- Email: [email protected]
ORBITAL ABSCESS FOLLOWING REMOVAL OF TONSILS AND ADENOIDS.
978 carried out in this case nor was the virulence of the organisms tested. A brother of the boy was, however, admitted to hospital at the same time with a sharp attack of faucial diphtheria, and it is probable that the boy with the foreign body and nasal discharge was a carrier of diphtheria bacilli and infected his brother. The case which we have recorded in some detail is of interest, as the question arises as to whether
Medical Societies. ROYAL SOCIETY OF MEDICINE.
the boy was Schick negative because he had immunised himself by infecting his nose with diphtheria bacilli from the foreign body, and so administered to himself small doses of toxin. Immunisation through the Mucosa. De Stella,5 in 1903, showed by experiments on animals that the nasal mucous membrane in diphtheritic rhinitis secretes an antitoxin which neutralises the diphtheritic toxin, and so prevented toxic symptoms resulting. This is probably what happened in the case described. If this is so, a further interesting question arises as to whether it would not be practicable to immunise persons against diphtheria through the nasal mucous membrane instead of by subcutaneous injections. Peters and Allison have experimented with intranasal immunisation against scarlet fever by spraying the nose every other day with scarlet fever toxin, with the result that a number of Dick-positive persons I became Dick negative, while in others the Dick-positive reaction was much reduced in area. It seems theoretically possible to devise a method of intranasal immunisation against diphtheria which would give still more satisfactory results. If immunisation against diphtheria could be effected through the nasal mucous membrane it would also throw some light on the hypothetical latent immunisation by which natural acquired immunity is supposed to be obtained, for it would appear probable that it is through the nose that such immunity is acquired. It can be supposed that most persons on few or many occasions inhale diphtheria bacilli which produce sufficient toxin in the nose to cause, by repeated doses, immunity to develop, but not enough to cause an attack of diphtheria.
SECTION OF ANAESTHETICS. AT the meeting of this Section on Nov. 1st, with Dr. ASHLEY DALY in the chair, the subject of discussion was AVERTIN ANAESTHESIA. Dr. JOSEPH BLOMFIELD said that avert in was a tri-bromine-ethyl-alcohol, a white crystalline substance which dissolved in water only with difficulty up to 3-5 per cent. The makers had now produced it in a fluid form, in which every cubic centimetre contained 1 gramme. The dose recommended was 0-1 g. of avertin per kg. of body-weight (or two-thirds of a gramme per stone weight). The technique of injection the solution was run slowly into the was simple ; rectum by means of a soft tube, which should be passed for four inches ; owing to the varying reaction of different patients to anaesthetic drugs it was important that the aneasthetist should be present when the solution was introduced. When a patient had had no more than 4-0 g. he might be unconscious enough to go to the operating theatre. The need for care in dosage was emphasised by a reported case which occurred in this country. A man, aged 25, was prepared for the operation of radical cure of inguinal hernia. Before the avertin he had morphia gr. . The degree of anaesthesia induced by the avertin was not sufficient for the operation, and he The operation was duly was given gas and oxygen. carried out, and he left the theatre apparently in a normal state ; yet he never recovered consciousness, and he died eight hours later. The dose given was a safe one, and the autopsy revealed no reason for the death. Dr. Blomfield thought that some undetected error must have been made in the case ; nothing comparable to this fatal unconsciousness had come References. within his own experience. 1. Scholes, F. V. G. : Diphtheria, Measles, Scarlatina, 2nd ed., The induction of unconsciousness following avertin Melbourne, 1927. was extraordinarily satisfactory, continued Dr. 2. Keen, J., and Carson, T. A.: THE LANCET, 1922, i., 914. 3. Barnes, G. C.: Ibid., p. 1018. Blomfield ; it seemed to be as pleasant a way of going 4. Forbes, Duncan: Ibid., p. 966. to sleep as could well be imagined. He had not seen 5. Stella, de: Arch. Int. de Lar. D’Otol. et de Rhin., 1903, One nervy young any accompanying excitement. xvi., 970. 6. Peters, B. A., and Allison, S. F.: THE LANCET, 1929, i., 1035. man said he felt a strong temptation to try to expel the tube from his rectum; but he was not a good subject for any anaesthetic, since on several ORBITAL ABSCESS FOLLOWING REMOVAL occasions he had had ether which he disliked very OF TONSILS AND ADENOIDS. much, and which made him vomit. Usually respiration became somewhat depressed -i.e., rather shallower BY G. NORMAN CLARK, M.B. ABERD., and slower-and the condition was not unlike sleep, HOUSE SURGEON, BELGRAVE HOSPITAL FOR CHILDREN, LONDON. except that there was somewhat less colour in the and stertor easily developed. The blood face, A GIRL, aged 4 years and 7 months, had her tonsils pressure fell by 10 to 15 mm. of mercury. Often guillotined and adenoids curetted. and was discharged when a patient had avertin unconsciousness the from hospital the next day. Four days after the corneal reflex was absent, and yet, if a painful stimulus operation she was brought up again looking very ill were applied, a reflex movement occurred, and this with a temperature of 102-8° F., marked swelling of would be repeated on the first cut with the knife. the right eyelids, proptosis, and restriction of the The therefore did not rely on absence of the speaker movements of the eyeball in all directions. On the corneal reflex. The best means of knowing that the following day some swelling of the left eye appeared. patient did not need any more anaesthetic was to A deep incision was made below the right supraorbital give strong ether vapour to inhale ; if this was border, but no pus was found. Two days later there taken quietly, without holding of the breath, it was was no improvement in the condition, the eyeball safe to begin the operation. The muscles were was displaced markedly outwards, movements were relaxed, the breathing was quiet, the circulation was very limited, and there was much swelling of the quiet, and the blood pressure was only slightly orbital tissues and injection of the conjunctiva. The i lowered. Of his own cases, only about a quarter incision was deepened inwards, and on introducing a had had a anaesthesia with avertin only. satisfactory sinus forceps pus was found lying deeply outside the Much depended on the patient and the operation. lamina papyracea of the ethmoid, the bone here being ’, The kind of patient who had given him greatest bare. The patient had an uneventful convalescence. On satisfaction with avertin was the feeble elderly person discharge the movements of the eye were full, there who was having some such operation as gastrostomybeing only slight ptosis. The Staphylococcus aureus and the kind of patient who sometimes failed to recover the Friedlander’s bacillus were cultured from the pus. after inhalation anaesthesia. Often these old subjects I have to thank Mr. Cecil Wakeley for permission required no other anaesthetic than the avertin. The to publish this case. next satisfactory class were cases of exophthalmic -
Ii
Medical Societies. ROYAL SOCIETY OF MEDICINE.
the boy was Schick negative because he had immunised himself by infecting his nose with diphtheria bacilli from the foreign body, and so administered to himself small doses of toxin. Immunisation through the Mucosa. De Stella,5 in 1903, showed by experiments on animals that the nasal mucous membrane in diphtheritic rhinitis secretes an antitoxin which neutralises the diphtheritic toxin, and so prevented toxic symptoms resulting. This is probably what happened in the case described. If this is so, a further interesting question arises as to whether it would not be practicable to immunise persons against diphtheria through the nasal mucous membrane instead of by subcutaneous injections. Peters and Allison have experimented with intranasal immunisation against scarlet fever by spraying the nose every other day with scarlet fever toxin, with the result that a number of Dick-positive persons I became Dick negative, while in others the Dick-positive reaction was much reduced in area. It seems theoretically possible to devise a method of intranasal immunisation against diphtheria which would give still more satisfactory results. If immunisation against diphtheria could be effected through the nasal mucous membrane it would also throw some light on the hypothetical latent immunisation by which natural acquired immunity is supposed to be obtained, for it would appear probable that it is through the nose that such immunity is acquired. It can be supposed that most persons on few or many occasions inhale diphtheria bacilli which produce sufficient toxin in the nose to cause, by repeated doses, immunity to develop, but not enough to cause an attack of diphtheria.
SECTION OF ANAESTHETICS. AT the meeting of this Section on Nov. 1st, with Dr. ASHLEY DALY in the chair, the subject of discussion was AVERTIN ANAESTHESIA. Dr. JOSEPH BLOMFIELD said that avert in was a tri-bromine-ethyl-alcohol, a white crystalline substance which dissolved in water only with difficulty up to 3-5 per cent. The makers had now produced it in a fluid form, in which every cubic centimetre contained 1 gramme. The dose recommended was 0-1 g. of avertin per kg. of body-weight (or two-thirds of a gramme per stone weight). The technique of injection the solution was run slowly into the was simple ; rectum by means of a soft tube, which should be passed for four inches ; owing to the varying reaction of different patients to anaesthetic drugs it was important that the aneasthetist should be present when the solution was introduced. When a patient had had no more than 4-0 g. he might be unconscious enough to go to the operating theatre. The need for care in dosage was emphasised by a reported case which occurred in this country. A man, aged 25, was prepared for the operation of radical cure of inguinal hernia. Before the avertin he had morphia gr. . The degree of anaesthesia induced by the avertin was not sufficient for the operation, and he The operation was duly was given gas and oxygen. carried out, and he left the theatre apparently in a normal state ; yet he never recovered consciousness, and he died eight hours later. The dose given was a safe one, and the autopsy revealed no reason for the death. Dr. Blomfield thought that some undetected error must have been made in the case ; nothing comparable to this fatal unconsciousness had come References. within his own experience. 1. Scholes, F. V. G. : Diphtheria, Measles, Scarlatina, 2nd ed., The induction of unconsciousness following avertin Melbourne, 1927. was extraordinarily satisfactory, continued Dr. 2. Keen, J., and Carson, T. A.: THE LANCET, 1922, i., 914. 3. Barnes, G. C.: Ibid., p. 1018. Blomfield ; it seemed to be as pleasant a way of going 4. Forbes, Duncan: Ibid., p. 966. to sleep as could well be imagined. He had not seen 5. Stella, de: Arch. Int. de Lar. D’Otol. et de Rhin., 1903, One nervy young any accompanying excitement. xvi., 970. 6. Peters, B. A., and Allison, S. F.: THE LANCET, 1929, i., 1035. man said he felt a strong temptation to try to expel the tube from his rectum; but he was not a good subject for any anaesthetic, since on several ORBITAL ABSCESS FOLLOWING REMOVAL occasions he had had ether which he disliked very OF TONSILS AND ADENOIDS. much, and which made him vomit. Usually respiration became somewhat depressed -i.e., rather shallower BY G. NORMAN CLARK, M.B. ABERD., and slower-and the condition was not unlike sleep, HOUSE SURGEON, BELGRAVE HOSPITAL FOR CHILDREN, LONDON. except that there was somewhat less colour in the and stertor easily developed. The blood face, A GIRL, aged 4 years and 7 months, had her tonsils pressure fell by 10 to 15 mm. of mercury. Often guillotined and adenoids curetted. and was discharged when a patient had avertin unconsciousness the from hospital the next day. Four days after the corneal reflex was absent, and yet, if a painful stimulus operation she was brought up again looking very ill were applied, a reflex movement occurred, and this with a temperature of 102-8° F., marked swelling of would be repeated on the first cut with the knife. the right eyelids, proptosis, and restriction of the The therefore did not rely on absence of the speaker movements of the eyeball in all directions. On the corneal reflex. The best means of knowing that the following day some swelling of the left eye appeared. patient did not need any more anaesthetic was to A deep incision was made below the right supraorbital give strong ether vapour to inhale ; if this was border, but no pus was found. Two days later there taken quietly, without holding of the breath, it was was no improvement in the condition, the eyeball safe to begin the operation. The muscles were was displaced markedly outwards, movements were relaxed, the breathing was quiet, the circulation was very limited, and there was much swelling of the quiet, and the blood pressure was only slightly orbital tissues and injection of the conjunctiva. The i lowered. Of his own cases, only about a quarter incision was deepened inwards, and on introducing a had had a anaesthesia with avertin only. satisfactory sinus forceps pus was found lying deeply outside the Much depended on the patient and the operation. lamina papyracea of the ethmoid, the bone here being ’, The kind of patient who had given him greatest bare. The patient had an uneventful convalescence. On satisfaction with avertin was the feeble elderly person discharge the movements of the eye were full, there who was having some such operation as gastrostomybeing only slight ptosis. The Staphylococcus aureus and the kind of patient who sometimes failed to recover the Friedlander’s bacillus were cultured from the pus. after inhalation anaesthesia. Often these old subjects I have to thank Mr. Cecil Wakeley for permission required no other anaesthetic than the avertin. The to publish this case. next satisfactory class were cases of exophthalmic -
Ii