George Buchanan

SPIROCHAETOSIS ICTEROHAEMORRHAGICA: The Presence of the Causal Organism in Slime as a Source of an Outbreak in East Lothian

The Local Focus. The next poinlt is the removal of local focal infection as a factor in prevention. On June 7th, 1900, a man, age 28, came to St. Marys Hospital suffering from a sore throat. Thie condition was one of acute tonsillitis and he had mi.tral anid aortic disease, arthritis, and muscular pains. Thelrc was a previous attack of rheumatic fever four years before. Dr. Paine, by plate culture, isolated a strepto-diplococcus inorphologically and culturally indistinguishable from that we had isolated from the lesions of acute rheumatism. Intravenous injections into a rabbit produced acute aortic and mitral endocarditis. Fitz-Meyer, two years later, by extensive experiments supported these results, and later with Mr. George Waugh we repeatedly -verified the ability of this micrococcus obtained from unhealthy tonsils to produce cardiac and arthritic lesions without anv lrevious injury to the valves. This was the birth of the local focus in rhleumatism. . No one can be more convinced than I am that the rheumatic infection has one important site of entry. into the system.through diseased tonsils, and particularly those which resemble, in their deep lacunae, culture tubes. No one probably is less convinced than I that wholesale removal is indicated in the rheumatic child, or that the removal of the local focus shuts the door. Nature is not so easily managed, and I have seen severe carditis in a first attack occurring some years after a complete eniucleation. Recent American statistics bear out this exper-ienice, for. Ingerman and Wilson report that, of a series of cases in which tonsillectomy, had been undertaken for rlheumatic maniifestations there occurred, in a period between one and eleven years after. the operation, rheumatic relapses in 76 per cent. I look upon the tonsils as an important barrier; but as no man is more dangerousthan a clever man who has lost his capacity, so are badly damaged tonsils a constant source of langer. Careful treatment of the tlhroat, nasopharynx, and teeth in the prevention of acute rheumatism will be, in my opinion, a perm-iianent factor. More investigation is required to determine other local foci as equially definite.

Turner's and Noonan's Syndromes

SIR,-In a recent American case-report and review of the literature on Haemophilu(s influenzce cellulitis, published in a British journal, Rasmussenl stated that this syndrome had not been reported in the European literature. In fact, one case had been mentioned in a paper from Oxford albout haemophilus epiglottitis.2 In the light of Rasmussens commnents we wish to report two further cases of H. influenzae type b infection recognized in Oxford in the past few weeks.

II.-Operation for its Removal: Recovery.

This last cireumstance, coupled with the fact that the paralysis begani in the left arm, points to a lesion having its centre about the junction of the middle with the lower tllird of the ascen(ling parietal convolution. Tllis conclusion is somewlhat suipported by the pain wlhielh was complained of, and by the tenderness on percussion above and belhind the righft ear, although it must be remembered that the seat of pain does not necessarily correspond with the seat of the disease. 2). Te Nature of the Lesin.-Tlhe history of suppurative disease of tlhe middle ear naturally leads to the suspicion that there mighti be a cerebral abscess; b)it this suppuration occurred on tlhe left side, and in early life, a good many years before there were any symptoms of cerebral irritation; wlhile Dr. Barrs report furnishes evidence of prolonged absence of active disease of the middle ear. So that we may almost certainly exclude the hypotlhesis of abscess of tlle brain, more especially as D)r. Somervilles report on the urine is decidedly against suclh a view. That being so, we can come to no other conclusion than that we have to deal with a tumour of some kind. Tlle most common forms of cerebral growth are tuberculous or syphilitic in their nature, and whlich might possibly be influenced by the inoculation of Kochs fluid on the one hand, and antisyphilitic treatment on the other. But there is no history of .a hereditary tendency to tuberculous disease, nor is there any indication of a delicacy of constitution in the patient himself. And, as regards syphilis, there is no hiistory or symptom of hereditary transmission of the taint, nor is there any suspicioni of the disease having been acquired, not to speak of the age of the patient wlich, of itself, almost excludes it. A cancerous growth is out of the question, as the patient presents none of the characteristics of malignant disease, nor does there appear -to be a family predisposition thereto. If, tlhen, we are riglht in our view that the tumour is neither -tuberculous, syplhilitic, nor cancerous, all that we can say -further is that the intracranial growtlhs wlich are most cominonly met wit]h are glioma or sarcoma; and the only way of getting rid of thlemii is by operative interference.

Aneurism of Common Femoral Artery extending into the Iliac Fossa: Simultaneous Ligature of Arteries: Cure.

CAsrES of inguiual aneurism, in wvhich ligature of the maini trunk above, and the two subdivisions below, is niecessary, or at least has been followved by caire, are rare. I was iniduced to adopt the practice, in the patient here referred to, in consequence of the ultinmate result of a case I had a year ago, in which ligature Of the external iliac was accomplished with perfect success, so far as the operation was concerned ; cicatrisation toolk place in a week; but pulsation returned in tbe sac, which burst into the thigh, the blood infiltrating all the tissues; and the issue

Clinical Lecture on Mammary Tumours

GENTLEMEN,-I propose to bring before you to-day some cases that have happened at different times during the previous fexv wveeks, and of which we have another example to-day. I refer to cases of tumour of the mamma. Before introducing the patient, the history of whose case wvill form the text of our lecture, I have to remind you that the study of tumours, and especially of malignant tumours, may be viewed in three aspects. First, in your systematic lectures on surgery, you get a complete viexv of the whole subject of tumours, without reference to particular examples. Secondly, in your class of pathology, you study and have demonstrated to you the origin, growth, and internal structure of these tumours. The object of a clinical explanation of these subjects is to concentrate into a focus just as much of all that scattered informa tion as really avails you in practice. It is exceedingly interesting philosophically to study what are the causes, proximate and remote, the mode of growth, the internal structure, and the progress of these things; but wvhen you have to deal with a living person, only a certain amount of that great extent of information really comes into play. I wvish, if possible, to concentrate into these remarks the most of wlhat is avail able, supposing you in private have to deal with a case such as that now brought in. This woman is forty years of age, unmarried, of spare habit of body; and hitherto she has enjoyed good health. The catamenial function

Clinical Lecture on Naevus.

the nature of this affection, and the different modes that can be adopted for its remedy; because it is one of those surgical affections that are exceedingly common, and one wvhich almost every surgeon in active practice may at the outset undertake and probably cure, while there are many other examples of disease which it is out of the range of the ordinary practitioner to deal with. In order to explain to you the nature of this and allied cases, it may be necessary for me to recall to your minds for a few minutes the normal connection between the extremities of the arteries and the extremities of the veins. In the diagram you see before you, this is made intelligible by the different colours of the vessels. You see on one side

Abstract of a Lecture on the Operation of Tracheotomy: With Cases

OF A LECTURE