- Email: [email protected]
MEDICINE AND THERAPEUTICS.
THE ANNUS MEDICUS 1906.
1781
instance, in the matter of diagnosis. In this respect we must observers who maintain that a dis. tinction should be drawn between "open"" and closed" tuberculosis, the former class being a source of danger to the public, whilst the latter is practically devoid of risk of infection. The sanatorium treatment of tuberculosis continues to yield satisfactory results. In THE LANCET of Jan. 6th, p. 1, we published several essays by recognised authorities on the treatment of pulmonary tuberculosis, who were unanimous in their opinion as to the beneficial results which might be obtained by this method when the patients came under observation in an early stage of the disease. In regard to the after-care and possibilities of occupation for the tuberculous patient of the operative classes when discharged from a sanatorium the view formerly held that an open-air life was essential was challenged by Dr. M. S. PATERSON and Dr. F. C. SHRUBSALL in an article which we published in our columns on July 28th, p. 217. They maintained that the advice often given to such patients to change their occupation, if it was an indoor one, though eminently sound in theory, was impracticable. The conclusions arrived at by them was that on his discharge from a sanatorium a patient should so far as possible return to his own trade, whilst those patients without trades should be largely governed in their choice of an occupation by their wageearning capacity thereat. Reference was made to the statistics of German sanatoriums, which seem to prove that patients discharged with the disease in a quiescent or arrested state are capable of returning to their former occupations for periods of three, four, or more years. M. LANNELONGUE read a paper in June at a meeting of the Academy of Sciences giving an account of some investigations which he had made in association with Dr. ACHARD and Dr. GAILLARD in the serum treatment of tuberculosis. These observers had investigated the effect on guinea-pigs of a toxin extracted from the bacillus as it occurred in the human subject. The results were encouraging. The control animals showed a mortality of 90 per cent. when injected with tuberculosis, whilst those treated with the antituberculous serum had a mortality of only 40 per cent. The value of the tuberculo-opsonic index in the diagnosis and treatment of tuberculous infections has been further investigated, but no definite pronouncement has yet been made. Mr. W. WATSON CHEY1TE, writing in our columns (Jan. 13th, p. 78), while recognising the originality and the brilliance of the work carried out by Sir A. E. WRIGHT, regarded many of his contentions as theoretical and not proven. He deprecated any intemperance in applying the principles of inoculation to the exclusion of other well-tried methods, both surgical and hygienic, as likely to lead to disappointment and once again to cast discredit on tuberculin as a remedy. He thought that other as yet incompletely elucidated factors in the production and spread of local bacterial diseases would have to be taken into consideration and that, therefore, an exaggeration of the importance of the opsonic factor in the protective mechanism might tend to hinder rather than to promote progress. At present the method that has to be employed in estimating the opsonic index is a prolonged one. If some less laborious means of judging the protective power and its variations can be discovered, the usefulness of the procedure will be considerably increased.
give our support to those
THE LANCET. LONDON: SATURDAY, DECEMBER ,9, 1906.
THE ANNUS MEDICUS 1906. publish, in accordance with our usual custom
in the WE last number of the year, a summarised account of the more outstanding medical events of the past twelve months ; and, as on previous occasions, we have to confess our knowledge that such a compilation must make rather bald reading. We can only take notice, as far as medical science is concerned, of what appears to us to be the salient features of progress, and even then we must often mention these without making much attempt to appreciate their real significance. For this, indeed, is mere likely to become apparent after the lapse of some time, when extended observation and practical trial have supplied the necessary evidence. Year by year, as medical science enlarges her boundaries, it becomes more impossible within the scope of one article even to mention the facts and developments which rightly fall under the comprehensive title of the Annus ilfedious. Every year the inroads of medicine upon psychology, upon chemistry, and upon all branches of physics become more penetrating, and every year the invader makes new annexations. We beg our readers to look upon the summary which now follows as a chapter in a serial and abbreviated history, the perusal of which will remind them where further details upon any point of particular interest may be found, while keeping the general story of progress in their minds. ___
MEDICINE AND THERAPEUTICS. J.1we’J’()utostS.
I
The interest which the KING takes in the treatment of tuberculosis again assumed a practical form when on June 13th, accompanied by the QUEEN, he visited the King Edward VII. Sanatorium and performed the openingi ceremony. A full description of the buildings has already appeared in our columns. In addition to the primary object of the institution-the treatment of certain classes of the community suffering from tuberculosis who are not subjects for gratuitous relief at the hospitals-it is intended that special attention shall be given to research work. The munificent donation of 10,000 recently given by Mr. and Mrs. BISCHOFFSHEIM for assisting this purpose will enable the Advisory Committee to procure all that is necessary in order to insure the work being satisfactorily carried out. The question of introducing notification of pulmonary tuberculosis, either voluntary or compulsory, has been much discussed. In certain towns and boroughs modified notification has been adopted, but sufficient time has not yet elapsed to be able to judge of the success or non-success of the measure. Theoretically, compulsory notification, from which follows compulsory disinfection, should be a great power in aiding to stamp out the disease, but, as we have pointed out, there are differences in opinion as to the procedure which should be adopted. There are also numerous practical difficulties which will have to be overcome-for I
Typhoid Fever. The committee appointed by the Army Council to investigate the practical, prophylatic, and therapeutic value of current methods of immunisation against typhoid fever has issued an interim report setting forth the opinions arrived at after examining the work of those appointed to carry out the necessary investigations and suggesting propositions as to further research. The committee stated that having carefully
1782
THE ANNUS MEDICUS 1906.
considered the whole of the statistical material it was satisfied1
(medical officer of the county of Lanark) also published a that the records which were available up to date furnished1 valuable report of the cases occurring in four localities. proof that the practice of antityphoid inoculations in the! within four miles of the city of Glasgow. A report on the army had resulted in a substantial reduction in the incidence bacteriological work performed in connexion with the cases and death-rate of enteric fever among the inoculated. Thei was furnished by Dr. A. LRDiNGffA.) and the information committee further stated that statistical records supportedl contained in these reports may be briefly summarised thus: a the. scientific observations that the protective substances! few fatal cases of cerebro-spinal meningitis occurred annually which were developed in the human organism after anti-during the three preceding years 1903-05. During the typhoid inoculation were identical with those developed incurrent year (April to July) 25 cases were notified by medical the course of an attack of typhoid fever and that animalsI practitioners, but in six of these cases the diagnosis was Of the 19 undoubted cases of cerebro-spinal could be rendered resistant to typhoid fever by the same pro- doubtful. As a consequencei meningitis only three survived and two of these were very cess of inoculation as that used in man. of these conclusions the committee recommended that thei ill when the report was issued, thus demonstrating the practice of voluntary inoculation against typhoid fever in thei dangerous nature of the malady. The bacteriological results army should be renewed and that ample provision should bei were interesting, but there is need of further research and made for carrying out further investigations. When the inquiry as to how the disease is spread. From 11 patients enormous losses which this disease causes in the army both spinal fluid was obtained and the meningococcus was in war and peace are taken into consideration-for instance, recovered in ten, while in the other case the organism the deaths in India alone amount to half a battalion a seemed to be the pneumococcus. In three other instances. year-the importance of the investigation of prophylactic the nasal mucus was examined but showed the meningo. measures becomes at once apparent and the hope may be coccus in one only. The most prominent clinical symthat the will the Council recommendawere the sudden onset of severe headache with Army expressed put ptoms tions of the committee into effect as soon as the necessary vomiting. The duration of fatal illness was from one to four days in eight cases and from seven to 14 in seven cases. organisation can be brought into being. A curative serum was tried in one case but seemed to Soarlet Fever. produce no beneficial effects. Another on " return cases of scarlet fever has
B
.
I
report
been drawn up for the Metropolitan Asylums Board. Last year Dr. A. G. R. CAMERON was the author of a similar report, his conclusions being based on returns extending This year (1906) Dr. F. ill. over a period or 13 months. TURNER is the author and the figures for three years have been analysed. Unfortunately, the practical conclusions reached are no more encouraging than those arrived at by Dr. CAMERON ; indeed, the results of the second investigation neutralise some of the conclusions which the earlier series of figures appeared to warrant. Among the principal points emphasised in Dr. CAMERON’S report were the following two : that a large proportion of so-called "return" cases were in reality the result of mere coincidence and that in the majority of cases in which infection had really been conveyed by the discharged patient rhinorrhcea had been a feature of his attack. Dr. TURNER carefully tabulated statistics of 1000 consecutive cases at the Eastern Hospital and found that while among 397 cases without complications of any kind 3’ 27 per cent. caused infection on returning to their homes, among 343 cases with rhinorrhoea. only 2 ’62 per cent. proved infectious. Among 256 cases with other complications only I - 54 per cent. caused further outbreaks. A possible fallacy in these results as compared with those of Dr. CAMERON, however, may be found in the fact that 180 patients who exhibited rhinorrhaea were detained in hospital over ten weeks, by which time the nasal infection had very probably become attenuated. Another feature in Dr. TURNER’S report is the practical contradiction of Dr. CAMEROX’S contention that a large number of "return" Dr. TURNER’S cases of scarlet fever are pure coincidences. in refuting with that of Dr. CAMERON report agrees the ancient belief in the special contagiousness of the desquamation stage of the disease. Further investigation is obviously necessary before the true explanation of returncases of scarlet fever can be arrived at.
Epidemic Cerebro-spinal Meningitis. An outbreak of this disease, which occurred in and around Glasgow in the early months of the year, afforded opportunities for the study of its clinical and bacteriological characteristics. We published a paper by Dr. WILLIAM WRIGHT (senior assistant medical officer of health of Glasgow) and Dr. W. ARCHIBALD (junior assistant medical officer of health of Glasgow) detailing the course of some of the cases. Dr. J. T. WILSON
rellon’ Fever. Sir Rul3txT W. BOYCE visitei British Honduras in the autumn of 1905 whilst yellow fever was prevalent and subsequently issued a report to the Government of that colony. Starting with the definite knowledge (proved by other observers) that yellow fever is conveyed by the stego. myia fasciata mosquito, Sir RullERT BOYCE proceeded to show the distribution of the stegomyia, its constant presence in all districts in which the fever prevails, and the sanitary conditions which obtain and serve as factors in favouring the continuance of this species of mosquito. The stegomyia fasciata was shown to be essentially a " domestic mosquito;. its larvse were found in the receptacles used for the storage of water near houses and in the rain water collected in tins, bottles, or crockery thrown out from the houses and allowed to lie about the gardens, yards, or outhouses, where it flourished to the exclusion of other mosquitoes. It is plain, therefore, that for a successful fight against yellow fever a controlled and protected water-supply is necessary ; all vats, tanks, and barrels must be screened permanently with wire gauze or temporarily with cheese cloth. The early recognition of the disease and its prompt notification were other points upon which great stress was laid. In British Honduras the stegomyia fasciata can live all the year round owing to the country being within the zone of the permanent. distribution of this mosquito ; thus there is no season during which yellow fever may not prevail. Constant vigilance is therefore necessary on the part of the medical authorities. It is not always possible to arrive at an early diagnosis but the post-mortem signs are characteristic and Sir RUBERT BOYCE drew attention to the importance and indeed the imperative necessity of obtaining necropsies in the first suspicious deaths. In a paper published by Dr. F. I. WILBUR on the Home of Yellow Fever he stated that the stegomyia fasciata was not a native of American seaports in the Mexican Gclfg although it was found there. His opinion was that the Sargasso Sea was the real home of this mosquito and of yellow fever and that in the still water of this sea of seaweed around which the ocean currents sweep like rivers, was to be found the source of the disease.
I j
: I
! ,
I
I ,
I
I B i
,
,
I I
I
Sleeping Siolmess. alarming spread of sleeping sickness, or human trypanosomiasis, in Africa and the apparently hopeless
!
The
THE ANNUS MEDICUS 1906. when infection has taken place, render tbf establishment of effective preventive measures peculiarly ,urgent. Dr. J. L. TODD, director of the Runcorn Research Laboratories of the Liverpool School of Tropical Medicine, discussed in our columns (July 7tih, p. 6) the probable causes of the spread of the disease and offered practical suggestions -for checking that advance. He concluded that the enormous spread and great increase of sleeping sickness in the Congo basin have been due in great measure to the increase in travel following the opening up of the country. ’He also pointed out that patients suffering from trypano-somiasis, though apparently in good health, might be detected by enlargement of the glands, and he urged, therefore, that the advance of the disease might be checked by the serious application of quarantine measures, dependent for their efficiency upon palpation of the cervical glands. To carry out this measure he suggested the establishment of medical posts of inspection along - the trade routes leading from infected to uninfected districts and the removal of infected persons from posts in uninfected districts to places already infected. The danger to Europeans engaged in these districts is one to be borne in mind, since they possess no immunity to the disease other than that offered by the greater amount of clothing worn. It is to be hoped that the authorities will carry out without delay some such measures as those outlined by Dr. TODD.
prognosis
1783
minutely described the course and constitution of the bundle and discussed its development. Dr. JOHN HAY and Dr. STUART A. 210ORE have applied these physiological considerations to the pathology of Stokes-Adams disease. Dr. HAY made an ingenious and careful comparison of the radial and jugular pulses and his results suggest that a disturbance of rhythm may be caused at one time by a block in the conductivity of the heart muscle and at another by a disturbance in its excitability. In a case of Stokes-Adams disease described by Dr. HAY and Dr. MooRE the syncopal, and apoplectiform seizures were very marked. The case proved fatal and the necropsy revealed partial obliteration of the auriculo-ventricular bundle ; this would This was cause a persistent depression of conductivity. proved by numerous tracings which revealed marked variations in conductivity, all grades from normal conduction to complete heart block being in evidence at one or another time. The phenomenon of heart block has long been known to physiologists, although their explanation that it arises as the consequence of interference with the normal conduction of the wave of contraction is more recent.
epileptiform,
diabetes.
pathology of diabetes have been expressed by competent observers from time to time, but even now no unanimity of opinion can be said to exist. The kidney, the liver, and the pancreas have in turn been con. sidered to be the organ in which the disease originated, but Leprosy. Dr. R. S. BLACK, in a paper read before the Physiological most authorities now point to the nervous system as playing Section of the British Medical Association on Leprosy in the most important r6le in the production of glycosuria. In Cape Colony,gave an admirable summary of the present a paper which was read before the International Congress of state of knowledge of that disease. He pointed out that I Medicine at Lisbon Dr. F. W. PAVY adduced some strong the problems connected with it were not only pathological ; arguments in favour of the vaso-motor system supplying the there were administrative, legal, and even moral questions chylopoietic viscera being mainly involved. He pointed out which arose out of its existence which needed to be handled that it was in connexion with the neuropathic disposition with great circumspection, moderation, and sagacity. He that diabetes was most frequently found to exist, and the thought that all evidence tended to show that the disease more sensitive and highly strung the nerve organisation the began (how long after the implantation of the bacilli could more intense was the form that the disease assumed. He not at present with certainty be known) as a small collection further remarked that a cerebral influence over the vasoof round cells under the mucosa of some part of the nasal motor state was what was suggested as constituting the link cavity. With regard to treatment, he had experienced very between the brain and diabetes. Dr. PAVY contended from much better results with chaulmoogra oil than with any physiological considerations that a chain of connexion could other drug. He concluded that until further light could be be established rendering it possible for diabetes to constitute thrown on the pathology and treatment of leprosy the disease a disease belonging to the neurosis class, the difference in its must be combated chiefly by segregation and isolation, case being the implication of a particular area belonging to making the hardships to the patients unavoidable in such a the vaso-motor system instead of structures connected with procedure as tolerable as possible. He urged that a voluntary motion, sensation, and the mind. more sustained and continuous effort should be made on Lectitres of the Year. behalf of the sufferers in the way of experimental We published in THE LANCET as usual the official .and scientific research in the well-organised asylums lectures delivered before the Royal College of Physicians which were so suitable for a regulated plan of work. of London. The Lumleian lectures were delivered by Dr. The effort should be made in conjunction with a scientific DAVID FERRIER on Tabes Dorsalis. He dwelt in great detail organisation, such as one of the schools of tropical medi- on the pathology of the disease and also discussed its causacine. In cooperation with the Government these schools tion. He considered that the most probable pathogeny of might periodically send out to the asylums a research the tabetic degeneration was that it was the result of a scholar or scholars who would, under the direction of the toxin generated or conditioned by the syphilitic virus. He scientific staff of the school, have a definite objective admitted, however, that at present this was a pure hypomapped out for them to attain, if possible, during the period thesis. In view, however, of the brilliant therapeutic of research. triumphs of the present day Dr. FERRIER thought that it Stokes-Adams Disease. was not too optimistic to hope that with the progress of bioFew diseases offer such a field for the application of the source of the tabetic toxin, its nature and the known physiological principles to pathological phenomena as chemistry means of neutralising it and staying its ravages might yet Various theories
as
to the
that to which has been given the name of Stokes-Adams be discovered. Dr. H. BATTY SHAW was the Goulstonian The striking character of its symptoms-slow pulse lecturer, selecting as his subject Auto-intoxication, its Relawith syncopal, apoplectiform, or epileptiform attacks and tion to Certain Disturbances of Blood Pressure. A considerthe associated phenomena of Cheyne-Stokes breathing, angina able of the lecture was concerned with the facts pectoris, and cardiac arrest-combine to give it a peculiar whichportion had been elicited by the use of the sphygmomanometer interest. Dr. A. KEITH and Mr. M. W. FLACK contributed in health and disease. Dr. SHAW detailed the results of ex. an interesting article to our columns on the auriculo-ventriwhich he himself had made on the effects on the -cular bundle of the human heart (August llth, p. 359). They periments blood pressure of the intravenous injection of extracts of fresh 1 THE LANCET, Oct. 20th, 1906, p. 1064. organs. He showed that a rise of blood pressure occurred 18
disease.
THE ANNUS MEDICUS 1906.
1784
times out of 19 in which kidney extract was used and that was not noticed after the such frequency of a pressor of extracts of other organs except the suprarenals. injection He concluded that when the kidney cortex atrophied, as in cases of granular kidney, the pressor substance resident in the cortex entered the circulation and was responsible for the rise of blood pressure met with in that condition. The Bradshaw lecture was delivered by Dr. S. J. SHARKEY who chose as his subject Rectal Alimentation. He arrived at the conclusion that sugar, peptones, and pulverised casein were the best constituents that could be utilised. The OliverSharpey lectures were given by Dr. E. I. SPRIGGS on the Bearing of Metabolism Experiments upon the Treatment of S.)me Diseases. Dr. W, H. HAMER was the Milroy lecturer, his subject being Epidemic Disease in England-the evidence of variability and of persistency of type. Dr. NORMAN MOORE gave the Fitz Patrick lectures on the History of the Study of Clinical Medicine in the British Isles, and Professor WILLIAM OSLER was the Harveian orator.
effect
pleural cavity but at no time was any bsemoptysis present. Six days after the injury it was found necessary to lay open the wound, to drain the pleural sac, and to suture the ends of the intercostal artery lying under the sixth rib ; both ends A slight rise of temperature occurred were bleeding. for a few days after the operation but the wound healed well. The valvular nature of the original wound had prevented a pneumothorax until the time of the operation, but the air then admitted was soon absorbed and no pus was formed at any time.
I
I
.7?mpy
incision of the chest wall for empyema. He described fully A young man, 19 years one case and mentioned two others. of age, had an attack of pneumonia and on the tenth day an empyema developed on the right side. An exploring needle drew off some pus and then an incision was made (under local anxsthesia) and some pus with blood escaped. The bremorrhage continued in spite of attempts to stop it and Táe Official Nomenclature of Disease. the patient died 13 hours after the operation from hemorThe special committee of the Royal College of Physicians and exhaustion. At the necropsy no wounded vessel of London appointed in 1902 to revise the nomenclature of rhage be could found. The source of the bleeding in these cases diseases has now concluded its labours and copies of the is obscure but probably the toxasmia is in part responsible work have been distributed. The registration and classificafor its occurrence and for its failure to cease through loss of tion of the causes of fatal diseases are carried out with evercoagulability. increasing efficiency at Somerset House, and we doubt not Dr. J. F. LEYS has advocated the treatment of acute that the publication of a new authorised nomenclature will empyema by simple incision and drainage, though he be welcomed by the Registrar-General and his medical acknowledges that resection of a rib may be necessary in adviser as an invaluable aid in their work. cases of chronic empyema. Mere incision was used 2000 years ago but it has been replaced by resection of a portion of a rib. Professor W. OSLER and Dr. E. ADEws are SURGERY. both strongly of opinion that mere incision is quite sufficient The progress of surgery during the year now ending may in acute cases. The cases recorded by Dr. LEYS show that be well illustrated by cases taken from the columns of in some instances simple incision is sufficient. THE LANCET. Dislocation and Fraeiu?’e of the Sternum. The Surgery of the Heart. shows a advancement. The surgery of the heart steady Dr. W. A. JAMES has recorded a case of dislocation of the Only a few years have passed since first an attempt was manubrium from the gladiolus. The patient, who was 51 made to close by sutures a wound of the heart, and to years old, was working in a sewer and a fall of earth fixed FARINA must be given the credit of this bold advance in him against the wall. The first piece of the sternum was backwards for about an inch. There was much pain surgery. It is true that his patient died four days after the operation, but the death was due to pneumonia and there- on coughing or deep breathing and he had great difficulty in fore the operation can hardly be looked upon as a failure. sleeping. Gradually the depression diminished, but for more REHN’S was the first successful case, and now many instances than three months the patient could do only light work and are on record in which a stab wound of the heart has been he was easily fatigued, successfully sutured. We have had comparatively few cases Dr. J. FINLAY ALEXANDER of Lptstingham has published in this country; they are more common in Italy where a case of fracture of the sternum. The patient was a farm knives are more freely used in quarrels than in England. labourer, 60 years of age. He fell about eight feet on to We have been, however, able to record a very remark- the back of his head. A large bruise appeared covering able case of wound of the heart. Mr. FREDERICK T. nearly the whole of the front of the chest and a projection TRAVERS of Maidstone had under his care a boy, 19 was found across the sternum at the level of the second The patient had fallen on an iron intercostal years of age. space. The sternum was found to be broken spike which had been driven into the sternum, fracturing immediately above the third costal cartilage. The ridge the bone. Some of the broken pieces of bone had pene- was caused by the projection upwards and forwards of the trated the pericardium and had caused an extensive and lower fragment. The displaced portion was easily reduced irregular wound of the right ventricle. Mr. TRAVERS laid by making the patient lie flat on his back and good union open the pericardium and found and sutured the wound in occurred in three weeks. the heart. The patient survived nearly 11 days. The wound Rib ]11raotltred by Muscular Action. of the heart was remarkable for its extent and the skill of Dr. S. HERBERT DAUKES of High Wycombe has put on the operator deserved a better final result. In these cases of wound of the heart the chief cause of death is compression record a case in which a rib was fractured by muscular of the auricles by the blood poured out into the pericardial action. A man, 52 years of age, was straining at stool and " felt something go " ; on examination the left sixth rib was sac, and not the actual loss of blood. found to be fractured in the mid-axillary line. No predisHcemothorax. posing cause could be found but the patient was liable to Hsemotbojrax from an external wound without fracture of a gout. Union took place readily. rib or wound of the lung is rare, as the intercostal arteries are Rare Form of Dislocation of the Clavicle. well protected by the ribs under which they lie. Mr. DONALD DuFF and Mr. JOHN ALLAN of Glasgow have recorded a case Mr. J. ERNEST ACOMB has recorded a case which was in which a man, aged 46 years, fell through a glass door and under the care of Mr. A. PEARCE GOULD at the Middlesex wounded his left side. Blood slowly accumulated in his left Hospital. A man, 55 years of age, was knocked down by a
I
I
I
’
:
e
’
driven
!
i
I
’
!
1781
instance, in the matter of diagnosis. In this respect we must observers who maintain that a dis. tinction should be drawn between "open"" and closed" tuberculosis, the former class being a source of danger to the public, whilst the latter is practically devoid of risk of infection. The sanatorium treatment of tuberculosis continues to yield satisfactory results. In THE LANCET of Jan. 6th, p. 1, we published several essays by recognised authorities on the treatment of pulmonary tuberculosis, who were unanimous in their opinion as to the beneficial results which might be obtained by this method when the patients came under observation in an early stage of the disease. In regard to the after-care and possibilities of occupation for the tuberculous patient of the operative classes when discharged from a sanatorium the view formerly held that an open-air life was essential was challenged by Dr. M. S. PATERSON and Dr. F. C. SHRUBSALL in an article which we published in our columns on July 28th, p. 217. They maintained that the advice often given to such patients to change their occupation, if it was an indoor one, though eminently sound in theory, was impracticable. The conclusions arrived at by them was that on his discharge from a sanatorium a patient should so far as possible return to his own trade, whilst those patients without trades should be largely governed in their choice of an occupation by their wageearning capacity thereat. Reference was made to the statistics of German sanatoriums, which seem to prove that patients discharged with the disease in a quiescent or arrested state are capable of returning to their former occupations for periods of three, four, or more years. M. LANNELONGUE read a paper in June at a meeting of the Academy of Sciences giving an account of some investigations which he had made in association with Dr. ACHARD and Dr. GAILLARD in the serum treatment of tuberculosis. These observers had investigated the effect on guinea-pigs of a toxin extracted from the bacillus as it occurred in the human subject. The results were encouraging. The control animals showed a mortality of 90 per cent. when injected with tuberculosis, whilst those treated with the antituberculous serum had a mortality of only 40 per cent. The value of the tuberculo-opsonic index in the diagnosis and treatment of tuberculous infections has been further investigated, but no definite pronouncement has yet been made. Mr. W. WATSON CHEY1TE, writing in our columns (Jan. 13th, p. 78), while recognising the originality and the brilliance of the work carried out by Sir A. E. WRIGHT, regarded many of his contentions as theoretical and not proven. He deprecated any intemperance in applying the principles of inoculation to the exclusion of other well-tried methods, both surgical and hygienic, as likely to lead to disappointment and once again to cast discredit on tuberculin as a remedy. He thought that other as yet incompletely elucidated factors in the production and spread of local bacterial diseases would have to be taken into consideration and that, therefore, an exaggeration of the importance of the opsonic factor in the protective mechanism might tend to hinder rather than to promote progress. At present the method that has to be employed in estimating the opsonic index is a prolonged one. If some less laborious means of judging the protective power and its variations can be discovered, the usefulness of the procedure will be considerably increased.
give our support to those
THE LANCET. LONDON: SATURDAY, DECEMBER ,9, 1906.
THE ANNUS MEDICUS 1906. publish, in accordance with our usual custom
in the WE last number of the year, a summarised account of the more outstanding medical events of the past twelve months ; and, as on previous occasions, we have to confess our knowledge that such a compilation must make rather bald reading. We can only take notice, as far as medical science is concerned, of what appears to us to be the salient features of progress, and even then we must often mention these without making much attempt to appreciate their real significance. For this, indeed, is mere likely to become apparent after the lapse of some time, when extended observation and practical trial have supplied the necessary evidence. Year by year, as medical science enlarges her boundaries, it becomes more impossible within the scope of one article even to mention the facts and developments which rightly fall under the comprehensive title of the Annus ilfedious. Every year the inroads of medicine upon psychology, upon chemistry, and upon all branches of physics become more penetrating, and every year the invader makes new annexations. We beg our readers to look upon the summary which now follows as a chapter in a serial and abbreviated history, the perusal of which will remind them where further details upon any point of particular interest may be found, while keeping the general story of progress in their minds. ___
MEDICINE AND THERAPEUTICS. J.1we’J’()utostS.
I
The interest which the KING takes in the treatment of tuberculosis again assumed a practical form when on June 13th, accompanied by the QUEEN, he visited the King Edward VII. Sanatorium and performed the openingi ceremony. A full description of the buildings has already appeared in our columns. In addition to the primary object of the institution-the treatment of certain classes of the community suffering from tuberculosis who are not subjects for gratuitous relief at the hospitals-it is intended that special attention shall be given to research work. The munificent donation of 10,000 recently given by Mr. and Mrs. BISCHOFFSHEIM for assisting this purpose will enable the Advisory Committee to procure all that is necessary in order to insure the work being satisfactorily carried out. The question of introducing notification of pulmonary tuberculosis, either voluntary or compulsory, has been much discussed. In certain towns and boroughs modified notification has been adopted, but sufficient time has not yet elapsed to be able to judge of the success or non-success of the measure. Theoretically, compulsory notification, from which follows compulsory disinfection, should be a great power in aiding to stamp out the disease, but, as we have pointed out, there are differences in opinion as to the procedure which should be adopted. There are also numerous practical difficulties which will have to be overcome-for I
Typhoid Fever. The committee appointed by the Army Council to investigate the practical, prophylatic, and therapeutic value of current methods of immunisation against typhoid fever has issued an interim report setting forth the opinions arrived at after examining the work of those appointed to carry out the necessary investigations and suggesting propositions as to further research. The committee stated that having carefully
1782
THE ANNUS MEDICUS 1906.
considered the whole of the statistical material it was satisfied1
(medical officer of the county of Lanark) also published a that the records which were available up to date furnished1 valuable report of the cases occurring in four localities. proof that the practice of antityphoid inoculations in the! within four miles of the city of Glasgow. A report on the army had resulted in a substantial reduction in the incidence bacteriological work performed in connexion with the cases and death-rate of enteric fever among the inoculated. Thei was furnished by Dr. A. LRDiNGffA.) and the information committee further stated that statistical records supportedl contained in these reports may be briefly summarised thus: a the. scientific observations that the protective substances! few fatal cases of cerebro-spinal meningitis occurred annually which were developed in the human organism after anti-during the three preceding years 1903-05. During the typhoid inoculation were identical with those developed incurrent year (April to July) 25 cases were notified by medical the course of an attack of typhoid fever and that animalsI practitioners, but in six of these cases the diagnosis was Of the 19 undoubted cases of cerebro-spinal could be rendered resistant to typhoid fever by the same pro- doubtful. As a consequencei meningitis only three survived and two of these were very cess of inoculation as that used in man. of these conclusions the committee recommended that thei ill when the report was issued, thus demonstrating the practice of voluntary inoculation against typhoid fever in thei dangerous nature of the malady. The bacteriological results army should be renewed and that ample provision should bei were interesting, but there is need of further research and made for carrying out further investigations. When the inquiry as to how the disease is spread. From 11 patients enormous losses which this disease causes in the army both spinal fluid was obtained and the meningococcus was in war and peace are taken into consideration-for instance, recovered in ten, while in the other case the organism the deaths in India alone amount to half a battalion a seemed to be the pneumococcus. In three other instances. year-the importance of the investigation of prophylactic the nasal mucus was examined but showed the meningo. measures becomes at once apparent and the hope may be coccus in one only. The most prominent clinical symthat the will the Council recommendawere the sudden onset of severe headache with Army expressed put ptoms tions of the committee into effect as soon as the necessary vomiting. The duration of fatal illness was from one to four days in eight cases and from seven to 14 in seven cases. organisation can be brought into being. A curative serum was tried in one case but seemed to Soarlet Fever. produce no beneficial effects. Another on " return cases of scarlet fever has
B
.
I
report
been drawn up for the Metropolitan Asylums Board. Last year Dr. A. G. R. CAMERON was the author of a similar report, his conclusions being based on returns extending This year (1906) Dr. F. ill. over a period or 13 months. TURNER is the author and the figures for three years have been analysed. Unfortunately, the practical conclusions reached are no more encouraging than those arrived at by Dr. CAMERON ; indeed, the results of the second investigation neutralise some of the conclusions which the earlier series of figures appeared to warrant. Among the principal points emphasised in Dr. CAMERON’S report were the following two : that a large proportion of so-called "return" cases were in reality the result of mere coincidence and that in the majority of cases in which infection had really been conveyed by the discharged patient rhinorrhcea had been a feature of his attack. Dr. TURNER carefully tabulated statistics of 1000 consecutive cases at the Eastern Hospital and found that while among 397 cases without complications of any kind 3’ 27 per cent. caused infection on returning to their homes, among 343 cases with rhinorrhoea. only 2 ’62 per cent. proved infectious. Among 256 cases with other complications only I - 54 per cent. caused further outbreaks. A possible fallacy in these results as compared with those of Dr. CAMERON, however, may be found in the fact that 180 patients who exhibited rhinorrhaea were detained in hospital over ten weeks, by which time the nasal infection had very probably become attenuated. Another feature in Dr. TURNER’S report is the practical contradiction of Dr. CAMEROX’S contention that a large number of "return" Dr. TURNER’S cases of scarlet fever are pure coincidences. in refuting with that of Dr. CAMERON report agrees the ancient belief in the special contagiousness of the desquamation stage of the disease. Further investigation is obviously necessary before the true explanation of returncases of scarlet fever can be arrived at.
Epidemic Cerebro-spinal Meningitis. An outbreak of this disease, which occurred in and around Glasgow in the early months of the year, afforded opportunities for the study of its clinical and bacteriological characteristics. We published a paper by Dr. WILLIAM WRIGHT (senior assistant medical officer of health of Glasgow) and Dr. W. ARCHIBALD (junior assistant medical officer of health of Glasgow) detailing the course of some of the cases. Dr. J. T. WILSON
rellon’ Fever. Sir Rul3txT W. BOYCE visitei British Honduras in the autumn of 1905 whilst yellow fever was prevalent and subsequently issued a report to the Government of that colony. Starting with the definite knowledge (proved by other observers) that yellow fever is conveyed by the stego. myia fasciata mosquito, Sir RullERT BOYCE proceeded to show the distribution of the stegomyia, its constant presence in all districts in which the fever prevails, and the sanitary conditions which obtain and serve as factors in favouring the continuance of this species of mosquito. The stegomyia fasciata was shown to be essentially a " domestic mosquito;. its larvse were found in the receptacles used for the storage of water near houses and in the rain water collected in tins, bottles, or crockery thrown out from the houses and allowed to lie about the gardens, yards, or outhouses, where it flourished to the exclusion of other mosquitoes. It is plain, therefore, that for a successful fight against yellow fever a controlled and protected water-supply is necessary ; all vats, tanks, and barrels must be screened permanently with wire gauze or temporarily with cheese cloth. The early recognition of the disease and its prompt notification were other points upon which great stress was laid. In British Honduras the stegomyia fasciata can live all the year round owing to the country being within the zone of the permanent. distribution of this mosquito ; thus there is no season during which yellow fever may not prevail. Constant vigilance is therefore necessary on the part of the medical authorities. It is not always possible to arrive at an early diagnosis but the post-mortem signs are characteristic and Sir RUBERT BOYCE drew attention to the importance and indeed the imperative necessity of obtaining necropsies in the first suspicious deaths. In a paper published by Dr. F. I. WILBUR on the Home of Yellow Fever he stated that the stegomyia fasciata was not a native of American seaports in the Mexican Gclfg although it was found there. His opinion was that the Sargasso Sea was the real home of this mosquito and of yellow fever and that in the still water of this sea of seaweed around which the ocean currents sweep like rivers, was to be found the source of the disease.
I j
: I
! ,
I
I ,
I
I B i
,
,
I I
I
Sleeping Siolmess. alarming spread of sleeping sickness, or human trypanosomiasis, in Africa and the apparently hopeless
!
The
THE ANNUS MEDICUS 1906. when infection has taken place, render tbf establishment of effective preventive measures peculiarly ,urgent. Dr. J. L. TODD, director of the Runcorn Research Laboratories of the Liverpool School of Tropical Medicine, discussed in our columns (July 7tih, p. 6) the probable causes of the spread of the disease and offered practical suggestions -for checking that advance. He concluded that the enormous spread and great increase of sleeping sickness in the Congo basin have been due in great measure to the increase in travel following the opening up of the country. ’He also pointed out that patients suffering from trypano-somiasis, though apparently in good health, might be detected by enlargement of the glands, and he urged, therefore, that the advance of the disease might be checked by the serious application of quarantine measures, dependent for their efficiency upon palpation of the cervical glands. To carry out this measure he suggested the establishment of medical posts of inspection along - the trade routes leading from infected to uninfected districts and the removal of infected persons from posts in uninfected districts to places already infected. The danger to Europeans engaged in these districts is one to be borne in mind, since they possess no immunity to the disease other than that offered by the greater amount of clothing worn. It is to be hoped that the authorities will carry out without delay some such measures as those outlined by Dr. TODD.
prognosis
1783
minutely described the course and constitution of the bundle and discussed its development. Dr. JOHN HAY and Dr. STUART A. 210ORE have applied these physiological considerations to the pathology of Stokes-Adams disease. Dr. HAY made an ingenious and careful comparison of the radial and jugular pulses and his results suggest that a disturbance of rhythm may be caused at one time by a block in the conductivity of the heart muscle and at another by a disturbance in its excitability. In a case of Stokes-Adams disease described by Dr. HAY and Dr. MooRE the syncopal, and apoplectiform seizures were very marked. The case proved fatal and the necropsy revealed partial obliteration of the auriculo-ventricular bundle ; this would This was cause a persistent depression of conductivity. proved by numerous tracings which revealed marked variations in conductivity, all grades from normal conduction to complete heart block being in evidence at one or another time. The phenomenon of heart block has long been known to physiologists, although their explanation that it arises as the consequence of interference with the normal conduction of the wave of contraction is more recent.
epileptiform,
diabetes.
pathology of diabetes have been expressed by competent observers from time to time, but even now no unanimity of opinion can be said to exist. The kidney, the liver, and the pancreas have in turn been con. sidered to be the organ in which the disease originated, but Leprosy. Dr. R. S. BLACK, in a paper read before the Physiological most authorities now point to the nervous system as playing Section of the British Medical Association on Leprosy in the most important r6le in the production of glycosuria. In Cape Colony,gave an admirable summary of the present a paper which was read before the International Congress of state of knowledge of that disease. He pointed out that I Medicine at Lisbon Dr. F. W. PAVY adduced some strong the problems connected with it were not only pathological ; arguments in favour of the vaso-motor system supplying the there were administrative, legal, and even moral questions chylopoietic viscera being mainly involved. He pointed out which arose out of its existence which needed to be handled that it was in connexion with the neuropathic disposition with great circumspection, moderation, and sagacity. He that diabetes was most frequently found to exist, and the thought that all evidence tended to show that the disease more sensitive and highly strung the nerve organisation the began (how long after the implantation of the bacilli could more intense was the form that the disease assumed. He not at present with certainty be known) as a small collection further remarked that a cerebral influence over the vasoof round cells under the mucosa of some part of the nasal motor state was what was suggested as constituting the link cavity. With regard to treatment, he had experienced very between the brain and diabetes. Dr. PAVY contended from much better results with chaulmoogra oil than with any physiological considerations that a chain of connexion could other drug. He concluded that until further light could be be established rendering it possible for diabetes to constitute thrown on the pathology and treatment of leprosy the disease a disease belonging to the neurosis class, the difference in its must be combated chiefly by segregation and isolation, case being the implication of a particular area belonging to making the hardships to the patients unavoidable in such a the vaso-motor system instead of structures connected with procedure as tolerable as possible. He urged that a voluntary motion, sensation, and the mind. more sustained and continuous effort should be made on Lectitres of the Year. behalf of the sufferers in the way of experimental We published in THE LANCET as usual the official .and scientific research in the well-organised asylums lectures delivered before the Royal College of Physicians which were so suitable for a regulated plan of work. of London. The Lumleian lectures were delivered by Dr. The effort should be made in conjunction with a scientific DAVID FERRIER on Tabes Dorsalis. He dwelt in great detail organisation, such as one of the schools of tropical medi- on the pathology of the disease and also discussed its causacine. In cooperation with the Government these schools tion. He considered that the most probable pathogeny of might periodically send out to the asylums a research the tabetic degeneration was that it was the result of a scholar or scholars who would, under the direction of the toxin generated or conditioned by the syphilitic virus. He scientific staff of the school, have a definite objective admitted, however, that at present this was a pure hypomapped out for them to attain, if possible, during the period thesis. In view, however, of the brilliant therapeutic of research. triumphs of the present day Dr. FERRIER thought that it Stokes-Adams Disease. was not too optimistic to hope that with the progress of bioFew diseases offer such a field for the application of the source of the tabetic toxin, its nature and the known physiological principles to pathological phenomena as chemistry means of neutralising it and staying its ravages might yet Various theories
as
to the
that to which has been given the name of Stokes-Adams be discovered. Dr. H. BATTY SHAW was the Goulstonian The striking character of its symptoms-slow pulse lecturer, selecting as his subject Auto-intoxication, its Relawith syncopal, apoplectiform, or epileptiform attacks and tion to Certain Disturbances of Blood Pressure. A considerthe associated phenomena of Cheyne-Stokes breathing, angina able of the lecture was concerned with the facts pectoris, and cardiac arrest-combine to give it a peculiar whichportion had been elicited by the use of the sphygmomanometer interest. Dr. A. KEITH and Mr. M. W. FLACK contributed in health and disease. Dr. SHAW detailed the results of ex. an interesting article to our columns on the auriculo-ventriwhich he himself had made on the effects on the -cular bundle of the human heart (August llth, p. 359). They periments blood pressure of the intravenous injection of extracts of fresh 1 THE LANCET, Oct. 20th, 1906, p. 1064. organs. He showed that a rise of blood pressure occurred 18
disease.
THE ANNUS MEDICUS 1906.
1784
times out of 19 in which kidney extract was used and that was not noticed after the such frequency of a pressor of extracts of other organs except the suprarenals. injection He concluded that when the kidney cortex atrophied, as in cases of granular kidney, the pressor substance resident in the cortex entered the circulation and was responsible for the rise of blood pressure met with in that condition. The Bradshaw lecture was delivered by Dr. S. J. SHARKEY who chose as his subject Rectal Alimentation. He arrived at the conclusion that sugar, peptones, and pulverised casein were the best constituents that could be utilised. The OliverSharpey lectures were given by Dr. E. I. SPRIGGS on the Bearing of Metabolism Experiments upon the Treatment of S.)me Diseases. Dr. W, H. HAMER was the Milroy lecturer, his subject being Epidemic Disease in England-the evidence of variability and of persistency of type. Dr. NORMAN MOORE gave the Fitz Patrick lectures on the History of the Study of Clinical Medicine in the British Isles, and Professor WILLIAM OSLER was the Harveian orator.
effect
pleural cavity but at no time was any bsemoptysis present. Six days after the injury it was found necessary to lay open the wound, to drain the pleural sac, and to suture the ends of the intercostal artery lying under the sixth rib ; both ends A slight rise of temperature occurred were bleeding. for a few days after the operation but the wound healed well. The valvular nature of the original wound had prevented a pneumothorax until the time of the operation, but the air then admitted was soon absorbed and no pus was formed at any time.
I
I
.7?mpy
incision of the chest wall for empyema. He described fully A young man, 19 years one case and mentioned two others. of age, had an attack of pneumonia and on the tenth day an empyema developed on the right side. An exploring needle drew off some pus and then an incision was made (under local anxsthesia) and some pus with blood escaped. The bremorrhage continued in spite of attempts to stop it and Táe Official Nomenclature of Disease. the patient died 13 hours after the operation from hemorThe special committee of the Royal College of Physicians and exhaustion. At the necropsy no wounded vessel of London appointed in 1902 to revise the nomenclature of rhage be could found. The source of the bleeding in these cases diseases has now concluded its labours and copies of the is obscure but probably the toxasmia is in part responsible work have been distributed. The registration and classificafor its occurrence and for its failure to cease through loss of tion of the causes of fatal diseases are carried out with evercoagulability. increasing efficiency at Somerset House, and we doubt not Dr. J. F. LEYS has advocated the treatment of acute that the publication of a new authorised nomenclature will empyema by simple incision and drainage, though he be welcomed by the Registrar-General and his medical acknowledges that resection of a rib may be necessary in adviser as an invaluable aid in their work. cases of chronic empyema. Mere incision was used 2000 years ago but it has been replaced by resection of a portion of a rib. Professor W. OSLER and Dr. E. ADEws are SURGERY. both strongly of opinion that mere incision is quite sufficient The progress of surgery during the year now ending may in acute cases. The cases recorded by Dr. LEYS show that be well illustrated by cases taken from the columns of in some instances simple incision is sufficient. THE LANCET. Dislocation and Fraeiu?’e of the Sternum. The Surgery of the Heart. shows a advancement. The surgery of the heart steady Dr. W. A. JAMES has recorded a case of dislocation of the Only a few years have passed since first an attempt was manubrium from the gladiolus. The patient, who was 51 made to close by sutures a wound of the heart, and to years old, was working in a sewer and a fall of earth fixed FARINA must be given the credit of this bold advance in him against the wall. The first piece of the sternum was backwards for about an inch. There was much pain surgery. It is true that his patient died four days after the operation, but the death was due to pneumonia and there- on coughing or deep breathing and he had great difficulty in fore the operation can hardly be looked upon as a failure. sleeping. Gradually the depression diminished, but for more REHN’S was the first successful case, and now many instances than three months the patient could do only light work and are on record in which a stab wound of the heart has been he was easily fatigued, successfully sutured. We have had comparatively few cases Dr. J. FINLAY ALEXANDER of Lptstingham has published in this country; they are more common in Italy where a case of fracture of the sternum. The patient was a farm knives are more freely used in quarrels than in England. labourer, 60 years of age. He fell about eight feet on to We have been, however, able to record a very remark- the back of his head. A large bruise appeared covering able case of wound of the heart. Mr. FREDERICK T. nearly the whole of the front of the chest and a projection TRAVERS of Maidstone had under his care a boy, 19 was found across the sternum at the level of the second The patient had fallen on an iron intercostal years of age. space. The sternum was found to be broken spike which had been driven into the sternum, fracturing immediately above the third costal cartilage. The ridge the bone. Some of the broken pieces of bone had pene- was caused by the projection upwards and forwards of the trated the pericardium and had caused an extensive and lower fragment. The displaced portion was easily reduced irregular wound of the right ventricle. Mr. TRAVERS laid by making the patient lie flat on his back and good union open the pericardium and found and sutured the wound in occurred in three weeks. the heart. The patient survived nearly 11 days. The wound Rib ]11raotltred by Muscular Action. of the heart was remarkable for its extent and the skill of Dr. S. HERBERT DAUKES of High Wycombe has put on the operator deserved a better final result. In these cases of wound of the heart the chief cause of death is compression record a case in which a rib was fractured by muscular of the auricles by the blood poured out into the pericardial action. A man, 52 years of age, was straining at stool and " felt something go " ; on examination the left sixth rib was sac, and not the actual loss of blood. found to be fractured in the mid-axillary line. No predisHcemothorax. posing cause could be found but the patient was liable to Hsemotbojrax from an external wound without fracture of a gout. Union took place readily. rib or wound of the lung is rare, as the intercostal arteries are Rare Form of Dislocation of the Clavicle. well protected by the ribs under which they lie. Mr. DONALD DuFF and Mr. JOHN ALLAN of Glasgow have recorded a case Mr. J. ERNEST ACOMB has recorded a case which was in which a man, aged 46 years, fell through a glass door and under the care of Mr. A. PEARCE GOULD at the Middlesex wounded his left side. Blood slowly accumulated in his left Hospital. A man, 55 years of age, was knocked down by a
I
I
I
’
:
e
’
driven
!
i
I
’
!