191THE FIXATION ABSCESS.-SULPHÆLMOGLOBINÆMIA.

pupils other things which might be of importance,for instance, to wash. Curiously enough, as ismentioned in the recent annual report of the MedicalResearch Council, the latest plan which Dr. Leonard Hill has devised to achieve his ideal of warm feet anda cool head in a stimulating atmosphere is an imitationof the kangri in the form of an electrically heatedwarmer worn under the clothes and suitably regulated.It sounds very comfortable and perhaps under theartificial conditions of large workshops might beexcused by lTr. Tyndale-Biscoe.

THE FIXATION ABSCESS.

THE fixation abscess has had little vogue in this Icountry as a method of treatment, though on thecontinent it is used with, it is claimed, a considerable Idegree of success. The method is employed in thetreatment of acute bacterial disease and consists inthe subcutaneous inoculation of a small quantity,generally about 1 c.cm., of turpentine which, as iswell known, causes the development of a sterile abscesswhen injected into the tissues. In favourable casesthe classical clinical signs of inflammation are presentat the site of injection within 24 hours, and in fromfour to six days the focus exhibits definite fluctuation.A small incision is now made, the pus is expressed, andthe wound treated with hot fomentations until itdries up. Apart from the fact that a good deal ofpain may accompany the formation of the abscess, thereseems no serious drawback to this method of treat-ment, but, on the other hand, it cannot be said torest upon any well-recognised scientific basis. Fresum-ably it owes its value to the production of a leucocytosis,and it would appear to be particularly efficacious insuch pulmonary complaints as are usually associatedwith an increased number of neutrophile leucocytes inthe circulating blood. But that a leucocytosisinvariably accompanies the formation of the turpen-tine abscess is definitely disproved by Dr. A. T. Toddin an article on the fixation abscess which appeared inTHE LANCET of Jan. 7th. In two of the cases which hequotes full details of the daily blood examination aregiven, but no significant variation in the total leucocytecount can be distinguished following the formation ofthe abscess, though there is a sharp distinct shiftto the left in the Arneth count. It is possible, therefore,that the benefit of the treatment may depend uponsome factor other than the leucocytosis, and this isborne out by the results which have been obtainedin cases of encephalitis lethargica. So far as is knownthe neutrophile leucocyte plays no part in the patho-logy of this disease, but it is claimed that remarkablecures have been obtained in it by the use of the fixationabscess.Another aspect of this question is dealt with by

Dr. T. H. C. Benians in an article entitled Septicaemia :the Selective Deposition of the Colon Typhoid Groupof Bacteria in Fixation Abscesses in the current numberof the British Jouoracal of Experimental Pathology. Ifsterile gum tragacanth be injected into the subcutaneoustissues of an animal it forms a sterile abscess whicheventually becomes absorbed and replaced by fibroustissue. Various organisms can survive and multiplyin this fixation abscess if injected along with the gum.Further, if, at the same time as the gum is injectedinto the subcutaneous tissues, a living emulsion innormal saline of certain organisms be inoculated directlyinto the blood-stream, the organisms can be recoveredfrom the abscess after an interval of some three hours.This result is only obtained with any degree of con-stancy, however, when the organisms used are membersof the coli-typhoid group ; other microbes, suchas staphylococci, streptococci, Pfeiffer’s bacillus, andso forth, do not emigrate to the abscess, which remainssterile. In the experiments recorded in this paperother substances were used in the place of gum toform the abscess, but though they attracted numerousphagocytes, they did not cause the emigration ofbacilli. Dr. Benian suggests that the readiness withwhich fixation abscesses produced by mucoid bodiesattract organisms of the colon typhoid group bears a,

close resemblance to the infection of the mucous meln-branes of the body from the blood-stream which occursin enteric fever. The exact mechanism of the passageof the organisms from the blood-stream to the abscessis at present obscure. It seems certain that they arenot transported by phagocytes, but there is no positiveevidence to show the means by which they leave thecapillaries and are deposited in the tissues.

SULPHÆMOGLOBINÆMIA.

Dr. V. P. Mason and Dr. F. D. Conroy.! of theMedical Clinic of the Johns Hopkins Hospital, main-tain that the designation" enterogenous cyanosis,"introduced by Stokvis in 1902, should be abandonedin favour of the terms " methaemoglobinaemia " and"

sulphæmoglobinæmia," according to the nature ofthe abnormal haemoglobin compound. The writershave collected 12 cases of sulphæmoglobinæmia inwhich the diagnosis was supported by sufficientevidence exclusive of a case observed by themselves.The ages of the patients ranged from 9 to 67. All butthree, however, were over 20 and under 45. All excepttwo were females. In each case the symptoma-tology was very similar. The patients complainedof a variety of symptoms such as nervousness,weakness, palpitation of the heart, headache, andoccasionally periods of nausea, vomiting, and abdo-minal pain before they recognised the blue colourof their nails and lips, or suffered from characteristicattacks. Constipation was observed in the majorityof the patients. The duration of these prodromalsymptoms ranged from a few months to 12 years.The characteristic attacks consisted in a peculiarsensation behind the sternum, accompanied bypalpitation, giddiness, and nervousness, with markedcyanosis and dyspnoea. The attacks varied induration and severity, but usually lasted from twoto eight hours, and were followed by a sudden amelio-ration of the symptoms and a gradual diminution ofthe cyanosis. The diagnosis of sulphæmoglobinæmiais made by spectroscopic examination of the blood,which shows a definite dark band in the red nearthe orange if sulphæmoglobinæmia or methaemoglo-binæmia is present. Methæmoglobinæmia is differen-tiated from sulphæmoglobinæmia by the ammoniumsulphide test. If the band in the red persists aftera few drops of a dilute solution of ammonium sulphidehave been added, it is due to sulphæmoglobin. Ifit disappears it is due to methaemoglobin. Thepathogenesis of sulphaemoglobinsemia is not yetelucidated, but the evidence is in favour of van denBergh’s opinion that sulphides formed in the bowelin some manner gain access to the blood. As regardstreatment, frequent purging has relieved the symptomsin some instances, but in the majority of cases,including that reported by the present writers,permanent relief was not obtained.

URINARY INFECTIONS.

THE treatment of infections of the kidneys andbladder is often difficult. Brilliant cures are effected insome cases, but the condition is apt to become chronic,and, when once an infection is firmly established inthe urinary tract, the hindrances to be overcome beforethe patient can be counted free of it are immenselyincreased and may prove insurmountable. The subjectclaimed the whole attention of two recent meetings ofthe Royal Medico-Chirurgical Society of Glasgow, anddiscussion arose on such points as the following. Thediagnosis of urinary infections can largely be avoidedif the urine be carefully examined. Pus may not bepresent in more than small quantities, but it is usuallyevident and will certainly be found if the urine iscentrifugalised and the deposit then examined withthe microscope,whilst cultures of the urine will establishthe nature of the organism. Dr. Leonard Findlaypointed out that this is one of the rare conditions ininfancy in which rigors occur ; toxic symptoms are

1 Bulletin of the Johns Hopkins Hospital, December, 1921.

192 THE GROWING IXOPERABILITY OF CAXCER IX C.ERMAXT.

severe. and he expressed the opinion that in thesecases the disease is primarily a pyelitis. In this viewhe had Dr. John ThOIllson’s support. In older patientsthe clinical type is different : bladder symptoms pre-dominate. and cystoscopic examinations carried outby Dr. Findlay and Dr. J. M. Renton go to prove,contrary to the text-book teaching. that in these casesthere is more often a primary cystitis unaccompaniedby pyelitis. In regard to the path of infection. Dr.Findlay believed that the blood stream was thecommon route. Prof. C’arl Browning agreed that thepassage of organisms from the blood stream to therenal pelvis occurs freely and that this probably repre-sents an important manner of infection in pyelitis,though, as stated by Mr. Archibald Young, septicinfection can undoubtedly spread upwards to thekidney by way of the lymphatics around the ureter.When the condition is chronic the fact that organismsare found not only in the pelvis but remote from it inthe substance of the kidney suggests their immunityto any therapeutic agent which does not possess con-siderable penetrating powers, as was pointed out byProf. Browning. It is, of course, an important part oftreatment to remove all causes which predispose toinfection, such as stone or enlarged prostate, and SirKennedy Dalziel drew attention to this aspect of thesubject which is sometimes overlooked, cases beingtreated only with drugs when surgical measures areclearly indicated. Obviously, only an accurate investi-gation of each case of urinary infection can lead tosuccessful treatment. The ordinary physical signs andthe history given by the patient will often go far tolocalise the primary site of the disease, but probablythe most helpful method of diagnosis is cystoscopicexamination. This is usually not advisable in the acutestage, but as soon as it can safely be carried out thelesion can, in the great majority of cases, be accuratelylocated. Dr. Renton remarked upon the value ofureteral catheterisation as a means of deciding whetherthe infection is present in one or in both kidneys. X rayexamination may be necessary to exclude stone. Noneof the speakers were enthusiastic in regard to resultsobtained by vaccine treatment or pelvic lavage withsilver preparations. In their experience hexaminewas the most useful of the drugs available, but in acutecases the need of early and thorough alkalinisation ofthe urine was emphasised. With reference to the

patient’s dietary it should be remembered that milkmust be restricted in all cases of infection of the urinarytract due to B. coli conwwnis, for in the view of manyclinicians the constipation which so often occurs inpatients who take largely of milk is a condition whichpredisposes to infection by this organism. ITHE GROWING INOPERABILITY OF CANCER

IN GERMANY.

CERTAIN statistics recently published by Prof. G.W’inter,l of Konigsberg, would suggest that thewar and its aftermath have exerted a most un-

favourable influence on the early recognition ofcancer. His figures refer, however, only to cancer ofthe uterus, and to only one part of Germany. In1913, 46-3 per cent. of the 54 cases of cancer of theuterus admitted to his hospital were inoperable,whereas of the 54 cases admitted in 1920, as great aproportion as 72-2 per cent. was inoperable. In 1913he saw only seven

" missed " cases-i.e, cases inwhich the appearance of definite signs of cancer hadnot led to immediate admission to hospital. In 1920he saw 34 such cases, and all were inoperable. A

study of the reasons why the early signs of malignantdisease were overlooked showed that out of a total of1S2 " missed " cases observed between 1911 and 1920,the fault lay with the medical attendant in 39 cases(21-5 per cent. ). with the nurse or midwife in six, witha quack practitioner in one, and with the patientherself in as many as 136 cases. In this last categorythere were only six cases in 1913. as compared with

1 Zentralblatt f. Gyn., Dee. 3rd. 1921.

27 in 1920. Prof. Winter is at no pains to hide hisopinion of the medical attendant who dismisses asunimportant, and without a careful local examination.complaints by women of irregular haemorrhages andother signs indicative of malignant disease. As forthe patient herself it would seem that the war andits after-effects have nmnbed just those facultieswhich the early recognition of cancer require. Thelesson that Prof. Winter extracts from his findings isthat unless educational propaganda about the earlyrecognition of cancer are systernatically drummed intoall classes of societ,v, intelligent interest in thissubject wanes, and the facile doctrine, that if slightsymptoms are steadfastly ignored they will vanish, isfollowed to the ultimate undoing of the patient.Prof. Winter draws an interesting comparision betweenthe vigour of educational propaganda in East Prussia,from year to year and the proportion of inoperablecases in the same years, and he shows that the relationbetween the two is remarkably close. As he pointsout in a more recent publication the neglect of theearly signs of cancer is greater now than it was longbefore the war, when he first began his agitation forcancer education. And this state of affairs is the moredeplorable as recent advances in radium and X raytreatment give the patient, who is treated early in thedisease, a far better chance of complete recovery thanheretofore.

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THE FUNCTION OF THE TUBERCULOSIS

DISPENSARY.

THE tuberculosis service is still young enough to be.critical and active enough to be criticised ; moreover,its work has not yet become standardised and evenits boundaries are still in doubt. In Wales someprecision has been reached. Circular Tl. which hasrecently been issued by the Welsh Board of Healthto the local sanitary authorities and county councilsof Wales with respect to tuberculosis, will serve toemphasise certain things to which in England, as inWales, attention cannot too pointedly be directed.These include the examination of contacts, thevexed question of early notification, and the need ofsecuring cooperation with general practitioners in thework of the tuberculosis officers. Having regard tothe tendency for the tuberculosis dispensary tobecome more and more a consultative centre-forwhich few of them, it may be remarked, are as yetcompletely equipped-rather than a place whereroutine and symptomatic treatment is given (thatbeing left to the patient’s own medical attendant) itis obvious that one of the essential justifications forthe existence of the dispensary will come to lie moreand more in its capacity to search out cases ofhitherto unrecognised disease. The National ServiceBoard report in this country, and the Framinghamfigures in the United States, have revealed the factthat something like 2 per cent. of the populationsuffers from tuberculosis in a recognisable form, andof these a large proportion is unknown to anyauthority. It is not necessary to labour the dangerwhich faces the community from the presence in itsmidst of so abundant a source of infection. Obviously,no tuberculosis physician can attempt to tacklesingle-handedly a problem of these dimensions, andeven in the best equipped areas the work of dis-covering the unsuspected but definitely affectedpatients will always fall far short of completeness.But at least some approximation to the ideal may beaccomplished by the examination of the contacts ofa recognised case considered as a focus of infection.Opportunely enough, the importance of this work hasbeen demonstrated by Dr. A. Distaso and Dr. A.Carveth Johnson, of the Welsli National MemorialAssociation, in their paper, Epidemiological Studies inHuman Tuberculosis, which appears in the currentissue of Tubercle. In an area with, say, 300 annualnotifications, however, the further examination oftwelve or fifteen hundred contacts belonging to

2 Deut. med. Woch., Jan. 12th, 1922.