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THE TREATMENT OF CHRONIC INTESTINAL STASIS BY COLLOIDAL KAOLIN.
432 nourished infant with good pink colour, lying comfort- division. When I began to study the properties of in its cradle with no sign of anything amiss in colloidal kaolin as an adsorbent of intestinal toxins, heart or lungs, is not suggestive of any particular I was struck with its efficacy, and the benefit derived respiratory danger. It was of just such an infant as from its administration in stasis. Others, to whom I this that I gave a hopeful prognosis to the parents, introduced it, reported similar favourable results, and and five minutes later, before I had left the house, the time has come to publish an account of its use in attack another occurred which proved fatal. the treatment of stasis. Intestinal stasis is, I am convinced, at the root of Obviously such attacks as these may have an important medico-legal bearing, for it is possible that the most of the disorders of digestion, and the toxaemia first attack of this kind might prove fatal, and, indeed, of stasis is responsible for a number of local and general These have been fully described and would almost certainly do so unless someone happened disorders. to observe the cessation of breathing, so that death explained by Sir Arbuthnot Lane in his classic; they are also dealt with in my papers on. might easily be attributed to overlaying or some more I writings sinister cause, when an apparently healthy infant had stasis.1 without any apparent illness been found dead in its Surgical Treatment of Stasis. mother’s bed or in its cot. Stasis demands surgical intervention : (a) when What is the meaning of these attacks ?Are they it has led to a local disease, such as gastric orprimarily of pulmonary origin, or are they, if I may duodenal ulcer, gall-stones, an appendix abscess, or so say, syncopal attacks in the respiratory centre ? an obstructive kink ; (b) when the stasis has been It is difficult to see how atelectasis, assumed to date allowed to advance to the stage of permanent from birth, can account for attacks postponed until incurable disease of the large intestine, so that the infant is several weeks old, which has happened excision of the diseased bowel offers the only chance in some of my cases. Moreover, the condition of the of cure. Dental surgery must repair the havoc infant in the interval between the attacks is, as I wrought in the mouth by neglected stasis. Surgical have pointed out, curiously unsuggestive of respiratory intervention will become rare when stasis is recognised trouble. I have made two post-mortem examinations. early, and treated before organic mischief has arisen. One showed a certain amount of collapse in the bases of both lungs and probably a very early commencing Non-Surgical Treatment of Stasis. broncho-pneumonic process ; but the attacks had The successful treatment of stasis demands an exact occurred several times daily for seven days before of the pathological conditions present, death, so that it was at least as likely that the knowledge obtained by (a) a complete history and full account of atelectasis was the result as that it was the cause of the symptoms ; (b) a careful physical examination; the attacks. In the other case there was more extena chemical, histological, and bacteriological investi(c) sive atelectasis, the greater part of the right lung of urine and faeces, and a chemical and histoand part of the left lower lobe being atelectatic, but gation examination of the blood ; and (d) a complete here again, who shall say whether the atelectasis was logical X ray investigation of the alimentary tract with a the result or the cause ? The infant had several bismuth meal and a barium enema. attacks daily from the age of 5 days old, until he died Stasis usually starts in the large intestine, and at the age of 15 days. Is it not likely, indeed almost the(a) start can be traced to infancy or early childhood. certain, that more or less extensive collapse would The prevention of constipation and of gastric distenresult from such repeated bouts of arrest of breathing ? sion in childhood does much to ensure a healthy youth The appearance of the attacks, their sudden onset, and a vigorous adult life. Take a typical case of stasis and the good condition of the infant during the as seen in middle life, say between the ages of 45 and intervals is more suggestive of some affection of the 55. The patient looks careworn and unhappy; hisrespiratory centre than of any secondary asphyxia skin is dry and wrinkled, and he looks older than his from insufficient expansion of the lung. years. He complains of headache and aching limbs;. Treatment. his muscles are stilt ana easily ratiguea, his joints rneuIf life is to be saved in these cases, it is all important matic ; he is subject to lumbago, sciatica, or neuritis. that the sudden and absolutely silent onset of the His digestion is faulty and he suffers from flatulence attacks should be borne in mind. It is essential and " heart-burn " with foul breath and a coated that the infant should be watched closely by someone tongue. There is constipation, perhaps alternating. " night and day until the attacks have been entirely with a form of- diarrhoea " characterised by loose absent for some days. At any moment artificial stools, full of mucus, and very offensive. The patient of breath on slight exertion. respiration may be the only hope of saving the child’s is short (b) The physical examination of the abdomen reveals life, and the nurse or mother must be instructed thickening of the wall of the iliac colon and of the accordingly. I have had oxygen used in the attacks, terminal ileum ; pressure upon these parts causes pain. and it probably helps in re-establishing respiration ; it is certainly worth while to devote unremitting Thickening (and pain on pressure) may be felt also attention to these infants, for although recovery may over the pylorus, at the duodeno-jejunal junction and be the exception, there is undoubtedly the possibility in the position of the gall-bladder. A succussion splash of saving them, and this will depend largely upon is often elicited in the stomach. (c) The pathologist finds in the urine the products of careful watching for the first moment of arrest of breathing. Any delay in beginning artificial respira- intestinal putrefaction, and in the faeces the bacteria that are causing putrefaction. He also finds an excess tion can only diminish the chance of recovery. of mucus from the catarrhal mucous membrane. (d) The radiologist finds some or all the abnormal conditions described in my papers on stasis. In a THE TREATMENT OF typical case the pelvic colon is elongated ; the splenic flexure is sharply angulated in a high position ; the CHRONIC INTESTINAL STASIS BY caecum, ascending colon, and transverse colon are COLLOIDAL KAOLIN. dropped. The descending and iliac colon are narrowed BY ALFRED C. JORDAN, C.B.E., M.D. CAMB., by tonic spasm due to catarrh of the mucous membrane (mucous colitis). The catarrh causes exaggerated M.R.C.P. LOND., segmentation of the caecum, ascending and transCORRESPONDING FOREIGN MEMBER, BELGIAN ROYAL Small amounts of faecal material are verse colon. ACADEMY OF MEDICINE. forced with mucus through the narrowed descendingand iliac colon, while the main faecal mass remains KAOLIN, in one form or another, has long been in 1 In radiological practice use as a therapeutic agent. Proc. Roy. Soc. Med., 1911, vol. v. ; 1913, vol. vi.; 1915, I have found it a convenient substance for opaque vol. viii. Brit. Med. Jour., 1913, ii., 915 ; 1920, ii., 959. Practit., 1913. THE LANCET, 1920, i., 756. Also Sir Arbuthnot February, enemata mixed with barium sulphate and warm water. Lane’s Operative Treatment of Chronic Intestinal Stasis, In colloidal form it is in a state of very fine sub- Chapters 2 and 13.
ably
.
433 In severe cases of intestinal stasis the large intestine in the caecum and ascending colon. A barium enema shows not only the elongation of the is elongated, dropped, and angulated, its walls pelvic colon and the sharp bend of the splenic flexure, catarrhal and sodden, its mucous membrane congested but also the large capacity of the caecum and ascending and perhaps eroded, its contents hard and foul and colon. The habitual overdistension of the caecum covered with offensive mucus. The lower coils of the stretches the ileo-caecal valve, and allows some of the small intestine lie in a " pool " in the pelvis, full of - enema fluid to leak through the valve into the ileum. stagnant fluid which teems with virulent organisms, valve leads to of the ileo-cascal pouring out poisonous products, to be absorbed into spasm Incompetence of the ileo-csecal sphincter, and this causes stasis in the circulation unchecked. This stagnant pool has but the lower coils of the ileum, and hypertrophic thicken- one outlet-through the ileo-caecal valve-and this ing of the terminal coil of the ileum. Ileal stasis gives outlet is barred by spasm. This is no exaggerated rise to kinking at the duodeno-jejunal junction and picture, it is the condition which exists in an appredistension of the duodenum. Pyloric spasm is set up, ciable proportion of civilised men and women. The and causes delay in the evacuation of the stomach. least adverse result is a general decline in health and ’The pyloric spasm of stasis is exceedingly persistent vigour. Those who are less able to resist the poisons suffer from headache and various forms of digestive and obstinate. T1’eatment. disturbance, or from spasmodic asthma. Others are How are these changes best dealt with ? The X ray victims of lumbago, neuritis, and rheumatic fibrositis. off are those who become tuberculous or findings having excluded all conditions which require Still worse and cancerous, treatment be surgical intervention, may prescribed and the insane. most unfortunate are the epileptics with every prospect of success. The chief measures Now see how rational and effective is the treatment. are the following 1. The dropping of the stomach and large intestine Start with paraffin and a Curtis belt. The bowel is is corrected by a Curtis belt. supported so that it no longer drags on the mesentery, 2. Stasis in the large intestine is met by prescribing kinks are abolished, the faeces are softened (by the so that they can be evacuated with little liquid paraffin. If the pelvic colon is much elongated paraffin) effort. The belt aids the feeble toxic abdominal warm saline enemata should be given in addition. 3. Spasm of the sphincters (pyloric and ileo-cascal) muscles during defaecation. Now add colloidal kaolin. and spasmodic constriction of the large intestine are Most of the kaolin collects in the lower ileal pool, best overcome by belladonna, 8 or 10 minims of the adsorbs toxins there, and makes the foul contents of tincture with a little bicarbonate of soda twice a day the lower ileum innocuous. Next add belladonna. It after food. opens the sphincter and widens the narrowed large 4. Decomposition in the intestines is dealt with intestine. Lastly add a saline. It clears out the lower most effectively by means of colloidal kaolin, a dessert- ileal cesspool, already "treated" with kaolin. The spoonful of the kaolin powder if taken in half a saline and the paraffin together effect the speedy evacuation of the large intestine. If the pelvic colon tumbler of hot water night and morning. 5. The septic contents of the lower ileal coils must is much elongated a course of enemata is needed to be cleared out by salines. Streptococcal infection of complete the evacuation. Colloidal kaolin may most the intestines most often occurs in the lower ileum ; usefully be added to the enema fluid-an ounce of few streptococci pass on into the caecum and still kaolin to each pint of warm enema fluid. fewer reach the rectum. This has been proved by Vcce.—Autogenous vaccines are of considerable withdrawing material from the intestines during help in many cases. abdominal operations. Bacteriologists are able to Dte.—Correct feeding is of great importance in the grow streptococcal cultures from the faeces by giving treatment of stasis. The details of diet must vary to their patients lactose (with the object of increasing the suit individual needs, but certain principles of diet may growth of streptococci for the time being), and a saline be laid down. Articles to avoid are : (a) Those which aperient to propel the streptococcal chyle into and irritate the mucous membranes, especially alcohol and through the large intestine. Applying this experience, sharp spices (mustard, cayenne, &c.) (b) those which -colloidal kaolin is given to adsorb the intestinal toxins, decompose readily in the intestines. Meat is the most and a saline aperient to driveonward the contents of important of these, and it includes poultry and game. the lower ileum. Excess of sugars should be avoided as encouraging All the above measures aid one another in breaking streptococci. the vicious circle of stasis. The paraffin helps the Foods to take are : (1) Fresh iish ; (2) fresh dairy Curtis belt to support the dropped viscera ; it makes produce---eggs, milk, cream, butter, cheese ; (3) fresh the faeces specifically lighter than the watery contents garden produce-lettuce, fruits, and vegetables ; of the small intestine, so that the large intestine tends (4) grains of all kinds, including coarse oatmeal ; to float up, instead of being the heaviest part of the (5) nuts. Large meals should be avoided ; the intestines as it is when full of solid faeces. The belt, " static " stomach cannot deal with them. in its turn, helps the action of the paraffin and saline ’, - Re
imprisoned
-
-
I i
434 Colløidal Kaolin in Common Ailments.-There are can insert these pessaries at night by themselves in, secret. Patients like this pessary treatment because,. common ailments-not primarily or necessarily due to stasis-in which alimentary togaemia occurs, apart from the rapidity of clearing the discharge, it and where colloidal kaolin has been found most useful, is obviously convenient for a patient to be able to such as bronchitis, pharyngitis, and infantile diarrhoea. keep the pessaries, say in a chocolate box, and In the epidemic illnesses of children (measles, administer one to herself nightly unobserved, even colloidal kaolin is a great when other females are in the same room. To whooping-cough, &c.) stand-by. It helps the children through the bad days carry out ’vaginal treatment in secret with a with the minimum of discomfort to themselves and of douche is a great strain on a patient’s ingenuity anxiety to the parents and nurses. A dose of calomel and happiness. Contramine pessaries should only be used when the is a good prelude to the treatment with kaolin, belladonna, and paraffin. The morning sickness of discharge is chronic. One hundred cases have been pregnancy is alleviated, and kept at bay in many treated; in only seven cases was the gonococcus instances. During lactation both mother and child found before treatment, and in none was it found after reap the benefit of the cleansing action of colloidal treatment, though all cases had a definite vaginal kaolin saline, given to the mother with paraffin if discharge. But most observers agree, I think, that to need be. find the gonococcus in the adult female in a chronic Colloidal Kaolin in Tropical Affeetions.-Colloidal discharge is very difficult. These cases received 30-40 each, no other treatment was prescribed, kaolin, with or without saline, is the best remedy pessaries known in colitis and dysentery. It checks the diar- and they were kept under observation for two months rhoea and soothes and heals the eroded or ulcerated without treatment before being discharged. So far only four cases haverelapsed. mucous membrane. Asiatic cholera has lost most of its terrors since it has been shown to yield to frequent draughts of kaolin in watery suspension. Further experience will undoubtedly add to the range of FRACTURE OF THE HEAD OF THE FIBULA. Colloidal kaolin of usefulness of colloidal kaolin. BY A. W. LEMARCHAND, M.R.C.S. ENG. uniform composition and free from impurities, organic as well as inorganic, have been prepared for me by the Collasan Company (20, Holborn Viaduct E.C. 1), THE following is a record of an unusual accident who supply it, by itselfand with saline aperient, which occurred to a man, aged 56, who was standing " " " Collasan and Collasanunder the names of the side- line, watching a Rugby football Saline." When it is deemed advisable to prescribe match.by A full back went collasan without saline, or to prescribe the saline to charge an opposing separately, the following formula is recommended by forward, missed his man, I fell, and struck his head Dr. A. White Robertson :Collasan (colloidal kaolin) against the outer side of 3f oz.Water .. 8ox. this spectator’s knee. The Add the water to the collasan in a large basin, stirring tracing of thoroughly to form a fine cream. Now add, constantly accompanying an X ray photograph of 1 oz. of of 10 of and minims oil stirring, mucilage tragacanth of peppermint (or oil of dill). y. A port-wine glassful to be the knee shows the fracture of the head of the taken every six hours. fibula which resulted. There was no displacement and no appreciably increased lateral move-
many
close
-
..
Clinical and
Laboratory Notes.
GONORRHŒA IN WOMEN TREATED WITH CONTRAMINE PESSARIES.
BY
G.
W.
RUNDLE, L.R.C.P. & L.R.F.P.S. GLASG.,
S. EDIN.,
RESIDENT MEDICAL OFFICER, LONDON LOCK HOSPITAL FOR WOMEN.
IN June, 1921, I published some notes’- on the treatment of gonorrhoea, in women with intramine pessaries, showing the very satisfactory manner in which the discharge vanished. Though this method of treatment proved superior to all others, it had one drawback, in that 8 per cent. of the cases developed a local dermatitis. To obviate this development, Mr. J. E. R. McDonagh has elaborated a more active preparation of sulphur, di-ethyl-ammonium di-ethyldi-thio-carbamate (contramine), which has all the advantages of intramine, with none of the disadvantages. Contramine pessaries have been used in the London Lock Hospital for over a year, and not a single case of dermatitis has resulted. Further, the discharge disappears quicker and the erosions heal more rapidly than was the case with intramine
ment. I should be glad to hear if any reader of THE LANCET who has had experience of a similar injury can state whether any trouble followed in the nervewhich lies behind the head of the fibula. Barnstaple
I.
__
__
_____
A CASE OF "INFECTIOUS MONONUCLEOSIS." BY
P. D. H. CHAPMAN, M.B., B.CH. CAMB., M.R.C.S. ENG.
THE interesting annotation on Infectious Mononucleosis and its possible causation, which appeared in THE LANCET of Feb. 17th, prompts me to relate a recent case of mine, which corresponded very closely to the description of this disease. The patient was a. boy of 17 ; the first symptoms were enlargement of cervical glands and pyrexia, the throat remaining normal in appearance until the ninth day of illness, when a very acute follicular tonsillitis occurred. By this time the submaxillary, axillary, and inguinal glands were also enlarged and pyrexia had been continuous. The white cell count on the fifth day was 15,000 per c.mm. ; the differential count was: pessaries. The course consists of a pessary placed against mononuclear lymphocytes, 56 per cent. ; polymorphothe cervix nightly when the patient is in the recumbent nuclear leucocytes, 38 per cent. ; hyalines, 6 per cent. ; The progress of thecase was position, the pessary being retained in position by a eosinophiles,thenil.blood count returned to normal, and gauze tampon, which is taken out next morning. uneventful, One of the great advantages of contramine pessary all glands became no longer palpable within 20 days It is difficult to see how an infection treatment for a discharge of any origin over the of onset. the throat could be considered as a cause of douching and speculum treatment is that patients of the disease in this case. 1 THE LANCET, 1921, ii., 802. ]3ridlington.
ably
.
433 In severe cases of intestinal stasis the large intestine in the caecum and ascending colon. A barium enema shows not only the elongation of the is elongated, dropped, and angulated, its walls pelvic colon and the sharp bend of the splenic flexure, catarrhal and sodden, its mucous membrane congested but also the large capacity of the caecum and ascending and perhaps eroded, its contents hard and foul and colon. The habitual overdistension of the caecum covered with offensive mucus. The lower coils of the stretches the ileo-caecal valve, and allows some of the small intestine lie in a " pool " in the pelvis, full of - enema fluid to leak through the valve into the ileum. stagnant fluid which teems with virulent organisms, valve leads to of the ileo-cascal pouring out poisonous products, to be absorbed into spasm Incompetence of the ileo-csecal sphincter, and this causes stasis in the circulation unchecked. This stagnant pool has but the lower coils of the ileum, and hypertrophic thicken- one outlet-through the ileo-caecal valve-and this ing of the terminal coil of the ileum. Ileal stasis gives outlet is barred by spasm. This is no exaggerated rise to kinking at the duodeno-jejunal junction and picture, it is the condition which exists in an appredistension of the duodenum. Pyloric spasm is set up, ciable proportion of civilised men and women. The and causes delay in the evacuation of the stomach. least adverse result is a general decline in health and ’The pyloric spasm of stasis is exceedingly persistent vigour. Those who are less able to resist the poisons suffer from headache and various forms of digestive and obstinate. T1’eatment. disturbance, or from spasmodic asthma. Others are How are these changes best dealt with ? The X ray victims of lumbago, neuritis, and rheumatic fibrositis. off are those who become tuberculous or findings having excluded all conditions which require Still worse and cancerous, treatment be surgical intervention, may prescribed and the insane. most unfortunate are the epileptics with every prospect of success. The chief measures Now see how rational and effective is the treatment. are the following 1. The dropping of the stomach and large intestine Start with paraffin and a Curtis belt. The bowel is is corrected by a Curtis belt. supported so that it no longer drags on the mesentery, 2. Stasis in the large intestine is met by prescribing kinks are abolished, the faeces are softened (by the so that they can be evacuated with little liquid paraffin. If the pelvic colon is much elongated paraffin) effort. The belt aids the feeble toxic abdominal warm saline enemata should be given in addition. 3. Spasm of the sphincters (pyloric and ileo-cascal) muscles during defaecation. Now add colloidal kaolin. and spasmodic constriction of the large intestine are Most of the kaolin collects in the lower ileal pool, best overcome by belladonna, 8 or 10 minims of the adsorbs toxins there, and makes the foul contents of tincture with a little bicarbonate of soda twice a day the lower ileum innocuous. Next add belladonna. It after food. opens the sphincter and widens the narrowed large 4. Decomposition in the intestines is dealt with intestine. Lastly add a saline. It clears out the lower most effectively by means of colloidal kaolin, a dessert- ileal cesspool, already "treated" with kaolin. The spoonful of the kaolin powder if taken in half a saline and the paraffin together effect the speedy evacuation of the large intestine. If the pelvic colon tumbler of hot water night and morning. 5. The septic contents of the lower ileal coils must is much elongated a course of enemata is needed to be cleared out by salines. Streptococcal infection of complete the evacuation. Colloidal kaolin may most the intestines most often occurs in the lower ileum ; usefully be added to the enema fluid-an ounce of few streptococci pass on into the caecum and still kaolin to each pint of warm enema fluid. fewer reach the rectum. This has been proved by Vcce.—Autogenous vaccines are of considerable withdrawing material from the intestines during help in many cases. abdominal operations. Bacteriologists are able to Dte.—Correct feeding is of great importance in the grow streptococcal cultures from the faeces by giving treatment of stasis. The details of diet must vary to their patients lactose (with the object of increasing the suit individual needs, but certain principles of diet may growth of streptococci for the time being), and a saline be laid down. Articles to avoid are : (a) Those which aperient to propel the streptococcal chyle into and irritate the mucous membranes, especially alcohol and through the large intestine. Applying this experience, sharp spices (mustard, cayenne, &c.) (b) those which -colloidal kaolin is given to adsorb the intestinal toxins, decompose readily in the intestines. Meat is the most and a saline aperient to driveonward the contents of important of these, and it includes poultry and game. the lower ileum. Excess of sugars should be avoided as encouraging All the above measures aid one another in breaking streptococci. the vicious circle of stasis. The paraffin helps the Foods to take are : (1) Fresh iish ; (2) fresh dairy Curtis belt to support the dropped viscera ; it makes produce---eggs, milk, cream, butter, cheese ; (3) fresh the faeces specifically lighter than the watery contents garden produce-lettuce, fruits, and vegetables ; of the small intestine, so that the large intestine tends (4) grains of all kinds, including coarse oatmeal ; to float up, instead of being the heaviest part of the (5) nuts. Large meals should be avoided ; the intestines as it is when full of solid faeces. The belt, " static " stomach cannot deal with them. in its turn, helps the action of the paraffin and saline ’, - Re
imprisoned
-
-
I i
434 Colløidal Kaolin in Common Ailments.-There are can insert these pessaries at night by themselves in, secret. Patients like this pessary treatment because,. common ailments-not primarily or necessarily due to stasis-in which alimentary togaemia occurs, apart from the rapidity of clearing the discharge, it and where colloidal kaolin has been found most useful, is obviously convenient for a patient to be able to such as bronchitis, pharyngitis, and infantile diarrhoea. keep the pessaries, say in a chocolate box, and In the epidemic illnesses of children (measles, administer one to herself nightly unobserved, even colloidal kaolin is a great when other females are in the same room. To whooping-cough, &c.) stand-by. It helps the children through the bad days carry out ’vaginal treatment in secret with a with the minimum of discomfort to themselves and of douche is a great strain on a patient’s ingenuity anxiety to the parents and nurses. A dose of calomel and happiness. Contramine pessaries should only be used when the is a good prelude to the treatment with kaolin, belladonna, and paraffin. The morning sickness of discharge is chronic. One hundred cases have been pregnancy is alleviated, and kept at bay in many treated; in only seven cases was the gonococcus instances. During lactation both mother and child found before treatment, and in none was it found after reap the benefit of the cleansing action of colloidal treatment, though all cases had a definite vaginal kaolin saline, given to the mother with paraffin if discharge. But most observers agree, I think, that to need be. find the gonococcus in the adult female in a chronic Colloidal Kaolin in Tropical Affeetions.-Colloidal discharge is very difficult. These cases received 30-40 each, no other treatment was prescribed, kaolin, with or without saline, is the best remedy pessaries known in colitis and dysentery. It checks the diar- and they were kept under observation for two months rhoea and soothes and heals the eroded or ulcerated without treatment before being discharged. So far only four cases haverelapsed. mucous membrane. Asiatic cholera has lost most of its terrors since it has been shown to yield to frequent draughts of kaolin in watery suspension. Further experience will undoubtedly add to the range of FRACTURE OF THE HEAD OF THE FIBULA. Colloidal kaolin of usefulness of colloidal kaolin. BY A. W. LEMARCHAND, M.R.C.S. ENG. uniform composition and free from impurities, organic as well as inorganic, have been prepared for me by the Collasan Company (20, Holborn Viaduct E.C. 1), THE following is a record of an unusual accident who supply it, by itselfand with saline aperient, which occurred to a man, aged 56, who was standing " " " Collasan and Collasanunder the names of the side- line, watching a Rugby football Saline." When it is deemed advisable to prescribe match.by A full back went collasan without saline, or to prescribe the saline to charge an opposing separately, the following formula is recommended by forward, missed his man, I fell, and struck his head Dr. A. White Robertson :Collasan (colloidal kaolin) against the outer side of 3f oz.Water .. 8ox. this spectator’s knee. The Add the water to the collasan in a large basin, stirring tracing of thoroughly to form a fine cream. Now add, constantly accompanying an X ray photograph of 1 oz. of of 10 of and minims oil stirring, mucilage tragacanth of peppermint (or oil of dill). y. A port-wine glassful to be the knee shows the fracture of the head of the taken every six hours. fibula which resulted. There was no displacement and no appreciably increased lateral move-
many
close
-
..
Clinical and
Laboratory Notes.
GONORRHŒA IN WOMEN TREATED WITH CONTRAMINE PESSARIES.
BY
G.
W.
RUNDLE, L.R.C.P. & L.R.F.P.S. GLASG.,
S. EDIN.,
RESIDENT MEDICAL OFFICER, LONDON LOCK HOSPITAL FOR WOMEN.
IN June, 1921, I published some notes’- on the treatment of gonorrhoea, in women with intramine pessaries, showing the very satisfactory manner in which the discharge vanished. Though this method of treatment proved superior to all others, it had one drawback, in that 8 per cent. of the cases developed a local dermatitis. To obviate this development, Mr. J. E. R. McDonagh has elaborated a more active preparation of sulphur, di-ethyl-ammonium di-ethyldi-thio-carbamate (contramine), which has all the advantages of intramine, with none of the disadvantages. Contramine pessaries have been used in the London Lock Hospital for over a year, and not a single case of dermatitis has resulted. Further, the discharge disappears quicker and the erosions heal more rapidly than was the case with intramine
ment. I should be glad to hear if any reader of THE LANCET who has had experience of a similar injury can state whether any trouble followed in the nervewhich lies behind the head of the fibula. Barnstaple
I.
__
__
_____
A CASE OF "INFECTIOUS MONONUCLEOSIS." BY
P. D. H. CHAPMAN, M.B., B.CH. CAMB., M.R.C.S. ENG.
THE interesting annotation on Infectious Mononucleosis and its possible causation, which appeared in THE LANCET of Feb. 17th, prompts me to relate a recent case of mine, which corresponded very closely to the description of this disease. The patient was a. boy of 17 ; the first symptoms were enlargement of cervical glands and pyrexia, the throat remaining normal in appearance until the ninth day of illness, when a very acute follicular tonsillitis occurred. By this time the submaxillary, axillary, and inguinal glands were also enlarged and pyrexia had been continuous. The white cell count on the fifth day was 15,000 per c.mm. ; the differential count was: pessaries. The course consists of a pessary placed against mononuclear lymphocytes, 56 per cent. ; polymorphothe cervix nightly when the patient is in the recumbent nuclear leucocytes, 38 per cent. ; hyalines, 6 per cent. ; The progress of thecase was position, the pessary being retained in position by a eosinophiles,thenil.blood count returned to normal, and gauze tampon, which is taken out next morning. uneventful, One of the great advantages of contramine pessary all glands became no longer palpable within 20 days It is difficult to see how an infection treatment for a discharge of any origin over the of onset. the throat could be considered as a cause of douching and speculum treatment is that patients of the disease in this case. 1 THE LANCET, 1921, ii., 802. ]3ridlington.