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SUPPURATIVE ARTHRITIS DUE TO HÆMOPHILIC BACTERIA.
7
1341
this type of acromegaly. The kind of visual disturbwell. Although an ance in malignant acromegaly is the same as that adenoma causing benign acromegaly may have become observed in the dystrophia adiposogenitalis and in stationary, one or other of the acromegalic features the ocular type. I have discussed here only the ocular form of may progress so long as the adenoma continues to produce a secretion, as it may, for several years. That pituitary disorder and the acromegalic. The following a tumour is stationary is indicated by the absence of types have been recognised, in the sequence indicated : visual disturbances, coupled with an increase in some 1. Acromegaly (Pierre Marie. 1886). 2. Degeneratio of the acromegalic symptoms. Genuine diabetes adiposogenitalis (Frohlich, 1901). 3. The Ocular mellitus is observed only in a small number of cases; Type (Hirsch, 1911). 4. Pituitary cachexia (Simmonds, more frequently there is a reduced tolerance for 1914). 5. Diabetes insipidus pituitaria (Simmonds, 6. Nanosomia pituitaria (Erdheim, 1916). 1914). carbohydrates (alimentary glycosuria). I have operated on only three patients belonging to 7. Dysostosis pituitaria (Schüller, 1921). The last is this group, because until recently I followed the caused mainly, but not exclusively, by destruction of rule laid down by J. Wagner-Jauregg, in whose clinic the hvpophysis, thus resembling Falta’s multiple I operated on my first cases, according to which the sclerosis of the endocrine glands.
the normal pituitary secretion is increased, and if whether it is transformed
so,
as
indication for operation is above all the existence of progressive visual disturbances. In 1911 I wrotethat we would be able to give up this guiding principle when we could diminish the operative mortality of pituitary tumours, and after my experience of recent years I can say that, as a result of the improved technique, death after operation on the hypophysis is very rare. In the three cases of benign acromegaly in which I have operated benign tumours were found, consisting of eosinophil adenoma.
Malignant A cromegaly. I use the term malignant acromegaly because the condition is produced by a tumour which is progressively growing—i.e., a clinicallv malignant tumourinstead of being caused by the stationary tumour characterising benign acromegaly. I speak of a clinically malignant tumour because even by postmortem and histological examination its malignancy is sometimes not easily proved. Unrestrained growth is no doubt observed ; but it is generally expansive, and only seldom is there infiltration of the neighbouring structures by a tumour substance. Metastases so far I have not met with any. characteristic of the malignant form of acromegaly is the visual disturbance caused by a tumour with progressive growth which not only widens the sella downwards into the sphenoidal sinus but also grows upwards towards the base of brain. The optic chiasma is lying on top of the tumour and is thus pressed against the circle of Willis. In this malignant form wefind all the characteristic symptoms of acromegaly as in the benign form-viz., mask-like disfigurement of the face, thickened and projecting nose, thick and everted lower lip, spaced teeth, thickened tongue, paw-like hands, with analogous deformity of feet, kyphosis of the vertebral column, In malignant acromegaly, hypertrophic ribs, &c. unlike the benign form, the type of hair is not changed, and hypertrichosis of face as well as of trunk is rare. There are even cases in which loss of beard and axillarv hair has been observed. Genital disorders are found in the malignant form (in contradistinction to the benign) as regularly as in the other syndromes
are
very rare, and
The
SUPPURATIVE ARTHRITIS DUE TO HÆMOPHILIC BACTERIA. BY JOHN F.
TAYLOR, M.D. CAMB., THOMAS’S HOSPITAL.
ASSISTANT BACTERIOLOGIST, ST.
A
STUDY
of the medical literature
shows that
suppurative arthritis in which organisms conforming to the B. influenzœ type have been recovered in pure culture is very unusual. It appears that since 1899 only nine cases which fulfil the above conditions have been recorded. In view of the widespread distribution of these organisms this is sufficiently remarkable. A brief record of these cases may be of interest.
Slawyk,l 1899 : A child of 9 months with an abscess on the dorsum of the hand and arthritis of the ankle ; death occurred from general infection and meningitis. :Mya,2 1903 : A child of 1 year with purulent arthritis of shoulder-joint; meningitis, death. Dudgeon and Adams,31907 : A baby with suppurative arthritis of left elbow and right hip-joints ; meningitis, death. Fraser,1911 : A child of six months; suppurative arthritis of knee. Joint opened and drained ; complete recovery. Nabarro and Stallman,* 1924 : Three cases of purulent arthritis of the knee in children aged 1 year, 11 months, and 8 months respectively. In one of these cases the joint infection was preceded by a " cold " and pneumonia ; the patient died from meningitis. The other two patients had no preceding or following complications and recovered. Harris,6 1925, analysed a series of 51 cases of acute suppurative arthritis occurring in the six years 1918-1924 in the Hospital for Sick Children, Toronto. Two cases were caused by B. influenzœ, both were said to be haematogenous infections ; in one the primary focus was cellulitis of the orbit. No further details are given beyond the fact that in both cases the joints recovered completely. Maitland and Cameronevidently examined the organism from one of these cases. They refer to the strain as one from the knee-joint and blood stream of a child under Dr. Erb, in the Hospital for Sick Children, Toronto.
During the past year the following three cases by pituitary tumours—dystrophia adiposocome under my notice at St. Thomas’s Hospital, genitalis, and the ocular form. The violent headache have of the benign acromegaly is usually not observed in and the rarity of the condition seems to justify their the malignant form, though the pituitary tumour is publication. Clinical Records. far larger. CASE 1.—M. S., female, aged 7 months. Admitted under The course of development of malignant acromegaly can be explained in the following way. Originally there Mr. C. M. Page with an acute arthritis of the right hip-joint. Ternp., 100°-103°F.; is an active adenoma which during its initial stage No history of preceding illness. caused
secretion by which acromegaly is produced ; later the adenoma-provided it is primarily of a malignant nature—develops in a malignant way ; its quality of forming a secretion is lost, and it takes on the character of those inactive tumours found in dystrophia adiposogenitalis, and in the ocular type. On histological examination the tumour is not always W’e haveseen that the found to be eosinophil. syndrome of the malignant acromegaly consists of acromegaly and various symptoms of dystrophia adiposogenitalis or of the ocular form. Therefore vve must not wonder at the addition of adiposity to
discharges
a
2 Arch. f. Laryng. 1911. xxvi.
pulse, 100—140. The joint was incised by Mr. (’. V. Patrick, resident assistant surgeon, and about 2oz. of thick, viscous. yellow pus evacuated. Some caries of the head of the The temperature femur and the acetabulum was noted. and pulse fell to normal within a few days. Healing of the wound was somewhat slow, but complete after six to eight weeks. The destruction of bone produced a tendency to upward dislocation which was eventually overcome by means of plaster splinting and extension. When last seen (four months after operation) the patient’s condition was in every way
satisfactory.
Films of the pus, when stained bv Graul’s method and counterstained by dilute carbol-fuchsin, showed a moderate number of minute Cram-negative rods. Cultures on nutrient agar and in beef broth were sterile. on blood-agar very few minute, non-hæmolytic colonies appeared, but
a
1342 The doses employed in the animal experiments haemoglobin agar the growth was profuse. (This medium prepared by adding 4 per cent. of whole oxalated were very variable, but with this reservation in mind human blood to melted agar and heating at 80° C. for five it is seen that the results of human and animal minutes.) The colonies varied in size from those barely infection were fairly parallel. The exception is distinguishable with a hand lens up to a small pin’s head, Nabarro and Stallman’s Case 1, in which the guinea-pig but all were discrete, regular, faintly grey in colour, and was given approximately the same dose as in their on
was
Films translucent. No other organisms were present. A fair from the cultures showed marked pleomorphism. number of fine rods were still seen. but minute cocco-bacilli predominated and coarser rods and a few filamentous forms After the third subculture the organism were also present. Swabs from the patient’s nasopharynx gave an died. identical organism, not in pure culture. Three days after the operation the patient’s serum was tested for agglutinating properties. Emulsions of the organisms from the pus and nasopharynx were agglutinated in a dilution of 1 in 200. Controls with three normal sera and with saline were completely negative in all dilutions from 1 in 25 upwards. Pathogenicity.—Saline emulsions were made from 24-hour subcultures on haemoglobin-agar and doses estimated by A guinea-pig received Brown and Kirwan’s method.8 200 million bacilli intraperitoneally and two rabbits were given intravenous injections of 200 and 1000 million respectively. None of these animals showed any signs of illness. The early death of the organism prevented further experiments with fluid cultures or more massive doses.
Case 2. No definite conclusions can be drawn from the small number of cases available, but they are shown for what they are worth. Fatal to patient. Fatal to animals.
Author.
...... Mya ..... Fraser ......
Slawyk
Nabarro and Stallman "
Yes.
No.
i
1 ! ,, 2 3
Taylor 1 .....
Yes. No.
YeH. :No..* I’ea. No. Yes.†
Xo.t
Fatal to a mouse when grown on staphylococcus agar only. t Guinea-pig died, but the organism was not recovered from it. t Comparatively small doses only used.
to what
The question arises place in the CASE 2.-R. L., female, aged 18 months. Admitted under Sir Cuthbert Wallace. She had had whooping-cough and bacteriological nomenclature is to be given to these The problem of classifying the haemowas still coughing. The left knee was swollen and very organisms. tender. Temp., 102° ; pulse, 140. The joint was aspirated philic bacteria has been attacked from several and 4 c.cm. of semi-purulent fluid withdrawn. Reaspiration different angles. Cohen9 and Henry 10 found that was performed three times during the following week, and strains isolated from cases of meningitis were more the patient was severely toxic for a fortnight or more. The toxic to animals, and that they tended to kill more temperature became normal after three weeks, and recovery frequently by septicæmia, than those isolated from the was then uneventful. Two months later the joint was found to be normal, except for slight periarticular thickening. respiratory tract. Cohen further stated that animals The bacteriological examinations in this case were carried could be protected against meningeal strains by out by Dr. R. J. V. Pulvertaft, pathologist to the units, inoculation with such strains, but that respiratory St. Thomas’s Hospital, to whom I am indebted for strains did not so protect. On these grounds he conthe following information : The pus obtained at all four sidered them to be a different species. Henry also aspirations showed a minute Gram-negative bacillus in called attention to their marked pleomorphism in This organism was identical both morpho- culture but made no definite separation. pure culture. logically and culturally with that found in Case 1, and further Dible 11 separated the haemophilic bacteria found resembled it in soon dying out in subculture. It could not (a) hæmolytic; be found in the throat or nasopharynx, and blood culture in the throat into three groups : was also negative. (b) non-hsemolytic but with a tendency to production It was hoped to establish a serological relationship with of long leptothricoid threads ; (c) non-haemolytic, B. pertussis, but the death of the organism prevented further strictly hsemophilic, give uniform turbidity in fluid tests. media, appear in films as minute bacilli or coccoCASE 3.-P. K., female, aged 8 months. Admitted under bacilli, produce sharply outlined lenticular colonies. Mr. Percy Sargent with a hot tender swelling of the lower He considers that only group (c) should be called part of the left thigh. Temp., 102° ; pulse, 152. X ray Bacillus influenzœ Pfeiffer. examination by Mr. Geoffrey Fildes showed no bony change. Maitland and Cameronexamined a very large The swelling was incised over the inner side of the femur; number of strains as to agglutination and agglutinin no pus found. Four days later the swelling had extended that while a few strains considered absorption. They to the knee, the joint was opened on the inner side, and several ounces of fairly fluid yellow pus evacuated. The showed common properties in these respects, the general condition steadily improved, and the temperature great majority only reacted with their homologous reached and maintained a normal level after 10 or 12 days. sera. The strain recovered from Erb’s case of arthritis The operation wound was completely healed after three differed from other strains no more than they did weeks. Extension to prevent contracture was applied by from each other. The patient was a congenital means of a Balkan beam. Are any or all of the haemophilic bacteria found in syphilitic, and while under treatment for this condition these cases of suppurative arthritis to be called she contracted erysipelas, of which she died. At the postmortem no sign of disease was found in the affected joint. B. influenzce Pfeiffer, are they variants of it, or are Examination of the pus found at operation again showed they one or more different species ? It is interesting to read that the strain recovered from the first recorded a minute Gram-negative bacillus corresponding in morphological and cultural characters to the other two strains. case-Slawyk’s-was examined by Pfeiffer himself. Further examination of the organism was prevented by an Apparently he had no hesitation in accepting it as the insuperable contamination by B. subtilis. which bears his but at that time no now
organism
as
name,
haemophilic bacteria had been described. The Discussion. increased pathogenicity and pleomorphism of some The 12 cases now recorded show one common of the strains might lead us to class them with the feature in that the patients were all children. Otherwise meningeal strains described by Cohen and Henry. they fall into two groups : (a) suppurative arthritis Under Dible’s classification some might be included with fatal pyaemia and meningitis ; (b) suppurative in his group (b) on account of the formation of In this group not only does the filaments in cultures. In my Case 2 the occurrence arthritis only. but recover the joint also recovers its normal of the arthritis during an attack of whooping-cough patient condition and function. Indeed, Nabarro and Stallman suggests that further examination might have shown noted at the post-mortem on their fatal case that the the organism to have been B. pertussis. B. influenzœ infected joint showed a definite tendency towards Pfeiffer is said to live indefinitely if frequently subrepair. So far, then, as the joints themselves are cultured on haemoglobin agar. The strains from my concerned the prognosis in these infections is a Cases 1 and 2 both died after the third subculture, and Fraser had the same experience with hers. good one. In this connexion it is perhaps interesting to note I do not think it is possible to place these organisms. the relationship between the type of case and, when at all definitely, but the brief résumé of the evidence tested, the pathogenicity of the infecting organism available may lead others who meet similar cases to animals. (See table.) to do so. It seems advisable in the present state of other
1343
our knowledge to be content with the non-committal description of haemophilic bacteria." My thanks are due to Sir Cuthbert Wallace, Mr. Percy Sargent, and Ir. C. M. Page for access to their case-notes, and to Dr. R. J. V. Pulvertaft for his bacteriological findings in one of the cases. "
were not made, at cases-
but Balmainhas found in
Streptococci 43 times, 13 times in Staphylococci 52 21 Diphtheroids 3 1 "
"
"
"
a
series
pure culture. "
He states that the majority of cases were infected with both staphylococci and streptococci: He also notices the superiority of flavine and paraffin to other References. of treatment. 1. Slawyk: Ein Fall von Allgemeininfection mit Influenza- forms Most authors claim that impetigo can be easily bacillen, Zeit. f. Hyg. u. Infectionskrankheiten, 1899, cured by the application of ultra-violet rays. xxxii., 443. For 2. Mya, G.: Meningite cerebro-spinale fibrino purulenta de W. K. and E. II. Russellstate that impetigo Bacillo di Pfeiffer, Gazetta degli Ospedali e della Clinica, instance, contagiosa can be cured by means of the air-cooled 1903, No. 26, p. 268. 3. Dudgeon, L. S., and Adams. J. E.: A Case of Pyæmia mercury-vapour lamp if the crusts are previously due to the Influenza Bacillus with Multiple Arthritis removed, and if a third degree erythema is produced. and Meningitis, THE LANCET, 1907, ii., 684. It may be mentioned that a third degree erythema is T.: A Case of of the KneeE. Arthritis 4. Fraser, Suppurative joint due to Influenza Bacilli occurring in a Baby aged a severe reaction producing general coarse desquama6 months, THE LANCET, 1911, i., 1573. and is very painful. They further state that On Influenzal tion, 5. Nabarro, David, and Stallman, J. F. H.: the first application prevents the lesions from spreadArthritis, THE LANCET, 1924, ii., 743. 6. Harris, R. I.: Acute Suppurative Arthritis in Children, ing, and that the disease can be cured by three or four
Jour. of Bone and Joint Surgery, 1925, xxiii., 849. 7. Maitland, H. B., and Cameron, G. C.: Study of Hæmoglobinophilic Bacteria by Agglutination and Agglutinin Absorption, Brit. Jour. of Exp. Path., 1921. ii., 283. 8. Brown, H. C., and Kirwan, E. W. O’G.: Standardisation of Bacterial Suspensions by Opacity, Indian Jour. of Med. Research, 1914-15, ii., 763. 9. Cohen: La méningite cérébro-spinale septicemique, Ann. de l’Inst. Pasteur, 1909, iv., 273. 10. Henry, Herbert: Meningitis due to Hæmophilic Organisms, Jour. of Path. and Bact., 1913. xvii., 174. 11. Dible, J. Henry: The Hæmophilic Bacteria of the Normal Throat : their Types and Incidence, Ibid., 1924, xxvii., 2, 151.
THE TREATMENT OF
IMPETIGO CONTAGIOSA BY MEANS OF ULTRA-VIOLET RAYS. BY
J.
HOUSE
B. ELLISON, M.B., B.CHIR. CAMB., PHYSICIAN, QUEEN’S HOSPITAL
FOR CHILDREN.
TREATMENT by ultra-violet rays has recently become popular that there is practically no pathological condition for which it has not been advised. It must, nevertheless, be confessed that at present evidence of the value of these rays rests more on the assertion of enthusiasts than on the demonstration of scientific
so
investigators. Recently Roxburghhas published the results
of
treatment of 276 cases of 54 distinct diseases with the mercury-vapour lamp. He omits to give certain details of technique-for instance, the distance of the patient from the lamp, and the interval of time between each exposure-and does not allude to
applications.
Local treatment is advised at short range. " For the bactericidal effect, and to increase the flow of blood and lymph to the part." They add, " we have treated a large number of children with this condition, and have been uniformly successful." Unfortunately, only one case is quoted, in which cure was effected after four applications in a week. It is not stated whether any local antiseptic was used in this case. 5 quoted one case as cured after 12 applications, Fergusonsuggests local treatment at 12 inches with five minutes’ exposure, and says that a third degree erythema is desirable. He mentions three cases, but gives no details. Roxburgh6 has 11 cases of impetigo in his list. Of these, three were cured or much improved, three were somewhat improved ; there was no improvement in two cases and no report on three. He remarks : " In impetigo contagiosa the cure seemed to be definitely accelerated-in more than half the cases by the employment of ultra-violet light, in addition to ordinary antiseptic treatment " (he omits to define this further), "and in one or two cases to be possible with U.V.L. alone. X rays, as is well known, make impetigo worse." The kind of lamp used is not stated. type of lamp used appears to have an important bearing on the matter, since the nature of the rays escaping from the water-cooled variety differs from that of those which emerge from the more generally used air-cooled lamp. Thus HumphrisR states : " Near ultra-violet, intensity (filtered through mercury vapour as in the air-cooled lamp) has not much germicidal action, but is more penetrative." Tf this be so it would be expected that the cure of impetigo by means of the air-cooled lamp would be effected rather by building up bodily resistance than by the direct germicidal action of the rays. The following observations tend to confirm this view.
control cases. The present investigation has been undertaken in order to test the effect of ultra-violet light on a common superficial skin infection. In such a disease the results of treatment can be easily and accurately estimated and control cases can be easily obtained. Impetigo contagiosa was selected as being exceedingly common, and because it causes loss of very many school hours among London children, and does not always yield so readily to treatment as is commonlv I supposed, some cases requiring five or six weeks’ treatment with the orthodox ammoniated mercury ointment before they can be discharged as fit for school. A mixture of flavine and paraffin has been used now for some time at the Queen’s Hospital for Children as a routine treatment, and has proved very satisfactory, since it prevents the formation of crusts and necessity for their painful removal as with other forms of treatment. A record of the results of this treatment is quoted below for comparison. In selecting cases the diagnosis was made on clinical grounds alone. Crusting and a tendency to spread were the principal features looked for ; some cases of impetiginised eczema are included in the list, the eczema revealing itself on the disappearance of the
superficial impetigo.
Bacteriological investigations
Troup
The
Technique Employed in the Present lm:c",Ugrdion. One lamp was used for the treatment of all cases. This was the Cooper Hewitt direct current air-cooled quartz
mercury-vapour
arc
lamp.
- 4g’e of Lamp.-The lamp had been running for rather more than 1000 hours, and consequentlv the emitting power had become much less than that of a new lamp. Strength of Lamp.-No attempt was made to estimate the emitting power, since the units employed are purely empirical An and no general standard has as yet been adopted. exposure of five minutes at one foot was sumc’ent to produce a brisk erythema in the majority of normal children, and in one case a burn was produced by tirs exposure. An exposure of nine rninutes at three feet was sufficient to cause definite erythema of the skin of the abdominal wall in most All the patients treated were children of ages children. ranging from 6 months to 15 years. Two methods of exposure were used: 1. Local exposure of the affected area alone (e.g., face) at a range of one foot. 2. General exposure of the whole body at a range of three feet. After exposure in both cases a standard lotion was applied to the affected area. This consisted of a mixture of equal parts of lotio calaminm and lotio nigra. This lotion has weak curative properties, and was used alone on most
1341
this type of acromegaly. The kind of visual disturbwell. Although an ance in malignant acromegaly is the same as that adenoma causing benign acromegaly may have become observed in the dystrophia adiposogenitalis and in stationary, one or other of the acromegalic features the ocular type. I have discussed here only the ocular form of may progress so long as the adenoma continues to produce a secretion, as it may, for several years. That pituitary disorder and the acromegalic. The following a tumour is stationary is indicated by the absence of types have been recognised, in the sequence indicated : visual disturbances, coupled with an increase in some 1. Acromegaly (Pierre Marie. 1886). 2. Degeneratio of the acromegalic symptoms. Genuine diabetes adiposogenitalis (Frohlich, 1901). 3. The Ocular mellitus is observed only in a small number of cases; Type (Hirsch, 1911). 4. Pituitary cachexia (Simmonds, more frequently there is a reduced tolerance for 1914). 5. Diabetes insipidus pituitaria (Simmonds, 6. Nanosomia pituitaria (Erdheim, 1916). 1914). carbohydrates (alimentary glycosuria). I have operated on only three patients belonging to 7. Dysostosis pituitaria (Schüller, 1921). The last is this group, because until recently I followed the caused mainly, but not exclusively, by destruction of rule laid down by J. Wagner-Jauregg, in whose clinic the hvpophysis, thus resembling Falta’s multiple I operated on my first cases, according to which the sclerosis of the endocrine glands.
the normal pituitary secretion is increased, and if whether it is transformed
so,
as
indication for operation is above all the existence of progressive visual disturbances. In 1911 I wrotethat we would be able to give up this guiding principle when we could diminish the operative mortality of pituitary tumours, and after my experience of recent years I can say that, as a result of the improved technique, death after operation on the hypophysis is very rare. In the three cases of benign acromegaly in which I have operated benign tumours were found, consisting of eosinophil adenoma.
Malignant A cromegaly. I use the term malignant acromegaly because the condition is produced by a tumour which is progressively growing—i.e., a clinicallv malignant tumourinstead of being caused by the stationary tumour characterising benign acromegaly. I speak of a clinically malignant tumour because even by postmortem and histological examination its malignancy is sometimes not easily proved. Unrestrained growth is no doubt observed ; but it is generally expansive, and only seldom is there infiltration of the neighbouring structures by a tumour substance. Metastases so far I have not met with any. characteristic of the malignant form of acromegaly is the visual disturbance caused by a tumour with progressive growth which not only widens the sella downwards into the sphenoidal sinus but also grows upwards towards the base of brain. The optic chiasma is lying on top of the tumour and is thus pressed against the circle of Willis. In this malignant form wefind all the characteristic symptoms of acromegaly as in the benign form-viz., mask-like disfigurement of the face, thickened and projecting nose, thick and everted lower lip, spaced teeth, thickened tongue, paw-like hands, with analogous deformity of feet, kyphosis of the vertebral column, In malignant acromegaly, hypertrophic ribs, &c. unlike the benign form, the type of hair is not changed, and hypertrichosis of face as well as of trunk is rare. There are even cases in which loss of beard and axillarv hair has been observed. Genital disorders are found in the malignant form (in contradistinction to the benign) as regularly as in the other syndromes
are
very rare, and
The
SUPPURATIVE ARTHRITIS DUE TO HÆMOPHILIC BACTERIA. BY JOHN F.
TAYLOR, M.D. CAMB., THOMAS’S HOSPITAL.
ASSISTANT BACTERIOLOGIST, ST.
A
STUDY
of the medical literature
shows that
suppurative arthritis in which organisms conforming to the B. influenzœ type have been recovered in pure culture is very unusual. It appears that since 1899 only nine cases which fulfil the above conditions have been recorded. In view of the widespread distribution of these organisms this is sufficiently remarkable. A brief record of these cases may be of interest.
Slawyk,l 1899 : A child of 9 months with an abscess on the dorsum of the hand and arthritis of the ankle ; death occurred from general infection and meningitis. :Mya,2 1903 : A child of 1 year with purulent arthritis of shoulder-joint; meningitis, death. Dudgeon and Adams,31907 : A baby with suppurative arthritis of left elbow and right hip-joints ; meningitis, death. Fraser,1911 : A child of six months; suppurative arthritis of knee. Joint opened and drained ; complete recovery. Nabarro and Stallman,* 1924 : Three cases of purulent arthritis of the knee in children aged 1 year, 11 months, and 8 months respectively. In one of these cases the joint infection was preceded by a " cold " and pneumonia ; the patient died from meningitis. The other two patients had no preceding or following complications and recovered. Harris,6 1925, analysed a series of 51 cases of acute suppurative arthritis occurring in the six years 1918-1924 in the Hospital for Sick Children, Toronto. Two cases were caused by B. influenzœ, both were said to be haematogenous infections ; in one the primary focus was cellulitis of the orbit. No further details are given beyond the fact that in both cases the joints recovered completely. Maitland and Cameronevidently examined the organism from one of these cases. They refer to the strain as one from the knee-joint and blood stream of a child under Dr. Erb, in the Hospital for Sick Children, Toronto.
During the past year the following three cases by pituitary tumours—dystrophia adiposocome under my notice at St. Thomas’s Hospital, genitalis, and the ocular form. The violent headache have of the benign acromegaly is usually not observed in and the rarity of the condition seems to justify their the malignant form, though the pituitary tumour is publication. Clinical Records. far larger. CASE 1.—M. S., female, aged 7 months. Admitted under The course of development of malignant acromegaly can be explained in the following way. Originally there Mr. C. M. Page with an acute arthritis of the right hip-joint. Ternp., 100°-103°F.; is an active adenoma which during its initial stage No history of preceding illness. caused
secretion by which acromegaly is produced ; later the adenoma-provided it is primarily of a malignant nature—develops in a malignant way ; its quality of forming a secretion is lost, and it takes on the character of those inactive tumours found in dystrophia adiposogenitalis, and in the ocular type. On histological examination the tumour is not always W’e haveseen that the found to be eosinophil. syndrome of the malignant acromegaly consists of acromegaly and various symptoms of dystrophia adiposogenitalis or of the ocular form. Therefore vve must not wonder at the addition of adiposity to
discharges
a
2 Arch. f. Laryng. 1911. xxvi.
pulse, 100—140. The joint was incised by Mr. (’. V. Patrick, resident assistant surgeon, and about 2oz. of thick, viscous. yellow pus evacuated. Some caries of the head of the The temperature femur and the acetabulum was noted. and pulse fell to normal within a few days. Healing of the wound was somewhat slow, but complete after six to eight weeks. The destruction of bone produced a tendency to upward dislocation which was eventually overcome by means of plaster splinting and extension. When last seen (four months after operation) the patient’s condition was in every way
satisfactory.
Films of the pus, when stained bv Graul’s method and counterstained by dilute carbol-fuchsin, showed a moderate number of minute Cram-negative rods. Cultures on nutrient agar and in beef broth were sterile. on blood-agar very few minute, non-hæmolytic colonies appeared, but
a
1342 The doses employed in the animal experiments haemoglobin agar the growth was profuse. (This medium prepared by adding 4 per cent. of whole oxalated were very variable, but with this reservation in mind human blood to melted agar and heating at 80° C. for five it is seen that the results of human and animal minutes.) The colonies varied in size from those barely infection were fairly parallel. The exception is distinguishable with a hand lens up to a small pin’s head, Nabarro and Stallman’s Case 1, in which the guinea-pig but all were discrete, regular, faintly grey in colour, and was given approximately the same dose as in their on
was
Films translucent. No other organisms were present. A fair from the cultures showed marked pleomorphism. number of fine rods were still seen. but minute cocco-bacilli predominated and coarser rods and a few filamentous forms After the third subculture the organism were also present. Swabs from the patient’s nasopharynx gave an died. identical organism, not in pure culture. Three days after the operation the patient’s serum was tested for agglutinating properties. Emulsions of the organisms from the pus and nasopharynx were agglutinated in a dilution of 1 in 200. Controls with three normal sera and with saline were completely negative in all dilutions from 1 in 25 upwards. Pathogenicity.—Saline emulsions were made from 24-hour subcultures on haemoglobin-agar and doses estimated by A guinea-pig received Brown and Kirwan’s method.8 200 million bacilli intraperitoneally and two rabbits were given intravenous injections of 200 and 1000 million respectively. None of these animals showed any signs of illness. The early death of the organism prevented further experiments with fluid cultures or more massive doses.
Case 2. No definite conclusions can be drawn from the small number of cases available, but they are shown for what they are worth. Fatal to patient. Fatal to animals.
Author.
...... Mya ..... Fraser ......
Slawyk
Nabarro and Stallman "
Yes.
No.
i
1 ! ,, 2 3
Taylor 1 .....
Yes. No.
YeH. :No..* I’ea. No. Yes.†
Xo.t
Fatal to a mouse when grown on staphylococcus agar only. t Guinea-pig died, but the organism was not recovered from it. t Comparatively small doses only used.
to what
The question arises place in the CASE 2.-R. L., female, aged 18 months. Admitted under Sir Cuthbert Wallace. She had had whooping-cough and bacteriological nomenclature is to be given to these The problem of classifying the haemowas still coughing. The left knee was swollen and very organisms. tender. Temp., 102° ; pulse, 140. The joint was aspirated philic bacteria has been attacked from several and 4 c.cm. of semi-purulent fluid withdrawn. Reaspiration different angles. Cohen9 and Henry 10 found that was performed three times during the following week, and strains isolated from cases of meningitis were more the patient was severely toxic for a fortnight or more. The toxic to animals, and that they tended to kill more temperature became normal after three weeks, and recovery frequently by septicæmia, than those isolated from the was then uneventful. Two months later the joint was found to be normal, except for slight periarticular thickening. respiratory tract. Cohen further stated that animals The bacteriological examinations in this case were carried could be protected against meningeal strains by out by Dr. R. J. V. Pulvertaft, pathologist to the units, inoculation with such strains, but that respiratory St. Thomas’s Hospital, to whom I am indebted for strains did not so protect. On these grounds he conthe following information : The pus obtained at all four sidered them to be a different species. Henry also aspirations showed a minute Gram-negative bacillus in called attention to their marked pleomorphism in This organism was identical both morpho- culture but made no definite separation. pure culture. logically and culturally with that found in Case 1, and further Dible 11 separated the haemophilic bacteria found resembled it in soon dying out in subculture. It could not (a) hæmolytic; be found in the throat or nasopharynx, and blood culture in the throat into three groups : was also negative. (b) non-hsemolytic but with a tendency to production It was hoped to establish a serological relationship with of long leptothricoid threads ; (c) non-haemolytic, B. pertussis, but the death of the organism prevented further strictly hsemophilic, give uniform turbidity in fluid tests. media, appear in films as minute bacilli or coccoCASE 3.-P. K., female, aged 8 months. Admitted under bacilli, produce sharply outlined lenticular colonies. Mr. Percy Sargent with a hot tender swelling of the lower He considers that only group (c) should be called part of the left thigh. Temp., 102° ; pulse, 152. X ray Bacillus influenzœ Pfeiffer. examination by Mr. Geoffrey Fildes showed no bony change. Maitland and Cameronexamined a very large The swelling was incised over the inner side of the femur; number of strains as to agglutination and agglutinin no pus found. Four days later the swelling had extended that while a few strains considered absorption. They to the knee, the joint was opened on the inner side, and several ounces of fairly fluid yellow pus evacuated. The showed common properties in these respects, the general condition steadily improved, and the temperature great majority only reacted with their homologous reached and maintained a normal level after 10 or 12 days. sera. The strain recovered from Erb’s case of arthritis The operation wound was completely healed after three differed from other strains no more than they did weeks. Extension to prevent contracture was applied by from each other. The patient was a congenital means of a Balkan beam. Are any or all of the haemophilic bacteria found in syphilitic, and while under treatment for this condition these cases of suppurative arthritis to be called she contracted erysipelas, of which she died. At the postmortem no sign of disease was found in the affected joint. B. influenzce Pfeiffer, are they variants of it, or are Examination of the pus found at operation again showed they one or more different species ? It is interesting to read that the strain recovered from the first recorded a minute Gram-negative bacillus corresponding in morphological and cultural characters to the other two strains. case-Slawyk’s-was examined by Pfeiffer himself. Further examination of the organism was prevented by an Apparently he had no hesitation in accepting it as the insuperable contamination by B. subtilis. which bears his but at that time no now
organism
as
name,
haemophilic bacteria had been described. The Discussion. increased pathogenicity and pleomorphism of some The 12 cases now recorded show one common of the strains might lead us to class them with the feature in that the patients were all children. Otherwise meningeal strains described by Cohen and Henry. they fall into two groups : (a) suppurative arthritis Under Dible’s classification some might be included with fatal pyaemia and meningitis ; (b) suppurative in his group (b) on account of the formation of In this group not only does the filaments in cultures. In my Case 2 the occurrence arthritis only. but recover the joint also recovers its normal of the arthritis during an attack of whooping-cough patient condition and function. Indeed, Nabarro and Stallman suggests that further examination might have shown noted at the post-mortem on their fatal case that the the organism to have been B. pertussis. B. influenzœ infected joint showed a definite tendency towards Pfeiffer is said to live indefinitely if frequently subrepair. So far, then, as the joints themselves are cultured on haemoglobin agar. The strains from my concerned the prognosis in these infections is a Cases 1 and 2 both died after the third subculture, and Fraser had the same experience with hers. good one. In this connexion it is perhaps interesting to note I do not think it is possible to place these organisms. the relationship between the type of case and, when at all definitely, but the brief résumé of the evidence tested, the pathogenicity of the infecting organism available may lead others who meet similar cases to animals. (See table.) to do so. It seems advisable in the present state of other
1343
our knowledge to be content with the non-committal description of haemophilic bacteria." My thanks are due to Sir Cuthbert Wallace, Mr. Percy Sargent, and Ir. C. M. Page for access to their case-notes, and to Dr. R. J. V. Pulvertaft for his bacteriological findings in one of the cases. "
were not made, at cases-
but Balmainhas found in
Streptococci 43 times, 13 times in Staphylococci 52 21 Diphtheroids 3 1 "
"
"
"
a
series
pure culture. "
He states that the majority of cases were infected with both staphylococci and streptococci: He also notices the superiority of flavine and paraffin to other References. of treatment. 1. Slawyk: Ein Fall von Allgemeininfection mit Influenza- forms Most authors claim that impetigo can be easily bacillen, Zeit. f. Hyg. u. Infectionskrankheiten, 1899, cured by the application of ultra-violet rays. xxxii., 443. For 2. Mya, G.: Meningite cerebro-spinale fibrino purulenta de W. K. and E. II. Russellstate that impetigo Bacillo di Pfeiffer, Gazetta degli Ospedali e della Clinica, instance, contagiosa can be cured by means of the air-cooled 1903, No. 26, p. 268. 3. Dudgeon, L. S., and Adams. J. E.: A Case of Pyæmia mercury-vapour lamp if the crusts are previously due to the Influenza Bacillus with Multiple Arthritis removed, and if a third degree erythema is produced. and Meningitis, THE LANCET, 1907, ii., 684. It may be mentioned that a third degree erythema is T.: A Case of of the KneeE. Arthritis 4. Fraser, Suppurative joint due to Influenza Bacilli occurring in a Baby aged a severe reaction producing general coarse desquama6 months, THE LANCET, 1911, i., 1573. and is very painful. They further state that On Influenzal tion, 5. Nabarro, David, and Stallman, J. F. H.: the first application prevents the lesions from spreadArthritis, THE LANCET, 1924, ii., 743. 6. Harris, R. I.: Acute Suppurative Arthritis in Children, ing, and that the disease can be cured by three or four
Jour. of Bone and Joint Surgery, 1925, xxiii., 849. 7. Maitland, H. B., and Cameron, G. C.: Study of Hæmoglobinophilic Bacteria by Agglutination and Agglutinin Absorption, Brit. Jour. of Exp. Path., 1921. ii., 283. 8. Brown, H. C., and Kirwan, E. W. O’G.: Standardisation of Bacterial Suspensions by Opacity, Indian Jour. of Med. Research, 1914-15, ii., 763. 9. Cohen: La méningite cérébro-spinale septicemique, Ann. de l’Inst. Pasteur, 1909, iv., 273. 10. Henry, Herbert: Meningitis due to Hæmophilic Organisms, Jour. of Path. and Bact., 1913. xvii., 174. 11. Dible, J. Henry: The Hæmophilic Bacteria of the Normal Throat : their Types and Incidence, Ibid., 1924, xxvii., 2, 151.
THE TREATMENT OF
IMPETIGO CONTAGIOSA BY MEANS OF ULTRA-VIOLET RAYS. BY
J.
HOUSE
B. ELLISON, M.B., B.CHIR. CAMB., PHYSICIAN, QUEEN’S HOSPITAL
FOR CHILDREN.
TREATMENT by ultra-violet rays has recently become popular that there is practically no pathological condition for which it has not been advised. It must, nevertheless, be confessed that at present evidence of the value of these rays rests more on the assertion of enthusiasts than on the demonstration of scientific
so
investigators. Recently Roxburghhas published the results
of
treatment of 276 cases of 54 distinct diseases with the mercury-vapour lamp. He omits to give certain details of technique-for instance, the distance of the patient from the lamp, and the interval of time between each exposure-and does not allude to
applications.
Local treatment is advised at short range. " For the bactericidal effect, and to increase the flow of blood and lymph to the part." They add, " we have treated a large number of children with this condition, and have been uniformly successful." Unfortunately, only one case is quoted, in which cure was effected after four applications in a week. It is not stated whether any local antiseptic was used in this case. 5 quoted one case as cured after 12 applications, Fergusonsuggests local treatment at 12 inches with five minutes’ exposure, and says that a third degree erythema is desirable. He mentions three cases, but gives no details. Roxburgh6 has 11 cases of impetigo in his list. Of these, three were cured or much improved, three were somewhat improved ; there was no improvement in two cases and no report on three. He remarks : " In impetigo contagiosa the cure seemed to be definitely accelerated-in more than half the cases by the employment of ultra-violet light, in addition to ordinary antiseptic treatment " (he omits to define this further), "and in one or two cases to be possible with U.V.L. alone. X rays, as is well known, make impetigo worse." The kind of lamp used is not stated. type of lamp used appears to have an important bearing on the matter, since the nature of the rays escaping from the water-cooled variety differs from that of those which emerge from the more generally used air-cooled lamp. Thus HumphrisR states : " Near ultra-violet, intensity (filtered through mercury vapour as in the air-cooled lamp) has not much germicidal action, but is more penetrative." Tf this be so it would be expected that the cure of impetigo by means of the air-cooled lamp would be effected rather by building up bodily resistance than by the direct germicidal action of the rays. The following observations tend to confirm this view.
control cases. The present investigation has been undertaken in order to test the effect of ultra-violet light on a common superficial skin infection. In such a disease the results of treatment can be easily and accurately estimated and control cases can be easily obtained. Impetigo contagiosa was selected as being exceedingly common, and because it causes loss of very many school hours among London children, and does not always yield so readily to treatment as is commonlv I supposed, some cases requiring five or six weeks’ treatment with the orthodox ammoniated mercury ointment before they can be discharged as fit for school. A mixture of flavine and paraffin has been used now for some time at the Queen’s Hospital for Children as a routine treatment, and has proved very satisfactory, since it prevents the formation of crusts and necessity for their painful removal as with other forms of treatment. A record of the results of this treatment is quoted below for comparison. In selecting cases the diagnosis was made on clinical grounds alone. Crusting and a tendency to spread were the principal features looked for ; some cases of impetiginised eczema are included in the list, the eczema revealing itself on the disappearance of the
superficial impetigo.
Bacteriological investigations
Troup
The
Technique Employed in the Present lm:c",Ugrdion. One lamp was used for the treatment of all cases. This was the Cooper Hewitt direct current air-cooled quartz
mercury-vapour
arc
lamp.
- 4g’e of Lamp.-The lamp had been running for rather more than 1000 hours, and consequentlv the emitting power had become much less than that of a new lamp. Strength of Lamp.-No attempt was made to estimate the emitting power, since the units employed are purely empirical An and no general standard has as yet been adopted. exposure of five minutes at one foot was sumc’ent to produce a brisk erythema in the majority of normal children, and in one case a burn was produced by tirs exposure. An exposure of nine rninutes at three feet was sufficient to cause definite erythema of the skin of the abdominal wall in most All the patients treated were children of ages children. ranging from 6 months to 15 years. Two methods of exposure were used: 1. Local exposure of the affected area alone (e.g., face) at a range of one foot. 2. General exposure of the whole body at a range of three feet. After exposure in both cases a standard lotion was applied to the affected area. This consisted of a mixture of equal parts of lotio calaminm and lotio nigra. This lotion has weak curative properties, and was used alone on most