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posture was demanded of the school child. Manypoints raised by Mr. Widdows remained undiscussedfrom the medical aspect, but in view of their importanceit may be hoped that they will receive the earnestattention of those whose duty it is to interpret theresults of recent research to responsible authorities.

THE CLASSIFICATION OF BACTERIA.BACTERIOLOGISTS concerned with the examination

of water and milk have always felt the need ofsome form of classification which will differentiateorganisms of the B. coli group into those of humanand those of animal origin. Apart from the helpful workof W. M. Clark and other American workers on essen-tial differences of origin of organisms with differentcarbon dioxide to hydrogen ratio of gas production,little or no advance has been made in this directionduring the last two decades. It is easy enough toclassify by sugar-alcohol tests, but unless it can beshown that the groups so formed throw definite lighteither upon the functions or the sources of origin ofbacteria the classification is not of much use forpublic health purposes. In a recently publishedpaperl Mr. T. Redman, M.Sc., records the results ofpainstaking work in the classification of lactose-fermenting organisms of the B. coli group type. He hasisolated these micro-organisms from cheese, milk, andwater, and has endeavoured to group them along thelines of their cultural and agglutination characters.From the public health standpoint Redman’s laboriousefforts cannot be regarded as very helpful, for heclosely follows MacConkey’s method of classification,which has not been of demonstrable use. A con-siderable part of the paper is taken up with a studyof agglutination tests, a large number of strains beingused to prepare anti-sera. Here again these testsfail to give any clear-cut types, and although theauthor states that the strains differentiated intoMacConkey’s subgroups by cultural reactions are alsodifferentiated by their agglutinations, the tablesfurnished show that this is only true to a very limited’extent. We await with some anxiety the day whenan ingenious student of applied bacteriology willinvent a means of classification which will giveinformation of real practical value.

PACHYMENINGITIS HÆMORRHAGICA INTERNA.THE cause and nature of the pathological process

in pachymeningitis haemorrhagica interna, and therelation of this condition to traumatic subduralhaematoma. have always been subjects of much diversityof opinion, and nowhere in the text-books dealing withthem do we find any final conclusions expressed. At

present two hypotheses hold the field : the first thatthe lesion is primarily inflammatory-a true pachy-meningitis followed by repeated small secondaryhaemorrhages from the newly-formed blood-vessels ofthe organised exudate ; the second that haemorrhageis the essential factor and is followed by organisationof the clot.

In the current number of Tledical Science (1922, v.,496), Dr. F. M. R. Walshe discusses two important andrelatively recent papers in which both points of vieware represented. At the Seventeenth InternationalCongress of Medicine of 1913, held in London, Marie,Roussy, and Laroche discussed the morbid anatomyof pachymeningitis haemorrhagica interna. Theydescribed three main forms of lesion, with several sub-types. However, since in the great majority of theircases the diagnosis was made at autopsy, the conditionhaving been latent clinically, no information was

available as to the age of the lesion in any giveninstance. This clearly diminishes the value of theirobservations and conclusions, and we are left with theimpression that their classification is largely conven-tional and does not represent variations in a patho-logical process, but rather different stages in a more orless uniform process. In addition they carried outexperimental observations on animals by subduralinjections of blood, either sterile, infected, or mixed

1 Journal of Pathology and Bacteriology, 1922, xxv., 63.

with a chemical irritant. They failed to reproducetypical pachymeningitis haemorrhagica. This is notaltogether surprising for their experiments were acuteand completely neglected the essential time factor.However, they concluded that haemorrhage alone is notenough to account for pachymeningitis haemorrhagicain man and that a microbial or chemical irritation isessential, but without indicating how either arises. In1914 W. Trotter published in the British Journal ofSurgery what appears to be the most conclusive state-ment on the subject. He emphasises the importanceof the time factor in determining the symptomatologyof a nervous lesion. He points out that most progres-sive lesions produce their effects not by destruction oftissue but by interference with its blood-supply. Inhead injuries haemorrhage and oedema are the factorsleading to disturbances of cerebral function, and therate at which these processes impair the cerebral blood-supply determines the nature of functional disorderresulting. He contrasts rapid compression of the brainfrom traumatic extra-duraJ haemorrhage with thegradual compression occurring in subdural hsematoma.In the former case the haemorrhage is clinically latentuntil compression reduces the total venous capacityof the skull below that of its arterial blood. At this pointvenous engorgement results, with the appearance ofincreased excitability of nervous tissue and correspond-ing " irritative " symptoms-twitching of muscles,convulsions, delirium, and restlessness. Further com-pression produces capillary anaemia of the brain andparalysis of function in the affected part.In gradual compression, such as occurs in subdural

haematoma, a physiological compensation or tolerationensues, and hence no symptoms may be observed untila local anaemia is produced. Once the margin of tolera-tion is reached the patient passes suddenly into a stateindicating severe compression. Even normal variationsin intracranial tension may be sufficient to cause

startling symptoms to develop with great suddenness,and as rapidly to clear up. Trotter then compares thesymptomatology and morbid anatomy of traumaticsubdural hasmatoma and pachymeningitis haemor-rhagica and shows clearly that they are identical. Hebelieves that the source of haemorrhage is in the veinspassing from the cortex into the dural sinuses. Trivialblows on forehead or occiput may be sufficient to tearthese relatively unsupported vessels, from which inter-mittent oozing can go on for an indefinite period. Theperiphery of the blood mass clots and organises,leaving a fluid cyst into which further haemorrhagetakes place whenever venous pressure rises sufficientlyto overcome the resistance of the enclosing capsule.The absence of a history of head injury in many casesof pachymeningitis haemorrhagica is not a graveobjection to this point of view, for since trivial injuriesare most likely to be in question they are apt to beforgotten by the senile dements and alcoholics in whomthe condition is found, and who are especially prone toaccidents of the kind. Therefore Trotter concludesthat internal pachymeningitis haemorrhagica is a termwhich involves an unjustified hypothesis and shouldbe discarded in favour of some such term as chronicsubdural haemorrhage. Apart from certain cases

occurring in diseases which cause a strong tendencyto spontaneous haemorrhage, and possibly includingthem, hacmorrhagic pachymeningitis is a true traumatichaemorrhage coming from veins torn in their coursebetween brain and dural sinus. It should always bedealt with surgically. Finally, the variable and capri-cious course of such chronic haemorrhages, far fromrendering diagnosis exceptionally difficult, is capableof exact interpretation in accordance with the principlesof cerebral pathology, and constitutes a clinical typeat once well marked and characteristic. Marie, Roussy,and Laroche found that in almost all their cases thecondition was bilateral, and this also has been Trotter’sexperience, and he believes that surgical treatmentshould deal with both sides of the head simultaneously.The charm of Trotter’s lucid exposition is its strict

adherence to sound pathological principles. The trainof events he describes is eminently comprehensible andleaves less unexplained than any previous discussion of

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the subject with which we are familiar. The conceptionthat the site of a nervous lesion is of infinitely greaterimportance than its nature and mode of developmentis doubtless a valuable one, but in the past it has ledneurologists to neglect the physiological aspect ofdisease and injury of the nervous system. In itsreassertion of the physiological principle, Trotter’spaper has a value even greater than as an illuminatingexposition of a particular problem in neuropathology.

EXPERIMENTAL TRANSMISSION OF TYPHUSTO MAN.

A BELATED account of some interesting observationswhich were interrupted by the war has recently beenpublished by E. Sergent, H. Foley, and Ch. Vialatte. IIn November, 1913, a young native was brought tothe hospital at Beni-Ounif, southern Algeria, sufferingfrom an attack of fever of six days’ duration. Herehe came under the observation of the authors, whodiagnosed his complaint as relapsing fever on thefinding of spirilla in the circulating blood. On thefollowing day a typical crisis occurred, the spirilladisappeared from the blood stream, and recovery waslooked for. A fresh accession of fever, of a continuousnature, occurred however, accompanied by signs ofconsolidation in the right lung. Examination of theblood for spirilla and typhoidal infection was negative,and after eight further days of illness, in which thegeneral condition further deteriorated and the typhoidstate finally supervened, the patient died. Beingengaged in an investigation of the transmission ofrelapsing fever by means of lice, Sergent, Foley, andVialatte inoculated, by scarification, the materialobtained by crushing nits from the garments of thispatient into a second native (Z), who volunteered forthis purpose. Another volunteer (Y) was inoculatedin the same manner with crushed lice, and a batch of200 lice from the same source were nourished uponthe body of a fourth native (X). On the fifth dayafter inoculation Z was taken ill with a continuedfever lasting 13 days, accompanied by intense head-ache, delirium, constipation, and albuminuria, andterminating by crisis associated with collapse ;recovery followed. Subject Y developed the samemalady after -eight days’ incubation, whilst the hostof the lice fell a victim to the disease after nourishingthese creatures for 16 days. In all cases recovery fol-lowed. The disease was typhus fever, which apparentlyevolves in a milder fashion in the natives of this areathan in Europeans. One of the authors, who wasclosely associated with the patients but not subjectedto experiment, contracted the disease in a severeform. fortunately recovering. The extremely interest-ing facts detailed in this paper leave little doubt thatthe original patient, from whom the infected licewere obtained, was suffering both from typhusand relapsing fever. He had come from an

outlying district, where he probably contractedthe disease, and brought the infection to Beni-Ounif, where typhus had not been seen for severalyears prior to the time at which these experimentswere carried out. This fact probably emboldenedthe authors in their experiments, since they believedthemselves to be dealing with a pure infection withrelapsing fever. The fatal termination of the casewas a disturbing fact and was at first attributed topneumonia, a very uncommon complication ; typhuswas not thought of until the three inoculated subjectswent down with the disease. Confirmation of thediagnosis was obtained by transmission to monkeysbv means of the infected lice, carried out at the PasteurInstitute of Algiers, and also by the appearance ofRickettsia in the bodies of the involved lice, whichwere being examined in routine fashion for spirilla.The occurrence of debased forms of typhus is a matterof the greatest importance from an epidemiologicalpoint of view and is one of the many points emphasisedby the interesting, though entirely unlooked for,results of the above experiments.

1 Arch. des Inst. Pasteur de l’Afrique du Nord, vol. i.,3, 1921.

TRAUMA AND SYPHILIS.

Dr. 1. Harrison Tumpeer,l associate professor andhead of the department of paediatrics of the postgraduate school of Chicago, who records two personalcases, quotes several examples from recent literatureillustrating the action of trauma in exciting activelesions on the predisposing soil of syphilitic infection.It is well known that syphilitic patients have amarked tendency to fractures, this being due, as

Coues has shown by X-ray examination, to thepresence of old periostitis. The tendency of gummatato occur at, the site of repeated traumatism hasbeen best exemplified by Lacapere and Laurent, whotreated 40 cases of gummatous lesions in the dispen-sary at Fez, Morocco. Fourteen of these were on theforehead, this localisation being explained by theMohammedans’ custom of prostrating themselves onthe stone floor of the mosque five times a day withtheir brow in contact with the floor from 10 to 20minutes at a time. Some cases of general paralysishave been acutely precipitated and others adverselyinfluenced by cranio-cerebral injury, which permitsthe spirochaetes to invade the brain tissue by causingvascular injury and brain destruction, followed bygliosis and nerve-cell sclerosis. The cases reportedby Dr. Tumpeer occurred in a half-sister and brother.The girl, aged 15, with hereditary syphilis possiblyof the third generation, developed epileptiformseizures and mental disturbance after a head injurywhich produced coma, while her half-brother, aged 10,developed primary optic atrophy after a similartrauma, and the healing of a -fracture caused by thesame trauma was much retarded.

RUMINATION IN INFANTS.WHILE the comparatively scanty references to this

condition in medical literature may suggest its rare

occurrence in infancy, the fact probably is that a largenumber of cases, especially of the milder type, areoverlooked. On the other hand, however, some

writers apparently include under rumination cases ofsimple regurgitation, whereas the term should, ofcourse, be confined to those in which there is renewedmastication of the regurgitated food. Dr. W.Wernstedt, who in 1916 described a somewhatremarkable instance of rumination in an infant of 10months, writing in the Acta Pcediatri-a about a yearago, gave details of six other cases seen by him since1918. The essential movements involved havehitherto been little studied, nor has it been establishedhow far the act is voluntary or otherwise. Withregard to the latter point. Dr. Wernstedt convincedhimself in two of his cases that the strong abdominalcontractions preceding regurgitation of the food wereapparently involuntary on the part of the infant. Aninteresting point was the fact that in one of thesecases the X rays showed the cardiac orifice to remainpatent while the food rose and fell in the dilatedoesophagus ; this cardio-insufficiency was not, however,demonstrated in all the patients. In one or two casesthe infant was seen to make an effort to initiate theregurgitation, mainly by movements of mouth or

tongue, the abdomen remaining flaccid. In yetanother case the child apparently voluntarily regurgi-tated the contents of its stomach by momentaryabdominal contractions, thus raising the intra-abdominal pressure, the mouth and tongue at thesame time assuming the position seen in vomiting.In the second phase of rumination, after the food hasbeen regurgitated, the movements are no less diverseand complex, ranging from a rhythmical chewingmovement of the jaws to a gargling at the back of thetongue.

Discussing the aetiology of the condition, Dr.Wernstedt believes the importance of the neuropathicelement usually assigned to it to be exaggerated. Intwo only of his cases was there any evidence ofnervous instability, such as tremor or spasmophilia,the remaining patients being apparently normal in

1 Journal of the American Medical Association, Jan. 21st,1922.