THE RIBOFLAVIN AND NITROGEN METABOLISM OF SIX WOMEN
WITH ACTIVE TUBERCULOSIS
By
Wilma D. Brewer
A THESIS
Submitted to the School of Graduate Studies of Michigan State
College of Agriculture and Applied Science in partial
fulfillment of the requirements for the degree
of
DOCTOR OF PHILOSOPHY
Department of Foods and Nutrition
Year
1949
ProQuest Number: 10008267
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TABLE OF COMMENTS
Page
INTRODUCTION....................................................... 1
REVIEW OF LITERATURE............................................... 5
Riboflavin metabolism of w o m e n * ......... • • • • • • • • • •
5
Nitrogen and riboflavin interrelationships* • • • • * • • • • 1 2
Protein requirements of women...............• • • • • • • • • 1 5
Nutrition in tuberculosis • • * • • • • • • • • • • • • • • • 2 0
EXPERIMENTAL PROCEDURE............................................ 27
Subjects* • • • • • • • • • • • • •
Experimental plan • • • • • • • •
............
............
Collection and treatment of samples
• • • • • • 2 7
• • • • • • • 2 7
..........
.28
Nitrogen losses through sputum discharge. • • • • • • • • • • 5 1
Estimation of the urinary excretion of a test dose of
vitamins. • • • • • • • • • • • • • • • • • • ..............
51
Chemical methods* • • • • • • • • • • • • • • • • • • • • • • 5 2
RESULTS AND DISCUSSION............................................ 34
Description of subjects • • • • • • • • • • • • • • • • • • • 3 4
Nitrogen metabolism of tuberculous women. • • • • • • • • • • 4 1
Estimated nitrogen requirement of tuberculous w o m e n ..........52
Riboflavin metabolism of tuberculous women. * • • • • . . . • 5 2
Interrelationship of nitrogen ahd riboflavin metabolism • • . 63
Estimated riboflavin requirement of tuberculous women • • . • 68
Nutritive value of sanatorium diet.
......................69
SOMMAHT AND CONCLUSIONS.......................................... 71
ACKNOWLEDGMENTS.................................................. 73
REFERENCES CITED
74
Page
A P P E N D I X ....................................................
Patient Summaries* . . . . . . .
..........
81
. . . . . . . . .
81
T A B L E S ................................................. ..
1. The average urinary nitrogen excretion of 18 women with
active tuberculosis; values grouped according to calculated
nitrogenintakes...........................
4
2. The urinary excretion of women at different riboflavin
intakes....................................................
8
3. Description ofsubjects •
35
4. The erythrocyte count and hemoglobin of the blood of six
women with active tuberculosis.
37
5. Creatinine excretions of six women with active tuberculosis
on different intakes of nitrogen and riboflavin............ 38
6. Urinary ascorbic acid excretion of six women with active
. . . . . . . .
tuberculosis. • ........ •
40
7. The average retentions of nitrogen by six women with active
tuberculosis.
............................................. 42
8.
Menstrual losses of nitrogen by six women with active
tuberculosis • ........ • • • • • • • • • • ..........
•
9. Application of analysis of variance to nitrogen
retention data. • • • • • • ................ . . . . . . .
44
45
10. The average intakes and excretions of riboflavin by six
women with active tuberculosis............
53
11. Comparison of two procedures for calculation of percent
urinary excretion of test dose of riboflavin.............
62
12* Daily intakes and excretions of riboflavin by five college
women on a controlled diet with restricted nitrogen intake.
64
13. Analysis of covariance of nitrogen retention and urinary
excretions of riboflavin; values for six tuberculous
women
....................................
65
14. Analysis of covariance of nitrogen retentions and urinary
excretion of riboflavin following a test dose; values for
six tuberculous women
. . . . . . . . . . . . .
66
15. The average nutritive value of diets of six women with
active tuberculosis..................
70
i. Variations in temperatures of six women with active
tuberculosis........................... . .................
ii. Record of streptomycin administration . . .
90
••
91
iii. Records of sputum tests for six tuberculous women • • • • •
92
iv. The intake and retention of nitrogen by six women with
active tuberculosis; individual data.
93
v. The intake and retention of nitrogen by six women with
active tuberculosis; individual data; periods one and two •
95
vi. The intake and retention of nitrogen by six women with
active tuberculosis; individual data; periods three and
four.
............
96
vii. The intake and excretion of riboflavin by six women with
active tuberculosis; individual data; preliminary period. •
97
viii. The intake and excretion of riboflavin by six women with
active tuberculosis; individual data; periods one and two .
98
ix. The intake and excretion of riboflavin by six women with
active tuberculosis; individual data; periods three and
four. . . . .
.•.99
FIGURES...........................................................
1. The urinary excretion following a test dose of riboflavin
by patients with active tuberculosis and by college women •
3
2. Regression of nitrogen balance upon intake expressed as
gm • per kilogram of body w e i g h t ..........
47
3. Regression of nitrogen balance upon intake expressed as
gm. per square meter of body surface..................
48
4. Distribution of nitrogen retention data by McKay (1942)
for tuberculous women about regression line predicted
..............
from values for healthy women
50
5. Regression of urinary riboflavin excretion upon riboflavin
intake expressed as mg. per kilogram of body weight . . . .
55
6. Regression of urinary riboflavin excretion upon riboflavin
intake expressed as mg. per 1000 calories • • • • • • • . .
56
7. Regression of values for riboflavin intake and urinary
excretion of riboflavin by tuberculous women about regression
lines predicted by Brewer (1946) from values for healthy
women. • • • • • ...........................
...58
THE RIBOFLAVIN AND NITROGEN METABOLISM OF SIX WOMEN
WITH ACTIVE TUBERCULOSIS
Good nutrition has been considered an important aid in the
treatment of tuberculosis.
Since there have been few studies of
the quantitative requirements of the disease, emphasis has been
directed toward the qualitative aspects of nutrition.
Consequently
there have been wide differences in the dietary practices of
sanatoria (Sedgwick, 1946) and in the recommended allowances for
tuberculous patients (Pottenger, 1946; Baird, 1945).
The Foods and Nutrition department at Michigan State College
was asked in 1945 for recommendations for food subsidies for
persons with arrested tuberculosis.
Since there was inadequate
information concerning nutritive requirements in tuberculosis, a
survey of food habits was conducted among women with active and
arrested tuberculosis at the Ingham county sanatorium.
The survey
techniques used were similar to those which had been used in
previous investigations with apparently healthy women so that data
for women free from the disease were available for comparison with
data for the tuberculous series.
Results of the dietary survey
have been reported (Brewer, 1949).
One phase of the survey consisted of measurements of the
riboflavin, thiamine and ascorbic acid content of the urine of
patients for three days preceding and one day following a test dose
which contained three mg. riboflavin, three mg. thiamine and 400 mg.
-2 -
ascorbic acid.
Tests were carried out among patients who previously
had received vitamins in addition to their usual diet and also among
those who had had no dietary supplements.
A histogram which gives
the percentage excretion of a test dose of three mg. of riboflavin
by the tuberculous women and by college women under similar test
conditions is shown inBigure 1.
These data indicated that the ribo
flavin excretion of tuberculous women following a test dose of the
vitamin exceeded that for healthy women on their usual, self-selected
diet.
The test dose excretions also were higher than those for
college women receiving controlled intakes of 2.73 mg. riboflavin.
These values suggested the possibility of disturbed riboflavin
metabolism in tuberculosis and it was felt that there was need for
further study of the riboflavin nutrition of tuberculous patients
under controlled conditions.
The excretion of urinary nitrogen also was studied for the patients
sampled during the survey; these values have been grouped according to
calculated nitrogen intakes in Table 1.
If a relatively constant value
for fecal nitrogen is assumed, apparent storage of nitrogen occurred at
the higher nitrogen intakes.
Since dietary protein has been considered
an important factor in the treatment of tuberculosis and since an
interrelationship of nitrogen and riboflavin metabolism has been
reported (Oldham, 1946), it was planned to investigate simultaneously
the nitrogen and riboflavin metabolism of tuberculous women.
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TAELE 1
The average urinary nitrogen excretion of 18 women with active
tuberculosis; values grouped according to calculated nitrogen
intakes
Nitrogen Intake*
Number of
Subjects
Urinary Nitrogen
Gms./24 hours
5.0 -
9.99
Gms./24 hours
5
6.795
(5.234 -
9.853)
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* Nitrogen Intake ^ Protein, gm.
(by calculation)
6.25
REVIEW OF LITERATURE
Riboflavin metabolism of women.
The urinary excretion of riboflavin is directly related to the
dietary intake of the vitamin.
This relationship may be seen from
Table 2 which gives the mean urinary excretions of riboflavin
reported by various investigators for women at different riboflavin
intakes*
From studies of riboflavin intake and excretion, recommenda
tions have been made for human riboflavin requirements.
Earliest of
these studies was the investigation of Sebrell (1941) of the ribo
flavin metabolism of 10 women on a basal diet containing 0.5 mg.
riboflavin per 2400 calories.
Symptoms of ariboflavinosis which
responded to riboflavin therapy were observed for six of the 10
subjects after 89 to 232 days on the basal diet.
The average urinary
excretion on this diet was 77 micrograms and it was found that the
excretions increased in a step-like manner when supplements of ribo
flavin were added to the basal diet.
Whereas an intake of 0.05 mg.
of riboflavin per kilogram exceeded the requirement of the adult
women, an intake of 0.025 mg. per kilogram was insufficient.
Sebrell
evaluated the requirement for adult women at three mg. per day.
Studies reported by Strong (1941) supported this recommendation.
Williams (1943) found no evidence of clinical deficiencies at
intakes of 0.7 mg. per day although depletion of tissue stores of
riboflavin occurred.
The subjects of this study had received large
amounts of riboflavin prior to the investigation.
Williams estimated
the riboflavin requirement of women to be 0.5 mg. per 1000 calories
6-
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The average retentions of nitrogen by six women with active
tuberculosis
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The differences in nitrogen intakes for periods one and two were
not statistically significant (,t* test, Fisher, 1938); neither
were the differences between the nitrogen intakes of periods three
and four significant.
The menstrual losses of nitrogen by the subjects were not
calculated with the total output but are summarized in Table 8.
The
average daily losses ranged from 0.015 to 0.065 gm. nitrogen.
The nitrogen retention data expressed as gm. per 24 hours were
treated by analysis of variance.
in Table 9.
A summary of the analysis is given
Of the total 23 degrees of freedom which were available,
there were three degrees of freedom for differences between means of
periods, four degrees of freedom for individual differences and 15
degrees for the interaction (error term) of periods and individuals.
Differences between the means of periods were significant ( 0.05).
The three degrees of freedom for period differences were further divided
with one degree of freedom for a comparison of periods one and three
against periods two and four, and one degree of freedom for a comparison
of periods one and two against periods three and four.
There was not a
significant difference in nitrogen retention when periods one and three
were compared with periods two and four.
This was essentially a com
parison on constant nitrogen intake of nitrogen retention at moderate
riboflavin intakes with nitrogen retentions at high riboflavin intakes.
Since the differences were not significant, it can be assumed that for
these experimental conditions, variations in riboflavin intake did not
influence the retention of nitrogen.
Therefore the nitrogen metabolism
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TABLE 9
Analysis of variance of nitrogen retention data
Predicted
F
Source of variation
value
obtained
F
0.05
F
0.01
Between means of periods
3.65
3.29
5.42
Comparison of periods
1, 3 vs 2,4
3.00
4.54
8.68
Comparison of periods
1, 2 vs 3, 4
7.92
4.54
8.68
-4 6 -
data may be considered independently of period differences in ribo- ,
flavin intake.
The nitrogen intakes for the various periods also are expressed
in Table 7 as gm. per kg. of body weight and as gm. per square meter
of body surface.
Nitrogen retentions expressed as gm. per 24 hours
have been plotted against nitrogen intake expressed as gm. per kg. of
body weight in the scatter diagram shown in Figure 2.
A regression
line was drawn for these points from the predicting equation calculated
according to the equation, Y= a^bx.
The intercept of the line at
equilibrium occurred at an intake of 0.11 gm. per kg. of body weight.
The average body weight of the subjects was 57.5 kg.; therefore the
average requirement for equilibrium by these subjects would be 39.5
gm. of protein daily.
For a 56 kg. woman, this corresponds to an
intake of 38.5 gm. of protein.
The surface area for each individual was calculated according to
the formula of DuBois (1924):
Log surface area ^ (Log weight Ckg.] x 0 . 4 2 5 ) (Log height [cmi]
x 0.725)+ 1.8564
This equation was developed from a limited number of experimental
observations and therefore its validity can be readily criticized.
However it does express a weight-height relationship and it has been
"
widely used as an expression of total surface area.
In Figure 3, the nitrogen retentions expressed as gm. per 24 hours
have been plotted against nitrogen intakes expressed as gm. per square
meter.
An intake of 4.16 gm. per square meter would be predicted from
these data for nitrogen equilibrium.
Since the average body surface
area for the six patients was 1.62 square meters, this would be equiva-
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excretion of a three mg. test dose was 31 percent with a range of
27 to 38; for a dietary intake of 2.73 mg., the percent excretion of
four women was 56 with a range of 51 to 60.
Thus values for tuber
culous subjects in periods one and three were similar to those for
healthy women who had been receiving slightly higher riboflavin
intakes.
The values given in Table 10 for percent urinary excretion of
riboflavin following a three mg. test dose were calculated according
to the equation:
% test dose = Excretion after test dose (24 hr.)
(Riboflavin in dietH-3 mg.)
X
-r
100
This represents the relationship of the excretion of riboflavin in
the urine following the test dose to the total riboflavin intake for
the day.
This procedure for calculating the test dose response was
used for riboflavin studies with college women in this laboratory.
Therefore the two series were comparable.
Another procedure for
calculation of percent excretion of the test dose is based upon the
increment in urinary excretion which occurs following a test dose
of riboflavin and is calculated according to the equation:
fo test dose = Excretion after test dose (24 hr.) - basal
excretion (Avg. for 24 hr.) ■— 3 mg.
X
100
This method of calculation has been used in this laboratory for
survey studies which did not include food collections and analyses.
This method of calculation also has been used by Melnick (1945) in
-6 1 -
vitamin bioassay procedures.
In Melnick’s study, a basal diet was
fed previous to administration of the test dose so that basal urinary
excretions were constant preceding the test dose.
In the present
study, the variations of basal urinary excretion of riboflavin were
greater among subjects in periods of high riboflavin intake than for
periods of moderate riboflavin intake.
A comparison of values calculated by the two methods is given in
Table 11.
In each case the standard error is higher when the calcu
lation is based upon the increment in excretion than when the calcu
lation is based upon the total day’s intake of riboflavin.
variations were obtained for periods three and four.
The widest
The magnitude
of the values calculated by the two methods is of the same degree and
the two methods apparently would yield similar information.
The fecal excretion of riboflavin was relatively constant for
five of the six subjects within each period.
observed for subject EftT.
Wide variations were
The average fecal excretions were higher for
periods of increased milk intake than at restricted milk intakes.
For
periods one and two, the average fecal excretion was 0.68 mg. and for
periods three and four, the average excretion was 0.85 mg. per 24 hours.
These data do not indicate the source of the extra fecal riboflavin for
periods three and four.
The hypothesis that greater intestinal synthesis
occurred during the periods of increased milk intake seems acceptable in
view of various reports in the literature.
Moreover the increase in
excretion for the last two periods apparently was unrelated to riboflavin
intake since the riboflavin supplements were given during periods two and
four.
Since the fecal riboflavin values were related to the character of
-6 2 -
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the diet and since urinary riboflavin values were directly related to
the dietary intake of riboflavin, it would seem that absorption of
synthesized riboflavin did not occur in measurable amounts under
conditions of the study.
The range of fecal values for these subjects was similar to the
range of values obtained for six college women on a diet containing
1.06 mg. riboflavin daily (Table 12)*
These women were subjects of
nitrogen metabolism research in progress concurrently with this study;
the riboflavin metabolism was studied for one five-day balance period
to obtain fecal excretion values for comparison with the tuberculous
subjects.
The range of fecal excretions for the six women was 0.45
to 1.20 mg. per 24 hours.
The women were given an adequate diet of
mixed foods which supplied approximately 40 gm. of protein daily.
The
test dose responses for the women were much lower than for the tuber
culous patients; however the dietary intake also was lower than the
intakes studied for tuberculous women.
Interrelationship of nitrogen and riboflavin metabolism
Metabolic studies with college women reported by Oldham and coworkers
(1947)
indicated an inverse relationship of nitrogen balance and ribo
flavin excretion.
The data presented here were examined to determine
whether this relationship also could be demonstrated in tuberculosis.
Analysis of covariance was used to determine the correlation coeffic
ients for nitrogen retention and riboflavin excretion.
A summary of the
covariance analysis for nitrogen retention with daily riboflavin
excretions is given in Table 13 and the covariance analyses for nitrogen
retention with test dose responses is given in Table 14.
In either case
-6 4 -
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By calculation.
The average nutritive
value of diets of six women with
active
tuberculosis
02
SOMMAKT AND CONCLUSIONS
The riboflavin and nitrogen metabolism of six women with
moderately advanced, active pulmonary tuberculosis was studied.
The subjects were non-ambulatory patients of the Ingham county
sanatorium and the regular hospital diet was served throughout the
experiment.
Ages of the patients ranged from 25 to 39 years.
The
riboflavin and nitrogen contents of the diets were varied by adjust
ment of the milk intake.
The milk intake for periods one and two
was restricted to 300 gm. daily; for periods three and four, the
intake was increased to 1200 gm. milk per day.
Daily supplements of
five mg* riboflavin were given during periods two and four.
Fourteen
days of dietary adjustment preceded each seven day balance period
during which intakes and excretions of riboflavin were determined.
The average nitrogen intake of the subjects on the usual hospital
routine was 10.1 gm. per day.
When the milk intake was restricted to
300 gm. daily, the nitrogen intake averaged 8.90 gm.; the average
nitrogen retention was 1.15 gm. during period one and 0.57 gm. during
period two.
The nitrogen intake for periods three and four were 13.00
and 13.62 gm. respectively.
The mean retentions at these intakes were
1.95 gm. nitrogen for period three and 1.48 gm. nitrogen for period
four.
The relationship between nitrogen intake and retention for the
tuberculous women was similar to that reported for healthy, active
college women.
The urinary excretion of riboflavin was directly related to the
-7 2 -
dietary intake.
The riboflavin intakes for the four successive
experimental periods were 1.35, 6.41, 2.60 and 7.79 mg. daily; the
urinary excretion of riboflavin at the corresponding intakes were
0.31, 3.53, 1.08 and 5*62 mg.
The percent test dose responses for
the four periods were 39, 65, 55 and 72, respectively.
The fecal excretion of riboflavin was related to the amount of
milk in the diet rather than to the dietary intake of riboflavin.
The average excretion for periods one and two was 0.68 mg. and 0.85 mg.
for periods three and four.
The riboflavin metabolism of the tuberculous patients also was
similar to that of healthy college women.
The riboflavin content of the diet did not influence the
nitrogen retention but there was a significant inverse relationship
between the urinary excretion of riboflavin and nitrogen retention.
It is estimated that a diet adequate in calorie value and
supplying 80 gm. protein and 2.6 mg. riboflavin would meet the require
ments of these patients for these nutrients.
ACKNOWLEDGMENTS
The author wishes to express her appreciation to Dr.
Margaret A. Ohlson for her guidance, advice and encouragement
throughout this study; to Dr. C. J. Stringer who made available
the facilities of the Ingham county sanatorium for this research;
to the tuberculous patients who followed the experimental routine
carefully and conscientiously; to Mrs. Vivian Trapp and Miss
Olive Henderson of the staff of the Ingham county sanatorium for
cooperation and assistance; and to Dr. Dena Cederquist for the
opportunity to analyze the metabolic collections from the study
of the nitrogen metabolism of college women.
Further acknowledgment is made to Mrs. Helen Tobey, Mrs.
Betty Coles, Mrs. Dorothy Dunsing, Miss Violet Katainen, Miss
Patricia Wyatt and Miss Janet Traver of the Foods and Nutrition
staff; to Mr. Elbert Churchill of the department of Bacteriology;
and to Dr. Leo Katz of the Mathematics department.
The author also wishes to acknowledge with gratitude the
financial assistance provided by the graduate scholarship from the
Michigan State College Institute of Nutrition from 1946 to 1948.
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-7 9 -
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-8 1 -
APPENDIX
Patient histories.
Subject 3tJi
Patient*s discharge summary.
Date of Admission:
6-3-46
Date of Discharge:
7-13-48
The patient was admitted to Ingham Sanatorium as a refer from Genesee
County.
She had been x-rayed in May of 1946 because of an attack of
pleurisy and at the time of admission she complained of fatigue of one
month’s duration with right chest pain.
X-ray examination revealed that in the right lung there were infil
trations beneath the 2nd anterior rib and extending to within the circle
of the 1st rib.
In the left lung, there were infiltrations scattered
throughout the 2nd anterior intercostal space.
She was classified as
active moderately advanced pulmonary tuberculosis, II-B.
The sputum was
positive for tubercle bacilli by culture and guinea pig inoculation and
continued to be consistently positive until November 1947.
Since that
time it has been negative.
A right pneumothorax was established 11-11-46 followed by a right
closed pneumonolysis on 12-10-46 when one cord and one band-like adhesion
suspending the apex were cut.
Following the initiation of the pneumothorax
the sputum continued to be positive.
again on 9-20-47.
She was bronchoscoped on 5-6-47 and
A normal bronchial tree was found both times except for
some reddening of the right stem bronchus and mucoid discharge coming from
the right upper lobe.
Because of the persistently positive sputum, strepto
mycin, one gram per day, was begun in January, 1948, and continued for 120
days.
Sputum examination six weeks following the initiation of strepto
mycin ther apy was negative and has been consistently negative since that time.
-8 2 -
Subject H.
Patient’s discharge summary#
Date of Admission:
2-12-47
Date of Discharge:
1-21-49
This 24 year old housewife and ex-servicewoman was re-admitted to the
sanatorium because of the persistence of positive sputum*
She had pre
viously been treated at this hospital, between the dates of 6-18-46 and
8-4-46, by bed rest and the initiation of a right pneumothorax*
At the
time of her return after five months absence, x-ray examination revealed
that there had been some increase in the infiltrations in the right, upper
lobe.
She was classified as active moderately advanced pulmonary tuber
culosis, II-B.
The pneumothorax which had been initiated at the time of
the first admission had completely re-expanded.
The pneumothorax was
reinitiated but it was now noted that there were several adhesions
suspending the apex of the lung which required a closed intrapleural
pneumonolysis done on 3-6-47.
Since that time she has been maintained on bed rest and there has
been a gradual continued clearing of the infiltrations in the right upper
lobe so that at the present time there is very little density remaining.
The last examined specimen was a gastric which was negative for tubercle
bacilli by culture and guinea pig inoculation.
Discharge weight, 129 pounds.
over her first admission weight.
This represents a gain of 15 pounds
During her stay she received strepto
mycin, one gram per day for 125 days, beginning 1-7-48.
-8 3 -
Subject G.
Patient’s discharge summary.
Date of Admission:
12-9-46
Date of Discharge:
11-3-48
This patient was readmitted to the sanatorium because of finding of
positive sputum and marked deterioration in her general physical
condition.
There was no definite x-ray change.
She had previously been
treated at Ingham Sanatorium between the dates of 4-21-44 and 3-19-46.
Following her return to the sanatorium she was placed on bed rest.
She immediately began to gain weight.
improved.
Her general condition rapidly
The sputum became negative on concentrate but remained
positive on culture and guinea pig inoculation.
Following streptomycin
therapy the sputum became negative by all methods of investigation and
has remained so.
There has been no change in the x-ray appearance of
this patient’s chest.
She has gained approximately 25 pounds in weight.
-8 4 -
Subject B#
Patient’s discharge summary#
Date of Admission:
9-19-46
Date of Discharge:
5-18-49
This 33 year old housewife was admitted to the sanatorium as a refer
from the Ingham County Health Department#
An original diagnosis of
pulmonary tuberculosis was made in Morgan Heights Sanatorium in Marquette
May, 1933#
Originally the disease occupied the left upper pulmonary lobe
and was minimal in extent.
She entered Pinecrest Sanatorium, Powers,
Michigan for treatment in May 1938 where she was on bed rest for six
months.
She was then treated by left pneumothorax until January 1943
when a pneumothorax was also started on the right side.
There had been
very little follow up of this case since her discharge from Powers
sanatorium in 1943.
The sputum was found to be positive in June 1946#
On admission here, she complained of only a small amount of
expectoration and ease of fatigue.
X-ray examination revealed, in the
right lung, scattered areas of infiltration extending from the level of
the 3rd anterior rib to the apex with a rather well circumscribed area
of infiltration at the level of the 4th anterior rib in the middle lung
field.
On the left, there was considerable retraction of the mediastinal
structures to the left and there was a thickened pleura over the outer
field.
II-B.
She was classified as moderately advanced pulmonary tuberculosis,
The sputum was positive by culture and guinea pig inoculation of
the seven-day pooled sputum material#
Over nearly a two year period of bed rest, there was no appreciable
change in the x-ray appearance.
Bronchographic examination revealed a
normal bronchial tree except for lack of filling of the middle lobe which
-8 5 -
was obstructed*
Decortication of the left lung was carried out on
7-6-48 and after a period of two months, right middle lobectomy was
done.
At the time of operation a tuberculoma approximately three cm.
in diameter surrounding the middle lobe bronchus was found.
a direct, small communication to the middle lobe bronchus.
There was
Beginning
at this time the patient received streptomycin one gram per day for a
period of four months.
Since the lobectomy the patient has been
negative repeatedly by all methods of investigation.
Discharge weight was 137 pounds.
pounds over admission weight.
This represents a gain of 17
-8 6 -
Subject F.
Patient’s interval summary*
This 35 year old white woman was seen as a referral case on
H —29—45 at which time a single 4 x 5
inch projection showed infiltra
tions in the right 2nd anterior intercostal space and scattered throughout
the left lung*
She was admitted to the sanatorium January 2, 1946, and
her sputum was found to be routinely positive for tubercle bacilli*
She
gave a history of having had a severe cold the preceding February which
became somewhat better in April and May but a cough persisted and shortly
thereafter she began to notice fatigue.
Physical examination revealed a
normal developed, poorly nourished, white woman appearing chronically ill.
She weighed 123 pounds and her height was 63 inches.
showed:
X-ray examination
right lung, scattered infiltrations at the level of the 1st, 2nd
and 3rd anterior intercostal spaces;
left lung, dense infiltrations within
the circle of the 1st rib and less dense infiltrations scattered throughout
most of the entire lung.
The diagnosis and classification was moderately
advanced, bilateral pulmonary tuberculosis, II-B.
The patient was placed on strict bed rest and because of the wheezing
type of respiration and a history of occasional hoarseness, bronchoscopy
was done at which time the larynx was found to be normal but the mucous
membrane of the trachea was somewhat reddened and edematous.
bronchus appeared normal.
The right
The left bronchus was markedly reddened and
edematous and the lumen was so stricted that the bronchoscope could be
passed only a short distance into the stem bronchus.
7
A laryngoscopy on
-2 - 4 6 showed a fairly marked ulceration of both cords but especially the
posterior third of the right cord.
Because of the fairly extensive
involvement, cauterization of the cords was not indicated and the treatment
prescribed was absolute silence.
-8 7 -
Because of the obliterative pleuritis over the right lung the
pneumothorax was abandoned 11-17-47.
Beginning May 16, 1947 the
patient was placed on two grams of streptomycin daily which was con
tinued for 85 days.
Since her admission to the sanatorium there has
been a gradual improvement in the x-ray picture of her disease and the
sputum is now positive to culture and guinea pig inoculation only.
Her
laryngitis is apparently completely healed and the patient’s clinical
appearance has much improved.
She now weighs 135 pounds constituting
a gain of 12 pounds since admission.
Because of the continued positive
sputum she has once again been placed on streptomycin therapy following a
determination of sensitivity to the drug by the organisms.
-8 8 -
Su.bject DW.
Patient’s interval summary.
This 24 year old housewife was first seen as a referral case on
April 22, 1938.
She complained of cough and chest pain for the past six
weeks and an occasional hemoptysis for the past three weeks.
no knowledge of weight loss.
There was
Physical examination at that time disclosed
scattered rales throughout both lung fields.
An x-ray film dated 4-22-38
showed wide spread bilateral pulmonary tuberculosis involving the right
lung down to the anterior rib and throughout the left lung with a large
cavity beneath the 1st rib on the left.
patient was admitted 4—22—38.
Admission was advised and the
Following admission, a complete evaluation
of her case showed far advanced, bilateral cavernous pulmonary tubercu
losis as above described and it was decided that the treatment of choice
was bilateral pneumothorax.
The bilateral pneumothoraces were continued
in the sanatorium through 4-8-39 at which time the patient left against
medical advice.
Her pneumothorax refills were continued in the Outpatient
Department through July 18, 1941, after which time the patient failed to
return to the sanatorium for her usual treatments.
During this period
there had been gradual improvement in the pulmonary tuberculosis.
The patient was not seen again until 10-30-47 at which time she was
admitted to the sanatorium following an interpretation of a film.
Physical
examination at this time showed an undernourished, adult white woman
appearing older than her stated age and chronically ill.
There was a harsh
systolic murmur heard best at the level of the 2nd anterior intercostal
space at the sternal border.
60.
The blood pressure was systolic 88, diastolic
There was a respiratory lag on the right with decreased tactile
fremitus and the right chest was dull to percussion posteriorly.
Decreased
breath sounds were heard over the right chest posteriorly but no rales
-89-
could be heard at this time.
A thoracentesis done 11—10—47 yielded 25 cc. of a very thick
purulent material.
200,000 units of penicillin and saline were instilled
in the pleural cavity at this time.
She was seen at intervals thereafter
for aspiration and sterilization of this empyema cavity on the right.
Laboratory examination at this time showed the sputum to be positive by
culture and guinea pig inoculation.
slide examination.
The gastric samples were positive on
Examination of the pleural fluid did not reveal the
presence of organisms.
The fecal material was positive for tubercle
bacilli on slide examination.
An evaluation of the patient’s status indicated that arrest of her
tuberculosis would best be produced by decortication and re-expansion of
the right lung followed by thoracoplasty over the left upper lobe.
The
former procedure was done 9-28-48 and a satisfactory expansion of the
right lung effected.
done.
On 11-9-48, the first stage left thoracoplasty was
Following this procedure, the patient decided to postpone her
second stage until her condition seemed more suitable.
Inasmuch as a
single stage had failed to close the cavity in the upper lobe of the left
lung and the patient being in suitable condition, a second posterior
stage completing a six rib thoracoplasty was done 2-8-49.
She was placed on streptomycin therapy at the time of the first
operation 9-29-48 and this was continued J gram daily for 78 days through
12-15-48.
stage.
She was again started on streptomycin at the time of the second
There has been a gain of 37 pounds over admission weight and her
sputum has been negative on two occasions by culture and guinea pig
inoculation.
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