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COPPER AND BRASS IN HOUSEHOLD WATER SERVICES.
1324 of clinical diagnosis it has been much neglected. The contents of the parotid duct may not always be sterile even in health, and a positive culture obtained from this duct is therefore not an infallible sign ofE pyogenic parotitis. But a pure culture of such aL genm as the Streptococcus viridans is undoubtedly of great diagnostic value, particularly if it is obtained on several occasions. The presence of pus cells in the catheter specimen is, in the authors’ opinion, almost pathognomonic of infection of the parotid gland. Their procedure is simple. The catheter can be easily extemporised with a piece of glass tubing, one end of, which is drawn out into a capillary tube about one millimetre in diameter, while the other end is fitted with a rubber aspirating bulb. It will often be sufficient to note whether or not the opening of the duct is inflamed and gaping, pus escaping from it when pressure is exerted on the duct and gland from without. In doubtful cases the introduction of the glass tube into the duct and the aspiration of a little of its contents for a bacteriological examination should materially help towards a correct diagnosis. The introduction of the tube is facilitated if the ampulla of the duct is inflamed. The authors conclude that failure to examine closely the parotid duct is responsible for the majority of errors. They recomthat in every swelling of the face and neck mend in the region of the ear a possibility of septic parotitis should be considered seriously and a careful examination of Stenson’s duct should be made. means
.
’
.
,
.
PARENCHYMATOUS KERATITIS. THE first of the monographs published in connexion with the British Journal of Ophthalmology, which are to be sold at a cheaper rate to subscribers to that publication, is an authoritative work on parenchymatous keratitis. Although the main facts about the disease and its dependence on congenital syphilis were established by Jonathan Hutchinson more than 60 years ago, there are several matters connected with it on which ophthalmologists are not even yet in complete agreement. Mr. Holmes Spicer has made a special study of the subject for many years and this monograph, based on an examination of nearly 700 cases, is an embodiment of his conclusions. It is universally acknowledged that the principal In this cause of the disease is congenital syphilis. series of cases either other signs of syphilis were present or a family history was obtained in 70 per cent. In the remainder there was no mention of family history or other signs, but this does not necessarily preclude the presence of syphilis. The teeth were typical or suggestive in 44 per cent. Acquired syphilis, to the exclusion of the congenital form, was found in 3-3 per cent. of the cases, more commonly in women than in men. With regard to tubercle its influence in producing typical interstitial keratitis is disputable, says the author. Mixed
infections,
of course, occur. The most original part of the essay concerns the various forms of corneal opacity which are characteristic of the disease. Several figures illustrate the subject. Specially noteworthy are those of striate opacities caused by the folding of the posterior surface of the cornea, and of the curious forms sometimes assumed by the deposits, formerly called keratitis punctata," but better " K.P.," which may be considered to stand for the more accurate With regard description, " keratic precipitates." to the age of onset, in 80 per cent. of Mr. Spicer’s cases it was between 5 and 25, but a first attack sometimes occurs both at an earlier and a later age. There were three cases of infantile syphilis in which definite interstitial keratitis was present at birth, and in one case a typical first attack occurred in a "
1 Parenchymatous Keratitis ; Interstitial Keratitis ; Uveitis Anterior. The Gifford Edmonds Prize in Ophthalmology. By W. T. Holmes Spicer. London : Geo. Pulman and Sons, Ltd. With 41 figures. Pp. 63. 5s.
of 40 with scars of old choroiditis, so that in all probability the spirochæte had been lying latent in the cornea for 40 years. The interval between the attack in one eye and its fellow was in three-quarters of the cases less than a year, but there were many cases with much longer intervals. Two per cent. showed an interval of more than five years. The longest interval recorded was 26 years. As to the relation between interstitial keratitis and injury, it has been maintained by Harrison Butler that this relation exists in as high a proportion as 20 per cent., an association which, if it could be established, would be of great importance in view of claims for compensation. A history of injury, however, can often be found if it is looked for, without the true relation being anything more than accidental, and Mr. Spicer agrees with most authorities in putting the true ratio in which an injury had an important influence in determining an attack in an eye predisposed to the disease at not more than about 3 per cent. With regard to relapses, they occurred in 9 per cent. of the cases, in one case as much as 30 years after the first attack, the probable cause being that the cornea was incompletely scavenged by leucocytes in the primary attack. A question of some interest is whether or not inherited syphilis confers immunity to the acquired disease. As a rule no doubt it does, but there are instances of patients with interstitial keratitis where it did not..According to our present knowledge, the Spirochœta pallida is the cause of the attack. Though it has not been found in the human cornea, it has been found experimentally in the cornea of monkeys. A certain number of cases occur, however, in which syphilis can be excluded. These cases are generally called by a different name‘’ keratitis profunda." They often occur in middleaged men addicted to alcohol; generally, only one eye is affected, and the disease runs a comparatively man
mild course. As to treatment, the author decidedly inclines to conservative methods. He even warns us against using too much atropine on the ground that atropine irritation is not infrequent. Injections with the arsenical compouncls he reserves for severe cases where there is much irritability of the eye and in which the general condition of the patient calls for it. The greatest importance is attached to measures calculated to improve the general health, for which reason a stay in hospital is often attended by the best possible results. In minimising the importance of direct anti-syphilitic treatment the writer runs counter to considerable recent opinion. COPPER AND BRASS IN HOUSEHOLD WATER SERVICES. EVERY householder from time to time has trouble with his water-supply. If the water is hard deposits form in the kettles and boilers and hot-water pipes ; if very soft the water may act upon the material of which the service pipes are constructed, the water may become tinted and discoloured by the iron taken up and deposited, or zinc or lead may be taken into solution, and in the latter case there is serious danger of injury to health. The Copper and Brass Extended Uses Council has recently issued a " Treatise " for the information of water authorities, engineers, architects, builders, plumbers, and all interested in houses and house construction, in which they assert that practically all these troubles can be avoided if copper and brass only are used in the interior water fittings, boilers, tanks, pipes, &c., and they also contend that the cost is only a little over that of lead, and only from 18 to 38 per cent. more than iron, and that when the upkeep is taken into consideration there is an actual economy in the use of copper. Their arguments are very specious, but are well worthy of consideration, especially in districts where soft moor-" land watersare used; but unfortunately the " Treatise has been compiled by an engineer and presents the case only from the engineering point of view. No
1325 chemist seems to havebeen consulted with reference to the action of water on such pipes, nor has the view of any medical authority been obtained on the aspect from the health point of view, a course which is suggested by their admission that acid moorland waters do act upon copper. Moreover, the few words said about the action of water on lead and copper revision by the chemist. It is stated that requires " Lead is itself easily oxidised, and the oxide in general forms a protective coating. It is the organic acids in the plumbo-solvent water which, dissolving the layer of lead oxide, subjects the metal to successive attacks. Copper corrodes little, and, so far as it does, the product is protective." These statements, to say the least, require confirmation, and unless they can be confirmed, which is doubtful, the evidence from the chemical and medical point of view has no value. The Council would be well advised to give this matter its serious attention, as the subject is one of very great importance. No reference is made to the use of tinned copper pipes, save to say that the tin used to line such pipes often contains lead. This used to be the case, but it is alleged that the difficulty of coating the copper with tin free from lead has been surmounted. If such is the case tinned pipes would appear to be preferable to copper. The use of copper alone, as suggested, does not appear to have as yet received any practical trial, and such a trial with waters of various types is absolutely essential before their use can be recommended with confidence.
French
investigators, which has appeared in a recent number of the Annales de l’Institut Pasteur. By the use of a special technique, which involves the employment of an acid-fixing solution, they have demonstrated the presence of small elongated or oval bodies, occurring in various parts of the nervous system, both accompanying and appearing independent of the Negri bodies, which they resemble in being usually intracellular, but in size arevery much smaller. The figured appearances of these " parasites " is very striking, as is also their similarity to the bodies described by Levaditi in the encephalitis of rabbits to which we have just alluded. The relationship of the newly described formations to the Negri bodies is not clear, the authors of the present paper considering the latter to consist of accumulated and degenerated masses of the smaller parasite. The parasites are also described as being present in the salivary glands. It is not possible to pronounce any definite opinion upon this interesting piece of work, but, whilst waiting for further results, it may be out that the newly described parasite does not in any way appear to resemble bodies figured by Noguchi in 1913, which he then claimed to have cultivated by the special technique associated with his name and suggested as the causal factor of rabies. It is also interesting to note that on that occasion the claim was associated with the then prominent investigations upon poliomyelitis, whilst the present one comes obviously in the train of the investigation of
pointed
encephalitis. MICROSPORIDIA AS THE CAUSE OF RABIES. THE setiological agent of rabies has been the subject of numerous researches, and several claimants are in the field without any one of them being generally accepted at the present time. The latest suggestion is that of Y. Manouelian and J. Viala,1 who describe a protozoon of the microsporidia genus in the tissues of affected subjects. The possibility of a protozoal parasite was long ago suggested, and the question whether the well-known Negri bodies, small corpuscular formations found within the cells of the nervous system, especially in the large cells of the hippocampal region, are to be looked upon as protozoa, which is the view of many authorities, or merely as post hoc degeneration products of the diseased cell, which is perhaps the more favoured view, has not yet been definitely settled. The findings of Manouelian and Viala undoubtedly have their origin in the disputes which have arisen over the causation of lethargic encephalitis. Discordant findings in the experimental investigation of this disease in rabbits has led to the of the existence of a spontaneous form of encephalitis in the rabbit, whose existence was first described in this country by F. W. Twort. C. Levaditi, whose positive results with human encephalitis material have been at variance with the results of C. Kling, H. Davide, and F. Liljenquist in Sweden, investigated the lesions in the rabbit’s brain in the spontaneous disease, and has described the formation of small spore-containing cysts of a parasite which he has named Encephalitozoon cuniculi. The step from these findings to the suggestion that a like cause may operate in so similar a disease as rabies is a short one, and such a suggestion was actually made by Levaditi soon after the description and figuring of the parasite we have just mentioned. He put forward the view that the Negri bodies are spore-containing cysts which represent only one phase in the lifehistory of a protozoal parasite of which the individual units are, at another stage, so minute as to be ultramicroscopic and filtrable. Failure adequately to observethe intimate structure of the Negri bodies is, in his opinion, due to the impermeability of the capsule to chromatin stains, a property which can modified by the use of acid fixatives. This suggestion has apparently borne fruit in the work of the two
____
THE STORY OF "SAY NINETY-NINE."
ON June 24th Sir William Hale-White, as President of the Royal Society of Medicine, and Lady HaleWhite received the guests at a social evening, given by the Society to welcome medical men from overseas After cordially greeting the overseas now in London. visitors the President proceeded to give a short address on the history of percussion and auscultation. He pointed out that nothing that doctors do has seized the popular imagination more than their habit of tapping the chest and listening to it with a stethoscope, to learn whether the sounds of breathing and of the heart are natural and whether the patient’s voice is properly conducted. In the " Mystery of Edwin Drood," Durdles, from tapping a slab, concludes that under it is an " old ’un crumbled away in a stone coffin." In Kipling’s ’’Marklake Witches " is a description of how Jerry listened with a wooden toy trumpet to Rene’s chest. Wendell Holmes relates what happened from using a stethoscope with a fly in it. The pages of Punch contain many pictures in which the stethoscope appears. By noting how his spoken voice is carried through the chest by a stethoscope to the trained ear a physician can obtain further evidence confirmatory of the percussion findings as to whether a patient’s chest contains air, solid, or fluid. Since the words " ninety-nine " are produced in the larynx they are most suitable for this purpose and this phrase has become very popular. There exist " Say Ninety-nine " cough lozenges, " Say " 1B’inety-nine stays and " Say Ninety-nine boots ; jokes about Say Ninety-nine " are common on the stage and in comic papers. Sir William Hale-White recalled the fact that Auenbrugger was the first, in a little Latin book containing only 7000 words, published in 1761, to teach what may be learned from percussing the chest. He recorded that the chest of a healthy person yields a note resembling the stifled sound of a drum covered with a thick cloth. He explained also how to strike it to obtain the best results, and discussed the varying note at different parts of the chest and the differences of note according as the chest contains air, solid, or fluid. Auenbrugger’s work remained unnoticed until in 1788 Corvisart began to practise the method and in 1808 published a translation of Auenbrugger’s book. Fortunately who was born at Quimper in 1781, studied Laennec, 1 Y. Manouelian and J. Viala: Encephalitozoon Rabei: parasite de la rage. Annales de l’Institut Pasteur, vol. xxxviii., under Corvisart and it was to him that the introduction of percussion in medicine was chiefly due. He lived No. 3, March, 1924.
discovery
be
I
.
’
.
,
.
PARENCHYMATOUS KERATITIS. THE first of the monographs published in connexion with the British Journal of Ophthalmology, which are to be sold at a cheaper rate to subscribers to that publication, is an authoritative work on parenchymatous keratitis. Although the main facts about the disease and its dependence on congenital syphilis were established by Jonathan Hutchinson more than 60 years ago, there are several matters connected with it on which ophthalmologists are not even yet in complete agreement. Mr. Holmes Spicer has made a special study of the subject for many years and this monograph, based on an examination of nearly 700 cases, is an embodiment of his conclusions. It is universally acknowledged that the principal In this cause of the disease is congenital syphilis. series of cases either other signs of syphilis were present or a family history was obtained in 70 per cent. In the remainder there was no mention of family history or other signs, but this does not necessarily preclude the presence of syphilis. The teeth were typical or suggestive in 44 per cent. Acquired syphilis, to the exclusion of the congenital form, was found in 3-3 per cent. of the cases, more commonly in women than in men. With regard to tubercle its influence in producing typical interstitial keratitis is disputable, says the author. Mixed
infections,
of course, occur. The most original part of the essay concerns the various forms of corneal opacity which are characteristic of the disease. Several figures illustrate the subject. Specially noteworthy are those of striate opacities caused by the folding of the posterior surface of the cornea, and of the curious forms sometimes assumed by the deposits, formerly called keratitis punctata," but better " K.P.," which may be considered to stand for the more accurate With regard description, " keratic precipitates." to the age of onset, in 80 per cent. of Mr. Spicer’s cases it was between 5 and 25, but a first attack sometimes occurs both at an earlier and a later age. There were three cases of infantile syphilis in which definite interstitial keratitis was present at birth, and in one case a typical first attack occurred in a "
1 Parenchymatous Keratitis ; Interstitial Keratitis ; Uveitis Anterior. The Gifford Edmonds Prize in Ophthalmology. By W. T. Holmes Spicer. London : Geo. Pulman and Sons, Ltd. With 41 figures. Pp. 63. 5s.
of 40 with scars of old choroiditis, so that in all probability the spirochæte had been lying latent in the cornea for 40 years. The interval between the attack in one eye and its fellow was in three-quarters of the cases less than a year, but there were many cases with much longer intervals. Two per cent. showed an interval of more than five years. The longest interval recorded was 26 years. As to the relation between interstitial keratitis and injury, it has been maintained by Harrison Butler that this relation exists in as high a proportion as 20 per cent., an association which, if it could be established, would be of great importance in view of claims for compensation. A history of injury, however, can often be found if it is looked for, without the true relation being anything more than accidental, and Mr. Spicer agrees with most authorities in putting the true ratio in which an injury had an important influence in determining an attack in an eye predisposed to the disease at not more than about 3 per cent. With regard to relapses, they occurred in 9 per cent. of the cases, in one case as much as 30 years after the first attack, the probable cause being that the cornea was incompletely scavenged by leucocytes in the primary attack. A question of some interest is whether or not inherited syphilis confers immunity to the acquired disease. As a rule no doubt it does, but there are instances of patients with interstitial keratitis where it did not..According to our present knowledge, the Spirochœta pallida is the cause of the attack. Though it has not been found in the human cornea, it has been found experimentally in the cornea of monkeys. A certain number of cases occur, however, in which syphilis can be excluded. These cases are generally called by a different name‘’ keratitis profunda." They often occur in middleaged men addicted to alcohol; generally, only one eye is affected, and the disease runs a comparatively man
mild course. As to treatment, the author decidedly inclines to conservative methods. He even warns us against using too much atropine on the ground that atropine irritation is not infrequent. Injections with the arsenical compouncls he reserves for severe cases where there is much irritability of the eye and in which the general condition of the patient calls for it. The greatest importance is attached to measures calculated to improve the general health, for which reason a stay in hospital is often attended by the best possible results. In minimising the importance of direct anti-syphilitic treatment the writer runs counter to considerable recent opinion. COPPER AND BRASS IN HOUSEHOLD WATER SERVICES. EVERY householder from time to time has trouble with his water-supply. If the water is hard deposits form in the kettles and boilers and hot-water pipes ; if very soft the water may act upon the material of which the service pipes are constructed, the water may become tinted and discoloured by the iron taken up and deposited, or zinc or lead may be taken into solution, and in the latter case there is serious danger of injury to health. The Copper and Brass Extended Uses Council has recently issued a " Treatise " for the information of water authorities, engineers, architects, builders, plumbers, and all interested in houses and house construction, in which they assert that practically all these troubles can be avoided if copper and brass only are used in the interior water fittings, boilers, tanks, pipes, &c., and they also contend that the cost is only a little over that of lead, and only from 18 to 38 per cent. more than iron, and that when the upkeep is taken into consideration there is an actual economy in the use of copper. Their arguments are very specious, but are well worthy of consideration, especially in districts where soft moor-" land watersare used; but unfortunately the " Treatise has been compiled by an engineer and presents the case only from the engineering point of view. No
1325 chemist seems to havebeen consulted with reference to the action of water on such pipes, nor has the view of any medical authority been obtained on the aspect from the health point of view, a course which is suggested by their admission that acid moorland waters do act upon copper. Moreover, the few words said about the action of water on lead and copper revision by the chemist. It is stated that requires " Lead is itself easily oxidised, and the oxide in general forms a protective coating. It is the organic acids in the plumbo-solvent water which, dissolving the layer of lead oxide, subjects the metal to successive attacks. Copper corrodes little, and, so far as it does, the product is protective." These statements, to say the least, require confirmation, and unless they can be confirmed, which is doubtful, the evidence from the chemical and medical point of view has no value. The Council would be well advised to give this matter its serious attention, as the subject is one of very great importance. No reference is made to the use of tinned copper pipes, save to say that the tin used to line such pipes often contains lead. This used to be the case, but it is alleged that the difficulty of coating the copper with tin free from lead has been surmounted. If such is the case tinned pipes would appear to be preferable to copper. The use of copper alone, as suggested, does not appear to have as yet received any practical trial, and such a trial with waters of various types is absolutely essential before their use can be recommended with confidence.
French
investigators, which has appeared in a recent number of the Annales de l’Institut Pasteur. By the use of a special technique, which involves the employment of an acid-fixing solution, they have demonstrated the presence of small elongated or oval bodies, occurring in various parts of the nervous system, both accompanying and appearing independent of the Negri bodies, which they resemble in being usually intracellular, but in size arevery much smaller. The figured appearances of these " parasites " is very striking, as is also their similarity to the bodies described by Levaditi in the encephalitis of rabbits to which we have just alluded. The relationship of the newly described formations to the Negri bodies is not clear, the authors of the present paper considering the latter to consist of accumulated and degenerated masses of the smaller parasite. The parasites are also described as being present in the salivary glands. It is not possible to pronounce any definite opinion upon this interesting piece of work, but, whilst waiting for further results, it may be out that the newly described parasite does not in any way appear to resemble bodies figured by Noguchi in 1913, which he then claimed to have cultivated by the special technique associated with his name and suggested as the causal factor of rabies. It is also interesting to note that on that occasion the claim was associated with the then prominent investigations upon poliomyelitis, whilst the present one comes obviously in the train of the investigation of
pointed
encephalitis. MICROSPORIDIA AS THE CAUSE OF RABIES. THE setiological agent of rabies has been the subject of numerous researches, and several claimants are in the field without any one of them being generally accepted at the present time. The latest suggestion is that of Y. Manouelian and J. Viala,1 who describe a protozoon of the microsporidia genus in the tissues of affected subjects. The possibility of a protozoal parasite was long ago suggested, and the question whether the well-known Negri bodies, small corpuscular formations found within the cells of the nervous system, especially in the large cells of the hippocampal region, are to be looked upon as protozoa, which is the view of many authorities, or merely as post hoc degeneration products of the diseased cell, which is perhaps the more favoured view, has not yet been definitely settled. The findings of Manouelian and Viala undoubtedly have their origin in the disputes which have arisen over the causation of lethargic encephalitis. Discordant findings in the experimental investigation of this disease in rabbits has led to the of the existence of a spontaneous form of encephalitis in the rabbit, whose existence was first described in this country by F. W. Twort. C. Levaditi, whose positive results with human encephalitis material have been at variance with the results of C. Kling, H. Davide, and F. Liljenquist in Sweden, investigated the lesions in the rabbit’s brain in the spontaneous disease, and has described the formation of small spore-containing cysts of a parasite which he has named Encephalitozoon cuniculi. The step from these findings to the suggestion that a like cause may operate in so similar a disease as rabies is a short one, and such a suggestion was actually made by Levaditi soon after the description and figuring of the parasite we have just mentioned. He put forward the view that the Negri bodies are spore-containing cysts which represent only one phase in the lifehistory of a protozoal parasite of which the individual units are, at another stage, so minute as to be ultramicroscopic and filtrable. Failure adequately to observethe intimate structure of the Negri bodies is, in his opinion, due to the impermeability of the capsule to chromatin stains, a property which can modified by the use of acid fixatives. This suggestion has apparently borne fruit in the work of the two
____
THE STORY OF "SAY NINETY-NINE."
ON June 24th Sir William Hale-White, as President of the Royal Society of Medicine, and Lady HaleWhite received the guests at a social evening, given by the Society to welcome medical men from overseas After cordially greeting the overseas now in London. visitors the President proceeded to give a short address on the history of percussion and auscultation. He pointed out that nothing that doctors do has seized the popular imagination more than their habit of tapping the chest and listening to it with a stethoscope, to learn whether the sounds of breathing and of the heart are natural and whether the patient’s voice is properly conducted. In the " Mystery of Edwin Drood," Durdles, from tapping a slab, concludes that under it is an " old ’un crumbled away in a stone coffin." In Kipling’s ’’Marklake Witches " is a description of how Jerry listened with a wooden toy trumpet to Rene’s chest. Wendell Holmes relates what happened from using a stethoscope with a fly in it. The pages of Punch contain many pictures in which the stethoscope appears. By noting how his spoken voice is carried through the chest by a stethoscope to the trained ear a physician can obtain further evidence confirmatory of the percussion findings as to whether a patient’s chest contains air, solid, or fluid. Since the words " ninety-nine " are produced in the larynx they are most suitable for this purpose and this phrase has become very popular. There exist " Say Ninety-nine " cough lozenges, " Say " 1B’inety-nine stays and " Say Ninety-nine boots ; jokes about Say Ninety-nine " are common on the stage and in comic papers. Sir William Hale-White recalled the fact that Auenbrugger was the first, in a little Latin book containing only 7000 words, published in 1761, to teach what may be learned from percussing the chest. He recorded that the chest of a healthy person yields a note resembling the stifled sound of a drum covered with a thick cloth. He explained also how to strike it to obtain the best results, and discussed the varying note at different parts of the chest and the differences of note according as the chest contains air, solid, or fluid. Auenbrugger’s work remained unnoticed until in 1788 Corvisart began to practise the method and in 1808 published a translation of Auenbrugger’s book. Fortunately who was born at Quimper in 1781, studied Laennec, 1 Y. Manouelian and J. Viala: Encephalitozoon Rabei: parasite de la rage. Annales de l’Institut Pasteur, vol. xxxviii., under Corvisart and it was to him that the introduction of percussion in medicine was chiefly due. He lived No. 3, March, 1924.
discovery
be
I