Document M4v4N1pZnmG8pK7rg5r6xk10z

FILE NAME: ZK/L DATE: DOC#: BO/L DOCUMENT DESCRIPTION::ZWZZ . ., . ~- ,. i .. f''''':>\ .\" -, . r .. 1.) ~..1. .:::u: :...~U~~ ~ L.L."C=) ~-1-~ /./"~,~"\-..-1.;.;.''1 r\..' u.,lI f;;,OR[ r:O . I v.:;,.~ . J'7 ..... , '1' . f\~":~'::.:'~ ,~,,:" dl'~Yi! [ .... ,. I / , DRS. w. B. WOOD A..'"D , R. Gt,on"'E: prruroXAR1."" ASBESTOSIS J~ere :l uAini~~dl}J!or 'J'~' . an... ,4 ,;: that tbot 1 .. dV:lIlta.g~ .. unD:lPPJ' r a proper ':OotinUOIU dreaml~. Uy h..aprr ~our timei ! ,olT 1r:a~tl6 dL , both too .bitll&l u.~ !or l1ee ill ~ .tictLL II1 of a.&thm.& . :i'l'ell such 1 ':1l' attaa. ;-i Y Ca.&e to p3.rOXj5m lXjlim tbe ie SJ1llp&overcome ~ i ps.r:l..\yeo tUatea the 'he inlula. ::unonium .,r~('~ b lld ~..r .f' bal.&Dee ~ :i VlLIl t:1;e ~n.&taIlll:r to inject c tbe fint ., aborttod. It, !boU;h be h:ld 10 ioa at I be." ea ri..~ to :~u.sed by '~:lt prefer does Dot hoger of .:.u.eA ILt' cienc:r i!I prcp:u:I' '..;0 repro (;CC.1s'on. . d.i"ri", :J;d :will .n<icr 1 ll,' '!motiou. i-{~n:tjCl:1 :.I...~. tlao ~ J.<ireo:. :"'lC w !JeD ;.nmJ.! ;011 :.rc.n::t! ill,' d ::J~l'" ~IIO<.l:--- t c .e. in rr we h ".1' asthma coniihues ~~sand may end ~atal. eJ.:hJ.:h:rusbon, da , can ",.' . ass be a estoo. by the mei.~min enaline il:jocti ~hich I first used ab'O'm-!'enyea.r ago. The oet>dle is 'cpt in position with a full . e, and after an initial 'ection of a dose which is own to cause :1 no unplc injected el"ery symptoms. one or ore mllWll8 are - 30, or 60 secon ,according to the :~ patient's reaction, the rate b' ,ariad until it is ,.; found how frequen the' ection can be made 1 mthout tachv.cardia 0 oth symptom arising. The : injections are continned,' necessary, for even half :if 3D hour or more; relie hl ys follows and generally man.ifeats itself by e patl t falling into a. deep 5leep, which may ~ days. . the first haa had for several .Anaphyl . can also be most ciently treated ::. ~.t by this me Od of injecting adren more e~ ti\"'6 than ocea.&ional injectio which of is fa.r larger :; doses. f adrenaline' is alwan at han when a patie is '"van serum or other treatmen which 0- ~j mel"ercpa~u\s"e,~afna.atpalh. ylactic reaction, the latter ould . -'_ . A PRULL~nM;wONOAF ROYNE AHSUBNDERSETDOCSAISSES '",."'; ~ s . . . . .J }] Br W. BnTON WOOD, M.D. Camb., D.P H M.R.C.P. Lond.. ':] . :"-1.,' ClC)lO'SCU"NLeTInX.G: PHPHTRTBSoICIsCLpLLrL..u....L.l.",O.TlOnl TctO:r"otl;ITEaRuPC.At1.lTL'AIOll.SNRl'SKI'8'T. O.c.uT:rrm roYt lO!:Sl"8lLtXOCNODtOTNh'T!' S. R OODHOUSE GLO~E. ='U-.1.1. 'Leed D P H f'A.TB:OLOGlST TO TIm ROBPlT.4L .. .. ~ D'Oltn'G the time reported 1a.>t thE> few years we have from time to result of our observations of the '.~ meets of the in.hal.ation of asbestos dust as seen in :: patients attending a chest hospital or revealed at '"; autopsy. Our studies commenced in the year 1928, : ..: and a preliminary paper dealing principally with radiographic appearances was published by one of 11S in the following year. In 1930 we reported our findings in a series of 37 asbestos workers who had been examined at Victoria Park. As we now have '. Ud the opportunity of studying 100 cases, the time leems opportune for a brief survey of the whole cronp. ANALYSIS OF CASES Our cases may be divided into fOUI chief groups. L-l'CLMONAnY.LSBESTOSIS Fiity,three cases (19 males, 34 females); 12 deaths (t males, 8 females), including 2 with carcinoma of the hmg and 1 with a few deposits of growth in the pleura. l.o the cases still alive and under.o~ervation disgnosis /f'sts upon (a) typical appearances of the radiogram, !b) symptoms and pbysical eigns of fibrosis, and (e) preEence of asbesrosis bodies in the sputum. These three diagnostic ?oints are arranged in order of merit. Twentyfour caees Ig males, 15 fe::nales) were positive on ail three counts; 1(aU females) had positive radiograms and clinical symp. toms and signs, but no sputum WBJ! available-or if "a.ilable nO asbestosis bodies were found; 9 (5 males, 'females) gs\'e positive clinical figna and asbestosis :.:.dies were present in the sputum, but radiogTaID.B were '~Itahseren;ot1a('tm'aaillaeb) lheaodrafaoiolesdititvoe srhaodwiogdreafminiatendevaisdbeenscreosoisf ":ldies in the tputum but no clinical signa or symptoms. t-P~O~J..RYA.SBI:STOSlS wrnt .&.C'I'lVE TC'1ll':llCULOSI8 lTwenty-one ClL<e3 (" males, 17 (emales); of theEe 11 male!, 8 females) were fatlli. One had a tuberculous '::lPyema, one a pyopneumothorax and lardaceous dueBfe, the others pulmonary tuberculosis. Ten I male. u9 b(eesmtoaslei3s) baordeiesstiilnl athlieves.putAulml .have tubercle bacilli aDd IlL-P=~ON.Ul.Y ASBESTOS]'> wrnt OBSOIZSCI:1."T TUlIEBCULOSIS ~1ne cases (4 males, 5 females). This group emphasists the fact tb.a.t obsolescent tuberculosis is not ne.::essariil" reacth'ated by asbestosis. Three caaea have been taU! (1 male, 2 females); of thoStJ still under Obee1T!ltiOD 2 (females) have radiograms exhibiting typical asbestosis IUld the shpeuatluemd ;apaicnadl 4tucbaesrecsul(o3sims,alwesi,th1 afesbmeaslteo)sihsavbeodaisehsein.. tosia bodies present in the sputum and radiogr8.Ill.llshoWlDI!; uobstooleasscbeensttotsuibse. rculosis but indeterminat'3 or negativt. IV.-DOUBTYUL CASES Seventeen eases (6 males, 11 females) under observa tion. All but one have suggestive symptoms and aigna but the radiograms are indeterminate, and with two exceptions the sputum, where availa.ble, cont&in.a no asbesroais bodies. Of these exceptions one hu indefinite symptOmB, gram. but assibgensstoosfisebmopdhieysseamrea, parensdenat;net~haetiovetherradbiaoa. no physical signs or symptoms and a negative radiogram. but has asbestosis bodies in the sputum. . TKE CI..INICAL PIC'l'URE The picture of pneumonoconiosis pouclcmurornina~ry inasbae. sftoascitsoriys th3.t of a in which few precautions had been taken to protect the workers from a danger. Happily theae the gra\"'ity conditions of which are now was not realised.. a. thing of the past and elaborate precautions have been taken to protect the workers. There is thus good reaaon to belie\"'e that the disease is now under control. though ui tn ds eeermtshepo r o bl da b lceo ntdhiattI' Own so rwk ei rl ls ceOxpDot.mseude to the dn.st to present themselves for examina.tion for some time to come. There is no need to amplify the descriptions of pulmonary asbeotosla already given elsewhere. The symptoms .are indeed those common to all forma of pulmoxury fibrosis uncomplicated by bronchial d.ila- tation or pulmonary excavation-btubborn cough with little expectoration, discomfort or dull pain in the chest, occasionally perhaps a streak of blood in the phlegm, and dyspncea. It is this last symptom of which the patient complains. The distress occa.- Bioned by constant breathlessness is &0 great that the disease might almost be descnoed as mono symptomatic. It is the patient's first and last com plaint. In the earlier stages dyspncea is only apparent during exertion-" I found I could not hUITy to work in the morning! "-in the later stages the act of undIe6sing or enn the effort may cause the patient to pant required for for breath. speech \\"ben asbestosis is complicated by tuberculosis, broncho- pneumonia. or other thoracic disease, the symptoms of these be a~ded, but the dy6pncea ot'pneumo. nOCODlOSLS can still as a rule be reco~nised. .llal. nutrition is very endent in the tenD.m:u month! when t be patient may pass into a condition of extreme cacheri:l. DUG~OSrs Wben a. new diEe3.66 is under cons.idpr3.tion the salient featlu('s are first ohRervl'd, :lud di.lznosl& depends on the reco~llltion uf ;:;ro"8 ~yn:ptoms. Thus phthisis was formrrly only Ju.?nUbl'J when symptoms and E;i~ns of ad.anced di~al;e "rre t'\'Ident. \Ve now d.iat;nob6 incipIent phthililll WIt h conridence at a stJ.ge when the patirnt is be.althy In appeara.nce, well nourished, and little troubled ~y ~ym?tom~. In the dug-no6is of a6bestofiis we ha.'6 still to depend upon the symptoms and Eil;ns of more or le&& n08S dise.aBe. 'IVe hal"e no means dunn~ life the cristence of adequate the fuler to diAco,er dCb'rees of ,; '" . ,. _. '., 1334 nIl: u.:Ncrr] DRS. W. B. WOOD ,L'\"I) S. R. GLOY!\E: PUu!O~ARY pronelmntos,n:aun-ydfiibtroissisnwothiscuhrmpruissitnpgretcheadte tlhITea~pear.dtheo~elolgoips.t ASBESTOSIS (DEC. 22. 193{ Tduhsist idsidcenrtoatinalyv.aoilfteton ctrhueec,k btuhte wseprehaadveonf odwii.ease&een. soroetimes discovers post.mortem not recognised during lile. evidence of fibrosis In diagnosUr at the present patients whose condition appears to Iuve stationary since stopping work in the fac remaine.:l. sotnaratinhgistpooriynt.of e::rposure to taismbeestwoes hdau.s.et taos roeulyr e.en ~th serious damage many years of to the lungs is not tory. ~t incompatibla patient may The snpply a symptoms descnoed by the clue, for the malingerer does lB prond by such tolerably comfortable .erisrence an example as that of a patiel:1 not 3S ability. a rule emphasise In the physical dyspncea. as examination his chief dis- wl?-o at a was still able to carry out administrative fae.tory when nearly 40 years' exposure dIrt;1ll appea.r:tnce should reeeive advanced cases the special the patient's attention. In dust had caused apical regions of a fibrosis involving the lungs. all to except the the lciopms plexion and a s1ig.h. teavritohleyt" ticnhgaeraicntecrheoefksthoer wa hfoemaaflteerpatient. at the requeWsteorfeDcern. tlCy. eMxcaSmhianned~. Sllggeasrteivenboutetwnoervtheyr .conTchluesivpehyesviicdaelncsei.gnsThseuypply lDent as a a. period of two and a half years' spinner had retired to get married. emnlo,". TWeniT tphuolmseoonfaray bscaasrarlinfgibriossiisn,diacnadtetdhe fine nature of tahree years later symptoms, &L,oous. and X supplied convincing proof of pulmon ray pictUl'~ onfotemdipshsiymseilmar to those often hebayrdfinoevedrrythcerabcaksleess wa emreodreeraadteilydegdreeme oof severity, and aasrbyeoatsvbseisstobsoidsielo>f aprreodoutcteend mbiyngatlhteoednswmliouthvnegtmsh.eenfMtisborooretficsa.urpidleaermsf.icaigael dcrpalcekuleras despite some disabilintsytrtahteedpaitnientth, ewhscpzuetupmer.iodBuotf sheerrvseiclfe daisdfaniortlyenctoitmleiohretarbtloe,coamndpesnhseatiwoans, dsetislclnaoM ffiineTeldhstey; prteahdeaiofsfcgearcartrpiinhngigctihspeaicsltoiutwreeristwtho-atthiordf sa.offibthroesilsunogf toobvpieorufsortmhaht earnhyoupsae.htioelndt dwuhtioesb.e It is none the lebslse may be drawn to a. were etched in. Attention difficulty constantly encountered iwshreenquairdeedl.ineTahtieondiofatph~embaatsialcposhrtaidoonws ocfetnhseorlsunthges fibrosis or in whom any trays gymptOID4 of evidence of nbrosis is d.i&- tcioovne.resdh.owuhldethaet r obnycpehycesaicsael owrorrakdiinogloiii1ncaal ney:ra.dmUinS3ty- bases of the lungs, and in a radiogram the ordinary anteroposterior technique taken with occupation. A quiet and avoidance of the life. risk preferably not onlv of in the co=try, dust in two inches of the lung may extent of this .. silent" area be as much aa blotted onto The gbuuatrdosf acgaatianrsrthaaln iangfgecrativoant,iopnrondes the behaat lastaioi&n- wthheicnhorwmilall Inng by a. lipiodolcainnjebcetidonem, tohnestrreastueldt oinf moSneaprtyic tubbreorncchitis, broncho-ponfeuinmcoipmiean. t dainsedasep..ul. surprise those 6upra.-diaphragmatic area accustomed as the lnng to regard the baae. .Again. ulosis are the complications of the diseaae. commonest tertIllnal a la.teral view thickened or of if the the lung, if middle the interlobar lobe is opaq septum. i& COliM:E~T3 result of. for example, an shows that the lower m ue aa the epituberculous exudate, the lower portion of argin of the middle--i.e., of the right upper-lobe corre facOtocrcsupisatniocnt .p-Aosnsiebllaebionrattheisansahloyrstisaortficolcec. upational 67 women in our series had dtlIlt in the same factory been exposed to All the asbest", sopf onthdse adpiparpoh:rriamgamte. ly.Awtitha. threecsehnatdomweeotfinthge ocfuptohlae. tmhaetftorellsoswing departments:. spTihnenyingw,e2r4e ;ewmepalvoiynegd, 5in; Rontgen a more Society Dr. L. A. Rowden pointed e:rt.ended new of the lung out that miscellanemouaskionrg,un9s;tactaerdd,in1g8. anTdwoepnetyn.itnwgo, 1o1f ;thaenmd poabttiaeinnet din bthye tdhoersasilmpple expedient ofbapsleascicnagn thbee began their employment before the age is now no longer permitted under Hom of 18, which over tbe brow. veri osition and centring the tube We have tried this method and tions. cases) The shortest e:rposure and the long-eat was e til:: Office r~~ months (two fied its efficacy. boTdihees ienxathcet sdpiaugtunomstiics dsoigunbItDfucla.nceAsQfpoianstbeedstoosuist The 33 men came 15 years. under several categories. Abont ftwacototrhyirdass thofe wthoemmenwaenrde heamdplpoeyrefdormined tah. evarsaierrt:~ .by one of us (S. R. body is evidence G.) of the formation of tissue change. an asbestosis assume, however, that .the ~ectoratioWn eofcaa=feowt asbestosis bodies implies that pulmonary fibrosis has of jobs. The others included an was himself the owner of a. small elderly man } "hI) aged 18, whose spare time during factorv, :\ ~an bo"l', two and a hill y~' employment already occurred. Ii we could the problems of diagnosis and make claim this assumption asbestos in an had been open yard, spent in miI:ing powdereJ a middle-aged boiler rinter tion would be simple. will sometimes s for ~evertheless the compensa. microscope who had sen-ed his shop where asbestos apprenticeship as was used for hgg a youth in a . sections where reveal commencing fibrosis in lung antemortem radiograms failed to ma. amttraenbS1e>sboin hthade been employed hanid:Jli.n; !p; ipaessb.es:t:.onod reveal eridence of disease. present available do not The clinical enable us methods at the men fhe open air a.t an aerodrome. Arno::; shortest exposure was 11 ::Jonths (d:" incipient disease. The evidence of erposure asbestosis to body determine is simply reaction thereto. to asbestos dust and of tissue 'This tissue reaction mav be inte~rat illr; department 1. and the 40 ,('..:irs (clerical and ad ministrati,e lonc:e.o.t work). about the' g-roup of 18. b('g-an their employment under Four ui the s..;e accompanied by follow that this fibrosis, but it does not is sufficiently ertensive nece&sariJ, to Patholoqy.-In ab ad,lition to tLe autoDsies [Clentione.i symptoms or clinical signs or radiogram--or we might add abnormal prod uc'e shadows in a byoo.en.e 1o0t pUoBst.(mS.ornte.m(~f.'lramofU1C::llStieolllS hJ.:\l/aldLtn't'ont m,we to justify compensation. durinr; life (3 rn:d('6. 7 ! WI' fern:ut's), Lut these 8ceJI :n8 ~o' PROGNOSIS As the disease has only been included fibrosis is in our 100 best 6t:en ill calit'S. ~racroscoplc:illy the lower !obrJl. ~:ld :::e masaya. rcelqinuiicrael meondtiitfy our present riedceeanstloy'n repcroobgDniosseids pleura. is ren- common. not been en~ount('red. but 6uicotic :ldhenlll nuduJe.a !.Aye stated that the ication. ces&3tion In a. previous article we of e~osure. to asbe.st08 begins in the reSPIrator;" Histolor;icaU"I' bronchioles' the :lod dise~ aheo~ ducts. and is char~cteri~d by a celJul.u re.actioIl 01 ::::ono: follow Tut deilin 10 cru ::lonar noW r 10<0 (2 . ~V'er me centag t!t.e mostly to seek tioD at ot the oentar W!llLtev in Uhf 6ilico&is Illbject Comp monary cciosiB, to the a of spont and app m3.V ha.~ bullz.. We a.r for "Oem:: For a its beari:. exbusti 1. Gloyne. ~_ Wood.' l. ~el'ew~' a.nd l! 3y A. .l.SS:::sTL,-r OF ~cr:: SC1'! ~~:\"Y apar. fro u.U::";;. :ill L as we.il J.S I':Ot.:D t'!::t a:JJ0~!:!lenS hDJ:O,On: ho~we,"I'er. clisp:3.y 3. :: ~ NPlas: ulOU3 -dise ~a?e!". ><"2 ~O:::l abdc 1...::np0nmt as..soc:.:>ted L'11::ni,e C prO':XlrtioOE ::nl';';t'.ldin~ ;:'rt'ci.lt"ertict. ll.,.. :'la.~d co -\.\jr'\i~:::"1 .' r ~!'"d. !:J;, ,"j-. ':. ~ 'J E r..u:err) ~. A. L. n'.unu:u : 6URGICAL ASPECTS OF nn: 6P.!.5TIC COWX [DEC, !::!. 193-1 1035 -...4... -1.lM. ., ;f..oIDllOonwu~cd1eb:!y.I"thpehfaogromcayttieosn and of a asbesto&is gunt cells reticular fibrosis.1 ~ Tuberculosis and A,bestosu.-In a. pre~'"ious article J 3*'""" iling with tuberculosis and asbestosis we reeorded .,' cases of utive tuberculosis in 57 cases of pul. _ jllOW 0 ~:= ~vna.ry asbestosis (17'5 per cent.). The figures have reached 21 cases of uti'Ve tuberculosis out of ~:ie& 100 (21 per cent.). It must be borne in mind. how., frer, that these figures do not indicate the per. the tentage of cases of asbestosis with tuberculosis in ~tehde the industry. We have been dealing with a group, 4\lDostlY from one futory, who were sufficiently ill ..ne. ;OJ. 10 seek adl"ice I rion at length. ~aetrhewoestphitearl ~ In discussing this quea. consideI'!!, after a review J "~ ot.J.. colenthtaerywhtoolebeinddougstmrya,ticthaatt tthhee dmaotma eanrte, tbouot ftrhaagt- ,dis But l j ll' ill hatev asbes er" tosi th s. e i t add is ed les r s i sk tha o n f tube that rculos assoc i i s a t m ed a y w be ith ,i or ~oed ',i clicosis." We hope to publish our material on this ;1 IUbject at a later date. 1 J.ble ComplicatiMu.-Apart from pneumonia. and pul- Iell . S or .-, monary sepsis and '~clllosis, there have complications arising been none definitely from tuberattn'butable diJ. ~ 10 the asbestosis with the exception of two instancea '1 :i:la. of spontaneous pneumothorax diagnosed by X ray, : :: lrt trr' ; .I ~i Uld cay appar have ently been unasso due to eia.t the ed ru w pt ith ure tu o b f erculosis. which emphysematous .tlOD ballre. <.:U~. We are indebted to our colleagues at"Victoria Park ,-e. :JtU ;. ~ for permission to quote certain cases For a full account of pulmonary Been by them. asbestosis in all :baJ ~~ uuhbaeuastrii\n'"ges pthapeerre.1ader' is referred to Dr. Merewether's ~ lU:Fl:lU:NCl':S ~ ;ODU :r- _., '0"' ',; l Gloyne. S. Roodhouse: Tnbercle.1933. :tiv US. 493, And 550. Wl~o""o,d,...W~th.erB, .,EAonRd .GJAo.y.:ne.T8u.bRe.rc:lTe,ltE1L93L3-.3"{=,. 2 931. xv., li., 69, 95{. 109, a.nei 152. r diolocical interest, an attempt .ru.l be made to ablish spasm as an important :etiological f:l.ctor in the formation of di,erticula in the colon. 1ne disq ieti.n.g: thought that surgery, apart from de.ili.og with omplications such as' obstruction, perforation, absces .formation. and fistulous communications, only en; a dangerous operation for the cure of colon di erticulitis, makes predivert war state of in,estiQ-ation tremendous of the earlier importance .Advancea in the knowledg-e of the :etiology m~ enable eff til'e medical treatment to be employ If spasm b an important factor. the administrat' n bofe obfelglaredaot v uien assusappercot pph:yeldaictt"iecnmiceualsaurres. tat~ SPASTIC COLO~ is a wellrecognised entitl" Dr. t drew attention to it in hi book g of tbe Colon" 1; a teudeJi hard, contracted colon ay be palpated in patientt.hom I lu!.'Ve grouped int three classes. (a) The commo est Hardy I as b~ the sufferer is describe emotionally unstahle by Dr. type of indi'\idual whose c on is unstable a.lr,o."/ Often the patient is a nervoUs female. thin :l1l.d. unilappy. perennially dJSPept.i~ailing and constip.ite<i. throuzh whose thin abdomen the ruin!; aort:t and a hard tender colon ean be p ,pated with e:u>e/ Ra.diolo~cal and toni e biochem stomach ical ;nth en.lnination pYlo~spaam a discQ'Ver an active nd bffperch!orhyd..ri3. I ha'\e no endence. nor 0 r think. tjiat these patlentG fprreoqcueeendtlytmo et dwii.ethrtiincutlh~ur.fgoirCma oiuotn.patiTehnetyrooamre; it is no place for them an they epay surgery WIth groans and :More than a. constantly in rea ' one has under. one g list of symptoms. pyloroplasty. many appendicectom'<', without t e least relief of theU' dyspepsia. ,J .,-. '!:('m ::Ucb .... :u1s. :;J (t,..o .. bout >'1m~ riel,. 'oj ., who l)o~. .C.:1l'1i . rmi ,rll'r In ~ GrCAL ASPECTS ON AND THE PREDIVERTICULAR STATE = S=GICJ.L m.-rr. 'rIlE ~H XA.TIO_' SCHOOL THE ROYAL IXTIRX&.R1'. CA.RDIYF, un: Rl;GIS~. GEXI:lU.L no AL. BIP.l!I!' G fUl<{ It is important to remem r th.i3 cla.ss of patient hen innstigating easel' 0 pylorospasm. Cannon and Murphy S ha\e pro u ed pylorospasm by traumatising inteiitinea nd have declared Ita occurrence in the...--e eirc cea to be due to a viscero.visceral reflex. c y, suitable general treatment combined th th administration of medicine containing cl.la.donn. tbe tincture of hyoscyamus, the perc oride of' n and of mercury, often leads to great' provement. (0) Occasionally sp stie colon oc UTS in the young athletic man who ers from co stipation; pain may be a pro ' nt feature an may lead to operation for sup sed acute abdo 'al conditions. No abnormality is seen other th n generalised enterospasm. :ln,l '. ~to"" ~l(1n;: IJ,.. l'(fu! cf ,.! .l:r .n,,! .:.. ,J .. ~ :~ r. .. ~ t!.~ r. ~~ !,' ~.J:- 'r '\.. lased on .. ~hort p"p~r read before the Assad" on of ." I\. 000. of Great ' - - r ~td. 1~3'. l:lritalll a.nd , Ireland at BinnlnCOBJh . on (e) Far dillere t is the last group re resented by the rather fat ddle-aged man. muscular"\.-lnd athletic \in in his '\ouns:er da.s. sane and sangUlDe outlook. but wo'ITied-b an' alteration in h.i3 bowel~abit and becaU6e his mple meals. formerly enj . ed with relish. cause digetion and discomfort.; ! equentlv def:ecation un6.1tisfactorv and irre!:;ula Sm::u.l internal b:r orrhoids often d~'Velop and the de~enal!.:;; colon is t~!)der and hard. Rectal enminJ.\ion 1& more paidM than usual. but once the s!,~\::;ctpr has been passed I he ftC! urn itseU is uormJ..l, \ \~.' e will con, .der later that the import~cnt ratbulo;Xlcal chancre i lhe-'>8 cases Les in the lUu,de l.,y('r :l:Jll ~ot in tbe urous membrane; mucus .lod c:oo,l .ae therefo e not :tln-ars rre~f'nt, Tbe ttst,r:Jc..:U ;' \ f:u- all the CJses ,&0 ill\e>licated) !'bows h!p~rcl.do, r bydna. utline ill tbe r:tdHJJo:lt'al pIcture ot t :16 barium enema. as in the clinical pIcture. i3 11lcitCli.IHI ,~ ) ['1 I I J J' ,I I ,1 :i ,,I ' , I -, j "" . ~ ~ l \ ! i .' ~ ~:y: " ,: .1 .. ~j I I ' I ! ! Ii !I ! II: 1" :I!' :~