the operative treatment of cancer of the larynx
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of flexion and extension, but movements of rotation Iwere normal. Kernig’s sign was marked, and the
meningeal streak was persistent. The reflexes werenormal, but the pupils responded sluggishly to light.Lumbar puncture was immediately performed and
yielded clear fluid, not under increased tension. On
centrifugalisation the deposit was slight, but micro-
scopic examination showed undeformed red corpusclesand numerous cells, about 40 to the field. The leuco-
cytes did not appear altered ; their outlines were clear,their nuclei intact, and they preserved their tinctorialaffinities. The formula was as follows : Polynuclears,49’5 per cent. ; lymphocytes, 3 per cent. ; and largemononuclears, 47’5 per cent. The amount of albuminwas greatly increased. Neither direct examination norcultures showed any microbes, and the Wassermannreaction was negative. Next day the temperature fellto 99’50, and recovery ensued.The meningeal symptoms in this case are note-worthy, being more marked than is usual in sun-stroke. The conditions found in the cerebro-spinalfluid did not altogether correspond to thosedescribed by Dopter, though, as stated by him, thepuncture immediately relieved the symptoms. Hedid not find large mononuclear cells in any of hiscases. The intact condition of the leucocytes inthe cerebro-spinal fluid is an important diagnosticpoint. They differ entirely from those found inthe ordinary forms of meningitis. The conceptionof
aseptic meningitis " with intact leucocytes haspreviously been introduced by Widal. He notedthese in the
aseptic puriform meningitis " whichoccurs in syphilis of the central nervous system.MM. Desqueyroux and Lartigaut attribute the
meningeal irritation, a veritable aseptic meningitis,to a phlogogenic influence of poisons accumulatedin the organism as a result of the sunstroke. Theaccumulation is particularly marked in the cerebro-spinal fluid. This fact, according to Dopter, explainsthe curative action of lumbar puncture, which bothabolishes the high tension and removes a certainquantity of the poisons.
AMERICAN ANTI-TYPHUS WORK IN POLAND.
IN fighting typhus in Poland great activity wasshown last autumn by the Polish Typhus ReliefExpedition of the United States Army. Thisexpedition was commanded by Colonel H. L.Gilchrist of the Medical Corp, U.S.A., and newsabout it has come to us in his reports.! Hehad some 30 officers and 420 men with him, and32 trains brought over from Coblenz to Warsawthe stores bought by Poland from the AmericanExpeditionary Force, and those contributed by theAmerican Red Cross. Amongst the stores are
mentioned 1000 tons of soap and 1,000,000 suits ofunderclothes. The American officers were postedto districts and worked through the Polish medicalhealth officers. They established field columnswhich travelled about the country with laundryand disinfecting plants ; where they had operatedthere were no more cases of typhus. The work doneby the Americans was largely educative ; they weretraining the Poles to do the work for themselves,that they, the Americans, might get home. Theyhad also to commend their work to the people.There is evidence that they succeeded. Thus atWlodawa it is observed that
" much opposition was
at first encountered, and the assistance of themilitary was required to get the people to thebathing and delousing plant; conditions have sochanged it now requires the assistance of themilitary to keep them away. The people realise
1 Military Surgeon, February, 1920.
the necessity of the work and are cooperating inevery way." 28,000 people are, on Nov. 15th,reported to have been washed and deloused. It isto be regretted that operations were begun so late.In the spring 40 field columns will be in action.Each sanitary train comprised 20 specialists, to
superintend the bathing and delousing of 800 peopledaily. Petrol ran short, which delayed work, a motorrepair park and chauffeur’s school was established,a dentist arrived, and a quarantine cordon wasestablished on the Eastern border. With all this fooddistribution was never forgotten, it was of so greathelp in fighting typhus. A most creditable recordof industry, good organisation, and philanthropy.
THE OPERATIVE TREATMENT OF CANCER OFTHE LARYNX.
THE history of external operations for the removalof malignant disease of the larynx dates from 1870,when Czerny showed by experiments on dogsthe possibility of total laryngectomy, and Fouliscollected 11 years later 25 cases of this operation,none of which had survived for 12 months. In
consequence of these bad results an attempt wasmade to treat the disease by laryngo-fissure, butwith no better success, for in 1887 P. Bruns collected19 cases with 16 local recurrences and 2 immediatedeaths. The illness and death of the German
Emperor Frederick in 1888 stimulated interest inthe subject. The importance of Krishaber’s divisionof laryngeal malignant growths into intrinsic andextrinsic became generally recognised, and the workof Butlin and Semon established the operation oflaryngo-fissure or thyrotomy, which is now acknow-ledged in Great Britain as the operation of choicefor intrinsic cancer which has neither spreadextensively to the upper aperture nor penetratedbeyond the cartilaginous framework of the larynx.Semon, in 1907, reported 24 cases with 1 deathand 3 recurrences, while Sir StClair Thomson
reported in 1919 38 cases in his own practicewithout a death and with 9 recurrences. It willbe seen that these results compare very favourablywith operations for malignant disease in any partof the body. The important point is early diagnosis,which can usually be made easily enough if onlypatients be submitted to expert examination on theappearance of the one early symptom, which ishoarseness. Unfortunately, and especially in hos-pital practice, a large proportion of cases are notseen in time for treatment by laryngo-fissure, andthe only alternatives are palliative treatment,which may include tracheotomy and gastrostomy,and laryngectomy; this operation is also the
only one available for cancers which beginextrinsically, if we except a few localisedgrowths of the arytenoid and epiglottis, whichmay be removed by partial operations. Hemi-
laryngectomy is seldom performed now in this
country, principally because it does not permit theair-passages to be shut off from the wound area,a modification which has considerably lowered themortality of total laryngectomy. It still remainstrue that the majority of cancers of the larynxreach the surgeon too late for removal by anyoperation. Total laryngectomy is a very severe
operation, and cases should be. carefully selectedwith regard both to the general health of thepatient and the local condition. The growth isgenerally more extensive than appears on laryngo-scopic examination. Any considerable glandularinvolvement is a contra-indication ; so also is the
invasion of a large part of the pharyngeal wall,though there have been a few successful cases ofremoval of the pharynx after preliminary gastros-tomy. However, the results of the operation aresteadily improving, and its position is now wellestablished. In reviewing statistics from abroad itmust be remembered that laryngectomy is often per-formed for cases which would be treated by laryngo-fissure in this country. Thus, Crile, in 1912, reported24 cases with 2 deaths from operation, but does notuse laryngo-fissure; Botez, of Barcelona, in 1914, col-lected about 200 cases and reported 17 per cent. ofdeaths, 52 per cent. of recurrences, and 20 per cent.of cures. Chevalier Jackson, who performs laryngo-fissure for intralaryngeal cancer, reported in 1906that, of 29 cases of extrinsic cancer, he did 8
laryngectomies with no deaths due to the opera-tion, 3 recurrences, and 3 cures at the end of12 months (1 case too recent to report and 1 lostto view); and in England F. G. Harvey reported6 cases in 1901, of which 3 were successes. It is
being increasingly recognised, as the result of
experience, that after this operation patients arenot reduced to a miserable existence, to whichdeath would be preferable. On the contrary, theycan swallow without discomfort or difficulty, andmost of them learn to utilise the air of the mouth andpharynx to produce a whisper easily understood,or can do so with the aid of a tube leading fromthe tracheal opening to the mouth. Sir ChartersSymonds, in a paper which we publish in thepresent issue of THE LANCET, gives a descriptionof four patients who have survived in comfort andhappiness and done useful work for 8, 12, 15, and22 years respectively; it is to be hoped that thisarticle will encourage doctors to submit suitablecases to operation before it is too late. Sir ChartersSymonds does not give any account of the remainderof his cases of laryngectomy, and the publicationof these would prove interesting, as also would adescription of the details of his operative method,for the technique of this operation has by no meansas yet been finally determined.
RECENT ADVANCES IN VETERINARY SCIENCE.
THE work of the Division of Veterinary Science,described in the annual report of the College ofAgriculture and the Agricultural ExperimentStation of the University of California, has beeninteresting and instructive. The diagnosis of tuber-culosis by the complement-fixation test, howeversuccessful in man, has proved unsatisfactory inanimals; 9’3 per cent. of positive results wereobtained in non-tuberculous cattle, and the testproved of no value in the diagnosis of tuber-culosis in 20 hogs. It is stated to have beenshown by experiments in the field that tuberclebacilli from diseased cattle became harmless in17 days in dry weather, whereas they retaintheir virulence for a long time (94 to 171
days) when exposed to rain and moisture. Inwater-holes tuberculous material was found toremain infectious still longer, in one case for687 days and in another for 548 days. Theseresults have an important bearing on the disinfec-tion of the surroundings of a tuberculous cow, forany medium which may contain infected materialshould obviously be freed from sensible moisture.Hypochlorite solution is largely used in disinfect-ing the stalls of tuberculous cattle, though whollyfavourable conditions for its effective actionseldom exist; nevertheless, the mechanical
removal of discharges and the use of disinfect-ants on general principles is a sane and safe pro-cedure. Other experimental results recorded inthe report include the beneficial effect of sour-
milk treatment in coccidiosis of chicks and entero-hepatitis of turkeys, the detection of aviantuberculosis by the intra-dermal test, and theexpulsion of intestinal round worms from fowlsby the use of 1 lb. of tobacco-dust to50 lb. of dry mash, or a dose of llb. oftobacco-dust per 100 birds. Investigation of
preparturient paralysis of ewes, a troublesomedisease from which many losses occur, did notreveal its cause ; but as a preventive measure it isadvised that the amount of dry food given to ewesduring the last months of pregnancy be limited,and that they be made to rustle for their food inorder to gain plenty of exercise. An interestingaffection of rams denoted by enlargement of one orboth testicles, and known locally as
big ball," wasfound post mortem to involve the whole of thegenito-urinary tract and to be due to the .6<MtHMSpyogenes, which produced pus and necrosis ofsoft tissues. A contingent of these rams, not
visibly affected, or apparently recovered, onlygot 33 per cent. of the ewes in lamb. Infec-tion appeared to occur through the urethra. Afarm is kept where students may see demonstra-tions of the methods of clean milk production. It,is here that science ought to be able to produceexcellent results without greatly upsetting or dis-organising present operations. Cleanliness of cow-houses, cows, milkers, properly constructed milk-cans, and care in the distribution and storage ofmilk are matters of intelligence and industry, andcow-keepers, farmers, and dairymen can secure
much more favourable conditions by the exerciseof watchfulness and zeal.
A HOSPITAL FOR THE METROPOLITANPOLICE FORCE.
IN a report recently made to the Home Secretaryby Sir C. F. Nevil Macready, Commissioner of theMetropolitan Police, it is stated that a committee,under the chairmanship of Sir Hamar Greenwood,has recently had under consideration the wholequestion of the medical treatment and hospitalaccommodation for the Force, which seemedcapable of some improvement. It is hoped that inthe near future the Force may be in possession of ahospital to meet the needs of all ranks, which willgo far to put an end to the present system, underwhich officers and men requiring treatment areoften kept for long periods before being able toobtain admission to one or other of the greathospitals of the metropolis.
THE BACTERIOLOGY OF TUBERCULOSIS OFTHE SKIN.
IN the last number (Vol. XXIII., No. 2) of the Journalof Pathology and Bacteriology Dr. A. Stanley Griffithdescribes the results he has obtained in the examina-tion of 52 strains of tubercle isolated from cases ofsubcutaneous tuberculous abscess (scrofulodermia)occurring in Middlesbrough. In 32 instances theorganism was of the human type, in 20 of thebovine type, and in testing the virulence of thesecultures he made the interesting discovery that13 per cent. of the former and 20 per cent. of thelatter were of definitely low virulence. Hithertothese " attenuated " strains of tubercle bacilli have