Gitlin, N.

Silber, W.

English

AJOL - African Journals Online

29 May 1965 S.A. MEDICAL JOURNAL 453D. HaemorrhageForty-eight patients have presented with bleeding. Mas-sive haemorrhage is typical of incarcerated hernias. Thefirst serious symptom may be haematemesis or melaenaand the history of dyspepsia may then only serve tostrengthen the diagnosis of duodenal or gastric ulceration.A lateral che~t X-ray may suffice to establish the diagnosisif an incarcerated hernia is responsible. Treatment shouldthen be confined to hernial repair.Anaemia due to slow blood loss can result from eitherform of hernia. If the hernia is small, it is unlikely to beresponsible for the bleed and of course the common asso-ciation of duodenal ulceration enhances the diagnosticdifficulties.l3SUMMARY AND CONCLUSIONSThe histories of 317 patients with hiatus hernia have beenanalysed. An attempt has been made to account for the fre-quent early misdiagnosis and mismanagement of this condition.These are due partly to the fact that the early symptoms aretreated lightly by both patient and practitioner. Only whenthe dyspeptic symptoms become persistent and severe are in-vestigations ordered. The specific dyspeptic features of hiatushernia are now quite widely known and the 'typical' hiatushernia is being diagnosed more and more readily. This doesnot apply to the atypical case where often the mistakendiagneses of coronary artery disease, duodenal ulcer, cholecys-titis, primary lung disease or hysteria are retained for longperiods of time. The features of these conditions can be closelymimicked by hiatus hernia because its effects are exerted uponthe stomach, oesophagus and lung. The symptoms producedare due to specific efi"ects upon these organs but are nonethe-less direct results of the hernia. Mismanagement is furtherencouraged because other disease conditions such as duodenalulcerations, cholecystitis, coronary artery disease and diverti-culitis of any part of the alimentary tract often co-exist.Associated diseases such as duodenal ulceration and oesopha-geal diverticulae may be directly related to the hernia whileothers are fortuitous and owe their co-existence to the wide-spread degenerative body changes which occur among the age-group of patients affected with hiatus hernia.It has been emphasized that reflux or acid dyspepsia isspecific of gastro-oesophageal reflux. Nocturnal regurgitationof undiluted gastric enzymes may produce oesophageal ulcera-tion, and oesophageal pain or dysphaiPa may then dominate thesymptomatology. Regurgitation at mght may result in inhala-tion of gastric contents and only because of the secondarypulmonary effects may the patient seek medical help.Haemorrhage, when massive, is usually caused by gastriculceration within the incarcerated pouch of stomach, but severeanaemia may result from a slow ooze from an area of oeso-phagitis. Pylorospasm, cardiospasm, oesophagospasm andspasm of the crico-pharyngeal sphincter may be reflex to thehiatus hernia or the reflux of stomach contents which it causes.The symptoms of these spastic states are clear-cut and oftendistract the diagnosing physician from the basic anomaly.The adult forms of hiatus hernia are caused by a combina-tion of factors of which obesity, pregnancy and senile degene-ration are important. Consequently cholecystitis, duodenalulceration, diverticulitis, coronary ischaemia and other herniasare associated conditions which serve to obscure the hiatalhernia symptoms.I wish to thank the Photographic Unit of the Department ofMedicine, University of the Witwatersrand, for reproducing theillustrations.REFERENCESI. Aker1und, A (1926): Acta radiol. (Stockh.), 6, I.2. Allison, P. R. (1946): J. Thorae. Surg., IS, 308.3. Idem (1948): Thorax, 3, 20.4. Idem (l951): Surg. Gynec. Obstet., 92, 419.5. Allison, P. R. and Johnstone, A. S. (1953): Thorax, 3, 20.6. Barrett, N. R. (1950): Brit. J. Surg., 38, 175.7. Bright, R. (1836): Guy's Hosp. Rep .• I, 598.8. Eisen, D. (1938): Canad. Med. Assoc. J., 3', 207.9. Marchand, P. (1955): Brit. J. Surg., 92, 504.10. Idem (1957): Thorax, 12, 189.11. Idem (1958): S. Mr. Med. J., 31, 423.12. Idem (1959): J. Thorae. Surg.• 37, 81.13. Idem (1960): Brit. J. Surg., 'J7, 515.14. Idem (1962): Brit. Med. J., I, 754.IS. Idem (962): Leech (Johannesburg). 31. 14.16. Pare, A. quoted by Ohler, W. R. and Ritvo. M. (1943): New EngL J.Med., m. t91.17. Sweet, R. R. (1952): Ann. Surg., 135. I.PROGRESSIVE SYSTEMIC SCLEROSIS (DIFFUSE SCLERODERMA)TREATMENT WITII POTABA-A PRELIMINARY REPORTW. SILBER, M.B., CH.B. (CAPE TOWN), F.R.C.S. (EDIN.) AND N. GITLlN. M.B., CH.B. (CAPE TOWN), PeripheralVascular Clinic, Groote Schuur Hospital, Departments of Surgery and Medicine, University of Cape TownProgressive systemic sclerosis or diffuse scleroderma is adisease of the ccnnective tissue of unknown aetiology. Nosystem of the body is immune in the disease process andthe course is variable and unpredictable. In its fully deve-loped form the disease produces severe disability and isnot uncommonly associated with a high mortality rate.The purpose of this preliminary communication is todescribe a case of diffuse scleroderma which has respondedto Potaba (potassium p-aminobenzoate Glenwood). Thebeneficial effect of this drug was first described by Zara-fonetis in 1950.'Case ReportMrs. K.A., a 46-year-old White female, had in 1953 deve-loped Raynaud's phenomenon involving the fingers and toes ofall the limbs, and which was always precipitated by coldweather and associated with tightness of the skin.The diagnosis of scleroderma was made and she was treatedwith ACTH which, however, produced hypoglycaemic episodes.Cortisone thereafter precipitated hypercortism. In 1956, at thePeripheral Vascular Clinic, Groote Schuur Hospital, it wasfound that she had Raynaud's phenomenon of the hands andfeet, associated with gangrenous patches of the fingertips andtoes, and cutaneous scleroderma involving the upper and lowerlimbs, trunk, face, and neck. There was marked limitation ofthe large and small joint movements and gross reduction in theopening of the mouth.The blood count showed a haemoglobin of 12·5 G and thesedimentation rate was 10 mm. in the 1st hour (Westergren).Barium studies and limb X-ray examination was normal. Shewas again treated with cortisone with only intermittent effect.She was admitted to the surgical wards in 1957 for quad-ruple sympathectomies. Postoperatively all the symptoms per-sisted and later became aggravated.In 1959, with the cutaneous and joint symptoms still evident,she developed gastro-intestinal symptomatology, viz. epigastricpostprandial discomfort, heartburn, and constipation. Variouscourses of therapy were instituted with no lasting effect.In 1964 her joint stiffness was incapacitating, the cutaneousscleroderma involved the whole body, and Raynaud's pheno-menon was gross and associated with tapering and ulcerationof the digits. Dysphagia was very marked in addition to heart-burn, epigastric pain and constipation.A barium meal showed marked incoordination of oesopha-geal peristalsis, motility abnormality of the stomach, small454 S.A. TYDSKRIF VIR GENEESKUNDE 29 Mei 1965intestine and large bowel. There was in addition gross scarringof the duodenum.Augmented histamine test: Basal secretion 4·7 mEq. andthe maximum acid output was 40·5 mEq.Potaba was prescribed as a last resort in November 1964since the patient had already threatened suicide and becauseof the progress and deterioration of the patient's physical con-dition. The response was phenomenal. In March 1965 the skintexture had improved, the mouth was mobile, joint movementshad remarkably improved and the gastro-intestinal symptomshad practically abated except for the duodenal ulcer symptomswhich, however, were responding slowly to an ulcer regime.She now felt normal again.COMMENfThe purpose of this case report is to indicate to general prac-titioners that we are conducting a trial with this drug in thetreatment of diffuse sclerodenna, and would appreciate it if allcases of cllifuse sclerodenna could be referred to the PeripheralVascular Clinic, Groote Schuur Hospital, by appointment, forinvestigation and treatment.We wish to thank Dr. J. G. Burger for permission to publishthis case report, and Protea Pharmaceuticals for the generoussupply of Potaba.REFERE CE1. Zarafonetis, C. J. D. et al. (1950): Arch. Intern. Med., 85, 27.A PORTABLE MEDICINE-DISPENSING TRAY FOR HOSPITAL USE1. MIRVISH, M.B., M.R.C.P. (EDlN.), Cape TownThis tray has been designed to ensure that the procedureof handing out medicines in a ward should be simple,efficient and safe.It consists essentially of a tray bisected by a verticalpartition. On either side of the partition, as shown in theaccompanying illustrations (Fig. 1), are tapered slotsand circular cut-outs, t-inch deep, to hold the medicineFig. 1. See text.bottles and the glass measures. Additional bottles for aparticular patient are held in place by a rubber bandattached to the partition, as shown. In a children's wardit has been found most convenient to cut the slots toaccommodate standard 6-fluid-ounce bottles; smal1erbottles stand in these slots easily even if not fitting snugly.Standard glass measures fit comfortably in the circularcut-outs. To make identification easy each child has itsown glass measure adjacent to its medicine bottle. Thepatient's name on a strip of adhesive tape attached to theedge of the tray is a further help to identification.The tray is kept on a movable ward trolley and neednot be removed except for cleaning. The full tray andtrolley, when not in use, are locked in a special cupboardin the ward-sister's room.The medicine-dispensing tray described is made of woodand has 7 slots on either side; another 6 or 8 bottles canbe accommodated by the rubber bands alongside thepartition. Many modifications of this design are, ofcourse, possible. The tray could be made of plasticmaterial, and the size and number of slots varied. Insteadof slots, the bottles could be held in position (behindrubber bands) on narrow platforms or shelves (Fig. 2).Fig. 2. See text.Obviously the cooperation of the nursing staff is essentialwhen apparatus of this kind is contemplated.The fol1owing advantages are claimed for this tray:1. Safety. It ensures that the procedure of administeringmedicine in a ward will be simple, efficient and safe.2. Identification. The bottles are displayed in such away that they may be easily identified when required.Much valuable nursing time is saved thereby.3. Checking. The arrangement described makes check-ing easy, and so the danger of handing out thewrong mixture is reduced.4. Hygiene. It is good hygiene for each patient to havehis own glass measure.5. Convenience. The tray on its trol1ey can easily bewheeled from patient to patient and room to room,and safely locked away when not in use.I wish to thank the nursing staff working in my wardsat the Red Cross War Memorial Children's Hospital fortheir great interest and cooperation.

Progressive systemic sclerosis (Diffuse scleroderma)

https://www.ajol.info/index.php/samj/article/download/182696/172070

Progressive systemic sclerosis (Diffuse scleroderma)

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online