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the case now reported. A woman, aged 24 years, complainedof fulness in the abdomen and chronic constipation. The
abdomen was tense and slightly tympanitic. The stools
were intimately mixed with small black or brown sand-likegranules. A stool was washed through a fine sieve and thegreater part of the sand was found in the water. It was
brownish and felt gritty. Under the microscope the
sand was seen to consist of irregularly, shaped more
or less oval grains, varying in size from 0 - 05 to 0 - 2
millimetre in diameter. They were translucent and variedin tint from light yellow to dark yellow, brownish,and greenish yellow. By reflected light they had a beau-tiful appearance, resembling variously coloured quartz. Theywere hard and brittle and were crushed with difficultyunder the cover-glass. On applying a strong acid gas wasevolved and the sand became of a lighter yellow colour.
Chemical analysis showed 17 - 2 per cent. of moisture; theresidue contained 95-8 8 per cent. of organic matter. The
inorganic portion consisted principally of phosphate of
calcium. The high proportion of organic matter pointed toa vegetable origin. By ingestion of various vegetables theyendeavoured to produce sand artificially, but failed. The
presence of a chain of sand with two or three fibro-vascularbundles originating from a common point and separatedby a mass of parenchyma cells suggested a remnant of
banana tissue. It was then found that on eating one or twobananas intestinal sand could be found in the motions in
quantities varying from a teaspoonful to a tablespoonful inthe 24 hours for several days, and in cases of constipationfor much longer. As a rule, the grains were found singly,but also in chains if the stool was not manipulated toomuch in washing. If a banana is cut transversely andexposed to the air light brown markings appear on it.
Under the action of perchloride of iron they form rapidlyas black strands, which under the microscope were found tobe identical with the grains of sand in the fasces. These
strands are the milk tubes" of the banana and are com-
posed of cells containing a resin suspended in a fluid rich intannin. The action of the intestinal secretions on the resin
forms the sand.
BOARDS OF GUARDIANS AND PUBLICVACCINATORS.
FOR many years there has been much dissatisfaction
amongst public vaccinators as to the conditions under whichthey are called upon to do their work, and although a depart-mental committee which sat a few years ago made certain
recommendations, some of which were calculated to improvethe position of the officers concerned, the Local GovernmentBoard has up to the present only acted upon such of therecommendations as were to the- detriment of the publicvaccinators. This is not, we think, quite the proper spiritin which a State department which depends so much uponthe medical profession for its status in the country shouldact-that is to say, if the department desires to receivethat support from the medical profession without which itwould find administration a difficult matter. If there is one
thing more than another to be read between the linesof the Royal Commission on the Poor-laws it ’is the
appreciation of the services of the medical profession anda demand for its employment ,in greater degree than
formerly. The duties of the public vaccinator are alreadysufficiently onerous and, with general slackness as regardsthe administration of the Vaccination Acts, they are
steadily increasing. The most recent development is a
,growing disposition on the part of boards of guardians tomake the post of public vaccinator dependent, as it were,
upon that of district medical officer and vice versd,the advantage to the guardians ’of this fictitious arrange-ment being that when a public vaccinator who is also a
district medical officer resigns his post as public vaccinatorbecause of the smallness of the fees and the difficultiesof the position his appointment as district medical officer isalso terminated. And conversely, when a district medicalofficer, who is also public vaccinator, relinquishes his positionin the former capacity because it is not consistent with his
conscience to supply medical advice and medicine for lessthan twopence per attendance his contract as publicvaccinator is forthwith terminated Instances of this kindof treatment have recently been brought to the notice of Mr.Burns by the Association of Public Vaccinators, and he hasbeen asked to receive a deputation upon the matter as wellas upon the question of the security of tenure of publicvaccinators as recommended by the departmental committeealready referred to: This request for an interview has, how-ever, been refused, and the petitioners have been told thatin the opinion of the Board when the offices of publicvaccinator and district medical officer are held together theremuneration of each office should be proportioned to the
duty of each office, but that when an officer is requiredto devote his whole time to public appointments the
guardians may properly have regard to the total re-
muneration which will accrue to him in respect to those
appointments. As to the question of security of tenure, theBoard states that it has no powers under the existinglaw to grant such security. Both these replies seem to ussomewhat evasive and illogical. The appointments of dis-trict medical officer and public vaccinator are quite distinct ;according to this ruling of the Board the district medicalofficer might be called upon to do the vaccinations for
nothing, which is, of course, absurd. As to the other point,it is, we presume, common knowledge that fixity of tenurewould require legislation, and the public vaccinators inwishing to discuss the matter with the President of theLocal Government Board were probably anxious to inducehim to introduce a Bill into Parliament giving effect to therecommendation of the departmental committee which eitherhe himself or his predecessor in office must have appointed.The public vaccinators are greatly to be sympathised with.The departmental committee prescribed some stones and somebread. The stones have already been thrown with disastrouseffect, but when the public vaccinators ask for the bread thedepartmental granaries are empty. The attempts which arebeing thus indirectly made to cut down the pay of
district medical officers must be strenuously resisted, moreparticularly so when this fact is considered in conjunctionwith the circumstance that greater attention is daily requiredfrom these officers and that the cost of living and medicaleducation is steadily rising. If the public medical service ofthe country is to improve in proportion with the demandsmade upon it by the public, that service must receive greaterrecognition by the State than has hitherto been the case.
THE LARYNGITIS OF MEASLES.
IN another column we publish an article by Dr. A. A.Warden, entitled ’’ A Plea for the Use of Ainti-diph-theritic Serum in the Laryngitis of Measles." Althoughwe cannot altogether support this plea, yet the communica-tion is of value in drawing attention to a most grave com-plication of measles-namely, diphtheria. Some degree ofcatarrhal laryngitis is so common in the course of measlesthat it can almost be considered a symptom of the diseaserather than a complication, and therefore if Dr. Warden’s
suggestion were adopted-namely, " In the laryngitis ofmeasles do not wait for a bacteriological diagnosis butat once inject antidiphtheritic serum "-this procedurewould have to be carried out in nearly every case.
If, however, this dictum were to be applied to everyinstance in which a membranous laryngitis occurs, then Dr.
Warden’s suggestion might well be followed. Indeed, it ispossible that this is what he intends to imply, and if such bethe case we endorse his advice. The membranous laryngitismay be produced by pyogenetic cocci, but this can only bepositively distinguished from diphtheritic membrane bybacteriological culture, and much valuable time would belost in waiting for the result to be received from the
laboratory. The success of the antitoxic treatment is con-
siderably greater if it be employed at an early stage of thedisease, and therefore practitioners would be taking a wisecourse in administering the antitoxin in cases of measles inwhich a membranous laryngitis makes its appearance.
NASAL CRISES IN TABES DORSALIS.
THE day is passed when tabes dorsalis was considered adisease to be limited to-the posterior columns of the spinalcord. The field covered by locomotor ataxia in its manifesta-tions has been very greatly extended, till now it is admittedthere is no part of the nervous system, central or peripheral,which may not be the seat of the tabetic process. The
aspects under which the disease may present itself are sovariable that the clinician cannot afford to neglect any ofthem. In a recent number of La Semaine Médioale M.
Klippel and M. Lhermitte have directed attention to a littleknown corner of the tabetic field, one which, however,concerns the general practitioner as much as the professedneurologist. They have written an instructive paper on affec-tions of the gustatory and olfactory apparatus in tabes, andthe clinical cases which they quote emphasise once again theextreme importance of recognising that the symptoms forwhich the patient consults his physician may be but a purelylocal indication of a much more widespread condition.M. Klippel and M. Lhermitte consider that the nasal crisisof the tabetic may be represented by one of three differingtypes-viz., sensory, spasmodic, and secretory-althoughthis division is somewhat schematic. The disturbance, of
whatever type it be, may occur in those who show a
permanent defect in their olfactory sense as well as in thosewhose smell is normal. The common impairment found inthe subject of tabes is partial or complete anosmia, withhypoassthesia of the face and nasal mucosa, and vaso-motor ortrophic changes in the olfactory mucosa itself. In the first
variety of nasal crisis the patient feels a pricking sensa-tion at the root of the nose, a disagreeable tickling in
his nostrils, and then suddenly experiences a strong and un-pleasant subjective odour commonly compared to that ofrotten eggs. Occasionally it is associated with an equallyunpleasant taste in the mouth. Among the many instancesquoted by the authors are cited those described by Mr. HerbertTilley’ 14 years ago as three cases of parosmia, and thesuggestion is made that they were in reality cases of tabes inwhich the ordinary symptoms of the condition were not
present or not recognised. They do not ignore the occurrenceof similar phenomena in intracranial tumours of a particularlocalisation, but the diagnosis presents no real difficulty.The spasmodic type of nasal crisis is characterised
by attacks of sneezing ; one of their patients usedto notice a sensation of coolness and of pins andneedles over the left half of the face and then sneezingset in ; it was sometimes accompanied by flashes in
front of the left eye and bilateral tinnitus. An instance is
given where this form of nasal crisis proved to be the firstsymptom of tabes. Sometimes the crisis is succeeded bya flow of tears or of mucus from the nose ; in practicallyevery case some objective modification of facial or olfactorysensibility can be discovered, Where there are definite
vaso-motor or secretory phenomena we are dealing with the
1 THE LANCET, Oct. 9th, 1895, p, 907.
third or rhinorrhoeic form of nasal crisis. One of the cases
concerned a patient with locomotor ataxia, whose ’attack’
always began with a series of short abrupt respirations,followed by a bout of sneezing of several minutes’ duration.As soon as these spasmodic phenomena ceased, a slightlyviscid reddish fluid poured from the nose, soaking a
handkerchief in very little time ; towards ’ the end
of the flow it became clear and much more watery.Examination of the nasal fossag revealed no abnormalitywhatever, but there were changes in cutaneous, mucous, andolfactory sensibility. The differential diagnosis of these
symptoms may no doubt be difficult, but the discoveryof any of the classical signs of tabes is very significant,in particular any notable alteration in sensibility in thedistribution of the trigeminal nerve. In one of their casesM. Klippel and M. Lhermitte have found unmistakeable
histological changes in the olfactory bulbs. Of the en-
cephalic manifestations of the tabetic process several are,of course, very well known, in particular optic atrophy.-Sir William Gowers has drawn attention to the occurrenceof ’’ auditory atrophy" in the shape of constriction of theauditory field, and this latest contribution to the subject isequally suggestive and likely to repay research.
AT a meeting of the Royal Society on May 6th the
secretary announced that Colonel Sir David Bruce, whois in charge of the Sleeping Sickness Commission at presentin Uganda, had cabled to the Society on April 3rd to
report that the Commission had confirmed Kleine’s observa-tions on the period during which the tsetse fly was capable oftransmitting a trypanosome infection. A letter had beenreceived by the Society on April 30th from Sir David
Bruce, dated Mpumu Chagwe, Uganda, April 3rd, confirmingthe telegram, and stating that the Commission had repeatedDr. Kleine’s experiments with ’l’l’ypanosoma gambiense andGlossina palpalis, also with a trypanosome of the dimorphontype and the same Tsetse-flies, and found the flies infectiveafter 16, 19, and 22 days."
THE EARLY RECOGNITION OF UTERINECANCER.
AT the annual meeting of the British Medical Association,at Exeter in 1907 the Section of Obstetrics and Gynascologyadopted a resolution requesting the Council of the Associa-tion to appoint a committee to consider the best means ofdisseminating knowledge of the importance of the earlyrecognition of uterine cancer. That committee presented areport which was considered, and generally approved, by thesame section of the annual meeting of the British MedicalAssociation in Sheffield in 1908. At its meeting on
April 28th, 1909, the Council of the British Medical Associa-tion approved for publication the appeals to medical practi-tioners, and to midwives and nurses, and directed that theyshould be communicated to British and colonial medical andnursing journals. We have consequently received from theEditor of the British Medwal Journal the appended importantdocument addressed in its main bulk to all medical practi-tioners, but with a brief and earnest note to midwives andnurses appended :-
A.AN APPEAL TO MEDICAL PRACTITIONERS TO PROMOTE THE
EARLIER RECOGNITION OF UTERINE CANCER.The attention of all medical practitioners is directed to
the necessity of emphasising the curability by operation ofuterine cancer in its early stages.The adoption of a more extensive operation by the
abdominal route has made it possible to deal successfullywith cases hitherto regarded as inoperable, and to removemore of the pelvic cellular tissue as well as a portion ofthe vaginal walls ; it is in these situations that recurrenceis prone to develop.