1189

service of health insurance) happily render legislationlargely unnecessary. One might add another dis-crimination in the treatment of human beings andanimals. Under the 1911 Act (replacing the InjuredAnimals Act of 1907) the police can, on the certificateof a veterinary surgeon, obtain the destruction of ananimal which is mortally injured or so diseased or insuch a physical state that it is cruel to keep it alive.We have not yet reached the point at which on formalmedical certificate human beings can be similarly putout of their misery.

CATARACT IN DYSTROPHIC MYOTONIA.

MYOTONI3 congenita or Thomsen’s disease is a

condition in which any attempt to use certain musclessets up a. rigidity in them so that, for example, whena patient grasps anything he is unable to relax hisgrasp for an appreciable time. Fifteen years agothe late Dr. F. E. Batten with Mr. H. P. Gibbpublished a paper showing that certain cases thathad been described as examples of muscular atrophyin Thomsen’s disease really belonged to a distinctand independent category. Two facts were subse-quently discovered-one, that the disease whichhad been known to be, as a rule, familial, alwaysoccurs in some members of a number of families ofthe same child-rank in relation to a common ancestor ;the other, that one of the extra-muscular symptomsthat go along with the disease is a form of cataract.In the dystrophic generation some members whoare not otherwise aftected may have prematurecataract alone. Affected members may also have it,and-a very remarkable circumstance-even in othergenerations of the same stock where there is no memberaffected with the muscular symptoms cataract is Inot uncommon. If we go back for two generationsbefore the affected one the cataract is generally ofthe ordinary senile type. In the generation imme-diately preceding the one with the affected stock itis generally presenile and in the affected generationalways. The subject has recently been investigatedby Dr. W. J. Adie, who, in the November number ofthe British Journal of Ophthalmology. suggests thatmany of the cases which have been described as

tetany cataract are examples of this disease. In1912 J. Hoffmann put forward the theory that all thesymptoms, both muscular and ocular, were the resultof a general intoxication, due to a disturbance inthe organs of internal secretion or of the centralnervous mechanisms that control them. Anothersuggestion is that the toxin that causes the cataract isthe result of the breaking down of the musculartissue. According to Dr. Adie, cases of dystrophiamyotonica have been reported from all over the world,their numbers now running into hundreds. He hashimself found records of 66 cases in which cataractwas a symptom occurring along with the muscularsymptoms. In 41 cases he found records of cataract

occurring in the affected stock, either in the same orin previous generations, without the accompanimentof muscular symptoms. This evidence, supportingas it does that of many other authorities, makes itclear that a connexion exists between cataract and

a congenital constitution, one of whose manifestationsis a peculiar affection of the muscular system.According to all observers the cataract begins in theposterior cortex. According to B. Fleischer 2 itripens fairly quickly to a total soft cataract with asmall nucleus at about the same time in both eyes.It is highly probable that the connexion that many ofthese cases have with a general disease has hithertopassed unnoticed. It would therefore be well ifwhenever an ophthalmic surgeon comes across a

case of presenile cataract he would make carefulinquiries with a view of eliciting a possible connexionwith muscular cramps and muscular atrophy,either in the patient or in the relatives, near or

remote.

1 Brain, 1909.2 Archiv für Ophthalmologie, 1918 xcvi., 161.

BISMUTH TREATMENT OF SYPHILIS.

Dr. H. de T. Shivers, chief of the United StatesPublic Health Service for the Treatment of Genito-urinary Diseases, records his observations on 60syphilitic patients treated by bismuth, nearly all ofwhom were in the tertiary stage. The vast majorityshowed improvement, and with the exception of threecases the reactions following the administration of thedrug were rare and not severe. Potassium bismuthtartrate with butyn was the preparation exclusivelyused; 0-lg. was the dose given in ordinary casesonce a week, and 0 ’2 g. in more severe cases. A totalof 2 g. was administered, and after an interval offour weeks a second course comprising the samenumber of injections was given. If a third series of20 injections was needed the rest interval was longer.A few patients with early secondary syphilis whoresisted arsenic responded to bismuth. The effect ofthe drug on tertiary lesions was rapid and in somecases more favourable than that due to arsenic. Inneurosyphilis relief of meningeal headache was asprompt as after salvarsan. In cerebral syphilisbismuth was effective in controlling convulsions andin relieving insomnia and nervousness, while in tabesit was more successful in checking the lightning painsthan arsenic. Its action on the Wassermann reactionwas fairly satisfactory, as 16 patients, or 26 ’6 per cent.,gave a negative reaction after a total dosage of 4 g.None of the patients developed stomatitis, probablybecause the drug was never given more often thantwice a week, and also because they received carefulinstructions in the proper care of mouth and teeth.Bluish-grey lines on the gums were seen in a fewpatients receiving 0 -2 g. a week. Only three patientsdeveloped severe reactions which consisted in severechill, high fever, nausea and vomiting, and a feelingof marked oppression in the chest, but the occurrenceof such reactions is a warning that the administrationof bismuth is not without some danger to the patient,and that the same care should be exercised in its useas in the cases of salvarsan preparations.

SCHISTOSOMIASIS IN NATAL.URINARY schistosomiasis, or bilharziasis, is quite

the most common form of parasitic infection in manin Natal. Although the prevalence of this disease hasbeen recognised since 1864, when Dr. Tobn Harleyfirst detected the characteristic terminal-spined eggsin a case of haematuria in that colony, its importancefrom a public health standpoint has once more beenemphasised by Dr. C. G. Kay Sharp, Medical Inspectorof Schools, Natal, in an article he has contributed onthis subject to the South African Medical Record ofOct. 25th. The infection appears not to be confined tothe native or Asiatic, but is also prevalent in Europeanschool-children. The coastal area of the province isheavily infected, especially the river estuaries, whereswamps and lagoons form in which the molluscs whichact as intermediaries abound. The exact proportionof natives infected with this parasite is difficult toascertain, since a large number never seek Europeanmedical advice, but the incidence amongst women isknown not to be high, as they are not permitted tobathe in public places, and so do not risk the dangerof infection. Dr. Kay Sharp has collected records of300 eases of urinary schistosomiasis in school-children,the proportion being 40 out of 300 in an Indian schoolat Stanger, while in nine European schools 64 cases ofhaematuria were discovered, and it is estimated that inDurban 2--1 per cent. of the male school population isafflicted in this manner. In young persons thehaematuria is most marked after exertion, especiallyon a hot day. Symptoms may include headache,digestive disturbances, and giddiness, results oftoxic absorption, pyrexia, urticaria, abdominal pain,pulmonary symptoms, and emaciat.ion. The tingling,or itching, of the skin, due to penetration of thecercariae through the integument, is a fairly common

1 Archives of Dermatology and Syphilology, October, 1924.

1190

symptom after bathing. Attacks of appendicularcolic, due to deposition of the eggs in the appendix,have also been observed. Dr. Kay Sharp’s recommen-dations regarding the prevention of the spread of thisform of schistosomiasis are various. Firstly, it shouldbe made compulsorily notifiable to the healthauthorities, while indigent sufferers should be given freetreatment. Every effort should, therefore, be made topersuade sufferers, by means of propaganda andeducation, to seek treatment. All rivers, spruits, andlagoons which are known to be infected should beadvertised to the public, and warning notices erectedat public bathing-places. The keeping of domesticducks, which feed on freshwater snails in infectedwaters, should be enthusiastically encouraged. It isstated that small minnows, known as

" millions," areuseful also in this respect, as they are said to feed uponthe cercariae. Certain wild birds, such as ducks,egrets, herons, flamingoes, ibis, and storks which alsofeed on snails, should be vigorously protected. It haseven been suggested that the importation of a bird,known as the Australian mudlark, might be advisable.

INTRA-UTERINE OVARIAN GRAFTS.

THE operation of transposing the ovary with itsneurovascular pedicle into the uterus is intendedto preserve menstruation with the possibility ofpregnancy in women after double salpingectomy.In a recent communication read to the Académiede Medecine, Paris, Prof. T. Tunier brought forwardconsiderable clinical and experimental evidence infavour of this procedure. In his experience theefficiency of the operation is undoubted, althoughthe results are not constant. Since July, 1922,he has performed the operation on 38 occasions ;after excluding seven cases operated upon sinceMay, 1924, it was found that nearly 90 per cent. ofthe remainder had regular periods, sometimes moreprofuse than formerly and occasionally preceded bypainful symptoms. Pregnancy with normal labourwas recorded in one instance. There were no deaths,but late hysterectomy was necessitated on twooccasions, including one for intestinal obstructionnot related to the ovarian transposition ; also, onelaparotomy was performed for a post-operativeheemorrhagic extravasation. Two other patients ran-a temperature of 38° C., which was accompaniedby a painful sero-purulent vaginal discharge, and inone a gangrenous ovary was extruded. Theseaccidents were ascribed to imperfections inseparablefrom the evolution of a new technique, of which adetailed account, illustrated by 14 well-printedplates, appeared recently. 2 The operation includesresection of both tubes, mobilisation of the intactovary, and its fixation into a previously dilated uterus ;the uterine wound is afterwards brought togetherby three or four interrupted catgut sutures followedby a second series of linen Lembert serous suturesclose together. It is necessary to be sure that theovarian pedicle is not constricted and that peritoneal-isation is perfect. No definite conclusion can, of course,be drawn from such a small number of cases, nor hassufficient time elapsed to judge of the after-results,but the incidence even of one pregnancy among his38 cases is of great interest. On the other hand,the preservation of menstruation which may bemore profuse than formerly and may be preceded bypainful symptoms is not likely to be welcomed bythe patient unless she is keenly desirous of embracing.even a slender chance of another pregnancy.

A CASE OF LEISHMANIASIS IN RIGA.

Dr. R. Adelheim reports, from the Pasteur Instituteof Riga (Latvia), a very carefully investigated case ofleishmaniasis in a child of 5. He observes that I

1 Bulletin de l’Académie de Médecine, 3e série, tome xcii.,No. 33. Paris : Masson et Cie.

2 Surg., Gyn., and Obst., October, 1924, p. 401.3 Archiv für Schiffs- u. Tropen-Hygiene, September, 1924,

xxviii., 9, 367.

tropical diseases are always slipping into Europenow and must be kept well in mind by doctorswho see puzzling cases. The child’s illness hadcome on insidiously four months before with fever,loss of weight, and anaemia. Dr. Berkholz, who sawher on July 30th, 1921, noted that the spleen wasgreatly enlarged and hard, and that the liver wasslightly enlarged too. A blood examination showedred blood corpuscles, 2,290,000 ; white blood corpuscles,4100 ; haemoglobin, 40 ; differential counts taken aboutthat time gave, per cent., lymphocytes, mostlysmall, 77 ; neutrophiles, 20 (3 immature, 12 band-form, and 5 segmented nuclei); large mononuclears,2 ; no eosinophiles; myelocytes, 1. No malariaparasites could be found, but there were manyleishmania parasites in a smear of blood obtainedby splenic puncture. Various remedies were tried,but no improvement was observed until antimonytartrate was given intravenously about the middleof September, when she began to pick up rapidly.The red count went up quickly to 4,000,000, thewhite to 7400, and, per cent. in differentialcount, there were: lymphocytes, 50; neutrophiles,40 (2 immature, 26 band form, and 12 seg-mented nuclei) ; large mononuclears, 8 ; myelocytes, 2.By Christmas the child was well, thanks to theantimony. The father was a high Russian official,three months returned from Tashkent, RussianTurkestan, where the family had lived comfortably,and the little girl had hardly been at all in touchwith native children. It appeared, however, thatthey had brought back with them a German dog, inbad health, and always getting thinner. No leish-mania were seen in a smear of its blood either, but,at the post-mortem, the spleen was found muchenlarged, the liver slightly, there were characteristicabdominal haemorrhages, and many parasites in thespleen smear. With the spleen juice Dr. Adelheiminjected white mice subcutaneously, and some ofthem contracted the disease. The author is ofopinion that the disease is not carried by a parasitesuch as a flea, but most likely by the stools. Thisquestion might well be the subject of a research by amedical officer in the Mediterranean, where thisdisease is tolerablv freauent.

THE MEDICAL DIRECTORY, 1925.THE eighty-first annual issue of the Medical

Directoryl appears a month in advance of its date,while many of the corrections which it contains arequite recent. A sign of the times is the omission ofthe Dental Section, after an association of 57 years’standing, owing to the fact that the publishers proposeto issue shortly a separate directory of graduates andlicentiates in dental surgery, intended to fill the wantfelt by many people for an inexpensive self-containeddental directory. The space so saved seems likelyto be utilised in other ways, for on pages lxxxvi. andlxxxvii. will be found the first instalment of a list ofmembers of the British Association of CertificatedMasseurs, which is to be increased in a later edition.There is no doubt that further additions of names andaddresses of other groups of medical helps would beuseful to practitioners. Other features of the Directoryremain unchanged, except that in the list of titlesconferred upon members of the medical professionappears for the first time the name of a woman. Thenumerical summary records a total of 49,351 names,showing a substantial increase in every section exceptthat of the Services, where the 1922 figure of 3475names looks unlikely to be again reached. In roundnumbers, the additions in London are 250, in theProvinces 500, in Wales 80, in Scotland 550, inIreland 200, abroad 300. The section of British Spasand Climatic Health Resorts, fresh and informingthough it is, loses prestige from the omission of thecorresponding section on foreign resorts which usedto appear. The only misprint we have noticed is in thetitle of a well-known medical official, but it is unfortu-

1 Messrs. J. and A. Churchill. 30s.