A PROSPECTIVE CURE FOR ELEPHANTIASIS.

31 had been admitted for what was considered to be empyema of the right side of the chest. A needle was inserted and no pus found, yet so certain was the diagnosis considered to be that the child was operated upon for the removal No fluid, however, could be of the supposed fluid. discovered. The child eventually died and virtually the whole of the right lung was found to be occupied by a The caseous mass, while the left lung remained healthy. caseation was of somewhat unusual character. It shelled out in rounded masses from the interstitial structure of the lung, leaving fibrous strands and remains of bronchial tubes and blood-vessels, with here and there small portions of compressed lung tissue. It may be thought that possibly the disease was not tuberculous, but the presence of caseation in the bronchial and mediastinal glands, of tuberculous ulcers in the small intestine, and of tuberculous dactylitis in one finger seemed to leave no doubt as to its

th diagnosis of chronic disease of the lung in children and, the associated with the difficulty of diagnosis, the need for as caution as regards prognosis. PS.-Since writing the above I have read the valuable p1 paper by Dr. Clive Riviere on Pulmonary Fibrosis in C Childhood which is based upon 40 cases. Dr. Riviere lays st stress on the possibility of mistaking the disease for chronic tt tuberculosis and enters fully into diagnosis and prognosis.

A

PROSPECTIVE CURE ELEPHANTIASIS.2

BY W. SAMPSON

FOR

HANDLEY, M.S., M.D. LOND., F.R.C.S. ENG.,

SURGEON TO THE MIDDLESEX HOSPITAL AND SURGEON TO Â ASSISTANT

HOSPITAL; HUNTERIAN PROFESSOR, ROYAL COLLEGE OF SURGEONS OF ENGLAND.

THE BOLINGBROKE

nature. From time to time one meets with cases in the out-patient room where there is said to have been severe bmmoptysis. History is too often unreliable and the description of the amount of blood coughed up is generally received with some measure of scepticism. In one case, however, a boy, aged four and a half years, brought up about half a pint of blood in the out-patient waitingroom. The cause for the bleeding was not clear,

Elephantiasis Arabum has up to the present been r regarded as an incurable disease. The improvement which t the operation of lymphangioplasty has produced in the ffollowing case is so great and striking as to justify the hope a cure has been found. t that My experience in other c directions has shown that the effect of the operation is not r merely transitory. The boy presented nothing which indicated marked In this operation a number of stout silk threads running t whole length of the limb are introduced into the subill-health, and there was no evidence of dilatation of the the bronchial tubes or of tuberculosis of the lungs. Such cutaneous ( tissues of the swollen part. The threads are cominstances of severe haemoptysis may possibly occasionallypletely and permanently buried. Their capillary action be due not to tuberculosis of the lung itself but to suppura- enables them to replace the trunk lymphatics and to transfer tion in a caseous bronchial lymphatic gland as occurred in the t excess of fluid from the area of lymphatic oedema to the case from which the specimen that Fig. 4 illustrates was iregions where the lymphatic circulation is normal, and taken. In this case, however, suppuration within a caseouswhere i consequently the excess of fluid is absorbed and ( off into the general circulation. gland not only opened a branch of the pulmonary artery but carried the pus had previously burst into the oesophagus and the In my preliminary communicationon lymphangioplasty I blood followed the path formed by the course of the pus.recorded ] two cases in which it had been successfully applied The accident happened in a boy, aged five years, who was1to relieve the "brawny arm"of breast cancer. Further at school on Friday, was thought to be unwell on Saturday, and experience in this field has confirmed my conclusions and has died in the course of a few hours, during which large quantitiesshown that the effect of the operation in my earliest cases is of blood were brought up, on Sunday. In this case the cause permanent to date. of the bleeding from the lungs was, it is needless to say, The case which I am about to record is the fulfilment of perfectly clear, but as an illustration of the obscurity of some my anticipation that the method could be used with success cases of hemoptysis in children the following may be in elephantiasis. But before this result was reached harsh mentioned. A girl, aged seven years, was said to suffer experience compelled me to recognise that elephantiasis, from repeated slight attacks of bmmoptysis,and on oneunlike the lymphatic cedema of breast cancer, cannot be occasion about a teaspoonful of bright blood was brought for treated on purely mechanical lines. In the latter affection, examination by the mother as evidence of her statement. as I have shown, the lymph of the swollen limb is a sterile Nothing could be found in the lungs or mouth to account forfluid, but in elephantiasis there is present a chronic infection the bleeding. On visiting the home of the child a few yearsi of the tissues with micrococci. Vaccination against the later it was found that she had lived for nearly three yearsinfective micrococci, although in itself powerless to reduce after the time when she was first seen. The bringing up of’ the cedema, would appear in elephantiasis to be an essential blood had continued and had occurred about once every two) preliminary to the operation of lymphangioplasty. My case The child’s health was said to have remained veryis thus at once a vindication and a criticism of the methods One good. day, however, she complained of abdominalassociated with the name of Sir Almroth Wright, showing at pain, vomited several times, and was found dead in bed ont the same time their power to arrest an infective process the following morning. The cause of the child’s death was9and their incapacity to deal with its secondary results. probably some accident which had no connexion with the: The patient, a man, aged 46 years, was sent to haemoptysis, yet there seems to be a remote possibility thattme in April, 1908, by Dr. J. J. Udale suffering from the haemoptysis may have been the only evidence of diseaseasporadic elephantiasis of the left leg dating from the year of the nature of Henoch’s purpura in which abdominal1 1895. In that year the left testicle became swollen, hard, symptoms were at first absent. Eventually haemorrhage mayr and nodular, as if the seat of a sarcomatous growth. The have occurred into the walls of the intestine the shock off left leg presented patches of erythema and was painful but which caused death. not at first greatly swollen. The left inguinal glands were Henoch’s purpura, it is scarcely necessary to remark,, enlarged. About 1898 the swelling of the leg became more rarely proves fatal in this way. I have, however, made amarked and had since been progressive until the limb had necropsy on a boy, aged nearly four years, who died as areached its present enormous size. The patient continued up consequence of hæmorrhage into the walls of the intestines.. to the present time to have recurrent pyrexial attacks, There had been no passage of blood by the rectum and thee ushered in by a rigor and headache and accompanied by nature of his disease was obscure until after death. To patchy erythema of the leg. During these attacks the limb discuss, however, questions connected with Henoch’s purpurawas painful, especially at night. He had never been abroad. is to wander from chronic affections of the lung in children.. Since 1895 he had been in various London hospitals. In 1905 Whatever the nature of the haemoptysis may have been in she was in the Seamen’s Hospital, Greenwich, under the care the above case, the continued good health of the child up p of Sir Patrick Manson. The leg was incised and portions of e to the time of her death seems to be in itself an evidence tissue were removed, with temporary benefit. The swollen of the obscurity that may surround the symptom haemoptysis, testicle was also incised and its subsequent removal became which, as in adults, is supposed in children to indicate thee necessary, owing to an attack of acute sepsis, doubtless of presence of serious disease of the lung. endogenous origin. In conclusion, it may be remarked that while the above 1 St. Bartholomew’s Hospital Reports, 1905. observations may appear to be superficial and disconnected 2 The case described was shown before the Society of Tropical in some in common-that are intended have this they they Medicine on Nov. 20th, 1908. 3 THE LANCET, March 14th, 1908, p. 783. small degree to illustrate the difficulty which may surround

months.

0

32 On admission to the Middlesex Hospital in April, 1908, the specimen of lymph withdrawn from the leg by a Southey’s condition of the patient was as follows. The left lower limb t was reported by Mr. A. G. R. Foulerton to contain was enormously enlarged by solid oedema, especially below ( From a similar specimen taken on the 18th an diplococci. the knee. On the posterior aspect of the calf were two hugeaapparently identical diplococcus was obtained in pure culture. masses separated by a deep cleft or crease. Another large The ’. extermination of this organism seemed essential before any mass occupied the dorsum of the foot. The patella could notfurther operation was undertaken. Mr. Foulerton accordingly be felt. The thigh was much enlarged but presented no prepared for me from the micrococcus in question a vaccine pendulous folds. The skin was much thickened, coarse, andwhich was injected subcutaneously at suitable intervals from rugose. Repeated nocturnal examinations by Mr. RichardAugust 31st to Oct. 12th. On Oct. 5th and again on the 12th lymph from the leg was found to be sterile. It was Paget showed that filariæ were absent from the blood. On April 18th I performed lymphangioplasty, leading thetherefore i presumed that the vaccine treatment had destroyed threads from the foot up to the iliac fossa, where they wereall the micrococci present in the limb. imbedded in the iliacus muscle. At first all went well and By this time the leg, which had become progressively the success of the operation seemed almost assured. The swollen since the silk was removed, had attained a size drainage of lymph from the limb was so free that on the daygreater than ever before. The sterility of the tissues being secured, lymphangioplasty following operation a large cushion of oedema appeared in the left loin. Concurrently the swelling of the limb subsided was again performed on Oct. 17th, after most careful and rapidly, the bandages became loose, and the pendulous folds thorough preparation of the skin. On this occasion the silk of subcutaneous tissue shrank and took on the consistency of threads, so as to avoid the scars of the previous operation, a sucked orange. Within five days the ankle diminished in were carried up to the gluteal region, where they terminated circumference from 21 to 142 inches and in nine days the in the subcutaneous fat. All again went well until Oct. 26th, calf shrank from 242 to 17 inches. About April 27th trouble when the temperature rose to 9940 F. -It was on this very began. When the stitches were removed all the wounds had day, the ninth after operation, that trouble had begun on the healed except one on the outer side of the calf, from which first occasion, so that the situation was alarming, although The temperature rose, other no local irritation could be seen about any of the incisions. a little pus could be expressed. incisions reopened, and red lines appeared along the silk A dose of vaccine (200,000,000 cocci) was immediately tracks. On May 2nd, therefore, I removed all the silk and syringed out the tracks with zinc chloride. By May 5th the FiG.2 swelling of the leg had begun to recur. Constitutional disturbances remained slight. Suppuration continued for some time and an abscess formed in the thigh, but by June 19th the leg was soundly healed, a result mainly due to the unremitting care of Mr. P. J. Chissell, at that time house surgeon. Up to this point the case had been a disastrous failure, but it seemed to me that hope need not be abandoned, a

tube

s

FIG. 1.

The condition of the leg 18 days after the operation of

lymphangioplasty. and the supports which had raised the foot of the bed 18 inches so as to promote drainage were transferred to the head of the bed. The effect of this was, of course, to produce a passive oedema of the left leg, the tissues of which rapidly began to refill. The limb was practically treated by Bier’s method. Following the application of these measures, although the temperature rose to 100° on the day following, it then rapidly subsided without the development of any local trouble. The stitches were removed on Oct. 27th and all the incisions were found to be healed except one on the foot where the skin was extremely thick and indolent. Any possible risk from this was guarded against by the use for a few days of weak carbolic baths for the foot. On Nov. lst the dressings were left off and the limb was re-elevated. The remarkable effect of the operation in reducing the swelling of the limb is shown in the following measurements. It may be remarked that on Oct. 27th neither elastic bandaging nor massage had been begun. The subsidence so

injected,

The condition of the

leg before operation,

view which the patient fortunately shared. It was remarkable that suppuration had not set in until the ninth day after operation. If it had been due to infection of the silk from the skin it seemed to me that it would probably have begun earlier. I felt strongly that the suppuration was of endogenous origin-that it indicated a prior chronic infection of the tissues of the leg. On August 1st the patient was readmitted in good general health upon his return from the seaside. On the 4th, the pulse and temperature being at that time normal, micrococci On the 12th a were cultivated from the blood of the arm.

33 far (as shown in Fig. 2) was entirely due to the action of the silk, aided by gravity :-

on Oct. 10th, 1907, suffering from a severe attack )f scarlet fever, with a history of vomiting, sore throat, and rash on the day of admission. The history of contact with his brother, the patient in Case 1, who was admitted on the same day with symptoms commencing three days previously, sufficiently indicated the source of infection. The patient exhibited a universal punctate erythema, circum-oral pallor, severe adenitis and angina, and a typical so-called ’’ I strawberry " tongue. Desquamation began on the face and neck on the 15th and was noted on the hands on the 30th. Three days later the patient complained of sore throat, the pulse went up to 130, but the temperature was only raised to 990 F. Examination showed the presence of a punctate erythematous rash and a moderate degree of swelling and injection of the throat. A second desquamation did not take’ place, the second attack was less severe than the first, and the boy was discharged well on Dec. 14th. CASE 3.-A sister of the two patients whose cases have been related, aged five years, was admitted to hospital on Jan. 10th, 1908, suffering from a well-defined attack of scarlet fever. There was a history of sore throat and vomiting on the 7th, with rash on the 10th. On admission the rash was definite ; the fauces, tonsils, and cervical glands were moderately affected. A few days after admission peeling began and the patient remained quite well until Feb. 3rd. On that day vomiting took place and the girl was found to have a well-marked punctate erythema on the body

capillary hospital

(Second operation of lymphangioplasty on Oct. 17th, 1908.) Since about Nov. 12th the patient has been allowed to get up and to walk about for several hours daily, and an elastic bandage has been applied to the limb. In this way a still

further diminution in the size of the limb has been obtained. The tissues are now abnormally softened and lax, hanging in folds about the bones, and the thickened skin has become thin and supple. In conclusion, my best thanks are owing to Mr. Foulerton and to his assistants Mr. W. T. Hillier and Miss H. K. Whittingham for undertaking the bacterial investigations without which the case could not have been brought to a successful issue, to Dr. H. P. Noble who gave the ansestethic, to Mr. P. J. Chissell and Dr. D. Ligat who as house surgeons and limbs and a moderately inflamed throat. The temperature 99 -50 F., but it reached 100 -50 two days later, and then successively had charge of the case, and to the nursing staff was fell to normal on the 10th. A second desquamation began of Bischoffsheim Ward who were responsible for the herculean on the 6th and the second attack proved to be mild in task of cleansing the thickened skin. I believe that Mr. Foulerton proposes to publish later a character. The patient was discharged well on March 5th, 1908. detailed account of the case in its bacteriological aspects. CASE 4.-The patient was another sister, aged ten years, New Cavendish-street. who had been in contact with the subject of Case 3. She complained of sore throat and headache on Jan. 14th, 1908, and the rash was first noticed on the 17th. She was admitted to hospital on the same day with a moderate but well-defined attack of scarlet fever, showing in fact a peelAND ing tungue at the time of admission. Desquamation appeared and proceeded in the usual way, and the child was quite THERAPEUTICAL. well until the morning of Feb. 4th, when she complained of sore throat and was sick. The temperature was 101 . 5° F. FAMILY TENDENCY TO RELAPSE IN SCARLET In the evening a characteristic rash appeared, but this was not followed by a second desquamation. The secondary FEVER, WITH NOTES ON FOUR CASES. attack was more severe than the primary, being attended BY CLIFFORD BEARDS, B.A., M.B., B.CH. OXON., with troublesome adenitis. The patient was discharged well D.P.H. R.C.P.S. LOND.,

Clinical Notes:

MEDICAL, SURGICAL, OBSTETRICAL,

March 5th. It may be pointed out that three of these cases (Cases 1, 2, and 4) illustrate the complementary nature of the primary and secondary attacks. In many cases of scarlatinal relapse the secondary attack is severe if the primary has been mild and vice versd. An inquiry failed to elicit a history of similar relapses in the case of the parents or members of collateral branches of the family. I have to thank Dr. Sidney P. Phillips and Dr. William Hunter, under whose care the patients were treated, for permission to report the cases.

on

RESIDENT MEDICAL

THE

OFFICER, LONDON FEVER HOSPITAL, ISLINGTOT,

occurrence

of

relapse

in

cases

of scarlet fever is

event which receives but scant attention in the text-books. In view of this fact a note on four

N.

an

ordinary cases

of

relapse recently observed in the London Fever Hospital may not be without interest, and more particularly as all four patients were members of one and the same family-two brothers and two sisters. CASE 1.—The patient, a boy, aged 11 years, was admitted to hospital suffering from a typical attack of scarlet fever on Oct. 10th, 1907, the fourth day of his illness, with a history of sore throat on the 7th and headache and rash on the 8th. Examination on admission showed the presence of a widely spread fading punctate erythema, injected and swollen tonsils and fauces, enlarged and tender cervical glands, and a peeling tongue. The temperature, which was 99’ 50 F. on became normal on the 15th, on which day typical admission, " pin-point" desquamation appeared on the neck. From this time onwards until Nov. 10th the patient had a normal convalescence ; peeling was noted on the hands on Oct. 26th and on the feet on the 29th. On Nov. 10th the boy did not feel well, he vomited two or three times, and the temperature rose to 1000. On the next morning the temperature was 101°, the boy complained of sore throat, and a few hours afterwards a punctate erythema developed on the chest and slowly spread over the whole body and limbs. The fauces and tonsils were injected and much swollen, but there was no adenitis. Two days later a second desquamation began and followed the usual course. The second attack was more severe than the first, for it was attended with well-marked secondary adenitis and rheumatism. The patient was discharged well on Dec. 14th. CASE 2.-The patient, a boy, aged six years, was sent to

London Fever

Hospital.

A NOTE ON A CASE OF CEREBRAL VENOUS THROMBOSIS. BY W. E. McKECHNIE, M.B., CH.B. EDIN., CAPTAIN, INDIAN MEDICAL SERVICE.

THE following note may be of interest in connexion with Dr. C. 0. Hawthorne’s article upon thrombosis and its relation to the cerebral and ocular complications of anæmia which appeared in THE LANCET recently.1 About ten years ago I was called to treat a mill girl of about 20 years of age. Her chief complaint was vertical headache which appeared to be of the clavus variety. She had mistiness and dimness of vision at times. She appeared to be slightly anaemic, but no accurate determination was made of this. However, she looked anæmic enough to cause me to treat her for chlorosis. She had dysmenorrhoea and dreaded her periods. She remained at her work of weaving, and one day she lost consciousness at the loom and fell backwards and struck the back of her 1

THE LANCET,

Sept. 19th, 1908, p. 857.