive gastrointestinal bleeding occurred in 21 per cent of the patients at some time in their clinical course, and in the 10 per cent of these in whom ulcer was demonstrated, one-fifth died as a result of the hemorrhage. Of those presumed to be bleeding from esophageal varices, 64 per cent died at the first hemorrhage and 10 per cent at subsequent hemorrhages; 85 per cent of all those who bled from varices were dead at the end of one year, and 91 per cent were dead at the end of three years.The survival curve of a group of patients who bled once and were good operative risks but had received no operative treatment was compared to the survival curve for entire group who survived the first hemorrhage. The three-year survival in the good risk group was 47 per cent; for the group as a whole it was 30 per cent. The difference in mortality rate was primarily due to an increased number of deaths from hepatic failure in the combined group, whereas 60 per cent of the good risk group died of recurrent gastrointestinal hemorrhage.As 86 per cent of those who were to die of gastrointestinal bleeding did so at the first hemorrhage, it was concluded that any decided improvement in the salvage rate achievable by operation must come from some means of diagnostic forecast of the likelihood of bleeding, with resort to prophylactic operation in such cases.     

Mortality rates in patients with burns; a report of experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956. The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection. No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived. No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection. The lowest mortality rate was in the age group of 15 through 35 years.     

ACUTE GALLBLADDER DISEASE—Experiences with 103 Consecutive Cases

One hundred and three cases of acute cholecystitis in patients ranging in age from 19 to 88 years were reviewed. Operation was done in all cases. Seventy per cent of the patients were women.Primary cholecystectomy was done in 72.8 per cent of the series. Primary cholecystostomy was performed in the remainder, and one-fourth of these patients had a secondary cholecystectomy. No specific time, with relation to interval after onset of symptoms, was chosen for operation.Jaundice was present in 14.5 per cent of patients at the time of admittance to hospital. Serum amylase was above normal in five of 27 patients on whom this determination was carried out. All five were women.The gallbladder was perforated in 13 cases. Common duct exploration was done in 25 cases and in 12 of them stones were found.The morbidity rate for the series was 11.6 per cent; the mortality rate 9.7 per cent.     

Survival in acute myocardial infarction; factors observed in 318 patients

Factors influencing survival in a group of 318 cases of acute myocardial infarction were analyzed. The mortality rate for the entire series was 41 per cent. Among the men it was 39.5 per cent; among women, 44.4 per cent. The mortality rate increased with the age of the patient. Twenty-six per cent of all deaths occurred within the first 24 hours, 44 per cent within 72 hours, and 71 per cent within the first week following hospital admission. Increased mortality rate was associated with previous history of congestive failure, myocardial infarction, hypertension or cardiomegaly. As to circumstances immediately preceding an infarction, the only ones that seemed to be related to a high mortality rate were hemorrhage and the postoperative state. Not only the presence but the degree of shock, congestive failure, cyanosis and dyspnea adversely influenced chances for survival. Duration, location, radiation and number of attacks of pain did not appear to be associated with extraordinary mortality rates. Anterior was slightly more common than posterior infarctions, and the mortality rate was much higher. Thromboembolic complications and certain disorders of rhythm and of conduction definitely worsen prognosis. Comparison of average mortality data as reported in different studies on acute myocardial infarction is improper and misleading because of the great differences between the kinds of patients included in various series reported upon. A standard method of grading the severity of acute myocardial infarction would help toward sounder comparisons.     

The structure and antibiotic sensitivity of the causative agents of community-acquired infectious diseases of bacterial origin in children]

Four hundred and forty pediatric patients at the age of 7 days to 15 years with various infections admitted to the Hospital within a month were examined. The biological material was inoculated to blood agar on the first days of the patient admittance to the Hospital and after the growth the organisms were isolated and identified. Antibiotic susceptibility of the isolates was assayed with the disk diffusion method. 479 strains in all were tested. The most frequent cases requiring hospitalization and antibiotic therapy were those of respiratory tract infections (54.09 per cent), urinary tract infections (26.36 per cent), cutaneous and subcutaneous fat diseases, gastrointestinal diseases and others (about 25 per cent of the cases in all). The main pathogens were Streptococcus viridans, S.aureus and S.epidermidis, as well as Enterobacteriaceae (chiefly E.coli) whose frequencies were practically equal (in 25-35 per cent of the cases). The Pneumococcus isolates amounted to 6.3 per cent. Nonfermenting bacteria (Pseudomonas aeruginosa and Acinetobacter) and some representatives of Enterobacteriaceae (Citrobacter, Serratia, Morganella) were isolated from 7 per cent of the patients. The frequency of Klebsiella and Enterobacter was about 11 per cent. The main pathogens were tested for their susceptibility to amoxycillin/clavulanic acid, ampicillin, oxacillin and gentamicin. The least active antibiotic was ampicillin. 88.8 per cent of the E.coli isolates and 100 per cent of the Klebsiella, P.mirabilis, Morganella, Citrobacter, Enterobacter and Serratia isolates were resistant to it. 53.2 per cent of the Streptococcus isolates including 64.5 per cent of the Pneumococcus isolates were as well resistant to ampicillin. 59.5 per cent of the Streptococcus isolates (mainly S.viridans and Enterococcus) was susceptible to oxacillin, 22.2 per cent of them being moderately susceptible. 62.5 per cent of the Pneumococcus isolates and 78.1 per cent of the Staphylococcus isolates were also susceptible to oxacillin. The highest susceptibility of the isolates was that to amoxycillin/clavulanic acid, i.e. 90.1 per cent of the strains, 79.9 per cent of them being highly susceptible. All the isolates of Citrobacter, Serratia and Morganella and some isolates of P.aeruginosa, Acinetobacter, Enterobacter, Klebsiella and E.coli were resistant to amoxycillin/clavulanic acid. As for the latter 5 organisms their susceptibility to amoxycillin/clavulanic acid was comparable with that to gentamicin. The susceptibility of the Streptococcus and Staphylococcus isolates to amoxycillin/clavulanic acid was significantly much higher than that to oxacillin, gentamicin and ampicillin: 93 per cent of the Streptococcus isolates (62.7 per cent of the Pneumococcus isolates) and 90.7 per cent of the Staphylococcus isolates.     

ACUTE AND CHRONIC ASTHMA—Treatment with Theophylline in Hydro-Alcoholic Solution: Clinical Evaluation and Pulmonary Function Studies

A flavored solution containing 80 mg. of theophylline and 3 cc. of ethyl alcohol per 15 cc. was given orally to 31 patients with acute asthma to terminate the attack. Thirty patients with moderate to severe chronic asthma were alternated for three or four weeks on daily multiple doses of either the theophylline solution or a placebo.In the acute cases three-second Vital Capacity increased by 33.8 per cent and Maximal Breathing Capacity by 30.2 per cent in one hour after taking 60 cc. to 75 cc. of the theophylline solution. When placebos were given, both measures of lung function declined during the first half hour.Seventy-one and a half per cent of patients with acute cases felt moderate to complete relief of symptoms. In persons with chronic asthma the regular use of the theophylline solution did not change the frequency of asthma in most cases, but it decreased the severity in 59 per cent of cases. The values for three-second Vital Capacity and Maximal Breathing Capacity rose only a little.Gastric irritation was noted in one-third of the chronic cases and one-fourth of the acute cases. This could be reduced by appropriate measures.     

MORTALITY RATES IN PATIENTS WITH BURNS—A Report of Experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956.The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection.No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived.No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection.The lowest mortality rate was in the age group of 15 through 35 years.     

Value of x ray examinations of the cervical spine.

The value of x ray examination of the cervical spine was studied. In one district general hospital it has been estimated that such examinations occupy one radiographer and one room for four hours a week. Eighty-five per cent of patients aged 60 or more who had been referred for an x ray examination of the neck in one year were reported as having cervical spondylosis, and there were no unexpected findings of infection or malignancy at any age. The reports of patients referred for x ray examination of the cervical spine were compared with those of control patients who had originally attended for barium studies. There was no significant difference in the prevalence of cervical spondylosis between the two groups, although the severity of the disc changes was greater among cases than controls. There were no consistent relations between symptoms and changes seen on x ray films. It is suggested that x ray examinations should be performed only when there is a clinical suspicion of malignancy or infection, after trauma, or when surgery may be indicated. There is little point in taking x ray films of the neck to diagnose cervical spondylosis.     

Characteristics of the antibiotic sensitivity of nitrofuran--resistant Gram-negative bacteria of clinical origin]

494 persons with various purulent inflammatory diseases were examined. Gram-negative nitrofuran resistant organisms isolated from the clinical material were found in 22.9 per cent of the cases. Representatives of Enterobacteriaceae, Klebsiella-Enterobacter-Serratia (26.8 per cent), Proteus-Providencia (16.8 per cent) and E. coli-Arizona-Citrobacter (16.1 per cent) predominated. Pseudomonas (32.1 per cent) and Acinetobacter (5.3 per cent) predominated among the aerobic gram-negative bacteria. Sensitivity of 131 strains to 10 chemotherapeutic drugs was determined. 60.4 per cent of the aerobic and 44.2 per cent of the Coli bacteria had multiple drug resistance (to 5 and more drugs). The organisms isolated from the urine and wound excretion were most resistant. Representatives of Pseudomonas and Klebsiella-Enterobacter predominated among the polyresistant cultures. High sensitivity of the isolates to gentamicin, carbenicillin and nalidixic acid was noted.     

Some causes of blindness seen at Noor Eye Institute, Afghanistan

This is a survey of the causes of blindness recorded by three students of The City University during a six-week stay at NOOR Eye Institute in Kabul, Afghanistan. The nature of the sample used makes it unsuitable for direct comparison with surveys from other countries. Nevertheless, broad conclusions can be drawn. Severe eye disease is a considerable problem in Afghanistan, in common with other developing countries. The survey included all new patients seen in the outpatient clinic, blind to the extent of being unable to count fingers at more than three metres, in one eye or both. The sample of patients was examined by an ophthalmologist working with our team. A diagnosis was made and various social and demographic questions were asked with the help of an interpreter. In all, 473 patients were examined and included in our survey sample, a very high proportion of the new patients attending the clinic (40.46 per cent). The main causes of blindness were found to be cataract (31.12 per cent), corneal scarring (19.8 per cent), chorioretinal degenerations (6.79 per cent), glaucoma (6.65 per cent) and aphakia (5.52 per cent). Of the major causes of blindness, about forty per cent of the cases were considered remediable, and about thirty per cent could have been prevented. An outstanding difference between the causes of blindness in developed nations and those seen in Afghanistan was the amount of blindness caused by infection, especially in the younger age groups (up to 30 years). Cataract is a major cause of blindness in the older age groups of both societies. People suffering from ocular disease in Afghanistan wait until their sight is badly impaired or lost completely before seeking treatment. This results from a lack of knowledge of what could be done to conserve sight, the irreversible nature of many eye diseases, the distances involved in travelling to the clinic, and even a lack of knowledge of its existence.     

UNDESCENDED TESTES

Orchiopexy was performed upon 152 patients. Follow-up observation was inadequate, but of known results 14 per cent were poor. As an increasing number of investigators have observed spontaneous descent of undescended testes, this possibility should be considered in weighing indications for operation on boys before the age of puberty. Coexisting clinically demonstrable hernia (59 per cent in this series) is an indication for early operation. Otherwise, orchiopexy may be best delayed, perhaps until the twelfth year. This was done in 25 per cent of the cases in this series. Three methods of operation were used, the Torek, the Cabot-Nesbit, and the Bevan. There were fewer poor results with the Torek than with the Cabot-Nesbit procedure. The greatest number of poor results was in cases in which the Bevan technique was used.     

UNDESCENDED TESTES

Orchiopexy was performed upon 152 patients. Follow-up observation was inadequate, but of known results 14 per cent were poor.As an increasing number of investigators have observed spontaneous descent of undescended testes, this possibility should be considered in weighing indications for operation on boys before the age of puberty. Coexisting clinically demonstrable hernia (59 per cent in this series) is an indication for early operation. Otherwise, orchiopexy may be best delayed, perhaps until the twelfth year. This was done in 25 per cent of the cases in this series.Three methods of operation were used, the Torek, the Cabot-Nesbit, and the Bevan. There were fewer poor results with the Torek than with the Cabot-Nesbit procedure. The greatest number of poor results was in cases in which the Bevan technique was used.     

LAMINECTOMY FOR HERNIATED INTERVERTEBRAL DISC

In a study of 59 patients surgically treated by various surgeons for relief of herniated lumbar intervertebral disc accompanied by symptoms that persistently recurred or had become resistant to conservative therapy, it was noted from review of hospital and office records that laminectomy either greatly relieved or entirely abated symptoms in 83 per cent of the cases.Postoperative complications reported by the surgeons who did the operations consisted of one death and five wound infections. Contrast myelography and electromyography, used in almost all cases in the series, appeared to be valuable adjuncts in the diagnosis of herniated lumbar intervertebral discs. The most common site of the lesion in this series was between the fourth and fifth lumbar vertebrae. Strain upon lifting was the most commonly reported precipitating factor.     

TUBERCULOSIS CONTROL IN CALIFORNIA MENTAL HOSPITALS

Diagnosis, the first step in tuberculosis control, is accomplished in the mental hospitals of California by x-ray examination of all patients annually and of new or returning patients on admission. This routine has been carried on since 1937.Tuberculous patients with active disease are segregated in one of three specially staffed and equipped units at the Patton, Sonoma and Napa hospitals. Those in whom disease is likely to recur are likewise segregated for special care and observation. Those in whom disease is inactive or not definitely diagnosed are not segregated but are observed by physicians of the Bureau of Tuberculosis Control of the California Department of Public Health in collaboration with the staffs of the institutions.Since the establishment of this program the proportion of new or previously unrecognized cases of tuberculosis has been reduced from 0.83 per cent, a year after the program was begun, to 0.37 per cent, while recurrence or progression of previously recognized disease has been reduced from 12.3 per cent at the first survey to 5 per cent at the most recent.Overcrowding in all hospitals has been the chief obstacle to the success of the program.     

Primary carcinoma of the gallbladder; review of 173 cases

One hundred seventy-three cases of primary carcinoma of the gallbladder were analyzed. In the group studied they made 2.11 per cent of all malignant tumors found at autopsy and were found in 1.89 per cent of all cases in which operation was done on the biliary tract. There was no appreciable change in the incidence of this tumor at autopsy during the period studied (1918-1948) at the Los Angeles County Hospital. Sixty-eight per cent of the cases were in females. A particularly high incidence was noted in Mexican females. Upper abdominal pain, loss of weight, nausea and vomiting, jaundice, and palpable mass or enlarged liver were the most common clinical features. Approximately one-third of the patients in whom the lesion was found at operation and one-fifth of all the patients whose records were studied had a history of chronic gallbladder disease. All but two of the 38 patients operated on were dead or had clinical recurrence within two years. One was alive and well 12 years after cholecystectomy. The most common gross appearance, particularly at autopsy, was a large tumor mass replacing the gallbladder and radiating to nearby organs, particularly the liver. In about one-third of the cases the tumor was grossly limited to the gallbladder. Polypoid tumors occurred in only about 10 per cent of the cases and most of the tumors were diffusely growing adenocarcinoma. Perforation appeared in nine cases, usually with fistula to the gastrointestinal tract. All of the tumors were histologically adenocarcinoma, usually of simple glandular structure. No purely squamous cell growth occurred. Gallstones were found in 79.8 per cent of the cases.