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PROFESSOR OERTEL ON DIPHTHERIA.1

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643 dition of the uterus being always recognisable. Here the ’, permanganate proved useless. DREP INJECTIONS OF CREASOTE IN PHTHISIS. Dr. Rosenbusch gives an account in a Polish medical journal (Przeglad Lek arski, Feb. 4th and 11th, 1888) of the cases of nine phthisical patients whom he treated by injecting creasote into the tissue of the lung. The results he obtained were excellent. The injections, which were given at intervals of two or three days, caused the cough almost to disappear and the quantity of sputum to diminish. In those cases which were not very far advanced the patients gained flesh, the dyspnoea and sweats ceased, the body weight increased, and frequently spots which had been dull on percussion cleared up. The temperature decreased from five to eight hours after the injections, the fall continuing at first for ten or twelve hours, a permanently normal tem- perature being subsequently registered. The injections were made into the affected portion of the lung, which was usually, of course, the apex. The instrument employed was an ordinary Pravaz syringe, with a needle from six to eight centi- metres in length. About eight minims (half a syringeful) of a 3 per cent. solution of creasote in almond oil was injected in each of two spots, the piston of the syringe being pressed down slowly. The patient was told not to breathe deeply, and after the injection to lie quite still for a few minutes. When the needle was not inserted deeply enough, some lancinating pain was apt to be produced by the irrita- tion of the pleura. This, however, did not last long. No heemorrhage was ever observed after the injection, though in the case of one patient, who was subject to heamoptysis, a slight colouring of the sputum was observed for a short time. If the injections were made into a cavity, or into one of the large bronchi, the patients said they could smell creasote when they coughed, and this substance could be detected in the sputum by chemical means. Of course great care was taken to perform the operations under aseptic conditions, the skin, the needle, and the syringe being previously carefully washed with an antiseptic. The creasote used was the creasotum e bitumine fagi, or beech creasote. The writer promises a subsequent communication on the effect of these injections on the number of Koch’s bacilli. STRYCHNINE IN ALCHOLISM. Dr. T. J. Korona speaks strongly in favour of the value of hypodermic injections of strychnine in most forms of chronic alcoholism. From five to ten milligrammes were ad- ’ministered daily in divided doses for three or four days, and a mixture containing ethereal tincture of iron and nux vomica, prescribed for internal use. Under this treatment the neuralgic pains in the waist and calf of the leg, shaking of the hands, and the tabetic gait ceased entirely, but no diminution in the size of the enlarged liver could be detected. In acute alcoholism strychnine appeared to have but little effect. In ten of eleven cases the patients stated that after three or four injections, vodka, the spirit to which they were addicted, became repugnant to them. In cases where no symptoms had been produced by drink, strychnine had much less effect than in cases of a much more serious description. THE ESTIMATION OF NITRITES. Mr. T. Cuthbert Day communicated to the Chemical Society - at the last meeting, March 15th, a new method of estimating nitrites, either alone or in presence of nitrates and chlorides. The method consists in saturating the solution containing the nitrite with solid ammonium chloride, boiling the mixture in a suitable apparatus, after removal of the air by carbonic anhydride, and collecting and measuring the nitrogen evolved; interaction takes place according to the equation N02K+NH4Cl=KCl+20H2 + 1V., ; hence the quantity of nitrite present in the substance under analysis is calculated from half the volume of nitrogen obtained. PRESENTATIONS. Dr. Andrew Mi]roy has been ;presented with a silver gilt and cut crystal dessert service by the members of the Saltcoats Ambulance Class, as a mark of their appreciation of his services as instructor during the past session.-Dr. J. W. Shaw of Partick has been presented with a case of surgical instruments in recognition of his ser- vices as tutor of the Dumbarton Ambulance Classes.-Dr. Higgins, who has gratuitously trained in ambulance work a class of the Birkenhead borough police force, has just been presented with a silver-mounted marmalade jar, bearing an appropriate inscription, as a small mark of gratitude and II appreciation of his services as their instructor. PROFESSOR OERTEL ON DIPHTHERIA.1 IV. HAVING completed his exhaustive survey of the histo- logical changes met with in the various tissues and organs in diphtheria, Professor Oertel proceeds in his monograph to discuss in greater detail the cell phenomena which form the most characteristic and constant feature of these lesions. There is no need for our present purpose to follow him in this section of the subject, which, although of much interest to the advanced histologist, so abounds in technicalities con- cerning the intimate constitution of the cell and its nucleus as to make any mere abstract of it impossible. Suffice it to say that he differentiates the modes in which nuclear dis- integration occurs, and contrasts the processes leading to necrobiosis with those concerned in repair, or those which are the normal expression of changes due to age. He infers that in the production of necrobiotic areas, and the subsequent chemical changes which the disintegrated nuclei undergo, there is evidence of the operation upon the cells of a poisonous agent, influencing the cells with which it is brought into contact. The same holds for the peculiar hyaline transformation of connective- tissue elements that is met with, especially in the blood- vessels of the affected organs. He next devotes a chapter to the development of the diphtheritic false membrane, upon which, as he points out, the attention of pathologists has for the most part been concentrated. He shows that, whereas it had come to be considered that the false membrane was of inflammatory origin, due, it was supposed, to a specific irritant, yet Heubner’s researches pointed to some necessary antecedent condition of the circulation in the affected mucous membrane, so that the formation of false membrane might conceivably be secondary to general infection of the system. Now, according to the present researches of Oertel, the false membrane is to be regarded as part and parcel of the necrobiotic process that occurs in many organs-in the depth of the pharyngeal and tonsillar tissues, in lymphatic glands &c.; and the differentiation of a membrane" to be due to the accident of position- viz., on the free surface of a mucous membrane. He shows clearly that in its earlier stages the epithelial and leucocytal elements disintegrate to form the substratum of the false membrane just as like cell disintegration produces the deeper-seated "necrobiotic foci." Indeed, for the most part the false membrane is due to the extension of such foci formed beneath the epithelial layer. Another chapter deals with the regeneration of diphtheritic tissues, based upon the study of two cases where death occurred in the one from cardiac paralysis eighteen days after severe pharyngeal and laryngeal diphtheria, in the other from paralysis of respira- tory muscles some five or six weeks after the subsidence of the local pharyngeal manifestations. These cases showed that the false membrane is removed by purulent infiltration ; the necrobiotic products and hyaline masses by liquefac- tion and absorption; whilst there is a new formation of epi- thelium and connective tissue from germ cells or fibroblasts. The descriptive portion of the work is closed by a chapter dealing with bacteriological researches of interest, because Professor Oertel himself twenty years ago published facts in support of diphtheria being a bacterial disease, and also because of Loeffler’s more recent inquiry with cultiva- tions and inoculation experiments upon a particular bacillus met with in the false membranes. In the earliest- formed membranes many varieties of microbe can be isolated; but practically there are two chief kinds- chain-forming cocci (streptococcus) and rod-shaped bacteria with rounded extremities (bacilli). In the septic form of the disease the cocci were especially abundant; but in a case of laryngeal and tracheal diphtheria the secre- tion from a tracheotomy wound yielded a great preponder- ance of bacteria. In a diphtherial membrane of twelve hours’ date micrococci abounded mostly on the surface, whilst in the fibrinous meshwork the bacilli, often in colonies, pre- ponderated. In another specimen of twenty-four hours’ date the upper margin was full of cocci, with a few rods between them, extending a short distance into the substance of the membrane. In a third specimen of membrane, detached after 1 See antea, pp. 389, 439, 540.
Transcript
Page 1: PROFESSOR OERTEL ON DIPHTHERIA.1

643

dition of the uterus being always recognisable. Here the ’,permanganate proved useless.

DREP INJECTIONS OF CREASOTE IN PHTHISIS.

Dr. Rosenbusch gives an account in a Polish medical

journal (Przeglad Lek arski, Feb. 4th and 11th, 1888) of thecases of nine phthisical patients whom he treated by injectingcreasote into the tissue of the lung. The results he obtainedwere excellent. The injections, which were given atintervals of two or three days, caused the cough almost todisappear and the quantity of sputum to diminish. Inthose cases which were not very far advanced the patientsgained flesh, the dyspnoea and sweats ceased, the bodyweight increased, and frequently spots which had been dullon percussion cleared up. The temperature decreased fromfive to eight hours after the injections, the fall continuingat first for ten or twelve hours, a permanently normal tem-perature being subsequently registered. The injections were made into the affected portion of the lung, which wasusually, of course, the apex. The instrument employed was anordinary Pravaz syringe, with a needle from six to eight centi-metres in length. About eight minims (half a syringeful) ofa 3 per cent. solution of creasote in almond oil was injectedin each of two spots, the piston of the syringe beingpressed down slowly. The patient was told not to breathedeeply, and after the injection to lie quite still for a fewminutes. When the needle was not inserted deeply enough,some lancinating pain was apt to be produced by the irrita-tion of the pleura. This, however, did not last long. Noheemorrhage was ever observed after the injection, thoughin the case of one patient, who was subject to heamoptysis,a slight colouring of the sputum was observed for a shorttime. If the injections were made into a cavity, or intoone of the large bronchi, the patients said they could smellcreasote when they coughed, and this substance could bedetected in the sputum by chemical means. Of coursegreat care was taken to perform the operations under asepticconditions, the skin, the needle, and the syringe beingpreviously carefully washed with an antiseptic. The creasoteused was the creasotum e bitumine fagi, or beech creasote.The writer promises a subsequent communication on theeffect of these injections on the number of Koch’s bacilli.

STRYCHNINE IN ALCHOLISM.

Dr. T. J. Korona speaks strongly in favour of the value ofhypodermic injections of strychnine in most forms ofchronic alcoholism. From five to ten milligrammes were ad-’ministered daily in divided doses for three or four days, anda mixture containing ethereal tincture of iron and nuxvomica, prescribed for internal use. Under this treatmentthe neuralgic pains in the waist and calf of the leg, shakingof the hands, and the tabetic gait ceased entirely, but nodiminution in the size of the enlarged liver could be detected.In acute alcoholism strychnine appeared to have but littleeffect. In ten of eleven cases the patients stated that afterthree or four injections, vodka, the spirit to which they wereaddicted, became repugnant to them. In cases where nosymptoms had been produced by drink, strychnine had muchless effect than in cases of a much more serious description.

THE ESTIMATION OF NITRITES.

Mr. T. Cuthbert Day communicated to the Chemical Society- at the last meeting, March 15th, a new method of estimatingnitrites, either alone or in presence of nitrates and chlorides.The method consists in saturating the solution containing thenitrite with solid ammonium chloride, boiling the mixturein a suitable apparatus, after removal of the air by carbonicanhydride, and collecting and measuring the nitrogenevolved; interaction takes place according to the equationN02K+NH4Cl=KCl+20H2 + 1V., ; hence the quantity ofnitrite present in the substance under analysis is calculatedfrom half the volume of nitrogen obtained.

PRESENTATIONS. - Dr. Andrew Mi]roy has been;presented with a silver gilt and cut crystal dessert serviceby the members of the Saltcoats Ambulance Class, as a markof their appreciation of his services as instructor during thepast session.-Dr. J. W. Shaw of Partick has been presentedwith a case of surgical instruments in recognition of his ser-vices as tutor of the Dumbarton Ambulance Classes.-Dr.Higgins, who has gratuitously trained in ambulance worka class of the Birkenhead borough police force, has just beenpresented with a silver-mounted marmalade jar, bearing anappropriate inscription, as a small mark of gratitude and IIappreciation of his services as their instructor.

PROFESSOR OERTEL ON DIPHTHERIA.1

IV.

HAVING completed his exhaustive survey of the histo-logical changes met with in the various tissues and organsin diphtheria, Professor Oertel proceeds in his monographto discuss in greater detail the cell phenomena which formthe most characteristic and constant feature of these lesions.There is no need for our present purpose to follow him inthis section of the subject, which, although of much interestto the advanced histologist, so abounds in technicalities con-cerning the intimate constitution of the cell and its nucleusas to make any mere abstract of it impossible. Suffice itto say that he differentiates the modes in which nuclear dis-integration occurs, and contrasts the processes leadingto necrobiosis with those concerned in repair, or thosewhich are the normal expression of changes due to

age. He infers that in the production of necrobioticareas, and the subsequent chemical changes which thedisintegrated nuclei undergo, there is evidence of theoperation upon the cells of a poisonous agent, influencingthe cells with which it is brought into contact. The sameholds for the peculiar hyaline transformation of connective-tissue elements that is met with, especially in the blood-vessels of the affected organs. He next devotes a chapter tothe development of the diphtheritic false membrane, uponwhich, as he points out, the attention of pathologists hasfor the most part been concentrated. He shows that,whereas it had come to be considered that the false membranewas of inflammatory origin, due, it was supposed, to a

specific irritant, yet Heubner’s researches pointed tosome necessary antecedent condition of the circulationin the affected mucous membrane, so that the formation offalse membrane might conceivably be secondary to generalinfection of the system. Now, according to the presentresearches of Oertel, the false membrane is to be regardedas part and parcel of the necrobiotic process that occurs inmany organs-in the depth of the pharyngeal and tonsillartissues, in lymphatic glands &c.; and the differentiation

of a membrane" to be due to the accident of position-viz., on the free surface of a mucous membrane. He showsclearly that in its earlier stages the epithelial and leucocytalelements disintegrate to form the substratum of the falsemembrane just as like cell disintegration produces thedeeper-seated "necrobiotic foci." Indeed, for the most partthe false membrane is due to the extension of such fociformed beneath the epithelial layer. Another chapter dealswith the regeneration of diphtheritic tissues, based uponthe study of two cases where death occurred in the one fromcardiac paralysis eighteen days after severe pharyngeal andlaryngeal diphtheria, in the other from paralysis of respira-tory muscles some five or six weeks after the subsidenceof the local pharyngeal manifestations. These cases showedthat the false membrane is removed by purulent infiltration ;the necrobiotic products and hyaline masses by liquefac-tion and absorption; whilst there is a new formation of epi-thelium and connective tissue from germ cells or fibroblasts.The descriptive portion of the work is closed by a chapterdealing with bacteriological researches of interest, becauseProfessor Oertel himself twenty years ago published factsin support of diphtheria being a bacterial disease, andalso because of Loeffler’s more recent inquiry with cultiva-tions and inoculation experiments upon a particularbacillus met with in the false membranes. In the earliest-formed membranes many varieties of microbe can beisolated; but practically there are two chief kinds-

chain-forming cocci (streptococcus) and rod-shapedbacteria with rounded extremities (bacilli). In the septicform of the disease the cocci were especially abundant;but in a case of laryngeal and tracheal diphtheria the secre-tion from a tracheotomy wound yielded a great preponder-ance of bacteria. In a diphtherial membrane of twelve hours’date micrococci abounded mostly on the surface, whilst in thefibrinous meshwork the bacilli, often in colonies, pre-ponderated. In another specimen of twenty-four hours’ datethe upper margin was full of cocci, with a few rods betweenthem, extending a short distance into the substance of themembrane. In a third specimen of membrane, detached after

1 See antea, pp. 389, 439, 540.

Page 2: PROFESSOR OERTEL ON DIPHTHERIA.1

644

six days, there was a like admixture of the microbes, but IIthe specimen had suffered from the local applications used. 4

In the sections of tissues and organs these organisms were 4

met with almost solely in the mucous membranes, nor did ]they penetrate mostly to any great depth; they did notoccur in necrobiotic foci, and it is especially noticeable thatthey were not found in any of the sections of the kidneysexamined. Their absence from the kidney is in markedcontrast with Oertel’s former results, and he suggests thatin his previous examinations (1865-71) he was dealing withspptic cases, which prevailed then more than they do now.He attributes, perhaps with reason, this disappearance ofseptic infection to the adoption of disinfecting measures,and the rejection of the old vigorous escharotic treat-ment and forcible detachment of membrane that formerlyprevailed.The facts thus obtained are then collated for the discussion

of the great question of the Pathogenesis of EpidemicDiphtheria that forms the second part of the monograph.The several points are dealt with in turn. It is shown thatthe essential and characteristic lesions, as distinct from theconcomitant and sequential, are those of cell change-thenecrobiotic processes which are initiated in the leucocytesand larger round cells that so early appear in the affectedtissue. These necrobiotic areas are met with in theepithelium of the respiratory mucous membrane; in thesubstance of that membrane itself; in the tonsils; in themucous.membrane of the fauces, uvula, epiglottis, larynx,and trachea; in the cervical, submaxillary, and bronchialglands; in the follicular and agminate glands of theintestine; in the mesenteric glands and spleen. But in theirextent they vary in these different situations, apparentlyin proportion to the amount and intensity, as well as to thecontinuance of the operation, of the virus that induces thechange. Everything points to the infectiveness of theprocess, which extends from one part to another inthe substance of an organ, or by the lymph stream, orby the blood, as in the case of the spleen, the dis-integrated products furnishing the virus. The conclusionthen, that diphtheria is primarily a local disease seemsclearly to follow, for although it has been objected that theintestinal lesions are evidence of general blood infection,yet the amount of change in the intestine points to a

diminished virulence there, and the date of these lesionsshows that they follow the pharyngeal affection, and maypossibly be due to the swallowing of infected productsfrom the mouth and pharynx. This does not precludethe occasional though rare occurrence of a diphtheriastarting primarily from the stomach. As to the lungs, theentire absence in them of any of the characteristic lesionsshows that a primary infection of the system throughthese organs has in no way been proved. Diphtheria is,then, a disease in which there is a direct infection, by theimmediate action of the contagium with the epithelium of amucous membrane, whence the disease spreads, and in avariable time becomes a general infective or systemic disease.The nature of the virus is less clear. It manifestly actsupon cells, causing their disintegration and death, and theirinfected particles cause the disease to extend to other cells;whilst it seems as if leucocytes and phagocytes convey thevirus into tissues, lymph, and blood. The action of thevirus on the bloodvessels is seen in the hyaline changesinduced in them, in the alteration in their walls that causesthem to readily rupture, producing hsemorrhage. And theunequal distribution of these vascular lesions depends pro-bably upon the greater or less length of time during whichthe circulation in them allows the infected blood to be incontact with their walls. The secondary inflammatoryand degenerative processes-as in the lungs, heart, liver,kidneys, and in the nerve tissues, central and peripheral--occur in varying degrees, and must be due to the bloodinfection, the amount of virus thus brought into con-tact with these organs being insufficient to lead tonecrobiosis. Of course, there is great room for variationin such results and their duration upon this hypothesis,which admits of every degree of concentration of thevirus in the blood, as well as of vital resistance on the partof individual organs. It may, indeed, take long for theinfective virulence to be quite exhausted. That the virus isdue to the presence of bacterial organisms is highly pro-bable ; but that it is the product of their metabolisra-aptomaine-is also most likely, since the microbes themselveeare almost wholly confined to the surface, whereas theaction of the virus is widespread and deep. It must bt

admitted, however, that the specific diphtherial micro-organism has not been isolated with certainty; and thedifferencea between man and animals render experimentalproof in this matter difficult.

In a few pages Professor Oertel alludes to the clinicaland therapeutical bearings of these considerations. In thefirst place, the false membrane must no longer be regardedas the first pathological and pathognomonic sign of diph-theritic infection, and it is not surprising that energeticmeasures towards its removal are followed by fresh forma-tion, since the morbid process is going on in the mucousmembrane. Still, local treatment should aim at thoroughdisinfection of the buccal and pharyngeal cavities,whichwill at least prevent secondary infection of the stomachand intestines, and this is best effected by the frequent useof disinfectant spray. How far the disease is spreadingmay be judged by the degree of lymphatic gland swelling;and the degree of fever may bear upon the extent ofgeneral infection. When we know more of the influence ofdrugs upon ptomaines, in preventing their formation orhastening their conversion into innocuous materials, weshall be better able to prescribe general remedies-such asquinine, mercury, or arsenic-with confidence; but mean-while the chief hope lies in prophylaxis and the maintenanc&of the body in a state of nutrition, so that its cell elementsmay be able to resist successfully, and annul, the virusagainst which they have to contend. That this is possibleis evident from what we know respecting other poisons andindividual capacities of resistance.

In conclusion, Professor Oertel points out that the wholesubject, from the first migration of leucocytes into theinfected epithelium to the formation of necrobiotic foci inthe spleen, proves the important part played by cells inthe disease. It shows, he considers, that we must stillgo back to the cell theory if we would explain morbidaction, and he puts forward his work as a contribution toVirchow’s doctrine of cellular pathology, which is by no

I means so effete as some declare.

THE MEDICAL, MEDICAL STUDENTS’, ANDDENTISTS’ REGISTERS.

THESE Registers, which, we understand, are in much

demand, were published on the 21st inst., and copies maynow be had from Messrs. Spottiswoode and Co., the MedicalCouncil’s publishers.The Medical Register, corrected and revised throughout

from all available data, has had prefixed to it some addi-tional preliminary matter of interest in the form of statisticsand tables. From these statistics it appears that, whereasthe number registered in 1877 was but 940, the numberregistered last year was 1531, showing an increase of 591.While the total number in the Register for 1876-the firstyear in which any such data as are now presented wereascertained-was 22,200, the number on the present Registeris 27,246, showing an increase of 5046, whereof about 66 percent. were registered in London, 19 in Edinburgh, and 16 inDublin. The number of pages in the present Register B1172-a large increase from the 335-paged volume thatsuffiepd for 1850, the 548 pages for 1870, and the 598 pagesfor 1876.The Medical Students’ Register has prefixed to it simi-

lar tables of statistics, showing, inter alia, for each divisionof the United Kingdom, the respective numbers registered in1887 as having passed the several recognised examinations,and the numbers registered at each place of medical study.The Dentists’ Register appears to have been subjected

to a most thorough and searching investigation, a pro-. cess already rendered absolutely necessary owing toI carelessness or neglect on the part of registered dentists.I Soon after midsummer, inquiry letters, under Sec. 13, of the Dentists Act, were sent to all persons onI the Register; and, three months later, nearly a thou-j sand registered second inquiry letters had to be sent,B as prescribed in the cited section, to those who had not> answered the first inquiry. By this heavy labour an unpre-- cedented amount of error has been disclosed and corrected.a From the tables and statistics contained in the preliminarys matter of the Register, it appears that the unqualified den-a tists were, in 1879, 4806, or 91 per cent. of the whole, whilea the dental licentiates were 483; but in the present Register


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