Medicine 29

RECENT ADVANCES IN MEDICAL SCIENCE.

MEDICINE.

UNDER THE CHARGE OF

W. T. RITCHIE, M.D., EDWIN MATTHEW, M.D., J. D. COMRIE, M.D and A. GOODALL, M.D.

The Relationship of Diphtheroid Organisms to Hodgkin's Disease.

At the present time it is generally believed that Hodgkin's disease is due to a specific infection. This belief has led to a considerable amount of research with a view of determining the nature of the causal organism. Various types have been described, but there has been some confirma- tion of the observations of Frankel and Much that the disease is often

associated with a granular non-acid-fast bacillus. Their observation

was, however, weakened rather than strengthened by the finding of a

similar organism in five cases of lymphatic leuksemia.

Cunningham (Amer. Journ. Med. Sci., March 1917) has carried out a research on the organisms found in a large number of cases of

glandular enlargement. Most of his material was obtained from the

operating-room. He isolated a large number of organisms, but reaches the conclusion that they may all be placed in the diphtheroid group. In some cases the diphtheroids were associated with cocci which later overgrew them. He regards it as reasonable to suppose that glands draining the mouth, throat, and tonsils should harbour such organisms as are commonly found in these portals. With the evidence at hand ?the occurrence of organisms in the laboratory, in blood cultures, appearing rather late in the heart blood at the mortuary, in ascitic

fluid, and in a series of gland cultures of questionable technique and not in a series where technique was definitely controlled?Cunningham is led to believe that the natural habitat of the organisms is the

laboratory. The diphtheroid organism found by various observers as well as by the author is not believed to have any causal relationship to Hodgkin's disease.

Clinical Significance of Blood Examination after Wounds.

Govaerts (La Pressc M&dicale, 29th March 1917) publishes some

interesting and useful observations on the blood after the infliction of wounds. In severe cases there is a condition of acute asthenia depend- ing upon an enormous fall of blood-pressure, a state of nervous depres-

30 Recent Advances in Medical Science

sion, and a lowering of temperature. This state results from several factors which may be combined. These are shock, acute infections, and haemorrhage. The last factor is the easiest to isolate and it is necessary to assess its importance in any case, since it may afford important indications for treatment. It is notoriously difficult to predict whether in a given case of low pressure the injection of artificial serum will have a favourable and prolonged effect or will be inoperative. A knowledge of the actual condition of the blood may indicate the necessity for transfusion and in certain cases may point to the desirability of

operative interference, for example, in abdominal haemorrhage. Post-haemorrhagic anaemia becomes evident when the mass of blood

is restored by the passage into the vessels of fluid from the tissues.

In man this is a slow process, but in dogs and rabbits it is complete in about four hours. It follows that the blood-counts made in man

after a haemorrhage do not correspond at first to the importance of the anaemia. In a typical case the red corpuscles diminish in number for three or four days after a haemorrhage. The number remains at the

lowest point for three or four days and begins to rise again slowly on the seventh or eighth day. If a fall of corpuscles continues after the fourth day there is a likelihood of infection having occurred. A

complication such as peritonitis causes the red count to rise. An increase of leucocytes takes place very rapidly after a severe

wound. In one case the count was 25,000 one hour and a half after the wound ; in another, two days after the wound, the count was 35,500. The increase rapidly diminishes and has often disappeared in forty-eight hours. Its degree corresponds roughly to the severity of the wound. The polymorphonuclear cells are chiefly involved, their percentage often being about 85. The following practical conclusions are reached.

For some hours after a haemorrhage the number of red corpuscles is not in accord with the severity of the blood loss. If in the first six

hours after a haemorrhage the number of red cells has fallen below four millions per c.cm., and the number of leucocytes exceeds 30,000, the haemorrhage has probably been severe and the prognosis is grave. In

some such cases the injection of artificial serum has been ineffectual and there appears to be a clear indication for transfusion. If one has any reason to suspect an important internal haemorrhage (abdominal con- tusion without any external sign) the determination of the presence of a leucocytosis a short time after the injury ought to suggest the

diagnosis and give an indication for operation. In a case of abdominal

contusion from the kick of a horse the author found a normal number

of red corpuscles (5,360,000) and a high leucocytosis (31,600) seven hours after the injury. There was a complete rupture of the spleen. A sharp rise in the number of red corpuscles during the course of the treatment of a wound strongly suggests the possibility of a peritoneal reaction or an effusion into a serous cavity.

Medicine 31

Influenza.

Some interesting papers dealing with influenza as it is seen on the other side of the Atlantic have recently appeared.

Park (New York Med. Journ., 24th March 1917) deals with bacteri- ology and points out that there is a doubt whether all the great epidemics have been due to the organism discovered by Pfeififer. It is

not proved that the epidemic which reached America in 1890 was due to it. This does not mean that there is any doubt about the importance of the influenza bacillus in a great many of the inflammations of the

respiratory tract as well as of other parts of the body. The epidemic which spread from west to east in America in 1916 was widely studied, and various observers in different cities found that streptococci, pneumo- cocci, and micrococcus catarrhalis were all more common than the

influenza bacillus. Brill (ibid.) points out the same difficulties and states that the

presence of influenza must necessarily be established on clinical

manifestations. On this account errors in judgment will arise and

doubt will attend diagnosis. While in the main the clinical signs of the disease are fairly constant in some of the sporadic forms, this is not true when the disease appears under pandemic conditions. Under the

latter conditions the symptoms may be so unusual that the disease is

not recognised as in the pandemic of 1889-90. The primary division of clinical types might rest on an epidemiological basis of pandemic, epidemic, and sporadic types. So great are the differences that one who had seen merely the mild sporadic disease might be nonplussed when he observes the varied clinical types which appear when the

disease occurs pandemically. The pandemic form is a protean disease

whose clinical characteristics vary widely, and the virulent nature of the organism and its toxins respects not a single tissue of the body. The pandemic form is noted for its high incidence in communities, almost 50 per cent, of all individuals therein being affected. It is

noted also for the overwhelming nature of its onset, the extreme

prostration which accompanies it, and the intensity of the other clinical

manifestations. During the pandemic invasion of the disease all degrees of intensity may be noticed, from prostration with fatal results within a day to a mild fever without an}^ special clinical localisation of the infection or perhaps with the mildest signs of a nasopharyngeal catarrh. Between these two extremes many variations and combinations of

system-forms may be seen. Symptoms depend upon the intensity of

infection, its toxic products and the resistance of the individual. The

prostration is usually severe out of proportion to other symptoms in all the types. The fever is subject to many variations. It often rises

abruptly to 103? or 10-1?. Hyperpyrexia is not rarely met with.

Occasionally the rise of temperature is gradual. The temperature may

32 Recent A dvances in Medical Science

decline abruptly in twelve to thirty-six hours or it may descend

gradually over a period of several days. Not infrequently there is a temperature lasting over two weeks which closely resembles the fever of typhoid. Rarely the fever resembles that of a quotidian or a tertian malaria. Should extensive bronchitis or pneumonia supervene the

temperature will, of course, be modified. Atypical onsets are common. These are chiefly associated with the

forms affecting the nervous system. The infection may be ushered in

by unconsciousness which may last for hours and there may be only a slight elevation of temperature. After regaining control of his mental faculties the patient may show either slight or severe respiratory symptoms. The infection may begin with a definite psychosis, such as maniacal excitement or confusional stupor. Onset may show gastro- intestinal disturbance with vomiting, watery or even hemorrhagic stools, tympanitis, and rigidity of the abdomen. In spite of the stormy onset these cases are soon convalescent. Relapses, both late and early, are frequent. Possibly some are due to an entirely new infection.

Convalesence is established in most cases in ten days but may be

delayed for weeks, during which time the patient suffers from physical and mental fatigue, dyspnoea, palpitation, and sleeplessness and mental

depression. The various types of the disease are discussed in detail.

Respiratory Type.?This is by far the most common manifestation of influenza. The disease may implicate one, several, or all of the

respiratory structures, including the accessory sinuses. Some of the

affections require special mention. Influenzal bronchitis may be

localised or may involve the whole bronchial system. In influenza

there is a special tendency to involvement of the terminal bronchioles. Patients have sibilant and sonorous ronchi which give place in a day or two to fine crepitations. These may persist for days and may be heard over one or more lobes, often at the apices. There is no evidence

of consolidation. The sputum remains bronchitic in character. This type of disease is particularly dangerous in infancy and in old

age. In the latter there is a swinging temperature, weakness, cyanosis, emaciation, collapse, and death.

Influenzal pneumonias present a varied clinical and pathological picture. The influenza bacillus is often the causal organism, but

pneumococcal and streptococcal infections are common. The pure influenzal pneumonia is definitely a catarrhal one which has a tendency to involve the lung in disseminated patches, more particularly in its

upper lobes, though it may be confined to the upper. It may follow

bronchitis or may be a primary alveolar infection. During outbreaks of influenza there is a great increase of lobar pneumonia. Whether this is initiated by the influenza bacillus which is later outgrown by the pneumococcus is unknown. Clinically, this lobar pneumonia does not differ much from that seen in the absence of influenza epidemics. It is

Medicine 33

usually of longer duration, and is more likely to subside by lysis than by crisis. The sputum is never rusty. It is composed of greenish clumps surrounded by sticky mucus.

There is a type of broncho-pneumonia which may start as a dis-

seminated bronchitis. There are patches of consolidation all over the

lungs. In a week or ten days all the signs have disappeared except consolidation at the apices. Fever is constant, there are sweats and

weakness with emaciation. There is great difficulty in distinguishing such cases from tuberculosis. The sputum may become blood-stained or even hsemorrhagic. After weeks or months the condition ameliorates.

The cough lessens, the temperature does not reach its former height, the sputum lessens, breath sounds become vesicular and strength returns. It is probable that a large number of these cases are regarded as

pulmonary tuberculosis with negative sputum even by experts. Some cases of influenzal broncho-pneumonia go on to purulent

infiltration with bronchial dilatation and usually die, but may escape with a fibroid induration of the lungs.

A few cases of lobar pneumonia follow a similiar course. Involve-

ment of the pleura as a primary manifestation of influenza is a rare

condition. It may occur as a secondary invasion and is often purulent. Cardiac Type.?Bradycardia is common, probably due to the

susceptibility of the cardiac nerves to the influenza toxin. The heart

muscle itself is also subject to the toxins, as witnessed by the fatty degeneration seen on pathological examination. This may account foi

the attacks of svncope and other circulatory disturbances. 1 rimary

influenzal endocarditis and pericarditis have been observed but are very unusual. There is a definite form of endocarditis to which 110 attention

has been drawn since the great epidemic in 1890. This is a subacute

or chronic affection due to the bacillus which can be isolated from the

blood. Heart valves which have been previously injured are specially liable to attack. The clinical picture is an endocarditis with bacterisemia. There are erythematous rashes, and rarely these may ulcerate.

Nervous Type.?Nearly all cases show some disturbance of the

nervous system, either toxic or functional. In the pandemic type of the disease meningitis, encephalitis and myelitis have been observed.

Polyneuritis is not uncommon. Encephalitis may result from direct cerebral infection and may show as numerous small haemorrhages with necrosis and secondary miliary abscesses, or it may show as a purulent infiltration resulting from sinus inflammation or meningitis. Meningitis is not uncommon, but it may be simulated by a condition showing Kernig's sign, delirium, and rigidity of neck muscles as a result of the toxaemia.

Gastro-Intestinal Type.?These symptoms are common in the pandemic type, but are more rare in the epidemic and sporadic forms of the

disease. The symptoms are toxic rather than inflammatory. Nausea, 3

34 Recent Advances in Medical Science

vomiting, and prostration are dominating symptoms. There may be

excessive diarrhoea and colic, and symptoms may closely resemble

typhoid. A. G.