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History. Right Upper Arm. the Prepuce Lhad Hlealed, and in Either

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History. Right Upper Arm. the Prepuce Lhad Hlealed, and in Either M TIlE I3RSE ] DOMICILIARY TREATMENT IN PHTHISIS. [APRIL 1I, 1914 lhave previously suppurated, give real diffictulty wlhen in and incubated a8robically and ana6robicallv at 37° C. and close contact witlh inerves or large vessels. 22° C., were all negative. Special attention was given to a We use blunt:pointed scissors curved on tlle flat, a possible sporotlhrix infection by means of cultures on dry stronig tissue separator, and special ring-slhaped gland glass, etc. A portion of tlhe pus was inoculated sub- forceps witlh a spritng catcli and long handles, whlich cutaneously into two guinea-pigs, which both slhowed well- enable an assistailt to assist tlle operator. marked tuberculosis wlhen examined four weeks later. Drainage slhould be euployed in extensive alid doubtful Smears from the caseous glands and from the spleeni cases. But we do not favour drainage ttubes for aseptic showed numerous long, slender, acid-fast and alcohol-fast cases; a narrow gauze wick suffices. Tlhe laslimir sawv- bWcilli. Cultures fromn the caseous glands and splenic dust pads are useful as outside dressings, and, with a well- emulsion of the guinea-pigs were inoculated on plaiin anid applied knitted baud(lage of loose mieshi, the head is com- glycerine egg medium and on fulhsin egg mediumni. All th-e fortably fixed almost as if splinted. We remove the drain tubes inoculated gave a luxurianit growth of the tuberele usually after twenty-four hiours, and tllen do not dress bacillus after two weeks' incubation at 370 C. Rabbits aseptic cases till the ninth day, wlhen tlle stitchles are were inoculated subcu aneously and -intravenotusly with remioved. For ligatures we use locally prepared iodine- caseous gland material and splenic emulsion froiml the clhronmic gut, and tor sutures local silk thlread. guinea-pigs, but were apparently unaffected. At autopsy, So far as I can judge, tlle end results are very satisfac- two months later, no evidence of tuberculosis was fouind. tory. I lhave not scen pulmlonary plltllisis as a later com- While awaiting the results of the guinea-pig iniocula- plication, nor tuberculous peritonitis. tions I inquired of a second doctor wlho was nowv in Tllere is an increase of pulmonary tubercle in Kashmir, attendance as to a family history of tuberculosis. He kindly but nio apparent increase in glanidular disease. The informed me that there was no family history of tuber- clim-iate is favourable, and it is proposed slhortly to start a culous disease in either parent, and thlat tihe child lhad never State sanatoriumu, which is likely to attract tuberculous lived in close contact with a tuberculous person.- The patients from the plains of Northi India. child had always been breast-fed. Havilng satisfied myself that the cllild was in all probability infected at the timle of the circumcision by a human type of tubercle bacillus, I MULTIPLE SUBCUTANEOUS TUBERCULOSIS was at a loss to account for it till some montlhs later, wlhen the practitioner whlo performed the operation died sucldenily FOLLOWING CItCUMCISION AND TREATED from tuberculous laryngitis, the supposition beinig that BY TUBERCULI,N. the raw wound was infected by cougliing during the operation. BY SYDNEY T. CHAMPTALOUP, MI.B., Cii.B., Subsequent History of Case. B.sc.((P. tI)EDIN., Though the child was extremelv ill the parents were rPOFESSOR OF PUBI IC HEALTH AND BACTEItIOLOGY, OTAGO UNIVERSITY, NEW ZEALAND; DISTIRICT HEALTH OFFICElt AND BACTERIOLOGIST, anxious tllat "injections" slhould be tried, seeing that NEW ZEALAND GOVERNM: NT HEALTH DEPARTMENT. they were in the first place advised to comIle to town for vaccine treatment. With some misgivings I prescribed IN April, 1913, a male infant, suffering from several re- weekly injections of P.'T'.O., starting witlh 0.0001 c.cin.; curring subcutaneous abscesses,-was sent to my laboratorv tlhey were adiiiinistered by Dr. B. in gradually increasing, at the General Hospital by Dr. A., witlh a view to diagnosis doses for several months. Coincident withi tlle adniiiii- and vaccine treatment. The appearance of the lesions stration of tuberculin the child became less fretful, all(n its suggested a tubercu ous ratlher than a pyogenic origin. appetite and general condition improved. Wheln seen eight Thle clhild lhad been circumcised eight mouitlhs previously, montlhs later all the lesions had completely healed, and aind the practitioner wlho performled the operation, and who the child looked thle picture of lhealtlh. The nmotlher senit tlle chiild to tovn for an opinion was, unknown to us, informned me that the lhealing commenced shortly after the suffering at the tinle of the operation from tuberculous tuberculin was first admninistered. laryngitis, wlicll subsequently proved fatal. The case is of interest from the somewhat unusual source of infection, and, considering the child's serioLus History. condition, from the rapid improvement wllich set in At tlle age of 7 weeks the clhild was circunmcised by coincident with the adminiistration of tuberculin. More- Dr. A. The wound suppurated badly, and three weeks over, although the infection was widespread, it was, as fatr later the riglht inguinal glands enlarged, and- an abscess as could be ascertained by physical examinationi, coltined formiled wlliclh was incised. No laboratory investigation of to the subcutaneous tissues. the pus was miade. A week latet, whlat the motlher de- scrib3s as a mieasles-like raslh appeared on the child's face, body, and limllbs; this gradually faded, except for several snmall areas, whlicll becamue indurated and suppurated at THE POSSIBILITIES OF DOMICILIARY intervals. At the same time tlle child lost its appetite TREATMENT IN PHTHISIS. and became eniaciated. As eaclh indurated area softened it was incised, but in most cases failed to lheal after several BY montlhs' treatmiient. Eighit miontlhs after the circumcision GEORGE JESSEL, M.A., M.B., B.CH.OxON., the clhild caule under miiy notice. D.P.N.VICT., TUBERCULOSIS OFFICER TO THE LANCASHIRE COUNTY COUNCIL Condition on Exammination. AND THE COUNTY BOROUGH OF WIGAN. The child was now 10 montlhs old, ernaciated, and hectic. There were numierous suppurating foci on tlle body, face, ALTHOUGH considerable progress is being made in the pro- and liinbs, several of wlich lhad failed to heal after vision of sanatoriuins, the vast majority of consumptives incision and evacuation of pus. On the outer margin and perforce remain at lhome during tlle greater part of their tlhe sole of the riglht foot there were several disclharging illness. Tlle problom of domiciliary treatment thus mnerits SinDuses, dressed with1 gauze drain1s. There was a simiilar careful attention, but doubts have been expressed as to the lesioni on the left instep. On the outer surface of the likelillood of any measure of success resulting fromn it. rigiht upper armn there were two recently lhealed scars This is not tlle view expressed ill the interim report of the sulrloulided by indurated tissue of a purplish red colour. Departmental Committee on Tuberculosis as follows: Over eachi gluteus maxiuntis, and on tlle riglht clheek, and It should, however, be borne in min(d that a shlort stay in an over the riglht lower jawv there were superficial ulcerations institution in which the patient may be edlucated, followe(d by witlh similar purplish indurated edges to those seen on the a course of home treatment, in shelters, etc., under close right upper arm. The prepuce supervision, is a form of sanatorium treatmenit wliCill has lhad hlealed, and in either certain a(lvantages and which may successfully be adopted in a ingfuinial region tllere were healed scars of recent incisions. large niumber of cases. Oni tllh right side a small abscess -was pointing, from which 0.5 c.cm. of thiick pus was aspirate(l. No other tuiber- In the present article an attempt will be made to slhow culous lesions but those indicated could be detected. what mlay be done in an average working-class lhomle. It would be futile to overlook the influence of tlhe locality Laboratory Investigation. and of the actual lhouse in wlhich treatmnent is attenmpted. Films stained by the Gram, Leishman, anid Zielhl- It is unfortunate that in many cases the lhom-ie conditions Neelsen methods and the usual laboratory media inoculated, are such as to hold out scant prospects of suc.ess. More-.
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