Glanders in Man

Glanders in Man

GENERAL ARTICLES. 223 fully than Ruffus with the matter of the hygiene and management of the horse at all periods of life. Delprato had the opportun...

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fully than Ruffus with the matter of the hygiene and management of the horse at all periods of life. Delprato had the opportunity of examining a very early codex of Rusius which came to light in his day, and was found to differ from those of the fifteenth and sixteenth centuries, for, as he says, it had neither been disfigured nor spoiled by unskilled copyists and presumptious commentators. This codex apparently explains why Delprato is enthusiastic regarding the work of Rusius. He claims that Rusius established a rational division of diseases, showed exact knowledge of morbid processes, wrote intelligently on the treatment of fractures in the equine, and described the operation of unsoling and the diseases in which it was indicated. He points out that Rusius was possibly the first veterinarian to employ leeches in the treatment bf inflammatory affections of the limbs of horses. Delprato further brings forward two very strong points in his championship of Rusius. He shows that he recognised the possi" bility of septic infection from wounds, especially those of the back and withers, and what is of even greater importance, he was the first to describe the communicability of farcy from the horse to man. Of the importance of these two observations there can be no question. Rusius may have seen septic infection after castration; at any rate, he is severe on the "castrator" and deplores his methods. He urged that the rational surgical system of procedure was the wooden clamp. Rusius employed fomentations to the chest wall in pulmonary trouble; he also taught that rupture of the intestine might occur in colic owing to the violence of the animal. Finally, he assigned to drugs their true action, emerging, as Delprato states, from the bonds of vulgar empiricism then , and for long after, so common. Rusius believed in astrology and the constellations, and in this respect he compares unfavourably with Ruffus, though considering the times he can scarcely be blamed . . (To be continued.)

GLANDERS IN MAN.

By S. H. GAIGER, M.R.C.V.S., Indian Civil Veterinary Department. CASES of glanders in man are rare, and detailed records of such cases seem to be still more rare. . The descriptions of the disease and its treatment as given in medical works seem to be largely modelled on what is found in the equine species, and the consequence is that when a case occurs in man the patient suffers considerably more than he need, owing to the lack of knowledge of the disease, its course, and the best treatment. Having been myself the victim of an infection with the bacillus mallei, and having now, after a period of twenty-eight months, thrown off the last traces of the disease, I think it may be of interest to record my experiences, and these will perhaps be of benefit in the treatment of cases which may arise in future.

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In March 1911 I was at work on an obscure case of disease in an Arab pony in the contagious ward of the Punjab Veterinary College. Lahore, India. At first there was nothing to lead one to suspect glanders in the pony, and I made several cultures on gelatin-agar from an abscess which I opened. The resulting growths aroused my suspicions, which were confirmed after cultivating the organism 011 potato. I had in the meantime inoculated part of the agar culture into a guinea-pig, which began to develop diagnostic symptoms. The pony's temperature had not permitted testing with mallein. The pony, the guinea-pig, and all the cultures were then destroyed_ This work had been going on during the week preceding the 4th March, and it was during the night of the 3rd March that I first became ill with severe headache and a temperature of 102 F. There was no reason why I should connect my illness with my laboratory work, and 1 did not. I had on many previous occasions done exactly the same kind of work on glanders, and always with every precaution against infection of anyone. All the 4th March my temperature was IOI o F., but I continued to go about in the usual way, expecting the attack would pass off. However, on the 5th I had acute pain between the diaphragm and liver, which felt as though the peritoneal surfaces were inflamed, and any movement which rubbed the surfaces together accentuated the pain. I could only get relief in a sitting posture and by thoracic breathing. The peritoneal pain ceased to be acute in a few days. It was the first internal symptom I had, and seems to point to the bacillary infection as having taken place through the alimentary canal. Infection did not take place by accidental inoculation and no lesions of the respiratory tract have ever been observed. From the 4th March, when my temperature first rose, a period of three weeks elapsed before the first external lesion appeared on my left hand. During this period I had intermittent fever. Sometimes. I was in bed for a couple of days, with two or three days in between. when I was at work, but whether in bed or at work I felt very ill indeed. The case was diagnosed as malaria, and I was treated for this, pending further developments. During one febrile attack I took 45 grains of quinine in solution within twelve hours, and this had no effect whatever on the fever, as would have been the case' had it been malaria. I then began to feel pain in the intercostal muscles on my right side, and this became so acute and extensive that I feared pleurisy. Careful examination by a doctor revealed nothing, and, like the peritoneal pain, the pleural pain became less acute in a few days. In due course both peritoneal and pleural pains completely disappeared, and there has been no recurrence of them. I believe that for a time there was some adhesion of the adjacent pleural surfaces, because some weeks after pain had dis~ appeared, and during a fit of loud laughter, I distinctly felt a wave of pain down the chest wall as though the two pleural surfaces had separated, and I have never been troubled there in any way since. I was beginning to think I was throwing off my attack of fever when on 24th March I knocked the back of my left hand. I should not have remembered the blow, as it caused no pain or mark on the skin, but next day a very painful deep-seated swelling and redness appeared on the back of my hand between the second and third 0

GENERAL ARTICLES.

metacarpal bones. The pain and swelling were out of all proportion to the knock I had given the hand, so much so that I remarked on this disproportion to several friends, thinking the lesion was due to a slight sprain. By evening the pain was intense, but was relieved somewhat by soaking the hand in hot water. No sleep was obtainable, and my temperature rose to 102° F. On 26th March the pain was most acute, with fever and severe general symptoms, so I was removed to a nursing-home. The swelling was very hard and seemed raised at one place as though it \vould corne to a head there. The pain necessitated morphia for three nights, and as no improvement set in I insisted on an incision. This was done-a scalpel was pushed into the prominent place without an ancesthetic, but no pus had accumulated. There was, however, a good deal of bleeding and I obtained immediate relief. The fever disappeared, and as the pain was slight I had three nights' sleep. Then the temperature began to rise again and pus was suspected, but the wound had apparently healed over. I was told the pus must be let out, and the surgeon pushed the handle of a Spencer-Wells forceps down into the wound without an ancesthetic and so opened it afresh. A trace of pus, not more than a minim,. appeared. Cultures were made from the wound and from my general circulation, and that from the wound gave a growth which was said to be a bacillus which "was most like glanders, but yet showed differences." My temperature va,ried between 1000 and 102 0 F., and now red lines began to run up my wrist and forearm. There was no pain or swelling in the arm, only the lymphatics showed as red lines, which gradually extended higher and higher, and in a few days had reached my shoulder. There was slight discomfort in the glands of the axilla, and I thus realised that the poison had reached there. Treatment at this time consisted in applying linseed poultices, made with an antiseptic, to the back of my hand both before it was opened and after. Lint soaked in belladonna was wrapped round my arm from wrist to shoulder, and the whole enveloped in cotton wool. A piece of plugging was daily inserted in the wound as a drain. The linseed poultices could hardly be called a success. They were cold five or ten minutes after application, and their weight on the hand was the cause of so much pain that I frequently had to remove them myself within a short time. The invasion of my lymphatic system from the hand seemed to receive a check at the shoulder, then day by day the red lines began to recede and fever to subside. The damage from this invasion was that my axillary glands were left infected and there were two inflamed places on the back of my forearm on the course of one of the lymphatics. Fever now subsided, and I began to feel better; the treatment of the hand was changed to boracic fomentations, and I was soon able to become an out-patient at the hospital, and later to dress my hand myself, only visiting hospital when anything wanted operating upon. During April, May, and June 1911 frequent operations were performed on my hand and the two lesions on my forearm, both in Lahore and Siml<\. Fortunately I was a good subject for chloroform, and frequent minor operations seemed to make little difference in my general p

GENERAL ARTICLES.

condition. During one period of two weeks l was given chloroform four times. Wherever there was any sign of pus burrowing or collecting an incision was made, and on one or two occasions only a local ancesthetic-ethyl chloride-was used . From one of the a bscesses on the forearm I made my own cultures immediately after the incision was made and took them over to the Veterinary College Laboratory for incubation. After twenty-four hours no growth was visible, but after forty-eight hours the growth was luxuriant, and I was struck by the resemblance to glanders cultures. Cultivation on potato was diagnostic. I had each year destroyed many horses on such evidence, and yet when the facts showed that I myself had the disease I could not bring myself to believe it. I gradually persuaded myself there must be some mistake, and as time went on became nearly convinced of it. Instead of facing the facts, I made no more cultures and destroyed those I already had, with the exception of one tube, which I sent to a Research Institute, asking for a vaccine. They named the bacillus " 53 A," and made me a vaccine. I do not propose to give details of this attempt at treatment with killed bacilli, because the vaccine did not have a fair trial and only five doses were used, and these at very irregular intervals. The use of the vaccine had no apparent effect on the course of the disease. Owing to various circumstances in India, I was seldom treated by the same surgeon for a long period , and on the 14th June my case was diagnosed as tuberculous caries of the second metacarpal. An X-ray photograph was taken of my hand, and I was shown the changes in the metacarpal, which could be seen by comparison with the sound metacarpals. I mentioned that the bacillus which I had obtained was like the bacillus mallei, and not the tubercle bacillus, but did not press the matter, as I considered that if there was diseased bone the proposed operation for its removal was necessary whatever the cause. Two days later an operation was performed and part of the shaft of the metacarpal was removed, three large incisions being made, and the whole cavity swabbed out with pure carbolic acid. The head of the metacarpal was left in position, i.e., no joint was opened. Speaking in the light of after experience, I have no hesitation in saying that a very grievous error was made in interfering with the bone. At that time I was unacquainted with the changes which can be seen in bone when photographed by X-rays when that bone is in a limb which has been in splints or quiescent for some time. The changes which I was shown as being due to disease of the metacarpal were merely due to my forefinger having been kept perfectly quiet in bandages for nearly three months. The same appearances were shown to me in a later photograph by an X-ray specialist in the digital bones of the first finger where there was never any disease. The removal of this bone was the indirect cause of the loss of my arm six months later. My whole experience shows that the bacillus. mallei does not attack bone or joints. It will eat away connective and lymphatic tissue, but leave everything else untouched. I left India on 24th June 1911. Treatment on board ship consisted in daily cleansing the sinuses with pure hydrogen peroxide

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and inserting iodoform plugging. Before I left India the lesions on my forearm had healed, and when I ended the sea-voyage the lesions in the hand were all narrow sinuses leading to the same place, namely, the bare bone which could be detected easily with a probe. There was slight pain now in the glands of the axilla which had become infected three months previously. On IOth July I reached London and went into hospital. Fresh cultures were made on agar, then on potato, and a guinea-pig was inoculated. The evidence was submitted to authorities, who would admit no doubt that the organism was· the bacillus mallei. I asked that the glands might be removed and also the first finger with the diseased end of the metacarpal. On 19th July the whole of the axilla was cleaned out, but, as it was considered the lesions in the hand were on the point of "clearing up," the sinuses were merely scraped out and a few bits of bone removed. A fortnight later the hand had to be again operated upon under an an;esthetic and fresh incisions made. Daily treatment in hospital consisted in irrigating the sinuses in the hand with a solution of hydrogen peroxide (I drachm to a pint) and plugging with iodoform ribbon. The glands from the axilla were removed whole and the cut lymphatic vessels drained, so that the operation wound healed as a clean one, though with a tremendous flow of lymph, in a period of five weeks. The only treatment necessary was the daily renewal of tp.e iodoform plugging. In August I was advised that if 1 went to the country or a healthy seaside place the sinuses might heal up. August was spent in Hampshire and September at Yarmouth, and I became as fit in general health as it was possible for me to be. The sinuses narrowed down to the size of a probe, but all continued to discharge and all led to the one place-bare bone, and being now satisfied that healing could not take place as long as the bone was infected, I came tq London for expert advice. A new X-ray photograph (see fig.) showed on comparison with the previous one that the bone was being eaten away, and this could be inferred by the increased shortening of the forefinger as the metacarpal shaft became absorbed. I was told that this suppurative process might go on for years, and that the best plan would be to have the finger removed, the metacarpal taken off where it was healthy, and the whole treated as an open wound. This operation was done on 14th October in a nursing-home in London. The cavity, necessarily a large one, was treated with pure carbolic, and it was unnecessary to remove the plugging for some days. In six or seven days the wound was suppurating freely, but the healthy end of bone was covered over with granulations. The bone infection was therefore removed, this being the object in view. In about three weeks the wound began to contract and draw the thumb and middle finger together, in such a way that two purulent surfaces were opposed to one another, forming a kind of crevice which was difficult to drain. From the bottom of this crevice pus soon burrowed into the ball of the thumb and gave rise to pain and fever. This necessitated a further operation, in which the ball of the thumb was slit open, but by this time the infection seemed to have gained access to a tendon sheath and so spread upwards, for pain

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was felt just above the wrist joint. In a few days a large, painful, fluctuating swelling appeared on the front of the wrist, and operation was again necessary; a large quantity of pus was removed, and as the cavity was a deep one a tube was inserted. It was a difficult place to drain properly, and, moreover, the disease did not stop

Radiograph taken six months after the original infection of the left hand and three months after part of the shaft of the second metacarpal bone was removed. The shaft of the bon" at this stage was being slowly eaten awa.y by the suppura.tive process, and the finger wa.s shortening.

there, for very acute pain was soon felt on the front of the forearm rather nearer the elbow than the wrist. The violence of the pain was such that another operation was necessary over the seat of it, when it was found that communication was obtainable with the wrist down the centre of the arm. In

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the upper operation wound two tubes were inserted, one pointing towards the elbow and the other towards the wrist. I was now becoming somewhat weak from this constant operating, and the wounds seemed to be making no attempt to do anything at all towards improving, and pain was commencing nearer my elbow. The spread of the disease up the arm was apparently mechanical, by way of the tendon sheaths, and quite different from the invasion, which had occurred eight months previously along the lymphatics. An attempt at vaccine treatment was now made, but my condition necessitated its being discontinued after three doses. It seemed apparent now that the arm must be amputated to save my life. A consultation was held, and I gave my consent to amputation, which DECEMBER

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was performed without delay above the elbow on 15th December. At the time I thought, and I think the surgeons thought, that amputation would remove the disease from my body, but a couple of days after operation I felt tenderness above the wrist of my right arm and deep-seated between the radius and ulna. Three days sufficed to bring up a truly enormous and hard enlargement round the wrist, accompanied by acute pain and a temperature varying between 100° and I03° F. This proved to be the most critical stage of my illness, and it seemed very doubtful whether recovery could take place. The wrist was treated with fomentations and slowly commenced to go down, leaving two places, one on the back of the hand and one above the wrist, which slowly showed signs of fluctuation and were ready for operation on 20th January 1912, four weeks after the first

GENERAL ARTICLES.

symptom. The amputation wound healed by first intention, but for some months I was troubled with ligatures working their way from the depths of the wound. On 1st January I put my feet on the floor for the first time since the amputation and detected a pain over my left ankle. For four or five weeks the pain was subacute with absolutely nothing to show for it, then it became very acute and a slight pink tinge became visible. Pus was felt under the skin on 21st February and an operation was performed. During February one of the glands in the groin became slightly enlarged. I will refer to this later. The end of February seemed to bring a crisis in the disease. Disheartened by pain and the apparently never-ending lesions, I had given up hope and was rapidly sinking, when I was removed from London by ambulance to the country (Wraysbury, Bucks.) The change and open air worked wonders, and I quickly improved in general condition and gained strength. During the next few months, March, April, May, and June, repeated operations were performed on my right forearm and round my left ankle. Altogether, seven incisions were made in the forearm. The pus worked its way up the centre of the arm between the radius and ulna, and an abscess appeared just below the elbow. This incision caused much trouble, because as it healed the elbow became fixed at a right angle owing to my not taking the precaution of exercising the joint. The joint regained its freedom of movement later with massage. Round the left ankle the infection was very severe and occasioned much suffering, which was increased owing to the impossibility of resting the foot anywhere on account of incisions all round it. A tube had to be inserted through the foot behind the joint and in front of the tendo-achilles, and in addition there were ten wounds which were daily plugged. The agony caused by these daily dressings is indescribable. Frequently morphia had to be injected hypodermically to allow proper dressing; sometimes 20 grains aspirin was sufficient. Later we found that a warm 4 per cent. cocaine solution dropped into the sinuses allowed of plugging to the bottom, and it was not till this was done that the sinuses commenced to heal up soundly. In May fresh cultures were taken and the bacillus mallei found. A vaccine was prepared and I was treated with it during June and July as follows : Date.

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GENERAL ARTICLES.

The injections were given hypodermically over the seat of operation for appendicitis. There was slight swelling and some pain, which passed off in a few days. It will be seen that the doses were given over a period of two months, reaching a dose of 200 millions. This treatment was necessarily somewhat experimental, as we had no recorded cases for guidance. This experience showed that perhaps it would have been better had the doses been raised less quickly and given with shorter intervals over a longer period. The vaccine was apparently beneficial; the tissues in the neighbourhood of the sinuses looked healthier, and there was less tendency to sloughing of the JUNE

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sinus lining and the skin round the sinus mouths. A quite noticeable effect of the vaccine was the bringing of doubtful places to a head more quickly than they would have come in the ordinary way. After the fifth dose both the forearm and foot had to be operated upon. After the sixth dose the forearm was opened in a new place. After the ninth dose the gland in the groin, which was first felt in February, i.e., nine months previously, and which when the vaccine treatment was commenced showed no sign of softening, broke down, forming a cavity as large as a small walnut which opened to the full extent of its diameter. This place was healed in two months from the time of incision. The vaccine was also,the cause of the glands in the popliteal space

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of my left leg coming more quickly to a head, though this operation was not done till 3 I st August. My temperature for three weeks after the last dose of vaccine was better than it had been for ten months. During three weeks it was only above 99° F. on three occasions, but after this there was trouble owing to defective drainage of the foot sinuses, and two old sinuses opened owing to another sinus closing too soon. On 12th July, during the course of the vaccine treatment, I left Buckinghamshire and went to Norfolk. The change was certainly beneficial. On 31st August the glands behind the left knee were operated upon and pus was found very much deeper than was expected. It was thought that the sinuses, two of which were unhealthy looking, would be benefited by scraping and carbolising, so this was done to all the foot sinuses and to the deep sinus in the forearm. This scraping was soon seen to have been a mistake, on account of the severe general disturbance it set up for nearly three weeks. During my stay of three months in Norfolk nine sinuses healed up soundly. In October I returned to London. The cavity behind the knee gradually narrowed down to a deep sinus, which slowly seemed to become more superficial. When three quarters of an inch long and running at an angle of 45° to the surface it was opened to the bottom on 7th December, z:e., three months after the first operation. The place soon filled up, and was healed on 1st January. In November a pain over the os calcis and in the heel, which had been "dull" ever since the use of the vaccine in July, suddenly became most acute and was accompanied by a temperature of anything up to 103° F. I was put under an amesthetic and the heel explored with a hollow needle. On the outer side of the heel a small exploratory incision was also made, but nothing was found. The incision healed up at once, but on 22nd November a small abscess was opened over the os cal cis, and on 1st December an abscess the size of a hazel nut was opened on the side of the heel. Both these places gave little trouble and healed up in a few weeks, a sign that my resistance was now very much greater; indeed, November and December were months in which everything seemed to be healing up soundly, and by 1st January 1913 only two sinuses remained. It was noticeable how much more quickly the sinuses healed after a bout of fever, provided this was short and not too high. An evening temperature of 100° F. for two or three days had a distinct healing effect, whereas on one occasion in December, when my temperature nearly reached 104° F., healing seemed to be retarded. It was difficult to account for this very sudden rise of temperature on 11th December. The remains of a sinus had been opened behind the knee four days previously, and a good deal of healthy tissue had had to be cut through, and this largely increased the suppuration. Some toxin may have become absorbed. The fever abated in a few days, and the temperature was practically normal till complete recovery on 25th June 1913 . .I will now sum up the treatment which was found to be best. The surgeon who remarked that "Glanders is the most painful

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disease from which man can suffer" must have been very near the truth. I think the explanation is that in the cavities and sinuses the connective tissues become eaten away, leaving the nerves unattacked and therefore exposed. The pain was not so acute when granulation commenced. For many months I endured indescribable torture daily. At one time as many as sixteen sinuses had plugs removed and fresh ones inserted daily. Sometimes for the dressings morphia i grain or heroin l2 grain had to be given hypodermically. At other times 20 grains of aspirin was swallowed about an hour before the dressings. The removal of plugs the day after the operation was the most unspeakable horror, and when several large tight plugs had to be removed it was found impossible to continue without an increased dose of morphia or heroin, and on one occasion chloroform was contemplated. These dressings were necessarily done by nurses, and I am afraid the surgeons never realised the truth. Of course the trouble in dressing made it next to impossible to do any of it properly, and few of the sinuses were plugged to the bottom; the consequence was that a granulation would grow over a sinus half way down and imprison pus in the bottom half, with the result that it burrowed and burst an outlet for itself elsewhere in the neighbourhood. A dressing which was used for a time, and which was quite the most painful application that was used, was an ointment of scarlet red 4 per cent. put on to stimulate the wounds. It had to be discontinued on account of the pain it caused. Hot baths with an antiseptic were used to soak the foot and arm before the removal of the plugs. This facilitated their removal and lessened the pain. The antiseptics used were, first, potassium permanganate, which was discontinued as unsatisfactory; then boracic acid, but as this caused much pain in the wounds it was stopped; and, finally, lysol, I drachm to a pint, which was found fairly satisfactory, except for the slime it formed when brought in contact with pus. For many months cyanide plugging was used , then dry iodoform plugging, and later iodoform plugging soaked in the above lyso! solution. Sulphate of zinc (red lotion) was also found useful. For the last six months of the disease iodine was principally used. It was always put into the bottom of the sinus by m eans of a narrow rubber tube of T11) inch bore attached to a hypodermic syringe. When the pure tincture was used, generally a measured quantity of about 6 minims was injected. It was found that this much decreased the suppuration in a few days, and then a dilution of I to 6 or I to 10 of the tincture with water was used. Continued use of the pure tincture sometimes caused irritation of the sinuses and a tendency for blood to show when the plug was afterwards removed, and this was taken as an indication for the discontinuance of the pure tincture and for the use of the diluted tincture, or even the discontinuance of iodine altogether and the use of plain iodoform plugging for a few days. When the diluted iodine was used a larger syringe was attached and the sinuses were syringed out. The longest sinus of all, in the later stages of the disease,

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which went 2! inches up the right forearm, yielded only to iodine. The last stage of nearly every sinus was a skin pocket, which, if left alone, made no attempt to heal, and ordinary plugging of the pocket was also useless. These were always treated with novocaine and then snipped with scissors and painted with pure tincture of iodine, and the process repeated as often as necessary. The surface places always yielded to iodine treatment. Iodine, when used frequently as with the longest sinuses, caused some irritation of the skin round the orifices on account of its overflowing from the sinus. The use of zinc ointment on the skin prevented this. When pure tincture of iodine was used on a sinus the plug afterwards inserted was soaked in the pure "tincture, and when dilute tincture was used the plug was soaked in dilute tincture. Iodine does not mix with Iysol or with cocaine, so it was necessary to avoid washing out syringes with Iysol previous to their use for iodine, and when on account of pain in the sinuses a solution of cocaine was first injected it was necessary to wash out the excess of cocaine with sterile water before injecting the iodine. It was estimated that about I inch of narrow (k inch) sinus healed in a month when favourably treated, so it will be understood that the mouths of such narrow sinuses were very difficult to keep open for such long periods, and when dressings (gauze, lint) were applied dry the difficulty was much greater than when the dressing was a boracic fomentation. Latterly it was found best in such cases to run the plugging through a small piece of rubber tubing (-111" inch bore and -~ inch long), and when the plug was pushed to the bottom with the probe to slide this piece of tube along the plugging and into the orifice of the sinus This method kept the mouth of the sinus open and also ensured free drainage from the bottom. Drainage tubing as a means of treatment for the entire sinuses was found most unsatisfactory, as it increased sloughing. After the plugs had all been inserted a thin layer of plain gauze wrung out of weak lysol was wrapped round, then over all a boracic fomentation was applied. The gauze had the advantage of preventing the plugs sticking to the lint with discharge, and then being torn out when the fomentation was changed. The last of the old sinuses to heal was the one which ran through the foot in front of the tendo-achilles, and it presented a difficult problem for some months. Owing to thickening of the leg at this place the sinus was nearly 2t inches long. All other sinuses had a bottom from which healing could commence, but this last sinus was open at both ends, and refused for a long time either to heal from one end or to bridge over the middle. The plug running right through was made gradually narrower until only the finest cotton was passed through daily by means of a probe with a groove on the point. This cotton was removed daily and tincture of iodine was syringed through for about three weeks, then the narrow sinus was measured with a marked probe and plugged with cotton thread from each end, so as to leave about half an inch unplugged in the middle. The sinus bridged over in the middle, and in two and a half months had healed soundly up to each I

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end. Before the last sinus was quite healed I stumbled when walking and struck my right temple a severe blow on some woudwork. This brought up a hcematoma, which subsequently broke down and had to be operated upon. At this time, too, an abscess appeared on my left leg above the knee and had to be opened, and was over two months in healing. I think this last lesion was a septic· infection from the ankle sinus, and I have no proof that the hcematoma on the head contained the bacillus mallei. Not counting the smallest of the incisions, I have been operated

Photograph of the author (and patient) taken .July 1913. desire of the Editors.)

(Inserted at the express

upon forty-five times, and of these twenty-seven operations were done under a general ancesthetic. The disease commenced on 4th March 191 I, and on 25th June 1913 my last lesion healed. I am writing this in July 1913. I have never been in better general health than at the present time, and believe that I have made a complete recovery. My weight is II stone 6 lbs., which is nearly a stone heavier than ever I have been before, even when in health and with an additional arm. The left ankle has not quite regained its former freedom of move-

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ment and is apt to tire after a 3 or 4 mile walk, but I anticipate this will right itself in time. I must finish by saying that I should not have had the slightest chance of recovery had it not been for the patience and generosity shown to me by the surgeons who treated me, and for the kindness of numerous friends who looked after me during my somewhat horrible experience.

ENDOTHELIOMA OF THE SEROUS MEMBRANES IN THE OX.

By A. W. · TROTTER, M.R.C.V.S., Glasgow. PATHOLOGISTS are not in unison as to whether endothelioma ought to be classed with the carcinomata or with the sarcomata. This form of neoplasm undoubtedly originates from non-epithelial structures, and it is upon this that those who claim that this neoplasm ought to be regarded as a sarcoma base their contention. On the other hand, as the histology of these neoplasms is similar to that of a hard cancer, others assert that they ought to be classified among the carcinomata. It may therefore be described as a hybrid neoplasm originating from tissues which ought to produce, according to pathological laws, a typical sarcoma, but which on the contrary presents on microscopical examination the characters of a cancer. The causation of endothelioma is, like all other forms of neoplasm, obscure, and much investigation is still required to elucidate its etiology. It would appear that endothelioma of the serous membranes may occur in man, either as a large single growth or as small multiple diffuse growths. Senn, in his work on Pathology and Surgical Treatment of Tumours, p. 554, 2nd Edition, states; "The tumour may be nodular and of considerable size, or multiple," and quotes a case recorded by N epvue, who described an endothelial sarcoma of the pleura in a child seven years of age. The tumour was the size of an adult's head, and displaced the lung. The condition which forms the subject of this article differs from the ca'5e referred to above and conforms to that referred to by Ziegler in his Special Pathological Anatomy. At p. 875 this author states: "Endothelioma takes the form of diffuse white fibroid thickenings of the pleura, with a certain number of nodose swellings scattered through them; it may appear on any of the parietal, pulmonary, or diaphragmatic surfaces. Its coarse fibrous stroma encloses nests and reticulated strings of cells that give it an appearance not unlike that of a hard cancer." Again, p. 69 I, "Endotheliomata (of the peritoneum) generally take the form of multiple flattened nodular growths, white in colour, and either coalescent or connected by neoplastic bands . . . The tumour is characterised by the presence in it of nests and clusters of endothelial cells, which lie in a dense fibrous stroma and follow exactly the course of the lymphatic vessels. They arise from the multiplication of the endothelial cells of the serous surface or of the lymphatics." The translators of Kitt's Text-Book 0/ Comparative General Pathology, in a note on p. 383, state that "Endotheliomata of the