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HÆMOPHILIA TRANSMITTED THROUGH THE MALE.
1385
difficulty of in erting the sutures. The bowels are not are two distinct ungual phatangts, ehch bearing a nail. There naturally sensitive and therefore no discomfort was felt from are two joints which allow of a certain amount of movement, he being able to pick up small articles with the two their handling. The method of opening the peritoneal cavity on the "thumbs." The first phalanx is double as far as the base in the where it articulates with the metacarpal bone in the ordinary proximal side of the hernial sac as an early step has often way. The interspace is filled in by a web. (Fig. 1.) It seems hernia relief of the for strangulated operation shafts of the phalanx have been developed from proved of service to me. In this case it shortened the dura- that the two tion of the operation, a matter of considerable importance separate centres and that the base has only had one centre, when the anesthetic is local and when the general condition FIG. 2. of the patient is bad. The whole procedure only took 35 minutes. In inguinal as well as in femoral hernia this method enables the bowel both above, below, and also at the site of the stricture to be inspected thoroughly, just as it lies, without pulling down of the constricted part and so running the risk of tearing the softened coats. In inguinal hernia there is no difficulty in opening the peritoneal cavity on the proximal side of the neck of the sac, but in femoral hernia the sac is so surrounded by important structures that at earlier operations I could not see any way of following out this principle in cases where it appeared necessary. However, in working at the anatomy of the part I saw that Poupart’s ligament could easily be raised from the femoral vessels and space obtained towards the outer side of the femoral canal. The deep epigastric vessels may require division and the vas may need to be drawn aside. Enough room may be obtained in this way to get the hand into the abdominal cavity if necessary. In femoral hernia it is the narrowness of the neck of the sac which causes the constriction and not Gimbernat’s ligament, which has so often been blamed. By incising the neck of the sac on the outer side, this ligament, which is as a fact an expansion of the inner attached end of Poupart’s ligament, is spared and an almost perfect repair is made possible. In a case of Richter’s hernia I was able by this method of entering the peritoneal cavity to find the piece of bowel in which a small patch of the wall had sloughed, thus avoiding the necessity of dividing Poupart’s ligament. This patient, whom Dr. R B. Lorraine and Dr. D. C. Welsh had asked me to see, made a good recovery-a rare event with this variety of hernia. Newcastle-on-Tyne. _____________
there does not appear to be any sign showing two centres which have subsequently become fused. (Fig. 2.) The condition causes the man no inconvenience and he has no other abnormality. There are no means of finding out at what period of the mother’s pregnancy the incident took as
place. HÆMOPHILIA TRANSMITTED THROUGH THE MALE. BY A. J.
Clinical Notes :
THE
SWANTON, L.R.C.P.&S.IREL.
note of a hsemophilic family that has under my notice presents an example of an unusual method of transmission in this disease. It arose THERAPEUTICAL de novo in S. P., in whose parentage or ancestry no history of it could be traced; he suffered from severe haemorrhage from the most trivial cut and also from epistaxis. He had 13 THE THUMB. OF A CASE OF MALFORMATION children, all of whom were free from the affection with the BY BRYAN PICK, M.R.C.S. ENG., L.R.C.P. LOND., exception of one son, J. P., who was a 1, bleeder" from SURGEON, R.N. infancy ; it is a pious opinion in his family that this fact was due to the father, who was suffering from a brisk epistaxis, THE following malformation came under notice quite rushed home and frightened his wife who was then having recently in a case in which a very curious history was given. of the son, J. P. I had no personal knowledge of The man states that before he was born his mother was bitten S. but know the son, who is now over 40 years of P.’s case, by a crab. The left thumb is not unlike a crab’s claw. There age, and his family, which consists of six girls and one boy, age from two months to 19 years, all of whom FiG[. 1. show symptoms of bsemophilia except one girl aged eight years. Four have died, two boys at eight months and four years respectively, from " convulsions." said to have been due to epistaxis, and one boy, aged ten months, and a girl, aged two years and eight months, from pneumonia following measles accompanied by severe epistaxis and bleeding from the mouth. The disease in J. P. chiefly takes the form of spontaneous epistaxis which is difficult to control and is preceded by malaise and headache. He also suffers from painful swelling of his large joints. All the children look healthy ; they have very soft white skin and fair hair. The only surviving son suffers frequently from epistaxis, which is most alarming in its persistence. It is preceded, for a few days, by an elevated temperature with frontal headache, faintness, loss of appetite, and pain in the back. The elbows, wrists, knees, and ankles are swollen and very painful. With the onset of bleeding he perspires freely. Any form of traumatic bleeding is only controlled with the greatest difficulty. He also bleeds per anum when suffering from diarrhoe-t,. A baby (girl), aged two months, has been subject to attacks of epistaxis from birth. The two girls, aged five years and 14 years respectively, suffer from troublesome attacks of bleeding, the chief form being epistaxis, and from the
MEDICAL, SURGICAL, OBSTETRICAL,
following
AND recently come
pregnant
varying in
Tr4
1386 mouth to a less extent, receded by a general feverish condi- endocarditis,
accompanieq.
and
pericarditis
were
the most fatal.
Peri-
tion and by swollen and painful joints. carditis in a bad case of pneumonia was a difficult thing to Traumatic bleeding in their case is also very persistent. The diagnose and was often unsuspected ; it should be most care-
remaining two daughters, aged
17 years and 19 years respecand serious epistaxis as well as oozing of blood iroca the gums around decayed teeth. For some days previously to the onset they complain of frontal headache, feeling languid and faint, loss of appetite, and pains in the back. The joints become swollen and painful ; the knees, ank’es, and wrists are those principally involved. Perspiration starts with the bleeding, steam actually rising from their bodies. The loss of blood leaves them very weak, anasmic, and short of breath, but they seem rapidly to regain their health and strength again until another attack lays them prostrate. Menstruation is excessive in both cases and haemorrhage from a cut or wound is extremely resistant to treatment. The mother of these children has told me she is kept constantly busy washing blood-stained cloths as it rarely happens for even a few days to pass without some member of her household bleeding. There can be no doubt that the disposition has been transmitted throughI the male line, the mothers of the two families having I no history whatever of any tendency from either side to this affection. When the patients have come under treatment the usual remedies have been tried with varying success, such as ergot, tinctura ferri perchloridi and calcium chloride internally, I am adrenalin externally, with rest and compression. rather anxious to know if there is any recognised form of treatment which would tend to counteract this tendency to abnormal bleeding. The comparative rarity of these cases, together with the sense of helplessness in regard to treatment which confronts the ordinary practitioner, are my reasons for bringing them under notice. Attercliffe, Sheffield.
tively, are subject
to very
frequent
Medical Societies. ROYAL SOCIETY OF MEDICINE. MEDICAL SECTION. Oomplioations of Pne?lmonia. A MEETING of this section was held on Nov. 5th, Dr. S. J. GEE, the President, being in the chair. Dr. W. J. HADLEY, in reopening the adjourned discussion on the Complications of Pneumonia, said that the statistics supplied by the medical registrars of the London Hospital referred to the last ten years, and they must remember that those figures came from the working classes and he thought that they would differ in many ways from those collected from the well-to-do. In the first place it was noticeable that pneumonia was three times as common in the male as in the female. That difference held in all the returns except where children were concerned (East London Hospital for Children) where the figures stood at 443 males to 316 females. Secondly, the figures showed that mortality increased with age from about 5 per cent. to 49 per cent. Thirdly, it was seen that the mortality was rather higher in females than in males, males being 23-21 per cent, and females 25’45 per cent. In considering complications, it was most important to separate antecedent conditions from those which resulted from the disease itself. Many antecedent conditions considerably influenced the mortality. With alcohol as an antecedent condition the death-rate was 66· 66 per cent. out of 105 cases. With cardio vascular disease (including aneurysm) as an antecedent the death-rate was 46 ’ 14 per cent. out of 91 cases. In the case of chronic nephritis it was 82 6 per cent. out of 23 cases, and with chronic pulmonary troubles as an antecedent condition the death-rate was 31’ 64 per cent. out In many of those cases the death of 79 cases. was not due to the pneumonia at all but to the original disease, whilst in others it was simply a modus moriendi, At the same time it was most important to remember the greatly increased danger of pneumonia occurring in the Of complications as a course of some chronic diseases. result of pneumonia itself empyema, delirium, and pericarditis were the most important, and gangrene, abscess,
fully watched for, as there was but little chance for the patient unless the pericarditis was opened and drained. It should be noted that, especially in the young, a pericardium distended
with fluid pushed directly backwards and gave rise to marked dulness at the leftbase posteriorly simulating consolidation or fluid of the left lung and showed very little in front unless carefully searched for, when the displaced apex beat, hidden heart, and muffled sounds could generally be made out. In regard to abscess as a complication of pneumonia it was frequently an interlobar empyema. Concerning meningitis it must be borne in mind that meningeal symptoms were often present as a result of toxasmia. without any meningitis. Retraction, headache, vomiting, irregularity of pupils, squint, fits, and twitchings might be observed, and he had seen the mastoids explored in such circumstances. Referring to peritonitis and colitis complicating pneumonia, Dr. Hadley said that abdominal pneumonia" was a condition which they must recognise. They were quite familiar with the case admitted as appendicitis which after or before operation was transferred to the medical side as a pneumonia. They had probably all read the accounts of outbreaks of pneumonia in an institution where it was noticeable that many of the cases were purely abdominal, resembling enteric fever. He had seen an epidemic in a country village where nearly half the cases were abdominal, resembling enteric fever but of shorter duration, and several occurring in the same house, some being abdominal and others pulmonary. Sometimes acute paralytic distension of the stomach occurred which was apparently toxic, but it was often seen in lesser degree in the intestines, especially the colon. He knew nothing which embarrassed the heart so much in pneumonia and it was most important to get rid of it by enemas or by using a long tube. He had left the tube in sometimes as the condition recurred so frequently. Gentle massage would often enable the patients to pass the ilatua through the tube readily. In regard to arthritis as a complication of pneumonia, he noted that most of the cases were in patients younger than ten years of age. The treatment by inoculations was hindered by the difficulty of getting cultures. The acuteness of the disease made it hard to get vaccine before the crisis occurred and many cases were admitted to hospital only a short time before the crisis. In his opinion the more chronic complications would give the best chance for inoculations such as arthritis and empyema. Pneumonia, rheumatism, and tubercle formed a group of which it could be said that one attack appeared to predispose to subsequent ones. With such a characteristic how could they expect a preventive inoculation; at any rate the immunity must be very short-lived. Dr. N. DALTON considered that when lysis was observed it could be explained by the fact that there was some latent complication or some secondary infection interfering with the ordinary course of the pneumonia. With reference to dilatation of the stomach he did not think that it was an uncommon
complication.
that the complications of in childhood than in adult life and the death-rate in children from complications was higher than in adults. In children under the age of one year it was found that there was great mortality from the toxoamia of pneumonia. In children a’large number of cases occurred of primary pneumococcic empyema. Dr. A. C. LATHAM said that, judging from the monthly returns made at St. George’s Hospital, the maximum incidence of pneumonia was in May and in October. About May people were prone to take to their thin clothes too soon and about October people sometimes failed to take to their warmer clothing soon enough. He had been told that the Bulawayo hospital statistics showed that in the rainy season the beds were full of cases of malaria and in the cold season the hospital was crowded with cases of pneumonia. In regard to the knee-jerk in pneumonia, out of 120 cases investigated it was present in 90, and it was sluggish or absent in the remaining bO. Referring to the treatment of pneumonia by antidiphtheritic serum he said that it had been tried in severe cases where the prognosis was grave and in no case in which the serum had been given had the temperature reached the point where it stood before the introduction of the serum. Dr. J. FAWCETT stated that the Guy’s Hospital cases did not include " terminalpneumonias and that probably accounted for the fact that the mortality-ratio was only 15 - 6 per cent. ;
Dr. A. M. GOSSAGE
pneumonia were
more
thought
important
difficulty of in erting the sutures. The bowels are not are two distinct ungual phatangts, ehch bearing a nail. There naturally sensitive and therefore no discomfort was felt from are two joints which allow of a certain amount of movement, he being able to pick up small articles with the two their handling. The method of opening the peritoneal cavity on the "thumbs." The first phalanx is double as far as the base in the where it articulates with the metacarpal bone in the ordinary proximal side of the hernial sac as an early step has often way. The interspace is filled in by a web. (Fig. 1.) It seems hernia relief of the for strangulated operation shafts of the phalanx have been developed from proved of service to me. In this case it shortened the dura- that the two tion of the operation, a matter of considerable importance separate centres and that the base has only had one centre, when the anesthetic is local and when the general condition FIG. 2. of the patient is bad. The whole procedure only took 35 minutes. In inguinal as well as in femoral hernia this method enables the bowel both above, below, and also at the site of the stricture to be inspected thoroughly, just as it lies, without pulling down of the constricted part and so running the risk of tearing the softened coats. In inguinal hernia there is no difficulty in opening the peritoneal cavity on the proximal side of the neck of the sac, but in femoral hernia the sac is so surrounded by important structures that at earlier operations I could not see any way of following out this principle in cases where it appeared necessary. However, in working at the anatomy of the part I saw that Poupart’s ligament could easily be raised from the femoral vessels and space obtained towards the outer side of the femoral canal. The deep epigastric vessels may require division and the vas may need to be drawn aside. Enough room may be obtained in this way to get the hand into the abdominal cavity if necessary. In femoral hernia it is the narrowness of the neck of the sac which causes the constriction and not Gimbernat’s ligament, which has so often been blamed. By incising the neck of the sac on the outer side, this ligament, which is as a fact an expansion of the inner attached end of Poupart’s ligament, is spared and an almost perfect repair is made possible. In a case of Richter’s hernia I was able by this method of entering the peritoneal cavity to find the piece of bowel in which a small patch of the wall had sloughed, thus avoiding the necessity of dividing Poupart’s ligament. This patient, whom Dr. R B. Lorraine and Dr. D. C. Welsh had asked me to see, made a good recovery-a rare event with this variety of hernia. Newcastle-on-Tyne. _____________
there does not appear to be any sign showing two centres which have subsequently become fused. (Fig. 2.) The condition causes the man no inconvenience and he has no other abnormality. There are no means of finding out at what period of the mother’s pregnancy the incident took as
place. HÆMOPHILIA TRANSMITTED THROUGH THE MALE. BY A. J.
Clinical Notes :
THE
SWANTON, L.R.C.P.&S.IREL.
note of a hsemophilic family that has under my notice presents an example of an unusual method of transmission in this disease. It arose THERAPEUTICAL de novo in S. P., in whose parentage or ancestry no history of it could be traced; he suffered from severe haemorrhage from the most trivial cut and also from epistaxis. He had 13 THE THUMB. OF A CASE OF MALFORMATION children, all of whom were free from the affection with the BY BRYAN PICK, M.R.C.S. ENG., L.R.C.P. LOND., exception of one son, J. P., who was a 1, bleeder" from SURGEON, R.N. infancy ; it is a pious opinion in his family that this fact was due to the father, who was suffering from a brisk epistaxis, THE following malformation came under notice quite rushed home and frightened his wife who was then having recently in a case in which a very curious history was given. of the son, J. P. I had no personal knowledge of The man states that before he was born his mother was bitten S. but know the son, who is now over 40 years of P.’s case, by a crab. The left thumb is not unlike a crab’s claw. There age, and his family, which consists of six girls and one boy, age from two months to 19 years, all of whom FiG[. 1. show symptoms of bsemophilia except one girl aged eight years. Four have died, two boys at eight months and four years respectively, from " convulsions." said to have been due to epistaxis, and one boy, aged ten months, and a girl, aged two years and eight months, from pneumonia following measles accompanied by severe epistaxis and bleeding from the mouth. The disease in J. P. chiefly takes the form of spontaneous epistaxis which is difficult to control and is preceded by malaise and headache. He also suffers from painful swelling of his large joints. All the children look healthy ; they have very soft white skin and fair hair. The only surviving son suffers frequently from epistaxis, which is most alarming in its persistence. It is preceded, for a few days, by an elevated temperature with frontal headache, faintness, loss of appetite, and pain in the back. The elbows, wrists, knees, and ankles are swollen and very painful. With the onset of bleeding he perspires freely. Any form of traumatic bleeding is only controlled with the greatest difficulty. He also bleeds per anum when suffering from diarrhoe-t,. A baby (girl), aged two months, has been subject to attacks of epistaxis from birth. The two girls, aged five years and 14 years respectively, suffer from troublesome attacks of bleeding, the chief form being epistaxis, and from the
MEDICAL, SURGICAL, OBSTETRICAL,
following
AND recently come
pregnant
varying in
Tr4
1386 mouth to a less extent, receded by a general feverish condi- endocarditis,
accompanieq.
and
pericarditis
were
the most fatal.
Peri-
tion and by swollen and painful joints. carditis in a bad case of pneumonia was a difficult thing to Traumatic bleeding in their case is also very persistent. The diagnose and was often unsuspected ; it should be most care-
remaining two daughters, aged
17 years and 19 years respecand serious epistaxis as well as oozing of blood iroca the gums around decayed teeth. For some days previously to the onset they complain of frontal headache, feeling languid and faint, loss of appetite, and pains in the back. The joints become swollen and painful ; the knees, ank’es, and wrists are those principally involved. Perspiration starts with the bleeding, steam actually rising from their bodies. The loss of blood leaves them very weak, anasmic, and short of breath, but they seem rapidly to regain their health and strength again until another attack lays them prostrate. Menstruation is excessive in both cases and haemorrhage from a cut or wound is extremely resistant to treatment. The mother of these children has told me she is kept constantly busy washing blood-stained cloths as it rarely happens for even a few days to pass without some member of her household bleeding. There can be no doubt that the disposition has been transmitted throughI the male line, the mothers of the two families having I no history whatever of any tendency from either side to this affection. When the patients have come under treatment the usual remedies have been tried with varying success, such as ergot, tinctura ferri perchloridi and calcium chloride internally, I am adrenalin externally, with rest and compression. rather anxious to know if there is any recognised form of treatment which would tend to counteract this tendency to abnormal bleeding. The comparative rarity of these cases, together with the sense of helplessness in regard to treatment which confronts the ordinary practitioner, are my reasons for bringing them under notice. Attercliffe, Sheffield.
tively, are subject
to very
frequent
Medical Societies. ROYAL SOCIETY OF MEDICINE. MEDICAL SECTION. Oomplioations of Pne?lmonia. A MEETING of this section was held on Nov. 5th, Dr. S. J. GEE, the President, being in the chair. Dr. W. J. HADLEY, in reopening the adjourned discussion on the Complications of Pneumonia, said that the statistics supplied by the medical registrars of the London Hospital referred to the last ten years, and they must remember that those figures came from the working classes and he thought that they would differ in many ways from those collected from the well-to-do. In the first place it was noticeable that pneumonia was three times as common in the male as in the female. That difference held in all the returns except where children were concerned (East London Hospital for Children) where the figures stood at 443 males to 316 females. Secondly, the figures showed that mortality increased with age from about 5 per cent. to 49 per cent. Thirdly, it was seen that the mortality was rather higher in females than in males, males being 23-21 per cent, and females 25’45 per cent. In considering complications, it was most important to separate antecedent conditions from those which resulted from the disease itself. Many antecedent conditions considerably influenced the mortality. With alcohol as an antecedent condition the death-rate was 66· 66 per cent. out of 105 cases. With cardio vascular disease (including aneurysm) as an antecedent the death-rate was 46 ’ 14 per cent. out of 91 cases. In the case of chronic nephritis it was 82 6 per cent. out of 23 cases, and with chronic pulmonary troubles as an antecedent condition the death-rate was 31’ 64 per cent. out In many of those cases the death of 79 cases. was not due to the pneumonia at all but to the original disease, whilst in others it was simply a modus moriendi, At the same time it was most important to remember the greatly increased danger of pneumonia occurring in the Of complications as a course of some chronic diseases. result of pneumonia itself empyema, delirium, and pericarditis were the most important, and gangrene, abscess,
fully watched for, as there was but little chance for the patient unless the pericarditis was opened and drained. It should be noted that, especially in the young, a pericardium distended
with fluid pushed directly backwards and gave rise to marked dulness at the leftbase posteriorly simulating consolidation or fluid of the left lung and showed very little in front unless carefully searched for, when the displaced apex beat, hidden heart, and muffled sounds could generally be made out. In regard to abscess as a complication of pneumonia it was frequently an interlobar empyema. Concerning meningitis it must be borne in mind that meningeal symptoms were often present as a result of toxasmia. without any meningitis. Retraction, headache, vomiting, irregularity of pupils, squint, fits, and twitchings might be observed, and he had seen the mastoids explored in such circumstances. Referring to peritonitis and colitis complicating pneumonia, Dr. Hadley said that abdominal pneumonia" was a condition which they must recognise. They were quite familiar with the case admitted as appendicitis which after or before operation was transferred to the medical side as a pneumonia. They had probably all read the accounts of outbreaks of pneumonia in an institution where it was noticeable that many of the cases were purely abdominal, resembling enteric fever. He had seen an epidemic in a country village where nearly half the cases were abdominal, resembling enteric fever but of shorter duration, and several occurring in the same house, some being abdominal and others pulmonary. Sometimes acute paralytic distension of the stomach occurred which was apparently toxic, but it was often seen in lesser degree in the intestines, especially the colon. He knew nothing which embarrassed the heart so much in pneumonia and it was most important to get rid of it by enemas or by using a long tube. He had left the tube in sometimes as the condition recurred so frequently. Gentle massage would often enable the patients to pass the ilatua through the tube readily. In regard to arthritis as a complication of pneumonia, he noted that most of the cases were in patients younger than ten years of age. The treatment by inoculations was hindered by the difficulty of getting cultures. The acuteness of the disease made it hard to get vaccine before the crisis occurred and many cases were admitted to hospital only a short time before the crisis. In his opinion the more chronic complications would give the best chance for inoculations such as arthritis and empyema. Pneumonia, rheumatism, and tubercle formed a group of which it could be said that one attack appeared to predispose to subsequent ones. With such a characteristic how could they expect a preventive inoculation; at any rate the immunity must be very short-lived. Dr. N. DALTON considered that when lysis was observed it could be explained by the fact that there was some latent complication or some secondary infection interfering with the ordinary course of the pneumonia. With reference to dilatation of the stomach he did not think that it was an uncommon
complication.
that the complications of in childhood than in adult life and the death-rate in children from complications was higher than in adults. In children under the age of one year it was found that there was great mortality from the toxoamia of pneumonia. In children a’large number of cases occurred of primary pneumococcic empyema. Dr. A. C. LATHAM said that, judging from the monthly returns made at St. George’s Hospital, the maximum incidence of pneumonia was in May and in October. About May people were prone to take to their thin clothes too soon and about October people sometimes failed to take to their warmer clothing soon enough. He had been told that the Bulawayo hospital statistics showed that in the rainy season the beds were full of cases of malaria and in the cold season the hospital was crowded with cases of pneumonia. In regard to the knee-jerk in pneumonia, out of 120 cases investigated it was present in 90, and it was sluggish or absent in the remaining bO. Referring to the treatment of pneumonia by antidiphtheritic serum he said that it had been tried in severe cases where the prognosis was grave and in no case in which the serum had been given had the temperature reached the point where it stood before the introduction of the serum. Dr. J. FAWCETT stated that the Guy’s Hospital cases did not include " terminalpneumonias and that probably accounted for the fact that the mortality-ratio was only 15 - 6 per cent. ;
Dr. A. M. GOSSAGE
pneumonia were
more
thought
important