1696 with work next day, making him think he is worse and refuse to attend again. A week or two later the nurse visits and is told that he does not need to go on with treatment because he is quite well. How is he to be classified ? There are many points in connexion with the course of tuberculin treatment in different types of cases that are very difficult to investigate at a dispensary. More knowledge is needed first of the course of similar methods in patients whose environment is under better observation and control, but since an important feature of tuberculin treatment is the fact that it can be given in certain cases without interfering with home life and work, it is necessary to study the complicated relationships of sensitiveness, type of disease, and environment under these conditions. As in the other difficulties to which I have referred, careful observation, analysis, and classification, with scientific methods of correlating the series of facts thus recorded, may be expected to lead us to a better comprehension of the problem.
NOTES ON THREE CASES OF GLANDERS. BY H. M.
L.R.C.P. LOND. ; AND
K. B. CLARKE, M.R.C.S. ENG., L.R.C.P. LOND.
is always looked upon
ease of extreme rarity, average of four cases a year as the usual number in some writers being given by this country. The diagnosis is often a matter of great difficulty, and even with frequent bacteriological examinations the bacillus may not be found until a short time before death or even not until the autopsy. When we think, however, of the very large numberof fatal cases of septicaemia and pyasmia occurring during the course of the year without any bacteriological examination being made, or, at any rate, without the bacteriology of the casebeing followed up before and after death, it is surely reasonable to conclude that glanders may be much more common than is supposed. The following three cases, treated at St. John’s Hospital, Lewisham, serve to illustrate this point. They were all three admitted for severe pyrexia. The first is of great interest, as a definite diagnosis was made from a bacteriological examination of the urine a few days after admission. And the case shows the great importance of examining the urine for bacteria in all cases of obscure pyrexia where nothing can be found on physical examination, where there is no demonstrable focus, and where no organism can be found in the blood. an
CASE I.-The patient, aged 19, a sailor, who had been ill for three days, was admitted for pyrexia and complaining of There was a deep-seated pain in the right epigastric region. nothing of importance in his previous history, and as far as The can be ascertained he had nothing to do with horses. physical examination of his chest showed some slight dulness over the right apex, The leucocyte count was normal. A syringeful of blood was taken from a vein and planted out on various media which remained sterile. During the first few days the drowsy condition of the patient continued to increase. On the fourth day after admission, as he had complained of some pain after micturition, a catheter specimen was taken and planted out on all the ordinary media. In 24 hours there grew colonies of staphylococci and of a Gram-negative bacillus which proved on further investigation to be the bacillus mallei. The condition of the patient became worse, his temperature was of a septic
developed intense jaundice, and there appeared over an eruption simulating small-pox. After having delirium for several nights he gradually passed into a state of coma, and died 11 days after admission. type,
the chest, back, and face At the
found in both
lungs, the base of the right lung being chiefly affected. A large retroperitoneal abscess was discovered on the anterior
Cultures from both these situations. The bile was. of the bacillus mallei. yielded growth inspissated and could not be squeezed through the cysticduct. The liver and spleen were normal, and cultures from them and the heart’s blood remained sterile ; the brain and its coverings were normal. CASK 2.-The patient, a mechanic aged 43, was admitted for acute rheumatism. He gave a history of typhoid fever diphtheria four years previously and had suffered bring him in contact. from gout. His work did not with horses, and he did not live near any stables. He ill a few days before admission with an was taken acute pain in the right ankle-joint. He was pale and much wasted, having lost weight rapidly during the previous. three months. He complained of severe pain in the right ankle-joint, the outer aspect of which was red, oedematous and very painful. The examination of the heart, lungs, and urine showed nothing abnormal. His condition began gradually to get worse ; the temperature kept high, with one well-marked rigor. A small abscess formed and was opened on the outer aspect of the right leg; other joints became involved, particularly the knee-joint, right shoulder, and left ankle. Inflammatory foci appeared on various parts of the body, but slowly disappeared without suppuration. A well-marked pleuritic rub was heard at both bases of the lungs, but these were the only physical signs heard throughout the illness. No definite diagnosis up to this time had been made though several had been suggested. At various times it was thought to be a case of acute rheumatism, acute gout, and then phthisis, and now a diagnosis of gonorrhoeal pyaemia was suggested. Blood was taken from a vein, but remained sterile on all the media. Pus taken from the wound on the right leg contained streptococcus pyogenes. Smears taken from the urethra showed the presence of gonococci. The pysemia increased and the patient rapidly lost ground. An abscess formed on the right leg and was opened, a quantity of pus escaping. In this pus was found a Gram-negative bacillus, which proved on further investigation to be the Five weeks after admission a papule bacillus mallei. appeared on the left side of the neck which soon became vesicular, and in 38 hours the whole face was covered with pustules and the eyelids were very cedematous, the condition simulating small-pox. In these pustules was also found the bacillus mallei. The patient died six weeks after admission. CASE 3.-The patient, aged 14, was admitted as being a possible case of cerebro-spinal meningitis. He was very drowsy, with a distinctly septic temperature varying between 990 and 105° F. He was quite conscious, declared to have no pain, was rather sleepy, and his head was very slightly retracted. Cultures were taken from his blood and cerebrospinal fluid, from his nose and throat, and from some ulcers he had on his legs. The first two remained sterile. The cultures from his nose and throat grew the ordinary organisms found in these parts; from the ulcers a mixture of staphylococci and streptococci grew. After a fortnight the retraction of the head, somnolence, and slow cerebration were more marked, but he gave perfectly sensible answers. Repeated cultures from the various parts always gave the same results and never threw any light on his condition. Some of the ulcers healed, whilst fresh ones broke out. From inquiries it was discovered that the patient a fortnight before he fell ill had been looking after a horse which was suffering from ulcers, and that a dog which was kept in the same stables had died from an unknown disease. The head became more and more retracted so that it obliterated the cesophasgus, and in the end also the trachea. The occiput actually touched the back between the shoulder blades. The patient died five weeks after admission. At the autopsy all the organs were found to be normal but very emaciated, as in a subject who had died from starvation. The brain and medulla were normal, and only in the cerebellum a small patch of grey-greenish, viscous pus Cultures from all the various organs were taken, was found. and also from the pus in the cerebellum. Most of the
aspect of the a
1697 cultures remained sterile ; some showed post-mortem bacteria. The cultures taken from the pus in the cerebellum grew the bacillus mallei.
illustrated many subjects in the private life of the ancients more or less closely concerned with medicine, such as baths, latrines, cosmetics, prostitution, the homosexual or rather bisexual life of the ancients, popular remedies and superstitions ; (5) as a source of medical satire and caricature it deserved to rank with the works of the Latin poets. Mr. C. J. S. THOMPSON showed objects of medical and surgical interest from the historical medical museum of Mr. Henry Well come. Amongst the exhibits wasa chastity belt," an early bullet extractor which seemed to be older than the time of Ambroise Pare, and a beautiful ivory model of the temporal bone showing the structure of the internal ear.
The perusal of all three cases shows in what varied and obscure ways glanders manifests itself, simulating first one disease and then another, all of them being quite unlike the ordinary text-book description of glanders. And yet when we realise the very infectious nature of the disease-for the bacillus mallei will infect through the unbroken skin-great stress should be laid on the importance of making a definite diagnosis as early as possible. And it must also be borne in mind that glanders may remain latent in the system for a long time, sometimes for years; and sometimes, although the patient may appear to be in excellent health, with the exception, perhaps, of the occasional recurrence of small abscesses, the disease is still present as the organism has not actually been eradicated, and the patient may still be said to be suffering from glanders. In fact, we may say that the incubation period of glandersis unknown and that this disease is more difficult to eradicate from the system even than tubercle or syphilis.
SECTION FOR THE STUDY OF DISEASE IN CHILDREN. Exhibition of Cases and specimens. A MEETING of this section was held on Nov. 28th, Dr. LEONARD G. GUTHRIE, the President, being in the chair. Dr. C. E. ZUNDEL showed a case of Recrudescent Rickets with Tuberculosis and Infantilism. The patient, a boy aged 14 years, had been, when 7 years old, treated as an outpatient and then as an in-patient, when he was described as very undersized and with marked rickets. At the present time his height is 3 ft. 4 in. and his weight 2 st. 131b. There are marked deformities of the forearms due to multiple fractures. There is some broncho-pneumonia and considerable ascites. Dr. F. G. CROOKSHANK and Mr. L. E. C. NORBURY showed cases of Bilateral Congenital Dislocation of the Hip in Twins. The patients were females aged 8 years and 11 months. In each case there was marked displacement of the head of the femur on to the dorsum ilii on either side. Dr. CROOKSHANK showed a case of Nervous Cretinism ROYAL SOCIETY OF MEDICINE. in a girl aged 5years. In August, 1912, it was recorded that the skin was harsh, the gait tottery, and the knee-jerks increased. Subsequently the ataxy increased, but as the SECTION OF THE HISTORY OF MEDICINE. ’, result of a course of thyroid treatment there had been great lNfcz-rticcl and Medicine.-Medical Aspects of the Greek is growing fast and she ’, improvement Dr. CROOKSHANK also showed a case of "Jaw-winking." Ant7eolog.-Elcibition of Specimens. A MEETING of this section was held on Dec. 3rd, Sir The patient, a girl aged 9 years, has congenital unilateral WILLIAM OSLER, the President, being in the chair. ptosis. When the muscles of her face are at rest the ptosis Dr. John Ferguson, professor of chemistry in the Uni- is considerable. When she depresses her jaw and I I rings " her versity of Glasgow and a former president of the Biblio- mouth, not only does the ptosis disappear, but the sclerotic graphical Society, was unanimously elected an honorary becomes visible on the affected side, above the cornea. Mr. PHILIP TURNER and Dr. H. TIPPING showed a case of a member in place of the late Dr. J. S. Billings. Dr. Leslie Cowlishaw, Dr. J. F. Halls Dally, Dr Philip Hamill, and Mesenteric Cyst Simulating an Intussusception. The patient, a boy aged 4 months, had a sudden attack of pain followed Dr. Herbert R. Spencer were elected ordinary members. Dr. RAYMOND CRAWFURD read a paper entitled ’’Martial by the passage of blood per anum. Under an anaesthetic a and Medicine," in which he cited the chief allusions to lump could be readily felt. The cyst, about an inch in medicine by Martial, the Roman satirical poet, and submitted diameter, was situated in the angle between the ileum and ascending colon, causing obstruction at the ileo-cascal renderings of these epigrams into English verse from his the own pen. The paper has been published in THE LANCET.’ valve. Histological examination showed the cyst to be lined -Dr. R. 0. MOON criticised the paper in a friendly spirit, by intestinal mucous membrane. The cyst did not comwith the intestine. saying that he demurred to Asolepiades being considered a municate Dr. W. J. MIDELTON showed two cases of Dermatitis charlatan, and saying that Martial was poor and wrote to make money. It was for this reason that he pandered to Herpetiformis treated by counter irritation. The first case, the vilest tastes of the decadent Roman empire and indulged a child aged 7 years, in whom the disease first appeared at I in the grossest flattery of the Emperor Domitian, who was one the age of 3 years, was well within three weeks, though there had since been several relapses of short duration. of the worst of the immortals. Dr. J. D. ROLLESTON read the second part of his paper on The second case was equally satisfactory. Dr. G. A. SUTHERLAND showed a case of Anterior Poliothe Medical Aspects of the Greek Anthology. He dealt with the allusions to medicine and religion, puerperal mortality, myelitis with Paralysis of the Abdominal Muscles and . deaths at different ages, modes of death, acute and chronic Collapse of the Lung. The child, a female, aged 15 months, He also pointed out possible references to was wasted and rickety. Both lower extremities showed infections. malaria, tuberculosis, and syphilis. There were definite signs of former poliomyelitis. On coughing or crying two allusions to alcohol and other intoxicants, gout, digestive marked bulgings were seen, one occupying the upper twodisorders, latrines, baths, cosmetics, deformities and dwarfs, thirds of the right abdominal wall and the other the lower giants, diseases of the nervous system, and veterinary two-thirds of the left side. Over the lower lobe of the right medicine. In conclusion, he stated that although many of lung there were posteriorly impaired resonance and faint the medical epigrams were anonymous or by writers whose breath sounds. It was suggested that the signs in the right date was uncertain the Greek anthology deserved more lung were due to massive collapse of the lower part of the attention than it had hitherto received for the following right lung due to paralysis of the muscles of the abdominal wall. reasons : (1) It offered numerous illustrations of the relations Dr. J. W. CARR showed a case of Enlargement of the between Greek medicine and religion, especially as regard with Ascites in a boy aged 2!years. Dr. Carr conLiver definite it to certain contained references Asklepios ; (2) diseases, such as gout, alcoholism, and malaria, as well as sidered that the liver was almost certainly cirrhotic, but the cause of the cirrhosis was very obscure. numerous allusions to epidemic diseases, the nature of which Dr. F. J. POYNTON showed a case of Osteogenesis could not be determined; (3) it supplied valuable negative evidence of the existence of syphilis in antiquity in spite of Imperfecta with great distortion of the bones of the lower the numerous facilities for the spread of the disease ; (4) it limbs. The child had been admitted to hospital on several occasions for fractures of the bones of the legs from very 1 THE LANCET, Dec. 6th, 1913, p. 1643. slight violence.