close

Вход

Забыли?

вход по аккаунту

?

The Secondary Infection of Sinuses Occurring in Cases of Non-Pulmonary Tuberculosis

код для вставкиСкачать
THE
IN
SECONDARY
CASES
INFECTION
OF
OF
SINUSES
NON-PULMONARY
TUBERCULOSIS.
by
ROBERT
BINGHAM
THESIS
FOR
THE
McMILLAN.
PRESENTED
DEGREE
OF
OCCURRING
M .D.
ProQuest N um ber: 13905564
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is d e p e n d e n t upon the quality of the copy subm itted.
In the unlikely e v e n t that the a u thor did not send a c o m p le te m anuscript
and there are missing pages, these will be noted. Also, if m aterial had to be rem oved,
a n o te will ind ica te the deletion.
uest.
ProQuest 13905564
Published by ProQuest LLC(2019). C opyright of the Dissertation is held by the Author.
All rights reserved.
This work is protected against unauthorized copying under Title 17, United States C o d e
M icroform Edition © ProQuest LLC.
ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 4 8 1 0 6 - 1346
INTRODUCTION.
T he p r o b l e m o f t u b e r c u l o s i s i s o n e w h i c h i s i n t i ­
m a te ly concerned w ith th e g e n e r a l w e ll b e in g o f th e
p o p u la tio n .
is
It,
p e r h a p s m o re t h a n a n y o t h e r d i s e a s e ,
a r e f l e x o f t h e e n v ir o n m e n ta l c o n d i t i o n s u n d e r w h ich
p e o p le l i v e .
A s t u d y o f t h e s t a t i s t i c a l d a t a sho w s t h a t
d u r i n g t h e l a s t 60 y e a r s t h e d e a t h - r a t e fro m t h i s d i s ­
e a s e h a s d e c l i n e d i n a s t r i k i n g f a s h i o n , a n d i t w o u ld
se e m t h a t t h e m e a s u r e s a d o p t e d d u r i n g t h a t p e r i o d f o r
th e r a i s i n g o f th e s ta n d a rd o f l i v i n g , h y g ie n ic as w e ll
a s e c o n o m ic , w ere b e a r i n g f r u i t .
D u rin g t h i s
p e r io d th e d e a t h - r a t e fro m a l l form s
o f t u b e r c u l o s i s o c c u r r i n g i n t h e B r i t i s h I s l e s sho w s
a p p r o x i m a t e l y a 7 0 p e r c e n t r e d u c t i o n : an d t h e c r e d i t
f o r t h i s h a s b e e n g i v e n t o many f a c t o r s . O f t h e s e
f a c t o r s s o c i a l a n d e c o n o m ic i m p r o v e m e n t s h a v e u n d o u b t ­
e d ly p la y e d t h e i r p a r t b u t p r o b a b ly t h e m ost b e n e f i c i a l
p o w e r h a s b e e n t h e a p p l i c a t i o n o f m e d i c a l k n o w le d g e t o
t h e h e a l t h p ro b le m s o f t h e p e o p l e .
When m e d i c i n e l a i d a s i d e m e d i a e v a l c o n c e p t i o n s o f
d i s e a s e and i t s
c a u s e s and a d o p te d i n t h e i r p l a c e c o n ­
c i s e s c i e n t i f i c f a c t s t h e p ro b le m o f t h e s p r e a d o f
d i s e a s e b y i n f e c t i o n becam e e v i d e n t .
P ra o tic a l ex­
p e r i e n c e h a d sh ow n t h a t c e r t a i n d i s e a s e s o c c u r r e d an d
s p r e a d m o re r e a d i l y i n c e r t a i n c i r c u m s t a n c e s a n d s t e p s
w ere ta k e n t o m in im ise t h i s
ad v erse/
sp read by e ra d ic a tin g th e se
ad v erse c irc u m sta n c e s.
To t h i s e n d r e f o r m s a n d i m p r o v e ­
m en ts w ere b e in g c a r r i e d o u t i n h o u s i n g , s a n i t a t i o n ,
w a te r s u p p l i e s and o t h e r e s s e n t i a l s e r v i c e s .
I n a w o r d , t h e r e s p o n s i b l e g o v e r n i n g b o d i e s b ecam e
'P u b l i c H e a lth c o n s c i o u s '.
n a tio n a l in te re s t re su lte d
T h is q u ic k e n in g o f th e
in th e fo rm a tio n o f P u b lic
H e a l t h o r g a n i s a t i o n s now s c a t t e r e d t h r o u g h o u t t h e w o r l d ;
o r g a n i s a t i o n s s t a f f e d by s p e c i a l l y
t r a i n e d men an d
women; w h o se p a r t i c u l a r d u t y i t i s
to see th a t ev ery ­
t h i n g may b e d o n e t o c o m b a t t h e c o n d i t i o n s g i v i n g r i s e
t o , and h e lp in g , th e s p re a d o f i n f e c t i o u s d i s e a s e .
As i t h a p p e n e d , t u b e r c u l o s i s w as o n e o f t h e e a r ­
l i e s t d i s e a s e s i n w h i c h a s p e c i f i c i n f e c t i o n w as p r o v e d
but its
s i g n i f i c a n c e w as n o t a p p r e c i a t e d b y t h e a d m i n ­
istra tiv e
a u t h o r i t i e s , and f u l l y t h i r t y
y e a rs e la p se d
a f t e r K o c h ' s d i s c o v e r y , b e f o r e i t b ec a m e a n o t i f i a b l e
d i s e a s e . T h i s o r d e r i n t e n s i f i e d t h e u p w a rd t r e n d w h i c h
had a lr e a d y begun i n t h e h o u sin g c o n d itio n s
h y g ie n e o f th e p e o p le .
and p e r s o n a l
By p r o v i d i n g h o s p i t a l acco m m o da­
t i o n f o r s e g r e g a t i o n o f th o s e s u f f e r i n g from t h e d i s ­
e a s e o r , a t l e a s t t r a i n i n g th e m t o d e s t r o y c o n t a g i o u s
d i s c h a r g e s , t h e way w as f u r t h e r p a v e d t o w a r d s t h e i m ­
p r o v e m e n t w h i c h now e x i s t s .
C l a i m s h a v e b e e n m ade t h a t
th e s e e f f o r t s a lo n e a r e n o t r e s p o n s ib le f o r th e im p ro v e ­
m ent b u t t h a t t h e r e a r e o t h e r f a c t o r s a l s o , y e t w h a t­
e v e r th e c a u s e , th e f a c t rem a in s t h a t i n t u b e r c u l o s i s
th e re /
t h e r e h a s b e e n a m a rk e d im p r o v e m e n t i n b o t h i n c i d e n c e
a n d m o r t a l i t y r e t u r n s w i t h i n a s h o r t n umbe r o f y e a r s .
As i t
a f f e c t s man t h i s d i s e a s e i s r o u g h l y d i v i d e d
i n t o tw o g r e a t g r o u p s , t h e PULMONARY a n d NON -PULMONARY
fo rm s and i t
i s t h e l a t t e r w h ic h i s
th e s u b je c t o f t h i s
in v e stig a tio n •
N o n -p u lm o n a ry t u b e r c u l o s i s i s o f t e n c a l l e d s u r g i c a l
tu b e r c u lo s is b ecause o f i t s d i s t r i b u t i o n and b e c a u se ,
i n c o n tr a s t to th e o th e r , i t
to s u rg ic a l tre a tm e n t.
b lem o n ly i n t h e f i r s t
len d s i t s e l f p a r tic u la r ly
In a d d itio n i t
i s a m a jo r p r o ­
te n to f i f t e e n y e a rs o f l i f e ;
b e c o m in g d i s t i n c t l y r a r e a t t h e a g e s w hen t h e p u lm o n a r y
ty p e ta k e s i t s
to ll.
T he a c c o m p a n y i n g g r a p h d e m o n s ­
t r a t e s t h e d i f f e r e n c e b e t w e e n t h e tw o t y p e s .
GRAPH 1 .
Red
A f£>w
tf t l t - 'c r i
* r o n r iy jT y
P£orfr~ J lV 'H G . A— T I
rm try
=
ttk n n
*■
s
/?•*■
ffs n& cve
-TUSEKcv[o
50
P h i l i p , q u o t i n g f i g u r e s f o r S c o t l a n d sh o w e d t h a t
t h e m ost s u b s t a n t i a l r e d u c t i o n i n t u b e r c u l o s i s f a t a l i t y
to o k p la c e In th e f i r s t y e a r o f l i f e
ages/
and t h e l e a s t a t
a g e s o f 35 y e a r s a n d o v e r .
I n v ie w o f th e t a b l e s an
i n f e r e n c e may b e d r a w n t h a t a n i m p r o v e m e n t o c c u r r e d i n
t h e r e s u l t s o f c a s e s o f n o n -p u lm o n a ry t u b e r c u l o s i s r e ­
c o rd e d and t r e a t e d .
T h i s i m p r o v e m e n t may h a v e b e e n d u e
t o a change in th e ty p e o f i n f e c t i o n fo llo w in g tu b e r c u l i s a t i o n o f t h e p o p u l a t io n w ith a lo w e re d f a t a l i t y
as
s u g g e s t e d b y some o r , a t t h e o t h e r e x t r e m e , t o i m p r o v e d
m eth o d s o f t r e a t m e n t .
One o t h e r p o t e n t f a c t o r i s t h e
s u p e r v is io n o f th e m ilk su p p ly t o th e g e n e r a l p u b lic
and i t
is
a l s o p o s s i b l e t h a t e a r l i e r a n d m ore a c c u r a t e
d i a g n o s i s o f t h e d i s e a s e b y t r a i n e d o b s e r v e r s , glided b y
m odem ra d io lo g y , p la y s a la rg e p a r t .
D e s p ite t h i s
im p rovem ent t u b e r c u l o s i s o f t h e b o n e s
and j o i n t s i n c h i l d r e n i s s t i l l
a g r a v e p ro b le m and p r e ­
s e n t s t o t h e p e r s o n t r e a t i n g i t many g i n o m a l i e s .
A p a t­
i e n t w ith a s im p le l e s i o n o f t h i s n a t u r e t r e a t e d on
m o d e m l i n e s may g i v e a g o o d r e s u l t d e m a n d i n g n o t r e a t ­
m e n t o t h e r t h a n r e s t an d g e n e r a l c a r e .
On t h e o t h e r
h a n d a n a p p a r e n t l y s i m i l a r c a s e may d e v e l o p a n a b s o e s s
and e v e n t u a l l y fo rm a s i n u s .
T h i s c o m p l i c a t i o n may r e ­
s u l t i n t h e d e v e lo p m e n t o f am y lo id d i s e a s e and d e a th ;
o r , a t t h e b e s t I t may b e h e a l e d a f t e r much t r o u b l e w i t h
a re s id u a l c rip p lin g d e fo rm ity .
C o m p lic a tio n s o f t h i s
ty p e o o c u r f r e q u e n t l y and t h e i r im p o rta n c e c a n n o t be
o v e r-ra te d .
F r a s e r , i n h i s boo k on T u b e r c u l o s i s o f
t h e B ones and J o i n t s , s a y s t h a t " a b s c e s s f o r m a t i o n i s
se rio u s/
s e r io u s i n so f a r as i t
i s so o fte n th e p re c u rso r of
th e n e x t d a n g e r, v i z . s e p tic in f e c tio n .
In i t s e l f i t
i n c r e a s e s t h e g r a v i t y o f th e d i s e a s e and b y i t s
te n d e n c y
t o b u r r o w i t may o p e n u p t o i n f e c t i o n w id e a r e a s o f
so ft tissu e " .
I n a n o t h e r p a r t o f t h e sam e b o o k h e s a y s ,
" M ix e d i n f e c t i o n i s t h e m o s t s e r i o u s c o m p l i c a t i o n w h i c h
can o ccu r.
I t fo llo w s a b sc e ss fo rm a tio n o r im p e rfe c t
s u r g i c a l i n t e r f e r e n c e and i t s d a n g e r l i e s
in th e a p p a r­
e n t im p e tu s w h ic h i t g i v e s t o t h e t u b e r c u l o u s p r o c e s s " .
A n o th e r a u th o r , D udgeon, r e f e r s t o th e im p o rta n c e o f
m ix e d i n f e c t i o n s i n b o n e
and j o i n t t u b e r c u l o s i s , r e ­
m a r k i n g , " I n t h e o l d d a y s o f m ix e d i n f e c t i o n s , d u e t o
e r r o r s i n th e s u r g i c a l t r e a t m e n t, p y o g e n ic v a c c in e s
w e r e s o m e t i m e s o f u s e , b u t I h a v e n o t e m p lo y e d s u c h a
v a c c i n e s i n c e 1912"
(B a c t. v a c c in e s and t h e i r p o s t,
i n t h e r a p e u t i c s , D u d g eo n 1 9 2 7 ) .
F r a s e r i s d e a l i n g w i t h p r e - w a r t u b e r c u l o s i s an d
D u d g e o n 's r e m a r k I m p l i e s t h a t some c h a n g e h a s t a k e n
p la c e in t h i s fo rm o f tu b e r c u lo s is s in c e 1912.
T h is
c h a n g e may h a v e r e s u l t e d f r o m b e t t e r m e t h o d s o f t r e a t ­
m ent o r fro m a change i n th e ty p e o f t h e l e s i o n .
W ith p r e s e n t d a y m e th o d s o f t r e a t m e n t i n u s e a
s u p e r f i c i a l s u r v e y o f a n u m b e r o f c a s e s seem ed t o show
t h a t s e c o n d a r y i n f e c t i o n o f s i n u s e s w as n o t s o im ­
p o r ta n t a f a c t o r as in fo rm er d a y s .
Y et c e r t a i n
s i n u s e s d e v e lo p e d c o m p lic a tio n s and r e f u s e d t o h e a l
w h ile /
6
w h i l e o t h e r s r a i l a s h o r t c o u r s e an d h e a l e d q u i c k l y .
I n f o r m a t i o n was s o u g h t u p o n t h e m a t t e r i n t h e l i t e r a ­
t u r e b u t i t wa 3 f o u n d s a d l y l a c k i n g .
A b s c e s s e s an d
t h e i r t r e a t m e n t r e c e iv e d a f u l l m easure o f c a r e i n a l l
books b u t , i n m o st, th e q u e s tio n o f s i n u s e s , th e re a s o n
f o r t h e i r tro u b le s o m e c o u rs e and th e f a c t o r s g o v e rn in g
t h e i r f o r m a t i o n a n d h e a l i n g was n o t a v a i l a b l e .
Even
in fo rm a tio n r e l a t i n g t o t h e i r e f f e c t upon th e c o u rse o f
t h e p r im a r y f o c u s o f d i s e a s e w ere l a c k i n g .
One r e f e r ­
e n c e w as f o u n d g i v i n g t h e i n f e c t i n g o r g a n i s m s i n
s in u s e s to in c lu d e s tr e p to c o c c i, d ip h th e ro id b a c i l l i
a n d s t a p h y l o c o c c i b u t n o e v i d e n c e w as g i v e n a s t o t h e i r
r e l a t i v e im p o rta n c e .
I t w as t h o u g h t , i n v i e w o f t h e s i m i l a r i t y b e t w e e n
s i n u s e s a n d w o u nd s t h a t some i n f o r m a t i o n m i g h t b e f o u n d
i n w o r k s d e a l i n g w i t h wound i n f e c t i o n s .
D o u g la s,
F l e m i n g a n d C o l e b r o o k i n a n M .R .C . r e p o r t o n t h i s s u b ­
j e c t s t a t e t h a t " a l m o s t e v e r y s e o o n d a r y i n f e c t i o n com­
p l i c a t i o n o f any s e r i o u s n e s s i s
caused by S tre p , pyo­
g e n e s, e .g . th e p e r s is te n c e of s in u s e s , fe v e r e tc .*
A3 a r e s u l t o f r a n d o m o b s e r v a t i o n s m ade u p o n s i n u s e s
s u s p ic io n had a lre a d y f a l l e n upon s te p to c o c c i as th e
m i s c h i e f m a k in g s e c o n d a r y i n f e c t i o n a n d a n i n v e s t i ­
g a t i o n was p l a n n e d p r i m a r i l y t o a n s w e r t h e f o l l o w i n g
q u e s tio n s .
I.
The d e t e r m i n a t i o n o f t h e p r e s e n c e o r a b s e n c e o f
s tre p to c o c c i in s in u se s.
I I./
7
II.
III.
T he c l a s s i f i c a t i o n o f s u c h s t r e p t o c o c c i .
T he e f f e c t o f t h e s e s t r e p t o c o c c i o n t h e l o c a l
and g e n e r a l c o n d itio n o f t h e p a t i e n t .
IV .
T he m e th o d a n d t i m e o f i n f e c t i o n
THE
HISTORY
OF
THE
STREPTOCOCCI
TO
DISEASE
IN
IK
RELATION
MAH.
S t r e p t o c o c c i w e r e f i r s t d e s c r i b e d an d n am ed b y
B i l l r o t h i n 1 8 7 4 a n d t h e i r e x i s t e n c e w as c o n f i r m e d b y
o t h e r o b s e r v e r s i n t h e y e a r s w h ic h f o ll o w e d .
Doubt
l i n g e r e d r e g a r d i n g t h e i r r o l e i n t h e t i s s u e s fro m w h ic h
t h e y w e r e r e c o v e r e d a n d i t was n o t u n t i l a l m o s t t e n
y e a r s h a d e l a p s e d t h a t O g s t o n o f A b e r d e e n was a b l e t o
p r o v e t h e i r p a t h o g e n i c p o w e r t o w a r d s hum an b e i n g s .
C o in c id e n t a lm o st w ith t h i s
i n v e s t i g a t i o n w as t h a t o f
C h e y n e who h e l d t h a t t h e s e o r g a n i s m s w e r e n o n - p a t h o g e n i c a s h e h a d f o u n d th e m i n h e a l t h y w o u n d s .
L a te r
i n v e s t i g a t i o n s u p h e ld th e s e s ta te m e n ts and t h e genus
w as e n l a r g e d b y p a t i e n t r e s e a r c h an d a c k n o w l e d g e d t o
c o n t a i n m em b ers w h i c h w e r e w i d e l y d i f f e r e n t i n t h e i r
p a th o g e n ic po w ers.
Even p h y s i c a l c h a r a c t e r i s t i c s w ere
f o u n d t o v a r y a n d V e i l l o n i n 1893 d e s c r i b e d a s t r a i n
w h i c h w o u ld n o t g ro w i n t h e p r e s e n c e o f a i r , t h e n u ­
c l e u s o f a g r o u p w h ic h was s i m i l a r l y i n c r e a s e d a s t i m e
passed.
E v e n t u a l l y , t h e r e f o r e , t h e g e n u s w as e n l a r g e d
t o c o n t a i n s t r a i n s w h ich w ere v e r y d i f f e r e n t i n t h e i r
b i o l o g i c a l r e q u ir e m e n ts and p a t h o g e n i c pow ers and w h ic h
w ere w id e s p re a d th ro u g h o u t n a t u r e p a r t i c u l a r l y
in
r e f e r e n c e t o m an .
A list
o f p a t h o l o g i c a l c o n d i t i o n s i n m an f r o m
w h i c h s t r e p t o c o c c i h a v e b e e n r e c o v e r e d w o u ld b e v e r y
g re a t/
g r e a t and th e f o llo w in g i s
i o n s i n w h ic h i t
w h ic h i t
i s t h e s o l e c a u s a l o rg a n ism o r i n
i s a common c a u s a l o r g a n i s m .
1.
S c a rle t fe v e r.
2.
P u erp eral s e p sis .
3.
E ry s ip e la s .
.
C e llu litis .
4
o n ly r e p r e s e n t a t i v e o f l e s ­
5.
A c u te r h e u m a tic f e v e r .
6.
S u b -a c u te u l o e r a t iv e e n d o c a r d i tis .
7.
P r im a r y and s e c o n d a r y b ro n c h o p n eu m o n ia.
8.
T o n s illitis .
9.
S e p tic so re th r o a t.
10.
O t i t i s m e d ia , i n t r a c r a n i a l a b s c e s s , m e n in g itis
11.
V a rio u s s k in l e s i o n s .
12.
P e rito n itis .
13.
S e p tic a e m ia .
U n f o r t u n a te l y fro m t h e v ie w p o i n t o f s i m p l i c i t y
i t was f o u n d i m p o s s i b l e t o s a y t h a t a c e r t a i n s t r a i n
w o u ld b r i n g a b o u t a c e r t a i n l e s i o n , a s v i r u l e n c e , e v e n
o v e r s e v e r a l g e n e r a t i o n s o f a p a r t i c u l a r s t r a i n , was
found to v a ry .
R e a o tio n on th e p a r t o f a h o s t a ls o
v a r i e d a n d many i n t e r e s t i n g e x p e r i m e n t s h a v e b e e n
c a r r i e d o u t u p o n t h e im m u n ity r e s u l t a n t f r o m i n f e c t i o n .
T h i s im m u n i t y was f o u n d t o b e o f tw o f o r m s , o n e l o c a l
and t h e o t h e r g e n e r a l and t h e s e fo rm s w e re so m etim es
d ev e lo p e d s e p a r a t e l y .
(G ay a n d R h o d e s 1 9 2 2 ) .
The
e x i s t e n c e o f a g e n e r a l a n t i t o x i c im m u n i t y w as f i r s t
d e m o n stra te d /
d e m o n s tr a te d by t h e D ic k s
(1924) t o o c c u r i n s c a r l e t
f e v e r an d o n t h e b a s i s o f t h i s d i s c o v e r y a d i a g n o s t i c
t e s t w as p o s t u l a t e d a n d f o u n d s u c c e s s f u l .
A m o re w i d e s p r e a d a p p l i c a t i o n o f i t s
gen eral p rin c ip le s
e l i c i t e d s e v e r a l i n t e r e s t i n g f a c t s r e g a r d i n g im m u n ity
in g e n e ra l to s tre p to c o c c a l in f e c tio n s .
T hese w ere,
( 1 ) t h a t t h e n a t u r a l im m u n ity t o s t r e p t o c o c c a l i n f e c ­
t i o n was lo w ( 2 ) t h a t v a r i a t i o n i n t h i s i m m u n it y o c c u r ­
r e d fro m tim e t o tim e ( e . g . d u r in g p re g n a n c y p a r t u r ­
i t i o n and th e p u e rp e riu m ) an d (3 ) t h a t e x p o s u re o r i l l ­
n e s s re d u o e d im m u n ity .
L o c a l im m u n i t y w as f o u n d t o v a r y i n d i f f e r e n t s i t e s
o f t h e b o d y a n d w as f o u n d t o b e p u r e l y t r a n s i e n t i n
n a tu re .
A c o m b i n a t i o n o f t h e s e v a r i a b l e f e a t u r e s an d
t h e v a r i a b l e v i r u l e n c e o f s t r e p t o c o c c i m ak es i t
e v id e n t
why n o c l e a r c u t a c t i o n c o u l d b e a s c r i b e d t o a p a r t i c ­
u la r s tra in .
A g e n e r a l s t a t e m e n t may b e m ade t h a t t h i s
g e n u s c o n t a i n s many o f t h e m o s t d a n g e r o u s p a t h o g e n s
o f m an .
Of p a r t i c u l a r i n t e r e s t i n th e p r e s e n t i n v e s t i g a ­
t i o n was t h e p r o b l e m o f w ound i n f e c t i o n a n d w i t h i t ,
s e v e r a l o f th e c u ta n e o u s and g e n e r a l le s i o n s cau sed by
s tre p to c o c c i.
T he i m p o r t a n c e o f t h e s e o r g a n i s m s i n
w oun ds o f t h e s k i n a n d m ucous m e m b ra n e s w as b r o u g h t o u t
v e r y f o r c i b l y d u r i n g t h e G r e a t W ar.
D u rin g t h i s tim e
t h e p o s s i b i l i t i e s f o r s u c h an i n f e c t i o n w ere e n o rm o u sly
e n h a n c e d b y t h e c o n d i t i o n s u n d e r w h ic h t h e t r o o p s w ere
liv in g /
l i v i n g a n d f u r t h e r m o r e , a m p le f a c i l i t i e s
f o r a d e q u a te i n v e s t i g a t i o n .
v e s tig a tio n s
w ere p r e s e n t
As a r e s u l t o f t h e s e i n ­
s t r e p t o c o c c i w ere g iv e n a p la c e o f im p o r t­
a n c e i n wound i n f e c t i o n s .
L e v a d i t i (1918) p o i n t e d o u t
t h a t d e l a y i n t h e h e a l i n g o f w a r w oun ds r e s u l t e d i f
s tre p to c o c c a l in fe c tio n o ccu rred .
a
B r u c e , B e r l i n and
L aw ren ce (1918) fo u n d t h e s e o rg a n is m s p r e s e n t i n 24#
o f a s e r i e s o f 9 8 5 w oun ds a n d r e g a r d e d t h e i r p r e s e n c e
a s th e c h ie f ca u se o f th e f a i l u r e o f seco n d ary s u tu r e .
I n 1920 D o u g la s , C o le b ro o k and F le m in g r e p o r t e d t h a t
a l t h o u g h o f t e n n o t p r e s e n t i n i t i a l l y , S . p y o g e n e s was
f o u n d i n p r a c t i c a l l y e v e r y s e p t i c w ound a n d w as r e s p o n ­
s i b l e f o r many o f t h e c o m p l i c a t i o n s a n d s e q u e l a e s u c h
a s e r y s i p e l a s and p e r s i s t i n g s u p p u ra tin g s in u s e s .
A n a e ro b ic s t r e p t o c o c c i w ere a l s o r e c o v e r e d i n a p e r c e n t ­
a g e o f c a s e s b u t w e r e a s s e s s e d t o b e o f lo w v i r u l e n c e
and r e l a t i v e l y u n im p o rta n t.
One e x c e p t i o n t o t t i i s was
a f a t a l c a s e r e p o r t e d by M a rrw e d e l and W e h rsig i n 1915.
I t w as t h o u g h t t h a t t h e s e o r g a n i s m s w e r e v e r y p r o ­
b a b ly p r e s e n t as se c o n d a ry i n f e c t i o n s i n tu b e rc u lo u s
s i n u s e s a l t h o u g h , a s h a 3 a l r e a d y b e e n re m a rk e d , no
e v id e n c e e x i s t s re g a rd in g t h e i r r o l e i n t h i s ty p e of
le sio n .
T he p r o b a b i l i t y i s f u r t h e r e n h a n c e d b y t h e
w i d e s p r e a d n a t u r e o f t h e g e n u s a s w as s h o w n e a r l i e r i n
th e c h a p te r.
12.
CHAPTER
THE
HISTORY
OF
THE
II.
CLASSIFICATION
OF
STREPTOCOCCI.
P r e s e n t i n g many p r o b l e m s r e g a r d i n g t h e i r p a t h o ­
g e n i c pow ers t h e s e o rg a n ism s p r e s e n t e d s t i l l g r e a t e r
p ro b le m s w ith r e g a rd t o t h e i r c l a s s i f i c a t i o n a n d , i t
i s s a f e t o s a y , t h a t m o re e f f o r t h a s b e e n e x p e n d e d t o
th is
en d t h a n t o i n v e s t i g a t i n g t h e i r r e l a t i o n t o d i s ­
ease in recen t y e a rs •
The f i r s t a tte m p te d c l a s s i f i c a t i o n o f t h e s e o r g a n ­
i s m s w as o n a m o r p h o l o g i c a l b a s i s .
When F e h l e i s e n a n d
R o s e n b a c k i s o l a t e d t h e tw o s t r a i n s , w h i c h t h e y c a l l e d
t h e S . e r y s i p e l a t i s and th e S . pyogenes r e s p e c t i v e l y ,
t h e b e l i e f w as t h a t t h e s e s t r a i n s w e r e c l e a r l y d i f f e r ­
e n t i a t e d a n d R o s e n b a c k m ade a n a t t e m p t e d c l a s s i f i c a t i o n
b a s e d on t h e i r g ro w th s on g e l a t i n and a g a r .
T h i s m e th o d
w as f o u n d I n a d e q u a t e b y F r a e n k e l ( 1 8 8 9 ) a n d V . L i n g e l s h e i m ( 1 8 9 1 ) a n d t h e l a t t e r an d K u r t h s e p a r a t e l y i n
1891 p ro d u c e d p a p e r s a t t e m p t i n g a c l a s s i f i c a t i o n on
th e a p p e a ra n c e s o f s tr e p t o c o c c i b r o th m e d ia .
I n th e
y e a r s w h i c h f o l l o w e d t h e f i e l d w as e n l a r g e d b y t h e w o rk
o f V e i l l o n ( 1 8 9 3 ) who d e s c r i b e d a n a n a e r o b i c s t r e p t o ­
c o c c u s w h i l e o t h e r i n v e s t i g a t o r s r e c o v e r e d o t h e r , and
su p p o se d ly d i f f e r e n t , s t r a i n s fro m v a r io u s s o u r c e s .
F u r t h e r c o n f u s i o n w as c a u s e d b y t h e w o rk o f K o c h a n d
P e t r u s h k y ( 1 8 9 6 ) who p r o v e d t h a t s t r e p t o c o c c i f r o m a
v a r i e t y o f s o u r c e s w ere c a p a b le o f p r o d u c in g e r y s i p e l a s
i n a n i m a l s p r o v i d e d t h e v i r u l e n c e was e x a l t e d s u f f i c ­
ie n tly /
s u f f i c i e n t l y by p a s s a g e .
By now i t was o b v i o u s t h a t m o r p h o l o g i c a l t e s t s a s
s u g g e s t e d w e r e i n a d e q u a t e , an d f u r t h e r t e s t s w e r e d e ­
v ise d .
H iss
(1902) i n t r o d u c e d f e r m e n t a t i o n r e a c t i o n s
a n d S c h o t t m u l l e r ( 1 9 0 3 ) made a c l a s s i f i c a t i o n o f a
n um ber o f s t r a i n s b a s e d on t h e i r a c t i o n on b lo o d a g a r .
W it h i m p r o v e m e n t i n k n o w l e d g e a n d t e c h n i q u e im m uno­
l o g i c a l t e s t s w e r e i n t r o d u c e d , an d now a l l t h e s e m e t h o d s
a r e i n u s e f o r t h e c l a s s i f i c a t i o n o f s t r e p t o c o c c i when
reco v ered .
F o r d e s c r i p t i v e p u r p o s e s , t h e s e t e s t s may
b e d e a l t w ith u n d er th e fo llo w in g h e a d in g s* I .
II.
III.
M o r p h o l o g i c a l and C u l t u r a l .
B io ch em ical*
Im m u n o lo g ic a l.
(A)
A c tio n on B lo o d .
(B )
F e rm e n ta tiv e P o w ers.
14
I.
MORPHOLOGICAL
When d i f f e r e n t i a t i n g
AND
CULTURAL.
s t r e p t o c o c c i on t h e above
g r o u n d s a p r i m a r y d i v i s i o n o f t h e g e n u s w as m ade i n t o
t h o s e o r g a n i s m s w h i c h w e r e a e r o b i c an d f a c u l t a t i v e l y
a n a e r o b i c a n d t h o s e w h io h w e r e s t r i c t l y
a n a e ro b ic .
To t h e s e tw o g r o u p s , o f w h i c h t h e f o r m e r w as t h e l a r g e r ,
f u r t h e r t e s t s w ere a p p l i e d .
S t r a i n s w h ic h w ere a e r ­
o b i c o r f a c u l t a t i v e l y a n a e r o b i c w e r e sho w n t o h a v e a
r e l a t i o n s h i p m o r p h o l o g i c a l l y t o t h e i r h a e m o ly tic pow ers
and w ere f u r t h e r s u b d iv id e d i n t o S c h o t t m u l l e r 's d i v ­
i s i o n s o f h a e m o ly tic and v i r i d a n s s t r a i n s an d th o s e
w h ic h w ere i n e r t to w a rd s b lo o d .
II.
the
h a e m o l y t ic
st r e pt o c o c c i.
S t r a i n s o f t h i s ty p e w ere u s u a l l y o b s e rv e d a s w e ll
ro u n d e d c o c c i i n c h a i n s o f m o d e ra te l e n g t h and w ere
f o u n d t o g ro w r e a d i l y o n a g a r a n d t o y i e l d c u l t u r e s o f
good v i a b i l i t y .
I t w as f u r t h e r c l a i m e d t h a t t h e s e
o rg a n ism s h ad t h e e le m e n ts o f t h e c h a in co m p ressed so
as to b e lo n g e r in th e a x is a t r i g h t a n g le s to th e
c h a i n (H olm an 1 9 1 6 j K i n s e l l a & S m i t h 1 9 1 8 ; a n d M c L e o d ) .
M o rp h o lo g ic a l v a r i a t i o n s w ere n o te d b y T a d d e r (1909)
who d e s c r i b e d g i a n t f o r m s an d N o r t o n , R o g e r s a n d
G e o r g i e f f (1921) d e s c r i b e d a b a c i l l a r y fo rm w h ic h th e y
o b ta in e d u n d e r abnorm al c o n d i t i o n s .
I t w as s h o w n t h a t
t h e m o rp h o lo g y v a r i e d i n a c c o r d a n c e w i t h t h e r e c e n t
e n v iro n m e n t/
15
e n v iro n m e n t a s i l l u s t r a t e d by th e d i p l o c o c c a l fo rm o f
a s t r a i n i n a n e a r l y s u p e r f i c i a l l e s i o n a s com pared
w ith t h e lo n g c h a in fo rm o f a s i m i l a r o rg a n ism i n a
w e ll-fo rm e d a b s c e s s .
C a p s u l e f o r m a t i o n w as show n t o
b e a b s e n t w ith th e e x c e p tio n o f B a ile & K le in h a n s)1 9 1 2 )
who c l a i m e d t h a t a c a p s u l e may b e o b s e r v e d i r r e g u l a r l y
a ro u n d s t r e p t o c o c c i i n th e a n im a l body b u t becam e
v isib le
' i n v i t r o ' w hen t h e o r g a n i s m s w e r e e x p o s e d
s im u l t a n e o u s l y t o t h e a c t i o n o f le u c o c y t e s and se m rn .
When s t a i n e d t h e o r g a n i s m s w e r e sh ow n t o b e G ram p o s i ­
t i v e w ith o c c a sio n a l v a r ia tio n s
i n o ld c u l t u r e s .
in in te n s ity , e sp e c ia lly
Two s t r a i n s w e r e r e p o r t e d b y J a f f e
( 1 9 1 2 ) w h i c h g a v e Gram n e g a t i v e s u b c u l t u r e s a n d K i n s e l l a
n o t e d a t e n d e n c y t o l o s s o f Gram p o s i t i v e 3 t a l n i n g when
th e s t r a i n s in c re a s e d in v iru le n c e .
T h e a p p e a r a n c e s w hen g r o w n i n ' b r o t h m e d i a ' w e r e
e i t h e r a g e n e r a l t u r b i d i t y o r a g r a n u l a r d e p o s i t , and
t h i s f e a t u r e w as show n t o b e o f n o v a l u e i n a d i f f e r ­
e n tia l sense.
W e i s s e n b a c k ( 1 9 1 8 ) show ed t h a t t h e p r e ­
s e n c e o f b i l e i n f l u i d m e d i a i n h i b i t e d g r o w t h an d
W h e a tle y p ro v e d t h a t 40 p e r c e n t b i l e i n a g a r i n h i b i t e d
t h e g r o w th o f S . h a e m o l y t i c u s w h e r e a s i t h a d n o e f f e c t
on th e S . f a e c a l i s .
T he g e n e r a l o b s e r v a t i o n w as t h a t h a e m o l y t i c s t r a i n s
g a v e a d i s t i n c t b u t n o t c o p io u s s u r f a c e g ro w th on th e
u s u a l n u t r i e n t a g a r p l a t e a n d a d i s t i n c t i v e f e a t u r e was
t h e t e n d e n c y f o r t h e s e c o l o n i e s t o r e m a i n d i s c r e t e an d
to /
to
s to p g ro w in g a f t e r 24 h o u r 3 .
C o lo n y fo rm an d i t s
v a r i a t i o n s w e r e i n t e n s i v e l y s t u d i e d a n d some i n t e r e s t ­
i n g o b s e r v a t i o n s w ere m ade.
In s t r i c t c h ro n o lo g ic a l
o r d e r t h o s e o f Cowan ( 1 9 2 2 ) come f i r s t .
She m a in ta in e d
t h a t by th e re p e a te d p la tin g and s e le c t io n o f c o lo n ie s
i t w as p o s s i b l e t o s p l i t s e v e r a l s t r a i n s o f s t r e p t o ­
c o c c i i n t o r o u g h an d s m o o th v a r i a n t s , t h e o n e w i t h a
tra n slu c e n t b lu is h f l a t
c o lo n y and t h e o t h e r w i t h a
m o re o p a q u e a n d r o u g h l y g r a n u l a r f o r m a t i o n g i v i n g r i s e
r e s p e c t i v e l y t o a d i f f u s e t u r b i d i t y and a g r a n u l a r d e ­
p o s i t w hen g ro w n i n b r o t h m e d i a .
S e c o n d l y , W a l k e r ( 1023)
n o t e d o n e o r tw o c o l o n i e s o f a m u c o id a p p e a r a n c e o c c u r ­
r i n g i n a c u l t u r e ta k e n fro m t h e p l e u r a o f an an im a l
i n t o w h ich a h a e m o l y t i c s t r e p t o c o c c u s h a d b e e n I n j e c t e d
an d o b s e rv e d t h a t t h e s t r a i n s grow n fro m t h e s e c o l o n i e s
w e r e m o re v i r u l e n t a n d a c t i v e l y h a e m o l y t i c t h a n s t r a i n s
g ro w n f r o m t h e n o r m a l c o l o n i e s .
T hese h y p e r -- v iru le n t
s t r a i n s , how ever, l o s t t h e i r p r o p e r tie s
g e n e ra tio n s.
T h ir d ly - E a g le s
( 1 9 2 4 ) w as o f t h e
o p i n i o n t h a t tw o c o l o n y f o r m s e x i s t e d :
g r e y i s h p i n p o i n t c o lo n y and ( i i )
c o lo n y .
a f t e r a few
(i). a s m a l l
a f l a t s c a le lik e
In th e fo u rth p la c e G r i f f i t h
(1927) d e s c r i b e d
3 m o rp h o lo g ic a l ty p e s o f c o lo n y ,
(i)
r o u g h and c o h e r e n t c o lo n y j
a c o lo n y w ith r a i s e d
(ii)
an o p a q u e ,fla t,
o p aq u e c e n t r e and a t h i n n e r t r a n s l u c e n t m a r g in w h ich
w as n e v e r c o h e r e n t a n d ( i i i )
m u co id /
a l a r g e , m o re t r a n s l u c e n t ,
m u c o id c o l o n y .
I n c o n t r a s t t o C o w an , M s r o u g h c o l o n y o n s o l i d
m e d ia g av e r i s e
to th e u n ifo rm t u r b i d i t y i n b r o th
c h a r a c t e r i s t i c o f C o w a n 's s m o o th v a r i a n t .
He f u r t h e r
o l a i m e d t h a t , w h en M s s t r a i n s w e r e c l a s s i f i e d o n a n
a n t i g e n i c b a s i s , a d e g r e e o f c o r r e s p o n d e n c e w as show n
to
e x i s t b e t w e e n t h e g r o u p i n g s o o b t a i n e d an d t h e
m o rp h o lo g y o f t h e c o l o n i e s .
To c a p t h e s e o b s e r v a t i o n s ,
L a n c e f i e l d a n d T odd g r o w in g t h e s e o r g a n i s m s o n b l o o d
a g a r , w ere a b l e t o d i f f e r e n t i a t e m o r p h o l o g i c a l l y a
r o u g h a n d a s m o o th c o l o n y f o r m an d cam e t o t h e c o n ­
c l u s i o n t h a t a g iv e n s t r a i n c o u ld v a ry I n c o lo n y fo rm .
I n v e s t i g a t i n g f u r t h e r on an a n tig e n ic b a s i s , th ey
show ed t h a t i t was o n l y t h e r o u g h c o l o n y w h i c h was
c a p a b l e o f g i v i n g r i s e t o a t y p e s p e c i f i c a n t i g e n , arri
w i t h t h i s v i e w F .W . A n d rew es a g r e e d .
T h is l a s t o b serv a
t i o n i s th e one m ost g e n e r a l l y a c c e p te d .
THE
VIRIDAJS
GROUP.
T he v i r i d a n s g r o u p may b e s u b d i v i d e d i n t o t w o :
s t r e p t o c o c c i w hose h a b i t a t i s
t h e m o u th a n d ( i i )
th o se
w hose h a b i t a t i s i n t h e b o w e l.
T he m o u th s t r e p t o c o o c i w e r e s h o w n ’ t o h a v e t h e
g e n e r a l c h a r a c te r s o f th e genus u n d e r th e m ic ro sc o p e
b u t form ed c h a in s i n t e r m e d i a t e i n l e n g t h b e tw een th e
h a e m o ly tic s t r a i n s and t h e t r u e b o w el s t r a i n s .
fre sh ly /
(I)
When
f r e s h l y i s o l a t e d s t r a i n s w e r e g ro w n i n l i q u i d m e d i a ,
a d e p o s i t was f o r m e d , b u t t h i s f e a t u r e was l o s t o n r e ­
p e a te d s u b c u ltu r e .
T he I n d i v i d u a l c o c c i w i t h i n t h e
c h a i n s w ere fo u n d t o o c c u r e i t h e r s i n g l y o r i n p a i r s
and w ere e i t h e r s p h e r i c a l o r s l i g h t l y
sh o w ed c o n s i d e r a b l e v a r i a t i o n i n s i z e .
e lo n g a te d and
I n s o l i d m e d ia ,
s m a l l d i s c r e t e c o l o n i e s w e r e f o r m e d w h i c h sho w ed l i t t l e
t e n d e n c y t o c o a l e s c e a s d i d t h e b o w e l s t r e p t o c o c c i an d
w h ic h grew l e s s l u x u r i a n t l y t h a n S . h a e m o l y t i c u s .
C a p s u l e f o r m a t i o n was n o t f o u n d t o o c c u r , an d o n c e
a g a i n b i l e w as f o u n d t o i n h a b i t g r o w t h i n f l u i d m e d ia
(W e isse n b a c h ).
T he B ow el S t r e p t o c o c c i .
th is
U nder t h e m ic ro sc o p e
o r g a n i s m was f o u n d t o b e a l a n c e o l a t e d l p l o c o c c u s
and w h ich o c c u r r e d i n t h i s fo rm i n b r o t h c u l t u r e s a l ­
th o u g h o c c a s i o n a l s h o r t c h a in s o f 6 t o 8 e le m e n ts w ere
re p o rte d .
T he a p p e a r a n c e o f a b r o t h c u l t u r e w as f o u n d
t o be t h a t o f u n ifo rm t u r b i d i t y
a n d g r o w t h w as n o t
i n t e r f e r e d w i t h i f b i l e w as p r e s e n t .
On t h i s f e a t u r e
W e isse n b a c h s u g g e s te d t h a t t h e s e s t r a i n s c o u ld b e
d i f f e r e n t i a t e d b y u s i n g a 10 p e r c e n t b i l e p e p t o n e
b r o t h t e s t m e d iu m .
G r o w t h o n a g a r w as f o u n d t o b e v e r y
good and c o l o n i e s w ere p ro d u c e d l a r g e r t h a n th o s e o f
S . h a e m o l y t i c u s , s o m e t i m e s 1 mm. i n d i a m e t e r a f t e r 2 4
h r s . g ro w th .
The p r e s e n c e o f b i l e i n s o l i d m e d i a a l s o
w as i n h i b i t o r y a n d t h e o r g a n i s m w as f o u n d t o g ro w w e l l
o n m e d i a l i k e M cC o n k ey s.
G e n e ra lly /
19.
G e n e r a l l y s p e a k i n g , t h e bow el s t r e p t o c o c c i w ere
by f a r th e m ost e a s y t o k eep i n c u l t u r e .
One f i n a l o u t s t a n d i n g f e a t u r e o f t h i s g r o u p was
d em o n stra te d by D ib le in
1921 when h e p r o v e d t h a t t h e * e
o rg a n is m s w ere c a p a b le o f s u r v i v i n g e x p o s u re t o a
t e m p e r a t u r e o f 6 0 °C . f o r 30 m i n u t e s , i n d i s t i n c t i o n t o
t h e o t h e r s t r e p t o c o c c i w h ich w ere k i l l e d b y s u c h a
te m p e ra tu re a f t e r f i v e m in u te s e x p o s u re .
T he s t r e p t o c o c c i i n e r t t o w a r d s b l o o d w e r e f o u n d t o
h a v e no p a r t i c u l a r m o rp h o lo g ic a l f e a t u r e s and l a s t l y
t h e a n a e r o b ic s t r e p t o c o c c i rem ain s to b e d e s c r i b e d .
THE
AMAEROBIC
STREPTOCOCCI.
The e x i s t e n c e o f s u c h o rg a n is m s w a s , a s h a s a l ­
r e a d y b e e n m e n t i o n e d , sh ow n b y V e i l l o n i n 1 8 9 3 .
quent in v e s tig a to r s , R e st, H a lle
a n d M e n g e , L e w k o w ic y , e t c . ,
&
S ubse­
G u ille m o t, K ro n ig
d e s c r i b e d o t h e r s t r a i n s and
a c o n s i d e r a b l e m o r p h o l o g i c a l v a r i a t i o n w as show n t o e x ­
i s t w ith in th e g ro u p .
C e rta in of th e s e s tr a in s v iz :
t h e M. f o e t i d u s o f V e i l l o n , t h e S . a n a e r o b i u s a n d t h e
S . p u t r i d u s i n s p e c i a l c ir c u m s ta n c e s fo rm ed g a s .
S p lit
i n t o t h o s e w h i c h f o r m e d g a s a n d t h o s e w h ic h d i d n o t , i t
w as f o u n d t h a t t h e g a s f o r m e r s s t r i c t l y
re se m b le d th e
a p p e a r a n c e o f S . p y o g e n e s an d t h a t i n t h e c a s e o f t h e
o t h e r s t h e s i z e o f t h e c o c c u s w as t h e v a r i a b l e f e a t u r e ,
a l l b e in g s m a ll.
on/
When g ro w n u n d e r a n a e r o b i c c o n d i t i o n s
20.
o n s o l i d m e d i a , c o l o n i e s w e r e p r o d u c e d w h i c h w e re
sm o o th , f l a t and s e m i - t r a n s p a r e n t w ith a n o c c a s i o n a l
re v ise d p a p illa in o ld e r c o lo n ie s .
I n poured c u l t u r e s
t h e c o l o n i e s a p p e a re d w h ite o r y e l l o w i s h g re y and w ere
f i n e l y g r a n u l a r u n d e r t h e m ic ro s c o p e - and i n f l u i d
m e d ia , u n d e r a p p r o p r ia te c o n d i t i o n s , a s l i g h t g e n e ra l
t u r b i d i t y w i t h a f l o c o u l e n t w h i t e d e p o s i t w as n o t e d . .
The o rg a n ism s o f t h i s g ro u p w ere f o u n d t o b e n o n r e s is ta n t to h e a t.
I n c o n c l u s i o n i t may b e s a i d t h a t t h e f e a t u r e s
d e s c rib e d above a r e o f a c e r t a i n v a lu e i n d i f f e r e n t i a ­
t i o n b u t o n ly a s a p r e lim in a r y s te p i n th e i d e n t i f i c a ­
tio n of a s tra in .
I t w o u ld seem t o b e a n e c e s s i t y t o
make a n o t e o f c o l o n y f o r m u n d e r t h e m i c r o s c o p e w h en a
f u r t h e r im m u n o lo g ic a l s tu d y i s in t e n d e d and t h e n e c e s ­
s i t y i s c l e a r f o r a u n ifo rm te c h n iq u e i n d e a lin g w ith
th e s e o rg a n ism s.
T he f o l l o w i n g i s a s h o r t r e s u m e o f t h e p o s i t i o n
w ith re g a rd t o B io c h e m ic a l t e s t s .
A.
AOTIOH
OH
BLOOD.
The a c t i o n o f d i f f e r e n t s t r a i n s o f s t r e p t o c o c c i i n
p r o d u c i n g c e r t a i n c h a n g e s w hen g ro w n o n f r e s h b l o o d a g a r
p la te s is
to /
a f a c t o r o f p rim a r y im p o rta n c e i n any a tte m p t
21.
to c l a s s i f y th e s e o rg a n ism s.
T hese changes a r e n o t
l i m i t e d t o s o l i d m e d i a b u t t a k e p l a c e w hen a s u s p e n s i o n
o f w ashed r e d b lo o d c o r p u s c le s a r e exposed t o t h e a c t ­
i o n o f a f i l t r a b l e s u b s t a n c e c a l l e d H a e m o l y s in f o u n d
in e a rly b ro th c u ltu re s of c e rta in s tr a in s of s tr e p to ­
c o c c i.
I t h a s b e e n show n t h a t a d e f i n i t e r e l a t i o n s h i p
e x i s t s b e t w e e n t h e r e a c t i o n s o b t a i n e d b y t h e s e tw o
m e th o d s.
H i s t o r i c a l l y , th e h a e m o ly tic pow er o f s tr e p t o c o c c i
w as f i r s t r e c o g n i s e d b y K n o o r i n 1 8 9 3 , w h en h e o b s e r v e d
e v id e n c e o f t h i s change i n th e b lo o d o f a n im a ls e x p e r i ­
m e n ta lly i n f e c t e d w ith s t r a i n s o f t h i s o rg a n ism .
F rench i n v e s t i g a t o r s ,
T hree
. ( B i s r e d k a , 1 9 0 1 ; M a rm o r e k , 1 9 0 2 ;
B r e t o n , 1 9 0 3 ) a l s o show ed t h a t h i g h l y p a t h o g e n i c s t r e p ­
to c o c c i had th is
pow er b u t t h e f i r s t c l a s s i f i c a t i o n o f
t h e s e c h a n g e s w as made b y S c h o t t m u l l e r .
I n a c l a s s i c a l w o rk p u b l i s h e d i n 1 9 0 3 , t h e l a t t e r
d iffe re n tia te d
t h e s t r e p t o c o c c i i n t o 3 m ain t y p e s
b a s i n g h i s c l a s s i f i c a t i o n on p a th o g e n ic p o w e r, s o u r c e
o f o r i g i n , m o rp h o lo g y and t h e a p p e a r a n c e o f g ro w th s
on f r e s h b lo o d a g a r p l a t e s .
as fo llo w s :-
T yp e 1 :
B r i e f l y , t h e s e t y p e s w ere
s tr e p to c o c c u s lo n g u s p a th o g e n -
s i v e - e r y s i p e l a t o s , w h ich in c lu d e d a l l h i g h l y p a th o g e n ic
s t r a i n s a n d w as c h a r a c t e r i s e d b y t h e d e v e l o p m e n t o f
c l e a r c o lo u r le s s h a lo e s around t h e c o l o n i e s ;
Type I I :
S t r e p m i t i o r s i v e v i r i d a n s ; w h ic h i n c l u d e d s t r a i n s
m a in ly d e r iv e d fro m t h e r e s p i r a t o r y o r d i g e s t i v e t r a c t s ,
of/
o f lo w p a t h o g e n i c i t y a n d c h i e f l y d i s t i n g u i s h e d b y
t h e i r te n d en cy t o p ro d u ce a g re e n d i s c o l o u r a t i o n o f
t h e b lo o d a g a r I n t h e im m e d ia te v i c i n i t y
c o lo n ie s.
o f th e
I n t h i s c a s e c e r t a i n f a l l a c i e s w ere fo u n d
t o e x i s t , and th e y w ere t h e p r e s e n c e o f n a rro w r i n g s
o f c l e a n i n g a r o u n d t h e c o l o n i e s o n a g a r o f lo w b l o o d
c o n t e n t o r w hen b l o o d s p e c i a l l y s u s c e p t i b l e t o d i s ­
i n t e g r a t i o n was u s e d i n m a k i n g t h e p l a t e s .
Type I I I
S tre p to c o c c u s m ucosus, o f r a r e r o c c u rre n c e th a n th e
f o r e g o in g , m a in ly c h a r a c t e r is e d by i t s
abundant c o l ­
o n i e s , and b y t h e w e l l - d e f i n e d c a p s u l e s e e n i n m ic r o ­
s c o p i c p r e p a r a t i o n s ev en fro m c u l t u r e s on s o l i d m e d ia .
T h i s m e th o d r e c e i v e d g e n e r a l a c c l a i m , e s p e c i a l l y
when i t w as f o u n d t o y i e l d a s e p a r a t i o n i n t o g r o u p s
w h i c h c o r r e s p o n d e d t o a d e g r e e w i t h t h a t o b t a i n e d when
t h e o r g a n i s m s w e r e e x a m in e d s e r o l o g i c a l l y .
D issa tis­
f a c t i o n w as e x p r e s s e d , h o w e v e r , a n d t h e s u b j e c t r e ­
c e iv e d f u r t h e r s tu d y .
As a r e s u l t o f t h i s
a m o n o g ra p h
w as p r o d u c e d b y B row n ( 1 9 1 5 ) i n w h i c h t h e o r i g i n a l
c l a s s i f i c a t i o n was e l a b o r a t e d a n d w h e r e i n t h e n e c e s s i t y
f o r a f i x e d an d c a r e f u l t e c h n i q u e w as s t r e s s e d .
B row n
d i f f e r e n t i a t e d 3 t y p e s a l s o w h i c h h e n am ed A, B , Y .
O f t h e s e , h i s A & B . t y p e s c o r r e s p o n d e d w i t h t h e T y pe
II
a n d T y pe I o f S c h o t t m u l l e r r e s p e c t i v e l y b u t i n h i s
Y ty p e h e l a i d s t r e s s upo n a ty p e w h ic h g a v e n e i t h e r
h a e m o ly s is n o r g r e e n p i g m e n t a t i o n when grow n on b lo o d
agar /
a g a r , a f a c t w h i c h was n o t made s u f f i c i e n t l y c l e a r b y
S c h o ttm u lle r.
E l a b o r a t i o n o f B ro w n ’ s c l a s s i f i c a t i o n
f i n a l l y y ie ld e d a d i f f e r e n t i a t i o n o f th e A ty p e I n to
tw o g r o u p s a n d a l a t e r w o r k e r s t i l l
( B r y a n t , 19 2 7 )
c la im e d t h e e x i s t e n c e o f a ty p e w h ic h g av e g re e n
o o l o u r a ti o n around i t s
b lo o d a g a r p l a t e .
c o lo n ie s in th e d e p th s o f a
W h eth er t h e s e e l a b o r a t i o n s w ere
n e c e s s a r y i s d o u b t f u l i n v i e w o f t h e r e s u l t s w h ic h
w e r e o b t a i n e d b y o t h e r s i n v e s t i g a t i n g t h e p h en o m en o n
i n f l u i d m ed ia.
U s i n g f l u i d m e d i a L y a l l ( 1 9 1 4 ) w as a b l e t o s p l i t
th e s tre p to c o c c i In to 3 groups:
(I)
t h o s e w h ic h p r o ­
duced h ae m o ly sin ;
(II)
g l o b i n and
th o s e w h ic h p ro d u c e d n o c h a n g e s i n
(iii)
t h o s e w h i c h p r o d u c e d m e th a e m o -
b lo o d , th u s c o rre sp o n d in g w ith th e c l a s s i f i c a t i o n
a r r i v e d a t b y B ro w n u s i n g s o l i d m e d i a .
C o n firm a tio n
o f L y a l l ' s v i e w s w as r e c e i v e d f r o m M is h u lo w ( 1 9 2 1 ) a n d
Cumming ( 1 9 2 7 ) .
O t h e r i n v e s t i g a t o r s w h en c o m p a r i n g
t h e tw o m e th o d s f o r d e t e r m i n i n g h a e m o l y s i s f o u n d d i s ­
c r e p a n c i e s t o e x i s t b e t w e e n th e m i n w h i c h r e s p e c t i t
i s i n t e r e s t i n g t o q u o t e c o n c l u s i o n s m ade b y Cumming
i n 1927.
He f o u n d t h a t a l l s t r e p t o c o c c i f r o m f r a n k l y
s u p p u r a t i v e l e s i o n s w e r e e q u a l l y h a e m o l y t i c o n hum an
b lo o d a g a r p l a t e s and on r a b b i t s b lo o d by e i t h e r th e
p l a t e o r t h e t u b e m e th o d o f o b s e r v a t i o n b u t t h a t a
n u m b e r o f s t r a i n s I s o l a t e d f r o m s p u tu m w e r e h a e m o l y t i c
o n ly /
24.
o n l y o n h u m an b l o o d a g a r p l a t e s .
I t w as h i s s u g g e s t i o n
t h a t t h e s e s t r a i n s s h o u ld b e term e d p s e u d o -h a e m o ly tic
and t h a t t h i s
i r r e g u l a r i t y was t h e p o s s i b l e e x p l a n a t i o n
o f some o f t h e d i s c r e p a n t r e s u l t s .
T he o b s e r v a t i o n s o f t h e s e g r o s s c h a n g e s w e r e s u p ­
p lem en ted b y a n i n v e s t i g a t i o n i n t o t h e ch em ical r e ­
a c t i o n s b r i n g i n g th e m a b o u t a s a r e s u l t o f w h i c h i t
b e c a m e a p p a r e n t t h a t many c o m p l e x a n d , w i t h i n l i m i t s ,
v a r ia b le f a c t o r s e n te re d i n t o t h e i r c a u s a tio n , th u s
a g a in s t r e s s i n g t h e need f o r a f ix e d and c a r e f u l t e c h ­
n iq u e .
C l a i m s w e r e m ade t h a t c e r t a i n s t r a i n s h a d b e e n
o b s e rv e d t o ch an g e i n h a e m o ly tic pow er fro m A t o B , and
v i c e v e r s a , b u t n o p r o o f w as a d v a n c e d , a n d t h i s c h a n g e
is
c o n s id e re d u n l i k e l y .
T h u s i t may b e s a i d t h a t i n a c l a s s i f i c a t i o n o f
s tre p to c o c c i, i t
i s i m p o r t a n t t o know t h e h a e m o l y t i c
p o w e r o f t h e s t r a i n s a n d t h a t t h i s f e a t u r e may b e d e ­
t e r m i n e d b y e i t h e r t h e p l a t e o r t h e f l u i d m e th o d b u t
th a t t h is t e s t in i t s e l f i s n o t s u ff ic ie n t to render
an id e n tific a tio n o f a s tr a in p o s sib le .
I t does a c t,
how ever, a s a p o in te r to th e v ir u le n c e o f th e s t r a i n
u n d e r o b s e r v a t i o n (M cL eo d , 1 9 2 3 ) .
B ./
25
B.
FERMENTATION
The p o s s i b i l i t y
REACTIONS.
o f d i f f e r e n t i a t i n g th e s t r e p t o ­
c o c c i b y m ean s o f t h e i r f e r m e n t a t i v e r e a c t i o n s was
firs t
su g g e ste d by H iss i n 1902.
su g ars,
E m p lo y in g v a r i o u s
g l u c o s i d e s a n d a l c o h o l s , h e show ed t h a t t h e s e
o r g a n i s m s w e re p o s s e s s e d o f w i d e f e r m e n t a t i v e a c t i v i t i e s .
H i s e x p e r i m e n t s w e r e r e p e a t e d b y M e rv y n G o rd o n i n 1903
who e m p lo y e d many d i f f e r e n t s t r a i n s a n d s u c c e e d e d i n
e s t a b l i s h i n g a form o f c l a s s i f i c a t i o n .
T he p o s i t i o n
w as c l a r i f i e d t o a c o n s i d e r a b l e e x t e n t b y a n i n v e s t i ­
g a t i o n c o n d u c t e d b y A n d rew es an d H o r d e r a s a r e s u l t
o f w h ic h th e y w ere a b l e t o i n d i c a t e s i x m ain g r o u p s
w h i c h t h e y n am ed a s f o l l o w s : - ( i )
S. m itis;
(v)
(iii)
S . pyogenes;
S . an g in o su s and
(v i)
S . e q u in sis;
(iv )
(ii)
S. s a liv a riu s;
S. fa e o a lis.
T h is g ro u p in g ,
w h ich th e y o b t a i n e d b y t h e a p p l i c a t i o n o f f e r m e n t a t i o n
t e s t s , w as f o u n d t o r e l a t e t h e f e r m e n t a t i v e p o w e r s o f
t h e o r g a n i s m t o t h e s o u r c e f r o m w h i c h i t was r e c o v e r e d .
I n a d d i t i o n t h e g ro u p s w ere n o t c l e a r l y d e f i n e d b u t
w ere fo u n d t o m erge i n t o a n o t h e r w i t h an i n t e r m e d i a t e
s e r i e s o f s t r a i n s w h ic h g a v e m o d if ie d r e a c t i o n s u n d e r
t e s t c o n d itio n s.
T h e s e r e a c t i o n s w e r e e x a m in e d a s t o
th e ir re lia b ility
and b o t h H o p k in s an d Lang w o rk in g i n
c o l l a b o r a t i o n and L y a l l i n d e p e n d e n t l y i n 1914 r e p o r t e d
f a v o u ra b ly on t h i s
w ith i t s
a sp e c t.
T h i s mode o f i n v e s t i g a t i o n ,
o r i g i n i n E n g l a n d , w as n o t p u r s u e d on t h e
C o n t i n e n t w i t h t h e sam e a v i d i t y , b u t t h e g e n e r a l o p i n i o n
expressed/
e x p r e s s e d i n F r a n c e a n d Germ any w as u n f a v o u r a b l e w i t h
reg ard to i t s d i f f e r e n t i a l v a lu e .
I n A m erica, h o w ev er,
t h e s u b j e c t a t t r a c t e d c o n s id e r a b l e a t t e n t i o n and o u t ­
s t a n d i n g a m o n g s t t h e w o r k d o n e w as t h a t o f H o lm a n i n
1916.
He b e g a n b y d i v i d i n g t h e s t r e p t o c o c c i t o b e
ex am in ed i n t o t h o s e w h ic h w ere h a e m o ly tic and t h o s e
w h ich w ere n o n - h a e m o l y t i c •
H av in g d e te r m in e d t h i s
f e a t u r e h e a p p lie d to each group th e f e rm e n ta tio n of
3 's u g a r s ’ e v e n tu a lly p ro d u c in g a t o t a l o f s ix te e n
t y p e s , e v o l v i n g a c l a s s i f i c a t i o n w h ic h becam e w id e ly
known an d u s e d .
T he v a r i o u s i n v e s t i g a t i o n s d e t a i l e d a b o v e h a d a l l
b e e n f a v o u r a b l e t o t h e t e s t s a s a m eans o f d i f f e r e n t ­
i a t i o n , b u t i n t h e m e a n tim e s t r o n g c r i t i c i s m h a d b e e n
le v e lle d
a t th e m .
I n F r a n c e an d G e rm a n y , a s a l r e a d y
q u o t e d , t h e m e th o d w as r e g a r d e d w i t h d i s f a v o u r .
B u r n e t and W e isse n b a c h (1918) s t a t e d t h a t a f t e r e x ­
c l u d i n g t h e pneum ococcus and th e e n te r o c o c c u s fro m th e
fie ld
t o b e i n v e s t i g a t e d , t h e re m a in in g fo rm s f e l l i n t o
tw o m a i n c a t e g o r i e s , h a e m o l y t i c a n d v i r i d a n s s t r a i n s ,
a c l a s s i f i c a t i o n w h ic h w as s u p p o r t e d b y i m m u n it y r e ­
a c t i o n s w h ich i s n e v e r t h e c a s e i n an y g r o u p in g o b t a i n e d
by th e fe rm e n ta tio n t e s t s .
I n G e rm a n y , M a a s s ( 1 9 1 3 )
s t a t e d t h a t t h e r e w as n o c o r r e s p o n d e n c e b e t w e e n g r o u p ­
in g s by su g ar fe rm e n ta tio n t e s t s
and t h e s o u r c e o f
t h e p a th o g e n ic im p o rta n c e o f th e o rg a n is m s .
w as/
B la k e (1 9 1 7 )
27
w as p r a c t i c a l l y o f t h e same o p i n i o n a s B u r n e t an d
W e i s s e n b a c h b u t o b s e r v e d t h a t h e w o u ld r e s e r v e t h e s e
f e r m e n t a t i o n t e s t s f o r a f u r t h e r d i f f e r e n t i a t i o n among
th e non h a e m o ly tic s t r a i n s .
S i m i l a r o b s e r v a t i o n s w ere
m ad e b y K i n s e l l a a n d S w i f t ( 1 9 1 8 ) a m H o w e l l i n t h e
sam e y e a r , who c o n t r o l l e d t h e i r i n v e s t i g a t i o n s b y com­
p le m e n t f i x a t i o n t e s t s .
A n o t h e r b l o w was s t r u c k b y
D o u g l a s , C o l e b r o o k & F l e m i n g i n t h e M .R .C . R e p o r t N o.
48 i n w h ich th e y p o i n t e d o u t t h a t n o s e r o l o g i c a l d i f ­
f e r e n c e e x i s t e d b etw e e n m a n n ite f e r m e n tin g s t r e p t o c o c c i
o f p y o g e n i c t y p e an d t h o s e w h i c h d i d n o t f e r m e n t m a n n i t e .
R itc h ie
( 1 9 0 8 ) an d A i n l e y W a lk e r ( 1 9 1 1 ) a m o n g s t
o th e rs s ta te d t h a t in t h e i r o p in io n th e fe rm e n ta tio n
r e a c t i o n s w ere n o t g iv e n c o n s t a n t l y enough t o s e r v e as
a b a s i s o f d i f f e r e n t i a t i o n a n d B u e r g e r ( 1 9 0 7 ) show ed
t h a t i t w as o n l y n e c e s s a r y t o g i v e t h e s t r e p t o c o c c i
m o re f a v o u r a b l e c o n d i t i o n s i n o r d e r t o e n a b l e t h e m t o
fe rm e n t t e s t su b sta n c e s p re v io u s ly u n a tta c k e d .
T a k in g
s e c o n d a ry s t r a i n s p ic k e d fro m s e p a r a t e c o l o n i e s o f a
s tr e p to c o o c u s T hro (1 9 1 4 ) d e m o n s tra te d t h a t t h e s e
v a r i e d i n t h e i r r e a c t i o n s f r o m t i m e t o t i m e an d
M c L a c h la n ( 1 9 2 7 ) r e p o r t e d t h a t h e w as u n a b l e t o d i f f e r ­
e n tia te
s c a r l a t i n a l s tr e p t o c o c c i fro m o t h e r h a e m o ly tic
s t r a i n s by th e s e m e th o d s.
H o lm a n ’ s c l a s s i f i c a t i o n was
c r i t i c i s e d b y D i b l e ( 1 9 2 1 ) who s t a t e d t h a t h e f o u n d
th e fo rm e r’ s fe rm e n ta tiv e ty p e s d i s t r i b u t e d e q u a lly
in /
in d iffe re n t le s io n s .
I t w i l l be se e n fro m t h e above a c c o u n t t h a t t h e r e
is
a c o n s id e ra b le d if f e r e n c e o f o p in io n as t o th e v a lu e
and s i g n i f i c a n c e o f f e r m e n t a t i v e t e s t s i n t h e c l a s s i ­
f ic a tio n of s tre p to c o c c i.
They a r e o f d o u b t f u l v a lu e
i n r e l a t i n g t h e o rg a n is m t o d i s e a s e and do n o t a p p e a r
to agree w ith th e r e s u lt s o f s e ro lo g ic a l t e s t s .
The
c o n s e n s u s o f o p i n i o n w o u ld a p p e a r t o b e i n f a v o u r o f
t h e i r u s e a s a s u b s i d i a r y m eans o f d i f f e r e n t i a t i o n ,
su p p le m e n tin g f o r e x a m p le , s e r o l o g i c a l t e s t s i f n e c e s ­
sary .
29
I M M U N O L O G I C A L .
T he f o u r t h an d l a s t m e th o d o f a t t e m p t i n g t o
c l a s s i f y t h e s t r e p t o c o c c i i s b a s e d o n seru m r e a c t i o n s .
I n t h e l a t e n i n e t e e n t h and e a r l y t w e n t i e t h c e n tu r y
b a c t e r i o l o g i s t s , h e a d e d b y M a rm o re k ( 1 8 9 5 ) a n d A r o n s o n
(1 8 9 6 ), d isc o v e re d v a rio u s p r o p e r tie s
a n im a ls w h ich h a d b e e n a r t i f i c i a l l y
v a rio u s o rg a n ism s.
i n s e r a from
in f e c te d w ith
In v e s tig a tio n in to th e se p ro p e rtie s
re v e a le d th e p re se n c e o f o p s o n in s , b a c t e r i o t r o p i n s ,
p r e c i p i t i n s , a g g l u t i n i n s , b a c t e r i o l y s i n s an d b a c t e r i c id in sj
s p e c i f i c f a c t o r s w h ic h w e r e t h e a n i m a l r e s p o n s e
t o th e in v a d in g o rg a n ism .
B a c te ria v a rie d in t h e i r
p o w e r t o p r o d u c e t h e s e s u b s t a n c e s , b u t i t w as d e t e r m i n ­
e d a t a n e a r l y d a t e t h a t t h e s t r e p t o c o c c u s was c a p a b l e
o f p r o d u c in g a s e ru m i n w h ich t h e s e im m u n o lo g ic a l s u b ­
s t a n c e s w ere p r e s e n t i n a f a i r l y h i g h d e g r e e .
T e sts
w ere d e v is e d w hereby t h e p r e s e n c e o f th e se s u b s ta n c e s
c o u ld b e a s c e r t a i n e d and e s tim a te d and o f th e s e th e
t e s t m o s t commonly u s e d was t h a t w h i c h d e a l t w i t h t h e
p h en o m en o n o f a g g l u t i n a t i o n , s u p p l e m e n t e d l a t e r w i t h
t h e f i x a t i o n o f c o m p le m e n t.
U s i n g t h e s e t e s t s , e i t h e r s i n g l y o r c o m b in e d i n
some m a n n e r many i n v e s t i g a t o r s a t t e m p t e d t o c l a s s i f y
s t r e p t o c o c c i re c o v e re d fro m a v a r i e t y o f s o u rc e s w i t h ,
i n many c a s e s , c o n f u s i n g a n d i n c o m p a t i b l e r e s u l t s .
D u rin g /
30
D u r i n g t h e i n c e p t i o n o f t h i s m e th o d o f i n v e s t i g a t i o n
th e v a l i d i t y o f a c l a s s i f ic a t io n o f s tre p to c o c c i based
o n s u g a r f e r m e n t a t i o n r e a c t i o n s w as b e i n g b i t t e r l y
f o u g h t b u t t h e c o n c e n s u s o f o p i n i o n was t h a t a c l a s s i ­
f i c a t i o n b a s e d on t h e im m u n o lo g ic a l p r o p e r t i e s o f
s t r a i n s w as m o re c e r t a i n a n d a p p r o x i m a t e d m o re c l o s e l y
t o th e g ro u p in g o b ta in e d by h a e m o ly sis th a n t h a t o b ­
ta in e d by fe rm e n ta tio n t e s t s .
T h is p la c e d th e v a lu e
o f t h e m e th o d o n t h e h i g h e s t p l a n e a s y e t a t t a i n e d a n d
t h e t r e n d o f i n v e s t i g a t i o n w as t o a s c e r t a i n f i r s t o f
a l l t h e h a e m o l y t i c p o w e r o f t h e s t r a i n i n q u e s t i o n an d
t h e n t o ex am in e i t f ro m a s e r o l o g i c a l p o i n t o f v ie w ,
w i t h , a s an a i d i f r e q u i r e d , an i n v e s t i g a t i o n i n t o i t s
su g ar fe rm e n ta tio n r e a c tio n s .
I n v ie w o f t h i s
it
w ill be c o n v e n ie n t to d e s c rib e
th e s e ro lo g ic a l p ro p e rtie s o f th e s tre p to c o c c i under
th e fo llo w in g h e a d in g s : I.
II.
STREP. HAEUOLYTICUS.
S . VTRIDANS:
( a ) MOUTH STREPTOCOOOI.
( b ) BOWEL STREPTOCOCCI.
( o ) THOSE WHICH PRODUCE NO
CHANGE IN BLOOD.
III.
I .
ANAEROBIC
STREPTOCOCCI.
S . H a e m o ly tlc u s:
T h is group c o n ta in s th e t r u e
h a e m o l y t i c s t r e p t o c o c c i a n d f o l l o w i n g M c L e o d 's s t a t e ­
m e n t/
s ta te m e n t t h a t , a lth o u g h n o t a l l h a e m o ly tic s t r e p t o ­
c o c c i w ere v i r u l e n t , few v i r u l e n t s t r e p t o c o c c i w ere
n o t h a e m o l y t i c , i t may b e t a k e n t o c o n t a i n m o s t o f t h e
h ig h ly p a th o g e n ic s t r a i n s .
T he o r g a n i s m s w i t h i n t h i s
g roup have b een proved t o g iv e r i s e to s c a r l e t f e v e r
and o t h e r a c u te i n f e c t i o n s s u c h as p u e r p e r a l f e v e r ,
e ry sip e la s e tc .
A t t e m p t s w e r e made t o r e l a t e e a c h
d ise a se to a s p e c ific s tr a i n , but such s p e c if ic ity
s t i l l d o u b tfu l.
is
S ta te m e n ts such as th o s e of B l i s s
| ( 1 9 2 0 ) a n d D o c h e z ( 1 9 2 5 ) who w e r e o f t h e o p i n i o n t h a t
' 80%
o f s c a r l a t i n a s t r e p t o c o c c i w ere o f one g r o u p , w ere
;d i s p r o v e d b y G r i f f i t h s
(1 9 2 6 , 1927) and S m ith (1927)
who c l a i m e d t h a t t h e r e w e r e s i m i l a r s e r o l o g i c a l f o r m s
o f h a e m o ly tic s t r e p t o c o c c i r e c o v e re d fro m o t h e r s o u r c e s .
M c L a c h la n a n d M a c k ie ( 1 9 2 8 ) i n a m ore r e c e n t a n a ­
l y s i s found t h a t , w h ile s t r a i n s p r e s e n tin g c e r t a i n s e r o ­
l o g i c a l c h a r a c t e r i s t i c s w e r e m o re f r e q u e n t l y a s s o c i a t e d
w ith s c a r l a t i n a th a n o th e r l e s i o n s , h a e m o ly tic s t r e p t o ­
c o c c i w i t h common s e r o l o g i c a l p r o p e r t i e s o c c u r r e d b o t h
i n s c a r l a t i n a an d i n v a r i o u s o t h e r c o n d i t i o n s .
When
i n v e s t i g a t i o n was e x t e n d e d t o e x a m i n i n g t o x i n f o r m a t i o n
f o r s p e c i f i c i t y , i t w as f o u n d b y a n u m b e r o f w o r k e r s
(R o sen o w 1 9 2 4 ; W i l l i a m s 1 9 2 5 ; B i r k h a u g 1 9 2 6 ; E a g l e s
i 1926) t h a t c u l t u r e f i l t r a t e s
of s tra in s
i s o l a t e d fro m
j e r y s i p e l a s , p u e r p e r a l f e v e r e t c . , p roduced r e a c t i o n s
s im ila r/
s i m i l a r t o t h o s e y i e l d e d by f i l t r a t e s
of s c a rla tin a
s t r e p t o c o c c i a n d M c L a c h la n ( 1 9 2 8 ) s t a t e d t h a t t h e
s c a r l a t i n a l s t r a i n s re se m b le d each o th e r m a in ly in
t h e i r a lm o st u n ifo rm pow er o f p ro d u c in g a t o x i n a c t i v e
i n h i g h d i l u t i o n s w h ereas o n ly a m in o r ity o f n o n s c a r l a t l n a l s t r a i n s pro d u ced to x in i n a s i m i l a r d e g re e
and t h a t t h e s e o r i g i n a t e d m a in ly i n t h e t h r o a t .
The o rg a n ism s i s o l a t e d fro m c a s e s o f e r y s i p e l a s
w ere c la im e d t o b e h i g h l y s p e c i f i c and B ir k h a u g (1925)
s ta te d th a t
9 1 .2 %
o f e r y s i p e l a s s t r a i n s w h ic h he
s tu d ie d c o u ld be d i s t i n g u i s h e d by a g g l u t i n a t i o n t e s t s
fro m s c a r l a t i n a l and p u e r p e r a l s t r a i n s .
I n t h i s cla im
h e w as s u p p o r t e d b y T u n n i c l i f f ( 1 9 2 0 ) a n d E a g l e s ( 1 9 2 4 ,
1926).
A g a i n s t t h i s t h e r e w as t h e d i s p r o v i n g o f a s i m i l a r
c la im w ith r e g a rd to s c a r l a t i n a l s t r a i n s and th e o b s e r ­
v a t i o n s o f S t e v e n s a n d D o c h e z ( 1 9 2 6 ) who s t a t e d t h a t
n o c l e a r d i s t i n c t i o n c o u l d b e made b e t w e e n e r y s i p e l a s
an d s c a r l a t i n a s t r e p t o c o c c i b y a g g l u t i n i n a b s o r p t i o n
te sts .
In t h e i r o p in io n th e a n tig e n ic i n d i v i d u a l i ty o f
e a c h s t r a i n was a m o re m a r k e d f e a t u r e t h a n a n y g r o u p
c h a ra c te ris tic .
A p a rt fro m t h e s e a tte m p ts t o p ro v e
s p e c i f i c i t y a t t e m p t s w e r e b e i n g made t o s p l i t t h e
e n tire /
e n t i r e s e c tio n in to g ro u p s, b u t h e re a g a in o p in io n s
w ere v a r i e d .
S m i t h ( 1 9 2 7 ) d e f i n e d tw o g r o u p s b y
a g g l u t i n a t i o n m eth o d s and d e s c r i b e d an a s s o c i a t i o n
b e tw e e n t h e s o u rc e o f e a c h s t r a i n and t h e g ro u p i n
w h i c h i t w as u l t i m a t e l y p l a c e d .
I n d i s t i n c t i o n was
t h e s t a t e m e n t o f D o u g l a s , C o l e b r o o k an d F l e m i n g i n
t h e M .R .G . R e p o r t N o . 5 7 who f o u n d t h a t 2 4 h a e m o l y t i c
s t r e p t o c o c c i f r o m w a r w oun ds w e r e i d e n t i c a l o n e x a m i n a ­
t i o n , a ls o by a g g l u t i n a t i o n m e th o d s.
S i m i l a r l y , em­
p l o y i n g t h e c o m p le m e n t f i x a t i o n t e s t , K i n s e l l a an d
S w if t (1918) c la im e d t h a t a l l th e H a e m o ly tic s t r e p t o ­
c o c c i w h i c h t h e y e x a m in e d w e r e i d e n t i c a l .
In te rm e d ia te
b e tw e e n t h e s e d i v e r g in g r e s u l t s w ere th o s e o f D ochez,
A very and L a n c e f i e l d (1 9 1 9 ) w h i l e u s i n g a g g l u t i n a t i o n
m e th o d s.
T h e y e x a m in e d 100 s t r a i n s o f h a e m o l y t i c
s t r e p t o c o c c i , m o s tly fro m t h e r e s p i r a t o r y t r a c t , and
sh o w ed t h e e x i s t e n c e o f 4 w e l l d e f i n e d i m m u n o l o g i c a l
g r o u p s i n w h ich t h e m a j o r i t y o f t h e s e s t r a i n s c o u ld b e
p la c e d .
A num ber o f u n c l a s s i f i e d s t r a i n s w ere fo u n d
t o r e m a in , and w here t h e s e s t r a i n s w ere s u f f i c i e n t l y
v i r u l e n t , i t w as f o u n d t h a t a n i m a l s w e r e p r o t e c t e d b y
t h e p r o p h y l a c t i c i n j e c t i o n o f h o m o lo g o u s s e r u m b u t n o t
b y t h e I n j e c t i o n o f a seru m b e l o n g i n g t o a n o t h e r g r o u p .
T h e p o s i t i o n , t o a l a r g e e x t e n t , was c l a r i f i e d b y
t h e w o rk o f L a n c e f i e l d i n 1 9 2 8 .
She a p p l i e d t o t h i s
g r o u p o f o r g a n i s m s t h e m e th o d o f p r e l i m i n a r y c h e m i c a l
se p a ra tio n /
s e p a r a t i o n o f a n tig e n s fo llo w e d by th e t e s t i n g o f th e
s e p a r a t e d f r a c t i o n s by t h e p r e c i p i t i n r e a c t i o n and
succeeded in d e m o n stra tin g th a t a t l e a s t 3 a n tig e n ic
co m p o n en ts e x i s t e d i n v a r i o u s s t r a i n s o f S . h a e m o ljrtic u s.
One o f t h e s e was a n u c l e o p r o t e i n w h ic h sh o w e d a
w id e r a n g e o f c r o s s r e a c t i o n s w i t h a n t i s e r a p r e p a r e d
a g a in s t r e l a t e d ty p e s , e x te n d in g in to th e
g ro u p .
h a e m o ly tic
A n o t h e r w as a p p a r e n t l y a p o l y s a c c h a r i d e i n
n a t u r e a n d w as s p e c i f i c f o r t h e s p e c i e s S . h a e m o l y t i c u s ,
b u t w as s h a r e d i n common b y a l l t h e s e r o l o g i c a l t y p e s
w ith in th a t s p e c ie s .
The t h i r d w as p r o t e i n i n n a t u r e
a n d sho w ed t y p e s p e c i f i c i t y .
A s tr u c t u r e such as t h i s
w o u ld e x p l a i n many c o n f u s i n g r e s u l t s p a r t i c u l a r l y i n
v ie w o f t h e f o llo w in g o b s e r v a t i o n s .
T odd ( 1 9 2 8 ) sh ow ed
t h a t r e c e n t l y i s o l a t e d , v i r u l e n t s t r a i n s o f S . haem o­
l y t i c u s u s u a lly gave g r a n u la r , c o h e re n t 'm a t t '
c o lo n ie s
when g ro w n o n b l o o d a g a r a n d t h a t t h e s e s t r a i n s c o u l d
l o s e much o f t h e i r v i r u l e n c e w h i l e r e t a i n i n g t h e i r
c o l o n i a l form b u t t h a t a f t e r p ro lo n g e d s u b - c u l t u r e
th e s e in n a te s t r a i n s gave r i s e to
'g l o s s y '
o r sm o o th er
v a r i a n t s w h ic h w ere p e r m a n e n tly a t t e n u a t e d .
J o in t
o b s e r v a t i o n s w e r e m ade b y L a n c e f i e l d a n d T o d d ( 1 9 2 8 )
a n d i t w as show n t h a t t h e c h a n g e f r o m t h e
'm a tt'
t h e g l o s s y t y p e w as a s s o c i a t e d w i t h t h e l o s s
ty p e s p e c ific
to
of th e
a c id e x tr a c ta b le p r o te in c o n s ti t u e n t .
T h i s w as m e n t i o n e d b e f o r e w hen d e s c r i b i n g t h e m o r p h o ­
lo g ic a l/
m o r p h o l o g i c a l f e a t u r e s o f s t r e p t o c o c c i a n d a n o t e w as
m ade t h a t t h e s e s h o u l d b e c a r e f u l l y r e c o r d e d b e f o r e
d e p a r tin g on an a n tig e n ic c l a s s i f i c a t i o n .
I t i s ob­
v i o u s t h a t t w o a n t i g e n i c a l l y d i s s i m i l a r s t r a i n s m ig f tt
b e o n e a n d t h e sam e o r i g i n a l l y a l t h o u g h o n e o f th e m
h a s d e t e r i o r a t e d and l o s t t h e ty p e s p e c i f i c f a c t o r .
In v e s tig a tio n s b e a rin g t h i s
i n m in d ,m a y f i n a l l y
e n a b le
t h e h a e m o l y t i c s t r e p t o c o c c i t o b e d i f f e r e n t i a t e d among
th e m s e lv e s , b u t a t th e p r e s e n t th e r e i s no proved
g r o u p i n g , a n d t h e y a r e r e g a r d e d b y som e a s a l a r g e
g ro u p o f h e te ro g e n o u s s t r a i n s .
S . YIRIDABS;
M o u th S t r e p t o c o c c i .
T h e se o rg a n is m s w ere fo u n d m a in ly l i v i n g a s a p r o ­
p h y t i c e x i s t e n c e i n t h e m o u th a l t h o u g h p a t h o g e n i c
p o w e r s w e r e a s c r i b e d t o th e m i n R h e u m a t i c f e v e r a n d
su b -a c u te in f e c tiv e e n d o c a r d itis .
T he t e c h n i c a l d i f ­
f i c u l t i e s o f a n t i g e n i c c l a s s i f i c a t i o n w ere l e s s i n
t h i s g ro u p t h a n i n t h e h a e m o ly tic g ro u p and t h e s e r a o f
a n i m a l s im m u n is e d a g a i n s t t h e s e o r g a n i s m s c o n t a i n e d
c o n s i d e r a b l e a m o u n ts o f t h e o r d i n a r y a n t i b a c t e r i a l
b o d ie s .
I n c o n tr a d is tin c tio n to th e r e s u l t s o b ta in e d in
t h e S . h a e m o l y t i c u s g r o u p , i t w as t h e e x p e r i e n c e o f
many i n v e s t i g a t o r s t h a t t h e m em b ers o f t h i s
show ed/
group
s ho w ed c o n s i d e r a b l e h e t e r o g e n e i t y .
tio n te s ts
U sin g a g g l u t i n a ­
( K l e g l e r (1 9 1 5 ) fo u n d t h a t s t r a i n s w ere t o
a l a r g e e x t e n t i n d i v i d u a l and d i d n o t fo rm g r o u p s , an
o p i n i o n w h i c h w as c o n f i r m e d b y b o t h G o rd o n ( 1 9 2 2 ) an d
N o rto n (1923) u s in g a b s o r p t i o n a g g l u t i n a t i o n t e s t s .
K i n s e l l a and S w if t (1917) u s i n g t h e c o m p le m e n t- f ix a tio n
t e s t w ere a l s o o f th e o p in io n t h a t t h e g ro u p c o n s is t e d
o f a l a r g e num ber o f h e te r o g e n e o u s s t r a i n s b u t th o u g h t
t h a t th e y w ere j u s t i f i e d
i n d i v i d i n g th em i n t o 2 l a r g e
g ro u p s , t h e r i g h t and l e f t hand groups a s th e y ap p eared
on t h e i r t a b l e s .
T hese i n v e s t i g a t o r s a t a l a t e r d a te
c la im e d t h a t a r e l a t i o n s h i p e x i s t e d b e tw e e n th e haem oly tic
s t r e p t o c o c c i and t h e i r l e f t h a n d g r o u p , and i n
1 9 2 5 , H i t c h c o c k , who was o f t h e o p i n i o n t h a t t h e r e ­
l a t i o n b e tw e e n g ro u p s o f s tr e p t o c o c c i depended upon
t h e p r o t e i n o r p r o t e i n l i p o i d f r a c t i o n , c o n firm e d t h i s
a n d f u r t h e r sh o w ed t h a t t h e r i g h t h a n d g r o u p w as a p p a r ­
e n tly r e l a t e d to th e pneunococous.
L a n c e f i e l d (1925)
show ed t h a t s e r a p r e p a r e d a g a i n s t t h e p r o t e i n f r a c t i o n
p r e c ip ita te d th e p ro te in s d e riv e d f ro * th e o th e r g reen
s t r e p t o c o c c i , h a e m o ly tic s t r e p t o c o c c i , p n eum ococci and
to
a c e r t a i n e x te n t s ta p h y lo c o c c i b u t n o t B • c o l i o r
C. d ip h th e ria s.
tra te d
U t i l i s i n g a b s o r p t i o n t e s t s s h e dem ons­
t h a t th e p r o t e i n f r a c t i o n o f th e n o n -h a e m o ly tic
s t r e p t o c o c c i c o n s i s t e d o f 3 e l e m e n t s , o n e o f w h i c h w as
common t o a l l s u c h o r g a n i s m s a n d p e c u l i a r t o t h e m ; a
second/
s e c o n d w h i c h was a l s o f o u n d i n h a e m o l y t i c s t r e p t o c o c c i
a n d a t h i r d w h i c h w as p r e s e n t i n a l l s t r e p t o c o c c i an d
a ls o in s ta p h y lo c o c c i.
T h e r e w as some e v i d e n c e t o show
th a t th e p r o te in o f th e in d iv id u a l s tr a in s d if f e r e d
s lig h tly
an d t h e p r e c i s e r e l a t i o n t o t h e p n e u m o c o c c a l
p r o t e i n was u n d e t e r m i n e d .
in
T he n o n p r o t e i n s u b s t a n c e
e a c h g r o u p w as c o n s i d e r e d t o b e a p o l y s a c c h a r i d e
a n d w as s t r i c t l y
s p e c i f i c a lth o u g h i t
c o u ld n o t p r o -
d u o e a n t i b o d y w hen d i s s o c i a t e d f r o m t h e o t h e r c o n s t i t u ­
e n ts o f th e b a o te riu m .
I t w as o n l y when t h e w h o le
b a c t e r i u m w as i n j e c t e d t h a t a n t i b o d i e s w e r e p r o d u c e d
w h ic h r e a c t e d w ith t h e c a r b o h y d r a te t o p ro d u c e a t y p i c a l
p r e c i p i t a t e as i n th e c a s e o f th e pneum ococcus.
S era
p r o d u c e d a g a i n s t w h o le b a c t e r i a , c o n t a i n e d a p r e d o m i n ­
a n t am ount o f s p e c i f i c
a n t i c a r b o h y d r a t e s u b s ta n c e and
a v a r y i n g am ou nt o f a n t i p r o t e i n s u b s t a n c e w h i c h g a v e
ris e
to
t h e o r o s s r e a c t i o n s w i t h m em hers o f t h e o t h e r
g ro u p s.
I n c o n c l u s i o n i t may b e s a i d t h a t ,
a lth o u g h th e r e
i s som e r e l a t i o n s h i p among t h e o r g a n i s m s i n t h e g r o u p ,
i n d i v i d u a l i t y i s a m arked f e a t u r e .
(b)
The Bow el S t r e p t o c o c c i >
T h e s e o r g a n i s m s , a s w as sho w n b y D i b l e ( 1 9 2 1 ) ,
h a v e d e f i n i t e m o r p h o lo g ic a l, c u l t u r a l and b io c h e m ic a l
f e a t u r e s a s s o c i a t e d w i t h a v e r y lo w v i r u l e n c e a n d a
te n d e n c y t o
le a d a s a p ro p h y tic e x is te n o e .
F ro m a s e r o l o g i c a l p o i n t o f v i e w B a g g e r ( 1 9 2 6 )
fo u n d /
fo u n d t h a t a tte m p ts a t a g g l u t i n a t i o n w ere u n f r u i t f u l
a n d t h a t a b s o r p t i o n a g g l u t i n a t i o n e x p e r i m e n t s w e re
e q u a l l y v a l u e l e s s i n a t t e m p t i n g t o c l a s s i f y t h e m em bers
o f th is g ro u p .
group i s
THE
T h e se m eth o d s a r e u n n e c e s s a r y a s t h e
e a s ily re c o g n ise d .
ANAEROBIC
STREPTOCOCCI.
P r e v o t i n 1924 w orked o u t t h e a g g l u t i n a t i o n r e ­
a c t i o n s o f t h e s e o rg a n ism s and a r r i v e d a t t h e c o n c lu s io n
th a t,
s o f a r a s we know i t s
m em bers, t h e i n d i v i d u a l
s t r a i n s w e r e d i s t i n c t b u t t h a t some r e l a t i o n s h i p t o
e a c h o t h e r was i n e x i s t e n o e .
C o m p a ra tiv e ly l i t t l e
is
known o f t h i s g r o u p a s t h e i r r o l e i n t h e c a u s a t i o n o f
d i s e a s e i n t h e hum an s u b j e c t i s
a lim ite d one.
i s e d , t h e a n t i g e n i c p i c t u r e may b e p u t :
I.
Sum m ar­
A n u c le o -
p r o t e i n a n t i g e n w h ic h i s w id e ly d i s t r i b u t e d y i e l d i n g
n o m ean s o f s e r o l o g i c a l i d e n t i f i c a t i o n ;
II.
V a rio u s
p o l y s a c c h a r i d e a n t i g e n s w h i c h m a rk o f f t h e S . h a e m o l y t i c u s g r o u p a s a w h o le fro m S . V i r i d a n s ;
I I I . C e rt­
a i n p r o t e i n a n t i g e n s w h ich d i f f e r e n t i a t e v a r i o u s s e r o ­
l o g ic a l ty p e s w ith in th e s p e c ie s S . h a e m o ly tic u s.
By s e r o l o g i c a l m e th o d s i t
I s p o s s ib le to d e te rm in e
t h e r e l a t i o n s h i p o f one s t r a i n o f c o c c u s t o a n o t h e r
and i t s
p la c e i n th e group g e n e r a lly b u t o th e r c r i t e r i a
m u st b e e m p lo y e d .
u res/
In a c la s s if ic a tio n , c e rta in f e a t­
f e a t u r e s o f t h e o rg a n ism m ust b e known.
T hese a r e ,
m o r p h o lo g ic a l and c u l t u r a l a p p e a r a n c e s , a c t i o n on
b lo o d and s e r o l o g i c a l r e a c t i o n s w i t h , on o c c a s i o n ,
p a r t i c u l a r l y i n th e n o n -h a e m o ly tic g ro u p o f s t r e p t o ­
c o c c i, th e su g ar fe rm e n ta tio n re a c tio n s .
That i s , a l l
m e t h o d s t o h a n d may h a v e t o b e u s e d i n a c o m p l e t e
c la s sific a tio n .
THE
OASES
OF
FORMIHG
THE
THE
BASIS
INVESTIGATION.
T h e c o m p l e t e I n v e s t i g a t i o n d e a l t w i t h 132 p a t i e n t s
o f b o th s e x e s .
T h e se p a t i e n t s ra n g e d fro m one t o
seven­
t e e n y e a r s o f age and w ere a l l s u f f e r i n g fro m n o n p u lm o n a ry t u b e r c u l o s i s .
T h a t no d o u b t s h o u ld e x i s t
r e g a r d in g th e tu b e r c u lo u s n a t u r e o f th e p rim a ry l e s i o n
b a c t e r i o l o g i c a l p r o o f w as o b t a i n e d w h e r e v e r p o s s i b l e .
T u b e r c l e b a c i l l i w ere c u l t u r e d fro m 81 p a t i e n t s and
i n t h e r e m a i n i n g 5 1 i n w h i c h t h e s p e c i f i c o r g a n i s m was
n o t r e c o v e r e d , t h e c l i n i c a l a n d , i n some c a s e s , r a d i o ­
l o g i c a l d a t a w e re c o n s i d e r e d a d e q u a t e .
A ll d o u b tfu l
c a s e s w ere e x c lu d e d .
When t h e c a s e s w e r e d i v i d e d i n t o s e x e s an d c l a s s i ­
f i e d a s s i m p l e 5 y e a r a g e g r o u p s i t w as s e e n t h a t t h e
d i s t r i b u t i o n o v er th e f i r s t
15 y e a r s o f l i f e w as g o o d
and t h a t t h e s e x e s w ere e q u a l l y r e p r e s e n t e d .
TABLE
Age G r o u p .
I .
H a le .
F em a le .
0 - 5
y rs.
14
19
5 - 1 0
y rs.
34
26
10 - 15 y r s .
17
17
1
4
66
66
15 y r s . +
T o ta l
T h i s l a s t f e a t u r e was p u r e l y f o r t u i t o u s
s e le c tio n /
a s no
41.
s e l e c t i o n o f m a t e r i a l was m a d e .
I t w ill a ls o be seen
fro m th e t a b l e t h a t th e g r e a t e s t num ber o f c a s e s o c c u rs
i n t h e 5 - 1 0 y e a r a g e g r o u p a f e a t u r e w h ic h may b e e x ­
p l a i n e d w h en i t
i s r e m e m b e re d t h a t t h e a g e o f g r e a t e s t
i n c i d e n c e o f m a jo r n o n -p u lm o n a ry l e s i o n s l i e s on t h e
young s id e o f t h i s g r o u p , w h ic h , by th e tim e s in u s
fo rm a tio n o c c u rre d , g e n e ra lly brought th e p a tie n ts
w ith in th i s l a t e r group.
In o rd e r to f a c i l i t a t e
c la s s ifie d
s ta tis tic s
t h e c a s e s w ere
i n groups a c c o rd in g to th e s i t e
o f th e
p rim a ry l e s i o n .
T hese groups w e re :I.
TUBERCULOSIS OF THE VERTEBRAL COLUMN:
in c lu d in g
a l l c a se s of d is e a s e in v o lv in g th e v e r te b r a e ,
t h e sacru m and t h e s a c r o - i l i a c
II.
jo in ts.
TUBERCULOSIS OF THE H IP JO IN T S:
in c lu d in g bone
a n d s o f t t i s s u e l e s i o n s i n v o l v i n g t h e j o i n t an d
th o se bone le s io n s o f th e p e lv ic g i r d l e , ex ­
c lu d in g th e sacru m and th e s a c r o - i l i a o
III.
TUBERCULOSIS OF THE KNEE JO IN T S:
in c lu d in g s o ft
t i s s u e and bone l e s i o n s in v o lv in g th e
IV .
TUBERCULOSIS OF ANKLE JO IN T S:
jo in ts.
jo in t.
in c lu d in g s o ft
t i s s u e a n d b o n e l e s i o n s i n v o l v i n g t h e j o i n t an d
le s io n s o f th e o s - o a lc is .
V,
TUBERCULOSIS OF LONG BONES:
in c liv lin g le s io n s
o f a l l lo n g b o n e s i n s o f a r as th e y d i d n o t i n ­
v o lv e a j o i n t ,
V I ./
V I.
TUBERCULOUS DACTYLITIS:
in c lu d in g bone le s io n s
o f th e c a r p u s > t a r s u s , m e ta c a rp u s, m e ta ta rs u s
and p h a la n g e s b u t e x c lu d in g l e s i o n s o f t h e o s c a lc is .
V II.
TUBERCULOSIS OF GLANDS AND OTHER SOFT TISSUES:
in c lu d in g a l l g la n d u la r le s io n s ex cep t m e se n te ric
and r e t r o p e r i t o n e a l and a l l s o f t t i s s u e l e s i o n s
n o t a r i s i n g f r o m j o i n t c a p s u l e s , an d
V I I I . MISCELLANEOUS;
a h e te ro g e n e o u s c o l l e c t i o n i n ­
c lu d in g l e s i o n s o f r i b s , m a x illa , m a n d ib le ,
m e s e n te r ic and r e t r o - p e r i t o n e a l g la n d s and o t h e r
s tr u c tu r e s n o t in c lu d e d In th e f i r s t seven g ro u p s.
T he n u m b e r o f c a s e s i n e a c h o f t h e s e g r o u p s i s
seen
i n T a b le I I .
T u b e r c u l o s i s o f V e r t e b r a l C o lu m n .
I.
H ip J o i n t 3 .
I I .
III.
•
>
M
V.
V I.
V II.
V III.
32.
25.
Knee
*
8.
A n k le
*
9.
D a c ty litis
11.
Long B o n e s .
15.
G la n d s and S o f t T i s s u e .
20.
M is c e lla n e o u s .
12.
E x a m p le s o f d i s e a s e i n t h e V e r t e b r a l C o lu m n a n d
H ip j o i n t s p r e p o n d e ra te b e c a u s e a b s c e s s e s i n r e l a t i o n
t o th e m w e r e common i n t h e h o s p i t a l d u r i n g t h e i n v e s t i ­
g a tio n .
common/
G la n d u la r and s o f t t i s s u e
l e s i o n s w ere a ls o
43.
common b u t o n l y a r e p r e s e n t a t i v e n u m b e r w e r e t a k e n .
A b s c e s s e s i n r e l a t i o n t o t h e k n e e and a n k le j o i n t s w ere
r a r e w h ich a c c o u n t s f o r t h e i r p o o r r e p r e s e n t a t i o n i n
th e s e r ie s .
In o rd e r to o b v ia te w r itte n
case h i s t o r i e s and to
o b t a i n p e r t i n e n t d a t a fro m th e c a s e s u n d e r o b s e r v a tio n
t h e i r v a r io u s f e a t u r e s w ere ta b u la te d u n d e r th e f o llo w ­
in g h e a d in g s .
I.
AGE:
T h i s w as d i v i d e d i n t o 4 g r o u p s , v i z .
0 - 5
y ears.
5 - 1 0
y ears.
10 - 15
y e a r s an d 15 y e a r s +
II.
III.
SEX.
FAMILY HISTORY o f T u b e r c u l o s i s w h e t h e r p o s i t i v e
o r n e g a tiv e .
IV .
P r e s e n c e o r a b s e n c e o f b a c t e r i o l o g i c a l PROOF o f
t u b e r c u l o s i s and w here p o s s i b l e t h e ty p e o f
b a c illu s is o la te d .
V.
V I.
P r e s e n c e o r a b s e n c e o f SINUS f o r m a t i o n .
T h e ACTIVITY o f t h e p r i m a r y t u b e r c u l o u s l e s i o n .
No e m p h a s i s w as l a i d u p o n t h e r e s u l t o f t h e M a n to u x
t e s t a s t h i s w as p o s i t i v e i n e v e r y c a s e .
T he f i r s t f i v e f a c t o r s a r e s e l f e x p l a n a t o r y .
T he
s i x t h an d l a s t w as e s t i m a t e d f r o m t h e h i s t o r y , c l i n i c a l
and r a d i o l o g i c a l f e a t u r e s p r e s e n te d by each c a s e u n d e r
o b s e r v a tio n up t o t h e tim e o f s in u s f o r m a tio n .
In
som e o a s e s t h i s o b s e r v a t i o n p e r i o d e x t e n d e d o v e r o n e
y ear/
year.
a c tiv ity
P u r e l y a r b i t r a r y d i v i s i o n s w e r e m ade a n d t h e
o f e a c h p r i m a r y l e s i o n w as d e s c r i b e d a s e i t h e r
ACUTE, SUB-ACUTE OR CHRONIC.
U tilis in g th e se f a c to r s
t h e T a b le s w ere p r e p a r e d and a r e in c lu d e d a s an
A p p en d ix f o r r e f e r e n c e .
D e a lin g o n ly w ith th e a c t i v i t y
o f t h e p rim a ry
t u b e r c u l o s i s l e s i o n i t was f o u n d t h a t i n 132 p a t i e n t s ,
t h i s f e a t u r e w as c l a s s i f i e d a s ACUTE i n 4 6 , SUB-ACUTE
i n 5 1 a n d CHRONIC i n 3 5 .
c la s sifie d
T h a t i s , p rim a ry l e s i o n s
a s a c u t e an d s u b - a c u t e s e e m e d t o f o r m m ore
a b sc e sse s th a n th o se c l a s s i f i e d
a s c h r o n i c w h ich i s
in acco rd an ce w ith e x p e c ta tio n .
When c o m p a r a t i v e f i g u r e s f o r e a c h s e x w e r e t a k e n
i t w as s e e n t h a t t h e y a p p r o x i m a t e d c l o s e l y e x c e p t i n
th e le s io n s c l a s s i f ie d
a m a jo rity .
a s 's u b - a c u t e ' w here f e m a le s had
T h i s m a j o r i t y w as b y v i r t u e o f t h e p r e ­
p o n d e ra n c e o f fe m a le s o f t t i s s u e l e s i o n s o v e r m ale i n
w h i c h f o r m o f t u b e r c u l o s i s t h e a c t i v i t y w as m o s t commonly
su b -a c u te .
TABLE
A cu te
Age
G ro u p
IV .
-a c u te
M.
F.
12
4
3
12
10
9
5
6
4
5
6
6
-
1
1
1
-
2
24
22
23
28
19
16
M.
F.
M.
0 - 5
4
4
6
5 -10
13
11
10 - 1 5
7
15 +
. T o ta l
F.
C h ro n ic
T a b l e IV sh o w s t h e s e g r o s s f i g u r e s d i v i d e d i n t o
a g e g r o u p s when i t b e c o m e s a p p a r e n t t h a t t h e a c t i v i t y
o f t h e p rim a ry l e s i o n v a r i e s i n e a c h g ro u p .
F ro m t h i s
t h e p e r c e n ta g e o f p a t i e n t s w ith a c u t e , s u b - a c u t e and
c h ro n ic /
c h r o n i c d i s e a s e w e r e c a l c u l a t e d w i t h r e s u l t s sho w n i n
T a b le V.
TABLE
Age
G ro u p
1-5
A c u te
V.
S u b -a c u te
%
C h ro n ic
%
%
y rs•
2 4 .2
5 4 .5
2 1 .3
5 -1 0 y r s .
4 0 .0
3 6 .6
2 3 .4
LO-15 y r s .
3 8 .2
2 6 .5
3 5 .3
15 y r s . +
2 0 .0
4 0 .0
4 0 .0
I n v ie w o f t h e s m a l l n u m b e rs o f p a t i e n t s o v e r 15
y e a r s o f a g e i t w as d e c i d e d t o n e g l e c t t h e i r r e s u l t s
in a g en eral c o n s id e ra tio n .
Of t h e r e m a in d e r, a c u te
p r im a r y l e s i o n s w ere a t t h e i r lo w e s t b e tw e e n 0 -5 y e a r s
o f a g e , r e a c h i n g a maximum b e t w e e n 5 - 1 0 y e a r s o f a g e
and d e c l i n i n g v e r y s l i g h t l y b e tw e e n 10-15 y e a r s o f a g e .
T u b e r c u l o s i s g r a d e d a s s u b - a c u t e w as a t i t s
maximum
i n t h e y o u n g e st ag e g ro u p and d e o lin e d s t e a d i l y w h ereas
c h r o n ic p rim a ry d i s e a s e in c r e a s e d i n in c id e n c e as th e
p a t i e n t s grew o l d e r .
T hese f i g u r e s r e l a t e o n ly t o th e
s e r i e s u n d e r o b s e r v a t i o n b u t n o s u r p r i s i n g f e a t u r e was
p re se n te d .
N o r m a l l y , i t w as e x p e c t e d t h a t a s a g e a d ­
v a n c e d t h e p r i m a r y t u b e r c u l o u s l e s i o n w o u ld d e c r e a s e
i n a c u i t y an d s u c h w as t h e c a s e w i t h t h e e x c e p t i o n o f
t h e p h e n o m e n a l l y lo w f i g u r e f o r d i s e a s e o f a n a c u t e
c h a ra c te r in th e f i r s t f iv e years of l i f e .
Even/
47.
Even t h i s
e x c e p t i o n was c a p a b l e of* e x p l a n a t i o n
w h en t h e s i t e s
a tta c k e d by tu b e r c u lo s is in th e d i f ­
f e r e n t a g e g r o u p s was c o n s i d e r e d .
T h u s , i t was f o u n d
t h a t l e s i o n s o f lo n g b o n e s , o f g la n d s and s o f t t i s s u e
and d a c t y l i t i s
of life ,
o c c u rre d m a in ly i n th e f i r s t t e n y e a r s
in c o n t r a d i s t i n c t i o n t o a n k le j o i n t le s io n s
w h i c h o c c u r r e d m a i n l y b e t w e e n 10 a n d 15 y e a r s o f a g e .
L e s i o n s o f t h e k n e e j o i n t s w ere s c a t t e r e d b e tw e e n 0
a n d 15 y e a r s o f a g e w i t h a s l i g h t i n c r e a s e i n f r e ­
q u e n c y b e t w e e n 5 an d 15 y e a r s o f a g e an d l e s i o n s o f
t h e v e r t e b r a e an d m i s c e l l a n e o u s p a r t s w e r e m a i n l y f o u n d
b e t w e e n 5 an d 10 y e a r s o f a g e .
L e sio n s o f th e h ip
j o i n t s w ere g r e a t e s t b e tw e e n 5 - 1 0
years o f age, but
t h e r e w e r e many s u f f e r e r s b e t w e e n 10 an d 15 y e a r s o f
age.
T h i s d i s t r i b u t i o n w as g r a p h e d ( s e e g r a p h ) a n d
a n a t t e m p t made t o i n d i c a t e t h e r e l a t i v e p r o p o r t i o n o f
a c u t e , s u b - a c u t e , and c h r o n ic l e s i o n s f o rm in g e a c h
to ta l.
_
*
Site Sj- t i s s u e
O-Syr?
a g e
-
5 -lO y «
dK oups
•
.0 -1 5 -y p
y
lify rs
4 —.
J oints
Jo/NTS.
D n c 7 y i_ ,r i5
ty g C E jijin E tijs
VERTICAL 3 0 ° * * E.
E Q 0 A |_ 5
ACrrsJi-r/ * f
Sh a o c d t h u s
f\T
EA CH
F rom t h e g r a p h i t i s c l e a r l y s e e n t h a t t u b e r c u ­
lo sis
o f t h e a n k l e j o i n t s was m a i n l y a c u t e i n c h a r a c t e r
a n d w as f o l l o w e d c l o s e l y i n t h i s r e s p e c t b y l e s i o n s o f
th e h ip
j o i n t s an d d a c t y l i t i s .
I n th e knee j o i n t s and
l o n g b o n e s a good b a l a n c e b e tw e e n a c u t e and s u b - a c u t e
p rim a ry d is e a s e o c c u rre d w ith c h ro n ic d is e a s e in th e
m in o rity .
W ith g l a n d u l a r and s o f t t i s s u e t u b e r c u l o s i s
t h e p r e d o m i n a t i n g a c t i v i t y was s u b - a c u t e w h i c h d e g r e e
o f a c t i v i t y was a l s o p r e s e n t , a l t h o u g h o v e r s h a d o w e d
by a c u te d is e a s e , in d a c t y l i t i s
a n d l o n g b o n e s an d t o
a l e s s e r d eg ree in th e h ip j o i n t s .
T u b e rc u lo sis o f
s u b - a c u t e an d c h r o n i c t y p e p r e d o m i n a t e d i n d i s e a s e
a f f e c t i n g t h e v e r t e b r a e an d m i s c e l l a n e o u s p a r t s w i t h ,
i n th e case o f v e r te b r a l l e s i o n s , a c u rio u s s p a te o f
a c u t e d i s e a s e b e t w e e n 5 an d 10 y e a r s o f a g e .
I t was
t h i s te n d e n c y f o r t u b e r c u l o s i s a f f e c t i n g d i f f e r e n t
a r e a s t o d o so m a in ly w i t h i n s e t ag e g ro u p s and th e
f a c t t h a t t h e a c t i v i t y o f t h e d i s e a s e v a r i e d so m ark­
e d l y f o r e a c h s i t e w h ic h r e s t a t e d i n t h e c u r i o u s p e r ­
c e n t a g e s o b t a i n e d w hen t h e g e n e r a l f i g u r e s f o r t h e
a c tiv ity
o f t h e p r i m a r y l e s i o n s i n a g e g r o u p s w as t a k e n .
G e n e r a l c o n c l u s i o n s w e r e d r a w n frcofa t h e s e f a c t s
r e g a r d i n g t h e a c t i v i t y o f p r im a r y l e s i o n s w h ic h g iv e
ris e
to ab scess fo rm a tio n .
I t w o u ld a p p e a r t h a t i t
r e q u i r e s a n a c u t e p r i m a r y f o c u s i n t h e m a in t o g i v e
r i s e t o a b sc e ss fo rm a tio n in r e l a t i o n to h ip j o i n t s ,
a n k l e j o i n t s an d k n e e j o i n t s a l t h o u g h i n t h e s e s i t e s
su b -a c u te /
s u b - a c u t e o r c h r o n i c d i s e a s e may o r i g i n a t e a s i m i l a r
p ro cess.
On t h e o t h e r h a n d when t u b e r c u l o s i s o c c u r s
on t h e h a n d s o r f e e t
( D a c t y l i t i s ) , i n th e lo n g b o n e s ,
o r in s o f t tis s u e s it e s g e n e ra lly , a l l degrees of a c ti c i t y may g i v e r i s e t o a b s c e s s f o r m a t i o n a l t h o u g h t h e
g r e a t e s t num ber a r i s e fro m d i s e a s e c l a s s i f i e d
o r su b -a c u te .
as a c u te
A t t h e o t h e r e n d o f t h e s c a l e come
l e s i o n s o f t h e v e r t e b r a l c o lu m n a n d m i s c e l l a n e o u s p a r t s
w h e r e a b s c e s s f o r m a t i o n may o c c u r f r o m t u b e r c u l o s i s o f
a l l g r a d e s o f a c t i v i t y b u t w here l e s i o n s c l a s s i f i e d
as
s u b - a c u t e an d c h r o n i c h a v e a g r e a t e r t e n d e n c y t o d o
s o t h a n i n any o t h e r a r e a .
T he e f f e c t o f s e x o n a l l f a c t o r s w as c o n s i d e r e d
a n d i t w as f o u n d t h a t t h e a c t i v i t y o f t h e t u b e r c u l o s i s
i n a g e g r o u p s w as c o m p a r a b l e e x c e p t f o r t h e h i g h i n ­
c id e n c e o f s u b -a c u te d is e a s e i n fe m a le s u n d er 5 y e a rs
o f a g e an d t h e h i g h i n c i d e n c e o f c h r o n i c d i s e a s e i n
m a l e s b e t w e e n 5 a n d 10 y e a r s o f a g e .
I n th e fe m a le
u n d er 5 y e a rs o f age s u b -a c u te d is e a s e o ccu rred i n th e
h ip
j o i n t s , lo n g b o n e s , g la n d s and s o f t t i s s u e and
d a c ty litis
i n g r e a t e r num bers t h a n i n m a l e s .
S im ila rly
t h e r e w as m o re d i s e a s e o f a c h r o n i c n a t u r e a m o n g s t
m a le s b etw een 5 - 1 0
y e a r s o f age w ith l e s i o n s o f th e
v e r t e b r a e and m is c e lla n e o u s p a r t s t h a n am ongst f e m a l e s .
T a k i n g e a c h r e g i o n s e p a r a t e l y i t w as f o u n d t h a t
m o re f e m a l e s t h a n m a l e s w e r e s u f f e r i n g f r o m t u b e r c u l o s i s
o f t h e v e r t e b r a l c o lu m n u n d e r 5 y e a r s o f a g e a f e a t u r e
w h ic h /
w h i c h w as r e v e r s e d w i t h i n t h e n e x t 5 y e a r s when t h e
f e m a l e s a l s o h a d l e s i o n s o f a m o re a c u t e c h a r a c t e r a n d
t h a t , b e t w e e n 10 a n d 15 y e a r s o f a g e , t h e l e s i o n s w e r e
c lo se ly s im ila r in a c tiv ity .
I n th e h ip jo in ts th e re
w as a t e n d e n c y f o r t h e p r i m a r y l e s i o n t o b e m o re a c u t e
i n m a le s th a n i n f e m a le s a t a l l a g e s b u t m ost m ark e d ly
b e t w e e n 5 an d 10 y e a r s o f a g e .
No d i s t i n g u i s h i n g
f e a t u r e was n o t e d b e t w e e n t h e s e x e s i n t h e a c t i v i t y
w h en t h e d i s e a s e o c c u r r e d i n t h e k n e e an d a n k l e j o i n t s ,
b u t tu b e rc u lo u s d a c t y l i t i s
a f f e c t e d m o re g i r l s t h a n
b o y s a t a y o u n g e r a g e a n d t h e l e s i o n i n t h e m a l e w as
o f a m o re a c u t e c h a r a c t e r .
The n e x t g ro u p , t u b e r c u ­
l o s i s o f t h e l o n g b o n e s , sho w ed m o re m a l e s t h a n f e m a l e s
w i t h a m o re a c u t e l e s i o n i n t h e f o r m e r , a s e r i e s o f
f a c t s w h i c h w as c o m p l e t e l y r e v e r s e d when t h e d i s e a s e
a t t a c k e d th e g la n d s and s o f t t i s s u e s .
T he a c t i v i t y
o f th e p rim a ry fo c u s a s i t o c c u rre d i n m is c e lla n e o u s
l e s i o n s was d i s r e g a r d e d a s t h e l e s i o n s w e r e b a r e l y
c o m p a ra b le .
F ro m t h e a b o v e i t w as I m p o s s i b l e t o g e n e r ­
a l i s e re g a rd in g th e e f f e c t o f sex upon in c id e n c e , s i t e
or a c tiv ity
o f th e p rim a ry l e s i o n by v i r t u e o f th e
s m a ll num ber o f c a s e s .
T he f o r m a t i o n o f s i n u s e s was t h e n c o n s i d e r e d .
I t was f o u n d t h a t a b s c e s s f o r m a t i o n d i d n o t i n e v i t a b l y
l e a d t o s i n u s f o r m a t i o n a l t h o u g h i n 113 i n s t a n c e s
i t d id .
(86$)
T h is t o t a l c o m p ris e d 56 m a le s and 57 f e m a le s
w h i c h m e a n t t h a t 10 m a le a n d 9 f e m a l e c h i l d r e n h a d
abscesses/
51.
a b s c e s s e s w h i c h h e a l e d w i t h o u t s i n u s f o r m a t i o n an d
t h e f o l l o w i n g t a b l e show s t h e n u m b e r and p e r c e n t a g e
o f c a s e s i n e a c h a r e a i n w h ich t h i s to o k p l a c e .
TABLE
V I.
I . V e rte b ra e .
8
••
32
25%
I I . L ong b o n e s .
3
••
15
20%
4 : 25
16 %
I I I . H ip J o i n t s .
I V . K n ee j o i n t s .
B . A n k le J o i n t s .
V I. M isc e lla n e o u s l e s i o n s .
V I I . G la n d a n d S o f t T i s s u e .
V III. D a c ty litis
T o ta l
1
••
8
1 2 .5 %
1
••
9
1 1 .1 %
1
••
12
Q .5% o
1 •• 20
5 .0 %
0 •• 11
0%
19 : 1 5 2
Of t h e s e 19 c a s e s 3 w e r e c l a s s i f i e d
14 A p p r o x .
as h a v in g
a c u t e t u b e r c u l o u s p r o c e s s e s , 4 s u b - a c u t e a n d 12 c h r o n i c .
T h e a c u t e l e s i o n s w h i c h d i d n o t f o r m s i n u s e s w e r e com­
p o s e d o f tw o c a s e s w h e r e d e a t h o c c u r r e d a s h o r t t i m e
a f t e r t h e o n s e t o f t h e d i s e a s e and o n ly one c a s e w h ich
r a n th ro u g h o u t i t s
c o u r s e an d e v e n t u a l l y h e a l e d .
The
l e s i o n s when d e a t h o c c u r r e d w e r e s i t u a t e d i n t h e l o n g
b o n e s an d e x p e r i e n c e o f i n f e c t i o n o f t h i s s i t e
ten d ed
to th e b e l i e f t h a t , had th e c a s e s liv e d lo n g e r , s in u s
f o r m a t i o n w o u ld h a v e o c c u r r e d i n e v i t a b l y .
T he r e s i d u a l
c a s e wa3 o n e w h e r e t h e l e s i o n was i n t h e h i p j o i n t and
in /
in th is
in sta n c e h e a lin g o ccu rred .
That i s ,
o n ly one
e x a m p le c a n b e show n w h e r e a p a t i e n t w i t h a n a c u t e
p rim a ry l e s i o n
s in u s .
an d a b s c e s s f o r m a t i o n d i d n o t f o r m a
W here t h e d i s e a s e was s u b - a c u t e i n n a t u r e s i n u s
fo rm a tio n d id n o t o c c u r i n 4 in s ta n c e s , a f ig u r e i n ­
creased to
12 w h e r e t h e p r i m a r y l e s i o n
w as o f a c h r o n i c
t y p e , a lth o u g h a l l th e s e c a s e s h ad a s u f f i c i e n t l y lo n g
c o u rse to e x c lu d e th e c o n tin g e n c y o f d e a th p re c e d in g
s in u s fo rm a tio n .
I n s h o r t t h e g r e a t e s t num ber o f
s i n u s e s w e r e f o r m e d w h e r e t h e p r i m a r y l e s i o n w as o f a n
a o u te n a t u r e , fo llo w e d c l o s e l y by l e s i o n s s u b -a c u te i n
c h a r a c t e r and a t a g r e a t e r d i s t a n c e by l e s i o n s w here
t h e a c t i v i t y was c l a s s i f i e d
as c h ro n ic .
T he o b s e r v a t i o n was a l s o made t h a t t h e g r e a t m a j ­
o r i t y o f s i n u s e s w ere fo rm ed i n t h e y o u n g e r ag e g r o u p s .
F o r e x a m p le , e x c lu d in g t h o s e c a s e s w here d e a t h i n t e r ­
v en ed ; 3 a b s c e s s e s d id n o t fo rm s in u s e s u n d e r 5 y e a rs
o f a g e , 5 b e t w e e n 5 an d 10 y e a r s o f a g e an d 9 b e t w e e n
10 a n d 15 y e a r s o f a g e .
E ach o f t h e few c a s e s o v e r
15 y e a r s o f a g e f o r m e d s i n u s e s b u t h e r e , a s w as m en­
t i o n e d b e f o r e , t h e r e a r e to o few c a s e s f o r a c o n c lu s io n
t o be draw n.
When p e r c e n t a g e s w e r e c a l c u l a t e d i t was
s e e n t h a t t h e o r d e r o f th e age g ro u p s w ith r e g a rd to
t h e i r t e n d e n c y t o s i n u s f o r m a t i o n w as
10 y e a r s o f a g e .
b e t w e e n 5 an d
I I u n d e r 5 y e a r s o f ag e and I I I b e ­
t w e e n 10 a n d 15 y e a r s o f a g e .
w as/
I
T he o u t s t a n d i n g f e a t u r e
w as t h a t a s t h e p a t i e n t s g r e w o l d e r t h e n u m b e r o f
c h r o n i c p r i m a r y l e s i o n s i n c r e a s e d an d t h a t i t w as t h i s
g r a d e o f a c t i v i t y w h ic h h a d t h e l e a s t te n d e n c y t o s in u s
fo rm a tio n .
S ex a p p e a r e d t o h a v e n o e f f e c t u p o n t h i s o c c u r r e n c e
a s 10 M a le s a n d 9 F e m a l e s d i d n o t f o r m s i n u s e s .
The n e x t f a c t o r i n v e s t i g a t e d w as t h e f a m i l y h i s t o r y
o f t h e p a t i e n t a s I t w as t h o u g h t t h a t a c h i l d w i t h a
p o s i t i v e f a m i l y h i s t o r y m i g h t t e n d t o f o r m a s i n u s m o re
r e a d i l y t h a n one i n w h ic h t h i s
s i n i s t e r omen was a b s e n t .
T he f i g u r e s r e v e a l e d t h a t i n t h o s e p a t i e n t s w h e r e s i n u s
f o r m a t i o n o c c u r r e d t h e f a m i l y h i s t o r y was p o s i t i v e i n
2 2 ,1 %
o f c a s e s c o m p a re d w i t h
s in u s e s w ere n o t fo rm e d .
2 0 .1 %
i n t h o s e w here
Thus t h e p o s s i b i l i t y o f a
h e r e d i t a r y p r e d i s p o s i t i o n t o t u b e r c u l o s i s w as show n
t o h a v e n o i n f l u e n c e on s in u s f o r m a t i o n .
R e v e r t i n g o n c e m o re t o t h e a c t i v i t y o f p r i m a r y
l e s i o n w h ich g i v e s r i s e t o s i n u s e s a s i m i l a r r e s u l t
w as o b t a i n e d w h en t h e e n t i r e s e r i e s o f c a s e s i n v e s t i ­
g a t e d w as a n a l y s e d .
F o r e x a m p le .
TABLE 7 . /
54.
TABLE. 7 .
S ite of
T u b e rc u lo sis.
ACUTE
PRIMARY
LESIONS.
S ex o f P a t i e n t .
M a le
A b s c e s s ­ S i n u s e s No S i n ­ A b s c e s s ­
es .
No.
uses
es .
No.
N o.
No.
F e m a le
S in u s 69
lo -
NF- S i n ­
uses
N o.
V e rte b ra e
2
2
0
3
3
0
Long Bones
5
4
1
2
1
1
H ip J o i n t s
8
7
1
4
4
0
K n ee J o i n t s
1
1
0
2
2
0
A n k le J o i n t s
4
4
0
3
3
0
M is c e lla n e o u s
0
0
0
1
1
0
G lan d s e t c .
1
1
0
4
4
0
D a c ty litis
3
3
0
3
3
0
.
-
F ro m t h e a b o v e i t was s e e n t h a t i n e a c h s i t e ,
i r r e s p e c t i v e o f ag e o r s e x , w here t h e p rim a ry l e s i o n
w as a c u t e , a b s c e s s f o r m a t i o n w as a l m o s t i n e v i t a b l y
fo llo w e d by s in u s f o r m a tio n .
A n o ta b le e x c e p tio n
w as i n l e s i o n s o f t h e l o n g b o n e s b u t , a s w as a l r e a d y
e x p la in e d , d e a th in th e s e c a se s o ccu rred f i r s t .
7 ABLE 8 . /
TABLE 8 .
S ite of
T u b e rc u lo sis.
SUB-ACUTE
PRIMARY
LESIONS.
S ex o f P a t i e n t .
F e m a le
M ale
A b s c e s s ­ S i n u s e s No S i n ­ A b s c e s s ­ S i n u s es.
uses
es.
No.
es.
No.
No.
No.
No.
No S i n ­
uses
No.
V e rte b ra e
8
8
0
5
4
1
Long Bones
4
3
1
2
2
0
H ip J o i n t s
3
3
0
4
3
1
K nee J o i n t s
2
2
0
2
2
0
A n k le J o i n t s
-
-
-
1
1
0
M is c e lla n e o u s
3
2
1
3
3
0
G lan d s e t c .
3
3
0
8
8
0
3
3
0
D a c ty litis
'
As i n t h e c a s e o f a c u t e d i s e a s e , s i n u s f o r m a t i o n
w as a l m o s t i n v a r i a b l y t h e r e s u l t o f a b s c e s s f o r m a t i o n .
TABLE » . /
TA&LE-d.
' S ite of
T u b e rc u lo sis.
CHRONIC
PRIMARY
LESIONS.
i^ex o f P a t i e n t .
M a le .
F e m a le .
A b s c e s s ­ S i n u s - No S i n ­ A b s c e s s ­ S i n u s ­ No S i n ­
es .
es
uses
es
es
uses
No.
No.
N o.
No.
N o.
No.
V e rte b ra e
7
4
3
7
Long Bones
2
2
0
-
lip J o in ts
3
2
1
3
2
1
K n ee J o i n t s
1
0
1
-
-
-
A n k le J o i n t s
-
-
-
1
0
1
M isc e lla n e o u s
3
3
0
2
2
0
G lan d s e t c .
3
2
1
1
1
0
D a c ty litis
*•
—
2
2
0
In
3
-
-
c o n t r a s t t o t h e p r e v i o u s t a b l e s i t w as n o t e d
t h a t t h e r e was a g r e a t e r t e n d e n c y f o r a b s c e s s e s t o h e a l
w ith o u t s in u s fo rm a tio n .
N o t a b l e e x c e p t i o n s w e r e when
t h e tu b e r c u lo u s p ro c e s s a tta c k e d th e lo n g b o n e s , m is ­
c e l l a n e o u s p a r t s o r t h e h a n d s and f e e t .
P a rtic u la rly
n o t i c e a b l e was t h e lo w i n c i d e n c e o f s i n u s f o r m a t i o n i n
r e l a t i o n to c h ro n ic d is e a s e a f f e c tin g th e v e r te b r a l
c o lu m n , a f e a t u r e s e e n a l s o t o a l e s s e r e x t e n t i n r e ­
l a t i o n to th e h ip j o i n t s .
a sp e c t, i t
T h u s, ta k e n fro m a n o th e r
a g a in becam e e v i d e n t t h a t s i n u s f o r m a tio n
w as d e p e n d e n t u p o n t h e a c t i v i t y o f t h e t u b e r c u l o u s p r o ­
c e s s g iv in g r i s e to th e a b s c e s s .
C e rta in /
4
57.
C e r t a i n e x c e p t i o n s t o t h i s r u l e w ere s e e n i n t h e
above t a b l e .
F o r e x a m p le , c h r o n ic p rim a ry d i s e a s e s i t ­
u a te d i n th e lo n g b o n e s, m isc e lla n e o u s p a r t s , th e hands
a n d f e e t an d t o a l e s s e r e x t e n t i n g l a n d s a n d s o f t
t i s s u e form ed s in u s e s i n a num ber f a r g r e a t e r th a n
l e s i o n s o f s i m i l a r a c t i v i t y i n t h e v e r t e b r a l c o lu m n
o r h ip j o in t s .
T he q u e s t i o n a r o s e , w e r e t h e r e o t h e r
f a c t o r s w h ich i n f l u e n c e d s i n u s f o r m a t i o n a s w e ll a s t h e
a c tiv ity
o f th e p rim a ry le s io n ?
E x a m i n in g many f e a t ­
u r e s i t w as d e c i d e d t h a t t h e s i t e
o f th e ab scess a r i s ­
i n g f r o m t h e p r i m a r y l e s i o n was o f i m p o r t a n c e .
A tu b e r c u lo u s a b s c e s s i s n o t m e re ly a c o l l e c t i o n
of in e r t m a te ria l.
Its
w a l ls a r e l i n e d by a p y o g en ic
m em brane a n d i t i s i n t h e w a l l s t h a t t h e t u b e r c l e
b a c i l l i a r e found i n g r e a t e s t num ber, a c t i v e l y e n ­
la rg in g th e ab scess by in v o lv in g h e a lth y t i s s u e .
When
su c h an a b s c e s s a p p ro x im a te s t o th e s k in s u r f a c e th e n
t h a t s u r f a c e w i l l b e in v o lv e d and e v e n t u a l l y b r e a k
down t h u s g i v i n g r i s e t o s i n u s f o r m a t i o n .
f e a t u r e s may a i d a n a b s c e s s i n i t s
s k in s u rfa c e .
V ario u s l o c a l
sp read to in v o lv e a
O b v io u sly a b s c e s s e s o r i g i n a t i n g fro m a
p rim a ry bone o r s o f t t i s s u e l e s i o n a lm o s t im m e d ia te ly
su b c u ta n e o u s w i l l in v o lv e th e s k in e a r l y .
E x a m p le s o f
t h i s w i l l b e f o u n d w hen t u b e r c u l o s i s a t t a c k s t h e l o n g
•
bone3 such as th e t i b i a , th e bones o r lig a m e n ts o f th e
a n k le and k n ee j o i n t s o r th e b o n e s o f t h e h a n d s and
fe e t.
On t h e o t h e r h a n d t h o s e a b s c e s s e s a r i s i n g f r o m
tu b e rc u lo s is o f th e v e rte b ra e o r th e h ip j o in ts have
a/
a c o n s i d e r a b l e am ount o f h e a l t h y s o f t t i s s u e t o t r a v ­
e r s e w h i c h f o r m s a b u f f e r an d s o h i n d e r s s i n u s f o r m a ­
tio n .
Thus s i t e
o f th e p rim a ry tu b e r c u lo u s l e s i o n i s
a f a c to r i n s in u s fo rm a tio n .
B u t a b s c e s s e s a r e n o t d i s r e g a r d e d w hen t h e y f o r m .
S t r e n u o u s e f f o r t s a r e made i n o r d e r t o p r e v e n t t h e i r
g r o w t h an d t h e s e
e f f o r t s t a k e t h e fo rm o f a s p i r a t i o n o f
t h e a b s c e s s c o n te n ts b e f o r e th e y h av e h ad tim e to
g a t h e r i n g r e a t q u a n t i t y a n d , i n many c a s e s , r e p l a c i n g
th e m w i t h v a r i o u s r e m e d i a l s o l u t i o n s .
abscess is
No t u b e r c u l o u s
a s p ir a te d th ro u g h i t s c e n t r a l p o in t u n le s s
a n a t t e m p t i s m ade t o f o r m a v a l v e a s i s o f t e n i l l u s ­
t r a te d i n th e te x t books o f su rg e ry .
be b e tte re d
if
Even t h i s can
a l o n g n e e d l e i s u s e d an d t h e a b s c e s s
a s p ir a t e d th ro u g h a la r g e a r e a o f h e a lth y t i s s u e .
E m p lo y in g t h i s
te c h n iq u e th e r e i s
s t i l l a c o n sid e ra b le
r i s k o f a b s c e s s m a te r ia l tr a c k in g th ro u g h th e n e e d le
p u n c t u r e an d i t
is
o b v io u sly im p o ssib le t o u t i l i s e
t h i s t e c h n i q u e i n an a r e a w here s o f t t i s s u e
and th e a b s c e s s i s
a lm o st s u b c u ta n e o u s .
i s sc a n ty
F in a lly , in
an a tte m p t t o c le a n o u t th e p rim a ry fo c u s o f t h e d i s ­
e a s e o r w here t h e s k i n i s i r r e p a r a b l y in v o lv e d t h e
abscess is in c is e d .
T h a t i s , a b s c e s s e s may f o r a s i n u s ­
e s n a t u r a l l y b y e x t e n s i o n and e v e n t u a l e r o s i o n o f a
s k i n o r rauoous s u r f a c e ; b y s p r e a d i n g t h r o u g h a p e r t u r e s
l e f t b y a n a s p i r a t i n g n e e d l e ; and l a s t l y b y b e i n g i n ­
c ise d .
D e t a i l s r e g a r d i n g t h e m e th o d s o f o r i g i n o f
s i n u s e s w e re t a k e n f o r t h e c a s e s u n d e r o b s e r v a t i o n an d
have been ta b u la te d as fo llo w s :-
TABLE
S ite of
D ise a se
1 0 ..
S ite of
A bscess.
No. o f
Cases
M e th o d o f S i n u s F o r m a t i o n .
In c isio n
N eed le
E ro s io n
P u n c tu re
N eck
2
-
1
1
L o in
3
-
3
-
Back
1
-
1
-
G ro in and
U pper T h ig h
6
1
4
1
P e rin e u m
1
1
-
-
10
1
2
7
T h ig h ( L a t . &
P o s t .)
6
1
—
5
K n ee J o i n t
A ro u n d J o i n t
5
2
-
3
A n k le J o i n t
A ro u n d J o i n t
4
4
-
-
H eel
2
1
-
1
S u b o u ta n e o u s
1
-
-
1
In deep tis s u e
5
1
2
2
A ll s u b c u ta n e o u s
6
5
-
1
52
17
13
22
V e rte b ra e
H ip J o i n t
T h ig h ( A n t.)
L o n g Bomes
G lan d s e t o .
TOTAL
-
I t w as f o u n d t h a t many s i n u s e s w e r e c a u s e d b y
in d is c rim in a te in c is io n of ab scesses b e fo re th e cases
reach ed h o s p ita l.
Of t h o s e w h i c h came u n d e r t r e a t m e n t
w i t h a b s c e s s e s o r d e v e l o p e d th e m i n h o s p i t a l s i n u s e s
w ere fo rm ed i n a v a r i e t y o f w ay s.
F o r e x a m p le i n
l e s i o n s o f t h e v e r t e b r a l c o lu m n t h e m a j o r i t y o f s i n u s e s
w ere fo rm ed by pus le a k in g a lo n g a s p i r a t i o n n e e d le
t r a c k s , w h ereas i n l e s i o n s o f th e h i p j o i n t s th e m ost
common m e th o d o f s i n u s f o r m a t i o n was b y t h e a b s c e s s
' e ro d in g th e sk in s u rf a c e .
L e sio n s o f t h e knee j o i n t s
an d lo n g b o n e s w ere s i m i l a r t o h i p j o i n t s i n t h a t
e r o s i o n w as t h e com m onest m eth o d o f s i n u s f o r m a t i o n b u t
i n th e case o f d is e a s e i n th e a n k le j o i n t s o r th e
g l a n d s a n d s o f t t i s s u e s m o s t s i n u s e s w e r e f o rm e d a s a
r e s u lt of in c isio n .
Why a c e r t a i n m a n n e r o f s i n u s f o r m a t i o n s h o u l d p r e ­
d o m i n a t e i n e a c h g r o u p o f c a s e s was c a p a b l e o f e x p l a n a ­
tio n .
T u b e r c u l o s i s o f t h e v e r t e b r a l c o lu m n we saw
e a r l i e r w as m a i n l y s u b - a c u t e a n d c h r o n i c i n a c t i v i t y
t h u s t e n d i n g t o s l o w a b s c e s s f o r m a t i o n an d s l o w r e ­
fillin g
o f t h e a b s c e s s c a v i t y when a s p i r a t e d , c o n ­
d u c i v e t o many a s p i r a t i o n p u n c t u r e s an d a c o n s e q u e n t l y
g r e a t e r r i s k o f le a k a g e th ro u g h th e n e e d le p u n c tu re s .
A dded t o t h i s was t h e s i t e
o f th e a b s c e s s e s .
Those
i n t h e n e c k f o llo w e d t h e f a s c i a l p la n e s and w ere o f t e n
c lo s e t o th e s k in s u r f a c e b e fo re t h e i r p r e s e n c e , as
in d ic a te d /
i n d i c a t e d b y s w e l l i n g , was s u s p e c t e d .
I n v iew o f th e
num erous s t r u c t u r e s w i t h i n t h e n e c k a lo n g a s p i r a t i o n
t r a c k was o f t e n i m p o s s i b l e a n d n o g r e a t v a r i e t y o f
p u n c t u r e s i t e s w ere a v a i l a b l e s o t h a t t h e t i s s u e s
a ro u n d t h e a b s c e s s w ere dam aged and a lo o p h o le f o r
t h e e s c a p e o f p u s was p r e s e n t e d .
p e r t a i n e d i n t h e b a c k an d l o i n .
t h e p o s i t i o n was d i f f e r e n t .
S im ila r c o n d itio n s
W ith p s o a s a b s c e s s e s
They r e q u i r e d a s p i r a t i o n
a t l o n g r a n g e a t f i r s t b u t , i f t h e a b s c e s s w as p r o ­
g re ssiv e , i t
l e d t o v e r y n e a r t h e s k i n s u r f a c e i n w h ic h
t h e p u n c t u r e s w e r e m o s t c o n v e n i e n t l y made a n d e i t h e r
s p re a d th ro u g h o ld n e e d le tr a c k s o r th ro u g h th e l a t e r
and, o f n e c e s s ity , s h o rte r ones.
A b s c e ss e s a r i s i n g fro m t h e h i p j o i n t w ere d i f f e r ­
e n t.
They w ere fo u n d t o p o i n t a lm o s t i m p a r t i a l l y
aro u n d th e u p p e r th ig h w ith a s l i g h t p re fe re n c e f o r th e
fro n t.
H e re t h e c o n d i t i o n s f o r p e r f e c t a s p i r a t i o n w ere
a l l p r e s e n t , l o n g n e e d l e t r a c k s w e r e o b t a i n a b l e an d
b a n d a g i n g w as p o s s i b l e .
B u t i n t h e s e l e s i o n s we saw
t h a t t h e t u b e r c u l o u s p r o c e s s was m a i n l y a c u t e r e s u l t i n g
i n th e s te a d y p ro g re s s o f th e a b sc e ss d e s p ite re p e a te d
a s p i r a t i o n and t h e e v e n tu a l e r o s i o n o f t h e s k i n s u r f a c e .
W it h t h e r e m a i n i n g g r o u p s , e x c e p t i n g l e s i o n s o f
lo n g b o n e s , t h e a b s c e s s e s w ere fo rm ed a lm o s t s u b c u t a n e o u s ly i n t h e f i r s t p l a c e and in v o lv e m e n t o f t h e s k in
s u r f a c e w as e a r l y .
As t h i s
s u r f a c e w hen I n v o l v e d m e r e l y
s lo u g h e d o f f , i n o r d e r t o s a v e i t
and/
i n c i s i o n s w e r e made
a n d a n a t t e m p t made t o c l e a n o u t t h e d i s e a s e d t i s s u e .
That i s ,
i n c i s i o n was m e r e l y t o p r e v e n t e r o s i o n .
T h is
m ig h t h a v e b e e n done i n t h e c a s e o f th e h i p j o i n t s b u t
s in u s fo rm a tio n in r e l a t i o n to t h i s
j o i n t w as f e a r e d
s o much m o re t h a n i n r e l a t i o n t o t h e s e o t h e r a r e a s t h a t
n o o p p o r t u n i t y was n e g l e c t e d i n o r d e r t o a v o i d i t s
o ccu rren ce.
T hus, s in u s e s r e l a t i n g to th e knee j o in t
w e r e f o r m e d i n tw o c a s e s b y i n c i s i o n an d i n 3 c a s e s
by e r o s io n w h ereas n e e d le p u n c tu r e p la y e d no p a r t .
A ll s in u s e s a r i s i n g fro m l e s i o n s o f th e a n k le j o i n t s
w ere fo rm ed b y i n c i s i o n w i t h one e x c e p t i o n , w h ic h fo rm ed
by e ro s io n .
S in u s f o r m a tio n a s a r e s u l t o f i n c i s i o n
w i t h e r o s i o n a s a n a l t e r n a t i v e s e c o n d was a l s o t h e
co m m o n est m e th o d i n l e s i o n s o f g l a n d s an d s o f t t i s s u e
and i n d a c t y l i t i s .
G la n d u la r and s o f t t i s s u e t u b e r c u ­
l o s i s g i v i n g r i s e t o a b s o e s s f o r m a t i o n was o f t e n
t r e a t e d by i n c i s i o n and s c r a p in g t o o b t a i n b e n e f i c i a l
r e s u l t s r a t h e r th a n on c o n s e r v a t i v e l i n e s .
W ith a b s ­
c e s s e s a r i s i n g fro m l e s i o n s o f t h e lo n g b o n es s in u s
fo rm a tio n o c c u rre d i n 3 c a s e s by e r o s io n , 2 c a s e s by
n e e d le p u n c tu re and i n 1 c a s e by i n c i s i o n .
The t h r e e
s i n u s e s f o r m e d b y e r o s i o n a n d t h a t w h i c h w as f o r m e d
a s a r e s u l t o f i n c i s i o n a l l a r o s e fro m a b s c e s s e s w h ic h
w e r e i m m e d i a t e l y s u b c u t a n e o u s i n o r i g i n an d i n v o l v e d
th e s k in su rfa c e e a rly in th e ir co u rse.
T he tw o s i n u s e s
form ed by n e e d le p u n c tu r e a r o s e fro m d e e p - s e a te d b u t
p ro g re ssiv e /
p ro g re s s iv e a b sc e sse s r e s u l t i n g in th e pus fin d in g i t s
e x i t i n th e e a s i e s t m anner.
T h e r e f o r e i t may b e s a i d t h a t t h e s i t e
p rim a ry t u b e r c u lo u s f o c u s , i t s
a c tiv ity
o f th e
and th e t i s s u e
t h r o u g h w h ich a b s c e s s e s t r a c k i n f l u e n c e t h e p a r t i c u l a r
m anner i n w h ich s in u s f o r m a t i o n w i l l o c c u r .
THE
TECHNIQUE
EMPLOYED
FOR
EXAMINING
THE
SINUSES.
The i n v e s t i g a t i o n , d e a l i n g l a r g e l y w ith th e r e ­
c o v e ry o f o rg a n ism s from p u r u l e n t d i s c h a r g e s , n e c e s s i ­
t a t e d a t e c h n i q u e w h i c h w o u ld e n a b l e t h e s e o r g a n i s m s
t o b e i s o l a t e d r e a d i l y an d w i t h o u t f a i l .
I n a num ber
o f c a s e s t h e s e c o n d a r y i n f e c t i o n was p u r e l y s t r e p t o ­
c o c c a l b u t i n t h e m a j o r i t y o f c a s e s t h e i n f e c t i o n was
m u l t i p l e a n d i s o l a t i o n o f t h e v a r i o u s o r g a n i s m s w as
e f f e c t e d i n th e f o llo w in g m anner.
When a d r e s s i n g w h i c h h a d b e e n i n u s e f o r a p e r i o d
o f f r o m 4 . t o 2 4 h o u r s was r e m o v e d , t h e a r e a o f s k i n
a r o u n d t h e s i n u s was c a r e f u l l y c l e a n s e d w i t h s u r g i c a l
s p irit,
c a r e b e in g ta k e n to p r e v e n t t h e s p i r i t from
e n te r in g th e s in u s .
One l o o p f u l , o r s o m e t i m e s m o re i f
i t was known t h a t t h e s e c o n d a r y i n f e c t i o n was s c a n t y ,
o f t h e s i n u s e x u d a t e w as t a k e n w i t h a f r e s h l y s t e r i l ­
i s e d p la tin u m lo o p a t t h e b e d s id e o f t h e p a t i e n t and
im m e d ia te ly t r a n s f e r r e d to a tu b e c o n ta in in g H a r t l e y 's
b ro th .
Two o f t h e s e t u b e s w e r e t h u s i n o c u l a t e d a n d o n e
w as i n c u b a t e d a e r o b i c a l l y an d t h e o t h e r a n a e r o b i c a l l y
a t 37°C w i t h o u t l o s s o f t i m e .
T h e t u b e w h i c h w as i n ­
c u b a t e d a e r o b i c a l l y was a l l o w e d t o r e m a i n i n t h e i n ­
c u b a t o r g e n e r a l l y f o r 2 4 h o u r s when i t w as re m o v e d an d
a l o o p f u l o f t h e c u l t u r e t a k e n a n d s t a i n e d a n d exam ­
in ed m ic ro s c o p ic a lly .
A n o t e w as m ade o f t h e o r g a n i s m
o r t h e v a r i o u s o r g a n i s m s g r o w i n g t h e r e i n an d a l o o p f u l
o f t h e c u l t u r e w as t h e n s p r e a d u p o n a s e r u m - a g a r p l a t e
and i n c u b a t e d a e r o b i c a l l y f o r a f u r t h e r 24 h o u r s a t
37°C w hen i t was re m o v e d an d t h e c o l o n i e s e x a m in e d
e i t h e r by th e n ak ed eye o r w ith th e a id o f a l e n s .
S u b c u l t u r e s o f t h e v a r i o u s c o l o n i e s w e r e made on
H a r t l e y ' s b r o t h an d o r d i n a r y a g a r s l o p e s an d r e p l a c e d
in th e in c u b a to r f o r a f u r th e r
24
h o u r s when t h e y w e r e
r e -e x a m in e d t o a s c e r t a i n i f t h e y w ere p u r e c u l t u r e s .
I n t h e e v e n t o f th e m b e i n g p u r e c u l t u r e s t h e n e x t s t e p
i n t h e e x a m i n a t i o n w as t a k e n b u t i f n o t t h e n a n o t h e r
a t t e m p t b y p l a t i n g was m ade t o a c h i e v e s u c h a d e s i r e .
C o in c id e n t w ith t h i s th e second tu b e in o c u la te d
w as b e i n g i n c u b a t e d u n d e r a n a e r o b i c c o n d i t i o n s f o r 48
h o u rs.
A n a e ro b ic c o n d i t i o n s w ere a c h ie v e d b y t h e u s e
o f s o d iu m h y d r o x i d e an d p y r o g a l l i c a c i d i n a B u c h a n a n
tu b e .
On t h e c o m p l e t i o n o f 48 h o u r s i n c u b a t i o n t h e
t u b e was o p e n e d a n d t h e o r g a n i s m s p r e s e n t d e t e r m i n e d
by an e x a m in a tio n u n d e r th e m ic ro sc o p e as i n t h e c a se
o f th e a e ro b ic c u l t u r e .
When m o re t h a n o n e m o r p h o ­
l o g i c a l t y p e o f o r g a n i s m was p r e s e n t a l o o p f u l o f t h e
c u l t u r e was s p r e a d o v e r t h e s u r f a c e o f e a c h o f tw o
s e r u m - a g a r p l a t e s , o n e o f w h ic h was i m m e d i a t e l y p l a c e d
i n t h e i n c u b a t o r u n d e r a e r o b i c c o n d i t i o n s an d t h e
o t h e r la n d e r a n a e r o b i c c o n d i t i o n s .
T h e p l a t e w h i c h was
i n c u b a t e d a e r o b i c a l l y w as rem o v ed a f t e r 2 4 h o u r s an d
th e /
t h e v a r i o u s c o l o n y f o r m s n o t e d a n d c o m p a re d w i t h t h o s e
o b t a i n e d by p u r e l y a e r o b i c c u l t u r e from th e b e g in n in g
w hen, i f d i s s i m i l a r , s u b c u lt u r e s w ere ta k e n .
A n a ero b ic
i n c u b a t i o n w as a l l o w e d t o p r o c e e d f o r 48 h o u r s an d t h e
c o l o n i e s o f t h i s p l a t e w e r e e x a m in e d an d e a c h t r a n s ­
f e r r e d t o tw o t u b e s o f H a r t l e y ' s b r o t h , o n e o f w h ic h
w as i n c u b a t e d a e r o b i c a l l y a n d t h e o t h e r a n a e r o b i c a l l y
f o r t h e u s u a l p e r i o d s o f 24 and 48 h o u r s r e s p e c t i v e l y
a t t h e en d o f w h i c h t i m e t h e c u l t u r e s w e r e s t a i n e d and
e x a m in e d u n d e r t h e m i c r o s c o p e .
I f t h e o r g a n i s m g re w
a e r o b i c a l l y and a n a e r o b i c a l l y t h e n t h e f u r t h e r s u b ­
c u l t u r e s w ere c o n tin u e d a e r o b i c a l l y b u t i f t h e o rg a n ism
grew o n ly u n d e r a n a e r o b ic c o n d itio n s th e n i t
was t r e a t ­
e d a s s u c h a n d s u b c u l t u r e s a n d f u r t h e r e x a m i n a t i o n w as
c o n d u c te d u n d e r s i m i l a r c o n d i t i o n s .
The o c c u r r e n c e o f
a n a e r o b e s w as v e r y r a r e .
I t w as t h u s p o s s i b l e i n t h e g r e a t m a j o r i t y o f
c a s e s to o b ta in a p u re c u ltu r e o f th e seco n d ary i n ­
f e c t i o n i n f e c t i n g o r g a n i s m s i n n o t m o re t h a n 3 g e n e r a ­
t i o n s and th u s o b v i a t e to o g r e a t c h a n g e s i n th e c h a r ­
a c t e r s o f t h e o rg an ism s by s u b c u l t u r e .
When t h e i n v e s t i g a t i o n w as e x t e n d e d t o i n c l u d e
t h e e x a m i n a t i o n o f p u s re m o v e d f r o m t u b e r c u l o u s a b s c e s ­
s e s a s i m i l a r r o u t i n e was o b s e r v e d .
A d i f f e r e n c e was
t h a t m o re p u s was u s e d t o i n o c u l a t e t h e o r i g i n a l b r o t h
m ed ia th a n i n th e c a s e o f t h e s i n u s e s .
One m o re r o u t i n e w as e v o l v e d f o r t h e r e c o v e r y o f
o rg a n ism s/
o rg a n ism s fro m th e s k i n .
A sm a ll p ie c e o f s t e r i l e
a b s o r b e n t g a u z e was s o a k e d i n n u t r i e n t b r o t h a n d p l a c e d
a s a w e t d r e s s i n g on t h e s k i n s u r f a c e t o b e e x a m i n e d .
A f t e r tw o h o u r s i t w as re m o v e d an d c u t i n t o p i e c e s
w h ich w ere added t o o r d i n a r y b r o t h i n c u l t u r e t u b e s .
T h e s e t u b e s w e r e t h e n i n c u b a t e d a e r o b i c a l l y and a n a e r ­
o b i c a l l y a t 37°C f o r v a r y i n g p e r i o d s .
The d i f f i c u l t y
o f p r e v e n t i n g s t r e p t o c o c c i from b e in g r a p i d l y o v e r ­
g ro w n b y s t a p h y l o c o c c i w as o v e r c o m e b y i n s p e c t i n g t h e
c u l t u r e tu b e s a t r e g u l a r , s h o r t i n t e r v a l s and e x a m in in g
a l o o p f u l o f t h e i r c o n te n t m ic r o s c o p ic a lly , w hen, i f
i t was t h o u g h t a d v i s a b l e , a g a r p l a t e s w e r e i n o c u l a t e d
an d t h e r e q u i r e d o r g a n i s m s p i c k e d o f f i n t h e u s u a l
m anner.
The o t h e r t e s t s w h i c h w e r e u s e d a t l a t e r s t a g e s i n
t h e c o u r s e o f th e i n v e s t i g a t i o n w ere th o s e o f s ta n d a r d
la b o ra to ry p r a c tic e .
I t w as f e l t t h a t t h e i r d e t a i l e d
d e s c r i p t i o n m i g h t b e o m i t t e d an d t h e y a r e m e n t i o n e d a s
th e y a p p e a r.
THE
SINUSES
INFECTED
WITH
STREPTOCOCCI.
T he c e n t r a l f e a t u r e o f t h e i n v e s t i g a t i o n w as t h e
m ic r o s c o p ic and b a c t e r i o l o g i c a l e x a m in a tio n o f t h e d i s ­
c h a rg e from s i n u s e s a r i s i n g from a r e p r e s e n t a t i v e s e r i e s
o f tu b e rc u lo u s le s io n s .
Some p a t i e n t s h a d m u l t i p l e
tu b e r c u lo u s f o c i g iv in g r i s e t o s e p a r a t e s in u s e s w hereas
o t h e r s had one f o c u s o f d i s e a s e r e s u l t i n g i n m u l t i p l e
s in u s e s .
I n some i n s t a n c e s n u m e r o u s s i n u s e s w e r e e x ­
a m in e d i n a s i n g l e p a t i e n t .
it
I t i s f o r th is reaso n th a t
i s n e c e s s a r y t o s t a t e t h a t o n e h u n d r e d an d t e n s i n u ­
s e s , a r i s i n g f r o m o n e h u n d r e d a n d tw o p a t i e n t s , w e r e
e x a m in e d .
Of t h e s e p a t i e n t s f i f t y - f i v e w e r e f e m a l e s
a n d 47 w e r e m a l e s r a n g i n g i n a g e f r o m o n e t o
y ears.
se v e n te e n
T he p r e s e n c e o f t u b e r c u l o s i s was p r o v e d b a c t -
e r i o l o g i c a l l y i n 60 c a s e s a n d i n t h e r e m a i n i n g 4 2 t h e
s p e c i f i c o r g a n i s m was n o t r e c o v e r e d .
E very p a t i e n t in
t h e p r e s e n t s e r i e s was u n d e r d i s c u s s i o n i n t h e p r e ­
ce d in g c h a p te r re n d e rin g i t red u n d an t to r e p e a t a t t h i s
p o in t th e fe a tu re s ta b u la te d th e re .
As b e f o r e n o s e l e c t i o n w as made h e n c e t h e r e l a t i v e
i n c i d e n c e o f m a l e s t o f e m a l e s w as a c c i d e n t a l a n d n o t
a n i n d i c a t i o n t h a t m o re f e m a l e s t h a n m a l e s f o r m s i n u ­
ses .
T a b l e I w as c o n s t r u c t e d t o d e m o n s t r a t e t h e o r i g i n
o f t h e s i n u s e s w h ich w ere e x a m in e d .
TABLE 1 1 . /
69*
TABLE 1 1 .
V e rte b ra e
.
•
•
25
H ip J o i n t s
•
•
18
K n ee J o i n t s
•
•
8
A n k le J o i n t s
•
•
9
L ong B o n e s
•
•
13
D a c ty litis
•
•
13
G lan d s and s o f t t i s s u e
M isc e lla n e o u s
•
T o ta l.
15
9
•
110
D u r i n g t h e c o u r s e o f t h e i n v e s t i g a t i o n t h e m e th o d
o f e x a m i n i n g t h e d i s c h a r g e f r o m e a c h s i n u s was s t a n d a r d ­
i s e d b u t d i f f e r e n c e s e x i s t e d i n t h e tim e s a t w h ic h th e y
w ere e x a m in e d .
Some s i n u s e s w e r e e x a m in e d a t t h e i r
i n c e p t i o n , some m idw ay i n t h e i r c o u r s e a n d o t h e r s when
th e y w ere i n t h e p r o c e s s o f h e a l i n g .
C e r t a i n o f th e m
w e r e e x a m in e d a t o n e o r o t h e r o f t h e s e p e r i o d s an d o t h e r s
a t tw o o r a l l o f t h e m .
When r e p e a t e d e x a m i n a t i o n s w e r e
m ade t h e f i n d i n g s o f t e n v a r i e d and some d i f f i c u l t y was
e x p e rie n c e d c l a s s i f y in g th e r e s u l t s u n d e r a h e a d in g
such as th a t o f t h i s
c h a p te r.
T h i s w as o v e rc o m e b y d i v i d i n g t h e r e s u l t s i n t o
th re e la rg e g roups.
F o r e x a m p le , s i n u s e s w h ic h y i e l d e d
no s e c o n d a ry i n f e c t i o n on e x a m in a tio n w ere c a l l e d ' s t e r ­
ile '
a n d a s e c o n d g r o u p was f o r m e d b y t h o s e w h i c h
y i e l d e d o rg a n ism s o t h e r th a n s t r e p t o c o c c i , l e a v i n g a
th ird /
70.
t h i r d g r o u p f r o m w h i c h s t r e p t o c o c c i w e re r e c o v e r e d .
U nder t h i s
fe c te d
c l a s s i f i c a t i o n a s i n u s w h ic h w as o n c e i n -
i n a n y way was n e v e r c l a s s i f i e d a s s t e r i l e
i r r e s p e c t i v e o f th e r e s u l t o f an e a r l i e r o r l a t e r
e x a m i n a t i o n an d s i m i l a r l y , when s t r e p t o c o c c i w e r e o n c e
i s o l a t e d f r o m t h e d i s c h a r g e , t h e s i n u s was i n c l u d e d i n
t h a t group f o r a l l tim e .
T a b l e s w e r e t h e n made i l l u s t r a t i n g
th e fo llo w in g p o in ts ,
of s in u s e s ,
in p e rc e n ta g e s
(1) t h e g ro s s s e c o n d a ry i n f e c t i o n
(2) th e i n f e c t i o n by o rg a n ism s o t h e r th a n
s t r e p t o c o c c i an d ( 3 ) t h e i n f e c t i o n b y s t r e p t o c o c c i .
TABLE
S ite of
P rim a ry
L e sio n .
sin u s e s
G ross
In fe c tio n
%
12.
% s in u s e s i n ­
# sin u s e s
fe c te d by o rg s.
i n f e c te d by
o th e r th a n S tr e p s . S tr e p s .
V e rte b ra e
92 %
3 2 .0
6 0 .0
H ip J o i n t s
8 9 .0
1 1 .1
7 7 .9
K nee J o i n t s
8 7 .5
0
8 7 .5
A n k le J o i n t s
8 9 .0
0
8 9 .0
L ong B o n e s
9 1 .6
3 3 .3
5 8 .3
D a c ty litis
9 2 .1
3 0 .8
6 1 .3
G l a n d s an d
s o ft tissu e
8 8 .8
1 8 .8
6 8 .0
1 0 0 .0
7 7 .7
2 2 .3
M is c e lla n e o u s
...
. _______
In /
. . .
-------------
71.
I n t h e f i r s t p l a c e i t was s e e n t h a t a p p r o x i m a t e l y
91%
o f a l l s i n u s e s w ere s e c o n d a r i l y i n f e c t e d and t h a t ,
e x c lu d in g th o s e a r i s i n g fro m m is c e lla n e o u s p a r t s ,
in ­
f e c t i o n was a p p r o x i m a t e l y s i m i l a r i n e x t e n t i n a l l o f
th e m i r r e s p e c t i v e o f s o u r c e o f o r i g i n .
From t h i s i t
w as i n f e r r e d t h a t t h e s i t e o f t h e s i n u s h a d n o e f f e c t
upon th e o n se t o f seco n d ary i n f e c t io n g e n e r a lly .
H ig h
t h o u g h t h e i n c i d e n c e o f i n f e c t i o n was i t was f e l t t h a t
it
c o u ld h av e b een s t i l l h ig h e r had c e r t a i n s in u s e s ,
w h ic h w ere c l a s s i f i e d a s ' s t e r i l e *
b e e n e x a m in e d a t
e a r l i e r or l a t e r p e rio d s.
I n t h e n e x t c o lu m n o f t h e t a b l e i t was s e e n t h a t
t h e p e r c e n ta g e i n f e c t i o n by o rg an ism s o t h e r th a n
s t r e p t o c o c c i v a r i e d m a rk e d ly a n d , i n v ie w o f t h e s t a n d ­
ard p e rc e n ta g e o f s t e r i l i t y ,
in in v e rse p ro p o rtio n to
th a t f o r s tre p to c o c c a l in f e c tio n .
P a s s i n g on t o th e
t h i r d c o lu m n i t was n o t e d t h a t t h e p e r c e n t a g e o f
s i n u s e s w h i c h w e r e i n f e c t e d b y s t r e p t o c o c c i w as h i g h .
V a r ia tio n i n th e in c id e n c e o ccu rred a c c o rd in g to th e
s i t e o f th e p rim a ry tu b e r c u lo u s l e s i o n , b e in g h i g h e s t
f o r t h o s e s i n u s e s w h i c h a r o s e i n r e l a t i o n t o k n e e an d
a n k l e j o i n t l e s i o n s w i t h t h o s e fro m t h e h i p j o i n t s
fo llo w in g c lo s e ly .
T hose w h ich a r o s e fro m lo n g b o n e s ,
g la n d s and s o f t t i s s u e s , d a c t y l i t i s
and t h e v e r t e b r a l
c o lu m n w e r e i n f e c t e d i n a l o w e r b u t o l o s e l y s i m i l a r
d e g re e w hereas th e p e rc e n ta g e i n f e c t i o n o f t h i s ty p e
in /
i n m i s c e l l a n e o u s l e s i o n s was l o w .
Such a d i f f e r e n c e
i n f i g u r e s s u g g e s te d t h a t th e r e w ere f a c t o r s c o n t r o l ­
l i n g t h e t y p e o f s e c o n d a r y i n f e c t i o n , f o r e x a m p le
s t r e p t o c o c c i , w h ich g a in e d e n t r y t o s i n u s e s .
An a t t e m p t was made t o a s c e r t a i n i f t h i s was s o
and t h e c a s e s w ere s c r u t i n i s e d i n r e l a t i o n t o a g e , s e x ,
th e a c t i v i t y o f th e p rim a ry tu b e r c u lo u s f o c u s , th e s i t e
o f s i n u s , t h e n a t u r e o f t i s s u e th r o u g h w h ich t h e s i n u s
r a n an d f i n a l l y , t h e d u r a t i o n i n t i m e o f e x i s t e n c e o f
each sin u s .
D e a lin g w ith th e s e p o t e n t i a l f a c t o r s in th e o rd e r
e n u m e r a t e d a b o v e , t h a t o f a g e w as f i r s t i n v e s t i g a t e d .
I t was f o u n d , u t i l i s i n g
age g ro u p s as b e f o r e t h a t
6 9 .2 % o f s i n u s e s i n c h i l d r e n u n d e r 5 y e a r s o f age w ere
i n f e c t e d w i t h s t r e p t o c o c c i an d t h a t i n t h e o t h e r 3 a g e
g ro u p s th e f i g u r e s w ere
64% ,
66%
an d 60# r e s p e c t i v e l y .
F rom t h e s e f i g u r e s i t w as c o n c l u d e d t h a t a g e h a d n o
in flu e n c e upon th e p resen ce o r absence o f s tr e p to c o c c i
a s a s e c o n d a ry i n f e c t i o n i n t h e s in u s e s ex am in ed .
The d e t e r m i n a t i o n o f t h e i n f l u e n c e o f s e x n e c e s s i ­
t a t e d f r e s h t a b u l a t i o n o f t h e c a s e s b u t i t w as f o u n d
t h a t n o g e n e r a l c o n c l u s i o n c o u l d b e made a n d t h a t
p a r t i c u l a r i n f e r e n c e w as i m p o s s i b l e o n a c c o u n t o f t h e
s m a ll num bers o f e a c h s e x , i n e ach s i t e ,
g roup.
i n each age
I n v ie w o f t h e n e g a t i v e r e s u l t o b ta in e d th e
t a b l e w as o m i t t e d .
W hen/
When t h e a c t i v i t y o f t h e p r i m a r y l e s i o n i n e a c h
c a s e w as c o n s i d e r e d i t was f o u n d t h a t i n 67 c a s e s i n ­
f e c t e d b y s t r e p t o c o c c i t h e a c t i v i t y was g a u g e d t o b e
ACUTE i n 3 6 , SUBACUTE i n 24 an d CHRONIC i n 7 .
In con­
t r a s t w ere th e c o rre s p o n d in g f i g u r e s i n s in u s e s i n ­
f e c t e d by o rg a n ism s o t h e r th a n s t r e p t o c o c c i o r th o s e
c la s s ifie d
as s t e r i l e .
16 a n d CHRONIC 1 5 .
T h e s e w e r e ACUTE 5 , SUBACUTE
F rom t h e s e f i g u r e s i t was i n f e r r e d
t h a t s i n u s e s w h ic h a r o s e i n r e l a t i o n t o c a s e s w i t h a n
a c u te p rim a ry tu b e r c u lo u s l e s i o n
w e r e m o re p r o n e t o
s t r e p t o c o c c a l i n f e c t i o n t h a n t h o s e w h ich a r o s e i n r e ­
l a t i o n t o a s u b a c u t e f o c u s , who w e r e i n t h e i r t u r n m ore
v u l n e r a b l e t h a n th o s e w h ic h a r o s e fro m a c h r o n ic p r im ­
ary f o c u s .
T hese f a c t s w ere c a p a b le o f b e in g p ro v ed
i n a n o t h e r m a n n e r , a n d t o t h i s en d a f r e s h t a b l e was
m ade.
TABLE
1 3 ./
o
H
O
OJ
O
t
I
w a co
H
3
w
£
o
•H
03
«rl
CO
H
Q
'd
&*
,£
o
cS
©
o
O
M
>
w
o
o
l
W
W
O
I
O
iH
o
I
I
W
O
W
H
rH
I
I
w
w
O
H
H
IQ
rH
H
O
o
tH
H
tO
pH
r—I
rH
£
■H
M
Eh
t CO
Q
3
rH
CO
&
§
O
W
5
©
©
©
£
£
•rH
©
I O
0
H
O
O
1 CO
lO
O
tO
■
O
-
rH
J
^
W
W
I
O
I
H
r
H
r
O
O
O
rH
rH
rH
H
r
H
t
O
r
H
O
H
W
H
W
to
t"
w
w
to
w
to
t>
w
w
to
w
o
o
o
I
iH
O
O
rH
M
P
£
©
■H
P
05
Ph
<H
o
O
t
A
p
•H
*
O
£
©
a
3
£
rH
o5
P
O
P
©
,£
o
©
©
p
a
o
•H
«b '
©
i p
£
° §
tO
W
W
W W W
tO
W
W
to
w
w
9
3
•rl
©
rH
o3
£
©
CO
p
I
O
O
O
H
W
O
rH
O
rH
O
H
W
W
rH
fe
a
EH
H
O
*-5
Oh
H
a
CO
EH
a
H
O
►s
D
CO
CO
©
A
Eh
O
w
H
H
P
m
S3
a
o
EH
H
©
CO
M
o
•d
©
P
O
©
•ti
c
■H
£
©
£
3
£
bO
£
£
O
Ph
©
©
£
£
O
O
©
$
©
s*
O
©
rH
©
£
©
3
£
'd
©
£
§
§
T3
s
CO
CO
EH
>»
&
P
AS
S
•
•
■H
o
o
o
o
o
p
Ph
©
£
P
©
SK
©
A
p
T h i s t a b l e sh o w s t h a t t h e m a j o r i t y o f s i n u s e s
a r i s i n g fro m a c u te p rim a ry l e s i o n s , i r r e s p e c t i v e o f th e
age o f th e p a t i e n t o r th e s i t e
o f th e d i s e a s e , w ere
i n f e c t e d w i t h s t r e p t o c o c c i , a f e a t u r e w h ic h was l e s s
p r o n o u n c e d a s t h e p r i m a r y l e s i o n b ec a m e r e d u c e d i n
a c tiv ity .
A c o n c l u s i o n w as d r a w n o n c e a g a i n , t h e r e f o r e , t h a t
th e a c t i v i t y o f th e o r ig in a l le s io n p la y s a p a r t in
t h e p r o g r e s s o f e a c h c a s e an d t h a t i t was a f a c t o r i n
d e t e r m i n i n g t h e t y p e o f s e c o n d a r y i n f e c t i o n w h ic h was
r e c o v e r e d from th e s i n u s e s .
T h a t a p a r t i c u l a r m i c r o - o r g a n i s m was c a p a b l e o f
s e l e c t i v e a c t i v i t i e s d i d n o t se e m t o b e r e a s o n a b l e a n d
o t h e r f a c t o r s w ere o b v io u s ly e x i s t a n t .
T he r e m a i n i n g f a c t o r s , v i z , s i t e
o f sin u s , d u ra ­
t i o n o f s i n u s and n a t u r e o f t i s s u e th r o u g h w h ich e a c h
s i n u s r a n , w e r e c o n s i d e r e d t o g e t h e r an d a s u r v e y r e ­
v e a l e d t h a t s i n u s e s a r i s i n g fro m d i f f e r e n t a r e a s w ere
s u b je c t to d if f e r e n t lo c a l c o n d itio n s.
A s s umi n g a n E x o g e n o u s i n f e c t i o n t h e f i r s t d i f f e r ­
e n c e w as f o u n d t o e x i s t o n a n a t o m i c a l g r o u n d s a l o n e .
S i n u s e s a r i s i n g fro m v e r t e b r a l d i s e a s e w ere fo u n d m ost
oommonly o n t h e n e c k , b a c k an d l o i n a n d o n t h e g r o i n .
T h o s e i n t h e n e c k w e r e l o n g w i t h o p p o s e d w a l l s an d a
n a rro w m o u th , th o s e i n th e b a c k and l o i n v a r i e d from
s h o r t t o m edium i n l e n g t h s o m e t im e s p a t e n t a n d s o m e tim e s
w ith /
w ith opposed w a lls w hereas th o s e i n th e g r o in a r i s i n g
v i a t h e p s o a s m u s c l e w e r e l o n g an d w i d e l y p a t e n t .
T hose w h ic h a r o s e fro m t h e h i p j o i n t s w ere so m etim es
s t r a i g h t , l o n g a n d p a t e n t a n d s o m e t im e s l o n g , n a r r o w
and d i f f u s e b u t in a l l c a s e s th e y r a n th ro u g h v a s c u la r
t i s s u e , a f e a t u r e w h ic h w as s h a r e d b y some s i n u s e s
a r i s i n g fro m l e s i o n s o f th e lo n g b o n e s .
L e sio n s in
r e l a t i o n t o t h e k n e e , a n k l e a n d e lb o w j o i n t s h a d f e a t ­
u r e s i n common.
T hese w e re , th e 3 h o rt s in u s su rro u n d ed
o f t e n by d is e a s e d s o f t t i s s u e and th e c lo s e p ro x im ity
t o s y n o v i a l c a v i t i e s w h i c h w o u ld b e a m o s t s u i t a b l e
n i d u s f o r an added p y o g e n ic i n f e c t i o n .
Somewhat s i m i ­
l a r i n t h a t t h e s u r r o u n d i n g s o f t t i s s u e was o f t e n i n ­
v o l v e d , an d t h e s i n u s w as s h o r t , w e r e s i n u s e s s u c h a s
a r o s e fro m d a c t y l i t i s , g la n d s and s o f t t i s s u e
o f th e lo n g b o n e s .
and some
T hose w h ic h a r o s e fro m m i s c e l l a n ­
e o u s l e s i o n s w e r e e i t h e r s h o r t , o r t h e d i s e a s e was n o t
e x te n s iv e o r had th e f e a tu r e th a t p e r f e c t c le a n s in g
w as p o s s i b l e w hen d r e s s i n g .
A n o t h e r d i f f e r e n c e was f o u n d t o e x i s t i n t h e t i m e
o f o n s e t o f s t r e p t o c o c c a l i n f e c t i o n an d t h i s w as o f
im p o r ta n c e a s r e g a r d s t h e d u r a t i o n i n tim e o v e r w h ich
t h e s i n u s w as p a t e n t , a f a c t o r r e g a r d i n g w h i c h m o re
w ill be s a id in a l a t e r o h a p te r.
M e a n tim e i t may b e
re m a rk e d t h a t s i n u s e s a r i s i n g fro m t h e v e r t e b r a e w ere
u n co m m o n ly i n f e c t e d e a r l y b y s t r e p t o c o c c i b u t a s t i m e
passed/
p a s s e d t h e p o s s i b i l i t y o f r e c o v e r in g su ch an o rg a n ism
fro m th e d is c h a r g e in c r e a s e d .
In m isc e lla n e o u s le s io n s
t h i s i n f e c t i o n was r a r e a t a n y t i m e w h e r e a s i n l e s i o n s
o f th e knee j o i n t , a n k le j o i n t o r h i p j o i n t i t
a t an e a r ly s ta g e i n th e h i s t o r y o f th e s in u s .
o ccu rred
The
tim e o f o n s e t o f th e i n f e c t i o n v a r ie d f o r each p a r t i c ­
u l a r g r o u p o f c a s e s an d i t w as s u p p o s e d t h a t e a c h s i n u s
w as e x p o s e d t o t h e sam e r i s k .
A d e d u c t i o n was made
t h a t c e r t a i n a r e a s m u s t b e m ore s u i t a b l e f o r t h e r e ­
c e p t i o n and r e t e n t i o n o f a s t r e p t o c o c c a l i n f e c t i o n th a n
o t h e r s and t h a t t h i s e n c o u ra g in g f a c t o r m ust b e l o c a l .
When t h e a n a t o m i c a l f e a t u r e o f e a c h a r e a w e r e r e ­
l a t e d t o t h e a c t i v i t y o f th e p rim a ry t u b e r c u l o u s l e s i o n
som e t h e o r i e s w e r e f o r m e d .
F o r e x a m p le t u b e r c u l o s i s
o f t h e k n e e a n d a n k l e j o i n t s was t o a l a r g e e x t e n t
a c u t e i n c h a r a c t e r r e n d e r i n g a w id e a r e a o f t i s s u e d e ­
v i t a l i s e d and a n e a s y p r e y t o added i n f e c t i o n a g a i n s t
w h ic h t h e body h a d had no tim e t o p r e p a r e .
S im ila r
c o n d i t i o n s p e r t a i n e d t o a d e g r e e i n s i n u s e s w h ich a r o s e
f r o m t h e h i p j o i n t s w h e r e a s t h e c o m p a r a t i v e im m u n ity t o
i n f e c t i o n w ith c o m p lic a tio n s w h ic h e x i s t e d i n t h e
s i n u s e s a r i s i n g f r o m p s o a s a b s c e s s e s was d u e p a r t l y t o
t h e d r a i n a g e a f f o r d e d and p a r t l y t o th e e f f i c i e n t p y o ­
g e n i c m em brane w h ic h h a d h a d t i m e t o f o r m w i t h t h e
le s s a c tiv e d ise a s e .
S in u s e s fro m th e v e r t e b r a e a r i s i n g
i n t h e n e o k and l o i n w ere s i m i l a r t o th o s e fro m t h e
h ip /
h ip
j o i n t w h en o n c e s t r e p t o c o c c a l i n f e c t i o n h a d g a i n e d
e n t r y , a lth o u g h i n th e neck p o c k e tin g d id n o t o c c u r.
G la n d s, d a c t y l i t i s
and some l o n g b o n e s w e r e a l r e a d y
com pared t o a n k le and knee j o i n t s and h e r e t h e o n ly
d i s t i n g u i s h i n g f e a t u r e s w e r e t h e r e d u c e d e x t e n t an d
a c t i v i t y i n some c a s e s o f t h e t u b e r c u l o u s p r o c e s s .
T h u s a c o n c l u s i o n was m ade t h a t t h e f a c t o r s b e a r ­
in g upon th e in c id e n c e o f s tr e p to c o c c a l in f e c tio n in
t h e s i n u s e s w ere t h e s i t e o f t h e s i n u s and t h e n a t u r e
o f t h e t i s s u e th r o u g h w h ic h i t r a n and t h a t t h e s e
f a c t o r s w ere g o v e rn e d s o l e l y i n t h e i r e f f e c t by t h e
a c tiv ity
o f th e p rim a ry t u b e r c u lo u s p r o c e s s a l l o f
w h ic h f a c t o r s g o v e rn e d t h e d u r a t i o n o f t h e s i n u s e s i n
tim e .
THE
STREPTOCOCCI
FROM
WHICH
THE
WERE
RECOVERED
SINUSES.
The t a s k o f t y p i n g t h e num erous s t r a i n s o f
s t r e p t o c o c c i w h i c h w e r e r e c o v e r e d was r e n d e r e d d i f ­
f i c u l t b y t h e many d i v e r g e n t o p i n i o n s e x p r e s s e d b y
a u t h o r i t i e s on t h e v a lu e s o f c e r t a i n d i f f e r e n t i a l
m e th o d s.
I t w as f i n a l l y d e c i d e d t h a t e a c h s t r a i n w h i c h
w as r e c o v e r e d w o u ld h a v e i t s m o r p h o l o g i c a l an d c u l t u r a l
c h a r a c t e r i s t i c s n o te d and i t s h a e m o ly tic pow er t e s t e d .
T he m o r p h o l o g y o f a s t r a i n was t a k e n f r o m i t s
g ro w th i n b r o th ; th e sh ap e o f th e co ccu s and t h e le n g th
o f th e c h a in b e in g n o te d .
The c u l t u r a l c h a r a c t e r i s t i c s
w ere n o t e d on a 24 h o u r s s u r f a c e g ro w th on an o r d i n a r y
a g a r p l a t e w i t h , i n some i n s t a n c e s , a n e x t e n d e d exam ­
i n a t i o n o v e r a s e r i e s o f d i f f e r e n t m e d ia .
F in a lly th e
h a e m o l y t i c p o w e r was e s t i m a t e d o n t h e c h a n g e s c a u s e d
b y t h e s t r a i n s w hen g ro w n o n a f r e s h b l o o d a g a r p l a t e .
I n a d d i t i o n t o t h e s e b a s i c t e s t s a num ber o f
s t r a i n s w e r e e x a m in e d b i o c h e m i c a l l y a n d c e r t a i n o t h e r s
s e ro lo g ic a lly .
Whan t h e i n v e s t i g a t i o n was c o m p l e t e d 132 s t r a i n s
h a d b e e n e x a m in e d i n c l u i i n g a n u m b e r o f s t r a i n s w h i c h
h a d n o t b e e n r e c o v e r e d fro m t h e s i n u s e s b u t w h ic h w ere
in c lu d e d f o r th e p u rp o se o f c o m p a riso n .
T a b l e 14 i n ­
d ic a te s th e so u rce o f th e v a rio u s s t r a i n s .
TABLE
U .
Humber o f
S tra in s .
S ource
H a e m o ly tic P ow er.
q u ery .
b.
n il.
4
1
T yp e c u l t u r e s
6
a.
1
Faeces
1
1
-
-
-
T h ro a ts
7
2
5
-
-
S k in
2
1
-
1
-
116
S in u se s
V e rte b ra e
25
«•
19
3
3
H ip j o i n t s
51
-
23
7
1
9
-
9
-
-
A n k le j o i n t s
12
-
10
1
1
Long b o n e s
11
-
10
1
-
D a c ty litis
13
-
12
1
-
G la n d s e t c .
13
10
3
-
2
-
20
5
Knee j o i n t s
M is c e lla n e o u s
T o ta ls
..
2
-
132
5
102
T h e re w ere 6 ty p e d c u l t u r e s fro m t h e L i s t e r I n s t i ­
tu te in c lu d in g S. pyogenes, S . e q u i, S. in fre q u e n s ,
S. s a liv a riu s , S. fa e c a lis
an d S . e r y s i p e l a t o s u s .
One
o t h e r s t r a i n w as r e c o v e r e d f r o m t h e f a e c e s o f a p a t i e n t
w ith e n t e r i t i s
an d tw o m o re f r o m t h e s k i n s u r f a c e o f
h e a lth y c h ild re n .
S even s t r a i n s w ere r e c o v e r e d from
th e th r o a ts of v a rio u s in d iv id u a ls .
T h ere i s
a lso
show n o n t h e t a b l e t h e p a r t i c u l a r s o u r c e o f o r i g i n o f
t h e s t r a i n s r e c o v e re d fro m s i n u s e s .
The t h i r d
c o lu m n r e v e a l s t h e h a e m o l y t i c p o w e r s o f
th e v a rio u s s tr a in s
ly s is
and t h e p re p o n d e ra n c e o f B . haem o­
am ongst t h e s i n u s s t r a i n s i s o f i n t e r e s t a s i s
th e ab sen ce o f s t r a i n s a . h a e m o ly tic in c h a r a c t e r .
U n f o r t u n a t e l y h a e m o l y t i c p o w e r was n o t a l w a y s c l e a r l y
d e f i n e d a n d i t was n e c e s s a r y t o p l a c e a s m a l l n u m b e r
o f th e o rg a n ism s u n d e r th e h e a d in g 'q u e r y '.
V a ria ­
t i o n i n t h i s p o w e r was w e l l m a rk e d a n d i n g r e a t e r
d e t a i l t h e t a b u l a t e d r e s u l t s show ed t h e f o l l o w i n g
fe a tu re s.
T he t y p e c u l t u r e s g a v e d e f i n i t e r e a d i n g s
w ith one e x c e p tio n .
S tre p to c o c c u s e r y s i p e l a t o s is ,
i n f r e q u e n s an d e q u i w e r e a l l d e f i n i t e l y B . h a e m o l y t i c
w i t h w id e r a n g e o f c l e a r i n g a r o u n d t h e c o l o n i e s w i t h
b l o o d c e l l d e s t r u c t i o n an d a s h a r p l y d e f i n e d m a r g i n .
T h e e x c e p t i o n was S . p y o g e n e s when t h e c l e a r i n g was
sm a ll in e x te n t b u t y e t d e f i n i t e .
sho w n b y S . s a l i v a r i u s
h a e m o ly tic pow ers.
fro m /
a . h a e m o l y s i s was
an d S . f a e c a l i s e x h i b i t e d n o
T h o se s t r a i n s w h ic h w ere r e c o v e r e d
fro m t h r o a t s
show ed B . h a e m o l y s i s i n f o u r i n s t a n c e s an d
a . h ae m o ly sis in t h r e e .
4 o f th e m w e r e r e c o v e r e d
f r o m p a t i e n t s w i t h s c a r l a t i n a and t h e i r h a e m o l y t i c
p o w e r w as B . i n c h a r a c t e r i n 3 i n s t a n c e s a . i n o n e .
One s t r a i n w as r e c o v e r e d f r o m a t h r o a t i n h e a l t h a n d
w as B . h a e m o l y t i c w h e r e a s t h e r e m a i n i n g two w e r e r e ­
c o v e r e d fro m s c a r l a t i n a c o n t a c t s sh o w in g B . h a e m o ly s is
i n o n e i n s t a n c e an d a . i n t h e o t h e r .
The s t r a i n w h i c h
w as r e c o v e r e d f r o m t h e f a e c e s show ed a . h a e m o l y s i s an d
t h o s e i s o l a t e d f r o m t h e s k i n s u r f a c e show ed a . h a e m o ­
ly sis
i n o n e i n s t a n c e an d n o h a e m o l y t i c p o w e r i n t h e
o th e r.
T h e s e r e s u l t s w e r e d e f i n i t e b u t i t w as a m o n g s t
t h e s t r a i n s w h ic h w ere r e c o v e r e d fro m t h e s i n u s e s t h a t
v a r ia tio n o ccu rred .
I t was n o t e d t h a t 102 sh ow ed B .
h a e m o l y s i s o n c u l t u r e , b u t t h e d e g r e e o f c h a n g e w as n o t
u n ifo rm in e x t e n t .
Some show ed e x t e n s i v e an d u n d o u b t e d
c l e a r i n g w h ereas o t h e r s had o n ly a s m a l l , th o u g h c l e a r
c u t, re a c tio n .
None show ed a . h a e m o l y s i s o n f i r s t
c u l t u r e a n d 20 s t r a i n s w e r e d e f i n i t e l y d e v o i d o f h a e m o ­
ly tic
pow er.
reaso n s.
5 s t r a i n s w ere d o u b t f u l f o r t h e f o l l o w i n g
When a s t r a i n e x h i b i t e d n o h a e m o l y s i s o r a n
a . r e a c t i o n o n f i r s t c u l t u r e t h e t e s t w as a l w a y s r e ­
p e a te d i n o r d e r to c o n firm th e o r i g i n a l o b s e rv a tio n
a n d , w h e r e t h e s e c o n d r e a d i n g w as c o n f i r m a t o r y , t h e
s t r a i n was c l a s s i f i e d
tio n s/
as su ch .
In 5 in sta n c e s v a r i a ­
v a r i a t io n s o c cu rred d u rin g th e c o u rse of th e s e t e s t s
and t h e s e w ere t h e s t r a i n s c l a s s i f i e d u n d e r ' q u e r y ' .
They e x h ib ite d th e f o llo w in g c h a r a c t e r i s t i c s .
S tra in 1.
iso la te d
H .S .
9 .1 0 .3 3 .
T h i s o r g a n i s m was f i r s t
i n p u r e c u l t u r e o n 1 3 . 1 0 . 3 3 an d w as p l a t e d o n
b l o o d - a g a r when n o h a e m o l y s i s w as o b s e r v e d .
A fte r r e ­
p e a t e d s u b c u l t u r e t h e s t r a i n w as a g a i n p l a t e d o n b l o o d a g a r w hen h a e m o l y s i s a . i n t y p e w as n o t e d o n 8 . 1 1 . 3 3
a n d tw o d a y s l a t e r a n o t h e r b r o t h c u l t u r e e x h i b i t e d
v a r y i n g d e g r e e s o f h a e m o l y s i s o n a s i m i l a r m ed iu m .
S tra in 2 .
N .S . 6 .1 1 .3 3 .
T h i s s t r a i n was f i r s t o b t a i n e d
i n p u r e c u l t u r e o n 9 . 1 1 . 3 3 b y w h ic h d a t e i t
no h a e m o ly s is on b l o o d - a g a r .
e x h ib ite d
R e -in o c u la te d i t
show ed
a . h a e m o l y s i s o n 1 0 . 1 1 . 3 3 an d a g a i n o n 1 4 . 1 1 . 3 3 .
Sugar f e rm e n ta tio n .
A c id an d c l o t i n l a c t o s e , m a l t o s e ,
g lu c o s e and a c id i n litm u s m ilk .
M o r p h o lo g ic a lly and
c u l t u r a l l y s i m i l a r t o t y p i c a l S . v i r i d a n s , m ig h t b e
c la s s e d in t h i s gro u p .
S tra in 3.
M.M. 1 0 . 3 3 .
When t h i s o r g a n i s m was f i r s t
r e c o v e r e d i t w o u ld n o t g ro w i n a i r .
ever re su lte d in a f a i r l y
c o n d itio n s.
S u b c u ltu r e how­
l u x u r i a n t g ro w th u n d e r t h e s e
H a e m o l y s i s w as a b s e n t o n 2 7 . 1 0 . 3 3 an d
2 .1 1 .3 3 , f a i n t l y p r e s e n t on 8 .1 1 .3 3 and d e f i n i t e o f
B . c h a r a c te r by 1 1 .1 1 .3 3 .
M o rp h o lo g ic a lly S . haem o-
l y t i c u a o r S . v i r i d a n s i t was i m p o s s i b l e t o s a y c l e a r l y
w h ic h on h a e m o ly tic pow er a s e x h i b i t e d .
S tra in 4 .
cov ered /
D .L .
2 0 .4 .3 4 .
T h i s s t r a i n w as f i r s t r e ­
r e c o v e r e d o n 2 2 . 4 . 3 4 f r o m t h e a n a e r o b e c u l t u r e w hen i t
grew b u t s p a r i n g l y i n a i r .
S u b c u l t u r e d i d n o t im p r o v e
e i t h e r i n a e r o b i c o r a n a e r o b i c c o n d i t i o n s an d t h e s t r a i n
d i e d o u t o n 3 0 . 4 . 3 4 h a v i n g shown n o r e a c t i o n o n b l o o d agar p la te s.
S tra in 5.
S .M . 1 0 . 3 4 .
T h is o rg a n ism n e v e r gave p r o o f
o f s t r o n g h a e m o l y tic pow er a l t h o u g h a lw ay s c a u s in g
v e r y f a i n t c le a r in g around i t s
c o lo n ie s.
I t was im ­
p o s s i b l e t o m e n t i o n t y p e a l t h o u g h n o d e f i n i t e m e th a e m o g l o b i n f o r m a t i o n w as n o t e d .
A g a i n m o r p h o l o g i c a l l y an d
c u l t u r a l l y v i r id a n s o r h a e m o ly tic u s g ro u p s.
I n some i n s t a n c e s t h e h a e m o l y t i c p o w e r o f t h e
s tr a i n s v a rie d d i r e c t ly as t h e i r ap p aren t p a th o g e n ic ity
to th e h o s t.
F o r e x a m p l e , i t w as n o t e d t h a t t h e m o s t
m a r k e d B . h a e m o l y s i s w as show n b y o r g a n i s m s i s o l a t e d
f r o m s i n u s e s w h e r e a n a c u t e c o m p l i c a t i o n w as o c c u r r i n g .
To w h i c h r u l e , a s t o a n y o t h e r , t h e r e w e r e a f e w e x ­
c e p tio n s.
B . h a e m o l y s i s w as show n b y o r g a n i s m s r e ­
c o v e r e d f r o m a p p a r e n t l y n o r m a l c l e a n w ou nd s w h e r e t h e y
w ere le a d in g a s a p ro p h y tic e x i s t a n c e .
F u r t h e r c l a s s i f i c a t i o n w as c o n t i n u e d u t i l i s i n g
h a e m o l y t i c p o w e r a s a p r i m a r y d i v i s i o n an d a d d i n g
c u l t u r a l an d m o r p h o l o g i c a l c h a r a c t e r i s t i c s .
I t was
f o u n d t h a t th e c o c c i w ere l a r g e l y o v o id w i t h t h e g r e a t ­
e s t d i a m e t e r a t r i g h t a n g l e s t o t h e m a in a x i s o f t h e
o h a in w ith a m in o rity t r u l y o v o id .
T h e i r s i z e was
s t a n d a r d w i t h v e r y few e x c e p t i o n s b u t t h e i r c h a i n l e n g t h
v a rie d /
v a rie d c o n s id e ra b ly .
C o lo n ie s w ere m a in ly p i n p o i n t ,
o p a q u e a n d c o n v e x u p w i t h r e g u l a r e d g e s an d a n o t h e r
d i f f e r e n c e n o t e d was t h e v a r i a t i o n i n g r a n u l a r i t y a s
s e e n u n d e r th e m ic ro sc o p e .
On t h e s e c o m b in e d f e a t u r e s
t h e f o l l o w i n g g ro u p s w ere p r o d u c e d .
G ro u p 1 .
B . h a e m o ly tic , f in e ly g ra n u la r, p in p o in t
c o l o n i e s , lo n g c h a in s , t r a n s v e r s e l y f l a t t e n e d c o c c i.
2 0 STRAINS.
G roup I I .
As g r o u p I , medium l e n g t h c h a i n s .
3 7 STRAINS.
G ro u p I I I . As b e f o r e , s h o r t c h a i n s .
2 6 STRAINS.
U t i l i s i n g th e g r a n u la r ity o f th e c o lo n ie s u n d er th e
m ic ro s c o p e t h r e e f u r t h e r g ro u p s w ere fo u n d w h ere t h i s
f e a t u r e was m o re m a r k e d t h a n i n t h e p r e c e d i n g s e r i e s .
G ro u p I V . B . h a e m o l y t i c m o d e r a t e l y g r a n u l a r , p i n p o i n t
c o l o n i e s , lo n g c h a in s , t r a n s v e r s e l y f l a t t e n e d c o c c i .
1 STRAIN.
G ro u p V .
As g r o u p I V , m edium c h a i n s .
3 STRAINS.
G ro u p V I .
As a b o v e , s h o r t c h a i n s .
5 STRAINS.
S t i l l o n e m o re g r o u p w as f o rm e d b y c o l o n i e s w h e r e
g r a n u l a r i t y was v e r y m a r k e d .
c h a i n s m edium i n l e n g t h .
A ll o f th e s e s t r a i n s had
86
G ro u p V I I .
4 STRAINS.
F i n a l l y , am ongst th e B . h a e m o ly tic s t r a i n s w ere th o s e
w here t h e i n d i v i d u a l c o c c i w ere t r u l y o v o id .
G roup V I I I .
B.
H a e m o ly tic , p in p o i n t , f i n e ly g r a n u la r ,
o v o id c o c c i.
Long c h a i n .
N IL .
M edium c h a i n .
S STRAINS.
S hort c h a in .
N IL .
G roup I X .
S im ila r g e n e r a l f e a t u r e s b u t w ith g r e a t e r
g ra n u la rity in th e c o lo n ie s.
Long c h a i n .
Medium c h a i n .
N IL .
3 STRAINS.
T h e re w ere no o rg a n is m s r e c o v e r e d fro m t h e s i n u s e s
w h ich p ro d u c e d a . h a e m o ly s is b u t f i v e
s t r a i n s w ere p r e ­
se n t w ith in th e s e r ie s e x h ib itin g th i s f e a t u r e .
T h e ir
d e t a i l s w ere I.
C J.
S ource, f a e c e s .
O p a q u e , f i n e l y g r a n u l a r c o l o n i e s u p t o 1 mm. i n d i a m e t e r .
S hort c h a in s o f tra n s v e re ly f la tte n e d c o c c i.
I I . J .P .
S o u rce, s k in .
S im ila r in d e t a i l to S tra in I .
III.
T y pe c u l t u r e
S. s a liv a riu s.
S im ila r t o S t r a i n s I and I I .
IV ./
IV .
R.
S im ila r to th e f i r s t 3.
V.
G.
a . h a e m o ly tic , f in e ly g ra n u la r c o lo n ie s ,
1 mm.
d i a m e t e r , o v o id c o c c i i n s h o r t c h a i n s .
T h e r e m a i n i n g s t r a i n s , a l l n o n - h a e m o l y t i c w hen
s im i l a r l y c l a s s i f i e d r e s u l t e d i n th e fo llo w in g g ro u p in g .
G ro u p X .
N o n -h a e m o ly tic , f i n e l y g r a n u la r c o l o n i e s ,
1 mm. d i a m e t e r , m edium c h a i n s , t r a n s v e r s e l y f l a t t e n e d
c o c c i.
8 STRAINS.
G ro u p X I .
S im ila r b u t w ith m o d e ra te ly g r a n u la r c o l ­
o n ie s.
4 STRAINS.
G ro u p X I I .
G ra n u la r c o lo n ie s .
1 STRAIN.
F i n a l l y t h e r e w ere t h e n o n -h a e m o ly tic s t r a i n s w ith
o v o id c o c c i .
G ro u p X I I I .
Long c h a i n s .
2 STRAINS.
G r o u p X IV .
M edium c h a i n s .
3 STRAINS.
G ro u p XV.
S hort c h a in s.
2 STRAINS.
O u tsta n d in g /
O u t s t a n d i n g a s a r e s u l t o f t h i s g r o u p i n g w as t h e c l o s e
r e l a t i o n s h i p e x h i b i t e d b e tw een th e m a j o r i t y o f t h e
s t r a i n s w hen m o r p h o lo g y a n d h a e m o l y s i s w e r e t a k e n a s
fa c to rs fo r c la s s ific a tio n .
E q u a l l y n o t i c e a b l e was
t h e m o r p h o lo g ic a l s i m i l a r i t y am o n g st t h e s t r a i n s w h ich
w ere
B
h a e m o ly tic and t h e a b s e n c e , w i t h one e x c e p t i o n ,
o f a n y s t r a i n w h ic h m i g h t b e s t r e p t o c o c c u s f a e c a l i s .
A n o t h e r f e a t u r e w as t h e s h a p e o f t h e i n d i v i d u a l c o c c i .
O p in io n h a s b e e n e x p r e s s e d t h a t c o c c i w ith t h e i r lo n g
a x i s a t r i g h t a n g l e s t o t h e c h a i n a r e m o re v i r u l e n t
t h a n t h o s e s h o w in g t h e s t a n d a r d o v o i d f o r m , i n w h i c h
c a s e m o s t o f t h e s t r a i n s e x a m in e d w e r e o f t h i s
m o re v i r u l e n t n a t u r e .
s lig h tly
I n o p p o s i t i o n , h o w e v e r w as t h e
e v id e n c e a f fo rd e d by th e g r a n u l a r i t y o f th e c o lo n ie s
u n d e r t h e m i c r o s c o p e , w hen t h e v a s t m a j o r i t y w e r e s o
f i n e l y g r a n u l a r a s t o b e a lm o s t sm o o th , a f e a t u r e r e ­
p u te d to i n d i c a t e an a v i r u l e n t s ta g e i n th e l i f e
of
an o rg a n ism .
S u p p o r t w as g i v e n t o t h i s
a s s u m p t i o n w hen t h e
v i r u l e n c e o f some o f t h e s t r a i n s r e c o v e r e d w as t e s t e d
i n m ic e .
T he m e th o d i n u s e w as t o i n j e c t i n t r a p e r i t o n -
e a l l y i n t o a h e a l t h y m o use 0 . 5 o o . o f a 2 4 h o u r s o r d i ­
n a r y b r o t h o u l t u r e o f t h e o rg a n ism t o b e t e s t e d .
T w e n t y - f i v e s t r a i n s w e r e t h e n e x a m in e d a n d a l l w e r e
f o u n d t o b e a v i r u l e n t w i t h tw o e x c e p t i o n s .
The f o ll o w ­
in g t a b l e i n d i c a t e s t h e s o u rc e and c h a r a c t e r s o f t h e
v a rio u s s tr a in s te s te d .
TABLE
1 5 ./
8.9.
TABLE
S o u rc e o f O rg a n ism .
15 .
N o.
H a e m .P o w e r
21
B.
20
1
4
B.
3
1
25
B.
23
2
A v iru le n t
V iru le n t
I n l e s i o n s fro m w h ic h an
a c u t e d i s t u r b a n c e was
in p ro c e ss.
F ro m q u i e s c e n t l e s i o n s
T he " b ro th c u l t u r e s u s e d w e r e t h o s e w h i c h sh o w e d t h e
b e s t g ro w th fro m a s e r i e s o f 3 tu b e s w h ic h w ere in o c u ­
la te d .
One m ou se o n l y w as u s e d f o r e a c h t e s t .
A c o n c lu s io n , b a se d on a l l th e p r e v io u s d e t a i l s
was t h a t m o r p h o l o g i c a l a n d c u l t u r a l c h a r a c t e r i s t i c s
a p p eared to be o f v a lu e b u t o n ly as an a c c e s s o r y t o th e
h a e m o ly sis t e s t .
E x a c t d i f f e r e n t i a t i o n o f a c e r t a i n num ber o f
s t r a i n s was t h e n a t t e m p t e d u t i l i s i n g t h e b i o c h e m i c a l
p r o p e r tie s o f th e o rg a n ism s.
H iss'
The t e s t m edium u s e d w as
s e r u m w a t e r i n w h ic h was d i s s o l v e d v a r i o u s s u g a r s
a n d g l u c o s i d e s a n d t h e t e c h n i q u e w as 3 u c h a s w o u ld b e
fo llo w e d in s ta n d a rd la b o r a to r y p r a c t i c e .
T w e n ty -six
s t r a i n s w ere s u b j e c t e d t o t h i s t e s t w i t h r e s u l t s
T a b le 1 6 ./
as in
M il k
Litmus
Glucose
I
I
I + + + + + +
+ + + +'+ + + + + + + + + + + + + • I » + + + + + +
M annlte
M altose
+ + + + + + + + + + + + + + + + +
S a llcln
I
!
I +
I
I
I
+
+
+
+
+
+
+ +
I
I
I
» +
+
+
+
I
I
I
I
f
I
I
I
I
I
I
I
I
I
I
I
«
I
» +
I
I
I
I
I
I +
I
*
I
I
•
> +
R affln o se
S a c o h a ro se
L a c to se
TABLE
16
.
( +
=
A .c .)
<<
<5 < J
+
+
I
+
+
I
+
I
+
I
I
I
+
I
+
I
+
I
I
+
+
+ + + + + + + + + + •*+ + + + + + + • I I I + + 1 +
tO
to
N
»
rH
•*
to
•
to
iH
• • H
H H
•
O f c
Q
J
jL aaaoooaao
•
•
•
•
C J CQ < ! <5
«
•
•
•
03 m
*H fl
r - i tO tO tO tO tO
iH tO tO tO tO tO
• « < • • •
O O J H H H
‘ W H H H H H
•
M w It , a
©
d
”4*
CT
• • • t O
®
• M j «
^ t I h H
iH
ro
d
*»«as:ianaHWtoto&siucQ
o
i n
a
T!
-H
+5
• -H
-P
•
•
•
•
•
•
•
•
•
#
•
•
•
•
•
< l H a H h i t f M M W p Q C < H h
When t h e s e s t r a i n s w e r e g r o u p e d o n t h e b a s i s o f t h e i r
h a e m o l y t i c p o w e r s , tw o l a r g e g r o u p s w e r e f o r m e d .
G ro u p I c o n t a i n e d t h o s e w h i c h sh o w ed B . h a e m o l y s i s o n
b l o o d a g a r a n d G ro u p I I
in c h a ra c te r.
t h o s e w h ich w ere a . h a e m o l y t i c
No n o n - h a e m o l y t i c s t r a i n s w e r e e x a m in e d
i n t h i s m anner.
G ro u p I c o n t a i n e d t h e f o l l o w i n g s e c t i o n s , nam ed
a c c o r d in g t o t h e t y p i c a l r e a c t i o n s s u g g e s te d i n T o p le y
& W ils o n 's T e s t book o f B a c t e r i o l o g y .
S e c tio n I .
S t r a i n s f e r m e n t i n g l a c t o s e , m a l t o s e an d
g l u c o s e w i t h t h e f o r m a t i o n o f a c l o t an d p r o d u c i n g
a c id i n litm u s m ilk .
E f f e c t on P a t i e n t .
S .M .
1 1 .3 3 )
C e llu litis .
)
I.R .
1 1 .3 3 )
) G ro u p f o r m
M .M .I 1 1 . 3 3 )
) S . ANGINOSUS.
S .M .I 1 1 .3 3 )
)
I.W .
1 1 .3 3 )
C e llu litis .
C e l l u l i t i s & A c u te A b scess
fo rm a tio n .
C e llu litis .
S u rg ic a l S c a r la tin a .
)
J .N .
)
S e c tio n I I .
S c a rla tin a .
S tr a in s fe rm e n tin g sa c c h a ro se w ith th e
p ro d u c tio n o f a c l o t ,
in a d d itio n th e re a c tio n s of
S e c tio n I .
G .P .
1 1 .3 3 )
( G ro u p f o r m
S .M .
1 1 .3 3 )
) S.PYOGENES.
A.Mc D . 1 1 . 3 3 )
S e c tio n I I I . /
A c u te A r t h r i t i s .
C e llu litis .
C e llu litis .
S e c tio n I I I .
fe rm e n tin g as S e c tio n I I w ith , i n a d d i t ­
io n , m a n n ite .
A.M.
)
( C e llu litis.
)
)
M .C . 1) 1 0 . 3 3 )
)
K .C . C . 1 1 .3 3 )
)
J . McL.
)
S e c tio n IV .
( C e llu litis.
G ro u p f o r m (
( E ry s ip e la s.
S . PYOGENES. (
( S c a rla tin a .
R e a c tin g o n ly w ith l a c t o s e , s a l i c i n ,
m a lto s e , g lu c o se
K. C .
P.
M. M.
2)
and litn ru s m ilk .
)
( E ry s ip e la s .
1 1 . 3 3 ) G ro u p f o r m ( C e l l u l i t i s , A c u t e A b s c e s s
) S.PYOGENES (
F o rm a tio n .
)
(
N il
R .B .M .
S e c tio n V.
S tra in s fe rm e n tin g , la c to s e , sa c c h a ro se ,
s a l i c i n , m a n n ite , m a lto s e and g lu c o s e , and p ro d u c in g
a c id i n litm u s m ilk .
M. C .
M. C .
1 0 .3 3 )
)
1 2 .3 3 )
S e c tio n V I.
G ro u p f o r m
( C e llu litis*
S . INFREQUENS.(
( C e llu litis.
S tr a in s fe rm e n tin g la c t o s e , m a n n ite ,
m a lto s e and g lu c o s e w ith th e p r o d u c tio n o f a c id i n
litm u s m ilk .
A . W. ( L . a n k l e ) ) P r o b a b l e
( C e llu litis.
g ro u p fo rm
)
A . W. ( R . a n k l e ) ) S.INFREQUENS. ( C e l l u l i t i s .
S e c tio n V I I .
S t r a i n f e r m e n tin g o n ly m a lto s e and
g l u c o s e and p r o d u c in g a c i d i n l i t m u s m ilk .
D. S .
I.
)
Im p o ssib le
N il.
t o nam e.
N il.
)
D. S .
II.
)
I.
1 .3 4
)
R.
C e llu litis very s lig h t
F i n a l l y t h e r e w as o n e s t r a i n
(J .S .)
r e c o v e re d fro m t h e
t h r o a t o f a p a t i e n t w i t h S c a r l a t i n a w h ic h f e rm e n te d
l a c t o s e , s a c c h a r o s e , r a f f i n o s e , s a l i c i n , m a l t o s e an d
g lu c o s e w i t h t h e p r o d u c t io n o f a c l o t and p ro d u c e d a c i d
in litm u s m ilk .
I n v iew o f t h i s r e a c t i o n t h e c u l t u r e
t e s t e d w as t h o u g h t t o h a v e c o n t a i n e d s t r a i n s o f
S . v ir id a n s in a d d itio n to S . h a e m o ly tic u s.
F o r t h e p u rp o se o f c o m p ariso n t h r e e ty p e c u l t u r e s
w ere a l s o s u b je c te d t o th e t e s t .
S. M a stitld is.
T h e ir r e a c t i o n s w ere -
A. C . i n l a c t o s e , s a l i c i n , m a n n ite ,
m a l t o s e , a n d g l u c o s e an d A i n l i t m u s m i l k .
S. In freq u en s.
A. C . i n s a l i c i n , m a n n ite , m a lto s e and
g l u c o s e an d A . i n L .M .
S . E q u i.
G ro u p I I
ly tic
A. C . i n s a l i c i n o n ly .
c o n t a i n e d t h e few s t r a i n s w h ich w ere
in n a tu re .
A ll th r e e fe rm e n te d l a c t o s e ,
haem o­
saccha­
r o s e r a f f i n o s e , s a l i c i n , m a lto se and g lu c o se w ith th e
p r o d u c t i o n o f a c l o t , and a c i d i n litm u s m i l k .
F ro m
t h i s i t was i m p o s s i b l e t o s a y m o re t h a n t h a t t h e y w e r e
s t r a i n s o f S . v i r i d a n s , a f a c t a l r e a d y e l i c i t e d from
th e b lo o d a g a r p l a t e .
Two o f t h e s e s t r a i n s w e r e r e ­
c o v e r e d fro m t h r o a t s , one d u r i n g an a t t a c k o f s c a r l a ­
t i n a and one fro m a c o n t a c t .
fro m th e f a e c e s .
T he t h i r d was r e c o v e r e d
A ppended t o e a c h s t r a i n i n G roup I
w as a s h o r t n o t e r e g a r d i n g i t s
w i t h i n t h e h o s t and i t
s o u rc e and a c t i v i t y
sh ow s c l e a r l y t h a t t h e m ore
a c t i v e s t r a i n s i n a f e r m e n t a t i v e r e s p e c t w ere c u l t u r e d
g e n e ra lly /
g e n e r a l l y f r o m l e s i o n s w h e r e t h e l o c a l u p s e t was g r e a t e s t .
D e c is iv e r e a c t i o n s w ere o b ta in e d w ith th e m a jo r it y o f
s t r a i n s t e s t e d , n o ta b le e x c e p tio n s b e in g th o se f a l l i n g
i n t o S e c t i o n s VI a n d V I I .
Of th e s e th e s t r a i n s f a l l ­
i n g i n t o S e c t i o n V I I sh ow ed n o e v i d e n c e o f v i r u l e n c e
on c l i n i c a l g r o u n d s .
I t w as a l s o w o r t h y o f n o t e t h a t
th e ty p e c u ltu r e s r e a c te d a s e x p e c te d in th e in s ta n c e s
o f S . e q u i and S . m a s t i t i d i s b u t t h a t S . in f r e q u e n s
fa ile d
to a tta c k la c to se fo r a ty p ic a l re a c tio n .
U t i l i s i n g a l l t h e known f e a t u r e s o f t h e s e s t r a i n s
t a b l e s w e r e m ade t o s e e I f t h e m o r p h o l o g i c a l a n d c u l t ­
u r a l c h a r a c t e r i s t i c s w ere o f d i f f e r e n t i a l v a lu e b u t th e
c o n c l u s i o n w as d r a w n t h a t t h e s e f e a t u r e s w e r e c a p a b l e
o f to o c o n s id e ra b le v a r i a t i o n .
The v a l u e o f t h e haem o­
l y t i c t e s t w as u p h e l d b e i n g o n l y u p s e t o n c e a s n o t e d
b efo re.
At th e o n se t o f th e su g ar fe rm e n ta tio n t e s t doubt
w as e n t e r t a i n e d a s t o t h e i r v a l u e .
O p in io n s w ere re a d
w h ich s t a t e d t h a t t h e r e s u l t s w e re u n s t a b l e and l i a b l e
t o v a r i a t i o n w i t h t h e m edium i n w h i c h t h e o u l t u r e h a d
b e e n grow n.
In o rd e r to o b v ia te t h i s
so u rce o f e r r o r
a l l s t r a i n s w ere c u l t u r e d on a p r e c i s e l y s i m i l a r m anner
and t o o b v i a t e v a r i a t i o n s i n th e f e r m e n t a t i v e pow ers o f
t h e s t r a i n s , e a c h t e s t w as t r i p l i c a t e d w:I t h ,
c a s e s , s im ila r r e s u lts .
in a l l
E ncouraged by t h e s e r e s u l t s
a n e x t e n s i o n o f t h e t e c h n i q u e w as made t o i n c l u d e
s t r a i n s w h i c h h a d b e e n g ro w n p r e v i o u s l y o n o r d i n a r y
ag ar/
95.
a g ar* b lo o d
a g a r and 3 $ ,
The r e s u l t s
w e r e o n c e m o re u n i f o r m w i t h v e r y
6 f0
and
9%
g ly c e rin ©
agar.
o c c a sio n a l
v a r i a t i o n a n d a n o p i n i o n was f o r m e d t h a t t h e b i o c h e m i c a l
t e s t s a p p e a re d t o o f f e r an a c c u r a t e and c o n s i s t e n t d i f ­
f e r e n t i a t i o n b e tw e e n t h e s t r a i n s w h ic h w ere b e i n g r e ­
covered d u rin g th e c o u rse o f th e i n v e s t i g a t i o n .
C o m p lem en t f i x a t i o n t e s t s w e r e t h e n a p p l i e d t o a
f u r t h e r s e r i e s o f o r g a n i s m s , t h e m e th o d an d t e c h n i q u e
e m p lo y e d a g a i n b e i n g t h a t o f s t a n d a r d l a b o r a t o r y p r a c ­
tic e .
Each
(V .l)
and a
t e s t w as c a r r i e d o u t i n t h e f o r m
illu stra te d
p o s i t i v e r e s u l t was n o t e d o n l y w h e n l y s i s
o c c u rre d th ro u g h o u t th e f u l l range o f tu b e s .
F o rty -
se v e n s t r a i n s w ere s e l e c t e d i n c l u d i n g ty p e c u l t u r e s
and t e s t e d u s in g a n t i s e r a p ro d u c e d a g a i n s t t h e ty p e
c u ltu re s.
The r e s u l t s o f t h e s e t e s t s w ere t a b u l a t e d .
EXAldPLE
i0 .2 5 c c . S . E . + 0 . 0 5 c c . I S . +
*
a
+ a
+
a
a
+ a
+
a
a
+ a
+
a
a
+ a
+
OF
TEST
1 M .H .D . C .
2
*
*
3
*
"
4
*
*
5
*
*
S .E .= S t r e p t o c o c c a l E m u lsio n .
C . = C o m p le m e n t.
CONDUCTED.
In c u b a te d + 1 c o .
w ith
+
F requent
+
S h ak in g f o r
+
90 m in u te s
+
a t 37°C .
■
•
"
n
I . S . Immune S e r u m .
S . R . C . S e n s i t i s e d Red
C o rp u s c le s .
S .R .C .
«
«
"
"
R e su lt
TABLE
S .p y o g .
Name.
S .in f.
17.
S .e q u i.
S .e n g .
S .S a l.
S. F aea.
-
-
-
+
-
-
-
-
-
-
-
-
H . McK. 1 0 . 3 4
+
+
W. G.
1 0 .3 4
-
+
A. C.
1 0 .3 4
-
+
S. u .
-
-
J . B.
+
+
-
-
-
+
M. McC.
-
+
-
-
-
-
H. R.
-
-
-
-
-
-
J . S.
-
-
+
-
-
-
A. McD.
-
-
-
-
-
-
S.M. I I .
-
-
-
-
-
-
S.M. I I I .
-
-
-
-
-
-
J • G.
-
-
-
-
-
-
R. P . 1 1 . 3 4
-
+
-
-
-
-
B.C.
-
+
-
-
-
-
H. J .
-
-
+
-
-
-
J . G.
-
+
-
-
-
-
M. B .
-
+
-
-
-
-
C . D. 1 1 / 3 4
-
-
-
-
-
-
M.McC. 1 1 . 3 4
-
-
-
-
-
-
-
-
-
-
-
-
-
+
+
-
-
-
M. M.
+
-
-
-
-
-
I . R. I .
+
+
-
-
-
-
I . R. I I .
-
-
-
-
-
-
do.
C »D.
3 .3 5
3 .3 5
+
-
97.
T a b le 1 7 . o o n t d .
----Name.
S .in f.
S .e q u i.
-
-
-
B .H .
-
-
-
A. McM.
-
-
C J3.
-
A.McD. 'B*
J .A •
S .p y o g .
1•
S .& n g .
S .F a o a .
S’. S a l .
-
-
-
-
-
+
-
-
-
-
-
-
-
-
-
+
-
-
-
-
W.G.
-
-
+
-
-
-
A .S .
-
-
-
-
-
-
G.D.
-
+
+
-
-
-
R.B.M.
-
-
-
+
-
-
J .P . 111.
-
-
-
-
+
-
-
-
-
-
R.K.
-
-
-
-
-
-
R .P . 3 . 3 . 3 5
-
-
-
-
-
-
J 3 • 6 .3 5 •
-
-
-
-
-
-
H.McK. 7 . 3 5
-
-
•
-
-
-
D.McN.
-
-
-
+
-
-
O.H.
+
—
*
•
•
3 .3 6 .
•
«
B a s e d o n t h e r e s u l t s o f t h i s t e s t I t w as p o s s i b l e t o
form g ro u p s r e l a t i n g th e v a r i o u s s t r a i n s t o t h e ty p e
c u ltu re .
G roup 1 . /
-
98.
G ro u p I .
R e la tin g of S . e r y s ip e la to s is .
R .B .M . a n d D . McN.
G ro u p I I .
7 .3 5 .
R e la tin g to S . pyogenes.
M .H . 3 . 3 5 . C .H . an d M.M. 1 1 . 3 4 .
G ro u p I I I . R e l a t i n g t o S . p y o g e n e s a n d
S . in fre q u e n s .
G ro u p I V .
I .R . 1.
R e la tin g to S. in fre q u e n s.
A .C • 1 0 . 3 4 : A . McD. ' B 1 : M. McC. 7 . 3 5
B .C .: R .P .
1 0 .3 4 : R .P . 3 .3 5 : J . G . :
an d M.B •
G ro u p V .
R e l a t i n g t o S . i n f r e q u e n s an d S . e q u i
H.McK. 1 0 . 3 4 : W .G .: C .D . 1 . 3 5 : and
C »D. 3 . 3 5 .
G ro u p V I .
R e la tin g to S . equi
S .M .: W .G .: H . J . : J . s . : A.McL.
G ro u p V I I . I n d e t e r m i n a t e s t r a i n s r e l a t i n g t o n o n e
o f th e ty p e c u l t u r e s .
H .R : M.McC . 3 . 3 5 * S .M . 1 1 : S .M . I I I ,
I . R . 1 1 : J .A . 1 : J . G : C .D . 1 1 . 3 4
B J I : M.McC• 1 1 . 3 4 : C 3 : J . P .
R .K : J J :
Ill,
6 . 3 5 H.McK. 7 . 3 5 : A . S .
T h a t i s , r e a s o n a b l y c l e a r c u t r e a c t i o n s w ere g iv e n i n
a p p r o x im a te ly one h a l f o f th e s t r a i n s ex am in ed .
F e a tu re s o f i n t e r e s t w e re :I.
T he l a r g e n u m b e r o f s t r a i n s w h ic h a p p e a r e d t o b e
u n r e l a t e d to th e ty p e c u l t u r e s .
II.
III./
The s t r a i n s w h ich w ere r e l a t e d
to 2 ty p e c u l t u r e s .
III.
T he o v e r t u r n i n g o f t h e h a e m o l y s i s t e s t o n 2
o c c a sio n s.
IV .
T he s u b s t a n t i a t i o n s e r o l o g i c a l l y o f p r e v i o u s l y
a s c e rta in e d b io -c h e m ic a l f e a tu r e s
V.
(R .B .M .= S . p y o g e n e s ) .
T he c l a s s i f i c a t i o n a s S . e q u i o f o n e s t r a i n w h e re
t h e h a e m o l y s i s t e s t was d o u b t f u l .
T he f a i l u r e t o r e l a t e e a c h s t r a i n e x a m in e d t o a
t y p e c u l t u r e r e s u l t e d i n a n a t t e m p t b e i n g made t o d i s ­
c o v e r t h e r e l a t i o n s h i p b etw een th e v a r i o u s s t r a i n s
w h ic h w ere i s o l a t e d fro m t h e s i n u s e s .
as in th e p re v io u s in s ta n c e u t i l i s i n g
T h i s w as d o n e
a n tise ra p re ­
p ared a g a in s t s e le c te d s in u s s t r a i n s in p la c e o f th o se
a g a i n s t th e ty p e c u l t u r e .
The r e s u l t s w e r e t a b u l a t e d
and a p p e a r in T a b le 18.
TABLE 1 8 .
S .U .
M.M.
J .S .
I .R .
C .D .
W.G.
+
+
+
+
+
A .C .
+
+
+
S .N .
+
+
+
+
-
J .B .
+
+
+
+
-
H .R . 1 .
+
+
1
+
-
J .S .
+
+
+
-
+
S .M . 1 1 .
+
-
-
+
-
J .G .
+
-
-
-
-
R .P . 1 0 .3 4
+
+
-
-
-
C .D . 1 1 . 3 4
+
+
+
+
+
S tra in .
+
100.
TABLE
S tra in .
1 8 . ( c o n tin u e d )
S.M .
M.M.
J .S .
I.R .
C .D .
G «D • 3 . 3 5
+
+
+
+
+
M.M.
+
+
+
-
-
M. McC. 1 . 3 5
-
+
-
+
+
I .R . 1.
+
-
-
+
-
I.R . 11.
+
-
-
+
-
J .A . 1 .
+
-
-
-
+
A . McM.
+
+
-
-
+
A . McD• *B1
-
-
-
+
-
W.G.
+
+
-
-
+
A .S .
+
-
-
wm
+
G .D .
+
+
-
-
-
R .B .M .
-
-
-
-
-
M .H. 3 . 3 5
+
-
-
+
-
R .K .
+
-
-
-
-
R .P . 3 .3 5
-
-
-
-
-
J . B . 7 .3 5
+
-
-
-
-
D . McN.
+
-
-
-
+
0 .H .
+
-
-
-
+
S .in fre q u e n s .
+
+
-
-
+
S .e ry s ip .
+
+
-
-
-
S .fa e c .
+
-
+
-
+
S .p y o g e n e s
-
-
+
+
+
S .e q u l
-
—
-
-
-
A c o n s i d e r a b l e g r o u p a s s o c i a t i o n was show n a m o n g s t
t h e s e o r g a n i s m s an d i n o n l y a f e w i n s t a n c e s w as a c l e a r
r e l a t i o n s h i p e x h i b i t e d b etw een t h e v a r io u s s t r a i n s .
T hese is o la te d
e x a m p le s w e r e -
X.
J . A . 1•
II.
J . G . : R .K .: J 3
III.
A. McD. ' B ' = I . R . 1 .
—:
C . D•
: = S . M.
A g g l u t i n a t i o n t e s t s w ere th e n c o n d u c te d .
The
d i l u t i o n s u s e d w e r e 1 i n 1 0 0 , l i n 2 0 0 , 1 i n 4 0 0 an d
1 i n 800 w h ich w ere f o u n d b y p r e v i o u s e x p e r im e n t t o b e
w ith in th e t i t r e
o f th e v a rio u s a n t i s e r a b u t o th e rw ise
t h e t e c h n i q u e w as s t a n d a r d .
T he r e s u l t s w e r e t a b u l a t e d ,
n u m e ra ls up t o 4 b e in g u se d to i n d i c a t e th e d i l u t i o n a t
w h i c h a g g l u t i n a t i o n w as o c c u r r i n g .
TABLE
1 9 ./
i
n
1
n
s
1
•
h-
' *
«
3
’ 3
3 > a 3
I
I
>
£
%
CO
tH
E
(6
5
C0
CO
o
0
ta
5 3 5 3'
03
>»
u
H
CO
•H
&
W
I
I
I
I
f
I
f
CO
03
■H
T3
tH
■p
■H
P
03
H
H
<6
a
CO
03
e
1
©
<H
e
•H
CO_
ca
©
S
©
110
•"*
o
>»
>
>
r-l
>
>
H
M
H
H
H
ft
CO
E
(
«
*
£+ r
H• oO
^•
CO
W H
^
*
•
<5
^
*
*
•
•
»-3
* to
d
« o
iH
• to
•
4• _H:
»•
o
O IQ
s w• • «
O H
»
3
r-H
M
•
•
♦
«
m
•
*
<•
a
O
a•
<J
CQ
■H
rH
a
M
o
H
©
05
M
>
M
rH
rH
rH
&
rH
rH
rH
«H
CO
§
P.
ca
5>
•H
c3
CO
•
CO
■p
oS
rH
©
PH
m
rr
W
>
19.
(c o n tin u e d )
■tH
w
Hi
5
rH
>
H
f5
rH
rH
CO
w
co
n
■H
rd
•H
■P
■H
+3
m
a
H
CO
0}
1
&
©
S -i
CO
©
©
PI
©
bO
rH
rH
rH
o
ft
m
§
bO
CO
•H
■P
(Q
to
to
•
CO
•
ca
O
•p
co
•
n
o
o
a
.
<J
©
Q
►a
©
to
to
•
is
•
w
a
•
a
■p
<p
o
•
o
The t y p e c u l t u r e s , o n t h e s e t e s t s , w e r e c a p a b l e o f
d i f f e r e n t i a t i o n w ith th e e x c e p tio n o f S . s a l i v a r i u s .
In 2 In sta n c e s
te sts
( S . e r y s i p e l a t o s u s and S .e q u i)
th e se
ap p eared to g iv e a c l e a r l i n e o f d e m a rc a tio n b u t
i n o t h e r 3 (S .p y o g e n e s , S . f a e c a l i s and S .i n f r e q u e n s )
t h e c o m p le m e n t f i x a t i o n t e s t s
a l l o w e d a w id e r e l a t i o n ­
s h i p w h i c h w as a n n u l l e d b y t h e a g g l u t i n a t i o n t e s t .
I t w as i n t e r e s t i n g t o n o t e t h a t S . p y o g e n e s an d
S . f a e c a l i s w ere i n d i s t i n c t l y s e p a r a t e d .
T he s e r o ­
l o g i c a l r e a c t i o n s o f S . s a l i v a r i u s w ere g e n e r a l and
n o n -sp e c ific .
Of t h e o t h e r s t r a i n s o f s t r e p t o c o c c i w h i c h w e r e
e x a m i n e d i n a s i m i l a r m a n n e r , tw o w h i c h w e r e r e c o v e r e d
f r o m s i n u s e s an d w e r e s i m i l a r o n m o r p h o l o g i c a l and
c u l t u r a l g ro u n d s w ere c o n s i s t e n t i n t h e i r r e a c t i o n s .
T h e s e s t r a i n s w e r e M.M. 1 1 . 3 4 a n d D.McH. 6 . 3 5 an d
c o r r e s p o n d e d r e s p e c t i v e l y w ith S .p y o g e n e s and S . e r y s i p ­
e la to su s.
O n ly o n e o t h e r s t r a i n , r e c o v e r e d f r o m a
t h r o a t i n h e a l t h a n d s i t u a t e d i n g r o u p I I I , w as c l e a r l y
d e m a rc a te d .
T h i s w as s t r a i n R.B»M. w h i c h c o r r e s p o n d e d
w ith S .e r y s ip e la to s u s .
T he r e m a i n d e r o f t h e o r g a n i s m s
e x a m in e d a p p e a r e d t o l a c k s p e c i f i c c h a r a c t e r s an d
beyond b e in g a b le to say t h a t a c lo s e r e la tio n s h ip
e x i s t e d b e t w e e n th e m a n d o t h e r m em bers o f t h e g r o u p
S . h a e m o l y t i c u s , w as i m p o s s i b l e o n t h e i r r e a c t i o n .
C o n f u s i o n o c c u r r e d i n some i n s t a n c e s w h e r e a
s tra in /
s t r a i n r e l a t e d t o t h e g ro u p S . h a e m o ly tic u s on one t e s t
was m o re c l o s e l y a l l i e d
t o g ro u p S . f a e c a l i s on a n o th e r
an d v i c e v e r s a .
I n v ie w o f th e i n a b i l i t y
o f th e p re c e d in g t e s t s
to d i f f e r e n t i a t e th e v a rio u s s tr a in s of s tre p to c o c c i
w h i c h w e r e r e c o v e r e d f r o m t h e s i n u s e s ab s o r p t i o n - a g g l u t ­
i n i n t e s t s w ere c a r r i e d
o u t am ongst t h e 6 s t r a i n s
a g a i n s t w h ic h a n t i s e r a had b een p r e p a r e d .
The r e s u l t s
w ere e n t i r e l y n e g a t i v e each a n tig e n b e in g c a p a b le o f
a b so rb in g th e a g g lu tin in p re s e n t in th e a n tis e r a
a g a i n s t w h ic h i t
was b e i n g t e s t e d .
The l a c k o f s p e c i f i c i t y
am ongst t h e s e s in u s
s t r a i n s w as t h o u g h t t o b e d u e t o t h e i r a v i r u l e n t n a t u r e ,
a f e a t u r e w h ic h w as s u s p e c t e d f r o m t h e a l m o s t e x c l u s i v e
a p p e a r a n c e o f a c o lo n y fo rm on c u l t u r e w h ich c o i n c i d e d
w i t h t h e ’ sm ooth*
on t h i s
io n s .
f o r m d e s c r i b e d b y Cow an.
V a ria n ts
c o l o n y f o r m w e re r a r e b u t o c c u r r e d o n 3 o c c a s ­
I n o n e o f t h e m t h e * ro u g h * v a r i a n t w as v i r u l e n t
o n i n j e c t i o n i n t o a m ouse w h e r e a s t h e c o l o n y e x h i b i t i n g
t h e m o re common 's m o o th *
f e a t u r e s w as a v i r u l e n t .
I t a p p e a re d t h a t th e s in u s e s w ere i n f e c t e d w ith
s t r e p t o c o c c i l a r g e l y b e lo n g in g to t h e g ro u p S . haem o­
l y t i c u s and t h e r e f o r e p o t e n t i a l l y p a t h o g e n i c , a lth o u g h
t h e i r a p p e a r a n c e o n c u l t u r e an d t h e i r r e a c t i o n on
t e s t i n g i n d i c a t e d t h a t t h e i r p a t h o g e n i c p o w e r w as l o w .
OTHER
ORGANISMS
IH
ASSOCIATION
WITH
STREPTOGOOCI
H i t h e r t o m e n tio n e d o n ly i n p a s s i n g , o rg a n ism s
o t h e r t h a n s t r e p t o c o c c i w ere r e c o v e r e d fro m t h e s i n u s e s
w h ich w ere i n v e s t i g a t e d .
T hese w ere m a in ly v a r i e t i e s
o f s t a p h y l o c o c c i and d i p h t h e r o i d h a c i l l i w i t h a few
c o l i f o r m b a c i l l i a n d 3ome o t h e r s w h i c h i t was f o u n d
im p o s s ib le t o nam e.
G ross s t a t i s t i c s
re v e a le d th a t
t h e s e o rg a n is m s w ere r e c o v e r e d i n t h e f o l l o w i n g num bers
S ta p h y lo c o c c i
.......................
D ip h th e ro id b a c i l l i
....
21
.............
6
.........................................
5
C o lifo rm b a c i l l i
O th e rs
86
W h i l s t t h e s e b a c t e r i a w e r e n o t m ade t h e s u b j e c t
o f an i n v e s t i g a t i o n so d e t a i l e d as t h a t i n th e ca se
o f th e s t r e p t o c o c c i , s t e p s w ere ta k e n to w a rd s e s t a b l i s h
i n g a p a r t i c u l a r i d e n t i t y i n many i n s t a n c e s .
S t a p h y l o c o c c i , t h e l a r g e s t g r o u p , w ere s u b j e c t e d
t o th e fo llo w in g t e s t s .
(I)
T h e c o l o u r o f t h e c o l o n i e s g ro w n o n a n o r d i n a r y
a g a r p l a t e f o r 2 4 h o u r s a t 3 7 ° C . was n o t e d i n
a l l in sta n c e s.
(II)
S e v e r a l s t r a i n s w e r e e x a m in e d b i o c h e m i c a l l y ,
u tilisin g
a r a n g e o f s u g a r s and g lu e o s I d e s
s im ila r to t h a t i n th e case o f th e s tr e p to c o c c i
(III)
A few s t r a i n s w ere t e s t e d f o r v i r u l e n c e , by
in je c tin g /
107
i n j e o t i n g 0 .5 c c . o f a 24 h o u r b r o t h c u l t u r e
i n t o a m ouse ( i n t r a p e r i t o n e a l l y ) .
T he f i r s t t e s t r e v e a l e d t h a t t h e r e w e r e 2 0 s t r a i n s
o f s t a p h y l o c o c c u s a u r e u s , 05 s t r a i n s o f s t a p h , a l b u s
and 1 s t r a i n o f s t a p h , c i t r e u s .
A c k n o w le d g in g t h e
g e n e r a l o p in io n t h a t s ta p h , au reu s i s
t h e m ost p a t h o ­
g e n ic w ith s ta p h , a lb u s as a v e ry f e e b le p ath o g e n ic
a n d s t a p h , c i t r e u s a n o n - p a t h o g e n i c s a p r o p h y t e , i t was
i n f e r r e d t h a t t h e m a j o r i t y o f t h e s i n u s e s w ere i n f e c t e d
w ith s t r a i n s p o te n tia lly p a th o g e n ic .
T he r e l a t i v e i n ­
c id e n c e o f a u re u s t o a lb u s s t r a i n s m o d ifie d t h i s
in ­
f e r e n c e b y i n d i c a t i n g t h a t t h e p a t h o g e n i c i t y was o f a
lo w o r d e r .
T h e m a rk e d r a r i t y
of s tra in s c la s s ifie d
s t a p h , c i t r e u s w as o f i n t e r e s t ,
as
i t b e in g e x p e c te d t h a t
a v a r i e t y w h i c h a b o u n d s on t h e s k i n s u r f a c e w o u ld b e
p re s e n t in a g re a te r in c id e n c e .
S t r a i n s e x a m in e d u n d e r t h e s e c o n d h e a d i n g w e r e
e le v e n i n num ber.
H e r e t h e w id e f e r m e n t a t i v e p o w e rs
o f th e s ta p h y lo c o c c i n e c e s s ita te d th e a d o p tio n o f a
c l a s s i f i c a t i o n o u t l i n e d i n t h e M .R .O 's S y s t e m o f B a c t ­
e rio lo g y .
U t i l i s i n g m a n n ite f e r m e n ta tio n as th e d i f f e r ­
e n t i a l f a c t o r and n e g l e c t i n g c o lo n y p ig m e n ta tio n t h i s
m e th o d d e l i n e a t e s f o u r v a r i e t i e s o f s t a p h y l o c o c c i »
(1 ) P y o g e n ic .
(2) S k in .
(3 ) S c u r f A and (4 ) S c u r f B .
P rom t h e e l e v e n s t r a i n s
a n d tw o w e r e ' s k i n ' .
e x a m in e d 9 w e r e ' p y o g e n i c '
I n tr o d u c in g th e p r e v io u s ly n o te d
f e a t u r e o f p i g m e n t a t i o n t h e 'p y o g e n i c '
' a lb u s' /
s t r a i n s w ere
108
’ a lb u s*
's k in '
i n 6 i n s t a n c e s an d ' a u r e u s ’ i n t h r e e a n d t h e
s t r a i n s w ere 'a u r e u s *
in th e o th e r .
i n one i n s t a n c e and 'a l b u s '
In th is l a t t e r re sp e c t a lo ss o f v ir u ­
l e n c e w o u ld a c c o u n t f o r t h e p r e s e n c e o f a n a u r e u s s t r a i n
w h ic h d i d n o t f e r m e n t m a n n ite .
F ro m t h e s e t e s t s
i t was
f e l t t h a t t h e m a j o r i t y o f t h e s t r a i n s i s o l a t e d w ere
p o t e n t i a l p a th o g e n s i n v ie w o f th e h i g h p e r c e n ta g e
c l a s s i f i e d a s 'p y o g e n ic '
i n a n o n - s e l e c t e d sa m p le .
T he t h i r d t e s t was a p p l i e d t o 8 s t r a i n s , t h r e e o f
w h ich w e re 'a u r e u s '
and t h e re m a in d e r 'a l b u s '
on t h e
p ig m e n ta tio n t e s t
( o n e o f t h e l a t t e r w as ' p y o g e n i c '
b io c h e m ic a lly ).
None o f t h e s e e i g h t s t r a i n s t e s t e d
w ere v i r u l e n t b i o l o g i c a l l y .
T he a n i m a l s u s e d w e r e m ic e
a s r a b b i t s w ere n o t a v a i l a b l e f o r t h i s t e s t d e s p i t e
t h e i r known g r e a t e r s u i t a b i l i t y .
From a n a g g r e g a t e o f a l l t h e f e a t u r e s i t w as c o n ­
c lu d e d t h a t t h e s i n u s e s w ere l a r g e l y i n f e c t e d b y p o t e n t ­
ia lly
p a t h o g e n i o s t a p h y l o c o c c i b u t t h a t t h i s p o w e r was
v e r y lo w .
T he n e x t l a r g e s t g r o u p o f o r g a n i s m s i s o l a t e d w e r e
t h e d i p h t h e r o i d b a c i l l i w h ere 21 s t r a i n s w ere i s o l a t e d
in pure c u ltu r e .
T he d i f f e r e n t i a l f e a t u r e s u t i l i s e d
h e r e w ere:
(I)
M o rp h o lo g ic a lj th e a p p e a ra n c e o f a 24 h o u r
o
a e r o b i c g ro w th a t 37 C . b o t h on a n o r d i n a r y A gar
p l a t e and on L o e f f l e r * s se ru m .
(II)
The a p p e a ra n c e o f th e b a c i l l i i n th e s e c o lo n ie s
w hen s t a i n e d b y G ra m s '
(III)/
an d P u g h ' s m e t h o d s .
109.
(III)
T he B i o c h e m i c a l f e a t u r e s o v e r t h e same r a n g e o f
s u g a rs a s t h e s t a p h y l o c o c c i and t h e s t r e p t o c o c c i
an d
( IV )
The v i r u l e n c e i n m ice u t i l i s i n g
q u a n titie s as
b efo re.
U n f o r t u n a t e l y t h e s e o r g a n i s m s p r o v e d m ore d i v e r s e
i n t h e i r c h a r a c t e r i s t i c s t h a n an y o f t h e o t h e r s r e ­
co vered.
F i n a l l y fro m t h e d a t a o f s e c t i o n (1 ) and (2)
a b o v e , 19 s t r a i n s w e r e d i v i d e d i n t o 6 g r o u p s a s f o l l o w s : G ro u p I .
One e x a m p l e . .
C i r c u l a r s m o o t h s u r f a c e , 1 mm.
d i a m e t e r c o l o n i e s o n L o e f f l e r s m e d iu m .
A sim ila r
g r o w th w i t h a r o u g h s u r f a c e on o r d i n a r y a g a r .
T y p ic a l
C h i n e s e l e t t e r a r r a n g e m e n t , o f Gram P o s i t i v e B a c i l l i
w h ich w ere s t a i n e d u n i f o r m l y b y P u g h 's s t a i n w ith t h e
e x c e p t i o n o f a c l e a r c e n t r a l s e p tu m .
G roup I I .
Two e x a m p l e s .
L o e ffle r:
C irc u la r irre g u la r
e d g e d r o u g h s u r f a c e c o l o n i e s 1 mm. d i a m e t e r ;
agar:
sm a ll p in p o in t c o lo n ie s .
O rd in a ry
Gram p o s i t i v e : P u g h s :
m edium s i z e u n i f o r m l y s t a i n i n g r o d s .
G ro u p I I I .
Two e x a m p l e s .
c o lo n ie s.
u la r edges.
O rd in a ry a g a r i
Gram p o s i t i v e .
s ta in in g b a c i l l i .
G ro u p I V . /
L o e ffle r:
L a rg e , f l a t , sh in y
A s i m i l a r g ro w th w ith i r r e g ­
Pughs:
S m all u n i f o r m l y
G ro u p I V .
L o e ffle r.
1 mm. d i a m e t e r .
S h in y , o p aq u e, convex up c o lo n ie s
O rd in a ry a g a r:
l u x u r i a n t g ro w th .
Gram p o s i t i v e .
A s im ila r but le s s
Pughs:
G e n e ra lly
s m a ll u n if o r m ly s t a i n i n g r o d s w i t h p le o m o rp h ic fo rm s
e x h i b i t i n g g r a n u l a r m a rk in g and o c c a s i o n a l B i p o l a r
s ta in in g .
G roup V .
L o e ffle r:
L arg e i r r e g u l a r l y c i r c u l a r f l a t ,
s h in y c o l o n i e s , n a p le s w h ite i n c o lo u r : O rd in a ry a g a r
A s i m i l a r b u t l e s s lu x u r ia n t g ro w th .
Pughs:
Gram p o s i t i v e .
L a r g e u n i f o r m l y s t a i n e d b a c i l l i w i t h a fe w
m ark ed ly g r a n u l a r v a r i a n t s .
G ro u p V I .
L o e ffle r:
S m a ll w h ite s t r i n g y c o l o n i e s .
O rd in a ry a g a r:
s i m i l a r b u t l e s s l u x u r i a n t g ro w th s.
Gram p o s i t i v e .
P ughs:
S m all s l i g h t l y c u rv e d b a c i l l i
u n ifo rm ly s ta in e d .
I t w i l l b e n o t e d t h a t o n l y 19 s t r a i n s w e r e t h u s
c la s sifie d .
T he tw o r e m a i n i n g w e r e i n s u f f i c i e n t l y
e x a m in e d t o a d m i t o f t h i s d i f f e r e n t i a t i o n .
T he b i o c h e m i c a l f e a t u r e s w e r e a s c e r t a i n e d i n
t h i r t e e n o f t h e n i n e t e e n s t r a i n s g ro u p e d above and
w hen r e l a t e d t o t h e m o r p h o l o g i c a l a n d c u l t u r a l c h a r ­
a c t e r i s t i c s gave th e fo llo w in g r e s u l t s .
G ro u p I .
T h e o r g a n i s m w h i c h g a v e t h e s e f e a t u r e s was
0 . H o ffm an n .
G ro u p I I . /
G ro u p I I .
E a c h o f t h e tw o s t r a i n s g a v e d i f f e r e n t f e r ­
m e n ta tio n r e a c tio n s .
G ro u p I I I .
S i m i l a r t o G ro u p I I .
One o f t h e s t r a i n s f e r ­
m en ted s a c c h a r o s e w h e re a s t h e o t h e r d i d n o t .
G ro u p I V .
C o n ta in e d a num ber o f d i f f e r e n t b io c h e m ic a l
r e s u l t s o n l y tw o s t r a i n s b e i n g s i m i l a r .
G ro u p V .
4 s t r a i n s g i v i n g r i s e t o tw o p a i r s s i m i l a r
b io c h e m ic a lly .
T h e s t r a i n s i n G ro u p VT w e r e n o t e x a m i n e d b i o ­
c h e m ic a lly .
The f e a t u r e s a d o p te d f o r c l a s s i f i c a t i o n w ere
t h o s e s u g g e s t e d i n T o p l e y a n d W i l s o n 1s P r i n c i p l e s o f
B a c t e r i o l o g y a n d im m u n ity r e s u l t i n g i n t h e e x a c t
d e f i n i t i o n o f one s t r a i n o n ly .
I n v iew o f t h i s , r e ­
c o u r s e w as h a d t o t h e g r o u p s s u g g e s t e d b y A ndrew es
(M .R .C . M o n o g ra p h 1 9 2 3 ) r e s u l t i n g i n tw o o f t h e s i n u s
stra in s fa llin g
In to h is
s u g g e s t e d G ro u p V a n d G ro u p VT.
T h e f e r m e n t a t i v e f e a t u r e s o f t h e v a r i o u s s t r a i n s ex a m ­
i n e d a r e show n i n t h e a c c o m p a n y in g T a b l e : -
112.
T A B L E
REACTIONS
IN
20.
H IS S '
SERUM
WATER.
S t r a i n N o . L a c t . S a c o . R a f . I n u l i n S a l . M ann. M a l t G l u o . G l y c .
L i t .M ilk
I.
A
-
-
-
-
-
A
A
-
S L .A .
II.
A
A
-
-
-
-
A
A
-
S L .A .
III.
-
-
-
-
-
-
A
A
-
S L .A .
IX .
A
A
-
-
-
-
A
A
-
SL .A .
X I.
A
-
-
-
-
-
A
A
-
-
X II.
A
-
-
-
-
-
A
A
-
-
XIV.
A
-
-
-
A
-
A
A
A
-
XV.
A
-
-
-
-
-
A
A
A
-
X V II.
A
A
-
-
-
-
A
A
-
A
X V III.
A
-
A
A
-
-
A
A
-
-
XX.
A
-
-
-
A
-
A
A
A
-
XXI.
A
-
"
•
*
A
A
A
'
A c o n c l u s i o n was f o r m e d t h a t t h e d i p h t h e r o i d
b a c i l l i i n f e c t i n g t h e s i n u s e s w ere d i f f e r e n t i n t h e i r
r e a c t i o n fro m th e v a r io u s s t r a i n s re c o rd e d i n th e
lite ra tu re .
T he f o r e g o i n g d e t a i l s w e r e o f a c a d e m ic i n t e r e s t
o n l y b u t t h e v i r u l e n c e t e s t , u t i l i s i n g m ic e a s b e f o r e ,
w as o f p r a c t i c a l i m p o r t a n c e an d t h e r e s u l t s show ed t h a t
o f e i g h t u n s e l e c t e d s t r a i n s , none w ere v i r u l e n t .
It
w as c o n c l u d e d t h e r e f o r e o n t h e s e r e s u l t s t h a t t h e
s in u s e s w ere i n f e c t e d by a s e r i e s o f d i p h t h e r o i d b a c ­
illi,
i n c l u d i n g C . H o ffm a n n b u t t h a t t h e s e w e re e i t h e r
s a p r o p h y t i c o r o f lo w p a t h o g e n i c p o w e r .
T h e ir ro le
w i t h i n t h e t i s s u e s o f t h e h o s t w i l l b e m o re f u l l y d i s ­
cu ssed I n a su c c e e d in g c h a p te r .
T h e t h i r d g r o u p o f o r g a n i s m s i s o l a t e d , m uch s m a l l e r
t h a n e i t h e r o f t h e f o r e g o i n g , c o m p rise d t h e C o lifo rm
b a c illi.
T h e s e w e r e 6 i n n u m b e r an d w e r e s u b j e c t e d t o
t h e r o u t i n e b io c h e m ic a l l a b o r a t o r y t e s t s f o r o rg an ism s
of t h i s g roup.
So t e s t e d t h e y w e r e :
(I) )
B.
( I I ) ) N .S .1 0 /3 3 .
(III) j
p n e u m o n ia e
B . N e a p o lita n u s.
(F rie d la n d e r)
(E m m eric h )
B . rh in o s c le ro m a tis .
( IV )
M .L .1 0 /3 4
B . p ro te u s. v u lg a ris .
(V)
D .M c N .3 /3 4 .
B . N e a p o lita n u s.
(E m m erich )
(V I)
M.McV.1 2 / 3 4
B . N e a p o lita n u s.
(E m m e ric h )
A l l o f th e m w e r e r e c o v e r e d f r o m l e s i o n s o p e n i n g
upon/
u pon t h e ab d o m in al w a l l , u p p e r t h i g h o r b u t t o c k s .
In
o n e i n s t a n c e a f a e c a l f i s t u l a was f o r m i n g a n d i n a n o t h e r
t h e y w ere r e c o v e r e d fro m a h e a l i n g a p p e n d ic e c to m y wound.
A f e a t u r e o f n o t e w as t h e i r r e m a r k a b l e s c a r c i t y .
F i n a l l y t h e r e w ere t h e o rg a n ism s i s o l a t e d b u t tin id e n tifie d .
T h ey w e r e 5 i n n u m b e r a n d p r e s e n t e d t h e
fo llo w in g f e a t u r e s .
S e rie s I .
A s m a l l Gram p o s i t i v e b a c i l l u s , w h ic h g re w
s p a r i n g l y u n d e r a e r o b i c an d a n a e r o b i c c o n d i t i o n s on
o r d in a r y m e d ia , p ro d u ced a s l i g h t b u t u n ifo rm t u r b i d i t y
on o r d i n a r y b r o t h and grew s p a r i n g l y i n b lo o d a g a r
p l a t e s w i t h o u t a n y a c t i o n o n t h e c o r p u s c l e s , was r e ­
covered in 3 in s ta n c e s .
One s t r a i n w as f r o m a h e a l i n g
s i n u s a n d was p r e s e n t i n a s s o c i a t i o n w i t h ‘ a f e w s t r e p t o ­
c o c c i.
T h e o t h e r tw o w e r e f r o m s i n u s e s v e r y e a r l y i n
t h e i r c o u r s e an d w e r e o b t a i n e d i n p u r e c u l t u r e .
T e sts
on s u g a r ran g es s u i t a b l e f o r C o lifo rm b a c i l l i o r
s t r e p t o c o c c i f a i l e d t o r e v e a l any f e r m e n t a t i v e p o w e rs.
T h e y d i d n o t g ro w o n M cConkeys a g a r .
I n tw o I n s t a n c e s
t h e y w e r e t e s t e d f o r v i r u l e n c e i n m ic e a n d f o u n d a v l r u le n t.
S e rie s I I .
T he o t h e r tw o e x a m p l e s w e r e Gram p o s i t i v e
d i p l o c o c c l , l a n c e o l a t e i n s h a p e , c a p s u la te d and p r o ­
d u c in g a h a e m o ly sis on b lo o d a g a r p l a t e s .
One g re w
i n t h e p r e s e n c e o f b i l e and f e rm e n te d l n u l i n b u t th e
absence/
115
a b s e n c e o f a v i r u l e n c e t e s t made i t
t h e o rg a n ism a pneum oco ccus.
im p o ssib le to c a l l
S ubsequent a tte m p ts to
r e c o v e r t h i 3 o rg a n ism f a i l e d .
The o t h e r d i d n o t g row o n b i l e an d w as s o f r i a b l e
th a t i t d ie d o ut in 3 g e n e ra tio n s of c u ltu r e .
I t g rew
b o t h a e r o b i c a l l y an d a n a e r o b i c a l l y a n d was r e c o v e r e d
on s e v e r a l o c c a s i o n s .
I t a p p eared t o have no fe rm e n t­
a t i v e p o w e r o n s u g a r s an d was a v i r u l e n t w h en i n j e c t e d
i n t o a m ouse.
T h a t i s , t h e s i n u s e s i n v e s t i g a t e d w ere open t o a
s e c o n d a ry i n f e c t i o n by o rg a n ism s o t h e r th a n s t r e p t o c o o c i b u t when t h e s e o r g a n i s m s w e r e i n v e s t i g a t e d
b a c t e r i o l o g i c a l l y t h e y w e r e f o u n d t o b e o f lo w p a t h o ­
g e n ic pow er w ith th e e x c e p tio n o f t h e c o lif o r m b a c i l l i .
An a t t e m p t made t o d i s c o v e r w h i c h o r g a n i s m was
m o s t commonly p r e s e n t , a n d t h e r e s u l t s o f 100 m i c r o ­
s c o p ic e x a m in a tio n s o f s in u s e x u d a te s w ere c o l l e c t e d .
T hese r e s u l t s w ere t a b u l a t e d
( T a b le 21) sh o w in g t h a t
t h e m o s t common o r g a n i s m a n d t h a t p r e s e n t i n g r e a t e s t
n u m b e r s i n t h e d i s c h a r g e w as t h e s t r e p t o c o c c u s , b e i n g
f o llo w e d b y s ta p h y l o c o c c i and f i n a l l y d i p h t h e r o i d
b a c illi.
I t w as a l s o n o t e d t h a t a s e c o n d a r y i n f e c t i o n
w as p r e s e n t m i c r o s c o p i c a l l y i n t h e v a s t m a j o r i t y o f
c a s e s i n d i c a t i n g t h a t i t was n o t a v e r y m in o r f e a t u r e
r e c o v e re d o n ly as a r e s u l t o f c a r e f u l c u l t u r e o f th e
pus fro m th e s i n u s e s .
A n o t h e r f e a t u r e was t h e i n ­
a b i l i t y , w ith one e x c e p tio n ,
b a c illi/
to d is c e rn tu b e rc le
b a c i l l i m i c r o s c o p i c a l l y a lth o u g h th e y w ere r e c o v e r e d
b i o l o g i c a l l y i n many i n s t a n c e s .
L a s t l y t h e n u m b e r 58
r e f e r r i n g to s tr e p to c o c c i does n o t in d ic a te t h a t i n th e
m a j o r i t y o f i n s t a n c e s when t h e y w e r e s e e n t h e y w e r e
p r e s e n t i n a d e g r e e much g r e a t e r t h a n o c c u r r e d w i t h an y
o f th e o th e r o rg a n ism s.
T A B L E
No. o f E x a m in atio n s
21.
..................................................................
N o . s h o w in g s e c o n d a r y i n f e c t i o n m i c r o s c o p i c a l l y
100
77
N o. o f o c c a s i o n s on w h ich O r g s . w ere s e e n J I .
S ta p h y lo c o c c i
............................
31
II.
S tre p to c o c c i
............................
58
III.
D ip h th e ro id B a c i l l i
IV .
O th e rs
V.
............
6
.............................................
2
T u b e rc le B a c i l l i
..................
1
Some a t t e n t i o n was a l s o p a i d t o t h e c y t o l o g y o f
t h e d i s c h a r g e , an d i t was n o t e d t h a t i n t h e m a j o r i t y
o f in sta n c e s th is
m ato ry p r o o e s s .
re se m b le d t h a t o f an a c u te in f la m ­
I n f a c t , o v e r a s e r i e s o f e x a m in a tio n s
o f a n y p a r t i c u l a r s i n u s i t w as n o t e d r e p e a t e d l y t h a t ,
as a seco n d ary i n f e c t io n a p p e a re d , th e d is c h a rg e l o s t
its
tu b e rc u lo u s c h a r a c te r g r a d u a lly .
I n c a s e s w here
t h i s i n f e c t i o n w as b y s t a p h y l o c o c c i o r d i p h t h e r o i d
b a c i l l i t h i s f e a t u r e was o f t e n n o t m a r k e d a l t h o u g h
p r e s e n t t o some d e g r e e b u t i n a l m o s t e a c h i n s t a n c e
w h e r e a s t r e p t o c o o c u s w as r e c o v e r e d i t w as a m a rk e d
fe a tu re .
and i s
An e x a m p le o f s u c h a n o c c u r r e n c e w as s e l e c t e d
s e e n i n T a b le 2 2 ..
©
•H
+
u
«
1
t
I
f
t
I
p
i ro
&0©
©o
I
I
OH
S
S
a
o
02
M
.
t
t
'
,
,
t
P
® •
fo 3 ©
o
w
J3 rH
©rH
H ©
HO
I
1X 7
01
01
o
I
I
I
I
+
+
I
I
+
t
+
I
t
*
I
+
+
I
+
I
I
I
I
I
I
+
I
I
I
1
'
I
I
I
I
to
to
s ,
to
to
V
tO
to
03
rH
03
to
s
O
8,
a
W
P
m
<
H
+
>»
rH
O
a*
©
u
©
o
©
■&
•H
Q
04
©
Sh
+3
CO
a
©
■o
t
CO
w
Q
rH
rH
V
ts
rH
rH
N
H
•*
03
rH
t
•*
to
N
rH
rH
\
o
H
TIME
o n s e t" s r
S in u s
Name Age S i t e o f D ie .
25 / 2 /3 5
C V .4 -7
I.L . C
6 / 2 /3 4
R .K . C.
CV.7 D V .l
P . P . (5
C V .4 -7
J .S . C
C V .6-D V .1
J .3 .
C V .4 -6
32
P .O . 0
D V .l,2 ,3 .
IV
I . R . C.
D V .5-10
1 9 2 9 /3 0
W.McD.C
D V .4 -6
1930
M.G. 0 .
DV.12 L V . l .
1 /3 4
Do.
0
Do.
C.
9/
2 /3 3
30 /
4 /3 5
4 /3 3
J.M cB .O
DV.12 L V . l
& 2.
28 / 1 1 /3 3
N . S . C.
DV.12 L V . l
& 2.
L V .1 - 5
8 / 9 /3 3
23 /
9/
l v .3 -5
A .G . C.
L .V .4
A.lficN.C
LV .4
H .R . C.
L V .3 - 4
1 5 /1 1 /3 2
J .S .
C.
L V .4 - 5
14 / 1 2 /3 4
M .L . C.
L V .2 - 3
1 0 /3 4
u .u . c.
S acro­
ilia c .
1930
Do.
Do. C
J . B. 0 •
P .A . 0 .
Do.
Sacrum
LV 3-5
-1 2
-1 8
21 24
*
*
3 te ri le
*q t a j h . A Lb.
♦ S tre p s .i)D o .ii)S .A n g in o s u s
♦
i ) B .H a e m .
♦
i ) B . i i ) B.Haem.
S ta p h A lb .
♦ S t r e p s (B)
* 3 t a Dh. A l t
a t a b h . Alti .(P|)
♦ >ta;o h
Dipfii .
S t aph, A l b . ( P )
*Di Dh.
♦S t j a p h . A l b .
s-tl, r e p s . (B )
(* l b )
♦ S tre p s
♦ 5 t r ap s
♦ S t a Dh. A]3 b .
S t r eps
♦ S tre p s(? )
♦ S t.A lb .
S tre p s
2 /3 3
♦ S ta p i . A l
DLph
1 / 5 /3 3
*
D ip h .B .
(2)
♦ S t , A lb
(n o n haem )
X
S ti r e p s
(n o , c u l t u r e d )
♦ S ta p h .A lb .
S tre p s .I & I I
B.Haem.
♦ S o r e o s . A l l B .H ae n.
B. Pro te u s Vu lg
♦ S t aph • A1 b .
S tre p
?
S ta p h .A lb .
♦ D ip h .
2 / l l / 31
6 /
♦ C a p su la te d C o c c i.
♦ S ta p h .A lb .
S t r e p .( N o n h a e m .)
♦ S te rile .
7 / 1 /3 1
27/
2 y ears & o v er.
♦ S ta p h . A i b
6 /3 1
6 /3 1
N . S . C.
D.McN.C
-11
* 4 t a p ti Au r
21/
Do.
10
♦ S t A lb
.Haem . S t r e p .
Lph. ( Jnnam e d )
6 /3 4
DV.10 L V . l
c.
8
i 16
RECOVERED.
?
A.McM.C
D.M. C.
V E R T E B R A E .
OF EXAMINATION IN MONTHS AND ORGANISMS
8 /3 2
1 1 / 1 0 / 3 4 *« t e r l i e
9 /3 0 .
♦ S t a p h A lp
C o l i f o rm
♦ S t r e p . (?)
♦ S tr e p 1 0 /3 4
B.Haem .
S ta p h .A u r.
B . Haem. S t r e p . ♦ 1 1 / 3 4 .
♦<;ita p h
♦ S t r e p s i ) i i ) n o n h aem .
♦ S t a p h . A tlr.
♦ S tre p s.
B.H aem .
♦ S ta p h . A lb .
(
.
(Groin
(
(Rt.Leg
(Thigh
(Groin
T h e r e a c t i o n o f t h e t i s s u e s o f t h e h o s t was a l s o
e s t i m a t e d f r o m t h e d e g r e e o f p h a g o c y t o s i s w h ic h was
o c c u rrin g .
I n a b o u t 30# o f c a s e s t h i s f e a t u r e was
p r e s e n t i n v a r y i n g d e g r e e an d g e n e r a l l y i n r e s p o n s e t o
an i n f e c t i o n by s tr e p t o c o c c i .
I n n u m e ro u s i n s t a n c e s
h o w e v e r t h e i n v a d i n g o r g a n i s m seem ed t o h a v e t h e u p p e r
h an d , d e s tro y in g th e a tta c k in g c e l l s .
The m ore g e n e r a l
l a c k o f a n ta g o n ism t o s ta p h y lo c o c c i and d i p h t h e r o i d
b a c i l l i w as f e l t t o u n d e r l i n e t h e s a p r o p h y t i c o r l o w l y p a th o g e n ic r o l e th e y f i l l e d
in th e s in u s e s as in d ic a te d
b a c te rio lo g ic a lly e a r lie r.
The c o m b in a tio n o f t h e s e o rg an ism s i n t h e s in u s e s
was a l s o o f i n t e r e s t and i n o r d e r t o i l l u s t r a t e t h i s
p o i n t e a c h a r e a was t a k e n s e p a r a t e l y .
TABLE
S3
- o p p o s ite .
The r e s u l t s o f e x a m in a tio n s o f s in u s e s a r i s i n g
f r o m t u b e r c u l o s i s o f t h e v e r t e b r a e w e r e shown i n T a b l e
2 3 r e l a t e d t o t h e p e r i o d o f t i m e a t w h ic h t h e e x a m i n a ­
t i o n s w ere m ade.
C l e a r l y shown was t h e f a c t t h a t t h e
b u l k o f t h e s e c a s e s w ere i n v e s t i g a t e d a t p e r i o d s a ro u n d
2 y e a r s o r m o re a f t e r t h e i n c e p t i o n o f t h e s i n u s and
t h a t t h o s e e x a m in e d a t p e r i o d s e a r l i e r t h a n t h i s
h a rb o u re d m a in ly s ta p h y lo c o c c i i n p u re c u l t u r e o r
s ta p h y lo c o c c i i n a s s o c ia tio n w ith d ip h th e ro id b a c i l l i .
I n f o u r o u t o f f o u r t e e n i n s t a n c e s s t r e p t o c o c c i w ere
reco v ered /
r e c o v e r e d i n p u r e c u l t u r e a n d o n l y i n tw o e i n u s e s .
S t a p h y l o c o c c i w ere r e c o v e r e d i n p u r e c u l t u r e i n
f i v e i n s t a n c e s an d o n l y w i t h i n t h e f i r s t f o u r m o n th s
o f th e course o f th e s in u s .
One v e r y e a r l y e x a m i n a t i o n
s h o w ed t h e s i n u s t o b e f r e e f r o m s e c o n d a r y i n f e c t i o n
w h e r e a s a n o t h e r show ed t h e a s s o c i a t i o n o f s t a p h y l o c o c c i
and d ip h th e r o id b a c i l l i .
T h is c o m b in a tio n ap p e a re d i n
3 i n s t a n c e s i n a l l , t h e o t h e r tw o b e i n g i n t h e e i g h t h
a n d n i n t h m o n th s o f t h e c o u r s e o f a s i n u s .
The a s s o c ­
i a t i o n o f s ta p h y lo c o c c i w ith s t r e p t o c o c c i , non haem oly tic
In c h a r a c t e r , ap peared f o r th e f i r s t
t w e l f t h m o n th .
tim e i n th e
T he e x a m i n a t i o n s w h i c h w e r e c o n d u c t e d
l a t e r sh o w ed m ore e x a m p le s o f t h e p r e s e n c e o f s t r e p t o ­
c o c c i , m a in ly B . h a e m o ly tic i n p u re c u l t u r e , o f s ta p h y ­
l o c o c c i i n a s s o c i a t i o n w ith s t r e p t o c o c c i ( a g a in m a in ly
B . h a e m o l y t i c ) a n d f e w e r e x a m p le s o f s t a p h y l o c o c c i i n
p u re c u l t u r e o r in a s s o c i a t i o n w ith d ip h th e r o id b a c i l l i .
I n o t h e r w o r d s s t r e p t o c o c c i w e re p r e s e n t i n g r e a t e r
n u m b e r s i n t h e s i n u s e s w h i c h w e r e e x a m in e d a f t e r a p r o ­
l o n g e d p e r i o d o f a c t i v i t y , a f e a t u r e w h ic h w i l l b e
r e f e r r e d to a g a in .
T A B L E
HIP
TIMS
NO
Name •
S ite of
D isease.
D a te o f
fo rm a tio n
of S in u s.
1.
M.M.
C.
R .H ip .
17 / I O / 3 2
2.
P .T .
C.
R .H ip .
5 /1 2 /3 3
3-
J .B .
C.
R .H ip .
7 /1 2 /3 3
4.
R *L.
0.
R .H ip .
1 /1 2 /3 3
5-
C .H .
0.
R .H ip .
1 0 / 3 /3 3
6.
J »F •
C.
R .H ip .
2 /3 1
7-
W.G.
0.
R .H ip .
3 /3 4
8.
M.McC.C.
R .H ip .
14 / 9 /3 4
M.H.
C.
R .H ip .
1 2 /3 4
1 0 . J .M c L . O .
L .H ip .
1 1 . C .D .
C.
L .H ip *
1 0 /3 4
1 2 . W.K.
C.
L .H ip .
16 / 1 2 /3 2
13- J .B .
C,
L .H ip .
1 4 . W .L.
0.
L .H ip .
25 / 1 2 /3 3
15,. M .P .
C,
L .H ip .
22/
J .A .
C1
L *Hip •
13/ 12/ 3 1 .
1 7 . M .S .
C.
L .Iliu m
8 /3 4
A .S .
0.
L .Is c h iu m
9 /3 4 .
16.
18.
1/
2/
6 /3 5
AND
24.
JO IN T S .
RESULT
OF
EXAMINATIONS.
10
8
11
12
15
18
♦ S tre p s, B.
24
S t a p h Alb.
B.
♦S t r e p s
♦S' . r e p s . 1 I S .A n g in c s u s
11 S . P y og.
♦S t e r i Le
♦ s t r e p 3 .(n o n )^ S tre p s B
s t . ALb.
♦ s t r e p 3 (B|)
21
2 y ears
&
over.
P .M . S t r e p s .
♦ S t : ’e p s B
♦ S ta p h .A l b .
S t r l e p s (B)
♦ S ta p h .a lb
(m a in ly
S ti eps
ana erob 0
♦ S tir a p t- .A lt . (P>
♦ S t p h . Al b . ( )
D o ik b tf u l .
S ti eps
♦ S t a p h . A lb .
♦ s ..Alt!
(B
St r e p
♦B S t r e
♦B S t r e p s
♦SI tre p fi
♦S' r e p s (B
♦S e r i i e
ps.
♦ a -v e B a c i l l i
Fey S t r e p s .
♦ S te ril.e .
♦ S ta p h .A lb
S tre p a .
S t a p h .A u r e v s .
♦ S t e p s . 1 B.
♦S t |a p h .iA l b .
Siir e p s . ( n o n haem
3 s t i a in s
♦ S t r e p s . (B)
4 /3 1
6/ 3 3 .
♦S t a p h Aure u s .
Dip h .
♦ S t r e p s B.
♦S r e p s
B.
♦ S te rile
ears
♦Sjtrepfc (dp.d n q t g r ow) 9 m>.oh t h s l a t j e r o i l y B Haem S t r e p s .
( o n s e t <f c 4 l l u l l L t i s )
D lp th s.
♦St e rile
♦ S t a p h .A l b
S t r e p 3. ( n o n i a e m . )
Do 6 no n t h s
la t e r st i l l .
A .♦ S tre p s .B .
(d o u b tfu l)
D ip h .
B .♦ S tre p s.B .
C .♦ S tre p s.B .
KNEE
JO IN T .
TIEE AND RESULT OF EXAMINATIONS.
N o . Name
S ite
M.B
O nset
of
S in u s
10
A u r< u s
St: e p s II.
♦ st
9 /H /3 3
B .H . C . L .K n e e
21
12
♦ S t A lb
D ip h .
A id
e p s (C o u ld n o t
ci l t u r o . )
♦ S t A lb
S t r e p s (B]
♦ S t.A ld .
S t . C i s reu n
S t r e p , (u n k n o w n )
B . I ’r o t i u s
"
R .K n e e
♦S' . e r i Le
♦ S tr e p s .^ S . I n ’.)
♦ S tra p s
L .K n e e .
(lo w e r
end of
fem u r)
18/ 8/33
♦ S t.A i i r e i . s .
S t r e p s . (S .P y o g .)
,A lb
;s .I:if.)
24
2 y ears
&
over.
120.
TABLE
24.
A s i m i l a r t a b l e was made f o r s i n u s e s a r i s i n g f r o m
t u b e r c u l o s i s o f t h e h i p J o i n t s b u t i n t h i s e x a m p le t h e
m a j o r i t y o f e x a m in a tio n s w ere c o n d u c te d w i t h i n t h e
f i r s t y e a r a n d a l m o s t a l l w i t h i n t h e f i r s t tw o y e a r s .
H e re t h e m a j o r i t y o f s i n u s e s w ere i n f e c t e d w ith s t r e p t o ­
c o c c i , m a in ly B . h a e m o ly tic a t an e a r l y s t a g e i n t h e i r
c o u r s e a n d n o g r a d u a l c h a n g e o f t y p e o f i n f e c t i o n was
s e e n s u c h a s w as e x h i b i t e d i n t h e c a s e o f t h e v e r t e b r a e .
T h r e e c a s e s e x a m in e d v e r y e a r l y w e r e f r e e f r o m s e c o n d a r y
i n f e c t i o n a s w e r e tw o a t a v e r y l a t e s t a g e .
O n ly one
e x a m p le o f t h e a s s o c i a t i o n o f s t a p h y l o c o c c i an d d i p h ­
t h e r o i d b a c i l l i was s e e n w h e r e a s t h e a s s o c i a t i o n o f
s t a p h y l o c o c c i an d s t r e p t o c o c c i was o f f r e q u e n t o c c u r ­
ren ce.
S ta p h y l o c o c c i i n p u r e c u l t u r e w ere r e c o v e re d
i n tw o i n s t a n c e s o n l y , o n e f a i r l y e a r l y a n d t h e o t h e r
la te .
The o n s e t o f seco n d ary i n f e c t i o n i n t h i s a r e a
s e e m e d t o b e much m ore r a p i d t h a n i n t h e c a s e o f t h e
v e rte b ra e .
T a b l e 2 5 sho w s t h e r e s u l t s w h i c h w e r e o b t a i n e d
w hen s i n u s e s a r o u n d t h e k n e e J o i n t s w e r e e x a m i n e d .
ANKLE JOINT
TIME AND RESULT OF EXAMINATION.
S ite of
D ise a se .
No . Name
1.
I.G .
2.
A .W . C . L . A n k l e
(S o ft
tissu e
& bones
a lso p e r i­
o s titis .)
0
L .A n k le
(S o ft
tissu e
& bones)
O nset o f
S in u s.
8
1 4 / 1 1 /3 3
♦ S t,e r i e (Heal<! d 1 m o n t i )
2 4 / 9 /3 2
4 . J .B f c l. C . L . A n k l e .
20/ 1 1 /3 1
S .M .
J .G . C
K. n n k le .
S o ft
tiss u e .
7
A«M« C
R.A n k le .
(o s C a lc isJ
8 .. M.lfcC. C
12
15
18
O v er 2 y e a r s .
♦ S t.A u re u s
S t r e p s . (Non HaemJ
♦ S t. A lb .
P ne um ocoicci
S t r e p s .( B .H a e |m .)
1 8 / 6 /3 4
♦ S t.A lb .
S t.A u re u s .
S t r e p s , (stro n g ly
■ p r o b a b le B.)
♦S r e p 3 (B
♦ S t r e p s . ( S . Pyog.)
4 /3 1
3 1 / 7 /3 4
24
♦ S trjep s B
♦ S t. A lb .
S t r e p s .E
i)
R .A n k le .
2 7 / 5 /3 2
(o s c a lc is)
H.McK. C . R . A n k l e .
21
♦ S t r e p s (B )
(Ifew)
C . L .A n k le
1 7 / 9 /3 2
(o s c a lc is)
6.
11
7 / 6 /3 2
A .W . C . R . A n k l e
do.
5-
10
♦
ii)
* S '. r e p
. C3)
♦ S te e p s.
(B )
S t r e p s . B.
S t.A lb .
S t.A u re u s ,
S t r e p s . B.
In t h i s
i n s t a n c e , on a c c o u n t o f t h e s h o r t e r c o u r s e o f
t h e d i s e a s e a l l e x a m in a tio n s e x c e p t one w ere c o n d u c te d
w ith in 1 y e a r o f th e fo rm a tio n o f th e s in u s .
The
f e a t u r e s w e r e r a t h e r s i m i l a r t o t h o s e shown b y h i p
j o i n t s i n u s e s b u t , i n one i n s t a n c e t h e a s s o c i a t i o n o f
s t a p h y l o c o c c i and d i p h t h e r o i d b a c i l l i , b e in g r e p la c e d
l a t e r b y B . h a e m o l y t i c s t r e p t o c o c c i , was s e e n .
S t a p h y l o c o c c i w e r e r e c o v e r e d i n p u r e c u l t u r e I n one
in sta n c e o n ly , v iz :
t h e l a t e s t e x a m in a tio n m ade, i n a
h e a l i n g wound.
S i n u s e s a r i s i n g f r o m t h e a n k l e j o i n t w e r e e x a m in e d
a t a p e r i o d m a i n l y a f t e r o n e y e a r ' s d u r a t i o n an d h e r e
t h e f e a t u r e s n o t e d p r e v i o u s l y w e re r e v e r s e d .
TABLE
2 8 ..
TABLf i
ARM
TIMS
No
Name
S ite
D .P .
C. L .T ib ia
S .M .
C. L . T i b i a .
A • McD» C • R . F i b u l a .
J
.G •
J •S •
H .J .
3 /3 5
C . R .H u m e r u s
(lo w e r
elb o w . 1
C. R .E lb o w
OF
EXAMINATIONS.
10
♦Stl • A1
s tre p s
♦ S t a p h . A l b •(P)
S t r e p s . i ) S . Ajjte*
i i ) S.P. og.
11
2 6 /9 / 3 *
5 /H /3 4
G .D .
G- L . T i f c i a
lo w e r
5 /H /3 4
G .J.
C . R e a m r R.
10/
4 /3 4
21
24
2 years
♦ S t a p h JA lb
t .A lb
♦S , e r i l e
S -aph . A l b
♦ s x e p s.(B D
♦S t r e p s
(B )
♦ S t.A u r.
1930.
9 /3 3
18
* s tr e p s .(B )
About
L .T ib ia
15
♦S ,.A 1 D. (P )
S r e p s . (B )
1 / 6 /3 3
A .K .
12
( 3)
28/ 8/ 34-
H u m e ru s
J .M c L . 0 . R .U ln a
T .5 .
9 /3 3
BONES.
8
2 7 / 6 /3 3
18 / 6 /3 2
R .M c K . 0 . L . E l b o w
AND RESULT
u a te o f
O n se t.
C » R .H u m e r u s
0 •
LONG
2Z
♦ s t a p h .A u r ( S k i p )
g Lph.
t r e p s . Ndn Ha em.
3
♦ s e r i Le
♦S t reps
(B
•
io.
(B
♦ S tre p a .
(B )
&
ovg
T A B L I
28
DACTYLITIS.
TIMS
No
Nam e.
I.
M .L .
2.
r t . McM • (
3.
N .P .
4.
S ite .
S in u s
O nset
L eft
2nd m e ta c a rp .
& p rox.
p h a la n x .
L . 5 th p ro x .
p h a la n x &
H and.
7 /3 3
C
P ro x .P h a la n x
3 rd .F in g e r.
4 /3 4
B .C .
C
P ro x .P h a la n x
L . Thum b.
5 /3 4
5.
M .C .
C
L . Hand
3 & 4
M e ta c a rp .
4 /3 3
6.
A .M cD . C
L .C u b o id .
8 /3 3
R t. 4 & 5
M e ta ta rs a ls
5 /3 4
8 /3 4
7.
R .P .
C
8.
D .S .
C. R t. C u b o id .
9.
10.
J .B .
C
M .C .
C
R t.N a v ic u la r
M e ta ta rs u s.
11.
R .S .
0
L . l s t M e ta ta rs 1 0 /3 3
12.
T .H .
0
R t.P ro x .
P h a la n x
1 s t Toe
6 /3 3
L . l s t M e ta ­
ta rsa l.
1 /3 2
13.
A .C .
0
AND
RESULT
OF
EXAMINATIONS.
8
3
10
12
15
18
21
24
2 y e a r s & ove
S1t a p h A l b .
♦ s -t r e p f . Non . Haem
♦G--ve t a c i l L i .
♦ S t.A lb .
♦ S t r e p f (B )
♦ o t r e p s B . ( s p y o g .)
S tap h
♦ S t.A u re us
Diphw
♦S'tjre p s i v e r y f:: : i a t l e ) S Ang
S t .A ur
♦ S t .A lb .
♦ S t A lb . Pyog
St: e p s .JJ.Haedi
S t . A lb . S k in
S t r e p s .( B )
♦ S t . A u r eu s
4 /3 3
♦B.H a e m . S t r e p s ,
♦Si .A lb
S t.A u r eus
S tr e p s .(B )
2 6 /7 /3 2 .
H /3 3
11
♦ S te e p s .(B )
♦St;:’e p s .
♦ S t A ureus
D ijbh.
) B . Kaem.
S tJfe p s ii )
♦St,:r e p s , (B )
(B
♦ S ta p h A lb .
D Lph.
♦ S ta ril
♦S .A l b .
T he e a r l i e r e x a m i n a t i o n s d e m o n s t r a t e d t h e p r e s e n c e o f
B . h a e m o l y t i c s t r e p t o c o c c i i n p u r e c u l t u r e an d o n l y
t h o s e c o n d u c t e d a t a l a t e r s t a g e y i e l d e d m ix e d c u l t u r e s
o f s ta p h y l o c o c c i and s t r e p t o c o c c i .
No i n s t a n c e was
found o f s ta p h y lo c o c c i i n p u re c u l t u r e o r even o f th e
p re se n c e o f d ip h th e ro id b a c i l l i in th e le s io n s .
One
s i n u s was f r e e f r o m s e c o n d a r y i n f e c t i o n an d t h i s s i n u s
was a v e r y m i n o r o n e w h ic h h e a l e d w i t h i n o n e m o n th
a f t e r th e e x a m in a tio n .
The s e c o n d a ry i n f e c t i o n r e c o v e re d fro m s in u s e s
a r i s i n g fro m t h e lo n g b o n e s w ere v e r y v a r i a b l e and a r e
sh ow n i n T a b l e 2 7 . .
Once a g a i n a l l e x a m i n a t i o n s
e x c e p t one w ere c o n d u c te d w i t h i n t h e f i r s t y e a r o f th e
c o u rse o f th e s in u s .
S ta p h y lo c o c c i w ere r e c o v e r e d i n
p u r e c u l t u r e i n 3 i n s t a n c e s , tw o e a r l y and o n e l a t e ,
and a l l i n h e a l i n g w ounds.
D i p h t h e r o i d b a c i l l i w e re
r e c o v e r e d i n one i n s t a n c e o n ly and t h a t e a r l y and in
a s s o c i a t i o n w i t h a s t a p h y l o c o c c u s an d a n o n - h a e m o l y t i c
stre p to c o c c u s.
Two s i n u s e s w e r e f r e e f r o m s e c o n d a r y
i n f e c t i o n , b o t h b e i n g e x a m in e d v e r y e a r l y i n t h e i r
co u rse.
One o f t h e s e h e a l e d q u i c k l y b u t t h e o t h e r
becam e i n f e c t e d b y B . h a e m o ly tic s t r e p t o c o c c i b e f o re
a m o n th h a d e l a p s e d .
S t r e p t o c o c c i i n p u r e c u l t u r e and
i n a s s o c i a t i o n w i t h s t a p h y l o c o c c i w e r e t h e com m onest
i n f e c t i o n , th e s tr e p to c o c c i b e in g a l l B .h a e m o ly tic .
T he f e a t u r e s o f t h e r e s u l t s o f e x a m i n a t i o n o f
sin u s e s /
t a b l e
MT.snTST,TANEOUS
TIME AND
S ite of
D ise a se
Name
RESULT
OF
O nset of
S in u s.
3 0.
LESIONS .
EXAMINATIONS.
10
11
T .B
J .M c L . 0
T .B .A b d o m e n
A1
do
M .M 'V . 0
♦ S \ r e p a . N 0.1 Haem
do
R .M cH . 0
L eft
C .M c C . C
L eft
♦ C o l i f orms
♦S
2 8 / 6 /3 2
i/re p s . (N 0.1 Haem.
2 / 1 2 /3 3
E .A
A ur
A lb
L .M a n d ib le
♦ S te rile .
1 2 /1 0 /3 4
R IB
♦S
R. 7th
.INftPHRIC
C. R ig h t.
A lb u s
ABSCESS
7 / 8 /3 3
♦ S t Au:
A1
12
21
24
2 years
&
ws
123
s i n u s e s o f t h e h a n d s an d f e e t w e r e s e e n i n T a b l e 28
a n d n o h i t h e r t o u n r e m a r k e d f e a t u r e was n o t e d .
T he
chan g e o f s e c o n d a r y i n f e c t i n g o rg an ism s o v e r a p e r io d
was show n v e r y w e l l i n o n e I n s t a n c e .
G la n d u la r and s o f t t i s s u e tu b e r c u lo s is gave r i s e
to s i n u s e s w h ic h r a n a s h o r t c o u r s e h en ce a l l t h e
e x a m in a tio n s t o o k p l a c e w i t h i n one y e a r .
Two s i n u s e s
h a d n o s e c o n d a r y i n f e c t i o n a n d b o t h w e re h e a l i n g a t
th e tim e o f th e e x a m in a tio n .
One s i n u s show ed t h e
t r a n s i t i o n w hen h e a l i n g f r o m a p u r e i n f e c t i o n w i t h
s tr e p t o c o c c i to an i n f e c t i o n by s ta p h y lo c o c c i.
A rare
e x a m p le o f t h e a s s o c i a t i o n o f d i p h t h e r o i d b a c i l l i and
a B . h a e m o l y t i c s t r e p t o c o c c u s o c c u r r e d an d o n l y i n one
i n s t a n c e w as t h e r e a n a s s o c i a t i o n b e t w e e n s t a p h s ( and
s tre p s .
The g e n e r a l te n d e n c y ap p e a re d to b e f o r w h a t­
e v e r o r g a n i s m w as p r e s e n t i n t h e s i n u s t o r e m a i n t h e r e
in pure c u l t u r e .
T h e se f e a t u r e s a r e s e e n i n T a b le £9
S i n u s e s w h ic h a r o s e fro m m is c e lla n e o u s p a r t s w ere
o u t s t a n d i n g i n t h e a lm o st c o m p le te a b se n c e o f s t r e p t o ­
c o c c i.
T h e s e o r g a n i s m s w e r e p r e s e n t on o n l y two o c c a s ­
i o n s , b o t h t im e s i n p u r e c u l t u r e and b o th w ere n o n h a e m o ly tic .
S ta p h y l o c o c c i w ere r e c o v e re d i n p u re c u l ­
t u r e on 5 o c c a s i o n s , d i p h t h e r o i d b a c i l l i on o n e ,a n d
s t a p h y l o c o c c i c o m b in e d w i t h c o l i f o r m b a c i l l i on o n e
o th e r o c c a sio n .
T h e r e was a l s o a n e x a m p le h e r e o f a n
i n f e c t e d s i n u s b e c o m in g ' s t e r i l e ’ i n t h e p r o c e s s o f
h e a lin g .
A s/
T a b le 50 i l l u s t r a t e s th e s e f a c t s .
As a r e s u l t o f t h e s e t a b l e s i t was s e e n t h a t d i f ­
f e r e n t s i t e s v a r i e d i n t h e r a p i d i t y w i t h w h ic h i n f e c ­
t i o n g a in e d in g re s s
( f o r e x a m p le v e r t e b r a l an d m i s c e l ­
la n e o u s s in u s e s c . f . knee o r h ip J o in ts ) b u t t h a t th e
m o s t common e a r l y i n f e c t i o n w as o n e b y s t a p h y l o c o c c i
a lo n e .
At a l a t e r s t a g e t h e s e w e re s o m e tim e s J o i n e d
b y d i p h t h e r o i d b a c i l l i b u t much m ore commonly b y
s t r e p t o c o c c i an d t h a t s t r e p t o c o c c i i n a s s o c i a t i o n w i t h
d i p h t h e r o i d b a c i l l i w ere s e e n v e r y r a r e l y .
T h e r e was
a te n d e n c y f o r s tr e p t o c o c c i to p e r s i s t as an i n f e c t i o n
and a t tim e s to b a n i s h th e o t h e r o rg a n ism s fro m th e
s in u s e s .
F u r t h e r , i t was n o t i c e d t h a t s i n u s e s w h ic h
w ere h e a l i n g o r a lm o st h e a le d te n d e d to b e f r e e from
se c o n d a ry I n f e c t i o n o r c o n ta in s ta p h y lo c o c c i i n pure
c u ltu re ,
even i n i n s t a n c e s w h ere, f o r a lo n g p e r io d o f
t h e i r c o u r s e , t h e s e c o n d a r y i n f e c t i o n was a s t r e p t o ­
coccus.
T h ese f e a t u r e s r e l a t e d t o th e m ic ro sc o p ic
e v i d e n c e r e g a r d i n g t h e t y p e o f o r g a n i s m m o s t commonly
p r e s e n t and th e b a c t e r i o l o g i c a l e v id e n c e o f th e n a t u r e
and v i r u l e n c e o f t h e o rg a n ism s o t h e r th a n s t r e p t o c o c c i
le d to
a c o n c l u s i o n t h a t t h e s e l a t t e r o r g a n i s m s w e re
th e m ost p o t e n t o f th e se c o n d a ry i n f e c t i o n s .
That i s ,
th e o t h e r s w ere p u r e ly i n c i d e n t a l .
T he c l i n i c a l d a t a o n t h i s s t a t e m e n t w i l l b e g i v e n
la te r.
THE
EFFECT
T u b e rc u lo sis i s
OF
IHFECTIOB.
commonly a c h r o n i c i l l n e s s a n d
t h e n o n - p u lm o n a r y t y p e w i t h w h ic h t h e i n v e s t i g a t i o n
d e a l s p ro v es no e x c e p tio n to th e r u l e .
C ases a d m itte d
t o h o s p i t a l f o r tr e a tm e n t re m a in t h e r e f o r v a r y in g
p e r i o d s o f t i m e w h i c h p e r i o d s may b e i n c r e a s e d b y t h e
o c c u r r e n c e o f any u n to w a rd c o m p lic a tio n s i n th e c o u rs e
o f th e i l l n e s s .
Such a c o m p lic a tio n i s
a fo rm a tio n of
a s i n u s a f e a t u r e common t o t h e m a j o r i t y o f c a s e s w h ic h
have been d isc u sse d p re v io u s ly .
A su rv ey o f th e cases
r e v e a l e d t h a t r e s i d e n c e was p r o l o n g e d i n many i n s t a n c e s
b u t t h a t th e f ig u r e s v a r ie d a c c o rd in g to th e s i t e
t h e p rim a ry tu b e r c u lo u s l e s i o n .
of
The l e n g t h s o f tim e
o v e r w h i c h s i n u s e s r e m a i n e d p a t e n t when t h e y a r o s e i n
e a c h a r e a w e r e e s t i m a t e d a p p r o x i m a t e l y an d t a b u l a t e d
and com pared w ith t h e a v e r a g e d u r a t i o n o f r e s i d e n c e
o f a l l c a s e s o f d i s e a s e i n a s i m i l a r a r e a w h ic h w e r e
d is m is s e d from t h e h o s p i t a l i n v h ic h th e i n v e s t i g a t i o n
w as c o n d u c t e d .
TABLE 3 1 . /
©
o
s
m
©
CD
oJ
o
©
*
o
73
u
ft
m
©
Pi
ft
&
CD
©
>.
©
'd
©
o
o
to
u
4
03
o
CO
ts
c«-
o
o
CO
o
io
o
o
■>*
o
to
02
•
m
©
©
2
C
ft
m
ft
o
CO
©
CO
o
fl
o
ft
ft
©
u
3
73
ft
•H
©
©
•
©
ft
0c
©
•
©
£•
t>»
©
©
u
>»
u
ro
©
u
u
>»
>»
>»
is
•#
m
u
>»
>»
9
1*
>»
3
to
u
©
>
<U
m
o3
o
©
©
©
©
c
ft
©
CO
ft
>»
o
c
o
ft
ft
©
u
u
>>
t*» * | * «
CO
H
©
u
>»
to
©
u
t»
02
to
i
I
©
©
f-4
I
I
I
I
©
©
©
©
t>»
>»
©
u
u
>.
Ei
u
>»
M
>»
u
U
>»
rl
>»
©
u
>»
02
ft
>
>»
02
3
>
©
ft
©
O
ft
3
o
k
©
©
"§
ft
©
©
©
u
ft
c
O
©
■P
ft
CO
-p
u
©
>
ft
ft
w
©
ft
C
©
P
C
o
ft
ft
O
TO
TO
©
©
©
rH
,u
ft
<
M
•
©
©
c
o
&
C
o
h
©
ft
ft
ft
ft
t>»
ft
o
©
Q
o
p
©
m
2
8
rH
CJ
2
O
©
C
©
rH
rH
©
o
m
ft
a
From t h e t a b l e I t w i l l b e s e e n t h a t s i n u s e s s o m e ­
t i m e s r e m a i n p a t e n t f o r v e r y l o n g p e r i o d s and t h a t i n
d i s e a s e o f some a r e a s t h e s i n u s e s r e m a i n p a t e n t f o r
p e rio d s in ex cess o f th e av erage t o t a l d u ra tio n of
tre a tm e n t of a l l s im ila r c a se s.
T h is f e a t u r e i s m ost
m arked i n d i s e a s e o f t h e v e r t e b r a e and o f t h e a n k le
J o in ts
and t o a m in o r d e g r e e i n t h e l e s i o n s o f th e
h ip J o in ts .
I n d i s e a s e a f f e c t i n g t h e k n e e J o i n t s and d a c t y ­
litis
t h e o p p o s i t e p e r t a i n s an d i n l e s i o n s o f t h e l o n g
b o n e s and o f g la n d s o r s o f t t i s s u e t h e p e r io d s a lm o s t
sy n c h ro n ise .
A p o s s ib le e x p la n a tio n o f th e f ig u r e s
f o r k n e e J o i n t s l a y i n t h e f a c t t h a t much t i m e i s
expended in t h i s p a r t i c u l a r l e s io n i n e x c is in g th e
J o i n t a f t e r th e l e s i o n h a s h e a l e d th u s a d d in g a p p r e c ­
ia b ly to th e p e rio d o f re s id e n c e .
S im ila rly in th e
in s ta n c e o f d a c t y l i t i s t h i s le s io n i s o fte n m u ltip le
a n d d i s m i s s a l may b e im p ed ed e i t h e r b y a f r e s h l e s i o n
fo rm in g o r by one o f m u ltip le l e s i o n s n o t h e a lin g
q u ic k ly .
L e s io n s o f th e lo n g b o n e s and g la n d s s h a r e
t h e common f e a t u r e o f a v e r y h i g h i n c i d e n c e o f a b s c e s s
and s i n u s f o r m a tio n (a p p ro x im a te ly 80$ o f a l l c a s e s )
th u s re n d e rin g th e cases w ith in th e scope o f th e i n ­
v e s t i g a t i o n a lm o st t y p i c a l o f th e d is e a s e as i t o c c u r ­
red g e n e ra lly .
G e n e ra lly sp e a k in g how ever s in u s
f o r m a t i o n p r o l o n g e d t h e r e s i d e n c e o f t h e c a s e s an d was
th e re fo re /
t h e r e f o r e an im p o r ta n t f a c t o r i n t h e eco n o m ics o f
tre a tm e n t.
R eg ard ed from a n o th e r a s p e c t th e t a b l e r e v e a l s
t h a t t h e s e p a t i e n t s h a d o p e n w oun ds o v e r p e r i o d s o f
y e a r s w h ic h w e r e , a s h a s b e e n show n, i n f e c t e d w ith
p y o g e n ic b a c t e r i a .
T h e s e o r g a n i s m s w e re n o t e n t i r e l y
s a p ro p h y tic b u t a tta c k e d th e t i s s u e s o f th e h o s t g iv in g
r i s e to d istu rb a n c e s c a lle d
' a c u t e c o m p l i c a t i o n s ' w h ic h
w e re r e l a t i v e l y f r e q u e n t and s e r i o u s .
T he c o m p l i c a t i o n s
w ere 6 i n num ber and w e r e :1.
T o x a e m ia .
2.
C e l l u l i t i s , s u p e r f i c i a l and d e e p .
3.
A cu te a b s c e s s f o r m a t i o n , t r a c k i n g fro m a s i n u s .
4.
A cu te l y m p h a d e n i t i s .
5.
E ry s ip e la s.
6.
S u rg ic a l S c a r la tin a .
T h e ir d e g re e v a r ie d m a rk e d ly .
T o x a e m ia , f o r e x am p le
w as a m a rk e d f e a t u r e t h r o u g h o u t t h e c o u r s e o f some
c a s e s w h ereas i n o th e r s i t
Its
was s l i g h t a n d t r a n s i t o r y .
p r e s e n c e was g a u g e d f r o m t h e t e m p e r a t u r e o f t h e
p a t i e n t i n t h e a b s e n c e o f any o t h e r d i s t u r b a n c e su ch
a s m arked c e l l u l i t i s .
C e l l u l i t i s w as o f t e n p r e s e n t
i n t h e s k i n s u r r o u n d i n g t h e s i n u s m o u th v a r y i n g i n
e x t e n t f r o m a s m a l l l o c a l i s e d p a t c h t o an a r e a many
in c h e s i n d ia m e te r.
In th e se in sta n c e s p a r tic u la r care
w as t a k e n t o d i s t i n g u i s h i t f r o m e r y s i p e l a s .
o ccu rren ce/
Its
o c c u r r e n c e was n o t i n f r e q u e n t i n t h e d e e p e r t i s s u e s
and p re s e n te d a l i t t l e
d if f ic u lty in i t s d if f e r e n tia ­
t i o n fro m l o c a l i s e d a c u te a b s c e s s f o rm a tio n i n th e
d e p th s o f a s in u s .
T h is l a t t e r c o m p lic a tio n o c c u rre d
m o s t f r e q u e n t l y i n l o n g s i n u s e s w h ic h r a n t h r o u g h a
c o n s i d e r a b l e m ass o f s o f t t i s s u e an d w as f e l t t o b e
d u e t o t h e a c c u m u la tio n o f p y o g e n ic m a t e r i a l i n an
i n a c c e s s i b l e an d u n d r a i n e d a r e a o f t h e s i n u s .
When i t
o c c u r re d th e p r o c e s s r a p i d l y e x te n d e d n e c e s s i t a t i n g
f r e s h i n c i s i o n s b e i n g made f o r d r a i n a g e p u r p o s e s .
I n a r e a s w h ic h w e r e t h e s i t e o f p r e v i o u s c o m p l i c a t i o n s
a c u t e i n f l a m m a t i o n s o m e tim e s o c c u r r e d i n t h e lym ph
g l a n d s w h i c h d r a i n e d t h e a r e a an d i t s
o ccu rren ce,
p u re ly in re sp o n se to th e seco n d ary in f e c te d ,
n o te d .
was
As a l r e a d y s t a t e d i t was r e m a r k a b l y r a r e .
The f i f t h
c o m p l i c a t i o n , e r y s i p e l a s , a p p e a re d on s e v e r a l
o c c a s i o n s a n d l i k e c e l l u l i t i s i t was v e r y v a r i e d i n
d eg ree.
T h e m o s t m a rk e d c a s e s w e re tw o i n n u m b e r
w h ere a 'm i g r a n s ' fo rm o f th e d i s e a s e In v o lv e d an
e n t i r e arm an d l e g r e s p e c t i v e l y .
S u rg ic a l s c a r l a ti n a
o c c u r r e d i n o n l y o n e i n s t a n c e b u t was s u f f i c i e n t l y
m arked t o b e w o rth y o f r e c o r d .
T hese f e a t u r e s t h e r e f o r e , c o m p le te ly tra n s fo rm e d
t h e c h a r t s o f t h e p a t i e n t s from t h o s e o f c h i l d r e n s u f f e r ­
in g fro m an i l l n e s s
o f lo w t o x i c i t y i n t o a l i k e n e s s o f
t h o s e o f s u f f e r e r s from v e r y a c u te i l l n e s s e s .
T h e ir
o c c u r r e n c e w as n o t e d i n e a c h c a s e t h r o u g h o u t i t s
course
and a t a b l e c o n s tr u c t e d r e l a t i n g t h e i r o c c u rre n c e to
t h e ty p e o f s e c o n d a ry i n f e c t i o n r e c o v e re d from t h e
s in u s e s .
§
©2
©
C
05 -H
&
kJ a&
©
rH
•H
a
O
53o
o3
•H
a©
o3
X
O
EH
ro
• m
©
© o •
•H © G
P
■H .o o
rH
p
©
P
rH P S
rH 3 G
© OO
o <! f t
© tH
n1
03
©
G
•H
P
©
rH
G
©
O
CD
©
rH rH
© ©
P< o
•H
bO
& G
G 3
(xj CD
©
©
©
•H
a
©
•H
•H
a
©
X
o
EH
rH
•H
S3
©
©
X
o
EH
©
©
rH
©
O
03
03
1C
©
-H
03
CD
03
I
CO
»
CD
CO
I
W
H
£>
lO
»
CO
CO
co
03
©
•H
ft
•rH
rH
© >»
ft
o
I 03
cd Q
ft
o
CD
S'S
OO
G H CQ
•H
to
•H ©
G ©
O —i
m
ft
rH
*♦
O
rH
H
I
03
rH
I
10
rH
I
rH
rH
03
CO
©
oS
G
lq
©
CO
FP
to
03
to
03
G
©
>
1
O
G P
I
t3 ft
© © © -H
J
0 ft
o
© ©
ft
O
Eh H
©
CD
© ft G o
TO O P O
3 © CDO
■H g ►, O
CD <rl ,Q P
03
c
o
•H
P
O
©
CD
© ft
©
P G
O P
©
CO
£
•
•H
© C O
to © O
G G O
o p
o
§
•H
P
O
©
CD
©
rH
■H
G
©
P
CD
131.
T h e t a b l e show s t h a t t h e i n c i d e n c e o f c o m p l i c a t i o n s was
h i g h e s t i n s i n u s e s f r o m w h ic h a s t r e p t o c o c c u s w as r e ­
c o v e re d and t h a t th e o n ly c o m p lic a tio n o c c u r r in g i n th e
o t h e r tw o g r o u p s w as t o x a e m i a .
A stra ig h tfo rw a rd
s t a t e m e n t b a s e d on t h e s e ' f i g u r e s ’ t h a t s t r e p t o c o c c i
w e r e t h e c a u s a l o r g a n i s m s o f t h e s e c o m p l i c a t i o n s was
p r e v e n t e d b y t h e o c c u r r e n c e i n S e c t i o n 1 o f a few c a s e s
i n w h ic h no c o m p lic e /tio n o c c u r r e d .
th e
fo llo w in g f e a tu r e s .
1.
J .S .
T h e s e c a s e s show ed
D ise a se o f c e r v i c a l v e r te b r a e ; c h ro n ic in
n a t u r e w ith an o ld d i s c h a r g i n g s i n u s .
S econdary i n f e c t i o n ;
a fe w n o n - h a e m o l y t i c
s tre p to c o c c i.
2.
R .L .
Bone d is e a s e o f h ip
jo i n t ; h e a le d c l i n i c a l l y
and r a d i o l o g i c a l l y w ith th e te m p o ra ry r e ­
cu rren ce o f a s in u s .
S econdary i n f e c t i o n ;
a few a n a e r o b ic s t r e p t o c o c c i .
3.
C*H•
As R . L .
S econdary I n f e c t i o n ;
a few n o n -
h a e m o ly tic s tr e p to c o c c i.
4.
W.G. 'A l m o s t h e a l e d b o n e d i s e a s e o f h i p
jo in t.
A bscess rea p p e a re d s h o r tly a f t e r an a tta c k
o f s c a r l a t i n a a n d e r o d e d i t s way t h r o u g h .
M in im a l d i s c h a r g e f r o m r e s u l t a n t s i n u s w h i c h
h e a le d q u ic k ly .
S e c o n d a r y i n f e c t i o n ; fe w
B . h a e m o ly tic s tr e p t o c o c c i .
5 ./
5.
A .S .
Bone d i s e a s e o f isc h iu m ;
s h o r t open s in u s
w h ich h e a l e d v e r y r a p i d l y upon re m o v a l o f
d ise a se d bone.
S e c o n d a ry i n f e c t i o n ; few n o n -
h a e m o ly tic s tr e p to c o c c i.
6.
J . McL. B o n e d i s e a s e o f u l n a w h i c h was rem o ved e n ­
tire ly
l e a v i n g a n o p e n g u t t e r on t h e s u r f a c e
o f t h e b o n e w h i c h r e m a i n e d c l e a n an d h e a l e d
ra p id ly .
S econdary i n f e c t i o n ; B . h a e m o ly tic
stre p to c o c c i.
7 . J .M c Q . T u b e r c u l o s i s o f g l a n d s o f n e c k w h ic h w e r e
i n c i s e d and t h o r o u g h l y c l e a n e d o u t an d h e a l e d
ra p id ly .
S econdary i n f e c t i o n ; few n o n -
h a e m o ly tic s tr e p to c o c c i.
8.
L .C .
S m all l o c a l i s e d s o f t t i s s u e a b s c e s s a l s o
th o r o u g h ly s c ra p e d o u t and h e a l e d r a p i d l y .
S econdary i n f e c t i o n ;
few B . h a e m o ly tic
s tre p to c o c c i.
I n n o i n s t a n c e t h e r e f o r e was t h e s e c o n d a r y i n ­
f e c t i o n g r o s s and i n m ost t h e s u i t a b l e s o i l f o r t h e
c o n t i n u e d r e s i d e n o e o f t h e o r g a n i s m s was re m o v e d b y
e r a d ic a tin g th e tu b e rc u lo u s f o c u s .
A lso i n f o u r i n ­
s t a n c e s t h e s t r e p t o c o c c i r e c o v e r e d w ere n o n - h a e m o ly tic
i n t y p e a n d i t w as a f o r t u i t o u s c o m b i n a t i o n o f t h e s e
f a c t o r s w h ich p r o b a b ly p r e v e n te d s e r i o u s c o m p l i c a t i o n s .
A s i m i l a r r o u t i n e was u n d e r t a k e n w i t h r e g a r d t o
t h e c a s e s f a l l i n g w it h i n S e c tio n s 2 and 3 o f t h e t a b l e
w h ic h /
153.
w h i c h show ed c o m p l i c a t i o n s .
D ealin g f i r s t l y w ith
S e c tio n 2 th e c a s e s p re se n te d th e fo llo w in g h i s t o r i e s .
1.
I.L .
S u f f e r i n g from s u b a c u te t u b e r c u l o s i s o f t h e
c e r v i c a l s p in e w ith an o ld s t a n d i n g p r o f u s e l y
d i s c h a r g i n g s in u s on h i s n e c k .
F requent
e x a m in a tio n y ie ld e d no b a c t e r i a b u t f i n a l l y
a n u n i d e n t i f i e d Gram p o s i t i v e d i p l o c o c c u s was
is o la te d b efo re d e a th .
T h i s o r g a n i s m w as v e r y
d i f f i c u l t t o c u l t u r e an d may h a v e b e e n p r e s e n t
in th e d eep er p a r ts o f th e s in u s th r o u ^ io u t.
2.
M .G . S u f f e r i n g f r o m s u b a c u t e d i s e a s e o f t h e d c r s c lu m b ar s p in e w ith a r e c u r r e n t s in u s i n th e
lo in .
T o x a e m ia b ecam e m ord m a rk e d a f t e r a
b a c t e r i o l o g i c a l ex a m in a tio n o f th e s in u s M
r e v e a le d o n ly th e p re se n c e o f s ta p h y lo c c i
and th e p r o b a b i l i t y o f an added s t r e p t o c o c c a l
i n f e c t i o n w as g r e a t .
U n f o r t u n a t e l y a n exam ­
i n a t i o n o f t h e s i n u s a t t h i s s t a g e was im ­
p o ssib le .
3.
M .L . S u f f e r i n g f r o m a c u t e t u b e r c u l o s i s o f t h e
lu m b ar s p in e w ith an a b s c e s s e x te n d in g w id e ly
i n t h e b u t t o c k s an d p o i n t i n g t o a s i n u s i n
th e n a ta l 6 1 e f t.
A o cu rate i s o l a t i o n o f
s e c o n d a r y i n f e c t i n g o r g a n i s m s was n u l l i f i e d
on acco u n t o f th e prep o n d eran ce o f B . p r o te u s
in th e d is c h a rg e .
The t o x a e m i a h e r e was
m a r k e d an d t h e p r e s e n c e o f s t r e p t o c o c c i i n
s m a l l n u m b e r s was s u s p e c t e d .
134.
4.
J . F . A boy w ith a s m a ll s in u s a r i s i n g bone d i s e a s e
o f t h e h e a d and n e c k o f f e m u r and a c e t a b u l u m
w h i c h was a l m o s t c u r e d a t t h e t i m e o f exam ­
in a tio n ,
C u ltu r e re v e a le d o n ly s ta p h y lo c o c c i
a n d t h e r e w as n o d i s t u r b a n c e a t t h e t i m e o f
th e e x a m in a tio n .
C e l l u l i t i s had o ccu rred
i n t h e p a s t when t h e l e s i o n was v e r y a c t i v e
an d t h e p o s s i b i l i t y o f a n e a r l i e r s t r e p t o ­
c o c c a l i n f e c t i o n b e i n g p r e s e n t t h e n an d d i s ­
a p p e a r i n g a s t h e l e s i o n h e a l e d was g r e a t .
T h i s f e a t u r e was r e m a r k e d u p o n e a r l i e r .
5.
T . S . S u f f e r i n g f r o m d i s e a s e o f t h e e lb o w j o i n t an d
d i s p l a y i n g e x a c t l y t h e sam e f e a t u r e s and
h i s t o r y a s c a s e N o .4 .
6.
J . G . Had e x t e n s i v e b o n e d i s e a s e o f t h e s h a f t s o f
t h e hum erus w i t h a p r o f u s e l y d i s c h a r g i n g s in u s
w h ich y i e l d e d o n ly s t a p h y l o c o c c i .
T h is c a s e
h a d a m a rk e d t o x a e m i a an d was t h o u g h t t o b e
one o f o s t e o m y e l i t i s u n t i l t h e d ev elo p m en t
o f a tu b e rc u lo u s h ip j o i n t .
The c o m p l i c a ­
t i o n p r e s e n t was v e r y p o s s i b l e o n a c c o u n t o f
t h e e x t e n t o f bone in v o lv e d i n th e arm .
7.
M .P . S u f f e r i n g f r o m d a c t y l i t i s w i t h v e r y e x t e n s i v e
d e s tr u c tio n o f s o f t tis s u e over th e d ise a se d
bone.
H e r e t h e e x a m i n a t i o n was c o n d u c t e d
e a r l y r e v e a lin g o n ly s ta p h y lo c o c c i b u t th e
a r e a i n v o l v e d was s u f f i c i e n t t o a c c o u n t f o r
t h e to x a e m ia w h ich o o o u r r e d .
8 ./
8.
E .P .
W ith a p e r i n e p h r i c a b s c e s s and a w i d e , f e e b l y
d i s c h a r g i n g s i n u s w h ic h y i e l d e d o n l y s t a p h y ­
lo c o c c i .
T h e s e o r g a n i s m s fo rm e d a s m a l l
a c u te a b s c e s s i n t h e d e p th o f th e s i n u s , w h ich ,
when i n c i s e d , h e a l e d r a p i d l y .
9.
C.M .
W ith e x t e n s i v e t u b e r c u l o s i s o f t h e m a x i l l a
and e x te n s iv e s e q u e s t r a t i o n w i t h a w id e ly
p a t e n t p r o f u s e l y d i s c h a r g i n g s i n u s w h ic h
y i e ld e d o n ly d i p h t h e r o id b a c i l l i .
In th is
i n s t a n c e t o x a e m i a was s l i g h t an d n o t in c o m ­
p a t i b l e w ith th e f a c i l i t i e s o ffe re d f o r a b ­
so rp tio n o f to x in s .
T h e c o n c l u s i o n was f o rm e d t h a t t h e s e c a s e s c o n ­
t a i n e d som e i n whom i t was i m p o s s i b l e t o e x c l u d e t h e
p o s s i b i l i t y o f s tr e p to c o c c i a id in g th e p re se n c e of
t h e c o m p l i c a t i o n b u t a l s o t h a t t h e r e w e r e some i n whom
s t a p h y l o c o c c i w ere e x h i b i t i n g f a i n t p a th o g e n ic p o w e rs.
S e c t i o n 3 e x a m in e d l i k e w i s e r e v e a l e d o n l y one
e x a m p le o f a t o x a e m i a o c c u r r i n g an d i n t h i s c a s e i t
was s o t r a n s i e n t t h a t i t m i g h t h a v e b e e n b r o u g h t a b o u t
b y any m in o r i n t e r c u r r e n t i n f e c t i o n .
T h u s , i n n o i n s t a n c e , was an y c o m p l i c a t i o n e x c e p t
a d e g re e o f to x aem ia b ro u g h t about i n th e ab sen ce o f
s tre p to to c c i.
P o s it iv e p ro o f o f t h e i r p ath o g e n ic r o le
w as a f f o r d e d w hen t h e b a c t e r i o l o g i c a l f i n d i n g s i n a
n u m b e r o f s i n u s e s w h ic h h a d b e e n ex a m in e d i n t h e c o u r s e
o f a n a c u t e c o m p l i c a t i o n w ere t a b u l a t e d .
136.
TABLE
83.
VERTEBRAE.
Name.
1 N .S .
D ate o f
N a tu re o f
C o m p lic a tio n . C o m p lic a tio n .
1 1 .3 3
T o x a e m ia
D ate o f
E x a m in a tio n .
O rg an ism s
R eco v ered .
1 1 .3 3
S tre p to c o c c i
2 D.McN.
7 .3 5
C e l l u l i t i s , a c u te
a b s c e s s fo rm a­
tio n .
7 .3 5
S tre p to c o c c i
3 J .S .
6 .3 4
T o x a e m ia
6 .3 5
S tre p to c o c c i
4 M.M.
1 0 .3 3
5 .3 4
1 0 .3 3
1 0 .3 4
S tre p to c o c c i
Do.
T o x a e m ia , a c u t e
a b s c e ss fo rm a­
tio n .
1 .3 4
3 .3 4
9 .3 4
S tre p to c o c c i
Do.
Do.
4 .3 4
S tre p to c o c c i
S tre p to c o c c i
++++
S t . A lb +
T o x a e m ia ,a c u te
ab scess fo rm a­
tio n
H IP
JO IN T S .
5 P .T .
1 .3 4
6 J .B .
G eneral
T o x a e m ia
7 W.K.
G eneral
C e llu litis
T o x a e m ia
1 1 .3 3
A cu te a b s c e s s
fo rm a tio n
1 1 .3 4 )
3 .3 5 )
8 M.McC .
1 .3 5
S tre p to c o c c i
9 C J).
1 1 .3 5 '
3 .3 5
5 .3 5
A cu te a b s c e s s
fo rm a tio n
E ry sip e la s
1 0 .3 4
2 .3 5
4 .3 5
S tre p to c o c c i
S tre p to c o c c i
++++++
S t. Aur +
10 M.H.
3 .3 5
A cu te a b s c e s s
fo rm a tio n
3 .3 5
S tre p to c o c c i
11 M .P.
1 0 .3 3
T o x a e m ia
1 1 .3 3
S tre p to c o c c i
12 M.M.
G eneral
T o x a e m ia ,c e llu ­
l i t i s a c u te
a b s c e ss fo rm a­
tio n
1 1 .3 3
6 .3 4
S tre p to c o c c i
S tre p to c o c c i
+++++
S ta p h +
TABLE .53
Nam©
o o n td .
D a te o f
C o m p lic a tio n
13 H *B •
1 .3 4
6 .3 4
14 M .C .
1 0 .3 3
1 1 .3 3
15 G . P .
9 .3 3
KNEE
JO IN T S .
N a tu re o f
C o m p lic a tio n .
C e l l u l i t i s an d
a c u te ab scess
fo rm a tio n
6 a te of
E x a m in a tio n
O rg an ism s
R eco v ered .
2 .3 4 )
3 .3 4 )
S tre p to c o c c i
C e llu litis
S e p tic A r th r itis
1 0 .3 3 )
1 2 .3 3 )
S tre p to c o c c i
S e p tic A r th r itis
1 0 .3 3
S tre p to c o c c i
+++++
S t a p h , fe w
1 1 .3 4
S tre p to c o c c i
ANKLE
JO IN T S .
16 J . G .
1 1 .3 4
C e l l u l i t i s a c u te
ab sc e ss fo rm a­
tio n .
17 M.McC.
G eneral
T o x a e m ia ,c e llu ­
l i t i s a c u te
ab sc e ss fo rm a­
tio n
5 .3 4 )
4 .3 5 )
S tre p to c o c c i
2 .3 4
C e llu litis
2 .3 4
S tre p to c o c c i
19 A.W .L.
1 1 .3 3
C e llu litis
1 1 .3 3
S tre p to c o c c i
20 A.W.R.
1 1 .3 3
C e llu litis
1 1 .3 3
S tre p to c o c c i
21 H.McK.
G eneral
C e llu litis
do.
1 0 .3 4 )
7 .3 5 )
S tre p to c o c o i
18 A.M.
LONG
BO NES./
138.
TABLE 33.
Name
o o n td .
LONG
D ate o f
C o m p lic a tio n
BONES.
M a tu re o f
C o m p lic a tio n
C a te o f
E x a m in a tio n
O rg an ism s
R eco v ered .
22 G .D .
1 2 .3 4
C e l l u l i t i s an d
a c u te ab scess
fo rm a tio n
1 2 .3 3
S tre p to c o c c i
23 J . G .
1 0 .3 4
A c u te a b s c e s s
fo rm a tio n
1 0 .3 4
S tre p to c o c c i
24 S.M .
1 0 .3 3
C e llu litis
1 0 .3 3
S tre p to c o c c i .
DACTYLITIS.
25 B . C .
1 1 .3 4
C e llu litis
1 1 .3 4
S tre p to c o c c i
26 R . P .
1 0 .3 4
C e llu litis
1 0 .3 4
S tre p to c o c c i
27 J . B .
1 .3 4
5 .3 4
C e llu litis
su rg ic a l
S c a rla tin a
1 2 .3 3 )
5 .3 4 )
S tre p to c o c c i
28 M .C .
9 .3 3
C e llu litis
1 0 .3 3
S tre p to c o c c i
GLANDS e t c .
29 I . C .
1 0 .3 3
A c u te
abscess
fo rm a tio n
1 2 .3 3
S tre p to c o c c i
30 K .O .
1 0 .3 3
E ry sip e la s
1 1 .3 3
S tre p to c o c c i
—
---- -------------------------------------------------------------------------------------
139.
T h i s show s c l e a r l y t h a t t h e o r g a n i s m s r e c o v e r e d d u r i n g
t h e s e p h a s e s w e r e m a i n l y s t r e p t o c o c c i an d i n p u r e c u l ­
t u r e a l t h o u g h i n a few i n s t a n c e s th e y h a d a s s o c i a t e d
w i t h th e m a f e w s t a p h y l o c o c c i .
I t was w o r t h y o f n o t e
t h a t i n t h e s e e x a m p l e s t h e s t r e p t o c o c c i w e re i n h u g e
p r e p o n d e r a n c e o v e r t h e l a t t e r a r e v e r s a l o f t h e common
f in d in g in q u ie sc e n t s in u s e s .
T he s t r e p t o c o c c i w h ic h
w ere i s o l a t e d i n t h e s e ex am p les w ere B • h a e m o ly t ic w ith
o n e e x c e p t i o n w h ic h was a
h a e m o ly tic in n a tu r e .
D u rin g th e e n t i r e c o u rse o f th e i n v e s t i g a t i o n seven
o t h e r ex am p les o f
a
o r n o n -h a e m o ly tic s tr e p t o c o c c i
w e r e r e c o v e r e d f r o m s i n u s e s i n w h ic h t h e r e h a d b e e n
p r e v i o u s a c t i v i t y b u t i n a l l o f th em t h e o r g a n i s m s , on
c l i n i c a l g ro u n d s, appeared to be le a d in g s a p ro p h y tic
e x i s t e n c e s a t t h e t i m e o f e x a m i n a t i o n , w h ic h p e r i o d was
r e m o t e f r o m t h e p e r i o d w h en d i s t u r b a n c e s w e re o c c u r r i n g .
T h e c o n c l u s i o n was f o r m e d t h e r e f o r e , t h a t t h e s e r i o u s
c o m p l i c a t i o n s w h ic h o c c u r r e d i n t u b e r c u l o u s s i n u s e s w e r e
p u re ly r e l a t e d to th e p re se n c e of s tr e p to c o c c i as a
s e c o n d a r y i n f e c t i o n an d t h a t i t was o r g a n i s m s o f t h e
t y p e S . h a e m o l y t i c u s w h i c h w e re t h e m o s t common and
g r e a t e s t p a th o g e n s.
A p a rt from t h e s e o b v io u s d e f e c t s se c o n d a ry i n f e c ­
t i o n h a d o t h e r an d m o re f a r - r e a c h i n g e f f e c t s u p o n t h e
p a t i e n t a n d a n a t t e m p t w as made t o d e t e r m i n e t h e e f f e c t
o f t h i s f a c t o r u p o n :1 ./
1.
The l o c a l s p r e a d o f t u b e r c u l o s i s .
2.
The g e n e r a l s p r e a d o f t u b e r c u l o s i s .
3.
T he a c t i v i t y
4.
The g e n e r a l h e a l t h and r e s i s t a n c e o f
o f th e p rim a ry f o c u s .
th e p a t i e n t .
C o n s i d e r a b l e d i f f i c u l t y was e x p e r i e n c e d i n e s t i ­
m a tin g t h e s e f a c t o r s , p a r t i c u l a r l y i n th e in s ta n c e o f
e s tim a tin g lo c a l sp re a d .
T he f a c t t h a t a b s c e s s f o r m a ­
t i o n h a d o r i g i n a l l y t a k e n p l a c e m e a n t t h a t m o re b o d y
t i s s u e w as i n v o l v e d i n t h e t u b e r c u l o u s p r o c e s s t h a n
w o u ld h a v e b e e n t h e c a s e i n a 3 i m p l e l e s i o n .
T hese
a b s c e s s e s w e r e l i n e d w i t h a n a c t i v e t u b e r c u l a r m em brane
c a p a b l e o f a t t a c k i n g m o re h e a l t h y t i s s u e a n d s o i n ­
c r e a s i n g t h e i r d i m e n s i o n s , a f a c i l i t y w h i c h was r e t a i n e d
a f t e r th e fo rm a tio n o f a s in u s by th e s in u s w a l l s .
m e a n t t h a t t h e s i n u s w as n o t a s t a t i c
a k in to
a h e a lth y shoot w ith i t s
T h is
t u b e b u t w as m ore
ro o ts deep in th e
b o d y t i s s u e s an d c a p a b l e o f b r a n c h i n g o u t a t a n y p a r t
of its
l e n g t h w h ich , o c c u r r in g as i t d i d , a c c o u n te d f o r
t h e t o r t u o u s c o u r s e o f many s i n u s e s .
When s e c o n d a r y
i n f e c t i o n was a d d e d t h e s e o f f - s h o o t s c a r r i e d i t w i t h
th em , a p ro c e s s norm al to th e s in u s
and n o t a c c e l e r a t e d
i n a n y way b y t h e p r e s e n c e o f t h e i n f e c t i o n .
Y e t, i f
o n e o f t h e s e b r a n c h e s b ecam e b l o c k e d a n d a p r o c e s s a k i n
to
a c u te ab scess fo rm a tio n o c c u rre d , r e s u l t i n g i n a
r a p i d s p r e a d n e c e s s i t a t i n g i n c i s i o n and f r e s h s in u s
fo rm a tio n /
f o r m a t i o n , t h e n t h e s e c o n d a r y i n f e c t i o n was j u d g e d t o
h av e a id e d i n th e l o c a l sp re a d o f t u b e r c u lo s is th ro u g h
h e a lth y tis s u e .
S u rro u n d in g c e l l u l i t i s
and a c u t e
a d e n i t i s s o m e t i m e s g a v e s i m i l a r r e s u l t s and t h e y t o o
w ere in c lu d e d i n t h i s
c a te g o ry .
I t was a l s o d i f f i c u l t t o e s t i m a t e when a g e n e r a l
s p r e a d o f t u b e r c u l o s i s r e s u l t e d a n d i n o r d e r t o do t h i s
t h e e n t i r e c a u s e o f e a c h c a s e was c o n s i d e r e d an d i t s
f e a t u r e s c o m p a re d w i t h t h o s e o f o t h e r c a s e s i n whom
t h e r e w as n o s e c o n d a r y i n f e c t i o n .
T h is m eant t h a t , i f ,
b y v i r t u e o f t h e n a t u r e o f th e p rim a ry l e s i o n and i t s
c o u r s e i t was c o n s i d e r e d p o s s i b l e f o r a g e n e r a l s p r e a d
to have ta k e n p la c e w ith o u t th e a id o f a s e c o n d a rily
in fe c te d
s i n u s t h e n s u c h a s p r e a d was a s c r i b e d t o t h a t
r e a s o n an d e x a m p le s o f t h i s w e re n o t i n f r e q u e n t .
I f , h o w e v e r, a p a t i e n t d ev elo p ed m u l t i p l e l e s i o n s o r
even a m i l i t a r y t u b e r c u lo s is o u tw ith th e e x p e c te d
c o u r s e o f h i s o r h e r ty p e o f d i s e a s e and i n a s s o c i a t i o n
w ith an in f e c te d s in u s th e n th e c r e d i t f o r th e s p re a d
w as l a i d u p o n t h e i n f e c t i o n .
T h e sam e p r o c e s s o f
e l i m i n a t i o n was c o n t i n u e d i n e s t i m a t i n g t h e s p r e a d o f
t h e p r im a ry f o c u s and t h e f e a t u r e u s e d t o d e te rm in e
t h e e f f e c t u p o n t h e p a t i e n t s g e n e r a l h e a l t h was t h e
w e ig h t r e c o r d .
T h e se f a c t o r s w ere t a b u l a t e d f o r d i s e a s e a f f e c t i n g
t h e v e r t e b r a e a n d a n a t t e m p t made t o a n s w e r t h e v a r i o u s
q u e s tio n s .
TABLE
54 . /
142.
TABLE
34.
VERTEBRAE.
Colum n I .
E f f e c t o f 3 i n u s f o r m a t i o n and s e c o n d a r y
i n f e c t i o n on l o c a l s p r e a d o f t u b e r c u l o s i s .
G eneral s p re a d .
On a c t i v i t y o f p r i m a r y f o c u s .
show n + o r 0 .
II.
III.
H . R.
+
0
0
Loss a t f i r s t , g a in e d l a t e r .
M. G.
0
0
0
G r. g a in .
A. G.
+
0
0
Loss f i r s t th e n a g r a d . g a in .
J . McB .
0
0
0
G a in , l o s s , g a in .
A. McH.
0
0
0
I.S .Q .
A. McM.
0
0
0
I.S .Q .
D. M.
?
0
0
I.S .Q . a t f i r s t lo s s l a t e r .
P. P.
0
0
0
S I. g r . g a in .
M. L .
+
0
0
S I. g a in .
J . B.
0
0
0
S i. g r . g a in .
M. M.
+
0
0
I.S .Q . th e n lo s s .
D. McH.
+
0
0
F lu c t. a t f i r s t , f in a l s i .
th en lo s s .
J.
S.
0
0
0
I.S .Q . th e n s i . g a in .
J.
S.
0
0
0
V. s i . g a in .
R. K .
0
0
0
I.S .Q . S I. lo s s .
H• S .
0
0
0
I* S .Q .
N. S .
0
0
0
S I. lo ss.
P. 0.
0
0
0
S I . w t. g a in .
J. c.
0
0
0
G a in .
0
0
0
S I. g a in .
I . L.
0
0
0
I.S .Q . lo s s .
P . A.
0
0
0
S I. lo ss.
W. McD.
0
0
0
I.S .Q . lo s s .
I.
R.
t
g a in
143.
I.
The e f f e c t o f l o c a l s p r e a d .
I n s i x i n s t a n c e s a d e g r e e o f l o c a l s p r e a d was
a t t r i b u t e d to th e seco n d ary i n f e c t io n .
I t d id n o t
o c c u r i n s i n u s e s r e l a t i n g t o t h e c e r v i c a l and d o r s a l
v e r t e b r a e b u t o n ly i n r e l a t i o n t o l e s i o n s o f th e lu m b ar
r e g i o n an d s a e r o - i l i a c
j o i n t s an d t h e n o n l y i n s i n u s e s
w h e r e t h e r e was a s t r e p t o c o c c a l s e c o n d a r y i n f e c t i o n .
On f o u r o f t h e o c c a s i o n s t h e t u b e r c u l o u s a b s c e s s
t r a c k e d th ro u g h t h e s a c r o - s c i a t i c fo ra m e n and re a c h e d
t h e a b u n d a n t s o f t t i s s u e s o f t h e b u t t o c k an d u p p e r
t h i g h w h e re , l a c k i n g d r a i n a g e , an a c u t e p r o c e s s r e ­
s u l t e d w ith e x t e n s iv e d e s t r u c t i o n o f s o f t t i s s u e and
th e e v e n tu a l fo rm a tio n o f f r e s h s in u s e s th ro u g h th e
c o u n t e r i n c i s i o n s w h ic h h a d t o b e m a d e .
I n one o t h e r
c a s e th e a b s c e ss tr a c k e d th ro u g h th e s o f t t i s s u e s o f
t h e b u t t o c k w h e r e t h e s e c o n d a r y i n f e c t i o n b ecam e v e r y
v i r u l e n t i n t h e s h e l t e r e d a r e a s a f f o r d e d t h e r e and i n
t h e f i n a l c a s e a s m a ll o f f - s h o o t fro m an i n f e c t e d p s o a s
a b sc e ss tra c k e d o v er th e i l i a c
c r e s t to th e g lu te a l
m u s c l e s w h e r e a n a c u t e a b s c e s s w as f o r m e d o n c e m ore
n e c e s s i t a t i n g I n c i s i o n and d r a in a g e .
No o t h e r e x a m p le s
l i k e t h e above w ere s e e n a lth o u g h n o rm a l e x t e n s i o n o f
a s i n u s t h r o u g h t h e s o f t t i s s u e s w as n o t e d o f t e n .
II.
The g e n e r a l s p re a d o f t u b e r o u l o s i s .
No e v i d e n c e w as a f f o r d e d t h a t t h i s
o ccu rred in
re s p o n s e to th e s tim u lu s o f seco n d ary I n f e c t i o n .
III.
T h e p r i m a r y f o c u s was n o t a d v a n c e d o r s t i m u l a t e d
i n a n y way b y t h e p r e s e n c e o f i n f e c t i o n .
IV .
The e f f e c t o f s in u s f o r m a tio n upon t h e c o u r s e o f
th e i l l n e s s
a tin g .
an d t h e p a t i e n t ' s r e s i s t a n c e was i l l u m i n ­
I t was f o u n d , w h e r e t h e s e c o n d a r y I n f e c t i o n was
o f a s u b s i d i a r y and p a r a s i t i c n a t u r e o r a b s e n t , t h a t
s in u s fo rm a tio n a p p eared to have no d e t e r r e n t e f f e c t
a s th e p a t i e n t c o n tin u e d to g a in s t e a d i l y i n w e ig h t.
A s i m i l a r e f f e c t w as s e e n i n tw o i n s t a n c e s w h e r e t h e r e
w as a s t r e p t o c o c c a l i n f e c t i o n i n t h e s i n u s .
One w as a
p a t i e n t who h a d a s h o r t o p e n s i n u s f r e e f r o m a c u t e com­
p l i c a t i o n a lth o u g h h a rb o u rin g B . h a e m o ly tic s t r e p t o ­
c o c c i , an d t h e o t h e r was a p a t i e n t w i t h a n o l d c h r o n i c
s in u s h a rb o u rin g n o n -h a e m o ly tic s t r e p t o c o c c i .
T he r e ­
m a in in g c a s e s , p a r t i c u l a r l y th o s e w ith a heavy se c o n d a ry
i n f e c t i o n and v i s i b l e c o m p l i c a t i o n , l o s t w e i g h t a t
firs t,
o r e q u iv a le n t to lo s i n g w e ig h t i n a c h i l d , r e ­
m a i n e d a t a s t a t i o n a r y w e i g h t f o r some t i m e .
As t h e
i n f e c t i o n d i e d o u t an d h e a l i n g o c c u r r e d some o f t h e s e
c a s e s commenced t o g a i n w e i g h t b u t w h e r e t h e a c t i v i t y
o f t h e s i n u s e s w e r e m a i n t a i n e d w e i g h t w as s t e a d i l y l o s t .
The m a j o r i t y o f t h e s e l a t t e r c a s e s d i e d .
One c a s e
w h ic h d e v e lo p e d am y lo id d i s e a s e a p p e a re d t o g a i n w e ig h t
i n t h e l a s t f e w m o n th s o f l i f e d u e t o t h e a m y lo id
c h a n g e s and t h e s u b s e q u e n t oedem a.
I t r e m a i n s t o be
rem ark ed t h a t th e m ost s e r io u s s e c o n d a ry i n f e c t i n g
o r g a n i s m w as t h e B . h a e m o l y t i c s t r e p t o c o c c i .
TABLE
55/
145.
TABLE 55.
H ip s.
L .S .
G .S .
P .F .
W e i g h t ___________R e m a rk s ♦
W. G.
0
0
0
S I . g r . g a in
P . T.
+
0
0
L oss th e n a
s i . g a in .
W. L .
0
0
0
S I. g r . g a in
M. H .
+
0
0
L oss s te a d y
th en g a in ..
M.
+
0
0
G r. l o s s .
0
0
0
G a in .
+
0
0
W t. I . S . Q .
0 . D.
+ ■
0
0
S I. g a in
M. McC.
+
0
I .S .Q . th en
lo ss .
A. S .
0
0
0
S I . g a in .
J . A.
+
0
0
S I . g r . g a in
J. B
0
0
0
G a in .
W. K .
+,
0
+.?
S I. lo ss la te r
a s te a d y r i s e .
0 . H.
0
0
0
S I. ris e lo st
w hen s i n u s r e ­
opened g a in e d
on h e a l i n g .
M. P .
0
0
0
S I. lo s s .
D.
L .
0
0
0
G a in .
J . B.
0
0
0
S I. lo s s .
J. F.
0
0
0
S I . g r . g a in
sp re a d in g
la te r.
J
M.
. McL•
•
R ecu rren ce
s in u s .
•
•
CO
a
Second s in u s
fo rm ed .
A d e n itis h ere
T h is ta b l e g iv e s f a c t s r e g a rd in g th e h ip j o i n t s im i l a r
to th o s e g iv e n i n T a b le 34 f o r th e v e r t e b r a e .
I.
T he l o c a l s p r e a d o f t u b e r c u l o s i s was a i d e d i n
e ig h t i n s t a n c e s , a h ig h e r f ig u r e th a n i n th e p re v io u s
s e rie s.
A l l t h e s i n u s e s w h ic h show ed t h i s f e a t u r e w e r e
in p o s itio n s
s im ila r to th e v e r te b r a l s in u s e s w ith a
s im ila r c lin ic a l course.
Of i n t e r e s t w as t h e f a c t t h a t
o n tw o o c c a s i o n s a n a c u t e i n g u i n a l a d e n i t i s o c c u r r e d
a n d b r o k e down t o b e s u b s e q u e n t l y i n v o l v e d i n t h e t u b e r ­
c u lo u s p r o c e s s .
II.
T h e s e c o n d a r y i n f e c t i o n was a n a d j u v a n t t o t h e
g e n e r a l s p r e a d o f t u b e r c u l o s i s i n one i n s t a n c e o n ly .
III.
A s t i m u l a t i o n o f t h e a c t i v i t y o f th e p rim a ry
l e s i o n w as s u s p e c t e d i n o n e i n s t a n c e a l t h o u g h h e r e t h e
p r i m a r y l e s i o n w as a l m o s t s u f f i c i e n t l y a c u t e t o
ju stify
an u n a id e d s p re a d .
IV .
The e f f e c t upon t h e h e a l t h
s im ila r to th a t seen
o f th e
in th e case o f th e
p a t i e n t w as
v e r tb r a e w ith
t h i s d i f f e r e n c e t h a t a g r e a t e r num ber o f c a s e s c o n tin u e d
to g a in w e ig h t d e s p i t e t h e o c c u rre n c e o f a s i n u s .
In
tw o i n s t a n c e s s i n u s e s r e c u r r e d a s s o c i a t e d w i t h s t r e p t o ­
c o c c i i n t h e d i s c h a r g e and f u r t h e r r e f e r e n c e w i l l be
m ade t o p h e n o m e n a o f
th is ty p e .
As i n
s i n u s e s a r i s i n g from
th e v e r te b ra e , th e
th e case of
s tre p to c o c c u s
w as t h e p a t h o g e n r e s p o n s i b l e f o r a l l s e r i o u s m i s c h i e f .
TABLE
K nees,
3 fi.
L .S .
G .S .
P .F .
W e ig h t
R em arks,
M .C .
(R)
0
0
0
S I. g r.
g a in .
.
M .C .
(1)
0
0
0
S I. g r.
g a in .
—
M 3.
+
0
0
I.S .Q .
th e n a
g a in
la te r.
G .P .
+
0
0
L oss.
A m p u ta tio n .
A .C .
0
0
0
S I.
g a in .
-
B .H .
+
0
0
I.S .Q .
flu c tu a ­
tio n la te
g a in .
M .C .
+
0
0
lo ss g r . g a in .
W.H.
0
0
0
I.S .Q . s i . g a in .
I.
A cute
a b 3 c e s3
a ro u n d
jo in t.
-
S in u s f o r m a t i o n and s e c o n d a r y I n f e c t i o n was c o n -
s id e r e d re s p o n s ib le f o r th e l o c a l sp re a d o f tu b e r c u lo s is
I n f o u r ex am p les i n t h i s s e r i e s .
On e a c h o c c a s i o n t h e
s p r e a d o c c u r re d t o in c lu d e t h e bony s t r u c t u r e s around
t h e j o i n t an d t h e p r i m a r y l e s i o n was o f a n a c u t e
c h a ra c te r.
T h is l o c a l s p re a d o c c u r re d i n t h e form o f
a c u t e a b s c e s s e s i n t h e u p p e r c a l f an d b e h i n d t h e j o i n t
r e s u l t i n g fro m a g r a v i t a t i o n a l s p re a d o f i n f e c t i o n i n
tw o i n s t a n c e s a n d i n t h e r e m a i n i n g tw o t o o k t h e f o r m
lof a n a c u t e a r t h r i t i s .
th e /
I n a l l th e s e cases a n k y lo s is of
148.
t h e j o i n t w i t h d e f o r m i t y was t h e r e s u l t e x c e p t o n e
w h e r e a n a m p u t a t i o n i n m i d - t h i g h was p e r f o r m e d .
II.
G e n e r a l s p r e a d o f t u b e r c u l o s i s o c c u r r e d i n one
o f t h e e x a m p le s c i t e d a b o v e .
III.
T h e a c t i v i t y o f t h e p r i m a r y l e s i o n was t h o u g h t t o
h a v e b e e n i n c r e a s e d i n o n e e x a m p le w h e r e a s m a l l s i n u s
l e a d i n g fro m s o f t t i s s u e d i s e a s e becam e s e c o n d a r i l y
i n f e c t e d and b e f o r e h e a l i n g o c c u r r e d a l l t h e s t r u c t u r e s
o f t h e j o i n t w ere i n v o lv e d .
IV .
T he e f f e c t o n t h e g e n e r a l h e a l t h c o r r e s p o n d e d w i t h
p re v io u s f in d in g s .
TABLE
S 7 -.
THE AHKLE JO IH T S.
L .S .
G .S .
P .F .
A.M.
0
0
0
H.McK.
+
0
0
W eig h t.
S I. g r . g a in .
L oss.
A.W.
(L )
+
0
0
A.W.
(R)
+
0
0
D o.
I.G .
0
0
0
G r. g a in .
S .M .’
+
0
0
L oss
- I.S .Q .
ra p id g a in .
M.McC .
+
0
0
I.S .Q .
J .G .
+
0?
0
S I. g a in .
J .M c L .
+
0?
0
S I. g a in .
S I. g r . g a in .
-
g a in .
D ise a se o f t h i s
j o i n t was f o u n d t o b e p r o f o u n d l y a f f e c ­
t e d by th e a d d i ti o n o f seco n d ary i n f e c t i o n .
I.
L o c a l s p r e a d o f t u b e r c u l o s i s was n o t e d o n s e v e n
o c c a sio n s•
II•
D o u b t e x i s t e d a s t o w h e t h e r a g e n e r a l s p r e a d was
a i d e d i n tw o o c c a s i o n s .
I I I . I n n o i n s t a n c e was t h e r e a n y e v i d e n c e t h a t t h e
p r i m a r y l e s i o n was e f f o o t e d i n i t s
IV .
c o u r s e i n a n y w ay .
T he w e i g h t c h a r t s e x h i b i t e d t h a t , a s a g e n e r a l
r u l e , i n f e c t i o n s u p e r - a d d e d t o s i n u s f o r m a t i o n was l e s s
fo rm id a b le to th e p a t i e n t t h a n ^ n y
s e r i e s s o f a r ex am ­
in e d a s a g r e a t e r num ber c o n tin u e d t o g a i n s lo w ly i n
w e ig h t th ro u g h o u t t h e c o u rs e o f th e d i s e a s e .
Y et to x ­
a e m i a a n d w e i g h t l o s s w as m a rk e d i n two e x a m p l e s w h e r e
a m p u t a t i o n was f i n a l l y p e r f o r m e d r e s u l t i n g i n a n e x c e l ­
l e n t d e m o n stra tio n o f th e d e trim e n ta l e f f e c t o f a d i s ­
c h a r g in g s in u s upon t h e g e n e r a l h e a l t h and r e s i s t a n c e .
I n t h e f i r s t o f t h e s e tw o c a s e s 7 l b s . w e i g h t was
g a i n e d w i t h i n t h e f i r s t tw o m o n th s a f t e r t h e a m p u t a t i o n
a n d i n t h e o t h e r 5 l b s was g a i n e d i n 3 m o n t h s .
TABLE
,3 8 ../
150.
TABLE
58.
DACTYLITIS.
«
•w #
*
•
VVOXgUl, •
J .B .
+
0
?
L o s s ,la te g a in .
A .C .
0
0
0
S I. G r. g a in .
T .H .
+
0
0
Do.
M .C . (H)
0
0
0
M .C . ( F )
0
0
0
B .C .
0
0
0
L oss
R .McM.
0
0
0
L oss.
M .P .
0
0
0
I.S .Q .
s i . g a in .
M .L .
0
0
0
S I. g r . g a in .
R .S .
0
0
0
D o.
R .P .
+
0
0
D .S .
0
0
0
A.McD.
+
+?
0
I.
)
)
)
S I. g r. g a in .
- g a in l a t e r .
L oss g a in .
D o.
L oss
I.S .Q .
L o cal sp read o c c u rre d in 4 in s ta n c e s o n ly .
In
1 i n s t a n c e i t w as s l i g h t b u t r e s u l t e d i n a m p u t a t i o n o f
th e o ffe n d in g d i g i t in o rd e r to p re v e n t f u r th e r sp read
b u t i n t h e r e m a i n i n g 3 i n s t a n c e s i t w as e x t e n s i v e an d
r e s u l t e d i n v e r y m arked c e l l u l i t i s
and l o c a l i s e d a b s ­
c e ss fo rm a tio n in th e s o f t tis s u e s o f th e f e e t n e c e s - ,
s i t a t i n g f r e s h s in u s fo rm a tio n f o r d ra in a g e .
In /
I n 2 o f th e s e c a s e s an in g u in a l a d e n i t i s
arose in r e ­
l a t i o n t o t h e a f f e c t e d s i n u s e s i n o n e o f w h i c h i t was
a c u t e and d u e e n t i r e l y t o s t r e p t o c o c c i b u t i n t h e o t h e r
i t was p r i m a r i l y t u b e r c u l o u s .
II.
No e x a m p le was s e e n o f a g e n e r a l s p r e a d o f t u b e r ­
c u lo s is h a s te n e d o r b ro u g h t about by seco n d ary i n f e c t i o n .
III.
I n one c a s e ( J .B .)
t h e s e c o n d a r y i n f e c t i o n was
h e ld to be re sp o n s ib le f o r th e ra p id d is s e m in a tio n of
d is e a s e th ro u g h o u t th e bones o f th e f o o t .
H ere th e
p r i m a r y l e s i o n w as s o c h r o n i c t h a t i t was t h o u g h t t o b e
K o h l e r 's d i s e a s e u n t i l th e f o r m a tio n o f a s i n u s , w hen,
a f t e r th e o n s e t o f an a c u te seco n d ary i n f e c t i o n a w id e ­
sp read tu b e rc u lo s is r e s u lte d .
IV .
a
D e t r i m e n t t o t h e p a t i e n t s ' h e a l t h w as n o t e d i n
num ber o f c a s e s , t h e i n i t i a l s l i g h t l o s s b e in g
g e n e r a l l y f o l l o w e d b y s lo w g a i n i n w e i g h t .
I n s in u s e s
n o t i n f e c t e d by s t r e p t o c o c c i t h e w eig h t c o n tin u e d to
i n c r e a s e g r a d u a l l y a f e a t u r e s h a r e d b y some o t h e r s i n
w h i c h t h e r e was a s t r e p t o c o c c a l i n f e c t i o n .
W here
s e r io u s c o m p lic a tio n s o c c u rre d th e seco n d ary in f e c tin g
o r g a n i s m w as i n v a r i a b l y a s t r e p t o c o c o u s .
152.
TABLE
89.
TUBERCULOSIS OF THE LONG BONES.
L ;S .
G .S .
P .L .
W e ig h t.
R.McK.
0
0
0
S1« g r . g a in
J .S .
0
0
0
S te a d y lo s s
-
J .M c L .
0
0
0
S te a d y g a in
-
S .M .
+
0
0
L o s s - s lo w
g a in .
-
A .K .
0
0
0
I.S .Q .
-
H .J.
0
0
0
S lo w g a i n
-
G .D .
+
+?
0
LOS3
-
T .S .
0
0
0
S I. g a in
J .G .
0
0
0
S I. g a in
-
D .P .
+
0
0
L oss s i . g a in .
-
J .G .
+
0
0
G r. g a in .
-
A.McD.
0
0
0
Loss - I .S .Q .
-
I.
R em arks.
A n k y lo s e d
O n ly 4 e x a m p le s w e r e s e e n w h e r e a l o c a l s p r e a d
was a i d e d .
II.
One d o u b t f u l e x a m p le o c c u r r e d w h e r e a g e n e r a l
s p r e a d was a i d e d .
III.
No e x a m p le was s e e n o f a n y c h a n g e i n t h e a c t i v i t y
o f th e p rim a ry l e s i o n as a r e s u l t o f i n f e c t i o n .
IV .
Once a g a i n t h e w e i g h t f e a t u r e s c o n f o r m e d t o t h o s e
s e e n p r e v i o u s l y a l t h o u g h m a rk e d d e t r i m e n t a l e f f e c t s
w ere a b s e n t .
stre p to c o c c u s .
T he i m p o r t a n t p a t h o g e n t h r o u g h o u t w as t h e
153
GLANDULAR AND SOFT TISSUE TUBERCULOSIS.
L e s i o n 3 o f t h i s n a t u r e e s c a p e m o re l i g h t l y f r o m t h e
d e p r e d a tio n s o f seco n d ary i n f e c t i o n th a n o th e r s i t e s .
TABLE
40.
L .S .
G .S .
P .L ,
c .w .
+
0
0
I .S .Q . - g a in
L.C .
0
0
0
S I . g a in
JJ3.
0
0
0
Loss
J .McG .
0
0
0
S tead y g a in
J .McC .
0
0
0
I.S .Q
C .C .
0
0
0
I.S .Q .
I.e .
0
0
0
S te a d y g a in
c .w .
+?
0
0
L oss - g a in
M .D.
0
0
0
G a in
M .F .
0
0
0
G a in
.L .
+
0
0
I .S .Q . - g a in
H .H .
0
0
0
D o.
A .C .
+?
0
0
S te a d y g a in
I.W .
0
0
0
D o.
A.McD.
0
0
0
J
I.
- g r . g a in .
- g a in
L oss - I .S .Q .
A lo c a l sp read o ccu rred in 2 in s ta n c e s as a r e ­
s u l t o f g r a v i t a t i o n a l p o c k e t i n g o f p u s w h ich r e q u i r e d
f r e s h s in u s fo rm a tio n f o r d ra in in g .
II-. & I I I .
T h e r e was n o e v i d e n c e o f g e n e r a l s p r e a d o r
o f an y c h a n g e b e i n g e f f e c t e d o n t h e t u b e r c u l o u s p r o c e s s
by in fe c tio n .
IV ./
154.
IV .
W e ig h t l o s s was s e e n i n 3 i n s t a n c e s i n o n e o f
w h i c h i t was p r o b a b l y d u e t o t h e p u l m o n a r y l e s i o n w h i c h
c a u s e d d e a t h a n d i n a n o t h e r i t was d u e t o t h e p r e s e n c e
o f m u l t i p l e l e s i o n s and u n l i k e l y t o b e i n f l u e n c e d by
t h e m in o r g l a n d u l a r l e s i o n .
The re m a in in g c a s e s a l l
g a in e d w e ig h t s t e a d i l y th ro u g h o u t th e c o u rse o f t h e i r
i l l n e s s , e x h i b i t i n g th e r e b y t h e r e l a t i v e im p o ten ce
of th e ir le sio n .
TABLE
H
.
MISCELLANEOUS LESIONS.
L .S .
G .S .
P .L .
W.A.
+
+
0
R J.
0
0
0
D o.
C.McC .
0
0
0
D o.
E .B .
0
0
0
D o.
E .A .
0
0
0
Do.
M.McV.
0
0
0
Do.
S .M .
0
0
0
Do.
J .M cL.
0
0
0
Do.
F.M cH .
0
0
0
Do.
W e ig h t
S I. g a in
R em ark s
D ied .
-------------------
T h e s e l e s i o n s e s c a p e d w h a t was e v e n t u a l l y r e g a r d e d a s
s e r i o u s s e c o n d a r y i n f e c t i o n and i n n o e x a m p le was t h e r e
a n y e v i d e n c e o f a l o c a l s p r e a d o f t u b e r c u l o s i s o r an y
chan ge i n th e p rim a ry l e s i o n cau sed by th e i n f e c t i o n .
G e n e ra l s p re a d r e s u l t i n g i n d e a th from m i l i a r y t u b e r ­
c u lo sis/
155
t u b e r c u l o s i s was f e l t t o h a v e r e s u l t e d f r o m a n i n f e c t e d
a b d o m in a l s in u s i n a c a s e w ith t a b e s m e s e n t e r i c a .
Each
p a t i e n t g a in e d w e ig h t g r a d u a lly th ro u g h o u t th e c o u rse
o f th e d is e a s e .
I n t h e a g g r e g a te t h e f o ll o w i n g c o n c lu s io n s w ere
m ade: I*
T h a t a b s c e s s an d s i n u s f o r m a t i o n u n d o u b t e d l y
o p e n e d u p f r e s h t i s s u e s t o t h e r i s k o f i n f e c t i o n an d
t h a t l o c a l s p r e a d o f t h e d i s e a s e was s e e n o n n u m e ro u s
o c c a s i o n s an d m o s t m a r k e d l y i n l e s i o n s i n w h i c h t h e
p r i m a r y f o c u s w as a c u t e a n d d e e p l y i n g w i t h a s i n u s
t r a c k ru n n in g th ro u g h an e x te n t o f s o f t t i s s u e .
II.
T h at g e n e r a l s p re a d r e s u l t e d fro m i n f e c t i o n i n
v e r y f e w i n s t a n c e s an d e v e n t h e n was n o t d e f i n i t e l y
caused by i t .
III.
T h a t o n o n l y 3 o c c a s i o n s was t h e r e i n c o m p l e t e
e v id e n c e t h a t th e a d d itio n o f a seco n d ary i n f e c t i o n to
a s in u s a c te d a s a s tim u lu s to th e p rim a ry f o c u s .
IV .
T hat s in u s f o rm a tio n p lu s seco n d ary i n f e c t i o n
w as d e t r i m e n t a l t o t h e p a t i e n t s ’ g e n e r a l h e a l t h a n d was
a d e f i n i t e d e t e r r e n t t o r e c o v e r y i n a num ber o f o a se s
b u t t h a t i n t h e m a j o r i t y t h e e f f e c t was m i n i m a l an d
w as o v e r c o m e b y t h e p a t i e n t q u i t e r e a d i l y .
On t h i s
b a s i s t h e m ost s e r i o u s s i t e s w i t h added i n f e c t i o n w ere
v e r t e b r a e , h i p j o i n t s , k n e e j o i n t s an d a n k l e j o i n t s .
V ./
V.
T h a t i n e v e r y e x a m p le s h o w in g an y d e t r i m e n t a l
f e a t u r e t h e s e c o n d a r y i n f e c t i o n was a s t r e p t o c o c c u s
arid t h a t i n a l l s e r i o u s c a s e s t h i s o r g a n i s m was
B . h a e m o ly tic in c h a r a c te r .
T h e r e r e m a i n s t o b e d i s c u s s e d o n e m o re f e a t u r e
sh ow n b y s i n u s e s , n a m e l y , t h e i r r e c u r r e n c e .
T h is
f e a t u r e h a s b e e n a s c r i b e d t o many f a c t o r s i n c l u d i n g
t h e r e c r u d e s c e n c e o f a dorm ant s e c o n d a ry i n f e c t i o n .
An e x a m i n a t i o n o f s e v e r a l o f t h e s e s i n u s e s b a c t e r l o l o g i c a l l y , a f t e r t h e i r re c u rre n c e , re v e a le d th e p r e ­
s e n c e o f v e r y f r i a b l e an d v e r y s p a r s e o r g a n i s m s .
I n c e r t a i n i n s t a n c e s s t r e p t o c o c c i w ere r e c o v e r e d b u t
th e y w ere e i t h e r n o n -h a e m o ly tic i n c h a r a c t e r o r so
f r i a b l e t h a t c u l t u r e w as i m p o s s i b l e , f a c t o r s w h i c h
au g u red i l l f o r t h e i r a b i l i t y to reopen a s in u s tr a c k
by v irtu e
of t h e i r p ath o g e n ic po w ers.
A c c o rd in g ly
a t t e n t i o n was d i r e c t e d t o o t h e r f e a t u r e s p r e s e n t e d b y
t h e c a s e s w i t h i n t h e i n v e s t i g a t i o n a n d a g r a p h was
p r e p a r e d c o m p a rin g t h e d a t e s on w h ich s i n u s e s h e a l e d
w i t h t h e d a t e s on w h ic h t h e t u b e r c u l o u s l e s i o n c o r r e s
p o n d in g becam e i n a c t i v e c l i n i c a l l y
GRAPH
3 ./
and r a d i o l o g i c a l l y
157.
GRAPH
3.
-----
■f-T" —
~~T~
r
i —r
m
t =
...'I.
Cj
5
M hooH iS
I
i non/*!<
i .
/
'D o .fr S
/Jh,o
n th i
'U
? f '
* f
«,u 7
* <■
©
XL
&
\(5
s
*
*
t—
6
* A
u
^ £
IS. 3
s
—
0
©
@
<3)
>
«■©
-- I W
■4
i
i t
er
<
€>
y
SHg £
-H -+
<9
>.
2:
u
s
t= b a j
G
©
Di s e a s e
_I------ ---!---!_—i l l .
_L
—1
« « o i o i o a iC R IL y
n
R A P'iL O G |C A Il-V
N ncnȣ
1
ftc rW E
_LJ_
T h u s o f 43 c a s e s o f b o n e t u b e r c u l o s i s w i t h d i s ­
c h a r g i n g s i n u s e s t h e p r i m a r y l e s i o n was i n a c t i v e c l i n ­
ic a lly
and r a d i o l o g i c a l l y b e f o r e o r a t t h e sam e t i m e
a s t h e s i n u s h e a l e d i n 30 i n s t a n c e s an d a f e a t u r e o f
n o t e w as t h e c l o s e r e l a t i o n s h i p e x h i b i t e d b e t w e e n
t h e s e tw o f a c t o r s .
it
W here t h i s
o r d e r was r e v e r s e d , a s
was i n 12 i n s t a n c e s , f i r m h e a l i n g o c c u r r e d i n 8
and r e p e a te d r e c u r r e n c e to o k p la c e in 4 .
I n one i n ­
s t a n c e t h e p r i m a r y l e s i o n w as i n a c t i v e b u t t h e s i n u s
w as s t i l l p a t e n t a f t e r a p e r i o d o f one y e a r .
An i n ­
f e r e n c e w as d raw n t h a t t h e h e a l i n g o f a s i n u s was
c lo se ly /
c l o s e l y r e l a t e d to th e h e a l i n g o f a p rim a ry l e s i o n
w h ic h c a u s e d i t .
tio n s
A d d in g t o t h i s t h e p r e v i o u s o b s e r v a ­
t h a t se c o n d a ry i n f e c t i o n te n d e d to d is a p p e a r in
h e a l i n g s i n u s e s an d t h a t t h e m o s t g r a v e i n f e c t i o n w i t h
s e r io u s con seq u en ces a lm o st i n v a r ia b ly o c c u rre d in
a c u t e f o r m s o f t u b e r c u l o s i s i t w as f e l t t h a t t h e
s e c o n d a r y i n f e c t i o n s w e r e a p t l y named a s t h e y w e r e
o n l y c a p a b l e o f t h e i r g r e a t e s t d e s t r u c t i v e p o w e rs i n
t h e s u i t a b l e s o i l p r o v i d e d f o r th em b y t h e t u b e r c u l o u s
pro cess.
E x a m p le s o f t h i s w e r e s e e n i n t h e u n c o m p l i c a ­
t e d c o u r s e f o l l o w e d , e v e n b y w i d e s i n u s e s , when t h e
p r i m a r y f o c u s w as t h o r o u g h l y rem o v ed s u c h a s w as p o s ­
s i b l e i n some l o n g b o n e and g l a n d u l a r l e s i o n s .
C o n tin u in g th e i n v e s t i g a t i o n o v e r a lo n g p e rio d
e n a b le d t h e end r e s u l t s o f t h e i l l n e s s t o be a p p r e c i a ­
t e d , a s w i t h c o m p a r a t i v e l y fe w e x c e p t i o n s a d e f i n i t e
r e s u l t was a c h i e v e d w i t h t h e c a s e s u n d e r o b s e r v a t i o n .
TABLE
- 4 2 ./
to
01
o
a
•H
O
H
o
o
o
o
01
rH
CO
01
in
rH
H
CO
p
ft
©
u
p
o
©
rH
TO
•
o o
3*"
o
©
p —
3
to
01
s °
>>
p
TABLE
H
O)
o
o
o
o
o
33
01
to
CO
oi
to
CO
*
01
CO
p
ft
©
p
co
<
in
to
H
H
05
O
P
01
CO
a
01
co
to
rH
%
P
a
Sh
o
2m
©
PS
•H
u
id
©
•H
Q
01
o
H
p
rH
to
to
•
O’
©
•
CO
p
©
Q
•
M
f
Tl
©
>
O
rP
©
p
ft
7J
ft
u
y
H
©
w
o5
3
E m b o d y in g t h e r e s u l t s , r e v e a l e d t h a t t h e r e was a m o r t ­
a lity
o f a p p r o x i m a t e l y 12$ a n d a c o m p l e t e r e c o v e r y o f
a p p ro x im a te ly 65$.
C e r t a i n c a s e s w ere s t i l l
a c tiv e
and o f t h e s e 7$ w ere d e t e r i o r a t i n g , 8$ w ere im p ro v in g
a n d 10$ w e r e i n s t a t u quo a n t e .
T hese r e s u l t s a p p e a r
g o o d b u t c o m p a re u n f a v o u r a b l y w i t h t h o s e t a k e n f r o m t h e
t o t a l d i s m i s s a l s o f c o m p a r a b l e c a s e s f r o m t h e same
h o s p i t a l f o r tw o c o n s e c u t i v e y e a r s i n t h e m i d d l e o f
th e in v e s tig a tio n .
T hese w e re , i n a p p ro x im a te f i g u r e s :
D ied 7 . 4 $ , I r r e g u l a r l y d i s m i s s e d 2 . 2 $ , H e a le d 9 0 .4 $ .
Of t h e c a s e s i n v e s t i g a t e d 65 h a d h a d a s t r e p t o c o c c a l
s e c o n d a r y i n f e c t i o n and 37 h a d n o t an d t h e f i g u r e s i n
t h e c o lu m n s I I
a n d I I I o f t h e t a b l e show ed t h e v e r y
m uch b e t t e r r e s u l t s o b t a i n e d i n p a t i e n t s who r e m a i n e d
f r e e fro m s t r e p t o c o c c a l se c o n d a ry i n f e c t i o n s •
i n t o t h e s e r e s u l t s was t h e a c t i v i t y
E n te rin g
o f t h e p rim a ry
l e s i o n and t h e s e f i g u r e s g iv e d e f i n i t e p r o o f o f an
e a r l i e r s t a t e m e n t t h a t s t r e p t o c o c c i w e r e m o re commonly
f o u n d i n a s s o c i a t i o n w i t h t h e m o re a c u t e c a s e s o f
tu b e rc u lo sis.
I t was t o b e e x p e c t e d t h a t t h e m ore
a c t i v e p r i m a r y l e s i o n s w o u ld h a v e a g r e a t e r m o r t a l i t y
th a n th e le s s a c tiv e y e t th e s e r ie s of f ig u r e s
suggest
t h a t t h o s e s i n u s e s i n f e c t e d w i t h s t r e p t o c o c c i showed
a r e l a t i v e l y g r e a te r m o rta lity th an a s t r i c t p ro p o rtio n
w o u ld h a v e a l l o w e d .
The r e s u l t o f t r e a t m e n t v a r i e d a c c o r d in g to th e
s ite /
s ite
a f f e c t e d b y t h e d i s e a s e and w hen t h e s e f i g u r e s
w e r e a b s t r a c t e d i t w as s e e n t h a t t h e m o s t d i s a p p o i n t i n g
o ccu rred in r e l a t i o n to d is e a s e of th e v e r te b r a e .
VERTEBRAL
TUBERCULOSIS.
Of 23 p a t i e n t s w i t h d i s e a s e i n t h i s a r e a t h e r e
w e r e 6 who d i e d , 5 who w e r e d e t e r i o r a t i n g , 4 i n a
s ta tio n a r y c o n d itio n
, 2 who w e r e i m p r o v i n g an d o n l y
6 i n whom t h e d i s e a s e was h e a l e d , f i g u r e s w h i c h co m p are
u n fa v o u ra b ly w ith th e r e s u l t s o f tre a tm e n t o f a l l cases
o f d i s e a s e o f t h e v e r t e b r a e w h e r e t h e r e w e r e 10 d e a t h s
a n d 6 1 c a s e s h e a l e d o u t o f 73 d i s m i s s a l s .
A ll 6 p a t i ­
e n t s who d i e d w e r e e x t r e m e l y t o x i c f r o m t h e i r s e c o n d ­
a r i l y i n f e c t e d s i n u s e s an d a l l w e r e s u f f e r i n g f r o m
am y lo id d i s e a s e .
Am ongst t h o s e w hose c o n d i t i o n was
d e t e r i o r a t i n g 2 h a d d e v e lo p e d am y lo id d i s e a s e a n d , w ith
one e x c e p t i o n , w ere e x tr e m e ly t o x i c fro m t h e i r s i n u s e s .
T he e x c e p t i o n w as a c a s e w i t h c h r o n i c d i s e a s e o f t h e
c e r v i c a l v e r t e b r a e w h ic h h a d b e e n i n e x i s t e n c e f o r 10
y ears.
T h e 4 w h i c h r e m a i n e d s t a t i o n a r y h a d t h e common
f e a t u r e o f a m ild i n f e c t i o n i n t h e i r s in u s e s and s t i l l
a c t i v e p r i m a r y l e s i o n s a n d , i n a l l i n whom im p ro v e m e n t
o c c u r r e d , t h e s e c o n d a r y i n f e c t i o n was m i l d i n d e g r e e
and t h e r e s i s t a n c e o f t h e p a t i e n t g o o d .
T hose w h ich
h e a le d had a s tr e p t o c o c c a l se c o n d a ry i n f e c t i o n i n o n ly
one i n s t a n c e , th e re m a in d e r b e in g e i t h e r s t e r i l e
h a r b o u rin g l e s s p a th o g e n ic o rg a n ism s.
or
W ith in t h i s
s e r i e s w as a p a t i e n t who made a r e c o v e r y f r o m w h a t w as
c lin ic a lly /
c l i n i c a l l y am y lo id d i s e a s e .
T h i s p a t i e n t was a d m i t t e d
w i t h d i s c h a r g i n g s i n u s e s an d a c t i v e t u b e r c u l o s i s .
He
w as t o x i c an d d e v e l o p e d a n e n l a r g e d l i v e r , a *waxy*
a p p e a r a n c e an d a l b u m i n u r i a .
F o llo w in g an a t t a c k o f
j a u n d i c e h i s sym ptom s a n d s i g n s a b a t e d an d h e s l o w l y
im p r o v e d t o b e d i s m i s s e d , h e a l e d .
On t h e w h o le t h e s e r e s u l t s w e r e v e r y d i s a p p o i n t i n g
and d i s p l a y e d th e g r a v i t y o f th e s e c o n d a ry i n f e c t i o n as
a f a c to r m ilita tin g a g a in st re c o v e ry .
TUBERCULOSIS
OF
THE
H IP
JO IN T .
W i t h i n t h i s s e r i e s t h e r e w e r e 18 c a s e s o f whom
2 d ie d , 2 d e te rio ra te d ,
p r o v e d an d 11 h e a l e d .
1 r e m a in e d s t a t i o n a r y , 2 im ­
C o m p arativ e f i g u r e s f o r a l l
c a s e s o f t h i s a r e a w ere 3 d e a t h s , 1 i r r e g u l a r d i s m i s s a l
a n d 60 who h e a l e d o u t o f 64 c a s e s , s t i l l
sh o w in g p o o r e r
r e s u l t s w ith in th e s e r i e s in v e s tig a te d b u t n o t so
m a r k e d ly i n f e r i o r a s w ere t h e p r e v i o u s r e s u l t s .
D e a th
o c c u r r e d i n two i n s t a n c e s w h e r e t h e r e was a c u t e p r o ­
g r e s s i v e t u b e r c u l o s i s w i t h h e a v i l y i n f e c t e d s i n u s e s an d
am y lo id d i s e a s e a s a te r m in a l f e a t u r e .
B o th ex am p les
w h ere d e t e r i o r a t i o n o c c u r r e d w ere s t i l l
s u f f e r i n g from
a c t i v e t u b e r c u l o s i s when t h e i n v e s t i g a t i o n was c o n ­
c l u d e d an d i n b o t h t h e r e was a h e a v y s e c o n d a r y i n f e c ­
t i o n b y s t r e p t o c o c c i w i t h m ark ed t o x a e m i a and o t h e r
c o m p l i c a t i o n s , f e a t u r e s a l s o shown b y t h e c a s e s w h i c h
w ere/
w ere re m a in in g i n a s t a t i o n a r y c o n d i t i o n .
Im provem ent
o c c u r r e d i n 2 an d h e a l i n g i n 7 i n s t a n c e s w h e r e t h e r e
w as a s t r e p t o c o c c a l s e c o n d a r y i n f e c t i o n o n t h e s i n u s e s
a n d i n some o f th e m t h e e f f e c t o f t h o s i n f e c t i o n was
o n l y o v e rc o m e a f t e r l o n g a n d c a r e f u l t r e a t m e n t .
d ise a se of th is
In
j o i n t , even w ith a s e r io u s seco n d ary
i n f e c t i o n , t h e r e s u l t s o f t r e a t m e n t w ere b e t t e r d e s p i t e
t h e f a c t t h a t t h e i n f e c t i o n was a s s e v e r e , i f n o t m ore
s e v e r e , t h a n i n many o f t h e v e r t e b r a l l e s i o n s .
The
o n ly d i f f e r e n c e la y in th e r e l a t i v e l y s h o r t e r c o u rs e o f
t h e t u b e r c u l o u s p r o c e s s I n t h e h i p j o i n t s w i t h , a s was
p o in te d o u t,a s h o r te r co u rse f o r th e s in u s e s r e s u ltin g
i n a l e s s p ro lo n g e d d r a i n upon th e p a t i e n t 's r e s i s t a n c e .
TUBERCULOSIS
OF
ME
KNEE
JO IH T .
T h i s l e s i o n show ed much b e t t e r r e s u l t s .
p a tie n ts,
Of 7
1 d i e d , 1 was i m p r o v i n g and 5 w e r e h e a l e d .
S t i l l w o r s e , h o w e v e r , t h a n 2 d e a t h s i n 33 p a t i e n t s
w h ic h w ere t h e g e n e r a l r e s u l t s .
The c a s e i n w h ic h
d e a t h o c c u r r e d was o n e i n w h i c h t h e s t r e p t o c o c c a l
s e c o n d a r y i n f e c t i o n was h e l d p a r t l y r e s p o n s i b l e f o r
t h e r a p i d d e t e r i o r a t i o n o f t h e p a t i e n t an d t h e g e n e r a l
s p r e a d o f t u b e r c u l o s i s w h ich r e s u l t e d i n d e a t h .
The
c a s e i n w h i c h im p ro v e m e n t w as r e c o r d e d was o n l y u n d e r
o b s e r v a tio n f o r a r e l a t i v e l y s h o rt p e rio d o f tim e b u t
i t was f e l t t h a t a s a t i s f a c t o r y r e s u l t was u n d e r w a y .
O nce m o re t h e s e c o n d a r y i n f e c t i o n s w e r e g r o s s an d
caused/
c a u s e d e x t e n s i v e dam age w h i c h was f o r t u n a t e l y l i m i t e d
by th e r e l a t iv e ly s h o rt course of th e i l l n e s s .
TUBERCULOSIS
OF
THE
ANKLE
JO IN T S -
T he r e s u l t s h e r e w e r e e x c e l l e n t an d 100$ r e c o v e r y
w as a c h i e v e d , t h u s e q u a l l i n g t h e f i g u r e s a c h i e v e d o v e r
a l l ty p e s o f t h i s l e s io n .
A g a in , h o w e v e r, t h e s e c o n d ­
a r y i n f e c t i o n s an d c o m p l i c a t i o n s w e r e s e v e r e , n e c e s ­
s i t a t i n g am p u ta tio n i n 2 in s ta n c e s as a c u r a t i v e m eas­
u re.
A t t h e b e g i n n i n g o f t h e c h a p t e r a n o t e was made
on th e r e l a t i v e l y lo n g c o u rse o f l e s io n s o f t h i s
re g io n .
O b s e r v a t i o n r e v e a l e d t h a t t h i s was d u e t o t h e t e n d e n c y
f o r t h e o s c a l c i s t o f r a g m e n t and f o r m s e q u e s t r a w h ic h
cam e away f r o m t i m e t o t i m e .
TUBERCULOSIS
OF
THE
LONG
BORES.
L e s io n s o f t h e s e a r e a s w ere s a t i s f a c t o r y i n t h e i r
t e r m i n a t i o n a s , o f 12 c a s e s , 8 h e a l e d , 1 w as h e a l i n g
and 3 w ere s t a t i o n a r y .
T hese c a s e s c a l l f o r n o rem ark
e x c e p t t h a t o f th e s t a t i o n a r y c a s e s 2 w ere u n d e r o b ­
s e r v a tio n f o r r e l a t i v e l y s h o rt p e rio d s o f tim e .
TUBERCULOUS
DACTYLITIS.
D a c ty litis d id n o t y ie ld such s a tis f a c to r y r e s u l t s
m a i n l y o n a c c o u n t o f t h e dam age c a u s e d b y t h e s e c o n d a r y
in fe c tio n .
Of 11 c a s e s , 1 d i e d , 1 s u f f e r e d a n a m p u t a ­
t i o n , 3 show ed a n I m p r o v e m e n t a n d 6 h e a l e d , y i e l d i n g a
c o m p a r i s o n w i t h 3 d e a t h s an d 17 r e c o v e r i e s f r o m 2 0 u n ­
s e le c te d /
u n s e le c te d p a t i e n t s .
The d e a t h o c c u r r e d p u r e l y by
re a s o n o f th e v ir u le n t n a tu re of th e tu b e rc u lo u s i n ­
fe c tio n .
TUBERCULOSIS
OF
GLAKDS
AHD
From a t o t a l o f 14 p a t i e n t s ,
SOFT
TISSUES.
1 d i e d an d 13 r e ­
c o v e r e d ; f i g u r e s c o m p a r a b l e w i t h 2 d e a t h s an d 5 8 r e ­
c o v e r i e s o u t o f a g r o s s t o t a l o f 60 p a t i e n t s t r e a t e d
o v e r a n u m b e r o f y e a r s i n t h e h o s p i t a l when i t was r e ­
m em b ered t h a t t h e d e a t h w h ic h o c c u r r e d w as d u e t o
a d d e d p u lm o n a r y d i s e a s e .
I t w as t o b e e x p e c t e d t h a t
t h e s e r e s u l t s w o u ld c o r r e s p o n d v e r y c l o s e l y
as
approx­
i m a t e l y 8 0 $ o f g l a n d u l a r l e s i o n s fo rm a b s c e s s e s an d
s in u s e s .
MISCELLAIBOUS
L E S I0 1 S .
I n t h i s g r o u p o f 9 c a s e s , 1 d i e d , 1 w as i m p r o v i n g
a n d 7 h e a l e d b e y o n d w h i c h s t a t e m e n t n o m ore c a n b e
s a i d a s n o c o m p a ra b le s e r i e s o f c a s e s w ere p o s s i b l e .
A c o n c l u s i o n w as f o r m e d t h a t t h e g r a v i t y o f a c a s e
d e p e n d e d u p o n t h e s i t e o f t h e p r i m a r y l e s i o n an d t h a t
l e s i o n s o f g l a n l s , s o f t t i s s u e s , l o n g b o n e s an d m i s c e l ­
la n e o u s p a r ts pursued t h e i r co u rse r e g a rd le s s o f ad d ­
i t i o n a l p y o g en ic i n f e c t i o n .
in
A lso t h a t t h e r e v e r s e h e l d
ex am p les o f d i s e a s e o f th e v e r t e b r a e o r h i p j o i n t s
t o a m a r k e d d e g r e e an d l e s s m a r k a b l y i n t h e i n s t a n c e s
o f t h e k n e e an d a n k l e j o i n t s .
tio n /
I n s h o r t, sin u s fo rm a­
166
f o r m a t i o n an d s e c o n d a r y i n f e c t i o n w e r e t o b e f e a r e d
w here t h e s i t e , n a t u r e and c o u r s e o f t h e p rim a ry l e s i o n
a f f o r d e d t h e i n f e c t i o n a p r o l o n g e d r e s i d e n c e an d a c t ­
iv ity .
I t w as a l s o c o n c l u d e d , i n v i e w o f t h e e x p e r i ­
m e n t a l l y a s c e r t a i n e d lo w v i r u l e n c e o f t h e m o s t d a n g e r ­
o u s s e c o n d a r y i n f e c t i o n , n am ely s t r e p t o c o c c i , t h a t t h e
l o c a l r e s i s t a n c e o f t h e a f f e c t e d p a r t s was m a r k e d l y
d im in ish e d .
b a c t e r i o l o g i c a l l y f o r se c o n d a ry i n f e c t i o n from t h e i r
i n c e p t i o n u n t i l t h e y f o rm e d s i n u s e s .
A c c o rd in g ly th e
p u s w h i c h was a s p i r a t e d f r o m 57 a b s c e s s e s was e x a m in e d
i n t h i s m a n n e r w i t h a t o t a l o f 188 e x a m i n a t i o n s .
In
som e i n s t a n c e s o n e s p e c i m e n o n l y w as e x a m in e d w h e r e a s
o t h e r s w e r e e x a m in e d o n n u m e r o u s o c c a s i o n s , t h e g r e a t e s t
num ber o f s e r i a l e x a m in a tio n s i n one a b s c e s s b e in g 2 3 .
T h e s e 57 a b s c e s s e s w e r e g r o u p e d a s f o l l o w s
I .
T hose w h ich w ere t r a c e d t o b r e a k in g
p o in t o r in c is io n .
I I .
.
.
.
21
T hose w h ic h h e a le d w ith o u t s in u s f o r m a ­
t i o n o r f a i l e d f o r o t h e r r e a s o n s t o form
s in u s e s .
III.
.
.
.
.
.
30
T h o se w h ich w ere i n c l o s e r e l a t i o n t o
sin u se s
6
an d t h e r e l e v a n t d e t a i l s w ere t a b u l a t e d .
TABLE 4 3 . /
169.
TABLE
Name
S ite of
d ise a se .
No. o f
Exam s.
J .B
S a c ru m
J .B .
T h ig h
J .S .
Lv.
8
J .M c B .
D orsal
s p in e
J .A
R t. h ip
R .K .
43.
D a te o f
L a s t e x a m in a tio n
b a te o t
S in u s
F o rm a tio n
R e su lt.
1
1 5 .1 0 .3 3
1 8 .1 0 .3 3
S te rile
18
1 8 .1 1 .3 4
1 .7 .3 4
Do.
1 1 .2 .3 4
1 4 .2 .3 4
Do.
2
1 3 .1 1 .3 3
2 8 .1 1 .3 3
D o.
23
1 2 .6 .3 4
1 4 .6 .3 4
Do .
C erv.
sp in e
1
3 0 .1 .3 4
2 .2 .3 4
Do.
W.G.
H ip
7
2 4 .3 .3 4
2 8 .3 .3 4
D o.
P .T .
H ip
1
3 .1 2 .3 3
T .C .O .
H ip
1
7 .4 .3 4
W .L.
H ip
1
J .G .
K nee
M .C.
5 .1 2 .3 3
Do.
2 4 .4 .3 4
Do.
2 3 .1 1 .3 3
2 5 .1 2 .3 3
Do.
9
1 0 .4 .3 4
1 0 .4 .3 4
Do.
K nee
4
1 5 .5 .3 4
5 .6 .3 4
D o.
M .B.
K nee
1
9 .1 1 .3 3
9 .1 1 .3 3
Do.
I.G .
A n k le
5
1 8 .1 2 .3 3
1 9 .1 2 .3 3
Do.
J .G .
A n k le
8
1 2 .6 .3 4
1 8 .6 .3 4
Do.
H «McK •
A n k le
3
2 2 .7 .3 4
2 3 .7 .3 4
D o.
J .R .
G lan d s
1
3 1 .1 0 .3 3
J u s t b efo re
in c isio n
2 7 .3 .3 4
Do.
JJio G .
G lan d s
2
2 5 .3 .3 4
2 7 .3 .3 4
J .C .
S o ft
tissu e s
3
2 3 .5 .3 4
2 8 .5 .3 4
D .R .
R ib
1
2 5 .6 .3 4
2 .8 .3 4
in c ise d
S te rile
A.K.
L eft
e lb o w
8
2 9 .3 .3 4
1 .4 .3 4
D o.
Do.
S tre p to c o c c i.
170
T a b l e 43. w as b a s e d o n t h e c a s e s
f a l l in g
in to
G ro u p I a b o v e , an d shew s t h e b a c t e r i o l o g i c a l r e s u l t s
and d a t e s o f th e l a s t e x a m in a tio n o f th e a b s c e s s c o n ­
t e n t s w h i c h was made b e f o r e s i n u s f o r m a t i o n o c c u r r e d .
I n s e p a r a t e c o lu m n s a r e show n t h e n u m b e r o f o c c a s i o n s
o n w h ic h e a c h a b s c e s s w as e x a m in e d a n d t h e d a t e s o n
w h ich t h e s i n u s e s fo rm e d .
T he m a j o r i t y o f t h e c a s e s
form ed s in u s e s s h o r t l y a f t e r th e d a t e o f th e l a s t
e x a m i n a t i o n b u t i n some i n s t a n c e s t h e p e r i o d was p r o ­
lo n g e d .
One e x a m p le i n c l u d e d sho w s t h a t a p e r i o d o f
tw o an d a h a l f m o n th s e l a p s e d b e t w e e n t h e l a s t e x a m i n a ­
t i o n an d s i n u s f o r m a t i o n b e c a u s e i n t h i s i n s t a n c e n o
a p p r e c i a b l e am ount o f p u s g a t h e r e d i n t h e i n t e r v e n i n g
p e r i o d , t h e s i n u s b e i n g fo rm ed b y a v e r y s m a l l l e a k
th ro u g h an o ld n e e d le p u n c tu r e .
T he o t h e r e x a m i n a ­
t i o n s h o w e v e r, w ere s u f f i c i e n t l y c l o s e t o t h e d a t e o f
s in u s fo rm a tio n to be c e r t a i n th a t th e p o s s i b i l i t y o f
a s e c o n d a ry i n f e c t i o n e n t e r i n g and m u l t i p l y in g i n th e
i n t e r v a l , s u f f i c i e n t l y t o b e h a r m f u l , was n e g l i g i b l e .
Y e t i n a l l i n s t a n c e s e x c e p t tw o t h e e x a m i n a t i o n s f a i l e d
t o r e v e a l t h e p r e s e n c e o f any s e c o n d a ry i n f e c t i o n .
The e x c e p tio n s w e r e J I*
a g r o i n a b s c e s s , s u b c u ta n e o u s i n i t s
l a t e r sta g e s
a n d d i f f i c u l t t o a s p i r a t e an d
II.
a s m a ll s u b c u ta n e o u s s o f t t i s s u e
a b scess o f th e
lo w e r c a l f .
T he i n f e c t i o n s r e c o v e r e d w e r e r e s p e c t i v e l y : i./
;
I.
a s m a l l unnam ed Gram n e g a t i v e b a c i l l u s and
I I . a f a i n t l y B . h a e m o ly tic s tre p to c o c c u s ,
b u t i n n e i t h e r c a s e was t h e r e a n y c l i n i c a l m a n i f e s t a ­
t i o n o f th e p re se n c e of a seco n d ary i n f e c t io n .
In
b o th th e i n t e g r i t y o f th e s k in s u rfa c e over th e ab scess
w as d o u b t f u l .
T h e r e f o r e i n G ro u p I ,
21 tu b e r c u lo u s a b s c e ss e s
f o r m e d s i n u s e s u n d e r o b s e r v a t i o n a n d i n 19 n o b a c t e r i o ­
l o g i c a l e v id e n c e o f any s e c o n d a ry i n f e c t i o n o c c u r r i n g
p r i o r t o s i n u s f o r m a t i o n w as n o t e d .
I n 2 w here t h i s
i n f e c t i o n was f o u n d t h e c l i n i c a l f e a t u r e s c a s t d o u b t
upon th e i n t e g r i t y
o f t h e a b s c e s s a t t h e tim e o f t h e
e x a m i n a t i o n and show ed n o e v i d e n c e t h a t t h e s e o r g a n i s m s
w ere an a id t o s in u s f o r m a t i o n .
F ro m t h i s i t w as i n ­
f e r r e d t h a t t h e p y o g e n ic c o c c i and o t h e r o rg a n ism s
w h ic h w ere i s o l a t e d fro m t h e s i n u s e s m ust g a i n i n g r e s s
a f t e r th e s in u s had fo rm ed .
T he c a s e s c o n p r i s i n g G r o u p I I w e r e t a b u l a t e d a s
w e r e t h o s e i n G ro u p I , a n d t w e n t y - s e v e n o f th e m show ed
no e v id e n c e o f a seco n d ary i n f e c t i o n g a in in g in g r e s s to
th e a b sc e ss.
TABLE
4 4 ./
TABLE
Name.
S ite of
d ise a se .
J .B .
S acru m
G .McC .
D orsal L.
s p in e
J .M .
A .C .
S ite of
abscess
No. o f
E xam s.
44
b a te o f 1st
& l a s t exam .
R e su lt of
Exam .
P in a l
R e s u lt.
4
1 3 .2 .2 3 2 0 .3 .3 4
S te rile
H e a le d
Back
1
1 .2 .3 4
S te rile
No s i n u s
d ie d .
D.L . s p in e
Psoas
1
3 1 .1 .3 4
S te rile
H ealed
D orsal
s p in e
L um bar
10
2 2 .1 .3 4 1 1 .7 .3 4
S te rile
H e a le d
L .s a c ro ­
ilia c
Back
1
2 5 .1 1 .3 3
S te rile
H ealed
H .A .
Lum bar
s p in e
Psoas
1
0 .3 3
S te rile
H e a le d
M .S.
LV3-5
Psoas
1
1 3 .1 .3 4
S te rile
H e a le d
D.H.
LV5 8 V . I .
P soas
3
1 9 .1 .3 4
S te rile
H ealed
T .K .
L .h ip
T h ig h
2
1 5 .1 .3 4
1 2 .3 .3 4
S te rile
H ealed
E .M o I.
L .h ip
T h ig h
11
1 2 .1 .3 4 4 .7 .3 4
G.M.
L .h ip
T h ig h
13
1 1 .1 1 .3 5 2 4 .0 .3 4
S te rile
H e a le d
E.W.
L .h ip
T h ig h
5
1 1 .3 3 7 .1 .3 4
S te rile
H e a le d
W.G.
H ip
T h ig h
2
1 0 .2 .3 4 7 .1 .3 4
S te rile
H e a le d
R .C .
K nee
1
1 3 .1 1 .3 3
S te rile
H e a le d
AJ3.
M se n t.
G lo s.
G ro in
1
1 9 .1 .3 4
S te rile
H e a le d
J .P .
In g .
g la n d
G ro in
1
2 0 .8 .3 4
S te rile
H e a le d
J .C .
C erv.
g ld .
Neck
4
4 .1 .3 4 1 2 .1 .3 4
S te rile
H e a le d
J
.McG •
R t.g ro in
S te rile
H ealed
TABLE
Name.
M .S .
4 4 . (co n tin u ed )
S ite of
d ise a se .
S ite of
abscess
C erv .
g ld .
N eck
llo . o f
Exam s.
D ate o f 1 s t
& l a s t exarc
fe e su lt o f
Exam .
P in a l
re su lt.
1
2 4 .4 .3 4
S te rile
H e a le d
H .McD.
Do.
D o.
1
1 3 .2 .2 3
S te rile
H e a le d
E.M.
D o.
Do.
5
1 8 .5 .3 4 2 6 .8 .3 4
S te rile
I *D .
H .C .
W rist
1
1 1 .1 1 .3 3
S te rile
D ie d
I.D .
R ib s
1
1 6 .1 1 .3 5
S te rile
S in u s &
I .D .
J .H .
W rist
1
1 3 .3 .3 4
S te rile
H e a le d
M.T.
Os
C a la is
H eel
1
2 6 .3 .3 4
S te rile
H ealed
LJ3 .
R ib s
C hest
w a ll
2
1 2 .8 .3 4 1 5 .8 .3 4
J .N .
D orsal
s p in e
Back
3
R.McK.
E lbow
C hest
w a ll
Leg
S t a p h s . an d
G .-v e b a c i l l i
A c u te
abscess.
S te rile
H ealed
f i n a l l y s im s '
3
1 4 .2 .3 4 2 1 .4 .3 4
S te rile
H e a le d .
3
6 .7 .3 4
1 9 .7 .3 4
S te rile
D ie d .
W.H.
L .tib ia
J .B .
G ro in
1
1 9 .5 .3 4
S tre p to c o c c i
A cu te
A bscess
H e a le d .
L.O .
Ear
1
.4 .3 4
S tre p to c o c c i
D o.
T h r e e e x c e p t i o n s o c c u r r e d b u t t h e i r c l i n i c a l and
b a c t e r i o l o g i c a l f e a t u r e s s u g g e s te d t h a t th e y w ere
a c u t e in fla m m a to ry p r o c e s s e s and n o t t u b e r c u l o u s .
T h e ir d e t a i l s w e re :I.
An a b s c e s s o f t h e c h e s t w a l l , p u r e l y s t a p h y l o ­
c o c c a l i n o r i g i n an d n e g a t i v e f o r t u b e r c u l o u s when
te ste d b io lo g ic a lly .
II•
An a b s c e s s b e h i n d t h e e a r i n r e l a t i o n t o an
a c u te m a sto id .
III.
An a c u t e i n g u i n a l a d e n i t i s o c c u r r i n g i n r e l a t i o n
to a se v e re ly in fe c te d s in u s in a f o o t.
T hese l a s t
tw o b o t h y i e l d e d p u r e c u l t u r e s o f B . h a e m o l y t i c s t r e p t o ­
c o c c i.
T h e r e f o r e , d i s r e g a r d i n g t h e e x c e p t i o n s , i t was
a g a i n show n t h a t n o s e c o n d a r y i n f e c t i o n s g a i n e d i n ­
g re s s to tu b e rc u lo u s ab scesses d u rin g tre a tm e n t.
F i n a l l y t h e r e w e r e t h e f e w c a s e s i n G ro u p I I I , d i f f e r ­
e n t fro m t h e o t h e r s i n t h a t t h e s e a b s c e s s e s w ere i n
c l o s e p r o x im i t y b u t n o t co m m u n icatin g w i t h e x i s t i n g
s in u s e s .
TABLE
-4 5 ../
■S 15
•H
Cl? f t
-P t H
CO p
•H
05 - P
3 CO
&
^
a eg c
■P
+J o
CO
CO «
3 -P
.a co
£ °J
fttJ j
CO CQ
M
-H
T h e se a d j o i n i n g s i n u s e s w ere s e c o n d a r i l y i n f e c t e d i n
f o u r i n s t a n c e s and ' S t e r i l e '
i n tw o an d t h e p u s a s p i r ­
a t e d fro m t h e a b s c e s s e s w h ich w ere i n p r o x im i t y t o t h e
l a s t tw o was a l s o f r e e f r o m a d d e d i n f e c t i o n .
In th re e
i n s t a n c e s w here t h e s i n u s e s w ere s e c o n d a r i l y i n f e c t e d
t h e a b s c e s s c o n t e n t s w e r e s t e r i l e b u t one was s e c o r d . a r ily in fe c te d .
T h is a b s c e s s y i e l d e d s t a p h , a lb u s
and d ip h th e r o id b a c i l l i w ith th e b a c i l l i i n th e
m i n o r i t y a n d t h e s i n u s w as i n f e c t e d w i t h s t a p h , a l b u s
a n d B . h a e m o l y t i c s t r e p t o c o c c i i n t h e sam e o r d e r .
I n v i e w o f t h e c l o s e p r o x i m i t y o f t h e a b s c e s s an d
s in u s in t h i s
in sta n c e th e p o s s ib ility
o f an i n f e c t i o n
s p r e a d i n g f r o m o n e t o t h e o t h e r was h i g h , y e t t h e
s t r e p t o c o c c i i s o l a t e d fro m t h e s in u s w ere n o t p r e s e n t
in th e a b s c e s s .
T h e re f o re , i f a c o m p a ra tiv e ly ro o te d
o r g a n i s m l i k e a s t a p h y l o c o c c u s was a b l e t o c r o s s t h e
in te rv e n in g t i s s u e th e n th e lik e lih o o d o f a s t r e p t o ­
c o c c u s d o i n g t h i s wa3 much g r e a t e r a n d i t s
f a ilu r e to
do so s u g g e s te d t h a t th e o rg a n ism s r e c o v e re d fro m th e
a b sc e ss d id n o t o r ig in a te in th e s in u s .
T he a b s c e s s was c o v e r e d o n l y b y t h e t h i n n e s t
l a y e r o f s k i n a n d an i n f e c t i o n may h a v e b e e n c a r r i e d
t h r o u g h w hen a s p i r a t i n g .
A n o t h e r f e a t u r e w as t h a t
t h e r e w ere n o c l i n i c a l s i g n s o f s e c o n d a ry i n f e c t i o n
in th e a b sc e ss.
A t e n t a t i v e c o n c l u s i o n was made f r o m t h i s s m a l l
num ber o f c a s e s t h a t th e s o f t t i s s u e i n t e r v e n in g b e ­
tw een t h e s i n u s e s and t h e a b s c e s s e s fo rm ed a n e f f i c i e n t
b a rrie r/
b a r r i e r t o t h e s p r e a d o f i n f e c t i n g o r g a n i s m s f r o m one
t o t h e o t h e r and t h a t t h e o rg an ism s w i t h i n t h e s in u s e s
w ere v e r y c l o s e l y l i m i t e d i n t h e i r d i s t r i b u t i o n to t h e
c o n fin e s o f th e s in u s .
F u rth e r pro o f o f th is l a s t
s t a t e m e n t w as d e m o n s t r a t e d b y t h e a l m o s t c o m p l e t e
ab se n c e o f a c u te ly m p h a d e n itis o c c u r r in g i n th e g la n d s
d ra in in g a re a s c o n ta in in g a p ro fu s e ly d is c h a rg in g s in u s .
F ro m t h e c o m b in e d r e s u l t s i t w as c o n c l u d e d t h a t s e c o n d ­
a ry in f e c tio n s o ccu rred a f t e r s in u s fo rm a tio n in a l l
b u t a v e r y f e w c a s e s an d a l s o t h a t t h e p r e c a u t i o n s
t a k e n i n a s p i r a t i n g t h e a b s c e s s e s w ere s u f f i c i e n t l y
good to p re v e n t th e in g re B s o f i n f e c t i o n .
A t t e n t i o n was n e x t f o c u s s e d o n t h e s i n u s e s w h ic h
w e r e e x a m in e d a t v a r y i n g p e r i o d s o f t i m e a f t e r t h e i r
i n c e p t i o n an d c e r t a i n r e s u l t s w e r e t a b u l a t e d .
TABLE
46 ./
178.
TABLE
N am e.
J .McG.
S ite of
le sio n .
G lan d s
(neclc)
46.
D ate o f E x a m in a tio n .
1 0 .3 .3 4 2 5 .3 .3 4 2 6 .3 .3 4 2 7 .3 .3 4 .
C.W.
do.
A bscess b e f o r e i n c i s i o n .
I.e .
Do.
1 3 .1 2 .3 3
1 6 .1 2 .3 3 •
2 5 .1 2 .3 3
1 0 .2 .3 4 .
9 .1 1 .3 3
1 .2 .3 4
1 7 .1 1 .3 3
1 9 .3 .3 4
1 .1 2 .3 3
1 0 .1 1 .3 4
5 .1 2 .3 3
1 2 .1 .3 4
1 9 .3 .3 4
W.L.
L. h ip
2 3 .1 2 .5 3
M 3.
R . knee
Not a s p i r a t e d .
P .T .
L. h ip
J.McB .
S p in e
2 9 . 1 0 . 3 3 1 3 . 1 1 . 3 3 2 8 . 1 1 . 33 1 0 . 1 . 3 4
R.McK.
Elbow
2 1 .3 .3 4 2 1 .4 .3 4 5 .6 .3 4
W.G.
R. h ip
1 9 .1 .3 4
Reaccunt l l a t i o n .
3 .1 2 .3 3
2 .2 .3 4
1 3 .7 .3 4
H e a le d u n i n f e c t e d .
1 9 .2 .3 4 2 0 .2 .3 4
Do.
1 0 .3 .3 4 2 4 .3 .3 4 2 8 .3 .3 4
1 9 .6 .3 4
J .R .
G lan d s
(neck)
3 1 .1 0 .3 3
J .McL.
L . h ip
M.G .
S p in e
J .S .
S p in e
4 .2 .3 4
1 1 .2 .3 4 1 4 .2 .3 4 1 9 .2 .3 4
2 1 .6 .3 4
H.McK.
A n k le
1 9 .7 .3 4
2 2 .7 .3 4 2 3 .7 .3 4 3 0 .7 .3 4
1 3 .1 0 .3 4
J .G .
Fem ur
2 5 .3 .3 4
1 0 .4 .3 4 1 0 .4 .3 4 2 1 .1 0 .3 4
J .G .
A n k le
1 2 .6 .3 4
B .H .
Knee
2 7 .4 .3 5
9 .5 .3 5
1 .6 .3 5
H e a le d u n i n f e c t e d .
1 7 .6 .3 5
H e a le d u n i n f e c t e d .
4 .5 .3 4
D o.
1 8 .6 .3 4 2 9 .6 .3 4
1 2 .1 1 .3 4
1 9 .1 0 .3 3 1 7 .1 1 .3 3
9 .1 1 .3 4
1 4 .5 .3 4
8 .1 2 .3 4 2 2 .1 2 .3 4
D a t e u n d e r l i n e d i n r e d i s d a t e o f s i n u a f o r m a t i o n and
D a t e u n d e r l i n e d i n b l a c k I s t h a t o n w h ic h s e c o n d a r y
i n f e c t i o n w as r e c o v e r e d f r o m t h e s i n u s d i s c h a r g e .
179
From t h e t a b l e i t was s e e n t h a t t h e o n s e t o f i n f e c t i o n
v a r i e d i n tim e and d i d n o t o c c u r a u t o m a t i c a l l y u p o n th e
fo rm a tio n o f a s in u s .
I n a f e w i n s t a n c e s 3 u c h was t h e
case b u t in n e a rly a l l in sta n c e s in fe c tio n in e v ita b ly
o ccu rred .
D e p a r t i n g f r o m t h i s s m a l l s e r i e s o f c a s e s an d
u t i l i s i n g d a t a o b ta in e d fro m th e t a b l e s i n th e p r e ­
c e d i n g c h a p t e r t h e r e s u l t s o f a l l t h e e x a m in a tio n s w h ich
w e r e c o n d u c t e d w e r e g r a p h e d t o show t h e r e l a t i v e p r o ­
p o r tio n o f s e c o n d a rily in f e c te d s in u s e s t o th o se f r e e
fro m i n f e c t i o n a t d i f f e r e n t p e r io d s o f tim e .
4.
GRAPH
- t —I— f
-i—
■
+ -
-
r '
— i— h
— L.
...
liW f'v ro F 9io
m
I >4
From t h e g r a p h i t was s e e n t h a t n o n - i n f e c t e d s i n u s e s
w e r e f o u n d r a r e l y a f t e r t h e f i r s t m o n th a l t h o u g h a
few ex a m p le s w ere n o t e d a t l a t e p e r i o d s .
R e c a llin g
t h e o b s e r v a t i o n made i n t h e p r e c e d i n g c h a p t e r t h a t
h e a l i n g s i n u s e s w ere o f t e n f r e e fro m i n f e c t i o n t h e s e
l a t t e r r e s u l t s w ere re -e x a m in e d and i t
was f o u n d t h a t
a l l t h e e x a m p le s r e p o r t e d u p t o t h e t e n t h m o n th w e r e
h e a lin g le s io n s .
T h is l e f t f o u r e x a m p le s i n t h e l a t e r
m o n th s s t i l l , b u t t h e s e w e r e c a p a b l e o f e x p l a n a t i o n a s
fo llo w s .
That in th e
1 2 -1 5
m o n th s p e r i o d was i n
a t o x i c p a t i e n t who h a d h a d a p r e v i o u s h e a v y s e c o n d a r y
i n f e c t i o n by s t r e p t o c o c c i .
C l i n i c a l l y t h e c h i l d was
s e c o n d a r i l y i n f e c t e d b u t t h e s i n u s w as c a p a b l e o f
c o m p l e t e c l e a n s i n g i n i t s u p p e r r e a c h e s an d i t was
f e l t t h a t t h e f a i l u r e t o r e c o v e r p y o g e n i c c o c c i was
due t o th e c o n c e n tra tio n o f a n t i s e p t i c s in t h i s r e g io n .
T h i s c a s e a l s o a c c o u n t e d f o r a s i m i l a r e x a m p le i n t h e
1 5 - 1 8 m o n th p e r i o d a s a f u r t h e r a t t e m p t was m ade t o
r e c o v e r a s e c o n d a r y i n f e c t i o n w h ic h a g a i n f a i l e d .
T h e r e w as a l s o t h e p o s s i b i l i t y i n t h i s i n s t a n c e o f t h e
in f e c tio n te rm in a tin g i t s e l f .
A s i n g l e c a s e w ith
d i s e a s e o f th e c e r v i c a l v e r t e b r a e a c c o u n te d f o r th e
r e m a i n i n g tw o s t e r i l e
s i n u s e s o c c u r r i n g i n t h e 15-18
m o n th s a n d t h e 1 8 - 2 1 m o n th s p e r i o d .
H ere th e
f e a t u r e s a ls o s u g g e ste d a seco n d ary i n f e c t i o n a lth o u g h
none/
n o n e w as c u l t u r e d .
F i n a l l y , h o w e v e r , a g ra m p o s i t i v e
unnam ed d i p l o c o c c u s was r e c o v e r e d w h ic h p r o v e d v e r y
f r i a b l e an d w h i c h d i e d o u t i n s u b c u l t u r e .
T h is o rg an ism
may h a v e b e e n p r e s e n t e a r l i e r a n d d e f i e d c u l t u r e .
T h e r e f o r e a s e c o n d a r y i n f e c t i o n w as p r e s e n t i n e v e r y
s i n u s w h i c h was n o t a l m o s t h e a l e d a f t e r i t h a d b e e n
i n e x i s t e n c e m o re t h a n o n e m o n th w i t h o n e n o t a b l e
e x c e p tio n i n th e i n s t a n c e o f a s in u s a r i s i n g fro m a
h ip
j o i n t l e s i o n w h i c h was m a i n t a i n e d f r e e f r o m i n ­
f e c t i o n t h r o u g h o u t i t s f o u r m o n th c o u r s e .
T h i s was
done by o b s e rv in g s c ru p u lo u s c a r e i n d r e s s i n g and th e
s h o r t d u r a t i o n o f t h e s i n u s was i n t e r e s t i n g t o n o t e .
A g e n e r a l c o n c l u s i o n w as f o r m e d t h a t s e c o n d a r y i n f e c t ­
in g o rg an ism s w ere su p e ra d d e d s h o r t l y a f t e r s in u s
fo rm a tio n had o c c u rre d .
The s o u r c e o f t h i s
in fe c tio n
w as t h e n s o u g h t a n d t h e tw o p o s s i b l e s o u r o e s w h i c h
e x i s t e d , e n d o g e n o u s an d e x o g e n o u s , w e r e e x a m i n e d .
E n d o g e n o u s i n f e o t i o n w as p o s s i b l e i n n o r m a l h e a l t h
b u t was much m o re l i k e l y t o o c c u r i n t h e c o u r s e o f a n
a c u te i l l n e s s o r in a s e p tio a e m ic c o n d itio n .
The
o n ly a c u t e i l l n e s s w h ich o c c u r r e d d u r i n g t h e i n v e s t i ­
g a t i o n w as S c a r l a t i n a a n d h e r e t h e c l i n i c a l a p p e a r a n c e s
i n c e r t a i n p a t i e n t s s u g g e s te d t h e p o s s i b i l i t y o f an
added in f e c tio n s tim u la tin g th e a c t i v i t y
c u lo u s p r o c e s s .
of th e tu b e r ­
T h r e e p a t i e n t s o n l y sh ow ed t h e s e
fe a tu re s.
I.
JJI.
T u b e r c u lo s is o f d o rs o lu m b ar v e r t e b r a e
w i t h a r e - a c c u m u l a t i o n o f p u s w i t h i n a n a b s c e s s w h ich
had/
182.
h a d b e e n q u ie s c e n t f o r e ig h t m o n th s.
T h is o c c u rre d
7 days a f t e r th e o n se t o f S c a r la tin a .
II.
W.G.
A lm o s t i n a c t i v e b o n e l e s i o n o f R . h i p .
F r e s h a b s c e s s a p p e a r e d i n t h i g h 10 d a y s s i f t e r o n s e t o f
S c a rla tin a .
III.
J *B.
T u b e r c u l o s i s o f sacru m w ith an a b s c e s s o f
t h i g h w h ic h i n c r e a s e d v a s t l y i n s i z e , s t a r t i n g 3 d a y s
a f t e r th e o n set o f S c a r la tin a .
A l l t h e s e c a s e s p r e v e n t e d t h e common f e a t u r e o f a r a p i d
acc u m u la tio n o f pus i n t h e i r a b s c e ss e s c lo s e ly f o llo w ­
in g an a t t a c k o f S c a r l a t i n a .
An o b v i o u s i n f e r e n c e was
t h a t s t r e p t o c o c c i m ig h t b e r e s p o n s i b l e f o r t h i s and
t h e a b s c e s s c o n t e n t s w e r e e x a m in e d b a c t e r i o l o g i c a l l y
on s e v e r a l o c c a s io n s f o r th e p re s e n c e o f su ch i n f e c t i o n
w ith n e g a tiv e r e s u l t s .
T h i s seem ed t o e x c l u d e t h e
p o s s i b i l i t y o f an endogenous i n f e c t i o n i n tu b e r c u lo u s
a b s c e s s e s even i n th e s e e m in e n tly s u i t a b l e c a s e s .
A p o s s ib le e x p la n a tio n of th e in c re a se d a c tiv ity of
th e tu b e r c u lo u s p ro c e s s la y i n th e f a c t t h a t i n none
o f t h e s e c a s e s was t h e p r i m a r y l e s i o n i n a c t i v e an d
t h a t t h e u n w o n te d m ovem ent p l u s t h e s u s p e n s i o n o f
n o rm a l t r e a t m e n t w h ich to o k p l a c e d u r in g t h e c o u r s e
o f t h e i n t e r c u r r e n t i l l n e s s was d e t r i m e n t a l t o t h e
h e a lin g p ro c e ss.
o b serv ed /
O t h e r c a s e s , n u m b e r in g 2 1 , w e r e a l s o
o b s e rv e d d u r in g and a f t e r an a t t a c k o f S c a r l a t i n a b u t
i n n o n e was t h e r e a n y c h a n g e i n t h e t u b e r c u l o u s l e s i o n
c lin ic a lly o r ra d io lo g ic a lly .
A n o t e was t h e r e f o r e made
t h a t S c a r la tin a as a c o m p lic a tio n o f s u rg ic a l tu b e r c u ­
l o s i s was a d e t r i m e n t a l f a c t o r , a l t h o u g h o n l y i n a
m in o r d e g r e e .
T hese c a s e s w ere n o t th o u g h t t o b e s u f f i c i e n t e v i ­
dence to d isc o u n te n a n c e th e p o s s i b i l i t y
o f endogenous
i n f e c t i o n and t h e p r o b l e m was a p p r o a c h e d i n a n o t h e r
m anner.
I t was t h o u g h t t h a t a s e p t i c a e m i a m i g h t o c c u r
am ongst t h e s e c a s e s i n r e l a t i o n t o o t h e r a c u te s t r e p t o ­
c o c c a l i n f e c t i o n s i n t h e s i n u s e s s u c h a s e r y s i p e l a s and
c e llu litis.
A c c o r d i n g l y b l o o d c u l t u r e s w e r e made f r o m
8 p a t i e n t s w h e r e t h i s p o s s i b i l i t y was p r e s e n t a n d t h e
r e l e v a n t d e t a i l s w ere t a b u l a t e d .
TABLE 47.
Name •
M .H .
A cu te
L e sio n .
C e l l u l i t i s , A cu te a b s c e s s
fo rm a tio n , to x a e m ia .
R e su lt.
S te rile .
M.McG.
d itto .
D o.
P .T .
d itto .
Do.
M .MoG.
d itto .
D o.
J .S .
d itto .
Do.
S .M .
d itto .
D o.
C .D .
E ry s ip e la s
Do.
C .D .
d itto .
Do.
J .S .
C h ro n ic to x aem ia
Do.
I n t h e s e ex am p les no e v id e n c e o f
fo u n d .
a
s e p t i c a e m i a was
A c o n c l u s i o n was m a d e , b a s e d o n a l l t h e ex a m ­
i n a t i o n s w h i c h w e r e made t h a t s e c o n d a r y i n f e c t i o n o c c u r ­
r i n g i n t u b e r c u l o u s a b s c e s s e s and s i n u s e s was n o t e n d o ­
genous in o r i g i n .
T he o n l y r e m a i n i n g s o u r c e o f i n f e c t i o n was t h e r e ­
f o r e e x o g e n o u s w h ic h m e a n t f r o m t h e s k i n s u r f a c e o r
fro m th e a i r .
W it h r e g a r d t o t h e f o r m e r H a x t h a u s e n
sh o w ed t h a t s t r e p t o c o c c i c o u l d b e r e c o v e r e d f r o m t h e
s k in s u rfa c e in
5%
o f c a s e s and t h a t t h e s e o rg a n ism s
w ere p o t e n t i a l l y p a t h o g e n i c .
U t i l i s i n g a sim p le t e c h ­
n i q u e a n a t t e m p t was made t o r e c o v e r t h e s e o r g a n i s m s
from t h e s k i n s u r f a c e o f 21 p a t i e n t s .
The r e s u l t s
w ere t a b u l a t e d and a p p e a r a s f o l l o w s : TABLE
48.
A tte m p ts t o R ec o v er S t r e p t o c o c c i from S k i n .
Nam e.
S ite .
S ta p h .
S tre p .
D ip h .
M.C .
T h ig h
A lb u s
-
-
M.McC.
T h ig h
A lb u s
-
+
M .H.
T h ig h
A lb u s
-
-
J .P .
G ro in
C itre u s
a lb u s
E «B •
G ro in
A lb u s
-
+
H .A .
T h ig h
A lb u s
A ureus
-
-
L .C .
G ro in
A lb u s
S.M .
G ro in
A lb u s
a . haem .
N o n -h a e m .
-
-
-
4 8 . ( c o n tin u e d )
TABLE
N am e.
S ite
S ta p h .
S tre p .
D ip h .
H .G .
G ro in
A lb u s
-
**
S .M .
G ro in
A lb u s
-
+
J .U o L .
T h ig h
A lb u s
c itre u s
-
+
A .F .
Arm
A lb u s
c itre u s
-
+
MJ3 .
G ro in
A ureus
-
-
C .M .
G ro in
A lb u s
A ureus
-
H .C .
G ro in
-
-
R .McK .
G ro in
C itre u s
a lb u s
A ureus
-
+
J .B .
G ro in
C itre u s
a lb u s
-
-
S .S .
Arm
a lb u s
aureus
-
-
R .J •
G ro in
A lb u s
-
-
S 3.
G ro in
A lb u s
-
+
P.D .
T h ig h
A lb u s
—
-
S t a p h y l o o o c c i , s o m e ti m e s m o re t h a n o n e t y p e , w e r e
re c o v e re d i n every i n s ta n c e , d ip h th e r o id b a c i l l i in
7 i n s t a n c e s and s t r e p t o o o c c i i n 2 .
T w e n ty -n in e s t r a i n s
o f s t a p h y l o c o c c i w ere i s o l a t e d , 20 b e in g S t . a l b u s , 4
S t . a u re u s and 5 S t . c i t r e u s .
c o lo u r/
Beyond n o t i n g t h e
c o l o u r n o f u r t h e r o b s e r v a t i o n s w e r e made o f t h e s e
o r g a n i s m s a n d t h e f e a t u r e o f i n t e r e s t was t h e h i g h
in c id e n c e o f S t . c i t r e u s .
No a t t e m p t was made t o
c l a s s i f y t h e d i p h t h e r o i d b a c i l l i b u t an e x a m in a tio n
w as made o f t h e s t r e p t o c o c c i .
One was a . h a e m o l y t i c on
b l o o d a g a r an d t h e o t h e r was a n o n - h a e m o l y t i c o r g a n i s m
w h ich g rew i n s h o r t c h a i n s .
w as t y p e d .
O n ly t h e f i r s t o f t h e s e
On i t s b i o c h e m i c a l c h a r a c t e r i s t i c s i t was
a n i n d e t e r m i n a t e s t r a i n o f S . v i r i d a n s w h i c h , when
e x a m in e d s e r o l o g i c a l l y ,
show ed i t s e l f t o h a v e n o r e ­
l a t i o n t o a n y o f t h e t y p e c u l t u r e s b y c o m p le m e n t f i x a ­
t i o n t e s t s b u t was m o s t n e a r l y r e l a t e d
its
t o S . e q u i on
a g g lu tin a tio n f e a tu re s .
T h i s e x a m i n a t i o n sh ow ed t h a t i t w as p o s s i b l e f o r
th e seco n d ary i n f e c tin g
o rg an ism s t o g a i n a c c e s s t o
t h e s in u s fro m th e s k in s u r f a c e p a r t i c u l a r l y i n th e
i n s t a n c e o f s ta p h y lo c o c c i and d i p h t h e r o i d b a c i l l i .
The a b s e n c e o f h a e m o ly tic s t r e p t o c o c c i fro m t h e s u r f a c e
a n d t h e i r m a rk e d p r e p o n d e r a n c e w i t h i n t h e s i n u s e s i n ­
f e r r e d t h a t t h e s e o r g a n i s m s m u s t g a i n i n g r e s s f r o m some
o th e r so u rce.
T h e o n l y r e m a i n i n g s o u r c e was a i r b o r n e an d t h e
c o n c l u s i o n was f o r m e d t h a t s u c h an i n f e c t i o n o r i g i n a t e d
f r o m t h e b u c c a l s p r a y , a r o u t e w h i c h was sho w n t o b e
o f im p o rta n c e by o b s t e t r i c i a n s p a r t i c u l a r l y w ith r e g a r d
to s tre p to c o c c i.
c o c c i/
A t t e m p t s w e r e m ade t o c u l t u r e s t r e p t o ­
s t r e p t o c o c c i f r o m t h e b u c c a l s p r a y an d t h e m eth o d
a d o p t e d w as t o a s k 8 p e o p l e t o c o u g h o v e r e x p o s e d b l o o d
agar p la te s .
S t r e p t o c o c c i w ere r e c o v e r e d i n 3 i n s t a n c e s ,
2 fro m p a t i e n t s w ith S c a r l a t i n a and 1 from a p e r s o n in
good h e a l t h .
T he d e t a i l s o f t h e s e s t r a i n s w e r e -
I.
B . h a e m o ly tic s tr e p to c o c c u s .
W.G.
C om plem ent f i x a t i o n t e s t = S . e q u i .
A g g lu tin a tio n - in c o m p le te S . f a e c a l i s
and S . p y o g en es.
R e la te d t o s e v e r a l s in u s s t r a i n s .
II.
R .B .M . B . h a e m o l y t i c s t r e p t o c o c c u s .
B io c h e m ic a lly = S . p y o genes.
C o m p lem en t f i x a t i o n t e s t = S . e r y s i p e la to su s .
A g g lu tin a tio n t e s t = S . e r y s ip e la to s u s .
III.
J .S .
B . h a e m o ly tic s tr e p to c o c c u s .
B io c h e m ic a lly i n d e f i n i t e .
S e ro lo g ic a lly in d e f in ite .
( p r o b a b l y a m ix e d s t r a i n )
T hese o rg an ism s b o r e a d i s t i n c t re se m b la n c e to th o s e
w h ich w ere i s o l a t e d fro m t h e s i n u s e s i n c r e a s i n g th e
p o ssib ility
s ib ility
o f a d ro p le t in fe c tio n of s in u se s, a p o s­
w h i c h w as f u r t h e r e n h a n c e d b y t h e b e h a v i o u r
o f s in u s e s in th e v i c i n i t y
of S c a rla tin a .
I n t h i s r e s p e c t t h e r e w ere 9 ex am p les o f s t r e p t o ­
c o c c a l/
188.
s tr e p to c o c c a l c o m p lic a tio n s o c c u rrin g i n th e s in u s e s
and r e l a t e d
to a d e f i n i t e o u tb re a k o f S c a r l a t in a .
A t t e n t i o n was f i r s t d r a w n t o t h i s r e l a t i o n s h i p i n t h e
in s ta n c e o f a c h ild w ith a d is c h a rg in g s in u s o f th e
a n k l e w hen t h e f o l l o w i n g e v e n t s w e r e n o t e d . I n F e b r u a r y 1933 a c a s e o f S c a r l a t i n a o c c u r r e d i n a
w a rd a n d w i t h i n t h e n e x t 2 4 h o u r s a w e l l m a rk e d c e l l u ­
litis
ap p eared around th e a n k le s in u s o f th e p a t i e n t
o ccu p y in g a n e ig h b o u rin g b e d .
E x a m in atio n o f th e
s i n u s d i s c h a r g e r e v e a l e d t h a t t h e c o m p l i c a t i o n was
a s s o c ia te d w ith th e s o le p re se n c e o f s tr e p to c o c c i in
g r e a t n u m bers.
T h i s o r g a n i s m was t y p e d w i t h t h e a i d
o f b i o c h e m i c a l t e s t s a n d was show n t o b e S . p y o g e n e s .
C u l t u r e s w ere t a k e n fro m t h e t h r o a t s o f 2 h e a l t h y
c h i l d r e n o ccu p y in g s i m i l a r l y a d j a c e n t b e d s y i e l d i n g
s » p y o g en es i n one i n s t a n c e and S . v i r i d a n s i n t h e
o th e r.
T h e i n f e r e n c e was t h a t i n f e c t i o n g a i n e d a c c e s s
t o t h e s i n u s f r o m t h e a i r when t h i s m edium w as h e a v i l y
in fe c te d .
Had t h i s a s s o c i a t i o n o c c u r r e d o n l y o n c e
t h e n i t m ig h t have b e e n s a i d to be a c o - in c id e n c e b u t
f u r t h e r ex am p les a r o s e .
A n o th e r c h i l d s u f f e r i n g from
d a c t y l i t i s w i t h a d i s c h a r g i n g s i n u s on h e r h a n d d e ­
v e lo p e d S c a r l a t i n a on 2 6 .9 .3 3 w hen, w i t h i n 3 d a y s ,
m a rg in a l c e l l u l i t i s
o c c u r r e d a r o u n d t h i s s i n u 3 and t h e
d i s c h a r g e i n c r e a s e d i n am o u n t.
An e x a m i n a t i o n i n t h i s
in sta n c e ^ y i e l d e d s t r e p t o c o c c i i n p u r e c u l t u r e o f t h e
ty p e S . p y o g en es.
by/
S t i l l f u r t h e r e v i d e n c e w as shown
b y a c h i l d who h a d s o f t t i s s u e t u b e r c u l o s i s o f t h e k n e e
j o i n t s w ith a s m a ll d i s c h a r g i n g w ound.
She d e v e l o p e d
m i l d S c a r l a t i n a o n 5 . 1 0 . 3 3 w h ic h was f o l l o w e d o n e d a y
l a t e r by th e o n set of c e l l u l i t i s
jo in t.
around th e d is e a s e d
T h e s e f r e s h symptom s w e r e a s s o c i a t e d w i t h t h e
p re s e n c e o f s tr e p to c o c c i o f th e g roup S . in f r e q u e n s .
A n o t h e r p a t i e n t i n t h e a d j a c e n t b e d who h a d a n a x i l l a r y
a d e n i t i s i n c i s e d on 1 6 .1 0 .3 3 d e v e lo p e d e r y s i p e l a s from
t h e s i n u s on 2 1 .1 0 .5 3 and t h e o rg a n is m s r e c o v e r e d h e r e
w ere o f t h e g ro u p S . p y o g e n e s .
T h i s a s s o c i a t i o n was
m o re r e m o t e y e t t h i s l a t t e r p a t i e n t ’ s d r e s s i n g was d o n e
by th e s t a f f in a tte n d a n c e upon th e case o f S c a r l a t in a
and t h e p r e c a u t i o n s i n u s e e l i m i n a t e d a l l s o u r c e o f
i n f e c t i o n o th e r th a n t h a t c a r r ie d by a i r o r frcm th e
buccal sp ray .
S p o ra d ic c a s e s o f S c a r l a t i n a w ere o f in f r e q u e n t
o ccu rren ce b u t in 3 f u r th e r in s ta n c e s th e f e a tu re s
a p p e a r i n g i n t h e w ard s i n w h ic h th e y o c c u r r e d w ere o f
in te re st.
I n one w ard t h e s e w ere a s f o l l o w s . -
T h e d i s e a s e a p p e a r e d i n o n e c a s e o n 8 . 1 0 . 3 4 a n d w as
a s s o c i a t e d w ith i n c r e a s e d a c t i v i t y from th e s i n u s e s
o f 2 a d j a c e n t p a t i e n t s , one on 6 . 1 0 .3 4 and t h e o t h e r
on 1 3 .1 0 .3 4 and i n b o t h o f t h e s e c a s e s th e d i s c h a r g e
a
f r o m t h e s i n u s y i e l d e d Ap u r e c u l t u r e o f s t r e p t o c o c c i .
I n a n o t h e r w ard t h e d i s e a s e a p p e a r e d on 3 . 1 . 3 4 and an
a c u te in fla m m a tio n o c c u rre d i n th e s in u s o f th e n e i g h ­
b o u rin g /
190.
n e i g h b o u r i n g p a t i e n t on 8 . 1 . 3 4
from w h ic h o n c e a g a i n
a p u r e c u l t u r e o f s t r e p t o c o c c i was o b t a i n e d .
In th e
t h i r d and l a s t i n s t a n c e , w h e re t h e o c c u r r e n c e o f a
’ c a r r i e r ' was p r o v e d , c o m p l i c a t i o n s i n s i n u s e s w ere
c e l l u l i t i s a ro u n d an a n k l e and a d e f i n i t e i n c r e a s e i n
th e a c t i v i t y o f a g ro in s in u s a s s o c ia te d i n b o th i n ­
s ta n c e s w ith th e ap p earan ce o f h a e m o ly tic s t r e p to c o c c i
in th e d is c h a r g e s .
T h ese f e a t u r e s w e re c h a r t e d a s was
t h e o c c u r r e n c e o f s t r e p t o c o c c a l t h r o a t s and S c a r l a t i n a
am ongst t h e s t a f f and p a t i e n t s .
Prom t h e c h a r t t h e
r e l a t i o n s h i p o f th e s in u s c o m p lic a tio n s t o an in c r e a s e
fro m t h e a i r b o r n e i n f e c t i o n i n t h e w ard was c l e a r l y
seen.
CHART
5.
«A
In o rd e r to d isc o v e r i f th is r e la tio n s h ip e x iste d
b e tw e e n S c a r l a t i n a and s in u s c o m p lic a tio n s d u e to
s tr e p to c o c c i th e d e t a i l s
o f each p a t i e n t w ith a d i s ­
c h a r g i n g s i n u s who d e v e l o p e d t h i s d i s e a s e w e r e o b t a i n e d .
F iv e c a s e s a p a r t fro m th o s e re c o rd e d f e l l i n t o t h i s
c a t e g o r y , an d n o c h a n g e t o o k p l a c e i n t h e c o u r s e o f
s in u s .
In c o n c lu s io n , endogenous i n f e c t i o n o f a b s c e s s e s
a n d s i n u s e s was show n t o b e a b s e n t a n d a l s o t h a t a b s ­
c e s s e s w ere a lm o s t e n t i r e l y f r e e fro m s e c o n d a ry i n f e c ­
t i o n w h i c h , when i t
exogenous o r i g i n .
o c c u r r e d was m o s t p r o b a b l y o f
E x o g e n o u s i n f e c t i o n was show n t o
b e p o s s i b l e f r o m t h e s k i n s u r f a c e w h i c h , h o w e v e r , was
in c a p a b le o f e x p la in in g th e p resen ce o f th e s t r e p t o ­
c o c c i w h i c h w e r e r e c o v e r e d f r o m t h e s i n u s e s an d i n t h i s
r e s p e c t i t was show n t h a t t h e s e o r g a n i s m s m o s t p r o b a b l y
o r i g i n a t e d fro m t h r o a t s by d r o p l e t i n f e c t i o n .
T h is
p o s s i b i l i t y was e n h a n c e d b y t h e f a c t t h a t a s i n u s w h ic h
r e m a i n e d a c t i v e an d p a t e n t f o r a c o n s i d e r a b l e p e r i o d
a lm o s t c e r t a i n l y had an i n f e c t i o n by t h e s e o r g a n is m s .
I n s h o r t , t h e s e w ounds, d i f f e r e n t fro m m ost i n t h a t
t h e y r e c e i v e c o n s i d e r a b l e c a r e b e f o r e an d a f t e r t h e i r
o n s e t , w ere open t o i n f e c t i o n s u c h a s i s f e a r e d by
g y n a e c o l o g i s t s and g e n e r a l s u r g e o n s , n am ely d r o p l e t
i n f e c t i o n , a n d t h i s s o u r c e o f i n f e c t i o n was o n e o f
i m p o r t a n c e j u d g i n g f r o m t h e s e e m in g i n e v i t a b i l i t y
of
a d d itio n a l seco n d ary i n f e c t io n o c c u rrin g in s u ita b le
s o il.
THE
TREATMENT
OF
THE
CASES
The b a s i c p r i n c i p l e o f a l l t r e a t m e n t was t h e
norm al r o u tin e o f a s a n a to riu m .
E a c h c a s e was p l a c e d
u n d e r c o n d itio n s as n e a r ly id e a l as p o s s i b le , r e s te d
a d e q u a t e l y , f e d s u i t a b l y a n d g i v e n a s much e x p o s u r e t o
s u n an d a i r a s p o s s i b l e .
T hese f e a t u r e s p lu s th e
n e c e s s a r y i m m o b i l i s a t i o n o f t h e d i s e a s e d a r e a w e re
d e s i g n e d t o b u i l d u p t h e p a t i e n t ' s b o d i l y h e a l t h an d
to in c re a s e h is o r h e r g e n e ra l r e s is ta n c e to th e
tu b e rc u lo u s in f e c tio n .
A b s c e s s f o r m a t i o n , when i t
o c c u r r e d was c o m b a t t e d
m a i n l y b y a s p i r a t i o n , t h e t e c h n i q u e an d a im s o f w h ic h
w ere d e s c r ib e d I n an e a r l i e r c h a p t e r .
E f f o r t s w e r e made
t o p r e v e n t a b s c e s s e s o c c u r r i n g and c e r t a i n fo rm s o f
t u b e r c u l o s i s l e n t th e m se lv e s p a r t i c u l a r l y to t h i s e n d .
F o r e x a m p le , i f
a s m a l l a r e a o f d i s e a s e was s e e n r a d i o -
l o g i c a l l y in th e c e n tr e o f th e neck o f th e fem u r, n o t
in v o lv in g th e j o i n t c a v ity b u t th r e a te n in g to do s o ,
t h e n a n a t t e m p t was made t o rem o v e i t
a v o id in g th e j o i n t c a v ity .
s u rg ic a lly ,
T h i s m e a s u r e was a p p l i c a b l e
o n ly i n a l i m i t e d num ber o f s i t e s , g e n e r a l l y lo n g b o n es
s u c h a s t h e u l n a , t i b i a a n d t h e l o w e r en d o f t h e f e m u r
a b o v e t h e k n e e j o i n t , a s w e l l a s t h e e x a m p le c i t e d .
I n many i n s t a n c e s i t was s u c c e s s f u l i n c u t t i n g s h o r t
th e p ro g re s s o f th e d is e a s e .
N e x t when a b s c e s s f o r m a ­
t i o n h a d ta k e n p la c e and p r o g r e s s e d t o in v o lv e t h e s k in
su rface/
s u r f a c e and a p p e a re d l i k e l y t o fo rm a s in u s th e n th e
s k i n was i n c i s e d an d a n a t t e m p t made t o re m o v e t h e
u n d e rly in g t u b e r c u lo s is .
An a d d e d v a l u e i n t h i s was
t h a t s k i n s u r f a c e , d i f f i c u l t t o r e p l a c e , w as c o n s e r v e d .
As a m e a s u r e t h i s was n o t a d i s t i n c t s u c c e s s b u t show ed
its
g r e a t e s t v a l u e i n g l a n d u l a r an d s o f t t i s s u e l e s i o n s .
No o t h e r i n t e r f e r e n c e was c o n d u c t e d w i t h a b s c e s s e s .
When a s i n u s h a d f o r m e d a n d s e q u e s t r a t i o n was
t a k i n g p l a c e i n i t s d e p th s t h e s e q u e s t r a w ere rem o v ed .
I n i n s t a n c e s w h e r e t h e s e q u e s t r u m was s i n g l e i t s
re­
m o v a l h a s t e n e d h e a l i n g b u t i f g r a d u a l an d p r o l o n g e d
s e q u e s t r a t i o n o c c u r r e d t h e n r e p e a t e d i n t e r f e r e n c e was
n ecessary .
T h i s , i n a n i n f e c t e d s i n u s an d p a r t i c u l a r l y
o n e i n w h ich t h e r e w ere s t r e p t o c o c c i , o f t e n r e s u l t e d
i n a f r e s h a c t i v i t y o f t h e s e c o n d a r y i n f e c t i o n some
d a y s l a t e r , w h i c h , f o r t u n a t e l y , w as n e v e r m a rk e d i n
d eg ree.
An e x p l a n a t i o n o f t h i s o c c u r r e n c e was t h o u g h t
t o b e i n t h e f a c t t h a t i n t e r f e r e n c e rem o v ed t h e t u b e r ­
c u l o u s m em brane o f t h e s i n u s a n d e x p o s e d h e a l t h y b o d y
t i s s u e s to th e a c tio n o f th e seco n d ary in f e o tin g o rg a n ­
ism s.
As h a s a l r e a d y b e e n m e n t i o n e d t h i s m em brane was
f e l t to be a d e f in ite b a r r i e r to th e a c t i v i t i e s
t h e s e o rg a n ism s.
of
At t h e o t h e r end o f t h e i r h i s t o r y
w hen s i n u s e s w ere p r o g r e s s i n g to w a rd s h e a l i n g th e y
w ere c a r e f u l l y w atch ed t o s e e t h a t no e p i t h e l i u m grew
down t h e i r w a l l s a n d t h e y w e r e s u b j e c t e d t o a n o c c a s ­
io n a l sc ra p e w ith a spoon.
h e a lin g /
T h is a p p e a re d to h a s te n
h e a l i n g a n d , a s i t h a s b e e n show n t h a t t h e s e s i n u s e s
la c k e d a d an g ero u s seco n d ary i n f e c t i o n , no a fte rm a th
o ccu rred .
When t h e t o x a e m i a f r o m i n f e c t i o n was g r a v e t h e
m a jo r s u r g i c a l m easure o f a m p u ta tio n o f t h e d i s e a s e d
m em ber was c a r r i e d c u t .
T h i s p r o c e d u r e was a p p l i c a b l e
i n some c a s e s w i t h a p r i m a r y l e s i o n s i t u a t e d i n t h e
h i p j o i n t o r t h e k n e e j o i n t b u t was m ore commonly u s e d
w here t h e d i s e a s e a f f e c t e d e i t h e r t h e h a n d s o r f e e t
o r th e a n k le j o i n t .
Its
g r e a t e s t v a l u e was s e e n when
u sed i n t h e l a s t th r e e e x am p les, p ro b a b ly b e c a u se i t
was o n l y a t t e m p t e d a s a l a s t r e s o r t when t h e d i s e a s e
a f f e c te d th e h ip o r knee j o i n t s .
w h ich r e s u l t e d
T h e m a rk e d im p ro v e m e n t
in s u i t a b l e c a s e s te n d e d t o encourage
i t s u s e i n many i n s t a n c e s w h e r e c o n s e r v a t i v e m e a s u r e s
and p a t i e n c e a c h ie v e d a n
e v e n tu a l c u re .
T h i s was
p a r t i c u l a r l y m a rk e d i n t u b e r c u l o s i s o f t h e a n k l e j o i n t
w h e r e t h e s o u r c e o f t h e d i s e a s e was p r o t r a c t e d an d t h e
l o c a l d i s t u r b a n c e s g r e a t , y e t many s e v e r e c a s e s h e a l e d
w ith o u t am p u ta tio n .
No o t h e r m a j o r s u r g i c a l m e a s u r e s
w ere em p lo y ed .
T h e common c o m p l i c a t i o n s a r i s i n g f r o m a s i n u s s u c h
as c e l l u l i t i s
and a c u t e a b s c e s s f o r m a t i o n w e re t r e a t e d
o n o r d i n a r y s u r g i c a l p r i n c i p l e s an d o r t h o d o x t r e a t m e n t
was g i v e n t o t h e f e w c a s e s o f e r y s i p e l a s w h i c h a r o s e .
T h e g e n e r a l t r e a t m e n t w h ic h t h e s i n u s e s r e c e i v e d
w as/
was a r o u t i n e d a i l y d r e s s i n g w i t h a n a n t i s e p t i c , t h e
m o st common b e i n g c a r b o l i c l o t i o n o r e u s o l .
Where t h e
s i n u s e s r a n d e e p l y i n t o t h e t i s s u e s p a c k i n g was i n ­
s e r te d to a s s i s t d ra in a g e .
’ P o c k e tin g * was p r e v e n t e d
as f a r as p o s s ib l e b y c a r e f u l p ro b in g w ith s in u s f o r ­
c e p s and a t t e m p t i n g t o i n c r e a s e t h e d r a i n a g e o f pus
f ro m t h e ' p o c k e t ' i n t o t h e g e n e r a l s i n u s t r a c k . C o u n t e r
I n c i s i o n s t o a s s i s t d r a i n a g e w e re made b u t m a in ly in
a n em ergency s u c h a s a c u t e a b s c e s s f o r m a t i o n .
D u r in g
a p h a s e o f a c t i v i t y i n a s i n u s i t was n e c e s s a r y i n
many i n s t a n c e s t o h a v e more f r e q u e n t c h a n g e s o f d r e s ­
sin g .
W ith r e g a r d t o t h e m a t e r i a l s u s e d when d r e s s i n g i t
was a l r e a d y re m a rk e d t h a t t h e f a v o u r i t e s w ere c a r b o l i c
lo tio n or e u so l.
D u r in g t h e i n v e s t i g a t i o n a l l m anners
o f s p e c i a l f l u i d s and p a s t e s w e re u s e d b u t t h e y d i d
n o t h a v e an y m arked e f f e c t .
Amongst t h o s e w h ic h w ere
u s e d w e re B . I . P . P . , B e c k 's p a s t e , M o rto n ’ s f l u i d and
C a l o t s f l u i d s and p a s t e s .
The l a s t nam ed, u s e d p u r e l y
e m p i r i c a l l y , a p p e a re d t o b e o f v a l u e a s a s u r f a c e
d r e s s i n g on t h e t y p e o f l e s i o n c a u s e d b y i n f e c t e d s i n u ­
s e s a r i s i n g a ro u n d t h e w r i s t o r a n k l e j o i n t s .
C o n tin u o u s i r r i g a t i o n o f s i n u s e s was a t t e m p t e d
u s i n g weak e u s o l o r n o r m a l s a l i n e s o l u t i o n w i t h o u t
im prov em en t b u t c o m p le te im m e rs io n o f l e s i o n s o f t h e
h a n d s , f e e t o r a n k l e j o i n t s was fo u n d t o b e o f v a l u e
in iso la te d cases.
H e lio th e ra p y /
H e l i o t h e r a p y , o r e x p o s u r e o f t h e wound t o t h e
s u n ’ s r a y s was s i m i l a r l y t r i e d , a g a i n w i t h o u t m arked
c h a n g e i n t h e l o c a l c o n d i t i o n a n d , i n v ie w o f t h e r i s k
; o f f u r t h e r i n f e c t i o n b e i n g a d d e d , i t was d i s c o n t i n u e d , j
The c h e m ic a l arm am ent r e d u c e d i t s e l f t o c a r b o l i c
l o t i o n , e u s o l , n o rm a l s a l i n e s o l u t i o n , C a l o t ’ s p a s t e
! and o c c a s i o n a l l y a 1 /1 0 0 0 a c r i f l a v i n e e m u l s i o n .
T h e ir
v a l u e e s p e c i a l l y when t h e i n f e c t i o n was g r o s s was d o u b t | f u l i n v ie w o f t h e f a c t t h a t t h e s e c o n d a r y i n f e c t i n g
o r g a n i s m s w ere p r e s e n t i n t h e d e e p e s t r e c e s s e s o f t h e
s i n u s e s w h e re t h e a n t i s e p t i c w ould r e a c h o n l y i n a
g reat d ilu tio n , i f a t a l l .
In s u p e rfic ia l le s io n s ,
c a p a b l e o f t h o r o u g h c l e a n s i n g t h e i r a c t i o n was s i m i l a r
t o w h a t i t w ould h a v e b e e n i n a n o rm a l wound a n d r a p i d
! c le a n in g o c cu rred .
T h i s was p a r t i c u l a r l y n o t i c e a b l e
in s u p e r f ic ia l g la n d u la r le s io n s .
[
The h i g h d e g r e e o f i n f e c t i o n n o t e d i n t h e s i n u s e s
j im p ressed th e d a n g e rs o f an i n f e c t i o n b e in g c a r r i e d
‘ fro m one s i n u s t o a n o t h e r b y d e f e c t i v e d r e s s i n g t e c h ­
n i q u e and t h i s p o i n t was c a r e f u l l y w a tc h e d d u r i n g
d re ssin g .
A r o u t i n e was e v o lv e d w h ereb y t h o s e s i n u s e s
w h ic h w e re f r e e fr o m s e c o n d a r y i n f e c t i o n w e re d r e s s e d
first;
t h o s e w hich c o n t a i n e d o r g a n i s m s o t h e r t h a n
s t r e p t o c o c c i n e x t ; and f i n a l l y , t h o s e i n f e c t e d b y
stre p to c o c c i.
T h i s c a r e was f e l t t o b e r e s p o n s i b l e f o r m a i n t a i n ­
i n g c e r t a i n l e s i o n s f r e e fr o m s t r e p t o c o c c i a n d , i n one
in sta n c e /
i n s t a n c e , f o r m a in ta in in g c o m p le te ' s t e r i l i t y '
in a
s i n u s a r i s i n g f r o m a h i p j o i n t d u r i n g t h e f o u r m o n th s
o v e r w h ich i t
rem ain ed p a t e n t .
I n s h o r t , i t was f e l t t h a t t h e s e c o n d a r y i n f e c t i o n !
o f s i n u s e s n e e d n o t o c c u r b u t t h a t when i t d i d t h e m o s t
s u i t a b l e t r e a t m e n t a p p e a r e d t o b e t h a t f o u n d e d on
o rd in a ry s u r g ic a l p r in c ip le s .
198.
C O N C L U S I O K S .
I.
A s e r i e s o f 132 c a s e s o f n o n - p u l m o n a r y t u b e r c u ­
l o s i s in c h ild r e n c o m p lic a te d by th e p re s e n c e o f
a b s c e s s o r s i n u s f o r m a t i o n was i n v e s t i g a t e d f r o m
t h e c l i n i c a l an d b a c t e r i o l o g i c a l a s p e c t s .
II.
T he r a t i o n a l e o f f o r m a t i o n o f ’ c o l d ’ a b s c e s s e s
was o b s e r v e d a n d i t was f o u n d t h a t t h e y w e r e
d ep en d en t upon th e a c u ity o f th e i n i t i a l i n ­
f e c t i o n and a l s o o n i t s
's i t e 1.
I n th e s e r i e s
u n d e r c o n s i d e r a t i o n t h e y o c c u r r e d m o re f r e ­
q u e n tly in th e younger c h ild re n b u t sex d id n o t
a p p e a r t o p l a y an y p a r t , n o r d i d t h e f a m i l y
h i s t o r y qua t u b e r c u l o s i s .
III.
When a s i n u s r e s u l t e d i t was f o u n d t o b e d e t e r ­
m in e d b y t h e same f a c t o r s b u t t h e s i t e o f t h e
l e s i o n was m ore s i g n i f i c a n t .
IV .
8 6 $ ( 1 1 3 ) o f t h e c a s e s I n v e s t i g a t e d f o rm e d
s i n u s e s an d i t was f o u n d t h a t i n 9 1 $ o f t h e s e
s i n u s e s t h e r e w as p r e s e n t a s e c o n d a r y i n f e c t i o n
b u t t h a t th e s e r io u s seco n d ary i n f e c t in g o rg a n ­
is m was t h e s t r e p t o c o c c u s w h i c h was p r e s e n t i n
8 4 .8 $ o f a l l th e c a s e s .
V- /
T he t y p e s o f s t r e p t o c o c c i r e c o v e r e d f r o m t h e
sin u s e s v a rie d c o n sid e ra b ly in t h e i r c u ltu r a l
an d b i o l o g i c a l c h a r a c t e r s b u t w e r e , i n a p r e ­
ponderance, c a p a b le o f b e in g c l a s s i f i e d w ith in
th e group S tre p to c o c c u s h a e m o ly tic u s .
T he e f f e c t o f t h e p r e s e n c e o f t h e s e s t r e p t o c o c c i
on t h e l o c a l and g e n e r a l c o n d i t i o n s o f t h e
p a t i e n t s was o b s e r v e d when i t w as f o u n d t h a t
t h e y w e r e r e s p o n s i b l e f o r a l l t h e a c u t e com ­
p lic a tio n s o c c u rrin g in th e s in u s .
I t was a l s o
found t h a t th e y in c r e a s e d th e r i s k o f l o c a l
s p r e a d o f t h e t u b e r c u l o u s p r o c e s s an d a i d e d i n
i t s m ore w i d e s p r e a d d i s s e m i n a t i o n .
T h e r e w as
no e v id e n c e t h a t th e y in flu e n c e d th e ’ a c t i v i t y 1
o f th e p rim a ry l e s i o n i t s e l f .
The t o x a e m i a
a r i s i n g f r o m t h e i r p r e s e n c e i n t h e t i s s u e s was
th o u g h t to d im in ish th e n a t u r a l r e s is ta n c e o f
th e p a tie n ts to th e tu b e rc u lo u s p ro c e s s , t h e r e ­
by p r o tr a c tin g th e i l l n e s s
i n many c a s e s , w h i l e
i n o t h e r s c o n t r i b u t i n g i n some m e a s u r e t o t h e
f a t a l iss u e .
O rg an ism s o t h e r t h a n s t r e p t o c o c c i w ere fo u n d
a s s e c o n d a ry i n f e c t i o n s and t h e s e w e re , i n
o rd er o f in c id e n c e , s ta p h y lo c o c c i, d ip h th e ro id
b a c illi,
c o l i f o r m b a c i l l i a n d some unn am ed
o rg a n ism s.
th e /
They w ere w ith t h e e x c e p t i o n o f
200
t h e c o l i f o r m b a c i l l i , a v i r u l e n t o r o f lo w v i r u ­
le n c e .
S y m b i o s i s was t h o u g h t t o o c c u r m a i n l y
b e tw e e n s ta p h y l o c o c c i and s t r e p t o c o c c i , r a r e l y
b e t w e e n t h e l a t t e r an d d i p h t h e r o i d b a c i l l i
a l t h o u g h i t was n o t e d t h a t t h e s t r e p t o c o c c i w e re
c a p a b le o f o u s t i n g t h e o t h e r s from t h e i r h a b i t a t .
V III.
O f a l m o s t e q u a l i m p o r t a n c e was t h e t i m e a t w h ic h
s e c o n d a r y i n f e c t i o n t o o k p l a c e and i t s
so u rce.
I t was f o u n d t o b e a b s e n t i n a l l c o l d a b s c e s s e s
e x a m in e d i n t h e s e r i e s an d o c c u r r e d s u b s e q u e n t
t o t h e b r e a k i n g down o f t h e s k i n .
The s o u r c e o f
t h e i n f e c t i n g o r g a n i s m s was d i f f i c u l t t o d e t e r ­
m in e b u t i n t h e b u l k o f t h e c a s e s i t w as e x o ­
genous in o r i g i n and c o u ld o n ly b e a t t r i b u t e d ,
in th e case o f s tr e p to c o c c i, t o d r o p le t in f e c ­
t i o n o r p erh a p s t o f a u l t y te c h n iq u e d u rin g
d re ssin g .
I n a c e r t a i n n u m b e r o f c a s e s i t w as h i g h l y
p r o b a b l e , m o re e s p e c i a l l y i n t h e d i p h t h e r o i d ,
s t a p h y l o c o c c a l an d c o l i f o r m g r o u p s f
th a t th e
s o u r c e o f i n f e c t i o n was t h e p a t i e n t ’ s s k i n .
I t was a n i n t e r e s t i n g o b s e r v a t i o n t h a t t h e
com m o nest e a r l y i n f e c t i o n w as s t a p h y l o c o c c a l
and d i p h t h e r o i d i n c h a r a c t e r b u t t h e s t r e p t o ­
c o c c i , a p p e a r in g l a t e r , d o m in ated th e c o n d it i o n
d u rin g /
d u r i n g t h e h i g h l y a c t i v e p e r i o d a n d seem ed t o
le a d t o th e d isa p p e a ra n c e o f th e o t h e r s , w ith
a te n d e n c y f o r th e r e v e r s e p ro c e s s to ta k e p la c e
d u rin g th e s ta g e o f h e a lin g .
L a s tly s in u s e s g e n e r a lly h e a le d in c lo s e r e ­
l a t i o n s h i p to th e h e a lin g o f th e u n d e rly in g
t u b e r c u l o u s p r o c e s s a n d t h a t q u i c k h e a l i n g , an d
an u n c o m p lic a te d c o u rse r e s u l t e d i n e v e ry i n ­
s t a n c e w h e r e i t was p o s s i b l e t o e r a d i c a t e t h e
tu b e rc u lo u s p ro cess e n t i r e ly .
REFERENCES•
Andrewes e t a l .
M .R.C . M o nograph.
Andrewes and H o r d e r . 1 90 6.
Brow n. 19 19.
C h a lo t.
D ib le .
D i p h t h e r i a . 1923.
L a n e ., i i ,
708, 775, 852.
M ono. R o c k . I n s t . Med. R e s . , N o .9 .
In d is p e n s a b le O rth o p o e d ic s.
J . P a t h , and B a c t . , x x iv , 3 .
1921.
D o c h e z , A v e r y , L a n c e f i e l d . 1 9 1 9 . J . E xp . M e d ., x x x , 1 5 9 .
D o u g la s , C o le b ro o k and F le m in g .
D udgeon.
M .R .C . R e p o r t N o . 4 8 .
B a c t . V a c c . and t h e i r p o s i t i o n i n T h e r a p e u t i c s .
E a g le s . 1926.
B .J .E x p . P a t h ., v i i ,
286.
F raser.
T u b e r c u lo s is o f t h e Bones and J o i n t s .
G riffith
(1926.
(19 27 .
H o lm a n .
1916.
J . H y g ., x x v , 385.
J . H y g ., x x v i, 363.
J . M ed. R e s . , x x x i v , 3 7 7 .
H o p k i n s an d L a n g .
1914.
L a n c e fie ld .
J . E x p . M ed. x l v i i , 9 1 .
1928.
J . I n f . D is . , x v , 63.
ib id .
x lv ii,
469.
ib id .
x lv ii,
481.
L y a ll.
1914.
J . M ed. R e s . , x x x , 4 8 7 .
M cL eod.
1912.
J . P a t h , and B a c t . , x v i , 3 2 1 .
ib id .
M c L a c h la n & M a c k i e . 1 9 2 8 .
x ix , 392.
J . H y g ., x x v i i , 225.
M .R .C .
S y s te m o f B a c t e r i o l o g y .
S m ith .
1 9 2 7 .J . H y g . , x x i v , 4 2 0 .
T hro.
1914.
J . I n f . D is ., x v , 234.
Todd.
1928.
J . E x p . M e d ., x l v i i i , 4 9 3 .
T o p le y & W ils o n .
W alk er. 1911.
'T h e P r i n c i p l e s o f B a c t e r i o l o g y
an d I m m u n i t y . '
P r o c . Roy. S o c. B . , I x x x i i i , 541.
APPENDIX.
To a b b r e v i a t e c a s e h i s t o r i e s a n d g i v e o n l y
r e l e v a n t d e t a i l s t h e f o l l o w i n g t a b l e s w e r e m ad e.
Column 1 . g i v e s i n i t i a l s o f p a t i e n t s .
2 . F am ily h i s t o r y .
3 . Type o f p r i m a r y l e s i o n : A cu te
=
A
S u b acu te
=
S
C h ro n ic
=
C
4. R e su lt o f search fo rtu b e rc le b a c i l l i
i f p r e s e n t a n d t y p e d t h e n Human
-
(H) o r
B o v i n e ( b ) e n t e r e d i n f i r s t c o lu m n :
i f c u l t u r e d a n d n o t t y p e d *+» i n s e c o n d
c o lu m n , i f n e i t h e r c u l t u r e d n o r s e e n
m ic ro sc o p ic a lly
*0* i n s e c o n d co lu m n .
5 . F o r m a t i o n o f s i n u s f ro m a b s c e s s .
6. R e su lt o f tre a tm e n t.
EXAMPLE.
4
A . S .C .
+ 0
6
6
+ 0
+
VERTEBRAE.
MALES
4 -------- _J_
3—
Kama
JL
J-
s c
J.M cB
j& m *
B ig g ie
t e t .f lm p
H.B,
H
H a a la d
R .E .
0-5 yra.
D iad
A .O .
♦
X .S .Q .
♦
Xopravlfi^
♦
♦
D ia d
J .B .
0
♦
Improving
P .O .
0
♦
J .B .
0
♦
D a to r io r ­
a tin g .
H a a la d
A.M .
♦
M.3.
♦
♦
D a ta r ia r a tin g .
♦
♦
D ia d
0
♦
H a a la d
D.M.
5 -1 0 y ra,
V.M .
P .A .
P .H .
♦
I.M .
♦
J .B .
B.
H a a la d
H a a la d
B
H a a la d
0
♦
X .S .Q .
X .L .
0
♦
D ia d
■o
X .R .
•M.
H
a s s i s s i
D ia d
sL zca
10-15
hr*
FEMALES
Hu m
F .H .
L e s io n
A S C
VERTEBRAE.
T.
B.
S in u s
R e s u lt
D e te r io r a tin g
H .S .
-
♦
H
+
A . MOM
-
■f
H
♦
H .A .
-
♦
H
M .S.
♦
I.S ,Q .
-
0
♦
-
♦
0
♦
D ied .
H .R .
-
♦
0
♦
H e a le d .
J .S .
-
♦
♦
D e te r io r a tin g
M .C.
“
♦
J .S .
m
♦
U .L .
♦
mm
H.M.
-
M.M.
P .P .
-
♦
♦
♦
H
♦
H
♦
0
♦
=ss=s is: s: =SSc=; : c :
===
ss:
H e a le d .
H e a le d .
0
5 -1 0 y r
D e te r io r a tin g
♦
♦
♦
U .Q .
0
♦
J .T .
-
yrs
J .S .Q .
-
H
0-5
H e a le d .
D.M .
♦
A g e G rou p
-
H e a le d .
-
H e a le d .
10-15
yrs
D ie d .
I.S .Q .
15
yrs
♦
H e a le d
=3S : : : = = s : e = = : : : : : : s i : : : : = 3 s
FEMALES
1
Name
-
H IP JO IN T .
2
^
4
$
F .H . L e s i o n T ■B. S i n u s
A S C
N.G.
-
Im . m .
-
+
H
6
R e su lt
+
H e a le d .
+
+
+
D ied .
C .D .
+
+
+
+
D e te rio ra tin g
M.H.
+
+
+
+
H e a le d .
0
+
H e a le d .
0
+
H e a le d .
+
H e a le d .
+
H e a le d .
N .3 .
-
A .S .
-
+
C .H .
-
+
J .M .
-
c.w.
H
+
+
+
E.M .
-
M.M.
- +
=====
+
+
+
H
-
H e a le d .
H
-
H e a le d .
H
-*•
D ie d
Age G r o u p .
5-10 y r s .
1 0-15 y r s .
15
+
y rs.
MALES
-
KNEE J'UINT.
1 2
^
4
5
Name F .H. L e s i o n T. B . S i n u s
A S C
tf.H .
-
C .P .
-
A .C .
-
R .C .
+
+
+
+
H
+
+
+
F em ales
H
-
6‘
R e su lt
Age G r o u p .
+
H e a le d
0-5 y r s .
+
D ie d .
+
Im proved
-
10-15 y r s .
H e a le d .
Knee J o i n t .
M.C
H e a le d
M.B
H ealed
R.H
H ealed
M.C
H ealed
5-10 y r s
MALES
-
ANKLE JO IN T.
1
Name
2
^
4
5
F . H. L e s i o n T . B. S i n u s
A S C
J .G .
+
6
R e su lt
Age G r o u p .
0-5 y r s .
+
H
+
H e a le d
I.G .
-
+
H
+
H ealed
M.M.
-
+
B
+
A m p u ta te d .
A.M.
-
+
+
H e a le d .
0
1 0-15 y r s .
l
FEMALES
/
1
6
-
S.M .
J .M .
ANKLE JO IN T .
+
H
+
+
A.W.
-
+
H.M.
-
+
M.T.
-
0
H
+
+
H
+
A m p u ta te d .
+
H e a le d .
+
H e a le d .
+
H e a le d .
-
H e a le d .
5-10 y r s .
1 0 -1 5
y rs.
MALES
-
LUNG BONES.
1
_ _2 _ _ V
4
5
_____ 6
X Jl T
H ' . 'D
Hame F .H
S. sSi linn nu s£ a e s u l t
. L aecsHi or \nr \ T.
A S C
S.M.
+
-
H.J .
+
+
+
+
X.S.<*.
0
+
H e ale d .
G.D .
-
+
+
+
H e ale d .
»G •
-
+
0
+
H e ale d .
0
+
H e ale d .
+
+
H e ale d .
+
+
Im p ro v in g
+
H e ale d .
J
T .S .
+
+
J .M.
-
D .P .
-
J.G .
+
+
+
+
J .H .
-
W.H.
-
+
J .S .
-
+
H
+
H
-
H e ale d .
a
-
D ied .
0
+
I .S.(^«
Age
G ro u p .
0 -5 y r s .
5-10 y r s .
1 0 -1 5 y ^ s .
LONG BONES.
FEMALES
1
6
S.M.
-
+
R.M.
-
+
+
H e ale d .
H
+
H e ale d .
+
A .K .
+
+
H
+
I.S .Q .
H ,C .
+
+
H
+
D ie d .
0-5 y r s .
1 0 -1 5
y rs.
DACTYLITIS.
F .H
R e su lt
L e s i o n T .B
Age G roup
R .P
5-10 y r s
H e a le d
J .B
FEMALES
M.L.
-
K.McM •
-
R .S .
-
NT. P .
+
B .C .
+
T .H .
+
+
+
+
+
-
+
-
DACTYLITIS.
0
+
H e a le d .
+
+
D ie d .
0
+
Im p ro v in g .
0
+
Im p ro v in g .
+
+
H e a le d .
+
H e a le d .
+
H e a le d .
+
Im p ro v in g
H
0-5 y r s .
5-10 y r s .
+
A .C .
A.M.
-
+
0
H
10-15 y r s .
MALES
Name
GLANDS AND SOFT TISSUES.
4
5_
F •H. L e s i o n T .B . S i n u s
A S C
J .L .
-
J .R .
-
G.M.
-
J .C .
-
+
+
+
+
-
J .M .
0
+
H e a le d .
+
+
H e a le d .
+
H e a le d .
0
+
H e a le d .
+
+
H e a le d .
+
H e a le d .
H
+
+
6
R e su lt
Age
G roup
0-5 y r s .
5-10 y r s .
J .M .
+
+
-
H.M.
B
+
FEMALES
+
1
+
—
M.M.
H e a le d .
1 0-15 y r s .
GLANDS AND SOF'r TISSUES.
i
2
1
i.e .
-
0
6
+
+
H ealed
+
+
+
H ealed
+
+
+
H e a le d
+
+
+
H e a le d .
0
+
D ied .
H
+
H e a le d
B
+
H e a le d
0 -5 y r s .
A .C .
L .C .
-
J .B .
-
M .F .
-
C.W.
-
M.D.
-
+
0
+
H e a le d
E.M.
-
+
+
+
H ealed
M .S.
-
+
+
+
H ealed
C.W.
-
+
0
+
H e a le d
0
+
H ealed
0
+
H ealed
K»C.
I .W .
+
+
+
+
-
+
5-10 y r s .
10 -15 y r s .
MALES
-
MISCELLANEOUS.
1
2
^
4 ____ 5______ 6
Name F .,H. L e s i o n T .B. S i n u s R e s u l t
A S C
tf.A .
-
+
0
+
D ie d .
R .B .
—
m
+
0
♦
H ealed
J .M .
-
+
0
+
H e a le d
F .M.
-
+
0
+
H e a le d
I.D .
+
0
D .R .
+
+
+
H e a le d
FEMALES
-
MISCELLANEOUS.
Age
G roup.
5-10 y r s .
H e a le d
1 0 -1 5
—
E .A .
+
-
+
+
Im p ro v in g
+
+
+
H ealed
+
0
+
H e a le d
y rs.
0-5 y r s .
E .B .
+
M.M.
5-10 y r s .
C.M .
-
+
0
+
H e a le d
S .N .
-
+
0
+
H e a le d
0
+
H e a le d
A .B .
+
+
1 0-15 y r s .
Документ
Категория
Без категории
Просмотров
0
Размер файла
8 571 Кб
Теги
sdewsdweddes
1/--страниц
Пожаловаться на содержимое документа