The China Iftedical Journal.

V o l. XUV. MARCH, 1930 N o. 3

PLASMOMA OF THE CONJUNCTIVA IN CHINA P. S. SOTJDAKtJFF, M.D.

During recent years the problem of plasmoma has been actively discussed in the general literature, but there is still difference of opinion in regard to the nature of the disease: whether it is a chronic inflammatory process or a real tumor. In view of these facts the appearance of this clinical and pathological essay may be timely. This communication is based upon a study of seventeen cases observed in the course of the last seven years, and it contains the richest material which has so far been studied by one person. By intention only tumorshaped plasmacellular infiltration, i.e. “plasmoma,” will be discussed in this paper, and hyaline and amyloid tumors, whose clinical picture is similar to that of plasmoma will be excluded, as well as the simple plasmacellular infiltration without the appearance of tumorshaped growth, so frequently met with in trachoma. Plasmoma of the conjunctiva has been observed by clinicians in Central China, although it has not been recognized as such. McAll of Hankow in 1920 published a detailed description of the clinical picture of this disease under the title “Notes on a Rare Form of Subconjunctival Granuloma met with in Central China.” Elliot referred to McAIVs paper in his book entitled “ Tropical diseases of the eye.” In 1921 JuAd of Yachow reported four similar cases. The clinical picture, as given by Me All and Judd, coincides with an affection which we have had opportunity to observe more or less frequently in our clinic and which we have diagnosed as either a plasmoma or a hyaline degeneration of the conjunctiva. Differential diagnosis can be made only by histopathological examination. A patholo­ gical study of eight such cases of tumor-shaped affection of the conjunctiva confirmed our clinical diagnosis. A preliminary

196 The China Medical Journal

report on these cases was presented by the writer before the Ophthalmologic Section of the China Medical Association at the Hongkong meeting in 1925. McAll in his brief pathological description stated that the growth was chiefly made up of round lymphocytes. We are indebted to him for the opportunity of studying sections of his three cases. This study convinced us that these “round lymphocytes” were typical plasma cells and that his “cases of subconjunctival granuloma” were either plasmacellular infil­ tration of the conjunctiva or more or less advanced cases of hyaline degeneration of the conjunctiva.

This paper represents a clinical and pathological study of seventeen cases of tumorshaped plasmacellular infiltration of the conjunctiva. Nine of these were cases from our eye clinic in the Peking Union Medical College. The specimens of five others were supplied by Dr. Smith of the Methodist Hospital in Peking and the other three were sent to us by Dr. Lambert of Honan, Dr. Dunlap of Chefoo, and Dr. Pearson of Hunan, respectively. The majority of the specimens were fixed in Muller’s fluid or in formalin 10% solution and most of them were embedded in paraffin, some in celloidin. Sections were stained in hematoxylin-eosin, by Van Gieson’s method, in Mallory’s connective tissue stain, in VerhoefFs elastic tissue stain, by Verhoeff’s method for tubercle bacilli, in methyl-violet, Kongo-red, Pappenheim methyl-green pyronin, and Giemsa stains.

Case i: (Path. No. 03817. Specimen of the tissue was sent by Dr. Smith, in 1924, with following history) : “Wang-, man, aged 27. Two months ago a small nodule appeared between cornea and caruncle on the eyeball, apparently beneath the conjunctiva. The mass gradually increased in size and now it measures 7 mm X 5 mm.” (No clinical description of the condition of the lid conjunctiva was given in the history).

Microscopic Examination: Section is that of an oval piece of tissue partially covered with stratified epithelium. The superficial epithelial cells are flattened and the deeper ones are cylindrical in shape. The epithelium is moderately invaded by leucocytes. For convenience of description the section may be divided into two parts, namely (1) the part immediately beneath the epithelium, and (2) the deeper portion of the tissue. Th^ entire growth is traversed by fibrous connective tissue, the r.trr’-na of which is very fine in the superficial portion and quite coarse in the deeper part (fig. 1). The portion (1) consists of a dense mass of plasma cells separated from the epithelium by a loose connective tissue which is also invaded by plasma cells, about 60%, and lymphocytes. Just Plasmoma of the Conjunctiva in China 197 beneath the epithelium a nodule composed of lymphocytes is found. Some of the plasma cells possess two nuclei and a few have three. Am ong the plasma cells lymphocytes, a few mast cells and plasmacytoids are seen. The blood vessels are numerous and their walls are somewhat thickened due to hyaline degeneration of their adventitia. The deeper portion (2) of the tissue is made up almost entirely of fibrous stroma, a small part of which has lost its fibrous structure and has undergone hyaline degenera­ tion. Within the latter islets of loosely arranged plasma cells are found, most of them around the blood vessels, either encircling them or accumulating on one side of the wall. The walls of these vessels are thickened due to separation of the fibers of their adventitia by the infiltrating cells. The junction area between portion (1) and portion (2) is densely invaded with lymphocytes. As the cut of the specimen passes through the densely infiltrated area (left side of fig. 1), it is evident that the excision of the growth was not complete.

Summary of Case 1. A young man developed tumor-shaped growth of the bulbar conjunctiva, which was excised two months after the onset. This tumor-shaped growth micros­ copically appears to be a diffuse plasmacellular infiltration with a narrow strip of connective tissue separating the epithelium from the mass of plasma cells. Fibers of the connective tissue, especially those o f the deeper portion, as well as the walls of blood vessels, have undergone hyaline degeneration. Many blood vessels are surrounded by a collar of plasma cells. Although no mention was made in the history of a trachomatous condition, the presence of a lymphocytic nodule beneath the epithelium suggests trachoma.

Case 2: (No. 107176) P. L. Liu, a female servant, aged 47, was seen in 1927 in the eye clinic of the Peking Union Medical College. A clinical diagnosis was made of papillary trachoma of both eyes, plasmoma of plica semilunaris, and chronic dacryocystitis of the left eye. The patient complained of a fleshy growth from the left cul-de-sac of more than ten years duration. There was no history of inflammation of the eyes. Both lids appeared normal. Mucous discharge came out on pres­ sure over the left lacrimal sac. The palpebral conjunctiva showed moderate papillary hypertrophy and numerous lime deposits in the Meibomian glands. The left plica semilunaris showed a fleshy growth gradually disappearing in the upper palpebral conjunctiva and slightly overlapping the bulbar conjunctiva. There was a moderate pannus in the upper segment of both corneae. Vision: O.D. 6/7.5, O.S. 6/10. The growth, measuring 7 x 5 mm was completely excised. In spite of many attempts to get the patient to return to the outpatient clinic for observa­ tion she failed to reappear.

Microscopic Examination: The epithelium of the conjunctiva is thickened and infiltrated with leucocytes. The conjunctiva itself shows papillary hypertrophy. A narrow strip of connective tissue, infiltrated 198 The China Medical Jourmi

with lymphocytes (about 20% ) and plasma cells (80%) separates a dense mass of plasma cells from the epithelium. Plasma cells with two or three nuclei are fairly .common. There are a few plasma cells with red stained cytoplasm. The tissue is richly vascularized. The plasmacellular infiltration ends more or less abruptly at the deeper portion of the growth (similar to Cases 1 and 6). The tissue beneath the area of plasma cellular infiltration is composed of connective tissue which has undergone hyaline degeneration so that the fibers are no longer recognizable. Only here and there is their fibrillary structure preserved. In this region the plasma cells tend to accumulate around the blood vessels. Among these plasma cells plasmacytoids also are found. The area at the junction between the plasmacellular infiltration and the basal portion of the growth is densely infiltrated with lymphocytes.

Summary of Case 2: A female servant, with papillary trachoma had a growth of the semilunar fold of more than ten years duration. This growth appeared clinically as a small tumor and microscopically as a diffuse plasmacellular infiltra­ tion with a narrow strip of connective tissue between the epithelium and the mass of plasma cells.

Case 3 : (No. 39334). J. C. Fan, a man, aged 27, came to our eye clinic complaining of a redness of both eyes for one month. Since child­ hood, he had had poor vision of the right eye. A diagnosis of follicular trachoma of both eyes and plasmoma of the conjunctiva of the left eye was made.

Lids of both eyes were slightly swollen. The right eye : The lower conjunctiva showed follicles, the upper conjunctiva papillary hypertrophy. The left eye: The upper conjunctiva was thickened and lobular in appearance. The lowsr conjunctiva showed a few adhesions to the bulbar conjunctiva (symblepharon). Vision O.D. 3/60, O.S. 6/7.5. A piece of the left upper conjunctiva was excised for pathological examination. The next day the patient received 5 mgm hours of radium irradiation directly on the everted eyelids, with aluminum and rubber tissue screen. He did not return to the clinic.

Microscopic Examination: The specimen consists of a piece of tissue made up principally of plasma cells. It is covered with thickened epithelium. Beneath the epithelium there are several nodules composed of lymphocytes (follicles). The area of plasmacellular infiltration is separated from the epithelium by a strand of a loose vascularized con­ nective tissue, and infiltrated with leucocytes and lymphocytes. Between the plasma cells small hyaline masses are found. Some of the plasma cells are eosinophilic. The plasma cells lie in the meshes of a reticulum formed by fine fibers of connective tissue. Strands of connective tissue cross the whole specimen and extend to the deeper portion which is exclusively made up of fibrous tissue. This part of the specimen as well as the strands have undergone hyaline degeneration, but they still contain numerous elastic fibers and some of them give an amyloid reaction. Plasmoma of the Conjunctiva in China 199

Summary of Case 3: A patient with follicular trachoma showed a lobulated mass in the left upper conjunctiva which histologically was made up of a dense mass of plasma cells. A narrow strip of connective tissue between the epithelium and the mass of plasma cells was infiltrated with lymphocytes. Some of the connective tissue fibers and walls of blood vessels had undergone hyaline degeneration.

Case 4 • (No. 108084) K. C. T ’ien, a man, aged 35, was seen in our eye clinic in 1927. A clinical diagnosis of plasmoma of the right eye and mixed trachoma of both eyes was made. A month before, the patient had noticed the appearance of a small mass in the inner angle of the right eye and swelling of the upper and lower lids. The right eye: The upper lid was thickened and slightly prominent and could only be slightly raised with great effort on the part of the patient. The skin was movable over the underlying tissue. The maximal opening of the palpebral fissure was 5 mm. The lower lid appeared normal. The upper lid could be everted but with some difficulty. The conjunctiva showed papillary hypertrophy and linear scars. The lower lid was also hypertrophic. The hypertrophic caruncle had the appearance of a tumor which gradually disappeared in the upper and lower palpebral conjunctiva. The left eye: The con­ junctiva showed papillary hypertrophy with some linear scars. Vision: O.D. 6 /9 , O.S. 6/2 0. A piece of the right semilunar fold was excised for study. Scrapings of the conjunctiva were positive for trachoma inclusion bodies. The Wassermann reaction was reported negative.

From May 10 to June 3, the patient received trachoma treatment. During the next two months the patient received four applications of radium plaque, applied directly on the everted eyelids with a piece of rubber tissue as a screen. The total amount of irradiation was 20 mgm. hours. The irradiation was usually followed by swelling of the eyelids. On August 22, the maximal opening of the palpebral fissure was 10 ma¡. A s the patient could not attend the clinic for a long time, it was decided to excise as much of the growth as possible and the caruncle and a small piece of the upper palpebral conjunctiva were excised. When the patient was last seen on September 16, 1927, the right upper lid was less ptotic and vision remained the same as before.

Microscopic Examination: The tissue is a piece of semilunar fold covered completely with stratified epithelium which shows papillary-like ingrowths and is infiltrated with mononuclears and leucocytes. Beneath the epithelium lies a strand of loose connective tissue infiltrated with plasma cells which tend to accumulate around the blood vessels. Some of the plasma cells possess two to four nuclei. Among the plasma cells a few plasmacytoids are found.

Another piece of the growth of the caruncle region was removed after the fourth irradiation. Microscopic examination revealed that the connective tissue stroma beneath the stratified epithelium is densely in­ filtrated with plasma cells and a few lymphocytes. Pycnotic plasma cells are numerous. Those with multiple nuclei are rarely found. 200 The China Medical Journal

Summary of Case -4: A patient affected by trachoma showed enlargement of the semilunar fold, due to a diffuse plas- macellular infiltration. Ptosis was considerably improved after four applications of radium, a total of 20 mgm. hours of irradiation. It was histologically found that, after irradiation, plasma cells with multiple nuclei were rare and that many of them were in a state of pycnosis.

Case 5! (Pathol. No. 03037) (Specimen of tissue and history of case were sent by Dr. A. Lambert of Honan on May 8, 1923). Y. S. Yang a -farmer, aged 26, twelve months earlier had had an attack of inflamma­ tion of both eyes followed by a gradual growth of a nodular mass of the plica. The patient complained of no pain, but came for advice because of interference of vision by the growth. On examination there was found a small tongue-shaped nodular mass covering the left plica and extending to the conjunctiva of the upper and lower lids, with the lower portion the larger. Under local anesthesia as much of the tumor was removed as possible. (No description of the condition of the palpebral conjunctiva was given in the history).

Macroscopic Examination: Specimen consists of an irregular piece of tissue, measuring 21 x 10 X 5 mm.

Microscopic Examination: The conjunctiva is thrown into folds. Beneath the proliferated epithelium lies a narrow strip of connective tissue infiltrated by lymphocytes, beneath which are found an accumula­ tion of plasma cells divided in groups by strands of connective tissue fibers. Among these plasma cells, lymphocytes and plasmacytoids are found. Many plasma cells show vacuolization of their nuclei. Summary of Case 5 : A young farmer had a nodular growth over the left plica, extending into the upper and lower conjunctiva of the lids. Microscopically this growth appeared to be a diffuse plasmacellular infiltration divided into small islets by strands of the connective tissue fibers and separated from the epithelium by a narrow strip of non-infiltrated con­ nective tissue. No data was given in regard to the presence or absence of trachoma.

Case 6: (Pathol. No. 93476. Specimen and history were sent by Dr. R. Dunlap of Chefoo, Shantung, on December 20, 1923). L. P. Liu, a man, aged 34, complained of a rapidly growing small mass in his right eye. Clinical examination showed the presence of papillary trachoma and a small growth in the right lower fornix, lying in its outer third and extending to the bulbar conjunctiva. The tumor, including the overlying conjunctiva, was excised. It measured 12 X ll X 16 mm.

Microscopic Examination: The conjunctiva is folded and covered with attenuated epithelium (one to two layers of cells), directly beneath which lies a dense mass of plasma cells. In some places, especially beneath Fig. 1.— General microscopic aspect of tumor-shaped plasmacellular

infiltration of the conjunctiva: (a) dense plasmacellular

infiltration, (b) hyaline-degenerated connective

tissue fibers. Case 1. Photo X 23.

Fig. 2.— Tumor-shaped plasmacellular infiltration of lower

palpebral conjunctiva of left eye. Case S. F ig . 3.— Tumor-shaped plasmacellular infiltration of left

upper conjunctii'a. Case S.

F ig . 4.— Extensive plasmoma of both right lid conjunctivae.

Case 17. Front view. Plasmoma of the Conjunctiva .in China 201

the epithelium, numerous lymphocytes also invade the tissue. Plasma cells with two to three nuclei are fairly common, and mast cells and plasmacytoids are also found. The tissue is rich in capillaries. The deeper portion of the specimen is composed of a connective tissue poor in cells and homogeneous in appearance. Some blood vessels within the degenerative connective tissue are surrounded by plasma cells. The boundary area between the plasmacellular infiltration and degenerated connective tissue is densely invaded by lymphocytes. Summary of Case 6 : A patient affected with trachoma developed a tumor mass of the left lower lid in a period of one year. This histological picture resembles that of cases 1 and 2 with the exception that plasmacellular infiltration was found just beneath the epithelium.

Case 7: (Pathol. No. 03312. Specimen and history sent by Dr. Smith, on October 16, 1923). The patient C.M. Lu was a man, aged 21. Two years before, a small hard mass had appeared in the right upper lid and had grown gradually larger, without pain or inflammation. The skin was movable over the tarsus, but the conjunctiva was firmly adherent over the tumor mass. The upper lid could barely be everted. Wassermann reaction was negative. There was no history of important general diseases. A diagnosis of beginning hyaline or amyloid degeneration of the conjunctiva was made.

Microscopic Examination: The bulk of the specimen is composed of plasma cells which are accumulated directly beneath the epithelium. In one place beneath the epithelium two roundish nodules composed of numerous lymphocytes and some plasma cells are found (trachomatous follicles). The cytoplasm of some plasma cells is stained uniformly red and these became eosinophilic. The fibrous tissue of the deeper portion of the specimen is homogeneous in structure and no fixed cells are visible within it. Some fibers are in the form of small fragments. The examined specimen is rich in blood vessels; there are numerous capillaries between the plasma cells and the larger vessels in the area of hyaline degenerated connective tissue.

Summary of Cfise 7: A small tumor developed in the right upper lid of a young man which micrcspically appeared to be a tumor-shaped diffuse plasmacellular infiltration lying directly beneath the epithelium. Fibrous tissue showed hyaline degeneration. Two probably trachomatous follicles were found beneath the epithelium.

Case 8: (P.U.M.C. Hospital no. 7683). Yang Yu, a youth, aged 18, was admitted to our eye ward on April 14, 1924, complaining of a growth', of ‘the left lids. Two and a half years earlier he had noticed a small yellowish growth at the inner canthus of the left eye, which gradual­ ly increased in size. Three months after the onset it was partially 2Ò2 The China Medical Journal

excised by a layman, but later on the growth gradually extended down­ ward and involved the lower lid without pain or change in visual acuity. About three years before, he had had a similar growth in the right eye, which involved the caruncle and the lower lid but was much smaller than the present one, and it also was excised by a layman. The growth subse­ quently disappeared entirely. The Right Eye : Thé lid was normal. The conjunctiva showed a mild mixed trachoma with swelling of thé plica. The Left Eye : There was incomplete non-inflammatory ptosis of the upper lid. The skin of the lids was normal. On everting the lower lid there appeared along the entire conjunctival fornix a reddish tongue­ shaped growth with smooth surface measuring 25 X 4 mm. Thegrowth was rather firm in consistency and homogeneous in appearance. _ It was thicker and broader in the center, tapering toward the outer and inner canthi and disappearing in the bulbar conjunctiva. After pulling down the lower lid it stood out as a lobulated mass (fig. 2). The tumor of the plica appeared as a triangular mass measuring 10 X 4 mm. Its free border extended to the margin of the cornea, the eye being in the primary position. The upper palpebral conjunctiva was thickened and covered with numerous irregularly-shaped nodules. On exposing the retrotarsal fold a thin pale-red tissue projected from its entire length (fig. 3). This tumor was similar in appearance to the growth in the lower fornix, but much smaller, and was continuous with that in the lower lid at the external canthus. The bulbar conjunctiva was not involved. A diagnosis of follicular trachoma in both eyes and plasmoma of the conjunctiva in the left eye was made. The small nodules of the left upper lid were ex­ cised for pathological examination. The patient received two applications of radium, altogether 100 mgm. hours. A month later he received 5 mgm. hours of radium, the radium plaque being applied directly on the everted conjunctiva, with rubber tissue as a screen. A month after the last irradiation the patient came back to the eye clinic. A s there was no apparent change in the size of the growth, it was excised in two sittings. The patient was seen last on August 1, 1924 and there was no evidence of recurrence. Microscopic Examination: The specimen is composed of a mass of plasma cells which lie so close to each other that connective tissue fibers are not recognizable. There are numerous capillaries and larger blood vessels within the area infiltrated by plasma cells. The piece of the tumor­ shaped tissue excised two months after irradiation shows a pathological picture similar to that described above with the exception that many of the plasma cells are in a state of pycnosis. Summary of Case 8: A young man, affected with follicular trachoma, developed a tumorshaped mass of the right plica and lower lid which were excised by a layman and which showed no recurrence for a period of four years. Later a similar tumor­ shaped mass appeared over the left semilunar fold and gradual­ ly spread over both lids and the bulbar conjunctiva. The patient received application of radium, amounting to 105 mgm. hours. Two months later the tumor mass was excised as com- Plasmoma of the Conjunctiva in China 203

pletely as possible. Histopathological examination showed that this tumorshaped growth was due to a diffuse plasmacellular infiltration. Irradiation led to pycnosis of plasma cells.

Case 9: (Hospital no. 14694). Mrs. W.S. Liu, aged 25. was admitted to our eye clinic on August 27, 1926. She complained that for the last three months the upper left eyelid had become swollen and ptosis had gradually developed. Right E y e : The palpebral conjunctiva showed mixed trachoma. On everting the upper eyelid a tumor-like mass, pinkish in color and lobulated in appcarance, was seen in the upper fornix ex­ tending toward the outer angle where it went over into the palpebral conjunctiva. The caruncle was normal. L eft E y e : The upper lid was ptotic. On everting it the conjunctiva showed lobulated masses occupying the entire surface of the tarsal conjunctiva and extending to the fornix. Scrapings of the conjunctiva showed trachoma inclusions bodies. 25 mgm. hours of radium were given to the left - eye. A small piece of tissue, measuring 5 X 3 x 15 mm., was excised for examination. The blood count was normal and there was no sign of general disease. The patient did not come back to the clinic for further observation. A diagnosis of mixed trachoma of both eyes and plasmoma of the conjunctiva of both eyes was made.

Microscopic Examination: The specimen is made up chiefly of plasma cells and covered with proliferated epithelium. The latter is in­ vaded by numerous leucocyctes. Plasma cells show no sign of degenera­ tion. There are numerous capillaries between the plasma cells and a few polymorphonuclear leucocytes and mononuclear lymphocytes. The fibers of the connective tissue which traverse the area of plasmacellular infiltration are homogeneous in appearance and show hyaline reaction. The deeper portion of the connective stroma is free of plasma cells and the walls of blood vessels have undergone hyaline degeneration. Summary of Case 9: A trachomatous patient developed ptosis which was due to tumorshaped masses on both upper tarsal conjunctiva and fornices. Histologically these appeared to be a diffuse plasmacellular infiltration.

Case i o : (Hospital no. 335). Y.T. Wang, a man, aged 27, was admitted December 6, 1920. A diagnosis of papillary trachoma and plasmoma of the conjunctiva was made. A year before admission the patient had noticed a growth in his left upper lid, which had sinco grad­ ually increased in size.

Right E y e : The upper palpebral conjunctiva showed papillary hypertrophy, the lower was congested. There was pannus at the upper segment of the cornea. Vision 6/5. Left. E y e : A large soft granular mass extended over the palpebral conjunctiva to the lid margin. The upper half of the cornea showed pannus. Vision 6/60. The growth was excised.

Microscopic Examination: The specimen, which measures 30 X 12.5 X 9 mm., is covered with epithelium to a short extent, and is principally 204 The China Medical .Journal composed of plasma cells. This accumulation of plasma cells lies directly beneath the epithelium but at certain places it is separated from it by a narrow strip of connective tissue, which is invaded by a small number of plasma cells and lymphocytes. Strands of connective tissue fibers with numerous blood vessels traverse the area of plasmacellular in­ filtration. A few eosinophiles are found among the plasma cells. Summary of Case 10: A patient with papillary trachoma had a tumor-shaped mass of the left upper tarsal conjunctiva, for about a year. This growth microscopically appeared to be a diffuse plasmacellular infiltration.

Case i i : (Pathol. No. 03366. History and specimen sent by Dr, Smith, on October 25, 1923). For the past three years, Shen, a woman, aged 34, had had a swelling of the inner corner of the left eye, which increased without pain or disturbance of vision, the swelling gradually extending all over the left eye. A similar swelling appeared in the right eye causing swelling in the lids and difficulty in moving them. There was discharge. The swellings filled both upper and lower fornices of both eyes and on everting lids they appeared like a coxcomb mass. The skin was easily movable over these masses. Physical examination and Wassermann reaction were negative. On excision the growth proved to be a hard friable mass, which was easily removed except for the part going into the orbit. The wound healed uneventfully. There was no statement about any trachomatous condition of the conjunctivae of lids.

Microscopic Examination: The specimen is that of a piece of con­ junctival tissue artificially devoid of its epithelial covering, with a piece of lacrimal gland attached. The conjunctiva is thrown into folds and thei’e are papillae which are invaded exclusively by lymphocytes. The growth is principally made up of plasma cells, some of which show vacuolisation of their nuclei. Plasmacytoids are quite common. Mast cells and Russell's bodies are also found. The area of plasmacellular in­ filtration is crossed with strands of fibrous tissue, some of which have undergone hyaline degeneration. Blood vessels are surrounded by rings of plasma cells. Some of the blood vessels show thickening of the adventitia, hyaline changes of the walls and obliteration of the lumina by­ hyaline substances. Summary of Case 11: The patient had a tumor-shaped growth of the conjunctivae of all the lids for a period of three years. Microscopic examination .showed that this tumor­ shaped growth was due to a diffuse plasmacellular infiltration with marked hyaline degeneration of the connective tissue. There was no statement of the existence of trachoma.

Case 12: (N o. 17267). T.P. W ang, a man, aged 58, came to our eye clinic on September 5, 1922, complaining of lacrimation and blurring of vision of both eyes, and recurrent attacks of inflammation. Both eyes were affected by follicular trachoma with incipient pannus,. In the Plasmoma of the Conjunctiva in China 205 fornices there were small tumor-shaped masses, yellow and waxy. Vision O.D. 6/12, O.S. 6/12. Blood chemistry and blood count were normal. Wassermann reaction and examination of feces for parasites were negative. A piece of the granular tissue of the left upper palpebral con­ junctiva, measuring 9x6x3 mm., was excised for pathological ex­ amination.

Microscopic Examination: The epithelium is two cells in thickness and is invaded by leucocytes. The surface of the tissue is thrown into folds and shows several papillae. Beneath the conjunctiva the tissue is densely infiltrated with lymphocytes, but deeper from the surface more plasma cells and less lymphocytes are seen. (There are about 10f/r of plasma cells at the periphery and about 80% in the center of the specimen). Parallel and close to the epithelium there are strands of fibrous tissue which are stained red with eosin and which contain a few nuclei. These strands are continuous with the deeper ones which traverse the infiltrated area by plasma cells, contain no connective tissue cells, look swollen, and are homogeneous in appearance. The interstices between the fibers are filled with plasma cells. The tissue is richly vas­ cularized and some of the blood vessels show hyaline degeneration of the walls. Almost all the blood vessels are surrounded by plasma cells and a few plasmacytoids. Summary of Case 12: A trachomatous patient developed tumor-shaped masses of the tarsal conjunctiva and fornices of left eye. Microscopically these granulated masses appeared to be composed of fibrous tissue densely invaded by lymphocytes and plasma cells, the former predominating in the subepithelial lay«r and the latter in the deeper tissue. Some connective tissue fibers and blood vessel walls had undergone hyaline degeneration.

Case 13: (Pathol. No. 03365. Specimen and history sent by Dr. Smith on Oct. 25, 1923). The patient was a well-to-do woman, aged 51. About six years earlier “small swellings appeared in spaces between upper lids and eyeball,” gradually increasing in size. Later the lids were in­ volved and became thick and hard. Two years later the growths were removed by operation and from the specimen a diagnosis of hyaline degeneration of tarsal conjunctiva was made. Two years after the operation the patient noticed a small recurrence of tumor masses which since then had slowly grown larger. At present the masses, which were hard in consistency and easily removed, were chiefly in the lower fornix of both eyes. In some places the conjunctiva was adherent to the masses. The line of demarcation between tumor and deep tissue was not very dis­ tinct. (No statement was given in regard to existence of trachoma).

Microscopic Examination: The specimen is a piece of the fornix which is folded and covered with stratified epithelium, beneath which several follicles are seen. Beneath the epithelium lies a strip of con­ nective tissue and still deeper is found a fine reticulum the interstices of 206 The China Medical Journal which are. filled with lymphocytes and plasma cells. The cytoplasm of some plasma cells stained deeply red and a few Russell’s bodies were observed. Only a few strands of connective tissue contain nuclei and these are moderately invaded by plasma cells. Others have lost their fibrillary structure, are homogeneous in appearance and give amyloid reaction. The tissue is rich in blood vessels. The larger vessels have undergone hyaline degeneration to such a degree that their lumina are partially or completely obliterated. Summary of Case 13: A well-to-do woman developed re­ current tumor-shaped growth of the upper conjunctiva. Mic­ roscopic examination showed follicles within the conjunctiva and diffuse plasmacellular infiltration of the deeper subcon­ junctival tissue. Connective tissue fibers and walls of the larger blood vessels had undergone hyaline degeneration. Some of the fibers gave amyloid reaction.

Case 1 4 : (No. 40750). T.S. Chang, a woman, aged 24, came to the eye clinic on November 8, 1925, complaining of tumor masses on the right eye. Three years earlier a small nodule appeared at the inner corner of the right upper lid a part of which was excised by a layman, but it soon began to grow again. The inner third of the right lid was thickened and hard in consistency. There was a granulation-like growth in the caruncle region, extending to the inner portion of the upper lid and lower fornix. There were trachomatous scars on the upper tarsal conjunctiva. The left eye was normal. Vision: O.D. 6/10, O.S. 6/10. A clinical diagnosis of amyloid degeneration of the conjunctiva and cicatricial trachoma of both eyes was made.

Microscopic Examination: The surface of the excised piece is ccvered with stratified epithelium, beneath which lies a thin stratum of connective tissue, the fibers of which form a reticulum whose meshes are filled with numerous plasma cells. Beneath this area of plasmacellular infiltration there is a stratum of fibrous tissue which is composed of small roundish irregular-shaped structureless masses. Within some of these a small lumen is seen. They are evidently hyaline-degenerated vessels. The deeper portion of the specimen is composed of firm fibrous tissue, with Meibomian glands, a part of which is infiltrated with loosely arranged plasma cells. The homogeneous fibrous tissue and the wall of some of the vessels give an amyloid reaction. Summary of Case 1U: A trachomatous patient developed tumor-shaped growth of the right upper fornix which was ex­ cised by a layman, but which grew uj> again rapidly. The growth microscopically presented a diffuse plasmacellular in­ filtration. A certain part of the connective tissue had under­ gone hyaline and amyloid degeneration. The blood vessel walls also showed hyaline degeneration and some of them were completely obliterated by hyaline- masses. Plasmoma of the Conjunctiva in China 207:

Case 15: (Pathol. No. 03743. Specimen was sent by Dr. Pearson of Paoking, Hunan, on May 2, 1924). D.C. Tang, a man, aged 24, had had a sudden attack of inflammation of one eye (which one not stated). Later a tumor-like swelling appeared in the inner angle involving the plica semilunaris and spreading over the bulbar conjunctiva as far as the limbus of the cornea, slightly overhanging the latter. The tumor was excised and measured 16 X 9 mm.

Microscopic Examination: The great part of the excised tumor is covered with markedly proliferated epithelium, beneath which there is a pinkish stroma homogeneous in structure in which solitary groups com­ posed of lymphocytes, about 707r, and plasma cells are scattered. Between the cells small masses of hyaline degeneration and plasmacytoids are found. The cytoplasm of some plasma cells stains red and appears homogeneous. Here and there there within the pinkish stroma degenerated blood vessels with a narrow lumen are seen. Some vessels give an amy­ loid reaction. Summary of Case 15: A young man had a tumor-shaped growth of the bulbar conjunctiva of four months duration, wrhich pathologically appeared to be an advanced hyaline de­ generation with plasmacellular infiltration of the conjunctiva and invasion of lymphocytes. (No statement was given about trachoma).

Case 16: (Pathol No. 03310. Specimen and history sent by Dr. Smith on October 16, 1923). T.M. Yang, a well-to-do youth, aged 17, had had a tumor mass forming in the lower fornix of his left eye for about six months. It gradually enlarged without pain or discharge. About three years ago he had had a similar but smaller mass removed from the upper lid of the right eye with no recurrence there. The present growth- was removed, the mass seeming to have extended backward.

The patient was seen by the writer four years after removal of the growth from the left eye. Eyelids of both eyes were thickened. Upon eversion conjunctivae of both lids showed pinkish granulated masses and follicular trachoma.

Microscopic Examination: The specimen is made up of a pinkish mass homogeneous in appearance. Only in some places is the fibrillated structure of this tissue recognizable and are nuclei still present. The tissue is richly vascularized, and there is a collar like accumulation of plasma cells around the blood vessels, among which numerous plasmacy­ toids are found. In the pinkish stroma are scattered numerous blood vessels, the walls of which have undergone hyaline and amyloid degeneration. Summary of Case 16: A well-to-do young man affected by trachoma developed a tumor mass in the left lower fornix which was excised six months after its appearance. A similar tumor­ shaped growth of the right upper lid had been removed three 208 * ... The China Medical Journal

years ago and at the time of the examination by Dr. Smith it showed no recurrence. The excised tumor was composed of mixed hyaline-amyloid degenerated connective tissue with solitary groups of plasma cells around blood vessels. The patient was seen four years after the last operation and showed recurrent tumor-shaped thickening of eyelids.

This is a case of an advanced hyaline amyloid degeneration of the conjunctiva with plasmacellular infiltration around the blood vessels. ,

Case 17 : (Hospital No. 22 5). W . I. Tu, a military officer, aged 27, came to our eye clinic on June 30, 1921, complaining of a large growth of the conjunctivae of both eyes and also of impaired vision due to the growth. Four years earlier a small growth had appeared at the inner canthus of the right eye which gradually spread to the upper and lower fornix, and forwards to the bulbar conjunctiva, leaving the cornea uninvolved. 18 months after the onset the patient was admitted to the Pei Yang hospital in Tientsin where one-third of the growth was excised. Three weeks after the operation the growth began to increase in size and in three years it had gradually reached its present dimensions. A similar growth had also appeared at the left caruncle. This gradually increased in size, but it did not become as extensive as the one in the right eye.

Examination-. Right Eye'. Lids showed tumor-like swelling. The skin was stretched but was freely movable. The margin of the lower lid was rounded and devoid of cilia, the upper lid margin was normal (figs. 4 and 5). A lobulated mass protruded from the palpebral fissure which was displaced toward the temporal side. The eyelids could not be everted. The palpebral conjunctiva was red and thickened and the upper conjunctiva was adherent to the globe in places (symblepharon). When the eyelids were separated by force the reddish lobulated mass protruded from the palpebral fissure. This mass was pear-shaped with its apex pointing downwards, measuring at its base about 45 mm. and at the apex 15 mm. This mass filled the whole cul-de-sac almost hiding the cornea. L eft Eye'. The upper eyelid was thickened and could not be everted. The lower palpebral conjunctiva showed a tongue-shaped tumor going along the fornix and extending to the inner canthus, disappearing in the upper palpebral conjunctiva. From the plica semilunaris this tumor-shaped mass extended also toward the bulbar conjunctiva reaching the inner cantkus of the cornea but not overlapping it.

Operation: The tumor-shaped masses of both eyes were excised as completely as possible and a skin graft was introduced into the cul-de-sac. After the masses of the right eyelids had been removed the exposed cornea appeared to be small and non-transparent with a rough and uneven surface. As soon as the patient realized that vision of that eye was reduced to light perception he requested enucleation. In spite of dis­ suasion he insisted upon the operation and finally the eyeball was ¿nucleated. The patient did not return for observation. Fig. 6.— Hyaline degenerated cornea infiltrated with vessels and plasma cells. Case 17, Photo x 23. F ig . 7.— Hyaline degeneration of the subconjunctival tissue with calcification

and ossification. Case 17, Photo X 23.

Fig. 9.— Vacuolisation of the nucléus of plasma cells. Case 5. Plasmbma of the Conjunctiva in China 209

Microscopic Examination: The eyeball of the right eye: the greater part of the cornea is devoid of epithelium. Bowman’s membrane is destroyed by pannus. The corneal stroma is thickened, its surface uneven, and the anterior half of the stroma replaced by a thick layer of vascular, newly formed fibrous tissue which has undergone hyaline changes. Within the tissue numerous plasma cells are found. The walls of the newly formed vessels are thickened owing to hyaline degeneration, and are invaded by whorls of plasma cells, while their lumina are almost obliterated. Here and there are seen roundish homogeneous masses which are evidently blood vessels in a state of complete obliteration due to hyaline degeneration. Some of the superficial corneal lamellae are broken up in globules of different sizes. They react to tests for hyaline and amyloid. The deeper corneal lamellae (two-thirds) are more or less regularly arranged and show an increase of fixed corneal cells. Descemet’s mem­ brane is present. The sclera is normal but the episcleral tissue next to the cornea is thickened, infiltrated with plasma cells, and has the appearance of hyaline degeneration. The filtration angle and the canal of Schlemm are open. The uvea shows no pathological changes. There are Blessig-Iwanoff’s cysts near the ora serrata. The optic nerve is normal, (fig. 6).

The excised nodules of the right conjunctiva show irregular areas of hyaline and fibrous tissue and whorls in which plasma cells with pycnotic nuclei are found. The blood vessel walls show hyaline degeneration and some of them are obliterated and contain deposits of lime salt. Close to these areas new-formed bone-substances are seen (fig. 7). L eft E y e : The conjunctival tissue, in which numerous plasma cells' and pycnotic nuclei are scattered, is devoid of its epithelium and appears homogeneous. Hyaline degeneration is less advanced than in the tissue of the right eye. The vessel walls are hyaline and show thickening of their adventitia. Some of the vessels are obliterated, others are surrounded with plasma cells. Among the plasma cells a few mast cells and Russell’s bodies are recognized. A part of the lacrimal gland, attached to the specimen, is also densely infiltrated with plasma cells. Summary of Case 17: A young officer had recurrence of tumor-shaped growths of the conjunctiva of all four lids. The growth of the right eye filled the whole cul-de-sac, protruding from the palpebral fissure and covering the cornea. There was tongue-shaped growth at the left lower fornix. The right eyeball and the tumors of the four lids were removed. The growth of the conjunctiva and cornea miscroscopically presented hyaline and amyloid degeneration. These tissues were mode­ rately invaded by plasma cells, chiefly around the blood vessels. Otherwise the eyeball was normal. 210 The China Medicai Journal

D is c u s s io n

All seventeen cases presented, clinically, a tumor-shaped growth of the conjunctiva, and histologically, a diffuse plasma- cellular infiltration which occupied the conjunctiva, in some cases spread over the epitarsal tissue, and in cases 11 and 17, affected even the palpebral lacrimal glands. This diffuse infil­ tration was found either directly beneath the epithelium or separated from it by a more or less wide strip of connective tissue (cases 1-5). In most of the cases, plasma cells so densely invaded the tissue that it gave the clinical picture of a mere or less sharply defined tumor; but in no case was the demarcation line between infiltrated and uninfiltrated area anatomically sharply cut, and usually solitary groups of plasma cells were found beyond the densely infiltrated area. One case (case 4) showed a loose arrangement of plasma cells. Eight cases (cases 6-13) presented a histological picture similar to that of the first five cases with the exception that plasma- cellular infiltration began immediately beneath the epithelium. In the remaining four cases (cases 14-17) plasmacellular infil­ tration was confined to solitary groups, since in these cases the degenerative process was prevalent. Case 11 may be regarded as a transitional case between plasmoma and tumor-shaped hyaline and amyloid degeneration of the conjunctiva, because it manifested both phenomena almost equally.

Type of cells: 1. Plasma Cells.— As stated above, the chief mass of the growth was composed of typical plasma cells, which possess a considerable amount of cytoplasm and an eccentrically placed nucleus with the wheel-spoke like arrange­ ment of the chromatin. Within the cytoplasm, close to the nucleus, there was a lightly stained area which according to Altman-Schridde shows granules similar to the granules found in lymphocytes. At the periphery of plasmacellular infiltration and within the connective tissue, some plasma cells became less globular and more spindle-shaped, (fig. 8). Very frequently plasma cells were found with multiple nuclei (two to five), due to mitosis of the nucleus without a division of cytoplasm. We never observed any mitotic division of the cells, although three authors, Pascheff; Hoffmann and Schivarzkopf (see their case 1) stated that they found mitotic figures in plasma cells. Among the plasma cells various forms of degeneration were found ; pycnosis, vacuolization and caryolysis of the nucleus and Plasmoma of the Conjunctiva in China 211

degeneration of the cytoplasm. In the cells with vacuolization of the nucleus, the chromatin is often seen in the nuclear periphery giving the nucleus a more or less ring-shaped appearance (fig. 9). The central part of the nucleus, free of chromatin, took the acid stains. This phenomenon which was observed in cases 5 and 11 and which is due to the shrinkage of the nucleus by fixation agents, was also described by Schwarzkopf and Hoffmann. Some cells manifested degenera­ tion of their cytoplasm which became larger, appeared homogeneous, and was stained uniformly red. If the nucleus disappeared, a reddish homogeneous mass lying free among the cells— so called Russell’s bodies was found (fig. 10). W e never had an opportunity, however, to observe confluence of these degenerated cells into a large mass, as described by Pascheff and Schwarzkopf.

2. Lymphocytes.— These were fairly common in these tumors. They were chiefly small round cells with a centrally located nucleus. Large mononuclear-phagocytes were observed in the hyaline-degenerated cornea (case 17). Lymphocytes were found: a) scattered within the areas of plasmacellular infiltration, b) directly beneath the epithelium, and c) around plasmacellular infiltration. In some cases (12, 14, and 15) lymphocytes were predominant in the anterior portion of the tumor gradually giving place to plasma cells.

3. Eosinophiles.—Eosinophile leucocytes were found in a very small number in two cases only (10 and 15). More frequently there were found so-called plasmacytoids which were first described by A. Fuchs. They have a granular cytoplasm, stained red with eosin. Their nuclei are placed eccentrically (fig. 10). These cells were found chiefly in the areas with loosely arranged plasma cells and also among the cells accu­ mulating around the blood vessels. 4. Polynuclear leucocytes were found in the epithelial layers and in the tissue beneath it, but in relatively small numbers. The origin of plasma cells continues to be a matter of dis­ pute. Unna inclined to consider them as derivatives of normal connective tissue cells by the increase and rounding of the cell body and the peculiar arrangement of chromation of the nucleus. Councilman, Marshalko and Schridde are of the opinion that 212 The China Medical Journal plasma cells are derived from large lymphocytes. Pappenheim came to the conclusion that they originate from the cells of con­ nective tissue stroma and that plasma cells have a tendency to be converted into spindle-shaped cells. According to Marchand plasma cells originate from the adventitia of blood vessels. Pascheff and Rund also found a close relation between plasma cells and the connective tissue elements of the adventitia of blood vessels, but Deutschmann opposes this point of view\ Collins and Mayou as well as Hoffmann are inclined to the opinion that plasma cells are derived from endothelial cells and Hoffmann described transitional forms around the capillaries. We could not confirm the existence of such transitional forms, but in almost all the cases examined we found within the fibrous tissue solitary groups of plasma cells around the blood vessels, a fact which supports Marchand’s point of view. The role of plas- macytoids is more obscure. A. Fuchs considered plasmacytoids as derivatives from plasma cells while E. Fuchs was of the opinion that they belong to the group of eosinophilic myelocytes found in foetal organs such as thymus and marrowT of the bones, and he was inclined to refer them to the group of mononuclears wrhich, according to Marchand, can be changed into myelocytes. As to Russell’s bodies, most authors consider them as degenera­ tive products of plasma cells (A. Fuchs, Komoto and Lubarsch).

In many of our cases we observed degeneration of plasma cells similar to that described by other authors (Pascheff, Schwarzkopf, Hoffmann, Botteri and Spanie). Their cytoplasm became enlarged and was stained easily with eosin. In some cells the nucleus disappeared and then only small red globules were seen among the normal plasma cells. This degeneration is considered to be hyaline.

Epithelium.—The epithelium of the conjunctiva in our cases of plasmacellular infiltration varied in thickness according to the location of the growth in the conjunctiva. In three cases (6, 7, 12) it was two to three cells in thickness, in all others it was proliferated and in some cases reached twelve layers. The superficial cells were flattened out and the deeper were polygonal or cylindrical in shape. In almost all the cases the epithelium was more or less infiltrated with leucocytes and lymphocytes.

In cases 1, 3, and 13 follicles were found either directly beneath the epithelium or within the papillary formation of the Plasmoma of the Conjunctiva in China 213

«conjunctiva. Trachoma bodies were observed in the scrapings •of the conjunctiva in cases 4 and 9. (We may add by way of •explanation that examination for the presence of trachoma bodies was begun in our clinic only in 1925).

Stroma.—In most cases the connective tissue fibers in the superficial portion of the tumor-shaped growth were thin and formed a reticulum the meshes of which were filled with plasma cells. In the deeper portion connective tissue fibers appeared as strands of wavy fibrillated tissue, which did not take Van Gieson stain, became thicker, and had already undergone degenerative changes. These strands soon lost their fibrillate structure and appeared as homogeneous hyaline substance of various shape and size. The deeper portion of the growth was chiefly composed of fibrous tissue, which also showed either hyaline degeneration or an intermediate stage of this degenera­ tion. In cases 14, 15, 16, and 17, the fibrous tissue was com­ pletely degenerated and appeared as a homogeneous mass stained pinkish or red with eosin. In the hyaline degenerated conjunctiva, lime deposits were found in two cases (14 and 17), a phenomenon which is more or less common for this kind of degeneration (see Eleonsky, Gifford and Pascheff). Case 17 showed a beginning of ossification of the hyaline degenerated conjunctiva (fig. 8), a phenomenon which is more rarely encountered (Kolominsky). Blood vessels: Within the mass of plasma cells numerous small vessels were found, mostly capillaries. Some of the vessel walls were thickened, due to degeneration of their adventitia and media and, in advanced cases their lumina were considerably narrowed or even obliterated, being filled with hyaline substances (figs. 11 and 12). The obliterated vessels appeared as a homogeneous reddish mass in which might be distinguished concentric fibers. Around the many blood vessels accumulations of plasma cells were found. In the cases where hyaline degeneration predominated, plasma cells were found exclusively around blood vessels walls. In six cases (3, 13, 14, 15, 16, and 17) blood vessel walls had undergone partial or complete amyloid degeneration. In the literature on the subject at my disposal we find that up to the present ninety-seven cases of plasmoma of the con­ junctiva have been reported since Paschsff published his first paper on this condition (in 1908). Among these, twenty-eight 214 The China Medical Journal cases were from central Europe; thirteen cases from Russia; two cases from Italy; thirteen cases from the Balkans; one case from Algeria; five cases from India; sixteen cases from Japan and three from the United States. We can add to this list fifteen cases from China, although they were not recognized as plasmoma, but were classified by McAll and Judd as subcon­ junctival granuloma. Out of all these cases of subconjunctival plasmoma we could get a more or less detailed description of fifty four cases only. Reviewing these fifty four we see that majority of the patients were male, but that age apparently has no influence upon the affection.

5U cases of other authors:

A tre 1-10 1 11-20 21-30 1 31-40 41-5" I 61 60 61-70 To. sili

M ale 1 S ó ! 4. 4 5 5 31 1 1 ! 7 6 1 4 1 ! 3 1 23 1

17 Our cases:

A.!?* 11-20 ! 21 30 31-40 41-50 51 -00 ¡ 61-70 Total

IVI ü 1 « 2 1 7 _ 1 “ 12 I F em ale - i 2 1 1 1 ~ 5 The case of plasmoma of shortest duration ever recorded in the literature was of two and one-half months’ duration (Hoffmann’s case No. 4) and the longest period of existence recorded was about 15 years (Judd’s case 1). The case of shortest duration to come under our observation was, according to the patient’s statement, of one month’s duration only (case no. 4), but from the clinical picture and the size of the growth,, the duration must have been much longer. We must remember that patients usually record not the date of the appearance of the growth, but the time when they first notice its presence. The most instructive case would be one which comes under observation from the very beginning. As far as we know no such case has been reported except experimental ones described by Botteri and Svanie. Here, in China, plasmoma of the con­ junctiva is such a common disease that it may be observed in various stages, even from its early beginnings. We have had the opportunity to observe many more cases of plasmoma than the seventeen here reported, among them cases so recent that the growth could hardly be differentiated clinically from «¡¡I lÉÉiil

F ig . 11.— Hyaline degeneration of blood vessel walls and obliteration

of some liuniva. Case 12. Photo X 100.

Fig. 12.— Advanced hyaline degeneration of the blood-vessel walls. Fig. 13.— Tumorshaped plasma cellular infiltration of the plica, (recently observed case)

F ig. 14.— Tumor-shaped plasmacellular infiltration of bulbar conjunctiva. One of the recently observed cases. Plasmoma of the Conjunctiva in China -215

trachomatous follicles. Reviewing our cases from a histopa- thological point of view we see the plasmoma can exist for two and half years without hyaline degeneration (see case no. 8), but that it usually undergoes hyaline degeneration more quickly (case no. 1). Undoubtedly all cases of plasmoma degenerate sooner or later, but while in one case (case no. 7) the degenerative process scarcely developed in a period of two years, in other cases (15 and 16) the conjunctiva had undergone in a period of four to six months an advanced hyaline degenera­ tion.

Clinical Symptoms The diseases were found among Chinese patients of all classes and professions; from poor farmers to officials and women of the better class. The age of patients ranged from 17 to 60 years, with more men than women. In 12 of the seventeen cases just reviewed the condition was unilateral, and in the remaining five the history was invariably of primary involvement of only one eye. The duration of the disease ranged from one month to ten years. There was no evidence of injury by trauma or by chemical agents and nc history of •organic disease, but it may be admitted that the history of some of our cases was not carefully enough taken. The onset of the disease was gradual and, with three exceptions, was accompanied by no noticeable inflammation. The first evidence was a small reddish granular mass which in twelve cases appeared on the semilunar fold near the inner canthus (fig. 13), and in the other cases began in the retrotarsal fold. In our clinical observation of many cases not reported here, these granular masses could scarcely be differentiated from trachomatous follicles. They gradually increase in size and become confluent, taking on the appearance cf a coxcomb. When the growth was situated in the fornix, it could be detected only on everting the eyelids. It was yellowish red in color, with a peculiar waxy appearance, a firm consistency and a smooth surface. The mass gradually increased in size, spread­ ing first along the lower or upper cul-de-sac (see rigs. 2 and 3). At this stage the growth had the appearance of an ill-defined tumor, which gradually lost itself in the palpebral or bulbar conjunctiva (fig. 14). Its surface remained even, or became granular or lobulated (cases 3, 9, 10, 12, and 17). The lobules were smooth and pale, covered by the conjunctiva, no blood .216 The China Medical Journal

vessels were visible in them, and there was no discharge of any kind. Scars of the conjunctiva were detected in cases 4 and 14. In eight cases (1, 2, 4, 5, 8, 11, 14, and 17) the disease extended, from the semilunar fold to the limbus. In case 17, the whole cornea was affected so that it was opaque and uneven (see fig. 6). In the later stage of the disease the entire bulbar conjunctiva was sometimes involved in such a way that the lobulated growTth overlapped the cornea (cases 15 and 17), thus more or less affecting vision. In three cases the morbid process spread into the tarsus of the lids (cases 11, 15, and 17). The line of demarcation between the growth and the normal tissue was anatomically not very distinct. The lids gradually thickened and were therefore more or less ptotic; in later stages complete ptosis with a very narrow palpebral fissure developed (see fig. 4). The skin was freely movable over the growth.

Differential Diagnosis In some cases not recorded in this paper incipient plasmoma manifested itself as a duplication of the retrotarsal fold with a granulated surface, thus rendering the differential diagnosis between plasmoma and trachoma very difficult. It is also very 'difficult and often almost impossible to differentiate clinically cases of plasmoma from those of hyaline degeneration of the conjunctiva, because their clinical appearance is so much alike. Several times our clinical diagnosis of plasmoma had to be changed after pathological examination to hyaline degeneration ■of the conjunctiva and vice versa. The differential diagnosis between plasmoma and papilloma is much easier, as the latter represents numerous lobules, usually smaller and more pointed, soft in consistency, and red in color with blood vessels shining through the covering conjunctiva. Granuloma can also be more or less easily differentiated, as it is more sharply defined. It is rich in vessels and therefore more reddish than plasmoma. These two growths, papilloma and granuloma, when touched or cut bleed more or less profusely, while excision of a plasmoma is practically bloodless. In some cases, however, it is quite* impossible to differentiate these affections clinically. The differential diagnosis between plasmoma and myeloma can be established only by differential count of white blood corpuscles, by the presence of myelocytes in the blood and by the enlargement of the glands. The characteristic feature of rhinosporidium Kinealyi of the conjunctiva according to Wright Plasmoma of the Conjunctiva in China 217 is as follows: the growth springs from a short narrow pedicle, its color and consistency resemble those of the spleen of a small mammal; there are minute white seed-like bodies or yellowish granules just under the surface of the epithelium seen with the naked eye; the thin edge of the growth is yellowish. Although we have had no chance to observe this disease it seems that a clinical differential diagnosis of these two diseases is quite possible. The fornix conjunctiva is the most common seat of the disease, as shown in the following table:

Fornix ¡ Bulbar Plica and Lacrimal Cornea conjunctiva j conjunctiva caruncle f-ac

Our cases j 15 5 9 — 1 Ca?ea of other 51 14 13 2 3 authors

Etiology The etiological factor of plasmoma of the conjunctiva is still unknown. In all our cases patients manifested no symptoms of any organic disease, and their Wassermann reactions were reported negative. These findings coincide with those of the other authors with the exception of Baurmann’s case 3, in which the Wassermann reaction was found positive and Pascheff’s case 2 with a history of syphilitic infection. No bacilli or any kind of microorganisms, except trachoma inclusion bodies and some saprophytes were found in our cases. It is a known fact that a chronic irritation caused by an infection may lead to a tumor-shaped plasmacellular infiltration. According to Kirk­ patrick Rhinosporidium Kinealyi may produce such tumor­ shaped plasmacellular infiltration of the conjunctiva and lacrimal sac. Wright confirmed these findings. Hence the possibility of an infectious cause of conjunctival plasmoma is not excluded. Inoculation of plasmoma under the conjunctiva was tried by Yerhoeff and Cange but the tissue was gradually absorbed. Botteri and Spanie excised a piece of plasmoma of the human conjunctiva, which showed no symptoms of trachoma, and inoculated it into the subconjunctiva of a monkey (pavian). In fourteen days a follicle developed which gradually increased in 218 The China Medical Journal

size. A histological examination revealed the same pathological picture as in the case of experimental trachoma in a monkey. Besides the eye and its adnexa plasmoma has also been found in various organs; Boit described it in sinus Morgagni, Pironne in gums, Hedinger in uvula. The pathological picture was similar to that in plasmoma of the conjunctiva. No etiological factor has. yet been found in these cases. Plasmoma of the conjunctiva is very frequently found in trachomatous patients. In forty-eight cases reported by various authors trachoma was found positive in twenty-eight cases and negative in six; in the remaining fourteen cases there was no statement in regard to presence or absence of a trachomatous condition of the conjunctiva. Trachoma was established clinically in twelve of our seventeen cases, and in two of the fifteen cases trachoma inclusion bodies were found. These five cases were outside cases and no detailed description of the con­ dition of the conjunctiva was given in the history sent with the specimens. In view of the fact that plasmoma of the con­ junctiva has been found almost exclusively among trachomatous patients, it is evident that trachoma has a close relationship to this morbid condition. We have no evidence at hand to state definitely, as Hiwatary and Kubik do, that trachoma is the cause of plasmoma, but we believe that prolonged irritation by trachoma may be a predisposing factor in the development of plasmoma. Hoffmann also pointed out that only two conditions may give rise to plasmoma, trachoma and vernal catarrh. Papvloczy is also of opinion that there is an indisputable con­ nection between trachoma and plasmoma. Botteri and Spanie on account of clinical and experimental observations came to the conclusion that the plasmoma of the conjunctiva is an infectious disease in meaning of trachoma, i.e. it is only a further stage in the development of trachoma. But they emphasized that plasmoma develops in very rare cases and in certain conditions only. Since plasmoma of the conjunctiva is very frequently associated with trachoma, and the routine treatment of trachoma consists of application of copper stick or ointment, the question rises whether infiltration could be caused by the chronic irritation due to this treatment. Although Kultchinsky believes that copper sulphate may influence the metabolic pro­ cesses in the connective tissue, there is no evidence at hand Plasmoma of the Conjunctiva in China 219

that application of copper sulphate may provoke plasmacellular infiltration. The majority of our cases had never been treated with the copper stick.

Treatment In the treatment of plasmoma we have no chemical or "biological substances by means of which this tumor-like growth can be absorbed or transformed into connective tissue. Unless the etiology of the disease is found, all our attempts to cure it will be in vain. Excision of the growth is the only radical treatment, and the earlier the excision is made the better the prognosis. In advanced cases complete excision of the growth is very difficult, as the whole palpebral and bulbar conjunctiva as well as the tarsus and lacrimal gland may be involved. In such cases, where excision of the whole growth may easily give rise to symblepharon, a plastic operation is required. Schwarzkopfs opinion that, if a partial excision is made, the rest of the growth will gradually disappear seems to be incorrect, since Rumjantzeff’s, Virchoff’s and one of Pascheff’s cases as well as six of ours (cases 8, 13, 14, 16, and 17) showed recurrence from one to four years after apparently complete excision. These facts are also in contradiction to Kubik’s statement that C.zermo.k’s case is unique, as it gave recurrence after extirpation of amyloid masses of the conjunctiva. Elschnig’s case, although it is a case of lymphogranulomatosa, may be of value in explaining these two contradictory state­ ments. Elschnig described a case of plasmacellular hyper­ plasia of the lids associated with lymphocytosis of blood and enlargement of glands. Excision of glands and x-ray treat­ ment had no influence on the blood picture; but as soon as the growth of the lids was removed, the blood picture became normal. From this fact we may conclude that the etiological factor of the disease lay in the conjunctival tissue. By analogy we can admit that some unknown irritant can be located in a certain part of the conjunctiva and the excision of this portion ■of the conjunctiva will lead to complete disappearance of the growth. Van Duyse claims that treatment with x-ray produces resorption of the growth. Radium treatment has been tried in the Peking Union Medical College Hospital for the treatment of this disease. Unfortunately, we were unable to follow up 220 The China Medical Journal many of the treated cases, as the patients did not return to the clinic for observation. One of our cases was completely cured by three applications of radium plaque direct upon the everted palpebral conjunctiva with rubber tissue screen. The totaL amount of irradiation was 20 mgm. hours. The patient pre­ sented herself one year after the treatment and showed no symptoms of recurrence. In another case (see case 2) the result of radium application was very encouraging. The thickening of the lids diminished in such a way that the patient could open his eye much wider, and the palpebral fissure measured 10 mm. instead of 5 mm. before the treatment was given. The total amount of irradiation, given in the same way as described above, was 105 mgm. hours. In these two cases the microscopic examination of the specimens of the plasmoma after radium treatment showed an increased pycnosis of plasma cells and a striking disappearance of the cells with multiple nuclei. According to our experience repeated ap­ plications of radium should be given to each case, and in advanced cases the radium treatment should be preceded by as complete an excision of the growth as possible. The nature of plasmoma is still obscure. Pascheff comes to the conclusion that plasmoma is the result of chronic inflam­ mation. Baurmann, Botteri and Spanie, Eleonsky, Pokroicsky, and Rados are inclined to take the same point of view. According to BoMrmann the following three points speak for chronic inflammation: 1) predominant formation of plasma cells in various kinds of inflammation, 2) participation of blood vessels as shown by the appearance of numerous “primitive” vessels and by perivascular infiltration 3) this infiltrated growth only exceptionally leads to a malignant growth. Hoffmann agrees with Baurmann’s postulates and takes his point of view, concluding his own paper with the following statement: “There is no doubt at all that plasmoma represents inflammatory irritation of the tissue, but what kind of irritation remains quite obscure.” Rund is of the opinion that plasmoma is an “aleucaemic heteroplastic lymphoma.” Lymphoma of the conjunctiva is a manifestation of a general disease which leads to hyperplasia of the whole lymphatic system and it is associated with lymphocytosis of the blood. Some cases of lymphoma of the conjunctiva without Plasmoma of the Conjunctiva in China 221 lymphocytosis of the blood and enlargement of glands have been described in the literature, but they were always associated with lymphocellular infiltration of the orbit or of some other tissue. The same condition we must expect to find in a case of aleucaemic heteroplastic lymphoma. Sooner or later other organs ought to manifest lymphocytic infiltration. But it is not the case in real plasmoma of the conjunctiva in which the blood picture in all the cases examined was invariably normal. For the same reason all other authors have declined to take Rund’s point of view. Schicarzkopf was inclined to concur with Rund that plasmoma is a real tumor. He quoted Boit’s four arguments, which in their opinion, prove that plasmoma is a real tumor, and which are: 1) uniformity of cells, 2) abundance of cells, 3) multiple nuclei in cells, and 4) a partial degeneration. But, as Baurmann and Hoffmann have already pointed out, these symptoms are so common in various pathological processes that any cellular infiltration in a case of acute inflammation, even tuberculous, should be regarded as a tumor. In plasmoma we have a simple accumulation of plasma cells by apposition. ¡Deutschmann did not find any signs of inflammation in his case and was inclined to believe that plasmoma is a tumor sui generis. His statement is in contradiction to our findings. All other authors have also found lymphocytes and poly­ morphonuclear cells in large or small numbers. The presence of these cells is usually indicative of an inflammatory process. As to the plasma cells themselves they are also usually found in cases of chronic inflammation, as, for instance, in syphilitic lesions and lupus. According to our present knowledge plasma cells are encountered in all chronic inflammatory diseases of the eye, mouth and nose and its adnexa. All these plasmomas are related to the same group of a chronic inflammatory pro­ cess. All these facts lead us to the opinion that we are dealing writh a chronic inflammatory process caused by some chronic irritant. This irritant may be of bacterial or toxic origin. As plasmoma of the conjunctiva is frequently associated with trachoma, it is quite probable that trachomatous toxin may act as a chronic irritant provoking plasmacellular infiltration, and it seems that it is the most frequent cause of irritation. 222 The China Medical Journal

According to our pathological study of the specimens, lymph-sheaths of blood vessels often are the first to be affected. This phenomenon would indicate a circulation of the toxins through the blood or the lymph stream, analogous to that observed in tuberculous and syphilitic processes. Irritation produced by the toxins circulating in blood vessels leads to inflammation of the surrounding tissues and is manifested by an accumulation of plasma cells. In certain cases this accu­ mulation of plasma cells may be explained by the irritation of the tissue by toxins acting directly from the surface of the epithelium as is also the case in trachoma, vernal catarrh and other bacterial infection of the conjunctiva. Plasma cells seem to form, in some cases, a kind of barrier for the deeper layers of the conjunctiva, thus acting as defence forces of the organism and hindering penetration of toxins in the deeper tissues. According to Pappenheim plasma cells may be transformed into connective tissue cells. If this is the case formation of connective tissue also helps the organism to fight against the destructive properties of toxins. * According to Schade connective tissue is not a simple sup­ porting tissue, but plays an important role in metabolism, having the property of storing to a certain limit split-products of metabolism. Toxins which may be produced during the course of a conjunctival disease are absorbed by the conjunctiva which reacts upon these toxins by plasmacellular infiltration, proliferation of the reticulo-endothelial system leading to degenerative changes of the blood vessels. If toxic virus is moderate, it provokes plasmacellular infiltration of the tissue, but if the toxins are very virulent or if they act upon the tissue for a long period of time, .the degeneration of plasma cell and connective tissue may take place. This may offer an explana­ tion of the transformation of tumor-shaped plasmacellular infiltration of the conjunctiva into hyaline-amyloid tumors.

S u m m a r y 1. Seventeen cases of plasmoma of the conjunctiva presented in this paper were studied clinically and histologically. 2. At the onset plasmoma manifested itself clinically as a small growth of the fornix or plica which gradually spread over palpebral and bulbar conjunctiva and may involve even the cornea. Plasmoma histologically appears to be a diffuse plasmacellular infiltration which begins either immediately Plasmoma of the Conjunctiva in China 223 beneath the epithelium or is separated from the latter by a strand of more or less normal connective tissue. In most of the cases at least a mild degree of hyaline degeneration of the connective tissue stroma is present. 3. Plasmoma is not a tumor but is a reaction of the organism to a chronic inflammation caused by some irritant. 4. The majority of the patients affected with plasmoma showed trachoma. We believe that trachoma plays an im­ portant role in the development of plasmoma ; trachomatous toxins act as an irritant provoking plasmacellular infiltration. 5. Plasmacellular infiltration acts as a defence of the organism preventing destructive action of the toxins upon the deeper situated tissues. 6. Prolonged action of the toxins may lead to advanced hyaline-amyloid degeneration of the connective tissue. 7. The effective treatment of plasmoma consists of early and complete excision of the growth followed by radium treatment.

R e f e r e n c e s 1. Baurmann, M.: Uber das Plasmom der Conjunctiva und seine Beziehung zum Amyloid.— Graef. Arch. f. Ophth. v. 109, p. 236, 1922. 2. Boit, X . : Ein Fall von Plasmacytom des Sinus Morgagni.— Frankf. Z’tschr. f. Pathol., v. 1. Referred by Baurmann. 3. Botteri, A. and Spanic, A.: Uber die Aetiologie des Plasmomes.— Klinisch. Monatsbl. f. Augenh., v. 78. p. 810, 1927. 4. Botteri, A. and Spanic, A .: Beitrag zum klinischen und histologischen Bilde des Plasmoms der Bindeh.— Refer. Klin. Monatsbl. f. Augenh. v. 82, p. 255, 1929. 5. Canga et Dubouchet: Une forme non décrit de Tarsoconjunctivite vegetante.— Arch. d’Opht., v. 42, p. 577, 1925. 6. Collins and M a yo u : Pathology and Bacteriology of the Eye. Second edition, 1925, p. 434. Phil. Blakiston. 7. Crossley. : Chronic hypertrophic Conjunctivitis.— Ann. of Ophth., v. 1, p. 196. 1918. 8. Deutschmann F.: Das Plasmom, die hyaline und amyloide Degen­ eration der Konjunctiva.— Zeit, f., Augenhl., v. 27, p. 242. 1912. 9. van D uyse. : Proliferation lvmphomateuse hyaline de la conjunctive bulbaire, Arch. d’Opht., v. 25, p. 40. 1905. 10. Elconskaja, W .: New growth on conjunctiva. Refer. The Ophthalmic Year Book. v. 21. p. 232. 1925. 11. Elliot, R. H.: Tropical Ophthalmology, pp. 341-345. 1920. Oxford Medical publication. 12. Elschnig. : Conjunctivitis acuta hyperplastica mit der Erschein­ ungen von Lymphogranulomatose, Med. Klin. v. 10. p. 675. 1913. 224 The China Medical Journal

13. Fuchs, A .: Uber die Derivate der Plasmazellen in Auge.— Arch f. Ophth., v. 103, p. 228. 1920. 14. Fuchs, Er. Uber luetische Choriciditis.— Graefe’s Archive f. Opth., v. 97. p. 85. 1918. 15. Fuchs, E .: Ubsr anatomische Veränderung bei chronischer Irido- choroiditis.— Graef. Arch. f. Opth., v. 98, p. 122. 1918. 16. Fachs, E .: Uber lymphocytäre Infiltration der Aderhaut.— Graefes Arch. f. Opth., v. 115, p. 585. 1925. 17. Halbertsma: Uber einen Fall von Plasmacytom der Konjunctiva.— Arch. f. Augenh., v. 92, p. 268, 1923. 18. Hedinger, E.: Zur frage des Plasmacytoms.— Frankf. Ztschr. f. Pathol., v. 7, p. 343. 1911. Ref. by Baurmann. 19. Hiwatary, K.: Plasmoma of ths conjunctiva. Am. Jr. of Opth., v. 11, p. 719. 1918. 20. Hoffmann'. Ein Bitrag zur Plasmomfrage.— Zeit., f. Augenheilk., v. 55, p. 164. 1925. 21. Judd: Several cases of a rare form of subconjunctival granuloma. China Medical Jour., v. 36, p. 397. 1922. 22. Kirkpatric: Referred by Elliot in “Tropical Ophthalmology” p. 200- 206, 1920. 23. Kolominsky, J.: Ein Fall von hyaline-amyloider Degeneration der Conjunctiva.— Klin. Monatsbl. f. Augenh., v. 50, p. 559. 1912. 24. Komoto, G.: Uber einen bischer unbekannten Tumor der Konjunc­ tiva.— Klin Monatsbl. f. Augeng., v. 53, p. 136, 1914. 25. Kubik, J.: Uber plasmacelluläre Infiltration, hyaline und amyloide Degeneration der Bindehaut.— Arch., f. Ophth., v. 114, p. 544. 1924. 26. K uboki: Ein Fall von Plasmom der Bindehaut. Refer, in Klin. Monatsbl. f. Augenh., v. 60, p. 270. 1912. 27. L ew itsk y: Zwei Fälle von Plasmom der Konjunctiva. Refer Klin. Monatsbl. f. Augenh., v. 52, p. 74. 1914. 28. Lubarsch, O.: Entzündung. Pathologische Anatomie herausgegeben von L. Aschoff. v. 1, p. 556, Sechste Auflage, 1923. 29. M c A ll: Notes on a rare form of subconjunctival Granuloma met with in Central China. Brit. Jour. Ophth., v. 4, p. 20, 1920. 30. Marchand: Handb. d. Allg. Pathol., v. 4, part 1., p. 470. Refer, by E. Fuchs (see our refer. No 16). 31. Marchi, F. A.: Some rare observations of atypical trachomatous pannus of the cornea in the form of tumor (plasmoma of the cornea). Refer. Brit. Jour. Ophth., v. 1, p. 569. 1917. "32. Machail, D.: Das Plasmoma der Conjunctiva und seine Bedeutung in der Pathogenese der hyalinen Degeneration der Bindehaut. Refer. Zentralbl. f. Ophth., v. 13, p. 410, 1924. 33. M in e: Plasmoma of the Conjunctiva.— Nippon Gank. Zashi., p. 896. 1919. ■34. Nakana: Conjunctival Plasmoma. Refer.: Ophthalmology, v. 12, p. 794. 1915-16. 35. Ogata, K .: Ein Fall von Plasmom der Konjunctiva. Refer. Klin. Monatsbl. f. Augenh., v. 68, p. 280. 1922. Plasmoma of the Conjunctiva in China 225

36. Pappenheim: Widerhalten sich die Unnaschen Plasmazellen zu lymphocyten? Virchow’s Arch. f. path. Anat. v. 165 & 166. 1901. 37. Papvloczy, F.: Plasmom der Bindehaut. Refer. Klin. Monatsbl. f. Augenh. v. 82, 404, 1929. 38. Pasche ff, C. : Plasmacelluläre Bildungen der Bindehaut und der Hornhaut.— Graefes Arch. f. Ophth., v. 68, p. 114, 1908. 39. Pasche ff, C .: Weitere Mitteilungen über die plasmacellularen B ild ­ ungen der Bindehaut. Arch. f. Ophth., v. 71, p. 569, 1909. 40. Pasche ff, C .: Conjunctivitis hyperplastica hyaliniformis. Sophia University Journal, 1926. 41. Pokrow sky: Uber so-genanntes Plasmom der Konjunctiva. Vestnic. Ophthalmologi, 1912. Refer.: Zeitschr. f. Augenheilk., 1912, v. 28, p. 285. 42. .jPironne, R .: Sur les cellules plasmatiques. Folia Haematol, 1909, v. 7. 43. Przybylska, J.: Plasmoma of Orbit. Annal d’Ocul., 1924, v. 161, p. 199. Refer.: Ophth. Year Book, 1925, v. 21, p. 241. 44. Rados, A .: Uber Plasmoma der Conjunctiva. Ztschr. f. Augenheilk. v. 29. p. 125. 1913. 45. Ramjanzewa, A.: Plasmoma der Bindehaut. Russ. Ophth. Jour. v. 5. p. 902. 1926. (Refer. Klin. Monatsbl. f. Augenh. v. 78. p. 143. 1927). 46. Rund, F .: Uber Plasmocytoma der Conjunctiva. Ztsch. f. Augenh. v. 26. p. 97. 1910. 47. Schade: Die physiologische Chemie in der inneren Medizin. Refer­ red by Baurmann. 48 . Schridde, H .: Die blutbereitenden Organe. Pathologische Anato­ mie herausgegeben von L. Aschoff. B. 2. p. 123-124, published by G. Fischer. Iena. 49. Schwarzkopf: Uber die Plasmazelle und das Plasmom der Con­ junctiva. Ztschr. f. Augenh. v. 49. p. 247. 1923. 50. Shikano: Drei Fälle von Plasmom der Conjunctiva. Refer. Klin. Monatsbl. f. Augenh. v. 52. p. 567. 1913. •51. Shinowara : Ein Fall von Plasmom des Bindehaut. Refer. Klin. Monatsbl. f. Augenh. v. 51. p. 564. 1913. 52. Shoemaker, TT7.: Hypertrophy of the Conjunctiva. Ophth. Record. v. 24. p. 340. 1915. 53. Soudakoff, P.: Plasmoma of the conjunctiva (Preliminary Report) Proceedings of joint conference of Chinese Medical Association and China Branch Brit. Med. Assoc., Hongkong, 1925, p. 16. 54. Soudakoff, P.: Plasmoma of the conjunctiva. Paper read at the Peking meeting of the China Medical Association, Sept. 1926. •55. Verhoeff, F. : Plasmoma of the lacrimal sac. Arch, of Ophth. v. 44. p. 250. 1915. 56. Wright, R.: Rhinosporidium Kinealyi of the conjunctiva. Ind. Med. Gaz. v. 67. p. 81. 1922. 226 The China Medical Journal

SPLENOMYELOGENOUS LEUKEMIA IN CHILDREN

B y r o n K oo, M.D. Severance Union Medical College, Seoul, Korea.

Judging from clinical observation, splenomyelogenous leukemia is rare in Korean chidren but we have had the opportunity of following one such case, for oyer seven years.

Case No. i- L.Y.O., Korean, female, aged 8 years, was brought to the pediatric clinic, complaining of a large tumor mas« in the abdomen. The tumor was noticed first in the left hypochon- drium, 8 or 9 months previous. The mass, at first, was scarcely palpable but gradually increased in size to 14 cm. below the costal margin. It was also 12 cm. in width. Past History. On March 19, 1928, the patient came to the O. P. D. of Severance Hospital, complaining of a severe hemor­ rhage from a tooth socket, the tooth having been extracted a couple of days previously. The dentist transferred the patient to us fo r the control of the hemorrhage. Physical Examination revealed a fairly well developed, but slightly anemic girl of 8 years of age. The conjunctival and oral mucosa were pale and there was bleeding from the socket, where the tooth had been extracted. Her tonsils were slightly inflamed and a few cervical glands could be palpated. Both lungs were full of moist rales. The spleen was enlarged to 5 cm. below the costal margin. The liver was not palpable. Laboratory Examination, Haemoglobin 55 per cent; W.B.C. 160,000. The feces showed ova of ascaris and trichuris. Staphylococci, streptococci, diplococci, but no tubercular bacilli, were found in the sputum. After two weeks treatment the hemorrhage from the tooth socket ceased and the lungs cleared up. The hemorrhage occupied our chief attention, not being controlled for about three days, and the importance of the W.B. Count was overlooked, the high count being ascribed to a leucocytosis due to the hemorrh­ age. The patient was discharged “ improved” on March 23, 1928. The patient was readmitted to the hospital on September 20, 1928. Case No. I.

Splenomyelogenous Leukemia, in Children 227

Physical Examination showed a fairly developed, though thifi girl, 8 years of age. The skin had an olive tint. The tonsils were somewhat enlarged. The chest was clear. The spleen extended 14 cm. below the costal margin and was about 12 cm. in width. There were no other glands palpable except for 2 or 3 small glands in the groins. The right lobe of the liver extended 35 cm. below the costal margin. (Plate No. I). The general condition of the child was good. She was happy and ran about like a normal child but tired easily. She also complained of occasional headaches and some shortness of breath on over-exertion.

Laboratory Examinations

Blood. Hemoglobin 7(K/r-; R.B.C. 3,728,000; W.B.C. 399,000.

Differential Count Polymorphonuclear leukocytes 50 per cent Neutrophil myelocytes 20 % Eosinophiles ...... 8 >38 „ „ Basophiles ...... 10 S. Mononuclear leucocytes 12

A second count Polymorphonuclear 40 per cent Large mononuclear 2 Small „ .... 14 Eosinophiles 2 Neutrophiles 20 Basophiles ...... Mast cells ...... 10 ■ 42 ” Eosino ...... 4 Malaria Negative. Wassernnan plus 2. Wasserman on mother plus 4. Follow-up history. After one weeks treatment with K.I., neosalvarsan and X ray, ths patient was sent home and treatment was continued by the pediatric department of the O.P.D., After 12 injections of Salvarsan the spleen was much decreased in size being only 5 cm. below the costal margin. The child was then sent to a home in the country, returning in six months she died of pneumonia. The spleen was as large as before the treatment with salvarsan.

Case No. 2. K.S.H., Korean, female, 15 years of age, entered Severance Hospital, J$n. 12, 1929, complaining of a large tumor in the 228 The China, Medical Journal abdomen, The tumor was first noticed, six months ago, in the left hypochondrium, and was about the size of the patients hand. It gradually increased in size until it filled two-thirds of the abdomen as shown in the illustration (Plate No. II). The brownish-yellow discoloration of her skin was first noticed about a year ago. Family History. Patient has had three brothers and two sisters; 3 brothers died' in infancy, cause unknown, the other sister is well. Her mother has had one miscarriage followed by facial paralysis. Her father is not in good health and also suffers from psychic irritation of the facial muscles. The par­ ents deny venereal disease. Past History. The patient had malaria and several attacks of dysentery two years ago. Otherwise the history was negative. Physical Examination. The patient was very emaciated, pale, with prominent veins below the costal margin. The heart and lungs were negative. The liver extended 2 cm. below the right costal margin. The spleen was enlarged to the floor of the pelvis (18 cm. from the costal margin and 15 cm. in width).

Co m m e n t .

One could hardly make a mistake in the diagnosis of this case unless one were in the habit of relying on symptoms rather than on the results of physical examination. No one could fail to notice the abdominal tumor if he palpated the abdomen with any care. No one with any knowledge of phy­ sical examination could have any doubt that the tumor was due to splenic enlargement. Splenic enlargement associated with such evidence of anemia as this patient presents, is characteristic of three dis­ eases seen in temperate climates, and among those who have never visited the tropics. The huge “ague-cake” of chronic estivo-autumnal malaria and Kala-azar are not probable. Leukemia, splenic anemia and syphilis are the most probable diseases. Leukemia, however, can be instantly recognized by the blood examination. Wasserman. Negative. Hemoglobin 55% ; R.B.C. 2,820,000, W. B. C. 406,000, God 'Liver Oit Emulsions 229

Differential Polymorpho-nucleai' leucocytes ...... 44 per cent Small mononuclear ...... 2 Eosinophiles ...... 6 Neutrophiles ...... 38 Eosin ...... 3 Basophiles ...... 7

S u m m a r y .

1. Both patients were Korean females, 8 and 15 y e a rs of age. 2. Both patients showed a typical olive color tint of the skin. 3. The size of the first spleen was 14 cm. X 12 cm. The second 18 cm X 15 cm. 4. The number of polymorpho-neutrophiles in .both patients was greatly increased. 5. There was an increase in eosinophiles and eosinophilic neutrophiles were present. 6. The basophiles (mast cells) were present in consider­ able numbers. 7. The first case had a concomitant syphilis and as her symptoms all cleared up for a time under anti­ syphilitic treatment it is felt this disease may have been the cause of her leukemia. 8. The white blood cells in the second patient were rapidly increasing and her general condition was gradually becoming worse when she was dismissed from the hospital. 9. Both patients were hemophiliacs.

COD LIVER OIL EMULSIONS

J o h n C a m e r o n , Ph.C., F.C.S., M.P.S. (Lond.)

The whole subject of emulsions and emulsification is one which has so far received but little treatment in well-known text books, it is therefore a matter of extreme difficulty for the pharmacist to find any reference as to what and how much of the emulsifying agent should be u^d. Wiial ia the Utn! way 230 The China Medical Journal

to prepare an emulsion? When should acacia, and when should tragacanth be used? Which is the most economical method of preparing commonly used emulsions on a small scale? We have received a great deal of correspondence during the past few years from hospitals in other parts of China asking all kinds of questions concerning emulsions. We have also receiv­ ed correspondence pointing out that when the method we suggested for making a certain emulsion was tried out it was found impossible to make an emulsion which had keeping pro­ perties beyond a few hours. We have therefore decided to write this preliminary note on emulsions for the benefit of the hospitals scattered throughout this country and as Cod Liver Oil Emulsion is unfortunately one which will be common to them all we will confine our remarks to this emulsion and give details of some experiments we have conducted here which we trust will prove of some value. An emulsion is a system containing two liquid phases, one of which is dispersed in globules in the other. The liquid which is broken up into globules, in this case, the cod liver oil, is termed the dispersed phase, whilst the liquid surrounding the globules (water) is known as the continuous phase or dispers­ ing medium. The two liquids, which must be immiscible or nearly so, are frequently referred to as the internal and external phases re­ spectively. For the two liquids mentioned C.L.O. and water, two sets of emulsions are theoretically possible, depending upon whether the C.L.O. is dispersed in the water, or whether the water is dispersed in the C.L.O. Also there should be no reason why emulsions of any desired concentration should not be made of either liquid in the other. An oil and water, when, shaken together or otherwise agitated will produce a temporary emulsion, but as soon as the shaking ceases the drops of the respective liquids coalesce and separation into layers occurs—the oil usually forms the upper layer. It is possible however to prepare an emulsion of oil in water if a little oil is boiled with water under a reflux con­ denser but the concentration1 of the oil is somewhere about 1 in 10,000. This emulsion is only of theoretical impQrtance. Cod Liver Oil Emulsions 231

In order to prepare- concentrated and stable emulsions of the oil-in-wa.ter type a third substance is necessary— known as the emulsifier or emulsifying agent. The choice o f a good emulsifying agent depends on the type of emulsion required. The emulsifying agents used in the preparation of pharmaceutical emulsions intended for internal use are egg-yolk, Irish Moss, Casein, Gum Acacia, Gum Tragacanth, Malt Extract, Saponin, and Condensed Milk. Experiments on these various emulsifiers have been made by Marshall2 (Acacia) Roon and Oesper3 (Gum Tragacanth.) Fischer and Hooker4 (Casein, Agar, Egg-yolk)., and Hass5 (Irish Moss). Their results indicate that for an oil like C.L.O. the best emulsifying agents are (1) powdered gum acacia, (2) powdered gum tragacanth and (3) yolk of egg. Marshall'2 carried out some experiments on emulsifying power, and found that 1 gm. gum acacia in 4 c.c. water emulsified 21 c.c. almond oil. 1 gm. soft soap in 4 c.c. water emulsified 210 c.c. almond oil. 0.2 gm. saponin in 4 c.c. water emulsified 90 c.c. almond oil. and using the pharmaceutical method of trituration in a mortar he found that 200 c.c. of almond oil at 13°C. could be emulsified by the following quantities of different emulsifiers. Gum Acacia 10 gm. in 23 c.c. water Soft Soap 1 gm. in 3.8 c.c. water Saponin 0.2 gm. 9.6 c.c. water Condensed Milk 5 gm. in 20 c.c. water Crockett and Oesper6 found qualitatively that powdered gum tragacanth was - much inferior to gum acacia for pre­ paring pharmaceutical emulsions. Experiment has shown that in the case of C.L.O. the smaller the globules and the more perfectly they are coated with gum, the more stable is the resulting emulsion. 232 The China Medical Journal

We have conducted a series of experiments in the phar­ maceutical laboratories of the P.U.M.C. on C.L.O. emulsions to test out firstly which method would be the most practical in hospital pharmacies in China where power emulsifiers were out of the question and secondly which emulsifying agent yielded the best emulsion and thirdly which emulsions remained stable for the longest time.

M e t h o d s o f P r e p a r in g G ood E m u l s i o n s

(1) The English Method7 (or Wet Method) : The emulsifying agent, mucilage of acacia, yolk of egg, etc. is placed in a perfectly dry mortar, then small quantities of the C.L.O. and water are alternately added. The pestle is rapidly and lightly rotated in a counter clockwise manner. This causes the oil to be broken up into small globules which are enveloped by the emulsifying agent. Great care should be exercised in this method of making emulsions— the oil and water must be added slowly at the beginning and if an attempt is made to add more oil or water before the previous lot has been properly emulsified— the whole emulsion will crack and then no amount of rubbing will produce a satisfactory emulsion. It will be found on examining a drop of a cracked emulsion microscopical­ ly that many globules of unenveloped oil will be seen floating about. Possibly this may account for the failure of many hospitals to prepare emulsions of C.L.O. which will remain emulsified for periods of one or two weeks. A' crackedi emulsion is not useless and need not be thrown away as is so often done., The mortar should be thoroughly dried and then more mucilage placed in it and the cracked emulsion added to it little by little until all the oil has been properly emulsified. When mucilage of acacia is used in C.L.O. emulsions it must be freshly prepared, because it rapidly becomes acid on standing and is then absolutely useless as an emulsifying agent, acacia instead of the mucilage— especially during the summer In China we have found it advisable to use powdered gum months. This method of making emulsions is probably the best all round method to use in general prescription practice because the quantities of gum oil and water must necessarily vary greatly. Cod Liver Oil Emulsions 233

Exam ple:— 01. Morrhuae, ...... 60.0 Pulv. Acacia...... 15.0 Aq. Q.S. ad...... 120.0 Method:— Place all the powdered acacia in a perfectly dry mortar add 30 c.c. water and triturate secundum artem until the mucilage is very smooth and free from all lumps. The oil should be added in 2 c.c. lots— stirring rapidly with the pestle, after each addition and taking care that each 2 c.c. o f . oil is thoroughly mixed and properly emulsified before the next 2 c.c. are added. Sometimes the liquid becomes too thick to be easily stirred— if this should happen add 3 or 4 c.c. of water and keep stirring until the emulsion becomes thinner and workable—then continue adding the oil in 2 c.c. lots until all the oil required has been added and emulsified. If the emulsion has been properly made the‘remaining water may be added, stirring1 the emulsion all the time, without fear of any separation taking place. This method is perhaps slow and requires a great deal of patience and from our experience of Junior dispensers their attempt to rush the process is the cause of the majority of failures to produce good emulsions. (2) The Continental Method (or Dry Method) : For C.L.O. emulsions this method may be used. It depends on the fact that one part of powdered acacia triturated in a dry mortar with four parts of a fixed oil (C.L.O.) forms a perfect emulsion (nucleus) on the addition, with brisk stirring, of two parts of water, not gradually, but all at once. This method of making emulsions may be easily remembered from the formula.

oil water gum four two one Once this nucleus has been properly emulsified an addition­ al quantity of water, or of some salts dissolved in water, or syrup diluted with water may be added without fear of any separation taking place. Roon and Oesper" found, as we have found, that if these particular ratios were departed from, less stable or no emulsions resulted. They found that if the powdered gum were wet to begin with no satisfactory emulsion could be produced—it is essential therefore that the mortar be thoroughly dried before commencing to make an emulsion by 234 The China Medical' Journal

this method. A great deal of work has already been done by various workers9 to- formulate a satisfactory explanation for this method of emulsion making. There are many conflict­ ing opinions, but the generally accepted explanation is that the particlés of gum, bèing insoluble in the oil and surrounded by it, are prevented from separating and dissolving in the water so as to form lumpis ; by stirring the mixture actively’ the water gradually dissolves the gum, the oil becomes incorporated at the same time and a homogeneous mixture is produced-because the quantities of oil water and gum are present in exactly the correct proportions to form an emulsion. We have found that the continental method, using powder­ ed gum acacia gave the whitest emulsions. It is useful to remember that in-preparing emulsions of C.L.O. 1.5 gm. powdered acacia is equivalent to 4 e.c. of mucilage of acacia. It should be noted that unpowdered acacia t is much less expensive than commercial powder of the same quality; and where it is necessary to be economical the lump acacia should be purchased and ground to powder in the pharmacy. If mucilage is used— this should always be tested with litmus before incorporating into the emulsion as some acacias yield mucilages having a strong acid reaction. If the mucilage is acid it is customary to add a little liq. calcis sacch, to reduce the acidity to almost zero. Powdered Gum Tragacanth Method:— By common consent gum tragacanth is much inferior to gum acacia as an emulsifier. It does not assist the dispenser in breaking the oil into small globules as acacia gum does. If two emulsions are examined under the microscopc—A emulsified with acacia and B with tragacanth, it Will invariably be found that the oil globules in B are at least ten times as large as they are in A. Tragacanth however, we have found, has one great advantage oVèfc othór emulsifiers' in that an emulsion of C.L.O. -using powdéretì tragacanth as the emulsifier may be made in one quarter o f the time. ' Wé have found in China that tlie tragacanth method is the one most commonly used and possibly its use is associated with the fact that it is perhaps the method which entails the smallest amount of'labour and the minimum of time, Cod ■ Liber -Oil ^Emulsions5

1 We have exj&rimented with C.L.O. - tragacanth 'femuisions '' recently in order to find an emulsion which'could be easily made arid which had good keeping properties. We conducted these ■-> experiments in1 series using intone series varying amounts yof trag4acariih—in another varying amounts of alcohol - and ■ in ■ . another varying, amounts ’of both. . VWe emulsified r30,% C.L.O. in every case and- prepared -2000 c.c. of- emulsion-«so that -we , might be able ..to detect the slightest separation. .In order that . no, unknown factor, should enter into our experiments we used . oiLfrom an original 224 lb. tin which we opened specially for. these, series of experiments.

' The oil was fresh beeause we used a-tin-which’ had> been • delivered to us from abroad one week before we opened it. The tragacanth we used was supplied,-by.,a...well..known,.British Chemical House; we took an unopened original bottle and used this throughout. There could-therefore be no variation-in the oil or the tragacanth and -any-differences-we found must have been due "to the emulsifying - power of -the tragacanth : alone. Unfortunately all powdered tragacanth,. we have-found, from experience, does not possess the same emulsifying power. We have had pulv. tragacanth in stock here of which we had to use almost double the quantity, in. order to prepare satisfactory emulsions., We have never seen any reference to this variation in the literature— it is however engaging our attention. .

The -following recipe and method of making proved the- best' ' ' -

01. Morrhuae...... V. ^V. ”30.00 ' ' Pulv. Tragacanth...... ,.. ; .. .1.00; Syrup. Tolut...... -20.00 - / ) '■ Spt. Cinna,m...... - .. ... > . • • f’2.00 • - - - :-Alcohol 90?r. • ...... V r.. ,r 2 .0 0 • :.} Aq. ad...... 100.00

. ' M & t h p d Take a- perfectly drybottie of at least twice-the ;- capacity o f the total volume o f emulsion you .wish to prepare— add the' alcohol and spirit cinnamon then add the tragacanth in 'fine powder • and carefully shake until /there are no. lumps, visible—=a matter of a’few. minutes oiiiy. Next add alhthe water: quickly and shake thoroughly for a few minutes; Next add-the '. 236 The China Medical Journal syrup in small lots shaking thoroughly after each addition and lastly add the oil in small lots shaking all the time .until all the oil has been emulsified. We found that about fifteen minutes were required to prepare 2000 c.c. emulsion and about twenty- five minutes for 7000 c.c. The smaller bottle contained a better emulsion than the larger. The emulsion we prepared by this method showed no signs of separation six weeks after we had prepared it. In all the others separation took place in periods ranging between a few days and one month. It was interesting to note that the amount of separation was directly proportional to the quantity of powdered tragacanth used. The optimum quantity we found was one per cent. Tragacanth does not produce milky emulsions—they usually have a straw colour.

4. Yolk of Egg Method:—

01. Morrhuae...... 60.00 P. Tragacanth...... 0.3 Ovi Vitelli. one Aq. cinnam. ad...... 200.00

Take a perfectly dry mortar add the tragacanth and about 2 c.c. C.L.O. and mix thoroughly, next add the yolk of one egg, which has been carefully separated from the white stirring con­ stantly all the while, next add the C.L.O. in 5 c.c. lots at one time stirring constantly until all the oil has been added; some­ times the emulsion becomes too thick, if this is the case add a few drops of cinnamon water to thin it slightly. When the oil has all been added then add the remainder of the water.

We have found that the yolk of an egg itself is not suffici­ ent to produce a stable C.L.O. emulsion but with a little powder­ ed tragacanth a very good emulsion may be produced. C.L.O. emulsion prepared with egg yolk has a distinctly yellow colour.

In China where eggs are so cheap this method may perhaps have a certain appeal. W e used 10 yolks to emulsify 600 c.c. C.L.O.—the total volume of emulsion measuring 2000 c.c. This emulsion on standing separated into three distinct layers. We would suggest that where egg emulsions are used only suffi­ cient for one days requirements in the pharmacy should be prepared at one time. Cod Liver Oil Emulsions 237

T h e E co n o m ics of E m u l s io n M a k in g in C h i n a . Price Current in October 1929 (Peiping)

ITEM UNIT PRICE

1. Pnlv. Gum. Acacia. Lb. Mex. $0.80 2. Gum Acacia Lumps. Lb. Mex. $0.41 8. Pulv. Gum Tragacanth. Lb. Mex. $6.15 4. EggB (Peiping). 10 Mex. $0.25

“ Quantities and Prices for 2000 c.c. Emulsion”

ITEM AMOUNT PRICE

1. Acacia. 150 Gm. Mex. $0.26 2. Acacia (Lump). 150 Gm. Mex. $0.14 3. Tragacanth. 20 Gm. Mex. $0.27 4. Egg Yolk (10) 10 Yolks Mex. $0.25 5. Egg Yolk 10 and Trag. 10 + 3 Gm. Mex. $0.29

It will be seen that with the exception of the yolk and tragacanth mixture the price of emulsifier per 2000 c.c. is approximately the same. Eggs may be cheaper in other parts of China than they are in Peiping— the cost of the emulsion will be correspondingly less. It should be noted that using lump acacia almost halves the cost of the emulsifier. It must however be powdered in the pharmacy, and this takes time. Care should be exercised in purchasing the lump acacia as there are some varieties on the market of a reddish-brown colour which are poor in emulsifying properties. There are some varieties of lump acacia which are more expensive than powdered.

S u m m a r y 1. We have discussed the Wet method of making emul­ sions. This is the best method to use. in general prescription practice because the quantities of gum, oil and water required may vary. 2. We have discussed the Dry method of making emul­ sions. This method gives the whitest emulsions and we have found that the oil globules in these emulsions, when properly 238 The China Medical Journal

made are smaller in size than emulsions of C.L.O. .made with other emulsifying agents. This is therefore the “best” method

REFERENCES

1. Lewis. Koll. Zeits. 4. 211 (1909). 2. Ph. J. 28. 257 (1909). 3. J. Ind. Eng. Chem. 9. 156 (1917) 4. “ Pats and Fatty degeneration” (1917) 5. Ph.J. 106. 485 (1921). 6. Koll Zeits. 7. 208 (1910). 7. Remington’s Practice of Pharmacy. P. 1657. 8. J. Ind. Eng. Chem. 9. 156-161 (-1917). 9. Briggs, Pu. -Casse ancl Clark. J, Phys. Ghem. 24 14.7-100. (1920),.;:. Asphyxia in Laryngeal Diphtheria 239

CAUSE OF ASPHYXIA IN INTUBATION FOR LARYNGEAL DIPHTHERIA* Report of Case

T s e K i n g , M .D . Peking Union Medical College, Peping.

A girl (Wang, K.) aged four was admitted to the Peking Union Medical College Hospital on January 23, 1928. She had been well until January 3, when she developed fever, slight croupy cough, and hoarseness. On January 20, she began to have aphonia, severe dyspnoea and croupy cough followed by vomiting especially at night. On admission, three days later, she was in extreme respiratory distress. The family and past histories were irrelevent. Physical examination: A well developed and nourished child, lying in bed conscious, exhausted and markedly dyspnoeic. The skin was hot and flushed, but not cyanotic; a few excoriated, red papules were seen over the back and chest. The head' and neck were extended backward but not rigid. The throat was congested. On the right tonsil, anterior pillar, and posterior pharyngeal wall were patches of thick elevated grayish pseudo­ membrane surrounded by a narrow hyperemic zone. They were removed readily, exposing bleeding surfaces. The sub- maxillary lymph nodes were enlarged. During inspiration there were tenseness of the sternocleidomastoids and retraction of the yielding portions of the chest wall, lower ribs and sternum, episternal notch, and supraclavicular regions. Numerous moist rales were heard all over the chest but there was no dulness nor bronchial breathing. Kneejerks were not elicited; the white count was 20,000. (Poly. 97% ) On admission the temperature was 39.6°C., pulse 160, and respiration 54. The diagnosis of laryngeal diphtheria was made and con­ firmed bacteriologically by the presence of the Klebo-Loeffler bacilli in the smear and culture of throat swab. The specific serum therapy w as. given, and intubation performed. The relief of dyspnoea was almost immediate after a few expulsive coughing spells. Patient soon went into a sound sleep. How­ ever, shortly afterwards without any signs of struggling or

*Read before the Section of Otolaryngology at the XlXth. Biennial Conference of the China Medical Association, Shanghai, 1929. 240 The China Medical Journal

coughing, the familiar.quiet respiratory murmur became silent, the patient’s face turned bli^e, while the chest and abdominal walls bellowed up and down, in an effort to get air into the lungs. Death appeared imminent from asphyxia. But it was plain that there was no other way of relieving the patient’s suffocation than removing the intubation tube. This was done by pulling on the silk thread attached to the tube,, and anchored on the cheek. Subsequent investigation showed that the tube < j was tightly corked by a piece of diphtheritic membrane, the exposed part of which was too large to be admitted into the lumen. With the removal of the membrane further intubation was found unnecessary and the patient recovered uneventfully except for a little cough and husky voice which lasted for two months.

C o m m e n t This case‘illustrates the importance of constant attention to patients with intubation. As Morse has emphasized, “A child that has been intubated should never be left alone. There should, moreover always be some one constantly at hand able to take out and replace the tube” 1 Jackson tells us that while it is true that dyspnoea may increase gradually, the onset of asphyxia is usually sudden and the' last stage short.2 It is worthy to note that in analyzing 685 deaths in 1553 intubations at the Boston City Hospital; Place3 found four were due to clogging of the tube. Lastly one should keep in mind that collapse and death of patients with intubation may also be due to the reflex inhibition of the respiration and of the heart, from mechanical stimulation of the superior laryngeal nerve in the manipulation of the tube (.Crile)4.

REFERENCES

1. Morse, L. L.: Clinical Pediatrics, Philadelphia, W. B. Saunders Company, 1926, p. 410-411.

2. Jackson, C.: Bronchoscopy and Esophagoscopy, Ed. 2, Philadelphia, W. B. Saunders Company, 1927, p. 382.

3. Osier, William; and McCrae, Thomas: Modern Medicine, Ed. 3, London, Henry Kimptorn, 1:736.

4. Crile, J. W .: Experimental Research into the Surgery of the Respiratory System, Philadelphia, J. B. Lippincott Company, 1899, p. 101. After-Treatment of Incised Wound of Larynx 241

THE-AFTER TREATMENT OF INCISED WOUND OF THE LARYNX* Report of Case

T se K in g , M .D . Peking Union Medical College, Peping.

The following case of incised wound of the larynx is reported to illustrate the usefulness of the combined suction and open method in removing the mucous coming from the air passage and accumulating in the wound. The patient S. C. F., a farmer’s wife, aged 30 years, entered Peking Union Medical College Hospital, on October 23, 1927, for treatment of suicidal incised wound across the neck, of fifteen hours duration. She was conscious and quiet. The bleeding had stopped. The voice was not audible. There was a gap wound about 5 cm. wide, 12 cm. across, and deep enough to display the normally moving vocal cords a short distance from the peripheral end of the squarely divided larynx. Apparently the thyro-hyoid membrane was the seat of incision. Swallowing was not impaired, as food, or saliva did not escape into the wound. Under local anesthesia, the defects of the larynx and the skin were closed by sutures. Phonation was soon restored. October 26, the stitches did not hold. The wound again opened widely, and phonation was lost once more. On account of abundant, overflowing tracheo-bronchial mucous, the wound was not resutured. In order to keep the glottis as free as possible from being clogged, frequent renewal of gauze dressing and application of swabs were necessary, although such manipulations caused pain, great distress in breathing and violent coughing. October 29, the temperature was 40 °C. A low tracheotomy was done under local anesthesia. This was performed with the hope that in case edema should develop in the glottis, asphyxia would be prevented, as by that time patient had already obstruction through the inflamed larynx.

*Read before the Section on Otolaryngology at the XlXth. Biennial Conference of the China Medical Association, Shanghai, 1929. ' 242 -• The. 'Ckiim'M.e'dioal'.

October th^-i^ick' /n^op^b^ftiifirji^ 4tip by coughing or forced expiation.either'adh€redct,Q' tha'AVQund and[ the dressing, or re-entered into trachea-.on^ subsequent acts of coughing and inspiration, only a small portion 'being expelled out into the air. It was so profuse -that 'the -gause covering was practically at all times sHmy outside and-soaked inside. - The temperature . was 39°C. Patient looked exhausted. Morphia induced sleep ,and comfort to some extent. :-.;j : The Jftanagement of the excretion by wiping and- frequept change of dressing wasted & great deal of time and . gauze. J t was then decided to adopt aspiration as the best method of removing' the secretion and to'abandon all dressings. , November IQ, since the radical change of treatment was made. the. patient made strides in improvement in every way, so, much so that in seventeen days the original gap t and tracheotomy wound were healed with full restoration of the voice .and respirktory" freedom.

' • - _ C o m m e n t ■

, The outstanding. problem, besides making the patient com­ fortable, was to hasten healing of the open and infected wound. There was constant output of excessive tracheo-bronchial mucopus1 which' could- not' be raised -to the pharynx by the forced expiration cough reflex, and expectorated. As Jackson ^had remarked, “The accumulation may literally drown the. patient in his own secretion.” It is. plain that mucous secretion and coughing’ were closely related; excessive secretion necessitated frequent swabbing and wiping which would cause reflex coughing and. jDossible inhibition of the respiratory and the .cardiac action. These reflexes were shown by Crile1 to be due to Afferent impulses set up by mechanic irritation of the terminals of the superior laryngeal nerve. Therefore, attention should be directed toward the application of a method of painless ■and.-.thorough-removal of the secretion, and at the same time, the>prevention of-its accumulation. For the-first object, many authors have applied suction with success, and for the second, rBartlett2 emphasized the open method advocated by such authors as Rollier, Crile, and . Dyes. Glushak3 recently criticized the removal of discharge from any cavity for diagnostic or therapeutic .purpose with cotton and applicators by saying that it offer; the-following objections: . After-Treatment of Incised' Wound of Larynx 243

1. ’It. is painful to the patient. ' - r

2. The discharge can hardly be reached in remote depths or around corners.

Bartlett2 ably said that any form of dressing makes a pus poultice, and Sheehan4 briefly pointed out that i air and light are not conducive to infection, while bandages are. Concerning the coughing, although it is a physiological -pro­ tective of the tracheo-bronchial tree, the observations made by Archibald and Brown5 should not be overlooked in this case. They have discovered" that coughing was able to force the material deeper'in the tracheo-bronchial tree.

S u m m a r y

For treatment of incised wound of the larynx, open method and suction seem to be bettet than the closed method.

REFERENCES :

1. Crile, G. W .: Experimental research into the Surgery of the Respiratory Septem, Philadelphia, J. B. Lippineott Company, 1899.

2. Bartlett, W . : A fter Treatment of Surgical Patients., St. Louis, C. V. Mosby Company, 2: 410-432, 1921.

3.' Glushak, L.: Suction Apparatus with Specimen Collector, Laryngos- ■eopej 38:278 (Apr.) 1928.

4. Sheehan, J. E.: Reconstructive Surgery, Arch. Otolaryngol. 7:209 (Apr.) 1928.

5. Bi’own, A. L., Archibald, E.: Action of Cough on Material in Tracheo-bronchial Tract, Am. Rev. Tuberculosis 16:111 (Aug.) 1927; abstr., J. A. M. A. 89: 1634 (Nov. 5) 1927. Archibald, E.,. Brown., A. L .: Cough: Action on- Material in Tracheo-bronchial Tract, Arch. Surg. 16:169 (Jan., Part II) 1928, Abstr., J. A. M. A. 90:648 (Feb. 25). 1928. Editorial, J. A. M. A. 90:984 (Mar. 24) 1928. 244 The China Medical Journal

SEPTIC INFECTIONS OF THE KNEE JOINT*

T h o r n t o n S t e a r n s M.D.t F.A.C.S.

Shantung Christian University Hospital apd Medical School Tsinan, Shantung, China.

This is a group of septic infections of the knee joint treated on the surgical service of the Shantung Christian University Hospital during the past four years. ■ The^e are nineteen cases. We will consider them from the point of view of etiology*-length of time of injury before admission^ whether ,or,not thprs was an associated fracture, the treatment, and. the results. Etiology. With one exception, No. 19, a case of blood stream infection following. dysentery, the cause was gunshot or shrapnel wounds. Length of time of injury before admission. Excluding the case of long duration which had become chronic, No. 5, the average number, of days between the time of injury and admis­ sion to the hospital was fourteen. Association with or without fracture. There were nine cases with fracture into the joint. In one of these a usable though stiff leg resulted, 11%. There were seven amputations, 77 %. Two of the amputations were followed by death. There was a mortality of 33% among the cases associated with fracture into the joint. There were ten cases in which there was no fracture into the joint. Eight usable legs resulted, 80%, three of which had restoration of function, five were stiff. There were two amputations, 20% ; there were no deaths. Whether or not a fracture is associated with a knee joint infection materially affects the results as to usableness of the leg and mortality. Treatment. Single incision, with drainage by means of rubber tubes and two hourly injections with eusol was used in five cases. One resulted in a leg which could after six months be freely and painlessly flexed to a right angle, No. 3. Three resulted in fibrous ankylosis, the. patients could walk however; and one resulted in death. In this case both knee joints were infected, in one joint there was a fracture and gangrene appeared in the foot and lower leg on the fourth day, the

*Read before the Section of Orthopedics at the XlXth. Biennial Conference of the China Medical Association, Shanghai, February 1929. Septic Infections of the Knee Joint 245 patient died on the sixth day. The condition was so bad from the beginning that nothing less than double amputation upon admission would have saved him, as we see it now, and it is doubtful whether this would have been effective. With the exception of this last case there were no fractures in this group. Treated by single incision there was a good result in 80% the cases. Multiple incisions. There were ten cases in this group. Two or more incisions were made at the time of admission and succeeding ones from time to time as drainage became inade­ quate. At the first operation medial and lateral incisions were made, if .the drainage was inadequate incisions were made just within the hamstring tendons communicating with the original incisions into the synovial cavity. Tubes were inserted into the wounds and irrigations with eusol were carried out two hourly as a general rule. No tubes were inserted deeply into the joint cavity. Three of these cases, 30%, resulted in fibrous ankylosis, a comparatively good result. In six cases amputation was done to save the life of the patient, and in No. 18, amputa­ tion was aid vised in order to save the patient’s life but he refused and left the hospital. Of this group 70% came to the place where amputation was necessary in order to save life. Cotton’s method of joint irrigation. This procedure consists in irrigating the joint through a hole in the quadriceps pouch with 1 to 15000 corrosive sublimate solution. For details one should read the author’s account in the Journal of Bone and Joint Surgery Vol. 24, p. 395. Two cases were treated in this way. No. 9 was a blood stream infection following dysentery, as the patient was a hospital employee :he was easily followed, there was complete restoration of function. No. 19 was a gun­ shot wound of two days duration, after excision of the edges of the wounds of entrance and exit, one of which was in the quadriceps pouch, the irrigation was done through it, the wounds healed, the patient left the hospital after 14 days with complete restoration of function. Amputation. There -were 8 cases, 40%. Two died, one twenty days after amputation which was done forty-four days after admission. On entrance the patient was in good condition and had amputation been done early in all probability he would not have died; there was an associated fracture of the patella. Although the drainage finally obtained after multiple incisions r 246 The China Medical- JowPml

was sufficient the general condition went down steadily so that'in order to save life-amputation was done, but it was too late, the -pati&nt died twenty days afterwards. Six of the eight eases ' were: associated with fracture into the joint. A ninth case, • No. 18, should be included in this group as the condition of the "patient made amputation necessary in order to save life but the patient refused and went home. There was an iritra- articular fracture in this case also.

Results.

a. Restoration of function. There were three: cases* 15%, all without fracture into the joint. Two of these cases were treated after the irrigation method of Cotton. The third was of one month’s duration upon admission, -there was a walled off pus pocket within the joint, which after wide drainage and irrigation cleared up, the patient is still under observation* after six months.

b. Fibrous ankylosis. Six cases, 31% , in which the legs were useful in walking. In one there was an intra-articular fracture. These six cases were treated by either single or multiple incisions.

c. Amputation. Eight cases, it should have been done in a ninth but the patient refused. In seven of these nine cases -there was intra-articular fracture. With the exception of one case, No. 12, operated upon the,day after admission,, ten days after the injury, the amputations were done on an average of 21 days after admission and 30 days after injury. There were two deaths in this group, excluding the case which refused amputation and went home in all probability to die. There were associated joint fractures in these two deaths.

d. Deaths. There were three in the entire series, a mortality of 15%. In one of them, No. 4, both knee joints were infected, there was an intra-articular fracture in one and gangrene of the foot and lower leg developed on the other side. Death was not unexpected since he came four days after injury. In No. 11, death, which took place 20 days after amputation, could in kll probability have been prevented had amputation not been deferred as long as it was, 44 days. The same is probably true of the third death in the series, No. 10, amputated 21 days after admission.' Septic Infections of the Knee Joint 247

Days Days HospitaU Days Age • JitioJogy N amber injury Treatment Hospital in Results to Fracture before Hosp. admission Amputation

1, 3656 27 Ct.S.W. 10 0 Single incision. 84 Fibrous ankylosis

2. 2705 23 12 0 99 - 27 )i ■

3.-1571 18 30 •' 0 99 82 Restoration function

4. .2673 22- „ 4 . 4 )9 6 Death

5. 2666 30 „ ' 2 yrs 0 >9 129 Fibrous ankylosis' *.

6. 4098 59 15 0 Multiple incisions 92 99

7. 5075 27 60 0 99 62 99

8. 4936 24 30 4 65 99

9. 4391 26 2 0 Cotton’s method 18 Restoration irrig. function

10. 5203 55 ,, 16 4 99 21 2° Death Amputation

11. 4113 46 9 4 Mult. Inc. & 44 64 99 Amputation 12. 4938 27 10 4 Amputation 1 54 W ell

13. 3800 ?3 20 4 Multi. Incis & 6 59 99 amputation 14. 2515 30 15 0 Multi. Incis & 12 40. amputation

15. 4121 32 2 4 Multi. Incis & 22 113 If amputation

16.; 224.1 23 1 4 Multi. Incis & 20 105 99 amputation

17.-1719 25 14 0 Multi. Incis & 21 60 99 amputation 18. 4079 55 „ 5 4 Multi. Incis 40 Disch.? death Amputation Blood refused Restoration 19.- 25 73 19 stream^ ■ 2 0 Cotton’s method 0 4 . function . infection of irrigation

G, od result Ankylosis Amputation Death

Fracfcures - 9 ^ 0 1(11%) 8(88%) 2 (22%) No F factures io 3(33%) 5(50%) 1(10%) 1 (19%)

Total 19 3(14%) 6(28%) 9(44%) 3(14-%)- 248 The China Medicai Journal

Conclusions. This group of cases indicates that where there ,,is an 'associated joint fracture, in 88% of the cases amputation is resorted to sooner or later, and that in order to save life it is necessary to do'the amputation'eafTjr; therefore one must consider amputation in every infected knee joint associated with intra-articular fracture as soon as the patient is admitted. In suppurative arthritis due to blood stream infection and in gunshot wounds where there is no fracture into the joint the irrigation method of Cotton gives excellent results. This method can only be used if the cases are seen early, within the first two or three days. In later cases not associated with fracture lateral and posterior incisions on each side of the joint give usable legs.

HEALTH PAST AND FUTURE*

J. G. V a u g h a n , M.D. New York City.

Health is one of the great key-words of progress. Disease has always been an enemy of success and achievement. It often places insurmountable bars before the individual blocking the attainment of his ideal; and it also desperately cripples the state or nation where it is allowed to run unchecked. Disease is a messenger of suffering and sorrow,—of blasted hopes and defeated ambitions. When one is stricken by disease he might well question why such a hateful thing is allowed in the world of a benevolent creator. However the benefits of free will of necessity entail the punishments for those violations of the laws of health which a man’s free will has elected for himself. Too often, it is ignorance which has brought this suffering upon himself and sorrow to his family and community. Not every one gripped and fettered by disease has the courage and genius to fight it successfully and rise to fame in spite of it. A few rare spirits have done it, and the pain of their struggles, and their fortitude give courage to ,,us all. Robert Louis Stevenson suffered from tuberculosis from early

*An .address delivered before the Wuhu University Club. Health Past and Future- 249

youth and finally succumbed to its steady inroads. He wrote sojne of his most famous stories, viz., “ Kidnapped,” “ Dr. Jekyl and Mr. Hyde,” and “Treasure Island” during bedridden periods when -his life was despaired of. Charles Lamb suffered from recurring attacks of insanity. His sister was similarly afflicted, and in an insane fit stabbed and killed her mother. Yet Charles Lamb produced essays and stories that have been classics for several generations, and have been notable for their poise and serenity and gentle humor. That famous story known to all of us telling of the origin-of the love for roast pork among the Chinese people came from a man who never knew when the light of reason might go out and. he would be sent to the mad­ house. Elizabeth Barrett Browning did some of her most brilliant work while suffering the ravages of tuberculosis. Emerson and Poe and De'Quincey and Sir Walter Scott and Keats all suffered from the same disease. Milton, to whom reading meant so much, suffered from blindness, and Beethoven whose genius for music made hearing seem the most precious of all senses gradually became completely deaf and yet there­ after produced sublime musical compositions. Caesar and Napoleon are both reputed to have suffered from epilepsy. But these are the rare exceptions of life. No one can deny that disease is the foe of achievement and few there are who can surmount its deadly restraints.

That disease in its dreaded and fearful forms is among us and sometimes very near to us, is a fact that needs no argument to prove, so painfully are we all aware of it. But in some places or among some classes of mankind it is working greater havoc than it is elsewhere. Why the difference? How can all mankind equally enjoy that highest degree of good health which now the most fortunate and favored ones enjoy?

There are two fundamental essentials if the inroads of disease and death are to be checked in: this land or in this com­ munity. The first is an intelligent, alert, and cooperative medical profession. This profession requires men of character and men of ability— men with the capacity of grow th . intel­ lectually and technically. Unless the medical profession attracts to its ranks promising young men and women, and unless they are adequately trained, and finally unless they are adequately compensated for their work, the first requirement cannot be met. 250 The China Medical Journal

The second essential for healthy homes and communities is intelligent public opinion in support of the ‘ medical ^profession. If the public conscience in health matters cannot be aroused to protect itself by carrying out the procedures advised by its medical expierts, then the case is hopeless. Confidènce and belief in the doctor and in the work he is trying to do is essential. It must be plain to all that he is not a mere money- getter but that he is an altruistic man o f science and that he has the welfare o f the people at heart. No one in the community has greater need o f public appreciation than he, and no one should -be more faithful than the doctor in order to déserve the confidence of his fellow citizens.

The record.: of health tragedies and of health progress through the centuries, is a fascinating story, and-the-reading of it .is full of profit for us to-day. Dr. K. C. Wang has shown us- through .his study of Chinese literature that as early as the tenth:, century B. G. there, existed in China some sort of a medical profession, and .that there was some intelligent differ­ entiation,, of diseases. Institutions are referred to that existed in the capital cfor the care of the deaf, dumb, blind, paralytic, deformed, and insane. During the Sui dynasty Sun Kung-yee is described-as courageously facing-a dread epidemic by gather­ ing the neglected sick into his courtyard and securing medicines and physicians for them.

The Nei Ching or Canon of Medicine, attributed to Huang Ti, B. C. 2697, is said to have anticipated Harvey’s epoch making discovery of the circulation of the blood by about 2000 years. Ranking with this most ancient writing is another by Chang Chung-kin g. This famous physician began the practice of medicine about 196 A.D. In his native village more than two thirds of the inhabitants died within ten years and 70% of the deaths was due to Typhoid Fever. He was so impressed with the severity of the epidemic that he determined to devote his time and energy to the study of this particular malady. As a result of his labors the immortal work, “Essay on Typhoid and Other Fevers,” (Shan Han Lun) was produced. During succeeding centuries this classic was repeatedly the storm center of discussion by numerous editors, scholars, and critics. Chang Chung-king in this voluminous treatise aban­ doned- the old philosophical attitude, o f discussing disease, and < introduced the clinical method, laying emphasis on physical " Health Past and Future 251

signs and symptoms. This ten volume work comprised 22 essays with 397 rules for the treatment of disease, and 113 prescriptions. He was perhaps the first in medical literature to direct the employment of enemas and very wisely warned against the use of drastic purgatives for constipation in Typhoid Fever.

With some notable exceptions, however, members of the medical profession in ancient China were rarely accorded any dignified position in society. Religion and astrology merged in the practice of healing, and superstition and chicanery were generally dominant. On account of this low estimate it is no wonder that doctors have often played a subordinate or secondary role in the treatment of patients. Dr. Wang gives a true picture of the old style Chinese practicioner of to-day He says, “Their prescriptions are viewed with suspicion, care­ fully examined, discussed and analyzed as to whether the medicine is cooling or heating, suitable or unsuitable for the patient. If in the opinion of the patient’s relatives or friends the medicine prescribed is not perfect, they will alter, remove some of the drugs mentioned, or will entirely reject it. Physicians have been called or dismissed at will. Two or three or even a dozen may be engaged at the same time. Only rarely is this for the purpose of consultation. Each writes a prescrip­ tion explaining the supposed cause of the illness, and his duty is done. The richer the family the mors numerous the doctors. Frequently half a dozen are waiting in the home for their turn in examining the patient. When each has written his prescrip­ tion the relatives and friends will hold a consultation and pass sentence on the relative merits or defects of all the prescriptions, and then one will be sent to the druggist for dispensing.”

The history of some of the terrible epidemics of the past should be sufficient stimulus to some of these laggard com­ munities to give them zeal in building the necessary barriers against disease. Between the eleventh and fifteenth centuries at least 30 minor epidemics of Bubonic plague appeared in different parts of Europe. In 1720 an important epidemic was traced from Syria to Marseilles where 86,000 people fell victims to the disease. A few years later during the epidemic of 1770-71 probably 80,000 persons died in Moscow alone. Early in the nineteenth century Constantinople became the seat of two severe epidemics— one in 1803 with 150,000 deaths, ■ and 252 The China Medical Journal

another ten years later which took 110,000 lives. But probably the worst record in history of devastation from Bubonic Plague came during the years 1334 to 1351. It was traced from China to Italy and then to Germany, France, England, and Sweden. In China 13,000,000 people were reported to have died, and in the rest of the Far East nearly 24,000,000. After it reached Europe, moderate estimates place the loss in human lives at 25,000,000. Rivers were consecrated to receive corpses, for which none dared to perform the rites of burial. Death was on the sea as well as on the land, and the imagination is quickened to a realization of the terrible mortality by accounts of ships without crews—the crews dead or dying on the decks— drifting through the Mediterranean Sea, the Black Sea, and the North Sea, and cursing with contagion the shores on which wind or tide chanced to cast them. But we need not turn to the past centuries for records of terrible epidemics. The government records of British India show that during the Influenza epidemic of 1918-1919 eight and one half million people died of the disease. If we include the independent states, there were probably, in all of India, twelve to thirteen million deaths in the two years. No, the day of world epidemics is not yet gone. Deadly germs still find abundant hiding places throughout the earth waiting for the most favorable moment to come out for their attack. Only great skill and eternal vigilance can protect the unsuspecting millions of human beings who otherwise might be the victims of these deadly microscopic creatures.

But as we look back over the brief span of half a century, we see marvellous strides in the science of Health and Hygiene. Conditions in the United States can perhaps be regarded as fairly typical of those in France and Germany and England. There we find Typhoid Fever almost obliterated. This is large­ ly due to the purification of public water supplies, as our distinguished Engineer-President (Mayor Shao, president of the Wuhu University Club) knows so well from his extensive studies in England. An abundance of pure, germ-free, potable water for every citizen is one of the best safe-guards against Typhoid Fever. The enormous cost involved in providing this public water, when covered by the sale of municipal bonds and thus spread over a term of years, does not work any great hardship on the people. Health Past and Future 253

Tuberculosis in western countries is no longer the dread menace threatening every home that it was fifteen years ago. Education of the public concerning the simple facts as to the spread and prevention of the disease, has been a continuous program for the past ten or twenty years until now everyone knows that the cough and the sputum of one sick of lung disease is dangerous. Treatment of tuberculosis also— as well as prevention— has made remarkable progress. The story of the conquest of malaria is another thrilling record. The poor tiny little mosquito has had his photograph prominently placed in the medical rogues’ gallery and a price placed on his head until now every man’s hand is against him. Man in his unscrupulous fury against the little creature has even heartlessly laid his murderous campaign against the innocent baby mosquitoes in their little cradles, and has heart­ lessly killed the helpless babies by the million. One can only imagine what the mosquito sanitarians must be saying to their mosquito audiences as they try to explain the terrific infant mortality. Some day we will be keeping the few surviving mosquitoes in beautiful glass cages and feeding them dainty viands lest the race become entirely extinct. Long before that day Malaria will have vanished because we will have taught the mosquito better feeding habits, for we will have discovered a means of promoting the vegetarian habit among them. When this has been done then Yellow Fever as well as Malaria will have gone. Cholera is on the way to final captivity. Before Typhoid Fever goes Cholera will have gone. When one knows its vulner­ able points it is more easily conquered than Typhoid. While ranging free and unchecked it is a terrible foe, but with the knowledge that we have of its habits, it is fairly easily captured and subdued. Bubonic Plague once so dreaded, has now been for decades practically unknown in Europe and America and is being controlled in the Orient. The good work of the Plague Prevention Bureau of Peiping has yielded large fruitage. The prevention of Small-pox by vaccination is so simple that it is only a problem of offering free vaccination and of popularizing it with the people. In the Orient we are in the pioneer days of health and hygiene. It thrills one to think of the vast changes that soon will be wrought. What an opportunity and what a future 254 The China Medical Journal awaits the progressive and public spirited Sanitarian, and Physician in this country during the next twenty years. Fame and wealth of achievement lies before him, but like all pioneer work it will be accompanied with plenty of hard drudgery and much discouragement. The doctor of this new day is going to reduce the terrible infant mortality that hangs like a great mill-stone about the neck of womanhood in the Orient. The present wastage of little lives is appalling. New lives must be produced to fill the gaps, and so women from their early adolescent years to their old age at forty or forty-five must have the burden and the danger and the agony of constant repro­ duction. When that new day comes the oriental peasant home will look different. Poverty, wretchedness, and uncleanness will give place to sunshine, and health, and happiness. And in these healthy homes little children and infants will thrive. It is said that nothing reveals the social and hygienic conditions of national life more surely than its infant mortality record. In India during 1923 more than 1,500,000 infants died before reaching one year of age giving a mortality rate for all of India of 267 per 1,000. In the city o f Bombay the rate was 556 per thousand births. Contrast this with London’s rate of 75 per thousand. For China as a whole we have no statistics, but for Hongkong the rate is 290 which is practically four times the rate for London. No doubt in many parts of China the infant death rate exceeds 50% the Bombay rate. To check the preventable diseases— Tuberculosis, Typhoid Fever, Cholera, Dysentery, Small-pox, Leprosy, Venereal dis­ ease, and many more— the citizens of China need a government planned educational campaign. Groups of doctors should be organized in every province and furnished abundantly with demonstration and lecture material. They should travel exten­ sively through their provinces giving their message of disease prevention in a way that would get to the minds of the people. The great mass of common folks is the hope or despair of any country. If any great health movement is to succeed, it is worth while to get them behind it. Perhaps such a campaign is more essential in China to-day than hospitals. The splendid work done in the past by the Council on Health Education need« to expand and grow. When the vision of the possibilities of such efforts gets into the consciousness of China’s leaders, great things will come to pass. Health Past and Future 255

“There is no place for despondency or despair. As for the dour dyspeptics in mind and morals who sit idly croaking like ravens,— let them come into the arena, let them wrestle for their flesh and blood against the principalities and powers represented by bad air and worse houses, by drink and disease, by needless pain, and by the loss annually to the state of thousands of valuable lives— let them fight for the day when a man’s life shall be more precious than gold. Now, alas, the cheapness of life is every day’s tragedy.” (Osier)

CHOLERA IN CHINA. 1929

Among other centres in which cholera is important, we may mention the Chinese ports, where the situation has beeen worse than in 1928. The principal focus of the disease was Shanghai, which had been free from cholera since October 20th, 1928. The first new case occurred on July 19th, 1929, followed at fairly long intervals by a few other cases. The epidemic reached its height between August 4th and September 7th, and by the end of September had almost died down. Altogether, 177 deaths occurred between the beginning of the epidemic and October 5th, compared with 7 for the same period in 1928.

At Canton, there was also more cholera than in 1928, although there was no serious outbreak (28 cases up to September 7th, 1929, compared with 18 in 1928). There was also a small outbreak at Sivatow in the first three weeks of September, during which 36 deaths were recorded, making a total of 60 deaths up to that date, compared with 10 in 1928. Two further cases were notified during the first fortnight of September, at- N-ewchwang.

Epidemiological Report League of Nations Sept. 15, 1929. 256 The China Medical journal

Clinical Doles

TERATOMA OF THE OVARY

J. E. G o s s a r d , M.D., Foochow.

Mrs. L. K., aged 29, came to the hospital complaining of sterility. Upon admission, had a normal pulse, temperature and respiration. Woman rather short of stature, looks to be the picture of good health, about 26 years of age. So far as her general health is concerned she has nothing to complain of. She was born at a small place about fifty miles up country from Yenping City and is now the wife of a pastor. She has been married for five years; has never had malaria or typhoid fever. She had the ordinary diseases of childhood but no bad effects. Her menstrual history, regular thirty day type. She had one miscarriage three years ago at the fourth month. At that time the patient was very sick with a fever that followed. The trouble started from a fall, having accidentally stepped off a ladder five steps up from the floor. This started a flow from which she lost considerable blood. Previous to that time she had an amenorrhoea for four months and believed herself to be .pregnant. The patient says that the Chinese doctor in attendance did not expect her to live because of high temperature and rapid pulse. She states that she has had no pain in her abdomen or any discomfort since her recovery which was com­ plete by two months after.the miscarriage mentioned above. Examination: Head and neck, heart and lungs, negative. Abdomen, negative except for a superfluous amount of adipose tissue. Reflexes, normal. Vaginal: Uterus is markedly retroflexed; position firmly fixed; the left ovary and tube cannot be made out. Vagina shallow. Per rectum: a very hard substance can be felt to the right of the retroflexed uterus, the extent of which cannot be entirely calculated. No particular pain or discomfort is experienced by the patient when pressure is applied. Impression: Retroflexed uterus involved in old scar from pelvic cellulitis following miscarriage three years previous. Clinical Notes 257

Operation: Under ether anesthesia, the vaginal examina­ tion revealed the uterus to be both retroflexed and firmly fixed with some hard mass lying in relation to the fundus posteriorly. The cervix dilated and curetted as a preliminary operation. Abdominal section: Incision in median line through two and a half inches of fat. A tumor the size of a small duck’s egg was encountered behind and above the uterus. This tumor was firmly adherent to the fundus of the uterus, posterior surface of the bladder, right and left tube. The left ovary was not entirely free from the cicatrix. When a tenaculum forceps was applied to the tumor it was found to be difficult to hold due to being so firm. However one side was rather friable from which thin yellowish pus flowed. The tumor was lying slightly posterior to the broad ligament. The supporting structures were ligated and the tumor removed while abdominal sponges were used to prevent contamination of our wound by what appeared to be an infected tumor. The right tube was removed. The left tube though swollen and thickened was freed and left. Wherever adhesions were broken up bleeding took place and was difficult to control by ligature or stitching. Fine black silk was used for this. No 0 chromic gut was used where silk did not seem to apply. No 2 chromic gut was used to tie off the tube. The left ovary was about normal in size and should function. The right ovary was not to be found but seemed to have given place to the tumor. The abdomen was closed in the ordinary manner and drainage was placed in the lower margin. A rubber glove finger containing two two inch gauze drains was placed deep into the pelvis and out through the abdominal wound, and was removed forty-eight hours after the operation. Posl-opci atirc: The patient came out of the operating- room in good condition, with pulse 100 and respirations 26. One hour later the pulse went to 160 and respirations 38. Glucose and soda-bicarb proctoclysis was started. Meantime the patient was vomiting. No fluids were allowed by mouth. Four hours after the operation the pulse came to 104, respiiation 24 and temperature 99. The patient having been put into Fowler's position, the wound dressings were observed to be badly soiled and were changed. The dressing contained a large amount of bright red and serum blood. Morphia was given hypodermically at intervals during the night and 2 1/j c.c. of 258 The China Medical Journal

P. D. & Co.’s hemostatic serum was given intravenously. Proctoclysis was discontinued at convenient intervals. Hypo- dermoclysis was also used in an attempt to do away with the patient’s intense thirst when the temperature came to 101 and the* pulse 124, respirations 28, twenty-four hours after the operation. The patient stopped vomiting after the hypodermo- clysis took effect but the pulse remained high and she remained very restless, complained of a great deal of pain in the upper abdomen due to gas. Hot turpentine stupes were applied and the rectal tube inserted to bring relief. Codiene gr. 1/ 2 was substituted for morphia hypodermically and the patient seemed to get on better. The highest point reached was 102, thirty hours after the operation. After the drainage ceased to be profuse and the temperature became normal, the drainage wick was removed. A few hours later the temperature again rose to ICO.5 and stayed around 100 for the following fifteen hours, then came to normal and remained so for the rest of the patient’s stay in the hospital, a period of three weeks. The skin clips were removed on the seventh day after operation. An indura­ tion remained along the line of the incision, which seemed to be about the depth of the fatty area subcutaneously. No stitch abcesses formed.

Vaginal examination three weeks after operation: Cervix normal, uterus evidently attached to the abdominal wall, nothing palpable on the sides of the pelvis, no pain on examina­ tion. The scar of the wound is still somewhat indurated. The temperature is normal, blood pressure 124/100. When the patient stands she feels a drawing downward and inward at the top and the bottom of the abdominal scar.

Comments on results: The terrific reaction following the operation appears to have been due to liberation of the pus from the tumor which proved to be an infected teratoma. The question as to whether she is cured of sterility depends upon whether or not her left tube remains open. It was suggested ito her that she return for secondary operation to free adhesions. Clinical Notes 259

DERMOID CYST IN YOUNG GIRL

Case Report

A . C. SlDDA,LL, M.D., Canton.

Dermoid, cyst of the ovary is by no means a rare finding but the tender age of this patient may make this case worthy of reporting.

History— This patient was a Chinese girl, age 8 years and 2 months admitted to Canton Hospital October 14, 1929, with complaint of mass in abdomen. This mass was first noticed three months ago being then the size of an egg. It gradually enlarged to the size of fetal head at term and gave rise to no untoward symptoms. Except for measles several years ago and recent presence of ascaris lumbricoides in stools her past history was negative. Family history is negative except that her aunt had mass removed from abdomen weighing 12 pounds.

Examination— shows this patient to be well nourished and with no complaints except for presence of abdominal tumor, which occupies the midregion of the abdomen and is very movable, not tender and is fluctuant. Provisional diagnosis was ovarian cyst right side.

Operation— was performed October 17, 1929 under rectal oil-ether anesthesia and upon opening the abdomen through midlinfe incision a thin walled cyst of right ovary was exposed. The cyst was freed from adhesions and was excised after the narrow pedicle was ligated.

Pathological report— states that the cyst presents a thin translucent wall that is glistening and smooth over entire sur­ face. The cyst contains 650 cc. of clear watery fluid. One area of cyst wall is thickened to 5 mm. and the extent of this area measures 3 cm. in diameter. Upon cutting into this thickened portion of the wall a thin plate of bone is encountered under, which is a mass of coarse black hair imbedded in white sebaceous material. The hair grows from tissue simulating skin. No teeth present. Across one side of the cyst is stretched the tube that shows no gross changes.

Diagnosis—Simple dermoid cyst, right ovary. 26Ó The China Medical Journal

GUNSHOT WOUND OF CHEST Case Report

C. M . C a n r i g h t , M.D., Tzechow W. China. Uzao Bin ,Wu, age 25, Case No. 93. O.P.D. No. 1179. Admitted April 22, 1929, with a diagnosis of Gunshot wound of the chest, discharged June 11, 1929, cured. The patient received a bullet wound in the chest, the bullet entering tangentially from the patient’s right and the point of exit was medial to this over the manubrium and slightly to the left of the midline. The bullet in its passage through the tissues fractured the manubrium and large bronchus on the right, causing a fistula of the same. The fistula caused marked dyspnea at times and three or four times the patient’s life was entirely dispaired of. Our native physician attempted to draw the tissues together over the wound of exit without result. I later made an attempt to .do the same thing. I succeeded in getting the tissues approximated after a fashion but the patient again had an attack of marked dyspnea the next day and the upper sutures were removed. I noted a large amount of fluid exuding from the wound and had a nurse sit by the patient the rest of that day and with cotton applicators keep the wound dry. We did not dare remove the fractured piece of manubrium for fear the fistula would be increased in size. In a measure it served as a covering to a portion of the bronchus, that had been pierced by the passage of the bullet. It was noted that when the fluid was large in amount the patient found difficulty in breathing. The only possible way we could remove the fluid without special suction apparatus was the simple expedient of swabbing the fluid away as soon it accumulated by the use of the cotton applicator. To merely put an ordinary absorbent bandage upon the wound was not sufficient because it did not reach the depths of the wound where the fluid accumulated in largest amounts. On the other hand we felt that it was inadvisable to insert a drain since it acted as a foreign body in the bronchus and might introduce infection from without Whether our treatment was theoretically false or not ws will leave the critics to decide. The simple fact remains the patient got well in spite of, or because of our treatment. It was found that the only way he could sleep or rest with comfort was upon his back. This may be explained by the fact that the patient by sleeping upon his side would get a seepage of fluid into his bronchus causing coughing and dyspnea. The patient was dis­ charged after 50 days in hospital, cured.

Hospital Technology Section 261

Hospital Technology Section

A SUGGESTION CONCERNING THOMAS SPLINTS

Hugh L. R o b in s o n , M.D. Lintsing, Shantung.

In treating fractures with a Thomas splint, especially com­ pound ones, it is necessary that the wrapped padding of the circle end be dry and non-absorptive, to prevent maceration of the adjacent skin. In the interior of China we have been unable to buy waterproof leather. Our expedient is as fol­ lows:— Wrap the ring with cotton and roller bandage. Cut away one side of an old rubber hot-water bag and wrap the piece around the padding, stretching it tightly enough to avoid wrinkling on the inner side, with the approximation of the edges on the outside of the ring. Cover the overlapped edges with adhesive, and rub the droppings of a candle all over the adhesive. This gives a smooth water-shedding ring which patients have worn for months without becoming macerated.

PREPARING HANGING DROP PREPARATIONS

T. H. W i l l i a m s , M.D., C.M. Chengtu.

Having watched in many laboratories the messy method of smearing vaseline with a toothpick or match for hanging drop preparations I offer the following. Take a tube of surgeons lubricant and drive a needle or pin from without inward through the soft lead cap, remove the layer of cork from tjie inside of the cap and with the cap in position squeeze out a rope of vaseline from the tube. The thickness of the rope may be regulated by the size of the aperture and it is easily directed where needed. 262 The China Medical Journal

A SIMPLIFIED ANAEROBIC CULTURE METHOD

T . H . W il l i a m s , M.D., C.M. Chengtu.

Being in a situation where an anaerobic culture was wanted with a minimum of facilities I found the following quite satis­ factory. An ordinary 20 cc. all glass Luer syringe was fitted with about 4 inches of small rubber tubing firmly attached to the syringe delivery tip. This was sterilized, a piece of sterile tissue dropped in, the plunger was inserted and the seeded culture media, fluid or melted, drawn into the syringe through the sterile tubing. Inverting the syringe all air was driven off and the tube clamped. The whole was placed in a sterile con­ tainer and incubated. A very good growth of anaerobes resulted. This method has the advantage of being extremely easy to prepare, examination of the culture from time to time is greatly facilitated, and one can use it where there is no ice to chill paraffin covers or any facilities for air extraction. The evolution of gas is shown by pushing up of the plunger and tke amount is thus easily measured. For solid media it would be necessary to insert at time of examination a fine sterile tube through the syringe delivery tip to the face of the plunger which may then be withdrawn for finishing of the culture.

LABORATORY WORK IN AN INLAND HOSPITAL

Dr. H. G. W y a t t , Taiyuenfu.

The writer has experience of working inland amongst a people whc for the most part wish to be treated quickly with the Elixir of Life, and have no use for diagnostic and laboratory methods. It is still common to be giyen a pulse to feel, and to be expected to diagnose and treat from that alone without even a history. One must not forget, if one is to maintain the confidence of the patient, to feel both pulses. The hospital also works under financial stringency, and it is not possible to secure the services of a trained technician, who would expect a reason­ able wage. Below I have related my experiences working with Hospital Technology Section 263

a youth whose main qualification was his willingness. Foreign­ ers often regret the Chinese lack of loyalty to institutions and organizations. These to the Mens Sinica are often so many figments of the imagination. But with family and personal loyalties, the springs of devotion are touched, even by the mere foreigner in these advanced days. I mention this to stress some of the advantages of the locally-trained boy over the imported skilled technician. The other factor in the situation ^is that one has been absorbed in the many calls of hospital work, and has not spared more than half an hour a day to the laboratory, on an average. Routine tests have been done on urines only, and here the test for sugar has not been done except when specially called for. It is so rarely found. All other tests are done by request, this saving unnecessary expenditure of time and materials. Urine— Casts and the various types of cells are found without difficulty. A small hand centrifuge is necessary. Simple tests for bile salts, and blood take no time. B. Coli is found without trouble, and on occasion the B. Tuberculosis will be discoverable. Threads in the urine will point to the con­ dition of gleet, but the Gonococcus is not found easily from a thread floating in urine. Faeces—To those interested in curing Ascaris infections, this should be made an object of routine examination, and also by those contemplating opening the intestinal tract in cold blood. The various ova and worms present no difficulty, and acute amoebic dysentery presents a very typical picture. When it comes to labelling other classes of amoebae, and finding the amoebic dysentery carrier, one would prefer to pass the job on to an experienced worker. E. Coli should be easily dis­ tinguished, if not in the iodine stain, then certainly in the Haematoxylin stain. The B. Tuberculosis may also be found here too. Sputum— Here the most essential test, and one of the easiest is that for Phthisis. One has the impression that if the bacillus does not appear at the first examination, it is better to do a number of simple stains, rather than embark on some of the sedimentation methods for concentrating the possible organisms. The same stain will give the B. Leprae from a nasal scraping, although the scarcity of this disease in our district has defeated our efforts to find it. 264 The China Medical Journal

Blood— The differential count is easily done by anyone, and the estimation of the numbers of red and white cells is an art soon acquired with a little care in details. Leishmann’s stain is the speediest for general use, though it requires a little care in preparation. It needs to come from a good firm, and to be made with a pure Methyl alcohol and distilled water that is not acid. Finally the slide on which the smear is made must be clean, and the smear must be made with care. Given this, it is a miraculous stain. Malaria has not come our way recently, but Kalar Azar has. The latter requires a liver puncture. We have not had relapsing fever here, but it is easily diagnosed, when present. Both cases of Pernicious Anaemia and Myeloid Leukaemia have turned up lately, and one has been able to watch their progress through the microscope, the one uphill, and the other down. Pus and other discharges—The Carrel-Dakin treatment requires the estimation of organisms in pus. This is very speedily done. At times the yellow points of Actinomycosis may be found, and more frequently a mould or yeast growing beneath the protection of a black Chinese plaster. Our only case of Anthrax paid us only a fleeting visit in his travels with his skins. Gonorrhoeal Urethritis should certainly be checked up by the very easy search of a stained slide; and one should not let a Gonorrhoeal Ophthalmitis escape without diagnosing it by the same method. The recent Meningococcus epidemic brought us a case, whose spinal fluid rendered up its secret before we had heard of cases in other areas. Tuberculous Meningitis also has fairly definite signs. Exudates from serous cavities are worth examining, though often there is very little to learn. An early and unmedicated venereal sore will some­ times reveal the Sp. pallida, though most of our cases still come at the time of the secondary rash. We use Fontana’s stain. Cases of Diphtheria are often causes of worry to the busy doctor, particularly from the point of view of diagnosis. A positive result from the examination of a simple slide preparation is a rapid and very helpful thing, a negative one misleading to the unwary. Cultures on egg media are easily performed. We have not got an incubator, but find a large Thermos flask just as good. The top of the tube needs to be well sealed with paraffin. A swab from the mouth that reveals Vincent’s Angina makes a very pretty picture. Hospital Technology Section 265

Kahn test—We have been doing the Kahn test, and find it invaluable. It is so simple that it is worth while doing it for one or two specimens, which cannot be said for the Wassermann test. It has helped us in many difficult cases, where in earlier days we walked in ignorance, or got a report on the blood from the coast long after the patient had left us. The agglutination test for Typhoid fever performed with a small and cheap apparatus put up by the drug houses, is another easy and invaluable test. We often have a run of typhoid and typhus cases at the same time, some of which would be quite confusing without this test. It seems scientific to look at our ringworm hairs, but not of mu<5h benefit in the long run. A predecessor has left here apparatus for the estimation of urea in urine, and another for the estimation of albumen. Both are rather obsolete, but they are simple to work, and give a rough idea. Their greatest use is in following the progress of a case. Sections— We have a small hand microtome, and though it does, not give the neat results of the more expensive instruments, one can get thin sections from it. One must have the art of sharpening a knife, and the experience of diagnosing the section when obtained. Some are very clear, but others require experience to read. One hopes to use this little apparatus in the future as a check on Anal Fistulae that are possibly tuberculous. Dak ins solution— One of the side lines of the laboratory is to prepare Dakins solution, as suggested in the China Medical Journal. We use the town current, and find that it varies so much that we need to have a voltmeter on the apparatus, and a supply of fuse wire handy. The secret of avoiding the blowing of the fuses appears to lie in the fact that when started up the cell has very little resistance. Later on as bubbles form on the plates the resistance increases. This means that one must start up with all the resistance there is on the resistance frame. After five minutes one can cut out resistance until the voltmeter show.; the correct reading. 266 The China Medical Journal

All the above tests can soon be picked up by an intelligent boy, though the doctor would retain the work of diagnosis. The running expenses are not high. One cannot charge patients for laboratory tests, as they would as soon do without them. It is the doctor who needs them. But when an intelligent patient comes along and asks if he has phthisis, he is only too pleased to pay a dollar to obtain expert laboratory diagnosis, and here lies a small source for meeting some of the expense ^involved.

REFERENCES

Stitts Bacteriology.

Carrel-Dakin solution. China Medical Journal Jan., May, Oct. 1923 Mar. 1924.

Kahn Precipitation Test for Syphilis. China Medical Journal, XLI, 1004. Editorials 207

editorials

PLASMOMA OF THE CONJUNCTIVA

The Members of the Association are greatly indebted to Dr. Soudakoff for his masterly paper on Plasmoma of the Conjunctiva which we publish in this issue and for the excellent illustrations that accompany it.

There are few doctors in charge of large hospitals in this country, where eye diseases of all kinds are so common, but must have seen cases from time to time of this condition. We can probably speak for others as well as ourselves when we confess that the condition has always frankly puzzled us in regard to nomenclature, cause and treatment. Under these circumstances we greet with a sigh of relief a paper like this which takes up the condition, efficiently labels it, for we are all still human enough to hate an unlabelled disease, and tells us something about its origin and treatment.

Unfortunately Dr. Soudakoff still leaves us with a good deal to learn both as to causation and treatment. For ourselves we are not too well satisfied about the trachomatous origin of this condition. The cases we saw in a very trachomatous region were at least not strikingly affected with this disease.

As regards treatment too we must confess to some dis­ appointment, for though a careful excision is possible every­ where, radium is very seldom available in this country, and it is equally impossible to send patients from long distances to centres where this is to be had.

None the less we are very grateful to Dr. Soudakoff for placing us in a position where we can now concentrate on the recognition of a well-formulated disease and study for ourselves its causation and treatment. 268 The China, Medical Journal

PARATYPHOID C. We wish to draw special attention to a description of Paratyphoid C. in British Guiana by Dr. George Giglioli, very considerable extracts from which we publish in the Current Medical Literature Section of this issue. For one thing this is about the most detailed description of the disease that we have read. For another it shows that Paratyphoid C is at least fairly common in one tropical region. Further it would appear that in Dr. Giglioli’s experience mild and usually undiagnosed cases of the disease are even more common than the severe and frequently fatal cases. Lastly, and this seems to us the most important point of all Paratyphoid C. appears to run pari passu with Malaria and may very possibly account for at least one group from among the undifferentiated fevers, for it must be remembered that it is not common in blood examinations to agglutinate against this type of the enteric group of bacilli. If this were merely a problem for British Guiana our interest in it would be academic only. It must be remembered however that Paratyphoid C. has been shown to be present in China and is probably much less rare than is commonly sup­ posed. In an article in the China M-edical Journal (Vol. xli, p. 709) Hicks and Robertson mention nine cases in eighteen months, where serum sent to the Public Health Laboratory agglutinated Paratyphoid C. In only two cases both fatal, was it possible to follow up the patient and full details of one of these cases was given. It seems to us that this is a matter well worth a careful investigation to see if we cannot further reduce the still com­ paratively large group of undifferentiated fevers which are little credit to the profession in this country.

EIGHTH BIENNIAL CONFERENCE OF THE NATIONAL MEDICAL ASSOCIATION Owing to the time of going to press only a very brief notice of the National Medical Association’s Conference was possible in our February issue. In our present number we publish a short account of the proceedings. Editorials 269

Apart however from our congratulations to our Sister Association on a very successful gathering, more than one matter of special interest and importance to our own Association developed in the course of the meetings.

Membership in the National Medical Association is now thrown open to all doctors of proper professional standing without regard to race. This is a matter on which we would heartily congratulate the National Association as the best proof of its attaining maturity. In the past when foreign physicians considerably outnumbered Chinese physicians of the same standard of qualifications, it was manifestly impossible that this should be done without detracting from the truly “ National” nature of the Association. This was a most reasonable precaution of which no one could complain. Now however it can only be a matter of rejoicing that the Association feels itself strong enough to throw down the barriers, and welcome all comers.

Just how this new factor is to affect the position of our own China Medical Association is a problem for future and careful consideration which it will undoubtedly receive in the same friendly spirit that has always inspired the relationships between the two Associations.

The National Medical Association has graciously invited our own Association to unite with it at its next Biennial Conference to be held in Nanking in 1932. This matter had not been before the Executive Committee at the time when this Editorial was written, and the question will evidently have to be considered in connection with the date of our own forthcoming Conference which would naturally fall due in 1931. It is doubtful whether we could hold this and yet take an effective part in a Conference the following year. If the invitation therefore is accepted the question of postponing our own Conference will necessarily arise. The whole subject will be considered without delay.

As regards the union of the Journals, no actual progress was made beyond friendly conversations. Difficulties of distance and of overlapping contracts for advertisements have to be over­ come before this union can be consummated, and it is unlikely that these will be settled before the end of the present year. 270 The China Medical Journal

We are very glad to be able to close this Editorial with a piece of news that will rejoice all our members. To many of the leaders of the National Medical Association who have been members also of the China Medical Association our own Association owes much for constant sympathetic interest and wise advice on Committees and Councils. Indeed it would be difficult to conceive of the success of our Councils without their help. While comparisons would be invidious when so many wise in counsel have to be thanked, there is no one who, because of his position in Shanghai and his natural ability in such work has done more to help our Association than has Dr. Way Sung New; it is therefore a very special pleasure to announce his election as the new President of the National Medical Association.

MEMBERSHIP DUES

The Treasurer would remind the Members that Membership dues should be paid at the beginning of each year, and that it is of considerable assistance to the routine work of the Office if this is done promptly. Dues should be sent to

The Treasurer China Medical Association, P. 0. Box 1121, Shanghai.

It is of real importance that the name and address of the Member should accompany his dues. It would appear hardly necessary to state this but every year sums of money come to the Office, sometimes from abroad, with no indication as to the sender. Mr. Main is at present puzzling over a money order for $10 from Peping which has reached the Office with no indication of any kind as to w^ho sent it. If this catches the eye of the Doctor in question will he communicate at once with the Treasurer. Editorials 271

THE UNIVERSITY HOSPITAL, TSINAN

Settlement of the Strike We have very great pleasure in publishing in the Section devoted to Association News in this Journal an account from Dr. Heimburger of the settlement of the Hospital strike.

In our issue of last month we gave an account of this very disgraceful incident and rightly compared it with the similar treatment of the Canton Hospital some years ago. Here we are glad to say the similarity ends. The forcible closing of the Canton Hospital lasted for years, the closing of the Tsinan Hospital lasted for one month. As we pointed out last month the position of the Central Government at the time of the Canton affair was precarious and its authority away from the centre of Government was small. It is a clear sign of the enormous improvement of conditions in China since then that the Central Government has been both willing and able to exert its authority in Tsinan without great delay. We congratulate the Government on its action and we feel that it bodes well for the future of this country that the Central authorities should be able to bring a scandal of this nature to a close with a fair measure of promptitude. We believe that with the conclusion of the Tsinan trouble the door is closing rapidly to such affairs as provincial authorities will not care to allow themselves to be placed in such a false position in future.

The matter is now ended and we do not desire to call atten­ tion again to the puerile attitude of the Tsinan authorities. We cannot however close this note without an expression of our indebtedness to the National Medical Association for the steps that Association took to bring this matter to the notice of the Central Government. It is but another proof of the splendid solidarity of the best elements of our profession in China. 272 The China Medical Journal

China IDedical Association Section

THE UNIVERSITY HOSPITAL, TSINAN A Sequel

Just a month had passed since the University Hospital in Tsinan was compelled to close it’s doors because of a general strike among the employees of the Shantung Christian Univer­ sity. The events leading to this drastic action on the part of the Hospital administration are reported in the last number of the China Medical Journal *

Because of the splendid spirit and cooperation of the medical students, the professional staff and the clerical force, the medical school continued to function as the sole survivor of the University which has tried to serve China in an unselfish way for many years.

During the period covered by this present report, in which the days rolled on piling up rumors, uncertainties, and threats to persons and properties, the situation seemed to be approaching a worse condition than at first thought possible even by the most pessimistic. For days the strike leaders and pickets occupied strategic centers on the University campus and in the Medical compound, threatening with their blue striped poles and red, green and yellow posters any who dared to oppose them. Although the majority of the employees were unsym­ pathetic with the motives lying behind the strike and were willing to return to their positions without questions or demands, the power rested in the hands of the few, who without consent, occupied the University property. Forces of both police and gendarmes were constantly present on both campus and com­ pound but their authority was again and again questioned by the strike leaders thereby adding to the morale of the strikers.

On at least four separate occasions, after the persistent insistance of the Western members of the administrative staff for some action, the police in force visited the strikers demanding

" China Medical Journal Vol. 1-1, February 1930. China Medical Association Section 273

that they leave the premises. After each attempt the police returned to report that they could not persuade the strikers to evacuate the premises because the leaders refused to take any orders except from the Tang Pu or the Labor Union. Finally a number of the Western members of the staff, esqprted by members of the Pao An Twei (gendarmes) persuaded some of the strikers to leave two of the three places occupied. Thereupon the strikers swarmed to the only remaining place, the Hospital laundry (a detached unit in the Medical Com­ pound), which was made the official headquarters of the local Labor. Union and from which they refused to be moved. Seeing that both municipal and provincial forces were inadequate to enforce a just settlement of the strike, the University started a campaign, of publicity through the press. At first attempts were made to get the sympathy of the Chinese press but of the eight large newspapers of China which were approached only two, one a local foreign owned paper, the second a widely circulated and unbiased paper published in Hopei, accepted the articles and then published them. The remainder not only refused to accept the articles but criticised the University for asking them to receive such material. On the other hand when the papers printed in the English language were approached not only was the material faithfully published, but representatives were sent to observe and learn at first hand. The effect of this type of defense has been most effective as will be seen in the developments during the subsequent days. During this time requests were being sent constantly to both the Municipal and Provincial authorities for a speedy settlement of the strike. Promises were received in answer and orders were supposed to have been given that the ring-leaders were to be arrested, the pickets forced out of the Hospital Laundry, and thereby the strike settled. After each letter received from the authorities bearing these promises the ringleaders not only were more in evidence but were noticeably more aggressive. Nothing could be done but to let matters drift hoping that very soon public opinion would be able to overcome the power that held the reins. At times it was thought impossible to keep the medical school in session and that consular /protection must be asked. 274 The China Medical Journal

Finally on February 4th word was sent to the University authorities by the secretary to the Mayor of Tsinan, that a conference was wanted in order to formulate ways and means for settling- the strike. Early the next morning three represen­ tatives of the University met with the Mayor’s secretary and after several hours of deliberation the following items were agreed upon:— *

1. 39 workmen are to return to work. The question of whether or not they are to get an increase in wages is to be discussed individually. (The normal force of workmen is 165). 2. The other workmen, because of the closure of the Hospital and the Arts School, will each be given $3.00 travel money and allowed to go home. 11' their homes are at a great distance, this money may be increased.

3. When the Hospital and the Arts School are re-opened, these workmen may apply for positions and their applications will be given preference. 4. This agreement will go into effect from February 6th, 1930.

This agreement was submitted to the Labor Union by the Committee on Community Welfare, whose representative had met with us and had agreed, and a report brought back the same afternoon. On reporting from the Labor Union, several requests were made by the workmen but refused by the Univer­ sity. Thereupon signatures were affixed to the agreement in duplicate; the University authorities signing their part and the ring-leader of the strikers, with whom we were told we had no longer any dealings, signed for the Union! Arrangements were then made to give the promised “ travel money” to the strikers the following morning and it seemed that the suspense was over. When the pay window was opened the next morning, not only did all the pickets first appear in the corridor but also the six ringleaders. This was rather alarming because we had been told again and again by the Municipal authorities and the representative of the Tang Pu that these ringleaders.^were China Medical Association Section 275 entirely out of it and we had nothing- to fear from them. Never­ theless when the workers were invited to the window to receive their money they were restrained by these leaders. When approached by one of the Westerner administrators to discover the trouble, information was forthcoming that in the first place the list of names posted was not satisfactory. When told that according to the agreement which their representative had signed the University held the right to hire and discharge any workman they so desired this objection was withdrawn. Then we were informed that some of the workmen had not had their vacation during the year so they must be paid an extra two weeks wage. They were told that every opportunity was given to workmen to take their vacation with pay during the year but neither could we compel them to stop work nor had we any rule whereby they had been promised extra wages if they con­ tinued work. The ringleaders then said that because they had carried all the responsibility for the strike and were instrumental in the settlement they demanded a full month's pay. They were told that such a demand was impossible and also directly contrary to the agreement just signed. They then drove the strikers out saying they would still occupy the buildings until this month’s wage was forthcoming.

The office of the Municipal Government was immediately called by telephone and the responsibility for any further trouble placed upon the Mayer. Word was given that a representative of the Mayor would be at the University in a few minutes. He delayed coming, but after a lapse of about two hours twenty soldiers, fully equipped even to an execution sword, appeared on the Medical Compound and stacked their guns. Three hours later the representative from the Tang Pu appeared and said that it might now be easily settled if we added more names to the list we had published. Among the names he submitted were those we had purposely left off as undesirable workmen. This request was refused and the representative told that the list was final and that if things were not put right immediately the University would be compelled to take more drastic action and also that full publicity would be given to the affair. Immediate­ ly he told the workmen to accept their pay which was already prepared. But even then, the ringleaders grasping at a last 276 The China Medical Journal

straw, tried to make trouble through impossible demands and blocking the pay window. Whereupon the squad of soldiers were called in, bayonets fixed, and the workmen surrounded. With complete orderliness and rapidity they accepted the money and departed.

The following morning found the desirable workmen at their posts smiling and bowing as though the whole affair had never happened. The ringleaders still hung around for several days making threats to the workmen on duty but at the time of writing, almost ten days since the men were paid off, no trouble has been started.

The Out-patient department has been opened and running since February 10th and now preparations are being made to open the Hospital.

We are thankful that the enforced closure of the work has not been for a longer period and we now look forward to a more progressive and better Christian service to the community of Tsinan and China in general.

We are very grateful to the writers in the various news­ papers who have helped in giving the situation full publicity, to the delegation appointed by the National Medical Association for approaching the Central Government and to those who have personally or indirectly assisted us in solving this problem.

Our experience has clearly pointed out that a Central Government with decision and promptness can not only prevent a repetition of this affair but can settle like difficulties with great satisfaction to both sides. It is generally believed that after sufficient publicity was given and the attention of the Central Government Authorities drawn to the state of affairs in Tsinan, then the authorities directly responsible for conditions locally began to move and did the things which they could have done many days previous to the ultimate settlement.

L F. H e i m b u r g e r , M.D.

February 19, 1930. CHINA MEDICAL ASSOCIATION

Statem ent of Account for Y ear Ending December 3 1 st 1929 hn Mdcl soito Section Association Medical China RECEIPTS EXPENDITURE Balance from 1928 « j 734 Journal Printing Membership Dues ...... ’ ’ 3'945' $ 5,353.50 Office Printing ...... Subscriptions ...... ’ 283.90 Sales ...... ” ’ g'j'y' Salaries and Wages 12,619.00 Travelling ...... Advertisements ...... ’ ’ ' 0 160.94 Postage. Telegrams, etc. . . Conference ...... 2 098 899.76 Appropriations ...... Appropriations ...... 1 OHIO 1,150.00 Office Furnishings and Supplies (Rookefeller Foundation, $10,0001 ’ ' 106.80 Rent and T a x e s ...... Donations ...... An 982.63 Donations to I.H .T ...... ’ 2 1 (54' C o n f e r e n c e ...... 1,962.94 Dividends and Bank Interest .. . . !! | ’ l]o66! Commission on Advertisements 524.53 Interest on Overdraft Gain on exchange ...... ' ' ; 32.37 Repairs to furniture, etc. . . 20.30 Miscellaneous ...... $27,307.30 25.07 Loss on exchange 5.20 "Balance carried to 1930 3,180.30 277 Total $27,307.30 Audited and found correct

W a l t e r M il w a r p February 14th, 1930.

-Balance includes the sum of $2,164.56 to be paid over to the Institute of Hospital Technology. 278 The China Medical Journal

BRANCH ASSOCIATIONS South China Branch

The regular meeting of the South China Branch of the China Medical Association was held at the home of Dr. W. W. Cadbury on the campus of the Lingnan University on January 17, 19,30. The first part of the meeting was devoted to reports of officers of the past year and election of new officers and members.

The new members elected were: Dr. R. C. Miller, Dr. R. L. Lancaster, Dr. and Mrs. Gustav Canaval, Dr. Q. T. Jee, Dr. T. P. Lee, and Dr. Y. K. Chan.

Officers elected for the year 1930: President: Dr. P. Early Vice-President: Dr. A. C. Siddall ¡Secretary-Treasurer: Dr. Y. K. Chan Chairman of Program Committee: Dr. F. Oldt.

The second part of the meeting consisted of the presentation of the following papers:

1. Chronic Anhj^dremia, Dr. Dobson

2. Empyema, Dr. McDonald

3. The Practice of Medicine in China in the Future, Dr. Oldt 4. Vaginal Operative Treatment of Prolapsus Geni­ talis, Dr. N orth.. Announcement 279

Announcement

THE ELLA SACHS PLOTZ FOUNDATION FOR THE ADVANCEMENT OF SCIENTIFIC INVESTIGATION In their first statement regarding the purposes for which the Fund would be used, the Trustees expressed themselves as follow s: 1. For the present, researches will be favored that are directed towards the solution of problems in medicine and surgery or in branches of science bearing on medi­ cine and surgery. 2. As a rule, preference will be given to researches on a single problem or on closely allied problems; it is hoped that investigators in this and in other countries may be found, whose work on similar or related problems may be assisted so that more rapid progress may be made possible. 3. Grants may be used for the purchase of apparatus and supplies that are needed for special investigations, and for the payment of unusual expenses incident to such investigations, including technical assistance, but not for providing apparatus or materials which are or­ dinarily a part of laboratory equipment. Stipends for the support of investigators will be granted only under exceptional circumstances. In accordance with the policy outlined in paragraph 2, seven of the investigations which have been aided in 1929 bear on the general subject of nephritis, in 1928 there were three grants for wrork in this same field, and in each of the four pre­ ceding years four grants. Other general subjects, especially metabolic investigations and studies of the glands of internal secretion, have been favored by grants in successive years, but none to so great a degree as nephritis. Applications for grants to be held during the year 1930- 1931 must be in the hands of the Executive Committee before May 1, 1930. Applications must include statements as to the character of the proposed research, the amount of money requested, and the objects for which the money is to be expended. Applications should be sent to Dr. Joseph C. Aub, Hunting­ ton Memorial Hospital, 695 Huntington Avenue, Boston, Massachusetts. 280 The China. Medical Journal

Hospital Reports

PEIPING UNION MEDICAL COLLEGE HOSPITAL Twenty=First Annual Report for the Year Ending 30 Ju ne, 19 2 9

The-total number of patients admitted to the hospital was 5,071, of whom 4,528 were Chinese and 543 foreign, showing an increase of 563 admissions over the previous year. There have been 286 beds available in the hospital. The total of outpatients amounted to 141,968, an increase of 21 per cent.

There were 324 deaths in the hospital and while this seems a queer thing to congratulate a hospital upon, it appears to us the acid test of the confidence that the public place in such an institution in China. In the past owing to local customs and superstitions it has been in many places the habit to remove patients when the chance of their recovery seemed doubtful. To have got over that stage is perhaps the finest certificate that can be given to the success of the work. Ninety-six autopsies were performed.

Reports of the various departments are given in detail. Space makes it impossible to quote at any length from these but such a figure as 5,242 cases examined in the x ray department gives some idea of the work accomplished.

A note in the report of the Division of Parasitology strikes one as of more than usual interest. Natives of Hopei, Kiangsu, Honan and Hupeh who were not Cantonese by descent, were proved by repeated faecal examination to be undoubted hosts of Clonorchis sinensis. We wish the report had further stated w7hether these patients had ever visited the Kwangtung province or not. The usual tables of diseases are given at the end of the re­ port on the same plan as in the previous year, which was a considerable improvement on former tables. Hospital Reports 281

HUCHOW GENERAL HOSPITAL. M.E-F.B. 1928 Medical Staff: Drs Manget, Patterson, S. P. T ’sen, M. S. Tongs, K. F. Yao, D. P. Lien, F. V. Chen, Y. H. Yu. Nursing Staff: 2 Foreign and 7 Chinese Nurses; 56 Pupil Nurses. Inpatients 2455. Outpatients 1 3 .3 4 3 . This is one of the best hospital reports that we have read. Without entering into too much detail it gives a clear and con­ cise picture of the work of the institution, the field it attempts to cover and its special needs. The report opens with an interesting account of the plan­ ning and building of the hospital, following which is a description of the new plant. There follows a full list of the Staff after which are given brief accounts of the different departments and a summary of hospital statistics and balance sheets. The tables of statistics of diseases are very clearly given and excellent in their way but we dislike the separation of these statistics under the different departments. The absence of a general anatomical classification makes these tables of much less value for speedy reference. Also we trust that before long the hospital may see its way to provide statistics of outpatient diseases as well as inpatient. This would add greatly to the very valuable material that the report already provides. The Laboratory report is particularly interesting and here outpatients are included. The incidence of typhoid, 0.8 per cent of admissions, appears to be very low and the complete absence of paratyphoid infections seems strange. The numbers dealt with are too small to carry much significance but the fact is worth notice.

THE ORTHOPEDIC HOSPITAL OF SHANGHAI 1928-1929 Superintendent and Chief Surgeon Dr. Way Sung New. Resident Surgeon Dr. Annie P. A. Tseng. Welfare Director. Mrs W . S. New, M. A. Nursing Staff: Superintendent, 10 Graduate Nurses and 6 Pupil Nurses. Inpatients 500. Our very hearty congratulations are given to Dr. and Mrs. Way Sung New on the completion of thefirst year’s wrork of this much needed hospital. It must be seldom that a first year’s report is able to give an account of such a successful start. The 282 The China Medicai Journal hospital, as noted above, has had no fewer than 500 patients admitted with an expenditure of $26,420 and has succeeded in raising more than $21,000 of this sum leaving a deficit of only some $5000, of which over $4000 is allowance for deprecia­ tion. There axe few hospitals that can boast such a successful beginning and we feel sure that a generous public will not be long in meeting the deficit and the amount still owing ($35,400) on the capital expenditure for land and buildings. The report has an interesting table of statistics and accounts of the x ray and nursing departments; also some very excellent photographs. We must confess however to one disappointment. We have carefully searched the pages of the report for an account of the Welfare Director’s work and have failed entirely to find it. We trust that this omission will be rectified when the story of next year’s work is given. Again we congratulate the Superintendent and his Wife very heartily and feel sure that they will find in this splendid work their own reward for all the energy they have put into it.

SHOKA CHRISTIAN HOSPITAL FORMOSA. E. P. M. 1929

Medical Staff: Drs Landsborough, Mumford and two Formosan Doctors; Nursing Staff: i Foreign and 10 Formosan Nurses Beds 76. Inpatieuts 1,138. Outpatie ts 16.329. This is an interesting general report of the work of the hospital and of the problems that have to be met. One of these difficulties is, alas, getting too common in China also, viz. the unscrupulous use of the hypodermic syringe. A case is quoted of a man who was admitted for acute pneumonia and who, in the previous three days, had received thirty hypodermic in­ jections! With such n wealth of clinical material it is a great pity that no classification tables of diseases are found in this report. A real duty is owed by those w hose experience is so gieat in helping the advance of our scientific knowledge of the incidence of disease. Hospital Reports 283

CHIENGMAI LEPER ASYLUM, SIAM. 1928 Dr. J. Hugh Mackean. Average Number of Lepers in the Asylum 316

This is always one of the reports that we look forward to from year to year for its fund of interesting- narrative, its ex­ cellent makeup and the unfailing supply of good illustrations. The 1928 report is no exception to this rule.

The Asylum is under the direct patronage of His Majesty, the King of Siam, and the growth of the work is very remark­ able. For the first time in twenty years the Asylum has been compelled to turn away applicants for admission for want of accommodation.

The report opens with a brief survey of Leprosy in Siam from which we gather that the country has approximately 20,000 lepers in a population of less than ten million.,

It is interesting to note that “for some years past Tai- speaking leper patients from Yunnan have come to the Chieng- mai asylum in considerable numbers. They have come with great difficulty on foot over mountain trails, a journey of from twenty to twenty-eight days.”

Active work is provided for the lepers in vegetable and fruit, gardening on lands belonging to the asylum. 284 The China Medical Journal

Conferente Reports

NATIONAL MEDICAL ASSOCIATION OF CHINA

The Eighth Biennial Conference From February 2nd to 8th, 1930, the National .Medical Association of China held its Eighth Biennial Conference at the Chinese Y.M.C.A. Building, Szechuen Road, Shanghai.

Attendance. The Conference, which was attended by more than 300 delegates coming from different parts of China, made a record unprecedented on any previous occasion.

Papers, Its program was very elaborate, and consisted of quite a large number of titles of scientific papers read by delegates during the different sessions. The fact that during the conference, in addition to the general medical meetings, Physiology, Bacteriology and Pathology were also emphasized, indicated that the medical professon in China has now realized the importance of the fundamental sciences and that quite a number of medical men are preparing their career?, on laboratory subjects. It goes without question that laboratory science serves as a corner stone for the building up of scientific medicine. Since the Chinese Medical Profession has already realized this point of view and has commenced to work toward that direction, there will be very little doubt concerning itfc future outlook.

Joint Sessions. The Conference of the National Medical Association was held jointly with the Nurses Association of China and the Physiological Society. Among the many pro­ blems which were both interesting and important to both the Nurses Association of China and the National Medical Associa­ tion of China, were those of Nursing Education, Midwifery, etc. Special sessions were arranged in order to provide an opportunity for the nurses and doctors to exchange their opinions.

Resolutions, (a) Of all the resolutions passed during the conference, the most significant one was the problem of solving the difficult situation existing in the Medical College of the Cheloo University, Tsinan, Shantung. Dr. Peter Kiang, Pro- Conference Reports 285

fessor of the College and a member of the Association, gave a detailed account of the real situation. After careful delibera­ tion, it was unanimously voted that a petition asking for steps to be taken immediately for the restoration of order of the Medical College be submitted to the National Government and that two representatives be sent to Nanking to interview the Ministry of Health and the Ministry of Education. In view of the valuable service the Medical College of the Cheloo University had rendered to the country and the excellent contributions it . had made toward medical education, the members of the Associa­ tion keenly felt that it would be a tremendous loss to the country in general, and the medical profession in particular, if it were allowed to be suspended indefinitely. (b) Inasmuch as medical science has no national bound­ aries, another resolution was passed to the effect that any physicians, irrespective of their nationalities, are eligible to the regular membership of the National Medical Association of China provided that their qualifications could meet the re­ quirements of the Association. It is gratifying to note that quite a number of foreign physicians have already applied to the Association for membership. (c) In consequence of the popularity modern medicine enjoys, cases of dispute involving lawsuit are bound to arise from time to time. Without any medical legal protection, medical practitioners will naturally be exposed to great danger and can hardly expect arbitration from the judgment passed by the layman. Feeling the necessity of remedying the difficulty, a resolution was passed to create a Legal Medical Council, which will serve in an advisory capacity to the Government as well as to the Public.

Lectures by Distinguished Guests. Representing the Ministry of Health and one of the distinguished guests of the Association was Dr. J. Heng Liu. Dr. Liu gave a detailed re­ port of the work which the Ministry of Health had accomplished in the past year. He also expressed the hope that .the next Conference of the National Medical Association would be held in Nanking, the capital of China. Before he left, he extended an invitation to all the members to go to Nanking for an in­ spection of the Ministry of Health as well as of the City. The other honored guests .were Dr. Earle of the- Henry Lester 286 The China Medical Journal

Institute, Dr. Maxwell of the China Medical Association and Dr, Dunlap of the P.U.M.C., Peiping-. Dr. Earle is well known as a distinguished scientist who emphasized the importance of research on such fundamental subjects as Physiology, Bio- Chemistry, and Pharmacology, etc. Dr. Maxwell’, the honorary Executive Secretary of the China Medical Association, indicated the desirability of holding joint conferences between these two sister Associations and hoped that this proposition could be early materialized.

New Officers. It is with great pleasure we state that the Association has been able to secure as its Executive Officers for the next two years men of good professional standing. Dr. W.S. New, a pioneer worker of the Association as well as a member of the Executive Committee of the China Medical Association, makes him fit admirably as Chairman of the newly elected Executive Committee of the Association. Other mem­ bers who have been elected are Drs. H. P. Chu, M. Y. Tsu, T. K. M. Siao, K. C. Pang, K. Z. Faung, C. Fong, H. C. Chang, and C. W. Low, men of national and international reputation in the medical profession.

Medical Directory. In connection with the Second Edition of the Medical Directory issued on the occasion of the Eighth Biennial Conference, the name of Dr. H. P. Chu, Editor-in-chief of this Directory is gratefully mentioned. Dr. Chu has devoted practically all his time and energy toward this piece of work and has done all he possibly can to accelerate the publication of such a voluminous and complicated book within such a limited period. This edition which is about 500 pages in thickness comprises a series of descriptions of all the important medical institutions both in Shanghai and Peiping as well as the regulations of the Ministry of Health and its affiliated organiza­ tions. In addition, comprehensive and detailed lists of both the hospitals and individual doctors throughout China have been provided.

Medical Journal- The National Medical Journal since being transferred to Peiping under the able guidance of Dr. C. E. Lim, the Managing Editor, has been considerably improved in its contents. The circulation of this Journal is wide both at home and abroad. In consideration of the satisfactory service Dr. C. E. Lim has rendered to the Journal, it was unanimously Conference Reports 287 jresolved that he be re-elected to serve for another period of two years. In conclusion it is gratifying to state that taking everything into consideration the Eighth Biennial Conference has been a great success and thanks are due to all the ex-officers for the hard work and valuable service they rendered in bringing about the success of this specially important meeting. H. P. Chu, M.D.

NURSES ASSOCIATION OF CHINA Report of Conference, Shanghai. February 2=8, 1930

The Conference recently held in Shanghai was a time of great inspiration and encouragement. It was unique in two respects: first in that it marked the twenty-first anniversary of the founding of the Association; second in that it was held in conjunction with the National Medical Association at their invitation. The Conference opened with a Joint Reception held at the International Recreation Club, presided over by Dr. Siao, a well known practitioner of Shanghai. Miss Lillian Wu, Pre­ sident of the N.A.C. and several Doctors were among the speak­ ers. Dr. F. C. Yen in his speech stressed the interdependence of the two professions and expressed the hope that both would develop along together. The Meetings of the Nurses Association were held each morning at the Bridgman School and began with half an hour’s devotional service led by men nurses. The spirit throughout the Conference gave great cause for thankfulness. It was in the year 1909 that a group of missionary nurses met together to discuss the possibility of training Chinese nurses and preparing for China a modern nursing profession. In those days the idea seemed a mere dream but the group of pioneers believed that “with God nothing was impossible” and this text was later adopted as the motto of the Association. 288 The China Medical Journal

In 1912 the group met again and in 1915 the first ex­ amination was given to seven nurses, three of whom passed and gained the diploma of the Association.

At the 1930 Coming-of-Age Conference the delegates could not but realise the remarkable progress that has been made and how greatly God has blessed the efforts of the pioneers and leaders.

The Association now numbers nearly two thousand nurses holding its diploma, engaged in all branches of nursing ser­ vice. Three years ago there were nearly sev-en hundred missionary nurses in China, now there are only two hundred and that number is diminishing.

The Programme of the Conference was entirely Chinese and Chinese Nurses gave the papers, reading them first in Chinese, and then in English with equal facility.

The Officers of the Association are now Chinese Nurses, and at the request o f the Government the Headquarters is to be moved to Nanking where an Office has been allotted to Miss Mary Shih, the General Secretary, in the Ministry of Health Department.

An announcement that gave great satisfaction was to the effect that the Ministry of Health has appointed Miss Shih as Director of Nursing in China and presented her with the badge of the Ministry of Health.

Just as the nursing profession was the first profession in the world to form an International Association in 1899, so nurs­ ing is the first profession in China to be admitted to Interna­ tional relationships. In 1922 the Nurses Association of China was accepted as a full member of the International Council of Nurses which has its headquarters at Geneva, and one of the questions discussed at this Conference was the possibility of inviting the I.C.N. to China a few years hence.

Another topic of interest was the subject of registration of Nurses and of Nursing Schools. An address on this subject given by Dr. J. Heng Liu, the Vice-Minister of Health was listened to with keen attention. Dr Liu informed the Con- Conference Reports 289

ference that regulations for the registration of Graduate Nurses were being drawn up and he looked to the Association for help and suggestions.

With regard to the Nursing Schools they are required to register with the local Bureau of Education.

Dr. Liu congratulated the Association on the excellent work done in the past and expressed gratitude to the pioneers. He stated that in a year or two the Government hopes to take over the work of examinations.

At a later session Miss Mary Shih, the General Secretary, read the tentative regulations for the registration of qualified nurses which have been drawn up with her assistance and asked for suggestions to be sent in before the regulations are pub­ lished as compulsory. One of the proposed regulations pro­ hibited Nurses giving drugs without the order of a qualified physician.

At one of the sessions held in conjunction with the National Medical Association the subject discussed was “Mid­ wifery.” Dr. Marion Yang of Peping said that all school train­ ing midwives were to be registered before the end of 1930. Speaking of the dearth of qualified mid wives Dr. Yang strongly advocated some training in cleanliness and hygiene being given to the unqualified native midwives, a work that she herself is doing most successfully.

Among the distinguished guests of the Conference were Miss Goodrich, D. Sc. Dean of the Yale School of Nursing in Newhaven, U.S.A. and Miss Beard of the Rockefeller Founda­ tion, New York, both of whom were on their way to Peping from New York. The newly elected President of the Association is Miss Victoria Pon of Wuhu;. the Vice-president being Miss Hilda Wang of Peping, and the Chairman of the Educational Com­ mittee, Miss Irene Chu, R.N. of the Hunan Yale Hospital, Changsha. The next. Conference is to be held in Peping in the summer of 1932. „ - G. E. S, 290 The China Medicai Journal

Current IDedical Literature

PARATYPHOID C. IN BRITISH GUIANA Clinical and Epidemiological Notes

G eorge G ig l iq l i, M.D. (Italy), D. T. M. & H. (London).

I. C l i n i c a l D e s c r i p t i o n .

INCUBATION. No conclusive data were obtained to determine the length of incubation of the disease, in all cases the exact source of the infection was unknown.

ONSET.

Some cases give a history of several days of general malaise; more often the fever starts suddenly, with marked headache, lumbar and joint pains, and alimentary, mucous or bilious vomiting. Epistaxis was noted in three cases. The possible influence on this sudden mode of onset of a concomitant malaria infection must be considered in a high proportion of cases.

TEMPERATURE CURVE. Paratyphoid C. is eminently a “fever,” and its temperature curve constitutes its most characteristic symptom in spite of very considerable variability. It is typically a daily remittent or intermittent tempera­ ture; the fastigium varies from 100°F. to 105°F., and usually occurs in the afternoon. In a few cases a double fastigium is observed in twenty-four hours. The temperature falls during the evening and night often with profuse sweating, and is normal or nearly so in the morning. More rarely the fastigium may occur in the morning and defervescence in the afternoon. The daily rise of temperature may be accompanied by a slight chill, headache is constant, pains in the joints and lumbar re­ gions are eommon. In the protracted cases one frequently notes a marked irregularity in the temperature curve; the tempera­ ture falls to normal, or nearly so, for several days, to rise‘again to 103°F. ot 104°F. Current Medical Literature 291

The end of the febrile stage may be reached gradually by lysis, with a progressive fall a half to one degree daily in the afternoon rise of the temperature. Not rarely it is abrupt, the morning fall to normal not being followed, as usual, by a rise in the afternoon.

The same remittent or intermittent curve is found in cases of short duration, from three days to two weeks. Much more rarely the temperature may remain persistently high with only slight remissions; in such cases the lungs are usually involved, and secondary infections dominate the scene.

The height of the fever has little relation to the severity of the disease. Patients running high daily temperatures often present a good general appearance and difficulty may be ex­ perienced in persuading them to remain in hospital and in bed.

Ladder-shaped curves are frequent.

Descending ladders are commoner, more characteristic, and often associated with the most desperate cases. Death in an apyretic condition is frequent. In infants the same remitting or intermitting character is found in the temperature curve. In fatal cases both a ladder-like fall with collapse, and a ladder­ like rise with hyperpyrexia ancj convulsions, have been noted.

PULSE.

Dissociation of the pulse rate and temperature is frequent; rates of 92 and 100 with temperatures of 104 °F. have been observed. In serious cases, as in those with continuous high temperature and involvement of the lungs, persistent rates of 120 and more are common. A progressive ladder-like fall of temperature, accompanied by a progressive increase in the pulse rate to 140 or 150, is a frequent symptom of very grave pro­ gnosis. In algid cases, the pulse increases in rate during the fall of the temperature, and often cannot be felt at all.

GENERAL APPEARANCE.

There is nothing characteristic in the majority of the mild cases, even if of long duration. The appearance of the patient is unusually good. In serious cases, the sunken eyes and anxious delirious expression contrast with the classical apathetic listless appearance of serious typhoid fever cases. 292 The China Medical Journal

<5ASTR0-INTESTINAL SYMPTOMS. The tongue is not characteristic. In mild cases a thin white or yellowish coating is found; in serious and advanced cases the tongue may present a brown, parched, cracked surface. The apex, margins and papillae, show no special alterations. Vomit­ ing, often bilious, is a very frequent prodromal symptom; it rarely continues when the disease is established. It is con­ stant in cases in which paratypoid C. and malaria co-exist. Haematemesis was noted in one case a few hours before death. In another fatal case the stomach was full of coffee-ground matter after death. Abdominal pain is frequent during the early part of the disease. Intestinal symptoms are conspicuous by their absence. In a series of sevénty-two cases, bacteriologically confirmed, forty-three showed a perfectly normal intestinal function; seven were slightly constipated, and eighteen had diarrhoea at the time of admission. The latter condition persisted throughout the disease in one case, in the remainder it cleared up from the second to the fourth day after admission, and was constantly related to the abundant use of purges before entrance to hospital. The stools were plain, watery and brown. In a fur­ ther series of thirty-four cases in which the diagnosis was only clinical, twenty-five had a normal bowel function, seven were constipated, two had a transitory diarrhoea on admission. Haemorrhage from the bowel was not observed. A small amount of coffeeground material was found in the bowel in some instances after death. In infants, the disease appeared nearly constantly associated with the passage of green mucous stools, identical with those of summer diarrhoea. The liver was enlarged, usually passing the costal margin by one or two finger-breadths; it was often slightly tender; a subicteric tinge of the sclerae was common; marked jaundice occurred in the majority of fatal cases during the terminal stage. Bilious vomiting has already been mentioned.

RESPIRATORY SYSTEM. Epistaxis was noted in three cases, as a prodomal symptom. With the exception of the very slight, abortive cases, slight diffuse bronchial symptoms were the rule; fine crepitant rales were present particularly over the lower lobes. Cough was usually present, sometimes persistent, troublesome, and with Current Medical Literature 293

abundant muco-purulent expectoration. In the majority of rapidly fatal cases, the involvement of the lungs was much more important, with distinct basal broncho-pneumonic symptoms. In three cases, the whole clinical picture, as also the appearance of the lungs after death, was typical of lobar pneumonia, with per­ sistent high temperature and characteristic rusty sputum. In these cases, the diagnosis was made postmortem, the unusual appearance of the spleen requiring cultures to be taken. Bacillus paratyphosus C. was grown in pure culture. Smears from the sputum showed abundant staphylococci, streptococci and pneumococci. Isolation of B. paratyphosus C. from the sputum was attempted in two cases, but failed.

CIRCULATORY SYSTEM

No special symptoms were noted during the onset and course of the disease. The characters of the pulse have been described. Heart failure with dilatation of the right cavities was a characteristic terminal feature in fatal cases.

THE SPLEEN.

This was constantly enlarged. Usually, the lower pole reached the anterior axillary line, or could be palpated at the costal margin; in one case the lower pole passing the umbilicus. The organ was tender, sometimes painful. The possible in­ fluence of co-existing malaria must again be considered. But there is no doubt that enlargement of the spleen is a constant symptom of paratyphoid C. infection, though its degree is very variable.

GENITO-URINARY SYSTEM. Albuminuria was present in 60 per cent, of cases, the amount varying from a trace to y± or 1 per thousand. Sugar was absent. Biliary pigments were frequently present. In most cases the urine was clear, often with fine light flakes in suspension. In many a few leucocytes and scarce hyaline and granular casts were noted. In a few the urine was cloudy, gave an abundant sediment, with a large number of white cells, hyaline and granular casts, and very numerous caudate cells from the pelvic epithelium. B. paratyphosus C. was easily obtained in all cases in which culture was attempted during the course of the fever. B. coli was also constantly present, and was frequently cultivated from the renal pelvis after death. The China Medical Journal

NERVOUS SYSTEM Headache was constant, restlessness and delirium very fre­ quent in severe cases, the latter often of a wild type requiring careful watching and restraint. ^Delirium with apyrexia was frequent. Dysarthria was noted in several instances. Symp­ toms of meningeal irritation, with convulsions, retraction of the occiput, Kernig’s sign, retracted abdomen, vomiting, were twice noted in small children with a fatal issue, and once in a 15-year- old girl who survived. Hiccough was frequent and annoying. In two fatal cases it lasted uninterruptedly for four and five days respectively, resisting all therapeutic attempts, and per­ sisting throughout sleep. Insomnia was frequent.

RELAPSES. The tendency to successive relapses or exacerbations has already been noted in the description of the temperature curve of protracted cases. In two cases, relapses after periods of thirty and sixty-two days respectively were noted. While in the first the relapse was much more severe than the first attack and ended fatally, in the second it was slight, the fever only lasting three days. In both cases B. paratyphosus C. was isolat­ ed by haemoculture during the relapse.

COMPLICATION Complications of varied nature were noted. These can be classed into two main groups:— (A ) Complications due to Abnormal Localisation of the Specific Agent of the Disease. (1) Arthritis.— Two cases of suppurative arthritis of the shoulder joint were noted in infants of 3 and 8 1/» months re­ spectively. In one instance a plain serous arthritis of the right knee was observed. (2) Abscess.—A spontaneous abscess was observed in one instance only, as a postmortem finding in a 45-year-old East Indian woman. She had died on the day of disease with­ out having shown signs of renal complications. At autopsy both kidneys showed numerous retention cysts containing a clear fluid. On the left side a subcapsular abscess the size of a small walnut was found with a very well-defined round cavity Current Medical Literature 295.

and a fibrous wall. Its characters were those of a suppurated cyst. Gram-negative rods were found in the pus and B. paraty- phosus C. was grown in pure culture. The formation of large nxacion abscesses in the gluteal region at the site of intramus­ cular injections of quinine bihydrochloride was observed in twenty cases. Their endogenous nature was proved by the following:—

(1) B. paratyphosus C. was obtained in many cases by haemoculture before the administration of quinine by injection.

(2) Strict aseptic and antiseptic precautions were observed in the technique of the injections. Parke Davis & Co.'s ampoules were used exclusively.

(3) In no instance were abscesses observed in many hundreds of malaria patients treated by repeated injections of quinine.

(4) Formation of bilateral abscesses was noted when the injections had been bilateral.

(5) Gram-negative' short rods were found in the pus.

(6) B. paratyphosus C. was obtained in pure culture from the pus in all cases. In no instance were the common pyogenic cocci observed or isolated. The occurrence of abscesses at the site of hypodermic or intramuscular injections of various substances has been re­ ported in cases of B. typhosus infection. In our cases, quinine injection did not invariably cause the formation of an abscess. Fifty-nine patients suffering from paratyphoid C., simple or complicated with malaria fever, received quinine by intramus­ cular injection (one to three injections of 10 to 15 gr. each) in the upper and outer quadrant of the buttock. Of these twenty developed abscesses. Of the thirty-nine who did not develop abscesses fifteen died within five days from the date of admis­ sion. Nine died after longer periods (from six to thirty days) and fifteen recovered without any sign of local complication. The interval between the administration of the quinine in­ jections and the appearance of the abscesses varied between five and forty-three days, the average being twenty-one days. The clinical features of these abscesses are markedly characteristic, and can be summarised as follows:—

(1) The appearance of the local symptoms (abscess) is constantly preceded or accompanied by the fall of the temperature to normal, and a very marked improvement in the patient’s general condition, pointing to the onset of convalescence. 296 The China Medical Journal

(2) The evolution of the abscess is afebrile, in spite of very ex­ tensive local suppuration, in 75 per cent, of the cases observed.

(3) The whole process of evolution of the abscesses is practically painless, and accompanied with no local subjective symptom, with the ex­ ception of the appearance of a fluctuating tumefaction on the buttock. Patients affected with large bilateral abscesses will sit up in bed without difficulty, and not complain of discomfort. In the cases in which the abscesses have been purposely provoked, careful watch has to be kept, as the subjective symptoms are often so slight as to be overlooked by the patient; the condition might thus continue to evolve to an unnecessary degree, without proper attention. The anatomical appearance of the lesions, as noted at operation, is also characteristic.

The abscess is situated between the gluteus maximus and medius muscles, extending under the former, in many instances to the median line. In some cases, pus collections are found also among the deeper muscles of the region. No proper limited abscess cavity is found; the pus, which is always very abundant, fills and distends the intramuscular spaces, forming large pockets; the muscles appear slightly oedematous, of a bright red shiny colour. The pus is watery, of a dirty yellow, of uneven consistency, containing large rag-like fibrinous masses. No odour is noticeable. The microscopic examination of smears shows an enormous number of highly degenerated polymorphonuclear leucocytes. Gram-negative short and long rods are constantly observed, but in varying numbers: in some cases prolonged search is neces­ sary, in others they are abundant. In one instance, with mark­ ed tumefaction of the buttock, exploratory puncture produced a large amount of sero-fibrinous exudate, only very slightly cor- pusculated. The exudate became purulent in the following days.

In spite of their great extent, these abscesses respond rapidly to treatment, and heal completely in from two to three weeks. After incision and drainage of the pus, the wound com­ monly appears quite dry and clean at the following dressing. In several cases, while the temperature has been normal up to the time of operation, a slight rise may develop in the days following intervention. This can easily be explained through the operative trauma, local reabsorption of toxins through the opened vessels, and by slight secondary exogenous infection. The afebrile evolution of suppurative lesions due to B. paratyphosus C. appears to be a very noticeable characteristic; it was observed not only in these numerous cases of abscess, Current Medical Literature 297 but also in one of suppurating arthritis of the shoulder in an infant and in another of suppurating cholecystitis. (3) Cholecystitis.— Only one case was registered. (B.) Complications due to Concomitant or Secondary Morbid Conditions. (1) Malaria Fever, mainly of the benign tertian variety, was demonstrated by positive blood examination in 29 per cent, of cases. It is probable that malaria frequently accounted for the sudden onset I have described. The temperature, which was often high and irregular on admission usually acquired its typical remitting or intermitting character after two or three days of quinine treatment. (2) Suppurative Parotitis was noted in one case; Staphy­ lococcus aureus was present in the pus, and was grown in pure culture. (3) Boils were frequent.

(4) Adenitis of the groin and of the axillary glands with suppuration was noted in two cases, and S. aureus isolated.

(5) Bedsores were noted in one case only. In this instance they were very severe, extending to the sacrum, and the patient died on the forty-second day after admission. (6) Pyelonephritis.— The presence of abundant epithelial cells from the renal pelvis in the urinary sediment has been mentioned as a frequent finding. In one case pyelonephritic lesions were found and accounted for the fatal termination of the disease. JB. paratyphosus C., as we have seen, was present in the urine of most cases; but B. coli was found in the pus from this case, and was isolated from the renal pelvis of most cases after death. (7) Respiratory Complications.— I have collected no evidence that the respiratory conditions so prominent both in the clinical and anatomical picture of the disease, may bs imputable to its specific agent. It appears more probable that, as as in most other infectious diseases, the lung condition is secondary— due to the organisms of the respiratory tract, favoured by the conditions of diminish­ 298 The China Medical Journal

ed general and local resistance. The respiratory complications may take the upper hand in the clinical picture, sometimes masking totally the real primary character of the disease.

II. C l i n i c a l F o r m s .

^ Paratyphoid C., as seen in British Guiana, presents then a varied symptomatology. Our cases can be classified in the following elinical forms:— (1) Abortive and Plain Febrile Forms, of short duration, lasting from two to ten days, remittent or intermittent in type. (2) Protracted Forms, with remittent or intermittent pyrexia, without apparent localisation, are the most char­ acteristic: to them belong the cases I had noted and grouped under the provisional diagnosis of "intestinal fever” since 1923. The course of the cases is usually benign. In uncom­ plicated cases a fatal termination is rare: in rare instances without appearance of definite localisation, the condition may gradually and progressively decline. The fever may persist or fall to normal during the latter stages. In some instances death may be due to the suppurative complications described. (3) Algid Forms.— The fever is high with deep remissions to normal or subnormal. The fall of the temperature is accompanied by profuse cold sweats; the hands and feet are clammy and icy cold, the patient is pulseless, anxious, restless, and delirious; death occurs'in collapse. A progressive ladder- like fall may be noted in these cases, death occurring in apyrexia. (4) Pulmonary Forms with prevalent involvement of the bronchi and lungs; the physical chest symptoms are those of a plain bronchitis, lobar pneumonia or broncho-pneumonia. Nervous symptoms are usually marked with delirium and restlessness. The temperature is of a deeply remitting type. In one instance it remained persistently high.

I I I . D ifferential D i a g n o s i s .

In the abortive and slight forms, as also in the protracted cases with a daily intermittent temperature, malaria fever is the first disease to be considered. Double infection, as we have seen, is very common; a temperature resisting active quinine treatment, particularly if malaria parasites have been present in the blood, requires further investigation, Current Medical Literature

In the protracted forms of long duration, septic fever due to deep-seated suppuration and tuberculosis must be considered. ■ With typhoid, f,ever, the clinical diagnosis is mainly based cn the deeply remitting or intermitting character’ of the tem­ perature, on the absence of intestinal symptoms, and of the intestinal complications so frequent in real enteric (haemor­ rhage, perforation, tympanites). " 'a Prom the other parenteric fevers thé diagnosis, on purely clinical grounds, appears much more difficult and uncertain’ biit ho cases of paratyphosus A or B have còme under my; observa­ tion in British Guiana. In the algid cases, the clinical diagnosis from an algid form of pernicious malaria is practically impossible, and, owing to the urgency of the symptoms, I have always administered quinine by injection as early as possible. The diagnosis of pneumonic or broncho-pneumonic forms was obtained exclusively by cultures from the blood or from the spleen after death. In the bronchitic forms, the serious state of the patient, with delirium and high remittent temperature, is in contrast to the relatively slight lung lesions. Under this heading I again, wish to emphasise and insist on the following important points.:-— (a) The absolute necessity of routine haemoculture for the investigation of protracted quinine-resistent fevers of obscure nature. (b) The importance of repeating the Widal test, with T.A.B.C., and eventually other . emulsions of - the salmonella group of organisms at weekly intervals, and if necessary 'during convalescence. (c) The greater sensitiveness of the Widal and agglutina­ tion test and their more marked specificity (exclusion of group agglutination) by the vital or cultural method.

IV. P r o g n o s i s . This is invariably -good in the abortive and plain febrile forms. It is usually good in the protracted cases, but the possibility of renal or hepatic complications should be enter­ tained. It is favourable in cases with slight bronchial involve­ ment; grave in the pneumonic and broncho-pneumonic forms; unfavourable in algid forms. 300 The China Medical Journal

V. M o r t a l i t y . Of ninety-two cases of confirmed paratyphoid C., thirty-two died. The case mortality was therefore 38 per cent. During the period October, 1926, to June, 1928, paratyphoid C. accounted for S3 per cent, of deaths from all diseases registered in Mackenzie Hospital. Though these figures give an accurate idea of the mortality as seen in hospital practice, they certainly do not correspond to the actual local mortality rate pf the disease. The great mass of abortive, slight and mild protracted cases, undoubtedly pass unobserved, as they never apply for treatment, or are seen only as out-patients, and not correctly diagnosed. Such cases can only be recognised by being kept under careful observation, and by laboratory methods. Such mild cases as were detected all occurred amongst employees of the Company, who are obliged to report to the medical officers when ill. The actual mortality should be considerably lower than our hospital statistics show. The association of the disease with malaria infection, which was evident in 29 per cent, of our cases, must also be considered as an aggravating condition. During the period November, 1926, to August, 1927, the disease not only appeared in epidemic form in the district, but showed a very marked increase in its virulence. There were registered eighty-two cases, with thirty-two deaths (39 per cent.) ; of thirty-five cases which were admitted to our hospital during the period January, 1923, to October, 1926, no fatality was recorded. From August, 1927, to June, 1928, the epidemic having subsided, the virulence of the disease equally decreased. Of twelve cases admitted only two (16.6 per cent.) died.

V . E pidemiology .

RELATION TO METEOROLOGICAL CONDITIONS AND SEASONAL INCIDENCE.

Table II shows no particular relationship between the rain­ fall and average mean temperature as registered at Mackenzie, and the number of cases of paratyphoid C. observed month by month from 1923 to June, 1928, with the exception of a marked decline in the incidence of the disease during the first half of the drought year 1924 and 1926. Cases occur more or less all the year round, but there is a decided increase during the winter Current Medical Literature 301

months from November to May. June and July show the lowest incidence.

MODE OF SPREAD OF INFECTION. No evidence was collected to incriminate the water supply. Milk is very scarce in the district; infection of food has been excluded above. Fli-es, never very abundant, were decidedly scarce at the height of the epidemic. Carriers, in form of abortive cases, slight ambulatory infections simulating malaria fever, and convalescent cases, are- the most likely means of distribution of the infection, by more or less direct contact.

We have seen how constantly and persistently B. para- typhosus C. was found in the urine of patients. I believe that urine is the most dangerous means of spread of the disease, not only on account of the large number of bacilli it harbours, but also in relation to the very insanitary habits of the population in this respect. The general state of sewage disposal in the district has been mentioned. Though some precaution is usually taken for the disposal of night soil, none whatever is taken as regards urine. Particularly during the night, urine is voided from the back steps of the houses, or anywhere in their im­ mediate vicinity. Frequently on the same steps the meals are prepared, and the small children play and roll about on the polluted ground. During the rainy months the soil around the houses is moist and muddy, and the sun’s rays weak; the survival of virulent organisms is thus favoured.

A small outbreak of five cases of paratyphoid C. in a very insanitary section of the village of Christianburg in May, 1928, gave a clear illustration of the importance of contact in the spread of the disease versus water pollution. The village had been flooded for some time, as the effect of heavy rains and spring tides. The creek which flows through it, and is the main source of the drinking water, was in direct connection with a large number of flooded pit latrines. The drain waters from the roads and the house yards flowed into this same creek, and in it as usual the children bathed and the women washed clothes. The high degree of faecal pollution of this water was demon­ strated at the time by a widespread outbreak of diarrhoea, with numerous cases of bacillary dysentery. The five cases of paratyphoid C. recorded, all occurred in a small block of houses, situated in a radius of about 50 yards at the following 302 The China Medical Journal intervals'¡“ Seventeen, eleven, two and five,days frOm-'lOth April, 1928. In spite of ample pollution of the creek from ..this particular block, no other case of paratyphoid C. was found in the rest of the village. - - -

EPIDEMIOLOGICAL RELATION OF PARATYPHOID C. TO MALARIA FEVER. Though the period of observation is short, and it in certainly premature to draw any definite conclusions, there appears to be a marked relation between the incidence of ^paratyphoid C. and malaria.

K e n n a r d has reported on continued fever amongst sugar plantation, coolies. Most medical men in the colony are familiar with cases of prolonged daily remittent or intermittent, qiiinme- resistant pyrexia-s, which give anegative T.A.B. Widal reaction! Recently, I carried out a Widal test (by the cultural method)" on the serum of a medical man residing in Georgetown, who had suffered from a similar disease six months previously. 1 obtained very definite agglutination for B. paratyphosus C. in a dilution of 1:100. . From what we have said of the relative incidence of para­ typhoid C. and of malaria fever, it appears likely that the distribution of the two diseases throughout the Colony will be found to coincide.

. . VII. T r e a t m e n t .

d i e t . ' - The diet need not be as strict as in enteric, and other parenteric fevers, as the intestinal tract is not specially involved; During convalescence the patients can soon be put on a .varied and nutritious diet.

. GENERAL TREATMENT. : ' Generaltreatment is symptomatic, and carried out on the same general lines as for enteric.

r FIXATION ABSCESSES. The formation of abscesses giving a pure culture of B. pam- kyphosus C., at the..site of intramuscular quinine injections, has .been, mentioned as a frequent complication of the,, disease, The first cases, were accidental, and developed in cases showing a double paratyphoid-malaria infection, which had received Gmmnt Medical Literature

.quinine injections for the treatment of the latter condition. With the .first appearance of signs of localisation of the infection at the site of injection, it was noticed that the general symptoms invariably cleared up and convalescence began, often in spite .of extensive suppurative lesions between the gluteal muscles. , In some ; cases the transformation of the disease from a virulent septicaemia to a mild and localised suppurative con­ dition was very striking. On the strength of these observations, it was considered justifiable to try to induce a fixation abscess by intramuscular injection of quinine, even in the absence , of a inalarial complication, in cases in which the disease appeared ,in a dangerous form.

By administering quinine by intramuscular injection, we do not provoke the formation of a chemical abscess as is often the case with thé injection of turpentine; we simply cause a slight, and in itself in no way harmful, irritation of the tissues, which may determine the localisation of the infection, if the complex conditions of individual resistance of the patient, and of virulence of the infection, are such as to favour such an issue. In the case of hypervirulent infections the disease evolves rapidly to its fatal termination, however, great the local tissue irritation ■we may produce; 011 the other hand, in mild cases the organic defensive resources will be sufficient to resist not only the general infection, but also the localisation of the infection in tissues only mildly irritated, as in the case of quinine injection. In conclusion, I believe that as a provocative of fixation abscesses, in paratyphoid C. at any rate, quinine by intramuscular injection, through the mildness of the irritation it determines, has the advantage of lim itingits action to those cases which are most apt to be benefited by abscess fixation. The interesting clinical characteristics of these abscesses, their -extremely mild symptomatology, and their immediate response to simple surgical treatment, have already been discussed, Out of fifty-nine severe cases (complicated or not with malaria fever) which received one or more intramuscular quinine injections, fifteen (25.4 per cent.) died within the first five days after admission; nine (15.2 per cent.) died after longer periods, without developing symptoms at the site of injection; fifteen (25.4 per cent.) recovered without local complications; and twenty (34 per cent.) developed fixation abscesses at the site of injection. Of the latter eighteen recovered and two died. Of 304 Thè China Medicai Journal

these, one died on the twenty-fourth day of the disease with bilateral pyelonephritis, and the other on the forty-second day with extensive sacral sores and left pyonephrosis. In both these cases the septicaemic phase of the disease had been overcome; death followed the onset of secondary complications. Amongst cases in which an abscess was produced, the mortality was only 10 per cent, (from secondary complications) against a general case mortality of 37 per cent. The indication for the induction of a fixation abscess appears most marked in the severe purely septicaemic cases with marked delirium and high temperatures; in these, the disease is usually and rapidly cut short in the week following the injection. There is little chance of success in the cases of severe pneumonic or algid forms, in which the rapid evolution of the disease will rarely allow time for the formation of an abscess. In such cases the use of turpentine as a provocative agent might be more appropriate. From what precedes, it appears evident that in presence of slight paratyphoid infections, with malaria as a complication, quinine should be administered per os and not by injection, in order to avoid the risk of determining an abscess, which, in a mild form of the disease, would be a totally unnecessary and annoying complication. Transactions of the Roy. Soc. of Trop. Med. and Hyg., November, 1929.

POSTVACCINAL ENCEPHALITIS Charles Armstrong, Surgeon, United States Public Health Service The occasional occurrence of acute nervous manifestations following acute infections, such as smallpox, chicken pox, measles, mumps, et., has been known for a long time; and there is an impression among many that they are relatively on the increase. These ailments, to which the so-called encephalitis which occasionally follows vaccination also belongs, constitute a group strikingly similar in their epidemiology, symptomatology, and pathology. Current Medical Literature 305

Encephalities as a complication of vaccination against smallpox first came into prominence in Europe in 1922, when 11 fatal cases developed in London. Four of these cases, all fatal were admitted to the London hospital, where the pathologist. Dr. Turnbull, recognized them as pathologically similar to a case which had come to his attention in 1912. The following year, 1923, some 53 cases were recognized in England. Holland was also severely hit. To date, England has reported nearly 100 cases, Holland nearly 150, and Germany 34. Sporadic cases have also occurred in Portugal, France, Switzer­ land, Poland* Austria, Czechoslavakia, Italy, and other countries. In Germany there has been 1 case to approximately every 700,000 vaccinations; in England 1 to 48,000, and in Holland 1 to 4,000. The importance of the complication in England is attested by the fact that it has been made the subject for study by two eminent commissions. In Holland, moreover, it has led to the temporary suspension of compulsory vaccination. Bijl and some others are inclined to think that postvaccinal encephalitis is a new disease entity. On the other hand, Gins cites Sacco as referring to nervous complications after vaccina­ tions as long as 100 years ago. Comby, Gins, and others have also reconstructed a number of probable cases from 1905 to 1921.

SYMPTOMS AND DIAGNOSIS

The symptoms in this complication usually appear suddenly and have their onset in 70 per cent of the cases from the tenth to thirteenth day, inclusive, following vaccination. That is, they appear when the vaccination, usually primary, is at its height. The symptoms as recorded for different cases vary some­ what, but four symptoms are quite constantly noted, namely, 1. Fever (104°F. or higher in severe cases) ; 2. Vomiting; 3. Headache ; 4. Stupor or coma. The stupor may develop within a few hours after the onset of the symptoms and is always present in fatal cases. 306 The China 'Medical Journal

Symptoms of meningeal irritation are usually present in conscious cases, absent in others. Convulsions ai*e common in young children, as are also cramps or spasms. Trismus has been occasionally observed and is worthy of note as it may lead to confusion of the ailment w7ith tetanus. Varying degrees of paresis or paralysis are noted in some cases. The eye muscles usually escape. The Babinsky is usually positive, a point con­ sidered as of high diagnostic significance. The spinal -fluid usually shows little or no change to chemical, microscopical, or bacteriological studies. The pressure may be slightly increased, however, and cell counts as high as 200 to 400 . have been observed. Death, which follows in from 30 to 40 per cent of the cases, usually occurs from the third to the tenth day following the onset of symptoms. Recovery, when it takes place, is usually rapid and complete; however, some degree of crippling has been noted in a few cases. Microscopic, examinations of the central nervous system in iatal cases reveal perivascular areas of demyelinization and cellular infiltration scattered throughout the white matter of the braiji, and usually of the cord. also. These lesions are similar to, if in fact, not indistinguishable from, those encoun­ tered in the encephalitis that occurs after smallpox, measles, chicken pox, and the like. -

EPIDEMIOLOGY

In England and Holland the tendency of postvaccinal ■encephalitis to occur mainly in villages and rural populations of definitely restricted areas, to the exclusion of other areas and large cities, where vaccinations were concurrently performed, has led to the assumption o f some “ local” or “ place” factor in the complication. The fact that multiple cases in families have not been uncommon has been held by some to point in the same direction, while others have interpreted this as indicating an hereditary predisposition to the ailment. The complication has usually, but not always, followed a primary “ take.” Girls are more often affected than boys (the opposite of postvaccinal .tetanus). The patients have varied in age from a few months 'to 22 years; however, cases below one year cr over 8 years of age are rare. Current Medical Literature 307

In Holland, England, and Germany, multiple- insertion methods of vaccination, which give severe “takes,” are employed. Reports, however, indicate that the vaccinations which have been followed by postvaccinal encephalitis have not been exceptionally severe. The complication has not been confined to virus from any one vaccine establishment nor to any particular batches of virus. In fact, its occurrence seems to be independent of the type of virus. Holland, for a period, gave up the use of her usual virus and substituted in its place a strain of rabbit brain virus such as had been used successfully in Spain for some years. Out of approximately 40,000 vaccinations with this strain, 11 cases of postvaccinal encephalitis have been reported. A strain of virus from Denmark, tubed and ready for use, was next secured (Denmark has been free from recognized postvaccinal encep­ halitis). While only a few vaccinations were performed with this virus, cases of encephalitis have occurred following its use.

CAUSE The cause of postvaccinal encephalitis is unknown, an immense amount of epidemiological and laboratory work having failed to elucidate the subject. Attempts to infect animals with the brain of fatal cases or with spinal fluid have failed. Several theories have, however, been offered : 1. That the complication is a result of the vaccination activating some known or unknown infectious agent present in the virus or, more likely, in the vaccinated individual, in a quiescent or carrier state. This view is held by most European authorities. 2. That it is due to the vaccine virus itself. This view is favored by Luksch, Leiner, McIntosh, Jarge, Gorter, Van Hederween, and others. 3. That it is due to some state of local anaphylaxis, or hyperergy, has been suggested by Glanzman, Rivers, and others.

PREVENTION (1) Those who attribute the complication to the presence of some type of concurrent virus advise against vaccinating other than perfectly well individuals, and think that vaccination should not be performed in the absence of smallpox, when poliomyelitis or encephalitis letharyica is prevalent. 308 The China Medical Journal

(2) In England, the Rolleston Committee has advised against the multiple insertion for vaccinations, and has recom­ mended substituting for it a single, small, superficial insertion patterned after the “American method.”

(3) Practically all authorities stress the importance of performing primary vaccinations during the first year of life, since at this period postvaccinal encephalitis is relatively much less common.

Public Health Reports of the United States. August 23, 1929.

PUERPERAL GAS GANGRENE

A primipara, aged 39, was admitted to hospital on March 25, with a diagnosis of prolonged labour and vomiting. Labour had commenced on March 21. On admission her general condition was good, temperature was 98.4°, pulse 88. Vomiting had ceased, and no pains were present. The uterus was not tender, and no foetal sounds could be heard. The cervix was dilated to the size of a crown, but not fully .taken up. There was no change on March. 26, but by the morning of March 27 she was seriously ill, restless, of toxic appearance, and with a rising pulse. By noon the pulse was 120, the abdomen distended, and the uterus tender. Preparations were made to assist the uterus to empty itself. The cervix was now half dilated, and an unsuccessful attempt was made to dilate it manually. This allowed the escape of highly offensive gas, and foul, frothy brown fluid. As immediate evacuation of the uterus was inadvisable axis traction forceps were applied, and a weight of 7 lb. was attached to the traction rods over a pulley. Pituitrin 4 minims was given at half-hourly intervals for five doses. These measures were successful, and by 5 p.m. the child’s head was born. There was considerable difficulty with the delivery of the trunk owing to enormous gaseous distension of the abdomen. Following delivery a brownish frothy fluid and much gas escaped. Swabs from the interior of the uterus, umbilical cord, and foetal abdomen gave a growth of B. ivelchii. The Current Medical Literature 309

patient stood delivery well, but in the evening restoratives were necessary. Next morning she was a little better, but the placenta was still in the uterus. It was left alone, as it was not causing symptoms. On March 28 10 c.cm. Weinberg antigas gangrene serum and 40 c.c. antistreptococcal serum were given. Further doses of antigas gangrene serum were given on the second, third, fourth, fifth, sixth, eighth, and eleventh days of the puerperium. Attempts to express the placenta on the fourth and fifth days were useless, but very painful. The patient remained in extremis for 4 days after delivery, and then changed for the better. Progress was then remarkable, despite a vesico­ vaginal fistula, manifest on the sixth day. Noteworthy points are: (1) the absence of haemorrhage; (2) the fact that the placenta was never recovered, which suggests that it was liquified; (3) the value of antigas gangrene serum. Medical Revietv December, 1929. 310 The China Medical Journal

Booh Reviews

INTERNATIONAL HEALTH YEAR-BOOK 1928. Reports on the Public Health Progress of Twenty Nine Countries. Issued by the League of Nations, Health Organisation, Geneva. Price Fr. Ss. 20. Local Agents Commercial Press, Ltd. Shanghai. This monumental work has grown enormously in the past year and now eonsists of a volume, of 117,2 pages. It is so essentially a book of .statistics that anything in the way of a proper review is impossible.' The present volume differs from the preceding ones, mainly in regard to the form in which vital and nosological statistics of the majority of the reports are presented. Unfortunately, however, even yet there is not a complete corres­ pondence in the matter of tables and this greatly detracts from the value of the book as a means of comparing the incidence of disease in different countries. China, too, has not yet attained to a place in this volume and this makes it of much less interest to us. Indeed, as regards the con­ tinent of Asia, the only statistics in any way fully given are those of Japan. From these we note the persistent high incidence and deathrate of typhoid fever in that country as compared with the West, the strikingly lower mortality from cancer, and the extraordinarily small proportion of deaths from appendicitis, 2.2 per 1000 deaths and 4 per 100,000 of population. We take it that this implies that appendicitis is still a com­ paratively rare disease in rural Japan as it is also in rural China. On the other hand syphilis is an enormously more frequent cause of death than in England. Scarlet fever is astonishingly rare in Japan or else of a particularly mild type, as only 300 deaths are recorded therefrom out of a population of some sixty millions, whereas deaths from measles are proportionately double those in England. Space prevents us from dealing with further points of importance, but this volume deserves the careful study of all interested in Public Health and Epidemiology. J. L. M.

SHANGHAI MUNICIPAL COUNCIL. P u b l ic H e a l t h D e p a r t m e n t . Municipal Laboratories Handbook of Information. We have received a copy of this very valuable little handbook of which the main part is taken up with a description of how and when to collect specimens of blood, urine, water, milk, etc. for examination and how to transmit these to the laboratory. Book 'Review's- 311

T > • tfris fc^a matter .that-.every- doctor might be expected’. tC>' know the„.r.everse .is. really the case,, and we ■ doubt not that the Public Health bepar.tm.ent has the usual experience of an enormous. amount of important material being wasted through such ignorance. With this little handbook as'-a. guide there, is-'no :excuse . for such happenings which are equally annoying to the laboratory .and to the doctor himself. 1

. T.he, handbook deals "with .such varied subjects as :- throat and naso­ pharyngeal swabs, cerebrospinal fluids, blood for agglutination tests and cultures,'blood films, stools for examination, gonorrhoeal swabs, material for spiromena examination, urinalysis and sputum. It contains also direc- tion£ for .histological specimens and toxicological examinations and for the examination of samples of waiter and milk. Information is given with regard to Pasteur treatment and stock and antogenous vaccines.

The book closes- with a note , on free examinations for local doctors and a scale of charges for out-port work. It is very clearly printed and nicely got up. . J. L. M.

SPECIAL SHORT COURSE IN PRACTICAL PHARMACY. Joh n C a m e r o n , Ph.C., FVC.S., M.P.S. (Lond.) Pharmacist, Peping Union Medical College.-

This little book of 84 pages is something more than a mere announce­ ment of a Course in Pharmacy., It is this to an unusually full extent with very clear details for the students for each of the twelve lessons which cover: Pulveres, infusa, creams, mixtures, unguents, liquors, syrups, pills, liniments, emulsions, ampoules, tinctures, suppositories, spiritus, elixirs, tablettae, and 'commonly used items.

. These- occupy rather less than half the book the remainder being mostly taken up with the elucidation of special points in the course, much of it drawn from the valuable papers published from time-to time by the Author in the China Modical Journal. Very interesting sections on w a te r £>.nd on pharmaceutical'sterilisatiori are to be found in this part of the book.

W e have two small Criticisms to make. A s will be seen above, the Author has been unable to make up his mind whether to use an English or Latin'terminology arid" has rather, fallen down between the two. The second criticism is that such a valuable little book deserves an index. It has neither chapter nor lesson heading at the beginning nor index at the end; it should have both. This booklet has' a yalue far beyond the immediate intention of the Author, it should find an ;honoured place in every hospital dispensary in China. J. L. M. 312 The China Medical Journal

INSECTS, TICKS, MITES AND VENOMOUS ANIMALS OP MEDICAL AND VETERINARY IMPORTANCE. W a l t e r S c o t t P a t t o n , Liverpool School or Tropical Medicine. Published privately. Price 20/-.

This work replaces Patton and Cragg’s “Textbook on Medical Entomo­ logy” which is now out of date and out of print.

That book was published 16 years ago and remains today the only comprehensive treatise on the subject. The present volume has been published privately in order that it may be sold at a very reasonable price.

Had it been published in the usual way its price would have been prohibitive to most medical officers and nearly all students of Entomology.

Under the circumstances it can only be obtained from the Entomological Department, Liverpool School of Tropical Medicine. The price 20/- includes packing and postage to any part of the world. All copies going to the United States will contain an invoice for customs purposes. The duty will bring the price to about $5 gold.

The book is the first of a series of four parts each complete in itself dealing with “Insects, Ticks, Mites and Venomous Animals of Medical and Veterinary Importance” and covers the course for the Diploma of Tropical Medicine given at the Liverpool School of Tropical Medicine. The course consists of twenty eight meetings of short lectures followed by practical demonstrations and laboratory work.

This treatise follows the plan and system of the course and should form a model for a lecture course in Entomology suitable for any Tropical School of Medicine.

The plans, working drawings and photographs are excellent and the purchaser of this volume may. rest assured he has got more than value for his money.

This treatise forms in the review's opinion a splendid companion volume to Knowles “Introduction to Medical Protozoology.” Both works are by late Indian Medical Service Officers and add to the many con­ tributions to the science of tropical medicine made by this very dis­ tinguished service.

Professor Patton dedicates his treatise to the memory of twelve well known medical men who gave their lives during the twentieth century as a result of investigating tropical diseases. These are Lazear, Myers, Dutton, Tulloch, Schaudinn, Carroll, Von Prowazek, Bacot, Cragg, Adrian Stokes, Hideyo Noguchi and Alexander Young.

W e think Professor Patton has given a leading here which might well be copied by other authors in Tropical Medicine. Science moves so quickly that our debt to our own generation is apt to be forgotten. In glancing through the pages of any new contribution to Medical Science the reader may well give a space of silent reflection to such a Roll of Honour.

R. C. R. Correspondence 313

Correspondence

Customs Duties The First Menses of Korean Girl Students To the Editor China Medical Journal. The Editor ” China Medical Journal. Jan. 23, 1930. Jan. 27, 1930. Sir, Dear Dr. Maxwell:— It seems to me that the time has The January number has come come when our Association should to hand and on page 33 I note that try to get the Nationalist Govern­ the Editor gives' a foot-note ment to aid Mission Hospitals by regarding the article of my assis­ a remission of the taxes on their tant Dr. Y . C. Lee, on “ The First supplies. Some years ago such an Menses of Korean Girl Students” attempt was made through the — stating that Table 1 does not various Foreign Ministers but the bear out the statement that the results was nil probably mainly average age of onset of menstrua­ from the fact that the proposal did tion is 15 years, that the average not meet with the approval of the should be 14% not 15. Ministers. The present taxation is a serious drain on mission The Editor in making this com­ hospital finances, and a recent ment makes a common error of example of it, where this Hospital men who are not careful of (the R.M.H., I’Chang) had to pay statistics. Dr. Lee’s figure is cor­ something like 1 2 % % on the re­ rect and I regret the Editor’s com­ turn of a parcel of instruments ment for a correction will not sent to Britain for repairs, seems reach the eye of all who noted the to the writer so unfair that the Editor's comment. Nationalist Government, if proper The Editor’s mistake is in tak­ representation on the general ques­ ing the years as. numbered and tion were made through our omitting to note the words “ to Executive, might be willing to following birthday” showing the forego all duty on medical and average age of each group is not surgical supplies, new and repair- ' exactly the even year. For in­ ed, that come from abroad, or stance, there were 111 girls 14 similar goods bought in the coun­ years of age, it is clear that the try, if destined for use in mission average age of this group is 14%, hospitals. and the same principle holds for Yours very truly, each group so that the 3 girls A n d r e w G r a h a m . eleven years average 11% years,

Rankine Memorial Hospital 4 girls 12% years, 89 girls I’chang. 13% years etc. 314 The China Medical Journal

If the Editor had considered ***The Editor humbly apologises this clear fact and recognized that to Dr. Lee for any mistake he may it was “age groups” he would not ,Jiaye made in the note in question. have fallen in into the error he A t the same time he still thinks made. There is a great difference that however correct the“ table may in comparing average, ages accord­ be it is hardly sufficiently clear. . ing to the way ages are reported. He fails to foliow the argument When the age is simply given as in this letter, which states-: “ there so .many, years to “ following birth­ were 111 girls 14 years of age,’ it day” it is quite different from -age is clear th&t the average age of ‘•'at nearest birthday.” In this this group is 1 4 % .” case Dr. Lee used the ordinary method of reporting the age and This doubtless is correct, but is in order that there should be no it clear? To take an extreme case1 mistake added the words “ to fo l­ merely for illustrationif 110 of lowing birthday.” Statistics are the girls menstruated at 14 years treacherous things and one needs and one month, and only one at a tov be- careful how they are used. later month it is evident that the average for the group would not Yours sincerely, be 14% though all would come J. D. V a n B u s k i r k . ‘ into the year period. Severance Hospital Seoul, Korea. Obituary 315

Obituary

Dr. R. P. Hadden Home to join up with the R.A.M.C. in 1914. He served through the News of the death of R. P. Gallipoli campaign, was with the Hadden from Typhoid will come rear-guard at the evacuation of as a painful surprize to those who Sulva Bay, served throughout the met him a year ago in Shanghai campaigns in Egypt and Palestine, when he seemed so full of health accompanied Allenby to Jerusalem, and workfulness. It was only dur­ was transferred to France, and, ing last Summer that he was sent still with the fighting forces, went to Chao T ’ong, Yunnan, to fill the through the Flanders campaign of gap left there by the death of 1918, where he gained the honour Dr. Dymond from Typhus in that of the Military Cross. city with so ruthless a medical history. And now he, too is gone. In 1919 he returned to China, and in 1925, after another fur­ Born at Wexford, Ireland in lough, went North under the 1885 “Dick” had a distinguished U .M .M .S. to Shantung. He was career at school and at Dublin particularly happy amongst the University. Blessed as he was country folk there at Chu Kia with an untiring industry, intense Tsai, until he was transferred to powers of concentration, and an fill the serious Mission vacancy at exceptional memory, scholarships Chao T’ong. That was only six and honours seemed to come to months ago, and he was full of him as a matter of course. Yet plans for his new work when God he was an athlete and Hockey- took him. player, and never missed a season in the Rugby football field until Years ago in Ireland a youngster he left Ireland for China. With it being asked to accept a rather tall all he was an indefatigable mission yarn replied,— “I’ll believe that if worker in the Dublin slums, and as Dick Hadden tells me so!” a Local Preacher he never refused And somehow others have felt a call which to him was ever a call that way too. of God. G. H. In 1911 he came to China under the W.M.M.S. in Canton, returning

WANTED COLUMN

Wuhu General Hospital, An experienced graduate Chi­ M . E. F. B. nese Woman Nurse.

W anted: Apply: Dr. J. G. Vaughan, Wuhu A Chinese Interne in Medicine Hospital. and one in Surgery. 316 The China Medical Journal

NEW MEMBERS PROPOSED

Thoroughman, J. C. B. S., M.D. (Emory) M. E. S. Soochow, Ka. Proposers : Dr. K . H. Li, Dr. John A Snell. Li, D. Y. M.D. (Chengtu) M.E.F.B. Chunking, Sze. Proposers: Dr. W . Max Gentry, Dr. James L. Maxwell,

Graham, Malcolm G. M.D. (Tor) P.C.C. Taihoku, Formosa, Proposers : Dr. W . B. McClure, Dr. G. Gushue-Taylor. Teh Hui-Seng M.B., B.S. (Hongkong) C.M.S. Chuanchow. Fu. Proposers: Dr. M. E. Bryson, Dr. L. G. Thaeker.

Frame, J. D. M.D. (Penn) P.N. Reshfc, Peruia. Proposers : Dr. James L. Maxwell, Dr. J. Lee H. Paterson.

Yun, I. S. M.D. (Kyoto) Severance Hospital Seoul, Korea. Proposers: Dr. Norman Found, Dr. A . 1. Ludlow.

NEW MEMBERS ELECTED

Dr. L C. P. Beauchamp, C. I. M. Chengtn, Sze. Dr. S. Y . Chao, U. C. C. Fowchow, Sze.

CHANGES IN “LIST OF MEMBERS”, 1930

Dr. Richmond Douglass, Loomis Sanatarium, Loomis, N.Y., U.S.A. Dr. D. E. Griggs, P.O. Box No. 1281, Shanghai. Dr. G. T. Tootell, Changteh, Hunan. Dr. A. Stewart Allen, Kiating, Szechuen. Dr. D. Faulkner, Hsin Min Hsien, Man. Dr. J. A. O. Gotteberg, Nordbergveien 28, Sogn haveby, V. Aker, Oslo, Norway. Dr. Andrew Wight, Missionary Guest House, Selly Oak, Birmingham. Dr. E. S. Tyau, 110 Range Road, Shanghai. Dr. S. C. Wolfe, Chungsiang, Hupeh. Dr. T. Gillison, Cheeloo University, Tsinan, Shangtung. Dr. M. P. Gell University Hospital, Tsinan, Sung. Dr. ■ N. D. Fraser E. P. M. Swatow, Tung. Dr. E. Devries P.U.M.C. Peking. Omission Dr. Suchen W. Lai Shanghai College, Shanghai.