PROCEEDINGS
OP THE
EOYAL SOCIETY OF MEDICINE
EDITED BY
JOHN NACHBAR, M.A., M.D.
UNDEH THE DIRECTION OF
THE EDITORIAL COMMITTEE
VOLUME THE FIRST
SESSION 1907-8
PART I.
CLINICAL SECTION ELECTRO-THERAPEUTICAL SECTION
DERMATOLOGICAL SECTION EPIDEMIOLOGICAL SECTION
LONDON
LONGMANS, GREEN & CO., PATERNOSTER ROW
1908
LONDON:
JOHN DALE, SONS AND DANIELSSON, LTD.,
OXFORD HOUSE,
GREAT TITCI1FIELD STREET, OXFORD STREET, W.
PROCEEDINGS
OF THE
EOTAL SOCIETY OF MEDICINE
VOLUME THE FIRST
COMPRISING THE REPORT OF THE PROCEEDINGS FOR THE
SESSION 1907-8
CLINICAL SECTION
LONDON
LONGMANS, GREEN & CO., PATERNOSTER ROW
1908
IV
Contents
November 8, 1907.
PAGE
Report on Mr. Jonathan Hutchinson’s Case of Aneurysm ... ... ... 21
Clinical Cases :—
Trigeminal Neuralgia : Excision of the Gasserian Ganglion after unsuc¬
cessful Intracranial Neurotomy of the Second and Third Divisions of
the Fifth Nerve. By Jonathan Hutchinson, Jun., F.R.C.S. ... 21
Myopathy. By Bertram Abrahams, M.B. ... ... ... ... 24
Myxoedema, with Unusual Features. By A. M. H. Gray, M.D. ... 26
Recurrent Dislocation of the Shoulders cured by Operation. By T. H.
Opknshaw, C.M.G., M.S. ... ... ... ... ... 29
Neuritis of Brachial Plexus, probably resulting from Arthritis of Shoulder-
joint. By W. P. Herringham, M.D. ... ... ... ... 31
Pigmentation with Enlarged Spleen and Leucopenia (? Splenic Anaemia).
By W. P. Herringham, M.D. ... ... ... ... ... 33
Congenital Heart Disease in Adults. By R. Murray Leslie, M.D. ... 34
Pneumothorax treated by Aspiration under the X-rays. (Abstract.) By
John Fawcett, M.D. ... ... ... ... ... ... 38
December 13, 1907.
Clinical Cases :—
Splenic Polycytlnemia with Cyanosis. By William Osler, M.D., F.R.S. 41
Traumatic Dislocation of Left Hip, replaced by Manipulation Thirteen
Months after the Injury. By T. H. Opknshaw, C.M.G., M.S. ... 43
Arteritis obliterans of Lower Extremity with Intermittent Claudication
(“Angina cruris ”). By F. Parkes Weber, M.D. ... ... ... 44
Methiemoglobinffimia of twelve years’ standing. By W. Essex Wynter, M.D. 48
Amyotonia congenita. By W. Essex Wynter, M.D. ... ... ... 48
Cure of Ascites by Permanent Drainage through the Femoral Ring. By
W. Essex Wynter, M.D. ... ... ... ... ... 49
Acute Anterior Poliomyelitis with Permanent Paralysis of the Diaphragm
and Abdominal Muscles. By W. Pasteur, M.D. ... ... ... 51
Gouty Deposit in the Olecranon Bursa. By J. Graham Forbes, M.D. ... 53
Bulbar Paralysis. By H. Batty Shaw, M.D. ... ... ... 55
Hepato-splenomegaly with Ascites. By H. Batty Shaw, M.D.... ... 56
Ochronosis. By Edgar Reid ... .. ... ... ... 57
Contents
v
January 10, 1908.
Clinical Cases :— page
Polycythaemia, with Enlarged Spleen without Cyanosis, in a girl aged 18.
By R. G. Hann.. ... ... ... ... ... ... 59
Hemihypertrophy. By P. Lockhart Mummery, F.R.C.S. ... ... 61
Multiple Telangiectases. By Sidney Phillips, M.D. ... ... ... 64
Multiple Hereditary Developmental Angiomata with Recurring Epistaxis.
By F. Parkes Weber, M.D. ... ... ... ... ... 65
Complete Transverse Resection of Pharynx with Laryngectomy for
Carcinoma of Posterior Pharyngeal Wall. By W. Sampson Handley,
M.S.. ... 66
Congenital Absence of Left Pectoral Muscles. By J. Graham Forbes,
M.D. 71
Meningitis complicating Otitis media, with Lumbar Puncture. By
A. E. Barker, F.R.C.S. ... ... ... ... ... ... 74
Multiple Subcutaneous Rheumatic Nodules. By Herbert French, M.D. 75
Fatal Acute Illness in a Child from Status lymphaticus. By Sidney
Phillips, M.D. ... ... ... ... ... ... ... 75
Report on Dr. Forbes’s Case of Gouty Deposit in the Olecranon Bursa ... 80
February 14, 1908.
Note on Two Cases of Gaertner Infection in Infants. By F. E. Batten, M.D.,
and J. G. Forbes, M.D. ... ... ... ... ... ... 81
Clinical Cases :—
Lymphangioma of Face. By J. Paul Roughton ... ... ... 91
Tumour of Mediastinum (? Hydatid Cyst). By Herbert French, M.D. 93
Old Fracture of Humerus, with Osteo arthritis of Elbow. By R. J.
Godlee, F.R.C.S. ... ... ... ... ... ... 95
Old-standing Dislocation of Patella, with Osteo-arthritis of Knee. By
R. J. Godlee, F.R.C.S. ... ... ... ... ... ... 96
Ruptured Aortic Valve. By Seymour Taylor, M.D. ... ... ... 97
Caseating Pulmonary Tuberculosis treated by Tuberculin (T.R.) and
Fresh Horse Serum, both administered by the Mouth. By Arthur
Latham, M.D. ... ... ... ... ... ... ... 100
Spurious (?) Acromegaly. By F. Parkes Weber, M.D. ... ... 104
Lateral Curvature Rapidly Developing in a Boy. By W. G. Spencer,
M.S. ... ... ... ... ... ... ... ... 105
Excision of the Body of the Scapula. By R. P. Rowlands, M.S. ... 105
Multiple Dislocations in a Child, aged 2 weeks, the result of mal¬
position in utero. By T. H. Opknshaw, C.M.G., M.S. ... ... 106
Myositis ossificans. By C. A. R. Nitch, M.S. ... ... ... 107
Sarcoma of Thigh. By H. A T. Fairbank, M.S. ... ... 109
VI
('on tents
March 13, 1908.
Clinical Cases :— page
Hermaphroditism, in which the Uterus occupied the Sac of an Inguinal
Hernia. By Thomas H. Kellock, F.R.C.S. ... ... Ill
Angina pectoris with Aortitis. By F. Parkes Weber, M.D. ... 114
Purpura hemorrhagica with Fatal Result from Cerebral Hemorrhage.
By S. W. Carruthers, M.I). ... ... ... ... ... 120
Cerebellar Tumour with Proptosis. By J. Porter Parkinson, M.D., and
J. Stroud Hosford, F.R.C.S.Ed ... ... ... ... ... 124
April io, 1908.
Fatal Lymphocythemia in Early Life. By J. Graham Forbes, M.D., anil
Frederick S. Langmead, M.I). ... ... ... ... ... 129
Clinical Cases :—
Right Hemiplegia and Atrophy of Left Optic Nerve. By Leonard G.
Guthrie, M.D., and Stephen Mayou, F.R.C.S. ... ... ... 180
A Case, three years and nine months after Complete Excision of the
Larynx, showing an Improved Method of Speaking. By Charters J.
Symonds, M.S. ... ... ... ... ... ... ... 184
A Case showing the Phonetic Condition after Removal of One Vocal Cord.
By Charters J. Symonds, M.S. ... ... ... ... ... 185
Two Cases of Lymphangioplasty for the Brawny Arm of Breast Cancer.
By W. Sampson Handley, M.S. ... .. ... ... ... 186
Ascites: Paracentesis performed twenty-five times in one year and three
months; patient quite well seven years later. By Francis Hawkins,
M.D. ... ... ... ... ... ... ... ... 190
(Edema of Hands and Feet with Mediastinal A flection. By F. Parkes
Weber, M.D. ... ... ... ... ... ... ... 192
Ha'mangiectatic Hypertrophy of the Foot, possibly of Spinal Origin. By
F. Parkes Weber, M.I). ... ... ... ... 193
Myxcedema with Optic Atrophy. By Norman Moore, M.I). ... ... 194
Spurious Acromegaly in a Patient suffering from Exophthalmic Goitre,
associated with a Congenitally High Forehead. By David Walsh, M.I). 195
Result 8f Operative Treatment for Chronic Bilateral Empyema of the
Frontal, Ethmoidal, and Sphenoidal Sinuses. By Herbert Tilley,
F.R.C.S. ... ... ... ... ... ... ... 196
An Appliance for obtaining Extension of the Spine in the Treatment of
Scoliosis and Caries. By T. H. Openshaw, C.M.G., M.S.
Report on Dr. Essex Wynter s Case of Cyanotic Amemia
196
197
Content*
Vll
May 8, 1908.
PAGE
A Case of Arterio-venous Anastomosis for Senile Gangrene. By C. A. Ballance,
M.V.O., M.S. ... ... ... ... ... ... ... 199
A Case of Leucodermia which died with Symptoms of Addison’s Disease, and in
which Cirrhosis of the Suprarenals was found. By Norman Dalton, M.D. 209
Clinical Cases :—
Hairball in the Stomach. By G. F. Still, M.D. ... ... ... 212
Rupture, of the Upper Cord of the Brachial Plexus at Birth. By Sir
Thomas Barlow, Bt., K.C.V.O., M.D., and C. A. Ballance, M.V.O.,
M.S. .215
Gross Lesion of Post-central Gyrus associated with Astereognosis. By
Porves Stewart, M.D. ... ... ... ... ... ... 220
Three Cases of Gout showing Destructive Changes in Bone. By J. Barnes
Burt, M.D. ... ... ... ... ... ... ... 223
A Case in which, for Recurrent Sarcoma, parts of the Femoral Artery
and Vein were excised. By C. H. Faggb, M.S. ... ... ... 281
Aneurysm of the Common Femoral Artery ; Excision of Aneurysm and
Common Femoral Vein. By C. H. Fagge, M.S. ... ... ... 232
Scleroderma. By G. A. Sutherland, M.D. ... ... ... ... 238
Multiple Symmetrical Lipomata. By Albert Carless, M.S. ... ... 238
Caries of Spine with Clubbing of Fingers and Toes. By P. Maynard
Heath, M.S. ... ... ... ... ... ... ... 234
Multiple Idiopathic Hemorrhagic Sarcoma of the Skin. By F. Parkes
Weber, M.D. ... ... ... ... ... ... ... 235
Two Cases of Congenital Absence of both Thumbs, &o. By Henry
Curtis, F.R.C.S. ... ... ... ... ... ... 236
Case of Multiple Rheumatic Nodules in an Adult. By Francis
Hawkins, M.D. ... ... ... ... ... ... 237
The Council think it right to state that the Society does not hold itself in any way
responsible lor the statements made or the views put forward in the various papers.
Clinical Section.
October 11, 1907.
Sir Thomas Barlow, Bt., K.C.V.O., President of the Section, inthe Chair.
PRESIDENTIAL ADDRESS.
At this our first meeting I crave your indulgence while I endeavour
to set forth some of the great services done for medicine by the Clinical
Society of London, of which our section is the lineal representative. It
is close upon forty years since the Society was founded. The draft rules
were prepared by a committee consisting of Dr. Buchanan, Mr. Callender,
Dr. Greenhow, Mr. Heath, Dr. Ringer, and Dr. Sanderson, and of these
Dr. Ringer is the sole survivor. From its start the primary object of the
Society was recognised as the record, investigation, and discussion of
individual cases. It was resolutely concrete, and the aim was to make
the bedside observation of disease as accurate, complete, and useful as
possible, and, where feasible, subsequently to sift and verify the records
in so far as they might be imperfect.
It is abundantly obvious that the founders of the Society were strongly
opposed to academic discourses on general topics, and by the suggestion
of ten minutes as the usual time to be allowed for a communication they
indicated the necessity of keeping close to the case. The lines of the
constitution were singularly uncongenial to medical advertisement and
medical rhetoric. The rules even dictated, somewhat didactically, the
order in which the various parts of a case should be given and
subsequently considered.
While pondering over these regulations of forty years ago, one can
fancy that behind them there emerges the embodied presence of some
great hospital clinical teacher, who keeps his students close to the bedside,
compelling the case ever to unfold itself under their investigation, then
takes them to the post-mortem room for verification, and throughout
all is absolutely intolerant of speculative nonsense and the non-scicntific
use of the imagination.
2 Barlow : Presidential Address
A special feature was to be the arrangement for small committees of
one or more members to co-operate in investigation with the original
contributor in the cases which were still incomplete. This practice was
maintained for two or three years, but gradually receded into the back¬
ground. It might be advantageous to resuscitate it. Authority was
also given to the president to appoint larger committees for the conjoint
investigation of clinical and‘therapeutical questions. Enormous advan¬
tage has accrued to medicine from the carrying out of this provision.
The first president of the Society was the venerable Sir Thomas
Watson, and the first ordinary meeting was held on January 10, 18()8.
In his introductory address he plunges at once into the great deficiency
of modern medicine on the therapeutical side. While recognising the
value, when it can be obtained 44 without harm or hazard to the sick, of
knowledge of the course, tendencies, and results of diseases when left to
themselves,” lie appeals “ for attempts to be made to bring the thera¬
peutic department of medicine to a nearer level with those other parts
which are strictly ministerial to this.”
In the first volume we find cases of hyperpyrexial rheumatism
• recorded by Hermann Weber, Murchison and Sanderson, following on
those which had been specially described by Ringer in 18B7. This
subject recurs again and again in our Transactions. At last it receives its
clinical quietus, along with the full discussion of the different methods of
cold-bath treatment, in the elaborate report of a special committee which
was submitted to the Society in 188*2.
Dr. Greenhow was for many years treasurer, and he was a tower
of strength to the Society. In this first volume he reports cases of
paroxysmal hemoglobinuria, in which the essential features of the
malady are set forth. These cases are investigated and verified by
Dr. Paw and Dr. Dickinson. It is interesting to note in limine that
Greenhow’s second case showed characteristic signs of Raynaud’s dis¬
ease. They are carefully described, though no comment is made upon
them. Burdon Sanderson was the first medical secretary. He discusses,
with the aid of the sphygmograph, the significance of the hard pulse in
a case of Bright’s disease.
The last case in the volume is a typical one. It is by Andrew Clark,
and it contains his exposition of fibroid phthisis, which he claimed to be
a clinical entity absolutely distinct from tubercle. That Clark’s
vigorous contentions were not accepted as entirely conclusive is shown
in the second volume by cases carefully recorded by Douglas Powell,
under the title of “ Phthisis with Contracted Lung.”
o
( 1 linical Section
3
In therapeutics examples are given of Pavy’s treatment of diabetes
with opium; Broadbent initiates his suggestion on tlie pharmacological
affinities of some of the metals, and Gee gives his report on the
pharmacology of apoinorphia.
Paget’s presidential address, reported in the third volume, is a
masterpiece. He maintains the dignity and value of case records.
He compares them to the case law of a sister profession, and holds
that clinical science has as good a “ claim to the name and rights and
self-subsistence of a science as any other department of biology.”
Clinical facts, he says, are as certain as anything in biology, and have
remained certain for centuries, while the explanation of them has
changed with every successive change in physiology. The piquant
dictum that there has never been an error in practice which has not
been supported bv deductions from contemporary physiology is a
warning that ought never to be forgotten. It reminds us of Gull's
charming paradox. A doctor told him of a drug which he said was
useful for the relief of a given symptom. Gull was grateful, but
when the doctor proceeded to explain the rationale of the action of the
drag Gull doubted the accuracy of the original observation. In this
third volume Lauder Brunton’s initial case of angina pectoris treated by
nitrite of amyl appears, and may be fairly quoted against Gull as an
instructive example of physiological suggestion. It has certainly opened
up a valuable field of therapeutic resource.
In the fourth volume, for the year 1871, the most masterly case is
one recorded by Hughlings Jackson on hemiplegia in a syphilitic subject,
which anticipates most clearly vrhat has subsequently become common
knowledge respecting the different modes in which syphilis can affect
the brain.
Gull’s tw T o presidential addresses, suggestive as they were, cannot be
compared in value to his two papers on anorexia nervosa and on the
cretinoid state supervening in adult life in women. If he had never
written anything more than these two papers they would stamp him as
one of the greatest clinicians of his time. With respect to anorexia
nervosa, it may be claimed that the title given by Gull is more truly
descriptive than any of those which have been subsequently employed ;
his clinical discrimination of this disease from tubercle, and his account
of the proper lines of treatment, are both admirable.
Far be it from me to belittle the value of Weir MitcheU’s subsequent
papers on treatment, with the three formulas of over-feeding, massage,
and isolation. But in this country I believe that compulsory and
4
Barlow : Presidential Address
specialised isolation has often been made a fetish, and that the elaborate
and costly ritual of rest cure in nursing homes has sometimes given
justifiable cause for the enemy to blaspheme against English medicine.
Some of the most important contributions to our Transactions are
those on myxoedema, a disease the major part of the elucidation of
which may be claimed by this Society. After the appearance of Dr.
Ord’s original memoir in the Medico-Chirurgieal Transactions , case after
case was demonstrated in our meetings. The mucous degeneration of
the connective tissue, to which I think it is not unfair to say Dr. Ord
ascribed a somewhat disproportionate importance, was for some time
placed in the forefront as the essential anatomical feature. It is signifi¬
cant that in some of the early cases which were demonstrated to this
Society no reference is made to the atrophy or alteration of the thyroid
gland, although Ord had described these morbid conditions.
The report of the committee, with Ord as chairman and Hadden
as secretary, appointed in 1883, was submitted in 1888. With its
wealth of experimental, pathological, and clinical data, the volume
constitutes the most valuable publication of the Society, and redounds
to the honour of its contributors. It is only fair to recall that the all-
important additions to the subject made by George Murray and Hector
Mackenzie, in the therapeutic employment of thyroid extract, were given
to the profession subsequently. But let it never be forgotten that the
pioneer in this subject was Sir William Gull, in his simple, concise, and
suggestive reports of cases of the cretinoid state supervening in adult
life in women, and that Hilton Fagge’s observations on sporadic cretinism
in children helped to pave the way.
After myxoedema comes acromegaly, and the earliest cases of Marie's
disease described in England were presented to the Clinical Society by
Mr. Godlee, Dr. Hadden, and Mr. Ballance.
The early volumes contain a succession of cerebral cases by
Broadbent which are models of diagnostic analysis, and the Society
owes a debt of gratitude to Buzzard, w r ho was the second secretary, and
to Anstie and to Dyce Duckworth, who in the early struggling years
helped with valuable clinical material when sometimes the general supply
was scanty. Jenner’s presidential address in 1874 is still vivid in the
minds of those who heard it, for its candid statement of the deficiencies
in knowledge of the etiology and personal receptivity of the acute
specific diseases, and for his claim for the recognition of the experiences
on these subjects of general practitioners in thinly-populated country
districts.
Clinical Section
o
In this connection ought to be mentioned Murchison’s contribution
on the period of incubation of scarlet fever and of some of the other
fevers. This appeared in 1878, and gave the impetus to further enquiry.
A committee which was then appointed was reconstituted ten years
subsequently to further investigate the periods of incubation of the acute
specific fevers. The report, edited by Dr. Dawson Williams, may be
claimed as the most complete summary of reliable data on this important
subject. Here also may be mentioned many valuable papers by Dr.
Goodall, Dr. Francis Hawkins and others, on the complications and
sequelae of typhoid fever, and an important summary by Dr. Tooth of his
personal experiences of typhoid amongst the English troops in the Boer
war. Finally, in this group of subjects the report on the antitoxin treat¬
ment of diphtheria, edited by Dr. Pasteur, must never be forgotten. It
represented a detailed and exhaustive enquiry on a large scale, and con¬
tributed largely to the confidence with which that form of serotherapy
has become universally adopted in the English treatment of diphtheria.
Sir Andrew Clark, for so powerful a hospital teacher and so successful
a general physician, left behind him far too little in medical literature
adequately to perpetuate his influence in succeeding generations, and we
are happy in possessing, in his presidential address of 1882, an excellent
example of his somewhat rhetorical style and of his vivid practical
teaching on the treatment of the common ailments of modern
civilisation.
Equally characteristic is the presidential address of one who was a
devoted member of this Society, and who, alas! has been recently taken
from us. I mean Sir William Broadbent. In this address his generous
recognition of experimental pathology and of the help of surgery to
medicine, his defence of the cold-bath treatment of hyperpyrexia, and his
warning against antipyretic drugs are forcibly stated, and so is the claim
which he repeatedly made for the consideration of chemical affinities
of the elements as suggestive of therapeutic employment. Time
prevents my alluding in detail to the addresses of the other medical
presidents—Sir Dyce Duckworth, Dr. Buzzard, Sir R. Douglas Powell
and Dr. Frederick Taylor—every one of which embodied important
practical suggestions arising out of the work of the Society.
But there are some papers of special interest which cannot be ignored
because it is earnestly desired that further illustrative cases may be
forthcoming in the early future. Amongst these I refer to the group of
cases of localised obliterative arteritis recorded by Mr. Pearce Gould,
Dr. Hadden, Mr. Morgan and Mr. Spencer. It is almost certain that other
6
Barlow : Presidential Address
types of recoverable arterial sclerosis and combined arteritis and phlebitis
will be found if looked for, and that chronic forms of erythromelalgia will
yield evidence of localised lesions more marked on the vascular than on
the nerve side. The family groups of inherited splenic enlargement
recorded by Dr. Claude Wilson and Dr. Batty Shaw are sure to bring to
light further examples, and the same may be said of Dr. Parkes Weber's
case of cyanosis with polycythaemia and splenic enlargement.
The Society has done its share towards the advancement of the
study of skin diseases. Urticaria pigmentosa was gradually placed on its
right basis by succeeding contributions at our meetings. The bromide
and iodide eruptions, the uraemic eruptions, generalised vaccinia,
Raynaud's disease, and the enema rashes, amongst others, have received
their early elucidation in this Society.
Concerning the surgical work of the Society I cannot trust myself to
speak in adequate terms. It has, to our shame, often loomed larger in
the horizon than medicine, and has seemed in many of our volumes to
show a fuller output of ameliorative result.
Let us never forget the work of our senior fellows, Heath and
Holmes (who have recently been taken from us in the fulness of years),
on distal ligature for aortic aneurism, and Croft on excision of
the hip. The special report on spina bifida, edited by Mr. Parker
and Mr. Shattock, is extremely complete with regard to the anatomical
types of this malformation and its operative treatment, and the report
on Charcot’s joint disease, edited by Mr. Pollard, not only gave
additional cases to those already demonstrated to the Society, but an
elaborate summary of all that was known of the morbid anatomy and
clinical characters of this affection.
With the papers dealing with surgical technique I am incompetent
to deal, but I may remind you of one very notable and philosophical
discourse by Lord Lister, when he was our president, concerning the
subject of ligatures. The most generally attractive of the surgical cases
have been those in which physicians and surgeons have jointly taken
part. Our Transactions mark the successive and beneficent invasions of
surgery into the diseases of the thoracic and abdominal viscera, as well as
into some of those of the brain and cord. Many of these advances have
not only benefited suffering humanity, but have added to our knowledge of
important points in the natural history of the respective diseases, and given
us information which the post-mortem room was inadequate to supply.
With respect to the surgery of the appendix, it is right to recall that
the first case of removal of calculus from the appendix for the relief
Clinical Section
7
of recurrent typhlitis was recorded in this Society by Mr. Charters
Symonds, and that the operation was performed at the suggestion of
Dr. Mahomed.
Mr. Henry Morris’s operation of nephrolithotomy has given a great
impetus to renal surgery, and the surgical treatment of intussusception,
thanks to Mr. Barker and others, is now on a far sounder basis than it
was before.
The operations for lesions of the biliary passages, for pancreatic
cysts, hydatid disease and abscess of the liver, for perforation of the
bowel in typhoid, for gastric ulcer, for neoplasms of the alimentary canal,
for injuries of the spleen, are only a few amongst the triumphs of
surgery which have been chronicled in our Transactions. The Clinical
Society has always welcomed the contributions of surgeons of the great
provincial centres. We trust we shall still secure their help, especially
in what I have called the combined cases.
I would remind you, in summing up our work, of the index to the
first thirty volumes, prepared by the indefatigable industry of Dr. Garrod.
The second part, which deals with subjects and contains endless cross
references, is invaluable for clinical investigation, and illustrates the
urgent necessity, emphasised by all medical bibliographers, that the titles
of papers ought to be made as complete and descriptive as is consistent
with a reasonable amount of head space.
After this somewhat lengthy revie'w I must ask your indulgence for a
very few minutes while I mention the modifications which must arise in
consequence of the absorption of the Clinical Society into the Royal
Society of Medicine. Mercifully, as regards the actual material and the
facility of placing it, there need be very little change. I need not labour
again the essential point that we are concerned with cases, and not
subjects. It is quite true that exceptionally, at times, our communications
broadened out into discourses on subjects illustrated by cases. Whatever
was permissible in this direction in former times, loyalty to our parent
Society will not now permit of papers of this type. Such papers ought
to be presented to the Medical and Surgical Sections of the Society, which
correspond to the old Medico-Chirurgical Society. But surely in times
past the accurate records of cases, duplicated, supplemented and corrected
by repeated subsequent reports, and ultimately collated by the special
committee, have been the staple of our wealth, and so they will continue
to be.
The later prosperity and popularity of the Clinical Society have been
nehanced by the increasing share given to the demonstration of living
8 Openshaw : Congenital Absence of Lower Part of Tibia
specimens. But it is extremely important that these living specimens
should be as thoroughly reported and investigated as possible.
The Council proposes to continue the custom of having the living
cases informally examined from 8 to 8.30 p.m. in the anteroom. But it
proposes to revert to the earlier custom of subsequently having them
demonstrated in the meeeting. I earnestly trust that comments which
have been made informally may be repeated in the meeting when the
demonstration takes place, so that moot-points may be canvassed and
illustrative examples may be quoted.
There is one development of the Section which I believe to be in
thorough harmony with its fundamental constitution, and which I will
explain. A clinical society or section ought surely to concern itself
with all improvements in clinical methods. I would remind you that
we have a few precedents for this. Among others I recall that Sir
William Gowers demonstrated his haunoglobinometer at one of the
meetings of our Society. We propose to get some of the modern methods
of clinical investigation demonstrated from time to time at our meetings.
As to the publication of our material, I believe the parent Society will
prove liberal and enlightened, and that our fellows will find that their
communications are in permanent print at an earlier period than in
former times.
Gentlemen, I cannot conclude without thanking you for the honour
you have conferred upon me. For the Clinical Section of the Royal
Society of Medicine I can desire no greater boon than that it should
maintain the great tradition of the Society of which it is the real repre¬
sentative, and for myself I can but say that to follow in the footsteps of
my great predecessors—the leaders of English medicine and surgery
during the last forty years—is not only an honour, but entails an infinite
obligation.
A Case of Congenital Absence of the Lower Part of the
Tibia.
By T. IL Openshaw, C.M.G.
H. H. W., a male child, aged l) months. The child was born at
full term. The labour was instrumental, and liquor amnii was absent.
The mother’s health during pregnancy was good, and there was no
history of injury. There was no family history of malformations. In
the right ley the tibia was fractured at its centre ; the lower end of the
upper fragment formed a conical projection forwards, beneath a well-
Clinical Section
9
marked dimple of the skin ; the lower fragment also ended in a somewhat
sharp extremity; the internal malleolus was absent. The fibula was
enlarged and curved, and there was a dimple over its upper extremity ;
the external malleolus was much enlarged. The foot was in a position of
extreme varus, but, wdth the exception of the great toe, which was
atrophic, it w r as well developed. In the left leg only the upper fifth of
the tibia was present. There was a deep depression over the centre
of the upper part of the leg, corresponding with the edge of the fibula.
The fibula was much enlarged and curved, and the external malleolus
was very prominent. The foot was in a position of extreme valgus, and
the great toe was absent.
Mr. Openshaw considered that amputation was not advisable in
these cases, but that the foot and leg should be straightened by means of
tenotomy, splints and manual osteoclasis, maintained in the straight
position, and allowed to grow. The stump thus produced, if properly
fitted with a suitable walking appliance, enabled the patient to walk much
better in later years than would be the case w r ere amputation at the
knee-joint to be performed in very early life. The result of such
treatment was illustrated by the following case.
Congenital Absence of the Fibula and Outer Half of the Foot.
By T. H. Openshaw, C.M.G.
W. M., a boy aged 10. Presented congenital absence of the right
fibula, outer half of the foot, and two outer toes. This boy had been
fitted with a leather walking appliance, accurately fitting the foot and
leg and affording a firm support, to wdiich an artificial foot was attached.
With this appliance the boy was seen to w r alk so well that it was
impossible to notice that he had any defect. He could play football
and cricket, and run about all day like other boys. He had no other
congenital defect.
When the boy first came under observation four years ago, the tibia
was bent outwards at an angle of 120° at the lower end of the upper two-
thirds, and amputation of the leg had been advised. Cuneiform resec¬
tion of the tibia was performed, and the bone straightened. The wound
healed up slowly, but completely, firm bony union resulting. The leg
was kept straight, and allowed to grow until two years ago, when the
appliance, which the boy was still wearing, was fitted.
In answer to the President, Mr. Openshaw' stated that no other
malformations w-ere present in either of these cases.
10
Drew: Tuberculous Synovitis of Knee-joint
Tuberculous Synovitis of Knee-joint in which Arthrectomy
was Performed on Two Occasions, a Movable Joint
Resulting.
By Douglas Dkkw, F.R.C.tt.
N. H., aged 7, caiue under observation in February, 1903, with
chronic synovitis. Previously she had been under treatment at another
hospital for some months. The joint was much distended by fluid, but
there was no limitation of movement. The case was treated on a
splint, and Scott’s dressing at intervals was applied until September,
1904, but no permanent improvement resulted.
Operation (September 24, 1904).—The knee-joint was opened by means
of Kocher’s external incision. Owing to the looseness of the ligaments
from the distension, it was found to be possible to completely dislocate
the patella inwards, over the internal condyle without dividing the
ligamentum patellae or chiselling away the tubercle of the tibia with the
ligament attached.
The synovial membrane, which was studded over with miliary tubercle,
was dissected away, the inner part being rendered more accessible by
dislocating the patella. It was completely removed, except for that
part lying behind the crucial ligaments.
Passive movements of the joint were commenced on the twelfth
day after the operation.
The case was shown before the Clinical Society early in 1905, and at
that time appeared to be a complete cure. However, a few months later,
fluid reappeared in the joint and in spite of treatment on a splint it
showed no signs of improvement.
On May 16, 1905, the joint was re-opened through the old incision.
A small quantity of fluid escaped; the cavity was lined by a smooth
shining surface which was studded with minute tubercles. The synovial
membrane, or what represented that structure (as the true synovial
membrane had been removed at the first operation), was carefully
dissected away. This was much more tedious to perform than at the
first operation, as the structure was so fibrous.
It was found impossible to dislocate the patella and to get at the
synovial membrane of the inner part of the joint through the external
incision, and a vertical incision was made outward to the patella and this
portion of the membrane was removed.
Clinical Section
11
Dislocation of the Patella. ? Congenital. Operation. Cure.
By Douglas Drew, F.R.C.S.
L. C., aged 13, first came under observation seven years previously
with marked genu valgum.
On fixing the knee, the patella slipped outwards over the external
condyle until the internal edge looked directly forwards. She had been
treated for two years with splints. Macew r en’s osteotomy 'of the femur
was performed, and for two years after the operation splints were worn
without any effect on the patella.
The child was eventually lost sight of, and did not again return until
April, 1907, when she was exhibited at the Clinical Society. At this
time the condition of the patella was as heretofore, and a slight degree
of genu valgum was present. There was some weakness of the limb,
and the thigh muscles were small.
Various suggestions as to treatment were made, but the consensus of
opinion appeared to be in favour of again rectifying the genu valgum
before attempting anything else.
Largely influenced by a completely successful case which he saw
operated upon by Mr. Bilton Pollard in 1890, Mr. Drew decided to
proceed upon his method.
On May 14, 1907, a long external incision was made over the joint
dividing the fibrous capsule, but this was not enough to liberate the
patella, and the bone could not be held in position when the knee was
fixed until the synovial membrane had been as freely divided as the
capsule.
A similar internal, longitudinal incision was made into the joint, and
the capsule was overlapped to the extent of an inch and sutured in this
new position after the trochlear surface on the femur had been widened
and deepened by cutting and gauging. So far the operation was much
the same as that performed by Mr. Pollard, but it was found that it was
not sufficient, in that, on flexing the knee, the patella still tended to
ride outwards until it was situated over the external condyle. Mr. Drew
therefore united the ends of the lateral incision by a curved one passing
below the tubercle of the tibia. The tubercle was chiselled off with the
ligamentum patella? attached, and after denuding the internal tuberosity
of the tibia of its periosteum, the tubercle of the tibia was implanted and
fixed upon the denuded surface. On gently flexing the knee it was then
12
Drew: Dislocation of the Patella
found that the patella moved inwards fully half an inch, instead of gliding
outwards as before.
The case presents several points of interest:—
The condition is usually associated with some degree of genu
valgum, and by many surgeons it is regarded as secondary and
dependent upon this cause. On the other hand, it is by some looked
upon as a congenital deformity, and it is held that the genu valgum is
produced by the abnormal line of traction of the quadriceps when the
knee is in a flexed position. Others hold that it is produced by weakness
of the vastus internus, or ill-development of the external condyle of the
femur. Mr. Drew considered that the congenital theory is probably
correct, and that it may arise from some deficiency in the vastus internus.
If dislocation were due to genu valgum, it would be reasonable to
expect that by correcting the position the tendency to dislocation, if not
cured, would be lessened ; but this was not so in Mr. Drew’s case or in
Mr. Pollard’s, in both of which Macewen’s osteotomy had been per¬
formed some years previously.
That the femur is ill-developed or ill-shapen is true, but this probably
results from the patella not resting in its proper position when the knee
is brought from extension to flexion.
An important question must be answered before resorting to any
operation. Does the infirmity damage the utility of the limb to such an
extent as to call for operation ? In this case the limb was weak and
ill-developed, and probably if the patient had to work as a servant, or
had to kneel much, she would have found that it would have caused
trouble. Except for this weakness and the accompanying genu valgum
the limb w r as very useful, and unless it could be rendered a better
member the deformity probably would be better left alone, as the opera¬
tion is an extensive one and not devoid of risk.
Many different operations have been suggested and performed :—
(1) Excision (subperiosteal) of the patella.
(*2) Over-correction of the genu valgum, so as to correct the pull
of the quadriceps.
(3) Division of capsule and deepening of the trochlear surface of the
femur (Pollard).
(4) Transplantation of the patellar ligament and tubercle of the
tibia.
(5) Transplantation of semitendinosus or other muscle—sartorius
(MacLennan).
Transplantation of the semitendinosus tendon appears to me to be
Clinical Section
13
liable to still further weaken the limb; however, MacLennan, of Glasgow,
reports a successful result.
Excision of the patella could do nothing but harm.
Transplantation of the ligamentum patellae has given satisfactory re¬
sults and is easy to perform. In the case under notice it would have been
useless without dividing the capsule freely on the outer side of the joint.
Mr. Drew added that if another case of this nature came under his
care he should proceed in the same manner, adopting Mr. Pollard’s
method, as he obtained a perfect result by this procedure in 1890. If it
did not prove sufficient, as in the case before the meeting, then
transplantation of the tubercle should be added.
Case of Multiple Rheumatic Nodules in an Adult.
By A. E. Garrod, M.D.
The patient was a young woman, aged k 25, who exhibited nodules
closely resembling the rheumatic nodules of children, over the meta-
carpo-phalangeal joints of both hands, and upon both elbows. There
was a single nodule over each patella, and a larger one on the right
shoulder. She had suffered from a rheumatic affection for rather more than
two years, and for fifteen months had been unable to follow her occupa¬
tion as a milliner. There was some general swelling of the hands, and
the fingers could not be fully flexed ; there was also much general stiff¬
ness. The nodules were said to have been present for fifteen months
without noticeable change. Her heart was not affected, the cardiac dul-
ness was not enlarged, and no murmur was heard. The patient’s condi¬
tion had considerably improved with rest in bed, rather large doses of
sodium salicylate, and the application of Bier’s passive hyperemia treat¬
ment to the upper extremities. The swelling of the hands was less
marked, their movements were freer, and the nodules felt softer and
appeared to have diminished in size.
Dr. Garrod expressed the belief that the patient’s trouble was true
rheumatism, and that the nodules, although more lasting, were of the
same nature as the subcutaneous nodules of rheumatic children. He
considered that, unless the name of rheumatoid arthritis were to be applied
to any unusually persistent joint trouble, the present case could not be
included in that category, nor did the appearance of the affected joints
suggest that diagnosis. The absence of cardiac lesions, which are almost
always associated with the development of the nodules in children, he
was inclined to connect with the decreasing liability to such manifesta¬
tions in older patients.
14
Garrod: Multiple Rheumatic Nodules in an Adult
DISCUSSION.
Dr. Samuel West had seen several such cases in adults, and the worst of
the kind he had ever observed was in a woman of about 40 years of age, who
had rheumatic fever, although at the time she had these nodules she had no
distinct organic heart disease. She was seen later in another attack, and then had
distinct mitral trouble. There were very many nodules all over her body. The
peculiarity of the present case seemed to be tbe long duration of the nodules.
Sir Dyce Duckworth felt no hesitation in accepting Dr. Garrod’s diagnosis
of the case. The nodules seemed to be quite truly bred, and he recognised
them as rheumatic. Such lesions had too often been considered to be
ephemeral; he thought that was an inappropriate term in most of the cases.
He was familiar with the condition in adults, and in some cases the nodules
certainly lasted a long time. He thought that there was certainly a greater
proclivity to cardiac rheumatism in childhood ; whereas in adults the tendency
for the heart to be implicated was much less. He had very little doubt that,
under treatment, the nodules would disappear and that considerable improve¬
ment might be looked for.
Dr. Bertram Abrahams said that he thought such nodules were not always
rheumatic. Both in children and adults he had seen cases in which, in the
course of five years, no signs of rheumatism appeared. He thought that these
cases in adults, of which he had seen three or four examples, differed, apart
from the question of duration, in their extreme symmetry ; the nodules were
not in little clusters on the fingers as in younger cases. He had seen instances
in which the nodules were quite discrete and separate. He would like to hear
from Dr. Garrod whether he had seen any cases in which there was a reason¬
able possibility of excluding rheumatism.
Dr. F. J. Poynton said that, without entering into the pathology, he could
not see any reason why those nodules should not last for a considerable time
and become gradually more fibrous. His experience was in accordance with
the more extensive experiences of Dr. West and Sir Dyce Duckworth, that one
did meet with such nodules in adults lasting much longer than in children.
Dr. Garrod, in reply, said he did not bring the case forward as in any way
unique. He had seen other cases of nodules in adults of very similar character.
He brought forward tbe case as a good example of the condition, and as one in
which tbe connection with rheumatism seemed unusually clear.
The President said he looked upon the case as one of typical subcutaneous
rheumatic nodules, and thus agreed with the view expressed. It was the
condition typically seen in children. The point made by Dr. Garrod with
respect to the difference between the manifestations in children and adults was
very sound. He had seen a number of cases in adults, and it was true that the
association with rheumatic heart disease was not nearly so frequent in them as
in children. It was also true that in children the nodules were generally much
more ephemeral. He could recall cases in adults which had lasted about as
long as the present one. He did not think anybody who had watched the
progress of subcutaneous rheumatic nodules could have any doubt that the
present ones belonged to that class.
Clinical Section
15
Case of Pyo-pericardium cured by Drainage.
By F. T. Steward, M.S., and A. E. Garrod, M.D.
Lily S., aged 5 years 6 months, was admitted into the Hospital for
Sick Children, Great Ormond Street, under Dr. Garrod, on April 8, 1907.
Two days previously her tonsils had been removed, and the same evening
she complained of pain in the abdomen and left chest. On admission
the temperature was 103 u F., pulse 120, and there was dulness and
diminished air entry over the left chest below the angle of the
scapula. During the next few days the temperature fell to some extent,
but the signs of fluid in the left chest increased.
April 15.—The left chest was explored and pus found. She was
given an anaesthetic, and the chest was opened, one and a half inches of
the eighth rib being removed in the scapular line. A considerable
amount of lymph and a small amount of pus were evacuated, and a drain¬
age tube inserted. Bacteriological examination proved the infection to
be pneumococcal. After this the child's condition improved for a time,
and the discharge gradually diminished, but the temperature remained
above normal, with daily variations between normal and about 102° F.
On May 6 the child was clearly not doing well, the temperature
having risen more during the last few r days, on May 4 reaching 104° F.
The pulse was also increasing in rapidity, 140 to 150, and the leucocyte
count increasing, being 31,000 on May 4, and 41,000 on May 6. The
child also vomited twice. It was thought that an undrained loculus of
pus might be the cause of the symptoms, so the wound in the chest was
explored with the finger. No pus was found, but a bulging mass in the
position of the pericardium was felt.
May 7.—Child worse ; skiagram of chest taken.
May 9.—Cardiac dulness extends two inches to right of sternum,
sounds clear but rapid, irregular ; pulse 140, respiration 36. The skia¬
gram clearly shows the shadow of a distended pericardium. Under light
anaesthesia the pericardium was opened through the empyema wound,
and several ounces of thick yellow pus were evacuated. After some
difficulty a rubber drainage tube, with a flange one and a half inches in
width, was adjusted so that the flange lay within the pericardium, the
tube passing through the pleural cavity to the skin surface. After this
the temperature fell gradually and reached ^normal on June 1. The
child’s condition also steadily improved, although it was very serious for
several days after the pericardium was opened. The tube remained in
position and drained the pericardium quite satisfactorily, so that very
little pus came away after the first few days.
n —2
B
1(3 Steward & Garrod : Pyo-pericardium Cured by Drainage
May 22.—The tube was removed and replaced by a gauze drain.
From this time the improvement was continuous and satisfactory, the
sinus finally closing on June 14.
The child was examined on October 10. She had recovered her
normal weight and appeared to be in robust health. The cardiac dul-
ness and heart sounds were normal, and pulse 100 and regular. The
wound was sound, and quite free from tenderness. The lung was found
to have fully expanded, and to have separated the adhesions between the
pericardium and the chest wall; resonance, and voice and breath sounds,
being normal for quite two inches below the level of the scar.
The skiagram, taken by Dr. Ironside Bruce, clearly shows the
increase in the area of cardiac opacity caused by the distension of the
pericardium with pus.
DISCUSSION.
Mr. Steward, answering the President, said he worked through the opening
made at the earlier operation and opened the pericardium behind, because that
was the most dependent part as the child was lying in bed; and, with the
flanged tube, the drainage was quite satisfactory and caused little trouble.
Dr. Samuel West attributed the result rather to the fact that this w T as not a
pyaemic case than to the position in which the pericardium was drained. He
had seen several similar cases in w r hich the pericardium had been opened from
the back, and the drainage wfcs satisfactory. The majority of the patients had
died because the pericarditis was pycemic. In his experience pneumococcal
cases ran a more favourable course than streptococcal. With regard to the
position of the opening, he had certainly seen one case in which the opening
was made in the front and the pericardium drained perfectly, and in about
a w r eek the patient was practically well. He had seen another case in which
the pericardium was opened in somewhat the same way as in the present one,
but the patient died; yet, so far as the pericardium was concerned, it was
emptied of pus, and was adherent three or four days after the operation. At
the autopsy this was found to be a pyaemic case. He did not think there
was any objection to opening the pericardium from the front, nor did he think
it necessary to perform so elaborate an operation as that recommended in the
books, such as removal of a portion of rib. He thought that in the majority of
cases a simple incision in front sufficed. Perhaps, being a physician, he
ought not to express an opinion upon surgery, but he had seen such cases and
been interested in them, and the conclusions he had expressed were those to
w r hich his experience had led him.
Mr. Godlee said he had very little to add to the discussion, because,
although he had seen many cases of pyo-pericardium, the opportunity of
operating upon them had been small. In one case of his, following acute
infective osteo-myelitis, Mr. Raymond Johnson operated. The trouble began
with an abscess in the femur, then followed pyo-pericardium, then an abscess in
one elbow, and later one of the brain. The boy recovered, although the incision
PROC. ROY. SOC. MED.
Clinical Section.
Vol. I. Part 1.
STEWARD i£ GARROD: Case of Pyo-pcricardiutn.
Clinical Section
17
was anterior. A year later the patient died from a second cerebral abscess.
Mr. Godlee also referred to a case of pyo-pericardium in which there was a
communication between the pericardium and the bronchus, and the pus was
expectorated. He agreed with Dr. Samuel West that an opening in the
anterior part should be quite satisfactory with such a cavity as the pericardium,
but he thought it well to try to avoid the pleura; if there was no indication
that the pleura was adherent, there was no great difficulty in doing this.
A Case of Fusiform Aneurism of the Right Common
Carotid Artery.
By Jonathan Hutchinson, Jim., F.R.C.S.
E. 1\, a woman, aged 50. She had lived in New Zealand, from the
age of ‘24, for nine years. She had had eight healthy children, and three
miscarriages' at abo\it the fourth month. After the age of 10 she
suffered from ulcerated throat for several years, and gave a history of
loss of hair, and of having been subject to a bright red rash every
summer. She had been abstemious in the use of alcohol. The patient
gave a history of kidney trouble five years ago, and of several subsequent
attacks of haematuria, accompanied with severe colicky pain in the left
side of the back, and increased frequency of micturition. The swelling
in the patient’s neck was first noticed by her daughter eighteen months
ago, when it was about the size of a cob-nut. During the last four
months she had experienced aching pain, shooting through to the back
of the neck. There was no interference with breathing, except
shortness of breath on exertion, but when she swallowed the lump seemed
to move up and down. On the right side of the neck was a fusiform
tumour, the size of a pigeon’s egg, extending from the middle line to the
external border of the sternal portion of the sterno-inastoid muscle, its
long axis reaching obliquely from the suprasternal notch nearly to the
hyoid bone. Expansile pulsation was visible, occurring just after the
ventricular systole ; the second sound was audible over the tumour, but
there was no thrill or murmur. The radial pulses were equal ; the
arteries were not thickened ; and the pulse tension w T as good. The
systolic blood-pressure in the left brachial artery equalled 200 to 205 mm.
of mercury, the diastolic pressure was 130. There was cardiac hyper¬
trophy, but no adventitious sounds were audible over the cardiac area.
The pulse m both subclavian and temporal arteries was normal. The
capillary circulation on both sides of the face was equal, and there was
no venous engorgement. The larynx and eyes were normal. There
were signs of osteo-arthritis in both knees, and a diffuse lipoma on the
inner side of the left knee; the veins of the lower limbs were slightly
varicose. The urine w'as normal.
18
Batten: Case of Cerebellar Atrophy
DISCUSSION.
In reply to the President, Mr. Jonathan Hutchinson, jun., said there were
no signs of pressure on the nerves of the neck, unless on the recurrent
laryngeal. The patient said she had noticed that her voice had become harder
since the lump had appeared. It was now causing her considerable pain and
inconvenience, and it had grown a good deal during the last six months. His
feeling as to treatment was that, in spite of the risk of hemiplegia from tying
the common carotid, it was advisable to try a distal ligature. Several such cases
had been successful, and in the present patient he thought there wa9 enough
healthy artery above to admit of it.
The Pbesidbnt asked Mr. Hutchinson to record the future treatment of the
case, and its result.
Case of Cerebellar Atrophy.
By F. E. Batten, M.D.
T. \\\, male, aged 02, was quite well up to six years ago, when he
had business worries. About that time he noticed unsteadiness in
walking. Four and a half years ago he lost his balance when getting out of
bed and fell. There was neither giddiness nor loss of consciousness, and
he was able to pick himself up and get into bed. Since March, 1903, he
has been unable to walk about. He has intermittent buzzing in the left
ear, which can always be stopped by lying on his left side. He has
neither headache nor vomiting. The patient had erysipelas in 1873.
His three children are all well. He is an old man, very thin and wasted,
but with remarkably good muscular power. Mentally he is quite clear,
and is an excellent witness. The gait is markedly ataxic, but he can
stand well and there is no Rombergism. The incoordination of the limbs
is slight as compared to the marked ataxia which the patient presents
when walking. There is slight incoordination of the hands. The pupils
are unequal, the right being smaller than the left; they react well to
light and to convergence. The ocular movements both to right and left
are defective, and are attended by fine nystagmus to the right and slow r
nystagmus to the left. The optic discs are normal. The knee-jerks are
active; there is no ankle-clonus, and the plantar response is flexor. All
forms of sensation are perfect.
Multiple Tumours of the Skin, of Doubtful Nature.
By H. A. Lediarp, M.D.
The patient, a schoolmaster, aged (>5, first came under observation
on August 13, 1907, on account of an affection which had recently com¬
menced on the head at the junction of the hair with the forehead. At
first there was a redness on the areas occupied by the tumours, which
afterwards became raised and acquired a bluish tint, and when these
Clinical Section
19
masses coalesced the elevations assumed a uniform deep violet colour
across the head, at the hair-line.
On August 22 it was noted that the blue raised patch on the head
was the size of a watch-glass, and raised like a node; and a second
raised area, the size of a shilling, was seen nearer the middle line. At
this time severe headache on the left side caused sleeplessness. The
cervical lymphatic glands at the nape of the neck were found to be
enlarged when the patient was first seen, and on August 22 those about
the collar level were also felt enlarged and hard, as were also the glands
behind the line of the sterno-inastoid a week later.
On September 11 there was soreness complained of, about the ribs in
the left axillary line, and raising the arm was painful.
On September 18 the area on the scalp assumed a violet-blue colour.
Fresh areas appeared on the temple (right), and in the neck,showing a rose-
pink colour ; and subsequently the shoulders and chest became more or less
covered with small isolated skin growths of a dusky tint. In spite of the
marked rapidity of the disease, the patient has kept to his school teaching.
At the present time there is no proof of any spread to any internal
organ. The heart is strong—beating (54 per minute—the urine is
normal. Pain no longer exists, and the weight of the body is kept up.
Though there was no evidence of specific taint, the patient was given
iodide of potassium in large doses, but without effect. Blood films
showed leucocytosis, but no count has been made. Microscopic examina¬
tion has not been made, and no tumour has been excised for the
purpose. The characters of the disease seem to justify the diagnosis of
rapidly spreading multiple sarcoma cutis.
There are no tumours on the arms, hands, or feet at the present time;
the disease does not extend below the belt level. The patient thinks
that some of the lumps come and go, but Dr. Lediard cannot satisfy
himself that this is so, as the scalp growth has been persistently increas¬
ing, and changes almost from day to day.
According to the statement of the patient's wife, there was a redness
on the head, at the hair-line in front, for four or five weeks before the
patient sought advice ; the redness came first, and the raising of the
scalp afterwards ; the redness resembled measles or scarlet fever rash
She attributed the complaint to her husband having worked in the
garden without a hat for three weeks in a blazing sun.
DISCUSSION.
In answer to the President, Dr. H. A. Lediard said that in the first instance
he treated the condition by giving iodide of potassium, starting with 10 grains,
n —3
20
liowntroc: Tumour in Tkif/h
then 20, and later 35 grains. But that produced no beneficial effeot at all.
Then he gave some mercury, and a little oleate of mercury was rubbed into the
head, but he did not think that made any difference. He had not tried
Rontgen rays, and would be very glad of any suggestions as to treatment, as
well as concerning the diagnosis.
Sir Dyce Duckworth said that sarcoma would not have occurred to him
as a diagnosis ; he did not consider that the patient was at all in a cachectic
state. He suggested giving the patient very large doses of sarsaparilla.
Dr. Stowers admitted that the case had features of unusual character, but
by a process of exclusion he would arrive at very much the same view which
Dr. Lediard had expressed. The only other ailments which occurred to him as
like it in distribution and character were specific disease, mycosis fungoides, the
latter of which was rare, and was accompanied by symptoms which were not
present in this case. He admitted that the diagnosis was unproved. He
thought the better plan would be to treat the case specifically at first, and to
include the suggestion of Sir Dyce Duckworth, who did not seem to regard it as
of the nature of syphilis. He thought the Light treatment should be tried in all
similar cases of doubtful diagnosis. In the treatment of mycosis fungoides by
such means during the past eighteen months he had seen results which had
exceeded his expectations.
Mr. Godlee suggested that before any of the plans of treatment mentioned
were adopted a microscopical examination of a nodule should be made.
Dr. Lediard undertook to try to obtain one of the small tumours for
microscopical examination.
Tumour in Thigh.
By Cecil Rowntree, F.R.C.S.
The patient is a man, aged (i7, who eighteen months ago noticed a
small swelling above and to inner side of right knee. It grew slowly for
six months, then took on more rapid growth, and now forms a very
large tumour, which extends from the gluteal fold to the popliteal space.
The tumour lies beneath the hamstring muscles, which are stretched
over its surface, and on extension of the leg cause the tumour to assume
a tabulated appearance. It is quite soft, not attached to the femur, and
very freely movable. There are no symptoms, beyond the inconvenience
due to the position and weight of the swelling. The man is in good
health and is able to walk ten miles a day.
DISCUSSION.
In reply to the President, Mr. Rowntree said he regarded it as myxoma, or
myxo-sarcoma. It had been punctured, but no fluid came away.
[Note ,—The tumour was subsequently removed. It weighed 14 lbs., and
was composed mainly of fatty tissue, with somewhat dense stroma. The
tumour surrounded, but did not infiltrate, the sciatic nerve. The specimen
was presented to the Museum of the Royal College of Surgeons.j
Clinical Section.
November 8, 1907.
Sir Thomas Barlow, Bt., K.C.Y.O., President of the Section, in the Chair.
Report on the Case of Aneurism shown at last Meeting (p. 17.)
Mr. Jonathan Hutchinson, jun., reported that he had operated
upon his case of carotid aneurism a few days after the last meeting, and
found that, as he had supposed, the aneurism was at the lower end of the
common carotid, and did not involve the subclavian. The aneurism was
fusiform, and extended into the innominate, but w r as not as large as he
had supposed from the pulsation in the neck. It was impossible to
ligature the innominate on the proximal side of the aneurism, and it w r as
a question of the simultaneous ligature of the carotid and subclavian.
As the patient was elderly, and the risk of cerebral complications from
ligature of the common carotid w*as at least 25 per cent., he decided to
close the wound. The wound had healed and the patient had left the
hospital.
Trigeminal Neuralgia: Excision of the Gasserian Ganglion
after unsuccessful Intracranial Neurotomy of the Second
and Third Divisions of the Fifth Nerve.
By Jonathan Hutchinson, jun., F.R.C.S.
A. W., a man, aged 62, began to suffer from epileptiform neuralgia
of the right fifth nerve about seven years ago. The pain commenced in
the lower jaw, and paroxysms lasting about thirty seconds recurred at
irregular intervals during the day and night. Three years ago the
inferior dental nerve was divided by trephining the lower jaw; the
operation gave only partial and temporary relief. About eighteen
months ago the patient w r as admitted into St. Bartholomew^ Hospital
and the Gasserian ganglion was reached through a free opening in the
bone forming the floor of the temporal fossa. The second and third
divisions of the fifth nerve W’ere completely divided, but apparently no
d —1
22
Hutchinson : Trigeminal Neuralgia
part of the ganglion was excised. For some time the patient was com¬
pletely relieved, but after about a year the attacks of pain returned, and
gradually became as severe and frequent as before.
When the patient was admitted into the London Hospital sudden
paroxysms of pain, lasting about thirty seconds, were easily caused by
such slight stimulations as talking, eating, or a touch on certain
areas of the right cheek. During a paroxysm the whole of the right
side of the face became flushed and apparently fuller; the right
eye became watery and the conjunctiva injected. The patient rolled
about in bed, groaning with pain and pressing both hands against the
right side of his face. At times the attacks recurred as frequently as
every five minutes. That the divided ends of the nerves had to some
extent united was shown by the fact that a considerable degree of sensa¬
tion had returned in the areas of skin supplied by the second and third
divisions of the fifth nerve.
On September 4, 1907, a further operation was performed. A semi¬
circular incision was made in the line of the scar resulting from the
previous operation, and a skin flap turned downwards from the temporal
region; the temporal muscle, which was much degenerated, was also
turned down, and the dura mater was exposed in the opening previously
made in the skull. Through this opening the dura mater was raised
from the base of the skull, the middle meningeal artery being ligatured.
The Gasserian ganglion was exposed with difficulty, and the ophthalmic
division of the nerve being left intact, the ganglion below it was excised,
together with the origin of the second and third divisions. The patient’s
convalescence was normal, and up to the present time there had been
no return of pain. The case proved that neurotomy close to the ganglion,
although it might afford temporary relief, was not an efficient cure for
this form of neuralgia of the fifth nerve.
DISCUSSION.
Mr. Charles A. Ballance said that he had had the opportunity last year
of seeing Dr. Abbe, to whom Mr. Hutchinson had referred, do an intracranial
neurectomy. He thought Mr. Hutchinson had done an excellent operation,
but that it was clear that he had removed only the lower half of the ganglion.
Mr. Ballance had done that operation on two or three occasions, removing the
lower half of the ganglion and the second and third divisions of the fifth
nerve. The operation was a very good one, and he agreed with much that
Mr. Hutchinson had said, but Mr. Hutchinson rather deprecated the operation
of intracranial neurectomy of the second and third divisions of the fifth
without removal of a part of the ganglion. Dr. Robert Abbe, of New York,
Clinical Section
23
who was a pioneer of intracranial neurectomy without interfering with the
ganglion, thought that an exceedingly good operation, and Mr. Ball&nce
agreed with him. In three or four of Dr. Abbe’s cases pain returned at the
end of five years. Dr. Abbe’s operation consisted in removal of a portion of the
second and third divisions of the fifth, perhaps half an inch of the second
division, and then filling the foramen rotundum and the foramen ovale with a
solution of indiarubber made liquid by heat. It was a very important matter
that in the cases in which pain had recurred it had not returned in the area
supplied by the first division of the fifth. This showed that it was unnecessary
in a further operation to interfere with the ganglion. The ganglion operation
was an intradural one, which was obviously more risky than an extradural
intracranial neurectomy, and if the whole ganglion was removed ulceration of
the cornea might ensue. Therefore an intradural operation should, if possible,
be avoided. In Dr. Abbe’s cases in which the pain returned he opened up the
flap again, and by careful dissection was able to see tiny filaments of nerve
joining the proximal and distal ends of the second and third divisions, so that
through or by the side of the rubber plugs the nerve filaments had partly
joined together the divided ends of the second and third divisions. The
filaments of nerve were divided and the openings in the base of the skull
refilled with solution of indiarubber, after which there had been no second
return of pain. In some of the cases five years had not yet elapsed since the
operation, therefore it was not yet certain that the cure was complete, and
Mr. Hutchinson’s operation had only been done so short a time that one could
not yet say what the final result would be. At the beginning of this year
Mr. Ballance had seen a case in which, four and a half years previously, he
had performed intracranial neurectomy of the second and third divisions of the
fifth for epileptiform neuralgia. The pain had returned in the third division.
The flap was reopened, and, following Dr. Abbe’s plan, he divided what he
thought to be the tiny filaments of nerve coming through the foramen
rotundum and foramen ovale, which he had filled with gold leaf. The pain
was immediately relieved, and he thought that even if pain did return every
five years it was a safer and better operation to do a neurectomy of the tiny
filaments which sometimes joined together the divided ends of the second and
third divisions of the fifth nerve rather than to open the intradural space and
remove the lower half of the ganglion.
Mr. Hutchinson, in reply, said that his criticism was directed rather to the
fact that intracranial neurotomy was obviously unsuccessful in such a case.
Mr. Ballance referred to intracranial neurectomy , which was a different matter.
Mr. Hutchinson had done intracranial neurectomy of the second division,
taking away more than half an inch from the foramen rotundum, and the case
had been a complete success. In another case the neuralgia had returned in
the third division. The patient was now in South Africa, but he knew that she
had had some spasmodic attacks of pain in the third division. He regretted
that he did not boldly attack the ganglion in her case. The pain was confined
to the second division, and therefore he did an intracranial neurectomy. The
present case was brought forward to show that after neurotomy nerves
24
Abrahams : A Case of Myopathy
reunited. Mr. Ballance’s only other point was as to the value of indiarubber
filling. Mr. Hutchinson had had no personal experience of this, and therefore,
perhaps, ought not to have spoken slightingly of it, but he did not feel attracted
by the method after what Mr. Ballance had said. He did not claim that the
whole of the ganglion was removed. If the ophthalmic division was left a small
part of the extreme upper end of the ganglion, through which it ran, also
remained. This apparently did not matter, and one could not remove the
whole ganglion without going boldly through the dura mater.
A Case of Myopathy.
By Bertram Abrahams, M.B.
T. W., an unmarried labourer, aged 43, was admitted to West¬
minster Hospital, July 31, 1907, complaining of pain in the back,
weakness in the legs, and muscular wasting.
Family History .—Father died at 54, of dropsy, mother at (54, of
pneumonia, one brother at 43 of pneumonia. Two brothers and three
sisters are alive and well ; the patient knows of no case of nervous
disease in his family.
Personal History .—Left pleuro-pneumonia in 1883. Gonorrhoea and
a bubo in 1887 ; no definite history of syphilis. The patient was
engaged in unloading barges till about 1890; since then he has been
occupied with lighter manual labour.
History of Present A ffection .—About seventeen years ago patient
fell down three times in one day, without apparent cause. His state¬
ment is that “his legs gave way under him, at the knees.” Since then
there has been gradually increasing weakness and difficulty in walking.
Soon (about two years) after the onset the patient noticed flabbiness
of the muscles of the front of the thighs; later on weakness of the
back developed, so that he was unable to retract the head. He has been
in the habit of stumbling if he put his foot upon a small obstacle, even
a match. He commenced to use a stick last March, and can still walk
with its aid. During recent years he has noticed weakness in the grip
of both hands, and wasting of the biceps muscles of the arms. Since
the onset of the illness there has been occasional pain in the lumbar
region. This became rather severe in April, 1907, increasing on
walking or stooping, but persisting even while at rest. During the last
two years there have been occasional “rheumatic ” pains in the neighbour¬
hood of the shoulders.
Present Condition .—The patient is an intelligent, well-nourished
Clinical Section
25
man, of medium height. He can stand and walk when supported by
a stick, and shows no sign of ataxy. The erect posture is only main¬
tained by the help of a marked lordosis, and the gait is straddling, with
wide separation of the feet and considerable swaying of the upper part
of the body. In walking the heels are not brought in contact with the
ground, especially the left, on which side there is pes cavus with talipes
equinus. In rising from the horizontal to the erect posture he
endeavours to “climb up his thighs’* like a patient with pseudo-
hypertrophic muscular atrophy, but the weakness of the back muscles
is so great that he is unable to rise completely without assistance.
Muscular System .—The following muscles are markedly wasted :
Bicipites, pectorales majores (especially the lower part), anterior muscles
of thighs (especially the quadriceps extensor), glutei maxirni, supraspinati.
The following muscles are somewhat wasted : Flexors of left wrist,
right hypothenar group, latissimi dorsi, adductors and abductors of
thighs. The calf muscles are flabby but not certainly wasted. The
following muscles are hypertrophied : Deltoids, serrati magni—especially
lower portion and particularly on right. Also, to a less extent, the
tricipites, infraspinati, and recti abdominis. The following muscles,
which are usually affected in similar cases, are here normal: Supina¬
tor es longi, trapezii, face muscles.
There is no gross tremor. Fibrillary tremors have been observed
from time to time in the forearm muscles, but are neither constant nor
widely diffused. There is no reaction either to faradism or galvanism
in the deltoids; the other muscles react fairly to both currents, and
KCC. is everywhere greater than ACC.
Sensation .—The patient complains of pain in the loins and some¬
times in the shoulders. During the last twelve months there has now
and then been a feeling of numbness and tingling in the arms, legs, and
neck.
Objective sensation is perfectly normal.
Rejtexors .—The knee-, elbow- and wrist-jerks are absent. The super¬
ficial reflexes are brisk, the plantar being of the flexor type. The
sphincters are normal.
There is no affection of any of the cranial nerves.
Treatment and Course .—The patient has been treated by massage
and galvanism, with the internal administration of strychnine. During
the three months that he has been under observation he has certainly
not retrograded ; he states that he feels stronger in walking, but this
is not objectively evident.
26
Gray : A Case of Myxoedema
Remarks .—On reviewing this case it will be seen that it does not
conform exactly to any of the usually recognised varieties of myopathy.
The character of the affection of the muscles of the shoulder and
pelvic girdles suggests the juvenile type of muscular atrophy described
by Erb. But it differs from this in the absence of atrophy in the biceps
serratus, supinator longus and trapezius, the first two of which are
actually hypertrophied. Moreover, the affection of the hand and
forearm seen here is not characteristic of Erb’s form of the disease.
The present example affords further evidence of the correctness
of the view put forward independently by Charcot and by Erb, that the
true myopathies are merely varieties of the same disease. The exist¬
ence of indeterminate forms such as this is one of the points relied upon
by Erb in his argument.
Further noteworthy facts in this case are: The age of the patient;
the extreme chronicity of the disease ; the absence of hereditary or
collateral nervous disease ; the apparent arrest of the affection during
the last three months; the affection of the feet; the various subjective
sensations; the loss of electrical response in the hypertrophied deltoids.
A Case of Myxoedema, with Unusual Features.
By Dr. A. M. H. Gray (introduced by Dr. Batty Shaw).
The patient is a woman, aged 41; she has a heavy expressionless facies,
has a large amount of subcutaneous fat all over the body, especially in
the supraclavicular regions, and a slightly transparent appearance of the
skin. The skin is dry and rough ; the hair is coarse and brittle, and
falls out very easily; the nails are curved, but otherwise normal.
The skin does not pit on pressure anywhere. The tongue is slightly
enlarged, and on the posterior aspect of the dorsum in the middle line,
about half an inch in front of the foramen caecum, is a small papillomatous
growth the size of a pea. The voice is rather husky. The patient’s
mental condition is quite good ; she answers questions quite rationally
and fairly briskly; she complains that her memory has been bad, but she
is able to give a very accurate history of her case. She has never had
any delusions. She states that she does not feel drowsy and sleeps well.
She has been getting deaf since this illness came on.
Her temperature varies daily from 97° F. in the morning to 98° F. in
the evening. Her pulse is usually about 70, but has fallen to 56 and rarely
rises above 80. Her respiration varies from 18 to 24. There is a slight
Clinical Section
27
degree of pulmonary emphysema, but otherwise her respiratory system is
normal. Her circulatory and alimentary systems are at the present time
quite normal. She has no paralysis or loss of sensation. Her superficial
and deep reflexes are not diminished. The urine contains no abnormal
constituents ; its specific gravity varies between 1010 and 1028.
The history of the case is of considerable interest. Sixteen years
ago, in July, 1891, the patient attended the out-patient department of
St. Bartholomew’s Hospital for a swelling in the neck, which throbbed
and sometimes caused difficulty in breathing ; she also had palpitation very
badly, very prominent eyes, and was very nervous and tremulous; she
was told that she had “ goitre.” She was under treatment, by medicines
and electricity, for six months, and her condition got quite well; but
afterwards she noticed that she was getting very stout and that her hair
tended to fall out. She also complained of pain in the small of the
back. Amenorrhoea occurred also at this time and lasted for seven
months, and she had morning vomiting, so that she thought herself
pregnant, but after the seven months menstruation commenced again
and she ceased vomiting, though her stoutness did not diminish. In
this connection it would be well to mention her previous menstrual
history. She was regular till marriage when aged 18, and had three
children before the symptoms of exophthalmic goitre appeared, but her
periods since marriage had been scanty and irregular, though she had
never missed more than one or two periods. Two years after the
symptoms appeared she had a child, her husband dying about this time.
Nothing more of note occurs until 1902, when she noticed that the
stomach and feet were becoming more swollen; and this condition
gradually became so bad that in June, 1903, she was taken into Fulham
Infirmary, where her abdomen was tapped and fluid drawn off. She
went out much improved, but the symptoms returned and she had to
seek readmission in July, 1904. She was tapped again and more fluid
was drawn off, but did not cause much relief. In the notes obtained
from Fulham Infirmary it is found that, when admitted in 1903, she
had marked ascites and some oedema of the feet; she also had albumen
in the urine and a double murmur at the heart’s apex; she was tapped
and 20 pints of fluid were drawn off. When admitted in 1904 she again
had ascites, with oedema of the feet and albumen in the urine, but no
note had been made as to the cardiac condition ; nearly 20 pints of
fluid were drawn off at the second tapping.
In October, 1904, she attended the out-patient department of the
Women’s Hospital, Soho Square, and was thought to have a ruptured
28
Gray : A Case of Myxceclema
ovarian cyst. She was admitted to the wards with a view to operation,
but as she had a trace of albumen in her urine, with ascites and oedema
of the feet, it was thought that the ascites was probably due to Bright's
disease, and she was advised to go to a general hospital and consult
a physician.
On October 30, 1904, she attended the medical out-patient depart¬
ment of University College Hospital with the same symptoms; a
provisional diagnosis of Bright’s disease was made, and she was admitted
to the wards in the following week. The following are extracted from
notes made on admission : “ November 9, 1904. Patient is a well-
nourished woman, aged 38. There is a large excess of subcutaneous fat
over the whole body. Skin very dry and somewhat rough. Hair dry
and crinkly. Face puffy ; cheeks red, otherwise complexion is sallow.
Skin somewhat transparent. Pulse 88. Temperature 97‘8°F. Respi¬
ration 20. The abdomen is enormously distended ; several inches of
subcutaneous fat on abdominal wall. Flanks bulge slightly. Nothing
abnormal felt in abdomen. Slight fluid thrill. Both flanks and lower
part of the abdomen are dull to percussion. Dulness in flanks shifts.
No oedema of feet. Tongue large and flabby ; not furred. Speech slow
and deliberate. Voice very husky. Mental conditions low, but otherwise
good. No sensory changes. Knee-jerks slightly increased. Urine
normal.” The diagnosis of myxoedema was made and the patient was
given thyroid extract by the mouth, the dose being rapidly brought
up to 15 grains per diem.
On November 28 considerable improvement had occurred, but fluid
was still present in the abdomen. One of the obstetric physicians was
called in, and he thought that a ruptured ovarian cyst was probably
present and the patient was transferred to his ward. Nothing further
was done, however, but the patient was watched and the thyroid
treatment persisted with.
On December 31 she was sent back to the medical ward and the
following note was made : “ All the dryness of the skin and puffiness
of the face have disappeared. Mental condition much less slow, and
patient feels much better. No signs of fluid in the abdomen ; girth now
43 inches as compared with 53 inches on admission.” The patient was
discharged shortly after this, but continued to attend the out-patient
department for about a year and then ceased attending, and gave up
taking thyroid extract, which had been reduced to three 5-grain tablets
a week. She was readmitted on October 7, 1907, about two years after
giving up treatment, and her condition was much the same as on
Clinical Section
29
admission three years previously, except that there was only a small
amount of fluid present in the abdomen. She has now been under
treatment for a month, having 5 grains a day for the first fortnight
and 10 grains since, and has shown marked improvement; the fluid in
the abdomen has quite disappeared, and her weight has decreased by 9 lb.
in the last fortnight, and her girth 2J inches.
DISCUSSION.
Dr. PARKES Weber asked whether the urine had been microscopically
examined. The character of the casts found might throw some light on the
condition of the kidneys. [Dr. GRAY replied that there was no albumen, but
he could not say anything about casts.] Dr. Weber, continuing, said that as
there was no albumen in the urine there probably was no nephritis in this case.
In some cases of myxcedema albuminuria was present, and cleared up under
thyroid treatment, but he thought it probable that some interstitial nephritis
remained in such cases. It was conceivable that an ascites secondary to
myxcedema might similarly disappear under treatment.
Dr. A. E. GARROD referred to the case of a man who had been discharged
from one of the public Services as having nephritis, who had a large quantity
of albumen in his urine and oedema of his legs. He certainly had myxcedema,
and under the thyroid treatment the albumen became reduced to a trace as his
general condition improved.
The PRESIDENT remarked that similar cases of this paradoxical occurrence
of myxcedema as a sequel to exophthalmic goitre had been described, and
referred to one recorded by Dr. Pasteur in the 23rd and 31st volumes of the
Transactions of the Clinical Society . In that case the first symptom of the
developing myxcedema w T as bradycardia.
Dr. GRAY, replying to Dr. Parkes Weber, said that in this case no albumin¬
uria existed when thyroid treatment was commenced, and its disappearance
could not be ascribed to the treatment. Albumen was found when the patient
was in the Fulham Infirmary, where the diagnosis of Bright’s disease was
made.
A Case of Recurrent Dislocation of the Shoulders cured by
Operation.
By T. H. Openshaw, C.M.G., M.S.
S. C., a man, now aged 27, was first admitted into the London
Hospital with sub-coracoid dislocation of both shoulders, caused by a
fall whilst in an epileptic fit. He had suffered from epilepsy since 1896.
The patient first dislocated his shoulder in 1897, and recurrent disloca¬
tions often incapacitated him for a week or a fortnight at a time.
On December 4, 1900, he was admitted to the London Hospital and
half a drachm of tincture of iodine was injected into the right shoulder-
d—2i
30 Openshaw: Recurrent Dislocation of the Shoulders
joint. Some arthritis followed, but, although a shoulder-cap was worn,
the shoulder redislocated within a few months. Whilst he was in
hospital the left shoulder was dislocated during a fit, and was reduced
under anaesthesia. On December 21, 1901, 2 drachms of Morton’s
fluid was injected into the right shoulder-joint. The shoulder was kept
at rest, and later on massage was applied. Some synovitis followed the
injections, but the dislocations recurred, and by July, 1901, the right
shoulder had been dislocated fifty times. In July, 1901, an anterior
incision was made down to the joint, the capsule was incised, a portion
of it was removed, and a part of the cartilage also removed from
the glenoid cavity and head of humerus. The wound healed by first
intention. For some time after the operation the patient complained
of severe pain down the right arm. For the next four years the
dislocation recurred, but less frequently than formerly.
In 1903 the pectoralis major was detached from the humerus, but
this operation also was ineffectual.
On November 13, 1905, a further operation was performed ; the sub-
scapularis was detached from the lesser tuberosity and sutured to a
portion of the deltoid, which had been previously detached. The wound
healed by first intention, and a poroplastic shoulder-cap was applied.
On July 2, 1906, there having been no recurrence of the dislocation
of the right shoulder for seven months, a similar operation, viz., detach¬
ment of the insertion of the subscapularis from the humerus and its
attachment to the anterior border of the deltoid, was performed upon
the left shoulder. The wound healed by first intention. The patient
had been watched for the past sixteen months, and had had no re¬
currence of dislocation in either shoulder. He still had epileptic fits
quite as severely as before, and had taken bromide of potassium in large
doses, sometimes as much as half an ounce three times a day. It would
appear, therefore, that nothing short of the final procedure above
described could be relied upon as an effectual remedy for recurrent dis¬
location. Mr. Openshaw had performed this operation altogether three
times, and in each case the cure was definite and permanent.
DISCUSSION.
Mr. Jonathan Hutchinson, jun., asked whether a similar method of
treatment had been previously reported. In a certain proportion of dislocations
in epileptics the subscapularis was more or less torn.
Mr. OPENSHAW said that, as far as he was aware, the procedure was
original.
Clinical Section
31
Neuritis of Brachial Plexus, probably resulting from Arthritis
of Shoulder-joint.
By W. P. Herringham, M.D.
The patient was aged 17, and for a fortnight had had fleeting
pains in various joints—wrists, ankles, knees, shoulders, elbows. He was
admitted into the ward with arthritis of his right wrist. He had never
had rheumatism nor any affection of his heart, and there was no rheu¬
matism in his family. He had had sore throat and fleeting pains in the
joints. There was no gonorrhoea. Therefore it was regarded as a case
of rheumatism, and was treated with salicylate of soda, and in two days the
pain and swelling were gone. But four days later there was pain in the
right shoulder again, and, thinking it was a recurrence of the rheumatism,
he did not examine the patient very carefully, but again gave salicylate
of soda. Two or three days later it was noticed that the deltoid was wasted.
The wasting increased, and spread to other muscles about the scapula, to the
biceps and brachialis, and in a less degree to the muscles of the forearm.
The deltoid gave the reaction of degeneration almost from the first. In a
fortnight the wasting was very marked, and he had reaction of degenera¬
tion in the deltoid, supraspinatus, infraspinatus, brachialis anticus, biceps,
and weakness of reaction in the flexor aud extensor muscles of the
forearms, except the flexor carpi ulnaris and the muscles of the hands.
Almost at the first it was noticed that pressure on the outer wall of the
axilla, where the plexus of nerves lies against the humerus and the
capsule of the joint, gave much pain, and a little later two fresh facts of
the same kind were observed, namely, tenderness at the point of emerg¬
ence of the circumflex nerve, and swelling with tenderness of the
musculo-spiral. There was comparative anaesthesia over the whole
limb, which was most marked down the inside of the axilla and the
outside of the arm, so that it evidently was not a lesion of one root, but
of every root in the plexus. The question he had raised before his
colleagues at the hospital was, whether it was a peripheral lesion or
one in the vertebral column. Had the patient got caries of his vertebrae ?
This was excluded by the skiagram, and the roots themselves were not
found to be tender. It appeared, therefore, certain that it must be a
neuritis, or, more strictly, a perineuritis so severe as to crush the nerve-
fibres, which had chiefly affected the posterior, but in a minor degree
also the other cords of the plexus. The patient had begun to improve,
32
Herringham : Neuritis of Brachial Plexus
but he still had tenderness of the nerves in the plexus, complete reaction
of degeneration in the above-mentioned muscles of the shoulder and
arm, great weakness and wasting, and a good deal of anaesthesia. He
asked, What was the connection of the arthritis with the present attack
in the nerves? Was the pain in his shoulder the expression of a neuritis
rather than of any true relapse of the arthritis ? or was it, as he thought,
an inflammation which had spread from the capsule and fibrous tissue
about the joint to the nerve-sheaths ? He had seen instances of this in
osteo-arthritis and in other forms of arthritis, but never, he thought,
after acute rheumatism. He had never seen a case of perineuritis from
any cause which had led to such irretrievable muscular atrophy as, he
feared, was present here.
DISCUSSION.
Dr. BUZZAED suggested that possibly the arthritis in the shoulder was due
to neuritis of the nerve supplying the joint.
Dr. Sidney Phillips suggested that there was affection both of the joint
and of the nerves or their sheaths. He thought that the primary affection was
rheumatic. He had himself suffered severely from neuritis in the arm, and he
had at the same time an effusion into the elbow-joint, with wasting of muscles
and acute pain. In a number of cases he had met with intense brachial
neuritis associated with effusion into the shoulder-joint. He had regarded
the two phenomena as due to the same cause. He believed such brachialgiae
were not examples of peripheral neuritis, but of affections of the fibrous nerve-
sheath, somewhere near the exit of the nerves between the vertebrae. He
expressed the belief that many cases of brachial neuritis would be found to be
associated with grating of joints.
Mr. Jonathan Hutchinson, jun., referred to a case of severe spreading
neuritis of the brachial plexus in a young woman, in which it was ultimately
discovered that there was a fracture of the olecranon, and the neuritis appeared
to have spread up from the ulnar nerve. The fracture had occurred a year
before, and its presence was not suspected when she was admitted.
Dr. HeEringham, in reply, said that he w T as familiar with the cases to
which Dr. Sidney Phillips had referred, in which a neuritis was associated with
a grating, apparently a dry arthritis ; but the case he had just shown was of
a different character. The patient had fleeting pains in many joints, a multiple
arthritis, and subsequently an arthritis of one particular joint. He accepted
the correction as to name ; he meant a perineuritis, similar to sciatica. The
affection extended to the fibrous tissues around the joint, and so to the fibrous
sheath of the nerves which lay in contact therewith.
Clinical Section
33
A Case of Pigmentation with Enlarged Spleen and
Leucopenia. ? Splenic Anaemia.
By W. P. Herringham, M.D.
The patient, a man, aged 42, till two years ago was in excellent
health. He was a soldier, and then a gymnasium instructor at
Aldershot. He had never been out of England, and had never had
syphilis. Two years ago he noticed that he was becoming very brown,
and he still had pigmentation over the body, with patches on each flank
and on the finger-tips, which were of the natural colour. The penis
and scrotum showed very dark and very light areas with sharp edges.
During the last year, he said, he had lost a considerable amount of flesh,
viz., 2 stones in weight, and for six months had been feeling very
languid and weak, so that he could not do any work. He also began
to vomit. He had had periodic attacks at intervals of a fortnight, each
attack lasting three or four days, the vomiting recurring three or four
times a day, and sometimes being accompanied with a little blood. One
began to think of Addison’s disease, but on examination he was found
to have a very large spleen, which reached almost to the umbilicus and
to the mid-line, which somewhat upset that idea. He had no ascites
or jaundice, and the liver so far as could be discovered was normal.' It
was established that he had not been taking arsenic, which had also
suggested itself as the cause of the pigmentation. At the consultation
held at St. Bartholomew’s some thought he might have a sarcoma
which affected the spleen and suprarenal capsules, others that he might
have a tuberculous spleen, with tubercular disease of the suprarenals;
others suggested cancer of the stomach, and others thought he had
splenic anaemia. This history so closely resembled that of a case of
Addison’s disease that the tuberculin test was applied, but the result
was negative, and there was nothing else found amiss with him, except
the enlarged spleen and a poverty of white cells in the blood. The
average of several counts had been 4,500,000 red cells, and the colour
index 0 93; in other words, the standard was practically normal, but he
had always had leucopenia. Once the count was as low as 1,700 white
cells, and there had never been more than 6,000, the latter number
being just after a meal. There had been no differential change, and
the red cells were normal in shape and size. He concluded that the
i nan had a form of splenic anaemia, and referred to a case published
by Stengel in which the distribution of the pigmentation closely
34
Leslie: Cases of Congenital Heart Disease
resembled that in the present case. An accurate gauge of the patient’s
muscular weakness was found in the fact that he had been unable
on the horizontal bar to pull himself up once with both hands together,
though when an instructor he could do so many times in succession.
The patient’s condition was now improving rapidly, and he could
almost pull himself up on the bar with one hand. He was taking
arsenic. He had previously had no drugs.
Two Cases of Congenital Heart Disease in Adults.
By E. Murray Leslie, M.D.
Case I.
C. F., a woman, aged 22, was admitted into the Eoyal Hospital for
Diseases of the Chest on January 31, and readmitted on October 7,
1907. There was no family history of rheumatism or heart disease, and
no personal history of rheumatism or chorea. She was an eight-months
child and had a cyanosed appearance from birth. Clubbing of the
fingers and toes had been a prominent feature from infancy. She was
a delicate child and difficult to rear. At 16 years of age she worked
for a period of six months in a confectioner’s factory, and at 18 years
of age was well enough to take a situation as housemaid, which she
retained for a year and then had to give up owing to increasing breath¬
lessness. During the last three years she had been unable to do any
work, and had been carefully nursed and'tended by her sister and
relatives. The catamenia appeared very late (at the age of 20), and
had always been irregular both in quantity and in time of occurrence.
She sought admission to the hospital because of her increasing dyspnoea,
which, however, became much less pronounced after a week’s rest in the
recumbent posture. She was intensely cyanosed, and presented the
characteristic appearances of morbus caeruleus. The lips, ears, nose,
tongue, and tips of the fingers were of a dark bluish-violet colour, and
there was well-marked clubbing of the fingers and to a less extent of
the toes and tip of the nose. The hands and feet were cold, but there
was no subcutaneous dropsy, haemoptysis, pulmonary oedema, nor enlarge¬
ment of the liver. The urine was acid, with a specific gravity of 1015,
and once or twice contained a trace of albumen. The average pulse-
rate was 90, while the pulse itself was regular and of fair volume of
tension. The cardiac apex was little if at all displaced ; the right border
of the heart extended somewhat to the right of the sternum. A soft-
blowing systolic murmur was audible over the lower half of the left
Clinical Section
35
margin of the sternum, the point of maximum intensity being the fourth
left costal cartilage ; the murmur was conducted inwards to the mid-
sternal line, upwards to the second left interspace, outwards to the
parasternal line, and downwards to the sixth left costal cartilage. The
pulmonic second sound was accentuated. The blood exhibited remark¬
able concentration of the cellular elements, the red corpuscles numbering
no fewer than 12,720,000 per centimetre, i.e. t two and a half times the
normal number. The haemoglobin varied from 110 to 120 per cent.
The temperature tended to be subnormal.
The skiagram of the chest revealed slight enlargement of the right
heart and a blunting of the cardiac apex, while the skiagram of the
hands showed the absence of osseous changes at the extremities of
the terminal phalanges (skiagrams exhibited). It was impossible to
express an opinion as to the precise cardiac lesion present in this case.
The site and distribution of the murmur suggested patency of the intra¬
ventricular septum, but there were probably other associated abnor¬
malities. There was no evidence of pulmonary stenosis. The main
interest of the case lay in the fact that the patient had reached adult
life notwithstanding the extreme degree of cyanosis present.
Case II.
E. W., a woman, aged 30, was admitted to the Prince of Wales’s
Hospital on October 18, 1900, and readmitted on September 6, 1901,
and February 12, 1903, and since then has been continuously under
observation until the present date. There was no family history of
rheumatism or heart disease, and no personal history of rheumatism or
chorea. She was a delicate child and suffered from slight attacks of
bronchitis. At the age of 9 she was an in-patient at the Royal Hospital
for Diseases of the Chest, under the care of the late Dr. Gilbart Smith,
who diagnosed congenital pulmonary stenosis. She was at that time
a poorly nourished child, her principal symptom being breathlessness on
exertion. There was then no enlargement of the cardiac area, but a
loud, harsh, high-pitched systolic bruit was audible over the praecordia,
loudest in the third left interspace, but heard distinctly over the greater
portion of the front of the chest, and also over the scapular and inter¬
scapular regions behind. Over the pulmonary cartilage the murmur
was followed by a short, sharp, second sound. The patient continued as
an out-patient at the hospital for some years, afterwards staying for
varying periods at different country and seaside homes, and in the
intervals being carefully looked after by her relatives. She had never
36 Leslie: Cases of Congenital Heart Disease
been able to engage in active work. The catamenia commenced early
(at the age of 13) and had been somewhat irregular; latterly she had
suffered a good deal from menorrhagia and metrorrhagia. At the age
of 16 she made a good recovery from an attack of acute pneumonia. At
the age of 21 she was again admitted into the Royal Hospital for
Diseases of the Chest, and afterwards w r as transferred to the Prince of
Wales’s Hospital.
On admission, the patient w T as found to be a well-nourished woman,
and complained principally of attacks of giddiness and shortness of
breath. The face w T as congested, and there was a moderate degree
of cyanosis, most noticeable in the lips. The fingers were clubbed and
the nails livid. She had occasionally slight oedema of the ankles. The
liver was not enlarged, but the existence of a few moist r&les at the
pulmonary bases indicated some pulmonary oedema. There had been
no haemoptysis. The temperature tended to be subnormal. The urine
was acid, with a specific gravity of 1028, and contained a trace of
albumen. The pulse-rate varied from 80 to 100, and the respiration
rate from 24 to 28. The pulse was regular but of small volume, the
sphygmographic tracing showing a rounding off of the tidal wave, with
a rather prolonged descent. There was some visible pulsation when the
patient became excited, in the second and third left interspaces, and
also above the clavicles. The right border of the heart extended w^ell to
the right of the sternum. There was no thrill to be felt at the base
of the heart, but there was a distinctly palpable diastolic shock in the
third left interspace. On auscultation there was a loud, harsh systolic
murmur heard all over the proecordia, but loudest over the pulmonary
cartilage, and audible also over the posterior aspect of the chest.
Examination of the blood revealed a great excess of haemocytes, which
numbered 9,630,000 per centimetre, the leucocytes numbering 9,300 per
centimetre. The skiagram revealed enlargement of the right ventricle.
The principal lesion in this case was undoubtedly pulmonary stenosis.
There w T as most probably also some patency of the septa, which w r ould
afford much relief to the overcharged right heart and thus tend to prolong
life. There might or might not be patency of the ductus arteriosus.
The occasional visible pulsation in the upper left interspaces suggested
the possibility of dilatation of the pulmonary artery.
The great interest of the case, however, lay in the fact that the
patient had now entered on her fourth decade, and appeared to be in
better health than ever. She could walk for a considerable distance
without undue fatigue or dyspnoea. In w r inter-time the cyanosis became
much more evident than in the summer.
Clinical Section
37
DISCUSSION.
Dr. A. E. GARKOD said there was a physical sign in the older patient which
had not been mentioned, namely, valve shock and a very loud second sound in
the pulmonary area. This he regarded as pathognomonic of pulmonary
stenosis. It was not present in young children with pulmonary stenosis, but
developed as life progressed. The late Dr. Peacock mentioned it in connection
with a case which he desciibed in his book on “ Congenital Heart Disease,” and
made the suggestion, which Dr. Garrod thought was correct, that the loud
second sound was aortic, and that as years went on the aorta had come to
occupy a position over the patent intraventricular septum, and that the large
aorta, which did the work of both arteries, was the seat of the very loud
slamming second sound. He asked whether Dr. Leslie thought it possible that
the other case was one of pulmonary atiesia, although such a diagnosis seemed
unlikely in the case of an adult patient.
Dr. PARKES Weber said that the increase in the red corpuscles was so
pronounced that the difficulty in oxygenating the blood must be very great, and
he therefore suggested that frequent oxygen inhalations should be tried, in order
to bring about a diminution of the red cells.
Dr. Box said he had been interested in the use of oxygen inhalation in
cases of this kind, but had been disappointed with the results. He had not had
blood-counts made, but it was easy to judge from the general appearance of the
patient that the oxygen was not benefiting him. He thought that the reason for
the failure was obvious, because cyanosis in these cases was practically always
due to one cause, viz., deficient blood supply to the lung. In some cases the
pulmonary artery and aorta were transposed, each circuit being kept separate.
He therefore failed to see how the inhalation of oxygen would ameliorate the
condition. He had also made attempts to introduce oxygen by giving oxygen-
containing compounds by the mouth, in the hope that the oxygen would reach
the blood via the stomach. That, however, was difficult, because when oxygen
was thus introduced in sufficient quantity it upset the digestion, and sickness
and diarrhoea resulted. The clubbing of the fingers also was probably due to
the obstruction of the blood-flow from the lungs. Recently he had seen an
instructive case in which a child had difficulty in swallowing and considerable
clubbing of fingers, toes, and nose. On first examination there seemed nothing
to account for the clubbing of the fingers, but on examining the mediastinum
post vwrtem there was found to be an ulcer of the oesophagus, and the inflam¬
mation around the base of the ulcer had extended into the mediastinal tissues,
and compressed the pulmonary veins as they opened into the auricle. That
was the only condition in the body to which the clubbing of the extremities
could be ascribed.
Dr. Murray Leslie said that he thought the age of the younger patient
excluded the idea that she had pulmonary atresia, as he understood that the
subjects of that condition practically never reached adult life. Oxygen had not
been tried in these cases.
38
Fawcett: Pneumothorax treated hy Aspiration
Pneumothorax treated by Aspiration under the X-rays.
(A hstract.)
By John Fawcett, M.D.
The patient, a man, aged 22, was admitted into Guy’s Hospital on
June 5, 1907, with a pneumothorax on the right side. On admission,
temperature was 102° F., pulse 128, and respiration 32 per minute. He
was dyspnoeic, and the signs of a pneumothorax were confirmed by the
X-ray photograph. The temperature gradually fell to normal in the
course of a week. Nineteen days after the onset the condition of the
chest was found to be much the same as on admission, very little absorp¬
tion of air having taken place. It was therefore decided, as the patient
seemed otherwise so well, to try to remove the air from the pleura.
The patient was placed on his back on the couch in the X-ray room.
The screen was put over the front of the chest, and a trocar and cannula,
of the usual form employed in aspirating the pleural cavity, were then
inserted into the pleural sac, in front of the posterior axillary fold, in the
sixth or seventh space. The lung was seen compressed towards the spine,
and therefore one could determine exactly the distance that the trocar
could be passed so as not to touch the lung. The trocar was then with¬
drawn, and the cannula connected up to a sterilised flask, containing a
solution of carbolic acid (1—40). On turning the tap of the cannula so as
to place the pleural cavity in communication with the flask, air was
seen to bubble through the other tube in the flask at each inspiration,
showing that the air in the pleural cavity was under negative pressure
during inspiration. No change occurred in the compressed lung.
The tap was therefore turned off, and the tubing attached to the
cannula was fixed on to a sterilised bottle from which the air had been
partially exhausted. This time, on connecting the cannula w r ith the
bottle, the lung was at once seen, on the X-ray screen, to expand.
As the lung expanded the cannula was gradually withdrawn until,
when the lung appeared to be fully expanded, it was removed and
the puncture sealed. The lung was then seen to expand and retract
with the respiratory movements. A second skiagram w r as taken, which
showed no difference in the lung on either side. The patient was carried
back to bed and kept there for two days ; he was discharged from the
hospital twelve days later, re-examination of the thorax during that
time with the X-rays showing that the lung continued to act perfectly.
Clinical Section
39
Remarks .—For the first two and a half weeks of the patient’s stay
in hospital he exhibited little, if any, improvement as regards the
absorption of air from the pleura. The improvement and relief pro¬
duced by aspiration were immediate and persistent.
The patient was seen again on November 6 last, and a photograph
taken, which is normal. The man looked in excellent health; he has
continued his work regularly.
Provided all reasonable precautions are taken, and if suitable cases
are selected, I do not see that any harm is likely to ensue from the
above procedure. No doubt aspiration should not be performed too
early, but if there is a reasonable prospect of the hole in the lung being
firmly sealed, and if the suction employed is only slight, there is little
danger of causing a fresh rupture. If the hole in the lung is not closed
the lung will not expand when suction is commenced, and the aspiration
can then at once be suspended. In some cases it may not be necessary
to aspirate, the pressure of the air in the pleural cavity being sufficient
to allow of its egress.
The case was a favourable one, but still when one remembers the
long periods for which some of these patients are incapacitated, the
permanent damage to the lung which at times occurs, and the, perchance,
chronic invalidism to which the patients are condemned, the advantages
of the method in selected cases is a very obvious one, and the risk of
doing any damage very small.
DISCUSSION.
Dr. Parkes Weber said that the same procedure had been adopted before,
under the control of the X-rays. There could be no doubt that in such cases
the plan was an excellent one. But if he were the patient he would not consent
to it because the results in cases of so-called idiopathic pneumothorax in
apparently healthy individuals were so excellent apart from any treatment.
Three weeks appeared to be the outside time for recovery, and some patients got
well without going to bed at all.
Dr. G. A. SUTHERLAND said that the case recalled to his mind one which
he published fifteen years ago, in connection with which he was severely criticised
by the late Sir William Gairdner. It was a case of pneumothorax associated
with early phthisis. As the condition was very alarming, he put a trocar into
the chest. There was no relief, and he therefore aspirated. He thought that
he was justified in so doing, as the acute symptoms were relieved and the patient
did very well. But there was much pleurisy afterwards and considerable pleural
effusion, though one would not associate that with the aspiration. Sir William
Gairdner adversely criticised the treatment employed, and referred to the state¬
ments of Bowditch. Dr. Sutherland found, however, that Bowditch was not
40
Fawcett: Pneumothorax treated by Aspiration
opposed to aspiration. He considered that the treatment should be adopted in
cases of severe emergency. The majority of the patients with pneumothorax
recovered with rest alone.
Dr. Herbingham asked whether there were any signs of tubercle in the
lungs, as the skiagram suggested that they were not normal.
Dr. FAWCETT, in reply, said that he had read the clinical history in brief
(vide Guy's Hospital Reports , 1907) so as to economise time. The man was
dyspnceic and the condition of the chest showed little improvement even at the
end of nineteen days. As regards the danger of the operation, he could only
repeat that he believed it to be slight. A proper selection of cases was essential,
and he did not recommend it for all and sundry. Even Dr. Sutherland’s
remarks seemed to indicate that practically any risk there was was small. His
own experience of untreated cases of pneumothorax was distinctly less favour¬
able than that of others who had spoken. The skiagrams taken by Mr. Shenton
after aspiration were considered by him to show nothing abnormal in the lungs,
and if Dr. Herringham had examined them with the X-ray screen he would
probably have agreed with this conclusion.
Clinical Section.
December 13, 1907.
Sir Thomas Barlow, Bt., K.C.Y.O., President of the Section, in the Chair.
Splenic Polycythaemia with Cyanosis.
By William Osler, M.D., F.R.S.
In 1892 a French physician described a remarkable case in which
increase in the number of red corpuscles was associated with enlargement
of the spleen. Cabot afterwards recorded two cases, and Saundby and
Russell, of Birmingham, another. Dr. Osier himself had had two cases
under observation, and had seen two others, and in 1903 he wrote a
paper on cyanosis with polycythaemia and enlarged spleen. Since the
appearance of that paper there had been 40 or 50 cases recorded, and he
thought that in the condition in question a new disease must be
recognised. The present patient showed the three characteristic features
in a very typical maimer. The hands and feet were much congested,
and on very cold days the fingers and toes present an appearance similar
to the peripheral asphyxia in Raynaud’s disease. The enlargement of
the spleen in the present case was greater than in any other he had seen;
the splenic tumour extended below the umbilicus, and could easily be
moved to and fro. The leucocytes numbered 50,000; the specific
gravity of the blood was 1075; the red corpuscles showed no special
changes. There was slight poikilocytosis, and an unusually large number
of nucleated red cells were present in the patient’s blood. The exact
nature of the disease was much discussed. There had been a few
examinations—one by Dr. Parkes Weber, one by Dr. Hutchison, and
three on the Continent, and all showed an enormous hyperplasia of the
bone marrow, particularly that of the long bones. The pathology of the
disease, as advanced by Turk, Parkes Weber, and Hutchison, was,
that it was a disease analogous to leukaemia, one in which there was an
over-production in the bone marrow of red blood corpuscles, a counter¬
part of the disease leukaemia, and he thought the anatomical conditions
ja —1
42
Osier: Splenic Polycytluemia ivith Cyanosis
met with bore out that view. The patient also showed one or two other
features of great interest, which had been noted by other observers.
There were vaso-motor changes, and some of the cases had a state not
unlike Raynaud’s disease. In some the condition was like Weir-Mitchell’s
erythromelalgia. There were practically no symptoms in many of the
cases. The present patient scarcely felt ill at all; she had had some
distension of the abdomen and a headache and a little dizziness at times,
but nothing of any moment. The first case which called his attention
to the condition was that of a physician whom he met frequently, who
exhibited marked cyanosis in winter time. One day the physician in
question came to consult Professor Osier, and he found his red corpuscles
numbered more than 10,000,000 per cubic millimetre, that he had an
enlarged spleen, and had for several years exhibited cyanosis. He believed
this to be a definite and distinct malady, and the question presented itself
to what group the cases had formerly been referred. Probably the con¬
dition was included among the conditions of “plethora” referred to by
older writers, von Recklinghausen had described it very w’ell.
DISCUSSION.
Dr. R. G. Hann asked whether the patient had suffered from any acute
attacks of abdominal pain. A girl, aged 17, had recently come under his care,
whose only symptom had been severe abdominal pain. Within a period of
eighteen months she had had seven or eight such attacks, each lasting from two
to six hours, of acute pain across the upper part of the abdomen, accompanied
by abdominal retraction. The abdomen moved with respiration, there was no
flatulence nor indigestion, nor other symptoms pointing to the stomach. The
patient had a very large spleen, and the red blood cells numbered 7,000,000
per cubic millimetre. Otherwise she was in good health. No jaundice,
cyanosis, nor enlargement of the liver were noted.
Dr. PARKES WEBER called attention to the fact that the case shown
resembled the one which he had described before the Royal Medical and
Chirurgical Society, in that there was an increase in the nucleated red cells
circulating in the blood. On very careful and repeated examination some
nucleated red corpuscles were to be found in all blood, as Dr. Boycott had shown.
In most of the cases of polycythaemia with enlarged spleen there appear to have
been changes in the spleen which did not seem to be necessary features of the
disease, namely, infarctions. Some six post-mortems on the condition had
been made, and infarctions in the spleen had been found in almost all. It
might be that during attacks of perisplenitis resulting from infarction abdominal
pain might be present. It seemed quite clear that the enlargement of the spleen
in these cases was not due to excessive functional activity. One was at first
tempted to imagine that the spleen had reverted to its total functions, and was
actively engaged in forming red corpuscles and other elements of the circulating
Clinical Section
43
blood, but the post-mortem examinations which had been made practically nega¬
tived this supposition.
Dr. PASTEUR mentioned, with reference to the suggestion that the pain
might be due to perisplenitis or to infarction, that he had a patient w'ith a very
large spleen under his care, on whom he made a post-mortem examination a
week previously. She had suffered from very severe attacks of pain in the
splenic region, occurring periodically ; and he had fully expected that these
attacks would find their explanation in one of the two conditions which had
been mentioned, but neither infarction nor any trace of perisplenitis were
detected.
The President said he had seen a case which showed the condition referred
to by Professor Osier, viz., the vaso-motor changes indicated by the alteration
in the colour of the hand when it was raised or lowered. The limbs of his
patient were almost black when in the dependent posture, and the discoloration
disappeared when they were raised. Also several of the veins became enlarged ;
those over the conjunctiva were enormous, and the lumen of veins in different
parts of the body seemed greater than normal. In the case to which he referred
the liver was somewhat enlarged, and the patient showed a very slight icteric
tint, which had also been noticed in other recorded cases. The lack of real
illness of the patient was very striking in view of the conditions present.
Abdominal pain seemed very exceptional in the disease, and was not present in
the case under his care. It was important to notice that in Dr. Hann’s case
there was no cyanosis, which was one of the cardinal points in typical examples.
There were also other cases of cyanosis, which must have come under the
notice of Fellows, in which the spleen was not enlarged, and in which, where
there was no sign of congenital malformation of the heart, the diagnosis
remained obscure to the end of the chapter. In a case which had come
under, his own observation a few years previously, he had imagined there might
be some thrombosis of some of the intrathoracic veins. The patient, who had
a red blood-count which was considerably in excess of the normal, had died
suddenly. He (Sir Thomas Barlow) believed that, as the study of the subject
advanced, it would be found that there were groups of cases in which some
one or other of the symptoms was wanting, and he hoped Dr. Hann would
record his case, so that the account of it might be put side by side with the
present records. In the absence of cyanosis, he thought it could hardly be
regarded as belonging to the group under discussion.
Traumatic Dislocation of Left Hip, replaced by Manipulation
Thirteen Months after the Injury.
By T. H. Openshaw, C.M.G., M.S.
T. A. W., a boy, aged 15, was admitted into the London Hospital on
January 21, 1907, with a history of having been run over by a motor-car
on February 22, 1906.
44
Weber: Arteritis obliterans of Lower Extremity
On admission the left leg was 3J in. short. There was a considerable
thickening of the shaft of the left femur at the seat of a united fracture,
the fragments of which overlapped to the extent of 1 £ in. The head of
the femur was felt projecting on the dorsum ilii. The great trochanter
was rotated in, and the hip was flexed to an angle of 45°, adducted to
25°, and rotated in to 15 c . There was very little movement possible at
the hip-joint. The boy was wearing a 5 in. clump boot. Tenotomy of
the adductors was performed, and the hip continually extended by
weight. After some six or more manipulations under an anaesthetic the
hip was reduced on March 14, 1907, the head of the bone being lifted
over the posterior rim of the acetabulum, just as is done in Lorenz’s
method of reducing congenital dislocation.
Present Condition (December 13, 1907).—The hip is in joint. Bryant’s
triangles are equal. The movements of the left hip are restricted, there
l>eing 10° each only of flexion, adduction, and rotation. The X-rays
show that a considerable erosion of the head of the bone has taken place.
Arteritis obliterans of the Lower Extremity with Intermittent
Claudication (“ Angina Cruris ”).
By F. Pahkf.s Weber, M.D.
The patient, M. M., a Russian Jew, aged 42, seemed fairly well
nourished, but complained of cramp-like pains in the inner part of the
sole of the left foot (muscles of the instep) or in the calf of the left leg,
which always attacked him after he had walked for three or four minutes
and obliged him to rest a few minutes before going on. No pulsation
could be felt in the left dorsalis pedis artery, nor in the posterior tibial
artery behind the internal malleolus, though both these arteries could be
felt beating in the right limb. The pulsation of the femoral artery was
normal in both groins. When the patient was examined lying in bed
scarcely any difference between the two feet could be observed, but when
the legs were allowed to hang over the side of the bed the distal portion
of the left foot (unlike the right foot) became red and congested-looking,
especially the fourth and fifth toes. If the patient then forcibly flexed
and extended the ankle-joint a few times the skin of the foot, in less
than a minute, lost its congested look and became blanched and alabaster¬
like. If muscular exertion (by walking) were continued for three or
four minutes the patient commenced to limp and had to rest on account
of cramp-like pains in the muscles of the instep or the calf. If examined
Clinical Section
45
at that time the foot appeared pale, but not so white as it did after only
a few movements. The blanching of the foot could be to some extent
lessened by making the .patient inhale amyl nitrite. There was no
anaesthesia, and the electrical reactions were normal and equal on the
two sides. A Rontgen ray photograph of the two feet showed that the
bones of the left little toe gave too little shadow.
There was no evidence of any disease elsewhere in the body. The
radial arteries felt normal. The pulse was about 84, of moderate size
and fair pressure. The brachial blood-pressure (estimated by the Riva-
Rocci apparatus with a broad band) was 135 mm. of mercury in each
arm. A blood-count gave 4,175,000 red cells and 9,000 white cells in the
cubic millimetre of blood, and the haemoglobin value was 90 per cent, of
the normal (by Haldane’s method). Microscopical examination of blood-
films showed nothing abnormal. The urine was free from albumin and
sugar. The knee-jerks and plantar reflexes on both sides were natural.
The pupils were equal and reacted naturally to light. Ophthalmoscopic
examination gave no evidence of disease. On the patient’s admission to
the German Hospital (August 8, 1907) there was ulceration on the little
toe of the left foot, but the ulcer had since then slowly healed up.
The treatment in the hospital had been rest in bed (at first), the
application on alternate days to the affected extremity of local hot air
baths and Professor Bier’s light ligature method of producing passive
congestion, subcutaneous injections of fibrolysin (altogether forty-seven
Merck’s ampullae had been used), medium doses of iodipin by the mouth,
dermatol powder for the ulcer and wrapping up of the foot. Afterwards
the patient had been given Levico water. By all this treatment it was
very difficult to know whether much good had been done. The patient
certainly thought he felt better, and had gained weight, and the ulcer on
the toe had healed up, but the cramp-like pains (already referred to) on
walking persisted.
The affection had commenced gradually about five years previously
with pain in the sole of the foot on walking. Various methods of treat¬
ment had been tried, including electrical baths at the London Hospital
(which certainly seemed to do good), under Dr. E. R. Morton, and treat¬
ment at a thermal water health resort. He was always more or less
threatened with local gangrene, but had so far escaped with two attacks
of slight ulceration on the little toe and one on the great toe. The
ulceration in such cases was very indolent and slow in healing, and
might be termed “ ischaemic ulceration ”; by “ ischaemic ” it was
meant to imply not that the blood in the affected part w T as actually
46 Weber: Arteritis obliterans of Lower Extremity
deficient in quantity, but that the rate and pressure of the supply were
insufficient.
It was necessary to explain that the patient suffered from two
distinct kinds of pain—(1) the cramp-like muscular pains of intermittent
claudication (angina cruris), as already mentioned, and (2) a local pain
and tenderness in the affected toes which sometimes kept him awake at
night, especially when there was ulceration. Sometimes there was also
a third kind of pain, apparently connected with the ankle-joint.
The patient had previously enjoyed good health, with the exception
of an attack of “scrofulous” abscesses (some connected with bone disease)
in Russia when he was aged 4. There was no history of any venereal
disease. He had always been moderate in the use of alcohol and like¬
wise in the use of tea and coffee. He had been accustomed to smoke
rather freely.
Dr. Weber said the case was a typical one of the class of obliterative
arteritis which often led to gangrene of extremities and occurred in men
in the prime of life, especially in poor Jews from Russia, who had been
accustomed to smoke cigarettes rather freely. Within the last few years
Dr. Weber had had the opportunity of seeing nine cases in male Jews of
the East End of London, aged between 30 and 52, some of them
employed in cigarette factories where they could obtain cigarettes without
paying for them. The essential cause of the arterial disease in these
cases still remained unknown. Cases in which amputation had had
to be performed had been described by Dr. Michels and himself. 1
Cases had been brought before the Clinical Society or published in
English medical literature by Mr. Pearce Gould, Dr. W. B. Hadden, Mr.
W. G. Spencer and others. The pathology of the affection had been
thoroughly studied and discussed by several writers on the Continent,
including F. von Winiwarter, C. Sternberg, A. A. Wedensky, W.
von Zoege-Manteuffel, Bunge, P. Wulff, and O. von Wartburg; and the
relation of the vascular changes to the phenomena of Charcot’s “ inter¬
mittent claudication of extremities ” had been specially considered by W.
Erb, of Heidelberg. Dr. Weber suspected that the cases described by
Dr. Batty Shaw 2 under the heading “erythromelalgia” were really
examples of a similar arteritis obliterans.
Gangrene might sometimes (as in the patient exhibited that evening)
be delayed for years. In a man of about the same age (likewise of the
1 Brit. Med. Journ. } 1903, ii., p. 5G6; Trans. Path. Soc. Lond. f 1905, lvi., p. 223.
* Trans. Path. Soc. Lond ., 1903, liv., p. 168.
Clinical Section
47
Hebrew race), recently seen by Dr. Weber, with arteritis obliterans in
the right lower extremity, the affection had remained at least two years
to Dr. Weber’s knowledge without getting worse. Curiously enough,
some of the cases with the most decided “ intermittent claudication ”
seemed to escape gangrene longest, as if, as Erb maintained, there were
a decided nervous element in those cases in addition to the arterial
obstruction. Similarly, with angina pectoris, it was often not the
patients with the best-marked attacks who died first.
Intermittent claudication of extremities (intermittent limping,
dysbasia intermittens of Erb, dyskinesia intermittens, dyspragia inter¬
mittens) had been described by H. Bouley (1831) in horses, by Charcot
(1858) in men, and afterwards by many other writers. Great analogy
between the phenomena of arterial obstruction in the leg and the
phenomena of angina pectoris had been insisted on by Allan Bums
(1809), Sir Benjamin Brodie (1846), Potain (1870), and notably by
Huchard. Some authors (G. L. Walton and W. E. Paul) even spoke
of intermittent claudication of the lower extremity as angina cruris.
Angina cruris, like angina pectoris, occurred much more frequently in
men than in women. The interest of the present case lay chiefly in the
remarkable spastic contraction of the minute cutaneous blood-vessels of
the foot which preceded the muscular cramp-like pains (angina cruris).
For this reason the case might almost be described as one of angina
cruris (or angina pedis) vaso-motoria. It presented a striking analogy
to the form of angina pectoris described by Nothnagel (1867) as angina
pectoris vaso-motoria, in which the painful phenomena of angina pectoris
were preceded by contraction of cutaneous blood-vessels; but it had
to be remembered that Nothnagel, in his cases, thought that the whole
symptom-complex was of vaso-motor origin and that there was no
organic disease present.
Dr. Weber thought that the congested condition of the foot in the
case he exhibited and in similar cases (best marked, of course, with the
limb in the dependent position) was of conservative nature, and that it
might be explained as an automatic attempt to compensate (for the
arterial obstruction) by dilatation of capillaries and venules; that is to
say, as an automatic attempt to favour collateral circulation as far as
possible, and to make up for deficiency of the arterial supply by increase
of the total quantity of blood in the affected part.
48
Wynter: Methivmagiobin<vmia
Methaemoglobinaemia of Twelve Years Standing.
By W. Essex Wynter, M.D.
F., aged 45 (under observation since March, 1902). Has been in
the same state of cyanotic anaemia for twelve years, and was originally
considered to be suffering from Addison’s disease. There is a general
yellowish pallor, with lilac-coloured mucous membranes, associated with
feebleness, constipation, anorexia, and occasional vomiting. Temperature
100° F. Pulse 74-96. A pulmonary systolic bruit existed while the
patient was in hospital. Urine normal. Blood chocolate-coloured, making
comparison difficult in the haemoglobinometer; the colour is not altered by
exposure to CO ; red cells, 3,010,000 ; white cells, 7,000 ; haemoglobin,
50 per cent.; index,0*74; lymphocytes, 22*6; transitional,2*8; hyaline, 1*6:
polymorphonuclear, 71; eosinophile, 0*2; mast-cells, 1*8; bacillus coli
not found in blood. The spectroscope showed the band in red of
methaemoglobin, which disappeared on the addition of ammonium
sulphide.
DISCUSSION.
Dr. Poynton said the patient was in St. Mary’s Hospital when he was
house physician there, twelve or thirteen years ago, and she was then in that
curious condition. At that time he thought it was aniline poisoning. She had
the present great difficulty in going upstairs, with breathlessness, and a dusky
condition of the skin which was puzzling.
The PRESIDENT reminded Fellows that it had been the custom of the
Clinical Society to refer an obscure case to a Committee, on which the exhibitor
served, for investigation. The case under discussion would bear investigation
from many sides: for instance, as regarded the occupation of the patient. She
was engaged in making artificial flowers, and there might be something in the
materials used which was an influence in the condition.
It was agreed to refer the case to a Committee, consisting of Dr.
Drysdale, Dr. Poynton, Dr. Garrod, and Dr. Essex Wynter, that Com¬
mittee to report to the Section.
Amyotonia Congenita.
By W. Essex Wynter, M.D.
F., aged fifteen months. Admitted to Middlesex Hospital Septem¬
ber 21, 1907, on account of general weakness and backwardness. The
parents and brother and sister are quite healthy. The child had been
attending for two months at the Hospital for Sick Children, and was
Clinical Section
49
stated to be getting weaker and thinner. The striking feature in the
condition is the flabbiness of muscles and freedom of movement in articu¬
lations, allowing of flexion and extension beyond normal limits, so that
the toes can be made to touch the front of the leg and the fingers the
back of the forearm, while the legs can be flexed up to the chin. The
child can sit up and walk, and is cheerful and intelligent. The face is
not affected. The muscles of the limbs, though flabby, show fair bulk,
and respond to voluntary impulses. They do not contract to strong
faradism, and moderate currents induce no pain. A full account of the
case will be published in Brain .
DISCUSSION.
The PRESIDENT said he hoped Dr. Wynter would keep his eye upon
the case with a view to seeing what the ultimate result was. He had himself
seen two such cases of it in years gone by, but he was not aware of the
ultimate issue.
Dr. Morley Fletcher asked why the case should not be regarded as one
of severe rickets, in which the stress fell not upon the bones but upon the
muscles. Cases of rickets sometimes resembled the present case closely,
and he thought that the patient shown was suffering from rickets. He had
seen a considerable number of cases with amyotonia and great flaccidity of the
muscles, which improved very much under the treatment appropriate for
rickets.
Dr. ERNEST Jones asked why the name amyotonia was preferred, as
Oppenheim, who first described the condition, assigned to it the name of
myotonia congenita, and it was so called in the writings on the subject.
Dr. WYNTER, in reply, said there was but little in the literature, as he
believed cases of the kind had only been described during the last year or two.
The flaccidity of the muscles had existed from birth. There were two other
children in the family, quite healthy. The absence of electrical reaction in the
present case was a feature which would scarcely exist in simple rickets, and
changes in the bones were not very marked.
Cure of Ascites by Permanent Drainage through the
Femoral Ring.
By W. Essex Wynter, M.D.
M., aged 50. Admitted to Middlesex Hospital July 11, 1907. For
a week there had been swelling of abdomen and legs, with slight jaundice.
He had been rather a free beer drinker. There was no evidence of cardiac
disease, but the daily output of urine was only 15 oz., and it contained
50 Wynter: Cure of Ascites by Permanent Drainage
a trace of albumin; specific gravity 1010. Purgative diuretics and
Canadian hemp were tried without effect. The ascites increased, and on
August 26 tension was relieved by removing 300 oz. of fluid. This was
only of temporary benefit, and on September 23 Mr. Sampson Handley
made a small incision below the umbilicus and several pints of fluid
escaped. An incision as for femoral hernia was then made, and with the
aid of one finger in the abdominal cavity the process of peritoneum was
drawn down, split, and the edges stitched right and left to maintain the
opening. The wounds were then closed. Owing to some leakage at
the femoral wound, paracentesis was performed a week after operation.
Some oozing from a stitch puncture in the thigh continued for about
three weeks, showing that the communication with the peritoneal cavity
remained open, but the ascites did not recur, and by November 20 there
was no perceptible fluid in the abdominal cavity. The patient has been
walking about the ward for a fortnight, and neither femoral hernia nor
oedema of the leg has developed ; indeed, the girth of the right thigh is
an inch less than on the opposite side. In this case the femoral operation
was performed deliberately for the cure of ascites, with the object of
draining the abdominal cavity into the tissues outside the abdomen, so
saving repeated paracenteses and the removal of quantities of albuminous
fluid, and to enable the patient to get about.
Mr. SAMPSON HANDLEY said that, although he was associated with Dr.
Wynter in the case, the idea was entirely due to Dr. Wynter, and that he had
simply carried out the operative work. He made a flap incision over the femoral
ring, as for femoral hernia, so that the line of the incision should not correspond
anywhere with the opening in the ling. The convexity of the flap was directed
outwards. The main difficulty was that the peritoneum did not bulge through
the femoral ring, notwithstanding the pressure of the ascitic fluid ; and that,
owing to the prominence of the abdomen, it was difficult to find the femoral
canal without risk to the femoral vein. It was therefore necessary to make
a small median abdominal incision, large enough to admit one finger, by which
he felt the crural ring, and made the peritoneum of the crural canal protrude
into the femoral incision. In future cases he proposed to tap the abdomen with
a curved trocar just above the pubes, and, through the cannula, having allowed
a certain amount of fluid to escape, to introduce a long curved seeker fitting the
cannula, by means of which one would find the ring from inside, and make the
peritoneum of the femoral canal protrude. The peritoneum was seized by two
pairs of forceps and snipped between by scissors. Two sutures were next
introduced, one on each side, taking up the i>eritoneum of the femoral canal
and also passing through Poupart’s ligament. When these sutures were tied,
the patency of the artificial opening was secured, its edges gaping widely. The
operation was completed by suturing the skin.
Clinical Section
51
A Case of Acute Anterior Poliomyelitis with Permanent
Paralysis of the Diaphragm and Abdominal Muscles.
By W. Pasteur, M.D.
J. B., a healthy schoolboy, aged 13J, complained on November 12,
1906, of shooting pains in both thighs and severe pain across the
abdomen at the level of the anterior superior iliac spines. There was
fever with delirium during the night and part of the next day, with
continuance of abdominal pain. In the night of November 13 there were
sharp pains in both legs, increased by movement, and on the following
morning the boy could not leave his bed on account of loss of power in
the legs. By November 16 he was quite helpless, and his mother noticed
that he could not cough. He was unable to move himself in bed, but
the arms were not entirely paralysed.
On admission, November 19 (eighth day of illness), he was found
to be completely helpless, but free from pain. The voice was clear, but
very weak, and there was an almost constant, toneless, non-explosive
cough. The expression was natural, the face high-coloured and rather
dusky. The boy was obviously gravely ill. Respirations were 40 per
minute, but not distressed as long as the boy did not talk or exert
himself; pulse 100, of good quality; heart normal. Sensation was
everywhere normal. There was total flaccid paralysis of both lower
limbs and buttocks, except faint flickering voluntary movements of the
right peronei. The paralysed muscles did not contract to faradic or
galvanic currents. The plantar and cremasteric reflexes and the knee-
jerks were absent; the sphincters were unaffected, except that a few
unconscious evacuations occurred during sleep in the first ten days.
There was no movement of the abdominal muscles during respiration,
which was entirely thoracic, nor was any visible contraction elicited
when the boy attempted to cough or to raise his head from the pillow.
The diaphragm was paralysed. The abdominal and epigastric reflexes
were absent. The patient was quite unable to turn to either side, but
could arch his back very slightly. The movements of the thorax were
equal on the two sides, but deficient. There was paresis of all the
muscles of both upper limbs, especially the right. The extensors only
contracted to strong faradic currents; the flexors reacted normally.
There was no paralysis of the face, tongue, palate or pharynx. The
ocular muscles were normal; the pupils were equal and dilated. Air
entered the front of the lungs fairly; in the axillary regions the breath-
52
Pasteur: A Case of Acute Anterior Poliomyelitis
sounds were weaker. The backs were not examined on account of the
critical state of the patient.
Progress .—Except for the integrity of the soft palate and pharynx,
the case, on admission, very closely resembled a widespread diphtheritic
polyneuritis. The condition of the patient was most serious, the least
attempt at disturbance or exertion causing a grave embarrassment of
respiration. This critical phase continued for ten days after admission.
The paralysis of the diaphragm had led to lobar collapse of the left
lung, with secondary pneumonia. Cyanosis deepened, and breathlessness
became so urgent that for several nights the boy could get no sleep. He
was literally kept alive during this period by artificial respiration every
two or three hours, very frequent inhalation of oxygen, and hypodermic
injections of strychnine. There was moderate fever (100° F. or 103° F.),
with a termination by crisis on November 30. After this the boy began
to gain strength slowly, and the constant hacking cough soon ceased.
On December 5 it was possible to make a complete examination of
the chest. The following note was made : “ There is marked flattening
of the subclavicular region on both sides. The area of visible impulse
of the heart is increased. There is general shrinking and very little
movement of the left chest. The intercostal spaces are depressed and
do not fill up during respiration. The percussion note is dull all over the
lower lobe and deficient over the remainder of the lung. The breath-
sounds are high pitched and tubular all over the base, with scanty
crepitations. The stomach note rises as high as the sixth rib in the
mid-axillary line. Physical signs more normal over right lung, except
at extreme base, where air entry is poor and the percussion note
somewhat deficient. There are no signs of diaphragmatic action.”
Recovery of muscular power began early in December. It was
mainly limited to the arms, neck and shoulders. By the end of the
month the boy could make full use of his upper limbs, was able to turn
himself over in bed, and could lift himself into the sitting posture. There
w T as no power to move the pelvis and lower limbs.
Recovery of respiratory power was slower. At the end of January
the left chest was still smaller than the right, the lung being only
partially expanded, with weak breath-sounds and impaired percussion
note. The diaphragm was still inert.
He returned from the convalescent home on March 21 in excellent
health, but without any appreciable improvement in the paralysis, w'hich
had remained in statu quo as regards the pelvis and legs. There was,
however, a marked recovery in the thoracic muscles. The subclavicular
Clinical Section
53
flattening had quite disappeared on the right, and was decidedly less
obvious on the left. Air entered well on both sides. Electrically there
was no response to faradism in the glutei and the muscles of the abdomen,
thighs and legs on both sides. Elsewhere the reactions were those of
health. This condition has persisted up to the present date, one year
after the onset.
Case showing unusual situation of Gouty Deposit in the
Olecranon Bursa.
By J. Graham Forbes, M.D.
J. W., A labourer, aged 3*2, has suffered from gouty deposits in the
ears, elbows and fingers for the last four to five years, i.e., since the age
of 28. Tophi first appeared in the ears four and a, half years ago, then
the olecranon bursae became enlarged, while the fingers and wrists have
only been affected for the last two years. The patient, who has been a
fairly heavy beer drinker for fourteen years, has never had an acute
attack of gout, beyond being laid up for a week tw r o years ago witli
what he describes as “ rheumatism ” ; and there is no history of gravel.
His father's brother is the only relative whom he knows to have suffered
from gout.
The interesting feature of the case is the condition of the bursa over
the left olecranon. It forms a swelling about the size of a small Tangerine
orange, and contains a mass of chalk-like concretion visible through the
thin layer of overlying skin. At one part is a soft fluctuating area covered
by red shining skin, suggesting the presence of pus; this has subsequently
burst, exuding a thick milky fluid, which under the microscope is seen to
be composed entirely of fine acicular crystals of sodium biurate. In
stained film preparations a scanty number of leucocytes and amorphous
masses are visible, but no organisms can be recognised.
The right olecranon bursa is also thickened and enlarged, but to a less
degree than the left. Here, too, there is evidence of uratic deposit.
There is no history of definite injury to the elbows, but his employ¬
ment as labourer and the uratic deposit elsewhere visible would explain
the occurrence of a bursitis, in which gout and a repetition of slight
unnoticed bruisings have taken part. The elbow-joints themselves are
unaffected and freely movable.
The rarity of this situation and size of uratic deposit occurring in a
man under the age of 30 is worth emphasising. In addition the patient
shows the distribution of gout in the more common parts of the body.
54
Forbes: Unusual Situation of Gouty Deposit
Both ears contain several tophi, notably the right. There is a definite
thickening about the left shoulder-joint and wrist, so that the hand
cannot be raised to the head, and movements at the wrist are much
restricted. Subcutaneous deposits also occur in the thumb, index and
little fingers of the left hand, and over the dorsum of the right, the
thumb, second, third, and fourth fingers of which are more or less crippled
by the thickening and deposit about the phalangeal joints, and now
present an acute recrudescence of the gout.
In the left leg the synovial membranes of the knee- and ankle-joints
are thickened, but there is no evidence of uratic deposit about the great
toe-joints. Examination of the chest reveals no abnormal physical signs
or evidence of cardiac hypertrophy. The pulse tension is not raised and
the arteries are not obviously thickened. In the abdomen the edge of
the liver can just be felt, but the normal upper limit of hepatic dulness
is unaltered.
Urine .—On November 23, pale in colour, specific gravity 1010;
albumin, definite trace. On December 7 and 14 it was highly coloured
and contained a heavy deposit of albumin.
It is noticeable that the elbow- and finger-joints show no evidence of
articular erosion, or changes associated with rheumatoid arthritis.
Excision of the tophous mass on the left olecranon is to be performed.
DISCUSSION.
Professor OsLER remarked that such very large tophaceous masses
might occur in gout without any other obvious signs, as also might large, flat,
plaque-like masses along the triceps tendon, apart from any tophi or other
signs suggestive of gout, until they were removed surgically. He had met
with several cases in which the diagnosis of gout was not made until the
removal of the tumour. In one case there was a very large flat plaque as large
as one’s hand in the lower part of the back, and when the tumour was removed
and sections of it were cut, it w’as found to be a gouty tumour. He thought
surgery was the proper treatment for such cases, and that early removal was
advisable. He believed that a certain number of fibrous swellings about the
patella were gouty, though they were not thought to be so in the absence of
tophi.
Dr. POYNTON agreed that in such cases there might be no sign of gout until
the tumour was removed, when in the centre of the nodule a tophaceous deposit
might be found. Under very high power tiny specks of urate were just visible
in sections. The earliest change was necrotic in nature. It would be interest¬
ing if Dr. Forbes could get a bacterial cultivation from one of the tumours, as it
was from such cases that one might hope to obtain evidence of a bacterial factor
in gout.
Clinical Section
55
Dr. PARKES Weber said that at the first meeting of this Session Dr.
Garrod had shown an adult woman with fibrous-looking nodules on the elbows,
and the opinion of the Society w r as that the case was not one of gout, but of
rheumatism. He himself had shown, last year, at the Medical Society of
London, a man with apparently similar nodules about the elbows. He believed
that such fibrous nodules in adults might or might not contain uratic deposit,
and he believed that the development of fibrous tissue in the nodules in question
was of the nature of a “ conservative " vital reaction. There might or might
not be a primary necrotic centre, as Dr. Poynton suggested.
Dr. A. E. Garrod regarded the bursa over the olecranon as one of the seats
of election for gouty tophi, but it was unusual to see them in a patient of the
age of the present one. It was an admirable course to treat them surgically, so
long as one was sure that one was dealing with a bursa, but surgical interference
with tophaceous deposits in other situations was likely to be harmful, as the
deposits often extended far into the deeper structures of the parts.
A Case of Bulbar Paralysis.
By H. Batty Shaw, MJD.
This case, shown through the courtesy of Sir Thomas Barlow,
President of the Section, is exhibited because of the association of
ingravescent bulbar paralysis with a malignant bronchocele.
M. A., a widow, aged 47, has suffered for the previous twenty years
with a large bronchocele and slight attacks of periodic huskiness of the
voice. In February, 1903, there was also cough, w r hich was observed to
be distinctly 44 brassy ” in character, unaccompanied by any paralysis of
the vocal cords, and probably due to pressure on the trachea. In addition
there was subsequently observed on occasions tachycardia, and tremor of
the hands was always more or less present; there were no other signs
of exophthalmic goitre. A systolic sound was constantly observed at the
apex-beat of the heart.
In June, 1907, the patient was admitted under the care of Mr. F. B.
Jessett, at the Cancer Hospital, for the symptom of pressure on the
trachea, which was intensified in recumbency. More than half the
bronchocele was removed on June 25, the operation being accompanied
by considerable haemorrhage. On July 8, the voice was almost com¬
pletely lost, stridor developed, and weakness of the left lower facial
muscle was observed; pain and stiffness of the back of the neck was
observed on July 15. On August 21, there was well-marked atrophy
of the right half of the tongue, and on the 28th of the same month
there was diplopia.
56
Shaw: Hepato-spleiiornegaly with Ascites
On admission to University College Hospital on November 5, she
was found to have lost over a stone in weight compared with the weight
in 1903 ; the pulse-rate was 146 and the temperature 99° F. The
following signs were also demonstrable: There was paresis of the
sixth nerve on the right side, paresis of the right half of the palate
(spinal accessory), paralysis and atrophy of the right half of the tongue
(hypoglossal nerve), paresis and atrophy of the right sterno-mastoid
muscle (spinal accessory) and of the right trapezius (spinal accessory,
first, third and fourth cervical nerves). The patient was found to be aphonic,
and only able to swallow solids with difficulty. In addition to the above
nervous lesions on the right side, there was weakness of the left lower
facial muscles and complete paralysis of the left vocal cord. A recent
symptom was vomiting.
At the operation, details of which were kindly supplied by Mr.
Jessett, the trachea was markedly deflected to the right, the thyroid
cartilage being felt below the right angle of the lower jaw; a spur-like
prolongation upwards of the thyroid gland was removed, as well as the
greater part of the left part of the gland ; the normal thyroid tissue w y as
found microscopically to be replaced by the development of a carcinoma¬
tous growth.
The diagnosis lies between a primary degeneration of the centres of
the various nerves involved, possibly due to thrombosis, and a secondary
deposit in and about the medulla; the latter hypothesis is supported by
the presence of severe pain and stiffness of the muscles of the back of
the neck.
There is no reason to think the patient suffered from syphilis; a son
recently died, aged 22, of diabetes mellitus. The patient suffered from
pleurisy of the left side of the chest seventeen years ago.
Hepato-splenomegaly with Ascites.
By H. Batty Shaw, M.D.
F., aged 3J, was noticed to be short of breath in June of this year.
She is now easily tired and unable to walk far owing to shortness of
breath. The abdomen was observed to be swollen on November 22 of
this year, and this has increased steadily. She is the eldest of three
children. Both mother and father have had rheumatic fever, and the
mother has had one miscarriage since the birth of the youngest child.
This child was breast-fed till eight months old, and then was fed on
boiled milk till solid food was given.
Clinical Section
57
There are no signs of tuberculosis or syphilis. The liver is enlarged
and the spleen could be felt easily until recently, when the ascites has
increased. There is no albumin in the urine, nor are there signs of
cardiac disease. The blood-count is normal for a child of this age except
that the percentage of haemoglobin is only 64. Jaundice has not been
observed.
A Case of Ochronosis.
By Edgar Reid (Swansea).
(Introduced by Professor Osler.)
The patient, a woman, aged 68, had a large ulcer upon each leg,
which had been dressed with carbolic oil (1 in 20) for a period of thirty
years. Six years ago pigmentation of the ears and whites of the eyes
was observed, and two years ago the urine was first noticed to be dark in
colour. In June, 1907, when she was admitted to the Swansea Hospital,
the concavity of each ear showed a deep blue-black staining, whereas the
peripheral part of the auricle was free from pigmentation. There w r ere
also patches of pigment in the exposed portions of the sclerotics of both
eyes. The extensor tendons of the fingers were bluish black in tint over
the knuckles, and the knuckles themselves showed a slight staining.
The skin of the face and exposed parts had a dusky hue, as compared
with that of covered parts. Since June the patient had been kept in
bed, and the ulcers had steadily diminished in area. Although carbolic
dressings had been continued the staining has perceptibly diminished. 1
Dr. Reid called attention to the fact that in three other cases of
ochronosis recently reported there was a similar history of prolonged
application of carbolic acid, and he agreed with Pick in attributing the
condition where this was the case to the slow absorption of carbolic
acid. He suggested that “ phenolism " would be a more appropriate
name for this group of cases of ochronosis.
DISCUSSION.
Professor OSLER said that, in the three cases of ochronosis which he had
seen, the condition was associated with alkaptonuria, but it appeared certain
that, in a certain number of the cases, ochronosis was associated with carbol-
uria, as in the present instance. Two aikaptonuric brothers whom he had
had under observation both presented exactly the same condition as was seen
in the present patient, namely, pigmentation of the sclerotics and of the hollows
1 A full report of the case, with a coloured plate, has appeared in the Quarterly Journal
of Medicine, 1908, vol. i., No. 2, p. 199.
ja —2
58
Reid: A Case of Ochronosis
of the ears and staining of the cartilages of the knuckles of a steel grey colour.
They suffered no inconvenience, save that one of the brothers had been
much troubled of late by a butterfly-shaped pigmentation, which began over the
bridge of his nose and spread on to his cheeks. The staining was not confined
to the cartilages, but affected the fibrous tissues also. Ochronosis was rather
a clinical curiosity than a phenomenon of any special morbid interest. It could
be very readily diagnosed by the pigmentation on the sclerotics and of the
hollows of the ears.
Dr. A. E. GARROD said that this was the first case of ochronosis he had
seen, but a study of the literature of the subject left no doubt that, among the
14 cases on record, there were examples, not only of the two conditions which
had been mentioned, viz., alkaptonuria and carbolic acid absorption, but of other
conditions also. There were two cases on record in which dark urine was passed
for many years, but in which observers who could speak with authority had
excluded the presence of either alkaptonuria or carboluria. A patient whose case
was recently described by Clemens was proved to have ochronosis at a post¬
mortem examination, and was almost certainly the subject of alkaptonuria. In a
specimen of the urine of Dr. Reid’s patient which he had recently had the
opportunity of examining, the aromatic sulphates constituted no less than 85 per
cent, of the total sulphates, which showed that the patient had some degree of
carboluria, and the urine showed a very slight smoky tint. Dr. Garrod added
that it was interesting to note that in carboluria and alkaptonuria the darkening
of the urine which occurred on exposure was due to the presence of hydro-
quinone in the one case, and of a hydroquinone derivative, homogentisic acid, in
the other.
Dr. Hale White pointed out that Dr. Reid’s patient had xanthelasma
palpebrarum. This condition was also observed in Dr. Pope’s case of ochronosis*
and although it was not mentioned in connection with any of the other recorded
cases, referred to by Dr. Pope in his paper in the Lancet , it seemed probable
that the association was not merely a coincidence.
Dr. Parkes Weber asked what were the first signs observed in cases of
ochronosis, and where the pigmentation was first noticed. There were some
remarkable cases of slaty blue pigmentation, of which he had seen an early
example a short time ago, which were apt to be regarded as examples of some
form of cyanosis. The case which he had seen showed how easily such a con¬
dition might be misinterpreted even by careful observers. A diagnosis of a form
of Raynaud’s disease was made, although the blue pigmentation was most
marked upon the face. If the skin were rendered anaemic by pressing a glass
slide upon it, the peculiar dusky bluish tint persisted. This sufficed to
exclude cyanosis, and showed that the skin was actually pigmented as in
haemochromatosis.
Dr. REID, in reply, said the condition first appeared in the ears and in the
conjunctivae simultaneously, and was noticed by the patient before there was
any noticeable alteration of the tint of the skin. The change was most marked
in the exposed parts.
Clinical Section.
January 10, 1908.
Sir Thomas Barlow, Bt., K.C.V.O., President of the Section, in the Chair.
Polycythaemia with Enlarged Spleen without Cyanosis, in a
girl, aged 18 .
By R. G. Hann.
Patient, an intelligent girl, aged 18, with the appearance and
manners of 15 or 16, living in comfortable circumstances, has been
under observation since December 3, 1907. She was perfectly well till
she was aged 13, never robust since, though her general health has been
better during the past twelve months than during the preceding four
years ; apart from attacks of abdominal pain, she is without symptoms.
She is growing in height and her weight is increasing. When aged 15
had two menstrual periods ; none since. Her long chest and abdomen
are infantile in character, showing no signs of broadening; external
genitals infantile, no growth of pubic hair, no mammary development;
she is very thin, and her muscular development is poor. She has never
been cyanosed or jaundiced. Spleen considerably enlarged, reaching
three fingers’ breadth below the costal margin; surface smooth, never
tender or painful. Liver and other abdominal and thoracic organs
apparently normal. Blood examined on December 6, 1907, by Dr. G.
Watson: Red cells, 6,800,000; white cells, 7,980; no abnormal forms;
differential count of white cells normal. Blood further examined by
Dr. O. C. Gruner on December 30, 1907 : Red cells, 6,200,000, slight
differences in size, otherwise normal; white cells, 11,580;
7,480 polynuclears per cubic millimetre
3,270 lymphocytes ,, ,,
715 large mononuclears ,, ,,
23 mast-cells ,, ,,
92 eosinophiles ,, ,,
, or 64 per cent.
28
62
0-2
08
/-I
60
Hanii: Polycythemia rvith Enlarged Spleen
haemoglobin, 115 per cent. (Gaertner’s apparatus) ; colour index, 0*915 ;
specific gravity, 1038 (Hammerschlag’s method) ; viscosity (water
being 1), 5*3 at 13° C. The osmotic pressure was measured in terms of
Na Cl by determining in what strength of Na Cl haemolysis would not
occur. In this way a 0*88 per cent, solution Na Cl w r as found to be
isotonic with the non-defibrinated blood. The haemolysis was determined
by centrifugalising the mixed blood and salt solution in Hamburger's
special pipette.
Severe attacks of abdominal pain have been the only symptoms com¬
plained of. They first appeared in 1906, in which year she had eight
distinct attacks; after a clear interval of eleven months she had one on
December 3, 1907, and another on December 27. The pain is extremely
severe, extends across the upper abdomen, and is not referred especially
to the splenic region. The paroxysms last from a quarter of an hour to
six hours, begin and end suddenly, come on at any time of the day or
night, and are independent of the ingestion of food. During the pain
the abdomen is retracted; it moves on respiration; no superficial or deep
tenderness; no flatulence, vomiting, or diarrhoea ; pulse about 120. The
temperature is never raised, and after the attack on December 3 it
remained subnormal during the succeeding fourteen days on which it
was regularly observed. It seems improbable that perisplenitis or
infarcts would account for these crises. No evidence of pancreatic
disease. Patellar reflex and pupil reaction normal. The lymphatic
glands in the neck and axillae can be felt, but cannot be said to be
definitely enlarged. There are no signs of tuberculous disease elsewhere.
It is likely that the condition has been present for the last few
years, and whatever it may be due to, the case is undoubtedly tending
towards improvement.
DISCUSSION.
The PRESIDENT (Sir T. Barlow) expressed the indebtedness of the Section
to Mr. Hann for bringing the patient all the way from Leeds. It was most
desirable that as many cases of the kind as possible should be seen. It did
not conform to the type with which the Section had lately been concerned, as
there was polycythaemia with enlarged spleen, but no cyanosis, so that it could
scarcely be regarded as even an outlying member of the group to which he had
referred. It was only by bringing forward such cases into clinical notice when
they occurred that it would be possible by degrees to differentiate them.
Dr. Robert Hutchison said he should not regard the present- case as
belonging to the group of splenomegalic polycythaemia. He had seen many
cases of the present type which were difficult to classify—adolescents who
had enlarged spleens, hut often very little else. He did not attach much
Clinical Section
61
importance to the polycythaemia in the present case, because it was of sucli
slight degree. There were many people with 6,000,000 red cells to the
cubic millimetre. In some of the cases which he investigated a few years
ago there was a history of the spleen having been enlarged in infancy, and
in some cases the enlargement of the spleen was a survival of that period.
In others there was a history of congenital syphilis. Inherited syphilis, with
enlargement of the spleen as its only sign, was occasionally seen, just as
ulceration of the soft palate sometimes occurred as an isolated late mani¬
festation of inherited syphilis. He was inclined to refer the present case to
that group. In reply to the President, Dr. Hutchison said that in the cases
in which the splenic enlargement of syphilitic origin had persisted from infancy
he had not met with polycythaemia, but there might be a normal number of
red corpuscles. He had seen many such cases in whom there was no anaemia.
Dr. PARKES Weber said that it was hard to account for all the facts
in Mr. Hann’s case by any diagnosis. The increase in the red blood cor¬
puscles was not sufficient to place the case in the class of splenomegalic
polycythaemia, but it might be accounted for as a conservative reaction
resulting from relative deficiency in the cardio-vascular system, the heart and
blood-vessels being perhaps imperfectly developed in proportion to the length
of the body. There was a doubtful history of syphilis, Dr. Weber gathered,
in the father, and the child’s retarded development and the splenomegaly
might possibly both be late manifestations of congenital syphilis. On the
other hand, the possibility of splenic tuberculosis had to be considered, and
it would be worth while trying the Wolff-Eisner-Calmette test (“ ophthalmo¬
reaction ”) for tuberculosis. There was likewise the question of the case being
an incipient one of Hodgkin’s disease, as the glands in both axillae were
considerably enlarged. It was doubtful whether the paroxysmal attacks of
abdominal pain were causally connected with the splenomegaly.
A Case of Hemihypertrophy.
By P. Lockhart Mummery, F.K.C.S.
The patient is a boy, aged 4£. He is the son of healthy parents,
and his brother, older than himself, is quite a normal child. I
first saw him in December, 1905, when he was brought up to the
North-Eastern Hospital for Children because one leg was shorter
than its fellow. When the child was stripped for examination it was
noticed that the whole of the left side of the child’s body was larger
than the right side. The mother said he had always been a healthy
child. She first noticed that the left side was bigger than the right
when the child was aged 1£. The child looks healthy and his mental
condition appears to be normal, nor can any abnormality be detected
beyond the difference in size of the two sides of the body. When
0*2
Mummery : Case of Hemihypertrophy
the child was first seen, two years ago, the difference in the measure¬
ments on the two sides of the body were as follow :—
Left lower extremity ... ... $ in. longer.
,, upper , f ... ... i in. longer.
Girth at umbilicus ... ... 1 in. greater.
,, of chest ... ... ... J in. greater.
All other measurements were similarly greater on the left side. The
left side of the tongue was obviously larger than the right side. An X-ray
photograph showed that the bones on the left side were larger than on
the right and that the ossification of the epiphyses was more advanced.
The right testicle was undescended and smaller than the left.
The case has been under my observation for over two years. During
that time the child has remained in good health except for an attack of
scarlet fever contracted in the hospital. During the two years, however,
the difference in the two sides of the child has increased, or in other
words the left side of the child has grown faster than the right. The
difference is now much more marked than when he was first seen, and
the left half of the child, especially the face, appears at least a year older
than the right. Whereas the left lower extremity was only in. longer
than the right two years ago, it is now nearly 2 in. longer, and
similar differences are apparent in the other comparative measurements.
Also it is now obvious that the left orbit and eyeball are larger than the
right, while two years ago no difference could be detected.
Both sides of the child appear to be perfectly normal, but to have
grown at different rates. To enable the child' to walk without a serious
limp a thick-soled boot lias been fitted to the left leg, and this has had
to be increased in thickness several times in the last two years. Even
the child’s left tonsil is larger than the right.
This condition is an extremely rare and curious one. I have only
been able to discover records of 10 other cases of a similar nature,
though, of course, local hypertrophy is common enough.
Logan, in 1868, recorded a case in a child, aged 4. The right half
of the body was the hypertrophied side.
Tilanus, 1 of Munich, reported a case in 1808. The patient was a girl,
aged 10. The left side was affected, and the condition was first noticed
at the age of 3.
A remarkable case is reported by M‘Gregor, of Glasgow. The
patient was a boy, aged 10. The condition was first noticed at the age
of 3. The hypertrophy was on the right side and was unequal, as the
1 Tilanus’s and Mbbius's cases are undoubtedly the same.
Clinical Section
63
right leg was the part chiefly affected ; the head does not seem to have
been affected at all. The hypertrophied leg was amputated when the
boy was aged 11J, and he died after the operation. Post mortem
an enlargement of the right optic thalamus was found. The pituitary
body was normal.
Mobius records a case in which the left side was hypertrophied, and
measurements taken over a period of eleven years showed no alteration
in the difference between the two sides.
R£dard records a case affecting the right side.
Milne has recorded a case. The patient was a girl, aged eighteen
months ; the right side was affected. There were six teeth on the right
side and only one on the left.
Robert Hutchison reported a case in 1904 to the Society for the
Study of Diseases in Children. The child was aged four months, and the
asymmetry appeared to involve the limbs and trunk only. The child
died from broncho-pneumonia, and post mortem it was found that the
paired organs were larger and heavier on the left side. Thus the left
kidney weighed 56 grm. and the right only 28 grm. The right testicle
2*3 grm. and the left 0*55 grm. The left lobe of the thymus gland was
larger than the right.
Cases have also been recorded by Finlayson, Langlet, Broca and
Demme. In one or tw r o instances, how r ever, it seems probable that the
same case has been recorded by more than one observer.
I have myself seen one other case, a child, aged ten months, a girl.
The left side was affected as in the present case, but the difference in the
two sides w r as slight, and I have lost sight of the child for the last
two years.
The present case would seem to be one of the best marked cases yet
recorded, as the hypertrophy seems to be fairly uniform over the one
side. It also brings out one important fact about the disease, namely,
that the condition is due to one half of the body growing faster than the
other half, and that this unequal growth is progressive. The child, if it
lives, must grow into a curve, with the concavity to the right.
Nothing is known about the pathology of the condition. It has been
suggested that the condition resembles acromegaly, but no disease
of the pituitary body has been discovered in any of the cases. In
M‘Gregor’s case an enlargement of the right optic thalamus w r as present,
but unfortunately no microscopical examination was made, and moreover
his case was not quite a typical one, as the hypertrophy was not uniform.
The condition would not appear to be fatal, but very serious deformity
64
Phillips: Multiple Telangiectases
would seem inevitable. The condition must, however, be due to some
lesion or maldevelopment of the central nervous system, as there is no
other system of the body which is strictly bilateral. The disease, or
condition, should therefore be, I think, considered as belonging to the
diseases of the nervous system and those centres of the brain which
govern nutrition and growth. There is apparently, at present, no
treatment for the condition.
BIBLIOGRAPHY.
Carpenter and Mummery. Hep. Soc. Study Dis. Child ., Loud., 1906, vi., 153.
Hutchison. Rep. Soc. Study Dis. Child., Loud., 1904, p. 145.
Lanolet. Union vied, du nord-est, Reims, 1882, vi., p. 276.
Logan. New Orleans Joum. Med ., 1888, xxi.
M‘Gregor. Glas. Med. Joum., 1894, xli., p. 189: and Trans. Med.-Chir. Soc. G7<is.,i.
Milne. Quarterly Med. Joum., Shuff., 1894-5, iii., p. 243.
Mobius. Milnch. vied. Wochensch ., 1890, xxxvii., p. 751.
Rkdahd. Archiv. (i<'n. dc vied., Paris, 1890, i., p. 31.
Multiple Telangiectases.
By Sidney Phillips, M.D.
F., married, aged 56, subject to free bleeding from both nostrils
since childhood; since 1897 bleeding at times from vascular patches on
the tongue, and in 1900 bleeding occurred from similar patches on
the roof of the mouth ; in October, 1907, free epistaxis with bleeding
from the tongue and from small naevus-looking spots on the lower lip
occurred. The former bleed occasionally when the teeth are cleaned.
Father of patient is subject to violent epistaxis and has some vascular
elevations on tongue which bleed at times. Patient's sister died of
haemorrhage from the gums. Patient has one child who has vascular
elevations on the tongue, but has bled from them only once. Patient
has stigmata on cheeks, and scattered about trunk small red spots size of
a pin’s head. On lower lip is a small elevated vascular patch which
often bleeds, also a smaller one on the upper lip ; a red spot on the
right little finger. Near the tip of the tongue is a small red elevated
patch which at times spurts up blood freely; several others much smaller
on surface of tongue, and one red speck behind alveolus of upper jaw,
which bleeds freely at times.
All the vascular patches have shrunk considerably since the patient
has been in hospital for two months. When admitted they were more
full of blood and more prominent.
('l ini cal Section
65
DISCUSSION.
Dr. Colcott Fox said there was at present a case in Westminster Hospital
of such multiple telangiectases. He showed a drawing of it sent to him by
Dr. John Norton. The case was subsequently admitted by Dr. Hebb, with
bleeding from the rectum. The rectal condition had not yet been thoroughly
investigated. There was a history of epistaxis dating back for many years,
and a sister of the patient had had some similar affection. There were no
telangiectases in the mouth or on the face, but they were abundantly present on
both sides of the body.
Dr. Phillips, in reply, said it was true that the condition sometimes
occurred at advanced ages, and that females were chiefly affected: but the
present patient’s father had a similar affection.
Multiple Hereditary Developmental Angiomata (Telangiectases)
of the Skin and Mucous Membranes, with Recurring
Epistaxis.
By F. Parkes Weber, M.D.
The patient, aged 60, is a pale, rather puffy-looking woman, with
small red angiomata distributed over the face, ears, lips, tongue, mucous
membrane of the mouth, and the conjunctival surfaces of the four
eyelids. There are likewise telangiectases inside both nostrils, on the
posterior wall of the pharynx, and on the anterior surface of the
epiglottis. Some of the angiomata on the face approach the “spider
naevus” type seen in patients with cirrhosis of the liver. There are
peculiar ophthalmoscopic changes. Both optic discs are rather pale,
especially the left one, and the blood-vessels are too thin. In the
macular region of the right eye there is a whitish area with a patch of
black in its centre, probably the remains of a haemorrhage. In the
region of the macula and outwards in the left eye the retina is dotted
with numerous small star-shaped pigment spots, somewhat resembling
the change found in cases of retinitis pigmentosa. In the left eye there
is likewise a small retinal haemorrhage. 1 During the last six years the
patient has been subject to very frequent epistaxis. The angiomata
were first noticed at about the age of 42. There is a history of a similar
affection in the patient’s mother and in several of the patient’s children.
Dr. Weber has described the case in full, 2 and similar cases have been
recorded by Professor Osier and others. 8
1 Dr. R. Gruber’s ophthalmoscopic examination of November, 1907.
- Lancet , 1907, i., p. 160.
See especially Osier, Quar. Journ. of Med., Oxf., 1907, i., p. 53.
66 Handley : Complete Transverse Resection of Pharynx
DISCUSSION.
Dr. C. O. Hawthorne said he had recorded a case of this kind, but
somewhat incompletely, owing to the fact that the patient could not submit
to detailed examination. But there were two points in connection with sucli
cases which should be borne in mind : First, they should be carefully distin¬
guished from cases of ordinary haemophilia. It would be found that there
was nothing in the family history to suggest that there was an undue tendency
to bleed, as, for instance, on a tooth being extracted. Secondly, these cases
bled not only from the nose, but from small naevoid patches. He ascertained
from one of the present patients that she sometimes had bleeding from one of
the fingers. He suggested that a patient might have such a patch on the skin
apart from any patches which caused bleeding from the mucous membranes.
He knew of one case in a woman who had a spot at the end of her thumb,
from which she bled frequently, though in her case there was no history of
epistaxis.
The PRESIDENT asked whether in the family groups the condition prepon¬
derated in females. He understood that in a number of cases the condition
came on at a ripe age. He recalled the fact that the occurrence of nsevoid
conditions all over the trunk in people past the climacteric had been supposed
to occur in patients developing malignant disease, but he did not think such
spots had been proved to be of any material diagnostic value. All must have
seen women past the climacteric who developed small naevoid growths on the
trunk which appeared to have no prognostic significance. It would be worth
while to enquire into the hereditary tendency in these cases.
Mr. Stephen Mayou said that some years ago he saw a case, which
was under the care of Mr. Watson Chevne, of multiple telangiectases in the
bladder, associated with the same condition on the legs. There was haematuria
of a very profuse character. The eyes were examined, and there was found to
be double optic neuritis, which at that time was thought to be due to the
anaemia produced by the large haemorrhages.
Dr. Parkes Weber, in reply, said he would like to urge that all cases
of the kind in the future should have the eyes examined, as in his case there
were remarkable ophthalmoscopic appearances.
Case of Complete Transverse Resection of the Pharynx with
Laryngectomy for Malignant Growth (Squamous-celled
Carcinoma) of the Posterior Pharyngeal "Wall.
Shown by W. Sampson Handley, M.S.
The patient, a woman, aged 44, was sent to the Bolingbroke
Hospital by Dr. McManus and was transferred to my care by my
colleague, Dr. E. A. Peters. For some months she had felt difficulty in
swallowing, and on admission even fluids were rejected. She was also
Clinical Section
67
suffering from nocturnal attacks of dyspnoea. She was wasted and
miserable, and was willing to take any risk in order to obtain relief.
Bougies were arrested at the level of the thyroid cartilage. A finger
introduced into the pharynx came upon a mass of fungating growth
entirely filling up its lower outlet. The laryngoscope showed oedema
of the ary-epiglottic folds, and although the vocal cords were but slightly
congested, it was clear that the growth had attacked the posterior wall
of the larynx. No glands could be felt. The larynx and pharynx
retained their lateral mobility when grasped externally, though the
distension of the pharynx by the growth was obvious on palpation.
A preliminary gastrostomy was performed. A week later, on
November 14, 1907, a low tracheotomy was done, the trachea being
plugged with gauze above the tube. The patient’s shoulders were raised
by a pillow, over which her neck was extended, an incision was made
along the anterior border of the left sterno-mastoid, and the upper end
of the oesophagus was exposed. At the root of the neck it was free from
growth, but the healthy portion was not long enough to reach the skin
surface. The left lateral incision w r as prolonged to the mastoid process,
and from the angle of the mandible on the right side a second incision
was carried downwards and inwards to join the first one at right angles.
The skin flaps were dissected up; the sterno-hyoid, sterno-thyroid and
thyro-hyoid muscles were separated from their upper attachments. The
carotid sheath was exposed and was dissected away from the wall of the
pharynx on either side. The two superior laryngeal nerves were sought
for and carefully isolated with a view to their preservation if the larynx
could be saved. An opening was now made through the thyro-hyoid
membrane into the pharynx. The insertion of a finger showed that it
would be impossible to separate the growth from the larynx. The
growth was also invading the left lobe of the thyroid, behind which
a single enlarged gland was found and removed. The incision through
the thyro-hyoid membrane was now prolonged backwards on both sides
as far as the posterior wall of the pharynx, which was adherent to the
longus colli opposite the growth. This adhesion was freed by the finger
and by a blunt dissector. The upper division of the pharynx was now
completed by cutting across its posterior wall with scissors, well above
the growth. The whole mass could now be pulled forward, and was
removed by cutting through the trachea and oesophagus as low down as
possible, after ligature and division of the isthmus of the thyroid. The
infiltrated left lobe of the thyroid was removed in one piece with the
larynx and pharynx. The trachea, the oesophagus, and the remaining
68 Handley: Complete 'Transverse Resection of Pharynx
upper part of the pharynx were respectively closed by sutures.
A drainage-tube was inserted, lying in the line between the right and
left angles of the mandible. The flaps were replaced and the wound
sewn up.
There was considerable shock, but convalescence was uninterrupted.
The wound healed by primary union, save in the middle line just below
the hyoid, where a pharyngeal fistula established itself. Within forty-
eight hours the patient expressed herself as feeling better than before
the operation. At present, six weeks after the operation, she has gained
in weight and her colour has improved. She is, however, somewhat
subject to temporary attacks of depression. She can swallow her saliva
by means of a rubber funnel, lying behind the tongue and emerging at
the subhyoid fistula, to be led into the stomach through the gastrostomy
opening. As regards speech, although no air passes through her mouth
she can make herself understood in a thin whisper. Sibilants are well
pronounced, apparently by expulsion of air contained in the mouth
cavity. During the past fortnight she has gained 4 lb. in weight.
Although partial resection of the pharynx has been frequently
performed as an incident of laryngectomy, I believe this to be the first
recorded case in this country of complete transverse resection of the
pharynx. In Geripany the operation has been performed by Professor
Gluck, of Berlin. The operation is a terrible one, and is to be offered
and not urged. It may, however, be pointed out that gastrostomy and
tracheotomy combined are no substitute for excision of the growth, even
so far as concerns the patient’s immediate comfort. The presence of
the foul, ulcerating, pharyngeal mass is an obsession on the conscious¬
ness of the patient, is a cause of chronic gastritis and malnutrition, and
involves a continual risk of broncho-pneumonia.
DISCUSSION.
Mr. Herbert Tilley congratulated Mr. Handley on the result of the
operation. He said it was always difficult to know what to do with such
cases. The growth was evidently very extensive, and it was often asked
whether it was worth while to do the operation and leave the patient in the
pitiable condition in which the present woman was. That, however, was a
matter for the decision of the patient. When the disease was far advanced,
starvation was only a matter of weeks; whereas operation had caused a
comfortable prolongation of life, in one case to seven years after, so that there
was something to recommend it. Ten years ago Dr. Cohen, of Philadelphia,
showed the first case in which such an operation had been performed ; the
whole larynx and part of the pharynx were removed, and there had been an
extensive resection of glands in both triangles of the neck. The case was
Clinical Section
m
shown about two years after the operation, and he should not forget the
excitement it caused, because the man’s whisper could be heard some distance
off, and he smoked a cigarette with comfort. In properly selected cases the
operation was justifiable, and held out brilliant prospects. The general health
of the patient was a great factor in determining the desirability of operation.
If the growth was extrinsic, and the patient had any metastatic deposits in
distant regions, or if the general health was bad, or if there was bronchitis
or renal trouble, the case should not be dealt with in that way. He thought
that there was no operation in surgery in which more careful preparation of
the patient was necessary, nor more careful after-treatment. Septic pneumonia
used nearly always to occur in such cases, and was difficult to prevent. But
that risk had been gradually overcome by improved technique and by keeping
the patient's mouth as aseptic as possible. He asked whether Mr. Handley
had the patient in the Trendelenburg-Rose position, and whether it would not
he possible to do a high tracheotomy as a preliminary measure, and to bring
the trachea forward and suture into the skin wound. That would have
avoided the need for a tracheotomy tube, and if the oesophagus could have
been brought into the skin wound, gastrostomy would have been unnecessary.
Mr. R. H. Jocelyn Sw r AN showed a specimen of carcinoma of the pharynx
invading the larynx, w hich he had removed by a very similar operation. The
patient was a man, aged 44, who first noticed a swelling on the right side of his
neck about four months before his admission to the Cancel Hospital on
December 16 last. This swelling gradually increased in size, and in a short
time he noticed some pain and difficulty in swallowing, at first with solid food,
and increasing so that he could only take fluids and soft puddings. During the
last month his voice became affected, and more recently he noticed difficulty in
breathing, especially at nights, when he was frequently awakened with dread
of suffocation. He had lost weight. On examination, there was a mass of
matted glands on the right side of the neck in the deep cervical group below
the stemo-mastoid, and extending upwards and backwards towards the mastoid
process. The mass could be moved easily from side to side, was firm and
smooth, and not adherent to the skin. No glands were felt enlarged in the
posterior triangle or on the left side of the neck. No growth could be seen in
the mouth or tongue, but the tip of the finger could reach the upper end of
a hard, nodular growth in the right lateral pharangeal wall at about the level
of the epiglottis. He was seen by Mr. Rose, who reported that he found a
carcinoma of the right lateral wall of the pharynx which had commenced to
infiltrate the right lateral portion of the larynx and right vocal cord. The
movements of the tongue were not impaired, but the larynx was distinctly
pushed over to the left of the mid-line of the neck. No evidence of metastasis
could be found. On December 19, after fully explaining to the patient the
nature of the trouble and the ultimate issue, a low’ tracheotomy and a gastros¬
tomy by Witzel’s method were performed as a preliminary to further operation.
The patient improved in general health, and on January 1, 1908, removal of the
larynx and the lower half of the pharynx, together with the glands in the neck,
70 Handley: Complete Transverse Resection of Pharynx
was performed. He was given chloroform by Mr. Chaldecott, when the trachea
was plugged and a long Trendelenburg’s cannula adjusted to the tracheotomy
tube. Flaps were turned back of the skin, platysma, and superficial fascia of the
neck, and the glandular mass on the right side exposed. The stemo-mastoid
muscle was divided, the carotid sheath opened, and all the glands of the anterior
triangle removed, together w r ith the internal jugular vein. On the left side a few
small glands were removed and the large vessels exposed and draw™ outwards.
The sternal muscles were reflected and the superior thyroid arteries of each
side ligatured, the lateral lobes of the thyroid being reflected. The thyro-hyoid
membrane w r as now’ fully exposed and incised on the left side, a good view of
the growth being thus obtained. It w r as then found that the larynx was
extensively encroached upon, but that the upper limit of the growth of the right
lateral pharyngeal wall was well below’ the level of the hyoid bone. The lateral
and posterior walls of the pharynx were rapidly separated, and the incision
below the hyoid bone extended, dividing the pharynx completely at this level.
The whole was raised from the prevertebral tissues and removed by dividing
the trachea obliquely upwards and backwards immediately above the isthmus
of the thyroid and by dividing the oesophagus at the same level. The pharynx
was closed above by catgut sutures, uniting the posterior wall with the thy ro¬
ll yoid membrane immediately behind the hyoid bone, the upper end of the
oesophagus closed by a double layer of sutures and the upper end of the trachea
united to the skin by fine silkworm-gut sutures. All bleeding was arrested, and
the skin flaps w r ere united by thread sutures, ample provision being made for
drainage. The operation, which lasted one and a half hours, was well borne, the
pulse remaining good throughout. The patient did well for three days, the
cervical wounds remaining clean, feeding being carried out by the gastrostomy
opening. On the fourth day he was troubled with cough, bringing up slightly
blood-stained expectoration, and fine rales were heard at the lmse of each lung.
Temperature rose to 102 F., and he was slightly cyanosed. He continued in
same condition until January 7, when he collapsed, rapidly lost ground, and died.
An autopsy was made hy Drs. Paine and Morgan, when the cervical wounds
were found healthy, except in the central portion, where a septic tract led from
the drainage-tube to the pharyngeal sutures, which had in part given way.
There was no inflammatory spread in the triangles of the neck or in the superior
mediastinum, w’here the cellular tissue was normal. There was marked septic
broncho-pneumonia of the bases of both lungs, with a small, foul abscess
cavity on the left side. The liver was fatty. Mr. Swan agreed that the opera¬
tion was a severe one, but that it w ? as quite justifiable, provided that the patient
fully understood the ultimate result of removal of the whole larynx and part of
the pharynx. That broncho-pneumonia was a severe danger was undoubted, as
in his case, in spite of a preliminary tracheotomy and plugging of the trachea
during the operation. He was convinced that no blood entered the trachea
during the operation, whilst subsequently the upper end was covered and some¬
times lightly packed with sterile gauze. He considered it better to suture the
trachea to the skin wound than to leave a permanent tracheotomy tube. The
Clinical Section
71
specimen showed an oval-shaped epitheliomatous ulcer of the right lateiul
pharyngeal wall which was directly invading the larynx in the immediate
vicinity of the right vocal cord, and considerably diminishing the air passage.
Mr. HANDLEY, in reply, said that Mr. Tilley’s remarks applied rather to
cancer of the larynx than to cancer of the pharynx. He did not know whether
Dr. Solis Cohen’s case involved the removal of the whole cross-section of the
pharynx or whether only the anterior part of the pharynx was removed.
Mr. TlLLEY replied that the lateral wall of the pharynx on one side was
removed, and there was a very extensive growth within the larynx.
Mr. HANDLEY said the case referred to was therefore not entirely analogous
to the present one, in which the whole cross-section was removed over the
lower half. . The patient was in the ordinary position, but with the shoulders
raised on a pillow, and he was very careful to plug the trachea above the tracheo¬
tomy tube, so that he was not afraid of blood getting into the lungs. Con¬
sidering the severity of the operation, there was very little shock. The growth
extended so low that it would have been impossible to do a high tracheotomy.
It involved the upper end of the oesophagus, and he had to divide the oesophagus
as low as he could reach, almost down to the suprasternal notch. For the
same reason it was impossible to bring the oesophagus up to the skin. He
thought Dr. Swan’s case was a more unfavourable case than his own because
of the number of enlarged glands. The prognosis after such operations was
largely dependent upon whether the carotid sheath had to be opened or not.
He had done the same operation in a second case, but with a fatal result. The
patient died on the table, apparently from the irritation of the vagus, after the
oj)eration was practically complete. He believed that it was due to a defect in
his technique, and that if he had frozen the two vagi below the point at which
he was working, death would not have occurred.
Congenital Absence of Left Pectoral Muscles.
By J. Graham Forres, M.I).
Male, aged 47, stickinaker ; under treatment since childhood for
chronic bronchitis. Until a year ago his attention had never been
drawn to the defective muscular development of the left side of the
chest, and his parents noticed nothing abnormal. No history of infantile
paralysis. Parents, brothers and sisters and children all normally
developed. When young he was able to take part in the usual games,
but was not athletic. Has apparently experienced no inconvenience
from the loss of the left pectoral muscles, and attributes the greater
strength of the right arm to its almost exclusive use in his work.
Patient is below medium height and of spare build. The chest shows
marked want of symmetry of the two sides, owing to the absence of
the sternal portion of the left pectoralis major and the whole of the
72 Forbes: Congenital Absence of Left Pectoral Muscles
left pectoralis minor. Only the clavicular attachment of the pectoral is
major and a small band passing to the first costal cartilage persist.
The former is hypertrophied and both are brought into relief by
abduction of the arm and flexion at the elbow.
The left side is much flattened, the first and sixth ribs and intercostal
spaces are only covered by a layer of thin smooth skin, and the anterior
fold of the axilla is missing. Extension and abduction of the arms
bring the pterygoid fold of skin into prominence as a fine ridge running
dowmwards along the line of the missing axillary fold, disappearing on
bringing the arms to the side, and apparently not composed of muscle
fibres. The left nipple is normal in appearance and position. The
sternum is deviated slightly to the right and forwards, the lower end
forms a sharp projection with the xiphoid cartilage directed backwards.
There is no defect in formation of the left costal cartilages. No
other muscles than the left pectorals are deficient. The poorer
muscular development of the left arm and hand is probably due to the
almost exclusive use of the right in the course of work ; at the same
time the movements of the left upper limb are perfect. Percussion of
the thorax show hyper-resonance of the left side, and on auscultation
sibili are audible over both lungs. Though his attention has only been
drawn to the absence of the left pectoral muscles during the last year,
the defect is probably congenital. There is no evidence in the history
to point to infantile paralysis, and, as no other muscles are wanting, the
condition is not likely to be a form of myopathy.
Remarks .—Itecords of some 05 to 70 cases of unilateral absence
of both pectoral muscles exist. In the majority, as in the case
shown, the hypertrophied clavicular portion of pectoralis major only
remains, with occasionally a few* rudimentary fascicles of the sternal
portion. The skin covering the affected side often shows trophic
changes, being smooth and thinned and sometimes adherent to the ribs,
and the nipple may be undeveloped. The deficiency is usually on the left,
and seems to occur more often in males. It proves no hindrance to
laborious occupation and athletic pursuits, such as boxing and swimming.
In several cases recorded in France the patients were able to perform
military service without exemption or inconvenience: the condition
may pass unnoticed until medical advice is sought for some ordinary
complaint.
Associated Anomalies. —(I) Absence of other muscles, such as latis-
simus dorsi, serratus magnus and teres major. (2) Defective development
of costal cartilages sufficient to allow 7 hernia of the lung on forced
Clinical Section
73
inspiration, as in case recorded by Jonathan Hutchinson. 1 (3) Deformities
and mal-development of the corresponding arm and hand.
A remarkable case described by Keboul 2 is the only one recorded of
bilateral absence of pectoral muscles, associated with undeveloped sterno-
mastoid and anterior neck muscles.
The patient, in other respects a powerful, muscular man, was capable
of lifting and supporting heavy weights. There was marked kyphosis,
the head being carried well forward in the attitude characteristic of the
chimpanzee, while the front of the chest was much sunken.
Etiology .—Several explanations have been put forward to account
for this rare anomaly. (1) Arrest of development of the blood-vessels
and nerve supply (peripheral or central) to affected muscles ; not supported
by dissections made of cases post mortem. (2) Physical deterioration
(Widal and Lemiere). Unsupported by the good physique presented in
many cases. (3) Retrogression to the normal state existing in certain
mammals, e.g., the porcupine and guenon monkey, which have no
clavicles (Testut). This view cannot be applied to the majority of cases
showing persistence of the clavicular head of pectoralis major. (4) Intra¬
uterine foetal paralysis (Berger), only affecting the pectoral muscles;
unsupported by post-mortem evidence. (5) Intra-uterine pressure.
Froriep in 1839 ascribed the anomaly to the influence of localized
intra-uterine pressure, which, by forcibly compressing the foetal upper
limb against the thorax, prevented the development of the underlying
muscles. As a further result grooving of the chest wall by the apposed
limb, together with malformation of the arm and hand, have been recorded
in a few cases met with in infancy and early childhood. 3 The absence
of a thoracic depression in adults may be due to obliteration of the groove
by the further growth of the chest wall. Pressure would also account
for atrophy of the skin and nipple and defective development of the
costal cartilages.
This explanation of Froriep receives the support of the majority of
authors. Keboul adopts it to explain his case of bilateral absence of the
pectoral muscles; he supposes that, in addition to compression of both
sides of the thorax by the upper limbs, the pressure of the chin of the
foetal head inclined forwards accounts for the undeveloped condition of
the anterior neck muscles. It is reasonable to apply this theory to
explain other congenital muscular deficiencies, e.g., absence of the
1 Arch. Surg ., Loud., 1894, v., p. 342.
2 Rev. d'orthopedic, Paris, 1905, vi., p. 353.
3 Souques, A., Rev. ncitrol ., Paris, 1902, x., p. 159.
74
Barker : Meningitis complicating Otitis media
abdominal muscles, possibly produced by pressure of the flexed lower
limbs on the abdomen of the foetus in utero.
DISCUSSION.
Mr. Raymond Johnson said that he had shown a similar case before the
Clinical Society five years ago, the patient being a boy with absence of the
pectoral muscles on the right side. The case differed from the present one in
two respects : (1) that there was a very broad fold of skin from the side of
the chest down the inner side of the arm to the internal condyle, with
a band of muscle in its free edge, a so-called chondro-epitrochlaris. He showed
it as a case of webbed arm and fingers associated with absence of pectoral
muscles. There were a few fibres of the clavicular portion present. In Germany
a considerable number of cases had been recorded in which there was an absence
of pectoral muscles associated with webbing of the fingers and the presence of
a fold of skin from the chest to the inner side of the arm. In the present case
the left scapula was higher than the right; in his own case the difference in
that respect was very striking. It was difficult to imagine that such a defect
was the result of pressure, especially when the absence of muscles was asso¬
ciated with webbing.
Dr. G. A. Sutherland thought that the pressure theory was probably the
correct one in the present case, and that one might exclude a nervous or
vascular lesion because the atrophy was so limited to a certain area of the
body, and involved all the structures of the part. In only a small proportion
of the cases was there an affection of hands or fingers, and if there was
pressure of the hand sufficient to cause such injury, on the principle that
pressure and counter-pressure were equal and opposite, one would expect that
the part pressing on the chest ought to be affected also. There was an
interesting parallel in a certain condition of the abdomen in which there
was a congenital absence of certain parts of the muscular wall in the right or
left hypochondrium, which had been traced to pressure upwards of one or
other knee. All the structures in the abdominal wall were atrophied, and as a
result, when the patient coughed or strained there was a ballooning of the
abdominal wall at the part affected.
Dr. Forbes, in reply, said there were one or two cases on record in which
there was a definite grooving of the chest wall corresponding to the position of
the limb in utero.
Meningitis complicating Otitis media, with Lumbar Puncture.
By A. E. Barker, F.R.C.S.
The case of C. W., aged 31, is shown to emphasise the point that
lumbar puncture may be of remedial as well as of diagnostic value. The
patient’s condition at the time when the meningitis was found in the
Clinical Section
75
temporal region was almost hopeless, and when thick, greenish, turbid
fluid was drawn off at the same time from the lumbar sac the pro¬
gnosis was not improved. Continued drainage through the temporal
wound and lumbar tapping of 20 c.c., repeated about every two days at
first, was followed by steady improvement and ultimately by convalescence.
Fourteen tappings were made in all. The first, soon after admission,
was normal: the next were thick, turbid, greenish and swarmed with
Micrococcus catarrhalis and leucocytes in all forms. Very soon the fluid
became clear and sterile.
A Case of Multiple Subcutaneous Rheumatic Nodules.
By Herbert French, M.D.
The patient, H. K., aged 20, has upwards of 150 well-marked
subcutaneous nodules, some no larger than split peas, others as big as
small beans. The latter project from the general level of the skin
surface so as to be visible from a distance. They are scattered over the
backs of the hands, knuckles and fingers, the extensor surfaces of the
forearms, the elbows, the knees, on the scalp and in the abdominal fascite.
There are none on the feet, nor over the malleoli nor elsewhere. The
youth had his first attack of rheumatic fever three years ago, and at
that time developed similar subcutaneous nodules which disappeared in
a fortnight. He had his second attack of rheumatic fever in July, 1907,
when he was laid up in Guy’s Hospital until the middle of October, 1907.
The attack was very severe, and left him with double aortic and double
mitral bruits, which are well heard. The heart is moderately com¬
pensated. The nodules now present developed during this second attack
of rheumatic fever; and instead of disappearing, as they did after the
first attack, they have persisted almost unaltered until now—a period of
six months.
Case of Fatal Acute Illness in a Child from Status lymphaticus.
By Sidney Phillips, M.D.
W. P., a boy, aged 5£, was stated by his mother to have always had
good health, and to have been quite free from any sign of illness until
October 12, 1906, when his breathing began to be noisy and difficult.
He was at once taken to a doctor, and afterwards remained under
medical treatment at home, though not in bed, as his breathing became
worse in the recumbent position ; probably for this reason it was worse
76 Phillips: Fatal Illness from Status lymphaticus
at night, sometimes so bad that he rose up screaming ; the breathless¬
ness increased day by day, and he came into St. Mary’s Hospital on
October 15. I saw him the same afternoon; he was a well-developed,
well-nourished boy, propped up in bed, gasping for breath in great distress.
The respirations were 36 per minute, and with each inspiration there were
three sounds, very like a hiccough thrice repeated; the first of the three
sounds was louder than the other two, which were separated from one
another by a shorter interval than from the first sound; the effect is best
represented by uttering the sounds “ hich-hichee.” There was marked
contraction of the platysma muscle and drawing downwards of the lower
jaw with each inspiration, and marked sinking in of the epigastric and
supraclavicular regions. The boy was too breathless to speak much,
but when he shrieked out, as he did at times in his extreme distress, the
voice was quite clear. He was pale rather than cyanotic, and his
extremities were not cold ; the pulse was feeble and small ; the tem¬
perature normal ; at times he came out in a clammy sweat. There was
moderate chronic enlargement of the tonsils. I could find nothing
abnormal in the larynx, nor could my colleague, Dr. Scanes Spicer, who
kindly examined him ; the vocal cords moved freely. There was nothing
wrong detectable in the lungs, though the breath sounds were weak over
both sides of the chest.
Dr. Simmonds, at my request, examined him with Kontgen rays, by
means of the screen, but there was no sign of any foreign body in the air
passages. He had been sent into hospital for diphtheria, but there
were no signs of membrane anywhere. It was clear the breathlessness
was not due to laryngeal or to pulmonary disease. The peculiar
character and sounds of the breathing were much like those sometimes
observed in hysterical girls, but the condition here was much too
grave to attribute merely to a neurosis. There was a suspicion of
some want of percussion resonance over the sternum, and I concluded
that the dyspnoea probably arose from pressure on the air passages in
the mediastinum. Not at the time thinking of the thymus gland,
I thought such pressure probably arose from enlarged lymphatic glands
about the tracheal bifurcation, or even their ulceration into a bronchus
as in the case recorded by Mr. Ii. W. Parker. 1
Tracheotomy in such a case could be of no avail, and all that could
be done was to administer a little morphia, which gave some temporary
relief. I saw him again at 10 p.m., but the distress was as great as ever
and the pulse weaker. He died during the night, apparently from heart
failure.
1 Trans. Clin. Sue. bond 1891, xxiv., p. 6.
Clinical Section
77
The autopsy was made next day by Dr. Spilsbury, and nothing was
found wrong in any organ of the body, except an enlargement of the
thymus gland and certain changes in the spleen and lymphatic glands,
which are described by Dr. Spilsbury as follows: Thymus, weight
4 oz. The thymus consisted of two lateral lobes, closely apposed but
not united ; it extended from the lower border of the thyroid body
downwards into the mediastinum, its lower part coming into close
relationship with the pericardium. The surface of the organ was
lobulated, and on section it was fairly firm.
Histology .—Thymus showed hyperplasia of the lymphoid tissue,
which extended outwards into the neighbouring areolar tissue and
inwards into the medulla of the lobules. The medulla and the cortex
were therefore indistinctly marked off from each other. Coarsely
granular eosinophilous leucocytes were present in large numbers.
Hassell’s corpuscles were numerous and large. Mesenteric lymph gland
showed simple hyperplasia. The lymph nodes were large, and in some
places two were fused together. The gland was well supplied with
blood-vessels. Spleen showed enlargement of the Malpighian bodies, due
to hyperplasia. The spleen pulp was extremely congested and showed
considerable deposit of pigment, in the form of fine granules, both inside
the cells of the spleen pulp and lying free. Liver showed early nutmeg
congestion and slight fatty degeneration. There seemed to be no
accumulation of pigment in this organ.
Remarks .—The case seems to be an example of the affection at one
time spoken of as “ thymic asthma ” and more recently as “ lymphatism ”
or the “ status lymphaticus.” Cases of unexpected death in young
infants, apparently from cardiac failure, after attacks of dyspnoea with or
without convulsions, in which no abnormality has been found post
mortem, except enlargement of the thymus and lymphatic glands, have
frequently been recorded.
Grawitz 1 records the case of a child, aged eight months, found dead in
bed without any previous sign of illness, and a second case of a child,
aged six months, which died in its father’s arms after a few moments of
illness ; in each of these cases the thymus gland was found greatly enlarged
post mortem, and in the second of the cases there was also enlargement
of spleen and mesenteric glands.
Jacobi 2 records the sudden death of a child, aged six months, which,
after autopsy, he could only attribute to enlargement of the thymus gland.
1 Dentsch . med. Wochensch 1888, xiv., p. 429.
1 Trans. Assoc. Amer. Phys ., Philad., 1888, iii., p. 300.
78
Phillips: Fatal Illness from Status lymphaticus
Dr. Crozier Griffith, in the same publication for the year 1903, gives
notes of a case of a child, aged seven months, and of a child, aged six
months, both of whom died suddenly, apparently of syncope, after sudden
difficulty in breathing. Each of these children had had convulsions,
though not at the time of the fatal illness, and instances in which
sudden death with dyspnoeal attacks has been found associated with
enlargement of the thymus and the lymphatic glands are so numerous
that it has been concluded that there is more than mere coincidence.
Death in these cases has been attributed to laryngo-spasm, but laryn¬
gismus stridulus does not, I think, kill off infants in this sudden way,
certainly not a child of the age of my patient; and in none of the
recorded cases is there any mention of the characteristic crowing
breathing; death, too, has appeared always to have resulted from
cardiac failure. The theory of laryngo-spasm appears to have been put
forward in default of any better explanation at a time before the changes
had been observed in the thymus and lymphatic glands
Death has been attributed to pressure upon the trachea by the enlarged
thymus gland. Marfan 1 found the trachea flattened and its calibre
narrowed in an infant, aged two and a half months, which died with an
enlarged thymus gland. Koenig, 2 Perrucker, 8 and Siegle have each recorded
a case in which, after the enlarged thymus gland had been raised from
over the trachea by operation the symptoms were relieved. These cases
go to disprove Friedleben’s statement that it is impossible for the trachea
to be compressed by the thymus gland. Nevertheless, pressure is not
the cause of the dyspnoea in the majority of the cases, for in most of them
the thymus gland is but slightly enlarged, and no signs of pressure upon
the trachea are found; and as Crozier Griffith remarks, if the symptoms
arose from pressure they would not come on so suddenly as they do.
Paltauf 4 advanced the theory that the enlargement of the thymus
and lymphatic glands of the body were evidences of a constitutional
state in which sudden cessation of the heart’s action may occur
from very slight causes—among others, administration of anaesthetics.
This theory is supported by Escherich, and it is suggested that the
symptoms arise from a toxaemia, the result of an over-secretion of the
thymus gland, and the affection has been called thymic asthma. More
recently Blumer 5 has suggested that the toxin is not necessarily the
1 Bull, et nUm. Soc. vu'd. des hop. de Paris, 1894, xi., p. 3G1.
- Zentralbl. f. Chir., Leipz., 1897, xxiv., p. G05.
8 Gas. hebd. de nu l d. t Paris, 1.899, p. 695.
1 Wien. klin. Wochensch 1889, ii., p. 877, and ix., 1898.
4 Trans. Assoc. Avicr. Phys ., Philad., 1903, xviii., p. ‘253.
Clinical Section
79
thymus secretion, but arises also from the lymphatic glands—is, in
fact, a lymphotoxaemia. There is still much doubt on the subject, and
even if the affection is toxic it is open to question whether the lymphatic
gland enlargement itself is not a result of some toxin possibly absorbed
from the alimentary tract. In my case the boy, being aged 5, was
able to struggle against his breathlessness for some three days instead
of succumbing at once, as was the case in young infants. During these
three days his symptoms were certainly not due to laryngeal spasm, and
the necropsy showed they were not due to any pressure by the thymus
gland. They seemed certainly more like toxic symptoms than anything
else, in fact, were not unlike those sometimes seen in what has been
called uraemic asthma. And I think the case may be deemed worthy of
record in this Section, as the history may perhaps be of use in affording
a clue to the cause of sudden dyspnoea in cases that may occur in
the future.
DISCUSSION.
Dr. PoYNTON said he had seen two similar cases, and in them there were
two clinical features of interest. There was very marked dulness over the
manubrium stemi, and the child died suddenly and unexpectedly. Post
mortem it was found that the dulness was due to a very large thymus. The
second case had been diagnosed as whooping-cough because of the curious
paroxysmal cough. The possibility of the presence of a retropharyngeal
abscess as the cause of the symptoms had also to be considered. The second
child also died unexpectedly, and very much the same condition was found as
had been so often described in such cases.
Dr. BERNSTEIN thought one ought to accept the diagnosis of status lymphat-
icus with some suspicion. Ever since that diagnosis had been brought forward
so frequently, especially in coroners’ courts, he noticed that one often found the
conditions which were described as “status lymphaticus ” in association with
an enlarged thymus and an increase of lymphoid tissue elsewhere. Yet the
clinical history did not give symptoms attributable to such enlargement, death
having been due to other causes. He considered that it had still to be proved
that the association of sudden death without dyspnoea with lymphoid enlarge¬
ments was more than a coincidence. In many of the cases the diagnosis
“ status lymphaticus ” was merely a euphemism.
Dr. G. A. SUTHERLAND said the case recalled one which he had seen of
a child, aged 3, who had marked symptoms of obstructed breathing, which he
localised in some part of the trachea. There was also well-marked dulness
behind the sternum. Above the sternum there was a small, soft swelling,
which he concluded to be the thymus, and he attributed the dyspnoea to the
pressure exerted thereby. He suggested to a surgical colleague that he should
remove the upper part of the sternum, to relieve the pressure of the thymus,
but no operation was performed. Dr. Sutherland thought that there were
/-3
80 Forbes: Report on Case of unusual Gouty Deposit
certain cases in which the thymus was enlarged and yet the condition was not
one of status lymphaticus. Dr. Phillips had said that in his case there was no
evidence of the trachea having been pressed upon, but Dr. Sutherland considered
that the absence of signs of compression after death did not exclude its having
been present in life. Possibly there might be irritation of the nerves, producing
spasm of the trachea. He was surprised to hear Dr. Phillips compare the con¬
dition with uraemic dyspnoea, because he understood that there was marked
tracheal stridor present, the absence of which was a characteristic of uraemic
dyspnoea. In this case there must have been some stenosis of the trachea.
Cardiac failure was a common cause of death in status lymphaticus, but such
failure was sudden. Dr. Phillips’ patient had suffered from obstructed breath¬
ing for several days, and he should say that death was due to this cause, the
cardiac failure being merely the terminal event.
Dr. A. E. Russell said that in many children found dead or dying suddenly
there was a considerable increase in the weight of the thymus. Dr. Dudgeon
published, four years ago, a paper giving particulars of 17 cases, collected
at Shadwell and St. Thomas’s Hospitals, in which children died suddenly or
were found dead. The average weight of the thymus in these cases w’as
25 grm., the normal weight for children of the same age being 5 grm. to 10 gnu.
All the children in question were under two years of age.
Dr. Phillips, in reply, said that he could not attribute the symptoms to
spasmodic occlusion of the trachea. The child was five and a half years old,
so that its trachea had firm cartilage in it, and he did not think that any spas¬
modic contraction sufficient to cause death could have occurred. Laryngeal
spasm had been excluded by the fact that Dr. Scanes Spicer and he found the
cords moving well, and therefore the dyspnoea was not due to pressure on the
recurrent laryngeal nerve. Death occurred from cardiac failure, breathing con¬
tinuing after the heart stopped. He was not wedded to the theory of status
lymphaticus ; but the speaker, who objected to the term, did not suggest any
other cause for the child’s death. Post mortem nothing was found wrong with
the heart or lungs, and there was no tracheal narrowing, and it was suggested
that death resulted from some form of toxaemia. The symptoms were remarkably
like those of a toxaemia and more closely resembled the gasping respirations of
uraemic patients than anything he had seen. As to whether the symptoms were
due to the enlarged thymus, everyone must judge for himself. He had not been
able to mention all the evidence in favour of this interpretation, but there were
scores of cases in which death was due to enlarged thymus, and he thought
that it was a factor in the present case.
Report on Case previously shown.
Dr. Forres showed the specimen of gouty olecranon-bursa removed
from the patient exhibited at the last meeting (p. 53). The man made
a complete recovery, and the wound healed by first intention. Cultures
made from the bursa proved sterile.
Clinical Section.
February 14, 1908.
Sir Thomas Barlow, Bt., K.C.V.O., President of the Section, in the Chair.
Note on Two Cases of Gaertner Infection (Bacillus enteritidis)
in Infants.
By Frederick E. Batten, M.D., and J. Graham Forbes, M.D.
The frequency or rarity of typhoid infection in infants is a subject on
which there is a considerable difference of opinion. Certainly in London
the disease as affecting infants below the age of 2 years is very rare. In
a ward of twelve beds devoted to the treatment of infants suffering from
infamtile diarrhoea—in which, during a period of six months, there were
134 cases—no case of known typhoid infection occurred. Two cases of
prolonged fever and diarrhoea occurred; the first, though repeatedly
tested, gave a negative Widal reaction, and at the time of death showed
no evidence of typhoid infection, but on examination of the stools by
Dr. H. de B. Morgan, at the Lister Institute, Gaertner’s Bacillus enteri¬
tidis was isolated. The second gave a negative Widal reaction, but a
positive reaction to Gaertner; the child died, and at the autopsy ulcera¬
tion of the mucous membrane in the small intestine, and especially in
the region of the ileo-caecal valve, was present.
The bacteriological evidence in this second case is complete. The
following is the history of the case :—
An infant, C. B., aged 1, who had been delicate from birth,
and had been previously admitted into the Children’s Hospital in
February, 1906, with “wasting and convulsions,” and was discharged
eighteen days later much improved, was again admitted on October 1,
1906. He had been breast-fed for three months, and after that time
mil—1
82 Batten & Forbes: Two Cases of Gaertner Infection
given cow’s milk and barley water. There were four other children
alive and four had died in infancy. The present illness began with
diarrhoea ten days before admission to the hospital on October 1, 1906.
The bowels had been moved seven or eight times a day, and the motions
had been green and slimy. The child had vomited frequently.
On admission the child was collapsed, with sunken eyes and cold
•extremities ; under suitable treatment the child recovered from this con¬
dition, and on examination was seen to be a very wasted child, weighing
11J lb. The abdomen w^as distended and the spleen was slightly enlarged.
The motions were green and offensive and contained mucus. On admis¬
sion there was nothing to suggest that the case was other than an acute
diarrhoea supervening on a chronic condition of intestinal catarrh. After
being fed for twenty-four hours w y ith albumen water and brandy the child
was given 1 oz. of “ lactated ” milk with equal quantities of water every
two hours. Three days later the child seemed much better; he had not
vomited and the motions had greatly improved in appearance, but still
contained some curd. Peptonised milk was now r substituted for the
4 4 lactated ” milk. The temperature now began to rise, and for the next
three weeks kept persistently above the normal, varying from about
99° F. in the morning to 102° F. to 103° F. in the evening (fig. 1).
On October 6 a purpuric rash developed over the abdomen and chest.
During the period from October 7 to October 19 the child did not vomit,
the diarrhoea was more severe, and the weight remained stationary at
11 lb. On October 16, the sixteenth day after admission and the twenty-
sixth after the onset of the disease, the blood was examined for a Widal
reaction with a negative result. No cause for the persistent high tem¬
perature could be found.
Clinical Section
83
On October 19, thanks to the kindness of Dr. William E. Marshall,
of the Lister Institute, the blood was tested with the Bacillus cnteritidis
(i Gaertner ) and gave complete agglutination in half an hour in dilution of
1 in 100. Normal serum gave partial agglutination in half an hour in
dilution of 1 in 20, and no agglutination in half an hour in dilution of 1 in
50 or 1 in 100. It was noticed at this time that the urine was offensive,
but it contained no pus, no albumin or blood. No bacteriological
examination was made. The further course of the disease was uneventful.
The temperature began to fall, and on October 24 the child was trans¬
ferred to Dr. Garrod’s care as my ward was closed. The child con¬
tinued to have diarrhoea, to lose weight, and died on November 4,
after being thirty-five days under observation. At the autopsy the
following condition was found : The brain and thoracic organs presented
nothing abnormal. The liver and spleen appeared normal to the naked
eye. The stomach and duodenum appeared normal; small ulcers were
present in the small intestine some few inches below the duodenum.
The ulcers were all small, circular in shape, having a diameter of about
^ in. with irregular edge and varying depth, irregularly placed at any
part of the intestinal circumference; one or two were almost down to
the peritoneal coat. Some of them appeared to have a minute slough.
There was one well-marked area with numerous ulcers about 2 in. above
the ileo-caecal valve. Peyer’s patches were swollen but not ulcerated.
Some 150 to 200 ulcers were present. The large intestine was normal.
On microscopical examination the following changes were found in
the viscera : Heart: showed slight fatty infiltration of the muscle fibres.
Lung: showed well-marked areas of broncho-pneumonia, many alveoli
plugged with cells and blood-corpuscles, others emphysematous, dis¬
tended and empty, alveolar capillaries congested ; the pleura was
thickened. Liver : showed much fatty infiltration, chiefly of the periphery
of the lobules, causing destruction and compression of numerous liver-
cells. Spleen : congested; capsule and trabeculae somewhat thickened ;
Malpighian corpuscles well defined. Kidney: cortex congested, convo¬
luted tubules show cloudy swelling and fatty changes in the epithelium.
Many tubules contained hyaline debris, and some glomeruli showed cell
exudation under their capsules. Mesenteric glands: congested ; active
lymph-cell proliferation and areas of necrotic cells in the cortex.
Intestine (small) : showed well-marked ulceration with sloping margin
extending to circular muscle coat, which formed the base underlying a
layer of inflammatory cells, which had also invaded the circular and
longitudinal muscle coats extending through to the thickened peritoneum.
84 Batten & Forbes: Two Cases of Gaertner Infection
The mucous coat for some distance on each side of the ulceration was
invaded and thickened by inflammatory cells, and the capillaries of the
submucosa were congested.
The bacteriological examination may shortly be stated as follows
(the full examination with details is added as an appendix to the note) :
The growth obtained was a Gram negative motile bacillus. This was
obtained in pure culture from the spleen, the mesenteric glands, and in a
mixed growth from the heart’s blood. The bile was sterile. Subcultures
w T ere made on a series of media and the organism gave the characteristic
reaction of the Bacillus enteritidis of Gaertner. Experiments on animals
were kindly carried out by Dr. Klein and Dr. Thursfield, which con¬
firmed the above observation. Dr. Klein kindly supplied the blood-serum
of a rabbit rendered immune to Gaertner’s bacillus and a number of
agglutination tests were applied to the original cultures; these showed
agglutination in dilution of 1 in 50 in twenty minutes, becoming com¬
plete in one hour.
The second case is that of a girl, aged 1, admitted to the Children’s
Hospital on July 16, 1906, with a history of diarrhoea and vomiting for
one week. The child had been fed during the daytime with bread and
milk at a “ nursery ” and by the breast at night when the mother
returned from work. On admission the child was very collapsed, with
sunken eyes, feeble pulse and cold extremities, and a temperature of
100° F. During the next twenty-four horns the child vomited three
times and passed eight motions. On physical examination nothing
abnormal could be detected. The child’s general condition improved
after the second day, the vomiting stopped and the motions became
much less frequent. The temperature, however, still remained high,
varying between 100°F. and 102° F. (fig. 2). On July 24, sixteen days after
the onset of the illness and nine days after admission to the hospital, the
Widal reaction was negative. This was again repeated on July 30, with
a similar negative result. The temperature now varied between 101° F.
and 103° F. The pulse-rate increased and the respiration became more
rapid. On August 7 some crepitations w r ere present at both bases and
the child developed some cerebral symptoms, viz., stiffness of the neck, a
slight squint, and tremor of the arms. The optic discs were normal.
It was considered probable that the case was one of tuberculosis, and the
cerebral symptoms pointed to tuberculous meningitis.
Three days later (August 10) purpura developed on the abdomen, and
the child died on August II, four weeks after admission to the hospital.
On post-mortem examination nothing was found to account for the
Clinical Section
85
child’s illness or death. The brain, lungs and heart appeared normal.
The liver was somewhat enlarged and fatty. The spleen was also
slightly enlarged. Covering the mucosa of the stomach for about half of
its area was a membranous white structure which could for the most
part be peeled off the mucosa. In some areas it was rather more
adherent and the mucosa appeared congested. The duodenum and
intestine were perfectly normal; no sign of inflammation of the Peyer’s
patches was present. Mesenteric glands were large, soft and white;
microscopically the liver showed fatty changes. Dr. H. de K. Morgan
examined the stools and isolated Gaertner’s bacillus.
But few comments are needed on these cases. The first was clinically
known to be a case of poisoning by Bacillus enteritidis and has been
j)roved to be so both pathologically and bacteriologically. The second
case is incomplete in that the organism was only isolated from the stools
Fig. 2.
and no blood reaction was obtained; still I think that this also was a case
of Gaertner’s infection, since the absence of the Widal reaction and the
presence of the Gaertner bacillus in the stools make it probable that the
infection was of that nature. Purpura w T as present in both cases, in the
first one early in the disease, in the second case practically as a terminal
manifestation. The cerebral symptoms which developed suggested tuber¬
culous meningitis, and at the time of death the opinion was held that
the case was one of tuberculous infection. In what way these two
children became infected must remain doubtful, since it was obviously
impossible to trace the milk or food supply in these cases. Appended
are two temperature charts, which show the type of fever.
Table showing Cultural Differentiation of Bacillus enteritidis (Gaertner), Bacillus coli communis and Bacillus typhosus,
and Bacillus paratyphosus (A and B).
Clinical Section
87
Appendix.
Bacteriological and Pathological Report on Case I. —Heart blood :
Cultures on agar-agar and in broth yielded a mixed growth of cocci and
Gram negative and positive bacilli. On subculture a pure growth was
obtained on agar of a Gram negative motile bacillus, which was submitted
to further subculture tests. Spleen: Stab cultures from the spleen
yielded a pure growth on agar of a Gram negative motile bacillus.
Mesenteric gland: small portions were removed from the centre of the
gland with every sterile precaution and incubated in a broth tube. The
culture obtained proved to be a pure growth of a Gram negative motile
bacillus. Bile : proved sterile in culture. Subculture tests were applied
to the growths obtained from the heart blood, spleen and mesenteric
gland, in litmus milk, peptone salt solution, neutral red broth, glucose
gelatine shake, and on gelatine and agar-agar slopes; lactose broth,
McConkey’s fluid containing Durham’s tubes, and plate cultivation on
Conradi-Drigalsky’s medium were also used. The results obtained are
recorded in tabulated form, and comparisons are made with the same
tests applied to Bacillus typhosus and Bacillus coli communis.
Fermentation Tests.
180-
dulcite
Glucose
Saccha¬
rose
Lactose
Raffln-
080
Glycerine
Mann-
ite
Salicin
Bacillus enter itidis
(Gaertner)
+
+
_
_
-
At first no change ;
later + perman¬
ently
+
-
Bacillus coli communis
+
+
-
+
+
+
-
Bacillus typhosus
+
I
-
-
+
+
-
Bacillus paratyphosus
(A)
1 +
+
At first no change ;
later -f and be¬
coming decol¬
orized
+
±
Bacillus paratyphosus
(B)
±
!
+
At first no change;
later + and be- j
coming decol¬
orized
1
+
+ acid. — no change.
Dr. Thursfield very kindly carried out animal experiments with the
growth obtained from the mesenteric gland. A guinea-pig was fed on
emulsion of the gland culture mixed with its food, and died four days
later. Post-mortem examination revealed no particular changes beyond
88 Batten & Forbes : Tivo Cases of Gaertner Infection
small haemorrhagic streaks in the omentum. Cultures takervfrom the
spleen and peritoneal fluid of the guinea-pig proved sterile, llie heart’s
blood, however, yielded a pure growth of a motile Gram negative
bacillus. This was put through the series of subculture tests and gave
identical reactions to those yielded by the original cultures from the
heart’s blood, spleen and mesenteric gland of the patient. The charac¬
teristic changes in litmus milk were well marked.
A culture of the original was submitted to Dr. Klein, who kindly
examined it and found it to behave like the Bacillus enteritidis of
Gaertner. We are also indebted to Dr. Klein for his courtesy in
supplying the blood-serum of a rabbit which had been rendered immune
to Gaertner’s bacillus.
A number of agglutination tests were applied to the three original
cultures and to the culture from the guinea-pig with the rabbit’s serum,
and comparison was made with the behaviour of Bacillus typhosus ,
Bacillus coli communis and Bacillus enteritidis of Gaertner under similar
conditions. The bacillus was also tested with a typhoid patient’s serum,
J. G. F.’s serum and the serum of a chance patient in one of the wards.
(1) Agglutination reactions of rabbit’s serum with:—
(а) Bacillus Obtained from Original Blood Culture. —Dilution
1 in 50, definite agglutination in twenty minutes; nearly complete
in one hour. Dilution 1 in 100, slight agglutination in twenty
minutes ; more marked but incomplete in one hour.
(б) Bacillus from Original Spleen Culture. —Dilution 1 in 50,
slight agglutination in ten minutes ; well marked in forty minutes.
Dilution 1 in 100, feeble agglutination in ten minutes; partial
incomplete agglutination in forty minutes.
(c) Bacillus from Original Mesenteric Gland Culture. —Dilution
1 in 50, marked agglutination at once; complete in thirty minutes.
Dilution 1 in 100, slight agglutination at once ; partially complete
in thirty minutes.
(d) Bacillus from Heart's Blood of Guinea-pig. —Dilution 1 in
50, marked agglutination in twenty minutes ; complete in one hour.
Dilution 1 in 100, slight agglutination in twenty minutes ; incom¬
plete in one hour.
(e) Bacillus enteritidis (Gaertner). —Dilution 1 in 50, marked
agglutination in thirty minutes.
(f) Bacillus typhosus .—Dilution 1 in 50, no agglutination in
thirty minutes ; slight in one hour. Dilution 1 in 100, traces of
agglutination in one hour.
Clinical Section
89
( g) Bacillus coli communis. —Dilution 1 in 50, no agglutination
in thirty minutes.
02) Agglutination reactions of convalescent typhoid patient’s serum
with :—
(a) Bacillus typhosus. —Dilution 1 in 100, agglutination began
at once and was well marked in fifteen minutes.
( b) Bacillus from Original Blood Culture. —Dilution 1 in 50>
very feeble agglutination in over one hour.
(c) Bacillus from Original Spleen Culture. —Dilution 1 in 50,
feeble agglutination in one hour.
(d) Bacillus from Original Gland Culture. —Dilution 1 in 50,
marked agglutination in one hour.
{e) Bacillus from Heart's Blood of Guinea-pig. —Dilution 1 in
50, feeble agglutination in one hour.
(f) Bacillus enteritidis {Gaertner) and Bacillus coli communis .—
Dilutions 1 in 50, no agglutinations in one horn.
(3) Control tests w T ith three different sera (J.G.F.’s and two chance
patients’) yielded negative results in the case of each organism w T ith
dilutions of 1 in 50.
Further Agglutination Tests were applied with Sera of
High Dilutions.
^ Bacillus enteritidis
| (fromC.B.)
!
Bacillus enteritidis
(Laboratory stock)
| Bacillus typhosus
Bacillus paratyphosus
1 (A)
Gaertner serum (dif¬
fering from one
previously used)
Dilution 1 in 100
Definite agglu-
i
Definite agglu-
No agglutina-
No agglutina-
tination
tination
tion
tion
,, 1 in 1,000
Slight agglu-
Slight agglu-
No agglutina-
No agglutina-
tination
tination
tion
tion
„ 1 in 10,000
Very slight,
Very slight
No agglutina¬
No agglutina¬
agglutination i
agglutination
tion
tion
Typhoid serum (dif¬
fering from one
previously used)
Dilution 1 in 100
i
No agglutina¬
No agglutina¬
1 1
Marked agglu¬
No agglutina¬
1
tion
tion
tination
tion
,, 1 in 1,000 1
No agglutina¬
No agglutina¬
Definite agglu¬
No agglutina¬
tion
tion
tination
tion
,, 1 in 10,000
No agglutina¬
No agglutina¬
Slight agglu-'
No agglutina¬
tion
tion
tination i
tion
As Bacillus paratyphosus ( B ) underwent rapid spontaneous agglutination in dilutions
with Gaertner and typhoid sera, and also with normal salt solution , the tests applied to it
were obviously valueless, though such a spontaneous agglutination seems to carry with it a
differentiating property of the organism.
90 Batten & Forbes : Two Cases of Gaertner Infection
Staining for flagella showed that the organism isolated possessed
numerous wavy and very long fine flagella, resembling those of Bacillus
enteritidis. The results obtained in subculture with the organism from the
patient C. B.’s blood, spleen and gland, and from the inoculated guinea-
pig’s blood, accurately agree with the behaviour of Bacillus enteritidis in
subculture. The positive agglutination to Bacillus enteritidis given by
the patient’s serum during life, taken together with the reactions of the
organism obtained post mortem, also afford sufficient proof that the case
was one of acute enteritis due to the Bacillus enteritidis of Gaertner.
That the serum of a convalescent typhoid patient should produce agglu¬
tination of the organism does not invalidate its claim to specificity, for
cases of typhoid fever are known to be associated with the presence of
Bacillus enteritidis.
Further it may be remarked that as with Bacillus coli communis
so with Gaertner, varying strains of the same organism are known to
exist. This variation naturally complicates matters and adds to the
difficulty of classification according to type. It may account for the
apparently uncertain behaviour of the typhoid patient’s serum with the
bacilli obtained from the heart’s blood, spleen and gland of C. B., from
the heart’s blood of the inoculated guinea-pig, and the laboratory stock
culture of Gaertner. The latter yielded no reaction, the bacilli from
C. B.’s blood and spleen, and guinea-pig’s blood showed feeble agglu¬
tination, but the bacillus from the mesenteric gland gave a marked
agglutination. These conflicting results are difficult to explain, and one
is tempted to suggest that though the organisms obtained from the sites
examined evidently belong to the same type, yet there may be a
variation in strain and agglutinability according to the particular organ
from which they have been derived ; further it is suggested that in an
infection produced by a specific organism that organism may be modified
under the influence of a different environment, and as a result show
variation from the original strain.
Clin ica l tied ion
91
Lymphangioma of Face.
By J. Paul Houghton.
M., aged 11. The whole of the right side of the face, with the
exception of the region below and to the right of the mouth, is
occupied by a swelling of a doughy consistency, the upper eyelid
especially being much swollen. The swelling crosses the middle line
of the forehead and upper lip. There are many cords and knots
distributed throughout the swelling, especially on the forehead, over
the parotid and in the cheek, and there is a distinct cord running
immediately behind the facial artery over the ramus of the jaw. There
Lymphangioma of Face.
is no pulsation. The swelling cannot be diminished or displaced by
pressure. There is no loss of sensation or of movement, except that
the latter is very much impaired by the infiltration of the tissues,
and the muscles readily react to faradism. There is no leucocytosis.
There is an enlarged gland under the sterno-mastoid. Eight years ago
the mother noticed that the right eye appeared smaller than the left,
92
Houghton : Lymphangioma of Face
and shortly afterwards the outer canthus began to swell, and from
thence the swelling has gradually spread. The family history is good.
The boy was at school till last December, when he left on account
of pain in the upper eyelid, which lasted about a fortnight, and this
is the only occasion on which he has had any pain.
DISCUSSION.
Mr. IiOUGHTON, in answer to a question by the President, said that the
patient had no other deformity. Two years ago a case resembling the present
one was shown at the Clinical Society by Dr. Sutherland, and there was a dis¬
cussion as to w T hether it was one of Recklinghausen’s disease or of I’ickets.
He would be interested to hear what had been the subsequent history of that
case. In the present case the morbid condition was increasing, but very slowly.
The patient had twice had attacks of pain, but it was chiefly inflammatory pain.
Mr. GODLEE asked whether the boy had moles in other parts of the body.
He thought that the swelling felt like a plexiform neuroma of the supra-orbital
nerve. Last year he had under his care an obvious case of Eecklinghausen’s
disease, and the patient had been in hospital with an encapsuled neuroma of
one of the nerves. The neuroma was easily removed and the patient came
back with a similar mass in the calf of his leg. There was no difficulty in
removing a piece as large as a hand from that situation. The patient was now
well, and Mr. Godlee recommended operation in the present case.
Dr. PARKEs Weber asked how Mr. Houghton explained the cords distributed
throughout the swelling, and expressed his agreement with Mr. Godlee’s dia¬
gnosis. The swelling felt like a bag of worms, and he regarded it as a Ranken-
neuroma (plexiform neuroma), analogous to neuromatous hyi>ertrophy of half
of the tongue such as had been described by Mr. Shattock. He asked whether
there was any enlargement of bone.
Mr. W. G. SPENCER said that if Mr. Godlee’s suggestion were correct it
would be reasonable te explore, because in the case described by Mr. Shattock
before the Pathological Society (the specimen from which was now in the
College of Surgeons Museum) the nerves were practically encapsuled, so that
they admitted of being shelled out. At all events a small incision might be
made and the operation proceeded with if such an encapsuled condition were
found. Although in the case to which he had referred infiltration occurred,
the tumour was sharply outlined in the neck and its margins were well defined.
Its extension was by means of displacement rather than by infiltration.
Dr. SUTHERLAND said the case which he showed two years ago was
similar to this ; the trouble was localized to tlie same region, and had the
same feel. The tumour was a neuro-fibroma, although some members had
raised the question whether the bone was involved. Skiagrams did not reveal
any change in the skull. In the present case he failed to find any distortion of
the hones of the nose. That the lesion should so frequently have this dis¬
tribution was curious. Dr. Sutherland asked whether there was pigmentation
Clinical Section
93
in any other part of the body. In Mr. Godlee’s case there was very well
marked pigmentation ; and over the trunk there were large splashes of brownish
yellow pigment. In the absence of confirmatory signs he was not prepared
to make a diagnosis of Recklinghausen’s disease.
Mr. ROUGHTON, in reply, said there was no bony change, nor was there
any pigmentation in other parts of the body. He would have a skiagram taken
and would again report on the case.
Tumour of Mediastinum (? Hydatid Cyst).
By Herbert French, M.D.
The patient is a robust woman, aged 4‘2. She looks perfectly well,
and her only complaint is that she cannot see properly with the left
eye. For this she came to see Dr. Eason at Guy’s Hospital. The
cause of the defective vision is, in part at least, complete paralysis
of the left cervical sympathetic nerve. This dates back for over two
years. There is slight but decided ptosis of the left upper eyelid ; the
left pupil is continuously small; the patient cannot blush upon the
left side of the face, and when she perspires the right side of the
face sweats but the left does not.
Further examination shows distinct fulness of the left external
jugular vein, and the veins over the upper part of the left side of the
chest in front are distinctly fuller than those over the corresponding
part of the right side. Examination of the chest with the stethoscope
shows complete absence of vesicular murmur and of voice sounds over
the region where the upper two-thirds of the upper lobe of the left lung
ought to be.
The conclusion is that, in the region of the left upper lobe, there
is a mass nearly as big as a good sized orange, large enough to displace
or destroy the lung there, to extend back far enough to compress the
cervical sympathetic nerve, and forward enough to compress the left
innominate vein.
The length of history and the general condition of the patient point
to its not being malignant; there has been no improvement under treat¬
ment by mercurials and iodides, so that gumma seems unlikely. The
X-rays show a perfectly globular mass not connected with the aorta
(a point less obvious in the skiagrams than it w r as when the screen was
used in different positions of the patient) and of a size precisely corre¬
sponding with the diagnosis made.
94
French: Tumour of Mediastinum
Hydatid cyst is suggested as a possibility, chiefly on account of
the perfectly globular character of the mass. The patient lias no
symptoms or signs of hydatid cyst elsewhere in the body. There is,
however, a slight eosinophilia, the coarsely granular eosinophile cor¬
puscles amounting to fl per cent, of the total leucocytes in the blood.
Mediastinal Tumour. View of thorax from behind.
The latter is otherwise normal. A dermoid cyst has also been suggested;
but it may be noted that Dr. Jordan’s skiagram shows no sign of
there being any differentiation of the contents of the mass into teeth,
bones or other similar structures.
Clinical Section
95
It is worthy of note that at the same time that this patient was
in the ward there was another case of hydatid disease under Dr.
Fawcett’s care. This was in a boy who had had an operation for the
cure of a hydatid cyst in the liver. He was skiagraphed also, and in
the thorax there was a spherical mass very similar to that in the case
shown, and this was, almost beyond doubt, a hydatid cyst within the lung.
DISCUSSION.
Dr. Eason remarked that the defective vision was not due to an inability
to accommodate; and in answer to the President he stated that the condition
had been present for two years. There was occasionally some pain, but not
much distress. There was nothing to show how the patient could have
acquired a hydatid infection, as she had never been out of England. The
voice was in no way affected.
Dr. Theodore Williams asked what there was against considering the
condition to be lymphoma. He had not heard any argument against it. He
did not at the moment remember having seen a hydatid tumour at the apex
of the lung. The interesting feature of the case was the state of the two
pupils. The patient told him objects seen with the left eye appeared only
half the size of the same objects as seen with the right, showing that there
was pressure on the sympathetic. He thought the case should be watched.
Dr. CYRIL Ogle said that two months ago he saw a circular tumour in the
lateral part of the right chest. It did not invade the back, but pushed down the
liver and displaced the heart. It proved to be a large dermoid cyst or teratoma,
weighing 10 lb. The case was the second of the kind which he had seen, and
there were unusual pressure symptoms. There was not much displacement of
the heart, but there was considerable distension of veins. On section the
tumour was seen to contain skin and other embryonic materials, was well
defined, partly cystic, and there had been recent haemorrhage into it. The
man eventually died of oedema and of difficulty of breathing. The mass
involved the anterior mediastinum, which was a more likely position for
teratoma than a posterior position, such as the tumour seemed to occupy in
the present case.
Old Fracture of Humerus, with Osteo-arthritis of Elbow.
By R. J. Godlee, F.R.C.S.
M., aged 34. Twenty-one years ago, when patient was aged 13, he
injured his right elbow; he says it was dislocated, but he does not know
that it was fractured. Three and a half years ago a small, painful
swelling appeared near the elbow, which was treated in hospital. Soon
afterwards a swelling appeared on the inner side of the back of the fore-
96
Godlee : Dislocation of Patella
arm, 2 in. below the internal condyle, which increased in size during the
last year till it reached that of a walnut. It proved to be a “ ganglion ”
with a thin wall, the pedicle of which extended up towards the joint
along the internal intermuscular septum. The clear, jelly-like contents
were evacuated and the pedicle was cut short. The wound healed by
first intention.
The skiagram shows an old fracture of the internal condyle and
irregular masses of bone attached to both the upper ends of ulna and
radius. The movements of the joint are almost perfect.
The case illustrates the good result which may sometimes be
obtained after fracture of the lower end of the humerus. It also
suggests that an injury to a joint in youth may determine the onset
of osteo-arthritis later in life. There is at present, however, no
creaking in the joint. No signs of osteo-arthritis have been discovered
in other joints.
Old-standing Dislocation of Patella, with Osteo-arthritis
of Knee.
By R. J. Godlee, F.R.C.S.
M., aged 50. The patient, who is a labourer, says that his right
knee has been out of shape since birth. He knows of no injury in
early life. It did not cause him much, if any, inconvenience until he
had a blow upon it six months ago, since which time his knee has been
painful. On flexing the knee the patella slips right over to the outer
side of the joint. There is marked genu valgum, and the signs of
osteo-arthritis are unmistakable. The patient is not the subject of
locomotor ataxy, and there is no indication that he suffered from
infantile paralysis.
The case illustrates the fact that dislocation of the patella need not
necessarily interfere much with the utility of the knee, and suggests that
an injury to a joint in early life may determine the onset of osteo¬
arthritis in the joint so affected.
DISCUSSION.
Mr. Openshaw said he had come to the same conclusion as Mr. Godlee, that
osteo-arthritis, when it attacked a single joint, often selected one which had
previously been damaged, either early or later in life. A friend of his had an
injury to his hip when a child, which necessitated the wearing of a Thomas’s
Clinical Section
97
splint for eighteen months. He was afterwards lame for a time, but ultimately
recovered. He went to South Africa, and there he caught dengue fever, after
which his hip got painful and became stiffer, in spite of all sorts of treatment,
including baths in many places and massage and plaster of Paris splints. He
had now developed severe osteo-arthritis and was permanently lame. Other
cases which he had met with also corroborated what Mr. Godlee had said.
Dr. Seymour Taylor said he had known a patient for a number of years
who had had osteo-arthritis of the hand, and the joint which was predisposed
to the injury was that which was constantly getting rapped and injured, viz.,
the index finger of the left hand. After some years, a tumour formed on the
proximal joint, and several surgeons and physicians gave various diagnoses,
from papilloma upwards. His own opinion was that it contained fluid and
that it was a ganglion. Six months afterwards it was cut by accident, and
exuded jelly-like fluid, confirming his diagnosis. No medicine was of avail; it
refilled three times and had now quite disappeared. He himself was the patient.
Dr. POYNTON said what had been said about osteo-arthritis attacking a joint
which had been previously injured was very interesting, but it was possible
experimentally to produce osteo-arthritis in one joint without any injury, by
the intravenous injection of organisms. This would cause osteo-arthritis, with
clear or gelatinous fluid and alteration of bones, so that infection, possibly many
infections, could cause the condition without previous injury. In the present
case one was in the dark as to whether injury was the actual cause or whether
it was the predisposing cause of some infection. The man had an ulcer, and
possibly an infection from that had got into the damaged joint. The injury
probably diminished the resistance of the part, but it was necessary to go
behind that and to consider whether there was not some infection superadded.
Dr. GARROD said it was certainly true that injury predisposed to osteo¬
arthritis, but that was also true of every form of joint disease. It was most
strikingly true of gout, which often was first manifested in a joint which had
been the seat of injury years previously. It was true also of infective
arthritis. He did not suppose injury was the cause of the joint lesions, but
rather that it rendered the joint a locus minor is resistcnticP and vulnerable for
any infection which might supervene.
Mr. Godlee, in reply, remarked that this discussion raised the question
whether patients already suffering from osteo-arthritis should be warned that
injury to a diseased joint was likely to aggravate the condition.
Ruptured Aortic Valve.
By Seymour Taylor, M.D.
M., aged 34, who has worked with lead for nearly two years,
complains of tightness across the chest, a choking sensation on exertion,
and a buzzing noise in the chest, which he hears best when lying down.
mh —2
98
Taylor: Ruptured Aortic Valve
These symptoms supervened suddenly after the strain of lifting a heavy
weight. He denies having had syphilis or acute rheumatism, but has
twice suffered from lead colic. He has a typical blue line at the edge of
the gums.
On palpation over the cardiac region a diastolic thrill is felt, most
intense over the second and third spaces on each side. On auscultation
a loud murmur is heard, loudest over the aortic area, diastolic in period
and musical in tone. The musical note corresponds to about B below
the staff. This point is of some interest as a similar observation was
made by Dr. Seymour Taylor in a previous case shown before the
Clinical Society. 1 The murmur is heard all over the chest and even
over the upper thirds of the humeri. The condition of the valve is
probably one of perforation of one cusp rather than of detachment or
true rupture. This diagnosis is made on the following grounds, viz.:—
(1) The sudden onset of urgent symptoms after a strain, pointing to
valve injury.
(2) The musical diastolic murmur.
(3) A marked diastolic thrill.
If a cusp were torn from its attachments one would expect to hear
harsh noises and also to feel a thrill, not only during diastole, but also
during systole.
DISCUSSION.
Sir John Bkoadbent asked whether there had been an autopsy on any
of the other cases mentioned by Dr. Seymour Taylor. In the only case of
ruptured aortic valve of which he had himself seen the autopsy severe
symptoms of breakdown came on very rapidly. Eight heart failure followed,
of which the man died a month later. When such a sudden lesion occurred
the ventricle had very little chance of undergoing hypertrophy and would
need to accommodate itself very quickly to the sudden change of pressure. He
asked whether Dr. Seymour Taylor had any knowledge of the condition of the
man’s heart before the time at which the accident was said to have happened.
There was recently a case under the care of Dr. Sidney Phillips which Sir John
Broadbent had thought was one of ruptured valve. The patient said that he
had suddenly been taken ill after violent exertion. There was a musical
murmur, similar to that heard in the present case, and a well-marked collapsing
pulse, failure of the left ventricle, secondary failure of the right heart, death
ensuing in a month. The diagnosis lay between rupture and recent endo¬
carditis with a tag of fibrin on the valve. The lesion proved to be an acute
aortitis with dilatation of the aorta. The aortic valves were not damaged by
Trans. Clin. Soc. Loud ., 1003, xxxvi., p. 243
Clinical Section
99
endocardial lesions. In a certain number of cases, in patients who said that
they had been doing heavy work and had suddenly experienced pain on exertion,
it was possible that there might have been an antecedent aortic lesion, of which
the man had not been conscious until the occurrence of the severe strain, upon
which followed sudden anaemia and deficiency of blood to the peripheral circu¬
lation. In one case the patient complained of sciatica and was found to have a
serious aortic lesion, of which he had not been aware as it was compensated.
Another man with such a lesion was the subject of tabes, and he died of
infective endocarditis with a large fungating vegetation on the aortic valve.
When such patients complained of sudden pain he thought that their hearts
had been subjected to acute dilatation, which proved just too much for the
ventricle. It would he very important in the present case to obtain evidence as
to whether there was any cardiac lesion before the strain was incurred.
Dr. F. J. Poynton said that such cases had become of great interest
recently owing to the Workmen’s Compensation Act. He had been drawn
into a very important case of ruptured aortic valve, which came into court and
was submitted to arbitration. Among the questions which were asked was :
“ Need there be severe pain at the time of the rupture ? ” Although there
was pain as a rule, he thought that one might say that it was possible for a
patient to rupture the aortic valve without feeling anything beyond discomfort.
In the case referred to pain had been wholly absent and the patient had
walked some distance after the rupture occurred. This Dr. Poynton attributed
to the fact that the ruptured valve was not sound, but was the seat of a small
aneurysm. The fact of the rupture was confirmed by autopsy. More recently
another case had come under his observation in which rupture of a valve
caused practically no pain.
Dr. Theodore Williams said he had seen several cases of similar aortic
murmurs, and in the one which he remembered best a post-mortem examination
had shown that two of the aortic cusps were degenerated but were not per¬
forated. One cusp was turned backwards on both sides, and seemed to have
been reorganised and to have acted as a valve below the level of the others.
The valve curtain hung like a tongue in the blood-stream, and this was
doubtless the cause of the musical murmur. There must have been considerable
regurgitation, and the sound was audible over the whole of the chest. The
man worked in Woolwich Dockyard and had lifted a heavy mass of iron, and
then fell down in a faint. He was seen by a medical man, who sent him to
the Brompton Hospital, where Dr. Williams saw him. He could substantiate
what Sir John Broadbent had said, that in such cases life, was prolonged only
for a short time.
Dr. PARKES Weber said it had been questioned whether perforation of an
aortic valve ever occurred apart from malignant endocarditis ; hut he had once
seen perforation of an aortic curtain which was not due to that disease. It was
connected with degenerative change of the valve. He thought there was
no recorded case in which the valve was perforated merely as the result of
accident.
mh —3 i
100
Latham: Caseatiny Pulmonary Tuberculosis
Dr. SEYMOUR Taylor, in reply, said that all the speakers on his case had
had the advantage of him, in that they had all seen post-mortem examinations
of their cases. Sir John Broadbent’s suggestion was a good one, but if there
were extensive aortitis there would be a murmur at both periods of the cycle,
whereas here, there being only one murmur, a perforation seemed more
probable. He would look up the record of Dr. Theodore Williams’s cases. If
there were a tongue which was torn off there should be a double murmur and
a double thrill. The fact that the thrill was only diastolic was also in favour of
perforation.
Caseating Pulmonary Tuberculosis treated by Tuberculin (T.R.)
and fresh Horse Serum, both administered by the Mouth.
By Arthur Latham, M.D.
The patient, a man, aged 22, was seized on June 3, 1907, with acute
pneumonic tuberculosis of the left lower lobe. He had continuous high
fever although he was kept in bed for the greater part (three months)
of the time till the beginning of October, when he sought advice at the
Brompton Hospital for Consumption. He was admitted to St. George's
Hospital on October 8 and kept in bed for one month without any
reduction of fever. At this time the patient was losing weight and there
was evidence that the disease was extending and that there was com¬
mencing infiltration in the apex of the right upper lobe and in the apex
of the left upper lobe. On November 6, 10 c.c. of horse serum with
mg. tuberculin were administered by the mouth. The temperature,
as may be seen from the accompanying chart, then dropped to nearly
the normal level for three days. On November 9 the temperature rose
again to 101° F. A further dose of serum and the tuberculin was given
on November 11. On November 12 the temperature w r as subnormal.
On November 13 the temperature again rose. On November 20 and 21
serum and tuberculin were again administered with immediate effect.
The temperature remained normal, or nearly normal, until December 12,
when the patient Avas allowed to get up. This led to immediate auto¬
inoculation with an unknowm dose of the patient’s own tuberculin and
consequent fever. Further administration of serum and tuberculin again
reduced the temperature. On January G the temperature rose to
I02°F., partly in consequence of an influenzal sore throat and partly in
consequence of the administration of three doses of 10 c.c. serum and
Tsoo tuberculin at intervals of eight hours, w-hich led to a summation of
DATE [ 8 9 1011 '1213 uJlS 16 17 1 8 1 9 20 2l[22 23 24 2 5 2 6 27 2812 9 3 0 3 lj 12 I 3 4 I 5 6 7 8^ I0ll|l2l3l4 15 16 1 1 7 18 1 1 9 1 202 I !22 2
Clinical Section
Chart showing the effect of Tuberculin (with Horse Serum) in Dr. Latham’s case of Caseating Tuberculosis.
102
Latham: Caseating Pulmonary Tuberculosis
negative phase and. a marked drop in the opsonic content of the blood.
This proved a temporary affair. From January 10 to the present time
(February 14) the temperature had been normal. The patient was now
up and taking an hour’s exercise a day. The physical signs now present
were those of a dry contracting cavity at the left base. The sputum,
which still contained tubercle bacilli, had diminished from 6 oz. to
2 dr. or 3 dr. in the twenty-four hours. The weight had increased 17 lb.
A daily observation of the opsonic index had been kindly undertaken by
Dr. H. D. Spitta and the curve obtained corroborated the clinical results.
Remarks .—Those who see much of pulmonary tuberculosis know
how long is the arm of coincidence in this disease. Tt is not necessary
for me to say that I do not bring this case before the Section as a con¬
clusive example of the value of a new method. I have brought it forward
that Fellows may have an opportunity of seeing it in its present
stage and again at a later period. I have given tuberculin and other
vaccine by the mouth—some with serum and some with normal saline
solution—in twenty-five cases and I am convinced that this method of
administration is effective. As to the part played by the horse serum I
am not prepared to speak with any definiteness. The administration of
vaccine in many cases is not, unfortunately, attended with good clinical
results. It is clear that we can often increase the opsonic content of the
blood by the administration of vaccines, and yet in many cases in spite
of this the disease continues to extend. The opsonic content of the
blood, whether it be the natural content or brought about by the adminis¬
tration of vaccines, does not therefore give as complete a picture of what
is taking place in the blood as the result of bacterial infection. Vaccines
may increase the opsonic content of the blood and yet bring about no
response, or an insufficient response, on the part of the patient's own
phagocytes. Again, although a vaccine like tuberculin undoubtedly has
a direct effect on the response made by the body to auto-inoculation with
tuberculin by remedying, to a greater or lesser extent, a deficient capacity
to produce specific opsonics, yet it probably has no direct effect on any
other deficiency in the patient’s own serum, whether this be inherent or
whether it be produced by poisonous bodies resulting from the action of
tubercle bacilli or tuberculin upon the tissues. From an extensive
clinical experience of various sera I have come to the conclusion that the
serum itself plays some part in the clinical results obtained in addition to
the part played by the specific bodies which some of these sera contain.
Whether horse serum is able to supply the patient with some substance
in which his own serum is deficient, or whether it stimulates the produc-
Clinical Section
103
tion of some such substance, or whether it has any action, direct or
indirect, on"the phagocytic cells I cannot discuss to-night. I intend to
bring this question of the administration of the vaccines by the mouth
together with (1) horse serum, (2) normal saline solution, before the
Medical Section at the end of March, I shall then deal with the results
obtained in several cases of staphylococcic and streptococcic infection,
pulmonary tuberculosis, tuberculous peritonitis and “ surgical ” tuber¬
culosis. These cases are being treated by me at St. George’s Hospital
and at the Brompton Hospital for Consumption in conjunction with
Dr. H. D. Spitta and Dr. A. C. Inman.
DISCUSSION.
Dr. PARKKS WEBER said that Dr. Latham’s remarks had some bearing
upon the question of using meat from tuberculous cattle for the feeding of con¬
sumptive patients. That was one of the possible future advances in the
therapeutics of tuberculosis.
Dr. Theodore Williams said that Dr. Latham had stated his case very
moderately. There were, however, other explanations possible for the improve¬
ment of the symptoms. We all knew cases in which a man had active mischief
going on in his lungs and a cavity formed, with large expectoration and reduc¬
tion of fever and other symptoms, and the case went on as a dry cavity case.
One often found that the cases which began with fever and acute symptoms
subsequently became chronic cases with a low temperature and quiet pulse,
like chronic abscesses in various parts of the body. This was a natural
occurrence and did not require the presence of tuberculin to produce it. He
understood Dr. Latham to say that when the patient was allowed up and the
temperature again rose, there was auto-inoculation ; but he did not see that
such was proved, though it might be true. In a recent excellent paper at the
Medical Society members were introduced to auto-inoculation quite early
in cases of phthisis, hut he confessed that if the opsonic index had not
been invented he should have regarded the symptoms as those of ordinary
phthisis. Dr. Latham’s method of giving tuberculin by the mouth was good,
as it saved the trouble of repeated hypodermic injection. He asked whether
Dr. Latham examined the expectoration for lung tissue; that should be
observed as thoroughly as the opsonic index and the number of bacilli dis¬
coverable, for the important point to ascertain was, what effect the tuberculin
was exercising on the lung tissue, healthy and diseased. He hoped Dr.
Latham’s efforts would be crowned with success.
Dr. Latham, in reply, said he agreed with Dr. Parkes Weber that there
was a possibility that people might be immunised by giving them cooked
tuberculous meat. Within the last month or two, at the Pasteur Institute,
they had been able to immunise animals against tuberculosis by feeding them
104
Weber: Sj)t(rious (!) Acromegaly
on (lead bacilli under certain conditions. That fact, had confirmed him in the
belief that the tuberculin given by the mouth was a possible therapeutic
measure. In answer to Dr. Theodore Williams, he said that his remarks were
directed not to auto-infection, but to what was now called auto-inoculation.
Nothing did consumptives so much harm as over-exertion and fatigue, and it
had been conclusively shown—especially by Dr. Inman’s work at the Brompton
Hospital—that that was chiefly due to an excessive absorption of tuberculin
which followed undue exertion, so much so that in early cases of tuberculosis
one could diagnose the presence of the disease by the effect on the opsonic
curve of auto-inoculation brought about by exertion. In caseous tuberculosis,
if the patient were allowed to get up after the temperature had come down to
the normal, the temperature frequently rose again. That was largely due to the
fact that under the influence of exertion there was a freer circulation through
the lungs and a freer absorption of tuberculin.
Spurious (?) Acromegaly.
By F. Parkks Weber, M.D.
Mrs. S., aged 4t>. This case is shown because of its remarkable resem¬
blance at first sight to acromegaly. The patient is a married woman,
rather corpulent, and very anaemic. Her face and head, with the large
lower jaw, prominent chin, and big, broad, fleshy nose, could be used as
a model for an illustration of acromegaly. She has very broad, fleshy
hands and thick fingers and very broad, thick, fleshy feet, but she has
no ocular symptoms of acromegaly; and her occasional headaches and
shortness of breath seem to be connected with her ansemia, which in
its turn may be accounted for by frequent hoemorrhoidal bleeding, from
which she has suffered during the last six or seven years. There is no
amenorrhuisi, as there is in many genuine cases of acromegaly. More¬
over, there is no evidence of any progressive change having occurred in
the shape or size of the hands, feet, face, skull, or other bones of the
body since she ceased growing at the ordinary age. An old photograph
(the only one obtainable for comparison), which was taken three or four
years ago, shows her face looking just as it does now. She has six
children, all healthy, and at least one of the daughters somewhat
resembles the patient in the shape of the chin. The case has probably
been more than once accepted as one of genuine acromegaly.
(Dr. Archibald I). Reid, who kindly examined the patient’s head with
Kontgen rays, found that there were no bony alterations in the region of
Clinical Section
105
the sella turcica, such as he had been able to demonstrate by the aid of
llontgen photographs in cases of pituitary tumour.)
Lateral Curvature rapidly developing in a Boy.
By W. Ct. Spencer, M.S.
M., aged 3, an inmate of a Poor-law school, was all at once noticed
to have a marked lateral curvature, the only previous observation being
that he seemed a little anaemic. He has a marked left thoracic and
lumbar scoliosis and walks with lordosis; both of these curvatures
disappear when he is suspended by the arms. The muscles of the left
side of the spine appear unduly w T eak, the abdomen is irregularly pro¬
tuberant, but there is no definite hernia, either inguinal or ventral.
Haemoglobin, 74 per cent. Beyond this, examination has discovered
nothing distinctly abnormal; the reflexes are normal, the muscles of the
spine react to faradism and galvanism, no muscles are absent.
Excision of the Body of the Scapula.
By R. P. Rowlands, M.S.
M., aged 35, from whom the whole of the body of the left scapula
was excised for enchondroma fifteen months ago. It was possible and
deemed advisable to save the coracoid process, with its important muscles
and ligaments, the glenoid cavity with the capsular ligament of the
shoulder-joint, and the acromion process, with the attachments of the
deltoid and trapezius to it. The origin of the long head of the triceps
was preserved.
The patient shows that both the functions and the deformity following
this procedure are much less than after complete excision of the shoulder-
blade. The man has been able to do his work as a painter’s labourer at
Guy’s Hospital from two months after the operation. Extreme abduction
is the only movement that is imperfect, but the hand can be easily made
to touch the back of the head. In the case of complete excision rota¬
tion is perfect, external rotation being probably carried out by the long
head of the triceps; rotation of the shoulder-joint is limited to one-half
the natural extent and the abduction to 45°.
106
Openshaw: Case of Multiple Dislocations
Radiograms are exhibited to show the comparative effects of the
operation adopted in this patient and of complete excision of the scapula
for extensive sarcoma by Mr. Dunn, who has kindly allowed me to make
use of his case. Photographs are also exhibited which show the
differences of function and degree of deformity in the two cases.
A posterior T-shaped incision was used, and through this the three
groups of large vessels were tied early in the operation to minimise
haemorrhage.
It is claimed that preservation of the processes and glenoid cavity is
both practicable and advisable in preference to complete excision of the
scapula for all innocent and some malignant growths, as well as for some
inflammatory conditions which do not affect the shoulder-joint.
Case of Multiple Dislocations, including Congenital Dislocation
of both Hips, in a Child, aged two weeks, incontestably
the Result of Malposition in Utero.
By T. H. Openshaw, C.M.G., M.S.
M. G., aged two weeks, was brought to me as an out-patient at the
London Hospital on February 7, 1908, presenting dislocation of both
shoulders, both elbows, both hips, and both knees, and extravagant
double equino-cavo-varus. The child otherwise is well formed; the
cranium presents no deformity. There is a large umbilical hernia and a
history of snuffles. The mother has five other children and has had
three miscarriages. The first was a miscarriage at seven months, the
second is now aged 8, the third was born dead at seven months, the
fourth is now aged 5, and the fifth is aged 2.
The pregnancy was normal, except that the mother had a fright
when four months pregnant. The position in which the child lay
in utero can be definitely reconstructed. The limbs in their abnormal
position fitted closely to the body; the hips fully flexed, the knees
hyperextended, and the feet twisted into the position of equino-varus.
The arms are flexed at the elbow-joints and rotated in at the shoulders,
so that the hands are situated in the armpits in a position of acute
flexion at the wrists.
The right leg : the head and neck of the right femur are rotated
outwards upon the shaft through an angle of 30°. The head is dis-
Clinical Section
107
located, and lies outside and in front of the anterior superior spine. The
thigh was acutely flexed on the abdomen, the inner surface of the
femur rested in utero upon the abdomen. The condyles are visible in
the popliteal space, the knee being retroflexed to an angle of 100 .
The knee can only be flexed, even with force, to an angle of 160 ,
and immediately drops back to an angle of retroflexion of 110°. There
is extravagant congenital equino-varus, the sole of the foot looking
upwards. The scaphoid is the lowest bone of the tarsus.
The left leg presents a similar condition, except that the knee
is hyperextended to an angle of 100°, and can only be flexed to an
angle of 170°. The left foot presents the same condition as the
right; the scaphoid is the lowest bone.
There is a large funnel-shaped umbilical hernia, which bulges
between the knees when the legs are in the position in which they
were in utero.
The right arm : there was a subcoracoid dislocation of the shoulder.
The elbow: both bones were dislocated backwards and outwards.
There is marked pronation of the forearm. The fingers are well
formed, but excessively hyperflexed at the metacarpal phalangeal
joints. The transverse metatarsal ligaments are extravagantly stretched,
so that the heads of the metatarsals can be separated and the hand
stretched out to a width equal to double the length of the palm.
The left arm presents a similar condition.
The muscular system of the child is normal. There is no paralysis.
The child, except for the dislocations, is well developed. There is no
lateral curvature.
This is incontestably a case of congenital dislocation of hips, knees,
shoulders, and elbow's from intra-uterine malposition. I have seen two
other cases where congenital dislocation of the hip has been associated
w ith congenital recurvation of the knees and talipes in the same leg, and
was, in my opinion, due to intra-uterine malposition and pressure.
A Case of Myositis ossificans.
By Cykil A. R. Nitch, M.S.
Edith W., aged 10, was seen at the Evelina Hospital for Children in
February, 1008. Her father, mother and eight brothers and sisters are
all alive and quite healthy. There is no history of syphilis or tubercle in
108
Nitch : Case of Myositis ossificans
Myositis ossificans.- Skiagram of right knee, showing bone in hamstrings and calf
muscles. Note the long spicule attached to the back of the tibia.
Clinical Section
109
the family. When aged 3J both tonsils were removed, and a fortnight
later a hard and tender swelling appeared in the neck on the right side.
This subsided in a couple of weeks, but fourteen days later a similar
swelling was noticed on the left side, which, however, soon disappeared.
Within a short time the mother noticed a hard mass in the right side of
the neck, and a few months later similar lumps were to be felt in the
left pectoral, scapular and lumbar regions.
When aged 4 the case was shown to the Society for the Study of
Disease in Children by Dr. George Carpenter and Mr. Walter Edmunds. 1
Her condition was then as follows: there was a spicule of bone in the
left sterno-mastoid, and the muscles of the neck on the same side were
infiltrated and hard. Just below the chin there was a prominence the
size of a pea due to bony infiltration of the genio-hyoid muscles. Plates
of bone could also be felt in the right sterno-hyoid, right coraco-
brachialis, left pectoralis major and erectores spinae. In September,
1901, Mr. Edmunds cut deeply into the back and removed some tissue
for microscopical purposes. No normal muscle fibres were present
their place being taken by fibro-cellular tissue.
Present condition. The disease has advanced considerably. The back
and neck are now quite rigid, movements at the shoulder are very
limited, full flexion of the leg is impossible, and owing to the fixation of
the thorax respiration is purely diaphragmatic. Osteoid tissue in the
form of plaques, bosses and spicules can now be felt in the erector spina 1 ,
latissimus dorsi, trapezius and pectorales of both sides, the right rhom-
boideus major and minor, the left rhomboideus minor, the left levator
anguli scapulae, the left infraspinatus, the sterno-mastoids, the right
vastus externus and the muscles in the popliteal space (see skiagram),
while the pea-like prominence of bone in the genio-hyoid noticed by
Mr. Edmunds in 1902 has now become a long spinous process. Micro¬
dactyly of both great toes is also present.
Sarcoma of Thigh.
By H. A. T. Fairbank, M.S.
G. S., a male, aged 4. A swelling, the size of a hen's egg, was first
noticed at the site of the main tumour about two months ago. The
mass has therefore been growing rapidly. The child has been able to
1 Kept. Soc.'Study of Dis. in Child ., 1902, ii., p. 96.
mh —4
110
Fairbank : Sarcoma of Thigh
run about and there has been no pain up till five days ago, when he
complained of pain oyer a gland below Poupart’s ligament. The delay
in seeking advice was the result of an attack of measles. The child is
said to have “ picked up ” since the measles, which had pulled him down.
No symptoms of disease elsew r here. The patient is the youngest of four
children. The others are healthy. No history of tubercle or syphilis.
There is now a large, very hard, nodular mass growing in the deep
fascia and muscles on the outer side of the thigh. The mass is not
attached to the skin nor to the bone. There are large, hard glands in
the groin and in the abdomen along the iliac vessels.
CUntcal Section.
March 13, 1908.
Sir Thomas Barlow, Bt., K.C.V.O., President of the Section, in the Chair.
A Case of Hermaphroditism, in which the Uterus occupied
the Sac of an Inguinal Hernia.
By Thomas H. Kellock, F.R.C.S.
Although cases of hermaphroditism are not extremely rare, the
particular complication met with in the following one must, I think, be
-very exceptional.
The patient, a professional man, aged 25, consulted me about a left
inguinal hernia; except that he was of very short stature and had very
little hair on his face, there was nothing noticeable in his appearance;
his voice was strong and markedly of the masculine type; the mental
faculties, if anything, above the normal. He stated that when he was
quite an infant he had been the subject of a left inguinal hernia, but that
he himself had never noticed its presence until quite recently, when a
strain brought it down again, and since then it had constantly been
making its appearance, at times causing him a good deal of pain;
on one or two occasions he had had a good deal of difficulty in
reducing it.
On examination the following condition was found: the penis was
of fair size, but incurved ; the prepuce hood-like ; and there was a marked
condition of hypospadias, the urethra opening at the junction of the
under surface of the penis with the front of the scrotum. The right side
of the scrotum was empty, and no testicle could be felt in the inguinal
canal or iliac fossa. On the left side the testicle was present in the
a —1
112 Kelloek : Case of Hermaphroditism
scrotum ; it was, perhaps, a little undersized and rather higher than
normal; sensation in it was normal. In the left inguinal region a rather
large hernia was present; part of this, which was either omentum or
intestine, was easily reduced, but there still remained a hard swelling in
the canal which was apparently irreducible and which, at the time of
examination, was thought to be a piece of omentum adherent in the sac.
An operation was undertaken with a view to curing the hernia.
When this was performed it w r as found that the swelling, which had
been thought irreducible, had disappeared, but had left a good deal of
fulness along the inguinal canal.
On exposing the spermatic cord by the usual incision a sac was very
distinctly seen lying quite superficially among the other structures of the
cord towards the lower part of the wound. This was separated and
opened. It was found that it did not extend upwards any further, and
so did not communicate with the peritoneal cavity ; but it extended down¬
wards to nearly the bottom of the scrotum and contained the testicle,
which was attached to its posterior wall near the centre; the testicle
was rather small, but of natural shape and consistence; leading down
from it to the low r er part of the sac was the spread-out epididymis, and
the vas deferens led from this upwards along the posterior wall of
the sac.
The greater part of this sac having been removed as in the operation
for hydrocele, the cord was examined above and another sac was found
adherent to the upper end of the other, but not continuous with it
internally, the vas deferens lying in close contact with its posterior wall.
On opening the second sac it was found to be empty and to communicate
directly by a rather large opening with the peritoneal cavity; on pulling
on the sac gently a mass of some size was brought out through this
opening, which was found to be adherent to the inner wall of the sac
and only partly covered by peritoneum. It was drawn well out and
proved to be a uterus about the size of a horse-chestnut; on the upper
side—that is, what w r ould be the right side of the organ—there was a
well-marked broad ligament, and, leading from the right cornu, a round
ligament terminating in a blind expanded end. Lying on the back of
the broad ligament and in the usual situation of the ovary was a small,
oval-shaped, very white body about the size of a haricot bean, irregular
on the surface. A definite fibrous band leading from the left cornu of
the uterus down the posterior wall of the sac towards the left testicle,
but not connected with this or with the vas deferens, was all that could
be found representing the left broad ligament.
Clinical Section
113
The opening into the upper sac was closed by a continuous suture,
the sac freed from its connections with external structures, and reduced,
with the uterus, into the abdominal cavity without much difficulty. The
operation was then completed by returning the left testicle to the
scrotum and closing the inguinal canal by sutures; when it had been
finished it was found that a little white glairy fluid had escaped from
the urethral opening.
Recovery was uneventful, and quite recently I heard from the patient
that, so far, the operation had been quite successful.
DISCUSSION.
Mr. Pearce Gould suggested that it would add to the interest of the case
if Mr. Kellock could say whether a prostate could be felt by rectal examination.
Mr. KELLOCK, in reply, said that he believed that he was right in stating
that no prostate could be felt, but he could not speak with absolute certainty
on this point.
114
Weber: Case of Angina pectoris with Aortitis
A Case of Angina pectoris with Aortitis.
By F. Parkes Weber, M.D.
The patient, a German married woman, aged 42, was admitted at
the German Hospital on the morning of January 2, 1908, and died in
the afternoon of the same day. She was a fairly well nourished, pale¬
looking woman of medium size, and complained of great pain in the
chest to the left of the sternum, just above the cardiac area. Over this
area there was a good deal of rather coarse crepitation to be heard, but
I could make out nothing special by examination of the heart and
abdominal organs. The pulse was 95 to the minute, regular and rather
weak. The radial arteries did not feel diseased. There was no dyspnoea.
The face was pale and the lips slightly bluish. There was no oedema.
The temperature was 99° F. The urine was of specific gravity 1017,
free from albumin, sugar and tube .casts, and giving no reaction for
aceto-acetic acid (Gerhardt’s reaction with perchloride of iron). She had
not been ill long, but the history which I obtained from the patient was
very incomplete. The temperature was against the idea of any acute
inflammatory condition. She was treated with hypodermics of camphor
in oil and with small doses of alcohol, as if for a condition of collapse.
In the afternoon she was given one subcutaneous injection of liquor
strychnin® hydrochloratis Rl iij. (which seemed to make no difference),
and oxygen inhalation was employed. The pain, however, persisted, the
pulse became weaker and the crepitation in the upper part of the left
lung (back as well as front) became more marked. There was likewise
a little fine crepitation over the right lung. She vomited three times in
the hospital, and had vomited once before admission. She died suddenly
about 5 p.m., that is, about eight hours after her arrival.
Information obtained later on from the husband threw fresh light on
the illness. The completed history seems to be as follows : The patient
used to enjoy good health, and never had a severe illness before the
present one. She was always pale. Her father died with “ dilatation
of the heart ” at about the age of (30. The husband gave no definite
history of syphilis. The patient herself had had four children: the two
younger ones only were still living; of the two first, one was born dead
and the other died soon after birth. During the summer of 1907 the
patient used to complain of pains in the stomach, and her fingers used
sometimes to turn white and cold (“ local syncope ”), but otherwise she
Clinical Section
115
remained in apparently good health and did her ordinary work as before.
From December 22, 1907, she commenced to complain of a sensation of
pressure in the stomach and pains on the left side of the front of the
thorax, and began to lose strength. She obtained pills and medicine
from a doctor, but the pains increased every day. The slightest exertion
would induce a pain on the left side of the chest. On the night before
admission the pain became unbearable. She vomited once.
This history suggested that the illness was a kind of ingravescent
angina pectoris ending in a “ status anginosus ” and syncope, and the
necropsy made it certain that this view of the case was the correct one.
The pathological changes were practically confined to the thoracic
aorta and the orifices of the coronary arteries, the whole being evidently
the result of a process of aortitis, affecting chiefly the first part of the
aorta. This first portion of the thoracic aorta was much sclerosed and
irregularly thickened and slightly bulged, as if aneurysmal dilatation
were commencing. The orifices of both coronary arteries were much
stenosed owing to the aortic change, but excepting for this stenosis at
their orifices both vessels were practically free from disease. The rest
of the thoracic aorta and the abdominal aorta were affected similarly to
the first portion, but to a very much slighter degree. The heart, of
about normal size, weighed 12 oz., and its muscular substance did not
appear diseased; there was no valvular affection. Both lungs were
(edematous ; there was no evidence of pneumonia, tuberculosis, syphilis
or infarction in these organs. There was no disease of the mediastinal
lymphatic glands. The liver (weight 55 oz.) showed signs of chronic
passive congestion, but not nearly sufficiently to be termed a “ nutmeg
liver.” There was a transverse constriction, a minor form of that
caused by “ tight lacing.” There were no biliary calculi. The kidneys
(weight together 11 oz.) appeared free from disease, and the capsules
stripped readily. The spleen was of about normal size and weight
(weight 6 oz.) and seemed healthy. In the stomach a little submucous
ecchymosis was noted. The intestines and generative organs were not
diseased, except for the presence of an ovarian cyst.
Microscopical examination of a piece of thickened ascending aorta
showed the pathological process to be one of aortitis, as yet unaccom¬
panied by any marked atheromatous or calcareous degenerative changes.
The intima was irregularly thickened, and in the media and adventitia
there were numerous patches of cell infiltration (lymphocytes, plasma
cells). These foci of cell infiltration were larger and more numerous in
the adventitia, whilst in the media they formed smaller spots and streaks
116
Weber: Case of Angina pectoris with Aortitis
around the vasa vasorum. The presence of one or two giant-cells
amongst the other cells was kindly pointed out to me by Mr. S. G.
Shattock, but they were not typical of tuberculosis, and an examination
of sections specially stained for tubercle bacilli gave a negative result.
Remarks .—In regard to the etiology of the aortitis in this case it is
impossible to arrive at any absolute conclusion, but there are certain
points suggesting a syphilitic origin in spite of the absence of syphilitic
changes elsewhere in the body. The character of the cell infiltration
(lymphocytes, plasma cells) and its distribution about the vasa vasorum
in the media is such as might be met with in syphilitic cases. 1 In
syphilitic aortitis, according to Heller and others, the ascending aorta is
especially affected, as it was in this case. Moreover, the age of the
patient, the history regarding her two first children, and the absence of
other obvious causes of arterial disease lend-a certain amount of support
to the syphilis theory. The clinical history of the case is characterised
by the rapid increase in severity of the anginal attacks. At first these
troubled the patient only occasionally on exertion, then muscular exertion
of any kind would invariably induce an attack; finally, a severe attack
occurred, in the absence of any obvious exertion, at night time, and next
morning the patient was admitted with the fatal “status anginosus.”
Heberden and Huchard have pointed out that nocturnal attacks of
angina pectoris are apt to be of long duration, and Huchard has laid
stress on the influence of the bed position in increasing the blood-
pressure and myocardial work, and thus inducing nocturnal attacks of
angina pectoris. In some patients subject to angina pectoris the position
of rest in bed at night time is by no means the position of maximum
rest for their cardiac musculature. In regard to the much discussed
question of the causation of angina pectoris this case is of some interest.
Sir Clifford Allbutt maintains that the only essential cause of attacks of
genuine angina pectoris is aortitis, but that coronary stenosis is frequently
present as a fatal complication. Disease of the coronary arteries, so
conspicuously present in many fatal cases, has, he thinks, been wrongly
regarded as the real cause of the anginal attacks. On Sir Clifford
Allbutt’s theory, cases of recovery from true angina pectoris might be
accounted for by supposing the anginal attacks to have been due to a
condition of aortitis unaccompanied by any considerable stenosis of the
coronary arteries. Moreover, the post-mortem discovery of coronary
1 So extensive wae the cell infiltration in the aortic adventitia around the commencement
of one of the coronary arteries (which was microscopically examined) that, if due to syphilis,
the process might almost be termed “ syphilomatous.”
Clinical Section
117
stenosis in persons who during life have never suffered from angina
pectoris might also be explained on the supposition that there had never
been sufficient aortitis present to determine an anginal attack. This
“ aortitis” theory does, however, not account for the occurrence of
coronary stenosis without typical angina pectoris when the stenosis is
due to an aortitis more or less occluding the coronary channels at their
commencement. 1 On the other hand, the occasional failure of coronary
stenosis to produce angina pectoris may be explained by supposing that
when the coronary stenosis is of exceedingly slow and gradual develop¬
ment, the patient may have time to accommodate himself to his disease
and may finally die of dilatation of the heart and gradual cardial failure
without ever having had an attack of angina pectoris. On the “coronary ”
theory it is also possible to account for occasional cases of recovery from
true angina pectoris, for the swelling (due to aortitis) at the commence¬
ments of the coronary arteries might in rare cases be supposed to subside
without giving rise to permanent coronary stenosis. The present case
appears to me to lend as much support to the “ coronary theory M as to
the “ aortitis theory,” but can certainly not be adduced as supporting any
of the other theories of angina pectoris.
DISCUSSION.
Dr. James Mackenzie said the case was of very considerable importance,
and was unique in some ways. It was manifestly a case of true angina pectoris
with no increase in the blood-pressure. There was none of that condition of
which a good deal was heard at present—high blood-pressure and contracted
arteries—which Dr. Eussell, of Edinburgh, spoke of as “ hypertonus.” He pre¬
sumed there was no attempt to give relief in this case by amyl nitrite; it would
have been interesting to see what the result of such treatment would have been.
He had seen somewhat similar cases in which that line of treatment had been
useless, while in others the nitrite had given relief, even when there was very
low blood-pressure. His opinion, after having administered amyl nitrite to many
patients suffering from angina pectoris, was that one was not justified in saying
that it simply relieved temporary spasm of the arteries. The question was a
complicated one which need not be discussed. It w r as of no use putting for¬
ward theories about the causation of angina pectoris, as there were already too
many. Not long ago Dr. Weber showed before the Section an interesting case
of intermittent claudication, and in that case it was evident that the muscles
1 Compare the case of obliteration of the commencement of the right coronary artery
(apparently from syphilitic aortitis and without history of attacks of angina pectoris) which
1 brought before the Pathological Society of London in December, 1905 ( Transactions , 189G,
xlvii., p. 16).
118 Weber: Case of Angina pectoris with Aortitis
of the legs were able to carry on their work when they had a good supply of
blood ; but when the blood-supply to the pail; was deficient, as when exertion
was made, pain resulted. In the present case there was much stenosis at the
mouth of the coronary artery. When the patient was at rest, his heart muscle
was able to carry on its work, but upon exertion there was pain. There was
no occasion to go into the question of the aortitis. If cases of angina pectoris
in people who worked hard, such as engineers, were watched, and the observa¬
tions were extended over many years, it w r ould be found that they did their work
while sclerosis was proceeding in their vessels; but that there came a time
when they did not feel fit for work, and then exhaustion came on, frequently
terminating in an attack of pain. As the damage was not very great, treatment
and rest enabled them to recover temporarily, the reason being that there was
a transient impoverishment of muscle.
Dr. F. de HAVILLAND Hall said that he thought it not improbable that
syphilis was the cause of the lesion when the sex of the patient was con¬
sidered—angina being rare in women—her age, and the rarity of changes in the
aorta in women, as well as the fact that the first child was born dead and the
second died soon after birth. In support of Sir Clifford Allbutt’s view that
the pain in angina pectoris was due to aortitis was the fact that angina pectoris
was almost confined to patients with aortic disease, as shown by the obstructive
or regurgitant murmur, or by the presence of an aortic aneurysm. Mitral
regurgitation was almost unknown in subjects of angina. There were cases of
mitral stenosis with anginoid symptoms, i.e., pseudo-angina. He thought a
distinction should be draw n between true angina pectoris and the milder attacks
which w T ere specially observed in females, and were not very uncommon in
association with mitral stenosis. He had hoped to hear that amyl nitrite had
been tried in this instance, as he had seen cases in which, though the blood-
pressure w’as comparatively low, that drug had afforded relief. Failing that,
he w r ould have injected atropine and morphine subcutaneously.
Sir Dyce Duckworth said that he had very little doubt as to the etiology
of the case or that it illustrated an effect of syphilis. The points to which
Dr. de Havilland Hall had directed attention were such as all might agree to,
and he thought the aortitis was syphilitic. He recognised that anginoid
symptoms did occur—the so-called pseudo-angina—and that this term was
required, at all events as an expression of ignorance. Grave angina was practi¬
cally never seen in a woman. There was no doubt about the agony of angina
being due to cardiac distension, just as when any hollow' viscus w T as stretched
there was great pain, especially when the distension was of acute onset.
Dr. GARROD said that ten years ago there was a patient in Sir William
Church’s wards at St. Bartholomew's Hospital who had been admitted with
pneumonia and was sufficiently recovered to be sitting propped up in bed
talking to his friends. He was suddenly seized w T ith a most intense praecordial
pain, which could not be relieved by any of the remedies which were tried,
and in half an hour he w'as dead. Next day Dr. Garrod made a post-mortem
examination. There was pneumococcal endocarditis, a long trailing vegetation
Clinical Section
119
being attached to one of the aortic cusps—which had not caused a murmur
during life—and the end of that vegetation was missing. It was found blocking
the mouth of the right coronary artery, which it had embolised. As far as he
could remember at that distance of time there was no disease of the aorta.
The only lesion which could have accounted for the acute anginoid pain was
the plug cutting off the circulation in his right coronary artery. The case,
which had been recorded by Sir William Church, 1 seemed to have an interesting
bearing on the present discussion.
The PRESIDENT asked whether there had been any bacteriological investiga¬
tions made, especially with regard to the Spiroclueta pallida.
Dr. Parkes Weber, in reply, said that the Spiroehaeta pallida had been
rarely found in tertiary syphilis, and he had not looked for it in the present case.
He had been glad to hear that both Dr. de Havilland Hall and Sir Dyce Duck¬
worth took the view that the aortitis was syphilitic, but he supposed one could
not be sure in a case like the present one until the local presence of the syphilis
microbe was demonstrated. Searching for the Spirochapta pallida in tertiary
syphilis, however, must be as tedious and discouraging as looking for the
Bacillus tuberculosis in lupus verrucosus, or more so. He had read of the
interesting case mentioned by Dr. Garrod, but was glad to hear of it from one
who had been present at the necropsy. He believed there had been one or
two similar cases recorded. 2 It was doubtless the suddenness of the obstruc¬
tion of the coronary artery in the particular case mentioned by Dr. Garrod
which gave rise to the rapidly fatal symptoms, because it was not very rare
at necropsies to find one of the coronary arteries obliterated without such
symptoms having been produced. In such cases the process of obliteration was
gradual, but in the case referred to by Dr. Garrod closure of one coronary
artery was so sudden that there was not time for collateral circulation to be
established through the anastomosing branches of the other coronary artery.
Dr. James Mackenzie’s remarks emphasised the coronary theory as furnishing
the most probable explanation of the anginal pain. Dr. Weber would have
tried amyl nitrite had it not been for the peculiar and misleading physical signs
(local crepitation) which he found, and the diagnostic difficulty before the more
complete history was obtained. If he had a similar case again, nitrite of amyl
would be the first thing he would try ; and he believed a good method was to
direct a stream of oxygen against the nostrils and hold the broken capsule of
nitrite of amyl in that stream.
1 The case referred to was recorded by Sir William Church in the St. Bartholomew's Hospital
Reports , 1896. xxxii., p. 7. The patient was a man, aged 40. There were two attacks of
severe prsecordial pain with an hour’s interval between them. The arch of the aorta was
somewhat dilated and the thoracic aorta was very atheromatous. The fact that the aorta was
atheromatous had escaped the memory of the speaker, but there can be little doubt that the
fatal attack with preecordial pain and dyspnoea was due to the embolism of the coronary artery.
2 See especially L. Hektocn’s case, Med. News , Philadelphia, 1892, lxi., p. 210; and
Korczynski’s case, abstracted in Jahrcsb. f. d. gesammt. Med., xxii. Jahrg. (1887), Berlin,
1888, ii., p. 219. There are other cases of sudden death from coronary embolism recorded
without mention of anginal pain.
120
Carruthers: Fatal Purpura hoemorrhagica
Purpura haemorrhagica with Fatal Result from Cerebral
Haemorrhage.
By S. W. Carruthers, M.D.
Mrs. I. M. B., aged 59 ; had been a healthy woman, w T ith no
history of serious illnesses; had one ovary removed (precise reason
unknown) a good many years ago; has occasional rheumatic pains,
chiefly muscular ; slight nodular enlargement of interphalangeal joints
present.
On December 27 she consulted me on account of slight blackish
marks in various parts of the body, chiefly on the shins, thighs and
forearms. These were ecchymotic in character, like faint bruises, and
the shape and position of several of them suggested that they had been
caused by a slight blow or squeeze. There were no diffuse ecchymoses,
no petechiae, no tenderness and no joint trouble. No cause could be
discovered for the condition. Tongue clean, bowels regular, temperature
normal, pulse normal in rate, beat slightly weak, tension average ;
arteries possibly rather “ old for her age.” No distinct malaise, but she
said that for two or three months she had felt a little below the mark,
and her ordinary duties had been an effort to her. She w T as ordered
calcium lactate in 10 gr. doses three times a day.
On December 30 she consulted me again ; new crops of subcutaneous
ecchymoses had appeared, some of which were more marked than the
earlier ones had been; one very dark one on the right forearm was dis¬
tinctly tender. In one instance, and one only, could she give a history of
violence producing an extravasation, namely, that while rubbing her left
hand with the towel after washing she noticed a blue spot come suddenly,
“ as if one of the veins had broken.” There were no haemorrhages from
the mucous membranes nor any extravasations in the mucous membrane
of the mouth. There were some pctechiae on the shins; the great
majority of the subcutaneous ecchymoses showed distinct foci.
On January 3, as the condition was progressive and one of the
extravasations in the right forearm was sufficient to cause distinct
swelling, the patient went to see Dr. T. H. Green. She took a specimen
of urine to him, which was found quite free from albumin and in other
respects normal. On his advice she was to rest considerably, to take
the juice of a lemon daily, and to have liquor ferri perchlor. uixv. and
Clinical Section
121
liquor arsenic, hydrochlor. wiiij. thrice daily. Calcium lactate was to be
administered in a single dose of 20 gr. each morning.
On January 4 she remained in bed, and I arranged that she should
not get up for three days. There was no change in her condition, save
that some of the subcutaneous extravasations seemed to be extending
slightly (possibly only by diffusion of the blood-pigment).
On January 5 I was called at 9 a.m. to find that she had had a
slight epistaxis, was feeling very sick, and had “ a splitting headache.”
Temperature and pulse were normal; she was sitting in bed holding her
head between her hands, and occasionally retching. Bile-stained fluid
was brought up on one occasion, but no blood. Soda-water in table¬
spoonful doses every ten minutes was prescribed, and a draught con¬
taining 20 gr. of potassium bromide was given. The calcium lactate had
not been taken that morning on account of the sickness. Shortly after
12 she got out of bed and passed a black, rather tarry, motion. She
seemed more comfortable on getting into bed, settled down as if to
sleep, and was left alone for awhile. Shortly before 1 p.m. her husband
entered the room, found her lying in the same position, but quite
unconscious and breathing heavily. He at once came for me, and I called
my partner, Dr. Grinling Bunn, to see her with me. We found her
quite unconscious, pupils reacting very faintly, if at all, to light, right
pupil distinctly contracted, left one rather dilated. Left arm motionless
and flaccid, right arm moving restlessly over face, neck and head; both
legs moving frequently—the right jerkily and spasmodically, the left in a
more natural way. There was no paralysis of the face and no strabismus.
Respirations, 27 ; pulse, GO, full; tension, 14, by Potain’s sphygmomano¬
meter. She retched a little and again brought up a little bile-stained
fluid without blood. An ice-bag was applied to the right side of the
head. During the next tw r o hours she lay with little change of condition.
A faint diffuse ecchymosis, without any focal centre, was noticed in the
circum-oral area, and this gradually increased during the remainder of
life. It was the only cutaneous or subcutaneous haemorrhage in the
head and neck. Pulse and respiration remained the same, and quite
regular, save for an occasional deep sighing inspiration. The uncon¬
sciousness deepened, however, as indicated by the gradual cessation of
movement of the right arm and the decrease in the movements of the
legs. Before the movements decreased, those in the right leg had
become more spasmodic in character. Both legs were slightly drawn up
on tickling the soles. The left arm remained flaccid till about 3.30 p.m.,
when it showed signs of rigidity, which increased thereafter. About
122
Carruthers: Fatal Purpura Iwemorrhagica
the same time the right pupil began to dilate, though at 4 o’clock
it was still rather smaller than the left. About 4 p.m. Sir Lauder
Brunton saw her and confirmed the details of the case; he found both
arms somewhat rigid, but the left distinctly more so than the right.
There had been no retching for over a couple of hours, but it showed a
slight tendency to begin again. About 4.30 p.m. I left her to order
at the chemist’s the enemata of calcium chloride and trinitrin suggested
by Sir Lauder Brunton. At 4.55 p.m. I w r as summoned back in the
greatest haste to find her dead. A relative gave a clear account
of what had happened to the following effect: The patient seemed in
absolutely the same condition till she gave a sudden gasp and changed
colour ; the relative felt her pulse, but could not detect it; in a moment
or two the pulse came back steadily, but almost immediately the patient
gave one more gasp and the pulse rapidly faded away.
Cerebral haemorrhage is a rare complication of purpura, so much so
that it is not even named in some text-books; and in one of the two cases
specially cited by Hilton Fagge the complication was not directly fatal.
The precise position of the haemorrhage in this case is perhaps not
absolutely certain, but the symptoms suggested a cortical extravasation
in the arm area, immediately becoming subdural, and extending in the
subarachnoid space over the surface of the right hemisphere. As to the
immediate cause of death, it seems to have been a medullary lesion ;
the blood may have gravitated in the subarachnoid space till it pressed
on the medulla, but the extreme suddenness of the death suggests an
independent medullary extravasation, improbable as such a coincidence
may seem.
DISCUSSION.
The President (Sir T. Barlow) said that there was a certain amount of
literature showing that, in cases of purpura with a fatal cerebral ending, there
was often a considerable blood extravasation into the subarachnoid space.
His attention had been directed to this more in connection with febrile purpuras
than any other form ; and in Sir William Jenner’s valuable statistical report on
post-mortem examinations of cases of typhus and typhoid fevers, he referred to
this point. Some years ago the President had seen a case of extensive purpura
in a patient with typhoid fever, some of the mucous membranes being affected.
The patient passed into a state of coma, lasting forty-eight hours, but subse¬
quently recovered. She died some time later in a relapse of the typhoid fever,
and there was found to be a large effusion of blood in the subarachnoid space
and similar haemorrhagic effusions into other parts, such as the mediastinum and
retroperitoneal tissue. One patient whom he had seen was dying from per-
Clinical Section
123
nicious anaemia, and transfusion was performed. In that case there were
cortical haemorrhages such as Dr. Carruthers had suggested.
Dr. J. PORTER Parkinson said that within the last eighteen months he
had seen a case of purpura haemorrhagica in which there was a large sub¬
arachnoid haemorrhage, which was the proximate cause of death. He reminded
the members of a paper read before the Royal Medical and Chirurgical Society by
Dr. Soltau Fenwick and himself in 1906, 1 in which two very severe cases of the
kind were mentioned. One patient was apparently at the point of death, and
for some days had been losing blood from the nose, mouth, stomach, and rectum,
as well as passing it with the urine. He was very much exhausted, and the
pulse was rapid. The case seemed hopeless, but 20 c.c. of polyvalent anti¬
streptococcic serum were injected per rectum. Next day the patient was better.
The dose was repeated and the patient ultimately recovered. The man was
aged 25, was suffering from phthisis, and had a cavity at the apex of one lung.
The other case was very similar, and before treatment the condition of the
patient was almost as serious. Such cases were rare, so that he had not had
many chances of repeating the treatment. But he had given the serum in
another case, which was not so severe, and that patient also had recovered.
In simple purpura he had not had such striking results. His experience of
calcium lactate and calcium chloride was much the same as the author's—fresh
haemorrhages appeared even while the drugs were being taken. No doubt the
pathology of the condition was very obscure. In his cases attempts had been
made to cultivate organisms from the blood, but without success. He had little
doubt that the disease was due to some form of toxaemia or septicaemia, and
that view was supported by the fact that, if searched for, some septic lesion
would be found preceding the condition, such as a whitlow, and purpura was
not rare in association with phthisis. Thus there was hope from the use of a
serum in certain cases. •
Dr. CARRUTHERS, in reply, pointed out that, as his case was a febrile one,
it had not occurred to him to administer a serum. He had not much hope
from treatment by calcium lactate, although in haemophilia of severe degree he
had had good results from it.
1 Transactions , lxxxix., p. 183.
124
Parkinson & Hosford: Cerebellar Tumour
Cerebellar Tumour with Proptosis.
By J. Porter Parkinson, M.D., and J. Stroud Hosford,
F.R.C.S.Ed.
The extreme rarity of proptosis occurring in cases of cerebellar
tumour, or more properly in cases of tumour in the posterior fossa of the
skull, is such that as far as I am aware there are only three cases
recorded, namely, those of Friedeburg, Van Hell, and Booth. The
following case came to the Ophthalmic Department at the London
Temperance Hospital on May 17, 1906, and was seen by Mr. Hosford
and diagnosed as a “ tumour of the cerebellum.” The patient was admitted
to the medical wards under Dr. Parkinson, w r here she remained for four
months, but as the malady appeared to be very chronic she w r as removed
to the Home for the Dying, Friedenheim, where she died suddenly the
next day.
L. V., aged 14, a tall, well-developed girl, had pains in the back of the
neck in October, 1905, which lasted on and off, the mother said, for two
or three weeks, and she had her tonsils removed. She was not sick.
There was no anaemia; patient had never menstruated. In February,
1906, she had “ rheumatic ” pains in the limbs and back, with headache
and sickness, and was attended by a private doctor, who kept her in bed
for what the mother called “ rheumatism.”
During April the patient had two convulsions and the headache
ceased, but she gradually began to “ see things in a mist,” and in the last
week of the month she “ saw things double,” and her mother noticed
that “ her eyes began to grow out.” In the first weeks of May the pains
disappeared, but the eyesight became very much worse and she constantly
complained of giddiness on sitting up. The mother brought the child to
the hospital on May 17 for “ spectacles,” but she could not w-alk or even
stand without leaning heavily on her mother’s arm. The aspect of the
face wais expressionless, her head thrown back, and the posterior neck
muscles firmly contracted. There w 7 ere no knee-jerks, nor w r as Kernig’s
or Babinski’s sign or ankle-clonus to be obtained. Sensation was
normal, memory good, and hearing, smelling, taste, and speech w r ere
natural. Patient was inclined to be emotional at times. The right
arm w^as decidedly w r eak, both in the grip of the hand and the forearm
Clinical Section
125
muscles, and of this she complained. The eyes were as follows: Great
proptosis of each eye, equal on the two sides, so that much of the sclerotic
was visible, and the eyelids correspondingly stretched. The lids and
conjunctive were otherwise natural. There was no oedema, congestion,
or chemosis, and the corneae w r ere natural. There was well-marked
paresis of the right external rectus muscle, and the centre of the cornea
could never be brought to the mesial line. The left external rectus was
weak, but not nearly so marked as the right. There was slight but
definite horizontal nystagmus, which disappeared on admission, but
reappeared the day before death. Altitudinal motions were normal.
Von Graefe’s and Stellwag’s signs were absent, but Dalrymple’s sign
(widening of the palpebral fissure) was present. The pupils were equally
dilated (8 mm.), and reacted very faintly and slowly to light. The
tension was normal and the media were clear. There was in each eye,
but more marked in the right, the most intense choked disc and neuro¬
retinitis accompanied by haemorrhages (some of which were becoming
decolorized). In the macula of the right eye there was a somewhat
stellate whitish mass of exudation. Vision was reduced to counting
fingers. Examination in the wards revealed nil abnormal in neck, chest,
or abdomen. The pulse was 98 ; bowels costive; temperature sub¬
normal ; urine normal; and there were no tremors. Treatment consisted
of mercury and iodides.
The patient continued in much the same condition until May 22,
when, in the early hours of the morning, she had three fits of a
general convulsion order, not severe, and accompanied by slight loss of
consciousness. These continued at intervals of a day or so. There was
no headache or vomiting. In some of the fits there was tonic spasm of
the right arm, forearm, and hand, and once or twice the fits started in
the right arm. They rarely lasted more than a minute. The notes then
ran as follow :—
June 7.—Still has fits daily, and vomiting occasionally of usual
cerebral type, but no headache. Asks for glasses. Passed a round
.worm.
June 11.—No fits since the last note and no more vomiting. Vision:
hand shadows. Swelling of nerve head is less, and haemorrhages are
not so evident. Pupils still widely dilated. Weakness and wasting of
right upper limb, grip on right side 10, that on left 21. Temperature
subnormal.
June 29.—Proptosis and tremors as before. No vomiting or head¬
ache ; is wasting.
126
Parkinson & Hosford: Cerebellar Tumour
July 12.—Fits daily for last five days. No warning of them. Loses
consciousness during fit and remains unconscious for about ten minutes.
Twitching begins, in some fits, at the right angle of the mouth and is
accompanied by enuresis. Patient cries on recovering consciousness;
does not know that she has had a fit; is becoming more drowsy.
August 7.—Patient getting more and more apathetic, and now passes
urine and faeces under her. She complains of pains in the right arm.
September 1.—Removed to Friedenheim. Horizontal nystagmus
again present. Died September 2 quite suddenly with asphyxial
symptoms. Temperature rose to 101*2° F. before removal from wards
of London Temperance Hospital on September 1.
Post-mortem , September 3.—Much emaciation. Proptosis not quite
so marked as before death, but still very pronounced, although the eye¬
balls could be pressed back into place. Convergence of each eye. No
sign of separation of the cerebral sutures. On opening the cranium the
meninges were natural, but there was an escape of a great quantity of
intraventricular clear fluid. The ventricles w r ere much dilated and the
cerebral cortex flattened and thinned, and the tunics of the optic nerve
sheath disturbed. The orbit was natural. Attached to the pia mater on
the under surface of the right lobe of the cerebellum was an irregular,
flattened, well circumscribed, encapsulated, very firm, pink growth about
the size of a large pigeon’s egg, and containing old blood-clot in the
centre. It pressed upon the restiform body and medulla oblongata on
the right side, dipping dowm so much into the foramen magnum that a
piece of the tumour was left behind by the pathologist during the process
of removing the brain. The whole growth appeared to have been
wedged between the bony wall and the right side of the medulla.
Microscopical examination showed the growth to be a fibro-
psammoma. There was a small post-mortem clot, in the right lateral
sinus, far back; the other organs in the body were natural.
It is of interest to compare the salient points of the only other three
cases in which exophthalmos coexisted with an intracranial growth, which
was apparently the cause of this symptom.
Booth’s 1 case occurred in a girl, aged 10, who suffered from headache
and vomiting, with giddiness and general wasting. There was papillitis,
followed by optic atrophy. The proptosis was slight, and only appeared
seventeen days before death. There w f as paresis of the left arm and
paralysis of the right sixth nerve. At the necropsy a large angio-sarcoma
Joum. of Nerv. and Ment. Dis. y 1890, xvii., p. 684.
Clinical Section
127
was found in the right lobe of the cerebellum pressing on the fourth
ventricle, pushing the medulla to the left and pressing on the right crus
of the cerebellum. There was marked hydrocephalus.
Van Hell's 1 case was in a soldier, aged 25, w T ho had suffered for a
month before being seen with weakness of gait, dimness of sight, and
occipital headache. There was slight exophthalmos, the pupils were
dilated, but reacted sluggishly. Optic neuritis was present. There was
paralysis of the right side of the face and incoordination of the legs, w T ith
increased reflexes. Fits, with forced movements from left to right,
occurred from time to time. Later there appeared ptosis on the right
side, sleepiness, slow pulse, and incoordination of the arms. At the
necropsy there was found a growth in the superior vermiform process
pressing on the left cerebellar hemisphere. Much hydrocephalus was
present.
Friedeburg 2 describes a case in a girl, aged 23, w r ho had suffered
for one and a half years from occipital headache and vomiting. She had
exophthalmos with dilated pupils and double optic neuritis. There was
a glioma the size of a chestnut attached to the under surface of the
cerebellum and involving the fourth ventricle. Extreme hydrocephalus
was present. In these three cases, as in the one recorded by us,
the exophthalmos cannot be accounted for by local causes in the orbit,
thrombosis of the cerebral sinuses, or thyroid disease, for there was no
evidence of any of them at the necropsy. Exophthalmos must be, there¬
fore, an occasional though rare symptom of a cerebral tumour. To what
condition can it be due ? The cases are too few to give an opinion upon,
but in all there was a tumour of the cerebellum extending towards the
fourth ventricle, and probably interfering with the exit of the cerebro¬
spinal fluid and producing hydrocephalus. This does not lessen the
difficulty, as tumours in this situation are not rare and are not usually
accompanied by exophthalmos, though hydrocephalus is generally
present.
DISCUSSION.
Mr. Hosford said that when the patient first came under observation the
right disc exhibited 4 mm. of swelling and the left 3 mm., so that the more
marked papillitis was on the same side as the tumour. That was six w f eeks
after the initial eye symptoms in the second week in March, when the mother
1 Neurol. Centralbl 1892, xi., p. 381.
- Bcrl. klin. Wochenschr ., 1895, xxxii., p. 719.
a —2
128
Parkinson & Hosford : Cerebellar Tumour
noticed that there was dimness of vision. The disc remained swollen until
June 10. On July 20 the swelling was reduced to 1 mm., and on August 10
the discs were nearly flat, but there was very much puckering. There was no
sign of haemorrhage nor of pigment on July 20. The eye symptoms never
completely subsided until about a week before the patient died. The proptosis,
he thought, was probably due to irritation of the sympathetic and not due to
distension of the ventricles ; he had not seen anything like it in hydrocephalus.
He suggested that the sympathetic was affected by a meningitis which probably
spread down the cord. He based this suggestion on the fact that in a syphilitic
case which he had observed, there was much pachymeningitis about the cord
and also proptosis on the right side. Dr. Paton recently, in a valuable series
of 250 cases from the Queen Square Hospital, expressed his opinion that
Parinaud’s theory, which invoked general oedema of the brain tissues as a
cause of intense choked disc, was correct. But he (Mr. Hosford) thought the
cause lay in the increased subtentorial pressure due to the binding down by
the tentorium of the cerebellum. In the recent Queen Square statistics the
papillitis was often more marked on the side of the tumour than on the other
side, but Dr. Hughlings Jackson had brought forward valuable cases in which
he showed that the optic neuritis was more marked on the side opposite to the
tumour.
The PRESIDENT remarked that it seemed to him that the question whether
hydrocephalus itself, if of extreme degree, might not be a cause of proptosis
was worthy of consideration.
Sir Dyce Duckworth said that he had long held that there were cases
of exophthalmos which had nothing to do with the thyroid body, and in such
cases he regarded the symptoms as due to a central neurosis in the medulla.
Dr. Porter Parkinson, in reply, said that the hydrocephalus was extreme,
although there was no evidence of it during life; and in all the other similar
cases there was hydrocephalus of extreme degree. At the post-mortem exam¬
ination the orbits were well explored, but there was no evidence of pressure
upon the orbital plates or frontal bone.
(Clinical Section
April 10, 1908.
Sir Thomas Barlow, Bt., K.C.Y.O., President of the Section, in the Chair.
Fatal Lymphocythaemia in Early Life.
By J. Graham Forbes, M.D., and Frederick S. Langmead, M.D.
It is only in comparatively recent years that attention has been
drawn to the existence of a blood-condition occurring among children
and adults essentially differing in its clinical course, haematology, and
morbid anatomy from other forms of blood-disease. The scope of the
present paper has reference only to such type as it occurs in early life,
and the title lymphocythaemia points to the chief distinguishing feature
of this invariably fatal condition. The disease is characterized by pro¬
gressive anaemia, associated with a tendency to haemorrhages in the form
of purpura, conjunctival or retinal haemorrhages, epistaxis, bleeding from
the gums, intestinal haemorrhage and melaena, and less commonly
haematemesis or haematuria.
There is usually, but not invariably, general enlargement of the
superficial glands, some increase in size of the spleen and liver, and
occasionally the kidneys are felt to be enlarged. The onset is somewhat
indefinite, the history denoting an increasing pallor and languor for some
weeks; and the duration, dating from the first illness observed, varies
from a week in the most acute to three or four months in the more
prolonged cases.
Examination of the blood provides the only certain means of diagnosis,
and yields a picture differing fundamentally from that presented by other
blood-diseases. The chief distinction lies in the existence of a condition
of absolute or relative lymphocythaemia, according to the total leucocyte
count. The variation in the number of leucocytes, as will be shown, is
often considerable, ranging from some hundreds of thousands, or less
my —1
130 Forbes & Langmead: Lymphocytluemia in Early Life
than 100,000, to below 10,000, with even a leucopenia; but whatever the
total leucocyte count may be, there is invariably an absolute or relative
increase in the number of lymphocytes.
Together with the lymphocythaemia there occurs a diminution in the
number of the red corpuscles to between one and two millions or lower,
and a variation in the percentage of haemoglobin yielding a colour index
above or below the normal.
The temperature is irregularly raised, but in the more prolonged
cases during temporary improvement falls to normal.
The urine frequently contains a trace of albumin, and occasionally
casts. Haematuria rarely occurs.
During the course of the illness the condition of the glands, spleen,
and liver may alter considerably, at one time increasing, at another
diminishing in size. A decrease in size is common during periods of
temporary improvement and shortly before death. Epistaxis, severe
haemorrhage from the gums and alimentary tract are not uncommon
towards the end. Coincident with the downward progress of the case
there is increasing pallor and feebleness; the red corpuscles may fall to
half a million per cubic millimetre and the leucocytes to less than 10,000.
This ante-mortem fall in the leucocytes is a common feature, but there
is still a relative excess in the number of lymphocytes.
Post-mortem examination verifies the slight enlargement of the
superficial glands observed during life, and in addition there is usually
found an increase in size of, and haemorrhages into, the mesenteric and
retroperitoneal glands. The heart is dilated and scattered with haemor¬
rhages on the epicardial and endocardial surfaces. Subpleural and
pulmonary haemorrhages may also be present. The liver and spleen
show some enlargement, the former being extremely pale. The kidneys
are, as a rule, greatly enlarged and occasionally weigh three or four times
the normal. They show a very pale surface extensively mottled with
haemorrhage, which may involve the whole cortex and destroy the
definition between cortex and medulla; the extreme yellow pallor of the
pyramids forms a strong contrast. The stomach and intestines show no
ulceration, but frequently contain blood and display a few submucous
haemorrhages. Peyer’s patches are invariably much swollen. The bones
show no changes. The marrow is seldom increased in amount, and its
colour varies from dark to pale red. Extensive haemorrhages may be
found underlying the dura mater.
Microscopical examination shows considerable hyperplasia of lympho¬
cytes in the adenoid tissues and bone marrow, and lymphocytic invasions
Clinical Section
131
of the spleen pulp, the portal canals of the liver, and the interstitial
tissues of the heart, pancreas and testicle, and to an extreme degree in
the kidneys.
In the literature of the past ten years is to be found an increasing
number of cases which fall into the same group as those on which this
paper is based. Eose Bradford and Batty Shaw [10], in 1898, described
five cases of acute lymphocythsemia, including four adults. The fifth
case was that of a boy aged 7, who died after an illness of seven weeks.
The features of the case were, briefly, purpura, swollen gums, enlarged
cervical glands and spleen, and melsena. Temperature 104° F. to 105° F.
Urine contained a trace of albumin.
Haemoglobin ...
Red blood-corpuscles ...
White blood-corpuscles
Small lymphocytes
Large lymphocytes
Blood-Examination.
= 26 to 36 per cent.
= 1,500,000 per cubic millimetre.
... = 34,000 to 68,000 per cubic millimetre.
= 12*2 per cent.
- 61-8
In 1904 Frederick Taylor [11] recorded the case of a boy aged 10,
whose illness covered a period of three months. Two blood-examina¬
tions made three or four weeks before death, at intervals of ten days,
gave the following results :—
Red blood-corpuscles
White blood-corpuscles ...
Small lymphocytes
Large lymphocytes
5,600,000 to 4,400,000 per cubic millimetre.
15,000 to 50,000
46*6 per cent, to 94 per cent.
93 „ 3 ,.
Post mortem there were found enlargement of the parotid, lachrymal
and submaxillary glands, marked increase in size of the thymus (weight
= 386 grm.), also of the liver (weight — 2,300 grin.), spleen (508 grin.),
and kidneys (1,100grm.).
Microscopically the kidney showed extreme lymphocytic and haemor¬
rhagic invasion ; the heart, spleen, liver, suprarenal, and thymus glands
w T ere all the seat of infiltration by lymphocytes. A rabbit inoculated
with the heart’s blood died in one month of pneumococcal septicaemia.
On account of the large size of the thymus in this case and its
persistence in those recorded by Bradford and Batty Shaw, the author
suggested the possibility of this organ being the primary seat of disease.
Hutchison [7], in his Goulstonian lectures (1904), under the head of
lymphatic leukaemia in childhood, alludes to the scanty attention devoted
132 Forbes & Langmead: Lymphocytlwemia in Early Life
to the condition until recent years, and quotes cases collected by various
authors up to that date. Thus McCrae described one in 1900, and gave
references to thirteen others under the age of 10. Gilbert and Weil,
among sixty recorded up to 1899, found five between 1 and 10, and
seventeen between 11 and 20. Guinon and Jolly, in 1899, described the
disease as represented by three types :—
(1) Profound anaemia with general glandular enlargement and haemor¬
rhagic tendency in the later stages.
(2) Haemorrhagic tendency from the onset, resembling infective
purpura.
(3) Pseudo-scorbutic cases in which lesions of the buccal cavity were
the chief feature.
Although the frequency of lymphatic leukaemia in childhood could
not be satisfactorily explained, Hutchison associates it with the greater
activity of the adenoid tissues in early life and their liability to patho¬
logical changes. He argues that the frequency of infection, particularly
through the throat, in childhood may explain the possible infective origin
of the disease. A reference is also made to the view that the condition
may be due to an overgrowth of the original mother cells, the supposed
progenitors of lymphocytes and myelocytes, constituting a return to the
foetal stage previous to the appearance of myelocytes. He recognizes
the difficulty of assigning a limit to acute cases, which may vary from
five to ten weeks in duration, and states that in the acute cases the large
lymphocyte, and in the chronic the small lymphocyte, tends to pre¬
dominate.
Cabot [2] observed a marked ante-mortem fall in lymphocytes in a
septicaemic case, and quoted other cases in which this fall occurred as the
result of intercurrent disease. McCrae [8], in 1905, out of a total of
17,100 admissions at the Johns Hopkins Hospital, collected thirty-seven
cases of leukaemia, of which five were acute, and of these one only was
in a child aged 3.
He summarizes the blood-counts of forty-five cases, including these
five, as follows: average colour index - 0*94; in eighteen cases, over 1 ;
in twenty, under 1; and in six, approximately 1. Ked blood-corpuscles,
over 2,500,000 in nine cases; between 1,500,000 and 2,500,000 in
thirteen; between 1,000,000 and 1,500,000 in twelve; and below
1,000,000 in ten. He considers that Neumann’s contention that the
marrow is primarily involved is supported by recent work, and that the
severe anaemia of these cases points to such an origin.
Donnan [4] (1905) attributes the absence of palpable glands and the
Clinical Section
133
moderate splenic enlargement to the rapid course of the disease, Which
allows no time for the glands to react, and suggests that the marrow is
the primary seat of disease.
Whipham and Leathern [13], in 1906, described two cases in girls aged
2J and 8. Duration, three months and one month respectively. Clinical
condition: Anaemia, purpura, slight glandular enlargement, definite
enlargement of spleen and liver. Leucocyte count, in one, 25,000, falling
to 8,300; in the other, 20,000. In each case the large lymphocytes were
in excess, and post mortem marked lymphocytic invasion of the various
organs was found.
In referring to other cases they divide the various forms met with as
follows:—
Acute.
Glands generally enlarged
(common type)
Glands not affected
(rare)
With extreme leucocytosis
(common)
Large lymphocyte Small lymphocyte
predominating predominating
(common) (rare)
Moderate leucocytosis
(rare)
!
Predominating cell the
large lymphocyte
More recent work on the subject is by Emerson [5], who published
an account in the Johns Hopkins Bulletin, 1907. He classifies the
disease under the following types without particular reference to age
incidence :—
Form 1: Type like chronic leukaemia, but more acute.
Form 2 : Acute infectious type, simulating acute streptococcal septi¬
caemia in all but the absence of streptococci.
He quotes Rose Bradford, Barlow and Osier as holding the view that
the blood-changes which occur are merely evidence of reaction. He also
gives three cases reported by Holst, in which streptococci were obtained
on cultivation—in one, from knee-joint, glands and blood ; and in another
from the bone marrow only. Therefore it is argued that this case was
due to primary streptococcic infection of the bone marrow. Leucocyte
counts are given of two of the cases: (1) 8,300 per cubic millimetre,
77 per cent, large lymphocytes and 14 per cent, small lymphocytes;
(2) 8,400 per cubic millimeter, 93 per cent, large mononuclears.
Form 3 : Haemorrhagic type ; under this heading is placed Shattock's
case of infective purpura and cases characterized by general haemorrhages,
134 Forbes & Langmead: Lymphocythaemia in Early Life
haematomata or cerebral haemorrhages, usually fulminant, and associated
with extreme anaemia.
Form 4 : Acute cachectic type, marked by languor, loss of flesh,
dyspnoea and prostration, but few petechiae, intense pallor and slight
jaundice.
Emerson also refers to pseudo-scorbutic and pharyngeal forms, the
latter starting as gangrenous ulceration of the throat, and states that
others are associated with diarrhoea and vomiting, or with acute nephritis
at the onset. He describes a case and quotes others showing the con¬
siderable variation and the frequent ante-mortem fall in the numbers of
leucocytes.
CASES?
We have collected twelve cases illustrating fatal lymphocythaemia in
early life. Eleven of these cases were admitted to the Hospital for Sick
Children, Great Ormond Street, and one to the Paddington. Green
Children’s Hospital. Nine have occurred in the last three to four years
out of an approximate total of 1,200 post-mortem examinations, consti¬
tuting 0*75 per cent., and have been under the observation and examination
of one or both of us.
Case I.
W. J., aged 24, was admitted to the Hospital for Sick Children on
April 12, 1894, under the care of Sir Thomas Barlow, with a history of
two to three weeks illness following an attack of bronchitis. On admis¬
sion, the boy was described as well nourished and of fair complexion ;
his face was pale and the respiration hurried. The throat showed septic
tonsillitis. Temperature, 99° F. ; pulse, 120; respiration, 70. Ophthal¬
moscopic examination showed retinal haemorrhages in the left eye. The
glands in the neck, axillae, and groins w r ere slightly enlarged. On
examination of the thorax the area of cardiac dulness extended above the
lower border of the second left costal cartilage and to the mid-line of
the sternum. The apex beat coincided with the nipple, and the heart
sounds were normal. There was impairment over the front of the upper
lobe of the left lung, and scattered rales were heard over both lungs
behind. The abdomen was distended, the spleen was enlarged, reaching
to the level of the umbilicus, and the liver was much increased in size.
Blood-examination (tabulated later) showed a high degree of lympho-
cythoemia. During the subsequent course of the case the patient became
steadily worse ; haemorrhages occurred from the gums; blood frequently
appeared in the stools, and there was occasional epistaxis. The urine
Clinical Section
135
contained urates and uric acid crystals and casts, but there was no
mention of the presence of albumin. The glands in the neck increased
in size and the patient died on June 4, ten weeks after the first onset
of illness.
Blood-Examinations.
April 18
May 3
May 23
May 31
Haemoglobin ...
35 per cent.
—
33 per cent.
35 per cent.
Colour index ...
0*58
—
0*58
0-87
Red corpuscles per
millimetre...
cublc | 3,000,000
3,000,000
2,800,000
2,000,000
Leucocytes
1,000,000
272,000
622,000
500,000
Differential Count (April 18).
Polymorphonuclears
1*5 per cent. =
15,000 per cubic millimetre.
Large mononuclears
0-8
»» ~
8,000 „
» »
Small lymphocytes
... 560
»»
560,000
1»
Large lymphocytes
... 41*7
417,000
i *
Nucleated Red Cells.
Four normoblasts seen in counting 1,100 white blood-corpuscles.
Post-mortem Examination .—Body wasted. Brain normal in appear¬
ance. Blood pale and milky-looking. Lymphatic glands in the cervical
region, mesentery and retroperitonenm were enlarged, pale and gelatinous
on section; but those in the mediastinum and at the roots of the lungs
were not enlarged. There were several necrotic areas in the cervical
glands. The heart was normal; the lungs were oedematous at the bases
and there were ecchymoses over the parietal pleurae. The gastric mucosa
was blood-stained, and the intestines showed prominent Peyer’s patches
and submucous haemorrhages below the ileo-caecal valve. The liver was
firm and paler than normal, weighing 27J oz. The spleen weighed
10 oz., its capsule was thickened and adherent to the anterior abdominal
.wall, the splenic substance was tougher than normal, and there appeared
to be an increase in the fibrous tissue. The kidneys were much enlarged,
very pale and firm in structure. In parts the cortex could not be dis¬
tinguished from the medulla and there were haemorrhages in the
pyramidal portions; the capsules stripped off easily. The ureters, bladder
and testicles were normal. The marrow was dark coloured and normal
in appearance.
Microscopical Appearances of A ffected Organs .—Kidney : The cortex
and medulla were equally crowded with an invasion of lymphocytes, in
the mass of which the greater number of tubules and glomeruli were
136 Forbes & Langmead : Lymphocytluemia in Early Life
obscured or appeared as islands scattered here and there. In addition to
this lymphocytic invasion several haemorrhages were seen in the medulla.
Liver : The connective tissue about the portal canals was crowded with
lymphocytes, which were to be found everywhere filling the intralobular
capillaries. Spleen: The capsule was slightly thickened, and under it
appeared a zone of congestion ; the rest of the splenic tissue was thickly
filled with lymphocytes, which prevented the Malpighian bodies from
being defined. Thymus : Congested and densely packed with lympho¬
cytes, but there was no marked increase in the amount of fibrous tissue.
Case II.
Eleanor M. H., aged 3 years and 2 months, admitted to the
Hospital for Sick Children on July 3,1896, under the care of Sir Thomas
Barlow, with a history of only a few days illness marked by palpitation
of the heart, shortness of breath, languor and headache. She had been a
weakly child from birth, had measles at 18 months and afterwards
whooping-cough, and she had recently been getting thin. Her mother
had had eleven children (four of whom died of consumption), and there
had been two miscarriages. On admission the child was thin and very
anaemic; there were purpuric spots all over the body. The lymphatic
glands in the neck, axillae and groins were slightly enlarged, but there was
more marked enlargement of the thoracico-parietal glands in the middle
of the right axilla. Examination of the chest showed that the cardiac
dulness extended on the left to one finger’s breadth outside the nipple
line, upwards to the third intercostal space, and to the right margin of
the sternum. The apex beat was felt just outside the left nipple line
and a systolic bruit was audible at the apex. Nothing abnormal was
found in the lungs. The edge of the liver could be felt two fingers’
breadth below the right costal margin. The spleen was very hard and
enlarged, reaching to the level of the umbilicus in the left nipple line.
In addition, tumours could be felt in each lumbar region occupying the
position of the kidneys, and hard enlarged glands w^ere palpable in the left
iliac fossa. The urine, on admission, contained no albumin; specific
gravity 1015, acid. Only an imperfect examination of the blood is
recorded. Haemoglobin ~ 38 per cent. Proportion of white to red
corpuscles 1 to 31. During the subsequent course of the case
the patient became steadily worse and more anaemic. For the first
fortnight the temperature was irregularly raised (99° F. to 101° F.,
102° F., and 103° F.), and later it became lower with occasional pyrexial
Clinical Section
137
rises. The liver and midaxillary glands increased in size, and the spleen
remained much the same and felt very hard and irregular ; the mass felt
in the left lumbar region became larger. Blood was observed in the
faeces on July 25 ; the urine frequently contained albumin in traces and
sometimes in greater quantity. During the last ten days of life the
temperature fell to 98° F. and 99° F., and was occasionally subnormal.
On August 3 vomiting and oedema of the feet and hands started, and
death occurred four days later, after an illness of five to six weeks
duration.
Post-mortem Examination .—Lymphatic glands : Cervical slightly
enlarged and pale; mediastinal enlarged and of a crpamy colour, dotted
with small haemorrhagic areas; mesenteric normal and pale; retro¬
peritoneal somewhat enlarged and very pale, with dark haemorrhagic
areas—they extended in a continuous chain along either side of the
vertebral column and along the iliac vessels to the inguinal region.
Lungs : Bound down by a few adhesions, crepitant throughout, and
scattered with small haemorrhages in the substance and under the pleura.
Heart: Right side dilated; its surface was mottled all over with small
subpericardial haemorrhages, the valves were healthy, and there were a
few endocardial haemorrhages in the right and left auricles. Kidneys:
Both much enlarged and lobulated, the left weighing 1\ oz. and the
right 6£ oz., very pale and whitish yellow in colour, scattered with
haemorrhagic purple areas on the surface. On section the cortex and
pyramids could be easily defined, and were of a pale creamy colour in
contrast to the haemorrhagic areas, which varied in size from a pin's head
to a threepenny piece. The capsules stripped easily. The pelves and
ureters were normal.
Microscopically the kidneys showed an extreme infiltration with
lymphocytes, which widely separated the tubules. The glomeruli
were enclosed by large areas of dense small-celled infiltration, which
did not extend under the capsules. The tubules and glomeruli in
themselves appeared unaltered. The liver was enlarged, very pale and
translucent on section, and scattered with opaque yellowish spots, but no
haemorrhages. The glands of the hilum were increased in size and
dotted with haemorrhagic areas. Microscopically the organ showed fatty
infiltration of the cells, more particularly at the periphery than in the
centre of the lobules. There were well-marked collections of lympho¬
cytes in the interlobular spaces spreading into the lobules between the
cells. The spleen was much enlarged and firm, weighing 7 oz., pale pink
in colour and contained no masses. Microscopically it showed a general
138 Forbes & Langmead: Lymphocytlwemia in Early Life
infiltration with lymphocytes, the capsule was slightly thickened, but
there was no obvious thickening of the trabeculae. The stomach was
normal, but the small intestines contained blood-stained faeces and
submucous haemorrhages. The pancreas and suprarenals appeared
normal.
Case III.
Dorothy B., aged 10 years and 11 months, was admitted to the
Hospital for Sick Children on June 16, 1899, under the care of Dr.
Penrose. Though ailing for some months with occasional epistaxis, she
had not been definitely ill until one month previous to admission; during
this time she complained of pain in the lower limbs. For two weeks
the gums had been swollen and bleeding, and within the last few days a
purpuric eruption had been observed. With reference to family ante¬
cedents, there was a doubtful history of syphilis in the father, and the
mother had three miscarriages previous to the patient’s birth. On
admission the child’s face was of a yellowish muddy pallor. Temperature
98° F. to 100° F ; pulse, 128 ; respiration, 18. Purpuric spots were
scattered over the trunk and limbs, there were haemorrhages from and
into the gums. Ophthalmoscopic examination of the eyes showed retinal
haemorrhages. There were no enlarged glands, nor could anything
abnormal be discovered on physical examination of the thorax. In the
abdomen the edge of the enlarged liver could be felt reaching to the
level of the umbilicus; the spleen could be felt, but was not much
enlarged. Urine, specific gravity 1020, and contained no albumin. On
the three days following admission bleeding occurred from the gums, and
there was both epistaxis, which was difficult to control, and melaena.
The temperature varied between 99° F. and 103° F. Death occurred on
the fourth day, after an illness of altogether four to five weeks duration.
Post-mortem examination revealed no enlargement of the lymphatic
glands, with the exception of one in the portal fissure of the liver. The
lungs showed nothing abnormal beyond a few subpleural haemorrhages.
In the heart haemorrhages were present on the visceral surface of the
pericardium, under the endocardium, also in the substance of the cardiac
muscle, which was elsewhere pale. On the inner wall of the aorta
occurred several opaque yellow patches. The right ventricle was dilated
and flabby. The stomach showed several small haemorrhages into the
mucous membrane. The liver was enlarged and weighed 44 oz. On
section it was of a tawny yellow colour, mottled throughout with white
patches, due probably to collections of lymphocytes. The spleen was
Clinical Section
139
softer than normal, somewhat enlarged, and weighed 5£ oz. The Mal¬
pighian corpuscles were not conspicuous. The kidneys were both enlarged,
weighing 4£ oz. and 4J oz. respectively. Their surface was pale, with
numerous projecting red bosses. On section the substance was very
pale, scattered with many round haemorrhages enclosed by white areas
measuring 1 mm. to 3 mm. in diameter. The definition between cortex
and pyramids was lost. The suprarenals and pancreas were normal.
Section of the sternum showed that the cancellous tissue was very red.
Although there is no record of the blood-condition obtainable in this case,
yet its clinical features and the appearances of the organs revealed by post¬
mortem examination .justify its inclusion in the group of cases reported
in this paper.
Case IV.
This case was that of a girl, D.R., aged 4, who was admitted into
the Hospital for Sick Children, under the care of Dr. Lees, on July 19,
1904. She was said to have got thinner and paler for five months,
during which time she had been sometimes in bed and sometimes run¬
ning about, but never quite well. Two months before admission she
had had a bout of diarrhoea and vomiting, passing blood and slime
by the bowel, and vomiting blood for about fourteen days. Since then
the pallor had been accentuated. She had had no previous illnesses of
importance, and there was nothing relevant in the family history.
On admission she was seen to be extremely anaemic and showed
evident signs of recent wasting. The temperature was 102° F., the
pulse-rate 148, and the respirations 48. By the ophthalmoscope old
punctate haemorrhages could be seen in the retinae, especially in the
right. The tonsils were not enlarged. The glands of the neck, groins
and axillae were moderately enlarged. Examination of the chest revealed
dilatation of both sides of the heart, and a loud systolic bruit could be
heard at all areas. The abdomen was distended in its upper zone, and
the liver edge was felt about two fingers’ breadth below the costal
margin, whilst the spleen was easily palpable. There was neither
blood nor albumin in the urine, and now no blood in the motions.
For the first month after admission she steadily improved, while
taking 10 gr. of dialyzed iron three times a day. The heart regained its
normal size, whilst the liver and spleen both receded, the former extend¬
ing to one finger’s breadth beneath the costal margin, the latter being
barely palpable. Her colour improved and her appetite and general con¬
dition were certainly better. The temperature, however, although it
140 Forbes & Langmead: Lymphocythaemia in Early Life
reached normal during the first week, remained irregular, and there
were occasional rises to 103° F. From this time onwards she again
began to go down-hill, and by August 30 the spleen reached nearly to
the umbilicus, and the glands were also very much larger. On Sep¬
tember 1 the uniformly enlarged spleen is noted as having reached the
umbilicus, and the liver was three fingers’ breadth below the costal
margin. The lymphatic glands were still larger, and formed definite
masses in the axillae, groins, anterior and pesterior cervical triangles on
both sides, the occipital region and left inguinal region. Examination
of the chest revealed dulness behind the manubrium and in the inter¬
scapular regions, which was also attributed to glands. There were
dilatation of the superficial veins and oedema of the face, chiefly on
the left side.
Two minims of liquor arsenicalis were now 7 added to the dialyzed
iron, and from this time onwards the spleen, liver and glands diminished
in size, although the child’s condition was evidently rapidly getting
w r orse, and she died with far smaller palpable lymphatic structures than
she had had previously. The temperature chart showed a gradual irre¬
gular ascent, reaching 104° F. on September 10. It remained there until
September 15, when it fell to 96° F. just before death. No haemorrhages
occurred whilst she was under observation.
Colour index
Hsemoglobin
Red corpuscles
August 1
0*7
38 per cent.
2,584,000
Blood-Examinations.
August 11 August 20
45 per cent. —
3,700,000 2,284,000
September 14
0-78
22 per cent.
1,424,000 per cubic millimetre
Leucocytes
5,000
40,000 61,000
14,000
»» »»
Polymorphonuclears
Differential Count.
Percent. Perc.mm. Percent. Per c. min. Percent. Per c.mni.
30-0=1,500 31-5=12,600 0*4= 244
Percent. Perc.mm.
2 0= 280
Large mononuclears
4*0= 200
60= 2,400
—
1-6= 224
Small lymphocytes
44-0 = 2,200
450= 18,000
50-6 = 30,866
69-2 = 9,760
Large lymphocytes
22-0=1,100
16*5= 6,600
49*0 = 20,890
28-0 = 3,970
Eosinophiles
--
1-0= 400
—
—
Myelocytes
—
— ■
—
o
ll
c*
a
5,000
40,000
61,000
14,000
Red corpuscles show defective staining and a tendency to chromatophilic changes.
Post Mortem .—To the naked eye the kidneys showed the most
obvious pathological change. They were both greatly enlarged, the
right weighing 5 oz., 7 dr., the left 7 oz. 1 dr. The renal structure
Clinical Section
141
was blurred, so that the contrast between the cortex and medulla was ill
defined. The greater part of the kidney was pale in colour, the apices
of the pyramids being almost white, but in the cortex were numerous
bright red haemorrhagic areas, which gave a curious mottled appearance.
The capsule stripped readily, and beneath it on the surface of the cortex
large irregular patches of haemorrhage alternated with pale-coloured
areas. The glomeruli were deeply congested, and stood out as red spots,
from which in some places haemorrhage had spread into the surrounding
cortex. Grey irregular lymphoid patches could be detected about the
pyramidal bases. The liver was slightly enlarged and was firm ; it cut
toughly on section. There was no visible change. The spleen was
moderately enlarged and firm, but otherwise was not obviously abnormal.
There was general enlargement of lymphatic glands up to the size of an
acorn, those in the thorax and abdomen and behind the peritoneum
participating. They were fleshy and deep red in colour, but showed no
other macroscopic change. The bone marrow was normal in amount and
consistency and bright red in colour. There was no oral sepsis, nor
was there any lesion in the alimentary tract which could have been the
source of the blood in the vomit and motions.
Pathological Report .—Cultivations taken at the time of the autopsy
from the heart’s blood and spleen yielded pure growths of a short,
chained streptococcus. A film taken from the femoral marrow showed
the cells to be composed almost exclusively of small and large lympho¬
cytes with comparatively but few polymorphonuclears, eosinophiles and
nucleated red cells; a few short streptoccocci were also seen. Cervical
glands on microscopical examination showed the medullary portion to be
much engorged. The cortex was crowded with lymphocytes, which also
invaded the capsule and surrounding connective tissue, so that the whole
gland was divided into haemorrhagic and lymphocytic areas. The spleen
was much engorged and scattered with irregular collections of cells,
chiefly composed of small and large lymphocytes which obscured the
definition of the Malphigian bodies. In the kidney the interstitial tissue
was literally crammed with lymphocytes, particularly that of the cortex,
where remnants of tubules and glomeruli appeared as irregularly
scattered islands. In addition there were large areas of haemorrhages
which with the lymphocytic infiltration gave the red and white mottling
visible to the naked eye. The cortical tubules contained masses of cell
debris and cell casts, and the glomeruli, though completely surrounded
by lymphocytes, showed no cell invasion penetrating the capsules. The
liver was scattered with small lymphocytic foci, particularly about the
142 Forbes & Langmead : Lympliocytheemia in Early Life
portal canals. The hepatic cells showed a considerable amount of fatty
infiltration; the capillaries beneath the surface were congested, and pre¬
sented but little or no invasion by lymphocytes.
Case V.
This case was that of a male, A.H., aged 1£, who was admitted
on November 6, 1904, under the care of Dr. Lees. The mother said
that he had always been pale, but had become much more so for the
few weeks preceding admission. Eight days before he had developed a
purpuric rash, and four days later epistaxis. There was no family
history of haemophilia. When examined he was found to be a pale but
fairly well nourished child, with some puffiness of the face and eyes, but
no general oedema. The skin, especially that of the lower extremities,
was stippled by a purpuric eruption, some spots of which were bright
red, others fading. There were also a few large ecchymoses. When
the mouth was opened a swelling could be seen on the inner side of each
cheek, evidently produced by haemorrhage beneath the buccal mucosa.
The tonsils were moderately enlarged and there was general slight
enlargement of the lymphatic glands.
The spleen reached to two fingers’ breadth beneath the costal
margin, the liver to one and a half fingers’ breadth. There was a
trace of albumin but no blood in the urine.
The blood-count on this occasion was as follows : haemoglobin, 32
per cent. ; red corpuscles, 2,554,000 ; white corpuscles, 3,000 per cubic
millimetre.
He was considered to be suffering from secondary anaemia, for which
iron was given. By November 22, i.e., fourteen days after admission,
his colour had so much improved and his general condition was so much
better that he was to have been discharged, but from this time he began to
get worse. On December 1 he was distinctly more anaemic, and a blood-
examination showed : haemoglobin, 20 per cent., red corpuscles, 1,839,000;
white corpuscles, 20,000, to which the lymphocytes contributed 77 per
cent. On December 8 the pallor was more obvious; fresh purpura
occurred, and there was some melama. The spleen now reached to the
level of the umbilicus. The glands were larger, and the liver edge was
three fingers’ breadth below the right costal margin. A blood-examina¬
tion gave: haemoglobin, 15 per cent.; red corpuscles, 1,106,000 ;
white corpuscles, 83,000, of which 91 per cent, now were lymphocytes.
The next day he died. The temperature was irregular, varying from
Clinical Section
143
100° F. to 98° F., and occasionally rising abruptly to 103° F. or to
104° F.
Blood-Examinations.
Colour index
Haemoglobin
Red corpuscles ...
Leucocytes
November 8
068
32 per cent.
2,554,000
3,000
December 1 December 8
0*54 ... 0*68
20 per cent. ... 15 per cent.
1,839,000 ... 1,106,000
20,000 ... 83,000
per cubic millimetre
ii i»
Differential Count.
Polymorphonuclears
Large mononuclears
Large lymphocytes
Small lymphocytes
Eosinophiles ...
Basophiles
Percent. Per c. min.
20*4 = 4,080
1*6 = 320
16*4 = 3,280
60*6 = 12,120
1-0 = 200
Per cent. Per c.inra.
4*8 = 3,984
4*0 = 3,420
8-8 = 7,240
82*1 = 68,143
0*2 = 166
0*1 = 83
20,000
83,000
There were no marked changes in the red corpuscles. No myelocytes were seen.
Post Mortem .—The kidneys, liver and a mesenteric gland were the
only organs which it was possible to examine. The kidneys were en¬
larged, weighing If oz. each. They were pale and mottled with
haemorrhages, especially in the cortices, and closely resembled those
in the case just described, but to the naked eye were less grossly
affected. The liver was large and showed small grey areas, but differed
little from the normal. The mesenteric gland was enlarged, red and
fleshy.
Pathological Report .—Owing to the restricted nature of the autopsy
no direct examination for cultural purposes was possible. Some blood
was obtained from the right side of the heart by puncture through the
skin, but a contaminating growth resulted on cultivation. Microscopical
examination of the kidney showed that the interstitial tissue was invaded
by closely packed collections of lymphocytes, separating off tubules and
glomeruli, not, however, to the same extent as in the previous case (D. R.).
In the pyramidal portion this cell invasion was more noticeable in the
neighbourhood of the blood-vessels, which were closely invested by a
sheath of lymphocytes, and also along the walls of the calices of the
pelvis; one arteriole was seen to be plugged by a lymphocytic mass. The
kidney substance was much congested and dotted with small interstitial
haemorrhages. Many of the cortical tubules were plugged with debris and
necrotic cells. The liver was scattered with large collections of lympho¬
cytes, which occurred chiefly about the portal canals, forming irregular
144 Forbes & Langmead: Lymphocytluemia in Early Life
masses of cells in the surrounding tissues, and also widely distributed
under Glisson’s capsule. The hepatic cells showed slight fatty infiltration.
The mesenteric gland was much congested and stuffed with lymphocytes,
especially in the cortical portion, where the follicular arrangement was
lost. The strands of connective tissue were also invaded by lymphocytes.
Case YI.
This case was that of a boy, H. S., aged 3, who was admitted into
the hospital on January 29, 1906, under the care of Dr. Voelcker. The
history given by the mother was that for eight weeks he had suffered
from “ a severe cold, and had been treated by the doctor for mumps.”
She had noticed that he had been getting increasingly paler, but had
herself noticed no glandular swelling. He was an extremely pale,
restless and irritable child. The lips were excoriated and bleeding, and
subcutaneous haemorrhages had occurred both around each ear and also
superficial to the cartilage of each pinna. There were definite bruises
about the ankles and a few purpuric spots scattered all over the body.
The lymphatic glands in the cervical triangles were enlarged to the size
of an acorn, whilst the axillary and inguinal glands were also en¬
larged, but to a less extent, and all were freely movable. The
epitrochlear glands were distinctly enlarged, and from them a chain
of glands could be traced upwards along the course of the brachial
arteries. The tonsils were considerably enlarged. No large buccal
haemorrhages were seen, but a few petechiae were present on the palate
and inside the cheeks. The spleen reached about two fingers’ breadth
below the costal margin ; the liver could just be felt. The urine contained
a trace of albumin but no blood. On the next day retinal haemorrhages
were seen in each eye. The patient became more restless and died about
forty-eight hours after admission.
Haemoglobin
Blood-Examination.
... 32 per cent.
Colour index
... 1-1
Red corpuscles ...
... 1,340,000 per cubic millimetre.
Leucocytes
. 14,000 „
Polymorphonuclears
Differential Count of 800 Leucocytes.
1*7 per cent. = 238 per cubic millimetre.
Large mononuclears
1*7 „ = 238
Small lymphocytes
94-0 „ = 13,100
Large lymphocytes
2-2 „ = 308
Eosinophiles
04 ,, - 56
14,000
Clinical Section
145
Post-mortem Examination .—The dura mater showed large areas of
haemorrhagic mottling. The cerebellum was thickly studded with small
petechiae. Both retinae were splashed with bright haemorrhages, chiefly
about the maculae and discs. The tonsils w r ere about the size of shelled
walnuts, were pulpy, and showed a few petechiae. The thymus was
large and in places densely fibrotic, whilst here and there in the fibrous
areas were patches of caseous material. In the less dense portions of the
gland foci of haemorrhage were seen. A slight haemorrhagic effusion had
taken place into each pleura, but there was no pleurisy. There were
many petechiae on the surface of the lungs and pericardium. The heart
was mottled, especially on the anterior surfaces of the ventricles, by
bright red haemorrhages, covering large areas. The spleen was large and
maroon-coloured, measuring about 6 in. by 4 in. It was soft and juicy,
but not diffluent, and no structural change w r as detected. The liver was
slightly enlarged but normal in appearance. The kidneys were slightly
enlarged and pale grey in colour, the apices of the pyramids being par¬
ticularly white. The cortex and medulla were poorly defined. In the
former were several haemorrhagic areas giving a bright red mottling to
the otherwise grey substance ; a few, however, were brownish green,
probably from changes in the effused blood.
A few petechiae were found in the stomach and peritoneum. Lym¬
phatic glands on each side of the neck, a small bunch in each axilla, and
a few retroperitoneal glands were found to be enlarged; the inguinal
glands also were just palpable. The largest, which were found in the
neck, did not exceed a shelled almond in size. All were discrete, soft and
fleshy. The retroperitoneal chain were dark red in colour. The marrow
in the femora was bright red and like red-currant jelly in appearance,
and did not appear to be increased in amount.
Bacteriological examination of the heart’s blood, spleen and marrow
at the time of the autopsy yielded pure cultures of a short streptococcus.
Fermentation tests applied to the streptococcal growth yielded the
following results: Saccharose, lactose, salicin, andraffinosewere fermented;
but mannite, coniferin and inulin were unchanged. Litmus milk became
acidified and clotted. A guinea-pig was inoculated with an emulsion of
the growth and died sixteen days after with a large abscess at the site of
inoculation. On cultivation of its heart’s blood a streptococcus was
obtained which behaved in the same manner to the fermentation tests as
the original growth.
Microscopical Appearances of the various Organs .—Lymphatic
glands : Cervical, axillary and retroperitoneal glands, particularly the
my —2
146 Forbes & Langmead : Lymphocythaemia in Early Life
last, showed marked increase in the number of lymphocytes, together
with the presence of young germinal, cells, and also considerable con¬
gestion. Tonsil was congested and the areas of lymphoid tissue were
increased. Thymus showed extensive areas of haemorrhage, and in
several parts well-marked lymphocytic invasion ; in the centre occurred a
large necrotic area. Thyroid was scattered with a few foci of lympho¬
cytes in the interstitial tissue. Heart: The muscle fibre showed no
interstitial cell infiltration, but here and there occurred definite areas of
haemorrhage. Liver: Collections of lymphocytes were to be seen sur¬
rounding the portal canal areas, but there was little general cell invasion.
The hepatic cells showed early fatty changes. Spleen: Much con¬
gested ; the Malpighian bodies were increased in size and ill-defined on
account of the accumulation of lymphoid cells around them. Kidney
showed large areas of the lymphocytic invasion, particularly in the
pyramidal portion, which was invaded to a greater extent than the
cortex. The glomeruli and cortical blood-vessels were much engorged,
and in places interstitial haemorrhages had occurred. In many parts the
cells of the cortical tubules were degenerated and their lumina plugged
with cell debris. In the small intestine Peyer’s patch showed thickening
due to an increase in the formation of lymphocytes.
Case VII.
Richard J., aged 1J, was admitted to the Hospital for Sick Children
on February 16, 1906, under the care of Dr. Garrod, with a history of
illness dating from the early part of January, 1906. He was said to
have been feverish and to have vomited after his feeds of milk. There
had been diarrhoea with green and offensive motions, which occasionally
were reported to have contained blood. After a period of three weeks
he had seemed better, but for a few days previous to his admission
he became ill again, refused his food, and the motions again became
offensive.
Up to the beginning of his illness the child had been breast fed,
and subsequently fed on cow’s milk. He had whooping-cough when
aged 4 months. There was a family history of phthisis, both the
maternal grandparents having died of it. He was the youngest of six,
the rest of whom were healthy. On admission the patient appeared
languid and ill; he was thin and very anaemic, the skin being of a
lemon yellow tint and waxy-looking. The mucous membranes were
very pale, and the body and limbs were scattered over with purpuric
Clinical Section
147
spots. Temperature 100*5° F., respiration 48, pulse 156, soft and regular.
There was slight general enlargement of the glands in the neck
(especially the tonsillar gland), axillae and groins, and also of the epitroch-
lear gland. They were all hard, discrete and freely movable. Scattered
bronchitic sounds could be heard over both lungs and harsh vesicular
breathing over the left lower lobe. The heart was acting tumultuously ;
a systolic bruit was audible at the apex, which was situated just outside
the nipple line. The abdomen was distended. The liver extended two
fingers’ breadth below the right costal margin. The spleen was also
enlarged and seemed tender on palpation. Its lower border could be felt
1 in. above the level of the umbilicus, and extended forwards to the left
nipple line. A large rounded mass, thought to be kidney, was felt in
each loin. The urine contained a cloud of albumin, but no Wood. The
temperature continued irregularly raised between 100*8° F. and 104° F.
Death occurred suddenly on February 17 as the result of heart failure.
The blood was examined on February 15, 16 and 17, with the follow¬
ing results:—
Haemoglobin ...
Colour index ...
Red corpuscles
Leucocytes
February 15
35 per cent.
1-2
1,326,000
29,000
February 16
30 per cent.
1-45
1,025,000
5,750
February 17
1,006,000 per cubic millimetre
3,500
Differential Count.
February 15 February 16
Polymorphonuclears ... 8 0 per cent. = 2,320 11*5 per cent. = 690 per cubic millimetre
SmaU lymphocytes ...65*5 ,, [ (70 0 ,, =4,200
Large lymphocytes ... 26*5 ,, ) “ ’ 118*5 ,, —1,110 ,, ,,
February 15.-—Nucleated red cells: 4 normoblasts seen in counting 400 white blood-
corpuscles.
February 16.—No nucleated red cells seen.
Red corpuscles showed poikilocytic and chromatophilic changes.
Post-mortem Examination .—The autopsy was made thirty-six hours
after death. The body was that of a small, wasted child. The face and
abdomen were scattered with petechiae. There were no visible haemor¬
rhages from the lips, tongue, or gums. The brain and meninges appeared
normal and there were no subdural haemorrhages. The eyes showed no
retinal haemorrhages. The tonsils were not enlarged or haemorrhagic;
there were a few adenoids. The thyroid and thymus appeared normal.
The lymphatic glands in the neck, axillae and groin were slightly
enlarged, soft, red and fleshy; those in the thorax and abdomen
appeared normal. The lungs were dotted with a few subpleural
haemorrhages, but were in other respects normal. Heart: The visceral
148 Forbes & Langmead : Lymphocythaemia in Early Life
layer of the pericardium was scattered with small haemorrhages. The
muscle was pale and the valves were healthy. The blood was very fluid
and showed no signs of clotting. The liver was slightly enlarged, pale
and mottled, and show r ed no haemorrhages. The spleen was enlarged,
reaching to 1 in. above the level of the umbilicus. It was uniformly
swollen, red in colour and soft. There seemed to be no increase of
fibrous tissue. The kidneys were both much enlarged, swollen and soft,
bulging forward from the loins as two nearly ovoid masses, black in
colour, due to large haemorrhagic areas into the cortices. The capsules
were stretched, but not adherent, and were dotted with a few capillary
haemorrhages. When stripped the organs w y ere seen to be mottled over
the surface by dark red and almost black areas of haemorrhage with very
little norn^al renal tissue showing between them. Here and there were
brighter splashes of more recent blood-extravasations. The cortex was
more involved than the medulla, but the normal definition between the
two was lost, as there were several central haemorrhages. In other
respects the renal tissue, where visible, was of a pale grey colour, the
apices of the pyramids being a creamy white, in marked contrast to the
rest. The pelves, ureters and bladder were normal. The stomach and
transverse colon showed a few submucous hemorrhages, but the rest of
the bowel looked healthy and contained no blood. Suprarenal and pan¬
creas appeared normal. The marrow in the femur was bright red and
drier than normal.
Bacteriological Examinations .—On the day before death the blood
taken from the ear yielded on cultivation a pure growth of a short
streptococcus. Spleen puncture made one hour after death also yielded
a similar streptococcus in pure growth. At the time of the autopsy films
taken from the heart’s blood, femoral marrow’, spleen, kidney and liver all
show T ed the presence of a short streptococcus. These results w r ere also
verified by cultivation from the same parts, yielding in each case a pure
growth of a similar streptococcus. Fermentation tests w y ere applied and
the following changes were observed within twenty-four to forty-eight
hours ; saccharose, lactose, salicin, and raftinose were fermented, but
inulin, coniferin, and mannite were unaltered. Litmus milk was
acidified and clotted. Inoculation of a subculture w r as made into a
mouse, and death resulted in three days. A streptococcus was recovered
in culture from the heart’s blood of the mouse.
The microscopical appearances presented by the various organs w r ere
as follow :—
Lymphatic Glands .—The tonsil, cervical, mediastinal and retro-
Clinical Section
149
peritoneal glands all showed congestion and considerable proliferation
and accumulation of lymphocytes, in addition to areas of cell necrosis.
The thyroid gland showed degenerative changes and collections of lym¬
phocytes in the interstitial tissue. The thymus w r as crowded with
lymphocytes; there was degeneration of the concentric corpuscles. The
heart muscle showed no particular interstitial cell invasion, but the capil¬
laries of the myocardium were congested. The kidney appeared to be
completely destroyed by the occurrence of large haemorrhages and an
extraordinary accumulation of lymphocytes in the interstitial tissue,
chiefly of the cortex. The gland tubules and glomeruli were widely
separated from each other by this extensive cell invasion and remained
only as straggling islands of renal tissue. In fact, the tissue might be
briefly described as entirely composed of lymphocytes and haemorrhagic
areas, dotted here and there with the remains of gland tubules and
glomeruli. The liver showed large collections of lymphocytes, especially
about the portal canals, without any marked invasion of the capillary
circulation. In places the liver cells at the periphery of the lobules
showed fatty infiltration* The spleen was much engorged and the
Malpighian bodies were increased in size by the accumulations of lym¬
phocytes. The pancreas showed extensive invasion of the interstitial
tissue by lymphocytes, which formed large cell masses in many places
between the glandular acini. The suprarenal showed extensive cell
necrosis. In the testicle the seminal tubules were widely separated by
collections of lymphocytes, which invaded the interstitial tissue in all
directions. The lymphoid tissue of Peyer’s patch was much thickened
by proliferation and accumulation of lymphocytes, and there was marked
cell necrosis.
Case VIII.
A boy, G. H., aged 2, attended the out-patient department at
Paddington Green Children’s Hospital on February 4, 1907. For a
month the mother had noticed that he was getting pale and listless and
disinclined to play. For a week the pallor had been intense and bruises
had appeared all over his body, beginning on his knees. He had lost his
appetite also and had occasionally vomited. He had not lost flesh, but
had become very flabby. No change had been noticed in his urine.
At the hospital he was seen to be extremely anaemic, the face and
skin generally being of a lemon tint. The muscles were soft and flabby;
there were no buccal haemorrhages, nor was there oral sepsis ; there were
numerous large and small haemorrhages over the limbs and also on the
150 Forbes & Langmead: Lymphocytlwmia in Early Life
forehead ; the lymphatic glands about the sterno-mastoid were slightly
enlarged, the largest being little bigger than a pea; no other lymphatic
glands could be felt; the liver reached two fingers’ breadth below the
costal margin; the spleen was large enough to be easily felt. The boy was
very collapsed and died soon after admission to the hospital.
Blood-Examination.
Haemoglobin ...
Red corpuscles
Colour index ...
Leucocytes ...
= 20 per cent.
= 1,200,000 per cubic millimetre.
= 0-8
— 196,840 per cubic millimetre.
Polymorphonuclears
Large mononuclears
Small lymphocytes
Large lymphocytes
Basophiles ...
= 0*2 per cent.
= 0*2
= S4-5
= 14-0
= 0-1
One normoblast was seen on counting 1,000 leucocytes.
Post-mortem Examination .—The body wfts that of a fairly well
nourished child. The blood was watery but had clotted. The heart
appeared normal except that its surface was mottled by bright red
haemorrhages of various sizes. The lungs showed many maroon-coloured
haemorrhages, both on the pleural surfaces and on section. The liver
was pale, not appreciably enlarged, and contained no lymphoid patches.
The spleen was enlarged and weighed 3 oz.; on its surface was a small
patch of perisplenitis ; its surface and a section were in some places
maroon-coloured, in others dark cherry-coloured. The right kidney
weighed just over 1 oz.; it was pale and its surface was spotted with
petechial haemorrhages; the apices of the pyramids were almost white,
and the contrast between cortex and medulla was lost. The left kidney
resembled the right, but contained also a deep-seated haemorrhage.
The suprarenal glands appeared normal; one small haemorrhage was
found in the intestine; the bone marrow w*as abundant and dark red in
colour; the abdominal glands, especially those in the mesentery, were
enlarged, pinkish and soft.
Histological Report by Dr. D’Este Emery .—“ Liver: The most
obvious feature in the liver is the presence in the region of the portal
canals of large areas of lymphoid tissue, which almost completely separate
the lobules from one another; in some places these areas are half as wide
as the lobules themselves; they are very well seen just under the capsule
of the organ, where the lobules are separated from one another in this
Clinical Section
151
way, so that their structure and relations can be well seen. There is in
general a fairly sharp line of demarcation between the lobules and
lymphoid tissue, and the latter does not infiltrate to any great extent;
there are, however, small detached portions lying inside many of the
lobules, apparently being formed within small blood-vessels ; here and
there columns of liver cells and isolated cells can be seen within the
lymphoid tissue, showing that it has in reality a very considerable amount
of invasive power. The lymphoid tissue in question appears to be badly
formed adenoid tissue, without germinal areas. The cells are mostly
lymphocytes, but there are larger endothelial (?) cells also present.
There is a badly formed fibrous reticulum. There is no blood mixed with
the lymphocytes, and few, if any, blood-vessels can be seen. The liver
cells in the outer zones of the lobules are apparently normal, whilst many
of those in the centre show marked fatty infiltration and probably also
degeneration. Kidney : The changes are limited to the cortex, the
medulla being normal. The lesions are similar in nature to those seen
in the liver, i.e., there is a deposition of small areas of miniature lymphoid
tissue, which are sufficiently large to be seen in this case with the naked
eye. They lie between the tubules, which thus come to be dissected
apart in much the same way as the lobules in the liver. The tubules and
the glomeruli do not show much change, and are in general healthy, but
here and there the remains of a tubule, which has been almost destroyed,
can be seen amongst the lymphocytes. In many cases the lymphoid
mass appears to have been developed in the walls of a vein or large
lymphatic vessel, since in the centre of the area there is frequently a
space lined with endothelium ; in some cases there is some blood still
present, but more often this lumen is empty. Occasionally the vessel
may be seen cut longitudinally, the lymphoid investment then clothing it
for its whole length. A study of the sections of the kidney renders it
probable that all the lymphoid tissue is formed in the walls of the small
veins, from which it infiltrates the surrounding tissues, and it seems
likely that in those cases in which this vein seems lacking the section has
missed it, cutting the lobule tangentially. This could only be settled
definitely by a study of serial sections. It will be noticed that the
lymphoid tissue resembles that of a lympho-sarcoma in two points: its
immaturity and its infiltrating propensities. It differs from it, however,
in that it does not seem to destroy the tissues it infiltrates. Liver cells,
renal tubules, and arterioles may be seen embedded in the tissue, but
intact. Lymphatic gland : In some parts, especially in the cortex,
there is no obvious abnormality. In other parts it shows a breaking
152 Forbes & Langmead : Lymphocythaernia in Early Life
up into alveolus-like areas of an excessive development of blood-vessels
(most of which are empty in the section), an absence of germinal areas,
an excessive number of lymphocytes, which are closely packed together,
and here and there an unusual degree of vascularity of the tissue itself.
At one point, at which there is a little adipose tissue, the lymphoid tissue
has extended through the capsule and separates the fat cells, which
remain intact. Spleen: No very definite changes can be made out,
though the appearance of the section is unusual, owing to the excessive
number of lymphocytes in the blood. Bone marrow : There are prac¬
tically no cells other than lymphocytes to be seen, and an examination of
measured films showed only lymphocytes with a very few eosinophile
myelocytes, and still fewer ordinary myelocytes; no nucleated reds of
any sort were to be seen. It was estimated that not more than one cell
in 10,000 was other than a lymphocyte. The sections show lymphocytes
mixed with blood and the usual scanty reticulum and sinuses. Adrenal :
Apparently quite normal.”
Case IX.
A. B., male, aged 9, admitted to the Hospital for Sick Children, under
the care of Dr. Voelcker, January 18, 1907. Died April 19, 1907.
Duration, from onset to death, three to four months.
Nature of Onset. —One month previous to admission : pallor, loss of
appetite, frequent headache. Since January 1: blood in urine; mic¬
turition not painful; nothing relevant in family or past history.
On Admission. —Temperature 99° F., pulse 78. Face pale, eyes
normal in appearance. Mucous membranes pale, lips ulcerated, no
bleeding from lips or gums. Teeth carious, tonsils enlarged and injected.
Haemorrhages: (1) Skin—Erythematous mottling on arms and legs,
fainter over abdomen ; subcutaneous haemorrhagic bruisings on left fore¬
arm and front of right leg on admission; (2) Gums—Later and per¬
sistent; (3) Haematuria on admission, disappearing later; (4) Retinal,
right eye ; later, April 5 and 13 ; (5) from bowel; later, April 12. Glands :
Cervical enlarged on right side, February 26 and April 5. Thorax,
lungs : Scattered bronchi at bases. Heart: Some dilatation. Abdomen :
Nil abnormal found. Urine: Specific gravity 1016; blood; albumin 1.
Microscopically. —Deposit of red blood-corpuscles, hyaline and granular
casts, renal epithelium.
Subsequent Course. —Persistent bleeding from gums. Urine became
normal, with the disappearance of blood, albumin and casts.
Clinical Section
153
Blood-Examinations from April 9 to 17.
April 9
April 12
April 15
April 16
April 17
Haemoglobin
40 per cent.
25 per cent.
25 per cent.
20 per cent.
—
Colour index
1*8
1*6
1*7
1*6
—
Red corpuscles
.. 1,086,000
754,000
730,000
647,000
528,000
Leucocytes
113,000
37,500
32,750
18,000
15,000
Differential Count.
April 9
April 12
April 15
April 16
Polymorphonuclears
... 2*2 percent.
11-4 per cent.
14*0 per cent.
16*7 per cent.
Large mononuclears
... 0*2 „
i-o „
—
—
Small lymphocytes
... 2*6 „
190 „
27*75 per cent.
24-6 per cent.
Large lymphocytes
... 95*0
670
58*0
58*4
Myelocytes
—
1-6 „
0*25
0-3 „
Nucleated red cells
... 1 normoblast
1 normoblast
1 normoblast
1 normoblast
Post-mortem (six hours after death).—Brain: No haemorrhages,
slight oedema of vertex. Mouth: Tonsils enlarged and fleshy; on
section, yellow in colour with blanching of deeper portion ; small amount
of haemorrhage over the pharynx. Glands: Cervical slightly enlarged,
injected and pale; thoracic, mediastinal, bronchial, not enlarged; mesen¬
teric and retroperitoneal slightly enlarged and pink, a few almost black
from haemorrhage. Thorax: Lungs and pleurae, normal. Heart :
Pericardium, normal; cardiac muscle very pale and soft, fatty striation
marked; many small epicardial haemorrhages. Liver: Enlarged and
pale fawn colour; pronounced fatty changes and some congestion were
present. Spleen : Not enlarged, normal in appearance. Pancreas large ;
parenchyma scattered with haemorrhages. Suprarenals normal. Kidneys
somewhat enlarged and intensely pale; left showed many small haemor¬
rhages and congested venules on the surface ; right, fewer haemorrhages.
Ureters and bladder normal; pale mucosa. Stomach and intestines
showed no ulceration or marked congestion; contained much altered blood.
Bacteriological and Histological Report. —The heart’s blood and
spleen proved sterile. Tonsil: The follicles were well filled with lym¬
phocytes, many of which were necrotic. Thymus: Some areas of
necrosis; the concentric corpuscles varied much in size, and in places
had disappeared or undergone calcareous degeneration. No great increase
in lymphoid tissue was present. Glands (cervical, bronchial and mesen¬
teric) : Cortical portions crowded with lymphocytes; follicular divisions
obscured. Retroperitoneal: Lymphoid follicles well defined and crowded
with lymphocytes, many of which showed necrotic changes; pigment
deposit in medulla of gland. Heart muscle showed marked fatty de¬
generation, but no obvious cell invasion. Liver showed everywhere
154 Forbes & Langmead: Lymphocytlisemia in Early Life
extreme fatty changes of the cells, very little normal tissue remained.
Here and there were small collections of lymphocytes. Kidney : In a
few places only the interstitial tissue show T ed slight invasion with
lymphoid cells, which were found also around the glomeruli. Here and
there were seen cloudy swelling and fatty degeneration of the cells of the
cortical tubules, whose lumina were filled with cell debris. There was
no definite evidence of nephritis. Spleen: Capsule and trabecula*
thickened. The organ was somewhat congested and densely crowded
w T ith lymphocytes; the Malpighian corpuscles were well marked ; the
pulp showed much pigmentary deposit.
Case X.
D. P., female, aged 3 years and 7 months, was admitted to the
Hospital for Sick Children, under Dr. Batten, on June 5, 1907, and died
June 7, 1907. Duration, from onset to death, ten days (?).
Nature of Onset. —Pallor had been increasing for six months, but she
had been able to run about till a week before admission.
Family History. —She was one of two children; the other had died
six months before from diphtheria.
The family occupied damp rooms on the ground-floor.
On admission she w r as seen to have an intensely waxy colour, and was
fretful and w r ailing. Temperature 100° F., pulse 136, respiration 5*2.
No haemorrhages were present; nothing abnormal was found in either
thorax or abdomen.
June 6, very restless; June 7, sudden collapse and death.
Blood-Examination.
Red corpuscles ... ... 255,000 per cubic millimetre.
Leucocytes ... _ 7,500 ,, ,,
Differential Count.
Polymorph onuclears
Small lymphocytes ...
Large lymphocytes ...
Kosinophiles
3*0 per cent.
910
55
0'5
A limited autopsy was performed twelve hours after death.
Bacteriological Exami)iation. —Culture from the heart’s blood yielded
a short streptococcus in pure growth.
Fermen tation Tests. —Saccharose, lactose and raffinose were fermented,
but mannite and salicin were not. Litmus milk was clotted and acidi¬
fied. Spleen, sterile.
Clinical Section
155
Post-mortem Examination. —Spleen was large and weighed 2^ oz.
Liver very pale. Kidneys: Right weighed 2 oz. 2£ drm.; they were
enlarged and very pale, but otherwise did not appear abnormal; free
iron was present. Intestines: Rectum contained very black faeces,
probably due to medicinal iron staining. No ulceration was found in
the stomach or any part of the alimentary canal. Peyer’s patches were
prominent. The mesenteric glands were somewhat enlarged.
Microscopical Appearances. —Mesenteric gland: There w r as general
hyperplasia of lymph cells, especially in the cortex and invading the
capsule. Kidney : Congestion of the cortex and cloudy swelling of the
cells of the cortical tubules w T ere present. A few groups of lymphocytes
appeared in the interstitial tissue and more dense collections along the
margin of the calyx. Liver: Cells showed fatty changes and cloudy
swelling. There were evident collections of lymphocytes about the
portal canals and under the capsule. Spleen : General increase of lymph
cells throughout, especially of the large lymphocytic form. They were
chiefly grouped beneath the capsule. Small intestine: Peyer’s patch
showed hyperplasia of lymph cells, which also invaded the intestinal
glands draining the patch.
Case XI.
G. D., female, aged 1, admitted on July 12, 1907, into the Hospital
for Sick Children, under the care of Dr. Colman. Died August 18,1907.
Duration, from onset to death, six weeks.
Nature of Onset. —The child had been noticed to be ailing for three
months. Pallor, restlessness and wasting had been present for one week.
On admission the patient w r as extremely pale and of a lemon yellow
tint, but well nourished. Pulse, 152; respirations, 40; temperature,
raised. Purpuric spots were present on the forehead, arms and legs.
No enlargement of glands was discernible. The heart was not dilated ;
a haemic systolic murmur was audible at the apex; no abnormal signs
were detected in the lungs. The spleen w T as enlarged, reaching three
fingers’ breadth below the costal margin, and the edge of the liver could
be felt extending dowmvards for the same distance.
Subsequent Course. —July 22: Purpura has disappeared ; occasional
vomiting ; the temperature is sometimes raised. July 2(5: Spleen some¬
what smaller; the patient shows a gain in weight of J lb. July 31 :
Discharged.
She had been treated by the administration of liq. arsenicalis ir[j. to
nxij. every six hours.
156 Forbes & Langmead : Lymphocytluzmia in Early Life
On August 11 vomiting occurred. August 15, convulsion lasting some
hours. On August 16 patient was readmitted. The skin was of a lemon
yellow tint and blue around the eyes and mouth ; the lips were cyanosed ;
purpuric spots were present on the face. The temperature was 102*6° F.,
pulse 176, respirations 72. She seemed better on the day after
admission. The temperature fell to 99° F., but rose again to 103° F.
Death occurred on August 18.
Blood-Examinations.
Haemoglobin
Colour index
Bed corpuscles
Leucocytes
Polymorphonuclears
Large mononuclears
Small lymphocytes
Large lymphocytes
Eosinophiles
Myelocytes
Nucleated Red Cells
61-5]
32*0 J
July 12
July 23
August IS
... 27 per cent. ... 32 per cent.
30 per cent.
1*2
1-3
1*4
1,046,000 ... 1,198,000
1,023,000
60,000 ... 31,500
14,000
Differential Count.
4-75 per cent.
3*5 per cent.
11*3 per cent.
0-5
0-5
0*3
61 *0 |
67 7)
93*5
oi-O
30 0) JiU
20-0) 87 ' 7 ”
0-5
20
—
0*75
20
0*66 „
2 normoblasts
Basophile 1, 5 normo¬
2 normoblasts and
blasts,poikilocytes,
marked poikilo-
and chromatophilic
cytosis
changes
Post-mortem Examination. —No bacteriological examination was
made. The body was that of a small, wasted infant; dark red purpuric
spots could be seen on the face. Brain: No abnormality. Lymphatic
glands : A few slightly enlarged glands, pale pink on section, were found
in the neck and axillae; the mesenteric glands were normal. Thorax :
Heart—Petechial hemorrhages were seen on the anterior surface of the
right ventricle, and to a less degree of the left. Lungs—Broncho-pneu¬
monic consolidation at the left apex. Abdomen: Liver—Fatty, not
enlarged. Spleen—Not obviously enlarged, rather hard. Kidney—Pale,
slightly fatty. Stomach—Slight haemorrhage into submucosa. Intestines
— Nil. Marrow : Bright red in colour.
Microscopical Changes. —Kidney : Cloudy swelling of the cells of the
cortical tubules and lymphocytic invasion and haemorrhages of the inter¬
stitial tissue between the tubules. Liver : Fatty and cloudy degeneration
of the liver cells; collections of lymphocytes invaded the connective
tissue of the portal canals. Spleen: Congested; increase of fibrous
tissue and consequent thickness of the trabeculae, hyperplasia of
Clinical Section
157
lymphocytes surrounding the Malpighian corpuscles. Mesenteric gland :
Definition between medulla and cortex lost by the hyperplasia of lymph
cells.
Case XII.
B. W., female, aged 7 months, admitted into the Hospital for Sick
Children, under Dr. Colman, on December 23, 1907. Died December 25.
Duration, from onset to death, one week (?).
Nature of Onset .—Pale since birth; wasting ; vomiting and some
diarrhoea had occurred during the w T eek before admission. Enlargement
of the cervical glands was noticed on December 21. There was nothing
of importance in the family history. On admission she was seen to be
very anaemic but well nourished. The temperature was irregular, rang¬
ing between 100° F. and 102° F. ; pulse, 164; respirations, 48. No
teeth had been cut. Numerous petechial haemorrhages were seen
scattered over the face, trunk and limbs. Some on the front of the
tibiae w T ere 1 in. in diameter. No enlargement of glands was noticed.
No oral sepsis or buccal haemorrhages were found. No abnormality was
noticed in heart or lungs. The abdomen was somewhat distended. The
liver w r as slightly enlarged. The spleen was hard and enlarged, reaching
tw r o fingers’ breadth below the costal margin. There was tenderness on
palpation in the right renal region, and both kidneys w T ere felt. The
urine was acid and gave a slight precipitate of albumin on boiling; it
contained no blood.
Blood-Examination.
Hemoglobin ... ... ... = 65 per cent.
Red corpuscles ... ... = 2,006,000 per cubic millimetre.
Leucocytes ... ... ... = 321,000 ,, ,,
Differential Count.
Polymorphonuclears ...
Small lymphocytes
Large lymphocytes
= 0*9 per cent.
= 33*4 ,, \
= 65-7 „ j
99*1 per cent.
Post Mortem .—The body was that of a very pale, fat infant. Purpuric
spots were found all over, especially on the front of the tibiae. Brain
and membranes normal. Lymphatic glands: The submaxillary pre-
auricular, inguinal and axillary glands were much enlarged and pale on
section, but the bronchial and mesenteric glands were not affected.
Lungs : Some haemorrhages in the lung tissue resembled infarcts, others
were subpleural. Heart muscle was very pale, except for numerous
158 Forbes & Langmead: Lymphocytluzmia in Early Life
epicardial petechiae. Abdomen : The liver weighed 15| oz., and was pale
yellow and soft, both superficially and on section ; no nodules were seen
in it. Spleen: Enlarged and hard, weight 2 oz. and 1 drm.; Malpighian
areas enlarged and grey in colour. Kidneys: Right weighed 5 oz.
6 drm.; left weighed 5 oz. 5 drm.; both very enlarged and lobulated, and
of a pale cream colour, spotted with many small haemorrhages. Stomach
normal. Intestine normal, except that Peyer’s patches were enlarged
and prominent. Cultivations taken from the heart’s blood and enlarged
cervical gland yielded a mixed growth of cocci and bacilli, evidently
contaminations, since the spleen, kidney and liver proved sterile. Films
from the bone marrow showed the cells to be nearly all large lympho¬
cytes, and the same condition was found in films from the kidney, liver,
spleen and subcutaneous haemorrhage. No organisms were seen.
Histological Changes .—The skin over the tibia (site of large petechial
haemorrhage) showed a mass of lymphocytes and red blood-corpuscles
situated in the subcutaneous tissue. No evidence of organization could
be seen in the patch. Cervical gland: The cortex and medulla w r ere
crowded with masses of lymphocytes, which obscured the normal appear¬
ance of the gland. The connective tissue and capsule of the gland were
equally invaded by lymphocytes. Lung : The alveolar w’alls w T ere much
swollen by the presence of lymphocytes in the capillaries. Many of
the alveoli contained loose lymphocytes and endothelial cells. The
pleura was thickened by subpleural haemorrhage and lymphocytic
deposit. Heart: Right ventricle—Section through the site of a petechial
haemorrhage showed a collection of red blood-corpuscles and lymphocytes
under the epicardium extending between the muscle fibres and also on
the endocardial surface in the recesses between the columnae carneae.
Left ventricle showed marked interstitial invasion by lymphocytes.
Liver: The portal canals were densely crowded by lymphocytes, which
were also grouped under the capsule ; the liver cells show cloudy
swelling and fatty changes. Kidney: Almost completely replaced by
lymphocytes, only scattered islets of glomeruli and glandular tubules
remaining; the capsule of the kidney was also increased in thickness
by the accumulation of lymphocytes. Small intestine : A Peyer’s patch
was swollen and crowded with lymphocytes, which infiltrated and dis¬
tended the neighbouring villi and submucous tissue. Spleen : Packed
with lymphocytes, which were chiefly found round the Malpighian
corpuscles and formed a sheath enclosing the blood-vessels, without
invading the vessel walls or occupying the vascular channels.
Clinical Section
159
Synopsis of Twelve Cases.
Age ranged from 7 months to 11 years—five cases of 2 years and
under, five cases of 4 years and under, one case aged 9 years, and one
case aged 11 years.
Sex. —Six male and six female.
Duration : I.—From onset of first symptoms to death, one week to
seven months: In two cases under two weeks, in seven cases under
six weeks, in one case ten weeks (average five to six weeks), in one
case three to four months, and in one case about seven months. II.—
From onset of acute symptoms : In four cases one week, in one case three
weeks, in four cases six weeks, in one case eight weeks, in one case three
months, and in one case five months. III.—Duration in hospital: In
five cases under three days, in one case five days, in two cases five weeks,
in two cases eight weeks, and in two cases thirteen weeks.
Nature of Onset. —Increasing pallor and languor ; haemorrhages,
chiefly in the form of purpuric rash over face, trunk and limbs; also
bleeding from gums, epistaxis, haematemesis (rarely), intestinal haemor¬
rhage and melaena, haematuria (rarely), occasionally vomiting and diarrhoea.
Clinical Features.
(A) Tendency to Haemorrhages. —(1) Purpuric and petechial: In
nine cases general distribution in greater or less degree over face, trunk
and limbs. (2) (i.) Retinal: In four cases in one or both eyes; (ii.) Con¬
junctival in one case. (3) Epistaxis : In three cases during the course
of the disease. (4) Buccal: In three cases severe haemorrhage from
gums associated with carious teeth; in two cases on lips, palate and
cheeks. (5) Intestinal: In five cases there was haemorrhage from the
bowel or melaena; in one case there was a history of haematemesis
and melaena two weeks before admission. (6) Renal: In one case the
early course was marked by haematuria, which disappeared two months
before death.
(2 ?) Glandular Enlargement. —In five cases there was slight enlarge¬
ment of the cervical, axillary and inguinal glands; in four cases slight
enlargement of the cervical glands only was recorded. In three cases
there was no evidence of glandular enlargement.
(C) Enlargement of Liver .—In ten cases the liver was felt to be
enlarged, extending in seven to two fingers’ breadth below the costal
margin and in three to the level of the umbilicus. In two cases the liver
could not be felt.
160 Forbes & Langmead: Lymplwcyth&mia in Early Life
(D) Enlargement of Spleen. —In ten cases the spleen was enlarged,
in four reaching to the level of the umbilicus, and in six two or three
fingers* breadth below the costal margin; but in two cases it was not
palpable.
(E) Kidneys. —In three cases both kidneys could be felt as large
rounded masses; in the remaining nine they could not be felt or palpation
was not recorded.
(F) Urine. —Blood was present in one case only ; in two cases casts
were found. In five cases albumin was detected in slight traces, but in
the case of haematuria to the amount of one-fifth. In the remaining six
the albumin was absent or not recorded.
(G) Gastrointestinal Symptoms. —Vomiting occurred in the early
course of five cases, more rarely shortly before death. It was associated
with a history of haematemesis in one case and with diarrhoea in two
cases. Unaltered blood was present in the stools in four cases, but only
in one in serious amount, while in two cases there was melaeQa.
(H) Temperature. —In every case the temperature ran an irregular
course with rises to 102° F., 103° F., or 104° F., but during temporary
improvement fell to normal in three prolonged cases.
Blood - Condition.
In every case there was marked anaemia, the skin being of a waxy
pallor or lemon yellow tint; the mucous membranes were correspondingly
pale, especially in the later course.
The Bed Corpuscles. —In seven cases the red blood-corpuscles num¬
bered under 1,500,000 per cubic centimetre and in one case fell as low as
528,000 per cubic centimetre before death. In three cases the earlier counts
varied between 3,000,000 and 2,000,000, and in three the count was not
recorded. The percentage of haemoglobin ranged between 65 per cent,
and 15 per cent., but not in direct proportion to the number of red cells,
so that the colour index showed considerable variation in the series of
cases. In four cases it lay between 0*87 and 0‘54, and in five cases it was
over 1. In a few cases there was a slight amount of poikilocytic and
chromatophilic change to be noted, and in five cases a very few nucleated
red cells were observed. In six cases, under observation for a period of
four to six weeks, a steady fall was traced in the number of red corpuscles
per cubic millimetre during the later stages; in one from 2,500,000 to
1,106,000, in another from 3,700,000 to 1,424,000, and in a third severe
case from 1,310,000 to 528,000.
Clinical Section
161
The Leucocytes .—The majority of cases showed an increase in the *
number of leucocytes at some period, but the figure varied very con¬
siderably in the different cases, and during the course of the individual
cases ; the highest count was 1,000,000 per cubic millimetre, subsequently
dropping to 500,000. Others gave the following counts : (1) 321,000 ;
(2) 196,800 on the day of death (the only examination possible) ;
(3) 126,000, falling steadily in the course of three weeks to 15,000
before death ; (4) 60,000, falling in five weeks to 14,000 ; (5) 29,000,
falling in three days to 3,500 per cubic millimetre. In two cases an
Fig. 1.
Blood-film. B.W., aged 7 months.
Large lymphocytes, 65*7 per cent.
Small lymphocytes,‘33 f 4 ,,
Leucocytes, 321,000 per cubic millimetre.
99*1 per cent.
i
(E.P. 8. Objective T \>, oil immersion.)
increase in the number of leucocytes developed while the patients were
under observation in hospital: (1) D.Ii. (Case IV.), on August 1, 1904^
leucocytes, 5,000; August 11, 40,000; August 29, 61,000 ; September 14
(two days before death), 14,000 per cubic millimetre; (2) A.H. (Case V.),
November 8, 1904, leucocytes, 3,000 ; December 1, 20,000 ; December 8,
83,000 per cubic millimetre. In two cases the only examinations made
my —3
162 Forbes & Langmead: Lymphocythaemia in Early Life
were on the day of death ; they showed counts of 14,000 and 7,500 per
cubic millimetre. From these results it would appear that in the severe
and acute forms of the disease the number of leucocytes is greatly
increased, as in the two cases with counts of 196,800 and 321,000 per
cubic millimetre on the day of death ; but in other cases, whose course is
less rapid, the number of leucocytes is considerably lower, and may show
a still further decrease in the later stages, and even result in a leuco-
pema shortly before death.
Differential Count of Leucocytes .—On the differential count rests the
diagnosis of true cases of lymphocythaemia. All of the ten cases ex¬
amined exhibited either an absolute or relative increase in the number
of lymphocytes, ranging from 66 per cent, (at the onset) to as high as
99 per cent, of all the leucocytes. The total figure per cubic millimetre
was found to vary according to the period of the case and its severity;
thus, towards the end the lymphocytes showed proportionately to the
other leucocytes a greater relative excess than at an earlier period,
although their absolute number was considerably reduced. Both small
and large lymphocytes were in all cases increased, but not in the con¬
stant proportions described in previously recorded cases, in which acute
forms of the disease are associated with an increase of the large, and the
more chronic with an increase of the small, lymphocytes.
This discrepancy seems to be due to the difficulty in defining pre¬
cisely the terms acute and chronic lymphocythaemia, and in fixing the
date of the onset of illness. Further, it is often impossible to draw a
hard and fast line between what constitutes the large and the small
lymphocyte. For purposes of only approximate distinction the terms
here used for the large lymphocyte include any lymphocyte measuring
10 /x to 15 or over, and, for the small, any lymphocyte with a diameter of
5 /x to 10 fi. Many cases show every gradation in size of the lymphocyte
from 5 /x to 15 /x, and therefore an accurate separation of the two types
becomes an impossibility.
Ten of the twelve cases were aged under 4; for this reason the
condition of the blood, especially the proportions of lymphocytes,
cannot be properly compared with the changes recorded in adult cases
of lymphocythaemia. Taking the twelve cases in order of duration,
the leucocyte counts mentioned on the following page were obtained.
These results seem to show that in the more acute cases, when the
lymphocyte count is highest, there is a greater numerical increase, both
relatively and absolutely, of the large lymphocytes than of the small,
and at this time death may occur, as in cases A. H. and B. W. In the
Clinical Section
163
more prolonged cases, as this period is passed, there is a marked decline
in the total number of lymphocytes, affecting the small lymphocytes
relatively less than the large ; and, as has been pointed out, the fall
may be so considerable as to result in a leucopenia immediately pre¬
Age
Duration
Leucocytes
Small
Lymphocytes
Large
Lymphocytes
Per c.mm.
Per cent. Per c.mm.
Percent. Per c.mm.
(1) D. R.
4 years
7 months
(Aug. 1) 5,000
44*0 = 2,200
22*0 = 1,100
(Aug. 11) 40,000
45*0 = 18,000
16*5 — 6,600
(Aug. 29) 61,000
50 6 = 30,866
49 0 — 29,890
(Sept. 14) 14,000
50-6 = 7,084
46-6 ; 6,524
(two days before
death)
(2) A. B.
9 years
3 to 4 months
(Mar. 27) 126,000
9*8 — 12,348
87*8 = 110,028
(April 9) 113,000
2-6 = 2,938
95*0 = 107,350
(April 12) 37,500
19*0 —- 7,125
67 0 = 25,125
(April 15) 32,750
27'75— 9,077
58-0 — 18,995
(April 16) 18,000
24 6 — 4,428
58*4 =r 10,512
(April 17) 15,000
—
—
(day before death)
(3) W. J.
2£ years
10 week b
(April 18) 1,000,000
56-0 = 560,000
41-7 = 417,000
(May 3) 272,000
—
—
(May 23) 622,000
—
—
(May 31) 500,000
—
—
1
(Day before
(4) H. S.
3 years
8 weeks
death) 14,000
94*0 =; 13,160
2*2 — 308
(5) G. D.
1 year
6 weeks
(July 12) 60,000
61-5 ^ 36,900
32-0 = 19,200
(July 25) 31,500
61 0 _ 19,215
30 0 = 9,450
|
(Aug. 18) 14,000
67 0 = 9,380
200 = 2,800
(6) A. H.
, 14 years
5 to 6 weeks
(Nov. 8) 3,000
—
—
(Dec. 1) 20,000
60-6 = 12,120
16*4 = 3,280
(Dec. 8) 81,000
50'6 — 40,986
! 45*7 = 37,017
i
(day before death)
(7) R. J.
15 months
5 to 6 weeks
(Feb. 15) 29,000
65-5 = 18,995
26-5 = 7,685
(Feb. 16) 5,750
1 70*0 = 4,025
! 18'5 = 1,064
(Feb. 17) 3,500
—
(Day of
(8) G. H.
2 years
1 month
death) 196,800
84-5 = 166,296
| 14*0 — 27,552
(Day of
,
1
(9) D. P.
3 yrs. 7 mon.
10 days
death) 7,500
91*0 = 6,825
5*5 = 500
(Day of
(10) B. W.
7 months
1 week
death) 321,000
33*4 = 107,214
65-7 = 210,897
ceding death. This ante-mortem fall in the number of lymphocytes
holds good for the majority of cases, and explains the low count obtained
in those which prove fatal shortly after admission.
The explanation of the occurrence of a true lymphocythsemia is
164 Forbes & Langmead: Lymphocytluemia in Early Life
necessarily a matter for surmise, when the role of the lymphocyte, par¬
ticularly in infancy and childhood, still remains unknown.
It may be suggested that in response to the influence of a microbic
infection or toxaemia, the lymphocyte plays an important part in the
defensive mechanism of early life, and invades the circulation in sufficient
numbers to produce a lymphocythaemia of varying degree. In those
cases terminating acutely, with a high lymphocyte count of 100,000 to
300,000 per cubic millimetre, the infection may have been so intense as
to prove fatal, in spite of the opposing reaction.
In other cases of longer duration a response is made, but proves
inadequate to deal with the infection; consequently the lymphocyte is
thrown out of the circulation, either from the failure of sufficient
stimulins or antibodies to maintain the lymphocytic reaction or from
the direct action of the infecting organism or poison. The accumulation
of lymphocytes in all parts of the body, except the blood-stream, almost
invariably found in these cases post mortem, seems to lend support to
this attempted explanation.
If, on the other hand, the lymphocyte is functionless and plays no
part as a protective agent, its over-production may be due to a passive
hyperplasia of the lymphoid cells of the marrow and adenoid tissues,
which in early life are the seat of constant change and therefore particu¬
larly liable to yield to infective processes. As a result of this over-pro¬
duction collections of lymphocytes make their appearance in parts of the
body where adenoid tissue is not normally present.
The other leucocytes call for but little remark. Polymorphonuclears
show an absolute decrease. Eosinophiles are much reduced or absent,
more particularly during the later stages. Myelocytes may occur in low
numbers in a very few cases. The prevailing feature of a lympho¬
cythaemia which characterizes these blood-changes, if due to an acute
microbic infection, may be compared with the relative lymphocytosis
which marks the course of infections of longer duration, such as typhoid
fever, malaria, syphilis and tuberculosis.
Summary of Post-mortem Examinations of Twelve Cases.
The brain and meninges, as a rule, showed no changes, but in one case
(H. S.) large subdural haemorrhages were found scattered over the
cerebrum, and numerous petechiae studded the surface of the cerebellum.
The tonsils were occasionally enlarged, red and fleshy, and in some
cases showed either deep-seated or superficial haemorrhages. The micro-
MIV" *.)Os *A<i1I \)n)ia
Loft. Kiduov (natural sizo). Weight, 7 oz*. 1 dnn. Measurements, 11 cart (tmlur«il si/c). Antorior surface. I xtonsivu o^icardial
i4 in. l»y 21 in. J). K., aged 1 year*. lisemorrhngo. II. S., aged :i years.
Clinical Section
165
scopical changes showed proliferation of lymphocytes with central areas
of necrosis or haemorrhage.
The thymus in only one case was found definitely enlarged, and in
three cases was microscopically examined. There was found proliferation
of lymphocytes, haemorrhages and necrotic foci, and lymphocytic invasion
of the connective tissue. The thyroid appeared normal to the naked eye.
One case showed, histologically, degenerative changes of the glandular
acini and collections of lymphocytes in the connective tissue.
Lymphatic Glands.
(1) Cervical: In seven cases there was definite or slight enlargement.
(2) Axillary : In four cases there was slight enlargement.
(3) Mediastinal : In two cases there was slight enlargement.
(4) Abdominal: (i.) Glands about the portal fissure were considerably
enlarged in two cases, (ii.) Mesenteric : there was definite or slight
enlargement in six cases, (iii.) Retroperitoneal : there was definite or
slight enlargement in five cases.
(5) Inguinal: In three cases slight enlargement was found.
Macroscopically the lymphatic glands were sometimes merely pale, but
more often fleshy, soft and red, and, particularly in the case of the mesen¬
teric and retroperitoneal glands, dark haemorrhagic discoloration was not
uncommonly found. The glandular enlargement was seldom really
marked or of universal distribution, affording a striking contrast to their
condition in chronic lymphocythaemia. Histologically the more enlarged
glands showed considerable hyperplasia of lymphocytes, affecting the
cortical portions more than the medulla, and frequently invading the
capsule and pericapsular fat. The medulla was usually congested and
sometimes showed haemorrhages, especially in the case of the retro¬
peritoneal glands. This haemorrhagic condition was found less often in
the cortex. The lymphocytic proliferation was in several cases so
abundant as to overrun and obliterate the follicular division of the cortex.
Germinal cell areas were absent or much diminished.
The Heart and Pericardium .—The pericardial sac contained no
excess of fluid. The visceral and particularly the parietal layers were
studded with fine petechiae or covered with extensive haemorrhagic areas.
The heart was frequently dilated. The cardiac muscle was pale, but
presented no fatty striation; the endocardium in some cases showed
scattered haemorrhagic points. The valves showed no changes micro¬
scopically ; the muscle fibres sometimes showed slight fatty degeneration
166 Forbes & Langmead: Lymphocythaemia in Early Life
and invasion of the interstitial tissue by lymphocytes, which were arranged
in rows between the fibres. The haemorrhagic foci were composed of red
corpuscles and lymphocytes underlying the endocardium or visceral
pericardium and extending into the muscle substance. The heart’s blood
showed delayed coagulation, and in every case at the time of the
post-mortem examination the heart cavities contained fluid blood,
with no attempt at clotting. It was usually pale red, thin and watery,
in contrast to the yellow colour shown by cases of chronic lymphatic
leukaemia.
The Lungs and Pleurae .—The pleural cavities in some cases contained
a small quantity of blood-stained fluid, and the parietal and visceral
layers were frequently scattered with small haemorrhages. Pleural
adhesions were occasionally found. The lungs were occasionally (edema¬
tous, and showed, in addition to subpleural petechiae, deeper-seated
haemorrhagic areas and broncho-pneumonia.
The liver was almost invariably enlarged. In one case (W. J.), aged
2£ years, it weighed 27£ oz. Its substance was firm and its colour varied
from very pale to light yellow, or was mottled with small white or faint
grey patches. Microscopically the following changes were observed :
The liver cells usually showed marked fatty infiltration, in the majority
of cases not universal, but limited to the periphery of the lobules; there
was also cloudy swelling. In one case (A. B.) the fatty changes were
extreme, and there was but little normal liver tissue remaining. In all
cases collections of the lymphocytes were found underlying the capsule
and closely investing the portal canals. Where a blood-vessel appeared
in longitudinal section the lymphocytes were found thickly arranged on
each side, although the channel itself showed but few cells. The inter¬
lobular capillaries contained lymphocytes, but w T ere never crowded. The
connective tissue enclosing the portal canals was the invariable seat of
lymphocytic invasion.
The spleen usually showed a variable amount of enlargement. Its
weight was 2 oz. to 3 oz. in three cases, aged 7 months, 2 years and 3£
years (the duration of whose illnesses was one week, one month, and ten
days respectively) ; 7 oz. and 10 oz. in two cases, aged 3 and 2 re¬
spectively (the duration of whose illnesses was ten weeks and five weeks) ;
and 5f oz. in a case aged 11, whose illness lasted five weeks. The
enlargement was therefore subject to considerable variation, but more
marked in cases under the age of 3.
It was generally firm in substance, dark red in colour, with greyish
definition of the Malpighian areas. Microscopically the capsule was
PROC. ROY. 80C. MED.
Clinical Section.
Yol. I. No. 7.
Cardiac Musole. Left, ventricle. B. W., aged 7 months. Interstitial lymphooytic '
invasion and area of hemorrhage.
(E. P. 3. Obj. 3, Leitz.)
Fig. 2.
Liver. B. W. f aged 7 months. Lymphocytic invasion of portal canal.
(E. P. 8. Obj. 3, Leitz )
FORBES cf LANQMEAD : Fatal Lymphocythamia in early life. Plate II.
Clinical Section
167
usually seen to be thickened, the pulp much congested and crowded with
lymphocytes; but the lymphocytes were more obvious around the Mal¬
pighian bodies and invested the blood-vessels in the form of a sheath.
The kidneys presented very striking changes, which may be con¬
sidered more characteristic of fatal lymphocythaemia than those in any
other organ. Though only occasionally palpable during life, the enlarge-
ment found post mortem was
remarkable, but differed considerably
the series of
cases, as shown in
the following table :—
Age
Weight of Kidneys
B. W. .
7 months
Right, 5 oz. 6 drm.; left, 5 oz. 5 drm.
G. D. .
. 1 year
No increase in size recorded.
R. J. .
15 months
Both much enlarged.
A. H. .
1£ years
Right, 1} oz.; left, 1 j oz.
G. H. .
2 years
,, 1 oz. ; ,, 1 oz.
W. J. .
. 2J years
Both much enlarged.
H. S. .
3 years
Both enlarged.
E. M. H.
3 years 3 months
Right, 6J oz.; left, 7$ oz.
D. P. .
3 years 7 months
Right, 2£ oz.
D. R. .
4 years
Right, 5J oz.; left, 7 oz.
A. B. ..
9 years
Enlarged.
D. B. ..
. 11 years
Right, 4£ oz.; left, 4j oz.
Normal adult
4 oz. to 6 oz. each.
The surface of the kidney was often lobulated and of a pale yellow
colour, mottled with dark areas of haemorrhage; occasionally the haemor¬
rhagic condition was so extreme as to cause a general dark red, almost
black, discoloration. On section the cortex was of a pale creamy colour,
scattered with haemorrhagic points or extensive mottling which prevented
the definition of the medulla. The pyramids showed marked contrast
by their pronounced pallor. In no case was haemorrhage into the pelvis
or ureters found.
These naked-eye appearances were remarkable, but the changes found
on microscopical examination were even more so. In nine out of the
twelve cases there was general invasion of the cortex by lymphocytes,
less often by actual haemorrhage. The lymphocytic infiltration was so
extreme as to leave scarcely any normal tissue intact. The sections
showed a mass of lymphocytes scattered with glomeruli and broken
fragments of tubules. This condition extended into the capsule of the
kidney, which was much thickened by the cell deposit. The changes in
the medulla were of a similar nature, though less marked. Where
blood-vessels appeared in longitudinal section and along the margins of
the calices, the lymphocytes were found closely investing the vessel walls.
168 Forbes & Langmead : Lyrnphocytlimnia in Early Life
Such tubules as were visible showed degenerative changes. The glo¬
meruli were much engorged and contained a few lymphocytes, but beyond
some invasion of the glomerular capsule showed little other change.
It is difficult to understand why the kidneys should show such
extreme changes, surpassing those found in other organs. It might
be suggested that an effort is made through the lymphatic channels
of the kidneys to relieve the circulation of cells, which are either
harmful or useless, and degenerate in their failure to deal with a microbic
or toxic invasion. The excessive lymphocytic accumulation and conse¬
quent widespread destruction of the renal tissue would also account for
the extensive haemorrhages so frequently present.
The pancreas in one case was scattered with small greyish white
areas, which microscopically proved to be areas of lymphocytes invading
the interstitial tissue.
A testicle was examined in one case, and, though presenting no naked-
eye changes, showed invasion of the connective tissue by collections of
lymphocytes.
The Alimentary Canal .—The stomach sometimes showed small sub¬
mucous and peritoneal haemorrhages and blood-stained mucosa, but more
often nothing abnormal was found. The small intestines sometimes con¬
tained unaltered blood or were scattered with submucous and peritoneal
haemorrhages. Peyer’s patches almost invariably shared in the general
hyperplasia of lymphoid tissue and appeared much swollen, and
microscopically they showed marked enlargement of the follicles owing
to the accumulation of lymphocytes, which had also invaded the under¬
lying muscular coat and neighbouring villous processes. In no case was
ulceration found.
The bones exhibited no change, such as subperiosteal haemorrhage.
The bone marrow varied in colour, and was sometimes pale or dark
red, but more often bright red and gelatinous, and, with the exception
of one case, showed no obvious increase in amount. Films taken from
the marrow in four cases showed an excessive number of lymphocytes,
both large and small, almost entirely replacing the normal cells. The
skin, as previously described, was of a pale, often lemon yellow
tint, and was usually scattered with numerous petechiae, but in some
cases large areas of subcutaneous haemorrhages and an appearance of
extensive bruising w T ere found. Histological section showed the presence
of a mass of red blood-corpuscles and lymphocytes situated in the sub¬
cutaneous tissue.
PROC. ROY, SOC. MUD,
Clinical Section.
J. G. F., del.
Fig. 1.
Kidney. H. J., aged 1 year 8 months. Haemorrhage and lymphocytic invasion.
(E. P. 8. Obj. 3, Leitz.)
J. G. F., del.
Fig. 2
Kidney. B. W., aged 7 months. Lymphocytic invasion.
(E. P. 8. Obj. 3, Leitz.)
FORBES ct LANG ME AD: Fatal Lymphocythamia in early life. Plate III.
Clinical Flection
169
Etiology of Lymphocyth/Emia.
(I.) The Bone Marrow.
Most recent authors—McCrae, Donnan, Neumann, Emerson, and
Treadgold [12]—are strongly of opinion that the bone marrow is the
primary seat of disease in acute lymphocythsemia and allied blood
diseases. Neumann, with Wolff and Pappenheim [5], claim that the
disease represents a pathological process capable of attacking spleen, liver,
glands and bone marrow; when confined to the first three of these organs
the blood shows no change, and the condition is described as “ pseudo¬
leukaemia ”; as s6on as the marrow is invaded “ sarcomatous tissue,”
compelled by the hard, inelastic bony capsule, invades the vessel walls,
and so long as the endothelium of the vessels remains intact the stage
is termed “ alymphaemic pseudoleukaemia.” With the passage of lym¬
phocytes into the blood-stream leukaemia sets in; if only to a slight
degree, the name “sublymphaemic lymphomatosis” is applied; if marked,
then a state of “ lymphatic leukaemia ” prevails.
Treadgold [12], in an exhaustive account of chloroma and acute lym-
phocythaemia (not, however, with particular reference to its occurrence
in early life), brings strong evidence in support of a primary affection of
the bone marrow, and quotes Flexner’s experiments with a cytotoxic
serum (lymphotoxin), which, when injected, gave rise to the proliferation
of lymphocytes in the marrow and their appearance in other parts of
the body. He decides positively that this formation of lymphocytes
constitutes a tumour of malignant nature arising in the marrow, while
the lymphocytic invasions of the various organs—the glands, spleen and
kidney—are in reality metastases.
The microscopical examination made of the bone narrow in four of
our cases showed in each an excessive number of lymphocytes both large
and small, resembling those in film preparations from lymphatic glands
and other organs; but their appearance did not suggest that they were
originally derived from the marrow. With one exception the marrow
in nine cases showed no increase in amount, and its colour varied from
a dark to a pale red.
Such an origin as the marrow does not seem satisfactorily to explain
either those cases in which the number of lymphocytes in the blood
steadily declined from a high to a low figure or those in which there
was only a condition of relative lymphocythannia at the single examina¬
tion made shortly before death.
170 Forbes & Langmead: Lymphocythaemia in Early Life
If the marrow is the primary seat of growth, malignant in nature
and capable of giving rise to metastatic deposits, the progress of such
disease should be marked by an increasing rather than a decreasing
lymphocytosis. Further, such an explanation does not account for those
acute cases whose duration is apparently not more than one or two
weeks. No growth, however malignant, has been known to run so
rapidly fatal a course.
(II.) The Thymus .
The view that the thymus is the primary seat of disease has been
brought forward by Frederick Taylor [11], who records a case showing
marked thymic enlargement with extensive lymphocytic invasion and
proliferation of the gland. He quotes four of five cases reported by
Rose Bradford and Batty Shaw, in which the thymus was persistent.
In one of our twelve cases (H. S., aged 3) the thymus was enlarged,
somewhat fibrotic, and contained areas of caseation and haemorrhagic
foci; microscopically there was in addition lymphocytic infiltration of
the connective tissue and proliferation in the adenoid portions. In two
other cases, though there was no enlargement of the thymus, there was
evident lymphocytic invasion of the gland, but not in excess of the
changes found in other parts.
(III.) Microbic Infection or Toxaemia.
A tempting explanation of the causation of lymphocythaemia is
provided by bacteriological evidence of blood infection in a certain
number of recorded cases and by some of the clinical features.
The temperature is always irregularly raised, and the haemorrhages
so commonly found resemble those occurring in the course of certain
septicaemias. Among other authors, Emerson [5] mentions the three
cases already alluded to and recorded by Holst, in which streptococci
were obtained from the knee-joint, glands and heart’s blood in one and
from the marrow in another. Pincus [9] quotes Askanazy as supporting
the transmission of infection through the damaged mucosa of the mouth,
and gives Obrastzow’s account of the isolated instance of a nurse who
was reported to have contracted the disease after attending a fatal case.
In four of our collected cases, evidence was found post mortem of
streptococcal infection:—
(1) D. R., aged 4; short streptococcus obtained in pure culture
from the heart’s blood and spleen, and in film preparations from the
femoral marrow.
Clinical Section
171
(2) H. S., aged 3; short streptococcus obtained in pure culture from
the heart's blood, spleen and marrow. Inoculation of a subculture into
a guinea-pig caused a fatal septicaemia on the sixteenth day, and the
same streptococcus was recovered from the heart’s blood.
(3) R. J., aged 15 months; short streptococcus in pure culture from—
(a) the blood taken from the ear on the day before death ; ( b ) spleen
puncture one hour post mortem ; (c) heart’s blood, spleen, kidney, liver,
and femoral marrow thirty-six hours post mortem; short streptococci
also present in smears taken from each. Inoculation of a subculture into
a mouse produced a fatal septicaemia on the third day, and the strepto¬
coccus was recovered from the heart’s blood.
(4) D. P., aged 3 years and 7 months; short streptococcus obtained
in pure growth from the heart’s blood.
Fermentation tests were applied to subcultures from H. S., R. J.,
and D. P. All agreed in fermenting saccharose, lactose, and raffinose
(two of them fermented salicin as well), in clotting and acidifying milk,
and in their reluctance to grow on gelatine.
From its behaviour in subculture it would seem that this short form
of streptococcus belongs to the streptococcus salivarius group [1].
Though suggestive, the finding of streptococci in pure culture cannot
be accepted as proof of such infection being the primary cause. It is
impossible to dispose of the insuperable objection that with one exception
the cultures were all obtained post mortem, and that their presence is
most likely due to an intercurrent or terminal infection. That they
belong to the salivarius group of streptococci points to such infection
being derived from the mouth, and is of importance in association
with the enlarged and septic state of the tonsils, carious teeth, swollen,
haemorrhagic gums commonly found in severe cases of lymphocy-
thaemia.
Cabot [3] attributes the marked ante-mortem fall in the number of
lymphocytes to the influence of intercurrent disease, such as septicaemia.
In Holst’s cases the same association was found. 1
In the four cases in which streptococci were obtained, the leuco¬
cyte counts showed the following variations, which agree with Cabot’s
statement:—
(1) D. R. Fall in leucocyte count in three weeks from 61,000 to
14,000 per cubic millimetre on the day before death (lymphocytes,
60,750 to 13,600).
1 Vide supra , p. 156,
172 Forbes & Langmead: Lymphocytluemia in Early Life
t
(2) H. S. Leucocytes, 14,000 per cubic millimetre on the day before
death (lymphocytes, 13,460).
(3) R. J. Fall in leucocyte count in three days from 29,000 to
5,750 per cubic millimetre on the day before death (lymphocytes 26,670
to 5,080) (see fig. 2).
(4) D. P. Leucocytes, 7,500 per cubic millimetre on the day of
death (lymphocytes, 7,230 per cubic millimetre).
In none of these cases was there a relative increase in the poly-
morphonuclears corresponding with the lymphocyte fall.
Blood-film (taken post mortem). R. J., aged 1J. Leucopenia, white
blood-corpuscles, 3,500 per cubic millimetre (day before death); many short
streptococci.
(j£.P. 8. Objective T ^, oil immersion.)
On the other hand, in the case of A. B., aged 9, cultivations of
the blood taken from the arm during life, of the heart’s blood and
spleen six hours after death, proved sterile, although the leucocyte
count showed a steady decline in three weeks from 126,000 to 15,000
per cubic millimetre on the day before death.
Clinical Section
173
Treadgold reviews the arguments for and against an infectious origin
and decides very positively against, partly on the ground that an organ¬
ism is seldom found at all and that in the few cases in which cultures
were obtained they usually belonged to the septic variety and merely
represented an intercurrent infection. He also attributes the raised
temperature to the action of the circulating products of degenerated
marrow lymphocytes on the thermogenic apparatus.
On the whole, therefore, the bacteriological evidence in favour of a
primary streptococcal origin, though suggestive, is not sufficient to admit
Fig. 3.
Chart showing variations in the leucocyte counts in cases of fatal lymphocythaemia.
of support; but it seems highly probable that an intercurrent infection
does considerably modify the changes shown by the blood, possibly by
an inhibitory influence on cell formation in the marrow and adenoid
tissues.
On the other hand, the clinical picture shows strong resemblance
to an acute infection, by the extremely rapid course of the disease in
174 Forbes & Langmead: Lymphocytlixmia in Early Life
Table of Blood-Examinations made in
Case j
Haemoglobin
Red Corpuscles
Colour
Index
Leucocytes
Polymorphon uclears
Per 2 . mm.
Per c.mrn.
Per cent. 1
Per c.tnm.
(1) W.J. 1
35 per cent.
(Apl. 18) 3,000,000
1,000,000
1*5 =
15,000
33 per cent.
(May 3)3,000,000
0*58
272,000
35 per cent.
(May 23) 2,800,000
622,000
(May 31) 2,000,000
0*87
500,000
(2) E.M.H.
38 per cent.
Imperfect record.
W 1
R “ 31
(3) W.B.
Blood condition not
1
recorded.
(4) D.R.
(Aug. 1)38 per cent.
2,584,000
07
5,000
300 =
1,500
(Aug. 11) 45 percent.
3,700,000
06
40,000
315 =
12,600
(Aug. 29) —
2,284,000
—
61,000
0*4 =
244
(Sep. 14) 22 per cent. )
1(2 days before death)j
1,424,000
078
14,000
20 =
280
(5) A.H.
(Nov. 8) 32 per cent.
2,554,000
0*68
1 3,000
(Dec. 1) 20 per cent.
1,839,000
0*54
20,000 |
20*4 =
4,080
(Dec. 8) 15 per cent.)
(day before death) )
1,106,000
0*68
83,000
30 =
2,988
(6) H.S.
32 per cent.
1,340,000
11
14,000
1-7 =
238
(7) R.J.
(Feb. 15) 35 per cent.
1,326,000
1-2
29,000
80 =
2,320
66,325
(Feb. 16) 30 per cent.
1,025,000
1*45
1 5,750
11*5 =
(Feb. 17) day of death
1,006,000
—
3,500
—
-
(8) G.H.
On day of death |
20 per cent. j
1,200,000
0 83
! 196,800
0-2 =
393
(9) A.B.
(Mar. 27) 10 weeks)
after admission, -'
1,310,000
1-5
126,000
1-2 =
1,512
40 per cent. J
(Apl. 9) 40 per cent.
1,086,000
1-8
113,000
2-2 =
2,486
(Apl. 12) 25 per cent.
754,000
1-6
87,500
11*4 =
4,275
(Apl. 15) 25 per cent.
730,000
1-7
32,750
14 =
4,585
(Apl. 16) 20 per cent.
647,000
1*6
18,000
16*7 =
3,006
(Apl. 17) day before)
death )
528,000
15,000
-
-
(10) D.P.
7,500
30 -
225
(11) G.D.
(July 12) 27 per cent.
1 1,046,000
1*2
60,000
4-75 =
2,850
1 (July 25) 32 per cent.
1,198,000
1 1*3
31,500
3*5 =
1,102
4 Aug. 18) 30 per cent. 1
(day of death) /
1,024,000
1-4
14,000
11*3 =
1,582
(12) B.W.
! 65 per cent.
2,006,000
1-6
321,000
0*9 =
2,889
Clinical Section
175
Twelve Cases op Lymphocyth^emia.
Large
Mononuclears
Small
Lymphocytes
Large
Lymphocytes
Eosinophiles
^ Basophiles
1
Myelocytes
Per Per
Per Per
Per Per
Per Per
Per Per
i Per Per
cent. c.mm. j
cent. c.mm.
cent. c.imn.
cent. c.mm. cent. c.mm. cent. c.mm.
0-8 — 8,000
I
56 = 560,000
* 1 1 i
c-
—
1
4-0 — 200
44 0 = 2,200
22*0 — 1,100
6 0 = 2,400
45 0 = 18,000
16*5 = 6,600
i 1-0— 400
—
—
— ;
50-6 ^ 30,866
49 0 = 29,890
i -
—
1-6 — 224
50-6 _ 7,084
46-6 = 6,524
02= 28
0-4 = 56 i
—
1-6 = 320
60-6 = 12,120
i
16*4 _ 3,280
, 10= 200
|
—
50-6 = 40,986
45-7 — 37,017
0-1= 83
i
1*7 — 238
94-0 - 13,160
2-2 _ - 308
0-4= 56
65-5 18,995
26-5 _ 7,685
— -
70-0 = 4,025
18-5 —1,063-75
—
0*2 = 393 1
184-5 =166,296
14 0 = 27,552
i
0-1 =197
—
1-2 = 1,512
9*8 = 12,348
j 87*8 =110,628
_
, _
_
0*2 = 226
2*6 — 2,938
95*0 =107,350
_
i
1
_
10 ~ 375
190 = 7,125
67 0 = 25,125
—
1
1
—
—
27*75= 9,077
58 0 = 18,995
—
1-6 =600
—
24-6 — 4,428
58-4 = 10,512
—
0*25= 82
—
1 “ I
|
!
—
—
0-3 = 54
—
1
91-0 = 6,825
5-5 = 412-5
0-5 =37-5
—
0*5 - 300
61-5 36,900
32-0 = 19,200
0-5 — 300 1
0*75- 450
0 5 = 157*5
610 -= 19,215
30-0 = 9,450
20 = 630
10 —315
2-0 =630
0-3 = 42
67-7 = 9,380
20-0 = 2,800!
—
—
0-66= 92
—
33*4 =107,214
65-7 =210,897
!
Nucleated Reds
4 normoblasts
in counting
1,100 w.b.c.
4 normoblasts
in counting
| 400 w.b.c.
1 normoblast
seen in count-
ling 1,000 w.b.c.
1 normoblast
seen in
counting
600 w.b.c.
2 normoblasts
5 normoblasts
2 normoblasts
17G Forbes & Langmead: Lympliocytlwemia in Early Life
some of our cases, by the invariably raised temperature, by the frequency
with which a septic condition of the mouth and throat appear to mark
the onset of the illness.
(IV.)
The lymphatic glands and other adenoid tissues in our opinion play a
prominent part in the causation of lymphocythaemia, but, as in the case
of the marrow, their role is probably secondary to a microbic infection or
toxaemia.
It is true that the enlargement of the glands was never very great,
but it was sufficiently definite in the majority of cases to attract atten¬
tion. As has been already stated, no positive increase of the marrow
could be observed sufficient to suggest that the marrow was more
involved than the glands.
A common histological feature of the changes found in the various
organs was the collection of lymphocytes around the blood-vessels, which
formed an investing sheath when seen in section parallel to their course.
The vessels themselves w r ere scarcely invaded at all and contained but few
or no lymphocytes. Such a condition suggests that the massing of cells
outside the vessel walls is due to the blocking of the perivascular lym¬
phatics with accumulated lymphocytes.
The frequency with which the small lymphocyte is found in excess of.
the large is evidence that the glands take a definite share in the produc¬
tion of the disease in early life.
The following distinction may be drawn between the parts played by
the marrow and lymphatic glands : In the one case a reaction by the
marrow gives rise to a predominance of the large lymphocytes, in the
other a reaction by the adenoid tissues is responsible for an excess of the
small lymphocytes.
In those cases showing intermediate forms between the small and
large lymphocyte no accurate separation into the two types of cell can be
made ; and their respective production by the adenoid tissues and marrow 7
is equally inseparable.
The nature of the primary factor in the causation of lymphocy¬
thaemia is purely hypothetical; possibly it may prove to be some toxin,
the result of perverted metabolism, such, for instance, as one of the
cytotoxins obtained by Flexner.
In conclusion, w T e wish to express our warm thanks to members of
the staff of the Hospital for Sick Children for kind permission to use the
No. Name | Age | Se:
1 W. J. ! 2£ years Ma:
2 IE. M.H.3 years, sj Ferni
months j
3 j D. B. lOyears, 11 Fem
, months
4 | D. R. 1 4 years j Fenii
5 ! A. H. 1 h years j Ma!
6 H. S. I 3 years Mai
7 R..J. |l5 months Mai
8 G. H. I 2 years j Mai
9 j A. B. 9 years Mai
10 D. P. 3 years, 7 Fem;
months
11 G. D. 1 year Fem
12 B. W. 7 months Fem;
Clinical Section
177
notes and material provided by their cases. We are also much indebted
to Dr. Leonard Guthrie for the use of the notes of Case VIII., and to
Dr. D’Este Emery for his pathological report on the case ; to Dr. F. E.
Batten for the loan of slides illustrating Case I., and to Dr. H. Thursfield
for his kindness in carrying out two animal inoculations.
' REFERENCES.
[1] Andrewes and Horder. Lancet , 1906, ii., p. 77G.
[2] Cabot. “Clinical Examination of Blood,” 19C0, p. 176.
[3J Ibid. Loc. cit.
[4] Donnan. Brit. Med. Journ ., 1905, i., p. 408.
[5] Emerson. Johns Hopkins Bull., 1907, xviii., p. 71.
[6] Ibid. Loc. cit.
[7] Hutchison. Goulstonian Lectures, Lancet , 1904, i., p. 1331.
[8] McCbae. Brit. Med. Journ., 1905, i., p. 404.
[9] Pincus. Nothnagel’s “ Encyclopaedia ” (English edition), “Diseases of the Blood,”
p. 566.
[10] Rose Bradford and Batty Shaw. Trans. Mcd.-Chir. Soc., Loud., 1898, lxxxi., p. 343.
[11] Taylor, Frederick. Trans. Clin. Soc., Lond., 1904, xxxvii., p. 46.
[12] Treadgold. Quarterly Joum. of Med., 1908, i., p. 239.
[13] Whipham and Leathem. Lancet , 1906, ii., p. 367.
DISCUSSION.
The President (Sir T. Barlow) said that the Section was very grateful
to the authors for their valuable paper. He had been much interested in the
possibility of the condition being due to some infection. The only case
under his own observation which he could recall at the moment was one
which had been partly embodied in the present paper. In that, the first event
was an exceedingly septic throat, which gave rise to the idea that the case
was one of diphtheria with the supervention of streptococcal invasion. He
feared that the investigation of the case was not so thorough as it should have
been, but he remembered that there was an extensive involvement of glands
in different parts of the body, some of which underwent some necrosis. One
of them was incised and a little thin ichorous fluid exuded. Post mortem
there w r as found some necrosis of portions of the glands. Haemorrhage from
the gums in these cases was very characteristic. The cases reminded him of
my —4
178 Forbes & Langmead: Lympliocytliaemia in Early Life
those of acute leuksemia which Dr. Bradford showed and described some years
ago. The general conclusion of Drs. Forbes and Langmead was rather against
infection as a direct cause. In his own case the septic throat might have
been only a manifestation of the disease and not its starting point.
Dr. Parkes Weber, in regard to the terminal drop in the number of white
corpuscles in the authors’ cases, said that in a case of acute lymphocytic
leukaemia, which was published in the Edinburgh Medical Journal by Dr. K.
Furth and himself, the number of white corpuscles in the blood fell before death
to only 3,000 in the cubic millimetre, so that there was actual leucopenia
at the time of death. 1 He wished to refer to the use of the term “ leucocy-
tosis.” He heard people talk of a leucocytosis stage ” of the blood in
leukaemia, that is to say, a stage of leukaemia when the leucocytes were not
extremely increased in number; but this he regarded as a very inconvenient
use of the term leucocytosis. The word leucocytosis was best restricted to an
increase in the number of white corpuscles when the increase constituted a
definite vital reaction to some recognized exciting agent, such as to a strepto¬
coccal invasion of the body. In leukaemia, however, there was no known cause
for the increase of leucocytes other than the leukaemia itself, and it was better
not to speak of a “ leukaemic leucocytosis.” With regard to the origin of
leukaemia in the bone marrow, he thought the general opinion in the last year
or so was that leukaemia was not necessarily a primary disease in the bone
marrow, but a more or less general disease of the lymphatic tissue all over
the body. The part played in the disease by the bone marrow was, however,
a very large one, especially in regard to the actual increase of white corpuscles
in the circulating blood.
Dr. PoYNTON pointed out how remarkable was the enlargement of kidneys
in cases of this form of leukaemia in small children. He recalled a striking case
of a child who had irregular fever, with marked anaemia, none of the blood-
changes which had been mentioned, but general enlargement of glands, without
notable enlargement of the spleen. The general enlargement of glands persisted
for six weeks ; finally a number of glands suppurated, and Staphylococcus
aureus was obtained from the pus. And if the recent researches on the
spirochaBta were correct, then those cases of syphilis with an enlarged spleen
and multiple enlargement of glands were very suggestive that the infectious
theory was more likely to be correct than any other. He hoped the authors
would not be too much put off by the idea of terminal infections, and he asked
them to pursue the matter by experiments on animals. There seemed no
reason why the streptococcus should not produce, under certain circumstances,
such a condition as was present in those children. He had seen cases of
malignant endocarditis in which there was an extraordinary condition of the
kidneys without suppuration, resembling in some ways those occasionally seen
in such cases as the authors were now describing, and streptococci were often
' Edin. Med. Jour tv ., 1905, N.S., xvii., p. 260, Case 2. Six days previously the blood-
count had shown over 77,000 white cells in the cubic millimetre.
Clinical Section
179
present in malignant endocarditis. Although much was known about those
blood-changes, the essential facts as to what they really meant were still
unknown. The leucocytosis in suppurative conditions was to him the most
pertinent observation upon the blood in regard to these leukaemic states.
Dr. FORBES, in reply, said that he had been much interested to hear the
details of the President’s case, because he thought it threw light on the
causation of some cases of lymphocythaemia. It suggested that the disease
might originate primarily in an infection gaining entrance through the tonsils
or the damaged mucosa of the mouth. That was the view which he had at
first been inclined to support. In a recent paper by Treadgold on acute
lymphatic leukaemia and chlorosis a microbic origin had been strongly opposed,
and it had been stated that the condition of the throat was only a secondary
and intercurrent complication. The work of other authors and the study of
the cases collected in the paper just read had led him (Dr. Forbes) to the belief
that a streptococcal infection was merely a terminal condition. It could not
be proved to be otherwise unless a number of positive cultural results were
obtained during life, yielding, on animal inoculation, evidence of transmitted
infection and pathological changes in animals similar to those found in cases
of lymphocythaemia. The presence of streptococci in the disease under dis¬
cussion was comparable with the terminal septicaemia occasionally found in
cases of lympho-sarcoma and lymphadenoma, conditions which could not be
attributed on that ground to a primary microbic origin. Treadgold, among
others, was strongly of opinion that acute lymphatic leukaemia arose primarily
in the bone marrow, and was malignant in nature. That view he (Dr. Forbes)
was not prepared to support, but considered the changes in the marrow and
adenoid tissues were possibly secondary to a toxaemia. He agreed with Dr.
Parkes Weber that the loose use of the terms leucocytosis and lymphocytosis
was confusing, and should be avoided in reference to definite forms of blood-
disease such as lymphocythaemia.
Dr. LANGMEAD said that clinically the condition more closely resembled
septicaemia than anything else, especially in the rapid course, the progressive
anaemia, the irregular and remittent temperature, the many haemorrhages, and
the death in a few weeks. He still had an open mind as to the etiology.
In most such cases there was no doubt as to the condition before examining
the blood. They had seen nine cases themselves in three or four years, and
they all presented a very definite clinical picture. That fact also seemed to
show that the disease is not so rare as is sometimes supposed.
my —4 a
180 Guthrie & Mayou: Hemiplegia and Optic Atrophy
Right Hemiplegia and Atrophy of Left Optic Nerve.
By Leonard G. Guthrie, M.D., and Stephen Mayou, F.R.C.S.
The patient, T. 8., is a boy, aged 7. On July 17, 1906, he was run
over by a cab, and was admitted to St. Mary's Hospital suffering from
concussion of the brain and fracture of several ribs on the left side. His
progress was satisfactory until July 21, when signs of pneumothorax
(dyspnoea, limitation of chest movement on left side, tympanitic reson¬
ance and displacement of heart to right) appeared. Temperature varied
from 101° F. to 103° F. for a few days, and remained elevated for a
fortnight.
On July 23 (six days after the accident) he suddenly became aphasic
and paralysed on the right side. His right pupil was larger than the
left; both reacted to light. No note was made as to vision or state of
optic disc, but his mother states that he seemed blind in the left eye on
this day, and has been so ever since. Power in the limbs and speech
improved, and he was discharged from hospital on August 6, 1906.
Present Condition (November 5, 1907).—Healthy in appearance.
Intelligence unimpaired. Paresis of the right face (supranuclear type),
arm and leg is present, with slight ataxy and athetosis of the right upper
limb. The right hand is almost useless. Tendon reflexes are exag¬
gerated ; plantar response is extensor. Tongue deviates to the right.
He walks quickly and without assistance, but gait is of hemiplegic type.
Eyes : Right is normal; left pupil reacts to about half the extent of
right; visual perception of light w r ith projection only on the temporal
side. [Two months later all perception of light disappeared, together
with the pupil reflex.] Media clear. Left fundus: Disc is dead white
in colour, the edges being sharply defined. Arteries are very minute
and thread-like, and can only be traced into the retina for a short
distance. Veins are small, and some of them have evidently been
thrombosed. On the disc there is a twisted vein, which possibly com¬
municated with the choroidal circulation round the disc. Along the
course of the vessels can be seen the remains of old exudation into the
perivascular lymph spaces. To the temporal side of the disc there is a
white area of old exudation, which extends outwards to the macula, in
which situation there is also a marked stippled condition. In the
Clinical Section
181
extreme periphery on the nasal side are a few areas of choroidal atrophy
and pigmentation. The changes in the fundus are not typical of simple
embolism of the arteria centralis retinae, but of complete occlusion by
thrombosis. The choroidal vessels at the posterior pole exhibit no
changes and are evidently patent. Speech : There is slight motor
dysphasia and verbal amnesia. Sensation appears to be normal except
for slight blunting to touch on right leg. Hearing is normal. Vascular
system : Heart's action is irregular; apex beat in fifth left interspace;
area of dulness normal. A faint systolic bruit is heard occasionally at
the apex and is conducted into the axilla. Pulsation can be seen and
felt in the suprasternal notch. The right carotid and both subclavians
can be felt pulsating, but no pulsation can be detected along the course
of the left carotid, nor in the direction of the left facial and superfacial
temporal arteries. Nothing in the shape of a fibrous cord can be
detected in the course of the left common carotid or its branches.
Remarks.
Unilateral atrophy of the optic nerve and contralateral hemiplegia
are conditions sufficiently uncommon to be worth recording. In this
instance the simplest explanation is that when pneumothorax supervened
on the accident, thrombosis occurred in the displaced heart, whence a
large clot became dislodged and completely blocked the left carotid
artery. No trace of this vessel or of its terminal branches can be
detected. It is possible, of course, that the whole vascular supply of
the left neck, face and brain may be abnormal, and that the place
of the left common carotid is taken by separate smaller vessels. At least
two instances of absence of the common carotid have been recorded.
However this may be, the probability is that occlusion has arisen in the
manner suggested in vessels which answer to the left Sylvian and left
ophthalmic arteries, for unilateral atrophy of the optic nerve, associated
with contralateral hemiplegia, is highly suggestive of occlusion of these
cerebral vessels on the side of the optic atrophy. The occluded vessels
are presumably branches of the middle cerebral, supplying some part of
the motor tract, and of the ophthalmic artery or of some of its branches,
including the arteria centralis retinae, which supply the optic nerve and
its sheath.
Complete unilateral optic nerve atrophy with contralateral hemiplegia
cannot be produced by a lesion involving the optic tract and the motor
tract on one side, because (except in cases where there is no decussation
182 Guthrie & Mayou: Hemiplegia and Optic Atrophy
of the tract fibres at the chiasma) the succeeding atrophy of the optic
nerves must be bilateral and also incomplete and hemiopic in character.
This distinguishes such cases from the present, in which the atrophy of
the optic nerve is entirely unilateral, and therefore due to a lesion of the
nerve itself.
One of us, in conjunction with Dr. F. E. Batten [1], has recorded
in the Transactions of the Clinical Society for 1903 three cases of
unilateral optic atrophy and contralateral hemiplegia. In the first of
these, an anaemic girl, aged 25, the symptoms were: sudden onset of
right hemiplegia, sudden loss of vision in the left eye, recurring fits of
Jacksonian epilepsy, increasing coma, and death in twenty months.
At the autopsy occlusion of the left middle cerebral artery and soften¬
ing in its area of distribution, atrophy of the left optic nerve, secondary
degeneration of the spinal cord and optic chiasma w'ere found.
The condition of the disc during life was attributed by Mr. Marcus
Gunn to thrombosis or haemorrhage into the nerve sheath. It is
impossible to say whether the occlusion was due to embolism or
thrombosis of the vessels.
The second case was that of a boy, aged 12, who, after union of a simple
fracture of the left femur, had a febrile attack lasting a fortnight and
associated with pain at the site of the fracture. A fortnight later he
developed right-sided hemiplegia, followed by failure of vision in the left
eye, with signs of retrobulbar neuritis, resulting in partial atrophy of
the left optic disc.
All the symptoms disappeared in about six months, except that slight
pallor of the disc remained. Here the condition was probably due to
thrombosis of branches of the left Sylvian and of the left ophthalmic
arteries. Polio-encephalitis may have been the cause.
The third case was in a woman, aged 22, who, nine days after
confinement, had three eclamptic attacks, followed immediately by left
hemiplegia. Three months later she discovered that she was almost
blind in the right eye. Ophthalmoscopic examination showed extensive
atrophy of the right optic nerve. Here, probably, a thrombus was swept
from the heart into the Sylvian artery, and subsequently blocked the
right ophthalmic artery by extension of the embolus.
Neither of the two latter cases proved fatal, but occlusion of the
Sylvian and ophthalmic vessels on the same side was probably the cause
in all.
Siegrist [5] has reported two somewhat similar cases following
ligation of the common carotid artery. But in these the choroidal
Clinical Section
183
vessels were also thrombosed, which is not so with our own patient
(T. S.).
Instances of obstruction of the arteria centralis retinae, associated
with contralateral hemiplegia, have also been recorded by Gowers [3],
Hughlings Jackson [4], and Elschnig [2], R. T. Williamson [6] has
described unilateral retinal changes in cerebral haemorrhage, embolism
and thrombosis.
We are indebted to Mr. W. T. Hancock for notes of one more case
resembling our own.
It would seem that simple embolism of the arteria centralis retinae
alone will not account for the condition of the disc in most reported
cases, but that a more complete occlusion by thrombosis is responsible
for the ophthalmoscopic appearances. Such thrombosis may, however,
be the result of previous embolism.
The comparative rarity of unilateral optic atrophy and contralateral
hemiplegia remains for consideration. The reason of this rarity is
probably an anatomical one. The optic nerve and its sheath are
supplied by the branches of the ophthalmic artery, itself a branch of the
internal carotid. The nasal branch of the ophthalmic artery courses
through its orbit on its inner side and anastomoses with more or less
regularity with the angular branch of the facial artery. The degree of
inosculation, however, varies greatly, and presuming blockage of the
ophthalmic artery to occur, the restoration of circulation in the optic
nerve will depend upon the amount of distal anastomosis between the
ophthalmic and other vessels which exists.
Should the blockage of the ophthalmic artery extend beyond its
branches to the nerve, restoration of the circulation to the nerve is
impossible. On the other hand, should the blockage be only of the
trunk of origin of the ophthalmic artery, collateral circulation may restore
function to the nerve.
In our own patient (T. S.), as previously mentioned, no trace of the
facial artery can be found on the left side, therefore anastomosis between
it and the nasal branch of the ophthalmic artery cannot exist. But the
choroidal vessels which are derived from the short ciliary branches of
the ophthalmic artery are obviously patent. Hence they must be
supplied by some vessels other than the ophthalmic, or the occlusion
must be of the arteria centralis retinae alone and not of its parent stem.
In none of the other cases to which reference has been made is the
condition of the great vessels in the neck mentioned, except when the
symptoms followed ligation of the common carotid.
184
Symonds: Improved Method of Speaking
It is impossible to decide, in the case of T. S., whether the apparently
missing vessels are obliterated by thrombosis or whether they are
congenitally absent. The latter supposition seems but to offer one
rare condition in explanation of another. Yet complete obliteration of
all the carotids on one side, including their terminals, the middle cerebral,
and ophthalmic arteries, is hardly compatible with the boy’s general
condition of physical and mental health.
Complete blockage of the Sylvian artery alone, as instanced in
Dr. Batten’s case, leads to so wide a degeneration of an important area
of the brain that recovery to any considerable extent is hardly possible.
The absence of fits of any kind and preservation of intellect suggest
that in T. S. only the Sylvian branches which supply the internal
capsule and its neighbourhood are occluded and so cause hemiplegia,
whilst a similar condition of the left arteria centralis retinae accounts
for the ocular condition described.
REFERENCES.
[1J Batten and Guthrie. Trans . Clin. Soc ., Lond., 1903, xxxvi., p. 52.
[2J Elschnig. Arch. f. Augenheilk ., 1892, xxiv., p. 65, Case 2.
[3] Gowers. Lancet , 1875, ii., p. 794.
[4] Jackson, Hughlings. Lond. Hosp. Repts. t 1864, i., p. 360.
[5] Siegrist. 27 Vcrsamml., 3, Heidelburg, Beitrag f. Ophth. t 1898, p. 10.
[6] Williamson, R. T. Brit. Med. Journ. t 1898, i., p. 1515.
A Case, three years and nine months after complete Excision
of the Larynx, showing an Improved Method of Speaking.
By Charters J. Symonds, M.S.
M., aged 52, admitted to Guy’s Hospital, July, 1904, with extensive
malignant disease of the larynx affecting primarily the left side. The
disease had penetrated the left ala and involved the muscles. Complete
extirpation was carried out in the usual way, together with removal of
the thyro-hyoid and sterno-hyoid, muscles on the left side. The fascia,
with lymphatics, and the left thyroid lobe, together with all surrounding
fascia, were also removed. The trachea w r as attached to the skin above
the sternum and the pharynx closed with three rows of catgut sutures.
Primary union was obtained.
Clinical Section
185
The patient is shown in order to exhibit his phonetic power, especially
with the aid of the device suggested by Professor Gluck, which, by insert¬
ing a rubber tube into the cannula, carries a current of air to the lips.
By this means he can be heard at some distance, and is able to carry on
his duties as a tax collector in a country district. In the discharge of
his duties he has to speak his reports to the magistrates, to barristers
and the Somerset House officials, and is heard without difficulty. There
is no difficulty in swallowing.
A Case showing the Phonetic Condition after Removal
of One Vocal Cord.
By Charters J. Symonds, M.S.
M., aged 55, is shown in contrast to the case of total extirpation of
the larynx. On October 17, 1906, the left cord was removed for a
strictly localized malignant growth. The excellent voice retained repre¬
sents the average phonetic result when the arytaenoid has not been inter¬
fered with and the opposite cord has not been injured in the operation.
The laryngoscope shows approximation of the false cord with the true
cord on the sound side.
DISCUSSION.
Mr. Sampson Handley asked whether in these cases there were any
enlarged glands, as it seemed to him to be a very important question whether
it was worth while operating for laryngeal and pharyngeal cancer when the
glands were already enlarged. Perhaps the present cases would help to settle
the point.
Mr. SYMONDS, in reply, said that in the cases shown there was no glandular
disease. In another case enlarged glands below the thyroid lobe on both sides
were removed, but the patient was quite well nine years afterwards. He
mentioned yet another case in which he had j>erformed hemilaryngectomy and
had previously removed a mass of carcinomatous glands which were fixed to
the tissues on the right side of the neck. The patient survived for five years
and died of pneumonia.
186
Handley: Cases of Lympliangioplasty
Two Cases of Lymphangioplasty for the Brawny Arm
of Breast Cancer.
By W. Sampson Handley, M.S.
The two cases I sliow r to-night are the first in which the operation of
lymphangioplasty has been performed. I may remind you that the
method will be found described in the Lancet of March 14, 1908. My
thanks are due to Mr. A. F. Palmer, Medical Officer and Registrar in
the Cancer Wing of the Middlesex Hospital, for the care and attention
he has devoted to the after-treatment of the cases.
Case I.
The patient, a woman, aged 50, was admitted into the cancer wards of
the Middlesex Hospital on January 18 last under my senior colleague,
Mr. J. Bland-Sutton, who kindly transferred her to me for treatment. In
1894 a portion of the right breast was removed for carcinoma at Chichester
Hospital. In 1896 recurrences in the breast and axilla were removed at
St. Mary’s Hospital. In 1903 two or three small recurrent growths
w^ere removed from the axilla. In 1905 the right arm became swnllen;
it slowly became paralysed, and has been the seat, during the past three
years, of excruciating pain, which frequently kept her awake at night.
On admission there w r as no evidence of cancer in the body in the form of
palpable tumours. The right nipple still remained intact and was not
indrawn, and there was no lump in what remained of the right breast,
nor was there any axillary mass of growth. The chest and abdomen
were free from deposits. The growth was evidently an atrophic scirrhus,
which had undergone an almost complete process of natural cure. The
right arm and hand below the deltoid insertion were greatly swollen.
The oedema pitted slightly on pressure, though it approached the solid
variety. There was complete paralysis of the limb, save that the third
and fourth fingers could be moved slightly. Sensation was lost in the
thumb and first finger, but not in the second, third, and fourth. The
hand was warm and of natural colour. Flexion of the elbow was only
possible through 15 degrees or rather less.
On February 1, under chloroform, a number of silk threads, each
running upwards from the wrist to the loose tissue upon the chest wall,
just below the axilla, were buried in the subcutaneous tissue. The
operation produced no general disturbance of note. On the next day it
Clinical Section
187
was obvious that the bandages were loose, and the strapping upoii her
fingers was in the same condition and had to be frequently replaced.
On February 6 it was noted that the arm and hand were quite flabby
and much reduced in size. The skin was much wrinkled and hung
awkwardly on the fingefs in folds. On February 7 the patient remarked
that she “ saw her knuckles for the first time for years.” The move¬
ments of the fingers were beginning to return and she was able to grasp
very feebly. The arm was still quite paralysed. On February 10 the
forearm and hand began to present an almost normal appearance, but
much swelling of the upper arm remained. On February 19 the
swelling about the elbow, which as the patient lay was the lowest point
of the limb, had somewhat increased, and the limb was ordered to be
put up on an inclined plane in an extended position and to be bandaged
during the night. On February 24 the limb was continuing to diminish
in size, though less rapidly than at first. Unfortunately, measurements
of the limb previously to operation were omitted, so that no accurate
record remains of its very rapid and marked subsidence in the earliest
days after operation. Its slower subsequent subsidence is recorded in
the following table :—
Feb. 6
I Feb. 13
Feb. 18
Feb. 19
| Feb. 21
I !
Feb. 24
April 0
Circumference of arm —
in.
in.
■ in.
in.
i in.
in.
in.
At wrist .
bi
6J
1 6 * i
6|
6
4* in. above wrist.
8.[
8i
8
,
7|
6|
Just below the elbow
10*
n
I ioi> ;
10*
9$ .
9!
92
8£ in. below the acromion
11
8*
10* 1
10!
9* |
9!
9!
1 Temporary return of swelling owiDg to dependent position of elbow.
Note .—The operation was performed on February 1.
In conclusion, it may be stated that the patient has lost her pain and
that she is very grateful for the operation. Flexion of the elbow is now
possible through about 110 degrees, as compared with about 15 degrees
or less before the operation. The movements of the hand continue to
improve, so that the patient can hold a pin between the finger and
thumb. It will be interesting to see whether the muscles of the arm
recover their power, but at present there is no sign of this. The
measurements of the limb in this case have continued to decrease up to
the time of writing (April 8, 1908).
188
Handley: Cases of Lymphangioplasty
Case II.
This patient, E. A., a woman, aged about 50, first noticed a small
lump in the left breast in 1897. In 1899 the bre % ast was removed at the
North-West London Hospital by Mr. Frederick Durham. Operations
for recurrence, four in number, have been performed at intervals since.
The first of these took place in 1902, the second in 1904, the last in
190(5. She was admitted to the cancer wards of the Middlesex Hos¬
pital on January 3, 1908, for inoperable recurrence in the left axilla and
near the scar, and for swelling of the arm, and was kindly transferred to
me for treatment by my senior colleague, Mr. John Murray. On
admission the left arm, and more especially the forearm, hand and fingers,
are much swollen, and the limb is completely paralysed. The hand is
purple in colour, but the fingers are warm. On account of the swelling
of the tissues the radial pulse cannot be felt. The oedema pits slightly
on pressure, although in places it is almost solid. The pain in the arm
is occasionally most severe, and in consequence of it the patient suffers
much from insomnia. Amputation had been suggested before the
patient’s admission, and her condition was so miserable that she was
prepared to welcome the loss of the limb.
Owing to the axillary recurrence and to the consequent absence of
loose skin on the thoracic wall in front, it was deemed well in this case
to carry the threads up on the posterior aspect of the axilla. They
terminated in the subcutaneous tissue over the scapula. Four pairs of
threads were used, as in the previous case ; two on the flexor and two
on the extensor aspect of the arm.
Measurements of Arms.
!
Eight
Left Arm
Arm
(normal)
1 Before |
operation
Mar. 3
! 1
Mar. 13
1
1
Mar. IS
April t*
in.
in.
in.
in.
in.
in.
in. above the wrist .
7 }
9*
7}
6*’
7
Just below elbow
8J
Hi
9}
8*
9 *
9
1J in. above elbow
8j
12}
10
9*
10}
10
8 in. below acromion ...
9
12
10}
1°}
9}
95
Just below fold of axilla
10
10}
11}
Hi
11
10}
Clinical Section
189
The swelling in this case, as in Case I., subsided from below upwards,
the subsidence being first noticed in the hand and forearm. The excru¬
ciating pain has been entirely relieved and the patient has good nights.
She appears to be putting on flesh, and her worn expression has been
replaced by a more contented look. She still has a certain amount of
axillary pain due to the recurrent growth in the axilla.
DISCUSSION.
Mr. Cecil Leaf desired to compliment Mr. Handley on the excellent
results in his two cases. Dr. Lomer, in a recent paper, discussed the curability
of cancer, and among other points which he noticed was the fact that patients
who bled much in advanced cancer were often much the better for it. Dr.
Copeman had suggested that the fact might be utilized in advanced cases of
cancer with brawny arm, and had suggested to him the advisability of trying
venesection. At that time Mr. Leaf had under his care at the Cancer
Hospital three cases of advanced carcinoma of the breast with brawny arms,
and on all of them he performed venesection, removing some | pint of
blood. In all of them the oedema of the arm rapidly diminished, although
he regretted to say it had subsequently again increased. But if, in these cases,
venesection could be performed repeatedly, he believed that not only would
the oedema be diminished, but that the mere fact of withdrawing blood might
remove the deleterious products in the blood, and so diminish the growth
of the cancer. He suggested that Mr. Handley’s operation could with advan¬
tage be supplemented by venesection, and he should be glad to know the
result of such a measure.
Dr. PARKES WEBER asked whether Mr. Handley’s operation would be
of any use in cases of so-called sporadic elephantiasis of the lower extremity,
particularly in an early stage.
Dr. ZUM Busch said that three or four years ago he had had some
correspondence with Professor Lauenstein, who had told him that he had for
some time been making experiments on the treatment of lymphatic enlargement
of the scrotum by introducing a silver wire beneath the skin of the scrotum
and leaving it there, and that he had had good results. It was a very similar
treatment to Mr. Handley’s.
Dr. Copeman said that in one of Mr. Leaf’s three cases treated by vene¬
section the effect was nearly as good as that in Mr. Handley’s cases shown
that evening. If, as Mr. Handley said, the lymphatics became converted into
solid cords, the good effect of venesection was difficult to understand unless,
owing to the diminution of pressure, the veins were enabled to carry off the
lymph. In one of Mr. Leaf’s cases the recovery of use of the arm was more
striking than in Mr. Handley’s cases. Possibly the combination of methods
might yield even better results.
190
Hawkins: Case of Ascites
Mr. Handley remarked on the short period of benefit from the venesection.
He thought it better that the two operations should be tried in separate cases,
in order that the results could be compared. In answer to Dr. Parkes Weber,
he thought that the method was applicable to elephantiasis, not only to the
sporadic cases, but also to the filarial cases in which the parasite had died out.
He was interested in Dr. Zum Busch’s remarks, as he was not aware that
Lauenstein had published anything of the kind. With regard to the recovery
of the use of the arm after venesection, he did not think that the two cases
were comparable, for the reason that the arm of his first patient had been
paralysed for three years, so that it was not fair to expect much recovery at
present of power, as three months had not yet elapsed since the operation.
Case of Ascites ; Paracentesis performed twenty-five times
in one year and three months ; patient quite well seven
years later.
By Francis Hawkins, M.D.
J. C., aged 43, a gardener, stated that he had not known what
illness was until August, 1899, when he noticed that his feet were
somewhat swollen, that he was losing flesh, his abdomen was increasing
in size, and that subsequently he had a difficulty in passing urine.
On September 6, 1899, he came under my observation. He had
never been a heavy drinker, but had taken a small quantity of whisky
every night; he had never suffered from venereal disease, nor vomiting,
epistaxis, haematemesis, or melaena. He was a thin, spare man with
small dilated venules over the cheeks. His feet and legs were oedema-
tous. There was some slight oedema of the chest wall, that is to say,
the stethoscope left a slight depression; there was also some oedema
over the sacral region. The abdomen was greatly distended, and there
was every evidence of free fluid within the abdominal cavity. The
heart sounds were normal, but there was some oedema of the bases of
both lungs. He passed during the first twenty-four hours 19 oz. of urine,
specific gravity 1016. His temperature w r as 98° F.
On September 11, five days after admission, the abdomen having
increased in size, paracentesis was performed, 23 pints 16 oz. of clear
amber-coloured fluid being withdrawn. Nothing abnormal could be
felt in the abdomen, and the liver dulness w r as about normal.
On September 17 he was again tapped, and 19£ pints were with¬
drawal. Four days later the urine, which had increased in quantity, was
Clinical Section
191
for the first time found to contain blood and albumin ; specific gravity
was 1014.
On September 30 paracentesis was again performed; 23 pints of
fluid were removed, and on October 9, 25£ pints. After this he com¬
plained of shooting pains all over the abdomen, and the temperature
rose to 99*6° F. The oedema of the legs now began to subside. Blood
and albumin were constant in the urine. The fluid within the abdo¬
minal cavity having reaccumulated, paracentesis was again performed on
October 25 ; 36 pints were withdrawn, and fourteen days later 23 pints
15 oz. He now complained of severe colicky pains, which were relieved
by carminatives and warm fomentations. He subsequently became so
much better that he was allowed to get up and go about the ward in a
wheel chair.
On November 20 paracentesis was again performed, 29 pints of fluid
being withdrawn. The oedema of the legs had now almost entirely
disappeared.
On December 5 paracentesis was repeated, and 23 pints 17 oz. of fluid
withdrawn. He had now been tapped eight times in four months, and
he was so much better in himself that I decided to let him walk about.
He was therefore discharged, being told to return to the hospital in a
fortnight. He, however, returned in twelve days ; there was now slight
swelling of the feet and legs. The urine (specific gravity 1020) con¬
tained a considerable quantity of albumin, but no blood.
All went on well till January 4, 1900, when he complained of very
severe abdominal pain, and only passed 10 oz. of urine, which con¬
tained a considerable quantity of blood. I ordered him to drink freely
of distilled water, with the result that on the following day 45 oz.
of urine containing much blood was passed, and five days later, the
fluid having again accumulated, I tapped him once more, withdrawing
27 pints 15 oz. The following day the urine contained no blood. A
few days later he again had severe colicky pains, which were relieved by
rhubarb and soda.
On January 30, 19 pints 15 oz., and on February 20, 30 pints 5 oz. of
fluid were removed, and two days later he was again discharged. He
continued to come to the hospital from time to time for paracentesis to
be performed, and was finally discharged December 21, 1900. Since
this date he has had good health and followed his occupation of a
gardener, working from 6 in the morning till 5 in the evening, and
during these seven and a half years he has not once been ill. I have on
several occasions asked him to come and see me at the Royal Berkshire
192
Weber: (Edema of Hands and Feet
Hospital, and on these occasions the urine was of a specific gravity
varying from 1004 to 1010, with a trace of albumin. The lower border
of the liver can be palpated ; it is hard and quite smooth. There are no
enlarged veins over the abdomen and the spleen is not enlarged.
DISCUSSION.
Dr. PARKES Weber thought that a chronic localized peritonitis was
present, probably around the liver, possibly around the spleen also. The liver
was now considerably enlarged. Probably the perihepatitis was not enough
to constitute a typical Zuckenjmsleher. The ascites disappeared in some
of these cases with localized peritonitis after repeated tapping, and might
remain absent permanently.
Dr. HAWKINS, in reply, said that he did not think that in his case the
liver and spleen were enclosed in thickened capsules. He had met with such
a case in which repeated paracentesis was required.
(Edema of Hands and Feet with Mediastinal Affection.
By F. Parkes Weber, M.D.
F., aged 21. The patient, an unmarried woman, was admitted into
the German Hospital on March 23, 1908, with great oedematous swelling
and cyanosis of the hands and feet. The oedema was symmetrical; in
the lower extremities it extended upwards as far as the knees, and in the
upper extremities to about the middle of the forearms, but the upper
limit was not sharply defined in either extremities. The swelling had
commenced to appear gradually in the feet about five or six w r eeks, and
in the hands about three w r eeks before admission. There w T as no oedema
of the face or loins, or elsewhere in the body. The patient said that she
had previously enjoyed good health and was not aware of having any¬
thing else the matter with her. Examination of the thorax, however,
showed dulness, with diminished breath sounds and voice sounds,
over the lower pant of the left anterior and axillary regions, up to the
second rib in front and up to the sixth rib in the middle axillary line.
The upper part of the dull area was separated by about £ in. from the
left border of the sternum. There was some impairment of resonance
over the left infrascapular region. Vocal vibrations could be felt over
the right front, but not over the left front. There were no pulmonary
adventitious sounds anywhere. The upper part of the left lung and the
Clinical Section
193
whole of the right lung appeared normal. The apex beat of the heart
was in the normal situation, but the cardiac dulness extended rather too
far to the right; there was no evidence of valvular disease. Rontgen ray
examination showed an extensive shadow on the left side of the thorax,
wdiich corresponded to the abnormal area of dulness, and was separated by
a fairly sharply defined, dome-shaped border from ay upper normally
clear area. The heart shadow, which was not separated from the
abnormal shadow, extended rather too far to the right of the sternum.
Nothing of pathological significance was found by examination of the
abdominal viscera and urine. Menstruation was regular. There was
slight anaemia. The blood-count gave 4,150,000 red cells and 8,470
white cells to the cubic millimetre of blood; haemogoblin (by Haldane 6
method), 80 per cent.; coagulation time (by Sir A. E. Wright’s coagulo-
meter), eight minutes. The microscopic examination of blood-films
showed nothing abnormal. The superficial lymphatic glands were not
enlarged. The thyroid gland was apparently of natural size. There was
no paralysis of either vocal cord. The pupils were equal and reacted
naturally to light and accommodation. Knee-jerjvs, very active, of the
“trepidation” or “ vibratory ” type. No ankle-clonus. Plantar reflexes
not obtained. The radial pulse, usually about 100 to the minute, was
regular and equal on the two sides, and of low" pressure. Brachial blood-
pressure (Riva Rocci method), 95 mm. Hg. in each arm. Ophthalmo¬
scopic examination show r ed nothing abnormal. Calmette’s ophthalmo¬
reaction (1 per cent, tuberculin) gave a positive result, as also did
von Pirquet’s cuti-reaction. The temperature varied between 99° F. and
101° F. (mostly about 100° F.). There w r as no cough or expectoration,
or history of haemoptysis. Respiration, 30 to the minute. There had
been no pain anyw’here except a little w r hen the feet were greatly swollen
and the skin very much stretched. The swelling, and especially the
cyanosis, of the extremities had greatly diminished on rest in bed.
Haemangiectatic Hypertrophy of the Foot, possibly of
Spinal Origin.
By F. Parkes Weber, M.D.
C. F. P., aged 19. The left foot is decidedly larger than the right,
and of a red or bluish red colour, as if turgid with blood. The skin over
part of the foot is closely studded with small venous loops (varices), and
194
Moore: Myxcedema with Optic Atrophy
in a lesser degree the skin over the knee-cap. The calf muscles and other
muscles of the leg are about equally developed on the two sides, but
there is considerable wasting of the left thigh and buttock, and the left
hip-joint is ankylosed. The pulsation in the dorsalis pedis artery is well
felt in both feet. There is no anaesthesia, and the reaction of the muscles
to galvanism is normal. There is considerable kyphosis in the dorsal
region of the spine. There is no evidence of any disease elsewhere in
the body. Kadiograms show that the hypertrophy of the left foot is
practically confined to the soft parts and that there is bony ankylosis of the
left hip-joint (of doubtful origin). The history is that about two years
ago the patient complained of pain in the back of the left thigh. He
was at first treated for sciatica, and was afterwards supposed to have hip
disease and w T ore a Thomas’s splint for eighteen months. The haeman-
giectatic hypertrophy of the left foot and the w r asting of the thigh muscles,
&c., have developed during the past two years, but the kyphosis of the
dorsal region existed to some extent previously, though it seems to have
increased during the last two years.
Myxcedema with Optic Atrophy.
By Norman Moore, M.D.
A man, aged 44, who was admitted to St. Bartholomew’s Hospital
on February 7, 1908, suffering from blindness and lethargy. He was
first conscious of defective sight in his left eye in September, 1906, and
in his right eye in June, 1907. He is a waiter, and realized his defect of
sight one day when he swept all the glasses off a table with the crumbs.
His sight was a little better in the summer. He was, on admission, very
drowsy and usually did not answer questions till after a long interval, but
now and then became so talkative that it was difficult to stop his flow of
conversation. His eyes were kept half open or shut. The thyroid gland
could just be felt. Complexion pale ; skin dry and thick all over, looking
cedematous, but without pitting on pressure; mucous membrane of mouth
thickened ; fingers thick, tremor of hands; temperature subnormal or
normal; knee-jerks exaggerated, ankle-clonus present. Optic discs both
show atrophy, the left much more than the right. Visual field not
markedly contracted, but slightly so on nasal side. He can perceive
light with his left eye and can count objects with his right.
After continued administration of thyroid extract his lethargy and
abnormal mental state have disappeared, and he can walk well and
Clinical Section
195
has no tremor of his hands. He speaks of his left eye as blind, but
can use the right better. The discs show no change.
DISCUSSION.
The PRESIDENT asked whether, in Dr. Moore’s opinion, the administration
of thyroid extract had made any difference to the condition of the optic nerves.
Dr. PARKES WEBER asked whether Dr. Moore had, as far as possible,
excluded all the other causes of optic atrophy. The patient looked very
anaemic, and he understood he had been for a long time on thyroid extract.
He thought there must be some general condition other than myxcedema
to which the optic atrophy w T as due.
Dr. Norman Moore, in reply, said that he would like to know more
particularly from Dr. Parkes Weber what the causes of optic atrophy were.
He had, of course, endeavoured to exclude the probable and common causes.
In reply to the President, he said that the thyroid extract had made no
difference to the condition of the optic nerves.
Spurious Acromegaly in a Patient suffering from Exoph¬
thalmic Goitre, associated with a Congenitally High
Forehead.
By David Walsh, M.D.
P\, aged 35. For five years the patient has been under treatment
for recurrent patches of alopecia areata of scalp. After a severe mental
shock at Christmas, 1907, the patient developed symptoms of exophthal¬
mic goitre. The face is suggestive of acromegaly, but the appearances
are similar in a photograph taken eighteen years ago. The patient
has a congenitally high forehead, a condition present in every one of
a consecutive series of thirty-five cases of exophthalmic goitre. This
congenital sign may be described as a band of baldness or semi-baldness
of variable width stretching across the frontal region of the scalp, with
a further triangular area or bay projecting backwards at each end.
Sometimes the band is outlined by a thin pencil of hair showing
where the hair should have reached in normal conditions of growth.
It is suggested that this congenitally high forehead is connected with a
peculiar temperament—“ potential exophthalmic goitre ”—and in several
cases exophthalmic goitre has actually developed under observation.
As regards the resemblance to acromegaly, the features may perhaps
be of a reversionary type.
196
Tilley: Chronic Bilateral Empyema
Case to show the Result of Operative Treatment for Chronic
Bilateral Empyema of the Frontal, Ethmoidal and
Sphenoidal Sinuses.
By Herbert Tilley, F.R.C.S.
M., aged 35, suffered for two years from a profuse, purulent, offen¬
sive discharge from both nostrils, associated with a feeling of “ tension ’’
in the lower central region of the forehead.
It was ascertained upon examination that pus was being discharged
from all the sinuses, and radical operations had been performed upon
the antra only in May, 1907, by another surgeon. The discharge con¬
tinued freely from the higher sinuses, and w r hen it was found that free
irrigation failed to check the flow, radical operations upon the fronto-
ethmoidal and sphenoidal sinuses were carried out.
February 12 : Killian’s radical operation was performed on the right
side, and the sphenoidal sinus w r as also opened.
March 4 : An incomplete Killian’s operation was carried out on
the left side.
The size and disposition of the sinuses before the operation are
well shown by the skiagram (exhibited).
The case is shown to illustrate the superiority of Killian’s complete
operation to any other in extensive suppurative disease of the upper
sinuses. It will be noticed that there is an almost entire absence of
deformity over the right sinus; there is slight deformity over the left,
where an incomplete, but otherwise successful, operation has been
performed. •
An Appliance for obtaining Extension of the Spine in the
Treatment of Scoliosis and Caries.
By T. H. Openshaw, C.M.G., M.S.
The appliance consists of a bed made of plaster of Paris, which is
accurately moulded to the w y hole dorsal surface of the patient, from the
head to the heels. It fits with the utmost accuracy, with the result that
the patient can lie on the back during the whole night or twenty-four
hours without the slightest discomfort. It is specially fitted with an
Clinical Section
197
arrangement of pulleys, weights and a Glisson’s sling, in order to extend
the spine. Counter-extension is obtained by means of a leather pelvic
girdle, which is attached by straps to the iron framework of the plaster
bed. This pelvic girdle is accurately moulded to the iliac crests and
pelvis, thus obviating pressure sores. There is also attached to the
middle line of the plaster bed, at a point corresponding with the
centre or most prominent part of the dorsal convexity or hump, a broad
band of webbing which passes laterally across the convexity and is
attached to a horizontal iron bar fixed in the plaster bed. The con¬
vex ribs rest upon this band of webbing, and are consequently con¬
tinuously subjected to considerable pressure in an anterior direction.
The influence of such pressure upon the dorsal convexity is enhanced
by the recumbency of the patient and by the simultaneous extension
of the vertebral column.
REPORT ON I)R. ESSEX WYXTER'S CASE OF CYANOTIC
ANAEMIA.'
The committee has had the opportunity, thanks to the kindness of
Dr. Essex Wynter, of examining further the patient, her blood and the
records of the case. The notes taken during her stay in St. Mary’s
Hospital have also been referred to.
In 1895 the patient presented herself at St. Mary’s Hospital,
cyanosed and anaemic, with indications of slight jaundice. She gave a
history of having had these same symptoms for two years previously, her
illness being dated from mental and bodily strain in nursing her mother.
At that time the red corpuscles numbered 4,000,000 per cubic millimetre
and the haemoglobin value was 50 per cent. In 1896 the red count fell
to 2,500,000 for a time. The diagnosis was thought to lie between
Addison’s disease and some form of aniline poisoning, but the former
diagnosis was considered the more probable, in view of the peculiar tint
of the skin and the fainting attacks and vomiting which were at that
time prominent symptoms.
Throughout her illness she has had continuous slight pyrexia, with
occasional bursts of high temperature, some of which have followed the
administration of suprarenal extract. The only additional point brought
out by the further examination of the patient was a distinct enlargement
1 Shown on December 13, 1907. See Proc. Roy. Soc. Med., i., No. 3., Clin. Sec., p. 48.
my —4b
198 Report on Case of Cyanotic Anaemia
of the spleen, which reached to about two fingers’ breadth below the
costal margin.
Further examination of the blood showed no evidence of active
haemolysis, the serum was untinted, the red cells were well formed, and
there were no nucleated red cells. Spectroscopic examination of the
blood, diluted with distilled water, showed, in addition to the bands of
oxyhaemoglobin, a narrow band in the red, which on measurement was
found to occupy the position of the corresponding band of sulphaemo-
globin (namely, from X 610 to X 625) as distinguished from that of
methaemoglobin (X 620 to X 645).
The band in red was not removed by a small addition of ammonium
sulphide, but only by such an excess as destroys the band of sulph- as
well as that of methaemoglobin. With carbon monoxide the band in.
red w T as shifted towards the D line, and the oxyhaemoglobin bands
were also shifted. This important test for sulphaemoglobin was
described by S. West and Wood Clarke. 1
The urine had a brownish tint. It showed no spectroscopic absorp¬
tion bands, and no nitrites could be detected in it by the meta-phenylene-
diamine test, which was checked by the addition of a trace of nitrite to a
second specimen.
The further examination of the blood was carried out because it is
only by exact spectroscopic measurements or by comparison of spectra
that a sure distinction can be made between methaemoglobin and
sulphaemoglobin.
We conclude that the case in question is one of intracorpuscular
sulphaemoglobinaemia. The obstinate constipation, which is a con¬
spicuous feature of the case, appears to be an important symptom of
that condition, whereas enterogenous methaemoglobinaemia is usually
associated with diarrhoea.
W. Essex Wynter.
J. H. Drysdale.
F. John Poynton.
Archibald E. Garrod.
1 Med.-Chir. Trans ., 1907. vol. xc.
Clinical Section.
May 8, 1908.
Sir Thomas Barlow, Bt., K.C.V.O., President of the Section, in the Chair.
A Case of Arterio-venous Anastomosis for Senile Gangrene.
By C. A. Ballance, M.V.O., M.S.
Mrs. P., aged 75, was admitted to St. Thomas's Hospital on
September 20, 1907, with arterial gangrene of the toes of the right
foot. Patient said that she dropped a fender on the right foot five years
previously and had subsequently felt pain from time to time in the right
leg and foot. Three weeks before admission the pain settled in the toes
of the right foot and the second toe became blue.
On admission the first, second and third toes were blue black in
their distal halves, and the fourth and fifth toes also were somewhat
discoloured. Patient complained of much pain in the foot, but no pain
was felt above the popliteal space. The fingers of the left hand were
bluish in colour and somewhat tender. % The urine contained no sugar
and only a very slight trace of albumin; the specific gravity was 1009.
All the palpable arteries were thick-walled and the pulsation in them
was feeble. The arteries of the right foot could not be felt. The right
femoral could be felt beating at the apex of Scarpa’s triangle. The toes
were powdered with boric acid and covered up with cotton wool.
During the next three weeks the local gangrene appeared to be
stationary, but the patient suffered a good deal of pain, for which
sedatives were required. The gangrene then began to extend; the
toes, especially the first three, became black and their whole surface
was affected. The discoloration of the skin advanced over the dorsum
of the foot, and the discoloured area w r as insensitive to light touches.
(See Plate, fig. 1.)
ju —1
200 Ballance: Arterio-venous Anastomosis for Gangrene
It was explained to the patient that either immediate amputation
must be done or a less severe operation first attempted in the hope of
saving the limb. She chose the latter alternative.
Operation .—October 17, 1907 : Dr. Mennell gave chloroform by the
Vernon Harcourt apparatus, spinal anaesthesia being considered inadvis¬
able. The gangrenous toes, foot and leg were bandaged in wool, and indeed
the whole body of the patient except the operation area was so encased.
The right lower limb was everted and the knee flexed and supported on
a sandbag. An incision 6 in. long was made on the inner side of the
thigh from the apex of Scarpa’s triangle downwards over Hunter’s canal.
The sartorius was displaced inwards and the long saphenous nerve and
the nerve to the vastus internus were drawn outwards. The artery and
vein were next isolated from one another, and one venous and two
arterial branches were tied.
The vein appeared to be unusually small, but this was because it was
not distended with blood. The sheath of the artery was adherent and
somewhat difficult to remove. On the middle of the exposed artery was
a yellow patch of atheroma. The plan of operation was to draw the
divided end of the vein like a sleeve over the divided end of the artery.
As the patient had never had any pain in the thigh, it did not occur
to me that the artery might be thrombosed at the site of operation.
Without further examination of the artery I proceeded with the opera¬
tion. The lower end of the exposed portion of the vein was clamped
and the upper end ligatured and divided on the distal side of the ligature.
At the upper end of the incision the artery was clamped w T here it was
visibly pulsating ; at the lower end the artery was tied and divided
proximal to the ligature. The artery was of the same size throughout
the whole length of the wound. The clamps used were Crile’s artery
clamps. There was a good deal of retraction of both artery and vein,
but the ends overlapped for about in. On cutting through the artery
I was surprised to find in it a partly organized thrombus, but this
thrombus I was able to remove with a fine curette. I slit up the artery
bit by bit hoping to come upon a portion in which the intima was
normal, but at least 2 in. of artery had to be removed before fairly
healthy intima was reached. Thus it became impossible to pass the
vein like a sleeve over the end of the artery, and the only method of
anastomosis possible was end-to-end suture under tension, because there
was now a gap of about | in. between the ends of the vessels. The end-
to-end anastomosis was accomplished by using eight 0 silk and No. 20
straight needles. On releasing the clamps the veins did not fill up with
Clinical Section
201
blood. On careful palpation I thought I could feel a small thrombus
just above the anastomosis. I made a longitudinal incision in the artery
and removed the bit of thrombus, which I supposed had been displaced
upwards by the curette at an earlier stage of the operation. The incision
in the artery was then closed by a few interrupted stitches and the
clamps again taken off. There was no bleeding from the anastomosis,
but there was a small leak from the longitudinal incision in the artery.
Two more stitches stopped the leak entirely. The incision should have
been made in the transverse direction, for when blood fills an artery a
transverse incision appears as a slit, while a longitudinal one appears as
a round or oval hole, the reason being that the transverse tension in a
cylindrical vessel is twice the longitudinal. There was no leakage from
the anastomosis or from the incision in the artery, so attention was
directed to the vein, w’hich, though filled with blood, was not pulsating.
About 1 in. below’ the anastomosis a small venous tributary had been
ligatured; this ligature was removed and a probe passed up through the
venule into the vein and thence, through the anastomosis, into the
artery. On withdrawing the probe the vein at once filled up to a size
larger than that of the artery and began to pulsate to an equal extent.
Another striking event occurred as the artery and vein became distended
with blood—they lengthened ; the vessels formed an S-shaped curve, and
my anxiety about the tension at the site of the anastomosis was at once
allayed.
During the operation the parts were kept moist by a constant stream
of sterilized salt solution and the sutures w-ere anointed with sterilized
paraffin. The sartorius was sutured in position and the wound closed in
the usual way. I was given excellent assistance during the operation by
my house surgeon, Mr. Unwin. I am much indebted to Mr. Thorburn,
dresser, for the beautiful drawings of the gangrenous foot (Plate).
Mr. Adams, the resident surgeon, reported the condition at 9 p.m. on
the night of the operation : “ There w T as full- pulsation to be felt in
Scarpa’s triangle, but below r the site of operation no pulsation could be
felt in the thigh or the popliteal space; neither could the tibial arteries be
felt pulsating at the ankle. In the veins, however, there was abundant
evidence of the passage of arterial blood, for in the middle of the leg the
internal saphenous vein in its usual situation, £ in. behind the inner
border of the tibia, could be felt pulsating, and arterial pulsation, syn¬
chronous with that in other parts of the body, could be both seen and
felt in the dilated veins visible on the dorsum of the foot. These veins
no longer conveyed venous blood, since pressure on the cardiac side of
202 Ballance: Arterio-venous Anastomosis for Gangrene
any particular trunk caused it to collapse and stopped the visible pulsa¬
tion ; while pressure on the distal side caused it to dilate and increased
the visible pulsation. There is no doubt, therefore, that at least the
superficial veins on the distal side of the anastomosis were functioning as
arteries.”
Mr. Adams made later the following note : “ This state of affairs did
not persist; after two days the pulse in the internal saphenous was
barely palpable, and though the dorsal veins of the foot remained dilated
there was very little pulsation to be seen in them, and the effects of
proximal and distal pressure approximated to those of pressure on
normal veins. The dorsal veins were less collapsible than normal and
rather seemed to contain stagnant blood, though there was no evidence
of thrombosis or phlebitis. They gradually became less prominent and
in a few days had entirely ceased to pulsate. At no time after the
operation was any pulsation felt in the tibial or peroneal arteries.”
The immediate effects of the operation were striking; arterial blood
was transmitted by way of the veins to the foot, the warmth of the foot
was increased, the advance of the gangrene (obvious before the operation)
was stayed, a definite line of demarcation appeared on the inner three
toes, and the skin proximal to the line of demarcation again became
sensitive, so that light touches were readily located. (See Plate, fig. 2.)
During the succeeding weeks the very cold weather tried the patient
much, and the left hand and the left foot became at times blue and
painful, but though pain w T as occasionally felt in the right foot, especially
in the earlv morning, it was less severe than before the operation, and
the patient slept well all night without sedatives. On February 14,
1908, the patient suddenly suffered acute pain in the abdomen, soon
followed by sickness and distension. She died the next day. At the
time of her death the black areas on the toes were separating,
granulation tissue appearing underneath the hard, black scabs, and
though during the cold weather a blue black patch appeared on the
plantar aspect of the little toe it may be affirmed that from the
time of the operation the gangrene of the right foot was arrested.
(See Plate, fig. 3.)
Autopsy .—The inner half of the caecum and the whole ascending and
transverse colon were greenish black in colour. A careful dissection
failed to discover any thrombosis in the main mesenteric vessels. The
anastomosis between the femoral artery and vein was closed by scar
tissue, which extended into the vessels above and below it for about
U in.
j
i
PROC. ROY. SOO. MI D.
Clinical Section.
Vo], 1. No. 8.
BALLANCE : A Case of Arterio-venous Anastomosis for Senile Gangrene.
Clinical Section
203
Remarks.
The experimental study of the suture of arteries and veins during the
last few years is one of the most fascinating of the many stories in the
history of surgical progress. This work and clinical suggestion have
opened up many possibilities of successful conservative surgery where
formerly nothing lay before the patient and the surgeon but a vista of
' mutilation or of death.
It is now known (1) that wounds of the heart and of the arteries and
veins may be sutured ; (2) that a thrombus or embolus may be removed
by incision of the arterial wall; (3) that portions of arteries and veins may
be transplanted; (4) that a portion of vein may be inserted between the
cut and separated ends of a divided artery, and that this portion of vein
has a strong tendency to reconstitute the artery, assuming the anatomical
characters and performing the function of an artery ; (5) that the venous
system of a limb may be made to carry red blood when the arterial
system is obstructed; (6) that an anastomosis may be made between the
portal and systemic veins; (7) that varicose veins of the leg may be
treated by anastomosis of the saphena vein with the femoral vein in the
middle of the thigh so that the blood of the saphena enters the femoral
below the valves ; (8) that organs such as the kidney and ovary may be
transplanted; (9) that in certain cases an aneurysm may, as has been
brilliantly demonstrated by Matas, 1 be treated by a new and striking
method, not by occlusion but by reconstitution of the artery from which
1 An attempt to close a traumatic aneurysm with restoration of the function of the artery
was made by an English surgeon 150 years ago, and was apparently successful. The
following is the published account of the case : “A case of aneurysm from bleeding occurred
and fell to the lot of Mr. Hallowell. I recommended the method that I have hinted at. He
put it in execution on June 15, 1759. Everything was done in the usual method till the
artery was laid bare and its wound discovered, and the tourniquet was now slackened; the
gush of blood per saltum showed that there was no deception. Next two ligatures, one above
the orifice and one below, were passed under the artery that they might be ready to be tied
at any time in case the method proposed should fail. Then a small steel pin, rather
more than \ in. long, was passed through the two lips of the wound in the artery and
secured by twisting a thread round it as in the hare-lip operation. This was found to
stop the bleeding, upon which the arm was bound up, the patient put to bed and ordered to
be kept quiet, &c., as usual in such cases. The wound was dressed on the fourth day, viz.,
June 18; it looked well for the time and continued to heal without interruption in a kindly
manner. The pin came away with the dressings on June 29, that is on the fourteenth day,
and on July 7 every part of the wound was healed except what was kept open by the two
ligatures, which remained loose in the flesh like two setons; these were therefore removed.
A few days after this the wound was completely cicatrized and on July 19 patient was
discharged from the hospital perfectly well and with the pulse in the arm nearly as strong
as in the other.”— Lambert, of Newcastle, in a letter to Hunter published in Medical
Observations and Enquiries , 1762, ii., p. 360.
204 Ballance: Arterio-venous Anastomosis for Gangrene
it arises, or the blood-stream may be diverted from the aneurysm, as was
done in 1906 by Jos6 Goyanes, by arterio-venous anastomosis, an
operation which might not only cure the aneurysm but prevent or arrest
gangrene.
The experiments of Carrel, Jensen, and Watts show that end-to-end
anastomosis of arteries and veins is best performed by simple suture,
a fact which has long been established with regard to suture of
the intestine. The extra-vasal magnesium rings of Payr, the glass
cylinders of Abbe and Gluck; the endo-vasal caromel cylinders of
Carrel and the glass bobbins of de Gaetano have now only an his¬
torical interest, like Senn’s plates and other mechanical aids to intestinal
anastomosis.
Further, the experiments show that the intima may be included in
the suture with impunity, the application of the suture being thus
greatly facilitated, just as the suture may perforate with impunity the
mucosa in intestinal surgery, as we have recently learned. In intestinal
suture the threads, even when inserted by Lembert’s method, gradually
become free in the lumen of the bowel, but those applied for vasal suture
remain in situ, as the interior of a blood-vessel, unlike that of the
intestine, is aseptic and not outside the body.
Arterio-venous anastomosis was first successfully performed by Gluck,
who writes : “ I have succeeded in anastomosing the arteria carotis with
the vena jugularis of the dog by means of a circular suture without any
thrombosis; it was interesting to observe how there was at first a sort
of whirlpool between the opposing streams of blood in the artery and
vein, when the arterial blood flowed in a pulsating stream through the
smaller channel of the artery into the wider vein. After a minute or
two the arterial blood-stream flowed with regular pulsation through
the vein and maintained its superior force and regularity.” The length
of time the animal lived after the operation is not mentioned.
Carrel and Morel, in 1902, successfully carried out the same operation
and showed the dog several weeks afterwards at the Societe Nationale de
Medecine.
Following upon these experimental results an attempt was made to
treat arterial gangrene in man by lateral anastomosis of the femoral
artery and vein. San Martin y Satrustegui operated upon two patients,
both men, one aged 52 and the other aged 66 ; and Jaboulay published
one case, that of a man, aged 47. All these cases w T ere unsuccessful.
Carrel and Guthrie maintain that lateral anastomosis fails because
(1) a very large proportion of the red blood returns at once to the heart
Clinical Section
205
through the central end of the vein ; (2) the peripheral portion of the
vein and its branches pulsate, but the valves are not forced and the red
blood does not circulate through them.
Hubbard, of Boston, Mass., published in 1906 the case of a man,
aged 80, in whom he did end-to-end arterio-venous anastomosis at the
apex of Scarpa’s triangle for senile gangrene of the right foot. The
vein below the anastomosis never filled up properly and only partially
pulsated. The superficial veins never pulsated, the gangrene spread and
amputation was performed.
Torrance, of Birmingham (Alabama), made an end-to-end arterio¬
venous anastomosis between the anterior tibial artery and the saphenous
vein in a case of compound fracture with injury to the artery, but the
anastomosis sloughed.
Mr. Adams, the resident surgeon at St. Thomas’s Hospital, and the
writer performed some experiments on the cadaver with a view of deter¬
mining how far fluid of the same specific gravity as the blood could be
made to traverse the lower limb under normal or more than normal
pressure through the veins. An injection into the femoral vein at the
apex of Scarpa’s triangle appeared immediately in the inferior vena cava
and azygos veins, and did not descend the limb further than the popliteal
space. An injection into the femoral vein in Hunter’s canal only reached
the middle of the leg. These experiments confirm those of Gallois and
Pinatelle, who found that the valves formed an insuperable obstacle,
and they came, therefore, to the opinion that arterio-venous anastomosis
was not a justifiable operation in man.
Carrel and Guthrie, however, while admitting that though logically
the reversal of the circulation is impossible, have shown that the living
tissues have a strong pow r er of adaptation, and by a series of beautiful
experiments have proved that it is possible. They watched the red
blood forcing the valves of the veins; in two hours all the valves in the
saphenous vein were forced and in three hours the reversal of the
circulation was complete.
It will be noted that, in the writer’s case, the thrombus, which was
the immediate cause of the gangrene, had blocked the femoral artery in
Hunter’s canal, though before the operation it was thought that the
popliteal was the artery occluded. Francis Street, in a paper on arteri-
otomy for thrombosis and embolism, remarks on the inability which is
sometimes encountered to locate definitely the obstruction by the mere
symptoms. He points out that the symptoms are caused, not by the
thrombus itself, but by the result of the arterial obliteration; “ the pain
206 Ballance: Arterio-venous Anastomosis for Gangrene
is referred to the area from which the blood is excluded, not to the seat
of obstruction.”
The arterio-venous anastomosis in my case could have had no effect
in increasing the arterial obstruction in the vessels of the limb, since the
artery was thrombosed at the site of the anastomosis. How long the
anastomosis remained patent it is impossible to guess. It may have
been occluded in three days or it may have been patent for a time
longer or shorter than three days. The fact remains that it had an
immediate and remarkable effect on the gangrenous process, and if it
had been permanently patent it cannot be doubted that a still more
striking result would have been attained. The result would appear to
justify the hope that we are in sight of a method which will replace,
in certain cases, the necessity for amputation in senile gangrene, and of
a method which may be applied to the relief of those distressing cases
of endarteritis obliterans in the limbs of young people which are some¬
times observed.
There is no doubt that the operation of arterio-venous anastomosis is
not an easy one and that it requires practice and manipulative dexterity.
Edwin Sweet writes: “ Now this seems very easy, and in truth it is not
very difficult, except for the extreme delicacy of the needles and the silk
and the vessel walls; it is unusual surgery, since it partakes of the art
of the watchmaker. Why, then, cannot everyone succeed in perform¬
ing these simple though delicate operations ? Why do we read reports
varying between absolute failure and uniform success?”
Stephen Watts observes: “ I wish also to emphasize the point, for
I consider infection by far the most important factor in producing
thrombosis after vascular sutures. I think, as Carrel does, that there
may be minor modes of infection which, although allowing of per primam
healing of the wound, may be sufficient to produce thrombosis of the
sutured vessels.”
But Edwin Sweet’s comment seems to me most apposite: “ That
some coagulation occurs in every case seems to be proven by the state*
ment that slight haemorrhage is to be controlled by gentle digital com¬
pression. Such a method could only stop haemorrhage, it seems to me,
by favouring the filling of the needle holes by coagulum. I think,
therefore, that those who report uniformly successful results have
succeeded, not because they enjoy a monopoly of aseptic technique, but
of mechanical technique.”
i j —
Clinical Section
207
REFERENCES.
Carrel, Alexis. “ Anastomosis and Transplantation of Vessels, Med., 1905, x.,p. 284 ;
“The Surgery of the Blood-vessels,” Johns Hopkins Hosp. Bull., 1907, xviii., p. 18.
Carrel and Guthrie. “The Reversal of the Circulation in a Limb,” Ann. Surg., 1906,
xliii., p. 203; “ Uni terminal and Biterminal Venous Transplantations,” Surg.,
Gyn. and Obstet ., 1906, xi., p. 266, and Amer. Joum. Med. Sci., 1906, exxxii.,
p. 415 ; “ Results of a Replantation of the Thigh ” and “ Successful Transplantation
of both Kidneys,” Science , New York and Lancaster, Pa., 1906, and Amer. Med.,
1905, x.; and several other papers.
Carrel. “La technique op6ratoire des anastomoses vasculaires et do la transplantation
des visc&res,” Lyon Mid., 1902, xcviii., p. 859.
Oklbet, Pierre. “Traitement des varices par l’anastomose saph£no-f6morale,” Dull.
Mid., 1906, p. 1119.
Kck, a Russian Army surgeon, in 1876, conceived the idea of making an artificial opening
between the portal vein and the vena cava, in order to relieve the congestion of the
portal system in cases of cirrhosis of the liver. He executed the idea experi¬
mentally. (Quoted from Sweet.)
Gallois and Pinatelle. “Un cas d’anastomose arterio-veneuse longitudinale pour
art^rite obliterante,” Rev. de Chir ., 1903, xxvii., p. 236.
I)e Gaetano. “ Aneurisma traumatico dell’arteria omeraie ; asportazione dell’aneurisma e
sutura dell’arteria ; guarigione,” Giorn. inter, di Soc. med., 1903, N.S. xxv., p. 529.
Gluck. “ Die moderne Chirurgie des Circulations-apparates,” Berl. Klin., 1898, H. 120, p. 1.
Gqyanes, Josfc. Siglomid., Madrid, liii., pp. 546, 561, 1906, xliv.
Jaboulay. “ Chirurgie des arteres,” Sem. m€d., Paris, 1902, xxii., p. 405.
Matas, R. “An Operation for the Radical Cure of Aneurysm, based upon Arteriorrhaphy,”
Ann. Surg., 1903, p. 161. “The Present State of Intra-saccular Suture or Endo-
aneurysmorrhaphy,” Joum. Amer. Med. Assoc., Chicago, 1906, xlvii., p. 990.
Monod and Vanverts, “Traite de technique operatoire,” 1907, i., mention suture of vessels,
Matas’ operation, arterio-venous anastomosis and veno-venous anastomosis, and give
many references to the literature of the subject.
Payr. “ Zur Frage der circularen Vereinigung von Blutgefiissen mit resorbibaren Prothesen,”
Arch. /Ur klin. Chir., Berl., 1903-4, lxxii., p. 32.
Satrustegui, San Martin y. “ Cirurgia del apparato circulatorio,” Madrid, 1902.
Stewart, Francis. Ann. Surg., Philad., 1907, xlvi., p. 339.
Stich, R., Makkas, M., and Dowman, C. E., of Breslau, in a paper entitled “ Beitriige zur
Gefasschirurgie,” and published in the Beit, zur klin. Chir., Tubingen, 1907, liii.,
p. 113, give as the result of their experiments to the following conclusions:—
(1) Arteries which have been completely divided transversely may be made to
unite by the method of suture we employed (fixation threads and continuous suture)
without special difficulty, and, provided the workmanship is good and the course of
the wound aseptic, with every prospect of complete restoration of function. The
method succeeds with both large and small arteries.
(2) Portions of arteries may be resected and a segment of an artery from the
same individual or from an animal of the same species may be put in its place.
(3) A portion of an artery from a recently killed animal may be put in the place
of a segment of artery resected in a living animal of the same species with complete
restoration of the function of the vessel.
(4) It is even possible to transplant a portion of artery from one animal to
another of a different species.
(5) A segment of vein may be transplanted into a gap in an artery ; the segment
of vein so transplanted undergoes changes in structure so as to, in time, come to
resemble an artery.
In this paper reference is made to an operation performed in 1906 by Jos<$
Goyanes, who treated a popliteal aneurysm by arterio-venous anastomosis.
208 Ballance: Arterio-venous Anastomosis for Gangrene
Sweet, J. Edwin. Ann . Surg ., Philad., 1907, xlvi., p. 350.
Torrance. Ann . Surg., Philad., 1904, xl., p. 107, and 1907, xlvi., p. 333.
Watts, Stephen. Ann. Surg., Philad., 1907, xlvi., p. 373, and Johns Hopkins llosp. Bull..
1907, xviii., p. 153. In this admirable paper a full bibliography, to which I am
much indebted, is given.
DISCUSSION.
Mr. FORBES Ross said he had been much interested in senile gangrene,
angina cruris, and other conditions affecting the arteries of the lower limb ; also
in spasms affecting the hands, as in pseudo-Raynaud’s and true Raynaud’s
disease. There was an occlusion of arteries which was physiological, but
enough use had not yet been made of it. In ordinary aneurysm of the popliteal
artery,, in which the vessel was ligatured above and below the sac, and the
aneurysm dissected out, in twenty-four hours the limb was flushed and a large
volume of blood was passing through it; there was positive vasomotor dilata¬
tion. His views on the matter had been driven home by a case shown by Dr.
Parkes Weber at the Neurological Section, and reinforced by one shown by
proxy for Sir William Gowers. He believed that what Mr. Ballance had done
simply amounted to ligature of the femoral artery. Nature was trying to
occlude the artery as fast as she could. In cases where one might expect
gangrene, or arterial spasm, or angina cruris it was feasible for the surgeon to
operate before necrosis set in, ligaturing the vessel as low as it could be
reached, and thus restoring to the patient an elastic circulation. Mr. Ballance
had tried to use a very elastic vein to replace a very inelastic artery. When a
blood-vessel was tied a collateral circulation was established, and the capillaries
had to hypertrophy to carry it out. He, of course, did not propose to ligature
the artery to produce gangrene, but to produce vasomotor dilatation, which
would end in giving the patient ten arteries instead of one. Alexander
Morison had shown the profession—and he worked with Dr. Morison w T hen he
did it—that all the arteries of the body were innervated by ganglia in their
walls, and that w r hen a main artery was tied, there was a disturbance of the
main nerve supply of the limb, and one perhaps destroyed the whole nervous
energy going dow T n that artery. So w-hen Mr. Ballance cut the artery he was
possibly disturbing the nervi cirteriorum , and ultimately the vein ceased to
pulsate. It w r as evidently occluded, and therefore practically ligatured. He
suggested that ligature, either deliberate or not, as low' dowrn as possible, was
the correct procedure in some of the cases, thus helping Nature in w T hat she
was trying to do, viz., to get the collateral circulation to open up.
Mr. BALLANCE, in reply, said he did not think the remark of Mr. Forbes
Ross was exactly apposite to his paper, as he was only dealing with arterio¬
venous anastomosis, not discussing other methods of treatment.
Clinical Section
209
A Case of Leucodermia, which died with Symptoms of
Addison’s Disease, and in which Cirrhosis of the Supra-
renals was found.
By Norman Dalton, M.D.
The patient, Sarah C., was aged 35 at the time of her death. She
was a charwoman and unmarried. There was nothing of any import¬
ance in the family or personal history. She was a teetotaller. The
leucodermia had existed for ten years before the gastric symptoms
set in, and she died in syncope three months later. The skin
affection was diagnosed as leucodermia by several eminent derma¬
tologists, and the photographs which are being shown, and which,
by the way, were taken after death by Mr. Keid, leave no doubt
that it was a genuine case. Consequently I need not describe the
appearances of the skin except to say that the white patches were
large, numerous and widely distributed over the body. There was
one curious point, however, namely, that though the patches were
quite devoid of pigment and appeared absolutely white after death,
during life they had the faintest possible tinge of pink, so that
she was not so much brown and white as brown and pale pink,
which made her appearance even more extraordinary than is usual
in such cases.
In July, 1907, she began to suffer from epigastric pain and
vomiting and general weakness, for which no cause could be found.
She improved during a visit to the seaside, but relapsed on her return
home and became so ill that she was admitted into King’s College
Hospital on October 4. On examination, nothing was noted but a
weak pulse of 80 to the minute, an absence of the cardiac impulse
and a septic condition of the mouth from bad teeth. While in
the hospital she continued to vomit in spite of all kinds of treat¬
ment. There was no blood in the ejecta, and as the taking of food
temporarily relieved the sickness, I thought that there could scarcely
be a gastric lesion. Tabes was easily eliminated, and, although it
crossed my mind, I cannot say that I seriously thought that it
was a case of Addison’s disease. The temperature was normal, not
subnormal. She rapidly became weaker, and on October 15, eleven
210
I )ahon : ( '<isr of Leucodermia
<I;i \ > after admission, she suddenly became deadly faint, with an
imperceptible pulse, &c., and she died in a few hours.
I had seen her during the final syncope and could not fail to
observe the resemblance to the manner of death in Addison’s disease,
so that at the post-mortem I turned my attention particularly to
the adrenals. At tin* time these appeared quite atrophied and to
consist merely of loose connective tissue, blood-vessels, and some
small buff-coloured areas which might be remnants of suprarenal
tissue. Thi> is rather remarkable because, when they were hard¬
ened, they contracted and became firm and compact, so that in the
specimen which I am showing they appear somewhat small, but other¬
wise normal. Howrwr. on microscopical examination they proved
to be cirrhotic. The fibrous capsule and stroma are increased in
quantity, the columnar arrangement of the cells is to a great extent
lost, and the cells are arranged in lobules surrounded by fibrous
tissue. In some places the fibrous i issue extends between the cells
as in intercellular cirrhosis of the liver, and many of the cells are
fatty or broken up. In one place the lobule is infiltrated with fresh,
bright-staining leucocytes. At the post-mortem there was apparently
no fibrosis around the adrenal, so that neither the semilunar ganglia
nor the suprarenal veins were likely to be compressed. Consequently
the ganglia were unfortunately not dissected out. There is nothing
else to be noted in connection with the post-mortem.
I am anxious to put this case on record because it is extremely rare.
Dermatologists state that leucodermia does not affect the general health,
and this patient was quite well for ten years in spite of the skin affec¬
tion. Further, it is not easy to find a record of a post-mortem on a case
of leucodermia, and most of us would have been inclined to say that
patients with that affection always die of some intercurrent disease.
Hence it is as well to know that in rare instances symptoms of Addison’s
disease may supervene, with fatal results, and that lesions of the supra¬
renal have been found in these cases after death. My case, though rare,
is not unique, for in the Glasgow Medical Journal for 1879 (first part)
Dr. McCall Anderson describes the case of a man, aged 50, who, after
suffering from asthenia with vague and varying pigmentations for some
years, eventually developed definite leucodermia, together with gastric
symptoms, and finally died of cardiac failure. In this case extensive
degeneration of the suprarenals was found. Dr. McCall Anderson
states that Dr. Greenhow had recorded a similar case, but I have not
been able to find it in the latter's work on Addison’s disease.
Clinical Section
211
I may say that I do not think that the conjunction of leucodermia
with symptoms of Addison’s disease is a mere coincidence, but I have no
theory of my own to explain the association. Before theorizing it would
be necessary to be more certain about the pathology of uncomplicated
leucodermia, and there is no time to discuss either the neurotrophic
or the toxic theories. It is possible, however, that this case may be
heard of again in connection with the pathology of leucodermia, for it
will be observed in the picture that there is a large white patch round
the eye, and I have the authority of Mr. Lenthal Cheatle for saying that
he has found a chronic inflammatory condition in the corresponding
Gasserian ganglion of this patient.
N.B.—The following points may be noted as show T ing that the
pigmentary changes in the skin in this case were typical of those seen
in leucodermia, and distinct from those seen in Addison’s disease. The
white patches were sharply demarcated from the dark, and they w r ere
situated in areas supplied by certain cutaneous nerves, notably on the
face, where the areas supplied by certain branches of the supra-orbital
nerve were quite white. The white patches were devoid of pigment,
and the only point in them which suggested anything not quite typical
of leucodermia was the faint pink blush to which I have alluded in my
paper. The dark patches were darker than the skin of Europeans.
There was nothing in the history or the appearances to suggest that the
white patches were areas which had escaped the pigmentation of
Addison’s disease. The patient did say that she first thought that she
had freckles, but this is, I am told, not infrequent in leucodermia, as
the white patches do not attract the patient’s attention. No change
occurred in the skin during the last few months of life, i.e., no increase
in the white or dark areas. There was a localized patch of white hair
on the pubes, such as is very typical of leucodermia. When the case
was admitted to the wards I asked Dr. Arthur Whitfield, physician to
the Dermatological Department in King’s College Hospital, to see it in
consultation with me. He then confirmed my opinion that the skin
condition was typical of leucodermia, and mentioned that he had seen
the case some time before in his department and had made the same
diagnosis. From the other point of view it may be mentioned that
there was no bronzing of the areolae of the breasts, or the pubes, or the
axilla, or the inside of the mouth. Exposed parts were also free from
bronzing, the backs of the hands (as seen in the pictures exhibited)
being the seat of a large white patch.
212
Still: Hairball in the Stomach
DISCUSSION.
Tho President (Sir Thomas Barlow) mentioned that the late Dr. Leech,
of Manchester, brought forward a similar case some years ago. The case was
published in the Transactions of the Pathological Society , vol. xxx.
Sir Dyce Duckworth said that it seemed clear that the condition of the
suprarenal bodies in this case w r as very different from that commonly found in
ordinary cases of Addison’s disease. In the present case there seemed to be
almost absolute atrophy, w T hereas -in ordinary Addison’s disease the adrenals
were much enlarged and in a tuberculous condition. There were many cases in
which modification of pigment had been observed in connection with changes
in the suprarenal bodies, but wiiich had not presented all the characteristic
symptoms of Addison’s disease. However, the present case and similar ones
seemed to point to a very close relationship betw r een the positive pigmentation
or vagaries of pigmentation and the functions of the suprarenal bodies. •
Dr. PARKES WEBER thought that the photographs of Dr. Dalton’s patient
showed great general melanodermia, ?>., except for the patches of pale skin. He
thought that the pigmentation might be the real melanodermia of Addison’s
disease, which had left circumscribed areas of normal skin untouched so as to
simulate the leucodermia of Vitilogo. He asked Dr. Dalton whether there was
any evidence against this view, either from the results of microscopic examina¬
tion of the pale and dark portions of the skin, or from clinical records as to the
commencement of the pigmentary abnormality. Did the white patches com¬
mence to appear when the skin generally was normal in colour ?
Dr. DALTON, in reply, said that the patches had not been examined w'ith the
microscope. The diagnosis had been decided by dermatologists who saw the
case during life and w T ere satisfied as to its nature. The condition started ten
years ago, and he could not say from personal observation what had been the
manner of its development.
Hairball in the Stomach.
By G. F. Still, M.D.
Lucy A., aged 9, was admitted into King’s College Hospital on
February 12, on account of an abdominal tumour, which had been
noticed first seven months previously. * The abdomen had been noticed
to be large for about a year, and there had been frequent sickness almost
daily for several months. The child had become more ill during the
last tw-o months. The appetite was very bad, the bowels w r ere regular,
and for the last three weeks the child had taken milk only. There
had been much “ pain in the pit of the stomach ” for three months.
Clinical Section
213
The mother stated that for several years past the child’s hair dropped
out during two days in June ! [No importance was attached to this
statement, nor, indeed, to the scantiness of the child's hair, until operation
showed the nature of the tumour, when it was ascertained that the child
had been in the habit of pulling out her hair and eating it since she was
3 years old.]
On admission the child was bright and intelligent, somewhat wasted
and pale, but not acutely ill. There was no sign of disease except in
Hairball removed by Mr. Burgbard from Dr. Still’s case.
the abdomen, which was large and lax, and showed, as the child lay on
her back, a slight prominence across the epigastric region, w r hichon pallia¬
tion corresponded to a very hard tumour extending from the left costal
margin in the splenic region to the right nipple line, where its lower edge
was at the level of the umbilicus; it was 2| in. w r ide at its thickest part,
which was near its right extremity. Its upper and lower edges and its
right extremity w^ere well defined and seemed quite superficial, though
214
Still: Hairbcill in the Stomach
evidently inside the abdominal cavity ; it was not tender, its surface
was smooth ; it was thought to be slightly movable up and down.
Various diagnoses w 7 ere suggested, including enlarged spleen (but the
spleen seemed to be definable by percussion and not continuous with
the tumour), lympho-sarcoma, and a tubercular infiltration. Whilst
in hospital the child seemed free from pain, and vomiting was only
occasional, but the child would take very little food.
It was decided to explore, and Mr. Burghard did laparotomy. The
stomach was found to be dilated by a hard mass, which w 7 as evacuated
through a longitudinal incision about 3 in. long, near the pyloric end of
the stomach. The mass proved to be a hairball, weighing 17 oz. and
measuring in its long axis 6 in., in circumference 7£ in., and along its
greater curvature 13£ in. It had exactly the shape of the stomach, of
which, indeed, it formed a solid cast; it tailed olf at the cardiac orifice
into a narrower tail-like portion, which must have extended quite 2 in.
up the oesophagus.
DISCUSSION.
In answer to the President, Dr. STILL said that a 3 in. incision was made
in the longitudinal axis of the stomach and very near the pyloric end, and
even then the incision was only just large enough. The hair had formed a
complete cast of the stomach, and a portion tailed off into the oesophagus.
Mr. C. A. BALLANCE said he had had a somewhat similar case, in a woman,
aged 21, who was in St. Thomas’s Hospital some years ago with an obvious
tumour in the epigastrium. She had occasional vomiting, and an operation
was done to determine the diagnosis. The stomach was found distended with
a hard mass, which occupied the whole of it. He incised the stomach wall
and pulled out an enormous mass of hair. It did not extend up into the
cesophagus, but down into the duodenum and into the jejunum. By careful
manipulation and gentle pulling he got it out from the intestines, and believed
he removed all the hair from the stomach and intestines. She made an
uneventful recovery, and denied that she had ever eaten any hair. He did
not think that she could have eaten her own hair, as she had an abundance of
it upon both sides of her head.
Dr. Dalton said that by the kindness of Dr. Still he had had an oppor¬
tunity of seeing the case before the operation, and it was obvious that the
condition was connected with the stomach. If the patient had been an adult,
one should have thought of an enormous lympho-sarcoma, such as was some¬
times found. The only point opposed to that was the extreme hardness of the
tumour.
Dr. A. Masters said that about fifteen years ago he was called to see a
girl aged 15, who had exceedingly thick hair, which was also very long. The
Clinical Section
215
mother complained that she could not prevent her chewing the ends of the
hair. A little plain talking seemed to put an end to the habit, and he believed
that no ill results in the shape of a tumour ensued. He remembered in child¬
hood having seen a hairball taken from a cow’s stomach, wherein it had formed
in consequence of the cow’s habit of licking itself.
Dr. Travers Smith said the statement of Dr. Masters reminded him of
a post-mortem examination which he made on a cat. Cats were very fond of
biting off bits of grass and swallowing them, and he believed that th^y did so
in order to introduce some foreign body into the stomach around which the
hair which they swallowed in cleaning themselves could be wound. In the
stomach of a cat which had not died of disease a whorl of hair and grass
would be found. This might afford some indication for treatment.
Mr. T. SUTTON Townsend remarked that lambs were very fond of pick¬
ing wool off their mothers, and the swallowing of that wool and the blocking
of the intestines was responsible for probably 40 per cent, of the deaths during
the lambing season.
A Case of Rupture of the Upper Cord of the Brachial Plexus
at Birth.
By Sir Thomas Barlow, Bt., K.C.V.O., M.D., and
C. A. Ballance, M.Y.O., M.S.
A. J. w t as seen in October, 1903. He was then aged 10 months.
On the day following birth, which was instrumental, the right arm was
noticed to be paralysed. On examination the right upper extremity
was seen to be rotated inwards, so that the palm of the hand looked
backwards and outwards. The deltoid, biceps, brachialis anticus and
supinator longus muscles were obviously paralysed. On palpation above
the clavicle a small hard lump could be felt in the region of the upper
part of the brachial plexus. A few days later the muscular reactions
were tested under chloroform by Dr. Purves Stewart. The deltoid,
biceps, brachialis anticus, coraco-brachialis and the supinator longus
were totally paralysed and devoid of faradic excitability, except the
deltoid, which had a slight flickering reaction in some of its fibres,
insufficient to abduct the shoulder. The extensors of the fingers, which
were somewhat feeble voluntarily, reacted w T ell, as did also the rhomboids,
latissimus dorsi, pectorals, triceps, flexors of wrist and fingers and the
supra- and infra-spinati. The lesion wus therefore below the place where
ju —2
216 Barlow & Ballance: Rupture of Brachial Plexus
the nerves to the rhomboids and the spinati are given off, and was, in
fact, in the most usual site of injury in birth palsies of the brachial
plexus, at or just below the junction of the fifth and sixth cervical
nerves (fig. 1).
BRACHIAL PLEXUS AND SUPPOSED SITE OF LESION
BEFORE OPERATION
SUPINATOR
LONGUS
Fig. 1.
On October 29, 1903, the upper part of the brachial plexus was
exposed by operation (fig. 2). The little lump felt before operation was
found to be on the distal extremity of the fifth nerve, and to it the sixth
Clinical Section
217
nerve was adherent. The lump was in reality the bulb on the proximal
end of the ruptured nerve. There w T as some matting of the tissues around
and below the bulb. Beyond the bulb was a small mass of scar tissue,
and from this three nerves seemed to proceed. These were stimulated ;
the upper was the suprascapular, the next caused contraction of the
deltoid and biceps, and the lowest contraction of the brachialis anticus
and supinator longus. On stimulating the fifth nerve above the bulb no
movement of the paralysed muscles occurred, but the spinati contracted.
It was clear, therefore, that the rupture was not complete, otherwise
the muscles supplied by the suprascapular nerve would have been
paralysed.
Rough sketch at operation. The sixth nerve was adherent to the
bulb, but its further course was not defined.
The bulb and scar tissue were excised. The part excised measured
^ in. The divided ends w T ere brought together by sutures of 0000 silk—
the finest needles being used. The wound healed by first intention and
shortly afterwards the child was taken by its parents to Hong Kong.
They were advised to have massage regularly carried out.
In October, 1907, the child, now aged nearly 5, was seen again on
his return to England. Massage had been carried out in Hong Kong
by a Japanese masseur. It was obvious at once that a remarkable
improvement had taken place; the whole limb no longer hung uselessly
218 Barlow & Ballanee : Rupture of Brachial Plexus
by the side, and on faradic stimulation all the muscles reacted briskly.
There was still deficient movement of the shoulder as regards abduction
and also some deficiency of supination, both of which conditions were
in part due to adhesions in the corresponding joints. It was clear, too,
that the pectoral muscles were shortened, for on raising the arm the
tendon of the pectoral is major became very tight.
The slight adhesions in the shoulder and radio-humeral or radio-ulnar
joints were broken down under chloroform. Since October, 1907, the
Showing extent of recovery in deltoid. Showing extent of recovery in biceps.
Fig. 3.
Condition of muscles, April, 1908.
treatment has consisted of massage and gymnastic movements to further
develop the muscles.
Present State .—Notwithstanding the strong action of the biceps,
complete supination by voluntary movement is not possible, and the
cause of this is not clear; the pectoralis major is still short, and whether
it would be wise to lengthen its tendon or not is a debatable question.
Clinical Section
219
DISCUSSION.
Dr. PoYNTON remarked that the hirth paralyses of children were very
puzzling, and that it was difficult to know what treatment to advise. In a
children’s hospital considerable numbers of such cases were seen, the majority
affecting the arm, which was held low and turned backwards. The difficulty
was when to advise operation, and when not. The indications for operation
in the present case were very clear and the operation was a magnificent success.
In other cases there were no clear proofs that any one cord was torn across,
but there were a number of cords more or less damaged. He had followed up
many cases with such lesions, and had been surprised at the degree of recovery
which was attained in some of them, even without operation. He admitted
that the recovery was seldom quite complete. He would be pleased to hear
more about the indications for operation in such cases, and what was con¬
sidered by surgeons to be the best time for an operation.
Mr. C. H. Fagge said his experience of such cases was limited to three,
and he was much interested in hearing what Mr. Ballance said when compar¬
ing the two diagrams which he showed. The first diagram showed a lesion
affecting the upper trunk of the brachial plexus; in the second diagram,
representing what was seen at the operation, there was a lesion of the fifth
nerve only. The second diagram confirmed what Dr. Wilfred Hams showed
to be the probable anatomical nature of these lesions in the common type
of brachial plexus, in which all the nerve supplies of the muscles involved
came from the fifth cervical nerve. But if the second diagram was correct, he
did not know why the spinati were not affected. In the first case on which
he had operated it was possible to dissect out the fifth nerve from a mass of
scar tissue, and although the operation was undertaken eighteen months after
the injury at birth, a very fair return of power ensued. In the second case
the fifth nerve was ruptured, apparently, behind the anticus, and its distal end
was grafted into the seventh nerve, but the result was not satisfactory. In the
third case the fifth and sixth were so damaged internally to the point which
they should have reached that no operation on the trunks themselves was
considered advisable. He asked whether Mr. Ballance could give any indica¬
tion as to the time limit beyond which it was of little use to operate on such
nerve trunks.
Mr. Lockhart Mummery said that he had had several such cases, but
had not operated on any of them. He had noticed that in nearly all cases of
birth palsy there was a tendency for marked ankylosis to occur after a time in
the shoulder, between the humerus and scapula. He regarded this as a com¬
pensatory process ; he had seen one instance of marked improvement in the
mobility and usefulness of the limb resulting from such ankylosis. In it there
was a surprising increase of movement, without any improvement in the
paralysed muscles. It occurred to him that in some of the cases in which
recovery did not take place, or in which the lesion was too severe to warrant an
operation, good might be done by producing ankylosis between the scapula
220
Stewart: Gross Lesion of Post-central Gyrus
and the humerus at some favourable angle, by movements and massage, with
the aim of encouraging the action of some of the scapular muscles.
Mr. Ballanc’e, in reply, said that one question asked had related to the
course of the suprascapular nerve. The reason the spinati reacted in his case
was that the rupture was not complete; at any rate it did not involve the
suprascapular fibres. He did not think there was any time limit for the
reunion of a nerve, so long as any movements could be obtained in response to
stimulation, this having sometimes to be employed in the shape of very
strong currents, with the patient under chloroform.
Gross Lesion of Post-central Gyrus, associated with
Astereognosis.
By Purves Stewart, M.D.
M., aged 50, a publican, without history of syphilis, was previously
healthy. In 1894 or 1895 he began to complain of buzzing tinnitus
in the right ear and occasional headaches, unilateral, but not always on
the same side. In 1901 he had paroxysmal pains in the right hand and
forearm for about three weeks. In 1904 the headaches became more
severe, and at the end of 1905 he began to have attacks of vomiting.
When first examined in 1906 he showed no evidence of aphasia nor of
weakness of any limb; the optic discs were normal.
In August, 1907, he began to complain of occasional subjective sensa¬
tions of tingling in the right index and middle finger and of difficulty in
finding his words. He made mistakes in spelling, and his memory
became impaired. On examination in September, 1907, there was
weakness of the right lower face, without weakness or ataxia of the limbs
on either side. The optic discs and cranial nerves were normal. The
deep reflexes were normal on both sides; the plantar reflexes could not
be elicited. Speech was hesitating, and in writing he made frequent
mistakes of spelling, tending to miss out letters or to write the wrong
letter. He could execute spoken or written commands. Shortly after
this, in spite of energetic antisyphilitic treatment, the headache became
more intense and was now localized to the left parietal region. The right
upper limb became clumsy and slightly weak. He developed astereo-
gnosis, failing to recognize objects such as a watch-chain or a safety-pin
with the right hand, and succeeding with the left. The deep reflexes
were normal on the two sides in upper and lower limbs. By the middle
Clinical Section
221
of October, speech had become still more impaired, with difficulty in
finding words and occasional jumbling of syllables. There was no hemian-
opia. The right lower face was weak, and the right fingers and wrist
were totally paralysed and flaccid, the elbow and shoulder being feeble.
The right leg dragged slightly in walking. There was no cutaneous
anaesthesia or analgesia; the supinator-jerk and knee-jerk were increased
on the right side; the plantars were not elicited. The optic discs
remained normal.
The astereognosis of the right hand, with the steadily progressive
right hemiplegia and the intense headache, in spite of the absence of
optic neuritis or vomiting, suggested a gross intracranial lesion in the
region of the left post-central gyrus. He was accordingly sent to Mr.
Ballance with a view to operation.
On October 28 Mr. Ballance performed the second stage of an
exploratory operation in the left parietal region. The pia-arachnoid
was thick and yellow’ over part of the left post-central gyrus, the patch
of infiltration being strictly limited anteriorly by the fissure of Rolando
and by the vessel coursing therein. The diseased area occupied the post-
central gyrus, in its middle third and the adjacent part of its lower third.
At a small distance anterior to the pre-central gyrus, over the middle
frontal gyrus, there was a small stellate patch of opacity in the pia-
arachnoid, not purulent as in the post-central gyrus. The diseased area
of meninges and subjacent cortex in the post-central gyrus was removed.
On November 5 speech was hesitating, the patient talking in mono¬
syllables or isolated words, not in sentences, and occasionally misplacing
his syllables. He could read aloud, but did not attempt to execute
written commands. He could repeat sentences spoken to him, and he
understood and executed spoken commands. He could copy written
sentences with his left hand, but could not write spontaneously. No
cutaneous anaesthesia or analgesia was present. Distinct atopognosis to
touches existed in the right hand, the touches being misjudged in a
proximal direction ; with pin-pricks localization was accurate. Joint-
sense was normal in the right shoulder and elbow, but lost in the right
wrist and fingers. Astereognosis of the right hand was as before. The
external ocular movements were normal ; the right lower face was weak,
both on voluntary and emotional movement. The right shoulder and
elbow were feebler than the left; the movements of the right w ? rist,
especially extension, were still more feeble. The fingers were totally
paralysed. There was some wasting of intrinsic hand muscles, especially
the interossei, in the right hand. The right lower limb was slightly
222
Stewart: Gross Lesion of Post-central Gyrus
feebler than the left and dragged a little in walking. The right
supinator-jerk was markedly increased, the right knee-jerk moderately
increased ; there was no ankle-clonus. Plantar reflexes were both flexor
in type.
On November 22 speech had begun to improve, though still “ tele¬
graphic” in style. He had been reading the sporting papers and remarked
“Cricket match,” “Australia,” “Draw.” He sang the airs of “God
save the King ” and “ Auld Lang Syne ” accurately, but confused the
words. He had no word deafness. He could copy written words and
write simple words to dictation. Atopognosis of the right hand was now
practically gone. There was no cutaneous anaesthesia or analgesia.
Joint sense was normal at shoulder and elbow, lost at wrist and fingers.
Astereognosis with objects placed in right hand was present as before.
There was now no absolute paralysis of any movement of the right upper
limb, though all movements were feeble, especially in the fingers. The
wasting of the intrinsic hand muscles was distinct. The deep reflexes
on the right side were increased, chiefly in the upper limb; the plantar
reflexes remained flexor in type.
Present Condition .—The aphasia has now largely cleared up, and
amounts merely to hesitation in speech with some slurring of articulation.
There is moderate weakness of the right lower face and of the right
upper limb at all joints. The right lower limb is practically normal.
There are no sensory changes save in the right hand. He can feel and
localize light touches and pin-pricks all over the hand, though there is
occasional atopognosis. Heat and cold are appreciated normally. Joint
sense is normal in the shoulder, elbow and wrist, but is impaired in all
the fingers, the thumb being least affected in this respect. Astereognosis
as before. With the eyes shut he fails to recognize objects placed in the
right hand, such as a bottle, a watch, a chain, a pencil, a penny, all of
which he recognizes promptly with the left hand. The deep jerks in the
right upper limb are markedly increased, in the right lower limb only
slightly increased; there is no ankle-clonus, and the plantar reflexes are
flexor in type.
As regards the question of astereognosis, some authorities, notably
Mills and Weisenburg, 1 have endeavoured to limit the stereognostic
function to a special cortical centre, separate from the other cortical centres
for cutaneous, joint and muscle sense. They go so far as to suggest the
postero-parietal lobule as the so-called “ stereognostic centre.” But we
1 Journ. of Ncrv. and Mcnt. Dis ., 1906, xxv., p. 617.
Clinical Section
223
should note that stereognosis, or the recognition of the shape of solid
objects, is not a sensation but a complex psychical process, arrived at by
the combination and comparison of various sensory impressions from the
hand—cutaneous, muscular, and articular. Moreover stereognosis also
implies the calling up of visual and other memories and their comparison
with the actual sensations felt in the hand at the moment. If any of
these primary sensations be deficient, a stereognostic judgment may be
impossible, even with an intact cerebral cortex. There are numerous
morbid states in which we may meet with astereognosis. Thus, for
example, it is a common phenomenon in cervical tabes, where the patient
complains that he cannot recognize objects in his pockets, such as coins
or keys; again, in some lesions of the optic thalamus, astereognosis is
w T ell marked in the contralateral hand, and in cortical lesions of the
sensory areas, as in the present case, astereognosis may be complete.
In this case the postero-parietal lobule was unaffected, the lesion being
in the middle part of the post-central gyrus. There is, therefore, no
sufficient reason to postulate a special stereognostic centre, whether in
the parietal lobe or elsewhere.
Three Cases of Gout showing Destructive Changes in Bone.
By J. Barnes Burt, M.D.
I have to thank Mr. J. R. Lunn for allowing me to show these
cases :—
Case I.
W. B., joiner, aged 67, has suffered from gout on and off for the
last twenty-five years. It began in the left ankle ; practically every joint
in the body has been affected at one time or another. The hands were
first affected tw r enty-one years ago ; “ chalk ” appeared twelve years ago.
There is no history of gout in any member of the family. The man
occupied a good position, and there is no history of alcohol or lead.
There are numerous tophi on both hands and around the toes, and a few
small deposits in both ears. The synovial membranes of the knee- and
ankle-joints are thickened, and the patient has been unable to walk
for the last eleven years. Both hands are much deformed by tophi ;
in several situations the skin has ulcerated.
Clinical Section
225
The skiagram of the left hand (fig. 1) shows a “ mashed-up ” appear¬
ance of the carpus and ulnar deflection of the fingers. There is necrosis
of bone the size of a sixpenny-bit in the proximal end of the first
phalanx of the index finger and the bone is expanded around the area.
There is a similar but smaller area in the corresponding phalanx of the
next finger; also several small punched-out areas of necrosis in the
distal end of the second phalanx of the index finger.
It is important to notice that there is no tophus over the metacarpo¬
phalangeal part of the index finger, the small hard lump felt there being
part of the head of the second metacarpal bone ; also the skin over the
area is quite healthy.
Case II.
E. B., charwoman, aged 36, has suffered from gout for the last five
years. The first attack was in the right big toe. The hands w r ere not
affected till three years ago ; most of the joints have been affected some
time or other. Her father suffered from stone in the bladder; no history
of gout. There is a history of alcohol.
At the end of last year she was seen in an acute attack of gout.
The toes, both knees, and the left wrist were affected. There is a
uratic deposit in the right olecranon bursa, also around the terminal
joint of the middle finger of the left hand. No tophi in the ears.
There is some limitation of movement in the right wrist. At the
present time there are no abnormal physical signs in any other joints,
with the exception of the terminal joint of the middle finger of the left
hand. There is a semi-soft, slightly tender swelling around this joint;
on the dorsum is a scar, the site of an incision made a year ago in
one of the London hospitals, where it was mistaken for a whitlow.
Crystals of sodium urate were obtained from the spot. The movement
in this joint is only slightly impaired.
The skiagram of the left hand (fig. *2) shows a necrotic area, about the
size of a pea, in the distal end of the second phalanx of the middle finger.
Case III.
H. J., stableman, aged 55, has suffered from gout on and off for the
last five years. He has had rheumatism in his feet ever since he was
a schoolboy, but these pains were slight and never prevented work.
Both his father and paternal grandfather had “ chalk gout.”
In January of this year he was seen in an acute attack of gout,
affecting first his feet and knees, and later both hands, hips, and neck.
Clinical Section
227
During the acute attack a blister appeared over the terminal inter-
phalangeal joint of the index finger of the left hand. On puncture a
milky fluid exuded, which under the microscope was seen to be com¬
posed of crystals of sodium urate, together with a few leucocytes. At
the present time there are no tophi to be seen. The metacarpo-phalangeal
joints of both great toes are ankylosed. In the left hand a small, bony
nodule can be felt over the .terminal joint of the index finger. Movement
in this joint is only slightly impaired. There is slight hyperextension
of the proximal interphalangeal joints of the middle finger. Movement
in this joint is free. The terminal joint of the little finger of the right
hand is ankylosed. Nowhere else on the right hand is there any definite
swelling over the joints. There is some hyperextension of the proximal
interphalangeal joint of the middle finger, which causes some prominence
of the first phalanx, but this disappears on reducing the hyperextension.
In three of the joints, viz., metacarpo-phalangeal, proximal interphalan¬
geal joint of the index and proximal interphalangeal joint of the middle
finger there is some limitation of movement; in the first tw r o joints
distinct grating is felt.
A skiagram of the right index finger (fig. 3) shows a light area in
the distal end of the second phalanx, a light area in the distal end of
the first phalanx, early changes in the cartilage of the proximal inter¬
phalangeal joint, a light area in the head of the metacarpal bone, some¬
what advanced changes in the cartilage of the metacarpo-phalangeal joint.
A skiagram of the right middle finger shows a light area in the distal
end of the first phalanx, a small bony addition on the inner side of the
middle phalanx, early osteo-arthritic changes in the proximal inter¬
phalangeal joint.
A skiagram of the left hand (fig. 4) shows a light area in the distal
end of the first phalanx of the middle finger, also another light area
in the distal end of the second phalanx of the index finger. A small
bony addition can be seen on the inner side of the first phalanx of the
middle finger.
I would draw attention to the fact that: (1) there are no accumula¬
tions of sodium urate over the greater number of these “ light areas ” ;
(2) there is an increased density of bone around these areas; (3) the
“ light areas ” have no apparent connection w T ith the joint surfaces. The
joints themselves nearest these areas have in some cases no impairment
of movement, and in others only slight impairment of movement.
These light areas, on dissection, are found to be erosions of bone,
the bone being filled with a deposit of urates. There is a definite
Burt: Cases of Gout
Fig. 3.
Case III. H. J., aged 55. Right hand.
230
Burt: Cases of Gout
destruction of bone, as definite as that found, for instance, in a tuber¬
culous abscess of the head of the tibia. In fact, I have known this
appearance shown in a skiagram of the wrist lead to a diagnosis of
tubercular wrist.
Rosenbach [3], on the Continent, and Berkart [1], in England, have
examined these destructive changes in the bones of gouty people micro¬
scopically. They found numerous deposits of uratic crystals in the bone
marrow cut across in places by dead bone trabeculae. Reactive changes
were pronounced, giant-cells being present in great numbers.
References to this condition of gouty bones are few. Last year the
Committee for the Study of Special Diseases, Cambridge [4], published
some details in their Bulletin , but many years before this Sir A. B. Garrod
[2] mentions erosion of bone in gout, but states that it is due to a direct
destruction of bony laminae by continual pressure of uratic accumulations.
That these destructive changes are not caused by pressure atrophy is
shown by the fact that (1) where erosion is marked, clinically no tophi
can be detected ; (2) in many cases there are large tophi in direct rela¬
tion to bone, but no atrophy occurs, in fact, it is not uncommon to find
bone thrown out underneath the tophus.
We must therefore conclude that in cases of gout there may be a
definite destruction of bone, following or preceding the deposition of
uratic crystals in the bone itself.
REFERENCES.
[1] Berkart, J. B. Brit. Med. Joum ., 1895, i., 243.
[2] Garrod, Sir A. B. “Gout and Rheumatic Gout,” Loud., 187G.
[3] Rosenbach. Virch. Arch., 1903, clxxix., p. 359.
[4] Strangeways, T. S. P. “ A Study of Joints from cases of Rheumatoid Arthritis and
Chronic Gout by means of Skiagrams and Dissection of the Affected Parts,” Bull, of
the Committee for the Study of Special Diseases , 1907, i., No. 6, p. 87.
DISCUSSION.
Sir Dyce Duckworth said that the question under discussion was one
of degree. There was no doubt that uratic deposit was met with in bone
unassociated with necrotic changes. One was reminded of the theory of
Ebstein, that before uratic deposit occurred anywhere there must be a pre¬
ceding necrosed state of tissue. He thought that had been shown to be
incorrect in many instances; certainly in cartilage, for where urates had been
Clinical Section
231
dissolved out of the cartilage, sections showed that the cartilage had been
intruded upon, but not destroyed. If pressure continued it was conceivable
that in many instances necrosis should occur, and that the necrotic cavity
should be filled with uratic deposit. He thought some of these cases illustrated
another fact, which was not so generally accepted, namely, that the gouty
irritation might provoke enlargement of bones in certain situations, quite apart
from all uratic deposit. The too common idea that gout meant uric acid and
uric acid meant gout had been largely exploded, he was glad to say. At post¬
mortem examination, and even during life, one foimd that many of the enlarge¬
ments occurred independently of uratic deposit. They might be due to uratic
irritation, but there was no deposit in them, hence the well-known similarity
between some gouty changes and the changes attributed to non-gouty
conditions.
A Case in which, for Recurrent Sarcoma, parts of the
Femoral Artery and Vein were Excised.
By C. H. Fagge, M.S.
F., aged 50, was admitted into Guy’s Hospital in September,
1906, for a tumour on the inner side of the right thigh; it had been
present six weeks, and had continued to grow in spite of treatment
with potassium iodide. It was situated below and internal to the
saphenous opening, and was 3 in. to 4 in. in diameter, hard, well
defined, not fixed to skin or bone, but was wdthin the muscles. By
a long incision the tumour and the whole of the adductor brevis, which
was spread out over it, were removed, as it was thought to arise in
this muscle. •
Microscopically, it was a spindle-celled sarcoma with some myeloid
cells, which in Mr. Targett’s opinion arose, not in the muscle, but from
the intermuscular fascia. The first recurrence was removed in July,
1907, and she was admitted in December, 1907, for a second recurrence,
the size of a golf ball, at the junction of the upper two-thirds and the
lower third of the thigh ; at this operation the growth was found adherent
to the femoral sheath within Hunter’s canal and in close proximity to
the femoral vessels. The artery and vein were therefore ligatured above
and below, and the portions within Hunter’s canal, with the long saphena
nerve, were removed. The circulation in the leg was quite restored on
her discharge eighteen days later. A third recurrence was removed on
March 13 of this year.
ju —3
232
Fagge: Aneurysm of Common Femoral Artery
Aneurysm of the Common Femoral Artery; Excision of
Aneurysm and Common Femoral Vein.
By C. H. Fagge, M.S.
M., aged 26, a fitter, was admitted into Guy’s for a tumour, the
size of an orange, in the right Scarpa’s triangle. Four years previously
he had a blow in this position with a crowbar, and a year ago he had
rheumatic fever ; he had had gonorrhoea. He had noticed the lump for
eight months; it had gradually increased, and had been painful for three
months.
The right external iliac artery was enlarged, and pressure over it did
not entirely stop the pulsation in the tumour, which was “ expansile ”;
the right posterior tibial pulse was delayed and small. There were no
signs of syphilis or cardiac disease. On March 30 the right external
iliac artery was exposed and trebly ligatured with No. 4 French catgut;
the lowest ligature was placed about 1£ in. above Poupart’s ligament, as
below this the artery was dilated. Pulsation in the aneurysm was
diminished but did not cease, so the deep epigastric was ligatured and the
incision was continued downwards and the superficial femoral artery tied.
The aneurysmal sac was dissected out, the anterior crural nerve being
peeled off it externally, and, behind, the superficial femoral vein was
separated from it to a point at which it joined the deep vein, where its
wall became so thin that it was thought necessary to ligature both veins;
the deep femoral artery was ligatured, and the whole aneurysm then
came away, the external iliac rupturing below the ligatures as it was
pulled down. After the deep circumflex iliac vessels had been exposed
and tied, the common femoral vein was tied just below Poupart’s liga¬
ment, and the wound was sutured with drainage. There was slight
superficial gangrene at the inner edge of the wound, and a small blister
formed on the heel. The leg and foot presented a mottled aspect for
forty-eight hours, after which sensation and power of movement returned,
but the pulse in .the tibial vessels could not be felt a month after operation.
The aneurysm sac measured 2i in. vertically, 3J in. antero-posteriorly,
and 2£ in. transversely; it is distinctly “ fusiform,” two-thirds of its
circumference projecting behind a line joining the external iliac and
superficial femoral arteries ; the origins of both the superficial and deep
femoral arteries are involved by the sac, from which they arise at an
Clinical Section
233
interval of -J in.; the external and internal circumflex arteries also arose
from the sac. Above the aneurysm the external iliac is dilated to twice
its normal size for a distance of 1 in.
Scleroderma.
By G. A. Sutherland, M.D.
Boy, aged 5i. Patient had an attack of measles six weeks ago, from
which he recovered, but three weeks ago his father noticed that the skin
of the boy’s face felt tense and hard. He also seemed unable to open
his eyes fully. The characteristic induration of scleroderma affects the
face, including the eyelids, the scalp, the neck, and the upper and low r er
extremities. The tongue is distinctly hard. The ears are quite free
from any thickening, and the skin over the trunk is only slightly affected.
There is no leucoderma or pigmentation. The skin for the most part is
dry and harsh. A scratch on the indurated parts produces a persistent
wffiite streak, w T hile one on a healthy part produces a red streak. The
boy’s general condition and development are good.
Multiple Symmetrical Lipomata.
By Albert Carless, M.S.
M., aged 37, first came under observation at hospital for this con¬
dition in 1905. He is a public-house manager, but has been very tem¬
perate of recent years. The trouble first showed itself on the left side
of the face, two years before admission, as a small lump, w T hich used
to vary in size; but subsequently other swellings appeared on the right
side of the face and behind the left ear. He had been operated on twdce
before admission.
Photographs w r ere shown representing his appearance in June, 1905.
There w r ere large tumours reaching from the zygoma downwards to the
angle of the jaw, and backwards behind the ear on either side; also
a submental mass, and one in the occipital region. The facial masses
were removed by operation, and it w r as found that the growths were
definitely limited, but burrowed deeply. Their removal was difficult in
the extreme, as the main vessels in the neck were laid bare and there
w r ere many adhesions.
234
Heath: Caries of Spine
In November, 1905, he was again admitted, and the median sub-
mental mass removed. Here, too, the mass, though apparently diffuse,
was in reality limited and well defined. This mass was easier of removal
than the previous ones. The occipital mass was removed during his
stay in hospital on this occasion. This, too, was definitely limited, though
very adherent to surrounding parts; it had burrowed into and amongst
the muscles at the back of the neck. At this time other growths were
noted, one in the middle line over the isthmus of the thyroid, and one
over each internal condyle in the arm.
In February, 1908, he again came under observation, and this time
the main trouble was in the neck. The tumour in front of the thyroid
isthmus had growm as large as a cocoanut, and projected above the
manubrium. It appeared to be well defined, did not move on deglu¬
tition, and caused no trouble in breathing or swallowing. It appeared
to burrow 7 deeply into the neck, and the veins over the chest wall were
dilated, as if there were some mediastinal pressure. The mass was
dissected away on February 15, and had burrowed deeply and widely;
prolongations passed backwards and downwards on each side, and finally
disappeared along the vessels into the chest, where they could not be
followed further. The side of the neck and the face have also been
occupied once again with fatty masses, and there are symmetrical
growths over the deltoids, over the spines of the scapulae, in the arms
on either side, &c.
The points of importance in this case are that these growths, though
sometimes termed diffuse lipomata, are in reality limited and localized,
although the limits are sometimes difficult to define in the midst of
the surrounding fat; that they tend to burrow and become adherent
to surrounding parts, and that this burrowing may occur into regions
such as the chest, where serious symptoms from pressure on important
structures may result.
Caries of Spine with Clubbing of Fingers and Toes.
By P. Maynard Heath, M.S.
S. W., A girl aged 6£, has suffered from spinal caries for four years.
The disease has apparently become arrested, but with great deformity of
the thorax. The clubbing of the fingers and toes has been noticed for
twelve months. There is no evidence of abscess formation or of lung
disease. The child suffers from occasional attacks of cyanosis. An
X-ray photograph show T s very little change in the terminal phalanges.
Clinical Section
235
Multiple Idiopathic Haemorrhagic Sarcoma of the Skin.
By F. Parkes Weber, M.D.
Jacob Z., aged 52, except for the present disease has enjoyed
good health. His father is still living, aged 87. The disease is said
to have commenced about six years ago, when he chanced to wound
the sole of his right foot with a nail. A pedunculated growth arose
from the wound, which was removed by a medical man. Afterwards
small, slightly elevated, hard, bluish or purple spots appeared in the
skin of the lower extremities, especially the feet, and the left foot
and ankle became swollen. From time to time sessile or pedunculated
outgrowths, mostly not larger than a lentil or pea, develop on the
affected parts, chiefly on the left foot, and the little pendulous tumours
tend to become ulcerated and drop off, or are knocked off accidentally.
At present, except for a few minute raised purple or bluish spots on the
hands and on the glans penis and neighbouring skin, the disease is con¬
fined to the lower extremities. It is most advanced in the left foot, over
a great part of which the dark purple spots are confluent, and there is
persistent oedema of the left foot and leg. Two or three characteristic
little pendulous tumours on the left foot are “ripe ” and quite ready to
drop off. On the right foot there has for years been a large patch of
brown pigmentation, the exact relation of which to the disease is un¬
certain. The lymphatic glands are not affected. The present case is
a typical one of Kaposi’s so-called “ multiple idiopathic haemorrhagic
sarcoma,” which J. Hutchinson has described as the “ sarcoma melanodes
of Hebra and Kaposi,” and for which other terms have also been pro¬
posed, such as “granuloma multiplex haemorrhagicum,” “ acro-angioma
haemorrhagicum,” and (Unna) “ acro-sarcoma multiplex cutaneum telan¬
giectodes.” A description of the present case with microscopic examin¬
ation was published three years ago (Parkes Weber and P. Daser 1 ).
Since then the disease has not progressed much. The patient has been
away from London most of the time, and apparently no prolonged course
of arsenic or atoxyl has yet been tried. There is no sign of any visceral
disease. In June, 1906, there was a temporary erysipelas-like attack
in the left (i.e., the cedematous) lower limb. Microscopic examination
Brit. Journ. Derm., 1905, xvii., p. 135.
230 C urtis: Cases of Congenital Absence of Thumbs
of one of the little polypoid tumours, removed in May, 1908, shows, as
before, that the abnormal growth in the corium consists chiefly of
spindle-shaped and elongated cells, arranged to some extent in strands
and bundles, and richly supplied with capillaries distended with blood.
Besides the dilated blood-vessels there are dilated lymph spaces in the
growth, and in places there is extravasation of blood.
Two Cases of Congenital Absence of both Thumbs, &c.
By Henry Curtis, F.RC.S.
Mb. BbnBI CtJBTIS showed skiagrams and one of the patients
exhibiting ibis somewhat rare deformity, both cases having been met
with at the Metropolitan Hospital, Kingsland Road, within the last four
months (January to April, 1908). One of these, a young man, aged 19,
a Russian Jew, was under Ins own care; the other, a girl aged (5 months,
w r as under treatment for scurvy rickets by Dr. Langdon-Brown,
physician to the hospital, to whom the exhibitor expressed his thanks
for ready permission to report the case .with his ow r n. This patient,
whose deformity is indicated in the skiagram, showed no other mal¬
formation, but Dr. Langdon-Brown made the interesting observation
that another child in the family suffers from congenital heart disease.
The skiagram showed the commoner variety of this deformity, namely,
absence of thumb and first metacarpal, associated with defective (or
in some cases absent) radius.
The patient shown to the Section, under Mr. Curtis’s care, is an
ftuwnplft of the other and rarer type, where the absence of thumb
and first metacarpal is unaccompanied by any defect in the radius,
which, as the skiagrams showed, is as normal as the ulna. The trape¬
zium and the scaphoid are also entirely absent ; the trapezoid is
present, but, perhaps, not quite normal in shape, all the other
carpals, metacarpals and phalanges (with the exception of the middle
phalanx of the little finger, which is shortened) appearing to be
normal. The little finger on both sides is shorter than normal.
There is some appearance of a thenar eminence, probably the
result of constant practice in attempts to adduct the first digit
(index finger) so as to grasp articles such as knife, or fork, or pen,
which the patient can hold between the first and second digits.
Clinical Section
237
He can write his name fairly well, but he says he cannot carry
dishes, and that, owing to his deformed hands, he is unable to
follow any occupation. He is stunted in body, and his facial aspect
and general physiognomy, together with his apparent lack of initia¬
tive, suggest that his intelligence is also somewhat defective. The
skiagrams, including the stereoscopic views, were prepared by the
radiographer to the hospital, Dr. Finzi.
Case of Multiple Rheumatic Nodules in an Adult.
By Francis Hawkins, M.D.
Mary A., a single woman, first came under my observation when
she was aged 35. She then complained of pain all over, from her head
to her feet, but more especially in the shoulders, and of frequent palpita¬
tion. On examination it was noted the face was red in colour and the
skin of the body a light olive tint and quite dry. There was no swelling
of the joints, but the knuckles were slightly enlarged. The apex beat
was in the fifth interspace in the nipple line. A presystolic thrill was
felt, and on auscultation a presystolic and systolic murmur were heard
at the apex, with reduplication of the second sound at the base. The
appetite was fair; bowels regular; liver normal in size; temperature
98*4°F. Urine: specific gravity 1020, acid, no albumin; periods
regular; no nodules present. Twelve days later patient complained of
pain over the cardiac area. The alae nasi moved on respiration, the
pulse was irregular, and distinct pericardial friction was heard; the
temperature was 99*8° F. A day or two later nodules were observed as
follows: on the spinous processes of the dorsal vertebrae, one nodule on
the inner side of the left scapula and two nodules on the right scapula,
several nodules over the occipital region and also on crown of the head,
on the left ulnar 3 in. from the elbow and one on the right ulnar
in a similar position, one nodule on the inner tuberosity of the left
humerus, and one in the middle of the supraciliary region. Four days
later several more nodules were noted on the ulnars, and two days
later two nodules appeared on right internal malleolus and one on the
left, and on the day following one nodule appeared on the index finger
of the left hand.
Previous Illnesses .—When aged 19 this patient had rheumatic fever;
this was followed by chorea. When aged 23 she had a second attack of
238 Hawkins: Case of Multiple Rheumatic Nodules
rheumatic fever, and she states that during this attack she had nodules
on the head and on the spines of the vertebrae. I have in my notes the
fact that she has also suffered from facial paralysis, but no note is made
as to time or which side of the face was affected.
Family History .—An aunt on her father’s side died from heart
disease following rheumatic fever; her father died from pulmonary
tuberculosis, as did also a sister.
One year later I again saw this patient when she was suffering from
oedema of the feet and legs. She then informed me that the nodules
previously described did not entirely disappear till four months after
their first appearance, but at this time I noted one nodule on the middle
of the left clavicle and two smaller ones at the outer end of the right
clavicle. I could neither see nor feel any other nodules.
One year afterwards I again saw this patient, when the nodules were
still present on the clavicles. On this occasion the patient was suffering
from severe anginal attacks.
PROCEEDINGS
OF THE
ROYAL SOCIETY OF MEDICINE
VOLUME THE FIRST
COMPRISING THE REPORT OF THE PROCEEDINGS FOR THE
SESSION 1907-8
DERMATOLOGICAL SECTION
LONDON
LONGMANS, GREEN & CO., PATERNOSTER ROW
1908
LONDON :
JOHN BALE, SON8 AND DANIELSSON, LTD.,
OXFORD HOUSE,
GREAT TITCHFIELD STREET, OXFORD STREET, W.
PROCEEDINGS OF THE ROYAL SOCIETY OF MEDICINE
DERMATOLOGICAL SECTION.
CONTENTS.
October 17, 1907.
PAG K
Presidential Address. By H. Badcliffe Crocker, M.D. ... ... ... i
Clinical Cases :—
Lupus erythematosus, affecting the hands and feet only. By H. G.
Adamson, M.D. ... ... ... ... ... ... ... 2
Morphaea in a Woman aged 65. By Graham Little, M.D. ... ... 6
By J. M. H. MacLeod, M.D.:—
(1) Chronic Inflammation and Desquamation of the Lips ... ... 4
(2) Multiple Lupus vulgaris, following Measles ... ... 6
Infective Granuloma of Septic Origin. By J. II. Stowers, M.D. ... 7
November 28, 1907.
Clinical Cases :—
Congenital Pigmentation with Atrophic Scarring, associated with other
Congenital Abnormalities. By H. G. Adamson, M.D. (for Dr. Oumkrod) 9
Circinate Erythema of two years’ duration in a Boy. By II. G. Adamson,
M.D. ... ... ... ... ... ... ... ... 10
Lichen spinulosus. By J. L. Bunch, M.D. ... ... ... ... 10
Coccogenic Sycosis. By T. Colcott Fox, M.B. ... ... ... 11
IV
Contents
Clinical Cases (continued)
PAGE
By Wilfrid S. Fox, M.D. :
(1) Verrucose Nicy us ... ... ... ... ... ... 12
(2) Chronic (Edema of the Face ... ... ... ... ... 13
By G. W. Dawson, F.R.C.S.I.
(1) Pityriasis rubra pilaris ... ... ... ... ... 13
(2) Lichen planus ... ... ... ... ... ... 13
Case for Diagnosis. By W. T. Freeman, M.D. ... ... ... 14
Erythema. By T. J. P. Hartigan, F.R.C.S. ... ... ... ... 14
Lichen planus, with some Unusual Features. By E. Graham Little, M.D. 14
By J. M. H. MacLeod, M.D.
(1) Grouped Comedones in an Infant ... ... ... ... 14
(2) Multiple Lupus vulgaris following Measles ... ... ... 15
Von Recklinghausen’s Disease. By Malcolm Morris, F.R.C.S.Ed., and
Wilfrid S. Fox, M.D. ... ... ... ... ... ... 16
Case for Diagnosis. By Malcolm Morris, F.R.C.S.Ed. ... ... 17
Pigmentation of the Face. By George Pernet ... ... ... 17
Lupus erythematosus of the Face, with a Condition of the Fingers
simulating Raynaud’s Disease. By J. H. Seqceira, M.D. ... ... 17
Case for Diagnosis. By J. J. Pringle, M.B. (for Dr. Ernest A. Crisp) ... 18
Circulate Erythematous Syphilide. By A. Shillitoe, F.R.C.S. ... ... 21
By A. Whitfield, M.D.
(1) Rodent Ulcer treated by the Introduction of Zinc Ions ... ... 21
(2) Long-standing Pruritus in a Woman aged 22 ... ... ... 22
Sections of Paraffinoma. By A. Winkklried Williams, M.B. ... ... 23
December 19, 1907.
Clinical Cases :—
Case for Diagnosis. By G. W. Dawson, F.R.C.S.I. ... ... ... 25
Vegetating Granulomata on the Face. By T. Colcott Fox, M.B. ... 25
Bv E. G. Graham Little, M.D. :—
(1) Two Cases of Favus of the Scalp ... ... ... ... 26
(2) Bazin's Disease (Erythema induratum) in a Young Woman ... 27
Two Cases of Advanced “Keratosis follieularis,” associated with Baldness.
By J. M. II. MacLeod, M.D., and E. Treacher Collins, F.R.C.S. ... 27
Erythema induratum (Bazin) in a Woman aged 21, with Positive Opli-
thalmo-tubcrculin Reaction. By J. M. II. MacLeod, M.D. ... ... 31
Report on Dr. Stowers’s Case of Infective Granuloma ... ... 32
Contents
v
t
4
January 16, 1908.
Clinical Cases :— page
By E. G. Graham Little, M.D.
(1) Acute lichen planus ... ... ... ... ... ... 33
(2) Granuloma annulare... ... ... ... ... ... 33
Annular Lichen planus affecting Penis and Forearm. By J. M. H.
MacLeod, M.D. ... ... ... ... ... ... 34
Pityriasis rubra pilaris. By J. A. Ormerod, M.D. ... ... ... 35
By H. Radcuffe Crocker, M.D., and George Pkknkt :—
(1) Case for Diagnosis ... ... ... ... ... ... 36
(2) Lichen planus verrucosus treated by Violet Light ... 38
Tuberculides. By J. H. Sequbira, M.D. ... ... ... ... 39
Rodent Ulcer. By J. H. Stowers, M.D. ... ... ... ... 40
Extensive Psoriasis with Suppurating Lesions. By James Galloway, M.D. 41
February 20, 1908.
Clinical Cases :—
By H. G. Adamson, M.D.
(1) Sclerodermia and Leucodermia ... ... ... .. 43
(2) Telangiectasis of the Cheek ... ... ... ... ... 44
Lichen piano-pilaris. By Wilfrid S. Fox, M.D. ... ... 45
Five Cases of Lupus erythematosus treated by a New Method. By T. J. P.
Hartigan, F.R.C.S. ... ... ... ... ... ... 45
By E. G. Graham Little, M.D.
(1) Lupus erythematosus ... ... ... ... ... 46
(2) Ringed Eruption ... ... ... ... .. ... 47
(3) Case for Diagnosis ... ... ... ... ... 49
(4) Leuconychia ... ... ... ... ... ... 49
J. M. H. MacLeod, M.D.
(1) Multiple Leiomyoma of the Skin ... ... ... ... 50
(2) Lichen spinulosus, associated with Seborrhoic Dermatitis ... 51
Glossitis in a Girl aged 3L By J. M. H. MacLeod, M.D., and A. N.
Lrathem ... ... ... ... ... ... ... 51
Case for Diagnosis. By Sir Malcolm Morris, F.R.C.S.Ed. ... ... 52
By H. Radcliffe Crocker, M.D., and George Pernet :—
(1) Two Cases of Elephantiasis grfficorum ... ... ... ... 53
(2) Senile Warts Developing into Fungating Growths ... ... 56
Case for Diagnosis. By J. H. Sequeira, M.D ... ... ... 57
VI
Contents
Clinical Cases (continued) :—
PAGE
Hfiemangiectatic Hypertrophy of the Foot, possibly of Spinal Origin. By
F. Parkes Weber, M.D. ... ... ... ... ... 59
By A. Whitfield, M.D.:—
(1) Macular Atrophy of the Scalp ... ... ... ... 60
(2) A New Substance for Shielding those Parts of the Scalp which it
is not wished to expose in the Treatment of Ringworm by means of
the X-rays ... ... ... ... ... ... ... 61
Rodent Ulcer of the Ala nasi in a Man aged 66. By A. Winkklried
Williams, M.B. ... ... ... ... ... ... 62
March 19, 1908.
Clinical Cases ;—
By II. G. Adamson, M.D.:—
(1) Pustular Ringworm of the Horse ( 1 ‘Conglomerate Folliculitis”) in a
Child ... ... ... ... ... ... ... 66
(2) Urticaria pigmentosa ... ... ... ... ... 66
Favus in a Mouse. Shown by T. P. Beddoks, F.R.C.S. (for Dr. Amiauam) 64
Ringed Eruption on the Hand. By G. W. Dawson, F.R.C.S.I. ... .. 65
Bilateral Telangiectases of the Trunk with a History of Marked Epistaxis
in Childhood and recent Rectal Haemorrhage. By T. Colcott Fox, M.B. 66
Case for Diagnosis. By Wilfrid S. Fox, M.D. ... ... ... 70
Acute Searlatiniform Eruption following the Administration of Small
Doses of Quinine. By J. Galloway, M.l). (in association with Dr.
Cohen) ... ... ... ... ... ... ... 71
Bromide Eruption. By E. G. Graham Little, M.D. ... ... ... 76
Effect of X-rays on Mycosis fungoidcs. By II. Radcliffe Crocker, M.D. 75
By J. H. Sequeira, M.D. :—
(1) Lupus, with Unusual Features, suggesting Lupus pernio ... ... 76
(2) Chronic X-ray Dermatitis of the Hands; removal of Warts by
measured doses of the X-rays ... ... ... ... .. 78
May 21, 1908.
Clinical Cases:—
By II. G. Adamson, M.D.:—
(1) Nodular “ Ringed Eruption ” ... ... ... ... ... Ml
(2) Case for Diagnosis ... ... ... ... ... ... M2
Leprosy. By T. J. P. Haktioan, F.R.C.S. ... ... ... ... 86
By E. G. Graham Little, M.D.
(1) (?) Dermatitis artefacta ... ... ... ... ... 86
(2) Varus nodulosus of Brooke ... ... ... ... ... 85
Co n tents
vii
Clinical Cases (continued) :—
PAGE
(3) Folliculitis decal vans (Pseudo-pelade of Brocq) ... ... ... 86
(4) Pseudo-xanthoma elasticum of Balzer ... ... ... ... 86
(5) Unusually Generalized Ntevus verrucosus zoniformis ... ... 87
By J. M. H. MacLeod, M.D.
(1) Lupus erythematosus affecting the Hands, Ears and Scalp ... 88
(2) Alopecia areata following Small-spored Ringworm of the Scalp ... 89
Spreading Telangiectases of the Feet and Legs. By Sir Malcolm Morris,
K.C.V.O., F.R.C.S.Ed., and S. E. Dork, M.D. ... . 89
By J. H. Sequkira, M.D. :—
(1) Morphcea ... ... ... ... ... ... ... 90
(2) Granulomatous Swellings at Left Angle of Mouth and in Right •
Inguinal Region ... ... ... ... ... ... 92
Multiple Xanthoma of the Face of the Diabetic Type in an Infant. By
F. Parkks Weber, M.D.... ... ... ... ... ... 92
Disseminated Lupus with Chronic Lymphangitis of the Face and Osteo¬
arthritis of the Hands. By A. Whitfield, M.D. ... ... ... 93
June 18, 1908.
Granuloma annulare. By E. G. Graham Little, M.D. ... ... ... 95
Clinical Cases ;—
Sclerodermia (Morphoea). By H. G. Adamson, M.D. ... ... ... 163
Tuberculosis Developing on the Site of a Vaccination Scar. By J. L.
Bunch, M.D. ... ... ... ... ... ... ... 164
By E. G. Graham Little, M.D.:—
(1) Case for Diagnosis ... ... ... ... ... ... 164
(2) Pseudo-pelade of Brocq ... ... ... ... ... 165
(8) Urticaria pigmentosa in an Adult ... ... ... ... 165
“ Dermatitis papillaris capillitii ” (Kaposi). By J. M. H. MacLeod, M.D. 166
Mycosis fungoides. By H. Radcliffk Crocker, M.D. ... ... ... 167
Unusual Case of Pustular Vegetating Dermatitis with Pigmentation
Changes in a Woman aged 26. By H. Radcliffk Crocker, M.D.,
and George Pernkt, M.D. ... ... ... ... ... 168
Lichen plano-pilaris. By T. D. Savill, M.D. ... ... ... 169
By J. H. Stowers, M.D.:—
(1) Lupus erythematosus in a Child ... ... ... ... 170
(2) Molluscum contagiosum in an Adult ... ... ... ... 172
Specimens from a Case of Syphilis. By A. Whitfield, M.D. ... 172
Contents
July 16, 1908.
Clinical Cases :— page
Tuberculides in a Girl aged 11 years. By J. L. Bunch, M.D. ... ... 175
Parakeratosis variegata. By G. Dawson, F.R.C.S.I. ... ... ... 175
Erythematous Eruption of Unusual Type. By T. Colcott Fox, M.B. ... 176
X-ray Dermatitis. By Wilfrid Fox, M.D. ... ... ... ... 177
Dermatitis herpetiformis. By J. Galloway, M.D. ... ... ... 177
By E. G. Graham Little, M.D.:—
(1) Well-marked Rosacea associated with Phlyctenular Conjunctivitis
and Ulceration of the Eyes ... ... ... ... ... 181
(2) Prurigo of Hebra ... ... ... ... ... ... 181
(3) Molluscum contagiosum ... ... ... ... ... 182
(4) Pityriasis rosea ... ... ... ... ... ... 182
Two Cases of Congenital Syphilis with late Cutaneous and Mucous
Membrane Lesions of the Gummatous or Phagedcenic type. By J. H.
Sequeira, M.D. ... ... ... ... ... ... 183
By David Walsh, M.D.:—
(1) Primary Cutaneous Carcinoma of the Chest involving the neigh¬
bouring Nerve Areas ... ... ... ... ... ... 187
(2) Fibromata of Skin with developing Neuro-fibroma ... ... 189
Microscopical Specimen and Pure Culture of a Yeast derived from a
Case of Intertriginous Dermatitis of the Cruro-scrotal Region. By
A. Whitfield M.D. ... ... ... ... ... ... 190
The Council think it right to state that the Society docs not hold itself in any way
responsible for the statements made or the views put forward in the various papers.
Dermatological Section.
October 17, 1907.
Dr. Radcliffe Crocker, President of the Section, in the Chair.
Before proceeding with the ordinary business of the meeting, the
President made the following remarks:—
Gentlemen,— As this is our tirst meeting for the ordinary work of
the Section, a few preliminary remarks from your President may not be
out of place.
We may regard the organisation of a Section of Dermatology, as a
part of the work of the Royal Society of Medicine, as a not unimportant
step in the recognition of the status of dermatology in medicine, both as
regards its immediate past and its near and distant future.
A new branch of medicine, and ours is barely a hundred years old,
passes through three stages. First, pioneers like Willan and Alibert
strive to penetrate into the virgin forest of isolated or ill-observed facts
and the crude or fanciful theories regarding them, and begin to clear
away the rubbish and fallen lumber of past ages and to make paths
through the hitherto trackless forests, putting up finger-posts or at
least blazing the trees as they go, so that their successors with little
effort may pass along where they have forced their way with such toil
and difficulty.
Others soon follow, making the paths plainer, and some go further
than their predecessors, but still progress is slow until the advent of
some great man, like Hebra, who makes the paths into broad roads, and
the second stage is reached. Along these highways, where there were
but solitary travellers, are now throngs of workers, until the roads are
clear enough for any one who takes the trouble to find his way, though
there are still byways and tracks enough for those who devote their
lives to their investigation. This is the third stage, which we have
reached to-day, and the main facts of dermatology are now open to
every student who has acquired the preliminary groundwork of a sound
knowledge of general medicine. I lay stress upon this, as whoever
takes up a specialty without it comes perilously near to the quack, and
puts a stone into the hand of those who are only too ready to throw it.
n —4
Adamson: Case of Lupus Erythematosus
The extremely rare occurrence of many of the diseases of the skin,
and the great gaps in our knowledge of the etiology and pathology of
many even common dermatoses, afford problems for the expert to work
at for another century at least.
Standing here in the presence of many who in the last twenty years
have by their work done much to place dermatology where it now is,
I say to our younger members that they have plenty to encourage them
to follow their predecessors' footsteps, and though it is not the rule in
science for workers to see the fruition of their labours as we do this day,
yet, starting from a higher platform than their teachers, they may reach
heights that we can barely dream of.
Gentlemen, I trust we shall work earnestly and harmoniously to
make this Section a success, each for all and all for each, and that
whether our respective knowledge be little or much we may place it
unreservedly at the service of this Section.
In conclusion, I have only to announce to you that the plan the
Council proposes to adopt is that the private cases shall be taken first,
and the rest of the cases as far as possible in the order of their announce¬
ment to the secretaries; that they shall be examined on the chair here
placed, and that then, when desired, a brief discussion may take place
on each case, but I would especially beg you to be terse and to the
point in your remarks.
Finally, it is earnestly hoped that exhibitors will furnish the secretaries
as soon as possible with a brief account of their cases in a form ready
for publication, and stating only essentials. For although there will be
a reporter present, his account, even though edited by the secretaries,
will often be unsatisfactory ; a personal report will not only materially
lighten the work of the secretaries, but add much to the interest and
value of the proceedings ; and though it involves some pains and self-
sacrifice, it is hoped that all members of the Section will be ready to
make it.
The following cases were shown :—
Case of Lupus Erythematosus, affecting the hands and
feet only.
By H. G. Adamson, M.l).
The patient was a young woman (L. C.), aged ‘2*2, a shop assistant.
She was well nourished, but had marked “ chilblain circulation" ; her
nose was blue and cold, as were also her hands and feet. Over the
Dermatological Section
palmar surface of tlu; fingers and thumbs, and along the thenar and
ulnar sides of the palms, were irregularly-shaped patches with dusky
red erythematous margins, and whitish, thinly raised central parts.
There was practically no infiltration of the patches, and the redness could
he pressed out, leaving only a brownish stain around the central scar.
There was a similar condition over the dorsal surfaces of the proximal
and penultimate phalanges. The toes were of a deep purple colour and
very cold; they also presented patches like those on the fingers, except
that some of the patches were here excoriated and others crusted.
There were no lesions on the ears, face, scalp, nor elsewhere. The
patient had a husky voice, but no cough, and there was no evidence
of tuberculosis. A sister had consumption, and was in the B romp ton
Hospital.
The patches had begun to get more red and aching during two or
three recent cold days. The patient had suffered as a child from cold
hands and feet, with chilblains in the winter, but the present condition
had begun only two winters ago. Towards the end of 1905 red patches
had appeared upon the fingers and toes. The patches had swelled and
had run together until the whole finger was swollen to twice its normal
size. This swelling, accompanied by much aching, had lasted through
the winter. It had subsided during the summer, but the red patches
had remained. The swelling had again appeared at the beginning of last
winter, and had subsided as before during the summer, but leaving more
marked and more numerous red patches—in fact, the condition which
was now present.
There was no evidence of paroxysmal attacks of “dead fingers*’
followed by lividity, such as was characteristic of Raynaud's disease.
Case of Morphoea, in a Woman aged 65.
By Graham Ijttle, M.D.
The patient had been under observation at St. Mary's Hospital at
long intervals during the past five years; the disease was stated to
have been noted by the patient for about six years. When she had first
come to St. Mary’s, the condition noted was that of a patch of morphoea
occupying the middle third of the anterior surface of the right leg. The
sclerodermic area was surrounded by the usual halo of redness, and this
condition had persisted unchanged for several years. She had ceased
to attend for a considerable period, and when seen again, a week ago,
the disease had very greatly increased in area, so that now the whole
4
Macleod : Cane of Chronic Exfoliation of the Lips
right leg and foot from the instep to the knee were sclerodermic, and
the soft parts of the leg had been constricted and atrophied, so that the
right leg was M ins. less in circumference than the left. The sclero¬
dermic condition was continued on to the dorsum of the foot, but the foot
was not equally atrophied with the leg. Two new areas of scleroderma,
circumscribed and the size of a sixpence, had appeared on the front of the
left leg, and a larger lesion, the size of a shilling, on the lower part of
the abdomen.
Within the past few months the middle third of the anterior surface
of the right leg—the earliest site of the disease—had become the seat of
an obstinate ulceration, causing considerable pain and discomfort, and at
a meeting of a medical society, at which the case had been shown by the
general practitioner under whose immediate care the patient was, an
opinion was generally supported that amputation of the right leg would
be preferable to retaining the diseased limb. Opinions as to this course
were now solicited, the exhibitor having considered that the solution
was too drastic to be recommended. The woman was in other respects,
considering her age, in fairly good health.
It was generally agreed that amputation was not desirable. Bier s
method of compression was suggested as likely to be useful in stimulating
the healing of the ulcer.
Case of Chronic Inflammation and Desquamation of the Lips.
By J. M. H. Macleod, M.l>.
An unmarried woman, aged ‘29. The patient was a delicate-looking
woman with a highly neurotic temperament. She worked as a dress¬
maker and had the amende appearance associated with an indoor life
and insufficient fresh air. There was a family history of tuberculosis,
her father and sister having died of pulmonary tuberculosis, and there
were suspicious signs of it in the patient, such as severe cough, dulness
at the left apex, Ac. The condition of the 1 ips for which she came under
observation was a peculiar crusted affection involving the red portions
of both lips, but (‘specially the lower one. Both lips were swollen and
protruding, and were encased in an irregularly-fissured scab of a
yellowish-green colour, which extended from the cutaneous margin
of the lips and gradually faded away in the mouth. The crusts were
somewhat firm in consistence and were loosely adherent to the lips, so
that they could be picked off easily, leaving the lip glazed, oozing in
places; and here and there, where* the scab had been more firmly
Dermatologic a 1 Section
attached, laceration had occurred and there was slight bleeding. There
was no definite hypertrophy of the labial mucous glands. At the time
when the case was exhibited the crust was comparatively slight, as
a mass of it had been removed three weeks previously and it had not
yet had time to re-form, but when it was at its maximum it reached
a thickness of half an inch. Associated with the affection of the lips
there was a septic state of the mouth. The teeth were covered with
tartar, the gums sodden, and there was slight pyorrhoea alveolaris. The
salivary and mucous secretions were viscid, and the tongue and mouth
were dry.
To illustrate Dr. Mac-leod’s case of chronic exfoliation of the lips.
The affection had begun eighteen months previously, immediately
after the death of her sister from phthisis. It commenced with slight
desquamation of the lower lip. This gradually increased till her lips
were encased in scabs. She was first seen bv the exhibitor at Charing
Cross Hospital, where she was sent by Dr. Samuel Welch on August T2,
when the whole of the scab was removed, the lips painted with 3 per
cent, silver nitrate solution, and an antiseptic salve and a mouth-wash
prescribed. She returned to hospital in the middle of October with the
affection as bad as ever. It was on this occasion that the accompanying
photograph was taken. The crust was again removed and is now
gradually recurring.
(> Macleod : Case of Multiple Lupus Vulgaris
This peculiar affection began as slight infective desquamation of the
lower lip, which was gradually transformed into its present condition by
more or less constant sucking and working the lip under the teeth, and
so inducing an excessive flow' of altered viscid saliva and mucus. Tin-
case had proved most resistant to treatment, a fact which was partly
accounted for by the hysterical character of the patient, who made no
great effort either to remove the scabs herself or to prevent their recur¬
rence.
Cases of a like nature to this have been exhibited at the Dermatolo¬
gical Society of London by Galloway (Brit. Jouni. Derm., vol. vii., 1895,
p. 113), and Morris (Brit. Jouni. Derm., vol. xi., 1899, p. 315). In
Galloway’s case there w-as also a marked neurotic element in the patient,
and a similar purulent state of the gums. Somewhat similar cases have
been described by Besnier and Doyon under the heading of “ Eczema
exfoliant des levres,” and by Brocq as “ Seborrhee des levres.” It may
possibly be allied to the “ Cheilitis glandularis ” of Volkmann, but in
these cases hypertrophy of the mucous glands was a definite character¬
istic, and it was absent in the above case.
Dr. Badcltffk Crocker said that he had seen a somewhat similar
case heal under X-rays.
Case of Multiple Lupus Vulgaris following Measles.
By J. M. H. Macleod, M.I).
The patient was a delicate girl, aged (5. She was an only child. Her
mother was healthy, but her father suffered from pulmonary tuberculosis.
When she W'as 4 years of age she had measles, and immediately after¬
wards the tuberculous lesions appeared on the skin. The patient was
fairly well nourished, but w 7 as pale and ansemic. With the exception of
the measles, however, she had had no serious illness. A physical
examination failed to detect any signs of disease in her lungs or other
stigmata of internal tuberculosis.
When she came under observation at the Victoria Hospital lor
Children, twelve tuberculous lesions w r ere counted on the skin; these
were situated on the face, both arms, right leg and right buttock. They
varied in size from a split-pea to a shilling, the tw r o largest being situated
on the right buttock. The lesions were typical of Lupus vulgaris of the
nodular variety ; they were slightly raised above the level of the skin, and
brownish-red in colour. The majority of them presented a smooth
surface, those on the buttocks being slightly verrucose.
Derma tolof/ica 1 Section
i
In addition to the Tuberculosis cutis a number of the lupus patches
were situated in the midst of a circular patch of inflamed, slightly scaly
skin. These patches were markedly circular, and varied in size from a
shilling to a half-crown piece. There were also a number of irregular
pinkish-yellow patches of dermatitis about the shoulders and neck. The
latter appeared to the exhibitor to be patches of seborrhoic dermatitis,
but he was uncertain of the nature of the circular lesions, and he con¬
sidered the possibility of their having been artificially produced by some
application which had been made to the lesions previously. These
}latches were of recent origin, having only been noticed for a few weeks.
The above case adds yet another to the list of cases of Lupus
vulgaris developing rapidly after measles. In these cases it is believed
that the tubercle bacilli reach the skin ria the blood-stream, and that
their source is probably an infected bronchial gland which has broken
down as a result of the measles and infected the blood-stream.
The feature of the case which attracted most attention was the
inflamed areas in which the lupus lesions were situated. Several mem¬
bers suggested the possibility of their being Lichen scrofulosorum, while
others considered that they were caused by an irritant application. The
exhibitor promised to report further on the case.
Note .—Since showing the case Dr. Macleod has found that an
irritating brown ointment was rubbed in, the nature of which he has not
been able to ascertain, and since this ointment has been discontinued the
circular patches have gradually faded.
Case of Infective Granuloma, of Septic Origin.
By J. H. Stowers, M.D.,
Who exhibited this patient, sent to him by Mr. G. Templeton.
James C., aged 48, unmarried (a mechanic engaged in the workshop
of a surgical instrument manufacturer), who, three months ago, suffered
from a small “ blind-boil ” upon the right cheek, an inch and a half
below the eyelid, on a level with the ala nasi. A few days later the
patient pricked it with a needle and a little sanious fluid escaped. The
inflamed area gradually increased and developed into a tense, circular
tumour, considerably raised from the cheek, with a smooth, dusky-red
surface, upon which a few dilated vessels were visible and freely movable.
In the course of eight or nine weeks the tumour was an inch in diameter,
and it had not increased in size since. The case was described as an
H
Stowers: Case of Infect ire Granuloma , of Septic Origin
Infective Granuloma, of septic origin, and the diagnosis was confirmed by
other members of the Section.
The treatment adopted was the application of gutta-percha plaster-
mull (Beiresdorf) containing mercury, carbolic acid, and zinc oxide, and
under its influence a marked degree of subsidence had already taken
place in the space of a fortnight. In every other respect the patient was
in good health.
Dr. T. J. P. Hartigan showed a case of Multiple Rodent Dicer and
two cases for diagnosis.
Dermatological Section.
November 28, 1907.
t
Dr. Colcott Fox, Vice-President of the Section, in the Chair.
Congenital Pigmentation with Atrophic Scarring, associated
with other Congenital Abnormalities.
By H. G. Adamson, M.D. (for Dr. Ormerod).
The patient was a girl, aged 19, small for her age, and of feeble
intellect. The skin presented a generalised, but not universal, retiform
pigmentation. The networks of pigmentation had a tendency to group¬
ing in certain parts, and also to distribution with linear arrangement.
There were patches occupying the cheeks and the forearms, and others,
with clear intervals between, upon the trunk, the upper arms, and the
thighs. The linear arrangement was most marked along the upper
arms, at the sides of the trunk (in the direction of the lines of cleavage),
and along the thighs. The pigmentation was pale brown to reddish-
brown, according to its position, being more red on the arms and legs,
where the red colour could be pressed out, leaving brownish stains.
Several of the areas showed scarring towards their central parts. The
scarring was very distinct, and in parts almost suggested the scar from
a burn. It occupied mainly the meshes of the pigmentary network,
overlapping the net to form uniform patches in the worst parts. This
condition of the skin had been present since a few months after birth.
In winter the patches were said to become darker and somewhat itchy.
The mother stated that the scar had been present as long as she remem¬
bered, and there appeared to have been no antecedent inflammatory
growth of any sort. Other abnormalities present were: absence of the
lobes of the ears, asymmetry of the face, a patch of congenital alopecia,
absence of first and second fingers of the right hand, the presence of four
toes only on each foot, and two nipples on the right breast.
The pigmentation in this case had recalled to Dr. Ormerod a case of
congenital pigmentation which had been shown by Dr. Garrod in 1905,
d —3
10
Adamson : Circinate Erythema in a Boy
at a meeting of the Clinical Society, and in the Clinical Society's
Transactions , vol. xxxix., p. 216, was the following record: The patient
was a female child, aged 2£, with characteristics of “ Mongolian ”
variety of idiocy and some evidence of congenital spastic diplegia. There
was a peculiar pigmentation of the skin, which had a linear distribution,
and in places was arranged in whorls in a remarkably symmetrical
manner. Dr. Colcott Fox had regarded the case as one of linear papillo¬
matous nsevus in a very early stage, preceding the actual papillomatous
development.
The case now exhibited recalled also another case, which had been
shown by Dr. Adamson at a meeting of the Dermatological Society of
London (Brit. Joum. Derm., vol. xix., No. 6, June, 1907, p. 198), an
extensive unilateral naevus in an infant, occupying the whole of the left
side of the trunk and the left leg. In this case, in addition to dusky red
mottled streaks made up of minute flat papules, there were on the calf
and on the sole linear warty growths. A remarkable feature about this
case was that the warty growths and flat papules had since disappeared,
leaving in their place a mottled pigmentation with atrophic scarring, and
the left nipple, which was absent, had since made its appearance.
Circinate Erythema of two years’ duration in a Boy.
By H. G. Adamson, M.D.
This case had been shown on a previous occasion (Brit. Joum. Derm.,
November, 1906, p. 403). The exhibitor compared it to two cases
recorded by Dr. Colcott Fox (Clin. Soc. Trans., vol. xiv., p. 67, and
International Atlas , plate xvi.) and to another case under his own
observation (Brit. Joum. Derm ., vol. xix., June, 1907, p. 199).
Since last shown (twelve months ago) the eruption had several times
disappeared, sometimes spontaneously, sometimes apparently under the
influence of salicin internally. The condition was now T much the same
as when described in November, 1906.
Case of Lichen Spinulosus.
By J. L. Bunch, M.D.
The patient was a boy, aged 6. The lesions were distributed over
the trunk, arms, and thighs, and were especially well marked at the back
of the neck, where there was a group of prominent spiny processes,
Dermatological Section
11
projecting a sixteenth of an inch beyond the surface of the skin. In
other positions also the lesions consisted of filiform spines and showed
a grouped arrangement. On the trunk there were numerous papules of
about the size of a pin’s head, apparently due to the blocking of pilo-
sebaceous follicles. These lesions did not, as a rule, differ in tint from
that of the normal skin, but on the abdomen especially some showed
slight redness. Scattered horny papules were present in considerable
numbers on the back. The boy was in good health, and did not
complain of itching, nor were any scratch marks visible. No plane
lesions of lichen planus were present. The case was evidently not one
of keratosis pilaris, nor was there any reason to suspect a tubercular
origin of the affection. There was no evidence of the disease being
infectious, and no black-topped comedones were present like those
occurring in the descriptions of Brooke’s disease.
Case of Coccogenic Sycosis.
By T. Colcott Fox, M.B.
The patient was a barman (F. G.), aged 27, suffering from double
otitis media, and now cured of a sycosis which had involved all the
hairy regions of the face for ten months. Dr. Fox, was indebted to
his colleague, Dr. K. G. Hebb, for his kindness in treating the case in
his wards at the Westminster Hospital, and for allowing the exhibition
of the patient. Dr. Hebb obtained from the beard greyish-white colonies
of a staphylococcus growing in tetrads, which was neither the S. pyogenes
aureus nor albus y and confirmed this result by subsequent careful cultiva¬
tions. On October 8 the patient was injected with 1,000,000,000 of the
dead cocci into the left forearm ; the face reacted, and an area of red
swelling appeared about the site of injection. The temperature on the
night of October 9 rose to 100° F. On October 14 the face inflammation
had notably subsided, and was now covered with fine, dry scales. On
October 16 the opsonic index was 0*84. On October 23 the patient was
injected with l£ c.e., containing approximately 1,500,000,000 cocci, and
there was no reaction. On November 1 the skin of the face was better,
but rather tender, though he shaved himself. Only two or three pustules
remain on upper lip and chin. On November 2 a third injection of
1,500,000,000 staphylococci. On November 11 a few fresh pustules
appeared, but the face generally looked cured, except for some redness
and desquamation, and a vegetating infiltrated patch on the chin. On
12
Fox: Case of Verrucose Naevus
November 17 a fourth injection was given of 2,500,000,000 cocci, and
a red rash appeared over the jaws. After that the condition improved
almost to a complete cure, and this afternoon (November 28) there are
only two or three pustules and the remains of the vegetating infiltrated
patch on chin.
Case of Verrucose Naevus.
By Wilfrid S. Fox, M.D.
The patient was a woman, aged 24. The condition was very exten¬
sive over the upper part of the trunk in front and was limited behind to
the interscapular region. The breasts and sternal region were covered
with linear and irregular clumps of typical acanthomata; in the axillae
the small growths were, as is usual in these cases, more pendulous and
hung in clusters, some of the individual ones being as large as a big
raisin. The increase of pigmentation was well marked, more especially
over the sternum. The first signs of the deformity were noticed very
soon after birth on the back, but nothing appeared on the chest until
after puberty, and at the age of eighteen there was a considerable
increase in the size and in the area covered by the small warty growths.
The points of interest in the case are that, on the situation where
it was first noticed soon after birth, there had been very little
increase; but on the front of the thorax, where there was nothing to be
seen in childhood, there had recently been very marked growth. Also
the opportunity had been taken for testing the effect of kataphoresis on
these warty growths, the larger pendulous tumours in the axillae being
chosen for this purpose. Magnesium ions were tried in the right axilla
and zinc ions in the left. The treatment had so far been carried out on
three occasions at a week’s interval; the current was taken from a drv-
cell battery, and varied between 20 and 25 milliamperes for fifteen to
eighteen minutes. The magnesium solution varied from a 5 per cent,
to a saturated solution of the sulphate. On the right side, where the
magnesium salt had been used, there was very little difference in the size
of the growths, but on the left the zinc had caused the tumours to shrivel
and shrink to less than half their previous size. The exhibitor desired
to express his indebtedness to Dr. Freshwater for carrying out the
electrical treatment.
Dermatological faction
13
Case of Chronic (Edema of the Face.
By Wilfrid S. Fox, M.D.
The condition had lasted for five years. The area affected was around
the eyes and the lower part of the forehead. The patient, a man, aged 34,
acquired the condition in South Africa, but could not attribute it to any
cause. The condition varied with the weather, being worse in cold
winds; but there were no erysipelatoid attacks, as are frequently noticed
in these cases. On the first occasion on which he was seen there was
some thickening of the lobes of the ears, and the condition somewhat
resembled leprosy; this diagnosis, however, was disproved by a biopsy,
of which a slide was show r n. Mr. Barwell was kind enough to make an
examination of the nasal cavity on two occasions, but failed to find any
purulent focus. The general opinion was, however, that the condition
was of streptococcal origin. Dr. Adamson kindly suggested treatment
with anti-streptococcal serum.
Case of Pityriasis Rubra Pilaris.
By G. W. Dawson, F.R.C.S.I.
The patient was a man, aged 46. The condition was not so marked
on exhibition as formerly, because ointments had been applied. There
had been papules on the backs of the hands and on the forehead. The
eruption had persisted for sixteen years. When he first saw it there
were some discrete papules, and unguent, acid, salicyl. was prescribed.
The condition was rough to the touch, and was unlike psoriasis. A
section was exhibited showing hyperkeratosis extending down to the
follicle and dilatation of the sweat-glands.
Case of Lichen Planus.
By G. W. Dawson, F.R.C.S.I.
The patient w r as a woman, with a condition which began on the
face as an erythema. There was redness about the forehead, the eyes,
and the chest. The colour, in good daylight, was bluish-red. The case
was diagnosed as an anomalous form of lichen planus. There was
a good deal of itching, which kept her awake at night, so that she had
become thin. The same condition w r as present on the knees and the
buttocks, and was now spreading.
14
Freeman : Case for Diagnosis
Case for Diagnosis.
By W. T. Freeman, M.D.
The patient was a man, aged 50, who presented a soft keratosis on
the lips not unlike mucous patches, while inside the cheeks there were
several slightly verrucose lesions, and an ulcer about the size of a six¬
pence inside the left cheek. On microscopical examination the lesions
proved to be simple epithelial growths. The affection had begun about
four years previously. There was no history of syphilis, and the patient
was a moderate smoker.
Case of Erythema.
By T. J. P. Hartigan, F.R.C.S.
The patient was an elderly man, with an erythema of the foot which
had persisted ten years. There was some oedema, but no affection of
the heart or kidneys. During the last six months the hands had become
involved, and on more than one occasion of late the lesions had vesicated.
There was no sign of atrophy. He regarded it as persistent erythema
multiforme.
Case of Lichen Planus, with some Unusual Features.
By E. Graham Little, M.D.
The patient, a young man, aged ‘25, had suffered for three years from
patches of dermatitis on the lower part of the right leg. These patches
were of a deep bluish-brown colour, and were covered from time to time
with heaped-up scales. No general eruption of any kind had been
present, and no other lesions were found on the body. There had been
no itching either in these patches or elsewhere. The patient had suffered
from varicose veins in this leg, and two years ago had had some of these
cut out. In the scar of these operations there was brown pigmentation,
similar to, but less deep in colour than, that in the spontaneous patches.
The absence of all lesions, or history of these, and of itching made the
diagnosis a little difficult. No treatment had been given at any time
for the disease.
Case of Grouped Comedones in an Infant.
By J. M. H. Macleod, M.D.
The patient was a somewhat delicate-looking boy, aged 14 months,
who presented groups of about twenty comedones on his cheeks, and
Dermatological Section
15
a smaller group on the chin. The comedones were small in size, and
were situated on apparently healthy skin. There were no pustules
associated with them, and only one of them was surrounded by an
inflammatory halo. The comedones were first noticed when the child
was four months old. The mother, who had nursed the infant, had
suffered since childhood from acne vulgaris affecting the face, neck,
shoulders, and chest, but not the breasts.
With the exception of the fact that grouped comedones in childhood
seem to be more common in males than in females, little is known of the
etiology of this affection. In this case neither seborrhcea capitis nor the
employment of some local irritant, both of which have been suggested as
causes, could be blamed for it, as the scalp was free of seborrhoea
and there was no history of anything unusual having been rubbed
on the face. In a case demonstrated by the exhibitor at the Dermato¬
logical Society of London (Brit. Journ. Derm., 1905, vol. xvii., p. 141),
in which grouped comedones associated with acneiform lesions were
present on the chest of a boy, aged 2, there was a definite history of
local irritation produced by wearing a flannel binder, frequently saturated
with camphor oil, on the chest.
The fact that the mother suffered from acne and presented numerous
large comedones on the face was suggestive of contagion. With the
kind assistance of Mr. Leathern, bacteriologist at Charing Cross Hospital,
an examination was made of comedones expressed from both the mother
and child. For this purpose, after cleaning the skin thoroughly, come¬
dones were extracted in which there was no evidence of inflammatory
disturbance, and were inoculated on various media. So far only the
Staphylococcus albus had been obtained in both cases.
Case of Multiple Lupus Vulgaris following Measles.
(Exhibited at the previous meeting of the Section—see p. 6.)
By J. M. H. Macleod, M.D.
The case w r as again presented • to show the result of treatment on
the red patches of dermatitis which surrounded a number of the tuber¬
cular lesions.
At the previous meeting there had been considerable discussion as to
the nature of these patches, and various suggestions had been made,
such as that (1) they were the result of the action of an irritating
10 Morris and Fox: Case of von Recklinghausen's Disease
ointment which had been rubbed into the lupus lesions; (2) that they
were patches of lichen scrofulosorum ; and (3) that they were patches
of seborrhoeic dermatitis. The patient was admitted into the Victoria
Hospital for Children, and has been under observation there during the
last month. It was ascertained that an irritating ointment had been
employed before admission, but though the patches faded during the
first fortnight in hospital they did not disappear, and at the time of
exhibition they were still present around the scars which resulted from
the scraping of the lupus lesions, in the form of circular, slightly scaly
patches. In addition there were several large irregular patches, inde¬
pendent of lupus lesions, situated on the left thigh. These irregular
patches presented all the characteristics of the dry, resistant patches of
dermatitis which it is customary at present to include under the some¬
what ill-defined heading of seborrhoeic dermatitis. For purposes of
comparison a case of this nature in a boy, aged 14, was presented,
in which several circular patches occurred, which seemed to be identical
in character with those on the girl’s thigh. The boy had been under
observation at Charing Cross Hospital, and in spite of thorough local
treatment the lesions had persisted.
During the last fortnight the patches in the girl had been rubbed
with sulphur ointment and had somewhat faded under the treatment.
Case of von Recklinghausen’s Disease.
By Malcolm Morris, F.R.C.S.Ed., and Wilfrid S. Fox, M.D.
The patient was a woman, aged 42, who stated that the condition
had been present almost since birth, and that the tumours had not
increased in size or number for some years. The case showed most of
the usual characteristics, and resembled very closely in some respects a
case shown by the exhibitors before the Dermatological Society of
London in the spring of this year. The tumours, which were countless,
were distributed all over the body and were of two kinds, some being
soft, almost fluctuating, subcutaneous masses, others being firmer, pro¬
jecting from the surface of the skin, and giving a gelatinous sensation
to the touch; there were none of the so-called “seedless raisin”
type which have been observed in this disease. On the scalp the
tumours were large and soft, the largest measuring about 3 inches in
diameter. On the face they were small and firm, the majority being
about the size of a split pea. On the trunk and limbs they were mostly
Dermatological Section
17
firm and projecting, several of them being as large as a hazel-nut. On
the left arm, just above the elbow, there was one large, soft tumour
below the deep fascia. The pigmentation was of both varieties usually
seen in this disease, namely, diffuse freckling and large plaques; the
former was well marked all over the trunk, and there were two examples
of the latter, measuring about 2 inches in diameter, on the lower part
of the back. The nervous signs were not well marked; the only
tumours which were painful were the large ones on the scalp; there was
no itching or pricking as was noticed in the previous case. The woman
was of average intelligence, and did not suffer from epileptiform fits, but
occasionally fainted.
Case for Diagnosis.
By Malcolm Morris, F.R.C.S.(Edin.).
The patient was a man, aged 63. About four months ago blisters
had appeared on the dorsal surfaces of his fingers and hands. One
month later similar large thick-walled bullae made their appearance on
his face, nose, and forehead, giving rise to excoriated patches and being
followed by well-defined areas of atrophic skin in the sites previously
occupied by the bullae. There were numerous large comedones on the
side of the nose and on the cheeks, and there was also well-marked
leucoplakia of both cheeks and of the tongue. The patient had taken
tar in considerable quantity for six weeks.
Case of Pigmentation of the Face.
By George Pernet.
The patient was a young woman, aged 21, with unilateral “freckle ”
pigmentation about the outer side of left orbit and cheek. The con¬
dition began like freckles about four to five years ago, occupying the
same area then as now, but the tint had become darker. At catamenial
periods the patient stated that the colour became deeper. When seen
the tint was a livid sepia.
Lupus Erythematosus of the Face, with a Condition
of the Fingers simulating Raynaud's Disease.
By J. H. Sequeira, M.D.
The patient, a single woman, aged 34, had suffered from lupus
erythematosus for twenty years. The first spot appeared on the tip of
the nose and was thought to be eczema. The disease had slowly spread
18
Pringle : Case for Diagnosis
on to the cheeks, but for five years was untreated. During the seven
years following she had various treatments. Two operations were
performed, and in 1896 she had injections of tuberculin. She stated
that the face had been better since the injections, and had not required
treatment for the last seven years. In 1900, however, her fingers
became affected. She said that they “ all gathered and discharged.”
Healing was slow, and during the past three years she described the
fingers as “ wasting away.” The wasting was progressive.
The fingers were tapering, and very thin and claw-like. They were
redder than normal, and the colour disappeared on pressure. The skin
was thin, shining, and atrophic. She complained that the, fingers and
hands were “ either very cold or very hot.” The terminal phalanges of
the fingers (not the thumbs) could not be fully extended. The
metacarpo-phalangeal joints could be fully flexed, but there was only
limited flexion of the interphalangeal joints of the thumbs, and whilst
they were bent the skin over the knuckles became very tense and white.
The skin of the backs and fronts of the hands showed the same changes
in a less degree.
There was evidence of old apical phthisis. The family history was
good.
Similar cases had been shown at the meetings of the Dermatological
Society of London by Dr. Pringle. The condition did not appear to
be true Raynaud’s disease, as the process was continuous and not
paroxysmal. There had been no haemoglobinuria at any time, and the
urine had been free from albumen while the patient was under Dr.
Sequeira’s observation. The condition of the fingers on exhibition was
a degree of sclerodactyly.
Case for Diagnosis.
By J. J. Pringle, M.B. (for Dr. Ernest A. Crisp).
The patient was a female, aged 18. The history of the case, obtained
from her mother, was as follows : No similar or other skin affection was
knowm to exist in the family. The patient’s father had probably suffered
from syphilis; her skin at birth was perfectly normal; at the age of
1 year a “ blister ” was noticed on the left buttock. The skin about the
privates and lower abdomen soon afterwards became inflamed, and some
suppuration occurred at the crown of the scalp, where “ the scurf was
very thick and the whole separated like a cap, leaving a mattery surface.”
The skin of the face also “ peeled off in ragged scales like tissue-paper.”
Dermatological Section
19
At the age of 3 years she came under the observation of Mr.
Jonathan Hutchinson, who had a water-colour drawing of the condition
done by Mr. Burgess on December 5, 1893, which Mr. Hutchinson
kindly allowed the exhibitor to show to the meeting. The drawing is
now in the Polyclinic , and is described as follows : “ Dermatitis perstans ;
portrait showing a very unusual form of chronic dermatitis, which has
persisted since infancy, in a child aged 3. The patches were covered
with scab and crust, which adhered so firmly that they could not be
removed. The skin upon which these horny crusts had formed was
somewhat contracted. The condition in infancy had been very severe
indeed, and had been supposed to be hereditary syphilis. It did not,
however, yield to specific treatment, and when the case came under
Mr. Hutchinson’s care there were no indications of specific taint. After
about a year’s treatment, exclusively by local means, the child is now
almost well.” (The nature of the local means used could not be
ascertained.)
Mr. Burgess’s drawings, already referred to, portrayed a state of
affairs very suggestive of a hystrix in large patches over the buttocks,
about the vulva, in the bends of the elbows and axillae, in broad streaks
dow’n the left forearm, with deep brownish-yellow bands of indeterminate
appearance on the neck transversely, on the upper and lower lips, as well
as on the cheeks, lower eyelids, and supraciliary regions.
The condition had clearly relapsed when she came under the observa¬
tion of Dr. Ernest Crisp, in August, 1905, who described it as “ raised,
hard patches, more or less completely covering the body ” and involving
the scalp. He commenced treatment by 10 minims of Donovan’s
solution three times a day with hydriodie acid, along with various local
applications of mercury, resorcin, and ichthyol; for a year no marked
improvement resulted. Dr. Crisp then applied iodised phenol to each
“ seborrhoeic ” patch, with the result that in six months “ all the body
was cleared ”; the head and face, though much improved by the local
treatment, failed to get well. A visit to Woodhall Spa in July, 1900,
proved of no benefit, so she was put upon 8 minim doses of liquor,
potassii arseniatis and of Donovan’s solution three times daily till she
went to Aix-les-Bains in April, 1907.
When the patient came under the exhibitor’s observation in October
of the present year it was noted that she had (1) typical diffuse arsenical
pigmentation over the limbs and trunk; most marked where a pre¬
existing lesion on the buttocks had been removed by iodised phenol; very
characteristic arsenical warty keratosis of the palms and soles, with
20
Pringle : Case for Diagnosis
marked hyperidrosis and bromidrosis of the latter region. The girl
herself was positive in her assertion that all of these phenomena had
developed rather suddenly in the spring of 1907, about the time she
went to Aix-les-Bains. (2) Diffuse slight xerodermia of neck, trunk, and
limbs, with very marked follicular keratosis of the backs of the upper
and forearms, thighs, and legs, attaining its maximum of intensity on the
tips of the elbows and knees, where irritable horny cones were present.
These abnormalities were stated to have dated from early infancy, and
were undoubtedly “ichthyotic” in nature. On the backs of the hands, and
especially on the proximal phalanges of all the fingers, there were closely
packed, horny follicular cones, with a central depression reminiscent
of the lesions of pityriasis rubra pilaris, and patches of similar nature
were noted on the dorsal surfaces of the feet (probably from pressure).
These changes were not depicted in Mr. Hutchinson’s drawings. (3)
Enormous hypertrophy of the nipples, which projected as filiform corneous
masses nearly an inch from the general level of the mammae. This was
stated to have existed as long as the patient could remember, and her
assertion was confirmed by the exhibitor that these horny masses fell off
from time to time, only to re-form again rapidly. (4) A dense, brownish-
yellow, rather gummy scab was firmly adherent to the supraciliarv
regions and to the upper parts of the cheeks, which could only be
separated at the expense of some laceration of the subjacent tissue; and
scattered scabby, rather impetiginous lesions were thickly present over
the face, ears, neck, prsesternal and interscapular lesions. In the latter
regions the base of the patches was distinctly hard, raised, and warty.
(5) At the vertex of the scalp was a large moss-like patch the size of the
palm of the hand, the hair over which was in normal abundance, but
which was suppurating freely and harbouring very numerous pediculi.
It was especially noted that the pre-existing lesions on the trunk and
limbs had been successfully removed without trace of cicatrices. While
under observation, and probably as the result of the application of
kerosene to remove scabs from the scalp and destroy pediculi, an acute
dermatitis had developed over the forehead and neck, with adherent crust
similar to that already described.
Dr. Pringle admitted that he was unable to make any firm diagnosis
of the case, which did not accord in its entirety with any type of skin
disease with which he was familiar. The arsenical manifestations were
obvious and characteristic, and easily separable from the other phenomena.
The patient was clearly ichthyotic, and the idea suggested itself that she
had also had hystrix, which had disappeared either spontaneously (as
Dermatological Section
21
reported in a few cases) or as the result of treatment. The tendency to
dermatitis on very slight provocation he thought due to some congenital
skin peculiarity rendering it specially liable to invasion by pyogenic cocci.
Case of Circinate Erythematous Syphilide.
By A. Shillitoe, F.R.C.S.
The patient, a man, single, aged 39, bootmaker, attended the Lock
Hospital on July 22 last with phimosis, concealed chancre, indurated
inguinal glands, and roseola, of five days duration, of the back of the
neck and upper part of the trunk. His weight was 9 st. 2 lb. He has
always had scurf in the head.
October 21.—He weighed Bst. 7 lb. He had gone on fairly in the
meantime up to two or three days previous, when, without any pre¬
monitory symptoms, he somewhat suddenly developed the condition seen,
viz., a series of large, complete, bright red, erythematous rings, raised
decidedly above the surface, about one inch in diameter, and at first
covered with a pellicle, without itching, or signs of inflammation. The
first ring started at the right angle of the mouth, in the moustache. In
addition there was one ring on the left cheek and several on the posterior
and lateral aspects of the neck on both sides, and also over the pectorales
majores, where they cease to form the anterior walls of the axillae.
November 11.—The weight was still falling. A fresh place had
developed on the left buttock.
November 18.—Weight 8 st. 6 lb. All the places were rapidly healing.
November 25.—He was not feeling so well, and all the rings were
threatening to relapse.
Rodent Ulcer treated by the Introduction of Zinc Ions.
By A. Whitfield, M.D.
The patient, a woman, aged 44, had noticed a spot beneath the
left inner canthus nine years ago. She had scratched this spot, which
bled and then extended. The patient was first seen in November,
1906, and the condition was then as follows : About a £ inch below
the left inner canthus there was an area of the shape of a figure of
eight, measuring about 1 inch in a vertical, and about £ inch in a
horizontal direction. It was infiltrated and hard, and covered with a
thick crust which, on removal, disclosed an irregular eroded surface of
a pinkish colour. The diagnosis of rodent ulcer was made, and as it was
22
Whitfield: Long-standing Pruritus
thought that excision would be difficult without causing extensive deformity
the patch was treated with radium. After continuing this treatment for
some time, with slight improvement, it was decided to substitute the
X-rays in order to save time. The patient, however, could not attend
very frequently, and therefore long exposures, about half a Sabouraud’s
pastille, were given at intervals of a fortnight. By this means, on more
than one occasion the area exposed was definitely reddened, but no
blistering was produced. For a time the case progressed very favour¬
ably, but the treatment seemed to lose its effect, and latterly the disease
spread while under treatment. The treatment recommended by
Dr. Lewis Jones was then inaugurated. The patch was, in two sittings
(October 5 and October 12 respectively) electrolysed with the negative
pole in contact with the growth, a zinc electrode and a 1 per cent,
solution of zinc sulphate being used. A current of ten milliamperes was
passed for ten minutes. At the end of that time the area so treated
was completely blanched, and a fortnight later there was an ulcer, with
rather firm edges, left. At first Dr. Whitfield was inclined to think,
from the firmness, that there was malignant tissue left, but as the
ulcer healed, which it did very rapidly, all trace of induration disap¬
peared from the upper part. The lower part, which was electrolysed
later, still showed some of this firmness, and Dr. Whitfield said he
brought it up in this stage to show this point. He should, of course,
watch the case very carefully for a long time to come, as it was obviously
too early to talk of cure, but he thought that at present the outlook was
very favourable, and he felt pretty confident that the slight hardness of
the lower edge which was still apparent would disappear spontaneously
as it did in the upper part.
Long-standing Pruritus in a Woman, aged 22.
By A. Whitfield, M.D.
The history showed that the patient had suffered from pruritus for as
long as she could remember. She had seen many doctors, but had derived
no benefit. On examination it was found that the whole of the skin,
with the exception of the palms and sole and scalp, was covered with
small, irregularly-shaped scars, varying in diameter from a J to J inch.
These were cribriform and slightly depressed, exactly resembling vaccina¬
tion scars. There were also present several deep excoriations, which
the patient said she dug out in the night, when the itching was at its
worst. The patient did not seem at all hysterical, and there was no
Dermatological Section
23
question of any intention to deceive, since the patient herself volunteered
the statement that the marks were self-inflicted, though she was not
always conscious of producing some of the wounds.
Dr. Whitfield said that he had investigated the case as far as his
knowledge went, and he had, perhaps, obtained some light. The blood-
coagulation was normal. The urine had been tested for albumen, sugar,
bile-salts, and indican, with negative results in each case. The blood-
count showed the presence of 2,675,000 red blood-corpuscles per cubic
millimetre, and 6,000 white corpuscles. A differential count had shown
the following proportions: Polynuclear leucocytes, 57’8 per cent.;
lymphocytes, 34 per cent.; eosinophiles, 2'4 per cent. ; hyaline, 5'8 per
cent. Remembering that pruritus had been recorded associated with
deficient polynuclear leucocytes, he had administered thymus extract, but
he could not say that in the short time she had been taking it any
marked improvement had been noticed that could be referred to the drug.
The patient was using an anti-pruritic cream, which did some good.
Sections of Paraffinoma.
By A. WlNKELRIED WILLIAMS, M.B.
The patient was injected with paraffin by an unqualified person. The
paraffin used was of too low a melting point and diffused into sub¬
cutaneous tissue and among the facial muscles. After several months
tumours developed along the areas of diffused paraffin. They were
excised subcutaneously and recurred; a second excision was followed by
same result. Great persistent oedema accompanied the tumours. A
portion of tissue excised was cut in two parts, one of which was desic¬
cated over H 2 S0 4 , then weighed and then digested in warm xylol for
twenty-four hours. After drawing off the xylol it was again weighed,
but the loss of weight was very slight. The other part of the same piece
was, without hardening or fixation, cut, frozen, and examined in Farrant.
It showed, here and there, fine streaks of a clear homogeneous material
differing in its refractive index from the tissue and the glycerine, &c., of
the Farrant’s medium. Other pieces were fixed and hardened in alcohol,
and sections showed bands of well-formed fibrous tissue enclosing areas
of cells, mostly of epithelioid type, with a large number of multi-
nucleated giant-cells. Sections stained with carbol fuchsin showed no
acid-fast organisms. Organisms were not found by any stains. The
cellular masses and giant-cells and fibrous tissue were irregularly infil-
24
Williams: Sections of Paraffinoma
trating between the muscle fibres of the facial muscles. The patient so
far had declined X-ray treatment. Thiosinamine injection and electro¬
lysis had not yet been tried, as a painless treatment was wished.
Arsenic was tried by mouth and pushed to 8 minims of Fowler’s
solution three times a day. At first slight improvement resulted ; some
reduction of the oedematous swelling was accomplished, but it relapsed.
Thyroid was of no use. The swelling was prevented from progressing by
massage and pressure.
Dr. Ormsby, of Chicago, had a similar case, which he showed to the
Chicago Dermatological Society. In a letter to Dr. Williams he stated
that his patient is deriving great benefit from X-ray treatment.
Dr. Unna, of Hamburg, with whom Dr. Williams discussed the case,
strongly advised X-ray treatment.
Dermatological Section.
December 19, 1907.
Dr. T. Colcott Fox, Vice-President of the Section, in the Chair.
A Case for Diagnosis.
By G. W. Dawson, F.R.C.S.I.
The patient, a young woman, aged 33, of healthy appearance, had
a peculiar condition of the extremities which began about six years ago
on the palms of the hands and soles of the feet, where it remained limited
for nearly two years. Since then it gradually extended up to the middle
of the forearms and legs, being fairly well demarcated from the sound
skin. It was of a brownish colour, and the numerous lines which
intersected one another, as well as the roughness that w r as present, gave
it the appearance of crocodile leather. There was, however, no appre¬
ciable thickening, no evidence of the follicles being involved, and no
itching. Besides this condition there were patches of a psoriatic-looking
eruption on the patellae and elbows.
The eruption, which had never been moist and was of a remarkably
uniform appearance, did not appear to correspond to any described con¬
dition.
Vegetating Granulomata on the Face.
By T. Colcott Fox, M.B.
The patient was a robust-looking married woman, aged ‘25. On
the face there were four disseminated vegetating granulomata of three
months’ duration. She had one healthy child and was pregnant with
a second ; no miscarriages. The four lesions, said to have begun as
“ pimples,” gradually enlarged. The patient said they evolved after
a severe cold and sore throat. One lesion, the size of a split pea, was
seated on the bridge of the nose and was the first to form; a second,
the size of a fourpenny piece, occupied the nasogenal furrow and
adjoining surfaces; the third and fourth were rather smaller and seated
ja —3
26
Little: Two Cases of Favus of the Scalp
respectively on the left upper lip and the left chin. The lesions were
rounded, granuloma-like infiltrations, surmounted by marked vegetations,
not florid and vascular, but warty in aspect. There were no miliary
abscesses from which pus could be squeezed out. Two other lesions
grew on the left cheek and chin, but had disappeared, leaving scars.
Although the nature of the disease had not yet been thoroughly
investigated, Dr. Fox thought the clinical aspects alone were of interest,
and, moreover, the lesions were already markedly subsiding under the
influence of the internal administration of mistura hydrargyri biniodidi.
As to the differential diagnosis, the exhibitor said no iodides had
been taken prior to the evolution of the eruption. The eruption was
immediately preceded by what the patient described as a bad cold and
sore throat, but there was no history of any widespread eruption. More¬
over, vegetating syphilides and tuberculoses of the face were usually of
the florid framboesioid type, and not warty like the verrucose tuberculosis
of the back of the hand. There was no chronic coccic inflammation as
in sycosis to account for the vegetating lesions. Clinically the eruption
was very similar to those described in blastomycosis.
Two Cases of Favus of the Scalp.
By E. G. Graham Little, M.D.
Case I.
The patient was a woman, aged 40, who had had the disease since
early childhood. She was an Englishwoman, a native of Essex, had never
lived abroad, and the origin was doubtful. The scalp was almost entirely
denuded of hair, old cicatricial atrophy having resulted from the favus;
but there was active disease over a large part of the scalp, and abso¬
lutely typical scutula were present in this area. The fungus had been
readily demonstrated in the hair. This patient had a diseased nail of
one finger, the enamel being destroyed and the nail giving the appear¬
ance of moelle de jonc , w'hich has been described by French authors as
typical of favus. Doubtful fragments of mycelium had been seen in
scrapings from the nail.
Case II.
The patient w r as a boy, aged 8, the nephew of the preceding case.
This patient had had the disease since early infancy, but it had spread
of late. There were no scutula at all, and the scalp showed circinate,
red, pityriasic patches with very little hair in the affected part. Fungus
had been seen in one hair after many fruitless examinations.
Dermatolo<jicaI Section
27
A Case of Bazin’s Disease (Erythema induratum) in
a Young Woman.
By E. G. Graham Little, M.D.
Nodose swellings had appeared about six weeks or two months
previously. These were painless, deep blue, infiltrated and numerous on
both legs and both feet. The patient gave the history of previous similar
swellings, which had left some permanent scarring. There was no tuber¬
cular history, and the patient herself, though anaemic, showed no sign of
tuberculosis. The opsonic index had been estimated on one occasion
only, and was then 0'96. The suddenness w r ith which the swellings had
appeared had at first suggested erythema nodosum, but they were
painless, and had now persisted beyond the time limits of erythema
nodosum. It might be considered too rapid in development for erythema
induratum, but with this exception the diagnosis of that disease would
better fit in with the symptoms than any other affection.
Two Cases of Advanced “Keratosis follicularis associated
with Baldness.”
By J. M. H. MacLeod, M.D., and E. Treacher Collins, F.R.C.S.
The patients were brothers, aged respectively 13 and 10. The two
cases and that of an elder brother similarly affected, whose photograph
was shown, first came under the observation of Mr. Collins in 1902, at
the School of the Metropolitan Asylums Board, at Swanley. As all the
three boys were suffering from trachoma the cases were sent up to
Dr. MacLeod’s clinic at Charing Cross Hospital, in August, 1907,
when the following notes were taken: (1) William B., aged 10,
suffering from keratosis follicularis associated with baldness, and
trachoma. The patient was a fairly well-developed lad whose general
health was good. He was the eldest of five brothers, two of the others
being affected with the same condition of the skin. All the regions of
the body where hairs occurred, with a few exceptions, were covered witli
small, pinhead-sized papules arranged in groups or diffusely distributed.
The papules were follicular and surmounted by conical horny plugs or
spines about 2 mm. in length, and where they were most marked they
gave to the skin the feeling of a nutmeg-grater. On picking out the
28 MacLeod & Collins : Keratosis follicularis
horny plug a central depression was left. The papules were not situated
on an inflammatory base, and except for slight scaliness in certain situa¬
tions the skin between them seemed to be normal. The distribution of
the papules tended to be symmetrical. They w r ere most numerous on the
extensor aspects of the arms, the back and sides of the neck, the buttocks,
and on the beard and ciliary regions of the face. On the back and loins
there were a few r groups and several disseminated lesions. A few T scattered
Keratosis follicularis associated with'Baldness.
lesions were also present on the abdomen, but there were none on the
chest, though many of the hair follicles were more visible and palpable
than normally. Lesions were absent from the extensor aspects of the
legs and part of the face, and in these situations the skin w r as rough like
ichthyosis. A small group of lesions w r as present on the dorsum of the
hands, but none occurred on the backs of the fingers. They w ere present ,
Dermatological Section
29
however, on the dorsal aspect of the toes. The eyelashes and eyebrows
were absent, but the hair of the scalp was unaffected.
The skin generally felt dry and harsh, though the patient perspired
freely in warm weather and after physical exertion. The hands were
cyanosed and felt cold. There were no subjective symptoms, such as
itching, associated with the lesions. At birth the skin appeared to be
normal, but when an infant in long clothes he was taken to Westminster
Hospital for advice regarding his skin and eyebrows. The eruption is
said to have begun on the face and eyebrows. He had measles when he
was five months old and the eruption spread rapidly afterwards.
The patient has had trachoma since he was aged 5, on account
of which he had to be removed from school as he suffered acutely from
photophobia. The family history shows that the father’s family suffered
from pulmonary tuberculosis, the father himself not being affected, but
the details of the family history were not obtained.
The accompanying photograph of the case shows the .absence of
eyebrows and eyelashes and the rough skin of the neck and beard region,
due to the presence of the spiny papules.
(2) Alfred B., aged 13, with keratosis follicularis. The patient
presented a similar condition of the skin to William’s, but the lesions
were less abundant and more scattered. In this case the front of the
chest was not exempt, but as regards the face only the chin was affected.
The backs of the hands were more involved and spiny lesions were present
on the backs of the fingers. The skin of the extensor aspect of the legs,
the front of the knees, and the elbows was ichthyotic. In this case the
scalp was markedly affected and was almost totally bald, only a few
downy hairs being present on the sides of the head. The scalp was red in
front and rough and scaly. The boy was born healthy and the affection
was first noted when he was aged about 2. At the age of 7 much
of the hair had come out in patches at the back of the scalp, but was
present then in front; the eyebrows and eyelashes had gone. The
patient has suffered from trachoma since birth.
(3) Leonard B., aged 10, with keratosis follicularis. The patient was
similarly affected to Alfred, but in a milder degree. The scalp was only
partially bald, a few tufts of normal hair being left at the sides. The
patient never had much hair on the scalp. The eyebrows and eyelashes
were involved and absent. The patient was born healthy. The disease
had begun during his first year, and when aged 2 the skin was rough
and the hair of the head had gone. He also suffered from trachoma.
A histological examination was made of several well-marked spiny
30
MacLeod & Collins: Keratosis follicularis
lesions excised from the back of the neck in the case of Alfred B., and
sections were exhibited. These showed that the mouths of the follicles
were dilated and filled with a homy plug occupying the whole of the
funnel of the follicle and extending about 1 mm. above the level of the
skin. The stratum comeum in the neighbourhood of the follicle showed
slight hyperkeratosis, the deeper layers of the epidermis not being notice¬
ably affected. The deeper portion of the follicle was somewhat shrunken,
and in one or two of them the remains of an atrophied hair were
detected. The sebaceous glands were absent. Sweat glands were present
and appeared to be healthy. Around the follicles there was a slight
cellular infiltration of small rounded cells, but the connective tissue
bundles in the neighbourhood of the follicles were not rarefied and there
was no definite evidence of inflammation.
The important features of all three cases were : (1) The plugging
of the hair follicles with homy spines over certain regions of the body
being most marked on the face, scalp (in two cases), back of the neck,
extensor aspect of the arms and buttocks, but occurring also to a greater
or less extent in all situations where hair follicles existed, and leading
to loss of the eyebrows and eyelashes in all the cases, and almost complete
baldness in two of them.
(2) The association of the spiny follicles with general dry and harsh
condition of the skin of the type of xeroderma or a mild degree of
ichthyosis.
(3) The fact that the condition appeared first in two of the cases
during the first year and in the other before the end of the second, all
three being reported to have been born with healthy skins.
(4) The absence of definite evidences of inflammation having pre¬
ceded the growth of the spiny papule, and also the apparent absence of
atrophic changes.
The cases suggested an ichthyotic condition in which the mouths of
the follicles were specially involved. In some respects they corresponded
to cases 'which have been described by Brocq under the heading of
“keratosis pilaris” and by Unna as “keratosis suprafollicularis,”
differing in the fact that the eyebrows, eyelashes, and scalp were so
markedly involved. The absence of atrophy distinguished them from the
cases described by Taenzer with the title of “ ulerythema ophryogenes.”
Mr. Treacher Collins said there was little for him to add to Dr.
MacLeod’s description. The cases came to him on account of the almost
intractable condition of the conjunctive, and they had been under his
observation for four years. They were suffering from trachoma when
Dermatological Section
31
they were first seen by him, and that was now almost cured, but the
children still had recurrent attacks of conjunctivitis. He believed that
the conjunctive were inoculated by means of the handkerchief from the
nasal discharge, the absence of eyelashes making it easier for the con¬
junctivae to be infected. The condition of the skin had not altered during
the four years they had been under his observation.
A Case of Erythema induratum (Bazin) in a woman, aged 21,
in which a Positive Ophthalmo-tuberculin Reaction had
been obtained.
By J. M. H. MacLeod, M.D.
The patient was a somewhat delicate-looking young woman who
worked as a milliner. She had a tuberculous family history, two of her
aunts on her mother's side having tuberculosis of the lungs. Three years
before she came under the exhibitor’s observation lesions of Bazin’s
disease made their appearance on both legs. These were scraped, but
new lesions developed later. At the time of exhibition she presented
a number of lesions on both legs consisting of the typical ulcers, reddish-
purple patches, deep-seated nodules, and the scars of former lesions.
She had no other evidences of tuberculosis. On December 10 a drop
of Calmette’s tuberculin solution, freshly prepared from the powder, was
dropped in the conjunctiva of the right eye near the inner canthus, the
eyes having been examined beforehand and proved to be healthy. Six
hours later the eye became inflamed, and when she was seen twenty-four
hours afterwards an acute reaction had taken place, the lower conjunctiva
and the caruncle being red and injected, and an exudation had collected
in the inferior conjunctival sac. The eye was so extremely painful and
there was such a degree of photophobia that a drop of adrenalin (1 in
1000) and cocaine (2 per cent, solution) were prescribed every six hours
to relieve the pain. This reaction in the eye was accompanied by a local
reaction in the lesions in the leg, which became definitely painful and
appeared to be more vivid in colour. The ophthalmic reaction persisted
at its maximum for twenty-four horns longer and then gradually subsided.
At the time of exhibition there were .still evidences of it.
The CHAIRMAN remarked that some years ago he had had material from
a case of Bazin’s disease inoculated into a guinea-pig, and the animal had
died of tuberculosis. He did not publish the case.
32 Stowers: Case of Infective Granuloma
Report on a Case of Infective Granuloma.
Dr. Stowers exhibited for the second time the male patient, aged
48, who was the subject of an infective granuloma of the right cheek
of septic origin, in order to show the effects of treatment. The tumour
(a description of which has been recorded in the Proceedings of this
Section—vol. i., no. 1, p. 7) had greatly diminished in size, and was still
undergoing a process of resolution. It was decided to continue the
mercurial application until the skin had resumed its normal condition.
Dermatological Section.
January 16, 1908.
Dr. Radcliffe Crocker, President of the Section, in the Chair.
Case of Acute Lichen planus.
By E. G. Graham Little, M.D.
The patient was a young man, a butcher by occupation, with a very
extensive eruption, of typical character, covering the greater part of the
body and, what was very unusual, much of the face. The eruption was
very closely set, of a vivid pink colour, and extremely itchy. The man
complained as well of pain in the limbs. No clue to the origin of the
disease could be obtained ; there was no history of sudden shock or chill,
and he appeared to be a fairly robust and healthy subject. The mucous
membrane of the mouth was very slightly affected. There were very
numerous linearly disposed papules, which had become so distributed by
following the course of superficial scratches; a slight linear abrasion of
the skin made experimentally by the exhibitor a few days previously was
now covered with papules.
Dr. Radcliffe Crocker stated that in his experience the cases which
showed most extensive eruption on the body often showed least eruption on the
mucous membranes, and vice versa. Cases of this acute type did best on
salicin. .
Case of Granuloma annulare.
By E. G. Graham Little, M.D.
The patient was a young woman, of robust appearance, with granu¬
lomatous-looking swellings, which the exhibitor showed tentatively as a
case of granuloma annulare. The diagnosis was based chiefly on the
appearance of the section of one of the nodules. This was shown at the
meeting. Its histology was identical with that of a section of granuloma
annulare (which was shown for comparison) in a man brought before the
/- 4
34
Macleod: Case of Annular Lichen planus
Dermatological Society of London some years ago by the exhibitor ; in
this latter case the diagnosis was universally accepted. The young
woman now shown had had no previous illness ; the nodules had begun
to appear five months previously, and some of them had left scars. They
commenced as white, sago-like Swellings, afterwards becoming red and
then blue. Nodules of this type were situated on the fingers, wrist,
arm, breast, neck, heel, and dorsum of one foot. The exhibitor promised
that this case should be tested for tuberculosis, and that a fuller account
of it would be published later in the British Journal of Dermatology.
Dr. PRINGLE hesitated, on clinical grounds, to accept the exhibitor s
diagnosis. He pointed out the presence of deeply pitted scars left where the
eruption had subsided. The lesions, which were distinctly nodular, in no
locality presented complete circination, and in many positions, most markedly
on the backs of the lower part of the legs, no sign of circination whatever. He
was of the opinion that the case was probably of tuberculous nature, and
suggested the trial of Calmette’s ophthalmo-tuberculin test as an aid to
diagnosis.
Case of Annular Lichen planus affecting the Penis and
Right Forearm.
By J. M. H. Macleod, M.D.
The patient was a fairly healthy-looking man, aged 26, who was
employed as a letter sorter. He had enjoyed good health till two years
ago, when he had a nervous breakdown and was treated in a hospital
for severe pains in the head. He suffered also from a weak peripheral
circulation, with cold hands and perspiring feet. He had never had
syphilis, was married, and had several healthy children. The eruption
about to be described appeared last August, at a time when he was run
down and nervous from having to do double work. It was confined to
the skin of the penis and right forearm, and consisted of (1) small irregu¬
larly shaped papules, about the size of a pin’s head, flat-topped, and of
a lilac pink tint; (2) larger roundish lesions about the size of a split-pea
with a scale in the centre, w r hich, on becoming detached, left a depres¬
sion ; and (3) incomplete ringed lesions with an irregular border, about
2 mm. in breadth, covered with adherent scales, broken transversely by
striae, and enclosing areas of normal or slightly atrophic skin about the
size of a threepenny piece. The lesions were superficial, but had a
definite and firm consistence. They appeared first as small, flat papules,
which increased peripherally, and involuted in the centre with the
Dermatological Section
35
formation of a scale, which separated and so produced a ringed lesion.
The lesions were associated with slight itching. In addition to the
lesions on the penis there was a solitary ringed lesion, about the size of
a large split-pea, on the flexor aspect of the left forearm. No lesions
occurred on the mucous membranes.
The case was of interest (1) as it showed the method of development
of the annular lesion by the peripheral extension of a papule and its
central involution, and (2) because the shaft of the penis is a somewhat
rare situation for lichen planus. In this connection it is of interest to
note that Felix Pinkus 1 has recently described a series of cases of a
nodular eruption, with a close resemblance to lichen planus, which
occurred in men and was usually confined to the penis, but occasionally
affected other parts, such as the abdomen, chest, and arms. He named
it “ lichen nitidus,” as it consisted of shiny papules with a central
depression. These lesions never became confluent, but showed a
tendency to be arranged in rows.
Dr. PRINGLE had seen on the day of the meeting a case which he had
diagnosed six weeks previously as one of lichen annularis, described by Dr.
Galloway in 1899 as distinct from lichen planus of annular type. The mani¬
festations were confined to the backs of the hands and wrists, and consisted of
numerous circular lesions with raised, firm margins, averaging the size of a
sixpenny piece. An eruption of lichen planus papules had, however, developed
upon both forearms during the previous week.
Case of Pityriasis rubra pilaris.
By J. A. Ormerod, M.D.
The patient was a healthy-looking man, aged 30, and by occupation
a coal-heaver. Previous to the onset of the present eruption his skin
had been healthy and he could cite no adequate cause for the rash. A
month before the outbreak he had attended the Seamen’s Hospital for a
scalp wound. The first indication he had of the skin affection was that
for two days he had noticed that, although working hard, he did not
perspire. The skin of his forehead began to feel “ tight,” and that of
the face and neck became red and scaly. The erythema and scaliness
had gradually spread down on to the trunk and limbs. He was admitted
to St. Bartholomew’s Hospital on January 3, 1908, and the onset of the
eruption had taken place five weeks before admission. At the time of
1 Arch , f, Dermctt. u. Syph., Wien, 1907, Ixxxv., p. 11.
30
Crocker & Pernet: Case for Diagnosis
exhibition the eruption had the following distribution and character:
It involved almost every part of the skin, but was most marked in the
neck, upper arms and trunk. The scalp was slightly scaly, but not
seriously affected, the face was red and scaly, while the neck and upper
arms were covered with a diffuse, red, harsh, scaly eruption. The
vaccination marks stood out as white, unaffected areas. On the abdomen
the eruption was profuse, but on each side there were areas arranged
symmetrically where the skin was less uniformly involved. On the
thighs there were discrete scaly papules, due to the follicles being filled
with epithelial plugs. The legs and forearms were less affected, but the
follicles were prominent and hard. The backs of the hands were harsh
and scaly, but the dorsal aspect of the phalanges did not present the
usual prominent follicles. There was slight scaling of the soles and
palms, which were horny, but not more so than was usually the case.
The scrotum and penis appeared to be unaffected.
Dr. Pringle remarked on the remarkably slight degree to which the seal])
was affected, but had noted the same peculiarity in two cases of pityriasis rubra
pilaris of acute type similar to that exhibited.
Case for Diagnosis.
By H. Radcliffe Crocker, M.D., and George Pernet.
The patient was a well-built and otherwise quite healthy male, aged
2(5, and Australian by birth. Seven years ago, whilst working in very
deep mines, he used to get very hot, and he suffered from a rash about
the body and inner part of the legs. Some of his mates also suffered from
rashes on account of the heat, but in their case the skin soon recovered,
whereas in the patient the rash remained for a considerable time, the
individual lesions running together and the limbs also becoming involved.
Except for an attack of fever in the Gulf of Carpentaria he had always
been quite well and strong. He had been under the care of various
medical men, some of whom had treated him for syphilis. The question
of leprosy and mycosis fungoides had also arisen. In 1906 he came
under the observation of Dr. H. G. Anthony, of Chicago, who came to
the conclusion that the case was one of parakeratosis variegata, and pub¬
lished an account of it, with histology, and a discussion on the diagnosis. 1
Dr. Anthony sent the patient to Dr. Radcliffe Crocker, but in the
latter’s absence the case was seen by Mr. George Pernet. The following
1 Join'll, of Cutan. Dis ., New York, 1906, xxiv., p. 455.
De i m a to tog ica l Sec t i0 n
37
notes were made on December 4, 1907 : Scattered about the body and
limbs were a number of patches, circular and more or less oval in shape.
On the back the patches varied in size from 2J in. in diameter to the size
of the palm. In colour and general appearance they were a pale pink
and yellowish pink, like the early patches of xantho-erythrodermia
perstans; but on the front of the body and on the limbs they were
mottled brownish and bluish, with intervening hues. The darker ones
presented pigmentary changes together with spotty superficial atrophy
and telangiectases, especially on the lower limbs and buttocks. On
pinching up the patches infiltration could not be made out, and the
atrophy was not very obvious to touch. There was but faint scaliness in
some of the older patches. As regards the general distribution, there
was distinctly a symmetrical tendency, and this became more obvious
when a diagram was made of the patches. The lesions, once formed,
never went away. There were no symptoms in connection with them.
They were not anaesthetic.
Mr. Pernet, when he saw the case, did not agree with the diagnosis
of parakeratosis variegata. He proposed to call the condition erythro-
atrophodermia perstans en plaques, just to label the case. • The condition
was possibly related to Brocq’s erythrodermies pityriasiques en plaques
disseminees (parapsoriasis en plaques), which Brocq considered had some
likeness to xantho-erythrodermia perstans. 1 Again, there are the cases
of idiopathic atrophy of the skin in circumscribed and multiple patches,
the description of which resembles the present patient’s condition in
some features. According to Bille 2 the afore-mentioned idiopathic
atrophy of skin cases appeared to him to be possibly identical with
Brocq’s erythrodermies pityriasiques. As the patient had had a variety
of treatment, but not X-rays, Mr. Pernet had given the pink patch
under the left nipple six exposures, with the result that the patch had
practically disappeared, as a comparison with a photograph taken before
the X-ray treatment showed. The idea was to treat the pink recent
patches in this way and thus prevent, if possible, the atrophic, telan¬
giectatic and pigmentary changes presented by some of the patches.
Dr. Kadcliffe Crocker saw the case on his return to town, and agreed
that the condition was not parakeratosis variegata, but that in most of
its features it corresponded with xantho-erythrodermia perstans, 3 the
‘Brocq, “Traits 614m. de Dermat. Pratique,” 1907, ii., p. 367; see also Civatte. •• Les
Parapsoriases de Brocq,” 1906, p. 223.
2 Bille, “Encyclop. der Haut- und Geschlecbtskrankh.,” 1900, p. 214, col. 1.
3 Radcliffe Crocker, Brit. Joum. Dermat ., London, 1905, xvii., p. 119. Histological note by
George Pernet, p. 134, which compare with Anthony, loc. cit., p. 460.
38 Crocker & Pernet: Case of Lichen planus verrucosus
only real difference being in the mottled pigmented and telangiectatic
patches on the front of the trunk and lower limbs, which were not only
different from those of xantho-erythrodermia perstans, in which the
characters of the patches were very uniform, but from the lesions of any
dermatosis with which he was acquainted. He was of opinion the
X-rays should be continued. The patches over one hip were now' being
dealt with in this way.
The patient w r as admitted to University Hospital in order that he
might be kept under careful observation, but as he preferred to attend
as an out-patient various points could not be readily gone into.
DISCUSSION.
Dr. J. M. H. Macleod said that although the case did not seem to
correspond perfectly to any member of the ill-defined group which Dr. Colcott
Fox and himself had provisionally named the “ resistant maculo-papular scaly
erythrodermias,” still, it appeared to him to be closely allied to that member of
the group which Brocq had designated as “ erythrodermie pityriasique en
plaques disseminees.”
Dr. PRINGLE thought that ill the absence of itching and of a tangible amount
of infiltration, the diagnosis of a condition of premycosis, w hich at once suggested
itself, could not be established. He was inclined to agree with Dr. Macleod in
including it among the inchoate group of affections synthesized by Brocq under
the title of “ parapsoriasis,” but some of its characters resembled those of a
severe case of IJnna’s “eczema seborrhoicum circumscriptum.”
Dr. Leslie Roberts regarded it as an example of parakeratosis variegata.
lie considered that the whole follicular system of the skin was involved, not¬
withstanding the patchy, discrete character of the eruption. The eruption was
not that of a typical seborrhoide.
Case of Lichen planus verrucosus treated by Violet Light.
By H. Radcliffe Crocker and George Pernet.
The patient was a man, aged 32, who had had lichen planus on and off
for three years, for which he had originally attended at University College
Hospital. In 1906 he came for a hard sore and secondary rash, and
he had suffered from various manifestations of the specific disease (ulcers
on tongue, throat troubles, cutaneous gummata, &c.). On the right leg
there were two nearly palm-sized patches of lichen planus, greatly
thickened, raised and verrucose, and extremely irritable. In April, 1907,
having been uninfluenced to any degree by other means, they were
exposed to the violet light obtained by means of the mercurial vapour
vacuum tube.
39
Dermatological Section
The following were details of the exposures:—
Upper Patch Mainly.
April 22
5 minutes
24
3
11
26
7 ,,
9 I
29
5
May
9 »
1
5
2
5 ,,
91
8
5 ,,
f ,
9
5 ,,
Jf
10
10
99
13
10
14
10 „ '
Lower Patch.
July
2
10 minutes i
5
10 „
9
15
,,
16
10 „
All at 10 iu. distance.
At in. to 0 in. distance.
For a time after the exposures were stopped in both series little was
observed in the patches, except that they felt softer and the irritation
ceased. But in the course of a month or so the flattening became accen¬
tuated and soon the patches became level with the skin, leaving purplish
patches behind, with some thinning of the skin. Mr. Pernet desired to
emphasise the importance of not going on indefinitely with the exposures,
but to stop them at intervals to observe what time would do.
Case of Tuberculides.
By J. H. Sequeira, M.P.
The patient, a domestic servant, aged 19, had suffered from an
eruption on the skin of the extremities, ears, and face since she was
aged 12J. The first appearance coincided with her first menstruation.
There had usually been an outbreak each spring and autumn, and the
lesions had gradually faded in the intervals. The present attack, which
was the most severe, began in January, 1907. Each attack began with
an eruption of small, painless, raised, red swellings, which slowly
increased in size, projected above the surface, then broke down in the
centre and slowly healed, leaving scars.
When first seen seven weeks ago the following conditions were
noted : On the backs of the hands, wrists, forearms, and the lower part
of the upper arms, and on the front of the legs and feet, were a large
number of roughly circular, dull red spots varying from 1 mm. to 2 cm.
40
Stowers: Case of Rodent Ulcer
in diameter. The margins of the spots could be defined with ease by
the finger, but each was surrounded by a rather livid area which shaded
into the surrounding healthy skin. In the centre of many spots there
was a yellow adherent seat, in others a depressed dry area, and again, in
others, an ulcer oozing a little thin yellowish pus. Most of the lesions
were discrete, but on the backs of the wrists, and about the elbows, and
on the front of the foot and leg, they had in some instances become con¬
fluent. The largest ulcers were at the back of the legs. In addition to
these active spots there were a large number of small white circular scars,
the sites of old lesions of similar type, and also some pigmented spots in
the situation of some more recent healed areas. On each cheek there
were a few white scars, and on the margin of the lobule of the left ear
there was a group of circular infiltrated spots, each showing central
necrosis. The right ear was similarly but less severely affected.
When shown at the meeting the ulcerative lesions had almost all
healed, the patient having had a prolonged rest in the horizontal position.
There was no evidence of tuberculosis in the patient. She had had no
serious illness, but “ years ago ” she had some swelling of the cervical
glands. These did not rupture, and there was no scar.
One brotherwas said to havedied of “ consumption " i?) when aged 8.
The conditions were those described variously as “folliculitis” and
“acnitis,” or preferably follicular and papular necrosing tuberculides.
The large ulcers were in the calf, and exactly like the ulcers in Bazin's
disease. They did not appear, however, to have been preceded by a
definite lump, but to have been produced by the extension of the small
lesions above mentioned. This the exhibitor could not be certain about
as the ulcers were present when he first saw the patient.
The opsonic index to tubercle was tested. It was found to be IT.
Calmette’s ophthalmic test was made and a characteristic reaction
obtained. The temperature throughout had been normal. There had
been no albuminuria.
Case of Rodent Ulcer.
By J. H. Stowers, M.D.
The patient was a bald-headed man, aged dd, the subject of rodent
ulcer of about twelve months duration. The lesion, which could be
covered by a threepenny piece, was situated upon the left side of the
scalp over the fronto-parietal suture. It was painless, but the special
Dermatological Section 41
characters of the ulcer supported the diagnosis. No enlargement of
glands existed.
Treatment by excision or X-rays was suggested, the majority of the
members preferring the latter.
Case of Extensive Psoriasis, with Suppurating Lesions.
By James Galloway, M.D.
The patient, a woman, aged about 40, had been previously shown at
the meeting of the Dermatological Society of London and reported in
the British Journal of Dermatology (1907, xix., p. 116). She had
suffered from extensive psoriasis of very inveterate type, yielding to
ordinary methods of treatment only with great difficulty. As the result
of the disease and the worries resulting from interference with work, the
difficulties of outdoor treatment, &c., she suffered severely in health,
and a suppurative condition of the lesions developed in many places, with
a tendency to enlargement and suppuration of the lymphatic glands.
On account of her loss of strength, loss of weight, and the development
of purulent lesions, she was admitted under Dr. Galloway’s care at
Charing Cross Hospital, and after a period of rest was subjected to treat¬
ment by means of inoculation of the “ vaccine ” prepared from the
Staphylococcus aureus grown from the lesions on her own skin. The
result of this course of treatment appeared to be highly satisfactory.
The suppurating lesions disappeared, and shortly afterwards the psoriasis,
which had been very extensive, vanished entirely. She left the hospital
in June, 1906, and has remained under observation since.
For several months the patient continued to be in good health, and
there was very little recrudescence of psoriasis. In the spring of 1907
the psoriasis commenced to recur and soon began to acquire the same
type as on previous occasions, being widespread, inveterate, and finally
developing a tendency to show purulent lesions in places. Such treat¬
ment as could be carried on out of doors had very little effect in control¬
ling the disease. Treatment by the stronger medicaments, such as by
ehrysarobin, was not borne well, and seemed to spread rather than
control the disease. In these circumstances the patient was admitted
under Dr. Galloway’s care on July 9, with the intention of again carrying
out treatment by means of vaccine inoculations. The vaccine was
prepared from a growth of Staphylococcus aureus grown from the lesions
presented by the patient; no other treatment was used. The patient
/- 5
42
Galloway: Case of Extensive Psoriasis
was kept in bed and had proper and sufficient food, and was washed in
the same way as other patients, so as to secure ordinary cleanliness, but
no special baths were permitted. In addition to ordinary washing of the
body by nurses she was permitted to have one general bath every four
days. The following course of inoculations was then carried out:—
Inoculation : strength of
Index
July
9,
1907
200,000,000 cocci
_
23
»>
—
1*06
,,
24
200,000,000 cocci
—
31
j,
—
0-94
August
1
400,000,000 cocci
—
7
—
1-28
22
—
10
24
500,000,000 cocci
—
September 21
,,
...
1*0
The discomfort after the inoculations was trifling, and only on one
occasion, after the injection on August 1, was there any rise of tem¬
perature. The temperature on August 1 rose to 99'5° F., on August 2
to 100° F., and then subsided to normal. During the course of treat¬
ment thus outlined the patient became steadily worse. The psoriasis
spread, assuming the irritable, highly erythematous type characteristic
of the case, and towards the middle of September treatment was com¬
menced on ordinary lines, by means, first of all, of soap baths, later
by the use of salicylic acid, chrysarobin, and, Anally, of chrysophanic
inunctions, with the result that the eruption began to disappear. On
the date of the meeting the patient was seen to be in good health, and
though traces of psoriasis remained on the skin very little was noted,
and not enough to produce serious discomfort.
Dr. Galloway brought the case forward in order that he might be
able to continue the report of the case previously given. The result
could not be described as otherwise than disappointing so far as the use
of staphylococcus vaccines is concerned in the treatment of psoriasis.
It is true that the case is a complicated one, pus infection to such
a degree as shown by this patient being very unusual in the course of
psoriasis. The apparently favourable result obtained during the flrst
course of treatment suggested the necessity for an experiment in the
way of control. There were difficulties in carrying out the second
course, but the steady spread of the disease while the patient was under
the influence of treatment by means of vaccine does not appear to lend
very much weight to the argument that the psoriasis was cured by the
vaccines in the Arst instance.
dermatological Section.
February ‘20, 1908.
Dr. Kadcliffk Ckockkk, President of the Section, in the Chair.
Case o{ Sclerodermia and Leucodermia.
By H. Gf. Adamson, M.P.
The patient was a girl, aged l(i. On the neck and chin on the left
side there was a large, irregular area of leucodermia, with a margin of
Fig. 1.
Shaded areas, sclerodermia | dotted line area, leucodermia.
deeper pigmentation and some finger-nail-sized pigment macules over
the white area. Occupying part of the same area were three elongated
patches of sclerodermia (fig. 1). Apart from the interest of the unusual
mh —5
44
Adamson: Case of Telangiectasis of the Chech
association of leucodermia and sclerodermia was the fact that tlie dis¬
tribution corresponded very closely with the sensory area of the second
and third posterior cervical roots. Towards the chin, however, it over¬
lapped this area and passed on to that of the third division of the fifth
cranial.
A diagram of the distribution of the lesions was shown, together with
one (after Cushing) showing the sensory area of the second and third
segments (fig. 2).
Diagram showing segmental area of tactual sensation, from a case in •
which the posterior root ganglia of second and third cervical were removed
for neuralgia. (After Cushing, Johns Hopkins Hosp. Bull., Halt., 1904,
xv., 213.)
Case of Telangiectasis of the Cheek.
By H. G. Adamson, M.D.
The patient was a girl, aged 10, who presented on the right cheek
a circumscribed patch, 2 in. by in., made up of a collection of closely
set tufts of dilated blood-vessels. The condition had been first noted at
the age of a few months as a patch, the size of a finger-nail, which was
taken for a bruise. The patch had gradually increased to its present
size. The exhibitor regarded the affection as an unusually large “ spider-
mevus," or, rather, a collection of “ spider-mevi.” Several members.
Dermatological Section
45
however, thought that some of the “tufts” showed also a certain amount of
increase of tissue, so that minute nodules could be felt, and the diagnosis
of adenoma sebaceum was suggested and a biopsy advised.
The PRESIDENT said that there was more than telangiectasis in this
case. One could not tell what such lesions of congenital origin were until they
were microscopically examined. He had noticed, also, some atrophic scarring
in one or two places.
Case of Lichen plano-pilaris.
By Wilfrid S. Fox, M.D.
The patient, a man, aged 24, was first seen two months ago, w T hen
he was suffering from typical lichen planus of six weeks duration,
scattered over the limbs and trunk. He was treated with intramuscular
injections of atoxyl with the addition of novocaine. The solution con¬
tained 20 per cent, of atoxyl for the first two injections, but later a
10 per cent, solution was found more satisfactory. The dose given was
1 c.c. of the stronger solution and 2 c.c. of the weaker, or 20 eg. of
atoxyl, twice a week. The papules disappeared rapidly under treatment,
and although no local treatment was used the pruritus was entirely
relieved after four injections. At the end of ten injections the lesions
were in the condition now seen, namely, level with the surrounding skin,
the pigmentation alone showing where the papule had been. The
patient then showed some toxic signs, such as irritation of the conjunctiva
and dyspepsia, and the injections were accordingly stopped. A fortnight
after the cessation of the injections the hair follicles over the extensor
surfaces of the forearms became inflamed and showed typical lichen
spinulosus. There were no signs of arsenical hyperkeratosis.
Five Cases of Lupus erythematosus treated by a
New Method.
By T. J. P. Hartigan, F.R C.S.
The cases brought before the meeting were of the circumscribed
variety, sebaceous and telangiectatic in type, and the method employed
might fairly be described as new, inasmuch as there was no mention in
mh —6i
4G
Little: Case of Lupus erythematosus
literature of the treatment of the condition by ionisation. Bearing in
mind the clinical history of the affection and the possibility of its
disappearing spontaneously in an unaccountable manner, an isolated
instance of improvement counted for very little. He submitted for the
consideration of the Section details of five cases, four of them hospital
patients, who attended for inspection. In every case a 2 per cent,
solution of zinc or copper sulphate was used, preferably the latter, and
the result was more prompt and satisfactory than could be obtained by
any other form of medication.
M.A.C., female, aged 44. Fifteen months duration, affecting the
whole of the nose and slowly spreading on to the adjacent parts.
She was treated early in October last year, when the disease rapidly
disappeared and has since remained barely recognisable.
A. S., female, aged 27. Twelve years duration, affecting the scalp
and face. The patch on the face was treated three times with zinc and
once with copper, each application lasting five minutes. Except for a
few dilated vessels and atrophy there is nothing now to see.
H. R., male, aged 27. Three years duration, affecting the nose,
cheeks, and both ears. Where the disease was treated the efflorescence
had disappeared.
A. C., male, aged 35. Three years duration, affecting the nose and
both cheeks, also situated in front of the right ear. Situations treated
were distinctly blanched.
Mrs. —, aged 47. Fourteen years duration, affecting the face.
After one application with copper the lesions were only to be seen
faintly, if at all.
The PRESIDENT said the cases were excellent, and the results of the treat¬
ment very satisfactory.
Case of Lupus erythematosus.
By E. G. Graham Little, M.D.
F. W., aged 38, with lupus erythematosus, who came under observa¬
tion for the first time in June, 1906, and then had a very small patch of
the disease on the left temple behind the left ear and in the concha of
the ear. It had then persisted for twelve months. The diagnosis was by
no means clear at that time, and he received no local treatment until he
came again, in December of this year, with considerable extension of the
Dermatological Section
47
disease. Beiersdorf’s salicylic plaster was used, applied continuously,
and appeared to benefit the already developed patches, but fresh places
made their appearance slowly ; in April, 1907, during an exceptionally
hot Easter, he got badly sunburnt, and a fresh acute and extensive
invasion of the disease took place. These patches were treated at first
with lactate of lead lotion until he was able to come to London, in July,
when he was put in a home, and constant application was made of soap
in the form of soft soap spread on lint cut to the shape of the lesions to
be treated; concurrently with this he was given from 12 gr. to 16 gr. of
quinine three times daily, for about four to five weeks. The condition
improved greatly, most of the patches healing with excellent, almost
invisible, scarring. He kept up this treatment at intervals during the
latter part of last year and 1 the beginning of this year, and had now
had a second period of soft soap plasters in a nursing home for three
weeks. Calmette’s ophthalmo-tuberculin test had been tried with nega¬
tive result.
Case of “Ringed Eruption” (“ Lichen annularis,” “Granuloma
annulare ” ?).
By E. G. Graham Little, M.D.
The eruption consisted of two patches situated on the buttocks of a
female child, E. C., aged 4. The patch on the right buttock was in the
shape of a perfect ring, made up of discrete firm white papules, enclosing
an area of skin which appeared darker in colour than normal. The
circumference of the ring was f in. by J in. The other lesion was in the
form of a deep-seated nodule in the left buttock, in the fold of the
buttock and thigh. This had been excised early in its history, and
sections were demonstrated from it at the meeting. Both lesions were
quite painless and accompanied by no subjective symptoms; the earliest
had persisted for about three months. No other lesions had appeared
than these two, and the child was exceptionally plump, rosy and well.
The brother of the patient was in the Children’s Hospital at the present
time, suffering from tuberculous knee; one paternal uncle had died-of
phthisis when aged 34.
The patient had been under the care of Dr. Fiddes, of Forest Gate,
to whom Dr. Little was indebted for seeing the case.
48
Little: Case of “Ringed Eruption"
With regard to the case of the young girl shown at the last meeting
(p. 33) as an instance of “granuloma annulare,” Dr. Little reported
that the patient had since been admitted to St. Mary’s Hospital, and
was diagnosed by his colleague, Dr. Sidney Phillips, to be suffering from
early pulmonary phthisis. Her opsonic index to tubercle, taken on
several occasions, varied between 0‘97 and 1'45, and she had shown a
very marked Calmette reaction. But the presence of pulmonary tuber¬
culosis would, perhaps, be sufficient explanation of these findings without
assuming that the skin lesions were tuberculous ; and the histology of
the sections in no way bore out the contention that these were tuber¬
culous. In favour of the diagnosis of granuloma annulare—which had
in several reported cases marked association with tuberculous histories—
was the fact that the sections from this case could not be distinguished
from sections of an undoubted case of granuloma annulare, shown by
Dr. Little in 1906 at the Dermatological Society of London. 1
DISCUSSION.
Dr. PRINGLE agreed that it was a case of lichen annularis, but thought it
was different from the case which Dr. Little showed last time, and in which
tuberculosis had been found.
The PRESIDENT agreed with Dr. Pringle that the case shown by Dr. Little
last time was not of the same nature as the present one ; the other seemed
more like folliculitis. The present one resembled Dr. Galloway’s cases of lichen
annularis in children and those of granuloma annulare in the adult which he
had himself described. But further investigation was necessary; there were
some points in the arguments in both directions. He would keep his mind
open longer as to whether they were identical with lichen annularis.
Dr. Galloway agreed that there w r as a difficulty in coming to a conclusion,
but thought that those adult cases were different from the cases he had met
with in children.
Dr. Graham Little, in reply, said he showed a case two years ago before
the Dermatological Society of London, which was accepted by those who saw
it as typical granuloma annularis. There were numerous lesions, and he
removed two and exhibited sections. The sections from the woman shown at
the last meeting were so similar that they were regarded as the same as those
shown at the earlier meeting.
1 Brit. Jo urn. of Derm., 190G, xviii., p. 117.
Derma tologica l Sec tion
49
Case for Diagnosis.
By E. G. Graham Little, M.D.
The patient was a little girl, aged ten months, and had been under
the observation of the late Dr. John Garrett, of Acton, whose sudden
death a few days ago was the cause of the scanty notes in this ca.se.
Dr. Garrett had intended to bring the patient to the meeting. The
history as obtained from the mother was that the child had had a raised
yellowish red patch on the dorsum of the right hand since birth. It was
brown at first but had grown redder, without enlarging. Blisters
appeared on this raised patch at intervals of four days to a month,
usually appearing during the night. She had been seen in November,
1907, by the exhibitor, and had then six blisters on the podalic eminence,
the longest being J in. across, and containing blood-stained fluid. They
usually healed within a few days, and were always confined to the site
of the raised patch, which was about 1£ in. in diameter. The blisters
had been noted for the first time when aged about seven weeks. The
confinement had been easy; it had lasted for four hours and had been a
head presentation without requiring instruments.
The exhibitor had tentatively offered the diagnosis of lymphangioma
circumscriptum, which was confirmed by the general consensus of the
meeting.
In reference to this case Dr. Adamson recalled a paper by Moncorvo, 1
entitled “ Sur trois nouveaux cas d’6l6phantiasis congenital,” in which the
author suggests the possible streptococcic origin of these cases by infection
through the mother, and advocates careful inquiry on the subject of accidents
to the mother during pregnancy. It was well known that similar cases of
acquired localised swellings or elephantiasis were due to streptococcic infection,
and the speaker suggested withdrawing blood by a syringe or taking fluid from
a blister for cultivation.
Case of Leuconychia.
By E. G. Graham Little, M.D.
The patient, aged 17, was a young man apprenticed to a printer, and
was in fair general health. A fuller report of this case will be published
in a subsequent issue of the British Journal of Dermatology.
1 Ann. de Dermat. et cie Syphilogr ., 1895, 3 me serie, vi., p. 965.
50
Macleod: Case of Multiple Leiomyoma of Skin
Sir Malcolm Mokris said he had seen four such cases altogether : one at
Buda-Pesth, Unna’s case at Hamburg, and two in London. The subjects of it
seemed to have a tendency to Raynaud’s disease.
Case of Multiple Leiomyoma of the Skin.
By J. M. H. Macleod, M.D.
The patient, a woman, aged 25, had always enjoyed good health and
appeared to be robust. The affection began five years ago near the angle
of the left cheek, but she could think of no cause which might have been
responsible for it. On exhibition she presented a group of about a dozen
small discrete nodules, each about the size of a split pea, on the left
cheek, extending from about the middle of the cheek to the angle of the
jaw. These lesions were rounded and smooth on the surface, and were
either oval or round in shape ; they were of the same colour as the
surrounding skin, but presented a slightly translucent appearance sug¬
gesting lymphangiomata. They were solid and almost cartilaginous in
consistence, and on being pressed with a diascope became white. Two
other lesions, each about the size of a split pea and pink in colour, were
present on the right forearm, and a group of three lesions, of the same
size and violaceous in tint, was situated on the right leg below the knee.
The lesions on the face were accompanied by no subjective symptoms
and were not painful on pressure ; those on the legs, however, occa¬
sionally irritated when she was warm. The only other abnormality
which was detected in the skin was the presence of two small pigmented
naevi on the nose. There was no history of a similar affection in any
other member of her family.
One of the lesions was excised from the leg and proved, on micro¬
scopical examination, to be a leiomyoma. A section was demonstrated
at the meeting. The tumour mass consisted entirely of long, smooth
muscle-cells with the typical strap-shaped nuclei. It was well defined
and separated from the epidermis by a thin layer of connective tissue.
There was no definite connective tissue capsule to the tumour, and the
elastic fibres spread into it for a short distance. Several sections showed
that it took its origin from the arrector pili muscles.
The President said he had seen a case very much like it, which was under
the care of Dr. Leslie Roberts, of Liverpool. He did not think it could be
exactly diagnosed without the microscope.
Derm a to l off i ca I Sec t ion
51
Case of Lichen spinulosus associated with Seborrhoic
Dermatitis.
By J. M. H. Macleod, M.D.
The patient was a healthy little boy, aged 5. The eruption consisted
of various-sized groups of spiny papules, situated chiefly about the
shoulders, neck, back, and extensor aspects of the arm and thighs. The
spines were most noticeable in the lesions about the shoulders and neck,
where the lesions were diffusely distributed rather than in definite patches.
The lesions about the neck were not inflamed, but those in patches
about the back and thighs were pinkish in tint. The eruption was
associated with itching, which was most marked when the patient was
warm and in bed. In addition to the spiny papules there was a raised well-
defined plaque, about the size of a florin, on the back of the left thigh.
It was yellowish in the centre and became pinkish at the periphery.
The surface was slightly scaly. This patch was considered to be a patch
of seborrhoic dermatitis. There was no evidence or history of tuber¬
culosis in the patient or his family to suggest the possibility of the
eruption being that of lichen scrofulosorum with spiny lesions. The
case was exhibited to demonstrate the occasional association of lichen
spinulosus with seborrhoic dermatitis.
DISCUSSION.
The President and Dr. Pringle suggested the possibility of the case being
one of lichen scrofulosorum with spiny lesions.
Dr. Adamson agreed with the exhibitor that it was lichen spinulosus, and
not connected with tuberculosis.
Case of Glossitis in a Girl, aged 31 .
By J. M. H. Macleod, M.I)., and A. N. Leathem.
The eruption consisted of a number of small, ringed, greyish white
lesions situated on the upper surface of the tongue. The lesions began
as small, slightly indurated papules covered with grey sodden epithelium.
These spread peripherally till they reached the size of a threepenny-piece,
while the centre became a superficial ulcer. In several instances two or
more lesions had coalesced to form gyrate figures. The lesions first
52
Morris : Case for Diagnosis
appeared a year ago and had developed gradually since then, none having
disappeared spontaneously. The tongue was not definitely thickened,
but the borders of the lesions were slightly indurated.
The case was brought forward on account of the difficulty in its
diagnosis. It was transferred to the skin department at Charing Cross
Hospital for a diagnosis by Mr. Daniel, to whom the exhibitors were
indebted for the opportunity of showing the case. The fact that the
lesions had persisted showed that it did not belong to the type of “ wan¬
dering rash ” of the tongue, and the presence of slight induration and
superficial ulceration suggested a syphilitic origin. There were no
stigmata of congenital syphilis present in the patient, and no definite
history of syphilis in the mother was obtained. The patient was the
sixth child; there was a miscarriage in the fifth pregnancy; the fourth
child died when a few months old “ with fits,” and the first three
children were healthy. Mr. Leathern made an examination of scrapings
from the surface of one of the ulcers and found various spirochaetes,
several being indistinguishable from the Spirockaste pallida . So far no
internal treatment had been prescribed, but it was intended to put the
child on antisyphilitic treatment, and it was hoped in this w r ay that the
diagnosis would be established.
Case for Diagnosis.
By Sir Malcolm Morris, F.R.C.S.Ed.
(For Dr, Kay.)
The patient was a man, aged 23, a mathematical scholar, whose
home was in Mauritius. He was well until February, 1906, when he had
an attack of bronchitis, and was attended by a medical man. For some
time after the appearance of the skin affection now seen he took Clark’s
blood mixture, sarsaparilla, and other things. A medical man diagnosed
the condition as molluscum fibrosum, and he was given more iodide.
There were some lesions on the arms and legs, but none on the trunk.
The eruption was much aggravated by the iodide. He asked for
opinions before giving the remainder of the facts of the history.
His own view was that it was leprosy, but there was some difficulty
about the eruption. Dr. Wilfrid Fox would test it shortly. He believed
a good part of the eruption had been produced by iodide of potassium,
and since that and local treatment had been stopped the condition was
Dermatological Section
53
much better. Some pf the lesions had been vesicular and pustular, and
had been watched by Dr. Kay. A careful examination would be made and
the result reported to the Section later on. He had had a case of leprosy
under his care at St. Mary’s Hospital at the time of the tuberculin boom,
and injected some* with the result that there was a distinct rise of tem¬
perature and the patient was very ill, and lesions came out all over his
body. The case was of the nerve variety. After the bullae subsided
there were tumour-like formations in various parts.
DISCUSSION.
The President said it was not unusual to find lepra lesions aggravated by
giving iodide of potassium in large doses. Possibly some of the lesions present
might be of a transitory character.
Dr. J. GALLOWAY agreed with the remarks of Sir Malcolm Morris. Many
of the lesions struck him as due to the iodine which had been taken. The
aspect of the patient was suggestive of lepra, and there was some thickening of
the ulnar nerves—an exceedingly strong point in the diagnosis.
Two Cases of Elephantiasis graecorum.
By H. Radcliffe Crocker, M.D., and George Pernet.
Case 1.
The patient, a woman, aged 23, had already been brought before the
Dermatological Society of London. She had been under observation
since June, 1907, when the disease was said to have begun three years
previously after an attack of enteric fever; pimples and blackheads,
according to the patient, making their appearance about the face, and
red patches about the body.
The following notes were made at the time she was first seen : The
face was of a uniform dusky brown tint, with marked thickening of
the cheeks, chin, nostrils and eyebrows. The eyebrows had fallen out,
but the eyelids were unaffected. The ears were thickened and had a
solid look as a whole, but the lobes were not much more involved than
the other parts. The skin of the trunk and upper limbs presented large
areas of dusky yellowish discoloration, but with areas of quite healthy
skin in between. The hands were somewhat bluish in tint, their dorsal
surfaces being swollen and puffy, the solid oedema requiring a good deal
of pressure before pitting occurred The fingers were also swollen and
54 Crocker & Pernet: Cases of Elephantiasis grtecorum
chilblainy-looking. The legs were rough to the touch, thickened, pre¬
sented a dusky, yellowish discoloration also, but not so obvious as on the
upper limbs. The dorsal surfaces of the feet were swollen and cedema-
tous like the hands, with a dry, reddish-brown condition of the skin
reaching halfway up the fronts of the tibiae. There'was no thickening
of the nerves. The skin, both of and away from discoloured areas, was
hvperaesthetic.
The treatment had been at first Chaulmoogra oil by the mouth in
increasing doses, which the patient had stood well. In August, 1907,
intramuscular injections of sozoiodolate of mercury J gr. were also
employed concurrently with the Chaulmoogra. Improvement occurred,
especially as regards the general condition, the patient becoming more
cheerful and better in health. But in December, 1907, she had a
febrile attack, influenza-like (influenza epidemic at the time), but,
of course, febrile attacks are well known to occur in the course of the
complaint, and it may have been of that nature. An effervescing
quinine mixture w T as ordered and the other treatment interrupted.
When she had recovered from this febrile attack it was found that
the Chaulmoogra oil upset her, even in small doses. The intramuscular
injections were resumed.
More recently the patient had another febrile attack, which gave
way to quinine. It was then decided to give her intramuscular
injections of Chaulmoogra (in accordance w T ith Tourtoulis Bey’s
experience, and also Jeanselme’s), but Captain Host, I.M.S., of
Rangoon, having very kindly offered to supply leprolin, the patient
was then under the latter in intramuscular injections. Up to now
she had had two injections. The further progress of the case would
be reported to the Section.
Case II.
The patient was a man, aged 44, in whom the disease had
commenced six years previously on the right parietal region, and had
slowly extended from the scalp on the temple and forehead almost
as far as the supra-orbital notch. The older lesions had undergone
involution, leaving loss of hair in patches and finger-tip depressions
with nodular infiltration of the borders over the parietal region. The
present active lesions had been present some three or four months,
and were situated on the right temple and supra-orbital region. They
formed dull red nodules in the skin, about 3 in. diameter, firm to the
Dermatological Section
55
touch, and aggregated together in irregular groups. On the supra¬
orbital region the nodules have coalesced into an infiltration of
1 sq. in. with a few isolated nodules above them, where a chain of
nodules was also present. There was another chain of nodules
extending into an irregular segment of a ring, reaching as far as
the outer angle of the orbit. There were no lesions in any other
part of the body except the right groin, in which situation there was
an irregular ring of nodules, about 1£ in. in diameter and of the same
general character, but less marked in size, colour, and induration. In
both situations the patient spoke very positively as to the sensation to
a prick being distinctly diminished. There was no enlargement of
nerves. The patient has been in the West Indies, Bermuda, Halifax
iN.S.), and South Africa. He left the West Indies in 1891 and was
in South Africa from that date. Neither Mr. Pernet nor Dr. Thiele,
Pathologist to University College Hospital, had found the bacilli of
Hansen in serum from a forehead nodule, but a further search would
be made, and, if possible, a biopsy obtained.
The patient had only just come under observation, and as the
case was unusual he had been shown to the Section. The facts pointed
to the condition being probably one of elephantiasis graecorum, but
it was proposed to put the patient on antisyphilitic treatment and to
watch its effects.
Although the bacillus of Hansen had not been found at the first
examination such a negative result was not conclusively against
elephantiasis graecorum. The serum w T ould again be examined, and
if possible sections of a nodule cut and stained. In Dr. J. Ashburton
Thompson’s Beport for New South Wales (year 1906) the bacillus
had not been found in some cases in which one would have expected
to find it. The scalp was very rarely involved in leprosy, but
Mr. Pernet had recorded two nodular cases (advanced cases, be it
noted) in which this complication had occurred. 1
If the cases exhibited this afternoon turned out to be undoubtedly
elephantiasis graecorum, the fact that the disease commenced in the
scalp would therefore be very exceptional.
DISCUSSION.
Dr. COLCOTT Fox said he thought the diagnosis of syphilis should be con¬
sidered in the case of the soldier.
1 Pernet, Brit. Med. Journ ., 1905, ii., p. 1280.
56
Crocker & Pernet: Senile Wai ts
Dr. Whitfield asked whether the bacilli of leprosy w T ere found in the
doubtful case. If not, he thought that would negative that diagnosis, as they
were found so easily, even at an early stage, if that were the disease.
The President said that further investigations on the point would be made.
In the case of the lady, Dr. Rost’s leprolin had been tried, and he asked
Dr. Rost to refer to it.
Dr. Rost said that four years ago he started to treat cases of leprosy by a
substance which, in its reaction, was like tuberculin. He excised the under part
of nodules of leprosy and soaked them in a medium of volatile alkaloids. A six
weeks incubation followed, and then the material was reduced with sulphuric
acid and other substances. On injecting this into the patient the nodules
swelled up, and, as a rule, sensation returned afterwards. About forty cases had
been treated in Rangoon, and now there were no signs of the original disease.
The injections were usually given at intervals of a week. The present case had
had two injections.
Dr. PRINGLE thought that anyone seeing the ears of the lady and Dr. Kay s
patient would agree that they were suffering from the same disease, though Sir
Malcolm Morris’s argument in favour of there being a complication in the case of
the man from Mauritius was very sound.
Mr. PERNET said there were fibrous changes taking place in leprosy, and it
was sometimes necessary to make several examinations before being sure there
were no bacilli. He felt no doubt about the case of the man being one of
leprosy, seeing the condition of the eyebrows, the ear, and the ulnar nerves.
Iodide of potassium, even in small quantities, was very poisonous to leprosy
patients, and he had seen purpuric rashes develop in consequence.
Senile Warts developing into Fungating Growths.
By H. Radcltffe Crocker, M.D., and George Pernet.
The patient was a man, aged 73, in whom the disease had been
going on for three years. When first seen on January 31, 1908, there
were several fungating crusted growths about the face, one of which
occupied the greater part of the nose. Scattered about here and
there were also a number of dirty w T arty growths in various stages of
development, some small ones of recent origin. On removing the
crusts reddened, raised, fungating, softish, oozing masses were found,
without induration of any kind at the borders. Some of the smaller
ones were framboosiform in appearance.
Dr. Radcliffe Crocker showed a coloured drawing of the man’s
condition at the time of his admission to hospital. Mr. Pernet had
thoroughly sharp'-spooned all the growths, followed by the application
Dermatological Section 57
of pure phenol, under an anaesthetic, and, as could be seen, the patient
was doing very well.
Mr. Cowell, house physician at University College Hospital, had, on
his own initiative, cut some sections of debris, and these were exhibited
at the meeting. Since then, at Mr. Pernet’s suggestion, Mr. Cowell had
stained some more sections by the Pappenheim-Unna method. Mr.
Pernet had examined some of these sections and had found they con¬
firmed his view as to the granulomatous nature of the growths, the sec¬
tions showing numberless plasma-cells, in parts very crowded together,
and building up the greater part of the growth. The sections also
showed that the papillae and epidermal downgrowths were elongated,
the sebaceous glands compressed, and their main normal characters
greatly altered, with some increase in grow r th of their skeletal network,
and the vessels dilated. Cellular exudation was also present. There
was no evidence in support of an endotheliomatous structure as suggested
originally by Mr. Cow'ell, to whom the exhibitors were indebted for the
opportunity of examining sections. Mr. Pernet considered that the
histological appearances resembled those of advanced fungating yaws
lesions, and supported the view that such yaws lesions were really the
result of secondary infection. 1 Thus a framboesiform appearance might
arise in various morbid conditions such as the present one, yaws and
syphilis for instance.
Case for Diagnosis.
By J. H. Sequeira, M.D.
Dr. Sequeira showed a negro with a large granulomatous tumour
at the left angle of the mouth and a penile ulcer with infiltrative
swellings in the right groin. The patient, a seafaring man, aged 26,
was born in Antigua, and he had spent most of his time in Jamaica
and other West Indian islands. He was sent to Dr. Sequeira from the
West Ham Infirmary by Dr. Culpin. The history given was that the
tumour at the angle of the mouth had developed in eight months, and
that the swelling in the groin was of the same duration, but that the
penile ulcer had only been present four weeks. The tumour at the angle
of the mouth at first sight suggested an epithelioma; it extended from
the upper to the lower lip around the buccal orifice. In its extreme
•Pernet, “Differential Diagnosis of Syphilitic and Non-syphilitic Affections of the Skin,”
1904, p. 15-2.
58
Sequeira : Cases for Diagnosis
width it measured ljin. and formed a horseshoe-shaped swelling around
the left side of the mouth. It was of a florid red colour, making a
startling contrast against the black skin of the patient. The tumour
was soft to the touch and vascular. There was very little glandular
enlargement.
The ulcer on the penis was on the skin of the dorsum. It was
almost triangular in shape, and presented little infiltration. There were
other scars of (probably) similar ulcers on the penis. In the right groin
there was a peculiar linear infiltration following Poupart’s ligament. In
parts this infiltration had broken down to ulceration, but in its greater
extent it was of a peculiar tough character.
Dr. Daniels, who kindly saw the case for the exhibitor, agreed that
the penile and groin condition was a well-recognised venereal, but not
syphilitic, “ ulcerative, or rather sclerosing, granuloma of the pudenda "
seen in the West Indies. In his experience, and so far as could be
gathered from an examination of the literature, the tumour on the mouth
was unique. It was mentioned that similar conditions had been seen
about the anus. Microscopical examination showed the tumour to be a
granuloma; examination for spirochaptae had been negative.
DISCUSSION.
Dr. GALLOWAY said he did not remember seeing or reading about a case of
granuloma inguinale affecting the region about the mouth. Some cases had been
recorded in which it appeared in the axilla and in other places as well. Colonel
Maitland, I.M.S., reported several cases of the disease.
The PRESIDENT said that if the patient had not been a native of the
West Indies, as the lesion was quite soft, one would probably have diagnosed
epithelioma.
Dr. J. M. H. MACLEOD said that, in the case of granuloma pudendi which
he had exhibited at the Dermatological Society of London , 1 a number of
exposures to X-rays had been given, using one-third of a Sabouraud pastille dose
once a week for about two months. As a result the diseased tissue dried up
and shrivelled, and the affected area diminished. It was then scraped at the
Military Hospital at Rochester Row, and Colonel Lambkin, R.A.M.C., reported
that the diseased tissue, instead of being tough, as is usually the case, had
become friable and w T as easily removed. The patient was seen by Dr. Macleod
after the wound had healed, and the result was excellent; the whole of the
diseased tissue appeared to have been removed and a healthy scar left. In this
case the disease did not spread up into the rectum, which it frequently does,
and hence the opportunity for complete extirpation was a good one.
1 Brit. Journ. of Derm., 1907, xix., p. 73.
Dermatological Section
59
Case of Haemangiectatic Hypertrophy of the Foot, possibly
of Spinal Origin.
By F. Parkes Weber, M.D.
The patient was a motor driver, aged 19, whose left foot was decidedly
larger than his right foot and of a red or bluish red colour, as if turgid
with blood. The skin over part of the foot, especially over the dorsum,
was closely studded with small projecting bluish venous loops (varices),
and so also, though to a lesser degree, was the skin over the knee-cap of
the same extremity. The calf muscles and other muscles of the leg were
about equally developed on the two sides, but there was considerable
wasting of the left thigh and buttock, and ankylosis of the left hip-joint.
The two lower extremities were about equal in length. The knee-jerks
and plantar reflexes were- natural and there was no ankle-clonus on either
side. The pulsation in the dorsalis pedis artery was well felt in both feet.
There was no anaesthesia to touch, pain, heat or cold, and the reactions
of the muscles to galvanism were normal. There was considerable
kyphosis in the dorsal region of the spinal column. There was no
evidence of any disease in the thoracic or abdominal viscera or elsewhere
in the body. Dr. Archibald D. Reid has taken Rontgen photographs of
the feet and hip-joints. They showed that the hypertrophy of the left
foot was practically confined to the soft parts and that there was bony
ankylosis of the left hip-joint (of doubtful origin). The history was that
about two years ago the patient complained of pain in the back of the
left thigh. He was at first treated for sciatica, and was afterwards
supposed to have hip disease and wore a Thomas’s splint for eighteen
months. The haemangiectatic hypertrophy of the left foot and the
wasting of the thigh muscles, &c., had developed during the last two
years, but the kyphosis of the dorsal region had existed to some extent
previously, though it seemed to have increased during the last two years.
He had experienced no pain in connection with the changes in the lower
extremity excepting the pain at the back of the thigh about two years
ago. Dr. Weber thought that the condition of the foot was of vaso¬
motor origin (vaso-constrictor paralysis?), possibly connected with some
organic change in the spinal cord. Under the term ^‘haemangiectatic
hypertrophy ” Dr. Weber wished also to include certain cases of congenital
or developmental enlargement of one low’er extremity in children, which
60
Whitfield: Case of Macular Atrophy of Scalp
he had described in an article 1 on “ Angioma Formation in Connection
with Hypertrophy of Limbs.” Haemangiectatic hypertrophy was to be
distinguished from other enlargements of the lower extremities, such as
congenital and acquired “trophoedema,” so-called “elephantiasis” (due
to chronic or recurrent lymphangitis and lymphatic obstruction), and
typical “ giant-foot.”
Case of Macular Atrophy of the Scalp (Pseudo-pelade of
Brocq).
By A. Whitfield, M.D.
The patient was a young man, aged 26. The disease had begun
somewhat acutely about four months previous to exhibition and affected
most of the top of the head, more especially on the left side. Sections
were shown to demonstrate the anatomical condition present, and it was
hoped to publish the case in detail later on.
•
DISCUSSION.
The PRESIDENT said he had not seen many such cases, but he thought the
clinical diagnosis was clear. Bunch, he believed, had found some kind of
coccus associated with it, not the pus coccus. He (Dr. Crocker) regarded it as
an infective follicular disease from the clinical standpoint. The cases were
very consistent in their characters—the easy way in which the hairs could be
pulled out, and the swollen root sheath. But he agreed that clinical evidence
of inflammation around w r as often absent; he had seen a very trifling evidence
of it in a few cases.
Sir Malcolm Morris said he showed a case which was thought to be of
the same nature, and everybody present agreed. But some months afterwards,
after careful investigation, favus was discovered. The outer angle of the eye¬
brows was affected in all cases.
Dr. PRINGLE said he thought that a case he had some months ago was an
example of the condition, but he noticed some suspicious scurf about the
margin. He accepted Dr. Whitfield’s diagnosis in the present case, as he had a
very marked instance of it which he showed before the Dermatological Society
of London. He sent it over to Paris, and Brocq confirmed it. The growths
were sterile ; there was nothing abnormal found.
Dr. Whitfield, in reply, said the patient’s doctor had given him chrysa-
robin, and apparently the condition stopped. But it sometimes did so auto¬
matically. The question of favus in the case had been investigated. In some
cases it gradually spread over the head in patches, in which the hair was not
denuded but only thinned. Sabouraud had found all such cases sterile.
1 Brit. Journ. of Derm., 1907, xix., p. 231.
Dennatolofjical Section
01
A New Substance for Shielding those parts of the Scalp
which it is not wished to expose in the Treatment of
Ringworm by means of the X-rays.
By A. Whitfield, M.I).
Thk idea of the substance was derived from the modelling clay
known as Harbutt’s plasticine, which itself was only partially
obstructive to the rays. It had been proposed by Dr. Whitfield to have
made a similar substance, but made with lead oxide instead of clay. On
consulting Professor Jackson, of King’s College, Dr. Whitfield was
advised to try barium sulphate as being entirely non-toxic if any should
get on the hands.
Accordingly Messrs. Hopkins and Williams had made the substance
exhibited, and although it was thought that further improvements might
be made, Dr. Whitfield thought that even the substance exhibited was a
distinct advance on the ordinary lead shield. The material was made
by incorporating by means of machinery coarse barium sulphate with
vaseline so as to form a kind of putty. It was grey in colour and quite
plastic, so that one could mould it on to the scalp with the greatest ease,
and it therefore did away with most of the trouble in fitting masks. If
bent too sharply the material would crack, but none of the curves of the
scalp were acute enough to give any trouble in this direction. It was
rather sticky to roll out, but Dr. Whitfield had found that by placing it
between two pieces of grease-proof paper it could be rolled out with ease.
A thickness of Jin. was so opaque that one could not detect the blade of
a knife behind it with the fluorescent screen. The material was also
exceedingly cheap, so that if there was any difficulty in sterilising it new
material could be used each time. If, owing to high room-temperature,
there was the slightest stickiness, it could be dusted over with boric acid,
which was transparent and would not obstruct the rays when the turn
came for the part previously screened to be exposed, or the material
could be laid on a single layer of ordinary gauze, which could be
stretched over the head. Mr. Edmund White, who had kindly under¬
taken the experimental manufacture of the substance at Messrs. Hopkins
and Williams’s, was still at work trying to improve the consistency, but
at present it worked very satisfactorily.
0-2
Williams: Case of Undent Ulcer of Ala Nasi
Case of Rodent Ulcer of the Ala Nasi in a Man, aged 36.
By A. WlXKELHTKP WILLIAMS, M.B.
The point of interest in this case was the absence of any distinct
border. The ulcer had a clean punched-out appearance, making the
diagnosis rather difficult. The history, however, showed that it began
as a hard lump which ulcerated and has existed for eighteen months.
There was a history of syphilis six years ago, but antisyphilitic treat¬
ment had been tried for the ulcer without avail. The case was to be
treated by X-rays.
The PEE si DENT agreed with the exhibitor that it was probably rodent ulcer.
Dermatological Section.
March 19, 1908.
Dr. Kadcliffe Crocker, President of the Section, in the Chair.
Case of Pustular Ringworm of the Horse (“Conglomerate
Folliculitis”) in a Child.
By H. G. Adamson, M.D.
The patient was a boy, aged 2, who presented on the front of the
right leg below the knee a circular patch 3 in. in diameter, red, deeply
infiltrated, and studded with pin-head-sized pustules. The appearances
had at once suggested ringworm of the horse, though it was unusual to
meet with this type of ringworm in a child. The father of the child
w r as a harness maker, and often received old harness for repairs. Pus
from an unbroken pustule showed chains of very large, oval, and rounded
spores—quite unlike the segmented mycelial threads of the vesicular
“ cat ringworm ” of children—and cultures gave the typical plastery
white, rapidly growing culture of Tricophyton megalosporon ectothrix
du cheval a cultures blanches. The exhibitor had seen two examples of
this type of horse ringworm in ostlers on the arm and two cases on the
beard region, but had not previously met with a case in a child.
Case of Urticaria pigmentosa.
By H. G. Adamson, M.D.
The patient was a boy, aged 2J, with urticaria pigmentosa of the
macular type. The child had been quite clear until aged about six
months. He had then been troubled with itching patches which
“ looked exactly like insect bites.” They were pink, raised, and with
a central darker “ spot ” ; when the pink colour faded there remained a
a —3
64 Beddoes: Case of Favus in a Mouse
brown patch. The brown patches had persisted, and fresh ones had
appeared. Now there were about sixty in all—forty on the front of the
body, chiefly on the chest and abdomen, and about twenty on the back.
There were a few lesions also on the thighs and legs. Factitious
urticaria was well marked. After briskly rubbing the patches for a few
minutes they became inflamed and surrounded by a pink, raised, sharply
margined w'heal. The patient had been brought to the hospital on
account of its restlessness at night, when the lesions became urticarial.
DISCUSSION.
Dr. Savill asked whether calcium chloride had been tried. He had had
one or two cases of urticaria pigmentosa which had been improved by it.
Dr. Adamson replied that he had not had the opportunity of trying it as
the patient had not been under his care more than a week. In four or five
other cases he had tried salicin, and it seemed to control the urticaria; he had
not tried calcium chloride.
Case of Favus in a Mouse.
Shown by T. P. Beddoes, F.R.C.S.
(For Dr. Abe ah am.)
The mouse was brought by a patient, a man, aged 43, who came
two weeks ago with typical parasitic sycosis, which he had had for
one month, forming a raised patch on the chin J in. in diameter with
swollen follicles. Immediate examination showed large spore mycelium
in the sheath of the hair. The patient was in the habit of being shaved
by a barber. He stated that one of his three children three months ago
had a sore patch on the chin which had been cured by vaseline.
The patient to-day brought his child, whose skin was quite normal,
and a dead mouse (the specimen exhibited) caught by patient’s wife with
her hand four days ago; it lived two days. It show r ed hard, white,
much raised crusts on the ears and forehead without any characteristic
smell. The mycelium under the microscope was indistinguishable from
favus.
Dr. Abraham considered that the man had typical tinea barbao due to
a trichophyton and that the mouse had favus, and that the two were
simply a coincidence. To make sure of this further examination with
cultures would be made.
Derm a tologica I Sec tion
65
Case of Ringed Eruption on the Hand.
By G. W. Dawson, F.R.C.S.I.
The patient was a young man, aged 22, with a ringed eruption about
Hin. in diameter on the middle knuckle of the left hand. The ring
consisted of a number of isolated, flat, clearly defined papules of the
same colour as the skin. They were slightly depressed in the centre,
hard, and rose abruptly from the skin. One of them was broken up
into five wedge-shaped portions. The eruption began seven years ago
on the apex of the knuckle, and the patient stated that each papule
gradually enlarged, broke into several portions, and finally disappeared
in four or five months, leaving apparently normal skin. Others then
developed outside this area and underwent the same cycle of changes.
Microscopic examination disclosed swelling of the cells of the stratum
mucosum and marked enlargement of the sweat glands and ducts.
DISCUSSION.
The President (Dr. Radcliffe Crocker) said that it was not typical lichen
annularis ; there was a lichen planus look about the present lesions. The first
case he published he described as lichen planus-like lupus erythematosus.
Dr. GALLOWAY considered it a case of lichen annularis, and said that the
case reminded him of one in a lady who was under observation for several years,
in which case the lesions, as they died away, became concave and very flat.
Dr. GRAHAM Little said he thought it was granuloma annulare. The
characteristic points were the hardness and whiteness of the papules, their
umbilication, and the fact that they were very chronic and occasionally disap¬
peared. At St. Mary’s Hospital he had a man under care for six months with a
continuous crop of similar lesions; they were first white and then red. The
section shown did not go very deep in the skin and the sweat coils were not well
seen, so that it was impossible to pronounce an opinion on this factor.
Mr. G. PERNET said he had maintained that lichen annularis was the same
thing as granuloma annulare. He had examined histologically a case which was
brought forward by Dr. Crocker and satisfied himself on the point.
66 T. C. Fox : Bilateral Telangiectases of the Trunk
Case of Bilateral Telangiectases of the Trunk with a History
of Marked Epistaxis in Childhood and recent Rectal
Haemorrhage.
By T. Colcott Fox, M.B.
The patient, E. B., aged 23, engaged in housework, was sent to me
by Dr. John Norton on account of peculiar telangiectases, and was sub¬
sequently admitted to the Westminster Hospital under the care of
Dr. Hebb, from December 12 to 23, 1907, and again from February 18
to March 14, 1908. I am greatly indebted to Dr. Hebb for allowing me
to report the case with the use of the notes.
The family history obtained was that the patient’s father died, aged
63, of “heart failure,” and the mother, aged 60, who had bleeding piles,
of “ dropsy.” A brother of the father is said to have died of pulmonary
tuberculosis, and also the mother’s two sisters. One brother of the
patient was killed by lightning and another suffers from “ fits,” dating
from an injury behind the ear. A living sister has a discharging, non-
bleeding “ tumour ” on the back of her neck, and a brother and sister
have consumption. No evidence was forthcoming of haemophilia or
marked epistaxis.
The personal history of the patient discloses an attack of measles in
childhood, mumps when aged 12, and “ ulcerated throat ” of about a
week’s duration when aged 15. When aged 10 she had considerable
epistaxis from both nostrils almost every morning for six months, and at
14 she noticed some red spots in the left lower axillary region, and later
on the left back, right lower axillary region, and lower part of chest.
These spots have gradually increased in number and appeared on a wider
area. There is some occasional itching. The menses commenced when
aged 18 and are now regular in time, but marked by much pelvic pain
a day prior to the commencement of the How, which is copious and
makes her feel weak and short of breath, and her hands and feet cold and
numb. For the last six months at least, and especially after standing,
she has noticed that her hands, especially the left, go cold and blue, with
pallor of the finger-tips and nails, and a tight sensation of these parts.
She has had some leucorrhuea for a year past. In the summer of 1907,
when walking about, her attention was attracted by bleeding from the
Derm a tologiva l Sec t ion
07
rectum, lasting about half an hour, and accompanied by a sensation of
swimming in the head and pain in the lower part of the abdomen
and bottom of the back. The blood was dark red and in part clotted.
Three months later she had a similar attack, and every week has passed
a little blood and matter. On December 6, 1907, she had a marked
rectal hemorrhage of bright blood, continuing for about four hours. The
patient has always been constipated, and generally loses a little blood
when she goes to stool. On December 27 a passage of about half a pint
of dark blood occurred from the rectum in about a quarter of an hour.
The next week and the w r eek after there were similar occurrences, and
again on February 10, always whilst walking. She states that recently,
after w r alking about a mile, she loses vigour in her legs, especially the
right, and experiences a pain in the region of the right buttock, back
and outside of thigh down the back of the leg to the ankle, and she
remembers that last midsummer she slipped and fell on the right hip.
The patient does not bleed unduly from cuts, and she is not subject to
blood effusions in the skin. She has had teeth extracted from time to
time without any unusual haemorrhage. On tw r o occasions the rough
usage of a bath-towel has caused some oozing of blood for a couple of
hours from the dilated vessels.
The patient is a well-formed, healthv-looking girl, with slightly
cyanotic hands and coloured cheeks and rather slow pulse (54 per
minute). The tongue is slightly coated. Disseminated without special
order over the lower two-thirds of the trunk, behind and at the sides,-
with predominance on the left side, there is a fairly copious purple
eruption simulating small haemorrhages into the skin (fig. 1). On close
examination these eruptive lesions are seen to be dilated capillary blood¬
vessels, punctate at first appearance and gradually conglomerating to form
slightly raised papule-like spots, about half the size of a split pea. They
do not disappear by pressure. An isolated spot is situated on the skin
outside the right eye. It is to be noted also that the patient has several
soft moles on the face and limbs. She complains of some tenderness
down the whole length of the right sciatic nerve, extending down the
back of the leg below the knee to the ankle. The knee-jerks are equal,
and the plantar reflexes almost absent.
Whilst under observation in the hospital there was no febrile disturb¬
ance, and nothing wrong could be detected in the various viscera, includ¬
ing the kidneys. Mr. Hartridge reported that the eyes were normal,
and Mr. de Santi examined the nose and throat and failed to find any
indication of enlarged blood-vessels, only some adhesion between the
68 T. C. Fox: Bilateral Telangiectases of the Trunk
inferior turbinate and septum nasi. Mr. Carling made, under anaesthesia,
an examination with the sigmoidoscope of the lower bowel for about
12 in., and found the mucous membrane normal. Two examinations of
the blood w T ere carried out. On December 13, 1907, the report was :
Proportion of serum to corpuscles obtained by centrifuging, 2 : 3 ;
haemoglobin, 85 per cent. ; red blood-corpuscles, 4,600,000; white blood-
corpuscles, 5,700. Polymorphs, 49 per cent, (fine granules 48, coarse 1).
Fig. 1.
Telangiectases of the trunk and moles ou the arm and face.
Monomorphs, 51 per cent, (large 8, transitional 23, small 20). Coagula¬
tion time, three minutes and fifty seconds, and the same on Decem¬
ber 19.
On March 10, 1908, the red corpuscles were 5,500,000, the hauno-
globin 92 per cent., and the proportion of serum to corpuscles 1:1. A
Dermatological Section
69
biopsy was made of a little cluster of the eruption of the back, and
the sections display the dilation of blood-capillaries without any other
changes (fig. 2). I am greatly indebted to Dr. H. G. Adamson for the
drawing of the section.
Fig. 2.
Section of Telangiectases from the back.
(A) Serum. (B) Blood-corpuscles. (C) Dilated capillary.
DISCUSSION.
The President said he had seen warts develop from such conditions, but
not true angioma. He understood that there were no lymphatic vesicles.
Mr. CoLCOTT Fox, in reply, said he would discuss the subject in a paper in
the Journal of Dermatology. Politzer, in his “ International Atlas of Rare Skin
Diseases,” reported a remarkable case of the kind all over the body, and called it
ntevus, as it occurred in very early life. The present patient had a number of
moles. It began when aged 14, and she was now 23.
70
W. S. Fox: Case for Diagnosis
Case for Diagnosis.
By Wilfrid S. Fox, M.D.
The patient was a girl, aged 18, who was suffering from two shallow
ulcers ; one, situated on the chest just to the left of the sternum, had
been present for a month ; the other, on the outer side of the left knee,
appeared only a fortnight ago. Both ulcers were similar in appearance,
measuring about 2 in. in diameter, the surface being covered by a dry,
semi-transparent parchment-like substance, through which the superficial
veins could be seen. A year and a half previously she had cut her hand
with a kitchen knife and the wound had become septic, and only recently
healed.
The exhibitor said he had questioned the patient with regard to the
artificial production of the ulcers, but had failed to get any confession.
She was a very quiet, sensible girl, not in the least hysterical, and
answered questions readily.
The general opinion of the members was, however, that the lesions
had been caused by artificial means.
DISCUSSION.
The President said he thought all would agree as to the factitious nature
of the lesions, which were on the left side, especially taken in conjunction with
the general aspect of the lady. The question was as to the agent employed ;
unless the lesions were seen fresh it was difficult to determine that. Acid,
vinegar, or mustard might be used. He was once called to a provincial town
to make a diagnosis in such a case, and suggested toilet vinegar as the agent.
It turned out to be a mixture of toilet vinegar, and Jeyes’ fluid. The same
patient used to have morphia suppositories and take them by the mouth.
Dr. PRINGLE said it was surprising what could be done by merely wetting
the finger and rubbing it on the skin. He had a patient in hospital for more
than a month and she did it at night, although there was a night nurse watch¬
ing her.
Dr. WHITFIELD suggested that either hydrochloric or acetic acid was the
probable cause.
]Jennatological Section
71
Case of Acute Scarlatiniform Eruption following the Adminis¬
tration of Small Doses of Quinine.
By J. Galloway, M.D.
(In association with Dr. Cohen.)
The patient was a man, aged about 27, of Jewish race, pallid in com¬
plexion and unduly stout for his years. He came of a family in which
there was a marked history of glycosuria. In his own case, however,
glucose had not been identified in the urine, though marked phospliaturia
had been observed. He suffered from a tendency to seborrhoic troubles
with slight scaly dermatitis of the scalp, which had been eczematous on
two occasions, two and three years ago.
Twelve months ago, feeling a little run down in health, he had
taken ^ oz. of the proprietary medicine known as Phosferine. Within
two hours he suffered from symptoms of faintness with a sensation
of choking, feverishness, followed by a violent scarlet blush over the
whole body, including the face and extremities. The most severe
symptoms began to subside in the course of a day or two, but were
followed by well-marked desquamation, which lasted for some time. A
fortnight ago, once more finding it advisable to take a tonic medicine, he
visited a house of public entertainment and obtained a bottle of what
was called “ tonic w r ater.” This he drank, hoping to benefit. Within
tw'o hours he again experienced the exceedingly uncomfortable and dis¬
tressing symptoms with which he had become familiar twelve months
previously after the dose of Phosferine.
The desquamation had not completely ceased when he consulted
Dr. Cohen on March 14, complaining of neuralgia affecting the right
side of the face. There were present one or tw*o carious teeth, and until
these w r ere properly attended to by the dentist, Dr. Cohen prescribed for
him a medicine containing 1 gr. of quinine to the dose. He took a
dose of this medicine at 3 o’clock on Saturday afternoon. At 0 o’clock
the symptoms now familiar to him w r ere fully developed. The tempera¬
ture was 102° F. He experienced shivering, marked nervous depression ;
the tongue became very furred ; he had “ foaming at the mouth,” the
fauces w r ere swollen, there w r as much difficulty in sw r allow T ing, and the
72 Galloway: Acute Scarlatiniform Eruption
patient not only felt seriously ill, but had all the aspects of a serious and
acute disease.
On Wednesday, March 18, he was taken by Dr. Cohen to sec
Dr. Galloway. The patient was now much more comfortable, the
acuter symptoms of the attack having to a great extent disappeared. He
still presented over large areas of the body, especially the lower part of
the abdomen, the inner side of the thighs, and the inner surfaces of the
arms, a bright scarlet eruption, now becoming patchy. The whole body,
during the acute attack of the previous Saturday and Sunday, had been
covered with this acute erythema. Over considerable areas a large
quantity of superficial desquamation of epithelium could be observed ; the
face was as if powdered, owing to this desquamation, and a good deal of
scaliness of the scalp existed, complicated, however, by the previously
existing seborrhoic pityriasis.
Dr. Galloway drew the attention of the Society to the fact that Phos-
ferine contained the phosphate of quinine, and that the bitter tonic
water which w r as now frequently sold as a form of aerated beverage
also contained quinine in small quantities. The key to the problem,
however, had been given when the prescription of 1 gr. of quinine was
immediately followed by the acute form of quinine erythema which they
now witnessed. Dr. Galloway remarked upon the comparative rarity of
the scarlatiniform type of quinine eruption. Its features, however, were
of so striking a character and the illness which they provoked was so
severe that its existence was well recognised. Numerous cases were on
record, and he referred especially to the case described by Dr. H. W.
S tel wagon. 1
This unhappy patient had been reduced to such a condition by
repeated attacks of the scarlatiniform quinine eruption that he
went about in fear and trembling lest he should inadvertently take a
small dose of quinine or have it prescribed to him in some form by his
physician. Dr. Stelwagon refers to eight or ten outbreaks ; they may
have been more numerous in the history of this unusually susceptible
individual. The case brought before them was another instance of this
susceptibility to quinine, and served to emphasise the serious character of
the attack.
Journ. of Cntan. and Gen.-Ur in. Dis., 1902, xx., p. 13.
Dermatological Section
73
DISCUSSION.
Dr. Dore drew attention to the fact that in all probability some of the
acute scarlat ini form eruptions described during attacks of influenza and from
unknown causes might very well be the result of the administration of quinine
in the case of individuals with this peculiar idiosyncrasy.
Mr. WlLMOTT Evans said that at the Dermatological Society of London he
showed a case of recurrent bullous eruption. The patient took quinine for
a time and then burst out into an eruption. She was now well.
The PRESIDENT said the etiology of the condition was an interesting matter.
Very often in such cases there was no history forthcoming. In some cases
there were obviously toxic intestinal conditions. In all the cases the patients
seemed to become increasingly susceptible to the drug.
Case of Bromide Eruption.
By E. G. Graham Little, M.D.
The patient was a female infant, breast-fed, aged nine months, who
had been under the care of Dr. Edgecumbe Burrows, of Manor Park,
Essex ; no bromide had been given by this gentleman to the infant, who
had had a little bronchitis, and had, according to the mother, been
taking a mixture containing paregoric and squills. But the mother was
a chronic epileptic, and since September, 1905, had, of her own accord,
been taking thrice daily a mixture composed as follows:—
ft Pot. brom. ... ... ... ^iss.
Sp. amm. arom. ... ... ... .yv.
Aquae ad ... ... ... ... t ^xvj.
5 ss. ter die.
The eruption had appeared in the child three months ago, apparently
on the scalp first. When shown the following was the distribution and
character of the rash :—
Bight Leg .—The eruption was most severe and extensive here, the
skin of the leg being almost obscured by the eruption, which consisted
of very large framboesioid tumours, surrounded by a red areola; thus
there was a patch 2% in. by 2 in., with a pearly nodular aspect and
raised J in. from the general level of the skin, on the outer surface of
the leg; another slightly smaller patch, but similar, on the knee;
another large fungating patch over the calf, another on the ankle,
74
Little: Case of Bromide Eruption
another on the middle of the front of the leg, and several smaller patches
dotted between these. On the right thigh there were two or three
smaller patches and some nodules in an early stage, which showed the
characteristic appearance of bromide eruption, the nodules being dotted
over with minute, deep-seated follicular pustules. A section from one
of these early nodules was obtained, and would be shown at a subsequent
meeting of the Section.
Left Leg .—There was a single lesion, the size of a two-shilling piece,
over the tendo Aehillis, raised, and consisting of pearly nodules fused
together into a plaque; there was a large, fungating, cauliflower-like
patch on the left thigh near the vulva, and several smaller patches and
nodules on the buttock.
Left Arm .—The sites of vaccination were covered by raised nodular
patches, and there were similar patches on the left shoulder, front of
neck, the summit of the right shoulder, the back of the neck, and the
occipital region of the scalp. The face was entirely free.
The mother had never had any similar eruption. The child had not
had any illness with the exception of the slight bronchitis mentioned,
and was apparently otherwise well. She had been breast-fed since birth.
The exhibitor had seen only two other cases of equal severity : one
shown by him at the Dermatological Society of Great Britain and Ireland
in 1900, and another which had come to St. Mary’s Hospital a year ago.
In both these cases quite small doses of bromide had been given directly
to the patients, who were in each case infants, and for quite short
periods; in the latter case mentioned the dose had been 2£ gr. a day,
given for one week previous to the development of the eruption. The
exhibitor had never seen anything approximating to this tumour
formation in adults taking large doses of bromides. Yet, in an inter¬
esting paper contributed to the British Medical Journal (March 14,
1908) by Dr. A. J. McCallum, that physician’s extensive and special
experience had convinced him that adults were proportionately much
less tolerant than children to the drug, and notwithstanding the large
doses habitually employed by him—as much as 820 gr. per diem being
given to a boy—“ bromide rashes had never given him any trouble.”
It would almost seem as if small doses were more likely to produce
eruption than large doses, and much the same conclusion had been
adopted by many clinicians in the consideration of the frequency of
eruption following the administration of iodides.
Dermatological Section
DISCUSSION.
Dr. Savill said that some years ago he went into the question of the
frequency of the eruption in the cases treated at the West End Hospital for
Nervous Diseases, where there was a large number of patients always taking
bromide. He was able to collect only about eight cases of the framboesial
variety in ten years. Sometimes the eruption came on in patients who were
taking quite small doses. One of the subjects of it never took more than 10 gr.
three times a day. Nearly all the subjects of the condition were young people
aged under 18.
The PRESIDENT said he agreed with what Dr. Savill had said, but nearly all
adults who suffered from bromidism had some affection of heart or kidneys,
unless, of course, they were taking gigantic doses. He was once asked to see a
case at a fever hospital. It had been sent in as a case of small-pox. The
medical men there knew it was not small-pox, but could not say what it was.
He recognised it as a bromide eruption, and said that it would probably be found
that she had cardiac disease, and it proved to be so. She was taking only small
doses of the drug. There was in his “Atlas ” a case pictured in which the patient
only had 5 gr. three times a day for a few days, but she had marked albuminuria.
The lesions were aggregations of minute pustules. If pricked very little fluid
exuded ; they were almost solid.
Dr. Whitfield quoted a case under his observation in which the bromide
eruption had appeared in an infant three days after birth, the mother having
taken the drug during pregnancy. He could thus confirm the experience noted
in the present case, where the child apparently derived the eruption entirely
from the mother’s milk.
Case illustrating the effect of X-rays on Mycosis fungoides.
By H. Radcliffe Crocker, M.D.
The patient was a woman, aged 31, and had a distinct specific history.
Eight months after the parturition an eruption appeared, which looked
like confluent small-pox, the whole skin being covered with pustules,
except the hands and feet. This was probably due to the fact that she
had been taking iodide of potassium two months, and an improvement
occurred soon after stopping the drug ; then pustules recurred on the
parts previously attacked and she developed some eczema. In June last
year she had an universal eczematous dermatitis, dry and scaly, very
much as seen at the meeting. The tumours began in November, 1900,
the first round the umbilicus on the right side. A few other cases of the
kind had a history of syphilis, but the bulk of them had not. She
70
Sequeira: Case of Lupus, with Unusual Features
exhibited a point which Mr. Pernet brought out, that there was great
longevity in the parents. He had traced such a history in many cases,
but he did not know what its significance was. There was a rather acute
dermatitis on the feet, and it was questioned whether that was due to
X-rays, but a little further treatment by those rays cleared it off. Eczema
yielded to X-rays if they were not applied too strong. Some time ago
there was shown a clergyman, the subject of mycosis fungoides, with a
large number of tumours, and they were entirely removed by means of
X-rays. Some recurred, the treatment was resumed, and the last news
of him was that he had married, so that presumably he was fairly clear
of the disease. He did not know of a case of permanent cure.
Case of Lupus, with Unusual Features, suggesting
Lupus pernio.
By J. H. Sequeira, M.D.
The patient, a married woman, aged 41, lives in Wales. She has
two healthy children, aged respectively 9 and l 2J. There is no history
or evidence of tuberculosis in the patient or her family. One of her
brothers has rheumatism.
She enjoyed good health until nine years ago, when, after an attack
of influenza, she noticed that there was a difficulty in breathing through
one nostril. She was treated without benefit. In the next year (1900)
the left nostril had become “ blocked,” and a swelling appeared about
the left wrist. In March of that year an operation was performed upon
the nose and some “ thickened bone ” removed. The patient states that
this operation gave her no relief, and it was followed by the spread of the
trouble to the other nostril. A month after a red spot appeared at the
tip of the nose, close to the site of the operation. The red area steadily
increased until the whole of the nose and part of the cheeks and upper
lip became affected. At the same time the swelling of the wrist spread
to the hand on both sides and ultimately to the fingers.
During the summers of 1906 and 1907 the patient states that she
suffered a great deal with swellings of the feet, which disappeared.
There is still, however, some swelling of both great toes.
In 1904 she had a rather severe attack of “ erysipelas ” in the face,
and in 1907 there were five attacks of similar character. There had
been no erysipelas-like outbreaks on the hands.
Derm a tologica l Sec t ion
77
The patient shows no signs of visceral disease. The urine on the
occasions on which it has been examined proved to be free from albumin.
She is a nervous woman, highly excitable, but has fits of great depression,
probably induced by the chronicity of her disease and the disfigurement
it causes. She is thin, but wiry and active. The nose is swollen and
red, and the red areas extend out on to the cheeks and on to the upper
lip. The skin of the nose is thickened, and when first seen was covered
with large dilated vessels. The left ala nasi is partially destroyed and
the orifice is contracted. This is the site of the operation. I have not
been able to make out any actual lupoid nodules in the tissue affected,
but Sir Malcolm Morris, who saw her before I did, kindly referred to his
notes and tells me that he found some distinct nodules. The affected
areas on the cheeks are red, raised, and also show dilated vessels. The
upper lip is in the same condition, the redness extending down to the
margin of the mucous membrane.
The ears are free from disease. Mr. Hunter Tod has examined the
interior of the nose. He remarks on the thickening of the mucosa,
but could find no evidence of lupus vulgaris. The buccal mucosa
and larynx are also free from disease.
The remarkable feature of the case is the condition of the hands.
Both are enormously swollen, the left a little more than the right. The
swelling begins at the wrist and involves both the palmar and dorsal
aspects. The skin is purplish in colour, thickened and tough, but there
is no pitting on pressure. There is swelling also of the digits, which
is more marked at the proximal part and produces a curious tapering
appearance. The character of the skin is the same as on the hands.
The nails are unaffected. Both great toes present a somewhat similar
appearance, but less severe. There is no swelling of the feet. From
the hypertrophy of the hands it would appear that not only the skin but
the subcutaneous tissue is affected.
The circulation at the periphery is obviously bad, but it is remark¬
able that the patient describes the trouble as being more acute in the
summer.
The facial condition has much improved under treatment. The
Finsen light has been applied and gave excellent reactions, which have
been followed by a diminution of the colour and swelling. The large
dilated vessels have been treated by electrolysis with advantage.
General tonic treatment has also been adopted, and the patient has
been taking cod-liver oil and a mixture containing iron and arsenic. No
alteration in the condition of the hands has been observed.
78 Sequeira: Case of Chronic X-ray Dermatitis of Hands
DISCUSSION.
Dr. Galloway said he brought to the Dermatological Society of London a
somewhat similar case, but affecting the lower extremities. The outstanding
feature was the constantly recurring attacks of erythema with solid oedema,
passing off from a condition almost resembling elephantiasis. The case was
associated with Graves’ disease, though that association was probably accidental;
still, it should be borne in mind as possibly associated with the lymphadenoma.
Three weeks ago he had a case affecting the left arm, sent up from Woolwich
to the hospital, in which a most careful examination failed to reveal any cause
for the lymphatic obstruction, X-rays also being used. Yet there seemed to be
elephantiasis of the whole left arm. He believed it to be an infective process,
but nothing septic could be detected in the case.
The PRESIDENT said it would be agreed that elephantiasis was a mere
symptom of blocking, the question being, What caused the blocking ? In the
past history of the present case there was recurrent lymphangitis, and possibly
there was now a faint degree of it in the hands. He thought there must be some
infective process.
Dr. WHITFIELD thought the fact that it was present in the two hands was
against the idea of septic lymphatic blocking, as also was the slow growth of the
condition. He thought they were somewhat allied to Raynaud's disease—
so-called recurrent erysipelas of the face ; and the lupus pernio which Dr.
Colcott Fox mentioned was much more likely to be associated with Raynaud's
disease.
Dr. SAVILL suggested that the condition was allied to erythromelalgia, which
Weir-Mitchell described. The condition was transitory at first, but became
established later. About five years ago he published in the Linn et a case of the
kind in which some toxic state was present.
Case of Chronic X-ray Dermatitis of the Hands ; removal
of Warts by measured doses of the X-rays.
By.J. H. Sequeira, M.D.
The patient, an operator in the X-rav department of the London
Hospital for the past eight and a half years, has suffered from dermatitis
of the hands for six years. During the first four years he assisted in the
radiographic work and used the screen in a large number of cases. He
also developed radiographs. For the past four years he has been
employed only in X-ray treatment. The X-ray dermatitis has shown
the usual exacerbations in the winter months. The nails have suffered
severely, and the patient is now on leave recovering from an operation
on one of them. The backs of the hands and fingers presented numerous
telangiectases and atrophy of the skin, and both had been studded with
Dermatological Section
79
numerous dark, dry warts, the left hand being worse than the right.
The palmar aspect w T as unaffected, but on the left there has recently
appeared a black spot, not raised, and like a pigmented mole in appear¬
ance. Several small black points have appeared on the left upper arm.
The patient is shown for two reasons, the first being that the back
of the left hand has been cleared of the warts by means of the X-rays.
It is important to realise that the diseased condition is due to long-
continued irritation of the skin by short, frequent exposures to the
X-rays, such as occur in screen work and in the old, and as has been
amply demonstrated, most dangerous habit of testing the penetration of
the tube by the hand and screen. This kind of irritation is entirely
different from the action of the X-rays given therapeutically by measured
doses. I have seen great improvement in the condition of the face of a
patient suffering from xeroderma pigmentosa, the warty growths being
removed by the X-rays; and recognising that the chronic form of X-ray
dermatitis is in many respects similar to Kaposi’s disease, it is natural
to expect a favourable result in the radio-dermatitis. The warty areas
were exposed once only to X-rays until the B tint was obtained on the
Sabouraud pastille. This dose is equivalent to about five Holtzknecht
units. A definite, but slight, reaction was noticed at the end of twelve
to fourteen days, and the areas are now 7 , five w’eeks later, quite smooth.
They still, of course, show telangiectases and atrophy, with a little
pigmentation. The left hand, the worst, has been treated, and I am
showing the patient at this early date to demonstrate the contrast
between the treated and untreated hands. It is intended at once to
treat the right hand. The case is not reported as one of cure of X-ray
warts, for the time is far too short to be certain w r hether the improve¬
ment is more than transient. The fact, however, that the warts may at
any time become epitheliomatous renders it of the greatest importance
to remove them if this can be done without risk.
The second point of interest in the case is the presence of the
pigmented spot, 1 cm. in diameter, on the palmar surface of the left
hand. In X-ray workers it is the dorsal aspect of the hands and
fingers which suffers, so that it is quite possible that the pigment
spot may have developed independently. The fact also that several
small pigment spots have appeared on the upper part of the arm, which
is always covered and protected from the rays, and where there has
never been any dermatitis, favours that view 7 . So far no record has been
made of the appearance of such spots in X-rav w-orkers, but there is still
so much to be learnt about the remote effect of the rays that I deem it
a —4
80 Sequeira: Case of Chronic X-ray Dermatitis of Hands
sufficiently important to call attention to the matter. In the interests of
the patient I suggest removal of the pigmented spot on the palm.
DISCUSSION.
Sir Malcolm Morris said the dermatitis did not necessarily go as a result of
the application of the rays. He had a case in which the warts had gone, but the
X-ray dermatitis was still going on. It seemed somewhat risky to treat the
dermatitis by the agency which was responsible for the original trouble, and
the time was too short to say that it was a case of cause and effect.
The PRESIDENT said there was a striking difference between the area which
had been treated by the rays and that which was not. He thought the pigmented
spots should be treated.
Dr. WHITFIELD said that he was told by Mr. Reid, the radiographer at King’s
College Hospital, that no one got X-ray warts on the hands who did not develop
photographic plates. The present patient had stopped developing plates five
years ago, but he appeared to have had the warts six years.
Dr. J. M. H. MacLeod, in a communication submitted subsequently, con-‘
sidered that the X-rays themselves were capable of producing the warty growths
seen in the patient’s hands, and that they were not entirely due to the action of
the chemical reagents he had been employing in developing X-ray photographs.
It had been asserted that the warty growths were not caused by the X-rays
and only occurred in X-ray photographers, but in opposition to this view he
cited a case of extensive X-ray dermatitis with warty growths in a man who
made X-ray tubes, and whose hands were frequently exposed to the rays, but
who was not in the habit of exposing them to chemical irritants. He considered
that the warty growths were as much a feature of chronic X-ray dermatitis as
the somewhat similar lesions were a characteristic of xeroderma pigmentosum.
With regard to the melanotic lesions on the left palm and arm, he*had never
seen such occur before, but thought it possible that they might be connected
with the X-ray dermatitis, and in view of the possibility of their being sarco¬
matous considered that they should be destroyed.
Dr. PRINGLE said the first case of the kind was shown by him at the
Dermatological Society of London, and the patient w r as a photographer. The
idea that the condition of his nails was due to X-rays was not generally
accepted, but was attributed to the photography.
Mr. Kettle (introduced by Dr. Graham Little) showed :—
(1) Sections of a hard Hunterian chancre, stained by Levaditi’s
method for Spirochwta pallida , and showing that organism with unusual
clearness and in great abundance.
(2) Film preparation, made from the unruptured vesicle of a bullous
congenital syphilide, and stained with Giemsa’s stain. The spirochaetoe
in the latter preparation were quite distinctly shown, but less perfectly
than in the former case.
Dermatological Section.
May 21, 1908.
Dr. Radcliffe Crocker, President of the Section, in the Chair.
Case of Nodular “ Ringed Eruption.”
By H. G . Adamson, M.D.
The patient was a printer, aged 17. Five months ago “ small red
lumps ” appeared upon the backs of the fingers and gradually increased
in size. When he first came under observation one month ago there
were present on the dorsal surfaces of the fingers of both hands raised,
firm, dusky red, nodulated, disc-like areas of from J in. to 1 in. in
diameter, and elevated about ^ in. to ^ in. All the fingers of each
hand were involved; in some the dorsal aspect of one phalange, in
others of two phalanges, and in the case of the first finger of the left
hand the lesion extended over the middle joint. On close inspection,
and particularly on palpation of the raised, disc-like areas, it was
evident that they were made up of closely set pea-sized nodules, but it
was only on careful examination that this feature could be made out,
for the individual nodules were close together and their margins were
ill defined. In some of the patches there was a tendency to ring forma¬
tion owing to the arrangement of the nodules towards the margin of
the patch. The hands were cold and of a dusky hue. There were, in
addition, a few isolated, pea-sized, dusky red nodules on the backs of the
hands. One of these was excised, and within a fortnight the whole
of the lesions had almost disappeared. It was curious that a similarly
rapid disappearance of the lesions had occurred in a case of “ ringed
eruption ” recorded by Dr. Graham Little after a biopsy. [A photo¬
graph of one hand, taken when the lesions were still present, was
shown.] The exhibitor regarded the case as belonging to the group
of cases variously described as “ringed eruption” (Colcott Fox), granu¬
loma annulare (Crocker), lichen annularis (Galloway).
ju —4
82
Adamson : Case for Diagnosis
A section of one of the lesions from the back of the hand showed
some widening of the prickle-cell layer and of the homy layer of the
epidermis (possibly due to the fact that the section had been cut
obliquely). In the corium the fibrous connective tissue was normal,
but in it there were numerous circumscribed collections of mononuclear
round-cells around the blood-vessels and a large mass of the same type
of cells around the sweat gland. There were no young connective
tissue cells, epithelioid cells, plasma cells, nor polynuclear leucocytes.
The absence of young connective tissue cells described in other cases
was probably due to the fact that the lesion excised was at a very early
stage. The clinical features and the histological findings suggested a
toxic rather than a microbic origin.
DISCUSSION.
The PRESIDENT (Dr. Radcliffe Crocker) said that the condition did not
suggest granuloma annulare to him.
Dr. Colcott Fox said he was not prepared to give a name to the condition.
When Dr. Adamson first showed the case to him it was very striking on the
fingers, but that had now gone. He regarded it as chronic, but not an ordinary
erythematous eruption.
Case for Diagnosis.
By H. G. Adamson, M.D.
The patient was a young woman ; she was very anaemic ; she had
suffered from an eruption on the back of the right hand for two years.
The lesions consisted of three herpetiform groups of split pea-sized
superficial erosions running together to form polycyclical areas (recalling
the erosions of preputial herpes). When first seen one week ago these
erosions had been actual vesicles, hemp seed-sized to split pea-sized,
thick walled, evidently of recent origin, although situated on an infil¬
trated, pigmented base obviously of longer standing. It has since been
found that the patient (who is a bottle-washer) uses nitric acid in her
work, and that the lesions date from the time of an application of strong
nitric acid for the cure of a tattoo mark on her arm. The evidence
therefore seemed in favour of the eruption being artificially produced
(i.e., feigned eruption ), although the herpetiform character of the lesions
w T as unusual.
Dermatological Section
83
The PRESIDENT said the condition suggested some microbic origin, but he
was not prepared to state the particular microbe. He had never seen an exact
parallel.
Case of Leprosy.
By T. J. P. Hartigan, F.R.C.S.
The case was shown to a post-graduate class, and two out of three
correctly diagnosed it. He showed photographs taken in 1905 and
1907. No lesion was visible by anterior rhinoscopy, but smear prepara¬
tions were found to contain the bacilli, and they were present in nodules
expressed from the face lesions. It was the first case which had been
treated with nastin, and thoi%h only two injections had been given so
far, several lesions were much reduced in size and much drier. The
patient said that on the day after he had the first injection he felt better
than during the preceding five years, feeling stronger and enjoying his
food more. He had treated leprosy with Chaulmoogra oil, but did not
think it did very much good. It was necessary to use the nastin with
care, especially when the eye was involved, as there might otherwise be
clouding of the media. He had begun by injecting only the smallest
dose. The preparation was made from a culture of streptothrix given
from a leprous nodule. A portion of the leprous nodule was grown in
sterilized water, then incubated for some time. After a few weeks a
fungus grew, which, though not the same as the leprosy bacillus, had
certain resemblances to it. That was afterwards extracted and mixed
with benzoyl chloride. The mixture was then standardized and injected
into the patient, and it produced a reaction analogous to that caused by
tuberculin in tuberculosis.
Dr. PARKES Weber thought it was Botryomycosis hominis , which was
practically a vascular structure. In the stroma there were plasma cells and
leucocytes.
Case of (?) Dermatitis artefacta.
By E. G. Graham Little, M.D.
The patient (sent to Dr. Little by Dr. Date,' of Culmstock) was a
lady, aged 36, who had suffered from ulcers on the legs, thigh, and arms.
The first of these had appeared, when aged 16, on the left leg, where
there was a large scar ; four years ago one had come upon the left arm;
ju —4 a
84
Little: Case of (!) Dermatitis artefacta
this had been scraped and had healed completely. The present crop had
made its appearance last autumn, and at the present time there were six
large but rather superficial ulcers, of an average size of 3 in. by 2 in.,
on the upper and outer part of the right thigh; they were quite close to
each other and of a curiously regular outline and symmetrical shape.
Upon the back of the right leg there was a much larger patch of super¬
ficial ulceration occupying nearly the half of the leg. It was notable that
these and all the lesions of previous ulcerations were in positions within
easy reach of the hands.
The patient had been variously treated during the illness. She had,
according to Dr. Date’s careful and excellent notes, been scraped ; she
had been put under X-ray treatment (which made things worse) ; she
had had potassium iodide in 15 gr. doses ^iree times daily for eight weeks
without good effect; she had been in a home at the seaside for months,
and had “ taken any amount ” of malt and cod-liver oil. A portion of
skin from the edge of one of the ulcers had been examined by Dr. Bulloch,
of the London Hospital, who had reported that he found no tubercle
bacilli in the section, but the condition of some of the arteries had sug¬
gested the possibility of syphilis. There was no tubercular history in
the family, and the patient herself was a plump, eminently healthy-
looking person.
When first seen the ulcers were covered with a very foetid dis¬
charge. The patient had been carried into the consulting room on a
stretcher, and the apparent lack of necessity for so much disablement
had suggested to the exhibitor a hysterical causation. On examination
with this idea it was found that there was a contraction of the right
knee, probably hysterical (which had, in fact, rapidly improved while
under treatment during one week), and some lack of sensation of the
right as compared with the left side. The palate was comparatively
insensitive also. The knee-jerks, especially on the right side, were greatly
exaggerated, and there was almost clonus of the right ankle.
The syphilitic treatment had been continued after a Calmette test
(1 per cent.) had proved negative. Iodism had shown itself within a few
days, so mercury only was administered. The ulcers were dressed with
occlusive dressings impregnated with hydrogen peroxide, and had shown
immense improvement in a few days. Within a fortnight of her admis¬
sion into a home most of the ulcerated patches had skinned over. This
fact, coupled with the hysterical features, had inclined the exhibitor to
the opinion that the case w T as one of “ dermatitis artefacta,” though no
definite evidence of the method of production was obtainable.
Dermatological Section
DISCUSSION.
85
Dr. GALLOWAY said some members would remember a case which was
brought from Amsterdam to the Congress in London in 1896, and he would
regard the present case as of the same class, namely, chronic granuloma.
Only on the previous day he had a post-mortem on a case which had been
admitted into hospital with the tentative diagnosis of endocarditis. It was
thought to be tuberculous, and Calmette’s reaction twice produced a positive
result. The post-mortem showed that the patient had rapidly advancing endo¬
carditis affecting the left side of the heart, but there was no trace of tubercle
anywhere in the body.
The PRESIDENT said it was not obvious to him that the condition was
artificially produced, though he could not suggest an alternative diagnosis.
Artificial lesions of that character were very rare.
Mr. PERNET favoured the artificial theory, which he considered was sup¬
ported by the shape of the lesions.
Dr. Whitfield thought the lesions showed what looked like apple-jelly
nodules. When the blood was expressed there was left a transparent appearance,
and he believed the condition to be tuberculous.
Case of Varus nodulosus of Brooke.
By E. G. Graham Little, M.D.
The patient, a man aged 40, was kindly sent for exhibition by Dr.
Purdie, of Kentish Town. The eruption was plentiful upon the face, and
the case recalled very faithfully the appearances depicted in the plate
with the title “ varus nodulosus ” in the “ Iconographia Dermatologica ”
of Jacobi. It consisted of small shiny nodules deeply situated in the
skin; some of these seemed to be vesicular, but on being pricked no fluid
escaped. There was little inflammation round the nodules, which were
closely grouped and most thickly distributed on the forehead, just below
the lower eyelid, on the cheeks, the chin, and upper lip. The skin of the
face was generally seborrhoic. The condition had persisted for eight
months. There was a mottling of the skin, with one or two ill-defined
nodules on the forearms. The patient was a grocer, and the aspect of
the forearms was perhaps explicable by his occupation. There was no
tubercular history. The man had suffered from chronic diarrhoea, but
was otherwise well.
DISCUSSION.
The President said he was of opinion that the condition was one of acne
agminata, and that it was due to intestinal toxins. The patient admitted he
86
Little: Case of Folliculitis decalvans
had chronic diarrhoea. In some cases there was constipation. Tilbury Fox
first described such cases, and they were successfully treated on the intestinal
toxin theory. The lesions were always of slow growth and showed a fungous
structure. There was a deep-seated folliculitis.
Dr. COLCOTT Fox said he had always considered the case described by
Brooke as “varus nodulosus ” as a tuberculide, and would accept this case as
of the same type.
Dr. Pringle did not think this case as of the same nature as his case of “ a
rare seborrheide " included by Brooke in his class of “ varus nodulosus."
Dr. GRAHAM Little promised to obtain a section of the skin and to report
later on its nature.
Case of Folliculitis decalvans (Pseudo-pelade of Brocq).
By E. G. Graham Little, M.D.
The patient was a young woman, aged 26. There were lines and
streaks of cicatricial atrophy, dating from only six months ago, and
without any history of previous inflammation. She had suffered from
headache, chiefly frontal, and the scalp was seborrhoic. The hair
adjoining the cicatricial patches w r as altered in appearance, the follicles
being slightly reddened and swollen.
DISCUSSION.
Sir Malcolm Morris asked why it should be called the pseudo-pelade of
Brocq. Such cases were shown at the Dermatological Society of London long
before Brocq wrote his paper on it.
The PRESIDENT said he agreed with Sir Malcolm Morris’s remark. He
believed alopecia cicatrizata was a better and more descriptive term.
Case of Pseudo-xanthoma elasticum of Balzer.
By E. G. Graham Little, M.D.
The patient was a woman, aged 56. The eruption consisted of
mesh-like patches of buff-coloured infiltration, lumpy in some places, in
others linear and hardly at all raised from the surface ; the whole of the
neck was occupied by the eruption, but it was especially marked at the
sides. The face was entirely free. Small patches of the same type
were present in the flexures of 'the elbow\ The condition had persisted
for more than twenty years and there were no symptoms in connection
w T ith it. The patient had never had jaundice or liver troubles.
Dermatologica I Section
87
The exhibitor had had two cases of much more limited distribution
of pseudo-xanthoma elasticum, in which a biopsy had corroborated the
diagnosis; this had not been obtainable in the present instance, but the
clinical similarity of the case now shown with these two made this
diagnosis more than probable. In Brocq’s recent treatise the statement
was made that only four cases had hitherto been recorded: one by
Balzer, one by Chaffard and Darier, one by Bodin, and one by Weither.
This remained, therefore, one of the rarest of skin diseases; but probably
the difficulty of diagnosis without a biopsy, and the impossibility of
obtaining this in many instances, added to the obscurity of the disease
and the rarity of its identification.
Case of Unusually Generalized Naevus verrucosus zoniformis.
By E. G. Graham Little, M.D.
This case in some of its features had suggested the diagnosis of
keratosis follicularis of Darier, but the diagnosis now substituted w r as
undoubtedly the correct one. The alternative name for this condition
mentioned by Brocq (noevi keratodermique kyperk^ratoses urigenitales
circonscrites) would, perhaps, fit this particular case better than the one
adopted; but the case resembled very closely that pictured under the
title of naevus verrucosus zoniformis in Brocq’s treatise. 1
The patient was a Jewish infant, now aged 18 months. The skin
was quite free from blemish at birth, with the exception of a small
patch of flat warty naevi on the dorsum of the left foot. At 3 months
of age other parts of the body had become invaded, and during the later
fifteen months of his life more and more of the body was affected. At
the present time the distribution was as follows : The most prominent
lesions were in both the axillae and the neck (vide Brocq’s plate,
mentioned above). Here there were continuous patches of flat and
acuminate elevations with a follicular distribution. The axilla of the
left side was more affected than the right, and the patches extended
downwards on to the side of the chest. Less prominently raised but
similar patches were present on the middle of the left flank and on the
left groin, on the back and side of the left upper arm, on the front of
the left wrist and the back of the left hand. On the left buttock there
was a patch which ended in a linear streak running down the middle of
1 “ Dermatologie Pratique,” 1907, ii., p. 588.
88
MacLeod: Case of Lupus erythematosus
the back of the thigh and leg to the foot; an exactly similar patch and
streak were present on the right buttock, thigh, leg and foot. On the
left foot, where the earliest example of the disease was recorded, there
was a continuous patch over the dorsum of the foot and over both
malleoli. There w r as a smaller but similar patch on the left foot.
There were isolated, grouped, small, flat, warty elevations scattered over
the right flank and side of the chest. In the mid-line of the neck,
from the chin to the sternum, there was a linear warty streak. The
face was quite free.
The curiously follicular arrangement and the symmetry made it
difficult to be certain that some degree of keratosis follicularis was not
present, and certainly constituted it an anomalous case of naevus verru¬
cosus, -which was much more commonly unilateral.
Case of Lupus erythematosus affecting the Hands, Ears,
and Scalp.
By J. M. H. MacLeod, M.D.
The patient was a delicate-looking woman aged 45, who worked as
a dressmaker. The disease began six months ago on the hands. Since
childhood she had suffered from a weak peripheral circulation, with cold
extremities and chilblains. Gradually the chilblains on her hands had
given place to permanent red patches associated with atrophy and indis¬
tinguishable from lupus erythematosus. When she was seen at Charing
Cross Hospital in April, 1908, the following lesions were noted: Both
hands presented a mottled, cyanosed appearance and felt cold and moist.
On the backs of several of the fingers were violaceous patches, roundish
in shape, the larger being about the size of a sixpence. The centre of
two of the patches was paler, somewhat atrophic, and covered by an
adherent scab, which gave the lesions a ringed appearance. The nail
of the middle finger of the left hand was discoloured, thickened, and
broken at the free margin, while several of the other nails were ridged,
opaque, and brittle. Atrophic scaly patches were present on both ears,
especially about the lobules. Behind and above the right ear, on the
scalp, there w r as an irregular atrophic patch about the size of a five-
shilling piece, with cribriform pits and a few telangiectases on its
surface. There was a family history of tuberculosis, one sister having
a tuberculous ankle, but there was no evidence of this disease in the
patient.
Dermatological Section
89
Coloured drawings of two other cases were also exhibited, showing
chilblains on the hands which had become persistent and assumed the
characteristics of lupus erythematosus. The chief interest of the case,
which was borne out by the drawings, was the close relationship of the
chilblains to the lupus erythematosus.
Case of Alopecia areata following Small-spored Ringworm
of the Scalp.
By J. M. H. MacLeod, M.D.
The patient, a girl aged 8, came under the observation of the
exhibitor six weeks ago, when it was noted that the ringworm was
widely disseminated over the scalp. In addition to the ringworm
several finger-nail-sized bald patches were observed. An ointment of
salicylic acid and sulphur was prescribed, to be rubbed in twice daily.
She has been seen several times during the six weeks she has been
under this treatment, and on each occasion the alopecia has been more
marked. At the time of exhibition irregular bald patches were distri¬
buted over the scalp. The incidence of these was not associated with
any definite inflammation. At the edges of the patches there were a
few atrophic hairs. The bald patches did not seem to occupy the
precise areas which had been affected by the ringworm, but extended
beyond these areas. Cases of this nature have been explained as the
result of the employment of some irritating ointment. This may be
true in some of them, but not in all, for in this case the alopecia was
noted in association with the ringworm before the active treatment was
commenced. Possibly in some of the cases it is simply a coincidence,
while in others the function of the papillae may be interfered with by
the presence of the fungus in and about the hairs.
Case of Spreading Telangiectases of the Feet and Legs.
By Sir Malcolm Morris, K.C.V.O., F.R.C.S.Ed., and
S. E. Dore, M.D.
The patient, a man aged 32, noticed red patches on the outer side
of his feet when he returned from a year’s military service in South
Africa in December, 1900. They were attributed to the wearing of
90
Sequeira: Case of Morphcea
tight putties for prolonged periods and to the intense cold. The peculiar
feature of the case was that although the patches remained stationary
on the feet and ankles they continued to spread up the legs to the knees,
and recently the calves of the legs had become involved. The patches
resembled an ordinary port-wine mark, consisting of dilated vessels
arranged in a close network or in parallel lines. They were almost
exactly symmetrical, leaving areas of unaffected skin on the dorsal
surfaces of the feet and toes. On the feet and ankles they were of
a blue tint with well-defined straight borders; on the legs the colour
was bright red or crimson, and the telangiectases were not so closely
aggregated. There was also slight erythema and some desquamation
of the skin of the legs. The patient had always suffered from coldness
of the extremities, which was aggravated in South Africa, but he had
never had chilblains. His health was good, and, with the exception of
the weakness of the peripheral circulation referred to, a careful examina¬
tion revealed nothing abnormal in his cardio-vascular or other system.
There was no history of haemorrhages or haemophilia either in himself
or his family.
Sir Malcolm Morris had asked himself why the lesion went on spreading
after the condition which produced it was withdrawn for so long. He did not
regard it as a case of Hutchinson’s infective angioma, and no part showed an
erythematous character. There had been no erythema multiforme, and there
was nothing on any other part of the body. The urine contained cloudy
phosphates, but there was nothing abnormal found in the viscera, and there
was no history of haemophilia. Neither was there any naevus, nor birth-mark,
nor were there any arterial changes.
Case of Morphoea.
By J. H. Sequeira, M.D.
The patient, a lad aged 19, had been seen previously at a meeting
of the Dermatological Society of London. 1 He is employed at a railway
works, and five years ago was injured by a fall. He had some extensive
bruising on the lower part of the left side of the chest, but apparently no
bones were broken. His general health has been excellent.
In January, 1907, he first noticed a change in the condition of the
skin of the left thigh and leg and trunk. When he was first shown
1 Brit. Journ. Derm., 1907, xix., p. 242.
Dermatologica l Section
91
he had a long patch of morphoea about 1J in. wide, beginning a hand’s
breadth below the anterior superior spine of the ilium on the left side,
and running obliquely across the upper part of the thigh to the inner
side. Thence it followed the sartorius muscle to the inner side of the
knee, and below the knee widened out to include the front and inner
sides of the leg. It terminated below by a line crossing the foot at the
level of the mid-tarsal joint. The area was tough, hard, dark at the
margins and pale in the centre. It had the characteristic unpinchable
quality, and in some parts resembled old ivory in colour. At that time
there was an extensive area of ulceration on the front of the leg dqe to
trauma.
There was also an area on the anterior and lateral parts of the chest
and upper abdomen. This extended exactly to the middle line of the
trunk in front. Posteriorly it ended along a line behind the level of
the anterior border of the axilla. This area was darker than the rest
of the skin of the trunk, and scattered over it there were a large number
of small atrophic spots of white colour. These spots measured from
J in. to i in. in diameter. There were also three or four larger dark
sclerosed areas. It was noted at the time that there were marked
atrophic as well as sclerotic changes.
During the last three months the diseased area has increased and
fresh areas have appeared. The dark area with atrophic spots on the
left side of the trunk now extends from just below the ribs to near
Poupart’s ligament. There is no spot on the back. A new area has
appeared on the right side of the trunk. It is about as large as the
palm of the hand, and its upper border is on a level with the umbilicus.
This shows atrophic spots only. On the thigh a new area of pigmenta¬
tion with atrophic spots has appeared between the upper margin of the
long band of morphoea and Poupart’s ligament. The thigh and leg are
in much the same condition as when he was seen before, and there is
again an area of ulceration due to slight injury. It is noteworthy that
the patient has been under observation the whole of the time, and the
new spots have appeared without any previous sclerosis, that is to say,
the spots have been, so far as could be judged by regular inspection at
least once a month, atrophic from the beginning.
92 Sequeira: Case of Granulomatous Sivellings
Case of Granulomatous Swellings at Left Angle of Mouth
and in Right Inguinal Region.
By J. H. Sequeira, M.D.
The patient, a negro from Antigua, was shown in February with a
large granulomatous tumour at the left angle of the mouth and a linear
patch of granuloma in the right inguinal region (granuloma inguinale
tropicum). 1
The tumour at the angle of the mouth and the granulomatous
swelling in the groin have entirely disappeared under the X-rays. In
the course of eight weeks seven pastille doses (measured by the pastille
of Sabouraud and Noir£) have been administered. This is equivalent
to about thirty-five Holtzknecht units given in the eight weeks. The
exhibitor mentioned that previously to giving the X-ray treatment the
patient had been taking large doses of iodide of potassium without any
benefit. While the X-rays w r ere being given no other treatment was
adopted beyond the application of protective dressings of zinc oxide and
lanoline and vaseline spread on lint.
Case of Multiple Xanthoma of the Face of the Diabetic Type
in an Infant.
By F. Parkes Weber, M.D.
The eruption is confined to the forehead and upper part of the
face. It consists of irregularly distributed papules and raised spots,
measuring 1 mm. to 7 mm. in diameter, and varying in colour from a
brownish red to a dirty pale yellow. When the blood is squeezed out
of the red spots a yellowish discoloration of the skin is left. The smaller
papules, such as those on the left lower eyelid, are the most elevated and
the most yellow (least reddish) in appearance. There is no itching or
pain or tenderness associated with the eruption, which was first noticed
about four months after the child’s birth. There is no factitious
urticaria. The patient, John H., now aged 10 months, seems well in
all other respects, and has apparently never been ill. He has taken no
medicines, such as bromides. Microscopic examination of one of the
Proc. Roy. Soc. Med., 1908, i., No. 5 (Derm. Sect.), p. 57.
PROC. ROY. SOC. MED.
Dermatological Section.
Vol. I. No. 8.
Granulomatous Tumour at left angle of mouth.
SEQ VKIRA : Case of Granulomatous Swellings.
Dermatological Section
93
spots showed merely an excess of connective tissue cells beneath the
epidermis, but the lesion which was examined was probably an imper¬
fectly developed one. At present the eruption seems to be practically
non-progressive, and no fresh spots have appeared recently or, according
to the mother, for a good time.
Dr. Weber added that the section under the microscope was from an
early lesion, and did not show much beyond connective tissue cells.
There had been no itching of the skin, nor anything of the kind before.
He believed the lesions were now increasing in number.
The PRESIDENT said Dr. Weber’s case did not follow the type of xanthoma ;
the lesions looked more like urticaria pigmentosa. Itching was not always
present in urticaria pigmentosa.
Case of Disseminated Lupus with Chronic Lymphangitis of
the Face and Osteo-arthritis of the Hands.
By A. Whitfield, M.D.
The history of the patient, a woman aged 28, showed that before
she was aged 7 she had had abscesses in the neck which had burst
or been incised, and had healed, leaving tubercular nodules in the scars.
Ten years ago she had been laid up with a violent attack of erysipelas,
which had rendered her severely ill for nearly three months. Two years
later she had another attack, which laid her up for three weeks, and since
then she had had many slight attacks which did not lay her up.
On exhibition there were to be seen, on both sides of the neck, scars
in which W’ere scattered, flat, brownish lupus nodules with practically no
hyperaemic redness around them. Several nodules were to be seen
scattered about the cheeks in the otherwise sound skin. There were
about half a dozen on the left cheek over and above the angle of the jaw,
one or two on the right side, and one on the lobe of the right ear. The
nose was distinctly swollen and red and the surface was scaly, while at
the junction of the left ala nasi and lip there was a persistent fissure,
from which, no doubt, the recurrent streptococcic infection took place.
The upper lip was greatly swollen and thickened, but not reddened, and
the mouth remained open with a curious pouting expression. The
carpal, metacarpo-phalangeal and inter-phalangeal joints were swollen
and contained a great deal of fluid, and there was marked atrophy of the
interosseous muscles. When first seen the opsonic index to tubercle was
ju — 4b
94
Whitfield: Case of Disseminated Lupus
0 85, and that to staphylococcus 0‘5. The streptococcus had not been
isolated, though several attempts had been made to do so.
The patient was treated with staphylococcic vaccine and later with
tuberculin, and a certain amount of improvement had taken place; but
it was difficult to estimate it as the condition varied too much.
Dr. Whitfield said he thought that the condition of the joints was
probably consequent on the repeated streptococcic infection.
DISCUSSION.
The President asked whether there was an attack of lymphangitis before
the lupus condition. The erysipelas toxin might have been the means of setting
the tubercle free.
Sir Malcolm Morris said he had recently, from Egypt, a case of strepto¬
coccal infection of similar type, and it terminated in erythematous lupus as soon
as the oedema began to go down. There seemed to be evidence of the original
condition starting in the erythematous lupus.
Dr. WHITFIELD said, in reply, that he thought the President’s suggestion
was correct. The patient had mild attacks every week.
Dr. Winkelried Williams showed a case of lupus erythematosus
saccharo-mycetiform, governing lines of growth, and band alopecia.
The President said he did not regard lupus erythematosus as a tuberculide.
It was probably toxic, the origin being the bowel. The case was an interesting
type of the disease.
Dr. Radcliffe Crocker showed a drawing of a case for diagnosis.
Dr. Crocker explained that the case was so far advanced towards cure
that there was very little to show. He had never met with an exactly
parallel case. The stained sections were not yet ready, and Dr. Bunch
had succeeded in, obtaining only staphylococci. If anything further was
to be learned from staining Dr. Bunch would communicate it. The
duration of the case was one year. He had cleared out the comedones
and used local bactericides, and the patient seemed to be in a fair way
to recovery.
Dermatological Section.
June 18, 1908.
Dr. Radcliffe Crocker, President of the Section, in the Chair.
Granuloma annulare.
By E. G. Graham Little, M.l).
A considerable number of cases have been reported of a type of
disease concerning which there is a great diversity of opinion and a
corresponding diversity of nomenclature. The names under which
these cases have been described—if they are all accepted as of the
same type—are as follows: ringed eruption (Colcott Fox, 1895), erup¬
tion circin^e chronique de la main (Dubreuilh, 1895), lichen annularis
(Galloway, 1899), granuloma annulare (Radcliffe Crocker, 1902), sarcoid
tumours (Rasch, 1903), n^oplasie circin^e et nodulaire (Brocq, 1904),
erythemato-sclerose circin£e du dos des mains (Audry, 1904), tumores
benigni sarcoidei cutis (Galewski, 1908). I propose in the following
paper to discuss the question of the relation of these cases one to
another, and their common symptoms, for I personally now believe
that all the cases are related.
I am naturally reluctant to differ in this point from the expressed
opinions of Dr. Radcliffe Crocker and Dr. Galloway, who have main¬
tained the differentiation of these two types of cases ; Dr. Radcliffe
Crocker, however, has recently confessed to his keeping an open mind
as to the possible future identification of the disease which he called
“ granuloma annulare ” with the disease called by Galloway “ lichen
annularis,” and it is obvious that all the other recorded cases fall into
one or other of these two categories.
Correction .
In the last issue of the Proceedings (No. 8), Dermatological Section, p. 83, Dr. Parkes
Weber’s remarks applied to another case shown by Mr. Hartigan, and not to the case to which
they are attached.
Note .—With regard to Dr. Sequeira's case, p. 92: As the illustration in this case is the first
of its kind that has ever appeared, Dr. Sequeira thinks it desirable to state that the plate was
made from photographs, in three colours, taken direct from the patient, by Dr. Arnold Moritz.
iy —i
96
Graham Little: Granuloma annulare
I have had, as I think, six instances of the disease under my own
observation, and have seen several other of the cases described in the
synopsis submitted in the appendix. I have also, by the kindness of
individual friends (whose favour is in each instance acknowledged),
had opportunities of examining sections of eleven cases other than my
own, and of my own in four out of the six cases, so that in fifteen
cases I have been able to compare the histological appearances. What
I have to say, therefore, is founded very largely on my own observa¬
tions, both clinical and histological, and I have, at any rate, convinced
myself that it is possible to reconcile the differences indicated in the very
diverse terminology adopted, and that it is worth while trying to do so.
Accepting the identity of the affections under the disguise of this
plurality of names, six memoirs of importance have been published on
this subject—those of Galloway (1899), Badcliflfe Crocker (1902), Rasch
(1903), Audry (1904), Brocq (1907), and Galewski (1908). Brocq closes
his description of the disease with these words : “ II est done impossible
de dire a l’heure actuelle s’il s’agit 14 d’une affection bien definie, ou
de plusieurs dermatoses ay ant un aspect 4 peu pres identique; e’est
une question 4 reprendre de fond en comble.” In order to enable
the reader to make as complete a survey as possible of this field of
disease I propose to offer a short abstract of all the cases hitherto
published, and to add detailed descriptions of those cases as yet un¬
published which have been communicated to me by the kindness of
friends, and of those cases which have come under my own observa¬
tion; these latter I shall reserve to the end of my paper. It will
be noted that I have excluded from my list a series of cases recorded
by Jonathan Hutchinson, sen., which are included in Dr. Galloway’s
collected examples of the disease, published in 1899. No histological
investigation of these cases was made, however; the notes are scanty,
and the clinical facts observed do not, to my mind, justify their
inclusion in the same category as the cases I am about to describe,
while the absence of histological detail leaves their nature quite
problematical.
Report of Cases. 1
I. Colcott Fox (British Journal of Dermatology , 1895, p. 91)
(February 13, 1895). A girl, aged 11, with “an unusual ringed erup¬
tion on the fingers.”
1 The figures in Roman numerals refer to the number of the respective case in the
synopsis, the figures in ordinary numerals to the number in the series of the individual
observer.
Dermatological Section
97
On the flexor aspect of the left ring Anger there was a ring of eruption
extending from the proximal phalanx to the distal phalanx and half-way up
the sides of the finger. This oval ring was characterized by a smooth, rounded,
projecting border, white in colour, doughy in consistence, quite i in. wide
and Yt in. in height. The enclosed area was normal, or perhaps a little
reddened. There were no subjective symptoms except that the border was
slightly tender on pressure. On the little finger of the right hand was a
similar ring, but rather smaller, and broken up in places into rounded nodules.
The affection was cutaneous, and seemed to involve all the layers of the skin.
The mother stated that the rings each began in a nodule, before Christmas,
and gradually extended peripherally. There were no rheumatic nodules, and
the only suspicion of rheumatism was some slight aching in the shoulders
after walking. She had never suffered from rheumatic fever.
Fox considered the case an indolent form of inflammation, “ allied to
erythema elevatum diutinum.”
II. Colcott Fox (.British Journal of Dermatology , 1896, p. 15) (De¬
cember 11, 1895). Kinged nodular eruption in an infant, aged 2.
On November 30 there were twelve or fifteen ringed erythema-like lesions,
up to the size of a thumb-nail, on the buttocks and backs of thighs. They were
in all stages, from a nodule the size of a split pea to the full-formed lesion ; these
were in the substance of the skin, felt thick, and projected slightly. They were
indolent throughout, discrete, perfectly smooth, of a dull red colour, and de¬
pressed or “ atrophic ” (?) in the centre. The mother said the lesions appeared
in the very hot weather—she thought in August—and none had gone away.
She pointed out two recent lesions not yet ringed. The child was well nourished
and healthy. On December 7 the eruption was declining and the continuous
border breaking up into papules.
III. Dubreuilh’s first case, “ eruption circinee ehronique de la main ”
(Ayinales de Dermatologie , 1895, p. 355).
The patient was a woman, aged 33, in fair general health but nervous and
constipated, with no past illnesses of importance but some family history of
rheumatism. She had suffered from chilblains up to the age of 16.
The disease had commenced five years previously with hard, pale swellings
on the radial edge of the two index fingers and the left thumb. These slowly
grew larger eccentrically, the skin becoming depressed in the centre, but this
finally returned to normal state. Within the previous four or five months new
lesions had appeared as lenticular patches on the dorsal surface of the first
phalanx of the index and middle finger of both sides. These swellings were
the size of a lentil, slightly paler than the normal skin, rounded, about 1 mm.
high, and covered by true epidermis, which was slightly scaly. The raised
edges were surrounded by a reddened border as hard as keloid, movable with
the skin, and completely painless. On the left index finger the lesion formed
98
Graham Little: Granuloma annulare
nearly a complete circle about 4 mm. large; on the left middle finger a semi¬
circle 2 mm. in diameter and on the middle finger and thumb segments of a
circle of 1 cm. to 3 cm. in diameter. All the lesions disappeared rapidly under
the use of ung. ichthyol., followed by Vidal’s ointment.
The section taken from the left middle finger (and therefore of recent
appearance) showed little change in the epidermis; the granular layer in
the section of the raised edge was diminished, the other layers of the rete
were normal. The epidermic interpapillary growths were flattened and the
papillae flattened and widened. In the middle zone of the corium there was a
focus of diffuse cell infiltration, the cells being large, rich in protoplasm, and
approximating to the fixed connective tissue cells ; very few mast-cells were
seen and no giant-cells. This focus of infiltration respected the superficial layer
of the corium and the deeper layers, the sweat-glands being unchanged. The
connective tissue and elastic tissue did not appear altered, the cells being in
masses between the connective tissue fibres. In the central part of the focus
of infiltration the nuclei coloured imperfectly, but the connective and elastic
tissue continued unaltered in this zone (coagulation necrosis). No micro¬
organisms were discoverable by methylene blue, polychrome blue, or Gram-
Weigert.
Dubreuilh considered the nearest analogue of this affection was
lupus erythematosus, but points out that the clinical aspect of the
latter disease when occurring on the hands does not recall in any
way the appearance of this case.
Dubreuilh’s subsequent cases [Annales de Dermatologic, 1905, p. 65).
IV. Case 1.—H. B., aged 19 months. Good family and personal history.
Disease had commenced four months previously with a group of papules, white,
hard, smooth and umbilicated, over the tendo Achillis on both sides. They
were not painful or itchy, and disappeared within two months. Fresh lesions,
however, appeared, about fifteen altogether, of the same type—ringed and cir-
cinate groups, situated on the front of the knees and the legs. The enclosed
skin was slightly depressed, a little purple, but otherwise normal. On the right
leg one of these patches, the size of a franc piece, showed a centre not depressed,
hut raised above the level of the edge with hardened sclerodermic skin, and a
deep infiltration below the patch, of the consistence of a lipoma.
Upon the palmar surface of the right index there w T as a group of these
nodules, not ringed. Upon the right temple there was a subcutaneous tumour
the size of a pea, hard and adherent to the periosteum (exostosis?). A year
later other lesions had come on the feet and over the mastoid and on the fore¬
arm. Two types were distinguished in this case : (l) Superficial ringed patches
on the feet, and (2) deep-seated nodules. The latter were of pasty consistence,
not adherent to periosteum, but in the substance of the skin. There seemed a
tendency to recrudescence in spring during about three years, the. individual
lesions lasting a twelvemonth or more. The lesion left no mark in disappearing.
Dermatological Section
99
V. Case 2.—N. C., aged 26, a nervous but healthy woman. Disease had
commenced four to five years previously with a white, hard pimple in the third
interdigital space. This initial lesion grew peripherally and became depressed
in centre, and disappeared, apparently spontaneously, in two months. Others
appeared on the left index and back of left hand. They were quite painless
and non-itchy, but when pressed laterally gave a sensation of pricking. They
disappeared without scarring.
VI. Case 3.—G. S., aged 18, in good health and with no family disease.
The disease had commenced two years previously on the left hand, and had
involuted when seen, but new lesions in the form of rings had appeared on the
index; the rings were made up of small papules, hard, pale, ill demarcated, and
forming part of substance of the skin. They were absolutely indolent, and even
less sensitive than normal. This eruption disappeared within two months, but
a year later fresh lesions came on the left index, which on pressure gave a
sensation of pain as well as of pricking.
VII. An unpublished case of Dubreuilh’s (communicated).
Boy, aged 3, well developed and healthy. When seen he had two nodular
indolent circles. Disease had commenced eighteen months previously on the
radial edge of the left hand, with a hard nodule which disappeared after some
months. Some time later another lesion, a circle of nodules, made its appear¬
ance on the back of the same hand at the level of the metacarpo-phalangeal
joint of the index. This circle was of the size of a lentil, 20 mm. by 15 mm.;
it had persisted without enlarging for some time ; it varied in the sense that it
was more noticeable at certain times than at others, but it had never disap¬
peared during the previous eight months ; the circle had, however, greatly
enlarged eccentrically, and had become bilobed so as to almost form two circles
intersecting; and at the point of intersection, which corresponded to the initial
site of the lesion during the previous month, there had appeared a nodule as
large as a hemp seed and more prominent than the rest of the lesion. The edge
of the circle was about 2 mm. to 3 mm. wide, hard and prominent; its colour
was slightly paler than the surrounding skin and the epidermic covering ; it
seemed somewhat smoother than normal, probably because stretched, without,
however, having lost the natural folds or markings of the skin, which remained
visible with a lens. '
The edge was perceived by palpation to be made up of a chaplet of hard
nodules more or less confluent, of the size of a millet-seed, and of a nearly
cartilaginous consistence, situated in the superficial layers of the skin, and
embodied in it, the skin below and around being perfectly normal. The area of
skin enclosed by this edge was perfectly normal, except that in one place there
was a nodule larger than those forming the edge and of the same type. There
was not the slightest infiltration or redness of the surrounding skin. The lesion
vr&s absolutely indolent, and neither itching, nor pain, nor tenderness was felt.
Over the right olecranon process there was an indolent subcutaneous nodule
the size of a lentil, perhaps slightly adherent to the bone, independent of the
100
Graham Little: Granuloma annulare
skin, which was normal. It was difficult to feel, and formed a slight relief
when the part was stretched by forcible flexion of the elbow. The child was
otherwise in perfect health. The father was rheumatic. The mother had been
subject to migraine and urticaria for eighteen months. The child Was treated
with syrup of orange and sodium iodide.
Professor Dubreuilh kindly sent me several sections from this case,
examination of which showed [see fig. 1) :— ' I
a Sweat-coils with infiltration.
b Nodule of necrosis.
c Broken up collagen with diffuse infiltration.
d Stratum corneum thickened.
c Rete thickened.
Section stained with cochineal-alum. (Lent by Professor Dubreuilh.)
De rma to logic a l Sec tio n
101
The stratum comeum, granular layer and rete are all much thickened.
There is a dense infiltration of cells in the middle and lower parts of the corium.
The cells are in places diffusely scattered between the fibres of the collagen, in
other places grouped in densely packed masses surrounded by collagen. The
cells are largely composed of connective tissue corpuscles and large mono¬
nuclear cells. In one cell-mass of this kind, forming a microscopic nodule,
the centre is degenerated and stains poorly, both as regards cells and con¬
nective tissue (necrosis). The sweat-coils seem rather large, and are sur¬
rounded by proliferated cells. The fat-zone was not included in the section.
The appearance of the corium in this section is very like that of Case XLIV.,
p. 132. The thickening of the epidermis is unique in this case, as well as the
increase of the granular layer.
VIII. Galloway’s case {British Journal of Dermatology, 1899, p. 221)
(first seen November, 1898).
Patient, was a boy, aged 10, pale, undergrown, and subject to fits up to the
age of 6. Never had rheumatism, and no family history of rheumatism. No
visceral disease detected. The skin-lesions had persisted for at least three
years, and had commenced as nodules near the knuckles, and had slowly spread
to form rings consisting of a pale white elevated border showing circular or
circinafce outlines ; the border was raised 1 mm. or 2 mm. above the skin and
was about 3 mm. in breadth : it was smooth and did not present evidence of
increase of epithelium nor of papillomatous structure ; it was not reddened ; it
had the aspect of deep-seated infiltration of the cutis. The area of skin enclosed
within the ring was apparently normal, but on more close examination was
distinctly altered, normal wrinkles being no longer obvious, and slight signs
of atrophy being present. The lesions had commenced as small papules or
nodules in the centre of the areas afterwards affected, and had advanced by
peripheral increase. The distribution was chiefly on the dorsal and lateral
aspect of the fingers, the thumb, index and third finger of right, and thumb,
index, third and fourth of left hand. One such lesion occurred on the pinna
of the left ear.
He was treated with salicylic acid ointment and cod-liver oil internally.
He improved, and within six months (May, 1899) the eruption had almost
completely vanished. But three years later (May, 1902) this patient was again
shown by Dr. Galloway with the history that the eruption had reappeared,
chiefly on the fingers and with the same features as at the previous exhibition.
Histologically the lesion was found to consist of an infiltration of cells in the
corium below tbe papillae, the cells being arranged in clumps. The infiltration
became less dense towards the hypoderm, but more profuse in the neighbour¬
hood of the coil-glands. The cells were larger than ordinary leucocytes, rounded,
and with a considerable quantity of protoplasm surrounding the nuclei. Others
were elongated or spindle-shaped like connective tissue cells. Mast-cells were
not numerous. There was great accumulation of cells, constituting a nodule,
and the central area was apparently degenerated. Connective and elastic tissue
102
Graham Little: Granuloma annulare
were partially displaced by the cell-masses, but were present even throughout
areas in which degeneration had occurred (see fig. 3).
Dr. Galloway kindly lent me a photograph and a section from this
case, which he has allowed me to reproduce (figs. 2 and 3).
Galloway considered the analogies with lichen planus to be the
nearest, and hence gave the name lichen annularis to this group, care¬
fully differentiating it in a footnote from lichen planus annularis (loc. cit.).
Fig. 2.
Dr. Galloway’s case.
liadclitfe Crocker's cases (British Journal of Dermatology, 1902, p. 1).
IX. CASE 1.—Male, aged 20, in good health. Disease had commenced
four years previously on right wrist and extensor aspect of root of thumb, with
flat nodules the size of a split pea, pale red, and slightly itchy. Fresh lesions
appeared on the back of the right and left hand, and on the fingers, on the scalp,
Dermatological Section
103
on the nape of the neck, over the mastoids, on the right ear, the right inner
canthus and the right lower jaw. The patches were made up of “ aggregations
of papules ” of a violaceous colour, finely scaly ; they underwent involution in
the centre and formed irregular gyrate patches. All patches showed a narrow
red areola ; some became yellowish in colour as they faded.
The patient was thin, and not strong, but showed no definite illness. Five
sisters and one brother had “ weak chests,” but no deaths from phthisis were
reported.
Fig. 3. (Drawn with camera lucida.)
Dr. Galloway’s case. (Leitz objective 3; ocular 2.)
a Sweat-coils with infiltration.
b Vessel with infiltration,
c Hair shaft.
Section stained with polychrome methylene blue. (Lent by Dr. Galloway.
Dr. George Pernet was good enough to lend me two sections
prepared by him from this case, examination of which showed the
following features (fig. 4) :—
The stratum corneum, the granular layer and rete generally are slightly
thickened. There is a dense cell-infiltration in the pars reticularis and
104
Graham Little: Granuloma annulare
hypoderm, the zone containing sweat-coils being especially involved. In this
part there is an area of apparent destruction of tissue in the middle of a nodule
of infiltration ( b ). Fat-lobules were not included in the section. The infiltration
became less dense towards the upper part of the section. There were clumps of
cells surrounded by connective tissue (c) in this part and a less marked, not
aggregated infiltration, chiefly around vessels in the papillary body. The cells
appeared to be connective tissue and mononuclear cells. No plasma-cells were
seen in sections specially stained for them. The elastin was not stained in
either of the sections submitted.
Fig. 4. (Drawn with camera lucida.)
Dr. Radcliffe Crocker’s case, No. IX. (Leitz objective 3; ocular 2.)
a Sweat-coils with infiltration.
b Area in which feeble staining occurs (destruction of tissue),
c Clump of cells, walled in by collagen.
d Thickened rete and stratum corneum.
Stained with ha?matoxylin-eosin. (Section lent by Dr. Pernet.)
Dermatological Section
105
X. Case 2.—Male, aged 21. Had had ordinary warts for two years.
Lesion, when seen, was a gyrate patch with raised border of yellowish white
colour, and with red areola, situated on back of right hand ; this had commenced
as a “ mattery head,” which had been picked, and had scabbed over. There
was also a patch at the root of the right thumb, an annular patch made up of
hemp-seed-sized papules : a nodule just above this ; a group of nodules on the
nape of the neck.
One brother had died of phthisis, aged 21. The patient showed no sign
of ill-health.
XI. Case 3.— Female, aged 5*2. Disease had been present two months;
lesion consisted of circinate groups of papules and isolated nodules, partially
coalesced and with depressed central area ; one patch had come out “ within
three or four days.” The situations were the left wrist, the nape of the neck,
the ulnar border of the palm.
The patient was bronchitic : her father, mother, sisters, and three of her
eleven children had died of phthisis.
Three months later one portion of the patch on the wrist had inflamed,
apparently as a result of laundry work, and had become suppurative. No new
lesions had appeared, but the original area had enlarged. Salicylic and creosote
plaster seemed to have effected a cure three months later.
XII. Case 4.—Male, aged 11. Disease had lasted a year ; the first lesion
was a flat wart, or described as such ; it enlarged slowly and formed a ring.
When seen there were white nodules and papules forming rings, with a pink
border and dusky red, slightly atrophic centre. Some of the papules formed
irregular, not ringed, groups. The situations were the left and right elbow
(where the disease began), the wrists and the knees. The disease was cured
with Beiersdorf s mercurial plasters. The patient had had sunstroke, but was
healthy. Gouty (paternal) history. No mention of tuberculosis.
XIII. Case 5. —Crocker and Pernet. Male, adult. The lesions consisted
of a circinate patch made up of nodules on the metacarpo-phalangeal joint of
right index: the duration and subsequent history are not given.
XIV. Case b.—Young adult male. Circinate lesions on backs of both
hands and outer side of left index finger. The border was formed by elevated,
smooth outline of bluish red colour, enclosing areas of skin more pigmented than
normal, and showing slight signs of atrophy. No details are given of personal
or family history, duration of disease, or result of treatment.
Pringle’s cases.
XV. Case 1 (British Journal of Dermatolonu , 1899, p. 435). —Male,
aged 18. Family history good and personal health excellent.
Disease had commenced with a circular patch £ in. in diameter, composed
of ten abruptly raised papules or nodules averaging the size of half a split pea,
firm to the touch, blight pink in colour, obtuse at summit, which was capped
106
Graham Little: Granuloma annulare
with thick, white, epidermic scales, their general appearance being distinctly
“ warty.’* The skin intermediate between nodules was normal in colour, but
its natural lines were perhaps somewhat deepened. The skin surrounding the
lesion was absolutely natural in every respect.
Three similar nodules, arranged in a line, existed immediately behind the
left angle of the jaw, and half a dozen were arranged in crescentic fashion so
as to form a fairly accurate semicircle behind the angle of the jaw on the
right side of the neck. On the back of the right wrist was a horizontal
band £ in. in length and about 1 in. in width, made up of very flat papules,
angular in outline, pale greyish pink in colour, and shiny at the top, resembling
a series of verrucae planae, or the warty type of lichen planus. Over forehead
in both temporal regions, and extending about 2 in. into the scalp, were more
than twenty distinctly inflammatory papules, not grouped, with adherent dry
scales and of warty appearance.
The patient stated that the “ spots ” had appeared on the neck eight months
previously, and that the grouping became noticed four months later and had
remained unchanged for four months. The other lesion had come later. There
was occasional itching.
In the discussion which followed the exhibition Dr. Radcliffe Crocker is
recorded as having identified this case as similar to the cases pictured by
him in his “Atlas ” as variants of lupus erythematosus, with some resemblances
to lichen planus; Dr. Galloway as having thought the wrist lesions might be
an early stage of the condition described by him as lichen annularis.
No sections were obtained in this case.
XVI. CASE 2.—This was a boy, aged about 10. Shown at the Dermato¬
logical Society of London on the same day as my case of H. M. (p. 130), and
it was recognized by all present that the two children had the same disease.
The boy had ringed lesions of exactly the same type as the girl, some of
which were situated on the thighs as well as on the hands. Notes of the
case were mislaid or lost, so that no details could be furnished, and lie was
not apparently seen again ; but a section was procured from one of the lesions,
and I owe to Dr. Whitfield the gift of one of these sections, examination of
which showed (fig. 5):—
The epidermis was unaltered. The section showed very little beyond
distinctly enlarged sweat-coils, round which a slight cell-proliferation was
visible. With a low power it gave the appearance of a nodule in the deepest
part of the coriurn, and from this as a centre a few rows of cells extended
upwards into the upper part of the cutis. The cells were chiefly connective
tissue cells.
XVII. Dr. Sequeira’s case (British Journal of Dermatology , 1902,
p. 270). (Dermatological Society of London, June, 1902.)
CASE 1.—Male, aged 28, with “ ringed eruption ” upon dorsal surface of hands
and fingers, which had begun two and a half years previously. There was
Derma tological Section
107
history of phthisis on the mother’s side : the patient himself was pale and thin,
suffering from indigestion and bad teeth, and showing symptoms of cardiac
disease. On the dorsum of both hands there was an irregularly oval patch,
about the size of half a crown; the centre of each patch was “ somewhat
atrophic,’* and round the margin there were closely set, smooth, pale red
“ spots,” free from scales, measuring from xV in. to i in. across, circular, not
angular as in lichen planus. Similar, but smaller, ringed patches were present
on the dorsum of both middle fingers, and two smaller and more recent
“ spots ” on the back of the right middle finger.
No histological examination was obtained. Dr. Sequeira, in a letter dated
March, 1908, writes: “I did not see the patient again after the meeting
Fig. 5.
Pringle’s case. (Leitz objective 3; ocular 2.)
a Dilated sweat-ducts and coils with slight cell-infiltration.
b Vessel.
c Vessel with infiltration.
Stained with rubin-orange-lnematoxyliu. (Lent by Dr. Whitfield.)
108
Graham Little: Granuloma annulare
(June, 1902), but some six months later, wishing to show the case to my
class, I wrote, and the patient came to see me at the hospital. The lesions
had entirely disappeared, apparently spontaneously. There had been no
treatment.”
Dr. J. H. Sequeira has furnished me with notes of the following
additional cases:—
XVIII. Case 2.—F. H., aged 8 (tig. (i). A characteristic example of
“ granuloma annulare.” The mother was indefinite as to its exact duration,
but it had lasted “several months.” When seen in June, 1904, she had a
Fig. 6.
ringed lesion, the size of a shilling, on the dorsum of the right index finger,
just below the nail; the ring was composed of nodules, the enclosed central
area being smooth. There were no subjective symptoms. A larger patch,
the size of a two-shilling piece, was situated on the back of the same hand,
below the cleft between the index and middle fingers. This patch also
consisted of nodules forming a ring. There was another ring, the size of a
sixpence, composed of nodules, on the back of the right wrist. There was a
Dermatological Section 109
ring, the size of a shilling, on the back of the left hand, with exactly the
same characters.
The patient was ordered to rub ung. acid, salicylic, into these lesions, and
the disease completely cleared up in less than a month.
XIX. Case 3.—D. B., a Polish woman, aged 21. She was seen on
December 12, 1907, when the disease had lasted for eight months. When
seen there was a ring, the size of a two-shilling piece, on the hack of the
right wrist, and a similar hut slightly smaller ring on the back of the left
wrist. There was also a ring on the knuckle of the index finger at the
junction of the proximal and the next phalanx. This had the same characters
as the other lesions—a ring, composed of nodules, with non-atrophic centre.
No irritation was complained of. This patient was seen only once. Ung.
hyd. oxid. rubr. was ordered, and the case presumably resulted in a cure.
XX. Case 4.—A Polish girl, aged 8, seen on February 19, 1907, in
whom a diagnosis of “ ringed eruption ” was made, but with some reservation.
There were ringed patches on the palms of both hands and on the front of
each ankle. No history was obtained as to the actual duration of these.
There was some irritation in connection with the patches, and a liniment of
menthol was ordered. The patient did not attend again.
XXI. Rasch and Gregersen’s case ( Archiv fib * Dermatologic , 1903,
Bd. lxiv., p. 337).
Patient was a female, aged 33, with a good family history. The patient
herself was conspicuously nervous, but otherwise well. No symptoms of
tuberculosis. Eight years previously she had had, on the dorsal surface of
left index, a whitish tumour of the skin, which she had destroyed herself
with acid after it had lasted for a year. There was a round, white scar left
by this lesion, of about 1 cm. in diameter. For six years after she had nothing
the matter with the skin, then there appeared again similar tumours on the
fingers of the right hand. These began as quite small white prominences
in the skin ; some of them grew slowly to a cross section of about 1 cm.,
others involuted spontaneously, after lasting some months, without leaving
any distinct mark or scar. There was no itching or smarting or subjective
sensation of any kind. Patient was fair, pale, and rather thin. Examination
showed nothing abnormal, with the exception of the condition of the fingers.
Here there were four little swellings, which were all on the dorsal surface
of the fingers of the right hand. On the index, between the first phalanx and
the knuckle and between the first and second phalanges respectively, there
were two tumours, the first about 4 mm. in diameter and the second 1 cm.
in diameter. On the medius was found one small tumour, about 5 mm. in
diameter, and at the base of the little finger a swelling about 1 cm. in
diameter. In the centre it showed an almost entire regression and so formed
a ring. The skin within the ring was smooth, faintly atrophic; all the
nodules were dry, white or whitish yellow in colour, like old ivory, with
110
Graham Little: Granuloma annulare
smooth, wax-like, shiny summits. They had their seat in the substance of
the corium, and were movable on the underlying tissue. The only trace left
by the tumours was a lentil-sized spot where the skin was slightly atrophic.
Nine months later the patient wrote that all the tumours, which had
afterwards grown somewhat larger, suddenly entirely disappeared during a
feverish attack of undetermined nature, leaving pale red spots.
Microscopic Examination .—A piece of skin carrying a ring-patch was
excised from the base of the fifth finger, was fixed in formol-Miiller, hardened
in alcohol, imbedded in paraffin, and serial sections cut and stained with
von Gieson-Hansen, with haematoxylin-eosin, with thionine, with elastic-fibre
stains (Unna-Taenzer), with protoplasm stain of Unna, and with Ziehl-Nielsen.
In the peripheral part of the tumour there were found in the earlier sections
in the true skin anastomosed blood-containing vessels. Their endothelium
was natural and the wall quite thin. They were surrounded by a cell-
mantle, partly consisting of round-cells, partly of cells of the type of con¬
nective tissue. Some of these cells had long, spindle-shaped small nuclei,
and their appearance did not differ from the usual connective tissue cell.
Others were plumper, with round or oval nuclei. These vessel-containing
connective tissue strands lay in the cutis proper, while the papillary body
showed nothing abnormal; it was separated from the strands of cells already
described by a normal-looking, thin connective tissue stratum. If one followed
these strands to the tumour-mass one found that the perivascular cell-infil¬
tration gained in breadth and formed a thick sheath on the finer vessels.
Little masses of round-cells were seen between the connective tissue, which
was also greatly increased in quantity. Between the connective tissue bundles
there were also lines of cells which had quite the same aspect as those around
the vessels. These cell-infiltrations in the meshes of the connective tissue
were more strongly defined the further one got to the centre of the nodule.
These cell-rows were in connection with the vessel-bearing rows of cells in
the periphery of the tumour, and contained often quite small vessels, which
consisted of a simple endothelial tube. The endothelial cells were always
normal, without sign of proliferation. The cell-forms in the central part of
the tumour were of extraordinarily manifold shapes ; cells with round or
oval nuclei were in preponderating number, also pear-shaped cells with plump,
rod-like, crooked, and other kinds of nuclei. All these nuclei had a finely
granulated protoplasm in which single or few dot-shaped distinct nuclear
bodies were found. The cell-body was also of varying forms ; often it was
quite big, with distinct protoplasmic processes, which were sometimes short,
sometimes long and fine. Often the cell-body was spindle-shaped, or it formed
a small collection round the nucleus, slightly filamentous at the edge. Mitotic
figures were not observed, but many cells contained two nuclei, one being
often placed alongside the other.
Occasionally one found bigger cells that contained as many as four nuclei
which partly covered one another. True giant-cells were not observed any¬
where. By reason of the accumulation of cells the connective tissue bundles
Dermatological Section
111
were dissociated and were found as thinner or thicker divisions between the
cell-masses, and merged without any sharp demarcation into apparently normal
tissue. In preparations stained with von Gieson-Hansen very fine connective
tissue fibres were found between the cells, a sparse inter-cellular substance
forming.
On examination with an immersion lens it would appear as if these fine
connective tissue fibres were formed from cell-processes. Normal connective
tissue cells were not met with in the cell-masses, and it seemed altogether
as if not only the perivascular (lymph space) connective tissue cells proliferated,
but that also the connective tissue at some distance from the vessels took
part in the process.
Besides the already named changes, one found, in the deeper part of the
tumour-tissue, irregularly formed areas in which the cells had undergone
destruction. The necrosis became more marked and deeper the more one
penetrated into the tumour tissue; moreover, it appeared with greater irregu¬
larity in that it showed bigger or smaller foci. In these places were found
extensive myxomatous metamorphoses. Thread-like masses were seen in the
peripheral part of the necrotic areas, which showed mucin reaction with
thionine. The mucous degeneration of cells became more marked the further
one got into the central part of the necrosed area, and mucin formation in
the cell-body was visibly accompanied by a disappearance of the cells, in
that the contours of these became less distinct and disappeared, and the
nuclei became paler and split up into granules and dispersed, so that in the
centre of the necrosed areas one found only thread-like mucin-masses that
here and there contained debris of nuclei. Between these mucin-masses
were found connective tissue bundles that showed up sharply as light blue
trabeculae between the red-violet mucin-masses, and therefore did not appear
to have undergone myxomatous changes. The transition of the necrotic areas
to the living connective tissue was not well defined.
In the last of the serial sections one found only on one side of the section
the already mentioned cell-proliferation, while on the other side of the section
(which contained the central regression of'the ring-shaped lesion) was found
“ partly compact fibrotic, partly loose fibrillar, connective tissue.” This last
part seemed vascularized very much like normal skin, and the vessels were
apparently quite normal, with the exception of a few round-cell masses in
the periphery. In the neighbourhood of the cell-proliferation zone the con¬
nective tissue was infiltrated with rod-like nuclei and with long, thin con¬
nective tissue cells that were continued into fibres. Here the connective
tissue bundles were thickly permeated with small, long clefts. On the other
side one found the connective tissue looser and not so rich in cells.
The transition from the cell-proliferation zone to the described part (which
was about half as thick as the part of the skin containing the tumour) took
place quite evenly and gradually. The masses of the elastic tissue appeared
normal in the places where no cell-proliferation was to be found. The sub-
epithelial meshes in the papillary bodies were everywhere well maintained,
j>J —2
112
Graham Little: Granuloma annulare
and appeared in orcein-stained sections as a plexus with extraordinarily fine
threads. In the places where the cell-proliferations were observed, and
where the tissue was wholly made up of cells, the elastic tissue was entirely
absent. It appeared also to be missing in the necrosed areas, although the
collagen bundles had here not been destroyed. Where the cell-strands were
to be found, and where the diseased tissue appeared between the connective
tissue bundles, one found a not inconsiderable quantity of elastic tissue,
which appeared in several places as if broken into fragments. In other
places, and in the broader bands of connective tissue, it was seen as longer
or shorter, curled or wavy, partly anastomosed fibres.
The small vessels round which the peripheral part of the cell-proliferation
was localized contained no elastic tissue; in the bigger vessels the conditions
were normal. In the epidermis, as well as in the sweat-glands, no patho¬
logical changes were found. No plasma-cells were found. Ehrlich’s mast-
cells occurred occasionally, chiefly in the papillary body; round the vessels
of the sweat-glands single mast-cells were found. Between the proliferated
cells in the cell-rows and in the cell-masses they were not found. There
were no bacteria visible.
Brocq’s cases.
XXII. CASE 1 (Annalrs dr Dermatologic, 1904, p. 1089).—Male “child,”
with “ circinations,” which had persisted for several months on the backs of
the fingers, and partly on the sides and palmar surface ; the rings had a
diameter of 1 cm. to 2 cm. ; their edges were unbroken and enclosed a slightly
depressed central area. Besides the rings there were nodular “patches,”
which were extremely indolent and which grew larger eccentrically, and in
disappearing left definitely “ cicatricial ” appearances. The earliest lesion seemed
to commence with a central wart, according to the maternal history. Vidal’s
plaster produced improvement. The child was otherwise perfectly well. Brocq
remarks at the close of his description that he had considered possible a con¬
nection between these cases and pulmonary tuberculosis, and consequently this
affection “ serait a rapproeher des sarcoi'des.”
XXIII. Case 2 (“ Traite £lementaire de Dermatologie,” ii., p. 277).—
A man ; the affection had lasted for more than a year, and was situated on the
dorsal surface of the fingers and the metacarpo-phalangeal joints. It was
diagnosed as a special form of lupus, and treated with electro-cautery.
XXIV. CASE 3 (ibid.). —A young girl, with lesions on the fingers and
hands; they were cured by the application of creosoted salicylic-pyrogallic
plasters.
XXV. CASE 4 (ibid.). —Girl, aged 8, with lesions on the knees and tibio-
tarsal articulation ; they had lasted for two years.
In a courteous communication Brocq expresses his regret at the loss
of the notes of these cases, which must therefore remain incomplete.
Verm atoloy ic a I Sec t io n
113
He very kindly sent me several sections from his first case. Examina¬
tion of these showed the following features (fig. 7) :—
The stratum corneum is slightly thickened ; the granular layer is two or
three cells thick, the rete normal. Focal accumulations of cells are seen almost
all through the section, increasing in denseness as the hypoderm is approached.
These masses of cells are seen to surround sweat-glands and coils, enlarged
vessels and hair-shafts, and they tend to become encapsuled by the dislocated
connective and elastic tissue. But in some parts, especially deeper in the
section, the collagen and elastin are split up and fragments lie among the
Fig. 7. (Drawn with camera lucida.)
Brocq’s case. (Leitz objective 3; ocular *2.)
a Sweat-coils with infiltration.
b Fat lobules with fibrosis,
c Thickened vessels with infiltration.
d Sweat-ducts, forming centre of a nodule of infiltration, walled in
by collageu.
Stained with von Gieson-Hansen.
114
Graham Little: Granuloma annulare
infiltrating cells. In portions of the section the collagen stains with difficulty,
as if it had undergone necrosis in circumscribed areas. Large masses of the
fatty lobules of the hypoderm have become converted into fibrous tissue
(sclerosis), which is also infiltrated with scattered cells ; and the vessels in this
zone are greatly dilated, thickened, and numerous, and surrounded by infiltrat¬
ing cells ; in many of the vessels the lumen is blocked and the vessel converted
into a fibrous cord. The cells consist of large mononuclear cells, connective
tissue corpuscles and epithelioid cells. No giant-cells were seen, and no undue
proportion of mast-cells.
XXVI. Audry’s case (Annales cle Dermatologies 1904, p. 9).
Female, aged 50, who for eight months had had lesions “ like those described
by Colcott Fox and Dubreuilh.” On both hands, especially on the right, on the
lateral border of the middle and ring fingers, there were rings formed by thin
edge of violaceous pink colour, very firm consistence, slightly scaly and shiny :
these ringed patches seemed formed by the juxtaposition of hard, pink nodules.
The lesion commenced with a nodule which healed in the centre and spread
peripherally. The skin enclosed was almost absolutely normal. There was no
pain or itching. Histological examination showed a condition of affairs “ like
Dubreuilh’s case.”
XXVII. Model of case of Quinquaud’s (dated 1891) in the St. Louis
Hospital Museum.
Identified from model by Crocker as clinically like his cases of erythema
elevatum diutinum. Dr. Wickham, the courteous administrator of the Museum,
was unable to furnish any further details than those contained in the catalogue,
viz.: “No. 1599. Fibromes multiples nodulaires des extr&nites. Diagnostic
histologique : Fibrome fasciculi, mains.”
It is interesting in this connection to call attention to Dr. Hyde’s addendum
to Dr. Montgomery’s case (p. 119). Was the case, clinically regarded by Hyde
and Montgomery as granuloma annulare, histologically as keloid, of the same
type as this St. Louis model {vide below) ?
XXVIII. l)r. T. D. Savill’s case {British Journal of Dermatology ,
1905, p. 23).
Male, aged 44, with a persistent ringed eruption situated upon the neck,
chest, and upper limbs. The condition had lasted for eight months. From the
scanty notes of the case, which Dr. Savill has been kind enough to lend to me,
it would appear that the diagnosis at first suggested was tinea, then syphilis,
and on this latest hypothesis mercury and iodides had been given. He was
under this treatment for five months, and then appears to have been lost sight
of. He was shown at the Dermatological Society of Great Britain and Ireland,
and the diagnosis of lichen annularis suggested.
Microscopically the section (kindly lent by Dr. Savill) showed (fig. 8) much
localized thickening of the stratum corneum, an increase in the thickness of the
DerviUtological Section
115
rete with a very much broader granular zone (five or six cells thick) than usual,
and with a copious, localized infiltration of cells in the papillary zone of the
corium directly under the epidermis and restricted to the superficial layer
entirely. This distribution of the infiltration is unlike that seen in any other of
the sections I have examined, and I cannot think that the diagnosis of lichen
annularis was correct in the light of the histological appearances, which are
certainly more like those of lichen planus.
Fig. 8. (Drawn with camera lucida.)
Savill’s case. (Leitz objective 3; ocular 2.)
a Dense cell-infiltration of papillary body.
b Hair shaft in cross section.
Stained with polychrome methylene blue. (Lent by Dr. Savill.)
XXIX. Case shown by Sir Cooper Perry and Mr. Sichel (British
Journal of Dermatology , 1905, p. 61) (communicated by Mr. Sichel,
1908).
f
116
Graham Little: Granuloma annulare
S. B., a boy aged 8, presented himself at Guy’s Hospital on January 3, 1905,
suffering from a nodular rash affecting sparsely the extensor surfaces of both
hands and feet. The tendency to the formation of circular patches—about the
size of threepenny-bits—was well marked, especially on the hands, where the
centres surrounded by the nodules were clear but rough. The spots on the
hands and feet were said to have begun about two weeks previously. There
was no marked scaliness.
Previous History. —Measles four years ago, and “ rheumatism ” twice before
that, the last attack followed by “ inflammation of the kidneys ” : his mother
also stated that he had had a similar rash to the present in the previous summer,
which went away.
Family History. —Father and mother alive and healthy ; one brother and
one sister, both alive and healthy.
Patient himself is pale but well nourished. No cardiac bruit, but heart
sounds not quite so clear as they should be. When shown he had an inter¬
current herpes zoster (abdomen).
January 5, 1905.—A fresh patch noticed in right lumbar region, also a
small, ring-shaped, bruise-like stain in left lumbar region.
January 6.—Urine acid, specific gravity 1024 ; no albumin or sugar.
January 10.—Slight attack of tonsillitis ; urine faintly alkaline, specific
gravity 1016. No albumin or sugar, phosphates came down on boiling.
January 17.—Rash of herpes on abdomen almost entirely cleared up. Spots
on hands and feet much faded, but otherwise not much changed ; a few nodules,
like “ rheumatic nodules,” on dorsum of right foot.
January 18.—Urine clear, acid, no albumin, no sugar, no excess of
phosphates.
February 21.—Rings all bigger and often not quite complete; the nodules
keep separate and do not run into each other. There have also appeared
numerous nodules in periosteum (?) of left temporal region, the skin over which
is unaffected, not painful or tender.
March 8.—Two nodules on back of left ear and one on hack of right ear.
March 15.—Painted with collodion salicylate.
March 23.—Some fresh spots on right foot.
Treatment was continued once or twice weekly with collodion salicylate
(5j. to 3j.), and the spots gradually faded. The subcutaneous nodules became
smaller without any application in temporal region and ears.
When he was again shown on March 8 Galloway recognized the case as one
of lichen annularis. G. S.
Histology of Perry and Sichel’s case. Dr. Arthur Whitfield very
kindly lent me a section from this case, from which the following
examination was made (fig. 9) :—
The epidermis was normal ; the granular layer was about three to four cells
thick ; the rete was not thickened. In the deeper part of the corium a nodule of
])ermatologicaI Section
117
cell-proliferation was seen with a low power, which, with higher magnification,
was seen to be centred round dilated sweat-coils. This cell-proliferation extended
down to the cut margin of the section at the junction of the subcutaneous
tissue, and strands of cells were seen ascending from this tumour-formation
vertically upwards, round enlarged sweat-ducts, to the middle of the corium.
The papillary body was free from infiltration. The cells seemed to be composed
chiefly of connective tissue corpuscles, with elongated nuclei. Some large
mononuclears also formed part of the cell-mass.
No data as to elastin were furnished by the section. The collagen was
dissociated by the cell-masses, which lay between the bundles in nodular foci,
hut appeared elsewhere normal.
a Dilated sweat-coils with infiltration.
b Perivascular infiltration.
c Hair shaft.
Section stained with rubiu-orauge-ha?matoxvlin. (Lent by Dr. Whitfield.)
XXX. Dr. Leslie Roberts’s case (communicated). Hinged eruption
on the foot, 1904. (Fig. 10 from water-colour drawing lent by Dr.
Leslie Roberts.)
118
Graham Little: Granuloma annulare
The patient was a girl aged 9, and the disease had been first noticed a year
previously. There were no subjective sensations, and the original patch felt
“ like a little hard lump under the skin.” The disease spread slowly. The
eruption occupied an area of 3 in. on the cuter side of the left foot, reaching
a point slightly above the malleolus. When the patient was lying down the
colour of the patches was light red, changing to bluish red when the patient
Derm a tulog ica I Sec t ion
119
stood erect. When the leg was elevated and the blood pressed out of the foot
the rings assumed a dull white aspect. The patches formed rings, the margins
slightly elevated, of dull ivory colour, presenting a waxy, glistening surface.
The hyperaemia varied also with the temperature ; on cold days it was more
pronounced, becoming less visible in warm weather. The progress of the
disease was very slow, persisting for many months, and spreading centrifugally.
There was no inflammatory reaction. Under treatment the rings disappeared,
leaving no scar.
In the section lent for examination by Dr. Leslie Roberts little
more than the epidermis is included in the excision. No changes were
apparent in that. Dr. Leslie Roberts proposes the name “ acanthoma
annulare ” in substitution for granuloma annulare. In the absence of
acanthosis this name seems undesirable.
XXXI. Case communicated by Dr. F. H. Montgomery in a letter
dated February 21, 1908. (Case referred to by Dr. Galloway, British
Journal of Dermatology, 1902, p. 218. Fig. 11 from photograph by
Dr. Montgomery, lent by Dr. Galloway.)
“ The case of ringed eruption concerning which you ask occurred in the
son of one of my colleagues in the graduate school with which I was connected
some years ago. The boy was brought to me in September, 1899. He was
then a rather delicate boy, aged 16. The cutaneous trouble began with what
he called ‘ a small smooth wart ’ on the radial side of the second joint of the
left index linger in the summer of 1897. It had gradually spread centrifugally.
At the time of my examination it extended in irregularly circinate lines about
1 in. on to the radial surface of the two adjoining phalanges, and slightly on to
the dorsal and palmar surfaces. The borders were elevated 2 mm. or 3 mm.,
from 2 mm. to 6 mm. in width, and were more or less distinctly subdivided
into individual nodules. The border in colour and density suggested somewhat
a keloid, being hard and smooth and presenting no evidence of inflammation or
of epithelial growth. The central portion over which the growth had passed
seemed to be practically normal ; there was no evidence of scar formation.
“I saw the boy again two and a half years later. At this time his father
said the lesions had increased until they reached the distal phalanx of the
finger, and then, without much treatment aside from irregular applications of
a 50 per cent, solution of ichthyol which I recommended, the lesions gradually
disappeared until at the time I saw him there were left two slightly umbilicated
nodules about the diameter of a small pea. These ultimately disappeared
completely.”
To this report Dr. Xevins-Hyde adds :—
It is proper to say, in order to show there can he errors made by the best
meaning of physicians, that about six or eight months ago a patient came to us
120
Graham Little: Granuloma annulare
with a lesion on the left leg which was so precisely similar to those of the
Galloway-Montgomery case that 1 at once called Dr. Montgomery in to see
her. In this case the patient was a woman, and he suggested to me without
very much hesitation that it was another instance of granuloma annulare.
There seemed to me, however, to be some distinction here, and this suggestion
was based on the special hardness of the underlying tissue. As the ringed
eruption did not disappear under what we thought to he appropriate treatment,
we excised it and examined it with special care, and found after staining a
section of the lesion simply a circinate keloid ! I give you this information
as it may hell) you in your critique in other supposed instances of the disorder.
Fig. 11.
Case of Dr. Hyde and Dr. Montgomery. (From photograph by Dr. Montgomery,
lent by Dr. Galloway.)
Externally, however, this patch looked precisely like the others we have seen
(vide fig. 16 following).
“ It might interest you further to know that neither Dr. Montgomery nor
myself has seen any such conditions save in the one case which we photographed
and which is referred to above.”
Dermatolorjical Section 121
XXXII. Professor Jadassohn’s cases (communicated by Professor
Jadassohn).
CASE 1.—Mine. X., aged 59. The eruption had commenced two or three
years previously in the inguinal region of both sides. Later, it appeared about
the axillae, and on the elbows and knees, on the left side prior to its appearance
on the right. There were no subjective symptoms in connection with the
eruption, and the patient had no family history of importance, and was herself
a stout healthy woman, possibly with “gouty” tendency, and of somewhat
nervous temperament, suffering from insomnia.
Distribution of the Eruption .—This was symmetric, hut everywhere more
pronounced on the left than on the right side. Near the axillae there were very
large patches extending on to the surface of the chest and arms. The central
part was smooth and perhaps atrophic to a slight degree; the hairs had not
fallen out, but the follicles in the centre were somewhat dilated, without,
however, being “ eornified.” In these parts there were some nodules the size
of a pin’s head, white, firm, and smooth, resembling follicular cicatrices. The
edges of the patches were thin (about 1 mm. wide), irregular, very little raised, of
a pale, slightly bluish tint, and very little infiltrated. Beyond the limits of the
patches there were some macules, very slightly infiltrated and raised, and pale
bluish in colour. On the right wall of the chest there were some isolated
circinate groups composed of small nodules, sometimes perhaps follicular, and
of a pale bluish colour, occasionally even red. The nodules in the middle of
these groups were generally paler and less raised, with a more pronounced edge
and more circumscribed. On the left elbow, above the olecranon, there was
a patch the size of a shilling, which was more raised, more infiltrated, and
redder. The infiltration was general, but the centre was somewhat depressed.
A little lower, over the ulna, there was a row of pale pink small nodules. Over
the wrist there was another group, about the size of a sixpence, of nodules, very
small and pale. On the left elbow, and on the inner sides of both knees, there
were some flat nodules, ungrouped and isolated, of a pale pink. (The patient
stated t*bat the large patches had all commenced in this way.) In the inguinal
regions there were some large patches (from which the biopsy was made)
exactly like those near the axilla. In no part was there any scaling, scratching,
or follicular keratosis. The face, neck, nape, and the rest of the body remained
wholly free.
Liq. arsenicalis in lffiij. to iflx. doses was prescribed, and a mercurial
plaster and ointment. This appeared to benefit the condition, the effect being
apparently due more to the arsenic than to the local remedies, since the
eruption improved in positions where no local treatment was used. The con¬
dition had recurred from time to time, and was now again troublesome.
Professor Jadassohn was kind enough to send me a section from this
case (fig. 12). There were less conspicuous changes in the skin than in
some of the other cases examined, but on the whole I think we have to
do with the same class of phenomena.
122
Graham Little: Granuloma annulare
There are a few collections of cells, encapsuled by connective tissue and
lying chiefly in the middle zones of the corium. These cells consist, for
the most part, of vividly stained mononuclears, with many connective tissue
corpuscles and few epithelioid cells ; mast-cells are not numerous. The sweat-
ducts and coils are in parts of the section surrounded by a fairly dense cell-
infiltration. There are also localized areas where the connective tissue and
elastic fibres are broken up and interspersed with cells. The epidermis appears
exceptionally thin, but the section was taken, I understand, from the inguinal
region, which explains this appearance. The granular layer is “ one cell thick.”
There is only a* small part of the fat-zone included in this section, and in a
portion of this there appears to be a slight inflammatory infiltration.
Fig. 12. (I)rawu with camera lucida.)
Professor Jadassohn’s ease (Mme. X). (Leitz objective 3; ocular 2.)
a Collagen and elastin broken up with diffuse cell infiltration.
b Sweat-coils and ducts with infiltration.
c Large blood-vessel cut obliquely.
Section lent by Professor JadassohD.
Dermatological Section
123
XXXIII. Case 2.—Girl, aged 4. Disease dates from the age of 1, com¬
mencing on the left hand with a patch which gradually enlarged. Within the
last three months other patches have appeared on the right hand, on the right
foot, and on the thighs. Some patches have disappeared spontaneously. The
child complains of itching, not confined to the patches, but to a slight degree
everywhere, especially about the genitals (the child has worms); she has never
scratched the patches ; she is a lively child, a little nervous, but of good general
health. She had diphtheria some time before the eruption. There is no family
disease and no gout. The child is well nourished, with delicate skin and blonde
hair ; the face, trunk and mucous surfaces are normal. On the right hand,
above the metacarpals of the thumb and index, there is a patch nearly the size
of a five-franc piece, roughly circular but somewhat irregular, and with the
circle broken towards the arm, the centre smooth, of a normal colour without
pronounced atrophy. The edge is nearly continuous, of somewhat serpiginous
outline, about j mm. to 1 mm. wide, of a pale pink colour, without scales, fairh
hard, but with a superficial induration and not sensitive; on pressure with
a glass this becomes of a pronounced white colour. On the left hand, in the
fold between the index and the third finger, there is a circle which crosses the
fold in such a way that the circle is continuous only when the fingers are
juxtaposed. There is a second circle on the back of the left hand ; both these
patches are composed of small nodules which form the edge. With this
exception they are exactly like those on the right hand. An exactly similar
patch, but somewhat larger, is present on the outer edge of the right foot. On
the thighs there are some red, smooth stains, sharply circumscribed, not raised
or infiltrated.
Fowler’s solution and a salicylic acid ointment were prescribed. Four weeks
later the patches had grown somewhat larger and a new area had appeared of
the size of a sixpence, without central depression, and pale pink, on the third
finger of the left hand. No biopsv was obtainable.
Dr. H. G. Adamson’s cases.
XXXIY. Case 1 (communicated).- The patient, W. A., was a boy,
aged 3i, who seemed to be in good health, except that he was restless at
night, which the mother attributed to thread-worms. The eruption, which
was not painful, tender, nor itching, had been noticed for six months, the
lesions gradually increasing in size and numbers. Over the buttocks and
the backs of the thighs there were about fifteen lesions, some in the form
of fiat, disc-like nodules of the size of a split pea and somewhat larger ;
others were well-marked rings of the size of a threepenny-piece to that of
a sixpence, the ring itself being formed by a raised, white, firm, J in. wide
ridge, surrounding a pink centre on a level with the skin surface, and having
a narrow pink areola. In some of the rings the ridge was apparently made
up of a string of closely set nodules. On passing the finger over the lesion
the firm, raised, circular ridge could be felt distinctly, like a ring let into
124
Graham Little: Granuloma annulare
the skin. There was one ring on the front of the right leg below the knee.
There had been no history of rheumatic fever nor any evidence of tuberculosis.
XXXV. Case 2 (communicated).—G. C., aged 2i. October 29, 1907.
North-Eastern Hospital for Children. “Lumps” noticed on elbows and “rings”
on buttocks, one month. At the back of the right elbow there are two circular
({ in. across), disc-like swellings in the skin. They are raised above the
surface. When pinched up they feel hard and like a corn in the skin. The
skin over them is dusky red. There is one similar patch on the left elbow.
On the buttocks there are several ring-like lesions, one on the right buttock
and three on the left. They appear as pale lilac rings, slightly raised, with
enclosed central part somewhat darker in tint. On pinching up these rings
they are found to be firm discs like the others on the arms, and on passing
the finger over the lesion the raised margin and central depression can l>e
easily felt. The case was lost sight of at this stage.
XXXVI. Case 3 (British Journal of Dcrnuitolcxju, June, 1908.) (Fig. 13
from photograph by Dr. Adamson.)—“ The patient was a printer, aged 17.
Five months ago “ small red lumps ” appeared upon the backs of the fingers
and gradually increased in size. When he first came under observation one
month ago there were present on the dorsal surfaces of the fingers of both
hands raised, firm, dusky red, nodulated, disc-like areas of from £ in. to lin.
in diameter, and elevated about A in. to A in. All the fingers of each hand
were involved; in some the dorsal aspect of one phalanx, in others of two
phalanges, and in the case of the first finger of the left hand the lesion
extended over the middle joint. On close inspection, and particularly on
palpation of the raised disc-like areas, it was evident that they were made
up of closely set pea-sized nodules; but it was only on careful examination
that this feature could be made out, for the individual nodules were close
together and their margins were ill defined. In some of the patches there
was a tendency to ring formation, owing to the arrangement of the nodules
towards the margin of the patch. The hands were cold and of a dusky hue.
There were, in addition, a few isolated pea-sized dusky red nodules on the-
backs of the hands. One of these was excised, and within a fortnight the
whole of the lesions had almost disappeared. It was curious that a similarly
rapid disappearance of the lesions had occurred in a case of “ringed eruption ”
recorded by Dr. Graham Little after a biopsy. The exhibitor regarded the
case as belonging to the group of cases variously described as ringed eruption
(Colcott Fox), granuloma annulare (Crocker), and lichen annularis (Galloway).
A section of one of the lesions from the back of the hand showed some
widening of the prickle-cell layer and of the horny layer of the epidermis
(possibly due to the fact that the section had been cut obliquely). In the
corium the fibrous connective tissue was normal, but in it there were numerous
circumscribed collections of mononuclear round-cells around the blood-vessels
and a large mass of the same type of cells around the sw r eat-glands. There
were no young connective tissue cells, epithelioid cells, plasma-cells, nor
Dermatological Section
125
polynuclear leucocytes. The absence of young connective tissue cells described
in other cases was probably due to the fact that the lesion excised was at
a very early stage. The clinical features and the histological findings suggested
a toxic rather than a microbic origin.” (Fig. 14 from a drawing by Dr.
Adamson.)
XXXVII. Galewsky’s case (“ Iconographia Derraatologica,” Fasci¬
culus iii., with coloured plate).
The patient, seen in autumn, 1904, was a female servant, aged 26, and
had had the condition for several months, during which she had been treated
Fio. 13.
C. D,, aged 17. April 24, 1908. O.P. No. 1,006. St. Bartholomew’s.
“Ringed eruption”—granuloma annulare (?)—erythema elevatum diutinum (?).
by a general practitioner without success. The eruption had commenced
with small round red spots, which by degrees developed into nodules, and
these again into rings. When seen by the author there were small lentil¬
sized spots on the forearm and two rather large ring-shaped patches on the
126
Graham Little: Granuloma annulare
right index finger. The “ spots ” on the forearm were a vivid red at the
edge, and in the middle of the papule of the colour and sheen of ivory. The
two ring-shaped patches on the right index formed half-circular rings, which
were open on one side, indolent, and of a hard, keloid-like consistence. From
this red infiltration the ivory white, shiny, hard, raised, keloid-like edge stood
a a Blood-vessels surrounded by masses of mononuclear round-cells.
b b Collections of similar cells around sweat-glands.
out conspicuously. These swellings were comparatively superficially placed
and could be easily moved over the underlying tissues. The central portion
of the crescents seemed quite normal, showing at the most a slight atrophic
Dermatological Sectioti
127
shininess. The condition disappeared slowly under treatment with arsenic
(Fowler’s solution) and local application of tar-lotion and plaster without
any pigmentation. In July, 1905, the patient came again with a recurrence
of the affection and remained under treatment for six months. The small
reddish nodules with waxy, ivory-like surface appeared on the forearm, and
on the right index thin half circles, exactly similar to the earlier lesions.
The patient did not react to tuberculin, and showed no symptoms of tuber¬
culosis. The lesions were treated with salicylic soap and thiosinamine plaster,
and the nodules gradually and slowly disappeared, with no other trace save
slight whitish atrophic patches.
Microscopical examination showed a normal epidermis, with no changes
in the sweat- or sebaceous-glands. There was a diffuse infiltration of cells
in the cutis which appeared to be fixed connective tissue cells, with very
few mast-cells, and in one preparation some foreign-body giant-cells. This
cell-infiltration was in the pars reticularis, the papillary body and the sub¬
cutaneous connective tissue being entirely free. In the peripheral part of
the tumour there were vascular connective tissue strands, between which
round-cell infiltration was seen in some places. There were no obvious
changes in the connective tissues or elastic fibres; in the central part the
nuclei did not stain, and in the midst of the infiltrated patches there was
necrosis.
XXXVIII. Dr. Dawson’s case (from notes taken by the present
writer at the meeting), Dermatological Section, March 19, 1908.
Male, aged about 22. In good general health. No tuberculous history. On
left hand, in the web of the fingers of the middle and index, and the back
of the hand in contiguity, there were some few circinate lesions, J in. wide,
made up of whitish, firm papules forming incomplete rings ; very little elevated
above the general level and apparently umbilicated in the centre in some
instances. On the distal phalanx of the index of the same hand there was a
single, whitish, raised nodule of more recent development, with vivid red areola.
The patient said that all the lesions commenced in this manner. They were
entirely painless, and the disease persisted for seven years. No other eruption
had been present at any time. “ Microscopic examination disclosed swelling of
the cells of the stratum mucosum, and marked enlargement of the sweat-glands
and ducts ” (note by Dr. Dawson).
XXXIX. Dr. J. M. H. MacLeod’s case (from rough notes com¬
municated by Dr. MacLeod).
The patient was a man, aged 43. He was seen first in January, 1907, with
a ringed and nodular eruption apparently restricted to the back of the left
hand. The lesions had commenced fourteen days previously and had graduallv
increased by peripheral extension. Dr. MacLeod made the diagnosis of grann
loma annulare. He was put on pot. iod. internally, and mercurial ointment, and
the lesion disappeared in about fourteen days. The rings were yellowish pink
jy-z
128
Graham Little: Granuloma annulare
in appearance. The mucosa was unaffected. The patient came again exactly
a year later with lesions similar to those described but more numerous, on the
hack of both hands, from 4 in. to J in. in size. They were pinkish in colour,
rather more rounded on the top than lichen planus, and angular in outline.
The circular lesions were due to peripheral extension. There was no itching
and no affection of mucosa. The lesion felt hard, like lichen planus, and lichen
planus annularis was suggested as a diagnosis. lie was put on mist. gent. acid.
Fig. 15.
Dr. MacLeod’s case.
as lie complained of indigestion ; no local treatment was adopted and the lesions
disappeared a week later. No biopsy was obtainable.
fThe appearance of the lesions, as shown in the photograph (fig. 15), and
the absence of chronicity seem rather to confirm the later diagnosis of lichen
planus.—E. G. L.]
Dermatological Section
129
Dl\ Darier has kindly sent me notes of some very interesting
cases of an uncertain type, in two of which lie regarded the
diagnosis of “ granuloma annulare ” as probable.
XL. Case 1.— A woman, the subject of diabetes and syphilis, with a
crescentic group of nodules on the thigh. Treatment resulted in mitigation of
the diabetes, but persistence of the nodules. No biopsy was obtained.
XLI. Case 2.—A woman, also the subject of diabetes, with crescentic-
shaped group of nodules on the hip. These also appear to have persisted.
The association of diabetes recorded in both these cases is very
unusual and not paralleled by any other that I have collected.
« In three other cases of eruption in the form of large raised rings,
covering very extensive areas of the body, Darier’s diagnosis was that of
“ erythema diutinum figuratum.” The biopsy in two of these showed
appearances more like those of seborrhoic eczema.
XLI I. Mention has been made of a case of Hyde, Montgomery
and Ormsby, referred to by Dr. Hyde (p. 119). Since this communi¬
cation I have been favoured with a photograph of the case (fig. 1(5)
and a section of the skin prepared by Dr. Ormsby. The case was
regarded clinically (vide Dr. Hyde’s note) as granuloma annulare;
histologically it appeared to be a keloid. This keloid-like stage has
been described in the histology of the case reported as erythema
elevatum diutinum (liadcliffe Crocker and Campbell Williams), and was
notable in a case of my own in an old lesion, although a recent lesion
from the same case showed the features which seem characteristic
of granulare annulare (vide Case XLIX.). 1 am therefore inclined
to think that the clinical diagnosis made by Dr. Hyde and Dr
Montgomery is not incompatible with the histological aspect revealed
by this section, and I tentatively include this case in my list (compare
with Cases 27 and 49, synopsis).
XLII1.—Dr. Colcott Fox has given me the following notes of a recent
private case (fig. 17) of his in a woman, aged about 85, with nodules and
rings made up of nodules, which had persisted for many years and were
situated on the back of the hand. The largest ring was of the size of a
shilling, and was composed of discrete, white, shiny nodules set like
pearls in a brooch, in a circle. Isolated white nodules were also present
on the back of the hand, and over the left index finger at the knuckle
there w r as a lumpy fiat swelling. The hands were cyanotic, with chil¬
blain circulation. No subjective symptoms were complained of. The
case was lost sight of.
130
Graham Little : Granuloma annulare
My own Series of Cases.
XLIY. Case 1 (British Journal of Dermatology , 1905, p. 16).—
H. M., female, aged 6, sent to St. Mary’s Hospital by the late Dr. John
Garrett, of Acton, and shown at the Dermatological Society of London
(December 14, 1904). The diagnosis then adopted was that of a
“ ringed eruption,” of the same type as Colcott Fox’s cases (1895),
Galloway’s case (1899), and Pringle's case (XVI.), shown at the same
Fig. 1G.
(From photograph lent by Dr. Hyde, Dr. Montgomery, and Dr. Ormsby.)
Case clinically regarded as granuloma annulare, histologically as keloid.
(Section lent by Dr. Ormsby.)
Derm a tological Sec t ioit
131
meeting. Its identity with granuloma annulare, as described by Crocker,
was disputed by many, adopted by some. The patient when seen at
the meeting had two lesions: a ringed group of papules which formed
a continuous edge, at first white in colour, afterwards becoming red,
J in. broad and raised about in. from the level of the skin. The ring
was about the size of a sixpenny-piece, quite circular, and enclosing an
area of skin which was redder than normal, rather more furrowed than
usual, but without signs of atrophy; there was another quite similar
lesion, except that it was crescentic and not an entire circle, on the skin
covering the right internal malleolus. Neither lesion was attended by
any subjective symptoms whatever, and these two lesions constituted
Fig. 17.
(?) Granuloma annulare (Crocker) with cyanotic extremities.
Dr. Colcott Fox’s case.
the whole eruption as seen by the writer of this paper; but Dr.
Garrett had recorded an attack of “ urticaria,” a transient eruption
lasting fourteen days and preceding the appearance of rings by some
time, not definitely stated, shortly before these were noted.
The ringed lesions had persisted for four months before the case was
brought to St. Mary’s, and lasted about three months after this date ;
they finally disappeared, leaving no scar or sign.
The child sweated freely, and her hands and feet were usually
clammy with perspiration ; the disease had commenced in August in the
height of a hot summer. The family history was not obtained. The
132
Graham Little: Granuloma annulare
patient was a small, delicate-looking child, but without any definite
illness.
Histology (fig. 18).—There was slight thickening of the stratum
corneum, and the granular layer was two or three cells thick. There
were large accumulations of cells, almost like the focal accumulation of
tubercle, round the sweat-coils in the deeper parts of the corium and
extending right into the hypodcrm. The fat-zone did not come into the
section except in a fragmentary manner, and no definite data as to its
condition were possible. The elastin was normal throughout the section,
but it was absent in the cell-masses, in the central part of some of
Fig. 18. (Drawn with camera lucida.)
H. M. (Leitz objective 3; ocular 2.)
a Sweat-coils and ducts with infiltration.
h Thickened vessels in fat lobules with infiltration.
c Infiltration round vessel.
d Area of destruction of tissue.
. Stained with polychrome methylene blue. •
these cell-masses an appearance of destruction, or at least of feeble
staining of the mass, was noted. The cells consisted chiefly of connective
tissue corpuscles, with mononuclear and epithelioid cells. In the hypo-
derm the larger vessels appeared thickened and were surrounded in
places with cells of the type described.
Dermatological Section
133
XLV. Case 2 (unpublished).—East London Hospital for Children.
E. W., male, aged about 3, came with a single lesion, a circinate patch
on the front of the left wrist. The ring was oval, with a firm, almost
cartilaginous edge, whiter than the surrounding skin, and raised about
in. from its level. When seen the patch was of the size of a sixpenny-
piece, and was said to be enlarging. It had persisted for three months.
The central portion of skin was pinker than normal, a little wrinkled,
but with no definite atrophy. There were no subjective symptoms
whatever in connection with it. The child seemed fairly well; he had
some remains of impetigo on the buttocks.
A recpiest to perform a biopsy on this case frightened the mother to
such a degree that the child was not seen again, and no answer was
returned to letters inviting her to attend the hospital, so that the
subsequent history was lost.
XLVI. Case 3.—St. Mary’s Hospital. A young girl, E. P.,aged l(‘>,
shown at the Dermatological Society of London in April, 1900. The
patient had come to St. Mary’s Hospital a week previously to being shown
with a ringed and papular eruption on the dorsum and side of the right
hand. The papules were somewhat itchy, white at their commencement,
becoming red later, and forming ring-shaped patches with rather indefinite
outlines. An ointment of glycerine of subacetate of lead applied on
lint with the part bandaged over had reduced the lesion to vanishing
point at the time of showing the case. The nature of this case is
perhaps doubtful ; the localization and clinical aspect of the lesions
strongly suggested the diagnosis of granuloma annulare; the rapid in¬
volution of the lesion is paralleled by an experience in the case of
W. S. (see below), in whom a bandage applied after a biopsy had
produced the almost complete disappearance of the nodules included in
the bandage within a week, and in the case of Adamson recorded above.
XLVII. Cask 4.—St. Mary’s Hospital. W. S., aged 42. He is
a 44 handy man ” at a little private hotel, and is a small, thin, ansemic-
looking person, but with no definite illness. He is probably overworked
and underfed. He perspires extremely freely and easily, and his skin is
usually clammy or wet. Three types of lesion are demonstrable : (1) An
early nodule, usually waxy white and almost translucent, which becomes
redder later ; (2) rings and crescentic-shaped groups of nodules, these
being discrete or running together to form a continuous edge, the central
portion of the skin so enclosed being dusky in colour, smooth, and
showing no signs of scarring; (3) doughy, circumscribed, violaceous,
134 Graham Little: Granuloma annulare
pad-like patches with uniform elevation and roughly circulate outline,
imparting a feeling of irregularity of surface, comparable to the surface
of a Lilliputian worn flock-mattress. These patches are possibly made
up of deep-seated, confluent nodules, but there is no ringed edge or
depressed centre, and individual papules cannot be made out.
The present distribution of the lesions, which have continued to
come out from time to time during his attendance of many months at
St. Mary’s Hospital, is as follows : The disease is said to have com¬
menced on the front of both wrists three years ago, and the lesions here
are whitish warty nodules, very numerous, and tending to form roughly
circinate groups, the area covered being about 2 in. by 2J in. Near
the olecranon process there is another definitely circinate patch of
a fortnight’s duration. There is another circinate patch at the base
of the dorsal surface of the index of the left hand, about i in. to
1 in. in diameter ; there are two patches on the external (radial)
surface of this hand near the base of the fifth finger. There is
a similar circinate, doughy patch on the dorsal surface of the right
hand near the base of the fifth finger, and another patch on the
radial edge of the proximal phalanx of the right ring finger, circinate
patches on the dorsal surface of the middle phalanx of the middle finger
and of the index. The patches on the fingers are said to have been
of recent origin, having appeared within the last nine months. There
was a small patch on the extensor surface of the left forearm
(excised for histological examination). There is a large circinate
patch 1£ in. across over the right patella. The colour of the enclosed
ring is a pale to a bluish pink ; the surface is perhaps a little wrinkled
or striated, but not shiny or presenting signs of atrophy. The man
sweats extremely freely, so that he has to change his garments some¬
times three times a day. He is anaemic, almost cachectic-looking, and
thin, but with no definitely tuberculous symptoms. Fresh papules
appeared in the case from time to time during some months that
he was under observation ; then a small grouped patch came out on
front of the right elbow. These new papules were pale, almost
colourless, and of the size of a split pea. There w T ere no buccal lesions
and no symptoms pointing to lichen planus. The disease slowly disap¬
peared with local treatment (salicylic acid, zinc ointment and carbolic
acid).
The patient was shown at the Dermatological Society of London
(British Journal of Dermatology , 1900, p. 117), and the diagnosis of
granuloma annulare was generally accepted.
Dermatological Section
135
Histology (fig. 19).—The epidermis is not in any way altered; there
is no acanthosis; the granular layer is about two cells thick, the
rete normal. The main changes affect the deeper layers of the
corium and hypoderm. There is a dense cell-infiltration in the zone
of the fat-lobules, and some of these have undergone fibrotic organ¬
ization, spaces corresponding to fat-cells being left here and there in
the organized mass. The sweat-glands and ducts, the hair-shaft,
Fig. 19. (Drawn with camera lucida.)
W. S. (Leitz objective 3; ocular 2.)
a Sweat-coils surrounded by cells.
1) Fat lobules infiltrated by cells,
c Clumps of cells, walled in by collagen.
(I Diffuse infiltration with breaking up of collagen.
Section stained with von Gieson-Hansen.
and the vessels are surrounded by dense cell-infiltration. The vessels,
especially in the hypoderm, are thickened, and in some cases their
lumen obliterated. In the lower parts of the corium the collagen and
elastin bundles are disintegrated, the cellular mass being interspersed by
136
Graham Little: Granuloma annulare
fragments of connective and elastic tissue. Tn other parts of the section,
especially in the upper zones, the cell-masses are, as it were, encapsuled
by collagen and elastin, nodular foci being thus formed. In many cases
it is possible to identify portions of sweat-ducts or vessels in the nodule,
which seems thus to serve as a centre for the infiltration.
The cell-infiltration consists of large mononuclear cells, staining
deeply with nuclear stains ; and of connective tissue corpuscles, stain¬
ing less deeply ; and large epithelioid cells. Mast-cells do not appear
especially numerous, and no giant-cells or typical tuberculous “nodules”
are discernible. No micro-organisms were seen in the few specimens
specially stained for these.
XLVIII. Case 5.—East London Hospital for Children. E. C.,
female, aged 4, sent to the Children’s Hospital, Shadwell, by Dr. Fiddes,
of Forest Gate. This case was shown at the meeting of the Dermato¬
logical Section of the Koval Society of Medicine (February 20, 1908),
and was generally accepted as an instance of “ lichen annularis.” 1
The eruption consisted of two lesions, one a group of pearly whitish
nodules, arranged in a complete circle \ in. by 4 in. with a pink areola
and situated below the left buttock, in the sulcus between the buttock
and thigh; the other was a single nodule in a corresponding position
on the right buttock, the size of a pea, deep seated and bluish in
colour. From this nodule the sections to be described were obtained.
The circinate lesion had persisted for about three months. It was
best seen when the skin on which it was placed was stretched, when
the nodules stood out as discrete white sw r ellings T \. in. in diameter
and rather less than that in height. The enclosed skin was a darker
colour than normal—slightly violaceous and wrinkled. Both lesions
were quite painless, and the child was unconscious of their presence.
No other had appeared at any time.
The patient herself was a fine healthy girl, fat, rosy, and well
in every way; but the family history was markedly tuberculous, a
brother of the child being at present in the Children’s Hospital with
tuberculous knee, and one paternal uncle having died of phthisis when
aged 34.
The position of this eruption on the buttocks was paralleled by
Fox’s and Adamson’s cases. The single remaining lesion, the ring
of nodules, had quite disappeared five months after she first came,
the treatment being salicylic acid plasters (10 per cent.), changed
1 Vide discussion IJrit. Journ. Derm., March, 1U08.
Dermatological Section
137
three weeks later, because of the pain they caused, to salicylic acid
ointment with 5 gr. of ichthvol to the ounce.
Histology (fig. *20).—The isolated nodule from the left buttock
was excised, hardened in alcohol and cut in paraffin. The section
showed a normal epidermis with no thickening of the rete. In the
coriurn there were clumps of cells aggregated together, and walled
in by connective tissue ; and rows of cells running up apparently
from the deeper to the superficial skin along the line of sweat-ducts,
vessels and hair shafts. These cell-collections were composed of mono¬
nuclears, connective tissue cells, a few epithelioid cells, and rather
numerous mast-cells. The elastic fibres were absent in the cell-masses.
There was a nodular area of necrosis in the connective tissue in the
deepest part of the coriurn.
Fig. 20. (I)rawu with camera lucidu.
E. C. (Leitx objective 3; ocular 2.)
a Sweat-coils, surrounded by cells, and lying in broken-up collagen.
6 Sweat-coils, centre of a nodule,
c Clumps of cells walled in by collagen.
d Area of necrosis.
c Thickened blood-vessel.
Section stained with von (lieson-Hansen.
138
Graham Little: Granuloma annulare
XLIX. Cask 6 . —St. Mary's Hospital. A. C., female, aged IS. A
fiorid-complexioned girl, with the “ faux embonpoint ” of the tuber¬
culous, came to St. Mary’s Hospital on January 8, 1908, with a
number of small, deep-seated nodules, about to be described. The
family history was unimportant, and she herself complained of no
illness, but she was detected subsequently by Dr. Sidney Phillips, who
kindly examined her for me, to be suffering from early pulmonary tuber¬
culosis at one apex. She is a Londoner, and a laundress by occupation.
Description of Lesions .—These are of three types: (1) An early
w hite papule, like boiled sago-grain; (2) A bluish, deep-seated nodule,
firm to the touch, and in the substance of the skin and movable with
it; (3) ’ Dough-like, and in some places keloid-like, masses, probably
composed of individual nodules, forming raised, infiltrated patches on
the fingers, the arm, and the breast. In some cases, e.g. y at the
wrist, there is an incomplete ring in the the shape of an umbilicated
large nodule, and some three or four of these are grouped in an
irregular crescent. With this exception the lesions are for the most
part isolated. All the lesions are painless, not tender on pressure, and
with no subjective symptoms associated with them.
Distribution : Right Hand .—There is an infiltrated patch, com¬
posed apparently of several nodules, on the proximal phalanx of the
little finger. This patch at first was a doughy infiltration ; it resolved
itself later into separate nodules w r hich became umbilicated; there
is also a circinate patch with a central depression and surrounded
bv a red areola, the edge raised, and of a diameter of \ in., on the
dorsal surface of the right hand £ in. from the metacarpo-phalangeal
joint. On the ulnar edge of the right forearm, 1 in. above the ulnar
prominence, there is a group of five circinate lesions with a central
depression, puckered but without actual ulceration. The foci form
a crescent of about 1 in. in diameter, each lesion being about J in.
across. On the middle of the forearm, extensor aspect, there is a
single depressed pitted scar, about \ in. in diameter, with some blue
staining and reddening around it, the remains of a previous lesion.
There is a similar depressed reddened scar on the inner aspect of
the forearm, near the olecranon process. On the extensor aspect of
the upper arm there w r as a deep-seated bluish recent nodule, which
was excised for examination. The wound healed with keloid-like
scar. On the inner aspect of the right upper arm there was a pro¬
minent purplish blue, deep-seated, keloid-like swelling, which was also
excised for examination; this was one of the oldest lesions; two
De nna tol-og i ca 1 Sec t io n
139
quite similar lesions of the same date were found on the skin just
above the prominence of the right breast. There is a white nodule
surrounded by a vivid violaceous areola on the point of the chin.
There is an isolated, deep-seated, blue nodule on the left side of the
back, about 1 in. below and internal to the angle of the scapula.
Left Hand .—On the proximal phalanx of the middle finger there is
a deep-seated hard nodule which can be felt easily in the substance of
the skin, but not readily seen. There are two bluish nodules with
depressed centres at the base of index (dorsal aspect). There is a pitted
scar on the radial edge of the forearm 2 in. below the point of the elbow.
There is a deep-seated blue nodule 1 in. below the olecranon process and
another on the point of the shoulder above the vaccination marks.
Right Foot .—There is a nodule with central atrophy at the base of
the little toe; near this, on the dorsal aspect of the foot, are four
grouped, white, sago-like nodules, all of recent development. There is a
deep-seated blue nodule, A in. external to the border of the tendo
Achillis, about 2 in. above the level of the malleolus.
Left Foot .—There is a single nodule on the dorsum of the foot,
at the base of the little toe.
There is a patch of infiltration, bluish red, with two small elevations,
with pitted centre, and one unpitted white nodule over the tibio-
astragaloid articulation, front aspect. There is a group of nodules on an
infiltrated patch over the prominence of the tendo Achillis, 1 in. above
its insertion. The abdomen is free. There is a group of pigmented
patches (remains of old nodules?) over the sacrum. There is a bluish
nodule and a scar, the remains of an older lesion, on the posterior
surface of the right thigh, at the level of the gluteal fold. There is a
small blue nodule in the middle of the right buttock and another close to
the internatal fold. There is a blue nodule in the middle of the left
buttock. There are'one or two small depressed scars on the forehead,
and one on the left cheek. The scalp appears quite free. There are no
glandular enlargements ; no hyperidrosis; no night sweating.
While under observation several of the nodules involuted, leaving
shallow pitted scars in many instances; in others no trace.
The patient was tested with a 0*5 per cent, solution of Calmette's
tuberculin dropped into the left eye (the conjunctiva). A doubtful
reaction followed, the conjunctiva being very slightly reddened. Ten
days later a 1 per cent, solution of Calmette’s tuberculin was used,
producing a violent conjunctivitis within twelve hours. The opsonic
index had been estimated on several occasions (sec table on next page).
140 Graham Little:
G ranuloma anint lave
Before admission to St. Mary’s Hospital
... Some time in January, 1908 ...
1-0-2
After admission ...
... February 5, 1908
0-97
,, ,,
„ 7. „ .
1-45
Ten minutes after “ Calmette ”
„ 10. „ .
0-87
Six hours after 4 * Calmette ”
10,
0-84
Twenty-four hours after “ Calmette”
,i IF i, .
103
m »» i»
,i 12, „ .
1-15
i» »> i»
» 13. - .
103
,, II II
.i 14, .
0*91
I am much indebted to Dr. Colebrook for these estimations.
A recent nodule from the back was excised and the tissue introduced
into a guinea-pig, under the direction of Sir A. E. Wright, by his
assistant, Dr. A. Fleming. The test animal was killed three months
later and showed no symptoms of tuberculosis.
Histology. — Two nodules were excised in this case. The first,
which had persisted for five months, was situated upon the upper arm,
and was a prominent purplish-blue keloid-like tumour. This had never
ulcerated, and similar lesions had, according to the patient, left the
pitted scars which w T ere to be seen on the arm and elsewhere. The
section showed the whole of the central part of the tumour, from the
epidermis to the hypoderm, occupied by thin strands of faintly staining
fibres, in horizontal wavy bands, contrasting with the normally thick and
normally stained connective tissue at the periphery of the swelling.
Interspersed between these fibres were very numerous groups of cells
encapsuled by the connective tissue. Elastin was entirely absent in this
part of the tumour, although present at the periphery. The epidermal
down-growths were also conspicuously absent, the line of junction of
corium and epidermis being, as in scar tissue and keloid, an unbroken
horizontal plane, without papillary bodies or hair follicles. The resem¬
blances of this section to keloid make me inclined to think that in certain
stages of granuloma annulare the clinical and histological features of
keloid may be closely imitated. I am confirmed in this view by the
experience of Dr. Nevins-Hyde, Dr. Montgomery, and Dr. Ormsby with
a case w’hich is alluded to in the description of Dr. Montgomery’s case
of ringed eruption, recorded elsewhere in this paper. These observers
met with a case which, clinically, they would have regarded as an
instance of “ granuloma annulare ” had not the histology been that
of “circinate keloid.” The photograph of this case, kindly sent to
me by these good friends of mine, together with a section of the case
bv Dr. Ormsby, recall very closely the appearances seen in the nodule
I am here describing. Further confirmation is given by the case of
Derm a tologi cal Sec t i o n
141
Quinquaud, the wax model of which is described in the St. Louis
Museum Catalogue as “fibromes fascicules,” a description which would
aptly fit the histological characters of both the present case and that
of Dr. Hyde, Dr. Montgomery, and Dr. Ormsby. The frequent
mention, in the synopsis of cases, of cicatricial and atrophic clinical
appearances in certain stages of the lesion of granuloma annulare
supports the suggestion I would make that keloid-like stages are met
with in the involution of the nodule of granuloma annulare.
In the second nodule from the case of A. C., which was a quite
recent lesion, also from the arm, but certainly not more than one
week old at the time of excision, the appearances are much more
in conformity with the other cases I have recorded, and are, indeed,
especially like the histological features of the case of W. S., of
my series, and the case of Brocq, sections of which are described
in detail under the description of these cases. These three cases, in
fact, form a series which has materially influenced me in the view
I now hold that lichen annularis and granuloma annulare are one
disease, and with strong associations with tuberculosis. My argument
is, briefly, that W. S. was clinically an undoubted case of granu¬
loma annulare as it appears in the adult; Brocq’s case apparently as
undoubtedly a case of lichen annularis in the child ; and A. C.,
though clinically a dubious instance of either, histologically is identical ;
and A. C. showed definite tuberculous symptoms.
To resume the description of the second (recent) nodule in this
case (fig. 21) :—
The stratum eorneum and granular layer are normal; there are
small accumulations of cells surrounded by normal connective and
elastic tissue in the cutis in its middle part, and more deeply there
are areas where the elastic and fibrous tissue is slightly broken up
and infiltrated with cells. This infiltration increases in severity in
the deeper layers of the skin, until in the hypoderm the w r hole fatty
zone is impregnated with cells, and there is here definite sclerosis
and fibrotic change of the fat-lobules, very clearly seen in the sections
stained with von Gieson-Hansen.
The cell-infiltrations in the corium, which are centred round
hair-shafts, vessels and sweat-ducts, are seen to consist chiefly of
large mononuclears with some polynuclears, of connective tissue cor¬
puscles and epithelioid cells, and in this case a considerable number
of mast-cells. Some multinuclear giant-cells without central casea¬
tion were seen in one section.
142
Graham Little: Granuloma annulare
General R e m a r k s.
Initial Lesion and Terminology .—In the.synopsis of all the cases
of which I have been able to find record or obtain information
I have set apart a special column describing the initial lesion; it
will be seen that in the overwhelming majority of cases this is a
nodule; Brocq’s name for the disease, “ neoplasie nodulaire et cir-
cin6e,” seems to me to be preferable to any of the others suggested,
although the term “ new growth ” may not be the happiest to describe
A. C. Recent nodule. (Leitz objective 3; ocular ‘2.)
a Dense infiltration with early fibrosis of fat.
b Fibrosis with large spaces.
d Clump of cells surrounded by collagen.
Stained with von Gieson-Hansen.
the histological features. Objection may be taken to all the other
names proposed. “ Lichen annularis ” seems to me to be a par¬
ticularly unfortunate selection owing to the liability to confuse this
disease with lichen planus annularis—with which, in my opinion, it
Dermatological Section
143
has no connection whatever ; “ ringed eruption ” is too vague, and
does not include the isolated nodule stage which may exist without
the ringed arrangement. The same objection is also valid against
“granuloma annulare,” and the histology is not that of “granuloma”;
but largely no doubt owing to Dr. Radcliflfe Crocker’s selection of
this term, it is probable that it w r ill eventually w r in in the competi¬
tion for supremacy.
I think it is important to insist rather on the character of the
nodule than the perhaps less constant arrangement in rings, which
when present makes the disease so striking that this feature has
monopolized attention. The nodule, then, in its first inception is a
whitish semi-translucent swelling, becoming more visible if the skin
is stretched, when it is easily felt as a deep-seated, hard, pea-like
body in the skin. Many observers have described the subsequent
development of rings as being due to peripheral enlargement of
individual nodules with involution in the centre. My own experience
would lead me to describe the phenomenon as more often due to fusion
of collateral nodules which are grouped in a circinate or crescentic
manner ; I have seen individual nodules become rings only in one
case, w r hich was considered the most doubtful of my series (Case 6)-
But I have repeatedly seen fresh efflorescences of nodules of equal
size and age grouped in rings from the outset, and I believe this to
be the sounder explanation of the circinate arrangement. This cir¬
cinate grouping is common to many diseases in which lesions follow’
the distribution of vessels in the skin. The nodule, in its earliest
stage, is usually white, w r ith something of the appearance and rather
less than the size of a boiled sago-grain. I w r ould emphasize this
early whiteness and semi-translucence, as I believe this feature serves
to differentiate it from the lesions of folliclis. (In Case 6 of my
series I opposed the latter diagnosis chiefly on this clinical difference
as w r ell as on the histology of the lesion.) In Case 4 of my series,
a man whom I had under my observation for many months at St.
Mary’s, it was possible to note the sudden appearance of these white
nodules, which later became red or blue and grouped in rings.
Inversely, too, in the course of involution of the disease, the rings
may become resolved again into nodules, and the ring character
quite disappear.
It is a most curious feature of a lesion, w r hich may be destined
to persist for months and which perhaps has tuberculous associations,
that it may spring into being almost w T ith the suddenness of an
jy—*
144
Graham Little: Granuloma annulare
urticarial wheal, and with no subjective symptoms whatever to mark
its coming. But Darier’s experimental production of typical tuber¬
cular nodules in the skin fifteen days after an injection of tubercle
bacilli proves that the rapidity of the tubercular process is greater
than one would be inclined to suppose from the contemplation of
the more ordinary clinical progress of tubercular manifestations.
Similarly, the demonstration of the histologically tubercular character
of the rash of lichen scrofulosorum resulting from the injection of
tuberculin, often within a few hours of that injection, proves that
histological tubercle may be of very rapid production.
The nodule is deeply seated in the skin, as both clinical and
histological evidence shows. In some of the cases the earliest inflam¬
matory collection of cells appeared to surround especially the sweat-
coils (Pringle’s case, e.g.) t a point which will be referred to later.
The nodule is usually the earliest lesion, but in some cases the
eruption was first seen in the form of a ring, which could generally
be made out as consisting of individual nodules, discrete, closely
grouped and enclosing a space of skin concerning which the descrip¬
tions differ greatly. Usually the colour of this central area is darker
than normal, more congested and red ; sometimes the skin has been
noted to be “atrophic” and even “cicatricial.” The size of the ring
varies also greatly, from J in. in diameter to 2 in. or more. The
border is usually about ^ in. in width and about the same in height.
A certain degree of erythema immediately surrounding the nodule
and the rings has been described, but is not constantly present ;
the “halo” of redness contrasts with the whiteness of the lesion.
The ring may involute unequally so that part of the edge may
flatten, leaving the rest unimpaired. The ring is thus often not
complete, but crescentic and festooned figures are formed by the
grouping of the nodules. The lesions on disappearance may be said
to leave, in the majority of cases, no permanent scar or pigmentation.
The distribution of the disease is very specialized. Upon reference
to the table it will be seen that the hand is the commonest seat, the
dorsum of the fingers and the wrist being especially often occupied.
Next in order of frequency come the feet, the ankle, the neck, elbows
and knees, and the buttock. The face and the scalp are rarely affected.
The number of lesions is usually restricted to quite a few T , sometimes
to a single instance; but there they may be, exceptionally, an extensive
distribution (Cases 32, 47, 49), which never, however, approaches the
degree of a general efflorescence.
Dermatological Section
145
The course of the eruption is very varied. The longest duration
noted in any case was seven years (Dawson). Lesions untreated
appear to be extremely indolent and to show little tendency to spon¬
taneous cure, but when treated the most obstinate lesions seem to
be dispersed by quite simple means, such as maceration. In one
case, after excising a small nodule from a large patch on the wrist,
I found a week later, apparently as a result of the bandage applied to
the part, that the neighbouring nodules had flattened down almost to
vanishing point. Adamson has reported a similar experience. Untreated,
the nodules, and* the rings made up of nodules, slowly enlarge and
apparently persist indefinitely (but see Sequeira’s and Jadassohn’s
cases, in which spontaneous involution occurred). Ulceration of the
nodules or rings does not appear to occur even where scars have been
noted ( compare w T ith sarcoids of Darier, where ulceration is also absent).
Subjective Sensations. —It has been noted that the lesions of the
disease may appear as suddenly as urticaria, and it is somewhat remark¬
able that with so acute an onset there are usually no subjective
symptoms associated with the eruption. The lesions are stated to
have itched slightly in a very few instances. With this exception
subjective symptoms are absent, and the first intimation that the
patient has of his affection is that he sees the nodules or rings.
Incidence of Season , Age and Sex. —In the few cases in which it
was possible to ascertain the date of commencement of the eruption,
a preponderating number appear to have begun in the summer months,
and this is suggestive in view of the involvement of the sweat-glands
indicated in the histological examinations of early cases. The age of
the patients varied within wide limits, the figures, in the cases where
the age of the patient is recorded, being nineteen cases under the
age of 1*2, as against twenty-eight in patients above that age; the
oldest age at which it was observed was 52 years, the youngest at
1 h months. In twenty-four cases the female, in twenty-three cases
the male sex is recorded.
Rarity of the Disease. —I had personally never had a case under
my own observation until the latter half of 1904, when Case 1 of
my series came to me at St. Mary’s Hospital. In the next two
months I had seen of my own and others four further examples
of the disease, and in the same six months Brocq and Dubreuilh
reported their series of cases. A careful examination of the records
of the Dermatological Societies of London and of Great Britain shows
a singular dearth of such cases since Galloway’s report in 1899 up to
146
Graham Little: Granuloma annulare
1904, and it remains a very rare disease. Hyde and Montgomery,
whose general turnover of cases is enormous, have seen only one of
this type prior to 1899, and in a quite recent letter inform me that
they have seen no other instance of it. The disease, however, is
certainly not so rare as is stated, e.g ., by Galewski, who could only
record four cases. Many new cases are reported in this paper, and
others are mentioned which are unreported.
Histological Consideration .—I think it is impossible to avoid the
conclusion that in the four cases which I have referred to as Pringle’s,
Perry’s, Galloway’s, and my own case of H. M., the disease is the
same. All these occurred in children; clinically they were manifestly
identical as far as I can testify, who saw them all. They are the
type to which Galloway’s name of lichen annularis applies. Similarly
I think that histologically it is impossible to refuse the conclusion
that the three cases of A. C. and W. S., of my series, and Brocq’s
case, described in the text (Nos. 49, 47, 22), are one disease; and
the question to be decided here is whether these two classes can be
approximated or identified. A detailed exposition of the histological
appearances in each of these groups of cases will be necessary before
this question can be decided.
First Group .—In all four cases the epidermis is little, if at all,
affected, a very moderate thickening of the stratum corneum, a granular
layer which is perhaps a little thicker than normal being all that is seen
to note. There is no acanthosis, no thickening of the rete.
In the corium the subpapillary zone is almost normal; in Galloway’s
case alone of this series is there any degree of infiltration here, and it is
obvious that in this case, too, the infiltration becomes more marked and
more extensive deeper in the skin, and that the more superficial
inflammation is a continuation of that which has taken place in the
deeper zones. In all four cases the chief changes, amounting to tumour
formation, take place in the zone where corium and hypoderm meet.
Here there is an accumulation of cells in the section, which constitutes a
microscopic nodule. Ift these four cases the central part of the nodule
round which the cell infiltration is grouped seems to be composed of
dilated sweat-coils ; but similar groups of cells are also found round the
hair-shaft and probably round blood-vessels. In two of the cases
(Galloway’s and H. M.) there appeared to be areas of degeneration in
some of these cell-masses, and elastic and connective tissue fibres were
absent from these cell-masses, or if found interspersed between the cells,
these fibres were fragmentary. In other parts of the section both elastin
Dermatological Section
147
and connective tissue (collagen) were normal. In the other two cases of
this series (Perry's and Pringle’s) no data were obtainable as to the elastin.
Besides these aggregations of cells in rounded clumps, there w r ere
numerous rows of cells ascending from the tumour-mass to the surface,
and distributed apparently along the course of sweat-ducts, hair-shafts
and vessels. There were less numerous horizontal rows, lying between
the fascicles of the connective and elastic fibres, and further a scattered
cell-infiltration permeating the connective tissue.
When examined with the higher power the cell-masses, both when
lying in clumps and surrounded by connective tissue, and when inter¬
spersed in rows between the fibres, appear to be of the same type,
and to be composed chiefly of three kinds of cells: (1) A large mono¬
nuclear cell, staining vividly with nuclear dyes, larger than a leucocyte,
but without the protoplasmic envelope of plasma cells, such protoplasm
as is present being like a thin halo with the nucleus in its centre. These
are probably the chief constituent of the cell-mass. (2) Numerous
spindle-shaped, or oblong, or pear-shaped cells, not staining so deeply as
the above, with an elongated nucleus, and indistinguishable from con¬
nective tissue corpuscles. (3) A few large faintly stained “ epithelioid ”
cells, interspersed in the cell-mass. Mast-cells appeared unduly numerous
in one case (H. M.).
In the case of H. M. and Galloway’s case the infiltration descends
to the deepest part of the corium and probably implicates the fatty layer,
since the section which terminates at this layer is strongly infiltrated
right up to the cut margin. The same is true to a less degree in Perry’s,
and to a still less degree in Pringle’s case. The latter seems, indeed, to
show the earliest type of inflammation of any of the cases examined.
Second Group of Three Cases .—The epidermis is unaltered, the
granular layer, the stratum corneum and the rete being all normal.
In the corium, in the upper parts immediately below’ the epidermis,
there are isolated small groups of cells lying between separated con¬
nective tissue, and found to be in association with blood-vessels. These
groups become far more numerous and larger as one descends into the
corium, so that the main changes appear in the middle and lower parts
of the cutis. Here the cell-masses come to occupy the greater part of
the tumour-formation. The cells are arranged in clumps surrounded by
connective and elastic tissue, and in long vertical and horizontal rows,
following the course of vessels. In the “ clumps ” the cells are closely
packed together and fill the pockets formed in the connective tissue; in
the masses themselves there is usually no elastin or connective tissue,
148
Graham Little: Granuloma annulare
but in localized areas of the section there are broken-up elastin and
collagen tissue lying between cells which are less closely packed, and the
tissue is here cedematous. In the rows of cells which appear to conic
from the tumour in the hypoderm and lower corium,and to ascend along
sweat-ducts and hair-shafts, as well as along blood-vessels not connected
with these structures, the same type of cells is seen as in the clumps:
and three kinds may here again be described as in the case of the first
group of cases, namely, mononuclears, connective tissue, and epithelioid
cells. Mast-cells are occasionally found in abnormal number. The
blood-vessels appeared in many parts of the section thickened and even
obliterated by endarteritis.
In many of the foci of cells there appears to be a central destruction.
Giant-cells were found in one case (A. C.), but there was no typical
“ tubercular ” structure.
A diffuse cell-infiltration in all these cases involved especially the
fatty zone, which was in many places actually fibrotic in large areas.
The cell-masses in many instances could be demonstrated to surround
sweat-coils and ducts and hair-shafts.
Upon comparing these seven cases together, I think a gradual
transition from the simplest case (that of Pringle) to the most com¬
plicated (that of Brocq) can be noted, and I am personally convinced
that the disease in these seven cases was the same; in fact, the
transition, to my mind, is almost like that of serial sections. In all we
have to do with a deep hypodermic inflammation gradually spreading
towards the surface and situated round vessels; the cell-masses observed
in all the cases have much the same character as regards the cells
composing them. In several instances of both groups there is a nodular
necrosis observable. The constancy of the clinical appearances is
another and an equally strong argument for their identity. In only
one of the cases reported as of this type, that of Savill, are the
histological features unlike, and on this ground I should be inclined
to refuse - recognition of this case, the diagnosis of which was very
uncertain and the records utterly inadequate. In the case of Dubreuilh
the thickening of the rete and other granular layers is also unusual,
but the infiltration is, as in the seven cases here compared, deep seated
and of the same type. In Jadassohn's case, which clinically was a little
doubtful, there is the same deep-seated nodular infiltration, and I should
regard this case as a true instance of the disease.
Nature of the Disease .—In view of the opinion of the tuber¬
culous associations, which will be discussed at length later, it is
Dermat a loyical Sectio/i
149
interesting to note that the earliest case recorded—that of Kadcliffe
Crocker, in his “Atlas” in 1893—was recorded under the title of lupus
erythematosus. Dr. Crocker expressly states in his later paper on
granuloma annulare that this earlier case was of this class.
Kadcliffe Crocker has drawn particular attention to the frequency
with which “warts” preceded the development of the eruption. It
seems to me probable, however, that the tendency of patients to
describe any excrescences on the hands under this generic title explains
this frequency, for evidence of which reliance must usually have
been placed on inexperienced narrators, who would be likely to
mistake the early nodules for warts. Warts are epidermal ; this disease
is essentially non-epidermal, and no association between the conditions
other than accidental can be conceived.
The exact relation to “ granuloma annulare ” of the group of
cases named by Crocker “erythema elevatum diutinum ” is very diffi¬
cult to determine, especially as no accepted case of the latter morbid
class has appeared at any of the dermatological societies for many
years. The description of the case which formed the basis of Dr.
Crocker’s paper reads much like the condition seen in granuloma
annulare in the histological features of a deep-seated inflammation
of the corium, with fibrous changes resembling keloid. Crocker was
“ doubtful ” as to the identification of this case with Galloway’s case. 1
Galloway and Brocq are both inclined to associate this type closely
with “granuloma annulare.” The cases of Hutchinson, Judson Bury,
and others included in erythema elevatum diutinum remain of
uncertain nature.
Dr. Colcott Fox has called my attention to a case reported by
Gallois under the title of gummata of the palm (which they certainly
seem very unlike), which may be an instance of the disease, 2 and to
an earlier case of Yolkmann’s, in a child, reported as spontaneous
keloid. The illustrations of this case do not very closely resemble
the clinical picture of granuloma annulare, but the position, the histo¬
logical evidence of fibrosis, and the spontaneous origin may suggest
this identification. 8
The opinion that the disease under discussion is a type of lichen
planus is held, I understand, by several observers; and there is no
doubt much difficulty in distinguishing the circinate lesions of lichen
1 Vide Galloway, Brit. Joitrn . Derm ., 1899, pp. 221, et scq.
■ Journ. de AL'd. dc Paris , November 24, 1901, p. 278.
:{ Von Langen beck’s Archiv , xiii.
150 .Graham Little : Granuloma annulare
planus from this eruption. Cases of lichen planus have, as I think,
for example in Savill’s report, been regarded as cases of this disease,
but the histology to my mind is quite different. The granular layer,
so notably increased in lichen planus, is not increased in the most
typical examples of “ granuloma annulare.” . The cell-infiltration in
lichen planus is much more circumscribed and superficial; clinically
the different incidence of granuloma annulare, its relative frequency
in young children, in whom lichen planus is rare, the complete
absence of notable itching, the lack of papules simulating lichen
planus, the different distribution, all contradict the assumption of
identity. The term lichen annularis for this disease, which l)r.
Galloway, its inventor, has assured me was not intended to assume
this identity, has undoubtedly confused the issue, and on these
grounds alone I think this name should be discarded. *
Kasch and Gregersen, in 1903, discussed in a very full and elaborate
record of a case (reproduced here) the etiology of a group of cases
which included Colcott Fox’s, Galloway’s, and Dubreuilh’s first case.
They drew attention to the close analogy with “ sarcoids ” of Boeek.
Brocq also suggested the approximation of this group to “ sarcoids,”
and Galewski, in fact, adopts this classification, his case being record (id
as “ tumores benigni sarcoidei cutis.” I have not personally had an
opportunity of seeing either a case or a section of “ sarcoid,” but on
reading through the paper by Darier and Koussy on this subject
I have been struck by several points of similarity.
Darier’s sarcoids, as distinguished from Boeck’s, originated deeper
in the corium and showed a more tuberculous structure. Sarcoids,
as described by Darier, are “ neoplasms composed partly of inflam¬
matory alterations of the adipose tissue, partly of tissue having all
the characters of tuberculous tissue; originating in the hvpoderni,
the neoplasm appears to extend by invading the neighbouring fat-
lobules and the lymphatic channels, and by following the vessels and
sweat-ducts which serve as an axis upwards into the corium. These
neoplasms are tuberculoid nodules surrounded by young connective
tissue infiltrated with round-cells.” Giant-cells may or may not occur.
From their histological characters, from the history of the recorded
cases, and from their tuberculin reactions, Darier regards sarcoids as
being of the nature of tuberculides; no bacilli have been found in
sections, and the injection of tissue from sarcoids into guinea-pigs has
been negative; so that sarcoids occupy the following relation, in his
opinion, to other clinically similar diseases with tubercular associations:—
De r ma to logic al Sect i o n
151
Scrofulodermata: virulent to guinea-pigs; -f bacilli.
Erythema induratum : virulent; no bacilli.
Sarcoids: non-virulent; no bacilli.
Patients the subjects of sarcoids react, both locally and generally,,
to tuberculin and the tumours diminish under treatment with tuber¬
culin injections.
In the case of A. C., noted above, the patient reacted strongly
to Calmette’s test, and the tissue of a recent nodule injected into
a guinea-pig produced no result. In her opsonic reaction she gave
on only one occasion a heightened index, the other estimations, seven
in number, showing a fairly constant index about the normal. This
patient, moreover, presented signs of pulmonary tuberculosis, so that
these tests, even if accepted as evidence of tuberculosis, are rather
vitiated as regards their bearing on the skin lesions. T submitted
sections of this case to Darier, who did not regard them as identical
with his cases of sarcoid, though somewhat analogous.
The tuberculous association of these cases suggested by their histo¬
logical similarities with “ sarcoid ” receives considerable confirmation
from the clinical histories—a fact noted long ago by Crocker. The
frequent mention in the synopsis of cases here submitted of tuber¬
culous antecedents is striking; this is, indeed, perhaps the most frequent
common factor in the cases recorded, and my personal view is strongly
in favour of this etiology.
Treatment .—In my own cases local measures seemed satisfactory
without any internal medication: salicylic acid, either in ointment
or plaster, ichthyol or resorcin in ointment being adopted. In two
cases the incidental application of dry dressings after a biopsy caused
apparently the involution of the neighbouring lesions covered by the
dressing. Jadassohn in his first case found cause to think internal
administration of arsenic w r as more successful than local measures.
The prognosis as regards the actual disease would appear to be uni¬
formly good, since in all the recorded cases the skin lesions ultimately
disappeared ; but the possibility of recurrences, and the graver possi¬
bility of tuberculous associations should not be lost sight of in the
general prognosis.
Bibliography.
The following synopsis of cases furnishes a complete bibliography,
which need not therefore be repeated.
152
Graham Little: Granuloma annulare
Table of Cases kepobted as " Gbanuloma annulabe,” “Lichen annulabis,” “ Ringed
Xo. Reference Recorded by Title of record Skx Age Distribution of eruption
1 Brit. Jo urn. Colcott Fox Riuged eruption F.
Derm.. 1895,
p. 91
11 Left ring finger, right
little finger
2 Loc. cit., 189 0, Colcott Fox Ringed eruption
p. 15
2 Twelve to fifteen ringed
lesions on buttocks
and backs of thighs
3 ,4ww. dc Derm., Dubreuilh Kruption circinec F..
1895, p. 355 eh r o nique de la
main
33 Index and middle fin¬
gers of both hands,
left thumb
4 Loc. cit., 1905, Dubreuilh Neoplasie uodulaire M.
p. 65 et circinec
On tendo Acliillis (both
sides), legs, and feet,
right index, forehead
5 Loc. cit., 190 5,
p. 08
Dubreuilh Neoplasie uodulaire F.
I et circince
20 Cleft of finger, back of
hand, left index
0 Loc. cit., 1 90 5, Dubreuilh Neoplasie nodulaire F. 18
p. 09 et circinec
Base of left index
7 Communicated Dubreuilh Neoplasie nodulaire M.
(1908) et circinec
8 Brit. Jo urn. Gallowav Lichen anuularis M.
Derm., 1899,
p. 221 .
3 Dorsal base of index
finger, radial edge of
left hand
10 Fingers and thumbs of
both hands, left ear
9 Loc. cit., 1 90 2, R a d e 1 i f f eGranuloma annulare M.
p. 1 (rocker
20 'Right wrist aud thumb,
left medius and fifth
finger, oar, inner can-
I thus, jaw, scalp
10 Loc. cit., 1 902, R a d c 1 i f fe Granuloma annulare M.
p. 5 Crocker
21 ^Back of hand, wrist,
nape of neck
11 Loc. cit., 1 902, R a d c 1 i f f e Granuloma auuulare F. 52
p. 5 Crocker
Wrist, nape of nock
Dermatological Section
153
Eruption,” “ Nkoplasie nodulaire et circinke,” 4 ‘ Tumores benigni sarcoidei cutis,” <fcc.
Initial legion Duiatioii Evolution of diseas** Histology General mnarks
Nodule
2 1110S.
Nodules formed rings,
which extended peri¬
pherally ; central skin
normal
Suffered from pains in
the shoulders, but no
rheumatism ; began in
winter ; no subjective
symptoms
Nodule
o mos.
Nodules formed riugs
with depressed atro¬
phic centres ; some
lesions remained no¬
dular throughout
Begau in very hot weather;
child quite healthy, no
subjective symptoms
Le 11 1 i c u 1 a r
s\ve 11 i n g s
the size of
lentils
5 vrs.
Nodules formed cres¬
cents and rings, cen¬
tral skin depressed,but
became normal later
Diffuse cell-infiltra- Eruption disappeared
tion in middle quickly with ichthyol ;
zone of corium no subjective symptoms
Papules, deep 1
nodules
2 mos.,
with re¬
currence
Nodules formed rings
and crescents, central
skin depressed, but
normal; recurred, no
traces left finally
Digestion disturbed, but
child otherwise healthy;
family history good
White, hard 4
nodule
- 5 vrs. Peripheral extension,
with central depres¬
sion ; no scar left
Very nervous patient, but
no disease present ; no
subjective symptoms ;
lesion disappeared in
two months with treat¬
ment
Nodule
2 yrs.
Nodules formed seg¬
ments of circle ; scar
left as result of treat¬
ment with caustics ;
lesions recurred
Patient had good general
health ; family history
good
Nodule
1.J yrs.
Kings made up of no¬
dules, central skin
normal
Child otherwise well ; no
family disease; no
phthisis
Nodule
(> yrs.
Kings with white bor¬
der, central skin
slightly atrophied,
rapid peripheral ex¬
tension
Cell-infiltration in Personal and family his-
eutis, slight de- tory good ; lesions de¬
struction of con appeared in six months
nective tissue with treatment, but re¬
curred three years later ;
wart on hand
P ale red
nodules
1 yrs.
Nodules coalesced toThickeued re to. Delicate man, but no
form circles with de- sweat-coils infil actual tubercular his-
pressed central skin trated with cells, tory ; lesions itched
dense cell - mass slightly
in cutis
B e g a n as
s w c 1 1 i n g
with mat¬
tery head,
also red
papules
2 yrs.
Kings made up of no¬
dules, which invo¬
luted, leaving reddened
depression
— One brother died of
phthisis; no other
family history; general
health good, had ordi¬
nary warts on hand
Papules
white, with
red areola
2 mos.
Involuted, forming
rings and crescents
Strong family history of
tuberculosis; lesion dis-
appeared within six
months
154
Graham Little: Granuloma annulare
Table of Cases reported as
2V 0 i Reference Recorded by Title of record Srx Age Distribution of eruption
12 Brit. Jo u m . R a d c 1 i f f e Grauuloma annulare M. 11 Elltows, wrists, knees
Derm., 190*2, Crocker
1 >. 0
l : t Loc. cit., 1 'JO '2, H a <1 c I i f f c Grauuloma annulare M. Adult Index
]). 7 Crocker
and Pernct
11 Loc. cit.,
p. ‘217
1 9 0 2, H a d c 1 i f f e Granuloma annulare M.
Crocker
Adult Back of both hands,
right index, left index
lb Loc. cit., 1899, Pringle
p. 435
AI. 18 Neck, face, scalp, wrist
10 Loc. cit., 1 9 0 5, Pringle Kinged eruption of M. 1*2 Hands, thigh
p. 19 extremities
17 Loc. cit, 19 O 2, J. H.Se<|iieira Kinged eruption M. 28 Back of hands and
p. 27o
fingers
18 Communicated J. 1 LSequeira Granuloma annulare F.
19 Communicated J.11 .Sotjueira Granuloma anuulare F.
20 Communicated J. I LSequeira Kinged eruption F.
21 .Ircltir. fit /K ascii amll Sarcoid tumours F.
1) e r in., 1903 < 1 regorsen
8 Kight index, back right
hand, right wrist,
back of left hand
*21 Back of right wrist,
back of left wrist, left
index
S Palms of hands, front
of ankle
33 I) o r s a 1 surface left
index, fingers of right
hand
22 Ann tie Derm..
1904, p. 1089
l>mc(| N< oplasie nodulaire M. Child Back, side’s, and front
et circince of fingers
*23
“ Traitc de Derm,
pratique," ii.,
p. 27(>
Brocq
G ranuloma
annulare
M.
Adult
Back of fin gets
24
Loc. cit.
P>roc(j
Granuloma
annulare
F.
Adult
Fingers and hand>
T)e rma to lofjical Her ti< > n
155
“Granuloma annulare,’’ Ac. (continued).
Initial lesion
Duration
Evolution of disease
I. i k e a flat Over 1 yr.
wart
Ring formed, with dark
atrophic centre
Nodules
•>
Rings formed, consist¬
ing of reddened no¬
dules
Ring with
o 1 e v a t o d
edge
*>
Ring enclosed pig¬
mented and slightly
atrophic skin
Papules and
warty no¬
dules
ft mors.
Skin between nodules
was uormal in colour,
with uatural lines
deeper than usual
Nodules and
rings
9
—
Pale red
24 vrs.
Centre of ring atrophic.
spots, ?
nodules
with some pigmenta¬
tion
Nodules
S c v c r a 1
months
Nodules formed rings
Nodules
ft mos.
Nodules formed rings
Ringed
patches
9
—
White no¬
1 yr.
Centre of ring smooth
dules, later
rings
p
Cu
p
— i
o
FT
Wart y no- — Rings formed with do-
dule pressed centre, becom¬
ing definitely cica¬
tricial
1 yr. Rings disappeared with
application of electro
cautery
Rings disappeared with
application of s a 1 i -
cylic acid plaster
Histology CJeneral remarks
Patient had bad sunstroke,
w arts appeared syn¬
chronously with lesions
In addition to the ringed
lesions there were uu-
group ed nodules on
forehead ; patient
healthy and family his¬
tory good
Sweat-coils slightly
infiltrated and
distended
History of tubercle in
mother’s family; patient
pale, thin, with mitral
disease; lesion disap¬
peared spontaneously
within six months
Cured with ung. acid. sal.
iu less than one month
Case lost sight of
Cell-infiltration in Family history good:
eorium, deeply disease recurred after
situated, some six years interval; dis-
areas of necrosis, appeared without trace;
elastin fragmeu- no subjective sensations
tary in parts, con¬
nective tissue
tumour
Cell-infiltration in C h i 1 d otherwise well;
hvpoderm and lesions commenced as
eorium, sclerosis ‘ warts” and were
of fat -lobules, cured by Vidal’s plaster
necrosis in some
areas of con¬
nective tissue
15G
Graham Little: Granuloma annulare
Table of Cases reported as
Title of record Sex Age Distribution of eruption
25 “ Traite de Derm. Brocq Granuloma annulare F. 8 Ankle and knees
pratique,’’ ii.
2f» A?in. de Derm ., Audry Erythemato - sclerose F. 50 Sides of medius and
1004, p. 9 circinee du dos de index
la main
27 St. Tjouis Hos- Quinquaud Fibrome fascicule — Hands
pital M n s. (1891)
Catalogue
28 Brit. Jo urn. T. P. Savill Lichen annularis M. 4 4 Neck, chest, upper
j Derm ., 1905, limbs
p. 23
29 Loc. cit. and com-P e r r y and Granuloma annulare M. 8 Extensor surface of
municated Sichel hands and feet
(1908)
30 Communicated Leslie Acanthoma annulare F. 9 Both ankles, but chiefly
(1908) Roberts right
Ml Communicated Hyde and Ringed eruption M. 10 Radial edge of left
(1908) Montgomery index
(notes by
F. H. M.)
M2 Communicated Jadassohn Granuloma annulare F. 59 Axilla*, groin, elbow.
(1908) wrist, knees
33 Communicated
(1908)
Jadassohn
G ranu 1 on \ a annulare
F.
4 Left hand, right hand,
right foot, both thighs
34 Communicated
(1908)
Adamson
Ringed eruption
M.
M! Buttocks, back of
thighs
35 Communicated
(1908)
Adamson
Ringed eruption
M.
2A Elbows, buttocks
30 Brit. Jon r n .
Derm., June.
1908
Adamson
Nodular ringed erup¬
tion
M.
17 Back of fingers of both
hands
Dermatological Section
157
“Granuloma annulare,” &c. ( continued ).
Initial lesion
Duration
Evolution of disease
Histology
General remarks
—
2 yrs.
Rings formed
—
—
Hard pink
nodules
8 mos.
Rings formed with H i s t o 1 o gy “like
nearly normal centre Dubreuilh’s ”
1
—
Nodules
—
1 _
Histology suggested
name “ fibrome
fascicule ”
—
Rings
G mos.
Diagnosis doubtful;
treated for five
months with mercury
aild iodides on syphi¬
litic hypothesis
Nodules :
1-4 mos.
Rings, made up of Sweat-coils dilated Personal and family his-
papules, disappeared and infiltrated; tory good
some general cell-
infiltration i n
cutis
Nodules
1 yr.
Large rings formed by
slow peripheral ex¬
tension ; no scar left
Hypertrophy of epi
dermis, no cell-in¬
filtration, sweat-
ducts dilated
Hands “ bluish ” ; no chil¬
blains
Nodules
•^4 y ? -
Border of rings sugges¬
ted keloid in colour
and density ; central
portion normal
Nodules were left after
rings disappeared ; even¬
tually no trace left;
patient delicate health
Nodules and
rings
3 jrs.
Some pigmentation
left; very large rings
and patches formed of
nodules disappeared
and recurred
Some grouped cell-
masses in deeper
part of corium,
elastin broken up
in these places
General health good ; no
tubercle ; some gouty
and nervous traits
C i r c i n a t e
patches of
nodules
1 yr.
Some patches disap¬
peared spontaneously
Itching complained of,
not confined to patches,
child otherwise in good
health
Nodules and
rings
G mos.
Rings with edge made
of distinct nodules,
and with pink centre
No history of rheumatic
fever; no evidence of
tuberculosis; child in
good health
Lumps and
rings
1 mo.
Lilac rings with central
enclosed part darker:
nodules on elbow
—
—
Small red
lumps
5 mos.
Tendency of nodules toCollectionsof mono¬
group in rings, erup- nuclear round-
tion disappeared sud- cells around
denly within fourteen blood-vessels and
days after biopsy of sweat-glands
one lesion
158
Graham Little: Granuloma annulare
Table of Cases reported as
Casr
No.
Reference
Recorded by
Title of record Sex
Distribution of eruption
37
“Iconog raphia'
Dermatologica,’*
Fasc. iii.. 1908
Galewski
Tumores benigni sar- F.
coidei cutis
20
Forearm, right index
finger
38
Brit. Jo urn.
Derm., 1908
I )awson
Granuloma
annulare
M.
22
Left hand, over fingers
and back
39
i Communicated
MacLeod
Granuloma
or lichen
annularis
annulare
planus
M.
43
Left hand ; later recur¬
rence on both hands
40
! Communicated
Darier
Granuloma
annulare
F.
9
Thigh
41
Communicated
Darier
Granuloma
annulare
F.
9
Hip
42
Communicated
Montgomery Granuloma
annulare
F.
Leg
43
Communicated
l
Colcott Fox
Ringed eruption
F.
35
Back of both bands,
index finger
44
Case
G r a h a m
Granuloma
an 7i ul are
F.
6
Radial edge, right hand,
external malleolus,
left foot
45 Case 2.—E.W. Graham Granuloma annulare M. 3 Front of left wrist
Little
40 Case 3.— E.P. G r a h a m Granuloma annulare F. 10 Dorsum and side of
Little right hand
47 Case 4.—W.S. Graham Granuloma annulare M. 42 Front of both wrists:
Little elbows, knees, nape
of neck, fingers
48 Case 5. K.C. G rah am Granuloma annulare F.
Little
4 Buttocks, one lesion on
each side; nowhere
else
49, Case 0.—A.C. G raham Granuloma annulare F. 18 Base of index and little
Little finger; .wrist, arm,
breast, tendo Acliillis,
toes, foot, back, neck
Dermatological Section
159
“Granuloma annulare,” &c. ( continued ).
Initial lesion
Duration
Evolution of <1 inea.se
Histology
General remarks
Spots de¬
veloping
into no¬
dules
6 mofi.
Nodules formed cres¬
cents and rings; the
centre of these showed
normal skin or at most
slight atrophy; disease
cured and recurred a
year later ; fi n a 11 y
disappeared
Diffuse cell-infiltra¬
tion in cutis of
fixed connective
tissue cells
Nodules with
red areola,
later rings
7 yrs.
Nodules with
involution,
forming
rings
14 dys.
Lesions disappeared
rapidly ; recurred a
year later on same
part and then also
disappeared rapidly
—
Digestive disturbances
and nervous depression
complained of
Nodules
?
Circinate rings
—
Diabetic and syphilitic
Nodules
?
Circin&te rings
—
Diabetic
Ring
?
—
Keloid-like
—
Nodules and
rings
Many
years
Case lost sight of
—
Chilblain circulation;
hands blue
Nodules
forming
ring
5 mos.
White raised border,
became red later; dis¬
appeared completely
in about three mouths
with treatment
Nodular infiltration
of cells round
sweat-ducts and
glands, some
areas of necrosis
Child perspired freely and
was not robust, but
showed no defiuite ill¬
ness; had had “nettle
rash ” fourteen days
before appearance of
“granuloma ”
Nodules
forming
rings
3 mos.
Central portion of ringj
pinker than normal,;
with some slight ap¬
pearance of atrophy
Ring of
papules
?
Lesion disappeared
within a few weeks
(probably fourteen
days)
i
Slight itching complained
of
Nodules and
rings
3 yrs.
Some lesions disap¬
peared rapidly, others
persisted, and new
ones came
Nodular infiltration Man perspired copiously
and grouped cells and was thin and deli-
round sweat-] cate-looking; no history
glands and ves- of phthisis
sels, fatty sclero 1
sis and necrosis 1
of connective
tissue
Nodule and
ring
6 mos.
Central skin darker in
colour; no actual
atrophy, but slight
whitish linos left
Nodular infiltration Strong tubercular family
of cutis, some history ; patient person-
areas of necrosis ally well
of connective
tissue 1
Nodules and
keloid-like
swellings
5 mos.
Nodules formed im-
i perfect ring in some
1 cases; no ulceratiorr,
1 but many lesions left
| pitted scars
Nodular infiltration ? Tuliercle of left apex ;
of hypoderm and positive Calmette re-
- cerium, fatty action; nodule injected
sclerosis, giant- in guinea-pig gave nega
cells tive result
JU —5
160
Graham Little: Granuloma annulare
Illustrations; of “ Granuloma annulare ” Previously Published.
i
Crocker. —“ Atlas,” Plate lxvii., labelled “ Lupus erythematosus of Backs of Hands,” figs. 1
and 2.
Galloway. — Brit. Joum. Derm., 1899, p. 221. Coloured plate showing clinical character,
and photograph of histological aspect.
Crocker.— Brit. J(mm. Derm., 1902, p. 1. Coloured plate of clinical characters of three
cases, and photograph of histological appearances of one.
Brocq. —“ Traits de Dermatologie pratique,” ii. Photograph of clinical aspect.
Rasch and Gregersen. —Archiv f. Derm., 1903, p. 387 (histology only illustrated).
Galewski, —“ Iconographia Dermatologica,” Fasc. iii. (clinical and histological).
DISCUSSION.
The President said that the Section was greatly indebted to Dr. Graham
Little for his important contribution. Those who had been through the “ mill ”
knew the enormous amount of time and trouble that such a paper entailed. He
(Dr. Badcliffe Crocker) naturally had special reason to be interested in the
subject. It was in 1893 that he published his first case of granuloma annulare,
although at that time he was under the erroneous impression that it was related
to lupus erythematosus. The similarity was one which had not escaped other
observers. In some cases lupus erythematosus was suggested very decidedly;
in others there was very little suggestion. Probably there was not much rela¬
tionship between the lesions save in slight clinical features. Dr. Graham Little
had put emphasis upon the observation that the lesion was produced from the
grouping of the nodules and not from a single nodule. This was a point upon
which he (Dr. Crocker) had also laid stress, and one in which his cases differed
from those of Dr. Colcott Fox. They had to remember that a single nodule
might be an accidental thing, and it was only by taking a large number of cases
that they could arrive at definite conclusions. Furthermore, the histology of
an old lesion and of a new one differed in many ways. When he first came to
the study of these cases he had only a single nodule to found his ideas upon.
He put the half dozen cases which fell under his notice into the British Journal
of Dermatology, l and reprinted the article as a pamphlet. There was one
feature of these cases that he believed Dr. Little had not mentioned, namely,
the presence of common warts. [Dr. Little signified that this was mentioned
in the full paper, of which he had only read an abstract.] It was a fact that
in several cases common warts had been antecedents and concomitants of
granuloma annulare, and although they did not know- that there was any rcla-
1 Brit. Joum. Derm., xiv., No. 159.
Dermatological Section
161
tionship, and histology certainly did not show any relationship, such a point
in a rare disease was worth mentioning. Another thing to be noted was the
frequency of nodules on the nape of the neck. Nodules on the neck appeared
on the neck were also found in some of them. In that region, of course,
they could be seen more easily than elsewhere. With regard to the likelihood
of the two diseases, granuloma annulare and lichen annularis, being one he
was quite open to conviction, and all would be glad to reduce the number
of diseases.
Dr. James Galloway said that lie desired to join Dr. Crocker in thanking
Dr. Graham Little for the very complete paper which he had read before the
Section. He considered that, as the result of Dr. Little’s painstaking work,
their position as to the class of disease to be considered as belonging to the
category of “ lichen annularis ” had been much more closely defined. It was
especially as regards the types of indolent tumefaction of the skin described by
Continental observers, commencing with Dr. C. Boeck, of Christiania, and more
recently by several French authors, under the name “sarcoid”—subcutaneous
or benign—that confusion may have arisen ; but these would now r disappear
from the horizon when considering the disease which was the subject of Dr.
Little’s paper. In reference to the group of benign “ sarcoid ” tumours, while
prepared to admit their analogies and possibly their relationship with certain
tuberculous affections of the skin on the evidence put forward by Boeck, Darier
and Roussy, and Thiebierge, he thought that by no stretching of classification
could they be put in the same category as the true cases of lichen annularis
mentioned by Dr. Little. With these “ sarcoid ” tumours members of the
Section were no doubt familiar. Examples, he thought, had been brought
forward on various occasions ; he recollected at the moment cases shown to
the Dermatological Society of London by Sir Stephen Mackenzie. In one of
the most recent, viz., that described by Dr. Galewsky, of Dresden, he thought
that the name of “ sarcoid ” was especially misleading ; judging by the descrip¬
tion and by the illustration it was an example of lichen annularis and had no
resemblance to the sarcoids of Boeck, Darier, and Thiebierge. The name used by
Gougerot in describing one of the French cases, viz., “ lymphosarcoide,” in which
numerous small tumours were present in the skin and subcutaneous tissues,
suggested how little was the resemblance between these and lichen annularis.
Dr. Little had been unable to suggest the factors concerned in producing this
skin affection, but he hoped that information as to this might be forthcoming.
Dr. Galloway added that he could not allow the opportunity to pass with¬
out entering a vigorous protest against the use of the term “ granuloma ” given
to this disease. The word “ granuloma,” an unhappy one at the onset, had
come to be specially applied to certain characteristic morbid processes occurring
in the course of certain specific infections—the infective granulomata. The
structure of these tumours was well known ; the peculiar cells which formed
part of the structure could be recognized, but according to the evidence of those
who were actually using the word “ granuloma ” in the name “ granuloma
annulare ” the histology of the small tumours present in that disease was
1G2
Graham Little: Granuloma annulare
in four out of six cases which he brought forward in 1902. When Dr. Graham
Little brought his cases for diagnosis to the Dermatological Society, nodules
clearly not that of the infective granulomata. Wrong, therefore, in its applica¬
tion in the histological sense, it was surely a still greater error to make use of
a term signifying a type of morbid process in order to designate as a clinical
term a special disease. He had a certain amount of sympathy with those who
evidently wished to limit the application of the ancient term “ lichen ” to the
disease known as “ lichen planus,” but he considered that it was as yet
premature to make such an effort with the prospect of success, for the etiology
of that disease was unknown. Indeed, the attempt to do so failed on all sides.
They had heard Dr. Little, in the course of his paper, speaking of lichen scrofulo-
sorum, and anyone listening to the discussions in this room would hear the
terms “ lichen spinulosus,” “ lichen pilaris,” &c., in constant use. He thought
that Dr. Crocker was more happily inspired when in the early days of this
discussion the idea had occurred to him of the relationships possibly existing
between such diseases as lupus erythematosus (so-called) and lichen planus, with
their strong suggestions of a toxaemic origin, and the disease to which Dr. Little
had drawn their attention, than when in later days, in an unhappy moment, he
had applied the name “ granuloma ” to the cases he had described. The disease
under discussion answered to the most strict definition of the old medical term
“ lichen ” used by Hippocrates and accepted by Willan; its curious annular
distribution could not fail to be recognized, so that its name of lichen annularis
was very naturally employed.
Dr. GEORGE Pernet said that he had already pointed out to the members
of the Section that in granuloma annulare there were no plasma-cells—a
point which had also been brought out by Dr. Graham Little. The absence
of plasma-cells inclined him to agree with Dr. Galloway that they ought to
re-christen the lesion, and not include it among the granulomata, a feature of
the granulomata being the plasma-cell formation. He suggested the name
of “ celluloma annulare,” which, although it might equally fall under Dr.
Galloway’s condemnation as barbarous, at least did not commit one to specific
histological surmises.
Dr. T. COLCOTT Fox said that he had brought two or three drawings of
cases bearing upon the subject of the paper. One was a case by Professor
Volkmann in which there was spontaneous keloid of the fingers and toes in
a little child. Another, which he thought would also interest the Section, was
by Tengier, who had published a case he had called “ sarcoma of the hands and
of the knees,” which was very suggestive indeed of erythema diutinum, or the
malady that Dr. Graham Little had been discussing. He mentioned a third
case which was called “ multiple gummata of the hands occurring in a child,”
the palms and backs of the fingers being covered all over with little nodules.
There was a history of syphilis in that case. Another case of interest was
recorded in the British Journal of Dermatology by Dr. Smith, of which a
drawing was shown by Dr. Colcott Fox. It was described as a case of erythema
diutinum. Microscopically the nodules were fibromatous.
Dermatological Section 163
Dr. CROCKER said that the nodules invariably became fibromatous at a later
stage of the lesions.
Dr. H. G. Adamson suggested that, in the present state of our knowledge,
the lesion having been referred to as an annular eruption, the name “ nodular
ringed eruption " would answer the purpose better than any other.
Dr. GRAHAM Little thanked the members for their attention, and explained
that he had only read an abstract of the paper, which was a very difficult one to
read in full. He thanked Dr. Crocker and Dr. Fox particularly for their pictures
of cases, which made a very important addition to the illustrations he had been
able to gather and to show upon the table.
Cjise of Sclerodermia (Morphoea).
By H. Gr. Adamson, M.D.
The patient was a girl aged 10 years. There was a characteristic
patch of sclerodermia measuring 1J in. by 1 in., with a well-marked lilac
border, situated on the back immediately to the left of the third dorsal
spine, with its long axis horizontally. The exhibitor w f as inclined to the
view that sclerodermia was a lesion of toxic origin, and that it was not
very distantly related to the scar-leaving erythemas. The case was shown
because it seemed to lend support to this view. The lesion had developed
rapidly (in two months) from an erythematous patch. Examination of
the patch by palpation at once caused a very marked erythema of the
skin immediately around, and there was an associated condition of
factitious urticaria. Cases of sclerodermia had been recorded associated
with rheumatic or arthritic symptoms, with urticaria, with peripheral
neuritis, with lupus erythematosus, and with changes in the thyroid
gland—all of which conditions pointed towards some form of toxaemia.
DISCUSSION.
Dr. PERNET said that he had long taught that sclerodermia was of toxaemic
origin, and that his treatment of these cases had been based upon this
assumption.
Dr. CROCKER said that there was nothing against such cases being toxiemic,
and, indeed, it was likely if associated with other evidence of toxaemia. He
regarded them as very mysterious cases.
164 Bunch : Tuberculosis on Site of Vaccination Scar
Case of Tuberculosis developing on the Site of a
Vaccination Scar.
By J. L. Bunch, M.D.
The patient was a little girl aged years, who had been vaccinated
when 3 months old. Portions of two vaccination scars are still visible,
but the greater part of these scars is now obscured by a red, scabbed,
irregularly shaped superficially ulcerating lesion, measuring about 3 in.
by 2 in. The edges are slightly thickened, the base of the ulcer shows
granulations, and at the margin are some indefinite nodules of small
size. The lesion commenced with one or two pinkish spots rather more
than six months ago, which gradually increased in size, became more
indurated and broke down, forming a superficial ulcer. * The parents are
apparently healthy. They lost one child when it was quite small, but
there is no history of tuberculosis in the family.
Case for Diagnosis.
By E. G. Graham Little, M.D.
A man aged 37 was shown with two large ulcers on the right cheek,
in the midst of greatly thickened infiltrated skin. These ulcers were
deeply excavated, the floor covered with granulation tissue ; they had
persisted in the present condition for about three months and had been
preceded by an eruption of “ sores,” which would appear to have been
sycosis of the beard, traces of which are still present. A similar
eruption, apparently a pustular folliculitis, had been noted in the hair of
the axillae. The ulcers, when shown, were scabbed over with heaped-up
rupia-like crusts ; they were 1 in. by 4 in. and J in. by J in. respectively.
A scraping from the surface showed no spirochaetae. No other symptoms
were present with the exception of some nebulae on the cornea. The
pupil was widely dilated, the iris possibly adherent.
He had had, when aged 14, a sore on the glans penis, apparently
occasioned by phimosis and subsequent slitting of the prepuce. No
specific history was obtained, and no signs of congenital syphilis in the
teeth. The report of the ophthalmic surgeon to St. Mary’s Hospital
was that there was “ pannus ” of the eye, but no symptoms either for or
against the diagnosis of syphilis.
Derma to log ical Sec tio ft
165
Case of “ Pseudo - pelade of Brocq.”
By E. G. Graham Little, M.D.
Emma G., aged 28. Hair began to come out five years ago at the
top of the scalp. No subjective sensation in connection with the loss of
hair. The mother had also lost her hair when aged 38, and the hair has
never returned. The beginning of the loss of hair in this patient was
not specially remarked. No redness seen. Nil elsewhere. Father died
suddenly of a “ complication of diseases.” No phthisis.
Present Condition .—The vertex is the principal seat of disease, and
for an area about 5 in. by 3 in. there is a bald expanse with some few
isolated hairs, quite long and apparently normal, but with unusually
deep infundibula of the follicle. The wide area is bounded by irregular
contour, there being small, round, bare patches in parts at the junction
of the central area.
In this way the baldness is encroaching upon the hairy scalp,
especially at the back. The hairs can be readily pulled out without
having the root-sheath adherent to the bulb; hairs extracted in this
way, cut into fine pieces and planted on agar and serum respectively,
produced no culture within forty-eight hours.
Sections from a Case of Urticaria pigmentosa in an Adult.
By E. G. Graham Little, M.D.
This was a private patient who had promised to come to the Society
that day, but had been prevented. The patient w r as a married lady,
aged 40, who for the previous eight years had had a slowly increasing
eruption of macules on the forearms. She had been sent by Dr. Dewey,
of Portsmouth, who had been kind enough to obtain a section of the
skin, now shown. This demonstrated the presence of mast-cells in
abnormal numbers in the papillary body of the corium, around the
surface vessels in that part, and confirmed the diagnosis of urticaria
pigmentosa. The case recalled clinically and in its history an adult case
shown by Sir Malcolm Morris at the Dermatological Society of London,
in which the diagnosis of urticaria pigmentosa had been made, but
166 MacLeod: Case of “ Dermatitis papillaris capillitii ”
without the confirmation of a section of the skin. Urticaria pigmentosa
with the history of commencement at so late an age was excessively
uncommon in adults. In the present instance the husband had had
syphilis, and it had been feared that the eruption in the wife was
syphilitic.
Case of 11 Dermatitis papillaris capillitii” (Kaposi).
By J. M. H. MacLeod, M.D.
The patient was a healthy-looking woman, aged 32, who was
sent up to Charing Cross Hospital by Dr. Thomas Pearson, of Peckham
Rye, four months ago on account of a pustular affection of the scalp,
which had proved singularly resistant to treatment. At that time
the scalp was found to be covered in places with adherent greenish
yellow crusts. On raising these up the underlying skin was found
to be irregular, raised, and moist from a sero-purulent discharge.
The affection had its origin several months before in an injury to
the back of the scalp by a hat-pin, which had resulted in a suppu¬
rating sore. This had healed, but the present eruption seemed to
have developed in consequence of it. An examination of a number
of short hairs on the patches was made to see if any fungus was
present, as several of the patches somewhat suggested kerion ring¬
worm. The hairs came out easily and were surrounded by a purulent
sheath. No ringworm fungus was found. From the clinical appear¬
ance and history of the lesions the diagnosis was made of a vegetating
pyodermic infection, of the type described by Kaposi under the heading
of “dermatitis papillaris capillitii.” Antiseptic treatment was recom¬
mended, which was thoroughly carried out but had comparatively
little effect, and the patient was again sent up to the hospital a
week before she was exhibited to the Society. Her condition, when
seen again, was as follows: The hair was clipped close over the
affected area and the crusts had been entirely removed from two
lesions. Extending from the forehead to the upper part of the
occiput were a number of irregularly shaped, pinkish red, vegetating
patches, varying in size from a split pea to 2 in. in diameter.
The vegetations were regular, rounded on the top, and were all
about J in. in height, and about the size of small shot. Much of
the hair had disappeared over the patches, but here and there tufts
of hair were noticed projecting from the vegetations or growing up
Dermatological Section
167
between them. The pre-auricular and post-auricular glands, especially
those of the left side, were enlarged. The case seemed to belong
to the type described by Kaposi, but differed from the classical cases
in that it did not affect the nucha and the neighbouring occiput, and
there were no nodular lesions or keloidal changes. It was decided to
treat the case bv X-rays, and a full Sabouraud dose was given to
each of the patches.
Dermatitis papillaris capillitii (Kaposi).
Case of Mycosis fungoides.
By H. Radcliffe Crocker, M.D.
The patient was a private case, a lady suffering from mycosis
fungoides. The lesions on the face had been treated with the X-rays,
but had not altered so much as the lesions in other parts, which
had been treated with internal administration of salicin. The charac¬
teristic tumours were fairly abundant on the limbs and shoulders.
168 Crocker & Pernet: Unusual Case of Dermatitis
DISCUSSION.
Dr. Pernet drew attention to the fact that the ancestors of patients
suffering from this disease had frequently been long-lived on one or other side
of the family. It proved to be so in this case.
Mr. HARTIGAN asked for particulars as to the X-ray exposures, and whether
the arm as well as the face had been exposed.
Dr. CROCKER said that he gave only one short exposure for the arm, and as
the lady was anxious about her face the X-ray treatment was then concentrated
there. The face received ten short exposures, with about ma. in the tube.
Unusual Case of Pustular Vegetating Dermatitis, with
Pigmentation Changes, in a Woman aged 26.
By H. Radcliffe Crocker, M.D., and George Pernet, M.D.
The disease in this case had been going on for nearly two
years, commencing on the scalp, according to Dr. Ransome, of Bungay,
who had observed the case from the first. The parts affected were
the scalp, the nares, the left eyebrow, the right axilla, pubic and
adjacent regions of the genitalia, and the greater part of the centre
of the back. The condition came apparently nearest to what had
been described by Hallopeau as 44 derrnatite pustuleuse chronique en
foyers a progression eccentrique,” but had also affinities with impetigo
herpetiformis. In the present case the disease commenced some six
months after confinement ; child living and healthy. The opsonic
index to staphylococcus was 1’2G. A drawing was shown of the
patient’s condition when first admitted to University College Hospital,
and also Hallopeau’s, Neumann’s, and Hebra’s plates. The case is being
worked out and details will be published later as a paper.
DISCUSSION.
Mr. Hartigan asked whether any histological examination had been made,
and if so whether any organisms had been found in the lesions.
Dr. PERNET said that they had not finished the examination. They had
not yet looked for fungus elements.
Dermatological Section
169
Case of Lichen plano-pilaris.
By T. D. Savill, M.D.
(Bor Mrs. T. D. Savill, M.D.)
In the absence of Dr. T. D. Savill this case was exhibited by
the Secretary. The patient was a married woman, aged 30. She
had two healthy children and considered that she possessed good
health. Her mother had died of “ consumption ” at the age of 34 ;
her father, three sisters, and a brother were alive and healthy. The
patient was first seen on April 28, 1908, and gave a clear account
of her malady. In the middle of March she had first noticed on
the external surface of the right thigh a number of “ rough grey
pimples ” ; gradually a redness of the skin had spread between these.
A few weeks later similar eruptions had started on the trunk, chiefly
on the anterior surface of the chest; and when “ red spots ” began
to appear on the arms, about the end of April, she thought it time
to seek advice. Only slight itching had been present at any time.
She had also experienced more lassitude than usual, but had not
been prevented from performing her customary duties.
When the patient was first examined the eruption presented
three distinct clinical types:—
(1) On the external and extensor aspect of the right thigh, where
the disease had first appeared, there was an irregular patch, some¬
what larger than the palm of the hand, of reddened thickened skin,
covered with spines which projected from the surface quite £ in.
These could be picked out, a gaping follicle with wide mouth being
left behind.
(2) On the chest and abdomen were numerous groups of tiny
conical papules ; some of these had horny spinous projections similar
to those on the thigh. There was, however, no redness at the base
of these papules, and the intervening skin was healthy.
(3) On the right arm were five or six definite lichen planus papules,
violet in hue, flat-topped and waxy in appearance.
On June 18, after emollient treatment had been employed for
nearly six weeks, the change in the eruption may be briefly described
as—(1) on the thigh the horny projections were less prominent;
170
Stowers: Case of Lupus erythematosus
(2) new groups of conical papules had appeared on the trunk, and in
the old groups a degree of congestion was visible at the base of
and spreading between many of the papules; (3) many definite new
papules of lichen planus were scattered about on the forearms.
Microscopic sections were taken from the thigh and the arm
on April 28. The section from the thigh, representing the clinical
appearances described under (1) on preceding page, showed follicles
widely dilated, especially at the mouth, and full of horny material, i.e., a
hyperkeratosis was present in the hair follicles. Between the follicles
the epithelium presented the condition of a lichen planus papule, with
swollen or hyaline cells, and marked small cell infiltration immediately
beneath the Malpighian layer. The section taken from the arm showed,
as was expected from the clinical appearance, a typical lichen planus
papule. On June 16 a section was taken from an old group of conical
papules on the chest, with some congestion at their bases [(2) previous
page]. The follicles were similar to those found in the section from
the thigh; infiltration of the corium was present around the follicles,
and spreading to the intervening parts; between the follicles the
epithelium was thrown into irregular ridges, and below one of these
ridges considerable infiltration was present in the corium, suggesting
that a lichen planus papule w r as in process of formation in that situation.
Case of Lupus erythematosus in a Child.
By J. H. Stowers, M.D.
The patient, a girl aged 5 years and 2 months, was sent to the
Hampstead and North-West London Hospital on account of a sym¬
metrical eruption of the face of several months duration, involving
the cheeks, nose, eyelids and forehead.
When first seen the inflammatory redness and swelling— quite
erysipelatoid in appearance—were so marked, especially at the margins,
and the secondary incrustation so considerable, that it was impossible
to decide immediately upon the exact nature of the case. A week
later, after the removal of crusts, &c., the inflammatory swelling and
surrounding oedema having lessened, the characteristics of the disease
were distinguishable. At that time the ears were not implicated,
the mucous membrane of the mouth was free, and the surface of
Dermatological Section
171
the body generally was normal. There was, however, upon the scalp
a rough scaly patch of irregular shape about 2 in. in diameter, on
which hairs of disordered nature and some superficial scarring were
visible. This patch was stated to have existed for over two years
and to have been actively treated for “ ringworm,” but a microscopical
examination by one of the resident medical officers was attended with
negative results. It is more than probable that this is part of the
original development of the present disease. Quite recently the skin
of the ears has become implicated and the eruption is now spreading
in a discrete form, with some coalescence upon the forearms attended
with itching.
So far the general health of the child has remained fairly good,
but the parents are in poor circumstances—the father being out of
employment; consequently she has suffered for want of appropriate
food, &c. The urine upon examination did not contain albumin, and
the specific gravity was normal. There is no history of tuberculosis
in the family, but it is quite possible that the glandular affection
of the neck was of tubercular nature, although corroborative evidence
does not now exist.
The patient is to be admitted into the children’s ward for observa¬
tion and treatment, and a subsequent report will be made to the Section.
The special features of the case, among others, are:—
(a) The age of the patient, but few instances of lupus erythematosus
occurring in early childhood being recorded :
(b) The rapid onset and markedly inflammatory nature of the disease ;
and—
(c) The symmetrical and increasing development upon the forearms.
DISCUSSION.
Dr. CROCKER said that he had drawn attention to cases of lupus erythema¬
tosus in which the patients had been of tender age. The earliest age he had
found a patient suffering from this disease was 5 years.
Dr. PERNET asked whether any albumin had been found in the urine.
Dr. Stowers said that the urine was normal; it had been examined that day.
172
Stowers: Case of Molluscum contagiosum
Case of Molluscum contagiosum in an Adult.
By J. H. Stowers, M.D.
A young married woman, aged 22, was exhibited with numerous
lesions of this ailment existing upon the dorsal surface of each hand
and upon the extensor and flexor aspect of each forearm. They were
first noticed about seven months ago, and have rapidly increased in
number since. The patient had been engaged in nursing several
infants last year, previous to her marriage at Christmas, but no
history of contagion was obtainable. Several of the nodules were
flat and elliptical in shape, due to coalescence of the lesions, but
the vast majority were characteristic in appearance, having the usual
umbilicated centre.
Dr. WHITFIELD said that certain birds, such as pigeons, linnets, and
domestic fowls, suffered from a similar disease, and when handled they some¬
times caused the affection to be set up in the human subject. In reply to
Dr. Whitfield, the patient said that she kept a linnet.
Specimens from a Case of Syphilis.
By A. Whitfield, M.D.
(1) A photograph of the axilla of a girl, aged 18, who had contracted
syphilis, as far as could be ascertained, about four months ago (fig. 1).
When seen the throat showed the common type of grey erosion, and on
the neck was a slight increase of pigmentation with leucodermic areas
(leucodermia syphilitica). There was no eruption elsewhere with the
exception of typical condylomata in the axillae, from one of which the
photograph was taken. Dr. Whitfield said that although a well-knowm
possibility, the occurrence of condylomata in the axillae was not, in his
experience, common. He thought when he saw the lesions that it would
afford good material for demonstrating the Spiroch&ta pallida , and this
had proved to be the case.
Dermatological Section
173
(2) A preparation from the foregoing case stained by Leishman’s
method. Dr. Whitfield said that he had obtained far better specimens
by this than any other method, and he had, he thought, tried most of
those published. The specimen was fixed w r ith methyl alcohol, then
washed over with normal human serum, and then stained for an hour
under cover w T ith equal parts of Leishman’s stain and distilled water.
It was then washed for about a minute in distilled water, dried in air,
and mounted.
Fig. 1.
Condylomata in the axilla.
(3) A photograph of the specimen at a magnification of about
1,700 diameters (fig. 2). This w-as shown to demonstrate how f well the
purple red of Leishman’s stain lent itself to photography, even in the
case of such delicate organisms as the Spirochwta pallida.
174 Whitfield: Specimens from a Case of Syphilis
Fio. 2.
Photograph of preparation stained by Lcishman’s method.
Dr. Crocker said that the specimens were excellent. With regard to
condyloma in the axilla, he thought it only occurred among people whose bodies
were very moist. He could not remember any special case.
Dermatological Section.
July 16, 1908.
Dr. Colcott Fox, Vice-president of the Section, in the Chair.
Case of Tuberculides in a Girl aged 11 years.
By J. L. Bunch, M.D.
The condition had been present since last Christmas, and the girl
had been treated with boracic fomentations. The mother first noticed
a patch on the left leg, and it had spread from there, the right leg sub¬
sequently becoming involved in a similar manner. It was now fairly
symmetrical on both legs. There were well-marked haemorrhages, and
a granulomatous swelling was present on the back of the right leg, and
to some extent on the left. There was a small lesion on the right
cheek, with papules round it, which was not present when he first saw
her; it was possibly partly due to the dressing. There was a history of
tuberculosis in the family, an aunt having died of the disease at the
age of 23.
Dr. Colcott Fox and Dr. GRAHAM Little regarded the condition of the
legs in this case as chronic pus infection, and questioned the tuberculous
character.
Case of Parakeratosis variegata.
By G. Dawson, F.R.C.S.I.
The patient, a woman, was shown last winter, when Dr. Crocker said
he thought it was a case of parakeratosis variegata. The rash occurred
two and a half years ago on the ears and face, and now it had extended
on to the knees and arms, and there was some on the buttocks. It was
jy —6
176 Fox: Erythematous Eruption of Unusual Type
intensely irritative, and kept her awake at night. It had not been
treated by any drug. He could not find any reason for the peculiar dis¬
tribution. At first he thought it was lichen planus, but there had never
been any thickening. He did not think the mucous membrane of the
mouth had ever been involved.
A section from the case was exhibited.
Dr. COLCOTT Fox questioned the diagnosis of parakeratosis variegata, but
was not prepared with an alternative one.
Erythematous Eruption of Unusual Type.
By T. Colcott Fox, M.B.
The patient, a milkman, aged 20, states that the present attack
began about Whitsuntide, first as small, slightly raised blotches on the
hands, then on the feet and body. He has not any joint trouble,
pains, or marked constitutional disturbance. There are confluent round
patches of erythema, disappearing on pressure, all over the hands and
feet. The palms and soles are diffusely involved, but there are large
round macules on the borders and disseminated over the dorsum of
several of the joints, where they are raised, thickened and opalescent,
suggesting a certain amount of serous exudation. There are a few
patches over the elbow-joints externally, and one or two symmetrical
patches on each forearm ; also on the sides of the legs. The mouth is
free. The man states that the scalp was affected, but it is now free, and
as there is an ill-defined roughened patch on the centre of the sternum
there may have been some pityriasis. The man also states that he had
a similar outbreak last Christmas, and that his scalp was first involved,
and then the arms and chest. The eruption disappeared about Easter
time. The exhibitor said he had brought the case because, although the
type was erythema, the picture on the hands and feet especially was very
striking and unusual, and the individual lesions and the eruption as a
whole were more prolonged than usual if the man’s story was to be
depended on. The exhibitor said he also had under observation a very
similar case in a woman, who had long suffered from a chronic patch of
lupus erythematosus of the nose, with lesions of the backs of the fingers,
and who suddenly had an outburst of large macular erythema (acute
lupus erythematosus?), with marked incidence on the hands and feet.
The outburst was, however, of short duration.
Dermatological Section
177
Case of X-ray Dermatitis.
By Wilfred Fox, M.D. ■
The patient, a medical man, showed on his hand an early stage of
X-ray burn. The first sign of it appeared in the middle of April, and
Sir Malcolm Morris had watched the condition with him since then. It
had gradually progressed, and there was steady infiltration. It arose
from the frequent screening of patients, and was a “ series burn.” It
was steadily becoming more painful, especially about the nails. There
had been no injected venules, but slight pressure produced pain. He
asked whether anyone could suggest any means of stopping the pain.
Dr. David Walsh showed, on his own first finger, the site of a typical
X-ray wart, which he acquired when using X-rays four or five years ago. He
had now ceased to do such work, but while he was working at it he was very
careful of his hands. His own was a “ series burn.”
Dermatitis herpetiformis of Unusual Type.
By J. Galloway, M.D.
The patient, a man, aged 23, describes himself as never having been
in robust health, but physical examination discloses no obvious visceral
lesion nor any signs of disease, with the exception of the condition to be
described. In December last he had an attack of what is stated to have
been influenza, the temperature rising on this occasion to 103° F. His
convalescence seems to have been somewhat protracted. During the
month of January he had an attack of gonorrhoea, from which he rapidly
recovered, and which had completely disappeared by the beginning of
April. During this attack he was at one time treated by the administra¬
tion of sandalwood oil in capsules, and suffered in consequence from an
erythematous eruption, which, however, seems to have vanished in the
ordinary course. At the end of March he developed a few spots on the
right forearm which he says was the commencement of his present
disease. These spots are stated to have been red and slightly raised
above the surface. He states that some of them showed slight blistering.
178 Galloway : Dermatitis herpetiformis of Unusual Type
The eruption rapidly advanced till it attained its present extensive dis¬
tribution. In the early part of May, the skin disease rapidly advancing,
he was sent to Margate for the benefit of his health, and consulted
Dr. John L. Sawers. During his stay in Margate the attack increased
in severity, and on account of this Dr. Sawers communicated with Dr.
Galloway respecting his condition. The acutest stage of this attack
seems to have occurred during his stay in Margate. On returning to
his home in Croydon he again came under the care of his usual medical
attendant, Dr. Robert C. Brown, who also communicated with Dr.
Galloway on account of the peculiar symptoms presented by the case.
The patient was then sent to be under Dr. Galloway’s care in Charing
Cross Hospital.
The following note was made of the condition of his skin shortly
after admission: “ The eruption consists of dark erythematous patches
distributed universally. It is most profuse, however, on the face, upper
and lower extremities, and the upper portion of the trunk. The parts
least affected are the anterior surfaces of the abdomen and thorax, the
lumbar region of the back, which is practically clear, the hands and feet.
On more minute examination the erythematous patches are found to
be made up of rounded spots of purple red tint, from 25 mm. to 50 mm.
in diameter, grouped in irregular corymbose areas. The patches so
formed are from 2 cm. to 3 cm. in diameter, but tend to become con¬
fluent, forming larger areas of eruption. The individual small spots
show distinct atrophy with a smooth, glossy surface. There may still be
seen vesico-pustules, especially at the margins of the areas of disease.
Here and there individual isolated spots may be noted. The skin disease
gives indications of having originated throughout as a vesico-pustular
eruption.
On admission the affected areas were thickly encrusted, partly, no
doubt, owing to the formation of true epithelial crust, but mostly as
the result of the concretion of dressings containing powders. On the
face, especially the bearded parts, a slight dermatitis, eczematoid in
character, was noticeable. The scalp is affected with the disease, but
there is no indication of affection of the mucous membranes, with the
exception of a slight amount of the eruption on the glans and preputium
penis. A slight marginal blepharitis exists, apparently of secondary
origin, and occasional slight conjunctivitis is observed, but it is not
clear that vesicles form on the conjunctiva*.
The patient has been examined carefully to ascertain if visceral
disease of any sort can be identified, but the results have been negative.
Dermatological {section
179
The urine, repeatedly examined, is normal; the blood, examined on
July 10, shows the following state :—
Haemoglobin
90 per cent.
Red blood-cells ...
4,890,000 per cubic
Leucocytes
6,000 per ,,
Polymorpbonuclears
63*6 per cent.
Lymphocytes
6*2
Large mononuclears ...
20*8
Transitional
4-2
Eosinophiles
5*2
100*0
There was a slight rise of temperature on admission to about 100° F.,
with widespread enlargement of lymphatic glands. These were most
noticeable on the neck, where those in the neighbourhood of the sterno-
mastoid were as large as filberts. They were, however, soft, and gave
the impression of glands enlarged from septic absorption, which might
easily be accounted for by reason of the crusted character of the erup¬
tion on the face and scalp.
The treatment made use of in the hospital was, first, the use
of daily bran baths. The surface was then dressed throughout with
a cream consisting of almond oil and lime-water. By this means
the crusts were rapidly removed, the temperature falling to normal.
The patient now had a bran bath daily, and was dusted from head
to foot with a neutral dusting powder of zinc oxide and silicious earth,
containing 10 per cent, boric acid. When shown to the Section the
deeply congested and atrophic appearance of the eruption could readily
be made out. It was apparent that the violence of the attack had
ceased ; no recent points of eruption could be seen. It was especially
to be observed that no lesions of simple erythematous or urticarial
character were noticeable, nor had they apparently occurred at any
time during the disease.
Dr. Galloway drew attention to the unusual type presented by this
case, although, no doubt, it could be grouped as an example of dermatitis
herpetiformis. He drew attention to the fact that there was little or
no pain, only a certain amount of general irritation; that none of the
concomitant lesions of dermatitis herpetiformis ( e.g ., urticaria and
erythema) had been observed. The spots affected by the disease became
universally congested; they gave rise to feeble vesication, the fluid
becoming turbid rather than definitely purulent, and, when the epidermis
180 Galloway: Dermatitis herpetiformis of Unusual Type
separated, the rounded spot of purple atrophic skin remained as the
relic of the disease. This type of dermatitis herpetiformis in his experi¬
ence was very unusual, and reminded him of the earlier descriptions
of hydroa herpetiformis before Duhring’s account of the disease became
so universally accepted. Dr. Galloway hoped to receive suggestions from
members of the Section as to any means of further investigation of this
very severe and unusual condition. To his mind it seemed probable that
the eruption was due to a cause, probably of internal origin, and in some
respects might be regarded as analogous to the rare acute “ exanthe-
matic” outbursts of what had been called lupus erythematosus.
DISCUSSION.
Dr. Colcott Fox said that he had had the opportunity of seeing this
interesting case previously with Dr. Galloway. The picture presented by the
patient immediately brought to his mind one of the patients from whom
Dr. Tilbury Fox had originally given the description of what he called hydroa
herpetiformis. He considered that the case could well be classified under the
heading of dermatitis herpetiformis, but the type was quite unusual and peculiar.
He was glad to observe that the patient was so much improved in his condition
since he had seen the case in Charing Cross Hospital with Dr. Galloway.
Sir Malcolm MORRIS remarked that he considered that the fact that the
disease before the Section consisted of lesions which w ? ere defined from the out¬
set, showing no tendency to peripheral spread, was sufficient to make a clear
diagnosis between the disease presented by the patient and cases of exanthe-
matic lupus erythematosus. As to the causation of the present case he was
especially interested to hear that an erythematous eruption had followed the
use of sandalwood oil. The disturbance so produced might, he thought, be of
some importance in the history of the case.
Dr. Whitfield said that at the present time, the violence of the eruption
having become spent, suggestions as to immediate treatment were not neces¬
sary. He considered, however, that during the development of such cases the
coagulation period of the blood should be carefully watched. He thought that
it w T as quite possible that the damaging effects of the disease on the skin might
be, at any rate to some extent, controlled by the use of lime salts according to
the variations in the coagulability of the blood. Dr. Whitfield did not agree with
the suggestion than any clinical analogy existed between this case and any of
the types of lupus erythematosus.
Dr. Galloway thanked the members present for their criticisms and
suggestions in this case, and hoped that he might be able to take advantage
of them in treatment. He especially desired to acknowledge the interest of
Dr. Sawers and Dr. Brown, who had sent the case to him.
Derm a tuloy ica l Section
181
Well-marked Rosacea associated with Phlyctenular
Conjunctivitis and Ulceration of the Eyes.
By E. G. Graham Little, M.D.
The patient was a man, aged 52, a carpenter by trade, and he had
suffered from rosacea for five years; the exacerbations of this disease
were usually accompanied by phlyctenular conjunctivitis. Both eyes
were affected, the right more than the left. The case had been sent
from an ophthalmic surgeon with a view to ascertaining whether
dermatologists w r ere as familiar with the association of eye affection
of this type with rosacea as ophthalmic surgeons were.
Dr. WHITFIELD said he had frequently seen the association. The
ophthalmic surgeon at King’s College Hospital had drawn his attention to
such cases, and had found staphylococci as a rule in the lesions of the eye,
which usually improved coincidently with treatment for rosacea directed to
remedying the dyspeptic symptom of that disease.
Case of Prurigo of Hebra.
By E. G. Graham Little, M.D.
The patient was a foreign Jewish girl, aged (>. The affection had
first been noted at the age of 18 months and had persisted ever since.
The child was covered with the characteristic itchy papules of the
disease, the whole body and face being involved. The papules were
closely grouped, of the size of a small pea, and very irritable. On the
arms and legs there was a secondary, very severe chronic pus infection.
All the glands in neck, axilla and groin were greatly and visibly enlarged.
The child was deeply pigmented, probably as a result of the itching, the
mother being moderately fair. No other members of the family had
the disease. The age at which the patient had become affected—
18 months—was older than the majority of cases reported by Hebra
and Kaposi, but it was certain that Hebra’s prurigo sometimes com¬
menced in later childhood. The exhibitor had recorded a case which
began at the age of 6 years, commencing after an attack of scarlet
fever, and other even later commencements had been reported.
182 Graham Little: Case of Molluscum contagiosum
Dr. COLCOTT Fox said that he had been struck with the fact that, whereas
lichen urticatus, which was sometimes regarded as the forerunner of Hebra’s
prurigo, commenced in the early months of infancy, true prurigo more com¬
monly, in his experience, commenced 'later—at the age of 4 or 5 years. It
remained, however, a very rare disease.
Case of Molluscum contagiosum.
By E. G. Graham Little, M.I).
The case, one of perfectly typical aspect, occurred in a man aged
about 35, with lesions confined to the pubic region of the abdomen and
the penis, two molluscum tumours being found on the prepuce. There
were about seven lesions in all, and the typical white waxy material had
been extruded from the tumours and demonstrated microscopically.
The exhibitor thought the distribution on the penis sufficiently interesting
to record. No source of infection had been identified. Molluscum con¬
tagiosum was not a common disease in adults, and it was curious that
in some parts of the country the disease itself seemed extremely rare;
Dr. Arthur Hall, of Sheffield, had told the exhibitor that they had not
met with a case in Sheffield for many years.
Dr. COLCOTT Fox said he had seen numerous cases of molluscum con¬
tagiosum in the children in the poor-law schools provided for ringworm, and
the scalp was a very frequent position for the tumour to appear.
Case of Pityriasis rosea.
Bv E. G. Graham Little, M.D.
A very extensive and characteristic eruption occupied the chest,
abdomen, back, anus and forearms, thighs and, what was extremely
uncommon, the face. The latter part was covered for three-fourths of
its surface with quite characteristic small circinate patches. The disease
had commenced as an acute efflorescence eight days previously, and
there was no history of a pioneer patch.
DISCUSSION.
Sir Malcolm Morris drew r attention to the unusual season of the year
for pityriasis rosea to develop, but said he had himself seen quite an epidemic
Dermatological Section
183
of the disease recently. He pointed out the extraordinary similarity of the
lesions on the forearms to a secondary syphilide; he had recently seen a case
of pityriasis rosea involving the face, which he had at first regarded as possibly
lupus erythematosus, considering the rarity of pityriasis rosea in this position.
Dr. WHITFIELD did not think the face was very rarely involved; he had
seen more than one such distribution, and had found it on the scalp as well.
Two Cases of Congenital Syphilis with late Cutaneous and
Mucous Membrane Lesions of the Gummatous or
Phagedaenic Type.
By J. H. Sequeika, M.D.
Case I.— Extensive Gummatous Ulceration of the Nose and Lip
w i th Gumm a to u s Hepa t i tis .
E. B., aged 11, admitted to the London Hospital on June 18,
1908. The mother, a Russian Jewess, gave the following history: She
has enjoyed good health. She has been married nineteen years. She
has had ten children, of whom six survive. Her first and second
children died within a few weeks of birth. The third child was still¬
born. The fourth child, a boy now aged 17, is in good health, and
there is no history of any syphilitic manifestation. The fifth child died
from measles at the age of 9 months. The sixth, a girl now aged 14,
had some skin eruption when she was between 11 and 12 years of age.
She shows no signs of syphilis. The seventh child is the patient now
shown. The eighth child, a boy now aged 9 years, had “ blisters ” on
his limbs when 2 or 3 years old. The ninth child, aged 5, had a “ sore ”
on the rocf of his mouth when 1 month old. The youngest child, now
aged 3, had a rash all over the body and upper and lower extremities
when one month old. The four younger children were examined, but
no evidence of congenital syphilis was discovered. The father is said to
have suffered from “ ulcerated legs” a few years after he was married.
No direct history of syphilis was obtainable.
Patient*s History .—When 6 weeks old she had an eruption between
the legs and around the genitals and buttocks. Vaccination “ took very
badly.” The mother describes the vaccination spots as forming deep
“holes” which took three or four weeks to heal. The child had some
“ inflammation of the eyes ” when she was 2 years old, and after this
184
Sequeira: Cases of Congenital Syphilis
the abdomen began to swell. Tuberculous peritonitis was diagnosed,
and she attended a dispensary for three years, being given ol. morrhua?
and malt. At one time also some inunction, apparently of mercurial
ointment, was prescribed. Two years ago (aged 9) a small lump appeared
at the left inner canthus, evidently a suppurating dacryocvst. The
abscess “ broke,” and has discharged more or less ever since. A little
later the opposite lachrymal sac was similarly affected. One year ago
nasal discharge began, and the mother describes the inside of the nose as
“ decaying and coming away.” The discharge at this time was offensive
and often blood-stained. During this period the nose became steadily
flatter. The child at this time attended two hospitals, and was an
in-patient at one for seven weeks. Six weeks prior to admission at the
London Hospital the upper lip became swollen and ulcerated. The
ulceration rapidly increased and the lip “ split ” on June 8.
[Dr. Sequeira acknowledges his indebtedness to his clinical assistant,
Dr. W. G. Parkinson, for his care in obtaining so complete a history in
very difficult circumstances.]
Condition on Admission (June 18, 1908).—The child is very anaemic
and her face is terribly disfigured. The nose is flat, level with the
cheek, and ulcerated. The upper margin of the ulcer has a serpiginous
punched-out margin, suggesting the coalescence of three gummatous
ulcers. The lower part of the nose is almost entirely eroded, and
presents an ulcerated surface which is continuous with a huge ulcer on
the upper lip. This extends the whole width of the nose, and presents
one very deep and one smaller fissure, which split the lip up nearly to
what would be the anterior nares. The surface is dirty yellowish brown,
and from it and from the interior of the nose a most offensive sanious
discharge is continually pouring. Both lachrymal sacs are suppurating,
and pus exudes from two sinuses connected with each. There is no
ulceration in the buccal cavity, and the pharynx and palate are free.
The upper central incisor (left) is of the Hutchinson type. There
is no interstitial keratitis, and no choroiditis has been made out on
ophthalmoscopic examination.
Visceral Lesions .—The abdomen 1 is enormously swollen, and huge
dilated veins cross from it on to the thorax. The umbilicus is protruded.
The liver is irregularly enlarged. Its lower margin extends in an
irregular curve downwards from just below the margin of the ribs in the
mid-axillary line to the umbilicus. On the left side the hepatic dulness
is continued into that of the enlarged spleen. The surface of the liver
presents large rounded bosses, which are obvious on inspection and
Dermatological Section
185
easily made out on palpation. The heart is pushed up, and the apex
beat is nearly one costal space higher than normal. The spleen extends
down to and a little beyond the umbilicus. Its surface is smooth to
palpation. There is universal enlargement of the lymphatic glands,
those in the groins, axilla?, and neck being easily visible, and on palpa¬
tion of extreme hardness. There has been no albuminuria and no
diarrhoea. There is advanced genu valgum on the right side.
The child has been kept in bed and given plenty of nourishing food.
Mercurial ointment, 1 dr. per diem , has been rubbed in, and iodide of
potassium, in 5 gr. doses, has been given internally. The nasal cavity
has been irrigated with lotio nigra. The ulcers have been dressed with
an ointment of peroxide of zinc (40 gr. to the ounce). Improvement
has been extremely rapid, and when shown at the meeting, exactly four
weeks after admission, most of the ulceration had healed. A remarkable
feature has been the amount of repair, especially in the lip. The child
will, of course, be terribly deformed, as a considerable part of the bony
nose as well as the cartilage has been destroyed.
Case II .—Extensive Gummatous Ulceration Hound the Mouth.
T. H., aged 15 years, admitted to the London Hospital on June *20,
1908.
Family History .—The patient is the eldest of five children, the other
four being girls. No details are obtainable as to their infancy, but so far
as is known they have been in good health. No information is to be
had of the health of the parents, the boy being sent from an institution.
Personal History .—There is no information as to the patient’s
condition in infancy, but until three years ago he states that he was well.
Present Illness .—The first manifestation was a “ lump,” w T hich
appeared on the middle of the right cheek three years ago. This
“broke” and ulceration extended over the right cheek, as high as the
outer canthus of the eye and inwards to the right side of the nose,
involving the ala and part of the tip of the organ. On one occasion the
area was scraped. The boy, who is intelligent, states that the ulcerated
area healed up while he w r as taking medicine, and remained well for
over a year. Three months ago a fresh outbreak occurred on the upper
lip, and the ulceration spread round the left angle. One month ago
a swelling appeared on the lower lip and this rapidly broke down into
an ulcer.
186
Sequeira: Cases of Congenital Syphilis
Condition on Admission (June 29, 1908).—A large area of scar tissue
extends all over the right cheek from the lower lid to the mandible,
internally reaching the side of the nose, of which the ala and part of the
tip have disappeared. There is extensive ectropion of the right lower
lid, the result of the contraction of the scar. On the upper lip there are
two foul ulcers covered with yellowish slough and with a yellowish
sanious discharge. The ulcer on the right side extends from the angle
of the mouth to near the middle of the lip. That on the left side starts
£ in. from the middle line and extends along the upper lip, round
the left angle in horseshoe form, and is continuous with a large ulcer on
the lower lip, which reaches nearly to the right angle. The ulceration
is partly of the skin and partly of the mucosa. It is everywhere about
£ in. to J in. across. Its edge is steep and irregular. The middle of
the upper lip is swollen and everted but not ulcerated. There is con¬
stant dribbling on account of the condition of the lower lip, but there is
no ulceration of the buccal cavity, or of the palate or pharynx. The
interior of the nose, so far as it can be seen, is normal. There is a small
opacity on the right cornea, but this looks more like the result of a
corneal ulcer than interstitial keratitis. No choroiditis could be made
out on ophthalmoscopic examination. There is a characteristic Hutch¬
inson tooth (upper incisor, left).. There is no evidence of visceral
implication. The boy’s general condition is good.
The patient was shown eighteen days after admission, and the ulcer¬
ation had almost entirely healed. The treatment had been identical
with that pursued in the other case.
Cases of this type of congenital syphilis are fortunately exceedingly
rare, but the exhibitor had another under his care in September, 1907. 1
The importance of early recognition of this condition is obvious. In
the first case shown the abdominal visceral disease was diagnosed as
tuberculous peritonitis, and when the nasal and cutaneous lesions ap¬
peared they were considered to be lupus. A diagnosis of lupus had
also been made in the second case. The fulminating character of the
disease and the terrible deformity which so rapidly results call for early
and energetic treatment.
It is of special interest to record that in both these cases Calmette’s
ophthalmic tuberculin test was tried, and in each instance there was no
reaction. In the event of there being doubt as to the diagnosis between
lupus and inherited syphilis this test is of value, as a positive reaction
has always been obtained in lupus vulgaris.
1 Described, with photographs, by H. Emlyn Jones, Brit. Joum. Child. Dis., April, 1908, p. 144.
Dermatological Section
187
Case] of ^Primary Cutaneous Carcinoma of the Chest involving
the neighbouring Nerve Areas.
By David Walsh, M.D.
The patient, H. M. M., aged 54, a clerk, was first seen on June 25,
1908, complaining of so-called “ shingles,” for which malady he had
been treated by a medical man. Patient looked thin and anxious; said
he weighed 10 st. 12 lb. (not enough for his height), and had lost 3 lb.
weight in the last twelve months. His general health had always been
good until eighteen months ago, when he was laid up six weeks with
what he described as “ a very bad heart.” Six months later he noticed
a hardness and red discoloration of the left nipple. This grew to the
size of a hand, when he consulted a medical man, who said it was
shingles. It had grown steadily ever since. There had been no pain
except on one occasion, four months ago, when he was suddenly seized
in the region of the liver with pain of a w r eek’s duration. Water formed
in the abdomen, and he was tapped twice. There had been no return
of either the pain or the dropsy.
On examination, a sheet of pink and red nodules, for the most part
confluent, was seen on the left chest. In the left nipple line it reached
from the lower border of the third to the eighth or ninth ribs with a
vertical measurement of some 7 in. It extended across the lower part
of the sternum, and at the right nipple line formed a tapering band
of discrete nodules about 2 in. broad. Higher up on the right chest
above the nipple were two small, recent patches, the highest at the
level of the third rib. The nipples looked normal in shape and size,
although the left was closely wedged in by a mass of nodules.
At the back the main sheet of eruption ends, about 2 in. behind the
posterior axillary line. Three inches from the spine at the lower level
of the main eruption is a group of discrete nodules, the size of half a
crown, with a similar group some 3 in. higher up inside the angle of the
scapula. Over the front of the left shoulder-joint is a group of firm
sparse nodules about the size of a hemp-seed, while at the back over the
long head of the triceps and beneath the deltoid muscle is a reddish
patch, about 2 in. across, in which can be felt minute commencing
nodules. In front of the middle of the left biceps is an irregularly
bordered reddish macule, about the size of a crow r n, in which a slightly
188
Walsh: Cutaneous Carcinoma of the Chest
nodular feel can be made out on careful palpation ; on the inner side of
the middle of the left upper arm is another similar patch, and a third in
the back of the triceps.
The nodules vary in size from a millet-seed to a pea, and are of
various shades of pink and lake colour, with a brownish tint in places.
They are firm and movable, not tender on pressure, and have never been
painful. About a week after coming under observation some small
haemorrhagic points appeared. A nodule the size of a split pea was
excised, and a microscopic examination showed an alveolar stroma of
connective tissue packed with epithelial cells beneath an unbroken
epidermis.
The heart sounds were normal. Superficial veins of abdomen
enlarged. Liver dulness about normal; somewhat enlarged area of
dulness in splenic region. Patient has not complained of pain in abdo¬
men (except during the single attack above mentioned), neither has
there been any marked bowel disturbance.
A mass of hard glands can be felt in each axilla, somewhat larger
in the left. Small hard glands can be felt both above and below the
collar-bones, especially on the left side.
There are several points of interest in this case. The new growth,
although it began at the nipple, appears to be not Paget’s disease, but
a lenticular scirrhus, apparently of primary cutaneous origin. If the
fleeting pain in the liver and the dropsy four months since were due to
secondary invasion the abdomen might be expected at this stage to show
more marked evidence of involvement. The main interest, however,
lies in the distribution and spread of the carcinomatous process in
definite nerve areas. In the earlier stages the eruption was so char¬
acteristic of nerve implication that it was actually mistaken for an
intercostal herpes zoster by a medical man. The main part of the
eruption began near the nipple in the segment supplied by the fifth
dorsal nerve, and now occupies the segments supplied by the third to
the sixth dorsal nerves. The right front of the chest is becoming
invaded in a corresponding area. The comparatively recent sites of
invasion on the front of the shoulder-joint and over the biceps occur
in areas supplied by cervical nerves. That on the inner side of the
arm is apparently in the intercosto-humeral (third dorsal) region. It is
not easy to imagine any growth of infection from the primary eruption
to the secondary patches on the arm along lymphatic routes.
The whole case is of much interest in connection with Mr. Lenthal
Cheatle’s observations on inflammatory changes in posterior spinal root
Dermatological Section
189
ganglia in certain cases of cutaneous cancer. In the present instance
the new growth presumably started in the cutaneous distribution of
a single dorsal ganglion, but it now reaches the cutaneous distribution
of neighbouring dorsal and cervical ganglia. The picture, viewed from
behind, is specially suggestive of involvement of the posterior and
lateral branches of dorsal, and, in the shoulder and arm, patches of
cervical nerve.
Operation is clearly out of the question in a case of extensive “ cancer
en cuirasse ” of this kind. On the recommendation of Dr. T. Shaw-
Mackenzie, preparations of pancreas and intestinal gland are being
administered by the mouth, with excess of sugar in diet.
Case of Fibromata of Skin with developing Neuro-fibroma.
By David Walsh, M.D.
The patient, H. G., male, aged 28, a Post Office worker, came
on June 18, 1908, complaining of painless growths on front of chest
and elsewhere of eight or nine years’ duration. He says the growths
appeared first at the time mentioned, and his mother is quite sure
he had none as a child. Both the mother and one brother have similar
growths on the arms.
On examination, a group of small, firm, thickly set movable sub¬
cutaneous nodules are to be seen on the right subclavian and sternal
region. The surface involved measures about 3 in. by 7 in. The
growths vary in size from a millet-seed to a split pea. They are
painless, and there is no tenderness on pressure except in the largest
nodule, which is about the size of a marrow-fat pea. This nodule
is extremely sensitive to pressure, a tenderness that is definitely due
to nervous causes and not to pressure irritation. A small group of
a dozen or more small nodules is below the right shoulder-blade,
one of them being the size of a pea. A few others in an early stage
are near the angle of the left scapula. About the middle front of
the left forearm is a linear transverse group of a dozen or so similar
small nodules. In this place slight tenderness is felt on firm pressure
upwards.
The distribution of the thoracic group is suggestive of a possible
nerve origin. The one tender nodule further suggests the development
190
Whitfield: Specimen and Culture of a Yeast
of a nerve element in the growth. The probability seems to be
that the nodules are simple fibromata, but it is hoped to settle the
matter by a biopsy.
Many members considered this case an example of multiple leiomyomata
cutis.
Microscopical Specimen and Pure Culture of a Yeast derived
from a case of Intertriginous Dermatitis of the Cruro-
scrotal Region.
By A. Whitfield, M.l).
The patient was an elderly gentleman, who had suffered from
what appeared to be ordinary eczema intertrigo of the groins and
perineum. No marked marginate appearance was present and no
other symptoms suggestive of parasitic origin. Examination of a
scale showed, however, that the horny layer contained an abundance
of large round bodies, considerably larger than the spores of a tricho¬
phyton. Two scales from different parts of the eruption were planted
on Sabouraud’s ringworm medium, and on both tubes a perfectly pure
primary culture of yeast was obtained. The urine had been tested but
no sugar had been found. Dr. Whitfield said that he considered that
the yeast w r as in all probability causing the dermatitis, since it was found
in such abundance and active growth in the scales.
PROCEEDINGS
OF THE
ROYAL SOCIETY OF MEDICINE
VOLUME THE FIRST
COMPRISING THE REPORT OF THE PROCEEDINGS FOR THE
SESSION 1907-8
ELECTRO-THERAPEUTICAL SECTION
LONDON
LONGMANS, GREEN & CO., PATERNOSTER ROW
1908
LONDON
JOHN BALE, SONS AND DANIELSSON, LTD.,
OXFORD HOUSE,
GREAT TITCHFIELD STREET, OXFORD 8TREET, W.
PBOCEEDINGS OF THE EOYAL SOCIETY OF MEDICINE
ELECTRO-THERAPEUTICAL SECTION.
CONTENTS.
October 25, 1907.
PAGE
The Future of Electricity in Medicine (Presidential Address). By W. Deane
Butcher ... ... ... ... ... .. ... 1
November 22, 1907.
The X-ray Diagnosis of Renal and Ureteral Calculi. By G. Harrison Orton, M.D. 15
December 20, 1907.
A Discussion on “ The Diagnostic Value of the Rontgen Kays in Diseases of tiie
Chest." Introduced by A. Stanley Green, M.B. ... ... ... 35
Mr. W. Deane Butcher (p. 44). Dr. David Arthur (p. 44). Dr. Halls
Dally (p. 45). Dr. Harrison Orton (p. 40). Dr. Squire (p. 48). Dr.
Lees (p. 48). Dr. Lyster (p. 50). Dr. D. Somerville (p. 51). Dr.
Samuel West (p. 51) I)r. Hinds IIowkll (p. 52). Dr. Allpress
Simmons (}. 52 1 . Dr. J. A. Codd (p. 53). Reply by Dr. Stanley Green
(p. 53).
IV
Contents
January 24, 1908.
PAGE
The Treatment of Leukemia, Exophthalmic Goitre, Sarcoma, &c., by X-rays.
By W. Ironside Brucf, M.D. ... ... ... ... ... 55
Cases and Specimens :
Fractures of the Scaphoid Bone. By G. Harrison Orton, M.D. .. 62
Gonorrhoeal Warts. By A. D. Reid ... ... ... ... .. 66
Plastic Rontgenography. By W. Deane Butcher ... ... ... 64
February 28, 1908.
The Principles of Ionic Medication. By H. Lewis Jones, M.D... ... ... 65
March 27, 1908.
Cauterization as an Adjuvant to Radiotherapy. By J. Goodwin Tomkinson, M.D. 86
The Electrolytic Method of Measuring X-rays. By Howard Pirik, M.D. ... 92
April 24, 1908.
The Electrical Treatment of Atonic Conditions of the Digestive System. By
Reginald Morton, M.D. ... ... ... ... ... ... 101
May 22, 1908.
Interrupted Currents for Electrical Testing and Treatment. By H. Lewis
Jones, M.D. ... ... ... ... . . ... ... 116
Some Reflections based upon the Work done in the Electrical Department of the
Royal Infirmary, Edinburgh. By Dawson Turner, M.D. ... ... 118
Ionic Medication in the Treatment of some Obstinate Cases of Pelvic Disease in
Women. By Samuel Sloan, M.D. ... ... ... ... ... 126
The Council think it right to state that the Society does not hold itself in any way
responsible for the statements made or the views put forward in the various papers.
filectro-Gberapeuttcal Section.
October 25, 1907.
M. W. Deane Butcher, President of the Section, in the Chair.
PRESIDENTIAL ADDRESS.
The Future of Electricity in Medicine.
Gentlemen, —I congratulate you on your presence here to-night on
what I cannot help thinking is an historic event, the first meeting of
the Electro-therapeutic Section of the Royal Society of Medicine, the
first occasion on which electrical science has been represented in the
Witenagemot of Medicine. It would be wearisome to recount the past
history of electro-therapy, or to dwell on the troubles and indignities
of its youth. Suffice it that the Electro-therapeutical Society has
taken its place by its sister societies, and it is for us, as servants and
votaries of medicine, to prove by zealous service our right to that place.
The subject of my address is the Future of Electricity in Medicine,
the role which electricity is destined to play in the future development
of the healing art. The first record of electro-therapeutic treatment
was in a.d. 34, when, as Scribonius Largus tells us, patients suffering from
rheumatism and gout were placed in a bath containing electric eels. Up
to recent times the progress of medical electricity has been a slow one.
But that progress of late years has been greatly accelerated. Seldom in
the evolution of a science has such a rapid advance been made as that
of Rontgen diagnosis and electro-therapeutic treatment during the last
decade. I propose to trace briefly the general trend of this advance,
and, from the direction of progress in the past, endeavour to predict the
course of the future development.
Rontgenography.
And first as to rontgenography or skiagraphy : the impression of
the shadow of internal structures on a photographic plate. Marvellous
as is the progress since the appearance of Rontgen’s original pamphlet,
“ Ueber eine neue Art von Strahlen,” we are still far from having
attained finality in this direction.
2
Butcher: The Future of Electricity in Medicine
The Focus-tube .—The Eontgen tube itself is but a very imperfect
instrument, the result more of chance than of design, and far from
realising our ideal of a focus-tube—a fixed and unvarying source for the
emission of ethereal undulations of definite wave-length and constant
intensity. Some such tube as this I seem to see foreshadowed : an
ethereal musical instrument able to give out and sustain without altera¬
tion of pitch any required note of the Eontgen gamut; able also, at the
will of the operator, to run through the whole of the scale with any
desired rapidity. We require a chord of Eontgen vibrations, the com¬
ponent notes of which will in turn bring out on the plate the softer
tissues, the muscles, the arteries, and the bones. * Something of this
sort has been already accomplished. In the latest development, the
plastic skiagraphy of Dr. B61a Alexander, a soft tube, the bass viol,
as it were, is used in conjunction with a hard tube, the flute of the
Eontgen orchestra. A practical advance in this direction would be the
construction of a tube-holder similar in principle to the nose-piece
of a microscope, which shall hold three or more Eontgen bulbs in such
a manner that any one of them can instantly be placed in position over
the diaphragm. By this means we should be able to switch on radia¬
tions of different penetration on the s$me plate during a single exposure.
It is evident that any photograph showing a large amount of detail and
differentiation of structure must be the product of a compound irradia¬
tion. This I believe to be the explanation of the supposed superiority
of long exposures in skiagraphy. Eadiographers giving a long exposure
are, in fact, using a tube which is gradually getting harder, and is there¬
fore giving out rays of ever-increasing penetration.
The Photographic Plate .—The photographic plate is susceptible of
as much improvement as the focus-tube. The compass of the Eontgen
scale may be greatly extended not only by using a more variable source,
but also by increasing the sensitiveness of the plate which registers the
vibrations. So the ripple-marks on the seashore are dependent not only
on the magnitude of tlie waves, but on the fineness of the sand which
receives their impressions. The improvement of the photographic plate
offers an inexhaustible field to the ingenuity of the inventor. The
present tendency seems to be to increase the thickness of the film and
the density of the silver salts in the emulsion. Some operators even
attempt to increase the absorption of the rays by using two plates placed
face to face.
Development .—The development of the plate is a matter of almost
equal importance. It is only an expert photographer who can attain
Electro-Therapeutical Section
3
proficiency in the art of developing the host of superimposed lights and
shadows which we call a negative. Let me explain. If I handle this
piece of glass you know r that the perspiration will leave on it an almost
invisible impression of my finger tips. By appropriate means, the use
of osmic acid, photography, and the like, we may obtain a permanent
record, a detailed plan and figuration of this chance impression. All the
lines of the finished picture were present in the original impression,
though invisible, and any want of skill in the handling and subsequent
treatment would have obliterated them completely. So in even the
most imperfect Rontgen negative there is imprinted a vast amount of
detail which may be brought out by careful manipulation.
Printing .—When the negative is developed we are still far from the
end of our labours if we would get the very best results of which our art
is capable. At the last Berlin Congress Dr. Bela Alexander showed how
details and differentiation of invisible or barely visible shadows may
be reinforced by repeated copying and recopying of the superimposed
negative and diapositive. In this method, the so-called “ Plastic Ront-
genography,” the negative is first copied as a diapositive ; the two are
then superimposed with a very slight displacement, and a plate is made
from this combination. To obtain a print this combination is copied
once more, and the final print is made from this fourth plate. In some
of Dr. Alexander's later work every smallest detail of muscle and tendon,
artery and vein, stands out with startling clearness.
As the length of exposure becomes shorter and shorter we may
expect an extension of the use of reinforcing plates, whereby the exceed¬
ingly brief Rontgen illumination is prolonged by phosphorescence. The
question of screening the plate from the effects of secondary radiations,
again, is becoming of ever-increasing importance. In rontgenography
for the detection of renal calculus and the like, the results may often be
improved by placing a sheet of aluminium immediately over the photo¬
graphic plate.
Time of Exposure .—In the future the time of exposure will certainly
be greatly reduced. The lightning flash of X-rays will be allowed to act
on the plate for only a fraction of a second. The enormous current
necessary for this will probably be switched on and off again by a single
motion of the key, so as to prevent its ever passing for a sufficient length
of time to overheat the anticathode or to damage the tube. The exposure
of the future must be instantaneous, not only with regard to the respira¬
tory movements, but also when compared with the heart-beat. This is
already quite within the bounds of possibility. I recently showed the
n —6 c
4
Butcher: The Future of Electricity in Medicine
skiagram of a bullet in the pericardium, taken by Professor Rieder, of
Munich. The absolutely round contour of the bullet shows that it was
practically unmoved by the cardiac beat during the time of exposure.
Those who have seen the beautiful pictures produced by tele-
rontgenography—skiagraphy at a distance—will agree with me that this
method has before it a great future. Dr. Rosenthal, of Munich, has
made some wonderful skiagrams by this method, which I hope to lay
before you at a future meeting. In this procedure the focus-tube is
placed at a distance of two or more metres from the patient. By this
means the magnification of the shadow is greatly reduced and the distor¬
tion avoided. Tele-rontgenography will probably be used in the future
to replace the more tediofis processes of orthodiascopy and ortho-
rontgenography.
At the Surgical Section of this Society, Professor Goldmann showed
a somewhat novel procedure for obtaining the necessary differentiation of
transparency in abdominal examinations. The procedure consists in
blowing up the colon as far as the ctecum with air, previous to the
Rontgen examination. By this method he has obtained most interesting
skiagrams of calculi and concretions in the appendix. This is a method
similar to that which has been in use for some time for the examination
of diseased joints, where the necessary transparency of the joint has been
obtained by injecting oxygen. The latter procedure is not without its
danger, as one or two fatal accidents have been reported by German
observers.
Compression .—I would draw your attention to one further point, and
that is the raison d'etre of compression. Compression alone does not
increase penetration. The absorption of the X-rays is determined by
the total amount of tissue traversed, not by the closeness of its packing.
What compression does is to abolish air-spaces and increase the
homogeneity of the tissue. Those who are familiar with the use of the
fluorescent screen in the examination of the stomach will have been
struck with the great increase of transparency obtained when the screen
is brought into intimate contact with the abdominal walls, and a still
further increase of clearness when pressure is used. This greater trans¬
parency is due to the greater homogeneity of the medium, and to the
expulsion of air from the region immediately under the screen. A
similar phenomenon is well known in optics. The transparency of a
wetted cloth is due to its increased homogeneity and to the exclusion of
layers of air. In order to obtain the best results the use of a compressor
of some sort is absolutely essential. Some of the best results have been
Electro - Therapeutical Section 5
obtained by using a pad of loofah under the compressor. In the search
for renal calculus compression is not so important, since the usual
position of the plate under the patient's body gives the two desiderata—
viz., pressure and intimate contact. In examination of the apex of the
lung, however, this is much more difficult of attainment. In order to
compare the opacity of the apices of the two lungs, it might be possible
to obtain a closer contact by means of an adherent photographic film.
In the same way the fluorescent screen might perhaps be made of some
flexible material, so as to secure complete apposition. Perhaps even it
might be possible to paint directly on the skin a collodion film which
shall be sensitive to the photographic or fluorescent action of the rays.
These, then, are some of the improvements which we may fairly expect
in the production and printing of that complex impression, a Kontgen
photograph. This is not a simple record, but a most marvellous
palimpsest, where shadow is superimposed on shadow, one record on
another, in seemingly hopeless confusion, but each capable of yielding up
its secret to the earnest and patient student.
Diagnosis .—In diseases of the chest, diagnosis by means of the
Kontgen rays is rapidly developing. Kontgenography is destined to
take its place beside, if it does not overshadow, the older classical
methods. The Kontgen diagnosis of infiltrations of the apices of the
lungs is already fairly advanced, and a very satisfactory instrument has
been designed which enables us to compare the opacity of the two apices.
What is of even greater importance is the possibility of diagnosing
infiltrations of the glands of the hilus of the lung, a condition
which is wholly beyond the ken of the older methods of diagnosis. It
needs no prophet, therefore, to foretell that the future hospital or
infirmary for diseases of the chest will be furnished with an X-ray
installation as a matter of course. The same may be said of ortho¬
diagraphy for diseases of the heart. In diseases of the stomach also a
whole new field of research has been opened up by the labours of Kieder
and Holzknecht, a field which we may rest assured will not be left
untilled.
One of the most vivid impressions of my life was my first sight of
the beating heart, like some living creature, tranquilly breathing within
its bony cage. Still more impressive was the sight of the stomach
during the digestion of a bismuth breakfast. The course of each
mouthful during mastication and deglutition was visible on the screen,
revealing as it passed the position of the oesophagus and the shape and
movements of the stomach. The whole progress of digestion could be
6
Butcher: The Future of Electricity in Medicine
followed, from the ingestion of the meal to the -final passage of the food
through the pylorus.
Even the cinematograph has been pressed into the service of
medicine. At the last Berlin Congress the movements of the diaphragm
and viscera during respiration were clearly reproduced on the lantern
screen. If this is possible only a decade after Rontgen’s discovery, what
may not our successors hope to witness in the future ? The differential
diagnosis of various forms of arthritis, gout, rheumatism, and rheumatoid
arthritis is well within our reach. Even now in some hospitals a
Rontgen examination of the hands is a routine preliminary to the
diagnosis of chronic disease of the larger joints.
Before I leave the subject of electricity in diagnosis, there is one
of its possible uses which has been hitherto overlooked, but which I
think might be of considerable utility. T allude to the employment of
electricity during the preparation and staining of microscopic specimens.
The demonstration of slight differences of structure, the enquiry into the
penetration of external remedies, and the study of ionic cataphoresis may
best be carried out in the field of the microscope. It would be in¬
teresting to know 7 what is the exact effect of a weak galvanic current or
of the X-rays on the staining of a microscopic specimen. In the early
days of the Rontgen rays they were used commercially in the operation
of tanning leather. It is quite possible that some interesting facts as to
skin structure might be obtained by careful experiment on the ionic
penetration of the skin under the influence of X-rays or radium.
Pathology .—I have no time to do more than glance at the use of the
X-rays in anatomy and pathology. In anatomy the tedious process of
dissection to trace the blood-supply is now replaced bv a series of Ront-
genograms of a suitably-injected organ. In pathology, also, specimens of
the blood-supply of the neoplasm and its influence on the glands can best
be examined by injection and rontgenography.
Electrotherapy.
We must now turn our attention to electrotherapy—the application
of electricity to the treatment of disease.
Radium .—And first with regard to radium, for radium-therapy may
fairly be included within the scope of electrical treatment, if we accept
the modern theory that electricity is but the displacement of electrons.
There is no fundamental difference between the natural radioactivity of
radium and the artificial radioactivity of the anticathode of an X-ray
tube. There is no more interesting phenomenon in medicine than the
Electro-Therapeutical Section
7
withering of a wart, a lupus nodule, a rodent ulcer or a patch of
epithelioma under the influence of radium irradiations. All embryonic
or rapidly growing neoplasms are apparently destroyed with equal
facility, provided they are sufficiently circumscribed and surrounded by
healthy tissues. Could we but discover the raison d'etre of this action
we should perhaps have the key to nature’s own method of cure. Do
radium and X-ray irradiations act by direct bacterial destruction, or do
they only awaken the resistance of the affected tissues? It w T ould seem
that an invaded tissue possesses three lines of defence—the first,
hyperaemia, a flushing of the invaded area with lymph ; the second,
pigmentation, a screening of the organism from malign radiations; the
third, an increased production of connective and scar tissue. All these
phenomena may be observed in the integument which has been exposed
to radium or to the artificial radioactivity of an X-ray tube. In the
early days of radiotherapy, when the X-rays were used much more than
they are now for hypertrichosis, one found again and again that the
hair bulbs were strangled by a reticulated growth of connective tissue.
After a long series of irradiations the face became smooth, pale, polished,
and cold, and this without any visible X-ray reaction. The curative
action of X-rays and radium on cancerous and other neoplasms appears
to depend greatly on this stimulating action on the protective growth of
scar tissue.
Rontgentherapy .—With regard to rontgentherapy, the most impor¬
tant point is the question of dosage. A recent paper by Rieder, of
Munich, emphasises the importance of exceedingly small doses of Rontgen
rays. It is now known that in cases of leukamiia an intense and
prolonged irradiation may even have a deleterious effect, even though
it results in a cure from a haematological point of view’. Formerly it
w r as the custom to continue the irradiation until the leukasmia had
completely abated. Rieder advises that the treatment should be inter¬
mitted as soon as there is a decrease in the number of leucocytes. The
first sign of leukopenia is a contra-indication of further X-ray treatment.
He obtains the best results from single irradiations of five minutes’
duration at intervals of one or even several weeks. The same obser¬
vation applies to the treatment of struma, Basedow’s disease, and the
various skin diseases. I myself have insisted again and again on the
efficacy of small doses, and shown that there is hardly any of these
affections, be it chronic eczema or acne, psoriasis or sycosis, wdiich is
not benefited by small doses of the Rontgen rays.
As to the bactericidal action of the rays, no one who has watched
8 Butcher: The Future of Electricity in Medicine
the cleansing of a foul varicose ulcer by the X-rays can doubt that they
are bactericidal in vivo , whatever they may be in vitro , or on a culture
plate. It may be that the effect is not directly bactericidal, but conse¬
quent on local hyperaunia. The efficacy of Bier’s “ Stauung ” treatment
seems to indicate that an abundant supply of lymph is the chief factor
in nature’s mechanism of healing. If this be so I know of no means
of producing this limited and localised hyperapmia more certain than
radium or X-ray irradiation. Whatever may be the rationale of the
Kontgen cure, there is certainly an increasing tendency to give smaller
and less frequent doses than in the early days of radiotherapy. Most
observers are now agreed that any visible and intense reaction should
be avoided. We have other more efficient and less dangerous means
of producing destruction of tissue or cauterisation. It is seldom necessary
to proceed even to epilation.
Ringworm .—It may, indeed, be doubted if Sabouraud’s epilation
method is the last word to be said in the treatment of ringworm.
Parents and practitioners alike are somewhat chary of subjecting very
young infants to so potent and powerful an agent, the action of which
is so obscure and the ill-effects of which are so occult and so long
delayed. In the future I believe that epilation will be reserved for
older children or for inveterate cases only. It is, moreover, somewhat
unscientific to root up the wheat in order to destroy the tares, when
we have such a discriminating agent as the X-rays at our command.
At the Berlin Congress, Forstling, of Hanover, read a paper on
“ The Ill-Effects of X-ray Irradiation on Development,” and showed
a puppy, one of whose legs had been exposed to ten minutes’ Kontgen
irradiation when it was eight days old. The limb was permanently
dwarfed and withered. It is true that, as Holzknecht has pointed out,
the development of a young animal is much more rapid, and therefore
more easily inhibited, than that of a child. Moreover, the skull of the
infant will filter out some of the softer or more deleterious rays. But
even so, the observation is not a pleasant one, and should give us pause.
The ill-effects, if any, caused by irradiation of the child’s nerve centres
would be recognisable perhaps only after the lapse of years. On the
other hand, I believe that small doses of Kontgen rays are of con¬
siderable utility in the treatment of ringworm. The method of intro¬
ducing the copper ion by electrolysis also bids fair to be of great utility.
The chief disadvantage is on the score of pain to the little patients, but
this may be obviated in great measure by the simultaneous introduction
of the cocaine ion.
Electro-Therapeutical Section
9
This question of the penetration of the copper or mercury ion under
the influence of the X-rays, high frequency, and the galvanic current,
might easily be set at rest by suitable experiment. A couple of small
pedunculated fibromata on the same patient might be treated with
ointment or lotion containing a copper or mercury salt. One of them
should then be irradiated or otherwise treated electrically. Both should
then be examined under the microscope, with suitable reagents, to
determine the depth to which the metallic ion had penetrated. Better
still, a limb that has been condemned for amputation might be made
the subject of experiment. Each finger or toe should be massaged wdth
an ointment of oleate of copper. One finger might then be exposed
to Bontgen irradiation, another to high-frequency effluve, another to
the galvanic current, and so on.
High Frequency .—We have but little time to linger on the other
modalities of electric treatment. High-frequency treatment has of late
been receiving more attention in England. There seems to be no doubt
that auto-conduction and auto-condensation are valuable means of re¬
ducing high arterial tension. The rapidly changing magnetic field appears
to set up a sympathetic vibration of the electrons. According to the
rapidity and wave-length of this vibration, it may cause either stimula¬
tion or inhibition of the nerve centres. It is possible that the same
frequency of vibration may cause inhibition of one nerve centre and
stimulation of another. In this way w T e might obtain simultaneous
stimulation of the vasodilator and inhibition of the vasoconstrictor
centres. The very marked action of high-frequency currents on the
kidneys and on the urinary secretion is probably also due to the direct
stimulation of the vasodilator centres.
It is surely unscientific to attempt to taboo high-frequency treatment
because it has claimed too much and been used, perhaps, for unworthy
purposes. The same may be said of any method of treatment, and,
indeed, of all human activities. The opposition in England and Germany
to d’Arsonvalisation, as it is called, has aroused the ire of a French
writer, who speaks of it in words which are applicable not alone in
France. “I speak,” he says, “to the body of medical men wrho work,
who desire to know r , and whose brain is not curdled by dull routine.
Le reste ne compte pas .” As students of electro-therapeutics we cannot
afford to neglect any of the modes of motion of the electrons, the gentle
flow in the galvanic current, the sudden rise and fall of velocity in the
faradic current, or the lightning rapidity of high-frequency vibrations.
A high-frequency apparatus, however, is a dangerous weapon in ignorant
10
Butcher: The Future of Electricity in Medicine
hands. It is not a plaything to be entrusted to an inexperienced
operator, be he qualified or unqualified in a legal sense. Only recently
I had an opportunity of seeing the dangerous results of a high-frequency
application in an unsuitable manner. The case, one of cardiac debility,
was treated by stimulation with a glass excitor over the solar plexus.
As might have been expected, it resulted in a considerable fall of blood-
pressure, accompanied by weak pulse and great exhaustion. It has
always been a matter of amazement to me how practitioners undertake
the management of these powerful instruments with the gav insouciance
of ignorance. The most important advance in electro-therapeutics will
be the adequate instruction of the practitioner in the use of such lethal
weapons. It is difficult to believe that the practitioners of the future
will undertake so grave a responsibility as the application of X-rays and
high frequency with so little preparation and so small a stock of physical
knowledge.
Tons .—One of the most interesting developments of electric treatment
is that of ionic medication, or ionic cataphoresis as I should prefer to call
it. It may be noted in passing that the time-honoured treatment by
internal medication, the introduction of drugs per inas naturales, is in
reality ionic medication ; since, as Van t’Hoff and others .have shown, a
weak solution consists of already dissociated ions. Internal medication
is, therefore, ionic medication. Again, the old-fashioned galvanism with
copper electrodes was in reality ionic cataphoresis. The pure effect of
a galvanic current is almost unknown, since even with a carbon electrode
and a thick pad of absorbent wool moistened with distilled water we
cannot get rid of the action and caustic properties of the hydrogen ion.
The successful treatment by ionic cataphoresis requires the most careful
technique, perfect cleanliness, and as many precautions as does surgical
asepsis.
. The chief obstacle to further progress in this direction is the difficulty
of producing sufficient ionic penetration without excessive pain or injury
to the skin. There are two precautions which are of the utmost impor¬
tance in ionic treatment—one is the absolute steadiness of the current,
and the second is the very gradual rise and fall of potential when switch¬
ing the current on and off. The first of these, the avoidance of acci¬
dental fluctuations in the current intensity, is absolutely impossible when
using the public electric mains. A much better method is to use a
battery of storage cells for all galvanic and ionic treatment. In repeat¬
ing the experiments on electric sleep, Dr. Louise Kobinovitch found that
the sleep w r as much more tranquil and profound at Nantes than at Borne,
FIecfro-The)'apen tica l Section
11
so much so that she imagined the difference must be due to variations in
the physiological susceptibility of different breeds of rabbits. Subse¬
quently she found that in the former town the current was obtained
from storage cells, whereas in the latter the laboratory was supplied
direct from the public mains.
Of equal importance is the gradual and imperceptible rise and fall of
the current intensity. In ionisation or electric stimulation the pain is
not caused by the intensity of the current, but by the variations of
intensity. One of the instruments that we most need is an automatic
contrivance for gradually turning on the current, increasing it very
slowly, and turning it off again with equal precautions. Such a contri¬
vance should not be difficult to design, and I commend it to the notice of
the mechanical members of this Section. In ionic cataphoresis, also, the
question of dose is of the utmost importance. Take, for example, the
zinc ion. With the introduction of small ionic doses of zinc there is an
increase of the vitality of the skin, as evidenced by the accelerated
growth of hair. With large doses we get paralysis of the function of the
skin and mortification of the tissue. It is curious to note that the lesions
due to the introduction of metallic ions greatly resemble those produced
by the X-rays, and exhibit a similar phenomenon of latency. This
observation, which is due to Leduc, may throw some light on the cause
of X-ray burns.
Electric Sleep .—Professor Leduc’s recent work on electric sleep has
opened up a magnificent and far-reaching vista. It has given us the
means of producing sensory and cerebral inhibition. In the future an
intermittent current of proper frequency may be at our disposal, by
means of which we can at will switch off any, or all, the nerve centres
one by one. Perhaps the Section will permit me to quote from an
editorial on this subject which I wrote for the “ Archives of the Rontgen
Ray,” and which has created a certain amount of interest in the
German press:—
In the armamentarium of medicine there is a good array of weapons for
stimulation, but comparatively few instruments for inhibition. Professor
Leduc has given us a sleep-compeller, acting, not by poisoning, or counter¬
irritation, or exhaustion, but by the direct and immediate inhibition of the
brain-cells themselves.
The inhibition is produced by an electrical stimulation of the nerve-cells,
with a rhythm which is incompatible with their physiological activity. To
produce the inhibitory effect the current oscillations must be in tune with the
physiological note. The frequency for the brain of the rabbit is 100 per
second, and the current duration one-thousandth of a second. Quietly,
n —7
12 Butcher: The Future of Electricity in Medicine
without a cry or movement, without the least sign of pain or discomfort, the
animal sinks into a condition of deep narcosis, similar to that produced by
chloroform. On the cessation of the current the animal awakens instantly,
without any sign of pain, or fear, or of fatigue.
Professor Leduc has subjected himself to the treatment with no ill-effects,
although in his case the experiment was not carried far enough to produce
complete narcosis.
Not only can general anaesthesia be produced, but by apprppriate modi¬
fications of the process a limited local anaesthesia is also obtainable by this
method. We are thus furnished with a most potent instrument for producing
nervous inhibition, and we may hope ere long to see the electric sleep in use
as a practical remedial agent, replacing or reinforcing the natural rest. More
than this, we have some reason for supposing that each muscle and nerve is
attuned to its own special period of electric stimulation, and therefore of
electric inhibition, so that in the near future we may be able to put to
sleep a tired member or an injured organ without obliterating the general
consciousness.
The necessity of finding some safe and simple means of inducing nerve
sleep is becoming ever more important as the stress of civilisation increases,
and the prevailing disease—a too widely extended and developed consciousness
of our environment—becomes more acute. We may live to hear “ two hours’
inhibition ” prescribed before an operation, or a “ week’s electric sleep ” before
an examination. The possibility of thus suspending growth and tissue changes
is brought forcibly to our notice by the modern methods of forcing vegetables
and flowers for the market. In the vegetable as well as in the animal world,
the axiom holds good that a period of quiescence or inhibition must precede a
period of stimulated growth. The winter sleep of plants may be induced at
any season of the year by placing them in cold storage, and plants whose
growth has thus been retarded will develop much more rapidly on being
reawakened by warmth. More recently the ether narcosis of plants has come
into use. By this method a brief nap of some couple of hours seems to fulfil
all the purposes of a long winter sleep, and the plant can be forced at once
into a new season of growth and activity. It would be a marvellous addition
to the forces at our disposal if we had some similar means for regulating
the development and activity of the animal organism, and perchance the electric
sleep may enable us to procure the inhibitory rest required as a prelude to
stimulated growth.
At all events, we may expect great developments in the electrical
treatment of neurasthenia and brain affections, since Leduc has shown
not only that the brain itself is within the domain of electrical treatment,
but that total inhibition of the cerebral function may be produced by the
mere pressure of an electric switch.
Theory .—We may look forward to great progress in electrical theory
and a clarification of our ideas as to the rationale of electricity, as the
result of the epoch-making discoveries of the last few years. The
Electro-Therapeutical Section
13
electron theory is so beautiful and so simple that we can only hope that
the physicist will leave it alone as it now stands. For us who endeavour
to visualise the passage of electricity through the human body, it is no
small matter to have replaced the vague conception of an electric current
by the mental picture of a double train of moving ions.
It is a most fascinating theme this—the future of electricity in
medicine. But my time and your patience are both exhausted. In
concluding, let me congratulate the members of this Section on having
chosen this, the most interesting and stimulating of all branches of
medicine. We stand on the utmost verge and boundary of things,
where the coast-line which separates the known and the unknown is
shifting most rapidly. For us is the supreme satisfaction of watching,
and, in some measure, assisting in this transformation. For us the
whole past of medicine is full of inspiration ; for us the future of
physical and electrical science teems with the very embodiments of our
most sanguine dreams.
Dr. Lewis Jones thought the President's survey of the whole
subject of electrical therapeutics had been a very admirable and sug¬
gestive one. He had lately been greatly interested in the question of
the penetration of ions. All investigators desired to discover how far
into the tissues it was possible to cause ions to penetrate by means of
the electric current, and whether they could be made to penetrate to
any considerable depth. After consultation with chemists who, he
thought, were able to illuminate the subject, he found the general
opinion was that if the ion which it was desired to drive in was one
which would form insoluble salts with the chemical constituents of the
body, it would most likely combine in that way, and be put out of
action at a comparatively slight depth, and could not then be made to
penetrate any deeper. The initial velocity with which the ions moved
on leaving the electrode and while passing through the epidermis w r as
due to the fact that at those levels they had to carry the w r hole of the
current concerned ; but within the tissues these ions formed only a small
proportion of a very large number of other ions, all of which were
available for the conduction of the current. One might compare the
condition to a stream of water running out of a small pipe into a river,
where the velocity of the flow inside the pipe and just outside its end
was rapid ; but as soon as it became merged in the general stream of the
river the velocity of the little stream would disappear. Zinc or copper
ions within the tissues must meet w r ith phosphates, and must almost
14
Butcher: The Future of Electricity in Medicine
certainly form insoluble phosphates of zinc or copper, and cease to share
in the transport of the current, the current from the positive pole being
subsequently taken on by the other kations of the body, such as
sodium, potassium, &c. For these reasons he thought it was unreason¬
able to expect that copjier or zinc ions could be conveyed very far into
the body. He thought it would be wise for electro-therapeutists to
limit their attention for the present, when dealing with ions of the
heavy metals, and to concentrate their efforts upon the treatment of quite
superficial diseases, of which there were many requiring improved forms
of treatment. On the other hand, with an ion like salicylic acid, which
did not form insoluble compounds with the juices of the body, one might
hope to cause penetration to take place to deeper levels. The difficulty
remained, however, which he had previously mentioned, namely, that
when the ions had passed away from the electrode their velocity of
movement became diminished.
Dr. Horace Maniiers, in dealing with the subject of the travelling
of ions, said he imagined that they would follow the law of inverse
squares, and therefore, following out that law, that they would not get
very far into the body. The President had referred to the subject of
electro-therapy and the brain, and in that connection he knew that
X-rays had a very great effect in epilepsy, as he had treated one or two
cases very successfully. Two or three years ago lie gave particulars of
the cases in the Archives of the Hontgen Hay. He followed the
method of finding out where the aura started from, and irradiating the
locality in the brain to which it corresponded w r ith short exposures fairly
frequently, say two or three times a week. He gradually increased the
length of the intervals, but not the length of the sittings. The cases
had done remarkably well; in one case a young man who had had
constant petit mat, and was no good for any work in life, was now
conducting quite a large farm and had not had a fit for a year. Per¬
sonally he believed there was a very large future for X-rays in epilepsy.
He did not claim that the method of treatment was original, but the
plan of ascertaining the portion of the motor tract corresponding to the
apparent point of origin of the aura, and irradiating that particular
portion of the brain, was an idea of his own.
On the motion of Dr. Lewis Jones, seconded by Mr. C. H. t\
Lister, a cordial vote of thanks was passed to the President for his
Inaugural Address, which the President briefly acknowledged.
(The meeting was adjourned to November FI next.)
£lectrcv£berapeutical Section.
November 22, 1907.
Dr. H. Lewis Jones, Vice-President of the Section, in the Chair.
The X-ray Diagnosis of Renal and Ureteral Calculi.
By G. Harrison Orton, M.D.
Gentlemen, —So much has now been written on the subject of the
X-ray diagnosis of renal and ureteral calculi that I owe, perhaps, some
apology for introducing the subject before this Section of the Royal
Society of Medicine. I cannot hope to introduce much, if anything, that
will be new to the bulk of those present. Nevertheless we still have
much to learn before this method of examination becomes perfect, and
I trust that the few remarks I have to make this evening will lead to
an interesting discussion, which may help us towards the solution of
some of the chief difficulties we have to encounter. I shall confine
my remarks, therefore, chiefly to my own experiences, and leave it to
others to give theirs.
For convenience I will adhere as closely as possible to the order in
w r hich the various points are printed on the agenda.
First, then, under the heading of Technique, a few words as to the
preparation of the patient. I do not think sufficient attention is as
a rule paid to this point. I prefer all patients to be prepared much
in the same way as for an anaesthetic, so that the intestines are as empty
as possible at the time of examination. There are two chief reasons for
this. In the first place, when a soft tube is used, faecal masses certainly
cast definite shadows. In the great majority of cases these shadows do
not present any difficulty in the way of diagnosis, but I have seen
at least two cases lately in which there were shadows quite definite
enough for some forms of calculus in patients not properly prepared.
These have entirely disappeared after an aperient and enema. Further,
should the patient be taking certain drugs, such as bismuth, very dense
shadows may be cast. These, although perhaps not in themselves likely
to be mistaken for calculus, may form a shadow sufficiently dense to
mask one. An interesting case of this sort, with a reproduction of the
skiagram, was published recently by Mr. Thurstan Holland in the
d —4
16 Orton: X-ray Diagnosis of Renal and Ureteral Calculi
Archives of the Rontgen Rays. Certain compressed drugs also, such as
some forms of Blaud’s pill, which have been found hard enough to be
hammered into a deal board after having passed through the entire
intestinal tract, might give shadows difficult to explain.
Again, after evacuation of the intestines, the colon, as a rule, is
found to be filled with gas. This acts much in the same way, though
to a less extent, as the artificial introduction of air, whereby a clearer
differentiation of the abdominal contents is obtained. Under such
conditions it is often possible to obtain an outline of the normal kidney,
such as could hardly be expected were the stomach and intestines
loaded. Naturally the more differentiation of soft parts we can obtain,
provided always we can interpret their shadows, the more data we have
to go on when trying to decide the position of any given shadow.
Position of Patient .—I prefer when possible to work from below, and
the following is the method I usually employ. The patient, having been
suitably prepared and clothed (I need hardly mention the importance
of the absence of buttons, &c., in the clothing), is placed face down¬
wards on a canvas-topped couch. Immediately below the ribs and
under the abdomen is placed a sausage-shaped air pillow, especially made
for this purpose, and I believe first introduced by Mr. Reid. The chief
advantages of this pillow are as follows: (1) It acts as an efficient com¬
pressor, whereby the movements of the diaphragm are much restricted,
so much so that a calculus remains practically stationary during ordinary
respiration. This can easily be verified by anyone watching the shadow
of a renal calculus on the screen. When the pillow is not in position
it can be seen moving up and down, with a range in some cases of quite
1£ inches on deep respiration, whereas with the pillow properly adjusted
the movements can hardly be detected. The negatives obtained in this
manner also demonstrate this point. If we consider the distance of the
calculus from the plate, which in itself is the cause of some indistinctness
of the shadow, it is evident, from the slight amount of blurring even after a
longish exposure, that the kidney may be considered practically stationary.
Another important point, to my mind, is that the arch of the spine
is obliterated by this method to a much greater extent than in any
other method I know of, and consequently the plate can be approxi¬
mated much closer to the region under examination.
Lastly, the presence of the bag does not in any way interfere with
the passage of the rays. In fact, I have often noticed that more detail
can be made out on the screen when the bag is in situ than when
it is not employed. In addition to the compression obtained by the
Electro-Therapeutical Section
17
weight of the patient, I myself always supplement this when it can
be borne in the following manner : I have had made a wooden frame,
over which parchment is stretched, and of such a size as to just take
a 12 inch by 10 inch plate. This is attached to a frame which slides in
grooves on each side of the couch. The frame is lowered on to the back
of the patient, and when as much pressure as can be borne is obtained,
it is clamped in position by a turn of two thumbscrews. It is a
recognised fact that the X-rays, after passing through the body,
produce secondary rays in the air. These tend to produce a fogging
effect on the plate, and I am convinced that it is an important point
to have the plate pressed as close to the body as possible. Of course
the pressure can be obtained in other ways, as by placing sandbags
or other weight on the top of the plates, but the method I have
described is, I think, more certain and convenient. Moreover, in stereo¬
scopic work the plates are quickly and easily changed, without any
disturbance of the patient. By adopting this method I find that the
movements due to respiration are in the majority of cases so slight
that it is not necessary to give multiple exposures while the breath is
held at the same phase of respiration. There are, however, some
cases where it is still an advantage to do this ; there are many pros and
cons with regard to this question which I hardly have time to go
into at present.
The focus-tube should be enclosed in an opaque box, which can
be moved freely in any direction under the couch. The opening in
the top of the box, through which the rays emerge, should be provided
with a diaphragm the aperture of which can be easily altered. There
should also be a means of centring the tube so that the normal ray
may pass through the centre of the opening in the diaphragm.
Not the least advantage in working from below is the fact that one is
enabled to obtain a view of the region to be examined on the screen
before placing the plate in position. I attach a good deal of import¬
ance to this, for after considerable practice one is enabled to judge
to a great extent from the appearance seen on the screen whether
or not the tube is working to the best advantage for each individual
case, and moreover valuable information as to the probable time of
exposure required may also be obtained by this means.
Working from Above .—I have tried many forms of compressor for
working with the tube above the patient. Most of these are clumsy
and difficult to manage, and I now have discarded them for the method
just described, which offers certain advantages not obtainable when
18 Orton : X-ray Diagnosis of Renal and Ureteral Calculi
working from above. In mv hands, at all events, the method from
below has given better results. In cases, however, where the patient
cannot be examined from below', then some form of compressor must
be used. In this case it is essential that the apparatus be rigid, and
provided with a diaphragm to cut off secondary rays. The method of
taking a large number of small plates, as adopted by Mr. Thurstan
Holland, is hardly practicable in a large and busy hospital department,
and I question whether any great advantage is obtained.
The X-ray Tube .—To obtain negatives of the required quality, as
soft a tube as possible should be used, for it is only a tube with low
vacuum that will give a good differentiation of the soft parts. A hard
tube does not have the same effect on a photographic plate as
a soft one, and a good black-and-white negative cannot be obtained, the
result, even after prolonged exposure and careful development, being
a dirty grey. I may here, perhaps, quote from a paper I read at the
Exeter meeting, and give the opinions of others who joined in the
discussion at that time. At the Rontgen Society a short time ago
the question was raised as to whether a plate could be over-exposed
when acted upon by the Rontgen rays. No definite conclusion w r as
arrived at. I think I am right in saying that with a low tube and heavy
current over-exposure is certainly possible. In the course of the discus¬
sion Dr. Howlett said: “ I have come to the conclusion that it is not
possible. The exposure can be prolonged indefinitely, and development
will still give a good result. My opinion is that exposure cannot be too
prolonged under ordinary conditions.” No other speaker gave a further
opinion on this point. I, however, am convinced that over-exposure is
possible. The negative which I now show you is one of the renal region
of a stout patient who was sent to me a short time back. The spark
gap of the tube was about 3 inches, or slightly under; the current, 4£ to
5 milliamperes through a Bauer air-cooled tube. The exposure was two
minutes. The next negative is from the same case, with the same tube,
and an exposure of fifty seconds. The development of the first negative
was four minutes, and of the second ten minutes, with the same strength
of solution. If this negative is not over-exposed, what has happened to
it? Negative 3 is a specimen of an intermediate stage, but in a
different subject. I do not believe that a negative of such a character
could be obtained w r ith a high tube. My contention that low tubes gave
results superior to those obtained by high ones w r as supported by Dr.
Morton, Mr. Lyster, and Dr. Arthur.
Mr. Shenton did not agree, and said : (1) “ I question w T hether great
Electro-Therapeutical Section
11 )
density is really wanted in negatives from the surgeon’s point of view.”
With this I agree, but it is not necessary to obtain great density with
a low tube. I maintain that you can get more density, with a
correspondingly greater differentiation of soft parts, than is possible with
a high tube. Moreover, with a high tube it is quite possible that a
small calculus of low atomic weight, such as pure uric acid, would be
entirely overlooked, owing to the greater penetrative power of such a
tube. (2) “ I have some radiographs taken with high tubes, and the
negatives are of the washy character familiar to all X-ray workers, yet
I find it possible to correct them in the printing process.” I fear that
negatives obtained with low tubes, too, are often thin and washy, especi¬
ally in stout subjects; but even when thin they show, I think, more
differentiation of soft parts. Thjs skiagram is very thin. The subject is a
man, 14 st. 3 lb. in weight, but as you see it shows a marked differentia¬
tion of soft parts; the edge of the psoas, outlines of the colon and other
shadows of soft parts not easy to interpret are distinctly visible, and
there is not that uniform grey appearance seen in a negative obtained
with a high tube. (3) “ In my opinion low tubes, in order to give these
high densities, are not needed; we can do quite well with the tubes we
have got.” Now, to my mind, the X-ray tube is at present a most
imperfect piece of apparatus, and I would rather say, considering the
tubes we have got, we do not do so badly. Some may be satisfied with
their results, but I venture to think that there are many, including
myself, who are not so satisfied, and will work away until still better
results can be obtained. Judging from the vast improvements in the
results of the last few years, I am inclined to think that the day when
perfection will be the rule rather than the exception is not so far off.
I believe personally that it is to improvements in the X-ray tube that
we now have to look before we can hope for much better results, and
the improvement will be in the direction of a better control over the
vacuum and the possibility of keeping the required vacuum constant
during the exposure necessary to obtain the best results. I know of no
tube at present with a spark gap, say, of 2£ inches that will stand even
a current of 4 milliamperes for a minute or two without getting too low
to be of value. There are coils to be had giving an output capable of
smashing any tube on the market. What we now want is a tube that
will stand the increased output now obtainable.
I have no doubt that during a single exposure the quality of rays
emitted by any given tube varies, and the tendency of a tube, if it does
not get too hot, is to rise : that is, give off more penetrative rays. I
20 Orton: X-ray Diagnosis of Renal and Ureteral Calculi
believe, too, that a low tube becomes higher when extra current is
forced through it. Now, although a negative giving marked differentia¬
tion of soft parts is probably the result of a composite irradiation, I do
not think it need necessarily be so, and I do not think that this
is necessarily the reason why a somewhat prolonged exposure gives
better results than very short ones. The results obtained in the
thicker parts of the body by giving a second or two exposure with a
very heavy current, at least such as I have seen, are certainly not
superior, and I do not think equal, to those obtained by moderate
currents and about fifty to sixty seconds exposure. Nevertheless I
believe that if we could get tubes with a spark gap, say, of 2 to 2£ inches,
that would stand these heavy currents for a sufficient length of time, we
should be on the road to being able to • get certain results even in the
heaviest individuals. I have obtained results good enough to give a
negative diagnosis in persons up to and somewhat over 14 st. in
weight, but in a friend of mine who weighs over 19 st. and who was
kind enough to lend me his abdomen to experiment with, although
I was able to get a faint image of the spine I quite failed to get any
attempt at differentiation of the soft parts. No tube I possessed would
stand sufficient current for a sufficient length of time. At present, then,
I believe that for this class of work there is no advantage in using
very heavy currents for the reasons stated. I was talking the other day
to a doctor from America, who had been using currents of 60 to 70
amperes in the primary of a coil which gave an enormous output (not
measured, however), and he told me that except for getting a flash
exposure of the chest he had given up using such heavy currents, as the
results in the thicker part of the body were inferior to those obtained by
moderate exposure and current. I understand that the same conclusion
has been arrived at by German workers. The excellent results obtained
by Dr. Charles Lester Leonard, of Philadelphia, in the X-ray diagnosis of
renal and ureteral calculi are well known to most of you, and as a
further support of my contention that low tubes are necessary I may
quote from a paper published by him in the Lancet (June 17, 1905), in
which he says :—
I insist upon the following features of my technique as producing accuracy,
and I believe that a disregard of them by other operators accounts in a measure
for their lower percentage of calculi found in the total of cases examined. . . .
The first essential of technique is the employment of a constant quality of
Rontgen ray, the penetrating powder of which is so low r that it will not penetrate
the least dense calculi. The negative diagnosis w T as established upon the
axiom that wiiere shadows of tissues less dense than the least dense calculus
Electro - Therapeu tical Section
21
are shown no calculus should escape detection. The recognition of a negative
as possessing these qualities and its proper translation are essentials of technique.
The quality of X-ray employed has been given off by a tube the relative
resistance of which, as measured by a parallel spark in air, was from l£ to 2
inches. The tube must be capable of maintaining itself during the entire
exposure at the same vacuum. Many tubes, and tubes of higher vacuum, often
vary in penetrating power, so that the light at one time during the exposure
penetrates the smaller calculi.
The Screen Examination .—The screen examination is useful, as I
have already stated, for gauging w r hether or not the tube is working to
the best advantage in each individual case; it may be useful in con¬
firming shadows seen on the photographic plate in some cases, since a
very large number of calculi can be made out on screen examination,
provided the luminous sensibility of the observer is at its maximum.
This can only be obtained by remaining in the dark or semi-darkness for
sdme time before the screen examination is made, and it is a point to
which not sufficient attention is paid by many who wholly condemn
such an examination, which undoubtedly has a sphere of usefulness. It
must not be forgotten, too, that the eyes of different individuals vary in
their ability to appreciate the fluorescence of the screen, and there are
some who never can, even after a long time in complete darkness,
observe details which are very evident to others. Constant practice, also,
enables the eye to see more than that of those who do not so practise.
For giving a negative diagnosis, how'ever, I consider the screen examina¬
tion absolutely valueless, for there are some shadows which appear quite
distinctly on the negative which cannot be seen on the screen even when
their exact position is known. I have tested this in all cases I have
examined in the last six or seven months, and have found two in which
distinct shadows were found on the plate of small calculi (since con¬
firmed by operation), which by no stretch of the imagination could I see
on the screen, even with a small diaphragm contracted round the area
where the shadow' was known to exist.
Under this heading I may mention a further use to which the screen
has now been put. I refer to the examination of the kidney at the time
of the operation. This has now been rendered quite practicable with
the aid of the sterilisable cryptoscope designed by Mr. Reid, which it
will be unnecessary to describe in detail; suffice it to say that the whole
apparatus can be completely sterilised. The chief difficulties I have found
in using it at present are the following:—
(1) When working in a light theatre it takes some time before the
eyes can accommodate themselves to seeing objects on the screen, and
22 Orton : X-ray Diagnosis of Renal and Ureteral Calculi
surgeons, as a rule, are not patient enough to keep their eyes glued to the
machine for a sufficient length of time ; further, the eyes of the majority
are not trained to screen work, and consequently they take more time,
even under favourable conditions, to see what is at once apparent to an
expert. This difficulty might be got over in the following way : (i.) If
the radiographer present were to wear smoked glasses and were allowed
to examine the kidney after delivery from the wound, his eyes would be
in better condition to see the fluorescence of the screen, and his experi¬
ence would enable him to decide quicker; (ii.) or the theatre might be
provided with dark blinds, which could be drawn at the proper time;
(iii.) or the operation might be performed in the evening, when one’s
luminous sensibility is always at its best.
(2) The eye-pieces of the present instrument do not entirely cut off
the light, and the ease with which an eye-bath fits the eye has suggested
to me that if the eye-pieces were made in this shape they would cut off
the light more efficiently.
Lastly, there is a difficulty in some cases of getting the kidney
sufficiently far out of the wound, but I have no doubt this is much
facilitated by the weapon which ftfr. Reid has now designed to help this
procedure, and of which at present I have had no experience.
There can be little doubt that when this instrument is more
generally known it will be much used, and gradually improvements will
suggest themselves. For it cannot be denied that it is a great advance
over the cutting and needling all over of the kidney, with a great possi¬
bility, even after this has been carefully done by a skilled surgeon, of a
small calculus being overlooked.
And now as to the value of the X-ray diagnosis of calculi. It is my
belief that every renal calculus, at any rate of sufficient size to warrant
surgical interference, no matter what its composition, is capable of being
demonstrated by the Rontgen rays, provided a certain quality of
negative can be obtained. The same holds good with regard to ureteric
stones, with, perhaps, the one rare exception of small uric acid calculi
being in such a position in the pelvis that their shadow is obscured by
that of the bones. I mean in such a position between the bracket in
this negative, which is one of a normal pelvis.
We now come to a very important point, namely, the interpretation
of the various shadows seen on the negative, and first of all I want to
show you a slide of one case which is typical of many similar I have
seen. The shadows are apparently normal, but are ever so much
more prominent in some cases than others. I will simply show it and
Elect ro- They ape u t tea l Sec tio n
23
ask those present to give their opinion, in the discussion to follow,
as to what they are due. Are they the shadows of the normal kidney ?
The number of cases in which a negative of the required
character cannot be obtained is, I am glad to say, in the hands of skilled
operators becoming gradually less, but there are still some few cases
which, owing to the thickness and density of the individual, render the
production of such a negative impossible; in such cases a negative
diagnosis cannot be given. I mention density as well as thickness, as
some individuals appear much more opaque to the rays than others
of a similar weight and size. Here again it is only the expert who
is able to judge the required character of negative, but it should show
a marked differentiation of soft parts; the edge of the psoas and trans¬
verse processes of the vertebrae should certainly be visible, and if the
outline of the kidney, divisions of the colon, &c., can be made out, so
much the better, but I certainly would never give a negative diagnosis
on a plate which did not show some differentiation of soft parts. There
are some who maintain that it is not necessary for the tranverse pro¬
cesses of the vertebrae to be seen, but I am sure that this is quite wrong,
for how can we expect to find a small uric acid calculus, which is less
dense than bone, if bony points themselves cannot be distinguished ?
I now show you several negatives which I consider are of such a quality
that a negative diagnosis with regard to the regions they represent can
be given with some degree of certainty, and this one shows con¬
clusively the possibility of showing the outline of the normal kidney.
In the two cases published by Mr. Clement Lucas (British Medical
Journal , October, 1904), under the heading, “Two cases of Renal
Calculus, in which the X-rays failed to indicate the presence of a stone,”
I feel sure that, either through faulty technique or density of the
individual, satisfactory negatives could not have been obtained, in
which case this ought to have been explained, and no opinion given.
One of the cases, however, gives a point for discussion. The patient was
a thin man, the stone was a large branching phosphatic stone immersed
in pus, and it is suggested that the pus masked the shadow of the stone.
This is contrary to my experience, and I should much like to hear the
opinion of others.
The negative I now 7 show you is from a case wdiich was operated
upon only this afternoon. The calculus which I have here, as you see,
corresponds exactly in size to the shadow; it is composed of phosphates
and carbonates, and was in the pelvis of a kidney which contained
3 or 4 oz. of very thick pus (PI. I., fig. 1). You see also a minute
d—5 i
24 Orton: X-ray Diagnosis of Renal and Ureteral Calculi
shadow to the outer side of the larger one ; this proved to be a minute
calculus no larger than a millet seed, which shows quite clearly in spite
of the presence of the pus.
I may here again quote from Dr. Leonard’s paper : “ The accuracy
which has been demonstrated for this method by clinical experience has
led me to hold that the negative diagnosis, when proper technique and
skill have been employed and a satisfactory plate has been obtained,
is of such accuracy that surgical interference with the purpose of
detecting calculi is unnecessary and not justified.” In his series of
330 cases the total amount of error in both the positive and negative
diagnosis was less than 3 per cent. “ This is a percentage of error
that compares very favourably with any other method or all other
methods of diagnosis, including exploratory nephrotomy.” I am spend¬
ing a little time over the subject of the negative diagnosis # because
I am convinced that too much importance cannot be attached to
it, and it is important from the physician’s as well as from the
surgeon’s point of view. There are a great number of cases of
oxaluria and phosphaturia which present symptoms so strongly resem¬
bling calculus conditions that medical treatment would be scarcely
justified unless a decided negative diagnosis could be given. To be able
to give such a diagnosis not only may save the patient from an
unnecessary exploratory operation, but justifies the continuance of
treatment by medical measures. The fact, too, that renal calculi may
produce albuminuria without other symptoms, and that such cases have
been mistaken for chronic interstitial nephritis and other forms of kidney
disease, must not be lost sight of. So much for the negative diagnosis.
We will now go on to consider the positive diagnosis, or the interpreta¬
tion of negatives which show definite shadows.
I have mentioned that all calculi met with in the urinary tract
throw shadows when exposed to the Rontgen rays; the intensity of the
shadow, as you know, varies with the size and composition of the stone,
uric acid being the least opaque, but casting quite a pronounced shadow
if a low tube be employed (PI. I., fig. 2). The three most important
groups of substances found in calculi are uric acid and its salts, calcium
oxalate, calcic and ammonio-magnesic phosphates, while other substances
such as calcium carbonate and cystine, 1 which latter casts a shadow
much denser than uric acid, are occasionally met with, and of course
each stone may be a combination of two or more of these substances.
I do not think, therefore, that with the exception, jierhaps, that a
Henry Morris, Lancet , 1906, ii., p. 141.
PROC. ROY. SOC. MED.
Electro - Tlie.rapeutical Section.
Fig- '• Fio. 2.
PROC. ROY. SOC. MED.
Electro-Therapeutical Section.
Vol. 1. Part 2.
ORTON X•rag THagnocii of Calculi. I’lato M.
Electro - Therapeutical Section
25
very faint shadow is suggestive of uric acid, any opinion as to the
composition of a calculus can be gleaned from the density of the shadow .
A caseous kidney may cast a shadow quite as dense as that of a
calculus (PI. II.). In the negative I now show you, the shadow which
you see is due to caseous material containing lime salts, and I certainly
thought this was due to calculus until the operation proved me to be wrong.
The negative also again shows the value of a low tube, for although the
patient came to me bearing a note to the effect that it was feared she
was too stout for an X-ray examination to be of value, you will see that
what proved to be a cyst at the lower end of the kidney casts a distinct
shadow, and also that not only the psoas but distinct fasciculi in this
muscle are easily made out.
From the shape of the shadow , however, some help may be ob¬
tained. Small calculi in the kidney are often irregular in shape, and
present no distinctive features, though they tend to assume gradually
the special forms obtaining among the larger varieties. Thus a large
stone in the pelvis of the kidney often possesses irregular projections
corresponding to the openings of the calices. Such forms often give
distinctive shadows, which are quite diagnostic. Small stones in the
ureter have as a rule sharp borders and a more or less oval shape. A large
and irregular shadow in the true pelvis, even though it lies apparently
in the track of the ureter, is probably due to other causes than ureteral
calculus. Stones in the bladder are generally round or oval; there are
exceptions to all these rules, however, so that we cannot place too much
reliance on the shape of the shadow.
Next as to the position of shadows. Shadows of renal calculi may be
found as high up as, and be overlapped by, the last rib, as in the case I
now show you. On the other hand, they may be as low as is shown by
the next slide—that is, below the iliac crest. Both these cases have been
confirmed by operation. It was thought that the shadow in this last
case, although rather far out, might possibly be due to stone in the ureter,
and the sterilisable cryptoscope was in readiness at the time of the
operation. On exposing the kidney, however, which was in a somewhat
lower position than normal, the stone could be distinctly felt in the lower
part, and was easily removed. It was of a flat circular shape as shown by
the shadow. Shadows may appear in any position between these two
extremes, as in the next two slides (PI. I., figs. 2 and 3). Now, although
shadows of calculi in the ureter may be in any part of the ureter, it is a
matter of experience that they are generally found low down in the pelvis.
Should they be higher up—and Mr. Hurry Fenwick has published a
26 Orton : X-ray Diagnosis of Renal and Ureteral Calculi
case in which a small oxalate stone was found 3 inches below the right
kidney—the shadow is always closer to the spine than that of a renal
calculus. The three great features of ureteric stone are, as stated by Mr.
Hurry Fenwick, “ that they are in the line of the ureter, their outlines
are sharp, and that their shapes are more or less oval.” Now the line of
the ureter is quite close to the spine. It crosses the transverse processes
of the lumbar vertebrae to enter the pelvis as a rule rather to the inner
side of the sacro-iliac synchondrosis. You will see that the shadow
in the skiagram I have just shown of a calculus below the level of the
iliac crest is well to the outer side of the synchondrosis, and therefore
the probability would be that, unless the ureter was in an abnormal
position, such a shadow must be outside the ureter. This, as I have
already said, was proved by operation to be the case.
Let us now consider the fallacies due to other conditions which
produce shadows simulating those of calculi, and how they may as far
as possible be avoided. And first a few general points which apply to
all cases.
(1) The shadow or shadows should be present on at least two
plates, obtained from two separate exposures. Never give an opinion
on a shadow which appears on one plate only. Defects in the plate or
errors in development may produce appearances which are very deceptive.
This was very forcibly brought home to me a short time ago. A plate
was shown to me with some glee by a friend who was somewhat
sceptical as to the value of the X-ray diagnosis of calculi. I was told
that the plate showed a marked shadow of a stone, that an operation
was performed, that no stone was found, or any other condition which
could account for the shadow. On looking at the plate it was evident
that this was no stone at all. It was a very thin, poor negative, with no
differentiation of soft parts, but the shadow of the supposed stone was
most marked, and as dense almost as if a piece of lead had been put on
the plate. I should think it was possibly due to a drop of fluid having
got on the plate before development. No confirmatory plate was taken,
and, as I have said, the patient was subjected to operation. It is such
defective technique and inexperienced interpretation of shadows which
tends to bring the method into disrepute.
(2) The impossibility by ordinary clinical methods of making a
differential diagnosis between stone in the kidney and stone in the
ureter in many cases makes it absolutely necessary that the whole
urinary tract on both sides should be examined in every case, before
a patient can be pronounced to be free from stone.
Electro - Therapeu tical Section
27
(3) All the facts of the case should be taken into consideration.
This method cannot be expected to produce the best results when
used alone; but, used in conjunction with other recognised methods of
diagnosis, it adds an accuracy and precision obtained by no other means.
We will t now take one by one, and discuss briefly, various conditions
which may lead to error.
The most confusing, perhaps, are the shadows cast by calcified
mesenteric glands. These may appear in any part of the urinary tract,
and may take various forms and shapes. Some of these, from their
distribution and irregular shape, make us at once suspicious of their
character. There are others, however, which it may be almost im¬
possible to distinguish from stones in the lower ureter. In such cases,
the passage of a shadowgraph ureteric bougie, as suggested by Mr. Hurry
Fenwick, is, I think, undoubtedly the best procedure. The bougie is
passed into the ureter, and a skiagram is then taken. The bougie
casts a dense shadow, and the relation of the suspicious shadow to the
bougie can thus be determined. I have here some illustrations published
by Mr. Fenwick in the British Medical Journal which show the value
of this method. It is not always infallible, however. I know of one
case in which a calcareous gland surrounded, and by pressure com¬
pletely blocked, the ureter. The bougie would have passed up to this,
and of course it would have been in the line of the ureter. Again Mr.
Thurstan Holland has lately published a case (Archives of the Rdntgen
Rays , August, 1907), in which a calcareous gland was found adherent
to the ureter, and in the ureter at the same spot was found a tiny
calculus. Nevertheless there can be little doubt that in certain cases
this procedure may be of great assistance.
Phleboliths , especially in the pelvic veins, are not infrequently met
with. Two cases were published in the Lancet (June 15, 1907), by
Dr. Harris, of Sydney, in one of which an operation for ureteral
calculus was performed. The shadows, however, were found to be
due to “ shotty ” bodies outside the ureter. The shadowgraph bougie
would have probably settled the question in this case. Again, the very
small size of the shadows would have warranted a course of expectant
treatment, during which time a careful watch on the signs and
symptoms would probably have given valuable information. Before
the introduction of the Rontgen method expectant treatment in many
cases was not warranted, owing to the impossibility of deciding
whether the symptoms were due to renal, ureteral or extra-ureteral
conditions. If a careful X-rav examination of such cases be made,
28 Orton : X-ray Diagnosis of Renal and Ureteral Calculi
however, and negatives of the required character show only a small
shadow, probably due to a small calculus low down in the ureter,
expectant treatment is certainly in many cases warranted, for
experience has shown that in quite a fair percentage of such cases the
calculus is eventually passed—twenty-six out of forty in Dr. Leonard’s
series. Such treatment must, of course, be carried out under strict
supervision. The negative I now show you is one in which I believe
the shadows may possibly be due to phleboliths, though again they
may be due to calcification in a gland. As you w T ill see, they lie very
near the track of the right ureter. On the other hand, there are two
side by side. These do not look like stones in the ureter, and there
are no symptoms pointing to renal or ureteral trouble. This patient
is perfectly well, with the exception that she has persistent oedema
of both feet and legs. She was X-rayed with a view to determine
whether anything could be found which might be exerting pressure
on the common iliac veins, as she was rather too stout for satisfactory
examination by other means. These two shadows I have confirmed on
three different plates, and the position just opposite the intei-vertebral
substance between the fourth and fifth lumbar vertebrae, although
perhaps rather far out, is suggestive, especially when taken in conjunction
with the symptoms of some organised thickening obstructing the flow
at the junction of the common iliac veins. Possibly they may be due to
calcification of glands exerting pressure on these veins. The shadows
can only be obtained by using a very low tube, and it is difficult to
maintain such a vacuum without its falling too low during the exposure.
On a negative obtained with a high tube no trace of these shadows
could be seen.
So great has been the improvement in technique during the last
few years that even small calcareous patches in an atheromatous vessel
are now capable of demonstration. These may in some cases cause
confusion, so that really the chief difficulty now is not in finding a
shadow, but in interpreting those we are able to obtain. The next case
I show you will demonstrate how plainly thin calcareous flakes can be
shown even when embedded in a dense structure. This patient, by
no means small or thin, was sent for an X-ray examination of the
renal region, and the shadows you now see were obtained and con¬
firmed. I gave it as my opinion that they w r ere calcareous flakes in
a hydro- or pyonephrotic kidney. An operation was performed and the
kidney removed. By the kind permission of Mr. Berry, who performed
the operation, I now show you the kidney itself, w T hich has been preserved
PROC. ROY. SOC. MED.
Electro-Therapeutical Section.
Vol. I. Part 2.
ORTON: X-ray Diagnosis of Calculi. Plate III.
Electro - Therapeu tical Section
29
in formalin. You will see how very dense it is and how very thin are the
small calcareous flakes.
The slide which I now show you is a somewhat interesting and unusual
one (PI. III.). The patient had several apparently quite definite attacks
of appendicitis. The surgeon, before undertaking the operation, wished to
exclude renal and ureteral calculi, for, as you are aware, the differential
diagnosis between these two conditions is often very difficult, and a
healthy appendix has on several occasions been removed when the real
cause of the trouble was ureteral stone. This, then, is what I found in
the pelvic region of this patient. You will see there are three distinct
shadows, two on the right side and one on the left. The two
on the right side are of such similar density that I believed them to be
due to one and the same cause, and I ventured to suggest that they were
concretions in the appendix. The one on the left side is not so dense,
and is in a position in w f hich I have seen similar shadows on several
occasions, and several have been published which might almost be
duplicates of this, so similar are they in shape and position. I do not
know to what they are due, and I know of no published account in
which the mystery has been solved. This print shows another similar
shadow in another part of the pelvis, discovered quite by accident, in a
patient examined after a fall from a bicycle. But to return to the two
shadows on the right, the patient was operated upon and the appendix
removed. It was found to contain nine small shots about No. 5 or 6, but
was otherwise healthy. I have no doubt now that the lower shadow is
composed of a group of five or six shots, and the upper shadow of three
or possibly four, for on close examination certain circular shapes, due
to individual shot, can be made out. The position of the lower shadow
is very suggestive of stone in the ureter, and the two together are
interesting as pointing to the regions in which shadows of cona'etions in
the appendix may be expected to be found, and the necessity, therefore,
of bearing this possibility in mind when endeavouring to interpret
shadows in this region.
Lastly, certain conditions, such as warts on the skin , are capable
of casting confusing shadows. Dr. Lewis Jones has an interesting
negative showing a shadow due to such a condition. No doubt
by the stereoscopic method these might be shown to be outside the body,
but as a routine I do not think that the stereoscopic method affords
much help in the abdominal region. Since, however, it is necessary
to take at least two negatives, this method might just as well be
employed ; it gives some idea as to the depth of the shadows from the
30 Orton : X-ray Diagnosis of Renal arid Ureteral Calculi
surface, but gives nothing like as much information in these cases as in
joint conditions, where I have found it quite invaluable. It has its
sphere of usefulness, however, and not the least is the fact that two
somewhat thin negatives, when superimposed by the stereoscope, reinforce
one another, so to speak, and often enable one to see more detail than
when either is viewed separately.
I have no time now to more than mention the fact that, in localising
small shadows in the pelvis, the introduction of air into the bladder may
be at times of great assistance, as by this means the outlines of this organ
can be distinctly made out. This slide is of a large vesical calculus, and
you will notice that the outline of the bladder in this case is distinctly
visible without this procedure, probably due to hypertrophy of its walls.
The artificial introduction of air into the intestines, as advocated by
Professor Goldmann before the Surgical Section of this Society a few
weeks back, may prove of valuable assistance in some doubtful cases,
especially in thick individuals where the abdomen is very dense, but at
the present I have had no experience of this method.
My thanks are due to Sir Dyce Duckworth, Dr. C. C. Gibbes,
Dr. Mary Scharlieb, Mr. Donald Armour, Mr. James Berry, Mr. Lock-
wood, Mr. Roughton, and others, for material furnished by cases under
their care.
DISCUSSION.
Mr. A. D. Reid said : I congratulate Dr. Orton on his paper. He has
covered the ground very carefully, and detailed his own and other methods of
procedure. I quite agree with him with regard to the greater value of the low
tube. There is not the slightest doubt that a high tube is a source of error,
particularly in diagnosing the more transparent calculi. The difficulty, of
course, is to maintain the tube at its proper vacuum, for it runs down so
quickly, and frequent changing is very annoying. With regard to exposures,
I have tried in turn the mercurial and the electrolytic break, and have found
that with the latter, while the exposures were shorter, the results were not
anything like so good. I have now gone back again to the mercury interrupter,
and am inclined to come down from the quick exposures. I have made several
experiments with what may be called the American methods, but do not obtain
such good results as with the mercury break and the longer exposure. By the
former methods I have occasionally been able to obtain an outline of the bone
in from one to two seconds, but generally speaking the negatives are inferior
to those obtained by other means. I found the breakage of the water-cooled
tubes to be too expensive, particularly when the results were so indifferent.
With regard to the “ cryptoscope,” I have already shown at one of our meet¬
ings the weapon or special retractor that Dr. Orton has referred to. It is
simply an aluminium plate with a hole in the centre, and when the kidney is
drawn out from the body, it is passed through this hole, and the tissues around
Electro - Therapeu tical Section
31
the kidney are depressed. By this means it is possible to see the pelvis of
the kidney and the upper part of the ureter. I have only used it in three
cases, and in each case the stone has been extracted with an incision not
exceeding an inch in length. The stones were all single ones. The shadows
in the neighbourhood of the lower end of the ureter are a great difficulty and
bugbear. I thought that I had got to the end of them when a new shadow
appeared which completely baffled us all. It turned out eventually to be a
calcified fibre depending from the ureter. The shadow was quite a large one,
being about the size of the biggest ureteral calculus I have seen. [Mr. Reid
showed lantern slides, illustrating some points in Dr. Orton’s paper, particularly
with regard to the shadows at the lower end of the ureter.]
Dr. W. Ironside Bruce, after thanking Dr. Orton for his exceedingly
interesting paper, said: Dr. Orton mentioned that he had had difficulty in
keeping the tube from getting lower during lengthy exposures. I would draw
his attention to a possible method of doing this. I have been very much
impressed by the fact that if one is working with a focus tube the equivalent
spark-gap of which is less than 3 inches, the glass of the tube becomes very
hot and the tube is lowered. I believe the lowering of the tube to be largely
due to the heating of the glass. If it were possible to oil-cool the glass we
might be able to pass a much larger amount of current for a longer time.
With regard to the length of exposure, I entirely agree with Dr. Orton that
as a rule the best results are gained with the longer exposures. Another
point insisted on was the necessity for a considerable distance between the
focus tube and the plate. The tube should be a considerable distance from the
plate, because it is obvious that the further the tube is away the sharper will
be the definition. In my work at the hospital, while the distance is altered
according to the condition of the patient, it is never less than 22 inches. The
advantage in sharpness more than compensates for the extra time wasted.
I aim at producing the outline of the kidney in every case. The information
that is obtained from a negative in which the outline of the kidney is visible
is very great. It is then possible to say in what relative position the stone
is to be found, and this is very important, from the surgeon’s point of view,
for it makes it possible to remove the stone without splitting the kidney.
With negatives of this description Mr. Clogg, of the Charing Cross Hospital,
has been able to remove the calculus from the kidney without any splitting
whatever. In a case in which stone has been found in a kidney, it is very
important also to diagnose the size and condition of the other kidney. With
regard to differential diagnosis in susi>ected tuberculous kidney, it is necessary
to observe the relative size of the kidneys, and if one of them is enlarged, this
fact, taken in conjunction with the presence of pus in the urine, may be held
to point with certainty to the evidence of tuberculosis. I should like to ask
whether the skiagrams have been taken in the same position with regard to the
vertebrae in every case.
Dr. C. THURSTAN Holland said : Dr. Orton’s paper has interested me from
so many points of view that it is impossible to enter into them all, but perhaps
a little of one’s personal experiences may be of service in a discussion of this
32 Orton: X-ray Diagnosis of Renal and Ureteral Calculi
kind. I use a 220-volt current, with one of Watson’s intensifying coils and the
motor-magnetic interrupter. I shall perhaps surprise you when I say that the
tube which I have used for the last two and a half years has taken every single
radiograph in my private practice—not in my hospital practice, of course—and
has been used for every part, including the kidney and bladder, the shoulder,
the hip, and so forth. During the last two and a half years I have examined
300 kidney cases, a large number of which have been operated upon. In every
case in which we pledged ourselves that there were stones, the subsequent
operation when it took place showed stones to be present. In no case, of which
we have had knowledge of the outcome, has the diagnosis proved inaccurate.
One continually gets these troublesome shadows in the abdomen, usually from
calcareous glands. I once found in the same subject a stone in the kidney and
a calcareous gland. I invariably use an equivalent spark gap of 3 inches, on a
10-inch coil worked from accumulators, and before I commence reduce the
vacuum to a spark gap of under 2 inches. I particularly never give an exposure
of more than one minute, and in ordinary subjects— i.e ., people who are not
very stout—the exposures often range from thirty to forty-five seconds.
Occasionally with an electrolytic heat I have taken negatives of the kidneys in
five seconds. I always use the method of placing the patient on his back,
raising up the shoulders, getting the arch of the back right on the board, and
using firm pressure with a compression tube, one side of which is about 5 \ and
the other about 4 inches in height. I put the X-ray tube over the compression
tube as nearly as it will go, centring it carefully w T ith a plumb-line. The
development of my plate is carried out in the most casual manner. I use a
pyro-soda developer: 6 grains of pyro to the ounce of pyro solution. I pour it
on to the plates, one after another, cover them over and get them well started,
leaving an interval of one minute between each. Then I get an assistant to
rock the plates for fifteen or twenty minutes, after which I take them out one
by one and put them into the hypo. The results are average good negatives.
I have done a little with screen examination of the kidney. I do not think it
is of much value. The presence of pus makes no difference whatever to the
result. On one or two occasions I have had the catheter passed into the
urethra, and it has been of assistance, but the method of dilating the bladder
with air and then taking stereoscopic radiographs is much more satisfactory.
With the use of the compressor it is perfectly easy to take a stereoscopic
radiograph. A definite outline of the bladder is thus obtained, and those little
shadows to which Dr. Orton alluded are seen in their relative positions to the
bladder-wall. I took a couple of stereoscopic photographs of a case in which
there was a chain of five shadows in the lower part of the ureter, in the position
instanced by Dr. Orton. Two of the shadows are on a different plane from the
other three. This fact rendered it improbable that any of them were ureteral
calculi. The whole subject is extremely interesting and difficult, and it is
only at meetings of this kind that one can hear all the details and arrive at
conclusions of any value.
Mr. E. W. H. SHENTON sent some notes, which were read by the Secretary.
Respecting technique, Mr. Shenton said: It is advisable to clear the intestine.
Electro - Therapeutical Section
33
Enquiry should be made as to whether the patient has been taking bismuth, as
prolonged administration of this drug will cause intestinal matter to become
opaque. I would deprecate compression, except in rare cases. It is important
to allow the kidney to move freely, and compare the range of movement of any
suspected calculus with surrounding intestinal matter. The careful observation
of these relative movements will often prevent erroneous conclusions. As no
two workers quite agree as to what is a high and what is a low tube, I think it
unwise to use the terms high and low. The tube giving a maximum quantity of
rays and a clear image of the renal regions upon the screen is the most suitable,
and this can only be selected by trial and error. The more experience the
operator has had, the less trouble he will encounter in the selection of a tube.
No reliance should be placed upon the milliampere meter in the selection of a
suitable tube. Unquestionably, diaphragms should in all cases be used, varying
from 4 inches to 1 inch, the larger being used for preliminary examination and
the smaller for careful search over small areas. I have examined more than
2,000 cases of suspected renal stone, and I am absolutely convinced that the
screen examination is all-important. With a suitable tube, it rarely happens
that the photographic plate reveals more than the screen, when the latter is
correctly used. On the other hand, there are many cases easy to diagnose upon
the screen which the plate fails to confirm. This is usually due to movements,
and at times a compressor will be of value in such cases. Photographs are
merely confirmatory of the screen examination. I give a short exposure, not
exceeding thirty seconds, and from this negative I print on No. 2 Glossy
Gravura—a paper which was first specially made for my work at Guy’s Hospital.
It is a paper of extraordinary contrast. I believe the system of a short exposure,
thin negative, and vigorous printing contrast is the correct one. The less ex¬
posure you are forced to give the plate the better, as the fogging rays—I think
every radiographer will understand what I mean by the term—will have less
time to act. The image, though faint, will be quite perfect, but it requires a
very powerful printing process to extract a good image. Though much depends
on the suitability of the tube and the transparency of the patient to the X-rays,
still more depends upon the operator’s skill in observation. It is no more fair
to say that X-rays do not show a calculus than that the ophthalmoscope does
not show a certain eye condition. In both cases the skill of the individual must
be taken into consideration. There can be no question of the efficiency of
positive X-ray diagnoses in urinary calculus disease, and though the negative
diagnosis is not infallible, it is incomparably better than any other form of
negative diagnoses in these conditions. To make a satisfactory diagnosis, the
eye of the operator must be in a condition to appreciate the screen image—that
is to say, he must have been sufficiently long in a darkened room. Lighting the
room with blue light, the complementary colour to the screen image, has been
a great help. I would like to call attention to the fact that many otherwise
excellent couches now on the market have no provision for tilting the X-ray
tube, and the operator is much handicapped thereby. For example, when
examining the lower end of the ureter and bladder, the general direction of the
rays must be in line with the axis of the pelvic canal, and not vertical.
34 Orton: X-ray Diagnosis of Renal and Ureteral Calculi
Mr. C. R. C. LYSTER said : I hold the view that a low tube with a lengthy
exposure gives infinitely the best results. Personally, I am old-fashioned
in still retaining the method of putting the plate at the back and the tube in
front. I use a parchment disc with two uprights, and an air cushion. One
point in favour of this method is, that with the patient lying on the back less
compression is necessary. The most important point, however, is the good
focus of the tube in order that contrast may be secured. Dr. Orton has hit the
right nail on the head when he says that the tube is the weak part in renal
skiagraphy. I have a few negatives that may be of interest. They were taken
with the focus-tube placed in front without any diaphragm. I am inclined
to think that the diaphragm is a little over-rated.
Dr. G. Allpress Simmons said: Like Dr. Thurstan Holland, I have been
fortunate in finding a most phenomenal tube. I have used the same tube
in St. Mary’s Hospital for a year, and have taken away every skiagram—
almost 950—by its means. I use accumulators and a Mackenzie Davidson
break. The tube is a Mueller tube with heavy anode, and the ordinary mica
apparatus for lowering the vacuum. It starts by being high, lowers itself after
running one minute, and remains steady. I have taken a dozen skiagrams
in the same afternoon without any lengthy interval.
Mr. JAMES Taylor asked what developer Dr. Orton used. He said:
I know that Dr. Orton uses a Lumtere plate, but it is my experience that
no better results are obtained on that plate than on certain others. With
the Imperial Orthochromatic I get better results than with the Lumi6re.
The Chairman (Dr. Lewis Jones) showed a couple of slides illustrating
a point in the paper. In one case an X-ray examination of the renal region
suggested the presence of renal calculi. The patient’s back was examined, and
a small mole was found, rather less than half an inch in diameter. A lead
wire was then wound round the mole, and the subsequent skiagram plainly
showed it to be identical with the shadow of the supposed calculus. It was
therefore possible that a wart on the skin in close contact with the plate
might produce an impression simulating the appearance of renal calculi.
The Chairman also showed a skiagram, taken by Dr. Graham, of
a peculiar injury in the hip region , with perforation of the acetabulum-
by the head of the femur. A lady, aged 20, sustained a severe fall upon
her side, the force of the blow being concentrated upon the great
trochanter. A severe bruise resulted, and the lady was in bed for three
weeks. When ultimately a skiagram was taken it was found that the
head of the femur had been driven right through the acetabulum and
protruded for some distance into the pelvis. Around the head of the
acetabulum a quantity of callus had formed, and this w r as visible in the
X-ray photograph.
Dr. G. Allpress Simmons showed some colour photographs taken
on the Lumiere Autochrome plate.
filectroGberapeutical Section.
December 20, 1907.
Mr. W. Deane Butcher, President of the Section, in the Chair.
The Diagnostic Value of the Rontgen Rays in some Diseases
of the Chest.
An Address introductory to a Discussion on the Subject.
By A. Stanley Green, M.B.
I believe that three years have elapsed since the last discussion
on this subject was held before the Electro-Therapeutical Society.
During this time some progress has been made, and physicians are now
more willing to seek and accept the opinion of the radiographer in some,
at least, of their chest cases, and I hope that ere long all cases where
doubt exists about the presence of pulmonary tuberculosis will be sub¬
mitted to a thorough examination at the hands of an expert radiographer.
The patients are always willing to undergo the examination because they
hold that “ seeing is believing,” and they place more faith on what the
physician tells them he has seen than upon what he has heard, and the
diagnosis of this disease in its earliest stage is a matter of vital import¬
ance, not only to the individual, but also to the State. To ascertain the
views that some of our most eminent physicians hold upon this subject,
I sent out papers to fifty consulting physicians in Great Britain, and I
had most courteous replies from thirty-three. Of these, nineteen informed
me that they had no experience on the subject worth mentioning,
and of the remainder five answered all three questions with an emphatic
negative. Queries: (1) Have you found the Rontgen rays of much
value in the diagnosis of early pulmonary tuberculosis ? (2) Have you
found that when the physical signs show the disease in one lung to be in
the so-called second stage, the X-rays in a large number of cases will
demonstrate early mischief in the other lung ? (3) When the larynx
ja —4
36 Green: The Rontgen Rays in Diseases of the Chest
is involved in the early stages of the disease, do you find that the
presence and extent of the disease in the lungs are more easily demon¬
strated by means of an X-ray examination than by the usual methods ?
To Query 1, three affirmative, four a qualified answer, looking upon
the X-ray evidence as confirmatory only; to Query 2, four affirma¬
tive, one a qualified negative, three negative emphatic, four a possible
help. The third question was badly worded, and the answers are
therefore not of any value.
It is quite clear, therefore, that physicians have not, up to the
present, made as much use of the rays as might have been expected,
and I gather that their reason for this neglect is because they feel that
they are capable of making a correct and accurate diagnosis without any
extraneous help. This leads me to think that what they consider to be
an early condition would be looked upon by the radiographer as more
advanced than the physical signs had led them to suppose ; moreover,
when disease is sufficiently advanced in one lung to admit of a diagnosis
being made in the ordinary way, the Rontgen rays will in many cases,
but not in all, show the presence of disease in the other lung. I do not
wish it to be understood from this that the X-rays are to be used alone
and the older methods discarded: far from it; the clinical history,
symptoms, and the physical signs must all be taken into consideration
and the rays used as an aid to the diagnosis, just as the ophthalmoscope
is in many medical cases, and this is the doctrine that I have preached
ever since I wrote my first paper on the subject.
It is only necessary to say a few words about apparatus. Personally I
use a Gaiffe d’Arsonval installation and find that it does all that I require,
though doubtless with a powerful coil and an intensive break the same
results can be attained with a shorter exposure. This is, however, not
of so much importance in thoracic work as it is in the radiography of the
kidneys ; thirty seconds is usually ample except in a very burly chest.
There is no doubt that good tubes are the all-important factor in pro¬
ducing good radiographs, and the difficulty in obtaining these is very
great, for if a large current, say anything over 1 m.a., is passed through
them for any length of time they soon deteriorate, and it is most
important that the light in the tube should always be absolutely steady,
and all reverse current suppressed. Until about two years ago I was in
the habit of using Muller tubes, and found them very reliable—in fact,
I had one in use for ten months and did all my thoracic work with it
during that period, but now I find the Chabaud-Villard the most reliable,
although they will not carry more than 1 m.a. for more than a few
Elec tro - Therapeu tical Sec tion
37
minutes without getting either very soft or extremely hard. I am
anxious to hear the experience of other workers on this important point.
I must say a few words about technique because I have from time to
time been asked so many questions on the details. I always screen and
photograph the patient in the erect position because I have found that
the diaphragm moves more freely when they are standing up than in any
other position, and they are photographed sitting as erect as possible
because they are less likely to cough if they are not asked to lie down; in
fact, I may say that I have never had a plate spoiled by the patient
coughing since I adopted the sitting posture for the exposure of the
plate. I mention this fact because I was speaking to a gentleman four
months ago who had been radiographed in London in the prone position,
and the negative was useless because his cough was so troublesome.
My method of screening the patient is best explained by this little
model: to ensure perfect darkness I had a corner of my electrical room
built off with black wood in which a large aperture was cut and then
covered with a black curtain; the screen, covered with a piece of ground
glass (for the purpose of making tracings), can be moved up and down in
slots, being held in position by two springs ; this device leaves both hands
free. It must not be forgotten that luminous sensibility to X-ray light
increases immensely after the observer has been in the dark more than
ten minutes. The patient leans up against the screen and the move¬
ments of the diaphragm are noted and exact tracings made by a method
which I will refer to later on; the patient turns about and leans with
the chest against the screen, and the movements are again traced on the
glass. The tube is now raised to the level of the third intercostal space,
and with the back to the screen the apical regions are carefully examined
for any shadows. If there is any doubt of the presence or extent of these
shadows a diaphragm is fitted on the tube-holder and small areas
illuminated, and the effect of inspiration on these shadows carefully
observed; if due to recent disease they light up, the fluorescence being
gradually diminished until the observer is satisfied ; the patient is again
turned round and, with the chest to the screen, a further examination is
made and the cardiac area marked out. This concludes the screen
examination, and the photograph is taken, the plate-to-back method
being always used, the advantage being that it is more comfortable for
the patient, the ribs do not obscure the shadows so much as they do in
the plate-to-chest position, and in a majority of cases the areas of infil¬
tration and consolidation are nearer to the back than to the front, and
for this reason a sharper outline is obtained. When both lungs are
ja—hi
38 Green: The Bontgen Bays in Diseases of the Chest
taken on the same plate the anode of the tube is placed opposite the
mid-sternal line at the level of the third intercostal space and about 20 in.
to 24 in. from the surface of the plate; exposure varies from twenty to
fifty seconds with the tube working at a 4£ in. spark gap and giving rays
of 5 to 7b penetration; if the tube is harder than this the results are not
reliable. The development of the plate must be done by the radio¬
grapher himself, especially in the very early cases, because in some of
these the shadows can only be detected by careful watching as they come
up in the plate, obscuring for a time the outline of the ribs. When one
apex only is affected the difference in the corresponding areas is very
marked during the first three minutes; development is carried on for
about fifteen to twenty minutes after the image has appeared. I always
use Lumiere plates because they w T ill stand a lot of developing without
showing any fog.
I will now place on the screen a slide of a normal thorax, and you
will note the width of the intercostal spaces, equal on the two sides, the
translucency of the lung tissue, the position and size of the heart shadow
(though, as I have mentioned, this is better seen in the anterior view),
and the level of the diaphragm on the two sides; this is nearly equal in
this case, but usually the curve is higher on the right than the left.
I cannot show you the movements of the diaphragm, but I can show you
the excursion which it makes when a deep inspiration is followed by
a full expiration: this is called the maximum, and averages 2£ in. on the
right and 2£ in. on the left; during quiet respiration the diaphragm moves
about i in. on each side : this is called the minimum. In this case the
movement was equal in both posterior and anterior views, but in the
next slide I will show you the thorax of a patient who came to me
complaining of a tired feeling, no appetite for breakfast, and a slight
early morning cough of three months’ duration. You will notice in this,
the posterior view, that the movement is less on the right side than the
left, the exact measurements being 1£ in. against If in. In this, chest
to screen, you will again see the difference, £ in. to in.
The next slide is that of a patient who came to me with a slight
haemoptysis ; in her case the movement as seen from behind on the right
side was practically nil, but there was some movement on the left. It
will be seen from these illustrations that there is no difficulty in estimat¬
ing the limitation of movement of the two sides, and also the difference
between the anterior and posterior views. Attention was first drawn to
this latter point by Dr. David Lawson, under the term “ associated
movements of the diaphragm,” and he proved that where consolidation
PROC. ROY. SOC. MED.
Electro • Therapeutical Section.
Vol. T. No. 3.
Early case of phthisis. Right apical region, very bright. Left apical region,
shadows commencing 2 in. below summit of left lung and extending downwards and
outwards.
STANLEY Git KEN : Diagnostic Value of the Rimtgen Rays.
E lec tro - T her ape u tical See tion
39
is apparently more marked towards the posterior aspect of the lung, the
amplitude of the range of movement of the diaphragm, as seen from the
back, was considerably less than the amplitude at the front, and vice
versa. Furthermore, the relative level of the diaphragm on the affected
side, as seen from the back, was higher than that observed at the front.
I have found this statement so full of truth that I am often able, from my
screen examination, to make up my mind about the situation of the
diseased area. I am more than ever convinced that “unilateral limita¬
tion of movement of the diaphragm ” is the earliest known sign of
pulmonary tuberculosis. I quite expect this statement to be challenged
to-night during the discussion which I hope will take place. In this case
there was a history of pleurisy, and therefore, though there was limitation
of movement on the left side, I should not have been justified in making
a diagnosis from this sign unless there had been further evidence, such
as the faint shadows that you see in the upper half of this lung. (Plate.)
Now, this patient had no idea that there was anything the matter with
her lungs, but was consulting me for her throat; she was suffering from
granular pharyngitis. However, the X-rays left no loophole for doubt,
and the patient consented to go to a sanatorium at once. She remained
there three months and regained her health, but three years later a
family bereavement had such a serious effect on her health that she
rapidly lost ground ; her right lung became involved and she is now
waiting for the end. In addition to the limitation of range of movement
there is also limitation in the freedom of movement; and though in some
cases the diaphragm may make an excursion of 1^ in., yet this is done in
a jerky or stammering manner, and the diaphragm only reaches its
lowest level by a series of jerks. Once seen, this is very striking, and I
consider it of almost as much importance as the limitation of movement
mentioned above.
You have seen the shadows that are present in this disease in the
early stage, but I will now enter into more detail. In 1903, Dr. Halls
Dally classified them as follows :—
RQntgen Rays.
Brightness.
Transr&diancy.
Faint shadow.
Dense shadow.
Opaque.
Percussion.
Hyper-resonance.
Normal.
Impaired resonance.
Dulness.
Absolute dulness.
The progress of the disease can be watched with the rays, and I will
now show you the alteration that has taken place in the apex of the right
42 Green: The Bontgen Bays in Diseases of the Chest
limit of the fluid is usually concave, and the outer extremity is, as a rule,
at a higher level than the inner, but the contour of the opacity changes
with every alteration of the patient’s body. This is not the case when
air as well as fluid is present, as we shall see later. The heart shadow
is pushed well over to the opposite side, and the appearance of the lung
above the level of the fluid varies. In some cases it is translucent, in
others it may be almost as dark as the fluid itself, and when this is the
case pulmonary tuberculosis must be suspected and the patient carefully
watched, and a second Rontgen examination made when the fluid has
disappeared. I feel sure that this is a point of some importance. In
this case you will notice that the shadow reaches very high up and the
displacement of the heart is well marked. I removed a large quantity
of serous fluid from this patient’s chest; the shadow of the ribs can be
seen through the opacity of the fluid. Some observers say that this is
one way of distinguishing between serous and purulent effusions, but I
have never been able to satisfy myself about this, and prefer to withdraw
a few drops with a syringe. This slide shows a very oblique line
running from above, downwards and inwards. The physical signs were
vague, and it was only the Rontgen examination which enabled me to
give a definite diagnosis when the fluid had disappeared. Definite
shadows were seen in the lung tissue, and the patient’s eye reacted to
Calmette’s tuberculin test. In this case we see an oblique line starting
at a higher level, and there was a large quantity of fluid present. When
it was withdrawn some air entered, and we notice that the upper limit
of this shadow, which is due to fluid, is horizontal. This patient also
reacted to the tuberculin test. Displacement of the cardiac shadow is
sometimes seen when the shadow is intrapulmonary, and is due to the
contracting lung drawing the heart over. In this case it is on the same
side as the lesion, and is usually accompanied by a condition of the ribs
known as roof-tiling. I do not attach much importance to the rib signs,
because they only occur in the later stages of the disease, but Dr. David
Lawson lays some stress on them, amongst other features, as a factor in
determining whether shadows are due to pleuritic or intrapulmonary
lesions.
I now show you a slide of a case of pyo-pneumothorax which was
mistaken for bronchitis by three medical men; we see the horizontal
upper limit which is always present in every position of the patient’s
body, except when he is lying flat on his back, this being due to the
presence of the contained air (also pointed out by Dr. Lawson) ; a rippling
movement was seen in the screen shadow, -due to the rhythmical contrac-
Electro - Therapeutical Section
43
tions of the heart; when the patient was shaken splashing could be seen,
and when he took a deep breath the level of the shadow rose perceptibly.
The area above the fluid is very bright, and is, of course, due to the air ;
this line above is due to the thickened margin of the compressed lung.
(Proved at the autopsy.) I have only had one case of miliary tuberculosis
to examine, and in that case there were no signs to indicate that he had
any disease of the lungs. The patient, however, was sent to a sanatorium,
but was only kept there a short time as no trace of disease could be found
in the lungs, and he had tubercular disease in the abdomen; when he died,
two months after this skiagraph was taken, his medical man wrote to
tell me that lung symptoms were a prominent feature during the last
three weeks of his life. Possibly other members have had more experience
of this condition than I have.
I have had two cases of primary abscess in the lung. I have been
able to find very little in the text-books on medicine about this condition,
which is certainly difficult to diagnose by the ordinary methods. In both
my cases physical signs were conspicuous by their absence, and the
symptoms were pain over a certain area, more severe in one case than
the other, a hacking cough without any expectoration until the pus was
coughed up, a high temperature, rapid pulse, and one case looked so much
like typhoid fever that I sent some blood to be examined, but the Widal
reaction was negative. Had I been able to examine the chest with the
Rontgen rays I believe that the diagnosis would have been made correctly,
but this I was not able to do until they were able to come to my surgery,
and by that time the lung was healing quickly; but we see that there
is still a shadow in each case, and this is the area over which the pam
was most severe and where the one physical sign that could be elicited
(impaired resonance) was found. I shall be glad to hear what experience
other members have had. There is no time to enter into the discussion
of other diseases, e.g ., new growths, actinomycosis, mediastinal tumour (of
which I have had three cases this year), enlarged bronchial glands,
aneurysm, pericardial effusion, hernia through the diaphragm, and car¬
cinoma of the oesophagus; in all these the radiographer can, I think,
assist in the diagnosis.
Gentlemen, if I have seemed too dogmatic upon some points I must
ask your pardon. I have examined a very large number of chests with
the Rontgen rays during the past six years, and upon that experience my
opinions have been formed, and I have given them to you to-night with
the sole object of provoking a discussion. If I am successful in this I shall
be satisfied, and I feel sure that I shall learn a good deal from other
44 Butcher: The liontgen Hays in Diseases of the Chest
members who have been working in the same field of radiography with
better opportunities than have fallen to me.
The President (Mr. W. Deane Butcher), in the name of the
Section, thanked Dr. Stanley Green for his interesting address and the
admirable slides with which it was illustrated. He (Mr. Butcher)
was pleased to see the examples of relief skiagrams, which he believed
were the first shown in this country, at all events of the lung. He
thought that plastic Rontgenography was destined to play an important
role in the future of Rontgen diagnosis. The printing need not
necessarily be done by the medical man himself. He hoped that in the
near future the technical process would be carried out by an expert or in
a public laboratory. The amount of detail shown by plastic Rontgen¬
ography, not only in the lung itself, but in the hilus, was marvellous.
He had seen examples showing very early stages of enlargement of
glands in the root of the lung. The shortening of the exposure within
the limits of respiration, or even of the heart-beat, was also a matter of
very great importance for the future of chart examination. He alluded
to the importance of the results of a Rontgen examination as an object-
lesson and a warning. Nature’s danger signal was usually haemorrhage,
but, short of that, he knew nothing better than a skiagram, or more
calculated to impress on a young patient and his friends the importance
of early treatment.
Dr. David Arthur thanked Dr. Green for his paper and for the
challenging spirit in which it was delivered. But he noticed that the
author used an equivalent spark-gap of in. in his tubes, which he
(Dr. Arthur) considered too high, and the skiagrams showed it, as the
heart came out very poorly. That was due to the tubes being too hard.
At one time Dr. Arthur altered his tube for chest cases until he got the
greatest amount of screen contrast, and then his results were fairly good.
Recently he had employed a tube a little softer than that which gave
the maximum screen contrast, and found that 2 in. to 2^ in. brought out
detail which a harder tube failed to do. The heart came out almost as
black as the ribs. He believed Dr. Green’s measurements of the
diaphragm were of no practical value, though he agreed that the
immobility of the diaphragm was the first sign of pulmonary tuber¬
culosis. The X-rays from the anti-kathode came out in a cone shape,
and the further the screen was away from the arch of the diaphragm
the more it was magnified. The measurement should be done by ortho¬
diagraphy, when the result would be the same whether the screen was
near the dome of the diaphragm or away from it. He had a patient at the
i
E lee tro- The rape utical Sectio n
45
hospital—whom he would show at the clinical meeting—a young man,
aged 21, who four months previously had been passed for an insurance
office, yet whose lungs were one mass of what seemed to be fibrosis.
Cough and physical signs were almost absent, and the diaphragm moved
1J in. equally on both sides, as shown by the orthodiagraph. He had
seen cases of other diseases in which the movement of the diaphragm
on one side was retarded. So, while that limitation was suggestive
of phthisis, it was not any proof of it, and this was especially
seen in a general hospital, where &11 sorts of cases were encountered.
Therefore X-ray examination alone was of but little importance, and,
indeed, might lead to gigantic blunders. Still, taken with other methods,
it was even more important than examination by the stethoscope alone.
In his experience, mediastinal tumours were very difficult to diagnose
from lung disease, and the only means of settling the matter was by the
stereoscope, which Dr. Green had not touched on or demonstrated. He
agreed with Dr. Green’s remark concerning tuberculosis in one lung.
Among all the cases which he had examined over many years he had
only had one in which, with disease of one lung, the other was shown by
X-rays to be quite unaffected.
Dr. Halls Dally said he was very glad to have heard Dr. Green’s
lucid exposition. He (Dr. Dally) had always held that unilateral
limitation of the diaphragm was the earliest known sign of pulmonary
tuberculosis, and the view was supported by many facts. He did not
consider that Calmette’s ophthalmic reaction was yet established on
definite lines ; some definitely tuberculous cases had, in his hands, failed
to react to it. The same was true of tuberculin injections. The limita¬
tion of the diaphragm, taken with other signs, was a very strong
suggestion of the existence of pulmonary tuberculosis, quite sufficient to
justify sending the patient to a sanatorium. To wait until there were
tubercle bacilli in the sputum was to allow very valuable time to go by,
and it was better to send a doubtful case to sanatorium than to wait
too long before commencing treatment. When, some years ago, he
worked at the subject of the diaphragm in connection with the
mechanism of respiration, he found that though the anatomical text¬
books were accurate as to the level of the diaphragm, the physiology
books were inaccurate, in that they made no reference to the excursion
of the central tendon. He regarded the movement of the diaphragm as
one of the important agents in the expansion of the apex of the lung.
The pericardium, the great vessels, and the root of the lung were all
pulled down by the diaphragm, and therefore influenced the expansion
46 Orton: The Rontgen Rays in Diseases of the Chest
of the apex far more than did the upward and forward movement of
the first rib. During the past year Dr. Walsham and he had been
working with Groedel’s form of ortho-diagraph, which he considered the
most accurate means yet known of measuring the movement of the
diaphragm. The measurements which he (Dr. Halls Dally) had given
in 1903 must now be revised in the light of later knowledge. Since
shadow magnification had caused these to be too great, and until the
introduction of the ortho-diagraph, it had been impossible to correct for
this. The absolute range of movetnent between deep inspiration and
expiration in an adult male was 34 mm. on the right side and 32 mm.
on the left; in adult females 27 mm. right and 25 mm. left, making a
total average of 30 mm. on the right side and 28 mm. on the left. That
“ normal ” difference which occurs between the range of movement on
the two sides must be taken into account in estimating whether there is
any pathological limitation. He thought the ortho-diagraph was also
useful in the diagnosis of aneurysms and in heart disease. In connection
with the Nauheim treatment of heart disease, the heart could now be
inspected before the course of baths was begun and afterwards, and the
difference accurately noted. By it also the size of the chest organs
could be accurately measured, and it eliminated the personal equation
largely and the shadow magnification altogether. In some cases, on
looking at the patient, apart from the X-rays, one could see a limitation
of movement of the chest wall, either at the base or the apex, on the
affected side, and in each case that was definitely due to the limitation of
the diaphragmatic movement. Owing to the connection between the
diaphragm and the apex of the lung, the costal portion of the diaphragm
turning up to be attached to the central tendon, the upper part of the
chest on the affected side would tend to show a diminution of movement.
Those other signs, such, for instance, as loss of transradiancy on screen
examination at the suspected apex, he did not regard as earlier than the
diaphragmatic evidence, but tending to confirm it. The limitation on
visual inspection often occurred long before physical signs developed,
but owing to density of overlying tissues was not apparent in all cases
where the diaphragm movement was limited, especially where this
limitation was but slight in extent.
Dr. Harrison Orton regarded a tube of 4| in. spark-gap as too high,
as many shadows would be penetrated by such a tube. He used a spark
of about 2£ in. and a heavier current. He agreed that with the tubes
used by Dr. Green it was impossible to use more than 1 m.a. of current.
Nothing had been said about a ready means of regulating the tube. If
Electro - Therapeutical Sect bn
47
the light coming through the tube were very intense it was almost
impossible to estimate the difference of density between two apices, there¬
fore, he thought a rheostat should be at hand in order to regulate the
amount of light passing through the chest at the time of the examination.
He regarded the erect posture for the patient as the best. When lying
down the chest of the patient assumed much the same position as in
expiration, i.e ., there was not such a clear differentiation of the pulmonary
area, and the movement of the diaphragm seemed to be impeded. In the
case of thick people it was very important to cut off secondary rays, and by
examining small areas of the chest at a time one got better ideas of the
shadows than by examining the whole of it at once. He agreed that the
best position for the plate was on the back, for then the lattice-work
effect formed by the crossing of the ribs was largely missed. The scapulae
could be largely moved from view, which is a distinct advantage, by
working from below, placing the patient face downwards and having the
arms hanging over the head of the couch. He (Dr. Orton) employed a
rather concentrated developer, and used it quickly, never taking more
than ten minutes. It was important to regard the X-rays as an aid to
diagnosis only. In an interesting case recently he would have concluded
from the X-ray examination that it was a case of fibroid lung. The right
side was clear and the left side in dense shadow, and no part of the
mediastinum on the right side could be seen. Post-mortem, it turned out
to be an aneurysm pressing on the left bronchus. The whole of the left
lung had collapsed, and had drawn the heart and mediastinum over to
that side. The ortho-diagraph he regarded as absolutely necessary for
measurement of the movements of the diaphragm, the arch of which
varied in different people, and the range of movement would depend on
the distance from the surface of the greatest convexity of the arch unless
the ortho-diagraph was employed. He did not now think the limitation of
movement of the diaphragm was so constant as he at one time believed.
He had seen several early cases in which there was no such limitation,
only the jerky movement which Dr. Green had mentioned. In more
advanced cases the diaphragmatic movement might not only be equal to
normal, but might surpass it. He had seen advanced cases in which one
apex was very deep in shadow, and where the movement of the diaphragm
on the affected side exceeded that on the sound side. He agreed that in
many cases where only one side was considered to be diseased X-rays
showed both to be involved. He asked how much shadow could be
obtained in a normal chest. He had two skiagrams of anaemic girls,
with no signs of phthisis two years ago, and still with no signs of it, but
48 Squire: The Bontgen Bays in Diseases of the Chest
with distinct shadows on each side of the mediastinum, extending much
farther out than the usual mediastinal cardiac lines. In one of them the
shadows seemed to follow the distribution of the vessels, and it had been
suggested they might be due to tubercle commencing round the lymphatics.
In a case of lymphadenoma the patient died of pneumonia ten days after
examination with the X-rays. There were very similar shadows, and
post-mortem nothing was found in the lungs except pneumonia, which
was just commencing at the time of the examination. He believed that
when using a very low tube, such as one of 2 in. spark-gap, the normal
chest might throw shadows which were likely to be confusing. There
was much to be learnt before a correct interpretation of normal shadows
could be arrived at.
Dr. Squire said he purposed speaking rather as one accustomed to rely
upon examination by the stethoscope and other physical methods than by
the skiagram, in which he could not pretend to be an expert. Even
physicians who were thought to ignore X-rays really regarded them as
valuable aids in diagnosis, especially in any doubtful cases. But the opener
was somewhat dogmatic about the diagnostic powers of the rays. He
(Dr. Squire) particularly wished to ask whether there was anything about
the shadows revealed by the X-rays as representing consolidation or
tubercular lung disease to show whether the lesion was quiescent or, on
the other hand, a focus which required active treatment. That point
alone would show that unsupported X-ray examination must not be relied
on any more than any other means. He asked, also, whether the pictures
shown were supposed to represent early cases of disease which would
yield no evidence to the skilled physician by the ordinary examination.
The amount of shadow in the majority of those cases seemed so great that
they would have caused no difficulty to anyone at all accustomed to
examine lungs. He had not heard anything to convince him that skilled
physical examination by the older methods would not detect mischief in
the lungs as early as could be found by X-ray examination, although he
agreed that the patient would be more impressed by seeing than by being
told what somebody else could hear.
Dr. Lees said that, for a considerable time, he had been very much
interested in the question of the exact determination of the earliest
indications of pulmonary tuberculosis, and he had attended on the
present occasion in anticipation of hearing some additional facts which
might be of service to a physician in investigating that most important
question. But he agreed with Dr. Squire that most of the skiagrams
thrown on the screen seemed to be from cases so advanced that there
E lec tro - T her ape u tical Sec t io n
49
would not have been the slightest difficulty in proving, by careful per¬
cussion, the presence of areas of dulness. He was not an expert in
skiagraphy, but, with the help of his friend, Dr. Simmons, he had made
a few observations at St. Mary's Hospital to ascertain whether the
X-rays were able to reveal the presence of tuberculosis of the lungs
when it was difficult or impossible to do so by physical examination.
That, he considered, was the crux of the whole question. All would
acknowledge that X-rays were a most valuable means of investigation,
and that they sometimes showed what otherwise would be difficult to
ascertain; but the question as to the earliest indications of tubercle was
not so definitely settled as the reader of the paper seemed to imagine.
The observations he had made convinced him—and he thought they
convinced Dr. Simmons also—that the X-rays failed to show any distinct
shadow in cases where the loss of resonance was quite definite on careful
examination. If that turned out to be true generally, he thought it
must be acknowledged that, however valuable the X-rays might be, they
could not demonstrate the existence of tuberculosis in the lung at as
early a stage as was already possible by methods of physical examination.
Unfortunately, text-books gave very little help when one asked the
question as to what were the earliest physical signs of tuberculosis of the
lungs; stress was usually laid on auscultation. But really that was
incorrect. The earliest indications of pulmonary tuberculosis were
exactly the same as those of pneumonia. In pneumonia, long before the
bronchial breathing, before the sharp inspiratory crepitus, there was
a period, in many cases at all events, as was pointed out by Professor
Osier, when the evidence was confined to local loss of resonance and
feebleness of air entry, showing that that part of the lung was not
acting. The same was true in the earliest stage of pulmonary tuber¬
culosis, and the signs to be looked for were not auscultatory mainly, but
indications given by careful percussion. That remark made it necessary
for him to say what he meant by careful percussion. He excluded at
once all percussion in which instrumental aid was used; the percussion
which must be employed was finger percussion alone. It must also be
a very light percussion. Hammering, such as some medical men prac¬
tised, was absolutely useless. The percussed phalanx of the percussion
finger must be firmly pressed on the point to be percussed, the rest of
that finger and the rest of that hand being kept entirely away from the
chest-wall. Such percussion was capable of detecting stages of pul¬
monary tuberculosis which were quite early and which he believed to
be undiscemible by the X-rays. It was a strange fact that, although
50 Lyster: The Bontgen Bays in Diseases of the. Chest
seventeen years ago Dr. Kingston Fowler drew attention to the precise
positions in the lung where the earliest deposit of tubercle was to be
found, and showed that the disease progressed in a definite course from
those spots, and although these statements had found their way into the
pathological descriptions of the text-books, they had not in any appre¬
ciable degree modified the clinical description of the disease. If physical
examination were carefully made it would be found that, exactly in
accordance with Dr. Fowler’s results, localised spots of dulness and
feebleness of air entry could be detected in certain definite places. It
was in the first intercostal space on either side of, and close to, the
manubrium that the first evidence of tubercle could be detected, not at
the extreme summit of the lung, but at a spot 1 in. to in. below it,
as seen in the post-mortem room, and therefore probably 2 in. below it
in the living body. Dr. Kingston Fowler also showed that in the outer
part of the lung, at the same vertical level, there was frequently another
area of disease ; this also can be detected by physical examination in the
outermost part of the first intercostal space. Both these areas can also
be detected posteriorly : the former close to the uppermost dorsal ver¬
tebrae, the latter in the outermost part of the suprascapular fossa. In
addition Dr. Fowler showed that an early deposit often occurred in the
lower lobe, at a similar distance below the apex of the lower lobe; this
can easily be detected by careful percussion behind the inner end of the
spine of the scapula, and below this point downwards and outwards. In
most of the cases of early tuberculosis physical signs of that kind were
to be detected at all four apices; and he was surprised to hear the opener
suggest that, in a considerable number of cases, physical examination
limited the disease to one side. Careful physical examination showed
that very rarely was the disease limited to one side. When there were
distinct signs at one apex, almost always something, though less, was to
be detected at the other apex also. He challenged discussion on the point
as to whether careful physical examination, especially by percussion,
did not reveal pulmonary tuberculosis at a very early stage, earlier, he
believed—though he was open to correction—than could be revealed by
X-rays.
Dr. Lystek said that, as a result of his personal experience, extending
some years back, he could not detect signs of pulmonary tuberculosis
before they were plain to the physician who sent him the cases. But it
was a pity to press the question too far at the present time, because
there was still room for improved accuracy in the instruments employed :
the tubes varied, and observers could not yet say, with sufficient
Electro - Therapeu tical Section
51
accuracy, what a shadow cast by the lung tissue meant in an early case.
Still, he thought radiographers could be of great service to physicians by
keeping charts indicating the progress of tubercular disease. He had
now pictures of several cases extending back three years, which had
been radiographed every three or four months, and in which the change
in the diseased areas was very instructive. It was a pity to attempt to
diagnose tubercular disease of the chest by means of the rays alone.
Dr. D. Somerville said he would like to hear more about the
interpretation of the shadows which were demonstrated. The most
important part of scientific research was not so much the collection of
facts as their interpretation, and he wished to hear whether, among the
radiographers, there were any definitely agreed lines of interpretation.
The tubes and the methods of development varied greatly; the personal
equation, however, always entered into the question. He had failed to
detect any definite lines along which one might safely reason in the
matter.
Dr. Samuel West thought it possible that enthusiastic X-ray
workers might be tempted to feel too sure of their ground in diagnosing
very early stages of pulmonary tuberculosis; but it must be admitted
that there were cases of lung disease, deep-seated, and manifest from the
clinical symptoms afterwards or by post-mortem examination, which
could not be practically detected during life. There were cases of fatal
haemoptysis in patients who had been most carefully examined, and in
whom the haemoptysis had come as a complete surprise. There was
a group of cases absolutely undiagnosable from physical signs, and in
those X-rays might give very great help. He agreed that there was
a danger of pressing the matter too far at present, and thus injuring the
cause which they had at heart. The author, no doubt owing to pressure
of time, had left much unsaid that he would have liked to say, and
Dr. West was inclined to accept some of his statements with reservation.
Dr. Green did not give any reason for believing that the cases he
referred to as abscess of the lung were such; they probably were
empyemata, perhaps interlobar. He did not see how the X-rays could
distinguish between these conditions—only a post-mortem could settle
that. He had received the the greatest benefit from X-rays in a certain
number of cases in which he could not interpret the physical signs. In
a recent one, a man had dysphagia, due, it was supposed, to stricture of the
oesophagus, but X-rays plainly showed that it was due to an aneurysm,
the pulsation of which was beautifully visible. With regard to the
curious curve in pleuritic effusion, he was a little sceptical about that, but
52 Howell: The Rontgen Rays in Diseases of the Chest
he would now study the matter with greater interest. He had not been
able to satisfy himself, from simple percussion, about the existence of the
S-shaped curve in pleuritic effusion. He agreed that the question was
not so much one of facts as the interpretation of them. Probably some
of the curve shown was due to collapse of the lung round its own root,
w T hich would allow fluid to flow up behind and at the same time raise it
a little further in front, and thus give the elevation shown in the radio¬
gram on the outside. The discussion had been a most useful one, and,
as was often the case, its chief value lay as much in suggesting lines of
investigation for the future as in imparting knowledge at the time.
Dr. Hinds Howell said he recently saw a tabetic patient, under Dr.
Ormerod’s care, at the National Hospital, suffering from paralysis of the
left vocal cord. Sir Felix Remon examined the larynx, and asked
whether there was any chest disease which might cause the laryngeal
condition. Dr. Ormerod and others had examined the chest, and had
found no evidence of any pathological condition which w T ould produce
pressure on the recurrent laryngeal nerve. But it was thought best to
have the patient examined with the screen, when it was at once seen
that there was an aneurysm of the transverse aortic arch, which was
probably causing the paralysis of the cord. Apart from the value of the
X-rays in making the diagnosis, that case was interesting as illustrating
a not very uncommon fact, that paralysis of the vocal cord might be the
first symptom caused by aneurysm of the arch of the aorta. Dr. Hinds
Howell exhibited the radiograph which he had taken of the patient’s
chest.
Dr. Allpress Simmons said he thought the discussion had been con¬
fined to tubercular disease and other conditions of the lung rather than
aneurysm. X-ray men were of opinion that aneurysms could be certainly
diagnosed by the method of oblique illumination, an interesting paper on
which was read by Dr. Orton some time ago. In all cases of suspected
aneurysm, or of paralysis of one vocal cord, an X-ray examination should
be held, as a diagnosis could sometimes be made in that way when it
could not by any other means. He thought chests should be examined
by the rays more frequently than was at present done. He agreed with
Dr. Lees that the highest percussive skill would reveal tubercular disease
before X-rays would, but all medical men did not possess that highest
percussive skill, and he was sure many cases of early phthisis were
missed in the rush of general practice. X-rays came in conveniently
between the highest percussive skill and the ordinary routine physical
examination.
Electro - Therapeu tical Sec tion
53
Dr. J. A. Codd (Wolverhampton) said he felt greatly indebted to
Dr. Green for bringing the subject forward. All present might not
share the author’s optimistic view as to the value of the present know¬
ledge of X-ray work in contrast to the ordinary physical examination,
but the subject required dealing with, and any contribution was welcome,
especially when it w r as accompanied by an accurate description of tech¬
nique. He was sure that the acme had not been reached in the diagnosis
of thoracic disease. He had not convinced himself that it was a superior
method to physical examination, but he was in a position of both physician
and radiographer to a provincial hospital, and the surgeons required him
so much that he had not much time for his own cases. But the address
had given him a stimulus to pay more attention to medical cases, and
especially cases of tubercle. There must be a large number of cases in
which aneurysm was suspected but could not be diagnosed, and yet in
which the rays showed it clearly. In some the rays showed it where it
had not even been suspected. But even in regard to aneurysm, the
details required to be carefully gone into, because sometimes pulsating
shadows could be seen on either side of the shadow of the vertebral
column which were not aneurysms, at least not of the saccular variety.
He was surprised to find that in none of the slides had the diaphragm
been used. He had invariably used it for some years, rather widely
open. He believed the increased definition was worth the sacrifice of
area. He proposed to go on with the same method, and also to get
exposures of the whole area for the sake of comparison, in the same way
as different magnifications were used in microscopy.
Dr. Green, in reply, said his object had been to raise a discussion,
and in that he had succeeded. He believed it was the first discussion on
the subject which had taken place for many years ; he had read papers
before audiences, but they had remained silent. He thanked all the
speakers for their courtesy, especially those who differed from him. It
was justifiable, from that point of view, to be dogmatic. There were
more questions to reply to than there was time for. He again insisted
that a patient was much more willing to go to a sanatorium if he saw the
skiagram than if he were told what he had got. He had tried all sorts of
tubes, and concluded that he had got better results with a 4 in. to 4J in.
spark-gap than with a softer tube. He did not want the heart shadow
but the lung shadow, which was what he obtained. He insisted that it
was very difficult to make lantern slides from radiograms ; the negatives
of them were much more instructive. In one case, he radiographed a
patient who was sent to a sanatorium, and in six weeks the physician
54 Green: The Bdntgen Bays in Diseases of the Chest
wrote that he found physical signs where the shadow was seen. He had
not used the stereoscope; it was a very expensive apparatus, and he was
not attached to a hospital. In answer to Dr. Arthur, he would not expect
to find the same limitation of movement of the diaphragm in fibroid
phthisis; when the patient began to improve, there was more movement
of the diaphragm. He believed more detail was obtained by a long
exposure; he had tried both. He used the diaphragm in screen work,
and found it useful. He believed physicians would agree that a large
number of cases of pulmonary tuberculosis were not diagnosed until they
had become fairly late cases ; but if they were put before the screen they
would not be missed. All physicians were not as skilled as those who had
spoken that evening. It was of the utmost importance that the patient’s
disease should be diagnosed at the earliest possible moment. As he had
laid down ever since he spoke on the subject five years ago, X-rays were
to be used as an aid , and only as an aid, not with the idea of usurping the
physician’s place. He did not say much about aneurysm, as that was
discussed by Dr. Orton at a previous meeting. He hoped to learn some¬
thing about abscesses of the lung; he did not think the cases of which
he showed pictures were interlobar empyema.
Electroftberapeutical Section.
January 24, 1908.
Mr. W. Deane Butcher, President of the Section, in the Chair.
The Treatment of Leukaemia, Exophthalmic Goitre,
Sarcoma, &c., by X-rays.
By W. Ironside Bruce, M.D.
The patients I wish to show at this meeting are suffering from
definite and easily recognised diseases, and their conditions have been
materially improved by exposure to the Kontgen rays; although the
results of these few cases, and indeed of many others reported on,
are exceedingly hopeful, no conclusion can yet be drawn as to the
efficacy of this method of treatment and the possibility of a cure. The
method of exposure has been the same in every case. In the early days
the not very encouraging results in radiography can be assigned to the
inadequate apparatus used. At the present time we can get better
results by using improved apparatus. Yet there is a tendency w T hen it
comes to therapeutic exposure to use rather less efficient machines.
I am of the opinion that the better the apparatus the better the results
therapeutically. In the cases shown this evening the coil used was a
10 in. Watson intensified with motor magnetic break; the primary
taking 5 to 6 amps. 100 volts; the tube being kept 8 in. to 12 in. from
the skin over the part to be exposed. Time of exposure ten minutes, not
more than three times a week. The most important points in managing
such exposures are, in my opinion : Firstly, the tube must be a good and
fresh one with an equivalent spark gap of not more than 6 in. It ought
to be capable of easy regulation, and should have a water-cooled anode.
The tube we are in the habit of using at Charing Cross Hospital has a
specially constructed anode (by H. Helm), and the mica used for regula¬
tion is unusually great in bulk. Secondly, the use of a filter. In the
cases I am about to show four layers of thick felt were used. This filter
/-6
56
Bruce : Treatment of Leukaemia, dc., by X-rays
is not an absolute preventative of dermatitis, but it prevents all risk of
severe bum, and keeps the reaction, if any, within reasonable bounds.
At the same time it does not in any way interfere with the action of the
X-rays, as proved by the results in the cases I am about to show you, and
especially in leukaemia.
The first case I bring forward is that of a man aged 441.
The case was seen by Dr. Mitchell Bruce and a diagnosis of spleno-
medullary leukaemia was made. Dr. Bruce found that he complained
of weakness and dropsy of the legs. His condition was : Complexion
pale, sallow ; very anaemic ; expression anxious ; some mental depression.
There was marked enlargement of liver and spleen, the spleen extending
downwards within 2 in. of groin, and to right 1J in. beyond the
umbilicus; the liver extending two fingers’ breadth below the costal
margin. There was also some breathlessness on exertion and some
oedema of the legs. X-ray exposure was commenced on October 21,
1907, the spleen only being exposed. No other form of treatment what¬
soever was adopted. The effect of the exposures on the blood-count is
shown in Table I. The improvement in the patient’s general condition
TABLE I.
Date
November 4, 1907
>• 7
„ 11
„ 19
.. 22
„ 29
December 3
„ 6
,, IB
28
January 8, 1908
,, 15 ,,
Leucocyte count
555,000
514,000 \
443,000
411,000 1
264.000 { Exposure three
150,000 f times a week.
152,000
120.000
101,000 )
45,000
38,000) No X-ray exposure
41,000 j to present date.
was somewhat slow, but lately he has lost the look of extreme anaemia.
He has gained weight and strength, and the feeling of depression has
gone. The spleen is markedly smaller in size, and now only extends
downwards a hand’s breadth below the costal margin, and its right
margin lies well within the umbilicus. There is to be seen only the
slightest sign of reaction of the skin over the exposed area.
The second case is that of a woman, aged 41, who was admitted into
Charing Cross Hospital under the late Dr. Montagu Murray. She was
suffering from symptoms of extreme anaemia, being unable to get about
and do her housework, and finally being obliged to take to her bed. The
spleen was markedly enlarged, extending to the right wall beyond the
Electro-Therapeutical Section
57
umbilicus and downwards almost into the left groin. The blood-count
on March 7, 1907, showed the white cells 360,000, the character of these
cells being largely myelocytes. X-ray treatment was commenced by
exposure of the spleen only on that date. No other form of treatment
was adopted. The subsequent blood-counts are shown in Table II. The
Date
March
7,
1907
June
12
1 »
July
1
» i
»»
19
M
August
2
y y
September 16
11
>»
30
it
October
14
i >
November
8
it
i »
December
20
ii
2
11
y »
January
27
yy
17, 1908
TABLE II.
Leucocyte count
360,000 \
58 000 [ Exposure three times a week.
47,000 j
59 000} ^ x P° 9Ure twice a week.
40 OOO1
29 000) Exposure three times a week.
48,000 Exposure once a week.
QA ,w\ |
30 000 1 Exposure twice a week.
32 000) ®' x P osure once a week.
most marked change in this case occurred in the general condition of the
patient. The extreme anaemia disappeared, and she was able to attend
as an out-patient at the hospital and to resume her household work.
The spleen has to some extent diminished in size and bulk, and on
palpation it is extremely hard and well defined in outline, a condition
which is characteristic of this organ during exposure to X-rays. It is to
be particularly noted that the skin shows little evidence of continued
exposure. It would appear from these two cases that it is only necessary
in spleno-medullary leukaemia, first, to expose the spleen only; second,
to be entirely dependent on the blood-count as an indication of the
number of exposures necessary; third, not to strive to get the white
count more near the normal than, roughly, 40,000; fourth, that the
improvement in the general condition of the patient is the most marked
beneficial result obtained.
The third case is that of a young girl, aged 16, who came as an
out-patient to Charing Cross Hospital under Mr. P. Daniel. He recog¬
nised the disease as being exophthalmic goitre. The thyroid gland was
enlarged and pulsating, and the patient suffered from the usual muscular
weakness, shortness of breath and palpitation. She was unable to get about
with comfort, and could not even walk short distances without stopping
to rest. The pulse-rate was taken as an indication of the condition of
the patient. On November 21, 1906, it was 106. X-ray treatment was
commenced, and an exposure on each side of the neck to include the
58
Bruce: Treatment of Leukaemia, dc., by X-rays
thyroid gland was made three times a week. The relation of the pulse-
rate to those exposures is shown in Table III. The general condition of
Date
November 21,
1906
December
3
y y
it
10
1 >
»i
14
l»
i»
28
ii
January
2,
1907
ii
11
ii
„ 25
January, 1908
ii
TABLE III.
Pulse-rate
100 \
98 |
801
88 l
92 f
72
84
84'
86
Exposure three times
a week.
Present condition.
the patient was found to be materially improved. The muscular weak¬
ness and palpitation had disappeared, and she was able to get about
without feeling out of breath. The thyroid gland was still prominent,
but the pulse-rate was no longer high. When taken last it was 86.
The fourth case is that of a girl, aged 19, a well-advanced ca§e of
exophthalmic goitre, suffering from all the usual symptoms associated
with this disease—profound muscular weakness, shortness of breath, loss
of flesh and palpitation. Her pulse when she began treatment was from
112 to 120. X-ray exposures were carried out three times a week.
Table IV. shows the relation between those exposures and the pulse-rate.
Date
August 4, 1906
»> 31 l»
September 3 ,,
24 „
October 1 ,,
November 16 ,,
December 14
January 18, 1907
February 24 ,,
March 22 ,,
May 1
July 12 „
September 2 ,,
October 9 ,,
January, 1908
TABLE IV.
Pulee-rate
V
112
112
108
100
96
88
96
84f
84
84
92
88
80
84
80
Exposure three times
a week, except for
holidays.
Present condition.
The treatment has been followed by the most marked beneficial effects.
The pulse has fallen from 120 to 80, and all the other symptoms have
been markedly relieved. There has been no great difference in the size
of the thyroid gland. The two cases of exophthalmic goitre seem to
suggest that it may be necessary to continue the exposure for a very long
time, and it is therefore absolutely necessary to use the filter to avoid
Electro-Therapeutical Section
59
damaging the skin. The improvement in the general condition so well
seen in these cases takes place apparently without reduction in the size
of the thyroid gland or improvement to any marked extent of the
condition of the eyes.
The fifth case is that of a man, aged 72. This patient had when first
seen a hard nodular growth with an ulcerating surface involving the
posterior part of the hard palate and extending to the soft palate; one
gland about the size of a small walnut in the submaxillary region;
a small papillomatous growth on the left side of the tongue £ in.
from tip. The case was considered inoperable. X-ray exposure was
carried out through the wide open mouth, the patient holding forward
the tongue, and the side of the neck on which the infiltrated gland was
to be felt was exposed from the outside. X-ray exposure was carried out
as shown in Table Y. The ulceration of the soft palate w r as found not to
December 12, 1905
April 4, 1907
April 15, 1907 ...
January, 1908 . .
TABLE V.
X-ray exposure three times a week.
Papillomatous growth removed from toDgue
and proved to be epitheliomatous.
Resumed X-ray exposures.
Present condition.
advance, and, indeed, at times it almost healed up. The submaxillary
gland gradually disappeared, and in April, 1907, the papillomatous
growth of the tongue, which had not increased in size, was removed
by operation. As soon as possible X-ray exposure was recommenced,
and the present condition of the case is, as you can see, fairly satisfactory.
The sixth case is that of a man, aged 47. This patient in 1899 had
a tumour of the lower jaw w r hich was excised by Mr. Stanley Boyd and
proved to be of the nature of an endothelioma. In 1905 some recurrence
was discovered and the growth was removed for the second time. In
August of the same year it was found that the grow r th had again recurred
and that it was not possible to be of any further assistance from a surgical
point of view. X-ray exposure has been carried out since then till the
present date somewhat irregularly. The greater part of the recurrence
has disappeared, and at the present time the patient shows little sign of
its presence.
TABLE VI.
Tumour of lower jaw excised (proved to be an endothelioma) ... 1899
Some recurrence operated upon ... ... ... ... 1905
Second recurrence, no further surgical assistance possible August, 1905
X-ray exposures from ... ... ... ... August 15, 1905
Present condition ... ... ... ... January, 1908
60
Bruce: Treatment of Leukaemia, dc., by X-rays
The seventh case is that of a man, aged 41, sent to me by Mr. Pardoe
as a case of recurrent sarcoma of the abdominal wall. Shortly, the
history of the case is : A tumour had been removed from the abdominal
wall which, when examined, proved to be sarcoma. Some time after
operation the growth recurred. On May 17, 1907, there was to be felt
extending for about 2 in. on either side of the scar of the operation a
hard mass. Some glands were to be made out in the left groin. The
scar had broken down and was discharging. X-ray exposure was carried
out three times a week, and the patient’s present condition is satisfactory.
Six of the seven patients whose cases are mentioned above came to
the meeting and submitted themselves for examination.
TABLE VII.
X-ray exposure commenced ... May 17, 1907
Present condition ... ... January, 1908
DISCUSSION.
Dr. E. Mobton said that he had been particularly interested in the passage
from Dr. Bruce’s paper which referred to the suitability of certain materials for
the purpose of X-ray filters. At the London Hospital they used a single thick¬
ness of felt or other material saturated with some substance having high atomic
weight, such as tungstate of soda. In no case that had come under his notice
had there been any dermatitis; indeed, he regarded acute dermatitis as a thing
of the past. Sometimes he got a small degree of hyperaemia. He could not
see that the therapeutic effects as regarded the deeper structures were at all
diminished by using the filter. Most commonly he used lint saturated with a
solution of tungstate of soda and laid it over the part. He regarded this
method as having advantages over that employed by Dr. Bruce, as the four
thicknesses of felt, in the summer at all events, were likely to cause discomfort
to the patient.
Mr. A. EDMUNDS said that the first thing that occurred to him on listening
to Dr. Ironside Bruce was the remarkable diversity of the cases which were
amenable to X-ray treatment, but on considering the matter a little more
closely they fell naturally into a group. Cases as widely separated as malig¬
nant disease and spleno-medullary leukaemia had one thing in common:
The prominent factor in both diseases was the overgrowth of some particular
ceil. There were cells in those diseases which were in excess of the normal
number of cells required. In malignant disease the large overgrowth of
epithelial cells was affected by X-rays, and in leukaemia the same thing was
true of the overgrowth of white cells. Dr. Bruce’s case of cancer of the tongue
was to him (Mr. Edmunds) a disappointment. He had been hoping that the
X-rays w’ould be of great value in that direction, but he feared that that
particular case must be struck out of the list. The punched-out ulcer of the
Electro-Tlierapeutical Section
61
soft palate made the diagnosis of malignant disease of the tongue doubtful. In
exophthalmic goitre one was dealing with another kind of condition, but here
he believed that the cases might be nothing more than the soft goitre common
among young girls. This he had seen improve under the simplest treatment,
such as the mere administration of iron, without any application of the X-rays
whatever.
Dr. Donald Baynes, speaking of the treatment of certain diseases by
X-rays, said that if there was any other possible means of curing the cases he
would be very much inclined to follow it, but cancer and sarcoma were, perhaps
more than any other class of cases, amenable to X-ray treatment. So far as
leukaemia and exophthalmic goitre were concerned, he thought other methods
of treatment would give more satisfactory results. At any rate there w f ould be
no danger with the ordinary methods of treatment of bringing about such
conditions as calcareous degeneration of the kidney, with necrosis of the renal
epithelium, &c., as Warthin’s experiments on animals and post-mortem examina¬
tions show to have taken place as the result of X-ray treatment or exposure.
He wished to congratulate their old colleague on his paper.
Dr. H. Lewis Jones thanked Dr. Ironside Bruce for the trouble he had
taken in bringing so many patients to the meeting. He was much interested
to see the cases of exophthalmic goitre because, as many of them remembered,
the X-ray method of treating that disease was first reported from abroad, and
good results had been observed. But the experience of most observers was
that the treatment of exophthalmic goitre by the X-rays was disappointing,
although sometimes one might secure a good result. In one instance he had
found benefit follow from mild X-ray treatment, the pulse-rate coming down to
82 and staying there for a considerable time after X-ray treatment had been
suspended. Although in Dr. Bruce’s experience long and heavy treatments
appeared to have succeeded, he (Dr. Lewis Jones) ventured to think that milder
treatment more spaced out would be quite as satisfactory.
Dr. Hinds Howell, speaking with regard to the first case of exophthalmic
goitre, said that he did not know what the condition of the patient was when
she first came under Dr. Bruce’s observation, but he could not agree with the
remark of one speaker that it was a case of soft goitre of young girls. The
patient (Dr. Bruce’s third case) seemed to be suffering at present from myx-
cedema. Her whole appearance was very phlegmatic and suggested the disease.
She said her hair was coming out, she never perspired, and she was getting very
stout. Her mental processes were slow. He thought she would be an inter¬
esting case to watch. He did not know whether myxoedema was a condition
which might be produced by the X-rays. Possibly the treatment this patient
had received was instrumental in producing her condition.
Dr. W. IRONSIDE Bruce, replying to Dr. Morton, said that although the
four layers of felt might be warm in summer they would have a compensating
advantage in the winter. He very much doubted whether anything cheaper
than the felt filter could be produced. No such elaborate arrangement as
mentioned by Dr. Morton was, in his opinion, necessary. With regard to the
C2
Orton: Fractures of the Scaphoid Bone
criticisms offered respecting the diagnosis of the cases shown, he hoped that it
would be understood that he was not wholly responsible, for in each case the
disease was recognised by independent and competent observers. He adhered
to his statement regarding the nature of the disease in case 5, and he knew
that other methods of treatment, such as potassium iodide, had been given a
fair trial without success before the diagnosis of epithelioma was made. The
girl (case 3) was certainly a great deal stouter than when treatment commenced.
He was not surprised at the suggestion that she was suffering from myxcedema,
and surely if, as a result of the X-ray exposure, she had developed this disease,
it was easier to treat than exophthalmic goitre ? For instance, the second case
of exophthalmic goitre attended as an out-patient for a very long period, and
never really derived any benefit from customary methods of treatment. Myx-
cedema, on the other hand, could readily be got under control. In reply to
Dr. Donald Baynes, who said that he had hoped something would have been
said about the effect of prolonged administration of X-rays on the kidneys,
Dr. Bruce said that he could not think at the moment of having had a case
brought to his notice with any bad effects following X-ray exposure.
Fractures of the Scaphoid Bone.
By G. Harrison Orton, M.D.
In showing a number of slides of fractures of the scaphoid bone of
the carpus, Dr. Orton said that of all the bones of the carpus the
scaphoid appeared most frequently to sustain fracture, and, as would be
seen in the slides, the fracture was almost always in the same situation.
As in a Colles’s fracture of the radius, fracture of the styloid process of
the ulna was often associated with it. There might be dislocation of one
of the fragments and also of other bones of the carpus, generally the
semilunar. The fractures he showed were all produced by indirect
violence, generally by a fall on the hand, though he knew of one pro¬
duced in a goalkeeper by fisting a football. The fractures were as a rule
undiagnosed except by X-rays, and there was a tendency for the frag¬
ments to remain ununited, which seemed to produce loss of power and
pain in the wrist. One of the cases had been ununited since November,
1906, and it caused more pain and inconvenience now than a few years
ago. He had heard it suggested that if the fragments did not unite it
would be a good thing to remove a portion of the bone. Other members
might be able to give the results of their experience on this point.
Mr. A. D. Reid showed a similar slide of a fracture in the carpus,
together with the fragment which was extracted. This case was not
Electro-Therapeutical Section 63
diagnosed for nine months after the accident. Eventually it was decided
to operate. One tiny strand had united, but beyond that there was no
union whatever
Dr. W. Y. Somerville also sent a slide showing a case of fracture of
the scaphoid.
Case of Gonorrhoeal Warts.
By A. D. Reid.
The patient was a boy with an enormous growth of very diffuse
gonorrhoeal warts on the penis. The case was not yet completed, but
showed great improvement. It was the only one he had seen of this
Case of Gonorrhoeal Warts.
particular kind. The boy was treated with X-rays, having in all twelve
sittings of five minutes each, spread over a period of two months. When
he first came under treatment the growth of warts was so diffuse that
the glans could not be seen, and the treatment by X-rays was regarded
as a forlorn hope in lieu of amputation. The X-ray treatment had been
discontinued for nearly a month, and beyond the use of wet boracic lint
and iodoform powder, which the boy dusted on himself, nothing had
been done. The boy came to the hospital in July, but did not commence
the X-ray treatment until the middle of November. As members would
see, a great improvement had already taken place. The case had been
examined microscopically, and gonococci had been found.
/-7
64
Butcher: Plastic liontgenography
DISCUSSION.
Mr. Beddoes said that the treatment appeared to be rather slow as com¬
pared with the ordinary savin and subacetate of copper treatment. He
suggested that a more rapid recovery might have taken place if iodoform had
not been used.
The PRESIDENT (Mr. Deane Butcher) said that he could bear testimony to
the value of the X-rays in the treatment of specific warts about the anus.
These were best treated by X-rays, by high frequency, or by the introduction of
magnesium ions. The treatment of pruritus and warts about the anus and
scrotum was most satisfactory. He had been surprised and delighted with the
quick results obtained. After long treatment extending over months and some¬
times years by other methods he had seen X-rays give prompt relief.
Plastic Rontgenography.
The President, Mr. Deane Butcher, showed some lantern slides
illustrating plastic rontgenography. The originals had been kindly
contributed by Dr. Bela Alexander, of Kesmdrk, the originator of the
method. He also exhibited two skiagrams of a foetus, taken from the
same negative. A great amount of detail was brought out by the mere
process of printing according to the plastic method. Another series of
plastic skiagrams was exhibited, taken by an English worker, Dr. David
Morgan, of Liverpool. An ordinary skiagram of the pelvis, showing the
outline of the bladder filled with urine, was compared w T ith the plastic
rontgcnogram from the same negative.
ElectrcvGberapeutical Section.
February 28, 1908.
Mr. W. Deane Butcher, President of the Section, in the Chair.
The Principles of Ionic Medication.
By H. Lewis Jones, M.D.
Since the publication of my papers on the treatment of rodent ulcer
by zinc ions, in 1905 and 1906, I have received many enquiries concern¬
ing the principles of ionic medication, and I feel sure that great interest
in the method has been excited among medical practitioners in this
country. This is only natural, because the plan of introducing drugs
into the tissues by electrical means appears to afford a new and useful
therapeutic procedure.
The laws governing the behaviour of solutions through which
electrical currents are flowing are well established, and a knowledge of
these laws is requisite if one is to succeed in the application of electro¬
lysis to medical work.
Before proceeding further with the subject of my paper I wish to
draw attention to an experiment which is proceeding before you, for, in
order to illustrate the movement or migration of ions I have prepared an
arrangement of a conductor composed of a number of layers of parch¬
ment paper and filter paper in which conduction and ionic movement
may take place in such a way as to allow of a visible recognition of the
changes which occur, because I feel that in a subject like our present one
an ocular demonstration is particularly useful (see fig.). The electrolytic
circuit is composed as follows : Between the poles of the metallic part
of the circuit (composed of two plates of iron) there are arranged, in
a double series, first some layers of filter paper, next a diaphragm
mh —7
66 Lewis Jones: The Principles of Ionic Medication
formed of a piece of gutta-percha tissue, with a central hole of 1 cm. in
diameter, next some twenty layers of parchment paper, and thirdly a
considerable block of filter papers. This last body of filter papers is in
the centre of the pile, with the other components arranged symmetrically
on either side of it. The parchment paper portions are made up of a
long strip, folded in such a way as to form a number of squares which
follow each other in order when the paper is unfolded. This parchment
paper has a thickness of 0*2 mm. when moist, so that the twenty layers
have a thickness of 4 mm. The object of the gutta-percha diaphragm
is to limit the path of the current, and therefore the stream of ions, to
the central part of the parchment papers, and is introduced simply for
demonstration purposes. The iron disc beneath is connected to the
negative pole and the iron disc above is connected to the positive pole.
All the papers are moistened with a dilute (2 per cent.) solution of a
simple neutral salt. Sodium sulphate is chosen for this experiment,
though any soluble salt might be used provided it were without action
upon the ions under examination. As an indicator the parchment papers
.^
-c
b
Us
Diagram of Electrolytic Arrangement: a, electrode; b, filter papers ; c, diaphragm
of gutta-percha tissue; d, strip of parchment paper folded into twenty layers ;
c , filter papers.
contain a trace of phenol-phthalein, a colourless body which has the
property of turning purple in the presence of hydroxyl ions.
Under the conditions just described the flow of current through these
papers will set up a double movement of ions. S0 4 ions will move to
the iron positive pole, which will also give off ferrous ions, and these will
migrate towards the opposite pole, penetrating the layers of paper as they
move. At the iron negative pole no ferrous ions will be formed, but
sodium will begin to appear from the sodium sulphate of the electrolyte,
riior. kdv. sor. mkd.
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hi iiu^'ih aiovt.' for < .(('n strip.
l‘> JS ; ] ‘ > t )i> </m«'s J >' n i c all >u.
EUctro-Tlierajpeutical Section
67
and through a secondary reaction with the moisture present will form
hydrogen, which is set free as a gas, and sodium hydrate (NaOH). The
hydroxyl ions will split off from this compound and will move away
towards the positive pole, and will indicate their progress as they advance
through the papers by a change of colour in the phenol-phthalein. At
the end of fifteen minutes I hope to demonstrate the presence of iron in
the layers of parchment paper on the anode side and of hydroxyl on the
side of the kathode. My reason for choosing iron as the metal to be
ionised and set in movement is that iron lends itself to a demonstration
of this kind by the readiness with which a colour reaction, due to the
formation of Prussian blue, is given when ferrous ions are brought into
contact with ferricyanide of potassium.
(At the conclusion of the experiment, which occupied fifteen minutes,
the current being 20 ma., the layers of parchment paper were unfolded
and showed a central red stain extending through the entire series from
the kathode to the central block of filter papers. On the anode side the
parchment showed no red stain of the presence of hydroxyl, but was
slightly discoloured from the presence of iron ions, and after being
washed and wiped it was immersed in a solution of ferricyanide of
potassium, which brought out the presence of iron ions by striking a
deep blue colour [see Plate].)
Conduction in Metals and Conduction in Liquids.
We speak of metals as conductors, and of saline solutions, solutions
of acids, of alkalies, &c., as conductors, but the mechanism of conduction
in these two classes of conductors is by no means identical. In con¬
ducting solutions, or electrolytes as they are called, the conduction is
invariably accompanied by chemical decomposition, and in fact only
occurs by means of it, and the electricity flows not through the atoms,
as in a metal, but with the atoms of matter which travel along and
convey their charges between the poles, for in electrolytic conduction
positive electricity is conveyed through a liquid by something equivalent
to a procession of the electro-positive ions (atoms or molecules) of the
compound in the direction called the direction of the current (namely,
from the positive to the negative pole), and at the same time negative
electricity is conveyed in the opposite direction by a similar procession of
the electro-negative ions towards the positive pole.
An ion signifies an atom or a molecule of a body with its electric
G8 Lewis Jones: The Principles of Ionic Medication
charge attached to it, and it differs from an element in its ordinary
condition solely by virtue of this electric charge. When copper is
electro-deposited from a solution of one of its salts it assumes its metallic
form on being deprived of the natural positive charge, which it had in its
ionic form, by contact with the negatively charged kathode of the cell.
The opposite electric charges cancel out and the copper in its metallic or
“ unelectric ” condition remains. The laws of electrolysis were formu¬
lated by Faraday and the term ion was also devised by him to express
the tendency to move towards the poles of the cell which he observed in
different chemical bodies. He gave the name of anions to the ions
which he found to move towards the positive pole and of kathions to
those which move towards the negative. He showed that the amount of
chemical action produced in any solution of an electrolyte was exactly
proportional to the quantity of electricity which had passed through it.
The weight of substance acted on measures the quantity of electricity
which had passed, and, conversely, the quantity of electricity or the
magnitude of the current, with the time during which it has been
allowed to flow, measures the amount of chemical change produced. He
also showed that for different chemical bodies the amount of decompo¬
sition in each substance is exactly proportional to its chemical equivalent.
For instance, an atom of silver is 108 times as heavy as an atom of
hydrogen, and is equal to it in combining power; hence a current which
will liberate 1 grm. of hydrogen will liberate 108 grm. of silver. Tables
of electro-chemical equivalents have been calculated which enable us to
determine the quantity of any ion set in motion from measurements of
the magnitude of the current and the duration of its flow. For example,
suppose zinc ions be driven into the skin of a patient with a current of
10 milliamperes for fifteen minutes, the calculation is as follows:—
The amount of zinc set in motion by a current of 1 ampere running
for one second is 0*00034 of 1 grm.
0*00034 grm. for 1 amp. per second.
0*00034 grm. for 0*01 amp. (10 ma.) for 100 seconds.
0*00034 grm. X 9 grm. for 900 seconds 15 minutes.
0*00306 grm. — 3 milligrammes.
By weighing the zinc electrode before and after an application one
might be able to determine that the loss of weight during the application
was of that order of magnitude, and indeed without weighing it is often
possible to recognise by the appearance of the surface of the metal that
there has been a loss of some of its substance. In the refining of copper
Electro - Therapeutical Section
69
the principle of the migration of ions is employed on a gigantic scale, for
almost all the metallic copper in commerce to-day has passed through
the ionic form. Thus in some copper statistics for the year 1902 I read
that over 210,000 tons of copper were electrolytically refined in the
United States alone during that year; the whole of this mass of
copper, therefore, passed into solution as copper ions from anodes
of crude copper, and was deposited at kathodes in the form of the
pure metal. The process is done for the purification of the copper,
and also for the recovery of the gold, silver and other metals present
in the crude material and these more than repay the cost of the
electrolytic process.
In addition to calculations of the amount of any substance set in
movement, we require, for medical purposes, to know the depth to which
a drug can be made to penetrate in the time of its application. Our
knowledge on this point is not yet very complete. Sir Oliver Lodge has
given the following rates for certain ions when impelled by an electric
pressure of one volt per centimetre : Hydrogen, 10*8 mm. per hour ;
K, 2*05 mm. per hour; Na, 1*26 mm. per hour; Cl, 2*16 mm. per
hour ; I, 2*16 mm. per hour. At higher pressures the rate is increased
proportionately. In the experiments which we have just seen with
the parchment paper it appears that the ions penetrated about one
thickness of paper 0*2 mm. per minute, under the conditions of the
experiment.
The rates of migration through simple conductors supply only
rudimentary information as to the behaviour of ions driven into an
electrolyte with such a complex composition as the human body, and
the question of the fate of the ions which enter the body must be
considered later.
The beginnings of the use of electricity for the purpose of introducing
drugs into the human body date back to 1833, when Fabre Palaprat
claimed to have introduced iodine into the tissues in this way. In this
country Benjamin Ward Richardson devoted a good deal of attention to
electrolytic medication about 1859, in the search for a mode of producing
local anaesthesia by means of solutions of aconite and of other drugs.
Bruns, in 1870, introduced iodine electrically and afterwards recovered
it from the urine of a patient, and Munk, in 1873, succeeded in setting
up tetanic convulsions in a rabbit by using electrodes moistened with
solutions of strychnine. Since that time the subject of cataphoresis, or
cataphoric medication, has been studied by a great number of persons,
including Foveau de Coumelles in France and Morton in New York, but
70 Lewis Jones: The Principles of Ionic Medication
the idea was imperfectly understood, and consequently failed to attract
attention and made no progress.
The establishment of the principles of ionic medication upon a clear,
scientific basis has been due to the writings of Professor St6phane
Leduc, who has published a number of papers on the subject since 1900,
when a paper 1 on the introduction of medical substances into the depths
of the tissues by the electric current was read by him before the Inter¬
national Congress of Electrobiology in Paris. On January 5, 1901, he
published, in the Gazette MSdicale, of Nantes, a paper 2 on the theory of
ions in medicine, in which the subject was carried further, and in 1903
he published a case of rodent ulcer cured by an application of zinc ions.
A very useful small work has lately appeared under the title of
“ LTonoth6rapie 61ectrique,” by Dr. Delherm and Dr. Laquerrifere, 3 in
which much useful information is embodied.
There are some points in connection with the choice of drugs for ionic
medication which need to be remembered. In the first place, there are
chemical bodies which possess powerful effects upon protoplasm when in
their ordinary elemental condition, but lose these properties entirely
when in the ionic form. For instance, chlorine in its free state is a
strong oxidising body and a destructive agent, but chlorine ions, which
are present in abundance in normal saline solution, have no such pro¬
perties, and it would be a futile proceeding to introduce chlorine ions
electrically for the sake of an effect like that of chlorine water as
observable in a test tube. The same applies to iodine, and, indeed, to
the whole class of strong chemicals whose action depends upon their
degree of concentration. Caustic potash or nitric or sulphuric acids are
all powerful reagents in the chemical laboratory, but lose these properties
when greatly diluted, whereas those bodies which are active in the ionic
form are independent of their degree of dilution.
Again, for ionic medication one can only use such substances as
undergo dissociation or ionisation when dissolved in a solvent. This
excludes a number of organic medicinal compounds which are insoluble
or are not dissociated when dissolved. Chloral, chloroform, ether,
alcohol, phenol, camphor, &c., are instances of medicines which are
not available for ionisation. Still there are a very large number of
active substances which can be used. We are not limited to inorganic
1 “ Introduction des substances medicamenteuses dans la profondeur des tissus parle
courant 61ectrique.”
- “ La th£orie des ions en m6decine.”
s Paris, J. B. Bailliere et Fils.
Electro-Therapeutical Section
71
salts, because among organic compounds there are many which fulfil
the conditions of solubility and dissociation. The alkaloids, as, for
instance, strychnia, quinine, cocaine, aniline, adrenalin, may be used
and have been found useful for ionic medication. Salicylic acid, too,
and many other of the coal tar compounds, are found to exist in the
ionic form.
In using electrolytic medication it is important to know which ions
migrate inwards from the anode and which from the kathode. This is
not difficult to learn, for the ions of all bases—that is to say, the ions of
the metals, the alkalies, and the alkaloids—are electro-positive, and
their ions, therefore, are repelled from the anode, and must be driven
into the skin by placing them at the anode of the circuit. The acids, on
the other hand, are introduced from under the kathode, and the same is
the case with the halogens, chlorine, bromine, or iodine. A minor
exception must be made for lead, which under some conditions migrates
to the anode as lead peroxide.
The question of the amount of penetration which can be obtained is
also one which requires further consideration. In particular also we
have to consider the effect of the components of the juices of the body
in combining with ions, and so arresting their further progress. Some
ions, especially those of the heavy metals, are likely to be precipitated in
the form of phosphates by the albuminous fluids of the body, although
the amount of phosphoric acid in the blood-serum and lymph is very
small (about 0*025 per cent, or one part in 4,000, the sodium chloride
being about 0*5 per cent, or one part in 200). The other ions may be
pictured as gradually losing their velocity after they have penetrated a
few millimetres, and subsequently passing into the circulation gradually
by diffusion, until they become eliminated.
The Strength of the Ionic Solutions.
I am often asked to specify the strength of the solutions employed
for moistening the pads used in ionic applications. The answer to the
question is that a 1 per cent, or 2 per cent, strength is the proper
proportion. As a matter of fact the strength matters little. In a 1 per
cent, solution there are abundant ions present to carry any reasonable
medical current, and if the ion being introduced is that of a metal,
such as zinc or copper, the supply of ions is continually being renewed
from the electrode, in exact proportion to the number of ions moving
72 Lewis Jones: The Principles of Ionic Medication
forward into the body. When the ion is not so renewed, as, for
instance, when a carbon electrode is used, it is better to use a stronger
(2 per cent.) solution for moistening the pad, and to employ a great
number of layers of lint in the pad to act both as a reservoir for the
solution and as an absorbent for the hydrogen or hydroxyl ions driven
inwards at the positive and negative electrodes respectively. Both these
ions are caustic and are the cause of the soreness which is sometimes set
up at the points of contact in galvanic applications, and we have seen
from our first experiment that hydroxyl ions migrate rapidly. The
hydrogen ions move more rapidly still; indeed, it is with the hydrogen
ions that the highest velocity has been observed.
(In a second experiment performed during the reading of the paper
iodine ions were caused to penetrate twenty layers of parchment paper
from a kathode, and copper ions were driven in similarly from a copper
anode. The iodine ions were demonstrated with mercuric chloride, which
gave an orange stain to the paper, and the copper ions with potassium
ferrocyanide [see Plate].)
Indications for Ionic Medication.
The class of cases for which ionic medication is likely to prove useful
is lo be found mainly among local disorders, for the treatment of general
diseases by drugs is already fairly met by other simpler modes of adminis¬
tration. It might also be thought that the simple procedure of hypo¬
dermic injection might bring about the same results in local medication
as can be obtained by the somewhat complicated method of driving in
ions electrically; but there is this difference, and I consider it an import¬
ant one. The injected fluid enters the interstices of the tissues, and
from there is rapidly carried away into the general circulation, while the
ions introduced electrically penetrate into every conducting element of
the tissues—that is to say, into the actual protoplasm of the cells of the
part traversed by the current. This is not merely a theoretical con¬
sideration, for it has been found that cocaine and adrenalin introduced
in the ionic form produce a physiological effect which is more durable
than that obtained by the method of injection, although the quantity of
the drug conveyed into the system by an injection may be by far the
greater. I have myself noticed that the effect produced upon a rodent
ulcer by zinc ions continues for a long time, as though the zinc were
locked up in the part treated. It has also been observed with lithium
Electro-Therapeutical Section
73
that after its electrical introduction into the tissues its elimination by
the urine is extended over a longer time than is the case after oral
administration.
Next, the conditions for which ionic medication is attempted should
be superficial conditions, so as to ensure that the ions employed shall
really penetrate into the parts submitted to treatment, and shall be
carried by the current into the whole thickness and the whole area of the
diseased part.
The number of local and superficial morbid conditions which are still
without any satisfactory means of cure is a large one, and instances of
various kinds will readily occur to each one of you. I am sure that it is
of the highest importance for the success of ionic medication to commence
with the attempt to treat superficial conditions only, and even with
superficial conditions to take plenty of time so as to ensure as far as
possible an effective permeation of the part treated with the drug employed.
I am sure that an important cause, and perhaps the most important cause,
of non-success is due to neglect of this important point. It is the slowness
of the ionic movement, and also the fact that the procedure of ionic
medication is apt to be painful, and so is likely to cause the operator to
cut his time too short, which are the stumbling blocks of the treatment,
and I believe that when we have perfected our technique by further
experiment we shall often employ ionic medication under local or even
general anaesthesia with larger currents, and for longer times of applica¬
tion. The times and magnitudes of current which I have given hitherto
for the treatment of rodent ulcer by zinc ions, namely twelve minutes and
3 ma. per square centimetre, are an irreducible minimum, and both time
and current strength may usually be increased with advantage.
Rodent Ulcer.
The disease for which ionic medication has proved most successful
so far is rodent ulcer treated with zinc ions. This application of ionic
medication was indicated by Leduc in 1903, when he reported a case of
the kind successfully treated by himself. Since then I have given a good
deal of attention to the treatment of rodent ulcers in this way, and I
consider the method to be valuable and to have given electro-therapy
a new procedure of first-class importance.
With certain limitations, the treatment of rodent ulcer by zinc ions is
uniformly successful when applied in the early stages of the disease, but
74 Lewis Jones: The Principles of Ionic Medication
1 have not yet learned how to cope with the extensive and appalling
examples of old neglected rodent ulcers which are seen from time to
time.
The procedure for the treatment of small rodent ulcers is quite
simple. The surface is covered by three or four layers of lint wet with a
2 per cent, solution of the sulphate or chloride of zinc; a zinc electrode of
suitable size is applied and connected to the positive pole of an ordinary
medical continuous current battery, the circuit is completed through a
second indifferent pad electrode, and the current turned on to 5 ma. to
10 ma., and kept on for fifteen minutes. The magnitude of the current
must be proportionate to the size of the area, and Leduc has suggested
3 ma. for each square centimetre. On the face this magnitude can
usually be tolerated well, but, if desired, a little cocaine can be introduced
first by proceeding identically as described for zinc, but with the positive
pad moistened with cocaine hydrochlorate.
Zinc ions are also useful in other superficial suppurative conditions.
In a case referred to me as lupus, but which I believe was merely pustular
eczema, the patient had two distinct purulent crusts upon the side of the
nose. One of these was treated by the zinc method while the other was
left alone. At the end of a week the one treated had completely healed,
the untreated spot remaining as before. Zinc was then applied to the
second place and the same result followed, viz. : complete healing within
seven days. It is probable that zinc ionisation might prove useful in
many forms of ulceration of the skin and mucous membranes, certainly
it should be tried in some of these conditions. Ionic medication has also
been used for the sterilisation of teeth, and I have lately met a dental
surgeon who told me that he frequently employed the method.
Diphtheritic Foci.
The following case of the treatment of a diphtheritic infection is very
suggestive. In a case of diphtheritic paronychia the finger-nail had been
removed, but it had not been found possible to eradicate the diphtheria
bacillus, which lurked and grew in the irregularities of the skin in spite
of antiseptic lotions. The case proved obstinate, and had gone on for
several weeks. By means of some layers of lint moistened with ammonio-
sulphate of copper and an anode in the form of a coil of copper wire
wound round the finger-tip, copper ions were ' introduced for fifteen
minutes, and in less than a week the patient w r as entirely well.
Electro - T her open tica l Section
75
Other Septic Conditions.
The employment of ionisation to introduce an antiseptic into the
walls of a sinus or into the base of an ulcer will readily suggest itself,
and I have had an instance myself in which an obstinate ulceration of
the mouth yielded to copper ionisation, while a friend of mine has told
me of a case in which an ulcer of the rectum, of long standing, healed
up well after ionisation with zinc.
Corneal Ulceration.
In one case of this troublesome affection the zinc applications proved
quickly successful, but in another, lately submitted to me, I met with no
success, the failure in my opinion being the result of too short an appli¬
cation, as referred to in my remarks just now.
Warts.
In the treatment of multiple warts of the hands I have found
magnesium ions very effective, so much so that I have several times
seen all the warts disappear from a hand after two applications of
magnesium ions. These can easily be applied from a solution of
magnesium sulphate, using a carbon electrode with a thick pad of lint
to hold sufficient solution. A magnesium metal electrode can also be
used, and I have on the table such an electrode which has been made for
the purpose. I have not found that all warts disappear so easily by
magnesium treatment, and for hard solitary warts I prefer to use zinc
ions, and to ensure the penetration of the metal by using a zinc needle
to transfix the wart. A current of 2 milliamperes for two minutes will
usually suffice in this case.
Lupus.
This is a disease which naturally occurs to one’s mind in connection
with ionic medication. It is superficial, accessible in most instances, has
no great mass or thickness, and, therefore, fills the requirements for ionic
action admirably. But I have found it extremely difficult to eradicate
lupus in this way, though I have had a few minor successes. Aniline
and zinc have both seemed valuable, but further perseverance, and the
76 Lewis Jones: The Principles of Ionic Medication
discovery of a more effective ion are needed before we can count lupus
as a success for ionic medication. Aniline has a high chemical combining
weight — 94, and, therefore, a larger quantity is carried in by a given
current than is the case with zinc and copper, whose equivalents are for
zinc 32*5, and for copper 31*5. Accordingly with aniline hydrochlorate
a current of 10 ma. for ten minutes will introduce 6 mg. of aniline ions.
Cocaine.
The introduction of cocaine ions will render a small patch of skin
insensitive in about five minutes, and I have frequently used it as a
preliminary to small cosmetic procedures of electrolysis for the removal of
xanthelasma, small naevi and moles on the face. The introduction of
cocaine will also relieve the pains of neuralgia temporarily, and in some
instances one or two such applications may be followed by a complete
disappearance of the neuralgia. My friend, Dr. Samuel Sloan, of
Glasgow, writes me regarding the application of ionic medication that
a patient with supra-orbital pain of a severe periodic character coming
on daily, at the same hour, was not only relieved by the introduction of
cocaine ions, but that after two or three applications, using about
3 milliamperes for ten minutes on each occasion, the neuralgic pain
entirely disappeared.
DISCUSSION.
Dr. Lewis Jones, after reading the paper, added that, apropos of neuralgia,
a number of observers on the Continent had reported good results in trigeminal
neuralgia after the introduction of quinine in some cases and salicylic acid in
others. He had had good results with salicylic acid from a solution of salicylate
of soda. It was quite possible that the drug, when introduced over the area of
the distribution of the nerve, might be absorbed by the lymphatics of the nerve
trunks, and so conveyed to the Gasserian ganglion. Although this method was
new, a number of cases of serious trigeminal neuralgia had been already reported
to have been completely cured or greatly improved, and he considered that the
method deserved further examination in this troublesome condition.
The President (Mr. Deane Butcher), in opening the meeting for discussion,
said that they had listened with a great deal of interest to Dr. Lewis Jones, who,
as the exponent of ionic medication, held relatively the same position in England
as was held in France by Professor Leduc, and in America by Dr. Morton.
Electro - Therapeutical Section
77
Dr. W. Ironside Bruce thanked Dr. Lewis Jones cordially for the
interesting paper he had read to the Section. He (Dr. Bruce) could not say
that he had had a great experience with ionic medication, but in such experience
as had fallen to his lot he had found the method of treatment entirely successful.
Mr. Frederick C. Wallis said that the subject was one of extreme
interest to him in connection with his study of various forms of ulceration at
the lower end of the alimentary tract. He was rather limited in any observations
he might make because he and a colleague had a paper already written on this
subject, and if he told the full story of their results that evening it would lessen
the interest of the paper when it was published. But he might say that certainly
so far as their experience went the treatment had met with marked success.
For some years he had been looking for an effective treatment for such forms of
ulceration of the large bowel. He had tried other methods with only limited
success, and the removal of the diseased part by means of the knife was only
possible in a small number of cases; but in those cases—they had not a large
number yet—in which ionic medication had been tried the success, particularly
in regard to one instance, made one quite enthusiastic as to the possibilities of
curing this form of ulceration, which hitherto he had been unable to cope with.
This form of ulceration was largely progressive by submucous filtration. It
did not belong absolutely to the superficial class of cases which Dr. Jones
insisted should be the one mainly tried, and the interesting question was as to
whether it was possible to drive the metals or ions through sufficient depth of
tissue to frustrate the further progress of the disease in the submucous tissue.
Dr. E. S. WoRRALL said that whenever Dr. Lewis Jones read a paper it
was sure to be worth listening to, and they were not disappointed on this
occasion. The speaker had been using this treatment in a considerable number
of cases and had found no great difficulties in the way of its application. It had
been used with uniform success in a variety of cases, excepting only some cases
of ringworm in which he had tried copper ionisation without success. Certain
practical difficulties had arisen in treating some of the cases. Some of the
patients would endure the burning sensation caused by this process better than
others. The position of the part affected also had some influence. The patients
would stand the burning near the angle of the mouth better than on the tip of
the nose. Dr. Jones spoke of the treatment of corneal ulcer. What intensity
of current was given in such a case ? In a case of rodent ulcer affecting the
lower lid he (Dr. Worrall) did not feel justified in applying the current of 3 ma.
per square centimetre. He applied a milder current, giving eight applications
of ten minutes each at intervals, and the result at the end of the treatment was
all that could be wished. Sometimes one could use the current at the density
specified and the patient would not complain, but in many other cases the patient
would not tolerate such a current. Recently he treated a case of rodent ulcer by
driving in a 10 per cent, solution of cocaine hydrochlorate in guaiacol for five
minutes, and then proceded with the zinc ionisation to the full strength of the
current, which could be readily tolerated after driving in the cocaine.
78 Lewis Jones: The Principles of Ionic Medication
Dr. Donald Baynes said that he was specially glad to have had the oppor¬
tunity of listening to Dr. Lewis Jones’s excellent paper, and to have something
other than X-rays brought before the Section. Sometimes at previous meetings he
had thought that the old British Electro-Therapeutic Society had become since
the Amalgamation part and parcel of the Rontgen Society. Dr. Jones thought
that ionic medication was specially adapted—indeed, one gathered from his paper
that it should be used only—for superficial conditions. Would it not be ionic
medication, however, that they had in the treatment of joint affections when
using iodide of potassium, &c., in cases of arthritis ? Certainly a benefit was
obtained from using it, and in these cases one required to have deep penetration.
Again, in the use of a copper plate connected to a positive pole in cases of
threatened appendicitis ; here there must be fairly deep penetration to relieve
the pain, and the pain is not relieved by the current without the copper plate.
He had never tried ionic medication in any such condition as ulcer of the cornea,
and was rather inclined to be afraid of using the continuous current to the eye,
because the eye was more or less composed of fibrous tissue, which the con¬
tinuous current had the effect of dissolving to some extent. He desired to have
Dr. Lewis Jones’s opinion on that point, for Dr. Jones had had a very considerable
experience in this method of treatment. One speaker had mentioned the pain
caused by the application of the current and the objection made to it by some
patients. To overcome the difficulty it had been suggested by the speaker that
cocaine might be introduced from the positive pole to prevent the pain. He found
that if cocaine were injected hypodermically the patients felt less pain than when
it was introduced cataphorically. But in cases of sciatica, &c., where Dr. Jones
had given cocaine hypodermically, it appeared that the effect was not lasting.
That was so to a large extent unless care was taken to cut off the circulation by
means of an Esmarch bandage, &c. If the circulation in the part were cut off
before injecting the cocaine the effect would be found to remain.
Dr. BOLTON (Nottingham) said that he was glad Dr. Jones had referred to
the treatment of affections of the joints because that was the only department
of this subject upon which he could offer an opinion. He wondered whether
Dr. Jones out of his experience could explain the effect he had noticed in the
treatment of rheumatoid arthritis. He found salicylate of soda by itself to
have but little effect, and the same was true of the high frequency current.
The case would improve for a fortnight and then come to a standstill. If,
however, he gave salicylate of soda by the mouth, and immediately followed it
up with high frequency the improvement was manifest. It was possible that
by using the electrical treatment and the salicylate together the salicylate was
driven deeper into those parts of the joints which could not be reached without
the electrical treatment. Benefit was obtained from the two together which
could not be obtained from either singly.
Dr. J. F. HALLS Dally said that he could only echo the remarks of the
preceding speakers in thanking Dr. Lewis Jones, of whom he would like to ask
two questions, viz.: whether he had tried ionic medication in cases of irritative
Electro - Therapeu tica l Sec tion
79
skin conditions such as pruritus, also whether he had tried it in neuralgias
apart from those of the face.
Dr. E. G. Graham Little said that they had reason to thank Dr. Lewis
Jones for introducing this system to England, and in view of its special efficacy
for superficial diseases dermatologists were most particularly indebted to him.
He asked whether this method could do any harm to the tissues which were
not diseased in cases in which it was not easy to fit the apparatus solely to the
diseased part. In the case of a small lupus, for instance, would harm result if
the treatment went beyond the diseased area? Would there be any risk
whatever of permanent venous dilatation or anything of that sort ? He suggested
that possibly hydrogen peroxide might be used as a bleaching agent in chloasma.
The treatment might be tried in histologically superficial diseases of the skin,
such as psoriasis, which was often obstinate. Had Dr. Lewis Jones any
suggestions to offer as to the method of choice of the electrolytic fluid ? Was
there any difference in using a zinc as against a copper solution in cases of
ringworm? On what principle were they selected? If there were any tech¬
nical points influencing the selections it would be very useful to know’ them.
He had at present a case of very persistent erythema with local dilatation of
the superficial blood-vessels which it was extremely difficult to treat by any
method at his disposal. He now thought of trying suprarenalin ionisation.
He concluded by expressing the thanks of dermatologists to Dr. Lewis Jones.
Dr. A. H. PlRlE said that it was eight years since, in Dr. Lewis Jones’s
room, he learned the method of driving in the cocaine. On two or three
occasions he had used copper sulphate solution for ringworm, and after about
three W’eeks succeeded in getting a great improvement. But on looking carefully
he found that two or three hairs had escaped the cure, and that seriously
reduced the value of the treatment to his mind. The way in which the patches
cleared was remarkable, but a few hairs always seemed to spoil the treatment.
In a case of rheumatism in which the patient’s wrist had been badly swollen
for about four months he applied by the ionic method a 2 per cent, solution of
salicylate of soda for about an hour. After the first treatment the swelling was
reduced by i in., and after a second treatment by another $ in. It was remark¬
able how the swelling went down with salicylate of soda ions after the disease
had continued for so long a time.
Mr. T. J. P. HARTIGAN said that the form of treatment they had had
brought before them that evening was one which he had been prescribing for
something like six months, and in some respects it was disappointing, in others
encouraging. He had no experience, or very little, of its usefulness in the
treatment of rodent ulcer, and in certain situations, e.g., the eyelids, he could
conceive that it would be attended with a certain amount of pain that might be
unendurable unless means were taken, such as the use of cocaine, to relieve it.
His experience of rodent ulcer was confined almost exclusively to the radium
form of treatment, and the results so far, except in extensive cases involving
80 Lewis Jones: The Principles of Ionic Medication
bones, left nothing to be desired. In saying this he did not mean to detract
from the merits of ionisation. There was no doubt that such treatment also
was attended with very excellent results. With regard to ulcers in other
situations he had treated varicose ulcer of the leg by the ionic method and thus
far had obtained very fair results ; the wounds seemed not only to clean up
better but also to heal appreciably faster, and usually the patient came back to
say that he felt a great deal better. In minor affections, particularly of the
face, necessitating a trifling operation, the previous introduction of cocaine by
this method was of material assistance. Considerable pain was caused by the
performance of electrolysis and could be similarly combated. Only the
previous week, for the sake of demonstration in a small operation for naevi
upon a boy, he had treated one part with cocaine and left the other alone, but
it was found necessary to anaesthetise the latter also before the operation could
be completed. At the Blackfriars Hospital they had not had the results which
might have been expected in the treatment of psoriasis ; possibly they had not
persevered as much as they ought to have done. The greatest successes which
seemed to have attended their efforts had been in the application of this treat¬
ment to lupus erythematosus. He brought before the notice of the Dermato¬
logical Section at its last meeting four or five cases, and in every case in which
the ionic method had been applied the patient’s condition had been attended
with marked improvement. One woman had the disease fifteen months,
affecting the whole of the nose. She was treated last October, and now, except
for a superficial scarring, it was hardly possible to tell that she had suffered
from the disease. In another case, that of a lady who had had the disease for
fourteen years, it was hardly possible to recognise where the patches had been
in the parts to which the ionisation had been applied. He leaned towards
copper rather than zinc in lupus erythematosus cases so far as his experience
had gone. He believed that the method had a future before it and was worthy
of an extended trial.
Dr. G. B. Batten said that he supposed many experiments had been
carried out in the past with regard to the voltage used and the rate of entry,
and it would be interesting to know whether it was recommended that to get
in, for example, the same amount of zinc, a higher voltage should be used for
a shorter time or a lower voltage for a longer time. Most of those who treated
ringworm in that Section used X-rays, but there was a class of cases of ring¬
worm of the scalp, consisting of small, disseminate patches, which was tedious
to treat by the X-rays. It would be useful to know whether metals or sali¬
cylates were the more promising for ringworm treatment, also whether boils
had been sterilised in this way. He also asked whether the cocaine must be
in a special solution or could be used simply with water. One member had
spoken of the effect of high frequency currents in driving salicylates into the
joints. Dr. Clarence Wright once read a paper on that subject before the old
Society, and suggested the use of the high frequency current electrolytically.
The use of high frequency under such conditions would possibly be a great
deal less painful than the constant current.
Electro-Therapeutical Section
81
Dr. Lewis Jones, in replying, wished first to thank Dr. Pirie, on behalf of
those present, for the skilful way in which he had performed the experiments
designed to demonstrate the movement of the ions through the layers of tissue.
He thanked Dr. Graham Little and Mr. Hartigan for their useful suggestions as
to certain new lines of work. His own experiments with lupus erythematosus
had been disappointing, but after hearing the remarks of Mr. Hartigan he would
try again. Evidently he had not learned how to deal with them in the way
Mr. Hartigan must have done. Dr. Graham Little had enquired what sort of
principles guided them in the choice of this or that drug. The principle was to
determine which was the active ion in any drug and to introduce it in the ionic
form. In some cases, such as the treatment of warts by magnesium, he had
ol>served notes in the medical journals to the effect that after the administration
of magnesium internally, warts had disappeared. This made him think that if
magnesium had that effect when given as a drug it would be better accomplished
by the regular introduction of magnesium ions into the warts themselves. In
the case of ringworm there were serious difficulties, and although at one time
he had proposed to write a paper on its ionic treatment he had been compelled
to withdraw from that position, for although improvement and new growth of
hair could readily be obtained by the introduction of the ions of zinc or of
copper, yet the actual curing of a case of ringworm was a different matter.
Some infected hair follicles escaped, and even if it were possible to sterilise
nine-tenths of the affected follicles by zinc or copper it was all of no value if
the remaining one out of the ten remained unsterilised. If they could succeed
in causing the ions to penetrate uniformly into all the follicles the conditions
of ringworm treatment would be comparatively simple. It was just this diffi¬
culty which had been experienced in the past with other medications for
ringworm. As to the most suitable ion for the purpose, zinc and copper
seemed to act well, but their solutions were astringent fluids, and perhaps
salicylic ions from a solution of salicylate of soda might have a greater tendency
to soften the epidermal tissues and to penetrate better and more uniformly.
Another serious difficulty in the application of the ionic method to ringworm
was the necessity of treating the whole scalp, and over such a large area a
current of 3 ma. per square centimetre was a large current for a child to bear.
Sycosis could be successfully treated by an electrolytic procedure by intro¬
ducing a fine copper wire, connected to the positive pole, into each of the
suppurating follicles. This was rather tedious, but seemed to answer well,
especially if combined with careful cleanliness of the skin, so as to avoid the
reinfection of fresh follicles. Mr. Hartigan’s remarks about varicose ulcers
were interesting and valuable. About rheumatism he had not very much to
say at present; the very vagueness of the term made definite statements
difficult or impossible. In the case of a woman who had hydrops articuli
of both knees he had tried the effect of iodine, introduced from the kathode,
and of lithium, simultaneously introduced from the anode, the electrodes being
two pads, applied one on either side of the joint. For purposes of experiment
it might have been better to have applied lithium to one knee and iodine to the
vih —8
82 Lewis Jones: The Principles of Ionic Medication
other, but as it happened both were introduced into the same joint. The
effusion in the joint rapidly disappeared after a single application and the joint
became normal, and the same treatment then being applied to the other knee
a similar result followed in that one also. Therefore, though he had failed to
discover whether it was the iodine or the lithium or the combination of both
which produced the good result he had at least obtained a curative effect.
With regard to the treatment of neuralgia he had not as yet had a very
extended experience, but if the treatment proved to be really useful in trigeminal
neuralgia one might expect it to be equally useful for the other forms ot
neuralgia, which were generally simpler in their nature and easier to treat.
dcctro-ZTbcrapcutical Section.
March 27, 1908.
Mr. W. Deane Butcher, President of the Section, in the Chair.
Cauterization as an Adjuvant to Radiotherapy.
By J. Goodwin Tomkinson, M.D.
The clinical forms of cutaneous tuberculosis in which I have employed
X-ray therapy in conjunction with cauterization have been so far the
non-ulcerative and ulcerative forms ^)f lupus vulgaris and tuberculosis
verrucosa. In the main my remarks will bear upon the treatment of
lupus vulgaris to which for some time I have been devoting considerable
attention. It is from the standpoint of the dermatologist that I would
direct your attention to the question of therapeutics, and in so doing
would claim neither the X-rays nor the Finsen light as the only method
at our disposal for the treatment of lupus vulgaris. With your permis¬
sion I will briefly refer to one or two of the older methods employed in
the treatment of this form of cutaneous tuberculosis. One of these
stands out with conspicuous prominence, and justifiably so, on account
of the excellent results obtained by its exhibition in extensive facial
lesions of an ulcerative and hypertrophic character. I refer to that of
multiple linear scarification, especially associated with the French school
of dermatology, much practised and recommended by such authorities as
Brocq and Hallopeau, the latter of whom strongly advocates, in addition
to the scarification, the application of a 5 per cent, aqueous solution of
permanganate of potash. In this country an objection to this treatment
is the necessity for repeated general anaesthesia, which, although quite
well induced by nitrous oxide, might not commend itself to every patient .
In Paris it is no unusual thing to see patients in the skin cliniques
a —5
84
Tomkinson: Treatment by Cauterization
submit to this treatment with a surprising and enviable stoicism without
the employment of any anaesthetic, local or general.
As the most common site of lupus vulgaris is the face, often the nasal
region, surgical interference is contra-indicated, save in lesions of extremely
limited dimensions. This restriction does not* of course, apply in the
same degree to lesions on covered parts.
Scraping in lupus vulgaris of non-ulcerative type is strongly re¬
commended by Brocq, and justifiably condemned in ulcerative lupus,
where it may be followed by most unsightly cicatrices and conspicuous
disfigurement.
With respect to the galvano-cautery, it may be said that while of
considerable value in isolated lesions, such as those appearing in an old
cicatrix or persisting from inefficient curetting, it should be used with
great caution in the vicinity of orifices, where vicious cicatrices may be
thereby very easily induced. It is not recommended in such cases; in
fact, for the reason just stated it is distinctly contra-indicated. It is, how¬
ever, of considerable value, and is much employed in lupus of the palate,
pharynx and mucous membranes generally.
In concluding this cursory review of the relative merits of some of
the various methods of treatment other than actinotherapy and X-ray
therapy, I would recall to your memory that method associated with the
name of Hollander, of Berlin, in which a stream of air heated to some
hundreds of degrees Centigrade is directed upon the lesion with the
production of an eschar, which is subsequently removed by scraping. At
the conclusion of a visit to Berlin I had the pleasure of manipulating
Hollander’s apparatus under his supervision, but was unable personally to
follow up the case treated. Hollander claims, however, most excellent
and rapid results from his treatment when properly carried out.
At the Paris Congress on Tuberculosis, of which I was a member,
much time was occupied with communications dealing with the value of
the newer methods—phototherapy and X-ray therapy—compared with
that of the classic ones of multiple scarification, physical and chemical
cauterisation, &c., employed in the treatment of lupus.
While the older methods had strong support from more than one
authority of eminence, the consensus of opinion of those who had had
practical experience of the newer methods was that the Finsen method
gave the best results. The adverse opinion of that method was largely
determined by its costliness and the prolonged treatment involved.
Opinions with respect to the X-rays were in the main only in favour of
their exhibition as an adjuvant to phototherapy.
Electro - Therapeutical Section
85
In reviewing the results of 633 cases treated at the great Paris
Hospital of Saint-Louis, my friend and master, Professor Gaucher, said :
“ Phototherapy gives very good results in the two varieties of lupus. It
has the merit of giving in general beautiful cicatrices, but it is a long and
costly process, not within the reach of everybody, and it is not applic¬
able to every region, in particular to cavities and mucous membranes.
The Finsen method remains at present the best. Radiotherapy has an
analogous action, but more intense than phototherapy, upon tuberculous
lupus. It is more difficult to control.”
While everyone must admit the high value of the Finsen method, of
which the resulting cicatrix is unsurpassed from the aesthetic point of
view—in fact, from every point of view—yet anyone at all experienced
in phototherapy will have found that the great length of time involved
in the treatment of extensive lesions is a great drawback to its value. In
fact, in hospital practice a large number of cases are of such dimensions
that phototherapy would be an almost interminable process, and in many
instances an almost impracticable one from the social position of the
patient, who, unless accommodated in a hospital, would be unable to
attend until a cure was effected.
About two years ago I began to use the X-rays more frequently for the
treatment of lupus vulgaris with the object of diminishing the length of
treatment, and found it was possible to obtain in ulcerated and hyper¬
trophic cases a relatively rapid response, culminating in a smooth and
flexible cicatrix free from the disfiguring keloidal developments not infre¬
quently following treatment by some of the older methods.
Keeping in view two objects—relative shortness of treatment and
aesthetic effects—I have been employing for facial lesions a combined
method of treatment — i.e., cauterization and X-ray therapy—which, so
far, has given very encouraging results. In brief, the method is as
follows: If any crusts exist they are removed by the application of a
salicylated ointment. A tentative X-ray exposure of from three to five
minutes is made upon a small area of the lesion. In a few days the
X-rays are directed for from three to five minutes daily upon a somewhat
wider area of the lesion, unless contra-indicated, until the whole lesion
has been exposed some three or four times. It is then plastered with
Unna’s 50 per cent, salicylic acid and' creosote pflastermulle, which is
renewed daily. If its application be badly borne, the part is previously
swabbed with 10 per cent, to 20 per cent, solution of cocaine. In a
variable number of days—approximately about ten, and determined by
the individual case—it is found that much of the tuberculous tissue has
86
Tomkinson: Treatment by Cauterization
come away. The lesion is then swabbed with cocaine solution, dried,
and afterwards painted with the following preparation:—
—Ac. carbolici...
Ac. lactici
Ac. salicylici
Alcohol abs....
50 per cent.
15
15
20
»>
»»
(well agitated before application as there is a considerable sediment). A
few minutes afterwards the lesion is painted with the following solu¬
tion :—
—Ac. carbolici... ... ... ... 80 per cent.
Alcohol abs. ... ... ... ... 20 ,,
(the formula employed in Billet’s phenol method).
• In very extensive cases a part only of the lesion is cauterized, the
remainder being cauterized on one or more subsequent occasions. How¬
ever, a whole cheek may be done at one time. More than once I have
cauterized both cheeks and nose at one and the same time. I do not,
however, recommend such extensive cauterization on account of the
associated oedema, which it is well to avoid. After cauterization the part
is dressed for a day or two with sterilised lint and carbolic oil (1 in 30),
and, thereafter, with 20 per cent, aqueous solution of ichthyol until heal¬
ing—usually relatively rapid—has taken place; or in some instances the
application of the ichthyol solution is deferred until the lesion has been
replastered and recauterized, perhaps three or four times. After heal¬
ing in the manner just described, which may be accelerated by bathing
the part at the time of dressing with a little of the ichthyol solution, to
which 25 per cent, to 50 per cent, of methylated spirit has been added
(cocaine swabbing is indicated), X-ray treatment is recommenced, short
exposures of from three to five minutes—rarely longer—being made.
At the end of three or four months the treatment is discontinued for a
considerable time, during which the patient returns periodically for
inspection. At the end of this interval in the treatment—some months
in duration—the patient is submitted to the second course of treatment,
which is repeated after another interval if necessary.
It should be mentioned that the patient, during the interval just
referred to, is sometimes instructed to use a mercurial ointment or lotion,
also that it is usual, prior to the dressing of the lesion, to clean it up with
a solution of perchloride of mercury (1 in 500).
Whenever indicated, local treatment is supplemented by the exhibi¬
tion of haRmatinics, ol. morrhuse, and saline aperients, and a generous
diet and residence amidst hygienic surroundings are enjoined.
Electro-Therapeutical Section
87
With reference to the X-ray apparatus a 10 in. coil is used. The
diseased area is exposed at a distance of about in. from the anti¬
kathode of a medium to soft tube, while the parts not under treatment
are protected by a lead glass diaphragm to which funnels of the same
material and of various sizes, allowing exit to the rays, are attached.
This method is slightly varied in some cases, the most important
modification being the submitting of the lesion to the X-rays during the
period of plastering and cauterization, with, I think, better results.
Obviously this modification calls for the exercise of great caution.
What are the disadvantages, if any, in the employment of X-rays
in this method ? Too long and careless exposure may induce a radio¬
dermatitis, which, if severe, will not only occasion the patient consider¬
able pain, but prove extremely difficult to heal. It will be noted,
however, that the individual X-ray exposures are short. No attempt is
made to produce a radio-dermatitis, and the periods during which they
are exhibited are not over-prolonged. It is, I venture to think, by small
dosage and lengthy intervals of rest, and so attempting to prevent the
onset of cutaneous X-ray intolerance, that the best therapeutic action of
the X-rays in lupus vulgaris will be obtained.
(Here a series of photographs was shown.)
In a discussion at the annual meeting of the British Medical Associa¬
tion held at Exeter last August—in which I had the pleasure of taking part
—the question of epitheliomatous degeneration in lupus scars which had
been treated with the X-rays received some attention. While not
prepared to say it may not occur, I have not had as yet any case to
record. And in reference to this it should be borne in mind that
epitheliomatous degeneration in lupus scar tissue following other methods
of treatment is a generally recognised complication.
What may be said in recommendation of this method ? The aim in
treating facial lesions is obviously the production of a cicatrix approxi¬
mating in character to the normal skin; in other words, one which is
smooth and flexible and with no marked tendency to contract. The
caustic element in this treatment is by no means drastic and is little
calculated to produce vicious cicatrices. Indeed, in cases w’here cica¬
tricial hypertrophy existed (primary or the result of previous treatment)
marked diminution in the scar tissue was recorded, doubtless due in a
large degree to the influence of the X-rays, the tendency of which to
reduce keloidal tissue I have also observed in dermatitis papillaris
capillitii, the acne ch^loidienne of French authors.
The cicatrices resulting from this combined method of treatment are
88
Tomkinson: Treatment by Cauterization
smooth and flexible—a recommendation not to be ignored when deciding
upon the treatment to adopt in lupus affecting the various orifices; very
occasionally I have observed in them trifling telangiectases, and in one
or two cases I have noted a few pigmented spots.
Lupus secondary to tuberculous adenitis has responded well to this
treatment, largely due, no doubt, to the beneficial effects of the X-rays
upon the under lying primary affection. In non-ulcerative lupus vulgaris
it is suggested that the epidermis may to some extent interfere with the
therapeutic action of the X-rays upon the underlying corium. Assuming
such to be the case the action of the salicylic acid and creosote pflaster-
mulle is to remove this obstacle, while the action of the caustic prepara¬
tions is to shorten the period of treatment by direct caustic action and
the associated reaction of the tissues. All .the cases submitted to this
combined treatment have responded more or less favourably to its
exhibition. Its greatest recommendation, however, is the relative rapidity
of improvement in extensive lesions of an ulcerative or papillomatous
type, where usually after three months treatment a patient is enabled to
return in comfort to his occupation for a quite considerable time before
the commencement of a second course of treatment.
Many cases of markedly rebellious character and of many years
duration have yielded so well that one might hope, without being too
sanguine, that in some of them, at least, complete cessation of the
tuberculous process might ultimately be recorded.
DISCUSSION.
The President (Mr. W. Deane Butcher) considered that Dr. Tomkineon’s
treatment was a somewhat novel and energetic one: the lupus was attacked, as
it should be, on every side, with horse, foot, and artillery. He had hoped that
a cauterization method brought forward for the consideration of the Electro-
Therapeutical Section would have been a physical and not a chemical one.
Perhaps those who took part in the discussion would give their experience of
other methods of electrical cauterization, cauterization by means of high
frequency sparks and the like. Dr. de Keating Hart’s method of sideration
or fulguration by means of high frequency sparks was attracting some attention
in Paris at the present time. In this method of cauterization by high frequency
there appeared to be a selective action on the diseased tissue. The sparks
seemed, as it were, to seek out and destroy the diseased cells, sparing to some
extent the healthy tissue. The combination of cauterization with X-rays was
of very great importance, since the primary action of the X-rays was not a
destructive one. Some recent observations appeared to show that irradiation of
Electro- Therapeutical Section
89
the glands of the diseased area was followed by amelioration both of cancer and
lupus, even when the lesion itself was not irradiated. Mixed cases of lupus
and syphilis did admirably under X-ray treatment. In such cases the high
frequency spark as a means of cauterization had advantages over the salicylic or
other method of chemical cauterization. In slight cases the sideration might
be carried out without anaesthetics. The high frequency sparks appeared to
control bleeding, and there seemed to be a selective action upon the diseased
tissue without so much destruction of the healthy parts. He wished to draw
attention to the unsatisfactory results of surgical intervention in the removal of
the affected glands. If the glands were removed in lupus of the face or neck,
action of the X-rays was hindered and the chances of recovery were greatly
diminished.
Dr. DAVID Arthur said that he had greatly appreciated Dr. Tomkinson’s
paper, but he had imagined that, coming as Dr. Tomkinson did from a place like
Glasgow University, he would have considered the subject more thoroughly
from the pathological standpoint. The work of the X-ray department was
inclined to be too empirical. They did this and that and gave no reason for the
choice of a particular method. At least they should have a provisional
pathology; one that had to be altered would be better than none at all. He
suggested that instead of giving particulars as to the treatment of lupus by
cauterization and the X-rays they should apply themselves to considering the
question as to how the cauterization acted and how the X-rays acted. A most
fruitful subject for consideration would be the absorption of neoplasms by the
X-rays. They knew that if the X-ray treatment were pushed far enough the
cells of new tissue would all be absorbed or destroyed somehow or other. * Take,
for example, a pathological specimen of rodent ulcer; after treatment the
pathological conditions had gone. In his (Dr. Arthur’s) opinion the hyperaemia
produced by the X-rays gave rise to a localized leucocytosis, and the more
recent growths were absorbed in preference to the older and more developed
ones. There were several ways of producing cauterization—X-rays, high fre¬
quency sparks, or chemical cauteries—but if it was the case that the X-rays pro¬
duced a local leucocytosis in which the newer growths were more or less absorbed,
it would be best to produce the cautery action by that means. For some time
in his own cases he had been purposely producing a dermatitis as fast as he
could, and he had found that such a plan reduced the time of treatment by over
100 per cent. It was now quite a common thing to have cases heal twice as
quickly as heretofore. Now, a theory which might have to be modified was
better than no theory, and therefore he put forward his own view as to what
happened in such cases. A patient who had a port-wine naevus on the face
was treated by the X-rays ; a strong dermatitis was produced and the part
improved considerably in three sittings. A month or six weeks aftenvards it
had improved to such a remarkable extent that the patient thought he would
like to undergo another term of treatment in order that it might be removed
completely. But after the second series of X-ray applications it got worse
instead of better. The reason in his (Dr. Arthur’s) opinion was that the
90
Tomkinson: Treatment by Cauterization
dermatitis produced a certain amount of connective tissue. The second applica¬
tion of the X-rays in some way or other absorbed the connective tissue, and
therefore the lesion came back. His chief point was that it would be better to
spend more time with the microscope in studying the pathology of such cases
than to gather so many empirical ideas which might be right or might be wrong.
Dr. Ross (Naval Hospital, Chatham) said that he had been interested in
some remarks of Dr. Tomkinson’s with reference to syphilis in the Sendees.
He (Dr. Ross) had had a little experience with that disease as he was at present
stationed in a naval hospital. He had found X-rays useful in the treatment of
tertiary syphilitic affections of the skin, especially in those cases which were
obstinate to ordinary local applications and general treatment. In speaking of
his case of the girl who was treated for lupus vulgaris, Dr. Tomkinson did not,
he thought, lay sufficient stress upon the hereditary syphilitic element in the
case. Of course the element of lupus came in, but the syphilitic basis ought to
be taken into account. The fact that the cases yielded to the X-rays did not
disprove their syphilitic character. One of his own patients with a decided
syphilitic history was recently under treatment for ulceration and thickening of
alas and septum nasi. The lesion was apparently a specific one, but it did not
respond readily to antisyphilitic treatment. X-rays, however, rapidly affected
a cure. The lesion in this case was somewhat similar in appearance and
situation to that of the girl mentioned by Dr. Tomkinson. The photograph of
the girl, he thought, showed distinct traces of hereditary syphilis.
Dr. W. Ironside Bruce said that his own experience of the treatment of
lupus with the X-rays was somewhat limited, but he had been very much
interested in noticing that in some cases the continued irritation of the skin by
X-rays for the treatment of lupus resulted in the development of rodent ulcer.
He was of the opinion that the rodent ulcer had been produced as a result of
chronic X-ray dermatitis. If X-ray dermatitis could be prevented from occurring
the possibility after prolonged X-ray exposure of rodent ulcer appearing was not
likely. He knew of one case where without doubt after a prolonged exposure
to X-rays for lupus rodent ulcer made its appearance. He had been interested
to notice the length of time which Dr. Tomkinson allowed to elapse between
the exposures. He supposed that in exposing lupus in the ordinary way to the
X-rays one should allow a like period of rest to elapse between the exposures.
If Dr. Tomkinson had left his cases to the X-rays alone, could he have produced
the results he had described ? In any case, without cauterization what would
the results have been ?
Dr. J. Goodwin Tomkinson, in reply to the points raised in the course of
the discussion, and more particularly to Dr. Arthur’s remarks about Glasgow,
said that he must not sail under any false colours. Although he occupied the
position of assistant medical electrician at the Glasgow Western Infirmary,
he simply engaged in cutaneous work. With regard to the question of patho¬
logy, his object in using the combined method of treatment for lupus vulgaris
was solely to diminish the length of time spent in treatment. He had seen
j Electro-Therapeutical Section
91
many patients coming up repeatedly and having the Finsen treatment—the
lamps they used were the Finsen-Reyn and the modified French model, the
Lortet-Genoud—but making little or no progress. He therefore adopted a
mixed method of X-rays and cauterizations, (fee., with a view to diminishing the
length of treatment. Without being prejudiced in his own favour he thought
he could say that the results had been eminently satisfactory. In every
instance there had been palliation, and in some instances such great improve¬
ment that he was vain enough to hope that eventually there would be a cure.
He followed the other speakers with regard to the action of X-rays and caustics,
but on the matter of producing good cosmetic results by means of the X-rays
pushed to an extreme he took a different view. He had been at an institution
that day and had seen a case of lupus vulgaris that had been treated solely by
the X-rays. Six months ago the scar had considerable aisthetic value, to-day it
was simply a disfigurement. Now he could say that, except for an occasional
isolated telangiectatic dilatation or pigmented spot in one or two cases, he had
had good cosmetic results in every instance, and as things now stood he had not
a single scar that could be denominated as ugly. Some still retained tuberculous
nodules, but these wopjd again be treated, and in some instances he was hopeful
of obtaining a permanent cure. One could not be too guarded, however, in
speaking of tuberculous lesions, and he would not be at all surprised to see even
in his best scars tuberculous nodules eventually manifest themselves. But the
results, so far as one could judge at present, were highly satisfactory. Dr. Ross
had criticised two of the cases of which he had shown photographs. In the
case of the policeman, who was formerly in the Army, and who might have
been judged syphilitic, the patient had responded to tuberculin. For this he
had the testimony of the house surgeon who brought him the case. That in
itself, he thought, was a sufficient proof that the lesion was a tuberculous one,
although the character of the lesion had suggested the possibility of tertiary
syphilis. Careful examination, however, confirmed by previous tuberculin
treatment, indubitably pointed to its tuberculous nature. With respect to the
girl, obviously the face was that of a congenital syphilitic. The depressed bridge
of the nose and the linear scarring about the mouth pointed to a syphilitic basis.
Nevertheless, the lesion was conclusively a tuberculous one. The case was
sent to the Western Infirmary by a physician from one of the Glasgow hospitals
as lupus vulgaris and he confirmed his diagnosis. He wished to join issue with
Dr. Ross in regard to some of these (Dr. Ross’s own) cases. Dr. Ross had re¬
marked that in one of his cases while there was no response on the part of the
lesions to syphilitic treatment, there was a marked response to X-rays. He (Dr.
Tomkinson) was inclined to think that the response to the X-rays pointed to
the lesion being of a tuberculous nature. If a syphilitic lesion, he felt sure that
a course of syphilitic treatment would have cleared it up. Thorough—that is
properly administered—antisyphilitic treatment would be sufficient. If syphilitic
treatment was pushed far enough even those terrible cases which the French
called syphilis vutligne responded to a greater or lesser degree. In reply to
Dr. Bruce, he had not attempted in many cases the form of treatment which
92
Pirie : Electrolytic Method of. Measuring X-rays
consisted of short exposures of X-rays without cauterization followed by a
period of rest. He had seen lupus vulgaris of the ulcerative type improve very
rapidly under the X-ray treatment alone ; other cases were very obstinate.
His theory with regard to non-ulcerative lupus (and rebellious cases were of
that type) and the X-rays—and at this period in the history of radiotherapy
he had no definite opinion about the action of X-rays, consequently he used
them very carefully—was that lupus vulgaris of non-ulcerative type left the
epithelium relatively uninvolved and manifested itself in the corium. The
epithelium probably interfered with the penetration of the rays from a them -
peutic point of view, and afforded a certain amount of resistance to them.
Therefore he used this mixed method, which caused the breaking down of the
epithelium and destruction of much tuberculous tissue, and allowed the rays to
have free penetration to the corium, and he ventured to think—indeed, experi¬
ence had proved—that his results were very much better than those which
would be obtained by the use of the X-rays alone. That, however, was a
matter rather for the medical electrician pure and simple to pronounce upon
than himself. His work had been necessarily somewhat empirical, as it would
\ie until he had formed a definite opinion as to the exact, nature of the action
of the X-rays, but nevertheless it had been productive of very good results.
The Electrolytic Method of Measuring X-rays.
By Howard Pirie, M.D.
In the production of X-rays in a Crookes* tube the law of conserva¬
tion of energy goes on in the same way as in an incandescent lamp. In
each case so much electric energy is supplied and so much work is done.
In the case of the incandescent lamp, the energy is transformed princi¬
pally into heat and light. By increasing the energy supplied to the
lamp, more heat and light are given out. There is, however, a change
in the wave length of the light given out—a small supply of energy
giving a yellow light and a large supply a white light.
The analogy of the incandescent lamp can be applied to the X-ray
tube. When electrical energy is supplied to an X-ray tube, it is trans¬
formed into kathode rays, heat, vibration, phosphorescence, light, and,
secondarily, X-rays.
The main part of the electrical energy, however, is transformed into
heat and kathode rays.
According to the efficiency of the X-ray tube, the proportion of
X-rays to heat varies just as in an incandescent lamp the proportion of
heat to light varies.
Electro-Therapeutical ftection
93
In an Osram lamp the proportion of light to heat is greater than in
an old carbon filament lamp; so in a good water-cooled X-ray tube the
proportion of X-rays to heat is greater than in a badly made light anode
X-ray tube.
But no matter what the tube is, it remains as a transformer of
energy, and follows the law of the conservation of energy. This is the
principle on which I have founded the electrolytic method of measuring
X-rays, and it may be stated thus: “ The output of X-rays from an
X-ray tube varies according to the watts supplied to the tube.”
Thus I imagine a tube supplied by a current of 20,000 volts and
1 ma. gives out the same amount of X-rays as measured by a Sabour-
aud’s pastille as the same tube supplied by a current of 40,000 volts
and J ma. Kelvin’s electrostatic voltmeter could be used to tell the
exact voltage, but for practical purposes the equivalent spark gap is
used, and for the same coil probably varies directly as the voltage.
To measure the quantity of current that flows through the X-ray
tube I have devised this meter. It is a capillary tube with 100 divi¬
sions. Each division is 1—200 c.c. One end of the capillary tube is
open and the other terminates in a dilatation. Through the walls of
the dilatation penetrate two platinum wires. The dilatation is filled
with tap water, and a drop (called the indicator drop) is left in the
capillary tube. This meter is put in series with the X-ray tube, and
as the current flows through the meter it decomposes the water into
oxygen and hydrogen. These gases collect in the bulb and make the
indicator drop rise. The number of divisions registered is a measure of
the quantity of electricity that has flowed through the X-ray tube. ' If
a constant current of 1 ma. is made to flow through this meter for ten
minutes, it liberates 22 divisions of gas at 60° F. (while at 70° F. 22*4
divisions are liberated). Practically the same result is got when the
meter is used in series with an X-ray tube. The difficulty is to keep
the milliamperemeter constant at 1 ma.
Now if the equivalent spark gap remains constant at, say, 6 in.,
while the meter registers 22 divisions, we have two figures which, when
multiplied together, are a measure of the electrical energy supplied to
the X-ray tube, for the equivalent spark gap represents volts and the
divisions of the meter represent milliamperes and time.
As the voltage and milliamperage vary, so the output of X-rays
varies. For example, in the three following experiments the same tube
was used with the following results: When the equivalent spark gap
was 6 in. and 10 divisions were registered on the meter, then (10 by (5
94
Pirie: Electrolytic Method of Measuring X-rays
equals 60) the B tint was shown by Sabouraud’s pastille. When the
equivalent spark gap was 4£ in. and 13 divisions were registered, the
pastille turned to the B tint (4£ by 13 equals 58£). When the equiva¬
lent spark gap was 2£ in., 24 divisions were required to turn the pastille
to the B tint.
E. S. G.
Divisions on Meter
Constant
Sabouraud’s disc
6
10
GO
B tint
44
13
58J
24
GO
B „
In each case the same quantity of electrical energy was supplied to
the tube and the same quantity of X-rays emitted as measured by
Sabouraud’s pastille. The judgment of the colour w’as usually done by
my wife, who gave her opinion without bias as she was not interested in
the experiment. The difficulty of getting a tube to remain constant at
one equivalent spark gap is overcome by taking the spark gap for every
division of the meter and adding up the sum, thus :—
E. S. G. 10$
E. S. G. 104
E. S. G. 10
E. S. G. 0}
E. S. G. 94
Meter 1 division equals 10.J
„ 1 „ „ 10i
M 1 „ 10
>• 1 >» »» 04
„ 1 „ „ 94
Total 50
X-ray tubes vary in their efficiency, and for this electrolytic method
they must be standardized. For this purpose place a Sabouraud’s
pastille 2 cm. from the wall of the tube, mounted on metal and shaded
from light. Let the X-rays fall on the pastille and at the same time
note the equivalent spark gap in inches and the number of divisions
registered by the meter. Suppose the pastille turns to the B tint when
15 divisions have collected, and the equivalent spark gap is 4; then
multiply 15 by 4, and you get 60 as the constant for the tube. I have
found for several tubes that the square of the distance in centimeters
from the source of the rays to the pastille is the constant for the tube.
Thus a tube of 6 cm. radius has in general a constant of 8 by 8
equals 64; but this is only approximate, and each tube must be
stardardized against a pastille or other standard of measurement. I have
found this true for a water-cooled tube, a Bauer tube and a light anode
Muller tube. In using the meter care must be taken that the reverse
current is suppressed, that there is no leak to earth, and that no current
is allowed to pass through the meter which does not also produce X-rays.
Electro - Therapeu tical Section
95
For instance, there must be no sparking of the softening apparatus
in a Muller tube. To reach its present form this meter has gone through
several changes. My first difficulty was that the bulb was made too
small, and a heating effect was produced by the passage of the current
through the water. This is avoided by making the bulb larger and
adding a little salt to the water. The next difficulty was with the
platinum electrodes in the bulb. When they were brought close to¬
gether in order to reduce the resistance and consequent heating of the
water, I found that instead of flowing through the water and causing
electrolysis, the electricity preferred to jump from one electrode to the
other in the form of a spark. 1 In fact, the meter once exploded from a
spark, thus passing and igniting the mixed gases. I therefore increased
the size of the electrodes and brought them close together. With a
meter made thus I found that, after stopping an X-ray experiment, the
meter kept on registering for the next few hours, and I concluded that
the platinum of the negative electrode was giving up the hydrogen it had
absorbed while the current was passing.
In order to set the indicator drop at zero, I expanded the free end
of the capillary tube so that when the drop reached the free end it was
expanded into a bubble, which, on bursting, ran down the sides of the
tube and was caught at a constriction at the zero point. This has also
been abandoned, as a fresh drop can always be put in position by giving
the meter a gentle shake. A lady’s hat pin can be passed down the
tube to alter the position of a drop. A small piece of cotton wool should
be kept in the cup at the top of the meter. The meter is filled in the
first instance by means of a capillary pipette, made by drawing out a
piece of glass tubing after heating it in a Bunsen. To anyone using
this meter for the first time I would advise the following : Use a tube that
remains constant with an equivalent spark gap of 4 in. to 5 in. An Osmo
regulating tube is preferable, as there is no necessity to disconnect the
meter while softening the tube. The meter must be disconnected when
softening a Muller tube. Several experiments should be made with a
Sabouraud pastille in order to standardize the tube. When a spark
passes about every ten minutes across the equivalent spark gap, one
should consider that the true equivalent spark gap is being measured.
Do not attempt to use the meter with a tube which varies its equivalent
spark gap quickly. Read the meter directly the experiment is finished,
1 With an equivalent spark gap of 10 in., and using London tap water, I found the current
preferred to go round the outside of the bulb of the meter in the form of a spark rather than
through the water. The addition of a little salt to the water at once stopped this.
96
Pirie: Electrolytic Method of Measuring X-rays
as the hydrogen and oxygen will slowly diffuse through the indicator
drop and so alter its position. The indicator drop usually falls one or
two degrees after a few hours.
I have used this meter now for a year and shall show you some of
the results of treatment by means of it. For practical use I have found
I can quickly train a nurse to read the meter, measure the spark gap, and
multiply the two numbers together. She uses a Butcher’s shield and a
tube which I have standardised, and I tell her to give the patient so
many units.
Arrangement of Apparatus for using Dr. Pirie’s meter
for measuring X-rays.
Estimation of Reverse Current.
I estimated the reverse current passing through an X-ray tube by
means of electrolysis as follows:—
I arranged an apparatus as follows : I cut the positive wire between
the coil and the X-ray tube. I connected the broken ends to platinum
wires, and passed these platinum wires into a glass vessel containing tap
water. Over each platinum terminal in the water I placed a eudiometer
(which I show you) filled with water, so that when the current flowed
through the water each eudiometer collected all the gas given off at that
terminal. The eudiometers were divided into 1—100 c.c. divisions.
When the apparatus was thus prepared I passed a current through the
X-ray tube. As soon as the current flowed, hubbies of gas came off from
the platinum terminals. These bubbles collected at the top of the eudio¬
meter tubes. After collecting a quantity of gas in each eudiometer tube
Electro-Therapeutical Section
97
I noted the quantity. Theoretically one eudiometer should have collected
twice the amount of gas the other had. Practically it was never so.
There were tw r o reasons for this :—
(1) Oxygen is more soluble in water than hydrogen is.
(2) Each eudiometer contained a mixture of oxygen and hydrogen,
due to the passage of reverse current. However, one eudiometer always
contained much more gas than the other, and I took the one with the
greater quantity of gas as if it was pure hydrogen and mixed it with
more than half its volume of oxygen. I then exploded the mixture by
means of a spark from the coil passing between two platinum wires
sealed into the top of the eudiometer. I allowed water to take the place
of the exploded gas and noted the volume of gas left, from which the
percentage of reverse current can be calculated. These are the figures of
such an experiment. Using a very soft tube, with equivalent spark gap
of 3 cm., I collected 23‘3 divisions of gas supposed to be hydrogen; with
this I mixed pure oxygen, making a total volume of 41 divisions of
mixed gas. I then exploded the mixture and a volume of 9 divisions
remained. Therefore (41 - 9) 32 divisions of oxygen and hydrogen had
combined, leaving 9 divisions of oxygen unexploded. There had there¬
fore been 10*6 divisions of oxygen and 21*3 of hydrogen previously
present. But I had collected in the first instance 23*3 divisions of gas
supposed to be hydrogen, and I found by explosion there had only been
actually present 21*3 divisions of hydrogen. Therefore the difference of
1*96 must have been oxygen. But oxygen takes twice as long as hydro¬
gen to collect, and therefore 3*93 divisions of hydrogen would have
collected in the time that 1*96 divisions of oxygen collected; and had
there been no reverse current I would have collected 25*23 divisions of
hydrogen instead of 23*3.
Let 100 = total time current flowed.
,, x = time of direct current.
Then __, 84-4
100 21-3 + 1-96 x 2 25-26
84*4 per cent, of the current was direct and therefore 15-6 per cent, was inverse.
I then turned to the other eudiometer and treated it in the same way,
and found 16*2 per cent, of reverse current had passed. This error of
0*7 per cent, with such small quantities used is, I think, excusable. I
expected to find a large reverse current in this experiment, as I was using
a very soft tube and no valve tube. On using a valve tube I found no
98 Pirie: Electrolytic Method of Measuring X-rays
reverse current was passing when using this electrolytic method. An
actual experiment with a valve tube was as follows: I collected 42'2
divisions supposed to be hydrogen, and mixed this with 54 8 divisions of
pure oxygen. Total, 97. I then exploded the mixture and found 33'2
divisions remained; therefore (97 — 33'2) 63'8 divisions of gas had united
to form water, of which 21'26 was oxygen and 42 53 hydrogen. But I
started with 42‘2 divisions supposed to be hydrogen. There had been no
reverse current, and my error of 0'3 accounts for the difference. Other
experiments are reported in the tables.
To SHOW THE VALUE OP A VALVE TUBE AS A RECTIFIER.
Gas collected,
supposed to be
hydrogen
- 1
Pure oxygen
added
Total of mixed
gas
Gas left after
explosion
Actual amount
of hydrogen
present
previous to
explosion
Per cent, of
inverse current
(A) 42 2
54*8
97*0
Explosion
j 33*2
42*52
Nil
(B) 23-3
1G-7
41-0
90
21-2
1G-2
(C) 21*3 i
15-9
37*2
7*2
19*86
i
11-5
TO SHOW THE VALUE OF A VALVE TUBE AS A RECTIFIER.
Gas collected,
supiK»sed to be
oxygen
Pure hydrogen
added
Total of mixed
gas
Gas left after
explosion
Actual amount
of oxygen
preseut
previous to
explosiou
Percent of
inverse current
(A) 87
21-5
302
4-2
i 86
Nil
(B) 10-5
22*5
33 0
Explosion
11-5
7-16
15 9
(C) 9-8
27-2
37 0
11-7
8*43
7-5
In the first experiment (A) (A) a valve tube was used, and the equivalent spark gap was
3 in. to 4 in. In the second experiment (B) (B) no valve tube was used, and the equivalent spark
gap was 1^ in. In the third experiment (C) (G) no valve tube was used, and the equivalent
spark gap was 3 in. to 4 in. There is an experimental error of not more than 4 per cent, iu this
last experiment.
Electro - Therapeu tical Section
99
DISCUSSION.
The PRESIDENT (Mr. Deane Butcher) remarked that Dr. Piiie had shown
once more that the quantity of the X-rays proceeding from a focus tube was a
function of two things—the voltage and the milliamperage. His method was
exceedingly useful for measuring a fractional dose. There was at present no
means of measuring satisfactorily a fractional part of Sabouraud and Noir6’s
dose save by Dr. Pirie’s instrument.
Dr. N. S. FlNZl said that he had worked with one of the older forms of
Dr. Pirie’s instrument, one in which the platinum wires came very close
together. When he held the bulb in his hand for thirty seconds the indicator
immediately rose about two or three degrees. That was a fallacy which could
be overcome by using as small a bubble of air as possible by filling the bulb with
water almost up to the point where the readings started. He found the instru¬
ment very useful indeed, given an X-ray tube that kept its vacuum fairly
constant. It was then easy to gauge the number of divisions necessary to
produce the requisite dose. But when the worker had an X-ray tube that
varied its vacuum, as a great many X-ray tubes did, he would find that a
comparatively small difference of 1 in. or 2 in. in the alternate spark gap made a
very great difference in the reading of the instrument. With tubes giving from
4 in. to 6 in. alternate spark gap the readings were fairly constant, but above
6 in. their constancy could not be relied upon. He agreed with the President
as to the extreme value of the instrument for partial exposures.
Dr. Reginald Morton asked Dr. Pirie whether his meter was an index of
the value of an X-ray tube for radiographic purposes. Dr. Pirie had provided a
good opportunity for raising the question as to the relative condition of tubes.
He (Dr. Morton) had never been satisfied that there was any real difference
within certain limits between the tube used for radiographic purposes and the
tube used for treatment. He took it that for any given expenditure of energy
in an X-ray tube the tubes that were moderately alike gave approximately the
same therapeutic results. He had two tubes, not indeed by the same maker,
but their resistance as judged by the alternate spark gap was in each case about
44 in. One was a Chabaud and the other was a Muller. There was not a
very large difference in the size of the tubes, but with identically the same
current they gave quite a different screen. With the Chabaud it was possible
to obtain a perfect radiogram of the kidney showing all the transverse process.
In some cases the outline of the kidney could be seen quite unmistakably when
the plate came fresh out of the fixing bath. But with the Muller tube, using
the same diaphragm and the same distance from the anti-kathode, no decent
radiograph could be obtained at all. Did Dr. Pirie consider that an X-ray tube
working under a certain constant ought to be of equal value for radiographic and
therapeutic purposes ? Why was it that he obtained these divergent results
from the same tube or from different tubes working under precisely the same
conditions ?
a —6
100 Pirie: Electrolytic Method of Measuring X-rays
Dr. W. IRONSIDE Bruce said that he considered Dr. Pirie’s method of
measuring the X-rays an excellent one, and would take the first opportunity of
putting it to the test. He suggested that the difficulty of absorption of gas
by the electrodes to which allusion had been made might to some extent be
obviated by collecting gas for measurement purposes from one electrode only,
namely, the one at which least absorption takes place. The gas from the other
electrode might be allowed to escape, and thus the danger of explosions would
also be removed. The trouble in getting a tube with a mica regulator to work
with Dr. Pirie’s meter might be solved by bringing it close up to the kathode of
the tube. The instrument was an exceedingly clever one, and was likely to prove
useful in the hands of X-ray workers.
Dr. A. H. Pirie, in reply,, admitted that there was at present no exact way
of measuring the X-rays ; his instrument was made simply to serve for practical
purposes. He found it difficult in some cases to register tubes which were above
6 in. spark gap. Other tubes would be quite constant with a spark gap of
10£ in. In answer to Dr. Morton, he said that 10 X on the Kienboch apparatus
equalled Sabouraud and Noir6’s B tint. If he produced the B tint in 50 units
of his own measurement, the Kienboch measurement of 10 X would at the
same time be produced. He expected that in order to produce a photographic
result equal to 10 X with Kienboch the Chabaud w T ould show about 50 units
of measurement and the Muller about 120. One tube was not such a good
transformer as the other, just in the same way as some coils were less efficient
than other patterns. There was a limit to the output of rays irrespective of the
character of the tube on the same principle as, no matter how much petrol was
supplied to a motor car, it could not exceed a certain speed. The difficulty
respecting absorption had been overcome by making the platinum point a tiny
one, but he thought that it would be very difficult to put the meter so close
up to the X-ray tube as had been suggested. He added his thanks to Messrs.
Watson and Son for providing the apparatus.
ElectroGberapeutical Section.
April 24, 1908.
Mr. W. Deane Butcher, President of the Section, in the Chair.
The Electrical Treatment of Atonic Conditions of the
Digestive System.
By Reginald Morton, M.D.
The frequency with which atonic disorders of the digestive system .
are met with in medical practice makes the question of their treatment
one of almost universal interest. Like all other fairly common disorders,
the list of suggested remedies is large, and each one has its trusted advo¬
cates. It is not the purpose of this paper to discuss treatment by
drugs and diet, and their respective merits; these are more or less
generally known and need not detain us, except to point out that the
question of diet is all-important in every case and to remind you that
in the majority of cases the action of electricity is not so rapid that you
can afford to discontinue drugs, e.g ., laxatives, entirely and at once.
Cases of atonic dyspepsia or constipation due to atony of the colon have
always been under a more or less prolonged course of treatment, and,
whatever electrical method is employed, I always insist on the laxatives,
&c., being continued as before. They are to be reduced in amount
gradually as improvement sets in. For convenience I divide cases of
atonic dyspepsia and constipation into two main classes:—
(1) Due to defective innervation—neurosis.
( 4 2) True atony of the muscular coat of the digestive canal.
In the first class the muscular coat is, presumably, not at fault, and
it is to the nervous system that we must direct our energies. For
this purpose almost any form of electricity may be tried, and with
equally successful results, preference being given, in my opinion, to the
my —5
102 Morton: Electrical Treatment of Digestive System
more stimulating forms, such as the induction coil currents and the
sinusoidal current from the main, or from a machine made for this
purpose where the alternating current is not available. In many of
these cases the moral effect is one of some importance, and for this
reason good results are sometimes obtained from static electricity or
high frequency currents, which may be more or less locally applied.
The constant current alone I do not consider to be of much good, but
in conjunction with the coil—the de Watteville current, as it is some¬
times called—it seems to be a very useful method, and one that has
achieved good results in the hands of some workers (Mangelsdorf,
Archives of Rontgen Ray , April, 1907).
Mangelsdorf also claims to have obtained good results in the more
severe cases of true atony of the muscular coat, but my experience does
not bear this out. Provided one can remove any mental or psycho¬
logical element that may be present in cases of this class the treatment
becomes a comparatively simple matter, and one or other of the electrical
methods mentioned will nearly always bring about a cure.
When we come to deal with cases of the second class we are brought
up against an entirely different problem, and one that will tax our
resources to the utmost—as, indeed, it probably has that of the medical
man who refers the case to us. Here we have to deal with an organ
whose muscular coat has undergone atonic changes, perhaps to an
extent almost amounting to degeneration. Regulation of diet has little
effect, and drugs afford but temporary relief. Massage will have been
tried with but slight success for reasons which are more or less obvious.
At the same time I do not mean to say that these methods are by
any means useless, but rather that we should use electricity as an
additional agent in many cases and, as I have already said, only reduce
the amount of drugs as the case shows signs of undoubted improvement.
In my opinion the person who sets out to treat a severe case of this
kind with electricity only will most likely be disappointed, chiefly on
account of the slowness with which the improvement is brought about.
From the very nature of the disease, it is unreasonable to expect that
any remedy can bring about a rapid cure.
Having a case of this kind to treat, the question arises : What
are we going to do for it in the way of electrical applications ? Every
form of this agent has been tried at one time or another, and so long as
this was confined to the more ordinary forms, such as constant and
faradic currents, no very great success was attained—so little, indeed,
that until quite recently most writers on gastro-intestinal disorders
Electro - Therapeutical Section
103
have ignored electricity when discussing modes of treatment. That
tjhis should be so is not surprising. It is difficult to see how the use of
the constant current could do very much; it is insufficiently stimulating,
and its application in sufficiently large currents to materially influence
the muscular coat of the digestive organs is attended by the risk of
severe burns, due to the deposition of electrolytic products in the skin.
Then take the induction coil currents—primary or secondary—as
ordinarily used; I consider the rate of interruption much too fast to
benefit the muscular tissue directly.
In the case of degeneration in a voluntary muscle, as is well known,
no reaction takes place when an ordinary faradic current is applied unless
the interrupter is set to work very slowly; the muscle can also be made
to contract rhythmically to the constant current if it be made and broken
equally slowly. The greater the degree of degeneration the less frequent
must be the interruptions if the muscle is to respond to each.
In unstriped muscle we have normally, to electrical impulses, a pro¬
longed latent period and a prolonged period of contraction. In a state of
atony these are increased and the condition, in my opinion, comes to
resemble somewhat that of a voluntary muscle in a state of degeneration.
Hence I consider ordinary faradic current to be unsuitable both from the
rapidity of its interruptions and the small density of current that could
be obtained, or used if obtainable. We must not forget that we can
reach the intestinal muscle only through the more superficial voluntary
muscles of the abdominal walls, which are necessarily thrown into con¬
traction, and this latter becomes unbearable to the patient if the current
density is at all high. The same objections apply to the sinusoidal
current at the frequencies ordinarily supplied, from 40 to 100 cycles
per second. While it is possible to set the interrupter of an induction
coil to work very slowly, even then only a comparatively small current
density can be employed owing to the painful nature of the contractions
produced when this is large. This is, of course, mainly due to the
inherent qualities of the current itself, notably to the very sudden rise
of potential at each break of the primary circuit.
From what has been said it will be seen that what we require is a
current of large magnitude, in view of the large mass of the abdominal
contents to be treated, and one that will vary this magnitude sufficiently
rapidly to cause the muscular coat of the intestine to contract and yet
slowly enough to allow a contraction to be completed and relaxed before
another is induced. It must also be practically free from the deposition
of electrolytic products in the skin to any possibly harmful degree.
my — 5 a
104 Morton: Electrical Treatment of Digestive System
These conditions are met very completely by a sinusoidal current of very
low frequency.
In a paper on this subject which it was my privilege to read before
the Electro-Therapeutical Section of the annual meeting of the British
Medical Association at Exeter last July, I then referred to what I called,
for the want of a better term, the “ periodic time " of a muscle, and by
this I mean the length of time taken by any given muscle in passing
through the various phases which follow the application of an electrical
impulse. These phases are: (a) the latent period ; (6) the period of
contraction; (c) the period of relaxation; the sum of the three con¬
stituting what I have termed the “ periodic time ” of the muscle. I
feel sure that this is a matter that will become increasingly important
in the future, both as regards diagnosis and treatment. Its practical
application here lies in the fact that it gives us a clue as to the proper
frequency to be employed in any given case. The time interval between
the cycles of the current should not exceed the “ periodic time ” of the
muscle. While it is not possible to determine the 41 periodic time ” of
the muscular coat of our patient’s intestine by actual experiment it is
found, as a matter of practical experience with degeneration in a super¬
ficial voluntary muscle, that it is only in the more severe cases that the
muscle makes no attempt to keep time with a current having a frequency
of one cycle per second, and this frequency, I may say, is very suitable for
the great majority of cases. I have been frequently asked if a three-
phase current is necessary or has any advantages over a single-phase
current. So long as the frequency is sufficiently low it matters little
which is used.
The method of application is practically the same for all cases. I
use three electrodes : one on each side of the lumbar spine and the third
on the anterior abdominal wall if the epigastrium of the stomach is the
part chiefly at fault, or over the course of the colon if the case is one of
constipation, commencing at the caecum and working gradually around
in the direction of the hands of a clock. If the rectum is at fault a rectal
electrode must be used, but not a bare metal one—it must be covered
with membrane and water-jacketed, so to speak. A certain amount of
electrolytic products are set free owing to the rapid diffusion of the
current, and these become objectionable when bare metal is placed in
contact with living tissues. If a single-phase current is being used the
two posterior electrodes are joined to the same terminal. With a three-
phase current the three electrodes are attached one to each of the three
terminals of the apparatus. The duration of the applications is at first
Electro-Therapeutical Section
105
from ten to fifteen minutes, and the current strength just enough to cause
gentle contraction of the abdominal muscles.
The length of the application and the strength of the current are
both increased on subsequent occasions, so that by the fourth or fifth the
duration is thirty minutes and the current strength sufficient to cause
strong contractions of the muscles of the anterior abdominal wall. This
must be continued three times a week for a month or six weeks, or more.
I will not take up your time by relating the details of the several
cases I have treated. There is a great sameness among them all, and I
can only say that in all those where the treatment has been regularly
attended to for a sufficient time great improvement has taken place in
the general health and in the local condition, so much so that the
patients have in most cases voluntarily assured me that it had been well
worth the time and trouble entailed.
The great difficulty is to get the patients to come regularly for a
sufficiently long time. Very often they are only too ready to throw it
up for some trivial excuse. This and the length of time required are
the chief drawbacks to the method. But as regards time I ask: What
other method gives better results ?
Before closing I should like to say something about the best means
of generating the current I am advocating. Personally I use a large
motor dynamo which has collecting rings connected to the commutator
on the motor side and allows one to take oft a three-phase alternating
current, and the armature is made to revolve slowly by means of a resist¬
ance in series, the field magnets being maintained at full magnetism.
A large machine is preferable to a small one, however the latter may
be arranged. The larger one is not so easily disturbed by small fluctua¬
tions in the current supplied to, or taken from, its armature, while its
weight, bearings and friction of brushes provide a light but steady
mechanical load, which is a great advantage.
Machines of small size, and made to run slowly by means of a friction
brake, have been in use but have not proved satisfactory in practice
owing to their tendency to rotate unevenly. Mr. Schall has got out a
motor of comparatively small size, arranged with collecting rings, and
supplying the primaries of three sledge coils. The patient is put in
circuit with the secondaries of these sledge coils.
With my large machine I use the same method of regulation, as it
seems to be the best; the regulation is very fine and the patient is
effectually cut off from the main current, so that there is no danger of
his getting shocks through touching anything connected to earth.
106 Morton: Electrical Treatment of Digestive System
While this paper has for its main object the treatment of atonic
conditions of the digestive system I would like to point out, before I
finish, that this slow sinusoidal current will be found invaluable in the
treatment of every condition where atony or degeneration of muscular
tissue is the chief factor. Furthermore, having at hand an alternating
or pulsating current of a frequency which is variable from one cycle in
two seconds to, say, ten per second, and a means of ascertaining the
frequency at any given moment, I foresee a method of expressing the
degrees of degeneration in muscular tissue in a numerical form, and,
according to the highest number of impulses per second or per minute
to which the muscle will rhythmically respond, we shall be able to
obtain a better idea of the degree of degeneration existing in different
cases and of the progress of any given case. I hope to have something
to say on this point at a future date.
DISCUSSION.
The President (Mr. Deane Butcher) expressed the thanks of the Section
for Dr. Morton’s interesting communication, which had been prepared at some
disadvantage and at short notice. The modes of electrical treatment he
regarded as threefold: first the gymnastic exercise of the abdominal muscles,
next a sort of electrical massage, thirdly, galvanization, which was an
important means of influencing the nutrition of the digestive organs. He had
seen cases in which galvanization alone had been of great assistance. The
de Watteville currents were occasionally of much benefit, and appeared to act
on the nervous rather than on the muscular mechanism. The galvanic current
was indicated in disorders of digestion, the de Watteville current for nervous
disorders, such as palpitation of the heart, and the triphasic current or some
form of slow intermittency for the necessary massage and exercise of the
muscles of the abdominal wall, which were generally in a very relaxed con¬
dition. Another point was the production of local hypersemia, which was
of great importance in such cases. It was probable that the constant current
might act in this way, like a hot fomentation or* mustard plaster. He had
been pleased to hear Dr. Morton allude to the question of the periodic time,
as it was one which would well repay study. Leduc had shown that the
production of electrical sleep was due to the synchronizing of the electric
oscillation with the natural periodic time of the animal’s nervous system.
The stimulation, the soothing, or the inhibition of the neurons depended on
the periodicity of the electrical stimulus.
Elec tro - Therapeutical Sec t ion
107
Dr. Lewis Jones said it appeared probable that the simple galvanic and
iaradic currents were likely to be displaced in treatment by the use of rhythmic
currents of one kind or another. He appreciated Dr. Morton’s paper as a step
in the right direction. No doubt there were several forms of current which
might be employed in the treatment of conditions for which simple galvaniza¬
tion or faradization were more or less unsatisfactory. There were the long
waves of simple sinusoidal type, which Dr. Morton had particularly dealt with
in his paper, and which appeared specially useful for stimulating such structures
as unstriped muscles or striped muscle in a state of degeneration. Another
form of rhythmic current treatment was to use, not single waves, but groups
of short waves, commencing with very small impulses, growing into large ones,
and then dying away again, followed by a period of rest, and then to
repeat the cycle. That form of current was rather more easy to produce
if one had at hand the ordinary sinusoidal current of the alternating current
electric lighting mains, or it could be obtained from a small motor generator.
An apparatus was in use at St. Bartholomew’s Hospital which some of the
members present might have seen, namely, a mechanical motor-driven device
in which a secondary coil was caused to move to and fro over a primary, which
was supplied by current from an alternating source. Another device which he
had had in use for a long time consisted of a little clockwork arrangement,
which was used as follows: The clockwork moved an arm up and down, and
that arm carried a wire, which dipped into a beaker of water, at the bottom
of which a metal plate was fitted. In order to produce a better graduation
of current between the zero and the maximum, it was found very convenient
to have an inverted glass funnel standing in the water. Under those con¬
ditions the wire, in its excursion downwards, not only approached the other
plate so as to reduce the length of the electrolyte through which the current
had to flow, but also passed from a narrow channel of electrolyte in the narrow
neck of the funnel into a progressively larger area as it descended, so that the
variation in the resistance of the electrolytic part of the circuit was consider¬
ably greater than would have been the case without the funnel. That was an
apparatus which could easily be made with the aid of a piece of cheap clock¬
work, and the results to be obtained by it were quite satisfactory. The whole
subject of interrupted currents was in need of re-examination from beginning
to end. He was sure that the interrupted currents generally used had too
high a periodicity, mainly, he thought, because the induction coil was the usual
source, and it was an apparatus which generally gave currents of rapid fre¬
quency. But for almost all treatment he was sure that waves of current which
were shorter than those of the induction coil would be better.
Dr. BUCKLEY (Buxton) said he had been very much interested in the
treatment of atonic conditions of the gastro-intestinal system for many years,
but, as he practised in a health resort, the number of patients who had come
his way, and w r ere willing to spend any length of time on the treatment, had
l>een small, and it was out of the question for him to obtain such apparatus
as had been described. Galvanism, as the President had mentioned, was
108 Morton: Electrical Treatment of Digestive System
perhaps not to be entirely overshadowed by sinusoidal currents. But the kind
of galvanization which he (Dr. Buckley) had used had been the galvanic cur¬
rent interrupted by hand, at a frequency averaging from 10 to 20 per minute,
and he believed he had obtained good results, though it was always possible
to deceive one’s self. A large number of his cases were those in which neurosis
was a well-marked feature, but in many there seemed to be genuine muscular
atony also ; indeed, many cases of muscular atony, he believed, started as
neurosis. There was a broad group of cases of dilated colon, perhaps dilated
rectum, generally constipation, or marked mucous colitis, to which he had
been applying the constant current by inserting a douche electrode into the
rectum. From the difficulty he had in obtaining such an electrode, he assumed
that the method was not common. It w r as a gum-elastic vaginal douche pipe,
in the interior of which ran a coiled wire, the pipe being perforated at various
parts to allow of the escape of the electricity. A pint or more of normal saline
solution was put into the rectum, and, the douche being cut off, the current
was turned on. In that way there was a large water electrode in the rectum,
and higher currents could be used than without it, for though he had seen
ulcers produced on the abdominal wall they never occurred in the rectum.
In a large majority of the cases much improvement resulted from this
method of galvanization. He was led to adopt the method because he was
sceptical of being able to get sufficient current through the abdominal muscles
by ordinary methods. He mentioned the matter so that he might hear Dr.
Morton’s criticisms on it for his own guidance.
Dr. David Arthur said that for many years he had treated chronic
constipation and atony of the digestive tract by interrupted galvanism—some¬
times interrupted by the hand and sometimes by an instrument such as Dr.
Lewis Jones described some time ago. Breaking by the hand, with an
electrode such as Dr. Buckley used, did tolerably well. Dr. Morton had dealt
so fully with the treatment that in order to extend the discussion it would be
necessary to embark on pathology. The atony caused by chronic constipation
did very well when treated electrically. He had examined large numbers of
school children, and found that the digestive troubles often started in quite
early life. During playtime it was not uncommon for bigger children to pull
smaller ones off the convenience and sit there themselves a long time reading,
so that many children returned into school without having been able to obey
the calls of Nature, and this, he believed, caused the commencement*of digestive
trouble. Similar conditions often obtained in millinery and other establish¬
ments, where work w T as carried on under such strict supervision and at such a
rush that the calls of Nature were largely neglected. For the conditions under
discussion he had not used faradism much, it was generally galvanism.
Mr. BOKENHAM said that with regard to the treatment of atonic condi¬
tions, especially constipation due to atony of the colon, he had long held the
view*, just expressed by Dr. Arthur, that the condition in many instances
arose in early life, and that if proper habits of regularity were more generally
insisted upon in the nursery, there would be far fewer sufferers from chronic
Electro - Therapeu tical Section
109
constipation in later life. When consulted by a patient suffering from atonic
constipation, he first made careful inquiry as to the periodicity of the natural
motions, and then went on to ascertain the condition of the colon and the
rectum. The colon would generally be found full, and the motions scybalous,
clayey, and difficult to eject. If there was a large, dilated, atonic colon, with
a big pouchy rectum, more or less full of faecal material, and therefore with
its irritability blunted, he did not think that any electrical measures, however
energetic, would do much good if applied straight away. One should first
secure complete irrigation of the intestine and empty it, for which he found
large injections of olive oil most useful, half a pint to a pint at the body
temperature being slowly injected by means of a douche with a soft rubber
tube long enough to reach well up towards the transverse colon, so as to secure
the emulsification of the contents and their dislodgment from the intestinal
pouches. When, in earlier days, he attempted electrical treatment without
those preliminary measures, the results were neither so good nor so rapid as
latterly, with a combination of both. With regard to the various forms of
current, he would like to hear the author’s^opinion of “.Morton. wave ” currents.
With a static machine working well one had under control, better than with
any other source, the character and frequency of the interruptions; a rapid
or a slow wave could be produced at will. He had found that, within limits,
the slower .the wave the better for such atonic conditions, whether for atony
of the gastro-intestinal tract or for conditions not strictly atonic, such as
Bell's paralysis or the finer neuro-muscular lesions. He believed that the
slowly interrupted or pulsatory currents, in whatever way generated, were
likely to prove the electric agents of greatest value in therapeutics.
Dr. PlRIE said that Dr. Morton had commented on the impossibility of
measuring the periodic time of unstriped muscle, and he asked Dr. Morton
whether he had ever filled the stomach with bismuth, put a sinusoidal current
through it, and watched it by means of X-rays with the screen, to see whether
it contracted in any way. The same could be done with the rectum. There
was a difficulty in regard to the de Watteville current, in that when applying
both faradic and constant electricity at the same time, one source went through
the circuit of the other. The resistance of the coil was less than the resistance
of the body, and the constant current went through the coil instead of through
the patient. He had found, under such circumstances, that he could get a
current of 220 ma. through a patient, but when he took out the coil a much
weaker current only could be tolerated.
Dr. G. B. Batten said Dr. Morton’s paj er was a very suggestive one.
He had done very little practical work in that way, but he saw many cases of
constipation due to atony of muscles. He asked whether the author considered
that the large current with slow alternation from the positive to the negative
phase was a more potent therapeutic agent than the constant current slowly
interrupted, either by such an apparatus as exhibited or any other. He had
used a clockwork arrangement which interrupted at the rate, of about twice a
second, with a needle dipping into an electrolyte—an inexpensive method. Or
110 Morton: Electrical Treatment of Digestive System
was it better to have a current such as he described a few years ago made
from a rectifier—a sinusoidal current, then interruption, and another phase of
the same kind? The constant current interrupted would be very much like
that if it dipped into a bad conductor; it would be only one-phase, and there
would be electrolytic deposits. But if they were used through a fluid con¬
ductor, and, instead of putting electrodes on the back of the body and on the
abdomen, they were used in baths, as on the Continent, the difficulty would
be got over. He asked w r hether Dr. Morton had had experience of his
apparatus, or similar ones, by baths. In private or hospital practice that
method might be very’ inconvenient, but the conditions could be brought about
easily in the patient’s house. In regard to the remark that the conditions of
constipation began early in life, that was not always so. He knew many
families where all the children had the same nurse and were brought up
in the same way, yet some had constipation and others were quite healthy.
Many children seemed to have disorders of digestion from the first week of
life. Later in life one came across terrible cases of constipation, in some of
w’hich Metchnikoff’s suggested removal of the colon had been carried out, and
he had treated such cases before, during, and after operation. Some of
them had been cured, others had a return of the atony of the digestive tract,
which remained as bad as ever. In one case a lady had suffered from chronic
constipation for a very long time. At first the bowel was short-circuited, but her
condition was still very bad. Douches were used, but regurgitation took place
into the blind end, and he had spent many hours trying to empty the colon.
Douches and the slowly interrupted constant current were continued for weeks,
but eventually the whole colon had to be removed ; nevertheless the small
intestine was now affected with the same atony. He asked whether Dr. Morton
had had experience of treatment of similar cases after operation. On the
other hand he knew of cases in which brilliant results ensued from the operation,
the condition having been proof against drugs and any other measures.
Dr. E. S. WORRALL said that for a long time he had looked upon atony
of the gastro-intestinal tract as a tiresome and troublesome condition, which
gave very little result from the use of faradism or galvanism, and sometimes
the combined current. But of late he had been much encouraged in using
high frequency currents, and he had employed them in several ways. He
believed the use of the glass electrode. was of very little value. Many cases
had given most satisfactory results when treated by a brush, the current being
taken from a large resonator or bipolar coil. Some cases in middle-aged people,
whose trouble dated back to school days, cleared up well under that treatment.
The treatment was administered about three times a week, the patient being
allowed to continue the use of aperients which he had been taking. Gradually
he would find he could do with less and less aperients, and in a short time could
dispense with them altogether. But the electrical treatment was continued for
a little time after that stage was reached. During the last three years he had
had many such cases, and had been able to ascertain in regard to some of
them that the benefit had persisted.
Electro - Therapeutical Section
111
Dr. Morton, in reply, said that from the beginning of his career as a
medical electrician he had been much impressed by the slow pulsating or alter¬
nating currents, and he confessed he had not given any great trial to other forms.
Possibly that was partly due to prejudice and partly to lack of opportunity for
carrying it out. The use of the galvanic current interrupted by hand seemed
to him to be a sound method of treatment. He could not find any objection to
it except that it was inconvenient, and that, whatever precautions were taken,
there was always the consciousness that one might be producing some sort
of burn, due to the deposition of electrolytic products. Even in the case of
the water-jacketed electrode for use in the rectum, which was enclosed in
a vaginal pipe, as mentioned by Dr. Buckley, the precaution was not too
great, but where there was nothing but membrane, that membrane, when
inflated with water, would not prevent the electrode getting near the mucous
membrane and an ulcer might result. That was one reason which made him
hesitate to use the galvanic current. Dr. Buckley’s method was a modification
of the system he used himself. He had nothing to say against massage, and
if massage had been in use in a case, he never had it stopped, because the
kind of case under discussion was one of the most difficult to cure, and he fully
recognized that electricity would not do everything. He thought the current
used by Dr. Lewis Jones, i.e . 9 the ordinary sinusoidal current, gradually
increasing and decreasing in amplitude, was exceedingly useful for treating
degenerated muscle. The only thing which bothered him about that current
was that the waves were too fast, although the magnitude was continually
altering. He felt that muscle in a state of degeneration could not respond
to waves that were going at such frequency. With the large and slow waves
time was given for a definite contraction and relaxation of the muscle, and
thus there was true electrical exercise. To produce such waves by hand was
tedious, and if a machine could be got to do the work it would be a very great
saving, and attention could meanwhile be given to other matters. It was a
great advantage to have an alternating current for another reason : not only did
one reduce the risk of damage from electrolytic action, but a more stimulating
action was obtained. A muscle was charged positively, and immediately a
current was passed in the opposite direction. There was a more marked result
by following a negative current by a positive. In regard to what Dr. Arthur
said on the question of pathology, he did not attempt in the paper to present
an exhaustive treatise on the pathology of constipation ; it would have taken
too long to deliver; but he confined his attention to setting out the forms
of electrical treatment he had employed. In answer to Mr. Bokenham, he
had not had experience with the Morton wave current. He would like to hear
evidence of its value. If a wave of that kind were used, it should be a slow
wave, not a fast one. He had not performed the experiment mentioned by
Dr. Pirie, namely, giving bismuth and testing the periodic time of the muscular
coat of the stomach with the assistance of X-rays, and he doubted whether
he would find a patient willing to stand it. By the time the latter was in the
dark tent, and the high and low tension currents had been arranged and
112 Morton: Electrical Treatment of Digestive System
applied, he (or she) would have had quite enough. The difficulty regarding
the de Watteville current which Dr. Pirie mentioned was due to his having
connected the coil, battery and patient all in parallel. The coil being of lower
resistance than the patient, a large current from the battery passed through
it, the patient getting very little. If he rearranged the connections so as to
join up coil, battery and patient in series , ha would find everything all right.
What Dr. Batten referred to was a modification of what he (Dr. Morton) spoke
of, and, as stated before, it was an advantage to have the muscle alternately
charged, because electrolytic action was not required and a higher stimulating
effect was obtained by reversing. He had not applied the current in baths for
atonic conditions of the digestive system ; he had always used electrodes. He
did not approve of simply laying the patient on two electrodes and letting the
other rest on the stomach ; it was necessary to take the anterior electrode and
sink it well into the abdominal wall, as far as the patient would allow. To get
the best results the operator must do some work himself. He used one
electrode on each side of the lumbar spine—about 15 cm. by 9 cm. was
a convenient size. He could quite see that the use of a bath for the pulsating
current would be a slight advantage, and would eliminate the chance of
damage to the skin ; but much current was wasted, and one did not know how
much went through the patient. Theoretically, in the ideal electric bath
pure distilled water should be selected. It would give such a high resistance
that the current would pass by preference through the patient. He had not
yet come across those unfortunate individuals who had had their intestines
short-circuited, and he did not know how his particular method would answer
with them. He had not had experience of high frequency currents in true
atony, but he had used high frequency where constipation was an element in
a case of neurosis, the latter being so pronounced that he did not give much
attention to the abdominal trouble. He put the patient on a condenser couch
and used an ordinary metal electrode across the stomach, connecting it with
the top of the resonator. He and the patient were both pleased with the
result.
Electro*Gberapeutfcal Section . 1
May 2‘2, 1908.
^Ir. W. Deane Butcher, President of the Section, in the Chair.
Interrupted Currents for Electrical Testing and Treatment.
By H. Lewis Jones, M.D.
Our views as to the best modes of applying electrical currents in
medical treatment are showing signs of an impending change. The
period during which the time-honoured faradism and galvanism have
held sway has been a long one, and when we remember how electrical
science has developed since they first came into medical affairs it is
difficult not to feel that it is time to take a fresh step forward.
In the matter of the principles w'hich we use to guide us in the
choice of current, things have never been completely satisfactory. Our
reasons for the choice of “ faradism " for one case and of “ galvanism ”
for another have oftentimes been as unconvincing as the results of their
-use have been unsatisfactory. We have pounded away at weak and
paralysed muscles w T ith induction coil currents, and have been forced to
sigh at the slow rate of improvement which the aforesaid muscles have
exhibited under such a regime. We have treated painful affections, such
as perineuritis and neuralgia, in the same way, and, I am sure, have
often made our patients actually w r orse instead of better. There is no
need for me to bring forward specific instances, for I expect that many
of those here present can recall such from their ow-n experience; and if
we consult the authorities on the treatment of, let us say, infantile
paralysis, we find that while one recommends interrupted or alternating
currents, another, perhaps equally experienced, will declare for con¬
tinuous currents, and will assert that interrupted currents are useless
for the treatment of muscles if a reaction of degeneration be present.
1 Meeting held in the Rooms of the Roval Philosophical Society, Glasgow.
ju— r *
114
Lewis Jones : Interrupted Currents
We, as students of electro-therapeutics, are confronted by the urgent
need of improvement in our methods and in our results if we are to
receive serious consideration from our colleagues who practise other
branches of medicine and surgery. Our field of work is a painfully
restricted one in reality, although in appearance it is ready to embrace
almost the whole domain of therapeutics. As I have pointed out on a
former occasion, we need work upon a higher plane than that in which
the competition of the nurse, the medical rubber, or the quack can be
encountered, and it is in this higher class of medical work that our
progress in the future must lie.
In all electro-therapeutic procedures we ought to know precisely
what we are aiming at, and should also have a reasonable expectation of
realizing it. It seems to me that unless there is a satisfactory likelihood
of our obtaining the desired result by electrical means, it is better to
decline to undertake a case. In the electrical stimulation of nerve and
muscle in cases of paralysis, and in all procedures of general electrical
stimulation for states of debility or defective nutrition, there is no doubt
at all that a slow periodic current with intervals of rest is far better than
a sustained tetanization. This was demonstrated by Debedat in 1894
by a series of experiments on the muscles of rabbits, from which he
found that induction currents rhythmically applied for four minutes
daily with periods of one second, followed by one second of repose, gave
a large (40 per cent.) increase of weight in the muscles treated, whereas
induction currents applied for the same time daily without rhythmic
intervals, so as to produce a sustained muscular contraction, caused
a loss of weight in the muscles so treated. I am of the opinion that
for a large proportion of the cases which come for electrical treatment
it is of advantage that rhythmically varying currents should be used,
both when interrupted currents are employed and when direct currents
are to be made use of, the most notable exception to this rule being in
the employment of electrolysis, whether as a destructive agent for
noevi, &c., or as a means of ionic medication. In almost everything
else the currents must be rhythmically interrupted.
A few years ago the term “ interrupted currents,” when used in
medicine, meant simply the currents of the medical induction coil.
Now the sinusoidal current of the alternating supply mains has come
into general use as an additional form of medical current, and the
employment of currents varying rhythmically at a slow rate is gradually
extending. I believe that it is to St. Bartholomew’s Hospital that we owe
the introduction of the rhythmic current into practice in this country,
Electro-Therapeutical Section
115
just as it is to St. Bartholomew’s that we owe the now universal arm-
bath as a medium for electrical applications. The use of rhythmic
currents was commenced at St. Bartholomew’s a number of years ago
with an apparatus consisting of a metronome which carried a wire
swinging to and fro, and in its excursions dipping into and out of a
vessel of liquid through which the current passed. The variations so
produced in the resistance of the liquid part of the circuit gave the
required rhythmically varying character to the current. This appara¬
tus, or an illustration of it, is probably familiar to most of you, but it
presented certain inconveniences, and has now been given up.
Following the metronome, another clockwork contrivance was used,
the principle still being the same, namely, a variation in current by a
variable liquid resistance. It consisted of a wire which dipped into a
dilute saline solution, and the range through which the resistance could
be caused to vary was increased by the following simple device : In the
vessel of liquid a small glass funnel was inverted, and the moving wire
entered the liquid through the narrow end, the level of the liquid coming
well up into the stem of the funnel. This gave better regulation.
I may digress for a moment to point out the necessity of propor¬
tioning the resistance of the variable part of the circuit to suit that of
the working part. A rheostat designed to reduce a current to, say,
one-tenth of its maximum value must have a resistance ten times that
of the rest of the circuit to be regulated, and thus it follows that when
three arm-baths are arranged in series, the resistance to regulate them
must have a range from maximum to minimum which is ten times the
resistance of the three baths, or thirty times that of one arm-bath. It
is this fact which limits us in the use of liquid cells for resistances, and
has made the inverted funnel so useful in the arrangement under con¬
sideration. Without it, it is difficult to secure a sufficient difference
between the strong and weak part of the cycle except by allowing the
wire to come out of the liquid and so to break the circuit abruptly, but
with the funnel the wire recedes upwards into its stem, and the liquid
part of the circuit at that point is of relatively small cross section, and
therefore has a relatively high resistance.
These clockwork resistances are valuable for treatment because they
are cheap and easy to make, but they need attention and adjustment,
and on these grounds the forms of variable resistance driven by an
electric motor are superior. Before going on to a consideration of these,
I wish to call your attention for a moment to another form of simple
resistance which has some useful applications. It consists of a simple
116
Lewis Jones: Interrupted Currents
ebonite water tap containing water or a conducting liquid, and connected
in the circuit to be regulated. The turning of the tap, by changing the
area of the orifice, changes the resistance within a large range, and the
contrivance is useful when current is to be slowly raised or lowered, as
is done in the treatment of certain conditions, particularly in applications
of electrical currents to the head.
Of more ambitious machines for producing slow waves of current,
I wish to mention two. One is particularly useful for the currents of an
alternator or of an induction coil, and consists of a sledge coil trans¬
former with an electric motor to set the secondary coil in motion to and
fro over the primary. A very well designed instrument of this kind is
made by the firm of Gaiffe, in Paris, and works well for long hours daily
in the electrical department at St. Bartholomew’s. Its wave form on
an alternating circuit may be represented as follows:—
The other, made by the firm of Schall, is a wire resistance upon
which a metal traveller slides to and fro, causing the current to increase
and decrease as it slides. It may be used to regulate interrupted cur¬
rents or to convert direct current into slow pulsating waves, or, finally,
by adjusting the connections, it may be made to convert direct current
into slow alternating weaves with a duration of a second or thereabouts.
Lastly, I wish to mention Dr. Morton’s slow moving motor generator,
which gives out sinusoidal current of very slow periodicity, though
hardly so slow as those of the machine last described. Dr. Morton has
found his apparatus valuable for treatment, and he considers that it
may well be used to take the place of the three-phase currents of
slow T periodicity which have been recommended in this country by
Dr. Herschell.
I come now to another form of interrupted current apparatus which
I tliink everyone should know, namely, the interrupter of Leduc. Its
essential value consists in the pow r er it gives us of producing currents
of definite wave form and duration, and of varying these at will within
wide limits.
Electro-Therapeutical Section-
Ill
It consists of a motor-driven commutator with its two brushes, the
current to be interrupted passing from brush to brush through the com¬
mutator segments at one time and being broken at another, the periods
of flow and of no flow being determined by the relative positions of the
metallic segments of the commutator and the brushes. When these
form a circuit from brush to brush the current flows, and when they do
not there is an interval. By the ingenious device of altering the posi¬
tion of one brush from its most advantageous position the duration of
the flow can be shortened so as to obtain short impulses with longer
intervals, and experiments w r ith this interrupter promise some useful
results in electrical diagnosis. Thus, by arranging the brushes to give
long waves one may obtain a tetanic * response in muscles which are
unable to respond in that way to short waves, and this opens out a very
important possibility in electro-diagnosis, namely, the possibility of a
further analysis of the cases which are now grouped indiscriminately
together as cases showing a reaction of degeneration, and the advantages
to be derived from such an analysis or splitting up of a somewhat hetero¬
geneous group of cases will be manifest to all.
The instrument I show here has been made for me by Mr. Leslie
Miller, and is fitted with a speed counter, so that the number of revolu¬
tions per minute can be read off at any time. The duration of each
wave can also be measured by observing the milliamperemeter with the
apparatus stationary, and comparing the reading with that observed
when it is running, for the fall in the magnitude of the reading gives a
measure of the fraction of time during which no current flows. Thus,
if at rest the reading is 10 ma., falling to 1 ma. when running, w r e
assume, and assume correctly, that the current flows only for one-tenth
of each cycle. The number of cycles per minute being obtained from
the speed counter, the duration in time of each impulse is easily
calculated.
I hope at some future time to deal more at length with this appar¬
atus, which I consider to be very valuable, and content myself to-night
with drawing attention to its capabilities.
118
Turner: Electrical Work in Edinburgh
Some Reflections based upon the work done in the Electrical
Department of the Royal Infirmary, Edinburgh.
By Dawson Turner, M.D.
Galvanic and faradic currents were the first to be used for elec¬
trical treatment and diagnosis in the Edinburgh Royal Infirmary,
bichromate and Leclanche cell batteries, and occasionally Bunsen's,
when an aneurysm had to be treated electrolytically. So matters
jogged on for years, and there was no separate electrical department
or even room; but the discovery of the X-rays gave a great impetus
to medical electricity. Three rooms were set apart, and a static
machine and an X-ray apparatus were installed, and later on a high
frequency spark gap and resonator. Now the department consists of
twelve rooms, and it occupies the whole of one floor of a pavilion. But
with the swing of the pendulum we are now returning to continuous
currents again, and my time is mainly spent in the galvanic room.
I will make a few remarks in turn upon the apparatus used and the
work done by us in these different branches of electrical practice. In
the static room we have a twenty plate Gaiffe ebonite machine and
a six plate glass machine ; we can treat three or four patients at once,
and there is a daily attendance of about nine. The treatment seems
to be of most service as a tonic agent in neurasthenia and in those
recovering from exhausting diseases ; but it is also of use in obscure
painful conditions. Patients are apt to contract a habit for the treat¬
ment, and to continue it for too long a time. I will not say much about
high frequency currents; they have had rather more than the usual
rise and fall associated with the introduction of new remedies—received
with too much enthusiasm at first, and pushed by quacks and inter¬
ested instrument makers, they now seem to be taking their proper
place, chiefly as a means of treating certain painful conditions, such
as sciatica. In my own opinion, which I have held since Tesla first
introduced these currents, their chief and most valuable action is one
of counter-irritation due to the innumerable minute sparks which pass
between the electrode and the skin. Turning now to the Rontgen ray
department, the tubes that we are using just now for radiography are
Bauer air-cooled ones, and for treatment Cossar’s therapeutic tubes and
Electro-Therapeutical Section
119
Dean's tubes. The Bauer tubes are satisfactory, but if pushed may
overheat and fall very suddenly in vacuum ; on the other hand, they
are also sometimes difficult to soften. The favourite plates with us
now are Jougla and Ilford, but I cannot say that I have found them
markedly superior to others. Each of our coils is furnished with tw r o
interrupters connected in parallel; either of these can be used at will
by the movement of one switch. To avoid overheating the tubes w r e
do not attempt to use very short exposures, in fact the time of our
exposures has remained sensibly the same for the last year or two. On
an average seven photographs and ten cases are treated by the X-rays
daily. Screen examinations have, owing to the risk of dermatitis or
other injury—and we do not yet comprehend all the ills they may
occasion to those constantly exposed to them—fallen into desuetude.
Whereas formerly cases were almost as a matter of course and with
keen interest at first examined with the screen, now a screen examina¬
tion is an exception, and to be made only in special cases. The staff
at the Edinburgh Royal Infirmary are all suffering more or less from
dermatitis. A word or two about a screen examination. It has been
suggested that the reason why we cannot see the detail on a screen
that we can on a negative is owing to the fact that the negative looks
longer and accumulates impressions, just as it does also in case of the
stars, but I think the real reason, as has been pointed out by Beclere,
is that we examine the screen image by a dim light and the negative
by a good light, for the part of the retina that is most sensitive to
a dim light, and also to certain colours, particularly blue, is the peri¬
phery, the sensibility increasing as we leave the yellow spot; thus it
is sometimes an advantage to examine a screen image with the eyes
not directly fixed upon it; but when you examine the negative you
use the yellow spot, the point of distinct vision, because you can use
bright daylight, and it is only by using the yellow spot that fine details
can be made out. I need say nothing about the value of the X-rays
in diagnosis, both medical and surgical, but what view is a calm and
unprejudiced observer to take of its value in treatment ? In derma¬
tology it ranks high in tinea tonsurans, favus, and mycosis fungoides.
It is not so successful in Scotland in tinea as it seems to be in France,
but Dr. N. Walker recommends it highly in favus. Whether, however,
one is justified in treating children suffering from ringworm or favus
with the X-rays is a reflection I am bound to make, and in my own
opinion the answer must be in the negative. I would not allow any
child of mine to run the risk of having the development of the delicate
120
Turner: Electrical Work in Edinburgh
cells of its growing brain interfered with or arrested. The remedy may
prove to have been a thousand-fold more serious than the disease. In
adults, and when not applied to the brain, this risk is at any rate
avoided. The rays are of service in superficial malignant disease, in
epithelioma and scirrhus, and I have seen several cases of sarcoma in
which great relief and prolongation of life have been obtained. Have
I ever seen a cure—say no recurrence for two years? In two cases
(about 1 per cent.) ; one of these was a recurrent epithelioma on the
back of the hand. The growth had been removed by the late Professor
Annandale and examined microscopically. Twenty-six seances sufficed
to cause a complete disappearance. The second case was a recurrent
scirrhus; the patient received a severe X-ray burn which caused her
great pain and distress for more than a year, but the disease seemed
to be eradicated. For deeper inoperable neoplasms the rays can, faute
de mieux , be tried, and in some cases undoubtedly do good.
J. G., aged 52. Diagnosis: Malignant disease of stomach (made by
Dr. Boyd). Admitted April 6, 1904. History : Present condition commenced
in December, 1903, with pain in the stomach and nausea; the day after this he
had vomiting; since then pain and sickness have been constant, always worse
after food; palpation brings out a mass in the stomach measuring 34 in. in
length. Treatment: X-rays daily for five minutes over epigastric region.
April 9 : Pain much relieved, sickness entirely abated. April 13 : No pain
whatever ; patient conscious that the tumour is decreasing in size. April 29 :
Feels well and strong; no pain or sickness; leaves for home. August 23 :
Returned on this date; a fortnight previously a recurrence of former sym¬
ptoms ; a large tumour can be felt with secondary growth in left lobe of liver.
August 27 : Feels much relieved. September 10: Pain and sickness all gone,
but tumour not decreasing as fast this time. September 30: Continued
improvement and gaining weight; patient is apparently quite well and has no
discomfort; leaves for home. October 19: Reported himself on this date ;
continues to enjoy good health, no pain or sickness whatever, and gaining
weight; the HC1, w’hich had disappeared from the stomach, has returned.
In rodent ulcer the results are good, but very slow compared with
electrolysis; w T e, therefore, have given up the X-ray treatment of rodent.
For very small rodents radium acts like a charm, but recurrence is the
rule. In leukaemia the results appear to be favourable—I say appear
to be because the long exposures may, and I venture to say probably
do, produce untoward effects on the kidneys and other organs. I have
notes of several cases in which great improvement occurred ; the spleen
becomes reduced in size, the red corpuscles increase, and the w r hite
corpuscles diminish in number; the patient feels much stronger and
E lee tro-Thera pen tical Secti o n
121
better. This is the usual effect of the X-rays applied over the splenic
area and long bones. Unfortunately the disease recurs when the treat¬
ment is interrupted, and I have records of cases w r hich have returned
tw’o or three times for treatment.
J. L., aged 28. Spleno-medullary leukaemia (Dr. Gibson). Admitted
February 28, 1905. History of nine months, commenced with an ovaritis.
Treatment carried on daily till June 16, 1905. Blood-count on admission : Red
corpuscles, 2,590,000 ; white corpuscles, 400,000 ; haemoglobin, 41 per cent.
March 21: White corpuscles, 320,000 ; haemoglobin, 66 per cent. May 2 :
White corpuscles, 27,000. Some dermatitis set up and treatment stopped for
three weeks : splenic area alone exposed. June 16 : Red corpuscles, 4,090,000 ;
white corpuscles, 9,800 ; haemoglobin, 95 per cent.
Readmitted on April 16, 1906. Patient has kept well since she went home,
but owing to recurrence of former symptoms has returned. White corpuscles,
380,000.
June 6: Not doing so well this time; white corpuscles, 780,000 ; haemo¬
globin, 42 per cent. July 6: Marked improvement in the last month; all the
long bones treated in addition to spleen. Red corpuscles, 4,260,000 ; white
corpuscles, 124,000 ; haemoglobin, 73 per cent. August 20: Discharged.
M. S., aged 27. Spleno-medullary leukaemia (Dr. Gibson). Admitted
March 8, 1906. History that in November of previous year patient had
influenza and immediately after became aware of spleen being enlarged. Treat¬
ment daily to splenic area and long bones. Blood-count on admission : Red
corpuscles, 2,830,000; white corpuscles, 200,000; haemoglobin, 56 per cent.
May 6: Red corpuscles, 3,800,000; white corpuscles, 9,660; haemoglobin,
42 per cent. May 15: Red corpuscles, 3,540,000; white corpuscles, 11,900;
haemoglobin, 46 per cent. June 8: Spleen much reduced in size. Red
corpuscles, 4,500,000; haemoglobin, 76 per cent. July 7: Patient leaves for
home; spleen practically normal; leucocytes, 1 per cent.
This patient remained in good health for ten months and was able to work.
She returned for treatment as spleen was enlarging, and after a course of
exposures extending over six weeks again went home apparently cured.
In lupus the rays do good, in lupus of the palate and larynx also.
Dr. Logan Turner recently showed a case of laryngeal lupus treated
by me which he considered to be cured. In tubercular glands, joints
and bones, slow benefit may occur. There are known risks in lupus,
for epithelioma may follow; Dr. Norman Walker states that in seventy-
two cases of lupus treated abroad by X-rays, ten developed epithelioma.
In a case, treated in my department, of lupus of the cheek, epithelioma
followed. Finally, I think the therapeutic use of the X-rays is potent
both for good and evil, but particularly for evil, for the good effects are
often transient, as in leukaemia, but the evil effects may be permanent
122
Turner: Electrical Work in Edinburgh
and incurable ; and while its use may be freely indicated in malignant
disease, yet its employment in less serious conditions should not be
lightly undertaken ; its possible risks should be explained to the patient,
and its effects should be most carefully watched.
In another room we have arm- and leg-baths supplied by a Morton
slow-running triphase sinusoidal machine for the treatment of local
paralysis and of sprains, and for the restoration of function. These
baths do more good in writer’s cramp and trade spasm than any other
form of electrical treatment I am acquainted with.
Lastly, we have a general electrical room fitted with three Milne
Murray switchboards; these were actually made by the late Dr. Milne
Murray. They are used for testing electrical reactions and for faradic
and electrolytic, treatment. It is in electrolysis or ionic medication, for
the reintroduction of which we owe so much to Professor Leduc in
France and to Dr. Lewis Jones in this country, that I think most
progress will be made in the future. Some of the conditions for which
electrolysis may be advantageously applied are as follow : ankylosis,
sclerosis, fibrous adhesions, strictures, rodent ulcer, parasitic affections,
sinus and fistula, tic douloureux, rheumatic and gouty affections. Eight
cases of ankylosis of joints have been treated by me with chlorine
electrolysis, and all have improved. I will refer to one case: A. B.,
under the care of Mr. Cotterill, a case of ankylosis of the left knee;
patient met with an accident, which resulted in a septic condition of
the knee ; he was in bed for fifteen weeks, the knee became stiff and
could not be flexed to more than a right angle. The knee was now
treated with chlorine electrolysis, and every application resulted in
greater freedom of motion; after three applications his foot could move
through an arc of 7 in. more. A continuance of the treatment led to
almost complete restoration of function, but at a slower rate of progress.
The treatment should be immediately followed while the tissues are in
a relaxed and supple condition by forcible movements. Four cases of
Dupuytren’s contraction fingers have been similarly treated with very
good results; in the case I show you the disease had lasted fifteen
years, the forefinger w r as bent to more than a right angle, and resembled
a hook. Each treatment loosened and eased the contraction, and after
eight seances of half an hour each the finger could be straightened.
The patient then ceased to attend, but returned in about six weeks
with his finger bent again, but not to the degree that it had been
previously; a resumption of the treatment had the same effect as before.
It is difficult in these cases to pass sufficient current through the skin
Electro - Therapeu tical Section
123
over the contracted tendons without the current density becoming too
great; this may result in a burn. Long seances with small currents are
therefore advisable. Skin contractions and cicatrices following burns are,
as might be expected, very amenable.
Another class of case in which I have had some small success is that
of sclerosis of the spinal cord. Five cases have been under treatment:
one of tabes dorsalis, two of spastic paralysis, and two of disseminated
sclerosis. As a rule I place over the affected area of the cord ten layers
of lint dipped into a weak solution of NaCl, and over this a metal
electrode attached to the — pole ; the feet may be placed in a bath
attached to the other pole; a strong current is now passed for half an
hour or more. By using a linear electrode some part of the current
will traverse the affected segment, there will be an interchange of ions
and the action of the chlorine ion will have a loosening and resolving
effect on the sclerotic tissue, so that nerve impulses will be conducted
more freely. The first case of spastic paralysis, aged 34, had been ill
for more than a year; he presented all the signs and symptoms of
spastic disease; he was not able to walk alone and suffered from urinary
incompetence. Six seances sufficed to remove these symptoms, and
under a continuance of the treatment he was soon able to walk quite
well by himself. After reaching this stage of improvement the applica¬
tions were discontinued and the patient was advised to remain quietly
at home. Unfortunately he returned to his work and his condition
became worse. A repetition of the former applications now failed to
relieve him, but when stronger currents w r ere employed the patient
steadily improved and was soon brought back to his former level. The
second case also improved steadily but then had a relapse. Of the two
cases of disseminated sclerosis one showed some improvement and the
other seemed to derive no real benefit. The case of tabes, aged 39,
a patient of Dr. Gemmel, has had about four applications and the effect
is still sub judice; but he says that he always feels better and stronger
after the treatment. The most striking feature in all these cases is the
temporary recovery of power following each application; the patient can
walk and use his limbs more freely. Of all the ions that can be intro¬
duced electrolytically that of zinc appears to be of most general use.
I show you some slides to illustrate its effects in rodent ulcer.
The first slide is that of D. H., aged 61, a patient of Dr. Maclaren,
taken before electrolysis; the next slide was taken three weeks after
the first application of electrolysis; he was now treated again, and
the next slide shows his condition three months later. Thus two
124 Turner: Electrical Work in Edinburgh
applications of zinc electrolysis sufficed to cure this case of rodent ulcer
of the nose. The next two slides exhibit the condition of a patient of
Dr. Laing’s before treatment and after three applications ; the lupoid ulcer
ha3 practically disappeared. The next slide is that of W. H., a patient
of Mr. Dowden’s, with a rodent ulcer of fifteen years duration. Two
years before, when it was smaller, fourteen weeks treatment with X-rays
had caused it to heal; it recurred, and on admission in January, 1908,
the ulcer measured 3 in. by 2 in. Six applications of zinc electrolysis
sufficed to cause it to heal. The next slide is that of a strumous ulcer
before and after treatment. A sinus yields readily to the same treatment
if plugged from the bottom. Cases of tic douloureux and neuralgia
are very amenable to the salicylic ion, which, indeed, often acts like a
charm.
Lastly, I am sometimes asked to assist a surgeon in the electrolytic
treatment of aneurysm. The late Dr. John Duncan used to introduce
both poles (steel needles) into an aneurysm and pass a current of 30 ma.
for twenty minutes. The modern method is that known as the Moore
Corradi, and it consists essentially in the introduction into the aneurysm
of several feet of wire and of the passage of a current through the wire
into the blood; the other electrode is placed on an indifferent spot. The
wire is always made the + pole, and this for two reasons : (1) To obtain
a firmer clot, (2) to diminish the risk of emboli, which might result from
the multitudinous bubbles given off at the — pole. The wire used may
be of silver, gold, platinum, or iron. Dr. Stewart, of Philadelphia, says :
“ Gold, silver, or platinum wire is undoubtedly the preferable material.”
Professor Leduc has, however, stated 1 that zinc is the best coagulant and
far superior to platinum. This experiment of his I have been repeating
and examining on an extended scale. I have had a number of electrodes
of different materials made, and I have compared the results obtained by
electrolyzing blood-serum. I should like to show you one or two experi¬
ments, for they are very striking. The net result is that with none of the
metals recommended is any coagulum worth the mentioning to be ob¬
tained. Further, in some cases much gas is evolved even from the + pole,
so that some surgeons have been unconsciously courting the very danger
they were endeavouring to avoid. We may draw the conclusion that this
danger is nothing but a bogy. With zinc electrodes you notice that no
gas is given off at the + electrode, but that a firm glove-like coagulum
is formed. This coagulum adheres to the electrode, and if shaken off
1 “ Les Ions,” p. 28.
Elec tro- T her ape it tical Sec tion
125
preserves its form. Hence I venture to suggest that surgeons should
introduce zinc wire into an aneurysm which they wish to treat electrolyti-
cally rather than the wire recommended either by Dr. Stewart or other
clinical authorities who have not tested the coagulating effects of these
metals experimentally in the laboratory, for my experiments convince
me that the passage of an electric current in the orthodox Stewart
Moore Corradi method in no way aids in bringing about coagulation of
the blood, but serves mainly to exhaust the patient’s strength and con¬
sume valuable time and energy, while whatever coagulation is produced
is due only to the introduction of the foreign body.
126
Sloan : Ionic Medication in Pelvic Disease
Ionic Medication in the Treatment of some Obstinate Cases
of Pelvic Disease in Women.
By Samuel Sloan, M.D.
Ionic medication is the application of electro-chemistry to thera¬
peutics. To students of recent advances in physical chemistry, chemical
affinity comes simply to mean electric attraction and electric repulsion
of the atoms or molecules in solution. These atoms or molecules have
each a charge of electricity, some of them being positive and some
negative. Being electrically charged, and capable of moving in virtue
of this charge, they are called ions or movers. Let an electric current
be passed through such a solution and at once, from a restless state
of activity, the ions proceed to arrange themselves so that the — ions
may move towards the + pole and the 4- ions towards the — pole; like
charges repelling and unlike attracting. The ions moving towards
the + pole are called anions, that is anode-goers ; those towards the
— pole kathions, that is kathode-goers. Hydrogen and all metals arc
kathions; iodine, chlorine, &c., are anions. In the case of compounds the
bases are kathions and the acids are anions. Thus, in the case of a
solution of sulphate of copper, the sulphuric acid, being an anion, will
drift towards the + pole ; whilst the copper will move towards the -- pole.
Any solution capable of conducting a current of electricity through it is
called an electrolyte ; and the passage of the current brings about decom¬
position of the electrolyte. The motions of the ions constitute the
current, each atom carrying with it an equal quantity of electricity.
The human body is an electrolyte in virtue of the salines in its tissues.
The principal saline being NaCl, the body acts electrically as a solution
of chloride of sodium.
Seeing that the ions or electrically charged atoms are some + and
some —, and that these are capable of moving freely about and against each
other, there must be a constant commotion amongst these ions. This is
shown at A in fig. I, 1 which is meant to illustrate diagrammatically the
arrangement of the molecules and atoms of water when uninfluenced
bv an electromotive force from the outside. Note how the molecule
has its atoms so arranged that the mutually repelling H ions are kept as
Not reproduced.
Electro-Therapeutical Section
127
far as possible apart, so that there would be no movement within the
molecule but for the action on its atoms of adjoining molecules. It is a
different matter, however, as you will observe, with the molecules them¬
selves, for, where these are so placed that two H atoms approach each
other or collide, repulsion will follow between the molecules, and, though
in less degree, between the H atoms within the molecules also, due to
the partial displacement of one of these by an H atom of an adjoining
molecule. Let a small controlling force, however, say 1 volt, be applied,
and instantly the molecules arrange themselves as at B, so that all the
O atoms point towards the + pole and all the H atoms towards the
— pole, but no decomposition takes place. Let at least 2 volts of
difference of potential, however, be brought to bear on the atoms of
the water and we have what is represented at C. The atoms have
changed partners all along the line, so that at the + pole an atom of 0
has broken off, and at the — pole two atoms of H. In the case of water
the atoms of the molecules are held together more firmly than are those
of some other electrolytes, for, though a slight difference of potential
between the electrodes inserted into the water would tend to make the
molecules stand at attention as in B, it requires over 1*47 volt to
bring about what is shown at C, the O and H having a strong
attraction for each other. Expressed chemically the O and the H have
a strong chemical affinity for each other; expressed electrically their
difference of potential is high, just as the inherent difference of potential
between Zn and Cu when brought into contact is relatively high. The
constituents of some electrolytes have much less affinity, however, for
each other. In such cases the movements of the ions must be more
vigorous, not only amongst the molecules but also amongst the atoms.
An atom may break off from one molecule to attach itself to an adjoining
one, or it may roam about free and be caught up for a time again; but
movement is constant, causing commotion from collisions amongst the
ions. That this is the case, especially with a solution of NaCl, was forced
upon my notice recently whilst investigating some electro-chemical
phenomena. I took a U-shaped tube containing normal saline solution,
placed a carbon electrode into the solution in each limb, and connected
these electrodes with a galvanometer giving milliampere readings. The
result surprised me when I first observed it. It may be well known
to electro-chemical experts, but it was previously unknown to me. Note
that these carbon electrodes have no difference of potential, and therefore
no migrations of ions towards the separate rods might be expected; yet
no sooner had the rods touched the solution than a current of 1 ma.
128
Sloan : Ionic Medication in Pelvic Disease
was found to be set up in the galvanometer. I show you this now.
I suspected, as an explanation of this phenomenon, that the carbons
might differ in potential owing to some impurities in one of them, since,
when I reversed them in the limbs of the U tube I found that the
direction of the current was reversed. That this was only occasionally
the case, however, was evident after a few trials, the direction of the
current varying apparently according to mere chance. That this is
so is indeed most likely ; and imagination can readily picture atoms
breaking off from their molecules, rushing about in a free state,
reuniting, changing partners, and darting off again. Like “ warlocks
and witches in a dance/’ “ They reel’d, they set, they cross’d, they
cleekit,” as Tam O’Shanter saw done at the midnight ball in Alloway
Kirk. Under such circumstances there must always be some free ions
in the neighbourhood of the carbon electrodes. Let a few + ions happen
to knock against one of the carbons in its rambles; these will give up
their charge of electricity to that electrode, which will then become
electro positive, and thus will a difference of potential be established
between the carbons. All the more will this be the case if some of the
— ions are at the same time similarly surrendering their negative charge
to the other electrode. Thus a current is set up between the electrodes
outside of the solution ; and, as this current must pass through the
galvanometer, its needle is deflected. The current, once formed, con¬
tinues, I find, to circulate for an indefinite time, though gradually
falling to about \ ma. The potential I found to be about £ volt. It
is not to be wondered at, therefore, that a solution of NaCl should be
a good conductor of electricity compared with water, which, if perfectly
pure, is almost a non-conductor, due to the close electrical union between
O and H, for no decomposition means no current, and the conductivity
of a fluid is proportional to the number of its free ions multiplied by the
velocity of their movement.
Whilst this illustration appeals to the imagination and helps to give
a living picture of ionic movements, a simple experiment illustrating the
decomposition of KI appeals to the eye. [Experiment here with a
U tube containing a solution of KI, starch and phenolphthalein.] The
starch, you will observe, is colourless because there is no free iodine ;
the phenolphthalein is colourless because there is no free potash. Now
apply to one limb of the tube the positive pole from a battery and the
negative pole to the other and note the change. In a few minutes the
solution in the limb into which is inserted an electrode connected w T ith
the + pole becomes blue, indicating the presence of free iodine ; whilst
Electro - Therapeutical Section
129
the solution in the other becomes red from the action of the K on the
phenolphthalein; the metal potassium, separated by the current, having
combined with hydroxyl, whilst the other atoms of H of the molecules
of the water escape, as you may see from the bubbles arising from this
pole. A reversal of the current would result in the colours changing
places. Note also that these changes are at the electrodes only. Changes
such as those shown in Table I. have been going on. I show the
potassium and the iodine only in this table to make the process less
complicated. Observe also the iodine atoms at the one end and the
potassium atoms at the other have parted with their electric charges to
their respective electrodes and have thus become free. This is electrolysis,
and is, as you see, accompanied by ionic migration, but it is not ionic
migration in the sense in which we are considering it to-night. In
electrolysis the changes, as you will observe, are at the poles only, though
this has been brought about by the ions throughout the liquid constantly
changing partners and going individually their respective ways.
Table I.
Simple Electrolysis
+ + + + + + + +
+ *“**““** —
i i i i i i i i
Before current.
4 - 4 4 - 4
+ KKKKKKKK
I I I I I I I I
After current.
Simple electrolysis has been employed in medicine for various
purposes, notably by Apostoli in gynaecological cases; and this treatment
is sometimes of undoubted benefit. The escape of nascent 0 and of the
acids of the tissue electrolyte at the + pole, usually the intra-uterine
one in the Apostoli treatment, has an antiseptic or a caustic action;
whilst when the — pole is made the active one the tissues are softened
and dissolved by the action of the sodium hydroxide, obtained from the
NaCl of the tissues and the hydroxyl of the split molecule of the water.
In ionic migration phenomena, however, there is besides this a transfer
of the ions of the applied solution or soluble electrode from one pole in
ju —-6
130
Sloan : Ionic Medication in Pelvic Disease
the direction of the other, of zinc or copper as the case may be from the.
+ pole, and of iodine, sulphuric acid or salicylic acid as the case may
be from the — pole. The question as to which pole the substances leave
is the important one because, in applying ionic medication in practice,
the other pole is at a neutral place, and so it may be for convenience
ignored. Table II. illustrates what would go on in the case of copper,
when applied at the + pole, as Table III. indicates how KI would
behave when applied at the — pole.
Table; II.
Ionic Migration.
Mucous membrane
+
4-
+
4-
+
+
+
+
Cu
Cu
Cu
Na
Na
Na
Na
Na
Cl
Cl
Cl
Cl
Cl
Cl
Cl
Cl
Before current.
Mucous membrane
-T-
4-
+
+
+
Cu
Cu
Cu
Na Na Na Na Na
Cl Cl Cl Cl Cl
Cl
Cl
Cl
After current.
Table III.
Ionic Migration.
Mucous membrane
4-
4-
4-
4-
4-
4-
4-
4-
K
K
K
Na
Na
Na
Na
Na
+
I
I
I
Cl
Cl
Cl
Cl
Cl
Before current.
Mucous membrane
+ + 4- +
K K K Na Na Na Na Na
I I I Cl Cl Cl Cl Cl
After current.
As ocular demonstrations of the power of electric currents to cause
the transit of ions from the pole of application, ! show you some pieces
of leather which have been suitably folded and tied round one end of an
Electro-Tlierapeu tical Section
131
open glass tube. This tube has been inserted into a vessel containing
a solution of NaCl, whilst the substance employed to penetrate the
skin is poured into the inner tube. A current of electricity has been
passed through the folds of leather for a definite time. As a contrast I
have placed alongside each of these a strip of the same material which
had been similarly treated, but without having had any electric current
passed through it. In this latter case simple diffusion had been in
operation for exactly the same time as in the former. In the case where
CuCl 2 has been the substance employed, solution of sulphurated potash
has been used to convert the comparatively colourless CuCl 2 solution into
the dark sulphide of copper. In this case both solutions were of the
same specific gravity and stood at the same level, so as to eliminate the
actions of osmosis and of gravity. Where salicylate of soda has been the
substance used, tincture of perchloride of iron has been employed to
render visible the passage of the salicylic acid from the — pole through
the layers of the skin. In this case transudation has been opposed bv
gravity and by osmosis, the solution in the inner tube being at a lower
level and of a lower specific gravity than that of the outer one. This
explains why the markings on the skin, which indicate the amount of
simple diffusion, are those of the reagent only, practically no salicylic
acid having passed through. In the case of ionization, on the other
hand, though the other conditions were identical, the salicylic acid, as
you will observe from the intense red of the action of the reagent upon
it, has penetrated to the last fold of the skin.
It will readily be admitted that, if this difference can be produced by
electric means, a similar result may be expected in the case of the
mucous membrane of the vagina and uterus, the conditions there as to
gravity and osmosis being practically the same as in the salicylic acid
experiment. But the difference is not one of degree only, for whereas
in the case of simple diffusion the substance will, in ordinary circum¬
stances, pass into the inter-cellular spaces only, and be at once carried
off by the blood- and lymph-streams, in the case of electric transudation,
on the other hand, the ions penetrate into the protoplasm of the cell
itself. No lodgment of micro-organisms can therefore escape the action
of the drug. The effect, of course, will be either germicidal or simply
antiseptic, according to the quantity of current employed. In estimating
how much of the substance has penetrated a membrane it must be borne
in mind that each atom carries the same quantity of electricity; but as
these atoms differ in atomic weight the amount will be directly as the
current and directly as the atomic weight. It will also be directly as the
132
Sloan : Ionic Medication in Pelvic Disease
time during which the current has been allowed to flow. What is called
the electro-chemical equivalent of an atom is the amount deposited by
1 amp. in one second, so that the transfer from 15 ma. acting during
twenty minutes will be the same in amount as would be yielded by a
current of 30 ma. acting for ten minutes.
Before proceeding to record the results of my treatment of obstinate
gynaecological cases by ionic medication, let me explain that these cases
have been obstinate, not in the sense of being obscure, difficult to dia¬
gnose, or fit for treatment by the gynaecological expert only. Far from
being so, they were all such as the general practitioner is probably treating
every day in his practice, and, if he is satisfied with my results, he can
easily himself carry out the treatment I have employed.
Most of the cases of disease of the pelvic organs in women arise from
a septic condition of the genital tract and its consequences. That present-
day treatment for many of these diseases leaves much to be desired goes
without saying. This is evidenced by the frequent and long-continued
visits of semi-invalid women to the doctor’s consulting-room, varied occa¬
sionally by a stay of a w T eek or two at a nursing home and a probable
operation requiring the administration of chloroform. Let me quote
from an excellent treatise on “ Medical Gynaecology,” just published by
Professor Howard A. Kelly, to prove that I am not exaggerating when I
make these statements. My gynaecological colleagues will admit that this
author is skilful, reliable, and thoroughly up to date. The sole treatment
he recommends for endometritis, including the haemorrhagic form, is, as
might be expected, curettage. Chronic septic cervicitis he rightly char¬
acterizes as one of the most obstinate of all gynaecological affections.
Patients subjected to mild treatments by applications for this affection,
he says, “ will be obliged to frequent the office of the doctor year after
year without gaining any substantial relief.” In his opinion the only
effective treatment is the actual cautery, repeated from once in ten days
to once in two weeks. For chronic vaginitis he finds the best application
to be a strong solution of nitrate of silver, applied in such a manner as
to cause him to consider it a wise plan to keep the patient in bed for
several days after, and to wait for two or three weeks before repeating
this treatment. As to membranous dysmenorrhoea, he says the treat¬
ment is “ discouraging and the prognosis as to recovery with or without
treatment is not good.” He believes that curettage “ may give temporary
relief.”
Seeing that a woman with a chronic muco-purulent discharge from
the vagina is likely to suffer from a septic condition of the vagina, of the
Electro - Therapeu tical Section
133
cervix and of the endometrium, it is obvious that frequently repeated
severe measures must be resorted to for the cure of such a condition.
This, at any rate, is the opinion of a man of wide experience in the
treatment of pelvic affections, and most gynaecologists of the present day
will substantially endorse this verdict, where a radical cure is to be
sought. I admit that considerable improvement often results from com¬
paratively mild measures, but this is, as a rule, only temporary. The
old condition sooner or later returns, and another course of treatment
has to be gone through. Of course I refer to cases of long standing, and
those that present themselves for treatment are, from the nature of the
cases, generally so. Such reflections induced me some time ago to try
the effect of ionic medication in the treatment of these cases, confining
myself at first to those which had resisted all ordinary remedies. I shall
not weary you with notes of all my cases—about twenty in number.
These may be published in due time. Let me give you a brief record,
however, of two of the septic cases, that you may have some idea as to
the chronic and obstinate nature of many of them:—
Mrs. K., aged 41, was never pregnant. First attendance December 3, 1903.
General health poor, stomach distress, constant sickness, muco-colitis, dysmenor-
rhoea, pain in left iliac region, vulva red, tender, “ burning/’ copious thin pus in
vagina and surrounding cervix ; has been curetted once but with little benefit.
December 29, 1903: Uterus curetted; some improvement afterwards,
but the “ creamy ” discharge returned three weeks after. Under treatment,
local and general, continuously from September, 1904, till September, 1905.
September, 1905: Curetted again ; some improvement for two months after.
December, 1905: Using tannic acid pessaries and vaginal douches of solution
of borax for muco-purulent discharge. April, 1906: Still copious yellow dis¬
charge from vagina in spite of regular treatment. October, 1906: Evidence of
left pyosalpinx, which fills and then empties itself into the uterus and vagina at
regular short intervals. December, 1906: Copper ionization, vaginal and
uterine, begun. April, 1907: The secretion from the vagina and cervix is
apparently now normal; there is no purulent discharge ; the general condition
is most satisfactory; the tongue is at last clean, which I have never before seen
it ; the patient herself says that she is more free from pain than she has been
during the past eight or nine years. May, 1907 : Patient now feels quite safe
to remove from Glasgow for permanent residence in the south of England ; she
had delayed taking this step on account of the state of her health.
Miss L. October 31,1906: Was curetted in June last on account of purulent
vaginal discharge, which had lasted for years; there is still a copious discharge
of pus from the vagina. Repeated applications of liquid carbolic acid into the
cervical cavity being found of only temporary benefit, ionization with copper
was now commenced. December 18, 1906: Has had, in all, six applications of
134
Sloan : Ionic Medication in Pelvic Disease
ionic medication ; there is now found only a little whitish yellow deposit around
the cervix ; general health has much improved ; no further treatment required,
except an occasional vaginal douche of a weak solution of alum. Novem¬
ber, 1907: Now in almost perfect health ; no douching lias been required
since July.
All the septic cases in which 1 have employed this treatment have
done equally w r ell with the exception of one. The discharge in this case
had been purulent, profuse, and of long duration, and it had proved
refractory to all treatment, including curettage. The micro-organism
found was the Bacillus coli. I may state here incidentally that in none
of my cases has the gonococcus been found. Ten ionic applications in
all were given to this patient, and about three months after the close of
the treatment Dr. John Ritchie reported to me as follows: “ The
discharge is less yellow, is rather, indeed, of a milky appearance; it is
probable, also, that the total amount is lessened; it seems that at times
it is absent.” This I reckon as one of my tw-o failures. With ordinary
treatment I should have considered the result a modified success.
What has impressed me during the practice of ionic medication has
been the rapid improvement in cases of cervicitis. The discharge, from
having been muco-purulent and copious, has become milky and of small
amount, whilst the gaping os has become normal in size,.with the everted
mucous membrane drawn in, and erosions have rapidly healed. That
the general health invariably improved, coincidently with the cure of the
septic condition, is only w r hat might have been expected, and that a
tongue w r hich had been foul for years owing to autotoxaunia should
become clean and remain so, without any gastric treatment, is one of the
evidences of this constitutional improvement. In two of my cases this
toxaemia was accountable for periodic attacks of severe gastric pain, due
evidently to the effect of the toxannia on the solar plexus. In such cases
the dread of malignant disease on the part of the patient is not the least
of the causes of distress. In one such case, where the pain had lasted
for twelve years, this was completely removed after a few intra-uterine
applications of the copper electrode. This was a year ago, and there has
been practically no return of the pain since.
No case of haemorrhage has failed to yield at once to the treatment
by ionic medication, with one exception—the other failure which I have
to record. This lady came under my care on May 7, 1907, complaining
of menorrhagia, which had been practically continuous since her marriage
seventeen years before. She had never been pregnant and had been
tw ice curetted. The menorrhagia had been severe, and had generally
K1 ec tro- Th era pe utic a 1 Secti o n
135
lasted from two to three weeks. I first curetted her and then applied
ionic medication to the interior of the uterus. At first the result was
gratifying, but later on the haemorrhage returned for a time. The
present report is : “Better than for years ; able to do now what previously
seemed impossible. Menstruation has been almost normal during the
past three months ; the last time was the best for many years.”
Although I am reckoning this as one of my two failures the result here
also would have been looked upon as a modified success under the
previous treatment. In another of the haemorrhage cases, where long-
continued treatment had been of no avail, the bleeding stopped two days
after the second application of ionic medication and it has not returned.
This was a year ago.
I have treated by this means one case only of membranous
dysmenorrhoea. I show you the amount of membrane expelled: first,
at the beginning of the treatment; second, at its close; and third,
two months after cessation of treatment. At the last menstruation no
membrane could be detected. This is the first occasion in which I have
been able to make a satisfactory impression on a case of membranous
dysmenorrhoea. Nine applications in all were given, extending over
a period of seven weeks. The pain, which previously had lasted for
twelve hours, has disappeared with the disappearance of the membrane.
Indeed there is now less dysmenorrhcea than since marriage ten
years ago.
In all my practice I had only one case of bacteriuria in women
which proved intractable. This patient suffered from autotoxsemia,
causing repeated attacks of gastric pain and sickness, which was often
uncontrollable. For years she had been on an average three months in
bed each winter from this cause. Some improvement had taken place
after other sources of sepsis had been removed, such as foul teeth and
septic endometritis; but no treatment by bladder injections or by
general remedies had proved of any avail. Ionic medication of the
interior of the bladder, extending over a period of less than three weeks,
was commenced in March, 1907. In July following my notes state :
“ Better in health than since girlhood.” The urine was still foetid,
however, though less so. In April of this year the urine was found
to be entirely free from odour, and it became perfectly clear on being
filtered through one ply of ordinary filter paper. The general health
had remained good since the last report, the past winter having been the
first for years which required practically no confinement to bed.
Having satisfied myself that ionic medication was of considerable
136
Sloan : Ionic Medication in Pelvic Disease
service in obstinate cases of pelvic disease, and in order to eliminate
as far as possible any post hoc argument, I decided to try this treatment
in the general run of cases. If those previously treated by this means
had benefited in spite of their obstinate character, and if the treatment
was the cause of this benefit, then a fortiori the same treatment ought
to be successful in less obstinate cases.
Before reporting my results in these milder cases let me state that
about a year ago I mentioned my experience of the treatment under
consideration to some of my medical friends. Two of these, namely,
Dr. W. F. Somerville, of this city, and Dr. Agnes Savill, of Harley
Street, have put it to the test, each in two cases where other treatment
had failed, and they have both been kind enough to send me notes of
these cases. Dr. Agnes SavilFs report is: “ The treatment which you
advised me to try worked like magic. I could not have believed it, had
I not seen it and done it.” Dr. Somerville was equally gratified with
his results.
My experience of ionic medication in the milder cases has been
monotonously gratifying. I shall not trouble you with their details, but
shall hasten to describe the method of application of this treatment
which I have found suitable. My experience has been practically limited
to the use of copper and iodine. There has been no necessity to try
other agents. My friend Dr. Lewis Jones has suggested to me, however,
that each micro-organism may have its own specially potent germicide—
copper for one organism, zinc for another, and so on. There is likely to
be something in this, but I cannot speak from experience.
My first difficulty was with electrodes. I have had some made,
however, which give me every satisfaction so far as convenience goes;
and this is more important to the physician and to the patient than
might at first be imagined. I have had a glass speculum made which
suits much better than the ordinary one, and the openings in it near to
the cervical end serve to convey the fluid to the sides of the vagina, thus
distending and filling it. The holder of the electrodes is kept in posi¬
tion by a bag of shot which rests on its broad end on the couch, the
patient being on her back with a bed slipper under the pelvis. This
holder, as you will observe, keeps the speculum in position, preventing
it from slipping out or from dropping. Everything being therefore fixed,
the cervical or intra-uterine electrode can, after insertion through the
speculum, be kept in position with perfect ease and safety. A spiral
of copper wire inserted into the speculum and fixed to it in the way
I show you serves for vaginal applications and also for vulvar by using
Electro-Therapeutical Section
137
it for the purpose of pressing against a pad of cotton soaked in the fluid
and packed carefully against the opened vulva.^The preparation of
copper which I employ is the cupric chloride, the solution being
1 per cent.; and I prefer now always to insert the cervical and the
intra-uterine electrodes through the speculum. This ensures asepsis
and, the uterine electrode having grooves in it, the fluid can pass
readily along its sides and so fill the uterine cavity. Being applied to
the + pole the current must be reversed for about one-third of the time
it has been allowed to flow in order to extricate the electrode ; other¬
wise there will be pain and bleeding. In order to avoid shock the
current must be started and stopped slowly and steadily. I formerly
applied the neutral electrode to the hypogastrium or to the sacral region,
but this involved the undressing of the patient and prevented the cur¬
rent from being diffused equally throughout the cavity of the uterus,
since it takes the most direct course to the neutral electrode. I find
the hands a convenient place for the neutral electrode—a large clay
one—because, being at a distance from the uterus, the current will more
readily diffuse itself over the whole of the uterine wall. All rings must
be removed, however, whilst the current is flowing, otherwise the fingers
may be burnt beneath the rings. No pain need follow the application
when the method I now follow is adopted ; but in some of my early
cases considerable pain and, in two instances, some pelvic cellulitis
followed. No permanent injury, however, resulted.
When the affection partakes at all of a subacute nature, or when
past experience has led to the fear of cellulitis, I prefer to start with
iodine as the ionic agent instead of with copper. Of course the — pole
must then be the active one, and the electrode there should be a
carbon one, such as I show you. There is no advantage in applying
the iodine wholly in an uncombined form, because, as you will observe
from one of the diagrams, it at once becomes converted into Nal when
it enters the tissues. The solution I employ is a 2 per cent, one of
iodide of potassium combined with 0*2 per cent, solution of liquor iodi.
It is well, I find, to have the vulva and vagina fairly free from sepsis by
the ionic measures before using the cervical or the intra-uterine elec¬
trodes, especially the latter. This treatment can with moderate care be
rendered absolutely safe ; and, with the electrodes I show you, involves
no discomfort to the patient, whilst it requires little watching on the part
of the physician. The current can be obtained from a battery of from
fifteen to twenty Leclanch6 cells of good size. I prefer this, as a source
of current, to that obtained by a shunt circuit taken off the electric main.
ju — 6a
138
Sloan : Ionic Medication in Pelvic Disease
A rheostat is required to regulate the current and a galvanometer to
register the quantity used. I find an average dose to be 15 ma. for
from fifteen to twenty minutes. Should a larger dose be desirable, this
can be obtained by placing one pad over the hypogastrium and another
connected with it over the sacral region.
Let me say, in conclusion, that since I commenced to treat pelvic
diseases by means of ionic medication I have treated fewer cases of
septic endometritis by curettage, and I am satisfied, from a long experi¬
ence of the treatment of pelvic affections, inflammatory and septic, that
no other form of treatment will give results in any way approaching
those to be obtained from ionic medication.
PROCEEDINGS
OP THE
«
ROYAL SOCIETY OP MEDICINE
VOLUME THE FIRST
COMPRISING THE REPORT OP TIIE PROCEEDINGS FOR THE
SESSION 1907-8
EPIDEMIOLOGICAL SECTION
LONDON
LONGMANS, GREEN & CO., PATERNOSTER ROW
1908
LONDON :
JOIIN BALE, SONS AND DANIELSSON, LTD.,
OXFORD HOUSE,
GREAT TITCHFIELD STREET, OXFORD STREET, W.
PROCEEDINGS OF THE ROYAL SOCIETY OF MEDICINE
EPIDEMIOLOGICAL SECTION.
CONTENTS.
October 25, 1907.
PAGE
Poverty and Disease, as illustrated by the Course of Typhus Fever and Phthisis
in Ireland (Presidential Address). By A. Nkwsholmb, M.D. ... ... 1
November 22, 1907.
Medical Inspection in Schools : the Gloucestershire Scheme. By Myf.r
Coplans, M.D. ... ... ... ... ... ... ... 45
December 2, 1907.
On the Present Methods of Combating the Plague. By W. M. IIaffkink, C.I.E. 71
Protection of India from Invasion by Bubonic Plague. Bv J. Ashburton
Thompson, M.D. ... ... ... ... ... ... ... 81
January 24, 1908.
Rubella. By E. W. Goodall, M.D. ... ... ... ... ... 101
Rubella: its Identity and Etiology. By H. E. Coubin, D.P.II. ... ... 117
IV
Contents
February 28 , 1908.
PAGE
Mendeli8ra in Relation to Disease. By R. C. Punnett, M.A. ... ... ... 185
March 37, 1908.
A Discussion on “ The Etiology and Epidemiology of Typhoid (Enteric) Fever ” : —
(1) Introductory Address. By Edward C. Seaton, M.D.
(2) Typhoid Carriers, with an account of Two Institution Outbreaks traced
to the same “ Carrier.” By D. S. Davies, M.D., and I. Walker
Hall, M.D. ...
(3) The Potential Dangers of Water derived from Wells in the Chalk.
By H. Meredith Richards, M.D., and J. A. H. Brincker, M.B. ...
(4) The Relation of the Bacillus typhosus to Typhoid Fever. By W. H.
Hamer, M.D.
General Discussion
April, 1908.
On an Epidemic of Small pox of Irregular Type in Trinidad during 1902-4.
By R. Sehrult, M.B. • •• ... ... ... ... ... 229
May 22 , 1908.
Preventive Medicine at Panama. By Sir Frederick Treves, Bt., G.C.V.O.,
C.B., LL.D. . ... ... ... ... ... 303
The Council think it right to state that the Society does not hold itself in any way
responsible for the statements made or the views put forward in the various papers.
169
175
191
204
218
fipifcemtolOGfcal Section.
October 25, 1907.
Dr. Xkwshoi.mk, President of the Section, in the Chair.
PRESIDENTIAL ADDRESS.
Poverty and Disease, as illustrated by the Course of Typhus
Fever and Phthisis in Ireland.
The occasion of this address coincides with an interesting phase in the
history of the Epidemiological Society. Founded in 1850, with a first
President in I)r. Babington, and such historical names amongst its Vice-
Presidents as Thomas Addison, Richard Bright, Southwood Smith, and
Thomas Watson, and among its Members of Council as W. B. Carpenter,
W. W. Gull, W. Jenner, Edmund Parkes, J. Simon, and J. Snow, this
Society during the last fifty-seven years has been the centre to which to
a large extent has converged, and from which lias radiated, our increasing
knowledge of epidemiology. Among its past Presidents are found the
names of Milroy, William Jenner, E. Seaton, J. N. Radcliffe, Joseph
Fayrer, George Buchanan, and R. T. Thorne, and I deeply appreciate
the honour which places my name on a list including not only such
names as the above, but also those of my distinguished living pre¬
decessors.
I address you this (‘veiling as President of the Epidemiological
Section of the new Royal Society of Medicine. Our Society, with
two exceptions, is the oldest of the thirteen societies which so far have
amalgamated; and under the new conditions we anticipate an even
fuller history of interchange of facts and opinions, of records of results
of and of stimulus to further research, and the appearance of annual
volumes of Transactions which will be as valuable and as completely set
forth as those hitherto published.
The amalgamation can be regarded by all alike as a subject for
congratulation, in so far as it indicates a realisation of and a deter-
n —H
2
Newsliolme: Poverty and Disease
urination to promote the unity of Medicine, and an appreciation of the
necessity to base its progress on etiological knowledge. Empiricism has
had its triumphs in medicine. Who can deny it on recalling the history
of the treatment of three of the most decimating diseases in the world’s
history—syphilis, malaria, and rheumatic fever ? Such triumphs are, of
course, rare, and the triumphs of the future, as have been those of the
recent past, will doubtless in the main be the result of accurate scientific
work. If the present hopeful prospect is realised, they will include many
conquests due to increased knowledge of bacteriology and protozoology,
and of general pathology, and to the application of this knowledge to
treatment and prophylaxis.
But, side by side with the brilliant and successful micro-analysis of
pathological processes which has distinguished the *last quarter of a
century, valuable results have already been secured and may be reason¬
ably expected to an increased extent from the enlightened macroscopy of
the community in relation to infective diseases. Although deficient
coordination between the various branches of medicine has impeded the
full utilisation of valuable information, much is being done to improve
our knowledge of the collective aspect of disease. In particular, the
sociological data for our epidemiological investigations are ampler and
more accurate than ever before, and we expect by their means to
improve on the results of our predecessors, who had to work on records
less ample and less accurate. There is only too much room for further
improvement in our records so far as they bear on disease, and it is
particularly incumbent on members of this Society not to allow the
admirable work by Dr. Tathain, our distinguished ex-President, and his
predecessors, to make them forgetful of the disadvantages under which
this work has had to be done, and the importance of helping to secure
the removal of all impediments to complete and accurate records.
Even with present material the epidemiological study of communities
furnishes us w-ith most valuable guidance in the administrative work of
public health; and for my present address I have chosen a subject which
I trust will be found to illustrate this statement.
Poverty and Disease.
Poverty and disease are allied by the closest bonds, and nothing can
be simpler or more certain than the statement that the removal of
poverty w r ould effect an enormous reduction of disease. The removal of
poverty must, therefore, be in itself an object always fascinating to those
w’hose study is the public health. The diseases which would be reduced
Epidemiological Section
3
by this means include not merely tliose which physicians treat, but many
moral diseases which persist because they are only to be avoided by the
poor through the exercise of discipline and self-restraint far beyond what
is practised by the average person in classes not subject to poverty. The
happiness of a community being in itself a desirable object, a national
asset, it is also not irrelevant to consider that the removal of poverty
involves enlarged opportunities for enjoyment, which, rightly directed,
would be only of less value than the removal of disease. It is not
surprising, therefore, that the first impulse of a student of the public well¬
being, in which the public health is the most important factor, is to
attack disease by demanding the reduction of poverty, with its more or
less inevitable accompaniments of over-fatigue, privation, over-crowding,
and dirt. And it must be freely admitted that when the most active
public health administration, including medical aid for the sick, has
attained its utmost efficiency and has in every respect done all that it can
to reduce disease, there will still remain a cruel residuum which can be
attacked in no other way than bv the removal of poverty, or by the
removal from poverty of the elements of personal privation which affect
the public health.
The data of epidemiology owe their chief importance to their use in
relation to the practical problems of public health ; and in prophylaxis it
is supremely important to know the relative value of every weapon that
is available against disease. There is a limit, none the less real because
it fluctuates from generation to generation, to the money and energy
which are available for public health administration ; and money or energy
expended without adequate return represents so much disease allowed to
persist, although it might have been prevented had the available funds
been spent to the best advantage.
It is to epidemiology that public health administrators look for such
data as will enable them to select, from the multitudinous measures open
to them, those which will yield the best return ; and the science is, I
think, well occupied when it is investigating not only the efficient causes
of a disease, but also, in such rough measure as is possible, the manner
and the extent in which each of these causes operates.
The relation of poverty to disease is eminently a problem which
deserves to be studied with this object. In this address I propose to
speak first on the manner in which poverty assists the spread of some
infectious diseases, as illustrated by typhus in Ireland, in order to exhibit
roughly the extent to which epidemics have been due to the migrations
of patients and their relatives, determined by exacerbations of poverty.
4
Newsholme: Poverty and Disease
In sucli an enquiry it is very far from my intention to imply that the
privations of poverty have not, apart from such migrations, played a
material part in the conveyance of infection. Such privations, I am
firmly persuaded, have facilitated not only the spread of infection, hut
also, and probably in much greater measure, the fatality of the disease.
The conditions of poverty in a community exposed to typhus, as to
phthisis, may be compared with the dryness of timber exposed to the
onset of fire. The poorer and the more over-crowded the population, the
drier and the more densely aggregated the timber, the more extensive
will be the epidemic or the conflagration produced by infection or flame.
Similarly with regard to preventive measures : in a community free from
fever or from fire, a most important preventive measure obviously would
be to increase the resisting power of the community to infection, of its
buildings to fire; though at the same time vigorous measures would be
taken to prevent the access of infection or sparks. But when the
community is infected or fires are burning in the vicinity of the desic¬
cated timber the choice of measures is more restricted; for reduction of
susceptibility can seldom be improvised at short notice, as it can in
the exceptional instance of small-pox. To fireproof the timber of a
wooden building is usually less practicable than to stop the access of fire
to it. Under these circumstances the most essential line of action is
to isolate the infection or the fire, so that it may not spread to other
patients or buildings which, however deplorably susceptible, have as yet
not actually been attacked. This line of action cannot reduce the exces¬
sive liability of a poverty-stricken community either to attack by, or to a
fatal issue of attack by, fever, nor obviate entirely the accidents by which
infection will from time to time, in spite of all precautions, gain access
to a susceptible community. So long as the poverty-derived condition
of diminished resistance to infection exists, so long will enhanced toll
be levied by an invading disease. Except on paper, no measures for
controlling the spread of a disease can give absolute protection against
invasion, and the suffering will be greater when the susceptibility of the
invaded population has been increased by privation and over-crowding.
It is conceivable that as our measures against the invasion of
infection become perfected, through our increasing knowledge of
epidemiology, and they become universally applied, the ease with which,
owing to lowered resistance, disease traverses a community may even¬
tually be the chief or even the sole objective of preventive medicine. It
has to be admitted, however, that we have not hitherto perfected our
measures for preventing invasion by infectious disease, and that, apart
Epidemio!ogical Section
from measures for increasing resistance to invasion, we have still much to
learn as to the laws of epidemicity.
My present purpose is to give certain historical facts which, without
furnishing a rigid demonstration, seem to me to indicate that the main
factor in suppressing typhus has been the occurrence of circumstances, or
the more or less unintentional adoption of means, tending to immobilise
infection in invaded districts, and to prevent its travel by means of
ambulatory cases. The practical effect of this view is to emphasise the
special importance to be attached to administrative measures for the
immobilisation of the infection of typhus and of other diseases which
appear to have similar methods of travel.
It is with no disparagement of the value of means for diminishing
susceptibility by removing privation and over-crowding that I seek now
to celebrate the triumphs secured by administrative measures against the
vagrancy of invaded populations and the associated travel of disease. I
have myself on various occasions drawn attention to the effect of over¬
crowding and of privation on the health of the community ; and further
experience and study of the subject have confirmed me in my sense of
the importance of these factors of the public health. I am, moreover,
increasingly sensible of the slowness with which improvements in these
respects can be expected, and, like all my colleagues in the public health
service, have had repeated experiences of occasions when the benefits of
improved nutrition and housing have been wasted because the population
has not been protected from periodical avalanches of infective disease.
Hence, while waiting for economic improvement to reduce further the
privations of poverty, the lesson which I am wishful here and now to
impress upon myself and others is the power of public health measures
to decrease its amount.
Typhus in Ireland.
The greatest prevalence of typhus in Ireland occurred before separate
statistics of this disease became available in 1869. The history of
famine and of typhus in Ireland is closely wrapped up with that of
the potato, introduced in 1610. Even in the early part of the reign of
Charles II. this “ demoralising esculent,” according to Petty, was already
the national food. It was thus described because the life of large
families could be supported by its means with little labour, so that
the subsistence of the population was thus placed at the mercy of a
single crop.
Between 1788 and 1881 the population of Ireland increased from
n— 9 I)
6
Newsholme: Poverty and Disease
3,900,000 to 7,767,401. The potato and the small amount of land
needed for its cultivation made this possible. The rate of wages was
kept down by the same conditions ; and Malthus 1 speculates with much
force on how different would have been the history of Ireland had the
staple food of its population been oatmeal or wheat.
An extreme subdivision of the land occurred during the eighteenth
and early part of the nineteenth century, and the potato enabled the
cottiers to live under the evil conditions thus initiated. During this time,
and especially throughout the Napoleonic wars, Ireland was the granary of
England, and the prosperity of the landlords led them gladly to subdivide
their farms, their tenants further sub-letting to the cottiers. The con¬
tinuing subdivision of the land into potato gardens tended “ slowly but
inevitably to that worst form of civil convulsions—a war for the means
of subsistence,” 2 and verified William Cobbett’s prophecy that “ the
dirty root will be the curse of Ireland.”
The absolute dependence of the Irish agricultural population on the
potato was increased by the fact that there was no such overflow of
population to urban districts as England enjoyed.
Bryce, in the introduction to “ Two Centuries of Irish History,
1691-1870,” says
It was among the Ascendency party that resistance to England began.
They saw Irish manufactures destroyed for the sake of English manufactures;
heavy duties laid on Irish exports to England ; Irish revenues jobbed away in
providing places or pensions for favourites too disreputable even for the corrupt
England of that day. England did nothing for Ireland, and suffered her to do
nothing for herself. (P. xx.)
The immediate effect of famine was widespread migration of popula¬
tion, and vagrancy. Thus Creighton 3 says :—
It was the enormous swarms of people begging at a distance from their
own parishes that spread the infection of fever ; and there appears to have
been as much of beggary in 1741, when Ireland was under-populated with
two millions, as in 1817-18, when it was over-populated with six millions.
Want and fever were endemic, with frequent exacerbations, in the
eighteenth century. During the Napoleonic wars, 1803-1815, fever
was less prevalent, a factitious prosperity being secured by the high
prices then prevailing. With the end of these wars crowding, poverty,
and mendicancy increased, typhus with them. In 1817 these conditions
1 Malthus, on 44 Population,” book iv., chap. xi.
* “ On Locil Disturbances in Ireland,” by Sir Geo. Cornewall Lewis, p. 338.
3 Creighton : 44 A History of Epidemics in Britain,” vol. ii., p. 244.
Kpi(lenu()lo()ic(iI Section
7
culminated in famine, and in the spring of this year “ the whole country
appeared to be in motion.”
J. H. Bridges, 1 referring to this epidemic, says:—
Hordes of starving families were driven from their homesteads into the
garrets and cellars of the nearest town ; when hope of finding work was gone,
and town after town had been visited in vain, they betook themselves to a life
of aimless vagabondage, living on wild turnips and nettles when alms failed,
and carrying death with them. . . . The most potent causes, vagrancy,
starvation, cold, and above all the moral lethargy and despondency resulting
from enforced idleness, . . . were for the statesman rather than for the
physician to cure.
There was no poor-law provision in Ireland until 1838, and its
absence was largely responsible for the wide wanderings of the starving
people. This distressful country was in fact very much in the same
condition as England in the reign of Elizabeth, before poor-laws were
enacted. The hospitable nature of the Irish caused rapid extension
of typhus in this and the next two years, 2 as did also the observance of
wakes, the distribution of soup at centres, and the ordinary annual
migration of agricultural labourers from one part of the country to
another, and over to England and Scotland for haymaking and harvesting.
Over 100,000 cases of fever are known to have passed through the
hospitals during this epidemic, and the total number of cases was
variously estimated at from 400,000 to 1,500,000. It is noteworthy that
certain isolated parts of Ireland, although suffering severely from famine,
escaped infection ; 3 and in this respect the analogous escape of the
inhabitants of lighthouses, &c., from influenza, as recorded by Parsons,
is significant. The teaching of these instances of exceptional freedom
from infection when there was no spread of* infection by the wanderings
and mendicancy of the people was, however, almost entirely lost. Thus
we find the then Chief Secretary of Ireland in 1819 expressing a hope
“ that the lower Irish would be better prepared in future to guard against
such a calamity ; that they would be more cleanly in their persons and
1 J. H. Bridges, in “ Two Centuries of Irish History, 1091-1870,” part iii., p. 2G5.
* Thus, Peel said in the House of Commons, April 22, 1818: “It was lamentable, at
least it was affecting, that this contagion should have arisen from the open character and
feeling of hospitality for which the Irish character is so remarkable.”
J Creighton, op. cit ., vol. ii., p. 262, gives the following instances: “The island of
Katblin, seven miles to the west of Antrim, which was as famished as the mainland, had no
typhus at the time when it was epidemic along the nearest shore. The island of Cape Clear,
at the southernmost point of Ireland, had a similar experience. The whole county of
Wexford, where the soil was dry and the harvest of 1816 had been fair, kept free from typhus
until 1818, partly because it was out of the way of vagrants.”
8
Newsholnie : Poverty and Disease
domestic habits, fumigate their houses, and change their bedding and
clothes.” Excellent advice in its way, but failing in recognition of the
most urgent and governing conditions of the problem. In this, as in
previous epidemics, although* the infectiousness of typhus and its liability
to be conveyed by migrants were recognised, no efficient steps were
taken to immobilise the infection, with the result that patients and their
relatives dragged their fever-tainted persons and clothes to remote
districts.
The need for fever hospitals and for poor-law provision was further
emphasised by the famine of 1822, which “ mowed down the inhabitants
like hay,” and by recurring years of scarcity and fever on a smaller scale
in other years. Finally the Act of 1888 1 was passed. This Act,
unlike the English Act, entirely prohibited outdoor relief, and there was
no law of settlement. Each union was divided into electoral districts,
each chargeable with its own poor. Before the end of 1840,127 unions were
formed, each with its own workhouses, and the total 130 arranged for
in the Act were soon afterwards established. Relief could not be
obtained except in these workhouses, and although some diminution of
suffering must have been caused by them, the unwillingness of the Irish
to enter them left vagrancy rampant, though probably less so than before
their establishment.
The (irent Potato Famine of ls47.
The great failure of the potato crop brought into further relief the
urgent need for reforms. By evicting their tenants landlords had evaded
ehargeability for them under the poor law when they became destitute,
with the result that the outcasts flocked into the towns, and soon were
thrown on their rates. In 1845 the potato crop failed partially,
and in 1840 and 1K47 completely. The blight to which this
failure was due had been seen in Belgium in 1842, in Canada in 1844,
and in England in August 1845. Alarm concerning it was felt in
September of the same year in Ireland, and in fact from one-third to
one-half of the total yield in that year failed. The Irish corn harvest
of 1845 was abundant, rents being paid in corn, oatmeal, and butter,
while the people were suffering the beginnings of starvation. The total
failure of the potato crop in 1840 completed the national calamity.
Epidemic disease prevailed in 1846-7, largely typhus—but along with it
relapsing fever, dysentery, scurvy and purpura—and the total cases of
1 An Act for the more effective Kelief of the Destitute Poor in Ireland (1 and 2 Viet.,
c. 5G, July 31, 1838).
Epidemiological Section
9
sickness were estimated at over a million, or about one-seventh of the
total population. The population of Ireland in 1845 was over eight
millions, of which it was calculated that one-half were dependent on the
potato for subsistence. 1 Its population before and after this period is
shown in the following table :—
Cknsus Populations.
Years of increasing
population
Percentage increase
in the decade
Years of decreasing
population
Fore»*ntage decrease
in the decade
1801
... 5,395,456
. _
1851
... 0,552,385 1
19 8
1811
... 5,037,856
110
1861
... 5,798,967
11*5
1821
... 6,801,827
11-5
1871
... 5,412,377
6-7
1831
... 7,767,401
! 11*4
1881
... 5,174,836
4*4
1841
... 8,175,124
5‘2
1891
... 4,704,750
9 1
1901
... 4,458,775
5-2
From 1846 to 1851 it was calculated that the emigrants from Ireland
numbered 1,240,737. This emigration was in the main subsequent to
the great famine. During its course relief works were organised on a
scale the magnitude of which is indicated by the following figures:—
In Oct., 1846, the average number employed on Relief Works in Ireland was .. 114,000
,, Nov. ,, ,, ,, ,, „ ... 285,000
,, Dec. ,, ,, ,, ,, ,, ... 440,000
,, Jan., 1S47 ,, ,, ,, ,, ... 570,000
,, Feb. „ „ ,, ,, ,, ... 708,000
,, Mar. ,, ,, ,, ,, ,, ... 784,000
In the last-named month it was estimated that 240,000 had already
perished of destitution. Under the schemes of the Relief Committees
that were organised, three million persons at one time were receiving
daily rations. During all this time a fleet of ships left the shores of
Ireland almost daily laden with corn, “ so that the Irish people . . .
perished of hunger in the granary of England.”
Some reference has already been made to the efforts made by the
Government to cope with this great calamity. In addition to the
purchase of maize and its free distribution in Ireland, three Acts were
passed in 1846-7 which made some attempt at dealing with vagrancy,
compelled the appointment of medical and relieving officers, made
owners of land liable to contribute to the poor-rate, authorised the
granting of outdoor relief to the permanently infirm poor, and to the
able-bodied when the workhouse was full, but only on the recommenda-
1 In 1839 Thomas Carlyle wrote in “Chartism”: “Ireland has near seven millions of
working people, the third unit of whom, it appears by statistic science, has not for thirty
weeks each year as many third-rate potatoes as will sullice him. It is a fact perhaps the
most eloquent that was ever written down in any language at any period of the world’s
history.”
10
Newslioline: Poverty and Disease
tion of the Poor Law Commissioners, and as a temporary relaxation,
accompanied by a rigid labour test. Occupiers of more than a quarter
of an acre of land were not entitled to relief; and this enactment
“ forced the Irish cottiers in masses from the soil,” with much immediate
suffering, in order to qualify for relief. “ Had the Act of 1847 been
purposely framed for the weeding out of the Irish cottiers, it could not
have been more effectual,” 1 and a silent exodus occurred ; famine and
the poor-law provisions produced widespread abandonment of holdings
and wholesale emigration.
M iy ra tion fro m I re l a n d .
In 1848 an Act was passed to check the clearances of cottiers,
compelling owners to give forty-eight hours’ notice to Boards of
Guardians, so that shelter for the evicted could be provided in the
workhouses; and in 1862 an amending Poor Law Act was passed,
modifying the “ quarter-acre clause ” except so far as outdoor relief was
concerned. In the three years ending March 1849, 160,000 persons had
been ejected from their holdings of all sizes; 2 between 1849 and 1860,
373,000 families were evicted. 3 Landlords suffered with their tenants,
the poor’s taxes taking all the rent ; and it is stated that one-sixth of
Ireland changed hands. In 1841 there were 698,549 agricultural
holdings in Ireland under fifteen acres; in 1851 the number had been
reduced to 317,665. Further details are shown in the following table.
It will be observed that the change was nearly complete in 1851.
Number
of Small Holdings
in Ireland.
One acre and under 1
i
One to live seres j
Five to fifteen acres
Over lifteen acres
1841
135,314 1
310,430
252,799
127,9G7
1851
37,728
88,083
191,854
290,401
1861
41,561 1
85,469
183,931
299,084
1871
48,4 48
74,809
171,383
j 297,952
1881
10,879
01,751
147,823
272,050
1891
i 18,243
55,554
139,195
1 273,873
1901
1 29,037
52,388
134,188
274,G88
According to official statistics, the number of
Ireland in
1831-41 was 214,047
1811-40 ,, 272,829
1810-51 ,, 1,240,737
1851-01 „ 1,149,118
emigrants from
1801-71 was 708,859
1871-81 „ 018,050
1881-91 „ 708,105
1891-1901 „ 430,993
1 J. H. Bridges, loc. ci(. f p. 425.
a G. L. Lampsou, “A Consideration of the State of Ireland in the 19th Century, 1907, ”p. 283
1 Mulhall, “ Dictionary of Statistics,” p. 175.
Epidemiologica l Sec tion
11
The exact ratio of emigration to population in successive years from
1842 to 1904 is shown in fig. 1, and it is interesting to compare, so far
as the statistical records extend, the coincidences between years of
excessive emigration and of excessive typhus, as shown in fig. 2.
Seasonal Migration from Ireland.
The migration hitherto mentioned was almost solely to the United
States. It was doubtless a temporary cause of increase of typhus both
at such ports as Bristol and Liverpool and in the States, though to
Fig. 1.
Annual Rate of Emigration from Ireland, per 1,000 of Population.
a less extent than the annual migratory movements of agricultural
labourers. Records of disease in England and Scotland show frequent
coincidences between the movements of emigrants and outbreaks of
typhus in the districts visited bv them. Graves, of Dublin, in 1843
wrote:— 1
It is curious that in those towns in England which have greatest inter¬
course with Ireland, as Liverpool, Manchester, Bristol, typhus predominates
more than in others not similarly circumstanced.
Graves's “Clinical Medicine,” 1843, p. 47.
12
Newsholme: Poverty and Disease
He does not, however, regard this as evidence of importation, but
expresses his opinion thus :—
It appears that, as regards Scotland, this explanation is anything but
satisfactory, and it seems more probable that the rest of England, Scotland,
and Ireland, in which the climate is almost the same, possessed almost the
same combination of circumstances which produce typhus.
Fio. 2.
Annual Death-rates from Typhus Fever in England, Scotland and Ireland, per 100,000
of Population since the deaths from this disease were first tabulated separately in the
official reports.
Migration to the United States was not, however, so permanently
dangerous as the inter-migration between different parts of Ireland and
between Ireland and Scotland and England, which annually occurred
Epidemiological Section
13
at times of hay-making, potato digging, and harvesting. This was an
annual phenomenon of old standing, Lecky describing the condition in
the eighteenth century, which still prevailed more or less during the
first half of the nineteenth century, in the following words:— 1
It was still true that, at the beginning of every autumn, the roads were
crowded with barefooted and half-naked mountaineers, who were travelling
on foot 150 or 200 miles, to work for the harvest in England, where they
commonly fell into the hands of contractors known as “ spalpeen brokers,”
who distributed them among the farmers, intercepted a substantial part of
their scanty wages, and imposed on them an amount of labour which few West
Indian planters would have extracted from their negroes. It was still true
that it was a common thing for large farmers, whose lands included barren
mountain tracts, to place cottiers on their lands in order to reclaim them, and
to turn them adrift as soon as by hard labour they had made them productive.
It was still true that cottiers were often obliged to work out the extravagant
rents that were charged for their potato plots, at the rate of fourpence or
fivepence per day; that their sole food, in many districts, was potatoes mixed
with the milk that remained when the butter had been made; that during part
of the year they were often reduced to potatoes and water; and that even
potatoes could not always be counted on.
Some light is thrown on the extent of migration between Great
Britain and Ireland by the fact, noted by Mackay, 2 that in 1841-48 the
difficulty in controlling vagrancy in England was greatly increased by
migration from Ireland. In the year ending March 25, 1848, 15,571
persons were removed under the powers of the Poor Law Acts from
England to Scotland, Ireland, and the Isle of Man, and of these 15,020
were Irish. A large number of the latter were returned by the next
boat after arrival.
Between December 1, 1840, and April 29, 1847, 150,000 persons
landed from Ireland in the one port of Liverpool, and it is noteworthy
that, following on the great epidemic of typhus in Ireland in 1845-47,
50,000 more persons died from “ fever ” in England and Wales than on
an average in each of the five previous years.
Mr. A. Wilson Fox, in his report as Sub-Commissioner to the Royal
Commission on Labour, 1893, says :—
The number of migrating labourers has been steadily decreasing for a
number of years, which is due to the decrease of tillage in England and
Scotland, and to the use of machinery. In Cumberland the adoption of
machinery has entirely done away with the employment of Irishmen at harvest,
1 Lecky, W. E. H.: “A History of Ireland in the 18th Century,” vol. iii., chap, viii.,
pp. 412-414.
- “ History of the English Poor Law,” vol. iii., p. 376.
14
Newsholme: Poverty and Disease
He also quotes the Registrar-General, who stated in his evidence
before the Royal Commission on the Land Acts (Ireland) 1886 :—
In 1841 this migration was common almost all over Ireland, but it is now
confined almost to Connaught and Donegal: in 1841 the migratory labourers
were 58,000; in 1884, 14,000; in 1885, 13,000; in 1886, 12,000. Of these,
10,000 were from Connaught, 7,000 from Mayo alone.
Vagrancy and Mendicancy in Ireland after 1847.
The Act of 1847 1 enacted that persons wandering abroad or
begging in public places, or going from one Union to another, for the
purpose of obtaining relief, should be sent to hard labour. In 1856 it is
noted in the 9th Annual Report of the Poor Law Commissioners in
Ireland that during the last three years there had been a steady diminu¬
tion of mendicancy; and this fits in with the diminished emigration
during these years following the great exodus by death and emigration.
The exact course of vagrancy, apart, from the indications furnished by good
and bad seasons, by emigration, and by seasonal migration, is difficult to
follow in later years, but all the facts point to the conclusion that vagrancy
increased or decreased according as agriculture was temporarily embar¬
rassed or successful.
The Repeal of the Corn Laws and its Effects.
It has been truly said that the rainy seasons accompanying the blight
and the potato famine of 1845-47 washed the corn laws out of the
statute book. 2 * * * * At the head of his reconstituted ministry, in 1846, Peel
proposed and carried the repeal of these laws. Although the removal of
impediments to cheap bread must have had some beneficial result, its
immediate benefits were limited, as the Irish in Ireland had no money.
The w r hole effect of unrestricted importation of corn in widening the
English market did not fully appear until about 1880, wdien the vast
fields of America and Eastern Europe became more generally cultivated,
and improved means of communication made the larger supply of corn
available and cheaper. It is convenient to follow 7 these changes a little
further. Gradually, in the interval from 1849 to 1880, pasture land
1 10 and 11 Viet., c. 84, July 22, 1847.
2 A letter, dated August 15, 1845, from Sir Jas. Graham to Sir ltobt. Peel, bears on this
point (“Life and Letters of Sir Jas. Graham,” vol. ii., p. 21): “ The sun at last is shining
brilliantly and the evening looks well. I know not that the state of affairs is exactly sound
when Ministers are driven to study the barometor with so much anxiety. . . The question
always returns, What is the legislation which most aggravates or mitigates this dispensation
of Providence ? ”
Epidemiological Section
15
replaced corn-growing. This is shown by Dr. Grimshaw’s figures, 1 from
which the following table has been extracted. The increase in pasturage
is the most marked feature, it is stated, in proportion to the decreasing
population. This decreasing agricultural population was the natural
result, as in England, of the replacement of small holdings by large
grazing farms, and cannot be taken as an indication of inferiority or
decadence among the remaining population. (See also p. ‘29.)
Average Acreage per Person under the several Distributions of Land, omitting
the Small Amount under Flax, Woods, Fallow and Bog.
HBHHB
1871-70
i !
1876-80 1
1881-85
| 18m). i>0
1
Cereal Crops
•47 J
[ -46
1 -42
i
j -40
•37
•35
•33
•32
Green Crops
•23
•27
•2G
•27
•27
•25 |
•25
! *2G
Meadow and Clover ,
•20 |
•24
■H8 1
•31
•35
■3G
•39
•45
Grass .]
1
1*49
1-GO
1-7°
1-83 1
1
1*94
, 1 -95 I
! 1
2 03
2*09
The potato famine of 1845-48 was a turning point in the history of
Ireland. Reasons will be given later (p. 2*2) for the conclusion that,
although the population of Ireland has steadily declined since that
disastrous period, “ the well-being of the people has steadily increased.” 2
It is not merely a case of ubi solitudinan faciunt , paean appellant.
While it is true that in agricultural districts cattle and sheep have
largely replaced men, women and children, this is true also of England,
and in the absence among farmers of co-operative production and sale
of products it was the natural result of the new economic conditions.
The keeping of cottiers on their small allotments, under the pre-famine
conditions, was undesirable from every standpoint. The circumstances
of their steady and continuous ejectment present features which no
Englishman can recall without mental discomfort. But the facts
remain, that apart from compulsory ejectments, similar changes in
agricultural conditions, were occurring in both England and Ireland, due
to the same social changes, but that in England these changes were
associated with the enormous development of manufactures and a vast
increase of national wealth, including population ; while in Ireland,
owing to the sparseness of such manufactures, the same changes led to
the transfer of the wealth of population to the United States.
As already stated, the effect on the price of corn of its free importa¬
tion only became felt to the full extent some twenty years after the great
1 Appendix to vol ii. of the “ Report of the Royal Commission on Financial Relations
between Great Britain and Ireland,” p. 447.
2 Creighton, op. cit. } vol ii., p. 295.
16
Newsholme: Poverty and Disease
famine. The same holds true for the competition in providing Great
Britain with meat. Fortunes were made up to 1874 by the price of
cattle; after 1875, owing to American competition, prices began to fall.
Even up to 1877 Ireland enjoyed, with a few exceptions, years of plenty
and high prices. The two bad crops of 1877 and 1878 were then
followed by the famine of 1879-80. Then ensued the usual course of
events—bad crops, inability to pay rent, ejectments. Dr. Grimshaw 1
gives the following figures, the value of potatoes in each year being
calculated at .±'3 a ton :—
Year 1876—potato crop valued at £12,464,300 being 4,154,784 tons.
„ 1877 „ „ 5,271,82*2 „ 1,757,274 ,,
„ 1878 „ „ 7,579,512 ,, 2,526,504 ,,
„ 1879 „ „ 3,341,028 „ 1,113,676 ,,
The difference between 187(5 and 1879 was more than three-fourths of
the entire agricultural rents of Ireland. Similarly, the general crops in
the same four years were valued at 36, 28, 32 and 22 millions sterling
respectively. The effect in respect of the actual number of ejectments is
shown in Dr. Grimshaw’s tables as follows :—
K.IECTMENT SUMMONSES.
Average annual number
in the 25 years, 1853-75
Year 15 m)
Ulster
1,489
2,846
Connaught ...
960
1,995
Munster
1,076
2,345
Leinster
912
1,363
4,437
8,549
In the whole of Ireland the increase in the number of families
recorded as having been actually evicted is shown by the following
table:—
Number of Families Evicted in Ireland.
1869 ... ... ... ... ... 374
1877 ... ... ... ... ... 463
1878 ... ... ... ... ... 980
1879 . 1,238
1880 ... ... ... ... . . 2,110
“ Just as, following the famine years, ejectments multiplied, and
threats of ejectments, so it was in 1879,1880,1881 and 1882.” 2 Collect¬
ing rent by this method of ejectment summonses meant not only
immediate misery, but the dissemination of disease by the scattered
tenants. The result is seen in the typhus curve (fig. 2.). A great increase
in the typhus death-rate occurred in the years 1880-83.
The curve for Dublin shows the oscillations of typhus more markedly
than the smoothed-out curve for Ireland as a whole. It also shows a
much higher death-rate from typhus than Ireland as a whole.
1 Grimshaw, loc. cit.
* Sir Chas. Russell, quoted by L. G. Lampson, op. c/7., appendix, p. 619.
silssisf"”
400
300
/oo\
Fig. 3.
Annual Death-rate per 100,000 living from Typhus in Dublin, from 18G9 to 1905. 1
For the figures relating to typhus and phthisis in Ireland as a whole and in Dublin for
a long series of years, I am indebted to Dr. Mathcson, the Registrar-General of Ireland.
8 88
■■■a
18
Xewsholme : Poverty and Disease
Poor Law Administration in Ireland.
Appalling as were the sufferings of the Irish in the great famine, they
would have been even worse but for the accommodation provided in the
130 workhouses of Ireland (p. 8). Although most of them, during the
recurring epidemics of fever, and particularly in the great epidemic of
1847, became over-crowded pest-houses, the spread of infection thus
caused was probably on a smaller scale than if the patients had been
left in their hovels or by the roadside.
The Special Commissioners (Dr. Lyon Playfair and Professor Lindley)
sent by the British Government to investigate and report on the
potato-blight and famine, in their report dated January 20, 184(5, said :—
The poor-houses will without doubt be found a most valuable means of
relief, and we consider it a most providential circumstance that such an
extensive resource is available against a calamity more widely extended, and
more serious in its nature, than any that has affected the Irish people since the
year 1817.
The number relieved out of the poor-rates at one time reached
800,000, and the workhouses and 207 temporary fever hospitals that
were built received 279,723 patients in the two years 1847-48. The
emigrants in 1849 numbered 214,425. Fig. 1 gives some indication
in emigration of the clearances of small holdings effected after
the famine. Had there been no poor-law provision the suffering
would have been even greater during these five years of rapid clearance
of small holdings. The restrictions as to the giving of outdoor relief
were temporarily relaxed during the great famine, a circumstance
which filled the landlords with alarm. In many instances owner and
occupier sank in a common ruin. In other instances estates were
cleared to avoid the charges. After the famine the rigid conditions as
to out-relief were re-imposed, but as shown by fig. 4, in which the
amount of indoor, outdoor, and total pauperism in Ireland in the years
1852 to 1906 is shown, outdoor relief steadily became more general, and
from 1880 omvards the policy of the poor-law authorities of Ireland was
to a large extent inverted. It cannot be said exactly what proportion of
the total typhus patients were treated in the fever hospitals and in¬
firmaries, but the proportion was high and became higher as time went
on. Objections to institutional treatment were not so great in an
acute febrile disease like typhus, presenting alarming symptoms, as in a
chronic disease like phthisis; in which, as I have shown elsewhere, 1
Journal of Jlugicmi, Vol. vi., July, 1906, p. 304.
Epide)nioloqical Section
19
institutional treatment was exceptional, relatively short in duration, and
under unsatisfactory conditions. Quite apart from the institutional
treatment of the sick, the poor-law provisions steadily restrained the
wanderings of convalescent patients and of their relatives, and the
2900
60
2600
50
2700
SO
2 600
50
2SOO
50
2400
SO
2300
SO
2200
SO
2100
60
2000
SO
/900
/600
SO
1700
SO
/« 00
so
/soo
1400
1200
so
1100
so
1000
* so
900
50
900
* 50
700
SO
600
Fig. 4.
Daily Average Number per 100,000 living in receipt of Poor Relief in Ireland in each
year, from the years 1851-‘2 to 1905-6. From returns kindly supplied by H. Courtenay, Esq.,
of the Local Government Board of Ireland.—(For data see p. 4‘2.)
epidemic of 1880-83, was not only on a much smaller scale than former
epidemics, but was also the last serious epidemic of typhus in Ireland.
The disease still smoulders, especially in its towns, and the curve for
20
Newsliolme : Poverty and Disease
Dublin (fig. 3) shows occasional epidemics on a smaller scale than
formerly, which are less recognisable in the smoothed-out curve for the
whole of Ireland (fig. 2). The general trend, however, has been one
of steady improvement, and a glance at fig. 2, shows that although
Ireland has lagged behind England and Scotland, and still has some
arrears to make up, the condition of the United Kingdom in respect of
typhus is rapidly approaching a condition equally satisfactory in all its
three countries.
Contrast between Typhus Fever and Phthisis in Ireland.
The study of typhus in Ireland has shown us that this country has
suffered more severely than Great Britain, and that the great decline in
the death-toll from this disease which characterises each part of the
United Kingdom has been belated in Ireland, and even now is less than
that in England and Scotland. This decline has been associated in each
part of the United Kingdom with elevation of the standard of well-being, 1
diminution of over-crowding, improvement of conditions of housing, and
increased enforcement of regulations and provisions preventing the
spread of infection. It has been impracticable for me to compare
the separate operation and effects on typhus of each of these factors in
different countries, in which they are operating in different combinations
and to a varying extent, as I was able to do in the case of phthisis
in an investigation the results of which were laid before this Society
last year. 1 I cannot, therefore, apportion exactly the relative share of
each of these factors in producing the favourable result, though there
can, I think, be no hesitation in placing means for immobilising infec¬
tion in the first place. In this respect typhus must take its place beside
small-pox, with the difference that in the latter disease we have the
means of rendering the population immune against the invading dis¬
ease. The immobilisation of infection, as we have seen, has been
secured in part by the segregation of patients in fever wards, and in
part by removing the inducements to vagrancy.
Although it is impracticable, when considering typhus, to state
separately and more exactly the precise share of each factor in pro¬
ducing the reduction in its amount, we have in our comparative
1 The separable elements under this heading are detailed in my paper on “ The Relative
Importance of the Constituent Factors involved in the Control of Pulmonary Tuberculosis,”
Tram. Epidem. Soc., 1905, p. 31, and more exactly in “ An Enquiry into the Principal Causes
of the Reduction in the Death-rate from Phthisis during the last 40 Years, with Special
Reference to the Segregation of Phthisical Patients in General Institutions,” Journal of
Hygiene , vol. vi., July, 1900, p. 328.
Epidemiological Section
21
experience of phthisis what approaches the character of a cheek experi¬
ment. This will be evident when the death-rates for a long series of
years from typhus and phthisis are compared. In the accompanying
figures (figs. 5 and (>) such rates are set forth for each disease as percentage
deviations from the average death-rate for the whole period under com¬
parison. In order that a correct interpretation may be given to these
figures, the following limiting and mean death-rates for the period
under consideration must be borne in mind :—
Death-rates per million
Ireland
Maximum
Minimum
Mean
Typhus
179 in 1880
12 in 1904
90 in 1869-1905
Phthisis
2,260 in 1900
1,780 in 1874
2,060 in 1869-1905
(Maximum
Dublin - Minimum
(Mean
548 in 1881
0 in 1905
150 in 1869-1905
3,670 in 1883
2,740 in 1874
3,230 in 1869-1905
England ( Maximum
aud j Minimum
Wales (Mean
193 in 1869
1 in 1905
30 in 1869 1905
2,530 in 1870
1,140 in 1905
1,806 in 1869-1905
London
Maximum
Minimum
Mean
225 in 1869
0 in 1905
28 in 1869-1905
2,770 in 1869
1,440 in 1905
2,120 in 1869 1905
In fig. 2, the death-rates from typhus in England. Scotland and
Ireland have been already given. On inspecting these diagrams, it is
at once clear that in England (and, it may be added, in Scotland) the
phthisis and typhus curves have moved in the same direction, and that
both diseases show great decreases. As might be expected from the
short-lived infectivity in typhus, and the protracted but much less
active infectivity in phthisis, the latter is much more remote from the
extinction-point than the former.
Now, if improvement in general well-being of the population, associ¬
ated w r ith better nutrition, diminished over-crowding, and improved
housing, has, as is commonly stated, been the main determining cause of
the diminished mortality from typhus and from phthisis in England and
in Scotland, how has the equally striking diminution of typhus in
Ireland been brought about, and why has it not only not been accom¬
panied by any diminution in the death-rate from phthisis, but by an
actual increase in the death-rate from this disease ? 1
1 I have left out of the discussion the question of the trustworthincss of the national
statistical returns for phthisis. This may be safely done for the following reason. There is
strong cause for believing that in England, and probably also in Ireland, in the earlier years
of registration of deaths, many diseases accompanied by cough and wasting were returned as
consumption which* were not really so. This may account for a in my opinion—small
n —10 E
22
Newsholme: Poverty and Disease
The same causes cannot in two countries have produced, so far as
phthisis is concerned, opposite results ; and as the same results have not
appeared in the two countries it becomes necessary to review the con¬
ventional list of causes, and to enquire whether any counteracting influ¬
ences have prevented their results from emerging. Thus either social
well-being, has or has not improved in Ireland. If it has not, the
decline of typhus cannot be ascribed in any measure to it. Other im¬
portant factors must have been at work. If Ireland has improved in
well-being, the non-decline and increase of phthisis must be due to
causes which are more weighty in increasing its fatal prevalence than
improved well-being is in tending to reduce it.
In attempting to explain this puzzling discrepancy, certain points
need preliminary discussion. These relate (a) to the changes in the
social and sanitary conditions of the population of Ireland; (b) to the
question as to whether, apart from human intervention, the diseases with
which we are concerned “ tend ” to die out; and (c) to the question as to
whether the present population of Ireland is less able to resist such a
disease as phthisis than its former population.
(a) The Social and Sanitary Conditions of Ireland.
The changes which Ireland as a whole has undergone in social and
sanitary conditions are intimately related to our subject, and may be
summarised here.
tl) Ireland has shared with Great Britain the increased cheapness of
peicentage of the great decline in the death-rate from phthisis shown by the English figures.
Assuming, as is likely, that the same cause has operated in Irelaud, the increase shown in its
death-rate from phthisis ought to be greater than the recorded figures indicate. For the
present purpose we may therefore ignore it. If a correction could be made the contrast
between England and Ireland would not thereby be made less striking.
A further statistical point may be mentioned here. The population of Ireland is on an
average much older than that of England, and than that of Ireland in the past, and as
phthisis is more fatal in younger adult life than later, a correction is needed for this. On
making the necessary correction, the corrected death-rate from phthisis in Ireland in 1891
became 17 7 instead of UK) per 10,000. In other words, the increase of the phthisis death-
rate in Ireland is greater than the curves in fig. 5 indicate.
This is a convenient place for noting that the part of fig. 5 relating to phthisis in England
and Wales is calculated from death-rates corrected for age and sex distribution kindly
supplied by Dr. Tatham. Sir Shirley Murphy has also favoured me with the results of an
elaborate calculation made in his office, which show that to compare with age and sex distri¬
bution like that of 1901 the death-rates from phthisis in London at earlier years, it is
necessary to add the following percentages to the uncorricted death-rates: for 1871, male,
412 per cent., female, 2 56 per cent. ; for 1881, male. 5*42 per cent., female, 3 78 per cent. ;
for 1891, male, 4*42 per cent,, female, 3 03 per cent. The correction would not very
materially alter the curve for London, given in fig. G.
in London, as shown in each case by Percentage Deviations from the Average Death-rate
for the entire period, 1869-1905. (For data see p. 44.)
Kp i (1 e mi 'olotj i ca 1 Section 23
food and of total cost of living which is so striking a feature of the past
twenty-five years. 1
(2) This increased cheapness in living has not been counteracted by
lower wages. Wilson Fox’s tables 2 show'that between 1870 and 1903
the wages of agricultural labourers have increased 23 per cent, in
England and Wales, 45 per cent, in Scotland, and 42 per cent, in
Ireland. They are still very much low'er in Ireland than in Great
Britain, but from our present standpoint the important consideration is
that they have greatly increased.
(3) In housing, Ireland has greatly improved its position. In some
respects its average condition is better than that of Scotland, which has
experienced a great reduction of phthisis. In 1901, in Scotland 17'5
per cent, of the total dwellings, in Ireland 8*7 per cent., and in England
3*0 per cent, of the total dwellings consisted of only one room; further¬
more, of these one-roomed tenements the proportion having five or more
persons in each tenement was 3*27 per cent, in Scotland, 1*78 per cent,
in Ireland, and 0*15 per cent, in England. 8
There has been also a great improvement in the class of house
occupied by the majority of the population. The figures on this point
are given more fully elsewhere. 4 In the following table they are
summarised for the w r hole of Ireland :—
Percentage of Different Classes of Houses in Ireland.
1841
1801
1881
185*1
15*01
1st dMB
3-0
8-3
9-7
10-5
... 11-2
2nd „
19-9
... 376
... 46-9
... 53*6
... 593
3rd „
40'1
... 45-7
... 39-2
... 33 8
... 28-4
4th „
37*0
8-4
4-2
2-1
11
100-0
100-0
100*0
100 0
100-0
The fourth class of houses comprises chiefly houses of mud or other
perishable materials, having only one room and w T indow r ; the third class,
a rather better class of house, having tw-o to four rooms and as many
windows; the second class is equivalent to what would be considered a
good farm-house, having five to nine rooms and window's; and the first
class comprises all better houses. The changes in the proportion of these
different classes of houses are set forth more clearly in fig. 7.
1 For details see the previously quoted paper in the Journal of Hygiene , 1906, p. 329 et scg.
■ Quoted in the same paper, and given in detail in the Official Blue Book, Cd. 2376, p. 5.
J “ The Housing of the People of Ireland during the period 1841-1900,” by It. E. Matheson,
LL.D., Registrar General of Ireland.
1 Journal of Hygiene , 1906, p. 325, quoted from Dr. Mathesoifs paper.
24
Newsholine: Poverty and Disease
In passing, evidence showing that the size of the dwelling does not
necessarily govern the total death-toll from phthisis in a given popula¬
tion may be noted. Dr. Matheson 1 gives the following table of housing
conditions, to which I have added the corresponding death-rates from
phthisis, as an index of social misery:—
! Number of
one-roomed j
) tenements per i
cent, of total !
! dwellings
1 or tenements
Number of one-roomed
tenements having five or
more occupants each in
every 100 tenements of all
classes
; i
Number of persons in
one-roomed tenements,
I with five or more
occupants in every 100
of the total population
Average death-
rate from
phthisis jier
100,000 living
in the three
years, 1900-1-2
Dublin
36-70
8-69
10*61
329
Belfast
1*00
0 09
010
313
London ...
14-66
0 57
0-70
i 171
Liverpool
6-14
0-22
0-24
190
Manchester
1-90
0 04
0-05
208
Edinburgh
16*98
1-80
2-33
164
Glasgow ...
.1 26-11
i
4*28
!
5-24
177
This does not imply that in a given town the death-rate from
phthisis is not higher in the smaller and more overcrowded tenements.
Abundant statistics show this to be the case. But it is clear from the
above table that size of dwelling or even degree of overcrowding may be
overshadowed by the effect of other influences.
(4) Further evidence of improvement in Ireland is furnished by the
fact that the amount of income assessed to income tax has increased 25
per cent, between 1853 and 1890, although incomes between £100 and
£150 have ceased to be assessed. As supplementing this somewhat
deceptive test, which applies only to incomes over £150, reference may be
made to the increase in wages of agricultural labourers (p. 23) and to the
lodgments in savings banks, which increased from £2,700,000 in 1870 to
£0,970,000 in 1894. Sir H. A. Robinson, in giving evidence before
the Financial Relations Commission, 2 although he quotes marriage-
rates and birth-rates and insanity-rates as evidence of national decadence
in Ireland, and doubts “if there is much improvement in their
financial condition/’ is emphatic as to the enormous improvement in
the standard of living, the reduced rents, and the lowered cost of
living. He states that the people do not live on potatoes as formerly ;
“ perhaps one meal a day, but twenty years ago they lived on them
almost entirely.“
1 Loc. cit., p. r.i.
* “ Report of the Royal Commission on Financial Relations between Great Britain and
Ireland,” p. 207.
Epidemiological Section
2 a
(5) The poor-law statistics at first sight appear to indicate an almost
stationary amount of pauperism between 1880 and the present time
(fig. 4). But if a statistical correction is made for the fact that the
proportion living at ages of dependency has increased (see table on
p. *29), the rates would then show some decline in the amount of total
Fig. 7.
Showing steady improvement in Housing Conditions in Ireland.
pauperism. Even though some share in the non-decline of the rate
of pauperism is due to the excessive proportion of the population
which is of dependent ages, this does not make the excessive pauperism
the less a burden on the community. This is so, and the fact is a
serious handicap to the prosperity of Ireland. But even with this handi¬
cap there is no increase of pauperism during the last twenty years, and
all the other indications show increased social prosperity during the
same period.
20
Xewsholme: Poverty and Disease
A further correction in the poor-law statistics needs to be made,
which cannot be expressed arithmetically. The amount of poverty
relieved officially depends very largely on the system of relief adopted.
In England the “house-test” has been insisted on to an increasing
extent, and at the same time, since 1805, there has been an immense
reform in the conditions under which the poor, and especially the sick
poor, have been treated in the workhouses and infirmaries. The
great decline of total pauperism, showing itself chiefly by decline of
outdoor pauperism, lias been undoubtedly aided by this method of
administration. Ireland has pursued an exactly opposite policy.
Beginning with a more rigid insistence on the indoor test for
relief than has ever been enforced in England, it has gradually relaxed
this test, until, as shown in fig. 4, it has settled down to a vast dispensary
system of home-relief of the sick, along with a large amount of indoor
relief, the statistical proportions of which are swollen by the fact that
the workhouses and infirmaries of Ireland are used very largely as
general hospitals, especially for surgical cases. 1 In the year 1908-4
the proportion of new cases of sickness attended either at outdoor
dispensaries or in their own homes formed nearly one in eight of the
total population of Ireland. If, then, it is taken into account that the
poor-law institutions are used largely for the same purposes as voluntary
hospitals in England, and that medical and general relief are given
and accepted very readily at the homes of the people, there can
remain little doubt that the non-decline of total pauperism in Ireland is
due to statistical and administrative causes.
(b) The "Tendency" of Certain Diseases to Die Out.
The doctrine indicated above* cannot be better described than in the
following paragraph from a recent article in a medical journal:—
While these far-reaching controversies are being waged the disease
(tuberculosis), in so far as England and Wales are concerned, continues to
decrease, as evidenced by the death-rate. Indeed, the behaviour of the
disease in this country seems to suggest that tuberculosis, like leprosy and
typhus fever, may be tending towards extinction, and the problem in adminis¬
tration which is presented to all intelligent minds is as to the means by which
the decrease in the death-rate may be accelerated. 2
1 For details see the evideuce given before the* recent Viceregal Commission on the Poor
Laws, and Journal of Hygiene, July. 1900, p. 381.
- Lancet, July 80. 1907, vol. ii., p. 108.
Kpirfemiolofjical Section
21
A careful perusal does not indicate that any injustice is done by
removing this extract from its context. Jt is remarkable that small-pox
does not appear among the diseases enumerated, for small-pox is as
clearly “ tending” towards extinction as typhus and tuberculosis, and who
shall say, in view of this mystical doctrine, to what extent its decline has
been caused by vaccination, by sanitary administration, including prompt
segregation of the sick, and by this “ tendency towards extinction”?
Probably, if the writer of the above words were questioned on the
subject, he would, on reflection, disclaim a mere tendency towards
extinction, which, like Melchizedek, is “without father, without mother,
without descent ” ; and would define the word “ tendency ’* as applying to
factors of whose method of operation we know nothing. When thus
reduced, the word leaves us less the victims of blind chance than at
first appeared. The diseases enumerated, and we might add plague and
malaria in this country to the list, have tended to extinction. No one
now, acquainted as we are with the relation of rats to plague and of
mosquitoes to malaria, would hesitate in giving first place to influences
inimical to these carriers of infection, in bringing about the disappearance
of these diseases from England ; though he might be uncertain as to
the exact mode by which the link in the chain of infection had been
broken in each instance. 1 Similarly, although there may still be
1 The history of the disappearance of endemic plague from England is full of interest in
this connection. After having been domesticated in England for about three hundred years,
this exotic infection finally disappeared as an endemic disease towards the end of the 17th
century. The fiction that the Great Fire in Loudon in 166G caused its extinction still
persists, as sefcn in a recent contribution on disinfection in the Practitioner (September, 1907).
In actual fact, this fire only involved a part of London, many parts affected with plague
escaping, and both London and provincial towns had cases of plague for years afterwards.
Furthermore, as Creighton points out (vol. ii., p. 4‘2), the streets and alleys of London were
somewhat closely reproduced on the old foundations.
Creighton makes the very interesting suggestion that it was the substitution of coffin
burial for burial in shrouds or cerecloths that was responsible for the disappearance of plague,
acting, lie suggests, by preventing contamination of the soil in the crowded churchyards.
Although burial in stone or wooden coffins had been prevalent for the well-to-do, burial in
winding-sheets only was still the usual method of burial in the time of Charles II. In 1666
Acts were passed permitting only woollen shrouds to he used in Eugland (Acts 30 Car. II. c. 3
and 36 ejusdem c. 1). The first of these Acts was “ for lessening the importation of linen
from beyond the seas, and the encouragement of the woollen aud paper manufactures of the
kingdom.*’ This Act was not repealed till 1816. The material generally substituted for linen
was flannel. According to Misson, it was “not lawful to use the least needleful of thread or
silk.” The above Acts were intended to protect the English woollen industry against the
Irish and foreign linen trade. It appears, however, that the use of woollen shrouds was
very unpopular, and coflius rapidly replaced them towards the end of Charles the Second's
reign.
The time of the Hanoverian invasion was then drawing nigh. And this brought with it,
even during Queen Anne’s reign, the brown rat, which rapidly decimated the number of the
‘28
Newsholrne : Poverty and Disease
differences of opinion as to the relative share borne by increased
domestic cleanliness and the extensive segregation of the sick in
producing the extinction of leprosy from this country, we have no
doubt that these, and not a vague “ tendency to extinction,” have
produced the result.
So also with typhus and phthisis. They are “ tending to extinction ”
when their known methods of spread are impeded. They still spread
when limits to their spread are imposed ineffectively. There may be
and are, in regard to typhus, differences of opinion as to the relative
share which diminution of malnutrition, of overcrowding, and of
personal infection have had in bringing about the result, but history
clearly shows that they are measurable factors and not mere “ tendencies."
So also with phthisis. In all these diseases it is unnecessary and
unwise to suggest the existence of factors tending to extinction—for a
“ tendency ” without some agency to produce it is inconceivable—not
merely because it offends against the old logical rule, William of
Occam’s razor, “ entia non sunt multipUcanda [meter necessitatem ,” but
chiefly because a mere suggestion, w ithout investigation of and search
after the unknown factor, is apt to make one l>elieve that a real
explanatory formula has been obtained, while investigation on known
lines of causation is being neglected. I think, therefore, it is important
to remember that when it is sought to connect the decrease in phthisis
and typhus w r ith an assumed tendency in these diseases to decrease apart
from prophylactic measures, the explanation is supported by no evidence
except the existence* of the fact which it is sought to explain.
indigenous black rat. So rapid was the invasion of this larger brown rat that it was uot
among the least of the causes of complaint by the Jacobites against the new regime. The
exact date of its invasion is doubtful. Pallas states that a great western movement of the
brown rat was noticeable in 1727, and that it reached Paris in 1750. Professor Boyd
Dawkins says that it reached England a little before 1730. Waterton states that it came
from Hanover in a ship soon after the year 1688. Millais (“ The Mammals of Great Britain and
Ireland,” 1905, vol. ii., p. 205 ct scq.) says that “ a middle date, that given by Pennant, who
said that it appeared in England about 200 years ago, is probably somewhere about the
correct time.” This would be almost forty years after the Great Fire. Probably it came
earlier than this. The change of rats was not complete, for black rats are still numerous in
the Channel Islands, and are to be seen elsewhere in the United Kingdom.
From the preceding historical facts two possible alternative explanations of the disappear¬
ance of plague emerge. It may have been due to the change of species of rat, involving the
overrunning of the country by a rat not infested by fleas which bite the human.species. I
suggest the tentative view that the coffin-burial was the more efficient agent in diminishing
plague ; not, as has been suggested, by diminishing the contamination of urban soil, but by
preventing the predations of rats on the buried and uncoffined corpses and their subsequent
raids on human food, and contamination more generally of dwelling houses.
29
K pidem i< >1<«jiea 1 See tu>u
(e) The Residual Population of Ireland.
In drawing inferences from the history of phthisis in Ireland, and
from the comparison between its course and that of typhus in Ireland,
it is necessary to ascertain whether this history has not been modified by
decadence of the population.
The view is very commonly held that the long stream of emigration
from Ireland (fig. 1) has left behind a physically inferior population
excessively susceptible to phthisis. . There has been much confusion in
writing on this point, which can only be removed by separating the
statistical from the. social sources of inferiority. Emigration has produced
the age distribution of population in Ireland shown in the following
table:—
Census Population of Ireland at Different Age Periods, stated in Proportion
to 10,000 Persons at all Ages.
Ages
1801
1881
1901
Uuder 15
3,278
3,503
3,035
l.V 55
5,500
5,164
5,539
55-65
740
704
788
05 and over
482
629
638
All ages
10,000
10,000
10,000
It will be noted
that there is
a great increase in
the number aged
sixty-five and over
between 1861
and 1881, but that since that time the
number at these ages has remained fairly constant. When the present
proportions at different ages are
Wales and Scotland the following
compared with those in England and
results appear:—
Ages
England and Wales Scotland
Ireland
Under 15
3,242
3,343
3,035
15—55
5,694
5,573
5,539
55-65
597
600
i 788
65 and upwards
467
484
638
All ages
10,000
10,000
10,000
Ireland evidently has a much larger proportion of aged persons in
its population than either England or Scotland. This source of error
can be corrected for, as has already been done for phthisis. Similarly,
to compare the rate of insanity or the birth-rate (without the necessary
correction in this instance for proportion of married people at child¬
hearing ages) of Ireland with that of England or Scotland, implies that
30 Newsholme: Poverty and Disease
trustworthy comparisons of insanity or of fertility in the three countries
are not obtained.
The greater average age of the population of Ireland in itself would
tend to produce a higher rate of pauperism or of insanity per 1,000 of
total population, and in actual fact, therefore, Ireland is seriously handi¬
capped in its care of its paupers and insane by the results of emigration.
There are, however, reasons for thinking that, apart from the greater
average age of its population, the present population of Ireland is not
physically inferior to its past.
(1) Some light is thrown on the subject by the birth-rate. This,
when corrected as above indicated, has slightly increased in Ireland. 1
There is no evidence of decadence in this respect.
(2) The chief emigration from Ireland has been to the United States.
If the cause of the increased death-rate from phthisis in Ireland is the
physical inferiority of its residual population, the death-rate from phthisis
of the Irish population in the United States ought to be lower than that
in Ireland. It is practically certain that no disturbing influence in such
a comparison is exercised by greater well-being or better sanitation or
housing in Ireland than in the United States. The American Census
Report for 1900 2 gives the death-rates from phthisis in the registration area
and its subdivisions among whites in the census year, classified according
to the birthplaces of the mothers of the deceased. For all inhabitants of
these States the phthisis death-rate in 1900 was 113, for English
(defined as above) 135, for Scotch 173, for Germans 167, for Irish
340. The difference is seen both in cities and in rural districts, the
phthisis death-rate of the Irish in rural districts being 239 as compared
with a general rate of 108. In Ireland in the same year the phthisis
death-rate was 226 and in Dublin 346. These are death-rates uncor¬
rected for age-distribution. For such correction we turn to the vital
statistics for the City of Providence, Rhode Island, which are well
known to be among the most trustworthy in the United States. Dr.
Chapin, the city registrar and medical officer of health, has published
statistics corrected for age distribution which enable a corrected com¬
parison to be made. He applied 3 the death-rate from phthisis in Ireland
in 1901 for sex and age periods to the population of Providence in 1900
1 See “Tbe Decline of Human Fertility ” (Newsholme and Stevenson), Journal lioynl
Statist. Society, vol. lxix., part 1, 190G, p. 40.
* “ Census of the United States,** 1900, vol. iii., Vital Statistics , part 1, p. clxxvii.
“51st Annual Report upon the Births, Marriages and Deaths in the City of Providence
for the year 1905,” by C. V. Chapin, M.D., p. 85.
Epidemiological Section
31
lx>rn of Irish mothers. “It was found that the theoretical mortality
from phthisis of this element of the population [of Providence] according
to these [the Irish] data was 258 per 100,000 living. The actual rate
for the period 1896-1905 was, however, 339. The mortality from phthisis
of the Irish in Providence is therefore 81 per 100,000, or 31*4 per cent,
more than the mortality of the Irish in Ireland.” We may, I think,
conclude that the Irish in America are a physically inferior population to
an even greater extent than the Irish in Ireland, if physical inferiority
is to be inferred from a high phthisical death-rate.
(3) Belfast is the part of Ireland which probably has suffered least
from emigration and which is commercially the most prosperous. And
yet the death-rate from phthisis was 307 per 100,000 of population
in the five years 1901-6 as compared with 315 in Dublin.
(4) The physically inferior condition of the residual population in
Ireland, contradicted by the preceding considerations, was equally im¬
probable in view of the history of Ireland since the great famine.
However lamentable from other points of view is its steady stream
of emigration, the majority of those driven out were among the poorest,
and these, owing to their extreme poverty, must have been among the
least fit. This is shown by the figures on p. 10. The cottiers and farm
labourers on the smallest holdings were those who emigrated in the
largest numbers; and although the great clearances and the formation of
large grazing farms (see p. 15) have made Ireland a land of silence,
those remaining are children of the families who could resist the
extrusive force of evictions, Ac., and who since that period have been
living under progressively better conditions than their predecessors in
the more distressful past.
licricw of the Factors cansiny Typhus, and of those Seen tiny its Steady
Progress towards Extinction.
ia) Specific Infection. —Our survey of the history of typhus in Ireland
shows that the disease has been associated with infection, malnutrition,
overcrowding and vagrancy. The difficulty in assigning to the last three
factors their relative importance in determining epidemics lies in the
fact that they mostly occur and vary together. The frequency with
which each of them has been associated with the disease has left no doubt
of the influence of all of them on its course. Indeed, the evidence of this
influence is so strong, and the difficulty of tracing the importation of
infection has been sometimes so great, that the necessity of the intro¬
duction of a specific organism has not infrequently been called in
32 Newsholme: Poverty and Disease
question. Thus Jacquot, the French medical historian of the Crimean
war, wrote :— 1
Pas une contestation ne s'est elev6e au sujet de la cause du typhus ; les faits
sont clairs et parlants ; le typhus spontan6 est du aux miasmes humains qui
s’exhalenfc au milieu de Tagglom^ration, de l’encombrement, etc. On pent
faire naitre le typhus a volonte , pour ainsi dire.
More recent writers give an opinion which is more in accord with
our general knowledge of infective diseases. Thus Dr. F. M. Sandwifch 2
says:—
It is often impossible to trace the infection, but the old doctrine of
spontaneous generation of typhus is opposed to all analogy, and need not be
discussed. . . .
Similarly, Professor Curschmann, of Leipzig, 3 says :—
If such objects (clothing, curtains, carpets, &c.) are protected against contact
with air, the contagion clinging to them may maintain its vitality for many
months, or even longer under especially favourable circumstances, and the
disease may thus be carried to distant localities. . . . Such a transmission
of the poison would furnish the most natural etiological explanation of the well-
known so-called spontaneous epidemics in prison, on board ships, &c. . . .
Healthy persons may, without becoming infected themselves, carry the poison
in their clothes or in their hair.
It is certain that the disease does not arise spontaneously. . . . The con¬
dition of the individual, especially a depraved state of nutrition and loss of vital
energy due to the effects of poverty, hunger and disease, exerts an enormous
influence on the disposition.
Between these two extremes comes an alternative which differs from
the theory of de novo origin theoretically rather than in its practical
conclusions. This is suggested, for instance, in the account of a small
outbreak in an English town in 1890, 4 in which “ it was found
entirely impossible to discover any source of infection as a cause of
either of the two portions of this outbreak,” and the narrator confirms
the common experience by his own, that it had been “ the exception to be
able to find a history of possible or probable infection from others ”; and
adds that the outbreak seems to suggest, “ unless we are prepared to
admit a de novo origin, the more or less universal existence of a specific
organism which under ordinary circumstances does not develop suffi¬
ciently to display its potential infectivity, but which under special
1 44 Du Typhus de PArm6e d’Orient,” Paris, 1858; quoted on p. 248 of Sir J. W. Moore’s
44 Continued and Eruptive Fevers.”
- “The Medical Diseases of Egypt,” part 1, p. 18.
J In Nothnagel’s 44 Cyclopedia of Practical Medicine,” Amer. Trans. 1902, pp. 485 and 498.
• Public Health , vol. iii., 1890, p. 16.
Eiride )n ioloy ical Sec tion
33
conditions may so develop. These favouring conditions, in the case of
typhus fever, are mainly dirt and destitution.”
The difficulty in the way of this suggestion is the fact that those
conditions of dirt and destitution which are suggested as causing the
disease have been repeatedly present, even in districts near which
typhus has been prevalent, and yet no outbreak has occurred; and the
alternative etiology of specific infection is supported by the fact that, so
far as is known, such places have received no imported infection. The
enormous balance of recorded opinion in recent years has regarded
imported infection as an indispensable antecedent to a typhus epidemic,
and with this opinion I agree.
(b) Malnutrition .—The acceptance of specific infection as necessary
to the disease does not, however, determine what influence is exerted on
its epidemic prevalence by agencies which may respectively foster and
spread it. Authority as to the effect of malnutrition is conflicting.
Thus Murchison 1 says : —
All the great epidemics which have devastated Ireland, Great Britain, and
other parts of the world, have occurred during seasons of scarcity and
want.
The great predisposing cause of typhus is defective nutrition. 2
He adds, however, that
Famine only generates typhus, in so far as it causes overcrowding. 3
Bateman 4 appears to have been the first definitely to state that
“ deficiency of nutriment is the principal source of epidemic fever.”
Corrigan, in 1846, wrote his well-known essay “ On Famine and Fever
as Cause and Effect,” and the notion of hunger-fever became widely
adopted. Graves, of Dublin, however, in 1843, wrote the following
remarks :— 5
In my report of the fever which devastated the west of Ireland in 1822, I
advanced the opinion that such epidemics are brought on by a great dearth of
provisions, and their unwholesome quality. These are, no doubt, aggravating
circumstances, but that they are not the sole or even the chief causes of
typhus epidemics is evident from what I have since frequently witnessed, viz.,
the occurrence of fever epidemics during years of plenty, of which 1826 was a
remarkable example.
1 Murchison: “The Continued Fevers of Great Britain,” 1888, p. 76.
2 Ibid, p. 119. 3 Ibid , p. 80.
4 Quoted by Hirsch, “Geog. and Hist. Pathology,” Syd. Soc. Transl vol. i., p. 579.
5 Graves, “Clinical Medicine ” 1843, p. 41.
34
Newsholme : Poverty and Disease
Graves’s view has been confirmed by subsequent experience.
Famine years have occurred in many countries without typhus, and
communities subject to famine in years of epidemic typhus have
escaped it, when they were isolated from imported infection.
Conversely, in the Dundee epidemic of 18(55-()() the workmen who
suffered severely were earning good wages, but were overcrowded owing
to the prosperity of Dundee’s trade and manufactures, and the conse¬
quent large immigration from country districts. On the same point the
following remarks by Sir Wm. Moore 1 are pertinent. Deferring to the
Irish epidemic of 184fi he says :—
The Irish physicians of the day asserted that this Irish fever was par¬
ticularly and distinctly due to famine. But, as a matter of history, the fever
in Ireland began in 1842, before the famine.
Similarly, speaking of a famine camp, he says:— 2
lu India, where the people, especially in a famine camp, live almost sub
Jove , there will be no typhus.
On these facts, therefore, it does not appear probable that malnu¬
trition has been the most important of the remaining three powerful
agencies in the causation of typhus. The suggestion to the contrary
has been frequently made ; and it is useful to remember in this
connection that poverty and its associated malnutrition and over¬
crowding have similarly been made responsible for other diseases.
Tims Dr. Dickson, 3 speaking of the plague in 1870 in Irak-Arabi,
said :—
The most palpable and evident of all the causes which predispose an indi¬
vidual to an attack of plague during an epidemic outbreak is poverty . No
other malady show r s the influence of this factor in so striking a degree; so
much so, indeed, that Dr. Cabiadis styles the plague miseria morbus.
There is no doubt or difference of opinion as to the view that
poverty produces conditions favouring infection in plague, as in many
other diseases. Recent work, however, has showm that far more direct
agencies than privation are responsible for its epidemic appearance,
and at the present day no one would dream of regarding the ameli¬
oration of poverty as the most immediate and powerful means of restrain¬
ing epidemics of plague.
1 Sir William Moore on “Famine: its Effects and Belief,” Epid. Soc. Trans., \ ol. xi.,
I h‘j 1-92, p. SO.
- hoc. cit., p. 37.
* Quoted by Hir>ch, he. cit., vol. i.. p. 5‘2-J.
Ei>i(Iemiolo<jical Section
35
(c) Overcrowding .—Overcrowding as a cause of typhus and other
infectious diseases has a multiple significance. It is certainly an index
of intimacy of contact and consequent freer opportunities for the
carriage of infection on a sufficiently massive scale to be effective. It
may also with a high degree of probability be regarded, like malnu¬
trition, as undermining the powers of resistance to microbial infection;
or some more subtle condition of infection may be caused by it. The
view commonly held until recent years, and even now maintained in
an attenuated form, is that, in accordance with the dictum of Hilde¬
brand in 1814, “ the source of all typhus matter is to be looked for solely
in concentrated human effluvia.” Hirsch puts the less extreme view
of this doctrine in the following words:—
The idea that overcrowding in filthy and unventilated rooms affords
the essential condition for the development of typhus-foci and for the
spread of the disease has been completely borne out by the experience of all
times.
This view implies that overcrowding involves concentration of virus
as well as greater opportunities of infection, and there is no reason to
disagree with it; though, as nurses commonly acquire typhus while
nursing cases of that disease under good conditions, it cannot be regarded
as proved that concentration of virus as well as free opportunities of
infection are needed for its propagation. If it should be proved that
fleas arc the chief, if not the sole, means by which it is spread, 1 the
practical importance of diminishing overcrowding and of securing
domestic cleanliness will be seen to consist, so far as typhus is concerned,
chiefly in the annihilation of these domestic pests. It must increase the
effectiveness of preventive measures against any disease to be able to
add specific to general precautions, as has been show'n strikingly in the
cases of malaria and plague. But, with full recognition of the ways in
which overcrowding must have favoured typhus in Ireland, it is difficult
to regard the facts as consistent with its having played the predominant
part. We have seen that the epidemic peaks of typhus in Ireland
occurred when famine and vagrancy were working in close and invariable
conjunction, and that districts where famine occurred without vagrancy
escaped. At these periods the pestilence showed epidemic peaks both in
overcrowded tow 7 ns and in sparsely populated rural districts. Probably
in many of these rural districts the low' density of population per acre
was not inconsistent w T ith considerable overcrowding per room ; but the
* On this point see a valuable report by Professor Matthew Hay, Public Health ,
September. 1907, p. 772.
36
Newsholme : Poverty and Disease
universal prevalence of the disease wherever traffic was unrestrained
makes it fairly clear that there must have been much typhus where
overcrowding in both senses of the word was absent. This view is
confirmed by the movements of population associated with famine.
Depopulation occurred on a gigantic scale, and yet the diminution of
overcrowding thus produced failed for a long time to make material
reduction in the pestilence, though it passed with the emigrants into
the ports which received them and determined there epidemic peaks of
considerable magnitude.
Phthisis in Inland.
These considerations appear to me to indicate vagrancy as the most
effective of the influences favouring the spread of typhus, and the
immobilisation of infection bv the diminution of vagrancy and the
provision of hospital accommodation as the main cause of diminution of
its spread in Ireland. The history of phthisis in Ireland confirms this
conclusion, and although the argument from analogy must always be
used with caution in inferences from one disease to another, it is
instructive to consider certain points in regard to typhus and phthisis. It
is common ground that, far more than most diseases, phthisis is affected
by privation and overcrowding. Typhus is like phthisis in this respect,
though there is no evidence that it is more sensitive to these influences
than is phthisis. It may possibly be less sensitive; for the infection of
typhus is distributed over a few weeks, that of phthisis over several
years; overcrowding and destitution, therefore, have much more time to
intensify infection and lower resistance to it in the latter than in the
former disease.
As we have seen, privation and overcrowding have both decreased
very materially in Ireland; but the history of phthisis in that country
shows that these ameliorations have not sufficed to overcome other
influences tending to increase the death-rate from phthisis (figs. 5 and 0).
This fact makes it the more difficult to believe that these ameliorations
have been the most effective of the factors producing a decline in the
death-rate from typhus of the magnitude shown in figs. 5 and 6.
It appears to me, moreover, that the history of phthisis in Ireland
throws a more positive light on the predominant cause of the decrease in
typhus. The reduction of typhus and the increase of phthisis have both
of them been associated with poor-law administration.
It has been noted that at first outdoor or domestic relief under the
Irish Poor Law was very restricted, but that as time passed the poor-law
Epidemiological Section
37
policy of Ireland was changed, medical and other forms of relief being
freely given to persons still living at home. A glance at fig. 4 will show
that during the last quarter of a century outdoor has been more largely
given than indoor relief, especially when allowance is made for the fact
that indoor relief includes the provision of a large portion of the
general hospital accommodation of Ireland. Associated with this
changing administration was the fact that residential conditions of
relief were imposed, which from the first, and still more as the
system of poor-law relief became better organised, tended to prevent
those vast movements of vagrancy and mendicancy with which Ireland
had been cursed. What would be the effect on typhus and on phthisis
of (1) the increasing immobilisation of the population in their own
districts, and of (2) the increase in the proportion of sickness in the
aggregate, and especially of phthisis, treated in the homes of the people ?
The readiness with which domestic doles and medical treatment both at
home and at the dispensary could be obtained undoubtedly led to the
greater portion of the lives of consumptive patients being spent at home.
For typhus fever it was otherwise. Here was a disease which, unlike
phthisis, was not infectious for several years but only for two or three
weeks, and which disabled immediately instead of after protracted
ill-health. The objections of the Irish to the infirmary were easily
overcome for this disease, only exceptionally in the case of phthisis.
Hence the same measures which were successful for typhus, led to an
actual increase of phthisis. Typhus has been brought towards the point
of extinction by its institutional treatment, acting in conjunction with
the removal of the motives for vagrancy. Phthisis has been rendered
even more prevalent than formerly by increasing for this disease
domestic at the expense of institutional treatment, and by thus con¬
tinuing the enormous number of domestic foci of this disease which are
implied by the home-treatment of phthisis among the poor.
Analysis of Individual Epidemics .
It is regrettable that the data available for Ireland have necessitated
the examination of this question to so large an extent on general
considerations. During the period of greatest prevalence of typhus
no exact statistics were available, and it has been' impossible to supple¬
ment my general examination by intimate analysis of the course of any one
or more epidemics in particular districts of Ireland, as I am unacquainted
with any work that would enable this to be done. It is fortunate that
w r e are able to check the inferences derived above from the broad survey
n —11 f
38
Newsholme: Poverty and Disease
of the history of typhus in Ireland by two investigations, one English and
one French. In these-two we are able to approximate towards a test
as to whether what may be called the intimate structure of an
epidemic confirms the conclusions to which our general considerations
point.
Miv Spear,-in the Annual Report of the Medical.Officer to the.Lpqal
Government Board for England, 1886 (p. 269), described a series of out¬
breaks of typhus in various parts of England, 1886-7. Some of these had
not before his visit been recognised as typhus, and it is interesting to
compare the date of their occurrence with that of the epidemic of typhus
in Ireland in the immediately preceding years. Mr. Spear particularly
draws attention to the frequent occurrence of unrecognised cases in
children, and to the circumstance that “ information as to typhus
outbreaks is peculiarly liable to be incomplete ”; though in a later part
of his report (p. 285) he adds :—
I cannot admit that any argument in favour of the so-called de novo origin
of the disease can be logically deduced from the frequent failure to demon¬
strate the source of typhus outbreaks.
It is unnecessary for me to give the details of the outbreaks in twelve
towns described by Mr. Spear. In five towns there was “ strong proba¬
bility ” that the disease had been introduced from without, by tramps,
returned hop-pickers, and once by a discharged prisoner. In three
other towns the outbreak originated in the Irish quarters, in parts where
there was free communication with Ireland, &c. It would be interesting
to tabulate a similar series of outbreaks of small-pox, and ascertain
whether the proportion in which the source was detected would be £o
much higher than for typhus as the more readily recognisable nature of
the disease would lead one to expect. 1
MM. Netter and Thoinot have summarised an account of a widespread
epidemic of typhus in France which during the years 1892-3 spread over
fifteen dApartements. Altogether 1,066 cases are known to have occurred,
the highest number being 200 in the dApartement of La Somme. In the
majority of districts the source of the outbreak could be traced, and
the reporters sum up their investigation, so far as the diffusion of the
disease is concerned, in the following words:— •
Le typhus de 1892*93 peut etre caracterise d’un mot: il a 6te avant tout le
typhus de vagabonds : dans la marche , dans la diffusion de l^pid6mie, dans la
creation des foyers, les vagabonds ont joue le r61e primordial.
1 It is scarcely necessary to do more than refer to the valuable work of Dr. H. A.
Armstrong in demonstrating what a large majority of the recent small pox outbreaks in
England are due to vagrants.
Kpidemiolofjical Sec tio u
39
There is the further analogy between this French and our English
outbreaks of typhus, that France has an Ireland, an endemic focus of
typhus, in Brittany, from which epidemics have at various times spread.
There can then, in spite of the difficulty which the case presents, be
no hesitation in arriving at the conclusion that vagrancy has played the
predominating part in the dissemination of typhus in Ireland, and that
the decrease of the disease must be attributed to the poor-law pro¬
visions for immobilising infection by the suppression of vagrancy and the
provision of fever wards, the part played by the decrease of poverty being
of notably less importance. From a practical standpoint this result
appears to me eminently encouraging. The ultimate objective of all who
are interested in the oommon well-being must be to mitigate poverty.
The magnitude of this task can scarcely be realised. But the task
is surely lightened by any means which can be shown to be wholly
effective in controlling a poverty-producing disease, without waiting for
the attainment of the main and major goal. Every disease thus con¬
trolled frees the community not only from a measurable amount of
sickness, but from the amount of poverty implied by this sickness.
It is no disparagement of the paramount importance of improved
housing and nutrition, in the protection and enhancement of the public
health, to find independent means of controlling individual diseases.
It is, on the contrary, a step forward in social amelioration, the funds
thus saved being available for further ameliorative work.
We may infer more generally, in considering diseases like typhus
and phthisis, to which poverty is contributory, that there is much
practical advantage not only in seeking to divide the consideration of
poverty into that of its component parts, but also in seeking to define
the operation of factors other than poverty. We are thus enabled to
particularise in our preventive efforts, with confidence that each set of
measures will help towards attaining the object of the others. If, on
the contrary, measures of only secondary importance in connection with
a disease are treated as if they were primarily important, we have failed
to exercise frugality in administration, and to that extent have been
responsible for inefficiency.
What I have said to-night, while it confirms w r hat is already known
as to the important bearing of well-being on the prevention both of
typhus and of phthisis, indicates that at the present time the largest
measure of control over them, and especially over phthisis, can be
obtained by administrative measures, and. that we cannot afford to leave
the abolition of phthisis to the relatively slow evolution of measures of
sociological reform.
40
Newsholme: Poverty and Disease
Summary of Argument.
(1) Epidemiology in its relation to administration is concerned hot
merely with the nature, but also with the relative extent of the influences
affecting the public health.
(2) The evils associated with and due to poverty favour both typhus
and phthisis, and it is important to know which of these evils has been
the most efficient in determining the courses of these diseases.
(3) Historically the great epidemics of typhus have occurred in Ireland
in years of famine. In these years overcrowding was not generally
increased, but nutrition was decreased, and vagrancy was greatly increased.
Such local increases of overcrowding as occurred were the result of
this widespread vagrancy, and while vagrancy and famine persisted
even wholesale depopulation did not arrest the epidemic.
(4) The introduction of poor-law relief at the expense of local funds,
and especially the “ quarter-acre clause ” in the enactment, induced in
years of famine evictions on an enormous scale, which in their turn
swamped the resources of the poor-law, and led to vagrancy and
emigration affecting a very large portion of the entire population.
(5) The continued provision of poor-law relief had a considerable
effect in immobilising an acute disabling disease of short duration like
typhus, though its institutional form was unpopular and inefficient in
respect of a chronic disease like phthisis.
(6) In considering whether increased immobilisation of patients,
diminished overcrowding, or improved well-being of the community has
been the chief agent in reducing typhus, a comparative study of the
course of phthisis in Ireland is needed. Phthisis is a disease the com¬
munal prevalence of which is influenced by well-being and by the
diminution of overcrowding, but which is more powerfully influenced by
segregation of patients, especially of advanced patients. In Ireland
great reduction of overcrowding and improvement of conditions of
housing and of general well-being have been accompanied by decrease
of typhus but increase of phthisis. Some more powerful influence must
have countervailed the influence of improved housing and greater well¬
being on the course of phthisis, and unless typhus is more susceptible
than phthisis to the influence of improved well-being, the decrease
of typhus probably has been due predominantly to the same cause,
while in the case of typhus this cause presumably has assisted these
beneficent influences. The influence which had the predominant share
in causing the decrease of phthisis in those countries in which decrease
Epidemiological Section
41
has occurred was the immobilisation of infection. Immobilisation of an
acute disease of short duration like typhus, even though the immobil¬
isation is largely domestic, when associated with the prevention of
vagrancy of relatives, prevents the wide and rapid spread of infection.
Immobilisation in a protracted disease like phthisis, in order to be
efficient, must be institutional, especially for advanced cases. The degree
of immobilisation secured in Ireland is such as on these principles
sufficed to control typhus, but not phthisis.
(7) An examination of the economic history of Ireland supports the
above considerations. There is no evidence of any spontaneous tendency
of the diseases in question to die out. The increase of phthisis is not to
be explained by decadence of population, the evidence showing that the
residual population in Ireland is superior physically to the emigrated
population.
(8) Of the operative causes of typhus, specific infection is admitted
generally to be indispensable. Malnutrition has not always been asso¬
ciated with epidemics of this disease, and there has been no constant
association of epidemics with exceptional overcrowding, or cessation of
epidemics when overcrowding has been enormously reduced. Vagrancy
is the one factor which has always accompanied specific infection, and in
the absence of which epidemics have failed to occur even in the vicinity
of infected populations.
(9) The records available have usually lacked the exactitude
required for checking these general considerations by the analysis of
large epidemics into separate cases. In two instances summarised in
this address such an analysis is provided, with the result that in the
English instance vagrancy was the only origin assignable in those
instances in which an exact history could be obtained ; and the French
epidemic of over 1,000 cases, distributed over a large part of France,
consisted almost entirely of cases among or derived from tramps.
(10) The suppression of typhus in Ireland has been due chiefly to
the efficient immobilisation of infection by means not intended expressly
for that purpose. These means have failed to control phthisis, because
the extent and duration of immobilisation which suffice for typhus do
not suffice for phthisis. Both England and Ireland, though not on the
same level, have enjoyed increased well-being for many years. England
for many years has treated a very large proportion of its advanced cases
of phthisis among the poor in public institutions under reformed con¬
ditions, and has secured a large decrease in its phthisis death-rate;
Ireland has encouraged to an increased extent the domestic treatment of
4*2
Newsliolme: Poverty and Disease
these cases, and its phthisis death-rate has increased. In the future the
control of typhus can be continued, and that of phthisis improved,
more rapidly and effectively by immobilisation appropriate to the disease
than by awaiting the slow operation of relief of poverty, which is the
chief object of economic effort. To this end it will be necessary in
Ireland, as in England, to pursue the institutional treatment of phthisis,
especially of advanced cases, on a scale not hitherto contemplated, and
to abandon poor-law restrictions and disabilities, which render such
institutional treatment unattractive.
Data fok Fig. 4.
Pauper ism.
Total
Indoor
Total
Indoor
(top line of
(lower line of
(top line of
(lower line of
diagram)
diagram)
diagram)
diagram)
1851-2
2,610
2560
1879-80 ...
1.792
1040
1852-3
2,088
2040
1880-1
2,200
1030
1853-4
1,566
1540
18812
2,168
998
1854-5
1,342
1310
1882-3
2,150
1000
1855-6
1,065
1050
1883-4
2,164
964
1856-7
865
849
1884-5
2,111
951
1857-8
794
773
1885-6
2,151
951
1858-9
708
686
1886-7
2,535
945
1859-60
740
706
1887-8
2,299
949
1860-1
736
675
1888-9
2,262
932
1861-2
1,030
933
1889-90 ...
2,223
913
1862-3
1,118
1010
1890-1
2,207
887
1863-4
1,134
996
1891-2
2,216
886
1864-5
1,120
965
1892-3
2,175
895
1865-6
1,087
908
1893-4
2,177
917
1866-7
1,175
954
1894-5
2,157
907
1867-8
1,259
987
1895-6
2,150
910
1868-9
1,273
965
1896-7
2,137
937
1869 70
1,249
913
1897-8
2,226
966
1870-1
1,256
860
1898-9
2,394
964
1871-2
1,269
851
1899-1900 ...
2,258
968
187*2 8
1,393
881
1900-1
2,217
927
1873-4
1,459
893
1901-2
2,255
955
1874-5
1,453
880
1902-3
2,275
975
1875-6
1,413
840
1903-4
2,277
987
1876-7
1,439
840
1904-5
2,303
993
1877-8
1,537
903
1905-6
2,414
1010
1878-9
1,648
961
Epidem ioloyica l Section
43
Data for Fig. 5.
Deviation from mean of —
Typhus, Ireland
Phthisis, Ireland
Phthisis, England
Typhus, Eng
1869
4-83
-11
436
+ 550
1870
+ 54
-11
4 40
4 400
1871
4-79
- 6
+ 36
+ 310
1872
+ 46
- 6
+ 32
4 170
1873
+ 45
- 6
t-27
+ 136
1874
4 59
-14
421
+ 149
1875
447
- 6
+ 28
+ 109
1876
+ 31
- 7
+ 23
-4 62
1877
+ 53
- 4
+ 20
+ 52
1878
-4 59
- 4
+ 23
4 21
1879
4 60
- 1
+ 17
-29
1880
+ 100
+ 4
+ 9
-29
1881
-4 86
- 6
4- 6
-29
1882
+ 62
- 2
r 8
4 21
1883
4 80
+ 5
+ 9
+ 12
1884
4 41
+ 3
- 6
-59
1885
4 15
+ 6
4- 3
-59
1886
- 9
+ 6
+ 1
-70
1887
- 7
+ 4
- 7
-73
1888
-16
± 0
-10
-80
1889
-16
+ 1
-10
-83
1890
- 7
+ 5
- 3
-83
1891
-36
+ 4
- 8
-83
1892
-35
+ 6
-16
-89
1893
-45
+ 4
-17
-83
1894
-43
+ 2
-21
-86
1895
-53
+ 4
-21
-93
1896
69
- 3
- 26
-93
1897
-70
+ 4
-24
-93
1898
-45
+ 4
-26
-96
1899
-71
+ 2
-26
-96
1900
-68
+ 10
-26
-96
1901
-76
+ 4
-30
-96
1902
-79
+ 3
-32
-93
1903
-81
+ 5
-33
-93
1904
-87
+ 8
-32
-96
1905
-83
+ 2
-37
-96
44
Newsholme: Poverty and Disease
Data fob Pig. 6.
Deviation from mean of —
Typhus, Dublin
Phthisis, Dublin
Phthisis, Loudon
Typhus, London
1869
+ 117
-
5
+ 31
+720
1870
+ 324
-
4
+29
+ 440
1871
+ 262
-
4
+ 22
+ 330
1872
+ 151
+
7
+ 20
+ 90
1873
+ 68
+
4
+ 20
+ 198
1874
+ 218
-
15
+ 15
+ 231
1875
+ 56
4
+ 21
+ 35
1876
+ 97
-
8
+ 18
+ 64
1877
+ 135
-
4
+ 14
+ 60
1878
+ 211
-
13
+ 17
+ 49
1879
+ 167
+
4
+ 15
- 31
1880
+ 399
+
7
± 0
- 27
1881
+ 448
±
0
+ 3
- 13
1882
+ 139
+
2
+ 3
- 49
1883
+ 293
+ 14
+ 8
- 49
1884
+123
+ 11
+ 6
- 71
1885
+ 48
+
8
± o
- 74
1886
+ 5
+
8
- 2
- 89
1887
- 40
+
8
- 9
- 82
1888
- 18
—
3
-14
- 93
1889
- 49
+
2
-12
- 85
1890
- 35
+
9
+ 2
- 93
1891
- 83
+
3
- 5
- 89
1892
- 77
+
9
-11
- 89
1893
- 58
+
7
- 9
- 96
1894
- 72
+
2
-18
- 96
1895
- 94
—
2
-14
- 96
1896
- 70
-
7
-17
- 96
1897
- 64
-
7
-16
-100
1898
- 95
-
2
-16
- 96
1899
- 86
... +
2
-10
-100
1900
- 95
+
7
-16
-100
1901
- 92
±
0
-19
- 96
1902
- 78
—
1
-23
-100
1903
- 95
-
5
-25
- 96
1904
- 97
±
0
-21
-100
1905
-100
-
6
-32
-100
Epidemiological Section.
November 22, 1907.
Dr. H. T. Bulstrode, Vice-President of the Section, in the Chair.
Medical Inspection in Schools : the Gloucestershire Scheme.
By Myer Coplans, M.D.
In the summer of 1904 it became necessary for the Gloucestershire
Education Committee to consider the condition of certain elementary
schools, at which the attendances had become seriously impaired by
reason of the continued prevalence among the scholars of various forms
of skin disorder. A provisional scheme, involving inspection of small
groups of schools by the medical practitioners nearest resident, had been
fully discussed and abandoned on the ground that administrative diffi¬
culties would prove insuperable.
On being approached to carry out the proposed inspection, I pointed
out to the Authority that there were no defined powers enabling me to
carry out an examination of school children save with the parents’
consent; moreover, the result of such an examination must be considered
private as between a doctor and his patient; and, finally, the only method
to be adopted in effecting amelioration of special or general conditions
must be in the nature of moral suasion. Thereupon I was given a free
hand to devise some scheme which, while satisfying the parents, would
elicit especially the main facts relating to the degree of prevalence of
various forms of skin disease among the scholars ; it was left for me to
devise means for the betterment of such conditions as might be found.
The area specially selected for carrying out this scheme W’as that of
the Stroud Union, which comprises the urban and rural districts of
Stroud as well as the urban district of Nailsworth ; the total population
is 40,000, spread over some GO square miles of hilly country. The
d —G
46
Coplans: Medical Inspection in Schools
number of separate schools to be inspected was 58, and the average
number of scholars on the books was 7,200.
To arrive at some preliminary scheme, I considered it essential to
interview as many parents as possible, in order to obtain a frank
expression of all shades of opinion. To all I explained the purport of
the proposed scheme—to carry out, with the parents’ sanction, such
a system of medical inspection as would best cope with the various
evils that w T ere said to arise in association with school life or in conse¬
quence thereof. There were many who considered that the proposed
experiment ought to go further and embrace both private and secondary
schools, Sunday schools, Band of Hope meetings and the like; otherwise
it might appear that an attempt was being made to introduce a medical
scheme which, in the end, would have the effect of exposing and
accentuating the poverty of the poor. All were united on the point that
the relationship between doctor and scholar must be confidential.
The outcome was a card schedule, and, in order that I might have
duplicate entries of all important information, the medical register form
was adopted. It was intended that there should be a separate card for
each scholar, while the medical register forms were to be filled up
according to standards. Manifestly the card scheme was intended to
secure a continuity of record in the case of each individual child ; and it
was hoped that these records w r ould be of value in the future study of
the complex conditions of school life. Early and continuous information,
moreover, would be furnished of affections of the special senses and of
those abnormalities of mind and body which render a separate classifi¬
cation imperative in any well-organised educational system. The card
schedule was designed to meet the varying requirements of individual
parents; all were reassured that the status of confidence as between
doctor and patient was to be maintained ; an attempt was to be made to
deal with contagious disease, and statistics as to past outbreaks were to
be collated and studied ; the individual scholar was to be kept under con¬
tinuous observation, so that school life might prove less arduous and
more profitable, nor would change of school affect the record.
In dealing with infectious disease and contagious conditions, it was
recognised that diagnosis without the corollaries of isolation and disinfec¬
tion was useless ; so, with the medical inspection in general, there would
be little profit to educational life without available classifying and
remedial agencies.
It was hoped that parents would in the first place readily assent to
the scheme, and that, once confidence had been established, they would be
Ep idem iolog ica l Sec tion
47
prepared to avail themselves of the advice which subsequently might be
tendered to them. Thereupon I invited the head teachers to a conference,
where I put it to them plainly that the success of the scheme would depend
mainly, perhaps entirely, upon their loyal co-operation. The proposed
experiment was explained to them in detail; they in their turn were to
explain the matter to their elder scholars and interview parents if
necessary; particularly this would be found necessary with infant
schools. To each head teacher I gave a supply of cards, sufficient for
distribution among the scholars ; the cards were to be taken home to the
parents, the important object at that stage being to obtain their consent
in writing, while making all fully acquainted w'ith the scope of the
proposed investigation.
The outcome of this method of procedure was that 97 per cent, of the
parents consented. It was at this stage that I realised fully the power¬
ful influence of the head teacher with the parents, and his authority
over the scholars. Parents were allowed at least a week to fill up the card
and vouch for the record of the child’s illness. In general, they took
great pains to give reliable information. All avenues of information and
confirmation as to exact dates seem to have been opened up. Some
consulted their private medical advisers, others their neighbours, and in
some instances I was able to verify statements as to epidemic diseases
from past epidemic-grant records.
Cases of boarded-out children from metropolitan poor-law 7 institutions,
Dr. Bamardo’s' waifs, as well as children from the local poor-law
institution, afforded instances in which such information was unobtain¬
able ; nor in these cases was it possible to obtain the exact date of
birth, a factor of importance in co-relationship with anthropometric data.
It was in reference to these data, as well as to the prevalence of tuber¬
culous conditions, that particulars w r ere asked for as to the parents’
occupation.
The Sunday school was registered for the reason that it might afford
a clue as to the child’s companions'and doings after ordinary school hours
—points of importance in dealing with contagious and zymotic disease,
either in tracing the origin or in attempting remedial measures. Those
head teachers who acted as Sunday-school superintendents volun¬
teered, when occasion arose, to apply in the Sunday school such measures
of isolation and disinfection as would be considered appropriate in the
day school.
The precise date of birth was available in the majority of cases. With
waifs and boarded-out children, however, such information was unreliable.
48 Coplans: Medical Inspection in Schools
Many children had been entered in the school registers at ages slightly
in advance of their true age, and the youngest child found in school,
presumably aged 3, proved to be but 2 years and 8 months old. There
were several reasons for over-stating the true age. First of all, it
permitted a child to be entered on the registers as of the minimum age—
viz., 3—a month or two earlier; secondly, a scholar having reached the
presumed age for leaving school would be- withdrawn from school and
sent to work before actually reaching the prescribed age-limit; indeed, I
met with one extreme case in which the child’s age was over-stated by
nearly one year, the real purpose being to make it possible for the scholar
ultimately to leave school a year sooner than the law intended. The
circumstances which rendered such a fraud comparatively easy arose
from the fact that the child’s elder brother, bearing the same Christian
name, had died in very early infancy, and the first child’s certificate of
birth was utilised for the second child. There are records of parents who
have wilfully altered birth-certificates in order that their statements as to
children’s age might be confirmed. 1 These points emphasise the necessity
for the introduction into schools of some reliable system of age registra¬
tion, without which the value of anthropometric data is manifestly
impaired.
Inspection of the Scholars. —I proposed conducting the inspection of
the scholars in several stages. At the first inspection : Examination for
skin disease ; state of vaccination ; auscultation in special cases ; anthro¬
pometric data; notes as to general and special points’, e.g. f clothing,
swimming. Second inspection: Eye examination; notes as to school
buildings. Third inspection : Ear and throat examination; mental
abnormalities noted. I anticipated that the first inspection would prove
an effectual method for obtaining rapidly a fair introduction to every
scholar who was to be examined. No notice was given of the intended
visit to any school; indeed, many head teachers preferred such method
of procedure, for they feared that certain scholars whom it was specially
desirable to examine might absent themselves on the date of the visit,
with the special object of evading the examination, notwithstanding their
parents’ consent. For this reason adjacent schools were not visited in
direct succession, and in such schools where at the first visit the
1 A case occurred at Wakefield Police Court, on October 9, 1907, when a parent was charged
under the Births and Deaths Notification Act with falsifying a birth-certificate. The school
attendance officer gave evidence that the object was to enable the son to leave school and
commence work. The Mayor intimated that, as the case had been brought only as a warning
to others, the defendant would be merely fined 13s. or fourteen days* imprisonment.
49
Epulemiologleal Section
attendance seemed below the average I paid second and even third
visits. Especially was this found necessary with infant schools. I
took care that the date of my visit to any school should not clash
with that of the Diocesan Inspector, nor with that of H.M. Inspector
of Schools.
Mode of Examination. —The children, on being given blank cards to
take home, were warned that, if they did not wish the teachers to
see the information given by their parents, the cards were to be
returned undercover. In the course of a week or so these cards were duly
returned to the teachers and arranged according to standards. Not a
single card was returned under cover. On the occasion of my visit the
cards were redistributed to the scholars. In the case of mixed schools,
boys and girls were examined apart. A woman teacher was always present
at the examination of girls. No parent ever asked to be present at
an inspection, nor did any school manager ask to be allowed to witness the
proceedings. The actual examination was designed to disturb the normal
curriculum of a school as little as possible, and therefore was conducted
in one room, to which the children catne in turn according to standards.
Where infant classes formed part of the school, these were examined
first. In all cases, however, I enlisted the voluntary services of the most
intelligent and robust girls of the upper standards to act as nurse-
attendants during the inspection, and, in order to accustom them to the
routine of the examination, these girls were examined first of all. They
loosened their hair, unfastened their dresses so as to expose the neck,
upper part of chest and arms, took off their boots and loosened their
garters. They were then arranged in single file and came up card in
hand. Skin and other conditions were duly noted, and the usual abbre¬
viations were used designedly to avoid disclosure. The child passed on,
card in hand, and was weighed and measured under my supervision, and
the record then completed. The child thereupon dressed and returned
to her class. The card was handed to a teacher who sat by me, and
duplicate entries were made into the medical register.
Later on in the course of the day’s proceedings I was able to delegate
with safety the weighing and measuring to the teachers. The apparatus
for weighing was of simple design—a Salter's balance graded in half-
pounds up to 200 lb. It was frequently tested to ensure accuracy.
Boys were similarly examined after discarding jackets, waistcoats and
boots, and loosening collars and shirts.
There was no necessity for a child to be absent from its class for more
than five minutes, and the average time for individual examination was
50
Coplans: Medical Inspection in Schools
two minutes. The first inspection of 6,652 children was completed
within sixteen weeks from the commencement. Result of examination :—
Table op Weights and Measures.
A g o Boys I Girls
(years and months)
Height (inches)
Weight (lb.)
Height (inches)
Weight (lb.)
3.0
35 2
29.3
3.1
—
3.6
36
32.9
35 8
31.3
3.7
—
4.0
40
36.4
38*3
33.2
4.1
—
4.6
40*7
37.1
38-4
35.4
4.7
—
5.0
42
38
39*4
36.2
5.1
—
5.6
43*1
40.1
40‘2
38.1
5.7
—
6.0
44
40.9
41*6
39.5
6.1
—
6.6
44-5
41.7
42 3
40.1
6.7
—
7.0
45 3
44.7
43*9
43.9
7.1
—
7.6
45*4
46.8
45 6
48.5
7.7
—
8.0
45 5
48.7
45tf
48.8
8.1
—
8.6
46*4
49.2
46*5
49.5
8.7
—
9.0
46 5
50.8
47-7
53
9.1
—
9.6
486
54
48*2
53.2
9.7
—
10.0
49 2
55.5
48*5
60.2
10.1
—
10.6
51
59.8
51*3
60.7
10.7
—
11.0
51*4
61.3
52 3
64.4
11.1
—
11.6
51 *5
61.8
52*9
65.4
11.7
—
12.0
52*5
65.7
53*2
68.2
12.1
—
12.6
54*1
67.7
54*8
71.1
12.7
—
13.0
, 54*7
72 2
55*8
79.3
13.1
—
13.6
55*9
76.4
56*9
81.1
13.7
—
14.0
57
77.8
58*3
83.7
Boys weighed and measured without boots, jackets and waistcoats.
Girls weighed and measured without boots.
Vaccination .—The state of vaccination of every child examined
was noted. Of the children in the big school, 35'9 per cent, are
unvaccinated, while in the infant school the unvaccinated equal 53 (3 per
cent. The remarkable falling off in vaccination first appears among
children bom about 1894 and 1895, and continues among those born
during the years 1896—1902. Of the children born previous to 1894
between 80 and 90 per cent, are fully protected by vaccination against
small-pox. Among the younger children the vaccinated and unvaccinated
are fairly evenly distributed. At one school, however, in the immediate
neighbourhood of Stroud, w r hile examining the first standard, I met with
20 children in succession, none of whom bore vaccination marks; and
again at an infant school in the neighbourhood of Nailsworth, out of 21
boys examined, 18 bore no vaccination marks. None of the four children
who were pitted by small-pox had been vaccinated.
Epidemiolor/ical Section
51
Table Showing State op Vaccination.
Boys and Girls
(Mixed)
On
books
1
Examined ,
Nil
Vaccination Marks
One Two j Three Four
i
.. 1 Per
No ‘ i cent. 1
No.
Per
cent.
No.
Per
cent.
No.
Per v .
cent. 1 *
Per
cent. x °*
Per
cent.
Big Sc
Stroud 1
Groups j
;hool
(No. 1
1,770
1.655 93-5
704
42 5
69
4-2
161
9*7 268
16-2 453
274
No. 2
j 2.092
1,952 93*3
648
33-2
175
8-9
282
14 4 270
13 9 577
29*6
[No. 3
i 1,208 !
\ j
1,109 91*8
340
307
64
5-7
111
10-0 | 190
171 . 404
36*5
!
Total ... I
I 5,070
4,716 93 0
1,692
35*9
308
6 6
.554
11*7,728
15*4 1,434
30*4
Infant School
( No. 1
767
656 85*5
389
59 3
54
8*2
64
9 8 83
12-7 66
100
ouuuu
Groups *
No. 2
907
783 86-2
413
52*7
70
9 0
48
61 94
12 0 158
20*2
1 No. 3 1
568 1
493 86*8
233
47*3
21
4 3
48
9 7 a5
17-2 106
21*5
Total ...
2,242
1,932 86-1 1
1,035
| 53 6
145
75
160
8-3 262
13*7 330
169
All Schools, Total
7,312
6,648 90-8
1 . !
2,727
410
453
6*8
714
10*7 990
14*9 1,764
26-6
Swimming. —Incidentally, inquiry was made among the big school
girls and boys in Stroud and district, at schools which are within easy
reach of a watercourse, with the following result:—
Big School (Boys) No. Swimmer*
Stonehouse ...
138
2
Ebley
54
2
Cainscross
90
Wljiteshill
93
1
Parliament Street
109
4
Church Street
252
11
Thrupp
74
2
Rodborough Council ...
100
,
4
Uplands
146
t
8
Total
1,056
34 = 3*2 percent.
Girls. —Enquiry made among a thousand big school girls. Result: Only one swimmer noted.
First Inspection.
Number on books, 7,294 ; examined, 6,652 = 91*2 per cent.
Result: —
No.
Per cent.
A. — Contagions' : Ringworm of head ...
,, body ...
86
11
97 .
1*46
Pediculosis live pediculi
eggs
238
670
908
13*65
Impetigo, body
„ scalp
Scabies ...
63
17
80
1*20
22
0-33
Inflamed eyelids
2 Scarlatina ...
4
17
0*26
2 Acute tonsillitis
25
2 Pertussis
1
34
0-52
2 Varicella
1
Tuberculous discharges
3
1,158
17*42
1 No child appears under more than one heading in connection with contagious skin disease.
2 Noted in the routine course of examination.
52
Coplans: Medical Inspection in Schools
B. — Non-contagious: Otorrhoea (foul)
Kczema
Seborrhcea sicca
Psoriasis
Alopecia
Ichthyosis ...
Urticaria ...
No.
Per cent.
10
40
570
8-57
7
5
6
5
045
90S
C.—Rheumatic fever, 2 ; phthisis, 2 ; heart disease, 6 ; nephritis, 1; goitre, 9.
Comparison of Conditions found among 1,600 Boys and Girls, taken according
to Families. (Results in Percentages.)
a.
—Contagious
B.— Non-Contacuous
a
9
i H
K
®
!S
1
O
SC
n
i *
n
m
ST
s
cc
X
O
u
u
Cm
Total
Eczema
8
■S3
!■=
w
Psoriasis
Ichthyosis
Cj
'z
u O
5-
Total
Boys
1*8
1-7
0*8
0-3
31
7-7
1-0
9*0
0-7
01
0 0
10-8
Girls
10
0 1
i 1*1
24*5
27*3
0*6 |
2-6
01
0-2
0-4
39
Average
1 1*4
0-9
0*95
1 0*45
13*8
17*5
0*8
5*8
0*4
0*15
0 2
7 35
Table showing Frequency of Seborrhcea Sicca in Urban as compared with
Rural Schools.
Name of District
1 Stroud
Examined
School Group
1
| Number |
Per cent.
Stroud Urban
Nailsworth Urban
No. I. i
. 1 No. II. j
2,711
103
.3*8
Stroud Rural
No. II.
2,342
242
10-3
Stroud Rural
No. III.
1,000
228
1425
Total
6,653
573
All the spring and well waters of this neighbourhood are hard ; those of the upland
country in which Stroud Nos. II. and III. school-groups are situate exhibit the maximum
amount of hardness (20 c —40 c ). In No. I. group the hardness is about 20 ; but by water-
softening process this is reduced to 5°.
I recall a few notes made on the occasion of this inspection :—
(1) Children from poor-law institutions, whether boarded out or in
the house, were on the average more cleanly than others of a similar
station in life; they were better clothed, equally well fed. So was it
with boarded-out waifs and strays from London institutions.
(2) Boys and girls disproportionately affected with regard to con¬
ditions of scalp and hair.
(a) Seborrhcea sicca.—Nearly four times as frequent among boys;
due, I consider, to insufficient rinsing and drying of the scalp after
soaping with cold water. Many of the well waters of this district are
intensely hard, and the hardness is often of a permanent character, so
Epidemiolofjical Sec tion 53
that it is extremely difficult to obtain a lather, which once formed is not
easily removed.
(6) Pediculosis.—Eight times as frequent among girls, due largely to
ignorance of parents as to the life-history of P. capitis , and in particular
the significance of nits. With girls who wear their hair cut short the
condition was comparatively rare.
(3) Clothing.—Boots generally too heavy. Boys' boots often weigh
5 lb. a pair. I consider this accounts for the trudging gait frequently
seen among country school children, for their boots are so clumsy and
ill-fitting that free movement of the ankle is often impossible.
Infants generally overclothed, and sometimes a child wears at one
time as many as eight layers of assorted garments.
Girls. —Many in the upper standard cannot take part in physical
exercise for the following reasons :—
(а) They wear the ill-fitting cast-off corsets of their elder relatives.
(б) Their sleeves are so tight around the armpits that the arm
cannot be raised above the head without tearing the dress. In addition
the sleeves are so tight-fitting at the wrists that it is quite impossible to
wash the arms without undressing.
(4) Children generally well cared for. I could find no evidence of
grinding poverty in their appearance.
(5) In nearly every school the prime source of contagion is traceable
to one, two, three, and perhaps four families, all of whom have long been
known to the head teachers, as to others, as excessively dirty.
Remedial Measures. —From the outset it w’as recognised that moral
suasion was to be the order of the day, and exclusion from school to be
employed only in exceptional circumstances. In general no action was
taken save in consultation with the head teacher. In the beginning I
sent a note to the parent indicating the condition found, and in cases of
pediculosis, there was enclosed a printed form which described a method
for effecting a cure ; but this form gave so much offence that its use was
almost abandoned. Head teachers, however, kept copies and gave
information when asked. In some schools the forms were nailed up on
conspicuous sites. At the close of the inspection all cards which bore
abbreviations showing special disorders w^ere collected and their owners
were called into the room where the inspection had been conducted.
Where several members of one family were affected, the most intelligent
member alone was interviewed. When children were too young to be
trusted with a verbal message a note w r as sent, signed always by the
medical inspector. In many instances teachers were personally acquainted
54
Coplans : Medical Inspection in Schools
with parents and became the bearers of messages. Only in cases of
pediculosis and seborrhoea were remedies directly suggested. Some head
teachers, however, urged by parents, applied so often for suggestions as to
suitable remedies for other conditions that I was forced to make it plain that
suggestions for the treatment of disease formed no part of the experiment.
As a compromise, in order to appease all parties and not to jeopardise
the scheme, I suggested certain remedies for conditions in general,
warning the head teachers that if parents chose to use such remedies
for special cases they were acting on the advice of the head teacher.
It appears that some of the abbreviations used on the cards
describing the conditions found inadvertently lent themselves to con¬
firming the advice I had tendered the head teachers. Thus:—
Pediculi capitis
P.C.
Paraffin cure.
Seborrhoea sicca
s.s.
Soft water and soap.
Tinea tonsurans
T.T.
Try the tincture (of iodine).
Scabies
s.
Sulphur ointment and scrubbing with soap
Children suffering from scabies were forthwith excluded from school;
they were informed w r hen they might present themselves for examination
for readmission. Those suffering from blepharitis, ringworm, impetigo,
and pronounced conditions of pediculosis, whether of scalp or trunk, were
isolated at separate desks in school until they could be declared free
of infection. They were not allowed to use the school towels. With
ringworm the scholar wore continuously a special cap made of light
oiled silk, and, as with pediculosis, the outdoor cap or hat was kept at
the special desk. With pediculosis, however, parents usually responded
with alacrity to the advice given, but relapses were common.
The effect of such methods as applied to Nailsworth and Stroud
groups of schools may be seen in the following table:—
Number of schools, 38; scholars, 5,062 ; all examined.
Conditions
Number found affected
Improve¬
ment
August to December, 1904
January to May, 1905
per cent.
Tinea
90
= 1*8 per cent.
25
— 0’5 per cent.
72
r, , • (Pediculi
Pediculosis ■ Q va
X 706
= 14 0
267,
= 7-2 „
49
Impetigo ...
65
- 1-3
26
= 0-5
60
Scabies
19
1
94
Blepharitis
15
5
66
Total Contagious
895
= 17*9 per cent.
418
= 8*4 per cent.
534
Icthyosis ...
8
8
Nil
Alopecia ...
4
3
25
Psoriasis ...
7
3
57
Seborrhoea sicca
369
= 7*4 per cent.
166
= 3*3 percent. ^
55
Eczema ...
40
20
50
Foul otorrhcea
7
9
,
Grand Total
1,330
= 26*0 per cent.
627
= 12*5 per cent.
529
Epidem iologica l Sec tion
OrJ
Tuberculosis and Consumption .—Inquiry was made as to the
presence of these forms of disease in the immediate family or household.
In general, 4*2 per cent, of the replies are in the affirmative, but I
have reason to believe that the actual number affected is not less than
(5 per cent.
Presence of Consumption or Tuberculosis in Family.
Big School children.
( No. 1 ..
Stroud Groups.- No. 2
( No. 3 ..
1 On books
1,770
2,092
1,208
Positive Replies
Number
90
79
63
Per cent.
5*1
3*8
5*2
Total
5,070
232
4*6
Infant School children.
{ No. 1
707
39
51
Stroud Groups.-j No. 2 ..
907
1 19
21
1 No. 3 ..
568
28
50
Total
2,242
86
3*8
All Schools total ...
7,312
U \
4*2
Vision .—The following table relates to the examination conducted
among the schools of the Stroud No. 1 group; 1,131 children, including
most of the upper standards, were examined during school hours by
means of test types and ophthalmoscope. Of this number 22*3 per cent,
proved to have defective eyesight and 5 per cent, undoubtedly require
spectacles.
Vision Summary. Result of Examination.
Big school
*
Number examined
Defective vision
Parliament Street ...
191
36
Castle Street, girls
256
78
Church Street, boys
200
50
Thrupp
155
22
Rodborough Council
100
23
Uplands ...
229
43
Total
1131
252 — 22*3 per cent.
Zymotic Disease .—In general, the information obtained relates to
children bom during the years 1891-1902. The period covered by the
information relating to the incidence of zymotic disease is that of 1891
to 1904. Throughout the district boys and girls are evenly distributed,
their numbers being approximately equal. The testimony of the
parents (stated in terms of per ten thousand children) is to be seen in
table Z.
56
Coplans: Medical Inspection in Schools
Ep idem io 1 oy /ca I Sec t ion
57
The changes in age and sex incidence both before and during school
life (1891-1904) are as follow:—
Scarlatina. —There has been slight reduction before school age, 128
to 123, and a great reduction in the infant school, 668 to 201. The
maximal age-period incidence for children in the big school was from
3 to 7, i.e., during the whole of the time they were in the infant school
as well as the first standard of the big school. For children in the
infant school this age incidence has changed to an earlier period, viz.,
2 to 4, i.e., for the year preceding school life and the first two years of
school life. Boys and girls are affected disproportionately both before
and during school life, the girls being always in excess. The numbers
are as follow':—
Sex Incidence.
Before school life ... Boys 9G ... Girls 135
During ,, ,, ... G50 ... ,, 831
Total, age 0-13 ,, 746 ... „ 966
Diphtheria. —There has been much reduction before school age, 16
to 4, and similarly in the infant school, 118 to 62. For big school children
the maximal age-period incidence is from 4 to 10, i.e., during the major
portion of infant school life as w r ell as for the period covered by the first
four standards. For infant school children the maximal incidence has
receded to the third and fourth years of life, i.e., during the first tw r o
years of school life. Boys and girls are affected as follow:—
Before school life
Bovs 11*5
Girls 19
During „
246
„ 207
Total, age 0-13
,, 257*5
„ 226
Quinsy. —Diminution before school age, 26 to 12, and an increase in
th^ infant school, 148 to 173. There is little variation in the disease
during school life, save that the maximal incidence has changed from
the seventh year of life for children in the big school to the fourth year
for infant school children.
Sex Incidence.
Before school life ... Boys 30 7 ... Girls 7‘6
During ,, ,, ... ,, 338 ... ,, 442
Total, age 0-13 „ 368*7 ... „ 449*6
Croup. —Increases before school age, 80 to 110. Diminishes in
infant school, 148 to 110. For big school children maximal age
incidence period is from 1 to 6, likewise with infant school children.
Sex Incidence.
Before school life ... Boys 100 ... * Girls 85
During „ „ ... 254 ... ,, 135
»»
Total, age 0-13
354
220
58
Coplans: Medical Inspection in Schools
Rheumatic fever and St. Vitus' dance have been included within
the scope of the enquiry in order to determine their epidemiological
relationship, if any, with other diseases.
Rheumatic Fever .—The incidence before school age is negligible.
Only one case is reported among big school children as having occurred
previous to school age. None are so reported from among the infants.
The change is as follows; In the infant school, diminution from '2s
to 16. The incidence in the big school is fairly evenly distributed over
ages from 5 to 11.
Sex Incidence.
At school age (3-13) ... Boys 42 ... Girls 112
St. Vitus' Dance .—No cases before school age. Diminution in the
infant school, 12 to 4. Incidence is, in the big school, at ages 5 to 12.
Sex Incidence.
At school age (3-13) ... Boys 27 ... Girls 65
Thus there is some parallel between rheumatic fever and St. Vitus'
dance as touching age and sex incidence. The relationship between
rheumatic fever and quinsy, however, appears to be somewhat remote.
Whooping cough .—Increases before school age from 906 to 960, as well
as during infant school life, 1,840 to 2,177. The maximal age-period
incidence is during the first eight years of life, and the year of maximum
incidence, both for infant school and big school children, is the third.
Sex Incidence.
Before school
Boys 869
Girls 938
At school
„ 2,388
„ 2,723
Total, age 0-13
„ 3,257
,, 3,661
Measles .—Great increase
before school age
from 938 to 2,093, and
diminution in the infant school from 3,874 to 1,573. The years of
maximal age incidence in the infant school are at 1, 2 and 3, while for
big school children the years were 4, 5 and 6. Thus the period of
maximal age incidence has changed by about two years.
Sex Incidence.
Before school ... Boys 1,196 ... Girls 1,119
At school ... ,, 4,542 ... ,, 4,685
Total, age 0 13 ,, 5,738 ... ,, 5,S04
Mumps .—Increases before school age, 106 to 217 ; diminishes in the
infant school, 942 to 681. For big school children period of maximal
age incidence is from 2 to 11; year of maximal incidence is at 6. For
Epidem i<)Io< 7 ical Section
59
infant school children period is from 1 onwards ; year of maximal inci¬
dence is at 4. Thus the period has changed by about one to two years.
c
>ex Incidence.
Before school age
Boys 176
Girls 143
At
,, 1,585
„ 1,619
Total, age 0-13
11 1,761
„ h762
Chicken-pox .—Increases before school age, 472 to 742, and diminishes
in the infant school 1,296 to 1,044. For big school children, period of
maximal incidence is from 2 to 8, and year of maximal incidence is the
fourth. For the infant school the period is 1 to 6, and the year is the
third. Thus the period has changed by dne year.
Sex Incidence.
Before school age
Boys 562
Girls 573
At „ .
„ 1,354
,, 1,692
Total, age 0-13
„ 1,916
! „ 2,265
Second Attacks.
Measles .—Of 4,287 cases, 26 instances reported (1 in 172). Average
interval between first and second attack - 3*6 years.
Instances.
2
4
3
5
10
2
Interval in years.
7
G
5
3
2
1
H
1?
Age of attack in each instance
Numerator
Denominator
.1 (three), $ (two), J, $, J, J, V° (two), i (three), f, 1, J,
age of 2nd attack \
age of 1st attack / ' T
i (two), $, (two), V-
(two), l
One instance of a third attack.
Age of attack : 8, 6 and 10 respectively.
Whooping Cough .—Of 2,559 cases, 2 instances (1 in 1,280) at five-
yearly intervals.
Age of attack : f (both).
Scarlet Fever .—Of 706 cases, 4 instances (1 in 177) ; average
interval 4*2 years.
Age of attack : y» ?>
Cliicken-pox .—Of 1,555 cases, 1 instance.
Age of attack :
Mumps .—Of 1,279 cases, 4 instances (1 in 320) ; average interval -
3 vears.
Age of attack : f, 5, \°» ?•
00 Coplans: Medical Inspection in Schools
Review .—It is clear that in the matter of medical supervision of
schools the schoolmaster must be regarded as the doctor’s lay coadjutor,
and further, that an organised system of medical inspection must be
comprehensive and sufficiently elastic to cope with individual require¬
ments. In this Stroud district of Gloucestershire, despite the absence of
all definite powers, almost every parent at the outset gave his adhesion
to the proposed scheme. Yet it must be borne in mind that the parent
held the master-key of the situation, for the law was clear on the subject
that no man need carry out medical treatment. Medical supervision is a
comprehensive expression, and two spheres are all-important: the
control of contagious and zymotic disease and the adaptation of the
school task to the individual scholar’s capacities. Whatever measure of
success attended this inspection for contagious skin disease was due to
the recognition of the principle of a separate desk for each affected
scholar, with the corollary of isolation of his belongings while in the
school. At the same time it was recognised that as one-seventh of the
child’s school life was spent under the school roof, it was equally
important to pursue the system beyond the school gate.
The institution of the medical register facilitated the control of
certain forms of zymotic disease, notably with measles, for the columns
revealed at a glance the amount of inflammable material existing in any
household, standard, school or area. The unwisdom of general school
closure when only a certain proportion of children was likely to be
affected was made plain; more especially did it seem inexplicable that
the precious school hours of children in the upper standards, preparing,
perhaps, for competitive scholarship examination, should be wasted by
school closure for considerable periods because an epidemic raged among
children in the infant classes. The task of controlling zymotic disease
among children in infant classes will be simplified when parents are
compelled to disclose a reason for the child’s absence from school when
once its name is on the school register. At present, with children
under 5, no such explanation as to absence is asked for or furnished.
Curiously enough, a similar condition seems to prevail with children of
all ages from poor-law institutions attending public elementary schools.
It is plain that with scarlatina and diphtheria the gregarious habits of
children must be taken into account, and complete inspection of house¬
holds should accompany inspection of the affected school, for a child’s
playmates are usually to be found at its day school.
The adaptation of the school task to the individual scholar’s capacities
means in effect a recognition of defects of the special senses, as well
Epidemiological Section
61
as the limitations of his general intelligence. The head teacher will
need some guidance to distinguish defects of the special senses from pure
inattentiveness, and to learn that the curious high-pitched reading voice
may be a sign of deafness, as may be the omission of words in taking
down dictation; further, that a child’s backwardness in geography may
be due to inability to follow the teacher’s map pointer; and finally, that
with observation a lesson in sight-singing, by the simple tonic sol-fa
system, may be utilised as a means of confirming all suspicions as to
defects of sight or of hearing. The practical school remedy for those
defective in the special senses will consist in the application of the
empirical principle of “ the front row,” so that the defective child shall
be nearest to the teacher.
The difficulties attending the inception of this pioneer scheme are
happily dispelled by the recent changes in legislation. Objection was
raised and sustained dining the course of this inspection that if it
were necessary to examine every child medically Stroud had no special
claims to be so singled out from all other areas; that in effect the
medical inspector was a universal requirement.
Medical History Card. [Boys .] 1
If the Parents will kindly answer these questions, and fill up particulars on this side
of the Card, it will be of great assistance in preserving the health of their children.
THE INFORMATION ASKED FOR WILL BE REGARDED AS STRICTLY
PRIVATE, and is for the use of the Medical Inspector only.
Name of Child . Date of Birth
Address .
Day School . Sunday School .
„ , . „ 1 14 years of age and under.
Number of Children in Family \
■ 2.0 i, ,, and over ..,
Is there any Consumption or Tuberculosis in the Family ?
Kindly say at what age the Child has had any of the following Illnesses, and please write the age under the
Illness suffered, if any
!
Quinsy or
Rheu-
Scarlatina
Ulcerated
matic
or
Scarlet
Measles
Chicken-
pox
Diph-
theria
Mumps
Whoop¬
ing-cough
Croup
8ore
Throat or
Fever or
Acute
St Vitus*
Dance
Small-pox
Fever
Acute
Rheu-
Tonsillitis
matism
At the age
Attheage
Attheage
At theage
Attheage
At theage
Attheage
At the age
At the age
At theage
At the age
of
o t
of
of
of
of
of
of
of
of
of
Does the child enjoy good health generally ?. Parent's Signature .
Remarks by Parent . Occupation .
. Date . 190
Does the child enjoy good health generally ?. Parent's Signature.
Remarks by Parent . Occupation .
d—1
Boy’s card, white. Girl’s card, pink.
62 Coplans: Medical Inspection in Schools
This side of the Card is reserved for the use of the Medical Inspector of Schools.
Please do not write on it.
Date
Age
School
St’nd’rd
Vaccin¬
ation
j | ;
Height | Weight | | Hearing
Breath¬
ing
Phjsicl
velop-
ment
Intell’c-
tual De¬
velop¬
ment
Days
absent
for
Illness
Other
Remarks
1 i
1
. .
.!.'.;.
1
.i.!.
.!.'.
.
.!.
i , i i
.!..i.
1 i , i i
.1..1.i..
. 1 .
1 ! 1
”'i
i
i
.!.
.1
!
.
.
1
!_—_
_I_i_
!
DISCUSSION.
The CHAIRMAN said members were greatly indebted to Dr. Coplans for his
interesting paper, which contained many points inviting serious discussion.
Dr. Martin, in whose county the inspection described took place, was unable to
be present, but he had sent a letter, which would be read. It had been his
intention to ask Dr. Martin to open the discussion.
The SECRETARY then read the following letter:—
Dear Dr. Hamer, —Very many thanks for your letter and the proof of
Dr. Coplans’ paper, which I have read. You will find an account of the origin
of our experimental scheme printed with the evidence which I gave before the
Inter-Departmental Committee on the Medical Inspection and Feeding of
Children attending Public Elementary Schools, beginning on page 134 of the
second volume of their report. You will also find some observations of the
Committee on our scheme in the first volume. You will notice that this does
not quite agree with Dr. Coplans’ introduction. The main point in the paper
as it now stands appears to me to be contained in the section, “ Zymotic
Diseases.” It seems to me that the effect of introduction of infectious diseases
into homes through school influence is entirely omitted, and, speaking generally,
it is from schools that infectious disease appears in the homes. With regard to
the footnote to the table on page 5, too much stress should not be laid on the
hardness of the water; that supplied to the Stroud Urban District is very
hard, while in any of the parishes in Group II. (Stroud Rural) are supplied by
the Stroud Water Company, who soften their water down to 6° or 7 °.
With kind regards, and many thanks for sending me the paper,
Yours very truly,
(Signed) J. Middleton Martin.
Epidemiological Section
63
Dr. SANDILANDS (Winchester) said he had listened to the paper with great
interest, and it contained so many points that it was difficult to know which to
pick out for discussion. He did not think, however, that some of the matters
touched upon were directly connected with medical inspection of schools, at
least, not so closely connected as they might be. For instance, vaccination
seemed to be a matter into which a medical inspector of school children need
not enter, because the matter had been so thoroughly dealt with under the
system devised by the Local Government Board. A similar remark applied to
notifiable infectious diseases. Those diseases came within the provinces of
medical officers of health, who had better information, and must have by the
terms of their appointment, their facilities being greater than that of a medical
man, who could only go into the schools and acquire information from the
children there. With regard to eyesight, he noticed that 22 per cent, of the
children were reported as defective. He would like to know what the standard of
eyesight was ; was anything below six-sixths regarded as defective, or was some
lower standard taken ? He thought six-sixths unnecessarily severe. He would
also like more information as to the degree of success which had attended getting
those children treated after notices had been sent to their parents pointing out
the defects. He had carried on that work in Winchester during the last seven
or eight months, and had just made his second visit to the schools to ascertain
what number of parents, to whom such notices had been sent, had taken their
children for medical advice. He was astonished at the great number who had
so responded. One result of that was that there was over-work in the eye
department of the County Hospital, and the surgeon there found himself unable
to deal with all the cases sent. That point would have to be seriously con¬
sidered in the near future. If the inspection must be done throughout the
country it would be impossible to carry it on without the appointment of at
least eye-specialists, if not specialists for other defects also.
Dr. H. Meredith Bichards (Croydon) said that at a time like the present
when the new Education Amendment Act was about to come into force,
members must be very much indebted to anyone who would take the trouble to
bring before the Society such a paper giving the results of practical experience
in school inspection. As he had not seen the paper until he entered the room
he would content himself with a few discursive remarks. He agreed with Dr.
Coplans that it was essential that at any rate administrative medical inspection
should be in the hands of a special officer. That did not necessarily imply that
treatment must be undertaken by the school doctor, but he was sure the medical
inspection should be the work of a medical officer directly responsible to the
education authority.
He thought the difficulty with the parents was more imaginary than real.
The difficulty in Croydon had rather been the other way about, in that they
were invaded by parents who wanted advice on all questions, and therefore it
became a question rather of limiting the advice given than putting stress or
pressure upon parents to seek the doctor. He agreed that it was of no use
undertaking medical inspection unless one was able to see that remedial
64
Coplans: Medical Inspection in Schools
measures were undertaken by the parents. It was not sufficient to go to the
schools and make a catalogue of the bodily and mental defects ; there should be
some means whereby treatment could be secured, not necessarily undertaken by
the education authorities. The method which he had adopted in Croydon
during the last few years was to co-ordinate the work with the work of the
health department, and, after medical inspection, to send a written notice to
the parents of the child in whom there was a defect, and give a similar notice
of the defect to the health officer of the district, who kept the case under
observation until the defect was remedied, otherwise most of the work was
thrown away. Reference had been made to the necessity of getting the parents*
consent. The method adopted in Croydon was to prepare a card, one side of
which was devoted to the history of the patient; the cards were given to the
health officers for the district, and they called at the homes of the children,
obtained the histories, informed the parents that the doctor proposed to examine
the children on a certain day, and that if they liked the parents could be
present. It was not found that the scholars absented themselves on those
occasions—not one in a thousand.
Dr. Coplans seemed to have adopted the system of first of all examining the
child and then measuring him. At Croydon one of the nurses went to the
school about twenty minutes before the arrival of the medical inspector and
weighed and measured the children, and the cards were handed to the medical
inspector, with the weights and measures attached. Then a British Association
standard table of weights and measures was referred to, and if any child was
obviously below that standard a more searching examination was made.
He had often been asked how long the examination took. The experience
in Croydon, after several experiments, was that about twenty-five children at
a sitting, lasting about two hours, was as much as could be conveniently done.
Also that was about the greatest time which could be conveniently fitted into
a morning or afternoon session. The number would depend on the amount of
assistance which could be asked for from the authorities. A guide in that
matter was not only the number of examinations which could be got through
in a stated time, but the number of children who could be examined with
advantage. All who had held hospital appointments must know that after
a certain time in out-patient departments the value of the work done
diminished, because the faculties were tired. He could not very well criticise
the percentages given on page 51 of the paper without reference to his own
figures, which he had not by him, but he was struck by the small proportion of
cases of pediculosis in the Stroud school. In the Croydon schools three or four
years ago it was found that more than half the girls and nearly half the \>oys
were affected with pediculosis, so he was surprised that the percentage at
Stroud was only 13£.
With regard to the treatment of some of the diseases, in Croydon they
had followed the good example of the London County Council, and in respect
of pediculosis they had been content to use a modification of the cards
designed by Dr. Kerr, and if that was not effectual, to follow the cases up
Epidemiological Section
65
by prosecution, either directly or by getting the Society for the Prevention
of Cruelty to Children to prosecute. With regard to tuberculosis in schools
he had not his own figures, but he thought the proper way to deal with the
disease in schools was to get a careful history of phthisis in the family, and
then regard all children w T ith a family history of the disease as children for
special inspection. That would mean that they would be very much more
frequently examined, and any changes carefully noted.
He could scarcely follow the figures in regard to the incidence of various
diseases among school children, but in regard to measles, mentioned on page 58,
it seemed curious that the age incidence was greatest in infant school children
at one, two, and three years of age, while for the big school children the years
were four, five, and six. Was not the explanation a simple one ? Did it not
mean that there was an outbreak of measles in that district three years
previously, and that at the same time it affected the children of four, five, and
six, and those of one, two, and three ? In towns one did not find the same
result, because in towns measles was present every other year, and its exacerba¬
tions were obscured by almost continued prevalence. It was interesting to see
second attacks of measles were very uncommon, and that showed that the
history given as to past measles was fairly reliable. At one school he got out
the number of children who were said to have had measles during previous
epidemics. When measles occurred again it was found that scarcely any of
those children suffered, showing that the history given had been reliable. The
same thing was borne out in the paper on page 59. He must also mention
a remark from which he dissented, namely, that “ no man need carry out
medical treatment.” He, Dr. Richards, thought that every parent was
responsible for the due care of his children, and if he so treated them as to
subject them to unnecessary harm or suffering, it was a clear case for prosecu¬
tion, and at Croydon there had been no difficulty in occasionally getting
convictions in the local courts. He agreed with the author as to the unwisdom
of school closure, and he believed it was also unwise to exclude from schools
children who had already suffered from measles or whooping-cough. Many
towns did not exclude from school older children who had already suffered from
measles and whooping-cough. That had been so at Brighton for many years,
and also at Croydon, without ill effect. In regard to the remarks on page 61,
he asked the author whether he had had much experience of the more
obscure mental conditions of children. In Croydon there had been a number
of cases of word-blindness and word-deafness. Such children needed not only
to be put in the first row, but to be placed under very special conditions. On
the previous day he saw a word-deaf child, who could hear ordinary noises, but
who did not understand more than three words in the English language, yet the
child was not an imbecile. It made strong efforts to speak and to understand
what was meant by watching the speaker’s face. Such a child would rightly
be sent to the Deaf Centre, even though it were not a deaf child, and it would
be taught orally, and would probably gain a good deal of power of speech. He
would have liked to have discussed the schedule at the end, but he had already
6G Coplans: Medical Inspection in Schools
spoken too long. He thought that what Dr. Sandilands said about the medical
officer of health having more information about infectious diseases emphasised
the importance of co-ordinating work. And the remark about the over-work in
the eye department of the hospital emphasised the need for the educational
authorities undertaking treatment, at least as far as the provision of glasses was
concerned.
Lieut.-Colonel MACPHERSON, R.A.M.C., endorsed what had already been
said as to the great interest of the paper, which threw considerable light on the
spread of epidemic and contagious diseases through the country. The two
points which struck him most had already been commented upon. The first
was the deplorable state of vaccination among children of the schools, and the
other was the very high percentage of children having defects of vision. The
facts brought out by the paper in regard to vaccination were very important,
and threw much light on the incidence of small-pox in England as compared
with that of other countries. Some time ago he saw a map of Europe prepared by
the Prussian Institute of Public Health, indicating the prevalence of small-pox,
and he found that England showed an incidence about equal to the less enlightened
Balkan States, and was very much behind that of most other European
countries. That fact should be brought to the notice of the British Govern¬
ment. It would have been interesting to hear what particular visual defect
was noticed in the children. Probably only a small percentage of them were
due to myopia. Perhaps the author w r ould say something more about that in
his reply.
Dr. BUTLER (Willesden) said the results of Dr. Coplans’ enquiries were
very interesting, and he believed they agreed closely with those of others who
had inspected school children. Much of the work set forth was not of epidemio¬
logical interest: much of it raised administrative problems which were not
suitable for discussion there, and the field for discussion in the paper was,
therefore, somewhat limited. One of the most interesting points, from the
epidemiological aspect, was the relationship between measles, whooping-cough,
and other non-notifiable infectious diseases and school attendance. His experi¬
ence had been that those diseases did bear a most intimate relationship to
attendance at school. In his district he had found that by far the greater
proportion of cases of measles and whooping-cough were school-spread ; he
believed it was two-thirds. It was a significant fact, and the measures to be
taken with regard to it raised problems which had been dealt with by the
author. He did not agree that school closure was useless in checking the
spread, more particularly of measles. He did not believe that measles could be
combated except by means of school closure. He had attempted class closure,
but with signal failure. It usually ended in cases escaping exclusion and other
classes being infected, and in the end giving rise to worse results than if the
school had been closed. If the measures were to be effective it was necessary
that there should be early intimation of the occurrence of cases in the class,
and the closure must be prompt and cover the period at which the next crop
ought to be anticipated. He believed that it was only in the infants' department
Ejridemiological Sec tion
G7
that the disease spread. He had repeatedly closed an infants’ school on the
occurrence of even a first case, though class closure was often sufficient there.
It often only meant a week’s closure, and a threatened epidemic had been
nipped in the bud by such a procedure ; moreover, the effect with regard to
saving of school time was economical. He had made the experiment so
frequently that he was satisfied, if early intimation was obtained, the next crop
could be anticipated. If one waited until the third or fourth crop of a disease
was established it was hopeless to expect to check it, because by that time it
had practically used up all the available' material. Class closure, as against
school closure, had the defect that one might overlook the occurrence of
another case in another class, and then the time of the class had been wasted
by the closure. There were administrative considerations which prevented one
from dealing with measles and whooping-cough on the ground that a previous
attack conferred immunity. He was satisfied that a previous attack conferred
immunity, and that there was no necessity to exclude children who had had a
previous attack from school. But those formed a comparatively small propor¬
tion in an infants’ department, and to open a school for their reception was not
practicable. With regard to eyesight he believed it should be based not upon the
standard of six-sixths, but upon that of six-twelfths. Out of 20,000 tests of
vision in school children, about 20 per cent, had, in the older departments, a
vision of six-twelfths or below. If the children with defective eyesight W’ere
sent to the hospitals, the medical officer in charge began to complain of over¬
work. And yet there was no escape from it. Children whose vision fell
below the normal ought to have their eyes examined by an ophthalmic surgeon,
and when one considered the serious disabilities which followed upon defective
vision which was left uncorrected, the importance of this was quite apparent.
Dr. HAMER said that a point which was of great interest to him was that
made by Dr. Coplans concerning the difficulty of being sure as to the precise
age of school children. This difficulty made it the more necessary to be con¬
tinually on the look-out for mere tricks of the figures. The greater part, if not
the whole, of the supposed increase of cancer, and some portion of the recorded
diminution of phthisis, were of course known to be the result of altered nomen¬
clature. Again, a mere trick of the figures, so to speak, was responsible for the
supposed failure on the part of infant mortality to show decline, corresponding
to the fall in the general death-rate, the failure being accounted for by the
improved registration of the deaths of very young children. This was indeed
obvious, having in view the fact that dissection of the figures relating to deaths
under one year of age showed improvement had occurred all along the line save
in the case of newly-born children. It was most desirable that in connection
with educational statistics the same kind of mistake should not be repeated.
It was essential the correct ages of the children should be known, otherwise
nice deductions based upon small differences observed in the heights and
weights at different ages were beside the mark.
As Dr. Richards had pointed out, the explanation of the table showing the
behaviour of measles was, no doubt, that an epidemic occurred about four years
before the date of Dr. Coplans’ enquiry. The same might be said about scarlet
68
Coplans : Medical Inspection in Schools
fever, diphtheria and croup, all those sets of figures running the same way.
The children in the big schools were comparatively exempt, and in the infants’
schools the children of four, five, six, and seven were exempt. So that in the
case of those diseases the explanation, in the main, was that epidemics of
measles, diphtheria, and scarlet fever occurred in the year 1900. But he was
at first puzzled by the behaviour of the whooping-cough figures, because the
heavy incidence upon the later ages in the big school made it apparent that
there must have been a recent prevalence of whooping-cough in Stroud. This
conclusion was borne out by the figures in infants’ schools. What was puzzling
was the very heavy incidence of the disease at ages from two to seven on
children in the big school; this seemed to suggest that an epidemic prevalence
must have occurred some seven years prior to Dr. Coplans’ inspection. Refer¬
ence to the Registrar-General’s returns showed the explanation was that there
was an epidemic of whooping-cough in 1897, and then comparative freedom up
to 1904.
The most comforting observation in the paper was that in which the author
pointed out that the prime source of contagion was, as a rule, traceable to two
or three families, all of whom had long been known to the head teachers as
excessively dirty. He thought a fact of that kind was most hopeful concerning
the results likely to accrue from school inspection.
The CHAIRMAN said Dr. Hamer was very pessimistic with regard to
statistical returns, but he admitted that there was a ray of hope in the paper.
Personally, he, Dr. Bulstrode, thought there was great hopefulness in the paper.
Notwithstanding Acts of Parliament no measure could be enforced upon the
people, as was shown by the measure of compulsory vaccination. The paper
showed that 97 percent, of the parents consented to the medical inspection, even
in the Stroud Valley district, noted for being the home of a stiff-necked people.
Therefore the enquiry was very hopeful for the rest of the country. The
remarks made by Colonel Macpherson in regard to vaccination were quite true,
but in the annual reports of the Local Government Board there were figures
which enabled them to practically predict what would be the behaviour of
small-pox all over the country in the event of a pandemic. Assuming a wave
of equal magnitude, and resistance the same all over the country, they could
predict where the disease would behave in a natural fashion, and where it would
behave in an artificial fashion. In the Stroud Valley it would behave in a
natural fashion in infants, while on a well-vaccinated community it would
behave artificially, and the incidence of the disease would be on adults.
Another hopeful point was that the general sanitary condition of the poor
law schools was better than that of others. That would be seized upon by
a certain class of political agitators as an argument for the State education and
protection of children. He thought that tuberculosis in schools had practically
not yet been touched. So far as could be gathered from the post-mortem records
in this country and France, the incidence of tuberculosis upon the age group
which went to school was considerable. But it appeared that the tuberculosis
was not of a dangerous and communicable nature. Still the book was scarcely
open with regard to the prevalence of tuberculosis in children. Dr. Coplans’
Epidemiological Section
69
remark in regard to seborrhoea sicca and its relation to the hardness of water
was very interesting, and suggested the possibility of applying a new means of
testing for hard waters.
Dr. BUCHANAN said he had no special knowledge of inspection of schools,
and he would only draw attention to one or two points which occurred to him
on % hearing the paper. One was an administrative point, and therefore was not
one which strictly concerned the Section. But he gathered that when Dr.
Coplans was in a difficulty with the head teachers, who wanted some suitable
remedy for the condition of the children’s heads, he suggested as a compromise
that he would advocate certain remedies, warning the head teachers that if the
parents chose to use such remedies for special cases they were acting on the
advice of the head teacher. He (Dr. Buchanan) did not think that was very
sound administration, in the absence of special reasons. Either treatment
should be recommended and the responsibility taken, or it should not be
recommended.
Dr. Hamer had touched on the conclusions to be drawn from Table Z. He
also had noticed that, and thought the occurrence of an epidemic at particular
times would account for the apparent distribution of the periods at which the
particular diseases appeared to especially fall. But another point the Section
was interested in was as to how Table Z was compiled. Perhaps the author
would say how he reckoned the cases so as to get the proportion per 10,000
children ? He believed it was that he had originally 7,000 children, divided into
5,000 in the big schools and 2,000 in the infants, and he sent round so many
cards to the parents to fill up the ages at which those children had had scarlet
fever, <fcc. In order to arrive at the figures he had brought the 5,000 children
in the big schools to 10,000, and the 2,000 in the infants’ to 10,000 also. That
would be quite right for children of thirteen because parents could say what
had happened to the child up to that age ; but at seven the parents could only
say what had happened up to that age, and at three up to that age, and so
forth. And as a matter of fact the cards, dealing with ages such as eleven to
thirteen were quite a minority.
So it seemed dangerous to draw from those figures an inference as to what
were the particular ages, from one to thirteen, at which scarlet fever, &c., showed
the highest incidence.
Dr. COPLANS, in reply, said that what he had put forward was intended to
be the nucleus of a scheme capable of easy expansion. It had taken him less
than a year to carry out. The investigation into eyesight was the last carried
out, for the conditions prevailing in the country were not very favourable, and
there existed a tendency to regard this form of inspection as interfering unduly
with the school time. He had been told that if the scheme was successful it
would be extended in all directions, and that more medical men would be
appointed to carry out examinations of special senses. He had merely brought
to light the result of a cursory examination. The work of medical inspection of
school children proved extremely laborious, and he had no assistance of any
sort. If the Croydon average of twenty-five children every two hours were
taken, he did not know when the doctor would complete the examination of
d —8
70 Coplans : Medical Inspection in Schools
8,000 children—the school year would be insufficient. It was customary for
him to examine 150 children per day. That had an interesting reference to
the remark of Dr. Kelynack at Liverpool, with regard to tuberculosis in
children: That physician said that five minutes spent on examination of a
child was not sufficient to reveal the presence of lung tuberculosis; moreover,
it required a clinician of much experience to detect that form of disease, in
children. In regard to eyesight standard, he thought the right test was
whether the child could see the board writing from any part of the class. He
did not set up a six-sixths standard. His own view concerning the scholar was
that anything below six-sixths was defective. In the 25 per cent, of defectives
he included those who had eye injuries, corneal and other opacities. Five per
cent, of the children required spectacles. His examination was necessarily
curtailed because of the exigencies of time. With regard to vaccination he
thought it well to have information concerning any particular school, for
epidemiologically it might prove of importance to know the state of vaccination
in any isolated area, however small. The Local Government Board statistics
would not help in such cases. The parents did not show anxiety to seek advice
until confidence had been established. The people of Gloucestershire were of
repute cantankerous and suspicious, and some felt that his examination might
prove the thin end of the compulsory vaccination wedge. But when they saw
from the cards distributed that the scheme was private, and the contents of the
card would not be disclosed to a third person, full confidence followed. That
was a reply to the remarks of Dr. Meredith Bichards as to the nurse calling at
the house. Such a step would have involved a breach of confidence, for he
could not lay any information before any third person, even a magistrate. As
to drug treatment of children, the law remained unchanged ; the parent was
the final arbiter, and the decisions of the Croydon justices should have been
reversed. With regard to the closure of schools for measles, children under
5, formed 10 per cent, of the total school population, and 30 per cent, to
50 per cent, of those in infants’ schools. Fourteen per cent, of the children
under 5 in infants’ schools were always away, and that was the clue to the
mystery as to the alleged sudden outbreaks of measles. The fact was that
when an outbreak occurred cases had been going on for some little time.
When 14 per cent, were away, it was difficult to control measles epidemics,
because the medical officer was usually called in too late. In one district
there had been no visitation of measles for ten years, and when at last it came,
the school' was attacked even up to the fifth standard. As usual, he was
notified after the event. Too many conclusions should not be drawn from
town experience; each epidemic should be judged separately. He laid much
stress on table Z, though it gave simply the facts as told by the parents. It
showed that in general the statements of the scholars’ parents were extremely
reliable. Dr. Butler had stated that financial considerations prevented infant
class closure as distinct from school closure, but he (Dr. Coplans) did not think
considerations for such finance should have any place in their discussions.
Dr. Hamer’s interpretation of table Z was right, and he quite followed
Dr. Buchanan’s criticisms.
Eptoemiolofltcal Section.
December 2, 1907.
Dr. Newsholme, President of the Section, in the Chair.
On the Present Methods of Combating the Plague.
By W. M. Haffkine, C.I.E.
I.
I shall begin my review by briefly enumerating the measures
suggested for stamping out the plague or preventing its importation.
These measures deal either with man, with inanimate objects, or with
the lower animals. The first category of measures comprises:—
(1) Discovery and notification of persons attacked w r ith the disease.
(2) Isolation of the attacked.
(3) Certain precautions with regard to the disposal of the dead.
(4) Segregation of those who have come in contact with the sick
or dead.
(5) Institution of cordons round infected areas.
(6) A less di'astic and less thorough plan than the last mentioned,
viz., placing in quarantine arrivals from infected places, detaining the
sick and suspected, and letting the rest free after a time of observation ; or
(7) A still less rigorous measure, which is merely to examine travellers,
isolate the sick and suspected, and let the others free under a system of
surveillance.
The following may, I think, be said in regard to this group of
measures:—
The part played by man in the causation of plague seems, on the
whole, subordinate to that of other agents. Thus, when the plague first
broke out in Bombay, in the summer of 1896, it remained for a consider¬
able time confined to a quarter called Mandvi. The mass of people there
are day labourers, working outside their quarter. Though they spent
the day in close communion with many other people, cases continued
ja —6
7*2 Haflkine: Present Methods of Combating the Plague
to occur among the Mandvi labourers alone and in their families, and
only subsequently and gradually appeared in other quarters. Since
that year Bombay has had eleven consecutive outbreaks. Every year
the epidemic lasts for some months and becomes relatively quiescent for
the rest of the time, but the recrudescence begins approximately in the
same locality and the same events are more or less uniformly repeated.
Subsequent to the appearance of plague in Bombay a town¬
ship called Kirkee, near Poona, became infected, and the disease
broke out among the native followers of the Royal Artillery. The
men and their families lived on a spot somewhat away from the
rest of the people, but spent the day at work in the batteries. Through¬
out the epidemic the batteries remained free from disease, while the
followers suffered heavily ; and they suffered practically in the same
proportion as their womenfolk and children, who did not leave their
homes. Similar facts were observed on the Colaba peninsula in
Bombay, among men who, in the daytime, were at work in the Army
and Navy Co-operative Stores and at the Gun Carriage Factory, and
spent the night with their families. The other people in the Army and
Navy Stores and at the Carriage Factory remained free, but the Colaba
men suffered equally with their families.
Further, on many occasions it has been observed that plague first
started in a town by attacking persons who had not been away and
among whom no history of contact with people from an infected place
could be discovered; and, vice versa, in every country invaded by the
disease, there are districts, towns, or villages in which, though the people
are in constant communication with infected places, and cases of plague
are constantly imported into them, the disease gets no footing and the
locality remains exempt from invasion.
The proposition illustrated by these facts, viz., that man does not
play a predominant part in the conveyance of plague, is supported also
by other observations. In 1897 a plague hospital was established in the
vast premises of the old Government House at Parel, in Bombay, and
a number of patients soon gathered there. In order to minimise the
objections to hospital treatment families were allowed, if they so wished,
to accompany their patients, stay at the hospital, and attend on them.
The officers in charge soon noticed that when a family took advantage of
this permission to dwell in the midst of numerous plague patients, its
members were safe from disease; but when they remained in their own
home, although the only case of plague had been removed, other cases
often followed. In the same way, very rarely has it been seen that any
Ki > i<] cm io It >(/)<■ a 1 Section
73
of tlie permanent attendants in plague hospitals have taken the disease.
Pneumonic cases alone have proved dangerous in this respect.
The observations above quoted warrant, I believe, the following pro¬
positions, now more or less generally recognised, viz., that (1) plague is
what has been termed, in a general sense, a disease of locality; (2) that
it is contracted principally at night; and (3) that the part which man plays
as direct agent in its propagation is a more or less subordinate one. This
being so, the measures taken with regard to man, even when carried to
perfection, can influence the propagation of plague only to the same
proportionately limited extent. In the vast majority of cases events
have conformed with this conclusion, in that precautions taken against
the importation or the spread of plague by man have failed to secure the
desired end. It must, however, be stated that these precautions can
rarely, if ever, be carried to perfection. Their application is fraught with
great difficulties, and is often impracticable. This is due to the impos¬
sibility of enlisting the self-sacrificing co-operation of individuals, to the
first cases being rarely recognised, to the reluctance of those falling ill
to deliver themselves into the hands of strangers and officials, to the
measures of prevention hurting trade and numerous private interests,
and to the consequent wholesale evasion of prescribed rules. The time,
therefore, arrives when the measures directed against man are relaxed or
dropped, and efforts are chiefly applied to inanimate objects.
II.
This part of the programme seems lighter of accomplishment. The
list of measures, within an area infected, comprises, in this case, destruction
or disinfection of houses, furniture, clothing, bedding, carriages, goods,
warehouses, grain and other stores, garbage, drains and streets. Outside
the infected area the measures consist in the refusal to admit carts,
trains and ships with goods from infected places; or in the refusal to
admit only certain goods ; or in mere inspection of trains, carts and ships,
and some procedure by which these, and the goods they convey, as well
as the belongings of travellers, are sought to be rendered harmless. All
these measures are intended for the avoidance or destruction of plague
germs which may possibly exist in the objects concerned.
Plague bacilli have, however, been very carefully looked for, but so far
have not been discovered in the earth, on the walls or floors of houses, or
on any inanimate object, unless they were quite obviously and recently
soiled by the products of a plague patient. I am not, moreover,
aware of a single instance in which the extension of this disease
74 Hafikine: Present Methods of Combating the Plague
by means of goods of an inanimate nature has been conclusively demon¬
strated, though linen, clothing, handkerchiefs, and other personal
belongings of a sufferer from pneumonic plague, if soiled with his
6putum or nasal discharge, must be dangerous for a certain, possibly
long, period of time. Further, the microbe of plague is not a resistent
organism. From the first it was seen that under ordinary circumstances
it was easily killed by disinfectants, and that exceptional conditions are
required for that microbe to resist and preserve its vitality. Under
these circumstances the following conclusion might seem justifiable: If
inanimate objects are important carriers of plague, disinfection should
generally be an effective check to its spread, and on this presumption the
above measures were devised.
According to numerous observations, however, made by health
authorities, a house, its furniture, all the belongings of the inmates, and
the inmates themselves may be washed and disinfected repeatedly,
and yet cases of plague may occur subsequent to each disinfection,
if people are allowed to stay in that house. Though general statements
to this effect have been made by earnest observers, I am not aware
of a precise demonstration of a case in which disinfection arrested the
development of an epidemic of plague.
The above theoretical considerations must be supplemented by the
following remarks of a practical nature: The expense and the difficulties
of destroying or thoroughly disinfecting houses, goods, and other property
over a vast area are very great, and the agency for properly carrying out
such measures is not available or is not forthcoming.
The enormous bulk of merchandise conveyed nowadays by rail and
ship admits of no process which would answer to elementary require¬
ments of disinfection ; and the opposition and hostility of vast numbers
of people, whose interests are interfered with by these measures, can only
be estimated when the task is actually undertaken.
III.
I come to the measures relating to the lower animals. These are :—
(1) Destruction or keeping away of rats by poisoning, trapping, tar
and sulphuric acid mixture, or through the agency of the domestic cat.
(2) Improvements in towns and villages, with a view of reducing or
keeping out the rat population, viz., structural alterations of dwellings,
warehouses and grain stores, demolition of insanitary buildings, introduc¬
tion or improvement of conservancy arrangements, prompt disposal of
garbage, periodical inspection of stores, paving and draining of streets,
and certain other measures.
Epidemiological Section 75
(3) Destruction and dispersion of fleas by petroleum or other
insecticides.
(4) Fumigation of houses as a temporary protection against rats and
fleas.
(5) Obligation on ships from infected regions to anchor away from
the shore; or,
(6) Provision of mechanical arrangements for preventing the landing
of rats along mooring cables and gangways; and
(7) Fumigation of ships arriving with plague patients or plague rats
on board.
The measures have, therefore, for their object, and, I believe, rightly
so, the rat and the flea, described by Rothschild under the name of Pulex
cheopis; but epizootics of plague break out also among squirrels, tarba-
gans, guinea-pigs, monkeys, mice, kangaroos in Australia, and some other
animals, which contribute to keeping the disease alive.
Measures for the destruction of rats were applied in India at the
beginning of the epidemic, viz., in 1896, by Professor W. J. Simpson,
then Health Officer of Calcutta, and have been carried on also in the
subsequent outbreaks in many places. A new impulse has been given to
them by the labours of the recent Plague Commission in Bombay. But
nowhere, possibly, has the effect of these measures been more carefully
gone into than in Sydney, under the direction of Dr. Ashburton Thompson.
The campaign against rats and fleas is the most rational and the best
founded of all the procedures suggested for stamping out the plague, for
outside the human body in animals alone have plague microbes been
actually seen so far in nature. It is, however, essential to estimate
the extent to which this is a promising direction. Various factors, such
as increase of the human population, destruction or planting of forests,
occupation of waste lands, building of canals, introduction of new animals
and plants, and a variety of other circumstances bring about, in the course
of time, important changes in the flora and fauna around us. I might
quote, as relatively modern instances, the disappearance of wolves from
Great Britain, or the practical extinction of the bison, or of the black
rat, from these islands and the continent of Europe, and a few others.
These changes have taken place gradually, and in such long periods of
time, that the exact causes which have brought them about are unknown.
Up to quite recently it would have been impossible to name a single
instance of a result of this kind having been effected in a short time by
steps of an administrative character, or even by the resolve of a whole
population. From time immemorial man has had to put up with the
76 Haffkine: Present Methods of Combating the Plague
presence in his proximity of animals and plants interfering with, and
devastating, his crops—locusts, field mice, spermophiles, campagnols,
phylloxera, mildew, rabbits in Australia, and so on. The power of
adaptation and reproduction with which nature has endowed many of
these animals and plants generally triumphs over the deliberate efforts
of man when the surrounding circumstances are favourable to their
multiplication. Still the problem is not wholly impossible.
The recent successful instances, to which I have alluded, are the
campaigns against mosquitoes in Ismailia, in Klang and Port Swettenham,
in the Panama Canal zone, and in a certain number of other places at
which it has been found possible to alter, in a short time, the surrounding
conditions so as to render the propagation of these insects impossible.
These examples are a grand and splendid lesson to the world, but a
lesson which, it must be acknowledged, is, in many cases, difficult, and
in others, impossible of imitation.
The observations made by the Chief Medical Officer of New South
Wales are of interest in this connection. I have in view his care¬
fully organised campaign against rats in Sydney, with the object of
protecting from plague a white population of a high standard of
intelligence and education. During that campaign Dr. Ashburton
Thompson found that the gross returns of rats and mice caught and
destroyed, week by week, were nearly uniform, and that there was thus
no evidence that the slaughter produced such an impression on the
general horde as would have rendered collection progressively more
difficult. The opinion he came to was that extermination of rats in any
large area by poisoning and trapping was practically impossible, and that
the plan of spreading among them an artificial epizootic by means of
Dr. Danysz’s rat vims failed on account of that virus rapidly losing its
virulence, liegarding this latter point, one cannot forget that India
has now had, in the plague bacillus, eleven years’ experience of a most
devastating virus for these animals, and as yet there is no sign that this
involuntary experiment has rid the country of their presence.
The observations coming from Japan, where determined efforts have
been made to destroy rats, are as little encouraging. The facts published
in June of last year were to the effect that in Tokyo alone 4,800,000
of these animals had been killed, but the slaughter seemed only to
have prepared more favourable conditions for the multiplication of the
survivors.
Dr. Ashburton Thompson’s experience, in regard to facilities given
by householders in Sydney for the detection of plague rats, was identical
Ep ide m iolog ica l Sec t io n
77
with that gained in India. He found that the people were reluctant to
admit to their premises rat-catchers and other strangers bent on that
task, and that the information supplied by the inhabitants, as well as
that gathered by the professional men specially appointed for the pur¬
pose, was so scant as to be barely sufficient to indicate the presence of
infection in a locality, but not to gauge its severity. Though, therefore,
the measures against rats, either by extermination or by change in the
construction of cities and villages, are a most important item in an anti¬
plague campaign, the question whether any noticeable impression can
be made on the epidemic by these measures within the length of a
generation, or even in a longer period, is a matter of great uncertainty.
Even the • destruction of rats on ships alone, if imposed as a general
measure, would cause a dislocation of traffic and an outcry formidable
to face. The result is that every day plague is imported, though fortu¬
nately it does not spread, into one part or other of the maritime countries
of the world.
IV.
The above analysis of the facts connected with the problem of
stamping out the plague leaves little room for surprise when it is seen
that, although in many places reached by the plague, the latt.er, as I
have just mentioned, does not take root and dies out, in others, where it
finds a congenial field for its propagation, the attempts at eradicating it
prove unavailing. Thus often ends in disappointment what may be
termed the first stage of the struggle against that disease, namely the
efforts of stamping or keeping it out. This result becomes apparent
to the population, who are the sufferers, long before the medical
or sanitary authority makes up its mind to acknowledge defeat; and
when they first become aware of it the people fly in a stampede in
all directions. For, although bare figures of the plague death-rate
impress different people differently, there can be no doubt as to a
plague actuality being a terrifying event. It takes time to get used
and, so to say, reconciled to it. European countries must still have
some recollection of their own experience of the matter. The people
therefore flee and seek shelter in other towns. But their means of live¬
lihood are left behind in the old place : nowhere is employment and
sustenance ready for new and sudden arrivals. After a period of
suffering and hardships the fugitives return in search of work to the
old place, and resign themselves to the inevitable.
I have referred, however, to the fact that when plague first occurs
in a given quarter of a city it remains confined to that quarter for
78 Haffkine : Present Methods of Combating the Plague
a certain time. There is thus no necessity for going far afield. In the
Himalayas and the plains of India the villagers, whenever possible, go
out a mile or two from their houses and live under trees or in open
fields. Often, however, the disease breaks out in the mountains in
severe winter, and in the plains during the season of rains. To remain
then in the open or in rapidly put-up shelters, with a scanty provision
of clothing and bedding, with the difficulties in preparing food, pro¬
tecting property, caring for and sheltering the small children and the aged,
becomes an untold hardship. In towns, on the other hand, unoccupied
land is scarce. The people, in fair weather, go into such open spaces and
public squares as are available. A water supply, conservancy arrange¬
ments, police administration, fire prevention, patrolling of ‘abandoned
houses and property, depots for boxes and bundles, and a number of
other arrangements become necessary. With this, the deprivation of
ordinary comforts of a settled home is felt so keenly that only families
in whose midst cases of plague have already occurred avail themselves
of these facilities. The others remain at their homes and furnish
material for the continuance of the epidemic. The plan of abandoning the
affected locality, for shorter or longer periods, may perhaps be termed
a second stage in a campaign against the plague.
To whatever extent that plan is feasible, to that extent the effect
of it is beneficial. It is the limited range of it and the innumerable
complications which it brings in its train that finally lead the adminis¬
tration and the people to resort to what always seemed to me the
ultimate method of combating the bubonic plague in the areas in which
it becomes endemic, viz., that of conferring on the population immunity
from the disease by means of an artificial treatment.
V.
I imagine that in this Section of the Koyal Society of Medicine it
w r ould be out of place to enter into the bacteriological aspect of the anti¬
plague inoculation, to examine the various views from which the subject
might be approached and solved, and the advantages and difficulties
of each. For the purposes of the present deliberations it may, perhaps,
be sufficient to enumerate the salient points of the matter, as ascertained
in India in the last ten years. These are:—
(1) That in a native of that country, who is more susceptible to the
disease than Africans, Europeans and some other races, the inoculation
now in force in India reduces the liability to attack to less than one-third
of what it is in a noil-inoculated Indian.
Epidemiological Section
79
(2) That in the one-third of cases which still occur, the recovery rate
is at least double that in the non-inoculated attacked, the ultimate result
being a reduction of the plague mortality by some 85 per cent, of what it
is in non-inoculated Indians.
(3) That in an inoculated European an attack of plague, if it sub¬
sequently occurs, has so far always ended in recovery.
(4) That the inoculation is applicable to persons already infected and
incubating the plague, and prevents the appearance of symptoms, or else
mitigates the attack, a fact which disclosed a basis for the bacterio-
therapeutic treatment of disease.
(5) That in natives of India the degree of immunity conferred by
this inoculation, though gradually vanishing, seems to last during several
outbreaks of plague; and that
(6) In Europeans the effect has not yet been seen to disappear in the
space of time, since 1897, that this inoculation has been under study.
I now proceed to matters which concern the epidemiological aspect
of the question, viz., the place which experience has indicated should be
assigned to this plan of defence in plague-stricken provinces.
His Majesty’s letter on the plague, addressed to the Governor-General
of India on August 13 last, and Lord Minto’s communication to the
heads of local governments and administrations, have brought about
a renewal of efforts to bring down the plague mortality. Lord
Minto’s letter points out that many expensive and harassing opera¬
tions carried on in the past may be safely abandoned, and expresses
the hope that, with the assistance of the people themselves, some distinct
advance will now be made towards bringing the ravages of the pestilence
under control. Consequently, in most places fresh campaigns have been
undertaken and organised in the light of the teaching gained during
the past decade.
The Province which has had most of this unhappy experience is
the Bombay Presidency, where the disease appeared first, viz., in
1896. The result of this experience may, I think, be gauged from
the following official utterances: On October 7 last, the Hon. Mr.
Muir Mackenzie, then Acting Governor of that Presidency, in a speech
addressed to the Municipal Corporation of Satara, summarised the
mutual position of the two principal measures on which the Bombay
Government have learned to rely in the struggle against the plague.
“Evacuation,” he said, “is no doubt effective quantum valeat. But
think of its drawbacks. I doubt if it would have been possible at all
during the torrential rains of July and early August. If managed, think
80 Hafikine: Present Methods of Combating the Plague
of the miserable discomfort, the risk of chills and fever ; and, at its best,
what a dislocation of business, what a disturbance of home, what
expense, what discomfort, is entailed by evacuation. Evacuation will
not cure the stoppage of business, the closing of schools of which you
complain. But if inoculation were general none of you need stir—your
business would continue, your schools would be full, everything would be
as before. I can fancy that in the old days small-pox may have entailed
the same miseries as plague does now—fleeing the town, the runaways
carrying infection ; deserting the home only to catch the disease on
daring to re-enter it. Now people, being vaccinated, are hardly disturbed
when small-pox breaks out. Let it be the same with plague. Be
inoculated at the first sign, and so obviate disturbance of the domestic
and educational and business avocations of yourselves and your children.”
Sir George Sydenham Clarke took over office as Governor of
Bombay a few weeks ago, and on November 12 addressed to the
vernacular newspapers a letter of which some telegraphic information
has reached this country. He emphasised the heavy responsibility which
rested upon the papers of using their influence with the natives to
prevent the spread of the scourge. He acknowledged that if the people
were unwilling to destroy the rats which were the vehicles of the disease,
their feelings must be respected, and he therefore urged that recourse
should be had to universal inoculation, which, he stated, was the easiest
and most certain method of prevention.
The experience gained in the Punjab (the other great Province
of India ravaged by the plague) has been stated in a memorandum
which the local government addressed to the Government of India
on June 30, 1902, after five years of the application of various anti¬
plague measures. According to this statement segregation of patients
and “ contacts under the conditions which are essential to the success
of that measure, is entirely out of the question, and intercourse between
infected and uninfected places is in most cases quite unrestricted;
evacuation is not a procedure which can be of assistance in checking the
extension of plague from one locality to another; disinfection cannot
be relied upon as a practical measure for the arrest of the epidemic; and
there remains only inoculation with the plague prophylactic, and its
benefits, the government declares, are so generally understood in the
Punjab that a large proportion of the population of the infected districts
can, without much difficulty, be induced to submit to the operation.
The part of India now exposed more dangerously than all the others
is the United Provinces of Agra and Oudh. These provinces have at
Epidemiological Section
81
present, as head of the administration, the able civilian who, in 1898-1900,
accompanied and took part in the investigations of the Indian Plague
Commission, and had an opportunity of making himself closely acquainted
with the working and the results of the various plans tested for com¬
bating the plague. In publishing, in the beginning of September last.
His Majesty’s and the Governor-General's letters on the plague, Sir
John Hewett, the Lieutenant-Governor, issued a detailed plan, approved
by the Government of India, of organising a special service to carry on
inoculation when plague reappeared. The poor, who cannot afford to
lose their earnings during the day or two of rest desirable after inocula¬
tion, are to be given assistance up to a sum of one rupee per person.
Government servants are to have inoculation leave for the necessary
period. Railway companies, and other employers of labour, are requested
to give similar facilities to their employes.
The resolution issued by the Government on the subject ends by
saying that the Lieutenant-Governor “ earnestly appeals to everyone
interested in preventing the manhood of the country from being sapped
and its vitality destroyed by the scourge of plague , and particularly to
the leaders of native society and non-official Europeans who employ
labour on a considerable scale , to aid in the endeavour to induce the
people to protect themselves by inoculation. " Subsequent to this resolu¬
tion the Government of the United Provinces issued orders offering also
facilities for those who wish to vacate their houses, and giving detailed
and well thought-out directions for the destruction of rats.
Mr. President and Gentlemen, I have endeavoured to place before
you the present position of the various measures suggested and tried so
far in combating the plague as an epidemic. I have not entered upon
the subject of curative treatment of plague, because this would perhaps
be outside the scope of this Section, and because the result of that treat¬
ment leaves much, if not everything, to be desired.
Protection of India from Invasion by Bubonic Plague.
By J. Ashburton Thompson, M.D.
Selection of this topic for discussion by a stranger to India requires
justification. I point out, therefore, first, that Australian conditions
happened to be so favourable to the epidemiological investigation of
plague that data of two classes were there acquired with comparative
ease, viz., (a) fundamental data which concerned the disease itself and
which, consequently, hold good in all countries and under all circum-
82 Thompson: Protection of India from Bubonic Plague
stances; and ( b ) data which concerned practical administration, which
are liable to modification in different countries by local habits. And
then, secondly, I would say that I have no intention of trespassing
on the province of the administrator, at least in the details of his work.
I propose to speak rather of the statesman, and to point out that which I
conceive to be the sole and irrefragible principle which he must impress
on administrative staffs if he would achieve any permanent reduction
in the susceptibility to invasion by plague which is so marked a feature
of the conditions of life in India.
The fundamental data acquired at Sydney were the following :—
(1) The epidemic spread of plague occurs independently of com¬
munication of the infection from the sick ; consequently, the infection
of plague spreads by means which are external to man, and which are
independent of his agency as subject of the disease. The data on which
this conclusion is founded were first published in November, 1900.
(2) The plague rat is harmless to man; it is, nevertheless, the
essential cause of epidemics; consequently, some intermediate agent is
necessary to convey the infection in efficient form from rat to man.
The evidence for this conclusion was first published in July, 1903.
(3) The intermediate agent between rat and man (and between rat
and rat) can be no other than the flea foreshadowed by Simond, and,
further, actually is the flea. This conclusion also was published in July,
1903, together with the exact observations made in the field from which
it was deduced.
The administrative data then acquired were many. They were
all referable to the fundamental data; and when it appeared, as it
sometimes did, that the conclusions of this class were not in accord¬
ance with experience in other parts of the world, it was still found that
the differences were apparent and not real, and were easily explicable
by the fundamental data already mentioned. For the sake of example
the following instances may be cited. One of them was that transfer
of the sick to hospital is a very important curative measure, but is quite
without importance as a preventive measure. Another was that there
is no such thing as infection of localities or places, although the disease
is acquired by resort to certain localities; the explanation is that the local
rats are infected, not the places themselves. A third was that clothing
never becomes infected with plague, and is never a cause of spread; and it
was easily seen that the contrary experience commonly recorded in India
was not inconsistent with that conclusion, but was explained by the funda¬
mental datum that the infection is communicated by fleas, which in India
Epidemiological Section
83
very much more commonly infest the people and their houses than in Aus¬
tralia, where such infestation is, for the most part, absent. Observations
of the class now referred to may or may not hold good in all respects in
changed social conditions; but there was another among them which
has not yet been mentioned, and which is certainly of universal applica¬
bility. This was that the infection of man was most usually contingent
on his being within buildings together with plague rats; and on con¬
sidering the fundamental data it became evident that a certain proximity
between man and the minute agent of his infection—the flea—must
be necessary. Hence it appeared plainly that the exclusion of rats
from occupied buildings must be an important item among steps for the
prevention of plague, for from the rat alone does the flea derive its power.
But more than that, the longer this point was contemplated the clearer
it became that the rendering of occupied buildings rat-proof was absolutely
the most important item in plague prevention, and even the only one
to which the epithet “ preventive ” could be justly applied. The reasons
will be referred to presently; here I would merely note that I advocated
this view also first in 1900, and then predicted that its simplicity, and
perhaps also its apparent indirectness, would militate against its accept¬
ance by the laity who control the purse, and consequently the means of
carrying it out. And it is still the case that attention is concentrated
on other measures which, in reality, are merely remedial, or merely
palliative, and which are consequently interminable. This, then, is the
point to which I wish to draw especial attention; but I must add that I
take it to include and to cover destruction of the harbourage which rats
find outside, and in the immediate neighbourhood of, buildings. The
difficulty of saving the people in a place from attack is proportioned to
any difficulty there may be in preventing the access of rats to the
buildings occupied by them ; but the difficulty of clearing plague away
from the place itself is proportioned to any difficulty there may be in
removing the harbourage which rats find in the mouths of sewers, in
heaps of lumber and rubbish, in loose earth and rubble-fillings, and in
dilapidated sheds or the like structures.
It should be noted that the administrator who is faced with an
outbreak of plague is perfectly right in relying on immunisation of the
people—a possibility laid open to him by the genius of Mr. Haffkine,
here present—on evacuation, and on the destruction of rats. These are
his only, and fortunately his very effective, means of staying it. But
the statesman should be caused to understand that the control of
existing epidemics is not a subject to engage his supreme abilities, and
84 Thompson : Protection of India from Bubonic Plague
that his preoccupation should be how best to diminish the susceptibility
to invasion of his country as a whole. The methods just mentioned
(I must repeat it) are in fact remedial, not preventive, and consequently
they are, as I have already remarked, interminable. If a population be
immunised this year it must, if it be reinvaded, be again immunised in
a twelvemonth, or a little later ; evacuation may have to be repeated
even during the same season; and to the killing of rats there is literally
no end at all. But every building which is rendered inaccessible to rats
may be regarded as a fortress impregnable to that enemy for ever.
This, then, indicates the only road the statesman can fitly take ; a road,
namely, on which every step must be directly towards the goal, and on
which there cannot be any backsliding.
The arrest of present outbreaks is a quite different matter from
diminution of the liability of the country to suffer them. Removal
of the conditions which constitute its susceptibility can alone be justly
spoken of as preventive action. And it is, I think, of little use to
place scientific truths before the laity unless the expert points out
their practical bearing and application at the same time. In order to
judge in how far true that is, it is only necessary to ponder the Gazette
Extraordinary which was published by the Government of India during
August of this year. That Gazette draws attention to the essential part
played by the rat, to the essential agency of the flea, and to the insignifi¬
cance of deposited infection; but it also expresses the opinion that this
knowledge, acquired by it from the remarkably brilliant reports of the
Plague Research Committee, will probably not render the task of pre¬
vention much easier than it was before. The Gazette even mentions the
desirability of excluding rats from dwellings, but only to dismiss this
method with the remark that it is impossible to expect much improve¬
ment in the construction of buildings in the near future. The all-
important distinction mentioned above between remedial and preventive
measures is not perceived.
This pronouncement, then, appears to be rather less far-seeing than
might reasonably have been expected. For there are many other con¬
siderations which must be entertained besides the crude facts which are
recited in the Gazette. It should be noticed that plague seems to have
taken its place among the endemic diseases; and if the uncertain
teachings of history seem to offer some prospect of its ultimate extinction
by natural process, it should be borne in mind that present circum¬
stances are vastly different from those which formerly obtained, and
especially in relation to traffic. To-day plague is a disease to be fought
Epidemiological Section 85
persistently in India, as, I suppose, typhoid fever and cholera are there
fought. No speedy exemption is, in my opinion, to be expected.
It must be frankly said that the method of exclusion is practically
impossible in the smaller villages, in the larger villages, and in the
lesser towns; but this admission is very far indeed from covering the
whole case. In the first place, it is precisely in those smaller and more
or less circumscribed collections of huts and houses that the palliative or
remedial measures are easily successful and, provided the infection be
not reintroduced, permanently successful. In the second place, whence
do Indian villages derive their infection ? Is it not from the great cities
on the seaboard and from the larger inland cities which have become
secondary distributing centres ? And is it, indeed, quite impossible to
apply the method of exclusion in them ?
I do not doubt that when a broad and comprehensive survey of all
the data has been taken, it will be perceived that the exclusion of rats
from occupied buildings in cities is the only measure which can per¬
manently diminish the susceptibility of India to plague; and that, as
soon as this principle of action has been grasped, resolutions taken by
Government will be conceived in the spirit which animated that courtier
who, when he was desired to undertake a business which the King him¬
self thought it hardly possible to carry through, replied “ Sire, if it be
difficult, it is already done ; if it be impossible, it shall be done.”
• Note .—With reference to this paper the following letter has been received : —
Southern Punjab Railway Company, Limited,
70, Cornhill, London, E.C.,
December 7 , 1907.
Sir,— In reference to the meeting of the Epidemiological Section of your Society on the
3rd instant, my Chairman, Sir Bradford Leslie, desires me to draw attention to a remark
made by Dr. Ashburton Thompson that “ Every building which was rendered inaccessible to
rats might be regarded as a fortress impregnable to that enemy (plague) for ever ”; and in
confirmation of that view I am to forward the enclosed report of his speech at our last half-
yearly meeting, at which he stated the fact that the members of the native staff on the North-
Western State Railway, who reside in rat-proof cubicles, with brick walls, brick and cement
roofs, and cement floors are virtually immune from plague. Sir Bradford hopes that this
corroboration of Dr. Ashburton Thompson’s views may be useful to him. I am also to
mention that in Bengal, where the climate is humid, water is abundant and daily bathing is
the rule, plague does not gain the same foothold as it does in the drier climate of the North-
West and the Punjab.
I am, Sir, Your obedient Servant,
Urban Broughton (Secretary).
Extract from Sir Bradford Leslie’s Speech.
“During the half-year under review, i.e., January 1 to June 30, 1907, the plague has
been worse than ever, the total number of deaths in the Punjab being not less than half a
million, or at the rate of nearly 25 per 1,000 of the population. This number is greater by
86
Haffkine & Thompson: Bubonic Plaque
400,000 than for the half-year to June 30, 1906, and about 150,000 more than for the whole
of the year 1905. Even in the town of Bhatinda, with a population of only 18,000, there
were over 700 deaths, and in Delhi over 11,000 deaths out of a population of 209,000, or about
1 in 20 of the population of each place. Unfortunately, it is generally young people in
the first vigour of their youth who are struck down. It is remarkable that the North-
Western State Railway employes, who number some 55,000 in the Punjab, where they are
housed in staff quarters on railway land, with proper regard to sanitation on European
principles, had a death-rate of only 1 per 1,000 per annum, including their families ;
but in places like Lahore, where, for want of space, the railway employes have to live in the
native towns, they do not escape the prevailing disease. It is hoped that His Majesty’s
gracious letter to India on this subject will stimulate investigation and remedial measures.”
DISCUSSION.
The PRESIDENT (Dr. Newsholme), in introducing the authors, reminded the
Fellows that the meeting was a special one, called in the first place to do
honour to two distinguished confreres, and secondly to enable Fellows to learn
that which they were so competent to teach. He did not think it possible to
imagine a greater contrast in the conditions under which plague might prevail
than those in India and those in New South Wales. In one instance was
a community fully invaded by the disease, in which differences of race, religion,
and civilisation held good, and in which measures which might be successful
under the conditions of western civilisation would obviously not be completely
available. On the other hand, there was a city like Sydney, well governed,
inhabited by a people who were our own blood relations, and who recognised
the importance of sanitation. Those were the two classes of experience which
would be placed before the meeting. In one case it was a relatively easy task
to keep the plague under control ; in the other it was extremely difficult,
especially when, as was the case in India, the disease was already rampant
when Mr. Haflfkine’s genius discovered the remedy which had done so much
to minimise the prevalence of the disease and to diminish its fatality
amongst those who were attacked by it. On that point there was no differ¬
ence of opinion among those who had had the opportunity of investigating
Mr. Haflfkine’s remedy for plague. One could realise the immense importance,
in a country like India, of having such a remedy which could be adopted when
ordinary measures of sanitary control and prevention of importation were,
to a very large extent, inapplicable. Those present would congratulate Mr.
Haffkine on the fact that he would shortly be returning to India to resume
his most important work there. That work had been interrupted for a short
time through no fault of his, and they congratulated not only Mr. Haffkine but,
still more, India, in that it was again to have the benefit of his invaluable
services. He had said that, in Sydney, the task of keeping plague out and
preventing its spread was a simpler one than in India; but that by no means
detracted from the merit of Dr. Ashburton Thompson’s pioneer work on plague
in Sydney. Those who had read his masterly reports on plague in Sydney
must have felt with what care he investigated every detail concerned, and got
to the bottom of every outbreak. They were masterly expositions of epidemio¬
logical research.
Ep idemiologica l Sec tio n
87
The following observations were contributed by Major AliNlM, I.M.S. : It is
true that in the earlier stages of an outbreak—when only a few foci of the
disease are known to exist—the use of the full epidemiological armament of
notification, isolation, disinfection, segregation, &c., is justifiable; and it is
expedient to isolate the patient, disinfect his house and belongings, segregate
contacts, &c. With regard to the isolation of the plague patient, it is a question
whether his removal to a suitably situated isolation hospital, where he is inac¬
cessible to the uninfected rat flea, is not quite as justifiable as is the measure—
now adopted in the prophylaxis of malaria—of isolating a malarial patient from
the possible attacks of the uninfected mosquito. In the earlier stages of a plague
outbreak the above measures are, I think, justifiable. But in instances where
the disease has assumed a widespread epidemic or pandemic form, these measures
are useless, and their application to a locality causes unnecessary inconvenience
and suffering. We are, under these circumstances, thrown back upon the three
lines of defence which experience and observation have shown to he of most
value. I refer to (a) preventive inoculation ; (b) the removal of the community
from the rat-infected area; (c) the removal of the rat from the infected or
threatened area. It is upon this latter measure that I would ask permission to
say a few words, and upon an aspect of this subject to which I believe sufficient
importance is not yet attached by plague administrators. The value of inocula¬
tion has already been referred to, as have also the advantages of evacuation and
the great difficulties often attending it; the task of efficient rat destruction by
poisoning, trapping, &c., has been declared to be “ practically impossible ” ; but
no great stress has been laid upon systematising what might be termed “ rat
prevention/’ I refer to the taking of simple but rigorous and systematic
measures to prevent the congregation of rats in large numbers in areas threat¬
ened with plague. Rats are natural scavengers, and will congregate where there
is waste food, garbage, or rubbish lying about. Where debris of this nature
does not exist, the rat will not be found—he vanishes. As an instance : I have
in mind a large Indian town of over 100,000 population where plague appeared
in 1897. Among my other duties connected with the outbreak I was asked to
take special charge—with regard to preventive measures—of the Sudder Bazaar,
an area which was situated between the military and European lines and the
native city in which the disease had appeared. The first step taken in dealing
with this area was to make a minute inspection of the houses. In the base¬
ment of each house was found a mass of garbage—filth and rubbish of all kinds-
Only to the person who is well acquainted with the interior economy of the
native house of India is known the heterogeneous mass of rubbish which is
allowed to collect in the basements of the premises. In this instance I ascer¬
tained that the reason of these unusually large collections of rubbish was mainly
due to defective scavenging, and to punishment being feared if the debris was
thrown on to the streets. Hence, all house sweepings, organic debris, old rags,
and in many instances absolute filth had been allowed for long periods to
accumulate in the house basements. I enlisted the assistance of the house¬
holders, and had all the basements of the houses cleaned. The rubbish was
ja —7
88
Haffkine & Thompson : Bubonic Plague
removed by sweepers into the roadways in front of the houses and there burnt
(for days afterwards the Sudder Bazaar was enveloped in smoke) ; and the
basements were then lime-washed, and latrine receptacles renewed and tar-
painted. Plague never appeared in this area in true epidemic form, and the
place came to be considered as protected from the disease, which was virulent
in its vicinity, and some people attempted to smuggle their sick into the area,
believing that they would become cured there. I believe that the removal of
the rubbish from the houses, and the systematic cleaning up of this area, had
discouraged the rats from infesting it to an abnormal degree, with a result that
the incidence of disease in the area was much diminished. It is a matter of
common observance that on occupying a house which has for some time been
tenantless, the place may be absolutely free from rats and mice. After a time,
when food has been left lying about in the larder, or on shelves and tables, rats
and mice will appear. So it is with houses in India, and more especially so on
account of the prevalence of the unpaved and uncemented basements which
exist in nearly all the native houses. I merely speak these few words in the
hope that general cleanliness of houses, and more especially of their basements,
will occupy a more prominent place in future plague policy. People should be
encouraged to keep the basements of their houses scrupulously clean, and should
be advised not to allow any refuse, waste food, old rags, or filth, or debris of any
kind to collect in their areas; and should be further urged to keep their cooked
food and uncooked food supplies in such a manner as to prevent rats having
access to them. The greatest boon to India would be if the natives—both
Mohammedans and Hindoos—could be induced to regard the rat as the
Mohammedan regards the pig, and that any food or matter with which the rat
had come into contact became regarded as spoiled and tainted.
Professor W. J. SIMPSON said he had had the advantage of reading Dr.
Ashburton Thompson’s paper, as well as Professor Haffkine’s, so that he was
in a better position than otherwise he would have been to take part in the dis¬
cussion. He had read both papers with an interest which was increased by the
fact that the authors presented the subject from different points of view. On
one point he thought most would agree with both authors, namely, that the
rat plague played a predominant rdle in the causation of human plague. Perhaps
Dr. Thompson had given expression to that opinion too broadly, for it had to
be qualified by the fact that pneumonia plague, at least, might have nothing to
do with rat plague. Unanimity on the relationship of rat plague to human
plague marked a distinct stage in the etiological and preventive aspects of the
disease, because in the one case it allowed of further investigations being under¬
taken without any disturbing uncertainty on a very fundamental question, and
because in the other case it indicated the direction in which plague measures
should be taken, and which Professor Haffkine had called a rational method
for dealing with plague, which could be done without waiting for the com¬
plete solution of the problem which it was hoped might be reached by con¬
tinuous and systematic investigation. Dr. Thompson had stated his views
shortly and clearly, and no one could complain of any hesitancies. On reading
Epidemiological Sec tion
89
the paper one would come to the conclusion that the whole problem of plague
was settled, because Dr. Thompson held that the plague rat was harmless to
man, and that the intermediate agent between the rat and man and between
rat and rat could be no other than the flea, and actually was the flea. Those
views were based on his own observations and on the results of experiments by
the Plague Commission. They, however, erred in an inclination to generalise
too much on insufficient data. In illustration of that he quoted an interesting
case in the last report issued by Dr. Thompson, that of a man and wife simul¬
taneously attacked with plague. Each of them had flea-bites on the drainage
area of the bubo. There were no rats at the residence, but at the man’s work¬
shop another workman had killed two sick rats and picked up two dead rats,
and there were found, in the process of cleaning, the carcases of ten rats in an
advanced state of decomposition. Plague bacilli were not found in them, nor
in a number of rats trapped in adjoining and neighbouring premises. The
husband’s illness was attributed to flea-bites received at the workshop, and as
the causation of the wife's simultaneous attack could not be put down to fleas
in the house, it was stated “ it would seem that the only possible source of
infection must have been a flea imported to her house by her husband from the
factory, which she herself had not visited.” The evidence was not very strong
in favour of that assumption, but it was about the strongest which had appeared
in any of the former reports. Hitherto with most people it had been merely a
working hypothesis, supported by a few experiments, that the flea was an active
agent in the propagation of plague. That hypothesis had been converted into
a certainty by the experiments of the Indian Plague Commission, which had
established the fact that the flea was perhaps the most important agent in the
dissemination of epizootic plague. The interpretation which he put upon those
experiments was that the flea was an active agent in the causation of epizootic
of plague in the rat, but it did not appear to justify the claim that the flea was
the only agent, or the setting aside of the successful feeding experiments of
Kitasato, Yersin and Wilm in Hong Kong, the German and Austrian Commis¬
sions in Bombay, and those of Klein in this country. There was always a
tendency to run the newest view to the extreme. It took time to obtain the
due perspective, and he thought that was the case in this instance. At one
time it was inoculation, then it was feeding, now it was the flea. Might it
not be that they were all responsible ? When one found that rats were suscep¬
tible to plague by inoculation, by feeding, and by the laying of plague materials
in the nostrils of rats, it was ‘difficult to see why the flea should be selected as
the only agent. That was still more the case with regard to plague being
always conveyed by the flea from the rat to man. The experiments on that point
had been but few. They were his own in Hong Kong and the few made by
the Indian Plague Commission, but the most that could be said with reference
to them was that the rat flea could infect the monkey, and probably man, and
they confirmed what was pointed out by Simond and Hankin in regard to that
point. But that was a very different matter from the flea being the only agent.
Monkeys were very susceptible to feeding with plague-in fee ted food ; why
ja—Si
90
Haffkine & Thompson : Bubonic Plague
should man be not similarly infected ? In Hong Kong, where many post¬
mortems were made, the pathological evidence was not small that many cases
of plague, apart from tonsillar and cervical cases, were produced by feeding. If
the post-mortem records of the cases in the early days of the Bombay plague
were examined, there would also be found evidence of lesions of the stomach,
intestines, and mesenteric glands in considerable number. Possibly it was
because Dr. Thompson’s experience had been mostly with bubonic cases that he
held such strong views on the flea theory. Septicaemic cases were not common
in Sydney, and it was a strange but interesting fact that bubonic cases of plague
appeared for the first time only during the sixth outbreak of plague last year.
It might be asked what happened to the flea that produced that phenomenon.
He thought that under the circumstances all the fundamental facts were not to
be found at present in Australia, and that the last word, however desirable it
was, had not been said on the causation of plague.
Mr. Haffkine’s paper dealt less with causes than with methods of prevention.
That gentleman accepted all the theories, for they were a matter of indifference
to him, and it was only essential for him to compare the failure of other methods
with the successes which attended the use of the prophylactic, and to show the
superiority of that method over others. If he, Professor Simpson, had to deal
with the epidemic in India, and had the choice of adopting only Dr. Thompson’s
method or that of Professor Haffkine, he would have no hesitation in selecting
Professor Haffkine’s. Dr. Thompson’s remedy, which was also Dr. Creighton’s,
was a good one, and must appeal to sanitarians, for he supposed that in
rebuilding the houses there would be included the provision of good light and
ventilation, as well as protection from rats. But it failed in the very important
particular that it would probably be useful for the protection of India when the
next epidemic invaded that country, say in about a couple of hundred years. The
statesman, therefore, who adopted Dr. Thompson’s policy might be hailed by
the remote descendants of the present generation as a benefactor, but he would
scarcely be considered to be carrying out what were ordinarily understood as
the functions of a statesman, namely, the solving as far as possible of the
problems which arose for the l>enefit of the present generation and those of the
near future. He would further state that even if the rebuilding of India could
be carried out in ten years, much of its value would be discounted by the
customs of the people. Wherever the Indian lived he liked to have his grain
with him, which was natural, just as our own housewives like to have then-
stores in the house. Plague had been known to attack Indians and leave
Europeans free, even in cantonment houses which were well built and where
Indians had at times been permitted to reside. The reasons for the invasion of
plague into such well-built and sanitary houses had been that the rats of the
locality had been attracted into the particular houses by the granaries established
there. Plague had also occurred in gaols, which were generally well built, and
it had occurred even in some of the newiy built houses erected by the Bombay
Improvement Trust. Last year he visited several of those houses with Dr.
Turner, the Health Officer. The rats gained access to the houses by creeping
Epi demiological Slection
91
up the rain-water pipes and by other means. There could be no doubt that
the most immediate and probably the most easily applied preventive, if the
confidence of the people were obtained, was inoculation. It could be applied
on a small or on a large scale. In Calcutta, whenever a case of small-pox
occurred in a house, the inmates of the house and those of the immediate
surroundings were, as far as possible, vaccinated. A similar arrangement might
he introduced in regard to plague. Simultaneously an organisation should be
formed to popularise and carry on inoculations on a large scale In every infected
centre. Probably that would be done when Mr. Haflfkine returned to India.
The w'eak point in the inoculations, however, was that the protective power did
not last very’ long, and so long as that defect lasted he feared it would always
be difficult to induce people to be inoculated every tw r o or three years, except
under the stress of a great mortality. It was for that reason that, although
inoculation must be recognised as a powerful weapon in the hands of the
sanitarian, it could not be depended on alone; a general fighting an enemy did
not depend only on his infantry . It w T as impossible to close one’s eyes to the
fact that the primary' cause was still existent, and as we thought we knew
what the primary cause w r as, w hich was not the case when we depended on
vaccination against small-pox, it appeared necessary* to go further and attack
the cause or causes as known to us at present. If the infected rat w r ere got rid
of, it did not much matter w hether man got the disease from the fleas of rats,
from infected foods, or from other agents. In the chain of causation the rat
was the more important factor to deal with, and he believed that just as
Professor Haffkine had been a benefactor to India by the discovery of the plague
prophylactic, he w r ould add still more to that country’s indebtedness to him if
lie could discover a more potent microbe than Danysz’s bacillus which would
destroy the rat and yet be harmless to human beings and other animals. It
should not be supposed that plague was endemic or epidemic in every village
and town in India, and he believed that the policy of a free and unrestricted
trade in plague distribution from infected centres to healthy localities had
contributed to the present deplorable conditions. Measures should therefore
be taken to prevent this, either on the passport system adopted in the Madras
Presidency or by r others which would readily appeal to the trained sanitarian.
With regard to disinfection and its supposed inutility on the grounds stated by
the Commission, that a contaminated flea lost its infection in a few days, and
that plague bacilli could not be found in the soil, he wished to add his dissent
to that which had already been expressed by Dr. Turner. In those particular
experiments it might be so, but he thought it was generally agreed that tetanus
bacilli lived in the soil, but how often were they looked for and could not be
found ? To search in an infected room for the bacillus of plague was like looking
for the proverbial needle in the haystack. Against those experiments of the
Commission were other experiments. How r was one to account for the fact
that, according to Gladdin, the bacillus would live for over three months on
food such as raw' and coagulated albumen, turnips, potatoes, plums, apples,
cucumbers, ifcc., or those of Batazoff, in which the organs of plague animals
92
Haffkine & Thompson: Bubonic Plague
dried in vacuum for thirty-eight days at the temperature of the room, infected
animals after that period, and of those of Gotschlich, who found the bacillus
alive and virulent in eight and half months old cultures which were dried ami
mouldy. Again, clothes would have to be disinfected, even if it was the flea
which only carried the infection, as he did not suppose that the clothes would
be opened up and fleas searched for. Even then they would have to be killed,
and he took it that destruction by disinfectant was easier than catching them
and destroying them, as the Chinese women did, by cracking them between the
teeth. For carrying out any of the measures a properly qualified sanitary
service was needed in India. It was because of the absence of that service that
most of the failures arose. It was also the secret of the failure of the great
inoculation campaign in the Punjab, where villagers, instead of properly
qualified men and women, were employed to open the battle and assist in the
technique of the inoculations. The Japanese had recently four towns infected,
and the organisation they brought to bear on the prevention of plague was 1,200
medical men. They had 513 deaths altogether. In the Punjab there were
during the epidemic of this year over 600,000 deaths, and there were in 1906
only ten Europeans and thirty-eight native medical men employed to combat
the disease. If the whole 750 medical men in the Indian Medical Service had
been released of their duties all over India, which was an impossibility, and had
been drafted into that one province, it would not have equalled the organisation
of the Japanese.
Dr. J. F. Payne said all the Fellows would be very grateful to Mr. Haffkine
and Dr. Thompson for their exceedingly valuable papers, more especially as the
authors had not remained immersed in the atmosphere of scientific doubt, but
had each put their views in the clearest and most definite manner. He did not
believe the views of those two gentlemen were opposed, and he did not see why
the plans respectively advocated should not be carried on simultaneously. With
such a combination of forces it might be hoped that a much more serious
impression might be made on the great invasion of plague than by adopting any
one separately. With regard to rats, it was clear that in all the places which
had been investigated of late during the great pandemic of plague, rats had been
found largely concerned with the distribution of the disease from one place to
another and with its local production. But it had not yet been proved that
that was the only source of plague, and for several reasons. Every epidemic
of plague recently described in the great pandemic had been carried from one
part of the earth’s surface—namely, from the mountain country of Yunnan, in
the south of China. There it had been endemic no one knew how long. In
that country particularly epidemics of plague were connected with the deaths of
animals living underground. That plague was carried from Yunnan to the
coast, and thence to the south of China and on to Hong Kong, and from there
distributed over the world. But plague had come from there just as cinchona
plants, wherever found, came originally from America. The relation of plague
to the death of rats had been before the profession for more than fifty years.
Not to mention some rather obscure earlier reports, in 1853, Surgeon-General
93
Ep id e min log i c a l Sec tion
Francis, of the Indian Medical Service, published a report in which he described
how the mountaineers of Kuma, on the slopes of the Himalayas, had turned out
of their houses on account of plague when they observed dead rats. That hail
been known to'people who investigated plague in other parts of the world. For
a long time the chief places for the investigation of plague were Mesopotamia,
Baghdad, Kurdistan, and Persia, hut not in the Far East. Those investigators
in Persia and Baghdad w r ere very careful and conscientious people, and included
Surgeon-Major Colville and a French physician, Dr. Tholozan. Surgeon-Major
Colville said they had never seen anything of the kind observed in the
Himalayas. Though his own personal experience was very small, he wished to
relate one incident. When he went out in 1879 to investigate the plague on
the Lower Volga, in the province of Astrakhan, especially at the village of
Vetlianka, which had become historic, the epidemic was practically over, and
they only saw a few patients who had recovered. It was being much talked
about, but never a word was said about rats. His own impression was that the
common European rat did not exist in that country at all. The great naturalist,
Pallas, who travelled there in the last century, said it did not exist there then.
While waiting in the village with nothing to do, it was their custom to walk
about and into the neighbouring country, where they saw many burrows made
by a little mouse. He noticed many skeletons of these animals, and on asking
about them was told that a number of the inice had died during the winter.
He believed it w’as the Mm montan nx. Since then it had occurred to him that
this might have had some connection with the epidemic. The plague had in
many other places not been connected with rats. At present the Yunnan plague
was being carried into Egypt and other old seats of plague, and it remained
to be seen what w 7 ould happen. Therefore he did not think there was
evidence that the connection of plague with rats was a universal law.
He had no doubt that the evidence in regard to fleas was correct, but it
was not necessary to suppose that clothing never transmitted the plague.
People who were just dead might have clothing which might have contained
fleas. In the celebrated village of Derbyshire, w r hich had plague communicated
from London, it arose from the clothes being put before the fire to dry, and it
was well known that the flea could jump. He thought that they were not
entitled to say that the cure or prevention of an epidemic disease like that by
inoculation had no effect in checking its endemic prevalence. With regard to
malaria, for instance, though it was strictly local, if there were a population
saturated with quinine mosquitoes could not get hold of the plasmodium and
carry it about, and this had an effect in stopping malaria. Quinine not only
cured the individual patient, hut diminished the prevalence of the disease.
Therefore in India, if at one time there were hundreds of thousands having
plague, and if that numbei were greatly reduced by inoculation, the chances were
that the dissemination of the bacillus, the parasitic circle by which the parasite
was carried from one animal to another, from man to the lower animals, and
from the lower animals back to man, would be checked ; it was scarcely fair, then,
to say that inoculation had only a temporary effect.
94
Haffkine & Thompson : Bubonic Plague
Colonel Macpherson said a good deal had been said about the effect of
inoculation in preventing plague, also the effect of getting rid of rats from
dwellings. It had also been said that the flea was the conveyor of plague from
rats to man. But he wished to ask Mr. Haffkine and Dr. Thofnpson whether
they had made many experiments as to the manner of preventing the flea from
biting man. One knew that there were many insecticides used by people in
common life for the purpose of preventing themselves being bitten by fleas ; and
if the flea was the transmitter of plague it would surely be a simple process for
each individual in the community to protect himself by using a definite
insecticide.
Dr. SANDWITH said that nobody who had read Dr. Thompson’s reports
could do anything but echo the President’s praise of them. Those reports first
converted him to the rat theory, and later to the rat-flea theory. He was
certain the rat theory was correct, and he believed the other was right also; but
he agreed with Professor Simpson that it was not fleas alone which caused
plague. In his paper, Mr. Haffkine said : 44 Though general statements to this
effect have been made by earnest observers, I am not aware of a precise and
convincing demonstration by experiment of a case in which disinfection arrested
the development of an epidemic of plague.” He (Dr. Sandwith) was very much
in favour of disinfection in preventing the spread of plague, because in Egypt
since 1899, though the officials of the Public Health Department had not stamped
out plague they had kept it under, and this had been achieved without any of
the special means recommended in the papers read to-night. Disinfection had
been carried out in two ways; first, by filling up the rat holes and destroying
the rats, by removing rubbish, whitewashing and cleaning buildings, isolating
patients and watching 44 contacts.” That was found to be insufficient. A second
measure which seemed to be of some importance was washing the floors and
walls of rooms with corrosive sublimate, 1 in 1,000. That was found to be
expensive and the natives complained when they came back to their homes that
their chickens had died ; so for several reasons it was temporarily given up.
But in the villages and houses where corrosive sublimate was used in addition
to the ordinary disinfection process, plague had never yet returned, though it
had often returned in places where this extra measure had not been adopted.
A reference had also been made to the domestic cat, and he wished to refer to
that because Major Buchanan, in India, had proposed that the plague could
be minimised by increasing the number of domestic cats. But the cat is
susceptible to plague, not quite so much as the rat, but still to a dangerous
extent. He asked Mr. Haffkine why he said that the native of India was more
susceptible to the disease than the African and European. He (Dr. Sandwith)
did not know any reason for considering the African and the Indian to be on
very different levels of susceptibility. It had been said that Dr. Ashburton
Thompson omitted reference to pneumonic plague, but plague had so recently
reached New South Wales that the authorities were fortunate in having stamped
it out before pneumonic cases had occurred. Pneumonic plague was a term
adopted in 189b from Bombay, although previous epidemics had been known as
Epidemiological Section
95
44 cough-illness.” Pneumonic plague in Egypt had sometimes caused eleven
deaths in a house of eleven people. He did not suppose that the flea was
responsible for that pneumonic plague, except indirectly. Any case of bubonic
plague may become septicaemic, and secondary pneumonia sets in, and then the
patient disseminating his sputum can cause primary pneumonic plague. He
hoped Dr. Thompson meant that not only the laity—who should be instructed
by medical men, and only by them—but also the medical men should work, not
only between seasons of prevalence as the various outbreaks were called, but all
the time, as some plague was present every month in endemic countries, and the
fight should be continued until the disease had been absent among humans for
at least a year.
Dr. Fremantle said there were many suggestions of definite theoretical
value which, on being put to the test, were often found wanting in regard to
plague, and he would be glad to hear whether one or two in particular had been
tried. In regard to houses, he would like to hear whether weight had been
given to the method of building which he saw at Rangoon, where, building
being carried on on land largely reclaimed from the Irrawaddy, houses were
built on piles, and in such a way, thanks to the general foresight of the sanitary
department, that there was a clear foot of daylight between the ground and the
floor of the house. It seemed also desirable to separate adjacent roofs in the
same way as in this country parapets were provided to prevent the spread
of fire. In such a form there would be a really rat-proof house. Whether
that was the reason that Rangoon had never taken plague he did not
know, but there was the fact, and he did not think it w r as simply due to
a thoroughly carried out quarantine system. There might be some similar
reason in the construction of their houses for the immunity of Japan from
plague, notwithstanding that there was a good deal of intercourse between
China and Japan. At any rate one saw the reverse system of house-building
in Hong Kong coincident with an annual recurrence of plague. There the rats
not only infected the houses, but actually burrowed again into the brittle bricks
which were used within a few r days of the most thorough disinfection. Unless
the approach of rats was cut off, it would be of little use to rebuild the houses.
It would surely be well to start experimental schemes in the centre of plague
infected areas, in villages, for instance, in the Bombay Presidency and in the
Punjab ; that could be done without difficulty, and different schemes could be
tried in different batches of houses. It had been said that the rat should be
exterminated, and those who, like Dr. Thompson, had tried it in earnest said it
could not be done. He (Dr. Fremantle) thought they were, in that matter,
going beyond their province as medical men, and were not giving due w r eight to
those essentially qualified to investigate it. They were dealing with a problem
outside their profession, and required for its solution the assistance of a natu¬
ralist like the late Frank Buckland or the present secretary of the Zoological
Society, Dr. Chalmers Mitchell, who would understand the different methods
of exterminating one pest by another set of animals. In India very much was
to be done by means of education, and he hoped the Government would take up
96
Haflkine & Thompson : Bubonic Plaque
the question of education in the schools, so that the community might be
instructed in the general methods employed in combating the plague. A great
question was how to induce the people to accept inoculation. In the Punjab
the plague officers were welcomed by the headmen of the villages and those
who wished to stand well with the Government, and they and their families
were inoculated, but unless plague was actually prevalent the number of inocu¬
lations would be limited to 120 or less. It might be well to adopt some method
of stimulating them through a monetary payment to the headmen of the
villages. Finally, he urged that the question was an Imperial one, and there¬
fore there should be definite correlation between the various Boards and
Departments interested in the matter throughout the Empire, rather than
action on isolated lines.
Dr. C. J. Martin, F.R.S., said he had listened to both papers with great
interest, but it was too late to discuss them at all fully. In Dr. Haffkine’s paper
there was so little, matter that was controversial that he felt he must agree with
him when, at the end of his paper, he pointed out that at the present time the
most hopeful method for India was the palliative. As to the method in which
the substance was given, all must have been struck by the extreme modesty
with which the facts were presented. Even if it had been presented in a
different way there would have been little cause for complaint. He listened to
Dr. Thompson’s paper with some emotion, because that gentleman was his
earliest preceptor into the mysteries of epidemiology. A good many years ago
Dr. Thompson asked him to read over a paper on the “ Epidemiology of
Leprosy,” perhaps on the principle at the bottom of trying a substance on a dog
before giving it to a human being. He did not understand much about the
snbject then, but the paper was crowned with a prize*as being the best paper on
the “ Epidemiology of Leprosy ” in any country, so probably the experiment
was justified. But he could not allow to pass without comment the part where
Dr. Thompson said that India should be rebuilt. It would be difficult to rebuild
India, with 300,000,000 people, most of whom had not got houses, as we under¬
stood the term. He did not know whether the concluding passage of the paper,
relating to the courtesan of the king, came from the “ Arabian Nights,” but it
might well have done so. He hoped that king had a firm treasurer, because
ultimately everything of the kind became a financial matter. Every unit of the
population of India had but a small amount of money. In the finances of the
country there might be a surplus of a million or so, but if the whole wealth
were divided among the people they would still be very poor. It would be
impossible to carry out in such a country measures which were successful in a
city like Sydney, with its wealthy population. In conclusion, he wished to pay
a tribute to the extraordinary epidemiological acumen by which Dr. Ashburton
Thompson was led, quite early in the study of plague, to realise first of all the
essential dependence of human epidemics upon rat epizootics, and, secondly, to
the fact that there must be some intermediary between the rat and the human
being in order that a rat plague might cause a human epidemic.
Epiclem iologicaJ Section
97
Dr. Chalmers (Medical Officer of Health, Glasgow) said he had scarcely
any reason for interposing in the discussion, because one of the papers was on
the prevention of plague in India and the other w T as devoted to a method of
combating plague which was not applicable to this country 7 , and which he
doubted the suitability of to India. He said that because in this country for
two or three generations we had had a similar experience in regard to small-pox ;
we had not yet succeeded in convincing people that they could, by vaccination,
protect themselves against small-pox. So he was not hopeful that, without a
panic in India—which no one wished to see—it would be possible to press
inoculation to the extent necessary 7 to stamp out the disease, because in twelve
months it might be necessary to do it all over again. The whole genius of the
country was against the rebuilding of houses rat-free; it had taken two genera¬
tions of medical officers to persuade the authorities that even in the matter of
ordinary diseases the rebuilding of houses was necessary 7 . And all knew how
slowly rehousing went on, even in slum areas in England and Scotland, and
one asked whether it was likely to be more successful in the case of plague.
His own knowledge of plague was acquired in this country, and the experience
of anyone here was that there was first of all a genial tolerance, as of a
momentary vagary on the part of the medical officer, and secondly, there was a
discussion as to whether this or that should be done, no credit being given for
acting as a reasonable being. All regarded the rat-flea theory as having some
association with plague. The work of the flea had been demonstrated beyond
cavil in the last report from India. In his first experience of plague in 1900 he
talked the matter over with Sir Thomas Fraser, and told him he was worried
about the rats, as people told him they were kept awake at night by them. Sir
Thomas’s reply to that was that unless the rats were seen and came into the
open there was nothing to fear, and that that was the experience in India.
But that was not the experience in Glasgow. They endeavoured to catch the
rats, but none of those caught were found to have plague, except one, which
was caught in the ordinary' run. Several times rats were caught which had
plague, but no one near was suffering from the disease. The most recent
experience was in a particular building, where there was a sanitary officer on
duty most of the day, police constables occasionally, a caretaker and a Sunday
school class muster. In that building thirty-one rats died, and by the merest
chance the thirty-first was found to have plague. Hankin, two or three years
ago, suggested that while one might accept the rat as being a continuer of
plague, possibly something made the flea at one time capable of carrying the
disease and another time incapable of doing so. That was only part of the
larger question as to why we were having plague in the last ten years. If any
explanation of that fact were forthcoming, any light as to means of overcoming
it might be clearer. He did not know whether the killing of rats would do any
permanent good, for there was a natural law that the birth-rate of any species
was directly related to its death-rate, and possibly the result of a vigorous
campaign against rats might be an increase in their birth-rate. In India it had
been said there were now as many rats as ever, notwithstanding the enormous
98
Haffkine & Thompson: Bubonic Plague
destruction of them during the last ten years. With regard to disinfection
there were two views to keep in mind. The plague organism must be assumed
to live outside the body, but only to a limited extent. If chemical methods of
disinfection were used there still remained the liea. He had used formalin,
but air-breathing animals would not be affected by formalin. It was known,
from the work done in India, that a flea fed on a septiciemic rat would communi¬
cate the disease for a definite series of days if it were fed daily. How long
would a flea not fed in the usual way live ? If the flea was capable of trans¬
ferring the infection from one animal to another, and if a rat could live without
feeding for that period, how far might it travel ? He asked because of a certain
association with rags in his own experience. Recently there was some cause
for suspecting that rags might have caused a case of plague. And in order to
catch the rat-flea guinea-pigs were put in cages in the rag store. Human fleas
were caught in the rag store, but no human fleas were caught in the house.
They put human fleas into test tubes, and allowed them to have plenty of air, and
until the ninth day those fleas remained active without any food at all. He did
not know whether the rat-flea would live longer. With regard to Mr. Haffkine’s
proposal as to the disposal of the dead he (Dr. Chalmers) did not appreciate
that. He had been anxious over the dead who died from plague in Glasgow,
and wanted to have cremation, but failed. He therefore arranged for the burial
under restricted conditions. But even in a body dead twenty-four hours it was
very difficult to recover the organism in a virulent condition. It had already
undergone considerable degeneration. There were many things in the character
of the organisnj which seemed to determine its virulence.
Mr. HAFFKINE, in reply, said that owing to the lateness of the hour he
would deal only with one or two points, viz., with those on which he had been
asked for some information. In reply to Colonel Macpherson he said that
Dr. Turner, Health Officer of Bombay, had given attention to a plan of protect¬
ing houses from fleas by means of naphtha or petroleum products. Certain of
his observations appeared encouraging, and the plan was being tried further
in Bombay, Poona, and elsewhere. Attention had also been directed in India
to the possibility of avoiding flea-bites by oiling the skin with mustard or other
oils used by Indians of certain castes. The matter called for close and perse¬
vering investigation. Dr. Sandwith had put to him one or two somewhat
difficult questions. The first concerned his view as to the difference in the
susceptibility to plague of Indians, Europeans and Africans. Somalis, Sidi-boys,
Kaffirs, and Europeans of all classes when attacked with plague recovered
comparatively easily, whereas in Indians the proportion of deaths to cases was
often as high as 70 per cent.; in the other communities it rarely went above
35. From the information kindly given him by Dr. Sandwith, and that which
appeared in publications, he concluded that the latter figures held good approxi¬
mately also for the Arabs in Egypt, at any rate in the case of the endemic form
of the disease. The fact that among Europeans inoculated against plague fatal
attacks were yet unknowm, while in Indians they were observed in a certain
proportion of cases, and that in the former the immunity conferred by the
Ep id e mio log ic a l Sec t io n
99
inoculation was apparently of a longer duration, seemed to him to stand in
relation to the same differences between the tw T o races. If Africans, Arabs,
and Europeans showed these advantages in ridding themselves of the plague
infection w T hen the attack was already on them, he surmised that they had the
same advantages when struggling with the virus in the incubation stage and
endeavouring to ward off the first onset of the attack. Dr. Sandwith had, further,
referred to his statements regarding disinfection, and quoted the villages in
Egypt where the treatment of native huts with corrosive sublimate had been
seen to permanently free them of plague. He attached great weight to Dr.
Sandwith’s observations, and must plead ignorance of the facts he referred to.
As far as his present experience went, he had not known cases pointing to a
relation between disinfection and the cessation of an outbreak of plague. He
was open to conviction, and held the opposite opinion entitled to attentive and
earnest consideration.
Dr. Ashburton Thompson said, in reply, that it was too late to discuss all
the interesting points which had been raised, but he would touch on some of
them. Drs. Payne, Simpson, and Chalmers had all declined to admit that the
rat was the sole cause of epidemic plague. He would first ask what other
cause had reasonably—nay, he would even say had plausibly—been suggested ?
However, their hesitation rested in reality on negative evidence, namely, the
non-discovery of plague rats in certain places. But he had again and again
remarked on the difficulty there most often was in detecting disease of the rats on
any area ; and, while the older observers had no means of identifying the cause
of death in any carcases they may have encountered, in the accounts of more
recent epidemics there was no evidence at all that an adequate search for plague
rats had been made. Dr. Chalmers went even further. He was able to say
that at Glasgow he had found no plague rats in close association with cases ;
where cases were found there were no plague rats, and where plague rats were
found there were no cases. He welcomed that statement, for it represented his
own early experiences. But he had had a more extensive and a more prolonged
opportunity than had fallen to Dr. Chalmers, who, if he had had the chance,
would have found ultimately that his observation, correct though it was, was
incomplete ; and he would unavoidably have come at last to the conclusion
already formally expressed by the speaker, that the plague rat was harmless to
man save in the presence of an intermediary agent. Professor Simpson had
fallen into one or tw T o inadvertencies which it seemed important to point out, just
as in the course of lectures recently delivered by him he had asserted that plague
had occurred at Sydney in a mild form—an assertion which was not founded on
any fact. Prof. Simpson, in the course of his remarks, had quoted a case in
which the speaker had appealed to the agency of the flea to explain the
observed facts, as though it had been adduced to establish the agency of the
flea ; and he had said that this case was about the strongest evidence which
the speaker had at any time adduced in favour of the active agency of the flea.
But, in fact, the epidemiological evidence for the reality and the essential
character of the agency of the flea was of a totally different kind, and had been
ja —9
100
Haffkine & Thompson: Bubonic Plcujue
set forth four years ago, in the speaker’s second report, not in the sixth report
from which Prof. Simpson had quoted. However, that was generally known
to those specially interested in plague ; and after having remarked that his
suggested remedy was not the same as Dr. Creighton’s, as Prof. Simpson had
alleged (for Dr. Creighton thought that the infection of plague was taken with
the breath from the ground-air, and not from rats, nor from any source other
than that), he would conclude by saying that as he was unable to share Prof.
Simpson’s views on the pathology of plague, there could not be any common
basis of discussion between them. Dr. C. J. Martin’s kindly criticism contained
the only direct reply to his suggestion which had been made, and for well-known
reasons it was entitled to the highest consideration. Dr. Martin had strongly
asserted that the rebuilding of India had been demanded, and was evidently
impossible. He would remind Dr. Martin of the maxim “ Divide et impera."
That which appeared impossible when viewed as a whole assumed a different
aspect when it was regarded in detail: and he thought that if the fact that the
infection was present in the concrete form presented by the animal body, in
particular places, and was thence by mechanical agencies transported afar, there
to form new local centres of infection and distribution, were more carefully
considered and dwelt upon, it would be seen on reflection that his recommen¬
dation was far from being chimerical.
Eptoemiological Section.
January 24, 1908.
Sir Shirley Murphy, Vice-President of the Section, in the Chair.
Rubella.
By E. W. Goodall, M.D.
It is now about 150 years since the suggestion was first mooted
that an infectious exanthematous disease existed which was essentially
different from scarlet fever and measles, though it resembled them closely
in some of its clinical aspects. To this disease many names have been
applied, amongst the best knowm of which are German measles, rotheln,
epidemic rose-rash, epidemic roseola, rubeola, and rubella. 1 If these
different names had been used invariably of the same disease, perhaps
little, if any, hindrance w T ould have been offered to its due recognition.
But a study of the narratives of different writers makes it clear that the
same name was not always applied to the same disease, and this
redundancy of names, their faulty application, and the natural duplicity
of the disease itself engendered a haziness which has only within
recent years been cleared away. Now, however, with hardly an excep¬
tion, writers on acute infectious diseases admit the separate existence
of rubella; and not only so, but there is amongst them an agreement
upon its principal features which is in marked contrast with the diverse
descriptions of their predecessors.
1 The name “ rubella ” was first proposed by H. Vcale in 1866 ( Eclin . Med. Journ., 1866,
xii., p. 404). It does not appear to have been misapplied to such an extent as have the other
names mentioned, and is on that account preferable to them. It is the name adopted by
most recent writers on infectious diseases. Accounts of rubella (under other names) will
be found by Sir B. W. Richardson in the Epidemiological Society's Transactions , (1862, ii.,
p. 1) and Dr. Babington (1864, p. 168), and by Dr. Kenneth McLeod in New Series,
1885, iv., p. 52).
102
Goodall: Rubella
Though I have a fairly large experience of most of the acute infec¬
tious diseases of this country, I do not happen to have seen very many
cases of rubella, but I have seen a sufficient number to be convinced of
its distinctness. I made my first acquaintance with it more than twenty
years ago at the London Fever Hospital; this acquaintance has been
kept up intermittently ever since, but last year (1907) it was renewed
with a closer intimacy than before, as will become evident presently.
During these twenty years I have not observed any marked change in
the clinical aspects of the disease, though as it is given to disguising
itself in the garb of some of its more familiar neighbours, I will not say
that I have not at times made a mistake and applied to it, and to them,
the wrong name.
Rubella is a disease, according to my own observations, of which the
following are the most common clinical features:—
Prodromal Period .—Usually none; if present, very short, seldom
more than twenty-four hours. Of 85 cases which I saw last year, in
GO the rash was the first, or amongst the first, symptoms. Other pro¬
dromes are sore throat, vomiting, enlargement of the lymphatic glands,
especially of the neck, and moderate pyrexia. Less frequent are
shivering, headache, giddiness, coryza, and pain in the back and limbs.
Rash .—This usually commences on the face and scalp, as discrete
pale pink spots, but not infrequently the spots come out on the face,
trunk and extremities simultaneously. When the face is first affected,
the rash will disappear from it within twenty-four hours, and will then
be seen on the trunk and upper extremities ; lastly the lower extremities
are invaded. The rash involves the skin of the face right up to the
lips. In most cases the rash becomes so confluent on the trunk and
extremities the day after its appearance as to present a uniform pink
or scarlet erythema, which is often punctate. As the rash has by this
time disappeared from the face, the resemblance to mild scarlet fever
is very striking. Sometimes the discrete spots fade and vanish without
becoming confluent; less often they become confluent so as to form
irregularly shaped macules, though the macules are not usually so large
as those of measles. Still less frequently the rash takes the form of
a scarlatiniform erythema on the trunk and limbs from the very com¬
mencement, avoiding the face. 1 The duration of the rash is rarely
longer than three days ; often it is shorter.
1 Dr. Watson Williams ba9 observed some cases in which a pale halo was to be seen round
the discrete spots (Brit. Med. Joum ., 1901, ii., p. 1797). I have observed this also, but I have
also seen this appearance in cases which were certainly not rubella.
Epidemiological Section
103
Glands .—The superficial lymphatic glands are often moderately
enlarged and tender. Those most commonly affected are the mastoid
and posterior cervical, so that some stiffness of the neck results ; but
all may be implicated. They do not become matted together, and sup¬
puration is extremely rare ; I have never seen it myself. Of 67 cases
last year in which a note was made as to the state of the glands,
enlargement was observed in 52. In 18 cases several sets of glands
were involved. I have known the mastoid and cervical glands to escape
when others have been affected.
Pyrexia .—In 41 cases observed all through the attack, the tem¬
perature rose above 99° F. in 15. In 14 cases admitted after the rash
bad come out, the temperature was above 99° F. in 20. The highest
temperature recorded in these 85 cases was 102*8° F. Seldom is the
temperature raised for longer than twenty-four hours, during the period
when the rash is attaining its greatest intensity.
The conjunctive are often, but by no means always, injected. In
only 29 of the 85 cases is a note made on this point—in 19 the con¬
junctive were injected, in 10 they were not. In the cases last year
I noticed that the conjunctive were not so frequently affected as in groups
of cases seen in former years. The conjunctival affection causes itching
and smarting of the eyes with lachrymation, and occasionally photo¬
phobia. Sometimes there is a slight watery discharge from the nose ,
with itching and sneezing.
Desquamation may follow; usually it is slight and branny, but it may
be profuse ; rarely is it “ pin-hole.”
Incubation Period .—My observations on this point are few; such as
they are they go to show that the duration of the period is between ten
and twenty-one days, commonly fifteen to eighteen.
Rubella does not appear to be a common disease. During the
sixteen years (1892 to 1907) that I have been at Homerton I have
seen only 287 cases, and some of those may have been cases of measles,
especially in the earlier years. On the other hand, it is extremely
likely that some sporadic cases have been diagnosed as scarlet fever
or some rash which was not specific. The following is the yearly number
of cases:—
Table I.
Rubella
Measles
1892 1893 1894 1S95 1890 li>97 1898 1S99 1900 1901 1902 1903 1904 1905 1900 1907
34 3 0 13 5 31 20 5 33 0 4 13 16 13 2 85
98 31 39 48 25 61 43 56 44 31 30 51 45 36 39 62
104
Goodall: Rubella
These figures, except, perhaps, those of last year, are much too small
to give any true indication of the annual prevalence of the disease.
Measles is not admissible, as such, to the Asylums Board’s hospitals, so
that measles and rubella are seen in them only accidentally. Rubella
gets sent in as scarlet fever. During the years 1900 to 1902 few scarlet
fever cases were admitted to the Eastern Hospital, the wards being
required for diphtheria. That circumstance would have affected the
numbers of the rubella admissions.
It is quite impossible to obtain an exact knowledge of the prevalence
of this disease from literature. Perhaps it is too inoffensive to attract
attention, being rarely fatal or even severe, but I gather that it is a
disease which occurs in small local outbreaks. Most of the accounts of
it are derived from observations of its occurrence in institutions, such
as boarding schools and hospitals. It is very likely to be confounded
with measles, and an epidemic might easily be merged in one of that
disease and so escape notice. The number of measles cases that have
been seen annually at the Eastern Hospital are given for comparison
in Table I.
Seasonal Prevalence .—My cases have occurred as follow :—
Jan.
F**l».
March
April
Table II.
May June
July
Aug.
Sept.
Oct.
Nov.
I >00.
Rubella
15
27
39
47
51
60
27
8
3
1
3
6
Measles
72
50
65
57
64
51
71
49
17
32
48
62
The measles figures given in this table are derived from 638 consecutive cases occurring at
the Eastern Hospital, analysed according to their monthly incidence. They are included
amongst the figures given in Table I.
From Table II. it appears that rubella is most prevalent from March
to June.
Climate. —Undoubted outbreaks of rubella have been observed in the
British Islands, on the Continent, in the United States, India, Australia,
and New Zealand.
Age Incidence .—My 287 cases, arranged according to age, are as
follow:—
Table III.
0- 0— 10— 15— 20— 25— 30— 35— 40—
Rubella ... 1*21 109 24 10 11 5 4 2 1 287
Measles ... 536 95 3 4 0 0 0 0 0 = 638
The youngest patient was aged five months, the oldest 42 years. The
large proportion of children aged under 10 is partly accounted for by the
Ep idem iological Sec tio n
105
fact that many of the attacks arose in children convalescent from scarlet
fever or diphtheria. These constitute about 75 per cent, of the patients
in a fever hospital.
Sex .—Of the 287 cases 145 were females and 142 males.
Injectivity .—In my experience the disease does not possess a high
degree of infectivity, even when it is more prevalent than usual. It is
not as infectious as scarlet fever or measles. Some instances of ward
outbreaks at the Eastern Hospital, Homerton, will illustrate this point.
Table IV.
Ward F. (19 beds).
January 17.
July 3; July 5—10.
July 30.
Ward G. (19 beds).
January 23.
March 17.
April 2.
April 12 ; April 17 ; April 20.
May 6; May 7.
May 24.
Ward F.H. (20 beds).
March 1.
March 16.
Ward St. V. (12 beds).
April 3.
April 24.
Ward H. (19 beds).
January 16.
February 11.
February 22 ; February 32 ;
February 26 ; March 1.
March 8—9.
February 23 ;
Ward P. (19 beds).
February 11.
March 16 ; March 18; March 18 ; March 21.
Ward H.R. (19 beds).
February 10 ; February 13 ; February 13 ;
February 15.
Ward St. P. (12 beds).
April 18—20; April 19 ; April 22.
The date is the date of the removal of the case from the ward. This was within a few
hours of the onset of the illness, except where a second date is given ( c.g ., July 5—10) or
when the date is in italics; in these last cases the patients were not moved from the ward
at all.
Besides the wards mentioned in Table IV., eight other wards had
cases—in five only 1 case, in another 2, and in two others 3. In
these last three wards the cases occurred at such intervals or under
such conditions that it was quite impossible (without accepting extremely
short or extremely long incubation periods in some of the cases) that the
first could have caused the others, so that in thirteen instances one case of
rubella failed to give rise to another. In all these cases the patient was
removed as soon as the nature of the disease was discovered, and was in
the ward for a few hours only.
106
Goodall: Rubella
A glance at Table IV. shows that the cases sometimes occurred in
little groups of t\yo to five at a time, which were by no means always
followed by others, even when the patients were left in the ward.
Nor were the cases from which the groups derived infection always
to be traced. This incidence quite corresponds with what one finds
outside the hospital. I have often noticed two or three cases coming
from one house, or institution, or circumscribed locality. For instance,
last year a number of children were sent to the Eastern Hospital from a
Poor Law school because they were suffering, or supposed to be suffering,
from scarlet fever. One girl was admitted with scarlet fever on
February 10 ; on March 1 she developed rubella, and another case
arose in the ward on March 16. On March 9 two boys were sent to
the hospital from this school suffering from well-marked rubella. I
ascertained that there were cases of this disease, as well as of scarlet
fever, occurring in this school. One of the nurses and one of my students
caught rubella at the Eastern Hospital in 1907.
Rubella is held by most authorities to be a very mild affection. It
seldom presents severe symptoms, and is very rarely fatal. But last
year one of my patients died of sudden heart failure following a slight
attack of arthritis, which appeared to have been due to rubella.
William T., aged 3, was admitted on April 28, 1907, certified to
have scarlet fever. It was stated that he had vomited on April 26,
and had a sore throat on April 27. The rash had appeared on the
26th. It was also stated that he had previously had measles.
On admission there was a dull, macular erythema on the trunk and
a somewhat papular erythema on the arms. The cervical glands were
enlarged; the tongue showed some enlargement of the papillae ; the
tonsils were enlarged. The temperature was normal; it rose the same
evening to 99*8° F., but was normal again next day. The patient was
placed in an isolation room ; when I saw him again the next day I made
the note that the case looked then rather like one of scarlet fever. On
May 2 desquamation was noticed on the neck, and on May 3 on the
left thigh, of the pin-hole variety ; on May 8 the peeling was very free
on the trunk and limbs. On May 10 the cervical glands became more
enlarged. On the evening of May 12 the temperature, normal up to that
day, rose to 101*2° F. ; and it continued to be raised (100° F. to 102° F.)
till the evening of the 17th. On the morning of the 18th it was normal.
It rose again to 100*6° F. on the evening of the 22nd, and was normal again
the next day. On May 14 there was pain and some puffiness of both
wrists. On the 16th the patient was better. On the 19th he was
Epidemiological Section
107
doing well. On May 23, at about 2 o’clock in the afternoon, cardiac
failure suddenly arose: dyspnoea, cyanosis, vomiting, pulse rapid and
soft. The patient was pallid and sweating. The heart was dilated,
and there was a loud, blowing systolic murmur at the apex. In spite
of the administration of stimulants the child did not rally, and died
at 7 p.m.
There was no albumin at any time. A post-mortem examination
w r as made the next day; nothing abnormal was found except an excess of
fluid in the pleural cavities and slight dilatation of the left ventricle.
Edward T., aged 4 (William T.’s brother), was admitted on April 30.
It was stated that he had had sore throat, headache and rash on
April 29, and also that he had previously had measles. On admission
there was a morbilliform rash on the face; on the limbs the rash was
much faded, but was macular. On the chest was a punctiform erythema.
The tonsils were enlarged, but clean. The mastoid glands were enlarged,
but no others. The tongue was furred. The temperature was 99*6° F.
It rose to 101° F. the same evening; next day it was normal and so
continued.
The diagnosis was rubella, and the boy was placed in the same room
as his brother. By May 2 the rash had become a faint pink blush. By
the 4th it had disappeared. On May 14 there was some desquamation
on the thighs and chest. There was never any albumin and not very
much peeling. The patient was detained till June 4, because his brother’s
illness had raised a suspicion of scarlet fever. No note was made in
either of these cases as to the presence or absence of Koplik’s spots, but
I am confident that they were looked for and not found, and that only
positive signs were noted.
William T. was suffering either from rubella or scarlet fever. I had
diagnosed rubella even before his brother was admitted. Edward T.
certainly had rubella. . The suspicion of scarlet fever was raised, so far
as the medical staff of the hospital were concerned, only when William
T. died very shortly after an attack of arthritis. Perhaps the arthritis
had nothing to do with the rubella, but was a mere coincidence.
Complications are rare ; I have twice seen otitis media amongst the
287 patients, once arthritis, the case of William T., and four times a
rash, which appeared a few days after the rash of rubella had gone. In
two of these cases the rash was something like that of the primary
attack (morbilliform) ; in the other tw r o it was scarlatiniform. These
recurrences of a rash have been described by other writers and are
usually termed relapses.
108
Goodall: Rubella
So much for rubella as I have observed it. I have been obliged to
enter into clinical details in order to make quite clear the nature of the
disease for the purpose of the discussions which follow; but I may add
that the description of rubella I have just given does not differ in any
essential point from the accounts given by various authorities during the
last twenty years.
Now, as I have said previously, the consensus of opinion amongst
these authorities is almost unanimously in favour of the separate
existence of this disease, and that it is not a mere variety of scarlet
fever on the one hand and measles on the other. 1 Clinically some cases
of rubella resemble scarlet fever, others measles, in the benign forms of
these diseases, so that we have rubella divided into two varieties, the
scarlatiniform and the morbilliform. According to my own experience
and the written accounts of other observers, the rash of rubella consists
very much more frequently of small discrete spots than it does of a
diffuse punctate erythema. What very frequently happens is that the
rash begins as discrete spots and ends as a scarlatiniform erythema.
Still, occasionally it is more or less scarlatiniform all through its course,
though such cases are usually accompanied by those which exhibit the
spotty rash.
I have spoken of the almost unanimous agreement upon the
distinctness of rubella that is to be found amongst modem writers.
I can hardly find a text-book published during the last twenty years
in which this is not admitted. But Henoch, at any rate in 1889, was
doubtful. De Gassicourt, in his work on the diseases of children, does
not mention rubella. According to a paragraph in the British Medical
Journal for December 31, 1898, Dr. Jackson, of the Brisbane Fever
Hospital, is no believer in the duality of the two affections, rubella and
measles. He states that cases of these diseases were placed together in the
same tents during an epidemic, and the patients who were suffering from
the one disease did not catch the other. In this country Dr. Donald Hood,
in a pamphlet published in 1895 on the etiology of rotheln, expresses
his conviction that it is an attenuated form of measles.
It must be admitted that sporadic cases of rubella may occasionally
be very difficult to distinguish from measles. But sporadic cases of most
1 The hypothesis that rubella is a hybrid between scarlet fever and measles has been
utterly abandoned, if it was ever seriously held by more than a sprinkling of writers. Like
the idea of breeding true, so often used when speaking of infectious diseases, it is based on a
false analogy; and the use of these terms has done nothing to advance our knowledge of
these diseases.
Ep ide m io log ica l Sec tin n
109
of the common infectious diseases often give rise to difficulties in the
way of diagnosis. The picture of rubella given above has not been
delineated from a study of sporadic cases. The disease, as I have met
with it, often occurs in little groups of cases, which occasionally give rise
to others, so that it is infectious, if only slightly. We are not dealing
with a disease which may be epidemic and not infectious, such as poisoning
by lead or arsenic. But simultaneously with the occurrence of these small
groups of cases, sporadic cases of an exactly similar character are met
with, which may or may not give rise to others. I have stated above
that last year I observed thirteen sporadic cases which failed to infect.
The disease is feebly infectious. Not so, however, is measles. If a case
of that disease remains in a ward for only a few hours it rarely fails to
show its infectious nature, and as often as not, in the course of a few
weeks, every patient in the ward who has not had the disease gets it.
Ward outbreaks of the two diseases, therefore, are quite different in
their behaviour. Their seasonal prevalence is also different. Rubella is
a disease of spring and early summer; measles, mostly of the late autumn,
the winter and the early spring. 1
The age incidence of the two diseases is also different. Thus, of the
638 consecutive cases of measles analysed in Table III. only 7 were
over 10 years, of age (1 per cent.), while of the 287 cases of rubella, 57
(20 per cent.) were over IT) years. The figures dealt with are small, but
they are drawn from the same environment. Again, measles is a fatal
affection—sometimes it is very fatal—and it is prone to be accompanied or
followed by complications. Rubella is rarely complicated, and is hardly
ever fatal. Each of the diseases protects against itself, but not against
the other. I have on five occasions seen a patient undergo attacks of
rubella and measles within a few weeks. I give the temperature chart
of one case {see next page). The child, a girl, aged 3, was admitted on
May 23, 1892, towards the end of a sharp attack of scarlet fever.
When she was convalescent, first rubella, and shortly afterwards measles,
broke out in the ward, and four patients, convalescent from scarlet fever,
of whom she was one, caught both diseases within a few weeks. I may
add that at the time the ward contained about thirty patients and was
much overcrowded.
But those who disbelieve in the existence of rubella might argue, and
might reasonably argue, that none of these points are sufficiently strong
to establish the disease. They might say, “ What you call rubella is
1 See a paper by Dr. G. N. Wilson in Public Healthy Lond., 1905-6, xviii., p. 65.
110
Goodall: Rubella
really only mild measles, which attacks adults more often than you
suppose. Nor do we admit that second attacks of measles are so
uncommon.” Certainly cases of measles are occasionally so benign as
to have hardly any febrile symptoms and very little rash. But with
respect to the other points, Dr. Wilson, in the paper already referred to,
found that of the 40,000 odd cases occurring during twenty consecutive
years at Aberdeen, only 5 per cent, were over 10 years of age; and that
second attacks took place in 2 per cent, of 24,000 odd cases notified in
ten consecutive years. No attempts appear to have been made in the
Aberdeen cases to distinguish between rubella and measles, but Dr.
Wilson hints that rubella may have been responsible for some of the
supposed second attacks of measles. Still, we have to rely, and in
sporadic cases we have entirely to rely, upon the clinical symptoms to
Chart illustrating Incidence of Rubella and Measles within a few weeks (p. 10G).
make a diagnosis. It is quite possible for two epidemic diseases to
possess an exactly identical seasonal prevalence, age distribution,
fatality, and so forth, and yet to differ clinically and pathologically as
widely as possible.
From the account of rubella given above it will be observed that it
differs clinically from measles in having usually no prodromal period, in
presenting a different, though not a markedly different, exanthem, in
running a much shorter and milder course, and in being devoid of compli¬
cations and after effects. There is also one other clinical sign which I
have not yet mentioned, because it is not to be found in rubella. I refer
to the minute whitish spots w’hich are to be seen on the buccal mucous
membrane in measles, and go by the name of Koplik’s spots. These
Epide mioh hj tea I Sec t io u
111
spots are of the utmost diagnostic importance. It is very seldom indeed,
in my experience, that they are absent from a case of measles, certainly
in less than 5 per cent, of the cases. 1 Now I have read through the notes
of the 85 cases of rubella I saw last year at the Eastern Hospital. In 5ti
of these cases a note was made that these spots were absent. In the
rest of the cases no note was made concerning the spots, almost certainly
because the reporter did not think it worth while to record a negative
observation. I may say that I examined nearly all the 85 cases myself,
because it is my practice to inspect all cases of this kind for the purpose
of directing where, if necessary, the patient is to be isolated. I can
therefore affirm with certainty that not only the 50 but the remaining 29
cases did not show Koplik’s spots. Had they done so, they would have
been isolated at once, (a number of them were not), because measles is
not only a very infectious but also a serious disease, and they would
have been diagnosed as measles and not rubella.
Now, if all these cases were cases of measles, then we have to admit
that cases of measles without a prodromal period, with a certain kind of
a rash, with a very mild course, and without Koplik’s spots, that is to say
exceptional cases of measles, give rise not only to sporadic cases, but also
to outbreaks of cases of an exactly similar, that is to say exceptional, kind.
That is not my experience of measles. Even the mildest cases of measles
present Koplik’s spots, and even though the general character of the
cases in any given epidemic or outbreak of measles may be mild, yet you
do see amongst them some severe, and perhaps even fatal, cases ; and a
mild case may give rise to a severe case, and a severe to a mild. And so
it is with any acute infectious disease which is commonly capable of
being at all severe.
Another fact I may mention. I noticed last January and February
that cases of rubella were occurring with unusual frequency for the
season of the year. I saw 7 cases in January and 20 in February,
besides some suspicious cases. I ventured to predict to my class of
students that there would be an unusual prevalence of the disease in the
spring and summer, and the event proved that I was right. My pre¬
diction was based upon what may be called almost a law of epidemic
diseases which have definite seasonal prevalences, that if the prevalence
1 L. Falkener found them in all of 59 consecutive cases of measles, and failed to find them
in 28 cases of rubella. They were present in all the 62 cases of measles occurring at the
Eastern Hospital in 1907. Falkener also searched for them in a large number of cases of
acute diseases of various kinds, without success. See Met. Asyl. Board's Reports , ii., 1899,
p. 198.
112
Goodall: Rubella
begins to be noticeable rather earlier than the usual period, then you
may expect an unusual number of cases during that period. But I do
not pride myself on being able to predict the prevalence of an unusually
mild and altogether exceptional sort of measles, which I should have
been doing if rubella is merely benign measles. The population amongst
which these cases occurred is not such as will afford measles of a modified
variety in any large number.
I hold, therefore, that even in sporadic cases there is, as a rule, little
difficulty in distinguishing rubella from measles.
Another aspect of the subject must now be considered. I have been
dealing with those who say there is no such disease as rubella. There
are those, on the other hand, who, far from denying the existence of
rubella, assert that under this name two diseases have been described, of
which one may be called rubella and the other is not rubella, nor measles,
nor scarlet fever. It was, I believe, Filatow, in 1885, who was the
first to affirm that the so-called morbilliform and scarlatiniform varieties
of rubella are two distinct diseases, and some such idea was in the
mind of more than one observer before the year 1900, when Dr. Clement
Dukes published his paper “ On the Confusion of Two Different Diseases
under the name of Rubella (Rose-Rash),” 1 and proposed, tentatively, the
name “ Fourth Disease ” for the affection which was not measles, nor
scarlet fever, nor rubella.
I think that it is extremely probable, if not absolutely certain, that there
are other acute infectious exanthematous diseases, as yet little known,
besides scarlet fever, measles, and rubella. I find in a recent text-book 2 3
an account of a disease called Erythema infectiosum . Escherich was
the first to differentiate it in 1897, but it had previously been described
as a local variety of rubella (ortliche Rotheln) by Tschamer, of Gratz, in
1880. It seems to have been observed chiefly in Germany. The same
disease has also been called Megalerythema epidemicum . 8
Then we have the epidemic, recorded by Dr. R. A. Dunn, in Hert¬
ford and East Essex during the winter of 1904-5. 4 But none of these
accounts brings conviction to the reader that the disease is a new one,
with the exception of infectious erythema. This disease appears, accord¬
ing to the descriptions, to be clinically quite different from scarlet fever,
measles, rubella, and even the hypothetical fourth disease. I have seen
1 Lancet , 1900, ii., p. 89.
2 “ A System of Medicine,” edited by Professors Osier and McCrae, 1907, ii., p. 399.
3 See a paper by Cheinisse, Scm. med ., Paris, 1905, xxv., p. 205.
' Brit. Med. Journ ., 1905, ii., p. 421. Republished separately with additions, Oct., 1905.
Ep idem io logic a l Sec t io n
113
a few cases resembling the description given by the writers to whom
I have referred, but they were sporadic, and I obtained no evidence
that they were infectious.
Epidemics, apparently due to milk contaminated in some way or
other, have also been recorded, in which the chief symptoms were sore
throat, fever, and an erythematous rash, which was not like that of
scarlet fever, or measles, or rubella. But in these outbreaks the disease
was not supposed to have been communicated from the sick to the
healthy, unless by means of milk; the disease was not infectious in the
ordinarily accepted meaning of the word.
The Hertford epidemic resembled in some cases scarlet fever, in
others influenza, in others meningitis, and in a few typhoid fever. And,
as one reads Dr. Dunn’s account, the question arises, Might not this
have been an instance of the simultaneous occurrence of more than one
epidemic acute disease? I call to mind an outbreak I had an opportunity
of investigating from the clinical point of view a few years ago. All the
cases, 122 in number, could be divided into three main groups, typhoid
fever, acute pneumonia, and indefinite febrile attacks, with or without
diarrhoea, but not typhoid fever. Yet this mixed outbreak w r as limited
to the population of a lunatic asylum with some 2,250 inmates, including
the staff, and it w r as shown that the water supply was contaminated by
sewage. 1
With Dr. Dukes’s “fourth disease” I must deal at greater length,
since the question of its separate existence is intimately connected with
the subject of this paper. I understand from his accounts that Dr. Dukes
believes that what other observers call the scarlatiniform variety of
rubella is really quite a separate disease. At any rate he will not admit
that the rash of rubella is ever scarlatiniform from its first appearance.
I cast in my lot with those who believe in the scarlatiniform and morbilli¬
form varieties of rubella, though in my own experience the former is not
very common. Some half dozen of the 85 cases I saw last year had a
rash which many an observer would have called scarlatiniform from the
commencement. But these occurred with others of the ordinary morbilli¬
form variety. I have recently read again most carefully Dr. Dukes’s
original paper, and also his articles on “ Rubella ” and “ Scarlet Fever ”
in the “ Encyclopaedia Medica.” In his original paper he refers to three
outbreaks in boys’ schools; the first and third he believes to have been
“ fourth disease ” ; the second to have been one in which scarlet fever
and “fourth disease” w T ere occurring simultaneously; some boys
Met. Astjl. Board's Re}>arts, 1899, ii., pp. 181 and ISO.
114
Good all: Hubei la
suffered from one of these diseases, some from the other, and some from
both. Now, in my opinion, a different interpretation may be given of
these outbreaks without any straining of the evidence brought forward by
Dr. Dukes, namely, that the first and third were mild scarlet fever, and
the second a mixed outbreak of scarlet fever and rubella, mainly of the
scarlatiniform variety. It appears to me that Dr. Dukes lays too much
stress on two points. The one is the supposed infectivity of the
desquamating cuticle at a late stage of scarlet fever. Because certain boys
went home, still peeling, two or three weeks after the commencement of
their illness, and did not give rise to other cases of scarlet fever, there¬
fore the disease w T as not scarlet fever. He has evidently forgotten
Dr. Priestley’s experience at Leicester some years ago, 1 when though
44 not less than 120 children in various stages of desquamation after
scarlet fever were sent to their homes, no single second case occurred
at any of these homes,” although Dr. Priestley carefully watched
them for three months. The other is the invariability of Cullen’s
law. The exceptions to this law are, I believe, more frequent in
the case of scarlet fever than Dr. Dukes would admit. We know,
indeed, that for some diseases this law does not exist, c.g., influenza
and pneumonia.
In his original paper Dr. Dukes states that the rash of the 44 fourth
disease” is indistinguishable from scarlet fever. In his article on 44 Scarlet
Fever” in the 44 Encyclopaedia Medica ” 2 he gives an elaborate table setting
forth the characteristics of rubella, 44 fourth disease,” and scarlet fever.
The table is arranged in three columns, and extends to four pages. The
following is the description of the rash of the 44 fourth disease ” : 44 (8) The
eruption is usually the first noticeable symptom, and will cover the whole
body with a considerable diffuse rash in a very few hours. The hue is a
bright rosy red, and the eruption is raised somewhat from the surface of
the skin. The sensation of heat of the skin to the touch, even where the
rash is very full, is much slighter than in scarlet fever.” One asks what
sort of a diffuse rash : macular, papular, punctate, or uniform ? Also, is
the face affected, and the limbs, or only the trunk 4 ? The distinctions
drawn by Dr. Dukes in this article between rubella, 44 fourth disease,”
and scarlet fever are extremely artificial, and I venture to assert that in
practice they would break down frequently. Reading carefully through
the three columns one cannot find that any feature has been clearly
1 Epid. Soc. Trans., 1895, new series, xiv., p. 73. See also paper by Dr. Millard, Epid.
Soc. Trans., new series, xxi., 1902.
2 Vol. x., p. 503.
Epidem iological Sect ion
115
established to distinguish the supposed “ fourth disease ” from mild
scarlet fever, on the one hand, and rubella on the other.
Dr. Dukes’s contention has received a certain amount of support.
I can refer to papers by Dr. F. T. Simpson 1 and Mr. J. J. Weaver. 2
Dr. Simpson’s account is based on 27 cases which occurred in a school
for the deaf, Hartford, U.S.A., in the spring of 1901. But here, again,
the interpretation that some of these cases were rubella and others
scarlet fever is quite an adequate one, and by no means forced; and as
a matter of fact the diagnosis was changed two or three times during
the epidemic. Mr. Weaver describes 13 cases. The descriptions are
not as full as one could wish. The cases may be divided into two
groups, one made up of those cases admitted to the fever hospital at
Southport as scarlet fever, but supposed really to be suffering from
“ fourth disease,” and the other of those admitted with scarlet fever and
catching the “fourth disease” in the hospital. In one of the latter
group the rash is described as consisting of “ small scattered red spots,
appearing first on the face, then spreading over body and limbs, and
gradually declining,” and in three others it is stated that the rash
appeared first on the face.
It is perfectly clear that what Mr. Weaver had to do with was scarlet
fever and rubella. The cases of so-called “fourth disease” admitted to
hospital were evidently cases of rubella in a late stage, when the rash
had disappeared from the face and become scarlatiniform on the trunk.
It may be mentioned as bearing on the value of the evidence that the
descriptive notes of some of the cases were made by the nurse at the
hospital, from which we may conclude that Mr. Weaver did not see
them at the time they were admitted. As for the cases which caught
“ fourth disease ” in hospital, a rash which begins on the face as scattered
red spots is very different from the erythema of the “ fourth disease,”
w r hich, according to Dr. Dukes, is indistinguishable from the rash of
scarlet fever; and yet we find Dr. Dukes appealing to Mr. Weaver’s
account in support of his own views! 3 Whatever he may have
observed, it is quite clear that Dr. Dukes has not succeeded in con¬
veying to his readers a clear idea of the clinical characters of his “fourth
disease.”
1 Archives of Pediatrics , xviii., p. 692.
2 Dub . Joum. Med . Set., 1901, cxi., p. 416 ; Journ. State Med., 1901 ; Public Health, Dec.,
1901; and Brit. Med. Joum., 1902, i., p., 364 ; but these papers all refer to the same group of
cases. I quote from that in the Dublin journal.
a Article on “Rubella/* Encyclop. Med., x., p. 470.
116
Goodall: ltubella
But of the few supporters of Dr. Dukes the most able is Dr.
Cheinisse. 1 In an article w r hich contains a very full bibliography of the
subject he establishes the existence of the “ fourth disease ” to his own
satisfaction, and proposes for it the name “ epidemic pseudo-scarlatina.”
A considerable portion of the article is devoted to urging Filatow’s
title to priority of discovery, for, as I have previously, mentioned, the
Moscow physician w : as the first to believe that the so-called scarlatini-
form rubella w r as not rubella at all. If, however, time shows that the
“ fourth disease ” does really exist, to Dr. Dukes w T ill certainly be due
the merit of having independently discovered it. But I am not at all
satisfied w r ith the nature of Cheinisse’s arguments nor the validity of
his conclusions. For instance, though the article is a critical review*,
while he quotes w'ith considerable fulness from papers which are in
favour of “ fourth disease,’’ he hardly does more than refer to the very
destructive criticisms that these papers have evoked. He refers to Mr.
Weaver’s paper, but does not appear to have noticed that Mr. Weaver
w*as describing as “ fourth disease ” a malady w T ith a spotty rash. And
yet Cheinisse insists upon it that “ fourth disease ” ought rarely to be
confused with measles or rubella, though it may easily be mistaken for
scarlet fever. I have not been able to obtain Filatow r ’s original papers,
but Cheinisse gives some long extracts from them, and it docs not
appear to me that Filatow really succeeded in demonstrating that this
supposed new* disease was not mild scarlet fever; nor have any subse¬
quent writers, for some of whom it is quite enough that cases, w'hich
are clinically exactly like mild scarlet fever, shall not peel to convince
them that they are not dealing with scarlet fever.
I have been on the look out for this “ fourth disease ” for years past,
but have so far not been able to satisfy myself that I have seen it. Nor
has anything I have read brought conviction to my mind.
1 Son. 1905, xxv., p. 145.
Epidem ioIogical Sec tion
117
Rubella : its Identity and Etiology.
By H. E. Corbin, D.P.H.
Although it is believed by some writers that this disease was
recognised by the Arabian physicians, there is no recorded observation
of the disease as a third specific eruptive fever distinct from measles and
scarlet fever until De Berger described it in Germany in 1752. The
older descriptions of the disease vary considerably, and Formey states
that between 1784 and 1796, 1,180 deaths occurred in Berlin from this
disease, while during the same interval 203 deaths occurred from scarlet
fever and only 103 from measles, but he describes the disease as very
severe, with often a white coating in the throat, vomiting, and severe
nervous symptoms. Another writer describes the eruption as consisting
of miliary pustules.
The disease as we know it was more accurately described in the
beginning of the nineteenth century as an eruptive fever running a
benign course and characterised by an exanthem which could not be
regarded as either measles or scarlet fever, and which many writers at
this time maintained to be a hybrid between the two. Some regarded
the disease as the outcome of an exhausted epidemic of scarlet fever.
The disease is first accurately described in England by Maton in the
Medical Transactions of the College of Physicians , London, 1815. He
says that, “ having several times seen cases called either scarlatina or
measles in which the symptoms were trivial, and the external characters
insufficient to decide their nature, he determined to carefully scrutinise
all similar cases/’ He describes a small epidemic of 8 cases.
The first case, a girl aged 13, on August 18, 1813, had this rash ;
her face suffused with innumerable points, but she did not feel ill. A
sister with her complained slightly and had some fulness of the small
cervical glands ; next day she had a rash. In the room with these two
sisters were four others of the family, aged between 10 and 17 ; tw r o
of these had the rash on September 4 and 5, and the other two on
September 7. Two other relatives, the eldest brother, aged 24, and his
infant son, aged 1£, were taken on September 24 and 30.
Dr. Maton says : “ There is only one other exanthem that I know
to which these cases can be considered referable, that is roseola;
but tumours do not occur in roseola, nor is it infectious. The period
/- 9
118
Corbin: Rubella: its Identity and Etiology
intervening between the application of the infectious influence and
the commencement of the disease was considerably longer than has been
noticed in scarlatina. Hence it seems requisite to form a new designation
which, however, I do not venture to propose, at present being satisfied
with calling the attention of my colleagues to the subject/' In this
early description the main characteristics of the disease are summed
up, namely, the contagious nature, the long incubation, and the enlarge¬
ment of the small cervical glands.
Cheadle describes an epidemic of unusual severity which occurred in
November, 1879, following an epidemic of measles, December, 1878.
Of 30 cases in 1879, 22 had suffered from measles, and these protected
individuals took the disease just as readily and suffered equally severely
with those who were exposed to the infection for the first time. He says :
“ It seems impossible to avoid the conclusion that the disease in the
second epidemic was rubeola, which exists not only in the slight and
unimportant form generally recognised, but as an eruptive fever of
considerable severity which may assume a dangerous and even malig¬
nant type. No other hypothesis will satisfactorily explain the facts.
Eight of the cases had had scarlet fever.”
From the above descriptions we may gather that the disease does
not always conform to the mild type with which we are acquainted, and
that many and wide variations may have occurred in the epidemiology
of this disease ; but on account of the confusion in the earlier days of
this disease with the other eruptive fevers, it is probable that some of
the older writers were describing quite another disease under this name.
The disease appears to be fairly universally distributed. First called
attention to in Germany, it has since been described by many writers in
England and France, by Cuomo in Italy, by McLeod in India, and it is
well recognised in both North and South America.
It is generally accepted that rubella is an infectious disease and that
it occurs chiefly in epidemic form, that these epidemics occur indepen¬
dently of either scarlet fever or German measles. The disease is
interesting on account of its frequent occurrence in the form of small
isolated epidemics in institutions, especially schools, homes for children,
and large business houses. The extent of these epidemics seems to be
determined by the quantity and nature—especially with regard to age
and previous protection by attack—of the inflammable material.
Dr. Lempriere, medical officer of Haileybury College, has been kind
enough to supply me with details of an epidemic which occurred in that
school in the Easter term of this year. Of 422 boys in the school, 332
Kp idemiologica 1 Section
119
were unprotected by a previous attack of rubella. The number of cases
which occurred was 152, being 35 per cent, of the whole school and 45'7
per cent, of unprotected boys. At the same time there was an epidemic
of measles in the school, in which 76 out of 118 boys previously
unprotected by an attack of measles developed measles, or 64*4 per cent.
In only two cases was there any doubt between the diagnosis of rubella
from measles.
An epidemic occurred in a large business house in London, the first
case being admitted into the London Fever Hospital on February 3, 1907,
with an undoubted attack of rubella. Two cases, contacts of the first,
came in on February 18, one on February 19, two on February 20, and
two more on February 21. There was an interval from this to March 3,
when cases came from this house from day to day until March 17, 22
cases in all, or about 7 per cent, from a total of about 300 individuals
freely intermingling. The lesser extent of these epidemics in large
business firms, compared with those in schools, may be attributed to the
smaller susceptibility of adults and to some extent to previous protection,
though it was impossible for me to determine the proportion of unpro¬
tected individuals.
It is interesting to know that both rubella and measles are admitted
into the same wards at the London Fever Hospital, and that, during the
last two years, not one patient with either of these diseases has developed
the other. It must be borne in mind that a large proportion of the
cases of rubella are protected from measles by previous attacks, and that
they are young adults who have most probably been exposed to the
infection on many previous occasions. Of 202 cases of rubella admitted
during 1907 to the London Fever Hospital 76*7 per cent, had had
measles and many others were uncertain. Moreover, the cases are kept
in bed until the catarrhal symptoms and rash have disappeared.
The degree of contagiousness of rubella has been much discussed,
and I am inclined to believe that it is at its maximum during the short
prodromal period of usually twenty-four hours which occurs before the
eruption is manifest, and that it declines rapidly during the following
twenty-four hours, disappearing entirely at the end of this period unless
faucial catarrh persists. There is little doubt that the question of age
enters much into the question of susceptibility, as shown by a com¬
parison of epidemics in schools and institutions for adults. And this is
perhaps more important than previous protection by the disease. During
the last ten years sixty-two nurses have been engaged in nursing this
disease at the London Fever Hospital. Of these only eight developed
120
Corbin: Rubella : its Identity and Etiology
rubella, and while most of these nurses who were unprotected from
measles by a previous attack developed this disease, so far as I have been
able to ascertain none of them had suffered from rubella before.
It is generally stated that rubella is a disease of. childhood, but the
large majority of cases admitted to the London Fever Hospital are
young adults. This is because the patients are mainly drawn from
large business firms and from the servants of private families, but the
figures are interesting as showing that the disease is commoner among
adults than is generally supposed.
The following table shows the age distribution of 1,523 cases of
rubella admitted to the London Fever Hospital during the years 1887
to 1907 :—
Under 5 years
Between 5
and 9
,, 10
u
„ 15
„ 10
„ 20
,, 24
,, 25
„ 29
,, 30
„ 34
„ 35
„ 39
„ 40
„ 45
„ 45
„ 49
50 years and over
12
23
38
385
652
275
87
25
15
3
8
The youngest case I have seen was aged nineteen days. The child
was born on July 7, 1907, and admitted with its mother to the London
Fever Hospital from a lying-in hospital on July 22. The mother on
admission had a temperature of 100*6° F., a well-marked discrete papular
rose-coloured eruption on the face, trunk and arms, accompanied by
slight catarrhal symptoms and enlarged tender posterior auricular glands.
The baby took the breast well, and appeared quite well until July 27,
when it became fretful, temperature 99° F. to 100° F., and occasionally
sneezed. The posterior cervical glands were enlarged. On the following
day the face and body became covered with small discrete bright rose-
coloured papules. Highest temperature 100*4° F. On the morning of
July 30 the temperature was normal, and the child quite well and again
at the breast.
Scholl reports a case of an infant with rubella a few days after birth,
the mother having had the disease two months before. Seitz has seen
a case aged 73. The oldest case I have seen was aged 56.
The sex distribution in the 1,523 cases is : males 775; females 748.
With regard to the seasonal incidence of rubella, it is essentially
a disease of the spring months, nearly 75 per cent, of the cases occurring
Ep irle m iolorj ic a l Sec tio n
121
between March and June, reaching a maximum incidence in May.
In this respect it contrasts markedly with measles, in which there does
not appear to be any constant seasonal incidence, although the mortality
curves, derived from the Registrar-General’s reports of the last fifty
years, show a double seasonal maximum in June and December, but the
incidence of the disease does not run parallel with the case mortality
because, during the warm summer and autumn months, the disease is
less fatal.
Curve showing Seasonal Incidence of 1,523 cases of Rubella.
From the curves showing the number of cases admitted to the
London Fever Hospital it will be seen that there are alternate epidemic
and non-epidemic years as in the case of measles, and that, considering
the incidence of the disease during the twenty-one years preceding 1908,
an epidemic of greater or less magnitude occurs every third or at the
most every fourth year.
I have attempted, by plotting on the same chart the number of days
of rainfall per month, the inches of rain and the mean temperature,
together with the relative humidity, extending over a series of twenty
122
Corbin: Rubella: its Identity and Etiology
years, to associate some relation of these with the incidence of the
disease, but have not been able to establish any definite climatic con¬
ditions which favour the development of rubella epidemics, although
it seems that a rising temperature of the air, together with a lowering
of the relative humidity and a small rainfall, combine to favour the
spread of rubella.
1887 1907
Annual number of cases of Rubella admitted to the London Fever Hospital
between 1887 and 1907.
I will now briefly review the facts upon which the identity of rubella
as a disease sui generis is established. It is characterised by certain
definite clinical phenomena which, though they may be said to resemble
in certain respects and to overlap those of measles and scarlet fever,
Epidemiological Section
123
vet when considered collectively constitute a syndrome which is entitled
to independence. It can be only those who have not had an opportunity
of observing many cases, or who attach too great importance to
the appearance of the rash in the specific fevers and fail “ to
grasp the sorry scheme of things entire/’ who still regard the disease
as a bastard and a hybrid of two diseases or refuse to grant it
an independent existence. The short period of invasion and the
long period of incubation differ markedly from the other exanthemata.
Tts seasonal incidence differs from that of measles and scarlet fever:
it is essentially a disease of spring and early summer. The mor¬
tality from the disease is practically nil. In the 1,523 cases at the
London Fever Hospital there was not one death, but it must be remem¬
bered that the age distribution of these cases is not typical. Edwards,
in the American Journal of Medical Sciences , 1884, lxxxviii., p. 448,
describes six deaths in 160 cases. Squire says that “ where a mortality
is reported as high as 3 per cent, of those attacked, measles is present.”
Kubella breeds true, and is in no way modified by a previous attack
of measles or scarlet fever, even though in some cases only a short
interval occurs between the diseases. One such case may be mentioned
here. A nurse went on duty in the measles ward at the London Fever-
Hospital on May 3, 1907. On May 15 she was attacked by well-marked
measles—Koplik’s spots and severe bronchitis being present. She was
discharged on May 27, and on June 1 developed a typical attack of
rubella.
No immunity from rubella is conferred by a previous attack of measles
or scarlet fever. Of 202 cases of rubella admitted during 1907 I was able
to get a history of a previous attack of measles in 155 cases, or 76*7 per¬
cent. ; of scarlet fever in 58 cases, or 28*7 per cent.; and of both of these
diseases in 18 cases, or nearly 9 per cent, liecurrence of rubella in the
same individual is probably rarer than a second attack of measles.
On account of the dual appearance of the rash in rubella it has been
suggested that two diseases are included under this head. Filatow
first called attention to the matter in 1887, and described the scarlatini-
1‘orm variety of rubella as a separate disease under the name of scarla-
tineole or pseudo-scarlatine. Dr. Clement Dukes, in 1894, says : “ I have
frequently raised this question, but I have signally failed to establish one
relevant fact to sustain the hypothesis. It must be a remarkable coin¬
cidence, if such be true, that after so many years of close observation and
investigation I am unable to record a single case pointing to this fact.”
In 1901 he maintains that he has adequately proved the existence of two
124
Goodall & Corbin : Rubella
clearly distinguishable diseases under the name of rubella, one of which
he has termed “ the fourth disease.” In his description Dr. Dukes
attaches considerable importance to the periods of incubation, which even
in an epidemic of one disease is difficult enough to obtain, but in a mixed
epidemic such as he describes must, in my opinion, be too difficult to be
reliable, especially as it is a matter of common observation that an
individual may be long exposed constantly to an infection before the
disease occurs. Many nurses, for example, are exposed to infection in
a scarlet fever ward for an indefinite period before they develop scarlet
fever, if they do at all.
Dr. Dukes describes an epidemic of “ fourth disease ” only which
occurred at Rugby affecting nineteen boys, none of whom had previously
suffered from scarlet fever, and in whom in this unmixed epidemic he
was unable to determine the incubation period. His description of these
cases corresponds very closely with many cases of scarlet fever admitted
into the scarlet fever wards of the London Fever Hospital, the notes of
which I should like to submit in detail if time permitted. None of
these cases which would correspond to Dr. Dukes’s description of “ fourth
disease,” and which I have admitted into the scarlet fever wards, ever
caused the disease in other patients or contracted scarlet fever them¬
selves, a fact which could only be accounted for by one of the following
assumptions: That the disease is not infectious, or that each confers an
immunity from an attack of the other disease. I have never seen a
case of the “ fourth disease,” and I am inclined to attribute Dr. Dukes’s
success in dealing with epidemics of the so-called “ fourth disease ” to
the fact that the desquamation per se of scarlet fever is very feebly
if at all infectious.
In conclusion, I have to express my gratitude to Dr. Sidney Phillips
and Dr. William Hunter for kindly allowing me to refer to many of
their cases, and also to thank Dr. Sidney Haynes for information con¬
cerning a small epidemic of rubella which recently occurred at Stansted,
in Essex.
DISCUSSION.
The CHAIRMAN (Sir Shirley Murphy) remarked that both the papers were
very interesting and valuable. There was a difference in the age incidence of
the disease as shown by the figures of Dr. Goodall and Dr. Corbin respectively.
In Dr. Goodall’s paper it was said that the maximum number of cases
occurred under five years of age, whereas in the other paper it was shown
that the maximum number occurred between the twentieth and twenty-fourth
years of life. Dr. Corbin had referred to the matter in relation to the
Epidemiological Section
125
class of patients received at the London Fever Hospital. The question arose,
Was rubella so common a disease that, amongst the poor especially, the majority
of people suffered from it without knowing it ? Was it that it attacked the
poor when they were very young, and that in the better circumstanced, who
were better defended against attack, it occurred in older subjects? Or was
it that Dr. Corbin’s cases were largely derived from houses of business and
hotels, where the clientele consisted largely of young adults ? He did not think
those questions could he answered from material contained in the present
contributions.
Dr. Corbin had shown a very interesting diagram showing intervals of three
or four years between successive epidemics. This was in accordance with what
was observed years ago in regard to measles, before there was such an aggrega¬
tion of population as now obtained. Therefore, although Dr. Corbin’s patients
might be enjoying the advantages of a better social condition, it only left them
to be attacked after all at a time of general prevalence of the disease. Dr.
Goodall’s patients, including the very poor, acquired the disease early in life,
owing to the lack of safeguards against catching it. Years ago he was engaged
in considering the question of the provision which should be made for children
entering industrial and reformatory schools, and one of the first wants, he
thought, was some place where the children could be quarantined in the event
of their being found to be suffering from infectious disease. But he later
discovered that to be unnecessary, because these children had practically always
passed through everything of the kind in quite early life. He did not deny that
the different class from whom Dr. Corbin received his patients had a different
age distribution, and that might also affect the result.
Dr. RANSOME, in response to the Chairman s invitation to speak, said he did
not feel competent to criticise the papers, from which, however, he had derived
much instruction. He thought Dr. Corbin had explained the point about the
different age incidence ; in the one case this incidence resembled that of measles
more than in the other, and that might have something to do with the different
class of patients from whom the statistics were derived. He remembered reading
a paper before the Epidemiological Society on epidemic cycles, from statistics
for 100 years, which he got from Dr. Berg, of Stockholm. It appeared that in
the sparsely populated country of Sw eden the periodic cycle w as distinctly longer
than in England, where the population w r as much more dense. It might be,
therefore, that there w r as a greater condensation of susceptible people in the
case of one set of statistics .than in the other. He did not see how a thing of
that kind could be decided without taking a whole nation ; statistics taken from
one or other fever hospital would not solve the question.
When he was in general practice he was early convinced of the existence of
rubella, and that it w r as absolutely distinct from measles. A short time ago,
when staying at Mentone, he had an instance of that. A young friend of his
had an attack of typhoid fever at San Remo, and he found that the sister, who
had been a nurse probationer, had been through an attack of what was called
German measles. She came out straight away to nurse her brother with
1*26
Goodall & Corbin : Rubella
typhoid fever, and in another fortnight he developed measles. Then she got
an attack of German measles afterwards.
Dr. CAIGEK thought no one who had listened to the papers could help
endorsing the Chairman's opinion as to their value. They represented a
summary of opinions drawn from the observation of many hundreds of cases,
by men who had special opportunities for observation. In the past the actual
existence of the disease had been much disputed, and even now there was
uncertainty in some quarters. Dr. Goodall's experience in the matter extended
over sixteen years, and the cases of which he spoke had been under his own
personal observation. Dr. Corbin had given records of an institution which
was far and away the most important in respect to rubella in this country, and
it would be admitted that the amount of that disease to be found at the London
Fever Hospital was unexampled. Two hundred cases were admitted there during
the past year. That high incidence, which had been mentioned by both authors,
was only part of a larger incidence which had been noticed all over London,
and, from certain information he had, in most provincial towns also. In his
own hospital at Stockwell, instead of having twenty or thirty cases during the
year, the number under treatment in 1907 was eighty or ninety.
What he wished to say was from a clinical standpoint, and by way of
supplement rather than of criticism. Dr. Goodall noted that there was usually
an absence of prodromal symptoms, and that if present they did not last more
than twenty-four hours. He then said that among the symptoms were sore
throat, vomiting, enlargement of the lymphatic glands, especially of the neck,
and moderate pyrexia. His own opinion was that the vomiting was there
unduly emphasised. His view was that vomiting was an excessively rare and
early symptom in rubella, and when remembering how frequently vomiting was
an early symptom of scarlet fever, that fact was of great value. Dr. Goodall
said that the macules, though discrete at an early stage, were apt to become
confluent, and were not, as a rule, so large as those of measles. The point to
emphasise there was that the macules were discrete at an early stage, and that
did not apply to the same extent to measles. He had not convinced himself
that the crescentic arrangement of the macules was more often seen in measles
than was any other shape. All the points of difference between German measles
and true measles should be paid attention to, considering the difficulty often
experienced in differentiating individual cases. The rubella eruption began in
the form of spots which were smaller and pinker than in measles ; they were
more discrete, more likely to spare the face, mpre transient, and therefore
caused less staining, and they were followed by more desquamation. They
were differences of degree, not of kind, hence the great difficulty which some¬
times arose. The stiffness of the neck mentioned by Dr. Goodall he thought
should be regarded as essentially a sign to be seen in adult patients. In
children it might exist and not be complained of; but the adult would often
complain of that before any other symptom. In the epidemic last year one of
the things which struck him was the absence of definite enlargement of the
cervical lymphatics, which was such a characteristic feature of the disease.
Epidemiological Section
127
There was an epidemic type of rubella, just as in other diseases. It was
satisfactory to him to see that in Dr. Goodall’s cases there was a rise in
temperature in only 33 per cent. He (Dr. Caiger) had felt that so strongly
that he had taught for several years that an increase of temperature was the
exception rather than the rule. Dr. Goodall said the conjunctive were often,
but by no means always, injected. He (Dr. Caiger) believed that when the con¬
junctive were definitely affected in rubella it was part of the hyperemia of the
face generally. The same applied to the nasal mucous membrane. Where the
patient complained of heaviness in the head, as if he had a cold coming on,
there was perhaps a vivid flushing of the face and injection of the conjunctiva?.
Dr. Goodall said : “ Desquamation may follow ; usually it is slight and branny,
hut it may be profuse—rarely is it ‘pin-hole’ ” ; and Dr. Caiger could endorse
that. As a rule, the desquamation in German measles tended to be more
distinct than in ordinary measles, but in certain cases there might be absolute
pin-hole desquamation, as in scarlet fever. He remembered the case of a
medical practitioner in the neighbourhood of Stockwell Hospital, who was not
in good circumstances, and asked Dr. Caiger to see him, as he had a vivid
erythema and sore throat. He concluded it was German measles, but felt
anxious as the patient began to peel in a way which was far above the average.
But he adhered to his diagnosis and allowed the patient to go about his
practice, wearing gloves, at the end of a fortnight. As far as could be
ascertained, no bad results accrued. That required considerable confidence
in one’s opinion.
He agreed that rubella did not possess a high degree of infectivity, and the
fact had an interest for him because of the experiment which had been in force
at Stockwell Hospital last year, namely, treating patients with different
infections in cubicles in the same ward. During last year sixty or seventy
cases of rubella were treated in the same ward as other diseases, shut off only
by a glass partition, the ward being ventilated as a whole, and only two
secondary cases of rubella had occurred in the ward: in one of those cases it
was possible that the child came in incubating; seeing that there was a very
hard run of cases throughout that time, this was a very satisfactory result.
But it was not such a fine record as Dr. Corbin showed in connection with the
London Fever Hospital, and it was with the greatest surprise that he learned
that 200 cases of rubella, and many cases of measles, were treated at the
London Fever Hospital without a single accident. He did not know why
that should be ; it almost seemed to dispose of the suggestion that rubella was
an infectious disease. It was true that the age incidence of rubella and
measles patients did not quite correspond ; again, a good many of the rubella
cases might have had measles in early childhood, and no doubt the greatest
care was taken at the London Fever Hospital; but in spite of those facts, he
did not see how Dr. Corbin was going to explain the absence of any accident.
It bore out the suggestion that the infectivity of rubella was very much higher
at the pre-eruptive stage than at any other, and seeing that it was on the
strength of the rash that they were certified and sent in, that was the strongest
argument in favour of early infectivity and its early disappearance.
128
Goodall & Corbin : Rubella
Dr. Mekedith Richards said that, in regard to the difference in the age
incidence, Dr. Corbin based his figures on cases admitted and Dr. Goodall on
cases observed. Probably a large proportion of Dr. Goodall’s cases contracted
the disease in hospital; if so, the age incidence of those cases would be
governed by the age incidence of the scarlet fever and diphtheria patients from
whom they occurred. He could not understand the good luck of the London
Fever Hospital in not having cross-infection in their common measles ward.
One would have expected a small amount of German measles, because it was
the general experience that if rubella was introduced into a scarlet fever or
diphtheria ward it did not tend to spread to any great extent. Dr. Goodall
referred to the great difficulty in preventing the spread of ordinary measles, and
Dr. Richards asked whether, since he had been on the look out for Koplik's
spots, he had not had to modify his opinion on that point. Fortunately, for
some years past, they at his hospital had been fortunate in limiting the spread
of measles, and if one was on the look out for a second crop, it could be limited
to that second crop, because one could isolate measles cases three or four days
before the rash appeared.
Dr. F. N. HUME said the difficulty of diagnosis had come under his notice
to a larger extent in relation to scarlet fever than to measles. During the last
year a large number of cases had been sent into his hospital with a diagnosis of
scarlet fever, though they were cases of rotheln. For various reasons, including
the difficulty of isolation, he had sent many of them home again. In that case
it was essential to have adequate grounds for forming that opinion. The
opinion, in most of those cases, was formed on the character of the rash, it
being, in his opinion, pinker than the scarlet fever rash. Thus it was a matter
of opinion and eyesight. The second point was the i>osition of the rash.
Dr. Goodall mentioned that the rash of rubella went up to the mouth, and that
ought to be emphasised very strongly, as it was of such great importance. In
many cases the diagnosis between rubella and scarlet fever could be aided, if
not established, by the fact that the rash of the one was present on the face,
with entire indifference to the neighbourhood of the mouth, whereas scarlet
fever was invariably absent from that region. The rash extended, in many
cases, on to the surface of the palm and the sole, and that was important as
distinguishing rotheln from scarlet fever. The difficulty in diagnosis was
enormously increased when the case was not seen until the second day. Then
there was a general erythema, which might be more or less punctate, and it was
very difficult to be certain that it was not a case of scarlet fever. He had seen
many cases in which the general distribution of the rash on the face, round the
mouth, had been of great assistance. He agreed that the prodromal symptoms
were unimportant and generally absent in the cases which occurred in hospital,
and he had seen many such in the last twenty-five years. But in certain cases
they were not to be despised. He had had the disease twice, and the second
time severely. On a certain Saturday a medical man was examining him for
life assurance, and said there was something wrong with him, though he was
himself unconscious of anything of the kind. He submitted himself to two
Epidemiological Section
129
other examiners, who said he had some temporary cardiac irritability. He was
referred by the insurance company for a month. On the Saturday and Monday
he had a considerable rise of temperature, and suspected that he might possibly
have typhus, of which disease he had been seeing a number of cases. On
Tuesday and Wednesday he felt comparatively well, but on Thursday, when he
got up, he was covered from head to foot with a rash, which was considered
to be rotheln. The incubation period was thus very clearly established. A
patient, exactly a fortnight before he (Dr. Hume) was rejected, had been
brought to the hospital as a case of small-pox, and was taken in for observation
for twenty-four hours. He was a German, and he (Dr. Hume) was brought
into communication with him, and there was no doubt that that patient was
the author of his own illness.
Dr. BUTLER said his experience was [that there was but little difficulty
in diagnosing scarlet fever from German measles, and none in distinguishing
between measles and rotheln. Some years ago, however, he had been greatly
troubled with an outbreak of rotheln in the scarlet fever wards. Successive
cases were sent in incubating the disease. There were other cases which came
in with the wrong diagnosis—sent in as scarlet fever—whereas they were really
cases of rotheln. But the frequent occurrence of cases incubating the disease
indicated what he had since confirmed, that there were times when rotheln was
very widely prevalent. There must be a fairly widespread prevalence of rotheln
to bring repeated cases within one’s ken at the same time. The superficial
resemblance to scarlet fever w r as in most cases set aside by the distribution of
the eruption. He had long regarded as almost pathognomonic the fact that
rotheln invaded the circumoral region, and was present up to the lips ; he had
never seen scarlet fever with anything like that distribution. Whenever cases
came in incubating it, he found that it was not easy to prevent the spread of
rotheln thus introduced. So great was the difficulty that it became his practice
to place all his contacts likely to incubate the disease in a separate ward, and
he was struck by the extreme definiteness of the incubatory period, namely,
eighteen days. He believed the absence of prodromal symptoms was not only
constant, but was very valuable from the point of view of the medical officer of
health. For several years he had been in the habit of differentiating, on some¬
what meagre evidence, between outbreaks of rotheln and of measles in his
district. Measles was notified by the teachers as soon as they were informed
that a scholar was absent from a public elementary school on that account; and
he had found there was a constant history of the onset of the illness. In the
absence of any history of prodromal symptoms, he had been in the habit of saying
he suspected that it was German measles, and, where medical men were called
in, that was the diagnosis in the greater number. It was a crude .way of
arriving at it, but the fact that there were epidemics in which no prodromal
stage was noticed, and that the cases generally proved to be German measles,
threw an important practical light on the value of that fact.
Dr. CLAUDE B. Ker (Edinburgh) said that in taking in measles many
cases of German measles were seen amongst adults. His age periods more
130
Goodall & Corbin : Rubella
closely corresponded with Dr. Corbin’s than Dr. Goodall’s. Considering the
large number who appeared to come in by accident, it was astonishing how few
young children came under that description. Two-thirds of his patients at the
Edinburgh City Hospital were aged over 10. He desired to raise the question of
prodromal symptoms. He had gone elaborately into the histories given by those
old enough to do so, and found that many had suffered before the appearance of
the rash, some of them many days before the appearance of any exanthem. One
hundred and one cases out of 200 which he had seen had distinct symptoms
twenty-four hours before the rash appeared ; 18 cases over two days before ; 21
cases three days before; 7 cases four days ; and 8 cases from five to seven days
before the rash occurred. These were adults, nearly all of them educated, such
as students who came with German measles, chiefly because it was inconvenient
to keep them at home. The absence of children among the subjects might be
largely accounted for by the fact that the condition was regarded as trivial.* The
symptoms complained of were: Catarrh, coryza, &c., in half the cases ; headache
in one-third of the cases ; sore throat in a quarter ; definite stiff neck, which he
had always been particularly on the look out for, in a quarter of the cases;
malaise, nausea, &c., in a certain number; and vomiting in only 7 out of
101. With regard to the mucous membrane of the mouth, he always had the
idea that a patient with German measles had a comparatively clean mouth.
One could not always count on getting Koplik’s spots in measles. But he
believed very much in Koplik’s spots. It was in the mild cases of measles,
which were on the border-line between measles and German measles (which
gave him more trouble than the diagnosis between German measles and scarlet
fever), that the condition of the mucous membrane was of the most assistance.
He had tried to see if the diazo reaction, which was so constant in measles, was
uniformly absent in German measles, but he had had a disappointment, as he
came upon two cases of German measles which gave just enough suggestion of
it to destroy the idea. He thought the presence of that reaction was a strong
point in favour of a case being measles.
Dr. J. T. C. Nash : I regret that the exigencies of time compelled me to
leave before the discussion opened on Dr. Goodall’s and Dr. Corbin’s paper, and
that I have to write this contribution under the disadvantage of not knowing
what has already been said, but it is extremely likely that I shall not have been
forestalled in the remarks I have to offer. The excellent papers which opened
the discussion have made it clear that at times series of cases occur with a
symptom syndrome sufficiently distinctive to justify the naming of a distinct
entity or disease. All of us who have had to deal with fever hospitals can no
doubt recall cases which we had no difficulty in diagnosing as typical rubella.
But Dr. Goodall talks of “ the natural duplicity of the disease itself,” and “ will
not say that I have not at times made a mistake and applied . . . the w T rong
name.” Dr. Corbin quotes the details of concurrent epidemics of rubella and
morbilli at Hailey bury College. “ In only two cases was there any doubt
between the diagnosis of rubella from measles.” But there were those two
cases. Neither Dr. Goodall nor Dr. Corbin bring forward any facts which in
Epidem iological Section
131
any way influence me to change the views I expressed in a paper on “ Evolution
in Relation to Disease,” 1 which I had the honour of reading before the Epidemio¬
logical Society in March, 1906. I said at that time : “I am personally inclined
to be of opinion that scarlet fever, diphtheria, rubella, &c., in typical instances
are specialised types of disease resulting from evolutionary factors which have
for a sufficient length of time been gradually influencing in various directions
(fairly defined for each special type) the life processes of some, perhaps common,
ancestral organism. As long as the evolutionary factors proceed on certain
fairly definite lines, the tendency is for a recognisable variety of affection to be
met with : and in this way a highly specialised variety of germ is evolved, and
naturally tends to breed pure, at any rate for a considerable time. The
specialised form will produce special toxins, which will give rise to special
reactive phenomena which we forthwith recognise as specific disease. Under
these circumstances, then, we see typical cases of scarlet fever, <fec., and
diagnosis is supremely simple. Should, however, the root of evolution be
disturbed, and the specialised germ become subjected to unusual perturbation
for a sufficient time, w T e shall have differences in the toxins formed, and a
corresponding difference in the reactive phenomena giving rise to atypical,
anomalous, or aberrant forms of disease. ... I merely suggest . . . that
if the Jonah of unalterable specificity is thrown overboard, such atypical forms
of disease become at once explicable when our ideas are founded on the broad
bases of evolution as applicable to infective diseases and their causal micro¬
phytes.” a In addition to the illustrations I gave in the paper above referred to,
I may mention two more recent ones of considerable interest. Although, at
first sight, they may appear to have nothing directly to do with the clinical
entity known as “ rubella,” they affect the question of evolution in relation to
disease, which in my view bears directly on all infectious diseases. The first
illustration has occurred quite recently in my own experience as follows:
In October I was asked by a medical colleague to see a little boy at the
Southend Victoria Hospital who had been admitted with severe scalds four
days previously. He had the usual symptoms of scarlet fever, including a sore
throat and strawberry tongue. There was no history of scarlet fever contact,
but it was conceivable that, somehow, germs on the body had found entrance
through the extensively damaged skin. He w r as removed to the fever hospital,
and peeled profusely. No other patient in the Victoria Hospital ward developed
scarlet fever, but the attending nurse had a sore throat a few days later.
Further cases of sore throat occurred among the staff, and a suspicion of a
diphtheritic infection arose in the mind of the attending physician, who
submitted swabs for examination, but no Klebs-Loffler bacilli were found in any
throat. The last case of all desquamated, upon which I w r as asked to investigate
the matter. The second illustration I would refer to is the interesting record of
an outbreak of sore throat in a large girls’ school in Dublin last autumn, so ably
1 Trans. Epidem. Soc 1900, xxv. N.S., p. 204.
* Ibid. % p. 228.
132
Goodall & Corbin : Rubella
reix>rted and discussed by Sir John Moore under the title of “ Diphtheritic
Fever/’ 1 For the details reference should be made to the original paper, but
Sir John Moore thus summarises the symptoms which make up the clinical
syndrome of diphtheritic fever. They are : (l) a more or less severe coryza;
(2) a moderate tonsillitis, usually one-sided, and unattended by high fever or by
much exudation; (3) thickly coated tongue and foul breath, the tongue
desquamating as in scarlatina; (4) a patchy or punctate rash on the roof of the
mouth and buccal mucous membrane; (5) swelling of the cervical lymphatic
glands ; (6) a roseolar rash on the skin (in 12 out of 18 cases; in 4 cases early;
in 8 cases on the fifth to the seventh day from the first symptoms); (7) distinct
desquamation (in 3 cases). The organism common to the throats of these
Dublin cases was a diphtheroid bacillus, probably a specialised form of the
diphtheria bacillus, which after a time tended to revert to the true diphtheria
bacillus, giving rise to two cases of diphtheria in the country when the girls
broke up for the Christmas holidays, about two months after their illness.
This interesting record strengthens the position I have taken up a with regard to
a subtle connection between two diseases so distinctly differentiated in typical
instances, as scarlet fever and diphtheria. Rubella is, in my opinion, a less
common disease than measles or scarlet fever only because it is a less specialised
disease. The “ fourth disease ” of Dr. Dukes is even more unstable. But for
the enlightenment which follows on a clear realisation of the possibilities of
evolution in relation to disease one might have attempted ere now to record
rare instances of even a “ fifth ” or a “ sixth ” disease. In my humble opinion
rubella is certainly a sufficiently stable entity under certain conditions to justify
its symptom syndrome, earning for it a distinctive name ; but I repeat my
conviction it is due to a less highly specialised germ than in either scarlet fever
or diphtheria or measles. Further, I think the evidence so far available points
to a common ancestral origin for the special germs, responsible, on the one
hand for measles, and on the other for rubella.
Dr. GOODALL, in reply, said he thought the different age incidence in the
two papers was due to the different class of patients admitted to the two
hospitals. It would be interesting to know what were the ages of the patients
with scarlet fever at the London Fever Hospital. He thought they were of
higher ages than those in the Metropolitan Asylums Board hospitals. After
two years at the London Fever Hospital he would have said that rubella
occurred chiefly among young adults. About half his own cases were contracted
in hospital. Some were admitted under the guise of scarlet fever. Seventy-five
per cent, of the cases had been children aged under 10. To get a true idea of the
incidence of rubella it was necessary to combine the statistics of Dr. Corbin and
Dr. Ker with his own. It was difficult to find records, as men treated the
affection as so trivial that they did not trouble to record it. He thought it
was fairly frequent, but not so much so as measles or scarlet fever. Last year
1 Dublin Journ . of Med. Science, 1908, cxxv., p. 10.
8 Brit. Med. Journ., 190*2, i., p. 5G. Trans. Epidem. Soc. y 1906, xxv. N.S., p. 205.
Kpulemiolofjtea / Section
133
it was very prevalent; every hospital under the Asylums Board had eases of it,
and he had heard of it also in other parts of the country. He agreed with what
had been said about the prodromal symptoms, but this was not a Clinical Section.
Sometimes the peeling was remarkable. With regard to Dr. Kichards’s remarks
about early isolation, he had in mind several cases which were left, for hours in
the ward. If measles was detected in the first few hours there might he no
more cases, blit if left longer than that there might he secondary cases : and
that went on gradually until perhaps the ward was not out of quarantine for
three months. Nearly all his patients had been children, and one could say
that the rash was nearly always the first symptom. At the London Fever
Hospital he saw cases with a longer prodromal period. He remembered
Dr. Hopwood diagnosing a case as having German measles several days before
the rash ; the patient had enlarged glands and a temperature. The diazo
reaction he had not tried. When he was at the London Fever Hospital twenty
years ago he saw many cases, and found the diazo reaction in some cases of
German measles.
Dr. CORBIN, in reply, said he thought the different age incidence was due
to the fact that children were not admitted to the London Fever Hospital
suffering from German measles because it was regarded as a trivial affection.
The cases admitted were turned out of business houses, schools, and hotels,
probably out of regard for other people’s feelings. It was true that the age
incidence of scarlet fever in that institution was higher than in the cases
admitted to the Metropolitan Asylums Board hospitals. But more children
were admitted to the London Fever Hospital with scarlet fever than with
German measles, because people regarded the disease as more serious. Much
as he liked clinical medicine, he had not ventured to touch on that aspect in
his paper. He would have liked to draw attention to symptoms which he had
noticed in connection with certain cases at the London Fever Hospital, but he
had left that out in obedience to a desire to make the paper as short as he
could. He agreed with Dr. Caiger’s remark about adenitis in German measles.
If the postauricular, mastoid, and occipital glands were enlarged and tender,
lie thought that was the sign as near to being pathognomonic as any could well
he in rubella. Five per cent, of his cases of rubella had not any adenitis, and
18 per cent, were confluent, the rash starting as discrete rose-coloured papules,
which became confluent rapidly, so that if those cases had not been seen in the
early stage, it would not have been possible to say whether the condition was
scarlet fever or not. He agreed with Dr. Ker as to there being a longer
prodromal period in some cases, the patients complaining, without any leading
questions, of enlarged and tender glands in several situations. Faucial catarrh
was common in rubella, and a condition which no one had referred to and
which was not usually recorded was a granular condition of the soft palate in
German measles, which was not seen in scarlet fever or ordinary measles.
When he said that German measles and measles were admitted to the same
ward, he knew that w f as throwing a bomb into the meeting. He was not
responsible for it; it had been going on for twenty years, and successfully.
f -10
134
Goodall <fc Corbin : Rubella
With regard to the reasons why more trouble had not arisen owing to cross
infection, he did not lay great stress on it, but he thought rubella was infectious
in the prodromal period almost entirely, and not at any subsequent stage. All
cases at the London Fever Hospital were kept in bed until the faucial catarrh
and rash had disappeared. It would probably be risky in a children’s hospital
to carry out such a regime, but he thought infections might be divided into
long and short, depending on the striking distance. Chicken-pox and small-pox
were long-distance infections, and one could scarcely remove such cases soon
enough; hut German measles would not infect except by actual contact.
Among nurses, only those who were great friends of the attacked nurse got the
disease from her, the incubation period being in each case seventeen days.
Witluregard to Dr. Hume’s and Dr. Butler’s remarks, he had seen several cases
admitted into scarlet fever wards in which the scarlet fever rash had invaded
the circumoral region, and he had a case now in which there was a definite
rash round the mouth, and in which desquamation was now occurring in the
circumoral region. It was not that a mere flush had been present there.
Epidemiological Section.
February 28, 1908.
Dr. Newsholme, President of the Section, in the Chair.
Mendelism in Relation to Disease.
By R. C. Punnett, M.A.
It was with some trepidation that I accepted an invitation to read
a paper bearing upon the inheritance of disease before a distinguished
body like the Royal Society of Medicine; but I recollected the motto
cut upon the wall of the medical schools at Cambridge— apia-Tos larpos
teat, <f>i\o(To<f>o<f —and I ventured to hope that, even if the remarks which
I have to offer to-night might fail to excite the interest of the physician,
they would, at any rate, claim the indulgence of the philosopher.
Since the rediscovery of Mendel’s paper a few years ago, the
experimental study of heredity has made rapid progress, and the recent
work has served to confirm and extend the principles which he laid
down. What these principles are may be most readily gathered from
the consideration of a concrete example, and as a simple illustration w'e
may take a well-known case among poultry, that of the Blue Andalusian
fowl. It is a bird which has long been known to possess an inconvenient
peculiarity : it will not breed true. It always throws “ wasters ” of two
sorts: blacks, and whites marked with some black splashes. There are,
therefore, three kinds of Andalusians, and consequently six possible types
of mating among these three varieties. With regard to the results of
these types of mating, careful experiment has brought out the following
facts :—
Blue x Blue gives Blacks, Blues, and Whites, in the ratio 1:2:1.
Blue
Blue
Black
White
Black
mh —9
Black ,, Blacks and Blues in equal numbers.
White ,, Blues and Whites in equal numbers.
Black ,, Blacks only.
White „ Whites only.
White „ Blues only.
136
Punnett: Mendelism in Relation to Disease
We are dealing here with a case in which every possible form of
mating has been carried out, and some of the results at first sight seem
paradoxical. Thus, for instance, the blacks always breed true whatever
their ancestry may have been ; and the same holds good for the whites.
The white that is produced by two blues, themselves the product of
mating blue with blue over many generations, breeds as true to white¬
ness as the white of pure white ancestry. A black is pure for blackness
and a white is pure for whiteness whatever the ancestry of the bird may
have been. Again, it seems at first sight incongruous that the mating
of black with white should give just twice as many blues as two blues
mated together.
The theory of heredity first propounded by Gregor Mendel enables
us to summarise all these results in a very simple and beautiful
way. Briefly it is as follows. We are dealing with an alternative
pair of characters, blackness and whiteness. Every germ-cell or gamete,
whether ovum or spermatozoon, bears a representative of this pair. But
it can bear only one representative, viz., either blackness or whiteness.
Hence for this pair of characters there are two, and only two, types .of
gamete: “ black ” gametes and “ white ” gametes. When a black
gamete meets a black the result is a black bird; when a white meets
a white the result is a white bird. But when a white meets a black the
resulting zygote contains the representatives or factors for both black¬
ness and whiteness, and develops into a blue bird. Now we must
suppose that the gametic representative of a character, the factor,
is an unsplittable entity so far as inheritance is concerned. The zygote
being formed by two gametes must contain two factors. It is a
double structure, and when it comes to form gametes these single
structures are produced by the separation of the two factors present in
any zygotic cell. The factors representing the characters are said to
segregate from one another in the process. In a zygote produced by
the union of similar gametes, the segregation is between like factors,
and all the gametes produced are alike. But a zygote which has been
formed by two dissimilar gametes, each bearing one of the factors
corresponding to a pair of characters, must on forming gametes give
rise to gametes of two sorts, and must give rise to them in equal
numbers. On this simple hypothesis is afforded a ready explanation
of the various experimental facts given above. A blue hen is producing
equal numbers of “ black ” and “ white ” eggs—let us say 2 n of each.
To fertilise these eggs are brought large numbers of spermatozoa of the
two sorts, black and white, in equal numbers. Every black egg, then,
Epidemiological Section
137
has an equal chance of being fertilised by a black or a white sperma¬
tozoon. In the former case it will form a black and in the latter a blue
bird. From our 2n black eggs we shall obtain n black and n blue birds.
Similarly from our 2 n white eggs we shall get n blue and n white birds.
That is to say, the mating of blue with blue must, on the assumption of
the purity of the gametes, give black, blue, and white birds in the
ratio 1:2:1.
Let us now put in a more general form what we have learned from
this and similar cases. The characters of plants and animals may in
many cases be regarded as existing in alternative pairs. Corresponding
to each member of such a pair is something representing it which may
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Fig. 1.
Scheme to illustrate inheritance in a simple Mendelian case, such as that of the
Andalusian fowl. Gametes from each of the pure parents, the black and the splashed
white, meet to form the heterozygous blues. When these come to form gametes the
elements representing blackness and whiteness in the germ-cells segregate from one
another, so that equal numbers of black and of white gametes are formed. The
scheme further illustrates how, from a male and female series of such gametes, the
resulting generation comes to consist of two homozygous individuals (one for each
character of the pair) and two heterozygotes.
be carried by the gamete. These factors which the gamete carries are
the channel by which the qualities of the parent are transmitted to the
offspring. Every gamete contains one, and only one, of the factors
corresponding to a given pair of characters, i.e., is pure for that
character. For any given pair of characters, therefore, there can be
138
Punnett: Mendelism in Relation to Disease
two, and only two, classes of gametes: those pure for one member of
the pair and those pure for the other member of the pair. But there
can be three different kinds of zygote, for each zygote is formed by
the union of two gametes; and since two kinds of gamete exist it is
obvious that three kinds of union among them are possible. Two
gametes, each pure for one member of the alternative pair of characters,
may unite ; or two gametes, each pure for the other member of the pair,
may unite ; or thirdly, two unlike gametes may unite. The zygote so
formed contains representatives of each member of the pair and is know r n
as a heterozygote (hybrid), whereas zygotes containing representatives
of but one member of the pair are termed homozygotes. Like the
homozygotes, the heterozygote produces pure gametes ; only it produces
equal numbers of the two kinds instead of producing all of one kind.
In this lies the explanation of the fact that hybrids mated together
produce a definite proportion of the pure forms, which subsequently
breed true without ever giving a hint of their mixed ancestry.
Dominant and Recessive.
In the simplest cases, such as those of the Andalusian fowl, we are
dealing with but a single pair of characters, in so far as the gametes are
concerned, and we are able to distinguish in appearance the birds arising
from the three forms of zygote that these gametes can form. But in a
large number of cases it is not possible to distinguish the hybrid from
one of the parents. Rosecomb bantams exist in two forms, white and
black. Each form breeds true, but when the two are crossed the hybrids
all resemble the black parent. The zygote which contains a single dose
of blackness grows up into a bird which is as black as the pure black
containing a double dose of blackness—a point of difference to the
Andalusian, w’here the zygote with only a single dose of blackness
develops into the more or less intermediate blue. In cases such as this
of the rosecombs we use Mendel's terms, and speak of the character
blackness as dominant to whiteness, which is said to be recessive . When
the hybrids (F x ) are mated together they give, as we have already seen
in the case of the Andalusians, one of each of the two homozygous forms
for every two heterozygotes. But since black is dominant to white the
heterozygotes are indistinguishable in appearance from the dominant
homozygote, and this, the E 2 generation, consists visibly of three blacks
to every white. The whites subsequently breed true, as do also the
Epidem iological Section
139
homozygous blacks when they are mated together. But if we wish to
separate these homozygous blacks from the heterozygous we must devise
some test. And the only test we know of at present is the test of
breeding. All the gametes of a homozygous black contain the factor for
blackness. Consequently, when such a bird is mated with a white all
the offspring must be black. But a heterozygous black is giving off
equal numbers of “ black ” and “ white ” gametes. Hence, when mated
with a white it will form equal numbers of zygotes with and without a
black factor, i.e., it will produce equal numbers of black and white birds.
The test between the pure dominant and the dominant which carries
the recessive character lies in crossing each with the recessive. The
former produces only dominants, while the latter gives rise to equal
numbers of dominants and of recessives. But whether the phenomenon
Black x White. P,
I
i I
Bhick x Black.F,
I
r i i i
Black Black x Black x White. F 2
(breeds true) | j ~j| j (breeds true)
Black Black Black White .F.
I I
Black White
Fig. 2.
Scheme illustrating inheritance in rosecomb bantams. Homozygous blacks in
italics to distinguish from heterozygous. P, signifies parental generation, F t first
filial generation, F a second filial generation, and so on.
of dominance is present or not, the essential feature of Mendel’s
discovery is unaffected, and this, of course, consists in the conception
of the characters of living things as existing in alternative pairs, and of
the purity of the gamete for either member of such a pair.
Diversity of Characters Showing Mendelian Inheritance.
Mendel’s principles have now been confirmed in many plants and
animals, and for many different characters. A few illustrations will
serve to give some idea of the diversity of the characters for which these
principles have already been shown to hold good. For the sake of
convenience they have been arranged under several headings.
140
Punnett: Mendelism in Relation to Disease
Size. —In peas, sweet peas, and many other plants there exist dwarf
forms. In the cases hitherto worked out the tall has been shown to be
dominant to the dwarf.
Structure. —In plants: the shape of the leaves and of the flowers in
primulas, of the seed in Pisum, of the flowers and pollen grains in
Lathy rus, the spines of Datura , the beard of wheat, &c. In animals:
the long Angora hair of rabbits; in fowls the silky plumage, taillessness,
shape of comb, crest, brain hernia, &c.; in mice, hairlessness and the
w r altzing habit.
Chemical.- —Sugary and starchy endosperm in maize; glutenous and
starchy endosperm in barley; colour and albinism in animals.
Time of Flowering. —Whether biennial or annual in Hyoscyamus.
Colour. —In most plants purple or blue is dominant to red; deeper
colours are usually dominant to dilute ones. In animals : grey is domin¬
ant to black in rabbits, rats and mice ; bay is dominant to chestnut
in horses. Black is dominant to brown in the down colour of chickens.
Colour differences readily lend themselves to experimental work, and
they have been largely made use of in this connection.
Sterility of the anthers in the sweet pea is recessive to the fertile
condition. In barley partial sterility is dominant to the completely
fertile form.
Immunity to disease in wheat.
From the point of view of medicine the last is probably one of the
most important experiments ever made. Mr. Biffen, in Cambridge,
crossed a wheat immune to the attacks of yellow rust ( Puccinia
glumarum) with another wheat highly susceptible to such attacks. The
hybrids were all severely attacked, and Mr. Biffen experienced some
difficulty in saving from them sufficient seed to get a reasonably large
crop- in the following year. Having grown them on, he found that in
this generation came rusted and rust-free plants. Though growing
all among and brought into the closest contact with their diseased
brethren these rust-free plants showed no sign of contamination. On
counting the F 2 generation it was found that out of 2,132 plants, 523,
approximately one-quarter, were immune; and such immune plants
gave rise to immune offspring only. Susceptibility and resistance to
disease in wheat are a pair of characters obeying the Mendelian law
of inheritance, and consequently brought completely within the scope
of human control.
Epidemiological Section
Human Examples.
141
And here I may bring forward certain simple cases which concern
our own species. Such cases are difficult to come by, for the marriage
system of the civilised nations is none too well adapted for the demon¬
stration of Mendelian principles. We have, indeed, but one method,
viz., the careful collection of pedigrees and the critical examination of
them in the light of the knowledge gained more directly from other
species. Among our scanty data a few cases stand out clearly. During
the past year Mr. Hurst 1 was able to demonstrate a Mendelian pair of
characters in eye colour. Brown pigmentation on the front of the iris is
a character dominant to the condition of the iris—whether grey, blue, or
violet—in which such brown pigment is absent.
But perhaps the most conspicuous example of Mendelian heredity in
man is the case of brachydactyly worked out by Farabee 2 in America,
and more recently by Drinkwater 8 in England. This peculiar condition
of the hands and feet, which is at the same time associated with short¬
ness of stature, was found by both these authors to be dominant to the
normal form. In fig. 3 I have reproduced from his paper the pedigree
of Drinkwater’s family. In this, as well as in the other human
pedigrees with which we shall have to deal, it is always assumed, unless
expressly stated to the contrary, that the diseased individual is always
mated to a normal. Consequently, in the pedigree, every brachydactylous
individual must be regarded as heterozygous and must produce abnormal
and normal gametes in equal numbers. Such an individual married to
a normal should therefore produce equal numbers of normal and
abnormal offspring, just as the heterozygous bantam, mated with
a white, produced equal numbers of blacks and whites. Drinkwater
found that all the families from abnormal parents together consisted of
thirty-nine abnormals and thirty-six normals—a close approximation to
the equality which we should expect on Mendelian principles. On these
principles, again, we should expect all the normals, being recessive, to
breed true, and to give no abnormals when mated with a normal. An
inspection of the pedigree shows that this condition is also fulfilled. The
evidence, taken with that collected by Farabee, is sufficient to put it beyond
all reasonable doubt that we are dealing with a simple Mendelian case,
and we may state with confidence that no member of a brachydacty¬
lous family who is free from the disease can transmit it to his or her
1 Proc. Roy. Soc. % 1908, Series B., lxxx., p. 85.
2 “Papers of Peabody,” Mus. of Am. Arch, and Ethnol., Harvard Univ., 1905.
3 Proc. Roy. Soc. Edin. f 1908, xxviii., p. 35.
142
Punnett: Mendelism in Relation to Disease
Epidem iolog ical Sec turn 143
offspring ; but it can and must be transmitted by the brachydactylous
members only.
For one of the most remarkable pedigrees that has ever been got
together we are indebted to Mr. Nettleship. 1 It concerns night-
blindness, a condition apparently due to loss of the visual purple, and
deals with the decendants of one Jean Nougaret, who was born in the
year 1637. The pedigree has been brought down to 1907. It extends
over ten generations and includes records of more than ‘2,000 individuals.
The diseased condition evidently behaves as a simple dominant over the
ftf®®® 99 ®?9?®^®@9 ?t°v$9<9
<|><I? qfd 1 yt <§<$ <?
9®@99
Fig. 4.
Pedigree illustrating the inheritance of diabetes insipidus (polyuria) (after Weil).
normal. During two and a half centuries no normal member of the
family who has married another normal, whether a member of the
family or not, has ever transmitted the disease. On the other hand, the
affected members, who have in almost all cases married normal persons,
have transmitted the diseased condition to many of their offspring.
The number of diseased is actually somewhat less than half, but, as Mr.
Nettleship points out, there is a marked inclination to conceal the disease,
which in some cases doubtless has been attended with success. By the
Opthalm Soc . Trans., 1907, xxvii., p. 269.
144
Punnett: Mendel ism in Relation to Disease
side of a history such as this the other pedigrees which I am able to
show you must seem comparatively insignificant. Mr. Bateson has
recently been collecting together evidence from various sources on
certain forms of hereditary disease. In some of these cases, notably
those of keratosis palmae and congenital cataract, the evidence points
to the diseased condition behaving as a simple Mendelian dominant to
the normal; and it seems not improbable that other cases, such as
diabetes insipidus (fig. 4), irideremia, ectopia lentis, hereditary chorea, and
epidermolysis bullosa, may eventually turn out to fall within the same
category. In some of them there are records of the disease being
transmitted by normals, but whether this is due to mistaken observation
or whether it indicates some more complicated scheme of inheritance
must be left for future investigation to decide.
So far we have considered only the simplest of cases, involving but a
single pair of alternative characters. Nevertheless, we have already been
able to analyse successfully cases in which two or more pairs of characters
play a part. Though no human examples of this nature are at present
known to us with any degree of certainty, there is little doubt but that
conditions similar to those I am about to describe will eventually have
to be investigated for our own species; and a proper understanding of
the principles based upon the hereditary behaviour of the colour of the
rabbit and of the sweet pea may well serve in the future to illuminate
some of the obscurer phenomena of disease in man.
Dihybridism.
Dihybridism is the term applied to cases in which the parents
crossed differ from one another in two pairs of alternative characters.
It was found by Mendel that in such cases the inheritance of each pair
follows the same rule, but follows it independently. Tallness in the pea
is dominant to dwarfness, and colour in the flowers is dominant to white.
When, therefore, a tall coloured is crossed with a dw'arf white all the
offspring are tall plants with coloured flowers. In the next generation
tails and dwarfs appear in the ratio 3:1, and coloureds and whites also
appear in the ratio 3:1. Hence each tall plant has three times as
many chances of being coloured as of being white. Similarly the dwarf
coloureds must be three times as numerous as the dwarf whites. A
moment’s consideration will serve to show that the simplest expression
which covers all these requirements is nine tall coloured, three tall
Epidem iolugical Section
145
whites, three dwarf coloured, and one dwarf white. And these are the
proportions actually found by experiment in this and other cases. This
is the 9 : 3 : 3 : 1 ratio characteristic of cases of simple dihybridism,
and we may state it in a more general form as follows: When two
individuals are crossed which differ in two pairs of alternative characters,
the F 2 generation consists of four classes, and, out of every sixteen, nine
on the average exhibit both dominants, three one of the dominants
and one of the reccssives, three the other of the dominants and the
other of the recessives, and one exhibits both recessives. The simple
and orderly distribution of the characters to form this ratio may be
taken as proof that each pair of characters, though obeying the same
hereditary law, obeys it independently of the other.
Coloured! (White
Tall ) * '(Dwarf
I
Coloured
Tall
I
Coloured
1
Coloured
Coloured
White
* ;
_ e8
'a ^
Tall. I
Tall. 1
Tall.
Dwarf... 1
Tall.]
Tall.
Tall.1
Dwarf... 1
Tall. 1
Tall. 1
Tall. i
Dwarf... '
Interdependence of Characters.
The distribution of two pairs of characters is not always so simple in
appearance as in the case of the peas. The characters belonging to
different pairs sometimes interact upon one another, and the way in
which this comes about may best be explained by an example. A grey
Belgian hare rabbit was crossed with an albino Angora. The progeny
were all of the wild grey type. They were in-bred and produced in the
next generation greys, blacks and albinos, the proportional numbers of
the three kinds being 9:3:4. The proportion of coloured rabbits to
albinos is 3 : 1, suggesting at once that colour and albinism are a pair of
alternative characters, of which the former is dominant; and among the
coloured the ratio of greys to blacks (9:3 3:1) points to grey ness
and blackness forming another pair of characters. If such is the case we
ought to find among our sixteen rabbits twelve greys and four blacks.
That we only find nine greys and three blacks is because one-quarter of
our sixteen rabbits must be albinos, lacking the colour factor w T hich
enables the particular colour present, whether grey or black, to declare
146
Punnett: Mendeli&m in Relation to Disease
itself. There must therefore be both grey albinos and black albinos, and
this may be tested by mating an albino with a pure black. Since colour
is dominant all the offspring will be coloured, but those albinos which
carry the factor for greyness will give greys and those without this factor
will give only blacks; and experiment has shown that this is the case.
Albino rabbits may be compared to exposed but undeveloped negatives.
The silver has undergone a change, but what the image is we cannot say
until the developer is poured upon it. So with albino rabbits. By
crossing with a black containing the factor which allows the colour to
appear, we are, as it were, pouring on the developer, and the resultant
colour, whether grey or black, tells us what manner of albino we had to
deal with.
Coloured)
Grey )
( Albino
{ [Black]
Coloured
Grey
Coloured
Coloured
Coloured
Albiuo
V
u
■ ^
>-, >* >> y
O V © eg
u u u Jz
£ £ £ *
<» O O c3
s-i Ui I-, r-.
2 £ £ j*
wCOffl
OCOM
O O C PQ
The Nature of the Alternative Pair.
At this stage we may ask ourselves a question : What is the nature of
these pairs of alternative characters? What is. the relation subsisting
between the two members of a pair? It is a remarkable fact that
we should be able to express all the diverse qualities with which we
have been dealing in terms of alternative pairs. Why do we never
find longer series of characters—three, four, or even more—w r hich can
replace one another as alternatives in the gamete ? As the explana¬
tion upon which I am about to enter may seem to verge upon the
metaphysical, it will be as well to commence it with a concrete illustra¬
tion. In fowls the rose comb is dominant to the single comb, and these
tw T o form an alternative pair. Now, the view of the nature of the rose
comb that I wish to suggest to you is that it is a single comb, to which
an additional element “ roseness” has been added. Singleness underlies
roseness, and if our methods were sufficiently delicate to remove this
element of roseness from a rose comb w r e should be left w T ith a single
Epidemiological Section
147
comb. A rose comb is a single in which an additional element of roseness
is present; a single comb is a single because this additional element is
absent. And herein lies the explanation of the curious circumstance
that the characters of animals and plants can be expressed in terms of
Fig. 5.
To illustrate various forms of comb connected with the Breda x Rose experi¬
ments. 1, Breda; 2, Single ; 3, Breda x Single ; 4, Rose ; 5 and 5a, Breda x Rose.
From two of these last mated together Singles appeared in F 2 .
alternative pairs. Such pairs represent the only two relations which
the unsplittable factor representing a given character can have with the
gamete. It can either be present or it can be absent, and no third
148
Punnett: Mendelism in Relation to Disease
relation is possible. When this view suggested itself to us we at once
set to work to devise an experimental test of its validity. We argued
that if we could find a fowl with some form of comb recessive to single,
and crossed such a bird with a rose-combed bird, we ought to get single-
combed birds in F 2 . We were fortunate in finding the breed for which
we were looking in the Breda fowl, a bird in w’hich the comb is
practically non-existent. When crossed with a single these birds
produced chickens with large double combs. The combs are duplex
because the Breda carries an element of “ duplicity ” which is dominant to
the “ simplicity ” of the single comb. But the point with which we
are immediately concerned is that the Breda cannot carry the factor
that makes the single comb, for our crossing experiment has shown
that if it did so it would no longer remain a Breda. Having, therefore,
proved the absence of single in our Breda, we proceeded to cross it with
a rose, and obtained birds with duplex rose combs. These Fi birds mated
together gave Breda combs, duplex and simplex roses, and duplex and
simplex singles . Having already proved that the single cannot have
been present in the Breda, it is obvious that it must have come from the
parent rose, and we must consequently suppose that single underlies
rose in the way that we have already suggested. The great majority of
Mendelian cases fit in with what we call the “presence and absence”
hypothesis, and in them we must regard the dominant as the additional
and the recessive as the underlying character. All tall peas are dwarfs
containing an additional “ tall ” factor ; all purple sweet peas are reds to
which a purpling factor has been added. There are, however, cases in
w’hich the presence of a quality in the zygote is recessive to its absence.
Thus the bearded is recessive to the beardless condition in wheat, and in
man the night-blind condition, with its probable absence of visual
purple, is, as we have already seen, dominant to the normal. It may
be that these cases will ultimately be brought into line by the discovery
of inhibitory factors, but the evidence is not at present sufficient to
render further discussion profitable.
I have laid some stress upon the presence and absence hypothesis
of the relation between the factors of an alternative pair because it is
of especial interest in connection with a human disease. The evidence
recently collected by Dr. Garrod 1 on alkaptonuria points strongly to this
condition being recessive to the normal. With very rare exceptions the
alkaptonuric patient is the offspring of normal parents. Such normals
Lancet , 1902, ii., p. 1G1G.
Epidemiological Section
149
must be regarded as heterozygous dominants, and it is striking to find
that the majority of cases involve first-cousin marriages, a condition
obviously favourable for bringing heterozygous dominants together. If
the diseased condition is recessive, the diseased should form one-quarter
of the total number of members of the families in which they occur.
Dr. Garrod gives figures for such families. Where the condition of all
the offspring has been recorded there are fifty-one normals and sixteen
alkaptonurics, a very close approach to the expected ratio of 3 : 1.
The chemistry of the alkaptonuric condition is well known, 1 and the
disease depends upon the inability of the organism to bring about a
specific reaction by which the benzene ring is broken down and
homogentisic acid transformed into lower products. Is the failure of
the organism to bring about this reaction due to the absence of a
specific intracellular ferment ? At present there is little evidence for or
against this view, though the work of Czapek and others on homogentisic
acid in plants is certainly suggestive. And the fact that the diseased
condition is recessive to the normal points to there being something in
the normal which is lacking in the diseased. If the chemist could isolate
this hypothetical ferment it would serve to clear up our ideas upon the
condition known as the diathesis to a disease, and would offer the hope
of these conditions falling within the scope of heredity and consequently
becoming amenable to human control.
Interaction of Characters.
A beautiful example of the interaction of characters is afforded by
the sweet pea. As in most flowers, white is here recessive to colour.
All white sweet peas breed true, and in most cases a cross between two
whites will result in white-flowered plants only, but when certain
strains of whites are crossed together the offspring are all coloured.
When a further generation is grown from these plants they produce
coloureds and whites in the proportion 9:7. The case has now been
fully worked out as far as heredity is concerned, and it is evident that
we must regard colour as made up of two factors. Each of these factors
may be present or absent in a sweet pea, in this way constituting two
alternative pairs. We must suppose each of the parent whites of our
cross to have been homozygous for the presence of one of these factors
and for the absence of the other. If we denote our two factors by C and
1 Cf. Leathes, J. B., “ Problems in Animal Metabolism,” 1906, p. 195.
150
Punnctt: Mendelism in Relation to Disease
R, then the gametes of one white all contained C and not R, while those
of the other all contained R and not C. By crossing two such whites a
zygote is formed which contains both C and R, the two factors necessary
for the production of colour. The gametes of the Fi plant segregate in
the normal way, and as in ordinary cases of dihybridism they give rise to
four classes of zygote in the proportion 9 : 3 : 3 : 1. But since only the
zygotes containing both dominants can appear different to the rest by
showing colour, the three last terms of the ratio, the 3:3:1 terms, are
indistinguishable; hence the ratio 9 : 7. What the symbols C and R
represent we do not know. It is tempting to suppose that one of them
is a ferment and the other a fermentable substance. Mendelian analysis
cannot do more than indicate the presence of these two specific sub¬
stances. The task of isolation and identification falls within the province
of the chemist. Interesting as the case of the sweet pea is from the
theoretical side it has also a conceivably practical aspect. In an
F 2 family with a 9 : 7 ratio the 7 group consists of five classes of
individuals. There are five different kinds of white sweet peas, and in
the various types of mating possible between them a cross between two
whites may give any of the following results:—
(a) All coloured ... ... ... ... [CCrr x ccRR] 1
(b) Equal numbers of coloured and whites ... [CCrr x ccRr]
(c) One-quarter coloured, three-quarters whites ... [Ccrr x ccRr]
(e l ) All whites ... ... ... ... ... [Any white x ccrr]
1 The letters in brackets give a form of mating which would produce the particular result.
In most cases the same result may be obtained by several types of mating. For simplicity,
however, only one is shown in each case.
And since there are also several kinds of coloured plants (indistinguish¬
able in appearance), the cross between coloured and white may produce
any of the following results :—
(a) All coloured ... ... ... ... [CCRR x any white]
(6) Three coloured to one white ... ... [CCRr x ccRr]
(c) Equal numbers coloured and white ... ... [CCRr x CCrrJ
(d) Three whites to one coloured ... ... [CcRr x ccrr]
Lastly, two coloureds crossed together may give either :—
(rt) All coloured ... ... ... ... [CCRR x any coloured]
(b) Nine coloured to seven white ... ... [CcRr x CcRr]
(c) Three coloured to one white ... ... [CCRr x CCRr]
Now for “coloured” write “diseased,” and for “ w r hite ” write
“normal.” The number of possibilities is great. Diseased may produce
Epidem iological Section
151
normals, and normals mated together may produce diseased. True, we
know of no such case so far among men, but that is no reason why it
should not exist, and it may be that some day the sweet pea will provide
the clue to a human disease.
This case of the sweet pea may be paralleled among poultry. We
have recently succeeded in finding tw T o white breeds of fowls which breed
true to whiteness, which each behave as recessive to colour, but which,
on crossing, produce only coloured birds. Moreover, for the following
reason, this case of the poultry is even more complicated, for there
exist also white fowls whose whiteness is dominant to colour. There are
therefore certainly three kinds of white fowls which breed true and may
be indistinguishable in appearance, but owe their whiteness to entirely
different causes. Fundamental chemical differences are doubtless in¬
volved, and the problem may one day be solved by the chemist. At
present there is only one method of distinguishing and of separating
these similar unlikes, and that is the method of Mendelian analysis.
Gametic Coupling.
In the cases with w T hich we have been dealing, the appearance of a
given character depends upon the presence of two factors in the zygote.
Yet these factors in heredity behave quite independently, each obeying
the simple Mendelian rule. There are, however, cases in which we
meet with a new phenomenon, in which there exists a tendency for
factors to become definitely associated together or coupled in the gamete.
Such coupling of distinct characters may be complete. In sweet peas
purple is dominant to red, and the erect standard is dominant to the
hooded standard; and in families in which purples and reds occur
together with erect and hooded standards, the ratio of purples to reds
is 3:1, and of erect to hooded standards is also 3:1. If this were
a simple case of dihybridism, such as we have already dealt with in peas,
we should expect the distribution of erect and hooded standards among
the purples and reds to be governed by the laws of chance, and w r e should
expect our generation to consist of the four classes: erect purple, hooded
purple, erect red and hooded red in the normal ratio 9 : 3 : 3 : 1. This,
however, is not the case. All the reds display the erect standard and
the hoods are all to be found among the purples. Consequently, our
family consists of hooded purples, erect purples, and erect reds in the
ratio 1:2:1. We are driven to suppose that all the gametes which
mh —10
152
Punnett: Mendelism in Relation to Disease
carry hood carry purple also, and that only the red gametes carry the
factor for erectness. In other words there is complete coupling in the
gamete between purpleness and hood on the one hand, and between
redness and erectness on the other. Since every red gamete must carry
also the factor for erectness, it follows that in such families as these all
the reds must be associated with, and breed true to, the erect character.
Fig. 6.
Showing three sweet peas : (a) red, with erect standard ; (6) purple, with erect
standard; and (c) purple, with hooded standard.
Nevertheless we know that hooded reds may occur in other strains.
What the conditions are which determine whether hood and redness
may or may not be found in the same gamete is a problem which we
are experimentally attempting to solve.
Epidemiological Section
153
Partial Coupling.
Coupling between characters is, however, not always complete.
Among sweet peas there are two distinct varieties of pollen grains—
elongated or “ long,” and “ round.” The long behaves as a simple
dominant to the round. In families which contain purples and reds, and
also long and round pollens, the ratio of purples to reds is 3:1, and the
ratio of longs to rounds is also 3:1, but there is a marked tendency for
long pollen to be associated with the purples and for round pollen to
stick to the reds. The coupling is, however, not absolute. The long
purples are about twelve times as numerous as the round purples, and
this deficiency of rounds is compensated for among the reds, where they
are more than three times as numerous as the longs. We must suppose
that there is a coupling of purpleness with long and of red with round in
most of the gametes, though not in all. If we imagine that out of every
eight purple gametes seven carry longness and one carries roundness,
and that out of every eight red gametes one carries longness and seven
carry roundness, we find that the calculated composition of a generation
produced by such a series of $ and of 7 gametes closely accords with
the experimental facts. We know of other cases of this partial coupling
of characters, though of the processes of cell division by which it is
brought about we can at present, say nothing. Enough, however, is
known to make it certain that it often plays an important part in
heredity, and I have laid some stress upon it because it may eventually
be found to throw light upon the alleged association of certain physical
peculiarities in man with particular forms of disease.
Sex-Limited Diseases.
It is well known that certain diseases are limited almost, if not
entirely, to one sex. In haemophilia, for example, it is, with the rarest
exception, the males alone who are affected. But the disease can be
and normally is transmitted by the unaffected female, though not all the
females of a haemophilic family are capable of doing so. The affected
male is also known to transmit the disease (cf. fig. 7). Besides haemo¬
philia there are certain other diseases which are known to exhibit
a somewhat similar mode of transmission—the “ Knight’s move ” in
heredity, as Bateson has termed it. Among these may be mentioned
colour-blindness, night-blindness when associated with myopia, and
154 Punnett: Mendelism in Relation to Disease
possibly also Gowers’s disease. Moreover, the data collected by
Herringham on peroneal atrophy seem to suggest that here again we
are concerned with a phenomenon of much the same class. In all
these cases, where the disease is almost exclusively confined to one
sex, it is probably not without significance that the males are the ones
to suffer.
Though, as we shall see later, the problem of these sex-limited
diseases offers points of special difficulty, the following experiments on
sheep suggest the lines along which the solution must probably be
sought.
L L L. I r—l
##^99 9
i r
i—r
9 9 f f 9 9
9
TTi-1 I I I
#*#99 ^9 ^*9 #^^9 ^^9
r i
Children
y i i att hta,,h / i—i
o o' 9 cf cf ^9
Fia. 7.
Pedigree illustrating the inheritance of hemophilia (after Stahcl).
Professor Wood recently crossed the horned Dorset with the hornless
Suffolk breed of sheep. Whichever way the cross was made the 3 3
were all horned and the 2 2 hornless. On breeding together the F,’s all
the four types appeared in the offspring, but the homed 3 3 were three
times as numerous as the hornless 3 3 , while only one out of every four
2 2 was horned. The simplest explanation is to suppose that horns
are dominant in the 3 but recessive in the ? . This was tested by a
pretty experiment, in which an F 2 hornless 3 was put on to the flock of
hornless Fi 2 I. On the suggested explanation the F 2 3 cannot carry
the homed character, but the Fi 2 2 from their breeding must carry
this character. The cross must therefore result in equal numbers of
animals pure for hornlessness and heterozygous for horns. Now the
3 3 which are heterozygous for the horned character show it, while
the 2 ? do not; hence the expected result of our mating is that half the
3 3 will be horned, half will be hornless, and that all the 2 2 will be
Epidemiological Section
155
without horns. The experiment gave eight horned 3 3, nine hornless
3 3 , and eleven hornless 9 9 . The visible effect is that the hornless
9 , in contradistinction to the hornless 3 , can transmit the homed
character, but only to her 3 offspring. Again, because the horned
character is recessive in the 9 , it follows that every homed 9 must be
pure for that character, and must therefore transmit it to all her
offspring. And since every heterozygous 3 is horned, all the male
offspring of any horned 9 crossed with any 3 must be horned. This
again is in accordance with experiment.
horned 3 x 9 hornless
_i_
i i
horned 3 x 9 hornless. .F,
I ' ' ^ I I I
3 3 9 9
horned hornless horned hornless. ..F 2
(3) (1) (1) (3)
Fig. 8.
Fig. 9.
Scheme to illustrate the inheritance of horns in sheep. 3 and f denote males
and females homozygous for the horned character; 3 and 2 denote males and
females homozygous for the hornless character; a heterozygous male is represented
by a black circle with a white central dot, and a heterozygous female by a plain circle
with a black central dot. Among these the males are horned and the females hornless.
On the assumption that horns are dominant in the <J and recessive
in the 2 , it follows that there are three kinds of males, viz., those
homozygous for the homed character, those homozygous for the hornless
character, and those which are heterozygous. Similarly the females are
156
Punnett: Mendelism in Relation to Disease
constitutionally of three kinds. But while the heterozygous males are
horned the heterozygous females are hornless. In fig. 10 I have drawn
up a scheme to illustrate the nine possible forms of mating between our
three females and our three males. One point to notice is that while
homed females can only appear when the male parent is horned (Nos. 1,
2, 4, 5), the horned males may also arise from two hornless parents
(No. 8). Another important point is that all the male offspring of
a horned female must be homed (Nos. 1, 4, 7).
2 . 3 .
4
sim
#XQ
rzr —i
9
6 .
r—i
**99
i^ i ^ Jw J— i 1 1 f
f'crcTcFf 999
cTtf 99
7
8 .
9.
fT?
Cfx $
crvg
<r 9
•rtf 9 9
Fig. 10.
cf 9
Scheme to illustrate the nine types of mating and their results in a case where a
character is dominant in one sex and recessive in the other. The character is here
represented as dominant in the male and recessive in the female. A heterozygous
male is figured as a black circle with a white central dot, and a heterozygous female
as a plain circle with a black central dot.
We may now inquire how far this scheme of inheritance fits such
cases as those of haemophilia. A haemophilic male or a female from
a haemophilic family will almost always marry a normal person outside
the family. With the rarest exceptions, therefore, every affected male
will be heterozygous in constitution. Consequently the three types of
mating with which we are mainly concerned are Nos. 5, 6, and 8. Since
a member of an affected family nearly always marries outside of the
family, the great bulk of the matings will be of types 6 and 8, and in
both of these the male offspring alone are affected. The third type of
Ei > id ('mil dog ica I Sec t ion
157
mating (No. 5), where an affected male marries a heterozygous female,
must be very much rarer than the other two. This type can lead to the
production of affected females, but as the chances of such females
appearing are only one in four, it must often happen that all the females
in these families are normal. The great rarity of female “ bleeders” is
the natural outcome of the exogamous habits of civilised man.
We have seen that the horned ewe must always transmit the horned
character to all her male offspring (fig. 9). By analogy we should expect
all the sons of a female “bleeder” to be affected. Unfortunately, our
data do not allow of this crucial test in the case of haemophilia, but in
the case of colour-blindness there exist a few records of the offspring of
colour-blind women mated with normal men. Mr. Bateson tells me that
the five such women, about w r hom he has been able to collect information,
had between them twelve sons, all of whom were colour-blind , while the
daughters, so far as is known, were all normal. It would therefore
appear that, qualitatively, the inheritance of these sex-limited diseases
is closely comparable to that of horns in sheep.
But Bateson 1 has already pointed out that the proportions in which
affected males appear in families of type 8 are far too high. A simple
Mendelian interpretation demands equal numbers of affected and
unaffected, but, as a matter of fact, the affected males are more than
twice as numerous as the unaffected. There is evidently some further
complication, possibly some form of coupling between the factors upon
which the disease depends and those of sex. That some such form of
coupling may exist is rendered probable from the following experiments
in animals.
Doncaster and Baynor 2 have recently investigated the inheritance
of the pale lacticolor variety of the common currant-moth, Abraxas
grossulariata (fig. 11). The variety behaves as a recessive to the normal
form in both sexes, but, as the accompanying scheme shows, there is
only one form of mating from which a lacticolor 3 can arise, viz.,
heterozygous 3 X lacticolor ? . For when heterozygous individuals
are bred together, or when 3 lacticolor is crossed with a heterozygous
? , the variety only appears in the female offspring. From these results
the authors have made some interesting deductions concerning the
nature of sex, but for our purpose it is sufficient to call attention to them
as illustrating a form of coupling between sex and another character
which is somewhat different to any other at present worked out.
1 Brain , 1906, xxix., p. 157.
* P/vc. Zc ol. Soc., 190 *).
158 Punnett: Mendelism in Relation to Disease
A more complicated case at which Mr. Bateson and I are at present
working concerns the inheritance of a peculiar deeply pigmented condi¬
tion of the skin and connective tissues found in the silky fowl. This
breed we crossed w’ith a brown Leghorn, and obtained the following
PlO. 11.
The currant-moth, Abraxas grossulariata , and its pale lacticolor variety.
rfx 9
X
- I i(- T ~Z I
C?x © •fo'xQ
I I
nr—i i -1
cf 9 «T^c?x9
Fig. 12.
Scheme to illustrate the inheritance of the lacticolor variety of the currant-moth.
Pure grossulariata shown black and heterozygotes black with white central dots.
9
cT
results: From? silky X 3 brown Leghorn the Fi birds were practically
unpigmented, and such birds bred together gave pigmented and
unpigmented birds of both sexes. So far, this is $ commonplace result.
Epidemiological Section
159
But a remarkable point comes out in crossing the Fi birds with pure
unpigmented brown Leghorns. The Fi 2 X 7 brown Leghorn gives
only unpigmented or practically unpigmented birds. But 2 brown
Leghorn X Fi 7 gives a definite proportion, 1 in 8, of pigmented birds;
and these are always 2 2 —again the “ Knight’s move.” The unaffected
7 can transmit, but only to the opposite sex. The difference in the
transmitting power of the two sexes is still more strongly brought out
when the 2 brown Leghorn is mated with a 3 silky. In such an
experiment we found that the 3 3 were practically unpigmented, but that
all the 2 2 were pigmented. The case is in reality more complicated
than I have here indicated, owing to the occurrence of different grades of
pigmentation and for other reasons. Nevertheless we hope soon to put
Silky 2 x 3 Br. L.
I
Br. L. 2.
1
2 .x.Br. L.
1 I I I I I I I I
<7 2 2 <7 / 2 2 3 2
Br. L. 2 x Silky 7
Br. L. ?
• <7 x f
7 2 2
I
I I I
7 7 2
Fig. 13
forward a scheme to cover it. The explanation will probably involve
the conception of sex as a character transmitted on Mendelian lines,
together with the existence of gametic coupling between the factors
influencing pigmentation and the sex factors. More at present we
cannot say, but these facts are sufficient to indicate that cases not
dissimilar to those of the sex-limited diseases in man occur among
animals, and we may reasonably hope that the solution of the problem
of the silky fowl will throw further light upon diseases like hemophilia
and peroneal atrophy.
There is little doubt but that a knowledge of Mendel’s principles
must be of value in the study of disease, for when once Mendelian
analysis has established the operation of the law, and the nature of the
100 Punnett: Mendelism in Relation to Disease
characters concerned, we are in a position to predict, always the probable,
sometimes the inevitable, result of a given mating. When a brachy-
dactylous man marries a normal woman we are certain that there is an
even chance of any given child being born diseased or normal. When
two normal people with night-blind parents and grandparents marry we
may predict with confidence that none of their children will inherit the
disease.
But before the Mendelian nature of a disease can be established,
full and accurate pedigrees must be forthcoming. And in the collection
of such pedigrees too much emphasis cannot be laid upon the necessity
of paying as much attention to the normals as to the affected, for the
interpretation turns as largely upon their behaviour as upon that of
the diseased.
The pedigree accomplished, the next task is that of reading it. If it
is a simple case of dominance and recessiveness this will be an easy
matter. If it is more complex the key may possibly be found in some
one or other of the standard cases which have been, and are now being
worked out in plants and animals; for careful experimental work in
animals and plants must for a long time be the basis upon which the
student of human heredity will have to build.
But, perhaps, after all, our pedigree may prove refractory, and may
refuse to take its place in any known hereditary scheme. In such cases
we may be dealing with a disease which is not, in the true sense of the
word, hereditary, because not represented in the structure of the gamete,
but, like syphilis, is caused by a foreign invasion. It is in the hope
of gaining information from those who are so well qualified to speak
upon these matters that I would venture to suggest that diseases fall
into at least three classes :—
(1) Diseases which depend directly upon a structural change in
the gamete, either by the addition or subtraction of some character
as compared w r ith the normal, e.g. y night-blindness, brachydactyly,
alkaptonuria.
(2) Diseases in which such structural change of the gamete is
without visible effect, but which renders the individual liable to inva¬
sion by bacteria, &c. The disease is not manifested unless the struc¬
tural change and the external organism are both present; e.g. y rust in
wheat.
(3) Diseases caused by external invasion, for which immunity, as
implied by gametic structure, is not known to exist, e.g. y syphilis,
ankylostomiasis.
Epidemiological Section
161
Of these three classes we should expect (1) and (2) to exhibit the
phenomenon of Mendelian heredity in some form or another. But class
(3) is of an entirely different nature, and cannot be inherited in the
biologist’s sense of the term. It seems not inconceivable that
Mendelian analysis may be sometimes valuable as a criterion for
separating this class of disease from the others. Undoubted non-
Mendelian inheritance may possibly in some cases suggest renewed
search for a parasite hitherto overlooked.
In conclusion, may I express the hope that those present to-night
will not let slip such opportunities as they may have of collecting
evidence upon the transmission of disease ? Except in a few cases the
available data are scanty, nor are they always of great value owing to
a not unnatural tendency to pay less attention to the normals than to the
affected. To-day we realise that all are equally important. It is only
through complete records that we can hope eventually to disentangle the
complexities of inheritance—to determine the unit characters involved,
and to state our problems clearly to the chemist, wdth whom the solution
must ultimately rest.
DISCUSSION.
The PRESIDENT (Dr. Newsholme) said that Mr. Punnett’s address had been
a most valuable and interesting one, as well as the demonstration, opening up
a large field for discussion by both physicians and epidemiologists.
Dr. H. M. VERNON (Oxford) sent a communication, which was read by
Dr. G. S. Buchanan. The writer regretted his inability to be present and said
that medical men should feel greatly indebted to Mr. Punnett for describing to
them the recent work on Mendelism, but he hoped that they would not be
carried away by the idea that it was the one all-important question of heredity,
especially in regard to hereditary disease. All the three diseased conditions
quoted by the author of the paper were very rare ones, probably not present in
more than 1 per 100,000 of the population, yet those were the best instances
he could adduce of the working of the law. Also in regard to normal characters,
Dr. Vernon believed that eye-colour alone (and possibly to a slight extent hair-
colour) have been shown to conform at all with the law. All the other measur¬
able characters in man and cases of hereditary transmission of disease (as
insanity, gout, disposition to tubercle, <fcc.) had nothing to do with the law, as
far as could be seen. The gametes corresponding to such characters were able
to blend and form blended zygotes, which gave rise to blended gametes and not
segregated alternative ones, as was required by Mendel's law. The vast amount
162
Punnett: Mendelism in Relation to Disease
of work done by Galton, Pearson and others on the transmission of such blended
characters and their relation to the characters of the parents, grandparents, &c.,
was practically ignored by the Mendelians. For the average medical man a
knowledge of the laws of ancestral heredity, as defined by the workers men¬
tioned, appeared more important than a knowledge of the segregated trans¬
mission of a few very rare diseases, interesting as such cases were.
Dr. A. E. GARROD, referring to the suggestion contained in Mr. Punnett’s
paper that alkaptonuria might result from the absence of an enzyme which
brought about the disintegration of the benzene ring of the aromatic fractions
of proteins, said that this view had been suggested in several quarters on quite
other grounds than those of heredity, and that from the standpoint of chemical
physiology there was much to be said in its favour. He called attention to the
difficulty of obtaining satisfactory evidence of the occurrence of such chemical
“ sports ” in the families of the patients. Although alkaptonuria was a fairly
evident anomaly it was not easy to find out whether members of back genera¬
tions of a family had stained their napkins in infancy or had passed urine which
darkened on standing. In connection with cystinuria the difficulty was still
greater, seeing that many cystinurics did not form calculi or develop any
conspicuous urinary troubles. Hence, for such anomalies it was practically
impossible to construct family trees showing, with any degree of accuracy, the
numbers of normal and abnormal members in successive generations. The
bearing of the Mendelian theory upon the question of the effects of con¬
sanguineous marriages, to which Mr. Punnett had not referred in his paper,
appeared to Dr. Garrod to be of extreme interest. The literature dealing with
this subject was most unsatisfactory, and most authors had set out to show
that consanguineous marriages had or had not evil consequences for the off¬
spring. On the other hand, the explanation that a rare recessive character was
most likely to appear in the offspring of the intermarriages of members of a
family who produced the recessive gametes seemed to remove the question
beyond the zone of prejudice and to explain in a satisfactory manner why so
large a proportion of human recessives, such as albinos and alkaptonurics, were
the offspring of marriages of first cousins. It also explained the undoubted
connection between such marriages and the appearance, in several children of
a family, of an anomaly which had not manifested itself in immediately
preceding generations.
Mr. Major Greenwood, jun., said he felt that, as a pupil of Karl Pearson,
he ought to say something with regard to the Mendelian school, and support to
that inclination was afforded by Dr. Vernon’s letter, there being a tendency,
apparently, on the part of the Mendelians, to sing a Te Deum on the slightest
provocation. Not so much in Mr. Punnett’s exposition as in the proof of the
paper which had been circulated, there was a long list of the conquests achieved
by the Mendelian school, and, in face of that, the adherents of that school had
no right to complain if criticism were minute in view of its being asserted to be
the theory instead of a theory of heredity. It was desirable to know what
meaning the Mendelians attached to the word “proof.” A statistician recently
Epidemiological Section
163
—perhaps enraged by Mr. Lock’s peculiar ideas on the subject of regression—
said that approximations could be classified into three groups: close approxima¬
tions, rough approximations, and Mendelian approximations. But, apart from
Mendelian approximations, the experimental side of the question was rather
interesting. With regard to moths, to which the author had briefly alluded,
Mr. Doncaster, a Mendelian who had worked on that subject, as a result of his
own and other people’s experiments on several species, concluded that black
wing coloration was, in general, a dominant character in the absence of purple,
purple being dominant over black in moth breeding (Prout’s Ferrugata). In
studying that subject, Mr. Prout, the leading English authority on Geometrid
moths, concluded that the geometers offered, for breeding, a good field in the
direction under discussion. There w T ere two very well marked forms of
Acidalia virgularia —one in the South of France and the other around London,
the melanic variety. The non-expert could readily distinguish those two
varieties. They were bred for six generations, and were found to breed perfectly
true. Prout and Bacot then obtained specimens from the South of France, and
crossed them with specimens from Clapton. Seven or eight crossings were
made, and they reared the first generation, and from the pairs seven generations
had been bred through, about 2,500 moths resulting. Examination showed that
there was not a trace of segregation ; in each generation there was a blend. That
was of very special importance, because Mr. Prout had not taken up moths as a
pawn in the game, but as a student of geometers ; and one knew that an
entomological specialist was a man who was very keen on creating differences
where none existed or where none were apparent to other people. If such a
man could not distinguish between offspring, it might be concluded that no
segregation had taken place. Mendelians might say that was not a simple unit
character ; but what was to be the criterion of the unit character ? If melanism
were a simple character in Doncaster’s cases but not here, then the definition
of a unit character was: a character which was inherited according to Mendel’s
theory. That had a superficial resemblance to arguing in a circle. Years ago,
Professor Karl Pearson published a paper in which he showed that on the
scheme propounded by Galton parental regression would be, in general, linear,
but on the Mendelian theory, as then propounded, it would take the form of a
hyperbola. There were many things about the Mendelian theory which might
be hyperbolic, but he doubted whether regression was one of them, and the
scheme had been so modified since that he thought one was entitled to ask for
a definition of unit character. With regard to night-blindness, in regard to
which such a splendid pedigree was exhibited, it was said to be due to the
absence of visual purple in all probability. But later it was more than a
suggestion and was fitted into the scheme. It would be interesting to hear Mr.
Punnett’s evidence that absence of visual purple was the cause. He believed it
was a deduction from a theory. In 1883, Parinaud and von Kries simultaneously
propounded the theory that normal vision depended on a double mechanism ;
one affecting the cones and fovea, giving ordinary daylight vision, and the other
associated with the rods of visual purple, which was characterised by sensitivity
164
Punnett: Mendelism in Delation to Disease
to feeble light, and might be regarded as the twilight factor. They suggested that
night-blindness might be a condition in which the visual purple of the rods was
either absent or functionless. Everyone would be glad of proof of the statement.
The only way of testing it would be to inveigle a subject of night-blindness into
a dark room, keep him there two hours, kill him, and then remove the retina
and soak it in bile-salts, which, of course, was not done in any of the cases.
Messmer 1 examined a small number of cases very carefully, and announced that
the night-blinds could be differentiated into cases in which dark adaptation was
quite normal when produced, but there was a very long latent period. But the
other type had a normal reaction-time after being brought intQ the dark, but
when the adaptation was produced it was very feeble in extent. So that night-
blindness was probably not the simple thing which could be represented by
black dots in a pedigree chart; it was not simply a question of being night-blind
or not night-blind, hornless or horned, but there were gradations. In the
night-blinds discussed by Mr. Punnett, Mr. Nettleship admitted he could not
examine all the cases, and the conditions did not favour him. So the suggestion
was that, at least in regard to night-blindness, there was not enough knowledge
to enable it to be dismissed in the simple way suggested by the ingenious
Mendelians. It would be better to collect much larger statistics of the various
commoner pathological conditions. He need not refer to tuberculosis, which
Karl Pearson had recently investigated. Assuming that the tubercular predis¬
position was a simple recessive character, he showed that the scheme failed
utterly, the disproportion between the predicted and the actual in one case
being as 57 to 100, which he, Mr. Greenwood, thought was outside even the
Mendelian limits of approximation. Therefore, in regard to pathological condi¬
tions and inheritance, they had no right to regard these conditions as being so
simple as to permit of their being summarised in a simple Mendelian pedigree.
Mr. IJDNY Yule said he spoke simply as a statistician who w’as interested
in the question of heredity. He was at one with Mr. Greenwood in being less
hopeful than the author as to the wide applicability of the Mendelian principles
to state medicine. Two distinct and important points arose out of the paper :
first, as to the applicability of the principles; secondly, as to the increased
effectiveness of state medicine, granted even that those principles were widely
applicable. Many of the cases dealt with by the author referred to the
inheritance of abnormalities rather than to disease properly so termed, e.g. t
such diseases as tuberculosis or insanity. Supposing a definite germinal charac¬
teristic decided whether or not a person should have the tubercular diathesis, that
did not mean that that man would certainly have tuberculosis, merely that he
was liable to have it; he might die of something quite distinct, after living as
long as the normal man. And was not that the case in regard to most diseases ?
The matter was extremely complicated, even if the germinal processes were
Mendelian. In reading Karl Pearson’s investigation concerning tuberculosis and
Heron’s on the inheritance of insanity he had not felt satisfied with the
1 Zeitschr. f. Phys. und Psych, d. Sinnesorg ., xlii., p. 83.
Epidemiological Section
165
arguments as to the non-applicability of Mendelian principles to the germinal
processes, so he went into the question himself, and in the end he had not felt
convinced whether the Mendelian principles applied or no. If insanity were
recessive, all we knew was that a man exhibiting insanity was a pure recessive.
But his sane mate was not necessarily a dominant, nor a heterozygote, but
might be also a pure recessive who simply had not had time or opportunity to
exhibit that character. The case was much more complicated than a first con¬
sideration w'ould lead one to suppose. Matings between sane persons might be
matings between pure recessives, between recessives and heterozygotes, or
between dominants. In what proportion was the various mating likely to
occur ? One could only form some theory on the assumption of random mating,
and that he had tried, but the proportions of insane offspring did not work out
very well. Quite obviously their divergences from the observed were outside
the limits of probable error. Further, if the mating were really random, one
w T ould not get a random selection of such matings between recessives and
heterozygotes by taking those matings in which at least one of the offspring
was insane, because mating recessives with recessives would give a larger pro¬
portion of insane cases amongst the offspring than would the mating of
heterozygotes with recessives. After all, what had to be dealt with was the
character which was exhibited, and he agreed with the last speaker that in cases
like these the actuarial method w T as likely to yield more valuable information to
the medical man than a discussion on the basis of germinal laws, which might
hold for the germ-cells but need not hold for the body, seeing how much the
element of circumstance entered into the matter. Other factors as important
as heredity must be taken into consideration. The actuarial statement included
what the germinal statement did not, namely, those factors of disturbance which
were of equal importance with the factors of pure heredity. It was necessary
to know, for example, in how T far selection operated on the different types of
character which were subject to heredity ; how far there w r as selection by death ;
how far by non-marriage, and, if such person did marry, how far there might be
selection by fertility or non-fertility in the case of persons possessing one
character or another. The importance of such disturbances seemed to be
enforced by some of the figures illustrating the Mendelian cases, which puzzled
him very much. Assuming that brown or duplex eye-colour was dominant over
blue, if matings of persons of different eye-colours were random (and that was
very nearly true), it was to be expected that in the population there would be
three persons with brown eyes to one with blue ; but that w ? as not so. There
were more blues than browns. The same applied to the examples of brachy-
dactyly. The author said that brachydactyly was dominant. In the course of
time one would then expect, in the absence of counteracting factors, to get three
brachydactylous persons to one normal, but that was not so. There must be
other disturbing factors of equal importance. Finally, to pass to his second
point, he doubted whether the theory would at all largely increase the
physician’s effectiveness in state medicine. On that point Mr. Punnett seemed
to be extraordinarily hopeful. Supposing it w~ere found that a certain diathesis
166
Punnett: Mendelism in Relation to Disease
was subject to Mendelian principles, did one advance much further, either in
treating the individual or in taking general measures ? Could the physician do
more in the light of such knowledge than he could now ? Could he do more
than endeavour to keep the individual free from infection and from predisposing
conditions ? It had been suggested by many writers that the characters were
amenable to human control by controlling marriage. That, however, seemed to
him a chimerical idea, and not in the bounds of the practical at present. Fur¬
ther, in such cases as tuberculosis and insanity, where one could not be certain
as to the germinal constitution of the individual, even marriage control would
largely break down. He concluded by thanking the author for his paper.
Dr. T. Lewis said that, in dealing with deformities of the hands and feet,
certain cases had been given by the author as instances, which agreed fairly
well with the Mendelian theory. But it was important to take account of the
fact that there was a tendency for the condition to die out in successive genera¬
tions. In examining a number of cases of deformities of the hands and feet
he had found that to be true. That was the crux of the whole matter in its
applicability to disease.
Dr. Fremantle asked what was the area over which the author took his
human statistics. If it was as small as it appeared to be, the margin of error
was far too great. Still-births and, moreover, miscarriages could not possibly
have been included. If they were not taken into consideration in drawing
conclusions, for instance as to night-blindness, it seemed to him that those
conclusions must be thrown out of gear. Secondly, having established full and
accurate pedigrees, including still-births and miscarriages, it became necessary
to interpret them, and in doing so it was necessary to come back to the original
principle: that inheritance of various qualities depended upon the union of the
gametes. It was surely only one single spermatozoon out of 50,000 at the very
least which was selected by various chances in the process of impregnation to
form the offspring; and it was pure chance whether that spermatozoon had the
particular characteristic in the dominant or in the recessive. Surely the element
of chance was mathematically so enormous, and the characters of any import¬
ance so complex, that only an inconceivably large number of offspring could
eliminate chance and represent the mathematical bringing together of the
gametes which had been represented.
Sir Shirley F. Murphy thought the Section ought to thank Mr. Punnett
very much for his excellent paper, as the subject matter of it was full of
interest. Mendel’s law seemed to be established for certain characteristics and
within certain limits. How far it might go beyond that was a matter for
further enquiry and research. One could not imagine conditions under w r hich
Mr. Punnett was going to interfere with the ways of love, but the theory had
arrived experimentally at the stage of being of considerable importance to the
agriculturalist, and even if it did not go beyond that it would have served its
purpose. The interest of that Section in the matter was not as to how far it
could be applied, but how far the law was one by which Nature worked. He
Epidemiological Section 167
moved a hearty vote of thanks to Mr. Punnett. This was supported by the
President and carried.
Mr. PUNNETT, in replying to Dr. Garrod, said it was possible for a diseased
(or anomalous) individual to come from two normal parents even though the
diseased condition behaved as a dominant to the normal. Among poultry
colour was in certain cases dominant to white, yet, when two pure white
strains, each recessive to colour, were crossed only coloured birds resulted.
Two things were necessary for the production of colour in this case, and absence
of either resulted in a white bird. Such experiments suggested that many of
the enzymes might be of a double nature, and he believed that this had already
been shown for the action of diastase on starch and for the lipolytic action of
the liver-cells. The case of the moth, cited by Mr. Greenwood, was a very rare
one, and interesting on that account. Mr. Bateson had come across another
such case in a butterfly (Pararge egeria). Much more experimental work was
required upon the heredity of these forms, and until it was forthcoming it was
safer to suspend judgment. Dr. Greenwood had asked for a definition of a unit
character. He would to-day define a unit character as one which exhibited
Mendelian heredity. It was a crude definition, but it could be tested by facts,
and facts, after all, were the basis upon which the Mendelians were building.
With regard to the absence of visual purple in night-blind people, he was quoting
a view which he understood was generally received among those most qualified
to judge. He quite agreed with Mr. Greenwood that the experimental method
was the only way of settling this, as well as many other questions connected
with heredity. But whatever the cause or causes it made no difference to the
facts of transmission of night-blindness. Mr. Greenwood's argument that the
inheritance of tuberculosis was non-Mendelian depended on the assumption that
the tubercular predisposition was a simple recessive character. He wondered
what medical men would say to that, for he had always understood that the
etiology of the disease was by no means simple. He was certain that no
Mendelian would have the temerity to-day to make the assumption upon which
Mr. Greenwood’s argument was based. Mr. Yule wondered why the nation was
not slowly becoming brown-eyed and brachydactylous, since these characters
were both dominant. So it might be for all he knew, but this made no
difference to the mode of transmission of eye-colour or brachydactyly. In
regarding the breeding of man as mixed up with all manner of conventions and
prejudices he quite agreed with Mr. Yule, but these were matters concerning
ethics rather than heredity. Dr. Lewis suggested that the brachydactylous
condition tended to die out in successive generations, presumably as the result of
crossing with the normals. He could not agree with this optimistic view. A
glance at Dr. Drinkwater’s table, for instance, showed that in the last genera¬
tion the children of brachydactylous people were relatively just as numerous as
ever, and were almost exactly the expected 50 per cent, of the total. Dr.
Vernon’s letter raised the old controversy between the Mendelians and the
biometricians, and dwelt upon the practical value of the law of ancestral
mh —11
168
Punnett: Mendelism in Relation to Disease
heredity as defined by Pearson and others. But it did not seem to him that a
law which utterly collapsed before such simple facts as the production of colour
from two pure strains of poultry or sweet peas was likely to be of much value to
the average medical man or to anybody else. Mendelian inheritance has now
been demonstrated for numbers of most diverse characters in plants and animals.
It has also been shown to hold for a few simple cases in man where the evidence
has been collected carefully and critically. How far it applies must be a matter
of opinion until much more in the way of accurately recorded pedigrees is forth¬
coming. Facts alone can decide the matter, and if this paper did a little to
stimulating the collection of such facts it would have amply repaid whatever
pains went to the making of it.
Epidemiological Section.
March 27, 1908.
Dr. A. Newsholme, President of the Section, in the Chair.
A DISCUSSION ON THE ETIOLOGY AND
EPIDEMIOLOGY OF TYPHOID (ENTERIC) FEVER,
Introductory Address.
By Edward C. Seaton, M.D.
By way of briefly introducing this subject for discussion, it may not
be inappropriate to recall the statement once made by a very eminent
practising physician of the Victorian era. It was far back in the
seventies. The occasion was somewhat similar to the present, and the
speaker to whom I refer was the famous Sir William Gull. His words
were to the effect that the water-borne doctrine of typhoid causation was
a very good working hypothesis, but nothing more. But great as was
the authority that men were wont to attach at that time to the
utterances of one who shared with Sir William Jenner the credit of
having saved the life of the Heir-Apparent to the Throne, his concise
statement was by no means accepted as an apt description of the
dominating view of the time.
The rising school of epidemiologists had amongst its founders experts
who, by their exact studies of outbreaks of epidemics, by their clear
reasoning thereon, and by the scientific character of their researches
and brilliant reports, had succeeded during the previous ten years in
enlightening the people as to the causation of cholera and typhoid in
this country. They had been able, in fact, to show definitely, with
mathematical precision, how epidemics of these diseases, which had been
referred to vague influences of one kind or another, rose and spread. To
a —7
170
Seaton: Discussion on Typhoid Fever
those prepared to follow in the footsteps of their leaders, such a sweeping
statement as that referred to appeared both unappreciative and mis¬
leading, for they naturally argued that, given Workers of sufficient
acumen and industry, together with the opportunities that had been
afforded to the eminent pioneers of the Public Health Service, every
considerable outbreak of these diseases would be found traceable to
water supplies, and even the few cases that occurred in detached or
sporadic form would in some way or other be connected with the same
source, as, for example, through milk infected by polluted water.
But, looking back from our present standpoint, may we not well
ask whether Gull’s assertion was very far wrong even thirty or
thirty-five years ago? Mark you, Sir William emphasised the fact
that the water-borne view was “ a good working hypothesis,” and so
it undoubtedly proved to be in after years, both at home and abroad.
Nay, further, may we not even say that it is still a good working
hypothesis at the present day, when we reflect that there still remain
sources of public water supply constantly exposed to danger, and liable
to be delivered to consumers in an unpurified condition ?
But the subject we have set ourselves to consider this evening is very
different, for it is nothing less than the whole problem of typhoid causa¬
tion at the present day. In order to discuss this fairly it is essential to
reduce the water carriage factor to its proper proportions. As time is
short, I w.ill endeavour to do this by putting before you a few considera¬
tions which strike me as being of cardinal importance. I will take them
in chronological order.
In the first place, going back to the decennial period, 1873 to 1882,
how many of us who were working in the large towns of England
(away from the metropolis) can be said to have succeeded in tracing
outbreaks to polluted water supplies ? On the other hand, were there
not a few who, working in large towns where typhoid incidence recurred
heavily every autumn—more especially in certain quarters where the
abominable midden system and other air- and food-polluting agents existed
—could not fail to note at the same time, and in the same localities, that
the public water supply was pure and abundant, being, in fact, delivered
on the constant system, and, moreover, free from suspicion of contamina¬
tion in its passage from the source to the standpipe or tap, such as that
first demonstrated many years ago at Cambridge, Sherborne and else¬
where ? I could give examples, under such circumstances, of failure to
sustain the water-borne doctrine from my own official experience, which,
judging from contemporary reports, was, I suspect, by no means singular.
Epidemiological Section
171
Again, taking the next decade, 1883 to 1892, when lake water
supplies had been and were being captured for the use of large cities,
and water of the highest organic purity was being furnished to
communities, including the dwellers in slums, the fact that typhoid
persistently continued to recur in the autumn furnished an even more
striking manifestation of the fact that typhoid prevalence is only to
a limited extent dependent on the purity of public water supplies.
For instance, there is the experience of the large towns of the North.
Do they not clearly indicate that water-borne infection cannot possibly
be a principal factor in the causation of typhoid ?
Indeed, by the time we reach 1893, it seems to have become only
too manifest that a polluted water supply was not by any means
the sole or general means of conveyance of the disease, and attention
was being directed to such agencies as dust and flies, and, above all,
to the direct effect of polluted or unwholesome foods.
Coming now to the period since then—viz., the fifteen years from
1893 to 1907 inclusive—we are furnished with negative evidence of
even a stronger character against the view with which we started.
By this time notification had become universal in operation, and
medical officers had become increasingly devoted to their special work,
so that in a very large proportion of cases of illness inquiries were
made at once, and pains were taken to ascertain the facts of the
circumstances attending the date of attack— i.e., some two or three
weeks before the onset of illness.
I have lately had the opportunity of summarising the results of
such a study, as is now possible, in the various parts of England.
They are fully given in the last Annual Report to the Surrey County
Council, and are illustrated by a series of diagrams (submitted).
I think we shall all agree that it is the rural districts that afford the
best opportunities for exact observation. Such observations have been
diligently made and carefully recorded in the County of Surrey. In
studying the reports thereon it will be often noted that the persons
attacked are at work during the daytime in London, and there is always
the possibility of their having caught their illness there.
To those who start with the assumption that the London water,
because of its somewhat impure condition when taken from the River
Thames, is therefore a potential cause of typhoid, the mere fact of
drinking a glass of water from a London source would be a sufficient
cause. But that is obviously begging the whole question which we are
now considering. To another aspect of this part of our subject I shall
have to presently return.
172
Seaton: Discussion on Typhoid Fever
In the meanwhile I repeat it is the country districts that afford the
best.opportunities. Now, besides having of late years had the opportunity
of observing carefully a great deal for myself, I have further had the
great advantage of studying very carefully reports of my old colleague,
Mr. E. L. Jacob, who personally investigated every case reported to
him. He used to record the observations he made in his reports very
methodically, noting not only both the date of the attack as well as the
onset of illness, but recording as well any imperfections in sanitary
conditions at homes and any ascertainable circumstances throwing light
on the possible cause of illness if contracted away from home. Looking
back through these reports, which extended over a period of twenty to
thirty years, they contain, as might be expected in the early days, notes
of insanitary conditions in the vast majority of cases, for the simple
reason that insanitary conditions, such as leaking privies, drains, and
fouled wells, were at that time the rule rather than the exception. But
my former colleague always recorded in a separate column those cases
where, apart from mere coincidence, he thought there was distinct
evidence connecting a polluted water supply with the occurrence of
illness as cause and effect.
These reports have been gone through very carefully, not only by
myself, but by my friend, Dr. Fox-Symons, in order that we might
tabulate and compare our results independently. I will sum them up by
saying that although there were undoubtedly a large proportion of cases,
more especially in the early days, in which Dr. Jacob would have
declined to say that the insanitary conditions noted were not connected
with the illness, yet the proportion of cases where he may be said to
have found satisfactory evidence of causal relationship was much less
than sanitarians would have expected, the origin of most of the cases
being frankly entered as doubtful or unexplained; while the cases
distinctly attributable to drinking water were much less than 10 per cent.
Dr. Jacob’s reports led to much-needed sanitary reforms, and his work
may be said to have been a good justification of the “working hypothesis”
views, inasmuch as they helped to close at least one door through which
infection undoubtedly takes place.
It may be added as a significant fact that when the connection of
polluted or diseased foods came into notice as a factor in the production
of typhoid cases, a comparatively large proportion of these were cases in
which the relationship of cause and effect might have been said to have
been established.
Last year I published the results of some observations in the county
Epidemiological Section
173
of Surrey based upon a study of the notifications for twelve years and a
study of the notifications in relation to the rainfall as affecting what
might be called the water theory, and so far as those observations go
they appear to be of a negative character. In the whole of the twelve
years now under notice there has not been a single epidemic of water¬
borne typhoid in the administrative county. The prevalence of the
disease during this long period has been endemic in character, that is to
say, chiefly made up of solitary cases or groups of cases confined to one
spot—sporadic outbreaks, as they are commonly called.
Taking the whole of the 2,100 cases now under review as regards
their causation, I think it very doubtful whether as many as 10 per cent,
can be said to have been actually caused by the drinking of a polluted or
infected water supply, either in Surrey, where the patients fell ill, or at
the place where their illness was contracted some two or three weeks
before.
Coming now to the question of rainfall and its effect on typhoid
prevalence I have considered the matter separately as affecting the
populations supplied from different sources, viz.: (1) the River Thames
[population 253,000] and those from (2 and 3) subterranean (sand for¬
mations [population 137,000] and chalk formation [population 147,000]).
The results of the calculations of the relation of typhoid cases to rainfall
are set forth in tables which have been gone through most carefully and
which are in print in the report.
The tendency of typhoid to increase in the autumn season is shown,
whatever the source of water supply may be and whatever the rainfall
may be. As regards the river water supply it has long been contended
by the experts of the London County Council and others that a. heavy
rainfall, leading to floods and a general washing of manured lands and
sewage into the river, and consequent strain put on filtration systems,
must increase the risk of typhoid to the river water drinking population.
The diagrams, however, furnish no evidence of this having occurred.
Indeed, as regards what they tell us, it would seem their information
is of a negative character. They show a gradual decline in the sum
total of the typhoid prevalence, and they generally show an autumnal
increase, which is observed everywhere, whether the water supplies
are derived from lakes, rivers or water-bearing strata. There is no
evident relation between the rainfall and consequent floods to typhoid
prevalence. But, though negative in character, the evidence of the
upper diagram (namely, that relating to river water) is of considerable
value. The period included is subsequent to 1894. In tliat year it will
174
Seaton: Discussion on Typhoid Fever
be remembered that the medical officer of the London County Council
made a report that suggested that the November incidence of typhoid
in the metropolitan area synchronised with the occurrence of heavy
autumnal rainfall and Hooding of the Thames valley two or three weeks
before, that is to say, the interval between “ flood ” and “ incidence ”
coincided with the incubation period of the disease. Now there is
nothing to show that any such connection of possible cause and effect
since that time may have taken place in the part of the administrative
county which derives its water supply from the same source as London,
for if on the one hand we take the long established official view that
typhoid is mainly a water-borne disease there must certainly have been
some indication of the effects of floods in the diagrams. The defences
against the effects of pollution by subsidence tanks and increase of
filtration areas have been in progress during the last seven years, but
they are not yet complete, and were much less so four years ago. If we
look back to the year 1903 the evidence appears decidedly against the
London “ water theory.” If, on the other hand, we conclude that it has
been too readily assumed that typhoid outbreaks generally, or even
frequently, have their origin in pollution of water supplies, we should
hardly expect markedly visible evidence of the connection of rainfall and
typhoid in any case.
There is, indeed, no reason for supposing there has been a simultaneous
distribution of typhoid in Surrey resembling that to which attention was
directed in London in 1894. Neither, so far as I am aware, has any
similar occurrence taken place in London since the date referred to
above. As regards the other indications of the diagrams much interest
attaches to that relating to the Chalk water supplies. The contention of
some experts has been that a quickening of the passage of polluting
matters through the earth when the springs rise rapidly after periods
of heavy rainfall adds to the chances of pollution. There again the
evidence with regard to the contamination of the chalk area, and its
effects on subterranean sources of water supply, by the pollution at great
distances through fissured chalk, and even through masses of unfissured
chalk, seems absolutely negative.
I would not have it supposed from the above statements that I am in
the least degree unappreciative of the real danger that exists from water
pollution infection at the present moment. The comparatively recent
occurrence, especially that at Basingstoke last year, to say nothing of
the Maidstone and Worthing epidemics, show us what a real danger the
polluted water supply is, and no one who has witnessed, as I have, the
Epidem io Iogival Sec t urn
175
efleets of such an epidemic as that at Maidstone can doubt for a moment
the propriety of urging every reasonable precaution for preserving the
purity of water supplies which are actually exposed to contamination, or,
as in the case of a water supply derived from a necessarily contaminated
source, as that of the River Thames, the paramount necessity for proper
means of purification being insisted upon at the present day. Such
measures would have obviated the disasters in the Tees valley and at
Lincoln. I would go further and say that in certain cases the rules as
to subsidence and filtration of river waters should be made compulsory,
and the possible risks of water derived from such strata as the chalk
formation in populous areas should be dealt with in a much more drastic
way now than formerly. Moreover the experience of such an outbreak
as that at Mountain Ash, which attracted so much attention years ago,
and has been dwelt upon so frequently by the supporters of the “ water
theory,” is one that should never be lost sight of, and the rules for the
preservation of water while in the mains from possible contamination by
insuction of sewage are most important points to be borne in mind.
But the question before us this evening is not whether reasonable
rules should be rigidly applied to the preservation of water supplies from
dangerous contamination, and their purification previous to supply, if
such contamination have taken place, but whether in the mass of typhoid
fever which we have to deal with every year we may not be thinking of
the polluted water doctrine too much, to the neglect of other more
tangible and immediate sources of mischief. That is the question of the
hour, and with these preliminary remarks I leave it for others to discuss.
Typhoid Carriers, with an account of Two Institution Out¬
breaks traced to the same “ Carrier.”
By D. S. Davies, M.D., and I. Walker Hall, M.D.
The occasional persistence of the Bacillus typhosus in the human
body over long periods has been recognised for some years, and the
possibility that this condition might afford the explanation of obscure
outbreaks was suggested by Horton Smith in his Goulstonian Lectures
in 1900 [16]. At that time it was generally accepted that the Bacillus
typhosus could be demonstrated in the stools, if care was taken, during
the first and second and early part of the third week of the disease, and
possibly during the early part of the relapse. Later than this it could
176 Davies & Hall: Discussion on Typhoid Fever
not be demonstrated by the laboratory methods then available. It was
known, however, from the experiments of Chiari [4], that the bile in the
gall-bladder contains the Bacillus typhosus in the majority of typhoid
cases, and often in pure culture.
It was naturally supposed at first that, as the fever passed away and
as health returned, the bacillus, the cause of the disease, would disappear
from the tissues also, and this was demonstrated to be the case in some
of the earliest observations. But the experiments of Blachstein and
Welch [1] showed that sometimes, at least, the typhoid bacillus might
remain for much longer periods; experimentally, in rabbits, it was
found in the bile 128 days after the date of inoculation, and this
suggested that the same thing might occur in man. Between 1894
and 1896, Buschke [3], Sultan [18] and Bruni [2] quoted cases in
which the bacilli were found in the pus from bone abscesses, in
two instances six years after the primary fever and in one case seven
years after. Hunner [7] quotes cases in which cholecystitis was shown
to be accompanied by the presence of the Bacillus typhosus in pure
culture, in one case three months after the fever, in another eight months,
and in a third after an interval of seven years. Yon Dungern [6] records
a case in which, fourteen and a half years after the attack of typhoid
fever, the bacilli were still present in pure culture in the cystic
contents [5].
These facts, with many others, were detailed by Horton Smith and
insisted upon by him as possible sources of reinfection, but they have
remained largely ignored in their epidemiological relationship, partly
because the assumed rarity of their occurrence suggested that they were
merely bacteriological curiosities and partly because the isolation of the
Bacillus typhosus from the faeces was at that time not only difficult but
very uncertain. In 1906, however, owing to the continued prevalence
of sporadic typhoid in South Germany, the subject was taken up with
the advantage of modern and more certain laboratory methods, and
Klinger [10] found that persons in apparent health can harbour typhoid
bacilli and excrete them. The German observers divide “ carriers ” into
two classes:—
(1) “ Acute carriers,” who have shown no symptoms, but, after being
in direct contact with patients, may carry and excrete bacilli for a short
time and in small numbers.
(2) “ Chronic carriers,” who have a short or a long time before gone
through a regular attack of typhoid and may excrete for months or years
more or less pure cultures of typhoid bacilli.
Epidemiological Section
177
The “ chronic carriers ” are obviously the most dangerous class;
about 4 per cent, of typhoid patients appear to become carriers; the
condition is most common in women, and the bacilli apparently are
harboured in the bile in the gall-bladder or in the intrahepatic bile
passages, whence intermittently they are discharged and excreted with
the faeces. This condition may persist for as long as twenty-nine
years [5]. When these chronic carriers are engaged in the preparation
of food, or in dairy work, they are apt to give rise to intermittent local
outbreaks of typhoid fever, probably by contamination of the food with
the hand after defaecation or micturition. Kayser [8] quotes the case
of a proprietress of a bakehouse at Strasburg who prepared the meals
for the employes, where each journeyman developed typhoid soon after
arrival; her stools were full of bacilli and she gave a distinct Widal
reaction (1—100). Soper [17], of New York, records the case of a cook
who, in five years, lived in four families and gave rise to twenty-eight
case$j the bowel discharges furnished practically pure cultures of the
typhoid bacillus, and the extrusion of bacilli in her case was shown to be
intermittent. A. [11] and J. C. G. Ledingham record thirty-one cases in
fourteen years at an institution in Scotland, finally traced to carrier cases.
We believe it will be found that the two instances we are about to
narrate are the first recorded outbreaks in England traced to the
influence of a typhoid “ carrier.’ 1 *
(I.) Outbreak of Typhoid Fever at the Brentry Certified
Inebriate Reformatory, Bristol.
In November, 1906, the attention of one of us (D. S. Davies) was
first called to an outbreak of typhoid fever at this institution. The
general circumstances of the outbreak have been so fully detailed in a
Parliamentary paper [14] that the case will now be presented as briefly
as possible.
The essential facts are these. The Home contains 240 inmates and
24 resident officers ; it has been opened since 1899, and typhoid fever
first appeared in 1906. The water supply is good and the drainage
presented no defects able to account for the occurrence or distribution of
the disease. No cases of typhoid fever existed in the neighbourhood.
In September, 1906, a kitchen helper developed typhoid, and in
November three more cases occurred (Chart I.). These cases already
suggested carriage by milk, for one was a female inmate who received
an extra allowance of one pint of milk daily as!she was nursing; another
178
Davies & Hall: Discussion on Typhoid Fever
Intercurrent Events .—As Danysz virus had been used in March, 1906, for one week, and it was suggested that this might have
some connection with the outbreak, a rat was examined, with negative results, in October, 1907. Swine fever occurred amongst the
pigs at the institution in July, 1906, and again from March to September, 1907. This was dealt with under veterinary advice.
Epidemiological Section
179
was the gardener’s wife, who lived in a detached cottage on the premises
and received only milk from the institution ; the third was an outdoor
policeman, who received an allowance of milk for his tea; but no
explanation of the origin of the initial case was forthcoming. In
January, 1907, the policeman’s wife sickened, probably from nursing
him; they lived in a cottage off the estate.
Then there was a lull until May, 1907, when fresh cases occurred,
continuing through July, August, September, October and November, in
small groups and at varying intervals. Already in November, 1906,
the Home Office medical inspector had installed a milk steriliser, and
all milk was sterilised before use and then stored in the dairy until
wanted. The evidence in the 1907 cases was still stronger against
the milk, which evidently had opportunity of contamination after
sterilisation.
On the reappearance of the disease in May, 1907, the Home Office
medical inspector and the medical officer of health for South Gloucester¬
shire (Dr. Bond) made a careful examination of the premises and dis¬
covered that rats had free communication with the dairy and food stores,
and it was supposed that they carried infection in from the sewers.
Accordingly the food stores and dairy were made rat-proof. This was
practically completed by the end of August, but still the cases dropped
in steadily month bv month.
The problem was at this point when I was invited by the Brentry
Committee, in the autumn of 1907, to inquire into the renewal of the
Brentry outbreak. T commenced this inquiry in November, 1907.
Dr. Branthwaite and Dr. Bond made me fully acquainted with the
results of their careful and detailed inquiries and left me a free hand.
As a matter of fact, they had narrowed the issue down so closely, and
had excluded so many possible sources of infection, that my task was
comparatively easy.
I was at once struck by tw r o facts. First, the obvious carriage of
infection by milk; secondly, the certainty that this must become infected
after sterilisation; whence followed the inference that, as rats and other
possibilities had been excluded, the agent distributing infection might
be a “ carrier ” case dealing with the milk. 1 I then learned, with the
aid of the chairman of the Brentry House Committee, that an inmate
employed as cook and dairymaid, Mrs. H., had suffered, in January, 1901,
'My attention had been especially redirected to this possibility by Savage, “Recent
Work upon the Bacteriology of Typhoid Fever in its relationship to Preventive Medicine,”
Public Health Land 1907. xx., p. 12.
180 Davies & Hall: Discussion on Typhoid Fever
from a severe attack of typhoid fever, from which she had apparently
recovered. She is a woman aged 50, to all appearance in perfect health.
She was admitted to Brentry in April, 1906, and was employed in
kitchen work up to October 13, 1906, when she was entrusted also
with the dairy work, which she continued up to November, 1907.
The milk, after sterilisation, is stored in the dairy, whence it is
measured out for the various “ villages ” by means of a hand-dipper.
All the milk passed through her hands. In the passage leading from
kitchen to dairy is a w.c. accessible to the kitchen workers, containing
a lavatory basin which was not in use. On November 13, I requested
that Mrs. H. should be absolutely excluded from all kitchen apd dairy
work and isolated as “ suspect ” until I could arrange for a pathological
examination of her blood, urine and stools. This was done. At the
same time I ventured the opinion that, allowing for the incubation period
of typhoid fever, no further case should occur. The last case occurred
on November 25, twelve days after her isolation commenced; and the
institution has remained free up to the present time (March, 1908).
Evidence of Milk Conveyance .—I have summarised the evidence
impheating milk on Charts II. and III. Chart II. shows that of the eleven
female inmates attacked, three were employed in the kitchen, two as
dining-room maids and three in the tea-house, all thus having access to
milk. The three other female inmates attacked were the only three
who, as they were nursing, received an extra supply of one pint of milk.
The baby (hand-fed) of one of these was also attacked. Three female
officers were attacked, including the matron, whose illness dated from a
tea party on July 31, 1907. On this occasion a visitor from a Bristol
institution, where there was no typhoid, called and shared with the
matron, a female officer, and the doctor’s little boy a meal of which
clotted cream, skimmed off the sterilised cooled milk by Mrs. H., formed
part. The officer refused this, the matron and visitor, who ate some,
sickened simultaneously on August 20. The little boy ate heartily but
remained well. Previously to this, however, on June 20, 1907, he
had developed a high temperature, which continued until June 27,
and was followed by considerable depression and slow recovery ; his
general appearance during this attack was consistent with a masked
attack of typhoid fever, although he gave a negative Widal on July 21
and on December 10. 1 If this was really a minimal attack of typhoid
* See Public Health Land !., 1907, xix., p. 607 : “ Some difficulties in preventing Personal
Infection in Enteric Fever,’ , for interesting points relating to mild attacks of typhoid fever in
children.
Epidemiological Section
181
182
Davies & Hall: Discussion on Typhoid Fever
it may account for his immunity. Chart III. shows that all the four
male inmates attacked were directly employed in the officers’ mess-room,
where they had access to milk. Cases (17) and (18) took on Case (9’s)
duty and sickened in turn. The three officers who lived out and were
attacked all had tea-milk regularly supplied ; one workman who had
milk served out to him once on September 28, 1907, but denies drinking
it, sickened on October 14. Of the nine officers who lived out, but
received no milk, not one sickened,
Pathological Investigation. —The laboratory results obtained in the
case of Mrs. H. are here summarised :—
(A) On November 18, 1907, two samples of her blood both gave the
following reactions (Widal) :—
Dilution Time
1 in 10 ... 00 rain.
1 „ 25
1 ,, 50
Reaction
Loss of motility ; agglutination complete.
Loss of motility; agglutination present, but
incomplete.
No change.
The urine yielded neither Bacillus typhosus nor Bacillus coli. The
faeces yielded no organisms resembling Bacillus typhosus, but chiefly
Bacillus coli. Generally the excreta appeared to be normal.
(B) On November 29, 1907, the faeces similarly yielded no organisms
resembling the Bacillus typhosus , and were apparently normal.
(C) On December 20, as Mrs. H., after slight abdominal pain, had
passed a light brown to yellow brown loose stool of uniform soft
consistence, not unlike an early typhoid stool, containing no excess of
mucus, blood or fat, opportunity was taken to make a third examination.
Typhoid bacilli, giving all the typical reactions, were upon this occasion
isolated from the faeces. The bacilli were freely motile and reacted to
immune serum thus :—
Dilution Time Reaction
1 in 25 ... 30 min. ... Loss of motility; complete agglutination.
1 ,, 200 ... ,, ... ,, *
The intermittence during November is noteworthy. Upon the
failure to recover the Bacillus typhosus in November it was decided to
make additional examinations of certain inmates w T ho had more or less
to do with food preparation or dairy work. Sixteen blood examinations
and twelve examinations of faeces w y ere carried out, but failed to demon¬
strate another “ carrier.” In the faeces of the typhoid convalescents
examined, the Bacilli coli communes exhibited many alterations from
Epidemiological Section
183
184
Davies & Hall: Discussion on Typhoid Fever
their usual reactions. They rarely were quite typical. One or more of
the biological tests was always less pronounced than usual.
Methods .—The faeces were collected free from urine and placed in
vegetable parchment paper and then in stoneware jars. They were
conveyed to the laboratory as rapidly as possible. On arrival, ten
platinum loopfuls, taken from different parts of the material, were trans¬
ferred to a tube of sterile normal saline solution. After shaking, a
loopful of this mixture was placed in a broth tube. From this latter
tube a loopful was taken and put into a tube containing the following
medium : ordinary beef broth with OT per cent, sodium taurocholate and
1 in 1,500 malachite green (Griibler).
In isolating the Bacillus typhosus from material other than faeces, the
Loffler malachite green gelatine medium has been used with successful
results. With the faeces, however, the green colour soon fades, organises
other than the Bacillus coli communis grow well, and the plating is
slow and less satisfactory. Hence the use of the present medium.
Klein [9] has suggested this manner of culture for the isolation of
organisms from shellfish. McWeenev (1908 meeting of the Pathological
Society of Gj;eat Britain and Ireland) showed cultures obtained in a
similar way, but without the addition of the bile-salt.
After twenty-four hours growth in the malachite green broth, a
loopful of the culture was transferred to a second broth tube, and a series
of six plates were inoculated by spreading a loopful of this culture over
the surface or allowing a few drops to run over the surface. The plates
were then left partially uncovered in the 37° C. incubator for half an
hour, and then fully covered and inverted. As a rule five McConkey
bile-agar plates and one Conradi-Drigalski plate were used for each
sample. Twenty-four hours later the colourless, non-lactose colonies
were examined for motility in a hanging drop preparation, and after
further plating were transferred to tubes containing the following media:
glucose broth, mannite broth and lactose broth. When colonies were
obtained which formed acid, but did not produce gas in these media,
they were further cultivated in dulcite, saccharose and sorbite broths;
and in litmus milk, neutral red agar, glucose-agar, Barsiekow’s medium
with glucose, and with lactose ; and in peptone water for the indol
reaction. The organism which gave the distinct typhoid reactions was
then treated with serum from cases attacked in the present epidemic and
with immune horse serum.
Danysz Virus. —As this had been used in an attempt to kill off the
rats infesting the premises, and it had been suggested that this might
Epidemiological faction
185
have some causal relationship to the outbreak, a rat was forwarded in
November, 1907, to Professor Hewlett, with negative results. Bain-
bridge has recently stated that Danysz’s bacillus and the bacillus of
mouse typhoid are practically identical. These organisms have been
considered non-pathogenic for man, but an outbreak of fatal enteritis
has followed the consumption of food contaminated by similar virus.
Although the substance is sold publicly as harmless, it is evident that
careful handling is necessary.
Swine fever broke out on two occasions, viz., in July, 1906, and
from March to September, 1907. This was dealt with under veterinary
advice. There is generally supposed to be no connection between human
and pig typhoid, but we should have liked to make some inquiries as to
the possibility of infection from “carrier” to pig, and generally into the
relationship between human and pig typhoid. However, as the pigs had
been destroyed before the investigation was taken up, no opportunity
offered itself.
Confirmation of Causal Influence of Carrier by evidence from a
Previous Outbreak. —The belief that Mrs. H. was the actual cause of the
Brentry outbreak, if not proved by the foregoing sequence of events, at
least provided a working hypothesis which stood the test of experiment.
The necessary control experiment was found by tracing back her
history to a period (1904) when she was in service at another institu¬
tion, where a similar outbreak occurred.
(II.) The Outbreak of Typhoid Fever at Grove House Home
for Girls, Brislington, near Bristol.
In 1904 this Home, opened in 1899, was occupied by thirty-six girls
(aged from 5 to 15) boarded out by the Bristol Guardians and super-vised
by four officers. Typhoid fever first appeared in the third week of May,
and from that time until the end of September, when the Home was
closed, cases continued to occur in crops at intervals of a week or more
(Chart IV). Twenty-five cases developed typhoid fever, eight other sus¬
picious cases occurred, and two deaths resulted. Thus nearly all the girl
inmates were attacked. How the first case arose it was found impossible
at the time to ascertain; there had been no typhoid in the district for
months. 1 The cases occurred in groups at intervals, many cases were
very mild, the water supply from the Bristol Waterworks Company was
1 Annual Report of the Medical Officer of Health (Dr. J. C. Heaven) to the Keynslmm
Rural District Council, Somerset, for the year 1904.
a —8
Epiderniological Section
187
above suspicion, there were no other cases among the dairyman’s other
customers, nor was the manner of the outbreak suggestive of contamina¬
tion of water or milk supplies; no defects in the drains were discoverable
likely to have any influence in causation. No cases occurred during
1904 in the district except at this Home. Every possible means were
taken to control the disease by disinfection, boiling of milk, cleanliness,
and precautions as to food, all without avail. The medical officer of
health, warned by previous experience in diphtheria, shrewdly suspected
a human “ carrier,” and the girls, but not the staff, were systematically
examined by the Widal test. Still the outbreak went on, and did not
cease until the Home was closed at the end of September and the
children boarded out at various other homes. The cook left to take a
private situation. This history might have been held to afford a fairly
complete example of an outbreak of typhoid fever due to “ insanitary ”
local conditions. It now appears, however, that on February 3, 1904,
Mrs. H., the same woman who was in 1906 cook and dairymaid at
Brentry , had been transferred from the Bristol Workhouse to assist at
Grove House, Brislington, in the kitchen. She proved so satisfactory
that on May 2 she was taken on as a paid servant, with rations and
lodgings. Her duties were to generally assist in the kitchen and to
cook; she received the milk from the tradesman, and attended to its
boiling and preparation for consumption by the children. All the milk
was kept in the kitchen.
On May 16 the first case of typhoid appeared. Cases continued
through June, July, August and September. The cook left to take a
private situation on September 2. The last case was notified twenty
days after, on September 22, and the Home was closed at the end of
September.
The Mechanism of Infection .—There is apparently little doubt that
the transference of infection by carrier cases may be defined as “ gross,”
and that definite though minute amounts of infective material are con¬
veyed into the food or milk by the hand of the carrier through careless¬
ness and neglect to wash the hands after attending to the calls of Nature.
Mittman has described in Virchow’s Archie [13] the finding of various
micro-organisms, including bacilli, under the finger-nails of schoolboys,
waitresses, cooks, and others, and the subject hardly needs elaboration,
though it suggests uncomfortable thoughts anent 14 our daily bread.”
It is significant that, although the proportion of convalescents from
typhoid fever who become carriers is quite substantial (Klinger gives 1*7
per cent, and Lentz 4 per cent., while Savage [15] considers these figures
188 Davies & Hall: Discussion on Typhoid Fever
too low), few, except those engaged in food preparation, achieve dis¬
tinction; and that the two known outbreaks in the neighbourhood of
Bristol were actually due, not to two distinct persons, but to the same
cook-carrier. A. and J. C. G. Ledingham, however, found [12] that
carriers not specially engaged in food work were occasionally effective.
Quiescent Periods .—The occurrence of quiescent periods, during
which either no typhoid bacilli are extruded or, if extruded, fail to
become effective, has been noticed by more than one observer. In this
connection we may draw attention to the fact that both the Bristol
outbreaks presented a period—at Brentry lasting from December to
May, at Brislington from February to May—during which the carrier,
although engaged in her usual occupations, proved ineffective ; but from
May onwards in each year the power of infection was markedly deve¬
loped. What is the reason and the full import of this “ close ” time for
typhoid carriers, which roughly corresponds to the seasonal incidence
of typhoid prevalence in communities ? Three examinations of Mrs. H.’s
dejecta during February, 1908, have failed to disclose the presence of
the Bacillus typhosus. We hope to continue the examination through
the year, as some contribution towards a determination of the periods of
intermittence in these cases. Furthermore, the importance of some
indication of the resumption of infectivity, such as was afforded bv the
passing of a typhoid-like stool in December, 1907, is obvious.
Prophylaxis may obviously be directed to at least three points:
(1) Revised criteria for determining recovery after typhoid fever and
the adoption of a prescribed routine for registration of, and bacterio¬
logical control over, all convalescents; (2) meanwhile, self - defence
indicates the necessity for greater care in selecting kitchen and dairy
workers for home or institution. As in the eighteenth century
servants were in request who had passed through the small-pox, so
in the twentieth century the competence of a cook may justly include
her incompetence as a “carrier”; (3) the urgency for stringent care
as to hand cleanliness before commencing or resuming food preparation
or dairy work is too obvious to need insistence; hand-washing drill
should become a routine part of institution discipline.
Cure. —Unfortunately, the various drugs and intestinal antiseptics
hitherto used have met with pronounced failure. Dehler (1907) has
actually performed cholecystostomy and drainage of the gall-bladder,
which seems to be followed by gradual disappearance of the bacilli, and
possible cure; but, as Ledingham pertinently observes, this treatment
cannot be expected to become popular. Horton Smith suggested in
Epi(1 em iolog ica l Sectio n
189
1900 (op. cit.) that typhoid bacilli in small numbers may be rapidly
destroyed as soon as they come in contact with the other micro¬
organisms in the alimentary canal, for the toxins of not a few of
them are extremely inimical towards the typhoid bacillus. Can bac¬
terial methods be looked to for a solution of the problem ? Meanwhile,
what is the legal status of a “ carrier ” capable of distributing disease
and death ? Are such persons “ suffering ” from a dangerous infectious
disorder, and can they be placed under any statutory restrictions ?
Addendum .—Another suggestive fact has been communicated to us
by Dr. George Parker. On March 4, 1905, Mrs. H. was taken on as
cook at a children's home in Clifton, where there # are thirty girls.
Nothing happened until May 8, when one of the girls duly developed
typhoid fever, for which no reasonable cause could be found. Mrs. H.
left at the end of April ; no further cases occurred.
Table I.—Showing Total Inmates and Staff, also Attacks and Deaths,
Biientky, 1906-07.
A.—Inmates
... Total inmates, 240
B.-Officera including Ri , f , .
indoor attendants, |
police constables, Non-resident, partial board (tea-milk)
and workmen en- Resident off premises, no food
or temporarily dur¬
ing the year
...I
ing milk)
No.
Attacked
©
it
3
a
©
©
*
Died
i F.
105
11
10-4
(M.
135
5
3 7
1
f F.
15
3
20 0 !
_
1M.
9
2
22-2
—
M.
19
3
15 6
1
M.
9
—
—
on
07;
nk-
M.
1
292
25
8*5
o
C.—Others . ... Visitor (tea and cream) on one occasion
only, tea party of July 31, 1907, sick¬
ened August 20, 1907 ... ... F. 1
Gardener’s wife, lives at lodge, receives
milk from Institution ... F. — 1
Police constable’s wife, non-resident, |
probably contracted from husband F. 1
To these may be added the doctor’s little boy, who developed suspicious symptoms con¬
sonant with mild typhoid on June 20 (Widal negative).
The incidence is heaviest on the male and female officers on full board (including extra
milk) and next on the non-resident male officers receiving tea-milk. The incidence on the
female inmates was restricted to those who helped in food preparation or received extra milk,
and on the male inmates to those who helped in food preparation (messroom attendants,
having access to milk).
190
Davies & Hall: Discussion on Typhoid Fever
Table II.— List of Cases of Typhoid Fever at Beentry.
1,1 I 1 -
| Approxi-'
Case |"“ , « t dat «: Sex
sickening ;
I 1906
1
N. B.
Sept. 16
F.
Inmate
Kitchen
2
A. H. i
Nov. 11 i
F.
Officer
(cottage)
Gardener’s
wife
— Extra (1 pint) milk for nursing
3
P. C. P. 1
” 11 i
M.
Lives out No food but milk
City 4
Mrs. E. „ 11
1007
F.
Lives in lodge, receives milk
5
Mrs. P. Jan. 9
! 1
F.
Wife of
No. 3
Lives out Probably contracted from nurMUg hus¬
band
6
A. St.
May 4
F.
Inmate
Tea house Messroom maid
7
S. Sp. ) July 4
F.
»»
— Extra (1 pint) milk for nursing
8
A. Sp. ) j
„ 4
M.
Babv
—
9
A. A.
„ 11
M.
Inmate
Wing Messroom attendant 1
10
A. R.
,, 13
F.
i
Kitchen
11
E. L.
,. 20
F.
»»
Tea house Messroom maid ; milk stands here
from 2 p.m. to 4 p.m.
12
G. G.
,, 26
F.
9 9
Pantry Attendant on officers ; dining - room
maid 1
13
Miss II. 1 Aug. 8
F.
Officer
Kitchen On full board
14
N. V. B.
8|
M.
! Carpenter
— Gets l)oard (officers’ rations) *'
15
M. J. 1
,, 10
F.
Inmate
Laundry Extra (1 pint) milk for nursing
D. 16
R.G.M.l
,, 131
M.
j Officer
Lives out Receives no food but milk ; died
17
C. W. !
,, 20
M.
Inmate
Messroom attendant, followed No. 9 in
his duties
I). 18
H. R.
20,
M.
— ■ Ditto, ditto ; died
City 19
Miss C.
,, 20
F.
Matron
Infected at tea party, July 31
„ 20
Miss F.
„ 20
F.
Visitor
Ditto
21
H. P.
,, 27
F.
Inmate
Tea house Messroom maid, followed No. 11 in
duty here; milk stands here from
2 p.m. to 4 p.m.
22
VV. W. Sept. 10
M.
M
Attendant 1
„ 23
E. C. I
!
Oct. 14
M.
Stoker
, Lives out Only had one meal in Institution, Sep¬
tember 28, 1907 (denies drinking milk
i supplied)
„ 24
L. P.
,, 31 !
M.
Engineer
„ Has milk occasionally to use for tea
25
A. W.
Nov. 7
F.
Inmate
Pantry Attendant on officers ; dining - room
maid
26
S. B.
„ 9
M.
Officer
— Indoor officer, full board
27
Miss P.
„ 13
F.
f 9
— Ditto
28
A. S.
1
,, 24
F.
j Inmate
Kitchen &
scullery
Description j
of Patient '
How
employed
JSource of Infection
1 Inmate attendants clear tables after food and have special access to food and milk.
- Inmates receive an allowance of a quarter of a pint of milk daily, which is put directly
into boiling tea in a large can ; only inmate attendants have access to milk. Officers receive
half a pint, part of which is used cold for porridge.
Total, 28. Inmates (includ- (M. 5) ir • M. Gi f .
ingbaby) ... , F. 11) lb Umccr ‘ s - < F. 3, J
Also two officers’ wives, one visitor, and (?) the doctor’s little boy.
Fj p i<le m iolog ic al Sect ion
191
REFERENCES.
1 Blachstein and Welch. Johns Hopkins Hosp. Bull., Balt., 1891, ii., pp. 96 and 121.
*2] Bruni. Ann. de VInst. Pasteur , Paris, 1896, viii., p. 220.
81 Buschke. Forts, der Med., 1894, p. 572.
r 4j Chiabi. Zeitschr. f. Heilk., 1894, xv., p. 199.
'5 Dean. In the Brit. Med. Joum ., 1908, i., p. 512, a case is recorded by Dean, in which
typhoid bacilli persisted in a medical practitioner for twenty-nine years ; there was
no evidence of his proving “ effective.”
[6] Dungern, von. Milnch. med. Wochenschr., 1897, xliv., p. 699.
17 j Hunneb. Arh. a. d\ kaiserl. Gcsundheits ., Berl., 1889, v., pp. 312-319.
i 8 [ Kayskb. Arb. a. d. kaiserl. Gesundheits.. Berl., 1906, xxiv., p. 176.
9, Klein. Lancet , 1907, ii., p. 1519.
10] Klinger. Arb. a. d. kaiserl. Gesundheits., Berl., 1906, xxiv., p. 91.
11] Ledingham, A. Brit. Med. Jonm., 1908, i., p. 15.
12] Ledingham, A. and J. C. G. Brit. Med. Journ., 1908, i., p. 15.
13] Mittman. Quoted in Brit. Med. Joum., 1888, ii., p. 1001.
141 Parliamentary Paper. Homo Office. “ Outbreak of Enteric Fever at Brentry Certi¬
fied Inebriate Reformatory.” Report to the Right Hon. the Secretary of State for
the Home Department, by R. W. Branthwaite, M.D., H.M. Inspector under the
Inebriates Act. (Presented to both Houses of Parliament by command of His
Majesty, 1908.) Wyman & Sons, Ltd., Fetter Lane, E.C.
f 1 5j Savage. Cf. Public Health Loud., 1907, xix., p. 608, and 1907, xx., p. 15.
i 16] Smith, P. Horton. “The Goulstonian Lectures on the Typhoid Bacillus and Typhoid
Fever,” Lancet , 1900, i., pp. 821, 910, 1050.
117] Soper. Med. Record , New York, 1907, lxxi., p. 818.
[ 18j Sultan. Dcutsch. Died. Wochenschr., Leipz. u. Berl.. 1894, xx., p. 34.
The Potential Dangers of Water Derived from Wells in
the Chalk.
By H. Meredith Richards, M.D.,and J. A. H. Bringker, M.B.
Though water derived from wells in the chalk is for the most part
of excellent quality, it [is common knowledge that on several occasions
epidemics of water-borne disease have been traced to such supplies. The
following are outstanding instances of such epidemics in this country:—
Plan*
Investigated by
Deaths
Sourre of Contamination
Caterham ...
Thorne Thorne
352
21
Contamination of headings by an
ambulatory enteric patient.
Worthing ...
Thomson
1,317
168
Contamination of heading from neigh¬
bouring sewer.
Newport, I.W.
Thomson
436
42
Contamination from house drains and
millpond near the well.
192 Richards & Brinckcr: Discussion on Typhoid Fever
In all these instances it is noteworthy that specific pollution had its
origin in the immediate neighbourhood of the well, and might have been
prevented by care in the construction of the well and the provision of a
zone of protection of quite moderate size. On the other hand, the risks
of more distant pollution are not fully appreciated, and it is for this
reason that we wish to put on record certain observations and experi¬
ments that we have made during the last four years. We can do this
with the greater freedom because, though no epidemic has occurred, the
water authority concerned has admitted the risk and taken the necessary
initial steps to obviate the danger. The subject is important because'
there are many similarly circumstanced wells, and the great increase in
the population living on the chalk outcrop must necessarily add to the
risk of similar pollution.
The well is situated 318 ft. above Ordnance Datum in the Thames
basin, in an area of uncovered chalk about half a mile south of a point
where the chalk is overlaid by London tertiaries. The chalk escarpment
is covered by varying depths of “ clay with flints,” as well as by a small
patch of Woolwich and Reading pebble beds. The whole of the surface
geology is clearly shown in the accompanying map. 1 The general flow of
underground water is obviously from south to north. The following
short account of the well, provided by the engineer, has been kindly
checked bv Mr. W. Whitaker, F.R.s/:—
Earth
Flinty
1, Ac. , .
Thick in***
It. in.
5 6
Depth
ft. in.
5 G
/ Chalk, with seven layers of Hints
28
6
34
0
Hard brownish chalk rock
1
0
35
0
Chalk, with five layers of flints
20
5
55
5
1 Open bed, with flint (water first found)...
3
0
5S
5
Open chalk ...
5
0
G3
11
Close bed and flints ...
2
1
06
3
. Close chalk ...
r>
5
72
3
Watery open flint bed
o
3
74
11
Chalk, partly open, mostly close, partly with
flints, with some layers of flint (one at the
bottom, 1 ft. thick, beneath which no more
v was found)
77
1
152
0
1 Close bed, and then plum-pudding chalk, with 3 in.
1 of bine [marl ? 1 at the base
5
0
157
0
Close bed
12
0
169
0
: Curly chalk (? irregular curved jointing with two
( layers of bine [marl ?J j
31
0
200
0
All the chalk presumably belongs to the Upper division, the flintless character of the
lower part being a local accident, probably of no very great horizontal extent.
The minimum yield of water from the well is nearly 1,000,000
gallons, with a maximum daily flow of nearly double that quantity.
Not reproduced.
Epidem iologteal Section
193
Within a quarter of a mile radius of the well there are only two cottages,
both of which are supplied with earth closets carefully supervised by
the water authority. As far as mere inspection can be relied upon the
well is in as satisfactory a situation as can be found in the uncovered
chalk, and from the time that the well was opened, in 1888, until June,
1903, the quality of the water was believed to be of uniform excellence.
Since 1897 a chemical and bacteriological examination of the water
was made three or four times a year by Mr. Dibdin, whose verdict for
the first six years was uniformly favourable, until we received the
following report of a sample taken on June 16, 1903. 1 For comparison
the report made of the same well in November 25, 1902, is also repro¬
duced, together with a further report on a sample taken June 22, 1903.
Table I.
November 25. 1902
Jiuit) 16, 1903
June 22, 19o:>
Appearance ..
Clear and bright
Slightly milkv
Clear and bright
Odour at 100 F.
None
None
None
Total solids, grains per gallon ...
23*2
21-9
22 M
Total solids, appearance on
Very slight blacken-
Very slight blacken-
No blackening
ignition
mg
ing
Phosphoric acid
No trace
No trace
No trace
Harduess, total degrees
21 *1
16*9
17 05
Hardness, permanent degrees ..
3*4
4-05
4 05
Ammonia, free, grains per gallon
Ammonia, albuminoid, grains
Trace
0-0014
0 0008
per gallon ...
<W)005
0-0037
Trace
Chlorine, grains per gallon
Oxygen absorbed from perman¬
ganate at 80 F. in fifteen
0-85
0-72
0-82
minutes, grains per gallon ...
Oxygen absorbed from perman¬
ganate at 80 F. in four hours,
0*0015
0-0219
0-0038
grains per gallon
Organic elements : —
0-0031
0-0353
0 0102
Carbon, parts per 100,000
0 039
0 079
0-054
Nitrogen per 100.000
0010
0027
0-014
Total per 100,000
Nitrogen, as nitrates, & c.. grains
0-049
0-106
0-068
per gallon
Cultivation on gelatine plates : —
0-194
0-481
0-214
Colonies per cubic centimetre
10 0
3820 0
635 0
Micro-filter, millimetres per litre
—
Trace
Trace
Pathogenic organisms
Not detected
/>’. coli communis
present in 100c.c.,
not detected in
20 e.c. ; B. enter i-
tidis sporogencs
present in 50 c.c.
B. coli communis
present in 100 c.c.,
but not detected
i n 20 c.c.; B .
c uteri t id is sporo¬
gencs not detected
Microscopical examination
Nothing
A clot of fibres with
many free bac¬
teria, some in
zooglcpa form ,
Fibres and veget¬
able debris
1 Twenty-three samples were examined from November, 1897, to March, 1903. The
number of organisms per cubic centimetre was below 100 on eighteen occasions, but
reached 140, 145, 228, 276 and 366 in the remaining samples.
194 Richards it Brinckcr : Discussion on Typhoid Fever
Consideration of the physical appearance of the water on June 1(>
obviously suggested that the contamination must have been massive, as
a vast volume 1 of water had been rendered distinctly milky and opal¬
escent. The chemical data, especially the diminution in the chlorine,
the marked increase in albuminoid ammonia and the comparatively small
increase in the free ammonia figure suggested surface water contamination
rather than sewage of human or animal origin.
At the consultation which immediately followed receipt of Mr.
Dibdin’s report the engineer indicated a spot where it was known
that surface water sank very rapidly into the chalk. This spot is
marked “ B ” on the map, 2 and it is situated rather more than two
miles directly south of the well and about (>00 ft. above Ordnance
Datum. We at once visited spot “ B ” indicated by the engineer and
found it to be a depression situated near the southern border of that
part of the gathering ground which is covered with “ clay, with flints
and loam.” At that time the depression received the natural (surface)
drainage of a considerable tract of more elevated land lying still further
south. Advantage had also been taken by the architect of a large
institution of the readiness with which water soaked through the over-
lying soil, and all the surface water drains of the institution, and of
the adjacent road, were led to the same spot. In spite of the large*
accession of water reaching the depression in times of heavy rain,
it was noticed that water rarely produced any pooling, but passed
through the soil as rapidly as it reached the depression. On inquiry
from the “oldest inhabitant" we were told that some fifty years ago
there used to be a pond where the depression is now found, and that
on one occasion the pond disappeared with a rushing noise, leaving
a hole of some depth, which was subsequently filled in with soil. For
this we have no other evidence than tradition, but in January, 1899,
four holes, measuring from () ft. to 20 ft. across, suddenly appeared
in the chalk at a point marked “ C ” on the map. 3 Three of these
holes have since been filled up, but the fourth is still visible. There
is, therefore, evidence that the chalk in this particular neighbourhood
is subject to accidents of the kind indicated. Furthermore the depres¬
sion “ B ” is situated near the top of one of the valleys, which ultimately
opens out near the well. As underground streams tend to run in valleys,
it did not seem improbable that water flowing into depression “TV
1 The well and adits have a storage capacity of over 5C0.(XM) gallons.
- Not reproduced.
Not reproduced.
Epidem iological Sec t ton
195
might reach a more or less defined channel and thus take a compara¬
tively short cut to the well. In order to verify this hypothesis the
following experiments were made:—
On June 21, 1903, at 7 a.m., 1£ tons of salt were placed in the
depression, and a similar quantity in a neighbouring part of the field,
where the soil also seemed to allow of free percolation. About
40,000 gallons of water from the public supply was then pumped
on to the salt. At the same time the pumps in the well were run
day and night at their maximum capacity, so as to favour the flow
of water towards the well and lower the water-level until the headings
could be explored. In the meantime samples of the well water were
analysed half hourly for chlorine. The first fifty-eight samples gave
the following results—fifty-one gave exactly 1*2 parts per 100,000, two
gave IT parts, and five gave 1*3 parts. The fifty-ninth sample, taken
twenty-nine hours and a half after the beginning of the experiment,
showed 1*3 parts per 100,000, and from that time until seventy-five
hours after the addition of the salt did not again show as low a figure
as 1*2 parts. The highest figure reached was 1*0 parts, found at the
thirty-eighth and forty-first hour of the experiment.
As we wished to confirm these results a further quantity of li tons
of salt was washed into the depression at 0 p.m. on June 23. This
resulted in a further rise in the sodium chloride figures, as much as
1*7 parts per 100,000 being found twenty-two and a half hours after the
salt had been washed down the depression. On this occasion the varia¬
tions in the sodium chloride figures were somewhat more erratic than
during the first experiment. This may partly be accounted for by
the fact that we were unable to wait until the sodium chloride figure
returned to normal, and partly to the prolonged pumping having pro¬
duced an unusually large cone of depression. In both experiments it
was found that the most definite results were obtained about twenty-
nine hours after the addition of salt to the depression. At the same
time opportunity was afforded for examining the headings, and samples
were taken of the chief springs. These were examined for chlorides,
but we had no opportunity of making a complete analysis. The figures
are, however, interesting :—
Tin* amount of chlorine in parts
per 100,000
The well under normal condition ... ... ... 12
The well on June 25, 12.30 p.m. ... .. ... 1*4
Main spring ... ... ... ... ... 1*4
Small spring ... ... ... ... ... 1*2
Branch heading ... .. .. ... ... 1*3
Branch heading with holes ... .. ... ... 1*4
Subsidiary headings ... ... ... ... ... 1-2
190 Richards dt Brinckcr: Discussion on Typhoid Fever
It will be noticed that only certain of the fissures yielded water
with an excess of chlorides, but unfortunately these included the
springs furnishing the bulk of the water to the well. While taking
these samples we made a note of the physical condition of the well
and its adits. The shaft itself was remarkably dry and presented
no evidence of surface water finding its wav behind the lining of
the well. The most striking feature was the projection from numerous
minute fissures in the headings of brown jelly-like masses of finely
divided clay. Obviously the constant flow towards the well had
washed this clay from the surface through the huge mass of super¬
jacent chalk.
In the meantime a complete inspection was made of the physiography
of the gathering ground and a house to house inspection of all the
premises situated within one mile of the well. The results of this
inspection need not be given in detail, but briefly amounted to this.
No other spot could be discovered where surface water was likely to
enter the chalk in large volumes, nor could any cesspool be found so
situated as to suggest risk of intermittent pollution of the well. Inquiry
was also made of the engineer in charge of the pumping station as to
whether he had previously noticed any similar opalescence of the water
in the well. We found that he had done so and noted the fact in his
diary, though the turbidity was never as marked as on this occasion and
had always been ascribed to the breaking down or opening up of fissures.
On examining the diary from June, 1897, onwards we found that the
water had been noticed to be cloudy once in 1898, 1899 and 1901, and
twice in 1900. The exact dates of these observations, together with
others made from June, 1903, to June 30, 1907, are given in the
following table. To this we have added some particulars as to the
rainfall on the days immediately preceding the observations (see
Table II.).
It will be seen that from June, 1897, to June, 1907, there were
seventeen occasions on which the physical appearance of the water was
noticed to be abnormal. It is a striking fact that excessive rainfall was
measured twenty-four to forty-eight hours before the opacity was noticed
on fourteen out of the seventeen occasions. Whether the cloudiness noted
on December 28, 1900, and November 5, 1904, was accompanied by
bacteriological pollution is unknown, as unfortunately no samples were
examined on these occasions. It may be that the cloudiness was simply
due to the flow of water breaking down some of the masses of finely
divided clay which project from the fissures into the adits. In any case
Epidem iological Section
197
the effect of excessive rain is undoubted, and on three occasions we have
forecasted the pollution of the well by watching the rain gauge. On one
of these occasions the total bacterial count was only raised to sixty, but
Bacillus coli was found in 1 c.c. of the water, though Bacillus coll was
absent from 100 c.c. of water from an adjacent well not subject to this
intermittent pollution. Again on examining the bacterial count previous
to June, 1903, there were five occasions on which more than 100
organisms per cubic centimetre were found. On four out of the five
occasions excessive rainfall had preceded the submission of the samples to
the analyst. Unfortunately the data in our possession do not enable us to
Table II.
Engineer's Notes
Rainfall observed at well.
Year
Mouth
!
Appearance of water
in <» ft. tank.
1898
i December 8
Very thick
0 74 on December 6, 1898
1899
| January 13 and 14
Little cloudv
0'67 on January 12, 1899
1900
1 February 17
Thick
0 96 on February 15, 1900
1900
| December 28
Cloudy
No excessive rain ; 0*32 on December 26
1901
j December 13
1*53 on December 12, 1901
1903
1 June 12
Very cloudy for 14 days
(167 on June 10, 1903
(0-87 on June 11, 1903
1903
October 28
Cloudv
1*20 on October 26, 1903
1903
1 November 30
A little cloudy
1 *63 on October 27, 1903
1904
January 31
Cloudy
0 98 on January 30, 1904
1904
February 14
0 70 on February 12, 1904
1904
July 25
A little cloudv
0-57 on July 25, 1904
1904
November 5
>9
No rain
1905
November 13
t 9
0 7 on November 11, 1905
1906
January 7
Slightly cloudv
0 55 on January 5, 1906
1906
January 17 to 20
Thick
1-05 on January 16, 1906
1906 i
February 18 and 19
Cloudy
0*33 on February 16 and 0*46 on Febru¬
ary 17, 1906
1906
November 8
Discoloured
0 73 on November 6, 1906
state with accuracy the exact relation between the rainfall and pollution
of the well, but we are now accustomed to look for evidence of pollution
when the fall of rain on the gathering ground approaches 1 in. in
twenty-four hours. To reach more accurate conclusions would require
much more frequent analyses to be tnade of the well water and more
complete observations of the rainfall. Hitherto we have had to depend
on a gauge situated at the well itself, and we have no record before 1907
of the amount of rain falling near the point “ B.” 1 Further observation
A gauge is now fixed near tbe depression.
198 Richards & Briucker: Discussion on Typhoid Fever
will doubtless show that the effect of rainfall on the well depends not
only on the amount observed but on the previous condition of the soil
and the speed with which the water is able to reach the depression.
So far our experiments only showed that soluble matter found its
way from the depression “ B ” to the well in about thirty to thirty-six
hours. As this time corresponded with the interval usually observed
to elapse between heavy rainfall and visible pollution of the well the
experiments with salt furnished valuable corroboration of our hypothesis.
Indeed, it was this coincidence in time and the shortness of the interval
itself that were most striking. The mere discovery in well water
of soluble salts or of colouring matter washed into the depression on
the gathering ground is not in itself necessarily indicative of risk of
pollution, though experiments with sodium chloride, lithia or fluorescine
are often of service, in as far as they suggest sources of pollution and
demonstrate the direction taken by underground streams. Obviously
such experiments cannot prove the possibility of particulate matter
following the same course. We therefore determined to ascertain
whether it w r ould be possible to recover from the well, known bacteria
previously added to the depression “ B.” For this purpose we intended
using cultures of Bacillus prodigiosus , but Dr. Houston, who was good
enough to discuss with us the details of the proposed experiment,
suggested that it would be more convenient to use one of the non-
pathogenic chromogenic organisms normally found in river water, which
for convenience we shall refer to as the “ test microbe.” Of this bacillus
Dr. Houston kindly supplied an active, pure culture. The test microbe
ferments sugar media; hence if the primary sugar media inoculated with
the well water showed no gas formation, its absence could be inferred
with certainty. Furthermore, if gas production occurred in the primary
media it could (owing to its being chromogenic and having special sugar
reactions) be differentiated readily from other gas-forming microbes ( e.g .,
Bacillus coli and allied forms).
Before proceeding further one of us (J. A. H. Brincker) worked
through the biochemical properties of the organism and also proved its
absence from the well water. A note of the reactions is appended.
Experiment III.
We next prepared six Winchester quarts of sterilised peptone water,
inoculated them with the test organism, and kept them in a warm place
(about 25° C.) for a week, when a copious growth was obtained. On
Epidemiological Sect ion
199
April ‘24, 1907, at 0.30 a.m. to 9.20 a.m., the contents of these bottles
were emptied into the depression “ B ” and washed into the soil with
some 60,000 gallons of water. Samples of water were taken from the
rising main of the well at 7 a.m., noon, and 6 p.m. each day. These
samples were carefully collected in sterilised bottles, and packed in ice
until examined.
(I.) One cubic centimetre of water was inoculated into a gelatine
plate and incubated for three days at 20 C.; the bacterial content
was then ascertained, and any organisms suspicious of being either
the Bacillus coli or the test microbe isolated and grown in broth. From
the broth culture gelatine plates were inoculated, and the biochemical
properties of the organism studied by its action on various media.
(II.) Various quantities of water 1 (15 c.c., 10 c.c., 5 c.c., 1 c.c.,
and to c.c.) were inoculated into bile-salt glucose broth and incubated
at 37° C. for three days. These tubes, as soon as they showed signs of
acidity or gas, or both, were removed, and subcultures made as follow :—
(1) (a) Gelatine plates. (6) Into media mentioned in Table V.
(2) Any suspicious colonies isolated from the gelatine plate were
treated as was done in (I.) above.
The results are given in Table HI. and Diagram B.
The results of this experiment are as follow:—
(1) The particulate matter introduced into the soil at “B” was
detected in the water of well “ A ” 78*5 hours afterwards.
(2) Its appearance in the well water was associated with a marked
rise in the bacterial content of the water.
(3) Bacillus coli , though present in 10 c.c. and 5 c.c. in the first two
samples taken, was absent from the next five samples, but made its
reappearance in the well water at about the time when the obvious
pollution was obtained; it could then be detected in 1 c.c. of the water.
The conclusions are that this pollution of the well water must have come
from the surface soil of the depression “ B,” two miles away. Unfortun¬
ately the experiment was stopped at the end of 78*5 hours, and the
organism was only found in the last sample of the water.
1 In Experiment III. the largest quantity of water used was only 10 c.c., but in Experi¬
ment IV. the quantity was increased to 15 c.c.
200 Richards & Brincker: Discussion on Typhoid Fever
Experiment IV.
Some months were allowed to elapse in order to allow the well
to purify itself of this micro-organism. By July 24 it was found that
the micro-organism used in the previous experiment had entirely
disappeared. To obtain a more pronounced result twelve Winchester
quarts of the organism in peptone water were prepared and arrangements
made to carry the experiment on for a week. The micro-organism was
washed into the soil of the swallow from 12 noon till 4.30 p.m. of
July 24, 1907, by about 81,000 gallons of well water. Eight-hourly
samples of water from the well were examined as in the first experiment.
The results are embodied in Table IV. and Diagram B. From these we
learn that:—
(1) This test organism was absent from all samples of water until
sixty-seven and a half hours after the swallow was infected. This is
a shorter interval than was observed on the previous occasion.
(2) The presence in the well water of this organism was accompanied
by a marked increase in its bacterial content, together with the presence
of Bacillus coli (Flaginac).
(3) The maximum pollution from “ B ” seems to have been attained
about seventy-eight hours after infection. Thereafter the pollution, as
indicated by the bacterial count, gradually diminished, but persisted for
at least 108 hours after infection.
General Conclusions.
The time at our disposal will not allow of adequate discussion of the
numerous problems arising out of the foregoing experiments, but we
make the following suggestions :—
(1) That wells in the chalk require to be safeguarded not only by an
adequate zone of protection, but by careful inspection of the gathering
ground to discover the presence of swallow holes or other weak spots in
the chalk.
(2) That danger is most likely to arise when the chalk is partially
covered by an impervious stratum, so that the surface water tends to be
concentrated at a few spots instead of passing equally into the chalk
outcrop.
(3) The necessity of frequent bacteriological examination of chalk
water even when the wells are apparently above suspicion.
Epidemiol-ogica l Sec tio n
201
(4) The necessity of providing some purification scheme if the water
be bacteriologically or chemically unstable, or if inspection or experiment
reveal any substantial risk. Whether the purification scheme should be
sand filtration, softening, ozonization, or a combination of these processes,
we must leave for future discussion.
Lastly, we wish to express our thanks to Dr. Houston for suggesting
such a convenient test microbe and for the information he was good
enough to place at our disposal.
Table III. -Experiment III. with Yellow Bacillus, April ‘24 to 27, 1907
(Dr. Houston).
No. of sample
Day, date, and hour
n c SQ — ^
= c - £
^11
° £• i •”
* 1 % *
Dbtei
Bacillus ct
Yellow Ba
] 10 c.c. |
&MIKATIG
)L1 - B.i
CILLUH ^
5 C.C.
>n or
C. \
B.Y. /
1 C.C.
IN
0*1 c.c.
'oh
o' 2 *
55 c Ss
X
« 3 C .
W
Remarks
1907
i
1
1
I
1
Wed., April 24
5-5 1
B.C.
+
—
—
12
Noon
1
B.Y. 1
—
—
— 1
—
1 1
2
Thurs., April 25
1 24 5
B.C. j
-f
+
—
—
! 15
7 a.m.|
B.Y.
—
—
- - |
- -
11 1
3
,, Noon
29-5
B.C. 1
—
—
—
—
B.Y.
—
—
—
—
1
4
„ 6 p.m.
35*5 1
B.C. 1
—
—
—
1 - .
ii !
B.Y.
—
—
—
1
i
5
Friday, April 26
48*5 ,
B.C. !
—
—
—
1 H
7 a.m.
B.Y.
I —
—
6
, t Noon
53 5
B.C.
—
—
j —
1
1 io
1 B.Y.
—
—
1 _
7
,, 6 p.m.
59-5
i B.C.
—
I _
! —
1 1^
B.Y.
—
—
—
—
8
Sat., April 27
72 5
| B.C.
+
—
—
—
19
7 a. n i .
1 H.Y
j —-
—
—
i
9
,, lp.m.
78*5
I B.C.
+
+
+
—
• 157
Typical yellow col¬
B.Y.
s +
+
— ■
—
onies and bacil¬
|
lus coli obtained
i
in this sample
Note.—In Experiment III. the largest quantity of water used for bacteriological analysis
was 10 c.c. This was increased to 15 c.c. in Experiment IV.
a —9
202 Richards & Brincker: Discussion on Typhoid Fever
Table IV.— Experiment IV. with Yellow Bacillus, July 24 to 31, 1907
(Dr. Houston).
©
1
I
6
X
Day, date, ami hour
2 S a r
ijli
o * iB
. CL a. r,
OcSi.ce
Z *
Determination o
Bacillus coli = B.C.
Yf.llow Bacillus = B.
15 c.c. j 10 c.c. ! '»c.c.
r
r.)
1 C.C.
01 C.c.
Total No. of
organisms per
1 c.c. water
Remarks
1907
1
Wed., July 24
Prelim-
B C.
—
—
—
—
—
21
7.30 a.m.
inary
B.Y.
—
—
—
—
—
2
,, Noon
—
B.C.
—
—
—
—
—
18
B.Y.
—
—
—
—
—
3
,, 6 p.m.
6
B.C.
—
—
—
—
20
B.Y.
—
—
—
—
4
Thurs., July 25
19*5
B.C.
—
—
—
—
—
23
7.30 a.m.
B.Y.
—
—
—
—
5
,, Noon
24
B.C.
—
—
—
—
—
13
B.Y.
—
—
—
—
—
6
,, 6 p.m.
30
B.C.
—
_
—
—
17
B.Y.
--
—
—
—
7
Friday, July 26
43-5 : B.C.
—
—
—
10
7.30 a.m
B.Y.
—
—
—
8
,, Noon
48
B.C.
+
+
—
—
9
Plate liquefied
B.Y.
—
—
—
_
in two days
9
„ 6 p.m.
54
B.C.
+
+
—
—
—
15
B.Y.
—
—
—
—
—
10
Sat., July 27
67 5
B.C,
+
+
—
—
—
61
First indica-
7.30 a.m.
B.Y.
+
-f
—
—
—
tion of con¬
tamination
11
,, Noon
72
B.C.
+
+
4-
—
1 —
201
B.Y.
+
4-
4-
+
12
,, 6 p.m.
78
B.C.
+
+
4-
—
—
260
B.Y.
+
+
4-
1
13
Sun., July 28
92
B.C.
4-
+
4-
—
1 —
238
8 a.m.
B.Y.
+
1 +
4-
! +
1 _
1
14
,, Noon
96
B.C.
+
+
4-
1
1
229
B.Y.
+
+
i + 1
+
1 -
15
,, 6 p.m.
102
i
227 1
No sample
1
1
taken
16
Mon., July 29
115 5
B.C.
+ ;
+
— |
1 ■ ~
—
222
7.30 a.m.
B.Y.
4-
+
+ j
, +
—
17
,, Noon
120
B.C.
+
1 +
+ ’
—
180
BY.
+
-1- |
4- i
i --
—
18
„ 6 p.m.
126
B.C.
4-
1 + ;
—
I —
—
156
B.Y.
4-
+
+
. —
—
19
Tues., July 30
139-5
B.C.
+
+ 1
!
-
—
150
7.30 a m.
B.Y.
+
+
4- :
—
—
20
,, Noon
144
B.C.
+
+ 1
! — 1
i —
—
130
B.Y.
; +
' +
4 1
—
21
,, 6 p.m.
150
s B.C.
! +
+
i
—
92
i
B.Y.
+
+ !
| 4-
—
1
22
Wed., July 31
163-5
B.C.
4-
4- !
—
—
84
7.30 a.m.
i
B.Y. i
+
4- i
-f
—
—
23
,, Noon
168
B.C.
+
4- 1
—
—
—
68
Last sample
I !
B.Y. i
+ i
+ 1
i + i
I — i
—
taken
1 Number of organisms here calculated to find place on curve.
Epidemiological Section
203
Table V.— Diagram B., showing Bacterial Count op Samples of Water.
-Experiment III., April 24 to 27, 1907.
- Experiment IV., July 24 to 31, 1907.
The micro-organism used in these experiments shows the following characteristics
(1) Microscopically : A small motile bacillus* very much like the Bacillus coli communis.
(2) Ou gelatine plates : The colonies are observed as small white or slightly coloured spots at
the end of forty-eight hours. In four days the surface colonies are large, heaped
up, and of a brilliant orange colour. In six to seven days they begin to liquefy. It
gives the following reactions :—
(3) Acid and gas formation in the following sugar media: dextrose, galactose, levulose,
lactose, maltose, mannite, sucrose.
Note: The action on lactose is very slow ; after forty-eight hours at 37° C. there
is only very slight production acidity and gas, differing, therefore, very markedly
from Bacillus colt communis.
(4) Ac»d and firm clot in litmus milk culture.
(5) Reduces nitrates to nitrites.
(6) No indol formation.
(7) Fluorescence in neutral red broth cultures.
(8) No reaction on dulcite.
(9) Ferments bile salt broth, producing acid and gas.
(10) Tendency to lose the power of producing pigment when subcultured, but regains this
power with rejuvenescence in broth at low temperatures.
204
Hamer: Discussion on Typhoid Fever
The Relation of the Bacillus typhosus to Typhoid Fever.
By W. H. Hamer, M.D.
A marked change of mental attitude towards the problems of
typhoid fever has been brought about by recent bacteriological work,
which has led, inter alia , to adoption by many of the view that “ the
causal organisms multiply only within the human body and cannot carry
on a saprophytic existence outside it.” 1 It is urged by those who think
thus that exaggerated importance has been attached in the past to water,
milk and food as vehicles of infection, and it is claimed that attention
should be more perseveringly directed to the question of “ contact
infection.”
When it was realised that the excretions of persons attacked by
typhoid often contain for weeks, and it may be for months—it is said, in
exceptional instances, even for thirty or forty years—vast numbers of
bacilli, it was at once declared that this must mean mischief, and
evidence of harm so caused was locked for, first in one and then in
another direction. As it w r as found that little or nothing came of the
search, one theory after another was propounded to explain this want
of success, and new branches of inquiry were successively exploited.
Thus one of the first points to receive attention, when infectivity from
person to person is in question, is whether there is a special incidence
upon particular houses. 2 Then secondly, in the absence of obvious
“ contact infection,” there still remains the possibility that the disease
may be spread by apparently healthy persons, the fire thus smouldering
unrecognised. In the light of Koch’s observations regarding malaria,
children naturally fell under suspicion, and it was conjectured that,
in particular areas, it w r ould be found the native-born adult had been
already rendered immune, while newcomers more especially suffered.
Suggestions of this sort prompted inquiry into conditions obtaining in
endemic areas of prevalence, both as to the immunity of particular
1 Vorwort. Arb. a. d. JcaiscrL Gesund ., 1906, xxiv., p. 1.
* It should be noted that, even if the existence of typhoid houses were demonstrated, it
would not necessarily follow that personal infection afforded the only possible explanation c f
such occurrence.
Epidemiohujical Section
205
sections of the population and as to the ability of apparently healthy
individuals to spread infection. Thus Frosch (Koch’s Festschrift)
observes that certain epidemiological problems necessarily now come
to the front, and, as he says, they cannot be settled in the clinic or the
laboratory. He mentions “typhoid houses” and “regional immunity.”
Quite recently Klinger 1 has emphasised the importance of the “ chronic
bacillus-carrier,” and he notes that, for solution of the problems which
arise in this connection, we are, since pathogenicity for the guinea-pig does
not necessarily imply pathogenicity for man, “ unfortunately compelled
to fall back upon epidemiological observations.” There is, then, an
appeal to the observer in the field with regard to these three questions.
(1) Typhoid Houses. —Some writers 2 go so far as to refer cases for
which no other etiology can be discovered to earlier cases in the same
house or in a neighbouring house , and this after an interval of years ;
Frosch (1907) describes “ Die Wanderung des Typhus eine Strasse
entlang von Haus zu Haus.” The facts recorded by von Donitz, in
Berlin (1903), are more in accord with those ascertained in this country.
Niven insisted ten years ago, in this connection, upon the need of deter¬
mining whether an observed incidence is any more remarkable than
mere chance will explain, and when this test is applied the case for
“ typhoid houses ” breaks down, just as that for “ cancer houses ” (Behla)
has been found to do bv Symons and others. 3
A particular instance of employment of the house incidence test in typhoid
fever may, however, be mentioned, as the outbreak presents special points of
interest. It occurred in Beuthen, in Upper Silesia , 4 and there were two waves
of disease ; the first prevalence reached its height in May, the second at the end
of July. Contact infection is said to have been responsible for the double out¬
break, and this is held to be proved by the occurrence of a large number of
secondary cases in houses. The report is a full one ; it is open to the criticism
that no attempt is made to separate primary from secondary cases, but this,
it may be said, is a petit io prineipii. At least it may be urged, however, that
the early and later cases in Beuthen occur in a way which suggests that the
1 Arb. a. d. kaiserl. Gesund ., 1900, xxiv., p. 35.
* Richter, Zeit. f. MedUinal-beamte , 1904.
* In an interesting study of the hoi^e incidence of phthisis in Posen, by Wernicke (Koch s
Festschrift ), the point is made that, in certain streets, some houses suffer severely while
many escape altogether. There is, however, no reference to the a priori probability of
occurrence of the phenomena observed. If the numbers of susceptible persons, in the
houses in question, may be assumed to have varied within the usual wide limits, I find
that chance, and chance alone, W'ould explain the results exhibited by the Posen figures.
1 Zeit.f. Hyg ., 1901.
206
Hamer: Discussion on Typhoid Fever
separation should have been made. 1 The report is open to the further criticism
that, arithmetically considered, the later incidence upon houses originally
invaded is no more remarkable than chance would explain. The houses, we
are told, are massive, two or three storeys high, and each contains four to ten
families. The inhabitants of any one house thus constitute a not inconsiderable
fraction of the total population at risk. The probability of occurrence, as a mere
coincidence, of later cases in houses already attacked is therefore appreciable,
and as no regard is paid in the report to this fact, the argument is vitiated.
Particularly noteworthy, in connection with study of “ contact infection,”
is the explanation given of the double prevalence. We are told how, in the
May outbreak, step by step a contact epidemic was built up; the authorities, it
appears, were then stimulated to undertake energetic measures (of isolation and
disinfection), with the result that slackening followed in June. Surely, however,
the report says, contact infection in the dwelling again corfies into operation;
. . . numerous convalescents, too, are discharged from hospital, pressure
upon accommodation leads to early return of cases to their homes, and these
spread abroad contagion in the disinfected houses. Now, too, those affected in
the first outbreak and not removed to hospital again begin to mix with their
fellows . . . and so on.
It is perhaps unnecessary to pursue the ‘‘house incidence question”
further, as during the last few years it has been practically abandoned in
favour of more novel lines of investigation.
(2) Regional Immunity .—On turning now to the study of the
smouldering of typhoid in particular communities, or in sections of
the population, a most instructive case is that presented by Conradi. 2 * * * * *
This observer had published an earlier paper on dysentery in and near
Metz, giving an account of an outbreak of 70 cases, in which not one
single native-born inhabitant more than 22 years old was attacked,
while twenty-five strangers, whose ages exceeded 25 years, suffered. 8 The
numbers, it will be felt, are too small to found conclusions upon, but the
1 Examination, for example, of Barry’s (Tees Valley, 1890-91) figures show that the per¬
centage of later or secondary attacks in houses to total attacks rose from quite a small to
quite a large percentage as the outbreak developed (3 per cent, in the first, to 35 per cent, in
the sixth fortnight). The Beuthen investigator draws no distinction between earlier and later
stages of prevalence; indeed, when he shows that second cases in houses are common, he takes
periods subsequent to those of development of the outbreaks. He would, of course, have
obtained results such as those he exhibits by treating in a similar way figures relating to
almost any food or water epidemic.
2 Arb. a. d. kaiserl. Oesund ., Berl., 1906, xxiv., p. 97.
8 The main group of cases occurred in the Hauptstrasse of Moulins, where there were
six cases in one house, four in each of two others, and so on. Clearly generalisations from
such figures are unwarranted. Moreover, it appears (see Koch’s Festschrift ) that there was
“ avoidance of medical treatment ” and “ concealment of cases.” May not this “ avoidance ”
and “concealment” have been especially manifested by Metz-born adults? Again, it
transpires that six native-born persons, whose ages ranged from 16 to 22, were attacked.
Epidemiological Section
207
experience is interesting as it no doubt led to the main inquiry to be now
referred to. Conradi’s thesis is that typhoid has prevailed from time
immemorial in Metz, and that it ever smoulders, mainly among the
babies and young children of the town, the native population at higher
ages being thus rendered immune. The disease spreads, however, to
newcomers and hence to the soldiers; this especially occurs during
campaigns; it did so very notably at the time of the siege of 1870, when
upwards of 30,000 cases occurred in Metz and its near neighbourhood ;
but the mischief continually operates and interferes, year in and year
out, with military efficiency.
The thesis is supported by a comparison of certain percentages, of
total deaths and of typhoid deaths, contributed by native-born persons.
Figures are given showing deaths at age-periods (1880 to 1904).
There were, it transpires, 382 deaths from typhoid among immigrants (173
among soldiers, 209 among civilians), and only 45 among the native-born
population. Unfortunately the proportions of these two classes of the inhabi¬
tants cannot be stated.' i
Conradi, however, calls particular attention to the fact that up to 15 years
of age natives and immigrants suffered from typhoid to something like an equal
extent; but over 25 there were only four natives as contrasted with 119 immi¬
grants. He says it may be suggested that this striking difference finds
explanation in the fact that, following upon the events of 1870, the native-born
element in Metz underwent an enormous diminution ; but he disposes, as he
believes, of this suggestion by giving figures from which he estimates the pro¬
portions of natives and immigrants respectively among the older people now
living in Metz. At ages over 30 there were, in 1890, 409 deaths, from all causes,
among immigrants and 120 among native-born persons. The argument thus
assumes this form :—
At ages over 30, in 1890, 22 per cent, of the total deaths occurred among
native-bora persons. At ages over 25, taking a period of twenty-five years (1880
to 1904), only 3 per cent, of the typhoid deaths occurred among native-born
persons. Hence, &c. Obviously these percentages should not be compared with
one another; the first is based on a single year, and that, it appears, was an
exceptional one; further, a rate in 1890 is not comparable with an average rate
taken over the period 1880 to 1904, having in view the admitted remarkable
changes of population in Metz. But the most important point is that, of the
120 deaths of Metz-born persons over 30 years old (upon which the first per¬
centage is based), no fewer than 79 occurred at over 60, and actually 99 at over
50 years of age.
Clearly the extent to which Metz-born persons are included among
1 In 1895, however, out of 45,480 persons, only 16,484 were native-born; 28,996 were
civilian immigrants, to whom must be added 16,776 soldiers, making 45,772 total immigrants.
208
Hamer: Discussion on Typhoid Fever
those dying at advanced ages is not much to the point. We have to
deal, if the comparison of percentages is to be precisely made, with
the typhoid ages. We cannot obtain from Conradi’s tables the per¬
centage of native-born persons attacked at the ages of special typhoid
incidence, but it must be considerably less than the percentage (14 per
cent.) at the ages 30 to 50. From the rates given in the tables we
may conclude with some degree of certainty that there were not, in
1903, more than 4,000 or 5,000 Metz-born persons in Metz at ages
exceeding 20 years, and on this basis there cannot have been at the ages
20 to 45 more than one Metz-born to some ten or twelve non-Metz-born
persons. This fairly corresponds with the proportion of Metz-born to
non-Metz-born persons among those attacked by typhoid at those ages in
1903. (The figures are given in Table V. 1 ) Thus the supposed immunity
of native-born persons proves to result from a mere trick of the figures ;
and as the native-born persons at the ages in question are in actual fact
an insignificant minority, there is no need to assume that their failure to
appear in larger numbers, in mortality returns relating to typhoid, can
only be explained by adopting the hypothesis that they are immune to that
disease.
It is especially deserving of note that the garrison, consisting of men
at susceptible ages, and constituting more than one-quarter of the total
population of Metz, is entirely immigrant—the Metz-born lads as they
reach the age of military service are apparently removed from the town.
Moreover, the special influence of the year 1870 needs to be considered.*
The tables given by Conradi supply evidence that few Metz-born babies
and children remained in Metz after the siege; hence it is no matter for
surprise that typhoid mortality figures relating to 1880 to 1904, i.e ., to a
period from some years after to upwards of thirty years after the war,
yield scanty evidence of the presence in Metz of native-born persons
between 15 and 35 years of age.
Another interesting contribution to the “regional immunity” question
is that of Frosch. 2 The paper has been much quoted in Germany, but
the figures are too small to carry weight. In a population (of apparently
400 to 500 persons) occupying sixty-six houses, in Wittlich, a town of
3,600 inhabitants, a water-borne epidemic of typhoid occurred in 1895.
Subsequently (1896 to 1903) further cases occurred in Wittlich, and in
1 This correspondence is observed on comparing an estimated population in 1903 with cases
in that year. Comparison of total deaths in a number of years with the deaths or population
of a particular year is, as already remarked, opeu to obvious objections.
* Koch’s Festschrift, 1904.
Epulemiological Section
209
the town generally new arrivals and natives of the place were indifferently
attacked; in the special area of the water epidemic no natives suffered,
but 44 several cases ” occurred among strangers. According to the case-
rates obtaining in Wittlich, only three or four cases would, on the law of
chance, have to be allotted, for the period 1896 to 1903, to the special area.
The fact -that no native of the .area was attacked does not, of course,
under these circumstances, furnish material upon which to generalise.
Conradi has made an elaborate study 1 of this question of 44 regional
immunity ” in Ottweiler. This town (5,028 inhabitants) suffered from
an extensive outbreak of typhoid (353 cases) in 1891 to 1892. Conradi finds
that 75 further cases occurred, during the succeeding fourteen years,
in natives who were , at the time of the outbreak of 1891 to 1892, living
in the epidemic area , and had since continued to do so. Clearly, as
Conradi says, more evidence is required before the doctrine of regional
immunity can find general acceptance.
(3) Chronic Carriers. —Study of chronic bacillus carriers, however,
has brought new problems to the front. If persons who have undergone
attack by typhoid be examined after a short interval of time, 3 per cent,
or 4 per cent, are found to have typhoid bacilli in their excretions.
When this was first demonstrated it was assumed that all diffi¬
culties with regard to the origin of cases of the disease were at an
end. The facts did not, however, fit into their places in the way
anticipated. Thus, in the first place, there is apt to be trouble as
regards discovering chronic carriers under circumstances in which they
might be expected to be found. Brummund 2 could not detect one
carrier among 160 persons examined two or three years after attack,
and he says: 44 Es ein besonders gliicklicher Zufall ist bei einem chron-
ischen Typhustrager bazillushaltigen Stuhl zu bekommen.” Kayser,
too, has pointed out the remarkable intermittency of appearance of the
bacilli ( 44 exquisit schubweisen Darmentleerung ”). Again, when chronic
carriers are actually kept under observation, no contact cases (Klinger)
are found to occur, but this is, perhaps not unnaturally, explained as
being due to the fact that proper precautions are taken. 3
1 “Klin. Jahrb.,” Bd. xvii., H. 2.
2 Zeit. f. Hyg Leipz., 1907, lvi., p. 425.
3 Dr. Geo. Dean {Brit. Med. Journ ., 1908, i., p. 562) has recorded a case of a carrier of
twenty-nine years standing from whom, so far as is known, no case has originated. Kirchner
(“ Klin. Jahrb.,” Bd. xvi.) has shown that when a cholera epidemic is declining the primary
baciUus carriers increase in numbers. Conradi thinks that in typhoid, too, the appearance of
carriers indicates loss of virulence of the organism. In point of fact, the practical outcome of
this teaching appears to be that iu a multitude of bacillus carriers there is safety.
210 Hamer: Discussion on Typhoid Fever
A curious explanation of this absence of contact cases is given by Brum-
raund. TheFwtbreak recently investigated by him at Mulsum was caused by
milk, and among those who did not consume the infected supply there were no
contact cases. Brummund points out that the inhabitants of the place were
divided into two hostile camps, according to their source of milk supply. “ Die
Mulsumer gewissermassen in zwei feindliche Heerlager mit dem Devisen; hie
Mulsumer, hie Kutenholzer Molkerei, gespalten sind, die sich grimmig befehden
und jedenfalls alien freundschaftlichen Verkehr miteinander vermeiden.” In
the schools, it is true, the children drinking one supply sat side by side with
those drinking the other supply, but here, we are told, the insistence of the
school teacher upon the risk of infection impressed the scholars and led to
proper precautions being taken.
The need for reconsideration of the whole position, in the light of the
facts ascertained with regard to “carriers,” is urged by Conradi. 1 He
now contends that typhoid is especially infective quite early in the disease,
even in the incubation period. Bacillus carriers, he says, are of three
kinds (primary, secondary and tertiary), and only the last kind really
constitutes a source of danger, and that only under exceptional circum¬
stances. Contact infections arise, as his detailed examinations show,
within the first or second weeks of illness of the original cases; late
contact cases rarely occur. Sporadic cases, however careful the investi¬
gation made, cannot, as a rule, be traced to previous cases, and these
sporadic cases, even in the absence of isolation, disinfection, &c., do not
give rise to secondary cases. He asks : “Why are outbreaks thus limited
to single cases, which again on their part give rise to no further infec¬
tion?” Too much reliance must not be placed, he adds, in linking up
cases of infection, uporf the healthy “ carrier.” “It is difficult to prove
that he is infectious, as we discover him only because of the fact that he
lives in infected surroundings. Post hoc ergo propter hoc.” Having
carefully watched bacillus carriers, he finds they are not, as a rule,
infective; nothing is known concerning the virulence of the organisms
they excrete, and he concludes that it can only be under exceptional
circumstances that they are a source of risk.
In striking contrast to this attitude stands that of Kayser, who has
from the first claimed that the role of the chronic “carrier” is an
extremely important one. In 1906 he wrote his “ Milch und Typhus-
bazillentrager,” and in the same year, in his “ Gefahrlichkeit von
Typhusbazillentragern,” he recounted the case of the Backerineisterin,
who ten years previously had typhoid, and w 7 hose young assistants, year
after year, suffered from gastro-intestinal disorders, until at length, upon
1 “ Ucber die Kontagiositiit. des Typhus,” “ Klin. Jahrb.,” Bd. xvii., H. 2.
Epidemiological Section
211
one of them developing typhoid, the Backermeisterin herself came
under suspicion, and the Bacillus typhosus was demonstrated in her
stools. Again, he gives the case of Frau M., who, having suffered
from typhoid thirty years before, was at length, on the occurrence of
the disease in her neighbours, proved to be a bacillus carrier. It is, of
course, always possible, working on these lines, to show that any given
bacillus carrier has suffered from, or has been in contact with, a case of
the disease, for we have thirty years at our disposal. While the signifi¬
cance of the presence of Bacillus typhosus in the stools is made clear,
the method of proof adopted suspiciously resembles argument in a
circle.
In the last year or two many further cases of chronic carriers
have been reported. One of the most remarkable is that from New
York, recorded by Soper. 1 The history of the carrier, a cook, is
traced for ten years, and in seven “ families ” (in this designation visitors,
gardeners and laundresses are included) with whom she lived during
that time a case or cases of typhoid are said to have occurred. The
difficulties in obtaining this record must have been great, as the cook
herself resolutely declined all information, and admittedly there is doubt
about certain particulars. Assuming, however, the substantial correct¬
ness of the story, it cannot be regarded as finally conclusive. Five of
the outbreaks—and they include those best attested—occurred at seaside
resorts near New York. Little is said about possible sources of infection
other than the cook, but in one outbreak there was strong suspicion that
shellfish and in another that water was at fault. “ The families were of
ample means and accustomed to living well.” They constituted, in fact,
a selected population. The problem assumes the form—Given a person,
associated with a number of selected persons, first at one and then at
another seaside resort, during a period of ten years, to find the chance
that at the end of that time inquiry will elicit expression of a belief that
cases of typhoid have occurred in correspondence with such association.
If the seaside resorts were, as is probable, also more or less selected, and
if at all of them, as we are told was the case at one, sewage-polluted
soft clams and oysters were consumed by the “ families,” the a priori
chance of the occurrence, apart from infectivity of the cook, of the
sequence of events recorded is far from being a negligible one.
There are, moreover, certain asylum observations to which great
interest attaches. Those recorded by Nieter, and by Nieter and
1 Journ. Amer. Med. Assoc., 1907, xlviii., p. 2019.
212
Hamer: Discussion on Typhoid Fever
Liefmann, 1 furnish instances of successful search being made, on the
occurrence of cases of typhoid, for a bacillus carrier, among a considerable
number (perhaps some hundreds) of persons more or less associated with
the cases. Facts of a similar sort have been recently reported by the
Ledinghams.
The question here arises as to the standard to be applied in such
investigations. What percentage of carriers may be expected in an
asylum, apart altogether from occurrence of typhoid in the institution at
the time of the examination? Klinger (1906), at the Strasburg typhoid
station, found eleven bacillus carriers among 1,700 healthy individuals
—0*6 per cent. 2 Minelli, 3 in a prison where there had been no typhoid
for three years, found 1 in 250 (0*4 per cent). It is noteworthy that
bacillus carriers are more common among females than males, and
there is a remarkable association of liability to excrete typhoid bacilli
with certain pathological conditions (e.g., gall-stones). The age-distri¬
bution of a population examined may be also expected to have influence.
Clearly, therefore, provided standards such as those just quoted are to be
applied, it must be held there is nothing much out of the common if,
out of a hundred or so individuals submitted to examination (by Nieter
and Liefmann or in the Ledinghams’ cases), a bacillus carrier or two
be found. There is a further point which should be kept in mind.
Inasmuch as chronic carriers only excrete bacilli intermittently (“ schub-
weise ”), repeated examinations as a rule have to be made. If, however,
a suspect be again and again examined we cannot take as our standard
1 in 100 or 1 in 200, as above; we require, of course, to know what the
idtimate result would prove to be were the control population submitted
to equally searching and persistent examination.
Nieter and Liefmann found thirteen carriers among 900 female
lunatics—1*5 per cent.; or, if consideration be limited to a particular
part of the asylum, used for some years previously for isolating typhoid
and dysentery, they found seven carriers among 250 persons examined,
2*8 per cent. They point out:—
(1) That their patients were women, among whom, according to
Klinger, carriers are three times as common as among men.
1 Mthick, mcd. Wochenschr ., 1906, liii., p. 1611, and 1907, liv., p. 1622.
* This is the figure sometimes quoted, but as a matter of fact, Klinger has found 27 cases
among 1,800 examined—1*5 per cent. In some of these there was a history of having in
the past suffered from typhoid, and for this reason, apparently, they are excluded from con¬
sideration.
3 Ccntralbl. f. Bakt. y Jena, 1906, xli., p. 406,
Epidemiological Section 213
(2) That the opportunities for spread of infection are especially great
in a lunatic asylum.
(3) That the 250 inmates occupied a building to which typhoid cases
had for years been sent' from all parts of the asylum.
Again, they emphasise the fact that their tests w r ere again and again
repeated, and it was only as successive examinations were made that the
percentage of carriers grew T , for some patients who gave a negative result
on a first examination yielded a positive one later. As the ultimate
percentage reached was only 2*8, there seems no reason for concluding
that the proportion of carriers was higher, in this institution, than it
might be expected to be, on the facts at present known, in any other
asylum for female lunatics in this country or in Germany.
Nieter and Liefmann themselves say: “ Our observations contribute
little towards determining the important and interesting question how
great the risk from association with bacillus carriers is. Cases of typhoid
were developed in wards in which we were able to demonstrate the
presence of chronic carriers, but the transference of patients from ward
to ward was such a common occurrence that too much stress should not
be laid upon the local distribution of these cases.”
The Ledinghams’ cases and, so far as figures are given, those from
Merzig, Hordt, Saargemiind and Klingemunster, referred to by Nieter,
tend to confirm a belief, which may now perhaps increasingly be enter¬
tained, that the appearance of typhoid in an asylum by no means necessi¬
tates a higher percentage of chronic carriers being found among the
inmates than might be expected in any similar population free from
typhoid.
Nieter also quotes Friedel's case. Only one carrier was found here, 1
but stress is laid on the fact that this carrier handled uncooked vegetables
in the asylum kitchen ; no attempt is made to differentiate, between
those attacked and those not attacked by the disease, as regards con¬
sumption of such vegetables. In gauging the significance to be attached
to discovery of a chronic bacillus carrier among those handling the food¬
stuffs consumed in an asylum it is important, of course, to remember that
many persons are more or less concerned with the supply of food to
large institutions, and that the chance of discovering a bacillus carrier is
enhanced pari passu with increase in the number of individuals submitted
to bacteriological investigation.
1 Examination of the excreta of all those employed in the asylum kitchen, scullery, milk
and laundry services was undertaken. The only positive result was in a womau, aged 65,
who had been for many years under observation in the asylum, and was believed not to have
had typhoid.
214
Hamer: Discussion on Typhoid Fever
Murchison records the fact that the President of the Society of
Engineers of the day, in a letter to the Times , December 4, 1871, stated
that “ having examined many houses in which enteric fever had occurred
he had in every instance been able to trace the outbreak to sorue unlooked-
for defect in the drainage/* Obviously, in connection with such experi¬
ences, as with inquiries made at the present time also, it is necessary to
have regard to control observations. If a milk supply or water supply
be suspected, the investigator does not content himself with discussing
whether individual persons attacked had consumed the milk or w r ater ;
the fact that any particular percentage of the sufferers did so does
not interest him, unless he be satisfied there was a greater incidence
upon consumers of the supplies in question than those supplies were
entitled to show. He would, of course, estimate how many consumers
of the milk or water, might a priori (having regard to all the facts as to
the distribution of , the milk or water) be expected to be attacked, and
only if that number was exceeded 1 would he attach importance to the
degree of special incidence observed. This plan of procedure is not
adopted in dealing with bacillus carriers in institutions: yet milk and
water are known to have communicated typhoid ; while Conradi tells us
we cannot say whether the bacilli excreted, by a healthy carrier are
capable of conveying infection.
On a review of the facts now known the conclusion may clearly be
formulated that the chronic carrier is not, as a rule, a source of mischief.
It may be, as Conradi conjectures, that there are special circumstances
under which he becomes dangerous, and the question in that case is,
What are those circumstances ? On the other hand, as the evidence at
present stands, we cannot lose sight of the possibility that the chronic
carrier may not be immediately concerned with transmitting typhoid
fever at all. Two further questions then arise. Does the Bacillus
1 As illustration of the need lor laying stress on considerations of this sort may be men¬
tioned the fact that, in an account of a recent inquiry as to the origin of 125 cases of phthisis,
it is stated that in 18 cases out of the total number infection was probably contracted from a
relative. The number of cases in which it might be anticipated there would be the appear¬
ance of such supposed transference of infection as result of chance coincidence (assuming for
the sake of argument that phthisis is never directly transmitted from one human being to
another) can be estimated arithmetically. I find that more than thirteen such instances
might be expected to present themselves in 125 cases examined, as a matter of pure chance,
provided it be taken for granted that the proportion of the population at the phthisis ages
who have within the last five years manifested symptoms is not less than 3 per cent. The
number (13), therefore, to which the casual reader might be disposed to attach special
significance, is really just what might be expected as result of mere coincidence. Obviously
it is unnecessary to seek explanation of the infection by an appeal to relatives in all, if iu
any, of the 13 cases.
Epidemiological Section
215
typhosus represent a particular phase in the life-history of the specific
organism of typhoid ? Or, on the other hand, is the Bacillus typhosus
merely a “ secondary invader ” ?
Many observers, having regard to the facts that the disease is 44 con¬
stantly springing up in isolated cases without any possible communication,”
and that, when well-defined outbursts occur, the number of secondary
cases is comparatively speaking small, are inclining to the view that
contact from man to man plays no great part in causing spread of the
disease. Arguing, moreover, from conclusively demonstrated instances
of origin of typhoid from consumption of polluted water and sewage
contaminated shellfish, from the involvement of dwellers near foul fore¬
shores, and from the incidence observed in Germany and in this country
upon certain riverside populations, it is natural to seek explanation of such
associated circumstances in a hypothesis that the disease is, as a rule, in
a wide sense of the word, 44 water-borne.” It might then, further, be
suggested that the typhoid organism has two phases in its life-history,
and that in one phase it is apt to produce typhoid fever; while in the
second, the Bacillus typhosus phase, it is only exceptionally, if at all,
capable of causing extension of disease by direct contact. On the other-
hand, the causal organism of typhoid may be in no way connected with
the Bacillus typhosus; and, indeed, apart from ‘considerations already
adverted to, there are several reasons for advocating a critical re-examina¬
tion of the relationship of the Bacillus typhosus to typhoid fever. The
following more particularly deserve mention:—
(1) There are the difficulties which are referred to from time
to time by bacteriologists. Numerous anomalies and exceptional
results have been recorded, with regard to agglutination (see, for
example, papers which have appeared in the last two or three years
by Zupnik, Poggenpohl, Gaehtgens, and others). There is, further,
a difficulty owing to the close resemblance—it may be the actual
interchangeability—of the typhoid bacillus and closely allied organ¬
isms, notably those known as paratyphoid bacilli. Mixed infections
of typhoid and paratyphoid occur, not only in individual cases, but in
epidemics. 1 Fornet and Levy, and Gaehtgens, in recent papers, 2 have
demonstrated remarkable epidemiological relationships ( 44 epidemio-
logische Beziehungen zwischen Typhus und Paratyphus B.”). Small-
man and MacConkey have obtained results which might naturally be
1 Pap- r by Thomas, “ Klin. Jalirb.,” Bd. xvii., H. 2.
• Arb. a. d. kaiser l. Gcsund ., 1907, xxv., pp. 247, 250.
216
Hamer: Discussion on Typhoid Fever
explained by assuming that one bacillus was changed into the other
in the animal body. 1
The bacillus is not, as has been seen, always possessed of
pathogenic property. It was found in the public water supply of
Detmold (by Beck and Ohlmuller) in 1904, about a month after
the cessation of an outbreak, and was not then causing inconveni¬
ence. The question whether the disease can be experimentally
produced in animals has never been satisfactorily cleared up. 2 The
recorded instances of accidental laboratory infection in man may
have been due to causes other than ingestion of Bacillus typhosus ,
and the swallowing of cultures has given, at any rate in some
cases, a negative result.
(2) A number of organisms, believed at one time to be
“ causal/’ are now classed as “ secondary invaders.” Particular
interest attaches here to the case of the hog cholera bacillus
(a near relation of the Bacillus typhosus ), an organism long supposed
to be the cause of hog cholera. It is now stated, however, that
while cultures of the hog cholera bacillus produce on inoculation a
disease closely resembling hog cholera, the blood of animals thus
inoculated is not, while the blood of animals which have acquired
the disease in a natural way is, infective. The hog cholera
bacillus is regarded in America as an inhabitant of the intestine
of the normal hog. Dorset, Bolton and McBryde 3 point out that
this state of things “ is entirely analogous to the condition under
which many pathogenic organisms exist—as, for example, the pneu¬
mococcus in the mouth of healthy individuals, and the swine plague
bacillus (Bacillus suisepticus) on the tonsils of healthy hogs. . .
They add: u Bacillus coli communis is a familiar example of an
organism constantly present in health and yet assuming under
certain conditions very great pathogenic power.”
(M) The known behaviour of the bacillus, as observed in the
laboratory, does not altogether accord with field observations, and
‘ See, moreover, Savage’s observations on “ variant forms” of Bacillus coli ; aud the work
of Twort, who has shown that sugar fermenting powers may undergo change; while Stephens
has made it clear that non-motility and the non-flagellate condition may be assumed by
Bacillus typhosus under certain conditions of growth.
- Gninbaum (Brit. Med. Jourti ., 1004, ii., p. 817) published a “ preliminary communication,”
containing an account of the appearances produced in the small intestine of the chimpanzee
by feeding experiments. His observations, he considers, “ assist in fulfilling Koch’s third
postulate as applied to Eberth’s bacillus.”
1 Aunuul Report of the Bureau of Animal Industry, 1904.
217
Epidemiological Section
with these the typhoid organism must comply. Thus Dr. Barry, in
giving evidence before the Water Commission (1892 to 1893) said:
“ If it is found that what is called the specific bacillus of typhoid
fever will not live under particular circumstances, as has seemed to
be shown in laboratory experiments, then I think that possibly the
true bacterium has not been found.” During the last fifteen years
a new difficulty has arisen, inasmuch as it has been ascertained that
large communities can with impunity be supplied with polluted
river water, for periods of some years, without manifest injury,
provided certain precautions are adopted, and these, it would seem,
are not of a kind which necessarily preclude the bacillus from
obtaining access to household supplies.
It may be urged, on the other hand, how can the common association
of a “ specific organism ” like the Bacillus typhosus with a particular
“ symptom complex,” not only in sporadic cases but also in outbreaks of
disease, be explained if the organism be a mere “ secondary invader ” ?
To this it may be replied that for many years the bacillus was held
not to occur in the blood; now it is readily demonstrated there. At one
time it was believed to be impossible to single it out from the faeces; now
it can be isolated from material in which there is only one typhoid bacillus
to hundreds of other bacilli. With perfecting of bacteriological methods
bacilli, which are now supposed to be very particular as to the company
they keep, may turn out to be travelling incognito in all sorts of places
Study, at a time when there is no cholera, of material from the intestines
of pilgrims at El Tor, reveals the presence of the cholera vibrio. Pratt,
Peabody and Long 1 hold that the typhoid bacilli in the alimentary tract
come chiefly from the bile, and that they are speedily destroyed in the
intestine. Neufeldt 2 explains the El Tor phenomenon by assuming that
the pilgrim suffered from cholera long ago, and that the vibrio has for
years ceased to be quite at home in its host’s intestines, but ow T ing to
slight dysenteric or other disturbances it is enabled ultimately to again
come to the front. In the same way, says Neufeldt, typhoid “ bacillus
carriers ” come under notice owing to rapid multiplication of the bacillus
as result of their suffering from some derangement of the biliary secretion
(gall-stones, &c.). The cholera or typhoid bacilli are always there, but
the dysentery or biliary colic places them in evidence ; they are repre¬
sentatives of the ordinary flora of the intestine brought into prominence
1 Joarn. Amer. Med . Assoc., 1907.
2 Arb. a . d. kaiserl. Gesund., Berl., 1907, xxv., p. 164.
a—10
218
Discussion on Typhoid Fever
by special favouring circumstances. Why, then, should not typhoid fever
also be competent to place typhoid bacilli in evidence? In other words,
why continue to regard the presence of typhoid bacilli as necessary for
the production of typhoid fever ?
However this may be, some discrimination is necessary in attributing
outbreaks of typhoid to contact infection. Murchison held all supposed
contact cases were “as readily explicable on the supposition that the
disease has had a local origin as upon that of contagion.” Without
accepting quite such an extreme view it is at least well to remember the
caution of Bulstrode 1 that we should always, in connection with supposed
contact infection in households, keep in mind the possible “ continued
operation of the cause, which may have given rise to the first case in any
house where many cases arose.”
DISCUSSION.
The PRESIDENT (Dr. Newsholme) spoke sympathetically of the absence,
through illness, of Dr. Seaton. The Section, he said, had had the great
advantage of listening to papers on the pathogenicity and specificity of the
typhoid bacillus and the important question of carrier cases. On the one hand
an able agnostic in this matter, like Dr. Hamer, said the typhoid bacillus was
possibly not the bacillus of typhoid fever, and suggested that carriers of the
disease did not frequently occur; while, on the other hand, Dr. Davies had
given a most lucid description of an outbreak in which carrier cases figured, and
in which the connection between these cases and the subsequent outbreaks was
practically demonstrated. It would be difficult to imagine circumstances under
which a more interesting discussion, might be expected.
Dr. E. W. Goodall said that several very important questions concerning
the etiology of typhoid fever had been raised in the papers read that evening,
but he would confine his remarks to three of them. The first, a fundamental
one, had been raised by Dr. Hamer, who appeared to have doubts whether the
Bacillus typhosus was the cause of typhoid fever. Nor were his doubts without
support, for Dr. C. J. Martin was reported to have stated before the Royal
Commission on Vivisection that the evidence that the bacillus was the cause
of typhoid fever was not absolutely complete. He (Dr. Goodall) was very much
surprised to read that statement, for he had been led to suppose that the experi¬
mental evidence, the unfortunately only too frequent occurrence of laboratory
infection, and cases such as that of the Paris nurse who developed typhoid fever
“ Whitehaven Report,” 1903.
.Epidemiological Section
219
after swallowing a pure culture of the bacillus with suicidal intent, were amply
sufficient to prove that the bacillus was the essential factor in the causation of
the disease. The second point to which he wished to refer was that of regional
immunity. He agreed with Dr. Hamer that the authors cited had by no means
proved its existence. It was worthy of note that Conradi attempted to account
for the immunity which he believed was possessed by the native adult popu¬
lation of Metz by supposing that the disease smouldered amongst the babies
and young children of that town. But it was a well-known fact that typhoid
fever was not a common disease of very young children, so that Conradi’s
hypothesis was quite inadequate to explain the adult immunity, even if that
immunity had been proved to exist. Thirdly, there was the question of the
earners. He was of the opinion that the explanation that had been given of
these cases had gone rather beyond the facts. Dr. George Dean had recently
published an account of a carrier of twenty-nine years standing, and both in
that paper and in a leading article in the British Medical Journal which com¬
mented upon it, it was confidently stated that during an attack of typhoid fever
the bacilli got into the gall-bladder, set up inflammatory" lesions therein, and that
these lesions subsequently recurred from time to time, apparently on these
occasions stirring up the bacilli into activity. Now, as a matter of fact, all
clinical observers were agreed that gall-bladder lesions were distinctly uncommon
during an attack of typhoid fever. During an experience of sixteen years at the
Eastern Fever Hospital the speaker had, out of a large number of autopsies,
met with only two in which lesions of the gall-bladder visible to the unaided
eye had been discovered. Bacteriologists stated that these carriers passed
bacilli in their stools only at intervals, often at long intervals. It was extremely
difficult to reconcile that observation with the gall-bladder hypothesis. Again,
it could hardly be supposed that carriers were frequent, or at any rate frequently
harmful. Otherwise there should be much more typhoid fever in this country"
than there was. Taking the average fatality of the disease at 16 per cent.,
according to the Registrar-General's return of deaths for the year 1906, there
were every year about 17,000 recoveries from typhoid fever in England and
Wales, of which he supposed a considerable number would be carriers. Another
point to be remembered was that return cases, such as were well known in
connection with scarlet fever, were very rare after typhoid fever. There was a
fallacy by which one might easily be deceived with respect to the connection
between a carrier and the outbreak of which he was supposed to be the cause.
Most of these carriers had suffered from typhoid fever some time before, and
were therefore immune to the disease. If such a carrier was exposed to the
infection of typhoid in common with a number of non-immune persons, say by r
drinking infected milk, it was quite possible that the bacilli would multiply in
his intestines and be passed in his stools without his becoming in the slightest
degree ill; on the other hand, those persons who were not immune would fall
victims to a general infection and have an attack of typhoid fever. It was
possible, for instance, that Mrs. H., in the outbreak at the Brentrv Reformatory,
was, in common with certain other inmates, consuming milk which had been
a —Hf
220
Discussion on Typhoid Fever
infected in some unexplained way. Mrs. H., having already suffered from
typhoid fever, would not become attacked again; but other persons, who had
not had the disease previously, would become attacked. Yet bacilli might, and
probably would, be found in Mrs. H.’s stools, having been conveyed to her
intestines in the infected milk, and she might, quite erroneously, be set down as
the cause of the other cases. Lastly, while the outbreak related by Dr. Davies
and Dr. Walker Hall had been investigated with great care and attention to
etiological details, the same could not be said of all the instances that had been
published. The explanation of the outbreak in the Scotch asylum recorded by
Dr. A. and Dr. J. C. G. Ledingham, and referred to more than once in the
papers to which they had just been listening, would not bear critical examina¬
tion. In that asylum cases of typhoid fever had been cropping up from time to
time since 1893, and probably they had occurred before that year. Yet of the
three inmates who were shown to be carriers, one had been in the asylum since
1895, when she had typhoid, another since 1896, and the third since 1904.
That these persons were carriers was doubtless true, but that they were the
cause of a disease which had been in existence in the institution before they
went to reside in it was a proposition which could only be characterised as
absurd.
Dr. C. J. Martin, F.R.S., said Dr. Seaton’s paper demonstrated the
inadequacy of water carnage as an explanation of all cases of typhoid ; but he
imagined that nobody believed that most fulminating outbreaks of typhoid were
not directly attributable to water contamination. He understood that since the
introduction of the Chamberland filter in the barracks of France typhoid fever
had become comparatively negligible amongst the troops. Dr. Davies’s and
Professor Hall’s pai>er had drawn attention in a striking way to the fact that
there might be outbreaks due to typhoid carriers, whereas Dr. Hamer had
shown the inadequacy of typhoid carriers as an explanation of epidemics of
enteric. It seemed a pity that typhoid carriers had been found, because as long
as enteric was accepted almost entirely as a water-borne disease the medical
officer of health was in a much simpler position, as he only had to have the
drains taken up and cause people plenty of expense and inconvenience, so that
they realised that he was doing something. He thought that Dr. Hamer’s
position as an agnostic was a very reasonable one, and he felt proud that
Dr. Goodall had associated him with Dr. Hamer. Nevertheless he thought
Dr. Hamer was a little heretical, and a good deal of his difficulty might be
answered. Dr. Hamer’s conclusion was that “ on a review of the facts now
known the conclusion may clearly be formulated that the chronic carrier is not,
as a rule, a source of mischief.” With the facts at our disposal that conclusion
might well be drawn, but he would point out that, supposing the chronic carrier
was not an immediate source of mischief, the true character of the factor in
the spread would he obscured. If a person got infected with typhoid, hut did
not have a severe attack, lie might long afterwards go on distributing th
affection, particularly if he got into such a position as that of cook to
regiment. Dr. Hamer also raised the question as to whether the typhoid
Epidemiolog ical &ec t io n
221
bacillus was the cause of enteric, and Dr. Goodall had charged him with having
expressed the same heresy. He did not remember what he himself said at the
Commission on Vivisection, but it was probably to the effect that the chain of
scientific evidence was not entirely complete, though the probability was strong.
The cl lain was not complete as in the case of the evidence in favour of the
anthrax bacillus being the cause of anthrax. One of the points raised by
Dr. Hamer was as to whether the typhoid bacillus was a secondary invader,
and lie referred to the analogy of hog cholera. The story of hog cholera was
a very interesting one. A certain bacillus, not unlike that of typhoid, was
stated to lie the cause of hog cholera. There were two varieties—one favoured
by Sir John McFadyean and one hy Salmon—that were more or less accepted
in this country and America because of their continual and almost universal
association with the disease. Dr. Hamer had quoted the experiments of Dorset
and his colleagues, which showed that these bacilli were not the cause, but that
these organisms occasioned a terminal affection, which invaded the body
towards death. Dorset’s work had been confirmed by McFadyean and
Stockman. When Dorset’s experiments came to his notice he felt it was
necessary to consider his position in regard to typhoid and many other things ;
but he thought there was no likelihood of our falling into the same error in
regard to typhoid, as there was sufficient evidence to show that a culture of the
typhoid bacillus would give rise to typhoid fever. The fact that typhoid fever
could not he exactly reproduced in animals did not matter very much. At the
Lister Institute there had been many observations made upon infection with
typhoid cultures, and the experience had been a rather sad one. Large quantities
of typhoid bacilli were being worked with which had been for numerous
generations out of the human body. There were nine cases of typhoid ; in fact,
nearly everyone who had been concerned in these researches with large
quantities of typhoid had taken the disease, so that considerable restrictions
had to he placed on the progress of the work. The other point made by
Dr. Hamer, namely, that the typhoid bacillus could remain in the alimentary
tract without causing definite infection, very much as the pneumococcus could
live in the throat without causing symptoms, had much truth in it, and there
was some analogy between typhoid carriers and pneumonia carriers.
Colonel FlHTH, K.A.M.C., said he had been much impressed with the papers
which had been submitted ; they presented the subject in a very catholic way.
From his own experience he could not go so far as Dr. Hamer, though he was
much charmed by the boldness of his suggestions. There were men, doubtless,
amongst those present, who had had their doubts about the precise etiological
significance of the Bacillus typhosus , but he did not think it could be abandoned
as the true causative agent of enteric fever. He (the Colonel) had had no
experience of carriers, though he had done his best to find them, and, of course,
his experience had been amongst soldiers. Recently a regiment came into the
command in which he was serving which had enteric fever badly last summer.
They were transferred to Aldershot, and a series of cases kept on cropping up
at intervals among them, but search for carriers proved unsuccessful ; but that
Discussion on Typhoid Fever
2 22
might be an accident and they might still exist. The net result of the inquiry
was that in this particular series of cases he was convinced the carriers of the
infection were the blankets and clothing of the men. Acting on that assump¬
tion he impounded all the blankets and bedding and subjected them to thorough
disinfection by steam. Since that had been done cases had ceased to crop up ;
possibly there might yet be some carriers discovered. Two autumns ago he
had to enquire into an outbreak of enteric occurring in a Militia battalion at
Fleetwood, which was entirely limited to the officers’ mess, among whom there
were fourteen cases. The conditions as to water and milk were the same as for
the men. There were five deaths. The cause was found to be a waiter at the
mess, who was found to be an ambulatory case of enteric, and was run to earth
in hospital in an almost moribund condition. It had to be recognised that in
enteric one had to deal with a hydra-headed disease, and it was necessary to
keep all the possible causative agencies in proi>er perspective ; one must not say
it was always the water, or always the milk, or always a personal carrier. It
might be derived from a variety of subsidiary agencies, such as shellfish and
watercress. The impression left upon his mind, after listening to the papers
which had been submitted, was that we needed to go into each case of enteric
infection very carefully and be prepared to find sources of infection where least
expected. The existence of carriers could not be disputed, but it seemed
probable that all carriers of the Bacillus typhosus were not necessarily
potentially infectious at all periods of the year. The facts shown by Dr. Davies
were very suggestive on this point, and it was worth bearing in mind that
possibly the enteric bacillus in the alimentary canal of a “carrier” had cycles of
dormancy and of infcctivity. What the controlling factor was we did not know.
l)r. FRANKLIN Parsons said it was difficult to know what Dr. Seaton
meant by the “ water theory.” If it meant that typhoid was conveyed only
by water, he did not know that anyone had maintained that. If it meant that
water was one of the means of spread, he would be a bold person who would
deny it. As to the small number of cases traced to water, it must be
remembered that that source had long been known, and that therefore care
had been taken to protect wells, &c., and thus make that means less effective.
Hence the circumstance that, of the greatly reduced number of cases of typhoid
fever now occurring, only comparatively few could be traced to water infection
was not inconsistent with the view that in old days the water supply was a
common mode of spread of the disease. With regard to the distance which
infective matter might travel through fissures in the chalk strata, he mentioned
the case of Beverley, in which two outbreaks of enteric fever had been reported
upon—by Dr. Page, in 1884, and by Dr. Farrar in recent years. At Beverley
most of the water supply was obtained from the company and a portion
from artesian wells which had been sunk privately. A mile away from the
company’s source was a brook which, after receiving the sewage of a village,
disappeared in a hole in the chalk. In 1884 Mr. Baldwin Latham made a test
by putting into the hole a salt of lithium, and in a short time lithium was
traced spectroscopically in the water of the company’s well.
Epidemiological Section
223
Dr. WHEATON said lie ranged himself on the side of Dr. Hamer in regard
to carriers. He thought it most likely that there was a connection between
the Bacillus typhosus and some other organism which produced typhoid fever.
If that were not so, why was it that in such severe and well-known outbreaks
as that at Maidstone, undoubtedly produced by infection by water, the bacillus
of typhoid could never be found ? In these cases the bacillus could not be
detected in such a comparatively sterile medium as water, yet one was
constantly told that the bacillus was easily discovered in subjects of the disease
in the faeces, i.e. t in a material positively swarming with other organisms. In
institutional visitations of the disease, his experience had been that it was
nearly always associated with defective drainage, and much allowance could be
made for overlooking such defects when it was remembered how difficult it
was to detect them and what a variety of defects was possible.
Dr. ANDREWES said he wished to mention an epidemiological point and
a bacteriological one. With respect to the first, as sanitary officer to
St. Bartholomew’s Hospital it was his duty to make inquiry into all cases
of infective disease which arose within its walls. Among those was a certain
proportion of cases of typhoid. During the last fifteen years the number would
work out at an average of two or three nurses i>er year attacked by typhoid.
Much more rarely a patient was attacked—perhaps four or five in the last
fifteen years. The interest of these cases is that they were practically all contact
cases, for the cases arose in medical wards, not in the surgical. There had
been, in his experience, one or two cases of surgical nurses being attacked, but
in one, at least, of these an unsuspected case of typhoid had been present in
the ward. These facts prepared him to believe in contact cases to a greater
extent than Dr. Hamer appeared to believe. On the bacteriological point he
confessed he found himself unable to agree with the attitude of scepticism
adopted by Dr. Hamer in his paper. It would take too long to go into all the
reasons for that, but he would mention one. It was known that prophylactic
inoculation with the Bacillus typhosus conveyed a certain measure of protection.
Where that measure had been carried out thoroughly and efficiently, statistics
showed that the protection was of a very high order. That one fact seemed
to upset the idea that the Bacillus typhosus had only a secondary and accessory
relation to the disease.
Sir Shirley Murphy desired to mention one fact in connection with the
readiness with which it was said food could be infected by a cook. Thirty or forty
years ago he was resident medical efficer at the London Fever Hospital, and at
that time the hospital was so arranged that a small kitchen intervened between
the scarlet fever ward and the typhoid fever ward. In that kitchen was kept a
large receptacle for milk, which supplied the needs of both wards. The nurses
were in the habit of walking out of the typhoid ward into the kitchen and ladling
out the milk required for their patients, and the nurses from the scarlet fever
ward did the same. How that milk contrived to escape infection during all
those years passed his comprehension.
224
Discussion on Typhoid Fever
Colonel DAVIES, R.A.M.C., desired to remark on the question of conveyance
through chalk. Probably most jieople derived their ideas as to the wholesome¬
ness or otherwise of the water supply from the opinion of the Rivers Pollution
Commission : that a chalk supply was a particularly pure one. At the Brussels
Congress, in 1903, he was rather surprised to find a chalk supply regarded with
suspicion; indeed, the Congress unanimously passed a resolution that all chalk sup¬
plies should he carefully watched, on account of possible imperfections of filtration
in fissured strata ; that they should be subjected to minute inquiry, geological,
chemical, and biological; and that strict supervision should be carried out,
both as to the water itself and as to the catchment area. He was led to take
up that point in inquiring into the supply for military camps on Salisbury Plain
and with regard to sewage disposal. There might be a good layer of alluvium
over the chalk, or the layer might be very imperfect; but there was considerable
risk of polluting that chalk, and therefore the water derived from it. He did
not know how deep the layer of soil should be, but in some cases there was not
a greater depth than 3 in. or 4 in., and that might be easily worn away.
The French observer, Martel, of Paris, did not regard chalk as a filter, or even a
sponge, but as a sieve. That seemed an exaggeration of the danger if the chalk
in question were solid ; but if it were fissured it was quite true, and it was well
known that water could not be obtained from solid chalk. In boring through
chalk one had to wait until a fissure was readied before procuring a good supply,
and such fissures might be miles long, and bacilli might therefore be conveyed
great distances. At Salisbury Plain he made experiments to determine how far
the bacteria would travel vertically; a tunnel was driven into the hillside, and
he discovered the Bacillus coli 9 ft. deep on ground which had been treated with
sewage. That was through absolutely solid chalk, without any fissures or cracks
of any kind which he could see. If the bacillus could go down 9 ft. in the time
allowed, he supposed that in time it would go 19 ft. or even 29 ft., and when it
arrived at a fissure it could be carried many miles, as Dr. Richards had said.
One important point in regard to chalk formations was as to whether the chalk
was covered with a sufficient layer of loam to oxidise surface impurities ; another
important ]x>int was the existence, extent and distribution of fissures.
Major Horkocks, R.A.M.C., said that during the last year he had been
working at the typhoid problem. If he had patients in the first week of illness
he could commonly recover the bacillus from the blood ; in the second and
third weeks of the illness he obtained it from the faeces. He felt convinced that
the Bacillus typhosus was associated with the disease. He had investigated the
question of carriers. The cases in Gibraltar were sporadic. As medical officer
of health there lie had control over the civil cases, and was able to trace what¬
ever communication there was between them, but he could not find any com¬
munication between the civil and the military cases. He went into the question
of contact cases in the barrack rooms themselves, and he found that in every
barrack room where there was enteric fever there were one or more soldiers
giving the blood-reactions of the typhoid bacillus. As a control of that he took
other barrack rooms where there were no typhoid fever cases, and, curiously,
Epidemiological Section
. 225
in a series of barrack rooms where there had been no enteric for a year he
found men giving blood-reactions up to dilutions of 1 in 100. Those studies
were made during epidemic time—August, September, and October. He had to
leave Gibraltar before he was able to complete the work in the winter; lie had
hoped to find out whether the same was present during the winter, i.e. y whether
during the winter the soldiers showed the summer reactions ; if not, it seemed
important as showing that soldiers, during the epidemic period, had changes
going on in their bodies, though he could not say whether that was due to the
presence of the bacillus in their bodies. In his work he had failed to isolate the
typhoid bacillus from the supposed carrier cases, but from a man in one barrack
room he isolated an organism which he at first regarded as the true typhoid
bacillus ; it gave the reactions, except that the glucose was fermented very
slowly, and it was agglutinated by a horse antityphoid serum and patient’s sera
in the same dilutions as the stock Bacillus typhosus , but when injected into a
guinea-pig it did not produce a serum reacting with the stock typhoid bacillus.
That was interesting, because from that barrack room lie got two other cases
of typhoid fever.
Dr. Prausnitz said it had been stated that the typhoid bacillus had never
yet been recovered from water supplies which were supposed to have produced
typhoid epidemics. On the Continent a number of cases were on record in
which the bacillus had been isolated from the water supplies which caused the
disease. The most important of those occurred at Prague, where the bacillus
was detected in the River Moldau and in the water supply of the town at the
time when a considerable number of typhoid cases existed.
Dr. BUTLER said he should like to speak from the point of view of the not
too incredulous practical person. The sceptic and the agnostic had approached
the questions they were considering with becoming philosophical aloofness, and,
ultimately, he supposed they all would still retain those scientifically acquired
resources of healthy scepticism. It was not certain, for instance, that there
was any uniformity in the course of Nature, and thus the basis of causation was
entirely an assumption when natural science was dealt with. But for practical
purposes certain observed unvarying sequences were accepted as sufficient evi¬
dence of etiological connection, and he thought he must be a bold man who
did not recognise in the paper of Dr. Davies and Dr. Hall a measure of evidence
of the truth of the causal connection between the carrier cases discovered and
the outbreaks they were investigating, sufficient to satisfy him of the need for
interference. If in the circumstances there presented nothing were done ; if the
sceptical attitude were maintained in practice, it was certain that the institution
epidemics would not have been stamped out. Practically they were satisfied
that carrier cases were effective in the spread of typhoid fever. One feature of
the carrier cases which was eminently striking was the intermittency which
marked the voiding of typhoid germs. On the assumption that typhoid bacilli
were causally related to typhoid fever, this was a case in which the intermit¬
tency of infectiousness was definitely established. Perhaps this fact bore upon
Dr. Goodall’s question as to why there were not return cases of typhoid, follow-
226
Discussion on Typhoid Fever
ing those which were discharged from hospital. They must remember that it
was many years l>efore return cases of scarlet fever were recognised, although
they must have been occurring since isolation was carried out. In the case of
typhoid the discovery of the return cases was further complicated by the inter¬
mittent infectiousness of the infecting cases, while on the other hand typhoid
fever was less common, and the return cases in consequence likely to be fewer
in number. It would therefore be premature to assume that they did not
occur.
Dr. Bond thought that one reason why return cases of typhoid fever were
not heard of was that they were called relapses on return home, and as it is
not customary to speak of secondary cases of typhoid as “return ” cases, such
cases are not so recorded. “ Return ” cases, however, do occur, for he had had at
least four such cases in the Holborn borough in recent years. “ Contact ” cases
were often heard of. In one of the districts of which he had been medical
officer there had been many contact cases, especially amongst the nurses of a
large hospital. When one read of the number of different germs which had
been supposed to cause such diseases as influenza and scarlet fever, it w T as not
surprising that Dr. Hamer should be sceptical as to the causal agent of typhoid
fever.
Dr. DAVIES, in reply, said that there had been very little criticism with
regard to the two outbreaks he had narrated, and he regretted that some of
the difficult points arising in the case of “ carriers ” had not been cleared up.
A very important question was the future control of “ effective ” carrier cases ;
for example, in the outbreaks quoted a woman inebriate concerned in the produc¬
tion of some sixty cases and four deaths will, on the expiration of her time,
be discharged, free to take situations in institutions or families. Although Dr.
Goodall was unaware of any “ return ” cases after discharge from his hospitals,
it must be remembered that this Bristol carrier was discharged from the Royal
Infirmary in 1901, and the physicians there did not know of the “ return ” cases
until they were elucidated by the present inquiry. Dr. Goodall’s warning that
the presence of a carrier ” in an institution at the time of an outbreak did not
prove that she was the cause of the outbreak was guarded against by the control
experiment of the previous outbreak at Brislington. The few instances in which
“carriers” become “effective” is explained by the necessity for opportunities
such as are afforded by dealing with food. If no such opportunities are present,
carriers are comparatively harmless ; if their habits are dirty and careless, and
they deal with food, or especially with milk, they become intermittently
“ effective.” Sir Shirley Murphy’s nurses were evidently well trained and a
credit to their hospital. As to Dr. Martin’s reference to “ drains,” and the easy
way in which outbreaks of typhoid fever could be referred to them, Dr. Davies
had intended to refer to the point. It was now time that the public should be
taught that “ drains ” had a very limited connection with the causation of
disease, and that a medical officer of health is not primarily interested in them.
He personally referred persons wishing to discuss drains to the sanitary in¬
spector, who was specially concerned in the matter; the medical officer of
Epidemiological Section
227
health is primarily interested in the causation of disease, which in the case of
the communicable diseases generally is a complex subject involving the study of
the life-history of the causal organism and its migrations and variations in
persons, animals, or places. He should be an epidemiologist first, a sanitarian
afterwards.
Professor WALKER Hall, in reply, said that the clinician had begun to ask
what he should do with typhoid cases as he discharged them from hospital.
A very useful function would be performed by the Section if suggestions on the
matter could be formulated. The public had a right to be supplied with definite
information on the matter, although admittedly much yet remained to be done
in regard to the bacteriology. There was also the question whether hospitals
might distribute printed pajjers to typhoid convalescents detailing the pre¬
cautions to be observed. Where a mother had been discharged after an attack
of typhoid fever, and w r ent back to her household duties, cases came back to
hospital from that family. It seemed to be really a matter of the handling
of food. If typhoid carriers did not have to do with food they did not seem to
be a danger to the public, and that fact needed emphasising in the pro]>er
quarters.
Dr. RICHARDS, in reply, said, in reference to Dr. Goodall’s remark con¬
cerning return cases, there did not seem any very distinct line between contact
cases, return cases, and carriers. Return cases were only carriers which
occurred in a limited time. For a long time his experience was the same
as Dr. Goodall’s. He had not seen a definite return case until last year, and
then a patient failed with enteric fever three months after the return home of the
father. Yet there were only about fifteen cases in Croydon in that year. At
about the same time the father developed an obscure abdominal abscess, prob¬
ably perinephritic, which discharged through the bladder; and probably that
was the cause of the infection in the child. He could not complete the case
bacteriologically because the man was admitted into a London hospital, where
no bacteriological examination was made. It seemed to be a genuine return
case of enteric fever.
Dr. HAMER, in reply, said that there were two main classes of difficulties to
be faced ; there were those arising out of the association of institution outbreaks
with chronic carriers, concerning which he had already spoken, and there were
those connected with cases of laboratory infection. Some of the last-named
were not worth much ; little detail was given ; or, again, alternative explanations
were possible. For instance, there was the case referred to by Dr. Goodall, that of
the hysterical French girl. Those who read the original description of that case
would certainly feel that it was by no means conclusive. He remembered
discussing the question of the typhoid bacillus some time ago and being silenced
by being told that the one argument which was unanswerable in this connection
was that based upon the cases of laboratory infection. He (Dr. Hamer) had
been interested, on looking into this matter since that time, to find the
matter was not free from all doubt, for it was admitted that the conditions
of scientific experiment were not rigorously fulfilled in these laboratory
Discussion on Typhoid Fever
228
-experiments. The cases mentioned by Dr. Martin were certainly difficult
to explain away, but even with regard to them there remained, perhaps, the
possibility that there were circumstances in common, other than the par¬
ticular circumstance held to be incriminated ; workers in laboratories were,
moreover, oftentimes liable to be infected by original material as well as by
the bacilli in pure cultures. In reply to Dr. Andrew T es, he could not agree
that the prophylaxis difficulty was a fatal one; it was generally admitted there
was close association between typhoid fever and the typhoid bacillus, and that
being so, cultures of typhoid bacilli might conceivably have a prophylactic effect.
The existence of such effect, if demonstrated, would not necessarily prove that
the typhoid bacillus was the causal organism of typhoid fever.
EptoemiolOGtcal Section.
April, 1908.
On an Epidemic of Small-pox of Irregular Type in Trinidad
during 1902-4.
By R. Seheult, M.B.
Small-pox was so prevalent in prevaccination times that hardly any¬
one escaped the disease. It entered the palace of the king with the
same freedom as it did the hovel of the peasant; it penetrated every¬
where, carrying desolation with it. Those who escaped death were left
disfigured or crippled for life; almost every face was seamed and
scarred, and on every side were met the blinded victims of the scourge.
At times whole towns were depopulated. When the contagion fell
upon virgin soil it raged with special virulence and wrought dreadful
havoc. Among the black races, whole tribes were extirpated ; its
ravages were then fearful to contemplate, and the mortality which
followed in its train was appalling. Macaulay, in his “ History of
England/ 5 thus alludes to this scourge in speaking of Queen Mary’s
death from it in 1694 :—
That disease, over which science has achieved a succession of glorious and
beneficent victories, was then the most terrible of all the ministers of death.
The havoc of the plague had been more rapid, but the plague had visited our
shores only once or twice within living memory. The small-pox was always
present, filling the churchyard with corpses, tormenting with constant fears all
those whom it had not yet stricken, leaving on those whose lives it spared the
hideous traces of its power, turning the babe into a changeling at which the
mother shuddered, and making the eyes and cheeks of the betrothed maiden
objects of horror to her lover.
Even more impresssive than this classical picture of the great-
historian is the evidence presented by statistics, in which is crystal¬
lized the experience of entire nations. The features of this loathsome
my —6
330
Seheult: Small-pox in Trinidad
and destructive disease were then familiar even to the man in the street,
and medical men had ample opportunities of becoming thoroughly
acquainted with its various manifestations; but since the discovery, or,
more correctly speaking, the introduction, of vaccination by the immortal
Jenner, this most dreaded of all the infectious diseases has been by
degrees stamped out in all civilized countries, or at any rate its pre¬
valence has been lessened to such an extent that there are nowadays
many experienced physicians who have never seen a case. Further¬
more, the practice of vaccination has rendered the diagnosis more
difficult, as the phases of the disease have been made by it far more
numerous and intricate than they were before. It is not surprising,
therefore, since its epidemic character has been so greatly modified by
vaccination and other causes, that difficulties in recognizing its true
nature are experienced at times.
After the great pandemic of 1871—2, small-pox did not again appear
in the Colony of Trinidad until April, 1902, when the disease was
introduced in a very mild and irregular form, giving rise to considerable
diversity of opinion in regard to its nature. Among the sixty medical
practitioners in the island there were not eight who had had any ex¬
perience of this disorder; and even the doyen of the medical faculty
there, who had witnessed the terrible ravages of small-pox in 1871—2,
was misled by the aberrant symptomatology of the disease in this latter
epidemic, and failed to recognize its true nature. The outbreak, which
commenced in 1902, appears especially deserving of detailed study,
having in view the interesting points connected with the origin and
spread of the epidemic, the somewhat anomalous features presented by
the disease, the instructive results obtained in regard to the relation
of vaccination to it, and, above all, the mortality, which was so
strikingly low.
The following account of the origin of the epidemic in Trinidad is
taken from a pamphlet by Dr. Dickson, the Assistant Medical Officer of
Health, and Dr. Lassalle, Assistant Surgeon, Colonial Hospital, Port-of-
Spain, entitled “Varioloid Varicella in Trinidad.” This paper was
read at the meeting of the British Medical Association at Swansea
in 1903:—
The first case of which there is a record was that of an inmate of the
Lunatic Asylum, St. Ann’s. The asylum is situated in an isolated position,
beyond the limits of the town. This patient had been an inmate of the asylum
for some years, and developed the disease on April 16, 1902. The case was
isolated on the appearance of the rash, but other cases appeared during May,
June, July and August, until nineteen inmates and attendants, all adults, were
Epidemiolog ical Sec tion
231
affected. The source of infection could not be traced, and must have been
either a visitor or attendant who had a mild attack and escaped notice. The
cases w T ere returned as “ varicella,” but the medical superintendent has since
reported that they were similar to the cases of eruptive fever now occurring, and
in one instance—that of an attendant who had the disease in August, 1902—a
few pigmented marks identical in appearance with the macules already described
were visible up to a month ago. It is of interest, that of the nineteen cases,
ten were in vaccinated and six in unvaccinated persons, and in three the
evidence of vaccination was doubtful. The patients most severely attacked were
an inmate vaccinated in infancy and an attendant revaccinated in 1898, and
showing three good marks of successful vaccination. 1
On May 2, 1902, a similar case in an adult was reported from Woodbrook, a
suburb to the west of Port-of-Spain. Cases next occurred in Dundonald Street,
in the north-west of the town, in September. Early in October a woman
who lived in a barrack-yard in the south-east of the town developed the
disease within a fortnight of her arrival from Yrapa, in Venezuela. About the
third week of October a case, that of a trader who had recently come * from
Guiria, in Venezuela, occurred in Duke Street, about the middle of the town.
Both of these cases lived in densely tenanted barrack-yards, did not seek
medical aid, and were not reported at the time; other inmates of these yards
were subsequently affected, but this fact was discovered only in the early part
of December and after they had recovered. During November eleven cases
occurred in the middle and south-east of the town, and though in all prob¬
ability the two cases above quoted were the sources of infection, yet there is
ground for believing that in three of the cases the contagion was derived from
other sources. Five of the cases occurred in one yard in Duncan Street in the
first week of November, and of these, two who showed the most distinct vac¬
cination marks were most severely attacked. During December eight cases were
reported from the eastern, south-eastern and middle portions of the town. Of
these, one was a vagrant who developed the disease within a week of his arrival
from Yrapa. In January, 1903, a house to house inspection was instituted,
other cases were discovered in various parts of the town, and the disease began
to assume epidemic proportions. At first the majority of persons affected were
hucksters, sailors and quay labourers, that is, were of that class of the popula¬
tion which would earliest be exposed to contact with an imported disease.
Reports of the prevalence of a similar disease in the adjoining coastal
villages of Venezuela had for some time been circulated, and early in
February information was received that several deaths had occurred, and
that the disease was now stated to be variola. With the view of
obtaining accurate information a commission of two medical practitioners,
one of whom had had extensive experience of small-pox, was sent to
Venezuela to investigate and report upon the nature of the eruptive
With regard to the influence of vaccination see p. 281.
232
Seheult: Small-pox in Trinidad
fever prevalent there. The commissioners visited Yrapa and Guiria.
The following extracts are taken from their report:—
The disease had existed in Yrapa for nearly a year and had not varied in
character, that is, had always been a mild affection. Two deaths had occurred
in the country around ; one was that of a chronic alcoholic, the other died
probably more from privation and neglect than anything else. We visited
Messrs. Fournelli and Cottin, both Frenchmen long established in Venezuela.
Their household had not been attacked, and they were under the impression
that Europeans were spared. Mr. Fournelli stated that in Carupano, where
there was a large European community and where this disease had been very
prevalent, no European had been attacked. These gentlemen informed us that
no alarm was ever felt at Yrapa about the sickness, that they called it “lechina”
(Spanish for chicken-pox). As a proof of the mildness of the disease they
referred to the attack of Guiria by the revolutionary forces from Yrapa, where
many of the troopers, though covered with the eruption, carried their Mausers
cheerfully to battle.
The commissioners came to the conclusion that the disease was
exactly of the same nature as that occurring in Port-of-Spain, and that it
was not small-pox. They expressed the opinion that the disease was
imported into Trinidad from Yrapa. There is a large daily passenger
and trade traffic between Port-of-Spain and the villages on the adjoining
Venezuelan coast, and the voyage does not occupy more than a day.
Under these circumstances, and in view of the instances above quoted,
there seems to be little doubt that the disease was introduced into
Trinidad from Venezuela. I may here add the population of Yrapa is
about 12,000 and is practically unvaccinated.
So aberrant and misleading were the clinical features of the disease
that its real nature was unrecognized in Trinidad except by a few. As
I had charge of the isolation hospital for seven months, and treated 504
cases, I had the opportunity of studying closely its various manifesta¬
tions. I was also placed in charge of the maternity ward, where fifty-one
women, who had the disease during pregnancy, were delivered.
Three different theories were advanced to explain the nature of the
“ eruptive fever.” At the commencement of the epidemic, and indeed
for a considerable time after, many of the medical men in the Colony
considered the disease to be chicken-pox of an aggravated form ;
the coexistence of syphilis and other constitutional taints, as well as
the presence of diathetic tendencies, were put forward to explain the
unusual severity of many of the cases. This theory was eventually
abandoned by all.
Those who could not countenance or accept this view of the nature of
Ep id e m iolog i c a 1 Sec t ion
233
the disease, and yet did not feel justified in considering it to be small-pox,
suggested the possibility of the existence of a hybrid between variola
and varicella, just as rubella was once considered by Schonlein and other
writers to be a hybrid between scarlatina and morbilli. This theory,
however, was never seriously maintained, but many were of opinion that
the disease w T as a specific entity, and called it “ varioloid varicella,” owing
to its supposed similarity to an eruptive fever which occurred in epidemic
form many years ago in Jamaica, and was described under that name bv
Dr. Izett Anderson, of Kingston.
I need not comment upon the name “ varioloid varicella,” which is
wholly unscientific and misleading, but some reference to the possibility
of the existence of a new disease in the form assumed by this epidemic
may not be out of place here. It is well known that at one time
measles, scarlatina, rubella and the “ fourth disease ” were included
under one name and were regarded as one malady. With the progress
of medical science they were gradually differentiated one from another, so
that at the present day they are considered to be perfectly distinct and
definite diseases.
It was not until the close of the seventeenth century that scarlet
fever was distinguished from measles, whilst the differences between these
two diseases and rubella were fully indicated only about the middle of
the eighteenth century, when that disease became known as “roseola.”
The existence of the “ fourth disease ” as a specific entity has been
claimed within very recent years.
Similarly small-pox was for a long period confounded with measles,
and even in the sixteenth century, when the former disease was generally
recognized, errors of diagnosis were not infrequent. English writers in
the early part of the eighteenth century mention varicella as a variety
of small-pox, but the end of that century saw the differences between them
clearly established.
Can the eruptive fever which forms the subject of this paper be
regarded as the “ third disease ” in the second group of infectious dis¬
eases which I have mentioned above, taking its place between varicella
and variola ? I think not.
The evolution of the diagnosis of the infectious fevers was no doubt
in the main due to careful clinical observation, but in those instances,
where inherent difficulties of diagnosis existed by reason of very close
resemblances, the application of Cullen’s law was necessary. “ One attack
of an eruptive fever entails immunity from a second attack in the same
individual during childhood.” This law has been regarded as a means of
234
Seheult: Small-pox in Trinidad
differentiating some of the very closely allied eruptive fevers, and, indeed,
as the final test in their elucidation; even now, where the bacteriologist
fails to enlighten in such cases, it may prove a very valuable test.
The opportunity for the application of this principle in the present case
has not arisen, but we have in vaccination a somewhat analogous and
equally convincing method of differentiation which can be applied to
distinguish other eruptive diseases from variola. Vaccinia and variola
are mutually protective, and if the same relation exists, as I shall
endeavour to prove, between vaccinia and the disease under review, it is
reasonable to infer the identity of the latter with variola.
Although some of the characteristics of the Trinidad epidemic were
very unusual and aberrant, yet the more salient features of the disorder
were identical with those of small-pox, so that apart from the vaccina¬
tion test there are grounds for the belief that the two diseases differed
only in type. In connection with the theory that the disease was a
new malady, the recent volcanic disturbances in the West Indies,
notably in Martinique and St. Vincent, appealed to the popular mind,
and the disorder was promptly attributed to these convulsions of
Nature.
The third view on the subject, and in my opinion the correct one,
as I have already indicated, w r as that the prevailing eruptive fever w r as
an irregular form of small-pox. To Dr. Masson is due the honour of
having been the first to recognize the variolous nature of the disease.
Early in November, 1902, he was called to see, in Duncan Street, Port-
of-Spain, a few cases of an eruptive fever which he at once suspected
to be small-pox. In this the Acting Surgeon-General of the Colony and
the Assistant Medical Officer of Health and others who saw these
cases did not concur; they held the opinion that the disease was
chicken-pox. In accordance with this official declaration no steps what¬
ever were taken to prevent the spread of the disease or to circum¬
scribe its area of infection until much later, when it became so
widespread as to be almost beyond control. On the other hand it
must be admitted that it would have been difficult to prevent dis¬
semination in view of the extreme mildness of a large proportion of
the cases. In any case the failure on the part of the Health Depart¬
ment to recognize the true nature of the disease led to its wide
diffusion in the town and its invasion of the country districts. This
was a blessing in disguise, for the disease not only retained its mild
character throughout the epidemic but it spread far and wide in the
country, so that a large proportion of the population have become
Epidemiological Section
235
immune from small-pox at a very small sacrifice of lives, through
protection afforded either by an attack of the disease or by the
operation of vaccination, which the people largely availed themselves
of. Fortunately the clamour of the anti-vaccinationists has not yet
reached this Colony, nor does a “ conscience clause ” exist in our
Vaccination Ordinance. Dr. Masson was not satisfied with the decision
arrived at by the health authorities. Early in December, 1902, he
visited Barbados, another West Indian island, which was in the throes
of a small-pox epidemic of a more or less mild form, with the object of
studying its clinical features and for the purpose of comparing them with
those of the cases which he had seen in Port-of-Spain. His observa¬
tions in Barbados only confirmed his former views on the matter. At
first the medical men in Trinidad felt great difficulty in accepting his
diagnosis owing to the unusual and variant features of the disease, but
subsequently, when they became more intimately acquainted with the
epidemic, many recognized the correctness of his contention.
In the meantime the disease, which had hitherto spread very slowly—
so slowly that it did not attract any particular attention—began to assume
epidemic proportions in the town at the beginning of the year 1903, and
to cause much alarm and anxiety to the authorities. Early in 1903
certain measures were adopted to repress its growth. As many cases as
possible were sent to the Isolation Hospital, but for want of accom¬
modation the vast majority of the patients were treated at their homes.
In February, 1903, two medical men were specially appointed for this
purpose. Contacts were vaccinated, and revaccination was encouraged
generally. The disease continued to spread, and, owing to its mild
character, many of those affected by it were seen in the streets in its
various stages, and in some instances they were actually able to pursue
their daily labours. In order to protect the public health against the
so-called “ varioloid varicella,” certain regulations were made by His
Excellency the Governor in Executive Council, but these were never
strictly enforced, and the disease followed untrammelled its own course
and spread throughout the whole island.
From April 16, 1902, when the first case was discovered, to Decem¬
ber 31, 1902, there were only sixty cases reported. The extremely slow
and insidious spread of the epidemic was one of the circumstances which
led the profession to persist in the error of diagnosis. The negro race is
known to be especially susceptible to the contagion of small-pox, and
when their conditions of life in crowded barrack-yards and their ignorance
of ordinary sanitation are considered, the slow advance of the outbreak
23(3
Seheult: Small-pox in Trinidad
is very remarkable. It was only in January that the outbreak began to
assume epidemic form, reaching its maximum height in May, and then
gradually declining until its entire disappearance from the town in
November, 1903, and from the country in January, 1904.
It must be borne in mind that although the native population is a
fairly well vaccinated one, owing to the rigidly enforced Vaccination
Ordinance, there is a large influx of unvaccinated immigrants from
neighbouring islands and from Venezuela, where apparently vaccination
is not in great favour. For ten years" ending in 1900 the average
proportion of vaccinations to births in Trinidad was 8311 per cent. In
the year 1898 the corresponding proportion was 96*48 per cent. Such a
result is not probably equalled in any other part of the British dominions.
Among the 564 cases which came under my observation in the isolation
wards only 118 were Trinidadians, the rest being aliens, and of these
254 hailed from Barbados {see Table I.). The protection afforded to
the Colony against an epidemic of small-pox w r ill not be complete until
provision is made for the successful vaccination of the large number of
unvaccinated persons coming from the other Colonies and the adjacent
continent. Every immigrant should be required to exhibit proof of
successful vaccination before being allowed to land in this country, as is
done in some States of America.
The slow spread of the epidemic was due to the slight infectivity of
the disease. In many cases the contagion or virus seemed to require
intimate contact for its transmission from one person to another, and
even then it was remarkable how frequently instances were found in
which such contacts escaped infection. The Assistant Medical Officer
of Health, ito a pamphlet already referred to, mentions that in several
instances in barrack-yards persons in close association with those affected
by the disease did not contract it and subsequently reacted to vaccination.
Such a case came under my own observation. A large number of patients
were admitted to the general wards of the Colonial Hospital in the
incubation or invasion period and were removed to the Isolation Hospital,
only a day, or sometimes two days, after the appearance of the rash, and
yet no fresh infection took place in these wards. Two cases which
developed the disease in the House of Kefuge were transferred to the
Isolation Hospital in the vesicular stage and none of the other inmates
contracted the disease. Four cases which were sent to the male and
female prisons in the incubation period were removed to the small-pox
wards only after the rash had appeared, and yet there was no spread of
the disease in these institutions, although there was no disinfection of any
Epidemiological Section
237
of these buildings. It was frequently observed that children born of
mothers in the invasion period or early eruption stage of the disease
escaped infection when they were removed from the mother within two
or three days after birth, but when left with her until pust.ulation or
desquamation had commenced they invariably contracted the disease.
The isolation w T ards were only 99 ft. from two of the nearest general
wards of the Colonial Hospital, and only one patient in each of these wards
developed the disease; one was thirty days and the other sixty-five days
in hospital before the initial symptoms of small-pox showed themselves.
It may be remarked that there were at this period more than 100
small-pox patients in all stages of the disease under treatment in the
isolation wards. From these observations it may be inferred that the
infectivity of the disease was slight, that the most active period of infec¬
tion was during pustulation and desquamation, and also that aerial
convection, which is held by some recent observers to play an important
part in the dissemination of small-pox, was apparently not concerned as
a factor in the diffusion of this epidemic.
The mode of spread of the disease to the country districts was also
very interesting. It was only in January that the disease occurred in
two districts, Tacarigua and Blanchisseuse, which are widely separated
from each other. The cases were derived from Port-of-Spain, and
occurred on January 8 in the one and on January 24 in the other.
The next cases in these districts occurred on February 5 and 12
respectively, and no further cases appeared until April 3 and May 1.
The first case which occurred in Blanchisseuse was that of a man who
arrived on January 21 from Port-of-Spain, where he had associated with
persons suffering from the disease. Three days after his arrival he
developed the initial symptoms of the disease.
In March several other districts became infected; the diffusion of
the contagion to the country districts in March is readily accounted for
by the fact that there is always a large influx of country visitors to
the town to witness the annual “carnival,” which is held at this period
of the year.
The first case which was admitted to the Isolation Hospital was
that of a woman who was received into one of the general wards of
the Colonial Hospital with an infant 35 days old, on November 22, 1902.
On December 4 she developed the prodromal symptoms of small-pox,
and was then transferred to an isolated room with her infant. I
afterwards discovered that this patient had come from a house where
there were several cases of “ eruptive fever.” Her child developed the
238
Seheult: Small-pox in Trinidad
disease on December 21, 1902, that is, seventeen days after the mother
had shown symptoms of small-pox. On January 4,1903, it was found
necessary, on account of the number of cases seeking admission to
hospital, to provide further accommodation. Accordingly a ward con¬
taining sixteen beds was opened on that day, but at the end of February
it had become so overcrowded that another with twenty-two beds was
provided on February 28. On March 1, forty-two patients were under
treatment. Owing to the rapid spread of the epidemic during this
month both wards soon became overcrowded. On March 19 there were
no less than sixty-six cases in hospital, so that only the urgent cases
were then admitted. On March 27 the number had risen to eighty-six.
A third ward with seventy-five beds was opened, but in a very short
time this increased accommodation was barely adequate, for on April 2
there were no less than 103 cases under treatment. In May a gradual
decrease in the number of cases seeking admission began to take place,
and this continued until October. The last patient was discharged on
the 19th of that month.
This eruptive fever, as already mentioned, was at its onset officially
declared to be chicken-pox, but this diagnosis was revised and altered in
the month of March, 1902. The disease then became known as
“ varioloid varicella,” a name which it bore to the end of the epidemic.
These diagnoses were accepted without demur by almost all the medical
men in the island. Early in 1903 disquieting rumours and conflicting
views on the subject of the “ Trinidad eruptive fever ” determined the
government of Barbados to send Dr. Bridger, the medical officer in
charge of their small-pox hospital, as a special commissioner to investi¬
gate and report upon it. He arrived in Port-of-Spain on February 2,
and furnished the government of Trinidad before his departure on
March 8 with a report in which he declared the disease to be small-pox
of a very mild type. Two days after the receipt of this communica¬
tion, a meeting of the medical board of the Island was convened, at the
special request of His Excellency the Governor, for an expression of
opinion upon it. Thirty-four members attended the meeting, the report
was read, -and after a full discussion on the subject the following resolu¬
tion was passed w r ith only three dissentients:—
“ That no such disease as mild small-pox exists in epidemic form,
and that the eruptive fever now prevailing in Trinidad is not small-pox.’*
Such, then, was the almost unanimous view of the medical profes¬
sion in Trinidad in regard to the epidemic at that period. The difference
of opinion between the Barbados Commissioner and the Trinidad
Epidemiological Section
239
medical practitioners gave rise to a bitter controversy; the columns of the
Press of both islands became the channel of much abuse and recrimination.
Severe comments were made in some of the British medical journals,
which reflected little credit on the diagnostic acumen of the West Indian
medical practitioners, and much ridicule was levelled at the profession.
In justification, or rather in extenuation, of the doubt and hesitancy
as to the nature of the epidemic, it may be stated that anomalous forms of
eruptive fevers, and especially of small-pox, have, at all times, presented
similar difficulties of diagnosis, even to experienced observers, causing
in many instances much diversity of opinion. Further on I shall refer
to two epidemics of a peculiar form of small-pox, popularly known as
“ swine-pox ” and “ pearl-pox ” respectively, which occurred in Jenner’s
time. We find in the Proceedings of the Epidemiological Society of
London a paper entitled “Varioloid Varicella in Jamaica,” which was
read by Dr. Izett Anderson before that Society in 1867. He describes
under that name an eruptive fever which occurred in epidemic form in
Jamaica in 1863. He states that in some cases the eruption was appar¬
ently that of simple varicella, whilst in others the “ inexperienced ”
would have pronounced it to be that of “ variola.” The disease
attacked young and old, the vaccinated as well as the unvaccinated,
and even one or two persons who had had small-pox in 1852, that is,
eleven years previously. There was no constitutional disturbance in
the majority of the cases, and no necessity to confine the patients to
bed. Some malaise and feverishness, but no continued fever of any
intensity, preceded the rash ; the fever existed for two days, and papules
appeared on the third day, usually first on the face in the severer cases,
and within twenty-four to forty-eight hours they became vesicles, with
sometimes a depression in their centre; the vesicles were then trans¬
formed into pustules. The full development of the eruption was attained
on the fifth or sixth day of the disease and desquamation followed.
Macules and pitting sometimes resulted. The larynx, and in one or two
instances the conjunctive, were occasionally affected. Secondary fever or
anything approaching to it was almost always absent. In the mild cases
the vesicles aborted. The epidemic lasted four or five months, and was
apparently unattended by any mortality. The disease originated in a
penitentiary, and no source of infection from outside could be traced ;
a fortnight after the appearance of the first case a boys’ reformatory,
three miles away from the penitentiary, with which there was daily
communication, became infected, and forty of the inmates contracted the
disease. About a fortnight after the first case appeared in the boys’
240
Selieult: Small-pox in Trinidad
reformatory the disease broke out in the girls' reformatory, which was
half a mile away, and thirty of the inmates were attacked. The disease
apparently did not spread to any extent among the general public,
although there w 7 as communication between the infected institutions
and the outside w r orld.
It would appear that the disease w T as not invariably regarded as
varioloid varicella, for in a memorandum Dr. Bow’erbank, of Kingston,
writes in 1863 :—
We are at present suffering from a severe influenza and also from a most
peculiar epidemic of varicella, I suppose. To me it looks much more like
“varioloid” or modified small-pox. Most of the vesicles suppurate and in some
instances are distinctly umbilicated and are sometimes confluent. 1 never saw
varicella like this before.
In connection with this epidemic in Jamaica it is interesting to note
that a fatal form of small-pox, which was introduced from Colon,
followed in 1864. It would be interesting to know whether those who
w 7 ere attacked in the previous epidemic were affected by this fatal form
of the disease. The eruptive fever described by Dr. Anderson certainly
bears very close resemblance to that which broke out here, but it appears
to have been milder in type.
Again, more recently, in the Lancet of October 22, 1898, Drs. Thom¬
son and Brownlee record their observations on an infectious disorder in
Lascars, having close relations with small-pox and chicken-pox. This
infectious disorder appeared to resemble both of these diseases in certain
respects and yet to possess symptoms alien to both. After careful con¬
sideration the diagnoses of small-pox and chicken-pox were excluded and
the disease was regarded by these observers as a specific entity.
I do not share with these observers the opinion that the Glasgow 7
epidemic w r as identical in nature w 7 ith that which was reported by
Dr. Anderson. The differences between it and the Trinidad eruptive
fever are even more marked.
In a pamphlet reprinted from the Journal of the American Medical
Association , August 3, 1901, Dr. Heman Spalding, Chief Medical
Inspector, Department of Health, Chicago, discusses the diagnosis of a
mild and irregular form of small-pox which broke out in the United
States in 1899. The following extract from this paper indicates the
difference of opinion w 7 hich existed in various parts of the United States
in regard to the nature of that outbreak:—
From March 9, 1899, to June, 1901, 310 cases of small-pox have been found
in Chicago; sixty-four of these, in various stages of the disease, were imported
Epidemiolog ical Secti0 n
241
into the city from nineteen of the surrounding States, and the cases came from
as far east as New York and from as far west as California. In the meantime
I visited three of the neighbouring States, where the diagnosis of this disease,
variously called impetigo contagiosa , “ giant chicken-pox,” “ Cuban itch,” or
some other indefinite name, was in dispute. With this opportunity of observing
cases from such widespread and various sources, I think it is fair to assume
that the disease we call small-pox in Chicago is the same disease which has been
the subject of controversy in all parts of the United States.
In the British Medical Journal of May 11, 1901, Dr. Montizambert,
Di reetor-General of the Public Health Department, Ottawa, speaks of a
mild tvpe of small-pox which was undoubtedly of the same nature as that
referred to by Dr. Spalding, and probably similar to that which broke
out in Trinidad. In this article, which is entitled “Notes on a Mild
Type of Sinall-pox (Variola ambulans),” the author writes:—
The Dominion of Canada is now being threatened with, and in some cases
invaded by, small-pox from her neighbour, the United States. It began on this
continent several years ago in the United States, the southern States especially.
It has gradually spread northwards. Its origin is difficult to establish, either as
to time or place, with any historical accuracy. It has been attributed by many
to soldiers returning from Cuba or from the Philippines. But it is certain that
it was prevalent in the United States before the beginning of the war between
that country and Spain. The difficulty in tracing back its history is due in
great part to the unusual mildness of the type. Many cases were diagnosed as
chicken-pox, many as German measles. In many of the lumber camps it went
by the name of “ cedar itch.”
In the Lancet of July 4, 1903, p. 65, reference is made to an out¬
break of disease in Cambridge which appears to have caused some doubt
and uncertainty in the minds of the health authorities. The main
features of the disease seemed at first incompatible with small-pox, and
the diagnosis of chicken-pox w T as made; as the epidemic increased in
severity, however, expert advice was sought, and Dr. Wanklyn, the
referee to the Metropolitan Asylums Board, who was invited to examine
the cases, reported the disease to be undoubtedly modified small-pox.
From these few examples it will be seen that sometimes irregular
forms of small-pox present great difficulty as regards diagnosis, raising
doubt even in the minds of the experienced. The strictures, therefore,
which were passed by those who were not confronted bv this atypical
variety of small-pox were unmerited and unjustified. The nature of
the Trinidad epidemic was apparently similar to that described by
Drs. Spalding and Montizambert. The disease probably originated in
the southern States of North America and travelled northwards to Canada
242
Seheult: Small-pox in Trinidad
and southwards to South America, whence it was imported to this Island
as already pointed out.
The main difficulties which presented themselves in the diagnosis of
the disease in Trinidad will best be appreciated when the features and
peculiarities of the epidemic have been considered.
Definition of the Disease .—A communicable febrile disease character¬
ized by definite periods of incubation, invasion and eruption, the last
passing through successive stages of papule, vesicle, pustule and crust.
Influence of (1) Age, (2) Sex, (3) Race, (4) Season.
(1) Age {see Appendix, Table II.).
The youngest patient attacked was aged 2 weeks, whilst the oldest
was aged 89. Adults were far more frequently affected than children;
56'20 per cent, of my cases occurred in adults between the ages of 20
and 34, whilst only 12*23 per cent, occurred amongst children aged
under 14. This is exactly what one would expect in an epidemic of
small-pox occurring in a vaccinated community such as exists in Trinidad,
where a Vaccination Ordinance which is strictly enforced requires the
successful vaccination of all infants before the age of 3 months. Again,
amongst adults more were affected during the quinquenniad 20 to
24 than during any other, and amongst twenty-one children under 5
years of age, twelve were unvaccinated infants whose ages ranged from
2 weeks to 4J months {see Tables III. and IV.). These figures
clearly indicate the role which vaccination played in connection with the
disease.
Even the foetus was sometimes attacked, and the earliest period at
which this occurred was after four and a half months of intra-uterine
life. Four such cases came under my observation. Fifty-one pregnant
women were admitted to the maternity ward after recovery from the
disease. Eleven aborted and nine were delivered prematurely. In the
aborted cases, eight of the foetuses showed distinct evidence of an attack
of the disease; and of the prematurely bom four showed external
manifestations of it, including a case of twins. All those who were
attacked were born in the eruptive stage of the disease except one, which
presented the characteristic macules on the body and a deep scar on the
left cheek. The history of the twin case referred to above is interesting.
Epidemiological Section
243
The mother developed the initial symptoms of small-pox on March 23
and the rash appeared on the face on March 26. Three days before the
onset of the invasion period she was vaccinated, and both vaccinia and
variola ran their course concurrently; the vaccine vesicles were typical
and the attack of small-pox was moderately severe. On April 17, when
she was in the desquamating stage of the disease, she was delivered
prematurely at the seventh month of twins. Both foetuses showed the
eruption of small-pox—white macerated vesicles—sparsely scattered on
the scalp, face and trunk and limbs, including the palms and soles (fig. 1).
There was one large placental mass which was partially implanted in
the lower uterine segment. Each foetus was enclosed in a separate bag
of membranes. The first foetus was stillborn and the second died a few
minutes after birth. In this case the foetuses were apparently infected
simultaneously, or almost simultaneously, with the mother. In the
other cases there was no correspondence as regards date of disease in
mother and child, although allowances were made for the peculiar con¬
ditions which affect the evolution of the rash in the foetus. The disease
was much more advanced in the mother than in the foetus. It would
appear, therefore, that either the incubation period is longer in the foetus
than in the adult or that the foetus becomes infected after the disease
has reached the eruptive stage in the mother. The liability of the foetus
to the disease seemed to decrease directly with its age.
The remaining thirty-one pregnant cases were delivered at term, and
of these one woman gave birth to a child showing evidence of having
passed through a complete attack of the disease. In this case the
mother contracted the disease in May, 1903, and was delivered in the
following July of a healthy female child with nine macules sparsely
scattered on the left cheek, right lower eyelid, right arm, both forearms
and buttocks (fig. 2). A similar case came under my observation in
which the mother developed initial symptoms on July 29, 1903, and was
admitted to the Isolation Hospital on August 6. She was discharged
well on September 5, and on the 21st of the same month gave birth to a
full-term infant w T ith twenty-seven macules scattered on the face, trunk
and extremities, and one mark with a depressed centre on the right
cheek. The macules on the extremities were smaller than those on the
face and trunk. In no instance was the eruption copious in the footal
cases, though the majority of the mothers were severely attacked. It
was also noticed that the face was not more affected than any other part
of the body; this observation supports the theory that light influences
the distribution of the rash in the adult.
Seneult: Small-pox in Trinidad
Seven months twin foetuses, with vesicles sparsely scattered on the
scalp, face, trunk and limbs, including palms of hands and soles of feet.
One foetus was born dead and the other lived only a few minutes.
Epidemiologica / Section
245
Fig. 2.
Mother, aged 28; unvaccinated. Had small-pox in May, 1903, and was delivered in
following July of a full-term child. Child aged 4 days. Macules on buttock.
my —7
246
Selieult: Hmall-pox in Trinidad
In the cases where the foetus showed evidences of an attack of the
disease in utero , we must assume the passage of the germs into the foetal
circulation. This would seem to require a breach of continuity in the
walls of the maternal vessels in the placenta, if this organ acts normally
as a barrier to microbes. The disease in the mother may undoubtedly
produce pathological changes in this organ. Toxins and antitoxins, on
the other hand, probably pass, along with nutrient matters, by osmosis.
Recent investigations seem to show that the placenta has a selective
power and is something more than a mere filter; in that case the
existence of a placental lesion may not be necessary to explain the
passage of the micro-organism of small-pox, and the transmission of its
toxins may take place in a more complicated way than by osmosis.
The proportion of cases of foetal infection which came under mv
observation in this epidemic appears to be unusually large, but the fact
that in small-pox of ordinary severity the mortality amongst pregnant
women is high, and that abortions or,premature labours occur more
frequently, and before the external signs of the disease in the foetus
declare themselves, explains this difference.
(2) Sex {see Table II.).
Amongst my cases more males were affected than females, in the
proportion of 352 to 212, and the number of attacks was greater abso¬
lutely among males than females at all ages except in the quinquenniad
10 to 14, the numbers being fifteen and nineteen respectively.
(3) Iiaee (see Table V.).
The blacks were almost exclusively attacked, very few persons
among the white section of the community suffering from the disease.
This fact is in conformity w r ith the observation that the negro race has a
peculiar susceptibility to small-pox; but in this epidemic the case mortality
was, contrary to all experience, exceedingly low amongst this class. A
very significant fact was the immunity enjoyed by the East Indian
population. This is to be attributed not to racial influence, but rather
to the protection afforded by efficient vaccination and revaccination ;
the “coolies/’ as they are called here, are particularly well vaccinated.
Their vaccination marks are numerous and large. There was only one
East Indian amongst the 564 cases that came under my care. The
estimated population of Trinidad is 280,000, and that of the East Indian
section of the community is 90,000. One of the most popular suburbs
Epidemiological Section
247
of Port-of-Spain is peopled mainly by East Indians, not one of whom
contracted the disease, although many cases occurred among the blacks
living in their midst. It is certain the sanitary conditions under which
these people live do not account for this immunity, for their habits are
primitive in all matters concerning public hygiene. This consideration,
however, may be of little moment, for it is a fairly well established fact
that while general cleanliness and purity of water and food are useful
against all diseases, the prevalence and spread of small-pox are not affected
by hygienic conditions as some of the other infectious diseases are, though
naturally overcrowding favours its propagation.
(«) Fig. 3. (6)
F. W., female, aged 13 ; unvaccinated.
(a) Photo taken on fifth day of illness. Papulo-vesicular stage. No oedema of face.
(b) Photo taken on ninth day of illness. Vesiculo-pustular stage. Face puffy.
(4) Season.
There are two distinct seasons in Trinidad, the wet and the dry.
Approximately the dry season extends from January to May, and the
wet from May to December; there is usually a spell of dry weather in
248
Seheult: Small-pox in Trinidad
September or October, which lasts two or three weeks, and is commonly
known as the “Indian summer/’
The disease made its appearance in April, 1902, and showed no
tendency to spread during the rainy season ; it was only in January, that
is, at the commencement of the dry-season, that it began to assume
epidemic form, and it continued to increase until it reached its maximum
height in May, when the onset of the rains checked it. It then gradually
declined until it finally disappeared—from the town in November, 1903,
and from the country districts in January, 1904. The seasonal prevalence
of small-pox in the tropics has long ago been observed. As far back as
the middle of the eighteenth century Holwell, in speaking of the ravages
of small-pox in Bengal, thus refers to the periodicity of the disease and the
influence of the seasons on it:—
Every seventh year, with scarcely any exception, the small-pox occurred in
these provinces during the months of March, April and May, and sometimes
prevailed until the annual returning rains about the middle of June put a stop
to its fury [ see Table VIII.] .
Incubation.
The determination of the duration of this period was surrounded
with some difficulty on account of the unreliability of the patients, who
for the most part were ignorant, and also on account of other unavoidable
sources of error; it may, however, be stated with a fair amount of
accuracy that this period lasted ten to fourteen days, and this was borne
out in a number of cases which afforded a decided opportunity for judging
the precise time of incubation.
Invasion.
This period was hardly ever ushered in by rigors. Headache, back¬
ache, fever, and occasional vomiting or nausea appeared without any
warning. Constipation was almost invariably the rule in adults, and
giddiness was often complained of. This stage lasted from one to seven
days, but in the majority of the cases it was of three days duration.
(1) Headache .—This was not a constant symptom and was not con¬
fined to any particular part of the head ; it was usually general and its
intensity varied very much.
(2) Backache .—This symptom was rarely absent. Sometimes it was
very slight, but in most of the cases it was severe, and in a few instances
it was described as being very violent. In pregnant women it was fre¬
quently mistaken for labour pains, so that many of the cases were
Epidemiological Section
249
admitted to the maternity ward, where the nature of their complaint
became at once apparent.
(3) Fever .—The fever developed usually without any preliminary
chill, at least its presence was almost invariably denied ; in children it
was often ushered in by convulsions. The usual conditions associated
with pyrexia were present, viz., general malaise, anorexia, thirst, furred
tongue, quick pulse and disturbed sleep. The temperature rose rapidly,
Fig. 4.
M. R., female, aged 28; unvaecinated. Photo taken on seventh day of
disease. Vaccinated on February 25. Developed initial symptoms of small¬
pox same evening. Three vaccine vesicles on left forearm and variolous
rash general.
250
Seheult: Small-pox in Trinidad
Fig. 5 ( a ).
E. S., male, aged 22 ; unvaccinated. Photo taken on tenth day of disease.
Front view. Large hemispherical pustules on front of thorax, abdomen, upper
extremities and thighs; some of the pustules on trunk and limbs umbilicated.
Gland in groin enlarged.
Epidem iological Section
•251
Fig. 5 (6).
E. S., male, aged 22 ; unvaccinated. Photo taken on tenth day of disease.
Back view. Shows arrangement of pustules in and around ringworm patches on
the back.
252
Seheult: Small-pox in Trinidad
and within twelve to twenty-four hours of the commencement of initial
symptoms it was at its maximum height, reaching from 102° F. to
105° F. even in the abortive cases. The fever persisted with slight morning
remissions as a rule during this period. Previous vaccination did not
seem to influence the temperature at this stage. On the appearance of
the rash it fell suddenly to normal or subnormal in the mild or abortive
cases ; in the severe, discrete and confluent forms defervescence was
gradual, but in the latter the temperature seldom dropped to normal.
(4) Vomiting .—This w r as not a constant symptom, but it was observed
in a large number of cases and was of short duration; in some instances
it was, however, very distressing and persistent, causing much exhaustion.
In four of my cases it ceased only when the eruptive stage was already
far advanced.
(5) Nausea .—This occurred in a fair proportion of the cases.
((5) Constipation was almost invariably the rule in adults, whilst in
children the opposite condition often obtained.
(7) Vertigo .—This was frequently complained of; most patients in
this stage reeled from side to side whenever they attempted to assume
the erect posture.
(8) Violent pulsation of the carotids was often observed at this
period. There was no relation between the intensity of the initial
symptoms and the severity of the disease, nor was there any relation
between the duration of this period and the abundance of the rash.
Indeed, a severe invasion period was sometimes followed by a very sparse
and insignificant eruption ; similarly, a long invasion period sometimes
ended in a very mild attack. In infants the initial symptoms were, as a
rule, so mild that the disease was often recognized only in the eruptive
stage.
Initial Hashes.
No preliminary rashes occurred, as far as I could ascertain, in any of
the cases that came under my care in the isolation ward. In one case a
rubeoloid erythematous rash appeared on the front of the thorax of a
boy during the desiccation period of the disease; it was at first very
faint, then deepened in hue and gradually faded away, leaving no marks
behind it.
Eruptive Period.
On the appearance of the rash all the initial symptoms of the disease
subsided more or less, according to the abundance of the eruption. A
sense of entire relief was experienced on the first day of the eruption in
Epidem iologica l Sectio n
253
the abortive and most of the mild cases, but in the severe discrete cases
this took place somewhat later, whilst in the confluent variety, owing to
the painful phenomena of the eruption on the mucous membrane and of
suppuration, it hardly occurred at all. The same remarks hold good
as regards the temperature. In the abortive and mild cases the fever
subsided at once to normal or subnormal on the appearance of the rash ;
in the severe discrete form this was generally accomplished only after
tw r enty-four to seventy-two hours, owing to crops of eruption, so that
there was a short intermission before the onset of the secondary -fever.
In the confluent cases, although defervescence took place, it did not
coincide with the beginning of the eruption; it was slow' and the
Fig. G.
A. B., female, aged 19 ; unvaccinated. Photo taken on tenth and eleventh day
of disease. Face puffy. Scabbing had commenced on face. Eruption was very
thick on face and upper extremities, sparse on chest except on breasts, especially
around the nipples. Pustules on forearms large and bullous. Did not die.
temperature rarely fell to normal, consequently there was only a
remission, which was of short duration owing to the early commence¬
ment of the secondary fever. In some of the severe discrete cases there
w T as no intermission, but only a remission of temperature ; w 7 hilst in some
confluent cases there was no intermission between the primary and the
secondary fever, the one form merging into the other.
254
Seheult: Small-pox in Trinidad
Generally on the fourth morning of the illness small papules
appeared on the forehead and face, then on the backs of the hands and
about the wrists; the eruption gradually extended to the arm, trunk and
lower extremities. The rash on the face was often shotty and usually a
day in advance of that on the trunk, and two or three days in advance of
that on the thighs, whilst the legs and feet became affected at a still
later period. During the first two or three days, especially in the severe
discrete and confluent cases, fresh papules kept appearing, even on those
parts* which w r ere more or less thickly covered. This probably accounts
for the slow and gradual fall of temperature. These secondary papules
as a rule remained small, and shrivelled up rapidly, especially in the
vaccinated.
In the great majority of instances the rash first appeared on the face,
the next most common site being the dorsum of the»hands_a fact which
I observed in 9*2 per cent, of my cases. Of eleven cases in which the
rash first appeared on sites other than the face or hands, the back, fore¬
arms, thighs and buttocks each furnished two instances, and the scrotum,
penis and feet one each.
The papules gradually enlarged and became hard and resistant to
pressure, and in about twenty-four to thirty-six hours they were trans¬
formed into vesicles; this change was observed to take place sometimes
even earlier than this. The vesicles were multilocular and their
contents were expressed only with great difficulty. Those on the trunk
and limbs were sometimes umbilicated (see for example figs. 5, 9, 10
and 11). The vesicles increased in size until about the sixth day of the
disease, when they became surrounded by an inflammatory areola which
appeared red or black, according as the colour of the patient’s skin was
white or black. The contents of the vesicles began to become turbid
and the central depression to disappear at about this time. Vesicles of
unequal sizes were not unfrequently seen side by side on the same parts.
On the seventh or eighth day of the disease the vesicles on the face were
fully converted into pustules, and this transformation gradually extended
to those on the trunk and limbs. In abortive cases, whether occurring
in vaccinated or unvaccinated persons, the papules shrivelled up before
reaching the vesicular stage, and in the instances w r here the papules had
become vesicles desiccation took place soon after, before pustulation had
occurred. The disease ran a similar course in a few of the mild discrete
cases.
The rash was generally very abundant on the face, back of hands
and forearms, dorsum of feet, buttocks and thighs. Frequently the back
Kpidemiological Section
255
was markedly involved (figs. 9 and 19). The front of the thorax and
abdomen were often remarkably free from eruption (tigs. 6, 7, 8, 10,
11 and 12), even in the severe cases; the palms of the hands and the
soles of the feet were invariably affected (figs. 1, 4, 9, 10, 14, 15, 19),
even in the mild cases. In a large proportion the scalp, ears, scrotum,
penis and vulva were invaded, especially in the confluent and severe
discrete varieties. The mucous membrane of the lips, palate; fauces,
uvula, pharynx, conjunctiva*, nostrils and meatus urinarius were not
unfrequently implicated in the severe cases and occasionally in the mild
discrete ones.
Fig. 7.
B. A., female, aged 3'J ; uuvaccinated. Photo taken on eleventh
day of disease. (Edema on face had begun'to subside ; crusting on
face. Pustules on trunk and upper arms, bursting here and there,
leaving crater-like depressions in their centre—“ pseudo-umbilica-
tion ” ; large hemispherical pustules on hands and forearms.
Eruption more copious on face and upper extremities than on chest
and abdomen (copious eruption on lower limbs).
Selieult: S'mall-pox in Trinidad
250
Special symptoms depended on the mucous membrane affected.
Thus sore throat was often complained of. The vesicles on the mucous
membrane were smaller, and they matured earlier than those on the
cutaneous surface; they were w T hite in appearance; in one case, where
they were not confluent, on the palate a dirty membrane was formed
simulating that of diphtheria. Again, these vesicles did not maturate
and scab as on the outer skin, from being constantly kept moist by
secretion; for the same reason the eruption on the foetus at birth
presented a similar appearance.
The presence of the eruption on irritated surfaces was well illustrated
in the case of an old man who had worn a truss for many years. The
eruption followed closely the part that had been chafed by the truss, and
formed a girdle round the waist. Where ringworm was coexistent with
the “pox” the vesicles formed a distinct chain along the margin of the
patches (fig. 5). In the case of ulcers the same ring-like arrangement
was observed, and in all these situations the vesicles were larger and
more advanced in development than those on other parts of the body.
There was a distinct “ shot t v ” feel of the papules, especially on the
forehead, in many cases. The resisting power of the vesicles and
pustules showed that they were invested with more than the mere
cuticle of the skin ; moreover, pitting, which resulted in a fair propor¬
tion of the cases, indicated the depth of the lesion. The bullous or
pemphigoid character of the eruption on the limbs, more especially on
the forearms and legs, was remarkable, and was observed in the con¬
fluent cases and in a few of the severe discrete variety (fig. 6). The
bulhe closely resembled the blebs of scalds or superficial burns; their
contents were dark, watery and Very offensive; the temperature was
septic in character. Such cases may be called “ variola pemphigoides."
I may here remark that the odour emitted from the cases generally was
very slight, except in those referred to above. The fully developed
pustules were more or less of the same size in all the cases, but there was
always a variation according to the part affected in each case. The
pustules on the face were invariably smaller than those on the trunk, and
those on the trunk smaller than those on the limbs. The largest pustules
were situated on the backs of the hands and the dorsum of the feet;
these were generally about o mm. in diameter when fully matured
(figs. 5 to 10). In a few instances the pustules were remarkably large
everywhere. In the confluent form the rash on the face was small and
fine, whilst large bulla; were* invariably present on the limbs.
Epiderniological Section
Maturation.
257
This process could hardly be said to occur in all the cases, even in
what seemed to be severe attacks of the disease; it began in the vesicles
which had appeared first—that is, on the face—on or about the sixth day
of the disease, and gradually extended to those on the trunk and limbs in
the order of their appearance. The areola which had begun to form
around the vesicles on about the sixth day became more extensive and
inflamed on the trunk and limbs ; umbilication when present began to
disappear, and the pustules became hemispherical and unilocular, espe¬
cially on the limbs, on about the tenth to twelfth day (figs. 5 to 19). On
Fig. 8.
*
P. W., female, aged 13; unvaccinatcd. Photo taken on eleventh
day of illness. (Edema of face had not disappeared altogether;
crusting on face. Pustules on arms bursting and leaving pseudo-
uinbilication ; pustules on hands and forearms largo, hemispherical
and uuruptured. Eruption sparse on chest.
pricking them their walls collapsed and the fluid which escaped was in
some cases, even at this late stage, clear, but on pressure upon them this
clear fluid was followed by sero-purulent exudation containing some solid
debris. The face was generally puffy at the commencement of the
maturation period, especially about the eyelids and lips, in severe cases
258
Seheult: Small-pox in Trinidad
Fig. 9 ( a ).
V. B., female, aged 23; unvaccinated. Photo taken on eleventh day of disease.
Front view. (Edema of face, especially about the eyelids and lips. Eruption
confluent on face. Some vesiculo-pustules on trunk and limbs, umbilicated.
259
Epidemiological Section
Back view. Eruption very thick. Some vesiculo-pustules umbilicated ; most of the pustules had lost their central depression and
had become fully hemispherical. This patient was discharged well.
260
Seheult: Small-pox in Trinidad
(figs. 3, 6 to 9, and 11). The facial oedema increased as the lesions
matured, only subsiding when scabbing commenced. On about the
twelfth to the fourteenth day the feet and legs sometimes became
(edematous, and less frequently the hands and forearms (fig. 11).
These swellings always caused considerable pain and discomfort, and
so caused insomnia.
Fig. 10 (a).
J. de F., male, aged 20 ; unvaccinated. Photo taken on about eleventh day of disease.
Eruption copious on face and hands, sparse on front of thorax and abdomen.
Epidemiological Section
261
Secondary fever was absent in the abortive attacks and also
sometimes in the mild discrete cases, and when present in these its
intensity and duration varied very much. As a rule, there was little
Fig. 10 (6).
J. de F., male, aged 20; unvaccinated. Photo taken on about eleventh day of
disease. Large hemispherical pustules on forearms, hands (including palms), legs and
feet (including soles). Some pustules on the backs of the hands are umbilicated.
my —8
262
Selieult: Small-pox in Trinidad
Fig. 11.
(a) H. F., female, aged 30; unvaccinated. Photo taken on twenty-fourth day of
disease. (Edema of legs was subsiding. Pustules had burst everywhere and were
drying up, leaving crater-like depressions in their centre, except a few on the
insteps, which were desiccating without rupturing.
(b) H., female, aged 6 weeks ; unvaccinated. Photo taken on fourteenth day of
disease. Face and limbs thickly covered with desiccating pustules, very few on trunk.
Face cedematous; crusts on face. A few pustules on iusteps drying up without
rupturing.
Epidemiological Section
263
Fio. 12.
T. P., female, aged 12; unvaccinated. Photo taken on about sixteenth day of
disease. Drying pustules on face and limbs, none on trunk. Scabs had nearly all
fallen off face. Pustules on forearms and thighs had begun I to burst; those on hands,
legs, and foot had not yet ruptured.
264
Seheult: Small-pox in Trinidad
constitutional disturbance at this period of the disease. In the severe
discrete and confluent varieties the secondary fever was generally severe,
but its severity was not commensurate with the abundance of the lesions.
In a few instances, however, the secondary fever was very severe and
prolonged. It began with the process of maturation, and its duration
and severity depended more or less upon the abundance of the pustules;
it lasted five or six days, but was not as high as that of the primary
fever. The morning remissions were well marked. At this period of
the disease, in the severe cases, all the painful and distressing symptoms
of the prodromal stage returned, and to them were added pain all over
Fig. 13.
B. H., female, aged 33 ; unvaccinatcd. Photo taken on fifteenth day
of disease. All oedema of face had subsided ; some crusts still on face.
Pustules on front of thorax and arms had burst and were drying up ;
those on the forearms, hands, and knees were hemispherical; some of
them had ruptured.
the body due to the tumefaction of the skin, especially on the face,
hands and feet, and discomfort in the throat and other mucous mem¬
branes wdiere the vesicles appeared. Even in these cases there was,
Epidemiological Section
265
generally speaking, little depression, and the constitutional symptoms
were mild in comparison with the abundance of the rash. In most of
the cases the patients were able to walk about and appeared cheerful.
The only inconvenience experienced by them was the pain caused by
pressure on the pocks in the soles of the feet whilst walking. In a few
cases, however, there was great prostration usually associated with fever
of a septic nature.
Fig. 14.
E. S., male, aged 28 ; unvaccinated. Photo taken on nineteenth day of
disease. Warty elevations on face left after scabs had fallen off. Pustules
over trunk and arms were drying up; nearly all pustules on forearms and
back of hands had ruptured, those on palms unruptured ; contents becoming
inspissated.
Secondary fever in small-pox is generally attributed to the absorption
of pus into the system from the foci of suppuration in the skin during
the maturation of the pocks. If this were the sole cause of the fever,
it would have been more severe and fatal, considering the extensive area
266
Seheult: Small-jpox in Trinidad
of cutaneous surface involved in many of the cases that came under my
care. In some instances there was hardly any healthy skin left, and yet
the temperature did not rise beyond 102° F. It is also noteworthy that
“cutaneous asphyxia” did not ensue in these severe cases.
Another theory regarding the cause of maturation fever assigns the
pyrexia to the absorption into the blood of the decomposed discharge
from the pustules. If this were so one would expect the fever to be
more or less within control, but in spite of great cleanliness and the
frequent use of antiseptic baths the temperature was not checked;
moreover, secondary fever begins before the rupture of the pustules and
terminates before they are dry. There seems, therefore, to be some
Fig. 15.
R. C., male, aged 20; unvaccinated. Photo taken thirty-one days after
commencement of attack. Face pitted. Macules on front of thorax and
upper extremities, including palms.
other agency at work causing the rise of temperature. It may be that a
specific variolous poison is evolved in the pustules and that it produces
this so-called maturation fever. The comparative mildness of the fever
in this epidemic could be better explained in this way, namely, on the
Epidemiological Section
267
1
*
Fig. 16.
C. G., male, aged 13; unvaccinated. Photo taken forty-two days after commence¬
ment of attack. Face pitted. Macules on trunk and limbs, centre light-coloured,
periphery dark.
268 Seheult: Small-pox in Trinidad
presumption that the poison was less virulent than that which is pro¬
duced in the pustules of small-pox of the ordinary type.
Desiccation.
This process began early on the face, usually on about the eighth or
ninth day of the disease ; the pustules burst and the exudation from
Fig. 17.
G. S., male, aged 27 ; unvaccinated. Photo taken sixty-four days after commence¬
ment of disease. Face pitted. Macules on trunk and upper extremities.
them caked and formed moist yellow crusts. As scabbing commenced
the oedema of the face began to subside. In only two cases did the
pustules on the face dry up without first bursting. When the crusts
Epidemiological Section
269
dried up and the scabs fell off on about the eleventh or twelfth day, the
solid bases of the pocks remained as warty elevations on the face (fig. 14).
Little by little these small pink excrescences, which were probably due to
the persistent tumefaction of the papillary layer of the skin, disappeared
by absorption, and in about two w r eeks they were replaced by macules
on a level with the skin, varying in hue, but usually pink in the centre
and dark at the periphery. In many cases further absorption took place
until actual pitting occurred (figs. 15 to 18 and 19). This peculiar con¬
dition, so-called wart-pox, was characteristic of this epidemic and was
Fig. 18.
R. G., male, aged 30; unvaccinated. Photo taken seventy-four days after
commencement of disease. Face pitted.
almost invariably present, even in the mild cases. It was confined to the
face. In only three instances did I observe similar excrescences on the
extensor surface of the forearms, and only once on the legs. Pitting
occurred in one or tw T o cases after the shedding of the scabs, notably in a
recurrent case, without the process of absorption referred to above taking
place.
Epidemiological Section
271
About twenty-four or thirty-six hours after the commencement of the
desiccation of the pustules on the face, the same process occurred on
the trunk and arms, then on the forearms and thighs, and later on the
legs. The pustules on the dorsum of the hands and feet were very
resistant, owing to the thickened epidermis on these parts. After the
rupture of those on the trunk and limbs, and the escape of their contents,
small|,crater-like depressions were left at the bottom of the pocks (figs.
7, 8 and 11). Occasionally, the pustules on the trunk and limbs dried up
Fig. 19 (c).
M. G., female, aged 48; unvaccinated. Photo taken two weeks after
complete recovery. Face pitted. Macules on chest and arms, centre light-
coloured and periphery dark.
without rupturing and formed brownish circular crusts, which on falling
off left a pink pale base gradually becoming lighter in colour and
eventually fading aw 7 ay. The pustules on the palms and soles never
ruptured spontaneously ; their contents became inspissated and were
absorbed ; the superimposed epidermis w T as shed later on.
As the pustules began to burst, the areola around them faded away.
272
Seheult: Small-pox in Trinidad
The face was the first part to clear up. The same order of succession
was maintained in the desiccation of the eruption as that in which it
originally appeared. Desiccation was rapid on the face, trunk and upper
part of the limbs, but very slow on the forearms, hands, legs and feet,
even in the mild cases. After the scabs had fallen off the trunk and
limbs circular macules were left on a level with the skin, having a dark,
pigmented periphery encircling a light coloured or pinkish centre (figs.
15to 17 and 19). These marks persisted fora considerable time and then
gradually disappeared after several months. During desiccation itching
was often a distressing symptom. The duration of this stage varied very
much, as it was dependent more or less on the severity of the attack, but
in many of the mild cases the process was long and tedious on the hands
and feet.
Convalescence.
Convalescence was short and rapid in the mild cases, whilst in the
severe discrete and confluent forms, especially when complications arose,
it was sometimes much prolonged; in the majority of the cases it was
uninterrupted. Hardly any emaciation resulted except in a few instances.
The patients usually developed a voracious appetite as soon as scabbing
commenced on the face.
The average duration of the disease in the 564 cases I had charge of
was 28'43 days; this is, however, below the mark, for unfortunately at
the beginning of the epidemic many cases were discharged before they
could be considered “ cured,” owing to the want of accommodation. The
shortest cases lasted seven days ; this occurred in three instances where
vaccination performed during the incubation period of the disease caused
its abortion. The longest case remained eighty-three days in hospital,
but its detention for such a long period was due to complications and
sequelae.
Treatment.
This resolved itself mainly into questions of scrupulous cleanliness and
judicious diet. In the initial stage of the disease calomel, followed by a
saline purge or castor-oil, was administered ; a diaphoretic mixture was
then given until the rash appeared. During the eruptive stage carbolic
acid or Fowler’s solution was tried in several cases at first, but as no
real benefit seemed to accrue from the use of these drugs they were dis¬
continued. Arsenic, which has been lauded in the treatment of small¬
pox by some writers, proved positively harmful in some of my cases, as it
caused much intestinal irritation which was difficult to allay. Internal
Epidemiological Beetlen
273
medication was abandoned during the eruptive and desiccation stages
except in special cases, where the use of digitalis, ether, strychnine, and
other drugs was indicated. Cinchona proved very beneficial in the
desquamating stage, especially where malaria was a complication. Mild
preparations of iron gave good results in the anaemic cases. Opiates
relieved pain and irritation, and induced sleep when most of the other
hypnotics failed.
External Applications .—Tepid antiseptic baths, especially Condy’s
fluid properly diluted, were used from the first in almost every case, much
to the comfort and relief of the patients. These baths were continued
until desquamation was quite complete. Boric acid or zinc ointment
and carbolized vaseline or cocoanut oil were largely employed, but the
application of guaiacol in olive or cocoanut oil (1 in 80) gave the best
results ; it relieved itching promptly and appeared to hasten the desicca¬
tion of the pustules. This drug has been recommended by Dr. J. J.
Ridge in the British Medical Journal of May 30, 1903.
In complications the remedies used were simply those for the dis¬
orders occurring in uncomplicated states. The wards were well
ventilated, and although there w T as at times some overcrowding the
death-rate did not seem to be affected thereby, as it invariably is in the
case of small-pox of a virulent type.
Diet .—During the invasion and early eruptive stages of the disease
there was, as in all febrile disorders, anorexia, and only liquid nourish¬
ment could be taken. As soon as the eruption had fully appeared the
appetite was restored and a liberal diet was allowed. At the onset of the
secondary fever the appetite was again impaired, necessitating a return to
low diet, but as scabbing commenced on the face the patient clamoured
for food. In the abortive and mild cases, where there was no secondary
fever, the appetite was impaired only during the invasion period.
Stimulants were given in the few instances where their use was in¬
dicated ; alcohol proved very beneficial in the old and debilitated.
Complications.
Complications occurred in all stages of the disease and w r ere in some
instances of a grave character.
(A) In the Invasion, or Early Eruptive Stage.
(1) Respiratory system :—
(a) Dyspnoea occurred in five cases ; in one of them it was
accompanied with much pain in the chest; this condition was very
274
Seheult: Small-pox in Trinidad
distressing while it lasted, but in every case except one, where there
was haemorrhage into the lungs, it subsided on the appearance of
the rash. In the other cases I was unable to detect any pulmonary
or cardiac lesion to account for it.
(b) Haemoptysis occurred in the haemorrhagic case just referred
to, which was the only one of this type that occurred during the
epidemic.
(2) Nervous system :—
(a) Delirium was observed in five cases, in two of which the
disease ran a mild course, whilst in the other three cases the attack
was severe, and in two of them motor aphasia was also present.
Delirium was more marked at night than during the day; it dis¬
appeared altogether as the eruptive stage was reached; in one case,
however, it lasted ten days.
(b) Convulsions occurred in three female adults, two of whom
had undoubtedly an hysterical tendency, whilst the third was an
epileptic. In children it usually ushered in the initial symptoms of
the disease and was often attributed at first to worms or dentition.
This condition was of short duration and was never an alarming
symptom at this stage.
(c) Aphasia, which sometimes occurs in acute disease, and is
generally considered to be due to the toxins engendered by the
specific bacilli operating upon the cells of the cerebral cortex
concerned in the production of articulate speech, occurred in two
cases, in both of which there was also delirium during the invasion
and early eruptive stage. Both patients, after the cessation of
delirium, were able to understand spoken and written speech and to
translate their thoughts in writing, but the power of articulation
.was lost, showing that the aphasia was purely motor. Although
some improvement took place during convalescence the defect of
speech was still marked, even after their discharge from hospital—
one forty-eight and the other forty-three days after admission.
(3) Alimentary system :—
(a) Diarrhoea developed in only four cases and was not a serious
accompaniment at this early stage, except in the case of an infant
who was already in a debilitated state.
(b) Melaena and hasmatemesis occurred in the haemorrhagic case
to which I have already referred.
Epidem iological Section
275
(4) Urinary system :—
(a) Albuminuria was present in 18 08 per cent, of my cases in
the stage of invasion, and varied in amount and duration ; it vanished
in the majority of the cases as soon as the rash appeared and the
temperature had fallen; sometimes it persisted for a considerable
period, disappearing in some instances only at the end of six weeks
from the commencement of the disease. In twenty-four cases
albuminuria occurred in persons suffering from chronic Bright’s
disease, a very common malady in this Colony, probably due to
malarial infection; in these the albuminuria, of course, persisted
after all the symptoms of variola had disappeared.
(b) Haematuria occurred in the haemorrhagic case.
(5) Reproductive system :—
The catamenia frequently appeared in this stage of the disease,
in many instances prematurely, but sometimes the appearance at
this stage was a mere coincidence. The period was often longer
and the flow more copious and bloody than normally.
(B) In the Pustular and Desiccation Stages.
(1) Respiratory system :—
Apart from a few mild cases of bronchitis and one of catarrhal
pneumonia there was marked freedom from complications.
(2) Nervous system :—
(a) Low muttering delirium occurred sometimes in the old and
debilitated, and usually signalled a fatal termination of the attack.
(b) Paralysis of the bladder was met with in one case at the end
of the desiccation stage.
(c) Peripheral neuritis was occasionally observed in this stage,
but this condition was more in the nature of a sequela than of a
complication.
(3) Alimentary system :•—
(a) Diarrhoea occurred in twenty-two cases at this late stage;
two adults succumbed to it. In children it was a frequent com¬
plication, but no deaths resulted from it.
(b) Salivation was observed in only one case; it began in the
eruptive stage and persisted during the maturation of the pocks;
there was not much enlargement or tenderness of the salivary
276
Seheult: Small-pox in Trinidad
glands, nor was there any eruption in the mouth. I may mention
that no medicine containing mercury in any form had been
administered to this patient.
( c) Vomiting, which occurred in only one case at this period,
was very persistent and difficult to check.
(4) Urinary system :—
Pyuria occurred in one case.
(5) Integumentary system :—
(a) Boils or small abscesses were by far the most frequent of
all the complications; they occurred in 46 per cent, of the cases
and developed during desquamation, usually in the axilla, or on the
back, thighs, and buttocks, and kept on appearing for a considerable
time in some cases. They varied in size from that of a pea to that
of a walnut and caused little constitutional disturbance. In one
case forty-two small abscesses formed on the back of the patient.
( b ) Carbuncles occurred in two cases and produced severe
general symptoms and also much exhaustion.
(c) Gangrene of the toes followed in a very anaemic and pregnant
woman.
( d ) Skin eruptions appeared in many instances at this stage,
especially ecthyma, acne pustulosa, rupia, and pustular scabies.
(6) Keproductive system :—
(a) Orchitis occurred in thirteen cases, and was accompanied by
effusion into the sac of the tunica vaginalis in six instances; the
fluid was always turbid. Both testicles were affected in one case
and in another an abscess formed.
( b) Ovaritis was diagnosed in two instances.
(7) Circulatory system :—
No complication could be assigned to this system except a case
of phlebitis of the brachial vein.
(8) Locomotory system :—
Synovitis of the knee- and ankle-joints occurred in a few cases,
but the effusion was never purulent and was rapidly absorbed.
(9) Lymphatic system :—
Enlargement of the inguinal glands, and more rarely of those in
the neighbourhood of the elbow, was observed sometimes ; the pain
Epidemiological Section
277
was usually of short duration, but the swelling persisted for a long
time.
(10) Organs of sense.
(i.) Eye:—
(a) Conjunctivitis was a rather frequent complication, especially
in the maturation stage.
(b) Keratitis was also present in some of the severer cases, and
was sometimes very rapid in its work of destruction.
(c) Panophthalmitis of the eye occurred in three patients ; in
one of them both eves were destroyed.
(ii.) Ear:—
(a) Otorrhoea was observed in two cases, but yielded quickly to
treatment.
(b) A mastoid abscess developed in one case.
Other Complications.
Malarial fever, which so often accompanies other disorders in the
tropics, was observed in a few of the cases. Typhoid fever was a com¬
plication in one case.
SKQI'EL/K.
(1) Respiratory system :—
Acute pulmonary tuberculosis developed in two cases, soon after
desquamation was complete, and ran a very rapid course. This
disease is common here, and sometimes ends fatally in a remarkably
short time.
(2) Nervous system :—
(a) Peripheral neuritis was not an uncommon sequela of the
disease ; it affected usually the extremities.
(b) Myelitis occurred in one case.
(c) Insanity. A young woman who had just recovered from
the disease developed acute mania.
Urinary system :—
(a) Chronic nephritis appears to have developed in a woman
during convalescence; she had small-pox when she was five or six
months pregnant. Her urine was then free from albumin ; it was
again examined shortly before labour and found to be loaded with
albumin ; this persisted for three months, after which time I lost
my —9
278
Seheult: Small-pox in Trinidad
sight of her. The persistent presence of albumin in the urine in
this case points to some cause other than pregnancy; at any rate
the albuminuria of pregnancy is, as a rule, temporary; it usually
disappears after labour.
(4) Integumentary system :—
(a) Pitting showed itself in a considerable number of the severe
and in a few of the mild cases ; it was confined to the face and
affected especially the forehead, cheeks and nose (figs. 15 to 19).
( b) Pigmentation. After the scabs had dropped off, macules
were left with a pale pink centre and a dark pigmented periphery.
These marks gradually faded away, and several months after re¬
covery disappeared entirely (figs. 15 to 17, and 19).
(c) Alopecia. In two severe cases the hair dropped out com¬
pletely, leaving the scalp bare during convalescence, but two or
three months after recovery it grew again. This condition was
observed also in an infant; in this case it was only partial, the
anterior portion only of the scalp being affected.
(d) Shedding of the nails. In several of the severe cases the
toe-nails were shed without any apparent sign of inflammation;
this process was probably trophic in nature. The finger-nails were
less frequently affected, and at a later period than the toe-nails.
Regeneration of these epidermic appendages followed in two or
three months.
(< e ) Exfoliation of the skin of the hands and feet was observed
in four very severe cases. The skin of these parts was cast off
entire, like a glove or a slipper.
Influence of the Disease on Pregnancy.
(A) Cases admitted to the Isolation Ward.
Thirty-eight pregnant women were admitted to the isolation ward
in the invasion or early eruptive stage of the disease; twelve gave birth
to, apparently, full-term healthy children at this stage. In these cases
the onset of labour may possibly have been precipitated a few days by
the initial fever or it may have been a mere coincidence in the regular
course of pregnancy. Of the remaining twenty-six women who had not
completed the full term of gestation, two gave birth to premature infants
and one aborted. The further history of twenty of the remaining
twenty-three, who were discharged cured of the disease, was traced.
Epidemiological Section
279
Sixteen carried the foetus to term, three were confined prematurely, and
one aborted. The age of the foetuses in the cases of interrupted gesta¬
tion ranged from six to eight months, and the date of delivery w T ith
reference to the disease in the mother was four to twelve weeks after the
commencement of prodromal symptoms.
(B) Cases admitted to the Maternity Ward.
Fifty-one women who had had the disease during pregnancy and had
recovered from it were admitted to the maternity ward under my care.
Thirty-one had reached the full period of gestation and were delivered
of healthy children—one of the children showed evidence of having
passed through the disease in utero; it exhibited the characteristic
macules (fig. 2). Of the remaining twenty women, eleven aborted and
nine were delivered prematurely.
It would appear that the disorder in the initial and early eruptive
stage had little or no immediate effect upon pregnancy; gestation
was usually interrupted in its course four to twelve weeks after the
mother had developed the prodromal symptoms of the disease. This
was due either to the death of the foetus, caused by an attack of the
disease in utero , or to fatty degeneration of the placenta—a condition
frequently observed in these cases. In the majority of instances
pregnancy ran a normal and an uninterrupted course. I may here
remark that potassium chlorate was administered to a pregnant case as
soon as desquamation began and was continued until delivery, when
a healthy child was born. The effect of the disease on the foetus has
already been described.
Varieties
Vaccinated
1
Unvaccinatkd
Grand
Total
One
mark
Two
marks
Three
marks
Four
marks
Total
(1) Abortive
6
6
3
5
20
21
41
(2) Mild discrete ...
21
30
4
3
58
258
316
(3) Severe discrete
14
6
1
2
23
165
188
(4) Confluent
2
—
—
—
2
16
18
(5) Haemorrhagic...
—
—
* —
—
—
1
1
43
42
8
10
103
461
564
280
Seheult: Small-pox in Trinidad
The above table shows the large proportion of mild and abortive
cases which occurred both in the vaccinated and unvaccinated. The
proportion of mild to severe cases among those who were treated in
their homes was even greater than is shown by this table, for as a rule
only the worst cases were removed to hospital. These mild cases pre¬
sented well-marked irregularities not only in the initial symptoms, but
also in the evolution of the eruption. The main irregularities in the
symptoms were:—
(1) The occasional absence of headache or backache and, in three
instances, of fever.
(2) The almost entire absence of constitutional symptoms in many
instances, these patients being able to pursue their daily labours without
discomfort or inconvenience.
(3) The complete absence of secondary fever, or w T hen present its
extremely short duration, as a rule lasting only a few hours.
Irregularities in the evolution of the eruption showed themselves in
the abortive development of the rash; the papules often shrivelled up
before being transformed into vesicles, and even when the papules
became vesicles these frequently desiccated without previous pustulation
(“variola vesiculosa” [Thomas] or “variola varicelloides”). As these
peculiarities occurred in such a large proportion of the cases, in the
vaccinated as well as the unvaccinated, the epidemic may perhaps be
considered to be the mildest which has yet been recorded. The anxiety
and alarm usually apprehended in the more familiar form of the disease
were conspicuously absent in the community during this epidemic.
Comparison of Vaccinated and Unvaccinated Cases in respect to
liability of Attack.
Vaccination had a decided influence upon the disease; of the 564
cases that came under my care, 103 occurred in vaccinated, and 461 in
unvaccinated persons. The patient’s word as to the success of previous
vaccination was not accepted without verification by careful examination
of the scars. Among the vaccinated the proportion attacked was in an
inverse ratio to the number of marks present. Thus forty-three cases
occurred amongst those who show r ed one cicatrix, whilst there were only
eight cases among those with three scars. The percentage of mild or
abortive cases was greater in the vaccinated than in the unvaccinated,
and no confluent or luemorrhagic case was observed in the former class.
Epidem iological Section
281
All the deaths—thirteen in number—occurred in unvaccinated subjects
(see Table VI.). These facts indicate clearly the role played by vaccina¬
tion in relation to the disease.
Observations on the incidence of the disease among the nursing staff
afford a striking confirmation of the previously stated facts regarding its
relation to vaccination. Thirty-six nurses, eight ward-maids and three
ward-men were employed in the Isolation Hospital (see Table VII.).
Of the thirty-six nurses only three contracted the disease , and these
three had never heat vaccinated; of the remaining thirty-three, seven,
who were successfully vaccinated a week to four years previous to their
joining the staff, escaped the contagion; of the remaining twenty-six,
fifteen were successfully revaccinated one week to four years previous to
their attendance on the small-pox patients and did not contract the
disease. Of the remaining eleven five were revaccinated without success
and were not attacked by the disease. Three of the remaining six were
revaccinated after they had been ten, fifty-two, seventy-seven days,
respectively, in the isolation wards, but only one of these reacted to the
operation. One nurse had been vaccinated three times without success;
another was vaccinated at the age of 12 successfully and suffered
from an attack of small-pox the same week; in June, 1903, she was
revaccinated with negative result; another, who had never been vaccinated,
contracted the disease before she joined the staff.
As regards the eight ward-maids , the only o?ie who was never
vaccinated took the disease. Of the seven others two were vaccinated,
four revaccinated successfully shortly before their services were engaged,
and one was vaccinated in childhood and showed a very large cicatrix on
the arm. Of the three male attendants who showed doubtful vaccina¬
tion marks, one was successfully revaccinated a few days after he came
into the ward; five days after this he developed the disease in an
abortive form, vaccinia and variola running their course concurrently.
Another was vaccinated three times with success and did not contract
the disease, whilst the third had already contracted the disease before he
was employed.
Keference has already been made to the immunity enjoyed by the East
Indian population. The evidence, therefore, of the influence of vaccination
upon the disease is strong, and is in conformity with the experience of
all observers.
The following cases of the disease deserve separate notice on account
of the special features which each presented.
282
Seheult: Small-pox in Trinidad
Case I.—Haemorrhagic Case.
B. L., a well-nourished and muscular negro, aged 30, unvaccinated,
began to complain of general malaise on June 8, 1903, but was able to
perform his usual w F ork on that day. On the morning of June 9 he felt
worse and took to bed; he then had fever and severe pain in the back ;
these symptoms, with the addition of headache from the 10th, continued
unabated until the 12th, when he noticed what he described as prickly
heat (lichen tropicus) on the hands and feet. On the appearance of this
rash the general symptoms subsided. On June 11 his eyes had become
very bloodshot; on June 13 he began to pass blood in his urine and to
expectorate blood-stained sputum, and on the evening of that day his
motions were observed to be black and tarry. He was admitted to the
Isolation Hospital on June 14 at 4 p.m. in a very critical condition; his
face was puffy and covered with an erythematous blush, but no distinct
eruption could be detected. There was a purpuric rash on the trunk and
limbs, which was rather abundant on the back of the hands and forearms
and the dorsum of the feet and also on the back. The conjunctivae were
injected and the lips swollen and bleeding. On the palate was a pseudo-
diphtheritic membrane. The tongue was coated with a thick dark fur.
The sputum was blood-stained and dyspnoea was urgent. The patient’s
mind was perfectly clear. His pulse was small and quick, and his tem¬
perature at 5 p.m. 102° F., and at 8 p.m. 100*2° F. He had no sleep
during the night, and experienced very great difficulty in swallowing even
liquid nourishment, owing to pain and soreness in the throat. The
vesicles on the limbs were observed on the morning of the 15th to contain
dark-coloured blood. The temperature at 7 a.m. was 100*2° F. He
expired at 9.45 a.m., and shortly before death vomited a large quantity of
bright red blood.
Post-mortem Notes. —Well-nourished, tall, muscular negro. Petechial
rash on face, trunk, and limbs. Petechias contained blood of a dark
colour. The blood generally was dark and fluid. Lungs: both bases
were congested; numerous haemorrhages into the lung tissue; the right
lung was bound down by old pleuritic adhesions. Heart: slightly
hypertrophied, valves healthy; no haemorrhages into its substance or
into pericardial sac. Liver : congested ; haemorrhages into its substance ;
weight, 5 lb. 9 oz. Spleen: very congested, not enlarged, capsule
thickened, substance firm. Kidneys: large, substance pale, in a state
of fatty degeneration ; haemorrhages into the pelves and calices ; right
kidney weighed 9 oz., left kidney 10£ oz. Bladder: contained bloody
Epidemiological Section
283
urine, but the mucous membrane was pale and normal in appearance.
Stomach: contained some blood-stained fluid ; haemorrhages into its
mucous membrane. Larynx : intensely congested, of a purplish hue;
well-marked vesicles on base of tongue, containing blood.
Case II. — Peculiar Form of Confluent Small-pox.
G. L., aged 42, unvaccinated, was admitted to the isolation ward
on March 30, 1903, with the history of having had fever, headache, and
backache, followed by an eruption which appeared first on the face and
hands and then spread over the body generally. The date of the first
appearance of symptoms could not be ascertained with precision, but,
judging from the eruption, the patient, when first seen by me, was
probably in the sixth or seventh day of the disease.
Condition on Admission. —A rather weak but fairly nourished woman
with a very copious, vesicular eruption on the face, trunk, and extremi¬
ties. The face was covered with large flat vesicles, having a dark
central depression, but ill-defined edges; there was no subcutaneous
oedema, not even of the eyelids; the skin presented the appearance of
coarse parchment; the vesicles on the trunk were more or less of the
same character as those on the face, but were larger and bleb-like in
parts; those on the legs and dorsum of the feet and backs of the hands
were still larger and more bullous ; there were a few vesicles on the
pharynx and palate ; the tongue was coated with a yellow fur; the pulse
was rapid and weak; temperature, 99*4° F.; the urine contained a trace
of albumin and bile; the feet and legs were swollen; the mind was
clouded and the patient was somewhat restless.
Progress of Case. —Prostration increased and the mind became more
confused ; large bullae formed on the trunk and extremities; some of the
vesicles on these parts much resembled vaccine vesicles, and the contents
were serous and bright yellow in colour ; the skin generally became
jaundiced. Extensive areas of epidermis exfoliated, leaving raw surfaces
on the chest and limbs, such as occur in superficial burns. The skin on
the buttocks sloughed away en masse , and the patient succumbed on
April 4, 1903.
Post-mortem Notes. —Body fairly nourished and covered with a
vesiculo-pustular eruption, large and flat, containing bright yellow sero-
purulent fluid. Large bullae everywhere, formed by the coalescence of
adjoining pustules; the contents of these were, for the most part, serous
and bright yellow in colour. The superficial layer of the skin w'as
284
Seheult: Small-pox in Trinidad
coming away from almost the entire surface of the body, and in some
situations, especially on the buttocks, there were gangrenous ulcers. The
feet were swollen. Liver: large, very soft and fatty. Spleen: slightly
enlarged and soft. Gall-bladder: distended with thick, yellow bile.
Heart: flabby. Kidneys : congested and fatty. This was the only case
of the kind which came under my observation.
Attacks in the Recently Vaccinated.
In their standard work on the theory and practice of hygiene, Drs.
Notter and Horrocks remark that 44 much valuable evidence has been
collected of late years in regard to the duration of the protection which
vaccination gives against small-pox. This evidence indicates that
although the susceptibility to the operation of vaccination returns com¬
paratively soon after primary vaccination, the susceptibility to small-pox
returns but slowly, so slowly, in fact, that the power of infantile vaccina¬
tion against attack by small-pox may be said to remain at least to one-half
of its original extent at 20 years of age.” It is interesting, therefore, to
note that, among the first 4,009 cases which were reported, the Assistant
Medical Officer of Health had observed the disease in twenty-eight
recently vaccinated and revaccinated persons; four cases had occurred
within one year of vaccination; eight within three years, and four
within four years, and eleven within from four to eight years. I also
observed the disease in a young married woman, aged 18, who had been
vaccinated four weeks previously and who showed three good recent
vaccinia scars; in this instance the initial symptoms were severe, but the
rash was sparse, although every part of the body, including the mucous
membrane of the pharynx and tongue, was affected ; the disease ran a
rapid course ; most of the vesicles shrivelled up, whilst a few became
pustular. The next most recently vaccinated case which contracted the
disease amongst those that were treated by me was a man who had been
vaccinated four years before and who presented four good vaccinia
cicatrices on his arm.
All experience goes to show that the duration of the protection
afforded by vaccination is limited and is directly proportionate to the
number and size of the vesicles produced, but it is very remarkable that
this protection was so fleeting and transient as the above cases indicate.
I do not think this unusual occurrence can be explained away by
assuming that the vaccine lymph was not efficacious or that the diagnosis
of small-pox was faulty, for the vaccinia marks were unmistakable and
Epidemiological Section
285
the course of the disease typical of varioloid, at any rate in the case that
came under my observation. Might the local manifestations of vaccinia
have been produced in these instances without the absorption into the
system of the immunizing substance which is supposed to be evolved in
the growing vesicles ? The fact that the disease was modified, at least
in my case, is a proof that a certain degree of immunity was conferred.
Does the duration of immunity depend upon the nature of the lymph,
the individual, or both ? It is true that at certain seasons of the year,
during the hot months, vaccine lymph suffers deterioration, but then
such lymph would be inert and would produce no reaction. For the last
seven or eight years glycerinated calf lymph has been used in this
Colony; previous to this, vaccination was practised from arm to arm.
The lymph which we now employ here is obtained from the Jenner
Institute for Calf Lymph, and is kept in refrigerators until required for
use. A fresh supply is received every fortnight, but the results are not
always satisfactory. It would appear that the duration of the immunity
afforded by vaccination depends to some extent on the potency of the
lymph employed. Voigt, of Hamburg, in 1881, succeeded in inoculating
a calf with human small-pox lymph and, after twenty removes in calves,
used the lymph, in 1882, as a vaccine on children. In 1893, when the
time came round for revaccination of the same children, the failures
were more numerous than with children vaccinated in 1882 with ordinary
lymph, showing greater potency of the Hamburg lymph (Edwardes).
The strain of lymph therefore determines the duration of immunity.
In my experience human lymph gives a greater reaction than calf lymph;
the former often succeeds where the latter has failed. The vesicles are
larger, and the resulting scars better marked and more persistent in those
vaccinated with human lymph than in those vaccinated with calf lymph.
It would appear, therefore, that the former is more potent than the
latter. This may partly account for the occurrence of the disease in
some of the recently vaccinated in whom glycerinated calf lymph was
used. Idiosyncrasy or exceptional individual susceptibility to the con¬
tagion of the disease was probably also a factor.
Second Attacks.
The possibility of second attacks was recognized as far back as the
tenth century by Ehazes, and his experience has been confirmed by many
observers up to the present day. Dr. Edwardes, in his admirable and
instructive book on “ Small-pox and Vaccination,” asks the question :
“ Can the same person have small-pox twice with an interval of some
286
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years between the attacks ? ” and answers it in the affirmative. He adds,
however, that such cases—fully established—are very rare, and that the
frequency of such second attacks in former times is suspicious, because
measles and various kinds of false small-pox were mistaken for variola.
The following extract is taken from his book :—
Dr. Kubler, a high modem authority on the subject [of second attacks] says
that the once survival of small-pox afforded, perhaps, no perfect protection but
a strong resistance against a fresh attack.
The German Vaccination Commission of 1884 referred to this point. Dr.
Koch said that second attacks were certainly rare; in the great epidemic of
1871—2, in 12,000 cases in South Germany no second attacks occurred.
Dr. Reisner pointed out that, in old times, all second attacks appear to have
occurred in children, never in adults; this pointed to error in diagnosis.
Dr. Grossheim, who represented the army, had only met with one peculiar case
out of 22,641 in military hospitals ; a man had a slight form of variola three
months after the first attack. Von Kerchensteiner (for Bavaria) had never
heard of an early second attack, but he believed in the occurrence of second
attacks, and he himself had seen a third attack. Professor Hebra, of Vienna,
had treated the patient in the first two attacks; he died in the third. Dr. Kruger
had seen one certain second attack in 500 cases of small-pox observed by
himself. Dr. Thierfelder had never heard or seen a second attack. Dr. von
Koch had met with tw r o in Stuttgart, both fatal; in each case the second attack
was many years after the first, “ a long interval of time.” Dr. Siegel stated
that Wunderlich found twenty-two second attacks in 1,727 cases in Leipzig in
1781; six were fatal, and one of these six patients had had small-pox already
in the same epidemic.
Dr. Friedberg, cited by Lotz, reported an extraordinary case from near
Breslau, during the severe epidemic of 1871—2. A child had small-pox, and
the attack left several cicatrices ; the child was vaccinated successfully some
months afterwards, and then contracted small-pox a second time, one month
after the vaccine crusts had fallen, and the second attack was fatal.
Trousseau, in his book on clinical medicine, tells of a medical student
who was three times attacked by small-pox; he also alludes to the death
of Louis XV. fVom confluent small-pox fifty years after the first attack,
which occurred when that monarch was aged 14.
Dr. Savill (Warrington epidemic, 1892—3) reports a woman,
aged 30, vaccinated in infancy successfully, revaccinated in 1873, that is
at the age of 10, contracted small-pox probably about the same time, and
yet, twenty years afterwards, had a severe attack of confluent small-pox
(April, 1893), which resulted in her face being badly pitted.
In the Lancet , August 1, 1903, Dr. Pierce records a case of recurrent
varioloid rash following vaccination. He states that a boy, aged 15,
whose primary vaccination took place when aged 10 and was said to
Epidemiological Section
287
have been normal, was revaccinated on December 5, 1901, successfully;
on December 24, that is, nineteen days after revaccination, small-pox
showed itself, being ushered in by febrile excitement with increase of
temperature, &c. The eruption developed fully and followed the normal
course; the general symptoms were mild. On March 6, 1902, he
developed three or four vesicles of large size about the upper lips and
alae of the nose, which were taken for herpes; the main part of the erup¬
tion appeared on March 7. A diagnosis of modified small-pox was made.
In this three experienced medical men concurred. He further says that
from the data available it was probable that the two attacks, whatever
their nature, were identical. Even allowing that the attacks were dis¬
similar in character, one being, e.g ., varioloid and one a manifestation of
vaccinia, the explanation of the attacks in view of the almost equal
immunity against recurrence, mutually exhibited by the tw T o infections,
would be more or less difficult.
In Clifford Allbutt’s “System of Medicine” (ii., p. 578) reference
is made to this subject by Dr. T. D. Acland, in his exhaustive article on
Vaccinia. He says :—
Great variations may be met with in susceptibility to vaccinia as well as to
small-pox, or any of the acute exanthems. It is commonly recognized that
one attack of small-pox renders the individual more or less immune against
contracting the disease again ; and similarly that one successful vaccination
protects, at any rate for a time, against the probability of a second successful
inoculation. But it would seem that, in some persons, one attack is no safe¬
guard against a second. This is well illustrated by a case that came under the
notice of Dr. C. Allbutt, in which a woman had small-pox three times, and was
also three times successfully vaccinated. Such a case seems to set at defiance
all laws deduced from ordinary observations, and may be regarded as the
exception which proves the rule.
It is generally recognized, therefore, that second attacks are very
unusual, and their occurrence within a short period of a first attack is
remarkably rare.
It is interesting to note, therefore, that from April, 1902, to May, 1903,
when 4,029 cases of the disease had been reported, the assistant medical
officer of health was able to record twelve cases of second attacks occur¬
ring one to seven months after complete recovery from the first attack,
and running a course identical with that of the primary infection. Two
such cases came under my own observation. One was treated by me in
the second attack in the Isolation Hospital, and the other was seen by
me in company w r ith her medical attendant at her own house. Both
cases presented unmistakable evidence of a recent (primary) attack ;
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they showed characteristic macules, which were scattered over the face,
trunk and limbs, including the palms of the hands and soles of the feet.
Furthermore, the account given by the patients themselves was in accord
with the facts observed by myself. In both instances the second attack
ran a mild course; the prodromal symptoms were slight and the eruption
desiccated rapidly. In one case marked pitting of the face resulted
after the second attack. This comparative frequency of reinfection in
this epidemic was another of the many peculiarities of the “ Trinidad
epidemic.”
It is not likely that faulty diagnoses w T ere made. The identity of
the attacks in the same epidemic could hardly have been mistaken,
especially as great care was exercised in the examination of these cases
so as to exclude any possibility of error, knowing the rarity of such a
condition under normal circumstances.
I may here mention, however, that five cases were sent to the Isola¬
tion Hospital which proved not to be cases of small-pox. Two were cases
of ordinary acne, one of malarial fever accompanied with sudamina, and
two of syphilitic rashes (pustular syphiloderm). The last two are of
some interest and demand special notice.
N. S., aged 21, vaccinated successfully in January, 1903, and showing
four large vaccinia scars on the flexor surface of the left forearm, was
admitted to the Isolation Hospital on April 9, 1903, with the history of
having had fever and sore throat for three days beginning on April 5,
and the appearance of a rash on the face on the second day of illness.
Condition on Admission .—A fairly w-ell nourished man with a measly
rash on the face, trunk and limbs, eyes injected, throat congested, small
ulcer with dirty greyish base and angry margin situated on left side of
uvula. Tongue furred. Temperature normal.
Progress of Case .—The rash, which was at first papular, became vesi¬
cular here and there on the chest and pustular on the thighs. The size
of the lesions did not increase, even when the vesicular or pustular stage
was reached. The ulcer in the throat rapidly grew larger, and involved
almost the whole of the uvula. For a long time the measly appearance
of the rash was retained, and then it became scaly everywhere except on
the chest and thighs. Under large doses of potassium iodide and
mercury the rash disappeared and the ulcer in the throat healed. The
patient also developed keratitis, but this yielded to persistent anti-
syphilitic treatment. General aches and pains were often complained
of, but there was no itching in the course of the disease. Fever in this
case began on April 12, and continued with irregular remissions until
Epidem iological Section
289
April 24. I was able to trace the past history of this patient, and found
out that he had been admitted on February 28 to the syphilitic ward of
the general hospital “ with a single indurated ulcer on the under surface
of the glans penis ” ; a w T ell-marked cicatrix w r as left to tell the tale.
This case, wdien first sent to the Isolation Hospital, was pointed out by
those w r ho held the view that the “ prevailing eruptive fever ” was not
small-pox, as a proof of the correctness of their opinion. This man w r as
unsuccessfully vaccinated by me during his stay in hospital.
A. F., aged 21, vaccinated at the age of 7, show r ed three good
stigmata on the arm ; was admitted on July 3 to the Isolation Hospital
with the history of having had fever and slight headache on the preced¬
ing two days, and of the appearance of a rash on the hands and feet on
July 2.
Condition on Admission. —Well-nourished man, with papular rash
on the back, chest and limbs. Face quite free from eruption. Some of
the papules were drying up, and others were capped w r ith a tiny drop of
pus. He had a chancre on the glans penis.
Progress of Case .—The papules never increased in size, nor did they
vesiculate; several acquired pustular summits; most of them became
scaly and w r ere very persistent. The patient suffered from fever until
August 4; he developed iritis of the right eye on July 21, which yielded
to antisyphilitic drugs. The rash disappeared entirely at the end of
August. This case w-as successfully vaccinated by me on July 21.
The history, the existence of chancre, the presence of pyrexia
throughout, the character of the eruption, which did not develop into the
large full pustules characteristic of variola, the w r ant of uniformity in
the size of the lesions and their polymorphic character, the slow course
of the eruption, the presence of general pains and the absence of itching
all marked out these tw r o cases from the “ prevailing eruptive fever.”
Results of Vaccination performed during Desquamation or soon
after Recovery from the Disease.
Owing to the uncertainty which existed in the minds of the profession
in regard to the nature of the epidemic, every conceivable means was
adopted to arrive at a correct diagnosis, and I thought some light might
be thrown on the subject by applying the vaccination test to a certain
number of cases. Accordingly I undertook a series of experiments w r ith
this object in view-. The results which I obtained confirmed the opinion
which I already entertained concerning the variolous nature of the
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disease. I performed 204 primary vaccinations among adults and children
who were in the desquamation stage of the disease or who had practically
recovered from it. Of these thirteen did not return for inspection. Of
the 191 cases that were inspected, 133 failed to react, fifty-four reacted
slightly to the operation, and four seemed to be fairly successful. The
“ slight reaction ” referred to above consisted in the delayed appearance
at the site of inoculation of small red excrescences without any areola,
resembling tiny mulberry growths, which dried up without further
development. There was no vesiculation. In those in whom the reaction
appeared “ fairly successful ” the vesicles w T ere late in appearing and were
ill developed; there was an absence in these cases of the inflammatory
zone around the vesicles, and also a lack of general symptoms. On
pricking these abortive vesicles a little viscid serum, followed by blood,
exuded from them; on drying up a thin scab was formed, which on
falling off left a small red excrescence, w T hich gradually became absorbed
until no trace of it w r as left behind. These vesicles therefore differed
from the normal vaccinia vesicles in size, contents, evolution and involu¬
tion. Amongst the 191 cases, four were vaccinated twice and three
cases thrice, with negative results.
I also revaccinated during convalescence tw r enty-five cases which
exhibited distinct evidence of previous vaccination. Sixteen of these gave
no reaction whatever; four reacted slightly, abortive vesicles of the same
character as already described being produced, and one gave a normal
reaction. The others were not available for further observation. The
case which gave a typical reaction was that of a child, R. H., aged 13, in
whom the local manifestations were normal and attended with some
constitutional disturbance. The child contracted the disease on June 15
and was vaccinated successfully on June 27, when she was practically
well owing to the mildness of the attack. This child had been vaccinated
in infancy and showed three good vaccination marks on the arm.
Besides these 229 cases one was vaccinated in the invasion and another
in the early vesicular stage of the disease, and both gave a very slight
reaction, which was much delayed. Four cases were vaccinated in the
papular stage, two of which gave negative results; one reacted slightly,
and the last exhibited an abortive vesicle. Thus 235 vaccinations were
performed at various periods of the disease, the large majority of them
being done during desquamation, with practically only one successful
reaction. The vaccinations were performed in twenty-nine different
series, and in fourteen of these “ controls ” w’ere used, which consisted
of forty-eight adults, eleven of w T hom had never been vaccinated before.
Epidemiological Section
291
All the primary vaccinations were successful amongst the “controls,”
both as regards local and general manifestations, while there were
twelve failures amongst the revaccinated. These experiments demon¬
strated clearly the variolous nature of the disease and the possibility of
vaccinia running a normal course even after a recent attack of small-pox.
It may be argued that the case of R. H. was not of a variolous nature,
but I have not the shadow of a doubt in my own mind that this child
passed through a mild attack of the disease.
I have not been able to obtain much information on the subject of
vaccination after small-pox. Indeed, it would seem from an article in the
British Medical Journal , January 31, 1903, p. 265, that observations on
this subject are scanty and vague. The following extract is taken from
that paper :—
The influence of a previous attack of small-pox on the success or failure of
a subsequent vaccination is a question which has engaged the attention of
several authorities. Beginning at the fountain-head, Jenner himself, in his
third publication, “ A Continuation of Facts and Observations relative to the
Yariolae Vaccinae, or Cow-pox,” writes as follows : “Although the susceptibility
of the virus of cow-pox is for the most part lost in those who have had the
small-pox, yet in some constitutions it is only partially destroyed and in others
it does not appear to be in the least diminished. By far the greater number on
whom trials were made resisted it entirely, yet I found some on whose arms
the pustule from inoculation was formed completely, but without producing the
common efflorescent blush around it or any constitutional illness, whilst others
have had the disease in the most perfect manner.” From the figures in a table
in Dr. Seaton’s “ Handbook on Vaccination ” it appears that something like one-
third of the adults who had suffered from small-pox were susceptible to the
local results of vaccination in a perfect manner. In this table it is interesting
to note that among the soldiers in the British Army—not recruits—the propor¬
tion of perfect success was 451 per 1,000, while among recruits the correspond¬
ing proportion was only 345. The difference suggests the element of time.
The likelihood is that the interval between the attack of small-pox and sub¬
sequent vaccination was shorter on the average in the recruits than in the
soldiers, the former being younger men. These statistics do not state the
actual interval between the attack of small-pox and successful subsequent
vaccination.
The writer of the article referred to above states that whatever may
be said about exceptional susceptibility of individuals, this general con¬
clusion is quite safely deducible from various recorded facts, viz., that
local reaction of the skin, either to inoculated vaccinia or inoculated
variola, does not in any way prove that the individual is susceptible to
attack by small-pox in the ordinary way. The system may be protected,
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Seheult: Small-pox in Trinidad
though the skin can still be used for the cultivation of the virus; this
principle applies both to small-pox inoculation and to vaccination. In
the epidemic under review the large proportion of recurrences goes to
prove that even after an attack of small-pox the individual may yet be
left, in some rare instances, susceptible to reinfection, and in the case of
R. H. it also shows that after an attack of small-pox the individual
may, though rarely, be left susceptible to vaccinia.
In the Lancet of October 22, 1898, Dr. Brownlee and Dr. Thomson,
in an article already referred to, write as follows on the relation of
vaccination and antecedent small-pox to an infectious disease which
closely resembled chicken-pox and small-pox :—
A certain amount of weight was given in the decision to the fact that three
of the patients had already passed through an attack of severe small-pox, two of
them comparatively recently. The small-pox in at least two of the cases was
unmodified. Four of the patients were revaccinated successfully during the
crusting stage, while the others had been revaccinated with success from two
to four weeks before the first appearance of symptoms. It may be supposed
that comparatively little value should be attached to this point, but successful
vaccination of small-pox convalescents, as well as the occurrence of small-pox
so soon after successful revaccination, is entirely contrary to the experience of
small-pox in Glasgow. An examination into the question among the cases
treated in hospital during the last five years shows that fifty-two small-pox
patients wero vaccinated at various periods during the stage of eruption and
convalescence, some twice or even thrice, but in no single instance was any
reaction manifested except in some cases a slight redness of the skin, such as
might occur in the neighbourhood of any superficial wound.
The conclusion deducible from my own observations is that in rare
instances vaccinia or variola may occur in a person recently attacked by
small-pox and run a normal course. This subject is surrounded with
difficulties, seeing that we have to deal with factors so variable as the
human body and the variolous disease, and also with vaccination, per¬
formed so very differently as regards degree of efficiency.
Several cases were vaccinated in the incubation period of the disease,
when they appeared to be in perfect health; the results were very
interesting and showed the influence of vaccination in modifying the
course of the disease when performed within a certain period after
exposure to the contagion. I have a record of nine cases. Three who
were vaccinated in the morning developed the initial symptoms of
small-pox in the evening of the same day, and both vaccinia and variola
ran their course concurrently without the one or the other being modi¬
fied (fig. 4). One case was vaccinated two days before the onset of
Epidemiological Section
293
prodromal symptoms and both diseases ran a normal course In four
cases the invasion symptoms of small-pox appeared at an interval of four
to eight days after vaccination, and in all these vaccinia ran a typical
course, but the variolous attack was modified. In one instance there
was an interval of eleven days between the vaccination and the onset of
initial symptoms of small-pox, and yet the latter disease was modified.
A case which at first sight appeared to be one of generalized vaccinia
came under my care in the course of my observations. J. J., aged 5
months, was seen by me on October 10; he had two small ulcers on the
left arm, evidently following vaccination, which the mother stated had
been performed at least three weeks before in St. Vincent. The child
arrived in Trinidad on October 4, and on the next day he developed
fever, which was followed on October 6 by a rash which was first
observed around the two ulcers on the arm. When the child came
under my care there were several small ulcers around the two referred
to above, and a few papules of varied sizes on the forearms, right arm,
chest and abdomen. The papules became transformed into vesicles,
which, on rupturing, discharged a clear, serous fluid, and subsequently
ulcers were formed, and these continued to exude serous fluid for some
time and then became’ covered with yellow crusts. I inoculated a
healthy infant, with lymph obtained from the vesicles on the thigh of
this child, on October 13; the result at the site of insertion was an
abortive vesicle which rapidly dried up, leaving no trace behind. No
general symptoms were present during its evolution and there was no
areola around the vesicle. On November 11 I revaccinated the same
infant with glycerinated calf lymph and two typical vaccinia vesicles
developed, accompanied by the usual constitutional reaction. This
showed beyond doubt that the eruption in the first child was not a
genuine “ vaccinide.”
Vaccination of Children born of Variolous Mothers.
(а) Children born of mothers in the invasion or very early eruptive
stage.—Two children born of mothers in the invasion stage of the disease
were vaccinated soon after birth, and both “ took ” well. I observed
that children born of mothers in this stage of the disease when exposed
to the contagion contracted the disease. I saw six such cases.
(б) Children born of mothers in the late stage of the disease, during
desquamation or convalescence.—Thirty-six children born of mothers at
this stage of the disease were vaccinated within a few days of their
my —10
294
Seheult: Small-pox in Trinidad
birth ; two of these showed external manifestations of having passed
through an attack in utero. Of the thirty-six cases, twenty-five failed to
react to the operation, that is, 69 45 per cent., and eleven “ took,” that
is, 30 55 per cent. Two of the eleven successful cases did not exhibit
quite typical vaccine vesicles. Of the twenty-five unsuccessful cases,
eleven were revaccinated, four unsuccessfully. I vaccinated five of the
remaining seven for the third time and obtained a successful reaction in
two cases. I again vaccinated one of the three unsuccessful cases for
the fourth time w'ith success.
All the children w T ere vaccinated in groups of four or five, and in every
series I used controls—seventy-two in all: five adults and sixty-seven
infants of the same age as the above cases. Sixty controls were success¬
fully vaccinated, that is, 83*34 per cent., and twelve were unsuccessful,
that is, 16*66 per cent. I revaccinated nine of the tw T elve unsuccessful
cases and obtained a typical reaction in five. I again vaccinated the
four refractory cases, and two of them reacted to the operation normally.
I observed that children born of variolous mothers at this late stage
of the disease were not attacked, though exposed to the contagion. It
would seem, therefore, that children born of variolous mothers at this
stage enjoyed a certain degree of immunity, but the further history of
the cases showed that this immunity was only temporary; vaccination
performed at a later period proved successful in all these cases. I was
also able to observe the effect of revaccination during pregnancy on the
fcetus in two instances. Two infants born of mothers who had been
successfully revaccinated in the later part of their pregnancy were used
among my “ controls,” and both were refractory to vaccination. They
were vaccinated a few days after birth. Three months after they reacted
in a normal manner to revaccination. Two women who had the disease
when one mouth and two months pregnant respectively gave birth to
full-term healthy children who reacted normally to vaccination.
The above observations show that besides the protection afforded bv
contracting the disease in utero , the foetus may acquire a certain degree
of immunity from the mother without itself passing through a regular
attack of the disease. This must take place either by the simple trans¬
mission of the already developed immunizing substances from the mother
to the foetus by way of the placenta, or (as a result of a reaction in the
fcetus) to the immunizing agent passing through the same channel from
the mother. By the former method, fluids which are already endowed
with properties upon which immunity depends are introduced into the
fcetus, whereas by the latter method these properties must first be
Epidemiological Section
295
elaborated in the foetus before immunity is conferred. The short dura¬
tion of the immunity conferred in my cases would seem to indicate that
the first method was the one which was operative, the children remain¬
ing protected only as long as the immunizing substances which were
transferred from the parent to them were retained.
Dr. Masson and I inoculated two monkeys with matter taken from
two patients under my care in the isolation ward in July, 1903. Both
monkeys were vaccinated with the same lymph, one by Dr. Masson and
the other by myself. My case gave only a slight reaction, whilst
Dr. Masson obtained a very successful result, which he recorded in the
British Medical Journal of September 2(5, 1903, p. 779 (fig. 20).
Fig. 20.
Monkey inoculated by Dr. Masson with variolous lymph ; three vesicles were developed
at the site of the inoculation.
Variations in Virulence of Epidemics and Mortality-Rate.
Small-pox, like all other epidemic diseases, varies in its intensity in
different outbreaks. Sydenham states that “ small-pox has its peculiar
kinds, which take one form during one series of years and another during
296
Seheult: Small-pox in Trinidad
another.” Mild outbreaks have been observed in all ages even in pre¬
vaccination times, and have occasionally, we are told, been mistaken for
chicken-pox.
In the great pandemic of 1871—2 this Colony suffered severely;
like all pandemic extensions of the disease this was characterized by its
great virulence. During that epidemic 12,531 persons were attacked
and 2,449 deaths occurred. This high death-rate (19'5 per cent.) bore
out the experience that in the negro and coloured races small-pox is a
severe affection and attended with a high mortality.
In the recent epidemic, mildness of type was shown in the slight
diffusiveness of the contagion, the insignificant symptoms exhibited by
a large proportion of the cases, and in the extremely low mortality. On
the other hand, a large number of vaccinated persons were attacked
even more severely in some instances than the unprotected. This cer¬
tainly appeared to be a very anomalous occurrence, but the term
“vaccinated” cannot be considered equivalent to “protected,” and the
apparent anomaly may perhaps be explained in the majority of instances
by the fact that in these persons the original protection afforded by
vaccination had worn itself out. There were some cases, however,
where vaccination was of comparatively recent date, and yet the protec¬
tive power was inoperative, at any rate against attack by the disease.
This epidemic maintained a degree of mildness which has never before
been witnessed in this Island since the introduction of the disease by the
Spaniards in the early part of the sixteenth century. Indeed, the case
mortality is the lowest that has ever been recorded in any country.
That only twenty-eight deaths should occur during an epidemic attack¬
ing 5,154 persons, consisting chiefly of negroes, is a result which is
without parallel in the recorded history of the disease. And the fact
that the disorder among infants and children was rarely fatal is also very
remarkable (Tables III. and IV.). Among the 564 cases that came under
my care, thirteen deaths occurred. When it is borne in mind that the
worst cases were treated in the Isolation Hospital, such a result is almost
incomprehensible. No small wonder that much doubt and hesitancy were
felt in the diagnosis of such an anomalous form of small-pox, especially
when cases literally covered all over with pocks escaped death. It would
appear that a fatal termination in small-pox is not determined solely
by the outward manifestations of the disease, but chiefly by the virulence
of the poison which attacks the system. As the virus in this epidemic
was mild, few deaths occurred, notwithstanding the abundance of the
eruption in many cases.
Epidemiological Section
297
Dr. Montizambert, in an article already referred to, says in regard to
the mildness of the epidemic which visited Canada in 1900:—
It has been suggested that the mildness of type is due to some meteoro¬
logical condition. Against this theory is the fact that during the period since its
commencement we have had at least one intercurrent outbreak of a very virulent
form of the disease introduced from the Orient. It was quickly limited and
stamped out. But in the score or so of cases that occurred the mortality ran
up to over 50 per cent.
Anomalous forms of small-pox were not unknown in prevaccination
times, though they were not invariably regarded as of a variolous nature.
At one time an almost unanimous belief was held by the medical pro¬
fession that an attack of small-pox was an absolute and lifelong protection
against another attack, so that when a person who presented the traces
of a previous attack became affected the disease was called “ horn-pox,”
“ water-pox,” &c.
Mild epidemics of small-pox have also been described under various
names. I shall refer to two classical outbreaks which occurred in
Jenner’s time.
At the latter end of 1789 an eruptive fever, which was known to the
common people as “ swine-pox,” broke out in various parts of Gloucester¬
shire and appeared to have greatly puzzled the medical men there. Jenner
cut the Gordian knot by inoculating his own child, then aged about 10
months, with matter taken from its nurse, who was affected with this
mysterious malady; this inoculation was successful, and the test of
variolation, which was afterwards applied on several occasions, showed
that the child had been protected against small-pox. From this experi¬
ment it may be safely concluded that that eruptive fever was variolous in
its nature.
In the year 1807, Dr. xAdams, of the London Small-pox Hospital,
took matter from an outbreak of what, owing to the white appearance
and small size of the vesicles, was called “ pearl-pox,” for inoculation
purposes. The result which he obtained with this lymph was identical
with that from the usual type of small-pox, showing that the disease was
undoubtedly variola. Death-rates in these two epidemics were low.
The mildness of type is due either to attenuation in the virulence of
the exciting cause, to a heightened resistance of the individual affected, or
to a combination of these factors. We know that all organisms are
susceptible of variation, especially w r ith changed conditions of environ¬
ment. Attenuated forms of bacteria are produced under injurious
influences, whereas exalted virulence may be secured under favourable
298
Seheult: Small-pox in Trinidad
conditions. Most of the variations with which we are familiar are
temporary, and soon disappear after a return to the normal conditions,
but some become permanent and heritable even after such a return, and
thus give origin to new varieties. If these variations in attenuation or
exaltation of virulence can be produced by artificial means, there is no
reason to suppose that spontaneous variations do not occur, especially as
we know that influences capable of affecting virulence in the laboratory
are operative in Nature. Indeed, we meet with varying degrees of
virulence under natural conditions in the case of some pathogenic bacteria,
e.g. y Bacillus diphtherias and pyogenic cocci. In this way may be
explained, perhaps, the varying characters of epidemics.
These variations are not confined only to micro-organisms; the
zoologist and botanist, by removing animals and plants to different
climates and different soils, have shown that the natural forms and
species are capable of alteration.
From experiments of Guillou, Thiele of Kasan, Trousseau, Delpech,
and others, it w r ould seem that there is a possibility of attenuating the
virus of small-pox without the intervention of the cow.
Jenner always looked upon variola and vaccinia as modifications of
the same distemper, and Somering expresses very well the identity of
these two diseases thus : “ Variola et vaccinia sunt morbi, non suit natura
sed gradfi, diversi.” The most recent scientific investigations of the
subject strengthen the theory enunciated by Jenner and supported by
Somering. Most of those who have worked in this field claim to have
obtained positive results as regards the production of typical vaccinia
after one or two removes, as the result of variolation of the calf. It may
be presumed, therefore, that variola and vaccinia sprang from a common
stock ; the former departed from the original type and, by successive re¬
production in man under conditions favourable to its propagation and
activity, acquired its well-known virulence. It may be that the organism
of small-pox in this epidemic had degenerated or reverted to its ancestral
type ow T ing to unfavourable influences.
Predisposition is also another factor w T hich must be considered ; but it
plays a less important r6le, especially in reference to small-pox ; though
there is a marked racial susceptibility to the disease, predisposition as
applied to individuals of the same race is of minor consequence. When
ordinary small-pox attacks a mixed population of whites and negroes the
latter are proportionately more frequently attacked, and the attacks are
more severe in this class, for the degree of susceptibility influences not
only the capacity to acquire the disease, but also severity. Predisposition
Epidemiological Sec tio n
299
in mild varieties of sinall-pox may, however, be a more important factor
than it is in the usual type of the disease. Probably to the combination
of these two factors is due the mildness of type in the present epidemic.
Essentially this eruptive fever and small-pox are alike; they differ
rather in degree than in kind. The absence or almost entire absence of
constitutional symptoms in comparison w T ith the abundance of the erup¬
tion ; the absence of secondary fever in a large proportion of the cases ;
the fact that a great number of unvaccinated persons had mild or abortive
attacks, whilst some of the vaccinated suffered severely; the frequency of
recurrences within a short period of the first attack or after recent
vaccination ; the bullous character of the eruption in some severe cases ;
the appearance of the rash in successive crops in many instances; the
apparently slight infectivity of the disorder, and its slow spread among
a black population largely leavened with unvaccinated immigrants; the
occasional vaccinal reaction during convalescence or after recovery from
the disease, and the extremely low case mortality, especially among
infants and children, are facts which are difficult to explain in association
with small-pox, but in the face of other and more important and salient
features which I have described, these anomalies must be regarded as of
little weight as affecting the diagnosis of the disease.
When one considers the history, the age-incidence, the initial sym¬
ptoms, the distribution, order of appearance, character and course of the
eruption in the majority of the cases, the frequency and nature of the
complications and sequelae, the occurrence of a typical haemorrhagic case
during the epidemic, the infection of the foetus, the influence of vaccina¬
tion and other facts mentioned in this paper, I think I am warranted in
coming to the conclusion and in recording the fact that the Trinidad
epidemic of 1902—4 was a mild and irregular form of small-pox.
300
Seheult: Small-pox in Trinidad
Table I.
Showing nationality of the 564 patients under treatment in the Isolation Hospital.
Barbados
Trinidad
St. Vincent
Grenada
Demerara
Tobago
Venezuela
Dominica
St. Kitts
Antigua
Montserrat
Nevis
Martinique
Cariacon
St. Martin
St. Thomas
St. Lucia
Saba ...
Colon
India
254
118
61
24
23
21
19
8
8
7
5
4
3
2
2
1
1
1
1
1
564
Table II.
Showing age and sex of the 564 patients under treatment in
the Isolation Hospital.
Male
Female
Total
Under 5 years
14
7
21
5-9
7
7
14
10—14
15
19
34
15—19
43
42
85
20-24
87
55
142
25—29
79-
32
111
30-34
45
19
64
35—39
27
12
39
40-44
16
10
26
45—49
8
4
12
50—54
7
2
9
55—59
2
2
4
60—64
0
0
0
65-69
0
1
1
70-74
0
0
0
75-79
1
0
1
80—84
0
0
0
85-89
1
0
1
352
212
564
Table
III.
Showing number of infants under treatment in the Isolation Hospital and the
mortality among them.
No. of Cases
No. of DeatliM
Abortive
2
0
Mild discrete
6
1
Severe discrete
4
1
Confluent
0
0
12
2
Remarks. — The two aborted
eases occurred
in infants who
had been vaccinated a few
’s before the attack of small-
pox declared itself. The two infants who died were twenty
and thirty-two days old respectively.
Epidemiological Section
301
Table IV.
Showing number of children aged 1—4, who were under treatment in the
Isolation Hospital.
Abortive
Mild discrete ...
Severe discrete ...
Confluent
No. of Cases
No. of Deaths
0
0
8
0
1
0
0
0
9 0
Remarks .—All were unvaccinated except one, aged 3, who was vaccinated at the age of
3 months and showed two good marks.
Table V.
Showing race of 5G4 patients under treatment in the Isolation Hospital.
Negroes
514
Whites
9
Mixed
. 40
East Indians
1
564
Table VI.
Showing
mortality in each
variety of the disease.
Vaccinated
Un vaccinated
Percentage
Abortive
0
0
—
Mild discrete
0
5
1*38
Severe discrete
0
2
104
Confluent
0
5
27-77
Haemorrhagic
0
1
100
0
13
Table VII.
Showing incidence of the disease upon the nursing staff of the Isolation Hospital.
(1) Unvaccinated
(2) Vaccinated successfully one week to four years previous
to joining staff ...
(3) Re-vaccinated successfully one week to four years pre¬
vious to joining staff
(4) Vaccinated successfully in infancy ...
(5) Vaccinated thrice unsuccessfully
(6) Vaccinated in infancy and contracted variola same week
(7) Unvaccinated, but contracted the disease at beginning
of epidemic before joining the staff
Number
employed
3
15
8
1
Number
attacked
3
0
0
0
0
0
36
Remarks .—Of the eight who were vaccinated successfully in infancy five were revaccinated
without success before joining the staff, and three after they had been ten, fifty-two, and
seventy-two days respectively in the isolation ward. The last was successful.
Table VIII.
Total number of cases reported to week ended April 11,1903 ... ... 2,009
Total number of deaths ... ... ... ... ... 10
Total number of cases reported during four weeks ended May 9 in—
(1) Port-of-Spain ... ... 1,123
(2) Country districts ... ... 96
my —10a
302
Seheult: Small-pox in Trinidad
Table VIII.— (continued).
Total number of cases reported to week ended May 9 ... ... 3,228
Total number of deaths ... ... ... ... ... 14
Total number of cases reported during four weeks ended June 6, in—
(1) Port-of-Spain ... ... 820
(2) Country districts ... ... 147
Total number of cases reported to week ended June 6 ... ... 4,201
Total number of deaths ... ... ... ... ... 20
Total number of cases reported during four weeks ended July 4 in—
(1) Port-of-Spain ... ... 3*29
(2) Country districts ... ... 123
Total number of cases reported to week ended July 4 ... ... 4,663
Total number of deaths ... ... ... ... ... 25
Total number of cases reported during four weeks ended August 1 in—
(1) Port-of-Spain ... ... 143
(2) Country districts ... ... 53
Total number of cases reported to week ended August 1 ... ... 4,849
Total number of deaths ... ... ... ... ... 20
Total number of cases reported during four weeks ended August 29 in—
(1) Port-of-Spain ... ... 09
(2) Country districts ... ... 08
Total number of cases reported to week ended August 29 ... 4,986
Total number of deaths ... ... ... ... ... 20
Total number of cases reported during four weeks ended September 26
in— (1) Port-of-Spain ... ... 34
(2) Country districts ... ... 56
Total number of cases reported to week ended September 26 ... ... 5,070
Total number of deaths ... ... ... ... ... 28
Total number of cases reported during four weeks ended October 24 in—
(1) Port-of-Spain ... ... 5
(2) Country districts ... ... 32
Total number of cases reported to week ended October 24 ... ... 5,113
Total number of deaths ... ... ... ... ... 28
Total number of cases reported during four weeks ended November 21
in— (1) Port-of-Spain ... ... 0
(2) Country districts ... ... 24
Total number of cases reported to week ended November 21 ... ... 5,137
Total number of deaths ... ... ... ... ... 28
Total number of cases reported during four weeks ended December 19
in— (1) Port-of-Spain ... ... 3
(2) Couutry districts ... ... 9
Total number of cases reported to week ended December 19 ... 5,149
Total number of deaths ... ... ... ... ... 28
Total number of cases reported during four weeks ended January* 16
in— (1) Port of-Spain ... ... 0
(2) Country districts ... ... 5
Total number of cases reported to week ended January 16 ... ... 5,154
Total number of deaths ... ... ... ... ... 28
Remarks .—From October 17 to November 21,1903, no new cases occurred in Port-of-Spain.
During the last week of November three cases were reported, and these were the last cases
which occurred in Port-of-Spain in the town. No cases were reported from the country districts
after January 6, 1904.
Eptfcenuoloflical Section.
May 22, 1908.
Dr. A. Newsholme, President of the Section, in the Chair.
Preventive Medicine at Panama.
By Sir Frederick Treves, Bt., G.C.V.O., C.B., LL.D.
The Isthmus of Panama is at this moment the scene of an enterprise
in sanitation of surprising magnitude, an enterprise which serves to
display the forces of Preventive Medicine on a scale never before paralleled.
I visited the isthmus in February of last year and had the advantage
of seeing this remarkable work under the guidance of Colonel Gorgas, the
chief sanitary officer. To Colonel Gorgas is due the credit of an under¬
taking which in its aims and its results is not one whit less astonishing
than the work of connecting by means of a canal the two great oceans
of the w T orld. Colonel Gorgas is clearing of disease one of the most
pestilential spots in the tropics, and is making of the same a place where
men can live in safety and in reasonable health. He is at the same time
demonstrating practically the soundness and efficiency of the most recent
claims of Preventive Medicine.
The isthmus is situated near to the Equator, the city of Panama
standing in about the latitude of 9° N. This part of the world, ever
since its discovery by Columbus, has been more or less notorious for its
unhealthiness. Enriquez de Guzman, who came here in 1534, says that
of every 100 men who went to Peru by way of the isthmus eighty
never returned. The mortality among the Spanish gold trains was known
to be very high. Equally disastrous did the isthmus prove to the hordes
of men who passed westward on their way to the goldfields of California.
The number of labourers who died annually during the construction of
the canal by the French company is not known, but the mortality was
so high that on more than one occasion the work had almost to cease
ju —7
304
Treves: Preventive Medicine at Panama
owing to the ravages of yellow fever. The deaths must have amounted
to many thousands. So high was the death-rate among the labourers
who constructed the Trans-Isthmian Railway that it ha« been said—
probably with some truth—that every sleeper beneath the lines repre¬
sents a human life. This railway was completed in 1855. The chief
causes of the great mortality on the isthmus have been yellow fever,
malaria and dysentery, with occasional outbreaks of small-pox. It may
be called to mind that Sir Francis Drake contracted on the isthmus the
dysentery of which he died, and that he lies buried just off the coast.
It was on the isthmus also that his brother succumbed to yellow fever.
The isthmus, at its narrowest part, is about thirty-three miles in
a direct line. The railway, which follows a winding course, covers
47J miles from Colon to Panama. Along the isthmus and parallel to its
shores runs a ridge of hills, the ultimate offshoot of the Andes. This line
of high ground is nearer to the Pacific than to the Caribbean Sea, the
Culebra Pass, through which the canal has to make its way, being some
ten miles from Panama. The rainfall on the Pacific side is from 50 in.
to 60 in. annually ; while on the Atlantic side it ranges from 100 in. to
150 in. The mean temperature of the district may be taken as 82° F.,
the mean humidity as 88. The tide on the Pacific coast rises 14 ft.,
while on the Atlantic shore the rise is only 14 in. The country for the
most part is covered by dense jungle, while the lowlands, especially on
the northern side, are occupied by extensive swamps. The highlands
present bare and open country with extensive tracts of prairie, grass
downs and breezy slopes. The denseness of the forest tracts may be
illustrated by the fact that Dampier when he crossed the isthmus in
1681, with Wafer, the surgeon, and forty-four pirates, only made on an
average five miles a day. He attempted a wider part of the isthmus and
followed a devious course, so that the traverse of 110 miles occupied
twenty-three days. Major Ronald Ross, speaking of sanitation in
Panama, says : “ The country is one of the worst to deal with which I
have ever seen.” 1
The unhealthiness of the Panama area has been due, as has been
already said, in the main to yellow fever and malaria. The actual mor¬
tality from these causes during the French occupation has never been
published, but the fatality of these diseases can be to some extent gauged
by the records of the British Army in the adjacent West Indies. Sir
John Moore’s garrison on St. Lucia amounted in June, 1796, to 4,000
1 Lancet , 1907, ii., p. 886.
Epidemiological Section
305
men. By November the force had been reduced to 1,000 fit for duty
and 1,500 sick. The campaign that lasted from 1793 to 1796 resulted,
writes Fortescue, “ in the total of 80,000 soldiers lost to the service,
including 4,000 actually dead, the latter number exceeding the total
losses of Wellington’s army from death, discharges, desertions and all
causes from the beginning to the end of the Peninsular War.” The
mortality was highest during the year 1794, when, of General Grey’s
original force of 7,000 men, no less than 5,000 perished during the
course of the twelve months. It is probably beneath the mark, says
Fortescue, that 12,000 Englishmen were buried in the West Indies
during this single year. In 1780, four newly raised regiments were
ordered to Jamaica. They stopped on the way at St. Lucia, where they
contracted yellow fever. By the time the transports reached Kingston
they had lost 168 men by death and had 780 on the sick list. During
the course of the first five months at Jamaica 1,100 more of the sur¬
vivors had died of fever. It was then that Dalling, the Governor, placed
the matter before the Secretary of State in the following words : “ Con¬
sidered only as an article of commerce , these 1,100 men have cost
£22,000, a sum which, if laid out above ground, might have saved half
their lives.” In this sentence lies no little of the secret of the great
success of the Americans in Panama. In addition to the dictates of
humanity they have realized the part played by the labourer as an
4 ‘ article of commerce.” The realization of this fact by governments
engaged in great enterprises of either war or peace comes, unfortunately,
very late in the history of State-controlled sanitation.
The Isthmian Canal Commission was created in May, 1904. The
commissioners found on the canal area a condition of chaos: the plant
neglected, the district overgrown by tropical vegetation, little, if any,
attempt at sanitation, and inadequate accommodation for the men
employed. They found 3,000 labourers—mostly Jamaican negroes—
still engaged on the works, and two French doctors, one at Panama and
the other at Culebra. The Commission obtained from the Kepublic of
Panama a grant in perpetuity of the land now known as the Canal Zone.
This strip of land is ten miles wide—the line of the canal being in the
centre—and extends from sea to sea. Over the Canal Zone the United
States have practically as complete control as if the territory were part
of the home country, maintaining within its limits their own police and
governing by their own laws. The grant included the group of islands
in the Bay of Panama, but did not include the towns of Colon and
Panama, although they are both on the canal strip. Colon, at the time
306 Treves: Preventive Medicine at Panama
of the occupation, had a population of 6,000 and Panama of 18,000.
The position of these two towns, however, is defined in the following
article : “ The Republic of Panama agrees that the cities of Panama and
Colon shall comply in perpetuity with the sanitary ordinances, whether
of a preventive or curative character, prescribed by the United States,
and in case the government of Panama is unable, or fails in its duty, to
enforce this compliance of the cities of Panama and Colon with the
sanitary ordinances of the United States, the Republic of Panama grants
to the United States the right and authority to enforce the same.”
A like authority is granted to the United States to maintain public order
in the tw T o cities, should the Republic not be able, in the judgment of
the United States, to maintain such order. The United States, more¬
over, obtained the power to drain these two cities, to provide them with
a water supply, and to levy a water and sewerage rate to defray the cost
of the same.
It may be said that the sanitation of the two cities at the time of the
creation of the Commission was that of the Middle Ages. Water was
obtained from rain-butts and shallow wells; there was no attempt at
drainage, and the disposal of refuse was left to the individual householder.
The Commission realized immediately that if the canal was to be
constructed, “ thorough sanitation was the first essential.” In every
published report sanitary measures occupy the most prominent position.
The medical officer of health was allowed absolute powers; he was
assured (1905 Report) that “the entire resources of the Commission”
were at his disposal, and funds were immediately forthcoming for all
such undertakings as he considered necessary.
The views of the Commission on this question are expressed in the
following words: “ The importance of completing the sanitation of the
Isthmus of Panama can hardly be exaggerated, for upon it depends not
only the construction of the Isthmian Canal, but also the utility of the
canal when completed, and the question as to whether the canal is to be
a blessing or an affliction upon the inhabitants of the earth.” It was
realized that unless yellow fever was stamped out the canal would
become the means of carrying that disease eastwards, since the lifetime
of the stegomyia has been shown to be about three months.
Sanitary works were among the very first undertaken by the Com¬
mission, and Colonel Gorgas must allow that his department has received
throughout the most liberal and sympathetic support of the Government.
In 1905 the number of men employed on the canal and railway was
19,500. In the sanitation section, nearly 2,000 men w*ere exclusively
Epidemiological Section
307
Fig. 1.
Bottle Alley, Colon, before paving, September, 1906.
Fig. 2.
Bottle Alley, Colon, after paving, June, 1907.
308
Treves: Preventive Medicine at Panama
engaged. The death-rate for the year was 24*3 per thousand. The
number of the constantly sick, 30 per thousand, and the deaths from
yellow fever, 47. In 1906, the deaths due to yellow fever fell to 7,
and since that time the disease has disappeared. The mortality for the
year 1906 was 17*5 per thousand among the whites and 53 per thousand
among the blacks. In 1907 the number of the employees was 29,446.
The constantly sick were 29 per thousand. The death-rate among the
white population had dropped to 15*9 per thousand and among the
blacks to 45*3 per thousand.
The sanitary works commenced in 1904, and since then developed or
completed, have been upon the following lines:—
In the first place the housing of the employees was taken in hand.
Excellent houses, barracks, boarding-houses and hotels were built along
the canal track. The rooms are lofty, light and well ventilated, while
all are screened with copper gauze. They are provided with modern
sanitary conveniences, with a good water supply and with modern
plumbing. Better dwellings for a tropical climate with a heavy rainfall
could hardly be designed. The feeding of the labourers has been a
matter of especial care and of exceptional difficulty, on account of the
fact that the bulk of the supplies have to come from the States.
Numerous public kitchens and restaurants have been established, where
excellent food can be obtained at a minimum cost. As the West Indian
negro is apt to feed himself meanly in order to save money, his wages
are paid partly in board, so the security is obtained that he is amply fed.
Previous to this arrangement many of the men almost starved them¬
selves, and became thereby reduced in efficiency and in health. Ample
holidays and rest days are instituted ; reading rooms have been estab¬
lished along the zone, and clubs founded for every kind of recreation
which is possible in a hot climate. A vessel is employed for free
excursions to the island of Taboga, in the Bay of Panama, and every
step is taken to keep the men upon whom the success of this great
work depends in sound condition. One of the earliest matters under¬
taken was the providing of accommodation for the sick. The hospital
at Ancon was greatly enlarged, and other hospitals built where required
along the Canal Zone. The hospital at Ancon is a model building of its
kind, replete with every modern appliance, and, indeed, as well equipped
as any first-class European hospital. It is served by a specially selected
staff, and in connection with the institution are ample laboratories for
bacteriological and pathological work, for the chemical analysis of foods,
Ac., and for general investigations in connection with the sanitation of
Epidemiological Section
309
the district. Looking back some ten years, it is scarcely to be believed
that a body of engineers entrusted with the most stupendous construc¬
tion of modern times should have recognized that among the first
requirements to ensure success was a bacteriological laboratory. Colonel
Gorgas, the chief sanitary officer, had further to secure proper hospital
accommodation for the sick poor of the two cities, for the lepers, and for
the insane. Such lepers as were unable to work lived in wretched hovels
on the beach, where they existed in much the same way as the land
crab. The insane poor were allowed to roam over the land or were
looked after by their friends. If they became violent they were placed
in the stocks or were cast into the city prison. The Commission has
now provided both lazar houses and lunatic asylums. The hospital
accommodation available on the canal area amounted in 1907 to
1,845 beds.
Then came the great undertaking of making reservoirs and of
providing Panama and Colon with a good and constant water supply.
As soon as this work was accomplished the numerous shallow wells
were filled in, water-butts, tanks and cisterns were removed, or, if left,
■were carefully covered in. Thus, in the year 1906, 307 wells were
filled in in Panama City alone, while in the two towns 23,031 tanks
or water barrels were dealt with. There followed upon this the still
more extensive work of draining both the cities and carrying out a
modern scheme of sewage disposal, of connecting the individual houses
with the sewers, of introducing water-closets, and filling in the innumer¬
able cesspools. It is very noteworthy with what determination the Com¬
mission insisted upon the carrying out of the sanitary orders they had
imposed. For example, in 1906 the canal zone police made no less than
584 arrests for violation of sanitary regulations, while in 1907, 925 persons
were arrested for the same offence. In the criminal statistics for the
latter year it will be observed for purposes of comparison that the
charge of ‘‘disorderly conduct ” heads the list with 1,176 arrests; then
comes “ violation of sanitary regulations ” with 925 ; and in the third
place “ drunk and disorderly,” with 787 arrests. Another great work
undertaken by the Commission was the paving of the public ways in
the two cities, and the levelling and draining of the roads. The state
of the streets in Colon and Panama in 1904 was no better and no worse
than that to be found in any of the old cities on the Spanish Main or in
the adjacent islands. Those who would form an idea of the condition
of these highways should visit Cartagena on the mainland, or the
famous city of San Domingo on the island of Haiti. They would find
310
Treves: Preventive Medicine at Panama
there the surface of the main street as full of holes and gulleys as
the bed of a dry torrent. To drive along these streets is an experience
not to be forgotten. After a shower of rain the highway is a waste of
mud interspersed by a hundred pools, which in the rainy season are
never dry. The practice, moreover, of throwing all odd garbage into
the streets makes their condition inconceivable. During the dry season
these public ways are heavy with dust. In some of the smaller lanes
about Cartagena the dust is as thick as the sand on a beach, and is
only kept in check by the happy practice of emptying all slop water
into the highway. To their other responsibilities the Canal Commission
added the cleaning of the streets and the removal and destruction
of refuse.
The most interesting work, however, undertaken by Colonel Gorgas
and his staff was a crusade against the prevailing diseases on the
isthmus. Of these the most important are yellow fever and malaria.
Against yellow fever the inhabitants of the isthmus are immune, but
they are not immune from malaria. Some 70 per cent, of the natives
are the subjects of the latter disease, and it has proved most fatal.
Taking the year 1907 as an example, the mortality lists on the Canal
Zone present the following features: The total number of deaths was
3,822. The chief contribution to this number was made by pneumonia,
which accounted for 716 deaths. The liability of the negro to pneumonia
is well known, and the prominence of this disease throughout the West
Indian islands is very striking. The fact that pneumonia heads the
death-list in every year has no doubt suggested to the Commission that a
crusade against this malady is a pressing matter. No data are forth¬
coming to explain the prevalence of pneumonia in the islands. The
negro spends practically the whole of his day out of doors in a warm
atmosphere, which is subject to but little variation of temperature the
year through. At night he retires to his tiny cabin, the windows and
doors of which he literally seals up ; and when the number of human
beings who may occupy one of these cabins during the night is noted,
it is astonishing that they do not die of mere suffocation.* This habit
of the negro of hermetically sealing his cabin at night appears to be due
solely to his fear of jumbies or ghosts, which are very troublesome on the
Caribbean coast and can enter through the smallest chink. On the
isthmus the houses provided for the labourer afford the amplest cubic
space per man and are perfectly ventilated. They are screened with
copper gauze, the meshes of which are too fine to admit even the
slenderest jumbie. It is evident, therefore, that the home cabin of the
Epidemiological Section
311
negro cannot wholly explain his liability to pneumonia, since it follows
him to the isthmus. The next disease in the mortality list is malaria,
which in 1907 was answerable for 605 deaths. Then come the following
in order: Tuberculosis of the lungs, 304 deaths; enteric fever, 150
deaths; Bright’s disease, 137 deaths; diarrhoea and enteritis (mostly
among children), 136 deaths; dysentery, 118 deaths. In this year the
number of deaths from small-pox was three. The liability of the negro
to acute nephritis is well known and is shown by forty-eight deaths in
1907 and sixty-four in 1906 from this cause. To beriberi are ascribed
111 deaths in 1906 and fifty-nine in the year following. This outline of
the death-rate may be completed by adding that in 1907, 236 deaths
were due to accident or violence, including eight suicides.
The plan of campaign against yellow fever is as follows : The houses
are in the first place screened. This screening is very complete. In the
better residences not only are all the windows and doors screened, but
also the verandahs. I have lived for a fortnight in a screened house and
never saw a mosquito, but was bitten when out of doors. Mosquito nets
are entirely dispensed with. Within the hotel at Panama I neyer saw
a mosquito and no nets are used. The spring doors seem to be quite
efficient. In the administration building guards are stationed at these
doors to see that they are not propped open and that no one loiters in
the doorway. In the fire buckets in this building larvap are now never
to be found. The stegomyia do not frequent the open country, nor do
they breed in swamps or large bodies of water. They are “ house
dwellers ” and require the protection of buildings, grass, foliage, &c.
A system of house to house inspection was instituted to see that no
mosquito larvae were breeding; water-butts and tanks were destroyed or
carefully covered over, while puddles in yards and elsewhere were oiled.
Any subject of yellow fever was immediately isolated and “ placed under
a mosquito-bar.” In order that no case, real or suspected, should pass
unnoticed eight medical men were appointed in Panama City “ to act as
medical inspectors and to make a daily house to house canvass of the city,
reporting all suspected cases to the Health Department.” The house
from which any case of yellow fever has been removed is cleaned and
fumigated. It is made as nearly smoke-proof as possible, all cracks and
openings are sealed with paper and paste, and each room is then fumi¬
gated with sulphur or pyrethrum. In from two to four hours the
house is opened and thoroughly swept out, the sweepings being taken
into the street and burned. Owing to the destructive action of sulphur,
pyrethrum powder is in general use on the isthmus. As in the month
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Treves: Preventive Medicine at Panama
of June, 1905, the number of cases of yellow fever had mounted to sixty-
two, the fumigation of the entire city of Panama was resolved upon.
Since twelve days must elapse after the mosquito has bitten a fever
patient before it can transmit the disease, it was desired to complete the
work within that period. It occupied, however, forty-four days. It is
impossible not to admire the docility of the people of Panama, especially
as they are themselves immune, and to note that even as late as 1907
no less than fifty-nine of these citizens were fined for “ having mosquito
larva? ” on their premises. The average number of men employed in
fumigating in Panama City alone was (in 1906) 110.
The crusade against malaria has been even more elaborate. Every
new arrival on the isthmus is handed a printed circular explaining the
cause of malaria and the means of its prevention and advising the
constant use of quinine in doses of at least 3 gr. a day. Quinine is
placed on the table in the dining rooms and boarding camps, and large
quantities of the drug are distributed broadcast. In the month of
September, 1905, for example, 675,000 gr. were dispensed, mostly for
prophylactic purposes. A large number of men are kept constantly
employed in cutting down the dense tropical undergrowth, in mowing or
burning the grass, in making and lining ditches, in filling in swamps and
in oiling the surface of any pool or puddle in which mosquitoes might
breed. Others are employed to inspect water tanks and barrels, to
destroy such as can be dispensed with, and to screen such as are retained.
As an example of the work of the anopheles brigade it may be noted
that in 1906 in Colon alone the surface oiled amounted to 330,000 sq. ft.
New ditches were cut to the extent of 200,000 lineal feet. Of these
ditches 20,000 ft. were stoned or cemented. Two million lineal feet of
old ditches were cleared, graded, stoned or filled in. The area of
brush and grass cleared amounted to 21,000,000 sq. yds. Never has
a crusade been carried out with such completeness, for never has a chief
sanitary officer had so free a hand. It is needless to point out that the
mere oiling of pools does not constitute the sole prophylactic measure
against malaria. In a well-to-do town in the tropics it may be supposed
that the land has been thoroughly drained and every suspected water
area oiled, but there are still many varieties of vegetation which afford
a breeding place for mosquitoes; as instances may be cited pines and
such a palm as the traveller’s palm. We may be sure that the pine
grower will not sacrifice his harvest in the public interest, nor will the
wealthy resident allow the palms, which are the glory of his garden, to
be cut down. It is much to be hoped that a list will be forthcoming of
E])iclemiological Section
313
garden and other plants in which mosquitoes breed. On the Canal Zone
no such list was needed. The place denounced was swept bare.
On one point of interest the reports of the Commission are silent.
They do not state upon what grounds the crusade against the land crab
is based. It will be noticed in the last report that in the course of the
year in Cristobal alone no less than 30,5(56 crab holes were oiled and
10,571 crabs were killed. I am not aware that the land crab has ever
been seriously studied from a medical or sanitary point of view. That
the animal is a remarkable and agile scavenger is allowed; that his habits
are disgusting and his place of hiding unhygienic are more or less evident;
but I have not met with any account which accuses this creature of
the dissemination of disease. The matter is of some interest. On the
Island of Barbados, for example, are to be seen more land crabs to the
square yard than I have noticed in any other part of the world, yet
Barbados is a remarkably healthy island, entirely free from yellow fever
and but slightly troubled with malaria. The land crab has there no
price upon his head, and, except for the damage he does to gardens,
graveyards, and roadsides, is not anathema.
Time will not permit of any account of the quarantine arrangements
on the Canal Zone, nor of the very vigorous and successful manner in
which an outbreak of bubonic plague was dealt with in 1905.
It will be seen, I hope, from the above brief description that the
Isthmus of Panama provides at this moment an object-lesson which
those who control the destinies of men might study with advantage. It
provides for the realization of a long contemplated and heroic ideal—the
medical officer of health with a free hand.
DISCUSSION.
The President (Dr. Newsholme) said Sir Frederick Treves had had a
wonderful story to tell the Section, and those who had heard Sir Frederick
before, and had read his writings, would know that the story had lost nothing
in the telling. The members, he was sure, were all much obliged to him.
Panama was evidently an administrative Elysium for medical officers of health.
The immense progress in sanitation there had been due to necessity, though
that did not detract from the credit accruing for the work, and in that respect
there was a parallel in our own country, where cholera was the immediate
determining cause of sanitary reform.
314
Treves: Preventive Medicine at Panama
Sir SHIKLEY Murphy said he had very much pleasure in proposing a vote
of thanks to Sir Frederick Treves for his address. The subject was of entran¬
cing interest to the Section, and its attractiveness was much heightened by the
manner in w T hich it had been presented. He knew the author had experienced
some difficulties in connection with preparation, but no obstacles were apparent
in the reading, and the Section was very grateful for the way Sir Frederick had
presented the subject.
Dr. SANDWITH seconded the resolution of thanks. No one, he was sure,
had enjoyed the paper more than he had, and he thought the author was a
living illustration of how a man might cease to be a practitioner, might even, if
he chose, cease to be a surgeon, but could not cease to be a citizen of the
Empire; he might still do good work, and he (Dr. Sandwith) was glad to see
that Sir Frederick had not ceased to be a teacher. The reader had made clear
the different treatment meted out to the American medical officer compared
with that accorded to his British confrere. At the time when yellow fever was
stamped out in Havana the American medical officers were given military
power, and he (Dr. Sandwith) suggested that medical officers of health in this
country should try to get the same powers. It was a great surprise to him,
after being some years abroad, to find the inferior position occupied by medical
officers of health in this country compared with what their colleagues enjoyed
abroad, for in the fight against epidemic disease it was essential to have
officers who could be trusted to act. Sir Frederick Treves had spoken about
yellow fever, malaria, and dysentery, and he (Dr. Sandwith) had been thinking
how little the present generation realized the evils of malaria. Less than ten
years ago the Egyptian Army was reoccupying the Sudan, and black troops
were sent up the Blue Nile because they were supposed to be less susceptible to
malaria than the Egyptians. Of course they were commanded by British
officers. On coming to Karkog, a village about 300 miles from Khartum, the
force consisted of 451 healthy men. Seventeen days later sixty-nine of them
were struck down, and in another two days 380 men, or about 84 percent., were
down with malaria, ten deaths occurring within a few days. Of the thirteen
British officers one died, six were seriously ill, and six were only slightly ill.
From experience in the United States, Egypt, and South Africa, he could confirm
Sir Frederick’s statement as to the liability of the black man to get pneumonia.
He had not an explanation to give for it, but thought there were obvious
contributing factors. It was not at all unusual for a European to live for
years with arrested or cured tuberculosis, but the African seemed always to
succumb rapidly to it, and when he had pneumonia he often died of it. Again,
a negro suffering from typhus was more apt than a European to die of hypo¬
static congestion of the lungs. One reason, he believed, was that the black did
not take full breaths; he was generally a man of the plains, unaccustomed to
deep breathing, and seemed to have no reserve of lung power which would tide
him over a respiratory illness. Also the black seemed to have very feeble
resistance to tubercle bacilli and pneumococci.
The resolution w T as cordially earned.
Epidemiological Section
315
Mr. Malcolm Watson said they had heard that night from Sir Frederick
Treves an interesting account of the success with which the Americans had
dealt with malaria and yellow fever in Panama. By the request of the Secre¬
tary he was there to ask them to turn to the other side of the lantern, and hear
how a British Government had dealt with a somewhat similar problem. Panama
was about 90 W. longitude, the Federated Malay States were some 90~ E.
They were within 5' of the Equator, had a heavy rainfall amounting to about
100 in. per annum, and had been notorious for a malarious climate. Early in
1901, on assuming duty as district surgeon in the district of Klang, he found
the hospital full of malaria ; Government officers were continually off duty
with the disease. The town was smothered in jungle; acres of swamp,
abounding with anophelines, stretched along the small hills on and around
which the town was built. Setting himself to collect statistics of the disease,
he was soon in a position to present a report to the Government of such a
nature that money for drainage works was promised for the following year.
Before, however, the year was out, the town was almost devastated by the
disease, and the Chinese suspended business for three days in order that
all their attention might be concentrated on processions, theatres, and such
other rites as were essential to the driving of the devil from the town. As
a result of the drainage, malaria had almost completely disappeared from
the town, only some eight or ten cases per annum being found in which it was
impossible to trace infection from outside. The result of the work at Klang
would have been very striking had it been alone, but at the same time as
the drainage of Klang was undertaken the drainage of Port Swettenham was
also carried out, with equally satisfactory results. There had thus been two
entirely independent experiments. Unlike Klang, in which there were small
hills, Port Swettenham was originally a mangrove swamp covered by all spring
tides. It was always malarious, and, early in 1901, he drew the attention of
the Government to the necessity for antimalarial measures. The port was
opened on September 15, 1901, and, in order to obtain statistics of the
malaria, he deputed a subordinate to visit each house daily to record and
treat each case of malaria as it arose. The epidemic, however, became of so
severe a nature that the business of the port was completely disorganized
and the propriety of closing it was discussed. A Commission, consisting of
Dr. H. Wright, Dr. E. A. O. Travers, the speaker and three inquirers, was
deputed by Government to report on and carry out the necessary sanitary
measures, and the Commission carried out the measures which he had
recommended some months before, viz., clearing jungle, draining, &c. The
result of these measures was that within a few weeks the port was work¬
ing smoothly and it was not found necessary to use wire gauze on the
houses. From 1902 to 1907 Port Swettenham was practically free from
malaria, but in 1907, as the result of the blocking of certain drains by new
engineering works, a small outbreak occurred again. It was a very striking
reversal of the experiment, but for the sake of the public health the drains had
to be reopened as soon as the damage they were doing was shown. He did not
316
Treves: Preventive Medicine at Panama
propose to go into the statistics of the malaria of the two towns in detail, but
some idea of the value of the antimalarial measures would be gathered from the
following : in 1901, 610 cases of malaria were admitted to Klang Hospital; in
1902, 1903, 1904, 1905, the numbers were respectively 199, 69, 32, 23; while
from the surrounding undrained area the numbers increased. Not only did the
admissions to hospital for malaria diminish, but there was an extraordinary
decrease in the number of deaths, not only from malaria but from all other
causes registered in the town, showing to what an extent malaria predisposed
persons to other diseases. The number of deaths from all causes registered in
the two towns were, in 1900 and 1901, 474 and 582 respectively, and in 1902,
1903, 1904, 1905, were 144, 115, 122, 113 respectively, and again the deaths
registered without the towns showed an increase. The children, too, within the
towns enjoyed an immunity from the disease in striking contrast to those
outside ; during 1904 and 1905 examinations of the children revealed no
infection of those permanently resident within the towns, while in 1904 33*89
per cent, were infected of 298 children residing outside of the towns. In 1901,
Government officers received 1,026 days sick leave on account of malaria; in
1905 only thirty days leave was given, and this was given to officers who,
although resident in Klang* had contracted the disease outside. Finally he would
like to say a word on the measures undertaken. In 1900 there was considerable
discussion as to the relative merits of mosquito-netting, quinine and mosquito
destruction. He followed the lines laid down by Ross, viz., mosquito destruc¬
tion, and in order to obtain permanent results adopted drainage as the method.
It appeared to him to be the method for towns, because first it was permanent
and secondly it could be carried out independently of the cooperation of the
population.
Professor Ronald Ross, C.B., F.R.S., said that a very pleasant evening
indeed had been spent in listening to Sir Frederick Treves’s most interesting
description and Dr. Malcolm Watson’s account of his good work, which was
perhaps scarcely second in importance and elegance-—if such a term were
permissible in that connection—to that of Colonel Gorgas, and only in the
extent to which it was carried out. The colonel had all the resources of the
American Republic behind him. Dr. Watson’s work had been most excellently
done. The point as to the great prevalence and fatality of pneumonia had been
dealt with by Dr. Sand with. He quite agreed that that disease was frequently
the terminal complaint following malaria, dysentery, and other things. The
same kind of pneumonia statistics were obtained in India among the troops
there, both native and European. With regard to mosquitoes in trees, he had
just come from Mauritius, and it was the same there. On the average, one
hole was found in every three trees ; but they did not breed anophelines there,
only stegomyia and culex. It was not necessary to cut down the whole tree;
the simplest way was to fill up the hole with mud. His moustiquiers made a
kind of concrete out of red earth and lime, which was placed in the hole, and
he believed it effectually stopped it for a long time. One of the mosquito
destroyers had to make a tour of the trees once a year and stop them up; but
Epidemiological Section
317
those holes did not cause much sickness in Mauritius, because they did not
breed the anophelines. The same remark applied to land crabs and their holes.
In Mauritius it was found to be only the big marsh which caused malaria, not a
few pots full of water. It was true that the anophelines bred in small collections
of water, but for an outbreak it was necessary that there should be many such
small collections of water. In Mauritius a careful observation was kept of the
rate of fall in the disease at different distances from a marsh. A few yards from
the marsh the spleen involvement rate was 95 per cent.; a few hundred yards
away the rate fell quite rapidly, and further away it was as low as 30 per cent,
or less of the children. The question of circumvallation was a very important
one. With regard to the use of petroleum, he did not think it was worth while
spending much on that for malaria ; drainage was best. Labour could be best
employed in clearing waters and draining. He agreed with Dr. Watson’s state¬
ment that engineers were sometimes very troublesome in connection with
operations such as had been described. There were many other points, all of
great interest to him, on which he could talk for a long time, but the hour was
late, and he must forbear.
Sir Frederick Treyes, in reply, said: With regard to the tree question,
he asked Major Ronald Ross whether such a tree as the Madagascar or
traveller’s palm was not a serious breeding ground for the anophelines and other
mosquitoes. When he, Sir Frederick, was in Trinidad there was an outbreak
of yellow fever there, and that tree was thought by some to play a possible part
in it. In their radical measures the Americans realized that there were other
collections of w T ater besides those on the face of the ground in which mosquitos
might breed. Colon presented the additional difficulty that the swamp in some
places was below the sea level. The Americans had another advantage in their
sanitary work which was exceptional, i.e., the privilege of what was called
14 dumping.” The enormous mass of earth taken from the cutting could be
dropped into the swamp. Thus the swamp at the back of Colon, which could
hardly be drained, was being closed by being made a dumping place.
Colonel MACPHERSON, in continuing the discussion, gave some interesting
and rather new facts about the subject of the paper, and said his excuse
for doing so must be that he returned from Panama only last month, after
studying, with Colonel Gorgas, the subject of Sir Frederick Treves’s lecture.
The reader mentioned that the Commission on Sanitation had absolute powers
from the commencement of the work, but that was not so. Colonel Gorgas
came from Havana, where he had extinguished yellow fever, in the year 1901,
in eight months. He came to Panama, where, to his astonishment, he found
* it took two years to blot out the disease. He told Colonel Macpherson that
the probable reason for that difference was that when he started the campaign
in Havana he had the advantage of two years of previous sound sanitary
work and organization in the city, whereas in Panama he had to start at the
beginning, and had had very great difficulty in obtaining necessary supplies
and authority to carry out thorough sanitary measures, even from the
people who ought to have supported him. The chief engineer, the Governor,
318
Treves: Preventive Medicine at Panama
and the chairman of the Canal Commission had all joined in a recommenda¬
tion that Colonel Gorgas’s work should be discontinued—they said it was not
practicable, or at any rate could not be put into practical execution. The
object-lesson pointed by the facts was that what Colonel Gorgas had set
himself to do was practicable, and that it was the result of determining to
triumph over obstacles. He was sure that a remark contained in a letter of
Colonel Gorgas’s to him, namely, that “ successes on these lines would make the
work of future sanitarians easier/* was one which all would agree with. He
(the speaker) had carefully studied the cost of such work, and it was not so
great as would be imagined. Colonel Gorgas received $2,000,000 for extin¬
guishing the disease in that zone, and that included all the hospital work for
the treatment of the sick, as well as measures for the prevention of disease.
The amount spent in actual prevention was only $500,000 per annum. That
worked out at an insurance of per cent, on the estimated cost of the canal
for preventive work alone. Another interesting point about the sanitation at
Panama was that it was despotic hygiene. President Roosevelt had told him
that he could not get the same results in the best cities of the States as he
could in Panama, simply because of that system of despotic hygiene. What
Sir Frederick said about the punishments meted out to those who had larvae in
their houses seemed surprising, but it was perfectly true. In Colon, occupiers
of houses were fined 50s. if larvae were found in the houses, but the same man
had never to be fined twice. In regard to pneumonia, Colonel Gorgas had
appointed a commission of medical officers and inspectors of health to go into
that, and they studied the subject very thoroughly. Only one fact seemed to
be established, namely, that negroes who got pneumonia always did so within
three months of coming to the Canal Zone, and this pneumonia seemed to be
the general sequel to attacks of a catarrh of the respiratory passages of the
nature of influenza. The draining of the swamps, so as to get rid of malaria,
was the chief trouble in the zone at present. Colonel Gorgas adopted the
means shown in Dr. Watson’s photographs, namely, draining along the con¬
tours—not along the centre—and in order to minimize the cost of keeping
drains clear he had begun to lay agricultural drains along the line of drainage
trenches, covering them with loose stones and clinkers. The anopheles would
not grow unless there was vegetation along the banks of the streams, drains, or
pools, and no vegetation grew where this method was adopted.
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