William Hughes

Deficiency Patterns in Metallic Poisoning

combined course over that represented by C.D. for the induction of ovulation would appear to be demonstrated by the fact that ovulation was shown to have occurred after the C.D. course in only two out of the nine cases in which it was used, whereas the D.S.-I.E. course succeeded in one case where previously the C.D. course had failed. Final conviction would seem to be provided by the occurrence of six pregnancies within 0 to 9 months of the completion of treatment, failure of ovulation having been the case prior to treatment in all of these patients. A sobering note must, however, be struck by the conspicuous failure to produce ovulation in cases of longstanding secondary amenorrhoea as well as most cases of marked oligomenorrhoea. It is tempting to speculate upon the mechanism whereby treatment with oestrogens and progestogen can lead to ovulation, but in the present lack of factual knowledge it would be unwise to proceed too far. That a direct action on the ovary could be implicated seems scarcely possible, so that one must invoke the anterior pituitary lobe as an intermediary, causing ovulation by the secretion of gonadotrophin. Unfortunately, although oestrogens can undoubtedly inhibit the pituitary, it is much less certain that they can have a stimulant action, and such an action is indeed strenuously denied by some. Be this as it may, it seems that the regular administration of oestrogens and progestogen, in the proper dosage, can so condition the pituitary gland as to secure its production of gonadotrophin in the manner necessary to cause ovulation.

Scurvy in Old Age

Investigation.-Blood picture: Hb, 90% (13.2 g.%); leucocytes, 8,000 per c.mm.; platelets, 140,000 per c.mm.; bleeding-time 2 minutes (Ivy); clotting-time, 5minutes (Lee and White); film appeared normal. The E.C.G. showed changes typical of an old anterior cardiac infarction. X-ray film of chest showed emphysematous and atheromatous changes. The blood urea was 48 mg. per 100 ml.; serum protein, 7 g. per 100 ml.; albumin, 3.9 g. per 100 ml. The urine contained occasional pus cells with a moderate growth of Bact. coli. No acid-fast bacilli were seen in the sputum. Sigmoidoscopy revealed no organic lesion in the distal 10 in. (25 cm.) of bowel. Tentative diagnoses of anterior cardiac infarction, haemorrhagic diathesis (probably scurvy), and epilepsy were made. Accordingly he was given a high protein diet and was saturated with ascorbic acid, 1 g. daily for two weeks, followed by 150 mg. daily for a month. During the course of treatment the haemorrhages rapidly decreased, and no new ones appeared. By June 27 occult blood had disappeared from the faeces. The epilepsy was satisfactorily controlled with I gr. (32 mg.) of phenobarbitone three times a day. But in view of the presenting symptoms of anorexia, epigastric discomfort, loss of weight, and haematemesis, it was decided to examine the gastro-intestinal tract further, in order to exclude the possibility of a neoplasm. On June 6 a barium-meal examination demonstrated an ulcer crater in the pre-pyloric area. The site of the ulcer led the radiologist to suggest a gastric neoplasm as the likely diagnosis. A surgical specialist confirmed the radiologists opinion; and the patient was placed on the waitinglist for a laparotomy. Following ascorbic acid treatment the patient continued to improve. He cast pff the air of lassitude, gained weight, and began to relish his meals. On July 26 his blood chemistry was as follows: blood urea, 28 mg. per 100 ml.; serum protein, 6.3 g. per 100 ml.; albumin, 3.9 g. per 100 ml.; thymol turbidity, negative; colloid gold, negative. Such satisfactory progress seemed to warrant a further radiological examination, and on July 11 an x-ray film revealed a normal pylorus, which was confirmed by gastroscopy the following day. Another barium-meal examination on August 12 was also normal. On September 12 gastric biopsy of a specimen taken as near as possible to the original site of the tumour revealed a natural glandular pattern, with haemorrhage into the superficial layer of the gastric mucosa. The patient was discharged on August 29, and when subsequently seen at follow-up clinics his condition had remained satisfactory. The intrinsic pre-pyloric tumour first demonstrated was therefore thought to be a submucosal haematoma which had resolved following a course of ascorbic acid.

Trial of a new remedy (Ciba 10870) in Parkinsonism.

is of no value-was found here in the two groups investigated--those with cutbreaks of violent tempers and those with Parkinsonism. Once again this minor investigation shows that inert substances produce the same effects as drugs with pharmacological properties; they are useful to patients who believe they will get benefit from them, and they cause undesired side-effects; and the side-effects may be present only with the inert tablets and not with the actual drug.

Cortisone in Rheumatism

ture exposures from the actinic fluorescence of a screen in the middle twenties, and the use of bromide paper in the traumatic surgery of the Palestine fracas of 1935-7. At the present time the greatest demand for large film is from tuberculosis clinics. In the last few years tuberculosis practitioners have come to rely solely on x-ray findings for both diagnosis and progress. It is my contention that the use of full-size film is not in all these cases justified. The original diagnosis may well be on the usual 15 by 12 film. The follow-up, the hordes of contacts, spread over a year or more in most cases, are surely the case for which mass miniature came into being. The mobile mass miniature is nowadays but a bus-ride away in most regions. Casualty and fracture work is efficiently performed on bromide paper, as is follow-up work in orthopaedics; one late film is all that is required in salpingography. In the majority of cases in barium meals, a serial-changer at the radiologists screening session will give a concrete diagnosis, in good hands, on one film. One tomograph film, after a moments thought, is as good as all the routine films at blunderbuss levels, in thick structures for which this technique was introduced. I submit that economy should not yet be applied to procedures which still show room for improvement. I instance cholecystography, pyelography, arteriography, and skull work. The amount of film likely to be used for these is trivial. A camera adaptation has been devised in my area which will have the approval of even the most financially embarrassed management committee. Its cost is a bagatelle, its upkeep is that of an amateurs camera, and its construction is within the scope of the hospital handyman. The details will shortly appear in the radiographers technical journal, for anyone who may be interested.-I am, etc.,

Acute Lymphocytic Meningitis

1. A series of seventy cases of enuresis in mentally normal children is described, with the procedure by which they were treated. 2. The results of treatment are analysed and show at least 60 per cent. of cures maintained over a length of time by the one method, and additional cures by other methods to suit the individual case. 3. Theories of aetiology and different methods of treatment are briefly discussed. 4. Most of the cases may be cured by simple procedures based on encouragement or suggestion.

Hormones and Rheumatism

questions to be answered. Where did influenza go in the summer ? Where did an influenza epidemic start ? Vaccines prepared and given in advance might confer immunity to influenza, but it must be confessed that they were often ineffective owing to a change of strain in the virus. Cases of atypical pneumonia, characterized by acute onset, intense headache, malaise, depression, hacking cough, and absence of fever or other physical signs were probably due to virus infections. One of these infections-so-called Q fever, due to Rickettsia burneti-appeared, at any rate in a proportion of cases, to be milk-borne. The incubation period was 14-25 days, and rashes were rare. The rickettsia could be excreted symptomlessly by cows, sheep, and goats for as long as three months, and had been found, though rarely, in cattle ticks and dog ticks. No serological tests were yet available in this country for differentiating strains of the virus of poliomyelitis. The viruses responsible for a large group of cases labelled encephalitis had still to be worked out. The syndrome of lymphocytic meningitis was probably caused by many different viruses. In 80 of 100 cases investigated the virus had not been identified. Finally Dr. MacCallum pointed out that the distribution of cowpox in this country had not yet been fully mapped, and he asked for scrapings from suspected cowpox lesions.

Treatment of Some Complications of Bacillary Dysentery.

was half an inch outside the mid-clavicular line in the fifth intercostal space, and a few extrasystoles could be heard. Examination of th.e chest, abdomen, and ears revealed nothing. Lumbar puncture was performed and turbid fluid was obtained; pressure, 120 mm. water. It contained 2,000 cells per c.mm., of which 98% were polymorphonuclears. No bacteria were seen in a direct smear, but a Type 18 pneumococcus was grown in pure culture. A blood count showed a leucocytosis of 22,500, of which 83.5% were neutrophil polymprphonuclears. Treatment with sulphathiazole was begun at 4 p.m. on May 9. Since oral administration was impossible, the soluble sodium salt was given intravenously, the patient receiving 20 g. in 6 pints of glucose-saline in the first 24 hours. Subsequently oral administration was possible, and he received 18 g. by this route in the second 24 hours and 24 g. during the next 48 hours, making a total of 62 g. in 96 hours. After a restless night the patient improved considerably during the course of May 10, becoming fully conscious and fully orientated by 4 p.m.; his temperature was then 100° F. and eye movements were normal. On the 11th improvement was maintained; the pupils were normal and the chest clear. A herpetic eruption on the lips started at this time, becoming more severe and extending to the left cheek during the next two days; it was accompanied by stomatitis and glossitis.. On May 14 the temperature had dropped to 98.4° F., and the C.S.F., which was under normal pressure, contained only a few degenerate polymorphonuclear leucocytes, and proved sterile even after cultivation in media containing p-aminobenzoic acid. The condition of his mouth was improving. On May 16 he had a shiver-ing attack and, since recurrence is common in this disease, a further course of 30 g. of sulphathiazole was given during the next four days. He continued to improve, however, and by May 24 was convalescent. He was discharged well on June 14, and has since returned to work. A primary focus of his infection was sought, with negative results; a radiograph of the chest (May 25) and of the accessory air sinuses (June 3) revealed nothing abnormal, and no focus in the middle ear could be discovered.