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CHEMICAL PROPHYLAXIS AGAINST POLIOMYELITIS
93 way first and the capsule of the joint may also be severely torn. The tenseness of the joint may then provide a valuable clue to the diagnosis, for a tense hsemarthrosis is obviously incompatible with an extensive rupture of the capsule, whereas complete absence of distension will suggest a serious capsular lesion. INTRAVENOUS MINERAL THERAPY APART from the administration of
salines, intra-
therapy has never achieved widespread popularity. Iron is apt to be very toxic administered by this route except in very small doses, and there is no justification for giving it in this way since it can be taken so safely and effectively by mouth. Intravenous calcium therapy undoubtedly has its uses. No one who has seen 1 g. of CaCl2 given intravenously to a case of post-operative tetany can forget the immediate relief of the patient. Intravenous calcium has been stated to be equally efficacious in lead colic and now its effects are being further explored. Lampson and Simeone have recently reported1 favourably upon the results of trials of intravenous CaC12 in renal and gall-stone colic, spasm of the bladder, and post-operative distension. This form of therapy clearly deserves further attention. It must not be used in patients who are taking digitalis and if the chloride is being administered the greatest care must be taken to ensure that the needle is snugly in the vein. Probably, however, the use of the gluconate would eliminate this difficulty. Treatment is safe enough in normal persons provided the subjective feelings of the patient are used to guide the rate of dosage. Sensations of heat are inevitable venous
mineral
but there should be no nausea and the administrator should remember that since there is a delay of several seconds between the injection and the onset of symptoms the drug must be given slowly and with
great
care.
CHEMICAL PROPHYLAXIS AGAINST POLIOMYELITIS
A YEAR ago we commented2 on the application of chemicals to the olfactory area of the nose as a method of prophylaxis against poliomyelitis, and alluded to the work of Schultz and Gebhardt3 who recommended the use of a 1 per cent. solution of zinc sulphate for this purpose. They now state4 that, to obtain protection, it is probably necessary that the solution should be applied thoroughly enough to induce a temporary anosmia and in order to maintain the resistance it should be reapplied as soon as the sense of smell returns. On the other hand, no one wants such a functional effect to be permanent. The superior meatus is usually narrower and deeper in adults than in children, and so tends to hold solutions for a longer time. Hence the application causes pain of greater severity and longer duration in adults. Similarly, though in children the sense of smell seems always to return within a few weeks, it may take much longer in adults ; indeed, Schultz and Gebhardt have learned of several adults in whom the sense of smell had not come back after more than six months. These considerations, together with their observations in monkeys that a rather severe exudative inflammation of the olfactory mucosa may be caused by the application, make them advise caution in its use until more is known about the
1 Lampson,
June, 1938,
R.
S., and Simeone, F. A., Surg· Gynec. Obstet.
p. 975.
3 Schultz, E. W.,
1937, 108, 2182.
2
Lancet, 1937, 2, 203. Gebhardt, L. P., J. Amer. med. Ass.
and
4 Ibid, June 11th, 1938, p. 2024.
mechanism of the protection given and about the inducing permanent anosmia. Though they
risk of
continuing their investigations on monkeys, they admit that the full answer to the problem cannot be obtained from experiments on animals, and they ask for the experiences of any doctors who have used the method. are
SCHISTOSOMIASIS OF THE LUNGS
ALTHOUGH it is nearly thirty years since G. A. Turner drew attention to pulmonary schistosomiasis in man and some twenty years since Hamilton Fairley confirmed its existence in man and produced it experimentally in the monkey, the condition has had little attention. Yet Shaw and Ghareeb,l examining 282 bodies of persons with schistosoma infection (homatobium and mansoni) in Egypt, find that in more than 2 per cent. death was directly due to the damage to the lungs caused by the parasites. Moreover, in a third of all these infected persons parasitic pulmonary emboli had caused lesions. In 10 of the 95 persons thus affected the emboli had been worms, but in the main they were eggs. This proportion fits in with the opinion that the female worm oviposits daily ; if the eggs are not held mechanically in the visceral vein in which oviposition takes place they may be carried through the right heart and filtered out by the thin-walled arterioles that accompany the bronchioles. Here by causing necrosis of the vessel wall ova will usually pass out into the surrounding tissues, and thus form a tubercle in the wall of the bronchiole or of an alveolus, the egg constituting a necrotic centre to the tubercle and the reaction being strictly limited in area. These enclosed eggs are, then, rarely found in the sputum. In 6 bodies there was, besides tubercles, focal degeneration of the wall of the arteriole, accompanied by- an endothelial thickening obstructing the lumen; this thickening is vascular, and the effect of the obstruction is to cause dilatation of its contained capillaries into what the writers name an angiomatoid, together with hypertrophy of the muscular coat of the small arteries that lead up to it. Moreover there were 6 other persons, or 2 per cent. of all the cases, in whom, evidently as the result of intensive bombardment by ova, this arteriolar change was so widespread as to constitute Ayerza’s disease ; indeed it was atheroma of the accompanied by large pulmonary arteries and such hypertrophy of the right ventricle that its wall might be thicker than that of the left. In all 6 patients death was due to congestive failure of the heart, the formation of angiomatoids having failed to relieve the strain on the right ventricle sufficiently. In addition there were, as noted, 10 persons in whom adult worms (nearly always dead males) had formed emboli. Reticulo-endothelial response with giant cells and a pneumonic exudate resulted in the enclosure of a now calcified worm by a fibrous capsule. As Fairley has shown, embolism of this kind is seen in experimentally infected monkeys which not under treatment, and it will presumably occur when any worm which dies and gets loose a vein has a clear runway to the lungs. But the effects of Fouadin in killing some of the dirofilaria worms which live in the right ventricular cavity of the dog, and in loosing them as pulmonary emboli, raises the doubt whether this is not one of the complications that should be in mind in the treatment of schistosomiasis by this and perhaps other antimony compounds, in cases where worms are not in the are
in in
man
1 Shaw, A. F. B., and Ghareeb, A. A., J. Path. Bact. 1938, 46, 401.
salines, intra-
therapy has never achieved widespread popularity. Iron is apt to be very toxic administered by this route except in very small doses, and there is no justification for giving it in this way since it can be taken so safely and effectively by mouth. Intravenous calcium therapy undoubtedly has its uses. No one who has seen 1 g. of CaCl2 given intravenously to a case of post-operative tetany can forget the immediate relief of the patient. Intravenous calcium has been stated to be equally efficacious in lead colic and now its effects are being further explored. Lampson and Simeone have recently reported1 favourably upon the results of trials of intravenous CaC12 in renal and gall-stone colic, spasm of the bladder, and post-operative distension. This form of therapy clearly deserves further attention. It must not be used in patients who are taking digitalis and if the chloride is being administered the greatest care must be taken to ensure that the needle is snugly in the vein. Probably, however, the use of the gluconate would eliminate this difficulty. Treatment is safe enough in normal persons provided the subjective feelings of the patient are used to guide the rate of dosage. Sensations of heat are inevitable venous
mineral
but there should be no nausea and the administrator should remember that since there is a delay of several seconds between the injection and the onset of symptoms the drug must be given slowly and with
great
care.
CHEMICAL PROPHYLAXIS AGAINST POLIOMYELITIS
A YEAR ago we commented2 on the application of chemicals to the olfactory area of the nose as a method of prophylaxis against poliomyelitis, and alluded to the work of Schultz and Gebhardt3 who recommended the use of a 1 per cent. solution of zinc sulphate for this purpose. They now state4 that, to obtain protection, it is probably necessary that the solution should be applied thoroughly enough to induce a temporary anosmia and in order to maintain the resistance it should be reapplied as soon as the sense of smell returns. On the other hand, no one wants such a functional effect to be permanent. The superior meatus is usually narrower and deeper in adults than in children, and so tends to hold solutions for a longer time. Hence the application causes pain of greater severity and longer duration in adults. Similarly, though in children the sense of smell seems always to return within a few weeks, it may take much longer in adults ; indeed, Schultz and Gebhardt have learned of several adults in whom the sense of smell had not come back after more than six months. These considerations, together with their observations in monkeys that a rather severe exudative inflammation of the olfactory mucosa may be caused by the application, make them advise caution in its use until more is known about the
1 Lampson,
June, 1938,
R.
S., and Simeone, F. A., Surg· Gynec. Obstet.
p. 975.
3 Schultz, E. W.,
1937, 108, 2182.
2
Lancet, 1937, 2, 203. Gebhardt, L. P., J. Amer. med. Ass.
and
4 Ibid, June 11th, 1938, p. 2024.
mechanism of the protection given and about the inducing permanent anosmia. Though they
risk of
continuing their investigations on monkeys, they admit that the full answer to the problem cannot be obtained from experiments on animals, and they ask for the experiences of any doctors who have used the method. are
SCHISTOSOMIASIS OF THE LUNGS
ALTHOUGH it is nearly thirty years since G. A. Turner drew attention to pulmonary schistosomiasis in man and some twenty years since Hamilton Fairley confirmed its existence in man and produced it experimentally in the monkey, the condition has had little attention. Yet Shaw and Ghareeb,l examining 282 bodies of persons with schistosoma infection (homatobium and mansoni) in Egypt, find that in more than 2 per cent. death was directly due to the damage to the lungs caused by the parasites. Moreover, in a third of all these infected persons parasitic pulmonary emboli had caused lesions. In 10 of the 95 persons thus affected the emboli had been worms, but in the main they were eggs. This proportion fits in with the opinion that the female worm oviposits daily ; if the eggs are not held mechanically in the visceral vein in which oviposition takes place they may be carried through the right heart and filtered out by the thin-walled arterioles that accompany the bronchioles. Here by causing necrosis of the vessel wall ova will usually pass out into the surrounding tissues, and thus form a tubercle in the wall of the bronchiole or of an alveolus, the egg constituting a necrotic centre to the tubercle and the reaction being strictly limited in area. These enclosed eggs are, then, rarely found in the sputum. In 6 bodies there was, besides tubercles, focal degeneration of the wall of the arteriole, accompanied by- an endothelial thickening obstructing the lumen; this thickening is vascular, and the effect of the obstruction is to cause dilatation of its contained capillaries into what the writers name an angiomatoid, together with hypertrophy of the muscular coat of the small arteries that lead up to it. Moreover there were 6 other persons, or 2 per cent. of all the cases, in whom, evidently as the result of intensive bombardment by ova, this arteriolar change was so widespread as to constitute Ayerza’s disease ; indeed it was atheroma of the accompanied by large pulmonary arteries and such hypertrophy of the right ventricle that its wall might be thicker than that of the left. In all 6 patients death was due to congestive failure of the heart, the formation of angiomatoids having failed to relieve the strain on the right ventricle sufficiently. In addition there were, as noted, 10 persons in whom adult worms (nearly always dead males) had formed emboli. Reticulo-endothelial response with giant cells and a pneumonic exudate resulted in the enclosure of a now calcified worm by a fibrous capsule. As Fairley has shown, embolism of this kind is seen in experimentally infected monkeys which not under treatment, and it will presumably occur when any worm which dies and gets loose a vein has a clear runway to the lungs. But the effects of Fouadin in killing some of the dirofilaria worms which live in the right ventricular cavity of the dog, and in loosing them as pulmonary emboli, raises the doubt whether this is not one of the complications that should be in mind in the treatment of schistosomiasis by this and perhaps other antimony compounds, in cases where worms are not in the are
in in
man
1 Shaw, A. F. B., and Ghareeb, A. A., J. Path. Bact. 1938, 46, 401.