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AMŒBIC DYSENTERY?
74 numbers of a highly influential medical journal. alveolaris, which at the post-mortem examina. To such vile uses may the best of literature be put! tions I observed to be present. But it is time to come to the point of I am Shortly after this, in a further series of five cases, or rather readers-I to I was called in to prepare the mouth for the operawish addressing you, your impress upon them, or more correctly some of them, tion. This was done by the extraction of all the how much they lose by not perusing, for example, teeth and stunips, followed by antiseptic treatment your pages, and how they should order their lives of the wounds for a week or ten days (painting the so to secure time for such study. as Take surface of the gums with a 2 per cent. solution of THE LANCET for four consecutive numbers and let me iodine in rectified spirit twice daily is probably the mention a few of the interesting tit-bits to be found best method). These five patients were alive and in the one month-November. I shall take them well three months after the major operation. as it happens the best, In my next case the patient absolutely refused at random. The first, and " is Mercier’s address on Heredity,’’ sparkling with to have all his teeth removed. He would only allow humour and full of sound sense, though I think he me to extract the loose ones. I carefully scaled forgets the apophthegm as to the mothers of men and cleansed the remainder. He died about six of genius; and next that on "Hysteria"by Glynn, days after the major operation from septic combased as all such "prospects should be on a plications. carefully recorded past experience. The report by My experience since has confirmed me in my Davis and Hall on the intensely interesting ques- belief that if periodontal disease is present even w " tion of Typhoid Carriers," and the not less valuable a slight degree the only safe course is to extmct remarks of Gowland Hopkins on "Diseases due to every tooth at least one week before the major Deficiencies in Diet." Tubby’s suggestive paper on operation. It should be remembered, too, that " on " Nerve Surgery," also Cammidge’s Diabetes," every hospital patient has pyorrhoea. practically " It is difficult to understand the attitude of the Eugenics," and the your review on Davenport’s leading article on " Housing in Dublin "-a problem surgeon who takes infinite precautions to sterilise on this side of St. George’s Channel, alas! as well the area of operation before making a skin incision as in Ireland. To Insurance panelists the continuaand who yet will perform an extensive operation in tion of the valuable local inquiries by your highly the mouth actually in the presence of pus. I am, Sir, yours faithfully, capable contributor is enough to make the one week’s issue interesting by itself. F. ST. J. STEADMAN, M.R.C.S. Eng., Dr. Mott’s able paper on the "Degeneration of the L.R.C.P. Lond., D.P.H., Assistant Dental Surgeon to the West London Hospital, &c. Neurone" should make the following number equally Wimpole-street, Cavendish-square, W., Dec. 20th, 1913. so, while Sir Dyce Duckworth’s Liverpool address constitutes a timely warning against the adoption of jejune theories as applied in the practice of AMŒBIC DYSENTERY? medicine. The subject of neurasthenia as dealt To the Editor of THE LANCET. with in the issue for the last week of the month affords an excellent example of the value of the SIR,—The greater part of the medical profession both in this country seem to be singularly blind to the as doctor and regards personal equation patient. An unprejudiced study of the combined possibility of their patients acquiring tropical wisdom of the leading London neurologists amounts diseases without going abroad, and yet we are all merely to this-that not one of them can properly familiar with the fact that many tropical animals define the subject in debate further than agreeing and plants become acclimatised and thrive here; that the nerve battery is " run down," though in there is nothing incredible, therefore, in the idea most cases it cannot be said whether the defects that the micro-organisms of tropical diseases may have arisen from bad initial construction, from equally thrive in England and reproduce their specific injury, or from failure in the supply of the chemicals diseases in this temperate climate. The following case may serve for an illustration. required. At the end of last August, a man aged 30, consulted And now, to cease to be garrulous and become I as to diarrhoea, from which he had suffered venture to advise medical brethren me didactic, my to take one forenoon out of the seven in bed, pre- continuously since childhood, at least 18 years. ferably on a Sunday, and post themselves up in the The stools were putty-coloured and varied between current literature of medicine, surgery, and 5 and 15 a day. It had been difficult for him obstetrics, as also in the pressing professional to carry on his business, and he was quite unable He had during the to join in social functions. problems of the day. I am, Sir, yours faithfully, worst attacks considerable pain and tenesmus, WILLIAM BRUCE. followed by bloody stools for a week at a time. Dec.29th, 1913. Abraham us with a Cowley supplies quotation: During several years he had been treated by various ’" *" The diagnoses varied" woe grieved, we sighed, we wept; we never blushed eminent physicians. "nervous diarrhoea," intestinal tubercle, and disease before. "-ED. L. of the colon (needing operation) were a few THE PREPARATION OF THE MOUTH out of many. One nasal specialist put the whole trouble down to post-nasal catarrh and wanted to FOR OPERATIONS. remove part of the turbinated bone. The patient To the Editor of THE LANCET. told me of many remedies which had been preSIR,-In reference to the case of cancer of the scribed with no effect for more than a day or two. A few months ago I had been discussing with my tongue and larynx removed by operation, and who practises in India, tropical dysentery in Kerr Mr. W. S. issue of daughter, your reported by Dec. 20th, 1913, some ten years ago I saw in a and other intestinal cases. Bearing in mind what of I had learned from her, I came to the conclusion nine consecutive cases London hospital major operations about the tongue and floor that the case before me might be one of amoebic of the mouth end fatally a few days after dysentery, and advised the patient to have a course the operation. Death in each case was due to of hypodermic injections of emetine hydrochloride. septic complications obviously caused by pyorrhoea After a delay of several weeks he agreed; for six
why
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75 of intestine, which properly splinted in position by adhesions would not become displaced, while an adjacent part fixed by the band remained in the proper site. Lastly, the band may produce stasis by constriction. Where an adhesion has been present for a time and later shrinks, causing kinking or narrowing of calibre of the gut, I believe this to result from a sclerosis largely the effect of change during middle age, and resembling the hardening got in the connective tissues generally, as in the brain, eye, heart, arteries, or prostate. " This I have named condensation obstruction," a condition which might be avoided were the general youthfulness of the tissues preserved in some way. Note especially how volvulus tends to occur after middle life from shrinking of an adhesion pedicle approximating a loop of intestine at its base. 2. A kink may produce obstruction; on the other hand, a sheath or veil of adhesions may prevent it by preventing over-distension. I have at present in my wards a patient whose great intestine at operation showed a reticulated cicatricial mosaic exactly like the striae albicantes after pregnancy, and suggesting a similar origin, coming on after alternate contraction and distension of the colon, causing slight tears and cracks which fill up with connective tissue. Such a cicatricial effect would exert centripetal pressure on the intestine, preventing over-distension and thus preventing stasis. This arrangement might be compared to the tartan envelope which encases the national instruINTESTINAL KINKS. ment of Scotland, preventing the stasis of its To the Editor of THE LANCET. melodies. Also the effect in causing enhanced SiR,-In THE LANCET of Dec. 20th your corre- velocity of the contents is as that in carcinoma of spondent, Mr. C. Hamilton Whiteford, has raised the rectum, where diarrhoea ensues when the some very pertinent queries regarding the effects natural ballooning is interfered with, and a portion of angulation or kinking of the intestines. This of dilatable intestine is replaced by an immobile subject has received so much attention lately tube of solid cancerous tissue. Apart from obstructhat by many it is looked on almost as a tion or diarrhcea, or neither, a kink or adhesion may fetish, invoked to explain all disorders, and the I produce chronic or recurrent pain in the abdomen. present mode in surgery is to introduce a new 3. The bowel to a kink may present no theory of cause and effect. Without apology, there- change, may be proximal to overcome resisthypertrophied fore, I conform to the general attitude, but ask ance, or may be dilated. Jordan’s plates clearly leave to plead rather for the utility of peri-visceral show the latter effect. In cases of atonic dilatation adhesions. Abdominal veils and bands, in my look to the neuro-muscular regulating apparatus as opinion, are sometimes noxious, yet in many well as to the muscular coats. instances a helpful function may be exercised by 4. The radiographer might decide the question of their presence. A decade ago one heard that an other symptoms than those of obstruction or all-wise Providence had provided the appendix, dilatation. tonsils, and foreskin as appropriate trophies for the 5. A kink in a portion of intestine drawn up to lesser surgeons; nowadays one imagines that the or beyond an incision in the abdominal wall is not large intestine is the legitimate prey for their proof that such exists in the passive state. On the maturer years. other hand, I have seen a case of fatal intestinal Nature does not always work viciously, and one with definite kinking without adhesions of must accept with caution the destructive pessimism paresis kind causing it, the condition being entirely of the over-zealous partisans of ileo-sigmoidostomy. any due to increased intravisceral pressure with sharp Taking Mr. Whiteford’s questions seriatim, I angulation at a flexure causing a collapse, much as believewhen a goose quill is bent acutely. 1. A band in itself may produce no symptoms of happens I am, Sir, yours faithfully, obstruction, either by angulation or by reducing SPENCER MORT, the calibre of the gut. Normal kinks are found in Ch.B. M.D., Glasg., F.R.C.S. Edin. the human intestine, and Keith has shown that Edmonton, Dec. 23rd, 1913. 20 per cent. of foetuses have aberrant accessory adhesions. How many cases endowed at birth with these present symptoms of stasis in infancy ? IODINE IN THE DRESSING OF WOUNDS. To the Editor cf THE LANCET. The band may for a time exercise beneficial control, I but afterwards become stretched and lax, allowing SIR,-I have recently returned from the Balkans enteroptosis to occur, with stagnation of the fiuid after a year’s absence. After leaving Adrianople, contents, and this effect is really due to non- where I worked for three months, I was invited to efficient support; the useful fixation of the band is join the fourth division of the Bulgarian army, as lost. It may by condensation and shortening drag a medical officer, during the operations against the upon a coil, pulling it up and causing angulation to Greeks and Serbs, and I remained from the outsuch degree that stasis occurs. In some cases break of war to the conclusion of the infamous misfortune arises from the non-support of portions treaty of Bucharest with the Bulgars.
consecutive days I gave hypodermically i gr. of the After the second dose, on salt each morning. Oct. 16th, the stools dropped to one a day, and became normally coloured and formed. When the drug was left off after the six doses the improvement remained, and on only four occasions since has he had more than one evacuation in a day. Three days before the hypodermic injections were begun his weight when stripped was 9 st. 4 lb., now it is 10 st. 1 lb. It seems, therefore, as if a cure has been effected, and that probably the diagnosis was correct. The patient has never been out of Great Britain. My opinion is that the disease was acquired when he was living in Plaistow, Essex, either through contaminated food or water. If, on the other hand, my diagnosis was wrong, then the treatment seems worth trying in other forms of obstinate diarrhoea, especially in cases where tubercle of the intestine is suspected. As a matter of precaution the patient has had six more hypodermic injections at intervals of three days, though no relapse has occurred. No other medicine has been used since Oct. 16th. The old name given to ipecacuanha by Helvetius, "radix antidysenterica," is more deserved than it ever was, now that the unpleasant effects of the remedy can be eliminated by the use of the alkaloid. I am, Sir, yours faithfully, VERE G. WEBB. Dec.25tb,1913.
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why
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75 of intestine, which properly splinted in position by adhesions would not become displaced, while an adjacent part fixed by the band remained in the proper site. Lastly, the band may produce stasis by constriction. Where an adhesion has been present for a time and later shrinks, causing kinking or narrowing of calibre of the gut, I believe this to result from a sclerosis largely the effect of change during middle age, and resembling the hardening got in the connective tissues generally, as in the brain, eye, heart, arteries, or prostate. " This I have named condensation obstruction," a condition which might be avoided were the general youthfulness of the tissues preserved in some way. Note especially how volvulus tends to occur after middle life from shrinking of an adhesion pedicle approximating a loop of intestine at its base. 2. A kink may produce obstruction; on the other hand, a sheath or veil of adhesions may prevent it by preventing over-distension. I have at present in my wards a patient whose great intestine at operation showed a reticulated cicatricial mosaic exactly like the striae albicantes after pregnancy, and suggesting a similar origin, coming on after alternate contraction and distension of the colon, causing slight tears and cracks which fill up with connective tissue. Such a cicatricial effect would exert centripetal pressure on the intestine, preventing over-distension and thus preventing stasis. This arrangement might be compared to the tartan envelope which encases the national instruINTESTINAL KINKS. ment of Scotland, preventing the stasis of its To the Editor of THE LANCET. melodies. Also the effect in causing enhanced SiR,-In THE LANCET of Dec. 20th your corre- velocity of the contents is as that in carcinoma of spondent, Mr. C. Hamilton Whiteford, has raised the rectum, where diarrhoea ensues when the some very pertinent queries regarding the effects natural ballooning is interfered with, and a portion of angulation or kinking of the intestines. This of dilatable intestine is replaced by an immobile subject has received so much attention lately tube of solid cancerous tissue. Apart from obstructhat by many it is looked on almost as a tion or diarrhcea, or neither, a kink or adhesion may fetish, invoked to explain all disorders, and the I produce chronic or recurrent pain in the abdomen. present mode in surgery is to introduce a new 3. The bowel to a kink may present no theory of cause and effect. Without apology, there- change, may be proximal to overcome resisthypertrophied fore, I conform to the general attitude, but ask ance, or may be dilated. Jordan’s plates clearly leave to plead rather for the utility of peri-visceral show the latter effect. In cases of atonic dilatation adhesions. Abdominal veils and bands, in my look to the neuro-muscular regulating apparatus as opinion, are sometimes noxious, yet in many well as to the muscular coats. instances a helpful function may be exercised by 4. The radiographer might decide the question of their presence. A decade ago one heard that an other symptoms than those of obstruction or all-wise Providence had provided the appendix, dilatation. tonsils, and foreskin as appropriate trophies for the 5. A kink in a portion of intestine drawn up to lesser surgeons; nowadays one imagines that the or beyond an incision in the abdominal wall is not large intestine is the legitimate prey for their proof that such exists in the passive state. On the maturer years. other hand, I have seen a case of fatal intestinal Nature does not always work viciously, and one with definite kinking without adhesions of must accept with caution the destructive pessimism paresis kind causing it, the condition being entirely of the over-zealous partisans of ileo-sigmoidostomy. any due to increased intravisceral pressure with sharp Taking Mr. Whiteford’s questions seriatim, I angulation at a flexure causing a collapse, much as believewhen a goose quill is bent acutely. 1. A band in itself may produce no symptoms of happens I am, Sir, yours faithfully, obstruction, either by angulation or by reducing SPENCER MORT, the calibre of the gut. Normal kinks are found in Ch.B. M.D., Glasg., F.R.C.S. Edin. the human intestine, and Keith has shown that Edmonton, Dec. 23rd, 1913. 20 per cent. of foetuses have aberrant accessory adhesions. How many cases endowed at birth with these present symptoms of stasis in infancy ? IODINE IN THE DRESSING OF WOUNDS. To the Editor cf THE LANCET. The band may for a time exercise beneficial control, I but afterwards become stretched and lax, allowing SIR,-I have recently returned from the Balkans enteroptosis to occur, with stagnation of the fiuid after a year’s absence. After leaving Adrianople, contents, and this effect is really due to non- where I worked for three months, I was invited to efficient support; the useful fixation of the band is join the fourth division of the Bulgarian army, as lost. It may by condensation and shortening drag a medical officer, during the operations against the upon a coil, pulling it up and causing angulation to Greeks and Serbs, and I remained from the outsuch degree that stasis occurs. In some cases break of war to the conclusion of the infamous misfortune arises from the non-support of portions treaty of Bucharest with the Bulgars.
consecutive days I gave hypodermically i gr. of the After the second dose, on salt each morning. Oct. 16th, the stools dropped to one a day, and became normally coloured and formed. When the drug was left off after the six doses the improvement remained, and on only four occasions since has he had more than one evacuation in a day. Three days before the hypodermic injections were begun his weight when stripped was 9 st. 4 lb., now it is 10 st. 1 lb. It seems, therefore, as if a cure has been effected, and that probably the diagnosis was correct. The patient has never been out of Great Britain. My opinion is that the disease was acquired when he was living in Plaistow, Essex, either through contaminated food or water. If, on the other hand, my diagnosis was wrong, then the treatment seems worth trying in other forms of obstinate diarrhoea, especially in cases where tubercle of the intestine is suspected. As a matter of precaution the patient has had six more hypodermic injections at intervals of three days, though no relapse has occurred. No other medicine has been used since Oct. 16th. The old name given to ipecacuanha by Helvetius, "radix antidysenterica," is more deserved than it ever was, now that the unpleasant effects of the remedy can be eliminated by the use of the alkaloid. I am, Sir, yours faithfully, VERE G. WEBB. Dec.25tb,1913.
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