A NOTE ON SOME UNUSUAL CASES OF TRICHOPHYTIC INFECTION.

237 easy, to conceive that for each living individual a peculiar form of protoplasm should exist. It is not difficult on this theory to understand how the one or other predisposition (determinant Anlage) in an individual may become active, pre-valent, or dominant, if we suppose that in dependence upon the surroundings the cell juice, &c., in one case this, and in another that, specific atom-group enters into reaction. We can imagine that for generations particular atom-groups in the individual plasma may behave as perfectly stable-i.e., remain latent-and then all at once under appropriate conditions again enter into action and thus permit a throwback or reversion to appear

specific individual

of strangulation appeared. When admitted the hernia presented as a smooth, tense, elongated tumour, extending from the left inguinal canal into the scrotum, the skin of which was tightly stretched. The temperature and pulse were only slightly above normal. When the sac, which was of the congenital variety, was laid open at the operation, the contents were found to consist of practically the whole omentum with about eight inches of colon. There was no definite band producing the strangulation as the canal was wide enough to permit the little finger to be passed along its whole length with the bowel still un-

reduced and yet there was sufficient interference with the circulation to cause not only marked congestion of the hernial contents but also numerous small hæmorrhages into the wall of the colon. The affected piece of bowel was greatly distended with gas. There were no adhesions between the sac and its contents. After a series of ligatures had been applied the omentum was removed and attempts were then made to reduce the colon through the comparatively wide canal, but these being unsuccessful thestructures surrounding the neck of the sac were fairly freely divided. A finger now passed through the wound into theabdomen could easily trace the continuation of the colon. (Erbmasse). Weismann has stated, as is well known, that in the so- from the hernia upwards, one limb of the loop passing called maturation division of the sexual cells before fertilisa- almost directly upwards and the other running towards thetion-i.e., in the so-called (Richtungskörperbildung) reducing right side of the abdomen. The bowel was now replaced division of the nucleus-a reduction in the number of the and the radical operation completed. Recovery was unheritable units must occur, so that the heritable charac- interrupted and the patient was dismissed at the end of a, teristics do not run on into infinity by the union of the germ and month. The second case occurred in a woman, aged 50 years, whosperm threads. This view is accepted by almost all authors. I hold, however, that such a process is a priori improbable. had been the subject of a left femoral hernia for eight Fertilisation takes place, in my opinion, by no means accord- months before the onset of acute symptoms. During theseing to a mere arithmetical summation of two individual months the hernia had varied in size from time to time and! plasmas (the male and the female), but is much more though it could never be quite reduced it did not cause any apparently, to some extent, a chemical reaction between two inconvenience till on making a sudden straining effort it forms of plasma. By this reaction in fertilisation a new increased in size considerably and became irreducible. individual plasma arises, the individual plasma of the new When seen by me, nine hours later, the symptoms of organism (Keim). Each individual plasma is thus the pro- strangulation were well marked though the bowels had duct of a genealogical synthesis, for in the constitution of moved once slightly after strangulation had taken place. the individual plasma of the ovum the continuance of the The pulse and temperature were normal. female parent is provided for by characteristic atom-groups When the sac was opened it was found to contain a loop and similarly in the constitution of the individual plasma of of deeply congested colon, about four inches in length, the sperm the continuance of the male parent is provided measured over the loop. Depending from its lower margin for. and forming the greater part of the hernial contents was a It is obvious also that the new individual plasma might large piece of the omentum, between which and the sac build up anew of itself the atom-groups which the individual there passed several firm adhesions. To relieve the conhas inherited from distant progenitors without containing in striction, which again was not very tight, Gimbernat’s ligaits own body any individual chemical molecules of such pro- ment was incised. Through this enlarged opening the genitor. This genealogical synthesis in the copulation of the finger could trace the limbs of the loop as in the former sexual cells is evidently the object of fertilisation, for in this case. The omentum was removed, the colon was returned way new kinds of individual plasma can come into being into the abdomen, and the radical operation was performed. which may be useful in the struggle for existence. The patient was dismissed from the hospital three weeks later with the wound healed. In neither of these cases was there a tight constriction at the neck of the sac and yet there was sufficient interference with the circulation to produce not only congestion in both even hæmorrhages in one of them. Further, though the AND but canal was comparatively wide it was only after it had been THERAPEUTICAL. enlarged by free incision that reduction was effected. Hernias of the large intestine seem to be specially liable to strangulation as symptoms of this condition are frequently TWO CASES OF STRANGULATION OF THE TRANS- found in cases where the neck of the sac can scarcely be VERSE COLON : ONE IN AN INGUINAL AND regarded as narrow. THE OTHER IN A FEMORAL Glasgow. HERNIA. A NOTE ON SOME UNUSUAL CASES OF TRICHOBY PETER PATERSON, M.B., C.M. GLASG., PHYTIC INFECTION. SURGEON TO THE ROYAL INFIRMARY, GLASGOW.

in the individual. imagine that such and for ever and so

In the

may easily atom-groups occasionally split off once special characteristics may be lost completely. Again, sports (Sprungweise mutationen) can be easily explained as due to intra-molecular changes in neighbouring atom-groups in the highly complex molecule of the individual plasma. In a similar way I conceive that there may take place in the cell quite of itself a reduction in the heritable characteristics-i.e., of the heritable predisposing conditions (Anlagen)-that is, a self-regulation of the heritable mass same

way

we

Clinical Notes:

MEDICAL, SURGICAL, OBSTETRICAL,

BY ARTHUR

THOUGH strangulation of the transverse colon in

inguinal

an

or femoral hernia does not present any symptoms by which it can be distinguished, clinically, from strangulation of the colon in any other region, the fact that such contents may be found in a hernia situated at a considerable distance from the normal situation of the transverse colon may be emphasised by placing on record two cases which have occurred in my hospital practice within the last few months. The first case was that of a well-built muscular man, 34 years of age. This patient for some years had suffered from a hernia which he could always reduce till about ten hours before he was admitted to hospital when it suddenly became larger, painful, and irreducible. Soon afterwards symptoms

WHITFIELD, M.D. LOND., F.R.C.P. LOND.,

PHYSICIAN TO THE SKIN DEPARTMENTS OF KING’S COLLEGE AND THE GREAT NORTHERN CENTRAL HOSPITALS.

I

BELIEVE the following cases of ringworm to be worthy report on account of certain peculiar features which might easily lead to an error of diagnosis and actually did

of

in one case. CASE 1.-A man who had spent a large part of his life in China was brought to me in consultation by Dr. Ernest

so

Playfair complaining of eczema of the soles of his feet and roughening of the toe-nails. The affection was first noticed three years ago and eight years after his return from China. He had tried several remedies and had been treated

by

one

238

specialist

for skin diseases who diagnosed the trouble as of the toes. On examination it was found that all the toe-nails of both feet were yellowish, friable, and longitudinally split. The patient kept them extremely short on account of this friability. The skin around the nails, especially at the posterior nail fold, was slightly ’i reddened and the surface was desquamating irregularly. There were a good deal of sodden hyperkeratosis between the toes and some fissuring in the angles of the fold. Most of the skin of the sole was apparently fairly healthy, the morbid condition being situated chiefly on the distal side of the heads of the metatarsals. The skin of the hands and the finger-nails were in a perfectly healthy consideration. There was considerable pain from the eczema " of the toes, probably caused by septic absorption from the frequent fissuring. There was also a history of an eruption on the leg of which it was said that "it must have been herpes,"though it is doubtful if the physician who made this diagnosis ever saw The patient spent much time in the actual eruption. trimming and scraping the nails, taking no precautions against the spread of infection, and yet his fingers were quite healthy, so that it did not seem likely that a local infection was present. In spite of this I thought it advisable to make a microscopic examination, and accordingly a large amount of scrapings and clippings of the diseased nails was collected and examined. After a somewhat prolonged search I found a number of specimens in which a fair abundance of trichophytic fungus was evident. I therefore advised that all the nails should be taken away under an anaesthetic and the toes dressed with an antiseptic ointment. The patient, however, would not consent to removal of the nails and I therefore advised treatment by the perchloride of mercury and alkaline potassium iodide solutions advised by Harrison, and failing this the weak iodine dressing of Sabouraud. Unfortunately, both these treatments caused so much pain that they could not be efficiently carried out, and when I last saw the patient he was not greatly eczema

improved. The greatest interest of this

case

lies in the fact that in

spite of frequent handling of the diseased nails without any precautions no infection of the finger-nails took place, a circumstance which undoubtedly threw off his guard the skin specialist previously consulted. The frequent attacks of pain up the legs were also diagnosed as neuritis by a nerve specialist, who said that the eruption must have been herpes, though it seems more probable that these were, as has been said, of the nature of lymphangitis. Lastly, it is probable that the true history of the infection is longer than the patient believes, as it is my experience that nail ringworm is especially common in those living in China and Japan. CASE 2.-This

case,

or

rather series of cases, has also

recently come under my notice. A man came complaining of peeling and itching of the soles of both feet, and gave the following history. For about four months he had been worried with itching of the feet and cracks between the toes. About two months later his wife began to be similarly affected and later his daughter. Suspecting some irritant left in the stockings these were washed at home and both his wife and the maid who washed some of the stockings as a test contracted the disease slightly in the palms. The three who came to me (I did not see the maid) all showed marked sodden hyperkeratosis between the toes and indefinite scaling of the soles spreading up slightly and with an illdefined edge on to the dorsum. The nails were all quite healthy. No vesicle formation was seen anywhere and no rings were present. Examination showed in every specimen extraordinarily abundant, short-jointed, large mycelium and the patients were accordingly treated for trichophytic infection. This group of

cases indicates the possibility of the washings being a source of infection and justifies the Anglo-Indian idea implied in the term dhobi (washerman’s) itch. CASE 3. -This patient, a young woman, was also brought The trouble consisted of an acute to me by Dr. Playfair. vesico-bullous eruption on the dorsal surface of the right forefinger and the right hypothenar eminence. The lesions were arranged more or less in patches but there were many outlying vesicles and there was no ring formation. On the hypothenar patch the vesicles had run together to form here and there large bullas on the surface of which were still

to be

seen

the

markings

of the constituent vesicles.

The

condition had developed five days before during the very hot weather and was similar to the acute eczema of the hands The history, however, so commonly seen during great heat. showed that about two and a half months previously the patient had rescued a common wild mouse which was being cruelly treated by some village children, and the mouse had bitten her in the exact sites of the present eruption. Both bites had drawn blood, but they had healed in an apparently satisfactory manner in a few days and nothing further had been seen until five days ago (i.e., about nine weeks later). The roofs of some of the fresher vesicles were cut off and examined and an abundance of large, short-jointed trichophytic mycelium was found and the cause of the eruption thus elucidated. The points of interest here are the long duration of latency of infection and the very definite history of inoculation by the mouse. Favus of the mouse has been well known for some time and it has been recently pointed out1 that widespread epidemics of trichophyton also occur in mice. In none of these cases were the clinical features of the eruption in the least characteristic of the disease, and I record them in the hope of again drawing attention to the immense importance of the clinico-pathological investigation in all doubtful cases. Bentinck-street, W.

Medical Societies. ROYAL SOCIETY OF MEDICINE. OTOLOGICAL SECTION. Exhibition of Cases,&c. THE first meeting held outside London took place at Edinburgh on June 27th, in the Ear and Throat Department of the Royal Infirmary, Dr. PETER McBRiDE, the President, being in the chair. The meeting was well attended, over 30 members being present. Cases of Lateral Sinus Thrombosis and Intracranial Abscess were shown by the PRESIDENT, Dr. A. LOGAN TURNER, Mr. HENRY WADE, and Dr. W. PERMEWAN. They The chief points of the discussion were discussed together. were the conditions requiring ligation of the jugular vein, the importance of nystagmus, the value of bacteriology, and examination of the blood, especially with regard to leucocytosis as a means of diagnosis and guide with regard to treatment. The next group of cases related to the Radical Mastoid Operation. Dr. LOGAN TURNER showed two cases with Preservation of the Tympanic Membrane and Ossicles. Dr. PORTER showed a case of Stenosis of the Auditory Canal which occurred twice in spite of subsequent operations and was chiefly due to the new formation of bone. Dr. J. STODDART BARR read some notes on Partial Skingrafting with the Aid of Local Anaesthesia as a Method of Shortening the After-treatment. Dr. GEORGE A. GIBSON and Mr. RICHARD LAKE communicated notes of a case of Ablation of Both Vestibules for the Relief of Vertigo. The case was first shown at the As a result of operation Society in 1905. coordination of movements was now perfect. Dr. ALBERT A. GRAY showed some Stereoscopic Photographs illustrating the Comparative Anatomy of the Labyrinth of Reptiles, Birds, and Mammals. Mr. SYDNEY R. SCOTT read notes of a case of Otitic Meningitis with Histological Specimens of the Labyrinth, demonstrating streptococci in situ,. Mr. JOHN M. DARLING read an abstract of his recent work on Cytological Examination of the Discharge in cases of Middle Ear and Maxillary Sinus Suppuration. At the close of the meeting Professor D. J. CUNNINGHAM gave a Lantern Demonstration of some of the Central Connexions of the Auditory Nerve which was much appreciated by those present. The meeting in itself was most successful and was rendered all the more so in consequence of the hospitality shown by the President and Dr. Logan Turner.

Otological

1

THE LANCET,

July 4th, 1908, p. 50.