Faulty Diagnosis Research Articles

MILK SAMPLING METHODS FOR A PROGESTERONE ASSAY FOR EARLY PREGNANCY DIAGNOSIS

Samples of foremilk, composite milk and strippings were obtained from 13 cows for progesterone analysis to determine the effectiveness of the different sampling methods to detect open and pregnant cows. The milk samples were taken during the afternoon milking of the day of breeding (day 0), day 14, day 24 and after day 35 (from pregnant animals). Progesterone concentrations, determined by radioimmunoassay, were 1.4 ±.4, 2.1 ±.8 and 2.8 ± 1.1 at day 0; 7.9 ± 5.0, 19.1 ± 9.1 and 30.1 ± 6.2 at day 14; 8.6 ± 6.5, 21.7 ± 7.4 and 29.4 ± 7.3 at day 24; 7.2 ± 2.8, 21.8 ± 4.8 and 33.5 ± 1.4 at day 35+ for foremilk, composite and strippings samples, respectively. It was determined by discriminate analysis that all three methods would correctly place samples obtained on day 0 into the correct group. Only in the case of strippings samples did there appear to be no danger of classifying pregnant animals in the day 0 (estrus) group. It is suggested that milk strippings represent the preferred sample to take for milk progesterone diagnosis of pregancy or non-pregnancy due to ease of sampling and to a reduced chance of making a faulty diagnosis.

A Socio-Medical Investigation of Deaf People in NorwayA Preliminary Report on Deaf Adults and Pupils at the Vocational School for the Deaf in Bergen

On examination of 252 deaf adults, we found nearly half of them to have hearing that might have rendered audiological treatment possible. Because of faulty diagnosis and treatment, many hard-of-hearing people today function as deaf. Diagnosis and availability of treatment are still inadequate. From 1961 to 1971 we examined 90 pupils in a vocational school for the deaf. They were from 16 to 20 years of age and came from different schools for the deaf throughout the country. 38 per cent had a pure tone loss less than 80 dB in average for the frequencies 500, 1000, and 2000 Hz. A good linguistic environment, apart from audiopedagogical treatment, seems to be the most favourable requirement for the development of good speech. Early diagnosis and treatment are the most important ways of avoiding the merely hard-of-hearing from behaving as if they were deaf. The audiopedagogical treatment should start at the age of 1 year at the latest. Our attempts at audiopedagogical treatment of young and adult deaf subjects were far from encouraging. Even at the age of 16, it was difficult to get these patients to accept a hearing aid if they had not previously received adequate audiological treatment.

IV. Differences in the distribution of return intervals between herds

Abstract Records from some dairy herds, whose owners used the A. B. service provided by the Auckland Livestock Improvement Association in 1973, were used to show how factors influencing a herd's conception rate alter the distribution of return intervals to first insemination. An above average conception rate may be recorded, in spite of an abnormal distribution of return intervals, if the herd owner fails to record many of the returns to service after using A. B. for only 4 weeks or less. The incorrect submission of a cow for insemination will result either through the misinterpretation of behavioural symptoms associated with oestrus (faulty diagnosis), or because an oestrous cow is incorrectly identified and another non-oestrous animal is presented (animal identification). The distinction between these two types of errors is important in considering recommendations to improve conception rates. The conception rate distribution for 4342 herds with 10 or more first inseminations showed that 14.9% of the herds had results of 55% or less compared to the Association herd average of 66.7%. Binomial variation accounted for 34.2% of the total between-herd variation. The widespread adoption of improved methods of oestrus diagnosis, such as vasectomised bulls fitted with the chin-ball mating harness or pressure-activated devices, should produce the greatest increases in the Association's average conception rate.

Radiologic changes in the formation of frontal sinus--mico-pyocele.

AbstractThe history, the gradual evolution of soft tissue changes as revealed by roentgenography and the gross and microscopic changes in the lining muco‐periosteums of two frontal sinuses which had been resected surgically, are presented.On the basis of these reports and that of past experience, the following generalizations in respect to these two cases seem valid:1. Radiographic mucosal changes in a frontal sinus may exist months or years without subjective symptoms.2. Obstruction of the fronto‐nasal opening with a subsequent gradually progressive increase in volume and pressure of the fluid contents of the sac or sinus, may eventually result in pressure absorption of the bony walls of the sinus.3. A mucocele does not cause sudden or acute symptoms, such as pain or fever, but objective signs such as a soft swelling above the eyebrow or the dislocation of the globe in the orbit, may appear and slowly increase.4. When in the presence of acute infection of the upper respiratory tract acute subjective or objective frontal sinus symptoms and signs become evident without previously recalled sinus disease or trauma and where prior radiographic study of the area has not been made, one cannot be certain that slowly developing changes of the sinal muco‐periosteum have not been present for a long time, and such pre‐existing disease might not have led to confused interpretation of the radiologic pictures, to misinterpretation of symptoms and signs and to a faulty diagnosis.5. The variation in the mucosal histological findings and sac or contents noted at the time of surgery will be those related to the nature of the causative or related organism, the degree of activity, the development time factor or duration of the condition, the effect of pressure on soft tissue surrounded by bone, and the circumstances precipitating the need for surgical treatment.6. Regardless of the origin, the muco‐pyocele of many years' duration under constant slowly expanding pressure may eventually result in sterile contents and loss of the original identity of the mucosal structure, making an exact disease classification difficult or impractical.7. The new although admittedly imaginative hypothesis that a previously undescribed type of disease of the frontal sinus of unknown etiology, may be present, is presented.8. This type of disease of the frontal sinus may be present more frequently than is reported, because of a “low‐index of suspicion” on the part of the rhinologist, because of the absence of signs and symptoms in the absence of infection and the lack of a history of (frequently hypothetical) trauma or infections in the past, such as are usually mentioned in the anamnesis of symptom producing unilateral frontal sinus disease.

The Epidemiology of Amoebiasis

Publisher Summary The didactic meaning of amoebiasis implies a host inhabited by an amoeba, whether it be Entamoeba histolytica, E . coli, E . gingivalis, Iodamoeba biitschlii, Endolimax nana, or any other, including those species of Hartmanella which have been shown to invade man. Current practice has confined the term to hosts harbouring E . histolytica. but some authors have further restricted the meaning to those with disease. As the information sought is some concept of the distribution of the parasite and its effects, a way must be found around this. No parasite is more often wrongly labeled than has E. hisrolyrica , and too few organisms has such a wide gamut of clinical presentations been attributed. The confusion surrounding the epidemiology of amoebiasis has arisen in part from a failure to appreciate the nuances in the host-parasite relationship, and in part from faulty diagnosis, not only of the parasite, but also of the host's reaction to infection. It has been shown that available data-either parasitological or clinicalgive but little information on the distribution of amoebiasis. The most reliable is that based on the occurrence of amoebic liver abscess, though this too is clouded by differing outlooks on the condition. In general, amoebiasis is no exception to the rule that uncritical adherence to the dicta of the great is apt to mislead. In malaria the story of the direct entry of the sporozoite into a red blood cell retarded progress for many years, and the false concept took a lot of destroying.

Calcification of the stylohyoid ligament

Calcification of the stylohyoid ligament is a very common phenomenon. The development, function, and course of the styloid process and stylohyoid ligament are discussed. References are cited from the literature regarding calcification and aberrant course of the ligament, leading to faulty diagnosis and treatment of suspected conditions. Radiographic views of four different patients are presented to illustrate their value in the discovery and definitive localization of the calcified ligament.

REMARKABLE RESPONSE TO BENZHEXOL HYDRO-CHLORIDE (ARTANE) IN CHILDREN WITH AN UNUSUAL PROGRESSIVE STRIATAL SYNDROME: A REPORT ON 3 CASES.

SUMMARYThree patients are described with progressive neurological disease producing defects of mainly extrapyramidal type. All had extensor plantar responses. None have so far shown evidence of epilepsy or dementia.In two patients the discovery of neurological disorder in infancy led to the faulty diagnosis of congenital cerebral palsy—a diagnosis later abandoned when the course of the disease was seen to be progressive. In one patient the disorder was familial, the onset of symptoms being delayed until the fifth year, at which age a sibling (a fourth patient, not described) developed a similar progressive disability. All three patients described (and the fourth not described) responded dramatically to benzhexol medication.These patients are considered worth recording for the following reasons: Two of the patients illustrate that progressive degenerative disease of the brain may begin so early in life that the responsible lesion is likely to be confused with the static lesion underlying congenital cerebral palsy. All three patients illustrate the value of benzhexol medication, which is occasionally very effective in progressive extrapyramidal syndromes of choreo‐athetoid type, as well as in torsion spasm, even when these disorders are familial with onset long after infancy has been passed. A plea is made that benzhexol be given a trial not only in progressive extrapyramidal disorders producing parkinsonism but also in progressive choreo‐athetosis and torsion spasm.

Isolated Traumatic Dislocation of the Distal End of the Ulna or Distal Radio-Ulnar Joint

Three of our five cases and approximately one-half the cases reported were misdiagnosed at the time of original injury. Increased awareness of this lesion and alertness to the relationship of the radius and ulna on lateral roentgenograms of the wrist would probably reduce the incidence of faulty diagnosis markedly.We believe that early closed reduction and adequate immobilization should result in excellent function in most cases. Delay in diagnosis will probably result in protracted disability and the necessity for surgical correction.

The Establishment of Occlusion: Using the Patient’s Mouth in Occlusal Rehabilitation

Physiologic movements should not be reduced to the field of mathematics or engineering principles. Failures in occlusal rehabilitation do not result from the use of, or the failure to use, any particular instrument, or the registration of the hinge axis or any other recording. Our failures generally are caused by our faulty diagnosis, by encroachment upon free-way space, or by trying to fit every patient into what we term “ideal” occlusion.

Paranoid Reaction During the Phase of Recovery from Subarachnoid Haemorrhage

Brain and Strauss (1945) emphasize that a patient recovering from the immediate effects of rupture of a congenital intracranial aneurysm may show “some reduction of mental function, varying from impairment of memory and inability to concentrate to more serious disturbances.” They add, “The importance of these residual symptoms lies in the possibility that they may lead to faulty diagnosis if the patient is first seen some time after the leakage which produced them.” In view of the significance of this eventuality, the following case is of relevant interest. I saw the patient for the first time when the paranoid features were already the most prominent clinical manifestations of the case.

PAROXYSMAL TACHYCARDIA IN AN INFANT WITH WOLFF-PARKINSON-WHITE SYNDROME

SINCE 1925¹paroxysmal tachycardia in infants has been reported infrequently and sporadically. In 1941 Hubbard²published the classic study of paroxysmal tachycardia in infants and emphasized the distinct clinical syndrome produced by this disorder. He further emphasized that failure to determine the heart rate accurately may result in a faulty diagnosis of pneumonia or of congenital idiopathic hypertrophy of the heart, and that the underlying disorder of heart rhythm and rate may go unrecognized and untreated. The infant in this case was at first believed to have pneumonia. The importance of the rapid heart rate went unrecognized, as the clinical syndrome was not suspected in so young a child. For this reason, it was deemed wise to report this case and to reemphasize a distinct clinical disorder observed in young infants, which usually responds promptly to proper therapy. Until 1946, no cases of the Wolff-Parkinson-White syndrome had been

Japan as a Political Organism

THE NAZI PARTY'S direct responsibility for German policy in all its evil manifestations has made quite clear where the enemy lies on the political front in Germany. A root-and-branch destruction of this party becomes an inevitable directive for the United Nations. Undoubtedly such a directive still remains oversimplified. Unless special additional measures are taken, the ultimate threat posed by the German monopolists, the Reichswehr, and the Junkers will not be eliminated. Even so the party has penetrated these groups to such an extent that its thorough destruction would go far to smash the whole system of German authoritarianism and aggression. Contributory to this result has been the rigid inflexibility with which the Nazis have sought to monopolize the German state apparatus and bend every internal opponent to their will. Japan presents no such clear-cut picture either in the content or operation of its political order. One of the commonest observations made with respect to Japan is that it has no Nazi party. The next step, in an effort to pin down political responsibility in Japan, is usually to attribute responsibility to some group, such as the military, or even to one individual. The latter attempt is proved wrong in such short order that it has to be abandoned soon after it is made. Nor is it possible to sustain the choice of any one group as dictator of Japan. The recent change from Tojo's militarist Cabinet to one approaching moderate in its complexion is merely the latest example proving how far Japan is or has been from a military dictatorship. Responsibility for policy and action in Japan is not centered at any one point, but diffused over a number of groups. Mutual accommodations are established in such form and by such methods as to enable each group to play its part in a unified but flexible authoritarian system. The enemy to be dealt with cannot be reduced below the level of the system as a whole without grave danger of an incomplete and therefore faulty diagnosis. Failure to give due recognition to this fact encourages a futile search for the particular devil in Japan's political organization. It may also lead to a neglect of certain imbalances in the economic structure that underlie and strengthen the dictatorship of a narrow ruling coalition which characterizes Japanese politics. Argument for postwar modifications in Japan's political system has turned mainly on single aspects of

The scalenus anticus syndrome: Faulty diagnosis in presence of Horner's syndrome—A modified technic of infiltration

In patients with brachial plexus pain, diagnostic infiltration of the scalenus anticus muscle with procaine must be interpreted very carefully. If, following injection, relief of pain is accompanied by a Horner's syndrome, the entire result should be ignored, and surgical approach should be postponed until a successful muscle infiltration without the sympathetic anesthesia has been obtained. Anesthesia of the cervical sympathetics will stop pain which is not scalenus anticus in origin. Also, it is an effect not duplicated by section of the muscle. In our experience, surgical failures have predominated when these facts have been ignored. We have introduced a hyponeedle technic, in which the scalenus anticus muscle may be successfully injected with little likelihood of producing a Horner's syndrome. Following these modifications of clinical interpretation and technic, our surgical efforts have been rewarded with gratifying results.

The rationale of the surgical technique in carcinoma of the rectum and sigmoid

1. 1. Carcinoma of the lower bowel costs 35,000 deaths a year in the United States of America. 2. 2. The main cause is late or faulty diagnosis. This is unforgivable, since 50 per cent of these tumors are within reach of the examining finger; therefore, a digital examination must be done as a routine. 3. 3. The next greatest cause is improper treatment. 4. 4. The abdomino-perineal operation, popularized by Miles, is unnecessary. 5. 5. Metastatic spread is along the course of the superior haemorrhoidal artery and lateral or retrograde spread occurs only with the establishment of a collateral lymphatic circulation. 6. 6. The perineal stoma is much to be preferred psychologically and functionally. 7. 7. Reference is made to a simplification of the operation of perineal excision of the rectum for carcinoma. 8. 8. The advantages of the use of 10 per cent tannic acid in alcohol in large granulating wounds is explained.

The importance of preliminary films in a routine examination of the abdomen

This brief outline of the preliminary film in reference to various conditions of the abdomen may serve to point out the intrinsic value of this procedure in diagnostic work. The preliminary film procedure is simple, without discomfort to the patient, and is a definite aid in diagnosing abdominal conditions which are not evident clinically. It may also serve as a means of controlling a faulty diagnosis and it can assist in designating the site of acute conditions. Because of this triple function of the preliminary film procedure, it is to be recommended as a routine procedure in all cases of abdominal complaints.

Problems in the Diagnosis of Cancer of the Stomach

In a recent editorial the statement was made that in 10 per cent of cases a diagnosis of cancer of the stomach is made when no cancer exists, or the diagnosis is missed when cancer is actually present, and that this faulty diagnosis is made by the roentgenologist, by the surgeon after the abdomen is opened, and even by the pathologist examining the specimen under the microscope. The purpose of this paper is to study the course of the disease in this group of cases and, if possible, to determine why mistakes are made, and how they can be avoided. The cases reported below should throw some light on this problem. Fifty per cent of all gastric cancers occur in the pyloric end of the stomach, 30 per cent occur in the pars media, and 20 per cent in the cardiac end. It is in this last group that the greatest number of mistakes are made so far as the roentgenologist is concerned. It is an interesting observation that whereas surgery in the cardiac end of the stomach is almost impossible, practically all examples of gastric cancer which are benefited by roentgen therapy occur here. Case I (Mrs. Y.): In this case the roentgenogram showed the filling defect typical of cancer of the cardiac end of the stomach (Fig. 1). A year earlier the patient had an x-ray examination which was negative (Fig. 2) in spite of the fact that symptoms had then been present for one year. Was there a cancer which could not be shown by x-ray at that time or did the cancer develop in the interval? While it is true that about 38 per cent of cases give a history of gastric symptoms for years, nevertheless, a careful study will reveal a change in the nature of these symptoms which marks the onset of malignancy. In Case I, even though the x-ray failed to show malignancy at the earlier examination, this must have existed, since the symptoms were always of the same type, with accompanying signs of anemia, loss of weight, and gross blood in the stomach contents. Probably a variation of x-ray technic to include a rugae examination would be helpful in cases of this kind. Even if this were negative, a laparotomy should be done in the presence of the symptoms observed. Case II (Mrs. P.): Fig. 3 shows another roentgenogram of the cardiac end of the stomach. For two years this patient had slight indigestion, gross blood in the stomach, loss of weight, and anemia. X-ray examinations by different roentgenologists were repeatedly negative, as this figure indicates. Laparotomy revealed cancer of the cardiac portion of the stomach. Case III (Mr. M.): This patient had had symptoms since December 1932. Fig. 4 shows the x-ray film taken several months after the onset of symptoms, which was reported negative. A filling defect is seen near the cardiac end.

THE ETIOLOGY OF VULVOVAGINITIS INFANTUM

In cases of children suffering from vulvovaginitis, the first question is whether or not it is a gonorrheal infection. The clinical picture of this infection is not typical enough to allow a diagnosis to be made without a bacteriologic examination. The diagnosis is almost always made on smears of the pus stained by Gram's method or only with methylene blue. Cultures are not considered necessary. As there are some cocci that resemble the gonococci more or less when different staining methods are used, the way to a faulty diagnosis is open. Clauberg¹pointed out that many cases of vulvovaginitis were falsely considered gonorrheal infections. From seventy children with vulvovaginitis he could not cultivate gonococci. Gradwohl^1acultivated gonococci in only two out of twenty-five cases. As I had found the ascites-Levinthal-agar plates and bloodwater-agar plates excellent mediums for the isolation of gonococci, I tried to find out which part

The Terminal Ileum, Cecum, and Ascending Colon from the Standpoint of the Roentgenologist

THIS discussion is based on findings in 10,000 colon fluoroscopies, studied with the clinicians at Presbyterian Hospital and Rush Medical College. It is my good fortune in x-ray work to be very closely associated with the clinicians. Seldom is a fluoroscopy done without the presence of the patient's attending physician, his interne, and often medical students. In case the physician cannot be present, he communicates with the roentgenologist. We study the fluoroscopy and films together and discuss the pros and cons of the x-ray findings in the light of the patient's clinical condition. This arrangement has been of inestimable value to patient and doctor. Preparation of Patient for Colon Examination The psychologic preparation of the patient should be stressed. A few words of explanation and assurance given to patients, particularly to those who are apprehensive, before they enter the dark room, help a great deal. The patients relax better and are easier to examine. We like to have the bowel emptied by the use of one or two one-quart enemas. Not less than two hours should elapse after the last enema before the fluoroscopy. If the patient has diarrhea, no preparation is needed. Medication which irritates the bowel produces spasm and may lead to a faulty diagnosis. Proctoscopy should not be done less than two hours previous to fluoroscopy, because of the air that enters the bowel and the relaxation of the anal sphincter which occurs. Technic A barium enema, composed of one part of barium sulphate to three parts of water warmed to body temperature, and well stirred, is the usual contrast medium employed in x-ray examination of the colon. The enema can is placed three feet above the patient; the flow is regulated by a bulldog clamp on a soft rubber tube leading to a sterilized hard rubber enema tip, three inches long. The air is expelled from the hose. We tell the patient, “We are going to give an enema which we can watch as it goes in. If it causes pain, tell us, and we will stop it.” We first fluoroscope the chest and abdomen. The enema is then injected slowly, under fluoroscopic control, until the colon is filled, or until the patient complains of pain. If there is pain, we stop the enema or decrease the flow by compression of the tube, and tell the patient to take deep breaths. As the pain subsides, we continue the enema, and so on, until barium passes into the small bowel, which is our signal that the colon is completely filled. If the pain does not subside or barium does not progress, we stop the injection. Except in cases with an obstructive process, the colon can usually be filled by a little persistence and without much difficulty or distress to the patient. As the colon fills, we turn the patient to left and right and palpate the abdomen in order to visualize all parts of the colon, to uncover or straighten out redundant loops, to test the mobility and pliability of the bowel, and to elicit any areas of tenderness.

PERSISTENT POSTERIOR FIBROVASCULAR SHEATH OF THE LENS CAUSED BY FETAL IRITIS

When the fibrovascular sheath which normally surrounds the fetal lens until the seventh month fails to disappear in the central part of its anterior portion, the condition is known as persistent pupillary membrane. When the posterior portion remains, the anomaly is referred to as persistent posterior fibrovascular sheath. The case presented is of interest for two reasons ; (1) faulty diagnosis, the eye having been removed for suspected glioma; (2) the congenital anomalies found are associated with definite inflammatory changes in the adjacent structures. Literature in proof of hereditary influence in the production of such congenital defects as colomboma of the iris, aniridia, cataract, ectopia lentis, etc., is not wanting, but possibly on account of the infrequency of occurrence, no such influence has been attributed to retained fibrovascular sheaths. M. T. MacKlin, in 1927, cited one interesting case in which the father had aniridia and his thirteen children all showed

The early diagnosis of carcinoma of the colon and rectum

(1) Painful peristalsis of the colon or pyloric spasm immediately after food in the presence of growth, may lead to the faulty diagnosis of an upper abdominal lesion. (2) Cancers of the lower colon and rectum are external cancers from the diagnostic point of view. (3) Digital and sigmoidoscopic examinations are too infrequently made. (4) Cancers of the hepatic and splenic flexures are best palpated with the patient in the erect stooping position. (5) Cancer patients develop a certain degree of immunity, but the possibility of more than one independent growth should be considered. (6) Palpable peristalsis is a reliable sign of obstruction in the colon: teasing tenesmus is a constant symptom of rectal growths.