930

hmmoglobin, 70-75 per cent. ; colour index, 0’6-0’8; leucocytes2000 to 3000. After treatment of the spleen by X raysthese had risen, on the last occasion, to 3800 with a pyrexialreaction, and the polymorphs were about 50 per cent. ;lymphocytes, about 40 per cent. No abnormal cells wereseen. The patient had been infected with syphilis in 1903,and was treated for three years with mercurial injectionsand by the mouth. In December, 1918, the Wassermannreaction was negative. In May, 1919, there was someenlargement of the cervical glands, the Wassermann againbeing negative. He prescribed for himself and receivedfive injections of galyl (0’4 g.). The negative Wassermannreaction and the leucopenia favoured a diagnosis of splenicansemia rather than one of syphilitic splenomegaly.The treatment being employed consisted of iodide and

X rays, the possibility of splenectomy being kept in view.Dr. F. PARKES WEBER thought that the diagnosis was

probably one of thrombo-phlebitis of the portal vein, whichhad also implicated the hepatic vein. He said that anyform of chronic enlargement of the spleen might produceleucopenia, for it occurred in the condition under discussion,in chronic malaria, in kala-azar, and in lymphadenoma,when the spleen was particularly affected. The question ofsplenectomy was of interest, for in cases of thrombosis ofthe portal vein accompanied by splenomegaly, splenectomyhad sometimes given satisfactory results, as it did in splenicanaemia.

Dilatation Aneurysm.Dr. A. H. GossE showed a case of Dilatation Aneurysm in

a man, aged 43.Four months previously the patient first noticed pain

in the right side of the chest; a cough developed withsome sputum, which was now streaked with bloodin the mornings. Dyspnoea had been very marked,especially on exertion, and some dysphagia had recentlybeen complained of. He had had occasional attacks of pal-pitation, and his appetite and digestion were poor. Hestated he had not had syphilis. On examination there wassome diffuse pulsation over the upper end of the sternum.There was no bulging in any part of the chest wall. Theleft border of the heart was obscured by emphysema. Theaortic second sound was accentuated and a faint diastolicmurmur was present to the left of the sternum. Rales andrhonchi were present over the lungs. There was trachealtugging. The pulses, which were collapsing in character,were not delayed. The pupils were equal andreacted. Thecough was brassy. A satisfactory examination of the larynxhad not yet been obtained. The Wassermann reaction waspositive. The X ray report stated: " General enlargementof aortic shadow; some encroachment into posterior medias-tinum. Pulsating. No positive sacculation." No tuberclebacilli were present in the sputum. The systolic bloodpressure was 140 mm. Hg and the’diastolic 60 mm.

It was proposed to administer one of the substitutes forsalvarsan in the next few days. The aneurysm was of thedilatation type and was an aneurysm of symptoms ratherthan of signs. The aortic incompetence had developed.during the past week. It was probable, therefore, that theincompetence was due rather to stretching of the aorticring than t6 disease of the valve segments. The blood inthe sputum might be due to the soft granulations whichsometimes occurred at the point of compression in thetrachea. A polygraph tracing of the two radial arteriestaken simultaneously showed no delay of the pulse on theleft side. The difference in the systolic and diastolicpressures, which were taken on the left arm, first drewattention to the possibility of aortic incompetence, whichwas then confirmed by the presence of the diastolic murmur.

THE TUBERCULOSIS SOCIETY.

INTESTINAL TUBERCULOSIS IN CONNEXION WITII PHTHISIS.

AT a meeting of this society, held at the Royal Society ofMedicine on Nov. 10th, Dr. H. A. ELLIS read a paper onIntestinal Tuberculosis in Connexion with Phthisis. The

question, the speaker said, had been overlooked to a greatextent because it was most apparent in the last and hopelessstage of the disease. There was, however, no doubt thatsymptoms due to intestinal tuberculosis occurred in theearlier stages of phthisis, and had a detrimental effect

upon the progress of the case. It was while giving doses oftuberculin by the mouth that he noticed symptoms whichpointed to intestinal disease; these consisted of flatulent

dyspepsia, inability to take food, specially fat, togetherwith obstinate constipation which, when corrected byaperients, tended to the opposite extreme. There were general

tenderness and irritability of the abdomen and pain on deeppalpation, most marked at a point to the left and above theumbilicus. The condition was made worse by foodstuffs contain-ing much cellulose. Dr. Ellis considered that these symptomswere due to the formation of tubercles between the mucousand muscular coats of the intestine, which, by coming intocontact with Meissner’s and Auerbach’s plexuses, upset themechanism of peristalsis. Food was thereby retained longerin the gut and decomposed, giving rise to wind and the signsof intestinal auto-intoxication. Treatment consisted in

avoiding foodstuffs containing much cellulose, and inrelieving constipation ; the latter was best accomplished bygiving saline aperients, night and morning, thus preventingfood from remaining in the stomach overnight and disturbingsleep. Dr. Ellis said that he first tried tuberculin by themouth with good results, and later his picric brass preparationsin oil. The oral administration of the latter was discontinuedbecause of the indigestion caused, and he commenced to giveit in the form of suppositories containing -a’- gr. twice weekly.This was followed by signs of reaction when tuberculosis waspresent, but otherwise had no effect. Pain and some degreeof diarrhoea resulted according to the severity of the disease.With repeated doses the reactions tended to become lessand less, and the general condition and well-being of thepatient at the same time improved, although it was sometime before a full diet could be taken. Where diarrhoea wasalready present the suppositories were found to cause almostuncontrollable looseness, but in mild cases 1/36 gr. wasgiven with success.

Disoussion.

Dr. HALLIDAY SUTHERLAND said that he had .tried brasspaste on six very bad cases of lupus with striking results andthought that there was no doubt that Dr. Ellis’s preparationhad a definite specific action upon tuberculous tissue.

Dr. A. J. WILLIAMSON thought that many of the

symptoms ascribed by Dr. Ellis to intestinal tuberculosismight well be explained by toxsemia due to the disease inthe lungs.

Dr. JAMES WATT did not think that the symptomsdescribed could be considered pathognomonic. When casescame into sanatoriums and were rested it was common foratony of the intestine to occur. It was possible that thesuppositories acted beneficially by clearing out the lowerbowel.

Dr. A. SANDISON compared the symptoms to those putforward by Sir Arbuthnot Lane in his book on " IntestinalIntoxication. "

Dr. ELLIS, replying, said that mechanical action wouldnot explain the facts, because in non-tuberculous cases

nothing happened, whereas in tuberculous enteritis violentdiarrhoea resulted. He did not consider that the symptomswere pathognomonic of the disease, but in conjunction withphthisis they led to a suspicion of the intestinal diseasewhich caused the auto-intoxication.

THE VOCAL THERAPY FUND.-A meeting washeld on Nov. llth, at 47, Portland-place, London, W.,when Lieutenant-Colonel Martin Flack, Director ofMedical Research, R.A.F.. spoke on Breathing Efficiency inRelation to Health, and Miss Bush described Vocal TherapyMethods of Voice and Health Restoration in use at theMaudsley Hospital. Colonel Flack demonstrated the use ofthe instruments by which the breathing efficiency andresistance to air-pressure of flying men are ascertained. Inthe course of his address he maintained that a big chestmeasurement necessarily indicates neither good respira-tory capacity nor respiratory efficiency. Nor does a

large breathing capacity always predicate flying efficiency;because, explained Colonel Flack, when the tone ofthe diaphragm and abdominal muscles is lowered,as happens when a man becomes tired or hashad a crash, the power of resistance to air-pressureis considerably lessened, a condition demonstrableby a diminished power of breathing out. As regardsbreathing from the general hygienic point of view, Colonel-Flack maintained that the power to fill the chest is not soimportant as is popularly believed. Too little attention ispaid to the supplemental air in which respiratory exchangestake place. The practice of thoroughly emptying the lungsis fully as important as that of filling them. Miss Bushsaid that 350 cases of dumbness and stammering have beendealt with at the Maudsley Hospital, and the condition of themen was alleviated by a scientific procedure applied in amanner which inspired them with faith and hope.Methodical exercises in breathing and articulation were

given, and use was made of the healing influence of music.