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CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS.
1774 when the heart was lifted forward with the right hand and rotated slightly to the left, the wound in the right auricle three-quarters of an inch above the auriculo-ventricular groove was seen. It was nearly half an inch long and with each beat a stream of dark blood spurted out. A suture of Number 0 chromicized catgut was passed on a curved intestinal needle ; the ends were left long at first in order to steady the heart, while three more similar sutures were inserted, and these completely controlled the haemorrhage. An attempt was made to avoid piercing the endocardium with the stitches, but the movements of the heart were so rapid that the operator was not certain whether they entered the cavity of the heart or not. The pericardium was emptied of blood and clot by means of the hand and a gauze sponge, and it was closed without drainage. The flap was replaced and an intravenous saline infusion was given. The operation lasted just over an hour and recovery followed. For the first week there were signs of a mild pleurisy, but these cleared up by the end of the second week. The patient left her bed on the seventeenth day and was discharged from the hospital 34 days after the operation. Dr. Peck discusses the details of the operation, and he expresses himself as in favour of the square flap with the binge externally. He gives a table of 159 cases classified according to the portion of the heart injured, and from this he shows that though most writers on heart wounds have considered wounds of the auricle to be more dangerous than those of the ventricle, yet the mortality of auricular wounds has been 363 per cent., while the general mortality of heart wounds is about 64 per cent. Dr. Peck’s case shows the value of rapid operation in heart wounds. From the great intrapericardial tension it seems to be practically certain that cessation of the beating of the heart would have occurred ’before long had not surgical intervention taken place.
A NEW FORM OF HUMAN TRYPANOSOMIASIS. IN the province of Minas Geraes, Brazil, a new form of human trypanosomiasis has been discovered by Dr. Carlo Chagas while engaged in organising anti-malarial measures for the protection of the labourers employed in constructing a new railway in that region. His attention was drawn to a ’large biting bug locally known as "barbeiro,"which, in,festing in large numbers the hovels of the poorer working class, remains hidden during the day time in the cracks of the walls or ceiling and issues forth at night when lights are extinguished to obtain its meal of blood from the occupants of the dwelling. This bug belongs to the Hemiptera heteroptera, family Reduvida3, genus Conorrhinus ; it is more than an inch in length and bites its human victim chiefly on In the hind gut of this insect Chagas found the face. numerous flagellates with the morphological characters of ’Crithidia. Some of these bugs were sent to Dr. Oswaldo Cruz, in whose laboratory they were allowed to bite monkeys, .and 20 or 30 days later in the blood of these animals were found numerous trypanosomes differing obviously from The parasite could also other members of the genus. be transmitted to guinea-pigs, rabbits, and dogs, in whose peripheral blood the trypanosomes were constantly found, at times in increasing numbers. The new parasite has been named by Dr. Chagas Schizotrypanum cruzi. An abstract of the discoverer’s original memoir has been recently published in the Sixteent7i Builetan (If the Sleeping Siokn688 Bureau, to which we are indebted for the following particulars. Dr. Chagas made search for the usual host of this new parasite and for this purpose he examined the human occupants of some of the bug-infested hovels. In the blood of some of these persons he found the trypanosomes, as also in a domestic cat. In some of the houses he found children suffering from an illness characterised by
anasmia, with delayed development, cedema general partial, enlargement of the peripheral glands and spleen, and functional disturbances, especially of the nervous system, with frequent occurrence of actual imbecility. No mention, however, is made of somnolence as a symptom ; in this particular the South American trypanosomiasis appears to differ from the African variety. The mortality among the children attacked seems to be great, the deaths being often attributed to convulsions." The local names of this malady-"opilacao or canguary" -are the same as are given to ankylostomiasis, which in many respects it resembles ; but Dr. Chagas excluded the latter disease from his cases by careful examination of the patients’ fasces. It is admitted that the course of this new disease is as yet only imperfectly known, and therefore more study of its clinical characters and progress is needed: From the blood of the patients experimental animals could be infected in the laboratory, and the parasites could also be cultivated- on artificial media outside the animal body. It is not contended that all the bugs in the hovels become infected, nor that all the bugs having flagellates in their extreme
or
"
"
"
"
hind gut can convey the disease to vertebrates. In a few instances the trypanosomes were found in the salivary glands of the insects, and it is therefore suggested that possibly only those bugs presenting this condition are capable of transmitting the disease. Dr. Chagas sums up the results of his laboratory investigations as follows : Schizotrypanum cruzi has in the organism of the Conorrhinus two methods of development-the first representing a simple culture of the parasite; the second, probably ushered in by sexual processes not yet observed, showing perhaps the cycle of development which occurs in the transmission from vertebrate to vertebrate. Conorrhinus is the true intermediate host of Schizotrypanum cruzi, the development cycle of which occupies a period of at least eight days. The in free of which occur the Crithidia living flagellates type, Conorrhinus, may be culture stages of the Schizotrypanum or exclusively insect parasites. The occurrence of the sexual cycle of development in the organism of Conorrhinus depends on states of the flagellates, in the blood of the vertebrates, as yet unelucidated. -
CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS.
i
THE Address- in Medicine delivered at the annual of the Canadian Medical Association by Dr. W. P. Herringham (the proceedings of which are rereported at p. 1787) was devoted to a practical clinical study of chronic diffuse parenchymatous nephritis, based upon his own experience of cases of this condition. The anatomy of this form of nephritis has been carefully studied by numerous observers, and it is generally recognised that various forms exist. In some fatty changes predominate, leading to the condition of "large white kidney,"while in others fibrous lesions are marked, leading to a " small white kidney," but perhaps the most common form is one in which both forms of change co-exist, constituting the fibro-fatty kidney. The pathology of these conditions is still obscure, since it is difficult to determine the part played by infection in their production, and the relation of the various forms to one another is still the subject of controSome authorities affirm that the small white versy. is kidney a later stage of the large white, while others, and among them Dr. Herringham,l consider that there is no evidence of this. One of the special dangers of an attack of nephritis to which Dr. Herringham paid special attention in his address is the vulnerability of the kidneys which it leaves behind as a sequel, rendering them especially liable
meeting
morbid
1
Text-book of Medical Practice.
1904, p. 443.
Edited
by William Bain. London,
1775 recurrence of the nephritis. He likened a patient with chronic Bright’s disease to a town of which the drainage was out of order. The diet in nephritis has been the subject of so much discussion on theoretical and experimental grounds that a statement of the results of clinical experience is of
to
special
value.
Dr.
Herringham,
while
urging
the
DERMOIDS AND THE RESULTS OF THEIR RUPTURE.
THE after-histories of cases in which cysts have ruptured into the peritoneum are always interesting. In the case of dermoid cysts the result would appear to depend generally upon whether there has been a leakage of the contents of the cyst or actual rupture with the escape of all or the greater portion of the contents into the peritoneal cavity. A most interesting case of the latter kind is recorded in this issue of In a single woman, 32 THE LANCET by Mr. R. H. Lucy. years of age, in whom the abdomen was distinctly distended and jutted on palpation, a diagnosis of a dermoid cyst was made. On opening the abdomen it was found that the cyst had ruptured and that the peritoneum was full of pultaceous material, of which some 11 pounds were scooped out. A large dermoid cyst, apparently of the right ovary, was removed, and probably also one of the left ovary, while a secondary implantation cyst was present attached to the parietal peritoneum, which presented a patch some 2t The inches in diameter, covered with black hair. abdomen was drained and the patient made a good The leakage of the tumour had probably recovery. existed for some 19 months before her admission to the hospital, although she herself was positive that the curious pitting of the abdomen had existed since puberty. As Mr. Lucy says, this case presents a most remarkable instance of the tolerance shown by a serous membrane to the presence Uf material foreign to its normal In a very interesting paper read before the secretion. Obstetrical Section of the Royal Society of Medicine Mr. T. W. P. Lawrence and Dr. Martin Randall’ recorded a case in which a puncture was made into an abdominal swelling which at the time, owing to the condition of the patient, it was impossible to remove. At a second operation, when the cyst was removed, several secondary cysts were found attached to, and growing in, the omentum. As the writers point out, when a dermoid cyst leaks a number of epithelial cells become scattered over the surface of the peritoneum, and from these cells small cysts develop. The second of case, of which Mr. Lucy’s is an instance, includes cases of large cysts which have burst and the contents have
in which in a woman 37 years of age, nine months after a fall from a cart, the abdomen was opened for an abdominal tumour, and no less than five litres of
and Dr. Randall, and in the discussion Dr. A. L. Galabin recorded a similar case, making with the present case a total of ten. Practically in all, except in Fraenkel’s patient already mentioned, the rupture occurred spontaneously, and there was no history of any injury indicating the time of the rupture, while in all the cases except that of Kolaczk the primary tumour was densely adherent. A most instructive case is that of Grawitz, in which at a necropsy a number of secondary implantation tumours were found in the abdomen, their walls consisting of fibrillated connective tissue, and so differing in structure from true dermoids. Mr. Lucy is to be congratulated on the successful result of his case, for in no less than five of seven of those operated upon a fatal result followed the operation. No doubt the case is one, as he says, of epithelial infection so-called, and. not an example of a malignant embryoma. A SPECIAL matinee on behalf of the National League for Education and Improvement, will be held at St. James’s Theatre, by kind permission of Mr. George Alexander, at 2.15 P.M. A number of dison Friday, July lst, tinguished actors and actresses have kindly promised to take part in the theatrical performances, and there will be a. display of physical drill by the students of Mme. Bergman Österberg’s College. Tickets may be obtained from the Secretary, National League for Physical Education and Improvement, 4, Tavistock-square, London, W.C., and the Box Office, St. James’s Theatre, King-street, S.W.
Physical
THE Cavendish lecture will be delivered before the West London Medico-Chirurgical Society by Sir Thomas Oliver at 8.15 P.M., in the Town Hall, on Friday, July lst, Kensington. The subject selected is, "Empyema and Some Problems Connected Therewith." .
COLONIAL MEDICAL SERVICES.—TFes African
lIIedical Staff.-Mr. H. Carlaw retires with gratuity. Dr. P. J. Kelly, medical officer, Gold Coast, has been transferred to Hong-Kong. The following promotions have been notified : Dr. M. C. Blair, senior medical officer, Northern Nigeria, to be Senior Sanitary Officer, Northern Nigeria ; Dr. R. H. Kennan, senior medical officer, Sierra Leone, to be Senior Sanitary Officer for Sierra Leone and the Gambia ; Mr. IN7. F. Macfarlane, medical officer, Southern Nigeria, to be Senior Medical Officer, Southern Nigeria ; and Mr. C. E. S. Watson, medical officer, Northern Nigeria, The retireto be senior medical officer, Northern Nigeria. ment of Mr. T. R. Frazer Toovey, medical officer, Southern Nigeria, has been cancelled. The following gentlemen have been appointed to the staff : Dr. J. A. Beamish (Gold Coast), Mr. C. W. S. Boggs (Gold Coast), Mr. D. T. H. (Gold Coast), Dr. D. Duff (Gold Coast), Dr. 1I. W. Fraser (Gold Coast), Mr. G. H. Gallagher (Southern Nigeria), Dr. S. Goodbrand (Gold Coast), Mr. J. E. Moffatt (Gold Coast), Mr. R. Mugliston (Gold Coast), Dr. W. A. Nicholson (Sierra Leone), and Dr. J. Y. Wood (Sierra Leone).-Other Colonies and ProP. Harper has been appointed a medical officer in Fiji; Mr. W. R. W. James, medical officer in. Uganda, has been appointed a medical officer in Ngamiland, Bechuanaland Protectorate; and Dr. J. C. McPherson has been appointed a supernumerary medical officer in the Leeward.
Croly
classtectorates I :-Mr.
T. W. P. Lawrence and Martin Randall: Society of Medicine, Obstetrical Section, vol. 1
ex.-
importance yellowish green fluid, containing fat, sebum, cholesterin, and epithelium, which had escaped from a ruptured dermoid cyst, were found in the peritoneum. Unfortunately, in this case the patient died from suppurative peritonitis. Of these most interesting cases eight were collected by Mr. Lawrence
of diet in the treatment of the disease, maintained that moderation in regard to quantity was of much greater importance than the elimination of certain articles from the diet list. He recommended ordinary diet, and did not restrict his patients to nah and certain special foods, but allowed them to partake of meat. In this he is in accord with the recommendations of von Noorden. There can be little doubt that undue and prolonged restriction of the dietary of patients with chronic parenchymatous nephritis is not beneficial and tends to aggravate the ansemia from which the patients are liable to suffer. In regard to treatment Dr. Herringham stated that the main object was to avoid the condition of uraemia by maintaining a fair excretion of urine. The treatment of haematuria and of oedema must often prove a difficult task. We shall await the full text of Dr. Herringham’s address with interest, for from the res2Ent.e we have received it was obviously an interesting practical contribution to the study of this complex disease. OVARIAN
escaped into the peritoneal cavity. A very good ample of this kind is that recorded by Fraenkel,
Proceedings of i., p. 105, 1908.
the
Royal
I
Islands.
A NEW FORM OF HUMAN TRYPANOSOMIASIS. IN the province of Minas Geraes, Brazil, a new form of human trypanosomiasis has been discovered by Dr. Carlo Chagas while engaged in organising anti-malarial measures for the protection of the labourers employed in constructing a new railway in that region. His attention was drawn to a ’large biting bug locally known as "barbeiro,"which, in,festing in large numbers the hovels of the poorer working class, remains hidden during the day time in the cracks of the walls or ceiling and issues forth at night when lights are extinguished to obtain its meal of blood from the occupants of the dwelling. This bug belongs to the Hemiptera heteroptera, family Reduvida3, genus Conorrhinus ; it is more than an inch in length and bites its human victim chiefly on In the hind gut of this insect Chagas found the face. numerous flagellates with the morphological characters of ’Crithidia. Some of these bugs were sent to Dr. Oswaldo Cruz, in whose laboratory they were allowed to bite monkeys, .and 20 or 30 days later in the blood of these animals were found numerous trypanosomes differing obviously from The parasite could also other members of the genus. be transmitted to guinea-pigs, rabbits, and dogs, in whose peripheral blood the trypanosomes were constantly found, at times in increasing numbers. The new parasite has been named by Dr. Chagas Schizotrypanum cruzi. An abstract of the discoverer’s original memoir has been recently published in the Sixteent7i Builetan (If the Sleeping Siokn688 Bureau, to which we are indebted for the following particulars. Dr. Chagas made search for the usual host of this new parasite and for this purpose he examined the human occupants of some of the bug-infested hovels. In the blood of some of these persons he found the trypanosomes, as also in a domestic cat. In some of the houses he found children suffering from an illness characterised by
anasmia, with delayed development, cedema general partial, enlargement of the peripheral glands and spleen, and functional disturbances, especially of the nervous system, with frequent occurrence of actual imbecility. No mention, however, is made of somnolence as a symptom ; in this particular the South American trypanosomiasis appears to differ from the African variety. The mortality among the children attacked seems to be great, the deaths being often attributed to convulsions." The local names of this malady-"opilacao or canguary" -are the same as are given to ankylostomiasis, which in many respects it resembles ; but Dr. Chagas excluded the latter disease from his cases by careful examination of the patients’ fasces. It is admitted that the course of this new disease is as yet only imperfectly known, and therefore more study of its clinical characters and progress is needed: From the blood of the patients experimental animals could be infected in the laboratory, and the parasites could also be cultivated- on artificial media outside the animal body. It is not contended that all the bugs in the hovels become infected, nor that all the bugs having flagellates in their extreme
or
"
"
"
"
hind gut can convey the disease to vertebrates. In a few instances the trypanosomes were found in the salivary glands of the insects, and it is therefore suggested that possibly only those bugs presenting this condition are capable of transmitting the disease. Dr. Chagas sums up the results of his laboratory investigations as follows : Schizotrypanum cruzi has in the organism of the Conorrhinus two methods of development-the first representing a simple culture of the parasite; the second, probably ushered in by sexual processes not yet observed, showing perhaps the cycle of development which occurs in the transmission from vertebrate to vertebrate. Conorrhinus is the true intermediate host of Schizotrypanum cruzi, the development cycle of which occupies a period of at least eight days. The in free of which occur the Crithidia living flagellates type, Conorrhinus, may be culture stages of the Schizotrypanum or exclusively insect parasites. The occurrence of the sexual cycle of development in the organism of Conorrhinus depends on states of the flagellates, in the blood of the vertebrates, as yet unelucidated. -
CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS.
i
THE Address- in Medicine delivered at the annual of the Canadian Medical Association by Dr. W. P. Herringham (the proceedings of which are rereported at p. 1787) was devoted to a practical clinical study of chronic diffuse parenchymatous nephritis, based upon his own experience of cases of this condition. The anatomy of this form of nephritis has been carefully studied by numerous observers, and it is generally recognised that various forms exist. In some fatty changes predominate, leading to the condition of "large white kidney,"while in others fibrous lesions are marked, leading to a " small white kidney," but perhaps the most common form is one in which both forms of change co-exist, constituting the fibro-fatty kidney. The pathology of these conditions is still obscure, since it is difficult to determine the part played by infection in their production, and the relation of the various forms to one another is still the subject of controSome authorities affirm that the small white versy. is kidney a later stage of the large white, while others, and among them Dr. Herringham,l consider that there is no evidence of this. One of the special dangers of an attack of nephritis to which Dr. Herringham paid special attention in his address is the vulnerability of the kidneys which it leaves behind as a sequel, rendering them especially liable
meeting
morbid
1
Text-book of Medical Practice.
1904, p. 443.
Edited
by William Bain. London,
1775 recurrence of the nephritis. He likened a patient with chronic Bright’s disease to a town of which the drainage was out of order. The diet in nephritis has been the subject of so much discussion on theoretical and experimental grounds that a statement of the results of clinical experience is of
to
special
value.
Dr.
Herringham,
while
urging
the
DERMOIDS AND THE RESULTS OF THEIR RUPTURE.
THE after-histories of cases in which cysts have ruptured into the peritoneum are always interesting. In the case of dermoid cysts the result would appear to depend generally upon whether there has been a leakage of the contents of the cyst or actual rupture with the escape of all or the greater portion of the contents into the peritoneal cavity. A most interesting case of the latter kind is recorded in this issue of In a single woman, 32 THE LANCET by Mr. R. H. Lucy. years of age, in whom the abdomen was distinctly distended and jutted on palpation, a diagnosis of a dermoid cyst was made. On opening the abdomen it was found that the cyst had ruptured and that the peritoneum was full of pultaceous material, of which some 11 pounds were scooped out. A large dermoid cyst, apparently of the right ovary, was removed, and probably also one of the left ovary, while a secondary implantation cyst was present attached to the parietal peritoneum, which presented a patch some 2t The inches in diameter, covered with black hair. abdomen was drained and the patient made a good The leakage of the tumour had probably recovery. existed for some 19 months before her admission to the hospital, although she herself was positive that the curious pitting of the abdomen had existed since puberty. As Mr. Lucy says, this case presents a most remarkable instance of the tolerance shown by a serous membrane to the presence Uf material foreign to its normal In a very interesting paper read before the secretion. Obstetrical Section of the Royal Society of Medicine Mr. T. W. P. Lawrence and Dr. Martin Randall’ recorded a case in which a puncture was made into an abdominal swelling which at the time, owing to the condition of the patient, it was impossible to remove. At a second operation, when the cyst was removed, several secondary cysts were found attached to, and growing in, the omentum. As the writers point out, when a dermoid cyst leaks a number of epithelial cells become scattered over the surface of the peritoneum, and from these cells small cysts develop. The second of case, of which Mr. Lucy’s is an instance, includes cases of large cysts which have burst and the contents have
in which in a woman 37 years of age, nine months after a fall from a cart, the abdomen was opened for an abdominal tumour, and no less than five litres of
and Dr. Randall, and in the discussion Dr. A. L. Galabin recorded a similar case, making with the present case a total of ten. Practically in all, except in Fraenkel’s patient already mentioned, the rupture occurred spontaneously, and there was no history of any injury indicating the time of the rupture, while in all the cases except that of Kolaczk the primary tumour was densely adherent. A most instructive case is that of Grawitz, in which at a necropsy a number of secondary implantation tumours were found in the abdomen, their walls consisting of fibrillated connective tissue, and so differing in structure from true dermoids. Mr. Lucy is to be congratulated on the successful result of his case, for in no less than five of seven of those operated upon a fatal result followed the operation. No doubt the case is one, as he says, of epithelial infection so-called, and. not an example of a malignant embryoma. A SPECIAL matinee on behalf of the National League for Education and Improvement, will be held at St. James’s Theatre, by kind permission of Mr. George Alexander, at 2.15 P.M. A number of dison Friday, July lst, tinguished actors and actresses have kindly promised to take part in the theatrical performances, and there will be a. display of physical drill by the students of Mme. Bergman Österberg’s College. Tickets may be obtained from the Secretary, National League for Physical Education and Improvement, 4, Tavistock-square, London, W.C., and the Box Office, St. James’s Theatre, King-street, S.W.
Physical
THE Cavendish lecture will be delivered before the West London Medico-Chirurgical Society by Sir Thomas Oliver at 8.15 P.M., in the Town Hall, on Friday, July lst, Kensington. The subject selected is, "Empyema and Some Problems Connected Therewith." .
COLONIAL MEDICAL SERVICES.—TFes African
lIIedical Staff.-Mr. H. Carlaw retires with gratuity. Dr. P. J. Kelly, medical officer, Gold Coast, has been transferred to Hong-Kong. The following promotions have been notified : Dr. M. C. Blair, senior medical officer, Northern Nigeria, to be Senior Sanitary Officer, Northern Nigeria ; Dr. R. H. Kennan, senior medical officer, Sierra Leone, to be Senior Sanitary Officer for Sierra Leone and the Gambia ; Mr. IN7. F. Macfarlane, medical officer, Southern Nigeria, to be Senior Medical Officer, Southern Nigeria ; and Mr. C. E. S. Watson, medical officer, Northern Nigeria, The retireto be senior medical officer, Northern Nigeria. ment of Mr. T. R. Frazer Toovey, medical officer, Southern Nigeria, has been cancelled. The following gentlemen have been appointed to the staff : Dr. J. A. Beamish (Gold Coast), Mr. C. W. S. Boggs (Gold Coast), Mr. D. T. H. (Gold Coast), Dr. D. Duff (Gold Coast), Dr. 1I. W. Fraser (Gold Coast), Mr. G. H. Gallagher (Southern Nigeria), Dr. S. Goodbrand (Gold Coast), Mr. J. E. Moffatt (Gold Coast), Mr. R. Mugliston (Gold Coast), Dr. W. A. Nicholson (Sierra Leone), and Dr. J. Y. Wood (Sierra Leone).-Other Colonies and ProP. Harper has been appointed a medical officer in Fiji; Mr. W. R. W. James, medical officer in. Uganda, has been appointed a medical officer in Ngamiland, Bechuanaland Protectorate; and Dr. J. C. McPherson has been appointed a supernumerary medical officer in the Leeward.
Croly
classtectorates I :-Mr.
T. W. P. Lawrence and Martin Randall: Society of Medicine, Obstetrical Section, vol. 1
ex.-
importance yellowish green fluid, containing fat, sebum, cholesterin, and epithelium, which had escaped from a ruptured dermoid cyst, were found in the peritoneum. Unfortunately, in this case the patient died from suppurative peritonitis. Of these most interesting cases eight were collected by Mr. Lawrence
of diet in the treatment of the disease, maintained that moderation in regard to quantity was of much greater importance than the elimination of certain articles from the diet list. He recommended ordinary diet, and did not restrict his patients to nah and certain special foods, but allowed them to partake of meat. In this he is in accord with the recommendations of von Noorden. There can be little doubt that undue and prolonged restriction of the dietary of patients with chronic parenchymatous nephritis is not beneficial and tends to aggravate the ansemia from which the patients are liable to suffer. In regard to treatment Dr. Herringham stated that the main object was to avoid the condition of uraemia by maintaining a fair excretion of urine. The treatment of haematuria and of oedema must often prove a difficult task. We shall await the full text of Dr. Herringham’s address with interest, for from the res2Ent.e we have received it was obviously an interesting practical contribution to the study of this complex disease. OVARIAN
escaped into the peritoneal cavity. A very good ample of this kind is that recorded by Fraenkel,
Proceedings of i., p. 105, 1908.
the
Royal
I
Islands.