A RARE FORM OF ABSCESS IN APPENDICITIS

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simple sellar decompression. Further, the sameobserver has often noted diabetes insipidus inanimals after operation on the hypophysis. It haslong been recognised that a transient hemianopia- hemianopia fugax-is sometimes associated withdiabetes insipidus, but the real significance of thefact is only now being appreciated. According toFutcher, in a large number of recorded cases ofdiabetes insipidus both hemianopia and primaryoptic atrophy have been described. Schafer and

Magnus were the first to show that extracts ofthe posterior lobe of the pituitary gland possessdiuretic properties of high degree, and Schaferand Stiles have used such extracts clinically asdiuretics. It is therefore clear that integrity offunction of the hYP9physis is intimately linked withcontrol over urinary output, and that the appear-ance of polyuria or diabetes insipidus as a clinicalsymptom must at once direct attention to thematter of hypophyseal function. In the Nouvelle

Iconographie de la Salpêtrière1 MM. P. Lereboullet,M. Faure-Beaulieu, and E. Vaucher have pub-lished an interesting case exhibiting a com-

bination of diabetes insipidus and infantilism.The patient was a young man, aged 24, who cameunder observation in January, 1913. He had

developed normally up to the age of 14. Veryshortly after a shock, sustained by involuntaryimmersion in cold water through falling out ofa canoe, he began to pass large quantities ofurine, 7 or 8 litres a day, and to suffer from

polydipsia. These symptoms have persisted, butthere has never been either sugar or albumin inthe urine. At the age of 16 the patient’s teeth alldropped out in the course of a few months as theresult of painful ulceration of the gums. A yearor two later generalised eczema of severe typeappeared and has proved very intractable. Onexamination the youth was found to presentextremely well-marked signs of infantilism. Therewas no hair on face or pubes, and only one or twosparse hairs in the axillae. His voice had not" broken." There was double testicular atrophy,

and the penis was very small, like an infant’s.There was complete absence of sexual desire andpower. No objective ocular signs were found,however, and the sella turcica was seen radio-

scopically to be of normal size and appearance.The patient’s mental condition was quite good. While under observation he often passed as much as 10 litres of pale limpid urine in the 24 hours. ’,Hypophyseal, thyroid, testicular, and pancreaticextracts were tried in turn during four months,but all failed to modify the patient’s symptomsmaterially. The authors who have published thecase are of the opinion that the condition is due todefect of function of the pars intermedia, usuallydescribed as belonging to, or at least mainly asso-ciated with, the pars posterior or nervosa of the

pituitary gland. A number of clinical cases havenow been reported where diabetes insipidusoccurred with other definite indications of pituitarydisease. Simmonds has published a case of tumourof the posterior lobe in which a polyuria of19 litres in the 24 hours occurred. Franck hasrecorded a case of attempted suicide with a

revolver in a man, aged 39, who, not long aftershooting himself in the right temple, began toput on fat and developed a well-markeddiabetes insipidus. Radiography showed clearlya ball occupying the posterior section of the sella

1 September-October, 1913, p. 410.

turcica. Marie and Boutier have described a

similar combination, as have Morley Fletcher,Berblisiger, Williams and Belfield, and others.Farini has treated a case of diabetes insipidussystematically with pituitary extract, but was ableto control it and reduce it only as long as thetreatment was active ; whenever the latter ceasedpolydipsia and polyuria returned. There are, no

doubt, difficulties in regard to the actual mechanismof production of the symptoms concerned. It isheld at present that infantilism is associated withdiminution of function of the anterior lobe, a hypo-pituitarism, while apparently the diabetes insipidusis a sign of liberation of an excess of posterior lobesecretion, a hyperpituitarism. On the one hand,however, different parts of the gland seem to beinvolved in the production of these two conditions,and, on the other, the study of the syndromesoccurring in the course of disease of other ductlessglands has accustomed us to analogous physio-pathological dissociations.

A RARE FORM OF ABSCESS IN APPENDICITIS.

AT a meeting of the Académie de Medecine onJan. 20th M. Routier reported a case of appendicitisin which an abscess formed in a very unusualsituation-in the mesentery. A woman, aged 24

years, previously quite well, was awakened in thenight of Jan. 30th, 1912, by severe abdominal pain.As she was menstruating she attributed the pain tothis condition. But next day the temperature was104’3° F. and she was very prostrate. A purgativewas given, but it was vomited. On the third dayher medical attendant, finding gurgling in the rightiliac fossa, diagnosed typhoid fever. Then the

spleen appeared to enlarge, which confirmed hisdiagnosis, and he sent the patient to hospital.Widal’s test and blood culture were performed withnegative results. For a fortnight attacks occurredevery five days, characterised by rises of tempera-ture to 1040 or 105’8°, followed by shivering andchattering of the teeth. Finally, a painful point tothe left of and a little below the umbilicus becamemanifest. On palpation there seemed to be a

swelling at this spot. The patient continuedin a prostrate condition and suffered fromconstant nausea. M. Routier then saw herin consultation. He found the whole abdomen

supple except at the spot mentioned, wherethere was a painful indurated zone of thesize of a 5-franc piece. He did not make a definitediagnosis, but considered that operation was neces-sary, and that probably an abscess would be found.This was done on Feb. 20th. The peritoneum andintestinal coils were found normal. On separatingthe latter an induration was found at the root ofthe mesentery, the anterior layer of which wasraised by the swelling. The pulsations of the aortawere transmitted to it. Having carefully isolatedthe field of operation, two fingers of the left handwere passed in front of the aorta beneath theswelling and a vertical incision was made. A largespoonful of thick creamy pus escaped. The cavityot the abscess was explored without result. Awick-drain was inserted, and the abdominal cavitywas closed. The patient at first considerably im-proved ; the pain disappeared, but the temperatureremained 104°, and she died on March 4th. The

origin of the abscess was a mystery until the

necropsy, which showed that an appendix in anabnormal situation-between the two layers of themesentery-had perforated. From the perforation a

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purulent track of the size of a quill ran to the abscess. : The patient had succumbed to septicaemia. M. lRoutier was of opinion that her life could have been saved by earlier operation. He considered it would be a good rule to think of appendicitis in abdominal ]

affections in which the pain is of sudden onset 1

even though it is not in the usual position. He ]

also referred to another case of abscess in themesentery, due to perforation of an appendixsituated between the layers of the mesentery,reported to the Académie by M. Jules Boeckel onOct. 8th, 1912. It differed from the present case inthat the neighbouring intestinal coils were inflamedand formed a lump around the abscess.

LEFT-HANDEDNESS AMONG SCHOOL CHILDREN.Dr. Schafer, a medical officer to the Berlin

municipal schools, having made an investigationconcerning left-handedness among the Berlin schoolchildren, found that of 17,000 children examinedfor that purpose 4’06 per cent. were left-handed-

namely, 5’15 per cent. of the boys and 2’98 per cent.of the girls. The number of ambidextrous childrenwas very small-only 0’21 per cent. Dr. Schaferconcluded that of the 228,455 pupils of the Berlin

municipal schools 9265 must be left-handed, andrecommended the establishment of special schoolsfor them. The Berlin school managers did notfollow that advice, but they made experimentsto try whether it was possible to train thechildren to the use of both hands equally.The results of the experiments lately published byDr. Dickhof, one of the school inspectors, weredescribed as rather unsatisfactory. A preferencefor the left hand on the part of the children wasnever observed. In making drawings the elderchildren showed a slight improvement in theirability to use the left hand, but in the lower classesthe children were quite unable to draw. In thewriting classes it was obvious that the right handbecame worse when the left hand was trained, andthe penmanship of the left hand was at the sametime quite impossible to be read. Weak andnervous children became nervous when they hadto write with the left hand and asked to be allowedto return to the use of the right hand. Dr. Dickhofconcluded that attempts to train children to a com-pulsory use of the left hand equally with the rightone ought to be abandoned, but that natural left-handedness should not be suppressed but helped.

THE BACTERICIDAL ACTION OF ORGANIC SILVERSALTS AND OTHER ANTISEPTICS ON THE

DYSENTERY BACILLUS.

WE understand that at the present time inCalcutta bacillary dysentery is the most difficultof the common tropical diseases to treat successfullyand that it has, moreover, the highest mortalitywith the single exception of that terrible malady,kala-azar. It is unfortunately the case that manyof the patients do not come under medical observa-tion until extensive ulceration of the large in-testine has taken place. Following up the admirablework which he has done in the treatment ofamcebic dysentery 1 Lieutenant-Colonel Leonard

Rogers,C.I.E.,I.M.S.,professor of pathology, Calcutta, has turned his attention to the bacillary form of Ithat disease and has carried out a number of ex-periments as to the bactericidal action of certain

1 THE LANCET, Oct. 19th, 1912, p. 1062.

substances upon the dysentery bacillus, a pre-liminary report on which he has lately published inthe Indian Journal of Medical Research (vol.i., No.2).In the course of his investigations he found that inmany of the acute cases nearly the whole length ofthe large intestine was involved, and that in themajority the caecum and lowest part of the ileumwere also affected. In chronic cases, on the otherhand, the lesions were limited to the lower half ofthe large bowel, the brunt of the disease fallingupon the descending colon, sigmoid, and rectum.It was therefore evident that, apart from treatmentby serums and remedies administered by themouth, it was very desirable to use some medica-ment which when injected by the rectum woulddestroy the dysentery bacillus and its toxins andat the same time heal the ulcerated surfaces.After a trial of a number of substances in the test-tube as to their power to destroy the specificorganism of the disease in sterilised water, andagain in the presence of organic matter, Lieu.tenant-Colonel Rogers arrived at the conclusionthat the organic silver salts had a considerablebactericidal action upon the dysentery bacillus.The organic combinations of silver yielding themost promising results were albargin or silvergelatose, nargol or silver nucleate, and protargol.For these a further trial is recommended.With regard to the action of antiseptics uponthe dysentery bacillus, the most active was

cyllin. A solution of iodine in iodide of

potassium, as also izal, gave almost equallygood results. Lysol was found disappointing. Both

potassium and calcium permanganates were ineff ec-tive in the presence of organic matter. Boracicacid and quinine, so much used as a bowel washin amoebic dysentery, have little or no bacteri.cidal action on the dysentery bacillus. Lieu-tenant-Colonel Rogers therefore recommends a

further trial of cyllin, iodine dissolved in iodideof potassium, and izal especially in early cases andunder conditions which can be carefully controlled.His experiments are being continued, and he hopesbefore long to have sufficient material at his

disposal to report more fully from the clinical pointof view. The result of these further observationsin the treatment of chronic bacillary dysentery willbe awaited with great interest not only in Indiabut in other parts of the East where this diseasegives rise to much suffering and causes manydeaths.

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Dr. Frederick E. Batten has been elected a corre-

sponding member of the Societe de Neurologic deParis, and Mr. Herbert Tilley a correspondingmember of the Laryngological Society of Berlin.

SOCIETY FOR THE ADVANCEMENT OF CLINICALSTUDY IN NEW YORK.-This institution was foundedas the result of a conference in 1912 between the com-mittees of the principal medical societies in New Yorkto render available to visiting and resident medical men thevast amount of clinical material that the hospitals of thecity afford. It has established a Bureau of Clinical lledi-cine, of which the secretary is Dr. George Gray Ward, jun.,at the New York Academy of Medicine, 17, West 43rd Street,New York, where daily bulletins of operations are posted. Ithas also issued a small handbook containing the lists of thevarious clinics, medical, surgical, and special, held in the

hospitals of New York and Brooklyn from November, 1913,to June, 1914, grouped under the days of the week. Theidea is a good one, and might with advantage be imitated inLondon and elsewhere.