438

was lessened air-entry and a few rales. The patient lookedill. It was decided that laparutomy should be performed.

Operati.ore.-_1 central incision above the umbilicus revealedblood in the abdomen. Examination of the spleen by thehand-it is not possible to deliver these enlarged spleensthrough a central incision-showed a tear about half aninch wide running across the lateral surface and continuinground to and across the medial surface. The organ was muchenlarged, being about 11 in. long and firmer than normal.The inci&ion was carried across to the left flank with theintention of performing splenectomy.

Recalling, however, the advice of my colleague, and thepatient’s condition being none too good, I felt that ifpossible something less radical must be tried. Stitching wasattempted, but proved useless. There was evidence at thisstage of a rupture of the diaphragm at the upper pole of thespleen. Air was blowing out and in with respiration. Itwas decided to try packing. This was done by means offive pieces of gauze each about 7<J c.cm. long. Three werepushed up on the lateral and two on the medial sides of theorgan, the last two respectively in front and behind thehilus. The spleen appeared to be quite tightly and fairlyuniformls- compressed in this way, and the lacerations werecovered. Some blood was swabbed out of the abdomenand the wound closed with through-and-through silkworm-gut sutures except at the lateral corner where the five endsof gauze were left out.

fro<’<M<&.&mdash;After operation the pulse was 122 and weak,and the temperature 380 C. One pint of saline was given.subcutaneously and later gr. of morphine hydrochloride.On thf- second day the temperature dropped to normal andalthough the pulse remained rapid the patient did remark-abl3- well. On the third day after operation the gauze wascarefully removed and the wound completely closed. Onthe eighth to eleventh days after operation the temperaturerose, the corner of the wound reopened, and pus discharged.Otherwise there were no complications and the patient lefthospital 26 days after operation.Packing for rupture of the spleen is mentioned in

the literature, but I had not heard of it before. In

publishing this case my object is to obtain, if possible,the experience of others working in countries wheremalaria prevails. If this line of treatment holds outrt fair hope of success it is. I should think, sounderthan splenectomy for such cases. ,

I am extremely indebted to Dr. F. Dejani, of theMunicipal Hospital, Jaffa, for his assistance in thiscase.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF DERMATOLOGY.AT a meeting of this Section held on Feb. 18the,

Dr. E. GrBAJtAM: LITTLE in the chair, a discussiontook place on the

Treatment of Ringworm by Thallium Epilation. Dr. E. B. DOWLING demonstrated four cases ofthe series reported in THE LANCET last week (page389). Three of them were showing active regrowthafter complete epilation, the fourth was of later dateand had not yet reached total defluvium. Thischild had complained of pains in the legs a weekafter taking his dose of thallium acetate, but hadcompletely lost the symptom a few days later.Dr. Dowling thought that these undesirable effectsmight be diminished or even prevented by keepingthe patients in bed whilst epilation is taking place-i.e., for about three weeks.

Dr. S. MONCKTON COPEMAN related personalexperiences of the use of thallium a,cetate in thetreatment of inoperable carcinoma. The patients’ages, he said. varied from 49 to 78, and the casescould not therefore be fairly compared with thoseunder discussion. A solution of the salt, preparedand tested by Prof. W. E. Dixon of Cambridge, wasadministered intramuscularly, at first on alternatedays in doses of 1 grain then every day, then in dosesof 2 gr. on alternate days, and finally in doses of1 gr. every other day. The total amounts injectedduring an average period of three weeks varied from

0.778 to 1’361 grammes ; thus a proportionately muchgreater dose had been given than in any of the casereported by Dr. Dowling. This dose was, howevt,spread out over three weeks instet.1 of being gir4.-Lin one draught, as the object was to "Ltain, if possible.a continuous inhibitory effect on the neoplasm".Some improvement had, in fact, been noted. Fivof the six cases treated had lost all their scalp hair,two of them even their eyebrows and lashes. Th"only one who did not suffer in this respect&mdash;a manof 49-had developed mental symptoms of a delu-sional type after only 0’778 g. had been administered,and in his case, therefore, the drug had had to btdiscontinued. He had subsequently recovered htj-normal mentality. All the cases had complained c4tingling pain in the limbs and a burning sensationin the soles of the feet. In two of them cotickyabdominal pains developed, ’. but no diarrhaea.Albuminuria did not occur. One woman, aged 70,who had advanced malignant disease of the breast,had complained of severe substernal pain in additionto the other symptoms cited above. In her cas-injections were stopped at once after 1 037 g. hadbeen given, but she died three days later from suddenheart failure without developing any other note-worthy symptoms. There were no very definitepost-mortem findings, except the secondary dposit<.to account for her death. It was to be presumed.therefore, that the thallium was at least a contributorycause.

Dr. H. W. BARBER called attention to the interest-ing similarity of the epilation produced by thalliumacetate, X rays, and alopecia areata, in all of whichatrophic " exclamation stumps " were to be found.He also remarked on the persistence of a frontalfringe of non-epilated hair in Dr. Dowling’s cases.

which he regarded as some evidence of a selectiveaffinity for different areas. He agreed with theview expressed by Buschke, Peter, and others, thatthallium acetate probably acted by way of the

sympathetic nervous system and only indirectly onthe hair.

Dr. II. C. SEMON said that he had noted verysimilar toxic phenomena during the intravenousinjections of a gold salt (krysolgan), with which hewas treating cases of lupus erythcniatosus. Thepains of which his patients had complained weresharp and fleeting. and suggested in their distributionan affection of fibrous sheaths round musules. Hehad quite recently discovered that an intravenousinjection of 0’6 g. of thiosulphah. of soda appearedto exercise a rapid and very effectual control of thesymptom, acting in much the same way as he haddescribed for the toxaemias of bismuth and mercurv.The atomic weights of gold (1P7’2), and thallium(204), were closely similar, and it might conceivablybe found that the antidotal effects of thiosulphatfof soda would be useful in preventing or alleviatingundesirable results from the administration of thallium.

MANCHESTER MEDICAL SOCIETY.

AT a meeting of this Society held on Feb. 2nd,Dr. A. A. MUMFORD in the chair, Dr. R. 1. POSTONopened a discussion on

Vertigo.He dealt first with the occurrence of vertigo inepidemic encephalitis (encephalitis lethargica) where,he said, this symptom often appeared in associationwith other signs of vestibular disorder. RecallingGertier’s " paralysing vertigo " of 1888, he went onto describe the endemic kubisagari of Japan. Thetwo affections had much in common, and there couldbe little doubt that they were variants of the samecondition. There could be no doubt that they wereboth due to an infective encephalitis, and he suggestedthat as kubisagari had occurred in Japan up to 1912.it was possible that it was responsible, or thatundiagnosed cases of Gertier’s disease in Europewere responsible, for the pandemic of the last decade.

439

An outbreak of encephalitis with vestibular symptomshad been reported in Strasbourg in 1921.Having dealt with the known pathology of the

dition and the results of several experimentalworkers who had actually found vestibular lesions inrabbits, Dr. Poston gave a brief description of sixcases of encephalitis which had come under his owncare. With Mr. F. H. Diggle’s help the vestibularreaction of these cases had been determined andabnormal induced nystagmus had been found in three.in a case in which there was complete externalftphthalmoplegia (seen through the kindness of Prof.A. J. Hall, of Sheffield) it had been found that simplesyringing of the ears with cold water not only relievedptosis, but enabled the patient to move his eyeballs in,.very direction and relieved the diplopia of which hecomplained. He described another case of Prof. Hall’swhich showed " spasmodic cramp of the upwardglance," and in which change of position changed thedirection, but not the character of the phenomenon.Discussing the diagnosis of vestibular encephalitis,

Dr. Poston urged the importance of first excludingcerebro-spinal syphilis, aural disease, and intracraniallesions. He pointed out that in cases of epidemict’ncephalitis with gross signs of cerebellar involvementit had been found at autopsy that the cerebellumwas normal. Nystagmus might suggest disseminatedsclerosis unless definite and incontestible signs ofParkinsonism were present. The following triadwas suggested as offering clinical evidence of disorderedvestibular function in the absence of aural disease :disorders of equilibration (e.g., vertigo), spontaneoushystagmus, and abnormal induced nystagmus or

abnormal Babinski-Weill reactions.Dr. Poston suggested a classification of epidemic

t-neephalitis as follows: (1) vestibular syndrome ;(2) juxta-vestibular syndrome with signs pointing toinvolvement of structures adjacent to or connectedwith the vestibular nucleus, such as oculomotorsymptoms, neuralgia, facial paralysis, silorrh&oelig;a,disorders of respiration and pulse, or dysphagia; t3) pallidal syndrome-e.g., tremor and rigidity ;tl) striate syndrome-e.g., tremor and myoclonus.Pyrexia and lethargy were the only common symptomsnot included in such a classification. In conclusion, hestated that the vestibular syndrome in epidemicencephalitis might occur alone or with such symptomsas those already mentioned ; it might occur at the=inset, during the acute stage of the disease, or itnught persist as a residuum. Interference withvestibular function might account for many of theoculomotor phenomena of the disease, if not for allof them.Mr. F. H. DiGGTB, after briefly referring to the fact

that vertigo was only one manifestation of a disturb-ance of the vestibular apparatus, pointed out that byartificial stimulation of the peripheral sense-organ inthe labyrinth it was possible to produce all thesymptoms and signs of such a disturbance-viz.,vertigo, nystagmus, reeling gait, and vomiting. Hefurther showed that by a close study of such inducedsymptoms it was possible not only to test the integrityof the peripheral end-organ, the labyrinth, but also,in a few cases, to locate a lesion in other parts of thevestibular nervous arc. Vertigo, he said, might beproduced by a lesion in the labyrinth, by a lesion in itsintracranial and spinal connexions, or by ocular lesions.Vertigo arising in acute inflammatory conditions ofthe middle ear was usually relieved by efficientparacentesis tympani. He drew attention, however,to the prevalence and seriousness of vertigo in acuteexacerbations in chronic suppuration in the ear. Thedanger lay in the fact that translabyrinthine infectionwas the commonest precursor of fatal meningitis, andthe warning signal of vertigo should not be neglected.Discussing non-suppurative labyrinthine lesions,

Mr. Diggle referred to the difficulty arising from thewant of pathological knowledge. Vertigo might bedue to abnormal pressure of the intralabyrinthinEttuids, to irregularities in the vascularity of the organfir to the effects of toxins upon the nerve end-organHe thought that vertigo associated with impacted

ceruminous plugs, intermittent Eustachian ubstruc-tion, and occasionally hydrops of the middle earcould be explained by abnormal intralabyrinthinepressure. Increased pressure of cerebro-spinal fluidmight directly raise intralabyrinthine pressure and soproduce vertigo, though often cerebral anaemia couldnot be excluded. Relief occasionally followed lumbarpuncture, and a few cases had been recorded byAboulker and Oolledge in which relief had followedthe operation of subtentorial decompression. Indismissing intralabyrinthine pressure Mr. Digglementioned cases recorded by Mollison of relief tovertigo after trephining the external semicircular canal.

In considering vascular lesions affecting thelabyrinth, Mr. Diggle drew attention to the fact thatmany patients on examination presented a normalinner ear. Massive haemorrhage as a cause of theM&eacute;ni&egrave;re’s syndrome was, he thought, infrequent,though it could not be denied that there were some-times small leakages from atheromatous vessels.Other remote lesions, apart from intralabyrintnineh&oelig;morrhage&mdash;such as arterio-sclerosis, abnormal bloodpressure, certain anaemias, metabolic disorders, andtoxins-might be responsible for M&eacute;ni&egrave;re’s syndrome.Was vertigo in such cases due to effusion into thelabyrinth, to atheromatous disease of the vessels. or totoxic neuritis ? Mr. Diggle pointed to the analogyin the eye-namely, tobacco amblyopia, retinalhaemorrhages in nephritis, and retinal detachmentsfrom effusion-and drew attention to the toxaemicconditions responsible for vertigo and to the frequentassociation of vertigo with nicotine poisoning and withnasal sinus suppuration. He considered that occultsepsis was a potent factor. In discussing treatment heurged that no operative ablation of the labyrinthshould be undertaken until all other measures hadfailed, and then only on a labyrinth functionallyinactive.

NORTH OF ENGLAND OBSTETRICAL ANDGYN&AElig;COLOGICAL SOCIETY.

THE annual meeting of this Society was held atManchester on Jan. 28th.

Dr. W. R. ADDIS read a paper on a

New Method of Inducing Labour.The method, he said, consisted in the intramuscularinjection of extract of ovarian residue (without corpusluteum) prepared by Parke Davis and Co. The amountgiven was 1 c.cm. of the extract, and this was injectedinto the pectoralis major muscle, where it formed theanterior border of the axilla. At first the contractionsof the uterus had to be recognised bv palpation asthe onset of labour was painless. The dose wasrepeated when the contractions began to diminish inintensity and frequency. The average time in whichthis occurred was about three hours. After the secondinjection a dose of one ounce of castor oil was givenby mouth. Dr. Addis had employed this method in22 cases at stages of pregnancy varying from 36 weeksto a week post-mature. He had come to the conclusionthat it was practically infallible as a method of

’

induction of labour. Only in the first case had the’ method been a partial failure. With this form of, induction the labour induced was almost painless.

throughout the first and beginning of the second stage,’ and pains were really only experienced when the: presenting part caused bulging of the perineum. Dr. J. W. BURNS (Liverpool) showed a specimen of an

Unusual Tlterine Tumour.The patient was a woman, aged 39, whose menstrual

. history was not abnormal until 18 months before she came, under observation, when the loss began to increase. For the past month there had been more or less constant bleeding,

and she complained of weakness. There were no symptoms: arising from either the bladder or rectum.’

On examination a smooth, hard tumour could be felt in the, lower abdomen reaching almost to a point midway between. the symphysis pubis and the umbilicus. Bimanually the1 cervix was found to be drawn up behind the pubes and the