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ROYAL ACADEMY OF MEDICINE IN IRELAND

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343 by a cell-free extract. Gye has demonstrated that this cell-free extract contains two substances, neither of which is capable of producing a tumour when used alone, though in combination they can do so. Gye claims that one of these factors is a non-specific living virus, and on the optical side he is supported by Barnard’s work. This work is still very recent, but it has received already a considerable degree of confirmation and is obviously of the first importance. Indeed, its bearing on the general problem of infection may eventually outshadow its application to the more limited pathology of tumours. ABERDEEN MEDICO-CHIRURGICAL SOCIETY. AT a meeting of this Society held on Jan. 13th, Dr. THOMAS FRASER, Vice-President, in the chair, t)r. ROBERT RICHARDS read a note on Some Cases of’ Dyserrtery in Aberdeen. Haoillary dysentery, he said, was classified under three main headings : (1) endemic, occurring in tropical and subtropical countries ; (2) epidemic, usually occurring in the minor form in local outbreaks in this country ; and (3) sporadic, occurring in strictly isolated cases where the two previous types were rare or unknown. Referring to the work done on infantile diarrhoea and the differences of opinion about the causal organisms, Dr. Richards said that American investigators had found that in a large proportion the Bacillus dysenteriœ of Flexner was responsible, the proportion found at the Boston Floating Hospital being 75 per cent. and at Baltimore 80 per cent. The latest figures for Britain were those of D. Nabarro who had found dysentery bacilli in 13 cases out of 1;)0 treated at the Hospital for Sick Children, Great Ormond-street. In the Aberdeen epidemic the first case recorded had been that of a boy aged 7, sent to the Royal Hospital for Sick Children with a diagnosis of intussusception. lIe had been ill for two days with vomiting, purging, and fever (101.2° F.) with the passage of large quantities of blood and mucus. on admission he had a pinched, anxious expression : -, the abdomen was retracted and tender, but no tumour was felt. Rectal examination caused severe I tenesmus with the expulsion of some blood and mucus. I A tentative diagnosis of ileocolitis or dysentery was made, but in view of the doctor’s statement that he had felt a I tumour the abdomen was opened. No tumour was found, ’, but the colon was thickened and swollen, and the appendix swollen and congested with great enlargement of the mesen- teric glands. The case was then treated as one of acute dysentery, and the condition rapidly cleared np on administration of magnesium sulphate. The finding of B. dysenteriœ (Flexner) confirmed the diagnosis. In this country, said Dr. Richards, the diagnosis of intussusception in such cases was not unlikely, but on rectal examination a distinct difference was to be made out. In dysentery the tenesmus set up was very great, and the examining finger was forcibly ejected, followed by the passage of blood and mucus ; in intussusception, on the other hand, the rectum was large and roomy-unless a tumour was felt-and no tenesmus was set up. The next three cases described were children aged 8, 4, and 5, all of whom showed typical symptoms of dysentery. B. dysenteriœ (Flexner) had been isolated in two of the cases ; examination of the stool in the remaining case had twice been negative for dysentery organisms, but this might have been due to delay in transmitting the specimen. In the fifth case, that of a child of 4, there had been practically the same symptoms, but the causative organisms had belonged to the food poisoning group, the Bacillus aertrycke. An interesting feature of this case was a sequela three years later, when the patient came up complaining of a painful left knee, the pain being evidently referred from the hip-joint where all move- ments were restricted and a certain degree of fixed flexion was present. The temperature was 100° and the pulse correspondingly rapid. Radiographic examination was negative. On the same aftemom the patient became sick and developed diarrhœa accom- panied by tenesmus and the passage of blood and mucus in the stool. A diagnosis of dysentery with toxic arthritis was made and the finding of the Sonne bacillus confirmed this.- Further confirmation was afforded by the clearing up of both conditions under treatment with saline aperients. Dr. Richards said that he believed that there was no previous record of such metastatic joint symptoms from Sonne dysentery, although arthritis was a common complica- tion of both Shiga and Flexner dysentery in Macedonia. After describing a further series of three cases of Sonne dysentery, he gave it as his opinion that true dysentery was not so rare amongst the general population as was usually stated. Treatment with magnesium sulphate was found to be almost specific. ROYAL ACADEMY OF MEDICINE IN IRELAND. SECTION OF MEDICINE. A MEETING of this Section was held on Jan. 28th, Dr. G. E. NESBITT, the President, in the chair. Dr. MAURICE DKUMMOND showed three cases of Ringworm in Children treated by Epilation with Thallium Acetate. The children were aged 6, 4, and 2 years and 5 months The method, said Dr. Drummond, had been used successfully in over 500 case;. by Cicero and Peter in ringworm schools in Mexico and in over 100 cases by Buschke and Langer in the Rudolph Virchow Hospital in Berlin. It was essential that one alone of the salts of thallium should be used-the protoxide of the acetate of thallium. He had used that of Kahlbaum. The Germans found that 8 mg. per kg. of body-weight was the most satisfactory dose for children of all ages. Peter in Mexico gave 5 mg. per kg. for children under 5 years of age. In each of the children shown R mg. had been administered, and Dr. Drummond had found it only just sufficient in the case of the two younger children. The drug was given in 2 ounces of sweetened water. Rapid and profuse fall of the hair took place on the fifteenth day with the two younger children. The fall had not been so satisfactory with the eldest child. The action of the drug was apparently selective, the eyebrows and fringe on the front of the head being unaffected. As X ray epilation could not be carried out in children under the age of 3, he thought that-apart from its general utility-thallium epilation should be of especial value in young children, as also in epidemics. In the case of the eldest child, who had been epilated in November, the hair was again growing well, and it was beginning to grow in the case of the second child who had been done in December. The youngest child had only just been epilated. The drug was contra-indicated in the presence of albuminuria. In case of partial failure, a further dose must on no account be given within at least two or three months, as the action of the drug was strongly cumulative and symptoms of acute poisoning might develop. Almost meticulous care was necessary in the weighing of the child and of the drug. Dr. Drummond was not yet sure that a slightly higher dose might not be necessary with older children. Constitution, climate, and the freshness of the drug were all factors to be considered. The PRESIDENT said that the effects of the treat- ment in the three cases shown were little short of miraculous. He regarded the method as much better than the use of X rays, but of course Dr. Drummond would require a larger experience of it before he could pronounce a final judgment on it. Dr. E. FREEMAN quoted a series of published cases. Dr. W. G. HARVEY referred to the original experi- ments with thallium, which had been carried out by Sabouraud, and which had been quite unsuccessful. Very large doses had been employed, and this, perhaps, had been the cause of the failure, as very serious symptoms had arisen after treatment, including hæmorrhage and purpura. This method now seemed to be of great use, quite apart from whether it would
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by a cell-free extract. Gye has demonstrated thatthis cell-free extract contains two substances, neitherof which is capable of producing a tumour when usedalone, though in combination they can do so. Gyeclaims that one of these factors is a non-specificliving virus, and on the optical side he is supportedby Barnard’s work. This work is still very recent,but it has received already a considerable degree ofconfirmation and is obviously of the first importance.Indeed, its bearing on the general problem of infectionmay eventually outshadow its application to the morelimited pathology of tumours.

ABERDEEN MEDICO-CHIRURGICAL SOCIETY.

AT a meeting of this Society held on Jan. 13th,Dr. THOMAS FRASER, Vice-President, in the chair,t)r. ROBERT RICHARDS read a note on

Some Cases of’ Dyserrtery in Aberdeen.

Haoillary dysentery, he said, was classified under threemain headings : (1) endemic, occurring in tropical andsubtropical countries ; (2) epidemic, usually occurringin the minor form in local outbreaks in this country ;and (3) sporadic, occurring in strictly isolated caseswhere the two previous types were rare or unknown.Referring to the work done on infantile diarrhoea andthe differences of opinion about the causal organisms,Dr. Richards said that American investigators hadfound that in a large proportion the Bacillus dysenteriœof Flexner was responsible, the proportion found atthe Boston Floating Hospital being 75 per cent. andat Baltimore 80 per cent. The latest figures for Britainwere those of D. Nabarro who had found dysenterybacilli in 13 cases out of 1;)0 treated at the Hospitalfor Sick Children, Great Ormond-street. In theAberdeen epidemic the first case recorded had beenthat of a boy aged 7, sent to the Royal Hospital forSick Children with a diagnosis of intussusception.

lIe had been ill for two days with vomiting, purging, andfever (101.2° F.) with the passage of large quantities ofblood and mucus. on admission he had a pinched, anxiousexpression : -, the abdomen was retracted and tender, butno tumour was felt. Rectal examination caused severe I

tenesmus with the expulsion of some blood and mucus. IA tentative diagnosis of ileocolitis or dysentery was made,but in view of the doctor’s statement that he had felt a Itumour the abdomen was opened. No tumour was found, ’,but the colon was thickened and swollen, and the appendixswollen and congested with great enlargement of the mesen- teric glands. The case was then treated as one of acutedysentery, and the condition rapidly cleared np on

administration of magnesium sulphate. The finding ofB. dysenteriœ (Flexner) confirmed the diagnosis.In this country, said Dr. Richards, the diagnosis

of intussusception in such cases was not unlikely,but on rectal examination a distinct difference was tobe made out. In dysentery the tenesmus set up wasvery great, and the examining finger was forciblyejected, followed by the passage of blood and mucus ;in intussusception, on the other hand, the rectum waslarge and roomy-unless a tumour was felt-and notenesmus was set up.The next three cases described were children aged

8, 4, and 5, all of whom showed typical symptoms ofdysentery. B. dysenteriœ (Flexner) had been isolatedin two of the cases ; examination of the stoolin the remaining case had twice been negative fordysentery organisms, but this might have been dueto delay in transmitting the specimen. In the fifthcase, that of a child of 4, there had been practicallythe same symptoms, but the causative organisms hadbelonged to the food poisoning group, the Bacillusaertrycke. An interesting feature of this case was asequela three years later, when the patient came upcomplaining of a painful left knee, the pain beingevidently referred from the hip-joint where all move-ments were restricted and a certain degree of fixedflexion was present. The temperature was 100°and the pulse correspondingly rapid. Radiographicexamination was negative. On the same aftemom thepatient became sick and developed diarrhœa accom-panied by tenesmus and the passage of blood and

mucus in the stool. A diagnosis of dysentery withtoxic arthritis was made and the finding of the Sonnebacillus confirmed this.- Further confirmation wasafforded by the clearing up of both conditions undertreatment with saline aperients. Dr. Richardssaid that he believed that there was no previousrecord of such metastatic joint symptoms from Sonnedysentery, although arthritis was a common complica-tion of both Shiga and Flexner dysentery in Macedonia.After describing a further series of three cases of Sonnedysentery, he gave it as his opinion that true dysenterywas not so rare amongst the general population as wasusually stated. Treatment with magnesium sulphatewas found to be almost specific.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF MEDICINE.A MEETING of this Section was held on Jan. 28th,

Dr. G. E. NESBITT, the President, in the chair.Dr. MAURICE DKUMMOND showed three cases of

Ringworm in Children treated by Epilation withThallium Acetate.

The children were aged 6, 4, and 2 years and 5 monthsThe method, said Dr. Drummond, had been usedsuccessfully in over 500 case;. by Cicero and Peterin ringworm schools in Mexico and in over 100 casesby Buschke and Langer in the Rudolph VirchowHospital in Berlin. It was essential that one aloneof the salts of thallium should be used-the protoxideof the acetate of thallium. He had used that ofKahlbaum. The Germans found that 8 mg. per kg. ofbody-weight was the most satisfactory dose for childrenof all ages. Peter in Mexico gave 5 mg. per kg. forchildren under 5 years of age. In each of the childrenshown R mg. had been administered, and Dr.Drummond had found it only just sufficient in the caseof the two younger children. The drug was given in2 ounces of sweetened water. Rapid and profuse fallof the hair took place on the fifteenth day with thetwo younger children. The fall had not been sosatisfactory with the eldest child. The action of thedrug was apparently selective, the eyebrows and fringeon the front of the head being unaffected. As X rayepilation could not be carried out in children under theage of 3, he thought that-apart from its generalutility-thallium epilation should be of especial valuein young children, as also in epidemics. In the case ofthe eldest child, who had been epilated in November,the hair was again growing well, and it was beginningto grow in the case of the second child who had beendone in December. The youngest child had only justbeen epilated. The drug was contra-indicated in thepresence of albuminuria. In case of partial failure, afurther dose must on no account be given within atleast two or three months, as the action of the drugwas strongly cumulative and symptoms of acutepoisoning might develop. Almost meticulous carewas necessary in the weighing of the child and of thedrug. Dr. Drummond was not yet sure that a slightlyhigher dose might not be necessary with olderchildren. Constitution, climate, and the freshness ofthe drug were all factors to be considered.The PRESIDENT said that the effects of the treat-

ment in the three cases shown were little short ofmiraculous. He regarded the method as much betterthan the use of X rays, but of course Dr. Drummondwould require a larger experience of it before he couldpronounce a final judgment on it.

Dr. E. FREEMAN quoted a series of published cases.Dr. W. G. HARVEY referred to the original experi-

ments with thallium, which had been carried out bySabouraud, and which had been quite unsuccessful.Very large doses had been employed, and this, perhaps,had been the cause of the failure, as very serioussymptoms had arisen after treatment, includinghæmorrhage and purpura. This method now seemedto be of great use, quite apart from whether it would

344

replace X ray treatment or not. The difficulty ofX raying young children, such as Dr. Drummond’spatients, was very great.

After further discussion, Dr. Drummond said thatLanger in Berlin said that he got the thallium onlyfrom one chemist.. It was stated that the drugdeteriorated with age. If the drug was fresh, the hairwould fall out on the fifteenth day after application,but if the drugs were not fresh when applied, the hairmight take three weeks to fall out.

Dr. V. M. SyxCrE showed specimens from a case of

Spontaneous Hœmorrhage into the Braiu.The specimens were from a young man aged 21. On

Oct. llth, 1926, whilst at work he suddenly fell downunconscious. lie had previously been perfectly healthyand had received no injury of any sort. When admitted tohospital a few hours later he was still unconscious, the limbswere rigid and tlexed, and occasional clonic spasms occurred.The neck was stiff. Pulse rate, 66 ; temperature, 99° F. ;respiration rate, 26. Ile vomited undigested food severaltimes. A catheter specimen of urine contained a fa.ir amountof albumin. The blood pressure was normal, and theblood urea 65 mg. per 100 c.cn1.During the following days the temperature rose to 101°;

the unconsciousness diminished. On Oct. 16th :30 c.cm. offluid were removed by lumbar puncture. It was under greattension and contained a good deal of blood. There was noimprovement after the puncture. The Wassermann reactionof the blood was negative. The patient remained semi-conscious, the neck stiffness increased, Kernig’s sign waspositive, and the limb -was stiff but without paralysis. OnOct. 21st lumbar puncture was again performed, and 35 c.cm.of fluid under tension removed ; the report being : a littleblood present (fluid otherwise clear) globulin slightlyincreased, glucose present, no pus, sterile on culture, and notubercle bacilli present.A dose of 15 c.cm. of sodium salicylate solution was given

intravenously, the high temperature, general condition,Kernig’s sign, and character of cerebro-spinal fluid suggestingthe probability of encephalitis lethargica. The temperaturedropped, the pulse rate fell from 100 to 60, but there was noimprovement in the general condition. The fundus of botheyes was normal. The patient got suddenly convulsed, andon Oct. 31st collapsed and died in a few hours.At autopsy there was no sign of any injury. In the anterior

horn of the right lateral ventricle there was a mass ofclotted blood which had destroyed a large part of the frontallobe ; all the ventricles were full of blood, and there was amass of effused blood on the base of the brain. The heart,spleen, kidneys, and other organs were normal; there was nosign of arterial disease. Sections failed to show any evidenceof a tumour in the brain. Sections of the kidneys were norrnal.

This apparently quite spontaneous haemorrhage,aaid Dr. Synge, had evidently originated in the rightfrontal lobe, afterwards bursting into the ventriclesand thence into the subarachnoid space.

The PRESIDENT said that the case was verv interest-ing, because in so young a patient no one would havethought of making a diagnosis of cerebral haemorrhage,especially in the absence of the phenurmena usuallysought for. Therefore the case was an important one.He thought that the cause of spontaneous haemorrhagewas always difficult to ascertain. It was possible tohave fairly advanced renal disease with a blood-ureaof no more than 65 mg., and he thought that in thiscase the boy probably had some chronic renal disease.He asked if there was anything in the brain to suggestencephalitis lethargica. lIe could not rememberhaving seen cerebral hæmorrhage under the age of 2’B

Sir JAMES CRAIG said although in this case the blood- I,urea was greater than normal. still the kidneys werehealthy : therefore he did not think that it could beassumed that the hæmorrhage was due to any rjnaldisease.

Dr. Sy,-N-c4E. in replving, said that on account of thedestruction done by the haemorrhage it had not beenpossible to egamine the artery that had actuallyruptured. The small arteries seen under the microscopeappeared to be perfectly normal, and lie thought thatan artery was unlikely to rupture unless the pressureinside it was very great. Nothing abnormal had beenfound in the kidneys, and there had been no evidenceof nephritis at all, except alburriinui-izi,, which had beenpresent at first. It had been very difftcult. however,to examine the urine as the patient had suffered frompersistent incontinence.

Reviews and Notices of Books.CÆSAREAN SECTION.

Witlx a Table of 120 Cases. Bv HERBERT R.SPENCER, M.D.. F.R.C.P.. Consulting ObstetricPhysician to University (’ollege Hospital. London:John Bale, Sons and Danielsson. Pp. 74. 6s.

Dr. Spencer states that this little book makes nopretence to be a treatise on Cæsarean section, butis a record as frank as he can make it of his ownexperience of the operation. lIe asks those who donot agree with his conclusions to publish a completeand detailed record bearing on the points of theirdisagreement. The publication of a selected seriesof cases is deprecated, since a proper judgment asto the value of the statistics can only be formed whendetails are given, and also particulars of the number ofcraniotomies.During the last 33 years he has operated on 120

cases, either in hospital or in private, with a maternalmortality and infant mortality-rate of 3.3 per cent.and 10 per cent. respectively. The majority of thesecases were derived from University College HospitalMaternity, where during this period over 80,000labours were conducted. He remarks that the smallnumber of cases is partly due to the fact that at thishospital premature labour is induced three and ahalf times as often as Cæsarean section is performedfor contracted pelvis. A careful analysis is madeof all the cases operated upon, full details beingset forth in tabular form at the end of the book.Contracted pelvis was an indication for the treatmentin 81.6 per cent. of cases, whilst 70 per cent. were notin labour at the time of operation. The classicalmidline upper uterine segment incision was employedon all occasions, and the author states his reasonsfor not using the extra-peritoneal and trans-

peritoneal cervical operations. The operative tech-nique is discussed in detail, and a strong plea ismade for the use of carbolised silk in suturing theuterine incision, the author having abandoned theuse of catgut more than 30 years ago.As to the anaesthetic employed, Dr. Spencer

insists on the use of chloroform until the child isdelivered, and open ether subsequently. Spinalanaesthesia is condemned, chiefly because theauthor believes it to be more dangerous thana general ansesthetic. As the latter was givenin all but one of his cases, this censure of spinalanæsthesia appears a little unwarranted, particularlyas it has been employed by others on many occasionswithout a fatality. The author also strongly dis-approves of sterilisation of the patient after Cæsareansection and denounces this procedure in no uncertainterms. We welcome this record of the personalexperiences of a practised surgeon, which is a valuable

addition to the literature of obstetrics.DIATHERMY.

With Special Reference to Pneumonia. Secondedition. By HARRY EATON STEW ART, M.D.,formerly Attending Specialist in Physiotherapy,U.S. Marine Hospitals. New York ; Consultant inPhysiotherapy, U.S.V.B. Hospital. New Haven,Conn. New York : Paul B. Hoeber. 1926.Pp. 208.$3.00.THIS introduction to the medical and surgical uses

of diathermy, with special reference to the treatmentof pneumonia, has been increased by 18 pages inits second edition. Additional instruction for theapplication of diathermy to the lungs of adults andchildren is given. The author is now able to speakfrom experience gained in the treatment of 248 casesof pneumonia—more than three tirnes the numberwhich had been treated when the first edition of thebook was published. Nearly all have been cases oflobar pneumonia. Particulars of 159 are given intabular form. Information is given regarding the


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