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A CASE OF PYÆEMIA DUE TO THE INFLUENZA BACILLUS, WITH MULTIPLE ARTHRITIS AND MENINGITIS.
684 At its apex was an inverted Meckel’s diverticulum. The treatment was excision of the intussusception, closure of the ends of the bowel, and a lateral anastomosis. The last point is the age of the patient, as I think that recovery after excision of an intussusception is rare under the age of four
years. With
regard to treatment, there is advisability of early operation when
little question as to the reduction is not spontaneous or is not effected by an enema, since the prognosis depends principally upon the time which has elapsed before the operation. Simple reduction, after opening the abdomen, is effectual in most cases, and the operations of shortening the mesentery or of fixing the bowel to the parietes are liable to produce unpleasant symptoms later. In irreducible intussusception excision is the best treatment; this is combined with end-to-end anastomosis when the small intestine is involved, and with lateral anastomosis and closure of the divided ends when the invagination is ileo-cseoal. It is essential to operate on healthy gut and to divide the bowel at least an inch away from the intussusception on each side. It is also of the utmost importance that the operation should be performed with the greatest celerity. As I do not know of any published description of the method which I employ for end-to-end anastomosis, I have had some drawings made which will make a description clearer. The method consists of a double continuous suture passed between guides, the adjacent pieces of intestine being held tightly stretched while the suture is passed. In this way contraction of the line of union is impossible. It is performed as follows. Two catgut sutures are insertedone at the convex border, the other close to the mesentery. These are passed through all the coats of each piece of gut and are tied with their knots on the mucous Both ends of one suture and the short end surface. of the other are clamped, and by pulling these clamps apart the line of suture is tightly stretched; a continuous suture is then run from B to A with the long end of suture B. (Fig. 1.) It is then tied to A and the ends cut off. The piece of bowel is then turned over and two silk Lembert sutures are inserted, one at the convex border and the other close to the mesentery. The one close to the mesentery, b, is tied and its short end clamped, the one at the convex border is not tied but its centre is pulled out and it is then clamped (this throws up a definite ridge of peritoneum for the Lembert suture). The two clamps are now held apart so a3 to put the edges of the gut on the stretch, and with the long end of the suture, b, a continuous Lembert suture is run from b to a. It is tied and its ends cut off (see Fig. 2). The gut is then turned over again and another catgut stitch C, uniting the two ends of the gut on the opposite side of the mesentery, is passed through all the coats of each piece of gut and tied with its knot on the mucous surface. The short end of this is clamped, and this is held apart from the end of the first passed suture B ; this makes taut the portion of the circumference of the two ends of bowel between the layers of the mesentery. A continuous suture is then passed from C to B and tied to the end B and then cut short (see Fig. 3). A Lembert suture, c, is then passed close to the mesentery and its centre pulled out and clamped. The clamps on the sutures a and c are then held apart (see Fig. 4) and a continuous catgut stitch is passed from C to A, its two ends being tied to the ends C and A respectively. The Lembert guides c and a are then tied and one end of c and both ends of a are clamped and held apart, while a continuous Lembert suture is passed from c to a with the long end of suture c and is tied to one eni of a. A mesenteric stitch passed a quarter of an inch below the bowel completes the anastomosis. The main advantage in this method is that the guides absolutely insure that corresponding portions of each piece of gut are united, and as the various portions of the gut are held tightly stretched by the guides during the insertion of the continuous sutures, these sutures can be pulled absolutely tight without any fear of producing subsequent constriction of the new opening. In passing each stitch of a continuous suture it is essential to pull the thread tight and to hold it firmly till the next stitch is passed. This operation as described may appear complicated but it is really simple and it can be done very rapidly (in the case recorded in 14 minutes). It dispenses with the use of all apparatus, such as bone bobbins and clamps, and it combines the advantages of interrupted sutures with the quickness of continuous sutures. Upper Wimpole-street, W.
A CASE OF PYÆEMIA DUE TO THE INFLUENZA BACILLUS, WITH MULTIPLE ARTHRITIS AND MENINGITIS. BY LEONARD S.
DUDGEON, M.R.C.P.LOND.,
BACTERIOLOGIST TO ST. THOMAS’S HOSPITAL: JOINT LECTURER ON GENERAL PATHOLOGY AND LECTURER ON SPECIAL PATHOLOGY IN THE MEDICAL SCHOOL; DIRECTOR OF THE HOSPITAL LABORATORIES;
AND
J. E. ADAMS, M.B., B.S. LOND., F.R.C.S. ENG., RESIDENT ASSISTANT SURGEON AND LATE SURGICAL THOMAS’S HOSPITAL, LONDON.
REGISTRAR, ST.
WE have thought it advisable to publish a detailed account of this case, inasmuch as we have been unable to find any record of a similar instance of infection due to this bacillus. The clinical history was as follows. The patient was a female, aged 10 months, born of healthy parents. There was There were five other children no history of miscarriages. in family and all enjoyed good health. There was no history of any recent infectious fever or illness suggestive of influenza. For two months the mother had observed that this child was fretful and that she was not thriving, though she did not appear to be seriously ill, but at the end of the first month it was noticed that the left elbow caused the child pain, and three weeks before admission to the hospital the joint was discovered to be swollen. The swelling was first situated over the head of the radius and the patient was first seen on April 8th last, when there was a tender puffy thickening over the radial head ; the following day the swelling had increased in size and fluctuation was readily obtainable ; movements at the elbow-joint were not limited, nor were those of pronation and supination, though these appeared to cause slight pain ; the case was thought to be one of epiphysitis of the radius, and the mother was told to bring the child for admission. This she failed to do until a week later, when the local state of affairs showed rapid progress of the disease and the child’s general condition was very grave. On April 17th, the whole region of the left elbowjoint was swollen, and on the outer and posterior aspect there was a fluid swelling close beneath the thinned and discoloured skin. The skin over the abscess was purplish in colour and not noticeably hot. Movements both at the elbow-joint and at the superior radio-ulnar articulation were abnormally free and caused well-marked grating; in fact, the elbow presented the characters of a flail joint. A skiagram was taken but this revealed no changes in the bones, a fact which will be referred to later. With the exception of some thickening in the neighbourhood of the right hip-joint, the remaining articulations appeared to be unaffected. The general condition of the child was profoundly altered from that observed a week previously, for she now showed the signs of meningitis with marked wasting, head retraction, increased knee-jerks, and frequent vomiting. The pupils were somewhat dilated but they reacted to light, and no squint was observable. No wound The temperaor sore was present on the child’s limbs. ture; was 101° F., the pulse-rate was 136, and the respiraOn the day after admission it was tions were 44. decided to open the abscess on the outer side of the elbow-joint, and no anaesthetic was needed for this as the pus was close beneath the distended skin. Thick, creamy, yellow, odourless pus was evacuated and the cavity was found to lead directly into the elbowjoint ; a counter opening was made on the inner side of the elbow and the joint was washed out with saline solution and drained with a rubber tube. The pus was preserved in a sterile test-tube for bacteriological investigation. The child’s condition steadily grew worse, there was persistent vomiting, the head retraction became more marked, and a squint was observed on the third day. On the evening of this day the temperature reached 105°, the pulse-rate was 160, and the child had slight diarrheea. The temperature fell to 100° on the next morning but the condition was not improved and lumbar puncture was performed with a view to the relief of the meningeal symptoms. This, however, was not successful, as the needle only withdrew a drop or two of cerebro-spinal fluid, and the child died about four hours later. This fluid was also preserved in a sterile tube. Report of post-mortem examination (performed by Dr. W. O.
685
MEEK).-The left elbow-joint had
been
freely opened,
but it
still contained some pus, and this was present also in the intermuscular planes outside the joint. The articular head of the radius possessed no cartilage cap and its end was rough and necrotic ; there was also superficial necrosis of the humerus in the olecranon fossa, while the articular cartilage of the ulna was eroded and the subjacent bone showed commencing disease. There was a large abscess in connexion with the right hip-joint, which passed upwards and then forwards over Poupart’s ligament into the extraperitoneal space in the iliac fossa, where it formed an encapsulated mass of the size of an orange, containing six ounces of thick, creamy, yellow pus. The neck of the femur showed necrosis and the articular cartilage was eroded. The bone at the bottom of the acetabulum was bare and necrotic, though there was no perforation. The serous cavities of the trunk were healthy. The intestines showed slight congestion of the lymphoid tissue. The liver and kidneys were pale, while the spleen was large and firm and of dark purple colour. The lower lobes of the lungs showed recent bronchopneumonia with collapse. The heart valves were healthy but the myocardium was pale. The lymphatic glands both in the thorax and abdomen were large and reddened. The brain surface was flattened and covered with areas of purulent exudate, particularly along the course of the vessels. This condition was also very markedly present over the base of the brain, where there was excess of cerebrospinal fluid. The choroid plexuses were infiltrated with pus. The grey matter of the cortex was softened and the lateral ventricles were distended with turbid fluid, while the third and fourth ventricles were little affected. No evidences of tuberculosis were found in the body. .ZMMy.—Film preparations were made from the thick pus which was obtained from the elbow-joint. The microphages, which were by far the most common variety of oells in the pus, were full of minute rod-shaped bacilli which failed to retain Gram’s stain. The pus was smeared on human blood agar and nasgar and incubated at 37° C. A good growth of minute, transparent colonies was obtained on the surface of both media. Each colony consisted of small Gram-negative bacilli. Cultivations which were made in liquid media remained sterile. Lumbar puncture was performed just before death and a few drops of turbid cerebro-spinal fluid were obtained. A pure culture of the influenza bacillus was grown from this fluid. A bacteriolcgical examination was made after death with the following result. Hip-joint.-A pure culture of the influenza bacillus was obtained from the pus present in this articulation. Spleen.-The splenic juice was spread on tubes of blood agar and nasgar. A delicate growth of the influenza bacillus was obtained in each instance. Lung.-In the patches of broncho-pneumonia minute rod-shaped bacilli were found in some of the polymorphonuclear neutrophiles and also diplococci. No cultivations, however, were made from the lung tissue. - NMs.—Thp primary lesion appears to have been epiphysitis of the upper extremity of the radius, but there was no evidence of any sore or wound on the limbs such as is sometimes met with in cases of acute epiphysitis and osteo-
myelitis
due to the
staphylococcus
aureus.
There
was no
history obtainable of any influenzal affection in any other member of the family, and apart from the fact that the child
was not thriving for one month before the onset of this disease her condition caused no anxiety. When first seen the case appeared obscure and examination by x rays failed to throw further light on the exact lesion. This was doubtless due to the absence of ossification in the epiphysis and the very small amount of destruction of bone at the time this examination was made. At the post-mortem examination, however, there was irregular pitting at the upper end of the radial shaft which would have been rendered evident had a second skiagram been taken. The disease proceeded with great rapidity both in the elbow joint and also as regards the
systemic infection, and the sequence following the radial epiphysitis appears to have been first the elbow-joint and then the right hip-joint, followed very closely by the diffuse meningeal infection, and terminating in acute broncho-pneu-
monia. From all these situations, except the lungs, the influenza bacillus was obtained in pure culture. The splenic juice gave a similar result, while microscopic sections of the lung showed a bacillus morphologically identical present in the polymorpho-nuclear neutrophils. The pus found in the elbow and hip joints and over the brain surface possessed no distinctive characters and has been described above.
An investigation of the literature on the subject of influenzal arthritis has shown no similar instance of multiple suppurative arthritis due to the influenza bacillus, and in" very few cases of what is termed " post-influenzal arthritis have cultures been taken, and so far as we can ascertain these have yielded a negative result. Nor have we been able to find records of a case of pyaemia proved bacteriologically to be due to this bacillus. St. Thomas’s Hospital, S.E.
RECORD OF CHANGES OBSERVED IN THE BLOOD COUNT AND IN OPSONIC POWER OF A MAN UNDERGOING A PROLONGED FAST. BY FRANCIS J. CHARTERIS, M.B. GLASG., ASSISTANT TO PROFESSOR OF MATERIA MEDICA, GLASGOW UNIVERSITY ; DISPENSING PHYSICIAN, WESTERN INFIRMARY, GLASGOW.
THE following observations were made upon a fasting man, B., who for the purposes of such scientific observations fasted for fourteen days. The primary object of the fast was to afford Dr. E. P. Cathcart an opportunity of examining the urinary excretions. The results of his observations have already been communicated to the Physiological Society. The fast took place in my house and I availed myself of the to keep a record of the blood changes. Similar opportunity observations have been made by Lucianil on the fasting man Succi and by Senator and Mulled on Cetti and Breithaupt. Neither of these records, however, give any information about the relative changes which take place in the white corpuscles though they note the number of red corpuscles, the percentage of haemoglobin, and the number of white cells. Differential counts were made by Okintschitz3 on rabbits deprived of food and water. Observations on the effect of starvation on resistance to infection have been published by Canalis and Morpurgo4 and Roger and Josué. An exhaustive index of the literature on inanition is given by Weber.6 Our experiment was divided into three periods. In the foreperiod the man was kept upon a constant diet and was in nitrogenous equilibrium. The fasting period lasted fourteen days. During it absolutely no food was taken, but a limited number of cigarettes was permitted which never exceeded two in the day. During the 24 hours one litre of ordinary tap water was consumed at the convenience of the subject. To obviate fraud the man was carefully watched day and night, and the analysis of the excretions show that the fast was genuine. At the close of the fasting period he was put upon a diet devised so as to contain no nitrogen. At the commencement of the experiment the man was in good health. His muscular development was excellent and he was not abnormally stout. When the fast began he weighed 10 stone 5 pounds and at the close of the fasting period his weight was 9 stones 2 pounds 6t ounces. The weighing took place at 9 o’clock in the evening when the patient was naked and just after the bladder had been emptied. During the fast the man remained in fair condition. There was a steady loss in weight and he became gradually less active. The mental condition did not appreciably suffer. He seemed to sleep soundly but complained
that he dreamt of various kinds of food. As the fast proceeded he suffered very much from coldness and had difficulty in keeping himself warm. The following table (Table I.) records the alterations which took place in the pulse, temperature, blood-pressure, and the blood condition during the fast. The temperature and blood-pressure were taken at the same hour in the evening, the latter being measured by Martin’s modification of Riva Rocci’s sphygmomanometer. The haemoglobin was estimated by Gowers’s hsemoglobinometer, and the corpuscles were counted with a Thoma Zeiss instrument. The films were stained with Leishman’s and Jenner’s stains. The result of my observations may be briefly summarised as follows. The pulse slowed gradually as the fast proceeded. The man was aware of this fact from previous 1 Das Hungern. 1890. 2 Virchow’s Archiv, Band cxxxii.
für
3 Archiv Band xxxi.
Experimentelle Pathologie 4
5
und
Pharmakologie,
Fortschrift der Medizin, 1890. Comptes Rendus de la Société de Biologie, 1900. 6 Ergebnisse der Physiolog. Biochemie, 1902.
years. With
regard to treatment, there is advisability of early operation when
little question as to the reduction is not spontaneous or is not effected by an enema, since the prognosis depends principally upon the time which has elapsed before the operation. Simple reduction, after opening the abdomen, is effectual in most cases, and the operations of shortening the mesentery or of fixing the bowel to the parietes are liable to produce unpleasant symptoms later. In irreducible intussusception excision is the best treatment; this is combined with end-to-end anastomosis when the small intestine is involved, and with lateral anastomosis and closure of the divided ends when the invagination is ileo-cseoal. It is essential to operate on healthy gut and to divide the bowel at least an inch away from the intussusception on each side. It is also of the utmost importance that the operation should be performed with the greatest celerity. As I do not know of any published description of the method which I employ for end-to-end anastomosis, I have had some drawings made which will make a description clearer. The method consists of a double continuous suture passed between guides, the adjacent pieces of intestine being held tightly stretched while the suture is passed. In this way contraction of the line of union is impossible. It is performed as follows. Two catgut sutures are insertedone at the convex border, the other close to the mesentery. These are passed through all the coats of each piece of gut and are tied with their knots on the mucous Both ends of one suture and the short end surface. of the other are clamped, and by pulling these clamps apart the line of suture is tightly stretched; a continuous suture is then run from B to A with the long end of suture B. (Fig. 1.) It is then tied to A and the ends cut off. The piece of bowel is then turned over and two silk Lembert sutures are inserted, one at the convex border and the other close to the mesentery. The one close to the mesentery, b, is tied and its short end clamped, the one at the convex border is not tied but its centre is pulled out and it is then clamped (this throws up a definite ridge of peritoneum for the Lembert suture). The two clamps are now held apart so a3 to put the edges of the gut on the stretch, and with the long end of the suture, b, a continuous Lembert suture is run from b to a. It is tied and its ends cut off (see Fig. 2). The gut is then turned over again and another catgut stitch C, uniting the two ends of the gut on the opposite side of the mesentery, is passed through all the coats of each piece of gut and tied with its knot on the mucous surface. The short end of this is clamped, and this is held apart from the end of the first passed suture B ; this makes taut the portion of the circumference of the two ends of bowel between the layers of the mesentery. A continuous suture is then passed from C to B and tied to the end B and then cut short (see Fig. 3). A Lembert suture, c, is then passed close to the mesentery and its centre pulled out and clamped. The clamps on the sutures a and c are then held apart (see Fig. 4) and a continuous catgut stitch is passed from C to A, its two ends being tied to the ends C and A respectively. The Lembert guides c and a are then tied and one end of c and both ends of a are clamped and held apart, while a continuous Lembert suture is passed from c to a with the long end of suture c and is tied to one eni of a. A mesenteric stitch passed a quarter of an inch below the bowel completes the anastomosis. The main advantage in this method is that the guides absolutely insure that corresponding portions of each piece of gut are united, and as the various portions of the gut are held tightly stretched by the guides during the insertion of the continuous sutures, these sutures can be pulled absolutely tight without any fear of producing subsequent constriction of the new opening. In passing each stitch of a continuous suture it is essential to pull the thread tight and to hold it firmly till the next stitch is passed. This operation as described may appear complicated but it is really simple and it can be done very rapidly (in the case recorded in 14 minutes). It dispenses with the use of all apparatus, such as bone bobbins and clamps, and it combines the advantages of interrupted sutures with the quickness of continuous sutures. Upper Wimpole-street, W.
A CASE OF PYÆEMIA DUE TO THE INFLUENZA BACILLUS, WITH MULTIPLE ARTHRITIS AND MENINGITIS. BY LEONARD S.
DUDGEON, M.R.C.P.LOND.,
BACTERIOLOGIST TO ST. THOMAS’S HOSPITAL: JOINT LECTURER ON GENERAL PATHOLOGY AND LECTURER ON SPECIAL PATHOLOGY IN THE MEDICAL SCHOOL; DIRECTOR OF THE HOSPITAL LABORATORIES;
AND
J. E. ADAMS, M.B., B.S. LOND., F.R.C.S. ENG., RESIDENT ASSISTANT SURGEON AND LATE SURGICAL THOMAS’S HOSPITAL, LONDON.
REGISTRAR, ST.
WE have thought it advisable to publish a detailed account of this case, inasmuch as we have been unable to find any record of a similar instance of infection due to this bacillus. The clinical history was as follows. The patient was a female, aged 10 months, born of healthy parents. There was There were five other children no history of miscarriages. in family and all enjoyed good health. There was no history of any recent infectious fever or illness suggestive of influenza. For two months the mother had observed that this child was fretful and that she was not thriving, though she did not appear to be seriously ill, but at the end of the first month it was noticed that the left elbow caused the child pain, and three weeks before admission to the hospital the joint was discovered to be swollen. The swelling was first situated over the head of the radius and the patient was first seen on April 8th last, when there was a tender puffy thickening over the radial head ; the following day the swelling had increased in size and fluctuation was readily obtainable ; movements at the elbow-joint were not limited, nor were those of pronation and supination, though these appeared to cause slight pain ; the case was thought to be one of epiphysitis of the radius, and the mother was told to bring the child for admission. This she failed to do until a week later, when the local state of affairs showed rapid progress of the disease and the child’s general condition was very grave. On April 17th, the whole region of the left elbowjoint was swollen, and on the outer and posterior aspect there was a fluid swelling close beneath the thinned and discoloured skin. The skin over the abscess was purplish in colour and not noticeably hot. Movements both at the elbow-joint and at the superior radio-ulnar articulation were abnormally free and caused well-marked grating; in fact, the elbow presented the characters of a flail joint. A skiagram was taken but this revealed no changes in the bones, a fact which will be referred to later. With the exception of some thickening in the neighbourhood of the right hip-joint, the remaining articulations appeared to be unaffected. The general condition of the child was profoundly altered from that observed a week previously, for she now showed the signs of meningitis with marked wasting, head retraction, increased knee-jerks, and frequent vomiting. The pupils were somewhat dilated but they reacted to light, and no squint was observable. No wound The temperaor sore was present on the child’s limbs. ture; was 101° F., the pulse-rate was 136, and the respiraOn the day after admission it was tions were 44. decided to open the abscess on the outer side of the elbow-joint, and no anaesthetic was needed for this as the pus was close beneath the distended skin. Thick, creamy, yellow, odourless pus was evacuated and the cavity was found to lead directly into the elbowjoint ; a counter opening was made on the inner side of the elbow and the joint was washed out with saline solution and drained with a rubber tube. The pus was preserved in a sterile test-tube for bacteriological investigation. The child’s condition steadily grew worse, there was persistent vomiting, the head retraction became more marked, and a squint was observed on the third day. On the evening of this day the temperature reached 105°, the pulse-rate was 160, and the child had slight diarrheea. The temperature fell to 100° on the next morning but the condition was not improved and lumbar puncture was performed with a view to the relief of the meningeal symptoms. This, however, was not successful, as the needle only withdrew a drop or two of cerebro-spinal fluid, and the child died about four hours later. This fluid was also preserved in a sterile tube. Report of post-mortem examination (performed by Dr. W. O.
685
MEEK).-The left elbow-joint had
been
freely opened,
but it
still contained some pus, and this was present also in the intermuscular planes outside the joint. The articular head of the radius possessed no cartilage cap and its end was rough and necrotic ; there was also superficial necrosis of the humerus in the olecranon fossa, while the articular cartilage of the ulna was eroded and the subjacent bone showed commencing disease. There was a large abscess in connexion with the right hip-joint, which passed upwards and then forwards over Poupart’s ligament into the extraperitoneal space in the iliac fossa, where it formed an encapsulated mass of the size of an orange, containing six ounces of thick, creamy, yellow pus. The neck of the femur showed necrosis and the articular cartilage was eroded. The bone at the bottom of the acetabulum was bare and necrotic, though there was no perforation. The serous cavities of the trunk were healthy. The intestines showed slight congestion of the lymphoid tissue. The liver and kidneys were pale, while the spleen was large and firm and of dark purple colour. The lower lobes of the lungs showed recent bronchopneumonia with collapse. The heart valves were healthy but the myocardium was pale. The lymphatic glands both in the thorax and abdomen were large and reddened. The brain surface was flattened and covered with areas of purulent exudate, particularly along the course of the vessels. This condition was also very markedly present over the base of the brain, where there was excess of cerebrospinal fluid. The choroid plexuses were infiltrated with pus. The grey matter of the cortex was softened and the lateral ventricles were distended with turbid fluid, while the third and fourth ventricles were little affected. No evidences of tuberculosis were found in the body. .ZMMy.—Film preparations were made from the thick pus which was obtained from the elbow-joint. The microphages, which were by far the most common variety of oells in the pus, were full of minute rod-shaped bacilli which failed to retain Gram’s stain. The pus was smeared on human blood agar and nasgar and incubated at 37° C. A good growth of minute, transparent colonies was obtained on the surface of both media. Each colony consisted of small Gram-negative bacilli. Cultivations which were made in liquid media remained sterile. Lumbar puncture was performed just before death and a few drops of turbid cerebro-spinal fluid were obtained. A pure culture of the influenza bacillus was grown from this fluid. A bacteriolcgical examination was made after death with the following result. Hip-joint.-A pure culture of the influenza bacillus was obtained from the pus present in this articulation. Spleen.-The splenic juice was spread on tubes of blood agar and nasgar. A delicate growth of the influenza bacillus was obtained in each instance. Lung.-In the patches of broncho-pneumonia minute rod-shaped bacilli were found in some of the polymorphonuclear neutrophiles and also diplococci. No cultivations, however, were made from the lung tissue. - NMs.—Thp primary lesion appears to have been epiphysitis of the upper extremity of the radius, but there was no evidence of any sore or wound on the limbs such as is sometimes met with in cases of acute epiphysitis and osteo-
myelitis
due to the
staphylococcus
aureus.
There
was no
history obtainable of any influenzal affection in any other member of the family, and apart from the fact that the child
was not thriving for one month before the onset of this disease her condition caused no anxiety. When first seen the case appeared obscure and examination by x rays failed to throw further light on the exact lesion. This was doubtless due to the absence of ossification in the epiphysis and the very small amount of destruction of bone at the time this examination was made. At the post-mortem examination, however, there was irregular pitting at the upper end of the radial shaft which would have been rendered evident had a second skiagram been taken. The disease proceeded with great rapidity both in the elbow joint and also as regards the
systemic infection, and the sequence following the radial epiphysitis appears to have been first the elbow-joint and then the right hip-joint, followed very closely by the diffuse meningeal infection, and terminating in acute broncho-pneu-
monia. From all these situations, except the lungs, the influenza bacillus was obtained in pure culture. The splenic juice gave a similar result, while microscopic sections of the lung showed a bacillus morphologically identical present in the polymorpho-nuclear neutrophils. The pus found in the elbow and hip joints and over the brain surface possessed no distinctive characters and has been described above.
An investigation of the literature on the subject of influenzal arthritis has shown no similar instance of multiple suppurative arthritis due to the influenza bacillus, and in" very few cases of what is termed " post-influenzal arthritis have cultures been taken, and so far as we can ascertain these have yielded a negative result. Nor have we been able to find records of a case of pyaemia proved bacteriologically to be due to this bacillus. St. Thomas’s Hospital, S.E.
RECORD OF CHANGES OBSERVED IN THE BLOOD COUNT AND IN OPSONIC POWER OF A MAN UNDERGOING A PROLONGED FAST. BY FRANCIS J. CHARTERIS, M.B. GLASG., ASSISTANT TO PROFESSOR OF MATERIA MEDICA, GLASGOW UNIVERSITY ; DISPENSING PHYSICIAN, WESTERN INFIRMARY, GLASGOW.
THE following observations were made upon a fasting man, B., who for the purposes of such scientific observations fasted for fourteen days. The primary object of the fast was to afford Dr. E. P. Cathcart an opportunity of examining the urinary excretions. The results of his observations have already been communicated to the Physiological Society. The fast took place in my house and I availed myself of the to keep a record of the blood changes. Similar opportunity observations have been made by Lucianil on the fasting man Succi and by Senator and Mulled on Cetti and Breithaupt. Neither of these records, however, give any information about the relative changes which take place in the white corpuscles though they note the number of red corpuscles, the percentage of haemoglobin, and the number of white cells. Differential counts were made by Okintschitz3 on rabbits deprived of food and water. Observations on the effect of starvation on resistance to infection have been published by Canalis and Morpurgo4 and Roger and Josué. An exhaustive index of the literature on inanition is given by Weber.6 Our experiment was divided into three periods. In the foreperiod the man was kept upon a constant diet and was in nitrogenous equilibrium. The fasting period lasted fourteen days. During it absolutely no food was taken, but a limited number of cigarettes was permitted which never exceeded two in the day. During the 24 hours one litre of ordinary tap water was consumed at the convenience of the subject. To obviate fraud the man was carefully watched day and night, and the analysis of the excretions show that the fast was genuine. At the close of the fasting period he was put upon a diet devised so as to contain no nitrogen. At the commencement of the experiment the man was in good health. His muscular development was excellent and he was not abnormally stout. When the fast began he weighed 10 stone 5 pounds and at the close of the fasting period his weight was 9 stones 2 pounds 6t ounces. The weighing took place at 9 o’clock in the evening when the patient was naked and just after the bladder had been emptied. During the fast the man remained in fair condition. There was a steady loss in weight and he became gradually less active. The mental condition did not appreciably suffer. He seemed to sleep soundly but complained
that he dreamt of various kinds of food. As the fast proceeded he suffered very much from coldness and had difficulty in keeping himself warm. The following table (Table I.) records the alterations which took place in the pulse, temperature, blood-pressure, and the blood condition during the fast. The temperature and blood-pressure were taken at the same hour in the evening, the latter being measured by Martin’s modification of Riva Rocci’s sphygmomanometer. The haemoglobin was estimated by Gowers’s hsemoglobinometer, and the corpuscles were counted with a Thoma Zeiss instrument. The films were stained with Leishman’s and Jenner’s stains. The result of my observations may be briefly summarised as follows. The pulse slowed gradually as the fast proceeded. The man was aware of this fact from previous 1 Das Hungern. 1890. 2 Virchow’s Archiv, Band cxxxii.
für
3 Archiv Band xxxi.
Experimentelle Pathologie 4
5
und
Pharmakologie,
Fortschrift der Medizin, 1890. Comptes Rendus de la Société de Biologie, 1900. 6 Ergebnisse der Physiolog. Biochemie, 1902.