Medical query

[Mavvi]

My query is almost off-topic, but is firmly rooted in the Great War, so I will take a chance.

My gt-gt-grandfather took part in the War, but was taken ill in February 1918 on the Western Front. He was taken to a field hospital, then shipped home as no-one knew what was wrong with him. The army discharged him in August 1919, while he was in hospital in London.

I am lucky in the respect that I have a medical paper from the 'British Journal of Dermatology and Syphilis' 1920, which is entirely about an un-named man from the trenches (my gt-gt grandfather) with the odd disease. They state it is 'recurrent ulceration of the skin caused by a diphtheroid bacillus.' Detailling their various attempts at curing him, which invariably seemed to make things worse for him. The paper includes gruesome photos of these ulcers.

He died, somewhat inevitably, in 1921.

My query (finally) is, where can I find out what was wrong with him, (in the modern sense)?, where did he most likely catch it, etc. Was it related to being in the trenches?

I ask here, as this is the most knowledgable place I know. Hopefully I could get pointed in the right direction...

Rob

[Robert Dunlop]

An interesting challenge, Rob. Basically, you should think of your gt-gt-grandfather as potentially having two separate things: skin ulcers; and infection. The former may not have been caused by the latter. Any break in the skin will become infected. He may have had a third problem, a disease that caused the ulcers. If the skin ulcers were caused by some condition such as vasculitis (an inflammatory condition of the blood vessels), then no amount of treatment to rid the infection will make a difference. Indeed, the underlying problem would get worse as a result of the vasculitis, not the treatments for the infection. Secondary infection of ulcers can cause additional tissue reactions.

Having said all this, the bug may have been the primary culprit. To make it even more complex, there may have been another bug/s lurking under the cover of the one that was seen, which the doctors could not detect with the technologies available at that time.

Do you have an electronic copy of the paper? If yes, please feel free to message me. Happy to decipher it and bring some more recent advances in medicine to bear on the problem.

Robert

[Mavvi]

Thanks for the quick, and useful, reply Robert. I thought this was a long shot, but if anywhere would come through, GWF would!

PM sent!

[Doc2]

Thanks for the quick, and useful, reply Robert. I thought this was a long shot, but if anywhere would come through, GWF would!

PM sent!

Also would be happy to review the article, if you would like to send it along via PM. Without seeing it, I generally agree with Robert's comments. Doc2

[Mavvi]

Pm sent.

I have it as seven files on the computer (total weight 5.51mb) - not sure how to send via PM, Would email be a better option?

Cheers,

Rob

[Robert Dunlop]

Thanks Rob. It is very clear from the description that your gt-gt-grandfather did have an extremely unusual form of infection that caused the ulcers. The diptheroid bacillus (so-called because it looks like the bug that causes diptheria) was found in great numbers at the edge of the ulcers, where they were also seen inside white cells trying to get rid of them. Some of the ulcers did become infected with other bacteria, but this is not surprising.

The diptheroid bugs have been renamed. They are now known as coryneform bacteria, which includes such exotic names as Actinomyces, Arcanobacterium, Corynebacterium, Oerskovia, and Rhodococcus. These bugs do not normally cause disease. Normally, there will be some immune problem that allows the infection to develop. I cannot be sure which of these bugs was the cause of the problem in your gt-gt-grandfather's case. There is one that has been associated with leg ulcers, known as Arcanobacterium pyogenes (formerly Corynebacterium pyogenes). It causes mastitis in cows in the UK.

I hope this information is helpful.

Robert

[Mavvi]

Very helpful information, thank you Robert. So, it is possible he suffered from some undetected immune disease which allowed the bacteria to get a hold on him through a cut on his wrist/hand?

Having looked again at his death certificate again just now, it does state the cause of death in 1921 as 1. Recurrent ulceration of the skin, etc etc. 2. Acute (or possible Uante?) Tuberculosis.

I have assumed this came on after the 1920 paper about him, when he was weakened by the former? His immune system certainly was taking a battering, whether he had an immune problem or not.

Thank you again for giving a modern perspective on this!

Rob

[MelPack]

Rob

I am intrigued to know how you managed to confirm that your greatgrandfather was the anonymous subject of the medical article.

regards

Mel

[Robert Dunlop]

Rob, the plot thickens. The reference to tuberculosis is likely to be very important, presuming that the diagnosis was correct. If TB was present ('acute' would fit, I don't recognise 'uante'), then this points to an immune deficiency. This is a secondary effect of TB, though normally with advanced disease which your gt-gt-grandfather did not have when he was admitted to Guy's. It could be that the 'TB' was, in fact, spread of the same organism causing the skin ulcers, with seeding to the lungs and possible cavitation/abscess formation. In which case, the immune problem is likely to have been very selective, as if his immune system had a blind spot for the coryneform bacterium. The immune system is very complex, and parts of it did get activated when the skin ulcers occurred, as evidenced by the reaction at the edge of the infection and the white cells ingesting the bacteria. These reactions were all after the event though - somehow the bacterium was able to get a hold, on several occasions. There MIGHT be a direct link between the immune defect/problem for the skin infections and the TB, presuming it was TB - ie the same problem predisposed to both. Your point is not unreasonable as well, that the TB occurred because the multiple skin infections ran the immune system down.

Lots of 'ifs', but I just wonder whether the 'TB' might have been spread of the diptheroid bacillus. It depends on whether they managed to make a positive ID on the TB bacillus, or whether the diagnosis was made on x-ray and/or clinically.

Robert

[Robert Dunlop]

Rob, here is an abstract of a paper that describes something similar:

http://www.ncbi.nlm.nih.gov/sites/entrez?D..._RVAbstractPlus

The difference is that your gt-gt-grandfather's immune system allowed such leg (and other) ulcers to expand much much more.

Robert

[Mavvi]

Mel,

I believe it is him in the Medical Paper for several reasons :

The paper mentions he was a Sergeant and Cook in the army on the Western Front. Which my grandfather was.

The paper concerns a 49 year old man. My grandfather's age at the time.

The paper states was treated at Guy's Hospital in Southwark - which is the local hospital to my grandfather and where he was treated.

The paper concerns 'recurrent ulceration of the skin caused by a diphtheroid bacillus' (1920) - my grandfather's death certificate states the exact same wording as the cause (1921). It's a rare description of a disease.

The paper was in the family already; I didn't have to buy it, etc. Possibly he was given a copy himself as the subject? The original we have is very old, so could be contemporary to the 1920 article.

I feel the chances of it being someone else are rather slim. Of course it could be another man, in which case ... the medical paper would have mentioned 'we had two patients with the odd disease that we are having trouble getting our heads round.' But it doesn't.

Rob

[MelPack]

Thanks Rob. I wasn't doubting the connection. I was simply curious about how you managed to establish it.

The affliction sounds horrendous. I now know that I must approach Robert's posts with some caution before I read them.

Regards

Mel

[Robert Dunlop]

Hehe

Robert

(who has always wanted an excuse to use the above icon)

[Mavvi]

Mel,

I can fully understand questioning how we know it is him. I did the same when I first saw the document. But having read it and got more details on my gt-gt grandfather, it all fits into place.

Rob

Ps .... The description of the affliction is horrendous. The pictures are quite awful! I'm glad they're not in colour.

[Mavvi]

Robert,

It is certainly getting more intriguing. The poor fellow didn't stand much of a chance in the 1920s with such an array of problems. It is odd how his body reacted to the bacteria; letting it get so far while seemingly doing nothing, but eventually fighting it off.

An interesting side note to this is, despite having this terrible illness, he was well enough to father a child, born just six months before his death. Interesting as it gives a clue that this disease wasn't a constant drain - at least not that night!

As a non-medical type, if a patient saw his GP today with this type of illness, what would be the procedure? Leaving aside an immune problem, I'm guessing antibiotics would sort out the infections?

Rob

[Robert Dunlop]

Rob, I have to say that I was expecting the pictures to look much worse! Most of what you see in the photos is the granulation tissue, which is the normal process for regrowing the skin.

The skin infections were very localized. As the paper mentioned, there were no signs that the bug got into the blood stream or caused general problems. This is why your gt-gt grandfather remained as well as he did for as long as he did. It was almost as if the immune problem was localized to the skin.

Today, antiobiotics would probably be attempted when one of the lesions first appeared. Quite likely the treatment would fail, given that these bacteria are often more resistant to standard antibiotics and also because there was some other problem (?immune system related) that enabled the infection to start. So the patient would re-present with a rapidly growing lesion. This is really unusual, and the GP would almost certainly refer to the dermatologist. If the GP took a swab of the lesion, which is not often done, then the lab would have phoned up or sent a report saying they had found this really unusual bug. That might trigger a referral - the rapid spread of the ulcer definitely would! It is just so VERY different from the routine skin infections that GPs deal with.

Once in the hands of a specialist, things would move forward quickly. Biopsy and swabs would be routine, as Guy's performed. The difference is that the lab would give a definitive answer on the type of bug and its sensitivities. Every dermatologist and medical student would be invited to see, which would mean that lots of people were thinking about the problem. Specialists in immune function would be called in. Yep, things are very different these days.

Robert

[Mavvi]

So even today a patient with these symptoms would be a challenge?

Do you believe with todays technology he could have been cured? A daft question, as we don't know exactly what he had. Perhaps it is better to say; would we be able to get a precise diagnosis today from the patient?

I have read up a little on the British Association of Dermatology, and how dermatology had rather a low standing in the UK in the early part of the century. The Association only had its first meeting in 1921 - one which H W Barber spoke at - maybe even mentioning this case?

In 1919 HW Barber was the first dermatologist to be appointed to the staff at Guy's. I was interested in finding out about dermatology in the 1920s (not a sentence that gets said much).

In some ways I am glad that a course of antibiotics would have failed. I always looked at this thinking the poor man was in pain for the want of some modern pills, but it is far more complex than that, - which is better in a sense.

As an interim review then:

It's uncertain how he would have got this bacteria? Family stories say he believed he got it cutting up horse meat (whilst in the army in France), but he wasn't a Dr.

For some reason his immune system was blind to it, allowing these infected lesions, which his body would eventually heal. Generally he was in good health, but the ulcers would cause problems, fevers etc, at their worst.

This goes on for three years.

He contracts TB, either because of the immune problem, or because the infection and dragged him down. He dies.

I feel I understand his case a lot better than before, despite the remaining mysteries!

Rob

[Robert Dunlop]

Rob, I doubt that the condition would be curable today. It is highly likely that the infections would have been better controlled with some antibiotics, although increasing drug resistance and the possibility of secondary infection with MRSA or some other resistant bug would likely cause different complications. The underlying cause, presuming an immune system problem, would probably not be found today.

It is still possible that the TB was unrelated - it was a common disease at that time.

Dermatology remains a Cinderella service, by and large.

Robert

[Doc2]

Rob, I generally concur with Robert's assessment, though I suspect that we would have been able to treat it today with various antibiotics (and perhaps some hyperbaric oxygen therapy). However, the issue of an immune deficiency allowing the infection to go so long is a difficult one-- I would be very surprised to see an immune deficiency in the 1920s which allowed him to live so long with the recurrent ulcers. If the basic cause of the immune deficiency didn't rapidly kill him, I suspect that the bacteria would have. Rob is correct that these diphtheroid bacilli have been renamed, and also that they generally do not cause any continuing problems. However, they may have been secondary infections to whatever caused the first ulcer, and may not have been causative. One possibility which has not been mentioned is that the photos make me wonder about Anthrax. As a meat-cutter, he certainly would have been a prime candidate to get that, and the initial lesions on his hand could have been cutaneous anthrax, which then could have become secondarily infected with the diphtheroids and other bacteria. We will never know, but thanks for bringing up such an interesting case. Doc2

[Mavvi]

Thanks for your analysis Doc2. Sorry for the late reply, - first time back here for a while!

It is very interesting that Anthrax comes up as a possibility. But, as you say, we will never know for certain.

Finally, a big thank you to both Robert Dunlop and Doc2 for reading through the details and giving me an insight into what he may, or may not, have had. I really appreciate it.

Rob