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Captain Rogers, I.M.H., in a report published in 1897 took the view that kala-azar is not ankylostomiasis but malarial ’,fever. In February, 1898, Major Ronald Ross, I.M.S.,was placed on special duty to investigate malaria and kala-azar. One result of his labours was the discovery (1) thatproteosoma (Labbe), one of the so-called malarial parasitesof birds, is capable of living and growing in a species ofmosquito and (2) that healthy birds were readily infectedwhen bitten by mosquitoes fed a week previously on birdscontaining the parasites of avian malaria. Major Ross’s ireport on kala-azar, published by the Government PrintingOffice in Calcutta, is a model of clinical and epidemiologicalinvestigation and is of considerable length, extending to 87large pages. He divides the symptoms into three periods orstages, the first of which is characterised (a) by recurrentaccessions of acute fever separated by periods of apyrexiaand (b) by rapid enlargement of the liver and spleen. Thesecond stage is that of established and still acute enlargementof the liver and spleen, accompanied by constant low feverand pronounced but not excessive anaemia. The third stage isthat of cachexia and when it is once firmly establishedrecovery seems to be impossible. With respect to durationthe first stage may be put at one or two months only andthe beginning of the third stage at nine months or a year,or even more, from the commencement of the illness. The

arguments in favour of the malarial theory of kala-azar arethe facts that the symptoms are almost if not quiteidentical with those of malarial fever, that the diseaseoccurs in malarious regions, and that most of the cases

contain yellow pigment, the remote derivative of the patho-genetic parasites. The arguments against the malarial

theory are the high death-rate, the intractability to quinine,the existence of a low constant fever in the second stage ofthe disease, the apparent absence of the parasites andmelanin of paludism from many cases, and the communica-bility from the sick to the healthy. Major Ross discussesthese various points very fully and in the result comes tothe conclusion that kala-azar is a form of malarial fever anda form which is probably by no means confined to Assam.The question of the spontaneous extinction of the parasiticinvasion in old cases of paludism deserves special attentionbecause of its bearing on treatment by quinine.

ARSENICAL PIGMENTATION OF THE SKINSIMULATING ADDISON’S DISEASE.

AT the meeting of the Societe Médicale des Hopitaux ofParis on June 30th M. Enriquez and M. Lereboullet describeda remarkable case in which arsenical pigmentation simulatedAddison’s disease. The patient was a man, aged 47 years,who had been in good health until April, 1897, when aneczematous eruption appeared on the left ankle and thenaffected the feet and hands. On Oct. 19th under medicaladvice he began to take about 16 drops of Fowler’s solutiondaily. He continued to take the solution in the same doseand in January, 1898, he felt depressed and experiencedpricking and congestion of the conjunctivas. In March henoticed that his skin was becoming black in certain parts.The pigmentation rapidly became generalised; in April itinvolved the whole body. In the meantime he always hadconjunctivitis and lacrymation. He also complained of

dryness of the throat. The practitioner who then attendedhim, basing his opinion on the characters of the generalmelanodermia which in parts assumed a bronze tint, the

progressive wasting, and slight asthenia, diagnosed Addison’sdisease and ordered the Fowler’s solution to be continued.M. Brissaud, who also saw the patient, concurred in this viewand advised in addition the use of suprarenal substance.The symptoms progressed. There were crises of abdominal

pain suggesting renal or hepatic colic. In June, struck bythe absence of asthenia, gastro-intestinal troubles, and

lumbar pains and by several special characters of the

I eruption, M. Brissaud requested his colleague, Dr. Gaucher,to examine the patient. The latter appeared to be robust and

, but little wasted. The face was very bronzed. The melano-i dermia was general but of variable intensity; the tint wasI slate or fawn colour in some places, bronze or almost black, in others ; as a whole it gave the impression of Addison’sI disease. But the pigmentation was not uniform ; a largeI number of light-coloured spots of from the size of a pea to: that of a lentil could be distinguished. In other places, on

, the contrary, especially in the neck, behind the ears, and atI the roots of the upper limbs, highly pigmented spots were

observed. The melanodermia was most marked in the groinsand axillae and at the waist and in general at the folds offlexion of the body. The hands and feet were almost exempt.On the face it was uniform, but relatively little marked.The genitals were less pigmented than other parts. Themucous membrane of the lips and cheeks was little affected.The skin of the palms and of the palmar surface of the

digits was markedly thickened with numerous hard papules.The soles showed similar changes, but in greater degree. In

this case the spotted character of the pigmentation, therelative immunity of the hands and feet, and the lesserdegree of genital pigmentation were in favour of the

diagnosis of arsenical pigmentation and against that ofAddison’s disease. The diagnosis was confirmed by diminu-tion of pigmentation and other symptoms three weeks afterthe patient ceased to take arsenic. The marked cutaneouseffect with the absence of all nervous symptoms are note-worthy and reveal a special predisposition.

THE SPHERE OF A MATRON.

AN extraordinary story is reported in a local London paperconcerning the Chelsea Infirmary. A patient was operatedupon by his own desire on May 24th for hernia and onJune 5th the matron of the infirmary, without, it is stated,instructions from the surgeon in charge, moved the patientfrom the position which he had been told to occupyin his bed by altering the position of his pillows. OnJune 6th serious haemorrhage took place from the

wound. The board of guardians have had the matter beforethem, when five voted in favour of a motion that the factsshould be laid before the Local Government Board and

12 negatived the proposal. This is a decision which willnot inspire anyone with much respect for the board of

guardians unless they supplement their refusal to seek theaid of the Local Government Board by vigorous treatment ofthe situation themselves. If the matron interfered with theorders given by the medical man with regard to the surgicalcare and nursing of a patient she is so much to blame thatit is almost no exaggeration to say that she is unfit for herposition. If she did not behave in the unwarrantablemanner which is alleged against her in at least one localpaper her character should be cleared from these aspersions.The debate upon the matter by the guardians, in the accountwhich has come before us, shows that they have been unableto regard the circumstances in a calm and unprejudicedmanner.

"KISSING THE BOOK."AT the Lambeth County Court on July 25th a medical

witness stated that ’’ he preferred to kiss the book ratherthan be sworn in the Scotch method." His Honour JudgeEmden was naturally surprised and according to the reportin the (}lobe said :-

"This is really an extraordinary action for a doctor totake. I have myself seen persons suffering from diseaseswhich I need not mention and which had been contractedfrom kissing the book while oath-taking. Physician afterphysician has pointed out this danger and an Act of Parlia-ment was actually passed in 1888 to legalise the oath being

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taken by uplifted hand. But, as we all know, the provisions 1of many Acts are not generally known and so I caused

i

placards to be put up in this court stating that persons 1desiring to be sworn without kissing the book may ask tobe sworn by uplifted hand, which in my opinion is the most Isolemn method. Since those placards were put up very fewpersons here have kissed the book. Take the oath in the- way you consider most binding. You are the only medicalman I have had before me who favoured the kissing of thebook."

We have again and again referred to the danger, to saynothing of the unpleasantness, incurred by kissing a greasybook which many other persons, some of them uncleanly,.have previously kissed, and in THE LANCET of Jan. 18th,1896, referred in laudatory terms to his Honour JudgeEmden’s action in publicly stating that kissing the bookwas not necessary. However, if any man likes to do so

.there is no one who can prevent him, only we should liketo ask those who still prefer to kiss such a copy of the HolyGospels as is generally found in courts of justice whetherthey would like to kiss some of the persons who have

(previously kissed the book? 2

THE ST. JOHN AMBULANCE ASSOCIATION ANDITS STOCKPORT CENTRE.

AT last it appears probable that a limit will be set

-to the policy which seems to have been selected bythe local secretary of this Centre as the best method’of dealing with the unpleasant situation in Stockport. Weunderstand that about a fortnight ago a formal applica-tion was made by the Medical Society of Stockport to thelocal chairman of the St. John Ambulance Association foran inquiry into the way in which the ambulance matters of.the Association were conducted. The reply of the local.chairman being evasive was sent to the Central Executive ofthe Association when an answer was received from SirHerbert Perrott saying that the Local Centre must hold an.inquiry first, and that until such an inquiry was heldthe Central Executive could not act as a court of

.appeal. Sir Herbert Perrott’s letter went on to

state that desiring a speedy termination of the

"unfortunate differences" " at Stockport the Central.Executive were prepared to appoint as arbitrators three

wholly independent gentlemen if all concerned would agree,to be bound by their decision. This offer has been acceptedby the medical society with the suggestion that there shouldbe adequate representation of the medical profession on theboard of arbitrators. If the local secretary now refusesarbitration he will occupy a position in the eyes of all fair

men somewhat difficult to defend. If he accepts arbitrationthere will, we feel certain, quickly be an adjustment of thematters so acrimoniously at issue.

CROUP IN WHOOPING-COUGH.

THE croup-like symptoms which are not uncommonly asso-- ciated with the early stage of whooping-cough occasionallygive rise to some difficulty in diagnosis. This point was wellbrought out in the course of a discussion at a recent meetingof the Société de Therapeutique of Paris. On this occasionM Gallois described by the term laryngite coqueluchoïde acondition of croup which is most prevalent among children,though found also in adult life, and which subsequently runsa course practically identical with that of whooping-cough.He attributes it to a form of laryngeal congestion and thinksthat post-nasal adenoids play an important part in its produc-tion. In face of the fact that true pertussis usually originatesin a species of laryngitis this explanation appears to us to besomewhat strained. We would rather endorse the view ofanother speaker at this meeting, M. Castel, and say that thepresence of laryngo-tracheitis does not suffice to eliminatethe diagnosis of whooping-cough. No doubt other causes

besides the action of the specific virus of this disease are

capable of producing a similar effect. Irritant pressure

by inflamed mediastinal glands upon the adjacent branchesof the vagus may do this. Gu6neau de Mussy longago attributed the peculiar spasmodic outbursts of true

whooping-cough to similar pressure by inflamed cervical,tracheal, and bronchial glands. Nevertheless, a coughbeginning like spasmodic croup and following the courseof an ordinary attack of pertussis even in the absenceof the characteristic inspiration can only be interpreted inthe light of its later manifestations. This initial croup isthe more noteworthy because it is in many, probably inmost, cases of whooping-cough by no means a marked

symptom. Its occurrence in quite young children is

possibly connected with the co-existence of teething. Its

persistence in spite of the ordinary treatment for croup andits association rather with the coughing effort than with theordinary processes of respiration and phonation should helpto guide practitioners as to its true nature and its most

appropriate mode of treatment.

IMPROPER BUSINESS METHODS.

IN the High Court of Justice on Tuesday last, August 1st,judgment was delivered on an interlocutory application in thecase of Tallerman v. the Dowsing Radiant Heat Company,Limited. The plaintiff, Mr. L. A. Tallerman, is the inventorof a mode of treating various diseases by means of super-heated air, to which we have had occasion to refer in ourcolumns. In THE LANCET of August 29th, 1896, we publishedan article by Dr. Knowsley Sibley which gave an account ofthe Tallerman mode of treatment in its application to certaincases. A rival mode of treatment, patented by a Mr.

Dowsing, an electrical engineer, came into the market a yearor two afterwards and for the purpose of making this systemfavourably known to the public and the medical professionthe new company circulated pamphlets inferring that Dr.

Sibley’s article in THE LANCET had reference to their

therapeutical methods. This conduct we have already un-favourably commented upon in our columns.l It was a dis-creditable way of doing business and we understand has beenoffered by the defendants to be discontinued, though themotion for an injunction was not successful.

DOUBLE CONSCIOUSNESS IN A CASE OFHYSTERIA OCCURRING IN A MALE

SUBJECT.

THE phenomena of "double consciousness" are in them-selves still of great interest. The few cases hithertorecorded and so elaborately investigated, especially by theFrench school of writers-viz., Azam, Binet, Charcot,Pierre Janet, and others-have been almost entirelyrestricted to female subjects. In a recent issue of2 -/t/<cowMo Moderno (1898, fasciculus 3, pp. 371-398) Dr.Baroncini, physician of the asylum at Imola in Italy, relatesthe extraordinary case of a young man admitted to the

asylum owing to a curious form of mental disturb-ance with double consciousness. The patient was a

professional singer whose normal life was at times

interrupted by nervous "crises" in which his person-ality seemed to undergo an extraordinary transforma-tion. The attack usually began with symptoms of

depression of spirits and malaise, which however quicklychanged. The patient then became joyous and lively andseemed to see all things eoitleur de rose. Thesesymptemsconstituted the first stage of his attack, after which he passedinto the second stage of his illness. There was a curiousfeature of interest in this case, in that the patient’spersonality did not undergo change suddenly-as is the rulein such cases-but quite gradually. He was noticed to

1 THE LANCET, May 6th, 1899, p. 1270.